“ . . . for the secret of the care of the patient is in caring for the patient.”
— FWP
I had spent a long month as an intern in the intensive care unit. Near the end of my rotation, I arrived for an overnight shift, and my resident promptly approached me. “You're up first for an admission—the kid in bed 12. Here are his transfer records.” The patient, Jimmy, was 27 years old, like me. For 8 weeks, he had needed multiple blood transfusions; however, no diagnosis had been made. Eventually, someone had examined his blood smear, seen
Ray C. Fish (1902–1962) was a leading figure in Houston's natural gas industry and a philanthropist. He believed in the American dream of “opportunity for success.” The Ray C. Fish Foundation was established so that others might be encouraged to broaden man's self-knowledge and to keep the American dream alive. After its founder's death from heart disease, the Fish Foundation granted $5 million to make the Texas Heart Institute a reality. For this reason, the Institute's highest professional award is given in honor of this extraordinary man. The award recognizes those whose innovations have made significant
Assessing thromboembolic risk is crucial for proper management of patients with atrial fibrillation. Left atrial volume is a promising predictor of cardiac thrombosis. To determine whether left atrial volume can predict left atrial appendage thrombus in patients with atrial fibrillation, we conducted a prospective study of 73 patients. Left atrial and ventricular volumes were evaluated by cardiac computed tomography with retrospective electrocardiographic gating and then indexed to body surface area. Left atrial appendage thrombus was confirmed or excluded by cardiac computed tomography with delayed enhancement.
Seven patients (9.6%) had left atrial appendage thrombus; 66 (90.4%) did not. Those with thrombus had a significantly higher mean left atrial end-systolic volume index (139 ± 55 vs 101 ± 35 mL/m2; P =0.0097) and mean left atrial end-diastolic volume index (122 ± 45 vs 84 ± 34 mL/m2; P =0.0077). On multivariate logistic regression analysis, left atrial end-systolic volume index (per 10 mL/m2 increase) was significantly associated with left atrial appendage thrombus (odds ratio [OR]=1.24; 95% CI, 1.03–1.50; P =0.02); so too was the left atrial end-diastolic volume index (per 10 mL/m2 increase) (OR=1.29; 95% CI, 1.05–1.60; P =0.02).
These findings suggest that increased left atrial volume increases the risk of left atrial appendage thrombus. Therefore, patients with atrial fibrillation and an enlarged left atrium should be considered for cardiac computed tomography with delayed enhancement to confirm whether thrombus is present.
We evaluated aortic tissue specimens from patients undergoing tetralogy of Fallot repair, to determine whether histologic abnormalities affect postsurgical aortic remodeling and other patient-related variables.
Using light microscopy, we studied full-thickness aortic wall tissue operatively excised from 118 consecutive patients undergoing intracardiac repair of tetralogy of Fallot. We performed multiple linear regression analysis to identify independent predictors of change in aortic root dimensions, which we measured with echocardiography after repair and every 3 months thereafter.
Thirty histologically normal specimens were used as controls. Elastic fiber fragmentation was found in 74.6% of the abnormal specimens, mucoid extracellular matrix accumulation in 49.2%, smooth muscle cell nuclei loss in 39%, smooth muscle cell disorganization in 28.8%, and medial fibrosis in 52.5%. At a mean follow-up time of 83.55 ± 42.08 months, mean aortic sinotubular diameter decreased from 28.79 ± 9.15 to 27.16 ± 8.52 mm/m2 (r =–0.43; P <0.001). Aortic sinotubular diameter decreased by 0.6 mm/m2 among females (β =0.6, SE=0.31; P =0.05) and by 0.88 mm/m2 in patients who had elastic fiber fragmentation or loss (β =0.88, SE=0.38; P =0.02). In bivariate and multiple linear regression analysis, duration of follow-up emerged as an independent predictor of aortic remodeling.
The aortic histopathologic changes in our patients had an independent negative impact on the degree of aortic remodeling after surgery. We observed the most improved aortic sinotubular diameter in patients who had either histologically normal aortas or aortas with elastic fragmentation.
Speckle-tracking echocardiography has enabled clinicians to detect changes in myocardial function with more sensitivity than that afforded by traditional diastolic and systolic functional measurements, including left ventricular ejection fraction. Speckle-tracking echocardiography enables evaluation of myocardial strain in terms of strain (percent change in length of a myocardial segment relative to its length at baseline) and strain rate (strain per unit of time). Both measurements have potential for use in diagnosing and monitoring the cardiovascular side effects of cancer therapy. Regional and global strain measurements can independently predict outcomes not only in patients who experience cardiovascular complications of cancer and cancer therapy, but also in patients with a variety of other clinical conditions. This review and case series examine the clinical applications and overall usefulness of speckle-tracking echocardiography in cardio-oncology and, more broadly, in clinical cardiology.
