Spontaneous coronary artery dissection in a patient with hereditary polycystic kidney disease and a recent liver transplant : a case report

Background Spontaneous coronary artery dissection (SCAD) is an underestimated cause of acute coronary syndromes. A predisposing arteriopathy is often present and a stressor can sometimes be identified. Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary kidney disorder; its associated arteriopathy has been described as a predisposing condition for SCAD. Case summary A 44-year-old woman with ADPKD presented in the emergency room with recent onset thoracic pain radiating to the left arm at rest. She had undergone a recent liver transplant, for which she had received high-dose corticosteroids during 1 month. She was still taking tacrolimus and mycophenolate mofetil. She had no traditional risk factors but had experienced stress post-operatively. She was known with moderate chronic kidney disease. The initial electrocardiogram (ECG) was normal but high-sensitive troponin T was significantly elevated. Coronary angiography demonstrated diffuse narrowing of the distal left anterior descending artery with preserved flow, compatible with a SCAD Type 2 that was treated conservatively. However, under dual antiplatelet therapy (DAPT) with clopidogrel, the coronary dissection was progressive with new ischaemic ECG changes, further rise of troponins and development of apicoseptal hypokinesia. Because of the small vessel diameter and the preserved distal flow, conservative treatment was maintained. Clopidogrel was interrupted and the patient remained stable. Discussion As SCAD remains an underestimated cause of myocardial infarction, clinicians should be aware of the possibility of SCAD in ADPKD patients with chest pain. This case report illustrates that the decision DAPT vs. aspirin should be individualized in these patients

Septal flash is a prevalent and early dyssynchrony marker in transcatheter aortic valve replacement-induced left bundle branch block

New-onset left bundle branch block (LBBB) is a frequent complication after transcatheter aortic valve replacement (TAVR) and provides an opportunity to study dyssynchrony immediately following acute LBBB. This study aims to (1) assess echocardiographic dyssynchrony in acute TAVR-induced LBBB (TAVR-LBBB), and (2) compare dyssynchrony parameters among different patient groups with LBBB. The study enrolled all TAVR-LBBB patients at Ghent University Hospital between 2013 and 2019. First, acute TAVR-LBBB dyssynchrony was assessed by: (1) septal flash (SF); (2) interventricular mechanical delay (IVMD; cut-off >= 40 ms) and (3) presence of 'classical dyssynchronous strain pattern' assessed with speckle tracking. Secondly, acute TAVR-LBBB patients with SF (LBBBTAVR+SF) were compared to randomly selected LBBB-SF patients with preserved (LBBBSF+PEF) and reduced ejection fraction (LBBBSF+REF). In TAVR-LBBB patients (n = 25), SF was detected in 72% of patients, whereas only 5% of TAVR-LBBB patients showed a classical dyssynchronous strain pattern. IVMD in these TAVR-LBBB patients was 39 ms. In 90% of LBBBTAVR+SF patients, SF was observed within 24 h after LBBB onset. Among LBBB-SF patients, a classical strain pattern was more prevalent in LBBBSF+REF patients compared to LBBBTAVR+SF patients (80% vs. 7%; p < 0.001). IVMD was significantly longer in LBBBSF+PEF patients (52 ms; p = 0.002) and LBBBSF+REF patients (57 ms; p = 0.009) compared to LBBBTAVR+SF patients (37 ms). SF is an early and prevalent marker of LV dyssynchrony in acute TAVR-LBBB, whereas strain-based measures and IVMD do not appear to capture dyssynchrony at this early stage. Our findings from the comparative analysis generate the hypothesis that progressive LBBB-induced LV remodeling may be required for a 'classical dyssynchrony strain pattern' or significant IVMD to occur in TAVR-LBBB patients

Feasibility and performance of a device for automatic self-detection of symptomatic acute coronary artery occlusion in outpatients with coronary artery disease : a multicentre observational study

