Publications by authors named "Bader Madoukh"

18 Publications

  • Page 1 of 1

Surgical management of patients with von Willebrand Disease: summary of 2 systematic reviews of the literature.

Blood Adv 2021 Oct 15. Epub 2021 Oct 15.

Department of Health Research Methods, Evidence and Impact, McMaster University, Canada.

Von Willebrand disease (VWD) is the most common inherited bleeding disorder. The management of patients with VWD undergoing surgeries is crucial to prevent bleeding complications. To systematically summarize the evidence on the management of patients with VWD undergoing major and minor surgeries to support the development of practice guidelines. We searched Medline and EMBASE through October 2019 for randomized clinical trials (RCTs), comparative observational studies and case series comparing maintaining factor VIII levels or VWF levels >0.50 IU/mL for at least 3 days in patients undergoing major surgery, and options for perioperative management of patients undergoing minor surgery. Two authors screened, abstracted data, and assessed the risk of bias. We conducted meta-analysis when possible. We evaluated the certainty of the evidence using the GRADE approach. We included 7 case series for major surgeries and 2 RCTs and 12 case series for minor surgeries. Very low certainty evidence showed that maintaining factor VIII levels, or VWF levels > 0.50 IU/mL for at least 3 consecutive days showed excellent hemostatic efficacy (as labeled by the researchers) after 74-100% of major surgeries. Low to very low certainty evidence showed that prescribing tranexamic acid and increasing VWF levels to 0.50 IU/mL resulted in less bleeding complications after minor procedures compared to increasing VWF levels to 0.50 IU/mL alone. Given the low-quality evidence to guide management decisions, a shared-decision model leading to individualized therapy plans will be important in patients with VWD undergoing surgical and invasive procedures.
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http://dx.doi.org/10.1182/bloodadvances.2021005666DOI Listing
October 2021

Von Willebrand Factor Levels in The Diagnosis of Von Willebrand Disease: A Systematic Review and Meta-Analysis.

Blood Adv 2021 Oct 5. Epub 2021 Oct 5.

University of Kansas Medical Center, Kansas City, Kansas, United States.

Von Willebrand Disease (VWD) is associated with significant morbidity as a result of excessive mucocutaneous bleeding symptoms. Patients with VWD can experience easy bruising, epistaxis, gastrointestinal and oral cavity bleeding, as well as heavy menstrual bleeding and bleeding after dental work, surgical procedures, and childbirth. Early diagnosis and treatment is important to prevent and treat these symptoms. We systematically reviewed the accuracy of diagnostic tests using different cut-off values of VWF:Ag and platelet-dependent VWF activity assays in the diagnosis of VWD. We searched Cochrane Central, MEDLINE, and EMBASE for eligible studies. Two investigators screened and abstracted data. Risk of bias was assessed using QUADAS-2 and certainty of evidence using the GRADE framework. We pooled estimates of sensitivity and specificity and reported patient important outcomes when relevant. This review included 21 studies that evaluated VWD diagnosis, including the approach to patients with VWF levels that have normalized with age (6 studies), VWF cut-off levels for the diagnosis of Type 1 VWD (9 studies), and platelet-dependent VWF activity/VWF:Ag ratio cut-off levels for the diagnosis of Type 2 VWD (6 studies). The results showed low certainty in the evidence for a net health benefit from reconsidering the diagnosis of VWD versus simply removing the disease in patients with VWF levels that have normalized with age. For the diagnosis of Type 1 VWD, in patients with VWF:Ag <0.30 IU/mL, VWF sequence variants were detected in 75-82% of patients in 2 studies, and for VWF:Ag between 0.30-0.50 IU/mL, VWF sequence variants were detected in 44-60% of patients in 3 studies. A sensitivity of 0.90 (95% CI: 0.83 to 0.94), and a specificity of 0.91 (95% CI: 0.76 to 0.97) were observed for a platelet-dependent VWF activity /VWF:Ag ratio of <0.7 in detecting type 2 VWD (moderate certainty in the test accuracy results). VWF antigen and platelet-dependent activity are continuous variables with an increase in bleeding risk with decreasing levels. This systematic review shows that using a VWF activity/VWF:Ag ratio of <0.7 versus lower cutoff levels in patients with an abnormal initial VWD screen is more accurate for the diagnosis of type 2 VWD.
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http://dx.doi.org/10.1182/bloodadvances.2021005430DOI Listing
October 2021

