An unusual complication after aortic valve replacement.

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa, though rare, can occur after aortic valve replacement. We report an asymptomatic patient who developed this unusual complication and describe the use of transesophageal and 3-dimensional echocardiography to help confirm the diagnosis.

Role of transesophageal echocardiography guided cardioversion in patients with atrial fibrillation, previous left atrial thrombus and effective anticoagulation.

AIMS: The value of transesophageal echocardiography (TEE) to prevent cardioversion-related thromboembolic events in patients with atrial fibrillation (AF) and left atrial (LA) thrombus is unclear. We compared the embolic risk associated with a strategy of follow-up TEE-guided direct-current cardioversion (DCCV) with that of blind DCCV in patients with AF, pre-existing LA thrombus and effective anticoagulation. METHODS AND RESULTS: We identified 67 subjects with TEE-documented LA appendage thrombi from a total of 520 consecutive patients with symptomatic non-rheumatic AF who were referred to us for elective DCCV. All patients received at least 4 weeks of effective warfarin therapy (target international normalized ratio, 2 to 3) before and after DCCV. At time of DCCV, 20 patients had TEE and 47 did not. There were no clinical and echocardiographic differences between the two groups. Thrombus resolution was documented in 18 (90%) patients. After a median follow-up of 4 weeks, two transient ischemic attacks were observed in patients who were blindly cardioverted and one in patients belonging to the TEE group. Sinus rhythm was documented at the time of each thromboembolic event. By multiple logistic regression analysis the TEE strategy was not associated with lower risk of thromboembolism as compared to blind DCCV (odds ratio 1.37; 95% confidence interval, 0.16% to 15.86%; p=0.20). CONCLUSION: In patients with AF, LA thrombus and effective anticoagulation, there is no difference in the risk of clinical thromboembolism between DCCV with or without follow-up TEE. Benefits of warfarin are related to thrombus resolution and prevention of new thrombus formation.

A case and review of acromegaly-induced cardiomyopathy and the relationship between growth hormone and heart failure: cause or cure or neither or both?

Growth hormone plays an integral role in the development and maintenance of structure and function of the heart. Specific involvement of the heart in acromegaly is termed acromegalic cardiomyopathy, manifested as concentric left ventricular hypertrophy and diastolic dys-function. Left untreated, it ultimately progresses to systolic heart failure. Heart failure from acromegalic cardiomyopathy is one of the most common causes of death in acromegaly. Current treatment options include different approaches to lower elevated growth hormone levels with improvement in symptoms, exercise tolerance, and echocardiographic improvement in regression of left ventricular hypertrophy and indices of diastolic dysfunction. On the other hand, growth hormone is essential for cardiac growth and function and exerts beneficial and protective effects on the cardiovascular system. Its potential role as adjunctive therapy in the treatment of heart failure as derived from experimental studies and clinical trials is discussed.

Benefits, unresolved questions, and technical issues of cardiac resynchronization therapy for heart failure.

This review aims to provide a synthesis of the published evidence regarding the rationale and clinical benefits of cardiac resynchronization therapy (CRT) with implantable atrial-synchronized biventricular pacing (BVP) devices in patients with moderate to advanced heart failure and intra- and interventricular conduction delays. In addition, it addresses clinical and technical issues that have yet to be resolved, such as the selection of the most suitable candidates for CRT; the usefulness of combining BVP with automatic defibrillation backup; the value of CRT in patients with atrial fibrillation; the importance of alternative sites of pacing, such as the atrial septum and the right ventricular (RV) outflow tract; the harmful effects of the long-standing practice of producing an iatrogenic left bundle branch block by conventional RV pacing in patients receiving standard permanent pacemakers; the question of precisely where on the left ventricle optimal pacing is achieved; and the potential applications of CRT in patients with pediatric or congenital heart disease. Considering how major advances have been achieved since the first clinical application of CRT in 1994, one can be optimistic about the future of the electrotherapeutic management of heart failure.

Vascular Steal Syndrome and Shewanella alga Infection Requiring Amputation in a Hemodialysis Patient.

Shewanella alga is a rare gram-negative marine bacterium. Its role as a pathogenic organism is gradually evolving with sporadic cases being reported in humans. We report a case of vascular steal syndrome secondary to a polytetrafluoroethylene (PTFE) graft in the upper extremity of an end-stage renal disease (ESRD) patient on maintenance hemodialysis, which was complicated by infection with S. alga. This resulted in extensive myonecrosis requiring amputation of the limb. To our knowledge this is the fourth case of primary S. alga infection, and the first case in a hemodialysis patient reported in the medical literature from the United States. We also discuss the biochemical tests for identification and differentiation of S. alga from a closely related strain S. putrefaciens.

Listeria monocytogenes-induced monomicrobial non-neutrocytic bacterascites.

Spontaneous bacterial peritonitis (SBP) is a common complication in patients with cirrhosis of the liver. The organisms most commonly involved in this infection are gram-negative bacteria like Escherichia coli and Klebsiella pneumoniae, and gram-positive bacteria like Streptococcus pneumoniae and Staphylococcus aureus. Listeria monocytogenes is an uncommon gram-positive bacillus implicated in infections in neonates, pregnant females, the elderly, and immunocompromised patients. Listeria monocytogene-induced SBP is rare, with less than 40 cases reported in the medical literature. Monobacterial non-neutrocytic bacterascites (MNB) is a variant of SBP, where the ascitic fluid culture is positive but the ascitic neutrophil count is less than 250/mm3. Forty percent of these patients will subsequently have SBP. Only 2 cases of MNB from L monocytogenes have previously been reported. We report a case of MNB in a patient with cirrhosis whose ascitic neutrophil count was 164/mm', but Gram stain and microbiologic culture showed the growth of L monocytogenes.