Obai Abdullah

Proximal balloon occlusion versus distal filter protection in carotid artery stenting: A meta-analysis and review of the literature

Carotid artery stenting (CAS) is typically performed using embolic protection devices (EPDs) as a means to reduce the risk of procedure‐related stroke. In this study, we compared procedural morbidity and mortality associated with distal (D‐EPD) vs. proximal (P‐EPD) protection.

Obesity and Cardiac Remodeling in Adults: Mechanisms and Clinical Implications

Obesity, particularly severe obesity is capable of producing hemodynamic alterations that contribute to changes in cardiac morphology which may predispose to impairment of ventricular function and heart failure. These include a high cardiac output state in most, left ventricular (LV) hypertrophy, and LV diastolic dysfunction. Right heart involvement may result from LV failure, the hypercirculatory state, and sleep disordered breathing. In recent years experimental studies and some studies in humans suggest that certain neurohormonal and metabolic alterations that occur commonly in obesity may contribute to alterations in cardiac structure and function. These include activation of the renin-angiotensin-aldosterone and sympathetic nervous systems, hyperleptinemia due to leptin resistance, low circulating adiponectin levels, insulin resistance with hyperinsulinemia, and possibly cardiac lipotoxicity. This review will describe the ways in which these factors weave together to promote adaptations and maladaptations that result in alterations in cardiac structure and function which may contribute to the development of heart failure.

ST-Elevation Myocardial Infarction in a Patient with Anomalous Left Anterior Descending Artery and Absent Left Circumflex

The left anterior descending artery originating from the right coronary sinus is very unusual. An absent left circumflex is very rare with a few reported cases in the literature. We report a combination of a non-dominant left anterior descending artery arising from the right coronary cusp and an absent left circumflex artery in a 60-year-old male presenting with ST-segment elevation myocardial infarction. The patient was managed by percutaneous intervention and recovered well. This case demonstrates an extremely rare combination of coronary anomalies.

Giant Negative T Waves and QT Prolongation in Non-cardiogenic Pulmonary Edema: A Case Report and Review of Literature

Giant negative T-waves have been linked to several cardiac and non-cardiac conditions. However, the presence of giant negative T-waves with QT prolongation in the setting of non-cardiogenic pulmonary edema is a rarely reported, female predominant, and poorly understood electrocardiographic phenomenon. We report a case of a 28-year-old white female who presented with acute diarrhea and was admitted due to acute kidney injury caused by a hemolytic uremic syndrome (HUS). She was managed with multiple blood product transfusions, plasma exchange, and hemodialysis. Subsequently, she developed acute pulmonary edema requiring intubation and urgent hemodialysis. During this acute event, a unique electrocardiographic finding of anterolateral giant negative T-wave and QT prolongation progressively developed and began resolving with the resolution of the pulmonary edema. In addition to our case, 12 cases were reported upon review of the literature with similar electrocardiography (ECG) findings in the setting of non-cardiogenic, non-ischemic pulmonary edema. Giant negative T-waves can be associated with non-cardiac pulmonary edema. Recognition of this rare Wellen’s-like electrocardiographic pattern in a patient without cardiac ischemia is crucial, especially in young females. Basic science and clinicopathological correlation studies are needed to understand the pathophysiology and prognosis behind these ECG findings.

Cough as the sole manifestation of pericardial effusion

A 59-year-old woman with paroxysmal atrial fibrillation (AF) presented with severe non-productive cough, malaise, low-grade fever and AF flare-up 3 weeks following pulmonary vein isolation with radiofrequency catheter ablation. She denied chest pain or dyspnoea. Patient was haemodynamically stable. There was no pulsus paradoxus. Laboratories showed leucocytosis and elevated C-reactive protein. ECG showed sinus tachycardia. CT abdomen and pelvis showed a large pericardial effusion (PE). Shortly after admission, she developed AF with rapid ventricular response, responsive to intravenous amiodarone. Transthoracic echocardiogram revealed 2.4 cm posterior PE without tamponade physiology, non-amenable to pericardiocentesis via sub-xiphoid approach. Patient underwent left thoracoscopic pericardial window with removal of 250 cc bloody fibrinous fluid. Cough improved significantly and she was discharged on oral amiodarone and apixaban. Repeat CT chest after 2 weeks for recurrent cough showed a small PE, treated with oral prednisone for suspected postablation pericarditis, with complete resolution of cough. Amiodarone was stopped without recurrence of AF.

