Texas Heart Institute Journal Volume 48: Issue 5

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CLINICAL INVESTIGATION

Surgical Treatment of Valvular Heart Disease in Nigeria: A 6-Year Experience

MBBS, FWACS,

MD, FWACS, and

PharmD

Surgical treatment of valvular heart disease in Nigeria, the most populous country in sub-Saharan Africa, is adversely affected by socioeconomic factors such as poverty and ignorance. To evaluate our experience in this context, we identified all patients who underwent surgery for acquired or congenital valvular heart disease at our Nigerian center from February 2013 through January 2019. We collected data from their medical records, including patient age and sex, pathophysiologic causes and types of valvular disease, surgical treatment, and outcomes. Ninety-three patients (43 males [46.2%]; mean age, 38.9 ± 10.0 yr [range, 11–80 yr]) underwent surgical treatment of a total of 122 diseased valves, including 72 (59.0%) mitral, 26 (21.3%) aortic, 21 (17.2%) tricuspid, and 3 (2.5%) pulmonary. The most prevalent pathophysiologic cause of disease was rheumatic (87 valves [71.3%]), followed by functional (20 [16.4%]), congenital (8 [6.6%]), degenerative (5 [4.1%]), and endocarditic (2 [1.6%]). All 3 diseased pulmonary valves had annular defects associated with congenital disease. Surgical treatment included mechanical prosthetic replacement of 92 valves (75.4%), surgical repair of 29 (23.8%), and bioprosthetic replacement of 1 (0.8%). We conclude that, in Nigeria, valvular disease is mainly rheumatic, affects mostly younger to middle-aged individuals, and is usually treated with prosthetic replacement

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REVIEW

Left Ventricular Ballooning Patterns in Recurrent Takotsubo Cardiomyopathy: A Systematic Review and Meta-analysis of Reported Cases

MD,

PhD,

MD,

MD, and

DOI: 10.14503/THIJ-20-7223

Recurrent takotsubo cardiomyopathy (TTC) and the clinical profiles and outcomes of patients have not been fully evaluated, nor has the effect of left ventricular ballooning pattern. After searching the medical literature for reports of patients with recurrent TTC, we identified 84 articles with 101 case descriptions. We divided the cases into those with only apical left ventricular ballooning patterns at recurrence (typical, n=60), and those with at least one midventricular or basal ballooning pattern (atypical, n=41). We then compared their clinical profiles and outcomes.

The groups were similar in terms of baseline demographic characteristics, presence and types of triggers, use of heart failure medications at TTC recurrence, electrocardiographic changes at presentation, initial left ventricular ejection fractions, timespans between recurrent TTC episodes, and recovery times after each event. However, patients in the atypical group had significantly fewer severe adverse events (cardiogenic shock and cardiac arrest) than did those in the typical group, with an estimated 63% lower odds (adjusted odds ratio=0.37; 95% CI, 0.14–0.97; P=0.039). Survival to hospital discharge was statistically similar but lower in the typical group (n=53; 88.3%) than in the atypical group (n=24; 96%).

Our results suggest that left ventricular ballooning patterns influence clinical outcomes, and that outcomes are more favorable in patients with recurrent TTC who have atypical left ventricular ballooning patterns.

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CASE REPORTS

Endovascular Treatment of Acquired Atheromatous Postsubclavian Aortic Coarctation

MD,

MD, and

DOI: 10.14503/THIJ-20-7270

Coral reef aorta is a rare calcifying obstructive disease that involves the thoracoabdominal aorta. Similar presentations in the postsubclavian aorta may result in acquired atheromatous aortic coarctation leading to systemic hypertension and heart failure. The associated calcification makes surgical anatomic or extraanatomic bypass and thromboendarterectomy challenging. Extensive circumferential calcification often precludes endovascular intervention. We present the case of a 25-year-old man with an acquired atheromatous coarctation of the postsubclavian aorta who underwent successful endovascular treatment with use of a balloon-expandable covered stent.

