Search

Cardiac sarcoidosis (CS) overlaps in clinical presentation with arrhythmogenic right ventricular cardiomyopathy and shares phenotypic classification, including the presence of epsilon waves. The presence of conduction disease is seen exclusively in CS, as an important phenotypic difference. We present a case of ventricular tachycardia and epsilon waves due to CS, without conduction disease. (Level of Difficulty: Intermediate.), Central Illustration

The HeartMate 3 (HM3) left ventricular assist device (LVAD) (Abbott, Inc, Chicago, Ill) is a fully magnetically levitated centrifugal implantable pump used to treat patients with chronic heart failure. The MOMENTUM (Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy With HeartMate 3) trial demonstrated that patients treated with the HM3 experienced reduced need for reoperation for LVAD replacement compared with a control group receiving an axial flow design, Heartmate II (Abbott, Inc). However, there are few reports of using HM3 as the replacement pump in patients who already are supported by a durable LVAD and experience a device-related complication necessitating replacement.An institutional LVAD database was used to identify 19 consecutive patients who underwent pump replacement to HM3 (group 1) versus 85 consecutive control patients who underwent pump replacement to either Heartmate II or HeartWare Ventricular Assist Device (Medtronic Inc, Minneapolis, Minn) (group 2), at a single institution from January 2010 to August 2018. Patient baseline characteristic and outcomes were obtained from a prospectively maintained database. The primary endpoint was a composite of freedom from death or need for another replacement surgery.There was no difference between the groups in heart failure etiology, indication for replacement, as well as the average days on the previous pump or the type of previous pump. The HM3 group did have a significantly greater body mass index (37 vs 31.6 P = .01), a greater number of previous LVAD implants (36.8% vs 5.9%, had 2 previous LVADs, P .001), and a greater number of previous sternotomies (31.6% vs 7.1%, had 3 previous sternotomies, P = .001). No difference was found between the groups in terms of postoperative adverse event rates. With regards to the primary endpoint, the patients with HM3 replacements (group 1) versus group 2 experienced significantly greater freedom from either death or need for another replacement during the follow-up period (P = .039). During follow-up, there were no thrombosis events for the patients who received replacement with HM3.LVAD replacement with HM3 can be performed safely and may be considered as the pump of choice in patients requiring LVAD replacement.

Background Ventricular assist devices (VADs) are increasingly used for the management of end-stage heart failure, but infection is a complication that has not been thoroughly studied. The purpose of our study was to compare patients who had surgical debridement vs. medical therapy alone for VAD-related/specific infections. Methods We performed a retrospective chart review on patients at Duke University Hospital (DUH) from 2015 to 2017. Patients with VAD-related/specific infections were included, per 2011 ISHLT definitions. We reviewed electronic medical records for demographics, VAD implantation data, infectious episodes, surgical debridements and mortality. Descriptive statistics compared patients with and without debridement and compared with and without relapse. Results We found 94 infections in 72 patients. Descriptive statistics of the cohort and comparisons with and without debridement can be seen in Table 1. Sixty-one cases (65%) included debridement and 5 (5%) required pump exchange. Notably, patients with fever or bacteremia were more likely to undergo debridement. Of the patients that had a preoperative CT, sensitivity for deep infection (pump, pocket, or deep to the muscle) was 38%, yet specificity was 95%. For superficial infections (involving the driveline or superficial to the muscle), preoperative CT sensitivity was 95%; specificity 65%. Table 2 shows intraoperative culture data. When the preoperative driveline culture grew Staphylococcus species or Pseudomonas aeruginosa there was strong correlation with intraoperative organism (matched in >75% of cases). Table 3 compares treatments among patients with and without infective relapse. Relapse rate appeared the same if patients received 2, 4, or ≥6 weeks of intravenous antibiotics. Conclusion We present a large single-center cohort [DCWM1] examining VAD-related/-specific infections. While patients chosen for debridement may be sicker, these patients had a longer hospital stay and relapsed more often. Preoperative CT should be used with caution as it underestimates the extent of disease. However, preoperative driveline cultures correlated strongly with intraoperative cultures for most common pathogens. There was no association between initial intravenous therapy duration and infection relapse. Table 1. demographic characteristics of total cohort and comparisons among patients who underwent debridement for treatment of infection and patients who did not undergo debridement for treatment of infection Table 2. Organisms found intraoperatively and the number of organisms found preoperatively that are the same as the intraoperative cultures Table 3. Comparing treatment and cultures in patients who suffered an infection relapse Disclosures All authors: No reported disclosures.

