Michael Ghannam

Ankle-brachial Index as a Clinical Tool

A 62-year-old woman with a medical history of smoking, hypertension, osteoarthritis, and diabetes presents to her primary care physician for evaluation of leg pain. She reports lower-extremity discomfort and fatigue that is exertional in nature but does not consistently resolve on rest. Physical examination reveals a blood pressure of 151/85 mm Hg, pulse rate of 75 beats/min, weak and thready popliteal pulses and posterior tibial pulses, and mild tenderness to palpation of her hips but no musculoskeletal weakness. There is a normal pattern of hair growth on her shins bilaterally with areas of light brown scaly patches throughout. Cardiopulmonary examination reveals clear lungs to auscultation bilaterally with good effort, a normal s1/s2 with no murmurs or gallops, and a laterally displaced point of maximal impulse. What tests can help in the evaluation of this patient’s leg pain?

Current Interest in Careers in Surgery and Cardiothoracic Surgery From the Millennial Generation

OBJECTIVE Interest in cardiothoracic surgery (CTS) as a career has decreased over the past decade. Anecdotal evidence suggests that many surgeons develop an interest in CTS before medical school and even before college. This study evaluates the interest of high-school students at a magnet high school, with regard to careers in medicine, in surgery, and in CTS. DESIGN A survey assessing career interests and values was conducted among junior and senior high-school students. Students were given a 1-hour presentation by a cardiothoracic (CT) surgeon on the postgraduate training process and then completed a postpresentation survey. SETTING A magnet math and science high school, the Kalamazoo Area Mathematics and Science Center. PARTICIPANTS Of 128 students, 117 (91% response rate) completed the survey. RESULTS Overall, 38% of students reported having a high interest in medicine; of this group, 58% reported a high interest in surgery and 36% reported having a high interest in CTS. Men were more likely than women were to have a high interest in surgery and CTS (p < 0.001). Students with at least 1 family member as a physician vs those without were more likely to be interested in medicine, surgery, and CTS and also have a higher level of concern for postgraduation debt (p < 0.01). Women were more likely than men were to have a high level of concern about postgraduation debt (p = 0.018). After a presentation by a CT surgeon, students showed no changes in interest in medicine careers but did report an increased level of knowledge about the process of becoming a CT surgeon, going from 31% to 72%. CONCLUSIONS There exists a large interest in both surgery and CTS at the high-school level, but there may be a need for more active outreach to maintain and foster their interest in surgery and CTS through undergraduate and medical school.

Correlation between computer tomography-derived scar topography and critical ablation sites in postinfarction ventricular tachycardia

Myocardial wall thickness (WT) in patients with a prior myocardial infarction has been used to indicate scarring. However, the correlation of WT with sites critical to ventricular tachycardia (VT) has not been previously investigated. The purpose of this study was to correlate electroanatomic mapping data obtained during VT ablation with WT determined by cardiac computed tomography (CT).

Reduced Myocardial Flow Reserve by Positron Emission Tomography Predicts Cardiovascular Events After Cardiac Transplantation

Background: We evaluated the diagnostic and prognostic value of quantification of myocardial flow reserve (MFR) with positron emission tomography (PET) in orthotopic heart transplant patients. Methods and Results: We retrospectively identified orthotopic heart transplant patients who underwent rubidium-82 cardiac PET imaging. The primary outcome was the composite of cardiovascular death, acute coronary syndrome, coronary revascularization, and heart failure hospitalization. Cox regression was used to evaluate the association of MFR with the primary outcome. The relationship of MFR and cardiac allograft vasculopathy severity in patients with angiography within 1 year of PET imaging was assessed using Spearman rank correlation and logistic regression. A total of 117 patients (median age, 60 years; 71% men) were identified. Twenty-one of 62 patients (34%) who underwent angiography before PET had cardiac allograft vasculopathy. The median time from orthotopic heart transplant to PET imaging was 6.4 years (median global MFR, 2.31). After a median of 1.4 years, 22 patients (19%) experienced the primary outcome. On an unadjusted basis, global MFR (hazard ratio, 0.22 per unit increase; 95% confidence interval, 0.09–0.50; P<0.001) and stress myocardial blood flow (hazard ratio, 0.48 per unit increase; 95% confidence interval, 0.29–0.79; P=0.004) were associated with the primary outcome. Decreased MFR independently predicted the primary outcome after adjustment for other variables. In 42 patients who underwent angiography within 12 months of PET, MFR and stress myocardial blood flow were associated with moderate–severe cardiac allograft vasculopathy (International Society of Heart and Lung Transplantation grade 2–3). Conclusions: MFR assessed by cardiac rubidium-82 PET imaging is a predictor of cardiovascular events after orthotopic heart transplant and is associated with cardiac allograft vasculopathy severity.

Indications and appropriate selection of novel oral anticoagulants in patients with atrial fibrillation

### Learning objectives Atrial fibrillation (AF) is the most common cardiac arrhythmia and the incidence and prevalence of this disease are rising.1 2 It is estimated that by the year 2050 there will be over 7.5 million patients with AF in the USA alone.3 This disease carries a significant risk of morbidity and mortality driven in large part by the development of heart failure and thromboembolism.4 Oral anticoagulation therapy is effective in reducing risk of stroke and systemic embolism and is the standard of care for patients undergoing either a rhythm or rate control strategy. For years warfarin has been the mainstay of stroke prophylaxis. More recently, direct-acting oral anticoagulants (DOACs) have entered the marketplace.5 Their site of action within the coagulation cascade is outlined in figure 1.6 7 These newer agents have rapidly been incorporated into modern practice,8 though there remains a role for warfarin among various subgroups. Selecting an appropriate agent is a complex decision and must take account a patient’s comorbidities, preference for dosing and monitoring, concern over the lack of a specific antidote, and importantly, financial constraints. Figure 1 Overview of the coagulation system and sites of action of novel oral anticoagulants. The extrinsic pathway is activated by the exposure of tissue factor-expressing cells to blood through vascular injury. The intrinsic pathway is activated by the binding of factor IXa to factor VIIIA on anionic cell surfaces to form the intrinsic tenase complex. Activated platelets provide binding sites for this interaction. These processes then proceed through a common pathway ultimately resulting in activated …

