Case Reports in Cardiology The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. A Case of Severe Carotid Stenosis in a Patient with Familial Hypercholesterolemia without Significant Coronary Artery Disease Thu, 23 Oct 2014 08:30:57 +0000 Familial hypercholesterolemia (FH) is an inherited metabolic disorder characterized by elevated low-density lipoprotein cholesterol levels in the blood. In its heterozygous form, it occurs in 1 in 500 individuals in the general population. It is an important contributor to the early onset of coronary artery disease (CAD), accounting for 5–10% of cases of cardiovascular events in people younger than 50 years. Atherogenesis triggered by hypercholesterolemia generally progresses faster in the coronary arteries, followed by the subsequent involvement of other arteries such as the carotids. Thus, symptoms of CAD commonly appear before the onset of significant carotid stenosis. Herein, we report the case of a patient with untreated FH who had severe carotid atherosclerosis at the age of 46 years but had no evidence of significant CAD. Marcos Aurélio Lima Barros, Hygor Ferreira-Fernandes, Ingrid Cristina Rêgo Barros, Adriel Rêgo Barbosa, and Giovanny Rebouças Pinto Copyright © 2014 Marcos Aurélio Lima Barros et al. All rights reserved. Long QTc Syndrome Type 2 Presenting in a Postpartum Patient on Medroxyprogesterone Tue, 21 Oct 2014 00:00:00 +0000 Introduction. Congenital long QT syndrome type 2 (LQTS2) is a rare inherited cardiac abnormality resulting in increased risk of polymorphic ventricular tachycardia (PVT). Case Description. A 21-year-old postpartum female presented with syncopal episode after phone alarm. She was noted to have PVT on telemetry monitoring in the emergency department. EKG revealed QTc of 530. The patient’s only medication was medroxyprogesterone. She ultimately received a dual chamber pacemaker with ICD. Discussion. LQTS2 is associated with alarm sounds as a precipitating factor. Postpartum hormonal shifts as well as medroxyprogesterone have significant effect on native QTc duration. John Kern, Margaret Duffy, Corinne Kern, and Victor Mazza Copyright © 2014 John Kern et al. All rights reserved. Traumatic Tension Pneumothorax as a Cause of ICD Failure: A Case Report and Review of the Literature Tue, 07 Oct 2014 14:00:59 +0000 Background. Tension pneumothorax can infrequently cause ventricular arrhythmias and increase the threshold of defibrillation. It should be suspected whenever there is difficulty in defibrillation for a ventricular arrhythmia. Purpose. To report a case of traumatic tension pneumothorax leading to ventricular tachycardia and causing defibrillator failure. Case. A 65-year-old African-American female was brought in to our emergency department complaining of dyspnea after being forced down by cops. She had history of mitral valve replacement for severe mitral regurgitation and biventricular implantable cardioverter defibrillator inserted for nonischemic cardiomyopathy. Shortly after arrival, she developed sustained ventricular tachycardia, causing repetitive unsuccessful ICD shocks. She was intubated and ventricular tachycardia resolved with amiodarone. Chest radiograph revealed large left sided tension pneumothorax which was promptly drained. The patient was treated for congestive heart failure; she was extubated on the third day of admission, and the chest tube was removed. Conclusion. Prompt recognition of tension pneumothorax is essential, by maintaining a high index of suspicion in patients with an increased defibrillation threshold causing ineffective defibrillations. Ehtesham Ul Haq and Bassam Omar Copyright © 2014 Ehtesham Ul Haq and Bassam Omar. All rights reserved. Potential Additive Effects of Ticagrelor, Ivabradine, and Carvedilol on Sinus Node Mon, 29 Sep 2014 00:00:00 +0000 A 51-year-old male patient presented to the emergency room with an anterior ST-elevation myocardial infarction. After a loading dose of both ticagrelor and aspirin, the patient underwent primary-PCI on the left anterior descending coronary artery with stent implantation. After successful revascularization, medical therapy included beta-blockers, statins, and angiotensin II receptor antagonists. Two days later, ivabradine was also administered in order to reduce heart rate at target, but the patient developed a severe symptomatic bradycardia and sinus arrest, even requiring administration of both atropine and adrenaline. Ivabradine and ticagrelor have been then suspended and this latter changed with prasugrel. Any other similar event was not reported during the following days. This clinical case raised concerns about the safety of the combination of beta-blockers and ivabradine in patients treated with ticagrelor, particularly