Case Reports in Cardiology The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. Multifactorial QT Interval Prolongation and Takotsubo Cardiomyopathy Mon, 14 Apr 2014 14:19:45 +0000 A 71-year-old woman collapsed while working as a grocery store cashier. CPR was performed and an AED revealed torsades de pointes (TdP). She was subsequently defibrillated resulting in restoration of sinus rhythm with a QTc interval of 544 msec. Further evaluation revealed a diagnosis of Takotsubo Cardiomyopathy (TCM) contributing to the development of a multifactorial acquired long QT syndrome (LQTS). The case highlights the role of TCM as a cause of LQTS in the setting of multiple risk factors including old age, female gender, hypokalemia, and treatment with QT prolonging medications. It also highlights the multifactorial nature of acquired LQTS and lends support to growing evidence of an association with TCM. Michael Gysel, Alexander Crystal, Jules C. Hancox, Michelle Methot, and Adrian Baranchuk Copyright © 2014 Michael Gysel et al. All rights reserved. A Rare and Serious Unforeseen Complication of Cutting Balloon Angioplasty Sun, 23 Mar 2014 13:53:59 +0000 Cutting balloon angioplasty (CBA) is one of the adept ways of treating “in-stent restenosis.” Various complications related to cutting balloon angioplasty have been reported including arterial rupture, delayed perforation and fracture of microsurgical blades. Here we report a very unusual and inadvertent extraction of a stent previously deployed in the ramus intermedius coronary branch by a cutting balloon catheter. This required repeat stenting of the same site for an underlying dissection. Even though stent extraction is a rare complication it can be serious due to dissection, perforation, and closure of the artery. Physicians performing coronary artery interventions would need to be aware of this rare and serious complication especially if any difficulty is encountered while withdrawing the cutting balloon. Therefore, after removal, cutting balloon should be examined thoroughly for possible stent dislodgment or extraction when used for “in-stent restenosis.” Praveen Vemula, Jagadeesh K. Kalavakunta, George S. Abela, and Milind Karve Copyright © 2014 Praveen Vemula et al. All rights reserved. Holt-Oram Syndrome in Adult Presenting with Heart Failure: A Rare Presentation Sun, 23 Mar 2014 10:13:38 +0000 Holt-Oram syndrome is a rare inherited disorder involving the hands, arms, and the heart. The defects involve carpal bones of the wrist and the thumb and the associated cardiac anomalies like atrial or ventricular septal defects. Congenital cardiac and upper-limb malformations frequently occur together and are classified as heart-hand syndromes. The most common amongst the heart-hand disorders is the Holt-Oram syndrome, which is characterized by septal defects of the heart and preaxial radial ray abnormalities. Its incidence is one in 100,000 live births. Approximately three out of four patients have some cardiac abnormality with common associations being either an atrial septal defect or ventricular septal defect. Herein, we report a rare sporadic case of Holt-Oram syndrome with atrial septal defect with symptoms of heart failure in a forty-five-year-old lady who underwent emergency cardiac surgery for the symptoms. Rupesh Kumar, Subhendu Sekhar Mahapatra, Monalisa Datta, Amanul Hoque, Swarnendu Datta, Soumyajit Ghosh, Santanu Datta, and Subhankar Bhattacharjee Copyright © 2014 Rupesh Kumar et al. All rights reserved. Inverted (Reverse) Takotsubo Cardiomyopathy following Cerebellar Hemorrhage Tue, 11 Mar 2014 13:21:09 +0000 Background. First described in 2005, inverted takotsubo is one of the four stress-induced cardiomyopathy patterns. It is rarely associated with subarachnoid hemorrhage but was not previously reported after intraparenchymal bleeding. Purpose. We reported a symptomatic case of inverted takotsubo pattern following a cerebellar hemorrhage. Case Report. A 26-year-old woman presented to the emergency department with sudden headache and hemorrhage of the posterior fossa was diagnosed, probably caused by a vascular malformation. Several hours later, she