Evaluation and Management of Mechanical Heart Valve Dysfunction and Thrombosis.

PURPOSE OF REVIEW: Dysfunction and thrombosis of mechanical heart valves, although uncommon, represents a challenge that requires multidisciplinary expertise for diagnosis and management. The aim of this review is to summarize strengths and weaknesses of diagnostic methods and therapeutic strategies for this uncommon but potentially life-threatening pathology. RECENT FINDINGS: Expeditious diagnosis of mechanical valve thrombosis and exclusion of other diagnostic considerations, often with incorporation of multimodality imaging, can inform the best treatment strategy. Presentation of mechanical valve thrombosis can be asymptomatic or can include heart failure, life-threatening embolic events, or cardiogenic shock. Echocardiography, fluoroscopy and computed tomography are important in the evaluation of mechanical valve dysfunction. Therapeutic strategies for thrombosis include anticoagulation, systemic thrombolysis, and surgery. Choice of treatment depends on multiple factors including thrombus size, degree of valve dysfunction, clinical presentation, and available surgical expertise.

Carotid Duplex Ultrasonography to Assess Severity of Low-Flow Low-Gradient Aortic Stenosis.

BACKGROUND: Patients with low-flow, low-gradient aortic valve stenosis constitute a substantial subset of all severe aortic stenosis patients. However, assessment of true severity of these patients can be challenging. In this analysis, we study the utility of the common carotid artery waveforms to distinguish true from pseudo-severe low-flow low-gradient aortic stenosis. METHODS: This is an observational analysis that included patients who underwent a transthoracic echocardiogram (TTE) and duplex carotid ultrasonography (DCUS) and had low-flow, low-gradient aortic stenosis with reduced left ventricular ejection fraction (LVEF) on the index TTE (LVEF <50%, calculated aortic valve area [AVA] of ≤1.0 cm2, mean and peak gradient of <40 and <64 mm Hg, respectively, and stroke volume index <35 mL/m2). Patients were classified as pseudo-severe and true-severe aortic stenosis based on additional subsequent testing. Differences in various TTE and DCUS waveform parameters across the aortic valve and the common carotid artery were compared between the 2 groups. RESULTS: The study included 30 patients (60 carotid arteries). Fifteen patients were categorized as pseudo-severe and 15 as true severe aortic stenosis. There were no significant differences in calculated AVA, LVEF, stroke volume/stroke volume index, and Doppler Velocity Index in the 2 groups. Mean and peak gradient were higher in patients with true-severe aortic stenosis. Carotid acceleration time (cAT) was significantly prolonged in patients with true-severe compared with pseudo-severe aortic stenosis. A cAT ≥80 ms was 83.3% sensitive and 83.3% specific for true-severe aortic stenosis. CONCLUSION: cAT acceleration time may be used to distinguish true from pseudo-severe low-flow, low-gradient aortic valve stenosis.

Pericardial mesothelioma presenting as constrictive pericarditis.

A 46-year-old woman underwent pericardiocentesis and pericardial window for recurrent pericardial effusion. She presented 17 months later with signs and symptoms consistent with constrictive pericarditis. Cardiac magnetic resonance imaging revealed an infiltrative mass surrounding the pericardium. A transcutaneous core needle biopsy of the pericardium confirmed the diagnosis of pericardial mesothelioma.

Bedside Manner 2020: An Inventory of Best Practices.

Bedside manner, a doctor's deportment with a patient, encompasses all aspects of the patient interaction, including all verbal and nonverbal communication strategies. Bedside manner can be a powerful adjunct for healing. In academic medical centers, trainees generally learn bedside manner by observing their attendings and mentors-in other words, as part of the "hidden curriculum." Because bedside manner is a critical component in the art of healing, it can be threatened by pressures on time in managing inpatients and by the explosion of technology. This article assembles an inventory of best bedside practices for inpatient care. Eight best bedside practices were identified by reviewing the literature, collecting the personal experiences of the authors, and consulting a group of attendings whom the authors regarded as exemplary clinicians. This inventory is presented with the goal of expanding clinicians' repertoire of best practices and encouraging explicit teaching of these practices to optimize care.

Impact of tricuspid regurgitation on postoperative outcomes after non-cardiac surgeries.

Objective: Tricuspid regurgitation (TR) severity has known adverse implications, its impact on patients undergoing non-cardiac surgery (NCS) remains unclear. We sought to determine the impact of TR on patient outcomes after NCS. Methods: We performed a retrospective cohort study in patients undergoing NCS. Outcomes in patients with moderate or severe TR were compared with no/trivial TR after adjusting for baseline characteristics and revised cardiac risk index (RCRI). The primary outcome was defined as 30-day mortality and heart failure (HF), while the secondary outcome was long-term mortality. Results: Of the 7064 patients included, 312 and 80 patients had moderate and severe TR, respectively. Thirty-day mortality was higher in moderate TR (adjusted OR 2.44, 95% CI 1.25 to 4.76) and severe TR (OR 2.85, 95% CI 1.04 to 7.79) compared with no/trivial TR. There was no difference in 30-day HF in patients with moderate TR (OR 1.48, 95% CI 0.90 to 2.44) or severe TR (OR 1.42, 95% CI 0.60 to 3.39). The adjusted HR for long-term mortality in moderate TR was 1.55 (95% CI 1.31 to 1.82) and 1.87 (95% CI 1.40 to 2.50) for severe TR compared with no/trivial TR. Conclusion: Increasing TR severity has higher postoperative 30-day mortality in patients undergoing NCS, independent of RCRI risk factors, ejection fraction or mitral regurgitation. Severity of TR should be considered in risk stratification for patients undergoing NCS.

