Fatal Acute Myocardial Infarction With Normal Epicardial Coronary Arteries Shortly Following COVID-19 Vaccination

Myocarditis and acute myocardial infarction (AMI) have been reported after COVID-19 messenger ribonucleic acid vaccination. Nearly all reported patients with myocarditis or AMI after COVID-19 vaccination have survived and become asymptomatic. Described herein is a previously healthy man who developed severe heart decompensation shortly after receiving a COVID-19 vaccination and died approximately 40 hours later. An autopsy disclosed massive AMI.

[Summary: International consensus statement on nomenclature and classification of the congenital bicuspid aortic valve and its aortopathy, for clinical, surgical, interventional and research purposes]

This consensus of nomenclature and classification for congenital bicuspid aortic valve and its aortopathy is evidence-based and intended for universal use by physicians (both pediatricians and adults), echocardiographers, advanced cardiovascular imaging specialists, interventional cardiologists, cardiovascular surgeons, pathologists, geneticists, and researchers spanning these areas of clinical and basic research. In addition, as long as new key and reference research is available, this international consensus may be subject to change based on evidence-based data1.

Causes of Malfunction of Bioprostheses Inserted Percutaneously in the Aortic Valve Position in Patients Whose Native Aortic Valve Was Congenitally Bicuspid and Stenotic

Transcatheter aortic valve implantation (TAVI) has brought in recent years relief of cardiac-induced symptoms to a large number of patients with aortic stenosis. Whether it is better to use TAVI for the treatment of aortic valve stenosis superimposed on a congenitally bicuspid valve has been debated in contrast to its proved usefulness in aortic valve stenosis involving a tricuspid aortic valve. From January 2020 to March 2023, surgical aortic valve replacement of TAVI valve and native aortic valve was done in 6 patients. The clinical findings of the patients and morphologic findings from the surgical specimens submitted to the cardiac pathology department were subsequently examined. All the 6 native aortic valves had bicuspid configuration. The TAVI valve in each patient was excised from 9 to 88 months (mean 36 months) after it had been implanted because of paravalvular leak in 4, severe stenosis of the prosthetic valve in 1, and bioprosthetic cuspal degeneration in 1. Prosthetic valve endocarditis was clinically suspected in 2 patients, but the specimen culture was negative. Before surgical aortic valve replacement, 3 patients experienced stroke after TAVI. All 6 patients had low hemoglobin levels (mean 9.5 mg/100 ml) and low hematocrit levels (mean 29.5%). Reticulocyte count was available in 4 patients and was increased in all (mean 3.5%). When the stenotic native aortic valve configuration is bicuspid, the raphe tends to be calcified first and located perpendicular to the flow of the blood and may prevent the ring of the caged bioprosthesis from being transferred to the aortic wall, which is a requirement for full opening of the lumen of the bioprosthesis. Thus, thorough consideration needs to be made before performing TAVI in patients whose native aortic valve is stenotic and bicuspid.

Giant-Cell Myocarditis, Cardiac Sarcoidosis, and Orthotopic Heart Transplantation

Described herein are 2 patients diagnosed clinically as "giant cell myocarditis." Both had short clinical courses (∼ 2 months) before lifesaving orthotopic heart transplantation (OHT). Examination of the hearts disclosed multiple widespread yellow lesions in the ventricular walls. The short clinical courses in these 2 patients are quite different from cardiac sarcoidosis, which typically has courses lasting years. In contrast to cardiac sarcoidosis, the ventricular myocardial lesions were yellow in color not white as in cardiac sarcoidosis. In conclusion, we consider giant-cell myocarditis and cardiac sarcoidosis to be different conditions and not simply different stages of the same condition.

