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Babapoor-Farrokhran S, Alzubi J, Port Z, Kaul R, Rasekhi RT, Farrokhran AB, Sooknanan N, Wiener PC, Khraisha O, Frishman WH, Mainigi SK, Aronow WS. Left Atrial Appendage Closure: What Do We Know? Cardiol Rev 2023:00045415-990000000-00146. [PMID: 37643211 DOI: 10.1097/crd.0000000000000601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia in the United States and the most common cause of embolic cerebrovascular events, with the majority of these thrombi originating in the left atrial appendage. The left atrial appendage (LAA) has separate developmental, ultrastructural, and physiological characteristics from the left atrium. Although LAA anatomy is highly variable, it can be categorized into 4 types: cactus, cauliflower, chicken wing, and windsock. The cauliflower type is associated with higher stroke risk in patients with nonvalvular AF. Although the cornerstone of therapy to prevent embolic strokes from AF has been anticoagulation with thrombin inhibitors, a large group of patients are unable to tolerate anticoagulation due to bleeding. This has led to the development and advancement of multiple surgical and percutaneous LAA closure devices to prevent embolic cerebrovascular accidents without the need for anticoagulation. In this article, we discuss the outcomes of major studies that utilized surgical LAA occlusion and its effectiveness. Furthermore, we summarize nonsurgical methods of LAA closure and future directions regarding LAA closure.
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Affiliation(s)
- Savalan Babapoor-Farrokhran
- From the Leon H. Charney Division of Cardiology, Cardiac Electrophysiology, NYU Langone Health, New York University School of Medicine, NY
| | - Jafar Alzubi
- vision of Cardiology, Department of Medicine, Einstein Medical Center, Philadelphia, PA
| | - Zachary Port
- vision of Cardiology, Department of Medicine, Einstein Medical Center, Philadelphia, PA
| | - Risheek Kaul
- From the Leon H. Charney Division of Cardiology, Cardiac Electrophysiology, NYU Langone Health, New York University School of Medicine, NY
| | | | | | - Naveen Sooknanan
- vision of Cardiology, Department of Medicine, Einstein Medical Center, Philadelphia, PA
| | - Philip C Wiener
- Department of Internal Medicine, Division of Cardiology, Washington University in St. Louis, St. Louis, MO
| | - Ola Khraisha
- vision of Cardiology, Department of Medicine, Einstein Medical Center, Philadelphia, PA
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - William H Frishman
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Sumeet K Mainigi
- vision of Cardiology, Department of Medicine, Einstein Medical Center, Philadelphia, PA
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
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Wiener PC, Moore KM, Contreras C, Robinson CG, Cuculich PS. Noninvasive Cardiac Radioablation for Chagas Heart Disease. Arq Bras Cardiol 2023; 120:e20230055. [PMID: 36995794 PMCID: PMC10392856 DOI: 10.36660/abc.20230055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023] Open
Affiliation(s)
- Philip C. Wiener
- Washington UniversitySchool of MedicineSt. LouisMOEUAWashington University School of Medicine, St. Louis, MO – EUA
| | - Kaitlin M.S. Moore
- Washington UniversitySchool of MedicineSt. LouisMOEUAWashington University School of Medicine, St. Louis, MO – EUA
| | - Carlos Contreras
- Washington UniversitySchool of MedicineSt. LouisMOEUAWashington University School of Medicine, St. Louis, MO – EUA
| | - Clifford G. Robinson
- Washington UniversitySchool of MedicineSt. LouisMOEUAWashington University School of Medicine, St. Louis, MO – EUA
| | - Phillip S. Cuculich
- Washington UniversitySchool of MedicineSt. LouisMOEUAWashington University School of Medicine, St. Louis, MO – EUA
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Babapoor S, Port Z, Wiener PC, Rasekhi RT, Farrokhran AB, Mainigi SK. COVID-19 Can Unveil Brugada: A Rare Case. Acta Medica (Hradec Kralove) 2023; 66:68-71. [PMID: 37930096 DOI: 10.14712/18059694.2023.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
Brugada syndrome (BRS) is a channelopathy with three characteristic electrocardiogram patterns and an increased risk of sudden cardiac death (SCD), in the absence of gross structural heart disease. Fever is shown to precipitate ventricular arrhythmias in patients with BRS. Here, we report a rare case of Brugada pattern in a patient with Coronavirus Disease 2019 (COVID-19) without fever. A baseline ECG should be considered for patients with COVID-19, even in the absence of fever. COVID-19 by itself may be a factor that can induce Brugada pattern ECGs.
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Affiliation(s)
- Savalan Babapoor
- Leon H. Charney Division of Cardiology, Cardiac Electrophysiology, NYU Langone Health, New York University School of Medicine, NY, USA.
| | - Zachary Port
- Department of Medicine, Division of Cardiology, Einstein Medical Center, Philadelphia, PA, USA
| | - Philip C Wiener
- Department of Internal Medicine, Division of Cardiology, Washington University in St. Louis, St. Louis, MO, USA
| | | | | | - Sumeet K Mainigi
- Department of Medicine, Division of Cardiology, Einstein Medical Center, Philadelphia, PA, USA
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Pressman GS, Darwish A, Friend EJ, Wiener PC, Kadem L. Severe MAC increases shear stresses on particles traversing the mitral valve: an in vitro study. Eur Heart J Cardiovasc Imaging 2022. [DOI: 10.1093/ehjci/jeab289.366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Mitral annular calcification (MAC) is a strong predictor of stroke but mechanism(s) are poorly defined. Severe MAC can produce a gradient across the mitral valve (MV) and, when studied in vitro, disturbs normal flow across the valve resulting in increased viscous energy dissipation.
