Cardiac magnetic resonance imaging in heart transplant recipients with biopsy-negative graft dysfunction.

AIMS: Graft dysfunction (GD) after heart transplantation (HTx) can develop without evidence of cell- or antibody-mediated rejection. Cardiac magnetic resonance imaging (CMR) has an evolving role in detecting rejection; however, its role in biopsy-negative GD has not been described. This study examines CMR findings, evaluates outcomes based on CMR results, and seeks to identify the possibility of rejection missed through endomyocardial biopsy by using CMR in HTx recipients with biopsy-negative GD. METHODS AND RESULTS: HTx recipients with GD [defined as a decrease in left ventricular ejection fraction (LVEF) by >5% and LVEF < 50%] in the absence of rejection by biopsy or allograft vasculopathy and who underwent CMR were included in the study. The primary outcome was a composite of all-cause mortality, re-transplantation, or persistent LVEF < 50%. Overall, 34 HTx recipients developed biopsy-negative GD and underwent CMR. Left ventricular late gadolinium enhancement (LGE) on CMR was observed in 16 patients with two distinct patterns: diffuse epicardial (n = 13) and patchy (n = 3) patterns. Patients with LGE developed GD later after HTx [4 (1.4-6.8) vs. 0.8 (0.3-1.2) years, P < 0.001], were more often symptomatic (88% vs. 56%, P = 0.06), and had greater haemodynamic derangement (pulmonary capillary wedge pressure: 19 ± 7 vs. 13 ± 3 mmHg, P = 0.002) as compared with those without LGE. No significant difference was observed in the primary composite outcome between patients with LGE and those without LGE (50% vs. 38% of patients with events, P = 0.515). During a median follow-up of 3.8 years, mean LVEF improved similarly in the LGE-negative (37-55%) and LGE-positive groups (32-55%) (P = 0.16). CONCLUSIONS: Biopsy-negative GD occurs with and without LGE when assessed by CMR, indicative of possible rejection/inflammation occurring only in a subset of patients. Irrespective of LGE, LVEF improvement occurs in most GD patients, suggesting that other neurohormonal or immunomodulatory mechanisms may also contribute to GD development.

Correlation Between CardioMEMS and HeartLogic in Predicting Heart Failure Events.

A 59-year-old male was admitted with acute on chronic decompensated heart failure. Review of his CardioMEMS (Abbott Laboratories, Atlanta, Georgia) device and HeartLogic (Boston Scientific, Marlborough, Massachusetts) index were helpful in guiding management of his volume status. This paper highlights the correlation between 2 monitoring systems which could be used to predict heart failure events. (Level of Difficulty: Intermediate.).

Anomalous origin of the right coronary artery from the mid-left anterior descending coronary artery: association with acute myocardial infarction.

Congenital abnormalities of the coronary arteries are uncommon but can be associated with important cardiac events depending on their location and the course of the aberrant artery. Conventional angiography has been the gold standard for the diagnosis of these anomalies. The recent development of cardiac CT has allowed accurate and non-invasive depiction of coronary artery anomalies in terms of their origin, course and termination. We describe the case of a patient presenting with acute inferior myocardial infarction who was found to have a very rare congenital abnormality consisting of an anomalous origin of the right coronary artery from the mid-segment of the left anterior descending. Coronary angiography and cardiac CT angiographic images are shown and discussed.

The Impact of Formal Training and Certification on the Relationship Between Volume and Outcomes in Percutaneous Coronary Interventions.

BACKGROUND: Little data are available on the impact of formal training and certification on the relationship between volumes and outcome in percutaneous coronary interventions (PCIs).The objective of this report is to study the relationship between PCI volume and outcome for a formally trained interventional cardiologist who is certified by the American Board on Internal Medicine - Interventional Cardiology subspecialty board. METHODS: The operator witnessed 3 different PCI volumes/yr over a 15-year practice period (2000-2014): <50 PCI/yr (years 2000-2006; n = 179), 50-100 PCI/yr (years 2007-2010; n = 256), and >100 PCI/yr (years 2011-2014; n = 427). Angiographic and procedural success rates were compared between the 3 volume groups, as well as in-hospital cardiovascular events (death, recurrent myocardial infarction, repeat PCI, stroke, or coronary artery bypass surgery). RESULTS: The in-hospital mortality rate throughout the study period was 0.8% and was not statistically significant among the 3 volume groups. There was also no significant difference among the 3 groups with respect to recurrent myocardial infarction or repeat PCI. There was a slightly higher rate of same-stay elective coronary artery bypass grafting in the early low-volume period compared with the other 2 groups (2.2% vs. 0.8% vs. 0.2%; P = 0.04). The overall angiographic and procedural success rates were 97.3% and 96.5%, and they were not significantly different among the 3 groups. CONCLUSIONS: Our study shows that the angiographic and procedural success rates of PCI, as well as the in-hospital mortality, do not seem to be dependent on the annual volume for formally trained and certified interventional cardiologists.

