Improvement of Cardiac Vegetations in Antiphospholipid Syndrome with Enoxaparin and Corticosteroids after Rivaroxaban Failure.

Cardiac disease is a well-known complication of antiphospholipid syndrome (APS), with many patients presenting with valvular thickening or vegetations, referred to as Libman-Sacks endocarditis (LSE). Because cases of APS with cardiac involvement are relatively rare, paucity of large clinical trials studying this complication has made management challenging. In the absence of acute heart failure and embolic events, a medical approach is usually selected, consisting of anticoagulation and possibly corticosteroids when another underlying autoimmune disease is present. However, the role of various anticoagulant classes and the duration of steroid therapy continue to be debated. Here, we present a 45-year-old woman who developed two vegetations in the setting of secondary APS while taking rivaroxaban before experiencing marked improvement with the use of enoxaparin and steroids.

Atrial Myxoma Presenting as Myocardial Infarction Diagnosed by Echocardiography, Managed Endoscopically with Robot-Assisted Surgery.

Atrial myxomatous embolization into the coronary arteries is a rare event. Management of large myxomas is usually via surgical resection involving a median sternotomy. Echocardiography is not a routine part of non-ST-elevation myocardial infarction (NSTEMI) management. Here, we present the case of a 70-year-old Caucasian man with a history of hypertension and hyperlipidemia who presented to the emergency department with an NSTEMI. Transthoracic echocardiogram and transesophageal echocardiogram revealed a large and highly mobile atrial mass, traversing through the mitral valve orifice during diastole. Coronary angiography revealed a focal 60% lesion in the right coronary artery and no other significant obstructive coronary artery disease, suggesting that the cause of his presentation was tumor embolization into the coronary circulation. The patient underwent robot-assisted endoscopic resection of his atrial mass and was discharged in stable condition on postoperative day 2. Pathology revealed atrial myxoma. To our knowledge, this is the first reported case of an atrial myxoma presenting with an NSTEMI and managed with a robot-assisted endoscopic approach. This case also highlights the importance of routine early echocardiography in patients presenting with NSTEMI.

No benefit from defibrillation threshold testing in the SCD-HeFT (Sudden Cardiac Death in Heart Failure Trial).

OBJECTIVES: This study investigated whether defibrillation threshold (DFT) testing during implantable cardioverter-defibrillator (ICD) implantation predicts clinical outcomes. BACKGROUND: Defibrillation testing is often performed during insertion of ICDs to confirm shock efficacy. There are no prospective data to suggest that this procedure improves outcomes when modern ICDs are implanted for primary prevention of sudden death. METHODS: The analysis included the 811 patients who were randomized to the ICD arm of the SCD-HeFT (Sudden Cardiac Death in Heart Failure Trial) and had the device implanted. The DFT testing protocol in SCD-HeFT was designed to limit shock testing in a primary prevention heart failure population. RESULTS: Baseline DFT data were available for 717 patients (88.4%). All 717 patients had a DFT of < or =30 J, the maximum output of the device in this study. The DFT was < or =20 J in 97.8% of patients. There was no survival difference between patients with a lower DFT (< or =10 J, n = 547) and a higher DFT (>10 J, n = 170) (p = 0.41). First shock efficacy was 83.0% for the first clinical ventricular tachyarrhythmia event; there were no differences in shock efficacies when the cohort was subdivided by baseline DFT. CONCLUSIONS: Low baseline DFTs were obtained in patients with stable, optimally treated heart failure during ICD implantation for primary prevention of sudden death. First shock efficacy for ventricular tachyarrhythmias was high regardless of baseline DFT testing results. Baseline DFT testing did not predict long-term mortality or shock efficacy in this study.

Myocardial perfusion imaging in acute coronary syndromes: potential use in decision making for emergent revascularization.

We report two cases of patients presenting to the emergency department with chest pain who had low risk electrocardiographic findings. Myocardial perfusion imaging (MPI) revealed a significant area of decreased uptake suggestive of acute transmural infarction. In both cases, biochemical markers later confirmed the diagnosis of myocardial infarction. Cardiac catheterization revealed a large area at risk which was then treated with percutaneous intervention. As MPI is increasingly utilized in the acute evaluation of chest pain, it may serve as a useful adjunct in selecting patients who may benefit from emergent cathertization and revascularization.

Cardiac pathologic findings reveal a high rate of sudden cardiac death of undetermined etiology in younger women.

BACKGROUND: Between 1989 and 1998 there was a 21% increase in estimated sudden cardiac death among US women aged 35 to 44 years. In contrast, the sudden cardiac death rate in age-matched men showed a decreasing trend (-2.8%). Due to under-representation of younger adults in published autopsy series, etiologies of sudden cardiac death merit further investigation. METHODS: We reviewed autopsy and detailed cardiac pathologic findings in younger women (age 35-44 years) from a 270-patient, 13-year (1984-1996) autopsy series of sudden cardiac death, and performed comparisons with findings in age-matched men. RESULTS: Women aged 35 to 44 years constituted 32% of all women in the series compared to men, who constituted 24% of total men (P =.004 vs women). A presumptive cause of sudden cardiac death could not be determined in 13 women (50%). Among women, 6 cases (22%) had significant coronary artery disease. Findings in others included coronary artery anomalies (n = 3), myocarditis (n = 2), hypertrophic cardiomyopathy (n = 1), coronary artery dissection (n = 1) and accessory pathway (n = 1). In younger men, a presumptive cause of sudden cardiac death remained undetermined in only 24% (P =.025 vs younger women), and coronary artery disease accounted for 40% of cases. CONCLUSIONS: In younger women, despite autopsy and detailed cardiac pathologic examination, an attributable cause of sudden cardiac death was not determined in 50% of cases; a 2-fold increase compared to men of the same age. Given the dynamic and multifactorial nature of sudden cardiac death, comprehensive population-based investigations are likely to be necessary to further investigate this unexpected sex-based disparity.