Case Reports in Cardiology The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. The Artery of Percheron Infarction after Coronary Angiography Tue, 26 Apr 2016 13:29:57 +0000 Coronary angiography is the golden choice for coronary artery disease evaluation and management. However, as with any invasive procedures, there is a risk of complications. We are reporting a case of 69-year-old male with past medical history of cardiac bypass surgery, CHF, hypertension, and hyperlipidemia who was admitted to the hospital to evaluate his chest pain. He had treadmill stress test that showed ischemic induced exercise. Patient underwent coronary angiography that showed proximal complete occlusion of the RCA with a patent graft. At the end of the procedure, the patient did not wake up and remained minimally responsive. An urgent brain MRI was ordered and showed infarctions consistent with an artery of Percheron infarction. Later, patient has improved slowly and was discharged home. We briefly here discuss this rare complication including the risk factor, clinical presentation, and the management. Haitham Mazek, Khaled Sherif, Jose Suarez, and Jason Wischmeyer Copyright © 2016 Haitham Mazek et al. All rights reserved. A Case of Arterial and Venous Tear during Single Lead Extraction Mon, 18 Apr 2016 09:55:54 +0000 Transcutaneous lead extraction can be associated with significant morbidity and mortality. The risk of causing concomitant arterial and venous injury is rare. We report a case of marginal artery rupture with coronary sinus rupture after a CS lead extraction. A 71-year-old male was admitted for extraction of a 6-year-old implantable cardioverter-defibrillator lead due to fracture from insulation break. During the lead extraction, blood pressure fell precipitously and echocardiographic findings were consistent with pericardial effusion. After unsuccessful pericardiocentesis, open chest sternotomy and evacuation of hematoma was performed. Subsequent surgical repair of several injuries was completed including the distal coronary sinus, a large degloving injury of posterior portion of the heart, and first obtuse marginal branch bleed. This case demonstrates that when performing transcutaneous lead extraction (TLE) with laser sheath, a degloving injury can cause arterial rupture with concomitant coronary sinus injury. A multidisciplinary team-based approach can ensure patient safety. Learning Objective. Implantable cardioverter-defibrillator leads will falter over time. With the advancement of new technology for extraction more frequent and serious complications will occur. Active fixation CS leads present unique challenges. In the presence of hemodynamic changes during extraction the occurrence of both an arterial and venous injury must be considered. Michael S. Green, Daniel Wu, Vishal Patel, and Rayhan Tariq Copyright © 2016 Michael S. Green et al. All rights reserved. Ventricular Septal Perforation after Biventricular Takotsubo Cardiomyopathy Successfully Repaired with an Amplatzer Device: First Report in the Literature Wed, 13 Apr 2016 14:20:39 +0000 A 79-year-old female was admitted with sudden onset dyspnea, mild oppressive chest pain, and severe anxiety disorder. Patient had history of hypertension, dyslipidemia, smoking, and chronic obstructive pulmonary disease. On admission blood pressure was 160/90 and heart rate was 130 bpm. Transthoracic echocardiography (TE) and contrast tomography showed a thin septum with an abnormal left and right ventricular contraction with an “apical ballooning” pattern and mild increase of cardiac enzymes. At the 4th day of admission, the patient presented symptoms and signs of congestive heart failure and developed cardiogenic shock. EKG showed an inversion of T waves in all precordial leads. In a new TE, a ventricular septal perforation (VSP) in the apical portion of the septum was seen. Coronary angiogram showed angiographically “normal” coronary arteries. With a diagnosis of VSP in takotsubo cardiomyopathy, a percutaneous procedure to repair the VSP was performed 11 days after admission. The VSP was closed with an Amplatzer device. TE performed 24 hours after showed significant improvement of ventricular function and good apposition