Christopher B. Overgaard

Fatal cardiomyopathy after revision total hip replacement for fracture of a ceramic liner

Symptomatic cobalt toxicity from a failed total hip replacement is a rare but devastating complication. It has been reported following revision of fractured ceramic components, as well as in patients with failed metal-on-metal articulations. Potential clinical findings include fatigue, weakness, hypothyroidism, cardiomyopathy, polycythaemia, visual and hearing impairment, cognitive dysfunction, and neuropathy. We report a case of an otherwise healthy 46-year-old patient, who developed progressively worsening symptoms of cobalt toxicity beginning approximately six months following synovectomy and revision of a fractured ceramic-on-ceramic total hip replacement to a metal-on-polyethylene bearing. The whole blood cobalt levels peaked at 6521 µg/l. The patient died from cobalt-induced cardiomyopathy. Implant retrieval analysis confirmed a loss of 28.3 g mass of the cobalt-chromium femoral head as a result of severe abrasive wear by ceramic particles embedded in the revision polyethylene liner. Autopsy findings were consistent with heavy metal-induced cardiomyopathy.We recommend using new ceramics at revision to minimise the risk of wear-related cobalt toxicity following breakage of ceramic components.

Hip Pain and Heart Failure: The Missing Link

A man presented with hypothyroidism, dilated cardiomyopathy, a pericardial effusion, liver failure, and polycythaemia. He had a history of bilateral hip replacements and new-onset hip pain. The patient progressed to develop shock. Given his acutely profound illness and constellation of symptoms, as well as the history of hip replacement, a diagnosis of cobalt toxicity was made.

Surgical Management of a Left Anterior Descending Pseudoaneurysm Related to Behcet's Disease

A 22-year-old woman suffering from Behcets disease and severe angina was diagnosed with a left anterior descending coronary artery giant pseudoaneurysm. Preoperative investigations, surgical management, and its principles, as well as specific postoperative follow-up considerations are described.

Outcome of previous tricuspid valve operation and arrhythmias in adult patients with congenital heart disease

BACKGROUNDnTricuspid valve operation or replacement has been associated with high perioperative mortality and poor long-term results. The prevalence of atrial arrhythmias before and after operation in these patients is undefined.nnnMETHODSnWe retrospectively examined the outcome and frequency of atrial arrhythmias in 85 adult patients (46% men) with congenital heart defects who underwent tricuspid valve operation between 1961 and 1995.nnnRESULTSnThe majority had either Ebsteins anomaly (22%), congenitally corrected transposition (19%), tetralogy of Fallot (15%), atrial (13%), or ventricular (11%) septal defects. Forty-two (49%) patients had sustained arrhythmias within 1 year before operation. After tricuspid valve operation, 21 patients (50%) had recurrence of atrial arrhythmias, and 7 in preoperative sinus rhythm developed late rhythm disturbances. Multivariate analysis identified age at operation and preoperative arrhythmias as independent predictors of late arrhythmias. Perioperative mortality was 5%, and there were seven late deaths. Survival was 91% at 5 years, and 83% at 10 years.nnnCONCLUSIONSnSurgical intervention does not prevent recurrence of atrial arrhythmias. Tricuspid valve operation in patients with congenital heart disease can be performed with a low risk of perioperative mortality and good long-term outcome.

The accuracy of noninvasive stress myocardial imaging for detecting coronary artery disease in clinical practice.

Abstract Background: There is a wide variation in reported accuracy of noninvasive stress myocardial imaging as a screening tool for coronary artery disease (CAD). This study was undertaken to determine its current accuracy in a wide spectrum of patients with chest pain syndromes using invasive coronary angiography as the gold standard. Methods: The patient population consisted of consecutive patients undergoing coronary angiography in whom noninvasive stress imaging, either nuclear or echocardiographic, was performed within 6 months prior to the angiogram. The specificity, sensitivity, positive and negative predictive values, and diagnostic accuracy for detecting ≥ 1 lesions with ≥ 50% diameter coronary stenosis were determined for each modality. Results: Of the 227 eligible patients, 141 were men and 86 were women; 70% had significant CAD. The diagnostic accuracy overall was 71% and was no different for nuclear or echocardiographic testing. The positive predictive value (86% vs 52%; P = 0.002) and diagnostic accuracy (83% vs 51%; P = 0.002) were better in men than in women. Interpretation: In this study, noninvasive stress imaging lacked the accuracy of a good screening test for significant CAD. This finding was particularly true for women, for whom it was not much better than a coin toss.

A Patient With Kawasaki's Disease and Increasing Breathlessness.

Kawasaki disease (KD) is an acute systemic vasculitis of unknown etiology that affects mainly children. Treatment is aimed at suppressing vascular inflammation during the acute phase of illness and preventing long-term myocardial ischemia. Cardiovascular events affect the long-term outcome. Aneurysm