Ahmed Khurshid Pasha

Successful management of acute massive pulmonary embolism using Angiovac suction catheter technique in a hemodynamically unstable patient

Massive pulmonary embolism with hemodynamic instability is a life-threatening condition requiring immediate treatment. Urgent thrombectomy or thrombolysis is commonly used for the treatment of this condition. However, surgery is associated with high mortality rate and many patients have contraindications to thrombolytic therapy and are at high risk for bleeding. Cather-based intervention has gained increasing popularity particularly in patients with contraindication to thrombolytic therapy or at high risk for surgical thrombectomy. Catheter-based thrombus removal can be achieved by many means such as suction, fragmentation, extraction or rheolytic thrombectomy. We present a case of an elderly lady who suffered from acute massive pulmonary embolism with hemodynamic compromise successfully treated with AngioVac catheter system (AngioDynamics, Albany, NY) with full recovery.

Fungal Endocarditis: Update on Diagnosis and Management

Fungal endocarditis is an extremely debilitating disease associated with high morbidity and mortality. Candida spp. are the most common isolated organisms in fungal endocarditis. It is most prevalent in patients who are immunosuppressed and intravenous drug users. Most patients present with constitutional symptoms, which are indistinguishable from bacterial endocarditis, hence a high index of suspicion is required for pursuing diagnosis. Diagnosis of fungal endocarditis can be very challenging: most of the time, blood cultures are negative or take a long time to yield growth. Fungal endocarditis mandates an aggressive treatment strategy. A medical and surgical combined approach is the cornerstone of therapy.

A distinctly rare case of candida endocarditis involving the bioprosthetic pulmonary and the Eustachian valve diagnosed on 3D transesophageal echocardiography.

*Department of Medicine, University of Arizona, Tucson, Arizona; †Division of Cardiology, Department of Medicine, University of Arizona, Tucson, Arizona; ‡Division of Infectious Disease, Department of Medicine, University of Arizona, Tucson, Arizona; §Division of Cardiothoracic Surgery, Department of Surgery, University of Arizona, Tucson, Arizona; and ¶Department of Pathology and Medicine, University of Arizona, Tucson, Arizona

Symptomatic radial artery thrombosis successfully treated with endovascular approach via femoral access route

Radial access has been increasingly utilized for coronary intervention due to higher safety profile in comparison to femoral access site with lower bleeding rate. Radial artery occlusion is not uncommon with radial access site. This usually does not lead to any harm due to ulnar artery collaterals that are sufficient to prevent hand ischemia and is usually left alone. However, in the case of significant hand ischemia, treatment is often necessary. We are reporting an interesting case of symptomatic radial artery thrombosis leading to arm ischemia that was successfully treated percutaneously using femoral access. Using femoral access for radial artery intervention has not been reported previously. This case is followed by review of the literature.

Comparison of tricuspid annular plane systolic excursion with fractional area change for the evaluation of right ventricular systolic function: a meta-analysis

Background Accurate determination of right ventricular ejection fraction (RVEF) is challenging because of the unique geometry of the right ventricle. Tricuspidannular plane systolic excursion (TAPSE) and fractional area change (FAC) are commonly used echocardiographic quantitative estimates of RV function. Cardiac MRI (CMRI) has emerged as the gold standard for assessment of RVEF. We sought to summarise the available data on correlation of TAPSE and FAC with CMRI-derived RVEF and to compare their accuracy. Methods We searched PubMed, EMBASE, Web of Science, CINAHL, ClinicalTrials.gov and the Cochrane Library databases for studies that assessed the correlation of TAPSE or FAC with CMRI-derived RVEF. Data from each study selected were pooled and analysed to compare the correlation coefficient of TAPSE and FAC with CMRI-derived RVEF. Subgroup analysis was performed on patients with pulmonary hypertension. Results Analysis of data from 17 studies with a total of 1280 patients revealed that FAC had a higher correlation with CMRI-derived RVEF compared with TAPSE (0.56vs0.40, P=0.018). In patients with pulmonary hypertension, there was no statistical difference in the mean correlation coefficient of FAC and TAPSE to CMR (0.57vs0.46, P=0.16). Conclusions FAC provides a more accurate estimate of RV systolic function (RVSF) compared with TAPSE. Adoption of FAC as a routine tool for the assessment of RVSF should be considered, especially since it is also an independent predictor of morbidity and mortality. Further studies will be needed to compare other methods of echocardiographic measurement of RV function.

Myocardial Infarction Related to a Coronary Artery Aneurysm

CLINICAL PRESENTATION The patient was hemodynamically stable on admission with a heart rate of 98 beats/min and blood pressure of 140/80 mm Hg. There was no jugular venous distension. All peripheral pulses were palpable, and no cardiac murmurs were auscultated. There were no diagnostic electrocardiographic changes. However, her troponin I level was increasing, peaking at 34.0 ng/mL. She received aspirin, clopidogrel, and statin on presentation. Transthoracic echocardiography showed no obvious wall motion abnormality, and ejection fraction was 55%. Because she had no cardiovascular risk factors, a low Thrombolysis in Myocardial Infarction score, no significant electrocardiogram changes, and high troponins, the clinical suspicion was acute myocarditis. Cardiac magnetic resonance was performed, which showed focal transmural delayed myocardial enhancement in the mid-inferolateral segment without any associated myocardial edema (Figure 1A). These findings were consistent with focal myocardial infarction in the inferolateral territory. In this patient with no established coronary artery disease risk factors, we opted for a noninvasive evaluation of the coronary arteries. Computed tomography angiography was performed, which showed a small aneurysmal dilatation in the mid portion of an obtuse marginal artery (Figure 1B). The location of the aneurysm correlated with the vascular

