Multiple strokes due to pulmonary arteriovenous malformation.

We present a case of recurrent strokes in a patient with absent left internal carotid artery (ICA) and pulmonary arteriovenous malformation. Pulmonary arteriovenous malformations (PAVMs) are abnormal communications between pulmonary artery and pulmonary vein, cause extracardiac right to left shunting of blood and are known to significantly increase the risk of stroke primarily due to paradoxical embolization. They are often hereditary and are commonly associated with hereditary hemorrhagic telangiectasias (HHT). Delayed bubbles seen in the left ventricle (after 3 cardiac cycles) on transthoracic echocardiogram with bubble study is often the first clue to the presence of PAVMs. CT scan of the chest can confirm the diagnosis. Percutaneous embolotherapy is the treatment of choice with reduction in stroke risk post embolization.

Association of baseline kidney disease with outcomes of transcatheter mitral valve repair by MitraClip.

OBJECTIVES: This study sought to determine the impact of baseline chronic kidney disease (CKD) on in-hospital outcomes of transcatheter mitral valve repair with MitraClip (MC). BACKGROUND: MC is now an established treatment in high surgical risk patients. However, limited data are available on outcomes of MC in patients with baseline renal dysfunction. METHODS: The authors used data from January 2014 to December 2017 National Readmission Database to identify all patients ≥18 years of age who underwent MC. International classification of diseases (ICD)-9 and ICD-10 codes were used to identify patients with no-CKD, CKD (without chronic dialysis), or end-stage renal disease (ESRD) on dialysis. Multivariable logistic regression models were constructed using generalized estimating equations to examine in-hospital outcomes. RESULTS: Of 13,563 patients undergoing MC, 8,935 (65.8%) had no-CKD, 4,152 (30.6%) had CKD, and 476 (3.5%) had ESRD. ESRD patients compared to CKD and no-CKD had significantly higher mortality (7.2% vs. 2.5% vs. 2.0%; p < .001), higher incidence of bleeding, blood transfusions, and 30 day all cause readmission. CKD patients compared to no-CKD had significantly higher mortality (odds ratio-1.29; CI 1.01-1.65; p = .04), acute kidney injury (odds ratio-3.0; CI 2.69-3.34; p < .001), new in-hospital hemodialysis (odds ratio- 2.70; CI 1.57-4.62; p < .001), blood transfusions, 30 day all cause and congestive heart failure (CHF) readmissions. In-hospital stroke and cardiac tamponade did not differ between the three groups. Patients with baseline kidney disease undergoing MC had higher mortality at high volume centers compared to low volume centers. CHF was the most common cause of readmission postMC in patients with or without preprocedural kidney disease. CONCLUSION: Patients with baseline kidney disease have worse outcomes after MC with higher readmission rates requiring careful patient selection and follow up in this population.

Long-term follow-up of percutaneous coronary intervention versus coronary artery bypass grafting in left main coronary artery disease: A systematic review and meta-analysis.

OBJECTIVES: We conducted a systematic review and meta-analysis to evaluate the long-term outcomes of PCI compared to CABG in patients with LMCAD. BACKGROUND: Recent data from randomized controlled trials (RCTs) has raised concerns regarding the long-term efficacy and safety of percutaneous coronary intervention (PCI) compared with coronary artery bypass grafting (CABG) in patients with left main coronary artery disease (LMCAD). METHODS: We searched MEDLINE and EMBASE databases for published RCTs comparing PCI using stenting with CABG in patients with LMCAD. Preferred reporting items for systematic review and meta-analysis guidelines were used for the present study. End-points of interest were all-cause mortality, cardiovascular (CV) mortality, myocardial infarction (MI), stroke, and repeat revascularization at longest available follow-up. Relevant data were collected and pooled odds ratio (OR) with 95% confidence intervals (CI) was calculated using random-effects model. RESULTS: Five RCTs including a total of 4,499 patients were included in the final analysis. Mean duration of follow-up was 96 months. The risks of all-cause mortality [OR 1.09 (95% CI 0.88-1.34)] and cardiovascular mortality [1.14 (0.88-1.47)] were comparable between PCI and CABG. There were no statistically significant differences between PCI and CABG for MI [1.52 (0.98-2.37)] and stroke [0.84 (0.48-1.45)]. Conversely, repeat revascularization was significantly higher with PCI as compared with CABG [1.82 (1.49-2.22)]. CONCLUSION: At long-term follow-up, PCI is associated with similar risks of mortality but a higher risk of repeat revascularization compared with CABG in LMCAD. Long-term risk of MI with PCI compared to CABG needs to be further explored in future studies.

