Cardiology Fellowship Education in the Era of High-density Training, Data Tracking, and Quality Measures

Background:Educating trainees during cardiology fellowship is a process in constant evolution, with program directors regularly adapting to increasing demands and regulations as they strive to prepare graduates for practice in today’s healthcare environment.Methods and Results:In a 10-year follow-up to a previous manuscript regarding fellowship education, we reviewed the literature regarding the most topical issues facing training programs in 2010, describing our approach at The Ohio State University.Conclusion:In the midst of challenges posed by the increasing complexity of training requirements and documentation, work hour restrictions, and the new definitions of quality and safety, we propose methods of curricula revision and collaboration that may serve as an example to other medical centers.

Urine Albumin to Creatinine Ratio and Echocardiographic Left Ventricular Structure and Function in Patients with Essential Hypertension

Background:Appearance of microalbuminuria, particularly in patients with hypertension, might be associated with a higher prevalence of left ventricular (LV) dysfunction and geometric abnormalities. This study was undertaken to determine whether high urine albumin to creatinine ratio (UACR) as a sensitive marker for microalbuminuria can be associated with LV hypertrophy (LVH) and systolic and diastolic LV dysfunction.Methods:The study population consisted of 125 consecutive patients with essential uncomplicated hypertension. Urine albumin and creatinine concentration was determined by standard methods. LVH was defined as a LV mass index >100 g/m2 of body surface area in women and >130 g/m2 in men. Echocardiographic LV systolic and diastolic parameters were measured.Results:The prevalence of microalbuminuria in patients with essential hypertension was 5.6 %. UACR was significantly no different in patients with LVH than in patients with normal LV geometry (21.26 ± 31.55 versus 17.80 ± 24.52 mg/mmol). No significant correlation was found between UACR measurement and systolic and diastolic function parameters, including early to late diastolic peak velocity (E/A) ratio (R=-0.192, p=0.038), early diastolic peak velocity to early mitral annulus velocity (E/E') ratio (R=-0.025, p=0.794), LV ejection fraction (R=0.008, p=0.929), and LV mass (R=-0.132, p=0.154). According to the receiver operator characteristic (ROC) curve analysis, UACR measurement was not an acceptable indicator of LVH with areas under the ROC curves 0.514 (95 % confidence interval 0.394–0.634). The optimal cut-off value for UACR for predicting LVH was identified at 9.4, yielding a sensitivity of 51.6 % and a specificity of 48.3 %.Conclusion:In patients with uncomplicated essential hypertension, abnormal systolic and diastolic LV function and geometry cannot be effectively predicted by the appearance of microalbuminuria.

Predisposing Factors, Demographics, Angiographic Features, and the Possible Role of Inflammation in Coronary Perforations—A 10-year Single-center Experience

Background:Coronary perforation during percutaneous coronary intervention is a rare but dreaded complication. The risk factors, optimal management, and outcome remain obscure.Objectives:To determine the predisposing factors, optimal management, and preventive strategies. We retrospectively looked at coronary perforations at our catheterization laboratory over the last 10 years. We reviewed patient charts and reports. Two independent operators, in a blinded approach, reviewed all procedural cineangiograms. Data were analyzed by simple statistical methodology.Results:Nine patients were treated conservatively and six patients were treated with prolonged balloon inflation. Six patients were treated with polytetrafluoroethylene (PTFE)-covered stents. One patient required emergency coronary artery bypass graft. No deaths were reported. Subjects with perforations also had a significantly higher total white blood cell count (means 12,134 versus 6,155, 95 % confidence interval [CI], p< 0.0001, n=22), total absolute neutrophil count (means 74.2 % versus 57.1 %, 95 % CI, p<0.0001, n=22), and neutrophil:lymphocyte ratio (means 3.65 versus 1.50, 95% CI, p<0.0001, n=22).Conclusions:Coronary perforations are rare but potentially fatal events. Hypertension, small vessel diameter, high balloon:artery ratio, use of hydrophilic wires, and presence of myocardial bridging appear to be possible risk factors. Most perforations can be treated conservatively or with prolonged balloon inflation using perfusion balloons. Use of PTFE-covered stents could be a life-saving measure in cases of large perforations. Subjects with perforations also had greater systemic inflammation as indicated by elevated white cell counts.

Life-threatening Takotsubo Cardiomyopathy

Objective:To report a case of seizure-induced takotsubo cardiomyopathy with rare etiology and rarer complications.Methods:A 50-year-old woman had multiple epileptic seizures and later developed acute heart failure complicated by ventricular fibrillation and shock. A two-dimensional echocardiogram revealed apical ballooning of the left ventricle resembling a takotsubo (a Japanese fisherman's pot used to trap octopi). The apex was also hypokinetic.Results:The hemodynamic abnormalities normalized with defibrillation, assisted ventilation, inotropic support, and pressor agents. More importantly, the apical ballooning deformity and systolic dysfunction reversed. The echocardiogram normalized three months later. A nuclear treadmill stress test was negative for ischemia.Conclusions:Apical ballooning of the left ventricle and hypokinesis are typical echocardiographic features in takotsubo cardiomyopathy, a stress-induced heart disease. It may follow severe emotional, physical, and neurologic stressors, in our rare case, grand mal seizures (0.2 % of all takotsubo disease patients). Also rare are life-threatening complications. Based on these observations, in a case with severe stress followed by acute heart failure, takotsubo cardiomyopathy should be a major diagnostic consideration. The dramatic initial triggering event, in our case an epileptic seizure, should not mask the possibility of coexisting takotsubo cardiomyopathy. Awareness of this disease, anticipation of complications, and two-dimensional echocardiography will help channel the management in the right direction.