Mitral Valve Replacement for Mitral Stenosis Secondary to Massive Mitral Annular Calcium

Mitral annular calcium (MAC) may produce mitral stenosis (MS) if its quantity is massive. We define massive MAC as the presence of a huge quantity of calcium underlying the posterior mitral leaflet and extending across all or nearly all of the ventricular aspect of the anterior mitral leaflet. This report was prompted to emphasize the hazards of performing mitral valve replacement in patients with MS secondary to massive MAC. The clinical data and morphology of the operatively excised mitral valves from the 11 patients who had mitral valve replacement for MS secondary to massive MAC are described. Of the 11 patients, 6 died postoperatively, 5 of whom had 4+/4+ MAC. The high mortality in these patients suggests that the decision to perform mitral valve replacement needs to be carefully considered if the quantity of MAC is massive.

Examination of Non-Infected Operatively-Excised Bioprostheses in the Aortic Valve Position to Determine the Reason for their Dysfunction

Described herein are findings in 55 non-infected bioprostheses that had been in the aortic valve position from 2 to 276 months (mean 107). The major purpose of this study was to illustrate the variable causes prompting excision of the bioprostheses. Fifty-three (96%) patients survived ≥ 30 days following the bioprosthetic excision and 50 (91%) patients lived ≥1 year postoperatively. The techniques used to explant the bioprostheses appear to vary considerably among the operating surgeons.

Origin of the Right Coronary Artery From the left Sinus of Valsalva in a Donor Heart With Unsuccessful Repair

Described herein is a 62-year-old man who had orthotopic heart transplantation (OHT) because of severe heart failure secondary to idiopathic dilated cardiomyopathy. Because of continued symptoms of heart failure, a coronary angiogram was performed 3 years after the OHT and it showed anomalous origin of the right coronary artery (RCA) from the left sinus of Valsalva. As a consequence, an operation was performed to transfer the origin of the RCA to the right sinus of Valsalva. Unfortunately, the lumen of the RCA clotted off shortly after the operative procedure. Because of clinical evidence of rejection, the donor heart was replaced 4 years later providing the opportunity to study the previously transferred anomalous RCA.

Circumferential Fibrosis of the Ascending Aorta After COVID Infection

After recovering from severe COVID-19 infection, 2 women presented with chest pain. Computed tomographic angiography suggested acute ascending aortic dissection. At operation in both patients, the ascending aorta was encased in dense fibrous tissue, within which were focal collections of mononuclear cells, including many plasma cells. There was no entry tear or dissection. Such findings we have not encountered previously, and PubMed search of “periaortic fibrosis and COVID-19” yielded no similar cases or possible relation.

Body Mass Index in Patients With Operatively-Excised Congenitally Bicuspid Aortic Valves Comparing Those With Stenotic to Those With Purely Regurgitant Valves

Several publications have examined the body mass index (BMI) in patients having aortic valve replacement for aortic stenosis with and without a congenitally bicuspid aortic valve (BAV). The present study examines BMI in 536 adults having aortic valve replacement for a congenitally BAV and compares the BMI in those with stenotic vs those with purely regurgitant BAVs. No significant differences were found between the 2 groups.

Ventricular Septal Myectomy for Obstructive Hypertrophic Cardiomyopathy (Analysis Spanning 60 Years Of Practice): AJC Expert Panel

Surgical myectomy remains the time-honored primary treatment for hypertrophic cardiomyopathy patients with drug refractory limiting symptoms due to LV outflow obstruction. Based on >50 years experience, surgery reliably reverses disabling heart failure by permanently abolishing mechanical outflow impedance and mitral regurgitation, with normalization of LV pressures and preserved systolic function. A consortium of 10 international currently active myectomy centers report about 11,000 operations, increasing significantly in number over the most recent 15 years. Performed in experienced multidisciplinary institutions, perioperative mortality for myectomy has declined to 0.6%, becoming one of the safest currently performed open-heart procedures. Extended myectomy relieves symptoms in >90% of patients by ≥ 1 NYHA functional class, returning most to normal daily activity, and also with a long-term survival benefit; concomitant Cox-Maze procedure can reduce the number of atrial fibrillation episodes. Surgery, preferably performed in high volume clinical environments, continues to flourish as a guideline-based and preferred high benefit: low treatment risk option for adults and children with drug refractory disabling symptoms from obstruction, despite prior challenges: higher operative mortality/skepticism in 1960s/1970s; dual-chamber pacing in 1990s, alcohol ablation in 2000s, and now introduction of strong negative inotropic drugs potentially useful for symptom management.

