Renal Sympathetic Denervation: A Comprehensive Review.

In 2017, the American College of Cardiology and American Heart Association released its updated blood pressure guidelines, redefining hypertension to be any systolic blood pressure ≥130 mm Hg or diastolic blood pressure ≥80 mm Hg. Among United States adults, these new parameters increased the prevalence of hypertension from 72.2 million (31.9%) to 103.3 million (45.6%) adults and decreased the rate of medication-controlled hypertension from 53.4% to 39% with the prevalence of resistant hypertension ranging from 12% to 18%. Results of the pivotal SPRINT trial showed that more intensive blood pressure control in diabetic patients decreased both cardiovascular events and all-cause mortality. However, even with ideal goals in mind, compliance remains an issue due to multiple causes, and approximately half of study participants had stopped taking their antihypertensive drug within a year. Renal sympathetic denervation is a process in which catheter-based techniques are used to ablate specific portions of the renal artery nerves with the goal of decreasing sympathetic nerve activity and reducing blood pressure. Several studies using renal artery denervation have already shown benefit in patients with resistant hypertension, and now newer trials are beginning to focus on those with stage II hypertension as an additional potential treatment population. This review will seek to summarize the current evidence surrounding renal artery denervation and discuss some of its future trials, current issues, and potential roles both in hypertension and other comorbidities.

Uterine intravenous leiomyomatosis with femoral vein, intracaval, intracardiac and pulmonary artery extension.

We report a 54-year-old female with recently diagnosed multiple cardiac thrombi and pulmonary embolism that was treated with thrombolytics and anticoagulants. She presented again with worsening dyspnea and was found to have persistent large cardiac thrombi on echocardiogram. Surgical findings revealed a single right atrial mass originating from inferior vena cava and extending into the pulmonary artery. The mass was successfully removed. Final pathology revealed a benign smooth muscle and vascular mass with estrogen and progesterone receptor positivity favoring uterine intravenous leiomyoma. She was discharged on warfarin and leuprolide therapy. This diagnosis requires a high index of suspicion, especially in a middle-aged woman with right atrial mass and history of an existing leiomyoma, hysterectomy or myomectomy.

Right ventricular metastasis from unclassified Renal Cell Carcinoma.

BACKGROUND: Cardiac metastasis of unclassified renal cell carcinoma (RCC) subtype is very rare, and even more so is an isolated right ventricular (RV) metastasis without vena cava extension or right atrial involvement. To the best of our knowledge, this is the first report of a cardiac metastasis of an unclassified RCC (an aggressive RCC) without vena cava extension. CASE PRESENTATION: A 61-year-old African American male with past medical history of hypertension and schizophrenia presented to the emergency room following 2 episodes of syncope and 3-month history of progressive neck mass. CT scan of neck, abdomen and pelvis showed bulky left cervical, supraclavicular and axillary lymph node, mass in anterior aspect of heart, and multiple solid left renal masses and probable right renal mass. Echocardiogram revealed a large RV mass with deformation of the RV free wall suggesting malignant growth. Core biopsy of the right superficial gluteal mass revealed a metastatic poorly differentiated carcinoma of likely renal origin, with a possibility of an unclassified RCC. Due to the extent and burden of metastasis, patient and family members agreed to conservative management and evaluation for hospice care. CONCLUSION: Cardiac metastasis of unclassified RCC is rare, and even more so is an isolated RV metastasis without vena cava extension or right atrial involvement, and the present case, to the best of knowledge is the first of such rare presentation.

Outcomes of Percutaneous Antegrade Intraluminal Coronary Intervention of Chronic Total Occlusion With Remote Surgical Backup.

Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) is not favored in facilities without on-site surgical backup. We reviewed outcomes of patients who had CTO intervention with remote surgical backup in our institution. All patients who underwent attempted antegrade intraluminal CTO PCI from January 2013 to July 2017 were analyzed. Twenty cases (18 patients, 58.1 ± 7.0 years, 70% males) were identified. Procedure was successful in 85% (17 of 20). There were 2 nonflow limiting dissections and 1 wire perforation. Two patients had post-PCI myocardial infarction. There was no cardiac death, myocardial infarction, target vessel revascularization, or stroke at 30 days and at mean follow-up of 19.5 ± 13.7 months. There were 4 rehospitalizations for angina requiring repeat angiogram in 3 cases: 2 without intervention, and 1 referred for coronary artery bypass grafting. Careful attempt at antegrade intraluminal CTO intervention done at a center with remote surgical backup is feasible in selected patients.

Modifiable Predictors of In-Hospital Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has become an acceptable therapy for patients with severe aortic valve stenosis at high or prohibitive surgical risk. Attempts are ongoing to validate risk prediction models for in-hospital mortality after TAVR. Our aim was to define modifiable risk factors predictive of in-hospital mortality after TAVR. METHODS: We identified patients who underwent TAVR from the 2012 database of the National Inpatient Sample. Patients who died during the index hospitalization were compared to those that were successfully discharged. The predictors of in-hospital mortality were analyzed using multivariate logistic regression. RESULTS: A total of 1,360 patients (mean age 81 ± 8.8 years, whites 80.1%, blacks 3.5%) had TAVR and 68 (5%) died during hospitalization (χ2 [1, n = 1,360] = 1,101.6, P < 0.001). The average length of hospital stay was 8.33 ± 6.7 days. The positive predictors of in-hospital mortality in the unadjusted model were comorbidities such as congestive heart failure, coagulopathy, fluid and electrolyte disorder, weight loss and history of drug abuse. Hypertension was a negative predictor of in-hospital mortality. Following multivariate analysis and adjustment for possible confounders, fluid and electrolyte disorder was the only significant positive predictor of in-hospital mortality (odds ratio = 1.89, CI: 1.11-3.22, P = 0.019). The odds of in-hospital mortality were reduced in patients with hypertension (odds ratio = 0.45, CI: 0.26-0.78, P = 0.004). CONCLUSIONS: Fluid and electrolyte disturbance could be a modifiable predictor of in-hospital mortality following TAVR. Efforts should be geared towards reducing its occurrence in this patient population.

Clinical and echocardiographic predictors of new-onset atrial fibrillation in patients admitted with blunt trauma.

BACKGROUND: Atrial fibrillation (AF) is a common arrhythmia after trauma or burn injury; however, its predisposing factors are not well known. Moreover, little is known about its effect on mortality and other short-term clinical outcomes. OBJECTIVES: This study is aimed at identifying risk factors for new-onset AF in patients admitted with blunt trauma or burn injuries at a Level 1 academic trauma center, and to determine its effects on the short-term clinical outcomes. METHODS: This case-control study compared patients with new-onset AF with a cohort of patients without AF during the hospital stay after trauma or burn injury. Patients with prior AF or lack of transthoracic echocardiogram were excluded. Demographic, clinical factors including injury severity score and echocardiographic parameters were compared in both cohorts. Risks of short-term clinical outcomes, namely persistent AF, new stroke, myocardial infarction, or death, were compared. RESULTS: Older age, sepsis, CHADS2-VASC score >1, larger left atrium (LA) size, left ventricular hypertrophy (LVH), and left ventricular diastolic dysfunction imposed a significant risk for new-onset AF on univariate analysis. On multivariate, independent predictors of new-onset AF were LA dilation and LVH. LA enlargement increased odds of new-onset AF by 23-fold (OR 23; CI: 5.7-92, P < 0.0001) and the presence of LVH increased the odds of new-onset AF more than 20-fold (OR 20.8; CI: 5-87, P < 0.0001). CONCLUSIONS: Dilated LA and LVH are independent predictors of new-onset AF in the patients with blunt trauma or burn. New-onset AF did not confer increased risk for in-hospital mortality.