Bleeding assessment tools in the diagnosis of VWD in adults and children: a systematic review and meta-analysis of test accuracy.

Blood Adv 2021 Dec;5(23):5023-5031

Department of Internal Medicine.

Von Willebrand disease (VWD) can be associated with significant morbidity. Patients with VWD can experience bruising, mucocutaneous bleeding, and bleeding after dental and surgical procedures. Early diagnosis and treatment are important to minimize the risk of these complications. Several bleeding assessment tools (BATs) have been used to quantify bleeding symptoms as a screening tool for VWD. We systematically reviewed diagnostic test accuracy results of BATs to screen patients for VWD. We searched Cochrane Central, MEDLINE, and EMBASE for eligible studies, reference lists of relevant reviews, registered trials, and relevant conference proceedings. Two investigators screened and abstracted data. Risk of bias was assessed using the revised tool for the quality assessment of diagnostic accuracy studies and certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework. We pooled estimates of sensitivity and specificity. The review included 7 cohort studies that evaluated the use of BATs to screen adult and pediatric patients for VWD. The pooled estimates for sensitivity and specificity were 75% (95% confidence interval, 66-83) and 54% (29-77), respectively. Certainty of evidence varied from moderate to high. This systematic review provides accuracy estimates for validated BATs as a screening modality for VWD. A BAT is a useful initial screening test to determine who needs specific blood testing. The pretest probability of VWD (often determined by the clinical setting/patient population), along with sensitivity and specificity estimates, will influence patient management.
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http://dx.doi.org/10.1182/bloodadvances.2021004368DOI Listing
December 2021

State-of-the-Art Review of Current Therapies for HFpEF: An Overview of Interatrial Septal Device Therapy in Heart Failure.

Curr Cardiol Rev 2021 ;17(5):e230421189012

Department of Cardiovascular Medicine, Kings County Medical Center, Brooklyn, NY 11203, United States.

Heart failure (HF) affects an increasing number of geriatric patients. The condition is classified according to whether the left ventricular ejection fraction (EF) is reduced or preserved. Many patients have heart failure with preserved ejection fraction (HFpEF) and face a shortage of effective therapeutic strategies. However, an emerging mechanical strategy for treatment is gaining momentum. Interatrial septal connection devices, i.e. V-wave device and Interatrial septal device, are new devices for patients with heart failure with preserved ejection fraction. We review the function of these systems and the data from the recent clinical trials. Interatrial septal connection device therapy provided favorable efficacy and safety profile applicable to a wide range of patients with HFpEF. However, the long-term effects of these devices on morbidity.
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http://dx.doi.org/10.2174/1573403X16999201210195455DOI Listing
November 2021

Iatrogenic Right Atrial Thrombus Complicated by Pulmonary Embolism: Management and Outcomes.

Curr Cardiol Rev 2021 ;17(4):e230421188336

Heart and Vascular Institute, West Virginian University, Medical Center, Morgantown, WV 26505, United States.

