All that Doesn't Enhance Isn't a Thrombus: Pitfalls Using Cardiac MRI TI 600 Sequence to Distinguish Between Cardiac Thrombus Versus Myxoma.

A 51-year-old male with a complicated medical history presented with shortness of breath. Preoperative workup confirmed the presence of a large atrial mass. However, delayed gadolinium enhancement CMR with long inversion time (TI 600) showed lack of enhancement, which was suggestive of a thrombus. During cardiac magnetic resonance imaging, delayed gadolinium enhancement sequences with long inversion time (TI 600) are commonly used to distinguish between an avascular thrombus versus a vascular tumor.

A case report of a rapidly growing giant coronary pseudoaneurysm: challenges and lessons learned.

Background: Coronary pseudoaneurysm is a rare, potentially fatal, complication of coronary intervention. A challenging management case of a giant right coronary pseudoaneurysm is presented. Case summary: A 56-year-old man presented with an atypical presentation for ST-elevation myocardial infarction. Initial angiogram showed a crescent-shaped ostial lesion with probable connection to the aorta, which disappeared after placing a drug-eluting stent. A few hours later, patient was found to have staph aureus bacteraemia and infective endocarditis for which he received a prolonged antibiotic course. Patient presented a few weeks later with second degree heart block. Echocardiography showed a large cystic lesion adjacent to the right coronary cusp suspicious for a coronary pseudoaneurysm, which was confirmed with angiography. Attempts to treat it with a covered stent were unsuccessful and patient ultimately underwent surgical resection. Discussion: Coronary pseudoaneurysm develops when there is a contained breach of all three layers of the vessel. It may develop from direct iatrogenic trauma to the vessel wall but can be infectious in aetiology. The treatment approach remains uncertain due to limited evidence. Here, we present the diagnostic and technical challenges of managing such an uncommon entity and discuss an algorithm for management.

Cryoballoon vs radiofrequency ablation of atrial fibrillation: insights from the Veterans Healthcare System.

PURPOSE: Catheter ablation is considered the mainstay treatment for drug-refractory atrial fibrillation (AF). The aims of our study were to compare the efficacy and safety of the most two currently approved approaches (point-by-point radiofrequency ablation (RFA), either with contact force (CF) or without contact force (nCF) catheters, and cryoballoon ablation (CBA)) in the Veterans Healthcare System. METHODS: We performed a retrospective study of patients who underwent ablation for treatment of AF at the veterans affairs healthcare system between 2013 and 2018. Only the first reported ablation procedure was included. RESULTS: We included 956 patients in the study (97.4% males, 91.5% Caucasians, 67% paroxysmal AF), with 682 patients in RFA-nCF, 139 in RFA-CF, and 135 in CBA. Thirty-day complication rates were comparable between the three groups with the exception of higher incidence of phrenic nerve injury in CBA group when compared to RFA-nCF (2.2% vs 0.0%, p < 0.01). Long-term recurrence rate of AF was significantly lower in the CBA group when compared to RFA-nCF (33.3% vs 47.7%, adjusted HR 0.60, 95% CI 0.44-0.83, p < 0.01). On the other hand, it was similar between RFA-CF and RFA-nCF groups (43.9% vs 47.7%, adjusted HR 1.01, 95% CI 0.76-1.33, p 0.97). After stratifying patients based on AF type, these findings were only present in patients with paroxysmal AF. CONCLUSION: CBA for paroxysmal AF, in male dominant patients' population, was associated with lower incidence of AF recurrence rate while having a comparable safety profile to RFA independent of the use of CF catheters.

Increased Prevalence of Fragmented QRS in Randomly Selected Group of Multiple Myeloma Patients: A Pilot Study to Assess Prevalence.

The presence of fragmented QRS (fQRS) on surface electrocardiograms (ECGs) has been associated with the myocardial scar in certain cardiac conditions and has been proposed as a potential marker of adverse cardiac outcomes. Since myocardial fibrosis not only has been recognized as a side effect of certain cancer therapies but also, fQRS have been shown in some breast cancer and lymphoma survivors post-chemotherapy treatment, we decided to investigate if fQRS could also be seen in multiple myeloma (MM) patients since this association has never been described. For this pilot study, we analyzed ECGs from 137 randomly selected MM patients during different stages of their treatment, and fRQS was found in 42% of these cases. The prevalence was much higher than the reported prevalence for the general population (19.0%) but closer to that reported for patients with myocardial infarction (39.5%). We also found that female MM patients are more commonly affected than women in the general population. Based on this small random sampling analysis, fQRS appears highly prevalent among unselected MM patients. This novel finding of fQRS in MM patients certainly adds to the growing data of cases among different cancer patients, opening the door to conduct larger prospective studies that undoubtedly will help to create a more robust database regarding the potential utility of this ECG abnormality.