Purpose
We hypothesized that severe MAC would increase shear stress on particles traveling across the MV into the left ventricle (LV). Given that shear stresses cause platelet activation this might represent a mechanism by which MAC could increase stroke risk.
Methods
A silicone model MV was created using a 3D TEE dataset. 3D printed calcium phantoms were incorporated into the valve simulate severe MAC. The valve was tested in a left heart duplicator under rest and exercise conditions and compared with a duplicate valve without the calcium phantoms. Fine particles suspended in a water/glycerol blood analogue allowed for measurement of vortex formation and shear stresses using particle image velocimetry (PIV). Particle residence time (PRT) maps were created to assess how long blood particles would remain in the LV. Particle residence index (PRI - ratio of remaining particles in LV/initial number of particles) is a more quantitative measure of how fast particles leave the LV. These calculations were used to approximate viscous shear stresses on blood particles. For each particle the induced viscous shear stress was evaluated for the entire duration of residence in the LV.
Results
For the normal MV all released particles left the LV by the 3rd cycle; with severe MAC particles completely left the LV shortly after the 7th cycle. PRI measurements confirmed that particles remained longer in the LV in the presence of severe MAC (figure 1). MAC also induced a shift in the accumulated shear stress levels from the high range > 0.4 Pa.s and the low range < 0.1 towards the middle region (0.16-0.32 Pa.s, figure 2). As shear stress is reported for one cycle, one may expect MAC to lead to higher accumulated higher viscous stresses as particles reside in the LV for a longer time.
Conclusions
In the presence of severe MAC blood particles remain longer in the LV and are exposed to greater cumulative shear stresses vs the normal situation. Given that shear stress is known to cause platelet activation this may be a mechanism by which MAC increases risk of ischemic stroke. Abstract Figure 1 Abstract Figure 2
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Affiliation(s)
- GS Pressman
- Albert Einstein Medical Center, Cardiology, Philadelphia, United States of America
| | - A Darwish
- Concordia Univeristy, Engineering, Montreal, Canada
| | - EJ Friend
- Albert Einstein Medical Center, Cardiology, Philadelphia, United States of America
| | - PC Wiener
- Washington University School of Medicine, Cardiovascular Division, St Louis, United States of America
| | - L Kadem
- Concordia Univeristy, Engineering, Montreal, Canada
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Friend EJ, Wiener PC, Murthy K, Pressman GS. Morphological features of mitral annular calcification leading to systolic anterior motion of the mitral valve. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.3335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Systolic anterior motion (SAM) of the mitral valve (MV) can develop after mitral valve repair with placement of an annuloplasty ring. It is occasionally seen in patients with mitral annular calcification (MAC) but mechanisms have not been carefully delineated. Using 2-dimensional echocardiography we explored morphologic parameters which may contribute to SAM in patients with MAC.
Hypothesis
We hypothesized that in cases of MAC where SAM is present there would be anterior displacement of the valve by the posterior annular calcification.
Methods
From our echocardiographic database we identified 20 patients with severe MAC who also had SAM with definite septal contact. Each subject was paired with 2 controls free of MAC and 1 control with severe MAC but no SAM. All controls were matched for age, sex, BSA, and septal wall thickness (±1.5 mm). 2-D echocardiographic measurements were taken from the parasternal long-axis (PLAX), apical 3-chamber and apical 4-chamber views.
Results
MAC+SAM vs MAC no-SAM. Three notable differences were observed: MAC+SAM patients, as compared with MAC no-SAM, had a smaller left ventricular outflow tract (LVOT), longer anterior mitral leaflet, and greater displacement of the MV coaptation point towards the interventricular septum (Figure 1). Median values for these 3 factors were determined using the no-MAC controls; each MAC subject was then scored for number of factors exceeding those values. MAC+SAM patients had a mean score of 2.7 vs 1.1 for MAC no-SAM patients. By combining anterior mitral leaflet length and coaptation point-septal distance as a ratio we could effectively separate MAC+SAM vs MAC no-SAM when >0.9 with one exception (Figure 2). We also observed a smaller anteroposterior annular dimension in the MAC+SAM group.
MAC no-SAM vs no-MAC. Comparing these groups there were no differences in LVOT diameter or coaptation-septal distance; effective anterior mitral leaflet length was smaller in MAC no-SAM subjects vs no-MAC controls while anteroposterior dimension of the annulus was larger.
Conclusions
SAM develops in a subset of patients with severe calcification of the mitral annulus. These patients have a smaller anteroposterior annular dimension, possibly due to severe MAC. Other notable differences characterize MAC patients with SAM from those without. The LVOT is smaller, the effective anterior mitral leaflet length is longer, and the point of leaflet coaptation is displaced towards the septum. Using the ratio of anterior mitral leaflet length/coaptation point-septal distance in this study sample effectively separated those MAC patients with SAM from those without.
