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Over the past 2 decades, radial artery access has increasingly become the standard approach for coronary angiography and intervention. Compared with femoral arteries, transradial access is associated with better hemostasis. Transradial access has increased patient preference, facilitates early ambulation, and is cost-effective. An important limitation of transradial access is access site failure, and it carries a crossover rate of 3% to 7% in randomized prospective trials comparing radial with femoral artery access among experienced operators. Crossover rates for failed primary radial artery access can be reduced with ultrasonography guidance and increased familiarity with alternative access sites in the wrist.

Background Knowledge of cardiac filling pressures is critical in the diagnosis and management of patients with dyspnea or heart failure. Echocardiography and B-natriuretic peptide (BNP) testing are commonly used to estimate these pressures, but their incremental value beyond physical examination remains unknown. Methods Right and left heart filling pressures were prospectively estimated as "normal" or "abnormal" by staff cardiologists and cardiovascular trainees based upon physical examination findings alone, or examination coupled with echocardiographic and BNP data in patients referred for cardiac catheterization. Net reclassification improvement was calculated to determine whether echocardiographic/BNP data had incremental value in the determination of right and left heart pressures. Results Two hundred fifteen observations were made by 9 examiners in 116 consecutive patients. Right and left heart pressures were accurately predicted from examination alone in 71% and 60% of observations, respectively. Examination-based accuracy was greater for staff cardiologists compared with trainees for right heart (82 vs 67%, P =.03) and left heart pressures (71% vs 55%, P =.03). Exposure to echocardiographic and BNP data did not enhance accuracy beyond bedside examination alone, both for left heart pressures (net reclassification improvement=−0.004; 95% confidence interval, −0.12-0.12) and right heart pressures (net reclassification improvement=0.02, 95% confidence interval, −0.09-0.13). Conclusions Cardiac filling pressures can be estimated from physical examination with modest accuracy, which is enhanced with experience. While echocardiographic and BNP data predict cardiac filling pressures, they may not provide information of incremental value beyond examination alone. Rigorous teaching and practice of cardiac examination skills should continue to be emphasized during medical training.

Objectives: The aim of the study was to document the frequency of optimal femoral artery access location and its correlation with vascular complications in contemporary practice. Background: Vascular access bleeding during coronary interventions is associated with adverse outcomes. A potential strategy for reducing access-site bleeding is to achieve optimal location for the femoral access. However, there is a paucity of data on how well this goal is achieved in clinical practice using anatomical landmarks. Methods: We retrospectively evaluated femoral angiograms of 300 patients undergoing percutaneous coronary intervention to identify the location of the access that had been performed using anatomical landmarks. Patients were divided into two groups based on the location of the arterial access: above the femoral bifurcation but below the inferior border of the inferior epigastric artery (optimal location) and those that were either above or below these landmarks (suboptimal location). Frequency of access site complications was recorded. Results: The femoral artery access site was located outside the optimal location in 38 (13.0%) patients. There was no significant difference regards to baseline characteristics. Overall, access-related complications occurred in 17 (5.7%) patients. Vascular complications were significantly more frequent in patients who had a femoral artery access outside the optimal location (18% vs. 4%, P < 0.001). Conclusions: The femoral artery access site is not at the optimal location in a significant proportion of patients, and this is associated with an increased risk of vascular complications. Improving the rates of optimal arterial access by routine use of fluoroscopy or ultrasound guidance has the potential of reducing vascular complications and improving outcomes. © 2011 Wiley-Liss, Inc.

Objective: To report complications in a consecutive series of patients undergoing percutaneous left ventricular apical puncture (LVAP) and sheath placement for diagnostic or interventional procedures. Background: Percutaneous LVAP is only rarely used to provide hemodynamic data in the presence of mechanical prosthetic valves. Recently, LVAP has been used to facilitate complex interventional procedures such as paravalvular leak closures. These frequently necessitate placement of 4–6 F sheaths, rather than smaller needles. Optimal technique and outcomes are largely unknown for this uncommon procedure. Methods: We retrospectively analyzed 32 patients undergoing LVAP with echocardiographic and fluoroscopic guidance at our institution between 2002 and 2009. These patients were referred to the cardiac catheterization laboratory for hemodynamic assessment to rule out prosthetic dysfunction and or to facilitate paravalvular leak closure. Sheaths ranged from 4 to 6 F were removed at the end of the procedure after reversing any anticoagulation. No specific closure devices were used for hemostasis. Frequency of access site complications associated with LVAP recorded. Results: Apical access site related complications were higher in patients requiring LVAP for intervention than for diagnostic purposes (25% vs. 12.5%). Hemothorax was the most frequent serious complication occurring in 6 (19%) patients and frequently required intervention 5(16%). Three patients had local bleeding with no drop in hemoglobin or need for intervention. Conclusions: LVAP is associated with a significant incidence of access-related complications. There is a need for safe and reliable methods of closing percutaneous LVAP access sites. © 2010 Wiley-Liss, Inc.

