Radial artery pseudoaneurysm rupture after cardiac catheterization

A 73-year-old man with history significant for paroxysmal atrial fibrillation on apixaban underwent percutaneous coronary intervention (PCI) of the left anterior descending artery via transradial access. The patient was discharged on clopidogrel, atorvastatin, carvedilol, isosorbide mononitrate, losartan, and apixaban.

Shock and Awe: Successful Revascularization with Intravascular Lithotripsy in Recurrent ST-Elevation Myocardial Infarction Secondary to Stent Under-Expansion

We report a case of recurrent ST-segment elevation myocardial infarction (STEMI) due to a previously implanted under-expanded stent with in-stent thrombosis refractory to traditional interventional techniques. We underscore the utility of bail-out shockwave intravascular lithotripsy to tackle previously under-expanded stents in this acute setting.

Shockwave Lithotripsy of Calcific Stenosis of the Distal Abdominal Aorta to Facilitate Transcatheter Aortic Valve Replacement

The transfemoral approach for transcatheter aortic valve replacement (TAVR) is superior to alternative access strategies. Only transfemoral access has been shown to have better clinical outcomes than surgical aortic valve replacement. In our patient, severe calcification of the distal abdominal aorta posed difficulty in using transfemoral access for TAVR. We applied intravascular lithotripsy (IVL) to the distal abdominal aorta to achieve necessary luminal gain facilitating bioprosthetic aortic valve deployment.

Real world single center experience with saphenous vein grafts interventions: should filters be filtered out?

BACKGROUND

Percutaneous coronary intervention (PCI) of saphenous vein grafts (SVG) can be challenging due to no reflow phenomenon from distal embolization of debris and microvascular vasoconstriction, resulting in myocardial injury post-procedure. Guidelines promote the use of distal embolic protection devices (EPD) to protect the distal arterial bed during SVG PCI. However, this approach has shown less-than-optimal results in many studies. We report our data using the Borgess protocol [prophylactic intracoronary (IC) nicardipine injection and direct stenting], as an alternative to EPDs in a large series of SVG interventions.

METHODS

This is a retrospective, cohort study of our single center experience with SVG interventions between 2017 and 2021. The primary outcome of the study was major adverse cardiovascular events (MACE) [a composite of death, emergent coronary artery bypass graft surgery (CABG), myocardial infarction (MI), and target vessel revascularization (TVR)] at 30 days post-procedure.

RESULTS

There were 424 consecutive SVG interventions performed during the study period, and 76% of cases presented with acute coronary syndrome. Full adherence to the Borgess protocol was observed in 36% of cases; IC nicardipine was utilized in 72% of cases. MACE rate was 3.5% at 30 days driven primarily by MI (2.6%).

CONCLUSION

The Borgess protocol approach to vein graft interventions proved good outcomes when compared to SVG PCI in randomized trials utilizing EPDs. Our study is limited by the retrospective nature and single center experience.

Thirty-Day Mortality for Proximal Femoral Fractures Treated at a U.K. Elective Center with a Site-Streaming Policy During the COVID-19 Pandemic

COVID-19 led to the reconfiguration of U.K. orthopaedic trauma services because surgical capacity was threatened in acute centers. We report the 30-day mortality of proximal femoral fractures in older adults treated at an elective orthopaedic center.

Prominent Thebesian Veins in Association With Takotsubo Cardiomyopathy

Thebesian veins are microvascular connections from the coronary arterial supply directly into the heart chambers. While they play an important role in providing nourishment to the myocardium by maintaining adequate perfusion, they are also responsible for a physiologic right to left shunt in the body’s circulation. We present a case report of this rare anatomic finding of extensive Thebesian veins causing acute coronary syndrome and Takostubo cardiomyopathy.

A case report of successful intravascular shockwave lithotripsy and ad hoc directional venous atherectomy of extensive chronic femoral deep venous thrombosis

Background

Conventional treatment for chronic deep venous thrombosis (DVT) is anticoagulation. However, limited interventional endovascular options exist for patients with non-healing venous ulcers secondary to chronic DVT.

Case summary

We present a case of 67-year-old man with severely symptomatic post-thrombotic syndrome (PTS) with persistent high-grade femoral DVT despite prior compressive therapy and chronic oral anticoagulation. It has been successfully treated with intravascular shockwave lithotripsy and ad hoc directional venous atherectomy facilitating subsequent mechanical thrombectomy and venoplasty. The procedure was without complication and resulted in significant clinical improvement.

