Case Reports in Cardiology http://www.hindawi.com The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . 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 http://www.hindawi.com/journals/cric/2014/681572/ 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 http://www.hindawi.com/journals/cric/2014/594396/ 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 http://www.hindawi.com/journals/cric/2014/531929/ 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 http://www.hindawi.com/journals/cric/2014/427045/ 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 http://www.hindawi.com/journals/cric/2014/523023/ 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 http://www.hindawi.com/journals/cric/2014/878915/ 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 http://www.hindawi.com/journals/cric/2014/809398/ 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 http://www.hindawi.com/journals/cric/2014/120607/ 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 http://www.hindawi.com/journals/cric/2014/964038/ 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 http://www.hindawi.com/journals/cric/2014/464579/ 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 http://www.hindawi.com/journals/cric/2014/769273/ 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 http://www.hindawi.com/journals/cric/2014/213842/ 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 http://www.hindawi.com/journals/cric/2014/246784/ 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 http://www.hindawi.com/journals/cric/2014/130617/ 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 http://www.hindawi.com/journals/cric/2014/781926/ 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 http://www.hindawi.com/journals/cric/2014/293476/ 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 http://www.hindawi.com/journals/cric/2014/289879/ Muscle overlying an intramyocardial segment of a coronary artery is termed a myocardial bridge. The intramyocardial segment, the tunneled artery, is compressed during systole. The condition is generally benign but may occasionally cause myocardial ischemia, infarction, arrhythmia, or sudden cardiac death. We present a case regarding a 52-year-old man with exercise-induced angina who was diagnosed with a myocardial bridge overlying the left anterior descending artery. He was initially treated with beta-blockers and later received coronary bypass graft surgery. Dragana Rujic, Mette Lundgren Nielsen, Karsten Tange Veien, and Manan Pareek Copyright © 2014 Dragana Rujic et al. All rights reserved. In-Stent Ulceration: An Unusual Pathology Tue, 04 Mar 2014 07:36:48 +0000 http://www.hindawi.com/journals/cric/2014/893143/ In-stent restenosis occurs in 10–60% of cases undergoing interventional therapy. Many mechanisms explain the reason for in-stent restenosis, but restenosis due to an ulcerated plaque is very rare and has not been well reported in the literature. We report an interesting case of 72-year-old man presenting with neurological symptoms secondary to in-stent restenosis of the carotid artery caused by an ulcerated plaque. We also explain the different mechanisms for restenosis along with the treatment options. Jagadeesh Kumar Kalavakunta, Shravan Gangula, and Vishal Gupta Copyright © 2014 Jagadeesh Kumar Kalavakunta et al. All rights reserved. Delayed Amplatzer Occluder Device Closure of Postinfarction Ventricular Septal Defect: A Case Report Mon, 03 Mar 2014 12:18:38 +0000 http://www.hindawi.com/journals/cric/2014/159010/ Postinfarction ventricular septal defect (VSD) is a rare complication after acute myocardial infarction, with an incidence rate of 1-2% of all myocardial infarcts (Hutchins, 1979). It is a medical emergency with sobering survival numbers, having a mortality rate of 70–80% within two weeks of the incident event (Bouchart et al., 1998). Cardiac surgery is considered the gold standard in the management of these defects; however, its main limitation is that it carries a high risk of perioperative mortality and postoperative sequelae. Percutaneous transcatheter closure of VSD is a relatively new method of repair. Due to scarcity of reports in the literature, there is limited data regarding survival data; however, noninferiority to surgery has been demonstrated in one case series (Papalexopoulou et al., 2013). Long-term follow-up studies are lacking, and thus long-term mortality has yet to be discerned. We present a case of an 87-year-old female who, following postmyocardial infarction VSD, developed clinically significant heart failure. The patient was reluctant to undergo open repair given her age and comorbidities and she