developed acute pulmonary edema due to acute heart failure. Echocardiography showed left ventricular dysfunction with hypokinetic basal segments and hyperkinetic apex corresponding to inverted takotsubo. Outcome was spontaneously favorable within a few days. Conclusion. Inverted takotsubo pattern is a stress-induced cardiomyopathy that could be encountered in patients with subarachnoid hemorrhage and is generally of good prognosis. We described the first case following a cerebellar hematoma. Sophie Piérard, Marco Vinetti, and Philippe Hantson Copyright © 2014 Sophie Piérard et al. All rights reserved. Bleeding Complication of Triple Therapy of Rivaroxaban, Prasugrel, and Aspirin: A Case Report and General Discussion Tue, 11 Mar 2014 09:50:52 +0000 Hemorrhagic side effects are the bane of oral anticoagulation. Despite careful selection of medications and close monitoring, some adverse events are unavoidable. The available literature about the risks of triple oral anticoagulation therapy versus dual antiplatelet therapy does not address all of the medication combinations currently available. This report describes a patient with atrial fibrillation and recent stent placement who developed severe, recurrent epistaxis on aspirin, prosugrel, and rivaroxaban. We believe this is the first case report of severe bleeding with this combination, and it may help provide insights into the risk for other patients. Dane D. Gruenebaum, Ahmad Alsarah, Osama Alsara, and Heather Laird-Fick Copyright © 2014 Dane D. Gruenebaum et al. All rights reserved. Nitroglycerine Induced Acute Myocardial Infarction in a Patient with Myocardial Bridging Tue, 04 Mar 2014 09:17:30 +0000 Muscle overlying an intramyocardial segment of a coronary artery is termed a myocardial bridge. The intramyocardial segment, the tunneled artery, is compressed during systole. The condition is generally benign but may occasionally cause myocardial ischemia, infarction, arrhythmia, or sudden cardiac death. We present a case regarding a 52-year-old man with exercise-induced angina who was diagnosed with a myocardial bridge overlying the left anterior descending artery. He was initially treated with beta-blockers and later received coronary bypass graft surgery. Dragana Rujic, Mette Lundgren Nielsen, Karsten Tange Veien, and Manan Pareek Copyright © 2014 Dragana Rujic et al. All rights reserved. In-Stent Ulceration: An Unusual Pathology Tue, 04 Mar 2014 07:36:48 +0000 In-stent restenosis occurs in 10–60% of cases undergoing interventional therapy. Many mechanisms explain the reason for in-stent restenosis, but restenosis due to an ulcerated plaque is very rare and has not been well reported in the literature. We report an interesting case of 72-year-old man presenting with neurological symptoms secondary to in-stent restenosis of the carotid artery caused by an ulcerated plaque. We also explain the different mechanisms for restenosis along with the treatment options. Jagadeesh Kumar Kalavakunta, Shravan Gangula, and Vishal Gupta Copyright © 2014 Jagadeesh Kumar Kalavakunta et al. All rights reserved. Delayed Amplatzer Occluder Device Closure of Postinfarction Ventricular Septal Defect: A Case Report Mon, 03 Mar 2014 12:18:38 +0000 Postinfarction ventricular septal defect (VSD) is a rare complication after acute myocardial infarction, with an incidence rate of 1-2% of all myocardial infarcts (Hutchins, 1979). It is a medical emergency with sobering survival numbers, having a mortality rate of 70–80% within two weeks of the incident event (Bouchart et al., 1998). Cardiac surgery is considered the gold standard in the management of these defects; however, its main limitation is that it carries a high risk of perioperative mortality and postoperative sequelae. Percutaneous transcatheter closure of VSD is a relatively new method of repair. Due to scarcity of reports in the literature, there is limited data regarding survival data; however, noninferiority to surgery has been demonstrated in one case series (Papalexopoulou et al., 2013). Long-term follow-up studies are lacking, and thus long-term mortality has yet to be discerned. We present a case of an 87-year-old female