Background Time delay between onset of symptoms and seeking medical attention is a major determinant of mortality and morbidity in patients with acute coronary artery occlusion. Response time might be reduced by reliable self-detection. We aimed to formally assess the proof-of-concept and accuracy of self-detection of acute coronary artery occlusion by patients during daily life situations and during the very early stages of acute coronary artery occlusion. Methods In this multicentre, observational study, we tested the operational feasibility, specificity, and sensitivity of our RELF method, a three-lead detection system with an automatic algorithm built into a mobile handheld device, for detection of acute coronary artery occlusion. Patients were recruited continuously by physician referrals from three Belgian hospitals until the desired sample size was achieved, had been discharged with planned elective percutaneous coronary intervention, and were able to use a smartphone; they were asked to perform random ambulatory selfrecordings for at least 1 week. A similar self-recording was made before percutaneous coronary intervention and at 60 s of balloon occlusion. Patients were clinically followed up until 1 month after discharge. We quantitatively assessed the operational feasibility with an automated dichotomous quality check of self-recordings. Performance was assessed by analysing the receiver operator characteristics of the ST difference vector magnitude. This trial is registered with ClinicalTrials.gov, number NCT02983396. Findings From Nov 18, 2016, to April 25, 2018, we enrolled 64 patients into the study, of whom 59 (92%) were eligible for self-applications. 58 (91%) of 64 (95% CI 81.0-95.6) patients were able to perform ambulatory self-recordings. Of all 5011 self-recordings, 4567 (91%) were automatically classified as successful within 1 min. In 65 balloon occlusions, 63 index tests at 60 s of occlusion in 55 patients were available. The mean specificity of daily life recordings was 0.96 (0.95-0.97). The mean false positive rate during daily life conditions was 4.19% (95% CI 3.29-5.10). The sensitivity for the target conditions was 0.87 (55 of 63; 95% CI 0.77-0.93) for acute coronary artery occlusion, 0.95 (54 of 57; 0.86-0.98) for acute coronary artery occlusion with electrocardiogram (ECG) changes, and 1.00 (35 of 35) for acute coronary artery occlusion with ECG changes and ST-segment elevation myocardial infarction criteria (STEMI). The index test was more sensitive to detect a 60 s balloon occlusion than the STEMI criteria on 12-lead ECG (87% vs 56%; p<0.0001). The proportion of total variation in study estimates due to heterogeneity between patients (I-2) was low (12.6%). The area under the receiver operator characteristics curve was 0.973 (95% CI 0.956-0.990) for acute coronary artery occlusion at different cutoff values of the magnitude of the ST difference vector. No patients died during the study. Interpretation Self-recording with our RELF device is feasible for most patients with coronary artery disease. The sensitivity and specificity for automatic detection of the earliest phase of acute coronary artery occlusion support the concept of our RELF device for patient empowerment to reduce delay and increase Survival without overloading emergency services. Copyright (C) 2019 The Author(s). Published by Elsevier Ltd

Different dynamics of new-onset electrocardiographic changes after balloon- and self-expandable transcatheter aortic valve replacement : implications for prolonged heart rhythm monitoring

Background: Newonset electrocardiographic (ECG) changes after transcatheter aortic valve replacement (TAVR) are used to assess the risk for late atrioventricular block. However, the time of ECG evaluation remains controversial. We aimed to compare the time course and dynamics of newonset ECG changes according to valve design in balloon- (BEV) and self-expandable (SEV) TAVR. Methods and results: This single center study enrolled 133 consecutive TAVR patients (28.6% SEV, 71.4% BEV). Patients with pre-existent permanent pacemaker implant (PPMI), procedural death or incomplete ECG registration were excluded. Standard 12-lead ECG was performed before the procedure, at 1, 24, 48 and 120 h and 1 month. In BEV patients, no significant PR prolongation occurred, whereas in SEV patients the PR interval prolonged significantly with 33.7 +/- 22.0 ms (p 24 h after TAVR) was higher in SEV compared to BEV patients (15.3% versus 1.5%, p= 0.008). Conclusion: Self-expandable valves cause more impairment in atrioventricular conduction with a delayed time course compared to balloon expandable valves. This might explain the higher pacemaker need beyond 24 h after TAVR. Our findings suggest that patients with self-expandable valves require at least 48 h ECG monitoring post TAVR. (c) 2020 Published by Elsevier Inc

Congenital hemangioma of the skull

Background: A newborn (male, 6 hour-old) was referred to the radiology department for imaging of a solid tumor-like nodular lesion on the vertex of the skull. The treating pediatrician wanted to exclude a (meningo)-encephalocele or other dysraphism-like lesion

A rare case of a uni-leaflet mitral valve in a 65-year-old woman

A rare case of a uni-leaflet mitral valve in a 65-year-old woma