Ganglionated Plexus Ablation Procedures to Treat Vasovagal Syncope.

Vasovagal syncope (VVS) refers to a heterogeneous group of conditions whereby the cardiovascular reflexes normally controlling the circulation are interrupted irregularly in response to a trigger, resulting in vasodilation, bradycardia, or both. VVS affects one-third of the population at least once in their lifetime or by the age of 60, reduces the quality of life, and may cause disability affecting certain routines. It poses a considerable economic burden on society, and, despite its prevalence, there is currently no proven pharmacological treatment for preventing VVS. The novel procedure of ganglionated plexus (GP) ablation has emerged rapidly in the past two decades, and has been proven successful in treating syncope. Several parameters influence the success rate of GP ablation, including specific ablation sites, localization and surgical techniques, method of access, and the integration of other interventions. This review aims to provide an overview of the existing literature on the physiological aspects and clinical effectiveness of GP ablation in the treatment of VVS. Specifically, we explore the association between GPs and VVS and examine the impact of GP ablation procedures as reported in human clinical trials. Our objective is to shed light on the therapeutic significance of GP ablation in eliminating VVS and restoring normal sinus rhythm, particularly among young adults affected by this condition.

Coronary Sinus Lead Placement in Patients With Coronary Sinus Ostial Atresia: An Innovative Approach.

This case series demonstrates 2 innovative approaches to successful coronary sinus lead placement in the setting of coronary sinus ostial atresia. Use of venous phase coronary angiography, a computed tomography scan with venous phase, or a left-sided upper extremity venogram may help reveal a variant anatomy and guide tool selection. (Level of Difficulty: Advanced.).

Two Birds With One Stone: The Decisive Role of Cardiac MRI in Identifying Both Hypertrophic Cardiomyopathy and Pericarditis Simultaneously in a Patient with Chest Pain.

A 35-year-old Hispanic male presented at an outside facility with chest pain a few days after a long road trip. The initial electrocardiogram (EKG) showed sinus tachycardia with no other abnormality. His D-dimer was positive but a subsequent computed tomography angiography (CTA) of the chest was negative for pulmonary embolism. An echocardiogram showed trace pericardial effusion with a normal ejection fraction (EF) of 70% and severe asymmetric septal hypertrophy. Satisfactory Doppler signals to assess the gradient across the left ventricle outflow tract (LVOT) could not be obtained on echocardiogram. The patient was diagnosed with acute pericarditis, which was treated medically with an improvement of his symptoms. Later, he presented to our facility for an outpatient cardiac magnetic resonance (CMR) with and without contrast, which showed severe asymmetric septal hypertrophy measuring 29 mm with substantial patchy myocardial delayed enhancement and systolic anterior motion of the mitral leaflet with flow dephasing of LVOT. These findings were diagnostic of hypertrophic obstructive cardiomyopathy. CMR also showed signs consistent with pericarditis. A Holter monitor was unremarkable for arrhythmia. A stress echocardiogram did not demonstrate any drop in blood pressure during exercise. His interventricular septum measured 29 mm on cardiac magnetic resonance imaging (MRI), which was very close to the 30 mm cut-off for an implantable cardioverter-defibrillator (ICD). In addition, he had a marked delayed enhancement in the hypertrophied septum due to gadolinium uptake, which is also considered a high-risk feature for sudden cardiac death. After discussions between the patient, cardiologist, cardiac imaging specialist, and electrophysiologist, a subcutaneous ICD was pursued, which was successfully implanted. He was started on medical treatment. He was followed closely in the clinic and has remained asymptomatic for the past two years.

Incidence of Left Ventricular Thrombus in Patients With Acute ST-Segment Elevation Myocardial Infarction Treated with Percutaneous Coronary Intervention.

Previous studies using 2-dimensional non-contrast echocardiography have reported a post-ST segment elevation myocardial infarction (STEMI) left ventricular (LV) thrombus incidence of 3% to 24%. However, these studies were not performed with ultrasound contrast agents (UCAs), which improve accuracy in the diagnosis of LV thrombus. We aimed to determine the early incidence and clinical correlates of LV thrombus in a large consecutive cohort of patients with STEMI. This study included consecutive patients admitted to Saint Luke's Mid America Heart Institute with STEMI who also underwent early percutaneous coronary intervention (PCI) and an echocardiogram. A total of 1,698 patients (1,205 men, mean age 61 ± 13 years) comprised the study group. Echocardiography was performed on hospital day 2, and a UCA was used in 1,292 patients (76%). LV thrombus was identified in 28 (1.6%) patients. A multivariable logistic regression model showed that left anterior descending intervention was independently associated with LV thrombus (odds ratio = 7.58, 95% confidence interval [CI] 2.20 to 26.19, p = 0.001), thrombolysis in myocardial infarction III flow was marginally associated with less LV thrombus (odds ratio = 0.41, 95% CI 0.16 to 1.04, p = 0.060), and higher LVEF was associated with less LV thrombus (odds ratio = 0.96, 95% CI 0.91 to 0.97, p <0.001). In conclusion, LV thrombus was identified in only 1.6% of patients in a large STEMI cohort, significantly lower than previous studies. A UCA was used in most echocardiograms, and it improves accuracy in the detection and exclusion of LV thrombus.