who, following postmyocardial infarction VSD, developed clinically significant heart failure. The patient was reluctant to undergo open repair given her age and comorbidities and she underwent successful percutaneous repair of her VSD using a 16 mm Amplatzer occluder device 18 months after her initial presentation. Francis Ting, Aditya Bhat, Neville Sammel, and David Muller Copyright © 2014 Francis Ting et al. All rights reserved. Possible Usefulness of Gadolinium-Enhanced Brain MRI for Evaluating Risk of Perioperative Hemorrhage: A Case of Infective Endocarditis Thu, 13 Feb 2014 14:14:59 +0000 A 59-year-old woman visited a local hospital for fever and was diagnosed as having infective endocarditis (IE) on the basis of blood cultures and transthoracic echocardiography. Based on clinical episodes of subarachnoid hemorrhage after admission, it was judged that she was not a good candidate for urgent open heart surgery, and it was decided to treat her with conservative medical therapy for the acute phase. We explored the optimum timing for surgery by employing gadolinium (Gd) contrast medium-enhanced magnetic resonance imaging (MRI) T2* weighted image (black dots) due to her high risk of perioperative cerebral hemorrhage. After the disappearance of the contrast media enhancement effect around the black dots, open heart surgery was performed successfully on the 103rd hospitalization day. The patient was discharged 22 days after the surgery with no clinical complications. This case suggests that disappearance of the contrast media enhancement effect around the black dots may be a useful marker for optimal timing of surgery to minimize the risk of perioperative cerebral hemorrhage in patients with IE. Learning Objective. The MRI T2* weighted images including those with Gd contrast medium enhancement effect may be useful for evaluating the risk of perioperative intracranial hemorrhage in IE. Chikahiko Koeda, Atsushi Tashiro, Tomohiro Takahashi, Masanobu Niiyama, Ryohei Sakamoto, Takumi Kimura, Yoshihiro Morino, Katsutoshi Terui, Ryoichi Tanaka, Kunihiro Yoshioka, Hajime Kin, Hitoshi Okabayashi, and Motoyuki Nakamura Copyright © 2014 Chikahiko Koeda et al. All rights reserved. Multiple Multilateral Coronary-Cameral Fistulae in a Patient with Minor Cardiac Venous System Thu, 06 Feb 2014 11:33:40 +0000 A 40-year-old man was hospitalized in the coronary care unit with chest pain and abnormal electrocardiogram. Twenty days earlier, the patient underwent laparoscopic gallbladder surgery. Due to chest pain and ischemic ECG changes, patient was subjected to coronary angiography. The selective coronary angiography revealed multiple multilateral fistulae arising from the left anterior descending artery, circumflex artery, and the right coronary artery draining to the left ventricle. Multislice computed tomography showed hypoplastic coronary sinus and minor cardiac venous system. Darko Markota, Zrinko Prskalo, Ivica Markota, Boris Starcevic, Josip Maskovic, Monika Tomic, and Ivica Brizic Copyright © 2014 Darko Markota et al. All rights reserved. An Unusual Cause of Transient Ischemic Attack in a Patient with Pacemaker Tue, 04 Feb 2014 14:07:38 +0000 Pacemaker lead malposition in various locations has been described in the literature. Lead malposition in left ventricle is a rare and an underdiagnosed complication. We present a 77-year-old man with history of atrial fibrillation and pacemaker placement who was admitted for transient ischemic attack. He was on aspirin, beta blocker, and warfarin with subtherapeutic international normalized ratio. His paced electrocardiogram showed right bundle-branch block, rather than the typical pattern of left bundle-branch block, suggesting pacemaker lead malposition. Further, his chest X-ray and echocardiogram confirmed the pacemaker lead position in the left ventricle instead of right ventricle. He refused surgical removal of the lead and we increased his warfarin dose. Diagnosis of lead malposition in left ventricle, though easy to identify in echocardiogram, requires high index of clinical suspicion. In asymptomatic patients, surgical removal may be deferred for treatment with lifelong