BackgroundCombined interpretation of late diastolic mitral annulus velocity (A′) with left atrial... more BackgroundCombined interpretation of late diastolic mitral annulus velocity (A′) with left atrial volume index (LAVi) may have additional benefits in the assessment of diastolic dysfunction.HypothesisThe LAVi/A′ ratio may be useful in the identifying advanced diastolic dysfunction (ADD) and predicting clinical outcomes in patients with dyspnea.MethodsWe enrolled 395 consecutive patients hospitalized with dyspnea (New York Heart Association class II–IV) and performed transthoracic Doppler echocardiography and B‐type natriuretic peptide (BNP) measurement. LAVi/A′ values were evaluated in terms of diagnosing ADD and predicting clinical outcome.ResultsOn the receiver operation characteristic curve analysis for the determination of ADD, the area under the curves of LAVi/A′ in the entire population was comparable to those of BNP (0.94 vs 0.93, P = 0.845) and mitral E/E′ (0.94 vs 0.93, P = 0.614) and higher than that of LAVi (0.94 vs 0.87; P = 0.014). A LAVi/A′ of 4.0 was the best cut‐off ...
Thrombus aspiration during primary percutaneous coronary intervention
The New England Journal of Medicine, Jun 12, 2008
... Der Kardiologe 4:2, 84-92. 23. C. Adlbrecht, K. Distelmaier, D. Bonderman, G. Beran, B.Redwan... more ... Der Kardiologe 4:2, 84-92. 23. C. Adlbrecht, K. Distelmaier, D. Bonderman, G. Beran, B.Redwan, G. Strunk, T. Binder, J. Jakowitsch, P. Probst, G. Heinze, G. Maurer, IM Lang. (2010) Long-term outcome after thrombectomy in acute myocardial infarction. ...
Electrocardiographic abnormalities in patients presenting with intracranial parenchymal haemorrhage
Acta Cardiologica, Dec 1, 2012
Objectives The electrocardiographic abnormalities associated with ischaemic stroke and subarachno... more Objectives The electrocardiographic abnormalities associated with ischaemic stroke and subarachnoid haemorrhage have been described frequently and studied systematically; however, these changes were not investigated thoroughly in patients with intracranial parenchymal haemorrhage (IPH). Methods We retrospectively reviewed the electrocardiograms (ECGs) and medical records of all patients who had been diagnosed with acute intraparynchemal haemorrhage (IPH) between 2006 and 2009. Results We included 160 patients (56% males). The median age was 71 years (interquartile range (IQR) 59 to 80) and 69% were above the age of 60 years. Most patients were hypertensive (81%). The majority of patients (86%) had at least one ECG abnormality. Sixty-eight (43%) patients had T-wave inversion and 65 (41%) had QTc interval prolongation. There was a signifi cant association between QTc prolongation and the bleeding size and the presence of midline shift; odd ratios were 2.8 (CI 1.4 to 5.5; P 0.003) and 2.2 (CI 1.1 to 4.2; P 0.04), respectively. In addition, sinus tachycardia was found to be signifi cantly associated with the presence of hydrocephalus (OR 4.1; CI 1.3 to 12.8; P 0.02). Conclusions ECG abnormalities are a common fi nding in patients with IPH. Repolarizaion abnormalities occur the most frequently. QTc prolongation was associated with bleeding size and midline shift. Patients who had hydrocephalus were more likely to have sinus tachycardia at presentation.