Warm blood cardioplegia has been an established cardioplegic method since the 1990s, yet it remains controversial in regard to myocardial protection. This review will describe the physiologic and technical concepts behind warm blood cardioplegia, as well as outline the current basic and clinical research that evaluates its usefulness. Controversies regarding this technique will also be reviewed. A long history of experimental data indicates that warm blood cardioplegia is safe and effective and thus suitable myocardial protection during cardiopulmonary bypass surgeries.
Endocarditis is a devastating complication of prosthetic aortic valve replacement. The infective process can destroy aortic annulus tissue, making conventional surgical valve replacement difficult or impossible and causing aortoventricular discontinuity. Several treatment techniques have been proposed. One of these, the Danielson technique, involves translocating the aortic valve to the native ascending aorta, débriding the abscess cavity, closing the coronary ostia, and bypassing the coronary arteries with a Y anastomosis between 2 vein grafts. We describe our use of a modified Danielson technique in a 68-year-old man with advanced prosthetic valve endocarditis that was associated with aortic annulus destruction and aortoventricular discontinuity. This modified technique enables safer, more secure anchoring of a replacement valve, reduces the risks and concerns associated with bypass grafts, and successfully treats aortoventricular discontinuity.
Cardiovascular disease (CVD) remains the leading cause of morbidity and death among women and men. Although a decrease in mortality rates among women has been well documented, progress still lags behind that in men. Meanwhile, mortality among younger women has increased alarmingly. Cardiovascular disease develops 7 to 10 years later in women than in men, but the prevalence of many risk factors among women is a growing concern. Women have an increased lifetime prevalence of stroke risk factors (including hypertension) and for abdominal obesity and metabolic syndrome, especially in middle age.
Greater life expectancy for women, together with improvements
The prevalence of type 2 diabetes mellitus continues to increase. In the United States, diabetes is diagnosed in 1 in 10 adults1 and by 2030 will affect an estimated 54.9 million individuals.2 The toll of diabetes on health has been well established; its diagnosis at midlife (45 years of age) can shorten lifespan by approximately 6 years.3 The last 2 decades have witnessed a substantial reduction in diabetes-related deaths; nevertheless, mortality rates remain higher in individuals with diabetes than in those without it, and most diabetes-related deaths are attributed to cardiovascular disease.4
Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death in women in the United States. Here, we explore and summarize for this population the general principles and sex-specific nuances of ASCVD risk assessment, risk enhancers specific to women, the value of evaluating coronary artery calcium (CAC), the benefit of statin therapy, and the perception of ASCVD risk in women (Table I).
Table ISummary of Atherosclerotic Cardiovascular Disease Risk Assessment and Perception in Women
Pooled Cohort Equations for Risk Assessment
The pooled cohort equations (PCEs), originally recommended in the 2013 American College of Cardiology (ACC)/American Heart Association
For decades, cardiovascular disease—specifically, myocardial infarction (MI)—was thought to be a disease of men. The major acute coronary syndrome (ACS) trials that guide daily clinical practice disproportionately enrolled men, thus promoting this fallacy. Fortunately, the medical literature and the lay media have increasingly recognized that heart disease is the primary cause of death in women and that cardiovascular disease has no sex preference.
Traditional cardiac risk factors of diabetes, smoking, obesity, and hypertension affect the cardiovascular system differently in men and women.1 In the INTERHEART study of more than 27,000 patients, diabetes increased risk in women 4-fold, but
Mitral valve regurgitation (MR) often occurs in patients who are poor candidates for conventional cardiac surgery, particularly in those with advanced heart failure (HF) who are at increased risk of perioperative surgical complications. Catheter-based therapies for mitral valve (MV) repair, such as the MitraClip (Abbott), have been developed.1 We discuss a conceptual framework for classifying MR by etiology and morphology; techniques, risks, and benefits of surgical and MitraClip repair; and indications for MitraClip therapy.
Mitral Valve Regurgitation and Carpentier Classification
When functioning well, the MV ensures unidirectional diastolic flow between the left atrium and left ventricle (LV). However,
Coronary artery fistulas are rare anomalies that often become symptomatic with age. They are typically diagnosed incidentally during coronary angiography. The chief nonsurgical treatment is transcatheter coil embolization. We evaluated the outcomes of this procedure in 17 symptomatic patients who had 22 fistulas in total.
