Correlation of the Neutrophil-to-Lymphocyte Ratio (NLR) and Platelet-to-Lymphocyte Ratio (PLR) with Contrast-Induced Nephropathy in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Interventions.

Introduction Contrast-induced acute nephropathy (CIN) in patients undergoing percutaneous coronary intervention (PCI) in the setting of acute coronary syndromes (ACS) is associated with adverse outcomes, including longer hospitalization and short and long-term mortality. Neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) are inflammatory markers that have been validated separately in prior studies as a predictor of CIN in patients with ACS who undergo a left heart catheterization. Our study aims to further investigate the role of NLR and PLR together as markers for predicting CIN in patients with ACS.  Methods A retrospective chart review was performed on a total of 1,577 patients aged 18 - 90 who presented with ACS and underwent PCI between January 2011 to December 2015 at the Florida Hospital Orlando. Cut-off values used for a high PLR and NLR were PLR > 128 and NLR > 2.6. CIN was defined as an increased serum creatinine level by ≥ 0.5 mg/dL, or ≥ 25%, over the baseline value within 72 hours after contrast agent administration. Patients with end-stage renal disease (ESRD) were excluded.  Results Of the 1,577 patients included in the study, 213 (13.51%) patients had CIN. On multivariate logistic regression analysis, high NLR showed an independent association with an elevated risk of CIN (OR 2.03, 95% CI: 1.403 - 3.176, P < 0.001). High PLR did not correlate with CIN (OR 0.831, 95% CI: 0.569 - 1.214, P = 0.339).  Conclusion Elevated NLR is an independent predictor of CIN in patients with acute myocardial infarction (AMI) and may be used to improve on current risk prediction models.

Comparative Clinical Characteristics of Rheumatic Heart Disease Patients Undergoing Surgical Valve Replacement.

Background To assess the prevalence patterns of isolated/mixed rheumatic valvular lesions and associated risk factors among rheumatic heart disease (RHD) patients undergoing surgical valve replacement. Methods An analytical cross-sectional design was used. Purposive sampling was used to select 87 RHD patients who underwent a first-time valve replacement for mitral, aortic, or both valves between April 1 and October 20, 2016, at Punjab Institute of Cardiology, Lahore, Pakistan. Patients with systemic hypertension, diabetes mellitus type-II, congenital heart defects, coronary artery disease, non-rheumatic valvular degeneration, positive test for hepatitis C, or undergoing concomitant coronary artery bypass graft or a 'redo' valve replacement procedure were excluded. A proforma was used to collect preoperative data on patients' demographics, laboratory investigations, electrocardiogram (ECG), and transthoracic echocardiography reports. Results Age (mean ± S.D.) was 32.79 ± 13.06 years, which was divided into four quartile-based groups. Forty-six (52.9%) cases were males. The majority (56.3%) of patients underwent mitral valve replacement. Mitral regurgitation (MR, 80%) was the most common lesion. Of 71 available ECGs, atrial fibrillation was observed in 46.5% cases. Increasing age group was negatively correlated with MR severity (τc = -0.188, p-value = 0.033) and positively with aortic stenosis (AS) severity (τc = 0.141, p-value = 0.010). No significant elevations were observed for anti-streptolysin O titer, C-reactive protein, and leukocyte count, though the erythrocyte sedimentation rate was abnormally high in 46.94% cases. Conclusions MR was the most common lesion. MR was more severe in younger patients whilst AS was more severe in older cases. There is little evidence of ongoing residual inflammation.

Anomalous Coronary Anatomy with Fistula Diagnosed on Coronary Computed Tomography Angiography.

Anomalous coronary vasculature is a rare finding among the general population. Identifying such cases is important for preventing adverse outcomes such as sudden cardiac death. We present two rare cases of aberrant coronary anatomy. In Case 1, a 4-year-old male who presented with non-exertional chest pain was found to have anomalous coronary architecture on echocardiogram. Coronary computed tomography angiogram (CCTA) confirmed an anomalous origin of the left coronary artery from the right coronary sinus with a malignant interarterial course and myocardial bridging of the left anterior descending (LAD) artery. The patient underwent a successful surgical correction of the defects. In Case 2, a full-term infant female was born with a hypoplastic right ventricle and pulmonary atresia. CCTA showed a large fistula originating from the coronary sinus on the left that drained into the superior aspect of the mid right ventricular cavity, an anomalous bridge between the left and right atrial appendages, and five fistulous connections between various vessels. The patient was transferred to another facility for cardiac transplant.

Catastrophic Prosthetic Valve Endocarditis Caused by Rare Black Fungi.

Fungal infection of prosthetic heart valves is rare and can lead to severe complications including death. Dematiaceous mold, also known as "black fungi," are an extremely rare cause of endocarditis that usually affect immunocompromised hosts. The infection is usually chronic and can lead to heart failure and embolic complications. These fungi have limited antifungal treatment modalities. We present a rare case of prosthetic aortic valve, root, and graft infection in an immunocompetent host that revealed itself through renal, mesenteric, and cerebral embolic phenomenon. The patient underwent removal and replacement of the aortic graft followed by small bowel resection for mesenteric infarction. Patient had a successful postoperative course and underwent a long-term antifungal treatment with amphotericin B and voriconazole.

Complex Vascular Ring Diagnosed on Cardiovascular MR in a 3-Day-Old Infant.