Background In patients with cryptogenic stroke, transcatheter (TC) closure of a patent foramen ovale (PFO) has not been shown to better prevent recurrent vascular events than medical therapy. However, randomized controlled trials (RCT) to date have included few vascular events, and lack of power has been raised as an important concern. Objective To conduct a systematic review and meta-analysis of existing RCT published studies assessing the recurrence of vascular events after TC PFO closure when compared to medical therapy. Methods Using the search terms “ patent foramen ovale ”, “ PFO ”, “ stroke ”, “ percutaneous closure ” and “ transcatheter closure ”, Medline, Pubmed, Embase, and Cochrane databases were reviewed from inception through April 2013, with no language restrictions. Only studies in adult humans were considered. Additional references were obtained from the bibliographies of studies reviewed. The following criteria were used for study selection: 1) randomized controlled trial, 2) subjects were adult patients with cryptogenic stroke who were randomized to TC PFO closure or medical treatment (antiplatelet therapy and/or anticoagulation), and 3) reported outcomes included cardiac death, all death, stroke, transient ischemic attack, and peripheral embolism. Methodological and descriptive data, adverse events (including raw data and risk estimates), as well as procedural success and complications were abstracted in duplicate from each study independently, and agreement was tested. We followed rigorously the recommended guidelines for reporting and conducting and assessing quality of meta-analysis of RCT. The primary endpoints pre-specified in advance were recurrent vascular events, and composite endpoint of death, and recurrent vascular events. Results Three studies were identified as meeting selection criteria. These included a total of 2,303 patients, with 1,150 patients randomized to TC PFO closure and 1,153 patients randomized to medical therapy. Mean follow-up was 3.5 years. Baseline characteristics (age, sex, and cardiovascular risk factors) were similar across studies. Intention-to-treat analyses showed a statistically significant risk reduction in stroke and/or transient ischemic attack in the TC PFO closure group when compared to medical treatment, pooled HR = 0.59, 95%CI (0.36-0.97), P = 0.04. The combined outcome of death, and vascular events, showed a borderline statistically significant benefit for TC PFO closure when compared to medical treatment, pooled HR = 0.67, 95%CI (0.44–1.00), P = 0.05 Subjects with a substantial PFO shunt seem to benefit the most with TC PFO closure, pooled HR = 0.35, 95%CI (0.12–1.03), P = 0.06, however, it did not reach statistical significance. Conclusion These results suggest that in patients with cryptogenic stroke, TC PFO closure may be beneficial in reducing the risk of recurrent vascular events when compared to medical treatment. The benefit of TC PFO closure may be greater in patients with a substantial shunt.

