Rafic F. Berbarie

Comparison of Force Exerted on the Sternum During a Sneeze Versus During Low-, Moderate-, and High-Intensity Bench Press Resistance Exercise With and Without the Valsalva Maneuver in Healthy Volunteers

Sternal precautions are intended to prevent complications after median sternotomy, but little data exist to support the consensus recommendations. To better characterize the forces on the sternum that can occur during everyday events, we conducted a prospective nonrandomized study of 41 healthy volunteers that evaluated the force exerted during bench press resistance exercise and while sneezing. A balloon-tipped esophageal catheter, inserted through the subjects nose and advanced into the thoracic cavity, was used to measure the intrathoracic pressure differential during the study activities. After the 1 repetition maximum (1-RM) was assessed, the subject performed the bench press at the following intensities, first with controlled breathing and then with the Valsalva maneuver: 40% of 1-RM (low), 70% of 1-RM (moderate), and 1-RM (high). Next, various nasal irritants were used to induce a sneeze. The forces on the sternum were calculated according to a cylindrical model, and a 2-tailed paired t test was used to compare the mean force exerted during a sneeze with the mean force exerted during each of the 6 bench press exercises. No statistically significant difference was found between the mean force from a sneeze (41.0 kg) and the mean total force exerted during moderate-intensity bench press exercise with breathing (41.4 kg). In conclusion, current guidelines and recommendations limit patient activity after a median sternotomy. Because these patients can repeatedly withstand a sneeze, our study indicates that they can withstand the forces from more strenuous activities than are currently allowed.

High-intensity track and field training in a cardiac rehabilitation program.

A 65-year-old male athlete with coronary artery disease enrolled in our cardiac rehabilitation (CR) program after successful coronary artery bypass graft surgery following an acute myocardial infarction. Unlike the typical sedentary cardiac patient in his age group, he loved to participate in hurdle events at masters division track meets (competitions for athletes aged 30 years and older). He expressed a strong desire to return to his sport, so we designed a sport-specific, symptom-limited exercise program that enabled him to train safely but at a higher intensity than is typically allowed in conventional CR programs. Although his measured peak heart rates during the sport-specific sessions were significantly higher than the calculated maximum heart rate limits usually imposed on patients during conventional CR exercise training, the patient had no adverse events and safely reached his fitness goal. When developing a CR plan, health care professionals should consider the patients goals, not just his or her age.

Preoperative exclusion of significant coronary artery disease by 64-slice CT coronary angiography in a patient with a left atrial myxoma

A 49-year-old man without any significant past medical history presented to the emergency department with complaints of diploplia, paresthesias in both arms, vertigo, tinnitus in the right ear, and dysarthria. Physical examination was unremarkable. A computed tomographic (CT) scan of the head was normal. These symptoms resolved within several hours, consistent with a transient ischemic attack. Magnetic resonance imaging of the brain revealed acute infarcts in the left cerebellar hemisphere and in the right occipital lobe, suggesting a thromboembolic source. Transesophageal echocardiography disclosed a 2 × 2-cm mass attached to the left atrial aspect of the atrial septum, and surgical excision was planned. As the patient was considered to have a very low risk for the presence of significant arterial narrowing, he underwent a 64-slice cardiac CT scan rather than invasive coronary angiography. The scan demonstrated minimal plaque in the coronary arteries (Figure ​(Figure11). The left atrial mass was also well visualized on both the axial slices and also with three-dimensional imaging (Figure 2a–c). Subsequently, the patients left atrial mass was excised without complication, and the mass was a typical myxoma (Figure 2d, e). This case demonstrates how, in the future, routine invasive coronary angiography may not be necessary as part of the workup for noncoronary cardiac surgery. In this instance, significant concomitant coronary artery disease was effectively excluded with multislice CT rather than an invasive procedure, thus allowing the surgery to proceed without a cardiac catheterization. In addition, CT imaging assisted with long-term prognostic information, as it suggested the need for the patient to be on cholesterol reduction therapy by demonstrating the early presence of coronary atherosclerosis. Figure 1 Three-dimensional reconstruction of the patients coronary arteries (3D) with multislice computed tomography. Curved reformat images of the left anterior descending (LAD) coronary artery, right coronary artery (RCA), and left circumflex coronary artery ... Figure 2 (a, b) Axial slices from the patients multislice computed tomographic scan demonstrating the myxoma attached to the left atrial aspect of the atrial septum (arrowheads). (c) The myxoma (arrowhead) shown via a “navigator” view inside the ...