Discussion

We believe our novel endovascular interventional approach represents a unique modality of intervention for patients with chronic DVT and PTS resistant to conventional venoplasty.

Impella-Assisted Intracoronary Lithotripsy of Severely Calcified Left Main Coronary Artery Bifurcation for NSTEMI With Cardiogenic Shock

High calcification of coronary artery plaque is a frequent cause of suboptimal stent expansion, which can result in stent thrombosis and restenosis. Shockwave intravascular lithotripsy (S-IVL) represents a new frontier in the treatment of highly calcified coronary lesions. It can be an excellent alternative to intracoronary atherectomy in extremely high-risk lesions. We present a case of a 57-year-old man with known severe coronary artery disease (CAD) who presented with non-ST segment elevation myocardial infarction (NSTEMI), cardiogenic shock and was successfully treated with impella-assisted shockwave-intravascular lithotripsy permitting successful percutaneous intervention of a high-risk left main coronary artery (LMCA) bifurcation in-stent restenosis.

Association between vestibular function and rotational spatial orientation perception in older adults

BACKGROUND

Spatial orientation is a complex process involving vestibular sensory input and possibly cognitive ability. Previous research demonstrated that rotational spatial orientation was worse for individuals with profound bilateral vestibular dysfunction.

OBJECTIVE

Determine whether rotational and linear vestibular function were independently associated with large amplitude rotational spatial orientation perception in healthy aging.

METHODS

Tests of rotational spatial orientation accuracy and vestibular function [vestibulo-ocular reflex (VOR), ocular and cervical vestibular evoked myogenic potentials (VEMP)] were administered to 272 healthy community-dwelling adults participating in the Baltimore Longitudinal Study of Aging. Using a mixed model multiple linear regression we regressed spatial orientation errors on lateral semicircular canal function, utricular function (ocular VEMP), and saccular function (cervical VEMP) in a single model controlling for rotation size, age, and sex.

RESULTS

After adjusting for age, and sex, individuals with bilaterally low VOR gain (β= 20.9, p = 0.014) and those with bilaterally absent utricular function (β= 9.32, p = 0.017) made significantly larger spatial orientation errors relative to individuals with normal vestibular function.

CONCLUSIONS

The current results demonstrate for the first time that either bilateral lateral semicircular canal dysfunction or bilateral utricular dysfunction are associated with worse rotational spatial orientation. We also demonstrated in a healthy aging cohort that increased age also contributes to spatial orientation ability.

Successful resuscitation of acute cardiogenic shock presenting as ventricular fibrillation via Bipella approach: a case report

BACKGROUND

The use of mechanical circulatory support (MCS) in acute myocardial infarction and cardiogenic shock (AMICS) complicated by biventricular failure is poorly discussed in the literature.

CASE SUMMARY

We present successful treatment of a 52-year-old old man presenting with AMICS following cardiac arrest and prolonged CPR via a Bipella approach for biventricular support and restoration of haemodynamic stability.

DISCUSSION

This case demonstrates the importance of understanding the role of MCS in the management of cardiogenic shock; the value of the cardiac power output and pulmonary artery pulsatility index as haemodynamic metrics to assess the cardiac function of a patient with cardiogenic shock; and the importance of a Bipella MCS approach in high inpatient morbidity and mortality AMICS with biventricular failure.

Dyschromatosis Universalis Hereditaria

Dyschromatosis universalis hereditaria (DUH) is a rare pigmentary genodermatosis usually inherited in autosomal dominant fashion characterized by multiple pinpoint to pea-sized hypo- and hyper-pigmented macules arranged in reticulate pattern that develops within the first few years of life. An 11 years old boy presented with multiple gradually progressive asymptomatic hypopigmented macules on hyperpigmented background on trunk, extremities and face since 2 years of age. Family history was absent. Punch biopsies revealed increased number of melanocytes in the epidermis with basal cell vacuolar alteration and pigmentary incontinence and perivascular infiltration by lymphocytes and melanophages in the dermis. We herein present a sporadic case of dyschromatosis universalis hereditaria.