Funding Acknowledgement
Type of funding sources: None. Figure 1Figure 2
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Affiliation(s)
- E J Friend
- Einstein Medical Center Philadelphia, Cardiology, Philadelphia, United States of America
| | - P C Wiener
- Einstein Medical Center Philadelphia, Cardiology, Philadelphia, United States of America
| | - K Murthy
- Einstein Medical Center Philadelphia, Cardiology, Philadelphia, United States of America
| | - G S Pressman
- Einstein Medical Center Philadelphia, Cardiology, Philadelphia, United States of America
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Wiener PC, Friend EJ, Pressman GS, Bhargav R, Radhakrishnan K, Kadem L. Response to: "Color Doppler Splay: A New Tool for the Assessment of Valvular Regurgitations?" by Allievi et al. J Am Soc Echocardiogr 2021; 34:1022-1023. [PMID: 34062241 DOI: 10.1016/j.echo.2021.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 05/25/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Philip C Wiener
- Division of Cardiology, Heart and Vascular Institute, Einstein Medical Center, Philadelphia, Pennsylvania
| | - Evan J Friend
- Division of Cardiology, Heart and Vascular Institute, Einstein Medical Center, Philadelphia, Pennsylvania
| | - Gregg S Pressman
- Division of Cardiology, Heart and Vascular Institute, Einstein Medical Center, Philadelphia, Pennsylvania
| | - Ruchika Bhargav
- Department of Medicine, Einstein Medical Center, Philadelphia, Pennsylvania
| | | | - Lyes Kadem
- Department of Mechanical, Industrial and Aerospace Engineering, Concordia University, Montreal, Quebec, Canada
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Wiener PC, Babapoor-Farrokhran S, Reinaker T, Mainigi SK. Unforeseen consequences: Class III antiarrhythmic amiodarone stimulated increase in prostate-specific antigen. HeartRhythm Case Rep 2021; 7:267-269. [PMID: 34026512 PMCID: PMC8134753 DOI: 10.1016/j.hrcr.2021.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- Philip C Wiener
- Division of Cardiology, Heart and Vascular Institute, Einstein Medical Center, Philadelphia, Pennsylvania
| | | | - Travis Reinaker
- Department of Pharmacy, Einstein Medical Center, Philadelphia, Pennsylvania
| | - Sumeet K Mainigi
- Division of Cardiology, Heart and Vascular Institute, Einstein Medical Center, Philadelphia, Pennsylvania
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Selvaraj S, Khan MS, Vidula MK, Wiener PC, de Feria AE, Rojulpote C, Krishnan S, Tamrat R, Julien H, Jacoby D, Litt H, Pryma D, Dubroff J, Guerraty MA, Bravo P. Incremental prognostic value of visually estimated coronary artery calcium in patients undergoing positron emission tomography imaging. Open Heart 2021; 8:openhrt-2021-001648. [PMID: 33963079 PMCID: PMC8108688 DOI: 10.1136/openhrt-2021-001648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/19/2021] [Accepted: 04/23/2021] [Indexed: 11/05/2022] Open
Abstract
Objective Visually estimated coronary artery calcium (VECAC) from chest CT or attenuation correction (AC)/CT obtained during positron emission tomography (PET)–myocardial perfusion imaging (MPI) is feasible. Our aim was to determine the prognostic value of VECAC beyond conventional risk factors and PET imaging parameters, including coronary flow reserve (CFR). Methods We analysed 608 patients without known coronary artery disease who underwent PET–MPI between 2012 and 2016 and had AC/CT and/or chest CT images. We used Cox regression to estimate the association of VECAC categories (≤10, 11–400, >400 Agatston units (AU)) with the primary outcome of all-cause death, acute coronary syndrome or stroke (mean follow-up 4.3±1.8 years). C-statistics assessed the relationship between PET parameters and VECAC with the primary outcome. Results Mean age was 58±11 years, 65% were women and 67% were black. VECAC ≤10, 11–400 and >400 AU was observed in 68%, 12% and 20% of subjects, respectively. Compared with VECAC ≤10, VECAC categories 11–400 (HR 2.25, 95% CI 1.24 to 4.08) and >400 AU (HR 3.05, 95% CI 1.87 to 4.98) were associated with the primary outcome after adjusting for traditional risk factors, MPI findings and CFR. Adding VECAC to a model that included PET–MPI, CFR and clinical risk factors improved the prognostic value for the primary outcomes (c-statistic 0.71 to 0.75 with VECAC, p=0.01). Conclusions VECAC is a potent predictor of events beyond traditional risk factors and PET imaging markers, including CFR. These data further support the importance for routine VECAC implementation.
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Affiliation(s)
- Senthil Selvaraj
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Muhammad Shoaib Khan
- Department of Medicine, Marshfield Clinic Health System, Marshfield, Wisconsin, USA
| | - Mahesh K Vidula
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Philip C Wiener
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, Pennsylvania, USA
| | - Alejandro E de Feria
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Chaitanya Rojulpote
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sheela Krishnan
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ruth Tamrat
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Howard Julien
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Douglas Jacoby
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Harold Litt
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel Pryma
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jacob Dubroff
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marie A Guerraty
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Paco Bravo
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA .,Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Wiener PC, Darwish A, Friend E, Kadem L, Pressman GS. Energy loss associated with in-vitro modeling of mitral annular calcification. PLoS One 2021; 16:e0246701. [PMID: 33591991 PMCID: PMC7886214 DOI: 10.1371/journal.pone.0246701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 01/22/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction Study aims were to compare hemodynamics and viscous energy dissipation (VED) in 3D printed mitral valves–one replicating a normal valve and the other a valve with severe mitral annular calcification (MAC). Patients with severe MAC develop transmitral gradients, without the commissural fusion typifying rheumatic mitral stenosis (MS), and may have symptoms similar to classical MS. A proposed mechanism relates to VED due to disturbed blood flow through the diseased valve into the ventricle. Methods A silicone model of a normal mitral valve (MV) was created using a transesophageal echocardiography dataset. 3D printed calcium phantoms were incorporated into a second valve model to replicate severe MAC. The synthetic MVs were tested in a left heart duplicator under rest and exercise conditions. Fine particles were suspended in a water/glycerol blood analogue for particle image velocimetry calculation of VED. Results Catheter mean transmitral gradients were slightly higher in the MAC valve compared to the normal MV, both at rest (3.2 vs. 1.3 mm Hg) and with exercise (5.9 vs. 5.0 mm Hg); Doppler gradients were 2.7 vs. 2.1 mm Hg at rest and 9.9 vs 8.2 mm Hg with exercise. VED was similar between the two valves at rest. During exercise, VED increased to a greater extent for the MAC valve (240%) versus the normal valve (127%). Conclusion MAC MS is associated with slightly increased transmitral gradients but markedly increased VED during exercise. These energy losses may contribute to the exercise intolerance and exertional dyspnea present in MAC patients.
