“. . . for the secret of the care of the patient is in caring for the patient.”
— FWP
My husband Ed recently died of amyotrophic lateral sclerosis (ALS), better known as Lou Gehrig's disease. His death march lasted 2 years, and I was with him every step of the way.
Ed and I met on a blind date in 1961. We married 4 years later and remained so for the next 50 years. After we completed college, I began a teaching career. Ed subsequently earned his MD and PhD and ultimately became chief of cardiothoracic surgery at a
Growing up in the 1930s, I was an avid baseball fan. My favorite team was the New York Yankees, and my favorite players were Babe Ruth, Lou Gehrig, and Joe DiMaggio. They all subsequently became prominent members of the Baseball Hall of Fame, but only one of them—Lou Gehrig—became forever linked with medicine. Consequently, he shares the batter's box in this editorial.
Lou Gehrig was perhaps the best first baseman of all time. Amid American sports heroes, his extraordinary achievements on the playing field, combined with his humility, kind-heartedness, and generosity, put him in a class by himself. He was
MicroRNA-27b (miR-27b) is frequently upregulated in pressure-overloaded hypertrophic hearts. The clinical implications of aberrant circulating miR-27b in the diagnosis and management of left ventricular hypertrophy warrant study. We investigated whether serum miR-27b is a biomarker for left ventricular hypertrophy (LVH).
We used stem-loop reverse-transcription quantitative polymerase chain reaction techniques to analyze serum miR-27b levels in 200 hypertensive patients with LVH, 100 hypertensive patients without LVH, and 100 healthy volunteers. We found that serum miR-27b levels were significantly higher in the hypertensive patients with LVH than in the hypertensive patients without LVH and in the healthy volunteers. Upon receiver operating characteristic curve analysis, serum miR-27b had an area under the curve of 0.885 with 91% sensitivity and 73% specificity in distinguishing hypertensive patients with LVH from healthy volunteers (P=0.021), and an area under the curve of 0.818 with 79.1% sensitivity and 70.3% specificity in distinguishing hypertensive patients with LVH from those without LVH (P=0.036). We conclude that circulating miR-27b might serve as a specific, noninvasive biomarker in screening for LVH.
The interrupted noneverting mattress suture technique is typically used in conventional surgical aortic valve replacement. The continuous suture technique, although faster, has been associated with a higher incidence of paravalvular leak. Using a slightly modified technique to minimize this risk, we investigated whether continuous suturing would shorten aortic cross-clamp time in aortic valve replacement in comparison with interrupted suturing.
We reviewed the cases and compared the perioperative data of 60 consecutive patients in Japan and Australia (35 men and 25 women; median age, 70 yr) who had undergone aortic valve replacement with or without septal myectomy. The continuous suture technique had been used in 41 patients (Group CS) and the standard interrupted suture technique in 19 (Group IS). The groups were similar in age, sex, pathologic valvular conditions, and operative urgency.
In Group CS, aortic cross-clamp time (47 vs 63 min; P=0.0001) and cardiopulmonary bypass time (76 vs 89 min; P=0.04) were significantly shorter. Neither group had early paravalvular leak. Using our continuous suture technique safely shortened aortic cross-clamp time during surgical aortic valve replacement.
Anomalous origin of the left coronary artery from the pulmonary artery is rare and typically results in mitral regurgitation, ventricular arrhythmias, heart failure, and sudden death. The condition most often manifests itself in early childhood, but some individuals are diagnosed much later. We describe the case of a 75-year-old woman with heart failure in whom stepwise multimodal imaging revealed anomalous origin of the left coronary artery from the pulmonary artery.
Late aneurysm formation in the proximal aorta or distal aortic arch is a recognized sequela of untreated stenosis of the aortic isthmus and is associated with substantial risk of aortic rupture. We describe the case of a 44-year-old man with untreated coarctation of the aorta who presented with a prestenotic dissecting thoracic aortic aneurysm. He declined surgery because he was a Jehovah's Witness. Instead, we performed emergency endovascular aortic repair in which 2 stent-grafts were placed in the descending aorta. Our experience suggests that this procedure is a useful and safe alternative to open surgery in patients who have aneurysms associated with coarctation of the aorta.
Bilateral recurrence of atrial myxoma has been reported only a few times. We describe the case of a 41-year-old woman who had undergone left atrial myxoma resection and presented 9 years later with myxomas in both atria. The patient underwent successful resection of both masses with resolution of symptoms. We discuss the phenomenon of recurrent biatrial myxoma.
Spontaneous coronary artery dissection is a rare condition, and diagnosis and treatment are challenging among patients who present with acute coronary syndrome. Typically, the condition affects young females who have no underlying atherosclerotic disease. To date, few cases of bioresorbable scaffold implantation for the treatment of spontaneous coronary artery dissection have been reported. Therefore, we describe the cases of 4 patients whom we treated with scaffolds. We evaluated the long-term results by using intravascular ultrasound and optical coherence tomographic scanning.
