Transcatheter interventions for severe tricuspid regurgitation: a literature review.

The prevalence of tricuspid regurgitation (TR) increases with age, affecting 65%-85% of adults. Primary TR is caused by a congenital or acquired abnormality of the tricuspid valve apparatus (leaflets, chordae, papillary muscles, or annulus). Secondary TR is due to insufficient coaptation from dilation of tricuspid valve annulus due to the right ventricle (RV) or right atrium (RA) remodeling and increased RV pressures. Isolated TR is without increased RV pressures and is associated with atrial fibrillation. Mild TR is a benign disease. Moderate to severe tricuspid regurgitation has independently been associated with increased mortality. Most of these patients are treated medically due to poor outcomes with surgical repair of isolated TR. The in-hospital mortality rate is 8.8%, and the median length of stay in hospital is 11 days resulting in higher healthcare costs. Even if the patients undergo surgical repair or replacement, available data do not show improvement in survival. With a more detailed understanding of the complex anatomy and physiology of the tricuspid valve and significant complications from untreated tricuspid valve disease, the approach to the management of TR has shifted from a conservative approach to a process of prevention and intervention. In the past decade, transcatheter tricuspid valve interventions and tricuspid annuloplasty rings have been developed, contributing to decreased mortality from surgical repair. Transcatheter tricuspid valve intervention techniques have improved survival, quality of life, and reduced heart failure rehospitalization. This review summarizes normal anatomy, types of TR, etiology and different mechanisms of TR, echocardiographic assessment of the severe TR, and highlights various percutaneous transcatheter techniques for tricuspid valve repair.

A case report of successful intravascular shockwave lithotripsy and ad hoc directional venous atherectomy of extensive chronic femoral deep venous thrombosis.

BACKGROUND: Conventional treatment for chronic deep venous thrombosis (DVT) is anticoagulation. However, limited interventional endovascular options exist for patients with non-healing venous ulcers secondary to chronic DVT. CASE SUMMARY: We present a case of 67-year-old man with severely symptomatic post-thrombotic syndrome (PTS) with persistent high-grade femoral DVT despite prior compressive therapy and chronic oral anticoagulation. It has been successfully treated with intravascular shockwave lithotripsy and ad hoc directional venous atherectomy facilitating subsequent mechanical thrombectomy and venoplasty. The procedure was without complication and resulted in significant clinical improvement. DISCUSSION: We believe our novel endovascular interventional approach represents a unique modality of intervention for patients with chronic DVT and PTS resistant to conventional venoplasty.

Successful resuscitation of acute cardiogenic shock presenting as ventricular fibrillation via Bipella approach: a case report.

BACKGROUND: The use of mechanical circulatory support (MCS) in acute myocardial infarction and cardiogenic shock (AMICS) complicated by biventricular failure is poorly discussed in the literature. CASE SUMMARY: We present successful treatment of a 52-year-old old man presenting with AMICS following cardiac arrest and prolonged CPR via a Bipella approach for biventricular support and restoration of haemodynamic stability. DISCUSSION: This case demonstrates the importance of understanding the role of MCS in the management of cardiogenic shock; the value of the cardiac power output and pulmonary artery pulsatility index as haemodynamic metrics to assess the cardiac function of a patient with cardiogenic shock; and the importance of a Bipella MCS approach in high inpatient morbidity and mortality AMICS with biventricular failure.

Cardiac papillary fibroelastoma.

Papillary fibroelastoma (PFE) is a primary, histologically benign endocardial neoplasm. Though PFE has long been reported as the second most common primary cardiac neoplasm, it has since pulled ahead of cardiac myxomas, largely due to evolving cardiac imaging modalities. While PFEs are benign histologically, they have the potential for devastating clinical consequences, transient ischemic attack, stroke, myocardial infarction, syncope, pulmonary, and peripheral embolism. Despite increased detection rate, there remains uncertainty regarding etiology, exact prevalence, and clinical management of PFEs. This paucity of information is reflected by the lack of official guidelines on this matter. In this article, we aim to summarize the current state of understanding regarding PFE and discuss areas of ongoing controversy.

Association Between Pulmonary Hypertension and Transcatheter Aortic Valve Replacement: Analysis of a Nationwide Inpatient Sample Database.