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Affiliation(s)
- Philip C. Wiener
- Division of Cardiology, Heart and Vascular Institute, Einstein Medical Center, Philadelphia, PA, United States of America
| | - Ahmed Darwish
- Department of Mechanical, Industrial and Aerospace Engineering, Concordia University, Montreal, Canada
| | - Evan Friend
- Division of Cardiology, Heart and Vascular Institute, Einstein Medical Center, Philadelphia, PA, United States of America
| | - Lyes Kadem
- Department of Mechanical, Industrial and Aerospace Engineering, Concordia University, Montreal, Canada
| | - Gregg S. Pressman
- Division of Cardiology, Heart and Vascular Institute, Einstein Medical Center, Philadelphia, PA, United States of America
- * E-mail:
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Babapoor-Farrokhran S, Port Z, Wiener PC, Amanullah A, Mainigi SK. Polymorphic Ventricular Tachycardia with a Normal QTc Interval in a Patient with COVID-19 and Fever: Case Report. SN Compr Clin Med 2020; 2:2387-2390. [PMID: 32989427 PMCID: PMC7511244 DOI: 10.1007/s42399-020-00531-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 09/17/2020] [Indexed: 11/26/2022]
Abstract
Arrhythmias or conduction system disease are not the most common manifestation of COVID-19 infection in patients requiring hospital admission. Torsade de pointes typically occurs in bursts of self-limiting episodes with symptoms of dizziness and syncope. However, it may occasionally progress to ventricular fibrillation and sudden death. In this article, we report a case of COVID-19 patient who developed polymorphic ventricular tachycardia with torsade de pointes morphology with normal QTc interval in the setting of fever. An 81-year-old woman was admitted with symptoms of COVID-19. She was treated with hydroxychloroquine, azithromycin, and doxycycline at an outside facility and finished the treatment 5 days prior to admission to our facility. Her course was complicated by atrial fibrillation with rapid ventricular response requiring cardioversion. Later, she developed two episodes of polymorphic ventricular tachycardia with TdP morphology with normal QTc. There was a correlation with fever triggering the ventricular tachycardia. We advocated aggressive fever control given the QTc was normal and stable. Following fever control, the patient remained stable and had no abnormal rhythm. COVID-19 patients are prone to different arrhythmias including life-threatening ventricular arrhythmias with normal left ventricular systolic function and normal QTc, and they should be monitored for fever and electrolyte abnormality during their hospital stay.
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Affiliation(s)
- Savalan Babapoor-Farrokhran
- Division of Cardiology, Department of Medicine, Einstein Medical Center, 5501 Old York Road, Philadelphia, PA 19141 USA
| | - Zachary Port
- Division of Cardiology, Department of Medicine, Einstein Medical Center, 5501 Old York Road, Philadelphia, PA 19141 USA
| | - Philip C. Wiener
- Division of Cardiology, Department of Medicine, Einstein Medical Center, 5501 Old York Road, Philadelphia, PA 19141 USA
| | - Aman Amanullah
- Division of Cardiology, Department of Medicine, Einstein Medical Center, 5501 Old York Road, Philadelphia, PA 19141 USA
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107 USA
| | - Sumeet K. Mainigi
- Division of Cardiology, Department of Medicine, Einstein Medical Center, 5501 Old York Road, Philadelphia, PA 19141 USA
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107 USA
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Babapoor-Farrokhran S, Batnyam U, Wiener PC, Kanjanahattakij N, Khraisha O, Amanullah A, Mainigi SK. Atrioventricular and Sinus Node Dysfunction in Stable COVID-19 Patients. ACTA ACUST UNITED AC 2020; 2:1955-1958. [PMID: 32901230 PMCID: PMC7471580 DOI: 10.1007/s42399-020-00497-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2020] [Indexed: 12/19/2022]
Abstract
There are now well-documented cardiac complications of COVID-19 infection which include myocarditis, heart failure, and acute coronary syndrome resulting from coronary artery thrombosis or SARS-CoV-2-related plaque ruptures. There is growing evidence showing that arrhythmias are also one of the major complications. We report two patients with no known history of cardiac conduction disease who presented with COVID-19 symptoms, positive SARS-CoV-2 infection, and developed cardiac conduction abnormalities. Cardiac conduction system disease involving the sino-atrial (SA) node and atrioventricular (AV) node could be a manifestation of SARS-CoV-2 infection.
