Mitral valve replacement may be indicated in delayed MitraClip (Abbott) failure. Although it would be best to preserve the chordal apparatus during surgical mitral valve replacement, this has not been reported for delayed MitraClip failure, probably because there is almost always impressive inflammation around the MitraClip, which has likely precluded previous attempts at chordal preservation. A successful surgical chordal preservation mitral valve replacement in delayed MitraClip failure is reported here.

We present the case of a 26‐year‐old female restrained front‐seat passenger who presents following a motor vehicle accident, with CT angiogram features suggestive of possible acute aortic injury. However, clinical features including relative hemodynamic stability and absence of typical symptoms were discordant with these imaging findings. This case illustrates that even with ECG‐gating, CT angiogram artifact mimicking acute aortic injury may still occur. Careful evaluation and clinical correlation is of vital importance, both to ensure acute aortic injury is not missed and that patients are not erroneously sent for aortic surgery when there is no aortic injury. Careful clinical evaluation must be combined with imaging in all cases of suspected aortic trauma, and at times multimodality imaging is indicated to direct the decision making strategy.

We sought to characterize mid-ascending aorta diameter reference values by age, sex, and body surface area (BSA) in a large echocardiography laboratory practice-based cohort. All subjects with transthoracic echocardiograms with mid-ascending aorta diameter measure from January 2004 to December 2009 were identified, and medical records were reviewed for medical history and anthropometric data. Those with aortic valve disease or replacement, congenital heart disease, any connective tissue or inflammatory disease that may affect the aorta, or known aortic aneurysm (>55 mm) were excluded. Mid-ascending aorta diameter was measured in a standardized manner using "leading edge to leading edge" technique at end-diastole. Of 27,839 eligible subjects, 16,620 did not have history of hypertension and were included in the analysis (56.3% female; mean age 52.0 ± 15.8 years), mean mid-ascending aorta diameter 31.7 ± 4.1 mm. Females had smaller diameter than males (30.5 ± 3.7 mm vs 33.3 ± 4.0 mm; p <0.001). Subjects with history of hypertension (n = 11,219; not included in the analysis) had larger mid-ascending aorta diameter compared with normotensive subjects (33.9 ± 3.8 mm vs 31.7 ± 4.1 mm; p < 0.001). Age had the greatest correlation with aortic size (r = 0.55), followed by sex (r = 0.35) and BSA (r = 0.35). Nomograms for predicted mid-ascending aorta diameter were generated at the 95th percentile using quantile regression for subjects without hypertension stratified by age, sex, and BSA. In conclusion, mid-ascending aorta diameter is predominantly associated with sex, age, and BSA. The nomograms established by this study may serve as useful reference values for echocardiographic screening and surveillance.

Cardiac sarcomas represent the majority of primary malignant cardiac tumors. They are usually located in the right atrium and are frequently angiosarcomas. We present a case of primary cardiac sarcoma originating from the left atrium in a 40-year-old woman that was treated with resection combined with mitral valve bypass.

BACKGROUND/AIMS:Pernio (chilblains) is an inflammatory condition classically characterized by localized erythema and swelling of acral sites upon exposure to cool and damp conditions. We sought to determine whether cold-induced vasospasm has a role in the development of pernio.METHODS:We retrospectively reviewed 5 patients with pernio who were seen at our institution between January 1, 2000 and December 31, 2011, and had undergone a noninvasive arterial vascular study of the upper extremities that corresponded to a site of clinical involvement of pernio and who had also undergone vasospastic testing and ice water immersion as part of the noninvasive arterial vascular study protocol.RESULTS:Vascular testing in all patients (mean age 37.8 years; 4 women) demonstrated vasospasm with ice water immersion.CONCLUSION:Our findings suggest that vasospasm likely has a role in the pathophysiology of pernio and may also provide a rationale for the pharmacological treatment of vasospasm in patients with pernio.

Abstract The various conditions affecting the aorta, including atheroembolism, abdominal aortic aneurysm, dissection, penetrating ulcer, intramural hematoma, and rupture are reviewed in this chapter. Causes, clinical presentation, evaluation, natural history, and treatment of conditions affecting the aorta are covered as well.

Peripheral vascular diseases, such as aneurysmal disease, intermittent claudication, acute arterial occlusion, and thromboangiitis, are prevalent in current medical practice. Vasospastic disorders, another class of vascular disease, are characterized by episodic color changes of the skin resulting from intermittent spasm of the small arteries and arterioles of the skin and digits. Vasospastic disorders are important because they frequently are a clue to another underlying disorder, such as arterial occlusive disease, connective tissue disorders, neurologic disorders, or endocrine disease. Characteristic clinical features, accurate diagnostic techniques, and improved treatment of peripheral vascular disease further emphasize the need for increased awareness of this group of disorders.

A 65-year-old black woman with hypertension and type 2 diabetes mellitus presented to her local hospital with acute chest discomfort. She had no history of connective tissue disease or family history of aortic catastrophes. An ECG showed inferior ST-segment elevation. Coronary angiography revealed multiple high-grade lesions in the right coronary artery (RCA) with evidence of thrombus (Movie I in the online-only Data Supplement). There were also critical stenoses in the left coronary system. Percutaneous coronary intervention of the RCA with 3 bare metal stents was successful in establishing Thrombolysis in Myocardial Infarction grade 3 flow, but deployment of the fourth stent was complicated by proximal RCA dissection with extension into the aortic sinuses (Figure 1 and Movie II in the online-only Data Supplement). Despite obliteration of the RCA dissection with the stent, persistent dye staining of the ascending aorta was present on final angiographic views (Figure 2). A computed tomography scan performed 2 days later showed an ascending aorta intramural hematoma (IMH;Figure 3). Plans were made for complete surgical revascularization in 6 weeks, and she was discharged. Aside from several brief episodes of chest discomfort in the first week after discharge, she remained asymptomatic. Three weeks after the initial event, the patient presented for a second opinion at our institution. Figure 1. Left anterior oblique angiographic view of the right coronary artery. An intracoronary guidewire (arrowhead) …

Abstract Different types of peripheral vascular disease, including claudication, pseudoclaudication, acute arterial occlusion, aneurysms, thromboangiitis obliterans, livedo reticularis, chronic pernio, and erythromelalgia are reviewed in this chapter. Causes, pathophysiology, clinical presentation, evaluation, natural history, and treatment of peripheral vascular disease are covered as well.

