Nonbacterial Thrombotic Endocarditis and Widespread Skin Necrosis in Newly Diagnosed Lung Adenocarcinoma.

Nonbacterial thrombotic endocarditis (NBTE) is a rare entity most commonly diagnosed postmortem with rates in autopsy series ranging from 0.9 to 1.6%. A 63-year-old female with past medical history of hypertension and mitral valve prolapse presented to the hospital with shortness of breath, headache, and necrotic skin lesions on her hands and feet. Computed tomography (CT) scan of her chest demonstrated a pulmonary embolus in the right lower lung segmental artery and right upper lobe lobar to segmental pulmonary artery, a mass-like consolidation in the left upper lung field impeding the hilum. CT scan of the abdomen demonstrated metastatic disease in liver and bone and bilateral femoral deep vein thrombosis. Transesophageal echocardiography revealed severe mitral regurgitation with two small mobile plaques on the mitral valve and two immobile plaques on the descending aorta. Magnetic resonance imaging of the brain was consistent with subacute infarcts and metastatic disease. Bronchoscopy was performed and pathology revealed primary adenocarcinoma of the lung. She was treated with anticoagulation and systemic chemotherapy. The patient and family elected to proceed with hospice due to her clinical decline, poor performance status, and poor prognosis after a prolonged hospital stay. Underlying malignancy is detected in approximately 40-85% of patients with NBTE. Lung cancer is the most frequently associated malignancy followed by pancreatic, stomach, breast, and ovarian cancer. Widespread necrotic skin lesions as presenting symptoms of primary lung adenocarcinoma are rare. In the present case, the diagnosis of necrotic skin lesions and NBTE preceded that of the neoplastic disease. Necrotic skin lesions and NBTE can be the first manifestations of an occult malignancy causing extensive multi-organ infarcts. NBTE can present with such extensive skin lesions as a first presenting sign of malignancy. To the best of our knowledge, this is the first case to present with such extensive skin lesions as the first presenting symptom of lung adenocarcinoma.

Aortic root and valve proportions: an example of the golden ratio?

Calcific aortic stenosis is the most common lesion requiring valve replacement. Transcutaneous procedures (TAVR) are rapidly increasing yet detailed information on aortic valve and root anatomy are sparse.  This study examined gated cardiac CT scans to make observations regarding the size and proportions of the valve leaflets, sinuses of Valsalva, and sinotubular junction. One hundred and fifty gated cardiac CT scans were performed for a variety of clinical indications. Area of each cusp (short axis plane) was measured along with sinus height (from leaflet base to sinotubular junction), sinus width (from central coaptation point to outer sinus edge), annular perimeter, perimeter at mid-sinus level, and perimeter at the sinotubular junction. The right coronary cusp was largest, the left cusp smallest, and the non-coronary cusp intermediate in size. Each cusp was larger in men than women, even after indexing for body surface area.  By contrast, indexed sinus width and height did not differ between genders. No significant differences were noted between races. Annular perimeter did not vary by age while the mid-sinus perimeter and sinotubular junction perimeter increased with age (p=0.01, r2 =0.05 and p=0.002, r2 =0.07).  Interestingly, the ratio of sinus height (average): annular radius was 1.69±0.18, very close to the "golden ratio" of 1.62 found throughout the natural world.  This might be important for proper vortex formation in the sinuses.

Transient Ischemic Dilation Ratio in Regadenoson, Single Isotope Gated Single-photon Emission Computed Tomography Myocardial Perfusion Imaging.