of the Amplatzer device. Three days later she was discharged from the hospital. To our knowledge, this is the first reported case of a VSP in a TCM repaired percutaneously with an occluder device. Alfredo E. Rodríguez, Carlos Fernandez-Pereira, Juan Mieres, Diego Ascarrunz, Eduardo Gabe, Alfredo Matías Rodríguez-Granillo, Romina Frattini, and Pablo Stuzbach Copyright © 2016 Alfredo E. Rodríguez et al. All rights reserved. A Case of Isolated Celiac Artery Dissection Accompanied by Splenic Infarction Detected by Ultrasonography in the Emergency Department Mon, 11 Apr 2016 09:49:36 +0000 A 46-year-old male with a history of hypertension visited the emergency department (ED) by ambulance complaining of sudden pain in the left side of his back. Ultrasonography (USG) performed at ED revealed splenic infarction along with occlusion and dissection of the celiac and splenic arteries without abdominal artery dissection. Contrast enhanced computed tomography (CT) revealed the same result. Consequently, spontaneous isolated celiac artery dissection (SICAD) was diagnosed. Because his blood pressure was high (159/70 mmHg), antihypertensive medicine was administered (nicardipine and carvedilol). After his blood reached optimal levels (130/80 mmHg), symptoms disappeared. Follow-up USG and contrast enhanced CT performed 8 days and 4 months after onset revealed amelioration of splenic infarction and improvement of the narrowed artery. Here, we report a case of SICAD with splenic infarction presenting with severe left-sided back pain and discuss the relevance of USG in an emergency setting. Kazumasa Emori, Nobuhiro Takeuchi, and Junichi Soneda Copyright © 2016 Kazumasa Emori et al. All rights reserved. Torsade de Pointes Triggered by Early Ventricular Escape Beats in a Patient with Complete Atrioventricular Block Wed, 06 Apr 2016 09:33:56 +0000 Torsade de pointes is an uncommon and malignant form of polymorphic ventricular tachycardia and associated with a prolonged QT interval, which may be congenital or acquired. Complete atrioventricular block may cause QT interval prolongation and torsade de pointes. In this paper, we present a case with complete atrioventricular block complicated with frequent episodes of torsade de pointes triggered by early premature ventricular contractions despite normal QT intervals. Erkan Yildirim, Baris Bugan, Suat Gormel, Uygar Cagdas Yuksel, Murat Celik, Yalcin Gokoglan, Serdar Firtina, Sinan Iscen, Emre Yalcinkaya, Ugur Kucuk, and Hasan Kutsi Kabul Copyright © 2016 Erkan Yildirim et al. All rights reserved. Tirofiban-Induced Thrombocytopenia Occurring with Crohn’s Disease Wed, 06 Apr 2016 08:10:17 +0000 A 69-year-old man, with severe refractory Crohn’s disease, presented with acute coronary syndrome that required angioplasty. He developed severe tirofiban-induced thrombocytopenia (TIT) heralded by type I allergic reaction that required steroids and a combination of antihistamine H1 and antihistamine H2 for symptomatic management. The thrombocytopenia spontaneously resolved uneventfully in 48 hours thereafter. This case report suggests a possible association between TIT and inflammatory bowel disease. Therefore, strict monitoring of the platelet count is required in patients who develop allergic reactions to tirofiban. Toni Ibrahim, Fady El Karak, Assem Araji, and Elie El Rassy Copyright © 2016 Toni Ibrahim et al. All rights reserved. Eosinophilic Myocarditis due to Toxocariasis: Not a Rare Cause Thu, 31 Mar 2016 11:32:10 +0000 Myocarditis is a clinically important disease because of the high mortality. From the perspective of treatment strategy, eosinophilic myocarditis should be distinguished from other types of myocarditis. Toxocariasis, caused by Toxocara canis or Toxocara cati, is known as a cause of eosinophilic myocarditis but is considered rare. As it is an unpopular disease, eosinophilic myocarditis due to toxocariasis may be underdiagnosed. We experienced two cases of eosinophilic myocarditis due to toxocariasis from different geographical areas in quick succession between 2013 and 2014. Case 1 is 32-year-old man. Case 2 is 66-year-old woman. In both cases, diagnosis was done by endomyocardial biopsy and IgG-ELISA against Toxocara excretory-secretory