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The nutcracker syndrome results from compression of the left renal vein between the superior mesenteric artery and the aorta. We present the first reported case of symptomatic left renal vein compression treated with balloon angioplasty and stenting with the Vici stent system.

Background Radial artery (RA) catheterization is the access of choice over femoral artery access for most interventional vascular procedures given its safety and faster patient recovery. There has been growing interest in distal radial artery (dRA) access as an alternative to the conventional proximal radial artery (pRA) access. Preserving the RA is important which serves as a potential conduit for future coronary artery bypass surgery, dialysis conduit or preserve the artery for future cardiovascular procedures . The dRA runs in close proximity to the radial nerve , which raises the concern of potential detrimental effects on hand function. Study design The Distal versus Proximal Radial Artery Access for cardiac catheterization and intervention (DIPRA) trial is a prospective, randomized, parallel-controlled, open-label, single center study evaluating the outcomes of hand function and effectiveness of dRA compared to pRA access in patients undergoing cardiac catheterization. The eligible subjects will be randomized to dRA and pRA access in a (1:1) fashion. The primary end point is an evaluation of hand function at one and twelve months follow-up. Secondary end points include rates of access site hematoma, access site bleeding, other vascular access complications, arterial access success rate, and RA occlusion at one and twelve months follow up. Conclusion Effects of dRA on hand function remains unknown and it's use questionable in the presence of a widely accepted pRA. DIPRA trial is designed to determine the safety and effectiveness of dRA for diagnostic and interventional cardiovascular procedures compared to the standard of care pRA.

Takotsubo cardiomyopathy predominantly occurs in women, with a high incidence in patients with psychiatric diseases. We present a 64-year-old white woman with an acute manic episode complicated by rhabdomyolysis and takotsubo cardiomyopathy.

Among patients with proximal iliofemoral deep vein thrombosis (DVT) and an elevated Villalta score, anticoagulation therapy alone may not be a sufficient management strategy in select cases. In this article, we report a case of severe bilateral iliofemoral DVT that resisted the standard treatment for DVT, requiring catheter-directed thrombolysis and subsequent mechanical thrombectomy.

Percutaneous treatment of peripheral arterial disease consists of a variety of technologies, ShockWave has been a promising new invention. Operators have a tendency to stent or surgically revascularize any lesion that was previously percutaneously treated. The patient is a 72 year old female with

Lower limb peripheral artery disease (PAD) affects 20% of population over 65 years. Shockwave peripheral intravascular lithotripsy has emerged as a safe and feasible treatment option for those patients. A 42-year old woman with history of PAD presented with severe claudication that did not improve

Surgical septal myectomy remains the gold standard for most patients with hypertrophic cardiomyopathy (HCM). Alcohol septal ablation (ASA) has been an emerging alternative treatment for non-surgical candidate patients A 71-year-old Caucasian woman presented with acute hypoxic respiratory failure

Background— The left ventricular ejection fraction (LVEF) has prognostic and therapeutic utility after acute myocardial infarction (AMI). Although LVEF assessment is a key performance measure among AMI patients, contemporary rates of in-hospital assessment and its association with therapy use have not been well characterized. Methods and Results— We examined rates of in-hospital LVEF assessment among 77 982 non–ST-elevation myocardial infarction patients and 50 863 ST-elevation myocardial infarction patients in Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With The Guidelines between January 2007 and September 2009, after excluding patients who died in-hospital or who were transferred to another acute care facility, discharged to end-of-life care, or had missing LVEF assessment status. LVEF assessment increased significantly over time, with higher rates among ST-elevation myocardial infarction than non–ST-elevation myocardial infarction patients (95.1% versus 91.6%; P Conclusions— The assessment of LVEF among patients with AMI has improved significantly over time, yet significant interhospital variability exists. Patients who did not have in-hospital LVEF assessment were less likely to receive evidence-based medications at discharge. These patients represent targets for future quality improvement efforts.

