Radioligand therapy (RLT) used to treat cardiac metastasis of pancreatic neuroendocrine tumor.

Radioligand Therapy (RLT) in the form of [177Lu] Lu-DOTA-TATE (Lutathera®) is a promising treatment for pancreatic neuroendocrine tumors (pNETs) with cardiac metastasis. We present a patient treated with [177Lu] Lu-DOTA-TATE that showed shrinkage of metastasis after four treatments at 7.4 GBq every 8 weeks.

Second-generation extracellular matrix patch for epicardial infarct repair.

Current myocardial infarction treatments focus on improving hemodynamics rather than addressing the problem of lost myocardium impairing left ventricular function. Epicardial infarct repair with a bioactive patch placed on the ischemic area is an emerging approach to promote endogenous myocardial repair. We report the use of a second-generation CorMatrix-extracellular matrix (ECM) patch as an adjunct to surgical revascularization in treating a young patient with diffuse, multivessel coronary artery disease unamenable to PCI and a large anterior myocardial infarction. The progressive myocardial scar shrinkage and increase in left ventricular ejection fraction from 10 to 51% are generally not observed with surgical revascularization therapy alone, suggesting this new patch has adjunctive potential to current revascularization therapy.

Cardiac involvement with amyloidosis: mechanisms of disease, diagnosis and management.

The amyloidoses represent a group of clinical disorders of diverse etiologies that have as a common pathophysiologic denominator the deposition of misfolded protein based amyloid fibrils in the interstitial space of various organs. They are uncommon diseases with protean clinical presentations. Cardiac involvement is the determining factor for a patient's prognosis. Clinicians have to maintain a high index of suspicion and actively search for signs and symptoms of cardiac involvement in patients with preexisting conditions known to be associated with the development of amyloidosis. Early diagnosis and accurate fibril typing are the first steps in managing the disease. Judicious use of various diagnostic modalities such as serum markers and imaging studies, and good communication among all the physicians involved in the care of these sick and frail patients, are keys to a better outcome.

Prognostic value of delayed gadolinium enhancement MRI in patients with ischemic cardiomyopathy.

BACKGROUND: Cardiovascular magnetic resonance imaging (CMR) with delayed contrast enhancement (DCE) using Gadolinium (Gd)-based magnetic contrastagents, is a technique which visualizes myocardial infarction (MI) as regions of bright signal (hyperenhancement) compared to normal myocardium. The prognostic value of DCE in patients with ischemic cardiomyopathy has not been fully characterized. METHODS: All patients with a history of coronary artery disease (CAD) who underwent DCE-CMR imaging between September 1999 and July 2004 were included. CMR-variables were: left ventricular ejection fraction (LVEF), wall motion, mitral regurgitation (MR) and DCE scores. The patient's clinical status was assessed using the New York Heart Association-classification (NYHA). RESULTS: One hundred and ninety-three patients (age 63+/-11, 42 women), including 160 with prior MI, were studied. The mean LVEF was 40+/-14%. Most patients (88%) were in NYHA-class I or II, and 8% had moderate or severe MR. Thirteen patients died during follow-up. Patients who died had a lower baseline LVEF and more significant MR compared to survivors (P=0.04). A higher DCE score was associated with more significant MR (P=0.01). No significant association was demonstrated between NYHA-class and DCE (P=0.34) or between DCE score andmortality (P=0. 8). CONCLUSION: The study reinforces the important prognostic value of resting LVEF and MR severity in patients with CAD and is the first to demonstrate an association between the degree of DCE and MR severity in these patients. Further investigations including a larger number of patients are needed to fully assess the prognostic value of DCE-CMR in ischemic cardiomyopathy.

Clinical applications of cardiovascular magnetic resonance imaging.

Cardiovascular magnetic resonance imaging (MRI) has evolved from an effective research tool into a clinically proven, safe and comprehensive imaging modality. It provides anatomic and functional information in acquired and congenital heart disease and is the most precise technique for quantification of ventricular volumes, function and mass. Owing to its excellent interstudy reproducibility, cardiovascular MRI is the optimal method for assessment of changes in ventricular parameters after therapeutic intervention. Delayed contrast enhancement is an accurate and robust method used in the diagnosis of ischemic and nonischemic cardiomyopathies and less common diseases, such as cardiac sarcoidosis and myocarditis. First-pass magnetic contrast myocardial perfusion is becoming an alternative to radionuclide techniques for the detection of coronary atherosclerotic disease. In this review we outline the techniques used in cardiovascular MRI and discuss the most common clinical applications.

Apical aneurysm in a patient with apical hypertrophic cardiomyopathy.

