Spontaneous Migration of Ventriculoperitoneal Shunt Into the Right Heart and Pulmonary Vasculature.

A 73-year-old woman with ventriculoperitoneal (VP) shunt presented for stress echocardiogram for evaluation of chest pain. Transthoracic echocardiogram revealed an incidental right heart mass representing a migrated VP shunt. This case highlights the role of multimodality cardiac imaging in diagnosing right heart masses and the multidisciplinary approach to management.

Electrocardiogram Criteria to Diagnose Cardiac Amyloidosis in Men With a Bundle Branch Block.

Diagnosing cardiac amyloidosis is challenging and requires a high index of suspicion in patients with an increased left ventricular wall thickness (LVWT). Low QRS voltage on electrocardiogram (ECG) has been regarded as the hallmark ECG finding in cardiac amyloidosis; however, the presence of low voltage can range from 20-74% and the voltage/mass ratio carries a greater diagnostic accuracy than QRS voltage alone. Patients with cardiac amyloidosis can have conduction system infiltration and this may result in a BBB. Therefore, the ECG or mass/voltage criteria established for patients with a narrow QRS in the diagnosis of cardiac amyloidosis may not be applicable in patients with a BBB. We sought to identify criteria to aid in the diagnosis of cardiac amyloidosis in patients with increased LVWT on echocardiogram and with a BBB on ECG. We calculated the total QRS score/LVWT, limb lead QRS score/LVWT, R in lead aVL/LVWT, R in lead I/LVWT, and Sokolow index/LVWT. In patients with an increase in LVWT and BBB, total QRS voltage that is indexed to wall thickness can help distinguish between patients with increased wall thickness who have cardiac amyloidosis from those who have LVH related to a pressure overload state. A unique index of Total QRS Score/LVWT is the best predictor of cardiac amyloidosis with a cutoff value of 92.5 mV/cm which is 100% sensitive and 83% specific for the diagnosis of cardiac amyloidosis. This may be a useful screening tool in patients with an increased wall thickness to raise diagnostic suspicion for cardiac amyloidosis.

The use of MitraClip to prevent posttranscatheter aortic valve replacement left ventricular "suicide".

Patients with concomitant severe aortic stenosis (AS) and left ventricular outflow tract (LVOT) obstruction undergoing transcatheter aortic valve replacement (TAVR) are at risk for hemodynamic collapse due to a sudden decrease in afterload causing worsening LVOT obstruction. We present a case of an 88-year-old female with symptomatic, severe AS, and LVOT obstruction with systolic anterior motion (SAM) of the mitral leaflet in whom alcohol septal ablation was contraindicated secondary to a chronic total occlusion of the right coronary artery that filled retrograde via septal collaterals. MitraClip at the time of TAVR was successfully performed to treat SAM with subsequent stabilization of LVOT gradients despite treatment of the patient's AS. This novel approach may represent a feasible option to prevent hemodynamic complications after TAVR in patients with significant LVOT obstruction secondary to SAM and AS.

Identifying patients for safe early hospital discharge following st elevation myocardial infarction.

OBJECTIVES: To examine whether the CADILLAC risk score is an effective method of patient stratification for early discharge following ST elevation myocardial infarction (STEMI). BACKGROUND: Patients with STEMI are typically hospitalized to monitor for serious complications such as arrhythmias, heart failure, and reinfarction. Optimal length of stay is unclear. Whether low risk patients can be safely discharged before 72 hr of hospitalization is unclear. METHODS: Patients with STEMI who underwent successful PCI were retrospectively stratified using CADILLAC risk score to low risk (n = 123) and intermediate to high risk (n = 105). The primary outcome was adverse clinical events at day 3 or later. Secondary outcomes were adverse clinical events on day 1 and mortality rates at 30 days and 31 to 365 days. RESULTS: Low risk patients had lower major adverse clinical events at day 3 or later (0 vs. 11.4%, P = 0.0002) and lower total mortality at 1 year (0 vs. 4.8%, P = 0.02) than patients with intermediate to high risk. Low risk patients were also less likely to have a cardiovascular event during the first 24 hr when compared to those with an intermediate to high risk score (3.3% vs. 13.3%, P = 0.006). CONCLUSION: Low risk patients identified using CADILLAC risk score with STEMI treated successfully with primary PCI have a low adverse event rate on the third day or later of hospitalization suggesting that an earlier discharge is safe in properly selected patients. Monitoring in a noncritical care setting following primary PCI for STEMI may be feasible for selected patients. © 2016 Wiley Periodicals, Inc.

