Impact of Pulmonary Hypertension Hemodynamic Phenotype on Incident Atrial Fibrillation.

INTRODUCTION: Atrial fibrillation/flutter (AF) is common among patients with pulmonary hypertension (PH) and is associated with poor clinical outcomes. AF has been shown to occur more commonly among patients with postcapillary PH, although AF also occurs among patients with precapillary PH. The goal of this study was to evaluate the independent impact of PH hemodynamic phenotype on incident AF among patients with PH. METHODS: We retrospectively identified 262 consecutive patients, without a prior diagnosis of atrial arrhythmias, seen at the PH clinic at Mayo Clinic, Florida, between 1997 and 2017, who had right heart catheterization and echocardiography performed, with follow-up for outcomes through 2021. Kaplan-Meier analysis and Cox-proportional hazards regression modeling were used to evaluate the independent effect of PH hemodynamic phenotype on incident AF. RESULTS: Our study population was classified into two broad PH hemodynamic groups: precapillary (64.9%) and postcapillary (35.1%). The median age was 59.5 years (Q1: 48.4, Q3: 68.4), and 72% were female. In crude models, postcapillary PH was significantly associated with incident AF (HR 2.17, 95% CI: 1.26-3.74, p = 0.005). This association was lost following multivariable adjustment, whereas left atrial volume index remained independently associated with incident AF (aHR 1.30, 95% CI: 1.09-1.54, p = 0.003). CONCLUSION: We found PH hemodynamic phenotype was not significantly associated with incident AF in our patient sample; however, echocardiographic evidence of left atrial remodeling appeared to have a greater impact on AF development. Larger studies are needed to validate these findings and identify potential modifiable risk factors for AF in this population.

Association of Neurohormonal Antagonists on Incident Cardiotoxicity in Patients With Breast Cancer.

Cardiovascular disease is the leading cause of mortality among breast cancer survivors. Anthracyclines and trastuzumab have been associated with an increased risk of cardiotoxicity, requiring close follow-up for signs of clinical heart failure or asymptomatic left ventricular systolic dysfunction. Whether neurohormonal antagonism with angiotensin-converting enzyme inhibitor (ACE-I), angiotensin receptor blockers (ARBs), or ß-blockers can prevent the development of chemotherapy-induced cardiomyopathy in this population remains unknown. We studied 459 women who were diagnosed with breast cancer at our medical center from January 2014 to December 2021 and evaluated baseline characteristics, oncologic treatment, and outcomes. The primary end point was the development of cardiotoxicity, defined as symptomatic decline in ejection fraction of ≥5% below 55% or an asymptomatic decline of ≥10% after treatment with chemotherapy. Patients who were exposed to neurohormonal antagonists were more likely to have hypertension, hyperlipidemia, and diabetes. There was an increased risk of cardiotoxicity noted for patients who were older (hazard ratio [HR] 1.04, 95% confidence interval [CI] 1.01 to 1.1), smokers within the past 10 years (HR 2.54, 95% CI 1.41 to 4.6), or who received a combination of both trastuzumab and anthracycline therapy (HR 2.52, 95% CI 1.01 to 6.3). Over a median follow-up of 12 months, there were no significant protective benefits noted for patients who were taking ACE-I/ARBs (HR 0.49, 95% CI 0.17 to 1.4), ß-blockers (HR 0.50, 95% CI 0.16 to 1.6), or both (HR 1.30, 95% CI 0.44 to 3.9). In conclusion, previous use of ACE-I/ARBs and ß-blockers, separately or in combination, was not associated with a reduction in the development of cardiotoxicity in patients receiving anthracycline or trastuzumab therapies. Older age, smoking, and combination chemotherapy were found to be associated with an increased risk.

Characteristics and Long-Term Outcomes of Patients With Prior Coronary Artery Bypass Grafting Undergoing Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction.

Limited data are available on characteristics and long-term outcomes of patients with coronary artery bypass grafts (CABG) undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction (STEMI). Between January 2000 to December 2014, we identified STEMI patients with prior CABG undergoing primary percutaneous coronary intervention from 3 sites. Kaplan-Meier methods to estimate survival and major adverse cardiac events (MACE) were employed and compared to a propensity matched cohort of non-CABG STEMI patients. Independent predictors of outcomes were analyzed with Cox modeling. Of the 3,212 STEMI patients identified, there were 296 (9.2%) CABG STEMI patients, having nearly similar frequencies of culprit graft (47.6%) versus culprit native (52.4%) as the infarct-related artery (IRA). At 10 years, the adjusted survival was 44% in CABG STEMI versus 55% in non-CABG STEMI (HR 1.26; 95%CI 0.86 to 1.87; p = 0.72). Survival free of MACE was lower for CABG STEMI (graft IRA, 37%; native IRA, 46%) as compared to non-CABG STEMI controls (63%) (p = 0.02). Neither CABG history nor IRA (native vs graft) was independently associated with death or MACE in multivariable analysis. Temporal trends showed no significant change in death or MACE rates of CABG STEMI patients over time. In conclusion, long term survival of CABG STEMI patients is not significantly different than matched STEMI patients without prior CABG; however, CABG STEMI patients were at significantly higher risk for MACE events.