antigen. Only a corticosteroid was used in Case  1, whereas a corticosteroid and albendazole were used in Case  2 as induction therapy. Both patients recovered. Albendazole was also used in Case  1 to prevent recurrence after induction therapy. Eosinophilic myocarditis by toxocariasis may in actuality not be a rare disease, and corticosteroid is an effective drug as induction therapy even before use of albendazole. Shunichi Shibazaki, Shunsuke Eguchi, Takashi Endo, Tadamasa Wakabayashi, Makoto Araki, Yoshiaki Gu, Taku Imai, Kouji Asano, and Norihide Taniuchi Copyright © 2016 Shunichi Shibazaki et al. All rights reserved. Solid Right Ventricular Compression by Intraventricular Septum-Hematoma Induced after Percutaneous Coronary Intervention Mon, 28 Mar 2016 07:17:53 +0000 Intraventricular septum-hematoma is a rare complication following percutaneous coronary intervention (PCI). This complication may represent a challenge for accurate diagnosis and treatment. This case report is about a 60-year-old male patient being admitted with an acute coronary syndrome. Despite successful PCI with drug eluting stent implantation into the right coronary artery (RCA) the patient complained about recurrent angina pectoris according to Canadian Cardiovascular Society (CCS) class IV. Cardiac magnetic resonance imaging and transthoracic echocardiography revealed a massive  cm sized end-diastolic septum-hematoma, which compromised right ventricular cavity. Emergent recoronary angiography ruled out further contrast extravasation from the RCA. Conservative treatment was intended after discussion in the “heart-team.” The patient completely recovered with nearly complete resolution of the hematoma after 6 months. Ibrahim El-Battrawy, Ibrahim Akin, Benedikt Münz, David Manuel Leistner, Michael Behnes, Thomas Henzler, Holger Haubenreisser, Theano Papavassiliu, Martin Borggrefe, and Ralf Lehmann Copyright © 2016 Ibrahim El-Battrawy et al. All rights reserved. Synthetic Marijuana Induced Acute Nonischemic Left Ventricular Dysfunction Mon, 28 Mar 2016 06:40:38 +0000 Synthetic marijuana is an uptrending designer drug currently widely spread in the US. We report a case of acute deterioration of nonischemic left ventricular dysfunction after exposure to synthetic marijuana. This case illustrates the importance of history taking in cardiac patients and identifies a negative cardiovascular effect of synthetic marijuana known as K2, not yet well detected by urine toxicology screening tools. Moustafa Elsheshtawy, Priatharsini Sriganesh, Vasudev Virparia, Falgun Patel, and Ashok Khanna Copyright © 2016 Moustafa Elsheshtawy et al. All rights reserved. Treatment of Iatrogenic Aortocoronary Arteriovenous Fistula with Coronary Covered Stent Sun, 27 Mar 2016 14:00:15 +0000 An 83-year-old man, who underwent coronary artery bypass operation of left internal mammary artery (LIMA) to left anterior descending (LAD) artery, with sequential saphenous vein to the first and second obtuse marginal (OM) branches of circumflex artery 5 years ago and coronary artery stent implantation to right coronary artery 2 months ago, was admitted to the hospital with syncope and chest pain. Aortosaphenous graft selective angiography revealed that first sequential side to side ligation was inadvertently anastomosed to left posterolateral coronary vein with resultant flow into the coronary sinus and distal end to side sequential anastomosis to OM 2 coronary artery which was filling very weakly. In order to close this iatrogenic coronary arteriovenous fistula and to supply saphenous vein flow to OM artery, we decided to implant a graft covered stent into the saphenous vein at the same session. Ender Ornek, Harun Kundi, Emrullah Kiziltunc, and Mustafa Cetin Copyright © 2016 Ender Ornek et al. All rights reserved. 