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O’Brien MP, Pryzhkova MV, Lake EMR, Mandino F, Shen X, Karnik R, Atkins A, Xu MJ, Ji W, Konstantino M, Brueckner M, Ment LR, Khokha MK, Jordan PW. SMC5 Plays Independent Roles in Congenital Heart Disease and Neurodevelopmental Disability. Int J Mol Sci 2023; 25:430. [PMID: 38203602 PMCID: PMC10779392 DOI: 10.3390/ijms25010430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024] Open
Abstract
Up to 50% of patients with severe congenital heart disease (CHD) develop life-altering neurodevelopmental disability (NDD). It has been presumed that NDD arises in CHD cases because of hypoxia before, during, or after cardiac surgery. Recent studies detected an enrichment in de novo mutations in CHD and NDD, as well as significant overlap between CHD and NDD candidate genes. However, there is limited evidence demonstrating that genes causing CHD can produce NDD independent of hypoxia. A patient with hypoplastic left heart syndrome and gross motor delay presented with a de novo mutation in SMC5. Modeling mutation of smc5 in Xenopus tropicalis embryos resulted in reduced heart size, decreased brain length, and disrupted pax6 patterning. To evaluate the cardiac development, we induced the conditional knockout (cKO) of Smc5 in mouse cardiomyocytes, which led to the depletion of mature cardiomyocytes and abnormal contractility. To test a role for Smc5 specifically in the brain, we induced cKO in the mouse central nervous system, which resulted in decreased brain volume, and diminished connectivity between areas related to motor function but did not affect vascular or brain ventricular volume. We propose that genetic factors, rather than hypoxia alone, can contribute when NDD and CHD cases occur concurrently.
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Affiliation(s)
- Matthew P. O’Brien
- Department of Pediatrics, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Marina V. Pryzhkova
- Biochemistry and Molecular Biology Department, Johns Hopkins University Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205, USA
- Department of Biochemistry and Molecular Biology, Uniformed Services, University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814, USA
| | - Evelyn M. R. Lake
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Francesca Mandino
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Xilin Shen
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Ruchika Karnik
- Department of Pediatrics, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Alisa Atkins
- Biochemistry and Molecular Biology Department, Johns Hopkins University Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205, USA
| | - Michelle J. Xu
- Biochemistry and Molecular Biology Department, Johns Hopkins University Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205, USA
| | - Weizhen Ji
- Department of Pediatrics, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
- Pediatric Genomics Discovery Program, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Monica Konstantino
- Department of Pediatrics, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
- Pediatric Genomics Discovery Program, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Martina Brueckner
- Department of Pediatrics, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
- Department of Genetics, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Laura R. Ment
- Department of Pediatrics, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
- Department of Neurology, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Mustafa K. Khokha
- Department of Pediatrics, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
- Pediatric Genomics Discovery Program, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
- Department of Genetics, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Philip W. Jordan
- Biochemistry and Molecular Biology Department, Johns Hopkins University Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205, USA
- Department of Biochemistry and Molecular Biology, Uniformed Services, University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814, USA
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Karnik R, Robinson B, Glickstein J, Schwartz A, Mink R, Neal AE, Frank LH, McMahon CJ, Kim ME, Turner DA, Srivastava S. Minimum Supervision Levels Required for Pediatric Cardiology Fellowship Graduation by Pediatric Cardiology Fellowship Program Directors. Pediatr Cardiol 2023:10.1007/s00246-023-03371-y. [PMID: 38117291 DOI: 10.1007/s00246-023-03371-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 11/30/2023] [Indexed: 12/21/2023]
Abstract
Entrustable professional activities (EPAs) are "observable essential tasks expected to be performed by a physician for safe patient care in practice." Six Pediatric Cardiology (PC) EPAs and their level of supervision (LOS) scales were developed by medical educators in PC using a modified Delphi process and reviewed by the Subspecialty Pediatrics Investigator Network (SPIN). However, their general use in assessment for PC fellows for graduation requirements has yet to be studied. The objective of this study was to determine the minimum LOS required for PC fellows to graduate and compare it with the minimum LOS expected for safe and effective practice for the six PC EPAs, from the perspective of the PC Fellowship Program Directors(FPD). All Fellowship Program Directors(FPD) of ACGME-accredited PC fellowships were surveyed through SPIN between April 2017 and August 2017. For each of the PC EPAs, the FPDs were asked to indicate the minimum LOS expected for graduation and whether they would allow a fellow to graduate if this level was not achieved and the minimum LOS expected for a practicing pediatric cardiologist to provide safe and effective patient care. The minimum LOS was defined as the LOS for which no more than 20% of FPDs would want a lower level. The survey response rate was 80% (47/59). The majority of the FPDs did not require a minimum LOS of five corresponding to unsupervised practice in any of the six PC EPAs at graduation. For EPAs related to imaging, arrhythmia management, and management of cardiac problems, the minimum LOS for graduation was 3, corresponding to being "trusted to perform a task with indirect supervision for most simple and a few complex cases." For the EPAs related to interventional cardiology, heart failure pulmonary hypertension, and cardiac intensive care, the minimum LOS for graduation was 2, corresponding to being "trusted to perform a task only with direct supervision and coaching." The minimum LOS considered necessary for safe and effective practice for all but one EPA was 3. For the EPA related to the management of cardiac problems, the minimum LOS for safe practice was 4, corresponding to being "trusted to execute tasks independently except for few complex and critical cases." Most PC FPDs reported they would not require fellows to achieve the highest entrustment level for any of the six PC EPAs for graduation. It is crucial that educational programs evolve to address these essential activities during training better and that stakeholders ensure that graduating PC fellows have adequate resources and infrastructure to continue professional development as early career pediatric cardiologists.
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Affiliation(s)
- Ruchika Karnik
- Department of Pediatrics, Section of Pediatric Cardiology, Yale School of Medicine, New Haven, CT, USA.
| | - Bradley Robinson
- Department of Pediatrics, Section of Pediatric Cardiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Julie Glickstein
- Department of Pediatrics, Division of Pediatric Cardiology, Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY, USA
| | - Alan Schwartz
- Department of Medical Education and Department of Pediatrics, University of Illinois at Chicago College of Medicine, Chicago, IL, USA
| | - Richard Mink
- David Geffen School of Medicine at UCLA and The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Ashley E Neal
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Heart Institute, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Lowell H Frank
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - Colin J McMahon
- Department of Pediatric Cardiology, Children's Health Ireland at Crumlin, Dublin 12, Ireland
| | - Michael E Kim
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - David A Turner
- Competency-Based Medical Education, American Board of Pediatrics, Chapel Hill, NC, USA
| | - Shubhika Srivastava
- Department of Pediatrics, Section of Pediatric Cardiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
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Nv B, McCollum S, Faherty E, Steele JM, Karnik R. Longitudinal Assessment of Left Ventricular Function in Patients with Myopericarditis After mRNA COVID-19 Vaccination. Pediatr Cardiol 2023:10.1007/s00246-023-03200-2. [PMID: 37294336 PMCID: PMC10251331 DOI: 10.1007/s00246-023-03200-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 05/27/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Multiple reports have described myopericarditis following mRNA COVID-19 vaccination. However, data on the persistence of subclinical myocardial injury assessed by left ventricular (LV) longitudinal strain (LVLS) is limited. OBJECTIVES Our aim was to assess LV function longitudinally in our cohort of COVID-19 vaccine-related myopericarditis using ejection fraction (EF), fractional shortening (FS), LVLS, and diastolic parameters. METHODS Retrospective, single-center review of demographic, laboratory, and management data was performed on 20 patients meeting diagnostic criteria for myopericarditis after mRNA COVID-19 vaccination. Echocardiographic images were obtained on initial presentation (time 0), at a median of 12 days (7.5, 18.5; time 1), and at a median of 44 days (29.5, 83.5; time 2). FS was calculated by M-mode, EF by 5/6 area-length methods, LVLS by utilization of TOMTEC software, and diastolic function by tissue Doppler. All parameters were compared across pairs of these time points using Wilcoxon signed-rank test. RESULTS Our cohort consisted predominantly of adolescent males (85%) with mild presentation of myopericarditis. The median EF was 61.6% (54.6, 68.0), 63.8% (60.7, 68.3), 61.4% (60.1, 64.6) at times 0, 1, and 2, respectively. Upon initial presentation, 47% of our cohort had LVLS < -18%. The median LVLS was -18.6% (-16.9, -21.0) at time 0, -21.2% at time 1 (-19.4, -23.5) (p = 0.004) and -20.8% (-18.7, -21.7) at time 2 (p = 0.004, as compared to time 0). CONCLUSIONS Though many of our patients had abnormal strain during acute illness, LVLS improved longitudinally, indicating myocardial recovery. LVLS can be used as marker of subclinical myocardial injury and risk stratification in this population.
