Streptococcus pyogenes Pericarditis with Resultant Pulmonary Trunk Compression Secondary to Mycotic Pseudoaneurysm.

Purulent pericarditis is a rare disease in the era of antibiotics, with Streptococcus pyogenes being a possible, though uncommon etiology. Even more uncommon are mycotic aneurysms secondary to group A strep purulent pericarditis and bacteremia. We report a case of an 18-year-old female with a history of strep pharyngitis develop Streptococcus pyogenes purulent pericarditis with subsequent ventricular fibrillation (VF). Following initial stabilization, she ultimately developed a 4.8 cm mycotic aneurysm of the ascending aorta, with resultant compression of the pulmonary trunk and right pulmonary arteries.

Acute myocardial infarction with isolated congenitally corrected transposition of the great arteries.

Congenital cardiac abnormalities diagnosed at the time of acute coronary syndrome are rare. A 43-year-old man presented to the emergency department complaining of recurring, severe chest pain. Subsequent emergent coronary angiography demonstrated unusual coronary anatomy: 1) one small caliber bifurcating vessel originating from the right sinus of Valsalva; 2) one very large vessel arising from the posterior sinus; and 3) no coronary artery from the normal left sinus of Valsalva. The large vessel from the posterior sinus was totally occluded in its midportion and was treated with intravascular ultrasound-guided percutaneous coronary intervention. Further diagnostic workup, including two-dimensional transthoracic echocardiogram and computed tomographic coronary angiography, demonstrated isolated corrected transposition of the great arteries with a dilated systemic ventricle and systolic dysfunction with an ejection fraction of 30%. The patient's clinical course was complicated by recurrent nonsustained ventricular tachycardia, treated with medical therapy and a dual-chamber implantable cardioverter defibrillator. This case is an example of a common clinical presentation with a very uncommon congenital heart disorder. Similar cases may become more frequent as the number of adult congenital heart patients increases in the population.

Comparison of clinical interpretation with visual assessment and quantitative coronary angiography in patients undergoing percutaneous coronary intervention in contemporary practice: the Assessing Angiography (A2) project.

BACKGROUND: Studies conducted decades ago described substantial disagreement and errors in physicians' angiographic interpretation of coronary stenosis severity. Despite the potential implications of such findings, no large-scale efforts to measure or improve clinical interpretation were subsequently undertaken. METHODS AND RESULTS: We compared clinical interpretation of stenosis severity in coronary lesions with an independent assessment using quantitative coronary angiography (QCA) in 175 randomly selected patients undergoing elective percutaneous coronary intervention at 7 US hospitals in 2011. To assess agreement, we calculated mean difference in percent diameter stenosis between clinical interpretation and QCA and a Cohen weighted κ statistic. Of 216 treated lesions, median percent diameter stenosis was 80.0% (quartiles 1 and 3, 80.0% and 90.0%), with 213 (98.6%) assessed as ≥70%. Mean difference in percent diameter stenosis between clinical interpretation and QCA was 8.2±8.4%, reflecting an average higher percent diameter stenosis by clinical interpretation (P<0.001). A weighted κ of 0.27 (95% confidence interval, 0.18-0.36) was found between the 2 measurements. Of 213 lesions considered ≥70% by clinical interpretation, 56 (26.3%) were <70% by QCA, although none were <50%. Differences between the 2 measurements were largest for intermediate lesions by QCA (50% to <70%), with variation existing across sites. CONCLUSIONS: Physicians tended to assess coronary lesions treated with percutaneous coronary intervention as more severe than measurements by QCA. Almost all treated lesions were ≥70% by clinical interpretation, whereas approximately one quarter were <70% by QCA. These findings suggest opportunities to improve clinical interpretation of coronary angiography.

Should we establish a new protocol for the treatment of peripartum myocardial infarction?

Peripartum myocardial infarction is a rare event that is associated with high mortality rates. The differential diagnosis includes coronary artery dissection, coronary artery thrombosis, vascular spasm, and stenosis. Our evaluation of 2 cases over a 5-year time period has led to a hypothesis that peripartum myocardial infarction is an immune-mediated event secondary to coronary endothelial sensitization by fetal antigen. In our patients, we supplemented standard medical therapy with immunotherapy consisting of corticosteroids, plasmapheresis, and intravenous immunoglobulin. Herein, we present our most recent case-that of a 29-year-old black woman (gravida V, para IV), 2 weeks postpartum with no relevant medical history. She presented with a 1-week history of chest pain. Initial electrocardiographic and cardiac biomarkers were consistent with acute coronary syndrome. Echocardiography revealed reduced systolic function with inferior-wall hypokinesis. Angiography revealed diffuse disease with occlusion of the left anterior descending coronary artery not amenable to revascularization. We were successful in treating the myocardial infarction without the use of catheter-based interventions, by modifying the immunologic abnormalities. Two cases do not make a protocol. Yet we believe that this case and our earlier case lend credence to the hypothesis that peripartum myocardial infarction arises from sensitization by fetal antigens. This concept and the immune-modifying treatment protocol that we propose might also assist in understanding and treating other inflammatory-disease states such as peripartum cardiomyopathy and standard acute myocardial infarction. All of this warrants further investigation.