during the acute phase of an acute coronary syndrome. These two latter drugs, in particular, might interact with the same receptor. In fact, ivabradine directly modulates the If-channel which is also modulated by the cyclic adenosine monophosphate levels. These latter have been shown to increase after ticagrelor assumption via inhibition of adenosine uptake by erythrocytes. Further studies are warrant to better clarify the safety of this association. Luigi Di Serafino, Francesco Luigi Rotolo, Augusto Boggi, Riccardo Colantonio, Roberto Serdoz, and Francesco Monti Copyright © 2014 Luigi Di Serafino et al. All rights reserved. Phantom Tumor of the Lung: Localized Interlobar Effusion in Congestive Heart Failure Sun, 28 Sep 2014 09:05:05 +0000 Localized interlobar effusions in congestive heart failure (phantom or vanishing lung tumor/s) is/are uncommon but well known entities. An 83-year-old man presented with shortness of breath, swollen legs, and dry cough enduring five days. Chest-X-ray (CXR) revealed massive sharply demarked round/oval homogeneous dense shadow 10 × 7 cm in size in the right inferior lobe. The treatment with the loop diuretics and fluid intake reduction resulted in complete resolution of the observed round/oval tumor-like image on the control CXR three days later. Radiologic appearance of such a mass-like configuration in patients with congestive heart failure demands correction of the underlying heart condition before further diagnostic investigation is performed to avoid unnecessary, expensive, and possibly harmful diagnostic and treatment errors. Mislav Lozo, Emilija Lozo Vukovac, Zeljko Ivancevic, and Ivan Pletikosic Copyright © 2014 Mislav Lozo et al. All rights reserved. An Unusual Cause of Cardiac Tamponade during Cardiac Catheterization Study Thu, 18 Sep 2014 00:00:00 +0000 Introduction. Catheter-based diagnostic and therapeutic procedures are rapidly advancing. However, catheter related complications sometimes become life threatening. Cardiac tamponade is a rare but serious complication of this procedure. We have summarized one cardiac tamponade pejoration due to secondary coronary vessels laceration by the implanted pericardial drainage. Case report. A 4-year-old baby having Tetralogy of Fallot was posted for diagnostic catheterization study. Patient was induced with sevoflurane and spontaneous respiration was maintained. After catheter insertion to RV, dye was injected through the catheter which rapidly spread into the pericardial cavity indicating right ventricle perforation. Immediately, blood was aspirated under transthoracic echocardiographic guidance and hemodynamics started improving. For the provision of quick access to aspirate further collection, an intrapericardial sheath was inserted after multiple attempts. Patient’s condition started deteriorating again. TTE revealed again some collection and it was increasing gradually. On exploration, it was found that there was continuous bleeding from a lacerated epicardial vessel which contributed to the pericardial collection leading to further tamponade effect. This second iatrogenic injury complicated the management of the first iatrogenic cardiac perforation and, thereby, created a life-threatening situation which needed immediate surgical exploration. Discussion. Usual cause of tamponade after right ventricular perforation is bleeding from the RV, but in our case the second tamponade was not due to bleeding from the RV, but was rather from new laceration injury of epicardial vessels which was remained undiagnosed till exploration. Deepanwita Das, Monalisa Datta, Somnath Dey, Jyotiranjan Parida, Rupesh Kumar, and Arindam Pande Copyright © 2014 Deepanwita Das et al. All rights reserved. Oral Phenytoin Toxicity Causing Sinus Arrest: A Case Report Thu, 11 Sep 2014 09:00:14 +0000 We present a case of sinus node arrest leading to symptomatic junctional bradycardia from oral phenytoin toxicity, which is a rare presentation. Our patient had no prior cardiac history and was on phenytoin therapy for seizure disorder. Although bradycardia is more commonly associated with intravenous phenytoin and there were few case reports of bradycardia with oral phenytoin reported, the literature is limited. In this case report, we also reviewed the pathophysiology of phenytoin-induced cardiac toxicity. Ravi K. Thimmisetty, Janardhana Rao Gorthi, and Mahmoud Abu Hazeem Copyright © 2014 Ravi K. Thimmisetty et al. All rights reserved. Thrombus Formation on Amplatzer Septal Occluder Device: Pinning Down the Cause Tue, 02 Sep 2014 10:19:41 +0000 The use of interatrial septal occluder devices is an efficacious and less invasive alternative to open heart surgery for the repair of atrial septal defects. These devices