Cardiorenal Syndrome Type 1: Renal Dysfunction in Acute Decompensated Heart Failure.

OBJECTIVE: To present a review of cardiorenal syndrome type 1 (CRS1). METHODS: Review of the literature. RESULTS: Acute kidney injury occurs in approximately one-third of patients with acute decompensated heart failure (ADHF) and the resultant condition was named CRS1. A growing body of literature shows CRS1 patients are at high risk for poor outcomes, and thus there is an urgent need to understand the pathophysiology and subsequently develop effective treatments. In this review we discuss prevalence, proposed pathophysiology including hemodynamic and nonhemodynamic factors, prognosticating variables, data for different treatment strategies, and ongoing clinical trials and highlight questions and problems physicians will face moving forward with this common and challenging condition. CONCLUSION: Further research is needed to understand the pathophysiology of this complex clinical entity and to develop effective treatments.

Conjunctival melanoma: outcomes based on tumor origin in 382 consecutive cases.

PURPOSE: To evaluate prognostic factors based on origin of conjunctival melanoma. DESIGN: Interventional case series. PARTICIPANTS: Three hundred eighty-two consecutive patients. METHODS: Retrospective chart review. MAIN OUTCOME MEASURES: Melanoma-related metastasis and death. RESULTS: The melanoma arose from primary acquired melanosis (PAM; n = 284; 74%), from pre-existing nevus (n = 26; 7%), and de novo (n = 72; 19%). The mean tumor base was 11 mm for melanoma arising from PAM, 6 mm for melanoma arising from nevus, and 10 mm for those arising de novo. At 5 years (10 years), melanoma metastasis occurred in 19% (25%) in melanoma arising from PAM (P = 0.003), 10% (26%) in melanoma from nevus (P = 0.193), and 35% (49%) in those de novo. Factors predictive of metastasis by multivariable analysis included tumor origin de novo (P = 0.001), palpebral location (P<0.001), nodular tumor (P = 0.005), and orbital invasion (P = 0.022). At 5 years (10 years), melanoma-related death occurred in 5% (9%) in melanoma arising from PAM (P<0.001), 0% (9%) in melanoma arising from nevus (P<0.057), and 17% (35%) in those arising de novo. Factors predictive of death by multivariable analysis included tumor origin de novo (P<0.001), fornix location (P = 0.04), and nodular tumor (P = 0.001). CONCLUSIONS: Melanoma arising de novo carries a higher risk of melanoma-related metastasis and death compared with those cases arising from PAM or nevus.

Sex Differences in Patients With Suspected Cardiac Sarcoidosis Assessed by Cardiovascular Magnetic Resonance Imaging.

Background: There are few data on sex differences in suspected cardiac sarcoidosis. Methods: Consecutive patients with histologically proven sarcoidosis and suspected cardiac involvement were studied. We investigated sex differences in presenting features, cardiac involvement, and the long-term incidence of a primary composite end point of all-cause death or significant ventricular arrhythmia and secondary end points of all-cause death and significant ventricular arrhythmia. Results: Among 324 patients, 163 (50.3%) were female and 161 (49.7%) were male patients. Female patients had a greater prevalence of chest pain (37.4% versus 23.6%; P=0.010) and palpitations (39.3% versus 26.1%; P=0.016) than male patients but not dyspnea, presyncope, syncope, or arrhythmias at presentation. Female patients had a lower prevalence of late gadolinium enhancement on cardiovascular magnetic resonance imaging (20.2% versus 35.4%; P=0.003) and less often met criteria for a clinical diagnosis of cardiac sarcoidosis (Heart Rhythm Society consensus criteria, 22.7% versus 36.0%; P=0.012 and 2016 Japanese Circulation Society guideline criteria, 8.0% versus 19.3%; P=0.005), indicating lesser cardiac involvement. However, the long-term incidence of all-cause death or significant ventricular arrhythmia was not different between female and male patients (23.2% versus 23.2%; P=0.46). Among the secondary end points, the incidence of all-cause death was not different between female and male patients (20.7% versus 14.3%; P=0.51), while female patients had a lower incidence of significant ventricular arrhythmia compared with male patients (4.3% versus 13.0%; P=0.022). On multivariable analyses, sex was not associated with the primary end point (hazard ratio for female patients, 1.36 [95% CI, 0.77­2.43]; P=0.29). Conclusions: We observed distinct sex differences in patients with suspected cardiac sarcoidosis. A paradox was identified wherein female patients had a greater prevalence of chest pain and palpitations than male patients, but lesser cardiac involvement, and a similar long-term incidence of all-cause death or significant ventricular arrhythmia.

Use of Computed Tomography to Distinguish Thrombus from Pannus on a Bioprosthetic Aortic Valve.

Bioprosthetic valve thrombosis was previously considered to be a relatively rare complication of surgical or transcatheter bioprosthetic valve replacement. Although echocardiograms can reliably show the characteristic findings of prosthetic valve stenosis, differentiating between thrombus formation and pannus overgrowth as the underlying cause of prosthetic valve dysfunction can be challenging. We present the case of a 75-year-old man who underwent transthoracic Doppler echocardiography in the presence of an elevated valvular gradient 2 years after his aortic valve had been surgically replaced with a bioprosthesis. The echocardiographic findings suggested prosthetic valve stenosis. Cardiac computed tomography, performed to distinguish between thrombus formation and pannus overgrowth, revealed hypoattenuated leaflet thickening and reduced leaflet mobility, which suggested thrombus. After the patient took oral anticoagulants for 3 months, images showed complete resolution of the previous abnormalities, thus confirming the diagnosis of bioprosthetic valve thrombosis. We found cardiac computed tomography valuable when evaluating our patient who had an elevated prosthetic valve gradient.