Gerbode defect following surgical mitral valve replacement and tricuspid valve repair: a case report.

BACKGROUND: Gerbode defect is a congenital or acquired communication between the left ventricle and right atrium. While the defect is becoming a more well-recognized complication of cardiac surgery, it presents a diagnostic and therapeutic challenge for providers. This case highlights the predisposing factors and imaging features that may assist in the diagnosis of Gerbode defect, as well as potential approaches to treatment. CASE SUMMARY: We report a patient with severe mitral stenosis as a result of remote mediastinal radiation who underwent extensive decalcification during surgical mitral valve replacement and tricuspid valve repair. Following the procedure, he developed progressive heart failure refractory to medical management. Extensive workup ultimately led to the diagnosis of iatrogenic acquired Gerbode defect. Close collaboration between adult cardiology, cardiothoracic surgery, and the congenital cardiology services led to an optimal treatment plan involving percutaneous closure of the defect. DISCUSSION: Gerbode defect is a rare complication of invasive procedures involving the interventricular septum or its nearby structures. An understanding of the key echocardiographic features will aid providers in timely diagnosis. Percutaneous repair should be strongly considered for patients who may be poor surgical candidates.

Multimodality Imaging of Right Ventricular Pseudoaneurysm Caused by Blunt Chest Trauma.

Right ventricular pseudoaneurysm is a rare but fatal complication of blunt chest trauma. Different imaging modalities including transthoracic echocardiogram, gated-CT angiography and cardiac MR can provide useful anatomic and functional information that can make the diagnosis and guide management. Surgical treatment is needed to avoid fatal outcome. (Level of Difficulty: Beginner.).

Does a similar procedure result in similar survival for women and men undergoing isolated coronary artery bypass grafting?

OBJECTIVES: To (1) identify sex-related differences in risk factors and revascularization strategies for patients undergoing coronary artery bypass grafting (CABG), (2) assess whether these differences influenced early and late survival, and (3) determine whether clinical effectiveness of the same revascularization strategy was influenced by sex. METHODS: From January 1972 to January 2011, 57,943 adults-11,009 (19%) women-underwent primary isolated CABG. Separate models for long-term mortality were developed for men and women, followed by assessing sex-related differences in strength of risk factors (interaction terms). RESULTS: Incomplete revascularization was more common in men than women (26% vs 22%, P < .0001), but women received fewer bilateral internal thoracic artery (ITA) grafts (4.8% vs 12%; P < .0001) and fewer arterial grafts (68% vs 70%; P < .0001). Overall, women had lower survival than men after CABG (65% and 31% at 10 and 20 years, respectively, vs 74% and 41%; P ≤ .0001), even after risk adjustment. Incomplete revascularization was associated equally (P > .9) with lower survival in both sexes. Single ITA grafting was associated with equally (P = .3) better survival in women and men. Although bilateral ITA grafting was associated with better survival than single ITA grafting, it was less effective in women-11% lower late mortality (hazard ratio, 0.89 [0.77-1.022]) versus 27% lower in men (hazard ratio, 0.73 [0.69-0.77]; P = .01). CONCLUSIONS: Women on average have longer life expectancies than men but not after CABG. Every attempt should be made to use arterial grafting and complete revascularization, but for unexplained reasons, sex-related differences in effectiveness of bilateral arterial grafting were identified.

Myocardial perfusion imaging in emergency department patients with negative cardiac biomarkers: yield for detecting ischemia, short-term events, and impact of downstream revascularization on mortality.

