One‐stop shop: Simultaneous direct mitral annuloplasty and percutaneous mitral edge‐to‐edge repair in a patient with severe mitral regurgitation

Percutaneous edge‐to‐edge repair of severe mitral regurgitation has been established as an alternative treatment option for patients at high risk for cardiac surgery. More recently, the introduction of the Cardioband system enabled percutaneous direct annuloplasty. Here, we present a case of simultaneous percutaneous direct annuloplasty with edge‐to‐edge repair. Moreover, annuloplasty did facilitate clip implantation bei approximating the anterior and posterior mitral leaflet. In conclusion, the combination of direct annuloplasty with edge‐to‐edge repair is feasible in a single procedure.     

Adverse event rates in congenital cardiac catheterization — A multi‐center experience

Objectives : To describe case mix variation among institutions, and report adverse event rates in congenital cardiac catheterization by case type. Background : Reported adverse event rates for patients with congenital heart disease undergoing cardiac catheterization vary considerably, due to non‐comparable standards of data inclusion, and highly variable case mix. Methods : The Congenital Cardiac Catheterization Outcomes Project (C3PO) has been capturing case characteristics and adverse events (AE) for all cardiac catheterizations performed at six pediatric institutions. Validity and completeness of data were independently audited. Results : Between 2/1/07 and 4/30/08, 3855 cases (670 biopsy, 1037 diagnostic, and 2148 interventional) were recorded, median number of cases per site 480 (308 to 1526). General anesthesia was used in 70% of cases (28 to 99%), and 22% of cases (15 to 26%) were non‐electively or emergently performed. Three institutions performed a higher proportion of interventions during a case, 72 to 77% compared to 56 to 58%. The median rate of AE reported per institution was 16%, ranging from 5 to 18%. For interventional cases the median rate of AE reported per institution was 19% (7 to 25%) compared to 10% for diagnostic cases (6 to 16%). The incidence of AE was significantly higher for interventional compared to diagnostic cases (20% vs 10%, p<0.001), as was the incidence of higher severity AE (9% vs 5%, p<0.001). Adverse events in biopsy cases were uncommon. Conclusions : In this multi‐institutional cohort, the incidence of AE is higher among interventional compared to diagnostic cases, and is very low among biopsy cases. Equitable comparisons among institutions will require the development and application of risk adjustment methods.     

NAFLD is related to Post‐prandial Triglyceride‐enrichment of HDL Particles in Association with Endothelial and HDL Dysfunction

NAFLD is closely related with the metabolic syndrome (MetS) and increased risk of cardiovascular disease. Liver fat associates with post‐prandial hypertriglyceridemia, potentially contributing to triglyceride‐enrichment of high‐density lipoproteins (HDL‐TG), and subsequent HDL dysfunction. We assessed liver fat by MR spectroscopy, and its association with HDL physiochemical properties, and endothelial function, measured as flow‐mediated dilation (FMD), before and following three consecutive meals, in 36 men with type 2 diabetes mellitus (T2DM), with the MetS, and controls. Plasma triglycerides increased significantly following the meals (P < .001). Fasting HDL‐TG was highest in T2DM, relative to MetS and controls (P = .002), and increased post‐prandially in all groups (P < .001). HDL function was negatively associated with HDL‐TG following three meals (r = ?.32, P<.05). Liver fat associated with HDL‐TG after three meals (r = .65, P < .001). HDL‐TG was independently associated with FMD following three consecutive meals (r = ?.477, P = .003). We conclude liver fat is associated with post‐prandial HDL‐TG enrichment which was closely related with endothelial and HDL dysfunction.     

Myocardial Scar in Sarcoidosis by 12‐lead ECG and Pathology

This case demonstrates the use of QRS scoring to quantify myocardial scar in a patient with cardiac sarcoidosis and left bundle branch block who progressively received an implantable defibrillator, cardiac resynchronization therapy (CRT), left ventricular assist device and cardiac transplantation. QRS scoring has been shown to correlate with magnetic resonance imaging measurements of scar, identify arrhythmogenic substrate and predict response to CRT, but had not previously been compared to pathology‐documented scar in nonischemic cardiomyopathies. Further study is warranted to assess the ability of QRS scoring to guide therapy for individual patients. Ann Noninvasive Electrocardiol 2011;16(2):219–222     

Creutzfeldt‐Jakob disease and blood transfusion safety

Transmissible spongiform encephalopathies (TSEs) are untreatable, fatal neurologic diseases affecting mammals. Human disease forms include sporadic, familial and acquired Creutzfeldt‐Jakob disease (CJD). While sporadic CJD (sCJD) has been recognized for near on 100 years, variant CJD (vCJD) was first reported in 1996 and is the result of food‐borne transmission of the prion of bovine spongiform encephalopathy (BSE, ‘mad cow disease’). Currently, 230 vCJD cases have been reported in 12 countries, the majority in the UK (178) and France (27). Animal studies demonstrated highly efficient transmission of natural scrapie and experimental BSE by blood transfusion and fuelled concern that sCJD was potentially transfusion transmissible. No such case has been recorded and case–control evaluations and lookback studies indicate that, if transfusion transmission occurs at all, it is very rare. In contrast, four cases of apparent transfusion transmission of vCJD infectivity have been identified in the UK. Risk minimization strategies in response to the threat of vCJD include leucodepletion, geographically based donor deferrals and deferral of transfusion recipients. A sensitive and specific, high‐throughput screening test would provide a potential path to mitigation but despite substantial effort no such test has yet appeared. The initial outbreak of vCJD appears to be over, but concern remains about subsequent waves of disease among those already infected. There is considerable uncertainty about the size of the infected population, and there will be at least a perception of some continuing risk to blood safety. Accordingly, at least some precautionary measures will remain in place and continued surveillance is necessary.     

