Diagnosing pulmonary arteriovenous malformations in the presence of atrial septal defect and anomalous pulmonary venous drainage—An imaging challenge

Saline contrast echocardiography is a simple and effective method to diagnose the presence and type of right-to-left shunt in patients with unexplained cyanosis. It is considered a very sensitive test to diagnose pulmonary arteriovenous malformations. Our patient presented with unexplained cyanosis and transthoracic echocardiography showed an atrial septal defect and anomalous pulmonary venous drainage of the right and left upper pulmonary veins to the superior venacava. We describe how we used saline contrast echocardiography to demonstrate the presence of pulmonary arteriovenous malformations even in the presence of atrial septal defect and anomalous pulmonary venous drainage.     

Endovascular transluminal stent grafting

Iliac vessels are prone to injury during lumbar spine surgery due to their proximity to the lumbar spine. Arterio‐venous fistula formation during lumbar spine surgery is an uncommon complication and can present as an asymptomatic incidental finding to rapidly deteriorating hemodynamics leading to cardiopulmonary collapse. We have reported three patients who had symptomatic iliac arterio‐venous fistula detected soon after lumbar spine surgery. All these patients were successfully treated by endovascular transluminal stent grafting. © 2013 Wiley Periodicals, Inc.     

Non-initiation of hepatitis C virus antiviral therapy in patients with human immunodeficiency virus/hepatitis C virus co-infection

AIM: To assess whether reasons for hepatitis C virus(HCV) therapy non-initiation differentially affect racial and ethnic minorities with human immunodeficiency virus(HIV)/HCV co-infection.METHODS: Analysis included co-infected HCV treatment-na?ve patients in the University of North Carolina CFAR HIV Clinical Cohort(January 1, 2004 and December31, 2011). Medical records were abstracted to document non-modifiable medical(e.g., hepatic decompensation, advanced immunosuppression), potentially modifiable medical(e.g., substance abuse, severe depression, psychiatric illness), and non-medical(e.g., personal,social, and economic factors) reasons for non-initiation. Statistical differences in the prevalence of reasons for non-treatment between racial/ethnic groups were assessed using the two-tailed Fisher's exact test. Three separate regression models were fit for each reason category. Odds ratios and their 95%CIs(Wald's) were computed.RESULTS: One hundred and seventy-one patients with HIV/HCV co-infection within the cohort met study inclusion. The study sample was racially and ethnically diverse; most patients were African-American(74%), followed by Caucasian(19%), and Hispanic/other(7%). The median age was 46 years(interquartile range = 39-50) and most patients were male(74%). Among the 171 patients, reasons for non-treatment were common among all patients, regardless of race/ethnicity(50% with ≥ 1 non-modifiable medical reason, 66% with ≥1 potentially modifiable medical reason, and 66% with ≥ 1 non-medical reason). There were no significant differences by race/ethnicity. Compared to Caucasians, African-Americans did not have increased odds of nonmodifiable [adjusted odds ratio(a OR) = 1.47, 95%CI: 0.57-3.80], potentially modifiable(a OR = 0.72, 95%CI: 0.25-2.09) or non-medical(a OR = 0.90, 95%CI: 0.32-2.52) reasons for non-initiation.CONCLUSION: Race/ethnicity alone is not predictive of reasons for HCV therapy non-initiation. Targeted interventions are needed to improve access to therapy for all co-infected patients, including minorities.     

The Use of Qualitative Methods in Developing Implementation Strategies in Prevention Research for Stroke Survivors in Nigeria

Implementing complex clinical interventions is a key challenge in many global regions. Local communities play a necessary role in enhancing feasibility and strengthening adaptive issues in the design and implementation of stroke interventions in developing countries. Drawing on the knowledge of physicians, patients, and caregivers, the authors employed qualitative methods as a phase 1 strategy to explore the challenges of stroke management and improve the adaptability and efficient delivery of a multimodal preventive intervention for secondary stroke disease in Nigeria. A total of 22 individual interviews were conducted with healthcare professionals, as well as 12 focus groups with patients and caregivers. Findings revealed four operational domains to improve strategies for phase 2 implementation and intervention: (1) barriers influencing optimal adherence in stroke survivors, (2) patient health beliefs and perceptions of patient health beliefs by others, (3) adoption of the “patient report card,” and (4) “medical action plan” and family management strategies.     

Pigtail catheter “propping” for MitraClip percutaneous transcatheter mitral valve repair

In recent years percutaneous therapy has emerged as a feasible and effective option for the treatment of mitral regurgitation, particularly in cases where the risks of conventional cardiac surgery are prohibitively high. To date the most widely used percutaneous approach is beating heart, edge‐to‐edge repair with the MitraClip device (Abbott Vascular‐Structural Heart, Menlo Park, CA). The technique requires simultaneous grasping and approximation of both mitral valve leaflets prior to securing and releasing the clip. However, this may be technically challenging or indeed impossible in patients with failure of coaptation, particularly when there is a large coaptation gap. We present an approach for overcoming this relatively common obstacle based on “propping” the anterior mitral valve leaflet toward its posterior counterpart with a diagnostic pigtail catheter to reduce the coaptation gap and to allow grasping of both leaflets without difficulty. © 2016 Wiley Periodicals, Inc.     

Partial anomalous pulmonary venous connection in a patient with tetralogy of Fallot: Infrequent,but not inconsequential

We hereby describe a rare case of partial anomalous pulmonary venous connection (PAPVC) in a patient with tetralogy of Fallot (TOF). It is imperative to identify PAPVC preoperatively in patients with TOF as it can have significant hemodynamic outcomes. This case highlights the importance of computed tomography angiography in demonstrating the same.