Reflections on a Posthumous Existence.

This essay describes the author's experience after surviving a 40-day in-hospital treatment for septicemia from Staphylococcus endocarditis on a prosthetic aortic valve.

My Transcatheter Aortic Valve Replacement.

This essay describes the author's reflections on the cost of and insurance coverage for a transcatheter aortic valve replacement procedure.

The Stress Test.

I felt good about myself, driving to the free medical clinic that evening. A full professor at a medical school, leaving my warm home on a cold night after a day at the hospital, seeing patients in clinic in the morning and teaching second-year students medical ethics in the afternoon (autonomy was the theme; we'd covered beneficence and maleficence earlier in the week). Once a month, patients with cardiac problems come to the clinic, and this was the night. Two students presented the patient, a middle-aged woman with chest pain. Their presentation was disjointed, in part because of their inexperience, in part because she spoke no English and her story was obtained with the help of a translator. Her eyes rarely met mine; she kept glancing at the translator. I auscultated her heart and lungs, letting the students listen through my stethoscope. What to do now? Had she been a patient that morning back in my clinic, I would have thought to myself, "I can't get a good history; why not do a stress test?" I thought, for what seemed like an eternity: If I send her for a stress test, that will deplete the funds needed for other patients. How important is this test? Is it really necessary? If I send her for a stress test, will someone with a suspicious mass on their chest x-ray not be able to get a CT scan because no money is left?

When I Take Off My White Coat .

Lay persons might think physicians spend all their time in hospitals or clinics or that physicians fly their private jets to exclusive resorts for long weekends. But physicians are regular people just like their patients, and, when not on the job, they do many of the same things for the same reasons: playing with pets and doing sports, music, and art. Physicians might not have a blue-ribbon dog, might not have played varsity basketball in college, might not have gone to Julliard before medical school, might not have had one-person exhibits at the Metropolitan Museum of Art, but what they do when they are not wearing their white coats can make them better physicians when they put the coats back on again.

Transradial right and left heart catheterizations: a comparison to traditional femoral approach.

OBJECTIVES: This study compares the transradial versus transfemoral approach to combined right- and left-heart catheterization. BACKGROUND: Central venous access from peripheral veins has been a historically useful technique. Although the need for right-heart catheterization has been considered an exclusion for transradial catheterization, we have combined a peripheral approach to the central venous system with radial arterial access which permits bilateral heart catheterization using a transradial approach. METHODS: Over an 18-month period all right-heart catheterizations done in conjunction with arterial access were reviewed. Salvage procedures, mixed site access, and biopsy procedures were excluded. Radial procedures were performed using radial artery access and a forearm vein. Femoral procedures used femoral artery/vein. Demographics, procedural information, and postprocedural complications including those requiring vascular ultrasound or transfusion were recorded and used for comparison between groups. RESULTS: Total of 175 femoral/105 radial cases done by 4 operators met criteria for comparison. Both groups had similar procedural indications and age. Procedural durations were shorter (P < .01) with radial 70 +/- 5.0 min (+/-95% CI) vs. femoral 75 +/- 5.4 min (+/-95% CI). Crossover was noted in several patients from both groups; radial procedures (n = 2) failed due to previous shoulder trauma. Femoral crossover to radial involved difficult arterial access. Complications related to access site occurred in 12 femoral and 0 radial patients. CONCLUSIONS: Using the forearm for central venous access appears safer than using the femoral vessels. Transradial catheterizations can be done in combination with forearm venous access procedures with excellent results and enhanced patient safety.

Differential release of cardiac enzymes after percutaneous coronary intervention.

We hypothesized that using calcium channel blockers (CCBs) that dilate microvasculature during percutaneous coronary intervention (PCI) would result in lower postprocedural creatine phosphokinase (CPK). PCI can be complicated by elevated CPK that has been associated with impaired microvascular perfusion. Nitroglycerin (NTG), the conventional PCI vasodilator, dilates epicardial arteries but does not affect the microvasculature. We hypothesized that using CCBs that dilate the microvasculature would result in lower postprocedural CPK values. Patients (n = 816) without evidence of acute myonecrosis undergoing PCI were divided into two groups based on whether they received intracoronary NTG or CCB during PCI. Postprocedural CPK values were compared using a repeated-measures ANOVA and a random coefficient model. By repeated-measures analysis, the NTG group had CPK values of 88%, 83%, and 89% of the CCB group's CPK values at < 8, 8-14, and > 14 hr after PCI (P = 0.0080, 0.0002, and 0.0244), respectively. In a random coefficient model, the NTG group had CPK values 84%, 84%, and 89% of the CCB group's mean CPK values at 6, 12, and 18 hr after PCI (P = 0.0003, 0.0006, and 0.0403), respectively. Peak CPK values occurred earlier with CCB, although the maximal CPK was similar in both groups. Intracoronary CCB use is associated with an accelerated release of CPK after PCI compared with NTG. This is consistent with more efficient relief of microvascular obstruction with CCB. It suggests that myonecrosis may originate with vascular trauma at the time of PCI and its enzymatic expression is modifiable with different vasodilators.

Usefulness of hyperglycemia in predicting renal and myocardial injury in patients with diabetes mellitus undergoing percutaneous coronary intervention.

A retrospective analysis of 165 patients who had diabetes mellitus and underwent percutaneous coronary intervention (PCI) between 1998 and 2003 demonstrated that those whose plasma glucose levels were >/=200 mg/dl before PCI exhibited greater creatine phosphokinase release and serum creatinine increases after PCI. These observations identified hyperglycemia as a potentially modifiable mediator of myocardial and renal injuries in patients who have diabetes and have undergone PCI.

Cardiac catheterization in morbidly obese patients.

The safety and findings of cardiac catheterization and coronary angiography in morbidly obese patients with suspected coronary heart disease (CHD) have not been fully examined in the modern era. From a database of 4,978 patients undergoing diagnostic cardiac catheterization, we identified 110 with morbid obesity (body mass > or = 145 kg and body mass index > or = 40 kg/m(2)). Relative to all the other patients in this database, morbidly obese patients had a lower prevalence of CHD (45% vs. 72%; P < 0.05), reflecting a higher prevalence of false positive noninvasive tests. Overall, noninvasive tests were only 75% sensitive and 39% specific for CHD in this group. Use of radial access (66%) and femoral closure devices (24%) was much more frequent in the morbidly obese cohort. Complications were no more frequent in the morbidly obese group, with major (0 vs. 0.9%) and minor (4.7% vs. 3.5%) adverse outcomes being similar to the rest of the database. We conclude that cardiac catheterization using the radial artery or a femoral closure device is a safe and effective method of evaluating CHD in morbidly obese patients. In contrast, noninvasive testing is frequently not definitive and may be misleading.