Chandra K. Nair

Cardiac papillary fibroelastoma: a comprehensive analysis of 725 cases

BACKGROUND With the advent of echocardiography, cardiac papillary fibroelastoma (CPF) is being increasingly reported. The demographics, clinical characteristics, pathological features, treatment, and prognosis of CPF are examined. DATA COLLECTIONS Cases, case series and related articles on the subject in all languages were identified through a comprehensive literature search. RESULTS AND CONCLUSIONS Seven hundred twenty-five cases of CPF were identified. Males comprised 55% of patients. Highest prevalence was in the 8th decade of life. The valvular surface was the predominant locations of tumor. The most commonly involved valve was the aortic valve, followed by the mitral valve. The left ventricle was the predominant nonvalvular site involved. No clear risk factor for development of CPF has been reported. Size of the tumor varied from 2 mm to 70 mm. Clinically, CPFs have presented with transient ischemic attack, stroke, myocardial infarction, sudden death, heart failure, presyncope, syncope, pulmonary embolism, blindness, and peripheral embolism. Tumor mobility was the only independent predictor of CPF-related death or nonfatal embolization. Symptomatic patients should be treated surgically because the successful complete resection of CPF is curative and the long-term postoperative prognosis is excellent. The symptomatic patients who are not surgical candidates could be offered long-term oral anticoagulation, although no randomized controlled data are available on its efficacy. Asymptomatic patients could be treated surgically if the tumor is mobile, as the tumor mobility is the independent predictor of death or nonfatal embolization. Asymptomatic patients with nonmobile CPF could be followed-up closely with periodic clinical evaluation and echocardiography, and receive surgical intervention when symptoms develop or the tumor becomes mobile.

Long-term follow-up of patients with echocardiographically detected mitral anular calcium and comparison with age- and sex-matched control subjects

One hundred seven patients with echocardiographically documented mitral anular calcium (MAC) and 107 age- and sex-matched control subjects without MAC were studied and followed for a mean of 4.4 +/- 2.4 (standard deviation) years. Fourteen (7%) patients were lost to follow-up. Compared with the control group, patients with MAC had higher frequency of precordial murmurs (p less than 0.0001), cardiomegaly (p less than 0.0001), left atrial enlargement (p less than 0.0001), and rhythm and conduction disturbances (p less than 0.0001). During the follow-up, patients with MAC had higher incidence of valve replacement (p less than 0.0025), permanent pacemaker implantation (p less than 0.0025), congestive heart failure (p less than 0.0001), thromboembolic cerebrovascular event (p less than 0.01), sudden death (p less than 0.001) and total cardiac death (p less than 0.0001). However, the frequencies of myocardial infarction, coronary artery bypass surgery and angioplasty, endocarditis or noncardiac death were not significantly different between patients with MAC and the control subjects. Thus, patients with MAC have higher frequencies of precordial murmurs, cardiomegaly, left atrial and ventricular enlargement, rhythm and conduction disturbances. They more frequently undergo valve replacement and permanent pacemaker implantation, develop congestive heart failure and die of cardiac causes than age- and sex-matched control subjects.

Clinical characteristics of patients younger than 60 years with mitral anular calcium: Comparison with age- and sex-matched control subjects

The clinical characteristics of 107 patients younger than 60 years with mitral anular calcium (MAC) were compared with those of 107 age- and sex-matched control subjects. The patients with MAC included 55 men and 52 women, mean age 51 years. The control group included 55 men and 52 women, mean age 51 years. Patients with MAC had a higher prevalence of cardiomegaly on chest x-ray (p less than 0.0001), left atrial and left ventricular enlargement by echocardiography (p less than 0.0001), precordial murmurs (p less than 0.0001), diabetes mellitus (p less than 0.0001), systemic hypertension (p less than 0.025) and total conduction defects on surface electrocardiograms (p less than 0.0001) compared with the age- and sex-matched control subjects. The mean serum phosphorus and product of serum calcium and phosphorus were higher in patients with MAC (p less than 0.0025) than in the control subjects. The prevalence of coronary heart disease, aortic stenosis and hypertrophic cardiomyopathy and the mean serum cholesterol, triglyceride, total protein, albumin, creatinine, alkaline phosphatase and calcium levels were not significantly different between patients with MAC and the control subjects.

