Vascular Complications of Percutaneous Transradial Cardiac Catheterization.

The percutaneous transradial approach for coronary angiography and percutaneous coronary intervention is increasing in the United States. Although its vascular safety profile is better than the traditional femoral approach, it is important to learn about potential complications. In this article, we present two cases of vascular complications, namely, pseudoaneurysm and radial artery occlusion, after transradial cardiac catheterization, along with a review of the relevant literature.

Incidental finding of aberrant mitral valve chorda during a transesophageal echocardiography evaluation for suspected endocarditis.

Congenital defects involving anomalous chordae of the mitral valve with attachment in the left atrium are an extremely rare finding and may result in valvular insufficiency. Few cases have been reported in the literature with multiple variations in anatomical location and insertion of aberrant chordae within the left ventricle and left atrium. Reported cases have presented with cardiovascular symptoms leading to diagnosis of anomalous mitral valve chordae. We present a case of a young female in which an aberrant mitral valve chorda was an incidental finding on transesophageal echocardiography.

Altered right ventricular contractile pattern after cardiac surgery: monitoring of septal function is essential.

Assessment of right ventricular (RV) function is important in the management of various forms of cardiovascular disease. Accurately assessing RV volume and systolic function is a challenge in day-to-day clinical practice due to its complex geometry. Tricuspid annular plane systolic excursion (TAPSE) and systolic excursion velocity (S') have been reviewed to further assess their suitability and objectivity in evaluating RV function. Multiple studies have validated their diagnostic and prognostic values in numerous pathologic conditions. Diminished longitudinal contraction after cardiothoracic surgery is a well-known phenomenon, but it is not well validated. Despite significant reduction in RV performance along the long-axis assessed by TAPSE and S' after cardiac surgery, RV ejection fractions did not change as well as the left ventricular parameters and exercise capacity. RV contractile patterns were markedly altered with decreased longitudinal shortening and increased transverse shortening, which are likely resulted from the septal damage during cardiac surgery. The septum is essential for RV performance due to its oblique fiber orientation. This allows ventricular twisting, which is a vital mechanism against increased pulmonary vascular resistance. The septum function along with TAPSE and S' should be adequately assessed during cardiac surgery, and evidence of septal dysfunction should lead to reevaluation of myocardial protection methods.

Emerging therapies for residual risk.

The role of statins in reducing the risk of coronary artery disease is well established. The use of statins in patients at high risk for cardiovascular disease has reduced the incidence of major clinical events by 25% to 40%. However, despite aggressive statin therapy and the achievement of target low-density lipoprotein cholesterol levels, the residual risk of cardiovascular events remains high. This review investigates emerging therapies to target the residual risk of cardiovascular events with concurrent statin therapy.

Coronary artery calcium scoring.

Numerous clinical studies have shown that coronary artery calcium scoring provides substantial incremental risk prediction beyond conventional coronary risk factors for coronary heart disease events. About half of all patients with coronary artery disease (CAD) present initially with unexpected myocardial infarction or sudden death. Early identification of this subgroup of patients is vital for institution of intensive, early preventive measures to decrease morbidity and mortality due to CAD.

Update on cardiac risk stratification of renal transplant candidates.

Numerous modifiable and unmodifiable risk factors have been identified that contribute to increased cardiovascular risk in renal transplant recipients. We reviewed several clinical studies and journal articles to identify these risk factors in an attempt to risk stratify chronic kidney disease patients who are candidates for renal transplantation. Cardiovascular disease has been identified as the leading cause of death with graft function among renal transplant recipients. No single test or diagnostic modality has been found to provide complete diagnostic and prognostic information. Hence, a combination of clinical, biochemical, and radiographic data is essential to risk stratify renal transplantation candidates.

Recognition of noncardiac findings on cardiac computed tomography examination.

Multislice computed tomography (CT) is rapidly emerging as a novel technique for the evaluation of coronary artery disease. It is anticipated that with increasing acceptance of this imaging technique, CT for calcium scores and CT angiography will be performed in ever greater numbers. Thus, it is all but inevitable that clinicians will stumble upon incidental findings given the sheer number of vital organs and blood vessels that are imaged in the field of view. This article reviews the literature on incidental findings on cardiac CT with a focus on pulmonary nodules, ethical aspects of following up such findings, and cost implications.