present significant risks including thrombus formation on the device and subsequent thromboembolic events. We present a case of a woman who presented with stroke-like symptoms five years after PFO closure. The patient was subsequently found to have a thrombus on the occluder device. Our case highlights the risk of such thrombolic phenomenon and the risk associated with the device structure as a nidus for such a complication. Kevin Belgrave and Shaun Cardozo Copyright © 2014 Kevin Belgrave and Shaun Cardozo. All rights reserved. Rapidly Progressive Atrioventricular Block in a Patient with Sarcoidosis Thu, 21 Aug 2014 13:16:18 +0000 Cardiac sarcoidosis is a major cause of death in patients with systemic sarcoidosis. Cardiac manifestations are seen in 2.3% of the patients. Atrioventricular (AV) block is one of the common manifestations of cardiac sarcoidosis. Other presentations of cardiac involvement include congestive heart failure, ventricular arrhythmias, and sudden cardiac death. The presence of AV block in young patients should raise the suspicion of sarcoidosis. AV block may be the only manifestation and patients may not have clinical evidence of pulmonary involvement. Here we describe a young male presented with exercise induced AV block rapidly progressing to complete heart block with recurrent syncope needing urgent pacemaker implantation. Factors that suggested an infiltrative process included his young age, rapidly progressive conduction abnormalities in the ECG in the absence of coronary disease, and previous history of cutaneous sarcoidosis. Nagham Saeed Jafar, Warkaa Al Shamkhani, Sunil Roy Thottuvelil Narayanan, and Anil Kumar Rajappan Copyright © 2014 Nagham Saeed Jafar et al. All rights reserved. Total Anomalous Systemic Venous Drainage with Heterotaxia Syndrome: A Rare Case Tue, 12 Aug 2014 09:26:21 +0000 Total anomalous systemic venous return is a very rare anomaly, where vena cava inferior, vena cava superior, and coronary sinus drain into left atrium. Two-day-old male baby was admitted with cyanosis and tachypnea after the birth. Left atrial isomerism with anomalous systemic venous drainage was found on echocardiographic examination. We present an unusual case of total anomalous systemic venous drainage in to the left atrium. Ali Yildirim, Pelin Kosger, Gokmen Ozdemir, Birsen Ucar, and Zubeyir Kilic Copyright © 2014 Ali Yildirim et al. All rights reserved. A Case of Kawasaki Disease with Coronary Aneurysm Responding to the 4th IVIG Treatment Tue, 05 Aug 2014 00:00:00 +0000 Kawasaki disease is an acute febrile illness that usually occurs in children younger than 5 years of age. The use of intravenous immunoglobulin (IVIG) within the first 10 days of illness has been shown to reduce the incidence of coronary artery aneurysms significantly. The relative roles of repeated doses of intravenous immunoglobulin (IVIG) are controversial in refractory Kawasaki disease (KD). Most experts recommend the second retreatment with IVIG, 2 g/kg in refractory KD. However, the dose-response effect of the third or fourth IVIG was uncertain. Although there have been a significant number of reports on new therapeutic options for refractory KD, such as steroid, infliximab, methotrexate, and other immunosuppressants, their effectiveness in reducing the prevalence of coronary artery aneurysms was unproven. We present here KD patient with small coronary artery aneurysm who is resistant to the third IVIG and steroid pulse therapy but showed improvement immediately after the infusion of the 4th IVIG on fever day 18. Ju Young Kim and Hyun Jung Kim Copyright © 2014 Ju Young Kim and Hyun Jung Kim. All rights reserved. High-Risk Acute Coronary Syndrome in a Patient with Coronary Subclavian Steal Syndrome Secondary to Critical Subclavian Artery Stenosis Mon, 04 Aug 2014 11:32:53 +0000 Patients with multivessel coronary artery disease are more likely to have extensive atherosclerosis that involves other major arteries. Critical subclavian artery (SCA) stenosis can result in coronary subclavian steal syndrome that may present as recurrent ischemia and even myocardial infarction in patients with coronary artery bypass graft (CABG). In patients with concomitant severe native coronary disease, occluded saphenous venous grafts (SVG) to other arteries, percutaneous intervention on critical subclavian artery (SCA) stenosis that will compromise the blood flow to left internal mammary graft (LIMA) and left anterior descending (LAD) artery will be a high-risk procedure and may be associated with cardiogenic shock, especially in patients with preexisting ischemic cardiomyopathy. The use of percutaneous left ventricular (LV) assist device like Impella will offer better hemodynamic support and