Integrating Yoga Into Undergraduate American Medical Education.

Undergraduate medical education (UGME) is the time when doctors' attitudes toward patients and their profession are formed. It is also a period of tremendous stress for future physicians, including high levels of negative stress. Such stress can be maladaptive and may sow the seeds of burnout and long-term dissatisfaction. We believe that the introduction of yoga practice in the 1st year of medical school could ameliorate the negative stressors to which undergraduate medical students are exposed. Although there are some studies in the U.S. and internationally that support the use of Yoga in UGME, they do not provide sufficient data to make a compelling case for widespread implementation of yoga programs in undergraduate curricula. We, therefore, wish to advocate for conducting a trial of the integration of yoga in the undergraduate medical curriculum to combine yoga's ancient health wisdom into the context of modern scientific medicine. Large, prospective, multicenter, and multi-method pilot projects are needed to identify how a program of yoga practice and theory could counter the UGME environment that ultimately produces depression, anxiety, and non-effective coping strategies among medical students. A curriculum for yoga for undergraduate medical students deserves serious consideration and a prominent place among efforts to improve UGME.

Accessing the Wrist: From Data to Tips and Tricks.

Over the past 2 decades, radial artery access has increasingly become the standard approach for coronary angiography and intervention. Compared with femoral arteries, transradial access is associated with better hemostasis. Transradial access has increased patient preference, facilitates early ambulation, and is cost-effective. An important limitation of transradial access is access site failure, and it carries a crossover rate of 3% to 7% in randomized prospective trials comparing radial with femoral artery access among experienced operators. Crossover rates for failed primary radial artery access can be reduced with ultrasonography guidance and increased familiarity with alternative access sites in the wrist.

Clinical features, management, and prognosis of spontaneous coronary artery dissection.

BACKGROUND: Spontaneous coronary artery dissection (SCAD) is an acute coronary event of uncertain origin. Clinical features and prognosis remain insufficiently characterized. METHODS AND RESULTS: A retrospective single-center cohort study identified 87 patients with angiographically confirmed SCAD. Incidence, clinical characteristics, treatment modalities, in-hospital outcomes, and long-term risk of SCAD recurrence or major adverse cardiac events were evaluated. Mean age was 42.6 years; 82% were female. Extreme exertion at SCAD onset was more frequent in men (7 of 16 versus 2 of 71; P<0.001), and postpartum status was observed in 13 of 71 women (18%). Presentation was ST-elevation myocardial infarction in 49%. Multivessel SCAD was found in 23%. Initial conservative management (31 of 87) and coronary artery bypass grafting (7 of 87) were associated with an uncomplicated in-hospital course, whereas percutaneous coronary intervention was complicated by technical failure in 15 of 43 patients (35%) and 1 death. During a median follow-up of 47 months (interquartile range, 18-106 months), SCAD recurred in 15 patients, all female. Estimated 10-year rate of major adverse cardiac events (death, heart failure, myocardial infarction, and SCAD recurrence) was 47%. Fibromuscular dysplasia of the iliac artery was identified incidentally in 8 of 16 femoral angiograms (50%) undertaken before closure device placement and in the carotid arteries of 2 others with carotid dissection. CONCLUSIONS: SCAD affects a young, predominantly female population, frequently presenting as ST-elevation myocardial infarction. Although in-hospital mortality is low regardless of initial treatment, percutaneous coronary intervention is associated with high rates of complication. Risks of SCAD recurrence and major adverse cardiac events in the long term emphasize the need for close follow-up. Fibromuscular dysplasia is a novel association and potentially causative factor.

Bedside assessment of cardiac hemodynamics: the impact of noninvasive testing and examiner experience.

