Case Reports in Cardiology The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Successful Stent Graft Insertion for Endovascular Aneurysm Repair and Closure of Patent Ductus Arteriosus in an Adult Patient Thu, 29 Jan 2015 14:07:43 +0000 Patent ductus arteriosus (PDA) is sometimes undetected until adulthood, and surgical closure of a PDA is dangerous because of the calcification of the ductus. Percutaneous approaches such as coil embolization and use of a PDA occluder are less invasive; however, these devices are not suitable for PDA with thoracic aortic aneurysm (TAA). We present the case of a 72-year-old female patient who underwent successful stent graft insertions for PDA with TAA. Toshiki Kuno, Koji Tsutsumi, and Yohei Numasawa Copyright © 2015 Toshiki Kuno et al. All rights reserved. Aspiration Thrombectomy in a Patient with Suprarenal Inferior Vena Cava Thrombosis Tue, 27 Jan 2015 14:09:06 +0000 DVT has rarely been observed in the inferior vena cava (IVC). Pulmonary embolism (PE), which can be life-threatening, often occurred in patients with IVC thrombosis. Therefore, an IVC filter is frequently used in those patients for the prevention of PE. A case of successful endovascular treatment of an IVC thrombus in a patient with relative contraindications to implantation of an IVC filter is presented. This case report shows that aspiration of thrombi caught in the removable IVC filter may be an alternative to surgery in high-risk patients with catheter-related suprarenal inferior vena cava thrombosis. Hideyuki Kishima, Masashi Fukunaga, Kunihiko Nishian, Ten Saita, Tetsuo Horimatsu, Masataka Sugahara, Takanao Mine, and Tohru Masuyama Copyright © 2015 Hideyuki Kishima et al. All rights reserved. Radiofrequency Ablation of Typical Atrial Flutter via Right Jugular Vein due to Bilateral Obstructed Iliac Veins in a Patient with Dilated Cardiomyopathy Tue, 27 Jan 2015 13:42:21 +0000 Ablation of cavotricuspid isthmus (CTI) is the gold standard method in the treatment of isthmus dependent atrial flutter (AFl). Venous access was obtained usually via right or left femoral veins. In rare cases of obstruction of iliofemoral veins, ablation of CTI can be performed only through the superior approach. We present a 74-year-old woman of typical AFl and dilated cardiomyopathy that was ablated through the right jugular vein because of obstruction of the left and the right iliac veins. This is the first report of successful ablation of CTI in a patient with dilated cardiomyopathy via superior approach. Tolga Aksu, Tumer Erdem Guler, Sukriye Ebru Golcuk, Kazım Serhan Ozcan, and Ismail Erden Copyright © 2015 Tolga Aksu et al. All rights reserved. Impella Induced Massive Hemolysis: Reemphasizing Echocardiographic Guidance for Correct Placement Tue, 27 Jan 2015 09:43:12 +0000 The Impella LP 2.5 (Abiomed, Danvers, MA) has been a tool of use for high risk coronary procedures and for cardiogenic shock. As with any invasive or intracardiac device, improper placement can result in disastrous complications. Hemolytic anemia secondary to Impella implantation is one of the documented complications. However, cases of severe hemolytic anemia are rare in the literature. Proven imaging modalities like ultrasound need to be used to guide proper placement. We present a case of device induced severe hemolysis due to Impella insertion and the need to use ultrasound guidance to avoid such an unnecessary complication. Shaun Cardozo, Tasneem Ahmed, and Kevin Belgrave Copyright © 2015 Shaun Cardozo et al. All rights reserved. Cardiac Tamponade following Mitral Valve Replacement for Active Infective Endocarditis with Ring Abscess Thu, 22 Jan 2015 08:55:22 +0000 Periannular extension and abscess formation are rare but deadly complications of infective endocarditis (IE) with high mortality. Multimodality cardiac imaging, invasive and noninvasive, is needed to accurately define the extent of the disease. Debridement, reconstruction, and valve replacement, often performed in an emergent setting, remain the treatment of choice. Here we present a case of severe IE in a 29-year-old intravenous drug user who after undergoing debridement of the abscess, annular reconstruction, and mitral valve replacement (MVR) presented with recurrence of shortness of breath and pedal edema. Transthoracic echocardiogram (TTE) showed a  cm cavity, posterior to and communicating with the left ventricle through a 3 cm wide fistulous opening, in proximity of the reconstructed mitral annulus. The patient underwent a redo MVR with patch closure of the fistulous opening, with good clinical outcome. This case highlights the classic TTE findings and the necessity for close follow-up in the perioperative period in patients undergoing surgery for periannular extension of infection. A