underwent successful percutaneous repair of her VSD using a 16 mm Amplatzer occluder device 18 months after her initial presentation. Francis Ting, Aditya Bhat, Neville Sammel, and David Muller Copyright © 2014 Francis Ting et al. All rights reserved. Possible Usefulness of Gadolinium-Enhanced Brain MRI for Evaluating Risk of Perioperative Hemorrhage: A Case of Infective Endocarditis Thu, 13 Feb 2014 14:14:59 +0000 http://www.hindawi.com/journals/cric/2014/158041/ A 59-year-old woman visited a local hospital for fever and was diagnosed as having infective endocarditis (IE) on the basis of blood cultures and transthoracic echocardiography. Based on clinical episodes of subarachnoid hemorrhage after admission, it was judged that she was not a good candidate for urgent open heart surgery, and it was decided to treat her with conservative medical therapy for the acute phase. We explored the optimum timing for surgery by employing gadolinium (Gd) contrast medium-enhanced magnetic resonance imaging (MRI) T2* weighted image (black dots) due to her high risk of perioperative cerebral hemorrhage. After the disappearance of the contrast media enhancement effect around the black dots, open heart surgery was performed successfully on the 103rd hospitalization day. The patient was discharged 22 days after the surgery with no clinical complications. This case suggests that disappearance of the contrast media enhancement effect around the black dots may be a useful marker for optimal timing of surgery to minimize the risk of perioperative cerebral hemorrhage in patients with IE. Learning Objective. The MRI T2* weighted images including those with Gd contrast medium enhancement effect may be useful for evaluating the risk of perioperative intracranial hemorrhage in IE. Chikahiko Koeda, Atsushi Tashiro, Tomohiro Takahashi, Masanobu Niiyama, Ryohei Sakamoto, Takumi Kimura, Yoshihiro Morino, Katsutoshi Terui, Ryoichi Tanaka, Kunihiro Yoshioka, Hajime Kin, Hitoshi Okabayashi, and Motoyuki Nakamura Copyright © 2014 Chikahiko Koeda et al. All rights reserved. Multiple Multilateral Coronary-Cameral Fistulae in a Patient with Minor Cardiac Venous System Thu, 06 Feb 2014 11:33:40 +0000 http://www.hindawi.com/journals/cric/2014/754703/ A 40-year-old man was hospitalized in the coronary care unit with chest pain and abnormal electrocardiogram. Twenty days earlier, the patient underwent laparoscopic gallbladder surgery. Due to chest pain and ischemic ECG changes, patient was subjected to coronary angiography. The selective coronary angiography revealed multiple multilateral fistulae arising from the left anterior descending artery, circumflex artery, and the right coronary artery draining to the left ventricle. Multislice computed tomography showed hypoplastic coronary sinus and minor cardiac venous system. Darko Markota, Zrinko Prskalo, Ivica Markota, Boris Starcevic, Josip Maskovic, Monika Tomic, and Ivica Brizic Copyright © 2014 Darko Markota et al. All rights reserved. An Unusual Cause of Transient Ischemic Attack in a Patient with Pacemaker Tue, 04 Feb 2014 14:07:38 +0000 http://www.hindawi.com/journals/cric/2014/265759/ Pacemaker lead malposition in various locations has been described in the literature. Lead malposition in left ventricle is a rare and an underdiagnosed complication. We present a 77-year-old man with history of atrial fibrillation and pacemaker placement who was admitted for transient ischemic attack. He was on aspirin, beta blocker, and warfarin with subtherapeutic international normalized ratio. His paced electrocardiogram showed right bundle-branch block, rather than the typical pattern of left bundle-branch block, suggesting pacemaker lead malposition. Further, his chest X-ray and echocardiogram confirmed the pacemaker lead position in the left ventricle instead of right ventricle. He refused surgical removal of the lead and we increased his warfarin dose. Diagnosis of lead malposition in left ventricle, though easy to identify in echocardiogram, requires high index of clinical suspicion. In asymptomatic patients, surgical removal may be deferred for treatment with lifelong anticoagulation. Jagadeesh Kumar Kalavakunta, Vishal Gupta, Basil Paulus, and William Lapenna Copyright © 2014 Jagadeesh Kumar Kalavakunta et al. All rights reserved. Vegan Triple-Ironman (Raw Vegetables/Fruits) Sun, 12 Jan 2014 00:00:00 +0000 http://www.hindawi.com/journals/cric/2014/317246/ Endurance sport requires a healthy and balanced diet. In this case report we present the findings of an ultra-triathlete (three times Ironman, means 11.4 km swim, 540 km bike, 125 km run in 41:18 h as a whole) living on a raw