International Journal of Case Reports and Images, 2018
Introduction: Takotsubo cardiomyopathy (TC) is a transient nonischemic cardiomyopathy causing wal... more Introduction: Takotsubo cardiomyopathy (TC) is a transient nonischemic cardiomyopathy causing wall motion abnormalities of a particular region of the heart, most commonly the apex. The classic presentation is of a postmenopausal female presenting with chest pain and congestive heart failure in response to an emotional stressor, but physical stressors may cause it as well. Uncommonly, men may present with this condition. We present a rare case of TC in a male, triggered by a COPD exacerbation. Case Report: A 62-year-old African American Male with a past medical history of COPD presented with shortness of breath, wheezing and chest tightness. The patient had increased his use of his albuterol inhaler to four times a day, which did not relieve his symptoms. His electrocardiogram showed right bundle branch block and nonspecific T wave changes and his troponins progressively increased to 2.47 ng/mL within 6 hours. Echocardiogram showed apical akinesis with a newly reduced ejection fraction of 30-35% Cardiac catheterization revealed nonobstructive coronary artery disease and apical ballooning
Cardiac amyloidosis is a rare disease that has significant sequelae if undetected and treated ear... more Cardiac amyloidosis is a rare disease that has significant sequelae if undetected and treated early. We report a case of a rare genetic mutation that leads to cardiac amyloidosis. This is a case of a 41-year-old Peruvian male without any known past medical history but with a family history of sudden death. The patient complained of episodic left-sided chest pain for 1 month that was associated with shortness of breath. A subsequent admission and workup for coronary artery disease was negative, but an echocardiogram showed global left ventricular hypokinesia. Cardiac magnetic resonance imaging (MRI) was performed which was suggestive of cardiac amyloidosis. A subsequent abdominal fat biopsy and bone marrow biopsy failed to show evidence of amyloidosis. However, the endomyocardial biopsy was consistent with cardiac amyloidosis. Familial cardiac disease was suspected because of the family history of sudden death. As such, genetic testing was performed which yielded a very rare genetic mutation corresponding to amino acid 23 of the transthyretin protein. A review of the literature shows that this gene mutation (AGT23AAT, gene sequence; Ser23Asn, protein sequence) has been described only once previously. This case is unique in that the patient's amyloidosis was limited to the heart, without involvement of any other organ.
Journal of the American College of Cardiology, Mar 1, 2017
Background: Patent ductus arteriosus (PDA) is an extracardiac left to right shunt and when its la... more Background: Patent ductus arteriosus (PDA) is an extracardiac left to right shunt and when its large it can lead to excess blood flow to left side of heart causing left ventricular (LV) dilation with secondary mitral regurgitation (MR). Also, chronic severe MR of any etiology can cause LV volume overload and enlargement. Case: A 51 year old male with no past medical history presented with shortness of breath on exertion and both leg swelling. No history of chest pain, orthopnea or palpitations. Physical examination revealed elevated JVP, rales in bilateral lower lung field, normal S1 and S2, irregular rhythm, and 4/6 systolic murmur. ECG showed new onset atrial fibrillation. Decision-Making: Transthoracic echocardiogram showed mildly dilated LV, reduced LV ejection fraction of 45%, moderate left atrium dilation and moderate-severe MR. Transesophageal echocardiogram confirmed severe eccentric MR due to posterior mitral valve (MV) leaflet prolapse and it also revealed a patent ductus arteriosus. In preparation for MV surgery, patient had left heart catheterization that showed normal coronaries and aortogram showed left to right shunt via PDA. Right heart catheterization showed an increase in oxygen saturation from 67 to 82% between right ventricle (RV) and left pulmonary artery (PA) with Qp:Qs of more than 2.2 indicating a large shunt. Mean PA pressure was 26 and pulmonary capillary wedge pressure was 14mmHg. LV dilation and pulmonary hypertension in our patient was attributed to both, chronic severe primary MR and large PDA. Hence, he was referred for MV repair and PDA closure. PDA was fixed first in order to avoid RV volume overload during cardiopulmonary bypass that is required for MV repair. Conclusions: This case highlights importance of meticulous investigation when evaluating the cause of LV dilation and that multiple etiologies may co-exist. This allows for correct diagnosis and correction of all cardiac abnormalities before LV dysfunction becomes irreversible.
