Cardiac Fibroelastoma versus Thrombus: Echocardiographic Evidence Can Be Misleading

We present a case of a young female with stroke symptoms who underwent valve sparing resection of a presumed fibroelastoma based on echocardiographic findings. After confirming embolic stroke, she underwent excision of the lesion, which on pathology revealed a nonbacterial thrombus. Ultimately, this led to a more extensive work-up leading to the discovery of a papillary serous ovarian carcinoma, the underlying cause of her hypercoagulable state. The initial echocardiographic findings painted the clear picture of a papillary tumor on the aortic valve which was likely the source of the emboli resulting in ischemic stroke. This unique case presentation illustrates that imaging, including echocardiography, may not always coincide with the clinical diagnosis. Thus, understanding the differential diagnoses of cardiac masses is of vital clinical significance. The distinction of fibroelastoma versus the much less common finding of aortic thrombus may lead to early diagnosis of malignancy and prevention of life threatening events due to stroke or undiagnosed disease

Extracorporeal Membrane Oxygenation as a Bridge through Chemotherapy in B-Cell Lymphoma

A 41-year-old female presented with a large anterior mediastinal mass adjacent to the heart. Biopsy demonstrated lymphoma. Upon administration of chemotherapy, she developed cardiogenic shock requiring a 5-day course of extracorporeal membrane oxygenation (ECMO) as a bridge through her treatment. After one cycle of chemotherapy, ECMO was discontinued and the patient completed her course of chemotherapy and recovered to hospital discharge

Cautionary tale of right ventricular perforation during Micra™ leadless pacemaker insertion

Abstract Transcatheter pacing systems are self‐contained, leadless, devices that offer the potential benefits of avoiding complications related to pectoral pocket and upper extremity vascular access. These systems in preapproval trials demonstrated excellent safety profile with the incidence of device‐related cardiac perforation as low as 1.6% with Micra™ (Medtronic) and 1.3% in Nanostim (Abbott). In post‐approval registry of Micra™ TPS, the rate of major complications was even lower than in the investigational study ranging from 0.63% to 0.77%. Recently, published report found much higher rates of need for rescue surgery, shock, tamponade, and death among patients implanted with the Micra™ device when compared with transvenous devices. This case report describes two cases of major right ventricular perforation requiring surgical intervention

Mechanisms of c-reactive protein up-regulation in arterialized vein grafts

Background. C-reactive protein (CRP), an acute phase reactant, is an independent predictor of coronary artery syndromes and a mediator of the vascular response to injury. CRP has been found in arterialized vein grafts and has been linked to atherogenesis; however, its involvement in vein graft early failure or intimal hyperplasia has not been assessed. This study was designed to investigate the mechanism(s) of CRP up-regulation in arterialized vein grafts. Methods. Carotid artery bypass with arterialized jugular vein grafts (AVG) was performed in 18 dogs. AVG were harvested at 3, 8, and 24 hours and 4, 14, and 28 days, using the femoral vein obtained at the time of AVG harvest as a control. Serum CRP levels were characterized by enzyme-linked immunosorbent assay; AVG expression of CRP was studied by immunofluorescence, Western blotting, in situ hybridization, Northern blotting, and quantitative RT-PCR. Results. CRP levels peaked at 24 hours in serum and AVG but remained at baseline in control veins. By double immunofluorescence, CRP was associated with the media and adventitia of AVG. However, Northern blotting analysis showed no CRP mRNA expression in AVG. Reverse transcriptase polymerase chain reaction analysis confirmed the lack of up-regulation of CRP in AVG. Conclusion. CRP levels are increased in AVG, peaking 24 hours after arterialization. However, no significant production of CRP was detected in AVG. Therefore, increased CRP levels within AVG appear to originate mostly from CRP diffusion from the systemic circulation. These results have significant implications for the development of strategies aimed at blocking CRP up-regulation in bypass grafts. © 2006 Mosby, Inc. All rights reserved