Apical hypertrophic cardiomyopathy (AHC) is a variant of hypertrophic cardiomyopathy (HCM) in which the hypertrophy predominantly involves the left ventricular apex. The typical features of AHC include giant negative T waves in the precordial ECG leads, a spade-like configuration of the left ventricle at end-systole, the absence of an outflow tract pressure gradient, and mild symptoms. We present a patient with AHC, evidence of prior myocardial infarction with aneurysm of the apical region, and myocardial ischemia on radionuclide scanning despite angiographically normal coronary arteries. The characteristic electrocardiographic, echocardiographic, hemodynamic and angiographic findings as well as prognosis and treatment options are discussed.

Coronary stenting is safe and effective in a high-risk octogenarian patient cohort.

BACKGROUND: Octogenarians represent an increasing percentage of patients with coronary heart disease and are an inherently high-risk population. We sought to define the immediate and long-term results of coronary stenting in the "real-world" environment of a community teaching hospital. METHODS: One hundred ninety-seven consecutive patients older then 80 years who underwent 214 coronary stent procedures were studied. Each patient had postprocedural serial cardiac enzymes and ECG's collected, and was followed for a minimum of 12 months after the procedure. Procedural success was defined as less than 20% residual stenosis, TIMI 3 flow, and absence of major complications (death, nonfatal myocardial infarction, emergent coronary artery bypass graft surgery and stroke). Sixty-five percent of patients presented with an acute coronary syndrome and 93% were functionally New York Heart Association (NYHA) Class III or IV. RESULTS: Procedural success was 95%. Death during the index hospitalization occurred in 3% of patients. An additional 4.1% of patients died during follow-up. The target vessel revascularization rate (TVR) during follow up was 8.6%. Multivariate analysis of selected angiographic and clinical variables did not reveal any predictors of major cardiac events. CONCLUSIONS: Despite a high-risk clinical and angiographic profile, coronary stenting can be safely performed in octogenarians with a high procedural success rate, low complication rate, and excellent 12-month outcome.

Circadian variation and outcome of in-hospital cardiopulmonary resuscitation.

OBJECTIVE: Assessment of contemporary in-hospital cardiopulmonary resuscitation outcomes. METHODS: The study was designed as a retrospective, single-institution, registry investigation of all adult patients for whom a cardiopulmonary resuscitation (CPR) was attempted between October 1, 2002 and September 30, 2004. Hospital, patient's, arrest and outcome variables were included based on the "Utstein Style" of reviewing, reporting, and conducting research on in-hospital resuscitation. RESULTS: 202 patients (94 women, age 70 +/- 15 years) received in-hospital CPR during the study period. One hundred-two events were primary respiratory arrests. Overall, 67% (95% CI 59%-72%) of patients were successfully resuscitated and 38% (95% CI 31%-45%) survived to hospital discharge. Of the patients with initial respiratory depression followed by circulatory collapse, 57% (95% CI 47%-66%) were alive at the end of hospitalization, while 20% (95% CI 13.3%-28.8%) of patients with cardiac arrest survived to hospital discharge (OR=5.2, 95% CI=2.8-9.5, P<0.0001). A circadian variation in the occurrence of primary cardiac arrests was noted with a nadir between midnight and 0600 hours. Though there were fewer events during overnight hours, CPR for patients with a primary cardiac arrest occurring at this time was less likely to be successful (OR = 2.5, 95% CI=1.01-6.1, p=0.04). This did not result in a difference in survival to discharge (OR=2.6, 95% CI=0.7-9.4, p=0.14). CONCLUSION: Primary cardiac arrest has a significantly worse in-hospital outcome when compared to an initial respiratory event. The finding of a circadian variation in both the incidence and outcome of in-hospital primary cardiac arrest is intriguing and warrants further study.

Intramural hematoma of the descending thoracic aorta.

Aortic intramural hematoma (AIH) is part of the acute aortic syndrome together with aortic dissection and penetrating aortic ulcer. AIH represents up to 12% of acute aortic syndrome cases and has a clinical presentation indistinguishable from that of classic aortic dissection. A patient with AIH is presented and the diagnostic, prognostic and therapeutic implications of the disease are discussed.

Horseshoe thrombus in a patient with mechanical prosthetic mitral valve: A case report and review of literature.

Patients with prosthetic cardiac valves are at high risk for thromboembolic complications and need life long anticoagulation with warfarin, which can be associated with variable dose requirements and fluctuating level of systemic anticoagulation and may predispose to thromboembolic and or hemorrhagic complications. Prosthetic cardiac valve thrombosis is associated with high morbidity and mortality. A high index of suspicion is essential for prompt diagnosis. Transthoracic echocardiography, and if required transesophageal echocardiography are the main diagnostic imaging modalities. Medically stable patients can be managed with thrombolytic therapy and anticoagulation, while some patients may require surgical thrombectomy or valve replacement. We present a case report of a patient with prosthetic mitral valve and an unusually large left atrial thrombus with both thromboembolic and hemorrhagic complications.