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IMAGES IN CARDIOVASCULAR MEDICINE

Echocardiography and Nuclear Scintigraphy in the Diagnosis of Transthyretin Cardiac Amyloidosis

MD,

MD, and

DOI: 10.14503/THIJ-20-7279

A 94-year-old man presented with worsening dyspnea and orthopnea of 4 days' duration. Physical examination revealed jugular venous distention, diminished breath sounds, and pitting edema of the lower extremities. An electrocardiogram (Fig. 1) revealed conduction abnormalities, low QRS voltage, and an old myocardial infarction; a chest radiograph (Fig. 2) revealed cardiomegaly. These findings prompted us to obtain speckle-tracking echocardiograms (Figs. 3A–B), which revealed speckling of thickened myocardium, normal left ventricular (LV) size, biatrial enlargement, and a plethoric inferior vena cava. A strain imaging map (Fig. 3C) revealed relative apical sparing of LV

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CASE SERIES

Atypical ST-Segment-Elevation Myocardial Infarction Presentation in Patients With COVID-19 at a High-Volume Center in New York City

MD,

MD, and

DOI: 10.14503/THIJ-20-7446

Atypical presentations of ST-segment-elevation myocardial infarction (STEMI) have been reported in patients who have COVID-19. We have seen this occurrence in our center in Bronx, New York, where multitudes of patients sought treatment for the coronavirus. We studied the prevalence of atypical STEMI findings among patients with COVID-19 who presented during the first 2 months of the pandemic.

Consistent with previous reports, 4 of our 10 patients with COVID-19 and STEMI had no identifiable culprit coronary lesion; rather, they often had diffuse ST-segment elevations on surface electrocardiograms along with higher levels of D-dimer and inflammatory markers. In contrast, 32 of 33 patients without COVID-19 (97%) had a culprit lesion. The patients with COVID-19 and a culprit lesion more often needed thrombectomy catheterization and administration of glycoprotein IIb/IIIa inhibitors.

Our study confirms that patients with COVID-19 often have atypical STEMI presentations, including the frequent absence of a culprit coronary lesion. Our findings can help clinicians prepare for these atypical clinical presentations.

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Focus on ECGs: Case #27

Electrocardiographic Changes in a Man With Acute Pancreatitis: A Myocardial Infarction?

MD,

MD, and

DOI: 10.14503/THIJ-20-7465

A 69-year-old man with a history of heavy alcohol use presented with abdominal pain and was diagnosed with alcohol-induced acute pancreatitis. On admission, he had not reported chest pain, palpitations, or dyspnea. Initial laboratory tests showed a lactic acid level of 8.3 mmol/L (normal, 0.5–2.2 mmol/L), normal renal function, and normal cardiac enzyme levels. An electrocardiogram (ECG) on admission showed sinus tachycardia. His symptoms and lactic acidosis resolved after aggressive fluid resuscitation and bowel rest. Two days later, sudden-onset dyspnea, tachycardia, and hypoxia necessitated the administration of 2 L of supplemental oxygen. A chest radiograph showed acute pulmonary edema. The

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NEW HORIZONS IN PULMONARY EMBOLECTOMY

Response Team Management of Acute Serious Pulmonary Embolism

DO and

MD, MSc

DOI: 10.14503/THIJ-21-7558

Pulmonary embolism (PE) is underrecognized and undertreated by clinicians, possibly because patients have widely varying clinical presentations and because different physician specialties are involved. In addition, there is little consensus about first-line therapies.¹ Compounding these challenges are institutional and systemic impediments to delivering appropriate, timely therapy. These include fear of complications, failure to recognize potential benefits of treatment and to integrate data in real time, and physician bias. The collective consequence is a treatment gap in which few patients with PE receive appropriate advanced therapy, even when clear indicators such as hypotension and right ventricular dysfunction are present.

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Large-Bore Aspiration Thrombectomy: Catalyst for a Revolution in Treating Pulmonary Embolism

DOI: 10.14503/THIJ-21-7570

Technological advances are setting the stage for much-needed innovations in treating pulmonary embolism (PE). Pulmonary embolism is a leading cardiovascular cause of death; the data in the medical literature are unclear, but according to some estimates, as many as 900,000 people experience PE and up to 100,000 die from it yearly in the United States. In addition, fatal PE events can be miscategorized as myocardial infarction (MI) or sudden cardiac death. Additional patients have chronic disabling symptoms after recovering from their acute PE event.

