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BACKGROUND: Mitral valve stenosis can be a highly symptomatic condition with significant complications if left untreated. In such cases, mitral valve replacement with a bioprosthetic or mechanical valve may be a viable solution to prevent progressive disease. Current guidelines do not recommend continued anticoagulation beyond 6 months for patients who have undergone bioprosthetic valve replacement without a separate indication for anticoagulation. With this case discussion we aim to 1) Review the current indications for anticoagulation for bioprosthetic mitral valves in patients without atrial fibrillation and 2) Discuss the constellation of comorbidities that may affect the decision to begin anticoagulation therapy. CASE PRESENTATION: We present a case describing a 55-year-old male with end-stage renal disease, coronary artery disease with coronary artery bypass graft surgery, and bioprosthetic mitral valve replacement 2 years prior with rapid degeneration of the replaced valve and on warfarin without a clear indication for anticoagulation. The patient was admitted for symptomatic, severe mitral stenosis and consideration of transcatheter mitral valve-in-valve replacement. During hospital admission, warfarin was discontinued and replaced with prophylactic anticoagulation. However, 8 days after warfarin cessation an intraoperative transesophageal echocardiography revealed a newly developed large left atrial thrombus leading to cancellation of the planned operation. CONCLUSIONS: This patient developed a left atrial thrombus after discontinuing warfarin in the setting of rapidly deteriorating bioprosthetic valve stenosis and vascular comorbidities. The decision to discontinue warfarin was made in concordance with current guidelines, which do not indicate systemic anticoagulation post 3-6 months after bioprosthetic valve replacement without separate indication for anticoagulation. This case identifies the need to investigate rebound hypercoagulability and further risk stratify comorbidities which may independently increase the risk of clot formation in the setting of severe mitral valve stenosis.
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Bioprótesis , Prótesis Valvulares Cardíacas , Estenosis de la Válvula Mitral , Trombosis , Humanos , Masculino , Persona de Mediana Edad , Anticoagulantes/efectos adversos , Estenosis de la Válvula Mitral/diagnóstico por imagen , Estenosis de la Válvula Mitral/cirugía , Trombosis/diagnóstico por imagen , Trombosis/etiología , Trombosis/prevención & control , Warfarina/efectos adversosRESUMEN
PURPOSE: South Asian (SA) persons have increased risks for diabetes mellitus (DM) and atherosclerotic cardiovascular disease (ASCVD). We examined whether the association of DM with subclinical atherosclerosis assessed by coronary artery calcium (CAC) differs in SA versus other ethnic groups. METHODS: We studied adults from the Multi-Ethnic Study of Atherosclerosis and the Mediators of Atherosclerosis in South Asians Living in America studies without ASCVD. CAC was examined among those normoglycemic, pre-DM and DM. Logistic regression examined pre-DM and DM with the odds of any CAC > 0 and CAC ≥ 100. RESULTS: Among 7562 participants, CAC > 0 and CAC ≥ 100 in those with DM was highest in non-Hispanic White (NHW) (80% and 48%) and SA (72% and 41%) persons. Adjusted Ln (CAC + 1) was highest in NHW (3.68 ± 0.21) and SA (3.60 ± 0.23) (p < .01) DM patients. SA and NHW adults with DM (vs normoglycemic) had highest odds of CAC > 0 (2.13 and 2.27, respectively, p < .01). For CAC ≥ 100, SA and Chinese adults had the highest odds (2.28 and 2.27, respectively, p < .01). Fasting glucose and glycated hemoglobin were most strongly associated with CAC among SA. CONCLUSIONS: Diabetes mellitus most strongly relates to any CAC in SA and NHW adults and CAC ≥ 100 in SA and Chinese adults, helping to explain the relation of DM with ASCVD in these populations.