Pseudohyperphosphatemia in a patient with multiple myeloma.

Hyperphosphatemia, in patients with multiple myeloma, is usually associated with severely reduced renal function. Paraproteins can interfere with the measurement of serum inorganic phosphate when certain types of automatic methods are employed. We present the case of a 44-year-old male admitted to our hospital with severe back pain and an osteolytic lesion of the first lumbar vertebra. He was diagnosed with multiple myeloma based on serum protein electrophoresis and bone marrow biopsy results. An initial serum phosphate level of 12.5 mg/dl, (normal 2.5-5 mg/dl), in the setting of normal kidney function, did not improve after treatment with oral phosphate binders. The inorganic phosphate determinations were repeated on sulfosalicylic acid deproteinized serum samples, yielding normal range phosphate levels. This case reiterates the importance of using deproteinized serum samples for phosphate measurements in patients with multiple myeloma, normal renal function and elevated phosphate levels, before initiating therapy with phosphate binders.

Comparison of different cardiac risk scores for coronary artery disease in symptomatic women: do female-specific risk factors matter?

BACKGROUND: Cardiovascular diseases remain the leading cause of death in women and there is a need for more accurate risk assessment scores. The aims of our study were to compare the accuracy of several widely used cardiac risk assessment scores in predicting the likelihood of obstructive coronary artery disease (CAD) on CT coronary angiography (CTCA) in symptomatic women and to explore which female-specific risk factors were independent predictors of obstructive CAD on CTCA and whether adding these risk factors to pre-test probability scores would improve their predictive value. METHODS AND RESULTS: Data were obtained from a cohort of 228 consecutively included symptomatic women undergoing evaluation for CAD and referred for CTCA. Obstructive CAD was defined as ≥50% luminal stenosis on CTCA. Pre-test probability for CAD was calculated according to the Diamond and Forrester score, New score, Duke clinical score, and an updated Diamond and Forrester score. Female-specific factors were obtained by a written questionnaire. Pre-test probability scores were compared with ROC analysis and showed that only the New score and the updated Diamond and Forrester score were significant predictive scores for obstructive CAD on CTCA (area under the curve, AUC, 0.67, p < 0.01; AUC 0.61, p = 0.04, respectively). Multivariable logistic regression analysis identified that gestational diabetes mellitus (GDM) and oestrogen status were independent predictors of obstructive CAD when adjusted for the pre-test probability scores. The updated Diamond and Forrester score was used for net reclassification improvement (NRI) analysis, since the New score already accounts for oestrogen status. Adding GDM and oestrogen status to the updated Diamond and Forrester score resulted in a significant NRI (p = 0.04). CONCLUSIONS: There is a large variability in prediction of obstructive CAD using different pre-test probability risk scores in symptomatic women. Logistic regression analysis revealed that oestrogen status and GDM were independently associated with the occurrence of obstructive stenosis on CTCA. The predictive ability of cardiac pre-test probability scores improved significantly with the addition of oestrogen status and GDM.

Left ventricular thrombus formation after acute myocardial infarction as assessed by cardiovascular magnetic resonance imaging.

INTRODUCTION: Left ventricular (LV) thrombus formation is a feared complication of myocardial infarction (MI). We assessed the prevalence of LV thrombus in ST-segment elevated MI patients treated with percutaneous coronary intervention (PCI) and compared the diagnostic accuracy of transthoracic echocardiography (TTE) to cardiovascular magnetic resonance imaging (CMR). Also, we evaluated the course of LV thrombi in the modern era of primary PCI. METHODS: 200 patients with primary PCI underwent TTE and CMR, at baseline and at 4 months follow-up. Studies were analyzed by two blinded examiners. Patients were seen at 1, 4, 12, and 24 months for assessment of clinical status and adverse events. RESULTS: On CMR at baseline, a thrombus was found in 17 of 194 (8.8%) patients. LV thrombus resolution occurred in 15 patients. Two patients had persistence of LV thrombus on follow-up CMR. On CMR at four months, a thrombus was found in an additional 12 patients. In multivariate analysis, thrombus formation on baseline CMR was independently associated with, baseline infarct size (g) (B=0.02, SE=0.02, p<0.001). Routine TTE had a sensitivity of 21-24% and a specificity of 95-98% compared to CMR for the detection of LV thrombi. Intra- and interobserver variation for detection of LV thrombus were lower for CMR (κ=0.91 and κ=0.96) compared to TTE (κ=0.74 and κ=0.53). CONCLUSION: LV thrombus still occurs in a substantial amount of patients after PCI-treated MI, especially in larger infarct sizes. Routine TTE had a low sensitivity for the detection of LV thrombi and the interobserver variation of TTE was large.