A 45-year-old man was walking his dog at 5:30 am in June 2009 and developed crushing 10/10 substernal chest pain. He called 911 at 6:05 am after his symptoms persisted for 35 minutes. Emergency medical services (EMS) paramedics arrived at the scene at 6:09 am and obtained a brief history and examination showing a diaphoretic man, pulse of 92 bpm, blood pressure of 170/140 mm Hg, normal respiratory rate, and no rales or murmurs. Treatment was initiated including supplemental oxygen, sublingual nitroglycerin, and aspirin. A 12-lead prehospital (PH) ECG was acquired at the scene at 6:16 am and interpreted by paramedics as showing acute ST-elevation myocardial infarction (STEMI) (Figure 1). On the basis of the PH ECG, paramedics made a single phone call to the closest community hospital emergency department and activated the PH ECG STEMI protocol at 6:17 am. The closest community hospital was located within 5 miles and did not have capability for percutaneous coronary intervention (PCI). The STEMI protocol activation consisted of autolaunching helicopter transport to intercept the patient at the community hospital and alerting the cardiac catheterization team at the tertiary PCI center located 50 miles away with the estimated patient arrival time. The patient arrived at the community hospital emergency department (door 1) by ground ambulance at 6:26 am. Helicopter transport picked up the patient and departed the community hospital at 6:37 am with a door 1 in–to–door 1 out time of 11 minutes. The patient arrived at the tertiary PCI center (door 2) at 7:10 am and was transported directly to the cardiac catheterization laboratory. During transport from the helipad to the cardiac catheterization laboratory, the patient had ventricular fibrillation in the elevator, and a shock was delivered with 120 J of selected energy. Coronary angiography showed a thrombotic occlusion of the …

Left ventricular noncompaction (LVNC) is a rare condition that is believed to represent an arrest in endomyocardial morphogenesis. This entity may be complicated by the development of mural thrombi and embolic events, however data on the associated thromboembolic risk is variable and poorly defined. We describe 2 cases of LVNC in African American patients presenting with thromboembolic manifestations and briefly review the available literature relevant to this complication.

Most events covered by insurance happen at a fixed point in time. Accordingly, in the typical context, timing issues relating to coverage under commercial general liability (CGL) insurance policies relate to whether the bodily injury or property damage happened during a particular policy period. This question is usually described as whether the policy is “triggered.” In the context of the usual claim, a court simply determines when the injury or damage took place, and whether the relevant policy was in effect at that time. Environmental, toxic tort, and some products liability claims, however, present more complex timing issues. These types of claims often involve progressive injuries or damage happening over substantial timeframes. In the insurance industry, such losses are often called “longtail” claims. Many long-tail claims involve injury or damage spanning multiple policy years. A court considering timing issues relating to coverage for such claims is faced not only with the challenge of determining which policies are triggered, but also with a far more complicated question: whether and how to allocate the damages between the relevant insurers and between the insurers and the policyholder. The most common approach used to determine how to allocate longtail losses among multiple triggered policy years is often called “pro rata

Congestive heart failure (CHF) is a major public health problem that results in tremendous economic burden. Diastolic heart failure (DHF) forms an important subset with increasing incidence and prevalence. There are widely variable estimates of the prevalence, ranging from 13% to 74% of all CHF presentations, and this is predominantly a result of a lack of uniform criteria for establishing a diagnosis. New developments in management of DHF have lagged behind those for systolic heart failure (SHF), for which numerous new therapeutic and device strategies have been instituted. The renin-angiotensin-aldosterone system (RAAS) plays an important role in the pathophysiology of both SHF as well as DHF. The beneficial role of ACE inhibitors as well as aldosterone antagonists in SHF has been well established. Because of its unique role of the RAAS in establishing fibrosis at a molecular level, RAAS blockade provides an opportunity to expand the therapeutic options for DHF. Thus far, in patients with primary DHF only the angiotensin receptor type 1 antagonist candesartan has been reported to decrease morbidity and probably mortality. Large, ongoing randomized trials including TOPCAT (Trial of Aldosterone Antagonist Therapy in Adults with Preserved Ejection Fraction Congestive Heart) and the I-PRESERVE (Irbesartan in Heart Failure with Preserved Systolic Function) are currently underway to establish the role of aldosterone antagonists in patients with DHF.

This study analyzed 255,256 patients who had acute myocardial infarction and were enrolled in the National Registry of Myocardial Infarction 2, 3, and 4 (1994 to 2002). The objective was to determine in-hospital mortality rate among patients who had ST-segment depression on the initial electrocardiogram. Patients who had ST-segment depression had an in-hospital mortality rate (15.8%) similar to that of patients who had ST-segment elevation or left bundle branch block (15.5%). After adjusting for observed differences, ST-segment depression was associated with only a slightly lower odds ratio (0.91) of mortality compared with ST-segment elevation or left bundle branch block.