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Aterosclerosis , Enfermedad de la Arteria Coronaria , Diabetes Mellitus , Calcificación Vascular , Humanos , Adulto , Etnicidad , Calcio , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Personas del Sur de Asia , Aterosclerosis/diagnóstico , Aterosclerosis/epidemiología , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/epidemiología , Factores de Riesgo , Calcificación Vascular/diagnóstico por imagenRESUMEN
Transcatheter aortic valve replacement (TAVR) has become increasingly common as the indications expanded to include valve-in-valve (ViV) applications and a wider patient population with lower surgical risk. Intra-operative coronary arterial occlusion remains a significant source of morbidity, particularly in ViV applications or cases with high-risk anatomy. We present a novel technique for coronary artery protection utilizing a guide extension catheter to secure coronary access during valve deployment and a ViV case demonstration in a patient with prior surgical aortic valve replacement.
Transcatheter aortic valve replacement (TAVR) is a minimally invasive procedure that has become an alternative to major cardiac surgery for replacing the aortic valve. A potential serious complication during this procedure is obstruction of the major coronary blood vessels supplying the heart itself. This may occur during deployment of the prosthetic aortic valve, a process which can inadvertently lead to blockage of the opening of the arteries of the heart. We present a novel method for protecting the opening of these arteries during TAVR to reduce the risk of this complication.
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Estenosis de la Válvula Aórtica , Edema Pulmonar , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Femenino , Anciano , Edema Pulmonar/etiología , Estenosis de la Válvula Aórtica/etiología , Estenosis de la Válvula Aórtica/patología , Ecocardiografía , Implantación de Prótesis de Válvulas Cardíacas/métodos , Catéteres , Dispositivos de Acceso Vascular , Resultado del Tratamiento , Factores de RiesgoRESUMEN
Radiation exposure in the cardiac catheterization laboratory (CCL) is an occupational hazard that predisposes health care workers to the development of adverse health effects such as cataracts, cancer, and orthopedic injury. To mitigate radiation exposure, personal protective shielding as well as permanently installed shields reduces these adverse effects. Yet, heavy protective lead aprons and poor ergonomics required for positioning movable shields remain barriers to a safer environment. Recent innovations to enhance personal protective equipment and revolutionize fixed shielding systems will permit the CCL team to work in a personal "lead-free" environment, markedly reducing occupational hazards. The purpose of this review is to update the status and future of radiation protection in the CCL.
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BACKGROUND: Atrial myxomas account for approximately 50% of all primary cardiac tumors. The size, location, risk of embolic event, and involvement of other cardiac structures, are all factors that contribute to the wide range of presentation for cardiac myxomas. Patients with myxomas may remain asymptomatic, while others may report symptoms such as fatigue and fever, dyspnea, and syncope. It is important to recognize arrhythmias as an uncommon symptom of myxomas. CASE PRESENTATION: We report a rare case of a 67-year-old man who presented with pre-syncopal episodes, symptomatic bradycardia, and night sweats found to have a 5.5 × 5.1 × 3 cm myxoma in the left atrium. During diastole the mass caused dynamic flow obstruction across the mitral valve. The patient underwent surgical resection of the mass given his symptomatology and risk of embolic events. Removal of the myxoma resulted in resolution of both pre-syncopal episodes and the patient's sinus bradycardia. CONCLUSION: Atrial myxomas are a rare cause of pre-syncope and symptomatic bradycardia. It is important to have a clinical suspicion for atrial myxomas given early diagnosis and surgical intervention are key in improving the prognosis of these patients. This case also highlights the importance of taking into account the source of the myxoma's blood supply in relationship to other cardiac structures, and further correlating these findings with clinical symptoms.
