A Rare Case of Traumatic Coronary Artery Dissection After a Motor Vehicle Collision.

Coronary artery dissection is a rare and life-threatening condition. It can result in thrombus formation and coronary occlusion with subsequent acute coronary syndrome, ventricular arrhythmia, and death. Traumatic coronary artery dissection is an especially rare type of dissection and usually happens in the setting of a high-speed motor vehicle collision. Early recognition and treatment are crucial for survival in patients suffering from this pathology. We present a case of a patient who developed right coronary artery dissection following a motor vehicle collision that was subsequently managed by coronary angiogram and revascularization.

Cardiac Rehabilitation in Patients With Left Ventricular Assist Device: A SYSTEMATIC REVIEW AND META-ANALYSIS.

PURPOSE: Exercise-based cardiac rehabilitation (EBCR) has been demonstrated to improve functional capacity in heart failure (HF). However, there are limited data on the effect of EBCR in patients with advanced HF and left ventricular assist devices (LVADs). This meta-analysis sought to evaluate the effects of EBCR on functional capacity in patients with LVAD. METHODS: PubMed, Web of Science, CINAHL, and Cochrane Library databases were searched for randomized studies assessing the impact of EBCR in patients following LVAD implantation compared with standard therapy (ST). Using pre-defined criteria, appropriate studies were identified and selected. Data from selected studies were extracted in a standardized fashion and a meta-analysis was performed using a random-effects model with DerSimonian Liard weighting. Analysis employed weighted mean difference (WMD) as the effect size and intention-to-treat (ITT) principle. Study quality, publication bias, and heterogeneity were assessed. RESULTS: Six trials with a total of 183 patients (EBCR: 125; ST: 58) were identified. Mean age was 51 years and 83% were males. The initiation of EBCR varied from LVAD implantation during the index hospitalization to 10 mo post-LVAD implantation. The median rehabilitation period ranged from 6 to 10 wk. Exercise-based cardiac rehabilitation was associated with improved peak oxygen uptake ((Equation is included in full-text article.)O2) in all trials. Quantitative analysis was performed on 3 randomized studies involving 61 patients (EBCR = 39, ST = 22). Exercise-based cardiac rehabilitation was associated with significantly greater peak (Equation is included in full-text article.)O2 (WMD: 3.00 mL/kg/min; 95% CI: 0.64-5.35, P = .001). Similarly, 6-minute walk distance (6MWD) showed significantly greater improvement in the EBCR group than in the ST group (WMD: 60.06 m; 95% CI, 22.61-97.50, P = .002). Heterogeneity was low among the included trials. Exclusion sensitivity and per-protocol analysis demonstrated results consistent with ITT analysis. None of the included studies reported serious adverse events related to EBCR, which supports the safety of EBCR after LVAD implantation. CONCLUSION: This systematic review and meta-analysis demonstrated that EBCR following LVAD implantation is associated with greater improvement in functional capacity compared with ST as reflected by improved peak (Equation is included in full-text article.)O2 and 6MWD. However, given the small number of patients, further research into the clinical impact of EBCR in LVAD patients is necessary.

Meta-analysis of Risk of Ventricular Arrhythmias After Improvement in Left Ventricular Ejection Fraction During Follow-Up in Patients With Primary Prevention Implantable Cardioverter Defibrillators.

Implantable cardioverter defibrillators (ICDs) reduce the risk of sudden cardiac death in patients with impaired left ventricular ejection fraction (LVEF). However, there are limited data on the long-term benefit of ICD therapy in patients whose LVEF subsequently improves. We conducted a meta-analysis to evaluate the effect of LVEF improvement on ICD therapy during follow-up. Incidence rate ratios (IRRs) with 95% confidence intervals (CIs) were calculated using random-effects modeling. Sixteen studies with 3,959 patients were included in our analysis. Study arms were defined by LVEF improvement at follow-up (improved LVEF [>35%]: 1,622; low LVEF [≤35%] 2,337). Mean age (64.8 vs 64.9 years, p = 0.97) was similar, whereas men were overrepresented in the persistent low LVEF group (79% vs 72%, p <0.001). Appropriate ICD therapy rate was 9.7% (improved LVEF) versus 21.8% (low LVEF) over a median follow-up period of 2.9 years. In the meta-analysis, improved LVEF group had significantly lower (3.3% vs 7.2% per year IRR 0.52; CI 0.38 to 0.70; p <0.001) appropriate ICD therapies which was uniformly seen across all subgroups (ICD-only studies: IRR 0.59; p = 0.004) (cardiac resynchronization therapy-defibrillator-only studies: IRR 0.31; p = 0.002) (super-responder studies [mean LVEF > 45%]: IRR 0.53; p = 0.002). Inappropriate ICD therapy rates were, however, similar in both groups (3.01% vs 2.56% per year IRR 0.76; CI 0.43 to 1.36; p = 0.35). All-cause mortality rates in our meta-analysis favored (3.63% vs 8.23% per year IRR 0.49; CI 0.35 to 0.69; p <0.001) the improved LVEF group. In conclusion, our meta-analysis demonstrates that an improvement in LVEF is associated with a significantly reduced risk of ventricular arrhythmia and mortality. However, inappropriate ICD therapy rates remain similar.

