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Article Excerpt
Section on Anesthesiology
ANE-2. Trauma and Pregnancy: a Level I Trauma Center Perspective.
Edgard J. Pierre, MD, Jong Lee, MD, Clint Chirstensen, MD, and Miguel A. Cobas, MD, Department of Anesthesiology and Perioperative Medicine, Miller School of Medicine at the University of Miami, Ryder Trauma Center, Miami, FL.
Background: Trauma and/or accidental injury complicate 1 to 7% of all pregnancies. The management protocols for trauma in pregnancy are based largely on case reports and small series. The purpose of this study is to describe the demographics of pregnant trauma patients at a level I Trauma center; identify the value of fetal heart rate monitoring and recommend an evaluation and management protocol after trauma based on observational data rather than anecdotal reports.
Methods: This is an institution-approved, retrospective review of data looking at pregnant patients admitted to the Ryder trauma center from January 1999 through December 2004.
Results: There was a total of 14,209 admissions to the Ryder Trauma Center, of which 88 were pregnant (0.6%). The majority of these patients were involved in motor vehicle crashes (53) and domestic violence (13). Four patients underwent emergent cesarean section; there were two perinatal deaths and two maternal deaths. All the other patients were evaluated and discharged home without any serious sequelae. Fetal heart rate monitoring was abnormal in 3% of cases; however none of these tracings dictated emergency C-section conduct but rather the need to continue observation. The perinatal deaths were associated with blunt trauma caused by motor vehicle accidents. Most of the injuries from domestic abuse were from penetrating trauma and occurred more commonly during the first trimester. Motor vehicle crashes were distributed equally throughout the gestation.
Conclusions: In this series, it was found that prolonged monitoring (>4 hours) does not add any valuable information in the management of pregnant trauma patients. We recommend that initial external fetal monitoring be performed for 4 hours, and, if reassuring, the decision to admit be based on associated injuries and not on the pregnancy by itself.
Section on Cardiology
CAR-1. A Case of Sustained Ventricular Tachycardia in a Patient With Commotio Cordis and Prolonged QT Syndrome: Which Came First, the Chicken or the Egg?
Pramil Cheriyath, MD, Wyndham Owens, MD, Vishal Bhatia, MD, and Mukta Panda MD, University of Tennessee, Chattanooga Unit, Chattanooga, TN.
Objectives: To discuss the entity, commotio cordis, and differential diagnosis of arrhythmias in the setting of commotio cordis.
Case: A 21-year-old healthy Hispanic male came to the ER complaining of fast heart beat and shortness of breath after a MVA 1 week prior (he fell asleep on the steering wheel and hit the curb). There was no significant family history. Vitals were BP, 94/45 mm Hg; pulse, 176/min; temperature, 98.6[degrees]F; oxygen saturation, 99% RA. Physical examination was normal except for tenderness without bruising around chest wall, tachycardia, and [S.sub.3] gallop. Hearing was normal. CBC, CMP, ABG, and TSH values were normal; BNP was 696 pg/mL. CKMB index was 13.3; CKMB units, 5.6 ng/mL; CPK, 171 [micro]/L, and troponin, 0.07 ng/mL. Initial ECG revealed ventricular tachycardia, right bundle branch pattern, and left axis deviation. Chest x-ray was suggestive of CHF, with no rib fractures. The patient was started on amiodorone and underwent cardioversion. When the heart rate slowed, the ECG revealed long QT interval (QTc, 522). The echocardiogram revealed EF of 45% and mild hypokinesis of left ventricle. As the patient remained in sustained ventricular tachycardia, an EP study showed inducible sustained monomorphic ventricular tachycardia and long QT syndrome. The patient underwent successful implantation of a cardiac defibrillator. Repeat echocardiography before discharge showed EF of 70%, without hypokinesis.
Conclusions: Sudden death due to nonpenetrating chest wall impact in the absence of injury to the ribs or sternum and heart is known as commotio cordis. Commotio cordis impacts are typically of low energy and velocity. Ventricular fibrillation is the most common rhythm observed in commotio cordis followed by nonsustained ventricular tachycardia. It is hypothesized that the blunt trauma induced sustained ventricular tachycardia in the patient, who was predisposed due to his congenital prolonged QT syndrome. The tachycardia together with stunning of the myocardium also resulted in CHF. This case highlights the importance of recognition and prompt treatment of blunt cardiac trauma and the exploration of other underlying abnormalities.
CAR-2. A Massive Pericardial Effusion in a Patient with Common Atrioventricular Canal Defect and Down Syndrome.
Michael Nillas, MD, Mahmood Heydarian, MD, and Tina Sias, MD. Departments of Cardiovascular Services and Pediatrics, Marshall University-Joan C. Edwards School of Medicine; Huntington, WV.
Background: Downs syndrome is one of the most common chromosomal disorders and is associated with congenital heart defects (particularly common atrioventricular canal defect) and hypothyroidism.