18F-FDG-PET Scanning Confirmed Infected Intracardiac Device-Leads with Abiotrophia defectiva Sun, 27 Mar 2016 11:48:47 +0000 Abiotrophia species are relatively slow growing pathogens, which may be present as commensal flora. However, invasive infections are frequently reported, like endocarditis, septic arthritis, osteomyelitis, and many other types of infection. In this case report we describe a 65-year-old male patient with an intracardiac device- (ICD-) lead infection caused by Abiotrophia defectiva. Diagnosis was confirmed by 18F-FDG-PET scanning. This is remarkable, since Abiotrophia defectiva is a slow growing pathogen causing low-grade infections. This case demonstrates that although infection of ICD-leads cannot be excluded in case of 18F-FDG-PET-negative findings, positive findings are highly suggestive for infection. Sonja van Roeden, Hans Hartog, Vivian Bongers, Steven Thijsen, and Sanjay Sankatsing Copyright © 2016 Sonja van Roeden et al. All rights reserved. Angiosarcoma of the Right Atrium with Extension to SVC and IVC Presenting with Complete Heart Block and Significant Pericardial Effusion Sun, 27 Mar 2016 08:58:29 +0000 Primary cardiac neoplasms are particularly unusual. Angiosarcoma is the most frequently seen histological subtype and is described by its infiltrating and damaging nature. Inappropriately, primary cardiac angiosarcoma is often missed as a preliminary diagnosis because of its scarcity. We present a 29-year-old previously healthy man with complete heart block and pericardial effusion who was finally diagnosed with angiosarcoma of the right atrium with extension to SVC and IVC. Hossein Vakili, Isa Khaheshi, Mehdi Memaryan, and Shooka Esmaeeli Copyright © 2016 Hossein Vakili et al. All rights reserved. Spontaneous, Postpartum Coronary Artery Dissection and Cardiogenic Shock with Extracorporeal Membrane Oxygenation Assisted Recovery in a 30-Year-Old Patient Thu, 24 Mar 2016 13:10:02 +0000 Coronary artery dissection is an infrequent cause of acute coronary syndrome in the general population. There is, however, a greater incidence of spontaneous coronary artery dissection (SCAD) in young women, especially in the peripartum period. However, the majority of cases have favorable outcomes with medical management or percutaneous coronary intervention; coronary artery bypass grafting (CABG) and transplantation are utilized in severe cases. This case is a one of a 30-year-old postpartum female with multivessel SCAD requiring CABG with subsequent biventricular failure and inability to wean from bypass. We believe this is the first reported case in which venoarterial extracorporeal membrane oxygenation (VA-ECMO) was used in the management of biventricular heart failure in a postpartum patient with SCAD. Kathleen E. Knapp, Ricardo A. Weis, Efrain I. Cubillo, Alyssa B. Chapital, and Harish Ramakrishna Copyright © 2016 Kathleen E. Knapp et al. All rights reserved. Carcinoid Syndrome-Induced Ventricular Tachycardia Mon, 21 Mar 2016 14:27:17 +0000 Introduction. Carcinoid tumors are rare neuroendocrine malignancies that secrete multiple bioactive substances. These bioactive substances are responsible for the carcinoid syndrome characterized by diarrhea, flushing, syncope, and right-sided valvular heart disease. Previous case reports have described carcinoid syndrome associated with coronary vasospasm and the well-characterized carcinoid heart disease. Case. Our patient is a 73-year-old female with complex past medical history most notable for metastatic carcinoid tumors diagnosed in 2013-05. She initially presented in 2014-09 with syncope and dizziness associated with sinus pause on an event monitor. She received a pacemaker given normal left ventricular function and was discharged. However, she was readmitted with similar symptoms corresponding to multiple episodes of ventricular tachycardia. She was started on high-dose beta blockade and has had no recurrence of arrhythmia over a follow-up period of 12 months. Conclusion. We hypothesize that the patient’s ventricular tachycardia was mediated by the multiple bioactive substances secreted by her carcinoid tumors. Her carcinoid tumor biomarkers were elevated and other explanations for arrhythmia were investigated and ruled out. To our knowledge, this is the first case of ventricular tachycardia mediated by carcinoid syndrome and suppressed by beta-blocker. Further investigation into this relationship is needed. Austin B. Rupp, Abdulmohsin Ahmadjee, Jack H. Morshedzadeh, and Ravi Ranjan Copyright © 2016 Austin B. Rupp et al. All rights reserved. New Stenting Technique to Achieve Favorable Jailing Configuration on Side Branch