Effective treatment of hypertrophic cardiomyopathy with left ventricular outflow tract obstruction using a covered stent.

A woman in her 60s presented with progressive exertional dyspnoea, exertional chest pressure and exertional dizziness. Echocardiogram identified a 156 mm Hg left ventricular outflow tract gradient with provocation, indicating hypertrophic cardiomyopathy with left ventricular outflow obstruction-confirmed with MRI and angiogram. An alcohol septal ablation was planned but due to communication of the second septal perforator with the right ventricle and a wire-induced mid-left anterior descending artery dissection, alcohol septal ablation was not performed. Instead, a covered stent was placed in the mid-left anterior descending artery covering the origins of the third and fourth septal perforators. The left ventricular outflow tract gradient decreased from 90 to 30 mm Hg with provocation and her symptoms improved. Follow-up showed a left ventricular outflow tract gradient of 35 mm Hg with provocation and decreased symptoms.

A Rare but Deadly Complication of Transcatheter Aortic Valve Replacement.

We present a rare case of delayed coronary artery obstruction following a transcatheter aortic valve replacement (TAVR). Interestingly, the patient did not meet the criteria for traditionally recognized risk factors for delayed coronary obstruction. This case piques interest as to whether the severity of calcification on aortic valve leaflets plays any role in coronary obstruction post transcatheter aortic valve replacement. There is no consensus as to the optimal approach to investigation and revascularization in patients with delayed coronary obstruction. We report a case with successful emergent revascularization of the left main coronary artery following transcatheter aortic valve replacement.

Interventional Echocardiography of the MV: What the Interventionalist Wants to Know.

The past 2 decades have seen a proliferation of transcatheter mitral valve (MV) therapies, which are less invasive and distinct from surgical MV repair or replacement. The commonly used MV transcatheter therapies include (1) percutaneous mitral balloon commissurotomy (PMBC) for rheumatic mitral stenosis; (2) edge-to-edge repair with the MitraClip for mitral regurgitation; (3) valve-in-valve implantation in bioprosthetic MV, native MV, or mitral ring; and (4) closure of paravalvular leaks (PVLs). This article will focus on the use of echocardiography in the diagnosis, patient selection, procedural guidance, and postprocedural follow-up for PMBC, with notes on the role of transesophageal echocardiography in transcatheter interventions for prosthetic valve degeneration and PVL closure.

Gender Differences in Presentation, Treatment, and In-Hospital Outcome of Patients Admitted With Heart Failure Complicated by Atrial Fibrillation (from the Get With the Guidelines-Heart Failure [GWTG-HF] Registry).

Almost 25% of patients with heart failure (HF) have coexisting atrial fibrillation (AF), the latter of which may increase morbidity and mortality. Despite the high prevalence of HF with concomitant AF, this subgroup of patients remains understudied. This study examines gender differences in presentation, treatment and in-hospital outcome of patients with HF and AF. The Get With the Guidelines-Heart Failure (GWTG-HF) database enrolled 6,496 patients with HF who presented to Cooper University Hospital from 2005 to 2012. Twenty-four percent (1,561 patients) had concomitant AF. Pearson chi-square tests and the Student T-tests were used to compare patient characteristics by gender. Multivariate logistic regression was used to predict in-hospital mortality. Six hundred sixty-nine (42.8%) patients with HF and AF were women. Women were older (p <0.001), had a higher ejection fraction (p <0.001), had systolic hypertension (p <0.001), and were more likely to have health insurance (p <0.001). Despite a higher CHADS2 score in women (p = 0.007), there was no gender difference in percent of anticoagulation medications prescribed before admission. Women were less likely to present with dizziness, lightheadedness, or syncope, and were more likely to be compliant with medications and diet recommendations before admission. Despite differences in presentation, co-morbidities, and therapy, in-hospital mortality was similar between men and women. Decreased appetite or early satiety predicted in-hospital mortality in women, whereas age, chest pain on admission, and decreased appetite or early satiety predicted in-hospital mortality in men. In conclusion, women presenting with HF complicated by AF clinically differ from men, but despite these differences, both groups shared similar symptom presentation and in-hospital mortality rates.

Impella left ventricular assist device in cardiac arrest after spinal anaesthesia for caesarean section.

Cardiac arrest after neuraxial anaesthesia is very well described. Inhibition of the sympathetic efferent system and vagal activation leading to decrease preload and severe bradycardia results in cardiac arrest. Pregnant patients undergoing spinal anaesthesia are at increased risk for vasovagal events due to aortocaval compression and higher level of spinal block. A 36-year-old pregnant woman at 39 weeks presented for an elective caesarean section. She underwent spinal anaesthesia. Immediately after, she had severe bradycardia followed by asystole cardiac arrest. She had spontaneous return of circulation. The patient was in cardiogenic shock causing pulmonary oedema and required four vasopressors to maintain her blood pressure. An Impella 2.5 percutaneous microaxial left ventricle (LV) support device was inserted to support her haemodynamics. She fully recovered and was discharged in stable condition. To the best of our knowledge, this is first case report of the use of an LV-assist device in a patient postcardiac arrest from spinal anaesthesia.

