Right atrial appendage thrombus in a patient with a left atrial appendage occlusion device.

Management of right atrial appendage (RAA) thrombus is a clinical dilemma. We describe a case of incidentally found RAA thrombus in a patient with a left atrial appendage closure device (WATCHMAN). Options for the management of RAA thrombus include observation, anticoagulation, thrombolytics, or surgical extraction. Size, mobility, site of attachment of the thrombi, patient factors (e.g., bleeding risk), and other indications for anticoagulation may be used to guide management.

Chylopericardium due to Subclavian Vein Thrombosis in the Setting of Protein S Deficiency.

BACKGROUND: Chylopericardium is the accumulation of lymphatic fluid in the pericardial cavity. It can be idiopathic or secondary to trauma, cardiothoracic surgery, neoplasm, radiation, tuberculosis, lymphatic duct dysfunction, thrombosis, or other causes. We present a case of chylopericardium due to subclavian vein thrombosis in a patient with protein S deficiency. Clinical Case. A 48-year-old man with a history of protein S deficiency presented to the emergency department with shortness of breath and a productive cough. CT of the chest showed pulmonary emboli, moderate pericardial effusion, and a large thrombus of the superior vena cava, brachiocephalic vein, and subclavian veins. He developed echocardiographic evidence of cardiac tamponade so he underwent pericardiocentesis with drainage of milky-appearing fluid. Analysis of the fluid showed elevated triglycerides consistent with chylopericardium. The pericardial effusion reaccumulated, likely secondary to lymphatic duct obstruction due to his subclavian vein thrombus. Catheter-assisted thrombolysis was performed with resolution of the patient's effusion and symptoms. CONCLUSION: Chylopericardium is a rare but important complication of subclavian vein thrombosis. Management is typically with surgical intervention, although our case represents successful treatment with catheter-assisted thrombolysis.

Correlation Between Aortic Angulation and Outcomes of Transcatheter Aortic Valve Replacement With New-Generation Valves.

The aim of this study was to assess the correlation of aortic angulation (AA) on immediate postprocedural and long-term outcomes following transcatheter aortic valve replacement (TAVR) with new-generation valves. There is limited and conflicting data on the impact of AA on short- and long-term outcomes in patients undergoing TAVR. Available studies to date were done with first-generation valves. We assessed 179 patients who underwent TAVR with either a balloon-expandable or self-expandable valve at our institute from May 2014 to June 2017 and had multislice computed tomography scans available for AA evaluation. All included patients received a second- or third-generation valve. TAVR endpoints, device success, and adverse events were defined according to the Valve Academic Research Consortium-2 criteria. The mean AA of the study population was 49.05 ± 10.07. Patients were divided into 2 groups: AA <49 and AA ≥49, and then further subdivided by valve type. There were no difference in mean age, The Society for Thoracic Surgery (STS) score, or race distribution between the AA <49 and AA ≥49 groups. The preimplantation balloon valvuloplasty rate was higher in patients with AA ≥ 49 compared to patients with AA <49, (70% vs 55.1%, P = 0.04). There was no difference in re-hospitalization, pacemaker implantation, postprocedural aortic regurgitation or mortality between patients with AA <49 and AA ≥49 irrespective of valve type (P < 0.05). AA does not significantly affect short- or long-term outcomes in patients who undergo TAVR with new-generation balloon-expandable or self-expandable valves.

The Impact of Cardiology Consultation on Medical Intensive Care Unit Patients with Elevated Troponin Levels.

