A Novel Cause of Acute Coronary Syndrome Due to Dynamic Extrinsic Coronary Artery Compression by a Rib Exostosis: Multimodality Imaging Diagnosis.

We report a case of acute coronary syndrome secondary to intermittent extrinsic compression of the left anterior descending coronary artery by inward-pointing rib exostosis in an 18-year-old woman during forceful repeated expiration in labour. The diagnosis was achieved using multimodality noninvasive cardiac imaging. In particular, we demonstrated the novel role of expiratory-phase cardiac computed tomography in confirming the anatomical relationship of the bony exostosis to the left anterior descending coronary artery. The case reminds us the heart and mediastinum move dynamically, relative to the bony thorax, throughout the respiratory cycle, and that changes in cardiac physiology in pregnancy may become pathological.

Optimising the imaging plane for right ventricular magnetic resonance volume analysis in adult patients referred for assessment of right ventricular structure and function.

INTRODUCTION: Our aim was to evaluate the reproducibility and accuracy of using short-axis and axial (transaxial) plane for magnetic resonance imaging analysis in adult patients referred for assessment of right ventricular (RV) structure and function. METHODS: Twenty consecutive subjects (10 male, 10 female, mean age 32.2 ± 14.8 years) who were referred for RV assessment and had cardiac magnetic resonance imaging were retrospectively selected. Axial and short-axis manual contouring was performed using cine steady-state free precession sequences by three experienced imaging specialists. The reproducibility of end diastolic volumes, end systolic volumes and ejection fraction was assessed with intraclass correlation coefficients (ICCs) and paired t-tests. Left ventricular stroke volume (LVSV) and RV stroke volumes (RVSV) were compared with concordance correlation coefficients (CCCs) and t-tests to determine accuracy. RESULTS: The concordance between the RVSV and LVSV was good using both methods (axial RVSV CCC = 0.93, short-axis RVSV CCC = 0.86). Paired t-test and analysis of variance showed that the LV/RV stroke volume differences were not significant (p = 0.17). There was slight improvement in interobserver reliability with end systolic volume measurements (axial ICC = 0.92, short-axis ICC = 0.81) but this failed to reach statistical significance (p = 0.37). There was excellent intraobserver variability (ICC > 0.9). CONCLUSION: This study shows that there is no statistically significant difference in reproducibility or accuracy using the short-axis or axial orientations in RV volume analysis in adult patients being referred for RV assessment.

Accessory mitral valve tissue: appearance on cardiac computed tomography.

Accessory mitral valve tissue is an uncommon congenital malformation and a rare cause of left ventricular outflow tract obstruction. Although echocardiography provides a "gold standard" for evaluation of valves, the high temporal and spatial resolutions of computed tomography technology makes it useful in the assessment of valvular structure and function.

Partial anomalous left pulmonary artery with associated bronchial anomalies in a patient with repaired Tetralogy of Fallot.

We present a 28 year old man with repaired Tetralogy of Fallot who underwent CT imaging prior to pulmonary valve replacement. CT demonstrated a partial anomalous LPA with associated bronchial anomalies and normal variant pulmonary venous drainage. The case demonstrates the utility of multislice CT in delineating 3-dimensional vascular and bronchial anatomy in these complex anomalies.

A randomized controlled trial to assess the effect of audiotaped consultations on the quality of informed consent in cardiac surgery.

OBJECTIVE: To evaluate the effect of audiotaping outpatient consultations on informed consent for cardiac surgery. DESIGN: Randomized controlled trial. SETTING: Tertiary health care center in Scotland. PARTICIPANTS: Eighty-four patients who had first-time coronary artery surgery conducted by 1 surgeon from February 10, 2005, through March 15, 2006, whose consultations before surgery were audiotaped. INTERVENTION: Randomization to 3 trial arms. The control group (n = 29) received no tape. The generic group (n = 25) received a tape about coronary artery surgery, which we scripted to include information covering the domains described by the General Medical Council. The consultation group (n = 30) received a tape of their consultation interview. On admission to the hospital, patients were interviewed with the Knowledge Questionnaire, the Multidimensional Health Locus of Control, and the Hospital Anxiety and Depression Scale. MAIN OUTCOME MEASURES: The effect of audiotaping in improving the informed consent process for cardiac surgery. RESULTS: The mean knowledge score of patients in the consultation group was much higher than that of the control individuals (P < .001). Patients in the consultation group reported a significantly greater sense of control with regard to their own health (P < .001) and being less anxious and depressed overall. CONCLUSION: Providing an audiotaped recording of the consultation before cardiac surgery appears to improve patients' knowledge and perceptions of control of their health status and to reduce anxiety and depression. TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN20081026.

A randomized, controlled trial of C0- Vs C2-guided therapeutic drug monitoring of cyclosporine in stable heart transplant patients.

BACKGROUND: Cyclosporine monitoring using 2-hour post-dose samples (C2) is thought to be more efficacious than using pre-dose levels (C0) in managing immunosuppression for transplant patients. We evaluated the effect of C2 monitoring on cyclosporine dose and clinical parameters in stable heart transplant patients. METHODS: 125 stable heart transplant patients were randomized to C0 or C2 monitoring of cyclosporine levels for a period of six months. All patients had both C0 and C2 samples taken, and clinicians were blinded to one of the samples depending on randomization. The primary endpoint was the relative change in cyclosporine (Neoral) dose during the study period and secondary endpoints were change in creatine clearance, mortality, infection, and acute rejection. RESULTS: There was a significant decrease in the cyclosporine dose for the C2 group as compared with the C0 group (-11 mg/day and -26 mg/day respectively, p = 0.0025). No proven rejection episodes occurred in either group and there was no significant difference in the incidence of infection (C0 6, C2 10; p = 0.14), the change in renal function (change in creatine clearance C(0) +0.54 ml/min; C2 -0.16 ml/min; p = 0.61), the number of blood tests or dose adjustments between groups over the study period. Analysis of the blinded samples revealed that the reduction of cyclosporine dose in the C2 group could not be accounted for by reduced immunosuppression . CONCLUSION: C2 monitoring allows a significant cyclosporine dose reduction without compromising patient outcome in stable heart transplant patients. Further studies are required to ascertain whether this dose reduction can be translated into clinical benefit.

A deer (subfamily Cervinae) genetic linkage map and the evolution of ruminant genomes.

Comparative maps between ruminant species and humans are increasingly important tools for the discovery of genes underlying economically important traits. In this article we present a primary linkage map of the deer genome derived from an interspecies hybrid between red deer (Cervus elaphus) and Père David's deer (Elaphurus davidianus). The map is approximately 2500 cM long and contains >600 markers including both evolutionary conserved type I markers and highly polymorphic type II markers (microsatellites). Comparative mapping by annotation and sequence similarity (COMPASS) was demonstrated to be a useful tool for mapping bovine and ovine ESTs in deer. Using marker order as a phylogenetic character and comparative map information from human, mouse, deer, cattle, and sheep, we reconstructed the karyotype of the ancestral Pecoran mammal and identified the chromosome rearrangements that have occurred in the sheep, cattle, and deer lineages. The deer map and interspecies hybrid pedigrees described here are a valuable resource for (1) predicting the location of orthologs to human genes in ruminants, (2) mapping QTL in farmed and wild deer populations, and (3) ruminant phylogenetic studies.