Mohammad El-Hajjar

Incidence of Contrast-Induced Nephropathy in Patients With Chronic Renal Insufficiency Undergoing Multidetector Computed Tomographic Angiography Treated With Preventive Measures

Contrast-induced nephropathy (CIN) is associated with adverse outcomes. Strategies for its prevention have been evaluated for patients undergoing invasive coronary and peripheral angiography, including treatment with N-acetylcysteine, sodium bicarbonate, and use of iso-osmolar nonionic contrast. Recently, multidetector computed tomographic angiography (MDCTA) of the coronary and peripheral arteries has been introduced as an accurate method for assessing vascular stenosis and has been widely adopted for assessment of outpatients with suspected coronary artery disease or peripheral arterial disease. To date, the incidence of CIN in outpatients with chronic renal insufficiency (CRI) treated with CIN-preventive strategies undergoing MDCTA remains unknown. Thus, we evaluated the incidence of CIN in outpatients with CRI (creatinine 1.5 to 2.5 mg/dl) undergoing MDCTA using CIN-preventive measures; 400 patients with CRI (78.5% men, mean age 76 years, 41% with diabetes) underwent MDCTA with iodixanol for detection of coronary artery disease or peripheral arterial disease (mean contrast volume 101 cc). CIN was defined as a nonallergic creatinine increase of >0.5 mg/dl. Creatinine levels were obtained before and 3 to 5 days after MDCTA; the average creatinine levels were 1.80 mg/dl and 1.75 mg/dl, respectively (p = NS), with an average change of -0.03 mg/dl. In the study cohort, only 7 patients (1.75%) experienced a creatinine increase >0.5 mg/dl, satisfying the definition of CIN. In conclusion, multivariate analysis, diabetes was the only predictor for CIN (odds ratio 5.9, 95% confidence interval 1.0 to 33.3, p = 0.045). No patient required hemodialysis. In conclusion, in patients with CRI undergoing MDCTA and receiving CIN-preventive measures, the incidence of CIN is low.

Myocardial Performance Index Correlates with Right Ventricular Ejection Fraction Measured by Nuclear Ventriculography

Background: Assessment of right ventricular (RV) ejection fraction (EF) by two‐dimensional echocardiography (2D ECHO) is practical but limited because of complex geometry of the RV. Techniques used for accurate measurement of RV EF are invasive or costly. However, derivation of 2D ECHO Doppler parameters to estimate RV function could be useful and inexpensive. Methods: RV EF measured by nuclear ventriculography was compared with 2D ECHO estimates of myocardial performance index (MPI) and peak tricuspid annular systolic velocity (PTASV). Linear regression analysis and sensitivity analysis were used to analyze the data. Results: RV EF measured by nuclear ventriculography correlated with MPI significantly (r =–0.55, P = 0.005) but not with PTASV (r = 0.09, P = 0.69). Using abnormal RV EF <45% measured by nuclear ventriculography, the sensitivity and specificity for MPI > 0.50 were 45.4% and 100%, respectively. The sensitivity and specificity of PTASV ≤ 17.25 cm/sec in detecting abnormal RV EF were 100% and 35.4%. Conclusion: MPI greater than 0.50 indicates that RV function is abnormal and a value of PTASV > 17.25 cm/sec indicates normal RV function.

A rare case of paradoxical embolism causing myocardial infarction: Successfully aborted by aspiration alone

A 58-year-old male presented with severe substernal chest pain along with bilateral lower extremity pain. He was tachycardic, tachypneic, and hypoxic with tender right calf. Electrocardiogram showed ST elevation in anterior-lateral leads. Emergency coronary angiography revealed widely patent proximal left anterior descending (LAD) artery and total distal occlusion with an abrupt cut-off. The remaining coronary arteries did not have significant disease. An Export aspiration catheter was used and thrombus was aspirated from the LAD with return of TIMI flow grade 3 and normalization of the ST elevations. Doppler ultrasound revealed deep vein thrombosis; transthoracic echocardiogram using agitated saline echocontrast showed a patent foramen ovale. Nearly 5% of patients with ST elevation myocardial infarction do not have demonstrable atherosclerosis by coronary angiography; paradoxical coronary embolism is among the leading causes in such cases. Paradoxical embolism to the coronary tree is under diagnosed and its antemortem diagnosis is difficult. Information regarding appropriate management of myocardial infarction due to coronary embolism is scant. Aspiration of intracoronary thrombus provides good clinical results, avoiding clot fragmentation and balloon injury associated with angioplasty. We present a rare case of antemortem diagnosis of paradoxical embolism to the coronary artery successfully treated with aspiration alone.

Simultaneous transapical transcatheter aortic valve replacement and transcatheter mitral valve replacement for native valvular stenosis.

Transcatheter aortic valve replacement (TAVR) is well established for patients who cannot undergo surgery (Leon et al., N Engl J Med 2010;363:1597) or are high risk for surgery (Smith et al., N Engl J Med 2011;364:2187–2198). Experience with the TAVR procedure has led to recent reports of successful transcatheter mitral valve replacement (TMVR) procedures (Cheung et al., J Am Coll Cardiol 2014;64:1814; Seiffert et al., J Am Coll Cardiol Interv 2012;5:341–349) separately or simultaneously with the TAVR. However, these reports were of simultaneous valve‐in‐valve procedures (Cheung Anson, et al. J Am Coll Cardiol 2013;61:1759–1766). A recent report from Portugal also reported simultaneous transpical implantation of an inverted transcatheter aortic valve‐in‐ring in the mitral position and transcatheter aortic valve (Hasan et al., Circulation 2013;128:e74–e76). There has been an experience of TMVR only in native mitral valve for mitral valve stenosis, but none in both aortic and mitral valves. We report the first in human case of simultaneous transapical TAVR and TMVR in native valves secondary to valvular stenosis. Our patient was not a candidate for percutaneous balloon mitral valvuloplasty secondary to a high Wilkins Score. Sizing of the aortic valve was based on the transesophageal echocardiogram (TEE), whereas sizing of the mitral valve was based on TEE measurements and balloon inflation during left ventriculography.

Aortic valvuloplasty via the radial artery: Case reports and review of the literature

The use of balloon aortic valvuloplasty (BAV) has increased with the development of transcatheter aortic valve implantation (TAVI) to medically optimize patients prior to procedure. It has been traditionally done by a retrograde approach via the femoral artery or an antegrade approach via the femoral vein. Large sheaths have been required with traditional balloons which require large vessel access. Use of a low profile compliant valvuloplasty balloon has been demonstrated to have adequate BAV results with smaller sheath sizes. We review the literature and report two cases where low profile compliant valvuloplasty balloons were used to perform BAV via the radial artery in patients without adequate femoral arterial access.

Solitary cardiac metastasis from primary oral squamous cell carcinoma presenting as ST-elevation MI

Cardiac metastases from oral squamous cell carcinoma (SCC) are rare, especially in the absence of systemic metastasis. We describe a case of a patient presenting with chest pain and ECG abnormalities concerning for ST-elevation myocardial infarction that eventually was found to have an incidental right ventricular mass on chest CT angiogram. Ultimately, she had an intracardiac echocardiography-assisted biopsy diagnosis of isolated cardiac metastasis from primary oral SCC. The extent of the disease precluded any surgical intervention, and the patient subsequently transitioned to hospice care. Most cardiac metastases remain clinically silent until widespread systemic disease leads to death. Thus, cardiac metastasis should be considered in a patient with SCC who develops new cardiovascular symptoms or conduction abnormalities.