Intracranial Mimics of Cauda Equina Syndrome: Heads or Tails?

BACKGROUND: To report cases of extraspinal mimics of cauda equina syndrome (CES) to enable prompt diagnosis and treatment in the future. CES results from compression of spinal nerve roots. Current practice mandates lumbosacral magnetic resonance imaging (MRI) scanning to diagnose CES. However, it may not reveal compression or provide an explanation for the presentation. We present 3 cases of suspected CES who went on to have intracranial pathology. METHODS: Retrospective review of all patients presenting with CES-type features who were subsequently found to have causative intracranial pathology over a 6-month period. RESULTS: Three cases were found, and these are hereby presented. CASE PRESENTATION: Case 1: A 57-year-old lady presented with urinary retention and bilateral leg weakness. She underwent an MRI spine which showed no evidence of CES. She was diagnosed with haemorrhagic intracranial metastases. Case 2: A 52-year-old lady presented with lower back and right buttock pain, with right-sided leg numbness, saddle hypoesthesia, and bowel and bladder incontinence. MRI spine showed no cauda equina compression. MRI neuraxis revealed a subdural haematoma. Case 3: A 69-year-old lady presented with a 6-day history of urinary incontinence, right foot drop, and leg weakness. MRI spine was negative for CES. She was diagnosed with an intraparenchymal haematoma of posterior left frontal lobe. CONCLUSIONS: Negative lumbosacral MRI will not exclude extraspinal mimics of CES and, although rare, these cases should be considered.

Magnetic resonance imaging scans are not a reliable tool for predicting symptomatic acromioclavicular arthritis.

BACKGROUND: We investigated whether magnetic resonance imaging (MRI) scans can accurately diagnose arthritis of the acromioclavicular joint (ACJ) because it has recently been suggested that bone marrow oedema on MRI scans is a predictive sign of symptomatic ACJ arthritis. METHODS: The MRI scans of 43 patients (50 shoulders) who underwent ACJ excision for clinically symptomatic ACJ arthritis were compared to a control group of 43 age- and sex-matched patients (48 shoulders) who underwent an MRI scan for investigation of shoulder pain but did not have clinical symptoms or signs of ACJ arthritis. The scans were evaluated by an experienced musculoskeletal radiologist, who was blinded to the examination findings. RESULTS: Bone marrow oedema was present in only 15 (30%) shoulders in the ACJ excision group, although this was higher than the six shoulders in the asymptomatic group (p = 0.03). Forty-one (82%) shoulders in the symptomatic group had grade III/IV ACJ arthritis compared to 31 (65%) in the asymptomatic group (p = 0.05). However, 44 out of 48 (92%) shoulders in the asymptomatic group had signs of osteoarthritis on MRI scans. CONCLUSIONS: In contrast to recent reports, the present study shows that MRI is not helpful in making the diagnosis of ACJ arthritis. A focused history and clinical examination should remain the mainstay for surgical decision making. LEVEL OF EVIDENCE: Level 3.

Characteristics and long term outcomes of patients with acute coronary syndromes due to culprit left main coronary artery disease treated with percutaneous coronary intervention.

BACKGROUND: Patients with acute coronary syndrome (ACS) due to unprotected culprit left main coronary artery disease (LMCAD) treated with percutaneous coronary intervention (PCI) are rare, high-risk, and not represented in trials. Data regarding long term outcome after PCI are limited. METHODS: Between January 2000 and December 2014, there were 8,794 patients hospitalized with unstable angina/non-ST elevation myocardial infarction (UA/NSTEMI) or ST-elevation myocardial infarction (STEMI) treated with PCI at our institution; of these, 83 (0.94%) patients were identified as having culprit LMCAD ACS. RESULTS: Of the 83 patients with unprotected LMCAD ACS, 40 patients presented with STEMI and 43 patients presented with UA/NSTEMI. As compared to LM UA/NSTEMI, LM STEMI patients were younger and had less hypertension, with a trend towards greater frequency of cardiogenic shock. Distal LM involvement was common in both groups and did not differ by ACS type. In-hospital mortality was 33% in LM STEMI and 9% in LM UA/NSTEMI (P = .009). Over median follow up of 6.3 years, long term survival rates in both groups were similar (46% for STEMI vs 51% for UA/NSTEMI; P = .50 by log-rank). CONCLUSIONS: Unprotected culprit LMCAD ACS necessitating PCI is uncommon, occurring in <1% of cases, but is associated with reduced survival, with long term follow-up noting continued and similar risk of death regardless of index ACS type.