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Affiliation(s)
- Savalan Babapoor-Farrokhran
- Division of Cardiology, Department of Medicine, Einstein Medical Center, 5501 Old York Road, Philadelphia, PA 19141 USA
| | - Uyanga Batnyam
- Division of Cardiology, Department of Medicine, Einstein Medical Center, 5501 Old York Road, Philadelphia, PA 19141 USA
| | - Philip C Wiener
- Division of Cardiology, Department of Medicine, Einstein Medical Center, 5501 Old York Road, Philadelphia, PA 19141 USA
| | - Napatt Kanjanahattakij
- Division of Cardiology, Department of Medicine, Einstein Medical Center, 5501 Old York Road, Philadelphia, PA 19141 USA
| | - Ola Khraisha
- Division of Cardiology, Department of Medicine, Einstein Medical Center, 5501 Old York Road, Philadelphia, PA 19141 USA
| | - Aman Amanullah
- Division of Cardiology, Department of Medicine, Einstein Medical Center, 5501 Old York Road, Philadelphia, PA 19141 USA.,Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107 USA
| | - Sumeet K Mainigi
- Division of Cardiology, Department of Medicine, Einstein Medical Center, 5501 Old York Road, Philadelphia, PA 19141 USA.,Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107 USA
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Wiener PC, Friend EJ, Bhargav R, Radhakrishnan K, Kadem L, Pressman GS. Color Doppler Splay: A Clue to the Presence of Significant Mitral Regurgitation. J Am Soc Echocardiogr 2020; 33:1212-1219.e1. [PMID: 32712051 DOI: 10.1016/j.echo.2020.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 05/04/2020] [Accepted: 05/04/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND The authors describe a previously unreported Doppler signal associated with mitral regurgitation (MR) as imaged using transthoracic echocardiography. Horizontal "splay" of the color Doppler signal along the atrial surface of the valve may indicate significant regurgitation when the MR jet otherwise appears benign. METHODS Splay was defined as a nonphysiologic arc of color centered at the point at which the MR jet emerges into the left atrium. The authors present a series of 10 cases of clinically significant MR (moderately severe or severe as defined by transesophageal echocardiography) that were misclassified on transthoracic echocardiography as less than moderate. The splay signal was present on at least one standard transthoracic view in each case. To better characterize the splay signal, two groups were created from existing clinically driven transthoracic echocardiograms: 100 consecutive patients with severe MR and 100 with mild MR. RESULTS Splay was present in the majority of severe MR cases (81%) regardless of vendor machine, ejection fraction, or MR etiology. Splay was particularly prevalent among patients with wall-hugging jets (28 of 30 [93%]). In patients with mild MR, splay was present less often (16%), on fewer frames per clip, and had smaller dimensions compared with severe MR. Color scale did not differ between subjects with and those without splay, but color gain was higher when splay was present (P = .04). Machine settings were further explored in a single subject with prominent splay: increasing transducer frequency reduced splay, while increasing color gain increased it. CONCLUSIONS The authors describe a new transthoracic echocardiographic sign of MR. Horizontal splay may be a clue to the presence of severe MR when the main body of the jet is out of the imaging plane. Splay is likely generated as a side-lobe artifact due to a high-flux regurgitant jet.
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Affiliation(s)
- Philip C Wiener
- Division of Cardiology, Heart and Vascular Institute, Einstein Medical Center, Philadelphia, Pennsylvania
| | - Evan J Friend
- Division of Cardiology, Heart and Vascular Institute, Einstein Medical Center, Philadelphia, Pennsylvania
| | - Ruchika Bhargav
- Department of Medicine, Einstein Medical Center, Philadelphia, Pennsylvania
| | | | - Lyes Kadem
- Department of Mechanical, Industrial and Aerospace Engineering, Concordia University, Montreal, Quebec, Canada
| | - Gregg S Pressman
- Division of Cardiology, Heart and Vascular Institute, Einstein Medical Center, Philadelphia, Pennsylvania.
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Kushchayev SV, Wiener PC, Teytelboym OM, Arrington JA, Khan M, Preul MC. Percutaneous Vertebroplasty: A History of Procedure, Technology, Culture, Specialty, and Economics. Neuroimaging Clin N Am 2020; 29:481-494. [PMID: 31677725 DOI: 10.1016/j.nic.2019.07.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Percutaneous vertebroplasty (VP) progressed from a virtually unknown procedure to one performed on hundreds of thousands of patients annually. The development of VP provides a historically exciting case study into a rapidly adopted procedure. VP was the synthesis of information gained from spinal biopsy developments, the inception of biomaterials used in medicine, and the unique health care climate in France during the 1980s. It was designed as a revolutionary technique to treat vertebral body fractures with minimal side effects and was rapidly adopted and marketed in the United States. The impact of percutaneous vertebroplasty on spine surgery was profound.
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Affiliation(s)
- Sergiy V Kushchayev
- Department of Radiology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA; Department of Radiology, Johns Hopkins Hospital, North Caroline Street, Baltimore, MD 21287, USA.
| | - Philip C Wiener
- Einstein Healthcare Network, 5501 Old York Road, Philadelphia, PA 19141, USA
| | - Oleg M Teytelboym
- Department of Radiology, Mercy Catholic Medical Center, 1500 Lansdowne Avenue, Darby, PA 19023, USA
| | - John A Arrington
- Department of Radiology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
| | - Majid Khan
- Department of Radiology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
| | - Mark C Preul
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 West Thomas Road, Phoenix, AZ 85013, USA
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Torres R, Wiener PC, Salacup G. PLATYPNEA-ORTHODEOXIA SYNDROME POST ATRIAL FIBRILLATION ABLATION. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)33943-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Wiener PC, Friend E, Bhargav R, Kadem L, Pressman G. P1577 Mitral regurgitant "splay": an important clue to severity of regurgitation. Eur Heart J Cardiovasc Imaging 2020. [DOI: 10.1093/ehjci/jez319.997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Visual assessment of mitral regurgitation (MR) severity by color Doppler can be difficult, especially in eccentric jets. Examination of the proximal flow acceleration signal (PISA) on the ventricular side of the mitral valve can be helpful but, is not always intuitive. We describe a color signal ("splay") on the atrial side of the valve that can often be helpful in recognizing significant MR.