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Affiliation(s)
- Barresi Nv
- Yale University School of Medicine, 20 York Street, New Haven, CT, 06510, USA.
| | - S McCollum
- Yale University School of Medicine, 20 York Street, New Haven, CT, 06510, USA
| | - E Faherty
- Section of Pediatric Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - J M Steele
- Section of Pediatric Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - R Karnik
- Section of Pediatric Cardiology, Yale University School of Medicine, New Haven, CT, USA
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Frye RE, Ittleman B, Shabanova V, Sugeng L, Steele J, Ferdman D, Karnik R. Left ventricular strain in pediatric patients with bicuspid aortic valves and aortopathy. Progress in Pediatric Cardiology 2023. [DOI: 10.1016/j.ppedcard.2023.101636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
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Abstract
Prenatal diagnosis of congenital heart disease (CHD) can be a life-altering and traumatic event for expectant parents. Parental anxiety, depression, and traumatic stress are common following a prenatal cardiac diagnosis and if untreated, symptoms often persist long-term. During prenatal counseling, parents must try to manage psychological distress, navigate uncertainty, process complex medical information, and make high-stakes medical decisions for their unborn child and their family. Physicians must deliver the diagnosis, describe the expected perinatal management plan, discuss short and long-term prognoses and introduce elements of uncertainty that may exist for the particular diagnosis. Physican training in these important skills is highly variable and many in our field acknowledge the need for improved guidance on best practices for counseling and supporting parents during pregnancy and early parenthood after prenatal diagnosis, while also sustaining physicians' own emotional well-being. We describe these challenges and the opportunities that exist to improve the current state of prenatal counseling in CHD.
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Affiliation(s)
- Theresa A Tacy
- Department of Pediatrics, Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - Nadine A Kasparian
- Center for Heart Disease and Mental Health, Heart Institute and Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital and University of Cincinnati College of Medicine, Cincinnati, OU, USA
| | - Ruchika Karnik
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | - Miwa Geiger
- Department of Pediatrics, Division of Pediatric Cardiology, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Erica Sood
- Nemours Cardiac Center, Alfred I. duPont Hospital for Children, Wilmington, Delaware; Department of Pediatrics, Thomas Jefferson University, Philadelphia, PA, USA
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6
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He M, Leone DM, Frye R, Ferdman DJ, Shabanova V, Kosiv KA, Sugeng L, Faherty E, Karnik R. Longitudinal Assessment of Global and Regional Left Ventricular Strain in Patients with Multisystem Inflammatory Syndrome in Children (MIS-C). Pediatr Cardiol 2022; 43:844-854. [PMID: 34993558 PMCID: PMC8739007 DOI: 10.1007/s00246-021-02796-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/23/2021] [Indexed: 11/18/2022]
Abstract
Multisystem inflammatory syndrome in children (MIS-C) is one of the most significant sequela of coronavirus disease 2019 (COVID-19) in children. Emerging literature has described myocardial dysfunction in MIS-C patients using traditional and two-dimensional speckle tracking echocardiography in the acute phase. However, data regarding persistence of subclinical myocardial injury after recovery is limited. We aimed to detect these changes with deformation imaging, hypothesizing that left ventricular global longitudinal (GLS) and circumferential strain (GCS) would remain impaired in the chronic phase despite normalization of ventricular function parameters assessed by two-dimensional echocardiography. A retrospective, single-institution review of 22 patients with MIS-C was performed. Fractional shortening, GLS, and GCS, along with regional longitudinal (RLS) and circumferential strain (RCS) were compared across the acute, subacute, and chronic timepoints (presentation, 14-42, and > 42 days, respectively). Mean GLS improved from - 18.4% in the acute phase to - 20.1% in the chronic phase (p = 0.4). Mean GCS improved from - 19.4% in the acute phase to - 23.5% in the chronic phase (p = 0.03). RCS and RLS were impaired in the acute phase and showed a trend towards recovery by the chronic phase, with the exception of the basal anterolateral segment. In our longitudinal study of MIS-C patients, GLS and GCS were lower in the acute phase, corroborating with left ventricular dysfunction by traditional measures. Additionally, as function globally recovers, GLS and GCS also normalize. However, some regional segments continue to have decreased strain values which may be an important subclinical marker for future adverse events.
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Affiliation(s)
- Michael He
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA.
| | - David M. Leone
- grid.47100.320000000419368710Department of Pediatrics, Section of Pediatric Cardiology, Yale School of Medicine, New Haven, CT USA
| | - Richard Frye
- grid.47100.320000000419368710Department of Pediatrics, Section of Pediatric Cardiology, Yale School of Medicine, New Haven, CT USA
| | - Dina J. Ferdman
- grid.47100.320000000419368710Department of Pediatrics, Section of Pediatric Cardiology, Yale School of Medicine, New Haven, CT USA
| | - Veronika Shabanova
- grid.47100.320000000419368710Department of Pedatrics, Department of Biostatistics, Yale School of Medicine, New Haven, CT USA
| | - Katherine A. Kosiv
- grid.47100.320000000419368710Department of Pediatrics, Section of Pediatric Cardiology, Yale School of Medicine, New Haven, CT USA
| | - Lissa Sugeng
- grid.47100.320000000419368710Department Medicine, Section of Cardiology, Yale School of Medicine, New Haven, CT USA
| | - Erin Faherty
- grid.47100.320000000419368710Department of Pediatrics, Section of Pediatric Cardiology, Yale School of Medicine, New Haven, CT USA
| | - Ruchika Karnik
- grid.47100.320000000419368710Department of Pediatrics, Section of Pediatric Cardiology, Yale School of Medicine, New Haven, CT USA
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Adlakha H, Malik P, Donthula R, Rajagopal H, Kan A, Srivastava S, Karnik R, Shenoy RU. Systemic ventricular strain is abnormal with elevated BMI in adults with congenital heart disease. Progress in Pediatric Cardiology 2021. [DOI: 10.1016/j.ppedcard.2021.101467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Soma G, Simmons MA, Canarie MF, Karnik R, Steele J, Tiyyagura G, Asnes J. A 13-Year-Old With Fever and Chest Pain. Pediatrics 2021; 148:peds.2021-050960. [PMID: 34344802 DOI: 10.1542/peds.2021-050960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
| | | | - Michael F Canarie
- Critical Care, Department of Pediatrics, School of Medicine, Yale University, New Haven, Connecticut
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Mayo M, Karnik R, Klaus C, Sharma K, McDonald A, Walker DH, Weiss M. KT‐413, A NOVEL IRAKIMID DEGRADER OF IRAK4 AND IMID SUBSTRATES, HAS A DIFFERENTIATED MOA THAT LEADS TO SINGLE‐AGENT AND COMBINATION REGRESSIONS IN MYD88
MT
LYMPHOMA MODELS. Hematol Oncol 2021. [DOI: 10.1002/hon.13_2879] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- M Mayo
- Kymera Therapeutics, Research Watertown Massachusetts USA
| | - R Karnik
- Kymera Therapeutics, Research Watertown Massachusetts USA
| | - C Klaus
- Kymera Therapeutics, Research Watertown Massachusetts USA
| | - K Sharma
- Kymera Therapeutics, Research Watertown Massachusetts USA
| | - A McDonald
- Kymera Therapeutics, Research Watertown Massachusetts USA
| | - D. H Walker
- Kymera Therapeutics, Research Watertown Massachusetts USA
| | - M Weiss
- Kymera Therapeutics, Research Watertown Massachusetts USA
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Kantharia B, Singh A, Karnik R, Shah A, Wu L, Narasimhan B. Impact of chronic sequential LV-RV pacing with cardiac resynchronization therapy for patients with narrower (<130 ms) QRS complexes following evaluation of acute myocardial strain characteristics. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Prior studies have shown acute improvement in myocardial strain patterns (SP) and strain rates (SR), left ventricular ejection fraction (LVEF), and long-term clinical improvement by Cardiac Resynchronization Therapy (CRT) preferential LV pacing. This relationship has not been studied in patients (pts) with narrower QRS.
