Ryohei Ono

Background: Cardiogenic shock secondary to acute myocardial infarction (AMI) is often complicated by acute kidney injury (AKI). Although percutaneous ventricular assist devices (pVADs) are used to treat organ failure in cardiogenic shock, it is difficult to predict whether AKI is reversible or not and how long treatment should be continued to improve renal function. Case summary: A 57-year-old woman with AMI complicated by cardiogenic and anaphylactic shock developed persistent anuria and required dialysis. Despite initial mechanical support, she remained dependent on advanced circulatory assistance. She received prolonged pVADs (Impella CP® and Impella 5.5®) for over 4 months. Remarkably, urine output resumed after 2 months of anuria, allowing discontinuation of dialysis. She underwent successful left ventricular assist device (LVAD) implantation on Day 138 and remained dialysis-free thereafter. Discussion: Cardiogenic shock complicated with AKI limits options for durable mechanical circulatory support. While dialysis-dependent renal dysfunction is considered a contraindication for LVAD implantation in our country, our case illustrates that recovery of renal function may still be achievable even after prolonged anuria. By maintaining renal perfusion with extended pVAD support, dialysis withdrawal was ultimately successful, enabling LVAD implantation. This case highlights that prolonged circulatory support may be a feasible bridge to durable LVAD or heart transplantation.

Background and Aims: It remains unclear what the safe serum potassium range is in heart failure (HF) and whether it is the same in HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF). Methods: A patient-level pooled analysis from 12 randomized controlled trials including 32 346 HFrEF and 13 723 HFpEF patients was performed. Baseline serum potassium level was categorized into six groups (<3.5, ≥3.5–<4.0, ≥4.0–<4.5, ≥4.5–<5.0, ≥5.0–<5.5, and ≥5.5 mmol/L) and serum potassium level at baseline was also analysed as a continuous variable using restricted cubic splines. The primary outcome was all-cause mortality. Secondary outcomes included cardiovascular death, sudden death, pump failure death, first HF hospitalization, and composites of HF hospitalization and cardiovascular or all-cause death. Results: The median follow-up was 24.2 and 36.8 months in HFrEF and HFpEF trials, respectively. In HFrEF, serum potassium levels showed a reverse J-shaped association with outcomes. Compared with ≥4.0–4.5 mmol/L (reference), potassium <3.5 mmol/L was associated with higher risks of all-cause mortality (adjusted hazard ratio 1.49; 95% confidence interval, 1.27–1.76), as well as cardiovascular, sudden, and pump failure death. The lowest risk for all outcomes was observed within the baseline serum potassium range of 4.2–5.0 mmol/L, but even ‘mild hyperkalaemia’ (5.0–5.5 mmol/L) was not associated with worse outcomes in HFrEF. Although the risk curve was U-shaped and flatter in HFpEF, the lowest incidence of all outcomes was observed over the same potassium range as HFrEF. Conclusion: In HFrEF, hypokalaemia is strongly associated with worse outcomes and should be avoided. In terms of safety, the optimal serum potassium concentration in both HFrEF and HFpEF appears to be in the range 4.2–5.0 mmol/L.