Tissue Engineering in Achilles Tendon Reconstruction; The Role of Stem Cells, Growth Factors and Scaffolds.

BACKGROUND: Achilles tendon injuries are common, and present a challenge in the acute and chronic setting. There is significant morbidity associated with the injury and the numerous management strategies, as well as financial implications to the patient and the health service. To date, repair tissue from all methods of management fail to achieve the same functional and biomechanical properties as the native tendon. OBJECTIVE: The use of tissue engineering technology may reduce morbidity, improve the biomechanical properties of repair tissue and reduce the financial burden. The goal is to produce completely integrated tendon repair tissue that has the functional and mechanical properties of the native tendon. This review evaluates the role of stem cells in tissue engineering for tendon reconstruction and the various sources for harvesting stem cells. RESULTS: They can be obtained from the embryo, foetus or adult, and require the correct conditions for proliferation and differentiation. There remain many ethical concerns with the use of embryo or foetus harvested stem cells, thus the focus remains on adult sources, haematopoietic and non-haematopoietic. The improving knowledge of the role of growth factors is addressed, as is their effect on animal models for tendon repair. Growth factors include bone morphogenic proteins, transforming growth factor ., insulin-like growth factor and platelet derived growth factor. The role of scaffolds in human and animal models is reviewed, both naturally derived and synthetic scaffolds. Whilst numerous animal studies have reported encouraging results, further work is required. CONCLUSIONS: The ideal source of MSCs still has not been agreed upon, and little is known regarding the signalling pathways involved in tenogenesis of MSCs. Whilst current studies have shown encouraging results with regards to improved biomechanical and histological properties, further work is required to ascertain the growth factors, biomaterials and source of stem cells required for tendon regeneration.

Comparing stress testing and fractional flow reserve to evaluate presence, location and extent of ischemia in coronary artery disease.

BACKGROUND: FFR provides an accurate and reproducible assessment of the functional severity of coronary stenosis. Whereas stress testing remains the preferred initial modality for assessment of ischemia, there is limited data comparing it with FFR. We sought to determine the correlation between cardiac stress testing and coronary fractional flow reserve (FFR) measurement for assessing the presence, location, and burden of myocardial ischemia in patients referred for evaluation of coronary artery disease (CAD). METHODS: Over 5-year study period, of the 5420 consecutive coronary angiograms that were screened, 326 patients had FFR measurements. Of these, 96 patients with FFR measurements who had a preceding stress test (stress echocardiography [SE] or myocardial perfusion imaging [MPI]) within a year were included. RESULTS: Of the 96 patients, there were 46 (48%) men and 50 (52%) women with a mean age of 61 ± 10 years. SE was performed in 57 (59.3%) and MPI in 32 (40.7%) of patients. FFR was ≤0.79 in 54 (56%) patients. Stress testing had low sensitivity (55%) and specificity (47%) compared to FFR. The concordance between FFR and stress testing was low for both presence (k=0.03) and location (k=0.05) of the ischemic territory. The number of ischemic vascular territories was correctly estimated in only 39% of the stress tests. SE was more likely to overestimate and MPI more likely to underestimate extent of ischemia. CONCLUSIONS: In patients referred for evaluation of CAD, there was poor correlation between stress testing and FFR. A prospective study comparing these two modalities with FFR is needed.

Limitations and strengths of doppler/echo pulmonary artery systolic pressure-right heart catheterization correlations: a systematic literature review.

AIMS: Because many recent studies have questioned the accuracy of Doppler echocardiography (D) in determining pulmonary artery systolic pressure (PASP), we performed a detailed literature analysis attempting add clarity. METHODS AND RESULTS: Studies through 2011 comparing D and right heart catheterization (RHC) PASP, with at least 25 studied patients and reporting correlation coefficients (r) were identified. Patient demographics, study characteristics, the percent of patients studied for left or right heart pathologies, and study biases were determined. After adjusting for differing study sizes, each study's r value was used as a single datapoint and dichotomized above or below the entire cohort's mean values. From 32 studies 2604 D-RHC parings were reported. Their overall weighted r was 0.68 ± 0.19. Poorer correlations were found for right heart pathologies compared to left heart pathologies (r = 0.58 vs. 0.84, P < 0.001) and for normal PASP patients in a study compared to abnormal PASP patients (r = 0.55 vs. 0.82, P < 0.001). Studies with predominately right heart pathology had a significantly greater D-RHC time difference, fewer successful D determinations, a greater percentage of normal PASPs on RHC, and more between-method differences >10 mmHg. Metaregression analyses indicated that both right heart pathology predominance and a greater percent of normal PASPs on RHC remained associated with poorer correlations. CONCLUSIONS: D PASP-RHC correlations were high and between-method differences less in patients with left heart pathology but were poorer for right heart diseases and studies with proportionately more normal PASPs on RHC for which further study is needed.