Analysis of Mechanical Prostheses Excised from the Aortic Valve Position

Described herein are certain clinical and morphologic findings in 33 patients who had their dysfunctioning native aortic valves replaced with a mechanical prosthesis and 4 to 302 months (mean 127) later had the mechanical prosthesis explanted because of developing prosthetic stenosis or regurgitation because of thrombus forming on a metallic disc, pannus on the cloth ring with overhanging the prosthetic orifice, or because of parabasilar regurgitation. Of the 33 patients, 25 were not infected and 8 were infected. At follow-up at least 23 of the 25 patients without infection and 7 of the 8 patients with prosthetic infection survived >1 year after the prosthetic valve explantation.

Massive Calcification of the Ascending Aorta Secondary to Irradiation for Hodgkin's Disease Decades Earlier in Association with Aortic Valve Stenosis

Described herein are findings in 2 men who developed massively calcified non-dilated ascending aortas decades after receiving mediastinal irradiation for treatment of Hodgkin's disease associated with aortic valve stenosis. The quantity of the intimal aortic calcium was remarkable and much greater than in other aortic conditions. The ascending aorta had to be excised in one patient in order to replace the stenotic aortic valve. The other patient underwent percutaneous transluminal aortic valve implantation.

Analysis of Dysfunctioning Mechanical Prostheses Excised from the Mitral Valve Position

Described herein are findings in 16 patients who had their dysfunctioning mechanical prostheses in the mitral valve position replaced. The mechanical prostheses had been in place from 2 to 157 months (mean 80). All but 1 patient had the mechanical prosthesis excised because of prosthetic stenosis or regurgitation or both secondary to prosthetic thrombus (despite warfarin therapy) on cloth-ring "pannus" overlaying the orifice or parabasilar detachment ("leak"). The dysfunction was the result of non-infected causes in 13 patients and to infective causes in 3. Three patients (19%) died in the early post-operative period; the other 13 patients survived >1 year. The prostheses were excised in a variety of methods by the explanting surgeons. The best procedure to excise the mechanical prosthesis appears to be mainly operator dependent.

Combined Cardiovascular Syphilis and Aortic Valve Stenosis (Due to a Congenitally Unicuspid Valve)

Described herein is a 53-year-old man who underwent resection of a fusiform aneurysm of the ascending aorta, and excision of a congenitally malformed stenotic unicuspid aortic valve. Examination of the wall of the aortic aneurysm disclosed classic features of syphilis. Although some degree of pure aortic regurgitation is common in patients with aortic syphilis, the presence of associated aortic valve stenosis, such as occurred in this patient, has been mentioned in only 4 previous publications, none of which included morphologic examination of the ascending aorta or aortic valve.

Examination of Operatively-Excised Bioprostheses in the Mitral Valve Position to Determine the Reason for Dysfunction

Described herein are some clinical and morphologic findings in 23 patients who underwent operative replacement of a previously implanted bioprosthesis in the mitral valve position. Photographs of the operatively excised bioprostheses were provided in 15 (65%) of the 23 patients. A variety of causes were responsible for the bioprosthetic dysfunction. Twelve surgeons excised the dysfunctioning bioprostheses, an average of <2/surgeon, and a variety of techniques were employed to excise the bioprosthesis.

