left bundle branch block A 60-year-old man presented with chest pain and palpitations. His troponin level was normal, and electrocardiography showed left bundle branch block (LBBB) (Fig. 1). Echocardiogram demonstrated moderate left ventricular systolic dysfunction, and no mass was clearly reported (Fig. 2). His invasive coronary angiogram was normal. Cardiac magnetic resonance imaging showed a solitary, ovoid (5 × 2.7 cm), well-circumscribed intramural mass in the mid- to apical lateral segments. The lesion showed low intensity relative to the myocardium on T1w images (Fig. 3A) and T2w imagesAbbreviations and Acronyms
Case Description
right ventricular A woman in her forties was referred to University Hospital Kyoto Prefectural University of Medicine for further examination and evaluation of heart disease. She was diagnosed with ventricular septal defect at birth and had been followed yearly since then. She had no history of hypertension and took no medications. She had no significant family history, such as sudden death or ventricular arrhythmia. Although she reported that she sometimes reported dyspnea, it seemed not to be reproducible. She did not report leg edema or general fatigue. Jugular venous distension was not observed. TransthoracicAbbreviations and Acronyms
Case Description
A 61-year-old male patient, who was previously healthy, presented to the emergency department with weakness. He had tachycardia at 180/minute with normal blood pressure. An electrocardiogram revealed atrial flutter. He was started on an intravenous diltiazem drip. Transthoracic echocardiography revealed 2 hyperechoic masses within the left ventricle; 1 measured 1.2 × 0.74 cm, and the other was 3 × 1.4 cm. The right ventricle also showed a mass of 1.1 × 1 cm (Fig. 1). The masses were suggestive of possible metastatic disease. A computed tomographic scan of the chest, abdomen, and pelvis showed diffuse metastaticCase Description
A 58-year-old White man with no known medical history initially presented to the emergency department for fatigue and was ultimately diagnosed with COVID-19. He was in stable condition and discharged to quarantine at home. He returned to the emergency department 2 weeks later with a chief report of progressive pain and swelling of his legs. Initial vitals were remarkable for a heart rate of 115/minute. Physical examination revealed edematous and erythematous lower extremities with weeping wounds. Laboratory workup was remarkable for a white blood cell count of 12.7 × 1,000/μL, platelet count of 81 × 1,000/μL, troponin ICase Description
perivalvular leak ventricular septal defect 14-year-old girl was referred to the cardiology clinic for worsening dyspnea and lower-limb edema. She had a history of Ebstein's malformation associated with bicuspid aortic valve, coarctation of aorta, perimembranous ventricular septal defect (VSD), and subvalvular fibromuscular aortic stenosis. She had undergone coarctation of aorta repair, subaortic fibromuscular stenosis resection, and VSD patch closure during the first months of her life. A Doppler color echocardiogram showed signs of Ebstein's disease (Carpentier type C) (Fig. 1) with severe tricuspid valve incompetence, mild left ventricular dysfunction (42%), bicuspidAbbreviations and Acronyms
Case Description
computed tomography right coronary artery A 35-year-old woman with Marfan syndrome presented to the emergency department reporting a 2-day history of chest pain and dyspnea. Transthoracic echocardiography revealed grade IV/IV aortic valve regurgitation, a markedly dilated aortic root, increased systolic and diastolic internal dimensions (49/67 mm) of the left ventricle, and a mild decrease in left ventricular ejection fraction (51%) in the Teicholz measurement. An enhanced computed tomography (CT) scan showed a 9.0-cm diameter in the sinotubular junction and a 9.9-cm diameter in the sinus level. Computed tomography coronary angiograms showed severe proximalAbbreviations and Acronyms
Case Description
A 10-month-old infant presented with a hard chest wall mass, palpable at the level of the left fourth rib, and was found to have a bifid left fourth rib on chest radiography (Fig. 1). This was later confirmed using 3-dimensional chest computed tomography reconstruction (Fig. 2), which also ruled out any other masses in the chest wall or in the pleural or pericardial spaces. Bifid rib isCase Description
Comment
Surgical approaches for mitral valve exploration vary, with the preferred approach being via the interatrial groove. Data on whether the interatrial groove approach can be used for mitral valve surgery in patients with a previously implanted Amplatzer septal occluder (ASO) (St Jude Medical, an Abbott company) are extremely limited. The authors performed mitral valve surgery using the transatrial septal approach on 2 patients following explantation of an ASO, which significantly impedes the interatrial groove approach. Concomitant surgical procedures with mitral valve replacement, removal of the ASO, and closure of an atrial septal defect with a patch significantly prolonged the cross-clamp and cardiopulmonary bypass durations, which is the reason for intraoperative low cardiac output syndrome. An intra-aortic balloon pump and venoarterial extra-corporeal membrane oxygenation were used in these 2 patients because of low cardiac output syndrome. When planning mitral valve surgery in patients with a previously implanted ASO, the device precludes the interatrial groove approach and can produce an unpredictable clinical scenario.Abstract
