Spontaneous Coronary Artery Dissection in a Liver Transplantation Candidate.

Spontaneous coronary artery dissection (SCAD) is an uncommon and potentially fatal cause of acute coronary syndrome, myocardial infarction, and sudden death primarily affecting women. While the exact cause of SCAD is unknown, associated risk factors are emotional or physical stress, female gender, pregnancy-related factors including hormonal changes, fibromuscular dysplasia, mixed connective tissue disorders, and inflammatory disorders. In this report, we present a middle-aged female with ulcerative colitis and cirrhosis secondary to primary sclerosing cholangitis who was found to have SCAD on cardiac evaluation for liver transplantation workup.

Treatment of Gabapentin Toxicity With Peritoneal Dialysis: Assessment of Gabapentin Clearance.

Gabapentin is almost exclusively cleared by the kidney and thus presents challenges in patients with kidney failure. Gabapentin is known to be effectively cleared by hemodialysis, but the efficiency of clearance by peritoneal dialysis (PD) has not been previously described. We report a case of gabapentin toxicity in a patient on long-term PD who was treated with continuous automated cycling PD. We find that continuous PD provides significant clearance of gabapentin. With 2-L exchanges every 2 hours, we document an apparent elimination half-life of 41.33 hours, which is substantially shorter than the reported elimination half-life of 132 hours in the absence of kidney function. Further, our patient's symptoms of gabapentin toxicity gradually improved and had fully resolved after about 36 hours of dialysis. Gabapentin clearance by PD was estimated at 94% of urea clearance. We conclude that intensive PD provides gabapentin clearance that approximates that of urea and is an effective but slow method to treat gabapentin overdose and toxicity.

Cardiac Structural Remodeling and Hemodynamic Patterns Following Transcatheter Aortic Valve Replacement.

Background Transcatheter aortic valve replacement (TAVR) is increasingly utilized for most patients with symptomatic severe aortic stenosis. TAVR is linked to enhanced long-term cardiac hemodynamics, reversal of left ventricle (LV) hypertrophy, and improved aortic valve gradients. We present a retrospective observational study assessing cardiac remodeling and valvular flow patterns post-TAVR. Methods Retrospective echocardiographic data were collected, evaluating cardiac function and valvular flow patterns before and after TAVR at a single institution. Data was compiled and statistically analyzed using a paired t-test evaluating variations at approximately 30 days and one-year post-TAVR. Results On echocardiogram 30 days and one-year post-TAVR, there was a reduction in LV mass index from 132 g/m² to 110 g/m² (95%CI: 98-122; p=0.01) and 118 g/m² (95%CI: 102-133; p=0.03), and a reduction in relative wall thickness from 0.54 to 0.49 (95%CI: 0.46-0.52; p=0.05) and 0.44 (95%CI: 0.38-0.49; p=0.03), respectively. Doppler velocity indices (DVI) increased from 0.24 to 0.61 (95%CI: 0.49-0.73; p<0.001) and 0.57 (95%CI: 0.48-0.65; p<0.001). Expected improvement in aortic valve velocities and gradients were observed post-TAVR. Conclusions Following TAVR, LV remodeling can be observed as early as 30 days. This is demonstrated by a reduction in LV mass index and relative wall thickness in conjugation with an anticipated improvement in valvular flow patterns and flow across the aortic valve.

Recurrent Stress-Induced Cardiomyopathy With Cardiogenic Shock Requiring Impella Left Ventricular Assist Device.

Stress-induced cardiomyopathy (SIC) is associated with varying etiologies. We present a case of a 65-year-old female with recurrent SIC secondary to seizures who presented in cardiogenic shock requiring mechanical circulatory support using an Impella CP via the right axillary approach.

Utility of Radiopaque Bypass Graft Markers During Coronary Angiography Following Coronary Artery Bypass Graft Surgery.

BACKGROUND: Radiopaque bypass graft markers allow easy visualization of the location of the graft and can minimize contrast use and radiation exposure during follow-up coronary angiography. METHODS: This retrospective study analyzed coronary artery bypass graft patients who underwent subsequent coronary angiography in the John Cochrane Veterans Affairs Medical Center from January 2009 until September 2017. RESULTS: Patients who underwent diagnostic coronary angiography with proximal graft markers required less contrast use (P<.02) and less fluoroscopy time (P<.01). The presence or absence of proximal graft markers had no significant difference on the rise of creatinine following coronary angiography (P=.28). CONCLUSION: Bypass graft markers reduce contrast and radiation use in follow-up coronary angiography and reduce incidence of contrast-induced acute kidney injury.

Management options of acute left main coronary thrombus.

The management of coronary thrombus is not well defined. Current therapies include medical management with anticoagulation, antiplatelet, and thrombolytic therapies or revascularization with percutaneous coronary interventions including mechanical thrombectomy, and coronary artery bypass grafting surgery. In this report, we present a patient with significant left main coronary artery thrombus burden with advanced cirrhosis and recent esophageal variceal bleeding who was successfully treated with conservative medical management.