INTRODUCTION: This study was done to review the association of pulmonary hypertension (PH) with Transcatheter Aortic Valve Replacement (TAVR) procedures done in the US for years 2010 to 2012. METHODS: We used Nationwide Inpatient Sample (NIS) data to extract data for patients who were hospitalized with a primary/secondary diagnosis of TAVR as specified by International Classification of Disease (ICD-9) codes 35.05 and 35.06. PH was identified with ICD-9 codes 416.0 and 416.8. Logistic regression models were used to analyze the association between PH and clinical outcomes of TAVR. RESULTS: A total of 8,824 weighted discharges were identified with a primary/secondary diagnosis of TAVR, of which 1,976 (22.4%) also had PH. Mean age of patients undergoing TAVR with and without PH was 81.4 and 81.1 years, respectively. More females had a diagnosis of PH with TAVR when compared to males, (56.9% vs. 43.1). When controlling for demographics, diabetes and hypertension; the association between PH and TAVR was statistically significant (p<.0001). Estimated odds of TAVR with PH was 5.46 (95% CI: 4.63, 6.41) times greater than for TAVR without PH. Similarly, the estimated odds for a length of stay greater than 1 week for TAVR with PH was 1.43 (95% CI: 1.12, 1.82; p=.0034) times greater than odds for TAVR without PH. PH was not statistically significant for in-hospital mortality in patients receiving TAVR (p=0.7067). CONCLUSION: This study suggests that underlying PH does not influence the immediate mortality of patients underlying TAVR. Further studies are needed to delve into the bearing of PH on TAVR.

Serpentine thrombus in the heart: a rare case of trapped thrombus in patent foramen ovale.

A 77-year-old Caucasian woman with recent abdominal surgery was diagnosed with multiple paradoxical systemic emboli in the mesenteric and renal circulation. Diagnosis was made by direct visualisation of a serpentine thrombus traversing both atria through patent foramen ovale (PFO) by transesophageal echocardiogram (TEE). Concomitantly, the patient was found to have deep venous thrombosis and pulmonary embolism. A decision was made to pursue cardiothoracic surgery preceded by inferior vena cava filter placement. She was started on intravenous anticoagulation. Repeat TEE was negative for thrombus and the patient did not present any new clinical signs of embolisation by this time. Consequently, the treatment plan was modified and the patient received oral systemic anticoagulation followed by PFO closure with the use of St. Jude Amplatzer Cribriform septal occluder device. During the outpatient follow-up the patient was asymptomatic and there was no significant flow through the device on transthoracic echocardiogram.

Can aldosterone break your heart? Takotsubo cardiomyopathy in a patient with newly diagnosed primary aldosteronism.

We report a case of a 47-year-old Caucasian woman with medical history of hypertension and hypokalemia, who presented to Emergency Room with symptoms resembling acute coronary syndrome ST-segment elevation myocardial infarction. Coronary angiogram revealed clear coronary arteries and left ventriculogram confirmed the diagnosis of Takotsubo cardiomyopathy. She was treated conservatively with good clinical outcome. Subsequent testing revealed underlying primary aldosteronism.

Nail to the heart: no big deal. A rare case of post-traumatic pericarditis.

This is a unique case report of a 32-year-old man who presented with pneumatic nail gun injury to his right chest at work. He removed the nail and continued to work through the day. With continued chest pain, he presented to the emergency room and an echocardiogram revealed moderate-size pericardial effusion. He was managed conservatively as he was haemodynamically stable. Serial echocardiograms revealed slow resolution of the effusion over 3 days. At his 3-month follow-up appointment, there was complete resolution of his effusion. This case highlights the importance of obtaining imaging studies in penetrating chest wall injuries and utilisation of medications to prevent expected complications.

May-Thurner Syndrome as a Rare Cause of Paradoxical Embolism in a Patient with Patent Foramen Ovale.

May-Thurner syndrome is an underrecognized anatomical variant that can lead to increased propensity for venous thrombosis in the lower extremities. We present a case of a 67-year-old female who presented with transient ischemic attack. Initial workup including CT scan of the head, MRI scan of the head, and magnetic resonance angiogram of the head and neck was unremarkable. A transthoracic echocardiogram with bubble study was also normal. Subsequently, a transesophageal echocardiogram was performed that revealed a patent foramen ovale with right-to-left shunt. Lower extremity duplex venous ultrasound showed no evidence of deep vein thrombosis. However, magnetic resonance venogram of the pelvis showed compression of the left common iliac vein just after its origin suggestive of May-Thurner syndrome. Hence, May-Thurner syndrome was recognized as the probable source of paradoxical embolism causing transient ischemic attack in this patient.

Trends in Vena Cava Filter Placement: An Analysis of Nationwide Inpatient Sample Database Over an 11 Year Period.