Patients who undergo implantation of left ventricular assist devices (LVADs) often have improved quality of life, but may eventually succumb to their heart failure and/or sustain LVAD-related complications. In end-of-life situations, decisions must be made about when to deactivate LVAD support. Previous studies have demonstrated that end-of-life planning, particularly with the use of advance directives (ADs), can clarify patients' end-of-life preferences when they are unable to speak for themselves. However, many patients do not have ADs, and among patients who do, the ADs may lack useful information on how to guide care surrogates and clinicians regarding patients' preferences on life-sustaining treatments. The authors retrospectively reviewed the charts of 68 patients with advanced heart failure (56 men [82%]; mean [standard deviation] age, 59.0 ± 12.2 years) who underwent LVAD implantation between March 2003 and January 2009. The indication for the LVAD was destination therapy in 36 (53%) patients and bridge to heart transplant in 32 (47%) patients. Overall, 32 (47%) patients had ADs of varying types; 25 (78%) ADs were completed before LVAD implantation. Although life-sustaining treatments (eg, tube feeding, cardiopulmonary resuscitation, mechanical ventilation, and hemodialysis) were mentioned, none explicitly mentioned the LVAD or withdrawal of LVAD support at the end of life. We hypothesize that if instructions regarding LVAD management in ADs are explicit, surrogate and clinician distress may decrease, and ethical dilemmas may be avoided.

Takotsubo cardiomyopathy is a relatively rare disease entity with a rapid reversible ventricular dysfunction, which usually occurs in post–menopausal women, and is frequently associated with a stressful event. Diagnosing Takotsubo cardiomyopathy can sometimes be challenging. The absence of coronary artery obstructive disease, and the dramatic presentation of the patient mimicking acute coronary syndrome, make this disease unique. We discuss here a case of Takotsubo cardiomyopathy with extremely rapid resolution in just two days, which we believe is being reported for the first time and touch briefly on the salient features, pathogenesis, diagnosis, treatment, prognosis, and clinical significance of this unique entity.

Platelet aggregation is one of the most important underlying mechanisms in acute coronary syndromes (ACS). Antiplatelet therapy is considered as a cornerstone therapy and is widely used in these patients. Clopidogrel is currently a class I indication in patients with ACS. However, different degrees of resistance to clopidogrel have been the subject of many recent studies that led to higher dosing regimens of clopidogrel. Failure of clopidogrel to provide consistent platelet aggregation inhibition in all patients made the emergence of new more reliable agents crucial. Prasugrel and ticagrelor are the 2 new antiplatelet agents that have recently been compared with clopidogrel in patients with ACS. This article reviews the current evidence that supports the use of each of those agents and provides clinicians with an objective summary supporting their use.

Introduction: Defining whether retrograde ventriculoatrial (V-A) conduction is via the AV node (AVN) or an accessory pathway (AP) is important during ablation procedures for supraventricular tachycardia (SVT). With the introduction of ventricular extrastimuli (VEST), retrograde right bundle branch block (RBBB) may occur, prolonging the V-H interval, but only when AV node conduction is present. We hypothesized that when AP conduction was present, the V-A interval would increase less than the V-H interval, whereas with retrograde nodal conduction, the V-A interval would increase at least as much as the V-H interval. Methods and Results: We retrospectively reviewed the electrophysiological studies of patients undergoing ablation for AVN reentrant tachycardia (AVNRT) (55) or AVRT (50), for induction of retrograde RBBB during the introduction of VEST, and the change in the measured V-H and V-A intervals. Results were found to be reproducible between independent observers. Out of 105 patients, 84 had evidence of induced retrograde RBBB. The average V-H interval increase with induction of RBBB was 53.7 ms for patients with AVRT and 54.4 ms for patients with AVNRT (P = NS). The average V-A interval increase with induction of RBBB was 13.6 ms with AVRT and 70.1 ms with AVNRT (P < 0.001). All patients with a greater V-H than V-A interval change had AVRT, and those with a smaller had AVNRT. Conclusions: Induction of retrograde RBBB during VEST is common during an electrophysiological study for SVT. The relative change in the intervals during induction of RBBB accurately differentiates between retrograde AVN and AP conduction.