Right atrial thrombus can originate from distal venous sources or can be iatrogenic, secondary to the placement of central venous catheters, atrial devices, or surgeries. One of the most common complications of Central Venous Catheters (CVCs) is thromboembolism, which can be either fixed to the right atrium or can be free-floating. Device-related Right Atrial Thrombosis (RAT) can result in catheter occlusion, vascular occlusion, infection, and pulmonary embolism. The true incidence of these complications is unknown because the diagnosis may not be considered in asymptomatic patients, and it might be missed by Transthoracic Echocardiography (TTE). In this literature review, we discuss iatrogenic etiologies of RAT that is complicated by pulmonary embolism. We highlight the importance of maintaining a high index of suspicion of iatrogenic RAT, possible complications, and its management.
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http://dx.doi.org/10.2174/1573403X16999201124201632DOI Listing
October 2021

Cardiogenic shock in autoimmune rheumatologic diseases: an insight on etiologies, management, and treatment outcomes.

Heart Fail Rev 2020 Jun 20. Epub 2020 Jun 20.

Heart and Vascular Institute, West Virginian University, 1 Medical Center Dr., Morgantown, WV, 26505, USA.

Autoimmune rheumatological disorders are known to have an increased risk for cardiovascular diseases including coronary artery disease (CAD), myocarditis, pericarditis, valvulopathy, and in consequence cardiogenic shock. Data on cardiogenic shock in rheumatological diseases are scarce; however, several reports have highlighted this specific entity. We sought to review the available literature and highlight major outcomes and the management approaches in each disease. Systematic literature search, including PubMed, Ovid/Medline, Cochrane Library, and Web of Science, was conducted between January 2000 and December 2009. We reviewed all cases reporting cardiogenic shock with rheumatologic conditions, including systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), Takayasu's arteritis (TA), granulomatosis with polyangiitis (GPA), giant cell arteritis (GCA), and antiphospholipid syndrome (APS). We selected 45 papers reporting a total of 48 cases. Mean age was 39 ± 7.3 years and 68.8% were females. Most common rheumatologic conditions associated with cardiogenic shock were SLE (31%), GPA (23%), TA (14.6%), APA (10.4%), and RA (8.3%). Cardiogenic shock was found to be caused by eosinophilic myocarditis in 58% of cases, CAD in 19% of cases, and valvulopathy in 6% of cases. Most patient required high-dose steroids and second immunosuppressant therapy. Mechanical circulatory supported was required in 23 cases, IABP in 16 cases, and ECMO in 12 cases. Complete recovery occurred in 37 patients while 9 patients died and 2 required heart transplant. Responsible for two-thirds of cases, eosinophilic myocarditis should be suspected in young cardiogenic shock patients with underlying rheumatologic conditions. Lupus and GPA are the two most common conditions.
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http://dx.doi.org/10.1007/s10741-020-09990-4DOI Listing
June 2020

Spontaneous Biliary Pericardial Tamponade: A Case Report and Literature Review.

Curr Cardiol Rev 2021 ;17(2):204-208

State University of New York: Downstate Medical Center, Brooklyn, NY 11202, United States.

Background: Biliary pericardial tamponade (BPT) is a rare form of pericardial tamponade, characterized by yellowish-greenish pericardial fluid upon pericardiocentesis. Historically, BPT reported to occur in the setting of an associated pericardiobiliary fistula. However, BPT in the absence of a detectable fistula is extremely rare.

Learning Objective: A biliary pericardial tamponade is a rare form of tamponade warranting a prompt workup (e.g., MRCP or HIDA scan) for a potential fistula between the biliary system and the pericardial space. A pericardio-biliary fistula can be iatrogenic or traumatic. People with a history of chest wall trauma, abdominal surgery, or chest surgery are at increased risk. The use of HIDA scanning plays a salient role in effectively surveilling for the presence of a fistula - especially when MRCP is contraindicated.

Case Presentation: A 75-year-old Hispanic male presenting with dyspnea and diagnosed with cardiac tamponade is the subject of the study. Subsequent pericardiocentesis revealed biliary pericardial fluid (bilirubin of 7.6 mg/dl). The patient underwent extensive workup to identify a potential fistula between the hepatobiliary system and the pericardial space, which was non-revealing. The mechanism of bile entry into the pericardial space remains to be unidentified.