Methods and Results: This case describes a 34-year-old woman with a history of Down syndrome and common atrioventricular canal defect, who underwent a routine 2-D transthoracic echocardiogram. The echocardiogram demonstrated a massive pericardial effusion without evidence of cardiac tamponade. Due to the size of the effusion, a pericardiocentesis for diagnosis was contemplated. However, the patient was asymptomatic. As Down syndrome is associated with hypothyroidism, hypothyroidism was suspected as the cause of the effusion. Effusions associated with hypothyroidism are characteristically large in size, asymptomatic in character, and indolent in progression. Laboratory studies demonstrated an abnormal serum TSH of 133 mIU/mL (normal, +0.37 to 4.42 mIU/mL), which confirmed clinical hypothyroidism. The endocrine disorder was treated appropriately with thyroxine replacement therapy. A pericardiocentesis was not performed. A repeat echocardiogram 3 months later demonstrated improvement of the pericardial effusion.
Conclusions: This case study is exceptional as it demonstrates (1) The association of Down syndrome with congenital heart defects and hypothyroidism; (2) the development of a massive pericardial effusion secondary to hypothyroidism; and (3) the challenges of managing a pericardial effusion in a patient with common atrioventricular canal defect.
CAR-3. A New Murmur Post-Acute Myocardil Infarction.
Mehiar O. El-Hamdani, MD, and Silvestre Cansino, MD, Department of Cardiovascular Medicine, Marshall University-Joan C. Edwards School of Medicine, Huntington, WV.
Background: A new murmur in the course of acute myocardial infarction represents serious complications for which the clinicians need to be aware. The differential diagnosis may include pericarditis, ventricular septal defect, mitral regurge, pseudoaneurysm of the left ventricle, left ventricular free wall rupture, and tricuspid regurge.
Methods and Results: This case presentation focuses on two of these possible clinical outcomes of acute myocardial infarction. An 83-year-old white male with history of myocardial infarction and coronary artery bypass grafting presented to ER with a typical angina. The diagnosis of ST-elevation myocardial infarction involving the inferior and lateral wall was made based on clinical and biochemical evidences. Emergency percutaneous intervention to the right coronary artery was performed, followed by cardiac rehabilitation, and patient discharged home on the 5th day. The patient returned the next day to the ER, with severe continuous constant retro-sternal pain and left shoulder and arm pain, with the pain somewhat eased by sitting up but never relieved. Hemodynamically stable, the examination revealed a new 4/6 pansystolic murmur and a friction rub, with ECG with persistent ST-elevation in the inferior and lateral leads. Acute stent restenosis was excluded by heart catheterization. Simultaneously an echocardiogram was performed and confirmed the presence of left ventricular free wall rupture and pseudoaneurysm formation of the posterior-lateral wall. The patient was treated conservatively and remained stable.
Conclusions: The National Registry of Myocardial Infarction found that the incidence of cardiac rupture less than 1% and responsible for 7% of all deaths. A pseudoaneurysm of the left ventricle is a myocardial rupture contained by pericardium and thrombus. It is a rare but life-threatening condition. Cardiac imaging is crucial in diagnosis, but history and physical examination remained the most important step in early detection of these complications and applying the appropriate management in timely fashion.
CAR-4. A Sea Anemone Living Inside the Heart: A Rare Intracardiac Tumor Causing Multiple Strokes.
Mehiar O. El-Hamdani, Silvestre Cansino, and Imran Arif. Department of Cardiovascular Services, Marshall University-Joan C. Edwards School of Medicine, Huntington, WV.
Background: Intracardiac sources of cerebrovascular ischemic events are increasingly being recognized and may account for the 15 to 20% of the 500,000 strokes that occur annually in United States. Primary cardiac tumors are found in only 0.002 to 0.03% of autopsy studies, with myxomas constituting more than 50% of these lesions. Papillary fibroelastomas are rare, benign tumors of the heart that often are incidental findings at autopsy or cardiac surgery or during echocardiography. It is the second most common tumor cardiac tumor and the most common valvular tumor of the heart. They resemble sea anemone in gross morphology, with frond-like arms emanating from a stalked central core.
Methods and Results: This report describes a patient with this rare tumor who had multiple cardio-embolic strokes.
Case Report: A 60-year-old male veteran underwent echocardiogram to look for cardiac source of embolism after having two episodes of stroke. The diagnosis of stroke was confirmed by MRI, with no clear cause found on routine testing. Echocardiography suggested a possible mass attached to aortic valve. TEE confirmed an elongated, highly mobile mass that was approximately 3 cm in size attached to ventricular side of right coronary cusp, most likely a fibroelastoma. Patient was started on coumadin and referred for aortic valve debridement. Surgery revealed a broken stalk on the noncoronary cusp and a mobile mass resembling fibroelastoma attached to right coronary cusp.
Conclusions: TEE should be done in patients with cryptogenic stroke. Cardiac papillary fibroelastoma is a benign tumor. Echocardiography, and particularly TEE, complemented by cardiac MRI, provides a defined structural resolution, location, and the extent of anatomic and hemodynamic involvement. Surgery is curative and holds an excellent short- and long-term prognosis. Those who are not surgical candidates should be subjected to long-term anticoagulation.
CAR-6. Anomalous Left Circumflex Coronary Artery and Sudden Cardiac Death.