coronary artery disease left ventricular noncompaction A 51-year-old man without cardiac risk factors was referred to the hospital after a complete left bundle block was discovered on an electrocardiogram; he had a 6-month history of fatigue and mild exertional dyspnea. Transthoracic echocardiogram showed a spongiform appearance of the left ventricle, with prominent hypertrabeculations in lateral and apical walls (Fig. 1A and B). The left ventricle was dilated and hypokinetic (diastolic diameter, 70 mm; ejection fraction, 25%).Abbreviations and Acronyms
Case Report
Blunt traumatic injuries to the brachiocephalic artery require surgical management. The operative technique used depends on the location of the injury, the patient's hemodynamic stability, and the surgeon's experience. Perfusion strategy can facilitate vascular control of the aortic arch and branch vessels. This report presents an urgent repair of a proximal posterior blunt traumatic brachiocephalic artery injury under circulatory arrest, with an excellent outcome.Abstract
This report involves a young woman with isolated cardiac paraganglioma that was diagnosed using 68Gallium-labeled [1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid]-1-NaI3-octreotide positron emission tomographic scintigraphy. For the preoperative evaluation, multimodality imaging accurately described the anatomic location of the tumor and its relationship with the surrounding tissues. The patient underwent successful surgical resection of the tumor along with right coronary artery bypass grafting. The 2-month follow-up scintigraphy was normal. Next-generation sequencing evaluation revealed a novel germline mutation for the succinate dehydrogenase subunit B gene.Abstract
Renal vein thrombosis after kidney transplant is a rare but potentially graft-threatening event. As sequelae of this complication can range from brief acute kidney injury to total graft failure, it is necessary to maintain close clinical observation postoperatively. If posttransplant renal vein thrombosis does occur, recanalization may be attempted with mechanical thrombectomy, suction thrombectomy, or explantation and reimplantation of the allograft. This is a novel report of the successful use of suction thrombectomy to treat renal vein thrombosis in a pediatric kidney transplant.Abstract
Left main coronary artery aneurysm is an unusual complication of infective endocarditis. Although this type of aneurysm is often asymptomatic, rupture and thrombus formation that result in myocardial infarction are known complications; therefore, prompt recognition and surgical intervention are warranted. This report describes a patient who presented with a giant left main coronary artery aneurysm 3.5 years after being treated for 4-valve endocarditis. The management and technical aspects of this challenging case are discussed here.Abstract
Sternal cleft accompanied by pectus excavatum is a rare type of congenital anomaly of the chest wall. Surgical correction is a suitable approach to restore the heart, large vessels, and respiratory dynamics early. This is a report of the successful surgical correction of upper sternal cleft anomaly accompanied by pectus excavatum in a child. The pectus excavatum was corrected without the use of any prosthesis. The cleft was closed by primary approximation with enough dissected pectoralis major muscle and partial thymectomy, mobility, and flexibility ensured by pectus correction. The integrity of the sternum and the chest wall was normal at the end of the 12-month follow-up period.Abstract
Because vascular geometric change during the long-term process of cardiac chamber remodeling in heart failure is usually unpredictable after coronary stenting, the risk of acquired metallic stent fracture can persist. This rare but possible complication could be minimized with the implantation of bioresorbable vascular scaffold because of its unique properties. Here, the authors report on 1 patient with heart failure who received optical coherence tomography evaluation between 3 and 3.5 years after bioresorbable vascular scaffold implantation. Measurement of the discernible struts of bioresorbable vascular scaffold provided evidence of coronary longitudinal remodeling without serious risk of complications related to metallic stent fracture resulting from cardiac remodeling.Abstract
A 67-year-old woman experienced pruritus, an urticarial rash, and acute, pressure-like chest pain following an insect sting. Initial electrocardiographic findings were notable for ST-segment elevations in the inferior leads without reciprocal changes, but a follow-up electrocardiogram showed pronounced ST-segment elevations in the inferior leads with reciprocal changes. Her troponin I level peaked at 3,053 pg/mL, and she was transferred to a large academic center for percutaneous coronary intervention. Balloon angioplasty was performed for 95% thrombotic occlusion of the mid–right coronary artery, and a drug-eluting stent was placed. The patient's presentation was consistent with type II Kounis syndrome.Abstract
