R. Michael Benitez

Surgery for Severe Mitral Regurgitation and Left Ventricular Failure: What Do We Really Know?

In ischemic and nonischemic cardiomyopathy, functional mitral regurgitation (MR) results from geometric abnormalities of the ventricle, which result in dysfunction of a morphologically normal mitral valve. Enlargement of the left ventricle causes geometric MR through annular dilation, increase in the interpapillary muscle distance, amplified leaflet tethering (elongation and stretch on the chordae tendinae), and decreased closing forces because of muscle weakness and asynchrony of papillary muscle contractile timing. The final common pathway of MR is a failure of coaptation of the morphologically normal leaflets and resultant central MR. These abnormalities can be favorably influenced by antiremodeling pharmacologic therapy and in selected cases by cardiac resynchronization therapy. Surgical repair of functional geometric MR with an undersized complete rigid annuloplasty ring can abolish MR and is associated with improved functional status and left ventricular remodeling. It is unclear if surgery is associated with improved survival in this setting. There is a pressing need for well-conducted prospective randomized clinical trials to quantify the benefits of surgical repair of functional geometric MR.

Blunt Cardiac Injury

Blunt chest trauma represents a spectrum of injuries to the heart and aorta that vary markedly in character and severity. The setting, signs, and symptoms of chest trauma are often nonspecific, which represents a challenge to emergency providers. Individuals with suspected blunt chest trauma who have only mild or no symptoms, a normal electrocardiogram (ECG), and are hemodynamically stable typically have a benign course and rarely require further diagnostic testing or long periods of close observation. Individuals with pain, ECG abnormalities, or hemodynamic instability may require rapid evaluation of the heart by echocardiography and the great vessels by advanced imaging.

Hellenic Holocaust: A historical clinico-pathologic conference

The traditional clinico-pathologic conference (CPC) begins with a case presentation. Next, a clinician analyzes the clinical information, illustrating the diagnostic process and proposing one “best-fit” diagnosis for the anonymous (and often dead) patient. Finally, a pathologist presents the actual autopsy or histologic findings, either validating or rejecting the clinician’s diagnosis. This “historical” CPC differs from the traditional CPC in two ways: first, we have no all-knowing pathologist to deliver a final answer, and second, we are challenged to name the patient. CASE PRESENTATION Fever, headache, sore throat, and vomiting developed in a 65-year-old man. He had been in excellent health until approximately 1 week earlier, when he had sudden onset of headache, ocular erythema, and halitosis. On the third day of illness, he began to sneeze and cough, and noted bilateral pleuritic chest pain. On the sixth day, he developed projectile vomiting of dark, bilious fluid. At this time, he complained of fever so intense that he would not allow himself to be covered with even the lightest clothing. He also complained repeatedly of intense thirst. Although he drank copious amounts of water, his thirst persisted, worsened by frequent vomiting. The patient had no history of major illnesses. He drank wine in moderation and did not use tobacco. He was taking no medications and had no known allergies. The patient was a resident of Athens, where he had lived his entire life, except for brief excursions throughout the eastern Mediterranean. He spent his early years in military service. In recent years, he had devoted himself to politics. He was married and both of his children by this marriage, sons aged 30 and 25 years, had died recently of illnesses similar to his own. Another son (by his mistress), aged 10 years, was alive and well. The patient’s father had died in battle at age 47 years; his mother’s history is not known. His sister had recently died while in her mid sixties of an illness similar to that of the patient. The condition of his brother, who was approximately 60 years of age, is not known. A similar illness simultaneously afflicted many of the patient’s fellow Athenians. The epidemic began about a year earlier, 1 year after the outbreak of hostilities with a neighboring city. Although enemy forces had besieged Athens continuously during this period, their troops do not appear to have been affected by the illness. Refugees entering the city from the surrounding countryside, however, were quickly affected. The disease attacked all age groups and socioeconomic strata, with the highest incidence among physicians and other caregivers. The illness, which was reported to have originated in subSaharan Africa, had not been seen in Athens before the current epidemic. It was believed to have entered Athens through Piraeus, the city’s port. Much of the eastern Mediterranean was also afflicted with the disease. The epidemic had waxed and waned since its appearance, with no apparent seasonality. Of those who contracted the disease, approximately one quarter died. Persons who recovered were immune to further attacks of the

Surgical and Transcatheter Mitral Valve Repair for Severe Chronic Mitral Regurgitation: A Review of Clinical Indications and Patient Assessment.

Significant mitral regurgitation (MR) is an increasingly common disorder affecting nearly 10% of the US population aged >75 years and is associated with increased morbidity and mortality in the setting of left ventricular (LV) dysfunction and heart failure symptoms. Mitral valve repair or

Acquired coronary artery–pulmonary artery connection

We report a patient who underwent resection of a mediastinal tumor with postoperative irradiation. Cardiac catheterization fifteen years later demonstrated coronary artery-pulmonary artery fistulas from both the right and left coronary arteries. This case report raises the issue of whether external beam irradiation may have been integral in neovascularization and the development of this acquired abnormality.

A 50-Year-Old Man with Chest Pain

A 55-year-old man presented to the emergency department complaining of epigastric pain, retrosternal chest pain, and dyspnea. His symptoms started suddenly early in the morning after he experienced 2 episodes of retching and forceful vomiting of food material followed by a small amount of bright red blood. The patient had consumed excessive amounts of alcohol the night before. He reported that he usually drinks on social occasions and smokes 1 pack of cigarettes a day. He had no other past medical history. On physical examination, the patient appeared slightly anxious and was in mild respiratory distress. He was afebrile, his blood pressure was 138/83 mm Hg in the right arm and 136/85 in the left, and his pulse was 116 bpm. Oxygen saturation was 97% on room air, with a respiratory rate of 16 breaths/min. His head was normocephalic, but he had subcutaneous emphysema in the neck and upper chest. Cardiovascular evaluation revealed tachycardia without audible murmurs. Lung examination showed diminished breath sounds to auscultation, dullness to percussion, and decreased tactile fremitus over both lung bases. His abdomen was soft with mild epigastric tenderness, but there was no guarding, rebound tenderness, or hepatosplenomegaly. Normal bowel sounds were present. No stigmata of liver disease were detected. Digital rectal examination was normal and negative for fecal occult blood. Laboratory studies revealed a leukocyte count of 11.7 × 103/μL, with 79% neutrophils and 9% bands. Other notable laboratory study results were as follows: alanine aminotransferase, 117 U/L (normal, 0–55); aspartate aminotransferase, 260 U/L (normal, 12–45); total bilirubin, 1.7 mg/dL (normal, 0.1–1.2); direct bilirubin, 0.6 mg/dL (normal, 0.0–0.4); alkaline phosphatase, 31 U/L (normal, 37–107); and albumin, 2.0 g/dL (normal, 3.5–5.0). Amylase was 250 U/L (normal, 34–122) and lipase was 2 U/L (normal, 22–51). Chest radiography revealed extensive pneumomediastinum and bilateral pleural effusions but no free air under the diaphragm (Figure 1). WHAT IS YOUR DIAGNOSIS?

A Psychiatric Clinicopathological Conference

Abstract The patient was a 36-year-old renowned military officer who, in the face of convincing evidence of an overwhelmingly superior enemy force, orchestrated a defeat so severe that it culminated in the annihilation of his personal command of over 200 men, his own death, and the deaths of 2 of his 3 brothers, a favorite nephew, and a brother-in-law.