BACKGROUND: In patients with possible acute coronary syndromes, guidelines recommend routine provocative testing after negative cardiac biomarkers. We hypothesized that myocardial perfusion imaging would be low yield with limited short-term value and that early revascularization would not affect mortality. METHODS AND RESULTS: We identified consecutive patients referred from our emergency department between October 2004 and September 2011 who had myocardial perfusion imaging after negative troponin T tests and nondiagnostic ECGs. We assessed the incidence of abnormal myocardial perfusion imaging, coronary angiography, revascularization, and mortality. In a cohort of 5354 patients (58.7% female, age 59 ± 13, 78.6% thrombolysis in myocardial infarction [TIMI] ≤2), 9% had >5% and 3.6% had >10% ischemic myocardium. Among patients with TIMI scores ≤2, 6.1% had >5% ischemic myocardium compared with 19.6% of patients with TIMI scores ≥3 (P<0.001). At 30 days, 7 patients were deceased, 187 had revascularization, and 6 had revascularization for an acute myocardial infarction. Over 3.4 ± 1.9 years of follow-up, 347 patients died. In propensity-matched groups of patients with ischemia, there was no association between early revascularization and mortality (hazard ratio, 1.00; 95% confidence interval, 0.49-2.07). CONCLUSIONS: Routine provocative testing to detect ischemia before emergency department discharge is low yield in patients with negative troponins and TIMI scores ≤2 and modest yield in patients with TIMI scores ≥3. In all patients, 30 days events are rare. Finally, in patients with ischemia, we are unable to demonstrate a mortality benefit with early revascularization.

Safety of ultrasound contrast agents in stress echocardiography.

Definity and Optison are perflutren-based ultrasound contrast agents used in echocardiography. United States Food and Drug Administration warnings regarding serious cardiopulmonary reactions and death after Definity administration highlighted the limited safety data in patients who undergo contrast stress echocardiography. From 1998 and 2007, 2,022 patients underwent dobutamine stress echocardiography and 2,764 underwent exercise stress echocardiography with contrast at the Cleveland Clinic. The echocardiographic database, patient records, and the Social Security Death Index were reviewed for the timing and cause of death, severe adverse events, arrhythmias, and symptoms. Complication rates for contrast dobutamine stress echocardiography and exercise stress echocardiography were compared with those in a control group of 5,012 patients matched for test year and type who did not receive contrast. Ninety-five percent of studies were performed in outpatients. There were no differences in the rates of severe adverse events (0.19% vs 0.17%, p = 0.7), death within 24 hours (0% vs 0.04%, p = 0.1), cardiac arrest (0.04% vs 0.04%, p = 0.96), and sustained ventricular tachycardia (0.2% vs 0.1%, p = 0.32) between patients receiving and not receiving intravenous contrast, respectively. In conclusion, severe adverse reactions to intravenous contrast agents during stress echocardiography are uncommon. Contrast use does not add to the baseline risk for severe adverse events in patients who undergo stress echocardiography.

The ultimate development of mitral valve endocarditis: atrioventricular separation, atrioventricular groove abscess and hemorrhagic pericarditis.

A 52-year-old non-insulin-dependent diabetic man presented with cerebral emboli and mitral valve endocarditis with posterior leaflet vegetations and perforation. Surgical intervention demonstrated hemorrhagic pericarditis and an atrioventricular groove abscess. Extensive debridement of the pericardium, valve and abscess cavities, reconstruction of the mitral annulus with a patch of fresh autologous pericardium, and mitral valve replacement with a pericardial bioprosthesis was performed. The chest was left open. Postoperatively, the patient required dialysis and prolonged mechanical ventilation, but recovered well without recurrent endocarditis and was discharged home after 40 days.

Benzocaine-induced methemoglobinemia: experience from a high-volume transesophageal echocardiography laboratory.

Benzocaine (ethyl aminobenzoate), a topical anesthetic widely used before transesophageal echocardiography, has been reported to cause acquired methemoglobinemia. The incidence of benzocaine-induced methemoglobinemia in clinical practice, however, has been difficult to estimate. After systematic review of our institutional experience for clinically recognized cases of benzocaine-induced methemoglobinemia in patients undergoing transesophageal echocardiography, we report an estimated incidence of 0.115% (95% confidence interval 0.037-0.269). This report also provides the largest analysis of the incidence of methemoglobinemia in readministration cases. Although controversy remains as to whether this is an idiosyncratic versus dose-related response, a description of purported patient risk factors is included.