Takotsubo cardiomyopathy and canalith repositioning procedure for benign paroxysmal positional vertigo.

BACKGROUND: Takotsubo cardiomyopathy, also known as left ventricular apical ballooning syndrome, ampulla cardiomyopathy, or transient left ventricular dysfunction is characterized by chest pain, electrocardiographic changes, transient left ventricular apical aneurysm, and normal coronary arteries. Takotsubo is a round-bottomed, narrow-necked Japanese octopus trap and lends its name to takotsubo cardiomyopathy because of its resemblance to echocardiographic and ventricular angiographic images of the left ventricle in this condition. This appearance takes its source from peculiar, transient regional systolic dysfunction involving the left ventricular apex and mid-ventricle with hyperkinesis of the basal left ventricular segments. Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo caused by peripheral vestibular dysfunction. The symptoms of BPPV are attributed to intralabyrinthine particles, presumed displaced otoconia. Thus, the treatment recommended for BPPV is head repositioning maneuvers. PURPOSE: To present the first takotsubo cardiomyopathy case in the English literature related to BPPV undergoing canalith repositioning procedure. CONCLUSION: This report will provide additional information for physicians encountering acute-onset chest pain and vertigo. It will also expand the spectrum of clinical correlates of the increasingly well recognized but poorly understood syndrome, takotsubo cardiomyopathy.

Use of Tocilizumab in Management of Post-Operative Myelomonocytic Leukemoid Reaction.

Interleukin 6 receptor (IL6R) inhibitor, tocilizumab, has been effectively used in the treatment of cytokine release syndrome in patients receiving chimeric antigen receptor T-cell therapy. Here we present a patient with chronic myelomonocytic leukemia (CMML) who developed a steroid refractory, post-operative myelomonocytic leukemoid reaction (PO-MMLR), effectively treated with tocilizumab. Although, further studies are needed to validate the effectiveness of tocilizumab in management of PO-MMLR, this case serves to provide a new management approach in treatment of this rare but lethal syndrome with no standardized treatment options.

Echocardiographic characterisation of left ventricular geometry of professional male tennis players.

BACKGROUND: The cardiac characteristics of various types of athletes have been defined by echocardiography. Athletes involved in predominately static exercise, such as bodybuilders, have been found to have more concentric hypertrophy, whereas those involved in dynamic exercise, such as long distance runners, have more eccentric hypertrophy. Tennis at the elite level is a sport that is a combination of static and dynamic exercise. OBJECTIVE: To characterise left ventricular geometry including left ventricular hypertrophy by echocardiography in male professional tennis players. DESIGN: Retrospective study of screening echocardiograms that were performed on male professional tennis players. SETTING: All echocardiograms were performed at the Mayo Clinic (Jacksonville, Florida, USA) between 1998-2000. PARTICIPANTS: A total of 41 male professional tennis players, with a mean age of 23. RESULTS: Left ventricular hypertrophy was present in 30 of 41 subjects (73%, 95% CI: 57%-86%). The majority of players manifested eccentric hypertrophy (n = 22, 54%). Concentric hypertrophy (n = 9, 22%) and normal geometry (n = 7, 17%) were encountered with similar frequency. Only 7% (n = 3) manifested concentric remodelling. The mean thickness of both the interventricular septum and the posterior wall was 11.0 mm. The mean LVEDd was 55 mm. The mean RWT was 0.41. The mean LVMI was 130 gm/m2 and the mean EF was 64%. Five of the 41 subjects had an abnormal septal thickness of 13 mm. CONCLUSION: This was the first study to specifically describe the full range of echocardiographically-determined left ventricular geometry in professional male tennis players. The majority of subjects exhibited abnormal geometry, predominantly eccentric hypertrophy.

Predictors of Suboptimal Gain in Exercise Capacity After Cardiac Rehabilitation.

Cardiac rehabilitation (CR) improves exercise capacity (EC), but not all CR participants achieve such improvements. Our primary aim was to develop a tool to identify those with suboptimal improvement in EC after CR. We retrospectively analyzed 541 patients enrolled in a phase-II CR program after a cardiac event or intervention from 2003 to 2014. EC was assessed with the 6-minute walk test. We developed a multivariate linear regression model and corresponding nomogram to predict EC after CR. The predictors included in the final model were age, gender, baseline EC, primary referral diagnosis, body mass index, systolic blood pressure at rest, triglycerides, low-density lipoprotein cholesterol, lipid-lowering medication use, and an interaction term of low-density lipoprotein cholesterol with lipid-lowering therapy. The prediction model was internally validated using bootstrap methods, and a nomogram was created for ease of use. In conclusion, this tool helps to identify those patients with suboptimal improvement in EC who could be targeted for individualized interventions to increase their performance.

Postoperative rescue closure of patent foramen ovale in the clinical setting of acute hypoxemic respiratory failure and stroke following coronary artery bypass surgery.

We describe a case of intraoperative diagnosis and successful deferred percutaneous closure of a patent foramen ovale (PFO) in the clinical setting of acute refractory hypoxemic respiratory failure and new-onset ischemic stroke in an elderly patient after coronary artery bypass graft. Perioperative morbidity (i.e. severe hypoxemia, worsening right ventricular dysfunction, and embolic stroke) that is potentially related to intraoperatively diagnosed PFO during cardiac surgery can complicate management in the Intensive Care Unit and perhaps affect the patient's outcome. Although the PFO closure can be challenging in the clinical setting of hypoxemic respiratory failure and stroke following cardiac surgery, it can be a reasonable perioperative option.

Upper-extremity exercise training in heart failure.

PURPOSE: Aerobic exercise training (ExTR), predominantly performed with lower extremities, has been used to reverse heart failure (HF)-related exercise intolerance. The present study determined the safety and efficacy of upper-extremity exercise in HF subjects because daily activities are performed using both upper and lower extremities and there is little cross-training effects between extremities. METHODS: Seven subjects underwent 36 sessions (40 minutes, 3 times per week for 12 weeks) of upper-extremity ExTR (ARM ExTR) using arm ergometers, the arm function of a NuStep device, and an Airdyne stationary cycle. Exercise intensity and duration during weeks 1 to 4 were gradually increased to achieve a 75% to 85% peak heart rate. Pre- and post-ExTR tests included arm ergometer cardiopulmonary testing with echocardiography and quality of life self-administered surveys. RESULTS: After ARM ExTR test duration increased by 22% (P = .008), respiratory exchange ratio increased by 10% (P = .02), whereas peak oxygen consumption was not improved. Echocardiographic parameters were not altered by ARM ExTR. The total scores of both the Minnesota Living With Heart Failure Questionnaire (P = .02) and the Medical Outcomes Study-36 questionnaire (P = .05) were improved, but the Functional Status Questionnaire scores were not improved. CONCLUSIONS: Although this study was limited in the number of subjects and lacked a control group, results indicate that ARM ExTR is safe and well-tolerated by persons diagnosed with HF, a finding that is relevant for individuals with HF who cannot exercise with lower extremities.

Benefits of aggressive drug therapy.

Significant advances have been made in both the development and implementation of drug therapy in the primary and secondary prevention of cardiovascular disease. Defining "aggressive" drug therapy mandates consideration of the target population, timing of initiation, time of administration, and, often, dose titration to achieve a desired effect on relevant "biomarkers" such as low-density lipoprotein levels. This review focuses on 2 groups of drug therapies now proven effective in prevention, namely the statins and antiplatelet drugs (aspirin, clopidogrel). Angiotensin-converting enzyme inhibitor(s), angiotensin receptor blockers, and beta blockers are also proven of great value but are only noted in the table.