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Introduction. Coupled with the increasing use of indwelling vascular catheters and prosthetic cardiac valves is an uptrend in sepsis secondary to fungemia. An insidious onset often shrouds the initial diagnosis, contributing to poor outcomes. Candida infective endocarditis (CIE) is a feared complication of candidemia, associated with high mortality rates. It requires prolonged hospital stays for medical and, often, surgical management. We report a case of a massive intracardiac Candida mass in an adult with native valve CIE. Case. A 51-year-old male on chronic total parenteral nutrition (TPN) because of bowel resection presented with fevers, night sweats, and unintentional weight loss. He was febrile and tachycardiac on admission, with a benign physical examination. Laboratory workup showed elevated inflammatory markers and an acute kidney injury. Extended blood cultures showed growth of Candida glabrata (C. glabrata) and Candida dubliniensis (C. dubliniensis). Transthoracic (TTE) and transesophageal echocardiography revealed a large mobile right atrial mass (4 cm × 6 cm × 2.5 cm), extending to the right ventricular outflow tract. Since he was a poor surgical candidate, management with micafungin was initiated and continued for 8 weeks. He responded well to the regimen with resolution of the fungal mass on follow-up TTE 3 months later. In anticipation of the future need for TPN, he continues on lifelong suppressive oral fluconazole. Conclusion. CIE may be an insidious complication of indwelling central venous catheters, necessitating a high index of suspicion. Conservative management, with antifungal therapy, can yield favorable outcomes in poor surgical candidates.

Introduction: Ventricular rate control is critical in management of atrial fibrillation (AF). When pharmacologic therapy fails in controlling the ventricular rate, atrioventricular nodal ablation (AVNA) and pacing is considered an effective therapy for symptomatic management. His bundle pacing (HBP) is considered a physiologic mode of pacing with AVNA ensuring synchronized activation of right and left ventricles preserving ventricular functioning. Hypothesis: HBP and AVNA are feasible, safe, and effective for management of refractory AF. Methods: We identified 218 studies after literature review of EMBASE, Medline, and Cochrane databases. Our analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Results: Six studies (two randomized controlled trials, four observational cohorts) were included in the final meta-analyses. A total of 275 patients underwent attempted permanent HBP and AVNA. The mean age of patients was 70.74 (SD 4.38; 95% CI 62.15-79.32). Mean implant success rate for acute HBP was 94.5% (SD 10.12; 95% CI 74.70, 100.00). Selective HBP was noted in 44.7% (95% CI 12.5-76.9), while Non-selective-HBP was noted at rate of 42.2% (95% CI 10.2-74.2). The mean follow-up duration was 21.71 months (SD 3.77; 95% CI 14.32-29.11). All-cause mortality had a pooled proportion of 0.107 (SD 0.110, 95% CI -0.109-0.323); hospitalization proportion was 0.078 (SD 0.072; 95% CI -0.063-0.219). We noted a significant improvement in left ventricular ejection fraction (LVEF) (Baseline [BL] 41.84%, Follow-up [FU] 53.63%, Standardized mean difference [SMD] 0.646, p 0.028), NYHA class (BL 2.77, FU 1.55, SMD -2.542, p Conclusion: HBP and AVNA are feasible, safe, effective and has high success rate for management of refractory AF. Further studies are needed to evaluate its role in comparison to left bundle branch area pacing and cardiac resynchronization therapy to evaluate comparative efficacy in refractory AF.