cardiac magnetic resonance imaging can be considered, preoperatively, in such cases to identify the extent of myocardial involvement and surgical planning. R. Ranjan and T. Lawrence Copyright © 2015 R. Ranjan and T. Lawrence. All rights reserved. Timing for Pacing after Acquired Conduction Disease in the Setting of Endocarditis Tue, 06 Jan 2015 06:22:14 +0000 A 53-year-old gentleman with a history of a mechanical aortic valve presented to the emergency department complaining of a sudden right-sided abdominal pain. He was found to have atrioventricular dissociation on his initial electrocardiogram and his blood cultures grew Streptococcus viridans. The suspicion for endocarditis with periaortic abscess was high so a transthoracic echocardiogram was performed and showed a mass in the left ventricular outflow tract. For better visualization, a transesophageal echocardiogram was recommended and revealed a bileaflet mechanical aortic valve with perivalvular abscess and valvular vegetation as well as severe eccentric paravalvular aortic regurgitation. After sterilization, the patient underwent a successful surgery. Postoperatively, he remained in complete heart block and a permanent pacemaker placement was performed after complete sterilization. He tolerated the procedure well and was discharged home in a stable condition. Perivalvular abscess is one of the most common cardiac complications of infective endocarditis and is associated with an increased risk of mortality. It is imperative to have appropriate treatment guidelines established. However, because of the relative nature of the disease process and the acuity at which intervention needs to be done, a true assessment of the duration of antibiotic therapy prior to surgical intervention, timing of pacemaker placement, and the type of pacemaker is controversial. Daniel Brancheau, George Degheim, and Christian Machado Copyright © 2015 Daniel Brancheau et al. All rights reserved. Entanglement due to Delayed Removal of a Buddy Wire Mon, 29 Dec 2014 11:25:42 +0000 A buddy wire is often used to aid in the delivery of balloons and stents when negotiating tortuous or calcified vessels. We present a planned two-stent mini-crush intervention complicated by entanglement of the buddy wire with the second stent and subsequent distortion of the stent within the guiding catheter. Based on this case, we suggest removing the buddy wire immediately after successful positioning of the first stent, because entrapment with a second stent is possible and may lead to challenging situations in a simultaneous two-stent strategy. Marc Vorpahl, Melchior Seyfarth, and Klaus Tiroch Copyright © 2014 Marc Vorpahl et al. All rights reserved. The Drop That Spilled the Cup: Acute Myocardial Infarction in a Young Woman with Underlying Thrombophilic Polymorphisms and Oral Contraceptive Use Tue, 23 Dec 2014 00:10:09 +0000 We present the case of a 28-year-old woman who was admitted to our cardiology unit for acute coronary syndrome. Her history was notable for cardiovascular disease familiarity, active smoking, and oral contraceptive use. On further analysis, she was noted to have thrombophilic polymorphisms involving the plasminogen activator inhibitor (PAI), angiotensin-converting enzyme (ACE), and methylenetetrahydrofolate reductase (MTHFR) genes. We discuss the implications that these cofactors may have had in the genesis of the disease. Nunzio Russo, Enrico Franzì, Gianfranco Capilli, Anella Antonietta Patané, Silvia Paola Russo, and Rosario Evola Copyright © 2014 Nunzio Russo et al. All rights reserved. Octreotide for the Management of Gastrointestinal Bleeding in a Patient with a HeartWare Left Ventricular Assist Device Thu, 18 Dec 2014 00:10:45 +0000 HeartWare is a third generation left ventricular assist device (LVAD), widely used for the management of advanced heart failure patients. These devices are frequently associated with a significant risk of gastrointestinal (GI) bleeding. The data for the management of patients with LVAD presenting with GI bleeding is limited. We describe a 56-year-old lady, recipient of a HeartWare device, who experienced recurrent GI bleeding and was successfully managed with subcutaneous (SC) formulations of octreotide. Geetanjali Dang, Ryan Grayburn, Geoffrey Lamb, Adrian Umpierrez De Reguero, and Nunzio Gaglianello Copyright © 2014 Geetanjali Dang et al. All rights reserved. Hepatocellular Carcinoma to the Right Ventricle Sun, 30 Nov 2014 00:10:15 +0000 Hepatocellular carcinoma (HCC) is the sixth most prevalent cancer in the world, but metastatic disease to the heart is rare. We present a case of a 63-year-old man with history of hepatitis C and cirrhosis, which had progressed to HCC. The patient had undergone two prior liver transplantations. He presented to the