Balloon rupture during transcatheter aortic valve replacement.

A distinctive complication with balloon-expandable (BE) THV platforms such as the Edwards Sapien (Edwards Lifescience) is the possibility of balloon rupture during THV deployment. Balloon rupture is a rare occurrence that can result in stroke due to fragment embolism, incomplete THV expansion, and/or vascular injury upon retrieval of the balloon. Careful evaluation of preoperative computed tomography is essential to identify high-risk cases. While annular and left ventricular outflow tract (LVOT) calcification are widely acknowledged as common risks for balloon injury, it's essential to note that balloon injury can manifest at various anatomical sites. In this review, we discuss the mechanism behind balloon rupture, methods to identify cases at a heightened risk of balloon injury, approaches to mitigate the risk of rupture, and percutaneous retrieval strategies.

Mechanical Circulatory Support for High-Risk Percutaneous Coronary Intervention.

PURPOSE OF REVIEW: This review will focus on the indications of mechanical circulatory support (MCS) for high-risk percutaneous coronary intervention (PCI) and then analyze in detail all MCS devices available to the operator, evaluating their mechanisms of action, pros and cons, contraindications, and clinical data supporting their use. RECENT FINDINGS: Over the last decade, the interventional cardiology arena has witnessed an increase in the complexity profile of the patients and lesions treated in the catheterization laboratory. Patients with significant comorbidity burden, left ventricular dysfunction, impaired hemodynamics, and/or complex coronary anatomy often cannot tolerate extensive percutaneous revascularization. Therefore, a variety of MCS devices have been developed and adopted for high-risk PCI. Despite the variety of MCS available to date, a detailed characterization of the patient requiring MCS is still lacking. A precise selection of patients who can benefit from MCS support during high-risk PCI and the choice of the most appropriate MCS device in each case are imperative to provide extensive revascularization and improve patient outcomes. Several new devices are being tested in early feasibility studies and randomized clinical trials and the experience gained in this context will allow us to provide precise answers to these questions in the coming years.

Antenatal Diagnosis of Jeune Syndrome (Asphyxiating Thoracic Dysplasia) with Micromelia and Facial Dysmorphism on Second-Trimester Ultrasound.

BACKGROUND: Jeune syndrome is a rare congenital malformation with a reported incidence of 1 in 100,000-130,000 live births. Thoracic hypoplasia is the most striking abnormality of this disorder. Here we report a case of Jeune syndrome with marked thoracic hypoplasia, micromelia and facial dysmorphism, which was diagnosed on a second-trimester antenatal real-time three-dimensional ultrasound. CASE REPORT: A 24-year-old primigravida came for routine anomaly scan at 19 weeks of gestation. Transabdominal grey scale and real time 3D ultrasound (US) was done with GE Logiq P5 with curvilinear array transducers (4C and 4D3C-L). US findings were consistent with the diagnosis of Jeune syndrome (Asphyxiating thoracic dysplasia). CONCLUSIONS: Jeune syndrome is an extremely rare congenital disorder with a spectrum of abnormalities of which thoracic hypoplasia is the most striking. It can be diagnosed on early antenatal US by its characteristic skeletal and morphological features which can guide further management of pregnancy in form of termination or preparation for surgical correction of the deformity.

Congestive Myelopathy due to Intradural Spinal AVM Supplied by Artery of Adamkiewicz: Case Report with Brief Literature Review and Analysis of the Foix-Alajouanine Syndrome Definition.

BACKGROUND: Spinal arteriovenous malformations (AVMs) can lead to development of congestive myelopathy (Foix-Alajouanine syndrome). Spinal AVMs are rare and so is this syndrome. Diagnosis is often missed due to its rarity and confusing definitions of the Foix-Alajouanine syndrome. CASE REPORT: We report a case of a 47-year-old male patient suffering from this rare syndrome with an AVM arising from the artery of Adamkiewicz, which is another rarity. Our patient was treated by embolization of the lesion with 20% glue, after which he showed mild improvement of symptoms. We also present a brief review of literature on spinal AVMs and elucidate the evolution of the term Foix-Alajouanine syndrome. CONCLUSIONS: Use of the term "Foix-Alajouanine syndrome" should be restricted to patients with progressive subacute to chronic neurological symptoms due to congestive myelopathy caused by intradural spinal AVMs. CT angiography should supplement DSA as preliminary Imaging modality. Patients may be treated with surgery or endovascular procedures.

