Showing papers in "Texas Heart Institute Journal in 2012"

The prevention of cardiovascular disease in cancer survivors.

Abstract: The number of cancer survivors in the United States has exceeded 12 million and is increasing. After secondary malignancies, cardiovascular disease is the leading cause of late morbidity and death among cancer survivors. The cardiovascular needs of cancer survivors have not been described. We describe the clinical characteristics of 53 patients seen during the first year of our Cardiovascular Prevention in Cancer Survivors clinic. The mean age of the patients was 40.1 ± 13.7 years. The mean survival since cancer diagnosis was 13.9 years. A history of chemotherapy-induced cardiomyopathy was present in 21%, and 5.7% had known atherosclerotic disease. One fourth had hypertension; 32.1%, dyslipidemia; and 13%, diabetes mellitus. Three quarters had received anthracycline chemotherapy, while half had received radiation. Half had an abnormal echocardiogram (55%), and 11 of 18 had an abnormal carotid ultrasonogram. The mean Framingham risk score for patients older than 30 years (n=37) was 8.4, yielding a 10-year risk of cardiovascular disease of 7.6%. The mean vascular age was 54.3 years, and the mean chronological age was 46.3 years. The mean follow-up duration was 566 ± 213 days. There were significant improvements in serum triglycerides and high-density lipoprotein levels, as well as trends toward improved blood pressure control. Cardiovascular risk factors are prevalent in cancer survivors. There is an immediate need for the widespread availability of cardiovascular preventive services to reduce the late adverse effects of chemotherapy and radiation. Early intervention might help to improve the cardiovascular risk profile.

Peripartum Cardiomyopathy: A Review

Abstract: Peripartum cardiomyopathy is idiopathic heart failure occurring in the absence of any determinable heart disease during the last month of pregnancy or the first 5 months postpartum. The incidence varies worldwide but is high in developing nations; the cause of the disease might be a combination of environmental and genetic factors. Diagnostic echocardiographic criteria include left ventricular ejection fraction 2.7 cm/m2. Electrocardiography, magnetic resonance imaging, endomyocardial biopsy, and cardiac catheterization aid in the diagnosis and management of peripartum cardiomyopathy. Cardiac protein assays can also be useful, as suggested by reports of high levels of NT-proBNP, cardiac troponin, tumor necrosis factor-α, interleukin-6, interferon-γ, and C-reactive protein in peripartum cardiomyopathy. The prevalence of mutations associated with familial dilated-cardiomyopathy genes in patients with peripartum cardiomyopathy suggests an overlap in the clinical spectrum of these 2 diseases. Treatment for peripartum cardiomyopathy includes conventional pharmacologic heart-failure therapies—principally diuretics, angiotensin-converting enzyme inhibitors, vasodilators, digoxin, β-blockers, anticoagulants, and peripartum cardiomyopathy-targeted therapies. Therapeutic decisions are influenced by drug-safety profiles during pregnancy and lactation. Mechanical support and transplantation might be necessary in severe cases. Targeted therapies (such as intravenous immunoglobulin, pentoxifylline, and bromocriptine) have shown promise in small trials but require further evaluation. Fortunately, despite a mortality rate of up to 10% and a high risk of relapse in subsequent pregnancies, many patients with peripartum cardiomyopathy recover within 3 to 6 months of disease onset.

Doxorubicin-induced cardiomyopathy 17 years after chemotherapy.

Abstract: Doxorubicin, an anthracycline antibiotic commonly used as a chemotherapeutic agent for breast cancer, is well known to cause cardiotoxicity. We report the case of an active, otherwise healthy 57-year-old breast cancer survivor who, 17 years after chemotherapy, presented with symptoms of overt heart failure. She had no cardiac risk factors, and neither laboratory nor imaging findings suggested myocarditis or dilated cardiomyopathy. Echocardiographic findings and differential diagnosis led us to attribute her condition to late doxorubicin-induced cardiomyopathy. By virtue of tapered medical therapy, her left ventricular ejection fraction improved from 0.20 to 0.55 in 8 months, and she was asymptomatic after 1 year. The reversibility of left ventricular dysfunction in our patient and the very late appearance of cardiotoxicity secondary to doxorubicin therapy raise questions about the pathogenesis and prevalence of late doxorubicin-induced cardiomyopathy and how to improve outcomes in patients who present with related symptoms of heart failure.

Obesity and sedentary lifestyles: risk for cardiovascular disease in women.

