Texas Heart Institute Journal Volume 49: Issue 3

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IMAGES IN CARDIOVASCULAR MEDICINE

Median Arcuate Ligament and Superior Mesenteric Artery Syndromes in a 28-Year-Old Man

BS and

A thin 28-year-old man presented at the emergency department with upper abdominal pain, nausea, and vomiting of many months' duration. His records showed multiple visits to emergency departments to seek prescribed narcotics. A computed tomographic angiogram revealed median arcuate ligament syndrome with celiac artery compression (Fig. 1A). Secondary dilation of the first and second parts of the duodenum (Fig. 1B) resulted from an acute (13.7°) superior mesenteric artery (SMA)-to-aortic angle (Fig. 1C). The duodenal compression by the SMA was consistent with SMA syndrome. The patient declined admission for further evaluation and definitive treatment and

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Iatrogenic Diversion of Superior Vena Cava Into Left Atrium

MD,

MD, and

DOI: 10.14503/THIJ-18-6947

A 72-year-old woman presented at our hospital with symptoms of a cerebrovascular accident (CVA). Her medical history included repair of a sinus venosus atrial septal defect (SVASD) at age 4, dual-chamber pacemaker placement for complete heart block at age 60, and multiple CVAs. Her blood oxygen content was 86% on room air, and cardiac auscultation revealed a soft systolic flow murmur at the left sternal edge. An electrocardiogram (ECG) showed paced rhythm with right bundle branch block (Fig. 1A), and a chest radiograph showed a pacemaker wire protruding into the left ventricle (LV) (Fig. 1B). On

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CLINICAL INVESTIGATION

Impact of Recent Acute Kidney Injury on Creatinine Clearance Estimation in Critically Ill Patients Undergoing Cardiac Surgery

PharmD,

PharmD, PhD,

PharmD, and

PharmD, MPH

DOI: 10.14503/THIJ-20-7382

Acute kidney injury (AKI), often present in critically ill patients and patients with cardiac dysfunction, may alter estimates of renal function. The impact of recent AKI on the accuracy of the Cockcroft-Gault creatinine clearance equation (CG-CrCl) before cardiac surgery is unknown.

This single-center, retrospective study included patients who underwent cardiac surgery from 1 January 2006 through 30 June 2012 and whose 24-hour urine creatinine clearance (24hr-CrCl) was measured in the intensive care unit before surgery. We evaluated CG-CrCl accuracy by calculating absolute differences between 24hr-CrCl and CG-CrCl estimates. Clinical impact was signified by discrepancies in United States Food and Drug Administration (FDA) renal impairment stage indicated by 24hr-CrCl versus CG-CrCl estimates. Acute kidney injury was evaluated by using Kidney Disease: Improving Global Outcomes criteria.

Of 161 patients, 93 (58%) had recent AKI: stage 1, 31 (33%); stage 2, 39 (42%); and stage 3, 23 (25%). In mL/min, the CG-CrCl overestimated 24hr-CrCl (absolute difference: total, −10 ± 25; no AKI, −7 ± 26; stage 1, −8 ± 17; stage 2, −16 ± 28; and stage 3, −10 ± 26; P=0.29). Renal impairment stages assigned by CG-CrCl did not match 24hr-CrCl in 70 (43%) of the 161 patients, especially those with recent AKI: no AKI, 24/68 (35%); stage 1, 13/31 (42%); stage 2, 23/39 (59%); and stage 3, 10/23 (43%).

The CG-CrCl consistently overestimated 24hr-CrCl in critically ill patients before cardiac surgery. Clinicians should use the CG-CrCl cautiously when estimating renal function and medication dosages in this population.

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CASE REPORTS

Supracardiac Total Anomalous Pulmonary Venous Return Repair in a 7-Month-Old Infant

MD,

MD, PhD, and

MD, PhD

DOI: 10.14503/THIJ-20-7393

Total anomalous pulmonary venous return is a congenital heart malformation characterized by anomalous pulmonary venous inflow to the right atrium. Surgical repair typically occurs during the first month of life, and survival beyond that age in untreated patients is unlikely. We report an extreme case of supracardiac total anomalous pulmonary venous return in an infant who survived 7 months despite atypical anomalous inflow without atrial-level communication and with right-to-left shunting only through a patent ductus arteriosus. We stabilized the patient's left-sided heart function before surgically repairing the anomalous venous return 2 months later. Three years postoperatively, the patient was well.

