Faculty Bibliography

Specialty care is associated with improved outcomes for adults with adult CHD and must be extended to the underserved. A retrospective cohort study was performed to describe the provision of care to adult CHD patients in America's largest municipal public health system including patient demographics, diagnostic and therapeutic procedures, and adherence to guideline-recommended surveillance. We identified 229 adult CHD patients aged >18 years through electronic medical records. The most common diagnoses were atrial septal defect, ventricular septal defect, patent ductus arteriosus, and valvular pulmonary stenosis. In total, 65% had moderate or greater anatomic complexity. A large number of patients were uninsured (45%), non-white (96%), and non-English speaking (44%). One hundred forty-six patients (64%) presented with unrepaired primary defects. Fifty eight patients underwent primary repair during the study period; 48 of those repairs were surgical and 10 were transcatheter. Collaboration with an affiliated Comprehensive Care Center was utilised for 28% of patients. A high proportion of patients received adult CHD speciality visits (78%), echocardiograms (66%), and electrocardiograms (56%) at the guideline-recommended frequency throughout the study period. There was no significant difference in the rate of adherence to guideline-recommended surveillance based on insurance status, race/ethnicity, or primary language status. The proportion of patients who had guideline-recommended adult CHD visits, echocardiograms, and electrocardiograms was significantly lower for those with more advanced physiological stages. These results can inform the provision of adult CHD care in other public health system settings.

Pectus excavatum is one of the most common congenital chest wall deformities. The degree of sternal depression, which may result in compression of the right heart by the chest wall, is variable. While typically asymptomatic, there are various symptoms that can result from severe pectus excavatum. We report on a patient with severe pectus excavatum leading to dynamic obstruction of the right ventricular outflow tract in the seated position.

LEARNING OBJECTIVE #1: Diagnose myocardial infarction (MI) in patients with ventricular-paced rhythms by using the Sgarbossa criteria LEARNING OBJECTIVE #2: Recognize the limitations of the Sgarbossa criteria CASE: A 93 year-old Polish man with complete heart block, treated with a dualchamber pacemaker, presented with acute onset chest pain to the emergency room of our institution. His electrocardiogram (ECG) showed sinus rhythm with atrial sensing and right ventricular pacing. There were >1mm ST segment depressions in leads V3-V5, leads in which the QRS complex was predominantly negative. His initial troponin I level was 1.9 ng/mL. Due to suspicion of an acute coronary plaque rupture, the patient was referred for urgent coronary angiography, which revealed severe stenosis of the distal right coronary artery, mid posterior descending artery, left main coronary artery, mid left anterior descending artery, and the ostial left circumflex artery. An intra-aortic balloon pump was placed to maintain coronary perfusion. The patient subsequently underwent successful coronary artery bypass grafting, with saphenous vein grafts placed on the left anterior descending artery, first obtusemarginal, and posterior descending artery, and was discharged home in stable condition. IMPACT: This case validates the application of the Sgarbossa criteria to the ECG of ventricular-paced patients to diagnose acute MI. It also highlights significant limitations of the Sgarbossa criteria and suggests a need to develop a more comprehensive system to allow for greater sensitivity in diagnosing acute MI in ventricular-paced patients. DISCUSSION: Interpreting the ECG in the setting of a left bundle branch block (LBBB) or ventricular-paced rhythm can be challenging. Depolarization and repolarization through the ventricular myocardial tissue, instead of the specialized conduction system, produces STsegment changes discordant to the major vector of the QRS complex, which may obscure underlying ischemic ST changes. Sgarbossa et al. found that ST elevations >5mm in leads with predominantly negative QRS complexes, ST elevations >1mm in leads with predominantly positive QRS complexes, or ST depressions >1mmin leads V1- V3 were all highly specific for an acute MI, based on a 17 patient cohort from the GUSTO-1 trial. There are significant limitations of the Sgarbossa criteria, however. It has not been validated for use in patients with biventricular pacing and the criteria are specific, but not sensitive. Other scoring systems exist, although they have been validated in patients with a LBBB, not in ventricularpaced patients. Subsequent research with a larger patient cohort is needed, due to the increasing number of ventricular-paced patients in our aging population and the importance of the emergency room ECG to triage patients with acute MI for immediate fibrinolytic therapy or percutaneous coronary intervention

