When the gold standard is not always golden: The value of invasive hemodynamic assessment to overcome the pitfalls of echocardiography in challenging cases of mitral stenosis.

Mitral stenosis is a uncommon valvular lesion in the developed countries. Noninvasive evaluation is the first-line modality for assessment of mitral stenosis, however the noninvasive methods may have limitations in certain cases. Invasive hemodynamics can be used as adjunct tool for assessment of mitral stenosis in such difficult cases. Mitral valve using three-dimensional planimetry is a promising technique for assessment of mitral stenosis.

Valve-in-Valve Transcatheter Aortic Valve Replacement, with Present-Day Innovations and Up-to-Date Techniques.

Approximately 51,000 to 65,000 surgical aortic valve replacement (SAVR) cases are performed in the United States anually. Bioprosthetic degeneration commonly occurs within 10 to 15 years, and nearly 800 redo SAVR cases occur each year. Valve-in-valve transcatheter aortic valve replacement (ViV TAVR) has emerged as a safe and effective alternative, as the Food and Drug Administration approved ViV TAVR with self-expanding transcatheter heart valve in 2015 and balloon-expandable valve in 2017 for failed surgical valves cases at high risk of reoperation. We review ViV TAVR, with specific attention to procedural planning, technical challenges, associated complications, and long-term follow-up.

Chest X-Ray to Predict Difficult Right Transradial Cardiac Catheterization Due to Vascular Tortuosity: A Retrospective Study.

Tortuous brachiocephalic artery may lead to procedural difficulties among patients undergoing right transradial cardiac catheterization. By prospectively identifying patients with this anatomic barrier, operators may choose an alternate catheterization site to avoid complications from switching midway. To assess brachiocephalic artery tortuosity, 23 patients who underwent challenging diagnostic coronary angiography by right transradial access were compared to a control group of 29 patients who lacked brachiocephalic artery tortuosity. Preprocedural, plain chest x-rays were analyzed for measurable anatomic parameters and assessed for statistical significance between groups. The vertebrocarinal distance-the distance in centimeters between the spinous process of the first thoracic vertebra (T1) and the most caudal point of tracheal bifurcation, measured at and parallel to the midline-was the most reliable and statistically significant radiographic predictor of brachiocephalic artery tortuosity. Using this novel concept reduces procedure duration and radiation exposure by decreasing transradial cardiac catheterization failure rates.

Peri-procedural antibiotic prophylaxis in ventricular septal defect: a case study to re-visit guidelines.

The current American Heart Association (AHA)/American College of Cardiology (ACC) guidelines do not recommend antibiotic prophylaxis for infective endocarditis (IE) in patients with acyanotic congenital valvular heart disease due to lack of any proven benefit and potential harm associated with antibiotics. As recognized by the guidelines, some acyanotic congenital heart disease, such as ventricular septal defects (VSDs), are associated with a high velocity jet and pose a greater risk of peri-procedural endocarditis. We suggest that an acyanotic congenital heart disease with high velocity jet should be considered for antibiotic prophylaxis for IE.

Hyperlipidemia: Management with Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Inhibitors.

Coronary artery disease is the leading cause of death in United States. Hyperlipidemia is an independent and potentially reversible risk factor for coronary artery disease. The 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors, collectively known as statins, have been the mainstay of pharmacologic therapy. Their availability, ease of administration, low cost, and strong evidence behind safety and efficacy makes them one of the most widely prescribed lipid-lowering agents. However, some patients may be intolerant to statins, and few others suffer from very high serum levels of cholesterol in which statin therapy alone or in combination with other cholesterol-lowering agents is insufficient in reducing serum lipid levels to achieve desired levels. In 2015, the Food and Drug Administration approved a new family of lipid-lowering agents, collectively known as proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors.PCSK9 inhibitors are biologically active molecules that decrease serum low-density lipoprotein cholesterol compared with statin therapy alone. They serve as an alternative to statins for patients who are intolerant to statin or as supplemental therapy in those patients for whom lower levels in serum low-density lipoprotein cholesterol are not achieved by statins alone. This article discusses PCSK9 inhibitors, their mechanism of action, indications, efficacy, safety, costs and limitations.

Double conduction through the atrioventricular node following acute medullary infarction: a case report.

Lateral medullary syndrome (LMS), also known as Wallenberg's syndrome, PICA syndrome, results from occlusion of the posterior inferior cerebellar artery, with associated infarction of parts of medulla oblongata, and cerebellum on the ipsilateral side. It often manifests as various patterns of sensory, motor, and autonomic deficits. While sensorimotor dysfunction presents as a predicted pattern of clinical signs and symptoms, autonomic dysfunction is usually less clinically apparent, and can be easily mistaken as a concomitant pathology in the end organ it affects. In this case, we present a case of an unusual pattern of cardiac arrhythmia as the first objective finding of LMS, caused by autonomic instability following infarction of vagus nerve nuclei in the medulla.

Occlusion of right coronary artery by microembolization caused by excessive diagnostic catheter manipulation.

With advancing technology and newer therapeutic and diagnostic techniques, physicians are now encountering new complications or increasing frequency of known complications than before. left cardiac catheterization and coronary angiography is not an exception. As transradial cardiac catheterization is now becoming more popular, operators should be more aware of related challenges and limitations associated. Tortuous right bracheocephalic artery is an anatomical variance that makes radial catheterization more difficult, and may indeed add additional time and risk to the procedure and patient, respectively. Hence, we present this case report.

Modifiable Predictors of In-Hospital Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has become an acceptable therapy for patients with severe aortic valve stenosis at high or prohibitive surgical risk. Attempts are ongoing to validate risk prediction models for in-hospital mortality after TAVR. Our aim was to define modifiable risk factors predictive of in-hospital mortality after TAVR. METHODS: We identified patients who underwent TAVR from the 2012 database of the National Inpatient Sample. Patients who died during the index hospitalization were compared to those that were successfully discharged. The predictors of in-hospital mortality were analyzed using multivariate logistic regression. RESULTS: A total of 1,360 patients (mean age 81 ± 8.8 years, whites 80.1%, blacks 3.5%) had TAVR and 68 (5%) died during hospitalization (χ2 [1, n = 1,360] = 1,101.6, P < 0.001). The average length of hospital stay was 8.33 ± 6.7 days. The positive predictors of in-hospital mortality in the unadjusted model were comorbidities such as congestive heart failure, coagulopathy, fluid and electrolyte disorder, weight loss and history of drug abuse. Hypertension was a negative predictor of in-hospital mortality. Following multivariate analysis and adjustment for possible confounders, fluid and electrolyte disorder was the only significant positive predictor of in-hospital mortality (odds ratio = 1.89, CI: 1.11-3.22, P = 0.019). The odds of in-hospital mortality were reduced in patients with hypertension (odds ratio = 0.45, CI: 0.26-0.78, P = 0.004). CONCLUSIONS: Fluid and electrolyte disturbance could be a modifiable predictor of in-hospital mortality following TAVR. Efforts should be geared towards reducing its occurrence in this patient population.