Fibromuscular Dysplasia with Spontaneous Coronary Artery Disease Presenting as Acute Myocardial Infarction.

A 40-year-old female presented to a rural hospital with crushing substernal chest pain. An initial electrocardiogram showed ST elevation in lead II and aVF with elevated troponin I. She was immediately transferred to a tertiary care hospital. An emergent coronary angiogram did not show any significant coronary artery disease. On the second day, the patient experienced recurrence of severe chest pain with ST elevations in leads I, aVL, V5-V6, ST depressions in V1-V3, T-wave inversion over V2-V5. The troponin I level increased to > 40 ng/ml (normal 0.0 to 0.04 ng/ml). An emergent angiogram was performed revealing local dissection of the mid to distal left main coronary artery and a totally occluded diagonal artery. It was deemed unsafe to perform percutaneous coronary intervention because it was a non-flow limiting left main coronary artery dissection and was difficult to cannulate with the guide catheter. Subsequently, an elective angiogram was performed after a 48-hour interval to evaluate the progression of dissection and to make a definitive decision for revascularization versus medical management. On the third angiogram, stenosis seen in the diagonal branch on the previous angiogram progressed to dissection, and local dissection of the left main coronary artery seen on the previous angiogram spontaneously resolved. The patient was symptom-free and hemodynamically stable. It was decided to manage the patient conservatively due to the spontaneous resolution of occlusion in the diagonal artery and dissection of the left main coronary artery. The patient was started on conservative medical treatment. A magnetic resonance angiography of the right internal carotid artery revealed a "string of beads" appearance, which confirmed the diagnosis of fibromuscular dysplasia. She was followed closely in the clinic and has remained asymptomatic for the past one year.

Thrombosis in the Surgically Corrected Anomalous Right Coronary Artery after Reimplantation in Aorta.

A 32-year-old African American female presented with dyspnea, and after several cardiac diagnostic tests, the diagnosis of an anomalous origin of the RCA from the pulmonary trunk was established by multislice coronary CT angiography. She underwent surgical correction with reimplantation of the RCA, from the pulmonary artery to the aortic root. However, 10 days after surgery, she developed frequent episodes of chest pain, and repeat coronary CTA showed a partially occlusive thrombus in the surgically reimplanted RCA. Anticoagulation with warfarin resulted in complete resolution of the patient's symptoms.

Nonbacterial thrombotic endocarditis involving both the tricuspid and aortic valves.

A 71-year-old male presented after sudden onset of confusion and expressive aphasia. MRI head revealed multiple ischemic lesions consistent with cardio-embolic pathophysiology. A computed tomography angiography of lung showed peripheral pulmonary emboli. He underwent a transesophageal echocardiogram as a part of the stroke workup and was found to have vegetations on both aortic and tricuspid valves. The blood cultures did not show any growth, and the patient remained afebrile during the course of hospitalization. A diagnosis of nonbacterial thrombotic embolism was made, and he was discharged on anticoagulation therapy with subcutaneous low molecular heparin.

Is the Pulmonary Embolism Severity Index Being Routinely Used in Clinical Practice?

Background. The Pulmonary Embolism Severity Index (PESI) score can risk-stratify patients with PE but its widespread use is uncertain. With the PESI, we compared length of hospital stay between low, moderate, and high risk PE patients and determined the number of low risk PE patients who were discharged early. Methods. PE patients admitted to St. Joseph Mercy Oakland Hospital from January 2005 to August 2010 were screened. PESI score stratified acute PE patients into low (<85), moderate (86-105), and high (>105) risk categories and their length of hospital stay was compared. Patients with low risk PE discharged early (≤3 days) were calculated. Results. Among 315 PE patients, 51.7% were at low risk. No significant difference in hospital stay between low (7.11 ± 3 d) and moderate (6.88 ± 2.9 d) risk, p > 0.05, as well as low and high risk (7.28 ± 3.0 d), p > 0.05, was found. 9% of low risk patients were discharged ≤ 3 days. Conclusions. There was no significant difference in length of hospital stay between low and high risk groups and only a small number of low risk patients were discharged from the hospital early suggesting that risk tools like PESI may not have a widespread use.