Abstract: It is well known that obesity and sedentary behavior coexist and that both are associated with cardiovascular disease (CVD) in women. Data from the Centers for Disease Control (CDC) show that in areas of the United States where rates of obesity are higher than 30% (Fig. 1), the prevalence of adults who report no leisure-time physical activity is also higher than 30% (Fig. 2). Likewise, the prevalence of obesity and physical inactivity predicts the presence of CVD death (Fig. 3). To highlight the association between the 3 conditions, one can nearly superimpose these 3 maps from the CDC. Fig. 1 Obesity trends* among U.S. adults. Behavioral Risk Factor Surveillance System, 2010. Fig. 2 County-level estimates of leisure-time physical inactivity among adults aged ≥20 years: United States, 2008. Available from: http://www.cdc.gov/obesity/data Fig. 3 United States: heart disease death rates. Women, aged 35+, 2000–2006. Available from: http://www.cdc.gov/dhdsp/maps/national_maps/hd_women.htm More recently, however, questions have been raised about whether obesity and physical activity are independently associated with CVD risk or if they simply are associated with risk through known risk factors: diabetes mellitus, hypertension, and hypercholesterolemia. If the latter is true, risk reduction with pharmaceutical interventions—in spite of cost, side effects, and incomplete efficacy—might spare providers the difficult task of encouraging weight loss and promoting increases in physical activity. If the former is true, however, weight loss and physical activity are crucial therapies for the prevention of CVD in women.

Coronary stent infections: a case report and literature review.

Abstract: Although rare, coronary artery stent infections are associated with a high mortality rate. Since the introduction of coronary stents in 1987, only 16 cases of infection have been reported. We report a new case in a 66-year-old woman who had undergone a difficult percutaneous coronary intervention procedure, during which 3 overlapping stents were implanted in the mid portion of the right coronary artery. Twenty-two days after the procedure, the patient died. Autopsy revealed the cause of death to be pericardial tamponade due to rupture of the right ventricular myocardium. The stented portion of the right coronary artery was enveloped by an abscess, and purulent material completely occluded the stents. Cultures of the myocardium were positive for methicillin-resistant Staphylococcus aureus. We conducted a review of the literature on coronary artery stent infections. Data suggest that early-onset infections (<10 days after stent implantation) are potentially amenable to medical therapy alone, but late-onset infections (≥10 days after implantation) or major complications necessitate combined surgical and medical therapy. Medical therapy consists of broad-spectrum antibiotics. Surgical intervention includes stent removal if possible, and abscess drainage or perforation repair when indicated.

Continuous-flow total heart replacement device implanted in a 55-year-old man with end-stage heart failure and severe amyloidosis.

Abstract: We implanted a continuous-flow total heart replacement device in a 55-year-old man who had severe end-stage heart failure due to amyloidosis and no other options for treatment. The device was composed of 2 modified HeartMate II ventricular assist pumps. After the implantation, our patient recovered normal neurologic function and was able to converse with his family and work on his computer. He died of multisystem organ failure caused by severe amyloidosis 5 weeks after the implantation. During the past 6 years, we have been developing and testing various technological iterations for total heart replacement in our animal laboratory and have achieved survival periods as long as 90 days in calves. We describe the development, preclinical trials, and adaptation for human use of the modified HeartMate II apparatus, as well as its role in our patient's survival.

Constrictive pericarditis treated by surgery.

Abstract: We reviewed the records of 45 patients (mean age, 46.6 ± 14.9 yr; range, 21–84 yr) with a diagnosis of constrictive pericarditis who had undergone pericardiectomy from 1994 through 2006. Preoperatively, 2 of the patients (4.4%) were in New York Heart Association (NYHA) functional class I, 20 (44.4%) in class II, 22 (48.9%) in class III, and 1 (2.2%) in class IV. Pericardial calcification was detected in 20% of plain chest radiographs. Constrictive pericarditis was caused by tuberculosis in 22.2%, chronic renal failure in 8.9%, a history of sternotomy in 4.4%, and malignancy in 4.4%. The cause was idiopathic in 60% of the patients. Low-output state was the most common postoperative problem (22.2%). The mean follow-up period was 40 ± 18 months (range, 3–144 mo). Three months postoperatively, only 1 of 43 available patients (2.3%) was in NYHA class III, while the rest were in class I (36 patients; 83.7%) or II (6 patients; 14%). The overall mortality rate was 4.4%: 1 patient with tuberculosis died of respiratory insufficiency while hospitalized, and 1 died of metastatic adenocarcinoma during follow-up. Our results show that pericardiectomy remains an effective procedure in the treatment of constrictive pericarditis. Tuberculosis is still an important cause of constrictive pericarditis in Iran, despite intensive vaccination and use of antitubercular drugs.

Carotid artery stenting versus endarterectomy: a systematic review.

Abstract: For about 2 decades, investigators have been comparing carotid endarterectomy with carotid artery stenting in regard to their effectiveness and safety in treating carotid artery stenosis. We conducted a systematic review to summarize and appraise the available evidence provided by randomized trials, meta-analyses, and registries comparing the clinical outcomes of the 2 procedures. We searched the MEDLINE, SciVerse Scopus, and Cochrane databases and the bibliographies of pertinent textbooks and articles to identify these studies. The results of clinical trials and, consequently, the meta-analyses of those trials produced conflicting results regarding the comparative effectiveness and safety of carotid endarterectomy and carotid stenting. These conflicting results arose because of differences in patient population, trial design, outcome measures, and variability among centers in the endovascular devices used and in operator skills. Careful appraisal of the trials and meta-analyses, particularly the most recent and largest National Institutes of Healthsponsored trial (the Carotid Revascularization Endarterectomy vs Stenting Trial [CREST]), showed that carotid stenting and endarterectomy were associated with similar rates of death and disabling stroke. Within the 30-day periprocedural period, carotid stenting was associated with higher risks of stroke, especially for patients aged >70 years, whereas carotid endarterectomy was associated with a higher risk of myocardial infarction. The slightly higher cost of stenting compared with endarterectomy was within an acceptable range by cost-effectiveness standards. We conclude that carotid artery stenting is an equivalent alternative to carotid endarterectomy when patient age and anatomy, surgical risk, and operator experience are considered in the choice of treatment approach.