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Trousseau Syndrome in a 25-Year-Old Woman with Occult Colon Malignancy, Lynch Syndrome, and Chronic Thromboembolic Pulmonary Hypertension

MD,

MS,

MD, PhD,

MD,

MD, and

DOI: 10.14503/THIJ-20-7419

We present a rare case of thrombosis associated with an occult colon malignancy (Trousseau syndrome) in a 25-year-old woman who also presented with previously unidentified Lynch syndrome and acute-on-chronic thromboembolic pulmonary hypertension. Staged treatment included bilateral pulmonary endarterectomy under deep hypothermic circulatory arrest, followed 11 days later by laparoscopic subtotal colectomy and creation of a primary anastomosis. The patient tolerated both procedures well and recovered normal functional status. Final pathologic analysis of the resected colon mass revealed a pT3N0, stage IIA adenocarcinoma; no adjuvant therapy was administered. At her one-year follow-up visit, the patient was cancer-free, remained on lifelong apixaban anticoagulation, and was undergoing routine monitoring and genetic counseling. This case highlights the need for multidisciplinary management of a patient with severe chronic thromboembolic pulmonary hypertension and a concomitant malignancy.

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Recurrent Parotid Adenocarcinoma Presenting as Diffuse Myocardial Metastatic Disease

MD,

MD, MBA,

MD, and

MD, MBA

DOI: 10.14503/THIJ-20-7424

A 64-year-old man who had undergone treatment for left parotid adenocarcinoma presented with progressive exertional shortness of breath. Evaluation revealed metastatic invasion of the myocardium as a rare presentation of recurrent parotid adenocarcinoma. This case highlights the importance of using multimodal imaging methods in diagnostic evaluation and a collaborative multidisciplinary approach in managing patient care.

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Fatal Autonomic Dysfunction Due to Guillain-Barré Syndrome After Cardiac Surgery

MD and

DOI: 10.14503/THIJ-20-7439

Guillain-Barré syndrome, a rare peripheral neuropathy, appears to occur more often in patients who have recently undergone surgery than in the general population. However, the pathophysiologic relationship between surgery and Guillain-Barré syndrome is elusive. Few cases of Guillain-Barré syndrome after cardiac surgery have been reported. Autonomic dysfunction, a serious complication of Guillain-Barré syndrome, has not been previously reported after cardiac surgery.

We describe the case of a 71-year-old woman in whom the acute motor axonal neuropathic subtype of Guillain-Barré syndrome developed after mitral valve replacement. Despite plasmapheresis and intravenous immunoglobulin therapy, she died of complications from severe autonomic dysfunction 25 days postoperatively. Recognizing the potential cardiovascular involvement of Guillain-Barré syndrome is important, because patients who undergo cardiac surgery can be vulnerable to autonomic dysfunction in the early postoperative period.

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Renal Cell Carcinoma Metastasis to the Left Atrium

MBBS,

MBBS, MRCP, and

MBBS, FCPS

DOI: 10.14503/THIJ-20-7452

Only 13 cases of renal cell carcinoma metastasis to the left atrium of the heart have been described. We report the case of a man in his 50s who had undergone radical nephrectomy for renal cell carcinoma in 2006 and presented with amnesia at our neurology department in 2020. Magnetic resonance images of the brain showed metastatic lesions; subsequent computed tomograms of the chest, abdomen, and pelvis revealed a mass in the left atrium and multiple metastases in the lung, pleura, and pancreas. Our cardiologists advised against surgical removal of the left atrial mass because of a poor prognosis, so radiation therapy and immunotherapy were initiated instead.