Journal of Community Hospital Internal Medicine Perspectives, Jun 28, 2023
Brugada syndrome is an inherited disorder characterized by a channelopathy of cardiac sodium, pot... more Brugada syndrome is an inherited disorder characterized by a channelopathy of cardiac sodium, potassium, and calcium channel. The pathophysiology of this disorder is not completely elucidated yet, however, most of the reported cases are caused by a pathogenic alteration in the SCN5A gene, leading to the malfunction of cardiac sodium channels. Several stressors are well known to unmask this pathology including fever and electrolytes imbalance. Three ECG patterns are frequently described in the literature, type 1, type 2, and type 3. However, only the type 1 pattern is considered diagnostic of Brugada syndrome in the appropriate clinical context. Therapeutic strategies can range from conservative medical management with antiarrhythmic medications to Automatic Implantable Cardioverter Defibrillator (AICD) placement. Prompt recognition is of utmost importance since this pathology can rapidly evolve into life-threatening arrhythmias and sudden cardiac death. Here we present a case of a 22-year-old male who presented after a syncopal episode and was found to have Brugada syndrome in the setting of Influenza A infection.
Abstract 18350: The Burning Question: Complete versus Culprit Only Revascularization in Patients With ST-Segment Elevation Myocardial Infarction and Multi-vessel Coronary Artery Disease
Introduction: Patients with ST-segment elevation myocardial infarction (STEMI) and multi-vessel c... more Introduction: Patients with ST-segment elevation myocardial infarction (STEMI) and multi-vessel coronary artery disease (CAD) have worst outcomes; yet the strategy of multi-vessel versus culprit on...
Journal of the American College of Cardiology, Apr 1, 2016
Background: Partial anomalous pulmonary venous return is a rare congenital cardiac defect with in... more Background: Partial anomalous pulmonary venous return is a rare congenital cardiac defect with incidence of 0.4 to 0.7% and is associated with sinus venosus atrial septal defect (ASD). While most cases are asymptomatic, patient can present with pulmonary hypertension (PH) and it can be difficult to diagnose. Case: Ms. C is a 33 year old female with morbid obesity who needs preoperative cardiac risk stratification for gastric bypass surgery. She denied any chest pain or SOB, but has had mild dyspnea on exertion since 2-3 months. No palpitations, syncope or cardiac problems in past. Her cardiac exam revealed normal S1, loud P2 and 3/6 systolic murmur in left 3rd intercostal space. Decision Making: Ms. C was seen at cardiologist office where her electrocardiogram revealed right bundle branch block and her chest x-ray revealed cardiomegaly so an echocardiogram was ordered for further evaluation. Her right ventricle (RV) was moderately dilated with moderate PH and left ventricle was normal. She had chest CT angiography which was negative for pulmonary embolism. Right heart catheterization was performed and it revealed elevated right atrial pressure of 11, mean pulmonary artery pressure of 25 and capillary wedge pressure of 13mmHg. There was an increase in oxygen saturation from 69 to 92% between superior vena cava (SVC) and high right atrium (RA). Cardiac MRI/MRA was then done and revealed enlarged right side of heart with preserved RV ejection fraction of 54%, large anomalous right upper pulmonary venous return into the SVC-RA junction and small anomalous right middle pulmonary venous return to RA with sinus venosus ASD. Qp:Qs was 2.78:1. Cardiothoracic surgery was consulted and correction of the defect was recommended before bariatric surgery. Conclusions: This case emphasizes the importance of meticulous and thorough investigation when evaluating pulmonary hypertension. This allows for correct diagnosis and correction of cardiac abnormalities before any non-cardiac surgery and before PH becomes irreversible.