Literature Review: A total of six previously published BPT were identified: all were males, with a mean age of 53.3 years (range: 31-73). Mortality was reported in two out of the six cases. The underlying etiology for pericardial tamponade varied across the cases: incidental pericardio-biliary fistula, traumatic pericardial injury, and presence of associated malignancy. - Conclusion: Biliary pericardial tamponade is a rare form of tamponade that warrants a prompt workup (e.g., Hepatobiliary Iminodiacetic Acid - HIDA scan) for an iatrogenic vs. traumatic pericardio- biliary fistula. As a first case in the literature, our case exhibits a biliary tamponade in the absence of an identifiable fistula.
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http://dx.doi.org/10.2174/1573403X16666200611132045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8226206PMC
June 2021

Myocardial Infarction as the Initial Presentation for Fibromuscular Dysplasia.

Am J Med Case Rep 2020 12;8(7):166-172. Epub 2020 Apr 12.

Department of Internal Medicine, State University of New York: Downstate Medical Center, Brooklyn, New York, United States- 11203.

Background: Fibromuscular dysplasia (FMD) is a non-atherosclerotic disease that affects medium-sized arteries and results in stenosis, dissection, aneurysm or occlusion. It is most commonly reported in the renal and carotid arteries. Involvement of coronary arteries is quite rare and and leads to serious consequences.

Case: 62-year-old African American woman with a history of mitral valve prolapse presented with chest discomfort associated with diaphoresis. Her EKG initially showed ST segment changes in leads II, III, and V2-V5 which resolved in approximately 30 minutes. Her troponin peaked to 20 ng/L during her hospital course. A bedside echocardiogram revealed an EF of 45% with mid, distal septal and apical hypokinesis.

Decision-making: The patient was admitted to the Cardiac Care Unit for treatment of an NSTEMI. She underwent cardiac catheterization, which revealed single-vessel coronary disease with diffuse narrowing of the distal LAD, beyond the first diagonal branch down to the apex. CT angiography of her abdomen and pelvis showed mild narrowing of the mid-right renal artery with a small fusiform aneurysm measuring approximately 5 mm. Her carotid duplex showed tortuosity in the right internal carotid artery. Given the multiple vascular anomalies, a diagnosis of fibromuscular dysplasia was considered.

Conclusion: Acute coronary syndrome in fibromuscular dysplasia requires an integrated approach to management, especially if there is associated malignant hypertension and/or dissection.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7252985PMC
April 2020

Pacing therapies for sleep apnea and cardiovascular outcomes: A systematic review.

J Interv Card Electrophysiol 2021 Jun 22;61(1):11-17. Epub 2020 May 22.

The Kansas City Heart Rhythm Institute (KCHRI) & Research Foundation, Overland Park Regional Medical Center, HCA Mid-West, 5100 West 110th Street, Suite 200, Overland Park, KS, 66221, USA.

Purpose: Phrenic and hypoglossal nerve pacing therapies have shown benefit in sleep apnea. We sought to analyze the role of pacing therapies in sleep apnea and their impact on heart failure.

Methods: A comprehensive literature search in PubMed and Google Scholar from inception to August 5, 2019, was performed. A meta-analysis was performed using fixed effects model to calculate mean difference (MD) with 95% confidence interval (CI).

Results: Six studies were eligible and included 626 patients, of whom 334 were in the control arm and 393 were in the experimental arm. Phrenic nerve pacing (MD - 23.20 events/h, 95% CI - 27.96 to - 18.44, p < 0.00001) and hypoglossal nerve pacing (MD - 20.24 events/h, 95% CI - 23.22 to - 17.27, p < 0.00001) were associated with improvements in apnea-hypopnea index (AHI). Phrenic nerve pacing was associated with a trend towards improvements in left ventricular ejection fraction (MD 3.95%, 95% CI - 0.04 to 7.94, p = 0.05). Hypoglossal and phrenic nerve pacing were associated with improvements in the quality of life as assessed by improvements in Epworth sleepiness scale (MD 3.71 points, 95% CI 2.89 to 4.54, p < 0.00001).

