Vijay Ramu

A Meta-Analysis of Mortality and Major Adverse Cardiovascular and Cerebrovascular Events Following Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement for Severe Aortic Stenosis

The purpose of this meta-analysis was to compare postprocedural mortality and major adverse cardiovascular and cerebrovascular events between transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) for severe aortic stenosis. Seventeen studies (n = 4,659) comparing TAVI (n = 2,267) and SAVR (n = 2,392) were included. End points were baseline logistic European System for Cardiac Operative Risk Evaluation score, all-cause mortality, cardiovascular mortality, myocardial infarction, stroke, transient ischemic attack, and major bleeding events. Mean differences or risk ratios with 95% confidence intervals were computed, and p values <0.05 were considered significant. The population was matched for risk between the 2 groups on the basis of logistic European System for Cardiac Operative Risk Evaluation score for all outcomes except 30-day all-cause mortality, which had a high-risk population in the TAVI group (p = 0.02). There was no significant difference found in all-cause mortality at 30 days (p = 0.97) and at an average of 85 weeks (p = 0.07). There was no significant difference in cardiovascular mortality (p = 0.54) as well as the incidence of myocardial infarction (p = 0.59), stroke (p = 0.36), and transient ischemic attack (p = 0.85) at averages of 86, 72, 66, and 89 weeks, respectively. Compared with patients who underwent TAVI, those who underwent SAVR had a significantly higher frequency of major bleeding events (p <0.0001) at mean follow-up of 66 weeks. In conclusion, TAVI has similar cardiovascular and all-cause mortality to SAVR at early and long-term follow-up. TAVI is superior to SAVR for major bleeding complications and noninferior to SAVR for postprocedural myocardial infarctions and cerebrovascular events. TAVI is a safe alternative to SAVR in selected high-risk elderly patients with severe aortic stenosis.

Bath salts induced severe reversible cardiomyopathy

Patient: Male, 27 Final Diagnosis: Bath salt induced cardiomyopathy Symptoms: Agitation • fever • pedal edema Medication: Intravenous nor-epinephrine for less than 6 hours Clinical Procedure: — Specialty: Internal medicine • cardiology Objective: Unusual clinical course Background: “Bath salts” is the street name for a group of recently identified and increasingly abused stimulant synthetic cathinones that are associated with multiple systemic effects. We present a case of a patient who developed reversible dilated cardiomyopathy secondary to their use. Case Report: A 27 year old male with no past medical history was brought to emergency department with agitation. He had been inhaling and intravenously injecting “bath salts”, containing a mephedrone/Methylenedioxypyrovalerone (MDPV) combination. On presentation, he was tachycardic, hypotensive and febrile. His initial labs showed an elevated white count, creatinine and creatinine phosphokinase levels. His erythrocyte sedimentation rate; C-reactive protein; urinalysis; urine drug screen; Human Immunodeficiency Virus, hepatitis, coxsackie, and influenza serology were normal. EKG showed sinus tachycardia. An echocardiogram was done which showed dilated cardiomyopathy with an ejection fraction (EF) of 15–20% and global hypokinesia. A left heart catheterization was done and was negative for coronary artery disease. At a 20 week follow up, he had stopped abusing bath salts and was asymptomatic. A repeat echocardiogram showed an EF of 52%. Cocnlusions: Bath salts (MDPV, mephedrone) are synthetic cathinones with amphetamine/cocaine like properties with potential cardiotoxic effects. Cardiovascular manifestations reported include tachycardia, hypertension, myocardial infarction, arrhythmias and cardiac arrest. “Bath salts” can also cause severe reversible dilated cardiomyopathy. Prior to diagnosis, other causes of cardiomyopathy including ischemic, infectious, familial, immunological, metabolic and cytotoxic may need to be ruled out; as was done in our patient.

Comparison of on-treatment platelet reactivity between triple antiplatelet therapy with cilostazol and standard dual antiplatelet therapy in patients undergoing coronary interventions: a meta-analysis.