Current State of Bioabsorbable Polymer-Coated Drug-Eluting Stents.

Drug-eluting stents (DES) have been shown to significantly reduce clinical and angiographic restenosis compared to bare metal stents (BMS). The polymer coatings on DES elute antiproliferative drugs to inhibit intimal proliferation and prevent restenosis after stent implantation. Permanent polymers which do not degrade in vivo may increase the likelihood of stent-related delayed arterial healing or polymer hypersensitivity. In turn, these limitations may contribute to an increased risk of late clinical events. Intuitively, a polymer which degrades after completion of drug release, leaving an inert metal scaffold in place, may improve arterial healing by removing a chronic source of inflammation, neoatherosclerosis, and/or late thrombosis. In this way, a biodegradable polymer may reduce late ischemic events. Additionally, improved healing after stent implantation could reduce the requirement for long-term dual antiplatelet therapy and the associated risk of bleeding and cost. This review will focus on bioabsorbable polymer-coated DES currently being evaluated in clinical trials.

Left Atrial Appendage Closure -The WATCHMAN Device.

Atrial fibrillation (AF) is one of the most common arrhythmias seen in clinical cardiology practice. Patients with non-valvular AF have an approximately 5-fold increase in the risk of stroke, with an exponential increase with advancing age. Cardioembolic strokes carry a high mortality risk. Although the potential of warfarin to reduce systemic embolization in AF patients is well established, its use is difficult due to narrow therapeutic windows and additional complications (e.g. increased risk of bleeding), especially for aging patients. Therefore, alternative means of treatment to reduce stroke risk in these patients are needed. The left atrial appendage is the major source of thrombus formation in patients with non-valvular AF. The WATCHMAN device (Boston Scientific, MA) is a percutaneous left atrial appendage closure device which has been tested prospectively in multiple randomized trials. It offers a new stroke risk reduction option for high-risk patients with non-valvular atrial fibrillation who are seeking an alternative to long-term warfarin therapy. Based on the robust WATCHMAN clinical program which consists of numerous studies, with more than 2,400 patients and nearly 6,000 patient-years of follow-up, the WATCHMAN LAAC Device is approved by FDA. In this article we reviewed the preclinical studies and clinical trials, as well as the next generation of the device.

Malignant Course of Anomalous Left Coronary Artery Causing Sudden Cardiac Arrest: A Case Report and Review of the Literature.

Sudden cardiac arrest has been reported to occur in patients with congenital anomalous coronary artery disease. About 80% of the anomalies are benign and incidental findings at the time of catheterization. We present a case of sudden cardiac arrest caused by anomalous left anterior descending artery. 61-year-old African American female was brought to the emergency department after sudden cardiac arrest. Initial EKG showed sinus rhythm with RBBB and LAFB with nonspecific ST-T wave changes. Coronary angiogram revealed no atherosclerotic disease. The left coronary artery was found to originate from the right coronary cusp. Cardiac CAT scan revealed similar findings with interarterial and intramural course. Patient received one-vessel arterial bypass graft to her anomalous coronary vessel along with a defibrillator for secondary prevention. Sudden cardiac arrest secondary to congenital anomalous coronary artery disease is characterized by insufficient coronary flow by the anomalous left coronary artery to meet elevated left ventricular (LV) myocardial demand. High risk defects include those involved with the proximal coronary artery or coursing of the anomalous artery between the aorta and pulmonary trunk. Per guidelines, our patient received one vessel bypass graft to her anomalous vessel. It is important for clinicians to recognize such presentations of anomalous coronary artery.

Neutrophils to lymphocyte ratio as a screening tool for swine influenza.

BACKGROUND & OBJECTIVES: During an outbreak of influenza like illness throat swab culture and virus isolation are done to identify causal virus, and it may cause a significant delay in diagnosis and isolation. There is a need to determine a sensitive laboratory parameter which could play a major role in identifying H1N1 infection among patients presenting with influenza like symptoms. We undertook this study to determine a laboratory parameter to identify swine influenza infection amoung patients presenting with influenza like symptoms while awaiting throat swab culture and virus isolation reports. METHODS: This retrospective study was conducted on patients presenting to A.P TB and Chest Hospital, Hyderabad, with swine influenza symptoms during September-October 2009. They were divided into swine flu positive (SW+) and swine flu negative (SW-) groups, based on their throat swab culture reports and laboratory data. Neutrophils to lymphocyte (N/L) ratio was calculated for every patient and also mean N/L ratio for two groups. Mean WBC count was also noted for both groups. RESULTS: There were 55 patients in each group. The WBC count in SW+ group varied from 3000 to 10600 cells/mm 3 (mean 5714), while in SW- group it varied from 4500 to 14300 cells/mm 3 (10252). The N/L ratio was less than two for 92.7 per cent of patients in SW+ group and for 3.63 per cent patients in SW- group. N/L ratio < 2 as an indicator for swine flu had a sensitivity of 92.7 per cent and specificity of 96.36 per cent. It has a positive predictive value of 96.22 per cent and a negative predictive value of 92.8 per cent. INTERPRETATION & CONCLUSIONS: N/L < 2 along with a decrease in WBC count can be used as a screening tool in patients presenting with influenza like symptoms, while awaiting throat swab culture reports for confirmation.