Potential role of plasma myeloperoxidase level in predicting long-term outcome of acute myocardial infarction.

Abstract: We investigated the prognostic importance of plasma myeloperoxidase levels in patients with ST-elevation myocardial infarction (STEMI) at long-term follow-up, and we analyzed the correlations between plasma myeloperoxidase levels and other biochemical values. We evaluated 73 consecutive patients (56 men; mean age, 56 ±11 yr) diagnosed with acute STEMI and 46 age- and sex-matched healthy control participants. Patients were divided into 2 groups according to the median myeloperoxidase level (Group 1: plasma myeloperoxidase ≤68 ng/mL; and Group 2: plasma myeloperoxidase >68 ng/mL). Patients were monitored for the occurrence of major adverse cardiovascular events (MACE), which were defined as cardiac death; reinfarction; new hospital admission for angina; heart failure; and revascularization procedures. The mean follow-up period was 25 ± 16 months. Plasma myeloperoxidase levels were higher in STEMI patients than in control participants (82 ± 34 vs 20 ±12 ng/mL; P=0.001). Composite MACE occurred in 12 patients with high myeloperoxidase levels (33%) and in 4 patients with low myeloperoxidase levels (11%) (P=0.02). The incidences of nonfatal recurrent myocardial infarction and verified cardiac death were higher in the high-mye-loperoxidase group. In multivariate analysis, high plasma myeloperoxidase levels were independent predictors of MACE (odds ratio = 3.843; <95% confidence interval, 1.625–6.563; P=0.003). High plasma myeloperoxidase levels identify patients with a worse prognosis after acute STEMI at 2-year follow-up. Evaluation of plasma myeloperoxidase levels might be useful in determining patients at high risk of death and MACE who can benefit from further aggressive treatment and closer follow-up.

Prolonged QTc interval and torsades de pointes induced by citalopram.

Abstract: Citalopram is a selective serotonin reuptake inhibitor with a favorable cardiac-safety profile. Corrected QT interval (QTc) prolongation and cardiac arrhythmias have not been previously reported in association with citalopram use except in the presence of overdose, abnormal electrolyte values, or renal or liver failure. Herein, we report the case of a 40-year-old woman with mental depression who presented with a prolonged QTc interval and torsades de pointes after the initiation of citalopram at therapeutic doses. The QTc interval improved when citalopram therapy was discontinued. We recommend that clinicians investigate the family history for sudden deaths and perform baseline electrocardiography before prescribing citalopram. We also recommend routine electrocardiographic testing during citalopram therapy, and that patients with long QT syndrome avoid taking citalopram.

Spontaneous celiac artery dissection case report and literature review.

Abstract: Symptomatic spontaneous celiac artery dissection is a rare condition that is being detected more often with the use of advanced imaging techniques. There is no consensus as to whether surgical or endovascular treatment is more appropriate. We describe the case of a 41-year-old hypertensive woman who presented with the sudden onset of sharp, persistent, right-upper-quadrant abdominal and epigastric pain. Magnetic resonance angiography of the abdomen revealed celiac artery dissection, with a flap compressing the lumen approximately 17 mm from the artery's origin at the aorta. Because of the patient's persistent epigastric pain, endovascular celiac artery stent implantation was performed with the use of 2 overlapping balloon-expandable stents. Twelve months after the procedure, the patient remained asymptomatic, and the stents were patent. This case and others in the medical literature suggest that endovascular treatment can be feasible in symptomatic patients with isolated spontaneous celiac artery dissection.

The successful use of octreotide in the treatment of traumatic chylothorax.

Abstract: Chylothorax is a well-documented complication of thoracic trauma and is associated with mortality rates of up to 75%. The conservative treatment of chylothorax includes pleural drainage and a low-fat diet rich in medium-chain fatty acids, followed by total parenteral nutrition and nothing by mouth. If these measures fail and drainage continues to exceed 1 L/d, surgical thoracic duct ligation is usually recommended. However, many patients are unable to undergo this surgical procedure and require an alternative treatment. We present the cases of 2 adult patients, one of whom developed chylothorax after an elective surgical procedure, and the other after a traffic accident that caused multiple injuries. In both patients, conservative management with the addition of octreotide was successful and negated the need for surgical intervention.

Self-experimentation and its role in medical research.