Background: The recent literature has shown that triple antiplatelet therapy with cilostazol in addition to the standard dual antiplatelet therapy with aspirin and clopidogrel may reduce platelet reactivity and improve clinical outcomes following percutaneous coronary intervention. The purpose of this meta-analysis is to compare the efficacy of triple antiplatelet therapy and dual antiplatelet therapy in regard to on-treatment platelet reactivity. Methods: Nine studies (n = 2179) comparing on-treatment platelet reactivity between dual antiplatelet therapy (n = 1193) and triple antiplatelet therapy (n = 986) in patients undergoing percutaneous coronary intervention were included. Primary end points were P2Y12 reaction unit (PRU) and platelet reactivity index (PRI). Secondary end points were platelet aggregation with adenosine diphosphate (ADP) 5 and 20 µmol/L and P2Y12% inhibition. Mean difference (MD) and 95% confidence intervals (CI) were computed and 2-sided α error <.05 was considered as a level of significance. Results: Compared to dual antiplatelet therapy, triple antiplatelet therapy had significantly lower maximum platelet aggregation with ADP 5 µmol/L (MD: −14.4, CI: −21.6 to −7.2, P < .001) and 20 µmol/L (MD: −14.9, CI: −22.9 to −6.8, P < .001), significantly lower PRUs (MD: −45, CI: −59.4 to −30.6, P < .001) and PRI (MD: −26, CI: −36.8 to −15.2, P < .001), and significantly higher P2Y12% inhibition (MD: 18.5, CI: 2.3 to 34.6, P = .025). Conclusion: Addition of cilostazol to conventional dual antiplatelet therapy significantly lowers platelet reactivity and may explain a decrease in thromboembolic events following coronary intervention; however, additional studies evaluating clinical outcomes will be helpful to determine the benefit of triple antiplatelet therapy.

Arrhythmogenic Right Ventricular Cardiomyopathy: A Case Presentation with a Review

Arrhythmogenic Right Ventricular Cardiomyopathy: A Case Presentation with a Review Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a rare but well known cause of sudden cardiac death (SCD) and malignant arrhythmias. Here we present a case of ARVC in a 26 year old male who had presented with syncope, palpitations and fatigue. Electrocardiogram (ECG) showed epsilon waves and T-wave inversion (TWI) in V1-V3, prolonged QTc of 498 msec and slurred S wave (>55 msec). He was discharged from the hospital on a betablocker and further evaluation with cardiac magnetic resonance imaging (MRI) as well as genetic testing was planned. This case indicates that any younger and middle-age patient who presents with syncope or palpitations, ARVC should be a differential and further work up with any non-invasive modality should be performed provided that there is a high suspicion of ARVC as in this patient with ECG findings suggestive of ARVC.

Cardiac Amyloidosis: An Updated Review With Emphasis on Diagnosis and Future Directions

Cardiac amyloidosis occurs because of abnormal protein (amyloid) deposition in the cardiac tissue. Even with advanced diagnostic techniques and treatments, the prognosis of amyloidosis remains poor. The diagnosis of cardiac amyloidosis particularly needs to be in the differential in patients presenting with heart failure with preserved ejection fraction. This entity remains underdiagnosed due to lack of suspicion on the part of many clinicians. Involvement of cardiac tissue is the utmost determinant factor for available treatment options and prognosis. Many cases of cardiac amyloidosis usually remain undiagnosed or diagnosed only in advanced stages when treatment options are limited and associated with poor survival. Hence, early recognition of cardiac amyloidosis is indispensable in halting the disease process before irreversible changes occur. The purpose of this review is to summarize the recent updates in the evaluation and management of cardiac amyloidosis and to discuss potential future treatments options.

