Yasir Yaqub

Postpartum Depression and Apical Ballooning Syndrome (Takotsubo Syndrome)

BACKGROUND Acute cardiac complications occur occasionally during pregnancy and in the immediate postpartum period. Some of these cardiac scenarios are rare and provide a diagnostic challenge. We report a case of apical ballooning syndrome (ABS), also known as takotsubo cardiomyopathy or broken-heart syndrome, in a postpartum patient. CASE A 32-year-old multigravid woman presented at 17 days after delivery with chest pain typical for cardiac ischemic pain. Her prior obstetrical history included two uncomplicated vaginal deliveries, and the current postpartum period had been uncomplicated until the time of presentation. Cardiac catheterization was performed and showed normal coronary blood vessels with no evidence of coronary artery occlusion. Left ventricular systolic function was moderately depressed, with an ejection fraction of 45%. The patient had full recovery of myocardial function in less than 40 days, with a subsequent echocardiogram during that time showing a normal ejection fraction of 65%. CONCLUSION Apical ballooning syndrome is a rare reversible cardiac condition that should be differentiated from ischemic and peripartum cardiomyopathy, especially in the immediate postpartum period.

Effect of Pioglitazone on Platelet Aggregation in a Healthy Cohort

Background: Peroxisome proliferator-activated receptor (PPAR) agonists can favorably influence atheroma proliferation, lipoprotein metabolism and macrovascular complications. Pioglitazone, one of the thiazolidinedione compounds, is a PPAR ligand activator and a clinically important PPAR agonist. There is controversy in the literature about its potential antiplatelet effects. Its direct platelet inhibition is a novel hypothesis tested in animal models and in human populations with underlying diabetic and/or cardiovascular diseases. The present study was aimed to test the hypothesis of direct platelet aggregation inhibition with the use of pioglitazone in a healthy population. Methods: This prospective study was started after obtaining institutional review board approval. The platelet aggregation response to adenosine diphosphate, epinephrine, collagen and arachidonic acid was measured in healthy subjects before and after treatment with pioglitazone. The fasting lipid profile including total cholesterol, low-density lipoprotein, very-low-density lipoprotein and high-density lipoprotein was also measured. Results: Twenty subjects, 12 males and 8 females, were enrolled with a mean age of 31.5 ± 7.6 years (range 24–46). Two subjects did not complete the study and were excluded. The mean HbA1C was 5.4% (range 4.7–5.7). The study showed a non-significant platelet aggregation reduction after taking a 7-day pioglitazone course. The adenosine diphosphate-mediated platelet aggregation difference was not significant (p = 0.99); the arachidonic acid-mediated platelet aggregation difference was 0.6% (p = 0.93), for epinephrine 0.9% (p = 0.88) and for collagen 0.2% (p = 0.94). Further, it did not show a favorable response of lipoprotein profile with a non-significant reduction in all lipid panel values even though there is a slight reduction in total cholesterol, triglyceride, low-density lipoprotein and very low-density lipoprotein and a slight increase in high-density lipoprotein. Conclusions: We conclude that pioglitazone does not have a direct platelet aggregation inhibition effect in a healthy population, nor does it have a favorable effect on lipoprotein profile after a short treatment period.

Emotional Stress and Tako-Tsubo Cardiomyopathy: Observations on 2 Distinct Clinical Phenotypes

