826
The American Journal of Cardiology (www.ajconline.org)
Konstam MA, Senni M, Nodari S, Vaduganathan M, Subacius H, Butler J, Gheorghiade M. Changes in serum potassium levels during hospitalization in patients with worsening heart failure and reduced ejection fraction. Am J Cardiol 2015;115:790e796. http://dx.doi.org/10.1016/j.amjcard.2015.06.001
Vortex Keratopathy: Fabry Related or Amiodarone Induced? The report entitled “PP-116 vortex keratopathy associated with long term use of amiadarone,” written by Altun et al and published in a recent issue of American Journal of Cardiology, was quite interesting.1 Here, we would like to emphasize some relevant points. Amiodarone is widely used for treatment of atrial fibrillation. It has varying side effects and vortex keratopathy is 1 of them. We would like to point out that the differential diagnosis for this clinical entity should also include Fabry disease (FD). FD is an X-linked inherited, rare, progressive, multisystem disorder of glycosphingolipid metabolism affecting multiple organs and causing varying degrees of dysfunction.2 Cornea verticillata (vortex keratopathy) is one of the pathognomonic features of the disease. Indistinguishable pattern of amiodarone-induced vortex keratopathy from FD related cornea verticillata may confuse the diagnosis if solely considered. It is also claimed that corneal opacities of FD usually do not affect vision.3 Because of the wide spectrum of the disease, patients with FD are generally diagnosed at late ages. Vortex keratopathy in a patient with potential Fabry-related chronic heart disease, using amiodarone, may obscure the diagnosis if we narrow the differential diagnosis. Beyond FD, drugs such as chloroquine, hydroxychloroquine, gentamicine, nonsteroidal anti-inflammatory drugs may also induce vortex keratopathy.4 Other possible causes for vortex keratopathy should be kept in mind at clinical practice. Alper Alp, MD Van, Turkey Hakan Akdam, MD Aydin, Turkey 4 June 2015
1. Altun S, Yolcu U, Ilhan A, Guler A, Sahin MA, Cingoz F. PP-116 vortex keratopathy associated with long term use of amiadarone. Am J Cardiol 2015;115:148.
2. Terryn W, Cochat P, Froissart R, Ortiz A, Pirson Y, Poppe B, Serra A, Van Biesen W, Vanholder R, Wanner C. Fabry nephropathy: indications for screening and guidance for diagnosis and treatment by the European Renal Best Practice. Nephrol Dial Transplant 2013;28:505e517. 3. Samiy N. Ocular features of Fabry disease: diagnosis of a treatable life-threatening disorder. Surv Ophthalmol 2008;53:416e423. 4. van der Tol L, Cassiman D, Houge G, Janssen MC, Lachmann RH, Linthorst GE, Ramaswami U, Sommer C, Tøndel C, West ML, Weidemann F, Wijburg FA, Svarstad E, Hollak CE, Biegstraaten M. Uncertain diagnosis of Fabry disease in patients with neuropathic pain, angiokeratoma or cornea verticillata: consensus on the approach to diagnosis and follow-up. JIMD Rep 2014;17: 83e90. http://dx.doi.org/10.1016/j.amjcard.2015.06.003
Impact of Hospital Volume on Outcomes of Lower Extremity Interventions: Only Half the Story We read the report published by Arora et al regarding the impact of hospital volumes on outcomes after lower extremity endovascular interventions.1 Although the results of the report come as no surprise to an experienced endovascular interventionalist, one would certainly express reservations about using an inpatient database for assessment of hospital volumes in lower extremity endovascular interventions. Lower extremity interventions may not be treated in the same light as other higher risk interventions such as transcatheter aortic valve replacement, which always requires inpatient admissions. Data from the Healthcare Cost and Utilization Project using State Ambulatory Surgical Database published in 2014 by Lo et al estimated that 65% of all endovascular procedures in men and 61% of all endovascular procedures in women, in 2009, were performed in the outpatient ambulatory setting.2 Although one would believe that major complications such as bleeding or need for amputation would require inpatient hospitalization, exclusion of a large number of low-risk procedures (that were discharged on the same day) from the denominator would lead to a marked overestimation of these estimates. In addition, one could surmise that the number of ambulatory
