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1.  Isolated Spontaneous Celiac Artery Dissection in a 47-Year-Old Man with von Willebrand Disease 
Texas Heart Institute Journal  2014;41(3):344-345.
Isolated spontaneous dissection of the celiac artery is rare, and its occurrence without aortic dissection is even rarer. The typical symptom of this dissection is acute-onset abdominal pain. Complications of the condition include aneurysm formation, rupture, and abdominal-organ ischemia or infarction, especially in the liver or spleen. We report the case of a 47-year-old man with von Willebrand disease who had an isolated spontaneous dissection of the celiac artery. We used computed tomography and computed tomographic angiography in the diagnosis and characterization of the dissection. To our knowledge, this is the first report of celiac artery dissection in a patient with von Willebrand disease.
PMCID: PMC4060327  PMID: 24955061
Celiac artery/pathology/radiography; tomography, x-ray computed/methods; von Willebrand disease
2.  Cardioverter-Defibrillator Implantation to Treat Cardiac Fibroma-Induced Ventricular Tachycardia in a 70-Year-Old Woman 
Texas Heart Institute Journal  2014;41(3):329-331.
Benign cardiac fibroma is rarely reported in adults. Its clinical symptoms are related to outflow obstruction or dysrhythmias. We present the case of a 70-year-old woman who had a syncopal episode from ventricular tachycardia caused by cardiac fibroma. Because of unfavorable tumor anatomy, the patient was not a candidate for surgical excision, and she declined orthotopic heart transplantation. To prevent sudden cardiac death, we placed an implantable cardioverter-defibrillator, and the patient remained well throughout the 2-year follow-up period. To our knowledge, this is the first report of implantable cardioverter-defibrillator therapy to treat an adult patient's unresectable cardiac fibroma.
PMCID: PMC4060326  PMID: 24955056
Adult; cardioverter-defibrillators, implantable/therapy/utilization; fibroma/diagnosis/pathology; tachycardia, ventricular/etiology; treatment outcome
3.  Slope of the Anterior Mitral Valve Leaflet: A New Measurement of Left Ventricular Unloading for Left Ventricular Assist Devices and Systolic Dysfunction 
Texas Heart Institute Journal  2014;41(3):262-272.
Left ventricular assist device (LVAD)-supported patients are evaluated routinely with use of transthoracic echocardiography. Values of left ventricular unloading in this unique patient population are needed to evaluate LVAD function and assist in patient follow-up.
We introduce a new M-mode measurement, the slope of the anterior mitral valve leaflet (SLAM), and compare its efficacy with that of other standard echocardiographically evaluated values for left ventricular loading, including E/e′ and pulmonary artery systolic pressures. Average SLAM values were determined retrospectively for cohorts of random, non-LVAD patients with moderately to severely impaired left ventricular ejection fraction (LVEF) (<0.35, n=60). In addition, pre- and post-LVAD implantation echocardiographic images of 81 patients were reviewed.
The average SLAM in patients with an LVEF <0.35 was 11.6 cm/s (95% confidence interval, 10.4–12.8); SLAM had a moderately strong correlation with E/e′ in these patients. Implantation of LVADs significantly increased the SLAM from 7.3 ± 2.44 to 14.7 ± 5.01 cm/s (n=42, P <0.0001). The LVAD-supported patients readmitted for exacerbation of congestive heart failure exhibited decreased SLAM from 12 ± 3.93 to 7.3 ± 3.5 cm/s (n=6, P=0.041). In addition, a cutpoint of 10 cm/s distinguished random patients with LVEF <0.35 from those in end-stage congestive heart failure (pre-LVAD) with an 88% sensitivity and a 55% specificity.
Evaluating ventricular unloading in LVAD patients remains challenging. Our novel M-mode value correlates with echocardiographic values of left ventricular filling in patients with moderate-to-severe systolic function and dynamically improves with the ventricular unloading of an LVAD.