Pharmacokinetic enhancement of marbofloxacin by alpha-1-monolaurin pre-treatment in broiler chickens.

The present study investigated the prospect of improvement in pharmacokinetic (PK) parameters of marbofloxacin due to alpha-1-monolaurin pre-treatment in broiler chickens. Two groups of broilers were administered a single oral dose of marbofloxacin (5.00 mg kg-1 body weight): Group-I without pre-treatment and Group-II with alpha-1-monolaurin pre-treatment (4.00 g kg-1 feed for 10 days). Blood sampling was done periodically for both groups and plasma marbofloxacin concentrations were determined using ultra-high performance liquid chromatography. Pharmacokinetic parameters using non-compartmental modelling approach were calculated with the PKSolver software. Statistical analysis revealed significant differences in plasma marbofloxacin concentrations between the two groups at 1, 2, and 24 hr. Group-II birds exhibited a higher mean maximum plasma concentration (2.43 µg mL-1) at an earlier time (Tmax: 1.38 hr) compared to Group-I. The plasma concentrations of marbofloxacin were maintained above 0.10 and 0.18 µg mL-1 up to 24 hr in Group-I and Group-II broilers, respectively. Significant differences were observed in PK parameters such as the area under the curve and total body clearance. The mean relative oral bioavailability of Group-II birds compared to Group-I was 119.61%. The findings of the study provided evidence of PK parameters enhancement of marbofloxacin in the alpha-1-monolaurin pre-treated group. The calculated PK-pharmacodynamic indices for marbofloxacin predicted clinical efficaciousness in the broiler chickens.

Contemporary use of anticoagulation in the cardiac catheterization laboratory: a review.

Anticoagulation during percutaneous coronary interventions has a rich history that has been shaped by several key clinical trials. The correct choice of anticoagulation during interventions can maximize patient outcomes and ensure a safe procedure. However, in some specific situations, anticoagulation may not be required at all. In this review article, we review the significant clinical trials and current guidelines regarding the use of anticoagulation in the catheterization laboratory and discuss the unique pharmacological aspects of the most commonly used agents, with an emphasis on the specific pharmacokinetic parameters that dictate how these agents are used and monitored. Finally, we discussed the future directions in anticoagulation therapy in coronary artery disease. This review serves as a robust synopsis of the clinical data for practicing clinicians and fellows in training.

Cardiovascular failure and cardiogenic shock.

Cardiovascular system failure is commonly faced by the intensivist. Heart failure can occur due to a host of predisposing cardiac disorders or as secondary effects of systemic illness. When the heart is unable to provide an adequate cardiac output to maintain adequate tissue perfusion, cardiogenic shock ensues. Without prompt diagnosis and appropriate management, these patients have significant morbidity and mortality, with in-hospital mortality approaching 60% for all age groups. Accurate and rapid identification of cardiogenic shock as a medical emergency, with expeditious implementation of appropriate therapy, can lead to improved clinical outcomes. In this review, we discuss optimal strategies for diagnosis and monitoring of cardiogenic shock. We discuss the diverse therapeutic strategies employed for cardiogenic shock, including pharmacological (e.g., vasoactive agents, fibrinolytic agents), mechanical (e.g., intraaortic balloon pumps, left ventricular assist devices, percutaneous coronary intervention [PCI]), and surgical approaches such as coronary artery bypass graft (CABG), valvular repair or replacement (e.g., for acute mitral regurgitation, ventricular septal rupture, or free wall rupture).

Successful use of the impella ventricular assist device for management of reverse Takotsubo Cardiomyopathy in the setting of acute intracranial hemorrhage.