Between 0.1% and 0.3% of all aortic dissections occur during pregnancy. Arterial hypertension, connective tissue disorders, and congenital cardiovascular anomalies—including bicuspid aortic valves—are well-known risk factors. The causality between pregnancy and aortic dissection is unclear, but there have been some observations that COVID-19 illness may increase the risk. This report describes a pregnant woman at 34 weeks of gestation who had a bicuspid aortic valve and experienced an acute aortic dissection while ill with COVID-19 pneumonia. Computed tomography confirmed a type A aortic dissection and bilateral patchy pulmonary opacities. Cesarean delivery was performed, followed by replacement of the aortic valve with a mechanical aortic prosthesis and reconstruction of the ascending aorta and hemiarch. The intraoperative course was uneventful, and the patient was successfully weaned from mechanical ventilation after 51 hours. COVID-19 during pregnancy seems to increase the risk for aortic dissection, although there is no evidence base for an association. Because guidelines for diagnosis and treatment in such complex cases are lacking, care from a multidisciplinary team is crucial for successful outcomes.Abstract
Measurement of fractional flow reserve (FFR) is the gold standard for determining the physiologic significance of coronary artery stenosis, but newer software programs can calculate the FFR from 2-dimensional angiography images. A retrospective analysis was conducted using the records of patients with intermediate coronary stenoses who had undergone adenosine FFR (aFFR). To calculate the computed FFR, a software program used simulated coronary blood flow using computational geometry constructed using at least 2 patient-specific angiographic images. Two cardiologists reviewed the angiograms and determined the computational FFR independently. Intraobserver variability was measured using κ analysis and the intraclass correlation coefficient. The correlation coefficient and Bland-Altman plots were used to assess the agreement between the calculated FFR and the aFFR. A total of 146 patients were included, with 95 men and 51 women, with a mean (SD) age of 61.1 (9.5) y. The mean (SD) aFFR was 0.847 (0.072), and 41 patients (27.0%) had an aFFR of 0.80 or less. There was a strong intraobserver correlation between the computational FFRs (r = 0.808; P < .001; κ = 0.806; P < .001). There was also a strong correlation between aFFR and computational FFR (r = 0.820; P < .001) and good agreement on the Bland-Altman plot. The computational FFR had a high sensitivity (95.1%) and specificity (90.1%) for detecting an aFFR of 0.80 or less. A novel software program provides a feasible method of calculating FFR from coronary angiography images without resorting to pharmacologically induced hyperemia.Background
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Aortic valve replacement improves survival for patients with low-gradient aortic valve stenosis, but there is a paucity of data on postoperative quality of life for this population. In a single-center retrospective analysis of 304 patients with severe aortic valve stenosis who underwent transcatheter aortic valve replacement, patients were divided into 4 groups based on mean pressure gradient, left ventricular ejection fraction, and stroke volume index. Using the Kansas City Cardiomyopathy Questionnaire-12, quality of life was assessed immediately before and 1 month after transcatheter aortic valve replacement. Most patients in the low-flow, low-gradient group were men; this group had higher relative rates of cardiovascular disease and type 2 diabetes than the paradoxical low-flow, low-gradient group; the normal-flow, low-gradient group; and the high-gradient group. All-cause mortality did not differ significantly among the groups at 1 month after surgery, and all groups experienced a significant improvement in quality-of-life scores after surgery. The mean improvement was 27 points in the low-flow, low-gradient group, 25 points in the paradoxical low-flow, low-gradient group, 30 points in the normal-flow, low-gradient group, and 30 points in the high-gradient group (all P < .001). Quality of life improves significantly across all subgroups of aortic valve stenosis after trans-catheter aortic valve replacement, regardless of flow characteristics or aortic valve gradients.Abstract
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Obstructive sleep apnea (OSA) is common in middle-aged adults and has been associated with various cardiovascular disorders; endothelial dysfunction may play a role in the pathogenesis of these disorders in patients with OSA. Endothelial cell specific molecule-1 (endocan) is a marker of vascular pathology, which is correlated with endothelial dysfunction. This study investigates the relationship between serum endocan levels and OSA severity in patients with hypertension. A retrospective review included 48 patients with OSA and hypertension but without conventional cardiovascular risk factors, and 67 patients with OSA who did not have hypertension. The correlation between serum endocan levels and the apnea-hypopnea index (AHI) was investigated in both groups. There was a significant correlation between the serum endocan level and the AHI in patients with OSA and hypertension (r = 0.308; P = .033), but there was no such correlation in patients without hypertension (r = 0.193; P = .118). However, when both groups were combined (ie, all patients with OSA), there was a significant correlation between serum endocan levels and the AHI (r = 0.228; P = .014). On multiple logistic regression analysis, endocan levels were independent predictors of OSA severity in patients with OSA and hypertension (P = .029). In patients with OSA and hypertension, serum endocan levels are significantly correlated with the AHI. Measurement of endocan may have a place in evaluating patients with OSA and hypertension for adverse cardiovascular events, and they may even help to guide OSA therapy for these patients.Background
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Do Patients With Arterial Occlusive Disease of Different Etiologies Benefit Equally From Cilostazol?