Digoxin-lnduced positive exercise tests: Their clinical and prognostic significance

Abstract To evaluate the influence of digoxin on the results of exercise testing and the prognostic significance of digoxin-induced positive exercise tests, 98 healthy men, aged 22 to 70 years, were studied. All had normal initial exercise test results. All took digoxin, 0.25 mg daily, for 14 days, and then performed daily exercise tests until each had a negative test response. Five years after these initial tests, a medical history was obtained from 92 of the 98 subjects, and 76 subjects performed repeat exercise tests. Six subjects were lost to follow-up study. Twenty-five percent of subjects (22 of 98) had a digoxin-induced positive exercise test. There was a direct relation between age and the incidence of digoxin-positive tests. The incidence of digoxin-positive tests in men over age 60 years was 100 percent. By 30 seconds after exercise no subject had greater than 1.9 mm S-T depression. No test remained positive for more than 6 minutes after exercise was discontinued. No test was positive 12 days after digoxin was withdrawn. With logistic regression analysis, it was possible to estimate the probability that a subject would have a digoxin-induced positive test. No subject had had a cardiovascular event at follow-up study, but five subjects had a positive repeat exercise test. Four of these subjects had had a digoxin-positive test initially. It is concluded that (1) useful information can be obtained from exercise studies of patients who receive digoxin, (2) the probability that a positive exercise test is due to digoxin can be estimated, (3) to remove the exercise-induced electrocardiographic effect, the drug should be withdrawn for 12 days, and (4) digoxin may unmask subclinical coronary arterial stenosis.

Clinical and echocardiographic characteristics of patients with mitral anular calcification. Comparison with age- and sex-matched control subjects.

The clinical and echocardiographic features of 104 patients (53 women and 51 men) with mitral anular calcification (MAC) were compared with those of 121 age- and sex-matched control subjects (62 women and 59 men) without MAC. The incidence of coronary artery disease, rheumatic heart disease, systemic hypertension, and diabetes mellitus was similar in both groups. Patients with MAC had a greater incidence of cardiomegaly (p less than 0.001), cardiac conduction defects (p less than 0.001), and aortic outflow tract murmurs (p less than 0.005) than did control patients. Patients with MAC and without aortic root calcification had a higher incidence (p less than 0.001) of conduction defects than did patients with aortic root calcification without MAC. Control patients with and without aortic root calcification had a similar incidence of conduction defects. A higher incidence of atrioventricular block (p less than 0.025) and bundle branch block or left anterior hemiblock or intraventricular conduction defect (p less than 0.05) was present in anterior MAC than in posterior MAC. In conclusion, patients with MAC have a higher incidence of cardiomegaly, cardiac conduction defects, and aortic outflow tract murmurs than a control group.

Diagnostic and prognostic significance of exercise-induced premature ventricular complexes in men and women: A four year follow-up

Two hundred eighty patients (197 men and 83 women) with normal rest electrocardiograms and no history of prior myocardial infarction were referred for evaluation of chest pain. It was found that exercise-induced premature ventricular complexes had a lower sensitivity, specificity, positive predictive value and negative predictive value in predicting significant coronary artery disease than exercise-induced ST segment depression greater than or equal to 1 mm. The incidence of exercise-induced premature ventricular complexes was not significantly different in patients with no significant coronary artery disease, single vessel disease or multivessel disease. The site of origin of exercise-induced premature ventricular complexes was not helpful in predicting the presence or severity of coronary artery disease. At a mean follow-up period of 47.1 months, exercise-induced premature ventricular complexes did not predict coronary events (cardiac death or nonfatal myocardial infarction) in men or women.

Cardiac conduction defects in patients older than 60 years with aortic stenosis with and without mitral anular calcium

The prevalence of conduction defects was investigated in 51 patients older than 60 years with aortic stenosis (AS) who underwent aortic valve replacement. Thirty one of the 51 patients, (61%) had associated mitral anular calcium (MAC). The mean age and prevalence of coronary artery disease, systemic hypertension and diabetes mellitus were similar in both groups. The prevalence of conduction defects (atrioventricular block, sinoatrial disease, bundle branch block, left anterior hemiblock or intraventricular conduction defect) was 18 of 31 (58%) in patients with MAC and 5 of 20 (25%) in patients without MAC (p less than 0.025). We conclude that patients older than 60 years with AS have a high prevalence of MAC, and that the prevalence of conduction defects is higher in patients older than 60 years with combined AS and MAC than in patients with AS without MAC.