Single isotope 99mTc single-photon emission computed tomography-myocardial perfusion imaging (SPECT-MPI) is the most commonly used protocol for nuclear stress testing. Transient ischemic dilation of the left ventricle (TID) has been considered a specific marker of severe coronary artery disease (CAD). Recent publications have questioned the clinical utility of TID, specifically with regadenoson as a stressor and 4DM-SPECT software for TID analysis. These findings have not been demonstrated using other imaging packages. The goal of our study was to establish the TID threshold in the identification of Multi-vessel CAD using Quantitative Perfusion SPECT (QPS) software. Included in this study are 190 patients that had undergone regadenoson-stress, same day, single-isotope 99mTc MPI and had a coronary angiography within a designated 3-month period. QPS (Cedars-Sinai, LA, CA) automated image analysis software was used to calculate TID ratios which were compared across different CAD categories. Coronary angiograms were reviewed to identify both obstructive and nonobstructive CAD. The mean TID for patients with nonobstructive CAD (n = 91) was 1.02 ± 0.11, and the threshold for TID was 1.24. A receiver operating characteristic curve showed that TID had a poor discriminatory capacity to identify MVD (area under the curve 0.58) with a sensitivity of 3% and a specificity of 97%. In our study with regadenoson MPI in a predominantly African-American population, TID was found to be a poor predictor of MVD using QPS software. The reason is unclear but possibly related to the significant decline in the prevalence of severe CAD in the area where our study took place.

Incidence and predictors of stroke during the index event in an ethnically diverse Takotsubo cardiomyopathy population.

Takotsubo cardiomyopathy (TTS) is a peculiar clinical condition often affecting postmenopausal women after a stressful trigger. The underlying mechanisms have not been completely elucidated but several hypotheses have been advanced, with catecholamine cardiotoxicity, microvascular dysfunction and coronary artery spasm each suggested to play a role. The incidence of stroke after TTS appears to range from 0% to 7.7%, and interestingly TTS has been described as both a cause and a complication of stroke. We sought to assess the incidence and predictors of stroke during the index event (peri-index event stroke) in a heterogeneous TTS population. We conducted a retrospective descriptive study reviewing patients who were discharged with a diagnosis of TTS from the Einstein Medical Center, Philadelphia, PA and Danbury Hospital, Danbury, CT in the period between 2003 and 2014. A total of Incidence and predictors of stroke during the index event in an ethnically diverse Takotsubo cardiomyopathy population 206 patients met the modified Mayo Clinic criteria and were included in the study. The patients' overall mean age was 67.8 years; 87% (n=179) were females and 25% (n=53) were African Americans. The following incidence rates were found: stroke 7%, in-hospital heart failure 26.7%, and in-hospital death 7%. On multivariate analysis independent predictors (expressed as odds ratios with 95% confidence intervals) of periindex event stroke were: i) African American race (OR 3.2, 95% CI 1.2-10.2, p=0.048); ii) hypertension (OR 10.5, 95% CI 1.3-88, p=0.03). ACE inhibitor use was a protective factor for developing peri-index event stroke (OR 0.15, 95% CI 0.04-0.5, p=0.001). There was a trend towards dual antiplatelet therapy (DAPT) being protective for stroke (OR 0.3, 95% CI 0.05-1.1, p=0.08). The incidence of peri-index event stroke was 7%. African American race and hypertension were found to be independent predictors of peri-index event stroke. Prospective clinical trials are needed to confirm these findings and to better determine the impact of hypertension as a risk factor for stroke and to assess the role of DAPT in preventing it.

Relation Between Epicardial Adipose and Aortic Valve and Mitral Annular Calcium Determined by Computed Tomography in Subjects Aged ≥65 Years.

Epicardial adipose tissue (EAT) has been linked to coronary artery calcium deposits and atherosclerotic disease. Mitral annular (MAC) and aortic valve calcium (AVC) have also been associated with atherosclerosis. This study examined the possible relation between EAT thickness and valvular calcium deposits. We included 294 patients aged ≥65 years who had noncontrast computed tomography scans of the chest. Mean age was 76 ± 7 years; 47% were men. Using reconstructed images, EAT thickness was measured at various locations. MAC and AVC were quantified by Agatston technique. The sum of AVC and MAC was reported as the grand total score (GTS). Subjects were divided into 2 groups based on the value of GTS; GTS = 0, no cardiac calcification and GTS ≥1, cardiac calcification group. Epicardial fat (left and right atrioventricular grooves and superior interventricular groove) was significantly greater in the cardiac calcification group compared with the no cardiac calcification (all values, p <0.05). After adjusting for clinical variables including BMI, EAT at the superior interventricular groove remained significantly associated with total calcium. Left atrioventricular groove EAT demonstrated a trend toward an association with total calcium, but this did not reach statistical significance. In conclusion, epicardial fat is associated with calcium deposits of the mitral annulus and aortic valve.