Background Apical ballooning syndrome (ABS) is a unique transient cardiomyopathy that mimics an acute myocardial infarction. The relative frequency of ST-segment elevation on the 12-lead electrocardiogram (ECG) and its prognostic significance is unknown. The aims of this study were to evaluate the frequency and the clinical correlates of ST- and T-wave abnormalities on the admission ECG in patients with ABS. Methods Patients were retrospectively identified from the cardiac catheterization database—those who underwent coronary and left ventricular angiography and fulfilled the Mayo criteria for ABS during the period January 1988 to November 2006. They were divided into 3 groups according to the presence of (1) ST-segment elevation (>1 mm in 2 contiguous lead) or new left bundle branch block, (2) T-wave inversion (>3 mm in 3 contiguous leads) but no ST shift, and (3) nonspecific ST-T abnormalities or normal ECG at the time of admission. Clinical and echocardiographic findings were compared between groups. Results Among the 105 patients, 36 (34.2%), 32 (30.4%), and 37 (35.2%) patients were in the three respective groups. There were no differences in the clinical characteristics, ejection fraction, and outcomes between the 3 groups. Over a median follow-up of 2.5 years, there was no difference in the 5-year recurrence rate of ABS between the 3 groups (13%, 5%, 17% patients, respectively, P = .25). The 5-year mortality was similar in the 3 groups (24%, 7.3%, 10.8%, P = .58). Conclusions ST-segment elevation is absent in two thirds of patients with ABS. Thus, the cardiomyopathy may mimic either ST-elevation or non–ST-elevation myocardial infarction. The ECG abnormalities at presentation do not correlate with the magnitude of ventricular dysfunction or outcomes.

Objectives We present a systematic overview of the literature on reported cases of chylous pericardial effusion in adults over the past 10 years, assessing clinical presentation, etiology, diagnosis, and treatment. Methods We conducted an evidence-based literature review searching for all reported adult cases of chylopericardium in the past 10 years (January 1996–December 2006). Results A total of 33 reported cases of chylopericardium were identified through a systematic literature search. There was no gender bias in the incidence of chylous pericardial effusion. Age at diagnosis varied from 18 to 68 years with a mean ± standard deviation of 36.78 ± 14.71 years. Time from symptom onset to diagnosis was variable (ranging from acute presentation to several years).The most common reported etiology was idiopathic. The diagnosis was made by pericardiocentesis in all patients. A search for secondary causes included computed tomography of the chest, lymphoscintigraphy, and lymphangiography along with radioactive oral 131I-triolein. Conservative therapy was prescribed in 28 patients and failed in 16, in whom subsequent surgery was necessary. Overall, 21 patients underwent various types of surgery. Thoracic duct ligation with creation of a pericardial window was the most common surgical procedure. Conclusion Chylopericardium is a rare entity. The fluid appearance, triglyceride content, cytologic characteristics, and negative cultures are crucial to make the correct diagnosis. Treatment is dependent on the etiology. Surgical management is the most successful. Conservative therapy is reserved for patients with idiopathic chylopericardium, those with an untreatable etiology, those considered at high risk for surgical treatment, or those with a predictably short lifespan.

The SVC may require ablation to treat atrial fibrillation. Phrenic nerve proximity identified with pacing maneuvers may preclude ablation.We tested a new method using "cryo-mapping" to ablate despite nerve proximity.Of 833 patients undergoing ablation, 110 (12%) had arrhythmogenic substrate at the SVC/RA junction. Of these 110 patients, 66 (60%) had consistent diaphragmatic stimulation when pacing at 10 mA at the prospective site of ablation. Of these 66 patients, 7 had continued arrhythmogenicity despite attempts to modify this substrate. For these 7 patients, we paced 4 cm into the SVC where consistent phrenic nerve stimulation was obtained, and cryoablation at -30 degrees C was performed at sites requiring ablation. In 6 of 7 patients (86%), with continued diaphragmatic capture, cryoablation at -70/-80 degrees C was then performed. In 1 of 7 patients (14%), diaphragmatic stimulation ceased at -30 degrees C, and energy delivery stopped. In the 6 patients in whom cryoablation was completed, the arrhythmogenic substrate was successfully ablated without phrenic nerve injury.A novel "cryo-mapping" technique during phrenic nerve pacing can be used to successfully ablate arrhythmogenic substrate at the SVC/RA junction despite phrenic nerve proximity.

Background: Noninvasive assessment of coronary flow reserve in the left anterior descending artery (LAD) by transthoracic Doppler echocardiography (TTDE) has been already validated as a new method for determining the degree of stenosis over the proximal flow. Objectives: The aim of the study is to determine, by TTDE, the feasibility and the value of the coronary flow reserve (CFR) (defined as the maximal increase in coronary blood flow above its basal pressure for a given perfusion pressure when coronary circulation is maximally dilated) in the mid-to-distal LAD before and after percutaneous angioplasty and to demonstrate the early recovery of microvascular tone immediately after stenting. Methods: The study population consisted of 36 patients with significant isolated LAD stenosis (70–90%) identified by coronary angiography. CFR was recorded in the mid-to-distal LAD at rest and during hyperemia obtained after adenosine intravenous infusion before and after stenting. Results: Adequate visualization of the LAD was obtained in 25 out of 36 patients (70%). At rest the mean CFR was 1.5132 ± 0.33 (1.1–2.58). However, after stenting the mean CFR was significantly higher: 2.18 ± 0.55 (1.3–3.8), with P