OBJECTIVES: There have been increasing concerns regarding inappropriate usage of vena caval filters. Our study was done to analyze the current trends in vena caval filter placement. METHODS: This study used the data from Nationwide Inpatient Sample database for the years 2002- 2012 to identify patients with vena caval filter placement. Trends in both therapeutic and prophylactic vena caval filter use over the eleven years' period were analyzed. Multiple simple logistic regression model was used to assess trends. RESULTS: The overall incidence of vena caval filter placement increased from 2002 to 2012. The odds of vena caval filter placement in 2012 were 1.340 (95% CI: 1.236, 1.453) times the odds of vena caval filter placement in 2002. However, a downward trend was observed after the year 2010. The odds of vena caval filter placement in 2012 were 0.854 (95% CI: 0.801, 0.911) times the odds in 2010. Similar trends were seen in both therapeutic and prophylactic placements. The proportion of prophylactic vena caval filter placements with indications of morbid obesity (P<0.0001), head injury (P=0.0007), surgery of the eye, brain, spine or other major surgery (P<0.0001) hemorrhage/bleeding (P=0.0046) significantly increased in 2012 when compared to 2002. CONCLUSION: Vena caval filter placement rates have increased significantly from 2002 to 2012 for both prophylactic and therapeutic indications. However, there seems to be downward trend when comparing 2012 to 2010. Measures such as physician education and hospital audits can be done to further bring down inappropriate vena caval filter placements.

Association Between Hypothyroidism and Takotsubo Cardiomyopathy: Analysis of Nationwide Inpatient Sample Database.

BACKGROUND: Takotsubo Cardiomyopathy (TC), also called transient left ventricular (LV) ballooning syndrome, resembles myocardial infarction and is characterized by LV dysfunction in the absence of coronary artery disease. Hypothesis described for TC has been an intense social stressor, pheochromocytoma, thyrotoxicosis among others. We performed this study to analyze the association of hypothyroidism with TC. METHODS: We queried the Nationwide Inpatient Sample which represents 20% of all the United States hospital data for our study. We identified TC and hypothyroidism through their respective ICD9. Codes for years 2006-2012. SAS 9.4 was used to perform a chi-square analysis to find any statistical significance and p < 0.05 used to determine statistical significance. Significant differences were identified using odds ratio (OR) estimates. RESULTS: A total of 19,713 cases with TC were identified of which 17,340 (87.96%) were females and 2,373 (12.04%) were males. 3,272 patients with TC had diagnosis of hypothyroidism. There is statistically significant evidence of an association between TC and hypothyroidism (OR 2.21 (95% CI: 2.11- 2.31); p<0.0001). There is evidence of increased statistical significance of females having TC 5.24 (95% CI: 4.96-5.53; (p<0.0001)) compared to males, with an increased statistically significance of females with hypothyroidism having TC, OR 6.65 (95% CI: 5.57-7.93; p< 0.001) compared to males. CONCLUSION: There is an increased association of hypothyroidism, especially hypothyroidism for females with TC.

Rare case of massive bilateral chylothorax.

We present a case of a 48-year-old woman who was referred from an outside hospital. There, she had initially underwent hysterectomy and left salpingo-oophorectomy for tubo-ovarian abscess. She later developed a colovaginal fistula and perforation of sigmoid colon and underwent Hartmann's procedure along with drainage of a left subphrenic abscess. Subsequently, she had to be intubated for acute respiratory failure and was transferred to our hospital. At our hospital, she was found to have massive bilateral pleural effusions. Bilateral small-bore chest tubes were inserted that drained milky fluid. Pleural fluid analysis was consistent with bilateral chylothorax. Thereafter, patient's respiratory status improved and she was extubated. The mechanism of chylothorax was thought be either secondary to the multiple abdominal procedures or alternatively as a complication of the right subclavian catheter that was placed at the outside hospital. Her chest tubes were removed eventually, and she had a slow but definite recovery.

Regadenoson cardiac stress test-induced stress cardiomyopathy.

Takotsubo cardiomyopathy, also described as apical ballooning syndrome/stress-induced cardiomyopathy, imitates acute coronary syndrome and is usually related to a massive physiological or emotional stressor. We describe perhaps the first reported case to the best of our knowledge of a 55-year-old Caucasian woman who presented with congestive heart failure after having a regadenoson cardiac stress test a few hours prior to presentation to the hospital. Transthoracic echocardiogram revealed reduced heart function. She had normal coronaries on cardiac catheterisation, and left ventriculography confirmed apical ballooning syndrome. She underwent guideline-directed therapy, and heart function improved in the repeat echocardiogram along with clinical resolution of symptoms.