procedures performed (vs inpatient procedures) in an institution would likely depend on the risk profile catered to by that institution, which in turn is dependent on the institutional volume. This would imply a differential impact of procedural risk on outpatient procedural volume in different institutions, which cannot be systematically evaluated without actually obtaining the real outpatient data. We agree that Nationwide Inpatient Sample is a rich resource of information, which has been used by several groups to answer important questions, this question in particular is only partly answered by use of this data set in isolation. Perhaps utilization of more robust databases, which provide insight into real-world outpatient surgical procedures, would provide more truthful and more complete insight into this important question. Shikhar Agarwal, MD, MPH Karan Sud, MD Cleveland, Ohio 9 June 2015
1. Arora S, Panaich SS, Patel N, Patel N, Lahewala S, Solanki S, Patel P, Patel A, Manvar S, Savani C, Tripathi B, Thakkar B, Jhamnani S, Singh V, Patel S, Patel J, Bhimani R, Mohamad T, Remetz MS, Curtis JP, Attaran RR, Grines C, Mena CI, Cleman M, Forrest J, Badheka AO. Impact of hospital volume on outcomes of lower extremity endovascular interventions (Insights from the Nationwide Inpatient Sample [2006-2011]). Am J Cardiol 2015;116:791e800. 2. Lo RC, Bensley RP, Dahlberg SE, Matyal R, Hamdan AD, Wyers M, Chaikof EL, Schermerhorn ML. Presentation, treatment, and outcome differences between men and women undergoing revascularization or amputation for lower extremity peripheral arterial disease. J Vasc Surg 2014;59:409e418.e3. http://dx.doi.org/10.1016/j.amjcard.2015.06.004
Gastroparesis Related to Atrial Fibrillation Ablation We read the article entitled “Gastroparesis as a complication of atrial fibrillation ablation” by Aksu et al.1 They presented their experiences in regard to cryoballoon ablation of atrial fibrillation (AF). In the study, a relatively high prevalence of symptomatic gastroparesis, 6 of 58 (10.3%) patients with cryoballoon application, was found, and more cooling of the inferior veins and smaller left atrial size were found to be
The American Journal of Cardiology (www.ajconline.org)
Konstam MA, Senni M, Nodari S, Vaduganathan M, Subacius H, Butler J, Gheorghiade M. Changes in serum potassium levels during hospitalization in patients with worsening heart failure and reduced ejection fraction. Am J Cardiol 2015;115:790e796. http://dx.doi.org/10.1016/j.amjcard.2015.06.001
Vortex Keratopathy: Fabry Related or Amiodarone Induced? The report entitled “PP-116 vortex keratopathy associated with long term use of amiadarone,” written by Altun et al and published in a recent issue of American Journal of Cardiology, was quite interesting.1 Here, we would like to emphasize some relevant points. Amiodarone is widely used for treatment of atrial fibrillation. It has varying side effects and vortex keratopathy is 1 of them. We would like to point out that the differential diagnosis for this clinical entity should also include Fabry disease (FD). FD is an X-linked inherited, rare, progressive, multisystem disorder of glycosphingolipid metabolism affecting multiple organs and causing varying degrees of dysfunction.2 Cornea verticillata (vortex keratopathy) is one of the pathognomonic features of the disease. Indistinguishable pattern of amiodarone-induced vortex keratopathy from FD related cornea verticillata may confuse the diagnosis if solely considered. It is also claimed that corneal opacities of FD usually do not affect vision.3 Because of the wide spectrum of the disease, patients with FD are generally diagnosed at late ages. Vortex keratopathy in a patient with potential Fabry-related chronic heart disease, using amiodarone, may obscure the diagnosis if we narrow the differential diagnosis. Beyond FD, drugs such as chloroquine, hydroxychloroquine, gentamicine, nonsteroidal anti-inflammatory drugs may also induce vortex keratopathy.4 Other possible causes for vortex keratopathy should be kept in mind at clinical practice. Alper Alp, MD Van, Turkey Hakan Akdam, MD Aydin, Turkey 4 June 2015
1. Altun S, Yolcu U, Ilhan A, Guler A, Sahin MA, Cingoz F. PP-116 vortex keratopathy associated with long term use of amiadarone. Am J Cardiol 2015;115:148.