Vestibular impairment, cognitive decline and Alzheimer's disease: balancing the evidence

The vestibular (inner ear balance) system senses head movement and orientation in space. Vestibular sensory input plays a critical role in spatial cognitive abilities such as spatial memory and spatial navigation. Vestibular function declines with age, and recent studies have shown that age-related vestibular impairment is associated with poorer spatial cognitive skills in healthy older adults. Moreover, vestibular impairment is disproportionately prevalent among individuals with mild cognitive impairment and Alzheimer's disease, and specifically in cognitively-impaired individuals who have spatial deficits such as disorientation and difficulty driving. Indeed, emerging evidence suggests that age-related vestibular impairment contributes to a 'spatial' subtype of Alzheimer's disease, characterized by highly morbid symptoms such as wandering and falls. Given that vestibular impairment can be treated through simple, physical-therapy based exercises, identifying and treating vestibular deficits in older adults with and without cognitive impairment may offer substantial benefit in preventing, mitigating and forestalling cognitive decline.

Successful Catheter-Directed Thrombolysis of Massive Bilateral Upper Extremity DVT Presenting as Superior Vena Cava Syndrome

Superior vena cava syndrome (SVCS) is traditionally associated with malignancy. However, approximately one-third of SVCS cases are due to intravascular devices and pacemakers. No specific guidelines exist for managing catheter-associated SVCS. We present catheter-associated SVCS resistant to anticoagulation, angioplasty, and thrombectomy but resolved with ultrasound-assisted catheter directed thrombolysis. (Level of Difficulty: Intermediate.).

Saccular function is associated with both angular and distance errors on the triangle completion test

OBJECTIVE

The present study was designed to determine whether healthy older adults with age-related vestibular loss have deficits in spatial navigation.

METHODS

154 adults participating in the Baltimore Longitudinal Study of Aging were tested for semicircular canal, saccular, and utricular function and spatial navigation ability using the blindfolded Triangle Completion Test (TCT). Multiple linear regression was used to investigate the relationships between each measure of vestibular function and performance on the TCT (angular error, end point error, and distance walked) while controlling for age and sex.

RESULTS

Individuals with abnormal saccular function made larger angular errors (β = 4.2°, p < 0.05) and larger end point errors (β = 13.6 cm, p < 0.05). Independent of vestibular function, older age was associated with larger angular (β's = 2.2-2.8°, p's < 0.005) and end point errors (β's = 7.5-9.0 cm, p's < 0.005) for each decade increment in age.

CONCLUSIONS

Saccular function appears to play a prominent role in accurate spatial navigation during a blindfolded navigation task.

SIGNIFICANCE

We hypothesize that gravitational cues detected by the saccule may be integrated into estimation of place as well as heading direction.

Reduced vestibular function is associated with longer, slower steps in healthy adults during normal speed walking

BACKGROUND

Vestibular signals contribute to balance and walking. With aging, vestibular function declines and gait speed decreases. Vestibular loss contributes to decreasing gait speed, but this influence could be linked to spatial and/or temporal aspects of gait. We investigated the relationship between vestibular function (semicircular canal and otolith function) and spatial and temporal gait parameters in a cohort of adults.

METHODS

113 community-dwelling healthy adults (mean age 72.2 (14.6) years) participating in the Baltimore Longitudinal Study of Aging were tested. Horizontal semicircular canal (SCC) function was evaluated using quantitative vestibulo-ocular reflex gain. Otolith function was measured with cervical and ocular vestibular evoked myogenic potentials. Gait kinematics were collected during normal speed walking. Multiple linear regressions examined the association between spatial and temporal gait parameters and SCC and otolith function separately, controlling for age, gender, height, and either cadence (for spatial gait outcomes) or stride length (for temporal gait outcomes) to account for gait speed effects.

RESULTS

Vestibular SCC function was significantly associated with both spatial and temporal gait parameters. Every 0.1 decrease in SCC function resulted in longer stride length (β = -.04 m, p = 0.004), longer stance time (β = 15.8 ms, p < 0.003), and a slower cadence (β = -2.1 steps/minute, p < 0.001). Otolith function was not associated with any gait parameter.

CONCLUSIONS

Reduced horizontal SCC function was associated with longer, slower steps in a cohort of healthy adults. These results indicate that vestibular signals contribute to specific spatial and temporal aspects of gait thought to contribute to upright balance.

Association Between Pulmonary Hypertension and Transcatheter Aortic Valve Replacement: Analysis of a Nationwide Inpatient Sample Database

INTRODUCTION

This study was done to review the association of pulmonary hypertension (PH) with Transcatheter Aortic Valve Replacement (TAVR) procedures done in the US for years 2010 to 2012.