Cardiac computed tomography: current practice and future applications.

Cardiac computed tomography (CT) has continued to make great strikes in cardiovascular imaging. New advances and refinements in technology have enable CT to render astonishingly detailed images. Cardiac CT depends on a high temporal resolutions to minimize coronary artery movement-related motion artifacts. There is ongoing debate as to the position of CT in the algorithm of diagnostic imaging in the realm of the cardiovascular sciences. There is a definite role for cardiac CT in patients with chest pain who have low or intermediate probability of coronary artery disease; a negative result on cardiac CT angiography could potentially exclude significant coronary artery disease and thus obviate further expensive workup. Further advancements in technique and validation of results will help establish CT on firmer ground. Such developments should proceed in tandem with reimbursement practices that encourage use of this tool in the right clinical context.

Normal anatomic variants on transthoracic echocardiogram.

Apart from their existence as medical curiosities, anatomic variants also double as diagnostic dilemmas. In the heart, more than in any other location in the body, misinterpretation of normal anatomic variants as pathologic entities can have a profound impact on treatment decisions and clinical consequences. Echocardiography is an easily accessible tool these days and is used routinely in most cardiac evaluations. Thus it becomes imperative for the echocardiographer to be cognizant of normal anatomic variants. Furthermore, echocardiographic findings should always be evaluated in their proper clinical context and diagnoses should never be entertained in a clinical vacuum. The literature is replete with numerous case reports and vignettes on these fascinating structures but is lacking in a formal review of normal anatomic variants. In this article, we have attempted a systemic review of normal variants, their embryologic origins, echocardiographic characteristics, and common pitfalls encountered in their evaluation.

Cardiac amyloidosis: A case report and review of literature.

BACKGROUND: Cardiac amyloidosis, a disease caused by the precipitation of amyloid proteins in the myocardial extracellular matrix has been historically difficult to diagnose due to lack of specific clinical manifestations and necessity of biopsy to demonstrate amyloid deposition. However, advances in cardiovascular imaging techniques have facilitated earlier recognition of this disease. In addition, while once thought of as incurable, treatment strategies are emerging for cardiac amyloidosis, making early diagnosis essential. CASE SUMMARY: We outline the case of a 73 years old African American female who was admitted with sudden onset shortness of breath and found to be in cardiogenic shock. Cardiac amyloidosis was suspected due to discordance between electrocardiogram and echocardiogram findings and this was subsequently confirmed with the aid of scintigraphy and an endomyocardial biopsy. CONCLUSION: Our objective is to highlight the diagnostic evaluation and clinical implications of cardiac amyloidosis.

Incidental Finding of Giant Coronary Artery Aneurysms Successfully Treated with Medical Therapy.

We report a case of a 30-year-old male who presented with signs and symptoms of respiratory infection with left lower lobe consolidation and cardiomegaly on a chest radiography. The presence of cardiomegaly lead to further cardiac evaluation revealing giant coronary aneurysms. The patient was treated conservatively with Coumadin and aspirin and has done well at four years of follow-up.

Isolated noncompaction of the left ventricular myocardium: a case report and literature review.

A previously healthy 30-year-old African American male presented to our hospital with diabetic ketoacidosis as his first manifestation of diabetes. A transthoracic echocardiogram (TTE) was performed with contrast, which showed isolated noncompaction of the left ventricular myocardium (INVM). The case presented here is followed by an extensive review of the available literature.

Elusive left ventricular thrombus: Diagnostic role of cardiac magnetic resonance imaging-A case report and review of the literature.