Cilostazol is a guideline-recommended drug that improves intermittent claudication and quality of life in patients with chronic atherosclerotic peripheral arterial disease. The drug is used for most etiologies of arterial occlusive diseases in clinical practice. This study aimed to evaluate whether patients benefit equally from cilostazol regardless of etiology. Patients on cilostazol were divided into 4 groups according to arterial occlusive disease etiology: (1) atherosclerosis, (2) diabetic angiopathy, (3) embolism/thrombosis, and (4) Buerger disease. Patients' maximum walking distance, ankle-brachial index score and distal tissue oxygen saturation (Sto2), clinical improvement onset time, ability to reach maximum benefit time, vascular surgeries, and wounds were compared before they started cilostazol and after 12 months. Results were evaluated at a statistical significance of P < .05. In 194 patients, 307 target extremities were evaluated in the 4 disease groups. After cilostazol use, maximum walking distance, ankle-brachial index score, and distal Sto2 increased significantly in all groups (P < .001), but distal Sto2 in the diabetic angiopathy and Buerger disease groups was significantly lower than in the atherosclerosis group (P < .001). Ankle-brachial index and distal Sto2 differences in the Buerger disease group were significantly lower (both P < .001). The vascular surgery counts decreased significantly in the atherosclerosis and embolism/thrombosis groups (P = .019 and P = .004, respectively). Patients with nonatherosclerotic arterial occlusive disease also benefit from cilostazol, but patients with Buerger disease or diabetic angiopathy seem to benefit less. Combining cilostazol with anticoagulant or antiaggregant agents and closer monitoring of these patients may produce better results.Abstract
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The optimal treatment strategy for patients with severe carotid artery disease undergoing coronary artery bypass grafting is still problematic. The important question is whether it is necessary to treat significant carotid disease in patients who have undergone coronary artery bypass grafting. This study analyzed short- and midterm results after same-day carotid artery stenting and coronary artery bypass grafting. From 2013 to 2020, a total of 69 patients were enrolled in the study. Same-day carotid artery stenting and coronary artery bypass grafting were performed in all patients. The study's primary end points were the evaluation rate of stroke, myocardial infarction, and death within short- and midterm periods after the procedures. The 30-day mortality was 0%. The occurrences of perioperative adverse events, namely stroke, myocardial infarction, and transient ischemic attack, were 1 (1.4%), 1 (1.4%), and 4 (5.8%), respectively. Mean (IQR) follow-up time was 28 (IQR, 17–43) months. Six (8.8%) patients died during this period. Fatal stroke was registered in 2 cases, and 1 patient experienced a disabling stroke with a fatal outcome. The other 3 patients died because of chronic renal disease, a traffic accident, and for an unknown reason, respectively. Midterm survival in the group was 91.2%. The study showed that same-day carotid artery stenting and coronary artery bypass grafting for concomitant carotid and coronary disease treatment could be a promising and feasible therapeutic strategy.Abstract
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The anomalous left coronary artery from the pulmonary artery is a rare congenital disease. Early surgical reconstruction is mandatory to prevent adverse cardiac events. Direct coronary button transfer, vein graft interposition, ligation, and coronary artery bypass construction are the most commonly used techniques. This case report presents a modified technique of Dacron graft interposition and reimplantation anomalous left coronary artery from the pulmonary artery on the ascending aorta.Abstract