Objectives
We aimed to evaluate myocardial speckle tracking SP and SR at different VV intervals in pts with narrow (<130 ms) and wide (>130 ms) QRS.
Methods
We assessed LVEF and speckle tracking myocardial SP and SR as per the American Society of Echocardiography (ASE) Dyssynchrony Writing Group methods in pts with CRT in acute settings at VV0, VV60 and LV-only pacing. For SP assessment, we used Bull's eye format display of the LV segments, and scores for SR, 2 = early stretch, late peak, 1= early stretch, early peak, and 0 = single peak at aortic closure.
Results
Total cohort of 271 pts; age 69.2±10.3 yrs (mean ± SD), male - 60%, divided into 2 groups; Gp A (QRS <130 ms, n=69) and Gp B (QRS >130 ms, n=202). QRS width and LVEF in Gp A and B were 120.1±12.3 ms and 152.1±12.9 ms, and 22.3±9.4% and 23.3±10.2% respectively. With VV0 increase in LVEF, 67±6.0% from baseline 22.3±9.4% was seen in Gp A compared to 43±6.5% from 23.3±10.2% in Gp B (p<0.01). With VV60 and LV-only pacing further rise in LVEF to 100.0±7.1% and 112.0±7.2% in Gp A and 80.2±8.0% and 93±8.1% in Gp B was seen. (Figure 1). Strain scores at different VV timings in both groups are shown in Table 1.
Conclusions
In pts with CRT, different VV timings show differences in acute myocardial speckle tracking SP and SR, and LVEF. These changes are markedly favorable with LV-only and sequential LV-RV pacing even in pts with narrower QRS. Our findings support chronic sequential LV-RV pacing programming in CRT pts with narrow QRS.
Figure 1
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- B Kantharia
- Cardiovascular and Heart Rhythm Consultants, New York, United States of America
| | - A Singh
- Phoenix Heart. PLLC, Phoenix, United States of America
| | - R Karnik
- Phoenix Heart Cardiovascular Consultants, Phoenix, United States of America
| | - A Shah
- Cardiovascular and Heart Rhythm Consultants, New York, United States of America
| | - L Wu
- Mount Sinai School of Medicine, New York, United States of America
| | - B Narasimhan
- Mount Sinai School of Medicine, New York, United States of America
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Deshpande R, Karnik R, Baer C, Kurup V. Resource Utilization in Implementation of a Point of Care Ultrasound Curriculum for Resident Training in Anesthesiology. Yale J Biol Med 2020; 93:423-427. [PMID: 32874148 PMCID: PMC7448394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Purpose: Point of care ultrasound (POCUS) brings high-quality patient care to the bedside but continues to be an expensive training to implement in a residency program. There are multiple resources available to train providers in ultrasound, but they are all associated with significant cost. The Accreditation Council for Graduate Medical Education (ACGME) mandates anesthesiology residents to be competent in diagnostic and therapeutic uses of ultrasound. In this paper, we describe how an academic anesthesiology department implemented a POCUS curriculum for resident training. Methods: An anesthesiologist intensivist directed program was created to train residents in POCUS. We started by training a group of seven critical care trained anesthesiologists with the guidance of cardiologists. These anesthesiologists participated in the training of our anesthesiology residents. A hybrid curriculum consisting of a simulator as well as hands-on scanning of patients was created. We recorded the time that personnel spent in the training program as well as the money spent in acquiring equipment. Results: Seven faculty utilized a total of 270 hours of scanning and teaching time to train 48 residents who rotated through the ICU between July 2017 and June 2018. Simulation technicians used 48 hours to guide residents through simulation scenarios. The education administrator used 24 hours to coordinate sessions for residents. The technician and coordinator were both employees of the department with no additional cost for their responsibilities. The cost of equipment, including the ultrasound machine and simulator, was $45,000. An additional charge of $3500 was incurred for technician training time. Conclusion: Implementing a robust, sustainable POCUS curriculum requires a significant investment of time and money. Simulators and e-learning can allow efficiency in resource allocation and control cost in orienting new students to ultrasound. Having residents go through the simulator decreased the time that faculty would otherwise have spent going over basics with the students while allowing students to master these skills at their own pace. Advances in ultrasound technology have created newer, more affordable machines which can decrease cost considerably. It would serve departments well to consider alternatives and plan for resources when deciding to implement POCUS curriculum for resident training.
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Affiliation(s)
- Ranjit Deshpande
- Department of Anesthesiology, Yale School of Medicine,
New Haven, CT,To whom all correspondence should be addressed:
Ranjit Deshpande M.B.B.S., Assistant Professor of Anesthesiology, Yale School of
Medicine, 333 Cedar Street, TMP-3, New Haven, CT 06511; Tel: 203-785-2802, Fax:
203-785-6664, , ORCID iD: https://orcid.org/0000-0001-7348-194X
| | - Ruchika Karnik
- Department of Pediatrics, Yale School of Medicine, New
Haven, CT
| | - Christine Baer
- Department of Anesthesiology, Yale School of Medicine,
New Haven, CT
| | - Viji Kurup
- Department of Anesthesiology, Yale School of Medicine,
New Haven, CT
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12
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Karnik R, Geiger M. Cardiac Manifestations of Noonan Syndrome. Pediatr Endocrinol Rev 2019; 16:471-476. [PMID: 31115199 DOI: 10.17458/per.vol16.2019.kpg.manifestationsnoonan] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Noonan syndrome NS, a RASopathy, is commonly seen in association with cardiovascular abnormalities, with structural defects and/or cardiomyopathy present in 80-90-% of cases. Though a wide spectrum of cardiac pathology has been reported, pulmonary stenosis is the most common structural abnormality and more likely to be seen in PTPN11 mutations. Hypertrophic cardiomyopathy is the second most common and is more often associated with RAF1 mutations. Cardiac disease tends to be more progressive in infants and children with NS and therefore close cardiology follow-up is indicated. In general, the earlier the presentation, the more severe the phenotype and worse the long term prognosis. As genotype phenotype associations are being better understood, the mechanisms for development of cardiomyopathy are also becoming elucidated, raising the possibility of medical therapies targeted at the involved pathway.