Vinyl glove ingestion: Rare cause of gastrointestinal bleeding

Aims: Given the emerging role of transcatheter valve repair in HFrEF patients with moderate/severe secondary mitral regurgitation (MR), we evaluated the prevalence and outcomes related to MR in the GALACTIC-HF trial. Methods: The randomized GALACTIC-HF trial compared the efficacy and safety of omecamtiv mecarbil to placebo in 8232 patients with HFrEF, with a primary composite outcome of a first HF event or cardiovascular death. Results: Of 7998 patients (97.2%) with baseline data on MR, 5782 (72.3%) had no MR, 970 (12.1%) had mild MR, and 1221 (15.3%) had moderate MR (only 25 had severe MR). Patients with moderate MR had a higher risk of the primary outcome than those without MR (adjusted HR 1.11; 95% CI 1.01–1.23); risk was not higher in patients with mild MR. The association between moderate MR and the primary outcome was most prominent in patients with less severe HF (milder NYHA class, higher LVEF, and lower N-terminal pro–B-type natriuretic peptide) compared to more severe HF. In adjusted analyses, MR was not associated with mortality, and the results of all analyses remained consistent after including patients with severe MR. The beneficial treatment effect of omecamtiv mecarbil versus placebo on clinical outcomes was not modified by MR. Over 80% of patients with moderate/severe MR fulfilled the broad inclusion criteria for COAPT and RESHAPE-HF2. Conclusions: In GALACTIC-HF, almost 15% of patients with heart failure and reduced ejection fraction had moderate MR, which was associated with a higher risk of the primary outcome.

Background: Takotsubo syndrome (TTS) is a transient cardiac condition primarily affecting left ventricular function and is often triggered by physical or emotional stress. Biventricular involvement in TTS has been recently reported, and such cases are associated with a more severe clinical presentation. However, biventricular TTS with cardiogenic shock (CS) requiring mechanical circulatory support (MCS) is rare. Furthermore, shark fin sign (SFS) is a distinctive electrocardiographic pattern typically associated with significant myocardial ischemia, but SFS associated with TTS has seldom been reported. Case summary: A 77-year-old woman with sepsis and pyelonephritis presented with fever and chest pain. An initial electrocardiogram showed SFS. Transthoracic echocardiography revealed a severely reduced left ventricular ejection fraction with apical ballooning, akinesis of the apical free-wall segment, and hyperkinesia of the basal segments of the right ventricle. Impella®︎ was inserted for CS, but the shock persisted due to severe right ventricular dysfunction and she required veno-arterial extracorporeal membrane oxygenation. After the treatments, her cardiac functions improved and MCS was weaned off. The follow-up findings of electrocardiographic changes and Thallium-201 and iodine-123-metaiodobenzylguanidine (MIBG) myocardial scintigraphy were consistent with TTS. Discussion: In the case of biventricular TTS with CS, the use of MCS for right ventricular support may be required. SFS may be associated with hemodynamic instability or shock even in TTS. Furthermore, repeated myocardial scintigraphy is useful for diagnosing TTS because the acute phase shows preserved myocardial perfusion with markedly reduced MIBG uptake indicating impaired sympathetic innervation, whereas the chronic phase shows improvement in MIBG uptake.

This case report describes a 47-year-old woman with coronavirus disease 2019 (COVID-19)-related multisystem inflammatory syndrome in adults (MIS-A), who presented with fulminant myocarditis and severe rhabdomyolysis. Despite the absence of severe respiratory symptoms, the patient showed remarkable myocardial and leg edema with significant systemic inflammation and elevated creatine kinase levels after the COVID-19 infection. The patient required venoarterial extracorporeal membrane oxygenation (VA-ECMO) and Impella CP® for hemodynamic stabilization; however, she was successfully treated. We also reviewed reported cases of concurrent myocarditis and muscular involvement in patients with COVID-19, as well as cases of fulminant myocarditis and MIS-A requiring VA-ECMO.

Retained placenta can lead to septic shock; however, sepsis-induced cardiomyopathy (SICM) due to retained placenta has not been reported previously. This report presents a rare case of SICM following septic shock due to retained placenta after miscarriage in a 40-year-old woman, accompanied by the "shark fin sign" on an electrocardiogram, a pattern typically linked to myocardial ischemia. She experienced ventricular tachycardia and required venoarterial extracorporeal membrane oxygenation; however, she was successfully treated. We also reviewed previous cases of shark fin sign in patients without myocardial infarction. A review showed that half of the cases experienced lethal arrhythmias, even without myocardial infarction.

Periorbital purpura, also known as “raccoon eyes,” is the key finding in identifying hematological disorders such as amyloid light chain amyloidosis, multiple myeloma, or monoclonal gammopathy of undetermined significance.