Case Reports in Cardiology The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Acquired Aorto-Right Ventricular Fistula following Transcatheter Aortic Valve Replacement Thu, 26 Mar 2015 12:40:07 +0000 Transcatheter aortic valve replacement (TAVR) techniques are rapidly evolving, and results of published trials suggest that TAVR is emerging as the standard of care in certain patient subsets and a viable alternative to surgery in others. As TAVR is a relatively new procedure and continues to gain its acceptance, rare procedural complications will continue to appear. Our case is about an 89-year-old male with extensive past medical history who presented with progressive exertional dyspnea and angina secondary to severe aortic stenosis. Patient got TAVR and his postoperative course was complicated by complete heart block, aorto-RV fistula, and ventricular septal defect (VSD) formation as a complication of TAVR. To the best of our knowledge, this is the third reported case of aorto-RV fistula following TAVR as a procedural complication but the first one to show three complications all together in one patient. Muhammad Tariq Shakoor, Ashequl M. Islam, and Samia Ayub Copyright © 2015 Muhammad Tariq Shakoor et al. All rights reserved. Comment on “A Unique Case of Cardiac Arrest following K2 Abuse” Thu, 26 Mar 2015 11:40:03 +0000 Joachim Alexandre, Danièle Debruyne, Antoine Coquerel, and Reynald Le Boisselier Copyright © 2015 Joachim Alexandre et al. All rights reserved. A Case of Coronary Vasospasm after Repeat Rituximab Infusion Wed, 18 Mar 2015 15:38:44 +0000 Coronary artery vasospasm (CAV) can be triggered by medication reactions. CAV occurring after multiple exposures to rituximab has not been previously described. A 61-year-old woman with no cardiac risk factors was treated with the sixth cycle of gemcitabine, cisplatin, dexamethasone, and rituximab therapy. Fifteen minutes after rituximab infusion commenced, she developed typical cardiac chest pain with ST segment elevations on electrocardiogram. Angiogram revealed evidence of coronary vasospasm. The patient was successfully treated with amlodipine. This case underlines the importance of monitoring cardiac side effects of rituximab therapy, even after multiple cycles. Calvin Ke, Amit Khosla, Margot K. Davis, Cameron Hague, and Mustafa Toma Copyright © 2015 Calvin Ke et al. All rights reserved. Acute Ventricular Wall Thickening: Sepsis, Thrombotic Microangiopathy, or Myocarditis? Sun, 15 Mar 2015 07:10:41 +0000 Background. Acute myocardial oedema has been documented in experimental models of ischemia-reperfusion injury or sepsis and is usually investigated by magnetic resonance imaging. Purpose. We describe a case of acute ventricular wall thickening documented by echocardiography in a patient developing sepsis and thrombotic microangiopathy. Case Description. A 40-year-old woman, with a history of mixed connective tissue disease, was admitted with laryngeal oedema and fever. She developed Streptococcus pneumoniae septicaemia and subsequent laboratory abnormalities were consistent with a thrombotic microangiopathy. Echocardiography revealed an impressive diffuse thickening of the whole myocardium (interventricular septum 18 mm; posterior wall 16 mm) with diffuse hypokinesia and markedly reduced left ventricular ejection fraction (31%). There was also a moderate pericardial effusion. Echocardiography was normal two months before. The patient died from acute heart failure. Macroscopic and microscopic examination of the heart suggested that the ventricular wall thickening was induced by oedematous changes, together with an excess of inflammatory cells. Conclusion. Acute ventricular wall thickening that corresponded to myocardial oedema as a first hypothesis was observed at echocardiography during the course of septicaemia complicated by thrombotic microangiopathy. Nicolas De Schryver, Delphine Hoton, Diego Castanares-Zapatero, and Philippe Hantson Copyright © 2015 Nicolas De Schryver et al. All rights reserved. Complete Heart Block with Diastolic Heart Failure and Pulmonary Edema Secondary to Enlarging Previously Diagnosed Thrombosed Aneurysm of Sinus of Valsalva in a Patient with History of Autosomal Dominant Polycystic Kidney Disease Wed, 11 Mar 2015 13:22:38 +0000 Autosomal dominant polycystic kidney