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Affiliation(s)
- Ruchika Karnik
- Division of Pediatric Cardiology, Yale School of Medicine, New Haven, CT 06519, USA
| | - Miwa Geiger
- Division of Pediatric Cardiology, Mount Sinai hospital, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1201, New York, NY 10029, USA, E-mail:
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13
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Kantharia B, Shah A, Chutani S, Karnik R, Singh A. P1828Effects of interventricular pacing timings on the left ventricle activation and clinical outcome in patients treated with cardiac resynchronization therapy. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p1828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- B Kantharia
- Cardiovascular and Heart Rhythm Consultants, New York, United States of America
| | - A Shah
- Cardiovascular and Heart Rhythm Consultants, New York, United States of America
| | - S Chutani
- Cardiovascular and Heart Rhythm Consultants, New York, United States of America
| | - R Karnik
- Phoenix Heart, Cardiovascular Consultants, Banner Thunderbird Medical Center, Phoenix, United States of America
| | - A Singh
- Phoenix Heart, Cardiovascular Consultants, Banner Thunderbird Medical Center, Phoenix, United States of America
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Rajagopal H, Uppu SC, Weigand J, Lee S, Karnik R, Ko H, Bhatla P, Nielsen J, Doucette J, Parness I, Srivastava S. Validation of Right Atrial Area as a Measure of Right Atrial Size and Normal Values of in Healthy Pediatric Population by Two-Dimensional Echocardiography. Pediatr Cardiol 2018. [PMID: 29523923 DOI: 10.1007/s00246-018-1838-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Right atrial (RA) size is a prognostic indicator for heart failure and cardiovascular death in adults. Data regarding use of RA area (RAA) by two-dimensional echocardiography as a surrogate for RA size and allometric modeling to define appropriate indexing of the RAA are lacking. Our objective was to validate RAA as a reliable measure of RA size and to define normal reference values by transthoracic echocardiography (TTE) in a large population of healthy children and develop Z-scores using a validated allometric model for indexing RAA independent of age, sex, and body size. Agreement between RAA and volume by 2D, 3D TTE, and MRI was assessed. RAA not volume by 2D TTE is an excellent surrogate for RA size. RAA/BSA1 has an inverse correlation with BSA with a residual relationship to BSA (r = - 0.54, p < 0.0001). The allometric exponent (AE) derived for the entire cohort (0.85) also fails to eliminate the residual relationship. The entire cohort divided into two groups with a BSA cut-off of 1 m2 to provide the best-fit allometric model (r = 0). The AE by least square regression analysis for each group is 0.95 and 0.88 for BSA < 1 m2 and > 1 m2, respectively, and was validated against an independent sample. The mean indexed RAA ± SD for BSA ≤ 1 m2 and > 1 m2 is 9.7 ± 1.3 cm2 and 8.7 ± 1.3 cm2, respectively, and was used to derive Z-scores. RAA by 2D TTE is superior to 2D or 3D echocardiography-derived RA volume as a measure of RA size using CMR as the reference standard. RAA when indexed to BSA1, decreases as body size increases. The best-fit allometric modeling is used to create Z scores. RAA/BSA0.95 for BSA < 1 m2 and RAA/BSA0.88 for those with BSA > 1 m2 can be used to derive Z scores.
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Affiliation(s)
- Hari Rajagopal
- Department of Pediatric Cardiology, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1030, New York, NY, USA
| | - Santosh C Uppu
- Department of Pediatric Cardiology, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1030, New York, NY, USA
| | - Justin Weigand
- Department of Pediatric Cardiology, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1030, New York, NY, USA
| | - Simon Lee
- Department of Pediatric Cardiology, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1030, New York, NY, USA
| | - Ruchika Karnik
- Department of Pediatric Cardiology, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1030, New York, NY, USA
| | - Helen Ko
- Department of Pediatric Cardiology, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1030, New York, NY, USA
| | - Puneet Bhatla
- Department of Pediatric Cardiology, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1030, New York, NY, USA
| | - James Nielsen
- Department of Pediatric Cardiology, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1030, New York, NY, USA
| | - John Doucette
- Biostatistics, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1030, New York, NY, 10029, USA
| | - Ira Parness
- Department of Pediatric Cardiology, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1030, New York, NY, USA
| | - Shubhika Srivastava
- Department of Pediatric Cardiology, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1030, New York, NY, USA.
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15
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Shenoy RU, Adlakha H, Malik P, Donthula R, Rajagopal H, Kan A, Karnik R, Srivastava S. SYSTEMIC VENTRICULAR STRAIN IS ABNORMAL IN OBESE ADULTS WITH CONGENITAL HEART DISEASE. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)31154-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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16
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Adlakha H, Karnik R, Adams D, Nguyen K, Love B. MITRAL VALVE REGURGITATION AFTER FONTAN PROCEDURE: WHEN AND WHERE TO REPAIR. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)33027-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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17
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Tozzi M, Karnik R, Tozzi R, Love B. DECISION-MAKING IN CONGENITALLY CORRECTED TRANSPOSITION OF THE GREAT ARTERIES. J Am Coll Cardiol 2017. [DOI: 10.1016/s0735-1097(17)35654-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Affiliation(s)
| | | | - Raj Sahulee
- Icahn School of Medicine at Mount Sinai, New York, NY
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Karnik R, Trailokya A, Kamlesh P, Mukaddam Q, Naik M. Evaluation and assessment of rosuvastatin 40 mg treatment in high risk dyslipidemic patients (EARTH Study). Indian Heart J 2014. [DOI: 10.1016/j.ihj.2014.10.241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Abstract
Children diagnosed with cancer are now living longer as a result of advances in treatment. However, some commonly used anticancer drugs, although effective in curing cancer, can also cause adverse late effects. The cardiotoxic effects of anthracycline chemotherapy, such as doxorubicin, and radiation can cause persistent and progressive cardiovascular damage, emphasizing a need for effective prevention and treatment to reduce or avoid cardiotoxicity. Examples of risk factors for cardiotoxicity in children include higher anthracycline cumulative dose, higher dose of radiation, younger age at diagnosis, female sex, trisomy 21 and black race. However, not all who are exposed to toxic treatments experience cardiotoxicity, suggesting the possibility of a genetic predisposition. Cardioprotective strategies under investigation include the use of dexrazoxane, which provides short- and long-term cardioprotection in children treated with doxorubicin without interfering with oncological efficacy, the use of less toxic anthracycline derivatives and nutritional supplements. Evidence-based monitoring and screening are needed to identify early signs of cardiotoxicity that have been validated as surrogates of subsequent clinically significant cardiovascular disease before the occurrence of cardiac damage, in patients who may be at higher risk.
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Affiliation(s)
- Steven E Lipshultz
- Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Fla., USA
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21
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Lipshultz SE, Chandar JJ, Rusconi PG, Fornoni A, Abitbol CL, Burke GW, Zilleruelo GE, Pham SM, Perez EE, Karnik R, Hunter JA, Dauphin DD, Wilkinson JD. Issues in solid-organ transplantation in children: translational research from bench to bedside. Clinics (Sao Paulo) 2014; 69 Suppl 1:55-72. [PMID: 24860861 PMCID: PMC3884162 DOI: 10.6061/clinics/2014(sup01)11] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
In this review, we identify important challenges facing physicians responsible for renal and cardiac transplantation in children based on a review of the contemporary medical literature. Regarding pediatric renal transplantation, we discuss the challenge of antibody-mediated rejection, focusing on both acute and chronic antibody-mediated rejection. We review new diagnostic approaches to antibody-mediated rejection, such as panel-reactive antibodies, donor-specific cross-matching, antibody assays, risk assessment and diagnosis of antibody-mediated rejection, the pathology of antibody-mediated rejection, the issue of ABO incompatibility in renal transplantation, new therapies for antibody-mediated rejection, inhibiting of residual antibodies, the suppression or depletion of B-cells, genetic approaches to treating acute antibody-mediated rejection, and identifying future translational research directions in kidney transplantation in children. Regarding pediatric cardiac transplantation, we discuss the mechanisms of cardiac transplant rejection, including the role of endomyocardial biopsy in detecting graft rejection and the role of biomarkers in detecting cardiac graft rejection, including biomarkers of inflammation, cardiomyocyte injury, or stress. We review cardiac allograft vasculopathy. We also address the role of genetic analyses, including genome-wide association studies, gene expression profiling using entities such as AlloMap®, and adenosine triphosphate release as a measure of immune function using the Cylex® ImmuKnow™ cell function assay. Finally, we identify future translational research directions in heart transplantation in children.