Abstract: Although experimentation involving human volunteers has attracted intense study, the matter of self-experimentation among medical researchers has received much less attention. Many questions have been answered only in part, or have been left unanswered. How common is this practice? Is it more common among certain nationalities? What have been the predominant medical fields in which self-experimentation has occurred? How dangerous an act has this proved to be? What have been the trends over time? What is the future likely to bring?From the available literature, I identified and analyzed 465 documented instances of this practice, performed over the course of the past 2 centuries. Most instances occurred in the United States. The peak of self-experimentation occurred in the first half of the 20th century. Eight deaths were recorded. A number of the investigators enjoyed successful careers, including the receipt of Nobel Prizes. Although self-experimentation by physicians and other biological scientists appears to be in decline, the courage of those involved and the benefits to society cannot be denied.

Aortic valve noncoronary cusp thrombosis after implantation of a nonpulsatile, continuous-flow pump.

Abstract: Different institutions have different strategies for managing both native and prosthetic aortic valves in recipients of left ventricular assist devices (LVADs). Anticoagulation protocols and pump-flow algorithms remain nonstandardized. We describe our institutional experience with thrombotic complications and our evolving approach to this important clinical problem. We report the cases of 4 HeartMate II LVAD recipients in whom, despite an anticoagulative regimen, thrombus formed on the noncoronary cusp of the aortic valve. The management of the closed aortic valve in LVAD-supported patients remains problematic.

Primary Pericardial Mesothelioma Unique Case and Literature Review

Abstract: A 72-year-old woman, on warfarin therapy and with a remote history of breast cancer and radiation treatment, presented with a 10-day history of nausea, dyspnea, dry cough, and dizziness. An electrocardiogram showed new-onset atrial fibrillation. Computed tomography of the chest revealed multiple pulmonary emboli and a pericardial effusion. Echocardiography showed a pericardial effusion with tamponade characteristics. The patient's condition deteriorated, and a pericardiectomy was performed. Histologic evaluation confirmed primary pericardial mesothelioma. She underwent palliative treatment and died 3 months after discharge from the hospital. We discuss the patient's case and the nature of primary pericardial mesothelioma, a rare oncologic entity.

Congenital coronary artery ostial disease: a spectrum of anatomic variants with different pathophysiologies and prognoses.