PMCID: PMC4060328  PMID: 24955040
Echocardiography, Doppler/methods/trends; health status indicators; heart failure/classification/physiopathology/therapy; heart-assist devices; models, theoretical; predictive value of tests; reference values; sensitivity and specificity; severity of illness index; ventricular function/physiology
4.  Multidetector Computed Tomographic Imaging of Erdheim-Chester Disease 
Texas Heart Institute Journal  2014;41(3):338-340.
Erdheim-Chester disease is a rarely reported disease that can affect nearly every organ and chiefly infiltrates the connective, perivascular, and adipose tissue. The disease is a form of non-Langerhans-cell histiocytosis characterized by the proliferation of foamy histiocytes; its cardiovascular complications carry a severe prognosis. We present the case of a 29-year-old woman who was admitted for analysis of her angina. Our evaluation with use of cardiac multidetector computed tomographic angiography revealed large mediastinal soft tissue that compressed the patient's left anterior descending coronary artery. To our knowledge, this is the first report of the use of low-dose, dual-source, 256-slice multidetector computed tomography to characterize Erdheim-Chester disease that exclusively caused angina and stenosis of a coronary artery in a young adult.
PMCID: PMC4060329  PMID: 24955059
Angina pectoris/etiology; coronary vessels/pathology; Erdheim-Chester disease/diagnosis/pathology/radiography; heart diseases/complications/etiology; histiocytosis, non-Langerhans-cell/diagnosis; tomography, x-ray computed/diagnostic use
5.  Patent Foramen Ovale 
Texas Heart Institute Journal  2014;41(3):306-308.
PMCID: PMC4060330  PMID: 24955048
Aspirin/therapeutic use; cardiac catheterization/adverse effects; embolism, paradoxical/prevention & control; foramen ovale, patent/complications/surgery; ischemic attack, transient/drug therapy/etiology/prevention & control; platelet aggregation inhibitors; risk factors; septal occluder device/adverse effects; stroke/drug therapy/prevention & control; warfarin/therapeutic use
6.  ★ CME Assessment Questions 
PMCID: PMC4060331  PMID: 24955050
7.  Natural Progression of Low-Gradient Severe Aortic Stenosis with Preserved Ejection Fraction 
Texas Heart Institute Journal  2014;41(3):273-279.
Because the natural progression of low-gradient aortic stenosis (LGAS) has not been well defined, we performed a retrospective study of 116 consecutive patients with aortic stenosis who had undergone follow-up echocardiography at a median interval of 698 days (range, 371–1,020 d). All patients had preserved left ventricular ejection fraction (>0.50) during and after follow-up.
At baseline, patients were classified by aortic valve area (AVA) as having mild stenosis (≥1.5 cm2), moderate stenosis (≥1 to <1.5 cm2), or severe stenosis (<1 cm2). Severe aortic stenosis was further classified by mean gradient (LGAS, mean <40 mmHg; high-gradient aortic stenosis [HGAS], mean ≥40 mmHg). We compared baseline and follow-up values among 4 groups: patients with mild stenosis, moderate stenosis, LGAS, and HGAS.
At baseline, 30 patients had mild stenosis, 54 had moderate stenosis, 24 had LGAS, and 8 had HGAS. Compared with the moderate group, the LGAS group had lower AVA but similar mean gradient. Yet the actuarial curves for progressing to HGAS were significantly different: 25% of patients in LGAS reached HGAS status significantly earlier than did 25% of patients in the moderate-AS group (713 vs 881 d; P=0.035).
Because LGAS has a high propensity to progress to HGAS, we propose that low-gradient aortic stenosis patients be closely monitored as a distinct subgroup that warrants more frequent echocardiographic follow-up.
PMCID: PMC4060332  PMID: 24955041
Aortic valve stenosis; blood flow velocity; calcinosis/complications; disease progression; echocardiography; forecasting; prognosis; retrospective studies; risk assessment; stroke volume; time factors; ventricular function, left
9.  What Is New in the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Risk in Adults? 
Texas Heart Institute Journal  2014;41(3):304-305.