Isolated right superior vena cava drainage into the left atrium diagnosed noninvasively in the peripartum period.

Isolated right superior vena cava drainage into the left atrium is an extremely rare cardiac anomaly, especially in the absence of other cardiac abnormalities. Only 28 of 5,127 reported consecutive congenital cardiac cases involved superior vena cava drainage into the left atrium, and all were associated with other cardiac anomalies. Of 19 reported cases of right superior vena cava drainage into the left atrium, most patients have been children who were experiencing mild hypoxemia and cyanosis. Herein, we describe the case of a 34-year-old woman who presented with asymptomatic hypoxemia in the peripartum period. She was diagnosed to have isolated drainage of the right superior vena cava into the left atrium. To the best of our knowledge, this is the 1st reported instance of such diagnosis by use of noninvasive imaging only, without cardiac catheterization. We also review the medical literature that pertains to our patient's anomaly.

Guidewire pacing safely and effectively treats bradyarrhythmias induced by rheolytic thrombectomy and precludes the need for transvenous pacing: the Scott & White experience.

Rheolytic thrombectomy (RT) is useful in certain percutaneous coronary interventions but may be associated with transient bradyarrhythmias. Clinicians have devised numerous strategies to deal with these arrhythmias apart from transvenous right ventricular pacing, some of which are described in other parts of this supplement. We report the Scott & White experience utilizing guidewire pacing to quickly and safely pace the heart in the event of bradyarrhythmia. We found this method to be safe and reliable (96.2% successful) during RT and now use this technique almost exclusively in the cardiac catheterization lab to deal with transient bradyarrhythmias during RT or due to any other cause.We also report an increased incidence of bradyarrhythmia occurring during RT when it is performed in the right coronary artery, with a trend toward an increased incidence during the clinical presentation of ST-elevation myocardial infarction.

Urinary levels of matrix metalloproteinase 9 and 2 and tissue inhibitor of matrix metalloproteinase in patients with coronary artery disease.

OBJECTIVES: To evaluate the feasibility of an assay for urinary levels of matrix metalloproteinases (MMPs) and the potential usefulness of urinary MMPs as a marker of coronary atherosclerosis or acute coronary syndromes (ACS). METHODS AND RESULTS: We measured urine and plasma MMP-9, MMP-2 and urine tissue inhibitor of metalloproteinase (TIMP-1) in patients with ACS (n=27), patients with coronary artery disease (CAD), but no clinical instability (n=47) and a group of healthy volunteers (n=15) who were <35 years of age, had no risk factors for CAD and did not undergo angiography. Compared with volunteers, patients with ACS and CAD had higher urine MMP-9, urine TIMP-1, plasma MMP-9 and plasma MMP-2 levels, but these did not differ between those with CAD and ACS. Using the volunteers to roughly establish an upper limit of normal, 84% of the urine TIMP-1 values and 95% of the urine MMP-9 values were abnormally elevated among those with CAD and ACS. CONCLUSIONS: Urine MMP-9 and TIMP-1 levels are elevated in patients with CAD and ACS compared with healthy volunteers. A high percent of patients with CAD or ACS had elevated urine values of MMP-9 and TIMP-1 suggesting these variables might be a useful marker of atherosclerotic disease.

Effects of methionine and lysine on fermentation in vitro and in vivo, nutrient flow to the intestine, and milk production.

Three experiments were conducted to investigate the feasibility of using crystalline methionine and lysine as protein supplements for lactating Holstein cows. In the first experiment, Met (dl-methionine) and Lys (l-lysine-HCl) were added to diets used in continuous culture bioreactors to estimate optimal concentrations for use in subsequent in vivo experiments. The second experiment measured ruminal fermentation and nutrient flow to the small intestine when Met and Lys were top-dressed on diets fed to nonlactating cows. The third experiment measured lactation performance when Met and Lys were added to diets fed to late-lactation cows. Providing 0.29 and 2.27% of dry matter as Met and Lys, respectively, provided the largest improvement in fermentation in vitro and these concentrations were used in subsequent experiments. When Met and Lys were top-dressed on diets fed to nonlactating cows, no changes in total tract N digestion were observed. No changes in microbial protein production or ruminal fermentation were observed. Adding Met and Lys did not change production or efficiency of production of milk or milk components by late lactation cows. These data indicate that providing supplemental Met and Lys during late lactation does not significantly improve the protein status of the cow and therefore may not improve milk production.