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Affiliation(s)
- Steven E Lipshultz
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit, MI, United States
| | - Jayanthi J Chandar
- Division of Pediatric Nephrology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Paolo G Rusconi
- Division of Pediatric Cardiology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Alessia Fornoni
- Division of Pediatric Nephrology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Carolyn L Abitbol
- Division of Pediatric Nephrology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, United States
| | - George W Burke
- Division of Pediatric Nephrology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Gaston E Zilleruelo
- Division of Pediatric Nephrology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Si M Pham
- Artificial Heart Programs, Transplant Institute, Jackson Memorial Division of Heart/Lung Transplant, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Elena E Perez
- Division of Pediatric Immunology and Allergy, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Ruchika Karnik
- Division of Pediatric Cardiology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Juanita A Hunter
- Division of Pediatric Cardiology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Danielle D Dauphin
- Division of Pediatric Clinical Research, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, United States
| | - James D Wilkinson
- Division of Pediatric Clinical Research, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, United States
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Karnik R, Rothmund T, Bonner G, Valentin A, Reuther G. Inline skating as a possible cause of consecutive bilateral vertebral artery dissection. Acta Neurol Scand 2012. [DOI: 10.1034/j.1600-0404.2000.00010.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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23
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Humplik T, Lee J, O'Hern SC, Fellman BA, Baig MA, Hassan SF, Atieh MA, Rahman F, Laoui T, Karnik R, Wang EN. Nanostructured materials for water desalination. Nanotechnology 2011; 22:292001. [PMID: 21680966 DOI: 10.1088/0957-4484/22/29/292001] [Citation(s) in RCA: 255] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Desalination of seawater and brackish water is becoming an increasingly important means to address the scarcity of fresh water resources in the world. Decreasing the energy requirements and infrastructure costs of existing desalination technologies remains a challenge. By enabling the manipulation of matter and control of transport at nanometer length scales, the emergence of nanotechnology offers new opportunities to advance water desalination technologies. This review focuses on nanostructured materials that are directly involved in the separation of water from salt as opposed to mitigating issues such as fouling. We discuss separation mechanisms and novel transport phenomena in materials including zeolites, carbon nanotubes, and graphene with potential applications to reverse osmosis, capacitive deionization, and multi-stage flash, among others. Such nanostructured materials can potentially enable the development of next-generation desalination systems with increased efficiency and capacity.
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Affiliation(s)
- T Humplik
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
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Karnik R, Slany J, Hanslik R, Leitner H, Marberger M. Der akute Nierenarterienverschluß - lokale Fibrinolysetherapie. Aktuelle Urol 2008. [DOI: 10.1055/s-2008-1062597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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25
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Karnik R, Valentin A. [Flying fitness of patients with cardiovascular diseases]. Wien Med Wochenschr 2002; 152:462-5. [PMID: 12385069 DOI: 10.1046/j.1563-258x.2002.02074.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Air travel of persons with coronary heart disease, heart failure and cyanotic congenital heart disease will be without complications and problems in the most cases. Prerequisite for an uneventful flight are stable cardiac conditions and an extensive cardiac examination including echocardiography and exercise testing before starting the journey. Careful travel planning and timing to reduce travel stress is mandatory. To determine fitness for air travel left heart catheterization is required in most patients with acute coronary syndrome. Patients with an acute coronary syndrome may repatriated with medical escort within the first 2 weeks after the acute event. Patients with a low risk profile can fly with reasonable safety 14 to 21 days after the acute event without medical escort. Fitness to travel may be given within a few days after successful percutaneous coronary intervention in individual cases. Patients with severe acute cardiovascular diseases and an appropriate medical indication may be transferred by air ambulance after acute local medical care and pretransfer stabilisation with ambulance jet under intensive care conditions. In these cases close cooperation between the doctor in charge, cardiologist and cardiologic department respectively and air ambulance is mandatory.
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Affiliation(s)
- R Karnik
- 2. Medizinische Abteilung, Krankenanstalt Rudolfstiftung, Juchgasse 25, A-1030 Wien.
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Schwarzmaier A, Riezinger-Geppert F, Schober G, Karnik R, Valentin A. Fulminant septic melioidosis after a vacation in Thailand. Wien Klin Wochenschr 2000; 112:892-5. [PMID: 11244616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Severe infection with Burkholderia pseudomallei (formerly Pseudomonas pseudomallei), the bacterium causing melioidosis, is a common cause of acquired septicaemia in south-east Asia and northern Australia. A few cases of infected travellers returning to European countries have been reported. Melioidosis is a tropical disease, the clinical presentation ranging from asymptomatic infection to fulminant sepsis. Predisposing conditions such as impaired cellular immunity, preexisting renal failure or diabetes mellitus seem to enhance the severity of the disease. For a definite diagnosis the bacterium has to be isolated. The antimicrobial treatment of choice is ceftazidime in combination with co-trimoxazole or doxycycline. Even with correct antibiotic treatment the mortality rate is high in cases of fulminant sepsis. We report a 29-year old man with Type I diabetes who acquired melioidosis during a vacation in Thailand. After returning to Austria he was admitted to the intensive care unit with multiple organ failure. Despite intensive care treatment the patient's infection proved lethal. Burkholderia pseudomallei was isolated from the blood and bronchoalveolar lavage.
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Affiliation(s)
- A Schwarzmaier
- Second Department of Medicine, KA Rudolfstiftung, Vienna, Austria
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Karnik R, Valentin A, Ammerer HP, Hochfelner A, Donath P, Slany J. Outcome in patients with intracerebral hemorrhage: predictors of survival. Wien Klin Wochenschr 2000; 112:169-73. [PMID: 10726330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
BACKGROUND AND PURPOSE The aim of this retrospective study was to determine in-hospital mortality and morbidity secondary to intracerebral hemorrhage and to analyse variables considered to be significantly associated with survival in these patients. PATIENTS AND METHODS The study cohort consisted of 135 consecutive patients with intracerebral hemorrhage, admitted to a large community hospital in the urban area of Vienna. The diagnosis of intracerebral hemorrhage was established in all cases with axial computed tomography. The following variables were analysed: age, sex, Glasgow coma score on admission, location of hematomas, intraventricular hemorrhage, neurosurgical interventions and medical complications. RESULTS Sixty-seven (49.6%) of the 135 patients died, 50 (37%) of them during the first 4 days after the acute event, 13 within the 1st week and 4 within one month. In a multivariate analysis the risk of death was significantly increased by the presence of intraventricular hemorrhage (p < 0.01), a Glasgow coma score of 6 or less (p < 0.0001) and age greater than 60 years (p < 0.001). Gender, medical complications and surgical removal of hemorrhage with or without additional ventriculostomy did not correlate significantly with outcome while an infratentorial location of hematoma showed a trend (p < 0.15) towards a higher mortality. CONCLUSION A Glasgow coma score of 6 or less on admission, age greater than 60 years and the presence of intraventricular hemorrhage appear to be predictors of mortality in patients with intracerebral hemorrhage.
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Affiliation(s)
- R Karnik
- 2nd Department of Medicine, Krankenanstalt Rudolfstifung, Vienna, Austria
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Karnik R, Rothmund T, Bonner G, Valentin A, Reuther G. Inline skating as a possible cause of consecutive bilateral vertebral artery dissection. Acta Neurol Scand 2000; 101:70-1. [PMID: 10660157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
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29
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Abstract
Coil embolization of tumor-related coronary arteries was successful in interrupting coronary supply to a cardiac metastasis from uterine leiomyosarcoma. In patients with cardiac metastases of highly malignant tumors this may be a palliative therapeutic approach.