A systematic review and meta-analysis of endovascular versus open surgical revascularization for chronic mesenteric ischemia

Background: Despite the enthusiasm for endovascular revascularization for chronic mesenteric ischemia (CMI), it is not clear if early benefits offset long‐term patency rates. This systematic review aimed to provide an up‐to‐date comprehensive evidence synthesis evaluating the two approaches. Methods: We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus through July 15, 2016, for studies that compared the endovascular with the open surgical approach for revascularization in CMI patients. We conducted a random‐effects meta‐analysis to pool outcomes of interest across studies. Results: We included 100 observational studies (22 comparative, 78 noncomparative; 18,726 patients; mean age, 69 years). Open surgery was associated with a statistically significant increase in the risk of in‐hospital complications (relative risk [RR], 2.2; 95% confidence interval [CI], 1.8‐2.6) and a nonsignificant increase in mortality at 30 days (RR, 1.57; 95% CI, 0.84‐2.93). Open surgery was associated with lower risk of 3‐year recurrence rates (RR, 0.47; 95% CI, 0.34‐0.66) and a similar 3‐year survival. Data from noncomparative studies provided similar inferences. The quality of evidence was low. Conclusions: Observational evidence suggests that the endovascular approach for revascularization in patients with CMI may offer better early outcomes than open surgery, although this effect may not be durable. Long‐term mortality appears to be similar.

Dual-Time-Point FDG PET/CT to Distinguish Coccidioidal Pulmonary Nodules from Those Due to Malignancy

It has been estimated that there are approximately 150,000 coccidioidal infections every year in the United States. The vast majority of these are acquired in coccidioidal endemic regions, including the San Joaquin Valley of California, the south central portion of Arizona, and some areas of Nevada, Utah, and Texas. A frequent outcome of pulmonary coccidioidomycosis is the development of a pulmonary nodule. Currently, there are no reliable noninvasive methods that can distinguish a coccidioidal pulmonary nodule from one due to other causes, including a malignancy. This frequently results in the need to perform a biopsy with its attendant risks. Recently, Reyes and colleagues published the results of a retrospective study demonstrating the utility of assessment of the uptake of fluorodeoxyglucose (FDG) by positron emission tomography with computed axial tomography (FDG PET/CT) at a single time point in differentiating coccidioidal lung nodules from those due to malignancy, but only when the uptake of FDG was very high [1]. Dual-time-point imaging (DTPI) employing FDG PET/CT is a promising next step forward in differentiating benign from malignant lesions [2]. This discrimination is related to the differences in the activity of the enzyme glucose-6-phosphatase (G6PD) in inflammatory compared to malignant nodules. Malignant cells have low enzyme activity and so continue to accumulate FDG over time, resulting in continued uptake on delayed imaging; the opposite occurs in inflammation, where there are relatively high levels of activity of G6PD [3] (Fig. 1). Two studies of DTPI FDG PET/CT have already demonstrated positive results in differentiating benign from malignant lesions [4, 5], but these did not include cases of coccidioidomycosis. A prospective study of DTPI FDG PET/CT among subjects with pulmonary nodules in the coccidioidal endemic could result in the development of a non-invasive method for distinguishing coccidioidal from malignant lesions and lead to a low-risk diagnostic test for this common clinical problem in the coccidioidal endemic region.

Depression in Heart Failure: Is It Well Recognized?

To the Editor: Heart failure (HF) is a serious entity affecting not only the physical health but also the mental health of individuals. Approximately 5 million people in the United States have HF.1 In the midst of guideline-directed therapy and prevention of hospital readmission for HF, depression often is underrecognized because the symptoms of HF and depression overlap. The prevalence of depression in HF ranges from 30% to 46% and varies with the stage in the New York Heart Association classification system.2 While managing HF, physicians should pay special attention to the presence of depression as a comorbid condition because it is associated with poorer clinical outcomes and increased mortality. Depressed patients often exercise poor self-care, which leads to reduced adherence to daily weight monitoring and dietary and fluid restriction, causing the worsening of HF. The direct and indirect costs for management of HF in the United States are estimated to be approximately

Acute severe aortic regurgitation: Imaging with pathological correlation

33 billion and depression accounts for 36% higher costs of care in patients with HF.3 Timely diagnosis and effective management of depression could lessen the economic burden of HF.4 As such, utilization of a periodic screening tool for patients with HF is highly recommended. The American Heart Association recommends screening cardiac patients for depression with at least the Patient Health Questionnaire (PHQ-2). It is not time consuming andwas found to have 90% sensitivity and 69% specificity for major depression in these patients.3 The cornerstone for management of depression includes psychosocial support, daily exercise, and pharmacotherapy, especially selective serotonin reuptake inhibitors. These therapies should be initiated at the initial encounter when the diagnosis of depression is made. Referral to a psychiatrist is necessary if there are refractory, psychotic, or manic symptoms. The optimal management of a patient with HF and depression requires collaboration among the cardiologist, primary care physician, and psychiatrist.