Introduction: The third generation transcatheter heart valve system aimed to improve the safety of transcatheter aortic valve replacement (TAVR). We performed systematic review and meta-analysis to compare clinical outcomes after TAVR with Edwards Sapien 3 (ES3) and Evolut series (MER). Methods: A systematic search was conducted by 2 independent researchers in MEDLINE and EMBASE for studies comparing clinical outcomes after TAVR with ES3 and MER. 1 randomized controlled trial and 11 observational studies met the inclusion criteria. Mantel-Haenszel odds ratios were calculated, and for heterogeneity I 2 statistics were reported. Results: 12 studies with total 7,749 patients were included for final analysis. ES3 and MER were implanted in 4,333 and 3,416 patients respectively. ES3 showed statistically significant decrease in permanent pacemaker implantation at 30-days (OR: 0.60; 95% CI: 0.52-0.70; p< 0.05). Furthermore, TAVR with ES3 showed non-statistically significant trend towards decreased all-cause mortality at 30 days (OR: 0.73; 95% CI: 0.51-1.02; p=0.07), and stroke at 30 days (OR: 0.55; 95% CI: 0.27-1.10; p=0.09). Cardiovascular mortality (OR: 1.03; 95% CI: 0.50-2.15; p=0.93), and acute kidney injury (OR: 1.08; 95% CI: 0.83-1.41; p=0.56) did not show statistically significant difference. Conclusions: While ES3 and MER had similar clinical outcomes, patients undergoing TAVR with ES3 had statistically significant decrease in permanent pacemaker implantation and hence may be favored in patients with pre-existing conduction system disease.

Introduction: Left bundle branch block (LBBB) because of dyssynchrony is a risk factor for heart failure (HF). We evaluated the baseline characteristics and comparative outcomes of atrial fibrillation (AF) patients with co-existing LBBB. Hypothesis: AF with concomitant LBBB is associated with poor cardiovascular outcomes. Methods: We conducted a retrospective analysis of hospitalizations for AF with and without LBBB from the National Inpatient Sample (NIS) between 2013 and 2014. Billing codes (International classification of diseases, 9th revision) were used to identify the target population. Results: A total of 1,531,704 hospitalizations for AF were identified, out of these, 1,496,742 hospitalizations had no LBBB and 34,952 hospitalizations had LBBB. AF with LBBB cohort was older with mean age (77.8 vs 75.3, p Conclusions: LBBB is a poor prognostic indicator in patients admitted for AF and is associated with worse cardiovascular outcomes. Aggressive management of AF in patients with LBBB may improve the clinical outcomes. Further clinical studies are required to study this relationship.

Spontaneous coronary artery dissection (SCAD) is a frequently missed diagnosis in patients presenting with acute coronary syndrome (ACS). Our aim was to evaluate the causes, trends, and predictors of 90-day hospital readmission in patients presenting with SCAD. The Nationwide Readmissions Database (2013 to 2014) was utilized to identify patients with primary discharge diagnosis of SCAD using the International Classification of Diseases, Ninth Revision, Clinical Modification, diagnostic code 414.12. The primary outcome was 90-day readmission. Among 11,228 patients admitted with the primary diagnosis of SCAD, 2,424 patients (21.6%) were readmitted within 90 days (68% women, 82%

Introduction. Cardiovascular implantable electronic devices (CIEDs) are being increasingly used in the primary and secondary prevention of malignant ventricular arrhythmias and conduction system disorders. Infectious complications associated with CIEDs include infective endocarditis, lead infections, and pocket-site infections, primarily involving Staphylococcus species. Infective endocarditis is a rare but life-threatening complication of gonococcal bacteremia. We report the first case of a CIED pocket-site infection secondary to Neisseria gonorrhoeae (N. gonorrhoeae). Case. A 56-year-old male with a history of congestive heart failure status postimplantable cardioverter-defibrillator (ICD) insertion presented with a pocket-site swelling initially concerning for a hematoma which began to exhibit erythema and tenderness. The patient reported a history of high-risk sexual behavior. On presentation, he was afebrile and hemodynamically stable. Physical exam showed a 5 cm × 6 cm pocket-site swelling with overlying erythema. Labs revealed elevated ESR and CRP levels. Transthoracic and transesophageal echocardiography was concerning for infective endocarditis and lead vegetations. Blood cultures tested positive for N. gonorrhoeae. He underwent surgical debridement with complete ICD extraction and drainage of infected serosanguineous pocket fluid. Tissue cultures were negative, but isolation of N. gonorrhoeae in blood cultures confirmed it as the causative agent of the pocket-site infection in the absence of prior Gram-positive coverage. He was started on a prolonged course of ceftriaxone for 4 weeks with reimplantation of ICD at a different site after completion of treatment. Conclusion. In patients with high-risk sexual behavior, gonococcal bacteremia can potentially lead to CIED infection. These individuals should be prudently evaluated for infective endocarditis or pocket-site infections as presenting complaints can be subtle.

