Coronary Artery Dissection and Myocarditis Caused by Eosinophilic Granulomatosis with Polyangiitis (EGPA): A Case Report.

Eosinophilic granulomatosis with polyangiitis (EGPA) also referred to as Churg-Strauss syndrome is a rare vasculitis of the small to medium vessels. We present a rare case of acute coronary artery dissection brought on by EGPA, which generally has a poor prognosis. A 41-year-old male with history of bronchial asthma presented to the emergency room with a 2-week history of dyspnea, cough with clear phlegm, and fever. For the past eight months he had experienced episodes with similar symptoms relieved by steroids. CT chest showed bilateral upper lobe patchy opacities with extensive workup for infectious etiology being negative. He had peripheral eosinophilia with sinusitis. He had acute coronary syndrome and Coronary angiogram showed Right coronary artery dissection. After making a diagnosis of EGPA based on American college of Rheumatology criteria, he was successfully treated with high dose immunosuppression. Coronary artery dissection is a fatal and uncommon complication of EGPA which is usually diagnosed postmortem. Early recognition of this condition ante mortem and aggressive treatment can be lifesaving as demonstrated in our case.

Large Epicardial Hematoma After Percutaneous Coronary Intervention: Multimodality Imaging.

Epicardial hematoma can manifest immediately or within a few minutes to hours after coronary intervention. Review of angiogram after the diagnosis of hematoma, in our case, showed deep distal positioning of a non-polymer jacketed wire, which is the most likely cause of the adverse outcome. Multimodality imaging is critical for diagnosis and management of such cases.

Impact of annular and supra-annular CoreValve deployment locations on aortic and coronary artery hemodynamics.

CoreValve is widely used in transcatheter aortic valve replacement, but the impact of its deployment location on hemodynamics is unexplored despite a potential role in subsequent aortic and coronary artery pathologies. The objectives of this investigation were to perform fluid-structure interaction (FSI) simulations for a 29 mm CoreValve deployed in annular vs supra-annular locations, and characterize resulting hemodynamics including velocity and wall shear stress (WSS). Patient-specific geometry was reconstructed from computed tomography scans and CoreValve was deployed using a finite element approach. FSI simulations were then performed using a boundary conforming method and realistic boundary conditions. Results showed that CoreValve deployment location impacts hemodynamics in the ascending aorta and flow patterns in the coronary arteries. During peak-systole, annularly deployed CoreValve produced a jet-like flow structure impinging on the outer-curvature of the ascending aorta. Supra-annularly deployed CoreValve having a lateral tilt of 10° led to a more centered jet impinging further downstream. At mid-systole, valve leaflets of the annularly deployed CoreValve closed asymmetrically leading to disorganized flow patterns in the ascending aorta vs those from the supra-annular position. Supra-annularly deployed CoreValve also led to high-velocity para-valvular flow supplying the coronary arteries. CoreValve in the supra-annular position significantly (P < 0.05) elevated WSS within the first few diameters of both coronary arteries as compared to the annular position for many time points quantified. These results afforded by the advanced simulation methods may have important clinical implications given the role of aortic hemodynamics in dilation and the pro-atherogenic nature of WSS alterations in the coronary arteries.

Expecting the unexpected: right atrial mass in a transplant patient.

We present a 71-year-old male, who had had a heart transplantation 24 years prior, who came to our clinic with a low-grade fever and a new II/VI holosystolic murmur. Echocardiography showed a large mass in the right atrium with attachment near the junction of the right atrium and superior vena cava. The patient was taken to the operating room for resection of the mass. Microscopic evaluation was consistent with thrombus. Differential diagnosis of cardiac masses after cardiac transplant includes tumour, thrombus, and vegetation. Final diagnosis can be challenging; multimodality imaging and biopsy or resection often are required for final diagnosis.

Right ventricular ejection efficiency: a new echocardiographic measure of mechanical performance in chronic pulmonary hypertension.

BACKGROUND: The severity of pulmonary vascular resistance (PVR) is known to be a critical determinant of right ventricular (RV) systolic function; this relationship remains poorly characterized. We therefore, designed a study to examine the relationship that exists between echocardiographically measured PVR and maximal tricuspid annular plane systolic excursion (TAPSE) to gain some insight regarding RV ejection efficiency (RVEe) in patients with chronic pulmonary hypertension (cPH). METHODS: Standard echocardiographic measures of RV size and systolic performance were recorded from 95 patients (age 54 ± 15 years and pulmonary artery systolic pressures [PASP] that range from 20 to 125 mmHg). For this study, RVEe was defined as TAPSE/Echocardiographic PVR. RESULTS: A strong negative correlation (R(2) = -0.51, P < 0.001) was seen between TAPSE and PASP; however, a power curve trend line fit the relationship between RVEe and PASP (R(2) = 0.77; P < 0.01). In a multiple regression analysis, abnormal pulmonary pressures were better identified when RVEe (P < 0.0001) was used. CONCLUSIONS: Based on these results, it appears that measurement of RVEe might be extremely useful for the assessment of RV mechanics and plasticity. The power curve relationship clearly demonstrates that minimal changes in PASP (up to 50 mmHg) result in dramatic reductions in RVEe. A steady decline in RVEe, though at a lower rate, continues to occur with increasing PASP. Additional studies are required using RVEe into a functional RV imaging algorithm and determine if RVEe correlates with development of symptoms, response to therapy and overall clinical outcomes.