Prenatal ultrasonography in the early third trimester showed an unusual branching pattern of the right aortic arch. Echocardiography performed 4 h after birth showed the right aortic arch with mirror-image branching, patent ductus arteriosus, and patent foramen ovale. Because the location of the ductus arteriosus was unclear on echocardiography, cardiovascular magnetic resonance imaging was performed 3 days after birth. Advanced techniques including contrast-enhanced time-resolved magnetic resonance angiography and 3D time-of-flight magnetic resonance angiography allowed accurate diagnosis of a vascular ring comprising ascending and descending aorta, right aortic arch with mirror-image branching, and diverticulum of Kommerell giving rise to a left ligamentum arteriosum. The infant had hiccups, but no other symptoms. The esophagram was negative for obstruction. The infant was closely monitored; however, she developed esophageal obstruction at 7 months of age because of the vascular ring. She underwent lysis of the left ligamentum arteriosum followed by aortopexy for relief of esophageal obstruction. This report shows the utility of neonatal cardiovascular magnetic resonance imaging to evaluate complex congenital aortic arch anomalies.

Takotsubo Cardiomyopathy Presenting with Sinoatrial Disease: A Rare Presentation.

Takotsubo cardiomyopathy (TCM), or apical ballooning syndrome, is a distinct nonischemic cardiomyopathy mimicking acute coronary syndrome. A 76-year-old female presented with ST elevation in the inferior lead and a troponin level of 0.81 ng/dL. An immediate coronary angiography showed non-obstructive coronary artery disease. A subsequent ventriculogram and echocardiogram showed anteroapical and distal inferior wall hypokinesis suggestive of TCM. Despite therapy with beta blocker, she was observed to have two significant sinus pauses, one eight-second, and a second 29-second pause. An urgent transvenous pacemaker was put in place and later followed by a permanent pacemaker. The patient was discharged on carvedilol and losartan. Although other arrhythmias such as complete heart block, torsades, and ventricular arrhythmias have been commonly reported, the association of TCM with recurrent sinus arrest has rarely been reported in the literature. The occurrence observed in this case implies that patients with TCM should be monitored closely for arrhythmias, and, if such a condition is identified, planning for permanent pacemaker implantation should be started early enough to avoid recurrent life-threatening episodes.

Funny Lumps, Flaming Pheo, and a Broken Heart: A Rare Case of Pheochromocytoma.

Pheochromocytoma is the underlying etiology in 0.1% of hypertensive cases. However, it may be present in up to 5.7% of patients with neurofibromatosis I (NF1). The burst of catecholamines inherent in pheochromocytoma has significant effects on the mechanical and electrical activity of the myocardium. Different theories have been postulated for myocardial stunning in patients with pheochromocytoma that include microvascular spasm, impaired fatty acid metabolism, increased production of oxygen-derived free radicals and dynamic left ventricular mid-cavity obstruction. QT interval prolongation is seen in 16% to 35% of patients with pheochromocytoma. Takotsubo cardiomyopathy (TS) is now being increasingly identified and it may be responsible for up to 40% of cases of acute catecholamine cardiomyopathy. These manifestations may sometimes precede or cloud the typical triad of a headache, sweating, and tachycardia. We herein present a case of a 42-year-old female with a unique combination of QT prolongation, torsades de pointes, and TS caused by pheochromocytoma in the background of NF1. All these complications are potentially reversible with the removal of the underlying adrenal tumor, underscoring the importance of a high suspicion for pheochromocytoma in patients with NF1.

A Reversible Cause of Complete Heart Block Causing Chest Pain and Syncope.

Vasospastic angina (VSA), also known as variant or Prinzmetal's angina, is a relatively uncommon cause of retrosternal chest pain with transient ST segment elevation, mainly due to vasospasm in the coronary arteries. This is a case of 37-year-old female who presented with chest pain and syncope. Her initial workup, including echocardiogram, was negative. Subsequently, she was sent home with an event monitor. During the next two weeks, she continued to have recurrent episodes of similar chest pains and presented to her cardiology appointment with a heart rate of 45 bpm and blood pressure of 100/60 mmHg and was taken to hospital emergency department. Event monitor review showed intermittent complete heart block. In the hospital, the electrocardiogram (EKG) showed complete heart block and inferior lead ST elevations concomitantly with the chest pains. Although suspicious for vasospastic angina, coronary artery disease had to be ruled out for which patient underwent coronary angiography without evidence of significant obstructive disease. Immediately thereafter, the patient underwent permanent pacemaker placement without recurrence of syncopal episodes. This case signifies complete heart block as one of the rare complications of vasospastic angina which otherwise can also lead to symptoms such as dizziness, shortness of breath, syncope, cardiac arrest, and sudden cardiac death.

Development of a novel score to predict the risk of acute kidney injury in patient with acute myocardial infarction.

BACKGROUND: Acute kidney injury (AKI) is common in patients with acute myocardial infarction. AKI in this setting is associated with short- and long-term adverse events. The aim of this study was to develop a simple score to predict AKI in patients presenting with acute myocardial infarction based on data available at time of admission. METHODS: This was a retrospective analysis of data collected as part of the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) registry at a tertiary care center between 1/1/2011 and 12/31/2013. Data were collected prospectively for all patients who presented within 24 h of the onset of myocardial infarction. AKI was defined as an increase in creatinine from admission level to peak level of ≥0.3 mg/dl or by ≥50 %. Patients with history of end-stage renal disease requiring renal replacement therapy were excluded. RESULTS: Of 1107 patients included in the study, 147 (13.3 %) developed AKI. The following factors were independently associated with increased risk for AKI: cardiac arrest, decompensated heart failure on presentation, diabetes mellitus, hypertension, anemia, impaired renal function on presentation, and tachycardia on presentation. These factors were combined to form a new predictive tool. The new score showed excellent discrimination for AKI: the area under the receiver operating characteristic curve (AUROC) was 0.76 (95 % confidence interval 0.72-0.80). CONCLUSION: A simple score using clinical and laboratory data available on admission can predict the risk of AKI in patients presenting with acute myocardial infarction.