Label-free optical biomarkers detect early calcific aortic valve disease in a wild-type mouse model.

BACKGROUND: Calcific aortic valve disease (CAVD) pathophysiology is a complex, multistage process, usually diagnosed at advanced stages after significant anatomical and hemodynamic changes in the valve. Early detection of disease progression is thus pivotal in the development of prevention and mitigation strategies. In this study, we developed a diet-based, non-genetically modified mouse model for early CAVD progression, and explored the utility of two-photon excited fluorescence (TPEF) microscopy for early detection of CAVD progression. TPEF imaging provides label-free, non-invasive, quantitative metrics with the potential to correlate with multiple stages of CAVD pathophysiology including calcium deposition, collagen remodeling and osteogenic differentiation. METHODS: Twenty-week old C57BL/6J mice were fed either a control or pro-calcific diet for 16 weeks and monitored via echocardiography, histology, immunohistochemistry, and quantitative polarized light imaging. Additionally, TPEF imaging was used to quantify tissue autofluorescence (A) at 755 nm, 810 nm and 860 nm excitation, to calculate TPEF 755-860 ratio (A860/525/(A755/460 + A860/525)) and TPEF Collagen-Calcium ratio (A810/525/(A810/460 + A810/525)) in the murine valves. In a separate experiment, animals were fed the above diets till 28 weeks to assess for later-stage calcification. RESULTS: Pro-calcific mice showed evidence of lipid deposition at 4 weeks and calcification at 16 weeks at the valve commissures. The valves of pro-calcific mice also showed positive expression for markers of osteogenic differentiation, myofibroblast activation, proliferation, inflammatory cytokines and collagen remodeling. Pro-calcific mice exhibited lower TPEF autofluorescence ratios, at locations coincident with calcification, that correlated with increased collagen disorganization and positive expression of osteogenic markers. Additionally, locations with lower TPEF autofluorescence ratios at 4 and 16 weeks exhibited increased calcification at later 28-week timepoints. CONCLUSIONS: This study suggests the potential of TPEF autofluorescence metrics to serve as a label-free tool for early detection and monitoring of CAVD pathophysiology.

Aortic Stenosis in African Americans: Focus On Disparities in Treatment and Outcomes.

Aortic stenosis (AS) is the third most common type of cardiovascular disease after hypertension and coronary artery disease, and it carries a high mortality rate when left untreated. Risk factors include male sex, hypertension, tobacco use, advanced age, elevated LDL cholesterol, and coronary atherosclerosis. Definitive treatment for AS includes valve repair, either percutaneously or surgically; however, in aging populations corrective surgery carries increased risk. While research suggests that patients of some non-White ethnic groups, including African-Americans, are less likely than their Caucasian counterparts to have AS, these minority patients may experience may experience differences in the way they receive and accept care. This paper seeks to explicate the mechanisms of racial disparities among the African-Americans affected by aortic stenosis as they pertain to healthcare utilization, referral for valve replacement, acceptance of therapy, and overall treatment outcomes.

Long Term Risk of Recurrent Atrial Fibrillation and Ischemic Stroke after Post-Operative Atrial Fibrillation Complicating Cardiac and Non-Cardiac Surgeries.