anticoagulation. Jagadeesh Kumar Kalavakunta, Vishal Gupta, Basil Paulus, and William Lapenna Copyright © 2014 Jagadeesh Kumar Kalavakunta et al. All rights reserved. Vegan Triple-Ironman (Raw Vegetables/Fruits) Sun, 12 Jan 2014 00:00:00 +0000 Endurance sport requires a healthy and balanced diet. In this case report we present the findings of an ultra-triathlete (three times Ironman, means 11.4 km swim, 540 km bike, 125 km run in 41:18 h as a whole) living on a raw vegan diet and having finished the competitions under these nutritional conditions. To this end, the vegan ultra triathlete and a control group of 10 Ironman triathletes of similar age living on a mixed diet were investigated, using echocardiography and spiroergometry. In addition, blood samples were taken from the vegan athlete both in the sporting season and in the off-season. The vegan athlete showed no signs of dietary deficiencies or impaired health. In comparison with the control group, the vegan athlete showed a higher oxygen intake at the respiratory compensation point. This case demonstrates that even top-class sporting performance, like that of a three-time Ironman, is possible on a vegan diet. Whether a vegan diet offers advantages or disadvantages for the performance of endurance athletes remains an open question. Roman Leischik and Norman Spelsberg Copyright © 2014 Roman Leischik and Norman Spelsberg. All rights reserved. Balloon-Assisted Tracking to Overcome Radial Spasm during Transradial Coronary Angiography: A Case Report Wed, 08 Jan 2014 16:14:45 +0000 Spasm of the radial artery is the most important cause of failure to perform coronary angiography via the transradial approach. Spasmolytic cocktail may prevent radial artery spasm but is relatively contraindicated in patients with aortic stenosis or diminished left ventricular function. In this case report we describe a recently published technique to overcome severe radial spasm during transradial coronary angiography in a patient with moderate aortic valve stenosis. N. J. W. Verouden and F. Kiemeneij Copyright © 2014 N. J. W. Verouden and F. Kiemeneij. All rights reserved. Late Presentation of Recurrent Monomorphic Ventricular Tachycardia following Minimally Invasive Mitral Valve Repair due to Epicardial Injury Mon, 06 Jan 2014 16:38:57 +0000 We report a 73-year-old male with late onset monomorphic ventricular tachycardia following mitral valve repair (MVR). Typically, injury to epicardial arteries following mitral valve repair/replacement presents immediately as ventricular tachycardia/fibrillation, difficulty weaning from cardiopulmonary bypass, worsening ECG changes, increasing cardiac biomarkers, or new wall motion abnormalities. Our case illustrates a “late complication” of a distorted circumflex artery following mitral valve repair and the importance of early diagnostic angiography and percutaneous intervention. Harry L. South, Moses Osoro, and Tjuan Overly Copyright © 2014 Harry L. South et al. All rights reserved. Triple Diuretics and Aquaretic Strategy for Acute Decompensated Heart Failure due to Volume Overload Mon, 30 Dec 2013 10:15:02 +0000 Diuretics, including furosemide, metolazone, and spironolactone, have historically been the mainstay of therapy for acute decompensated heart failure patients. The addition of an aquaretic-like vasopressin antagonist may enhance diuresis further. However, clinical experience with this quadruple combination is lacking in the acute setting. We present two hospitalized patients with acute decompensated heart failure due to massive fluid overload treated with a combination strategy of triple diuretics in conjunction with the aquaretic tolvaptan. The first patient lost 72.1 lbs. (32.7 kg) with an average urine output of 3.5 to 7.5 L/day over eight days on combined therapy with furosemide, metolazone, spironolactone, and tolvaptan. The second patient similarly achieved a weight loss of 28.2 lbs. (12.8 kg) over 4 days on the same treatment. Both patients maintained stable serum sodium, potassium, and creatinine over this period and remained out of the hospital for more than 30 days. Thus, patients hospitalized with acute decompensated heart