Incidental Finding of the Anomalous Origin of Left Main Coronary Artery from Pulmonary Artery in an Adult Presenting with Arrhythmia-Induced Myocardial Ischemia.

Anomalous origin of the left main coronary artery from the pulmonary artery (ALCAPA) is a rare congenital coronary anomaly with high mortality. It is associated with cardiovascular complications and is usually diagnosed soon after birth. Those who survive into adulthood can present with signs of myocardial infarction, heart failure, mitral regurgitation, severe pulmonary hypertension, or sudden cardiac death. We present a 53-year-old female presenting with atrial fibrillation and found to have an incidental diagnosis of ALCAPA who refused surgical correction. We also review the epidemiology, diagnosis, age-based clinical presentations, and treatment options for ALCAPA.

The day of the week and acute heart failure admissions: Relationship with acute myocardial infarction, 30-day readmission rate and in-hospital mortality.

BACKGROUND: In-hospital care may be constrained during the weekend due to lesser resources. Impact on outcomes of weekend versus weekday care in congestive heart failure (HF) needs further study. METHODS: Admissions with a primary diagnosis of HF using ICD-9CM codes were studied. 22,287 HF-admissions from Einstein Medical Center (2003-2013) and 2,248,482 HF-admissions from the 2002-2012 Nationwide Inpatient Sample (NIS) were analyzed separately. Primary outcomes were 30-day HF-readmission and in-hospital mortality. Logistic regression models were used to evaluate outcomes. RESULTS: Weekends experienced lower rates of admission and discharge. Mondays experienced the highest admission rate and Fridays experienced the highest discharge rate. Friday was independently associated with highest 30-day HF-readmission rates (Adjusted OR 1.12, CI 1.01-1.23; p=0.02) in addition to risk factors such as African-American race, hypertension, diabetes, hyperlipidemia, end-stage renal disease and coronary artery disease. Within the NIS sample, 85,479 in-hospital deaths (3.8%) were recorded. Compared to weekdays, patients admitted over the weekend had greater comorbidities, higher incidence of acute myocardial infarction (AMI) (15.8% vs. 16.8%; p<0.01), higher Charlson-comorbidity index and underwent less procedures such as echocardiography, right heart catheterization, coronary angiography, coronary revascularization or mechanical circulatory support. Weekend HF admission predicted higher in-hospital mortality (aOR 1.07, 95%CI 1.05-1.08; p<0.01) on multivariate analysis. This relationship was applicable for teaching and non-teaching hospitals. CONCLUSION: Friday was associated with the highest discharge and 30-day HF-readmission rate. Weekend HF admissions experienced more AMI, had greater comorbidities, received less cardiac procedures and predicted higher in-hospital mortality. Higher weekend mortality may be related to the greater degree of severity of illness among admitted patients.

Trends in Hospitalization for Hypertensive Emergency, and Relationship of End-Organ Damage With In-Hospital Mortality.

BACKGROUND: There are no comprehensive guidelines on management of hypertensive emergency (HTNE) and complications. Despite advances in antihypertensive medications HTNE is accompanied with significant morbidity and mortality. METHODS: We queried the 2002-2012 nationwide inpatient sample database to identify patients with HTNE. Trends in incidence of HTNE and in-hospital mortality were analyzed. Logistic regression analysis was used to assess the relationship between end-organ complications and in-hospital mortality. RESULTS: Between 2002 and 2012, 129,914 admissions were included. Six hundred and thirty (0.48%) patients died during their hospital stay. There was an increase in the number of HTNE admissions (9,511-15,479; Ptrend < 0.001) with concurrent reduction of in-hospital mortality (0.8-0.3%; Ptrend < 0.001) by the year 2012 compared to 2002. Patients who died during hospitalization were older, had longer length of stay, higher cost of stay, more comorbidities, and higher risk scores. Presence of acute cardiorespiratory failure [adjusted odds ratio (OR), 15.8; 95% confidence interval (CI), 13.2-18.9], stroke or transient ischemia attack (TIA) (adjusted OR, 7.9; 95% CI, 6.3-9.9), chest pain (adjusted OR, 5.9; 95% CI, 4.4-7.7), stroke/TIA (adjusted OR, 5.9; 95% CI, 4.5-7.7), and aortic dissection (adjusted OR, 5.9; 95% CI, 2.8-12.4) were most predictive of higher in-hospital mortality in addition to factors such as age, aortic dissection, acute myocardial infarction, acute renal failure, and presence of neurological symptoms. CONCLUSION: A rising trend in hospitalization for HTNE, with an overall decrease in in-hospital mortality was observed from 2002 to 2012, possibly related to changes in coding practices and improved management. Presence of acute cardiorespiratory failure, stroke/TIA, chest pain, and aortic dissection were most predictive of higher hospital mortality.