BACKGROUND: New onset post-operative atrial fibrillation (POAF) can complicate both non-cardiac(NCS) and cardiac(CS) surgeries. Long term differences in recurrence of atrial fibrillation (AF) and incidence of ischemic stroke/transient ischemic attack(CVA)between these types of POAFare lacking. OBJECTIVE: To compare thelong term recurrence rate of AF and incidence of CVAin patients withnew onset POAF after CS and NCS. METHODS: All patients who developed POAF between May 2010 and April 2014 were included in this single-center, retrospective study Exclusion criteria included a prior history of atrial tachyarrhythmias and pre-operative use of anti-arrhythmic drugs. Recurrence of atrial fibrillation and CVA was identified by review of medical records, electrocardiogram and Holter monitor. RESULTS: patients identified by the ICD9 code=523, 112 patients (61 cardiac; 51 non-cardiac) met inclusion criteria. Mean follow up was 943 days (range 32-2052 days).AF recurrence rate within 30 days after hospital discharge was higher in CS compared with NCS(10% vs 0%, p =0.03). Kaplan Meier analysis showed a trend towards higher recurrence in NCS compared with CS(HR 2.8; 95% CI 0.78-10.6, log rank p =0.03).In long term follow-up, CVA was numerically more common in patients with POAF after CS compared withNCS(10% vs 2%) though this difference was non-significant(HR 3.1; 95% CI 0.72-13.3; log rank p =0.26). CONCLUSION: The risk of recurrent AF and ischemic stroke is not different between POAF after CS or NCS. The overall high rate of AF recurrence and risk of ischemic stroke mandate careful long term follow-up.

Full stent expansion of chronic total occlusion lesions requires prolonged inflation.

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has been associated in some studies with higher target vessel revascularization (TVR) rates than non-CTO PCI. Optimal stent inflation time and its effect on TVR in CTO PCI is unknown. We investigated the time required for stent deployment using the previously described pressure optimized protocol (POP), which uses stent balloon pressure stability rather than an arbitrary inflation time as an end point for balloon deflation. We also compared TVR with CTO PCI vs non-CTO using the POP protocol in both groups. METHODS: Patients with successful CTO PCI using POP between 2012 and 2015 were included. Patients having non-CTO PCI using POP and matched for stent diameter and length and temporal proximity constituted the control group to compare inflation time (n=83 each). TVR at 1year was compared between PCI during the time period using POP (CTO=83, non-CTO=263). RESULTS: Stent inflation time to achieve optimal stent inflation using POP was longer in CTO vs non-CTO lesions (136±60 vs 108±51s, p=0.001). TVR at 365days was similar in CTO and non-CTO cohorts (2.4% vs 2.6%, p=0.9). CONCLUSION: Stent expansion using POP in CTO lesions requires longer inflation duration but leads to similar TVR rates at 1year in CTO PCI compared with non-CTO PCI.

Myocardial strain pattern in patients with cardiac amyloidosis secondary to multiple myeloma: a cardiac MRI feature tracking study.

Cardiac MRI is frequently used in the diagnosis of cardiac amyloidosis. Feature tracking is a novel method of analyzing myocardial strain at the myocardial borders. We investigated myocardial deformation mechanics of both the right and left ventricles in patients with multiple myeloma with suspected cardiac amyloidosis. Comprehensive strain analysis was performed in 43 patients with multiple myeloma and suspected cardiac amyloidosis. MRI strain by feature tracking was measured using 2D cardiac performance analysis MR software (Tomtec, Germany). Global longitudinal (GLS) and global circumferential (GLC) strain were calculated in endo and epicardium. In addition, right ventricular longitudinal strain was measured in the endocardium only. All patients later underwent endomyocardial biopsy. Average wall thickness in biopsy proven cardiac amyloidosis group (22 patients) was 1.4 ± 0.4 cm with wall thickness ≤ 1.2 cm in 36 %. LGE was present in all patients with biopsy confirmed disease. There was significantly decreased global longitudinal strain and strain rate in the epicardial and endocardial layers. Global circumferential strain was significantly reduced in the epicardial layer but not the endocardium. GLS was significantly decreased at the base in both layers compared to the mid and apical regions of the myocardium. However, the base to apex GLS gradient was suggestive of apical sparing in the endocardial layer among patients with amyloidosis (-8.2 ± 2 vs. -2.7 ± 1; p = 0.001) but not the epicardial layer. Apical sparing was evident even in those with normal thickness CA. This feature tracking MRI analysis sheds light on strain mechanics in a cohort of multiple myeloma associated cardiac amyloidosis with a significant number of cases with normal LV wall thickness and explains mechanism of apical sparing effect.

Cardiovascular complications of multiple myeloma in the elderly.