BACKGROUND: Knowledge of cardiac filling pressures is critical in the diagnosis and management of patients with dyspnea or heart failure. Echocardiography and B-natriuretic peptide (BNP) testing are commonly used to estimate these pressures, but their incremental value beyond physical examination remains unknown. METHODS: Right and left heart filling pressures were prospectively estimated as "normal" or "abnormal" by staff cardiologists and cardiovascular trainees based upon physical examination findings alone, or examination coupled with echocardiographic and BNP data in patients referred for cardiac catheterization. Net reclassification improvement was calculated to determine whether echocardiographic/BNP data had incremental value in the determination of right and left heart pressures. RESULTS: Two hundred fifteen observations were made by 9 examiners in 116 consecutive patients. Right and left heart pressures were accurately predicted from examination alone in 71% and 60% of observations, respectively. Examination-based accuracy was greater for staff cardiologists compared with trainees for right heart (82 vs 67%, P=.03) and left heart pressures (71% vs 55%, P=.03). Exposure to echocardiographic and BNP data did not enhance accuracy beyond bedside examination alone, both for left heart pressures (net reclassification improvement=-0.004; 95% confidence interval, -0.12-0.12) and right heart pressures (net reclassification improvement=0.02, 95% confidence interval, -0.09-0.13). CONCLUSIONS: Cardiac filling pressures can be estimated from physical examination with modest accuracy, which is enhanced with experience. While echocardiographic and BNP data predict cardiac filling pressures, they may not provide information of incremental value beyond examination alone. Rigorous teaching and practice of cardiac examination skills should continue to be emphasized during medical training.

Location of femoral artery access and correlation with vascular complications.

OBJECTIVES: The aim of the study was to document the frequency of optimal femoral artery access location and its correlation with vascular complications in contemporary practice. BACKGROUND: Vascular access bleeding during coronary interventions is associated with adverse outcomes. A potential strategy for reducing access-site bleeding is to achieve optimal location for the femoral access. However, there is a paucity of data on how well this goal is achieved in clinical practice using anatomical landmarks. METHODS: We retrospectively evaluated femoral angiograms of 300 patients undergoing percutaneous coronary intervention to identify the location of the access that had been performed using anatomical landmarks. Patients were divided into two groups based on the location of the arterial access: above the femoral bifurcation but below the inferior border of the inferior epigastric artery (optimal location) and those that were either above or below these landmarks (suboptimal location). Frequency of access site complications was recorded. RESULTS: The femoral artery access site was located outside the optimal location in 38 (13.0%) patients. There was no significant difference regards to baseline characteristics. Overall, access-related complications occurred in 17 (5.7%) patients. Vascular complications were significantly more frequent in patients who had a femoral artery access outside the optimal location (18% vs. 4%, P < 0.001). CONCLUSIONS: The femoral artery access site is not at the optimal location in a significant proportion of patients, and this is associated with an increased risk of vascular complications. Improving the rates of optimal arterial access by routine use of fluoroscopy or ultrasound guidance has the potential of reducing vascular complications and improving outcomes.

Transradial iliac artery intervention with dual downstream embolic protection.

We report a case of a thrombotic common iliac lesion with concern for elevated risk of downstream embolization during intervention. In this case, a transradial approach enabled the novel, simultaneous deployment of two embolic protection devices, one in the internal iliac artery and the other in the common femoral artery, for complete downstream protection during intervention. An endovascular stent, which accommodates a 0.035-inch wire lumen, was able to be delivered over both 0.014-inch protection device wires simultaneously and was successfully deployed with evidence of captured embolic material.

Complications associated with left ventricular puncture.

OBJECTIVE: To report complications in a consecutive series of patients undergoing percutaneous left ventricular apical puncture (LVAP) and sheath placement for diagnostic or interventional procedures. BACKGROUND: Percutaneous LVAP is only rarely used to provide hemodynamic data in the presence of mechanical prosthetic valves. Recently, LVAP has been used to facilitate complex interventional procedures such as paravalvular leak closures. These frequently necessitate placement of 4-6 F sheaths, rather than smaller needles. Optimal technique and outcomes are largely unknown for this uncommon procedure. METHODS: We retrospectively analyzed 32 patients undergoing LVAP with echocardiographic and fluoroscopic guidance at our institution between 2002 and 2009. These patients were referred to the cardiac catheterization laboratory for hemodynamic assessment to rule out prosthetic dysfunction and or to facilitate paravalvular leak closure. Sheaths ranged from 4 to 6 F were removed at the end of the procedure after reversing any anticoagulation. No specific closure devices were used for hemostasis. Frequency of access site complications associated with LVAP recorded. RESULTS: Apical access site related complications were higher in patients requiring LVAP for intervention than for diagnostic purposes (25% vs. 12.5%). Hemothorax was the most frequent serious complication occurring in 6 (19%) patients and frequently required intervention 5(16%). Three patients had local bleeding with no drop in hemoglobin or need for intervention. CONCLUSIONS: LVAP is associated with a significant incidence of access-related complications. There is a need for safe and reliable methods of closing percutaneous LVAP access sites.