Cardiac Findings at Necropsy in Acute Type A Aortic Dissection

Described herein are necropsy findings in 97 patients aged 22 to 82 years (mean 55), 37 women, 60 men, studied at necropsy with acute aortic dissection (AD) with the intimal-medial tear in the ascending aorta. The cases were studied from 1966 to 1989, a period when echocardiography and computed tomography were relatively infrequently available for diagnosis of AD. Arteriography was the method for diagnosis in most cases. Of the 97 cases, 30(31%) had operative intervention and 67 did not. Most appeared to have had systemic hypertension before the acute AD; only 4 had previous heart failure; only 8 had considerable atherosclerotic coronary disease; only 4 had a left ventricular (LV) scar and in each it was small; most (96%) had a normal-sized LV cavity (suggesting normal cardiac indices in them), and the other 4 had only a mildly dilated cavity; the heart weight in all 97 patients was increased; the quantity of subepicardial adipose tissue was increased in most patients, and the frequency of a congenitally malformed aortic valve was much higher than in the general population (6% - vs- 1%), but still uncommon. Thus, in > 90% of patients with acute Type A AD, coronary atherosclerosis was insignificant, myocardial fibrosis is absent, and the aortic valve has 3 cusps without stenosis.

Combined Cardiovascular Syphilis and Type A Acute Aortic Dissection

The occurrence of acute aortic dissection with the initiating tear in the ascending aorta superimposed on cardiovascular syphilis is an exceedingly rare occurrence. Such was the case, however, in a recently seen patient who presented with typical features of acute dissection (type A). Operative repair yielded the entire ascending aorta to examine both grossly and histologically and classic features of both conditions were observed.

Morphologic Findings in Native Mitral Valves Replaced for Isolated Acute Infective Endocarditis

Described here are some clinical and morphological observations in 37 adults having mitral valve replacement for active infective endocarditis limited to the mitral valve. The operatively-excised mitral valves are illustrated in 11 of the 37 patients, and photographs in them show that mitral valve repair in them would have been fruitless. Of the 37 patients, 32 (86%) survived the early operative period (30 days) and 31 (84%) were alive one year after the mitral operation. Of the 37 patients, 34 (92%) appeared to have had anatomically normal mitral valves before the infective endocarditis appeared.

Frequency of Peripartum Cardiomyopathy Among Women With Idiopathic Dilated Cardiomyopathy

Among women with idiopathic dilated cardiomyopathy (IDC), the percent who develop heart failure (HF) in the peripartum period (during pregnancy or within 6 months of parturition) compared with those women who develop HF outside the peripartum period is unclear. We studied 72 women with IDC who underwent orthotopic heart transplantation for severe HF, the onset of which was in the peripartum period in 8 (11%) and outside the period in 64 (89%). Comparison of many clinical and morphologic variables between these 2 groups showed significant differences only in the ages of onset of HF, age when orthotopic heart transplantation was performed, and the frequency of the presence of diabetes mellitus. Examination of the hearts in the 2 groups disclosed no significant differences. Thus, separation of the peripartum IDC cases from the nonperipartum IDC cases by either clinical or cardiac morphologic variables is difficult.

Cardiac sarcoidosis diagnosed after orthotopic heart transplantation and clinically mimicking arrhythmogenic right ventricular cardiomyopathy

Described herein is a 71-year-old man who underwent orthotopic heart transplant (OHT) for chronic severe heart failure secondary to cardiac sarcoidosis (CS) devoid of non-caseating granulomas but nevertheless characteristic of CS. Clinically, his heart disease had suggested the presence of arrhythmogenic right ventricular cardiomyopathy.

Frequency of Congruence and Incongruence Between the Clinical and Morphological Diagnoses in Patients Having Orthotopic Heart Transplantations at the Baylor University Medical Center at Dallas From 1993 to 2020

We studied the explanted hearts of 519 patients having Orthotopic Heart Transplant (OHT) at Baylor University Medical Center from 2013 to 2020 and compared the morphologic diagnoses to the clinical diagnoses before OHT. We then combined these findings with the findings from 314 patients who had been studied in the laboratory from 1993 to 2012. Thus, the total number of patients included in the overall study were 833. Among the 833 patients the morphologic and clinical diagnoses were congruent in 760 (91%) and incongruent in 73 (9%) cases. Most of the incongruity occurred among the patients with cardiac sarcoidosis (27/36 [75%]), arrhythmogenic right ventricular cardiomyopathy (11/19 [58%]), and hypertrophic cardiomyopathy (8/25 [32%]). The frequency of incongruence among 833 patients having OHT in an 27 year period was 9%, with no significant difference between the 314 patients studied from 1998 to 2012, and the 519 studied from 2013 to 2020.