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Affiliation(s)
- A Valentin
- II. Medical Department, KA Rudolfstiftung, Vienna, Austria.
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Valentin A, Karnik R, Winkler WB, Hochfellner A, Slany J. Transcranial Doppler for early identification of potential organ transplant donors. Wien Klin Wochenschr 1997; 109:836-9. [PMID: 9408980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Encouraging results in transplant medicine create a growing demand for organ transplant donors. Transcranial Doppler (TCD) has been used by several investigators to assess arrest of the cerebral circulation in brain dead patients. We report on TCD as a monitoring tool for early identification of potential organ transplant donors. DESIGN A prospective clinical study. SETTING Intensive care unit (ICU) of a 900-bed community hospital (primary and tertiary care center) in Vienna, Austria. SUBJECTS AND METHODS All patients with acute intracranial lesions admitted to our intensive care unit underwent TCD examination at least once daily. In patients with Glasgow Coma Scores < 7, TCD waveforms with high resistance profiles unchanged by therapeutic attempts to lower intracranial pressure indicated the need for repeated TCD up to four times a day. TCD waveform abnormality consisting of absent or reversed diastolic flow or small early systolic spikes in at least two intracranial arteries was considered to constitute intracranial circulatory arrest. Brain death was confirmed by clinical criteria, an isoelectric electroencephalography (EEG) or non filling of the intracerebral arteries on arteriography. RESULTS From January 1994 to July 1996 we identified 11 comatose patients as potential organ transplant donors with typical TCD findings indicating intracranial circulatory arrest. Diagnosis was subarachnoid hemorrhage in 7 and intracerebral hemorrhage in 4 patients. Brain death diagnosis according to the criteria of Austrian law was initiated immediately after the TCD findings suggested intracranial circulatory arrest. Confirmation of brain death was obtained by clinical criteria and either EEG (6 patients) or cerebral angiography (5 patients). CONCLUSION TCD examinations on a daily routine basis offer a noninvasive monitoring method for early assessment of intracranial circulatory arrest. TCD enables quick identification and further diagnosis of candidates for organ transplant donation.
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Affiliation(s)
- A Valentin
- II. Medical Department, Krankenanstalt Rudolfstiftung, Vienna, Austria
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Park PH, Lee YM, Jung YS, Koh Y, Lim CM, Lee JH, Lim TH, Asensio MJ, Peláez J, Yus S, Díaz D, Arce MA, Jiménez M, Sánchez M, López J, Valentin A, Karnik R, Winkler WB, Hochfellner A, Slany J, Parr MJA, Brown MM, Manara AR, Platikanov W, Rousseff R, Kolarov G, Moccia F, Colla G, Castelli F, Altomonte F, Greco G, Gionis D, Kalabalikis P, Vasilopoulos A, Papadatos J, Koh WY, Lew TWK, Seah TG, Chin NM, Wong M, Bruzzone P, Bellinzona G, Imberti R, Albertario F, Ticozzelli G, Dionigi RV, Gracia RM, Torres F, Báguena M, Vives I, Robles A, Palomar M, Garnacho A, Sahuquillo J, Massa LS, Hopton P, Walsh T, Lee A, Gianotti A, Piazzi B, Bettini C, Borghi T, Gemma M, Stokić A, Stokić E, Belopavlović J, Peković V, Radunović T, Drašković B, Kenaroy P, Poptodorov G, Kahveci SF, Bekar A, Tamgaç F, Korfali G, Alper E, Wagner F, Ziegler U, Behse F, Hummel M, Hetzer R, Moraine JJ, Brimioulle S, Kahn RJ. Posters. Intensive Care Med 1996. [DOI: 10.1007/bf03216438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
BACKGROUND AND PURPOSE Cerebral vasomotor reactivity can easily be assessed reliably by measuring vasodilatory response to acetazolamide by transcranial Doppler sonography. The aim of this study was to confirm the hypothesis that female sex is associated with an increased cerebrovascular flow reserve. METHODS Blood flow velocity of the middle cerebral artery was measured by transcranial Doppler sonography in 36 healthy sex- and age-matched subjects. After the initial blood flow velocities were recorded, the subjects received 14.3 mg/kg body wt acetazolamide, ie, 1 g/70 kg, intravenously. The measurements were repeatedly performed at 5-minute intervals starting 10 minutes after injection and lasting for 30 minutes. The highest measured flow velocities were used for further analysis. RESULTS In both groups mean blood flow velocity increased significantly after acetazolamide (women, from 60.2 +/- 12.5 to 89.9 +/- 14.4 cm/s, P < .006; men, from 54.5 +/- 18.8 to 75.7 +/- 24.5 cm/s, P < .02). The difference in mean blood flow velocity after acetazolamide between groups of women and men was statistically significant (P < .02). CONCLUSIONS Female subjects show an increased vasodilatory response to the acetazolamide test compared with men.
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Affiliation(s)
- R Karnik
- Second Department of Medicine, Krankenanstalt Rudolfstiftung, Vienna, Austria
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Abstract
We present two patients with an extremely rare condition: abnormal cardiac levoposition. Alterations in the ECG caused by this congenital abnormality and additional chest symptoms led to the false diagnosis of previous myocardial infarction. Chest X-ray and echocardiography suggested cardiac malformation. Correct diagnosis of cardiac levoposition was established by magnetic resonance imaging.
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Affiliation(s)
- A Valentin
- II. Medical Department, Krankenanstalt Rudolfstiftung, Vienna, Austria
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35
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Karnik R, Winkler WB, Valentin A, Khaffaf N, Slany J. Carotid sinus massage and the risk of cerebral embolization. Stroke 1995; 26:1124-5. [PMID: 7762034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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36
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Karnik R, Genée P, Ulram A, Winkler WB, Valentin A, Leitner H, Slany J. [Syringomyelia as a rare cause of respiratory insufficiency requiring ventilation]. Dtsch Med Wochenschr 1994; 119:1771-5. [PMID: 7736931 DOI: 10.1055/s-2008-1058899] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
For 17 years a now 45-year-old man had suffered from progressively more severe flaccid paresis of the arms and thoracic muscles, spastic paralysis of the legs and kyphoscoliosis. Artificial ventilation was required when he contracted pneumonia. Although it was being treated with antibiotics, frequent bronchoalveolar lavage had to be done because of repeated atelectases. After 6 weeks clonuses developed in the legs, predominantly on the right, stretch synergisms and opisthotonos. The pupils were small with sluggish reaction to light, and there was a positive "doll's head" phenomenon. The level of consciousness alternated between somnolence and sleepiness. Magnetic resonance imaging demonstrated cavities in cervical and thoracic spinal cord, supporting the diagnosis of an abnormal cerebrospinal circulation due to gliosis in syringomyelia. To secure cerebrospinal fluid drainage, the cerebellar tonsils were resected, together with a duraplasty and partial resection of the atlas. Following this he became fully conscious and the spastic state improved. During the following 8 weeks it became possible gradually to wean him from the artificial ventilation and achieve satisfactory mobilization so that he could be discharged to domiciliary care.
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Affiliation(s)
- R Karnik
- II. Medizinische Abteilung, Krankenanstalt Rudolfstiftung, Wien
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Abstract
Three male patients with purulent pericarditis, in whom complete drainage could not be obtained by pericardiocentesis, were treated with transcatheter intrapericardial urokinase to prevent the development of chronic constrictive pericarditis. As shown by echocardiography, the intrapericardial fibrin layers disappeared in two cases and were reduced by more than half in the third. Effects on systemic coagulation indices and complications related to intrapericardial lysis were not observed.
