Aneurysmal dilatation of saphenous vein graft (SVG), first reported in 1975, is secondary to true aneurysm or pseudoaneurysm. We report 1 case and review 107 cases published since 1975. Severe SVG dilatations are large (6 ± 3 cm), occur remote from surgery (12 ± 4 years) and are life threatening, with 15.7% in-hospital mortality. Symptoms are nonspecific and the abnormality is initially observed by chest X-ray in 57% of cases. The chest X-ray abnormalities have a distinctive appearance that may suggest both diagnosis and which SVG is involved. Diagnosis is made clinically by imaging, i.e. computed tomography, echocardiography, magnetic resonance and/or surgical observation (66 cases), or most accurately by tissue evaluation by the pathologist (42 cases). Aneurysm is more common than pseudoaneurysm by a 6:1 ratio.
1 Major clinical features of IE include fever, systemic emboli, congestive heart failure, and renal insufficiency; however, classic peripheral manifestations of endocarditis-splinter hemorrhages, Osler nodes, Roth spots, and Janeway lesions-are observed less often. Rarely is cardiac ischemia or myocardial infarction caused by coronary emboli or obstruction of the coronary ostia by large vegetations. Coronary artery compression by abscess formation, although even less frequent, is important to consider in patients who present with atypical features of an acute coronary syndrome. We discuss the case of an elderly patient in whom these features occurred, and we briefly review the relevant medical literature. Case ReportA 73-year-old woman with a history of aortic stenosis, atrial fibrillation, diabetes mellitus, and a chronic gastrocutaneous fistula and sacral decubitus ulcer presented with sudden-onset back pain and shortness of breath. In the emergency department, she had a temperature of 102.2 °F, a heart rate of 123 beats/min, and a blood pressure of 119/50 mmHg. Physical examination revealed a normal S 1 and S 2 and a harsh grade 2/6 systolic ejection murmur that radiated to the carotid arteries. Also noted were a fistula in the left upper quadrant that drained serous fluid, and a healing sacral ulcer with minimal skin breakdown and no signs of gangrene. Laboratory results included a troponin level of 0.746 µg/L, a creatinine kinase level of 140 U/L, and a creatinine kinase-MB fraction of 11.9 ng/mL. A 12-lead electrocardiogram showed ST-segment elevation in leads V 1 , V 2 , and III, with ischemic-appearing ST-segment depression in leads I and aVL (Fig. 1). Urgent coronary angiograms revealed a mildly dilated ascending aorta and a long, tubular area of the right coronary artery with narrowing that extended almost to the crux ( Fig. 2A). A possible flap suggested right coronary artery dissection, and the presumed diagnosis was coronary dissection. Computed tomographic angiograms of the ascending and descending aorta showed no dissection but revealed an irregular collection of contrast medium along the anterior right side of the aortic annulus (Fig. 2B).The patient's history of chronic infection and elevated white blood cell count on presentation (21 ×10 9 /L) raised concerns of IE, so further imaging of the heart was performed. Two-dimensional transthoracic echocardiograms (TTE) revealed a thickened, calcified, severely stenotic aortic valve with apparent vegetations. A 2-dimensional transesophageal echocardiogram (TEE) revealed vegetations on the aortic valve Case Reports
Background: The American College of Cardiology/American Heart Association (ACC/AHA) publishes recommendations for cardiac assessment of patients undergoing noncardiac surgery with the intent of promoting evidence-based, efficient preoperative screening and management. We sought to study the impact of guideline implementation for cardiac risk assessment in a general internal medicine preoperative clinic. Methods: The study was an observational cohort study of consecutive patients being evaluated in an outpatient preoperative evaluation clinic before and after implementation of the ACC/AHA guideline. Data was gathered by retrospective abstraction of hospital and clinic charts using standard definitions. 299 patients were reviewed prior to guideline implementation and their care compared to 339 consecutive patients after the guideline was implemented in the clinic. Results: Guideline implementation led to a reduction in exercise stress testing (30.8% before, 16.2% after; p < 0.001) and hospital length of stay (6.5 days before, 5.6 days after; p = 0.055). β-Blocker therapy increased after the intervention (15.7% before; 34.5% after; p < 0.001) and preoperative test appropriateness improved (86% before to 94.1% after; p < 0.001). Conclusions: Implementation of the ACC/AHA guidelines for cardiac risk assessment prior to noncardiac surgery in an internal medicine preoperative assessment clinic led to a more appropriate use of preoperative stress testing and β-blocker therapy while preserving a low rate of cardiac complications.
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