coronary perfusion and therefore results in decreased myocardial damage, maximized residual cardiac function, and lower incidence of cardiogenic shock. Zaher Fanari, Niksad Abraham, Sumaya Hammami, and Wasif A. Qureshi Copyright © 2014 Zaher Fanari et al. All rights reserved. Successful Venous Angioplasty of Superior Vena Cava Syndrome after Heart Transplantation Sun, 03 Aug 2014 11:19:06 +0000 Introduction. For patients with terminal heart failure, heart transplantation (HTX) has become an established therapy. Before transplantation there are many repeated measurements with a pulmonary artery catheter (PAC) via the superior vena cava (SVC) necessary. After transplantation, endomyocardial biopsy (EMB) is recommended for routine surveillance of heart transplant rejection again through the SVC. Case Presentation. In this report, we present a HTX patient who developed a SVC syndrome as a possible complication of all these procedures via the SVC. This 35-year-old Caucasian male could be successfully treated by balloon dilatation/angioplasty. Conclusion. The SVC syndrome can lead to pressure increase in the venous system such as edema in the head and the upper part of the body and further serious complications like cerebral bleeding and ischemia, or respiratory problems. Balloon angioplasty and stent implantation are valid methods to treat stenoses of the SVC successfully. Thomas Strecker, Iris Zimmermann, Marco Heinz, Johannes Rösch, Abbas Agaimy, and Michael Weyand Copyright © 2014 Thomas Strecker et al. All rights reserved. A Shocking Complication of a Pneumothorax: Chest Tube-Induced Arrhythmias and Review of the Literature Thu, 24 Jul 2014 08:43:29 +0000 We describe a patient with a recent chest tube insertion leading to atrial fibrillation with rapid ventricular rate that led to multiple inappropriate internal cardiac defibrillator (ICD) shocks. This is the first reported case of this occurring in a patient with an ICD leading to inappropriate shocks. Our elderly patient with emphysema presented with a spontaneous pneumothorax and developed rapid atrial fibrillation following emergency tube thoracostomy. The patient had a single lead ICD and received multiple inappropriate shocks for the rapid ventricular rate in the therapy zone. Although medical treatment helped stabilize the patient, resolution of the atrial fibrillation occurred only after the chest tube was removed. In a patient with a chest tube or other intrathoracic catheters, maintaining a high index of suspicion that chest tube insertions can cause secondary life threatening cardiovascular complications needs to be considered. In such patients, removal of the device proves to be the most prudent treatment action. Shaun Cardozo and Kevin Belgrave Copyright © 2014 Shaun Cardozo and Kevin Belgrave. All rights reserved. Novel Use of the GuideLiner Catheter to Deliver Rotational Atherectomy Burrs in Tortuous Vessels Wed, 23 Jul 2014 00:00:00 +0000 Rotational atherectomy (RA) for heavily calcified lesions is essential for improved stent delivery and stent expansion. In tortuous vessels it is often difficult to advance the burr without rotation and possible injury to the endothelium of healthy vessel. The GuideLiner catheter, a child in mother catheter, has recently been used to allow for increased support for delivery of stents through tortuous vessels. We report a novel use of the GuideLiner for the delivery of an RA burr in tortuous vessels requiring increased guide support. Minh Vo, Kunal Minhas, Malek Kass, and Amir Ravandi Copyright © 2014 Minh Vo et al. All rights reserved. Left Ventricle Pseudoaneurysm: Contribution of Multimodality Imaging to the Diagnosis Mon, 21 Jul 2014 07:18:45 +0000 The left ventricle pseudoaneurysm is an anomaly of the left ventricle and is severed and joined with a pocket look. There may be secondary to a myocardial infarction, trauma, or surgical procedure. Sometimes the cause is not found. Complications are heart failure, arrhythmias, vascular embolism, and sudden death. The treatment is surgical only. The authors report the case of a black patient of 64 years old, without medical history, had seen to a deformation of the cardiac shadow in radiography. The left ventricle pseudoaneurysm and in situ thrombus are visualized in echocardiography and CT scan. The patient is waiting for heart surgery. Ellenga Mbolla Bertrand Fikahem, Okemba-Okombi Franck Hardain, Mongo-Ngamami Flore Solange, Kouala Landa Christian Michel, Gombet Thierry Raoul, and Kimbally-Kaky Suzy-Gisèle Copyright © 2014 Ellenga Mbolla Bertrand Fikahem et al. All rights reserved. Accidental Left Circumflex Artery to Right Lung Fistula in a Suspected Case of Pulmonary Hypertension Thu, 17 Jul 2014 07:28:21 +0000 A 56-year-old