Utilization and outcomes of polytetrafluoroethylene covered stents in patients with coronary artery perforation and coronary artery aneurysm: Single center 15-year experience.

OBJECTIVES: Determine the outcomes of polytetrafluoroethylene (PTFE) covered stents for coronary artery perforation (CAP) and coronary artery aneurysm (CAA). BACKGROUND: PTFE covered stents have been used for treatment of potentially life-threatening CAP and CAA. The short and long-term outcomes of the PTFE covered stent for CAP and CAA have not been well studied. METHODS: We performed a retrospective study of PTFE covered stents that were placed in the patients from 2003 to 2017. Short term outcomes included in-hospital mortality, pericardial effusion, cardiac tamponade, and length of stay. Long-term outcomes included target lesion revascularization (TLR), in-stent restenosis (ISR), and long-term mortality. RESULTS: Fifty-three PTFE covered stents were placed in 32 patients of which there were 24 patients with a CAP with a mean age of 75 ± 8 years. Two patients died in-hospital, with no additional deaths at 30 days. The rate of ISR was 25%, with estimated rates of TLR of 2.6% (3 years) and 17.8% (5 years). The median survival was 55.6 months, with survival at 10 years estimated to be 30.9%. Eight patients received a PTFE covered stent for CAA with a mean age of 59 ± 15 years with no in-hospital or 30-day mortality. Median follow-up of 49 months showed no evidence of TLR. The all-cause mortality was 12% at 1 year and 38% at 3 years. CONCLUSIONS: PTFE covered stents is an effective option in patients with CAP and CAA. The long-term outcomes may be related to the pathology of the disease rather than the stent itself.

Prevalence of Post-Traumatic Stress Disorder Due to Community Violence Among University Students in the World's Most Dangerous Megacity: A Cross-Sectional Study From Pakistan.

Community violence among the youth can lead to a number of adverse psychiatric outcomes including post-traumatic stress disorder (PTSD). However, little research has been conducted in non-Western countries to assess this problem. This study aims to fill the void by assessing the lifetime exposure to traumatic events and burden of probable PTSD among university students in Karachi, Pakistan. A cross-sectional study was conducted at four private institutions in Karachi. Self-administered questionnaires were filled out by 320 students. Lifetime exposure and symptoms of PTSD were assessed using modified Composite International Diagnostic Interview (CIDI) and Post-Traumatic Stress Disorder Checklist-Civilian Version (PCL-C) questionnaires, respectively. A PCL-C score of 44 or above was used as cutoff for probable PTSD. Pearson chi-square test was used to assess the association between PTSD and different variables at a level of significance of 5%. Ninety-three percent of the respondents reported having lifetime exposure to at least one traumatic event with sudden unexpected death of a loved one (n = 187) and assaultive violence (n = 169) being the commonest reported traumatic events. Positive association for PTSD was seen with enduring physical attacks and motor vehicle accidents. Over a quarter of the students screened positive for probable PTSD, among them almost one third were male and 17% were female. Our results indicate a high exposure to violent events and elevated rates of lifetime PTSD among urban youth. Reduction in violence and better access to mental health facilities is warranted to decrease the health burden of PTSD in Pakistan.

Depression is linked to uncontrolled hypertension: a case-control study from Karachi, Pakistan.

BACKGROUND: High blood pressure is an important risk factor for cardiovascular disease and may be more prevalent in persons with psychopathology. OBJECTIVE: To determine the association between uncontrolled hypertension with depressive and anxiety disorders in two tertiary care centers in Karachi. METHODS: It was a case-control study conducted in two hospitals in Karachi. Cases were patients with uncontrolled hypertension and controls were patients with controlled hypertension. History of anxiety or depression as measured by Hospital Anxiety and Depression Scale (HADS) was the exposure. HADS of >8 was suggestive of having anxiety or depression. RESULTS: A total of 700 participants were approached, out of whom 590 fulfilled the inclusion criteria and consented to participate, 323 (54.7%) participants were enrolled as cases and 267 (45.3%) as controls. Mean (SD) age was 54.98 (12.38) years, 229 (38%) were males. Odds ratio (OR) (95% CI) of having uncontrolled hypertension and being depressed (HADS-D > 8) was 2.02 (1.44-2.83), p value ≤ 0.001. The association remained significant even after adjusting for age and gender in Model 1 OR (95% CI): 1.82 (1.27-2.60), p value = 0.001, ethinicity and education in Model 2 OR (95% CI): 1.87 (1.29-2.71), p value = 0.001 and comorbids, history of hospitalization body mass index in Model 3 OR (95% CI): 1.94 (1.31-2.85), p value = 0.001. CONCLUSION: There is association between uncontrolled hypertension and depression that is independent of sociodemographic factors, comorbids and history of hospitalization.