James L. Gentry

Transient Constrictive Pericarditis: Current Diagnostic and Therapeutic Strategies

Transient constrictive pericarditis is increasingly recognized as a distinct sub-type of constrictive pericarditis. The underlying pathophysiology typically relates to impaired pericardial distensibility, associated with acute or sub-acute inflammation, rather than the fibrosis or calcification often seen in chronic pericardial constriction. Accordingly, patients may present clinically with concomitant features of pericarditis and constrictive physiology. Non-invasive multimodality imaging is advocated for diagnosis of transient constrictive pericarditis. Echocardiography remains the mainstay for initial evaluation of the dynamic features of constriction. However, cardiac magnetic resonance imaging can provide complimentary functional information, with the addition of dedicated sequences to assess for active pericardial edema and inflammation. Although transient pericardial constriction can spontaneously resolve, institution of anti-inflammatory therapy may hasten resolution or even prevent progression to chronic pericardial constriction. Non-steroidal anti-inflammatory agents remain the initial treatment of choice, with subsequent consideration of colchicine, steroids, and other immune-modulating agents in more refractory cases.

Ranolazine for Treatment of Angina or Dyspnea in Hypertrophic Cardiomyopathy Patients (RHYME)

Hypertrophic cardiomyopathy (HCM), the most common inherited heart disease, is associated with ventricular arrhythmias and diastolic dysfunction secondary to electrophysiological signal abnormalities. Specifically, myocytes in HCM have prolonged action potentials, primarily during phase 2, which

The Role of Stress Echocardiography in Valvular Heart Disease: A Current Appraisal

Stress echocardiography is a widely available, safe, low-cost, versatile imaging modality which is becoming increasingly recognized as a valuable tool in the assessment of patients with native and prosthetic left-sided valvular heart disease. It provides a quantitative assessment to help guide clinical decision-making when discordance exists between symptoms and severity of valve disease. Exercise (treadmill or bicycle) remains the preferred stress modality, but pharmacological augmentation with dobutamine can be used if needed. Low-dose dobutamine stress echocardiography is specifically valuable in patients with low-flow, low-gradient aortic stenosis when attempting to differentiate true severe aortic stenosis from pseudo-severe aortic stenosis. Stress echocardiography not only identifies high-risk features that indicate need for earlier surgery, it also provides useful information for the peri- and postoperative period, including long-term outcome, risk stratification to guide monitoring frequency, and offers guidance for eligibility in competitive sports participation. As research continues to expand the utility of stress echocardiography in the management of patients with valvular heart disease, future research should focus on the recognition of newer parameters identifying high-risk features including subsequent validation in a large population.

Ascending Aortic Dimensions in Former National Football League AthletesCLINICAL PERSPECTIVE

Background— Ascending aortic dimensions are slightly larger in young competitive athletes compared with sedentary controls, but rarely >40 mm. Whether this finding translates to aortic enlargement in older, former athletes is unknown. Methods and Results— This cross-sectional study involved a sample of 206 former National Football League (NFL) athletes compared with 759 male subjects from the DHS-2 (Dallas Heart Study-2; mean age of 57.1 and 53.6 years, respectively, P<0.0001; body surface area of 2.4 and 2.1 m2, respectively, P<0.0001). Midascending aortic dimensions were obtained from computed tomographic scans performed as part of a NFL screening protocol or as part of the DHS. Compared with a population-based control group, former NFL athletes had significantly larger ascending aortic diameters (38±5 versus 34±4 mm; P<0.0001). A significantly higher proportion of former NFL athletes had an aorta of >40 mm (29.6% versus 8.6%; P<0.0001). After adjusting for age, race, body surface area, systolic blood pressure, history of hypertension, current smoking, diabetes mellitus, and lipid profile, the former NFL athletes still had significantly larger ascending aortas (P<0.0001). Former NFL athletes were twice as likely to have an aorta >40 mm after adjusting for the same parameters. Conclusions— Ascending aortic dimensions were significantly larger in a sample of former NFL athletes after adjusting for their size, age, race, and cardiac risk factors. Whether this translates to an increased risk is unknown and requires further evaluation.