failure due to volume overload can achieve euvolemia rapidly and without electrolytes disturbances using this regimen, while being under the close supervision of a team of cardiologists and nephrologists. Additionally, this therapy can potentially decrease the need for ultrafiltration and the length of hospital stay. Rita Jermyn, Naveed Rajper, Chelsea Estrada, Sagar Patel, Michelle Weisfelner Bloom, and Nand K. Wadhwa Copyright © 2013 Rita Jermyn et al. All rights reserved. Rare Presentation of Gerbode Defect in a 4-Month-Old Nigerian and a Review of the Literature Wed, 25 Dec 2013 11:59:19 +0000 A Gerbode defect is a very rare congenital anomaly which presents as a direct or an indirect type. We report a 4 month old Nigerian child who presented with poor feeding and failure to thrive and whose echocardiography confirmed an indirect Gerbode with a direct left ventricle to right atrial shunt due to adherent leaflets of the tricuspid valve. This was confirmed by surgery done outside the country. Barbara E. Otaigbe and Douye Orubide Copyright © 2013 Barbara E. Otaigbe and Douye Orubide. All rights reserved. Pericarditis in Takotsubo Cardiomyopathy: A Case Report and Review of the Literature Tue, 17 Dec 2013 11:38:03 +0000 Case. A 64-year-old Caucasian woman was brought to the emergency department with severe dysphagia and left chest pain for last 4 days. Initial evaluation revealed elevated ST segment in precordial leads on EKG with elevated cardiac enzymes. Limited echocardiogram showed infra-apical wall hypokinesia. Cardiac angiography was done subsequently which showed nonflow limiting mild coronary artery disease. Takotsubo cardiomyopathy was diagnosed and she was treated medically. On the third day of admission, a repeat ECG showed diffuse convex ST-segment elevations in precordial leads, compatible with acute pericarditis pattern of EKG. Decision was made to start colchicine empirically for possible pericarditis. Follow-up EKG in 2 days showed decreased ST-segment elevations in precordial leads. The patient was discharged with colchicine and a follow-up echocardiogram in 4 weeks demonstrated a normal ejection fraction with no evidence of pericarditis. Conclusion. Acute pericarditis can be associated either as a consequence of or as a triggering factor for Takotsubo cardiomyopathy. It is vital for physicians to be aware of pericarditis as a potential complication of Takotsubo cardiomyopathy. Joonseok Kim, Heather S. Laird-Fick, Osama Alsara, Venu Gourineni, and George S. Abela Copyright © 2013 Joonseok Kim et al. All rights reserved. Reactive Thrombocytosis Associated with Acute Myocardial Infarction following STEMI with Percutaneous Coronary Intervention Sun, 24 Nov 2013 10:49:34 +0000 The etiology of thrombocytosis can be classified into reactive and essential forms. The rate of thromboembolic events is higher in essential thrombocytosis, and these events include strokes, transient ischemic attacks, retinal artery or retinal vein occlusions, digital ischemia, and acute coronary syndrome. In a study of 732 medical and surgical patients with thrombocytosis, 88% had reactive thrombocytosis. Patients with reactive thrombocytosis do not require cytoreductive medications or antiplatelet treatment. We report a healthy 40-year-old man without any medical problems who developed a new episode of myocardial infarction associated with thrombocytosis after an episode of myocardial infarction followed by percutaneous coronary intervention. He had thrombocytosis, and his platelet function test did not reveal adequate inhibition. To treat his acute coronary syndrome, therapeutic enoxaparin was added, and clopidrogel was substituted with ticagrelor. We decided to start hydroxyurea to reduce platelets counts. Enoxaparin and hydroxyurea were discontinued when platelet count returned to baseline. JAK-2 and BCR/ABL mutations were negative. This case report highlights a clinical dilemma (reactive thrombocytosis), which is challenging in terms of management and pathophysiology. Nat Dumrongmongcolgul, Charoen Mankongpaisarnrung, Grerk Sutamtewagul, Nattamol Hosiriluck, Timothy Chen, Alexander Trujillo, Nicholas Dcunha, Kenneth