Incidence and predictors of acute coronary syndrome after transcatheter mitral valve repair.

BACKGROUND: Acute coronary syndrome (ACS) post-transcatheter mitral valve repair (TMVR) carries high mortality. We aim to study the incidence and predictors of ACS in patients who underwent TMVR. RESEARCH DESIGN AND METHODS: We queried the U.S. National Readmission Database to identify all cases of TMVR from 2016 to 2019. We further evaluated the incidence of ACS and used multivariable logistic regression to determine independent predictors of ACS in this population. RESULTS: Among 3,742 patients who underwent TMVR, 264 (7.05%) developed ACS. Among ACS patients, 204 (77%) had non-ST-segment elevation ACS and 66 (25%) had ST-segment elevation ACS. Independent predictors of ACS were acute limb ischemia, cardiogenic shock, history of coronary artery disease (CAD), smoking, cardiac arrest, respiratory failure requiring mechanical ventilation, and acute kidney injury. In-hospital mortality among ACS was three times higher in ACS patients than without ACS (16.76% vs. 5.45%, p-value < 0.01). CONCLUSIONS: ACS is not an uncommon complication after TMVR. The occurrence of ACS after TMVR is associated with high in-hospital mortality, longer length of stay, and higher hospital charges. The strongest predictors of ACS in these patients are the development of acute limb ischemia, cardiogenic shock, and a history of CAD.

A Rare Case of Isolated Cardiac Sarcoidosis With Negative Biopsy: Diagnosis by Clinical Criteria.

Cardiac sarcoidosis (CS) is a potentially life-threatening condition that can cause sudden, fatal conduction abnormalities, arrhythmias, and heart failure. The diagnosis of CS is challenging due to nonspecific symptoms and an unclear diagnostic criterion. Although biopsy is the gold standard method, the sensitivity of biopsy is low. About a portion of CS cases are detected through imaging. A unique aspect of our case is that our definitive diagnosis was made based on clinical and imaging criteria alone despite a negative biopsy. Our diagnosis was confirmed further on follow-up with improvement in cardiac function on imaging after a treatment course with corticosteroids. This case highlights the need to have a broad differential and more awareness of this rare etiology and the value of clinical criteria to make a definitive diagnosis.

Carcinoid heart disease: a potentially fatal complication of carcinoid syndrome.

Carcinoid heart disease is a unique and serious cardiac complication of the neuroendocrine tumour that affects the right side of the heart, especially the tricuspid and pulmonic valves, eventually causing right heart failure. We present a middle-aged man with a history of well-differentiated neuroendocrine tumours of the small intestine with extensive metastases to the liver, mesentery and spine who is receiving monthly octreotide therapy. He presented with generalised fatigue, severe ascites and worsening dyspnoea. Both the transthoracic echocardiography and transoesophageal echocardiography revealed severe tricuspid and pulmonic regurgitations. He was considered a poor surgical candidate, underwent transcatheter pulmonic valve replacement with two bioprosthetic valve-in-valve implantations and was discharged in a stable condition.

Outcomes of Intravascular Ultrasound-Guided Percutaneous Coronary Intervention Among Patients With Acute Coronary Syndrome.

Intravascular ultrasound (IVUS) use in percutaneous coronary intervention (PCI) improves outcomes. However, data on outcomes of IVUS-guided PCI in patients presenting with acute coronary syndrome (ACS) is scarce. Therefore, we sought to study the utilization rate and outcomes of IVUS-guided PCI in patients with ACS. Using the National Readmission database, we identified all patients with ACS who underwent PCI from 2016 to 2019. We used a 1:1 propensity-matched analysis to compare the outcome of patients with ACS who underwent PCI with and without IVUS. In 1,263,997 patients with ACS, 563,521 (44.6%) underwent PCI without IVUS and 40,095 (3.17%) underwent IVUS-guided PCI. A Propensity scored matched comparison of PCI with and without IVUS showed IVUS-guided PCI was associated with a lower risk of in-hospital mortality (odds ratio 0.74, 95% confidence interval 0.64 to 0.85, p <0.01) compared with PCI without IVUS. The utilization of IVUS increased from 2.64% in 2016 to 4.10% in 2019, p <0.001. In conclusion, IVUS-guided PCI is associated with lower in-hospital mortality in patients with ACS, yet the current utilization of IVUS-guided PCI remains low across the United States.

Morel-Lavallée lesion of the anterior leg: a rare anatomical presentation.

A Morel-Lavallée lesion (MLL) is a rare injury caused by blunt force trauma causing separation of subcutaneous tissue from the deep fascia. It is frequently seen in orthopaedic cases involving fractures of the hip or pelvis but is rare in the lower leg. The rarity of this condition often leads to misdiagnosis. A 66-year-old man presented to the emergency department after a 300-pound safe sheered across his left anterolateral leg causing skin avulsion, tenderness, swelling, ecchymosis, and erythema. The patient was treated for suspected cellulitis with oral antibiotics, but the lesion evolved into a necrotic eschar necessitating surgical intervention. In hindsight, MLL is a more appropriate diagnosis based on injury mechanism, disease progression and intraoperative findings. A history of shearing trauma with diffuse ecchymosis and erythema should prompt consideration of MLL. Due to rampant misdiagnosis, this case aims to increase awareness, as early diagnosis of MLL will improve patient outcomes.