Stress-induced thrombus: prevalence of thromboembolic events and the role of anticoagulation in Takotsubo cardiomyopathy.

BACKGROUND: Takotsubo cardiomyopathy (TCM), also known as stress-induced cardiomyopathy has a favorable prognosis with expected recovery in weeks. Left ventricular (LV) thrombus is a known complication of TCM, which can lead to embolization and potentially a stroke. The prevalence of LV thrombus and the role of anticoagulation have yet to be fully defined in this condition. METHODS: We performed a search of published literature through PubMed and Scopus, which identified 282 patients with TCM in whom the incidence of LV thrombus and/or thromboembolic event was reported. In order to contrast this to the current anticoagulation strategy of atrial fibrillation, the occurrence of LV thrombus was compared to the adjusted stroke rate using the CHADS2 score. RESULTS: Of the 282 patients identified through a literature search, 26 (9.2%) were noted to have a thromboembolic event in the setting of TCM. The incidence of thromboembolic event ranged from 5.3% to as high as 14.3%. When compared to the CH2sDS2-VASc score, the average incidence of LV thrombus in our study equated to a score between 4 and 5. CONCLUSIONS: While the occurrence of LV thrombus in TCM is variable among studies, the average incidence remains relatively high. Thus, making LV thrombus a significant complication of stress-induced cardiomyopathy. Prophylactic anticoagulation until recovery may have a role in reducing the rate of LV thrombus. Further studies will be needed to determine the rate of embolization and utility of anticoagulation in TCM.

Simultaneous acute cardio-cerebral infarction: is there a consensus for management?

Acute ischemic stroke (AIS) and acute myocardial infarction (AMI) are both life-threatening medical conditions with narrow therapeutic time-window that carry grave prognosis if not addressed promptly. The acute management of both condition is well documented in the literature, however the management of a simultaneous presentation of both AIS and AMI is unclear. A delayed intervention of one infarcted territory for the other may result in permanent irreversible morbidity or disability, and even death. In addition, the use of antiplatelet and anticoagulants that are inherently part of an AMI management may increase the risk for hemorrhagic conversion associated with intravenous thrombolysis used in AIS, and the use of a thrombolytic in AIS increases the risk of cardiac wall rupture in the setting of an AMI. Despite this ambiguity, there is no clear evidence-based guideline or clinical studies that have addressed the optimal management of this rare co-occurrence. This review paper examines the existing literature on the management of simultaneous acute cardio-cerebral infarction (CCI) and highlights the existing challenge to management.

Clinical outcomes of coronary occlusion following transcatheter aortic valve replacement: A systematic review.

BACKGROUND: Coronary occlusion (CO) is a rare but serious complication following transcatheter aortic valve replacement (TAVR) with limited published data. We sought to evaluate the immediate and short-term outcomes of CO complicating TAVR. METHODS: Studies, including case reports, case series and original articles published from 2002 to 2016 describing CO following TAVR were identified with a systematic electronic search using the PRISMA Statement. Only studies reporting data on demographic and procedural characteristics, management and follow up outcomes were analyzed. RESULTS: A total of 40 publications describing 96 patients (86 native, 10 bioprosthetic) were identified. Mean age was 83±7years and most (81%) were females. The mean logistic EuroSCORE and STS score was 23.5±14.6% and 9.1±3.2% respectively. TAVR access site was transfemoral in 73% and a balloon expandable valve was used in 78%. Among those with LCA occlusion, the mean LCA ostium height was 10.1±1.8mm while the mean RCA ostium height was 10.4±2.0mm among those with RCA occlusion. CO frequently involved the left main coronary artery (80%) and the most common mechanism was displacement of native valve leaflet (60%), and most cases occurred within 1-hour post-implantation (88%). Percutaneous coronary intervention was attempted in 82 patients and successful in 89%. Procedural death was 10.4%. CO following TAVR in native aortic valve stenosis was associated with a 30-day mortality rate of 35.3%. CONCLUSIONS: CO following TAVR is associated with a high procedural and 30-day mortality rate despite aggressive resuscitative measures including percutaneous coronary intervention.

