Utility of routine transesophageal echocardiography in patients with stroke or transient ischemic attack.

In several series of patients with presumed stroke, transesophageal echocardiography (TEE) has seemed advantageous over transthoracic echocardiography (TTE) in that it improves detection of cardiac sources and can lead to changes in the methods of treatment. We hypothesized that the real-world application of TEE in our institution produced results at variance from those previously reported. Our study of 219 patients, referred for TEE for an indication of stroke or transient ischemic attack, found few relevant findings that would have indicated a new diagnosis or required a change in treatment. These results suggest that for most patients in whom TEE is ordered, either a TTE or no cardiac testing would suffice.

Left-to-right cardiac shunt: perioperative anesthetic considerations.

Congenital heart disease (CHD) affects roughly 8/1000 live births. Improvements in medical and surgical management in recent decades have resulted in significantly more children with left-to-right cardiac shunts surviving into adulthood. Surgical care of these patients for their original cardiac defect(s) or other non-cardiac medical conditions requires thorough understanding of cardiopulmonary changes and mastery of treatment options. Commonly encountered CHD with left-to-right shunt include atrial septal defect (ASD), ventricular septal defect (VSD), endocardial cushion defect (ECD) and patent ductus arteriosus (PDA). The key pathological change is increased pulmonary vascular resistance (PVR) and pressure secondary to increased blood flow from the left-to-right shunt. Increasing PVR and pulmonary arterial hypertension (PAH) will lead to reversed direction of blood flow through the cardiac defect (Eisenmenger Syndrome) and heart failure. Cardiac defects with left-to-right shunt generally require surgical or trans-catheter repair at an early age. We review the current concepts and general principles of perioperative anesthetic management of CHD, including neuraxial anesthesia. Current techniques and unique pharmacodynamic and pharmacokinetic effects of some commonly used anesthetic agents in patients with left-to-right shunt are also reviewed.

Tumor-like coronary atheroma: a modern coronary evaluation with a historical perspective.

The concept that atherosclerotic disease could be a form of neoplasm has been proposed in the medical literature for centuries, yet few modern cardiologists or pathologists describe atherosclerotic plaques as having the appearance of tumors. Although atherosclerosis is now considered to be an inflammatory disease, parallels between the pathophysiologic courses of atherosclerosis and neoplasia have been described since the 19th century. Current research is increasingly focused on mechanisms common to both diseases.Herein, we present the case of a 70-year-old man with a tumor-like coronary atheroma that was diagnosed on computed tomographic coronary angiography and confirmed with the use of intravascular ultrasound. However, the large plaque was not apparent on conventional invasive angiography. This case serves as a reminder of the limitations of invasive angiography and of the superiority of both computed tomographic coronary angiography and intravascular ultrasound in identifying and quantifying coronary plaque. We discuss our interpretation of the patient's lesion and review various theories of atherogenesis.

The Kounis-Zavras syndrome with the Samter-Beer triad.

We present a case of Kounis-Zavras syndrome in the setting of aspirin-induced asthma, or the Samter-Beer triad of asthma, nasal polyps, and aspirin allergy. The Kounis-Zavras syndrome, also known as Kounis syndrome, leads to angina pectoris or acute coronary syndrome secondary to coronary vasospasm in response to an allergic stimulus, leading to mast-cell degranulation of vasospastic mediators. The vasospasm can result in myocardial infarction, as it did in our patient.