BACKGROUND: Cardiac troponin (cTn) is mainly used to diagnose acute coronary syndrome (ACS). However, cTn can also be elevated in critically ill patients secondary to demand ischemia or myocardial injury. The impact of cardiology consultation on the clinical outcomes of patients admitted to medical intensive care unit (ICU) with elevated cTn is unclear. METHODS: A retrospective analysis of medical ICU patients with elevated cTn without evidence of ACS between January 2013 through December 2018. Patients were stratified based on documentation of cardiology consultation. The primary outcome was 1-year mortality. Secondary outcomes were in-hospital and 30-day mortality, the length of stay (LOS), further cardiac testing, 30-day readmission rate, new prescription of cardiac medications, and the predictors of a cardiology consultation. RESULTS: Of 846 patients screened, 766 patients were included, of whom 63.2% had cardiology consultation. Cardiology consultation group had longer median LOS (7 vs. 5 days, P = 0.007), additional cardiac testing (90.3% vs. 67.7%, P < 0.001), and more new cardiac medications (52.1% vs. 16.3%, P < 0.001). No difference was noted in-hospital mortality (adjusted odds ratio [aOR], 0.6, 95% CI, 0.4-1.1, P = .117), 30-day mortality (aOR = 0.8, 95% CI, 0.5-1.4, P = .425), 1- year mortality (aOR, 1.4, 95% CI, 0.9-2.2, P = .193), or cardiac-specific 30-day readmission rate (aOR, 7.0, 95% CI, 0.7-14.9, P = .137). History of coronary artery disease (CAD) was the most independent predictor for a cardiology consult (aOR, 2.2, 95% CI, 1.3-3.8, P < .001). CONCLUSION: Cardiology consultation for elevated cTn in medical ICU patients was associated with increased cardiac testing and LOS, without significant impact on mortality.

Broken Scalpel Blade During Emergent Cricothyroidotomy: An Unexpected Complication in a Critical Situation.

Scalpel-bougie cricothyroidotomy is the most common surgical procedure to obtain emergency airway access when routine methods fail. We present a case of a broken scalpel blade during emergency cricothyroidotomy further complicating respiratory access.

Reversible bradycardia secondary to myxedema coma: case-report.

Myxedema coma occurs mostly in patients with long-standing untreated or undertreated hypothyroidism. Bradycardia is a well-known cardiac manifestation for myxedema coma; however, not all bradycardia with hypothyroidism are sinus bradycardia. Sick sinus syndrome is a group of arrhythmias caused by the malfunction of the natural pacemaker of the heart. Tachy-Brady syndrome is considered to be a type of sick sinus syndrome, where the heart alternates between tachycardia and bradycardia, and it is usually treated with pacemaker implantation along with rate slowing medical therapy. Here we report a case of an 83-year-old female who presented with myxedema coma and atrial fibrillation with tachycardia and intermittent slow ventricular response. We attempt to review the relationship between these two diseases and conclude that appropriate diagnosis of myxedema coma, may be beneficial in reducing the need for pacemaker implantation.

Lipoprotein(a) and calcific aortic valve stenosis: A systematic review.

Calcific aortic valve stenosis (AS) is the most common form of acquired valvular heart disease needing intervention and our understanding of this disease has evolved from one of degenerative calcification to that of an active process driven by the interplay of genetic factors and chronic inflammation modulated by risk factors such as smoking, hypertension and elevated cholesterol. Lipoprotein(a) [Lp (a)] is a cholesterol rich particle secreted by the liver which functions as the major lipoprotein carrier of phosphocholine-containing oxidized phospholipids. Lp(a) levels are largely genetically determined by polymorphisms in the LPA gene. While there is an extensive body of evidence linking Lp(a) to atherosclerotic cardiovascular disease, emerging evidence now suggests a similar association of Lp(a) to calcific AS. In this article, we performed a systematic review of all published literature to assess the association between Lp(a) and calcific aortic valve (AV) disease. In addition, we review the potential mechanisms by which Lp(a) influences the progression of valve disease. Our review identified a total of 21 studies, varying from case-control studies, prospective or retrospective observational cohort studies to Mendelian randomized studies that assessed the association between Lp(a) and calcific AS. All but one of the above studies demonstrated significant association between elevated Lp(a) and calcific AS. We conclude that there is convincing evidence supporting a causal association between elevated Lp(a) and calcific AS. In addition, elevated Lp(a) predicts a faster hemodynamic progression of AS, and increased risk of AV replacement, especially in younger patients. Further research into the clinical utility of Lp(a) as a marker for predicting the incidence, progression, and outcomes of sclerodegenerative AV disease is needed.