Methods
Clinical echocardiograms were reviewed to obtain two data sets: 100 patients with reported mild MR and another 100 with reported severe MR. All echocardiograms were reviewed to confirm that MR was truly mild or severe. Splay was defined as a non-physiologic arc of color (figure) centered at the point where the MR jet emerges into the atrium.
Results
Splay was present in the large majority of severe MR cases (table). It was seen across 3 vendors’ machines and was present with normal and reduced EF as well as primary and secondary MR. Color scale and transducer frequency did not differ according to presence or absence of splay, but gain was higher when splay was present (57.5 ± 6.8 vs 55.2 ± 6.1, p = 0.04). In mild MR patients, splay was present on fewer frames and had lesser dimensions vs severe MR. Splay was particularly prevalent in patients with wall hugging jets (28/30, 93%).
Conclusions
The splay signal occurs as a side lobe artifact, at the point where a high energy MR jet emerges into the left atrium. Its presence often indicates significant MR and may be a useful clue in highly eccentric jets which are otherwise difficult to grade.
Table 1 Mild MR Severe MR P value Splay Present (%) 18 82 <0.0001 No. of Frames 2 ± 1.6 3.6 ± 1.3 <0.0001 Width of Splay (cm) 2.2 ± 0.5 3.2 ± 0.9 <0.0001 Depth of Splay (cm) 0.36 ± 0.11 0.47 ± 0.16 0.01
Abstract P1577 Figure. Splay Image
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Affiliation(s)
- P C Wiener
- Albert Einstein Medical Center, Cardiology, Philadelphia, United States of America
| | - E Friend
- Albert Einstein Medical Center, Cardiology, Philadelphia, United States of America
| | - R Bhargav
- Albert Einstein Medical Center, Philadelphia, United States of America
| | - L Kadem
- Concordia Univeristy, Engineering, Montreal, Canada
| | - G Pressman
- Albert Einstein Medical Center, Philadelphia, United States of America
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Viray MC, Wiener PC, Batnyam U, Rasquin L, Pressman GS, Mainigi S. A Young Woman With Recurrent Palpitations: A Case of Ebstein Anomaly With Mahaim Fiber Tachycardia. CASE (Phila) 2019; 3:145-148. [PMID: 31468016 PMCID: PMC6710817 DOI: 10.1016/j.case.2019.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
EA is a distinct entity on echocardiography. Accessory pathways are commonly seen with EA. Mahaim fiber tachycardia is a rare accessory pathway–mediated tachycardia.
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Affiliation(s)
- Michael C Viray
- Division of Cardiology, Department of Medicine, Einstein Medical Center, Philadelphia, Pennsylvania
| | - Philip C Wiener
- Division of Cardiology, Department of Medicine, Einstein Medical Center, Philadelphia, Pennsylvania
| | - Uyanga Batnyam
- Division of Cardiology, Department of Medicine, Einstein Medical Center, Philadelphia, Pennsylvania
| | - Lorena Rasquin
- Department of Medicine, Einstein Medical Center, Philadelphia, Pennsylvania
| | - Gregg S Pressman
- Division of Cardiology, Department of Medicine, Einstein Medical Center, Philadelphia, Pennsylvania
| | - Sumeet Mainigi
- Division of Cardiology, Department of Medicine, Einstein Medical Center, Philadelphia, Pennsylvania
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Abstract
OBJECTIVE Monocyte-derived cells of the brain (MDCB) are a diverse group of functional immune cells that are also highly abundant in gliomas. There is growing evidence that MDCB play essential roles in the pathogenesis of gliomas. The aim of this review was to collate and systematize contemporary knowledge about these cells as they relate to glioma progression and antiglioblastoma therapeutic modalities with a view toward improved effectiveness of therapy. METHODS We reviewed relevant studies to construct a summary of different MDCB subpopulations in steady state and in malignant gliomas and discuss their role in the development of malignant gliomas and potential future therapies. RESULTS Current studies suggest that MDCB subsets display different phenotypes and differentiation potentials depending on their milieu in the brain and exposure to tumoral influences. MDCB possess specific and unique functions, including those that are protumoral and those that are antitumoral. CONCLUSIONS Elucidating the role of mononuclear-derived cells associated with gliomas is crucial in designing novel immunotherapy strategies. Much progress is needed to characterize markers to identify cell subsets and their specific regulatory roles. Investigation of MDCB can be clinically relevant. Specific MDCB populations potentially can be used for glioma therapy as a target or as cell vehicles that might deliver cytotoxic substances or processes to the glioma microenvironment.