Spontaneous coronary artery dissection: the management dilemma continues.

Spontaneous coronary artery dissection (SCAD) is an increasingly recognised cause of acute coronary syndrome, particularly in women. A 36-year-old Caucasian woman presented to our hospital with sudden onset chest pain and was diagnosed with a non-ST elevation myocardial infarction. Coronary angiography revealed mid and distal left anterior descending artery (LAD) dissection with distal LAD occlusion. A short segment of apical LAD filled late with incomplete opacification (Thrombolysis In Myocardial Infarction (TIMI) 1 flow). A decision was made to treat the patient conservatively, with subsequent resolution of dissection over the next 3 months. Our patient made a good clinical recovery with healing of her affected coronary vasculature on subsequent angiogram. The case illustrates that SCAD can be managed conservatively with antiplatelet agents, ß-blockers, heparin and statins, if the patient is haemodynamically stable and coronary flow is adequate.

Fibromuscular Dysplasia Leading to Spontaneous Coronary Artery Dissection with Sudden Cardiac Arrest.

A 30-year-old previously healthy female, who was six-week postpartum, experienced sudden collapse and tonic-clonic seizure. Emergency medicine services arrived at the scene and the patient was found to be in ventricular fibrillation. Advanced cardiovascular life support (ACLS) was initiated with return of spontaneous circulation. Afterwards, her initial EKG showed atrial fibrillation with rapid ventricular rate, ST elevation in leads II, III, and aVF, and ST depression in V2-V4. She was transferred to a tertiary care hospital where emergent angiogram was performed revealing obstruction of blood flow in the proximal and mid right coronary artery (RCA). A hazy and irregularly contoured appearance of the RCA was consistent with diagnosis of fibromuscular dysplasia. Subsequently, intravascular ultrasonogram (IVUS) was performed which confirmed the diagnosis of RCA dissection. Successful revascularization of the RCA was performed using two bare mental stents. After a complicated course in hospital, she was discharged in stable condition and did very well overall.

Refractory ventricular fibrillation managed by coronary revascularisation performed during ongoing manual cardiac resuscitation lasting 1½ h.

Myocardial infarction is the most common cause of ventricular arrhythmias. Although there have been several improvements and refinements in coronary catheterisation with percutaneous intervention over the years, this intervention is still rarely considered during active ongoing resuscitation of patients, especially in cases of persistent ventricular arrhythmias. We present a case of refractory ventricular fibrillations due to in-stent thrombosis that was managed by emergent coronary angiogram and stent placement during ongoing cardiopulmonary resuscitation in a code that lasted about 1½ h. The patient subsequently made an excellent recovery and was discharged home 13 days later.

Alcohol and cardiovascular health: the dose makes the poison or the remedy.

Habitual light to moderate alcohol intake (up to 1 drink per day for women and 1 or 2 drinks per day for men) is associated with decreased risks for total mortality, coronary artery disease, diabetes mellitus, congestive heart failure, and stroke. However, higher levels of alcohol consumption are associated with increased cardiovascular risk. Indeed, behind only smoking and obesity, excessive alcohol consumption is the third leading cause of premature death in the United States. Heavy alcohol use (1) is one of the most common causes of reversible hypertension, (2) accounts for about one-third of all cases of nonischemic dilated cardiomyopathy, (3) is a frequent cause of atrial fibrillation, and (4) markedly increases risks of stroke-both ischemic and hemorrhagic. The risk-to-benefit ratio of drinking appears higher in younger individuals, who also have higher rates of excessive or binge drinking and more frequently have adverse consequences of acute intoxication (for example, accidents, violence, and social strife). In fact, among males aged 15 to 59 years, alcohol abuse is the leading risk factor for premature death. Of the various drinking patterns, daily low- to moderate-dose alcohol intake, ideally red wine before or during the evening meal, is associated with the strongest reduction in adverse cardiovascular outcomes. Health care professionals should not recommend alcohol to nondrinkers because of the paucity of randomized outcome data and the potential for problem drinking even among individuals at apparently low risk. The findings in this review were based on a literature search of PubMed for the 15-year period 1997 through 2012 using the search terms alcohol, ethanol, cardiovascular disease, coronary artery disease, heart failure, hypertension, stroke, and mortality. Studies were considered if they were deemed to be of high quality, objective, and methodologically sound.