Atrial Fibrillation and Deterioration in Cognitive Function.

The link between atrial fibrillation and cognitive decline and dementia has gained interest of the medical community lately. More research is being conducted to prevent and or delay this morbidity as no curative therapy is available for cognitive decline and dementia. The exact mechanism of causation is unclear. Multiple pathophysiological mechanisms have been implicated. Lately, treatment for atrial fibrillation including anticoagulation and catheter ablation therapies have shown to decrease the risk of deterioration of cognitive function. In this review we summarize epidemiologic studies linking the association, potential mechanisms, and impact of various modalities of therapy of atrial fibrillation on cognitive function outcomes.

Spontaneous Rupture of Sinus of Valsalva Aneurysm Presenting as Perivalvular Hematoma.

Acute rupture of sinus of Valsalva often presents as an acute emergency with significant hemodynamic compromise whereas contained rupture of sinus of Valsalva with a perivalvular hematoma formation is rarely seen. We describe the case of a 63-year-old male who presented with acute shortness of breath and was found to have rupture of sinus of Valsalva aneurysm (SVA) with a perivalvular hematoma and severe aortic regurgitation. We also review the presentation, diagnosis, and management of SVAs.

Trends, predictors and outcomes of ischemic stroke and intracranial hemorrhage in patients with a left ventricular assist device.

BACKGROUND: Patients with a left ventricular assist device (LVAD) are at a higher risk of ischemic stroke (IS) and intracranial hemorrhage (ICH). There is limited data available on risk factors and outcomes associated with IS and ICH in LVAD patients. METHODS: All patients >18 years of age with an LVAD were identified based on the U.S. Nationwide Inpatient Sample (NIS) database from the year 2007 to 2011. Patients with a discharge diagnosis of IS were compared to those without IS. In a separate analysis, patients with a discharge diagnosis of ICH were compared to patients without ICH. Trends, predictors and outcomes of IS and ICH were analyzed using a multivariate regression model. RESULTS: Out of 17,323 discharges with a primary diagnosis of heart failure with LVAD, 624 (3.6%) patients had a co-diagnosis of IS and 387 (2.2%) had a co-diagnosis of ICH. From 2007 to 2011, the discharge diagnosis of heart failure with LVAD increased from 946 to 5,540, but the proportion of patients with IS remained about 3.4%, while the incidence of ICH decreased from 3.8% in 2007 to a plateau of around 2.2% in the following years. After adjusting for potential confounders, increasing Charlson Comorbidity Index (CCI) score was an independent predictor of IS and ICH. In-hospital mortality was four-fold higher in the IS group (odds ratio: 4.2; 95% CI: 2.3-7.6; P<0.0001) and 18-fold higher in the ICH group (OR: 18; 95% CI: 9-34, P<0.0001). Renal disease (OR: 5.3; CI: 1.3-22.1; P=0.02), liver disease (OR: 4.9; CI: 1.1-21.2; P=0.03) and abnormal coagulation profile (OR: 4.8; CI: 1.6-14.4; P=0.01) were independent predictors of mortality in LVAD patients with IS. Presence of diabetes mellitus (OR 4.3, P=0.1) and liver disease (or 2.8, P=0.2) showed trends towards predicting mortality in LVAD patients with ICH but did not reach statistical significance. CONCLUSIONS: Increasing comorbidity burden significantly increases the risk of both IS and ICH with LVAD. In our cohort, the incidence of IS and ICH increases the mortality 4- and 18-fold, respectively. Renal disease, liver disease and abnormal coagulation profile were independent predictors of mortality in LVAD patients with IS.

