Pulivarthi, Venkata Siva Krishna Kumar

Introduction: Pectus excavatum (PE) is the most common anterior chest wall deformity with dorsal deviation into the thoracic cavity. Depending on the severity, PE can cause minor cosmetic problem to significant cardiac compression in severe cases. This compression most frequently affects right heart chambers causing symptoms such as dyspnea, palpitations, fatigue, exercise intolerance, and difficulty with keeping up with peers. Previously, we reported the change in these symptoms with positon associated with change in right heart hemodynamics. Further, we are comparing the changes in right heart hemodynamics with position in pectus patients to normal healthy adults. Methods: A prospective cohort of 40 pectus excavatum patients (mean Haller index: 5.4±2) undergoing evaluation at Mayo clinic underwent 2-D transthoracic echo (TTE) with Doppler assessment of Right Ventricular Outflow Tract (RVOT) Velocity Time Integral (VTI). A cohort of 8 healthy adults without chest wall abnormality who had clinically indicated echocardiogram was used as control (Table). Additional assessment of the RVOT VTI was performed in sitting position in either group. A two-sample t-test was performed to assess significance between cohorts. Results: There is a significant difference in RVOT VTI between case and control cohorts in both supine and sitting positions (p=0.03 & p=0.001 respectively). Also, there is a significant decrease in RVOT VTI from supine to sitting position in PE patients compared to healthy adults (Table). Conclusion: This is the 1 st prospective cohort study in PE patients vs healthy adults showing the feasibility and utility of dynamic echocardiography in assessing the right ventricular hemodynamics. This study demonstrates a significant decrease in right sided hemodynamic changes with change in position in patients with PE which might explain their symptoms.

Background: We performed a meta-analysis to evaluate the benefit of patent foramen ovale closure in stroke prevention. Methods: We searched Medline/PubMed, EMBASE, Web of Science and Cochrane central database for randomized control trials assessing the incidence of recurrent stroke after patent foramen ovale closure when compared to medical therapy. Pooled odds ratio and 95% confidence intervals were calculated using a random effects model. The heterogeneity among studies was tested using the χ 2 test and inconsistency was quantified using the I 2 statistic. Results: Our search strategy yielded 71 articles. We included five studies with a total of 3440 patients. Median age in the device group was 45 (43, 5.5) years and in the medical group was 45 (44.5, 46) years; 52% were male, 27.7% of patients had an atrial septal aneurysm, 25% had hypertension, and 20.5% had diabetes mellitus. The median follow-up time was 44 (34.5–50) months. The pooled odds ratio of recurrent stroke, transient ischemic attack and composite end point of stroke + transient ischemic attack + peripheral embolism in the patent foramen ovale closure versus medical therapy group were 0.4 (95% confidence interval 0.25–0.63, I 2 = 57.5%), 0.93 (95% confidence interval 0.61–1.42, I 2 = 0%), and 0.6 (95% confidence interval 0.44–0.82, I 2 = 0%), respectively. The incidence of atrial fibrillation was found to be significantly higher in the patent foramen ovale closure group with odds ratio of 6 (95% confidence interval 3.13–11.4, I 2 = 33.5%). On subgroup analysis, patent foramen ovale closure appeared to benefit males and patients with a large shunt. Number needed to treat to prevent one recurrent stroke with patent foramen ovale closure is 42. Number needed to harm to cause one atrial fibrillation with patent foramen ovale closure is 39. Conclusion: This meta-analysis of randomized trials concludes that percutaneous patent foramen ovale closure is effective in recurrent stroke prevention especially in males and in those with a large shunt.

Olmesartan-induced enteropathy (OIE) typically presents with a constellation of signs and symptoms including chronic diarrhoea, weight loss and villous atrophy on biopsy. We describe a 68-year-old Caucasian woman with a history of hypothyroidism and hypertension who presented to our hospital with recurrent episodes of acute intermittent diarrhoea, nausea, vomiting, renal failure and 15 lbs weight loss. After an extensive workup, she was diagnosed with possible OIE. Cessation of the offending drug resulted in improvement of clinical symptoms and also hospital admissions for severe diarrhoea reinforcing the diagnosis of OIE. Among the adverse effects of drug therapy, diarrhoea is a relatively frequent adverse event accounting for about 7%. This report serves as an addition to existing literature and to increase the awareness of olmesartan-induced sprue-like enteropathy among the primary care physicians and gastroenterologists.

AbstractPatients with pectus excavatum (PE) frequently present with complaints of exercise intolerance and cardiopulmonary symptoms. There continues to be controversy regarding the physiologic benefits of repair. The aim of this review is to summarize and discuss recent data regarding the cardiopulmonary effects of PE deformity and the evidence for improvement obtained after surgical repair including (1) a greater efficiency of breathing (chest wall mechanics), (2) improvement in pulmonary restrictive deficits, (3) an increase in cardiac chamber size and output, with improved cardiac strain and strain rate, and (4) improvement in exercise capacity.