Efficacy and safety of intrapleural instillation of alteplase in the management of complicated pleural effusion or empyema.

We investigated the efficacy and safety of intrapleural instillation of recombinant tissue plasminogen activator (Alteplase) in 120 patients with complicated pleural effusion (CPE) or empyema. These 120 patients had failed simple chest tube placement and conventional medical treatment. The patients included 52 with empyema, 41 with CPE, 10 with hemothorax, and 17 with complicated malignant pleural effusions. A total of 345 doses of Alteplase were instilled intrapleurally in these patients, with doses ranging from 10 to 100 mg daily. Most patients required 3 to 4 doses of alteplase. After Alteplase therapy, complete resolution of CPE/empyema occurred in 102 patients (85%), partial resolution in 10 patients (8%), and failure to respond in 8 patients (7%). All patients who failed to respond to Alteplase treatment had either chronic empyema or empyema associated with lung abscesses. Adverse effects of Alteplase therapy were chest pain in 7 patients (6%) and bleeding at the chest tube site in 2 patients (2%).

Assessment of neovascularization within carotid plaques in patients with ischemic stroke

AIM To assess neovascularization within human carotid atherosclerotic soft plaques in patients with ischemic stroke. METHODS Eighty-one patients with ischemic stroke and 95 patients without stroke who had soft atherosclerotic plaques in the internal carotid artery were studied. The thickest soft plaque in each patient was examined using contrast-enhanced ultrasound. Time-intensity curves were collected from 5 s to 3 min after contrast injection. The neovascularization within the plaques in the internal carotid artery was evaluated using the ACQ software built into the scanner by 2 of the experienced investigators who were blinded to the clinical history of the patients. RESULTS Ischemic stroke was present in 7 of 33 patients (21%) with grade I plaque, in 14 of 51 patients (28%) with grade II plaque, in 26 of 43 patients (61%) with grade III plaque, and in 34 of 49 patients (69%) with grade IV plaque (P < 0.001 comparing grade IV plaque with grade I plaque and with grade II plaque and P = 0.001 comparing grade III plaque with grade I plaque and with grade II plaque). Analysis of the time intensity curves revealed that patients with ischemic stroke had a significantly higher intensity of enhancement (IE) than those without ischemic stroke (P < 0.01). The wash-in time (WT) of plaque was significantly shorter in stroke patients (P < 0.05). The sensitivity and specificity for IE in the plaque were 82% and 80%, respectively, and for WT were 68% and 74%, respectively. There was no significant difference in the peak intensity or time to peak between the 2 groups. CONCLUSION This study shows that the higher the grade of plaque enhancement, the higher the risk of ischemic stroke. The data suggest that the presence of neovascularization is a marker for unstable plaque.

Ten-year results with the St. Jude medical prosthesis

Although the hemodynamic characteristics and durability of the St. Jude valve prosthesis have been reported, the need for and the degree of anticoagulation in patients who receive these valves remain uncertain. Our 10-year experience with 165 patients (100 men and 65 women, mean age of 58 +/- 13 years), who underwent valve replacement with St. Jude prostheses, is reported. Of the 165 patients, 147 were treated with warfarin. A prothrombin time 1.3 to 1.8 times control (range 15 to 20 seconds) was maintained in 134 patients with single valve and 1.8 to 2 times control (range 20 to 25 seconds) in 13 patients with double valve prostheses. The 10-year actuarial event-free incidence from thromboembolic and hemorrhagic complications was 84 and 95%, respectively. Of the 8 patients receiving antiplatelet therapy alone, 4 had thromboembolic events. Of the 10 patients on neither warfarin nor antiplatelet therapy, 3 had thromboembolic events. The 10-year actuarial event-free incidence from valve failure was 95%. The 10-year actuarial patient survival was 55%. Thus, the St. Jude valve is a safe and reliable prosthesis with acceptable overall long-term performance in patients given a modest anticoagulation regimen. Patients who receive St. Jude prosthetic valves without anticoagulants have a high incidence of thromboembolic events despite therapy with antiplatelet agents.