Master of the Masquerade: An Atypical Presentation of Acute Aortic Dissection.

Acute aortic dissection (AAD) is associated with unacceptably high mortality rate. As such, early diagnosis and aggressive management are essential in order to avoid life-threatening complications. Herein, we report an atypical presentation of AAD and clinical sequelae.

Toward Resiliency in the Joint Blood Supply Chain.

The Joint military community provides a wide array of medical support services to its personnel, including the transfusion of blood and blood products. Ensuring that blood remains available and safe for transfusion requires sophisticated logistical support, especially for the military community's provision of blood to medical operations around the globe. However, that supply chain may become brittle in future potential operating environments, such as large-scale combat operations where adversaries may contest the U.S. military's freedom of movement. This study describes the elements in the military's current blood supply chain and outlines a framework for assessing its performance. Through that lens, the authors then explore an array of approaches offering promise in improving the resiliency of the blood supply chain, including alternative concepts of operation and technologies. By understanding the mechanisms that underlie blood supply chain resilience, the Joint medical community can be better positioned to tailor a robust portfolio of resiliency investments. Such a portfolio would better ensure the availability and safety of blood and blood products under a wide array of stressors and threats to the system.

Rapid Desensitization to Overcome Contrast Allergy Prior to Urgent Coronary Angiography.

Allergic reactions to contrast media are a frequently reported complication of coronary angiography. The majority of patients experience mild, self-limited episodes, but in rare cases patients may experience severe, persistent symptoms. A strategy of premedication with corticosteroids and anti-histamines and an optimal selection of contrast agent is almost always successful in averting contrast reactions, yet a select few patients will continue to have breakthrough events. This is a case of recurrent, severe allergy to contrast media despite standard precautions complicating the treatment of non-ST elevation myocardial infarction (NSTEMI). Our patient was successfully managed with a strategy of rapid desensitization to iodinated contrast media achieved by administering progressively incremental doses of the media.

Improvements in Left Ventricular Diastolic Mechanics After Parachute Device Implantation in Patients With Ischemia Heart Failure: A Cardiac Computerized Tomographic Study.

BACKGROUND: Percutaneous ventricular restoration therapy with the use of a left ventricle (LV)-partitioning Parachute device has emerged as a clinical treatment option for LV apical aneurysm after extensive anterior myocardial infarction (AMI). We assessed changes of diastolic mechanics and functional improvements following LV Parachute device implantation by means of cardiac computerized tomography (CCT). METHODS AND RESULTS: CCT data were obtained from 28 patients before and after LV Parachute device implantation. Diastolic functional indices were determined by means of quantitative CCT assessment: 1) transmitral velocities in early (E) and late (A) diastole and ratio (E/A); 2) early diastolic mitral septal tissue velocity (Ea) and E/Ea; and 3) vortex formation time (VFT). Functional improvements were assessed with the use of New York Heart Association (NYHA) functional classification. Among the study patients, there were no significant differences in all transmitral velocities and E/A, though there was significantly increased Ea, reduced E/Ea, and greater VFT 6 months after LV Parachute device implantation. Finally, the improvement of diastolic functional indices after Parachute treatment correlated with observed clinical functional alterations (Δ E/Ea and Δ NYHA functional class:, r = 0.563; P = .002; Δ VFT and Δ NYHA functional class: r = -0.507; P = .006). CONCLUSIONS: LV Parachute device implantation therapy in heart failure caused by AMI and LV apical aneurysm formation showed improvements in several diastolic functional mechanics according to CCT-based measures.

Evaluating the quality of implantation of percutaneous ventricular restoration device (Parachute®) by cardiac computed tomography.