Most pericardial changes appear within a few weeks in patients who have undergone radiation therapy for thoracic neoplasms. Chronic pericardial constriction typically occurs decades later, consequent to fibrosis. Early constrictive pericarditis after chest irradiation is quite rare. We report the case of a 62-year-old woman who underwent radiation therapy for esophageal cancer and presented with constrictive pericarditis 5 months later.
We searched the English-language medical literature from January 1986 through December 2015 for reports of early constrictive pericarditis after irradiation for thoracic malignancies. We defined “early” as a diagnosis within one year after radiation therapy. Five cases fit our criteria, and we summarize the findings here. To our knowledge, ours is the first definitive report of a patient with esophageal cancer to present with early radiation-induced constrictive pericarditis.
We conclude that constrictive pericarditis can occur early after radiation for thoracic malignancies, albeit rarely. When planning care for cancer patients, awareness of this sequela is helpful.
Aneurysm of the sinus of Valsalva, a rare cardiac condition, results from dilation of an aortic sinus. Sudden aneurysm rupture can trigger rapidly progressive heart failure.
We discuss the case of a 57-year-old woman with situs ambiguus, isolated levocardia, and polysplenia who presented with acute-onset heart failure. Transesophageal echocardiograms revealed an aneurysm of the right coronary sinus of Valsalva that had ruptured into the right atrial cavity. The patient underwent successful surgical repair.
To our knowledge, this is the first report of a sinus of Valsalva aneurysm in a patient with this combination of congenital abnormalities. We briefly review the association between congenital heart disease, situs ambiguus, and ciliary dysfunction.
Morquio A syndrome (mucopolysaccharidosis IV type A), an autosomal recessive lysosomal storage disorder caused by a defective N-acetylgalactosamine 6-sulfatase gene, leads to lysosomal accumulation of keratan sulfate and chondroitin 6-sulfate. This accumulation affects multiple systems and causes notable cardiovascular manifestations, such as thickening of the left-sided valves, ventricular hypertrophy, and intimal stenosis of the coronary arteries. There have been few reports of vasculopathy in this population. We present the case of a 58-year-old woman with Morquio A syndrome who was found to have aortic dilation on a routine screening echocardiogram. Magnetic resonance images revealed multiple tortuous, dilated arteries in her head, neck, and abdomen. The diffuse vasculopathy seen in this patient should prompt further study to determine whether this is an underreported phenomenon of clinical significance or an unusual finding in this rare disorder.
A 73-year-old man was admitted to the emergency department with acute-onset orthopnea. He had a history of rheumatic mitral stenosis and permanent atrial fibrillation (AF), and he was taking warfarin. His prothrombin time (33.3 s) and international normalized ratio (2.83) were within therapeutic limits. Transthoracic echocardiograms revealed rheumatic mitral leaflets, gross pericardial effusion (Fig. 1), marked left atrial (LA) enlargement (15.6 × 8.3 cm), grade 4 spontaneous echo contrast (SEC) (Fig. 2), and mild mitral insufficiency (Fig. 3). The mitral valve area was 0.8 cm2, and the LA volume was 1,966 mL.
A 57-year-old woman with diabetes mellitus, hypertension, and hyperlipidemia presented at the emergency department with chest pain. She had experienced this sharp, nonexertional, nonpleuritic, nonreproducible pain for approximately 10 years, and it had recently worsened.
A chest radiograph showed a linear metallic object in the heart. Echocardiograms (Fig. 1) and computed tomograms (Fig. 2) revealed that the object was in the right ventricular outflow tract and traversed the interventricular septum, with no evidence of pericardial effusion. The object was well seen on fluoroscopy (Fig. 3). Right ventriculograms revealed no left-to-right shunt and confirmed the
A 62-year-old man with nonischemic cardiomyopathy (left ventricular [LV] ejection fraction, 0.30–0.34) presented for evaluation of weakness. In 2011, he had undergone placement of a D224TRK Consulta® CRT-D (Medtronic, Inc.; Minneapolis, Minn) biventricular implantable cardioverter-defibrillator. The pacemaker, programmed in DDD mode, had a lower rate limit of 60 beats/min (cycle length, 1,000 ms) and an upper limit of 130 beats/min (cycle length, 430 ms), a paced atrioventricular (AV)-delay period of 130 ms, and a sensed AV-delay period of 100 ms. The LV lead threshold was 1.25 V at 0.6 ms and was programmed to deliver 1.75 V at
Impact of Travel Time on Same-Day Discharge after Elective Percutaneous Coronary Intervention
To the Editor:
Several investigators have shown the safety of same-day discharge (SDD) compared with next-day discharge after percutaneous coronary intervention (PCI).1 Benefits of SDD include improved patient satisfaction, shorter length of stay, and cost savings.2 Despite the demonstrated safety of SDD, its adoption has been poor in the United States.3 An important contributing factor may be the travel time between the patient's residence and the hospital. This phenomenon has been described in a few other contexts, including critical limb ischemia and