PMCID: PMC4060334  PMID: 24955047
Arterial disease, peripheral; atherosclerosis; cholesterol, low-density-lipoprotein; cholesterol, non-high-density-lipoprotein; guidelines, cholesterol-management; hypercholesterolemia; risk calculator; statin therapy, long-term; statins, use of
10.  Role of Isoproterenol in Predicting the Success of Catheter Ablation in Patients with Reproducibly Inducible Atrioventricular Nodal Reentrant Tachycardia 
Texas Heart Institute Journal  2014;41(3):280-285.
Noninducibility of the arrhythmia is the widely accepted endpoint of successful ablation of atrioventricular nodal reentrant tachycardia (AVNRT). However, to rely upon that as the only endpoint, the arrhythmia must also be inducible before ablation. Despite the fact that AVNRT is not reproducibly inducible in a significant number of cases, the role of reproducible arrhythmia induction and its relationship with the infusion of isoproterenol after successful ablation of AVNRT has not been well defined.
We studied 175 consecutive patients who all underwent successful radiofrequency ablation after showing that they had reproducibly inducible AVNRT without use of isoproterenol. In Group 1 (n=90), isoproterenol was used for arrhythmia reinduction after ablation, whereas in Group 2 (n=85) it was not. The procedural and follow-up data of both groups were recorded, and the results of appropriate statistical tests were analyzed.
During a mean follow-up time of 18.7 ± 4.5 months, 4 patients in Group 1 and 3 patients in Group 2 experienced recurrences. Regardless of elimination or modification of slow-pathway conduction, no significant difference was seen in the recurrence rates of AVNRT between the 2 groups (P=0.72).
We conclude that, when the original arrhythmia in patients with AVNRT is reproducibly inducible in the basal state, the use of isoproterenol after ablation in order to confirm the noninducibility of AVNRT does not appear to alter the recurrence rates and can be omitted.
PMCID: PMC4060335  PMID: 24955042
Arrhythmia induction; arrhythmias, cardiac/prevention & control; catheter ablation; isoproterenol; recurrence; retrospective studies; tachycardia, atrioventricular nodal reentry; treatment outcome
11.  Takotsubo Cardiomyopathy 
Texas Heart Institute Journal  2014;41(3):299-303.
PMCID: PMC4060336  PMID: 24955046
Apical ballooning syndrome; broken heart syndrome; cardiomyopathies; female; magnetic resonance imaging; sex factors; stress cardiomyopathy; takotsubo cardiomyopathy/diagnosis/drug therapy/epidemiology/etiology/physiology/physiopathology/psychology/surgery/therapy; ventricular dysfunction, left
12.  Spontaneous Coronary Artery Dissection (SCAD): New Insights into This Not-So-Rare Condition 
Texas Heart Institute Journal  2014;41(3):295-298.
PMCID: PMC4060337  PMID: 24955045
Acute coronary syndrome; angioplasty, balloon, coronary; coronary artery dissection, spontaneous/etiology/epidemiology; female; fibromuscular dysplasia; myocardial infarction; rupture, spontaneous; sex factors
13.  Outpatient Management of Heart Failure in the United States, 2006–2008 
Texas Heart Institute Journal  2014;41(3):253-261.
Better outpatient management of heart failure might improve outcomes and reduce the number of rehospitalizations. This study describes recent outpatient heart-failure management in the United States.
We analyzed data from the National Ambulatory Medical Care Survey of 2006–2008, a multistage random sampling of non-Federal physician offices and hospital outpatient departments.
Annually, 1.7% of all outpatient visits were for heart failure (51% females and 77% non-Hispanic whites; mean age, 73 ± 0.5 yr). Typical comorbidities were hypertension (62%), hyperlipidemia (36%), diabetes mellitus (35%), and ischemic heart disease (29%). Body weight and blood pressure were recorded in about 80% of visits, and health education was given in about 40%. The percentage of patients taking β-blockers was 38%; the percentage taking angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARBs) was 32%. Medication usage did not differ significantly by race or sex. In multivariate-adjusted logistic regression models, a visit to a cardiologist, hypertension, heart failure as a primary reason for the visit, and a visit duration longer than 15 minutes were positively associated with ACEI/ARB use; and a visit to a cardiologist, heart failure as a primary reason for the visit, the presence of ischemic heart disease, and visit duration longer than 15 minutes were positively associated with β-blocker use. Chronic obstructive pulmonary disease was negatively associated with β-blocker use. Approximately 1% of heart-failure visits resulted in hospitalization.