The 9 men and 8 women (mean age, 52 ± 16.5 yr; range, 27–74 yr) presented at 4 Turkish hospitals from October 2008 through March 2015. Three patients had multiple fistulas. Twelve fistulas originated from the right coronary artery and 10 from the left coronary artery, draining into the pulmonary artery in 18 instances. We evaluated results postprocedurally and after 2 to 5 months, defining angiographic success as a flow better than Thrombolysis in Myocardial Infarction grade 2 in the treated artery.
Twenty-one of the 22 procedures immediately produced the targeted flow. We observed 2 minor and no major complications. On follow-up, 3 symptomatic patients underwent successful repeat treatment of one fistula each. We found that transcatheter coil embolization afforded good success rates with few complications in closing coronary artery fistulas. We share our experience to add to the data on treating patients with coronary artery fistulas, and to raise awareness among clinicians.
Inferior vena cava (IVC) filter thrombosis can be fatal when it is not detected and treated. Its management can be challenging, because little evidence supports specific treatments. We present the case of a 72-year-old man with a history of deep vein thrombosis in whom IVC filter thrombosis developed 7 years after filter placement. Recanalization with oral anticoagulation had failed. Using intravascular ultrasonography, we performed pharmacomechanical thrombolysis, deploying 2 stents simultaneously through the IVC filter and then 2 more into the iliac veins, with excellent results. One year later, the patient's veins and IVC filter were patent, his symptoms were greatly improved, and only nonobstructive neointimal hyperplasia was seen. This case highlights the usefulness of balloon venoplasty and double-barrel stent placement in restoring blood flow through an occluded IVC, and the value of intravascular ultrasonography during and after such procedures.
Robotic-assisted percutaneous coronary intervention can reduce the exposure of interventional cardiologists to radiation and minimize the risk of occupational orthopedic injuries from wearing heavy protective aprons. The PRECISE (Percutaneous Robotically-Enhanced Coronary Intervention) study showed the efficacy and safety of robotic-assisted procedures for relatively low-risk lesions in single coronary arteries. Several reports have described robotic-assisted treatment of complex high-risk lesions, mostly through the transfemoral approach. We report 4 cases of patients in whom we used the transradial approach to treat complex lesions in the left anterior descending coronary artery with bifurcation balloon angioplasty reconstruction (2 cases), in the ostium of the first diagonal branch, and in the right coronary artery.
Successful surgical repair of aortic coarctation during childhood may have major late complications such as pseudoaneurysm formation. If left untreated, pseudoaneuryms put patients at risk for morbidity and death; if treated surgically, they are associated with complications. Endovascular aortic repair, an established safe alternative to open surgical repair, is associated with encouraging outcomes and fewer complications, and it is especially feasible for patients who have undergone multiple aortic surgeries. We report the case of a 41-year-old man who underwent endovascular repair of a pseudoaneurysm after previous surgical corrections of an aortic coarctation at 6 and 14 years of age. The pseudoaneurysm, involving the distal portion of an ascending-to-descending aortic 20-mm Dacron bypass graft, was successfully excluded with a thoracic stent-graft and sealed off with vascular plugs to prevent both blood flow into the pseudoaneurysm and type II endoleak.
Zinc, an essential micronutrient, affects the heart by modulating cardiomyocyte oxidative stress and maintaining myocardial structure, among other mechanisms. In cross-sectional studies, patients with heart failure have often had zinc deficiencies, suggesting effects on the ongoing pathogenesis of heart failure. Low plasma and myocardial zinc levels may cause reversible cardiomyopathy in patients who have nutritional deficiencies.
We present the case of a 24-year-old woman with anorexia nervosa and new-onset heart failure whose depressed left ventricular systolic function improved after zinc supplementation. To our knowledge, this is the first report of low plasma zinc levels as the chief cause of cardiomyopathy that resolved after zinc supplementation.
Stent underexpansion, a potential complication of percutaneous coronary intervention in severely calcified and stenotic coronary arteries, may result in in-stent thrombosis and restenosis. Different balloon-based and atheroablative techniques have been proposed to reduce the risk of these complications. We describe a simple triple-guidewire technique that we used to treat stent underexpansion in 2 elderly men.
