The management recommendations for patent foramen ovale (PFO) closure in cryptogenic stroke are rapidly evolving. The data has expanded recently with four major trials demonstrating superiority of ...

Anomalous origin of right coronary artery with interarterial course (ARCA-IA) is a risk factor for sudden death and other cardiac complications. Surgical correction remains its gold standard treatment. We describe clinical characteristics, workup, surgical techniques and outcomes of ARCA-IA at our center. A retrospective analysis of cardiovascular database was performed. From March 2005 through January 2011, 11 patients with mean age of 53 ± 18 years were diagnosed with ARCA-IA. Reported symptoms included chest pain (64%), arrhythmia [27%; i.e. atrial flutter (9%), recurrent supraventricular tachycardia (9%), ventricular tachycardia (9%)], syncope (18%), dyspnea (9%) and aborted sudden cardiac death (9%). Chest pain (n = 7) was episodic and lasted longer than 6 months before diagnosis. Initial diagnosis was made at coronary computed tomography in two patients and at cardiac catheterization in nine patients. Four patients had positive stress test and were subsequently found to have ARCA-IA at cardiac catheterization. There was no operative mortality. Surgery (bypass with ligation of native vessel or translocation and reimplantation) was performed in seven patients. Three patients refused surgery, and in one patient, surgery was not considered due to comorbidities. Symptom relief was noted in all surgical patients. At mean follow-up of 36 months, two patients had noncardiac-related deaths whereas nine were asymptomatic. There were no deaths reported in patients treated surgically. Definitive surgery is indicated in symptomatic ARCA-IA and is associated with excellent long-term outcome. RCA dominance in ARCA-IA is an adverse marker with increased symptoms; this hypothesis should be tested in larger studies.

Peripheral artery disease (PAD) is a prevalent disorder in the United States, associated with significant morbidity and mortality. Fractional Flow Reserve (FFR) is a physiological test used to assess the hemodynamic significance of intermediate lesions on conventional angiography. It is well studied in coronary artery disease and is as an important tool to guide decisions regarding revascularization in a significant percentage of patients with intermediate lesions. As compared to coronary FFR, the use of FFR in peripheral artery disease (PFFR) is much less prevalent. Overall data regarding the use of the PFFR is sparse. There are limited studies that have shown the correlation of PFFR with non-invasive testing including ankle-brachial index (ABI) and Doppler Imaging. Unlike coronary FFR, the optimal pharmaceutical agents and doses to induce maximal hyperemia in the peripheral vascular bed are also not well established. Moreover, there are no established standardized procedural protocols for measuring PFFR. Various studies have employed varying techniques, hyperemic agents and doses. The aim of this literature review is to summarize the current evidence on PFFR, the correlation with noninvasive studies used in PAD and to increase awareness of the potential role of the PFFR in peripheral interventions.

Takotsubo cardiomyopathy (TC), also recognized as stress-induced cardiomyopathy, is a transient condition of left ventricular (LV) dysfunction, which presents similarly to acute coronary syndrome (ACS) but with normal coronaries. Physical or emotional stressors usually precipitate TC. It is typically a benign condition, with a complete resolution once the triggering cause resolves. There have been a few cases of TC induced by diabetic ketoacidosis (DKA) that have been reported in the literature. A 50-year-old Caucasian female patient presented with lethargy, in addition to hypothermia and hypotension. Further investigation showed hyperglycemia with metabolic acidosis and ketonemia. Eventually, she was diagnosed with diabetic ketoacidosis (DKA). On Day 2 of the admission, the patient’s condition further deteriorated despite appropriate treatment of DKA. An electrocardiogram (EKG) showed ST-segment elevation in inferior leads, and troponin levels were elevated. Cardiac catheterization showed non-obstructive coronary arteries but a severely reduced cardiac index. Echocardiography showed an ejection fraction (EF) of 25% with global hypokinetic LV. Eventually, the patient was diagnosed with TC or stress-induced cardiomyopathy. TC should always be suspected in any patient presenting with acute heart failure during DKA treatment. TC is a transient syndrome; however, it can result in dreadful complications, including cardiogenic shock, arrhythmias, or thromboembolic events. Early recognition and timely treatment are pivotal in such cases.