2. Terryn W, Cochat P, Froissart R, Ortiz A, Pirson Y, Poppe B, Serra A, Van Biesen W, Vanholder R, Wanner C. Fabry nephropathy: indications for screening and guidance for diagnosis and treatment by the European Renal Best Practice. Nephrol Dial Transplant 2013;28:505e517. 3. Samiy N. Ocular features of Fabry disease: diagnosis of a treatable life-threatening disorder. Surv Ophthalmol 2008;53:416e423. 4. van der Tol L, Cassiman D, Houge G, Janssen MC, Lachmann RH, Linthorst GE, Ramaswami U, Sommer C, Tøndel C, West ML, Weidemann F, Wijburg FA, Svarstad E, Hollak CE, Biegstraaten M. Uncertain diagnosis of Fabry disease in patients with neuropathic pain, angiokeratoma or cornea verticillata: consensus on the approach to diagnosis and follow-up. JIMD Rep 2014;17: 83e90. http://dx.doi.org/10.1016/j.amjcard.2015.06.003
Impact of Hospital Volume on Outcomes of Lower Extremity Interventions: Only Half the Story We read the report published by Arora et al regarding the impact of hospital volumes on outcomes after lower extremity endovascular interventions.1 Although the results of the report come as no surprise to an experienced endovascular interventionalist, one would certainly express reservations about using an inpatient database for assessment of hospital volumes in lower extremity endovascular interventions. Lower extremity interventions may not be treated in the same light as other higher risk interventions such as transcatheter aortic valve replacement, which always requires inpatient admissions. Data from the Healthcare Cost and Utilization Project using State Ambulatory Surgical Database published in 2014 by Lo et al estimated that 65% of all endovascular procedures in men and 61% of all endovascular procedures in women, in 2009, were performed in the outpatient ambulatory setting.2 Although one would believe that major complications such as bleeding or need for amputation would require inpatient hospitalization, exclusion of a large number of low-risk procedures (that were discharged on the same day) from the denominator would lead to a marked overestimation of these estimates. In addition, one could surmise that the number of ambulatory
procedures performed (vs inpatient procedures) in an institution would likely depend on the risk profile catered to by that institution, which in turn is dependent on the institutional volume. This would imply a differential impact of procedural risk on outpatient procedural volume in different institutions, which cannot be systematically evaluated without actually obtaining the real outpatient data. We agree that Nationwide Inpatient Sample is a rich resource of information, which has been used by several groups to answer important questions, this question in particular is only partly answered by use of this data set in isolation. Perhaps utilization of more robust databases, which provide insight into real-world outpatient surgical procedures, would provide more truthful and more complete insight into this important question. Shikhar Agarwal, MD, MPH Karan Sud, MD Cleveland, Ohio 9 June 2015
1. Arora S, Panaich SS, Patel N, Patel N, Lahewala S, Solanki S, Patel P, Patel A, Manvar S, Savani C, Tripathi B, Thakkar B, Jhamnani S, Singh V, Patel S, Patel J, Bhimani R, Mohamad T, Remetz MS, Curtis JP, Attaran RR, Grines C, Mena CI, Cleman M, Forrest J, Badheka AO. Impact of hospital volume on outcomes of lower extremity endovascular interventions (Insights from the Nationwide Inpatient Sample [2006-2011]). Am J Cardiol 2015;116:791e800. 2. Lo RC, Bensley RP, Dahlberg SE, Matyal R, Hamdan AD, Wyers M, Chaikof EL, Schermerhorn ML. Presentation, treatment, and outcome differences between men and women undergoing revascularization or amputation for lower extremity peripheral arterial disease. J Vasc Surg 2014;59:409e418.e3. http://dx.doi.org/10.1016/j.amjcard.2015.06.004
Gastroparesis Related to Atrial Fibrillation Ablation We read the article entitled “Gastroparesis as a complication of atrial fibrillation ablation” by Aksu et al.1 They presented their experiences in regard to cryoballoon ablation of atrial fibrillation (AF). In the study, a relatively high prevalence of symptomatic gastroparesis, 6 of 58 (10.3%) patients with cryoballoon application, was found, and more cooling of the inferior veins and smaller left atrial size were found to be