Conclusions: Our analysis suggests that phrenic and hypoglossal nerve pacing improves AHI and quality of life with a trend towards improvement in left ventricular ejection fraction, especially in central sleep apnea. Complications were high but future refinement in technology will likely improve clinical outcomes and minimize complications.
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http://dx.doi.org/10.1007/s10840-020-00760-8DOI Listing
June 2021

Dofetilide Initiation and Implications of Deviation From the Standard Protocol - A Real World Experience.

J Atr Fibrillation 2019 Dec 31;12(4):2265. Epub 2019 Dec 31.

Kansas City Heart Rhythm Institute and Research Foundation, Overland Park, KS.

Background: Manufacturer/federal drug administration (FDA) recommends inpatient initiation of dofetilide with the manufacturer providing an initiation algorithm. The outcomes of algorithm deviation have not been reported outside of clinical trials.

Objective: We sought to perform a chart review of all the patients admitted for inpatient initiation of dofetilide to report on the incidence of protocol deviations and their implications.

Methods: We performed a retrospective review of all patients over a 15-month periodwho were initiated on dofetilide for the very first time or reinitiated on dofetilide after a break of three months or more at our institution. We assessed data about patients who were given dofetilide without adherence to the protocol (i.e. protocol deviation).

Results: A total of 189 patients were included in the study with a median age of 66 ± 9 years. Mean baseline QTc interval was 436 ± 32 msec, and 61% (116/189) were in atrial fibrillation (AF) at the time of dofetilide initiation. In 9% (17/189) of patients, the drug was discontinued due to intolerance or inefficacy. Therapy in 49% (93/189) of patients was noted to deviate from manufacturer recommended protocol with deviations more than once in some patients during the same hospitalization. Baseline QTc exceeding 440 msec(>500msec in conduction abnormalities) was the most frequent deviation (25%; 47/189).Ventricular tachyarrhythmia occurred in 4% (7/189) of patients, did not differ between patients, and occurred with and without protocol deviations (5% vs 2%; p = 0.27).

Conclusions: In our retrospective study, there were frequent deviations from the manufacturer-recommended algorithm guidelines for dofetilideinitation, primarily due to prolonged baseline QTc interval. The impact of these protocol deviations on drug discontinuation was uncertain; however, significant adverse events were higher in the deviation group compared to the group that fully adhered to the protocol. Further multicenter studies are warranted to clarify our findings.
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http://dx.doi.org/10.4022/jafib.2265DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7237080PMC
December 2019

Hydralazine-Induced ANCA Associated Vasculitis (AAV) Presenting with Pulmonary-Renal Syndrome (PRS): A Case Report with Literature Review.

Curr Cardiol Rev 2021 ;17(2):182-187

Department of Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, United States.

Hydralazine, an arterial vasodilator, is a widely used medication for the management of hypertension and heart failure, especially for patients who cannot tolerate the use of ACEIs or ARBs. It is generally well-tolerated and has a safe profile in pregnancy. However, hydralazine can induce immune-mediated side effects, such as hydralazine-induced lupus and less commonly hydralazine- induced ANCA vasculitis. The latter most commonly affects the kidneys with or without other organ involvement. There are several cases reported in the literature of hydralazine-induced ANCA associated vasculitis (AAV) that have pulmonary manifestations, also known as hydralazine- induced pulmonary-renal syndrome (PRS), a condition with a high risk of mortality. We are reporting a case of Hydralazine-induced ANCA associated glomerulonephritis with severe diffuse alveolar hemorrhage (DAH). In addition, we will review the current literature and discuss the importance of prompt diagnosis and early management to decrease mortality and morbidity associated with this serious condition.
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http://dx.doi.org/10.2174/1573403X16666200518092814DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8226194PMC
June 2021

Acute Myocardial Infarction in Systemic Mastocytosis: Case Report With Literature Review on the Role of Inflammatory Process in Acute Coronary Syndrome.