Dehiscence of a prosthetic heart valve or excessive rocking during the cardiac cycle is thought to preclude percutaneous paravalvular leak closure. However, surgical repair of paravalvular leak is associated with recurrent dehiscence and poor outcomes. We present the case of a symptomatic 74-year-old man in whom we performed percutaneous anchoring, involving multiple plugs and multimodal imaging, to stabilize a rocking mitral valve and close a substantial paravalvular leak caused by dehiscence. To our knowledge, using this technique to correct both conditions is novel.
Acquired long QT syndrome is typically caused by medications, electrolyte disturbances, bradycardia, or catastrophic central nervous system events. We report a case of myocardial infarction–related acquired long QT syndrome in a 58-year-old woman that had no clear cause and progressed to torsades de pointes requiring treatment with isoproterenol and magnesium. Despite negative results of DNA testing against a known panel of genetic mutations and polymorphisms associated with long QT syndrome, the patient's family history of fatal cardiac disease suggests a predisposing genetic component. This report serves to remind clinicians of this potentially fatal ventricular arrhythmia after myocardial infarction.
Anomalous origin of the left coronary artery from the opposite sinus of Valsalva with an intramural aortic course is a rare congenital anomaly with a poor prognosis. We report the case of a 14-year-old soccer player who briefly lost consciousness while sprinting. He had exertional chest pain, syncope, ischemic changes on his electrocardiogram, and elevated cardiac troponin levels. Computed tomographic angiograms showed an anomalous origin of the left coronary artery from the right sinus of Valsalva and a course through the aortic wall toward the left coronary sinus. A surgically created neo-ostium in the left coronary sinus relieved the patient's ischemia, and he resumed playing soccer after cardiac rehabilitation.
The case report by Garcia-Arribas and colleagues1 is a welcome addition to the literature on anomalous origin of the left coronary artery from the opposite sinus of Valsalva with an intramural aortic course (L-ACAOS-IM),2 a rare and often misunderstood condition. Severe coronary artery anomalies with an intramural course and proximal stenosis1 frequently lead to syncope during strenuous exertion, which can be the first clear sign of severe disease; less often, these anomalies cause sudden cardiac arrest or death. Some authors claim that syncope during exertion is frequent yet benign in children; however, when chest
Anomalous coronary arteries are rare and often incidental findings. Most variants are benign. We present the case of a 75-year-old man with exertional dyspnea in whom the left anterior descending coronary artery arose from the right sinus of Valsalva, and the left circumflex coronary artery originated from the distal right coronary artery and supplied the obtuse marginal branch. No arteries originated from the left sinus of Valsalva. The patient was prescribed optimal medical therapy for atherosclerotic stenosis in his ramus intermedius. His symptoms were stable 3 years later.
A 56-year-old multiparous woman presented with chest pain, palpitations, and worsening dyspnea on exertion. She had a history of substance abuse. A systolic ejection murmur was audible at the left sternal border. Laboratory findings were normal. An electrocardiogram revealed sinus rhythm with left ventricular (LV) hypertrophy.
A transthoracic echocardiogram showed right ventricular hypertrophy, normal right ventricular systolic function, and moderately depressed LV systolic function (ejection fraction, 0.35–0.40). Anomalous flow arising from the pulmonary artery (PA) was noted in color-flow Doppler mode (Fig. 1). A cardiac computed tomographic angiogram revealed an anomalous right coronary artery from the PA (ARCAPA)
An asymptomatic 70-year-old woman was referred to our hospital because of hypertension and diabetes mellitus. A grade 3/6 systolic murmur was heard at the 2nd left sternal border. The only abnormal laboratory finding was a high plasma brain natriuretic peptide level (84 pg/mL). Transthoracic echocardiograms revealed moderate aortic regurgitation caused by sclerotic aortic valve changes, and also a mobile, low-echoic, 40 × 10-mm restiform lesion on the left atrial septum near the foramen ovale (Fig. 1). We suspected trapped thrombus in the foramen ovale. Computed tomograms showed no cerebral infarction, thrombus in the pulmonary artery or deep veins,
A 76-year-old woman with a history of coronary artery disease, end-stage renal disease, and intermittent 2nd-degree (Mobitz II) atrioventricular (AV) block was admitted after an unwitnessed fall. She reported no symptoms during the episode. She had an Accent™ DR RF dual-chamber pacemaker (model PM2210) with Tendril™ STS Model 2088TC atrial and ventricular bipolar leads (all from St. Jude Medical, part of Abbott). The pacemaker was set in DDDR mode (pacing rate, 60–120 beats/min). Its programmed paced AV interval was 200 ms, and the sensed interval, 190 ms. Its Ventricular AutoCapture™ Pacing System, atrial and ventricular SenseAbility™ AutoSense function, and ventricular
