Importance of performing transesophageal echocardiography in acute stroke patients older than fifty.

BACKGROUND: The purpose of this study was to determine the value of transesophageal echocardiography (TEE) in determining the presence of cardiac manifestations that required anticoagulation in patients presenting with acute stroke. METHODS: Of 626 consecutive stroke patients who underwent TEE, 188 patients with no obvious etiology for stroke were subcategorized according to age. TEE results were analyzed for cardiac findings suggestive of a cause for embolic stroke, including complex atheromas in the arch/ascending aorta, patent foramen ovale (PFO), atrial septal aneurysm (ASA), and intracavitary thrombi. Data were analyzed using Fisher's exact test. RESULTS: Of 188 patients, 66% (125/188) were older than 50 years and 34% (63/188) were younger than 50 years. The incidence of complex atheroma was 12.8% (16/125) in patients older than 50 years as compared to 0% (0/63) in patients who were younger than 50 years (P = 0.002). In patients older than 50 years, findings that indicated a need for anticoagulation based on TEE results were found in 22.4% (28/125) (atheroma = 16, PFO = 12, ASA = 5, thrombus = 3, PFO + ASA = 1) compared to 14.3% (9/63) (atheroma = 0, PFO = 5, ASA = 2, thrombus = 2, PFO + ASA = 1) in patients younger than 50 years. CONCLUSIONS: TEE plays an important role in suspected embolic stroke patients of all age groups. Due to the higher incidence of complex atheromas in patients older than 50 years of age, TEE might be of added importance in identifying the candidates who may benefit from anticoagulation.

Biventricular takotsubo cardiomyopathy: case study and review of literature.

Biventricular takotsubo cardiomyopathy is associated with more hemodynamic instability than is isolated left ventricular takotsubo cardiomyopathy; medical management is more invasive and the course of hospitalization is longer. In March 2011, a 62-year-old woman presented at our emergency department with abdominal pain, nausea, and vomiting. On hospital day 2, she experienced chest pain. An electrocardiogram and cardiac enzyme levels suggested an acute myocardial infarction. She underwent cardiac angiography and was found to have severe left ventricular systolic dysfunction involving the mid and apical segments, which resulted in a left ventricular ejection fraction of 0.10 to 0.15 in the absence of obstructive coronary artery disease. Her hospital course was complicated by cardiogenic shock that required hemodynamic support with an intra-aortic balloon pump and dobutamine. A transthoracic echocardiogram revealed akinesis of the mid-to-distal segments of the left ventricle and mid-to-apical dyskinesis of the right ventricular free wall characteristic of biventricular takotsubo cardiomyopathy. After several days of medical management, the patient was discharged from the hospital in stable condition. To the best of our knowledge, this is the first review of the literature on biventricular takotsubo cardiomyopathy that compares its hemodynamic instability and medical management requirements with those of isolated left ventricular takotsubo cardiomyopathy. Herein, we discuss the case of our patient, review the pertinent medical literature, and convey the prevalence and importance of right ventricular involvement in patients with takotsubo cardiomyopathy.

Mural thrombus in the normal-appearing descending thoracic aorta of a chronic smoker.

Thrombus formation in an atherosclerotic or aneurysmal descending thoracic aorta is a well-described, frequently encountered vascular condition. In comparison, thrombus formation in a normal-appearing descending thoracic aorta is reported far less often. We describe the case of a 46-year-old woman who had splenic and renal infarctions secondary to embolic showers from a large, mobile thrombus in a morphologically normal proximal descending thoracic aorta. After the patient underwent anticoagulation, stent-grafting, and surgical bypass to correct an arterial blockage caused by the stent-graft, she resumed a relatively normal life. In contrast with other cases of a thrombotic but normal-appearing descending thoracic aorta, this patient had no known malignancy or systemic coagulative disorders; her sole risk factor was chronic smoking. We discuss our patient's case and review the relevant medical literature, focusing on the effect of smoking on coagulation physiology.

Risk Factors for the Development of Atrial Fibrillation in HIV Infected Patients.

Background: Patients with Human Immunodeficiency Virus (HIV) have an array of multi-organ involvement, including cardiovascular disease. CD4 count is one of the best parameters to monitor the severity of HIV disease. The arrythmogenic potential of HIV disease has not been well defined. The aim of the study is to establish whether an association between the severity of HIV and atrial fibrillation (AF) exists. Methods: Out of a retrospective cohort of 780 HIV patients from January 2006 to December 2008, 40 patients were selected that developed AF during this period .The age and sex matched controls (n=40) were selected for comparison. The comparison between both groups was done using Fischer Exact Test. Bivariate and multivariate analysis was also performed to analyze the results. Results: The data shows that 47%(19/40) of the patients with HIV who developed AF had CD4 count lower than 250 as compared to 20%(8/40) in the control group (P value = 0.017) Conclusion: The data supports the presence of a relationship between HIV and AF. Patients with lower CD4 counts are more susceptible to develop AF.

Takotsubo Syndrome in African American vs. Non-African American Women.

OBJECTIVES: Takotsubo syndrome (TTS) is a reversible cause of heart failure rarely described in African-American patients. This study aimed to compare and contrast the clinical characteristics of TTS in African-American (AA) and non-African-American (NAA) patients. METHODS: We retrospectively reviewed the charts of eight patients (four AA and four NAA) diagnosed with TTS, between June 2006 and August 2008, in four different teaching hospitals: St Michael's Medical Center, St Joseph's Medical Center, Trinitas hospital and St Louis' University Hospital. We compared the patients with regard to presenting symptoms, precipitating stressors, electrocardiographic findings, troponin levels, ejection fraction and in-hospital course. RESULTS: All patients were females (mean age 64 for AA and 67 for NAA). All patients experienced chest pain and had elevated troponin levels. Two AA and three NAA patients had associated shortness of breath and one NAA had syncope. All AA and three NAA had T-wave inversions. Three NAA and one AA had ST segment elevation. Three patients in both groups developed prolongation of the QT interval. Coronary angiograms did not reveal any significant obstructive coronary artery disease. Three patients, all NAA, needed hemodynamic support during their hospital stay but none died. CONCLUSION: AA and NAA women with TTS have similar presenting symptoms but may differ in the electrocardiographic findings and in-hospital course of the disease.

Concurrent primary cardiac tumors of differing histology and origin: case report with literature review.

Primary cardiac tumors are rare and are diverse in histology and anatomic origin. Approximately 75% are benign, and nearly 50% of these are myxomas. Herein, we report concurrent myxoma and papillary fibroelastoma, which tumors were found attached to the left atrial septum and aortic valve, respectively. Concurrent primary cardiac tumors of differing histology and origin are rare, and, to our knowledge, this is one of the few such cases reported in the medical literature.

Case report and literature review: acute pneumonitis and alveolar hemorrhage after subcutaneous injection of liquid silicone.

Lay (non-medical) injection of silicone may lead to serious clinical consequences. Most reports of illicit cosmetic procedures have dealt with failed, lay attempts at breast augmentation. Although these procedures have resulted in severe pneumonitis and alveolar hemorrhage, reports of similar complication after lay attempts at buttock augmentation have been sparse. We describe one of these rare cases and review the literature on clinicopathologic sequelae of lay attempts at cosmetic procedures using commercially available silicone preparations.