Improvements in Pulmonary Embolism Mortality Rates Trail Those in Myocardial Infarction

Whereas treatments for MI and

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Mechanical Thrombectomy of Pulmonary Emboli With Use of the Indigo System and Lightning 12 Intelligent Aspiration

MD, MS

DOI: 10.14503/THIJ-21-7571

Contemporary treatments for pulmonary embolism (PE) fall into 4 broad categories: systemic anticoagulation, systemic thrombolysis (ST), catheter-directed thrombolysis (CDT), and mechanical thrombectomy (MT). In general, MT has several advantages over CDT and ST in the treatment of submassive and potentially massive PE. This article describes a promising device that enables MT, and an illustrative case is presented.

In the SEATTLE II (Submassive and Massive Pulmonary Embolism Treatment With Ultrasound Accelerated Thrombolysis Therapy) trial, which evaluated CDT, thrombolytic agents were associated with a >10% rate of bleeding complications.¹ The results in an ST trial, PEITHO (Pulmonary Embolism Thrombolysis Study),

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Novel Pharmacomechanical Thrombolysis for Treating Intermediate-Risk Acute Pulmonary Embolism: The Bashir Endovascular Catheter

MBBS,

BS,

DO,

MD,

MD, and

DOI: 10.14503/THIJ-21-7589

Acute pulmonary embolism (PE) is the third most common cause of cardiovascular death.¹ Although there is little debate about how to manage low- or high-risk acute PE, therapeutic strategies for patients who have intermediate-risk acute PE are continuously evolving. This condition is associated with a substantial risk of death at 90 days and with possible progression to acute hemodynamic decompensation. In the Fibrinolysis for Patients with Intermediate Risk Pulmonary Embolism (PEITHO) trial,² normotensive patients were divided into 2 groups: one group was given tenecteplase plus heparin, and the other, placebo plus heparin. In the anticoagulation-only group,

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All Issues

Surgical Treatment of Valvular Heart Disease in Nigeria: A 6-Year Experience

Left Ventricular Ballooning Patterns in Recurrent Takotsubo Cardiomyopathy: A Systematic Review and Meta-analysis of Reported Cases

Endovascular Treatment of Acquired Atheromatous Postsubclavian Aortic Coarctation

Echocardiography and Nuclear Scintigraphy in the Diagnosis of Transthyretin Cardiac Amyloidosis

Atypical ST-Segment-Elevation Myocardial Infarction Presentation in Patients With COVID-19 at a High-Volume Center in New York City

Electrocardiographic Changes in a Man With Acute Pancreatitis: A Myocardial Infarction?

Response Team Management of Acute Serious Pulmonary Embolism

Large-Bore Aspiration Thrombectomy: Catalyst for a Revolution in Treating Pulmonary Embolism

Improvements in Pulmonary Embolism Mortality Rates Trail Those in Myocardial Infarction

Mechanical Thrombectomy of Pulmonary Emboli With Use of the Indigo System and Lightning 12 Intelligent Aspiration

Novel Pharmacomechanical Thrombolysis for Treating Intermediate-Risk Acute Pulmonary Embolism: The Bashir Endovascular Catheter

CHA₂DS₂-VASc Score Is Associated With Prognosis in Patients With Acute Ischemic Stroke Without Atrial Fibrillation

Long-Term Health-Related Quality of Life in Kawasaki Disease–Related Coronary Artery Aneurysm: A Large Single-Center Assessment in Nanjing, China

Coronary Myocardial Bridge Updates: Anatomy, Pathophysiology, Clinical Manifestations, Diagnosis, and Treatment Options

Shaping the Future of “Cardio-Kidney-Metabolic” Health: Insights From The Texas Heart Institute's 2024 Cardiometabolic Syndrome Conference

Analysis of Clinical Symptoms and Risk Factors Related to Functional Prognosis in Patients With Cardiogenic Stroke