Curr Cardiol Rev 2020 ;16(4):333-337

Department of Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, United States.

Background: Systemic Mastocytosis (SM) is a disorder of excessive mast cell infiltration in multiple organ tissues. Atherosclerosis is a major risk factor for developing acute coronary syndrome. In addition to lipid accumulation in the arterial wall, inflammation plays an important role in the pathogenesis of plaque rupture and activating the thrombosis cascade. The Mast cells contribution to plaque destabilization has been well established in multiple animal and human studies. In a recent study, SM has been proven to be associated with a higher incidence of acute coronary syndrome even with lower plasma lipids levels. The study showed that 20% of patients with SM had cardiovascular events compared to only 6% in the control group with adjustment to all cardiac risk factors.

Case: We presented a patient with no risk factors for heart disease other than old age and history of SM who developed acute myocardial infarction.

Conclusion: SM can be life-threatening and can result in ACS, anaphylactic reaction, syncope, or cardiac arrest. Clinicians should have a high index of suspicion of acute coronary syndrome (ACS) occurrence in the setting of inflammatory conditions, such as SM and KS, and vice versa, where SM should be considered or ruled out in patients who suffer from anaphylaxis and cardiac arrest or myocardial infarction.
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http://dx.doi.org/10.2174/1573403X16666200331123242DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7903504PMC
February 2021

Systematic Review of Contiguous Vessel and Valve Injury Associated with Endocardial Left Atrial Appendage Occlusion Devices.

J Atr Fibrillation 2019 Aug-Sep;12(2):2256. Epub 2019 Aug 31.

The Kansas City Heart Rhythm Institute, 5701 W 119th Street, Suite 430, Overland Park, KS 66209, USA.

Endocardial LAAO has been increasingly utilized in atrial fibrillation (AF) patients who are not suitable for long term oral anticoagulation. While overall procedural complications have decreased, rare complications like contiguous vessel and valve injury may be more frequently seen in the future with increase in the procedure volume. We performed a systematic search using predefined terms which reviewed all cases published in literature of contiguous vessel (pulmonary artery, pulmonary vein and left circumflex artery) and mitral valve injury caused by LAAO devices. Our results showed that Amplatzer Cardiac Plug (ACP) and Amplatzer Amulet devices were the most commonly used devices. Pulmonary artery perforation was the most commonly seen collateral vessel injury associated with LAAO. Close proximity of left atrial appendage to pulmonary artery was noted in all cases of pulmonary artery injury. Pulmonary artery injury commonly manifests as pericardial tamponade with hemodynamic collapse and is often fatal. Most common denominator of all the reviewed cases was the presence of an oversized LAAO device. In conclusion, collateral vessels and valve injury can be seen after LAAO mostly with double lobe devices such as ACP or Amulet. Increased awareness by the operators along with proper imaging and investigations could potentially mitigate such rare complications associated with LAAO.
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http://dx.doi.org/10.4022/jafib.2256DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6990055PMC
August 2019

Evaluating the role of transesophageal echocardiography (TEE) or intracardiac echocardiography (ICE) in left atrial appendage occlusion: a meta-analysis.

J Interv Card Electrophysiol 2021 Jan 17;60(1):41-48. Epub 2020 Jan 17.

The Kansas City Heart Rhythm Institute (KCHRI) HCA MidWest, Overland Park Regional Medical Center, 12200 W 106th Street, Overland Park, KS, 66215, USA.

Purpose: Intracardiac echocardiography (ICE) is increasingly common among periprocedural imaging modalities used during complex cardiac procedures. We sought to perform a meta-analysis comparing transesophageal echocardiography (TEE) and ICE in endocardial left atrial appendage occlusion (LAAO).

