Souheil Saba

Effectiveness of Implantable Cardioverter- Defibrillators for the Primary Prevention of Sudden Cardiac Death in Women With Advanced Heart Failure A Meta-analysis of Randomized Controlled Trials

BACKGROUND Numerous clinical trials have established a role for implantable cardioverter-defibrillators in the prevention of sudden cardiac death in patients with heart failure. However, questions remain that regard the clinical benefit of these therapies in different patient subgroups. Specifically, the role of implantable cardioverter-defibrillators in women with heart failure for the primary prevention of sudden cardiac death has not been well established. Our objective is to determine whether implantable cardioverter-defibrillators reduce mortality in women with advanced heart failure. METHODS We searched MEDLINE (1950-2008), EMBASE (1988-2008, week 24), the Cochrane Controlled Trials Register (third quarter, 2008), the National Institute of Health ClinicalTrials.gov database, the Food and Drug Administration Web site, and various reports presented at scientific meetings (1994-2007). Eligible studies were randomized controlled trials of implantable cardioverter/defibrillators for the primary prevention of sudden cardiac death in patients with heart failure that reported all-cause mortality as an outcome for the female population. Of the 2619 reports identified, 5 trials that enroll 934 women were included in the meta-analysis. RESULTS Pooled data from the 5 trials revealed no statistically significant decrease in all-cause mortality in women with heart failure who receive implantable cardioverter-defibrillators (hazard ratio, 1.01; 95% confidence interval, 0.76-1.33). CONCLUSIONS Implantable cardioverter-defibrillator therapy for the primary prevention of sudden cardiac death in women does not reduce all-cause mortality. Further studies are needed to investigate the reasons for this ob servation and to define the population of women who may benefit most from implantable cardioverter-defibrillator therapy.

Impact of a continuous quality improvement initiative on appropriate use of coronary computed tomography angiography. Results from a multicenter, statewide registry, the Advanced Cardiovascular Imaging Consortium.

OBJECTIVES The purpose of the study was to determine the effectiveness of a collaborative educational, continuous quality improvement (CQI) initiative to increase appropriate use of coronary computed tomography angiography (CCTA). BACKGROUND Potential overuse of CCTA has prompted multisociety appropriate use criteria (AUC) publications. METHODS This prospective, observational study was conducted with pre-intervention (July 2007 to June 2008), intervention (July 2008 to June 2010), and follow-up (July 2010 to December 2010) periods during which patients were enrolled in the Advanced Cardiovascular Imaging Consortium (ACIC) at 47 Michigan hospitals. Continuous education was provided to referring physicians. The possibility of losing third-party payer coverage in the absence of a measurable change in AUC was emphasized. AUC was compared between the 3 periods. RESULTS The study group included 25,387 patients. Compared with the pre-intervention period, there was a 23.4% increase in appropriate (61.3% to 80%, p < 0.0001), 60.3% decrease in inappropriate (14.6% to 5.8%, p < 0.0001), 40.8% decrease in uncertain (10.3% to 6.1%, p < 0.0001), and 41.7% decrease in unclassifiable (13.9% to 8.1%, p < 0.0001) scans during follow-up. Between pre-intervention and follow-up, change in CCTA referrals by provider specialty were cardiology (appropriate: 60.4% to 79.5%; inappropriate: 13% to 5.2%; p < 0.0001), internal medicine/family practice (appropriate: 51.1% to 70.4%; inappropriate: 20.2% to 12.5%; p < 0.0001), emergency medicine (appropriate: 83.6% to 91.6%; inappropriate: 9.1% to 0.6%; p < 0.0001), and other (appropriate: 61.1% to 83.2%; inappropriate: 18.6% to 5.9%; p < 0.0001). CONCLUSIONS Application of a systematic CQI and emphasis on possible loss of coverage were associated with a significant improvement in the proportion of CCTA examinations meeting AUC across referring physician specialties.

Sustained consciousness during ventricular fibrillation: case report of cough cardiopulmonary resuscitation.

A 54-year-old male developed ventricular fibrillation during right coronary angiography. Cough cardiopulmonary resuscitation was performed for 30 sec allowing the patient to remain alert and hemodynamically stable. Cough cardiopulmonary resuscitation is a simple, often overlooked technique that can be utilized during resuscitation in the cardiac catheterization laboratory.

A forgotten devil; Rupture of mitral valve papillary muscle.