Incidence of Renal Failure Requiring Hemodialysis Following Transcatheter Aortic Valve Replacement

Objective Studies have shown that iodinated radiocontrast use is associated with acute renal failure especially in the presence of chronic kidney disease and multiple factors modulate this risk. The purpose of this meta‐analysis is to compare the incidence of renal failure requiring hemodialysis between transfemoral (TF) and transapical (TA) transcatheter aortic valve replacement using the Edwards valve. Methods The PubMed database was searched from January 2000 through December 2014. A total of 10 studies (n = 2,459) comparing TF (n = 1,268) and TA (n = 1,191) TAVR procedures using the Edwards valve were included. Variables of interest were baseline logistic EuroSCORE, prevalence of diabetes mellitus, hypertension, peripheral arterial disease, chronic kidney disease and amount of contrast used. The primary endpoint was incidence of renal failure requiring hemodialysis. The odds ratio and 95% CI were computed and P < 0.05 was considered as the level of significance. Results The logistic EuroSCORE was significantly higher in TA compared to TF (P = 0.001) TAVR. The amount of contrast (mL) used was significantly higher in the TF group compared to the TA group (mean difference: 36.9, CI: 25.7‐48.1, P < 0.001). The incidence of hemodialysis following the procedure was significantly higher in the TA group compared to TF group (odds ratio = 4.3, CI: 2.4‐7.8, P < 0.00001). Conclusions This meta‐analysis suggests that despite the lower amount of contrast used in TA‐TAVR, the incidence of renal failure requiring hemodialysis was higher with the Edwards valve. This suggests that the incidence of renal failure requiring hemodialysis after TAVR is associated with baseline comorbidities in the TA‐TAVR group rather than the volume of contrast used.

A META–ANALYSIS OF MORTALITY AND MAJOR ADVERSE CARDIOVASCULAR AND CEREBROVASCULAR EVENTS FOLLOWING TRANSCATHETER AORTIC VALVE IMPLANTATION VERSUS SURGICAL AORTIC VALVE REPLACEMENT FOR SEVERE AORTIC STENOSIS

The purpose of this meta–analysis is to compare the post–procedural outcomes of transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) for severe aortic stenosis. Seventeen studies (n=4710) comparing TAVI (n=2288) and SAVR (n=2422) were included. End points

Right Ventricle Perforation Post Pacemaker Insertion Complicated with Cardiac Tamponade

Pacemaker-lead-associated right ventricular perforation is a life-threatening complication. Acute perforation usually presents within 24 hours. Patients with lead perforation are often asymptomatic but fatal complications like hemopericardium, leading to cardiac tamponade and death, are reported. Diagnosis is based on chest x-ray, computed tomography (CT) scan, and echocardiography. The management of the lead perforation is based on clinical presentation. Extraction is avoided in cases of chronic asymptomatic lead perforations because of the associated complications. Urgent intervention is needed in hemodynamically unstable patients with pericardial effusion or cardiac tamponade physiology.

Iatrogenic Pseudoaneurysm: An Uncommon Cause of Deep Vein Thrombosis

Femoral artery pseudoaneurysm (FAP) is a common complication associated with left heart cardiac catheterization. FAP is a pulsatile encapsulated mass usually formed three to seven days after removal of the arterial sheath post cardiac catheterization. Usually, FAP is asymptomatic. Groin pain and swelling are the most common complaints in symptomatic patients. It can be associated with multiple different complications including rupture, bleeding, and vascular compression leading to venous thrombosis, limb ischemia, and neuropathy. Deep vein thrombosis (DVT) resulting from FAP is an unusual complication with very few cases reported in the literature. We present a case of right-sided DVT secondary to the compression of femoral vein resulting in venous outflow obstruction due to iatrogenic FAP post cardiac catheterization that was successfully managed conservatively.

A Rare Case of Complete Fragmentation of Pacemaker Lead after a High-Velocity Theme Park Ride

Pacemaker lead fracture is one of the most common causes of pacemaker malfunction and is most frequently associated with weight lifting or chest trauma. These patients usually present with symptoms of dizziness, syncope, chest discomfort, and palpitations or less commonly with extracardiac symptoms. Diagnosis is made by ECG and careful review of chest imaging such as chest X-ray or fluoroscopy. Treatment involves placement of a new lead with or without extraction of the fractured lead. We present an interesting case of complete severance of the tip of a dual-chamber pacemakers atrial lead after a high-velocity theme park ride. In our case, the fracture occurred during amusement park rides and went undiagnosed until the patient presented for routine pacemaker evaluation. This case indicates that extreme physical forces in the absence of direct trauma, such as during amusement park rides, may result in lead fractures and patients with pacemakers should be cautioned regarding such activities.