woman was referred to the cardiology department of the Shahid Modarres hospital. The patient had a history of pulmonary thromboembolism 20 years ago which had been managed by the inferior vena cava filter and since then the patient has been on warfarin. Her chief complaint was chronic dyspnea on exertion (NYHA class II) from several years ago. Right and left heart catheterization was performed for evaluation of pulmonary artery pressure. We found rich collateral formations between LCX as well as RCA and right pulmonary artery, primarily assumed as multiple fistulas. Among patients who have chronic thromboembolic pulmonary hypertension, systemic collateral supply to the pulmonary parenchyma has been previously reported to occur from both bronchial and/or nonbronchial systemic circulations. Our patient had neither signs of heart failure nor myocardial ischemia and, thus, was a candidate for conservative management. The adenosine pulmonary reactivity test was not performed because of low pulmonary pressure which had been estimated to be high. Saeed Alipourparsa, Isa Khaheshi, Vahid Eslami, Mohammadreza Bozorgmanesh, and Habib Haybar Copyright © 2014 Saeed Alipourparsa et al. All rights reserved. Postpartum Coronary Vasospasm with Literature Review Mon, 07 Jul 2014 09:01:17 +0000 Acute myocardial infarction during pregnancy or the postpartum period is rare. We report a case of a 39-year-old postpartum woman who developed non-ST-elevation myocardial infarction due to severe diffuse coronary vasospasm. To our knowledge, this is the first case of angiographically evidenced coronary vasospasm, in a postpartum woman, with resistance to intracoronary nitroglycerin. Jayanth Koneru, Matthew Cholankeril, Kunal Patel, Fadi Alattar, Ashraf Alqaqa, Hirtaj Virk, Fayez Shamoon, and Mahesh Bikkina Copyright © 2014 Jayanth Koneru et al. All rights reserved. Shoshin Beriberi Induced by Long-Term Administration of Diuretics: A Case Report Thu, 03 Jul 2014 12:08:00 +0000 Previous studies have suggested that diuretic therapy for heart failure may lead to thiamine deficiency due to the increased urinary thiamine excretion. Herein, we present the case of a 61-year-old man with shoshin beriberi, a fulminant form of wet beriberi, induced by long-term diuretic therapy. The patient had a history of heart failure with preserved ejection fraction and was receiving furosemide and trichlormethiazide therapy. He presented with worsening exertional dyspnea and was admitted for heart failure exacerbation. His condition failed to improve even after intensive treatment. A hemodynamic evaluation with the Swan-Ganz catheter revealed high-output heart failure with low peripheral vascular resistance. Thiamine was administered for suspected shoshin beriberi; his hemodynamic status improved dramatically within the next six hours. The serum thiamine level was below the normal range; the patient was therefore diagnosed with shoshin beriberi. The common causes of thiamine deficiency were not identified. Long-term diuretic therapy with furosemide and thiazide was thought to have played a major role in the development of thiamine deficiency. This case illustrates the importance of considering wet beriberi as a possible cause of heart failure exacerbation in patients taking diuretics, even when the common thiamine deficiency causes are not identified with history-taking. Naoki Misumida, Hisashi Umeda, and Mitsunori Iwase Copyright © 2014 Naoki Misumida et al. All rights reserved. Iatrogenic Ascending Aorta Dissection during Diagnostic Coronary Angiography: Rare but Life-Threatening Mon, 16 Jun 2014 11:18:43 +0000 Dissection of the ascending aorta is a very rare but life-threatening complication during diagnostic angiography. We present a case of an elderly woman who underwent an elective diagnostic coronary angiography, complicated with an iatrogenic ascending aorta dissection that did not involve the coronary arteries but originated 4 cm distal of the aortic valve. The patient developed cardiogenic shock due to acute pericardial tamponade and so immediate, life-saving cardiac surgery with implantation of a supracoronary graft was successfully performed. A biopsy from the excised aorta showed loss of smooth muscle cells and accumulation of basophilic ground substance, clear features of cystic media necrosis. This is believed to be the underlying cause of the dissection besides a nonselective injection of the right coronary artery. Marc Lambelin, Luc Janssens, and Luc Haenen Copyright © 2014 Marc Lambelin et al. All rights reserved. A Unique Case of Cardiac Arrest following K2 Abuse Sun, 25 May 2014 08:37:07 +0000 Sudden cardiac death (SCD) accounts for up to 450,000 deaths every year in the United States (Zipes et al. (2006)). Most