John E. McGinty, MD, Silvestre Cansino, MD, and Imran Arif, MD. Department of Cardiovascular Services, Marshall University-Joan C. Edwards School of Medicine, Huntington, WV.
Background: The incidence of sudden cardiac death (SCD) in the United States varies from 250,000 to 400,000 annually. Structural abnormalities of the coronary arteries other than coronary atherosclerosis are infrequent causes of SCD. Among the congenital lesions, anomalous origin of the left circumflex coronary artery from the right aortic sinus has been reported in association with SCD. This is the most frequent coronary artery anomaly observed with an incidence of 0.5%. It is generally considered benign. This report describes a case of a 50-year-old male with an anomalous left circumflex coronary artery who had sudden cardiac death.
Case Report: The patient was referred for evaluation of exertional angina. An exercise stress test revealed poor functional capacity and met ECG criteria for myocardial ischemia. Myocardial perfusion was normal. Widely patent coronary arteries with preserved left ventricular systolic function was discovered on subsequent coronary angiography. The circumflex artery had an anomalous origin from the right aortic cusp with a retro-aortic course. Echocardiography was normal, and a Holter monitor demonstrated only frequent isolated premature ventricular complexes. He was tried on different anti-anginal therapies, but due to persistent exertional angina, he was referred for single-vessel coronary artery by-pass grafting (CABG). Two days before surgery, he had sudden cardiac death at home.
Discussion: Anomalous origin of the left circumflex from the right aortic sinus is usually considered a benign anomaly. Sudden cardiac death has not been widely associated with this anomaly although case reports, including associated ischemia and infarction, have been presented. Several theories have been postulated to explain ischemia, infarction and SCD including vasospasm, premature coronary atherosclerosis, and exercise-induced aortic dilatation, causing a slit-like compression of the proximal artery. No consensus opinion exists regarding definitive management. Medical therapy for atherosclerosis, including aggressive anti-anginal medications, has been used. Percutaneous coronary intervention and single-vessel CABG have also been performed.
Conclusions: We propose that single-vessel CABG may be the optimal therapy to control angina, eliminate ischemia, and prevent SCD for an anomalous circumflex coronary artery arising from the right aortic cusp.
CAR-7. Aortic Root Abscess Presenting as an Acute Coronary Syndrome.
Uzoma N. Ibebuogu, MD. Medical College of Georgia, Augusta, GA.
Background: Aortic root abscess is a life-threatening complication of infective endocarditis with a reported incidence of 40% in large autopsy series with endocarditis. This is a rare case of aortic root abscess presenting as an acute coronary syndrome.
Methods and Results: A 56-year-old male, status post renal transplant and coronary artery bypass graft for a three-vessel coronary artery disease and a prior history of coagulase negative staphylococcus bacteremia, presented with chief complaints of nausea, malaise, and lethargy. On examination, he was afebrile with a regular heart rate and a grade 2/6 systolic ejection murmur at the left sternal edge. He was admitted for presumed uremic syndrome secondary to transplant failure. In the dialysis unit, the patient had acute onset chest pain with nonspecific ST-T changes on electrocardiogram. The first set of cardiac enzymes was negative. Emergent treatment was initiated, and he was transferred to the coronary care unit (CCU) for further treatment. While in the CCU, chest pain recurred with an elevated second set of cardiac enzymes. Cardiac catherization done urgently showed patent grafts with good run off and patient improved on medical management. Three days after transfer to telemetry floor, the patient had acute shortness of breath with hypotension and was transferred back to the CCU. Chest x-ray showed diffuse pulmonary edema. Transesophageal echocardiogram revealed avulsion of the non coronary cusp with possible vegetation, severe aortic regurgitation, and an aortic root abscess. The patient was sent for aortic valve replacement. He improved clinically after surgery with no further episodes of chest pain or pulmonary edema.
Conclusions: Cardiac abscesses are reported in 30% of cases of infective endocarditis, and its presence is a poor prognostic factor. Although aortic root abscess is a well-recognized complication of aortic valve endocarditis, acute coronary syndrome from possible compression of the coronary arteries is an unusual mode of presentation
CAR-8. Dual Origin of Circumflex Coronary Artery: A Very Unusual Anomaly.
Pradeep K. Agarwal, MD, Pramod Menon, MD, Suresh Jain, MD, and D. Luke Glancy, MD, Section of Cardiology, LSU HSC at New Orleans, New Orleans, LA.
Background: A 61-year-old black male was referred for coronary angiogram for complaints of retrosternal chest pain.
Methods and Results: The medical history was significant for hypertension, smoking, and distal right coronary artery stent. The physical examination on presentation was unremarkable. The coronary angiogram revealed nonobstructive disease of left anterior descending and left circumflex artery. The right coronary artery had nonobstructive disease in proximal segment and widely patent distal stent. In addition, an anomalous circumflex artery was seen arising from right coronary cusp. This vessel had 70% disease in proximal segment and 50 to 60% in mid and distal segment. Due to small vessel size, coronary intervention was not done.