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Fibrilación Atrial , Neoplasias Cardíacas , Mixoma , Masculino , Humanos , Anciano , Bradicardia/diagnóstico , Bradicardia/etiología , Fibrilación Atrial/complicaciones , Atrios Cardíacos/diagnóstico por imagen , Atrios Cardíacos/cirugía , Neoplasias Cardíacas/complicaciones , Neoplasias Cardíacas/diagnóstico por imagen , Neoplasias Cardíacas/cirugía , Síncope/etiología , Mixoma/complicaciones , Mixoma/diagnóstico por imagen , Mixoma/cirugíaRESUMEN
Unilateral absence of pulmonary artery is a rare congenital abnormality that occurs due to malformation of the sixth aortic arch during embryonic development. The clinical presentation of unilateral absence of pulmonary artery can vary based on age of diagnosis; however, in the adult population, it can present with a variety of manifestations including hemoptysis, recurrent pneumonia, and pulmonary hypertension or as an incidental finding. Diagnosis and management of unilateral absence of pulmonary artery remain a challenge. Here, we describe a case of a 37-year-old female with no known past medical history who presented with progressively worsening dyspnea and fatigue. She was incidentally found to have unilateral absence of pulmonary artery on computerized tomography angiography of the chest. Her imaging and physical exam demonstrated signs of volume overload and severe pulmonary hypertension. She received diuretics with good response and was discharged with referral to pulmonary hypertension clinic and eventual follow-up with right heart catheterization. In summary, we describe a rare congenital condition and highlight its diagnostic and therapeutic challenges.
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BACKGROUND: Individuals with no history of coronary artery disease can develop acute coronary syndrome (ACS), often in the absence of major risk factors including low-density lipoprotein cholesterol (LDL-C). We identified risk factors and biomarkers that can help identify those at discordantly high risk of ACS with normal LDL-C using a novel validated coronary artery disease predictive algorithm (CADPA) incorporating biomarkers of endothelial injury. METHODS: Five-year predicted ACS risk was calculated for 6392 persons using CADPA. Persons were classified as low (<3.5%), intermediate (3.5-<7.5%) or high (≥7.5%) CADPA risk and by LDL-C levels <130 mg/dL (low) and ≥130 mg/dL (high) and whether in the discordantly low LDL-C (but high CADPA risk) or high LDL-C (but low/intermediate CADPA risk) group. Multiple logistic regression identified risk factors and biomarkers that predicted discordance. RESULTS: 31% were classified as low (<3.5%), 27% at intermediate (3.5-<7.5%) and 42% were at high risk (≥7.5%). 28% of subjects were identified in the low LDL discordant risk group (LDL-C< 130 mg/dL but 5-year CADPA predicted risk ≥7.5%) and 19% in the high LDL discordant risk group (LDL-C ≥ 130 mg/dL but 5-year CADPA risk of <7.5%). Diabetes (odds ratio [OR], 2.84 [2.21-3.66]), male sex (OR, 2.83 [2.40-3.35]), family history (OR, 2.23 [1.88-2.64]) and active smoking (OR, 1.99 [1.50-2.62]) predicted low LDL risk discordance more than other risk factors (all P < 0.01). Increased serum soluble FAS, hemoglobin A1c and interleukin-16 were the biomarkers most independently associated with increased risk. CONCLUSIONS: Discordance between LDL-C levels and ACS risk is common. Males with diabetes and a family history of myocardial infarction who are actively smoking may be at highest risk of developing ACS despite controlled LDL-C. Future studies should examine whether using the CADPA can help identify individuals that could benefit from earlier targeting of risk factor modification for the prevention of ACS.
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Biomarcadores/análisis , LDL-Colesterol/análisis , Enfermedad de la Arteria Coronaria/complicaciones , Endotelio/lesiones , Adulto , Anciano , Biomarcadores/sangre , LDL-Colesterol/sangre , Enfermedad de la Arteria Coronaria/sangre , Endotelio/fisiopatología , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Factores de RiesgoRESUMEN
Physiologic assessment has become an essential tool to guide revascularization decisions due to the multiple limitations of angiographic and anatomic measures of physiologic significance. However, in certain cases the apparent physiologic measurement may not accurately reflect the severity of coronary disease compared with anatomical measurements. This article will review how anatomy trumps physiology in cases of acute coronary syndromes, left main disease, saphenous vein graft lesions, and myocardial bridging, and how to overcome the limitations of physiologic measurement in these clinical situations.