The misleading electrocardiogram - Midventricular Takotsubo masquerading as anterior wall STEMI.

Midventricular Takotsubo cardiomyopathy (TC) is a relatively rare variant of stress induced cardiomyopathy, wherein there is akinesis of only the mid-ventricular segment with or without hyperkinesis of apical and basal ventricular segments. The ECG findings of TC typically do not include ST segment elevation in V1-V2 and are unlikely to be associated with reciprocal changes in inferior leads. The presence of these changes argues strongly in favor of anterior wall STEMI. In our patient, the ECG had changes strongly suggestive of STEMI, however had normal coronaries on cardiac catheterization. This case highlights the importance of carefully analyzing the ECG in emergency situations for differences between TC and STEMI and when in doubt, cardiac catheterization should be pursued.

Self-Expanding Metal Stenting in the Management of a Benign Colonic Stricture.

Colonic postanastomotic strictures occur in 1.5-8% of patients following colorectal surgery. Traditionally, colonic strictures were treated by multiple modalities including endoscopic dilatation. Self-expanding metal stents (SEMS) have been indicated in the management of benign colonic strictures; however, there are limited available data with regard to their efficacy. We present the case of a 68-year-old male who had perforated sigmoid diverticulitis followed by Hartmann's procedure with eventual reanastomosis 6 months later. He subsequently developed benign colonic stricture, which was treated with a metal stent. SEMS are associated with a low mortality rate and are appropriate in treating acute colonic obstruction as a result of benign stricture in the setting of postanastomosis.

The yield of routine pre-operative cardiovascular evaluation in stable patients scheduled for elective non-cardiac surgery.

Preoperative cardiovascular evaluation is commonly performed in patients scheduled for non-cardiac surgery. The recent ACC/AHA guidelines provide an algorithm for such an evaluation but whether all patients scheduled for surgery would benefit from it is not known. We determined the yield of preoperative cardiovascular evaluation in 522 stable patients, with no prior history of heart disease, who were scheduled for elective non-cardiac surgery. There were 14 patients (2.7%) in which the cardiac consultant requested further testing pre-operatively, and in 5 of them (1%), the findings on cardiac consultation and further testing would be considered to have impacted the decision on performing the surgery or the long term outcome of the patients. Using multivariable logistic regression analysis, the only clinical variable predictive of further testing was age > 65 years (OR = 4.47, p = 0.001). The yield of preoperative cardiovascular evaluation in stable patients scheduled for non-cardiac surgery is relatively low. Further studies are needed to identify what subgroup of patients might benefit most from it and those in whom it might not be warranted.

Vascular complications of early (3 h) vs standard (6 h) ambulation post-cardiac catheterization or percutaneous coronary intervention from the femoral artery.

BACKGROUND: The optimal time of ambulation post cardiac catheterization (CC) or percutaneous coronary intervention (PCI) done from the femoral artery is not well defined. The aim of this study was to determine whether early (3 hrs) ambulation post CC/PCI is as safe as standard (6 hrs) ambulation time. METHODS: This was a retrospective observational study comparing the vascular complications rate (bleeding, hematoma, pseudoaneurysm formation) among patients who underwent CC, alone or concomitant with PCI, from the femoral artery and who were ambulated after 3 or 6 hrs. RESULTS: The study population consisted of a total of 262 patients, 147 were ambulated after 3 hrs and 115 were ambulated after 6 hrs. There were no differences between the two groups with respect to age, gender, body mass index, prior history of cardiac events, as well as the indication for performing the current CC/PCI. The rate of vascular complications was similar between the two groups (2.7% vs 2.6%, p=0.97). All vascular complications were managed conservatively and non required surgical intervention. CONCLUSION: In this retrospective observational study, both early (3 hrs) and standard (6 hrs) ambulation after CC/PCI from the femoral artery had a similar and low rate of vascular complications. Cardiac catheterization laboratories need to be encouraged to adopt an early ambulation policy post CC/PCI from the femoral artery to improve patient comfort and expedite patient discharge from the hospital.