High-Degree Atrioventricular Block and Torsades De Pointes in Severe Aortic Stenosis Treated With Transcatheter Aortic Valve Replacement.

Severe aortic stenosis (AS) significantly elevates cardiovascular risk, predisposing patients to high-degree atrioventricular (AV) block and life-threatening tachyarrhythmias, including torsades de pointes (TdP). This case report presents a patient with severe AS who developed high-degree AV block and, subsequently, TdP, highlighting the interplay between bradycardia and mechanisms that trigger ventricular tachycardias. The case underscores the importance of identifying and managing these risk factors to improve patient outcomes.

Successful Rescue Transaortic Valve Replacement Using Edwards Sapien 3 Following Failed Evolut R Implantation in a Degenerated Surgical Bioprosthesis: A Case Report.

This study examines a complex scenario of structural valve degeneration (SVD) in a high surgical-risk patient with a previously implanted 25 mm Carpentier-Edwards (CE) Perimount Magna Ease 3300 (Irvine, CA: Edwards Lifesciences) surgical bioprosthetic valve (SAV), the patient presented with both paravalvular leak (PVL) and central prosthetic valve insufficiency (PVI). The patient was considered for a transaortic valve-in-valve (ViV) intervention with a self-expanding 29 mm Evolut R valve (Minneapolis, MN: Medtronic). The case describes a ViV intervention complicated by the malpositioning of the Evolut R valve secondary to micro-dislodgement into the left ventricular outflow tract (LVOT) after deployment and subsequent migration into the LVOT during an attempted bioprosthetic valve fracture (BVF) of the SAV that aimed to decrease transvalvular gradients. The resulting acute severe PVL resulted in significant hemodynamic deterioration, necessitating emergent intervention by implanting a balloon-expandable 26 mm Edwards SAPIEN 3 valve (Irvine, CA: Edwards Lifesciences), effectively averting the need for a surgical valve explant. This study illuminates the intricacies and emergency management strategies in transcatheter aortic valve replacement (TAVR) procedures, particularly in high-risk patients with SVD, and offers critical insights into the challenges and solutions in ViV implantations.

Assembling the Puzzle: Taking into Account Clinical Presentation and Predictive Scores.

Syncope is a common cause of emergency department visits. Physicians must scrutinize for life-threatening causes to avoid patient morbidity and mortality. Clinical decision rules are used to stratify risks and guide the course of action, including the need for further testing. This is the case of a 83-year-old man was brought to the emergency department after a 5-minute episode of sudden loss of consciousness. Vital signs showed hypotension and physical examination was unremarkable. Despite Wells score of 0, clinical suspicion for pulmonary embolism persisted, for which further testing was pursued. D-dimer was elevated at 13.77 mcg/mL and a chest computed tomography with angiography showed an extensive bilateral pulmonary embolism involving the distal right and left main pulmonary arteries. He was started on full-dose anticoagulation. This case exemplifies the need of high clinical suspicion along with the importance of applying predictive scores for diagnosing unusual causes of syncope.

Case Report: Prothesis-patient mismatch after aortic valve replacement.

Valve replacement is the standard surgical treatment of diseased valves that cannot be repaired. The main goal of replacement is to exchange the diseased valve with one that has the engineering and hemodynamics as close as possible to the disease free native valve. However due to mechanical and fluid dynamic constraints all prosthetic heart valves (PHVs) are smaller than normal and thus are inherently stenotic. This represents a challenge when it comes time to replace a valve. The correct valve with the correct and matching profile has to be selected before the procedure to avoid possible complications. It is well recognized that patients are also prone to patient-prosthesis mismatch at long term which could have consequences in the clinical outcomes (1). The evaluation of patient-prosthesis mismatch (PPM) has not been sufficiently emphasized in common practice. Failure to recognize this fact may lead to significant hemodynamic impairment and worsening of the clinical status over the time. Making efforts to identifying patients at risk may decrease the prevalence of PPM, the economic impact to our health system, the morbidity and mortality involved in these cases as well as creates efforts to standardized pre-operative protocols to minimized risk of PPM. We present a case of a 78 years old male patient who underwent aortic valve replacement due severe aortic stenosis, afterwards his clinical course got complicated with several admissions for shortness of breath and decompensated congestive heart failure (CHF).

Pulmonary arterial hypertension: from pathophysiology to management.

Pulmonary arterial hypertension used to be considered an ultimately fatal disease despite the formerly available therapy. It is a disease characterized by progressive elevation of pulmonary vascular resistance and pulmonary arterial pressure, eventually resulting in right ventricular failure and death. The purpose of this article is to review the basic pathophysiologic processes involved in pulmonary arterial hypertension, to discuss patient presentation, classification, and diagnostic workup. Regarding treatment, all patients with PAH should be considered for standard therapy with anticoagulation, oxygen, and diuretics for management of right heart failure. Calcium channel blockers are only indicated for patients with a positive acute vasoreactivity test. Patients with a negative vasoreactivity test and considered low risk can be treated with oral agents such as endothelin receptor antagonists or PDE-5 inhibitor. Patients at high risk should be treated with prostacyclin analogs. Finally, a brief mention of new and future potential therapeutic strategies is also included.