vegan diet and having finished the competitions under these nutritional conditions. To this end, the vegan ultra triathlete and a control group of 10 Ironman triathletes of similar age living on a mixed diet were investigated, using echocardiography and spiroergometry. In addition, blood samples were taken from the vegan athlete both in the sporting season and in the off-season. The vegan athlete showed no signs of dietary deficiencies or impaired health. In comparison with the control group, the vegan athlete showed a higher oxygen intake at the respiratory compensation point. This case demonstrates that even top-class sporting performance, like that of a three-time Ironman, is possible on a vegan diet. Whether a vegan diet offers advantages or disadvantages for the performance of endurance athletes remains an open question. Roman Leischik and Norman Spelsberg Copyright © 2014 Roman Leischik and Norman Spelsberg. All rights reserved. Balloon-Assisted Tracking to Overcome Radial Spasm during Transradial Coronary Angiography: A Case Report Wed, 08 Jan 2014 16:14:45 +0000 http://www.hindawi.com/journals/cric/2014/214310/ Spasm of the radial artery is the most important cause of failure to perform coronary angiography via the transradial approach. Spasmolytic cocktail may prevent radial artery spasm but is relatively contraindicated in patients with aortic stenosis or diminished left ventricular function. In this case report we describe a recently published technique to overcome severe radial spasm during transradial coronary angiography in a patient with moderate aortic valve stenosis. N. J. W. Verouden and F. Kiemeneij Copyright © 2014 N. J. W. Verouden and F. Kiemeneij. All rights reserved. Late Presentation of Recurrent Monomorphic Ventricular Tachycardia following Minimally Invasive Mitral Valve Repair due to Epicardial Injury Mon, 06 Jan 2014 16:38:57 +0000 http://www.hindawi.com/journals/cric/2014/976494/ We report a 73-year-old male with late onset monomorphic ventricular tachycardia following mitral valve repair (MVR). Typically, injury to epicardial arteries following mitral valve repair/replacement presents immediately as ventricular tachycardia/fibrillation, difficulty weaning from cardiopulmonary bypass, worsening ECG changes, increasing cardiac biomarkers, or new wall motion abnormalities. Our case illustrates a “late complication” of a distorted circumflex artery following mitral valve repair and the importance of early diagnostic angiography and percutaneous intervention. Harry L. South, Moses Osoro, and Tjuan Overly Copyright © 2014 Harry L. South et al. All rights reserved. Triple Diuretics and Aquaretic Strategy for Acute Decompensated Heart Failure due to Volume Overload Mon, 30 Dec 2013 10:15:02 +0000 http://www.hindawi.com/journals/cric/2013/750794/ Diuretics, including furosemide, metolazone, and spironolactone, have historically been the mainstay of therapy for acute decompensated heart failure patients. The addition of an aquaretic-like vasopressin antagonist may enhance diuresis further. However, clinical experience with this quadruple combination is lacking in the acute setting. We present two hospitalized patients with acute decompensated heart failure due to massive fluid overload treated with a combination strategy of triple diuretics in conjunction with the aquaretic tolvaptan. The first patient lost 72.1 lbs. (32.7 kg) with an average urine output of 3.5 to 7.5 L/day over eight days on combined therapy with furosemide, metolazone, spironolactone, and tolvaptan. The second patient similarly achieved a weight loss of 28.2 lbs. (12.8 kg) over 4 days on the same treatment. Both patients maintained stable serum sodium, potassium, and creatinine over this period and remained out of the hospital for more than 30 days. Thus, patients hospitalized with acute decompensated heart failure due to volume overload can achieve euvolemia rapidly and without electrolytes disturbances using this regimen, while being under the close supervision of a team of cardiologists and nephrologists. Additionally, this therapy can potentially decrease the need for ultrafiltration and the length of hospital stay. Rita Jermyn, Naveed Rajper, Chelsea Estrada, Sagar Patel, Michelle Weisfelner Bloom, and Nand K. Wadhwa Copyright © 2013 Rita Jermyn et al. All rights reserved. Rare Presentation of Gerbode Defect in a 4-Month-Old Nigerian and a Review of the Literature Wed, 25 Dec 2013 11:59:19 +0000 http://www.hindawi.com/journals/cric/2013/564786/ A Gerbode defect is a very rare congenital anomaly which presents as a direct or an indirect type. We report a 4 month old Nigerian child who presented