Bivalirudin versus unfractionated heparin in peripheral vascular interventions

BACKGROUND A number of studies suggest that bivalirudin (BIV) is associated with similar efficacy but reduced bleeding when compared with unfractionated heparin (UFH) in patients undergoing peripheral vascular interventions (PVI). METHODS A comprehensive literature search was conducted with the electronic databases MEDLINE, EMBASE and CENTRAL. These were queried to identify studies comparing BIV with UFH in PVI. Study endpoints included total bleeding events, major and minor bleeding events and procedural success. Random-effects meta-analysis method was used to pool endpoint odds ratios (OR) for both UFH and BIV with 95% confidence intervals (CI). RESULTS A total of 12,335 patients (70.6 years; 59.7% male) were included from seven observational cohort studies (two prospective and five retrospective) comparing outcomes between BIV and UFH during PVI between January 2000 and May 2017. Compared with BIV, UFH was associated with significantly higher total bleeding, (OR 1.52 with 95% CI 1.11 to 2.09, p = 0.009), major bleeding (OR 1.38 with 95% CI 1.13 to 1.68, p = 0.002), and minor bleeding (OR 1.51 with 95% CI 1.09 to 2.08, p = 0.01). Procedural success rates were not different between the two groups (BIV vs HEP: OR 0.90 with 95% CI 0.49 to 1.64, p = 0.72) CONCLUSION: Compared with BIV, UFH was associated with more bleeding when used during PVI. There was no significant difference in procedural success between the two anticoagulation strategies.

Symptomatic anomalous left circumflex artery arising from the right coronary cusp

The anomalous origin of the left circumflex artery as an independent branch from the right coronary cusp is considered a rare variation. In the variant, the left anterior descending artery, left circumflex artery and right coronary artery arise from three different discrete ostia. The anomalous left circumflex artery course passes posterior to the aortic root through the atrioventricular groove to supply the lateral wall of the left ventricle. Despite the usual benign and asymptomatic course, the clinical importance of this anomaly is evident from its association with sudden cardiac death, syncope, and arrhythmias as a manifestation of myocardial ischemia [1]. We report a case of a 70-year-old male patient who presented to the emergency department with generalized fatigue and exertional dyspnea of 2-month duration. Past medical was significant for hypertension and hyperlipidemia. The patient’s blood pressure was managed with hydrochlorothiazide, hydralazine, lisinopril, and metoprolol prior to this presentation. Vitals on admission were significant for an elevated blood pressure of 180/112 mm Hg. Physical examination was otherwise unremarkable. Troponin levels were normal and an electrocardiogram (ECG) demonstrated minimal T wave inversion in the inferior leads. A low normal ejection fraction of 50% was observed on the echocardiogram with moderate left ventricular hypertrophy and asynchrony of the basal inferior wall. A technetium-99m sestamibi myocardial perfusion scan was performed and revealed a small, mild, reversible hypo-perfusion defect that involved the anteroapical and inferior basal regions. The study was followed by coronary artery angiography which revealed non-obstructive coronary artery disease (Figure 1). An incidental finding of an anomalous left circumflex artery originating from a separate ostium located at the right coronary cusp was noted during the study. The left circumflex artery had a completely separate origin from the right coronary artery. The medical therapy was optimized by adding amlodipine and increasing the metoprolol dose. He was followed at the cardiology clinic one month after discharge with a significant improvement in blood pressure (140/86 mm Hg), symptoms and overall functional status. The anomalous origin of the left circumflex artery from the right coronary system was first described by Antopol and Kugel in 1933 and has an estimated frequency of 0.32–0.67% [2]. The anomaly may be classified according to the site of origin into different subtypes: left circumflex artery arising as a direct branch from the right coronary artery (RCA), a common right system ostium bifurcating into the left circumflex artery and RCA, and, as in our case, RCA and left circumflex artery originating from two separate orifices. Complications of this anomaly with myocardial ischemia resulting in sudden cardiac death are a result of the slit-like ostia, angling from the retroaortic course of the vessel or compression of the anomalous artery by a dilated aorta [3]. We propose the latter as a cause of our patient’s chest discomfort and transient ischemia contributing to his stress test findings. Our case report illustrates the impact of cardiac supply demand mismatch that may be present in hypertensive patients with an anomalous left circumflex artery and can become deadly if not properly managed. The report further highlights the improvement of overall functional status with adequate control of blood pressure in this group of patients.