hospital complaining of worsening lower extremity edema. His exam was also pertinent for jugular venous distension, a 3/6 crescendo-decrescendo murmur, and hepatosplenomegaly. A transthoracic echocardiogram showed a large irregular lobulated mass in the apex of the right ventricle with a mobile pedunculated component. An MRI of the heart revealed a 4.4 × 3.4 × 4.0 cm mass within the right ventricular apex, which was subsequently biopsied and found to be moderately differentiated HCC with myocardial fragments. The patient opted out of any further therapy, or intervention, and was enrolled in hospice care. George R. Marzouka, Apurva Badheka, Alexis P. Rodriguez, and Sandra V. Chaparro Copyright © 2014 George R. Marzouka et al. All rights reserved. A Case of Noncompaction at All Segments of Both Right and Left Ventricles Wed, 26 Nov 2014 11:44:45 +0000 Background. Noncompaction/hypertrabeculation left ventricle (NCM/HVM) is most commonly reported in one or more segments of left ventricle and sometimes both ventricles. In this case, we present noncompaction of all segments of right and left ventricle, in a young man with mental retardation. Case Presentation. A 19-year-old male was referred to us with sudden dyspnea at rest and chest discomfort. He was a known case of mental retardation. He was born full term with birth weight = 1250 grams. On physical examination. A systolic murmur (II/VI) at left sternal border was heard. ECG showed increased voltage in precordial lead and deep ST segment depression. Chest X-ray (CXR) was within normal limits. Transthoracic echocardiography showed situs solitus, D loop, normal connection of great vessels, noncompaction LV at all segments (noncompaction/compaction = 2.5/0.5) with moderate systolic dysfunction (LVEF = 40%), diastolic dysfunction grade II, normal RV size with mild systolic dysfunction and hypertrabeculation, mild tricuspid regurgitation (TR), and normal pulmonary artery systolic pressure. After injection of agitated saline some bubbles were passed from right to left through patent foramen oval (PFO). Conclusions. Extensive sinusoid formation and trabeculation of RV and nearby all LV segments and its association with mental retardation suggest presence of strong genetic background. Ali Pourmoghaddas, Reihaneh Zavar, and Mohaddeseh Behjati Copyright © 2014 Ali Pourmoghaddas et al. All rights reserved. Cheating the CHA2DS2-VASc Score: Thromboembolism in Apical Hypertrophic Cardiomyopathy Thu, 20 Nov 2014 11:34:03 +0000 Atrial fibrillation increases the risk of systemic thromboembolism in general and stroke in particular. Not all patients who develop atrial fibrillation are at significantly heightened risk of thromboembolic complications, however, with the development of risk scoring systems aiding clinicians in determining whether formal anticoagulation is mandated. The most commonly used contemporary scoring systems—CHADS2 and CHA2DS2-VASc—provide a reliable means of assessing stroke risk, but certain cardiac conditions are associated with an increased incidence of thromboembolism without impacting on these risk scores. Hypertrophic cardiomyopathy, with its apical variant, is such a condition. We present a case of a patient with apical hypertrophic cardiomyopathy and atrial fibrillation who suffered dire thromboembolic consequences despite a reassuringly low CHA2DS2-VASc score and suggest that this scoring system is modified to incorporate the thromboembolic risk inherent to certain cardiomyopathies irrespective of impairment of left ventricular systolic dysfunction or clinical heart failure. Robin A. P. Weir, Nicola MacKenzie, and Colin J. Petrie Copyright © 2014 Robin A. P. Weir et al. All rights reserved. An Extremely Rare Reason for Failure of Left Sided Pacemaker Implantation Wed, 19 Nov 2014 00:00:00 +0000 We reported a case of isolated anomaly of the left brachiocephalic vein which is diagnosed during a permanent pacemaker implantation. It is a very rare anomaly and makes the left sided pacemaker implantation impossible. Erdem Özel, Ali Öztürk, Emin Evren Özcan, and Berhan Genç Copyright © 2014 Erdem Özel et al. All rights reserved. Coronary Artery Fistulae Discovered during Presentation of a Patient Having Heart Failure due to Severe Aortic Stenosis Sun, 16 Nov 2014 00:00:00 +0000 Introduction. Coronary artery fistulae (CAF) are rare defects with abnormal communication between a coronary artery with either a cardiac chamber or another vascular structure, bypassing the myocardial capillary network. We report a rare multiple arterial coronary fistulae with drainage to the right pulmonary artery. Case Presentation. A 56-year-old male was brought to our hospital for work-up of severe aortic stenosis. Further evaluation revealed multiple CAF with abnormal drainage