IVC filters-Trends in placement and indications, a study of 2 populations.

Inferior vena cava filter (IVCF) placement appears to be expanding over time despite absence of clear directing evidence.Two populations were studied. The first population included patients who received an IVCF between January 2005 and August 2013 at our community hospital center. Demographic information, indications for placement, and retrieval rate was recorded among other variables. The second population comprised of patients receiving an IVCF from 2005 to 2012 according to the Nationwide Inpatient Sample (NIS) using ICD-9CM coding. Patients were divided into 2 groups based on the year of admission for comparison, that is, first group from 2005 to 2008 and the second from 2009 to 2012. In addition, we analyzed annual trends in filter placement, acute venothromboembolic events (VTE) and several underlying comorbidities within this population.At our center, 802 IVCFs were placed (55.2% retrievable); 34% for absolute, 61% for relative, and 5% for prophylactic indications. Major bleeding (27.5%), minor self-limited bleeding (13.7%), and fall history (11.2%) were the commonest indications. Periprocedural complication rate was 0.7%, and filter retrieval rate was 7%. The NIS population (811,487 filters) saw a decline in IVCF placement after year 2009, following an initial uptrend (Ptrend < 0.01). IVCF use among patients with neither acute VTE nor bleeding among prior VTE saw a 3-fold absolute reduction from 2005 to 2012 (33,075-11,655; Ptrend < 0.01). Patients from 2009 to 2012 were more likely to be male and had higher rates of acute VTE, thrombolytic use, cancer, bleeding, hypotension, acute cardiorespiratory failure, shock, prior falls, blood product transfusion, hospital mortality including higher Charlson comorbidity scores. The patients were younger, had shorter length of stay, and were less likely to be associated with strokes including hemorrhagic or require ventilator support. Prior falls (adjusted odds ratio-aOR 2.8), thrombolytic use (aOR 1.76), and shock (aOR 1.45) were most predictive of IVCF placement between 2009 and 2012 on regression analysis.Recent trends suggest that a higher proportion of patients receive temporary IVCF, for predominantly relative indications. Nationally, the number of filters being placed is decreasing, especially among those who did not experience acute VTE or bleeding events. Prior falls, thrombolytic therapy, and shock were most predictive of IVCF placement in latter half of the study period.

Therapeutic Hypothermia and Stent Thrombosis: A Nationwide Analysis.

OBJECTIVES: This study sought to determine whether "real-world" data supported the hypothesis that therapeutic hypothermia (TH) led to increased rates of stent thrombosis. BACKGROUND: TH, which is often instituted after cardiac arrest (CA) to improve neurologic outcomes, alters pharmacokinetics of antiplatelet medications, leading to a theoretical risk of stent thrombosis after percutaneous coronary intervention (PCI). METHODS: CA patients with acute myocardial infarction undergoing PCI were identified from the Nationwide Inpatient Sample from 2006 to 2011, with a defined primary outcome of stent thrombosis. The incidence of stent thrombosis in patients undergoing TH versus those not undergoing TH was compared using both logistic regression and propensity score matching. RESULTS: In this dataset, 49,109 CA patients underwent PCI for acute myocardial infarction from 2006 to 2011, of whom 1,193 (2.4%) underwent TH. The incidence of stent thrombosis in the TH group was 3.9% (43 of 1,193), compared to 4.7% (2,271 of 47,916) in the no TH group (p = 0.61). Logistic regression showed that TH was not a significant predictor of stent thrombosis with an adjusted odds ratio of 0.71 (95% confidence interval: 0.28 to 1.76; p = 0.46). Propensity matching was performed to adjust for baseline differences between the TH and no TH groups, matching 1,155 patients in the TH group with 3,399 patients in the no TH group. No difference was observed in the incidence of stent thrombosis in the TH and the no TH groups after propensity matching (3.5% vs. 6.1%; p = 0.17). CONCLUSIONS: TH does not increase the incidence of stent thrombosis after primary PCI in patients with acute myocardial infarction presenting as CA.

