Mustafain Meghani

Neutrophil to lymphocyte ratio and cardiovascular diseases: a review.

The role of inflammatory markers in cardiovascular diseases has been studied extensively and a consistent relationship between various inflammatory markers and cardiovascular diseases has been established in the past. Neutrophil to lymphocyte ratio (NLR) is a new addition to the long list of these inflammatory markers. NLR, which is calculated from complete blood count with differential, is an inexpensive, easy to obtain, widely available marker of inflammation, which can aid in the risk stratification of patients with various cardiovascular diseases in addition to the traditionally used markers. It has been associated with arterial stiffness and high coronary calcium score, which are themselves significant markers of cardiovascular disease. NLR is reported as an independent predictor of outcome in stable coronary artery disease, as well as a predictor of short- and long-term mortality in patients with acute coronary syndromes. It is linked with increased risk of ventricular arrhythmias during percutaneous coronary intervention (PCI) and higher long-term mortality in patients undergoing PCI irrespective of indications of PCI. In patients admitted with advanced heart failure, high NLR was reported with higher inpatient mortality. Recently, NLR has been reported as a prognostic marker for outcome from coronary artery bypass grafting and postcoronary artery bypass grafting atrial fibrillation.

Access-site complications and their management during transradial cardiac catheterization.

Transradial access for cardiac catheterization is now widely accepted among the invasive cardiology community as a safe and viable approach with a markedly reduced incidence of major access-related complications compared with the transfemoral approach. As this access technique is now being used more commonly for cardiac catheterization, it is of paramount importance to be aware of its complications and to understand their prevention and management. Some of the common complications of transradial access include asymptomatic radial artery occlusion, nonocclusive radial artery injury and radial artery spasm. Among these complications, radial artery spasm is still a significant challenge. Symptomatic radial arterial occlusion, pseudoaneurysm and radial artery perforation are rarely reported complications of the transradial approach. Early identification of these rare complications and their immediate management is of vital importance. Arteriovenous fistula, minor nerve damage and complex regional pain syndrome are very rare but have been reported. Recently, granulomas have been reported to be associated with the use of a particular brand of hydrophilic sheaths during the procedure. Generally, access-site complications can be minimized by avoiding multiple punctures, selection of smaller sheaths, gentle catheter manipulation, adequate anticoagulation, use of appropriate compression devices and avoiding prolonged high-pressure compression. In addition, careful observation for any ominous signs such as pain, numbness and hematoma formation during and in the immediate postprocedure period is essential in the prevention of catastrophic hand ischemia.

Association Between Coronary Artery Disease Diagnosed by Coronary Angiography and Breast Arterial Calcifications on Mammography: Meta-Analysis of the Data

BACKGROUND Previous studies evaluating breast arterial calcifications (BAC) as a risk marker for coronary artery disease (CAD) have been limited by sample size and have yielded mixed results. Our objective was to evaluate the association of BAC and CAD. METHODS Data sources included Medline (1970-2010), the Cochrane Controlled Trials Register electronic database (1970-2010), and CINAHL (1970-2010). The search strategy included the keywords, breast artery calcification, vascular calcification on mammogram, coronary angiography, and meta-analysis. Eligible studies included female patients who had undergone coronary angiography, the gold standard for diagnosing CAD, and had screening mammograms that revealed the presence or absence of BAC. Information on eligibility criteria, baseline characteristics, results, and methodologic quality was extracted by two reviewers. Disagreements were resolved by consensus. RESULTS A total of 927 patients were enrolled in the five studies. There was a 1.59 (95% confidence interval [CI] 1-21-2.09) increased odds of angiographically defined CAD in patients with BAC seen on mammography. CONCLUSIONS The presence of BAC on mammography appears to increase the risk of having obstructive CAD on coronary angiography; thus, BAC may not be a benign finding.

An unusual case of giant cardiac fibroelastoma mimicking left atrial myxoma in a patient presenting with syncope

Cardiac papillary fibroelastomas are the most common primary valvular tumors. Generally benign, they account only for about 10% of all primary cardiac neoplasms, can occur in normal or diseased hearts, and are associated strongly with open heart surgery and radiotherapy. They are, in most cases, incidental findings, but can be discovered after syncope. We report the case of an elderly female, who was referred for syncope and was found to have a large fibroelastoma at the mitral valve annulus, intermittently obstructing the left ventricular inflow tract, and mimicking the presentation of left atrial myxoma. This case illustrates another potential mechanism of syncope in patients with fibroelastomas.

Thymoma Presenting as Chest Pain

CLINICAL PRESENTATION A 75-year-old ex-smoker male with hypertension and diabetes presented to the emergency room with pressure-like, midsternal, nonradiating chest pain for 2 hours, not associated with dyspnea, diaphoresis, palpitations, fever and pleurisy. Electrocardiogram and cardiac enzymes were normal. Chest x-ray revealed a rounded mass along the left heart border (Figure 1A). A contrast-enhanced computed tomography scan of the chest defined it as a well-circumscribed, solid, lobulated anterior mediastinal mass measuring 6.2 [times] 5.3 [times] 9.5 cm consistent with thymoma (Figure 1B). Patient underwent a radical thymectomy that involved en-block resection of the tumor, 10.5 cm in greatest dimension, with adherent portion of the lung, mediastinal fat and portion of the pericardium (Figure 1C). Histopathology confirmed it as a Modified Masaoka Stage III, WHO Type A Thymoma with focal tumor extension into lung parenchyma and mediastinal fat (Figure 1D). Although tumor margins were uninvolved, the distance of tumor from the closest margin was only 0.5 mm. Therefore, the patient was referred to Radiation Oncology and was treated with 30 sessions of radiotherapy. After radiation therapy, the patient remains tumor-free and is being monitored at regular intervals for reoccurrence. Thymoma is a rare tumor. It originates within the epithelium of thymus and generally arises in the anterior mediastinum, where it represents 50% of all anterior mediastinal masses. Onethird to half of the patients are asymptomatic, one-third are diagnosed during a workup for myasthenia gravis and the remaining cases present with chest pain, cough, hoarseness, dysphagia or superior vena cava syndrome. Complete surgical resection, when feasible, is the preferred therapeutic modality. Chemotherapy and radiotherapy are used for patients with residual disease after resection or with histopathology revealing thymic carcinoma. Patients with locally advanced disease may undergo initial chemotherapy with re-evaluation for possible surgery afterward. Patients presenting with metastatic disease are treated with chemotherapy initially. Prognosis depends upon Masaoka Staging and WHO Histologic Classification. Surveillance is usually performed annually with computed tomography scan of the chest.