International Consensus Statement on Nomenclature and Classification of the Congenital Bicuspid Aortic Valve and Its Aortopathy, for Clinical, Surgical, Interventional and Research Purposes

This International Consensus Classification and Nomenclature for the congenital bicuspid aortic valve condition recognizes 3 types of bicuspid valves: 1. The fused type (right-left cusp fusion, right-non-coronary cusp fusion and left-non-coronary cusp fusion phenotypes); 2. The 2-sinus type (latero-lateral and antero-posterior phenotypes); and 3. The partial-fusion (forme fruste) type. The presence of raphe and the symmetry of the fused type phenotypes are critical aspects to describe. The International Consensus also recognizes 3 types of bicuspid valve-associated aortopathy: 1. The ascending phenotype; 2. The root phenotype; and 3. Extended phenotypes. ©  2021 Jointly between the RSNA, the European Association for Cardio-Thoracic Surgery, The Society of Thoracic Surgeons, and the American Association for Thoracic Surgery. The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. All rights reserved. Keywords: Bicuspid Aortic Valve, Aortopathy, Nomenclature, Classification.

LAMP2 Cardiomyopathy: Consequences of Impaired Autophagy in the Heart

Background

Human mutations in the X‐linked lysosome‐associated membrane protein‐2 (LAMP2) gene can cause a multisystem Danon disease or a primary cardiomyopathy characterized by massive hypertrophy, conduction system abnormalities, and malignant ventricular arrhythmias. We introduced an in‐frame LAMP2 gene exon 6 deletion mutation (denoted L2^Δ6) causing human cardiomyopathy, into mouse LAMP2 gene, to elucidate its consequences on cardiomyocyte biology. This mutation results in in‐frame deletion of 41 amino acids, compatible with presence of some defective LAMP2 protein.

Methods and Results

Left ventricular tissues from L2^Δ6 and wild‐type mice had equivalent amounts of LAMP2 RNA, but a significantly lower level of LAMP2 protein. By 20 weeks of age male mutant mice developed left ventricular hypertrophy which was followed by left ventricular dilatation and reduced systolic function. Cardiac electrophysiology and isolated cardiomyocyte studies demonstrated ventricular arrhythmia, conduction disturbances, abnormal calcium transients and increased sensitivity to catecholamines. Myocardial fibrosis was strikingly increased in 40‐week‐old L2^Δ6 mice, recapitulating findings of human LAMP2 cardiomyopathy. Immunofluorescence and transmission electron microscopy identified mislocalization of lysosomes and accumulation of autophagosomes between sarcomeres, causing profound morphological changes disrupting the cellular ultrastructure. Transcription profile and protein expression analyses of L2^Δ6 hearts showed significantly increased expression of genes encoding activators and protein components of autophagy, hypertrophy, and apoptosis.

Conclusions

We suggest that impaired autophagy results in cardiac hypertrophy and profound transcriptional reactions that impacted metabolism, calcium homeostasis, and cell survival. These responses define the molecular pathways that underlie the pathology and aberrant electrophysiology in cardiomyopathy of Danon disease.

Summary: international consensus statement on nomenclature and classification of the congenital bicuspid aortic valve and its aortopathy, for clinical, surgical, interventional and research purposes

This International evidence-based nomenclature and classification consensus on the congenital bicuspid aortic valve and its aortopathy recognizes 3 types of bicuspid aortic valve: 1. Fused type, with 3 phenotypes: right-left cusp fusion, right-non cusp fusion and left-non cusp fusion; 2. 2-sinus type with 2 phenotypes: Latero-lateral and antero-posterior; and 3. Partial-fusion or forme fruste. This consensus recognizes 3 bicuspid-aortopathy types: 1. Ascending phenotype; root phenotype; and 3. extended phenotypes.