Methods: We searched PubMed and Google Scholar regarding abstracts and manuscripts using keywords: atrial fibrillation, left atrial appendage occlusion, Watchman, Amplatzer Cardiac Plug, Amulet, intracardiac echocardiography, and transesophageal echocardiography from their inception to July 12, 2019. Data extraction was performed using standard form for the following: title, year of publication, sample size, comorbid conditions, LAAO device, type of pre-procedural imaging, intraprocedural imaging, and clinical outcomes including the following: acute procedural success, fluoroscopy, and total procedure time and complications.

Results: A total of 42 relevant studies were screened resulting in inclusion of 8 observational studies comparing TEE and ICE in endocardial LAAO. Outcomes assessed including procedural success (RR 1.00, 95% CI (0.97-1.03, p = 0.98)), complications (RR 0.77, 95% CI (0.52 to 1.15, p = 0.20)), fluoroscopy time (mean difference - 0.40, 95% CI (-3.12-2.32, p = 0.77)), and procedural time (mean difference - 8.02, 95% CI (-22.81 to 6.76, p = 0.29)) were found to be similar between both groups.

Conclusions: While TEE is the gold standard for perioperative imaging with LAAO, ICE is a feasible and safe alternative that reduces exposure to general anesthesia and associated potential risks.
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http://dx.doi.org/10.1007/s10840-019-00677-xDOI Listing
January 2021

A rare presentation of Austrian syndrome with septic arthritis in an immunocompetent female.

Egypt Heart J 2019 Sep 9;71(1). Epub 2019 Sep 9.

University of Texas Health Science Center at San Antonio, San Antonio, USA.

Background: Austrian syndrome, which is also known as Osler's triad, is a rare aggressive pathology consisting of pneumonia, endocarditis, and meningitis caused by Streptococcus pneumoniae and carries drastic complications.

Case Presentation: A case of a 68-year-old female with a past medical history of hypertension and had a recent viral influenza is presented. She developed bacterial pneumonia, endocarditis with mitral and aortic vegetations and perforation, meningitis, and right sternoclavicular septic arthritis. Two prior case reports have described sternoclavicular septic arthritis as part of Austrian syndrome. Our case is the third case; however, it is the first case to have this tetrad in an immunocompetent patient with no risk factors, i.e., males, chronic alcoholism, immunosuppression, and splenectomy.

Conclusions: Clinicians should maintain a high index of suspicion for the possibility of sternoclavicular joint septic arthritis as a complication of Austrian syndrome in immunocompetent patients.
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http://dx.doi.org/10.1186/s43044-019-0010-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6821411PMC
September 2019

STEMI and CVA in Hypercoagulable State with Ostium Secundum Defect.

Am J Med Case Rep 2019 22;7(12):320-324. Epub 2019 Sep 22.

SUNY-Downstate, Brooklyn, New York USA.

Atrial septal defect (ASD) is a risk factor for multiple vascular thrombotic events, which can occur either sequentially or simultaneously. In this report we present a case of ST-elevation myocardial infarction (STEMI) and cerebrovascular accident (CVA). The severity of adverse cardiovascular or cerebrovascular events can be increased by the presence of specific type of ASD, such as a patent foramen ovale (PFO) or osteum secundum defect. This case report discusses a unique presentation of a 48-year old male on warfarin therapy for a history of cerebral venous thrombosis (CVT) who subsequently presented with simultaneous STEMI with CVA, and who was incidentally found to have an ostium secundum defect on echocardiography. He was emergently taken for cardiac catheterization, which revealed significant proximal LAD occlusion. There has been a long standing debate within the international scientific communities regarding the therapeutic benefit of PFO closure for long-term secondary prevention of recurrence CVA. We discuss the different points of view regarding PFO closure for secondary prevention of CVA with a review of the literature on this rather controversial topic.
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http://dx.doi.org/10.12691/ajmcr-7-12-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6812527PMC
September 2019

Malignant Course of the Right Coronary Artery Originating from the Left Main Coronary Artery: An Odd Exit.