Conclusions: The prevalence of coronary artery anomalies varies from 0.3 to 1.3% in different series. The most commonly reported anomalies include separate origin of left anterior descending and left circumflex from left coronary cusp, anomalous origin of circumflex from right coronary cusp, and ectopic origin of right coronary artery from right coronary cusp. There is only one report of dual origin of left circumflex artery. In that case, anomalous circumflex artery originated above the left main from left coronary cusp. This is the first report of origin of circumflex artery from left and right cusp.
CAR-9. Embryology in the Elderly: Bilateral Coronary Artery Fistulae.
Michael B. Phillips, MD, and Keith R. Oken, MD. Department of Internal Medicine, Mayo Clinic, Jacksonville, FL.
Background: An 85-year-old male with known coronary artery disease and chronic moderate LV systolic dysfunction presented with acute worsening of dyspnea and orthopnea, associated with intermittent aching left sided chest pain of 5 minutes' duration. This pain resolved before presentation.
Methods and Results: Examination revealed symmetric upper extremity blood pressure of 142/84 while seated. The pulse was 88 beats per minute and the respirations were 22 breaths per minute. He was afebrile. Cardiac examination was remarkable for 1/6 systolic murmur and 2/6 diastolic murmur at the left sternal border. The jugular venous pressure was estimated at 6 cm [H.sub.2]O. The pulmonary component of the second heart sound was normal. The lungs were clear bilaterally. Extremities revealed normal arterial pulses with trace edema.
Methods and Results: The patient was admitted for elective cardiac catheterization. His films are shown. A massive coronary artery fistula was noted, emanating from the mid-left anterior descending artery to the main pulmonary artery. The left circumflex coronary artery arose in an anomalous fashion from the proximal portion of a dominant right coronary artery. It fed a medium-sized A-V fistula in the posterior surface of the left atrium, which appeared to drain via normal venous channels in the region of the vein of Marshall. Moderate left main coronary artery stenosis and moderate ostial left circumflex coronary stenosis were noted as well. Qp/Qs was calculated at 1.3:1. Pulmonary artery pressures were normal.
Conclusions: The patient's cardiac problems were medically managed due to symptomatic critical carotid artery disease and acute cholecystitis. The fistulae had been diagnosed 30 years earlier at an outside institution and surgical intervention was deferred at that time. As his other problems were managed successfully, his angina resolved and he has done well subsequently.
CAR-11. Failing Heart, Famished Kidneys.
Kelly Roberts III, MS, Sujata Agnani, MD, Naveen K. Atray, MD, and Tushar J. Vachharajani, MD, Overton Brooks VA Medical Center and Louisiana State University Health Sciences Center, Shreveport, LA.
Objectives: To understand the physiologic and hemodynamic consequences of congestive heart failure (CHF) on renal function and to understand the principles of CHF and renal failure management.
Background: Renal hypoperfusion causing prerenal azotemia can be from intravascular volume depletion, a change in vascular resistance or reduced cardiac output. Poor left ventricular ejection fraction (LVEF) can significantly reduce renal blood flow despite an increase in total body water.
Case: A 66-year-old male presented with severe azotemia, decompensated CHF, and altered mental state with medical history significant for CHF (ejection fraction, 15%), chronic atrial fibrillation, DM-2, and chronic kidney disease with baseline serum creatinine (Crt.) of 2.0 mg/dL and BUN of 52 mg/dL. Aggressive management of his CHF with ACE inhibitors and diuretics caused hypotension, requiring transfer to MICU, with further worsening of BUN to 261 mg/dL, Crt. of 4.3 mg/dL, K of 3.7 mEq/L, and C[O.sub.2] of 26 mmol/L. The urine sediment was bland. The fractional excretion of sodium was less than 1%, and blood and urine cultures were sterile. Stool hemeoccult was negative. Renal ultrasound showed normal-sized kidneys without hydronephrosis. Hemodynamic monitoring with a Swan-Ganz catheter revealed pulmonary wedge pressure (PWP) of 20 mm Hg, cardiac index (CI) of 1.4, and cardiac output (CO) of 2.9 L/min and systemic vascular resistive index (SVRI) 2200 dyne/sec/[m.sup.2]/[cm.sup.5]. After inotropic support, the PWP, CI, and CO improved to 14 mm Hg, 2.9 L/min/[m.sup.2], and 6.0 L/min, respectively. The renal chemistry improved significantly after approximately 3 weeks of therapy to BUN of 27 mg/dL and Crt. of 1.3mg/dL.
Conclusions: Acute renal failure due to hypoperfusion secondary to poor LVEF and diminished effective circulating volume is a well-known phenomenon. Severe azotemia as seen in our patient is an unusual presentation. The dramatic and complete recovery, without renal replacement therapy, with improvement in renal blood flow highlights the importance of correcting the underlying cause of hypoperfusion.
CAR-12. Genetics and Cardiovascular Disease Risk Factors in Obese West Virginians.
J.M. Chappell, A. Watson, M. Flood, C. Clark, S. Hesson, B. Hill, J. Jeong, N. Liette, M. Ramey, B. Kahle, G. Wright, T. Green, M. Studeny, P. Wehner, and E.E. Murray. Marshall University and Marshall University School of Medicine, Huntington, WV, and Fairmont State University, Fairmont, WV.