to the right pulmonary artery. He was discharged after aortic valve replacement and closure of the coronary fistula. Conclusion. This case demonstrates that patients with complex CAF and drainage to the right pulmonary artery can remain asymptomatic and diagnosed accidentally during cardiac imaging, presenting particular challenges in both medical and surgical treatment. Abdulrahman Khalifa Alammar Copyright © 2014 Abdulrahman Khalifa Alammar. All rights reserved. An Unusual Presentation of a Myocardial Crypt in Hypertrophic Cardiomyopathy Wed, 12 Nov 2014 11:51:02 +0000 Hypertrophic cardiomyopathy (HCM) is a common inherited cardiovascular disease with prevalence of 0.2% in the population. More than 1000 mutations in more than 10 genes encoding for proteins of the cardiac sarcomere have been identified. Cardiac magnetic resonance imaging (CMR) is used to characterize left ventricular morphology with great precision in patients with HCM and it identifies unique structural abnormalities in patients with HCM. We present a case of a 56-year-old man who had positive family history of HCM who was a carrier of the genetic MYH-7 2770 G > C, exon 23 mutation. Transthoracic echocardiography showed thickening of the interventricular septum (16 mm) and in particular the basal septum. CMR confirmed the diagnosis of HCM in the anteroseptal myocardium with a thickness of 23 mm and also revealed large and deep myocardial crypts in the anterior wall. These myocardial crypts are rarely found in the so-called genotype positive and phenotype positive patients, as in our case. Also the crypts in this case are deeper and wider than those reported in other cases. So in conclusion, this case reveals an uncommon finding of a myocardial crypt at an unusual myocardial site with the unusual morphology in a patient with genotypic and phenotypic expression of hypertrophic cardiomyopathy. Danny A. J. P. van de Sande, Jan Hoogsteen, and Luc J. H. J. Theunissen Copyright © 2014 Danny A. J. P. van de Sande et al. All rights reserved. Asymptomatic Late Migration of an Atrial Pacemaker Lead into the Right Lung Wed, 12 Nov 2014 07:00:44 +0000 This report illustrates an unusual case of asymptomatic late cardiac perforation by an atrial pacemaker lead into the right lung. In the present case, the lead was explanted by simple manual traction through the device pocket without any complications. Nicolas De Schryver, Sebastien Marchandise, Geoffrey C. Colin, Benoît Ghaye, and Jean-Benoît le Polain de Waroux Copyright © 2014 Nicolas De Schryver et al. All rights reserved. Aortic Balloon Valvuloplasty Prior to Orthotopic Liver Transplantation: A Novel Approach to Aortic Stenosis and End-Stage Liver Disease Sun, 09 Nov 2014 11:36:20 +0000 The combination of severe aortic stenosis and end-stage liver disease increases the morbidity and mortality of surgical aortic valve replacement or orthotopic liver transplantation resulting in a prohibitive operative risk. We propose a staged approach of balloon aortic valvuloplasty prior to orthotopic liver transplantation as a bridge to definitive aortic valve replacement. Between 2010 and 2012, four patients with severe aortic stenosis and end-stage liver disease underwent staged balloon aortic valvuloplasty followed by orthotopic liver transplantation. All patients had been deemed to be inappropriate candidates for liver transplantation or aortic valve surgery due to their comorbidity. One patient died of complications from a perivalvular abscess. Three patients went on to successful graft implantation and function and surgical recovery. Two of the three patients proceeded to definitive surgical aortic valve replacement with the remainder currently undergoing evaluation. In this case series, we present a novel approach of balloon aortic valvuloplasty prior to liver transplantation as a potential bridge to definitive treatment of severe aortic stenosis in the end-stage liver patient. Edward Coverstone, Kevin Korenblat, Jeffrey S. Crippin, William C. Chapman, Andrew M. Kates, and Alan Zajarias Copyright © 2014 Edward Coverstone et al. All rights reserved. Late Presentation of Persistent Left Superior Caval Vein in a Univentricular Heart with Successful Transcutaneous Occlusion Using Cera Lifetech Atrial Septal Occluder Thu, 06 Nov 2014 11:40:08 +0000 We present a case of persistent left superior caval vein in a univentricular heart presenting with progressive and disabling cyanosis in a 35-year-old man eighteen years after his Kawashima operation. The vein was successfully occluded using an atrial septal occluder with significant improvement of symptoms and oxygen saturation. Iyad AL-Ammouri, Ahmad Alhourani, and Ayoub Innabi Copyright © 2014 Iyad AL-Ammouri et al. 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.