In outpatient heart-failure management, gaps that might warrant attention include suboptimal health education and low usage rates of medications, specifically ACEI/ARBs and β-blockers.
PMCID: PMC4060338  PMID: 24955039
Ambulatory care/standards; cardiovascular agents/therapeutic use; clinical trials as topic; comprehensive health care; drug utilization/statistics & numerical data; health care surveys; heart failure/drug therapy/economics/epidemiology/prevention & control; office visits/statistics & numerical data/trends/utilization; outcome assessment (health care)/trends; quality assurance, health care
14.  Aortic Perforation by Active-Fixation Atrial Pacing Lead: An Unusual but Serious Complication 
Texas Heart Institute Journal  2014;41(3):327-328.
Perforation of a cardiac chamber is an infrequent but serious sequela of pacemaker lead implantation. An even rarer event is the perforation of the aorta by a protruding right atrial wire. We present here the first case in the medical literature of aortic perforation as a sequela to the implantation of a cardiac resynchronization therapy defibrillator.
The patient was a 54-year-old man with idiopathic dilated cardiomyopathy who underwent the implantation of a defibrillator, with no apparent sequelae. Six hours after the procedure, he experienced cardiac tamponade and required urgent open-chest surgery. The pericardial effusion was found to be caused by mechanical friction of a protruding right atrial wire on the aortic root. The aortic root and the atrial wall were both repaired with Prolene suture, which achieved complete control of the bleeding. There was no need to reposition the atrial wire. The patient had a good postoperative recovery.
PMCID: PMC4060339  PMID: 24955055
Aorta/injuries, iatrogenic; cardiac tamponade/etiology; cardioverter-defibrillator, implantable/adverse effects/complications; hemostasis, surgical; pacemaker, artificial/adverse effects/complications; pericardial effusion/etiology
15.  Born to Observe 
Texas Heart Institute Journal  2014;41(3):250-251.
PMCID: PMC4060340  PMID: 24955036
16.  Cor Triatriatum Sinister: Histopathologic Remarks 
PMCID: PMC4060341  PMID: 24955065
18.  Socioeconomic Status and Smoking Cessation: Neighborhood Context as an Underlying Mechanism 
Texas Heart Institute Journal  2014;41(3):309-310.
PMCID: PMC4060343  PMID: 24955049
Attitude to health/ethnology; educational status; health behavior/ethnology; income; models, theoretical; residence characteristics; risk factors; smoking/psychology; smoking cessation/economics/psychology/statistics & numerical data; social class; social environment; social support; socioeconomic factors; tobacco
19.  Cardiac Sarcoidosis Presenting as Constrictive Pericarditis 
Texas Heart Institute Journal  2014;41(3):319-323.
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 patient's clinical course, and his response to pericardiectomy led to our diagnosis of cardiac sarcoidosis presenting as constrictive pericarditis. In addition to the patient's 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.
PMCID: PMC4060344  PMID: 24955053
Cardiomyopathies/complications/diagnosis/pathology; diagnosis, differential; diagnostic imaging; myocardium/pathology; pericarditis, constrictive/complications/etiology/surgery; sarcoidosis/complications/diagnosis/pathology; treatment outcome
20.  Editorial Commentary 
PMCID: PMC4060345  PMID: 24955037
21.  Acute Anterior ST-Elevation Myocardial Infarction and Electrical Storm Secondary to Nondominant Right Coronary Artery Occlusion 
Texas Heart Institute Journal  2014;41(3):335-337.