Prevalence of anemia in a Hispanic population with decompensated congestive heart failure.

UNLABELLED: Anemia in patients with heart failure (HF is a frequent event, commonly associated with worse prognosis. Despite the high incidence and adverse outcomes associated with anemia no studies have been conducted amongst Hispanics with HF. OBJECTIVE: The study aims to determine the prevalence, predictors and outcomes of anemia in Hispanics admitted to Veteran Affairs Caribbean Healthcare System with diagnosis of Decompensated Congestive Heart Failure (D-CHF). METHODS: Retrospective review of 617 patient medical charts that had been previously discharged with a diagnosis of HF as per International Classification of Diseases-9 code. The clinical, demographic, laboratory and echocardiographic data was assessed for a total of 148 male patient electronic medical records that met the study inclusion criteria. The re-hospitalization and mortality rates were determined from the admission date until April 2010. RESULTS: The burden of anemia with HF is substantial, with anemia present in 68.2% of patients. Anemia was associated with hypoalbuminemia, higher New York Heart Association classification, elevated pro-BNP level at discharge, renal insufficiency and diastolic dysfunction, all of which demonstrated statistical significance. Anemia had 2.18 and 2.95 times likelihood of any-cause mortality (p = 0.003) and cardiovascular deaths (p = 0.02) when compared with HF patients without anemia. CONCLUSIONS: Anemia is a very frequent and serious finding in patients with D-CHF. The study reveals a higher prevalence of anemia in HF patients among Hispanics in comparison with formerly reported studies covering non-Hispanic populations.

Cardiac biomakers for the evaluation of acute coronary syndrome.

The traditional diagnosis of myocardial infarction relies primarily within the exhibited patient's clinical presentation, electrocardiographic changes, and elevation in cardiac markers. Since the clinical presentation can be highly variable and EKG changes are not readily present for all patients, the use of markers of cardiac injury to support the diagnosis of myocardial infarction has become a fundamental part of the evaluation of a patient with suspected acute coronary syndrome. In 2007 the Joint European Society of Cardiology/ American College of Cardiology Committee for the Redefinition of Myocardial Infarction concluded that the main criteria for myocardial infarction should be a rise or fall of cardiac biomarkers (namely cardiac troponins and CK-MB) along with: (1) ischemic symptoms, (2) ischemic changes in EKG, (3) Q waves in EKG, or (4) imaging evidence of loss of myocardial viability or (5) wall motion abnormalities. These changes have increased search interests for more sensitive and specific markers of acute myocardial injury; furthermore, dedicated research has commenced in order to specifically allocate markers that could even predict myocardial ischemia. Therefore this article will review traditional employment of cardiac markers, providing current insight, information and experimental data with respect to emerging markers of myocardial ischemia.

Management of chronic stable angina pectoris.

Agina pectoris is a discomfort in the chest or adjacent areas caused by myocardial ischemia. It is most commonly caused by the inability of narrowed atherosclerotic coronary arteries to supply adequate oxygen to the heart under conditions of increase demand. This review article will focus in the medical treatment of chronic stable angina, with a focus in new strategies or medications. Treatment by revascularization techniques will not be discussed in this article. The goal of treatment is to improve quality of life, decrease cardiovascular events and mortality. All patients should be evaluated for reversible causes of their angina, such as anemia, hyperthyroidism, sympathomimetic drugs and hypertension. Sublingual nitroglycerin should be used for immediate relief of symptoms. In general, all patients should be on aspirin (ASA) unless they are allergic or other contraindications, if so; clopidogrel should be added to the therapy. In addition to the antiplatelet therapy, which decreases mortality, patients should be started on beta blockers and nitrates. If there is no improvement in symptoms then a calcium channel blockers of the dihydropyridine family should be added. Patients with Diabetes Mellitus and/or left ventricular systolic dysfunction should be also started on angiotensin converting enzyme inhibitors. If the patient continues with limiting angina, ranolazine should be started and finally enhanced external counterpulsation should be considered in those patients who have not responded to maximal drug therapy.

Congestive heart failure and renal complications.

Congestive heart failure is the leading cause of hospital admission among patients over the age of 65 years. It affects population within the United States, including Puerto Rico, presenting itself as the leading cause of heart related deaths worldwide. Its management can include pharmacologic agents which will affect neuroendocrine axis mainly but also include novel non-pharmacologic approaches such as ultrafiltration. The coexistence of heart failure and renal dysfunctions are very common within our medical community, especially within the western hemisphere, causing greater concerns amongst the medical field with increased research and investigation activity. This clinical review article will address the theme of congestive heart failure, highlighting the edema formation concept, volume homeostasis, cardio-renal syndrome and neuroendocrine pathways. The management of acute decompensated heart failure is discussed, primarily focusing with available novel non-pharmacologic approaches.

Primary cardiac and pericardial tumors.