METHODS

We used Nationwide Inpatient Sample (NIS) data to extract data for patients who were hospitalized with a primary/secondary diagnosis of TAVR as specified by International Classification of Disease (ICD-9) codes 35.05 and 35.06. PH was identified with ICD-9 codes 416.0 and 416.8. Logistic regression models were used to analyze the association between PH and clinical outcomes of TAVR.

RESULTS

A total of 8,824 weighted discharges were identified with a primary/secondary diagnosis of TAVR, of which 1,976 (22.4%) also had PH. Mean age of patients undergoing TAVR with and without PH was 81.4 and 81.1 years, respectively. More females had a diagnosis of PH with TAVR when compared to males, (56.9% vs. 43.1). When controlling for demographics, diabetes and hypertension; the association between PH and TAVR was statistically significant (p<.0001). Estimated odds of TAVR with PH was 5.46 (95% CI: 4.63, 6.41) times greater than for TAVR without PH. Similarly, the estimated odds for a length of stay greater than 1 week for TAVR with PH was 1.43 (95% CI: 1.12, 1.82; p=.0034) times greater than odds for TAVR without PH. PH was not statistically significant for in-hospital mortality in patients receiving TAVR (p=0.7067).

CONCLUSION

This study suggests that underlying PH does not influence the immediate mortality of patients underlying TAVR. Further studies are needed to delve into the bearing of PH on TAVR.

Serpentine thrombus in the heart: a rare case of trapped thrombus in patent foramen ovale

A 77-year-old Caucasian woman with recent abdominal surgery was diagnosed with multiple paradoxical systemic emboli in the mesenteric and renal circulation. Diagnosis was made by direct visualisation of a serpentine thrombus traversing both atria through patent foramen ovale (PFO) by transesophageal echocardiogram (TEE). Concomitantly, the patient was found to have deep venous thrombosis and pulmonary embolism. A decision was made to pursue cardiothoracic surgery preceded by inferior vena cava filter placement. She was started on intravenous anticoagulation. Repeat TEE was negative for thrombus and the patient did not present any new clinical signs of embolisation by this time. Consequently, the treatment plan was modified and the patient received oral systemic anticoagulation followed by PFO closure with the use of St. Jude Amplatzer Cribriform septal occluder device. During the outpatient follow-up the patient was asymptomatic and there was no significant flow through the device on transthoracic echocardiogram.

Trends in Vena Cava Filter Placement: An Analysis of Nationwide Inpatient Sample Database Over an 11 Year Period

OBJECTIVES

There have been increasing concerns regarding inappropriate usage of vena caval filters. Our study was done to analyze the current trends in vena caval filter placement.

METHODS

This study used the data from Nationwide Inpatient Sample database for the years 2002- 2012 to identify patients with vena caval filter placement. Trends in both therapeutic and prophylactic vena caval filter use over the eleven years' period were analyzed. Multiple simple logistic regression model was used to assess trends.

RESULTS

The overall incidence of vena caval filter placement increased from 2002 to 2012. The odds of vena caval filter placement in 2012 were 1.340 (95% CI: 1.236, 1.453) times the odds of vena caval filter placement in 2002. However, a downward trend was observed after the year 2010. The odds of vena caval filter placement in 2012 were 0.854 (95% CI: 0.801, 0.911) times the odds in 2010. Similar trends were seen in both therapeutic and prophylactic placements. The proportion of prophylactic vena caval filter placements with indications of morbid obesity (P<0.0001), head injury (P=0.0007), surgery of the eye, brain, spine or other major surgery (P<0.0001) hemorrhage/bleeding (P=0.0046) significantly increased in 2012 when compared to 2002.

CONCLUSION

Vena caval filter placement rates have increased significantly from 2002 to 2012 for both prophylactic and therapeutic indications. However, there seems to be downward trend when comparing 2012 to 2010. Measures such as physician education and hospital audits can be done to further bring down inappropriate vena caval filter placements.

Association Between Hypothyroidism and Takotsubo Cardiomyopathy: Analysis of Nationwide Inpatient Sample Database

BACKGROUND

Takotsubo Cardiomyopathy (TC), also called transient left ventricular (LV) ballooning syndrome, resembles myocardial infarction and is characterized by LV dysfunction in the absence of coronary artery disease. Hypothesis described for TC has been an intense social stressor, pheochromocytoma, thyrotoxicosis among others. We performed this study to analyze the association of hypothyroidism with TC.

