Faculty Bibliography

Takotsubo cardiomyopathy is usually a transient condition and is treated conservatively. It is rarely associated with ventricular free wall rupture, a fatal complication of the disease described in this report. Cardiothoracic surgery performed emergent ventricular wall repair; however, treatment was unsuccessful, and the patient expired.

We describe a case of dengue shock syndrome, perimyocarditis, and low-pressure cardiac tamponade following a trip to the Caribbean. The case was managed in the critical care unit and 6 weeks after discharge the patient was asymptomatic with a normal ejection fraction. Dengue fever presenting as cardiac tamponade is exceedingly rare and emphasizes the importance of taking a thorough travel history as well as being aware of atypical manifestations of rare diseases to make a correct diagnosis.

Spontaneous coronary artery dissection (SCAD) is a rare entity that can cause acute myocardial infarction and sudden cardiac death (SCD) which often goes unrecognized. We report a case of SCAD in a young postpartum female who presented with sudden cardiac arrest. The patient was managed medically and found to have fibromuscular dysplasia (FMD). After being stabilized in the critical care unit, coronary angiography was performed which showed dissection of the left main artery, intramural hematoma, and the culprit lesion. Further investigation showed dissection of the left vertebral artery which was all consistent with a diagnosis of FMD. The patient was followed as an outpatient and a repeated coronary angiography demonstrated healed dissection site. In conclusion, this case exemplifies that prompt diagnosis along with medical management without the need of coronary artery bypass graft, and percutaneous coronary intervention can improve survival in SCAD.

Loperamide is over-the-counter antidiarrheal agent acting on peripherally located μ opioid receptors. It is gaining popularity among drug abusers as opioid substitute. We report a case of a 46-year-old male that was presented after cardiac arrest. After ruling out ischemia, cardiomyopathy, pulmonary embolism, central nervous system pathology, sepsis, and other drug toxicity, we found out that patient was using around 100 mg of Loperamide to control his chronic diarrhea presumably because of irritable bowel syndrome for last five years and consumed up to 200 mg of Loperamide daily for last two days before the cardiac arrest. We hypothesize that the patient's QTc prolongation and subsequent cardiac arrest are due to Loperamide toxicity. Patient experienced gradual resolution of tachyarrhythmia and gradual decrease in QTc interval during hospitalization which supports the evidence of causal relationship between Loperamide overdose and potentially fatal arrhythmias. It also provided the clue that patient may have congenital long QT syndrome which was unmasked by Loperamide causing ventricular arrhythmias. This case adds one more pearl in the literature to support that Loperamide overdose related cardiac toxicity does exist and it raises concerns over Loperamide abuse in the community.

A 43-year-old man presenting with acute coronary syndrome with ST segment elevation myocardial infarction underwent urgent coronary angiography. During the intervention, the patient was found to have several multiple filling defects with dynamic obstruction in the left coronary circulation. Thrombectomy was performed on distal left anterior descending artery and 2nd diagonal artery lesions with balloon angioplasty, which was unsuccessful. Considering the dynamic obstruction in the angiogram, immediate imaging was performed for structural evaluation of the heart. Cardiac CT revealed a circumferential groove on the heart, suggesting an external compression leading to dynamic obstruction of the coronary arteries on angiogram. Cardiac hernia, a very rare aetiology, was suspected to be the culprit for the ST segment elevation myocardial infarction. Thoracoscopy was performed, which revealed congenital cardiac hernia and a fibrous pericardial band encircling the apex. A left mini thoracotomy was performed to release the constriction imposed over the heart, with improvement in circulation.

OBJECTIVES: This study sought to assess the utility of ultrasound (US) guidance for transradial arterial access. BACKGROUND: US guidance has been demonstrated to facilitate vascular access, but has not been tested in a multicenter randomized fashion for transradial cardiac catheterization. METHODS: We conducted a prospective multicenter randomized controlled trial of 698 patients undergoing transradial cardiac catheterization. Patients were randomized to needle insertion with either palpation or real-time US guidance (351 palpation, 347 US). Primary endpoints were the number of forward attempts required for access, first-pass success rate, and time to access. RESULTS: The number of attempts was reduced with US guidance [mean 1.65 +/- 1.2 vs. 3.05 +/- 3.4, p < 0.0001; median 1 (interquartile range [IQR] 1, 2) vs. 2 (1, 3), p < 0.0001] and the first-pass success rate improved (64.8% vs. 43.9%, p < 0.0001). The time to access was reduced (88 +/- 78 vs. 108 +/- 112 s, p = 0.006; median 64 [IQR 45, 94] vs. 74 [IQR 49, 120] s, p = 0.01). Ten patients in the control group required crossover to US guidance after 5 min of failed palpation attempts with 8 of 10 (80%) having successful sheath insertion with US. The number of difficult access procedures was decreased with US guidance (2.4% vs. 18.6% for >/=5 attempts, p < 0.001; 3.7% vs. 6.8% for >/=5min, p = 0.07). No significant differences were observed in the rate of operator-reported spasm, patient pain scores following the procedure, or bleeding complications. CONCLUSIONS: Ultrasound guidance improves the success and efficiency of radial artery cannulation in patients presenting for transradial catheterization. (Radial Artery Access With Ultrasound Trail [RAUST]; NCT01605292).

Background: Transradial cardiac catheterization reduces bleeding compared with femoral access, but the initial arterial cannulation can be difficult due to weak pulses, hypotension, calcification, obesity or peripheral vascular disease. Multiple attempts at access may increase the time required, patient discomfort, risk of arterial spasm, and the need for cross-over to other access sites. Ultrasound (US) guidance has been demonstrated to facilitate vascular access and reduce vascular complications in multiple sites and locations, but has not been tested in a multicenter fashion in transradial access. Methods: We conducted a multicenter randomized controlled trial of 473 patients undergoing transradial cardiac catheterization. Four centers (6 hospitals) and 16 operators trained in US guidance participated in the study. Patients were randomized to needle insertion with either palpation (P) or real-time US guidance (237 P, 236 US). Primary endpoints were the number of forward attempts required for access, first pass success rate, and time to sheath insertion. Results: The mean number of attempts was reduced with US guidance (1.65 +/- 1.2 vs. 3.05 +/- 3.4, p< 0.0001) and the first pass success rate improved (64.8% vs. 43.9%, p< 0.0001). The mean time to sheath insertion was reduced (83 +/- 78 vs. 113 +/- 124 seconds, p=0.0016) as was the median time to insertion (60 [IQR 42-91] vs. 75 [50-119], p<0.005). Ten patients in the control group required cross-over to US guidance after 5 minutes of failed palpation attempts with 9/10 (90%) having successful sheath insertion with US. The number of difficult access procedures was decreased with US guidance (6 vs. 44 for > 5 attempts, p <0.001; 6 vs. 15 for > 5min, p=0.07). There was no significant difference in the rate of operatorreported spasm (4.2% P vs. 5.5% US, p=0.53), crossover to other access sites (2.5% P vs. 1.3% US, p=0.34), mean patient pain scores (range 0-10) following the procedure (0.82 P vs. 0.89 US, p=0.29), or bleeding complications (1.7% !