Primary cardiac tumors are rare, with a reported prevalence of 0.001 to 0.03% at autopsy series. Almost 75% of all primary tumors of the heart are benign, with primary malignant tumors accounting for the other 25%. Nearly half of the benign cardiac tumors are myxomas. Other primary tumors include papillary fibroelastoma, rhabdomyoma, fibroma, lipoma and hemangioma. In this review article, the clinical, pathologic and diagnostic feature of primary benign cardiac tumors is presented. In very rare occasions malignant tumors of the heart could be encounter such as primary sarcomas of the heart constituting less than 25% of primary cardiac tumors found in clinical practice. Cardiac sarcomas represent the commonest histology of primary malignant cardiac tumors, with angiosarcomas making up 33% of the cases. Sarcomas are common between the third and fifth decades of life and most frequently affect the right atrium.

A case of Brugada syndrome in a 63 y/o man with chest pain.

Brugada syndrome (BS) is an under recognized condition inherited through autosomal dominant transmission that consists mainly of characteristic electrocardiogram findings with ST segment elevation, in leads V1 through V3, complemented with right bundle-branch block pattern. Patients usually have medical history of prior syncopal episodes and are at risk of sudden cardiac death; although diagnostic studies reveal structurally normal heart. Adequate treatment consists of implantable cardioverter defibrillator which can prevent associated lethal arrhythmias that lead to sudden cardiac death. Correct diagnosis with medical history and characteristic electrocardiographic findings is essential to the physician to prevent unnecessary treatments that can further compromise patient's health status.

Paced right bundle branch block: identification and management of a malpositioned left ventricular pacemaker lead.

Malpositioning of a permanent pacemaker lead in the left ventricle is rare. Usually, a paced right bundle branch pattern is the initial finding that fosters other confirmatory studies such as chest films and transthoracic echocardiogram. We describe the unusual case of an asymptomatic 83-year-old male patient who was incidentally found with a permanent pacemaker lead placed through the atrial septum into the left ventricle. This patient had contraindications for chronic anticoagulation and was placed on antiplatelet therapy instead. He has been well after three years without evidence of embolic episodes.

Prosthetic valve endocarditis.

Prosthetic valve infective endocarditis represents a defined pathological entity which follows an epidemiological and nosological pattern in accordance to an arbitrary classification. Chronologically it is divided into the entities of early and late prosthetic valve endocarditis, each with its own unique characteristics. The clinical features, complications and diagnosis do not vary much from native valve endocarditis. There are clear and precise indications to aid in the diagnosis and treatment of this entity which differ from native valve endocarditis.

Hyperinsulinemic-euglycemic therapy for intoxication with calcium channel blockers.

Conventional therapy for intoxication with calcium channel blockers consists of crystalloid solutions, calcium gluconate, glucagon and vasopressor agents. These therapies often fail to improve hemodynamic function in intoxicated patients. The pathophysologic mechanism proposed for intoxication with these agents, suggest hypoinsulinemia as the determinant factor. We will describe the case of a 77 years old man treated for an overdose of nifedipine and atenolol who arrived at our institution with hypotension and bradycardia. After conventional therapy failed to improve the patient's hemodynamic status, hyperinsulinemia and euglycemia contributed to the improvement of the patient's neurologic and hemodynamic condition. Thus, hyperinsulinemic-euglycemic therapy was of benefit in this patient with hemodynamic compromise secondary to intoxication with calcium channel blocker not responding to conventional therapy. We will review the mechanism of action of calcium channel blocker drugs as well as the clinical presentation and treatment options for calcium channel blocker intoxication.

Early postoperative complications after coronary artery bypass grafting at the San Juan Veterans Affairs Medical Center.

OBJECTIVES: Describe the perioperative characteristics of the patients undergoing coronary artery bypass grafting (CABG) in San Juan, Veterans Affairs Medical Center (SJ-VAMC). Determine the in-hospital and 30-day morbidity and mortality following CABG and identify adverse predictors for postoperative complications. BACKGROUND: Preoperative risk factors for complications post-CABG have been identified; however limited data is available regarding the value of these predictors in the Puerto Rican Population. METHODS: Perioperative characteristics and 30-day complications were gathered from all patients undergoing CABG (n = 252) at the SJ-VAMC (2001-2003). Logistic regression analysis was performed to determine factors associated with the occurrence of complications. RESULTS: The population's mean age was 66.9 +/- 8.1 years. Associated illnesses included: hypertension (95.6%), diabetes (57%), past smoking (61%), COPD (26%), chronic renal insufficiency (CRI-11.5%), cerebrovascular disease (CVD-20.6%), disabling angina (78%), 3-vessel coronary disease (75.8%), significant left main stenosis (20%), and non-elective surgical intervention (54%). The most frequent primary complications were postoperative myocardial infarction (MI-4.8%) and congestive heart failure (4.8%). The 30-day mortality was 1.2%. Upon multivariate analysis PRBC transfusions > 3 units was associated to increased risks of primary complications, in patients with prior history of CVD. CRI and LVEF < or = 40% were independently associated to development of primary complications, in patients with prior MI and CVD. CONCLUSION: The preoperative characteristics are suggestive of an older and sicker patient that is undergoing CABG at the SJ-VAMC. Despite this, the death rate was low and the frequency of other complications comparable to the Society of Thoracic Surgeons (STS) National Adult Cardiac Database.