Background— Spontaneous coronary artery dissection (SCAD) is an acute coronary event of uncertain origin. Clinical features and prognosis remain insufficiently characterized. Methods and Results— A retrospective single-center cohort study identified 87 patients with angiographically confirmed SCAD. Incidence, clinical characteristics, treatment modalities, in-hospital outcomes, and long-term risk of SCAD recurrence or major adverse cardiac events were evaluated. Mean age was 42.6 years; 82% were female. Extreme exertion at SCAD onset was more frequent in men (7 of 16 versus 2 of 71; P Conclusions— SCAD affects a young, predominantly female population, frequently presenting as ST-elevation myocardial infarction. Although in-hospital mortality is low regardless of initial treatment, percutaneous coronary intervention is associated with high rates of complication. Risks of SCAD recurrence and major adverse cardiac events in the long term emphasize the need for close follow-up. Fibromuscular dysplasia is a novel association and potentially causative factor.

A 75-year-old woman with familial hypercholesterolemia was admitted with unstable angina. Thirteen years earlier, she had undergone coronary artery bypass grafting with a left internal mammary artery (LIMA) to the left anterior descending artery (LAD) and subsequently bilateral common carotid bypass surgery through a second sternotomy 3 years later. Physical examination revealed left brachial hypotension, a left subclavian bruit, and features of severe aortic stenosis. Transthoracic echocardiography demonstrated severe valvular and supravalvular aortic obstruction with an area of 0.50 cm2. Noncontrast computed tomography showed complete calcification of the ascending aorta (porcelain aorta) and confirmed supravalvular obstruction with calcific plaque (Figure 1). She was subsequently offered placement of a left ventricular apex-descending aorta conduit through a left thoracotomy. Preoperative diagnostic angiography revealed a critical ostial left subclavian artery stenosis, with flow reversal in the vertebral artery and preferential entering of contrast into the LIMA (steal phenomenon, Figure 2, Movie 1). The LIMA graft was widely …

[Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4] A 71-year-old man with a history of coronary artery bypass grafting 10 years earlier presented with recurrent angina. A repeat coronary angiogram revealed a large pseudoaneurysm in the saphenous vein graft supplying the right

Cleft mitral valve is a rare congenital anomaly that may present in isolation or accompany other cardiac malformations. Our illustrative case series highlights the advantages of three-dimensional over conventional two-dimensional echocardiography in the diagnosis and morphologic assessment cleft mitral valve in adults.

Quadricuspid aortic valve is a rare congenital anomaly. It may present as an isolated anomaly but is occasionally associated with aortic regurgitation. Sinus of Valsalva aneurysm (SVA) is also an infrequent congenital anomaly, typically associated with tricuspid aortic valves. There are only a few reported cases of SVA (ruptured) associated with quadricuspid aortic valves in the literature. We report the first case of the association of quadricuspid aortic valve with an unruptured SVA in an adult patient.

Brain natriuretic peptide (BNP) level is elevated in heart failure and reflects its severity. It is unknown why some patients have extremely high BNP levels. The authors retrospectively reviewed data on 179 consecutive patients whose BNP levels fell within one of several predetermined ranges: mild elevation, 500 to 1000 pg/mL (n=82); moderate elevation, 2000 to 3000 pg/mL (n=48); and high elevation, 4000 to 20,000 pg/mL (n=49). The statistical analysis was conducted with the unpaired t test and Pearson's correlation coefficient. Adjustments were made for age, sex, and serum creatinine level. Patients with moderate BNP elevation were more symptomatic and had more advanced structural and hemodynamic changes than did patients with lower BNP elevation. Characteristics of the high BNP level group did not differ from those of the moderate BNP level group. Serum creatinine level correlated with BNP level, but neither age nor sex did. High BNP level (4000-20,000 pg/mL) is determined more by renal dysfunction than by the severity of heart failure.

Melanoma is a neoplasm notorious for its dismal prognosis and its propensity for cardiac involvement. Roughly a third of patients diagnosed with primary cutaneous melanoma develop pulmonary, osseous, cerebral or hepatic metastatic disease ante mortem. In contrast, ante mortem cardiac involvement is reported in 2% of cases but in over 50% of patients with metastatic melanoma postmortem.1 Cardiac involvement is usually multifocal, believed to disseminate hematogenously and commonly involves the epicardium, myocardium, pericardium or may present as intracavitary tumors.2 The surgical management of cardiac tumors can be challenging, particularly when they occur in locations that make surgical access and resection technically difficult. Recent refinements in myocardial perfusion imaging, computerized tomography, and cardiac magnetic resonance imaging help provide precise information on anatomic location, vascularity, and tumor extension into adjacent mediastinal structures.3 Early detection of cardiac melanoma has important therapeutic and prognostic …