INTRODUCTION: Multiple myeloma is a malignant neoplasm characterized by plasma cell proliferation in blood and bone marrow. Approximately two-thirds of the patients with multiple myeloma are >65 years at the time of diagnosis. Patients in this age group often have co-existing cardiovascular diseases. Areas covered: The presence of multiple myeloma adds to the malady by direct deposition of amyloid protein in the heart or via toxicity of chemotherapeutic agents. Cardiac contractile dysfunction, arrhythmias and thromboembolic disorders are the main issues in the management of elderly patients with multiple myeloma. Expert commentary: Assessment of cardiac risk and functional status requires careful evaluation by history, physical examination and imaging studies such as echocardiography and magnetic resonance imaging. The management of cardiovascular disorders in the presence of multiple myeloma is difficult and poses a challenge for the internist, the oncologist, and the cardiologist alike. This review is an overview of the problem of cardiovascular risk in and management of elderly patients with multiple myeloma.

Controversies in postoperative atrial fibrillation after noncardiothoracic surgery: clinical and research implications.

Post operative atrial fibrillation after non-cardiothoracic surgery is an increasingly common problem. There is little high quality data to guide clinicians in risk prediction as well as short term and long term management. There appears to be a significant risk of recurrent atrial fibrillation and stroke but effective screening strategies have not been tested. In this commentary, we delineate various controversies in the management of post operative atrial fibrillation and briefly review the available evidence. Prospective studies in this clinically important area of cardiology should be encouraged.

Xanthine Oxidase Induces Foam Cell Formation through LOX-1 and NLRP3 Activation.

PURPOSE: Xanthine oxidase catalyzes the oxidation of xanthine to uric acid. This process generates excessive reactive oxygen species (ROS) that play an important role in atherogenesis. Recent studies show that LRR and PYD domains-containing protein 3 (NLRP3), a component of the inflammasome, may be involved in the formation of foam cells, a hallmark of atherosclerosis. This study was designed to study the role of various scavenger receptors and NLRP3 inflammasome in xanthine oxidase and uric acid-induced foam cell formation. METHODS AND RESULTS: Human vascular smooth muscle cells (VSMCs) and THP-1 macrophages were treated with xanthine oxidase or uric acid. Xanthine oxidase treatment (of both VSMCs and THP-1 cells) resulted in foam cell formation in concert with generation of ROS and expression of cluster of differentiation 36 (CD36) and oxidized low density lipoprotein (lectin-like) receptor 1 (LOX-1), but not of scavenger receptor A (SRA). Uric acid treatment resulted in foam cell formation, ROS generation and expression of CD36, but not of LOX-1 or SRA. Further, treatment of cells with xanthine oxidase, but not uric acid, activated NLRP3 and its downstream pro-inflammatory signals- caspase-1, interleukin (IL)-1ß and IL-18. Blockade of LOX-1 or NLRP3 inflammasome with specific siRNAs reduced xanthine oxidase-induced foam cell formation, ROS generation and activation of NLRP3 and downstream signals. CONCLUSIONS: Xanthine oxidase induces foam cell formation in large part through activation of LOX-1 - NLRP3 pathway in both VSMCs and THP-1 cells, but uric acid-induced foam cell formation is exclusively through CD36 pathway. Further, LOX-1 activation is upstream of NLRP3 activation. Graphical Abstract Steps in the formation of foam cells in response to xanthine oxidase and uric acid. Xanthine oxidase stimulates LOX-1 expression on the cell membrane of macrophages and vascular smooth muscle cells (VSMCs) and increases generation of ROS, which activate NLRP3 inflammasome and downstream pro-inflammatory mediators such as Caspase-1, IL-1ß and IL-18. Xanthine oxidase also induces CD36 expression. Activation of both LOX-1 and CD36 (LOX-1> > CD36) participates in the transformation of macrophages and VSMCs into foam cells. Uric acid formed from xanthine-xanthine oxidase interaction stimulates CD36 expression and triggers foam cell formation independent of NLRP3 activation.

Doppler vocal fremitus.

A young woman with metastatic breast cancer was found to have a regular spectral Doppler event spanning multiple cardiac cycles and timing to her tachypneic respiratory rate, which suggested an extracardiac source. A chest CT confirmed a large mediastinal mass causing a postobstructive pneumonia. This Doppler signal reflected increased turbulence across the obstructed bronchus due to sound wave conduction through a pulmonary consolidation-a Doppler equivalent of "vocal fremitus" elicited by physical examination of a patient with a lung mass or pneumonia. Careful attention to the timing of Doppler abnormalities is required to avoid misdiagnosis.