High-intensity cardiac rehabilitation training of a police officer for his return to work and sports after coronary artery bypass grafting

A 39-year-old male police officer with coronary artery disease enrolled in our cardiac rehabilitation (CR) program after coronary artery bypass grafting. He wanted to return not only to his job but also to playing ice hockey and outdoor soccer, and his responses to a self-assessment scale confirmed that he identified strongly as an athlete. On the basis of this unique profile, the CR staff designed an occupation- and sport-specific exercise program that was symptom limited and enabled the patient to train safely, but earlier and at a higher intensity than is typically allowed in conventional CR programs. The exercises were selected to replicate the various combinations of muscular strength, agility, and cardiovascular endurance required by the patients police work and two competitive team sports. He completed the high-intensity training with no clinically significant adverse symptoms.

High-intensity cardiac rehabilitation training of a firefighter after placement of an implantable cardioverter-defibrillator

Firefighters who have received an implantable cardioverter-defibrillator (ICD) are asked to retire or are permanently placed on restricted duty because of concerns about their being incapacitated by an ICD shock during a fire emergency. We present the case of a 40-year-old firefighter who, after surviving sudden cardiac arrest and undergoing ICD implantation, sought to demonstrate his fitness for active duty by completing a high-intensity, occupation-specific cardiac rehabilitation training program. The report details the exercise training, ICD monitoring, and stress testing that he underwent. During the post-training treadmill stress test in firefighter turnout gear, the patient reached a functional capacity of 17 metabolic equivalents (METs), exceeding the 12-MET level required for his occupation. He had no ICD shock therapy or recurrent sustained arrhythmias during stress testing or at any time during his cardiac rehabilitation stay. By presenting this case, we hope to stimulate further discussion about firefighters who have an ICD, can meet the functional capacity requirements of their occupation, and want to return to work.

High-intensity, occupation-specific training in a series of firefighters during phase II cardiac rehabilitation

Six male firefighters who were referred to phase II cardiac rehabilitation after coronary revascularization participated in a specialized regimen of high-intensity, occupation-specific training (HIOST) that simulated firefighting tasks. During each session, the electrocardiogram, heart rate, and blood pressure were monitored, and the patients were observed for adverse symptoms. No patient had to discontinue HIOST because of adverse arrhythmias or symptoms. For physicians who must make decisions about return to work, the information collected over multiple HIOST sessions might be more thorough and conclusive than the information gained during a single treadmill exercise stress test (the recommended evaluation method).

Embolization of a stent from an arteriovenous graft into the right ventricle in a patient on chronic hemodialysis.

Embolization of a venous stent is a rare but potentially catastrophic complication of peripheral vascular intervention. We report a case of a woman with chronic kidney disease who had recently received an endovascular stent to treat a compromised arteriovenous graft. While cases of stent embolization have been reported with other applications, this case represents the first reported proximal embolization of an arteriovenous dialysis graft stent. With the potential increase in utilization of percutaneous intervention to manage dialysis graft failure, the incidence of this complication will likely increase (1).

Late diagnosis of Wellens syndrome in a patient presenting with an atypical acute coronary syndrome

Atypical myocardial infarctions (MI) are one of the more feared diagnoses among cardiologists, emergency department physicians, and internists for patients presenting with presumed non-cardiac chest pain. Delays in care for patients presenting with atypical MIs can lead to increases in morbidity and mortality. This is also true in the case of Wellens’ syndrome where delays in coronary revascularization can also lead to left ventricular dysfunction and death. Here, we report the case of a 48 year old man with no known risk factors for coronary disease who presents with atypical symptoms, a very late rise in serum troponin, and ECG changes consistent with Wellens’ syndrome as part of an acute nonST elevation myocardial infarction (NSTEMI).

Utility of real-time three-dimensional echocardiography in improved assessment of a mitral valve papillary fibroelastoma

Primary cardiac tumors are exceedingly rare. They are usually first identified by transthoracic echocardiography. However, transesophageal echocardiography (TEE), with the aid of real‐time three‐dimensional (3D) imaging, can provide additional important mass characteristics. We present a case that demonstrates the usefulness of 3D TEE in characterizing a papillary fibroelastoma.