Background: Polymorphisms in genes involved in homocysteine (Hcy) metabolism (MTHFR) and coagulation (Factor V Leiden [FVL]) have been associated with venous thrombosis and cardiovascular disease (CVD), especially in patients with high Hcy levels. Elevated Hcy levels are a significant risk factor for CVD. The MTHFR variants (677T and 1298C) have been reported to modestly elevate Hcy in subjects consuming a low folate diet. FVL 1691A causes resistance to activated protein C, increasing venous thrombosis risk. Although obesity increases CVD risk, the role genotype plays in elevated Hcy in the obese is unknown.
Methods and Results: Using PCR and pyrosequencing, 581 subjects were genotyped for the MTHFR 677, MTHFR 1298, and FVL 1691 variants; 154 of the 581 subjects had plasma Hcy levels analyzed using the Abbott Diagnostics IMx immunoanalyzer. 77.2% of subjects were obese (BMIB Burnette 114033137Please check missing symbols. ? 30) and 10.9% were overweight (BMI ? 25 < 30). There is no significant difference between genotype distributions in the obese compared with a WV population of European origin not selected for obesity. The MTHFR 1298A allele is linked to MTHFR 677T, and the 1298C allele with 677C (P ? 0.001). Linkage disequilibrium (LD) is observed between MTHFR 1298A and FVL 1691G and between 1298C and 1691A (P ? 0.05). The FVL 1691 and MTHFR 677 loci had no LD.
Conclusions: Only the MTHFR 1298 genotype positively correlates with obesity. Additional genotyping of other variants associated with CVD is being performed on these DNA samples and is discussed.
CAR-13. Left Ventricular Outflow Obstruction Caused by Accessory Mitral Valve Tissue with Associated History of Coarctation of the Aorta.
Sarah J. Rinehart, MD, and Silvestre Cansino, MD. Department of Cardiovascular Services, Marshall University-Joan C. Edwards School of Medicine, Huntington, WV.
Introduction: Accessory mitral valve tissue is a rare cause of left ventricular outflow obstruction that increases the risk of sudden cardiac death.
Objectives: The objective of this study is to present a case report of a patient with multiple congenital cardiac anomalies in which accessory mitral valve tissue was initially identified after surgical repair of coarctation of the aorta and to discuss clinical implications.
Methods: Literature search was completed to review incidence of accessory mitral valve tissue, associated conditions, and treatment plans available.
tk;2Summary: This case was diagnosed by 2D-echocardiography in a 22-year-old asymptomatic pregnant female undergoing cardiac evaluation after surgical repair of coarctation of the aorta. She was found to have residual coarctation of the aorta, bicuspid aortic valve, and accessory mitral valve tissue causing left ventricular outflow obstruction.
Conclusions: After literature research, the patient has a rare cardiac anomaly that has significant implications regarding mortality, which is easily rectified with surgery. Although the accessory mitral valve tissue is associated with other congenital cardiac anomalies, the presence of the accessory mitral valve tissue, bicuspid aortic valve, and history of coarctation of the aorta makes this case unique.
CAR-14. Mitral Stenosis and Deep Vein Thrombosis: Recognizing the Common Link!
Shadi Ayyoub, MD, and Mukta Panda, MD. University of Tennessee College of Medicine, Chattanooga Unit, Chattanooga, TN.
Objectives: To recognize the association between MS with left atrial (LA) thrombi and/or spontaneous echo contrast (SEC) and hypercoagulable states.
Case: A 46-year-old, mildly obese female with no history was diagnosed 1 week prior with extensive deep vein thrombosis (DVT) of the left lower extremity. This was her first episode; she was anticoagulated and discharged on coumadin. Two days later, she presented with acute-onset dyspnea and palpitations. She was a nonsmoker and not on hormones. She denied trauma or long travel. Family history was unremarkable. Exam was unrevealing except for tachycardia and left thigh tenderness. The ECG showed supraventricular tachycardia (178/min); INR: 3.24; ABG, normal. Cardiac enzymes were negative. CT angiogram showed LA filling defect and no evidence of pulmonary embolism; TEE, severe MS, LA spherical mass, and SEC. The patient underwent mitral valve replacement, and the left atrial mass was a thrombus. Thrombophilia studies were only significant for mild elevation of fasting plasma homocysteine.
Conclusions: LA SEC, or "smoke," is a frequent finding on TEE but rarely detected with TTE is present in almost all patients with LA thrombus. LA SEC predicts future embolism and death and therefore assists in selecting patients with MS who benefit most from anticoagulation. Hematological studies have shown that LA SEC is a marker of hypercoagulable state, elevated venous levels of fibrinogen and soluble P-selectin. LA thrombi have been associated with significantly higher levels of plasma homocysteine than those without as in our patient. Mid-diastolic rumble is characteristic of MS, however may be difficult to hear in patients with tachycardia. The diagnosis of DVT requires detailed attention to identify potential risk factors. In the absence of obvious causes a workup for hypercoaguble states is helpful. Although the incidence of mitral stenosis in the USA is declining, clinicians must be able to recognize its clinical manifestations and potential complications including hypercoagulable states.
