Pragnesh Parikh

Shear stress-associated acquired von Willebrand syndrome in patients with mitral regurgitation

Mitral valve regurgitation is associated with an acquired hemostatic defect.

Detection of Lumbar Facet Joint Gouty Arthritis Using Dual-energy Computed Tomography

To the Editor: Gout (monosodium urate crystal deposition disease) has been estimated to affect 3 to 6 million Americans, and both the incidence and prevalence appear to be increasing1. Gout is characterized by serum urate supersaturation, extracellular tissue deposition of urate crystals in and around joints, and acute inflammatory episodes. In unusual cases, patients may present with tophaceous deposits in the absence of, or prior to, development of gouty arthritis2. Although acute gout typically affects peripheral joints, involvement of the axial skeleton has been recognized3. Dual-energy computed tomography (DECT) is a technique that is able to identify tophaceous deposits, which have a distinctive appearance. We describe a case of gouty lumbar facet arthritis utilizing DECT. An 82-year-old Caucasian man with a history of obesity, type 2 diabetes, ischemic cardiomyopathy, atrial fibrillation, and chronic kidney disease presented with a complaint of acute on chronic low back pain. The back pain had increased significantly over the previous year, with … Address correspondence to Dr. Calamia; E-mail: calamia.kenneth{at}mayo.edu

Reduced Resident “code Blue” Experience in the Era of Quality Improvement: New Challenges in Physician Training

Purpose Emergency resuscitation or “code blue” is a clinical event through which responding medical residents gain experience and proficiency. A retooling of practice has occurred at academic medical centers since the emergence of quality improvement initiatives and resident duty hours limits. The authors investigated how these changes may impact code blue frequency and resident opportunities to gain clinical experience. Method The authors conducted a single-center, retrospective (2002–2009) review of monthly code blue frequency. They compared code blue frequency with corresponding monthly first-year internal medicine resident call schedules (2002–2008 academic years). Using a Monte Carlo simulation they estimated annual code blue experience, and using Poisson regression, they estimated annual trends in resident code blue experience. Results The authors detected a 41% overall reduction in code blue events between 2002 and 2008; code blue events decreased by 13% annually (P < .001). These trends persisted, even after accounting for hospital census fluctuations: Rates fell from approximately 12 code blue events/1,000 admissions in 2002 to 3.8 events/1,000 in 2008. Overall, the model of code blue frequency and resident call schedules shows a dramatic reduction in the predicted number of code blue experiences, falling from 29 events (empirical 95% CI 18–40) in academic year 2002 to 5 events (CI 1–9) in 2008. Conclusions Physicians-in-training at one facility are seeing far fewer code blue events than their predecessors. Whether current numbers of in-hospital code blue events are sufficient to provide adequate experience without supplemental practice for trainees is unclear.

Emerging Role of Cardiovascular CT and MRI in the Evaluation of Stroke

OBJECTIVE. The purposes of this article are to explore the potential for use of CT angiography and MRI and to highlight data suggestive of their usefulness in specific cardiovascular abnormalities. CONCLUSION. The evaluation of stroke requires comprehensive assessment of potential stroke mechanisms, including cardiac sources. Despite an exhaustive search for secondary causes, the precise cause of many strokes remains unknown (cryptogenic). It is well recognized, however, that some of these potential causes occur as a result of embolism from the heart or great vessels. Thus, echocardiography, in particular transesophageal echocardiography, is instrumental in a careful assessment of cardiac causes in selected individuals. Unfortunately, transesophageal echocardiography is invasive, and some patients may have relative or absolute contraindications. Cardiovascular CT angiography and MRI have growing potential compared with conventional cardiovascular echography.

Retained cardiac implantable electronic device fragments are not associated with magnetic resonance imaging safety issues, morbidity, or mortality after orthotopic heart transplant

Background Cardiac implantable electronic device therapy (CIED) has revolutionized treatment for advanced heart failure. Most patients considered for orthotopic heart transplantation (OHT) are treated with implantable cardioverter defibrillators, cardiac resynchronization therapy, or both. These CIEDs are surgically extracted at the time of transplant. Occasionally, CIEDs are incompletely removed. Little is known about the outcomes of post‐OHT patients with retained CIED fragments. Methods We identified 200 consecutive patients that underwent OHT at our institution between April 2006 and December 2014 and performed a retrospective analysis of available radiographic images and clinical records. Chest radiographs prior to and following OHT were reviewed for the presence of CIED or retained CIED fragments. The outcomes of patients with retained CIED fragments that had subsequent magnetic resonance imaging (MRI) studies performed were further investigated. Results One hundred eighty of 200 patients were identified as having CIED prior to OHT, of which 29 had retained CIED fragments after OHT. Most retained CIED fragments originated from superior vena cava defibrillator coils. There were no adverse events in the retained CIED fragment cohort, and survival was unaffected. Ten patients with retained CIED fragments safely underwent a total of 28 MRIs after OHT, all of diagnostic quality. Conclusion Retained CIED fragments are not associated with adverse events or increased mortality after OHT. Diagnostic MRI has been safely performed in patients with retained CIED fragments after incomplete device extraction. Retrieval of these fragments prior to MRI does not appear warranted given the demonstrated safety and preserved image quality in this population.

Cardiac MRI as a diagnostic tool in pulmonary hypertension.

Pulmonary hypertension is characterized by alterations in the viscoelastic properties of the pulmonary arteries, leading to increased pulmonary arterial stiffness and elevated pressures. Early detection and accurate quantification of pulmonary hypertension are limitations to conventional noninvasive imaging and may have therapeutic implications. Cardiac MRI provides important information that can aid the clinician, particularly relating to morphologic right ventricular alterations and quantification of stiffness, as well as providing a novel prognostic framework.

Modern advances in cardiovascular imaging: cardiac computed tomography and cardiovascular MRI in pericardial disease

The pericardium is characterized by a two-layer sac that surrounds the heart and provides an enclosed, lubricated space. Diseases of the pericardium may occur due to active inflammation, scar, calcification or effusion. While clinical, ECG and hemodynamic evaluation have been the established methods for the diagnosis of pericardial disease, advances in cardiac computed tomography and cardiovascular MRI provide complementary tools for diagnostic, prognostic and therapeutic assessment.

Advances of cardiovascular MRI in hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is a genetic disease characterized by abnormal myocardial hypertrophy, which can lead to a wide clinical spectrum, including sudden cardiac death and heart failure. Cardiac MRI has a significant role in establishing the diagnosis of HCM. In the three principal management issues related to HCM; testing of family members of affected individuals; assessing the risk of sudden cardiac death from lethal ventricular arrhythmias; and selection of appropriate treatments for left ventricular outflow obstruction, cardiac MRI has established or emerging roles.

PREVALENCE AND RESPONSE OF BLEEDING, INCLUDING TRANSFUSION DEPENDENT BLEEDING, TO INTERVENTION IN HYPERTROPHIC CARDIOMYOPATHY

Loss of high molecular weight multimers (HMWM) of von Willebrand factor (VWF) and clinically significant bleeding have been described in hypertrophic obstructive cardiomyopathy (HOCM). However, there are no data describing the prevalence of bleeding and only case reports describing the effects of

IMPACT OF AGE, GENDER, AND METABOLIC SYNDROME COMPONENTS ON THE RATE OF PROGRESSION OF MILD CALCIFIC AORTIC VALVE DISEASE

Demographic and metabolic factors which promote progression of calcific aortic stenosis in its early phase are poorly understood. We identified patients with an initial aortic valve peak velocity of ≥ 1.8 but < 3.0 m/s by echo, and examined the effects of age, gender, and components of the