Periprocedural Management of New Oral Anticoagulants in Atrial Fibrillation Ablation.

BACKGROUND: Patients who undergo catheter ablation for atrial fibrillation (AF) are at increased risk of developing thromboembolic and bleeding complications periprocedurally. Many patients are now on newer oral anticoagulants (NOACs), but data regarding their safety and efficacy during AF ablation are limited. METHODS AND RESULTS: This article reviews the literature in PubMed from 1998 to 2014 and includes clinical trials and meta-analysis that analyzed the safety and efficacy of NOACs during AF catheter ablation. Dabigatran seems to be as effective and safe as warfarin, although most data are from single-center studies, with small samples and very low overall bleeding and thromboembolic complications. Periprocedural anticoagulation protocols also vary greatly between studies. Some recent meta-analysis has shown that warfarin could still be a safer and more effective alternative. There are fewer studies with rivaroxaban in AF ablation, and there have been no meta-analysis yet comparing rivaroxaban to warfarin or dabigatran. There seems to be no significant differences in safety or efficacy of rivaroxaban compared to warfarin. Interestingly, there are no available data for apixaban in AF ablation yet. DISCUSSION: There are no consensus guidelines regarding the use of NOACs during AF ablation. Dabigatran and rivaroxaban seem as safe and effective as warfarin, although larger studies with standardized protocols are needed, as available studies may be underpowered to detect small differences in bleeding and thromboembolic rates.

Atrial fibrillation following cardiac surgery: established and emerging strategies of prevention.

More than 250,000 patients undergo cardiac surgery every year. Although advances in surgical techniques have reduced the peri-operative morbidity and mortality in these patients, atrial fibrillation persists to commonly occur following these surgeries. Traditional therapies have reduced their occurrence; however there are still a significant number of patients who develop this complication. Newer and non-conventional medications are being studied to reduce this cardiac arrhythmia. This review will elaborate on the patho-physiology, and prevention of this arrhythmia. We also aim to summarize recent investigated and patented medications which may result in more effective strategies for prophylaxis against this cardiac arrhythmia.

Acute aortic syndromes: pathophysiology and management.

The acute aortic syndromes carry significant morbidity and mortality, especially when detected late. Symptoms may mimic myocardial ischemia, and physical findings may be absent or, if present, can be suggestive of a diverse range of other conditions. Maintaining a high clinical index of suspicion is crucial in establishing the diagnosis. All patients with suspected aortic disease and evidence of acute ischemia on electrocardiogram should undergo diagnostic imaging studies before thrombolytics are administered. The demonstration of an intimal flap separating 2 lumina is the basis for diagnosis. Tear detection and localization are very important because any therapeutic intervention aims to occlude the entry tear. The goals of medical therapy are to reduce the force of left ventricular contractions, decrease the steepness of the rise of the aortic pulse wave, and reduce the systemic arterial pressure to as low a level as possible without compromising perfusion of vital organs. Surgical therapy still remains the gold standard of care for type A aortic dissection, whereas in type B dissection, percutaneous aortic stenting and fenestration techniques have been developed and are sometimes used in conjunction with medical therapy in certain situations.

Lens and retina formation require expression of Pitx3 in Xenopus pre-lens ectoderm.

