Lung herniation has been defined as a protrusion of lung tissue through its bounding structure. We present a case of spontaneous intercostal lung herniation following bouts of cough, which was complicated by multiple rib fractures, in which we had to adopt a non-surgical approach due to the clinical circumstance. Its understanding in the field of internal medicine is important as appropriate therapeutic judgment, and long-term follow-up is essential for full recovery.
This study further defines the population suitable for the one-stop-shop CMR concept for preop evaluation of OLT candidates providing a road map for integrated testing in this complex patient population for evaluation of cardiac risk and detection of HCC lesions.
Catheter induced cardiac arrhythmia is a well-known complication encountered during pulmonary artery or cardiac catheterization. Injury to the cardiac conducting system often involves the right bundle branch which in a patient with preexisting left bundle branch block can lead to fatal arrhythmia including asystole. Such a complication during central venous cannulation is rare as it usually does not enter the heart. The guide wire or the cannula itself can cause such an injury during central venous cannulation. The length of the guide wire, its rigidity, and lack of set guidelines for its insertion make it theoretically more prone to cause such an injury. We report a case of LBBB that went into transient complete heart block following guide wire insertion during a central venous cannulation procedure.
BackgroundLeft ventricular (LV) mechanics are impaired in patients with severe aortic stenosis (AS). We hypothesized that there would be differences in myocardial mechanics, measured by global longitudinal strain (GLS) recovery in patients with four subtypes of severe AS after transcatheter aortic valve replacement (TAVR), stratified based upon flow and gradient.MethodsWe retrospectively evaluated 204 patients with severe AS who underwent TAVR and were followed post-TAVR at our institution for clinical outcomes. Speckle-tracking transthoracic echocardiography was performed pre- and post-TAVR. Patients were classified as: (1) normal-flow and high-gradient, (2) normal-flow and high-gradient with reduced LV ejection fraction (LVEF), (3) classical low-flow and low-gradient, or (4) paradoxical low-flow and low-gradient.ResultsBoth GLS (−13.9 ± 4.3 to −14.8 ± 4.3, P < 0.0001) and LVEF (55 ± 15 to 57 ± 14%, P = 0.0001) improved immediately post-TAVR. Patients with low-flow AS had similar improvements in LVEF (+2.6 ± 9%) and aortic valve mean gradient (−23.95 ± 8.34 mmHg) as patients with normal-flow AS. GLS was significantly improved in patients with normal-flow (−0.93 ± 3.10, P = 0.0004) compared to low-flow AS. Across all types of AS, improvement in GLS was associated with a survival benefit, with GLS recovery in alive patients (mean GLS improvement of −1.07 ± 3.10, P < 0.0001).ConclusionsLV mechanics are abnormal in all patients with subtypes of severe AS and improve immediately post-TAVR. Recovery of GLS was associated with a survival benefit. Patients with both types of low-flow AS showed significantly improved, but still impaired, GLS post-TAVR, suggesting underlying myopathy that does not correct post-TAVR.
As quoted in the letter by Hubert et al, 1 Owashi et al 3 recently proposed a very interesting mathematical model to derive with echocardiography specific LV pressure curves in patients with severe AS. Nevertheless, the proposed method also has some critical limitations: (1) it uses aortic valve area, among other parameters, to noninvasively predict the patient-specific LV pressure curve; however, calculation of aortic valve area with echocardiography has several known limitations 4 that can affect this estimation and critically influence the estimation of the LV pressure curve; (2) the method was derived from a small cohort of patients with moderate and severe AS from a single center and was not externally validated; (3) and finally, in the current form, the mathematical model is quite cumbersome to use in routine clinical practice and implement in any commercially available software. It would be important to validate the results by Owashi et al 3 in other groups of patients with severe AS.Importantly, another very recent publication by Jain et al 5 used the same method applied in our study 2 to derive LV MW indices in 35 patients with severe AS undergoing transcatheter aortic valve replacement (TAVR). In this study, while LV GLS improved after TAVR (from À14% 6 4% to À15% 6 3%, P = .020), LV global work index decreased (from 1,856 6 705 mm Hg% to 1,535 6 385 mm Hg%, P < .001) and global work efficiency remained relatively stable (from 88.7% 6 11.9% to 89.9% 6 5.9%, P = .498). The differences in the trend of these parameters of LV function after TAVR highlight, as much as our study, 2 the importance of correcting for LV afterload when assessing the LV performance in patients with severe AS. Although our study and the study by Jain et al 5 provided encouraging results on the potential utility of the echocardiography-based calculation of LV MW indices in severe AS, further data would be needed to investigate their clinical value and particularly their role in risk stratification of patients with severe AS, compared with the parameters recommended by current guidelines.
Coronary artery fistula is a rare coronary anomaly with communication between the coronary artery and either the cardiac chamber or other vessels. We present a case of coronary-to–bronchial artery fistula that resulted in likely coronary artery steal and was treated with coil embolization. (
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