Reverse Takotsubo Cardiomyopathy (rTTC) is a rare variant of Takotsubo Cardiomyopathy (TTC) that is characterized by hypokinesis of the base and sparing of the mid to apical wall of the left ventricle best seen on echocardiogram. Intracranial hemorrhage (ICH) has been identified as a risk factor rTTC. Nearly around 10% of the patients with TTC develop cardiogenic shock. We hereby report the successful use of the Impella Ventricular Assist Device (Impella CP®) for management of rTTC in the setting of acute ICH. Our patient is a young female who presented with loss of consciousness after an acute headache and imaging studies revealed left posterior cerebral artery aneurysm with intraventricular hemorrhage. Subsequently the patient developed hypoxia, severe hypotension and cardiac arrest. After resuscitation, an echocardiogram showed that the patient had rTTC and a cardiac angiogram showed patent coronary arteries. The Impella CP® was successfully inserted followed by immediate cerebral angiography and aneurysmal coiling. Systemic anticoagulation was started during coiling. In the next three days, the patient's left ventricular function recovered, and she was discharged home. Up to our knowledge, this is the first case report to mark the successful placement of the Impella CP® with delayed initial anticoagulation for management of rTTC. Our patient was challenging as there are no current guidelines in the management of cardiogenic shock secondary to rTTC in the setting of acute ICH.

A Rare Case of Multivessel SCAD Successfully Treated with Conservative Medical Management.

A female patient presented with severe, symptomatic multivessel spontaneous coronary artery dissection (SCAD) with no known medical history or risk factors. The affected vessels were left anterior descending artery (LAD), right coronary artery (RCA), and the ramus. She was treated with conservative medical management. Two months later, repeat coronary angiogram to evaluate for any residual disease was performed which showed near-complete resolution of all involved vessels.

Neoplastic and non-neoplastic proliferative disorders of the perirenal space: cross-sectional imaging findings.

The perirenal space, located between the anterior and the posterior renal fasciae, is shaped like an inverted cone with an apex that extends into the iliac fossa. Perirenal tumors and pseudotumors primarily originate either from the kidney or as part of a systemic disease process and have characteristic histopathologic features and biologic behavior. The lesions may be classified on the basis of their distribution and imaging features as solitary soft-tissue masses (renal cell carcinoma, lymphangioma, hemangioma, and leiomyoma), rindlike soft-tissue lesions (lymphoma, retroperitoneal fibrosis, and Erdheim-Chester disease), masses containing macroscopic fat (angiomyolipoma, liposarcoma, myelolipoma, and extramedullary hematopoiesis), and multifocal soft-tissue masses (metastases, plasma cell tumors). Because of overlap in imaging findings among these diverse perirenal lesions, a definitive diagnosis in most cases can be established only at histopathologic analysis. However, an imaging pattern-based approach may facilitate the diagnosis and optimal management of perirenal tumors and pseudotumors.

Incidental diagnosis of liver tuberculosis in a patient with jaundice.

A 30-year-old afebrile woman presented with anorexia, yellowish discolouration of the sclera and bilateral pedal oedema. Blood investigations revealed severe anaemia, raised erythrocyte sedimentation rate and thrombocytopaenia. Liver function tests were abnormal with raised bilirubin, alanine transaminase and prothrombin time. Chest roentgenogram was negative for tuberculosis. Abdominal ultrasonography (USG) revealed coarsened echotexture of the liver with surface nodularity. Contrast-enhanced CT scan revealed heterogeneity with surface and parenchymal nodularity scattered throughout the liver parenchyma. USG-guided liver biopsy was performed, which showed changes in granulomatous hepatitis with positive Ziehl-Neelsen staining for acid-fast bacilli. The patient was started on antituberculous drugs. After completion of the antituberculous regimen, the patient made an uneventful recovery with normal range of aspartate aminotransferase, serum albumin and prothrombin time. In summary, isolated liver tuberculosis is rare and a high index of suspicion is required in a patient from an area where tuberculosis is endemic, after excluding other common diffuse liver pathologies.