Clinical effects of physiologic lesion testing in influencing treatment strategy for multi-vessel coronary artery disease.

Background: The application of fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) in multivessel coronary artery disease (CAD) patients has not been definitively explored. We herein assessed how treatment strategies were decided based on FFR/iFR values in vessels selected clinically. Specifically, we sought to determine whether treatment selection was based on whether the vessel tested was the clinical target stenosis. Methods: 270 consecutive patients with angiographically determined multivessel disease who underwent FFR/iFR testing were included. Patients were classified initially based on their angiographic findings, then re-evaluated from FFR/iFR results (normal or abnormal). Tested lesions were classified into target or non-target lesions based on clinical and non-invasive evaluations. Results: Abnormal FFR/iFR values were demonstrated in 51.9 % of patients, in whom 51.4 % received coronary stenting (PCI) and 44.3 % had bypass surgery (CABG). With two-vessel CAD patients, medical therapy was preferred when the target lesion was normal (72.6 %), while PCI was preferred when it was abnormal (78.4 %). In non-target lesions, PCI was preferred regardless of FFR/iFR results (78.0 %). With three-vessel CAD patients, CABG was preferred when the target lesion was abnormal (68.5 %), and there was no difference in the selected modality when it was normal. Furthermore, the incidence of tested lesions was higher in the left anterior descending (LAD) compared to other coronary arteries, and two-vessel CAD patients with LAD stenoses were more frequently treated by PCI. Conclusion: The use of invasive physiologic testing in multivessel CAD patients may alter the preferred treatment strategy, leading to an overall increase in PCI selection.

Incidence of acute myocardial infarction and hurricane Katrina: Fourteen years after the storm.

INTRODUCTION: Historically, natural disasters have been known to have an effect on humankind including physical and mental health. Studies dating from the early nineteen hundreds have shown repeated associations between different catastrophic natural disasters and its effects on cardiovascular (CV)health, including increased morbidity and mortality. Knowing that these effects on CV health last sometimes up to a decade, we sought to study the effects of hurricane Katrina on incidence of acute myocardial infarctions (AMI) to see if the effects perpetuated and continued or mitigated after the first decade. METHODS: Ours is a single center, retrospective observational study at TUHSC to compare the incidence of AMI, chronobiology and other demographic characteristics between the 2-year pre-Katrina and 14-year post-Katrina group. After IRB approval, patients were identified using specific ICD 9 and 10 codes. Data was collected by chart review and stored in secure password protected files. Descriptive statistics including mean, standard deviation and percentages were calculated. Statistical analysis comparing mean and standard deviations were performed using Chi-square test and t-test. RESULTS: The pre-Katrina cohort saw a 0.7% incidence of AMI, whereas the post-Katrina cohort saw 3.0% incidence of AMI (p < 0.001). The post- Katrina group was also noted to have significantly higher comorbidities including diabetes, hypertension, polysubstance abuse and coronary artery disease. CONCLUSIONS: Even 14 years after the storm, there was a four-fold increase in the incidence of AMI. Additionally, psychosocial, behavioral and traditional risk factors for CAD were significantly higher more than a decade after the natural disaster as well.

Anomalous Coronary Origin and Malignant Course in a Young Patient With Palpitation and Demand Ischemia: A Serendipity or a Syndrome Without a Name?

Anomalous coronary artery remains the second most common cause for sudden cardiac death (SCD) in young athletes. The anomaly most commonly associated with SCD is the one that courses between the aorta and pulmonary artery, the malignant course. We present a case of a young gentleman who presented with symptomatic palpitations and was found to have anomalous right coronary artery from ostial left main coronary artery coursing between the aorta and pulmonary artery.

Eustachian and Tricuspid Valve Endocarditis: A Rare Consequence of the Automatic Implantable Cardioverter-Defibrillator Placement.

Eustachian valve (EV) is usually a rudimentary structure in adults. It is an embryological remnant of sinus venosus that directs oxygenated blood from the inferior vena cava across the foramen ovale and into the left atrium. Intravenous drug use is most commonly associated with infective endocarditis of the right-sided heart structures. Other documented causes of such an occurrence are intracardiac devices like pacemakers and central venous catheters. Patients presenting with concerns of infection and embolic phenomenon should promptly undergo evaluation for infective endocarditis. Although an embryological remnant, the eustachian valve normally regresses after birth, except in a minority of the patients, it persists as a vestigial structure. Here we present an unusual case involving infective endocarditis of the eustachian valve and tricuspid valve both in a patient with recent automatic implantable cardioverter-defibrillator (AICD) placement and history of IV drug abuse and its systemic consequences in a patient with patent foramen ovale.

A Rare Case of Bronchomediastinal Pulmonary Vein Fistula due to Fibrosing Mediastinitis.