Identification of left ventricular mural thrombus (LVT) may be challenging depending on the imaging modality used. We present a case of LVT which was incidentally identified on cine cardiac magnetic resonance imaging (CMR). A sixty-four years old female presented with worsening dyspnea on exertion with troponin elevation. Transthoracic echocardiography (TTE) revealed a dilated left ventricle (LV) and ejection fraction (EF 30%) with thinning and akinesis of inferior/inferolateral wall was noted with basal and mid inferior wall aneurysm, and thrombus was not identified. CMR done to ascertain viability of myocardium revealed a mural thrombus within basal inferior aneurysm. This was not visualized on transthoracic echocardiography with and without use of contrast. She underwent coronary artery bypass grafting, bioprosthetic mitral valve replacement, resection and plication of posterior left ventricular aneurysm with removal of mural thrombus, and was started on anticoagulation with warfarin post-operatively for the apical thrombi. Cardiac magnetic resonance is a well suited imaging modality in detecting LVT due to its high resolution images and is more reproducible than TTE. In our patient, conventional TTE despite administration of echo-contrast agents failed to diagnose the presence of LVT in the basal inferior aneurysm as well as the apical thrombi. Delayed-enhancement CMR provides the greatest sensitivity for detection of left ventricular thrombus, superior to standard transthoracic and contrast-enhanced transthoracic echocardiography.

Dehiscence and embolization of CorMatrix tricuspid valve replacement in the setting of infective endocarditis: a case report.

BACKGROUND: Due to increased morbidity and mortality, prosthetic valve infective endocarditis (IE) with dehiscence requires urgent intervention. Early identification and therapy may prevent embolization. CASE SUMMARY: A 27-year-old Caucasian woman with a history of hepatitis C, intravenous drug abuse, and tricuspid valve (TV) replacement was admitted for recurrent IE. She was found to have bacteraemia and fungaemia, and empiric antibiotics were initiated. Transthoracic echocardiogram (TTE) revealed a mobile 'mass' on the TV and dehiscence. The patient developed cardiogenic shock and repeat TTE showed a ruptured TV and absence of the 'mass', suspicious of embolization. She underwent emergent surgery with TV replacement using a Biocor valve and retrieval of the old CorMatrix valve found in the right mid pulmonary artery (PA). The patient was successfully weaned off inotropic agents and completed a prolonged course of antibiotics and anti-fungals. DISCUSSION: The multi-disciplinary decision on timing of surgical intervention was challenging, especially due to ongoing mycobacterial infection that increased operative risk. With clinical deterioration, urgent surgery was performed revealing an embolized prosthetic valve in the PA. New surgical options for TV replacement in IE with extracellular-based material have shown promising outcomes with little reported data of long term complications. This case demonstrates a rare occurrence of embolized CorMatrix TV and highlights the challenge in timing of appropriate surgical intervention in a septic patient with thrombocytopenia.

Incidental echocardiographic finding: Fractured inferior vena cava filter.

Inferior vena cava filters have gained increasing popularity in recent decades and knowledge on rare complications becomes vital to practicing physicians. A 30-year-old African American male with diabetes mellitus, hypertension, end-stage renal disease, history of deep venous thrombosis and placement of venacaval filter who was seen in the cardiology clinic for cardiac risks stratification prior to renal transplant. Patient denied any cardiac symptoms. A transthoracic echocardiogram was performed and showed two linear echoes bright densities in the right atrium and right ventricle embedded which was later found to be fractured filter struts by computed tomography. We discuss the various outcomes associated with non-retrieval of retrievable inferior vena cava filters.

Successful Biopsy and Removal of a Tricuspid Valve Papillary Fibroelastoma in Cardiac Catheterization Laboratory: A Case Report.

Papillary fibroelastomas are rare benign cardiac tumours with a predilection for cardiac valves. Because of the rarity of these tumours, management is individualized, but some recommend surgical removal of all papillary fibroelastomas due to the increased risk of embolization. We report a case of a 71-year-old man who presented with a sessile mass on the tricuspid valve. The mass, a papillary fibroelastoma, was successfully biopsied and removed in the cardiac catheterization laboratory. This report demonstrates a unique minimally invasive way of approaching a cardiac tumour wherein a major surgery was avoided.

Should angiotensin receptor blockers be added to angiotensin-converting enzyme inhibitors in the treatment of heart failure?

Angiotensin-converting enzyme (ACE) inhibitors have been the cornerstone of treatment of heart failure. Angiotensin receptor blockers (ARBs) remain an attractive alternative in heart failure patients intolerant of ACE inhibitors. The addition of ARBs to ACE inhibitors in the context of stable heart failure may lead to additional clinical benefits. This is in contrast to heart failure complicating acute myocardial infarction, in which it does not offer any therapeutic advantage.

Clinical correlation between increased lung to heart ratio of technetium-99m sestamibi and multivessel coronary artery disease.

