A successful anticoagulation protocol for the first HeartMate II implantation in the United States

Bleeding and thrombus formation are common problems with life-threatening implications in patients receiving a left ventricular assist device. We describe the anticoagulation protocol for the 1st patient in the United States to undergo successful implantation of the HeartMate II left ventricular assist system.     

Postoperative atrial fibrillation and mortality after coronary artery bypass surgery

OBJECTIVES: We sought to determine if the occurrence of postoperative atrial fibrillation (AF) affects early or late mortality following coronary artery bypass surgery (CABG). BACKGROUND: Atrial fibrillation is the most common arrhythmia seen following CABG. METHODS: The Texas Heart Institute Cardiovascular Research Database was used to identify all patients that developed AF after isolated initial CABG from January 1993 to December 1999 (n = 994). This population was compared with patients who underwent CABG during the same period but did not develop AF (n = 5,481). In-hospital end points were adjusted using logistic regression models to account for baseline differences. Long-term survival was evaluated using a retrospective cohort design, where Cox proportional hazards methods were used to adjust for baseline differences, and with case-matched populations (n = 390, 195 per arm). RESULTS: Atrial fibrillation was diagnosed in 16% of the population. Postoperative AF was associated with greater in-hospital mortality (odds ratio [OR] 1.7, p = 0.0001), more strokes (OR 2.02, p = 0.001), prolonged hospital stays (14 vs. 10 days, p < 0.0001), and a reduced incidence of myocardial infarction (OR 0.62, p = 0.01). At four to five years, survival was worse in patients who developed postoperative AF (74% vs. 87%, p < 0.0001 in the retrospective cohort; 80% vs. 93%, p = 0.003 in the case-matched population). On multivariate analysis, postoperative AF was an independent predictor of long-term mortality (adjusted OR 1.5, p < 0.001 in the retrospective cohort; OR 3.4, p = 0.0018 in the case-matched population). CONCLUSIONS: The occurrence of AF following CABG identifies a subset of patients who have a reduced survival probability following CABG. The impact of various strategies, such as antiarrhythmics and warfarin, aimed at reducing AF and its complications deserves further study.     

High-resolution ultrasonography in carpal tunnel syndrome: role of ancillary criteria in diagnosis and response to steroid injection

Clinical Rheumatology - (1) Development and validation of a composite ultrasound score (cUSS) for the diagnosis of carpal tunnel syndrome (CTS). (2) To predict treatment response after local...     

The pathologic basis of Q-wave and non-Q-wave myocardial infarction: a cardiovascular magnetic resonance study

OBJECTIVES: The purpose of this study was to determine the pathologic basis of Q-wave (QW) and non-Q-wave (NQW) myocardial infarction (MI). BACKGROUND: The QW/NQW distinction remains in wide clinical use but the meaning of the difference remains controversial. We hypothesized that measurement of total MI size and transmural extent by late gadolinium enhancement cardiovascular magnetic resonance (CMR) would identify the pathologic basis of QWs. METHODS: A total of 100 consecutive patients with documented previous MI had electrocardiogram and CMR on the same day. Patients with acute MI within seven days were excluded. Left ventricular function and the size and transmural extent of MI were quantified in the three major arterial territories and correlated with the presence of QW. RESULTS: Subendocardial MI showed QW in 28%. Transmural MI showed NQW in 29%. Of all MIs, 48% were at some point transmural, and 99% of these were at some point non-transmural. As MI size and number of transmural segments increased, the probability of QW increased (anterior: total size chi-square = 53, p < 0.0001, transmural extent chi-square = 36, p < 0.0001; inferior: total size chi-square = 16, p = 0.001, transmural extent chi-square = 10, p = 0.001). These findings did not hold for lateral MI. In a multivariate model, the transmural extent of MI was not an independent predictor of QW when total size of MI was removed. The QW/NQW classification was a good test for size of MI (area under receiver operating characteristic curve: anterior 0.90, inferior 0.77). CONCLUSIONS: The QW/NQW distinction is useful, but it is determined by the total size rather than transmural extent of underlying MI.     

Clear cell carcinoma of exocrine pancreas: a rare tumor with an unusual presentation

Metastatic clear cell carcinomas are relatively common from primary tumors arising in the kidney, female genital tract, adrenal cortex, and lung, but they rarely occur from primary tumors of the pancreas. We report a case of metastatic pancreatic tumor with marked clear cell changes in a 46-year-old white man presenting with a pseudocyst of the pancreas. At laparotomy, there was a hard area in the head of the pancreas and another hard nodule was present in the omentum. The histologic and immunohistochemical test of the excised omental nodule exhibited features consistent with clear cell carcinoma from pancreatic primary. To our knowledge, this is the first report of a metastatic clear cell pancreatic tumor with such an unusual presentation.     

Detection of high risk coronary artery disease by thallium imaging.

One hundred and three patients who underwent coronary arteriography were studied by thallium imaging and the results analysed by Bayesian principles to assess the usefulness of semiquantitative stress thallium imaging for predicting the presence or absence of multivessel coronary disease. Significant disease was found in 80 patients, of whom 77 had abnormal thallium scans (sensitivity 96%). Thallium images were normal in 15 of 23 patients with no significant disease (specificity 65%). Multiple thallium segmental defects were found to be 90% sensitive and 65% specific for multivessel coronary artery disease and were present in 80% of patients with left main stem disease and in 93% of patients with triple vessel disease. A single thallium defect or normal scan excluded multivessel, left main, and triple vessel disease with 81%, 94%, and 91% predictive accuracy respectively. By Bayesian analysis the predictive accuracy for excluding multivessel disease was greater than 90% in patients with a pretest probability of multivessel disease of less than or equal to 40%. Coronary arteriography to exclude multivessel disease is therefore unnecessary in a high proportion of patients with known or suspected coronary artery disease.     

Diagnostic accuracy of dobutamine stress echocardiography for detection of coronary heart disease in hypertensive patients

To compare the diagnostic accuracy between dobutamme echocardiographyand treadmill exercise electrocardiography in detecting coronaryartery disease in hypertensive patients, 43 patients withoutelectrocardiographic evidence of left ventricular hypertrophyand basal ST-T changes, who had also undergone coronary angiography,were further evaluated by dobutamine echocardiography. The patientsalso underwent treadmill exercise echocardiography. Left ventricularmass index was calculated by echocardiography. Twenty-nine patientshad coronary artery disease, of whom 22 had multi-vessel diseaseand 14 a normal coronary anatomy. Twenty-eight patients hadan increased left ventricular mass index. The sensitivitiesof dobutaniine echocardiography and exercise electrocardiographyfor detecting coronary artery disease were 93% and 72% (P=0·08)respectively, and the specificities were 100% and 29%(P<0·005),respectively. Logistic regression analysis showed exercise electrocardiographyto be a poor predictor of coronary artery disease (P<0·09)but dobutamine echocardiography was significantly better (P<0·00l).When patients with increased left ventricular mass index wereexcluded, prediction of coronary anatomy by exercise electrocardiographyimproved only marginally (P=0·4) while dobutamine echocardiographywas significantly better (P<0·00l). Thus dobutamineechocardiography is superior to exercise electrocardiographyfor diagnosis of coronary artery disease in hypertensive patients.     

Meningoencephalitis associated with COVID-19: a systematic review

Journal of NeuroVirology - With the growing number of COVID-19 cases in recent times. significant set of patients with extra pulmonary symptoms has been reported worldwide. Here we venture out to...