CAR-15. Outside of the Loop: Hemolytic Anemia after Mitral Valve Repair.
Scott Duffy, MD, Tina Sias, MD, Arthur McUnu, MD, Travis Hansbarger, MD, and Silvestre Cansino, MD. Department of Cardiology, Joan C. Edwards School of Medicine, Huntington, WV.
Background: Hemolytic anemia is a very rare complication of mitral valve repair surgery. A study at Cleveland Clinic identified only 32 such patients over an 11-year period. The proposed mechanism appears to be damage to red blood cells within the regurgitant jet.
Case Presentation: The patient was a 62-year-old white male who underwent repair of the mitral valve with ring annuloplasty for severe mitral regurgitation. Two months later, the patient presented with fatigue and shortness of breath. Hemoglobin at the time was 8 g/dL and had been normal before surgery. After further laboratory evaluation, a diagnosis of hemolytic anemia was made. TEE showed a fragmented regurgitant jet and what appeared to be a partial dehiscence of the mitral annular ring. At the time of surgery there was a small perforation of the posterior leaflet in the presence of a central jet from an anterior chordal rupture.
Discussion: Hemolytic anemia after mitral valve repair is rare, reported primarily in case reports. Significant hemolysis appears to occur only with regurgitation. Regurgitant jets after valve surgery can be divided according to fluid dynamics into five distinct categories. Only those jets creating shear forces greater than 3,000 dyne/[cm.sup.2] are associated with significant RBC destruction. This patient had a fragmented jet, which numeric simulation has shown to be associated with a maximum shear stress of 6,000 dyn/[cm.sup.2] and probably had some component of collision and acceleration.
Conclusions: Hemolytic anemia is a rare complication of mitral valve repair surgery. Very specific patterns of regurgitant flow on Doppler echocardiography are associated with significant hemolysis. Echocardiography is a valuable tool for assessing the etiology of hemolytic anemia in a patient who has undergone mitral valve replacement.
CAR-16. Reversible Right Ventricular Failure in an Elderly Patient with HIV Infection.
Division of Internal Medicine, University of Texas Medical Branch (UTMB), Galveston, TX.
Background: Cardiomyopathy associated with human immunodeficiency virus (HIV) infection commonly presents as biventricular failure and carries poor prognosis. The role of antiretroviral therapy in the management of heart failure is unclear.
Methods and Results: This report describes a 68-year-old white male with severe bilateral lower extremity swelling, arthralgias, unsteady gait, bilateral lower extremity weakness, and numbness. The patient was homosexual by history and denied use of alcohol, tobacco or illicit drug abuse. Physical examination was notable for elevated jugular venous pressure, edema of legs, positive Romberg test, mild weakness, and absent deep tendon reflexes in the lower limbs. Examination of heart, lungs, and abdomen were unremarkable. Laboratory studies showed pancytopenia, HIV test was positive with a viral load of 74091 (HIV BDNA, quantitative assay) and an absolute CD4 count of 183 (cu/mL). Serologic tests for opportunistic infections were negative. Nerve conduction studies revealed mixed polyneuropathy in the lower limbs. Echocardiogram showed moderate right ventricular enlargement, inferior vena cava and hepatic vein dilatation, consistent with right ventricular failure. Left ventricular size, function, and pulmonary artery pressures were normal. Treatment was started with zidovudine, lamivudine, and nevirapine. Low-dose diuretic was given for symptomatic improvement of edema. During 3 years of follow-up, symptoms of right ventricular failure progressively and remarkably improved; the patient regained leg strength and the gait normalized. HIV-RNA level became undetectable, CD4 count improved to 604 (cu/mL), and the pancytopenia improved. Diuretic therapy was stopped and a repeat echocardiogram showed significant regression in the size of right ventricle and atrium.
Conclusions: In the absence of other causes, it appears that the right ventricular failure in this patient was most likely due to isolated involvement of right ventricle by HIV infection. This case also illustrates that the antiretroviral therapy might reverse HIV induced cardiomyopathy.
CAR-17. Role of First-Drawn Indeterminate Troponin I Levels in the Emergency Department.
S. Mehta, R.M. Bautista, and B.A. Adams. Brooke Army Medical Center, Fort Sam Houston, TX.
Objectives: Although patients with elevated cardiac troponin I (TnI) are known to be at an increased risk of death, an indeterminate TnI (ITnI) level offers minimal prognostic value in determining which patients are at risk for adverse outcomes. This study determines the predictive value of the first-drawn Emergency Department (ED) ITnI level for adverse composite end-points (acute myocardial infarction, hospital invasive procedure, readmission for any diagnosis within 90 days, or hospital death).
Methods: This retrospective case-control study evaluated patients at a 50,000 annual visit ED between March 2001 and February 2004 who had negative or indeterminate first-drawn TnI levels obtained during the patient's ED course. All patients had at least two TnI levels drawn. There were approximately 6,500 negative TnI (NTnI) and 1,100 ITnI during the study period. One hundred fifty patients for each arm were randomly chosen from the sample and assigned to their respective study groups.
