David Min

Reversible cerebral vasoconstriction syndrome: Is it more than just cerebral vasoconstriction?

Background Systemic vascular alterations have not been described in reversible cerebral vasoconstriction syndrome (RCVS). We present a case series of RCVS patients having cardiac dysfunction during ictus, with a subset showing complete resolution of cardiomyopathy. Methods Retrospective case-series: Cardiac left ventricular ejection fraction (LVEF) and wall motion abnormalities (WMA) visualized on transthoracic echocardiography (TTE), performed during RCVS ictus and follow-up was analyzed. Results Of 68 patients, 18 (26%) had a TTE performed around ictus. Three of 18 (17%) patients demonstrated WMA on initial TTE. All three patients were female without previous coronary artery disease or heart failure, and were asymptomatic from the cardiac dysfunction. WMA resolved completely on follow-up in Patients 1 and 2. Global LV dysfunction persisted for at least 90 days in Patient 3. Conclusion Although the exact pathophysiology of the cardiomyopathy is uncertain, it may be related to localized coronary vasoconstriction causing myocardial ischemia/infarction. Vasoconstriction may not be limited to the cerebral vasculature and may involve extracerebral organs. Cardiac ventricular abnormalities may be a part of the RCVS spectrum.

Degenerative Mitral Stenosis: Unmet Need for Percutaneous Interventions

Degenerative mitral stenosis (DMS) is an important cause of mitral stenosis, developing secondary to severe mitral annular calcification. With the increase in life expectancy and improved access to health care, more patients with DMS are likely to be encountered in developed nations. These patients are generally elderly with multiple comorbidities and often are high-risk candidates for surgery. The mainstay of therapy in DMS patients is medical management with heart rate control and diuretic therapy. Surgical intervention might be delayed until symptoms are severely limiting and cannot be managed by medical therapy. Mitral valve surgery is also challenging in these patients because of the presence of extensive calcification. Hence, there is a need to develop an alternative percutaneous treatment approach for patients with DMS who are otherwise inoperable or at high risk for surgery. In this review, we summarize the available data on the epidemiology of DMS and diagnostic considerations and current treatment strategies for these patients.

Diagnosis of peri-valvular abscess by FDG PET/CT imaging in a Bentall aortic root

The diagnosis of infection within a prosthetic aortic root can be challenging to make when overt gas and fluid collection is not present on computed tomography (CT). Transesophageal echocardiography (TEE) is an essential tool for the interrogation of the aortic root when there is concern for endocarditis, however, it can be difficult to identify peri-valvular abscess by this modality. Fluorodeoxyglucose positron emission tomographycomputed tomography (FDG PET/CT) has been effective in identifying thoracic aortic graft infections and endocarditis by demonstrating inflammation in areas of nonspecific soft tissue and fluid accumulation.

RV Function: Trying to Listen to Second Fiddle

Until the late 20th century, many viewed the right ventricle (RV) as a subordinate to its muscular sibling. Emerging from this long-standing role as second fiddle to the left ventricle (LV), several treatises have since been written regarding the RV’s role in cardiopulmonary disease [(1–3)][1].

Pathological Evidence of Cardiac Papillary Fibroelastoma in a Retrieved Intracranial Embolus

Approximately one-quarter of all cardiac tumors present with systemic embolization. Cardiac papillary fibroelastomas (CPF) represent a potential embolic source, accounting for 8% of all primary cardiac tumors, second in frequency after cardiac myxomas. Most case reports describe papillary fibroelastoma as a potential source for stroke, but histopathological evidence of actual tumor fragment causing a stroke is lacking. We describe a case of histologically confirmed CPF mechanically retrieved from a cerebral artery during an emergent cerebral endovascular procedure with subsequent discovery of the CPF in the heart, providing in vivo demonstration of intracranial embolization of this cardiac tumor.

Transesophageal Echocardiographic-Guided Cardioversion

The incidence and prevalence of atrial fibrillation (AF) continues to grow especially as the population ages. The uncoordinated atrial activation and subsequent ineffective atrial contraction is a strong stimulus for left atrial (LA) thrombus formation especially in the LA appendage. AF is associated with increased risk of stroke, heart failure, and all-cause mortality. The presence of LA thrombus in AF portends a poor prognosis. Direct current cardioversion (DCCV) is the most effective method of restoring sinus rhythm and, with it there is relief of symptoms, improved LV filling, reversed atrial remodeling, and possibly reduced cardio-embolic risk. However, there are significant risks of systemic embolization following DCCV if LA thrombus is present. Transesophageal echocardiography (TEE) is an ideal non-invasive imaging modality to detect thrombus in the LA and especially in the LA appendage. Its proper use can lead to earlier DCCV for AF and improve safety of DCCV in AF. A key part of this strategy is proper use of anticoagulation therapy. This chapter illustrates the important role of TEE in patient evaluation and risk stratification prior to cardioversion.

Mitral Valve Adaptation in Ischemic Heart Disease

Literature is the art of discovering something extraordinary about ordinary people, and saying with ordinary words something extraordinary.—Boris Pasternak [(1)][1] The same can be said about scientific insights. In fact, profound scientific discoveries are often based on systematic approaches to

Extensive stretching of intracranial aneurysm coil causing TIAs

A 58-year-old man with a history of ruptured posterior cerebral artery aneurysm, repaired with coil embolization 5 years previously, presented with right hemi-numbness lasting 30 minutes. Cerebral MRI did not reveal acute stroke. CT angiogram showed a stretched wire complex extending through the posterior communicating artery, down the carotid artery, and into the most inferior visualized portion of descending aorta, terminating in a loosely coiled wire (figure, A and B). A transesophageal echocardiogram showed evidence of a possible thrombus on the coil in the aortic arch (figure, C and D; video on the Neurology® Web site at Neurology.org). Coil stretching and migration is a rare complication of endovascular coil repair1,2 and can predispose to embolic events.

APPROPRIATE AND INAPPROPRIATE IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR THERAPY IN PATIENTS WITH HYPERTROPHIC CARDIOMYOPATHY: INCIDENCE AND PREDICTORS

Previously described risk factors (RF) serve as reference for recommending implantable cardioverter-defibrillator (ICD) therapy in hypertrophic cardiomyopathy (HCM) patients for sudden cardiac death (SCD) prevention. In consecutive HCM patients with ICD placement, we sought to study the incidence &