All-terrain vehicle injuries: are they dangerous? A 6-year experience at a level I trauma center after legislative regulations expired.

All-terrain vehicles (ATVs) have increased in popularity and sales since 1971. This rise in popularity led to an increase in injuries resulting in voluntary industry rider safety regulations in 1988, which expired without renewal in 1998. Our purpose was twofold, to determine the incidence and severity of ATV injuries in our patient population and what, if any impact the safety regulations had. To further characterize the risk of ATV use, we compared them to a vehicle generally recognized as dangerous, the motorcycle (MC). Our trauma registry was reviewed from January 1998 through August 2004 for ATV or MC injured. Data collected included age, gender, mortality, Injury Severity Score (ISS), helmet use, and injury distribution. These were compared to our data from the decade of regulation. There were 352 MC and 221 ATV patients. ATV injured demonstrated a higher proportion of pediatric and female patients (P < 0.001 and P < 0.01, respectively), a decrease in helmet use (8.6% vs 64.7%, P < 0.001), and increased closed head injuries (CHI) (54.2% vs 44.9%, P < 0.05) compared with MC injured. ISS and mortality were similar. The average number of patients from 1988 to 1998 was 6.9/yr compared to 31.6/yr (P < 0.001) during 1998-2004 with equal ISS. Our data show that there has been a dramatic and progressive increase in the number of ATV crashes since expiration of industry regulations. ATVs are as dangerous as MCs based on patient ISS and mortality. There are significantly more children and women injured on ATVs. The lower rate of helmet use in ATVs may account for the significantly greater incidence of CHI. These data mandate the need for injury prevention efforts for ATV riders, in particular children, through increased public awareness and new legislation.

Relation of atmospheric pressure changes and the occurrences of acute myocardial infarction and stroke.

Previous studies have demonstrated variation in vascular events with respect to season and time of day. Changes in barometric pressure display daily and seasonal variations and could modulate the occurrence of vascular events. The objective of this study was to determine whether a relation exists between changes in barometric pressure and occurrence of stroke or acute myocardial infarction (AMI). A retrospective analysis of hospital admissions for AMI and stroke from 1993 to 1996 in central Texas was related to changes in atmospheric pressure that were obtained from the National Climatic Data Center. Patients who had AMI (n = 1,327) or stroke (n = 839) were identified from a computerized hospital database. Mean atmospheric pressure, greatest change in pressure, and rate of change in pressure per 24-hour period were computed. One-, 2-, and 3-day and seasonal groupings of cardiovascular events were related to corresponding changes in barometric pressure. The fall and winter seasons had the highest variability in atmospheric pressure readings. There was a significant correlation (p = 0.0083) between a decrease in atmospheric pressure and the occurrence of AMI the day after a pressure decrease, especially during the fall and winter seasons. No relation between stroke and atmospheric pressure was demonstrated. In conclusion, we conclude that rapid decreases in barometric pressure are associated with the occurrence of AMI but not of stroke.

Effects of zinc and sodium monensin on ruminal degradation of lysine-HCl and liquid 2-hydroxy-4-methylthiobutanoic acid.

Four nonlactating, mature, Holstein cows were fitted with ruminal cannula and used in a 4 x 4 Latin square-designed experiment to evaluate the impact of supplemental Zn and monensin on ruminal degradation of Lys and liquid 2-hydroxy-4-methylthiobutanoic acid (HMB). Cows were fed 4.54 kg (as fed) of alfalfa hay top-dressed with 4.54 kg (as fed) concentrate once daily. Concentrates were formulated to provide 0 or 500 mg/kg of Zn as ZnSO4 and 0 or 40 mg/kg of monensin in the total diet. Zinc supplementation provided approximately 22-fold greater dietary Zn than estimated by NRC requirements. On d 14 of each period, cows were dosed via the rumen cannula with 50 g of HMB and 100 g of Lys-HCl, and the concentrations of Lys and HMB were monitored every 0.5 h for 8 h. Supplemental Zn tended to decrease the proportion of acetate in ruminal fluid postfeeding and increased the proportion of propionate in ruminal fluid postfeeding. Supplemental Zn increased mean fluid passage rate from the rumen. Monensin decreased the proportion of acetate and increased the mean proportion of propionate in ruminal fluid, resulting in a decrease in the ratio of acetate to propionate. Monensin also increased the mean fluid passage rate from the rumen. Neither Zn nor monensin affected the apparent rate of ruminal disappearance of HMB or Lys. However, Zn and monensin interacted to alter the ruminal degradability of free Lys but not HMB. These data indicate that Zn and monensin may interact to alter ruminal degradability of free amino acids.

Temporary coronary guidewire pacing during percutaneous coronary intervention.