Nugent, and Leigh Ann Jenkins Copyright © 2013 Nat Dumrongmongcolgul et al. All rights reserved. Sinus of Valsalva Fistula to the Right Ventricle along with Coronary Artery Fistula to the Pulmonary Artery in a Young Native American Female Tue, 19 Nov 2013 13:40:50 +0000 Sinus of Valsalva aneurysm is a rare condition and associated with a high rate of mortality if rupture occurs. The aneurysms are rarely diagnosed until rupture occurs. This case describes a young Native American female whose only symptom was intermittent chest pain prior to the detection of the aneurysm along with a small ventricular septal defect. The patient was also found to have a coexisting coronary artery fistula, and it is rare phenomenon to have these coexisting anomalies. The anomalies were demonstrated on both cardiac computed tomography and coronary angiography. The patient underwent surgical closure of both anomalies, which is the recommended treatment to avoid future complications. Sarika Desai, Erica Flores, Akil Loli, and Peter Maki Copyright © 2013 Sarika Desai et al. All rights reserved. Fatal Huge Left Free Wall Ventricular Rupture after Acute Posterior Myocardial Infarction Tue, 08 Oct 2013 13:43:38 +0000 A 77-year-old man, with a recent history of an acute inferior myocardial infarction, was referred to our hospital with echocardiographic and clinical signs of left ventricular free wall rupture (LVFWR). The intraoperative finding demonstrated a huge double LVFWR. The inferoposterior wall was dramatically destroyed without any possibility to repair. Francesco Formica, Silvia Mariani, Orazio Ferro, and Giovanni Paolini Copyright © 2013 Francesco Formica et al. All rights reserved. Thrombus in Transit through Patent Foramen Ovale Mon, 30 Sep 2013 15:33:23 +0000 A thrombus in transit through a patent foramen ovale (PFO) with impending paradoxical embolism is an extremely rare event. Due to its transient nature, it is unable to identify the thrombus, and most of the cases have been reported at autopsy. We are reporting a case of thrombus straddling the foramen ovale which was diagnosed by echocardiography and treated surgically. Through this personal case, an exhaustive review of the literature was performed. There were 88 cases reported. We concluded that there is no medical consensus about the best option for treatment. Nevertheless, surgery, which is associated with fewer complications of recurrent embolic events than those of thrombolysis and anticoagulation, appeared to be the best approach in patients who are not at a high surgical risk. Anticoagulant treatment appears to be an acceptable therapeutic alternative to surgery, particularly in patients with comorbidities who are at high surgical risk and for patients with small PFO. Thrombolysis is linked to the highest mortality, which could be explained by the severity of the patient’s initial presentation. In conclusion, and after the cumulative effects of these case reports, we propose a diagram consisting of the use of the three therapeutic options in the different clinical scenarios. Hassan Baydoun, Iskander Barakat, Elie Hatem, Michel Chalhoub, and Ali Mroueh Copyright © 2013 Hassan Baydoun et al. All rights reserved. Chronic Constrictive Pericarditis Tue, 24 Sep 2013 14:13:04 +0000 Constrictive pericarditis (CP) is a rare clinical entity that can pose diagnostic problems. The diagnosis of CP requires a high degree of clinical suspicion. The gold standard for diagnosis is cardiac catheterization with analysis of intracavitary pressure curves, which are high and, in end diastole, equal in all chambers. We present a patient with unexplained dyspnea, recurrent right-side pleural effusion, and ascites. Analysis of the ascitic fluid revealed a high protein content and an elevated serum-ascites gradient. Echocardiography, computed tomography, and cardiac catheterization revealed the diagnosis of CP. He underwent complete pericardiectomy and to date has made a good recovery. The diagnosis of CP is often neglected by admitting physicians, who usually attribute the symptoms to another disease process. This case exemplifies the difficulty in diagnosing this condition, as well as the