Aortic Valve Regurgitation: A Comprehensive Review.

Aortic regurgitation (AR) has an estimated prevalence of 4.9% in the Framingham study, with moderate or severe AR occurring in 0.5% of the study population. The incidence and severity of AR increases with age, and may occur acutely or as a chronic valvular disease with distinct presentations, natural history and management strategy. Our review is a comprehensive description of the varied presentation of aortic regurgitation and its management.

Left Ventricular Noncompaction Cardiomyopathy and Recurrent Polymorphic Ventricular Tachycardia: A Case Report and Literature Review.

INTRODUCTION: Noncompaction cardiomyopathy is a rare phenotype of cardiomyopathy associated with severe cardiac arrhythmia and thromboembolic complications. CASE PRESENTATION: A 55-year-old woman presented with frank pulmonary edema and received a diagnosis of noncompaction cardiomyopathy. DISCUSSION: Left ventricular noncompaction cardiomyopathy is increasingly being diagnosed because of advances in imaging modalities. It is important to differentiate this new phenotype of cardiomyopathy from others because its diagnosis, management, and prognosis differ. We reviewed the literature and summarized the diagnostic criteria, associated complications, initial and long-term management, and the recommendation for family screening.

A Case of Fulminant Hepatic Failure Secondary to Congestive Heart Failure Without Evidence of Acute Cardiac Decompensation.

There are so far only a few reported cases of acute fulminant hepatic failure resulting from acute cardiomyopathy. This is a rare occurrence, especially in patients that do not exhibit any signs and symptoms of acute cardiac decompensation. We report a case of fulminant liver failure with nondiagnostic work up for the common causes of liver failure. This patient had concurrent history of congestive heart failure, but did not have acute decompensation. Right upper quadrant sonogram revealed hepatomegaly of 15 cm, trace amount of perihepatic ascites, pericholecystic fluid, and also thickened edematous gallbladder wall with no stones, no common bile duct stones, and no portal vein thrombosis. Echocardiogram revealed dilated left atrium and ventricle, severe mitral regurgitation, severe tricuspid regurgitation, grade 4 diastolic dysfunction, diffuse hypokinesis of left ventricle, and severely and newly reduced systolic function with an ejection fraction of 10 percent (decreased from 25 percent on last ECHO 18 months prior). Liver biopsy demonstrated marked centrilobular hepatocyte necrosis and dropout accompanied by congestion, some areas of bridging necrosis and focal confluent necrosis which was suggestive of severe congestive hepatopathy. With initiation of heart failure medications, liver function improved significantly.

Melatonin and Human Cardiovascular Disease.

The possible therapeutic role of melatonin in the pathophysiology of coronary artery disorder (CAD) is increasingly being recognized. In humans, exogenous melatonin has been shown to decrease nocturnal hypertension, improve systolic and diastolic blood pressure, reduce the pulsatility index in the internal carotid artery, decrease platelet aggregation, and reduce serum catecholamine levels. Low circulating levels of melatonin are reported in individuals with CAD, arterial hypertension, and congestive heart failure. This review assesses current literature on the cardiovascular effects of melatonin in humans. It can be concluded that melatonin deserves to be considered in clinical trials evaluating novel therapeutic interventions for cardiovascular disorders.

Association of Sleep Duration with Stroke in Diabetic Patients: Analysis of the National Health Interview Survey.