Background Neutrophil-lymphocyte (NLR) and platelet-lymphocyte ratios (PLR) mark systemic inflammation. Patients with high NLR and PLR have worse cardiovascular disease and outcomes. We assessed the role of these ratios in predicting outcomes after transcatheter aortic valve replacement (TAVR). Methods The association between NLR and PLR with baseline characteristics, 30-day outcomes, and 1-year readmission/survival was determined in patients that underwent TAVR between 2007 and 2014 and had baseline complete blood count with differential. A subgroup analysis determined the association between change in NLR and PLR (discharge-baseline) and 1-year outcomes. Results In 520 patients that underwent TAVR, a higher NLR (p=0.01) and PLR (p=0.02) were associated with a higher STS-PROM score, and with increased occurrence of the 30-day early-safety outcome (by VARC-2), even after adjusting for STS-PROM score, valve generation (Sapien vs. Sapien XT), and access (transfemoral vs. non-transfemoral) (NLR: OR 1.29, 95% CI 1.04–1.61; PLR: OR 1.27, 95% CI 1.01–1.60) but not with 1-year readmission or survival. In our subgroup analysis (N=294), change in PLR was not associated with the 1-year outcomes but a high change in NLR was associated with worse 1-year survival/readmission and 1-year survival, even after adjusting for STS-PROM score, valve generation and access (HR 1.22, 95% CI 1.04–1.44 and HR 1.26, 95% CI 0.99–1.6, respectively). Conclusions NLR and PLR correlate with surgical risk. An elevated NLR and PLR were associated with the occurrence of 30-day adverse outcomes, similar to the STS-PROM score. A high variation of NLR from baseline to discharge may help stratify patients that underwent TAVR in addition to traditional risk factors.

A coronary artery fistula is a communication between a coronary artery and a chamber of the heart (coronary-cameral fistula). Coronary ectasia is the luminal dilatation of the adjacent normal segment, believed to be a form of atherosclerotic process, and is reported in about 3-8% of patients undergoing coronary angiogram. Coronary-cameral fistula and coronary ectasia, when existing concurrently, may present as a prelude to ischemia even in the absence of obstructive disease. We report here one such case seen in an elderly female. She presented with recurrent episodes of angina despite the absence of occlusive coronary artery disease. We also review the literature.

In 2008, regadenoson, a selective adenosine2A (A 2A ) receptor agonist, was approved by the US Federal and Drug Administration for use as a pharmacologic stress agent in myocardial perfusion studies. By stimulating A 2A receptors in coronary smooth muscle, it can increase coronary blood flow by 2.5-fold or greater. Previous data showed non-inferiority of regadenoson in detecting reversible myocardial ischemia, compared to adenosine. Given less serious adverse effects, being better tolerated and easily administered, regadenoson has been widely used for myocardial perfusion imaging. As adenosine receptors have many sub-types and are located in multi-organ systems, regadenoson can cause various adverse effects, including bronchospasm, atrioventricular block, or hypotension. However, adverse effects on the central nervous system are rarely reported. As adenosine receptors (A 1 and A 2A receptors) play a major role in neuron–glial cells interaction, regadenoson can provoke seizure through A 2A receptor activation. We hereby report a case of regadenoson associated-seizure and review seizure mechanism. This may raise more concern for a rare serious adverse effect of regadenoson which should be taken into consideration when selecting cardiac stress modalities. Learning objective: Regadenoson can provoke seizure through central A 2A receptor activation. This should be taken into consideration when selecting cardiac stress test modalities, particularly in patients with known seizure disorder or history of organic brain disease.>

Objectives The aim of this study is to evaluate the efficacy of drug-eluting stents (DES) placed below-the-knee level in the parameters for wound healing. Background Critical limb ischemia (CLI) has a serious impact on quality of life with a major amputation rate of 30 percent within 12 months. Endovascular treatment has been used to perform revascularization of limbs over the past decade. However, the role of drug-eluting stent (DES) placement at below-the-knee level to improve wound healing is still inconclusive. Methods A single center retrospective study was conducted at Faculty of Medicine, Siriraj Hospital, Mahidol University. The outcomes of infrapopliteal DES placement among forty-six patients with critical limb ischemia (category 4-6 of Rutherford’s classification) from 2007 to 2011 were retrospectively reviewed. The primary endpoints were pre- and post-procedural Ankle-Brachial index (ABI) and transcutaneous oxygen tension (TcPO2). The secondary endpoints were limb salvage rate, time-to-major amputation and healing of ulcers. The differences between pre- and post-procedural parameters were analyzed with paired T-test. Results The mean follow-up time in the study was 490.21 days with limb salvage rate of 93.8 percent. Complete wound healing was observed in 81.3 percent of patients. Three of the patients underwent major amputations with the time-to-amputation ranging from 40 to 277 days post-procedure. The overall ABI was significantly improved from 0.64 ± 0.12 to 0.88 ± 0.28 (p-value Conclusions DES placement at below-the-knee level is both a safe and effective limb saving therapy in CLI patients. It has been shown to significantly improve parameters for wound healing: ABI and transcutaneous oxygen tension (TcPO2).