Functional dynamics of hippocampal glutamate during associative learning assessed with in vivo 1H functional magnetic resonance spectroscopy.

fMRI has provided vibrant characterization of regional and network responses associated with associative learning and memory; however, their relationship to functional neurochemistry is unclear. Here, we introduce a novel application of in vivo proton functional magnetic resonance spectroscopy (1H fMRS) to investigate the dynamics of hippocampal glutamate during paired-associated learning and memory in healthy young adults. We show that the temporal dynamics of glutamate differed significantly during processes of memory consolidation and retrieval. Moreover, learning proficiency was predictive of the temporal dynamics of glutamate such that fast learners were characterized by a significant increase in glutamate levels early in learning, whereas this increase was only observed later in slow learners. The observed functional dynamics of glutamate provides a novel in vivo marker of brain function. Previously demonstrated N-methyl-D-aspartate (NMDA) receptor mediated synaptic plasticity during associative memory formation may be expressed in glutamate dynamics, which the novel application of 1H MRS is sensitive to. The novel application of 1H fMRS can provide highly innovative vistas for characterizing brain function in vivo, with significant implications for studying glutamatergic neurotransmission in health and disorders such as schizophrenia.

Impulsivity and aggression mediate regional brain responses in Borderline Personality Disorder: An fMRI study.

Fronto-limbic brain networks involved in regulation of impulsivity and aggression are abnormal in Borderline Personality Disorder (BPD). However, it is unclear whether, or to what extent, these personality traits actually modulate brain responses during cognitive processing. Using fMRI, we examined the effects of trait impulsivity, aggression, and depressed mood on regional brain responses in 31 female BPD and 25 control subjects during a Go No-Go task using Ekman faces as targets. First-level contrasts modeled effects of negative emotional context. Second-level regression models used trait impulsivity, aggression and depressed mood as predictor variables of regional brain activations. In BPD, trait impulsivity was positively correlated with activation in the dorsal anterior cingulate cortex, orbital frontal cortex (OFC), basal ganglia (BG), and dorsolateral prefrontal cortex, with no areas of negative correlation. In contrast, aggression was negatively correlated with activation in OFC, hippocampus, and BG, with no areas of positive correlation. Depressed mood had a generally dampening effect on activations. Effects of trait impulsivity on healthy controls differed from effects in BPD, suggesting a disorder-specific response. Negative emotional context and trait impulsivity, but not aggression or depression, diminished task performance across both groups. Negative emotional context may interfere with cognitive functioning in BPD through interaction with the neurobiology of personality traits.

Hyper-modulation of brain networks by the amygdala among women with Borderline Personality Disorder: Network signatures of affective interference during cognitive processing.

Emotion dysregulation is a core characteristic of patients with Borderline Personality Disorder (BPD), and is often attributed to an imbalance in fronto-limbic network function. Hyperarousal of amygdala, especially in response to negative affective stimuli, results in affective interference with cognitive processing of executive functions. Clinical consequences include the impulsive-aggression, suicidal and self-injurious behaviors which characterize BPD. Dysfunctional interactions between amygdala and its network targets have not been well characterized during cognitive task performance. Using psychophysiological interaction analysis (PPI), we mapped network profiles of amygdala interaction with key regulatory regions during a Go No-Go task, modified to use negative, positive and neutral Ekman faces as targets. Fifty-six female subjects, 31 BPD and 25 healthy controls (HC), completed the affectively valenced Go No-Go task during fMRI scanning. In the negative affective condition, the amygdala exerted greater modulation of its targets in BPD compared to HC subjects in Rt. OFC, Rt. dACC, Rt. Parietal cortex, Rt. Basal Ganglia, and Rt. dlPFC. Across the spectrum of affective contrasts, hypermodulation in BPD subjects observed the following ordering: Negative > Neutral > Positive contrast. The amygdala seed exerted modulatory effects on specific target regions important in processing response inhibition and motor impulsiveness. The vulnerability of BPD subjects to affective interference with impulse control may be due to specific network dysfunction related to amygdala hyper-arousal and its effects on prefrontal regulatory regions such as the OFC and dACC.

Brain network dysfunction in youth with obsessive-compulsive disorder induced by simple uni-manual behavior: The role of the dorsal anterior cingulate cortex.

In an effort to elucidate differences in functioning brain networks between youth with obsessive-compulsive disorder and controls, we used fMRI signals to analyze brain network interactions of the dorsal anterior cingulate cortex (dACC) during visually coordinated motor responses. Subjects made a uni-manual response to briefly presented probes, at periodic (allowing participants to maintain a "motor set") or random intervals (demanding reactive responses). Network interactions were assessed using psycho-physiological interaction (PPI), a basic model of functional connectivity evaluating modulatory effects of the dACC in the context of each task condition. Across conditions, OCD were characterized by hyper-modulation by the dACC, with loci alternatively observed as both condition-general and condition-specific. Thus, dynamically driven task demands during simple uni-manual motor control induce compensatory network interactions in cortical-thalamic regions in OCD. These findings support previous research in OCD showing compensatory network interactions during complex memory tasks, but establish that these network effects are observed during basic sensorimotor processing. Thus, these patterns of network dysfunction may in fact be independent of the complexity of tasks used to induce brain network activity. Hypothesis-driven approaches coupled with sophisticated network analyses are a highly valuable approach in using fMRI to uncover mechanisms in disorders like OCD.