Abstract: Coronary ostial stenosis or atresia (COSA, a new acronym) is a spectrum of rare developmental conditions with different pathophysiologic mechanisms and clinical implications. Together, the various forms of COSA should be considered a subclass of congenital coronary artery anomalies (CAAs). Although COSA includes various entities, these entities have two features in common. First, the defect is congenital, although it may progress during pre-natal and postnatal life. Second, the developmental defect causes ostial or proximal coronary obstruction (that is, stenosis or atresia). A fundamental distinction must be made between COSA and a related condition that involves the ectopic origin of a coronary artery from the opposite coronary artery (which is frequently, although erroneously, called “single coronary artery”). Here, I present an in-depth discussion of COSA (Table I) to aid the clinical understanding and management of individual cases. TABLE I. Defining Features of COSA By definition, COSA is congenital1–6; however, in some clinical adult cases, it can be difficult to determine whether a given defect has been present since birth.7–9 Also, total or partial-obstruction COSA might not be recognized until late after birth, by which time mild or nonexistent functional stenosis at birth might have become severe or totally occlusive (atretic). In adult patients with coronary ostial or proximal coronary stenosis, it can be difficult to rule out acquired causes, such as arteritis, which can produce conditions morphologically similar to COSA; for example, atherosclerotic, syphilitic, Kawasaki, and Takayasu aortitis have all been cited as causes of acquired ostial stenosis or occlusion.7–9 The absence of significant risk factors for atherosclerosis is relevant to the diagnosis of COSA but, by itself, is inconclusive. Coronary ostial stenosis or atresia affects the left coronary artery (L-COSA) more frequently than it does the right coronary artery (R-COSA). The aortic ostium in a case of COSA can be in the normal location or at an ectopic site. When the left ostium is located at a sinus of Valsalva that is abnormal for the distal coronary distribution, the case is one of anomalous coronary artery origin from the opposite sinus with intramural course (ACAOS),10 in which the proximal “crossing” trunk is stenotic because it is located intramurally (passing to the correct side of the heart, taking a tangential direction off the ostium, and lying within the aortic wall). Other features present in some cases of COSA include an ostial dimple (a rudiment of the coronary ostium that is usually followed more distally by proximal coronary stem atresia11) and a blind distal left main trunk, which is best appreciated upon computed tomographic angiography. In COSA, the presence of only 1 or 2 full-diameter connecting collateral vessels (without narrowing at the transition between the providing and the receiving vessel, as shown in Fig. 1) is suggestive of congenital origin in any given case of ostial stenosis or atresia. In contrast, in cases of postnatally acquired collateral vessels, one should expect a rich network of channels that typically involves all of the septal, infundibular, and atrial branches. In addition, such acquired collateral vessels enlarge progressively after birth, and they are typically smaller than the distal recipient vessels; this “step-up phenomenon” is typically observed only in postnatally acquired collateral vessels. Collateral vessels with similar features occur in atherosclerotic occlusion of coronary vessels, as well as in anomalous origin of the left or the right coronary artery from the pulmonary artery.12 Fig. 1 Four selective coronary angiographic still images of the right coronary artery, obtained in a 52-year-old patient with chronic, atypical chest pain. The images were obtained in left anterior oblique (caudal and cranial: A and B) views, and 30- ... The absence of clinical angina (or ischemia at stress testing) tends to confirm the diagnosis of COSA, rather than acquired ostial stenosis or atresia. Similarly, myocardial scarring, which implies an event of acute ischemic myocardial damage, is rare in patients with COSA. As a corollary, only rarely is a surgical bypass intervention required to treat congenital coronary ostial atresia: the collateral vasculature is usually adequate. Single Coronary Artery “Single coronary artery” is a misnomer: because all of the normal coronary arteries are present (that is, right, left anterior descending, and circumflex), this entity is not defined by the presence of a single coronary “artery” but by the fact that all these arteries originate from a single ostium.12 This term is clinical jargon (convenient but incorrect) used in some of the literature to refer to cases of CAA that feature a single coronary ostium, which provides flow to the whole coronary tree without interruption of continuity and without evidence of collateral vessels. Table II lists subtypes of this condition.12 In essence, these anomalies consist of the ectopic origin of the right or left coronary artery from the opposite sinus, which artery shares a proximal common trunk with the normally originating coronary artery. Less frequently, the ectopic artery originates from a distal segment of the contralateral artery, such as when the left coronary artery originates from the right coronary artery at the crux and takes a posterior course at the atrioventricular groove. The proximal trunk is a common, mixed-nature trunk that generally provides normal blood flow to both coronary arteries. Coronary stenosis or atresia is missing in this condition (hence it is not a type of COSA) unless the ectopic vessel has the above-mentioned proximal stenosis, caused by an intramural pre-aortic course. This latter course is also called “between aorta and pulmonary artery”10,12 (and it results in a form of COSA, when significant stenosis occurs), but this label is inaccurate, because the artery's proximal, ectopic coronary segment lies inside the aortic wall, and not in the space between the 2 great arteries. TABLE II. The Most Common Courses of Ectopic Coronary Arteries that Originate from the Opposite Sinus of Valsalva It has become clear, mainly from recent experience with intravascular ultrasonographic imaging,10 that the pre-aortic course always features intramural location of the proximal coronary trunk inside the wall of the aorta. The name recently proposed for such anomalies is ACAOS,10 and this condition is indeed the most common form of COSA. The severity of the resulting intramural stenosis in cases of ACAOS is variable, ranging from minimal stenosis to atresia, and it depends both on the degree of hypoplasia of the intramural segment and on the amount of lateral compression. The possibility that the extreme degrees of stenosis associated with ACAOS could lead to total or functional atresia, preventing all prograde flow from the ectopic ostium, must be considered in any given case of coronary ostial atresia (whether anatomic or functional). An exceptional example of ACAOS with COSA is shown in Figures 1 and ​and22. Fig. 2 Computed tomographic angiogram of the same patient shows a proximal left main trunk, the presence of which was not suggested by the selective coronary angiograms (Fig. 1). Indeed, the proximal left main trunk must be severely stenotic as a consequence ...

Transcatheter retrieval of embolized AMPLATZER Septal Occluder.

Abstract: In selected patients, transcatheter closure of atrial septal defects with the AMPLATZER Septal Occluder has yielded excellent results. However, there is a slight risk of device embolization after deployment. We report the case of a 26-year-old woman in whom an embolized AMPLATZER device was retrieved percutaneously from the right pulmonary artery. We also discuss important technical principles for managing this uncommon but potentially severe complication.

Extremely high-pressure dilation with a new noncompliant balloon.

Abstract: Calcified nondilatable lesions remain a challenge for the interventional cardiologist, and they are becoming more frequent in the catheterization laboratory as the overall complexity of interventions increases. Stent underexpansion is the main risk factor for restenosis and thrombosis, which is the most feared complication for the interventionalist.In this report, we present our initial experience (8 patients) with a new noncompliant high-pressure balloon, the OPN NC balloon, a double-layered device. When we used this device at 40 atm, our rate of success was reasonable (75%) and our patients experienced no adverse sequelae. The OPN NC balloon appears to offer a new means of dilating lesions or underexpanded stents when other noncompliant balloons have failed. Safety seems reasonable, even at pressures as high as 40 atm.

Metastatic Colon Cancer Involving the Right Atrium

Abstract: Colorectal cancer rarely metastasizes to the heart. In the world medical literature, we identified only 7 cases of well-documented colorectal cancer metastasis to the right atrium. Herein, we describe the case of a 72-year-old man in whom metastatic mucinous adenocarcinoma of the colon involved the right atrium and caused superior vena cava syndrome. To our knowledge, this is the first case report of sudden cardiac death due to embolization of metastatic colon cancer from the right atrium. We also present the first comprehensive case series review of this rare entity. Given improvements in diagnostic and therapeutic methods that have increased the longevity of many cancer patients, the detection of cardiac metastases is likely to increase in frequency. Accordingly, we recommend that previously asymptomatic cancer patients with a history of colorectal cancer who develop cardiac symptoms undergo prompt investigation for possible cardiac metastasis.