Distal Perfusion Cannulation and Limb Complications in Venoarterial Extracorporeal Membrane Oxygenation

The utility of distal perfusion cannula (DPC) placement for the prevention of limb complications in patients undergoing femoral venoarterial (VA) extracorporeal membrane oxygenation (ECMO) is poorly characterized. Patients undergoing femoral VA ECMO cannulation at two institutions were retrospectively assessed. Patients were grouped into those who did and those who did not receive a DPC at the time of primary cannulation. The primary outcome was any limb complication. Secondary outcomes included successfully weaning ECMO and in-hospital mortality. A total of 75 patients underwent femoral cannulation between December 2010 and December 2017. Of those, 65 patients (86.7%) had a DPC placed during primary cannulation and 10 patients (13.3%) did not. Baseline demographics, indications for ECMO, and hemodynamic perturbations were well matched between groups. The rate of limb complications was 14.7% (11/75) for the overall cohort and did not differ between groups (p = .6). Three patients (4%) required a four-compartment fasciotomy for compartment syndrome in the DPC group; no patients without a DPC required fasciotomy. Of the three patients who required a thrombectomy for distal ischemia, two were in the DPC group and one was in the no-DPC group (p = .3). Two patients (2.7%) underwent delayed DPC placement for limb ischemia with resolution of symptoms. The in-hospital morality rate was 59.5% and did not differ between groups (p = .5). Patients in the present study, undergoing femoral VA ECMO without preemptive DPC placement did not experience a higher rate of limb complications. However, the two patients who underwent delayed DPC placement for post-cannulation ischemia experienced resolution of symptoms, suggesting that a DPC may be used as an effective limb salvage intervention

Reduced Right Ventricular Function Predicts Long-Term Cardiac Re-Hospitalization after Cardiac Surgery.

The significance of right ventricular ejection fraction (RVEF), independent of left ventricular ejection fraction (LVEF), following isolated coronary artery bypass grafting (CABG) and valve procedures remains unknown. The aim of this study is to examine the significance of abnormal RVEF by cardiac magnetic resonance (CMR), independent of LVEF in predicting outcomes of patients undergoing isolated CABG and valve surgery.From 2007 to 2009, 109 consecutive patients (mean age, 66 years; 38% female) were referred for pre-operative CMR. Abnormal RVEF and LVEF were considered 30 days) outcomes included, cardiac re-hospitalization, worsening congestive heart failure and mortality. Mean clinical follow up was 14 months.Forty-eight patients had reduced RVEF (mean 25%) and 61 patients had normal RVEF (mean 50%) (p<0.001). Fifty-four patients had reduced LVEF (mean 30%) and 55 patients had normal LVEF (mean 59%) (p<0.001). Patients with reduced RVEF had a higher incidence of long-term cardiac re-hospitalization vs. patients with normal RVEF (31% vs.13%, p<0.05). Abnormal RVEF was a predictor for long-term cardiac re-hospitalization (HR 3.01 [CI 1.5-7.9], p<0.03). Reduced LVEF did not influence long-term cardiac re-hospitalization.Abnormal RVEF is a stronger predictor for long-term cardiac re-hospitalization than abnormal LVEF in patients undergoing isolated CABG and valve procedures

Analysis of early (≤ 30-d) and long-term (> 30-d) outcomes associated with RVEF <35% and RVEF ≥ 35%.

<p>ICU, intensive care unit; IQR, interquartile range; LFT, liver function test; postoperative complications (i.e. reoperations for bleeding, early valve reoperations, deep sternal infection, early stroke, early transient ischemic attack, pacemaker implantation, myocardial infarction, atrial fibrillation and renal insufficiency requiring dialysis).</p><p>Analysis of early (≤ 30-d) and long-term (> 30-d) outcomes associated with RVEF <35% and RVEF ≥ 35%.</p