METHODS

We queried the Nationwide Inpatient Sample which represents 20% of all the United States hospital data for our study. We identified TC and hypothyroidism through their respective ICD9. Codes for years 2006-2012. SAS 9.4 was used to perform a chi-square analysis to find any statistical significance and p < 0.05 used to determine statistical significance. Significant differences were identified using odds ratio (OR) estimates.

RESULTS

A total of 19,713 cases with TC were identified of which 17,340 (87.96%) were females and 2,373 (12.04%) were males. 3,272 patients with TC had diagnosis of hypothyroidism. There is statistically significant evidence of an association between TC and hypothyroidism (OR 2.21 (95% CI: 2.11- 2.31); p<0.0001). There is evidence of increased statistical significance of females having TC 5.24 (95% CI: 4.96-5.53; (p<0.0001)) compared to males, with an increased statistically significance of females with hypothyroidism having TC, OR 6.65 (95% CI: 5.57-7.93; p< 0.001) compared to males.

CONCLUSION

There is an increased association of hypothyroidism, especially hypothyroidism for females with TC.

Rare case of massive bilateral chylothorax

We present a case of a 48-year-old woman who was referred from an outside hospital. There, she had initially underwent hysterectomy and left salpingo-oophorectomy for tubo-ovarian abscess. She later developed a colovaginal fistula and perforation of sigmoid colon and underwent Hartmann's procedure along with drainage of a left subphrenic abscess. Subsequently, she had to be intubated for acute respiratory failure and was transferred to our hospital. At our hospital, she was found to have massive bilateral pleural effusions. Bilateral small-bore chest tubes were inserted that drained milky fluid. Pleural fluid analysis was consistent with bilateral chylothorax. Thereafter, patient's respiratory status improved and she was extubated. The mechanism of chylothorax was thought be either secondary to the multiple abdominal procedures or alternatively as a complication of the right subclavian catheter that was placed at the outside hospital. Her chest tubes were removed eventually, and she had a slow but definite recovery.

Regadenoson cardiac stress test-induced stress cardiomyopathy

Takotsubo cardiomyopathy, also described as apical ballooning syndrome/stress-induced cardiomyopathy, imitates acute coronary syndrome and is usually related to a massive physiological or emotional stressor. We describe perhaps the first reported case to the best of our knowledge of a 55-year-old Caucasian woman who presented with congestive heart failure after having a regadenoson cardiac stress test a few hours prior to presentation to the hospital. Transthoracic echocardiogram revealed reduced heart function. She had normal coronaries on cardiac catheterisation, and left ventriculography confirmed apical ballooning syndrome. She underwent guideline-directed therapy, and heart function improved in the repeat echocardiogram along with clinical resolution of symptoms.

A case of congenital coronary-pulmonary fistulas presenting as spontaneous mediastinal haemorrhage

Coronary artery fistulas are rare anomalous vascular connections between coronary arteries and a cardiac chamber or a central vessel, without an intervening capillary bed. Coronary-pulmonary fistulas are a distinct subset of coronary artery fistulas. We present the case of a previously healthy 63-year-old-man who presented with chest pain and was found to have mediastinal haemorrhage. Upon further investigations, he was found to have multiple coronary-pulmonary fistulas with pseudoaneurysm formation in three of the fistulas. Two of these pseudoaneurysms showed inflammatory changes indicative of recent bleed. These were determined to be the source of the mediastinal bleeding and patient’s initial presentation. The patient was managed medically after obtaining multiple expert opinions from various institutions.

A warning sign

A 64year old man presented with atypical chest pain of 6h duration. Physical examination showed tachycardia and an irregularly irregular pulse. Initial EKG showed atrial fibrillation with rapid ventricular rate. Intravenous Diltiazem was administered following which there was resolution of atrial fibrillation as well as his chest pain. Troponin T and CPK-MB were minimally elevated at 0.05ng/ml (0.0-0.03ng/ml) and 8.6ng/ml (0.0-7.0ng/ml) respectively. A repeat EKG obtained after symptom resolution showed biphasic T wave inversions in V2 and V3 which prompted an emergent coronary angiogram that revealed 90% occlusion of the proximal LAD. The immediate recognition of Wellens' pattern lead to emergent coronary revascularization and prevention of acute myocardial infarction in our patient. Clinicians should be aware of this syndrome so that prompt invasive therapy can be done to avoid evolution into MI and subsequent left ventricular dysfunction.