Background Tako-tsubo syndrome is a transient cardiomyopathy usually precipitated by an acute emotional or physiological stress. Our study objectives were to review and analyze the impact of emotional stress on clinical variables, echocardiographic characteristics, and short-term outcomes in patients with tako-tsubo syndrome. Methods Retrospective chart review. Results Eleven patients presented with tako-tsubo syndrome (1 man and 10 women) during the 8-year period (January 2000 to January 2008). The patients were split into 2 groups, defined by presenting either after emotional stress (6/11, 54.5%) or after idiopathic/physical stress (5/11, 45.5%). The mean age was 53.8 (12.6) years. The mean peak troponin T level was 0.54 ng/mL (range, 0.03-2.06 ng/mL), and the mean left ventricular end-diastolic pressure was 15.8 (8.1) mm Hg. Emotional stress was associated with younger age (P = 0.024), a lower left ventricular end-diastolic pressure (P < 0.05), more ST segment changes on electrocardiogram (66.7% vs 40%), and a higher ejection fraction (P = 0.012). The patients in the idiopathic/physical stress group required more frequent hemodynamic support. Conclusions We conclude that clinical, echocardiographic, and outcome characteristics can differentiate tako-tsubo patients presenting with emotional stress from those with idiopathic/physical stress into 2 distinct clinical phenotypes. Clinicians should monitor idiopathic/physically stressed tako-tsubo patients carefully for hemodynamic compromise.

LASER endovascular atherectomy with secondary stenting of technically challenging calcified celiac trunk stenosis

Endovascular therapy for chronic mesenteric ischemia is a proven, feasible alternative approach to open surgical repair with significantly lower morbidity and mortality. A clinical dilemma is encountered when technically challenging lesions are encountered during the procedure. We present here an 86 year‐old woman who had intractable abdominal pain with postprandial exacerbation. The patient had successful endovascular light amplification by stimulated emission of radiation atherectomy of a highly calcified celiac truck, showing the feasibility of this technique.

Isolated Pulmonary Valve Endocarditis Complicated With Septic Emboli to the Lung Causing Pneumothorax, Pneumonia, and Sepsis in an Intravenous Drug Abuser

Intravenous drug users are at increased risk for developing right-sided infective endocarditis involving the tricuspid and pulmonary valves. Isolated pulmonary valve endocarditis in intravenous drug users is very rare, and these patients often have more complications, such as pulmonary embolism, sepsis, and pneumonia. We report a case with pulmonary valve endocarditis and extensive pulmonary complications, including sepsis, septic emboli, pneumonia, and pneumothorax. Early identification of pulmonic valve endocarditis and treatment with appropriate antibiotics with or without surgical management should provide better outcomes, and clinicians need to think about pulmonary valve endocarditis in patients with complex respiratory presentations.

Klippel-Trenaunay syndrome and radial artery coronary graft spasm.

A 75-year-old woman with known diagnosis of Klippel-Trenaunay syndrome presented with acute onset of chest pain, dyspnea and elevated cardiac enzymes. She had triple vessel coronary artery disease on subsequent coronary angiography. Given the unavailability of venous conduits secondary to lower extremity varicosities, coronary artery bypass grafting with radial and internal mammary arterial grafts was carried out. The radial artery graft went into spasm two days later and required intracoronary vasodilators to relieve the spasm. The patient remained hypotensive and finally expired.

The feasibility of transradial laser atherectomy for chronic total occlusion using the 5 Fr sheath system.

OBJECTIVE We present a case of chronic total occlusion (CTO) approached with LASER endovascular intervention by radial artery approach using a 5 French sheath. CASE REPORT A 57-year-old man presented to our hospital having had retrosternal chest pain for two days. Physical examination was normal at the time of presentation. The laboratory tests were within normal limits, including cardiac enzymes except the lipid panel which showed hypertriglyceridemia. The patient underwent a myocardial perfusion scintigraphy stress test that revealed inferior wall ischemia, with normal left ventricular ejection fraction. A 5-French vascular sheath was placed in the right radial artery. Selective coronary artery angiography was performed, which showed right coronary artery (RCA) CTO. A 5-French JR4 guide catheter successfully engaged the RCA and Laser angioplasty was performed across the CTO into the RCA. A marked improvement of flow was evident thereafter. CONCLUSION To best of our knowledge this is the first case report showing the feasibility of laser atherectomy using the 5 French sheath system in a coronary arterial CTO.