Impedance to retrograde and forward flow in chronic mitral regurgitation and the physiology of a double outlet ventricle.

OBJECTIVE: Mitral regurgitation (MR) is generally characterised as exhibiting a 'low impedance leak into the left atrium'. This notion is widely accepted without measured impedance data. The aim of this study was to define the impedance to retrograde and forward blood flow and to examine hydraulic (pressure-volume) and mechanical (stress-shortening) function in chronic severe MR. METHODS: A mathematical model of a double outlet ventricle was developed and the ratio of retrograde to forward impedance was plotted over a wide range of regurgitant fraction (RF). The model predicts that an impedance ratio >1 indicates that the impedance to retrograde flow exceeds that of forward flow. Left ventricular (LV) systolic pressure/flow rate was used as an index of impedance (mm Hg/mL/s). Data from 10 patients with severe MR were used to assess the clinical applicability of the model. All patients had degenerative valve disease with partial flail leaflet, an RF >50% and an ejection fraction (EF) >0.60. There were seven males and three females, aged 59±10. LV volumes as well as retrograde and forward flow rates were determined with echocardiographic and Doppler techniques. RESULTS: The model indicates that the impedance ratio is >1 when the RF ranges from zero to 57%. Clinical data: end-diastolic volume=184±47 mL; EF=0.63±3%; RF=53±4%. Values for retrograde and forward impedance were 0.77±0.17 and 0.63±0.12 (p=0.003); the impedance ratio was 1.22±0.19. Total impedance to LV emptying was low (0.35±0.06). The ratio of systolic wall stress to EF (580±81 g/cm2) was normal. Data are mean±SD. CONCLUSIONS: The model, supported by clinical data, indicates that the impedance to retrograde flow exceeds the impedance to forward flow in chronic severe MR. These findings refute the notion of a low impedance leak into the left atrium. The double outlet of an enlarged ventricle provides a mechanism for low total impedance to ejection in the presence of a normal stress-shortening relation.

Mycotic aneurysms of the ascending aorta in the absence of endocarditis.

Mycotic aneurysm formation is a rare and potentially fatal sequela of bacteremia. We present the cases of 2 octogenarians who had surgically confirmed mycotic aneurysms that involved the ascending aorta, with contained rupture (pseudoaneurysm). Neither patient had evidence of valvular endocarditis. Patient 1, an 82-year-old man, had streptococcal bacteremia. Imaging confirmed a mycotic aneurysm of the ascending aorta, and resection was successful. Patient 2, an 83-year-old woman, had recurrent staphylococcal bacteremia and progressive widening of the mediastinum, and imaging revealed a mycotic pseudoaneurysm. She underwent surgical repair with use of a bovine pericardial patch, but she died 2 weeks later because of patch dehiscence.We did not initially suspect mycotic aneurysm in either patient. Despite the availability of accurate, noninvasive imaging techniques, strong clinical suspicion is required for the early diagnosis of mycotic aneurysm.

Differential effects of dobutamine versus treadmill exercise on left ventricular volume and wall stress.