Fibrosing mediastinitis (FM) is a rare condition with extensive proliferation of fibrous tissue in the mediastinum usually happens few years after Histoplasma infection. FM usually occurs years later after presentation of Histoplasma infection, and usually what makes patients seek medical attention are symptoms from compression and occlusion of vital mediastinal structures, such as the central airways, superior vena cava, pulmonary arteries, and veins. Rarely, heart, pericardium, coronaries, and aorta are involved. We report a case of 39-year-old-male who was admitted with fever and cough. The patient's condition worsened despite being on broad-spectrum antibiotics, with worsening encephalopathy and a new onset lower extremity weakness. Brain imaging showed multiple strokes suggestive of embolic event. CT chest/abdomen was suggestive of FM along with cavitary lung nodules and pneumomediastinum. Splenic and renal infarcts were also noted. Infective endocarditis was one of the top differential diagnosis due to multiple embolic infarcts, and hence a transesophageal echocardiography (TEE) was pursued. TEE showed a mass along with air bubbles entering the left atrium from the pulmonary vein. On re-evaluation of CT chest images, a fistula was seen extending from the mediastinum to the left main bronchus and the left upper pulmonary vein. This supported the diagnosis of FM with erosion of lymph node into the left main bronchus and left upper pulmonary artery, leading to fistula formation and subsequent systemic air embolization. The diagnosis of FM requires a multimodality approach, high clinical suspicion, and accurate history taking. Treatment mainly aims at managing the mechanical complications.

Natural disasters and acute myocardial infarction.

Natural disasters are devastating to not only our physical property but also to our health. There have been several studies over the last few decades that have correlated different types of natural disasters with acute myocardial infarctions (AMIs). Since the early 1930's singular meteorological events have been reported to have some association and effect on cardiovascular (CV) mortality and morbidity. Multiple natural disasters regardless of location have repeatedly reported a significant increase in the incidence of acute coronary syndromes (ACS). Each event was associated with similar mechanisms, which increase the overall CV mortality. The most prominent of those being neurohormonal activation, total scarcity of supplies and access to health care, poverty, stress, increased incidence of smoking and drug abuse. Increased incidence of associated infections added to the burden of ACS. We know natural disasters are inevitable; however, disaster preparedness is surely a reliable way to help curb their devastating effects on human life. In this manuscript, the authors present many forms of natural disasters and their association with acute myocardial infarction (AMI).

Publisher Correction: Combining Biomarkers with EMR Data to Identify Patients in Different Phases of Sepsis.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Erratum: Radiation therapy-induced aortoesophageal fistula: a case report and review of literature.

[This corrects the article DOI: 10.1093/gastro/gou081.].

Cardiotoxicity with Itraconazole.

Itraconazole is a commonly used antifungal drug. In addition to commonly described adverse effects, there have been few reports of heart failure with its use. We present two cases that developed acute systolic heart failure with Itraconazole use. A man in his early 30s was admitted with worsening leg swelling and dyspnoea on exertion. He had been on Itraconazole for blastomyces skin ulcer. His ejection fraction (EF) was found to be 10%-15%. Another man in his 50s was admitted with similar symptoms; his EF was 40%-45%. He had been on Itraconazole for forearm cellulitis. No other aetiology was identified in both patients despite extensive work-up including cardiac catheterisation. Itraconazole was stopped in both the cases. Our first patient did not improve even months after cessation of therapy and was referred for heart transplant. Our second patient improved after a few weeks, and his ejection fraction had improved on repeat testing.

Unusual case of prosthetic joint infection caused by Francisella Tularensis.

Tularaemia is a zoonotic infection caused by Francisella tularensis.Ulceroglandular, glandular, oculoglandular, pharyngeal, typhoidal and pneumonic types are the different types of the disease. Infection of prosthetic joints occurs at an exceedingly uncommon rate. We report a case of prosthetic joint infection involving the hip with F. tularensis, which to the best of our knowledge after a thorough literature review is the second of its kind.

Combining Biomarkers with EMR Data to Identify Patients in Different Phases of Sepsis.

Sepsis is a leading cause of death and is the most expensive condition to treat in U.S. hospitals. Despite targeted efforts to automate earlier detection of sepsis, current techniques rely exclusively on using either standard clinical data or novel biomarker measurements. In this study, we apply machine learning techniques to assess the predictive power of combining multiple biomarker measurements from a single blood sample with electronic medical record data (EMR) for the identification of patients in the early to peak phase of sepsis in a large community hospital setting. Combining biomarkers and EMR data achieved an area under the receiver operating characteristic (ROC) curve (AUC) of 0.81, while EMR data alone achieved an AUC of 0.75. Furthermore, a single measurement of six biomarkers (IL-6, nCD64, IL-1ra, PCT, MCP1, and G-CSF) yielded the same predictive power as collecting an additional 16 hours of EMR data(AUC of 0.80), suggesting that the biomarkers may be useful for identifying these patients earlier. Ultimately, supervised learning using a subset of biomarker and EMR data as features may be capable of identifying patients in the early to peak phase of sepsis in a diverse population and may provide a tool for more timely identification and intervention.

Radiation therapy-induced aortoesophageal fistula: a case report and review of literature.

Aortoesophageal fistula (AEF) is a rare cause of massive upper gastrointestinal hemorrhage. Thoracic aortic aneurysm, esophageal foreign body, esophageal cancer and post-surgical complications are common causes of AEF; however, AEF induced by radiation therapy is a rare phenomenon and seldom described in the literature. It is a catastrophic condition which requires rapid implementation of resuscitative measures, broad-spectrum antibiotics and surgical or endovascular intervention. Transthoracic endovascular aortic repair (TEVAR) is a newer and less invasive technique, which helps to achieve rapid hemostasis in patients with severe hemodynamic instability and offers advantages over conventional repair of the aorta in emergency situations. However initial TEVAR should be followed up with a more definitive surgical repair of the aorta and the esophagus, to lower the mortality rate and achieve better outcomes. We describe here a case of a seventy-year-old male who presented with massive upper gastrointestinal bleeding due to AEF induced by radiation therapy, and his subsequent successful initial management with TEVAR.