Gilbert Boswell

Fatty liver disease is associated with underlying cardiovascular disease in HIV‐infected persons*

Cardiovascular disease is an increasing concern among HIV‐infected persons and their providers. We determined if fatty liver disease is a marker for underlying coronary atherosclerosis among HIV‐infected persons.

Clinically significant incidental findings among human immunodeficiency virus-infected men during computed tomography for determination of coronary artery calcium.

Those infected with the human immunodeficiency virus (HIV) have a greater risk of cardiovascular disease and might undergo computed tomographic (CT) scans for early detection. Incidental findings on cardiac CT imaging are important components of the benefits and costs of testing. We determined the prevalence and factors associated with incidental findings on CT scans performed to screen for coronary artery calcium (CAC) among HIV-infected men. A clinically significant finding was defined as requiring additional workup or a medical referral. A total of 215 HIV-infected men were evaluated. Their median age was 43 years; 17% were current tobacco users; the median CD4 count was 580 cells/mm(3); and 83% were receiving antiretroviral medications. Also, 34% had a positive CAC score of >0. An incidental finding was noted among 93 participants (43%), with 36 (17%) having ≥1 clinically significant finding. A total of 139 findings were noted, most commonly pulmonary nodules, followed by granulomas, scarring, and hilar adenopathy. Most of the incidental findings were stable on follow-up, and no malignancies were detected. The factors associated with the presence of an incidental finding in the multivariate model included increasing age (odds ratio 1.6 per 10 years, p <0.01), positive CAC score (odds ratio 2.3, p <0.01), and current tobacco use (odds ratio 2.5, p = 0.02). In conclusion, incidental findings were common among HIV-infected men undergoing screening CT imaging for CAC determination. The incidental findings were more common among older patients and those with detectable CAC.

Recurrent Takotsubo cardiomyopathy

We present the case of a 71-year-old woman with Takotsubo Cardiomyopathy as imaged with a dual source multidetector CT, MRI, and follow-up echocardiography. This demonstrates normal coronary arteries by use of CT angiography, and a 3D perspective of abnormal mid left ventricular hypokinesis and apical left ventricular akinesis.

The association of epicardial adipose tissue with coronary artery calcification among HIV-infected men.

Little data exist regarding the association of epicardial adipose tissue (EAT) and cardiovascular disease among HIV-infected persons. Among 213 HIV-infected men, there was a significant association between protease inhibitor use and increasing EAT volume. EAT was significantly associated with coronary artery calcium greater than 100. The elevated coronary artery disease risk in HIV-infected men may be partially explained by EAT associated with protease inhibitor use.

Right ventricular outflow tract pseudoaneurysm: two cases.

Right ventricular pseudoaneurysm is a rare complication following repair of Tetralogy of Fallot. Presented are two patients, both with history of Tetralogy of Fallot, successful repair and pseudoaneurysms discovered on symptomatic follow up. Because surgical intervention is often required, the location and characteristics of the pseudoaneurysm are critical determinants of successful outcomes. Cardiac gated CT provides physicians with an invaluable tool in evaluating pseudoaneurysms.

Cardiac Gated Computed Tomography Used to Confirm Iatrogenic Aortic Valve Leaflet Perforation after Mitral Valve Replacement

Aortic insufficiency from iatrogenic valve perforation from nonaortic valve operations is rarely reported despite the prevalence of these procedures. Rapid diagnosis of these defects is essential to prevent deterioration of cardiac function. In this paper, we describe a young man who reported to our institution after two open cardiac surgeries with new aortic regurgitation found to be due to an iatrogenic perforation of his noncoronary aortic valve cusp. This defect was not appreciated by previous intraoperative transesophageal echocardiography and was inadequately visualized on follow-up transthoracic and transesophageal echocardiograms. In contrast, cardiac gated computed tomography clearly visualized the defect and its surrounding structures. This case highlights the utility of cardiac gated computed tomography for cases of suspected valvular perforation when echocardiography is not readily available or inadequate imaging is obtained.

An unusual cause of postpartum abdominal pain: case report.