Temporary pacing is occasionally required during percutaneous coronary artery interventions. This can be accomplished by the insertion of a temporary transvenous pacemaker wire into the right ventricle, but there is some risk and inconvenience associated with this approach. Temporary pacing using the coronary artery guidewire was described in 1985 but is used infrequently. Using currently available equipment, we evaluated guidewire pacing in 26 patients. Guidewire pacing was successful in all patients, but not with all coronary guidewires at acceptable ventricular capture thresholds. No complications occurred from guidewire pacing. Bench testing of multiple different wires showed several with very high resistances likely unsuitable for clinical use. Temporary guidewire pacing is easily performed and should be considered as an alternative to the separate placement of a temporary transvenous pacemaker.

Effectiveness and safety of manual hemostasis facilitated by the SyvekPatch with one hour of bedrest after coronary angiography using six-French catheters.

Manual hemostasis facilitated by a SyvekPatch with 1 hour of bedrest after coronary angiography using 6Fr catheters was evaluated in a study of 200 patients. There were no major adverse events and 2% minor adverse events, all of which were managed successfully with additional bedrest of 1 to 2 hours. The findings suggest that the 1-hour bedrest protocol using the SyvekPatch is safe and effective in low-risk patients.

Assessment of anticoagulation using activated clotting times in patients receiving intravenous enoxaparin during percutaneous coronary intervention.

Enoxaparin is being used more frequently in patients undergoing percutaneous coronary intervention (PCI). In this study, we determined the effect of intravenous enoxaparin on activated clotting time (ACT) measurements in the setting of PCI. In 67 consecutive patients, either 1 mg/kg intravenous enoxaparin alone was given for anticoagulation or 0.75 mg/kg given in patients receiving eptifibatide. ACT was measured before and 5 min following enoxaparin administration. After 1 mg/kg enoxaparin (n = 22), mean ACT increased from 122 +/- 22 to 199 +/- 20 sec. After 0.75 mg/kg enoxaparin and eptifibatide (n = 45), mean ACT increased from 125 +/- 22 to 194 +/- 24 sec. The mean increase in ACT was 77 +/- 26 sec in the 1 mg/kg group and 69 +/- 23 sec in the 0.75 mg/kg group (both P values < 0.0001). Moreover, in a subgroup of 26 patients, there was an excellent correlation (r = 0.86) between ACTs and the ENOX test, a new point-of-care test for assessing enoxaparin anticoagulation. None of the patients had transient abrupt closure, thrombus formation, major bleeding, or required urgent revascularization. Intravenous enoxaparin at clinically relevant doses with and without eptifibatide increases ACT levels at 5 min in patients undergoing PCI. These data suggest the ACT may be useful in the assessment of anticoagulation by enoxaparin.

Hospital disposition and long-term follow-up of patients aged >/=80 years undergoing coronary artery revascularization.

Coronary artery revascularization by either percutaneous coronary intervention or coronary artery bypass graft surgery in patients >/=80 years of age can be accomplished with acceptable in-hospital and 2-year clinical outcomes. However, up to 20% of patients have a prolonged recovery and are unable to immediately return home. It is important that this information become part of the discussion with patients and their families so realistic expectations can be developed.

Effects of feeding milk replacer once versus twice daily on glucose metabolism in Holstein and Jersey calves.

Eighteen Holstein (experiment 1) and 15 Jersey (experiment 2) heifer calves were fed milk replacer once or twice daily to determine effects of feeding frequency on weight gain, starter intake, and glucose metabolism. Body weights were measured weekly from birth to 8 wk. Blood samples were collected at wk 1 through 6 from all calves before and at 30, 60, 90, 120 and 180 min after the morning feeding. Plasma was analyzed for glucose, insulin, glucagon, and nonesterified fatty acids (NEFA). Urine was collected 90 min postfeeding to measure glucose concentration. Treatment did not affect mean starter intake or body weight. In experiments 1 and 2 mean plasma glucagon, glucose, NEFA, and insulin and urinary glucose concentrations were not affected by treatment. There was an interaction of sampling time and treatment for plasma insulin concentrations but not for glucose concentrations in both experiments. Following feeding, calves fed milk replacer once daily had higher insulin concentrations than those fed twice daily. There was an interaction of sampling time and treatment for plasma NEFA concentrations in Jersey calves only. Jersey calves fed milk replacer once daily had higher plasma NEFA concentrations before the morning milk replacer feeding. At wk 3 and 6, frequently sampled intravenous glucose tolerance tests were performed to assess glucose effectiveness, insulin sensitivity, and acute insulin response. In experiments 1 and 2 glucose effectiveness and insulin sensitivity were similar regardless of milk replacer feeding frequency. In Holstein and Jersey calves fed milk replacer twice daily, acute insulin response was greater than in calves fed once daily. However, insulin sensitivity decreased with age, while acute insulin response increased with age. These data suggest that feeding calves milk replacer once daily did not deleteriously affect performance or glucose metabolism regardless of breed.