BACKGROUND: Dobutamine and exercise echocardiography are well-validated modalities used for the evaluation of patients with suspected myocardial ischemia. Patients undergoing dobutamine stress echocardiography (DSE), however, experience less angina, ST-segment depressions, and wall motion abnormalities. Other than the effect on heart rate, the physiologic and volumetric differences between pharmacologic and exercise-induced stress that affect myocardial oxygen demand are not well defined. The aim of this study was to test the hypothesis that in the absence of ischemia, dobutamine reduces left ventricular (LV) volume, wall tension (WTN), and peak systolic stress (PSS) compared with exercise. METHODS: Seventy patients without ischemia were prospectively enrolled (35 underwent exercise echocardiography and 35 DSE), and various hemodynamic parameters were measured and LV volumes calculated (using the Simpson and Teichholz formulas). Systolic WTN and PSS were determined at rest and stress. RESULTS: LV end-diastolic volume index fell significantly more with dobutamine than with exercise (-34% vs -9%, P < .0001), as did mean end-systolic volume index (-55% vs -37%, P = .07). Systolic blood pressure increased more with exercise (41 ± 22 vs 1 ± 33 mm Hg, P < .0001), as did cardiac index (2.5 ± 0.7 vs 1.0 ± 0.8 L/min/m(2), P < .0001). Systolic WTN increased with exercise by 24% (P < .0001) but decreased with dobutamine by 18% (P < .0001). PSS increased with exercise by 21% (P < .0001) but decreased with dobutamine by 23% (P < .0001). CONCLUSIONS: The degree of stress achieved with DSE appears to be considerably different than with exercise. DSE produces greater reductions in LV end-diastolic and end-systolic volumes than exercise and decreases rather than increases in WTN and PSS. The lower WTN and PSS were related to both a decrease in LV volume and lower systolic blood pressure with dobutamine. These observations support recommendations favoring exercise stress testing in patients able to exercise and reinforce the notion that high-risk echocardiographic features of ischemia such as stress-induced LV dilatation may be less striking or absent with DSE.

Cardiac events in patients with negative maximal versus negative submaximal dobutamine echocardiograms undergoing noncardiac surgery: importance of resting wall motion abnormalities.

OBJECTIVES: This study sought to evaluate the negative predictive value (NPV) of preoperative dobutamine stress echocardiography (DSE) in patients who fail to achieve target heart rate (HR) and assess the influence of resting wall motion abnormalities (WMAs) without demonstrable ischemia on perioperative events. BACKGROUND: The prognostic value of a negative-submaximal DSE study before noncardiac surgery is unknown. METHODS: Consecutive patients (n = 429) who underwent surgery over a three-year period, preceded by DSE, were included. We compared perioperative event rates among those without inducible ischemia according to whether or not 85% age-adjusted maximum HR was achieved, and whether WMAs were present at rest. RESULTS: Of 397 negative DSEs, peak HR was <85% maximum predicted in 62 (16%). Most were receiving beta-blockers (77%). The average dobutamine and atropine doses were 48 microg/kg/min and 1.2 mg, respectively. Average HR was 115 beats/min (74% maximum predicted). Perioperative myocardial infarctions occurred more frequently in patients with positive tests (3 of 32 [9.4%] vs. 7 of 397 [1.8%]; p = 0.03), but with similar frequency among the negative-maximal and negative-submaximal groups (6 of 335, 1.8% vs. 1 of 62, 1.6%, respectively). Accordingly, the NPV was 98% in both subgroups. Events occurred exclusively in patients with WMAs at rest: 7 of 100 (7%) versus 0 of 297 (0%) (p < 0.0001). CONCLUSIONS: In patients undergoing preoperative DSE, failure to achieve target HR is not uncommon despite an aggressive DSE regimen. A negative DSE without resting WMAs has excellent NPV regardless of the HR achieved. Patients with resting WMAs appear to be at increased risk for perioperative events even without provokable ischemia.

Paradoxical embolism in the left main coronary artery: diagnosis by transesophageal echocardiography.

We describe a patient with a paradoxical coronary embolism diagnosed by transesophageal echocardiography. The patient developed a stroke followed by a myocardial infarction. Coronary angiography showed an obstruction of the left main coronary artery. Transesophageal echocardiography showed the mechanism of the neurologic and cardiac events to be a paradoxical embolism. Emergency surgical retrieval of the thrombus lodged in the left main coronary ostium and of a separate thrombus traversing a patent foramen ovale was performed. To our knowledge, direct visualization of the paradoxical coronary embolism by echocardiography has not been reported previously. We discuss mechanisms responsible for paradoxical coronary embolism and review the literature pertaining to this condition.