Painless aortic dissection presenting as paraplegia.

Abstract: Acute dissection of the aorta can be life-threatening. As a presenting manifestation of aortic dissection, neurologic complications such as paraplegia are rare. Herein, we report the case of a 51-year-old man who presented with sudden-onset paraplegia and ischemia of the legs, with no chest or back pain. His medical history included coronary artery bypass grafting. Physical examination revealed pulseless lower extremities, and computed tomography showed aortic dissection from the ascending aorta to the common iliac arteries bilaterally. A lumbar catheter was inserted for cerebrospinal fluid drainage, and axillary arterial cannulation was established. With the use of cardiopulmonary bypass, the aortic dissection was corrected, and the previous coronary artery grafts were reattached. The surgery restored spinal and lower-extremity perfusion, and the patient walked unaided from the hospital upon his discharge 5 days later. Although acute aortic dissection presenting as paraplegia is rare, it should be considered in patients who have pulseless femoral arteries bilaterally and sudden-onset paraplegia, despite no pain in the chest or back. Prompt diagnosis and intervention can prevent morbidity and death.

Carbohydrate antigen-125 and N-terminal pro-brain natriuretic peptide levels: compared in heart-failure prognostication

Abstract: Carbohydrate antigen-125 (CA-125) is emerging as a prognostic biomarker of risk in heart failure. In a prospective study, we compared the prognostic values of CA-125 and amino-terminal pro-brain natriuretic peptide (NT-proBNP) in patients with stable heart failure.We enrolled 102 consecutive chronic, stable, systolic-heart-failure patients (68 men and 34 women; median age, 71 yr) from November 2008 through February 2010. We measured baseline NT-proBNP and CA-125 levels and compared their prognostic values. The primary endpoint was all-cause death and other major adverse events, defined as hospitalization for decompensated heart failure or acute coronary syndrome.During a mean follow-up period of 14 ± 2 months, 12 patients died and 35 others sustained major adverse events. We found that CA-125 level significantly correlated with New York Heart Association functional class, pulmonary artery pressure, microalbuminuria, creatine kinase-MB fraction, and hemoglobin, albumin, and NT-proBNP levels. Upon receiver operating characteristic curve analysis, CA-125 and NT-proBNP had similar accuracy in predicting major adverse events and death: for major adverse events, area under the curve (AUC) was 0.699 for CA-125 (P=0.002) and 0.696 for NT-proBNP (P=0.002); for death, AUC was 0.784 for CA-125 (P=0.003) and 0.824 for NT-proBNP (P=0.001). Multivariate Cox regression analysis showed that CA-125 levels greater than 32 U/mL and NT-proBNP levels greater than 5,300 pg/mL had independent prognostic value for major adverse events and death.We conclude that baseline CA-125 and NT-proBNP levels are comparably reliable as heart-failure markers, and that CA-125 can be used for prognosis prediction in heart failure.

The future of liver transplantation.

Abstract: Improvements in surgical techniques, postoperative care, and donor and recipient selection have all contributed to the increased success of OLT and to higher survival rates in patients with advanced liver disease This progress in liver transplantation has occurred in only 45 years, since the preliminary work of Dr Starzl, and provides a basis for future advances

Negative-pressure wound therapy and laparoscopic omentoplasty for deep sternal wound infections after median sternotomy.

Abstract: Deep sternal wound infection remains one of the most serious complications in patients who undergo median sternotomy for coronary artery bypass surgery. We describe our experience in treating 6 consecutive patients with our treatment protocol that combines aggressive debridement, broad-spectrum antibiotics, negative-pressure wound therapy, omentoplasty with laparoscopically harvested omentum, and the use of bilateral pectoral muscle advancement flaps. The number of debridements needed in order to attain clinically clean wounds and negative cultures varied between 1 and 10, with a median of 5. The length of stay after omentoplasty and bilateral pectoral muscle advancement flap placement varied between 11 and 22 days. One of the 6 patients developed a small wound dehiscence that was treated conservatively. No bleeding related to vacuum-assisted closure therapy was identified. Three patients had pneumonia. Two of the 3 patients had an episode of acute renal failure. The 30-day mortality rate was zero, although 1 patient died in the hospital 43 days after the reconstructive surgery, of multiple-organ failure due to pneumonia that was induced by end-stage pulmonary fibrosis. No patient died between hospital discharge and the most recent follow-up date (4–12 mo). Late local follow-up results, both functional and aesthetic, were good. We conclude that negative-pressure wound therapy—in combination with omentoplasty using laparoscopically harvested omentum and with the use of bilateral pectoral advancement flaps—is a valuable technique in the treatment of deep sternal wound infection because it produces good functional and aesthetic results.