disease (ADPKD) is associated with vascular aneurysms that can affect any part of the vascular tree, like ascending aorta or coronary arteries. Sinus of Valsalva is known as an anatomical dilation at the root of aorta above the aortic valve and very few cases show aneurysm at that site in patients with ADPKD. Sinus of Valsalva aneurysm (SVA) can present with rupture and acute heart failure and infective endocarditis or could be asymptomatic accidentally discovered during cardiac catheterization. We report a case of a 76-year-old male with a unique constellation of cardiovascular anomalies associated with ADPKD. Patient was previously diagnosed with aneurysms affecting ascending aorta, sinus of Valsalva, and coronary arteries. Several years later, he came with complete heart block which was discovered later to be secondary to enlargement of his previously diagnosed thrombosed SVA. His case was complicated with acute heart failure and pulmonary edema. Conclusion. Patients with ADPKD can present with extrarenal manifestations. In our case, aneurysm at sinus of Valsalva was progressively enlarging and presented with complete heart block. Sherif Ali Eltawansy, Martin Miguel Amor, Maria Joana Thomas, and Jeffrey Daniels Copyright © 2015 Sherif Ali Eltawansy et al. All rights reserved. Acute Spontaneous Coronary Artery Thrombosis as Initial Presentation of HIV Infection in a Young Man Mon, 02 Mar 2015 10:33:02 +0000 Introduction. The presentation of acute coronary syndrome (ACS) in young HIV patients may be atypical with different pathophysiological and clinical features. Acute coronary thrombosis, as a presentation of acute coronary syndrome in young patients with HIV, raises diagnostic and treatment challenges. Case Presentation. We describe a case of a 33-year-old African man, without traditional atherosclerotic risk factors, who presented with chest pain of acute onset. Emergent coronary angiography revealed extensive thrombus in the left anterior descending coronary artery with no evidence of atherosclerosis in this or other coronary vessels. Plaque and/or thrombus prolapse through the stent was noted following percutaneous coronary intervention (PCI). Resolution of chest pain and improvement in ST-segment elevation was noted after the procedure. A diagnosis of HIV infection was made during the workup for HIV infection. Conclusion. In young patients without traditional risk factors, HIV infection is a possible etiological factor for spontaneous coronary artery thrombosis. Percutaneous coronary intervention in patients with this presentation may be compounded with atherothrombotic complications. The likely pathophysiological pathway is superficial endothelial cell denudation as a result of chronic inflammation and immune activation. James Kayima, Wilson Nyakoojo, Damalie Nakanjako, Marco A. Costa, Christopher T. Longenecker, and Daniel I. Simon Copyright © 2015 James Kayima et al. All rights reserved. Right Atrial Metastatic Melanoma with Unknown Primaries Mon, 23 Feb 2015 12:48:43 +0000 A 54-year-old male with history of anemia and rheumatoid arthritis presented with a three-month history of dyspnea on exertion and lower extremity edema. Patient was referred for a transthoracic echocardiogram that revealed a large right atrial mass with reduced ejection fraction of 40% and an incidental large liver mass. Subsequent cardiac MRI revealed a lobulated right atrial mass measuring 5.4 cm 5.3 cm with inferior vena cava compression and adjacent multiple large liver lesions confirmed to be malignant melanoma through biopsy. Interestingly, no primaries were found in the patient. PET/CT imaging displayed hypermetabolic masses within the right atrium and liver that likely represent metastases, as well as bilateral pleural effusions, most likely due to heart failure. Preoperative coronary angiogram demonstrated perfusion to the mass by a dense network of neovasculature arising from the mid right coronary artery. The cardiac melanoma was surgically removed, and the right atrium was reconstructed with a pericardial patch. After surgery, all cardiac chambers appeared normal in size and function with associated moderate tricuspid regurgitation. The patient is currently being administered ipilimumab for systemic therapy of metastatic melanoma. Robin Kuriakose, Rakhi