A rare cause of ischaemia in late adulthood: multimodal imaging of an anomalous origin of left coronary artery from the pulmonary artery

A 62-year-old female with no cardiovascular history presented with months of angina and exertional dyspnoea. Regadenoson single photon emission computed tomography (SPECT) demonstrated a moderate inducible anterior perfusion defect ( Panel F ). Subsequent coronary angiogram demonstrated a large (>10 mm), tortuous, ectatic right coronary artery (RCA) with collaterals to the left main coronary artery (LMCA) emptying into the main pulmonary artery (MPA; Panel A , see Supplementary material online, Video S1 ). Right heart catheterization revealed pulmonary hypertension (mean PA 35 mmHg), elevated pulmonary arterial oxygen saturation (78%) and shunt fraction of 1.53. Transthoracic and transoesophageal echocardiograms …

Exercise N-13 cardiac positron emission tomography myocardial perfusion imaging detecting ischemia in an adult patient with anomalous aortic origin of the left main coronary artery from the right coronary sinus

Anomalous aortic origin of a coronary artery is a rare congenital condition that has variable presentations from atypical chest pain to syncope and cardiac arrest. Commonly used myocardial perfusion imaging techniques, stress agents, and perfusion agents may have limited ability to detect inducible ischemia in this rare patient group. We herein describe a unique case of anomalous left main coronary artery from a common right coronary sinus ostium with a subpulmonic and intramyocardial course. This patient had multiple atypical chest pain presentations and multiple-negative pharmacologic single-photon emission-computed tomography stress tests performed. Significant ischemia was detected via N-13 exercise cardiac positron emission tomography and with surgical intervention she had resolution of her symptoms.

Iatrogenic Left Circumflex Coronary Artery Fistula after Mitral Valve Replacement

Graphical abstract

Clinical Features, Natural History and Management of Pericardial Cysts

With the increased use of medical imaging, there has been an increase in the numbers of pericardial cysts identified. However, there is a paucity of data regarding the clinical course for pericardial cysts. Hence, we aimed to study the clinical features and natural history of pericardial cysts. We retrospectively studied all patients with the diagnosis of pericardial cysts based on computed tomography (CT) chest or cardiac magnetic resonance imaging (CMR) between 2008 and 2014. The maximum diameter of the cyst was measured at the initial study (CT/CMR) and was compared with the most recent follow-up imaging modality of the same type if available. A change in the maximum diameter more than 10% was considered significant. We included 103 patients in the study; 89% were asymptomatic and 67% were females. Twenty-nine asymptomatic patients had repeat imaging with the same modality (CT/CMR) with a mean follow-up of 23 months. The maximum cyst diameter decreased by a mean of 25% in 34% of the patients and increased by a mean of 13% in 17% of the patients. The remaining patients (48%) had no significant change. All 29 patients remained asymptomatic. In conclusion, most pericardial cyst cases were asymptomatic. On repeat imaging, approximately 1/3 of pericardial cysts were found to decrease in size, whereas interval enlargement was infrequent and unlikely to be clinically relevant. Therefore, within the limitations of our study, serial imaging in asymptomatic patients with CT or CMR does not appear to impact management decisions.

PERICARDIAL CYSTS: DO THEY GROW OVER TIME?

Pericardial cyst is an uncommon mass that represents approximately 5% of thoracic cysts. A majority of the pericardial cysts are asymptomatic and usually detected incidentally. Natural history of pericardial cyst is poorly defined in the literature. We sought to understand the characteristics and

Hot stuff: a rare diagnosis of a mitral valve mass confirmed on cardiac fludeoxyglucose positron emission tomography

A 29-year-old male with chest pain was incidentally found to have an anterior mitral valve leaflet mass during tomographic screening for pulmonary embolism. His history included pre-cursor B-cell acute lymphoblastic leukaemia, with multiple extramedullary relapses, despite chemotherapy and matched sibling donor stem cell transplant. His treatment was complicated by acute graft vs. host disease …