Reversible causes of miscarriage are many, but they affect only 1% of women who are trying to conceive. Herein, we describe the case of a 23-year-old woman who presented for evaluation of repeated miscarriages and was found to have hypoxemia and erythrocytosis. Further evaluation revealed hypoplastic right-heart syndrome with an intracardiac shunt. She underwent hybrid repair with pulmonary valve balloon valvuloplasty, followed by surgery to perform atrial septal defect closure and a Glenn anastomosis. The erythrocytosis and hypoxemia resolved, and she was able to conceive and deliver a healthy baby at term 2 years later. This is a unique case of a rare congenital heart defect that went unnoticed until adulthood, when attempts at pregnancy failed because of the associated hypoxemia. Timely and appropriate treatment led to a successful pregnancy after repeated miscarriages. This case exemplifies the need for a comprehensive medical evaluation of every woman with a history of multiple miscarriages to determine whether a reversible cause exists.

Atrial fibrillation/flutter is the most common cardiac arrhythmia that can potentially result in stroke and death. For many years, aspirin and warfarin have been the cornerstone of stroke prevention among such patients. Although warfarin therapy has been advocated for patients with high likelihood of stroke, it requires close surveillance and monitoring, has a narrow therapeutic window and is quite often affected by medication interactions and diet. Thus, the need for a better and more consistent anticoagulant therapy was necessary and has been under development with various successes for many years. This article will review 3 new antithrombotic medications that may potentially become the mainstay for treatment of patients with atrial fibrillation in the near future.

The infection rates of implantable cardioverter-defibrillators systems (ICDs) are higher than that of permanent pacemaker. Risk factors associated with ICD infection have not been characterized and are the subject of the current investigation. All patients who had an ICD implanted at Mayo Clinic Rochester between 1991 and 2008 were retrospectively reviewed. Each case of ICD infection was matched with two non-infected controls. Cases of ICD infection were further stratified by early- (≤6 months) versus late-onset (>6 months) infection. Multivariable analysis was performed to identify significant risk factors for ICD infection. Sixty-eight patients with ICD infection and 136 matched controls met the inclusion criteria. Thirty-five cases presented with early-onset infection and 33 had late-onset device infection. Staphylococcal species were the most common pathogens in both groups of patients. Patients with early-onset infection were more likely to present with generator pocket infection (p = 0.02). Patients with multiple comorbid conditions (high Charlson index) tended to have longer hospital stay during implantation admission (p = 0.009). In a multivariable logistic regression model, the presence of epicardial leads (odds ratio (OR) = 9.7, p = 0.03) and postoperative complications at the generator pocket (OR = 27.2, p

Infective endocarditis with systemic embolization of the gallbladder vasculature is very rare. We describe a case of subacute infective endocarditis in an adult complicated by embolization of the right hepatic artery with subsequent gallbladder infarction. In these cases, appropriate antibiotic therapy should be given before and after cholecystectomy. Gallbladder resection should be performed before valve replacement to decrease the potential seeding of a prosthetic valve.

Determining whether retrograde ventriculoatrial (VA) conduction is through the AV node (AVN) or an accessory pathway (AP) is critical for successful ablation of supraventricular tachycardia (SVT). With introduction of ventricular extrastimuli (VEST), retrograde right bundle branch block (retro RBBB) may occur and result in abrupt VH interval prolongation. We hypothesized when retrograde conduction is via an AP, VA interval change is less than VH interval change, whereas with retrograde AVN conduction, VA interval change is equal to or greater than VH interval change. We retrospectively reviewed the electrophysiology (EP) studies of patients undergoing ablation for AVNRT (n=55) or AVRT (n=50). The intracardiac electrograms were reviewed for induction of retro RBBB and change in VH and VA intervals during VEST. Parahisian pacing, decremental pacing, arrhythmia diagnosis and ablation outcomes were reviewed. All results were found to be reproducible between two independent observers with inter and intra observer reliability scores of 1.00 for identification of retro RBBB and greater than 0.85 for measurement of VH and VA intervals. Of 105 patients, 84 (80%) had evidence of induced retro RBBB during VEST. The average VH interval increase with induction of retro RBBB was 53.7 ms for patients with retrograde AP conduction and 54.4 ms for patients with AVN conduction (p=ns). The average VA interval increase with induction of retro RBBB was 13.6 ms with AP conduction and 70.1 ms with AVN conduction (P < 0.001). All patients with a greater VH than VA interval change had a final diagnosis of AVRT and those with a VH change less than VA change had AVNRT, yielding sensitivity and specificity of 100%. Using a cutoff of 50 ms for change in VA interval with onset of retro RBBB to diagnose AVNRT accurately identified AVNRT in 100% and AVRT in 95%. Induction of retro RBBB during VEST is common during EP studies for SVT. The relative change in the VH and VA intervals during retro RBBB accurately differentiates retrograde AVN from retrograde AP conduction with strong predictive accuracy. The use of retro RBBB based intervals is a useful technique facilitating the diagnosis of SVT in the EP laboratory, even in the absence of inducible tachycardia.