Conservative management of an elderly patient with Eisenmenger syndrome

Background Eisenmenger syndrome (ES) in the adult population has become exceedingly rare in developed countries owing to better recognition and treatment of congenital malformations of the heart. In the absence of transplantation, most patients survive an average of 20-30 years before succumbing to the cardiovascular and hemostatic sequelae. We present a rare case of an elderly woman with ES secondary to an uncorrected atrial-septum defect. She continues to have a high functional capacity despite impressive hemodynamic parameters. Case A 69-year-old woman with ES presented to our facility with atrial fibrillation and volume overload. She has a known sinus venosus atrial septal defect and associated severe pulmonary hypertension. She was managed conservatively and discharged on bosentan given her intricate physiology. Conclusion Given the similarity of the pathology with idiopathic pulmonary arterial hypertension (IPAH) and ES, drugs that are usually reserved for IPAH such as prostanoids and phosphodiesterase type 5 inhibitors may be beneficial in the management of ES. This case highlights that with our improving understanding of ES, non-operative management may have an expanding role in the care of these complex patients.<Learning objective: Advanced therapy for Eisenmenger syndrome (ES) is geared toward the endothelin-1 mediated pulmonary arterial plexus. Given the similarity of the pathology with idiopathic pulmonary arterial hypertension (IPAH) and ES, drugs that are usually reserved for IPAH such as prostanoids and phosphodiesterase type 5 inhibitors may be beneficial in the management of ES. Conservative management can achieve a favorable outcome, even in elderly patients with advanced disease.>.

HOSPITAL LEVEL VARIATIONS IN EPISODE COSTS FOR ATRIAL FIBRILLATION

Atrial fibrillation is a potential target for bundled payment payer models due to high costs and variations in management. We wished to understand the variability and drivers of cost of AF related episodes of care. The Michigan Value Collaborate maintains a claims-based registry providing payment

Multiparametric assessment of left atrial remodeling using 18F-FDG PET/CT cardiac imaging: A pilot study

BackgroundLeft atrial (LA) remodeling is associated with structural, electric, and metabolic LA changes. Integrated evaluation of these features in vivo is lacking.MethodsPatients undergoing 18F-fluorodeoxyglucose (FDG) PET-CT during a hyperinsulinemic-euglycemic clamp were classified into sinus rhythm (SR), paroxysmal AF (PAF), and persistent AF (PerAF). The LA was semiautomatically segmented, and global FDG uptake was quantified using standardized uptake values (SUVmax and SUVmean) in gated, attenuation-corrected images and normalized to LA blood pool activity. Regression was used to relate FDG data to AF burden and critical patient factors. Continuous variables were compared using t-tests or Mann-Whitney tests.Results117 patients were included (76% men, age 66.4 ± 11.0, ejection fraction (EF) 25[22-35]%) including those with SR (n = 48), PAF (n = 55), and PerAF (n = 14). Patients with any AF had increased SUVmean (2.3[1.5-2.4] vs 2.0[1.5-2.5], P = 0.006), SUVmax (4.4[2.8-6.7] vs 3.2[2.3-4.3], P < 0.001), uptake coefficient of variation (CoV) 0.28[0.22-0.40] vs 0.25[0.2-0.33], P < 0.001), and hypometabolic scar (32%[14%-53%] vs 16.5%[0%-38.5%], P = 0.01). AF burden correlated with increased SUVmean, SUVmax, CoV, and scar independent of age, gender, EF, or LA size (P < 0.03 for all).ConclusionsLA structure and metabolism can be assessed using FDG PET/CT. Greater AF burden correlates with the increased LA metabolism and scar.

Feasibility and Usability of a Mobile Application to Assess Symptoms and Affect in Patients with Atrial Fibrillation: A Pilot Study

Background Atrial fibrillation (AF) is the most prevalent arrhythmia leading to hospital admissions. The majority of patients with AF report symptoms that are believed to be associated with the arrhythmia. The symptoms related to AF traditionally are collected during a clinic visit that is influenced by biases associated with recalling the experience over a limited period of time. Purpose We designed this pilot study to assess the usability and feasibility of a mobile application to assess symptoms in patients with AF. Methods We designed a mobile application (miAfib) to assess symptoms (chest pain, palpitation, shortness of breath, fatigue, dizziness/lightheadedness), positive affect (happy, excited, content) and negative affect (worried, angry, sad) on multiple occasions throughout the day based on iOS platform. We performed a four-week feasibility trial to examine user adherence, acceptance and experiences with the mobile application. We administered questionnaires to assess factors affecting usage and self-reported acceptance of the application based on a five-point Likert scale with zero representing strongly disagree and 5 representing strongly disagree with. Results We included ten patients with paroxysmal and persistent AF. The mean number of completed assessments each day was 2.81 ± 1.59 with 94.7% of days with at least one assessment. The users found the application easy to use (4.75±0.46), intended to use it in the future (4.37±1.06) and found it easy to integrate into daily routine (4.5±1.07). Conclusion In this pilot study, we found participants in this four-week trial reliably used the application and were able to use the app to report their daily symptoms and affect regularly. Participants reported that they found the application easy to use and would consider using the application in the future.