Results: Sixty-six ITnI patients (44%) had some adverse outcome compared with 36 NTnI patients (24%) (OR, 2.488; P < 0.001). Twenty-two ITnI patients (15%) were diagnosed with an acute myocardial infarction compared with 5 (3%) (OR, 4.984; P = 0.001). Twenty-seven ITnI patients (18%) required a hospital invasive procedure compared with 12 (8%) (OR, 2.524; P = 0.016). Thirty-two ITnI patients (21%) required readmission within 90 days compared with 22 (15%) (OR, 1.578; P = 0.176). Ten ITnI patients (7%) died during that hospitalization compared with 3 (2%) (OR, 3,500; P = 0.089).
Conclusions: The first-drawn ED ITnI value was significantly associated with an acute myocardial infarction, hospital invasive procedure, and adverse composite end points. In patients presenting to the ED with symptoms concerning for an acute myocardial infarction, the first-drawn ITnI may be predictive of higher morbidity rates and adverse outcomes.
CAR-18. Sarcomatous Pleural Mesothelioma Metastatic to Left Ventricular Endocardium.
Neelavathi Senkottaiyan, MD, Jessica A. Birchem, DO, Matthew A. Fraley, MD, and Martin A. Alpert, MD. St. John's Mercy Medical Center, St. Louis, MO.
Background: Malignant mesothelioma is a rare, locally aggressive, asbestos-related malignancy. It usually arises from the pleura and is known to invade contiguous tissues such as lung, pericardium and myocardium. Endocardial involvement without pericardial or myocardial invasion is rare. Only one case of primary mesothelioma involving left ventricular endocardium has been reported.
Methods and Results: This report describes a patient with sarcomatous pleural mesothelioma metastatic to left ventricular endocardium without pericardial or myocardial invasion. A 71-year-old man had transient dysarthria and right facial weakness. Seven months earlier, he had been diagnosed with malignant pleural mesothelioma (sarcomatous type). Transesophageal echocardiography showed a mobile 2.0 X 2.0 X 2.0 cm mass near the left ventricular outflow track. At surgery, the tumor adhered to posteromedial endocardium near the papillary muscle base and was resected en bloc. There was no evidence of pericardial, myocardial or pulmonary vein involvement on gross inspection. Histopathology showed interlacing fascicles of plump spindle cells with pleomorphic nuclei and prominent nucleoli. Immunohistochemical staining was positive for WTI gene product, (a marker characteristic of mesothelioma) and was negative for mucicarnine, carcinoembryonic antigen and epithelial related antigen-MOC31. Despite treatment with chemotherapy his pleural disease progressed. Ten months after his original neurologic event, he presented with similar symptoms and was found to have a 2.5 X 2.4 X 3.8 cm mass in the left atrial cavity at the base of the mitral valve. He died 1 month later.
Conclusions: This is the first reported case of malignant pleural mesothelioma to metastasize to left ventricular endocardium without first invading pericardium or myocardium. Given the absence of involvement of pericardium, myocardium, and extrapulmonary pulmonary vein, it is plausible that metastasis occurred via invasion of an intrapulmonary tributary of a pulmonary vein with subsequent embolization of a tumor fragment. Thus, pleural mesothelioma may metastasize to left ventricular endocardium without prior pericardial or myocardial invasion.
CAR-19. Takotsubo Cardiomyopathy: A Mimicker of ST-Segment Elevation Myocardial Infarction.
Maria Conley, CPT, MC, Casey Cotant, CPT, MC, and Richard Krasuski, MAJ, MC. Wilford Hall Medical Center, San Antonio TX.
Background: Takotsubo cardiomyopathy, otherwise known as transient left ventricular apical ballooning, is an uncommon condition most often found in elderly women after an emotional or physiological stressor. The syndrome consists of reversible extensive akinesia of the apical and mid portions of the left ventricle with hypercontraction of the basal segment, resembling the shape of a Japanese fishing pot or takotsubo.
Methods and Results: The presentation of the syndrome is similar to that of an ST-elevation MI, with ST-segment elevations in [V.sub.2]-[V.sub.4] with mildly elevated cardiac enzymes. A 77-year-old white female presented with respiratory distress requiring intubation. Her ECG revealed ST elevations in [V.sub.2]-[V.sub.4]. Initial n-t-BNP was 2035 pg/mL, with a troponin T peak of 0.63 ng/mL. Bedside echocardiography showed an ejection fraction of 30%. The patient was rushed to the catheterization laboratory for presumed anterior myocardial infarction. Catheterization did not reveal any obstructive coronary disease; however, ventriculography demonstrated an abnormal left ventricle with basilar hyperkinesis and apical hypokinesis. The patient was then medically treated with diuretics and antihypertensives. ECG findings evolved from ST-segment elevation and Q waves in [V.sub.2]-[V.sub.5] to deep T-wave inversions and disappearance of Q waves 4 days later. Subsequent echo performed 3 days after admission showed an ejection fraction of 60% with normalization of left ventricular wall motion. Spontaneous clinical recovery occurred and the patient was discharged after 6 days.