Diclofenac is a widely used analgesic, anti-inflammatory, antipyretic drug. In several case reports, its use was associated with the occurrence of Kounis syndrome. The aim of this review was to investigate and summarize published cases of Kounis syndrome suspected to be associated with the use of diclofenac. Electronic searches were conducted in PubMed/MEDLINE, Scopus, Web of Science, Google Scholar, and the Serbian Citation Index. Twenty publications describing the 20 patients who met inclusion criteria were included in the systematic review. Specified patient ages ranged from 34 to 81 years. Eighteen (90.0%) patients were male. Five patients (25.0%) reported a previous reaction to diclofenac. Reported time from the used dose of diclofenac to onset of the first reaction symptoms ranged from immediately to 5 hours. Diclofenac caused both type I and type II Kounis syndrome, with the presence of various cardiovascular, gastrointestinal, dermatologic, and respiratory signs and symptoms. Most patients experienced hypotension (n = 15 [75.0%]) and chest pain (n = 12 [60.0%]). The most frequently reported finding on electrocardiogram was ST-segment elevations (n = 17 [85.0%]). Coronary angiogram showed normal coronary vessels in 9 patients (45.0%), with some pathologic findings in 8 patients (40.0%). Clinicians should be aware that Kounis syndrome may be an adverse effect of diclofenac. Prompt recognition and withdrawal of the drug, with treatment of both allergic and cardiac symptoms simultaneously, is important.Abstract
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The impact of chronic kidney disease (CKD) on adverse cardiovascular outcomes after percutaneous coronary intervention in patients with diabetes mellitus (DM) is still unclear. This study aimed to systematically assess evidence on this topic. The PubMed, Embase, and CENTRAL databases were searched for studies comparing mortality, myocardial infarction (MI), or revascularization outcomes between patients with DM with and without CKD. In 11 studies, the presence of CKD was associated with significantly increased risk of early all-cause mortality (risk ratio [RR], 3.45; 95% CI, 3.07–3.87; I2 = 0%; P < .001), late all-cause mortality (RR, 2.78; 95% CI, 1.92–4.02; I2 = 83%; P < .001), cardiac mortality (RR, 2.90; 95% CI, 1.99–4.22; I2 = 29%; P < .001), and MI (RR, 1.40; 95% CI, 1.06–1.85; I2 = 13%; P = .02) compared with no CKD. There was no difference in the risk of any revascularization between those with and without CKD. Analysis of adjusted hazard ratios (HRs) indicated significantly increased risk of mortality (HR, 2.64; 95% CI, 1.91–3.64; I2 = 0%; P < .001) in the CKD group but only a nonsignificant tendency of increased MI (HR, 1.59; 95% CI, 0.99–2.54; I2 = 0%; P = .05) and revascularization (HR, 1.24; 95% CI, 0.94–1.63; I2 = 2%; P = .12) in the CKD group. The presence of CKD in patients with DM significantly increases the risk of mortality and MI. However, CKD had no impact on revascularization rates.Abstract
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The medical community was saddened to learn about the passing of Dr Tomas Klima on July 7, 2022. Dr Klima was a pathologist at Baylor St Luke's Medical Center (formerly St Luke's Episcopal Hospital) and a long-time member of the Texas Heart Institute (THI) family. Dr Klima was born in Baltimore, Maryland in 1931, while his father, a Czech physician, was completing a public health fellowship at Johns Hopkins University Hospital. Dr Klima's mother was Jewish, and his father was Catholic. He returned to Czechoslovakia with his parents when he was 10 months old. Both of his
Ray C. Fish (1902–1962) was a philanthropist and a leading figure in Houston's natural gas industry. 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 self-knowledge and keep the American dream alive. After its founder died 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 contributions to cardiovascular medicine and surgery.
In January 1974, The Texas Heart Institute printed 2000 copies of Cardiovascular Diseases, Bulletin of the Texas Heart Institute, and mailed them to local physicians. The first issue included 10 short articles written by our medical staff and researchers who had gained a wealth of knowledge and experience during the decade following the Institute's founding in 1962. The editor, John C. Norman, MD, stated the vision for the journal in the foreword:
The purpose of the Bulletin is to provide an accessible, responsive, and expedient forum for brief and thoughtful topics of current interest in cardiovascular diseases,