Am J Med Case Rep 2019 Dec;7(12):311-316

Department of Medicine, State University of New York, Downstate Medical Center, United States.

Introduction: Congenital coronary artery anomalies are quite uncommon with estimates ranging from 0.2% to 1.3% on coronary angiography. The rarity of these anomalies makes their diagnosis a formidable challenge. Variable arterial courses have been described. In this report, we present a case with unique arterial course, which starts as a hyperacute take-off of the right coronary artery (RCA) from the left main coronary artery (LMCA), with subsequent coursing, without external compression, between the right ventricular outflow tract and aorta. Our case is relevant to the concept of whether we should keep a reasonable index of suspicion for coronary artery anomalies during cardiac evaluations of patients undergoing non-cardiac surgeries.

Clinical Case: This is an asymptomatic 47-year-old African American female who presented for cardiac clearance for renal transplantation. She had a past medical history of hypertension, bronchial asthma, and former smoking of 10 years (quitting 15 years prior to presentation). She also has end-stage renal disease on hemodialysis. Cardiac workup revealed left ventricular hypertrophy on EKG, multi-chamber dilation seen on echo, and anomalous RCA course seen on CT coronary angiography. Cardiac catheterization revealed non-obstructive coronary artery disease of the LCX and RCA. After consulting with cardiothoracic surgery, conservative medical management was decided based on the patient's risk stratification. She was advised to have close monitoring of her condition.

Discussion: Coronary artery anomalies represent the second most common cause of sudden cardiac death in young athletes. At this time, the prevalence of right coronary artery (RCA) take off from the left coronary sinus occurs at a percentage of 0.019% to 0.49%. The RCA origination from the left main coronary artery (LMCA) accounts for only 0.65% of these anomalies. Our patient had high-risk anatomy consisting of a hyper-angulated take-off of the RCA from the LMCA as well as course between the pulmonary artery and right ventricular outflow tract (RVOT). CT coronary angiography is the most useful imaging modality that characterizes coronary artery anomalies. Although this patient exhibited no signs or symptoms of cardiorespiratory compromise, she warranted a full cardiac workup preoperatively that incidentally revealed a coronary anomaly. Recognition of this disease is critical for timely prevention of potential complications as well as discussion of goals of care. Guidelines for medical versus surgical management are available, but the management strategy should be individualized, with the highest consideration given to risk-benefit analysis.
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http://dx.doi.org/10.12691/ajmcr-7-12-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6800227PMC
December 2019

Coronary Fistula Between Left Anterior Descending Artery (LAD) and Pulmonary Artery (PA) Leading to Sudden Cardiac Death: Case Report with Literature Review.

Curr Cardiol Rev 2020 ;16(2):98-102

Department of Internal Medicine, State University of New York, Downstate Medical Center, Brooklyn, New York, NY 12222, United States.

Coronary Artery Fistulas (CAF) are inappropriate connections between a coronary artery and a major vessel or a cardiac chamber. These fistulas may or may not present with symptoms, but they need to be detected as early as possible in order to decide the most appropriate treatment methodology (i.e. surgery vs. conservative management). We report the case of a 67-year-old female with no modifiable cardiovascular risk factors who had an unwitnessed sudden death at home during her ongoing evaluation of a fistula detected incidentally between the Left Anterior Descending Artery (LAD) and the Pulmonary Artery (PA). This case highlights that early diagnosis and treatment of symptomatic CAF are crucial to minimize the risk of sudden cardiac death. Although the symptomatic fistula of LAD to PA has been reported in the literature multiple times, it has been rarely reported that this fistula can result in sudden cardiac death.
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http://dx.doi.org/10.2174/1573403X15666191008100848DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7460707PMC
July 2020
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