Conclusions: Clinical presentation in Takotsubo cardiomyopathy includes ST elevation and mildly elevated cardiac enzymes without obstructive coronary artery disease. A peculiar shape of the left ventricle is seen, representing a transient dysfunction which completely normalizes within days to weeks. Possible causes of this syndrome include excessive sympathetic stimulation, multivessel epicardial spasm and metabolic injury. Takotsubo cardiomyopathy should be considered in any patient presenting with an apparent acute coronary syndrome without evidence of obstructive coronary artery disease.
Section on Chest Diseases
CHE-1. Multiple Bilateral Rib and Pelvic Fractures: An Uncommon Presentation of Sarcoidosis.
Uzoma N. Ibebuogu, MD, and John O. Oyakhire, MD. Medical College of Georgia, Augusta, GA.
Background: Sarcoidosis is a multisystem disorder of unknown cause characterized by noncaseating granuloma with varying presentation and a reported prevalence of 10 to 20/100,000. Involvement of the bones occurs in 5% of patients and commonly affects the hands and feet, with the involvement of the ribs rarely seen.
Methods and Results: This report describes a rare case of sarcoidosis presenting as multiple bilateral rib and pelvic fractures in a postmenopausal woman. A 54-year-old black woman with a history of hypertension presented with chief complaints of fever, pleuritic chest pain, nonproductive cough, poor appetite, and weight loss. Examination revealed an acutely ill-looking woman with temperature of 39.3[degrees]C. She was tachycardic with crackles in the right lower lung zone and bilateral lower extremity crusted plaques. Laboratory test revealed microcytic anemia, elevated calcium and angiotensin converting enzyme levels. HIV serology was negative. Urine and blood cultures were also negative. Chest x-ray showed multiple healing rib fractures and bibasilar airspace disease. CT scan revealed bilateral airspace disease, multiple bilateral rib and pelvic fractures with lytic changes (which have been described in osseous sarcoidosis) noted in the right public bone. Biopsy of her skin lesions revealed non caseating granuloma with negative cultures.
Conclusions: The diagnosis of osseous sarcoidosis was made after other potential diagnoses including physical abuse, granulomatous, metabolic, infectious and metastatic disorders were excluded on history, laboratory data, imaging studies and pathologic findings.
CHE-2. Not the Usual Community-Acquired Pneumonia.
Jasmine Shah, MD, and Mukta Panda MD. University of Tennessee College of Medicine-Chattanooga Unit, Chattanooga, TN.
Objectives: To recognize the differential diagnosis and importance of tissue diagnosis in nonresponsive pneumonia and to recognize the importance of the "hidden curriculum" in pursuing treatment availability for patients.
Case: A 52-year-old male presented with 2 weeks of shortness of breath, dry cough, night sweats, and 3-lb weight loss despite azithromycin. He had significant smoking history and high-risk behavior. Examination showed normal vitals, ABG, skin, lung, and heart. Laboratory values showed mild leukocytosis, otherwise normal; CXR, bilateral upper lobes noncavitary infiltrates; blood, initial sputum cultures; AFB smears, PPD, HIV, and hepatitis panel negative. The patient did not respond to conventional CAP therapy. BAL was negative for malignancy; AFB, fungi and PCP. Biopsy showed granulomata with encapsulated yeast. BAL grew blastomyces at 10 weeks. As in most resident clinics, patient was indigent. Time-consuming special requests to multiple sources led to provision of itraconazole for 6 months with successful management.
Conclusions: Blastomycosis is a systemic polygranulomatous infection caused by inhalation of blastomyces dermatitidis conidia and can mimic a variety of infectious and neoplastic diseases. Diagnosis needs a high index of suspicion, especially in nonresponsive CAP. Special stains of sputum help in early diagnosis. Cultures take 5 to 10 weeks. Asymptomatic pulmonary infection may be observed. Symptomatic pulmonary, disseminated, and infections in immunocompromised hosts need treatment. Treatment includes Amphotericin B for life-threatening infections; itraconazole for non-CNS infections. Itraconazole is very expensive but the only one effective in non-CNS infection. Despite obstacles, residents need to be patient advocates, and teamwork can be successful. Despite no insurance and time poverty, patience and persistence pay off.
Section on Colon and Rectal Surgery
COL-1. The Safety and Efficacy of a Less Invasive Anal Sphincteroplasty.
Rodney L. Clingan, MD, FACS, George Y. Apostolides, MD, FACS, Francessco Grasso, MD, FACS, Howard Berg, MD, FACS, Lisa M. Savoie, MD, Debra A. Vachon, MD, FACS, and Clifford F. Melick, PhD. Greater Baltimore Medical Center, Mercy Medical Center, Northwest Hospital, Baltimore, MD.
Purpose: This study compares the outcomes of overlapping and reefing sphincteroplasty for delayed repair of anterior anal sphincter defects.
Methods: Patients who underwent anterior anal sphincteroplasty, using an overlapping or reefing technique, from 1989 to 2003 were identified at three institutions. Demographic and perioperative data were obtained from chart review of hospital and private office records. Questionnaires returned by patients and completed by telephone interview were used to determine the current degree of fecal incontinence and associated quality of life using the fecal Incontinence Severity Index (FISI) and Fecal Incontinence...
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