Hemorrhagic and ischemic outcomes of Heparin vs. Bivalirudin in carotid artery stenting: A meta-analysis of studies

Bivalirudin, has been shown to have comparable efficacy and better safety profile when compared to unfractionated heparin (UFH) in percutaneous coronary interventions. Bivalirudins safety in carotid artery stenting (CAS) was associated with better outcomes than heparin in some studies. In this Meta analysis we examine the hemorrhagic and ischemic outcomes associated with Bivalirudin compared to UFH during CAS.

Percutaneous Angioplasty versus Atherectomy for Treatment of Symptomatic Infra-Popliteal Arterial Disease

BACKGROUND Outcomes for debulking by atherectomy (ATH) for adjunctive treatment of below the knee (BTK) symptomatic arterial disease compared to percutaneous transluminal angioplasty alone (PTA) are unclear. METHODS MEDLINE, EMBASE, PubMed and the Cochrane Central Register of Controlled Trials were queried from between 2000 and 2017 including studies comparing PTA alone to PTA-ATH. Random effect meta-analysis model was used to pool the data across the studies. Study endpoints included: vessel dissection, residual stenosis (<30%), mortality at 12months and amputation rates at 1 and 12months. RESULTS A total of 2587 patients (72.9years; 63% male) were included from 4 studies (2 prospective, one of which was randomized, and 2 retrospective) comparing PTA alone to ATH-PTA in patients with symptomatic infra-popliteal disease. There was no significant difference between the two approaches in terms of vessel dissection [OR 3.73 with 95% CI 0.83 to 16.64, p=0.08] or residual stenosis [OR 0.41 with 95% CI 0.11 to 1.60, p=0.18]. Clinical outcomes did not differ in terms of 12month mortality [OR 3.47 with 95% CI 0.15 to 81.37, p=0.44], or limb amputation at 1month [OR 1.23 with 95% CI 0.91 to 1.67, p=0.18] or 12months [OR: 1.02 with 95% CI 0.83 to 1.26, p=0.83]. CONCLUSION In patients undergoing (BTK) intervention, PTA alone and ATH-PTA was associated with similar outcomes in terms of vessel dissection and residual stenosis, mortality at 12months, and limb amputation at 1 or 12months.

Right coronary artery stenosis unmasking ischemia in a patient with bilateral coronary pulmonary fistulas

Introduction Coronary artery fistulas (CAF) are congenital or acquired formations between the coronary arteries and cardiac chambers or other vascular structures such as the vena cava, pulmonary artery, or veins [1]. Most of these are found incidentally during angiography [2]. Fistulas account for half of all coronary anomalies and are present in 0.002% of the general population. Coronary to pulmonary artery fistulas comprise 15–30% of coronary anomaly cases and only 5% of these involve bilateral coronary arteries [3].