Pitx3 is expressed in tissues fated to contribute to eye development, namely, neurula stage ectoderm and pre-chordal mesoderm, then presumptive lens ectoderm, placode, and finally lens. Pitx3 overexpression alters lens, optic cup, optic nerve, and diencephalon development. Many of the induced anomalies are attributable to midline deficits; however, as assessed by molecular markers, ectopic Pitx3 appears to temporarily enlarge the lens field. These changes are usually insufficient to generate either ectopic lenses to enlarge the eye that eventually differentiates. Conversely, use of a repressor chimera or of antisense morpholinos alters early expression of marker genes, and later inhibits lens development, thereby abrogating retinal induction. Reciprocal grafting experiments using wild-type and morpholino-treated tissues demonstrate that Pitx3 expression in the presumptive lens ectoderm is required for lens formation. Contradictory to recent assertions that retina can form in the absence of a lens, the expression of Pitx3 in the presumptive lens ectoderm is critical for retina development.

The correlation of left ventricular hypertrophy with the severity of atherosclerosis and embolic events.

OBJECTIVE: The study was undertaken to assess the correlation between the presence and degree of aortic atheroma with degree of Left ventricular (LV) mass index and subsequent clinical outcomes. MATERIAL AND METHOD: The authors studied the clinical profiles of 87 patients with aortic atherosclerosis and controls, who had undergone TEE between 1995 and 2000. RESULTS: Mean LV mass index was 116 gram/m2 in atherosclerosis group compared to 81 gram/m2 in the control group (p < 0.009). In the atherosclerotic group, there was a close correlation between LV mass index score and severity of the plaque in the aortic arch and descending aorta (p < 0.001, 0.001). The presence of large ulcerated plaque had a significant correlation with stroke (p < 0.002). CONCLUSION: 1) LV mass index correlates with the severity of aortic atheroma. 2) Smoking, elevated mean arterial blood pressure and a high LV mass index score are significantly correlated with large ulcerated plaque and stroke. 3) These findings may in part explain the higher cardiovascular risk in patients with increased left ventricular mass.

Effectiveness of echocardiographic imaging by nurses to identify left ventricular systolic dysfunction in high-risk patients.

Recognizing left ventricular (LV) systolic dysfunction is critical. The investigators sought to evaluate whether nurses could be trained to use a hand-carried ultrasound (HCU) device to screen for LV systolic dysfunction in high-risk patients. Sixty-three patients from an outpatient diabetes clinic underwent brief echocardiographic examinations by nurses using HCU devices. Of the 63 patients enrolled in the study, 3 (4.7%) had LV systolic dysfunction. The nurses correctly identified these 3 patients as having LV systolic dysfunction (sensitivity 100%, negative predictive value 100%). The identification of occult LV systolic dysfunction in diabetic patients may allow the initiation of therapies known to improve prognosis.

Inducible left ventricular outflow tract gradient during dobutamine stress echocardiography: an association with intraoperative hypotension but not a contraindication to liver transplantation.

BACKGROUND: Dobutamine stress echocardiography (DSE) is frequently used in the evaluation of cardiac risk prior to orthotopic liver transplantation (OLT). In the general cardiac population, an inducible left ventricular outflow tract gradient (LVOT Delta) during DSE has variable prognostic importance. The purpose of this study was to determine the prevalence and clinical significance of LVOT Delta in patients undergoing OLT during DSE. METHODS: Consecutive medical records of 106 patients who had undergone OLT at our institution from January 1997 until January 2002 were retrospectively analyzed and divided into two groups based on the presence (Group I, LVOT Delta >36 mmHg) or absence (Group II, LVOT Delta< or = 36 mmHg) of a significant LVOT Delta measured during DSE. We determined any outcome differences between these two groups with regard to intraoperative hypotension, cardiac mortality, length of hospital stay, graft function, and renal function post-OLT. RESULTS: Forty-six patients had an LVOT Delta > 36 mmHg (Group I) and 60 patients had LVOT Delta< or = 36 mmHg (Group II). Baseline demographics were similar in both groups. There was no significant overall difference in cardiac mortality between Group I versus Group II patients (0 versus 1 patient, respectively, P=0.57). Intraoperative hypotension occurred in 4 patients in Group I versus 0 patient in Group II (P=0.03). Length of stay, graft function, and postoperative renal function were similar in both groups. CONCLUSION: A significant LVOT Delta >36 mmHg is a frequent finding occurring in 46/106 (43%) of patients who have DSE pre-OLT. Intraoperative hypotension is associated with patients having an LVOT Delta. However, post-OLT patients with significant LVOT Delta have a similar in-hospital outcome compared to patients without significant LVOT Delta.