Left main percutaneous coronary intervention-Radial versus femoral access: A systematic analysis.

BACKGROUND: Debate still occurs of the benefits of transradial access (TRA) versus transfemoral access (TFA), especially for complex percutaneous coronary interventions. Recent data has shown equivalent efficacy and improved safety outcomes with TRA. OBJECTIVES: To systematically review and perform a meta-analysis comparing procedural characteristics and clinical outcomes of TRA versus TFA in patients who underwent percutaneous coronary intervention (PCI) for left main (LM) disease. METHODS: We conducted an electronic database search of all published data for studies that compared TRA with TFA in patients undergoing PCI of LM disease. Event rates were compared using the odds ratio (OR) as a measure of effect size. Random-effects models were used to account for interstudy heterogeneity. RESULTS: A total of 12 observational studies including 17,258 patients (TRA n = 7,971; TFA n = 9,287) were included. Compared to TFA, TRA was associated with a significant reduction in access site bleeding (OR = 0.11; 95% confidence interval [CI] = 0.04-0.26; I2 = 0%; p < .0001), major bleeding (OR = 0.44; 95% CI = 0.27-0.69; I2 = 0%; p = .0005) or any bleeding episode (OR = 0.43; 95% CI = 0.27-0.69; I2 = 12%; p = .0004). Rates of access site or vascular complications (OR = 0.26; 95% CI = 0.17-0.40; I2 = 0%; p < .00001) and in-hospital mortality (OR = 0.49; 95% CI = 0.31-0.79: I2 = 11%; p = .004) were also lower in the TRA group. There were no significant differences in procedural outcomes between TRA and TFA except for a significant reduction in the rate of long-term target vessel revascularization (TVR) in the TRA group (OR = 0.62; 95% CI = 0.41-0.94: I2 = 0%: p = .02). We further performed a subgroup analysis for unprotected left main PCI only, which showed a significant reduction in rates of any bleeding episode, lower access site or vascular complications, and in-hospital mortality with TRA as compared to TFA. CONCLUSION: Patients undergoing PCI for LM disease via TRA have with less bleeding, reduced access site or vascular complications, reduced in-hospital mortality, comparable procedural success, and possibly better long-term clinical efficacy when compared to those undergoing the procedure via TFA.

An Intensive Care Unit Outbreak of Acute Respiratory Distress Syndrome due to Human Metapneumo Virus Infection.

Human metapneumo virus is an emerging cause of upper and lower respiratory tract illness with increasing reports of a varied spectrum of disease over all age groups. We report an outbreak of 6 cases of human metapneumo virus infection in the intensive care unit of a metropolitan tertiary care center over 6 weeks, leading to severe acute respiratory distress syndrome. We report the subsequent favorable outcomes due to the institution of extracorporeal membrane oxygenation.

Electrocardiogram Changes with Acute Alcohol Intoxication: A Systematic Review.

BACKGROUND: Acute alcohol intoxication has been associated with cardiac arrhythmias but the electrocardiogram (ECG) changes associated with acute alcohol intoxication are not well defined in the literature. OBJECTIVE: Highlight the best evidence regarding the ECG changes associated with acute alcohol intoxication in otherwise healthy patients and the pathophysiology of the changes. METHODS: A literature search was carried out; 4 studies relating to ECG changes with acute alcohol intoxication were included in this review. RESULTS: Of the total 141 patients included in the review, 90 (63.8%) patients had P-wave prolongation, 80 (56%) patients had QTc prolongation, 19 (13.5%) patients developed T-wave abnormalities, 10 (7%) patients had QRS complex prolongation, 3 (2.12%) patients developed ST-segment depressions. CONCLUSION: The most common ECG changes associated with acute alcohol intoxication are (in decreasing order of frequency) P-wave and QTc prolongation, followed by T-wave abnormalities and QRS complex prolongation. Mostly, these changes are completely reversible.

Comparison of single versus dual antiplatelet therapy after TAVR: A systematic review and meta-analysis.