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REVIEW

Gadolinium-Based Contrast Agents: Updates and Answers to Typical Questions Regarding Gadolinium Use

FRCP,

MD,

MD, and

PhD

DOI: 10.14503/THIJ-21-7680

Gadolinium-based contrast agents have expanded the diagnostic usefulness and capability of magnetic resonance imaging. Despite their highly favorable safety profile, these agents have been associated with nephrogenic systemic fibrosis in a small number of patients who have advanced kidney disease. Recently, trace amounts of gadolinium deposition in the brain and other organs have been reported after contrast exposure, even in patients with normal renal function. In this review, we provide a brief overview of recent updates and discuss typical clinical situations related to the use of gadolinium-based contrast agents.

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FOCUS ON ECGS: CASE #29

Abnormal Electrocardiogram in a Man Presenting With Dyspnea and Chest Pain

MD,

MD, and

DOI: 10.14503/THIJ-21-7697

A 70-year-old man with a history of smoking presented at the emergency department with dyspnea and a 24-hour history of intermittent chest pain that had acutely worsened. His heart rate was 128 beats/min; blood pressure, 114/81 mmHg; respiratory rate, 24 breaths/min; and oxygen saturation, 85% on 4 L of oxygen. He had bibasilar crackles and a grade 3/6 holosystolic murmur over the left sternal border. A basic metabolic panel showed nothing unusual. A coronavirus nasopharyngeal swab test was negative. The patient's N-terminal pro-brain-type natriuretic peptide level was 1,583 pg/mL (normal, <100 pg/mL), and his cardiac troponin I level was 39

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CORRESPONDENCE

Complex Anesthetic Management of “Simple” Transcatheter Aortic Valve Replacement

MD,

MD, and

DOI: 10.14503/THIJ-22-7863

To the Editor:

We read with great interest the article by Postalian and colleagues¹ about “simple” transcatheter aortic valve replacement (TAVR). The Division of Cardiovascular Anesthesia at the Texas Heart Institute (THI) provides care during all TAVR procedures performed at THI, and our team has achieved excellent results with use of simple TAVR. The authors mention conscious sedation as the anesthetic protocol used in most of the TAVR procedures included in their review. We consider it important to expand on the levels of anesthesia delivered during these procedures.

The term conscious sedation (CS) can be misinterpreted, given the

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Inquiries Arising From a Proposed Coronary Vasospasm–Induced Pathophysiologic Mechanism of Takotsubo Syndrome

DOI: 10.14503/THIJ-22-7875

To the Editor:

Angelini and colleagues¹ proposed that coronary vasospasm (CV) is the underlying pathophysiologic mechanism of takotsubo cardiomyopathy (TTC), which prompts the following questions and considerations:

Blood catecholamine levels are only modestly elevated in TTC; however, they may be much higher at the onset of TTC, after which they drop precipitously because of their short half-life.²
High-dose catecholamine administration in animal models of TTC may be justified (equivalent to pheochromocytoma-triggered TTC, characterized by massive catecholamine levels).
Consequent to the above, TTC and “catecholamine toxicity” precipitated by pheochromocytoma and leading to TTC are not currently considered

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All Issues

Median Arcuate Ligament and Superior Mesenteric Artery Syndromes in a 28-Year-Old Man

Iatrogenic Diversion of Superior Vena Cava Into Left Atrium

Impact of Recent Acute Kidney Injury on Creatinine Clearance Estimation in Critically Ill Patients Undergoing Cardiac Surgery

Supracardiac Total Anomalous Pulmonary Venous Return Repair in a 7-Month-Old Infant

Trousseau Syndrome in a 25-Year-Old Woman with Occult Colon Malignancy, Lynch Syndrome, and Chronic Thromboembolic Pulmonary Hypertension

Recurrent Parotid Adenocarcinoma Presenting as Diffuse Myocardial Metastatic Disease

Fatal Autonomic Dysfunction Due to Guillain-Barré Syndrome After Cardiac Surgery

Renal Cell Carcinoma Metastasis to the Left Atrium

Gadolinium-Based Contrast Agents: Updates and Answers to Typical Questions Regarding Gadolinium Use

Abnormal Electrocardiogram in a Man Presenting With Dyspnea and Chest Pain

Complex Anesthetic Management of “Simple” Transcatheter Aortic Valve Replacement

Inquiries Arising From a Proposed Coronary Vasospasm–Induced Pathophysiologic Mechanism of Takotsubo Syndrome

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