Ostium: Bent Stent Technique Mon, 21 Mar 2016 09:56:27 +0000 According to data from stent-enhanced three-dimensional optical coherence tomography, incomplete stent apposition after side branch dilation in coronary bifurcation stenting can be reduced by the free carina type (no links bridged from a carina) and by distal cell rewiring. This is the first report to describe a bent stent technique that was devised to achieve the free carina type (no links bridged from a carina), as a favorable jailing configuration. Fumiaki Nakao Copyright © 2016 Fumiaki Nakao. All rights reserved. Reactive Pulmonary Capillary Hemangiomatosis and Pulmonary Veno-Occlusive Disease in a Patient with Repaired Scimitar Syndrome Wed, 16 Mar 2016 13:10:35 +0000 Pulmonary capillary hemangiomatosis (PCH) is a rare histological substrate within the spectrum of pulmonary arterial hypertension that possibly represents an unusual manifestation of pulmonary veno-occlusive disease (PVOD). One of the histological hallmarks of PCH is the proliferation of pulmonary capillaries in the alveolar septa that infiltrate adjacent structures such as bronchioles, vessels, and visceral pleura. The hyperplastic process involving the smallest vessels of the pulmonary vascular bed might reflect uncontrolled angiogenesis, but whether this vascular proliferation is idiopathic or, conversely, a reactive process remains to be elucidated. Here we discuss the pathogenesis of PCH exemplified by the first reported case of a young patient with repaired scimitar syndrome that developed unilateral PCH. Eva Güttinger, Bart Vrugt, Rudolf Speich, Silvia Ulrich, Fabienne Schwitz, Mattia Arrigo, and Lars C. Huber Copyright © 2016 Eva Güttinger et al. All rights reserved. Treatment of a Coronary Bifurcation Lesion Using One Dedicated Sirolimus Eluting Bifurcation Stent in Combination with a Bioresorbable Vascular Scaffold: A Novel Option for Coronary Bifurcation Approach Tue, 15 Mar 2016 13:25:21 +0000 We present a complex bifurcation lesion treated with a new two-stent strategy combining a dedicated sirolimus eluting bifurcation stent, BiOSS Lim, with a bioresorbable vascular scaffold (BVS). The advantages of this strategy compared with the conventional two-stent approach are as follows: the dedicated stent protects the carina from being damaged, the large cell at the middle zone of the BiOSS Lim gives possibility to enter easily into the side branch (SB) with any standard size conventional device, and, finally, the additional use of BVS in the SB could have a long-term benefit in terms of restenosis. Javier Benezet, Antonio Agarrado, and Jesús Oneto Copyright © 2016 Javier Benezet et al. All rights reserved. Neoatherosclerosis in Very Late Stenosis of Bare Metal Stent by Optical Coherence Tomography Sun, 13 Mar 2016 12:20:24 +0000 Bare metal stents (BMS) continue to be widely used in patients with coronary artery disease undergoing percutaneous revascularization. Progressive luminal renarrowing has been reported late after BMS implantation resulting in a significant rate of stent failure events. We present a case of very late BMS failure due to in-stent restenosis where optical coherence tomography (OCT) was used to demonstrate neoatherosclerosis as the underlying mechanism. We provide a brief review of neoatherosclerosis and showcase salient features on OCT evaluation. Samer Mowakeaa, Aline Iskandar, and Nikolaos Kakouros Copyright © 2016 Samer Mowakeaa et al. All rights reserved. Left Main Coronary Artery Hypoplasia in Elderly Mon, 07 Mar 2016 12:46:29 +0000 Congenital anomalies of the coronary artery causing coronary occlusive disease may be of many different types. A 67-year-old woman with no coronary risk factors was referred for coronary angiography with few months’ history of angina. The patient underwent coronary angiography due to ischemic cardiac symptoms with nondiagnostic exercising test. In coronary angiography, the left main coronary artery was arising from normal anatomical position; however, left anterior descending artery and circumflex artery were hypoplastic. The treatment of patient was discussed in cardiology-cardiovascular surgery council and coronary surgery was found inappropriate due to the hypoplasia of the