Objectives We sought to determine the frequency and outcomes with symptomatic arrhythmia in patients with apical ballooning syndrome (ABS). Methods A retrospective review of the Mayo Clinic Angiography database was conducted to identify patients who met the Mayo criteria for ABS. Patients with documented arrhythmias formed the study group, and 31 randomly selected patients with ABS but without arrhythmia formed the control group. Results Out of 105 patients identified with ABS, 6 (5.7%) women aged 69 +/- 9 years experienced significant arrhythmia (ventricular fibrillation, asystole), 2 patients died, and 1 required permanent pacemaker implantation. When compared with controls, the study group showed no significant difference with respect to ECG characteristics (QT, QRS duration or axis) except for R-R interval variability (see comments below) (30.6±6 vs 14.5±17 p = 0.0004), QTc, and P-R interval. Patients without arrhythmia were more likely to be on beta-blocker therapy than the study population (33% vs 80.6% p = 0.02). Conclusion Life-threatening arrhythmia is uncommon (5.7%) with ABS despite marked, structural abnormalities. When arrhythmias do occur, the outcome is poor. Prominent variability in R-R intervals appears to be predictive of significant arrhythmias in ABS. The role of beta-blocker therapy in preventing arrhythmia with ABS requires further investigation.

OBJECTIVES To analyze the cardiac findings that necessitate surgery in patients with relapsing polychondritis (RP) and to compare our results to cases in the literature. MATERIAL AND METHODS A systematic overview of the literature was completed with the addition of cases of RP from the Mayo patient population that necessitated cardiac surgery. RESULTS Thirty-three patients were identified (25 from the literature and 8 from the Mayo patient population). Nine patients (27%) were female, 22 (67%) were male, and sex was not stated for 2 patients (6%). The patient age ranged from 17 to 69 years (mean ± SD, 42.5±15.7 years). At operation, 30 patients (91%) had aortic regurgitation, 21 (64%) had aortic root disease, and 13 (39%) had mitral regurgitation. The most common surgical procedure performed was aortic valve replacement in 12 patients (36%). The most common complications were death in 12 patients (36%) and prosthetic valve dehiscence in 4 patients (12%). CONCLUSIONS Cardiac involvement is more prominent in the male population and requires more invasive procedures. Aortic valve replacement with composite graft replacement of the ascending aorta along with coronary artery ostial reimplantation should be considered in these patients. Postsurgical valvular complications include prosthetic dehiscence, paravalvular leakage, mediastinitis, and heart failure, and these complications are associated with postoperative corticosteroid therapy. Initiation of second-line immunosuppressive therapy should be substituted for corticosteroids after cardiac surgery.

Abdominal pain can be disabling in patients with gastroparesis. The pathogenesis of pain in these individuals is poorly understood. Agents commonly used in clinical practice, including tricyclic antidepressants, gabapentin, and pregabalin, have remained largely unsatisfactory in treating this pain. We report the case of a 50-year-old woman presenting with chronic unrelenting abdominal pain due to severe diabetic gastroparesis that was managed successfully with coeliac plexus block with local anaesthesia and steroid injection. Adequate analgesia was achieved and maintained for 10 weeks following the coeliac plexus block, which allowed elimination of opiate requirements for pain management (and avoidance of narcotic associated constipation), continuation of percutaneous endoscopy jejunostomy tube feedings, and avoidance of long term parenteral nutrition.

Takotsubo cardiomyopathy (TC) predominantly occurs in females with a high incidence with psychiatric diseases A 64-year-old caucasian female with bipolar-I disorder presented with an acute manic episode. Patient had not been sleeping well and was not taking her medications. She complained of