Bacteremia and infective endocarditis in patients on hemodialysis.

The number of patients with end-stage renal disease (ESRD) has risen dramatically over the last decade. There are 300,000 patients in the United States with ESRD who are receiving hemodialysis (HD), and the incidence is increasing at a rate of 6% to 8% per year. Bacteremia, a prerequisite for infective endocarditis (IE), occurs at a rate of 0.7 to 1.4 episodes per 100 patient-care months. Few other medical conditions, except for chemotherapy-induced neutropenia, immunosuppression, and intravenous drug abuse, are associated with higher rates of bacteremia. IE occurs in approximately 2% to 6% of patients receiving HD. The aim of this article is to review the pathogenesis, diagnosis, current therapeutic options, and determinants of prognosis of IE in patients receiving HD.

Undefined hypercoaguable state associated with massive right ventricular thrombus and embolism in a previously healthy 17-year-old male.

A right ventricular thrombus (RVT) is an unusual finding on echocardiography. We describe a healthy young male patient who developed RVT with subsequent pulmonary embolism (PE), the etiology of which remains uncertain.

Penetrating aortic atherosclerotic ulcer complicated by periesophageal hematoma.

Penetrating aortic atherosclerotic ulcers have been recently recognized as an entity among the acute aortic syndromes with a potentially fatal outcome. We describe the case of a patient presenting with severe chest pain who died as a result of a thoracic-aorta penetrating atherosclerotic ulcer complicated by a intramural hematoma of the esophagus and stomach, leading to exsanguination. To our knowledge this is the first case reported in the literature of such a complication from penetrating aortic atherosclerotic ulcers.

Epidemiology and outcome of infective endocarditis in hemodialysis patients.

BACKGROUND: Survival in patients with infective endocarditis (IE) ranges from 4 to 50% depending on the type of organism, the type of valve involvement and the type of treatment. METHODS: We conducted a retrospective analysis of data in hemodialysis (HD) patients at our center from 1990 to 2000. Demographics, risk factors, and outcome data were extracted in the subgroup of patients with first-episode IE diagnosed primarily by echocardiography. RESULTS: A total of 2239 patients underwent HD at our center. Thirty-two (1.4%) had IE defined using the Duke Criteria. Permanent and temporary venous dialysis catheters, arteriovenous (AV) grafts, and AV fistulae were used in 19 (59%), 12 (38%), and 1 (3%) patient respectively. Mean access duration was 7.6 +/- 7.9 months. Thirty (94%) patients had positive blood cultures, with the majority having Staphylococcus aureus bacteremia. Two (7%) patients had positive echocardiographic findings but negative blood cultures due to the commencement of empiric antibiotic therapy prior to blood cultures. The mitral valve was mainly affected. Transesophageal echocardiography was performed in 23 (72%) patients and detected an intracardiac mass in all 23 patients. One-year mortality was 56.3%. A poor 1-year prognosis was associated with presenting features of low hemoglobin, elevated leukocyte count, hypoalbuminemia, severe aortic and mitral regurgitation, and annular calcification in mitral valve IE. CONCLUSION: The prevalence of IE in HD patients is 1.4%. One-year mortality was 56.3%. Close observation is required during the first year when patients with severe valvular regurgitation and hematological abnormalities have a high mortality.