BACKGROUND: An increased lung to heart ratio (LHR) on thallium-201 (Tl-201) stress myocardial perfusion imaging (MPI) is a predictor of adverse cardiac events and identifies people with extensive coronary artery disease (CAD). The implications of increased LHR in patients undergoing stress technetium-99m (tc-99m) sestamibi are developing. Our aim is to evaluate the relationship between increased LHR and extent of CAD in patients undergoing tc-99m sestamibi MPI. METHODS: We reviewed the records and images of 530 consecutive subjects who underwent exercise or adenosine tc-99 m sestamibi MPI. One hundred thirty-two had transient or partially reversible myocardial perfusion defects and 79 (exercise=34, adenosine=45, male=43, female=36, mean age=61 years) of these underwent coronary angiography (study population). The average LHR of these 79 subjects was compared to 79 patients (control population) with normal scans (exercise=50, adenosine=29, male=34, female=45, mean age=60 years). RESULTS: The mean LHR (+/-SE) in subjects with normal scans was 0.30+/-0.01. The mean LHR for those with abnormal scans and single vessel CAD who underwent exercise was 0.32+/-0.01 and pharmacological stress was 0.31+/-0.01. There was no statistically significant difference between the LHR of those with a normal scan and those with single vessel disease and an abnormal scan. However, there was a statistically significant association between the elevated LHR and multi-vessel CAD. The mean LHR for subjects with multi-vessel CAD with exercise was 0.39+/-0.01 (p=0.000) and for adenosine was 0.39+/-0.02 (p=0.000). CONCLUSION: An elevated LHR in patients undergoing exercise or pharmacological tc-99m MPI correlates with multi-vessel CAD.

Pulmonary embolism and cardiac enzymes.

BACKGROUND: Pulmonary embolism (PE) is often associated with chest pain, electrocardiographic changes, and right ventricular (RV) dysfunction on echocardiogram. There have been reports of elevated troponin levels with PE. RV dysfunction and elevated troponin levels have prognostic implications in acute PE. The purpose of this retrospective analysis was to determine whether PE was associated with elevated cardiac enzymes and whether there was any difference among patients who presented with or without chest pain. METHODS: Records of 93 consecutive patients with high-probability ventilation/perfusion lung scan results for PE were analyzed for the presence or absence of chest pain on presentation, abnormalities in cardiac enzymes, and evidence of RV dysfunction on echocardiogram. RESULTS: A total of 56 of 93 patients had cardiac enzymes evaluated; 24 of these 56 patients had chest pains, and 32 did not. Only 1 patient of the 56 had abnormal cardiac enzymes. This patient had a known history of coronary artery disease (CAD) and had experienced an acute anterior myocardial infarction. Echocardiograms were performed in 36 of 93 patients. Evidence of RV dysfunction on echocardiograms was found in 22 of these patients. No significant relationship was found between RV dysfunction and chest pains (P > .10). CONCLUSION: We found no significant relationship between high-probability ventilation/perfusion scan results and abnormalities in cardiac enzymes irrespective of the presence or absence of chest pain. Patients with a history of CAD or RV dysfunction did not have a higher incidence of chest pain when compared with those with no known history of CAD or RV dysfunction.

Contrast induced neurotoxicity following coronary angiogram with Iohexol in an end stage renal disease patient.

Neurotoxicity is an infrequent adverse reaction to iodinated contrast agents. Contrast induced neurotoxicity following coronary angiogram is very rare. Renal disease is a risk factor for contrast induced neurotoxicity. We report a case of contrast induced neurotoxicity following coronary angiogram and intervention using Iohexol (Omnipaque 350) in an end stage renal disease patient on peritoneal dialysis who had prior exposure to iodinated contrast without any adverse reaction. Hemodialysis had to be initiated for rapid removal of the contrast agent with subsequent complete resolution of neurological deficits. This case highlights the need for interventionalists to be aware of an important adverse reaction to iodinated contrast agents, especially in individuals with renal dysfunction, and that neurotoxicity is a possibility even with prior uneventful exposures. The role and timing of hemodialysis in contrast induced neurotoxicity in patients with chronic kidney disease and in those without chronic kidney disease needs further deliberation.