Summary Background: Papillary muscle rupture is one of the catastrophic mechanical complications following myocardial infarction. Rupture leads to acute mitral valve regurgitation, pulmonary edema, and cardiogenic shock. Survival is dependent on prompt recognition and surgical intervention. Cases Report: We present two cases where acute myocardial infarction was complicated by papillary muscle rupture resulting in severe mitral regurgitation and cardiogenic shock. In both cases rupture occurred within one week of infarction. Both patients did not receive coronary revascularization; one patient presented late after the onset of chest pain, the other patient percutaneous revascularization attempted and was not successful. Both patients suffered an inferior wall infarction. Echocardiogram demonstrated severe mitral regurgitation with a jet directed posteriorly. In both cases rupture of the posteromedial papillary muscle resulted in flail of the anterior mitral valve leaflet, thus serving as a reminder that both the anterior and the posterior leaflets attach to both papillary muscles. Conclusions: While one case had a good outcome, the other reinforces the fact that this is a very serious complication requiring prompt recognition and treatment.

Unilateral Absence of a Left Pulmonary Artery Successful Therapeutic Response to a Combination of Bosentan and Warfarin

Unilateral absence of a pulmonary artery is a rare anomaly, with only 108 case reports since the first observation by Frantzel in 1868.1 Absence of a left pulmonary artery occurs at an even more infrequent rate, accounting for one third of all unilateral absence of a pulmonary artery.2 A late presentation in life, as with the patient described below, is uncommon, and delayed diagnosis may be the result of atypical symptoms earlier in life that went unrecognized. Such an anomaly can present with a wide array of symptoms including chest pain, shortness of breath, hemoptysis, fatigue, and decreased functional capacity for physical exertion. Therapeutic options are many and include surgical resection of lung lobe/tissue and medical therapy with endothelin receptor antagonists, prostacyclin, and nitric oxide. Despite evidence surrounding the vast array of therapeutic options, there has been no published data describing combination therapy using bosentan and warfarin. A 58-year-old white woman presented for an outpatient evaluation of dyspnea on exertion. The patient initially described progressive increase …

Cardiac Sarcoidosis Presenting as Constrictive Pericarditis

In patients with cardiac sarcoidosis, the sarcoid granulomas usually involve the myocardium or endocardium. The disease typically presents as heart failure with ventricular arrhythmias, conduction disturbances, or both. Constrictive pericarditis has rarely been described in patients with sarcoidosis: we found only 2 reports of this association. We report the case of a 57-year-old man who presented with clinical and hemodynamic features of constrictive pericarditis, of unclear cause. He was admitted for treatment of recurrent pleural effusion. After a complicated hospital course, he underwent pericardiectomy. His clinical and hemodynamic conditions improved substantially, and he was discharged from the hospital in good condition. The pathologic findings, the patients clinical course, and his response to pericardiectomy led to our diagnosis of cardiac sarcoidosis presenting as constrictive pericarditis. In addition to the patients case, we discuss the nature and diagnostic challenges of cardiac sarcoidosis. Increased awareness of this disease is necessary for its early detection, appropriate management, and potential cure.

Arteriolar vs. valvular thrombosis: Pick your evil!

BackgroundAnticoagulation therapy for mechanical prosthetic valves is limited to vitamin K antagonists, unfractionated heparin and low-molecular-weight-heparin. Other forms of anticoagulation are either contraindicated or have not been well studied. Hence, anticoagulation for preexisting mechanical valves is controversial if vitamin K antagonists are contraindicated. We present a case involving an end-stage-renal disease patient with both mitral and aortic mechanical valves who developed warfarin-induced calciphylaxis.Case presentationA 72-year-old male with history of end-stage renal disease, chronic atrial fibrillation and rheumatic heart disease status post mitral and aortic valve replacements presented with complaints of left thigh erythema with skin induration. Despite multiple antibiotic regimens for presumed cellulitis, the skin lesions progressed to necrotic ulcers. A biopsy revealed evidence of calciphylaxis; a lethal condition typically associated with renal disease. The patient was on warfarin for anticoagulation of his mechanical heart valves as well as prophylactically for atrial fibrillation. Warfarin contributes to the development of calciphylaxis and needed to be exchanged to avoid progression of the ulceration. The only other acceptable option for long-term anticoagulation was subcutaneous unfractionated heparin but this approach was not taken. The patient suffered from further sequelae of calciphylaxis and eventually expired.ConclusionCalciphylaxis is a rare, serious disorder that presents with skin ischemia and necrosis mainly in end-stage renal disease patients. The pathogenesis and treatment are poorly understood and the prognosis remains grave. It is proposed that certain medications, including warfarin, contribute to its evolution. The optimal anticoagulation therapy in those with concomitant warfarin-induced calciphylaxis and mechanical valves is undetermined. Further studies are essential to establish new anticoagulation regimens in these devastating circumstances.