Clinical and prognostic utility of cardiovascular magnetic resonance imaging in myeloma patients with suspected cardiac amyloidosis.

OBJECTIVES: AL amyloidosis affects up to 30% of patients with multiple myeloma (MM), and cardiac involvement is associated with worse outcomes. Traditional screening modalities including EKG, echocardiography and biomarkers have limited value. The aim of this study was to evaluate the clinical and prognostic value of late gadolinium enhancement (LGE) by cardiovascular magnetic resonance (CMR) imaging in patients with plasma cell dyscrasias and suspected cardiac amyloidosis (CA). METHODS: A total of 251 consecutive patients with plasma cell dyscrasias who underwent CMR were enrolled in this study. Primary endpoint was all cause mortality. Clinical, ECG, echocardiographic, biomarker and CMR predictors of mortality were analyzed. RESULTS: Mean age of population was 63 ± 10 years, 36% females and 19% African Americans. During a median follow-up duration of 28 months (IQR 5-56), there were 97 deaths (39%). Patients who died were more likely to have diabetes (28% vs. 14%; P = 0.03), CAD (28% vs. 16%; P = 0.04) and CKD (33% vs. 21%; P = 0.04). With endomyocardial biopsy as the gold standard (42 (17%) patients), amyloid pattern on CMR (LGE+) had sensitivity and negative predictive values of 100%; specificity and positive predictive values of 80 and 81% with an AUC 0.9 for CA. History of CAD (HR 1.64, 95% CI 1.01-2.6; P = 0.04), brain natriuretic peptide (HR 1.0003 95% CI 1.0001-1.0006; P = 0.004) and LGE + (HR 1.72, 95% CI 1.05-2.8; P = 0.02) were independent predictors of mortality. LGE+ possessed incremental prognostic value over clinical, laboratory and echocardiographic variables for mortality prediction. CONCLUSIONS: CMR is a clinically useful tool for diagnosis and prognostication in myeloma patients with suspected CA.

Refractory Hypoxemia After Laparoscopic Nissen Fundoplication.

Postoperative hypoxemia can result from a variety of causes. We describe a case of platypnea-orthodeoxia caused by shunting across a patent foramen ovale in a 72-year-old woman immediately after a laparoscopic Nissen fundoplication procedure. This was diagnosed by echocardiography and treated successfully with percutaneous device closure. An intracardiac shunt should always be considered as a potential cause of refractory postoperative hypoxemia after procedures on the thorax and upper abdomen.

Protracted hypocalcemia following post-thyroidectomy lumbar rhabdomyolysis secondary to evolving hypoparathyroidism.

Rhabdomyolysis is characterized by skeletal muscle breakdown. It is a potential cause of serious electrolyte and metabolic disturbances, acute kidney insufficiency, and death. Recently, rhabdomyolysis has been increasingly recognized following certain surgical procedures. We discuss the case of a morbidly obese 51-year-old woman who developed postoperative rhabdomyolysis of the lumbar muscles following a prolonged thyroidectomy for a large goiter. We discuss how her morbid obesity, the supine surgical position, the duration of surgery (including prolonged exposure to anesthetic agents), and postoperative immobility contributed to the development of rhabdomyolysis. Immediately after surgery, the patient developed hypocalcemia, which was likely due to rhabdomyolysis since her serum parathyroid hormone level was normal. Later, however, persistent hypocalcemia despite resolution of the rhabdomyolysis raised a suspicion of iatrogenic hypoparathyroidism, which was confirmed by a suppressed parathyroid hormone level several days after surgery. In post-thyroidectomy patients with risk factors for rhabdomyolysis, maintaining a high degree of clinical suspicion and measuring serum creatine kinase and parathyroid hormone levels can allow for an accurate interpretation of hypocalcemia.

A change of heart: reopening of a foramen ovale.

Platypnea-orthodeoxia is a rare syndrome characterized by dyspnea and hypoxemia that is exacerbated by assuming an upright position. The most common cause is intracardiac shunting through an atrial septal defect or patent foramen ovale (PFO). We present a 63-year-old man with dyspnea after right pneumonectomy for lung cancer, who was found to have a large PFO with right-to-left shunt in the presence of normal right-sided pressures. Percutaneous closure of the PFO led to resolution of symptoms.