Discordant Doppler right heart catheterization pulmonary artery systolic pressures: importance of pulmonary capillary wedge pressure.

BACKGROUND: Although the echo Doppler (D) estimation of pulmonary artery systolic pressure (PASP) was initially highly correlated with right heart catheterization (RHC), recent D-RHC studies have questioned its accuracy. The aim of this study was to reevaluate this relationship and to determine possible explanations for disparate D-RHC results. METHODS: We retrospectively identified all patients at one institution who underwent RHC and had an echocardiogram within the prior month. Echocardiographic and catheterization hemodynamic factors were evaluated by regression and Bland-Altman analysis. RESULTS: Of 69 patients, 52 (75.4%) had estimable D-PASP. D-RHC PASP r = 0.62 and 51.9% had a PASP difference >10 mmHg, comparable to other recent studies. The D-RHC difference correlated with pulmonary capillary wedge pressure (PCWP) (r = -0.60, P < 0.001) and right atrial pressure (r = -0.43, P = 0.002). Multivariate analysis including wedge pressure improved the relation between D and RHC for PASP (r = 0.86). These results were little changed using only the respective RV-RA pressure gradients from D and RHC. CONCLUSION: Pulmonary capillary wedge pressure appears to be a significant covariate in the correlation between D and RHC PASP.

Elevated troponin predicts long-term adverse cardiovascular outcomes in hypertensive crisis: a retrospective study.

BACKGROUND: Hypertensive crisis is associated with poor clinical outcomes. Elevated troponin, frequently observed in hypertensive crisis, may be attributed to myocardial supply-demand mismatch or obstructive coronary artery disease (CAD). However, in patients presenting with hypertensive crisis and an elevated troponin, the prevalence of CAD and the long-term adverse cardiovascular outcomes are unknown. OBJECTIVE: We sought to assess the impact of elevated troponin on cardiovascular outcomes and evaluate the role of troponin as a predictor of obstructive CAD in patients with hypertensive crisis. METHODS: Patients who presented with hypertensive crisis (n = 236) were screened retrospectively. Baseline and follow-up data including the event rates were obtained using electronic patient records. Those without an assay for cardiac Troponin I (cTnI) (n = 65) were excluded. Of the remaining 171 patients, those with elevated cTnI (cTnI ≥ 0.12 ng/ml) (n = 56) were compared with those with normal cTnI (cTnI < 0.12 ng/ml) (n = 115) at 2 years for the occurrence of major adverse cardiac or cerebrovascular events (MACCE) (composite of myocardial infarction, unstable angina, hypertensive crisis, pulmonary edema, stroke or transient ischemic attack). RESULTS: At 2 years, MACCE occurred in 40 (71.4%) patients with elevated cTnI compared with 44 (38.3%) patients with normal cTnI [hazard ratio: 2.77; 95% confidence interval (CI): 1.79-4.27; P < 0.001]. Also, patients with elevated cTnI were significantly more likely to have underlying obstructive CAD (odds ratio: 8.97; 95% CI: 1.4-55.9; P < 0.01). CONCLUSION: In patients with hypertensive crisis, elevated cTnI confers a significantly greater risk of long-term MACCE, and is a strong predictor of obstructive CAD.

Use of intra-aortic balloon counterpulsation during emergent cesarean section in a pregnant patient with myocardial infarction.

The intra-aortic balloon pump (IABP) is a tool to help improve myocardial perfusion, reduce afterload, and decrease myocardial demand by reducing cardiac work. We describe a unique case of an IABP placement in a pregnant woman in her third trimester with a non-ST elevation myocardial infarction. The IABP allowed safe delivery of the fetus by cesarean section prior to a successful percutaneous intervention for complex two-vessel coronary artery disease. This case report also describes the first-time use of an IABP during cesarean section.

A rare case of pigmented villonodular synovitis after unicompartmental knee replacement: a case report.

Pigmented villonodular synovitis is a benign proliferative disease involving the synovium. Pigmented villonodular synovitis is rare after replacement arthroplasty and has not been recognised and reported as a cause of failure of unicompartmental knee replacement in the literature.