Cardiac Rehabilitation in Firefighters

We read the case series, “High-intensity, occupation-specifi c training in a series of fi refi ghters during phase II cardiac rehabilitation” by Adams et al (1) with great interest. We applaud the authors’ eff orts to bring greater attention to the cardiovascular hazards of fi refi ghting. However, we are extremely concerned that this article’s anecdotal report on six fi refi ghters with a history of coronary revascularization provides physicians with the false impression that most fi refi ghters should return to unrestricted fi re department emergency duties after acute myocardial infarction, angioplasty, or cardiac surgery if they completed a similar cardiac rehabilitation program. Furthermore, the report fails to provide clinicians with the most relevant epidemiologic data regarding the risk of sudden cardiac death (SCD) during fi re suppression and other fi re emergency duties that would assist them to make more informed and evidence-based decisions on return to work in this dangerous occupation. While the authors correctly note that SCD due to coronary heart disease (CHD) is the leading cause of death in US fi refi ghters (2), they do not mention key facts that drive this observation. First, fi refi ghters with an established diagnosis of CHD (like the six patients reported on here) unnecessarily account for 25% to 30% of all on-duty CHD events and SCD (3, 4). Second, not only is a recurrent on-duty CHD event more likely, but the odds of case fatality during a fi refi ghting CHD event are four times higher for those with a prior diagnosis of CHD after adjustment for other risk factors (5). Th e relative risk of on-duty SCD death for such individuals is 35 times that of their colleagues without a CHD history. In fact, even after accounting for all other comorbid cardiovascular disease risk factors, the relative risk of on-duty SCD remains about 15-fold higher (4). Clinicians almost never face risks of such magnitude and then decide that it is still acceptable for the individual to engage in such a strenuous occupational activity. Th ere are other major problems with this report. Th e authors fail to state how the patients were selected or medically cleared to participate in this program and do not mention or do not have any inclusion/exclusion criteria based on disease severity. At what point would they determine that a fi refi ghter is not safe to enter the program? To the authors’ credit, they mention the CHD return to work criteria developed by the National Fire Protection Agency (NFPA) (6). From the data presented, however, the participants did not meet these criteria because of their persistent cardiovascular disease risk factors. Moreover, the authors do not describe how and when they determined that a cardiac rehabilitation program participant was eligible to return to work. Th e authors mention that the NFPA standard recommends >12 METS aerobic capacity for safe return to fi refi ghting activities, and the authors’ own previous paper on this subject showed that healthy fi refi ghters required an average of 12 METS and >85% of their age-predicted max heart rate to complete a fi re obstacle course (7). Clearly then, a safe cardiac rehabilitation program would need to address those aerobic capacity criteria as one of the many necessary requirements for determining safety to return to work. However, the rehabilitation subjects have no peak METS reported after completing the program. In addition, the peak heart rates during the cardiac rehabilitation program were uniformly below 150 bpm (and below 85% age-predicted heart rate max in 5/7 cases). Th is strongly suggests that even though they mimicked fi re suppression activities in terms of muscular activities, the self-paced nature of the program allowed the participants to perform below the 12 MET threshold. Published studies of various fi refi ghter activities and conditions consistently demonstrate peak heart rates of >160–180 (8–11). Th erefore, the intensity of a cardiac rehabilitation program targeting fi refi ghters would need to be higher than the one reported by Adams et al to meet this demand. While beta blockade is off ered as a reason for the low peak heart rates during exertion, such a confounding factor would make it even more imperative to objectively demonstrate participants’ aerobic capacities in a quantitative fashion. Accordingly, while the cardiac rehabilitation program the authors present is unique, it by no means simulates or approximates the cardiovascular stressors of actual fi re suppression duties for all of the reasons above. To the authors’ credit, they acknowledge that the program has no element of shift work, heat stress, dehydration, low oxygen tension, or exposure to inhalational toxins, which are additional cardiac stressors and part of the essential job duties that the returning cardiac patient would face (12, 13). Again, however, they fail to explain how they would infer from such limited data in a safe and controlled environment the participants’ ability to safely return to work under complex, unpredictable, and dangerous conditions. An even more serious fl aw of the paper is that the methodology cannot support any of the claims made by the authors about their proposed cardiac rehabilitation regimen. Th ere is no pres entation of preand post-rehabilitation exercise data (e.g., peak exercise heart rate and blood pressure response, electrocardiographic patterns during exertion, or aerobic capacity) to show that the fi refi ghters were more fi t and had better cardiovascular responses to exertion after completing the program. Firefi ghters did not complete a standard fi re service Physical Abilities Test and did not (or it was not reported) achieve 12 METS as a more standardized surrogate measure of the ability to safely perform essential fi refi ghting duties. Finally, no longitudinal follow-up was provided to document that the patients had indeed “safely” returned to unrestricted duties without further incidents. Th us, while we agree that