Incremental utility of real-time three-dimensional echocardiography in the diagnosis and preoperative assessment of cleft mitral valve in adults.

Cleft mitral valve is a rare congenital anomaly that may present in isolation or accompany other cardiac malformations. Our illustrative case series highlights the advantages of three-dimensional over conventional two-dimensional echocardiography in the diagnosis and morphologic assessment cleft mitral valve in adults.

Aberrant origin of the left anterior descending artery and quadrifurcation of coronary vessels associated with coronary artery disease: evaluation by computed tomographic angiography and coronary angiography.

Coronary artery anomalies occur in approximately 0.2-12.2% of the adult population. Origin of left anterior descending artery and left circumflex artery from the right coronary cusp is relatively rare. The case we present is unique in that all 4 vessels (right coronary, left anterior descending, left circumflex and atrioventricular nodal branch) take off from the right coronary cusp, making a quadrifurcation. In this case, the left main artery is also absent. To our knowledge, there are few published case reports of anomalous origin of left anterior descending artery, but the total absence of a left main artery and quadrifurcation are unique to our case.

Quadricuspid aortic valve associated with unruptured sinus of Valsalva aneurysm.

Quadricuspid aortic valve is a rare congenital anomaly. It may present as an isolated anomaly but is occasionally associated with aortic regurgitation. Sinus of Valsalva aneurysm (SVA) is also an infrequent congenital anomaly, typically associated with tricuspid aortic valves. There are only a few reported cases of SVA (ruptured) associated with quadricuspid aortic valves in the literature. We report the first case of the association of quadricuspid aortic valve with an unruptured SVA in an adult patient.

Factors determining extreme brain natriuretic peptide elevation.

Brain natriuretic peptide (BNP) level is elevated in heart failure and reflects its severity. It is unknown why some patients have extremely high BNP levels. The authors retrospectively reviewed data on 179 consecutive patients whose BNP levels fell within one of several predetermined ranges: mild elevation, 500 to 1000 pg/mL (n=82); moderate elevation, 2000 to 3000 pg/mL (n=48); and high elevation, 4000 to 20,000 pg/mL (n=49). The statistical analysis was conducted with the unpaired t test and Pearson's correlation coefficient. Adjustments were made for age, sex, and serum creatinine level. Patients with moderate BNP elevation were more symptomatic and had more advanced structural and hemodynamic changes than did patients with lower BNP elevation. Characteristics of the high BNP level group did not differ from those of the moderate BNP level group. Serum creatinine level correlated with BNP level, but neither age nor sex did. High BNP level (4000-20,000 pg/mL) is determined more by renal dysfunction than by the severity of heart failure.

Thromboembolic complications of left ventricular noncompaction: case report and brief review of the literature.

Left ventricular noncompaction (LVNC) is a rare condition that is believed to represent an arrest in endomyocardial morphogenesis. This entity may be complicated by the development of mural thrombi and embolic events, however data on the associated thromboembolic risk is variable and poorly defined. We describe 2 cases of LVNC in African American patients presenting with thromboembolic manifestations and briefly review the available literature relevant to this complication.

Role of the renin-angiotensin-aldosterone system in diastolic heart failure: potential for pharmacologic intervention.

Congestive heart failure (CHF) is a major public health problem that results in tremendous economic burden. Diastolic heart failure (DHF) forms an important subset with increasing incidence and prevalence. There are widely variable estimates of the prevalence, ranging from 13% to 74% of all CHF presentations, and this is predominantly a result of a lack of uniform criteria for establishing a diagnosis. New developments in management of DHF have lagged behind those for systolic heart failure (SHF), for which numerous new therapeutic and device strategies have been instituted. The renin-angiotensin-aldosterone system (RAAS) plays an important role in the pathophysiology of both SHF as well as DHF. The beneficial role of ACE inhibitors as well as aldosterone antagonists in SHF has been well established. Because of its unique role of the RAAS in establishing fibrosis at a molecular level, RAAS blockade provides an opportunity to expand the therapeutic options for DHF. Thus far, in patients with primary DHF only the angiotensin receptor type 1 antagonist candesartan has been reported to decrease morbidity and probably mortality. Large, ongoing randomized trials including TOPCAT (Trial of Aldosterone Antagonist Therapy in Adults with Preserved Ejection Fraction Congestive Heart) and the I-PRESERVE (Irbesartan in Heart Failure with Preserved Systolic Function) are currently underway to establish the role of aldosterone antagonists in patients with DHF.