OBJECTIVE: We aim to evaluate the efficacy of dual versus single anti-platelet therapy (SAPT) after TAVR through a systematic review and meta-analysis of published research. BACKGROUND: Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel is a commonly practiced strategy after transcatheter aortic valve replacement (TAVR). However, there is lack of sufficient evidence supporting this approach. METHOD: We searched PubMed, EMBASE, the Cochrane Central Register of Controlled trials, and the clinical trial registry maintained at clinicaltrials.gov for randomized control trials (RCT) and observational studies comparing DAPT with SAPT post TAVR. Event rates were compared using a forest plot of relative risk with 95% confidence intervals using a random-effects model assuming inter-study heterogeneity. RESULTS: A total of six studies (3 RCTs and 3 observational studies, n = 840) were included in the final analysis. Compared to SAPT, DAPT was associated with increased risk of significant bleeding (life threatening and major) [RR = 2.52 (95% CI 1.62-3.92, P < 0.0001)] with the number needed to harm for major or life-threatening bleeding calculated to be 10.4. There was no significant difference in the incidence of stroke [RR = 1.06 (95% CI, 0.43-2.60, P = 0.90)], spontaneous myocardial infarction [RR = 2.08 (95% CI, 0.56-7.70, P = 0.27)] and all-cause mortality [RR = 1.18 (95% CI, 0.68-2.05, P = 0.56] in the DAPT and SAPT groups. CONCLUSION: In this small meta-analysis of DAPT versus SAPT after TAVR, DAPT did not prevent stroke, myocardial infarction or death while the risk of bleeding was higher. Results from ongoing trials are awaited to determine the best anti-thrombotic approach after TAVR.

Routine Invasive Versus Selective Invasive Strategy in Elderly Patients Older Than 75 Years With Non-ST-Segment Elevation Acute Coronary Syndrome: A Systematic Review and Meta-Analysis.

OBJECTIVE: To evaluate outcomes of routine invasive strategy (RIS) compared with selective invasive strategy (SIS) in elderly patients older than 75 years with non-ST-segment elevation acute coronary syndrome (NSTE-ACS). METHODS: We systematically searched databases for randomized controlled trials (RCTs) between January 1, 1990, and October 1, 2016, comparing RIS with SIS for elderly patients (age>75 years) with NSTE-ACS. Random effects meta-analysis was conducted to estimate odds ratio (OR) with 95% CIs for composite of death or myocardial infarction (MI), and individual end points of all-cause death, cardiovascular (CV) death, MI, revascularization, and major bleeding. RESULTS: A total of 6 RCTs with 1887 patients were included in the final analysis. Compared with an SIS, RIS was associated with significantly decreased risk of the composite end point of death or MI (OR, 0.65; 95% CI, 0.51-0.83). Similarly, RIS led to a significant reduction in the risk of MI (OR, 0.51; 95% CI, 0.40-0.66) and need for revascularization (OR, 0.31; 95% CI, 0.11-0.91) compared with SIS. There were no significant differences between RIS and SIS in terms of all-cause death (OR, 0.85; 95% CI, 0.63-1.20), CV death (OR, 0.84; 95% CI, 0.61-1.15), and major bleeding (OR, 1.96; 95% CI, 0.97-3.97). CONCLUSION: In elderly patients older than 75 years with NSTE-ACS, RIS is superior to SIS for the composite end point (death or MI), primarily driven by reduced risk of MI.

Right ventricular infarction.

Coronary Heart Disease is a leading cause of morbidity and mortality worldwide. A great amount is known about left ventricular myocardial infarction. It was not until much later (1974) that right ventricular myocardial infarction was studied as a separate entity. Isolated right ventricle myocardial infarction is rare. Around one-third of patients with acute infero-posterior ST-segment elevation myocardial infarction, will present with concomitant right ventricular infraction. The aim of this paper is to review the literature on the importance of early recognition of right ventricular infarction, clinical presentation, pathophysiology, diagnostic evaluation, differential diagnosis, treatment, complications and prognosis.

Evaluation of serum galactomannan enzyme immunoassay at two different cut-offs for the diagnosis of invasive aspergillosis in patients with febrile neutropenia.