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Affiliation(s)
- W B Winkler
- Department of Internal Medicine II, Krankenanstalt Rudolfstiftung, Wien, Austria
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38
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Winkler WB, Karnik R, Seelmann O, Havlicek J, Slany J. Bedside percutaneous dilational tracheostomy with endoscopic guidance: experience with 71 ICU patients. Intensive Care Med 1994; 20:476-9. [PMID: 7995862 DOI: 10.1007/bf01711898] [Citation(s) in RCA: 116] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To assess the value of endoscopic guidance in bedside percutaneous dilational tracheostomy. DESIGN The medical critical care unit of a large community hospital. SETTING 71 consecutive adult patients who required prolonged mechanical ventilation. INTERVENTIONS 72 elective percutaneous dilational tracheostomies using the Ciaglia technique were performed under view of a flexible fiberoptic bronchoscope. MEASUREMENTS AND RESULTS Patients were examined during tracheostomy and on days 2 and 7 after the procedure, at discharge and after half a year if they were still alive. A correct median puncture was observed by endoscopic control in 59 interventions. An initial paramedian puncture was detected in 13/72 (18%) procedures and was corrected by renewed insertion in all cases. No severe complications related to percutaneous dilational tracheostomy were noticed. Minor complications occurred in 4/71 (5.6%) patients including minor bleeding in 2, inflammatory infiltration in 1 and one superficial lesion of the posterior tracheal mucosa. Long-term follow-up revealed stomal granulation in 3 patients including one at the tracheal site. At the end of the observation period the tracheostomy still was in use in 14/71 (20%) patients and 12/71 (17%) patients were decannulated. Due to their severe underlying diseases 45/71 (63%) patients had died. To facilitate weaning from the tracheostomy a minitracheostomy tube was used in 3 patients. CONCLUSION Percutaneous dilational tracheostomy is a simple bedside procedure associated with a low complication rate. We recommend the use of endoscopic guidance to increase the safety of tracheal puncture and dilation procedure.
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Affiliation(s)
- W B Winkler
- 2nd Medical Department, Krankenanstalt Rudolfstiftung, Vienna, Austria
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Abstract
BACKGROUND AND PURPOSE Embolic complications during ultrasound examinations are a rare cause of neurological deficits. The present case documents the occurrence of embolism by a nonobstructive compression maneuver during transcranial Doppler examination, resulting in a minor stroke. CASE DESCRIPTION A 63-year-old man suffered from recurrent transient ischemic attacks. Duplex sonography showed a small echogenic plaque at the right carotid bifurcation. During transcranial Doppler studies with a reverberating compression maneuver of the right common carotid artery low in the neck, multiple emboli signals were detected, and the patient developed a left-sided hemiparesis with slurred speech. Funduscopy revealed cholesterol emboli in the inferior temporal arteriole of the right eye. These findings suggested embolization as the cause of the stroke. CONCLUSIONS Compression maneuvers should not be performed in patients with recent neurological symptoms, even in the case of only small lesions in the extracranial carotid territory.
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Affiliation(s)
- N Khaffaf
- Second Department of Medicine, Krankenanstalt Rudolfstiftung, Vienna, Austria
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Abstract
BACKGROUND AND PURPOSE To assess the feasibility of intravascular ultrasound imaging during carotid endarterectomy. METHODS Intravascular ultrasound imaging was performed during carotid endarterectomy in eight patients using an over-the-wire catheter system with a 30-MHz ultrasound probe. In vitro studies were carried out before the intraoperative application, paying special attention to visualization of the wall layers of normal carotid arteries, structures of more or less diseased vessels, and surgically placed materials such as patch, suture material, and fibrin glue. Although intravascular ultrasound failed to distinguish between intima and media in areas of normal intima, fibrotic and calcified plaques were detected clearly. Dacron patch as well as sutures were identified as highly reflective structures. RESULTS In seven of the eight patients studied, intravascular ultrasound yielded cross-sectional images of good quality allowing identification of the vessel layers and the structures at the endarterectomy site. In all patients the three layers of the vessel wall were clearly differentiated and the transition zone between the site of endarterectomy and the genuine vessel appeared smooth without intimal flaps or residual arteriosclerotic plaques. In one patient severe eccentric thickening of the media was detected in the distal internal carotid artery. Neither damage of the vessel layers by the shunt nor thrombus formation in the operating area and the internal carotid artery were detected. CONCLUSIONS Intravascular ultrasound lends itself as a potentially valuable method of quality control during carotid endarterectomy. The method seems to enable an accurate evaluation of the endarterectomy site and the search for residual plaques.
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Affiliation(s)
- R Karnik
- 2nd Department of Medicine, Krankenanstalt Rudolfstiftung, Vienna, Austria
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Abstract
OBJECTIVE To determine the prevalence of venous thrombosis in patients with suspected paradoxical embolism. DESIGN Observational study. PATIENTS Two hundred sixty-four patients with clinically suspected embolic events underwent contrast transesophageal echocardiographic evaluation. Forty-nine patients (24 women, 25 men) had a patent foramen ovale. Forty-one patients had acute stroke, and 8 had acute limb ischemia. SETTING Echocardiography laboratory of a community hospital. MEASUREMENTS The presence of a patent foramen ovale was assessed by transesophageal contrast echocardiography. Forty-two patients had venographic evaluation of the lower-extremity venous system. RESULTS Venous thrombosis was clinically suspected in 6 patients and documented in 24 of the 42 patients with patent foramen ovale who underwent venographic study (57%; 95% Cl, 41% to 72%). Venous thrombosis was confined to calf or popliteal veins in 15 cases. Fifteen of 17 patients who had venographic evaluation within 7 days of the index event had thrombosis compared with 9 of 25 patients who had later evaluations (P = 0.001). More patients with venous thrombosis than without venous thrombosis had a history of previous thromboembolism (13 of 24 compared with 1 of 18 [corrected], respectively; P = 0.001). CONCLUSION When a patent foramen ovale is detected in a patient with embolism, occult leg vein thrombosis is frequently present.
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Abstract
Intra-operative transluminal angioplasty of supra-aortic vessels was performed in 9 patients. All subjects had lesions which were considered difficult or impossible to operate upon. In 2 patients a proximal occlusion of the left subclavian artery was dilated. Seven subjects showed severe stenoses of the supra-aortic vessels: common carotid artery: 1, internal carotid artery: 2, external carotid artery: 1, external carotid artery prosthetic graft: 1, brachiocephalic trunk: 1, vertebral artery: 1. All patients suffered from symptoms which corresponded to the site of the lesions in question. Intra-operative angioplasty was primarily successful in all 9 patients. Re-occlusion occurred within a few days in both patients who underwent angioplasty of the subclavian artery. Six of the seven subjects with stenotic lesions remained free of symptoms and of restenosis. In the case of dilatation of a prosthetic graft of the external carotid artery asymptomatic occlusion developed within 8 weeks. In selected cases intra-operative angioplasty is a potentially valuable alternative in the treatment of surgically inaccessible lesions of the supra-aortic vessels.