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Affiliation(s)
- Sergiy V Kushchayev
- Neurosurgery Research Laboratory, Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Yevgeniya S Kushchayeva
- Neurosurgery Research Laboratory, Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA; Department of Surgery, Medstar Washington Hospital Center, Washington, DC, USA
| | - Philip C Wiener
- Neurosurgery Research Laboratory, Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Adrienne C Scheck
- Neuro-oncology Research Laboratory, Division of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Behnam Badie
- Division of Neurosurgery, Department of Surgery, Beckman Research Institute, City of Hope National Medical Center, Duarte, California, USA
| | - Mark C Preul
- Neurosurgery Research Laboratory, Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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Kushchayev SV, Sankar T, Eggink LL, Kushchayeva YS, Wiener PC, Hoober JK, Eschbacher J, Liu R, Shi FD, Abdelwahab MG, Scheck AC, Preul MC. Monocyte galactose/N-acetylgalactosamine-specific C-type lectin receptor stimulant immunotherapy of an experimental glioma. Part 1: stimulatory effects on blood monocytes and monocyte-derived cells of the brain. Cancer Manag Res 2012; 4:309-23. [PMID: 23049280 PMCID: PMC3459590 DOI: 10.2147/cmar.s33248] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Objectives Immunotherapy with immunostimulants is an attractive therapy against gliomas. C-type lectin receptors specific for galactose/N-acetylgalactosamine (GCLR) regulate cellular differentiation, recognition, and trafficking of monocyte-derived cells. A peptide mimetic of GCLR ligands (GCLRP) was used to activate blood monocytes and populations of myeloid-derived cells against a murine glioblastoma. Methods The ability of GCLRP to stimulate phagocytosis by human microglia and monocyte-derived cells of the brain (MDCB) isolated from a human glioblastoma was initially assessed in vitro. Induction of activation markers on blood monocytes was assayed by flow cytometry after administration of GCLRP to naive mice. C57BL/6 mice underwent stereotactic intracranial implantation of GL261 glioma cells and were randomized for tumor size by magnetic resonance imaging, which was also used to assess increase in tumor size. Brain tumor tissues were analyzed using flow cytometry, histology, and enzyme-linked immunosorbent assay with respect to tumor, peritumoral area, and contralateral hemisphere regions. Results GCLRP exhibited strong stimulatory effect on MDCBs and blood monocytes in vitro and in vivo. GCLRP was associated with an increased percentage of precursors of dendritic cells in the blood (P = 0.003), which differentiated into patrolling macrophages in tumoral (P = 0.001) and peritumoral areas (P = 0.04), rather than into dendritic cells, as in control animals. Treatment with GCLRP did not result in a significant change in survival of mice bearing a tumor. Conclusions In vitro and in vivo activation of monocytes was achieved by administration of GCLR to mice. GCLRP-activated blood monocytes were recruited to the brain and exhibited specific phenotypes corresponding with tumor region (glioma, peritumoral zone, and contralateral glioma-free hemisphere). GCLRP treatment alone was associated with increased glioma mass as the result of the infiltration of phagocytic cells. Regional specificity for MDCB may have significant tumor treatment implications.
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Affiliation(s)
- Sergiy V Kushchayev
- Neurosurgery Research Laboratory, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix
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Kushchayev SV, Sankar T, Eggink LL, Kushchayeva YS, Wiener PC, Hoober JK, Eschbacher J, Liu R, Shi FD, Abdelwahab MG, Scheck AC, Preul MC. Monocyte galactose/N-acetylgalactosamine-specific C-type lectin receptor stimulant immunotherapy of an experimental glioma. Part II: combination with external radiation improves survival. Cancer Manag Res 2012; 4:325-34. [PMID: 23049281 PMCID: PMC3459592 DOI: 10.2147/cmar.s33355] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background A peptide mimetic of a ligand for the galactose/N-acetylgalactosamine-specific C-type lectin receptors (GCLR) exhibited monocyte-stimulating activity, but did not extend survival when applied alone against a syngeneic murine malignant glioma. In this study, the combined effect of GCLRP with radiation was investigated. Methods C57BL/6 mice underwent stereotactic intracranial implantation of GL261 glioma cells. Animals were grouped based on randomized tumor size by magnetic resonance imaging on day seven. One group that received cranial radiation (4 Gy on days seven and nine) only were compared with animals treated with radiation and GCLRP (4 Gy on days seven and nine combined with subcutaneous injection of 1 nmol/g on alternative days beginning on day seven). Magnetic resonance imaging was used to assess tumor growth and correlated with survival rate. Blood and brain tissues were analyzed with regard to tumor and contralateral hemisphere using fluorescence-activated cell sorting analysis, histology, and enzyme-linked immunosorbent assay. Results GCLRP activated peripheral monocytes and was associated with increased blood precursors of dendritic cells. Mean survival increased (P < 0.001) and tumor size was smaller (P < 0.02) in the GCLRP + radiation group compared to the radiation-only group. Accumulation of dendritic cells in both the tumoral hemisphere (P < 0.005) and contralateral tumor-free hemisphere (P < 0.01) was associated with treatment. Conclusion Specific populations of monocyte-derived brain cells develop critical relationships with malignant gliomas. The biological effect of GCLRP in combination with radiation may be more successful because of the damage incurred by tumor cells by radiation and the enhanced or preserved presentation of tumor cell antigens by GCLRP-activated immune cells. Monocyte-derived brain cells may be important targets for creating effective immunological modalities such as employing the receptor system described in this study.