International consensus statement on nomenclature and classification of the congenital bicuspid aortic valve and its aortopathy, for clinical, surgical, interventional and research purposes

This International Consensus Classification and Nomenclature for the congenital bicuspid aortic valve condition recognizes 3 types of bicuspid valves: 1. The fused type (right-left cusp fusion, right-non-coronary cusp fusion and left-non-coronary cusp fusion phenotypes); 2. The 2-sinus type (latero-lateral and antero-posterior phenotypes); and 3. The partial-fusion (forme fruste) type. The presence of raphe and the symmetry of the fused type phenotypes are critical aspects to describe. The International Consensus also recognizes 3 types of bicuspid valve-associated aortopathy: 1. The ascending phenotype; 2. The root phenotype; and 3. Extended phenotypes.

Summary: International consensus statement on nomenclature and classification of the congenital bicuspid aortic valve and its aortopathy, for clinical, surgical, interventional, and research purposes

This International evidence-based nomenclature and classification consensus on the congenital bicuspid aortic valve and its aortopathy recognizes 3 types of bicuspid aortic valve: 1. Fused type, with 3 phenotypes: right-left cusp fusion, right-non cusp fusion and left-non cusp fusion; 2. 2-sinus type with 2 phenotypes: Latero-lateral and antero-posterior; and 3. Partial-fusion or forme fruste. This consensus recognizes 3 bicuspid-aortopathy types: 1. Ascending phenotype; root phenotype; and 3. extended phenotypes.

International consensus statement on nomenclature and classification of the congenital bicuspid aortic valve and its aortopathy, for clinical, surgical, interventional and research purposes

This International Consensus Classification and Nomenclature for the congenital bicuspid aortic valve condition recognizes 3 types of bicuspid valves: 1. The fused type (right-left cusp fusion, right-non-coronary cusp fusion and left-non-coronary cusp fusion phenotypes); 2. The 2-sinus type (latero-lateral and antero-posterior phenotypes); and 3. The partial-fusion (forme fruste) type. The presence of raphe and the symmetry of the fused type phenotypes are critical aspects to describe. The International Consensus also recognizes 3 types of bicuspid valve-associated aortopathy: 1. The ascending phenotype; 2. The root phenotype; and 3. Extended phenotypes.

International Consensus Statement on Nomenclature and Classification of the Congenital Bicuspid Aortic Valve and Its Aortopathy, for Clinical, Surgical, Interventional and Research Purposes

This International Consensus Classification and Nomenclature for the congenital bicuspid aortic valve condition recognizes 3 types of bicuspid valves: 1. The fused type (right-left cusp fusion, right-non-coronary cusp fusion and left-non-coronary cusp fusion phenotypes); 2. The 2-sinus type (latero-lateral and antero-posterior phenotypes); and 3. The partial-fusion (forme fruste) type. The presence of raphe and the symmetry of the fused type phenotypes are critical aspects to describe. The International Consensus also recognizes 3 types of bicuspid valve-associated aortopathy: 1. The ascending phenotype; 2. The root phenotype; and 3. Extended phenotypes.

Malignant Ventricular Tachycardia, Ventricular Wall Ablation, and Orthotopic Heart Transplantation

Described herein are three patients with refractory ventricular tachycardia and one or more unsuccessful ablation procedures finally leading to orthotropic heart transplantation (OHT). The latter procedure allowed examination of the ventricular ablation sites, an unusual opportunity reported previously in few patients (all case reports). The acute ablation lesions are unique, with necrosis of the myocardial fibers adjacent to the endocardium and encircled by layers of extravasated erythrocytes in the deeper myocardial wall. All 3 patients returned to normal activities following the OHT.