An unusual shot‐retrograde transthoraco‐abdominal venous bullet embolization

A 72‐year‐old gentleman was brought to the emergency department, after sustaining an allegedly accidental airgun‐shot injury to the right side of his neck. A chest radiograph and plain CT chest revealed the bullet lodged deeply in the soft tissues of the right side of the neck. He was taken up for an emergency neck exploration for foreign body removal. Peroperatively, the bullet was observed to be lodged in the right internal jugular vein. During the attempt to retrieve the bullet, it inadvertently migrated downstream. An intraoperative fluoroscopy revealed the bullet in the thorax near the level of the diaphragm. A subsequent CT chest revealed an intracardiac location of the bullet in the right atrium, at its junction with the inferior vena cava. When it was decided to attempt a percutaneous endovascular retrieval strategy, fluoroscopic imaging of the chest in the cardiac catheterization lab, revealed that the bullet was no longer in the thorax, and had migrated again, and was found to be located in the left side of the pelvis. A subsequent venogram showed the bullet to be lodged in a tributary of the left external iliac vein. It was then snared percutaneously, through the left femoral vein, and delivered through a venotomy. Vascular bullet embolization is a rare phenomenon, especially, as in this case, a retrograde venous embolization with a transthoraco‐abdominal course. The treatment of bullet embolization, whether surgical or endovascular, depends on the final destination site, symptomatic status and propensity for complications.     

Transfusion‐transmitted hepatitis B virus (HBV) infection from an individual‐donation nucleic acid (ID‐NAT) non‐reactive donor

Lookback was initiated upon notification of an acute HBV infection in a repeat Irish donor, 108 days post‐donation. The donation screened non‐reactive by individual‐donation nucleic acid testing (ID‐NAT) using the Procleix Ultrio Elite multiplex assay and again when the archived sample was retested, but the discriminatory assay for HBV was reactive. The immunocompromised recipient of the implicated red cell component was tested 110 days post‐transfusion, revealing a HBV DNA viral load of 470 IU/ml. Genotype C2 sequences identical across two regions of the HBV genome were found in samples from the donor and recipient.     

Complete blood count parameters for healthy,small‐for‐gestational‐age,full‐term newborns

No previous study has investigated the full range of complete blood count (CBC) parameters in small‐for‐gestational‐age (SGA) newborns. The main aim of this study was to compare CBC and peripheral smear parameters in term, healthy SGA neonates and appropriate‐for‐gestational‐age (AGA) neonates, and to establish CBC reference values for full‐term SGA newborns. One hundred thirty‐two healthy, term newborns (73 SGA and 59 AGA) were included. On day 1, we obtained 109 samples and on day 7 we obtained 77 samples. A CBC and peripheral smear were analyzed for each sample collected and group data were compared. We observed higher mean values for normoblast count, hemoglobin, hematocrit, and red blood cell (RBC) count in the SGA babies than in the AGA babies on day 1. The mean corpuscular hemoglobin and mean corpuscular hemoglobin concentration values for the SGA babies were decreased because of the relatively high RBC count and relatively high mean corpuscular volume we observed in this group. Of the SGA newborns, 21.9% had neutropenia and 4.7% had absolute neutrophil counts lower than 1500/μl on day 1. On both day 1 and day 7, the SGA newborns had higher mean absolute metamyelocyte counts and higher mean I : T (immature : total neutrophil ratio) values than the AGA group. The SGA babies had a lower mean absolute lymphocyte count on day 7 than the AGA group. We detected thrombocytopenia in almost one‐third of the 64 SGA newborns tested on day 1. In summary, our study clearly demonstrates that CBC parameters for healthy, full‐term, SGA newborns are different from those of healthy, term AGA newborns. This is the first study that has documented different mean corpuscular volume, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, metamyelocyte counts, lymphocyte counts, and I : T in SGA babies compared with AGA babies.     

Radiation‐induced peripheral artery disease

Radiation therapy is a cause of cardiovascular morbidity and mortality. This is due to the significant degree of atherosclerosis seen in the vessels in the vicinity of the area being irradiated. Radiation‐induced peripheral arterial disease is increasingly being recognized as large populations of cancer patients survive longer, yet it is a problem that is often under reported. Although it has most commonly been associated with carotid artery disease, all vascular beds are prone to this form of injury. The injury is accelerated by usual risk factors for atherosclerosis. Developing a healthy lifestyle, dietary prudence and the aggressive treatment of hypertension, diabetes mellitus, and dyslipidemia should all be encouraged in this patient population. When revascularization strategies are warranted, the percutaneous approach may be superior to open surgery as technical difficulties may arise in the fibrotic, scarred tissue. Stenting with distal embolic protection devices should be considered as the treatment of choice for patients with radiation‐induced carotid artery disease. Several reports also suggest good results with balloon angioplasty with or without stenting in the case of radiation‐induced renal, iliac, and femoral artery disease. Lifelong antiplatelet therapy may be appropriate. © 2008 Wiley‐Liss, Inc.     

Phaeochromocytoma‐associated critical peripheral ischaemia

Limb Ischaemia is an exceptional complication of catecholamine toxicity caused by a phaeochromocytoma. We present a middle‐aged female patient with severe subacute peripheral ishaemia, gangrene and eventual amputation of all four distal limbs due to a large non‐metastatic left adrenal gland phaeochromocytoma and summarise the available literature concerning previously reported cases.