Cognitive Function and Control of Type 2 Diabetes Mellitus in Young Adults.

BACKGROUND: Type 2 diabetes mellitus (T2DM) has been associated with impairment of cognitive function. Studies show a strong negative correlation between the levels of glycosylated hemoglobin and cognitive function in adult patients above the mean age of 60 years. In healthy adults, age-related cognitive impairment is mostly reported after the age of 60 years, hence the decline in cognitive function can be a part of normal aging without diabetes. Since the majority of patients with diabetes are between the ages of 40 and 59 years, it is crucial to ascertain whether the levels of glycosylated hemoglobin negatively correlate with the levels of cognitive function scores in adult patients of age 60 years or younger, similar to the way it correlates in patients older than 60 years of age, or not. AIMS: We observed the relationship between the levels of glycosylated hemoglobin and the levels of cognitive function in patients of age 60 years or younger with T2DM. MATERIALS AND METHODS: Eighty-two patients with T2DM underwent cognitive assessment testing by using a Modified Mini-Mental State Examination (3MS), and their cognitive function scores were correlated with their glycosylated hemoglobin levels, durations of diabetes, and levels of education. RESULTS: Cognitive impairment was observed in 19.5% of the studied patients. We found a weakly negative relationship between the glycosylated hemoglobin level and cognitive function score (r = -0.292), a moderately negative relationship between the duration of diabetes and cognitive function score (r = -0.303), and a weakly positive relationship between the level of education and cognitive function score (r = 0.277). CONCLUSION: Cognitive impairment affects one-fifth of the patients of age 60 years or younger with T2DM. It is weakly negatively related to the glycosylated hemoglobin level, moderately negatively related to the duration of diabetes, and weakly positively related to the level of education.

Myeloproliferative hypereosinophilic syndrome presenting as cardiac failure and response to imatinib.

Idiopathic hypereosinophilic syndrome was first defined by Chursid et al in 1975; however, following the advances in molecular biology, the World Health Organization has proposed a classification in 2008. Hypereosinophilic syndrome is a heterogeneous group of uncommon disorders characterized by marked peripheral eosinophilia and end-organ manifestation. The authors describe a case of sudden-onset cardiac failure in a young individual who had marked peripheral eosinophilia and detection of FIP1L1/PDGFRA fusion gene. A diagnosis of myeloproliferative neoplasm with eosinophilia and eosinophilic endocarditis was made. His clinical and laboratory parameters showed a dramatic response to imatinib and prednisone.

Disseminated histoplasmosis: missed opportunistic infection in a HIV-infected patient.

Oral ulcers are common in HIV-infected patients, with a broad differential, including viral, bacterial, fungal, mycobacterial and neoplastic aetiologies. We present a case of a patient with AIDS with oral ulcer, which was a cutaneous presentation of disseminated histoplasmosis. Our patient responded excellently to treatment.

Prevalence of true therapeutic inertia in blood pressure control in an academic chronic kidney disease clinic.

Therapeutic inertia (TI) in blood pressure (BP) control has been traditionally defined as failure to initiate or intensify therapy when treatment goals are not met. The fallacy with this definition is that TI may be overestimated because it includes hypertensive patients deliberately uncontrolled. This is a retrospective chart review study that evaluated physicians' response to an uncontrolled clinic BP reading in a population of patients with stage 3 to 5 chronic kidney disease (CKD) and hypertension. Of 429 patients screened, 166 had controlled BP and 263 did not. Of these 263 patients, 115 patients had no clear reason documented for the absence of changes in medication regimen. This population was defined as cases with true TI. In the remaining 148 patients, the medication regimen was changed in 81 patients. In the rest of the patients, there was a reason documented for not changing the medication regimen. The prevalence of true TI rate (defined as percentage of uncontrolled hypertension as a result of physician inaccountability) in our study was 44% as compared with 69% if the traditional TI definition is applied. Thus, we conclude that the prevalence of TI in the literature overestimates the rate of true TI as it does not account for physician decision making. The current definition of TI in BP control needs to be revised, as it underestimates a provider's care to improve BP control and is misleading. The TI definition should include some mechanism to account for interventions beyond medication titration.

Pulmonary artery catheters for adult patients in intensive care.