investigation required, and provides a discussion of the benefit and outcomes of prompt treatment. Hossein Doustkami, Afshin Hooshyar, Nasrollah Maleki, Zahra Tavosi, and Iraj Feizi Copyright © 2013 Hossein Doustkami et al. All rights reserved. Giant Fibroelastoma of the Aortic Valve Wed, 04 Sep 2013 11:33:25 +0000 Fibroelastomas account for less than 10% of all cardiac tumours, representing the most common valvular and the second most common cardiac benign tumour, following myxomas. Fibroelastomas are histologically benign; they can result in life-threatening complications such as stroke, acute valvular dysfunction, embolism, ventricular fibrillation, and sudden death. Surgical resection should be offered to all patients who have symptoms and to asymptomatic patients who have pedunculated lesions or tumors larger than 1 cm in diameter. Valve-sparing excision produces good long-term results in most instances. We report our surgical experience of a giant fibroelastoma in the aortic valve. Michele di Summa and Federica Iezzi Copyright © 2013 Michele di Summa and Federica Iezzi. All rights reserved. First Diagonal Coronary Artery: Left Ventricular Fistula Presenting as Unstable Angina Mon, 12 Aug 2013 10:32:03 +0000 Coronary artery fistulae are characterized by communications between a coronary artery and a cardiac chamber or another vascular structure. They are usually congenital, but acquired forms may occur. Most patients are usually asymptomatic. However, some studies have emphasized that the incidence of symptoms and complications increases with age, particularly after the age of 20 (Liberthson et al. 1979, Hong et al. 2004). We aimed to present a very rare form of fistula originating from the first diagonal artery and connecting into the left ventricle. Murat Sener, Mehmet Akkaya, and Muammer Bilici Copyright © 2013 Murat Sener et al. All rights reserved. Remote Stab Wound Resulting in AV Fistula and High-Output Heart Failure Mon, 05 Aug 2013 08:21:00 +0000 A 54-year-old African American male with no medical history presented to an urgent care clinic with signs and symptoms of new-onset congestive heart failure. There was an initial concern for congestive heart failure secondary to an ischemic etiology as an echocardiogram revealed a depressed ejection fraction. However, a left heart cardiac catheterization did not demonstrate any significant coronary disease. As a loud bruit was auscultated over the right base of the patient’s neck, he underwent a carotid duplex ultrasound revealing a fistula between the right common carotid artery (CCA) and the right internal jugular vein (IJV). A diagnosis of high-output heart failure secondary to a large arteriovenous (AV) fistula was made, and the patient underwent ligation and repair of the fistula with resolution of symptoms of congestive heart failure. Jennifer A. Rymer, Lindsay L. Anderson, J. Trevor Posenau, and W. Schuyler Jones Copyright © 2013 Jennifer A. Rymer et al. All rights reserved. Coronary-Subclavian Steal Syndrome: Percutaneous Approach Mon, 29 Jul 2013 13:45:46 +0000 Coronary subclavian steal syndrome is a rare ischemic cause in patients after myocardial revascularization surgery. Subclavian artery stenosis or compression proximal to the internal mammary artery graft is the underlying cause. The authors present a clinical case of a patient with previous history of non-ST elevation myocardial infarction, triple coronary bypass, and effort angina since the surgery, with a positive ischemic test. Coronary angiography revealed a significant stenosis of the left subclavian artery, proximal to the internal mammary graft. Carina Machado, Luís Raposo, Sílvio Leal, Pedro Araújo Gonçalves, Henrique Mesquita Gabriel, Rui Campante Teles, Manuel Sousa Almeida, and Miguel Mendes Copyright © 2013 Carina Machado et al. All rights reserved. Acute Inferior Wall Myocardial Infarction due to Occlusion of the Wrapped Left Anterior Descending Coronary Artery Wed, 24 Jul 2013 13:33:50 +0000 Acute occlusion of the left anterior descending coronary artery (LAD) generally results in ST segment elevations in precordial leads and reciprocal ST segment depression in inferior