BACKGROUND: Habitual sleep duration is increasingly being recognized as an important risk factor for stroke. We sought to describe the association between sleep duration and stroke in a cohort of individuals with diabetes. METHODS: Data from the National Health Interview Survey for the years 2004-2013 were used. Only those answering "yes" to the question "Have you EVER been told by a doctor or other health professional that you have diabetes or sugar diabetes?" were included in the analysis. Sleep duration was categorized as short (≤6 hours), normal (7-8 hours), or long (≥9 hours). Self-reported diagnosis of stroke was the main outcome of interest. FINDINGS: A total number of 26,364 self-reported diabetic individuals provided data for analysis. Stroke was reported in 9.1% of short sleepers, 16.1% of long sleepers, and 8.3% of normative sleepers (P < .05). In the unadjusted model, short and long sleepers had an increased odds of stroke compared to normal sleepers (odds ratio [OR] = 1.12, 95% confidence interval [CI]: 1.02-1.23, P = .01; and OR = 2.18, 95% CI: 1.96-2.42, P = .01; respectively), but the association between short sleep and stroke became nonsignificant after multivariate adjustment (OR = 1.15, 95% CI: .95-1.40, P = .16) except in white participants. The association between long sleep duration and stroke persisted (OR = 1.46, 95% CI: 1.16-1.84, P = .01), especially in males (OR = 1.62, 95% CI: 1.14-2.28) and in white participants (OR = 1.97, 95% CI: 1.47-2.65). CONCLUSION: In diabetic patients, abnormal sleep duration was associated with increased risk of stroke, and this association varied among different sex and ethnic groups.

Correlation of Prehypertension with Left Ventricular Mass Assessed by Cardiac Magnetic Resonance Imaging.

Introduction. The purpose of this observational cross-sectional study was to assess left ventricular mass (LVM) in prehypertensive individuals in comparison to normotensives and to determine if central blood pressure (BP) correlates better with LVM index (LVMI) than brachial BP. Methods and Result. Brachial and central BP measurements were completed at first visit and at 4 weeks in 65 healthy volunteers who were at least 40 years old and not on medication. Subjects were divided into two groups of normotensives and prehypertensives based on JNC-7 criteria and LVM was obtained using cardiac magnetic resonance imaging. Prehypertensives had significantly higher LVMI compared to normotensives (P < 0.01). Brachial and central BP also both positively correlate with LVMI (r = 0.460, P < 0.01; r = 0.318, P = 0.012, resp.) in both groups and neither method was superior to the other. After multivariate regression analysis and adjusting for cardiovascular risk factors, prehypertension remained an independent determinant of LVM. Conclusion. Prehypertension is associated with cardiovascular target organ damage, and central BP was not superior to brachial BP or vice versa for association with LVMI.

Right Atrial Myxoma and Syncope.

BACKGROUND: Right atrial myxoma accounts for 15-20% of cardiac myxomas and syncope is a very rare manifestation. We present the case of an 89-year-old man with right atrial myxoma and syncope, and discuss the role of cardiac magnetic resonance imaging (MRI) in the diagnosis of myxomas. CASE REPORT: An 89-year-old man with a history of hypertension, hyperlipidemia, chronic kidney disease stage 4, mild dementia, and benign prostatic hyperplasia presented to the emergency department with an episode of syncope. Physical examination demonstrated normal and regular heart sounds, and normal respiratory rate and oxygen saturation. Echocardiogram described a well-circumscribed echo-dense mass in the right atrial cavity, which was attached to the septum but not obstructing the tricuspid annulus, measuring 1.7×2.2 cm at its widest diameter. Cardiac MRI revealed a mass with dark intensity which enhanced heterogeneously following intravenous administration of gadolinium-chelate, consistent with a myxoma. The location of this myxoma, coupled with the presence of a stalk allowing mobility, provides a clue to how this patient experienced transient obstruction of the tricuspid valve leading to syncope. CONCLUSIONS: Right heart tumors should be considered in the differential diagnosis of unexplained syncope. Cardiac MRI with gadolinium-chelate administration can help differentiate this tumor from a right-sided atrial thrombus, which can pose a diagnostic challenge.

A Rare Association of Sinus Venosus-Type Atrial Septal Defect and Persistent Left Superior Vena Cava Detected by Transthoracic Echocardiography and Cardiac Magnetic Resonance Imaging.