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Aortic valve (AV) thrombus, a rare complication of antiphospholipid syndrome (APLS), is important to distinguish from Libman-Sacks endocarditis because of its responsiveness to anticoagulation. This may be attributed to immunopathologic differences underpinning their development. We present the case of a 45-year-old woman with high-risk primary APLS who developed an AV mass and was taken for valvular repair surgery but found to have pure thrombus and normal valve leaflets. In such cases, a trial of conservative management with anticoagulation may be adequate. Echocardiography, computed tomography and MRI findings suggestive of thrombus without endocarditis are presented. A literature review of histopathologic, imaging and treatment implications of pure AV thrombus in the context of APLS is included.
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Síndrome Antifosfolípido , Endocarditis , Trombosis , Síndrome Antifosfolípido/complicaciones , Síndrome Antifosfolípido/diagnóstico , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/cirugía , Ecocardiografía , Endocarditis/complicaciones , Endocarditis/diagnóstico , Femenino , Humanos , Persona de Mediana Edad , Trombosis/diagnóstico por imagen , Trombosis/tratamiento farmacológicoRESUMEN
OBJECTIVES: 3D printed mitral valve (MV) models that capture the suture response of real tissue may be utilized as surgical training tools. Leveraging clinical imaging modalities, 3D computerized modelling and 3D printing technology to produce affordable models complements currently available virtual simulators and paves the way for patient- and pathology-specific preoperative rehearsal. METHODS: We used polyvinyl alcohol, a dissolvable thermoplastic, to 3D print moulds that were casted with liquid platinum-cure silicone yielding flexible, low-cost MV models capable of simulating valvular tissue. Silicone-moulded MV models were fabricated for 2 morphologies: the normal MV and the P2 flail. The moulded valves were plication and suture tested in a laparoscopic trainer box with a da Vinci Si robotic surgical system. One cardiothoracic surgery fellow and 1 attending surgeon qualitatively evaluated the ability of the valves to recapitulate tissue feel through surveys utilizing the 5-point Likert-type scale to grade impressions of the valves. RESULTS: Valves produced with the moulding and casting method maintained anatomical dimensions within 3% of directly 3D printed acrylonitrile butadiene styrene controls for both morphologies. Likert-type scale mean scores corresponded with a realistic material response to sutures (5.0/5), tensile strength that is similar to real MV tissue (5.0/5) and anatomical appearance resembling real MVs (5.0/5), indicating that evaluators 'agreed' that these aspects of the model were appropriate for training. Evaluators 'somewhat agreed' that the overall model durability was appropriate for training (4.0/5) due to the mounting design. Qualitative differences in repair quality were notable between fellow and attending surgeon. CONCLUSIONS: 3D computer-aided design, 3D printing and fabrication techniques can be applied to fabricate affordable, high-quality educational models for technical training that are capable of differentiating proficiency levels among users.
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Procedimientos Quirúrgicos Cardíacos , Válvula Mitral , Modelos Anatómicos , Impresión Tridimensional , Procedimientos Quirúrgicos Robotizados , Humanos , SuturasRESUMEN
Genome-scale models (GEMs) of metabolism were constructed for 55 fully sequenced Escherichia coli and Shigella strains. The GEMs enable a systems approach to characterizing the pan and core metabolic capabilities of the E. coli species. The majority of pan metabolic content was found to consist of alternate catabolic pathways for unique nutrient sources. The GEMs were then used to systematically analyze growth capabilities in more than 650 different growth-supporting environments. The results show that unique strain-specific metabolic capabilities correspond to pathotypes and environmental niches. Twelve of the GEMs were used to predict growth on six differentiating nutrients, and the predictions were found to agree with 80% of experimental outcomes. Additionally, GEMs were used to predict strain-specific auxotrophies. Twelve of the strains modeled were predicted to be auxotrophic for vitamins niacin (vitamin B3), thiamin (vitamin B1), or folate (vitamin B9). Six of the strains modeled have lost biosynthetic pathways for essential amino acids methionine, tryptophan, or leucine. Genome-scale analysis of multiple strains of a species can thus be used to define the metabolic essence of a microbial species and delineate growth differences that shed light on the adaptation process to a particular microenvironment.