Melvani, Venkataramanan Gangadharan, and Michael Cowley Copyright © 2015 Robin Kuriakose et al. All rights reserved. Isolated Perforation of Left Coronary Cusp after Blunt Chest Trauma Mon, 23 Feb 2015 11:42:38 +0000 Left coronary cusp perforation is an extremely rare consequence of blunt chest trauma. A 22-year-old male presented after a motor vehicle accident with dyspnea. Transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE) showed moderate to severe aortic regurgitation with prolapsing right coronary cusp. In the operating room he was found to have a left coronary cusp tear near the annulus and an enlarged right cusp. The patient recovered well after successful aortic valve replacement with a mechanical valve. Traumatic aortic regurgitation with left cusp perforation is serious and surgical intervention may be lifesaving if performed timely. Rohit Maini, Razvan T. Dadu, Daniel Addison, Luke Cunningham, Ihab Hamzeh, Matthew Wall Jr., Nasser Lakkis, and Rashed Tabbaa Copyright © 2015 Rohit Maini et al. All rights reserved. Myocarditis Leading to Severe Dilated Cardiomyopathy in a Patient with Dengue Fever Mon, 23 Feb 2015 09:00:26 +0000 Background. Majority of dengue fever cases follow a benign self-limiting course but recently rare presentations and complications are increasingly seen due to rising burden of disease. Cardiac involvement in dengue fever with fatal outcome is a very rare complication. We report a case of 44-year-old patient who presented with symptoms of severe acute congestive heart secondary to myocarditis induced cardiomyopathy caused by dengue virus infection. Case Presentation. A 44-year-old man presented to ER with the complaints of high fever, fatigue, and shortness of breath. Patient was lethargic and blood pressure was low when he was brought to the ER. CXR showed cardiomegaly with pulmonary congestion and echocardiography revealed dilated left ventricle and ejection fraction of 10%. Patient condition worsened and he got admitted to the ICU because of acute hypoxic respiratory failure. Despite aggressive measures, patient died on day 5. Conclusion. Dilated cardiomyopathy is a rare complication of dengue myocarditis. Early recognition of acute DCM caused by dengue myocarditis is imperative in the management of dengue fever as early detection and management of cardiac failure can improve the survival of patient. Hassan Tahir, Vistasp Daruwalla, and Saleem Hayat Copyright © 2015 Hassan Tahir et al. All rights reserved. Thrombus Formation in Left Atrium on Dabigatran Therapy Sun, 22 Feb 2015 11:45:24 +0000 Dabigatran is a direct thrombin inhibitor, approved in the United States for stroke prevention in nonvalvular atrial fibrillation and prevention and treatment of thromboembolism. It has been also used in patients with documented left atrial thrombus, where treatment with dabigatran effectively led to thrombus resolution. We present a rare case of left atrial thrombus formation in a patient with chronic atrial fibrillation being treated with dabigatran 150 mg twice a day. The patient presented with multiple embolic strokes. There are only three such cases reported in the literature till date, all of whom had thrombus in the left atrium. The possible mechanisms of dabigatran failure include compensatory increase in upstream coagulation factors due to single level downstream blockade of thrombin, lack of inhibition of all available thrombin, and lack of monitoring measures that can be implemented in common clinical laboratories that lead to failure to assess adherence, which in turn can lead to dabigatran failure. Priyank Shah, Priyam Mithawala, Donna Konlian, Aderemi Soyombo, and Mahesh Bikkina Copyright © 2015 Priyank Shah et al. All rights reserved. Emergent Unilateral Renal Artery Stenting for Treatment of Flash Pulmonary Edema: Fact or Fiction? Sun, 22 Feb 2015 06:03:30 +0000 Flash pulmonary edema is characteristically sudden in onset with rapid resolution once appropriate therapy has been instituted (Messerli et al., 2011). Acute increase of left ventricular (LV) end diastolic pressure is the usual cause of sudden decompensated cardiac failure in this patient population. Presence of bilateral renal artery stenosis or unilateral stenosis in combination with a single functional kidney in the susceptible cohort is usually blamed for