Degrees of Cross-Sectional-Area Luminal Narrowing of the Four Major Epicardial Coronary Arteries in Patients With Otherwise Functionally and Anatomically Normal Hearts

Described herein are necropsy findings in the 4 major (left main, left anterior descending, left circumflex, and right) epicardial coronary arteries in 86 patients aged 10-70 years who never had symptoms of myocardial ischemia, and at autopsy had otherwise anatomically normal hearts. All 86 died of a non-cardiovascular condition. In each of these patients all 4 major epicardial coronary arteries were excised intact from the heart, divided into 5-mm segments, and each segment prepared for histologic examination. The degrees of cross-sectional area (CSA) narrowingwere determined from histologic examination of each 5-mm segment. The degree of narrowing in each 5 mm segment was divided into 4 categories: 0% to 25%, 26% to 50%, 51% to 75%, and 76% to 100%. Twelve patients (14%) had ≥1 artery narrowed >75% in CSA, a single artery in 9 patients, and 2 arteries in each of 3 patients. In contrast to the relative infrequency of narrowing >75%, narrowing 51-75% was common, and was present in 36 (42%) of the 86 patients. Of the 258 major coronary arteries (excludes the left main) studied in the 86 patients, 15 (6%) were narrowed >75%, and 70 (24%) were narrowed 51% to 75% in CSA. Even mild narrowing (26% to 50%) of the left main coronary artery (66 patients) was generally accompanied by 51% to 75% or greater narrowing of at least one of the other major coronary arteries. In conclusion, even hearts which have functioned normally and are otherwise anatomically normal, usually have some degree of atherosclerotic plaque in the major epicardial coronary arteries.

Total 12-lead QRS voltage in patients with spontaneous acute aortic dissection with an initiating tear in the ascending aorta

Because nearly all patients with acute aortic dissection have systemic hypertension, we examined electrocardiograms (ECGs) in 21 patients with spontaneous acute type A aortic dissection. An earlier study had shown that total 12-lead QRS voltage was the best criterion for determining left ventricular hypertrophy from the ECG. We measured total 12-lead QRS voltage in 21 patients with spontaneous (no previous cardiac or aortic operation) acute type A aortic dissection and operative repair. Using >175 mm as evidence of left ventricular hypertrophy, only 8 patients (38%) had hearts of increased mass. Total 12-lead QRS voltage corresponded slightly with age but not with body mass index. In conclusion, total 12-lead QRS voltage is not useful for diagnostic purposes in patients with acute type A aortic dissection undergoing operative repair.

Huge right ventricular outflow tract aneurysm late following total repair of tetralogy of Fallot leading to orthotopic heart transplantation

Described herein are 3 patients who underwent successful orthotopic heart transplantation (OHT) because of huge, calcified right ventricular outflow tract (RVOT) aneurysms after repair of tetralogy of Fallot 35, 43, and 59 years earlier. Two of the 3 patients developed recurring episodes of ventricular tachycardia simulating arrhythmogenic right ventricular cardiomyopathy.

Isolated mitral valve endocarditis with ring abscess and pericarditis in end-stage renal disease

Described herein is a 68-year-old man with end-stage renal disease on hemodialysis who was found to have methicillin-sensitive Staphylococcus aureus endocarditis with an associated ring abscess that extended into the left atrioventricular sulcus and ruptured into the pericardial space causing pericardial effusion. In contrast to the frequency of infective endocarditis involving the aortic valve, ring abscess associated with infection of the mitral valve is uncommon.

Virtually All Complications of Active Infective Endocarditis Occurring in a Single Patient

Described herein is a 49-year-old black man with advanced polycystic renal disease, on hemodialysis for 6 years, who during his last 12 days of life had his vegetations on the aortic valve extend to the mitral and tricuspid valves, through the aortic wall to produce diffuse pericarditis, to the atrioventricular node to produce complete heart block, and embolize to cerebral arteries producing multiple brain infarcts, to a branch on the left circumflex coronary artery producing acute myocardial infarction, and to mesenteric arteries producing bowel infarction.

