Sandeep Banga

Patients’ and Physicians’ Perceptions Regarding the Benefits of Atrial Fibrillation Ablation: THE BENEFITS OF ATRIAL FIBRILLATION ABLATION

It is unclear whether patients and physicians understand that atrial fibrillation ablation (AFA) has been shown to only improve symptomology and not reduce morbidity or mortality.

Prevalence and predictors of inappropriate anticoagulation in patients with a CHA2DS2-VASc score of 0 and atrial fibrillation

BACKGROUND Previous studies have shown underutilization of anticoagulation therapy in patients with atrial fibrillation and a CHA2DS2-VASc score ≥2; however there exists little data regarding the inappropriate use of anticoagulation in patients with a CHA2DS2-VASc score of 0. We aimed to determine the true prevalence and predictors of inappropriate anticoagulation therapy in patients with atrial fibrillation and a CHA2DS2-VASc score of 0. METHODS A retrospective chart review was performed on all patients with atrial fibrillation and a CHA2DS2-VASc score of 0 in our institution from January 2009 to January 2016. Demographic and clinical data were collected from the electronic medical record. We utilized multivariable logistic regression analysis to determine independent clinical predictors of inappropriate anticoagulation administration. RESULTS 512 patients were identified with a CHA2DS2-VASc score of 0 and a diagnosis of atrial fibrillation. Of the 137 patients prescribed anticoagulation, 64 patients were identified as inappropriately treated with anticoagulation therapy after assessing for other indications of warfarin or novel anticoagulant therapy. Independent variables associated with inappropriate anticoagulation administration were age (OR 1.07; 95% CI 1.03-1.10), body mass index (OR 1.06; 95% CI 1.01-1.10), absence of current aspirin use (OR 13.50; 95% CI 6.00-30.54) and persistent atrial fibrillation (OR 2.34; 95% CI 1.11-4.94). CONCLUSIONS Our study shows that 12% of patients with a CHA2DS2-VASc score of 0 were inappropriately prescribed anticoagulant therapy. Independent predictors of unnecessary anticoagulation were age, body mass index, absence of current aspirin use and persistent atrial fibrillation.

Cutaneo-Pericardial Fistula After Transapical Approach for Transcatheter Aortic Valve Replacement

A 77-year-old male with severe aortic stenosis, prior coronary artery bypass graft, recurrent infective endocarditis, and chronic Q fever (taking hydroxychloroquine and doxycycline) underwent a transcatheter aortic valve replacement (TAVR) by the transapical (TA) approach via left thoracotomy. A 29-

Hiatal Hernia Mimicking ST Elevation Myocardial Infarction

A 72-year-old man with a history of hypertension, hiatal hernia, prostate cancer and lung cancer was admitted with complaints of abdominal pain, sweating and rigors. An electrocardiogram showed ST elevation in multiple leads. Noninvasive and invasive cardiovascular work-up was performed that was negative for occlusive coronary artery disease. Further studies demonstrated a large hiatal hernia; this was found to be the culprit causing his symptoms. Hiatal hernia is a very rare cause of ST segment elevation and should be considered in the differential diagnosis of disorders that can cause ST elevation.

Ascending Aortic Pseudoaneurysm: Sleeping Giant Arises in 3rd Decade after Surgery

Twenty-eight years earlier, a 68-year-old woman had undergone chordal shortening to correct rheumatic anterior mitral leaflet prolapse and severe mitral regurgitation. At a much more recent presentation, a routine transthoracic echocardiogram incidentally revealed a 5.8-cm echolucent mass arising from the ascending aorta (Fig. 1). The patient was scheduled for urgent follow-up computed tomography (CT) of the chest, which she refused. A month later, she presented at the hospital with severe, sharp precordial chest pain. An emergency chest CT scan showed a giant (14 × 11-cm) ascending aortic pseudoaneurysm arising from the anterior aortic wall just distal to the sinotubular junction—at the aortic cannulation site of the previous cardiac surgery (Figs. 2 and ​and33). Fig. 1 Transthoracic echocardiogram (parasternal long-axis view) shows a large pseudoaneurysm (PsA) arising from the aorta and lined by intramural thrombus (arrowheads). The pseudoaneurysm compresses both ventricular cavities. The arrow points to the mitral ... Fig. 2 Computed tomogram of the chest (cross-sectional view) shows a large, narrow-necked pseudoaneurysm (arrow) arising from the ascending aorta and lined circumferentially by intramural thrombus. Fig. 3 Contrast-enhanced computed tomograms (3-dimensional reconstruction) show a large pseudoaneurysm of the ascending aorta in A) coronal and B) sagittal views. The patient underwent an emergency repeat sternotomy for the purpose of vascular graft repair. Perioperative coagulopathy resulted in severe, uncontrollable bleeding and in her death.