BACKGROUND: The Parachute is a novel percutaneously implanted ventricular partitioning device (VPD) that has emerged as a safe and feasible treatment option for patients with heart failure following anterior wall myocardial infarction. VPD efficacy is likely dependent on optimal device placement, but to date there are no published data examining the effect of device positioning on patient outcomes. METHODS AND RESULTS: We retrospectively identified 32 patients successfully implanted with the Parachute device, all of whom underwent cardiac computed tomography (CCT) at baseline and after 6 months of follow-up. Patients were divided into two groups based on self-reported improvement in New York Heart Association (NYHA) functional class: "not improved NYHA" (n = 12) and "improved NYHA" (n = 20). There were significant differences between both groups with regard to device positioning on follow-up CCT. Compared to patients with "improved NYHA," patients with "not improved NYHA" had longer distances from device foot to left ventricular apex (8.0 ± 4.9 vs. 2.9 ± 4.6 mm; P = 0.01), and higher lateral angles (18.0 ± 14 vs. 9.1 ± 6.8 degrees; P = 0.02), respectively. There was no significant difference between the two groups in landing zone (45.4 ± 7. vs. 45.1 ± 6.9 mm; P = 0.92) and inferior angle (14.0 ± 11.9 vs. 14.3 ± 10.1 degrees; P = 0.95). There was a numerically larger malapposition area in the "not improved NYHA" group (5.1 ± 4.5 vs. 3.2 ± 2.2 cm2; P = 0.12). CONCLUSION: Quality of Parachute implant impacted clinical outcome, these findings should be applied prospectively in helping operators to achieve optimal implant. © 2016 Wiley Periodicals, Inc.

A Thoracotomy Approach for the Surgical Repair of a Left Ventricular Free Wall Rupture.

In the current era of rapid culprit vessel revascularization in acute myocardial infarction, ventricular free wall rupture is becoming increasingly uncommon. In rare cases adherent pericardium may contain this rupture, creating a temporary stable pseudoaneurysm. With the aid of intraoperative pictures, we describe herein a left thoracotomy approach for the surgical correction of a left ventricular pseudoaneurysm secondary to free wall rupture.

Feasibility of SPECT myocardial perfusion imaging in the super-obese using a multi-head semiconductor camera with attenuation correction.

BACKGROUND: Obesity is not only associated with an increased risk of coronary artery disease, but also decreases the accuracy of many diagnostic modalities pertinent to this disease. Advances in myocardial perfusion imaging (MPI) have mitigated somewhat the effects of obesity, although the feasibility of MPI in the super-obese (defined as a BMI > 50) is currently untested. We undertook this study to assess the practicality of MPI in the super-obese using a multi-headed solid-state gamma camera with attenuation correction. METHODS: We retrospectively identified consecutive super-obese patients referred for MPI at our institution. The images were interpreted by 3 blinded, experienced readers and graded for quality and diagnosis, and subjectively evaluated the contribution of attenuation correction. Clinical follow-up was obtained from review of medical records. RESULTS: 72 consecutive super-obese patients were included. Their BMI ranged from 50 to 67 (55.7 ± 5.1). Stress image quality was considered good or excellent in 45 (63%), satisfactory in 24 (33%), poor in 3 (4%), and uninterpretable in 0 patients. Rest images were considered good or excellent in 34 (49%), satisfactory in 23 (33%), poor in 13 (19%), and uninterpretable in 0 patients. Attenuation correction changed the interpretation in 34 (47%) of studies. CONCLUSIONS: MPI is feasible and provides acceptable image quality for super-obese patients, although it may be camera and protocol dependent.

Clinical significance of atrial fibrillation detected by cardiac implantable electronic devices.

The detection of atrial fibrillation (AF) by a cardiac implantable electronic device (CIED) in patients without a prior history of AF is increasing. This trend is the result of the increased number of CIEDs being implanted in a population whose multiple medical comorbidities are known to predispose to AF. Cardiac implantable electronic device-detected atrial fibrillation (CDAF) is independently associated with the development of ischemic stroke, and the annual risk may depend on both total AF burden and individual risk factors. No data evaluating the benefit of oral anticoagulation in this population are available, which makes the decision to initiate anticoagulation challenging. This review analyzes the available data on CDAF and the associated risk of ischemic stroke, and it presents a rationale for the use of long-term oral anticoagulation in this population.