Patients with durable left ventricular assist devices pose special problems for management in the setting of COVID-19 infection. We describe the successful management of a 44-year-old man with severe COVID-19 infection and HeartMate 3 left ventricular assist device. His course was complicated by cytokine storm and COVID-19-associated coagulopathy. We describe our institutional protocol for managing COVID-19 infection in patients on mechanical circulatory support, focusing on the need for a thoughtful, multidisciplinary approach.

A 46-year-old man presented with shortness of breath and recurrent, left-sided pleural effusions. A computed tomography (CT) scan of the chest showed a large, left-sided pleural effusion with a mass in the posterior mediastinum. A pleural tap showed lymphocytic exudate. The biopsy of the mass was inconclusive. A left posterolateral thoracotomy was performed, which showed a large posterior mediastinal mass adherent to the left lung. The mass was completely excised and the histopathology proved it to be giant predominantly cystic schwannoma. The pleural effusion resolved after tumor resection.

Objective:To investigate the relationship of vitamin D deficiency and risk of AMI in a Pakistani population, and to find out any association between vitamin D binding protein (VDBP) genotypes and risk of AMI in this population.Methods:In a comparative cross-sectional study, 246 patients (age: 20-70 years; 171 males and 75 females) with first AMI were enrolled with informed consent. Similarly, 345 healthy adults (230 males and 115 females) were enrolled as controls. Their fasting serum samples were analyzed for 25 (OH) vitamin D, lipids and other biomarkers using kit methods, while DNA was analyzed for VDBP genotypes using PCR-RFLP based methods. Chi-squared test and logistic regression were used for association of vitamin D deficiency and VDBP genotypes with AMI.Results:Mean serum concentration of 25(OH) vitamin D was significantly lower in AMI patients compared to healthy subjects (p=0.015) and percent vitamin D deficiency was higher in AMI patients compared to healthy subjects (p=0.003). VDBP IF-IF genotype was positively associated with the risk of AMI in subject above 45 years after adjusting for potential confounders [OR = 9.86; 95% CI=1.16 to 83.43].Conclusion:Vitamin D deficiency and VDBP IF-IF genotype are associated with AMI in Pakistani adults.

A 35-year-old man presented with a 3-month history of palpitations and shortness of breath. An ECG showed premature atrial contractions and episodes of supraventricular tachycardia. A subsequent echocardiogram showed a retrocardiac cystic mass that was compressing the left atrium. A CT scan confirmed these findings by showing a large left-sided posterior mediastinal cyst compressing the left atrium and pulmonary veins. The cyst was successfully excised from the retrocardiac position via left thoracotomy after which there was complete resolution of the palpitations. Histopathology showed it to be a mediastinal cyst, most likely a foregut duplication of the enterogenic variant. This is an extremely unusual case of foregut duplication cyst presenting with compression of the left atrium and pulmonary veins leading to atrial arrhythmias.

Background Tumor lysis syndrome (TLS) is serious complication of anticancer chemotherapy, leading to substantial morbidity and mortality in adults and pediatric patients. Objective To report the incidence and outcomes of TLS in pediatric patients with hematologic malignancies at a center in Pakistan. Methods Retrospective chart review of 317 pediatric patients with hematologic malignancies during January 2008-December 2013. Demographic features and clinical and laboratory parameters of TLS, with immediate and 6-month outcomes were determined using a semi-structured questionnaire. Results Median age at diagnosis was 9 years, with the 79.2% patients being male. Laboratory TLS was present in 36 patients (11.4%), with 27 (8.5%) developing clinical TLS and 13 (4.1%) requiring intensive care support. Hyperphosphatemia was the most frequent metabolic abnormality (14.2%), followed by hypocalcemia (13.9%), hyperuricemia (12.6%), and hyperkalemia (1.3%). 45 patients (14.2%) developed acute kidney injury (AKI). Patients who developed TLS had a signi cantly higher white blood cell count at initiation of chemotherapy (142.0 x 10 9 /L [SD, 173.1] vs 31.5 x 10 9 /L [SD, 58.0]; P = .01) and a higher incidence of AKI (58.3% vs 8.5% of patients; P < .001). Limitations Retrospective design of study, high rate of loss to follow-up, and unavailability of lactate dehydrogenase levels in a majority of patients. Conclusion The incidence of TLS pediatric hematologic malignancies was 11.4% at our center. The main cause of death was sepsis. Hyperphosphatemia was the common metabolic derangement and hyperkalemia was the least common. TLS warrants intensive supportive care to prevent further morbidity and decrease mortality.