Chronological age and its impact on associative learning proficiency and brain structure in middle adulthood.

INTRODUCTION: The rate of biological change in middle-adulthood is relatively under-studied. Here, we used behavioral testing in conjunction with structural magnetic resonance imaging to examine the effects of chronological age on associative learning proficiency and on brain regions that previous functional MRI studies have closely related to the domain of associative learning. METHODS: Participants (n=66) completed a previously established associative learning paradigm, and consented to be scanned using structural magnetic resonance imaging. Age-related effects were investigated both across sub-groups in the sample (younger vs. older) and across the entire sample (using regression approaches). RESULTS: Chronological age had substantial effects on learning proficiency (independent of IQ and Education Level), with older adults showing a decrement compared to younger adults. In addition, decreases in estimated gray matter volume were observed in multiple brain regions including the hippocampus and the dorsal prefrontal cortex, both of which are strongly implicated in associative learning. CONCLUSION: The results suggest that middle adulthood may be a more dynamic period of life-span change than previously believed. The conjunctive application of narrowly focused tasks, with conjointly acquired structural MRI data may allow us to enrich the search for, and the interpretation of, age-related changes in cross-sectional samples.

Dorsal anterior cingulate cortex modulates supplementary motor area in coordinated unimanual motor behavior.

Motor control is integral to all types of human behavior, and the dorsal Anterior Cingulate Cortex (dACC) is thought to play an important role in the brain network underlying motor control. Yet the role of the dACC in motor control is under-characterized. Here we aimed to characterize the dACC's role in adolescent brain network interactions during a simple motor control task involving visually coordinated unimanual finger movements. Network interactions were assessed using both undirected and directed functional connectivity analysis of functional Magnetic Resonance Imaging (fMRI) Blood-Oxygen-Level-Dependent (BOLD) signals, comparing the task with a rest condition. The relation between the dACC and Supplementary Motor Area (SMA) was compared to that between the dACC and Primary Motor Cortex (M1). The directed signal from dACC to SMA was significantly elevated during motor control in the task. By contrast, the directed signal from SMA to dACC, both directed signals between dACC and M1, and the undirected functional connections of dACC with SMA and M1, all did not differ between task and rest. Undirected coupling of dACC with both SMA and dACC, and only the dACC-to-SMA directed signal, were significantly greater for a proactive than a reactive task condition, suggesting that dACC plays a role in motor control by maintaining stimulus timing expectancy. Overall, these results suggest that the dACC selectively modulates the SMA during visually coordinated unimanual behavior in adolescence. The role of the dACC as an important brain area for the mediation of task-related motor control may be in place in adolescence, continuing into adulthood. The task and analytic approach described here should be extended to the study of healthy adults to examine network profiles of the dACC during basic motor behavior.

Affective context interferes with brain responses during cognitive processing in borderline personality disorder: fMRI evidence.

Emotion dysregulation in borderline personality disorder (BPD) is associated with loss of cognitive control in the face of intense negative emotion. Negative emotional context may interfere with cognitive processing through the dysmodulation of brain regions involved in regulation of emotion, impulse control, executive function and memory. Structural and metabolic brain abnormalities have been reported in these regions in BPD. Using novel fMRI protocols, we investigated the neural basis of negative affective interference with cognitive processing targeting these regions. Attention-driven Go No-Go and X-CPT (continuous performance test) protocols, using positive, negative and neutral Ekman faces, targeted the orbital frontal cortex (OFC) and the anterior cingulate cortex (ACC), respectively. A stimulus-driven Episodic Memory task, using images from the International Affective Pictures System, targeted the hippocampus (HIP). Participants comprised 23 women with BPD, who were compared with 15 healthy controls. When Negative>Positive faces were compared in the Go No-Go task, BPD subjects had hyper-activation relative to controls in areas reflecting task-relevant processing: the superior parietal/precuneus and the basal ganglia. Decreased activation was also noted in the OFC, and increased activation in the amygdala (AMY). In the X-CPT, BPD subjects again showed hyper-activation in task-relevant areas: the superior parietal/precuneus and the ACC. In the stimulus-driven Episodic Memory task, BPD subjects had decreased activation relative to controls in the HIP, ACC, superior parietal/precuneus, and dorsal prefrontal cortex (dPFC) (for encoding), and the ACC, dPFC, and HIP for retrieval of Negative>Positive pictures, reflecting impairment of task-relevant functions. Negative affective interference with cognitive processing in BPD differs from that in healthy controls and is associated with functional abnormalities in brain networks reported to have structural or metabolic abnormalities. Task demands exert a differential effect on the cognitive response to negative emotion in BPD compared with control subjects.