BACKGROUND: Association of persistent left superior vena cava (PLSVC) and sinus venosus-type atrial septal defect (SVASD) is rare. We describe a patient with dilated coronary sinus (CS) found to have PLSVC and SVASD. CASE REPORT: The patient is a 60-year-old man with history of stroke who underwent a transthoracic echocardiogram (TTE) for evaluation of shortness of breath. TTE demonstrated a markedly dilated CS. Agitated saline was injected into the left antecubital vein to further assess CS. The parasternal long axis view demonstrated immediate filling of the CS and confirmed the presence of a PLSVC. Apical 4-chamber view with injection of agitated saline into the right antecubital vein demonstrated immediate contrast opacification of both atria, consistent with a right to left cardiac shunt. Cardiac magnetic resonance (CMR) was performed, which confirmed the TTE findings of PLSVC and defined the cardiac shunt as SVASD. CONCLUSIONS: PLSVC should be suspected in a patient with an abnormally dilated CS. In this case we identified a rare association of PLSVC with a SVASD. TTE with agitated saline contrast injection and CMR are useful diagnostic tools for PLSVC and associated cardiac congenital anomalies, respectively.

Inadequate Blood Pressure Control in Hypertensive Patients Referred for Cardiac Stress Test.

The current study examined the degree of blood pressure (BP) control and incidence of myocardial ischemia in hypertensive patients (n=2039) referred for cardiac stress test. Patients were categorized into well-controlled (<140/90 mm Hg), poorly controlled (140-160/90-100 mm Hg), and very poorly controlled (>160/100 mm Hg) groups according to their resting BP. The mean age[±standard error of the mean] of the patients was 68±13 years, and 885 (43.4%) were men. The prevalence of well-controlled hypertension (HTN) was 47.2%, poorly controlled HTN was 29.5%, and very poorly controlled HTN was 23.3%. Evidence of ischemia was seen in 19.8% and 19.3% of the well-controlled and poorly controlled groups, respectively. The very poorly controlled group had the lowest incidence of ischemia (14.3%) (P<.05) compared with the other two groups. Symptoms that mimic ischemic heart disease in hypertensive patients may be partly explained by poorly controlled BP. Quality of care might be improved by optimally controlling BP in patients with angina symptoms prior to ordering diagnostic testing associated with radiation exposure and cost.

Trazodone and omeprazole interaction causing frequent second-degree Mobitz type 1 atrioventricular (AV) block (Wenckebach phenomenon) and syncope: a case report and literature review.

BACKGROUND: This case report highlights serious cardiovascular adverse effects with a conventional dose of trazodone as a result of its potential interaction with omeprazole. CASE REPORT: A 54-year-old man who was a former smoker, with dyslipidemia, coronary artery disease, and anxiety disorder developed lightheadedness and syncope the morning of admission. He was taking trazodone 50 mg daily, omeprazole 20 mg daily, and simvastatin 20 mg at bedtime. He doubled the dose of trazodone 50 mg on the night prior to presentation to calm his anxiety. An electrocardiogram revealed sinus rhythm at 60 beats per minute and second-degree Mobitz type 1 atrioventricular (AV) block with 5:4 AV conduction. Results of basic metabolic panel, thyroid-stimulating hormone, and chest radiograph were normal. A transthoracic echocardiogram revealed aortic valve sclerosis. We tested for Lyme disease given his history of hunting in the woods 8 months prior to presentation, but the titer was negative. Trazodone and omeprazole were discontinued. By the 3rd day of medication discontinuation, all symptoms had resolved and the frequency of second-degree AV Mobitz type 1 AV block had decreased to once per hour. CONCLUSIONS: Due diligence and meticulous attention to detail needs to be exercised to uncover drug interactions as potential causes of lethal and nonlethal patient symptomatology, as in this case of syncope caused by concomitant use of trazodone and a widely prescribed medication, omeprazole.