Introduction Electrical storm (ES) is cardiac electrical instability characterized by recurrent episodes of ventricular tachyarrhythmias. ES is associated with increased mortality and morbidity, hence requires prompt intervention. Treatment of underlying etiology is of prime importance in termination of ES. Anti-arrhythmic medications serve as an adjunctive therapy in suppression of ES by reducing myocardial excitability. The anti-arrhythmic conventionally employed is amiodarone in combination with non-selective beta-blockers to reduce the adrenergic input to myocardium. However, anti-arrhythmics at increased concentrations can lead to adverse systemic effects including hemodynamic instability. Hypothesis We hypothesize 1. The use of intravenous or oral anti-arrhythmic therapy for patients in electrical storm is limited by their toxicities and blood pressure lowering effect. Corollary 1. Injection of anti-arrhythmic medications into the pericardial space, an extra-vascular structure encasing the heart, provides an option for use of higher concentration of anti-arrhythmic while limiting systemic absorption. Corollary 2. The pericardial space has direct communication to the epicardium, the outer most layer of cardiac muscle, spatial proximity may allow for effective therapeutic options in electrical storm. We present experimental and clinical evidence in support of these hypothesis.

Rheumatoid vasculitis (RV) is an infrequent complication of longstanding severe rheumatoid arthritis (RA). The active vasculitis associated with rheumatoid disease occurs in about 1%-5% of the patient population. RV is a manifestation of "extra-articular" rheumatoid arthritis and involves the small- and medium-sized arteries in the body. Newer RA treatments, including biologic therapies, offer a broader array of potential therapeutic options, although no controlled trials exist to guide treatment. In general, following tissue confirmation of the diagnosis, the severity of organ involvement and disease manifestations can guide treatment decisions. We want to alert clinicians of this unique yet severe complication of RA which has high morbidity and mortality. We describe a thought-provoking case of a 44-year-old male with past medical history (PMH) of hypertension who presented with over three-month history of lower extremity (LE) swelling, discoloration, and ulceration. Arthralgias with constitutional symptoms (fatigue, weight loss), large pericardial effusion, was found to have leukocytoclastic vasculitis along with rheumatoid factor (RF) >650, and anti-cyclic citrullinated peptide (anti-CCP) antibodies >300, low C4 and normal C3. Pericardial fluid appeared serous, exudative, showed histiocytes, multinucleated giant cells and necrotic debris consistent with rheumatoid effusion. Skin, right shin, punch biopsy showed epidermal necrosis from underlying occlusive vasculopathy. Skin, left lower back, punch biopsy showed focal leukocytoclastic vasculitis. The patient was started on high dose steroids with marked improvement in the symptoms, Rituximab was planned awaiting QuantiFERON to be negative. Pan-CT angiography of the whole body was negative for any vascular changes ruling out polyarteritis nodosa (PAN).

A 64-year-old man presented to the internal medicine resident clinic with fatigue and abdominal pain of six-month duration. He did not have diarrhea, hematemesis, melena, or hematochezia. Physical examination was unremarkable. Laboratory findings were consistent with iron deficiency anemia. Upper and lower gastrointestinal (GI) endoscopies revealed normal findings. Duodenal biopsy showed trophozoites (tear-drop-shaped) morphologically consistent with Giardia duodenalis. He was prescribed metronidazole and iron replacement therapy, with a resultant improvement in symptoms as well as lab values at the four-month follow-up visit.