Diagnostic Usefulness of Histological Examination of the Left Ventricular "Core" Excised to Insert a Left Ventricular Assist Device in Patients With Severe Heart Failure

The left ventricular assist device (LVAD) has proven to be beneficial for patients with severe heart failure poorly responsive to anti heart failure medicine. To examine both grossly and histologically the portion of left ventricular (LV) free wall excised ("the left ventricular core") to insert a LVAD in 337 patients with severe heart failure from a variety of causes. We collected together all photographs of LV "cores" and the histologic sections prepared from them and reexamined both. Despite the fact that these LV cores usually weighed >100 times the quantity of myocardium available to examine compared with that available by biotome inserted via a transvenous catheter, the number in which histologic study allowed an unequivocal diagnosis was limited. Examination of the clinical records usually was required to establish the definitive diagnosis. Although the presence of a scarred myocardial wall usually suggested ischemic cardiomyopathy (IC), the scarring may not have involved the LV apex resulting in a nonscarred portion of myocardium simulating idiopathic dilated cardiomyopathy (IDC). Moreover, about 10% of the patients with IDC have myocardial scars thus simulating IC. Involvement of the LV core by amyloid, sarcoid, myocarditis, and acute infarction, of course, allowed a specific anatomic diagnosis. Despite the presence of ample tissue to secure a definitive diagnosis, the combination of clinical input and morphologic assessment was required to arrive at a definite diagnosis in most patients.

Relation of the quantity of coronary calcium to the quantity of aortic calcium determined from radiographs at necropsy

Described herein are radiographs of the heart and aorta at necropsy after "cleaning" these structures of extraneous tissue. As a consequence, the quantity of calcium is far more discernible than by computed tomography or magnetic resonance or ultrasonic imaging during life or before extraneous tissues are removed at necropsy. We illustrate these radiographic images at necropsy in three patients to show that the relative amount of calcific deposits in the coronary arteries and aorta may be subjectively similar or one of these structures may have far more calcium in the arterial walls than the other. The reasons for these differences are unclear.

The Importance of Acquiring Financial Security for Physicians

This review tries to make the case that physicians should be adequately rewarded financially so that they can have a clear fiduciary responsibility to do only what is best for their patients without unseemly personal financial gain. To develop financial security, physicians need to save a portion of their income regularly to invest. The stock market is the best place to increase one's monetary worth over a long period.

Location of the Cannula of the Left Ventricular Assist Device in Explanted Hearts After Orthotopic Heart Transplantation

Many patients having orthotopic heart transplantation (OHT) have previously had a left ventricular assist device (LVAD). Such a scenario allows the study of the position of the LVAD cannula in the explanted heart. We studied the explanted hearts in 105 patients who had had a LVAD inserted earlier and later underwent OHT at Baylor University Medical Center from January 2005 to September 2019, and compared the patients in whom the margins of the LVAD cannula contacted the mural endocardium with those in whom it did not. The margins of the orifice of the LVAD cannula contacted the left ventricular (LV) mural endocardium in 38 (36%) patients (considered potentially hazardous insertion) whereas in 67 (64%) patients there was no contact (considered "ideal" insertion). Comparison of the patients with ideal cannular insertion to those with potentially hazardous insertion disclosed insignificant differences in age at LVAD insertion or OHT; gender; interval between the LVAD insertion and OHT; body mass index; underlying cardiac disease; whether or not the heart floated in a container of formaldehyde, and the type of LVAD inserted. The margins of the LVAD cannula contacted the LV mural endocardium significantly more in patients with smaller mean heart weights than those with larger mean heart weights. In conclusion, of the 105 patients studied, the cannula of the LVAD resided in the LV cavity at an angle that allowed the margins of the orifice of the cannula to contact the mural endocardium in 38 (36%), a situation that at least potentially could cause partial obstruction of its orifice. Nevertheless, comparison of the 38 patients with nonideal cannular insertion to the 67 with ideal cannular insertion disclosed only 1 significant difference between the 2 groups.