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Affiliation(s)
- Sergiy V Kushchayev
- Neurosurgery Research Laboratory, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix
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Kushchayev SV, Moskalenko VF, Wiener PC, Tsymbaliuk VI, Cherkasov VG, Dzyavulska IV, Kovalchuk OI, Sonntag VKH, Spetzler RF, Preul MC. The discovery of the pyramidal neurons: Vladimir Betz and a new era of neuroscience. Brain 2011; 135:285-300. [PMID: 22075067 DOI: 10.1093/brain/awr276] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
As a consequence of nascent technology, the 19th century witnessed a profound change in orientation to the nervous system. For example, improved microscopy in the first half of the 19th century allowed high magnification without blurring. The subsequent observation of nucleated cells led to the identification of individual brain cells. Philosophical changes in approach to the natural sciences took their lead from those applied to physical observations. The Ukrainian anatomist and histologist, Vladimir Alekseyevich Betz (1834-94) played a pivotal role in reshaping scientific and philosophical approaches to the brain, connecting cerebral localization, function and brain microstructure. Betz revolutionized methods of cell fixation and staining. Sometimes his efforts yielded enormously complicated technological improvements. Betz's greatest contribution, however, was connecting his discovery of the function of giant pyramidal neurons of the primary motor cortex ('cells of Betz') with the cortical organization. Considering cortical cytoarchitectonics in relation with physiological function, Betz recognized this organization in two areas: motor and sensory. He defined a functional area on histological grounds and thereby opened the way to study precise cortical areas. Betz participated in the scientific transformation of cytoarchitectonics based on macro- and microscopic studies of the cortical surface, enabling him to view the paths of nerve cells in the brain. Betz's influence allowed systemization of scattered scientific findings. The discovery of pyramidal cells was a turning point in the prevailing philosophical and scientific approach to the brain, linking cytoarchitecture, neurophysiology and cerebral localization.
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Affiliation(s)
- Sergiy V Kushchayev
- Division of Neurological Surgery, Barrow Neurological Institute, St Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
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Abstract
The Flexiblade is a laryngoscope which has a 'flexible' blade. The 'front' half of the blade can be moved in an anterior direction during laryngoscopy, enhancing the view of the glottis. The degree of movement can be controlled with the lever. We studied 200 ASA 1 and 2 adult patients requiring tracheal intubation and the patients acted as their own controls. The view of the larynx was improved in 93% of the cases when the vocal cords were not completely visible at laryngoscopy with the lever in the neutral position. Ninety-seven per cent of patients with a Cormack and Lehane grading of 2 at normal laryngoscopy were transformed to grade 1 when the lever of the Flexiblade was depressed and 84% of cases with a grading of 3 were transformed to grade 2 or 1. In four patients, there was deterioration in the view of the cords: three patients with grade 1 were transformed to grade 2 and one with grade 2 to grade 3. There was no improvement in one case with grade 2 and three with grade 3.
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Affiliation(s)
- C N Perera
- Department of Anaesthetics, University Hospital of Wales, Cardiff CF14 4XW, UK
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Wiener PC, Hogg MI, Rosen M. Neonatal respiration, feeding and neurobehavioural state. Effects of intrapartum bupivacaine, pethidine and pethidine reversed by naloxone. Anaesthesia 1979; 34:996-1004. [PMID: 395854 DOI: 10.1111/j.1365-2044.1979.tb06247.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The effects on mature newborn have been compared at 0.5, 4, 8 12 24 and 48 hr after birth, of maternally administered epidural bupivacaine (11 babies) or pethidine (18 babies) or pethidine reversed by naloxone administered intramuscularly to the newborn (15 babies). Bupivacaine (mean dose 130 mg) had less effect that pethidine (mean dose 183.3 mg) on alveolar carbon dioxide tension (PACO2) at 0.5 hr after birth, but had a similar effect to pethidine on feeding, elicited reflexes and produced more depression of muscle tone up to 48 hr. Bupivacaine had more effect on PACO2 feeding measures, elicited reflexes and muscle tone at almost all examination periods than pethidine (mean dose 157.0 mg) reversed by naloxone (200 micrograms intramuscularly). Except at delivery, the effects of bupivacaine or pethidine on respiration and feeding up to 48 hr after birth were similar. There were more signs of depression with both drugs than when pethidine had been reversed by naloxone.
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Abstract
In seven neonates, whose mothers were given pethidine during labour, urine was collected for the first 24-40 h of life. Urinary volume and pH, and concentrations of pethidine and norpethidine in the urine were measured. Urine flow rate was low for the first 7-22 h, and then high for about 12 h. The rate of excretion of pethidine and norepethidine was approximately parallel to the urine flow rate. However, the ratio of the rate of excretion of norpethidine to that of pethidine increased with time and the concentration of norpethidine in urine decreased first and then, after 18 h, increased significantly. These findings that the neonate can metabolize pethidine, although the rate of metabolism is probably less than in the adult. The total amounts of pethidine and norpethidine excreted in the first 24 h after birth were positively related to the dose-delivery interval in the mother for intervals up to at least 5 h. From the data it is estimated that 95% of the total pethidine transferred from the mother would be eliminated by the baby by the 2nd to 3rd day after birth.
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Abstract
Infants whose mothers had had pethidine during labour were given either naloxone 40 microgram or isotonic saline administered intravenously double-blind within one minute of birth. Peak alveolar carbon dioxide tension, carbon dioxide excretion, alveolar ventilation, feeding behaviour, and habituation to a specific sound stimulus were measured regularly up to 48 hours after birth. Alveolar carbon dioxide tension was significantly lower and alveolar ventilation significantly higher half an hour after birth in the naloxone-treated group than in the saline-treated group, but these differences between the groups were not significant at any other time, and there were no significant differences in sucking frequency or pressure, milk consumption, or habituation to the auditory stimulus.
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Abstract
Thirty full-term infants whose mothers had had pethidine during labour were given either naloxone 200 microgram or normal saline intramuscularly. The drugs were chosen blindly and administered within one minute of birth. Naloxone produced a significant reduction in mean alveolar carbon dioxide tension and an increase in carbon dioxide excretion and mean alveolar ventilation at all times up to 48 hours after birth. The mean rate of habituation to a repeated auditory stimulus, the mean sucking frequency, the sucking pressure, and the mean consumption of milk were all significantly higher in the naloxone-treated group than in the placebo-treated group up to 48 hours after birth. Intramuscular naxolone therefore seemed to reverse the undesirable effects of pethidine.
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