this condition. We describe a patient who presented with flash pulmonary edema in the setting of normal coronary arteries. Our case is distinct as our patient developed flash pulmonary edema secondary to unilateral renal artery stenosis in the presence of bilateral functioning kidneys. Percutaneous stent implantation in the affected renal artery resulted in rapid resolution of pulmonary edema. Asaad Akbar Khan and Eugene Patrick McFadden Copyright © 2015 Asaad Akbar Khan and Eugene Patrick McFadden. All rights reserved. Dual Prosthetic Heart Valve Presented with Chest Pain: A Case Report of Coronary Thromboembolism Mon, 16 Feb 2015 14:06:28 +0000 Coronary embolism from a prosthetic heart valve is a rare but remarkable cause of acute coronary syndrome. There is no definite management of an entity like this. Here we report a case of 54-year-old male with a history of rheumatic heart disease with dual prosthetic heart valve and atrial fibrillation who developed chest pain from acute myocardial infarction. The laboratory values showed inadequate anticoagulation. Cardiac catheterization and thrombectomy with the aspiration catheter were chosen to be the treatment for this patient, and it showed satisfactory outcome. Supakanya Wongrakpanich, Natanong Thamcharoen, Pakawat Chongsathidkiet, and Sarawut Siwamogsatham Copyright © 2015 Supakanya Wongrakpanich et al. All rights reserved. Subacute Right Ventricle Perforation by Pacemaker Lead Presenting with Left Hemothorax and Shock Mon, 16 Feb 2015 06:37:03 +0000 Cardiac perforation by pacemaker is a rare but potentially fatal complication. Acute perforations occurring within twenty-four hours of insertion of pacemaker can lead to hemopericardium, cardiac tamponade, and death. Hemothorax occurring as an acute complication of pacemaker insertion is reported but extremely rare. Previously, hemothorax and shock as a subacute complication following pacemaker insertion have not been reported. We report the case of an 85-year-old patient who presented with shock from hemothorax caused by pacemaker perforation, two weeks after insertion. Device interrogation showed normal function. Chest X-ray and echocardiogram missed lead dislocation and the diagnosis was made on computed tomogram (CT) of the chest. Following surgical repair, a new ventricular pacemaker was placed transvenously in the right ventricular septum. This case illustrates that CT scan of the chest should be performed in all patients in whom cardiac perforation by pacemaker is suspected but not diagnosed on chest X-ray and echocardiogram. Normal functioning of pacemaker on device interrogation does not exclude perforation. Julianne Nichols, Natalie Berger, Praveen Joseph, and Debapriya Datta Copyright © 2015 Julianne Nichols et al. All rights reserved. Second-Degree Interatrial Block in Hemodialysis Patients Tue, 10 Feb 2015 14:34:31 +0000 Interatrial conduction delays manifest as a prolonged P-wave duration on surface ECG and the term interatrial block (IAB) has been coined. They are usually fixed, but cases of intermittent IAB have been described, suggesting functional conduction block at the Bachmann bundle region. We report 2 cases of patients on chronic hemodialysis therapy presenting with intermittent IAB. Andres Enriquez, Marco Marano, Anna D’Amato, Antoni Bayes de Luna, and Adrian Baranchuk Copyright © 2015 Andres Enriquez et al. All rights reserved. A Whole-Food Plant-Based Diet Reversed Angina without Medications or Procedures Tue, 10 Feb 2015 09:26:23 +0000 A 60-year-old man presented with typical angina and had a positive stress test. He declined both drug therapy and invasive testing. Instead, he chose to adopt a whole-food plant-based diet, which consisted primarily of vegetables, fruits, whole grains, potatoes, beans, legumes, and nuts. His symptoms improved rapidly, as well as his weight, blood pressure, and cholesterol levels. Plant-based diets have been associated with improved plasma lipids, diabetes control, coronary artery disease and with a reduction in mortality. Adoption of this form of lifestyle therapy should be among the first recommendations for patients with atherosclerosis. Daniele Massera, Tarique Zaman, Grace E. Farren, and Robert J. Ostfeld Copyright © 2015 Daniele Massera et al. 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.