Outflow Tract Ventricular Tachycardia

Abstract: Ventricular tachycardia (VT) can occur in hearts that appear upon conventional imaging to be structurally normal. In structurally normal hearts, VT commonly arises from the outflow tracts. Outflow tract ectopy can manifest itself as frequent premature ventricular complexes (PVCs), salvos of VT, and sustained VT. Exercise or emotional stress can trigger outflow tract VT. The prognosis for outflow tract VT is generally favorable, but there is potential for developing PVC-related cardiomyopathy and, rarely, for sudden cardiac death. Therapy is directed by the calcium-dependent delayed after-depolarizations that can lead to an underlying automatic focus. Calcium channel blockade by means of verapamil can be an effective therapy. The automatic focus can also be targeted for ablation by identifying the site of ventricular tissue that is activated earliest by a PVC. Catheter ablation of the automatic focus is an effective therapeutic option.1 A detailed understanding of the anatomy of the outflow tracts and their relation to the surface electrocardiographic (ECG) leads and neighboring cardiac structures is crucial to the understanding of outflow-tract VT electrocardiographic nuances and to the safe performance of catheter ablation. Despite their names, the right ventricular outflow tract (RVOT) is farther left in the body than is the left ventricular outflow tract (LVOT) (Fig. 1 2), and the RVOT is anterior to the LVOT (Fig. 2). Fig. 1 Normal heart, direction of blood flow through the great arteries. The right ventricular outflow tract is leftward in the body, in comparison with the ieft ventricular outflow tract. Reprinted from Sehar N, et al.,2 which contained this figure courtesy ... Fig. 2 Normal heart, ventricles. The right ventricular outflow tract lies anterior to the left ventricular outflow tract. This anatomic framework aids in understanding the electrocardiographic manifestation of outflow tract VT. First, the outflow tracts are superior structures, and activation originating from these sites is directed inferiorly, thereby producing a QRS appearance that is strongly positive in the inferior leads (II, III, and aVF) and negative in aVL and aVR. Additional leads (particularly leads V1 and I) can further refine the ECG localization within the outflow tracts.3 Lead V1 is both a right-sided and anterior lead. Since the RVOT is anterior and leftward within the body, when the impulse begins in the RVOT and spreads away posteriorly and leftward, V1 should manifest a predominately negative complex. In the evaluation of outflow tract ectopy, the presence of an R wave in V1 should trigger consideration of a more posterior origin, which could create an anteriorly directed vector (toward VJ. The more posterior structures to consider include the posterior RVOT, the anterior LVOT, and the posterior LVOT. A point of origin from the posterior RVOT might have a small amount of anterior myocardial tissue to activate, leading to a tiny R wave in V however, most myocardial activation is still at a distance from lead Vr Since the posterior RVOT is adjacent to the anterior LVOT, consideration should be given to mapping the neighboring LVOT to an earlier site of activation, should the automatic focus be mapped to the posterior RVOT. The aorta is a central structure within the heart, and the LVOT lies posterior to the RVOT. Consequently, the LVOT is farther from lead V1, and an LVOT origin can propagate toward V1, thereby producing an R wave.3 Lead I is a left-sided lead, and an RVOT origin near the pulmonary valve would manifest itself with a negative complex, as the impulse spreads from the left side of the body to the right. An RVOT origin can have a biphasic appearance if the origin is on the anterior or posterior aspect of the RVOT. Lead I can also be positive when activation originates from the right margin of the RVOT. Accordingly, the activation patterns of leads I and V1 can conceptually be synthesized to anticipate the site of outflow tract origin. Figure 3 shows an example of an RVOT VT. Fig. 3 Electrocardiogram shows ventricular tachycardia originating from the right ventricular outflow tract. The ventricular tachycardia is directed inferiorly, as is apparent by the positive complexes in leads II, III, and aVF and by the negative complexes ... A thorough understanding of the anatomy of the outflow tracts is crucial not only to mapping outflow tract ectopy but to anticipating and avoiding potential ablation complications, such as damage to the conduction system or the coronary arterial system. One can easily be misled by mapping to ablate at a distance from the true automatic focus. The bundle of His is located in the membranous septum, which is at risk of collateral damage due to its location relative to the outflow tracts.2 The bundle of His lies between the juncture of the right and noncoronary cusps and the juncture of the tricuspid valve's anterior and septal leaflets. Outflow tract morphologic ectopy can have supra-valvular automatic foci as a consequence of muscular sleeves that cross the pulmonary valve and the right and left coronary cusps of the aortic valve.4,5 The left main coronary artery is directly posterior to the distal RVOT and is at risk of injury due to ablation in the distal posterior RVOT. Another important consideration in ablation is correct identification of the source of the RVOT ectopy. Outflow tract ectopy is most commonly due to an automatic focus, so mapping and then ablating the earliest site of activation is vital.3 Remnants of the conduction system near the right ventricle can present a mapping challenge. In summary, the outflow tracts have a complex anatomy that is important to consider in the evaluation and treatment of outflow tract ectopy. The electrocardio-graphic patterns that the various outflow tract activations exhibit are better understood within the anatomic framework. An understanding of the anatomic relationships between the targets and the potential sites of complications improves the safety of ablation of outflow tract ectopy.