with poor feeding and failure to thrive and whose echocardiography confirmed an indirect Gerbode with a direct left ventricle to right atrial shunt due to adherent leaflets of the tricuspid valve. This was confirmed by surgery done outside the country. Barbara E. Otaigbe and Douye Orubide Copyright © 2013 Barbara E. Otaigbe and Douye Orubide. All rights reserved. Pericarditis in Takotsubo Cardiomyopathy: A Case Report and Review of the Literature Tue, 17 Dec 2013 11:38:03 +0000 http://www.hindawi.com/journals/cric/2013/917851/ Case. A 64-year-old Caucasian woman was brought to the emergency department with severe dysphagia and left chest pain for last 4 days. Initial evaluation revealed elevated ST segment in precordial leads on EKG with elevated cardiac enzymes. Limited echocardiogram showed infra-apical wall hypokinesia. Cardiac angiography was done subsequently which showed nonflow limiting mild coronary artery disease. Takotsubo cardiomyopathy was diagnosed and she was treated medically. On the third day of admission, a repeat ECG showed diffuse convex ST-segment elevations in precordial leads, compatible with acute pericarditis pattern of EKG. Decision was made to start colchicine empirically for possible pericarditis. Follow-up EKG in 2 days showed decreased ST-segment elevations in precordial leads. The patient was discharged with colchicine and a follow-up echocardiogram in 4 weeks demonstrated a normal ejection fraction with no evidence of pericarditis. Conclusion. Acute pericarditis can be associated either as a consequence of or as a triggering factor for Takotsubo cardiomyopathy. It is vital for physicians to be aware of pericarditis as a potential complication of Takotsubo cardiomyopathy. Joonseok Kim, Heather S. Laird-Fick, Osama Alsara, Venu Gourineni, and George S. Abela Copyright © 2013 Joonseok Kim et al. All rights reserved. Reactive Thrombocytosis Associated with Acute Myocardial Infarction following STEMI with Percutaneous Coronary Intervention Sun, 24 Nov 2013 10:49:34 +0000 http://www.hindawi.com/journals/cric/2013/707438/ The etiology of thrombocytosis can be classified into reactive and essential forms. The rate of thromboembolic events is higher in essential thrombocytosis, and these events include strokes, transient ischemic attacks, retinal artery or retinal vein occlusions, digital ischemia, and acute coronary syndrome. In a study of 732 medical and surgical patients with thrombocytosis, 88% had reactive thrombocytosis. Patients with reactive thrombocytosis do not require cytoreductive medications or antiplatelet treatment. We report a healthy 40-year-old man without any medical problems who developed a new episode of myocardial infarction associated with thrombocytosis after an episode of myocardial infarction followed by percutaneous coronary intervention. He had thrombocytosis, and his platelet function test did not reveal adequate inhibition. To treat his acute coronary syndrome, therapeutic enoxaparin was added, and clopidrogel was substituted with ticagrelor. We decided to start hydroxyurea to reduce platelets counts. Enoxaparin and hydroxyurea were discontinued when platelet count returned to baseline. JAK-2 and BCR/ABL mutations were negative. This case report highlights a clinical dilemma (reactive thrombocytosis), which is challenging in terms of management and pathophysiology. Nat Dumrongmongcolgul, Charoen Mankongpaisarnrung, Grerk Sutamtewagul, Nattamol Hosiriluck, Timothy Chen, Alexander Trujillo, Nicholas Dcunha, Kenneth Nugent, and Leigh Ann Jenkins Copyright © 2013 Nat Dumrongmongcolgul et al. All rights reserved. Sinus of Valsalva Fistula to the Right Ventricle along with Coronary Artery Fistula to the Pulmonary Artery in a Young Native American Female Tue, 19 Nov 2013 13:40:50 +0000 http://www.hindawi.com/journals/cric/2013/674608/ Sinus of Valsalva aneurysm is a rare condition and associated with a high rate of mortality if rupture occurs. The aneurysms are rarely diagnosed until rupture occurs. This case describes a young Native American female whose only symptom was intermittent chest pain prior to the detection of the aneurysm along with a small ventricular septal defect. The patient was also found to have a coexisting coronary artery fistula, and it is rare phenomenon to have these coexisting anomalies. The anomalies were demonstrated on both cardiac computed tomography and coronary angiography. The patient underwent surgical closure of both anomalies, which is the recommended treatment to avoid future complications. Sarika Desai, Erica Flores, Akil Loli, and Peter Maki Copyright © 2013 Sarika Desai et al. All rights reserved.