BACKGROUND: Since pulmonary artery balloon flotation catheterization was first introduced in 1970, by HJ Swan and W Ganz, it has been widely disseminated as a diagnostic tool without rigorous evaluation of its clinical utility and effectiveness in critically ill patients. A pulmonary artery catheter (PAC) is inserted through a central venous access into the right side of the heart and floated into the pulmonary artery. PAC is used to measure stroke volume, cardiac output, mixed venous oxygen saturation and intracardiac pressures with a variety of additional calculated variables to guide diagnosis and treatment. Complications of the procedure are mainly related to line insertion. Relatively uncommon complications include cardiac arrhythmias, pulmonary haemorrhage and infarct, and associated mortality from balloon tip rupture. OBJECTIVES: To provide an up-to-date assessment of the effectiveness of a PAC on mortality, length of stay (LOS) in intensive care unit (ICU) and hospital and cost of care in adult intensive care patients. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 12); MEDLINE (1954 to January 2012); EMBASE (1980 to January 2012); CINAHL (1982 to January 2012), and reference lists of articles. We contacted researchers in the field. We did a grey literature search for articles published until January 2012. SELECTION CRITERIA: We included all randomized controlled trials conducted in adults ICUs, comparing management with and without a PAC. DATA COLLECTION AND ANALYSIS: We screened the titles and abstracts and then the full text reports identified from our electronic search. Two authors (SR and MG) independently reviewed the titles, abstracts and then the full text reports for inclusion. We determined the final list of included studies by discussion among the group members (SR, ND, MG, AK and SC) with consensus agreement. We included all the studies that were in the original review. We assessed seven domains of potential risk of bias for the included studies. We examined the clinical, methodological and statistical heterogeneity and used random-effects model for meta-analysis. We calculated risk ratio for mortality across studies and mean days for LOS. MAIN RESULTS: We included 13 studies (5686 patients). We judged blinding of participants and personnel and blinding of outcome assessment to be at high risk in about 50% of the included studies and at low risk in 25% to 30% of the studies. Regardless of the high risk of performance bias these studies were included based on the low weight the studies had in the meta-analysis. We rated 75% of the studies as low risk for selection, attrition and reporting bias. All 13 studies reported some type of hospital mortality (28-day, 30-day, 60-day or ICU mortality). We considered studies of high-risk surgery patients (eight studies) and general intensive care patients (five studies) separately as subgroups for meta-analysis. The pooled risk ratio (RR) for mortality for the studies of general intensive care patients was 1.02 (95% confidence interval (CI) 0.96 to 1.09) and for the studies of high-risk surgery patients the RR was 0.98 (95% CI 0.74 to 1.29). Of the eight studies of high-risk surgery patients, five evaluated the effectiveness of pre-operative optimization but there was no difference in mortality when these studies were examined separately. PAC did not affect general ICU LOS (reported by four studies) or hospital LOS (reported by nine studies). Four studies, conducted in the United States (US), reported costs based on hospital charges billed, which on average were higher in the PAC groups. Two of these studies qualified for analysis and did not show a statistically significant hospital cost difference (mean difference USD 900, 95% CI -2620 to 4420, P = 0.62). AUTHORS' CONCLUSIONS: PAC is a diagnostic and haemodynamic monitoring tool but not a therapeutic intervention. Our review concluded that use of a PAC did not alter the mortality, general ICU or hospital LOS, or cost for adult patients in intensive care. The quality of evidence was high for mortality and LOS but low for cost analysis. Efficacy studies are needed to determine if there are optimal PAC-guided management protocols, which when applied to specific patient groups in ICUs could result in benefits such as shock reversal, improved organ function and less vasopressor use. Newer, less-invasive haemodynamic monitoring tools need to be validated against PAC prior to clinical use in critically ill patients.

Tuberculous myopericarditis: a rare presentation in an immunocompetent host.

Tuberculosis is a common cause of pericardial disease in India. Myocardial involvement, although well described in the literature, is a rare manifestation of tuberculosis. We report a patient with disseminated tuberculosis and myopericarditis manifesting as cardiogenic shock. The patient gradually improved on antituberculosis drug therapy, steroids and an evidence-based guideline driven therapy for heart failure. Follow-up imaging showed calcification of the pericardium and improvement of his left ventricular systolic function.

Idiopathic chylothorax in a young man.

Chylothorax refers to the presence of chyle in the pleural space owing to disruption or obstruction of the thoracic duct or one of its tributaries. We present a case of non-traumatic, idiopathic chylothorax in an 18-year-old man. Lymphoscintigraphy was used to identify the site of leak. We tried the full armamentarium of available non-surgical therapy on him, including a modified diet, chest tube insertion, total parenteral nutrition and octreotide. Yet, despite optimal medical therapy, his effusion continued to persist. He eventually required thoracic duct ligation, which resulted in resolution of the effusion.