Polymicrobial infective endocarditis caused by Neisseria sicca and Haemophilus parainfluenzae.

Infective endocarditis is a common clinical problem in industrialized countries. Risk factors include abnormal cardiac valves, a history of endocarditis, intracardiac devices, prosthetic valves and intravenous drug use. We report a case of polymicrobial infective endocarditis in a 33 year-old female with a history chronic heroin use caused by Neisseria sicca and Haemophilus parainfluenzae. We believe the patient was exposed to these microbes by cleansing her skin with saliva prior to injection. Pairing a detailed history with the consideration of atypical agents is crucial in the proper diagnosis and management of endocarditis in patients with high-risk injection behaviors.

Distinctive Electrocardiographic Features in African Americans Diagnosed with Takotsubo Cardiomyopathy.

BACKGROUND: Takotsubo cardiomyopathy (TC) can resemble acute anterior ST-elevation myocardial infarction. Most studies have examined TC in Asians and Caucasians (non-African Americans [AA]), while very few cases have been reported in AA. We aimed to assess the electrocardiographic features of TC in AA patients and compare them to non-AA TC patients. METHODS: We retrospectively compared electrocardiograms of 52 AA and 47 non-AA patients diagnosed with TC. All patients met the modified Mayo Clinic criteria for the diagnosis of TC. Information collected included PR interval, QRS duration and amplitude, QT interval in milliseconds (msec) adjusted for heart rate (QTc), ST-segment deviation at the J point in limb and precordial leads (≥1 mm), ST elevation (≥1 mm), and T-wave inversion (≥0.5 mm). RESULTS: T-wave inversion was more prevalent on presentation among AA patients (82% vs 48% in non-AA; P < 0.01), whereas ST depression was more common among non-AA (21% vs 7% in AA; P = 0.05). T-wave inversions in AA patients were frequent in both limb and precordial leads, whereas T-wave inversions in non-AA were limited to precordial leads. The average QTc upon presentation in AA was longer than non-AA (491 msec in AA vs 456 msec in non-AA; P < 0.01) as was the maximum average QTc during index hospitalization (527 msec in AA vs 497 msec in non-AA, P = 0.03). CONCLUSION: In patients presenting with TC, AA patients more frequently present with diffuse T-wave inversions and a more prolonged QTc, whereas non-AA patients more often present with ST depressions. AA patients also more frequently present with T-wave inversions diffusely, whereas non-AA patients present with T-wave inversions more limited to the precordial leads.

Effect of Mitral Annular Calcium on Left Ventricular Diastolic Parameters.

Assessment of left ventricular (LV) diastolic function by Doppler flow imaging and tissue Doppler is an integral part of the echocardiographic examination. Mitral annular calcium (MAC) is frequently encountered on echocardiography. The aim of this study was to assess the impact of MAC, quantitatively measured by computed tomography scan, on echocardiographic LV diastolic parameters. We included 155 patients aged ≥65 years. Computed tomography reconstructions of the mitral annulus were created, and calcium identified and quantified by Agatston technique. Calcium locations were assigned using an overlaid template depicting the annular segments in relation to surrounding anatomic structures. Echocardiographic assessment of diastolic function was performed in standard fashion. Mean age was 77 years; 49% were men; and 43% were black. Patients with MAC had lower septal e' (p = 0.003), lateral e' (p = 0.04), and average e' (p = 0.01) compared with those without MAC. They also had a higher E-wave velocity (p = 0.01) and E/e' ratio (p <0.001). When evaluated by severity of MAC, and after adjustment for multiple clinical factors, there was a graded (inverse) relation between MAC severity and septal e' (p = 0.01), lateral e' (p = 0.01), and average e' (p = 0.01). In conclusion, LV diastolic parameters, as measured by Doppler echocardiography, are altered in the presence of MAC. This could be due to direct effects of MAC on annular function or might reflect truly reduced diastolic function. Interpretation of diastolic parameters in patients with MAC should be performed with caution.