left coronary system entirely. Selma Kenar Tiryakioglu, Hakan Ozkan, Hakan Bahadir, and Osman Tiryakioglu Copyright © 2016 Selma Kenar Tiryakioglu et al. All rights reserved. Chest Pain: The Need to Consider Less Frequent Diagnosis Mon, 29 Feb 2016 09:30:18 +0000 Chest pain is one of the most frequent patient’s complaints. The commonest underlying causes are well known, but, sometimes, in some clinical scenarios, it is necessary to consider other diagnoses. We report a case of a 68-year-old Caucasian male, chronically hypertensive, who complained of recurrent episodes of chest pain and fever with elevated acute phase reactants. The first investigation was negative for some of the most likely diagnosis and he quickly improved with anti-inflammatory drugs. Over a few months, his symptoms continued to recur periodically, his hypertension was aggravated, and he developed headaches and lower limbs claudication. After a temporal artery biopsy that was negative for vasculitis, he underwent a positron emission tomography suggestive of Takayasu Arteritis. Takayasu Arteritis is a rare chronic granulomatous vasculitis of the aorta and its first-order branches affecting mostly females up to 50 years old. Chest pain is experienced by >40% of the patients and results from the inflammation of the aorta, pulmonary artery, or coronaries. Pedro Magalhães, Anabela Morais, Sofia Carvalho, Joana Cunha, Ana R. Lima, J. Ilídio Moreira, and Trigo Faria Copyright © 2016 Pedro Magalhães et al. All rights reserved. A Rare Case of Renal Infarct due to Noncompaction Cardiomyopathy: A Case Report and Literature Review Sun, 28 Feb 2016 16:25:07 +0000 Left ventricular noncompaction cardiomyopathy is a rare myocardial disorder which results from failure of left ventricle to compact in embryogenesis. We present a case of a 53-year-old female who came because of abdominal pain and was found to have renal infarct secondary to noncompaction cardiomyopathy. Karan Wats, On Chen, Nupur Nippun Uppal, Syeda Atiqa Batul, Norbert Moskovits, Vijay Shetty, and Jacob Shani Copyright © 2016 Karan Wats et al. All rights reserved. Symptomatic Trifascicular Block in Steinert’s Disease: Is It Too Soon for a Pacemaker? Sun, 28 Feb 2016 16:24:25 +0000 We report a case of a 62-year-old male with Steinert’s disease who presented with progressive intermittent episodes of lightheadedness five years after he was diagnosed with the disease. On evaluation, he developed a new onset trifascicular block (first degree atrioventricular block, new onset right bundle branch block, and left anterior fascicular block). A dual chamber pacemaker was inserted and lightheadedness improved significantly. Glenmore Lasam, Roberto Roberti, Gina LaCapra, and Roberto Ramirez Copyright © 2016 Glenmore Lasam et al. All rights reserved. Takotsubo Syndrome: A Pathway through the Pituitary Disease Thu, 25 Feb 2016 11:01:16 +0000 Takotsubo cardiomyopathy (TTC) is characterized by reversible left ventricular apical and/or midventricular hypokinesia with unknown etiology. The clinical presentation is similar to acute myocardial infarction in the absence of significant obstructive coronary artery disease. Various predisposing factors have been related to TTC, such as acute neurological illnesses, endocrine diseases, pain, and emotional stress. We present the first description of an association between TTC cardiomyopathy and panhypopituitarism. This case reinforces the connection between the hormonal and cardiovascular systems. Furthermore, it supports the importance of a comprehensive and integrated medical history in the approach of a patient with cardiac disease, towards clinical decision-making. Rui Plácido, Ana Filipa Martins, Susana Robalo Martins, Sónia do Vale, Ana G. Almeida, Fausto Pinto, and João Martin Martins Copyright © 2016 Rui Plácido et al. All rights reserved. Coronary Thrombosis without Dissection following Blunt Trauma Tue, 23 Feb 2016 09:38:03 +0000 Blunt trauma to the chest resulting in coronary thrombosis and ST elevation myocardial infarction (STEMI) is a rare but well-described occurrence in adults. Angiography in such cases has generally disclosed complete epicardial coronary occlusion with thrombus, indistinguishable from the