Placental growth factor: a new kid on the block?

Placental growth factor (PIGF) belongs to a family of vascular endothelial growth factors (VEGF) which includes VEGF itself (also known as VEGF-A) and other homologues like VEGF-B, VEGF-C, VEGF-D, VEGF-E, and PIGF. These growth factors bind to vascular endothelial growth factor receptors (VEGFR) and have been implicated in atherosclerotic plaque instability and coronary neovasculogenensis, 4 especially by activating VEGFR-1 found mostly in vascular endothelium. PIGF, originally discovered in placenta, has recently been found in cardiac, pulmonary, musculoskeletal, and thyroid tissues. Endothelial cells produce small amounts of this biomarker, but when stimulated by ischemia or injury, PIGF is produced in copious amounts triggering an angiogenesis switch. PIGF and VEGFR-1 interaction contributes to angiogenic switch by increasing the crosslinking interaction of VEGFR-1 and VEGFR-2, by amplifying VEGF-A activity on VEGFR-2 and by triggering PIGF-induced signaling on VEGFR-1. The ultimate effects are PIGF-induced endothelial cell enhancement of VEGF angiogenic activity and recruitment of inflammatory cells, hematopoietic stem cells, and vascular stem cells from the bone marrow. Inhibition of PIGF-related VEGFR-1 activation by an antiVEGFR-1 monoclonal antibody leads to inhibition of inflammation and atherogenic plaque proliferation in animal studies. Recently there has been evidence of a correlation between the short-term outcome in coronary artery disease (CAD) patients and PIGF. These studies have shown correlations between PIGF and CAD endpoints, including myocardial infarction (MI), death, and recurrent ischemia. Some studies have suggested its use as early biomarker for coronary artery disease activity, given its association with early inflammatory markers, angiogenesis, and macrophage recruitment causing plaque destabilization during an acute coronary event. These studies also have shown a better correlation between elevated PIGF levels and an increased risk of major adverse cardiovascular events (including nonfatal MI and death) at 30 days, six months, and four years than troponin T, high-sensitive C-reactive protein, and platelet activation markers (soluble CD40 ligands) in patients with suspected acute coronary syndrome (ACS) presenting with chest pain. Other studies have shown increased PIGF levels correlate with the whole spectrum of CAD, including acute myocardial infarction, unstable angina, and stable angina. High levels of PIGF predict a decreased mean, event-free survival. In the study reported in this issue of the Journal by Markovic et al, the authors analyzed the 30-day outcome in patients who presented with MI or ACS without ST segment elevation (NSTEMI or NSTACS). The authors prospectively investigated the role of PIGF as a single marker in NSTEMI patients as compared to previous studies which investigated PIGF with multiple biomarkers. PIGF was measured in 102 patients within 12 hours of arrival in the emergency room, and patients were followed for 30 days. PIGF was an independent risk factor for coronary disease outcomes at 30 days (HR 2.14; CI 1.08 – 4.22). Age 65 years (HR 2.16, CI 1.08 – 4.29) and male gender (HR 0.38; CI 0.14 – 0.66) also correlated with fatal outcomes. The authors conclude that increased PIGF levels are associated with adverse cardiovascular outcome at 30 days in NSTEMI patients. The precise role of PIGF in early detection of CAD patients who are at increased risk of plaque destabilization is an exciting avenue of investigation; studies like these can stratify CAD patients in various disease categories with high-to-low risk profile for plaque stabilization. The role of PIGF as a marker of unstable atherosclerotic plaque will also help to stratify disease management in CAD patients and may become a useful early biomarker in coronary artery disease diagnosis and in predicting prognosis. From the Department of Internal Medicine, Texas Tech University Health Science Center, Lubbock, TX; Division of Cardiology, Texas Tech University Health Science Center, Lubbock, TX; and Department of Internal Medicine, Texas Tech University Health Science Center, Lubbock, TX.