Warburg effect is a rare metabolic complication in hematologic malignancies, commonly presented with lactic acidosis and hypoglycemia. Mechanism explained by abnormality of mitochondrial oxidative phosphorylation in cancer cells and energy production is mostly dependent on anaerobic respiration or glycolysis pathway to meet large tumor demand. We present a case with history of lymphoplasmacytic lymphoma and Waldenstorm macroglobulinemia, partial response to chemotherapy. Lymphoplasmacytic lymphoma transformed to diffuse large B-cell lymphoma, which is aggressive and rapid progression, leading to Warburg effect. Patient developed more than 10-cm retroperitoneal mass less than 1 year, and his symptoms were progressively worsening within 3 weeks. Warburg effect represents poor prognosis no matter with or without hypoglycemia. Treatment of choice is cytoreduction with early chemotherapy. Our patient died 2 days after Warburg effect occurred.

1. IntroductionSpontaneous coronary artery dissection (SCAD) is an uncommoncause of acute myocardial infarction. The dissection of tunica intima ormedia,formingofhematomaunderneatharterialwallandcompressingthe true coronary lumen leads to myocardial infarction of distal cardiactissue. Thehigh suspiciousindexshouldmakein young female withoutany cardiovascular risk, especially in peripartum period. Emergent cor-onaryangiogramfollowedbyintravascularultrasoundisrecommendedfor diagnosis; however optimal treatment is still inconclusive [1].

To the Editor, We report a case of a 65-year-old male, who presented with abdominal distention for 1 day, with past medical history of diabetes, hypertension, atrial fibrillation, cerebrovascular accident with residual right hemiparesis, and mild expressive aphasia. He reported of having diffuse abdominal distention, feeling nauseated with multiple episodes of non-bilious vomiting. He was afebrile with normal blood pressure. Abdominal exams showed distended abdomen with tympanic note on percussion. Rectal examination revealed emptied rectal vault. Abdominal X-ray showed marked dilatation of sigmoid loop, extending from the pelvis into the right upper quadrant, with coffee-bean appearance. Due to a high suspicionofsigmoidvolvulus,immediaterigidsigmoidoscopywas

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute myocardial infarction, which should always be included in differential diagnoses of acute coronary syndrome among young patients without known atherosclerotic risk. Although, it is commonly observed in young women during postpartum period, there were cases reported in connective tissue disorders, eosinophilic arteritis, contraception use, cocaine abuse and repetitive chest trauma. We report a case of SCAD, presenting with acute ST-elevation myocardial infarction, which was successfully treated conservatively.