A review of racial disparities in transcatheter aortic valve replacement (TAVR): accessibility, referrals and implantation.

Racial disparities in transcatheter aortic valve replacement (TAVR) implantation results from several factors, including socioeconomic disparities, inherent biases in healthcare provision, fewer referrals to specialists and language barriers in some minority populations. In this review article, we discuss the current data on the racial disparities in TAVR, explore the prevalence of aortic stenosis in different demographics in the United States and we proffer practical solutions to these problems.

Access site complications in transcutaneous aortic valve replacement: frequency, outcomes, prevention, and treatment.

Aortic stenosis (AS) is a common cause of valvular heart disease with heavy disease burden in elderly patients. It is present in almost 7% of patients older than 65. The mortality rate increases significantly once it becomes symptomatic with average life expectancy of around 1-year. Symptoms include angina, syncope, or heart failure. This requires either surgical or transcutaneous replacement. Transcutaneous aortic valve replacement (TAVR) use has increased in recent years from high risk patients to now even including intermediate risk patients. With the increased number of procedures performed, one of the consequences is access site complications. These complications can lead to increased hospitalization, cost, infections, and eventually worse outcomes. In this manuscript, we provide a comprehensive review discussing the consequences, outcomes, frequency, predictors and some possible solutions to these complications set forth in these studies.

Asian-Indians: a review of coronary artery disease in this understudied cohort in the United States.

Coronary artery disease (CAD) is a major cause of cardiovascular death worldwide. Prevalence of CAD is highly variable among different races. Asian Indians have been noted to have the highest CAD rates and the conventional risk factors fail to explain this difference completely. Asian Indians constitute a fifth of the global population, and the higher rates of CAD in this population constitute a major health challenge. There have been studies in the early 2000s that investigate the risk factors in this population; however, very few studies have been done since then that explore the higher CAD rates in Asian Indians. This is a comprehensive and current review of the known risk factors for CAD in Asian Indians and strategies physicians should consider relieving this burden.

Neurological manifestations of scrub typhus in adults.

In order to study the neurological manifestations in adult patients suffering from scrub typhus, 323 patients aged over 18 years, admitted with a positive diagnosis, were screened for neurological dysfunction; 37 patients with symptoms and/or signs suggestive of neurological dysfunction were included in the study. Of these, 31 (84%) patients had altered sensorium, four (11%) had cerebellitis, one (2%) patient had acute transverse myelitis and one (2%) had bilateral papilloedema without focal neurological deficit. Of the 31 patients with altered sensorium, 15 (40%) had meningoencephalitis, three (8%) had seizures, two (5%) had cerebral haemorrhages, one (2%) had a presentation likened to neuroleptic malignant syndrome (NMS) and one (2%) had a 6th nerve palsy with inflammation of the right cavernous sinus. Cerebrospinal fluid (CSF) analysis was abnormal in 23 patients (raised lymphocytes in 68%, raised protein in 80%). All patients improved with anti-rickettsial therapy.

Neurobrucellosis: an often forgotten cause of chronic meningitis.

We report a 26-year-old man of neurobrucellosis who presented with intermittent fever and headache for 2 years, sensori-neural hearing loss with cerebellar ataxia. He responded well to a combination of antimicrobials with significant clinical improvement.

Three distinct urethral fistulae 35 years after pelvic radiation.

INTRODUCTION: While the development of fistulae is a well-known complication of radiotherapy, such fistulae can often be challenging to manage. CASE PRESENTATION: We describe the case of a 37 year old male who developed in succession a urethrocutaneous fistula to the thigh, a rectourethral fistula and a peritoneo-urethral fistula 35 years after radiotherapy for pediatric pelvic rhabdomyosarcoma. These complications were managed successfully after multiple surgical procedures. DISCUSSION: We subsequently discuss the different approaches currently employed for the management of radiation induced urinary fistulas and describe the rationale behind our approach towards their surgical management.