leads. The occurrence of isolated inferior myocardial infarction due to occlusion of LAD is very rare. We describe an isolated acute inferior myocardial infarction due to occlusion of a wrapped LAD at the apex which continues as the large posterior descending coronary artery (PDA) beyond the occlusion. Thottuvelil Narayanan Sunil Roy, Jafar Saeed Nagham, and Rajappan Anil Kumar Copyright © 2013 Thottuvelil Narayanan Sunil Roy et al. All rights reserved. A Fibromatosis Case Mimicking Abdominal Aorta Aneurysm Tue, 16 Jul 2013 10:33:40 +0000 Retroperitoneal fibrosis is a rare fibrosing reactive process that may be confused with mesenteric fibromatosis. Abdominal aorta aneurysm is rare too and mostly develops secondary to Behcet’s disease, trauma, and infection or connective tissue diseases. Incidence of aneurysms occurring as a result of atherosclerotic changes increases in postmenopausal period. Diagnosis can be established with arteriography, tomography, or magnetic resonance imaging associated with clinical findings. Tumors and cysts should be considered in differential diagnosis. Abdominal ultrasound and contrast-enhanced computerized tomography revealed an infrarenal abdominal aorta aneurysm in a 41-year-old woman, but, on surgery, retroperitoneal fibrosis surrounding the aorta was detected. We present this interesting case because retroperitoneal fibrosis encircling the abdominal aorta can mimic abdominal aorta aneurysm radiologically. Arzu Tasdemir, Cemal Kahraman, Kutay Tasdemir, and Ertugrul Mavili Copyright © 2013 Arzu Tasdemir et al. All rights reserved. Atypical Chest X-Ray Calcification in an Idiopathic Constrictive Pericarditis Case Wed, 10 Jul 2013 10:33:09 +0000 Constrictive pericarditis is an uncommon cause of heart failure. It is a clinical entity caused by thickening, fibrosis, and/or calcification of the pericardium. We present a 50-year-old female patient who was admitted to our institution with a 6-month history of progressive dyspnea on exertion, abdominal swelling, and lower extremity edema. Her chest X-ray revealed an oblique linear calcification in the cardiac silhouette. Transthoracic echocardiography revealed biatrial enlargement. Left ventricular size and systolic function were normal. Cardiac computed tomography revealed the pericardial thickening (>5 mm) and heavy calcification in left atrioventricular groove. Simultaneous right and left heart catheterization showed elevation and equalization of right-sided and left-sided diastolic filling pressures, with characteristic dip, and plateau. Pericardiectomy was performed which revealed a thick, fibrous, calcified, and densely adherent pericardium constricting the heart. The postoperative period was uneventful and was in NYHA functional class I after 3 months. Uğur Coşkun, İsmail Polat Canbolat, Ümit Yaşar Sinan, Cem Bostan, Kadriye Kılıçkesmez, Ahmet Yıldız, Murat Başkurt, Fatma Nihan Turhan Çağlar, Alican Hatemi, Cenk Eray Yıldız, Sadettin Cöhcen, Aziz Tevfik Gürmen, and Mehmet Serdar Küçükoğlu Copyright © 2013 Uğur Coşkun et al. All rights reserved. Left Atrial Myxoma: A Rare Nonatherosclerotic Cause of Acute Myocardial Infarction Sun, 23 Jun 2013 08:39:39 +0000 Myocardial infarction from coronary artery embolism is a very rare but potentially lethal sequel of left atrial myxoma. Most atrial myxomas causing myocardial infarction are diagnosed retrospectively after a 2D echocardiogram is performed for assessment of myocardial function after a myocardial infarction. We present a relatively healthy 53-year-old male with anterolateral wall myocardial infarction and 100% occlusion at the proximal part of the obtuse marginal branch of the circumflex coronary artery that was subsequently reperfused. A 2D echocardiogram performed two days later revealed a left atrial mass, which was successfully resected and proven to be a myxoma. No recurrence of the tumor was seen on follow-up after four months. An automatic implantable cardioverter defibrillator was placed for residual ischemic cardiomyopathy with clinical improvement. Rey Francisco Arcenas and Mir Ishtiaque Ali Copyright © 2013 Rey Francisco Arcenas and Mir Ishtiaque Ali. All rights reserved.