The global obesity epidemic and its impact on cardiovascular outcomes is a topic of ongoing debate and investigation in the cardiology community. It is well known that obesity is associated with multiple cardiovascular risk factors. Although life-style changes are the first line of therapy, they are often insufficient in achieving weight loss goals. Liraglutide, naltrexone/bupropion, and phentermine/topiramate are new agents that have been recently approved to treat obesity, but their effects on cardiovascular risk factors and outcomes are not well described. This review summarizes data currently available for these novel agents regarding drug safety, effects on major cardiovascular risk factors, impact on cardiovascular outcomes, outcomes research that is currently in progress, and areas of uncertainty. Given the impact of obesity on cardiovascular health, there is a pressing clinical need to understand the effects of these agents beyond weight loss alone.

Transient right bundle branch block following blunt cardiac injury is a known but under-recognized manifestation of cardiac contusion. The first case documented in the medical literature occurred in 1952 in a 22-year-old man who was thrown from a motorcycle. Due to their relatively anterior location, the right ventricle and right bundle branch are at particular risk of injury in contusion. We present here a case in which a 24-year-old man suffered a blunt chest trauma leading to a right bundle branch block and elevated troponin levels, consistent with cardiac contusion. His conduction system abnormalities rapidly resolved and he recovered completely, with no clinical sequelae. <Learning objective: Cardiac contusion is a heterogeneous syndrome with widely variable clinical manifestations and severity. Transient right bundle branch block has been described as a self-limited and benign manifestation of cardiac contusion. This case highlights the need for a better understanding of the natural history and predictors of serious complications of cardiac contusion, which can aid in determining appropriate diagnostic studies, risk stratification, and treatment.>.

The field of lipidology is evolving rapidly. Two novel medications have recently been approved for use in homozygous familial hypercholesterolemia (HoFH); the Apolipoprotein B (Apo B) mRNA antisense oligonucleotide (ASO), mipomersen (Kynamro) and the microsomal triglyceride transfer protein (MTP) inhibitor, lomitapide (Juxtapid). Equally important have been the disappointments in cholesterol research; the halting of further investigation into the cholesteryl ester transfer protein (CETP) inhibitor dalcetrapib, yet two others remain in development. The failure of the combination of extended release niacin and laropiprant to show benefit when combined with statin therapy has lead to the discontinuation of this product in Europe. Perhaps one of the most exciting avenues of future research is into the inhibition of proprotein convertase subtilisin/kexin type 9 (PCSK9). 2013 Springer Science+Business Media New York

BACKGROUND: There is a continued role for anterior spinal fusion (ASF) in the treatment of thoracolumbar scoliosis. Despite numerous previous reports of ASF in the treatment of thoracolumbar scoliosis, no single study has simultaneously evaluated clinical, radiographic, and pulmonary function outcomes. METHODS: Retrospective review of 31 consecutive thoracolumbar adolescent idiopathic scoliosis patients (Lenke type 5) who underwent ASF by a single surgeon. Patient records were comprehensively assessed for Scoliosis Research Society (SRS)-22 score, apical trunk rotation, radiographic changes, and pulmonary function before surgery and at 2-years follow-up. RESULTS: Thoracolumbar/lumbar curve correction averaged from 45 to 11 degrees (74%) and spontaneous correction of thoracic curves averaged from 26 to 15 degrees (42%). Instrumented segment lordosis increased by 11 degrees, whereas proximal junction kyphosis increased by 3 degrees. No significant changes were noted in T2-T12 kyphosis, distal junctional kyphosis, T12-S1 lumbar lordosis, or coronal balance. Thoracolumbar apical trunk rotation improved from 12 to 3 degrees. Average SRS scores significantly improved from 3.9 to 4.4. SRS assessments of self-image and pain also improved significantly from 3.6 to 4.5 and from 4.1 to 4.6, respectively. Absolute and percent predicted forced vital capacity and forced expiratory volume in 1 second were unchanged. Two patients suffered mild intercostal neuralgia postthoracotomy. There were no other complications. CONCLUSIONS: The thoracoabdominal anterior approach for thoracolumbar scoliosis facilitates excellent clinical and radiographic outcomes, minimal blood loss, powerful apical trunk rotation correction, relative maintenance of lordosis, relatively short fusion constructs, and improved SRS-22 performance, without significant pulmonary function impairment at 2 years. It continues to be an efficacious treatment for thoracolumbar scoliosis. LEVEL OF EVIDENCE: Level IV