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Affiliation(s)
- R Karnik
- Second Department of Medicine, Krankenanstalt Rudolfstiftung, Wien, Austria
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Karnik R, Valentin A, Winkler WB, Donath P, Slany J. Duplex sonographic detection of internal jugular venous thrombosis after removal of central venous catheters. Clin Cardiol 1993; 16:26-9. [PMID: 8416756 DOI: 10.1002/clc.4960160106] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Venous thrombosis is a very common complication of central venous catheters inserted via the jugular or subclavian vein. The aim of this prospective study is to test the suitability of duplex sonography in detecting thrombi in the internal jugular vein after catheter removal and to analyze the number and extent of such thrombus formations. The study group comprised 64 consecutive patients with an average age of 59 +/- 16 years admitted to an internal intensive care unit. In 54 cases the catheters were removed under sonographic control. In 10 cases duplex sonography was carried out within 24 h after removal of the catheters. The data of 63 patients were evaluated. In 40 patients (63.5%), thrombi of varying extent were present in the jugular vein. No significant correlations were found between thrombus formation and the basic disease, duration of cannulation, the type of catheters used, and the mode of heparinization (therapeutic vs. low-dose). Local inflammation signs and local hematoma showed a significantly higher incidence (p < 0.01) in patients with thrombus formation. Duplex sonography lends itself as a valuable diagnostic tool in the diagnosis of thrombus formation in the internal jugular vein after removal of central venous catheters. Sonographic examinations should be carried out in all long-stay patients at an intensive care unit, in whom central venous catheters are inserted repeatedly via the internal jugular vein.
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Affiliation(s)
- R Karnik
- Second Department of Medicine, Krankenanstalt Rudolfstiftung, Vienna, Austria
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Valentin A, Karnik R, Winkler W, Slany J. Outcomes of cardiopulmonary resuscitation in hospitalized patients. Resuscitation 1992. [DOI: 10.1016/0300-9572(92)90137-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Karnik R, Valentin A, Ammerer HP, Donath P, Slany J. Evaluation of vasomotor reactivity by transcranial Doppler and acetazolamide test before and after extracranial-intracranial bypass in patients with internal carotid artery occlusion. Stroke 1992; 23:812-7. [PMID: 1595097 DOI: 10.1161/01.str.23.6.812] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE The aim of this trial was to evaluate the effectiveness of extracranial-intracranial bypass with respect to vasomotor reactivity in patients with internal carotid artery occlusions and absent vasomotor reactivity, comparing them with a control group treated conservatively. METHODS To test vasomotor reactivity in 104 patients with unilateral occlusion of the internal carotid artery, we measured blood flow velocity in the middle cerebral artery by transcranial Doppler sonography both at rest and after injection of acetazolamide. Among the 39 patients who failed to show increased mean blood flow velocity after the acetazolamide test distal to an occluded internal carotid artery by greater than or equal to 10%, 14 subjects subsequently underwent extracranial-intracranial bypass surgery (group A) and 14 age- and sex-matched subjects in whom no such procedure was done composed the control group (group B). Follow-up examinations were performed 3-6 months postoperatively and in the control group 3-6 months after initial examination. RESULTS Baseline values of the mean blood flow velocity at rest on the affected side were reduced in both groups compared with the contralateral healthy side (group A, 46.0 +/- 15.1 cm/sec; group B, 48.1 +/- 16.7 cm/sec) and revealed only a marginal increase after acetazolamide. The contralateral side showed a normal blood flow velocity at rest and an adequate response to acetazolamide in both groups. On the follow-up examination group A demonstrated a normalized vasodilatory capacity. Blood flow velocity increased significantly after acetazolamide from 41.9 +/- 13.1 cm/sec to 53.5 +/- 16.0 cm/sec (p less than 0.002). In group B, the compromised vasomotor reactivity remained unchanged. CONCLUSIONS Our results demonstrate that transcranial Doppler sonography together with the acetazolamide test can identify subjects with reduced vasomotor reactivity distal to an occluded internal carotid artery, who may improve hemodynamically by an extracranial-intracranial bypass.
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Affiliation(s)
- R Karnik
- Department of Internal Medicine, Krankenanstalt Rudolfstiftung, Vienna, Austria
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Affiliation(s)
- R Karnik
- 2nd Department of Medicine, Krankenanstalt Rudolfstiftung, Vienna, Austria
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47
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Affiliation(s)
- R Karnik
- 2nd Department of Medicine, Krankenanstalt Rudolfstiftung, Vienna, Austria
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Karnik R, Stelzer P, Slany J. Transcranial Doppler sonography monitoring of local intra-arterial thrombolysis in acute occlusion of the middle cerebral artery. Stroke 1992; 23:284-7. [PMID: 1561660 DOI: 10.1161/01.str.23.2.284] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE The aim of this study is to report on the use of transcranial Doppler ultrasonography as a noninvasive diagnostic monitoring tool during local intra-arterial thrombolysis in a patient with acute embolic occlusion of the middle cerebral artery. CASE DESCRIPTION We describe a 41-year-old woman with mitral valve stenosis suffering from embolism of the middle cerebral artery. Local thrombolysis was performed with tissue plasminogen activator at a dosage of 0.05 mg/kg/hr. Progress of the thrombolysis was monitored by transcranial Doppler. The steps of recanalization could be ascertained by transcranial ultrasound showing a hemodynamically relevant residual stenosis after the first 120 minutes and complete patency of the M1 segment of the middle cerebral artery 180 minutes later. One branch of the middle cerebral artery still showed a filling defect. CONCLUSIONS Our report demonstrates the potential usefulness of transcranial Doppler monitoring during thrombolysis of a proximal occlusion of the middle cerebral artery for guiding the treatment by assessing the reperfusion of the obstructed artery.
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Affiliation(s)
- R Karnik
- 2nd Department of Internal Medicine, Krankenanstalt Rudolfstiftung, Vienna, Austria
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Abstract
A previously healthy man, aged 33 years, suddenly developed a hemiparesis and right facial paresis, as well as anisocoria and motor aphasia, preceded by recurrent attacks of dizziness. On admission he was somnolent. A flow murmur was heard over both carotid arteries; the blood pressure was 160/80 mm Hg. Cerebral computed tomography demonstrated multiple hypodense areas in the area supplied by several cerebral arteries, and marked cerebral oedema. Angiography of the aortic arch and the supra-aortic branches showed an occlusion of the left common carotid artery and a stenosis of the brachiocephalic trunk. The cerebral oedema, caused by ischaemia, did not respond to treatment. The patient died on the fourth hospital day from brainstem "strangulation". At autopsy syphilitic mesaortitis with characteristic lymphoplasmacellular endangiitis of the vasa vasorum of the aortic arch was demonstrated as the cause of the "aortic arch syndrome". Serology confirmed the diagnosis of an untreated tertiary syphilis. (VDRL titre 1:256; TPHA reactive; IgM-SPHA titre 1:64). Although a very rare cause, a late stage of syphilis should be considered in the differential diagnosis of cerebrovascular lesions in youngish patients.
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Affiliation(s)
- A Valentin
- II. Medizinische Abteilung und Zentralröntgeninstitut der Krankenanstalt Rudolfstiftung, Wien
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50
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Abstract
Cerebral blood flow was studied in 12 elderly patients with severe calcific aortic stenosis by means of transcranial Doppler sonography (TCD) during percutaneous transluminal aortic valvuloplasty (PTAV). In 8 of these 12 patients duplex sonography revealed a stenosis of the internal carotid artery (ICA) exceeding 50%. Frequency spectra of 10 patients showed a satisfactory quality and were analyzed. In 7 subjects balloon inflation was well tolerated and systolic blood pressure did not drop below 75 mmHg. In these patients, whether they had a stenosis of the ICA or not, blood flow velocity in the middle cerebral artery (MCA) did not decrease to a critical level. The authors defined "critical" as a reduction of mean blood flow velocity in the MCA exceeding 50% or a decrease below 35 cm/sec. Three patients showed a rapid decrease of systolic aortic pressure below 75 mmHg. In these subjects mean blood flow velocity in the MCA dropped to levels below 35 cm/sec. Deflation and retraction of the balloon resulted in a rapid increase of systemic blood pressure and flow velocity in the MCA. This report demonstrates TCD to be a useful monitoring method of determining residual perfusion in patients with aortic stenosis during PTAV.
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Affiliation(s)
- R Karnik
- Second Medical Department, Krankenanstalt Rudolfstiftung, Vienna, Austria
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