Cardiac tamponade associated with human immunodeficiency virus-associated immune complex kidney disease
Journal of Global Infectious Diseases, 2021
Cardiac tamponade is a life-threatening emergency, characterized by rapid accumulation of pericar... more Cardiac tamponade is a life-threatening emergency, characterized by rapid accumulation of pericardial fluid. There are multiple risk factors for cardiac tamponade, nephrotic syndrome is an uncommon one, especially in adults. Herein, we are reporting a 35-year-old African American woman with membranoproliferative glomerulonephritis secondary to human immunodeficiency virus-associated immune complex kidney disease (HIVICK), who presented with cardiac tamponade. The patient had pericardiocentesis and was discharged, with outpatient follow-up with cardiology, nephrology, and infectious disease. To the best of our knowledge, this is the first report of HIVICK nephrotic syndrome associated with cardiac tamponade.
Background and aim of the study: Infective endocarditis (IE) is a major cause of morbidity and mo... more Background and aim of the study: Infective endocarditis (IE) is a major cause of morbidity and mortality in patients with end-stage renal disease (ESRD). The study aim was to evaluate the demographic, clinical, microbiological and inpatient mortality data of IE in hemodialysis patients. Methods: Data were analyzed for all IE patients admitted to the authors' 800-bed tertiary care hospital between January 2001 and December 2014. These data included demographics, comorbidities, clinical and microbiological characteristics, echocardiographic findings, complications, outcomes, and in-patient mortality. Results: A total of 296 patients, including 52 on hemodialysis, was admitted with a diagnosis of IE. The median age of patients with ESRD (28 females, 24 males) was 55.9 ± 15.47 years. The prevalences of comorbidities such as hypertension (80%) and diabetes mellitus (46%) were significantly higher in ESRD patients, whereas other comorbidities were similarly distributed in both groups. The mitral valve was the most commonly involved (55.8%), followed by aortic (21.7%), tricuspid (21.2%) and pulmonary (1.9%) valves. Staphylococcus aureus was the most common organism (40%), followed by Enterococcus sp. (13.7%), Gram-negative staphylococci (13.7%), coagulase-negative staphylococci (11.5%), and Streptococcus sp. (5.7%). Polymicrobes were found in 11.5% of patients and cultures were negative in 19%. The mean ejection fraction in these patients was 42 ± 4.19% and the mean area of vegetation was 63.5 ± 40 mm2. The in-hospital course of 11 patients was complicated by embolic events, while three patients had acute heart failure and one patient had heart block secondary to IE. A total of four patients (7.7%) died during the index hospitalization. Conclusions: IE in patients receiving chronic hemodialysis is a very frequent occurrence. Its diagnosis is complex and its presence should be considered in all hemodialysis patients with bacteremia. In the present study the etiology was shown to be multifactorial, with the mitral valve being the most commonly involved and S. aureus the most common organism.
Journal of the American College of Cardiology, Mar 1, 2019
Background: Stenosis of the iliac artery due to compression from previous stent placement in ilia... more Background: Stenosis of the iliac artery due to compression from previous stent placement in iliac vein is extremely uncommon. Management of such lesion can often be challenging in symptomatic patients. Case: A 18 year old male presented with a complaint of left leg claudication for two months. Patient had a history of pulmonary embolism about two years ago when he was diagnosed with May-Thurner syndrome. He had a stent placed in his left iliac vein. Workup with computerized tomography angiography (CTA) revealed that he had mild to moderate stenosis of left external iliac artery. Decision-making: There was a discrepancy between the CTA findings and his claudication symptoms. The dilemma was whether to manage him medically or consider an angiogram and intervention. After extensive discussion with the patient and his parents, we decided to proceed with an angiogram. The angiogram revealed moderate stenosis in his left external iliac artery (Figure A). Intravascular ultrasound (IVUS) showed the lesion was severely stenotic and fibrotic. Finally, after multiple attempts of balloon inflation, the lesion was crushed and stented with an excellent result (Figure B). Patient reported marked improvement in his symptoms the next day. Conclusion: This case emphasizes that IVUS can be a useful tool in guiding the therapy in patients with symptomatic peripheral arterial disease when radiographic and angiographic images are inconclusive. .
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