A rare anomaly of the aortic arch: aberrant right subclavian artery associated with common carotid trunk.

With increasing use of transradial access (TRA) to perform coronary angiography, arterial anomalies of the upper extremity are more frequently encountered. We describe a patient with an aberrant right subclavian artery (RSCA) originating as the last major branch of the aortic arch, which eventually led to failure of the transradial approach. Subsequent arch aortography revealed an associated common carotid trunk. The combination of both anomalies is a rare finding and may be associated with a number of other arterial and/or mediastinal organ anomalies.

Double atrial septal defect: diagnosis and closure guidance with 3D transesophageal echocardiography.

Atrial septal defect (ASD) is a common form of congenital heart disease that often persists well into adulthood before discovery or intervention. The authors report the case of a patient referred for routine percutaneous ASD closure that was found on three-dimensional (3D) transesophageal echocardiography to have two large separate ostium secundum defects which were subsequently closed under 3D echocardiographic guidance.

Reduced estrogen in menopause may predispose women to takotsubo cardiomyopathy.

BACKGROUND: Takotsubo cardiomyopathy (apical ballooning syndrome) has been reported with increased frequency, most commonly in postmenopausal women. Despite the gender disparity, no clear link between estrogen and its possible cardioprotective effects has been shown. OBJECTIVES: We present a case series of takotsubo cardiomyopathy in women and examine the prevalence of estrogen replacement therapy (ERT), in addition to conducting a systematic literature review on this topic. METHODS: Consecutive cases of takotsubo cardiomyopathy were identified at our institution, Cleveland Clinic Florida, from January 2006 to December 2008, and patient-level data were extracted for analysis. For the literature review, we searched the MEDLINE database from January 1990 to March 2008 for English-language publications, using the terms apical ballooning syndrome, takotsubo, and stress cardiomyopathy, and identified case reports and series of takotsubo cardiomyopathy. Articles describing female patients and their medication use at time of presentation were included in the study. RESULTS: Eighteen cases of takotsubo cardiomyopathy were identified at our institution, all in postmenopausal women except for 2 who were still menstruating. Of the 16 postmenopausal cases, none were taking ERT at time of presentation. From the literature review, >400 publications were queried, of which 296 were recognized as case reports or series, with 7 articles meeting all of our inclusion criteria. From these reports, 13 women were identified, none of whom were taking ERT at time of presentation. CONCLUSIONS: Lack of estrogen replacement in the postmenopausal state may predispose women to takotsubo cardiomyopathy. Further studies are needed to establish the link more firmly.

Reclassification of patients for aggressive cholesterol treatment: additive value of multislice coronary angiography to the National Cholesterol Education Program guidelines.

BACKGROUND: National Cholesterol Education Program (NCEP) guidelines have been used to define treatment goals in patients with hypercholesterolemia. However, epidemiology-based guidelines are unable to identify all subjects with coronary artery disease for aggressive lipid intervention. OBJECTIVE: We sought to evaluate the additive value of multislice computed tomography (MSCT) angiography to the NCEP guideline classification for lipid treatment. METHODS: Multislice computed tomography was performed in 114 consecutive patients (mean age 57+/-14 y; 59% male) without known coronary artery disease. Subjects were classified into 3 categories (low-, intermediate-, and high-risk) according to their Framingham risk scores (FRS). RESULTS: Traditional cardiac risk factors were common: hypertension 59%, diabetes 13%, and smoking 22%. On the basis of the FRS, 11% (n=12/114) of the patients met high-risk criteria requiring aggressive cholesterol reduction. Of those in the low- and intermediate-risk groups, MSCT found coronary plaque in 76% (n=77/102), with moderate or severe plaque in 38% (n=39/102), thus reclassifying them in the high-risk category. Use of statin drugs increased from 32% at baseline to 53% (p=0.002) based on MSCT results; statin dose was increased in 31% of the patients who were already on a statin. The mean low-density lipoprotein cholesterol (LDL-c) decreased from 114 mg/dL to 91 mg/dL after MSCT (p<0.001). CONCLUSION: Multislice computed tomography reclassifies a high percentage of patients considered to be low- to intermediate-risk into the high-risk category based on their coronary artery lesions. Thus, the rise in MSCT use at present may have a large impact on clinician practice patterns in lipid-lowering therapy.