findings commonly found in spontaneous plaque rupture due to atherosclerotic disease. In all previously reported cases in which coronary interrogation with intravascular ultrasound (IVUS) was performed in association with acute revascularization, coronary artery dissection was implicated as the etiology of coronary thrombosis. We present the first case report of blunt trauma-associated coronary thrombosis without underlying atherosclerosis or coronary dissection, as documented by IVUS imaging. Archana Sinha, Michael Sibel, Peter Thomas, Francis Burt, James Cipolla, Peter Puleo, and Keith Baker Copyright © 2016 Archana Sinha et al. All rights reserved. Pulmonary Hypertension Secondary to Partial Anomalous Pulmonary Venous Return in an Elderly Tue, 23 Feb 2016 08:06:35 +0000 Background. Partial anomalous pulmonary venous return (PAPVR) is an uncommon congenital abnormality, which may present in the adult population. It is often associated with sinus venosus defect (SVD). The diagnosis and therapy for this condition may be challenging. Case Presentation. We describe a case of an elderly woman who presented with NYHA Class IV dyspnea and was suspected to have symptomatic pulmonary hypertension. She was later found to have anomalous right upper pulmonary vein return to the superior vena cava and associated SVD with bidirectional shunting. Therapeutic options were discussed and medical management alone with aggressive diuresis and sildenafil was adopted. Follow-up visits revealed success in the planned medical therapy. Conclusions. PAPVR is a rare congenital condition that may present during late adulthood. The initial predominant left-to-right shunting associated with this anomaly may go undetected for years with the gradual development of pulmonary hypertension and right heart failure due to right heart volume overload. Awareness of the condition is important, as therapy is time-sensitive with early detection potentially leading to surgical therapy as a viable option. Stefan Koester, Justin Z. Lee, and Kwan S. Lee Copyright © 2016 Stefan Koester et al. All rights reserved. Amphetamine Abuse Related Acute Myocardial Infarction Sun, 21 Feb 2016 16:35:54 +0000 Amphetamine abuse is a global problem. The cardiotoxic manifestations like acute myocardial infarction (AMI), heart failure, or arrhythmia related to misuse of amphetamine and its synthetic derivatives have been documented but are rather rare. Amphetamine-related AMI is even rarer. We report two cases of men who came to emergency department (ED) with chest pain, palpitation, or seizure and were subsequently found to have myocardial infarction associated with the use of amphetamines. It is crucial that, with increase in amphetamine abuse, clinicians are aware of this potentially dire complication. Patients with low to intermediate risk for coronary artery disease with atypical presentation may benefit from obtaining detailed substance abuse history and urine drug screen if deemed necessary. Archana Sinha, O’Dene Lewis, Rajan Kumar, Sri Lakshmi Hyndavi Yeruva, and Bryan H. Curry Copyright © 2016 Archana Sinha et al. All rights reserved. Spontaneous Coronary Dissection: “Live Flash” Optical Coherence Tomography Guided Angioplasty Wed, 17 Feb 2016 11:37:20 +0000 Optical Coherence tomography (OCT) is a light-based imaging modality which shows tremendous potential in the setting of coronary imaging. Spontaneous coronary artery dissection (SCAD) is an infrequent cause of acute coronary syndrome (ACS). The diagnosis of SCAD is made mainly with invasive coronary angiography, although adjunctive imaging modalities such as computed tomography angiography, IVUS, and OCT may increase the diagnostic yield. The authors describe a clinical case of a young woman admitted with the diagnosis of ACS. The ACS was caused by SCAD detected in the coronary angiography and the angioplasty was guided by OCT. OCT use in the setting of SCAD has been already described and the true innovation in this case was this unique use of OCT. The guidance of angioplasty with live and short images was very useful as it allowed clearly identifying the position of the guidewires at any given moment without the use of prohibitive amounts of contrast. Angela Pimenta