Abdominal pain is a common presenting complaint in the Emergency Department. It extends to all populations regardless of age, sex, or socioeconomic status. After gathering a history and examining the patient, most Emergency Physicians form a differential diagnosis and initiate an appropriate work-up. However, in the postpartum woman, additional causes must be considered and treated accordingly, knowing that there are consequences for both mother and child. We present a case of a postpartum woman presenting with right-sided abdominal pain, the cause of which, although atypical, has potential for significant morbidity and mortality if it goes undiscovered.

Adiponectin Levels and Coronary Artery Disease among HIV-Infected Men

Objective: HIV-infected persons frequently experience lipodystrophy and are at higher risk of cardiovascular disease, but the impact of adipose-related hormones, such as adiponectin, on Coronary Artery Disease (CAD) remains unclear. We evaluated the association of plasma adiponectin levels and the presence of CAD. Design: A cross-sectional study among HIV-infected men in a large HIV clinic. Methods: HIV-infected participants underwent CT scan imaging to determine CAD as measured by Coronary Artery Calcium (CAC) scores categorized as no detectable disease (0), minimum disease (1-100), and significant disease (>100). Factors associated with CAD, including adiponectin levels, were evaluated using multivariate logistic regression modeling. Results: 213 HIV-infected men were evaluated with a median age of 43 years, median CD4 count of 583 cells/ mm3, and 69% had HIV RNA 100 (p=0.09). Adiponectin levels were inversely correlated with lipohypertrophy, hypertension, and triglyceride levels (p<0.05), while FRS was marginally correlated (X2=3.1, p=0.08). In the final multivariate model, increasing age (OR 3.8 per 10 year increase, 95% CI 2.56-5.71, p<0.001) was significantly associated with CAC, and adiponectin approached significance (OR 0.8 per 1 μg/ml increase, 95% CI 0.69-1.00, p=0.05). Conclusions: Low adiponectin levels are common among HIV-infected persons. Adiponectin is correlated with lipohypertrophy and lower levels approached significance with CAD. Understanding the role of adiponectin in the pathogenesis of CAD may allow for targeted treatment and prevention strategies among HIV-infected persons.

Letter by Harrell et al Regarding Article, “Prevalence of Subclinical Coronary Artery Disease in Masters Endurance Athletes With a Low Atherosclerotic Risk Profile”

We read with interest the recent study by Merghani et al1 on subclinical coronary artery atherosclerosis in masters endurance athletes. We wonder if the presence of myocardial bridges was noted distal to the regions of atherosclerosis, or related to areas of infarction noted on cardiac magnetic resonance imaging. The prevalence of myocardial bridges is common, estimated …

Development and Early Experience of the First Joint Military Health System–Veterans Affairs Transcatheter Aortic Valve Replacement Program

BACKGROUND Transcatheter aortic valve replacement (TAVR) is a minimally invasive cardiac surgical procedure that has revolutionized the treatment of aortic stenosis. This is the most common valvular heart condition in developed countries, affecting 3.4% of those ages 75 and above. Because there is no medical therapy that can arrest progression of the disease, valve replacement forms the cornerstone of therapy. METHODS Naval Medical Center San Diego and the VA San Diego Healthcare System have developed a unique collaborative TAVR program-a first in the Department of Defense-to offer this revolutionary procedure to their beneficiaries. Herein, we review development of the program and outcome for patients referred during the first 9 months. FINDINGS Development of the program was a multiyear process made successful because of administrative support, facility upgrades, and collaboration within the crossfacility and multispecialty heart valve team. In the first 9 months, 29 patients were referred for evaluation. Twenty-two (average age 80 years) underwent TAVR, whereas others were deemed nonoperable or were pending disposition at the time of this report. Patients who underwent TAVR had a predicted risk of procedural mortality from surgical aortic valve replacement of 7.7%, similar to other trials and registry studies. After mean follow-up of 5.6 months (range 30-355 days), zero deaths were recorded in the patients who underwent TAVR. Compared to other nonfederal local institutions, the program also realized a cost savings of approximately 17%, or nearly