Progression of asymptomatic mild carotid artery stenosis: Implications for frequency of surveillance.

We looked retrospectively at the 3- to 5-year progression of mild, asymptomatic carotid artery stenosis (CAS). A random sample of 600 patients who had undergone at least two carotid artery duplex ultrasounds between 31 October 2006 and 1 November 2016 with a second duplex ⩾3 and ⩽5 years following the initial one were screened for inclusion. Internal carotid arteries (ICAs) were included if they had 20-49% stenosis on the initial duplex, with 440 carotid arteries meeting this criteria. Analyses were performed utilizing chi-squared and two-tailed t-tests. Twenty-four (5.45%) of the initial 440 carotid arteries progressed to moderate CAS. There was a statistically significant increase in the prevalence of hypertension (68% vs 47%, p=0.022) and diabetes mellitus (44% vs 22%, p=0.008) in patients with carotids that progressed to moderate CAS. There was a decrease in moderate-intensity statin use (32% vs 58%, p=0.005) and an increase in patients not on statins (36% vs 11%, p=0.001) in the group of carotids that progressed to moderate CAS. One carotid artery (0.2%) progressed from mild CAS to severe CAS. If supported by others, our data may lead to a change in the recommendations regarding appropriate follow-up of asymptomatic CAS.

Bacterial endocarditis presenting in an adult patient with undiagnosed double-chambered right ventricle.

Double-chambered right ventricle (DCRV) is a rare congenital heart defect often associated with ventricular septal defect and pulmonary stenosis. Cardiac catheterization or magnetic resonance imaging can differentiate between DCRV and Tetralogy of Fallot when echocardiogram is inconclusive. Patients are at an increased risk for bacterial endocarditis.

Successful Implementation of Extracorporeal Membrane Oxygenation Support as a Bridge to Heart-Lung Transplantation in an Eisenmenger's Syndrome Patient With Paradoxical Coronary Embolism.

We report a case of a 23-year-old female with a history of unrepaired ventricular septal defect and pulmonary arterial hypertension with Eisenmenger's syndrome (ES) presenting with chest pain. Electrocardiography demonstrated new anterior Q waves and anterolateral ST elevations, and coronary angiography revealed a large organized thrombus in the mid-left anterior descending artery consistent with paradoxical coronary embolism. Patient was treated with percutaneous coronary intervention and aggressive anticoagulation management. Intensive care unit course was complicated by respiratory failure requiring intubation due to hospital-acquired pneumonia in the setting of severe pulmonary hypertension. Patient was emergently initiated on veno-venous extracorporeal membrane oxygenation support (ECMO) as a bridge to heart-lung transplantation. After initiation of ECMO, patient displayed significant clinical improvement and underwent successful heart-lung transplantation. This case highlights veno-venous ECMO as a bridge to heart-lung transplantation in acutely decompensated patients with ES, and is the first reported case of paradoxical coronary embolism in a patient with ES.

Pulmonary vascular resistance index: Getting the units right and why it matters.

Pulmonary vascular resistance (PVR) and PVR index (PVRI) are key variables in a broad range of contexts, including prediction of outcomes in heart and liver transplantation, determining candidacy for closure of atrial or ventricular septal defects, and guiding treatment of pulmonary hypertension. Significant variability exists among the units used to report PVRI in current literature, making the interpretation of data and translation into clinical practice difficult. Here, we will review the measurement and derivation of PVR and PVRI and demonstrate the extent of confusion in the literature. We conducted a literature search of all published articles in PubMed using the term "PVRI." This yielded 218 sources with defined units for PVRI, including 33 unique variants. Among all reviewed literature, 45.4% of sources reported PVRI with units ending in m2 (meters squared), which we defined as correct, whereas 54.6% reported PVRI with units not ending in m2 , which we defined as incorrect. This lack of uniformity has led to considerable confusion among researchers and clinicians, with potentially life-altering consequences.

Left Atrial Appendage Occlusion Complicated by Appendage Perforation Rescued by Device Deployment.

The Watchman device is a transcatheter left atrial appendage (LAA) occluding device used in patients with nonvalvular atrial fibrillation (NVAF) and a high CHADS2-VA2SC score who are poor long-term anticoagulation candidates. Pericardial effusion related to device deployment and perforation can be a life-threatening complication. While not common in hands of experienced operators, management may require surgical intervention. Here we present a rare case of LAA perforation, which was corrected by successful repositioning of the device foregoing the need for surgical management.