The term acute aortic syndrome refers to a heterogeneous group of conditions that cause a common set of signs and symptoms, the foremost of which is aortic pain. Various pathologic entities may give rise to this syndrome, but the topic has come to focus on penetrating aortic ulcer and intramural hematoma and their relation to aortic dissection. Penetrating aortic ulcer is a focal atherosclerotic plaque that corrodes a variable depth through the intima into the media. Intramural hematoma is a blood collection within the aortic wall not freely communicating with the aortic lumen, with restricted flow. It may represent a subcategory of aortic dissection that manifests different behavior by virtue of limited flow in the false lumen. This article reviews the current literature regarding acute aortic syndrome, focusing on management options.

A 29-year-old man experienced a diffuse lichenoid rash that extended to his palms (panel A) and soles, peripheral blood eosinophilia, blurry vision, and recalcitrant generalized edema 2 weeks after donor lymphocyte infusion (DLI) for relapsed T-cell acute lymphoblastic leukemia. Skin biopsy revealed vacuolar interface inflammation consistent with graft-vs-host disease (GVHD). The rash improved with topical corticosteroids; however, the edema gradually worsened during the ensuing weeks, and the patient gained 23 kg. A thorough endocrine/metabolic evaluation for causes of anasarca was unremarkable. Transthoracic echocardiography, which had been completely normal 2 weeks before DLI, revealed a thickened pericardium, paroxysmal ventricular septal motion (supplemental video online linked to this article), high medial mitral annular velocity (panel B), and phasic respiratory changes of mitral valve inflow (E wave velocity; panel C). Cardiac magnetic resonance imaging demonstrated abnormal concentric delayed pericardial enhancement (arrow, panel D). The patient's condition was unresponsive to oral colchicine of 1 month's duration. Because his symptoms attributable to constrictive pericarditis occurred in the setting of GVHD development in other organs after DLI, the patient was treated with a moderate dose of corticosteroids (prednisone, 0.5 mg/kg/d). The anasarca rapidly improved. Six weeks after initiation of prednisone and 6 months after DLI, the patient remained in remission from T-cell acute lymphoblastic leukemia. His symptoms due to chronic GVHD were manageable; however, he died of infectious complications of profound immunosuppression. Pericarditis is an uncommon manifestation of chronic GVHD,1Ferrara JL Levine JE Reddy P Holler E Graft-versus-host disease.Lancet. 2009; 373: 1550-1561Abstract Full Text Full Text PDF PubMed Scopus (1754) Google Scholar and, to our knowledge, has been reported after DLI only once previously.2Silberstein L Davies A Kelsey S et al.Myositis, polyserositis with a large pericardial effusion and constrictive pericarditis as manifestations of chronic graft-versus-host disease after non-myeloablative peripheral stem cell transplantation and subsequent donor lymphocyte infusion.Bone Marrow Transplant. 2001; 27: 231-233Crossref PubMed Scopus (40) Google Scholar

BACKGROUND:Cardiac sonographers frequently have work-related muscular discomfort. We aimed to assess the feasibility of having sonographers receive massages during working hours in an area adjacent to an echocardiography laboratory and to assess relief of discomfort with use of the massages with or without stretching exercises.METHODS:A group of 45 full-time sonographers was randomly assigned to receive weekly 30-minute massage sessions, massages plus stretching exercises to be performed twice a day, or no intervention. Outcome measures were scores of the QuickDASH instrument and its associated work module at baseline and at 10 weeks of intervention. Data were analyzed with standard descriptive statistics and the separation test for early-phase comparative trials.RESULTS:Forty-four participants completed the study: 15 in the control group, 14 in the massage group, and 15 in the massage plus stretches group. Some improvement was seen in work-related discomfort by the QuickDASH scores and work module scores in the 2 intervention groups. The separation test showed separation in favor of the 2 interventions.CONCLUSION:On the basis of the results of this pilot study, larger trials are warranted to evaluate the effect of massages with or without stretching on work-related discomfort in cardiac sonographers.TRIAL REGISTRATION:NCT00975026 ClinicalTrials.gov.

Surgical repair of ruptured sinus of Valsalva aneurysm can be challenging, although it has been reported that mortality and morbidity is low. Distortion of sinus of Valsalva geometry can cause aortic valve regurgitation immediately or progressively after surgery. Maintenance of the appropriate geometry of sinus of Valsalva after resection of the aneurysm is critical in preserving the native aortic valve and its competency. Successful reconstruction with various patch materials such as Dacron patches (DuPont, Wilmington, DE) or pericardial patches has been reported. Nevertheless, the size and shape of patches used had to be created impromptu by surgeons without reliable methodology of reproducing the precise shape of the naturally occurring sinus of Valsalva. Herein, we report a successful repair of sinus of Valsalva aneurysm by utilizing a porcine sinus of Valsalva from a commercially available Freestyle valve (Medtronic Inc, Minneapolis, MN). We believe that this is a previously unreported technique. (Ann Thorac Surg 2009;88:2025-7) (C) 2009 by The Society of Thoracic Surgeons

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