Transient cardiogenic shock during a crisis of pheochromocytoma triggered by high-dose exogenous corticosteroids

We report a case of a 39-year-old woman who presented to the emergency department (ED) with symptoms of pharyngitis and fever. Diagnosed with streptococcal pharyngitis, she received antibiotics and dexamethasone, and was discharged. Within 24 h she returned to the ED with signs and symptoms of an acute coronary syndrome; she was thus given β-blockers. Her coronary angiogram was normal. She developed cardiogenic shock with an ejection fraction (EF) of 10% and apical ballooning on echocardiography. Her condition improved with optimal medical therapy. Subsequent testing weeks later confirmed the presence of a pheochromocytoma. Following prazosin and an adrenalectomy, all her antihypertensive medications were weaned and her EF normalised. We believe the high-dose exogenous corticosteroids triggered a pheochromocytoma crisis. The concomitant use of β-blockers without preceding α blockade resulted in cardiovascular collapse. Pheochromocytoma crisis must be included in the differential diagnosis of any dramatic haemodynamic collapse after administration of exogenous corticosteroid or β-blockers.

High-risk percutaneous coronary intervention in a patient with a single coronary artery presenting as STEMI and cardiogenic shock

Cardiogenic shock due to ST elevation myocardial infarction in a patient with a single coronary artery involving the sole vessel is a rare presentation. This can be clinically and angiographically challenging. Proper recognition of the topography of diseased vessels and a systematic guarded approach can lead to procedural success. We report a case of an 81-year-old woman who presented with chest pain followed by a near syncope associated with an acute myocardial infarction. Coronary angiography revealed a single proximally occluded right coronary artery and an anomalous left main coronary artery (originating from the proximal right coronary artery) and occluded distal left circumflex artery. The right coronary artery was successfully stented following predilation without compromising the anomalous left main origin. The flow in the chronically occluded left circumflex artery (originating from the anomalous left main) which was depended on the retrograde supply from right coronary artery through collaterals, was also re-established.

Transcatheter aortic valve replacement in membranous interventricular septum aneurysm with left ventricular outflow tract extension

We report a challenging case of a 81-year-old male with history of severe calcific aortic valve stenosis and aneurysmal membranous interventricular septum. The presence of anomalies in the sub-annular area can lead to valve malpositioning and its consequences. transcatheter aortic valve implantation (TAVR) in patients with aneurysm of the perimembranous interventricular septum extending into the left ventricular outflow tract has not been previously reported. This case describes a successful transfemoral TAVR with an Edwards SAPIEN XT valve (Edwards Lifesciences, Irvine, CA, United States) with such anomaly.

Metastatic right ventricular mass with intracavitary obliteration

Metastatic cardiac tumors are more common than the primary cardiac tumors. Cervical cancer metastasizing outside of the pelvis is commonly spread to the lungs, liver, bones and lymph nodes than to the heart. Right-sided metastasis to the heart is more common than to the left side. Intramural spread is more common than intracavitary growth of metastatic cardiac tumors leading to delayed clinical presentation. Intracavitary mass can be confused with intracavitary thrombus which can be seen in the setting of pulmonary embolism. Transthoracic echocardiography plays a major role in the decision making and management of pulmonary embolism, and this modality can also be used to diagnose cardiac masses. Other modalities like TEE, cardiac CT, cardiac MRI and PET-CT scan have further utility in delineating these masses. This may help to plan appropriate management of the right ventricular mass particularly in cases where the patient history and CT pulmonary angiography results favor the diagnosis of pulmonary embolism. We present the case of a 49-year-old woman with a history of supracervical hysterectomy and salpingo-oophorectomy on oral estrogen therapy who was admitted with complaints of pleuritic chest pain and respiratory insufficiency after a long flight. Initial work-up showed sub-segmental pulmonary embolus in the right posterior lower lobe pulmonary artery, and the patient was managed on intravenous heparin. Lack of appropriate response to standard therapy led to further evaluation. Multimodality imaging and biopsies revealed a large right intracavitary ventricular metastatic squamous cell tumor, with the cervix as the primary source.

PARADOXICAL LOW-FLOW SEVERE AORTIC STENOSIS IN THE SETTING OF APICAL VARIANT HYPERTROPHIC CARDIOMYOPATHY

Paradoxical low-flow severe aortic stenosis (AS) poses a unique diagnostic challenge due to discordant echocardiographic findings. Apical variant hypertrophic cardiomyopathy (HCM) is a relatively rare condition with symptoms that may mimic those of severe AS. An 86-year-old Caucasian man presented