Background Hemorrhagic cardiac tamponade (HCT) is characterized by rapid accumulation of blood in the pericardium causing hemodynamic collapse. We report a case of HCT due to Apixaban use in a patient with renal cell carcinoma, supplemented with a systematic review of pericardial tamponade associated with the use of direct oral anticoagulants (DOACs). Case report A 62-year-old African American male with a history of metastatic renal cell carcinoma presented with dyspnea while taking Apixaban. He was diagnosed with pericardial tamponade and 800 ml of hemorrhagic effusion was drained. The pericardial fluid analysis was negative for malignancy and suggestive of HCT. He had a complicated hospital course and died several days later. Methods We searched MEDLINE, EMBASE and other sources for published cases of pericardial tamponade associated with DOACs. Our outcomes of interest included patient characteristics, risk factors, timing from the start of anticoagulation to tamponade, treatment and mortality. Simple descriptive statistics using percentages for categorical variables were used to describe the included cases. Results A total of 26 cases were included in the final systematic review after searching MEDLINE, EMBASE and other sources. The mean age was 70 years (range 43–88) with 19 (73%) males. Twelve cases (46%) were associated with Rivaroxaban, 9 (37%) with Dabigatran and 5(19%) with Apixaban. Sixteen cases had elevated INR and 15 had elevated creatinine. Only 2 patients died but 24 had to undergo pericardiocentesis. Conclusion Cardiac tamponade is rarely associated with DOACs and elderly male patients with renal and coagulation abnormalities appear to have the highest risk.

Background: The clinical spectrum of carotid atherosclerosis is well characterized, but the events leading to plaque instability and stroke are less understood. Evidence suggests that platelets serve as an interface among hemostasis, inflammation, and atherosclerosis. Coated-platelets, a subset of platelets with high procoagulant potential, are increased in asymptomatic carotid stenosis patients at high risk for stroke or TIA. We now examine the impact of other soluble mediators of inflammation, cell adhesion, angiogenesis and coagulation on the association between coated-platelets and TIA/stroke in asymptomatic carotid stenosis. Methods: Consecutive asymptomatic patients with ≥50% carotid stenosis were enrolled. Coated-platelet levels were assayed and plasma was obtained for measurement of 58 biomarkers. Patients were followed at 6-month intervals for intensive vascular risk reduction. Those with signs or symptoms of TIA/stroke underwent either brain CT or MRI. Rank order correlations between inflammatory marker concentrations, coated-platelet levels and TIA/stroke were determined using the Spearman correlation coefficient. Variables associated with TIA/stroke (p Results: We enrolled 117 patients (97% male, average age 71, 94% on statins, 96% on antiplatelets, and 33% currently smoking, average HgA1c 6.6% and average LDL 86 mg/dL). There were 6 strokes and 2 TIA’s ipsilateral to carotid stenosis during a mean 21.3 ± 6.7 months of follow-up (incidence of 3.89/100 person-years). Stepwise logistic regression identified TNF alpha (OR=11.1, p=0.0300) and coated-platelet group (OR=14.1, p=0.0167) as predictors of TIA/stroke ipsilateral to stenosis. Cox Proportional Hazard analysis yielded a TIA/stroke HR of 11.8 for the high coated-platelet group (95% CI 1.4, 96.1, p=0.0215) and 8.0 (95% CI 0.97, 66.3, p=0.0529) for the high TNF alpha group. Discussion: Coated-platelets and TNF alpha predict TIA/stroke in asymptomatic carotid stenosis at 21 months. These findings expand on our previous work in coated-platelets and asymptomatic carotid stenosis and suggest that coated-platelets may represent a common link between hemostatic and inflammatory mechanisms of plaque instability.

Background: Silent brain infarction (SBI) is associated with both cognitive decline and recurrent stroke. While cortical SBI may have an embolic source, the etiology of subcortical SBI (80% of SBI) is less clear. We now examine the association between coated-platelets (procoagulant platelets observed upon dual agonist stimulation with collagen and thrombin), soluble mediators of inflammation, cell adhesion, angiogenesis and coagulation and SBI in carotid stenosis patients. Methods: Asymptomatic patients with ≥50% carotid stenosis were enrolled, coated-platelets assayed, and plasma obtained for measurement of 58 plasma biomarkers. Presence and location of SBI, defined as a focal, ≥ 3mm cavitary lesion with T1 hypointensity and T2 hyperintensity features on MRI within 12 months of enrollment, were recorded. Variables correlating (p Results: Thirty-two subjects were analyzed. Cardiac ejection fraction (r= -0.34, p=0.0325), coated-platelets (r=0.5471, p=0.0014) and IL-7 (r=0.35, p=0.0498) correlated with overall SBI number. Antiplatelet use (r= -0.63, p=0.0001), coated-platelets (r=0.43, p=0.0152) and RANTES (r=0.39, p=0.0283) correlated with cortical SBI number. Beta blocker use (r= -0.40, p=0.0238) and coated-platelets (r=0.52, p=0.0030) correlated with subcortical SBI number, with a trend for correlation between IL-7 and subcortical SBI number (r=0.35, p=0.0518). Multivariate analysis revealed coated-platelet levels ≥40.5% and lack of beta blocker use were associated with subcortical SBI (OR=35.22, p=0.0057 and OR=10.74, p=0.0347 respectively). Discussion: Our results demonstrate a strong association between coated-platelets and SBI regardless of anatomic location. We have also identified two inflammatory mediators associated with cortical (RANTES) and subcortical (IL-7) SBI location. Our findings suggest protective effects of antiplatelet use for cortical SBI and beta blocker use for subcortical SBI. Altogether, these data support a thrombotic mechanism of SBI with differing auxiliary mechanisms for cortical and subcortical SBI that may involve alternate inflammatory pathways.