Bento, Renato Gil dos Santos Pinto Fernandes, David Cintra Henriques Silva Neves, Lino Manuel Ribeiro Patrício, and José Eduardo Chambel de Aguiar Copyright © 2016 Angela Pimenta Bento et al. All rights reserved. Staphylococcus aureus Endocarditis with Multivalvular Involvement Secondary to an Atrial Septal Defect Tue, 16 Feb 2016 16:23:44 +0000 Infective endocarditis is usually diagnosed using modified Duke’s criteria. Our patient had a subacute presentation and a low suspicion for endocarditis during admission, unfortunately leading to her death. Despite advances in diagnostic and therapeutic measures including antibiotic therapy and surgical techniques, morbidity and mortality with staphylococcal infective endocarditis remain high. Hence, we stress the significance of having a low threshold for TEE in patients with multisystem involvement due to Staphylococcus aureus that have evidence of persistent infection despite antibiotic treatment, even if the suspicion for endocarditis is low based on Duke’s criteria. TEE substantially improves the sensitivity of diagnosis but may not be readily available in many medical centers. Presence of an ASD has been noted to have increased the risk of left sided endocarditis even with conditions that predispose to right sided endocarditis, particularly in patients with hemodialysis and diabetes as morbid risk factors. Vistasp Jimmy Daruwalla, Jahnavi Sagi, Hassan Tahir, and Srikanth Penumetsa Copyright © 2016 Vistasp Jimmy Daruwalla et al. All rights reserved. Tender Endothelium Syndrome: Combination of Hypotension, Bradycardia, Contrast Induced Chest Pain, and Microvascular Angina Sun, 14 Feb 2016 08:04:38 +0000 Hypotension, bradycardia, and contrast induced chest pain are potential complications of cardiac catheterization and coronary angiography. Catheter-induced coronary spasm has been occasionally demonstrated, but its relationship to spontaneous coronary spasm is unclear. We describe a 64-year-old female who underwent coronary artery bypass surgery in 1998 on the basis of an angiographic diagnosis of severe left main disease, who recently presented with increasingly frequent typical angina. Repeat coronary angiography was immediately complicated by severe chest pain, hypotension, and bradycardia but demonstrated only mild disease of the left main artery and entire coronary tree with complete occlusion of her prior grafts. This reaction was almost identical to that observed during her original coronary angiogram. We now believe her original angiogram was complicated by severe catheter-induced left main spasm, with the accompanying contrast reaction attributed to left main disease, and the occlusion of coronary grafts explained by the absence of significant left main disease. The combination of these symptoms has not been documented in the literature. In this instance, these manifestations erroneously led to coronary bypass surgery. It is unknown whether routine, systematic injection of intracoronary nitroglycerin prior to angiography might blunt the severity of such reactions. Shivesh Goberdhan, Soon Kwang Chiew, and Jaffer Syed Copyright © 2016 Shivesh Goberdhan et al. All rights reserved. Physiologic Functional Evaluation of Left Internal Mammary Artery Graft to Left Anterior Descending Coronary Artery Steal due to Unligated First Thoracic Branch in a Case of Refractory Angina Sun, 14 Feb 2016 06:11:56 +0000 Unligated side branches of the left internal mammary artery (LIMA) have been described in the literature as a cause of coronary steal resulting in angina. Despite a number of studies reporting successful side branch embolization to relieve symptoms, this phenomenon remains controversial. Hemodynamic evidence of coronary steal using angiographic and intravascular Doppler techniques has been supported by some and rejected by others. In this case study using an intracoronary Doppler wire with adenosine, we demonstrate that a trial occlusion of the LIMA thoracic side branch with selective balloon inflation can confirm physiologic significant steal and whether coil embolization of the side branch is indicated. Fadi J. Sawaya, Henry Liberman, and Chandan Devireddy Copyright © 2016 Fadi J. Sawaya et al. All rights reserved.