Percutaneous closure of a left ventricular pseudoaneurysm in a high-risk surgical candidate.

Abstract: Few cases of percutaneous device closure of a left ventricular pseudoaneurysm have been reported. We describe the case of a 67-year-old man with a history of coronary artery disease who presented with shortness of breath and chest pain. Computed tomographic angiography showed a left ventricular pseudoaneurysm that was filling from a small leak in the anterolateral aspect of the ventricle. The patient had undergone 3 previous sternotomies and was a high-risk candidate for surgical treatment of the pseudoaneurysm. Despite technical challenges, we closed the pseudoaneurysm percutaneously with use of a 6-mm AMPLATZER muscular ventricular septal defect occluder. The patient was released from the hospital the next day and was asymptomatic a year later. To our knowledge, this is the first report of the percutaneous closure of a left ventricular pseudoaneurysm via the femoral vein. We show that this manner of closure can be feasible in patients who have undergone multiple sternotomies and who are at high surgical risk.

Early cardiac metastasis from squamous cell carcinoma of the tongue: In 2 patients

Abstract: Cardiac metastasis from primary tumors is rare. Cardiac metastasis from squamous cell carcinoma of the tongue is rare; in the English-language medical literature, we read of only 4 patients with this condition. Here, we discuss the cases of 2 such patients who presented at our institution only a few months apart. In both, with the use of 2-dimensional echocardiography, we incidentally found cardiac metastasis from squamous cell carcinoma of the tongue. Resection of the cardiac masses was precluded. These cases illustrate the usefulness of early cardiac evaluation with 2-dimensional echocardiography in patients with head and neck cancer and known metastatic disease.

Left Circumflex Coronary Artery Occlusion after Mitral Valve Annuloplasty: “A Stitch in Time”

Abstract: The left circumflex coronary artery is susceptible to injury during mitral valve surgery because of its proximity to the mitral valve annulus. We report the case of a 73-year-old woman who had undergone mitral valve repair and experienced a perioperative myocardial infarction due to occlusion of the left circumflex coronary artery. After percutaneous coronary intervention, a fistulous communication had developed between the stented portion of the left circumflex coronary artery and the left atrium, which, to our knowledge, is the first report of such a complication. The patient underwent successful mitral valve replacement. Although injuries to the left circumflex coronary artery are rare during mitral valve surgery, we believe that increasing awareness of the risk will help to prevent potentially fatal complications. We also recommend that surgeons gather as much detail as possible about the patient's anatomy before operation, use careful and meticulous surgical techniques, and use transesophageal echocardiography to look for wall-motion abnormalities before closing the incision.

Eptifibatide-induced thrombocytopenia: with thrombosis and disseminated intravascular coagulation immediately after left main coronary artery percutaneous coronary angioplasty.

Abstract: Early clinical trials of eptifibatide did not show a significant association between eptifibatide and the development of thrombocytopenia, thrombosis, or disseminated intravascular coagulation. However, more recent literature has suggested a significant association between eptifibatide and the development of thrombocytopenia and thrombosis. Although the true incidence and the pathophysiology of these associations are unknown, the development of these events can be life-threatening. Herein, we describe the case of a patient who experienced acute onset of profound thrombocytopenia, developing thrombosis, pulmonary emboli, and disseminated intravascular coagulation. This paper adds to the few previous reports of cases that suggested an association between thrombocytopenia, thrombosis, and the administration of eptifibatide. To the best of our knowledge, this is the first case report in the medical literature that associates the new onset of thrombocytopenia, thrombosis, and disseminated intravascular coagulation with the administration of eptifibatide. We also provide a subject review.

Transjugular Approach to Device Closure of Atrial Septal Defect in a Child with Heterotaxia and Interrupted Inferior Vena Cava

Abstract: In heterotaxia syndrome with left atrial isomerism, the distinguishing feature is interrupted inferior vena cava with azygos continuation We report using a transjugular approach to device closure of an atrial septal defect in an 8-year-old boy with heterotaxia syndrome We found that device closure of the child's atrial septal defect through a jugular venous approach was safe when an inferior vena cava approach was not possible To our knowledge, ours is the first report of the use of internal jugular vein access to close an atrial septal defect in a child

Pediatric trauma centers: coming of age.

Abstract: Why is the topic of pediatric trauma centers (PTCs) important? The simple answer is that injuries are still the leading cause of death in children in the United States. Unintentional injuries kill more than 12,000 children and young adults between the ages of 1 and 19 years in the U.S. every year. Injuries are the principal cause of death for children in all nations in the Organization for Economic Cooperation and Development (OECD), the 26 wealthiest nations in the world. Injuries constitute almost 30% of the total burden of childhood disease in the OECD by disability-adjusted life years. For every 100,000 children, the pediatric-injury death rate in the United States is more than twice that of Sweden, Great Britain, or Italy. For every death, there are 160 hospital admissions and 2,000 emergency department visits.