BACKGROUND: Invasive aspergillosis (IA) is an increasingly common and fatal opportunistic fungal infection in patients with haematological diseases. Early diagnosis is difficult as mycological culture techniques have low sensitivity and the radiological tools have low specificity. Galactomannan enzyme immunoassay (GEI) detects galactomannan in the human serum with a reported sensitivity and specificity between 30% and 100%. AIMS: The aim of this study was to analyse the role of GEI in diagnosis of IA in patients with febrile neutropenia and to evaluate the role of GEI in the diagnosis of IA as per the revised (2008) European Organization for Research and Treatment of Cancer-Mycoses Study Group (EORTC-MSG) criteria at two different optical density (OD) cut-offs of 0.5 and 1.0. SETTING: This prospective study was conducted in Safdarjung Hospital, New Delhi, India. METHODS: GEI testing was performed in adult patients of febrile neutropenia with evidence of IA. Results at two different OD indices (ODIs) of 0.5 and 1.0 were analysed. The evaluation of the diagnostic parameter, that is, GEI was measured in terms of sensitivity, specificity and positive and negative predictive value and was validated with the revised (2008) EORTC-MSG diagnostic criteria of IA. RESULTS: One hundred and eleven patients had evidence of IA, of which 79 patients were GEI positive when cut-off ODI was 0.5, whereas with cut-off ODI 1.0, 55 patients were GEI positive. CONCLUSION: ODI of 1.0 should be considered as positive while in patients with OD between 0.5 and 1.0, repeat sampling from the patient is recommended.

Adult Onset Dysphagia: Right Sided Aortic Arch, Ductus Diverticulum, and Retroesophageal Ligamentum Arteriosum Comprising an Obstructing Vascular Ring.

A 49-year-old African American male patient with no past medical history was admitted because of 3 months of difficulty swallowing solid and liquid foods. He had constant retrosternal discomfort and appeared malnourished. The chest radiograph revealed a right sided aortic arch with tracheal deviation to the left. A swallow study confirmed a fixed esophageal narrowing at the level of T6. Contrast enhanced Computed Tomography (CT) angiogram of the chest and neck revealed a mirror image right aortic arch with a left sided cardiac apex and a prominent ductus diverticulum (measuring 1.7 × 1.8 cm). This structure extended posterior to and indented the mid esophagus. A left posterolateral thoracotomy was performed and the ductus diverticulum was resected. A retroesophageal ligamentum arteriosum was found during surgery and divided. This rare combination of congenital anatomical aberrations led to severe dysphagia in our patient. Successful surgical correction in the form of resection of the ductus diverticulum and division of the retroesophageal ligamentum arteriosum led to complete resolution of our patient's symptoms.

Screening of invasive fungal infections by a real-time panfungal (pan-ACF) polymerase chain reaction assay in patients with haematological malignancy.

BACKGROUND: Invasive fungal infection (IFI) is a fatal infection in haematology patients. There is an urgent need for reliable screening methods facilitating timely diagnosis and treatment. A real-time panfungal polymerase chain reaction (PCR) assay based on TaqMan technology targeting 18S ribosomal RNA gene was used to screen whole blood specimen obtained from series of Haematology malignancy patients for IFIs. MATERIALS AND METHODS: The panfungal (Pan-ACF) assay was employed to investigate specimen from 133 patients in duplicate with suspected IFI. In addition twenty healthy subjects and twenty patients with bacterial infections were taken as control. The patients with suspected IFI were also diagnosed by conventional methods including direct microscopy, culture techniques and antigen detection (galactomannan antigen ELISA and latex agglutination for cryptococcal antigen). The results of molecular testing were evaluated in relation to the criteria proposed by the European Organization for Research and Treatment of Cancer and patients were classified as having proven and probable IFD. RESULTS: Of 133 patients, 89 had proven, 18 had probable and 26 had possible IFI. One hundred four samples were reverse transcription-PCR positive. Of 89 proven cases, 84 were panfungal PCR positive. These 84 cases included 82 cases which revealed growth on fungal blood culture and two cases were negative on fungal blood culture. Of the 82 cases which revealed growth on culture: 74 grew Candida in culture, 3 grew Fusarium solani, 5 grew Aspergillus species on blood culture. The later five were also galactomannan antigen positive. The five specimen which were negative on panfungal PCR, two grew Trichosporon asahii, one grew Candida rugosa and two grew as Cryptococcus neoformans var. neoformans. Of the 18 probable cases, 18 were panfungal PCR positive. These were also galactomannan antigen positive. The sensitivity and specificity of panfungal PCR in proven cases were 94.3% and 95.2%, respectively. The positive and negative predictive values proven cases were 97.6% and 88.9%, respectively. CONCLUSIONS: The panfungal (Pan-ACF) real-time PCR assay can detect common fungal genera and it may be used as an adjunct to conventional methods for screening of IFI.