A 42-year-old man emergently presented with chest pain and anterior ST elevation. Refractory ventricular arrhythmias and shock developed rapidly. A coronary angiogram revealed the acute occlusion of a nondominant right coronary artery. After percutaneous coronary intervention, the anterior ST elevation and ventricular arrhythmias resolved. The electrocardiographic pattern was a result of isolated right ventricular infarction that in turn caused profound electrical and hemodynamic instability. We discuss the cause and pathophysiology of this patient's case, and we recommend that interventional and general cardiologists be aware that anterior ST elevation can be caused by the occlusion of a nondominant right coronary artery.
PMCID: PMC4060346  PMID: 24955058
Arrhythmias, cardiac/etiology; coronary disease/physiopathology; coronary vessel anomalies/diagnosis/therapy; electrocardiography; myocardial infarction/etiology; ventricular dysfunction, right/diagnosis/etiology
22.  Sex-Specific Biatrial Volumetric Measurements Obtained with Use of Multidetector Computed Tomography in Subjects with and without Coronary Artery Disease 
Texas Heart Institute Journal  2014;41(3):286-292.
Atrial volumetric measurement has proven clinical implications. Advances in cardiac imaging, notably the precision enabled by multidetector computed tomography (MDCT), herald the need for new criteria of what constitutes normal volumetric measurements. With use of 64-slice MDCT, we compared the atrial volumes in healthy individuals with those in individuals with coronary artery disease.
By means of manual segmentation, we measured biatrial volume in 686 participants who underwent retrospective electrocardiographic-gated MDCT angiographic evaluation. The study population included a control group of 203 persons with no cardiac abnormalities, and a study group of 483 patients with obstructive coronary artery disease. All variables were compared between men and women and between the groups.
We found a significant difference in left atrial end-systolic and end-diastolic volumes between men and women in the control group (P <0.05); however, right atrial volumes were similar. In comparison with the entire control group, the coronary artery disease group had significantly higher left atrial volume, significantly lower right atrial stroke volume, and significantly lower biatrial ejection fraction, except for left atrial ejection fraction in men. Right atrial volume and left atrial stroke volume were not significantly different. The results imply that a sex-specific reference value is necessary for left atrial volumetric evaluation, and that left atrial volume and biatrial ejection fraction (excluding left atrial ejection fraction in men) might be useful during diagnosis and prognosis in patients who have coronary artery disease.
PMCID: PMC4060347  PMID: 24955043
Atrial function; cardiac volume/physiology; coronary angiography/methods; heart atria/pathology/ultrasonography; image interpretation, computer-assisted/methods; imaging, three-dimensional; predictive value of tests; sensitivity and specificity; tomography, x-ray computed/methods/utilization
25.  Exertional Dyspnea as a Symptom of Infrarenal Aortic Occlusive Disease 
Texas Heart Institute Journal  2014;41(3):316-318.
Advanced atherosclerosis of the aorta can cause severe ischemia in the kidneys, refractory hypertension, and claudication. However, no previous reports have clearly associated infrarenal aortic stenosis with shortness of breath. A 77-year-old woman with hypertension and hyperlipidemia presented with exertional dyspnea. Despite extensive testing and observation, no apparent cause for this patient's dyspnea was found. Images revealed severe infrarenal aortic stenosis. After the patient underwent stenting of the aortic occlusion, she had immediate symptomatic improvement and complete resolution of her dyspnea within one month. Twelve months after vascular intervention, the patient remained asymptomatic.
In view of the distinct and lasting elimination of dyspnea after angioplasty and stenting of a nearly occluded infrarenal aortic lesion, we hypothesize that infrarenal aortic stenosis might be a treatable cause of exertional dyspnea. Clinicians should consider infrarenal aortic stenosis as a possible cause of dyspnea. Treatment of the stenosis might relieve symptoms.
PMCID: PMC4060350  PMID: 24955052
Aorta, abdominal/pathology; aortic diseases/diagnosis/therapy; arterial occlusive diseases/therapy; arteriosclerosis/complications/physiopathology; diagnosis, differential; dyspnea/complications; renal artery obstruction/complications/physiopathology; stents; treatment outcome

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