cases of sudden cardiac death occur in subjects with no prior history of heart disease (Myerburg et al. (1998)). The incidence of sudden death in a general population has been shown to increase contemporaneously with substance abuse (Phillips et al. (1999)). The causative association of sudden death with cocaine, methadone, and volatile agents is well established (Adgey et al. (1995) and Isner et al. (1986)). We describe a case of out-of-hospital cardiac arrest temporally related to abuse of the synthetic cannabinoid street drug known as K2. To our knowledge, there are no previously documented cases of sudden cardiac death associated with synthetic cannabinoids although they have been linked to myocardial infarction in teenagers despite normal coronary angiography (Mir et al. (2011)). Saif Ibrahim, Farah Al-Saffar, and Thomas Wannenburg Copyright © 2014 Saif Ibrahim et al. All rights reserved. Recurrent Acute Nonrheumatic Streptococcal Myocarditis Mimicking STEMI in a Young Adult Thu, 22 May 2014 11:58:06 +0000 Myocarditis consists of an inflammation of the cardiac muscle, definitively diagnosed by endomyocardial biopsy. The causal agents are primarily infectious: in developed countries, viruses appear to be the main cause, whereas in developing countries rheumatic carditis, Chagas disease, and HIV are frequent causes. Furthermore, myocarditis can be indirectly induced by an infectious agent and occurs following a latency period during which antibodies are created. Typically, myocarditis observed in rheumatic fever related to group A streptococcal (GAS) infection occurs after 2- to 3-week period of latency. In other instances, myocarditis can occur within few days following a streptococcal infection; thus, it does not fit the criteria for rheumatic fever. Myocarditis classically presents as acute heart failure, and can also be manifested by tachyarrhythmia or chest pain. Likewise, GAS-related myocarditis reportedly mimics myocardial infarction (MI) with typical chest pain, electrocardiograph changes, and troponin elevation. Here we describe a case of recurrent myocarditis, 5 years apart, with clinical presentation imitating an acute MI in an otherwise healthy 37-year-old man. Both episodes occurred 3 days after GAS pharyngitis and resolved quickly following medical treatment. Amanda Chikly, Ronen Durst, Chaim Lotan, and Shmuel Chen Copyright © 2014 Amanda Chikly et al. All rights reserved. Isolated Left Bundle Branch Block in a Toddler Sun, 18 May 2014 00:00:00 +0000 Left bundle branch block (LBBB) usually occurs as a postoperative complication from surgical correction of congenital heart disease and can be associated with hypertensive heart disease, coronary artery disease, myocarditis, and aortic valvular disease. Although isolated LBBB is a conduction abnormality found in some healthy adults, it has not been reported in pediatric population. We report a 2-year-old, healthy African American female who was incidentally discovered to have isolated LBBB that has persisted in a follow-up of 3 years. Hitesh Agrawal, Frank Zimmerman, and Zahra Naheed Copyright © 2014 Hitesh Agrawal et al. All rights reserved. Coronary Subclavian Steal Syndrome: An Unusual Cause of Angina in a Post-CABG Patient Tue, 29 Apr 2014 00:00:00 +0000 Coronary subclavian steal syndrome is a rare complication of coronary artery bypass grafting surgery (CABG) when a left internal mammary artery (LIMA) graft is utilized. This syndrome is characterized by retrograde flow from the LIMA to the left subclavian artery (SA) when a proximal left SA stenosis is present. We describe a unique case of an elderly male who underwent CABG 6 years ago who presented with prolonged chest pain, mildly elevated troponins, and unequal pulses in his arms. A CTA of the chest demonstrated a severely calcified occluded proximal left SA jeopardizing his LIMA graft. Subclavian angiography was performed with an attempt to revascularize the patient’s occluded left SA which was unsuccessful. We referred the patient for nuclear stress testing which demonstrated a moderate size area of anterior ischemia on imaging; the patient exercised to a fair exercise capacity of 7 METS with no chest pain and no ECG changes. Subsequent coronary angiography showed severe native three-vessel coronary artery disease with intermittent retrograde blood flow from the LIMA to the left SA distal to the occlusion, jeopardizing perfusion to the left anterior descending (LAD) coronary artery distribution. He declined further options for revascularization and was discharged with medical management. Usman Younus, Brandon Abbott, Deepika Narasimha, and Brian J. Page Copyright © 2014 Usman Younus et al. 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.