Antiplatelet therapy in Takotsubo cardiomyopathy: does it improve cardiovascular outcomes during index event?

Plasma catecholamines may play an important role in Takotsubo cardiomyopathy (TCM) pathophysiology. Patients with disproportionately high catecholamine responses to stressful events are prone to worse clinical outcomes. Catecholamines stimulate platelet activation and, therefore, may determine the clinical presentation and outcomes of TCM. We conducted a retrospective, descriptive study TCM patients admitted between 2003 and 2013 to Einstein Medical Center, Philadelphia, PA, USA and Danbury Hospital, Danbury, CT, USA. A total of 206 patients met Modified Mayo TCM criteria. Using a multiple logistic model, we tested whether aspirin, dual antiplatelet therapy (DAPT) aspirin + clopidogrel, beta blocker, statin, or ACE inhibitor use were independent predictors of major adverse cardiovascular events (MACE) during the index hospitalization. MACE was defined as in-hospital heart failure, in-hospital death, stroke or respiratory failure requiring mechanical ventilation. Incidence of in-hospital heart failure was 26.7 %, in-hospital death was 7.3 %, stroke was 7.3 % and MACE was 42.3 %. In a multiple logistic regression model (adjusted for gender, race, age, physical stressor, hypertension, diabetes, hyperlipidemia, smoking history, body mass index, initial left ventricular ejection fraction, single antiplatelet therapy, DAPT, beta blocker, statin, and ACE inhibitor) aspirin and DAPT at the time of hospitalization were independent predictors of a lower incidence of MACE during the index hospitalization (aspirin: OR 0.4, 95 % CI (0.16-0.9), P = 0.04; DAPT: OR 0.23; 95 % CI (0.1-0.55); P < 0.01. Physical stressor itself was also found to be an independent predictor of worse MACE: OR 5.1; 95 % CI (2.4-11.5); P < 0.01. In our study, aspirin and DAPT were independent predictors of a lower incidence of MACE during hospitalization for TCM. Prospective clinical trials are needed to confirm the findings of this study.

Distribution of Mitral Annular and Aortic Valve Calcium as Assessed by Unenhanced Multidetector Computed Tomography.

Aging is associated with calcium deposits in various cardiovascular structures, but patterns of calcium deposition, if any, are unknown. In search of such patterns, we performed quantitative assessment of mitral annular calcium (MAC) and aortic valve calcium (AVC) in a broad clinical sample. Templates were created from gated computed tomography (CT) scans depicting the aortic valve cusps and mitral annular segments in relation to surrounding structures. These were then applied to CT reconstructions from ungated, clinically indicated CT scans of 318 subjects, aged ≥65 years. Calcium location was assigned using the templates and quantified by the Agatston method. Mean age was 76 ± 7.3 years; 48% were men and 58% were white. Whites had higher prevalence (p = 0.03) and density of AVC than blacks (p = 0.02), and a trend toward increased MAC (p = 0.06). Prevalence of AVC was similar between men and women, but AVC scores were higher in men (p = 0.008); this difference was entirely accounted for by whites. Within the aortic valve, the left cusp was more frequently calcified than the others. MAC was most common in the posterior mitral annulus, especially its middle (P2) segment. For the anterior mitral annulus, the medial (A3) segment calcified most often. In conclusion, AVC is more common in whites than blacks, and more intense in men, but only in whites. Furthermore, calcium deposits in the mitral annulus and aortic valve favor certain locations.