Dear Editor, We would like to share an interesting case of congestive myelopathy involving a 26-year-old female with chronic gynecological chylous reflux disease who presented with bilateral lower extremities weakness, decreased sensation, and urinary incontinence of 2 months duration. A medical review revealed chronic vaginal discharge and lower-extremity swelling due to chronic chylous reflux disease. Upon examination, the patient had normal muscle strength in the upper extremities, motor power grades of 4 in the left lower extremity (LLE) and 1 in the right lower extremity (RLE), and loss of rectal tone. Sensory examination revealed decreased touch and vibratory sensation in both lower extremities. All cranial nerve and cerebellar functions were intact. Spinal MRI revealed T2-weighted hyperintense signals and atrophy of the thoracic cord with enhancing curvilinear T2-weighted hypointense signals within the thecal sac and flow voids anterior and posterior to the conus medullaris (Fig. 1). The findings were suggestive of a dural arteriovenous malformation (AVM). Surprisingly, subsequent spinal angiography did not reveal any evidence of either a dural AVM or a fistula. We therefore diagnosed this patient with congestive myelopathy secondary to venous drainage dysfunction as a result of chylous reflux syndrome. Fig. 1 Thoracic spine T2-weighted MRI. Sagittal view (A) and cross-sectional view (B) showing hyperintense signal and atrophy of the thoracic spinal cord (arrows). Primary chylous reflux syndrome is a rare lymphatic disorder that is characterized by retrograde flow of chyle from its normal route. Hypothesized pathophysiologies include an incompetent lymphatic valvular system, lymphatic hypoplasia, and dilated incompetent megalymphatics. However, the definite pathophysiology remains unclear.1,2 Approximately 20 cases of primary chylous reflux syndrome have been reported during the past century. The common manifestations are lymphedema, chyluria, and chylous genital discharge. Some patients may experience complications such as chylothorax, chyloperitoneum, and chylopericardium.3 However, neurological deficits have never been reported in association with this condition. This patient had been diagnosed with primary chylous reflux syndrome as a young child, and was conservatively managed with dietary control. At the age of 26 years she gradually developed venous congestive myelopathy or Foix-Alajouanine syndrome. Given that the most common cause of venous congestive myelopathy is spinal dural arteriovenous fistula, extensive investigations including MRI/MRA and spinal angiography were conducted.4 The results were negative for concurrent vascular malformations. To date, only 14 cases of venous congestive myelopathy without concurrent vascular malformation have been reported,5 none of which had underlying chylous reflux syndrome. Chyle is normally absorbed through the lacteals, drains into the thoracic duct, and empties into the venous system. In patients with chylous reflux disorder, the retrograde flow of lymph may contribute to retention of lymph within the pelvic cavity, with efflux into the vagina, causing vaginal discharge. These can ultimately lead to the development of aberrant vascular channels and can increase the lymph absorption through the venous system, as evidenced in the present patient by increased lower-extremity swelling. This can result in chylous reflux disorder eventually involving the spinal venous plexus or Batson venous plexus and causing chronic venostasis, contributing to venous congestive myelopathy. The treatment of choice for primary chylous reflux disorder remains lymphangiography- or lymphoscintigraphy-guided surgery. Removal of the pelvic megalymphatics can theoretically redirect the chylous lymphatic flow toward the thoracic duct.6 However, there is no recommendation regarding the treatment of venous congestive myelopathy resulting from chylous reflux syndrome. Our patient has been refusing surgery since she was young, and at this admission again selected conservative treatment with rehabilitation. The paraplegia was slightly improved in approximately 8 weeks (motor power grades: 5/5 in LLE and 2/5 in RLE) and the patient could finally ambulate with crutches.

Typhlitis or neutropenic enterocolitis (NEC) is a life-threatening condition that occurs in neutropenic patients. Early recognition is crucial owing to high death rate. We present a case of a 54-year-old man, diagnosed with non-Hodgkin lymphoma who received a first cycle of rituximab, cyclophosphamide, hydroxydaunorubicin (doxorubicin), oncovin (vincristine), prednisolone (R-CHOP) chemotherapy 10 days prior presenting. He developed fever, mucositis, watery diarrhoea and right lower quadrant pain with rebound tenderness. He also had neutropenia, with an absolute neutrophil count of zero. CT abdomen confirmed the diagnosis of typhlitis, demonstrating characteristic terminal ileum, caecal and right-sided colon involvement. Moreover, stool PCR was also positive for toxigenic Clostridium difficile. Therefore, the patient was diagnosed with concomitant typhlitis and C difficile-associated diarrhoea (CDAD). He was empirically treated with intravenous cefepime, intravenous metronidazole and oral vancomycin. His symptoms resolved in 10 days. This case illustrated a successful medical treatment of typhlitis in concomitance with CDAD.

Cirrhotic cardiomyopathy describes a constellation of cardiovascular abnormalities that can be present in cirrhotic patients. There remains a scarcity of data studying the relationship between cirrhotic cardiomyopathy and hepatorenal syndrome (HRS). We sought to identify cardiovascular abnormalities