Coronavirus Disease of 2019 is a highly transmissible and sometimes fatal infection caused by the SARS-CoV-2 virus.We present two patients with sub-massive pulmonary embolism in the setting of inactivity while in "self-quarantine" and reinforce the advice from the World Health Organization about measures to stay physically active while at home.
The coronavirus disease 2019 (COVID-19) pandemic and the "shelter-in-place" orders have placed a significant strain on patients and providers. We believe that patient education is crucial during these times, so together with their health care providers, the patients can make the best decisions in regard to their health. Anchored on a patient-perspective, we summarize frequently asked questions illustrating a growing thrombosis concern.
New and persistent left bundle branch block (NP-LBBB) following Transcatheter Aortic Valve Replacement (TAVR) is an ongoing concern with incidence ranging from as low as 4% to up to 65% (varying for different types of valves). Such patients are at risk of developing high-grade atrioventricular block (HAVB) warranting permanent pacemaker (PPM) implantation. However, currently, there are no consensus guidelines or large prospective studies to risk stratify these patients for safer discharge after TAVR.To provide insight from a single center study on using modified electrophysiology (EP) study to risk stratify post-TAVR patients to outpatient monitoring for low-risk versus pacemaker implantation for high-risk patients.Between June 2020 and March 2023, all patients who underwent a TAVR procedure (324 patients) at our institution were screened for development of NP-LBBB post-operatively. Out of 26 patients who developed NP-LBBB, after a pre-specified period of observation, 18 patients were deemed eligible for a modified EP study to assess His-Ventricular (HV) interval. 11 out of 18 patients (61.1%) had normal HV interval (HV < 55 ms). Three out of 18 patients (16.7%) had HV prolongation (55 ms < HV < 70 ms) without significant HV prolongation (defined as an increase in HV interval > 30%) with intra-procedural procainamide challenge. Four out of 18 patients (22.2%) had significant HV prolongation (HV > 70 ms) warranting PPM implantation based on a multidisciplinary approach and shared decision-making with the patients. Total of 50% of patients discharged with PPM (two out of four patients) were noted to be pacemaker dependent based on serial device interrogations. All patients who did not receive PPM were discharged with ambulatory monitoring with 30-day event monitor and did not develop HAVB on serial follow-up.Normal HV interval up to 55 ms on modified EP study after TAVR and development of NP-LBBB can be utilized as a threshold for risk stratification to facilitate safe discharge. The optimal upper limit of HV interval threshold remains unclear in determining appropriate candidacy for PPM.
Most studies have compared post-treatment electrocardiogram (ECG) abnormalities in cancer patients to the general population. To assess baseline cardiovascular (CV) risk, we compared pre-treatment ECG abnormalities in cancer patients with a non-cancer surgical population.We conducted a combined prospective (n = 30) and retrospective (n = 229) cohort study of patients aged 18 - 80 years with diagnosis of hematologic or solid malignancy, compared with 267 pre-surgical, non-cancer, age- and sex-matched controls. Computerized ECG interpretations were obtained, and one-third of the ECGs underwent blinded interpretation by a board-certified cardiologist (agreement r = 0.94). We performed contingency table analyses using likelihood ratio Chi-square statistics, with calculated odds ratios. Data were analyzed after propensity score matching.The mean age of cases was 60.97 ± 13.86; and 59.44 ± 11.83 years for controls. Pre-treatment cancer patients had higher likelihood of abnormal ECG (odds ratio (OR): 1.55; 95% confidence interval (CI): 1.05 to 2.30), and more ECG abnormalities (χ2 = 4.0502; P = 0.04) compared with non-cancer patients. ECG abnormalities were higher in black compared to non-black patients (P = 0.001). In addition, baseline ECGs among cancer patients prior to cancer therapy demonstrated less QT prolongation and intra-ventricular conduction defect (P = 0.04); but showed more arrhythmias (P < 0.01) and atrial fibrillation (AF) (P = 0.01) compared with the general patient population.Based on these findings, we recommend that all cancer patients receive an ECG, a low-cost and widely available tool, as part of their CV baseline screening, prior to cancer treatment.
involving physician trainees in the adjudication process would allow investigators to divide the workload and foster trainees' research experience.Aims: To evaluate the accuracy of the ISTH definition of pulmonary embolism (PE)-related death for autopsy-confirmed PE-versus non-PErelated death among physician trainees.Methods: In this retrospective analysis of consecutive autopsies performed at the NewYork-Presbyterian Hospital, we included all patients with PErelated death between 01/2010 and 07/2019 and patients who died in 2018 from a cause other than PE.The cause of death upon autopsy was determined by the responsible pathologist.Two physician trainees, blinded to autopsy results, reviewed premortem clinical summaries, and independently adjudicated the cause of death in each patient using the ISTH definition of PE-related death.We calculated the sensitivity and specificity of the ISTH definition for autopsy-confirmed PE-related death, and its interrater agreement using percentage agreement and Cohen's kappa.Results: Overall, 126 death events were adjudicated (median age 68 years; 60 [48%] women), of which 29 (23%) were due to PE, as confirmed by autopsy (Table ).Sensitivity and specificity of the ISTH definition for autopsyconfirmed PE-related death was 48% (95% CI, 29-67) and 100% (95% CI, 96-100), respectively (Figure).Interrater agreement for PE-related death was substantial ( percentage agreement, 93%; 95% CI, 87-96; Cohen's Kappa, 0.67; 95% CI, 44-85).