A Rare Case of Double-Chambered Right Ventricle Associated with Ventricular Septal Defect and Congenital Absence of the Pulmonary Valve

Double-chambered right ventricle (DCRV) is a rare congenital heart disorder involving 2 different right ventricle (RV) pressure compartments that is often associated with ventricular septal defect (VSD). Usually, the obstruction is caused by an anomalous muscle bundle crossing the RV from the interventricular septum to the RV free wall. We are reporting a case of double-chambered right ventricle associated with ventricular septal defect and congenital absence of the pulmonary valve, a rare form of congenital infundibular pulmonary stenosis. In addition to ventricular septal defect, our patient had congenital absence of the pulmonary valve, which is very unusual and has never been reported to our knowledge.

EFFICACY AND SAFETY OF PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS TREATMENT ON CHOLESTEROL LEVELS: A COMPREHENSIVE META-ANALYSIS OF ALL RANDOMIZED CLINICAL TRIALS

Recent clinical trials have demonstrated concomitant lipid lowering treatments (LLT) with Proprotein Convertase Subtilisin/Kexin type 9 inhibitors (PCSK9I) effective in reducing blood LDL levels in hypercholesterolemia. We conducted a meta-analysis to assess the efficacy and safety of PCSK9I. A

EFFICACY AND SAFETY OF PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS TREATMENT IN FAMILIAL HYPERCHOLESTEROLEMIA: A COMPREHENSIVE META-ANALYSIS OF ALL RANDOMIZED CLINICAL TRIALS

Clinical trials have demonstrated concomitant lipid lowering treatments (LLT) with Proprotein Convertase Subtilisin/Kexin Type 9 inhibitors (PCSK9I) effective in reducing LDL levels in patients suffering from familial hypercholesterolemia (FH). We conducted a meta-analysis to assess the efficacy and

9.1 cm abdominal aortic aneurysm in a 69-year-old male patient

We are presenting a case of one of the largest un-ruptured abdominal aortic aneurysm ever reported. Presented here is a rare case of a 69-year-old active smoker male with history of hypertension and incidental diagnosis of abdominal aortic aneurysm of 6.2 cm in 2003, who refused surgical intervention at the time of diagnosis with continued smoking habit and was managed medically. Patient was subsequently admitted in 2012 to the hospital due to unresponsiveness secondary to hypoglycemia along with diagnosis of massive symptomatic pulmonary embolism and non-ST elevation myocardial infarction. With the further inpatient workup along with known history of abdominal aortic aneurysm, subsequent computed tomography scan of abdomen pelvis revealed increased in size of infrarenal abdominal aortic aneurysm to 9.1 cm of without any signs of rupture. Patient was unable to undergo any surgical intervention this time because of his medical instability and was eventually passed away under hospice care.

A palpable pulse does not exclude radial artery occlusion in patients with previous arterial cannulation

ogy laboratory (Fig. 1). We then opted to proceed via the right femoral artery approach that was uneventful. Arterial duplex of the right radial artery was performed. The radial artery was found to be patent only proximally with evidence of total occlusion at the wrist. No pseudoaneurysm or arterio-venous fistula was noted (Fig. 2). A hypercoagulability work up was negative. Histopathology study confirmed that the specimen is a well organized thrombus. Radial artery thrombosis is not an uncommon complication of transradial coronary angiography. Incidence is the highest in the first few days following the procedure and is up to 10.5 % in some series (3). It tends to decrease shortly after discharge (4). However, late thrombosis still occurs in 2.5% to 5% of cases (2, 4, 5). Also, this complication can be seen with any arterial canalization as in this case after arterial line placement. Catheter manipulation induces a cascade of inflammatory events leading to intimal hyperplasia (6) and thrombus formation. Larger sheath diameter is associated with slow antegrade flow and acute radial artery occlusion (2, 7). Sheath length or coating does not seem to affect radial occlusion rates (8). Prolonged and tight compression at the access site may also lead to acute or chronic radial artery occlusion (8,9). Absent radial flow during compressive bandages removal is a major and independent predictor of radial artery occlusion at follow-up (10). A full history including intensive care unit stay, arterial line insertions, and arterial blood gases drawing should alert the operator to a potential occlusion prior to a transradial approach. Assessment of radial artery patency is performed using ultrasound or pulse oximeter signal in the index finger during ipsilateral ulnar compression (1-2). In an attempt to spare the left radial artery for possible use in coronary bypass grafts or hemodialysis access (11), or in situations where femoral access is not recommended or contraindicated, “canalization” of an early occluded right radial artery using various wires and aspiration devices is possible (12,13). While our patient presented weeks after an initial transradial arterial line placement, a recanalization was not an option. A palpable pulse does not exclude radial artery occlusion in patients with previous arterial cannulation