Background The hormones of the hypophysis-thyroid axis (HTA), thyroid stimulating hormone (TSH), and thyroid hormones, L-thyroxine (T4) and 3, 3', 5-L-triiodothyronine (T3), modulate the metabolism, differentiation, and proliferation of almost every cell in the body. Several studies have examined the effect of HTA hormones on platelet count and mean platelet volume (MPV), but have reported inconsistent results. Our aim was to examine the association between HTA hormones and platelet count and MPV in a large cohort of the adult population of the United States. Methods We used the continuous National Health and Nutritional Examination Survey (NHANES) which made available data on HTA hormones (1999-2000, 2001-2002, 2007-2008, 2009-2010, and 2011-2012) to examine the association between HTA hormones and platelet count and MPV. Analyses were performed with adjustments for the complex survey sampling methods of NHANES data. Unadjusted and adjusted generalized linear regressions were performed to examine the relationship between HTA hormones and platelet count and MPV. Regression models were adjusted for age, sex, race, alcohol use, smoking status, serum c-reactive protein, red blood cell folate, diabetes mellitus, glomerular filtration rate, body mass index, and hypertension. Results Of the 10,619 individuals eligible for inclusion in the analyses, 5,267 (49.6%) were females and 2,132 (20.08%) were African Americans. The mean ± standard deviation of platelet count was 256.4 ± 67.1 109/L, MPV 8.04 ± 0.92 fL, serum T4 7.92 ± 1.68 mg/dL, and serum T3 114.08 ± 24.6 ng/dL. In unadjusted analyses, an increase in the serum levels of T4 or T3 was associated with a significant increase in the platelet count and MPV (all p-values < 0.05). In contrast, an increase in serum TSH level was associated with a significant decrease in the platelet count (p-value = 0.05) but had no effect on MPV. After adjustment for potential confounders, serum T4 levels were significantly associated with platelet count but not with MPV. Individuals in the lowest quartile of T4 had 18.73 x 109/L lower platelet count than individuals in the upper-most quartile (p-value = 0.03). Serum TSH and serum T3 levels had no effect on platelet count or MPV after adjusting for potential confounding variables. Conclusions We report that only serum T4 levels, and not TSH or T3 levels, are independently associated with platelet count and there is no independent association between HTA hormones and MPV. Our findings suggest a possible role of serum T4 on thrombopoiesis or on platelet lifespan.

The periendoscopic management of anticoagulation (AC) in patients with valvular atrial fibrillation and history of embolic stroke is an area of uncertainty. Despite the availability of some guideline recommendations, the decision regarding bridging AC is usually at the discretion of the physician.

Transesophageal overdrive atrial pacing (TEAP) is a minimally invasive technique for terminating atrial tachycardia (AT). Use of TEAP in pregnant women is limited, while the more commonly used direct current cardioversion (DCCV) for AT can be dangerous to the fetus. We report TEAP successfully

Microangiopathic hemolytic anemia (MAHA) is usually caused by infection, autoimmune disorders, and or genetic predisposition. More recently MAHA secondary to cocaine use has been described. We report a case of cocaine-induced MAHA presenting as non-ST elevation myocardial infarction (NSTEMI). A 44