Case Reports in Cardiology http://www.hindawi.com The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Tender Endothelium Syndrome: Combination of Hypotension, Bradycardia, Contrast Induced Chest Pain, and Microvascular Angina Sun, 14 Feb 2016 08:04:38 +0000 http://www.hindawi.com/journals/cric/2016/8574025/ Hypotension, bradycardia, and contrast induced chest pain are potential complications of cardiac catheterization and coronary angiography. Catheter-induced coronary spasm has been occasionally demonstrated, but its relationship to spontaneous coronary spasm is unclear. We describe a 64-year-old female who underwent coronary artery bypass surgery in 1998 on the basis of an angiographic diagnosis of severe left main disease, who recently presented with increasingly frequent typical angina. Repeat coronary angiography was immediately complicated by severe chest pain, hypotension, and bradycardia but demonstrated only mild disease of the left main artery and entire coronary tree with complete occlusion of her prior grafts. This reaction was almost identical to that observed during her original coronary angiogram. We now believe her original angiogram was complicated by severe catheter-induced left main spasm, with the accompanying contrast reaction attributed to left main disease, and the occlusion of coronary grafts explained by the absence of significant left main disease. The combination of these symptoms has not been documented in the literature. In this instance, these manifestations erroneously led to coronary bypass surgery. It is unknown whether routine, systematic injection of intracoronary nitroglycerin prior to angiography might blunt the severity of such reactions. Shivesh Goberdhan, Soon Kwang Chiew, and Jaffer Syed Copyright © 2016 Shivesh Goberdhan et al. All rights reserved. Physiologic Functional Evaluation of Left Internal Mammary Artery Graft to Left Anterior Descending Coronary Artery Steal due to Unligated First Thoracic Branch in a Case of Refractory Angina Sun, 14 Feb 2016 06:11:56 +0000 http://www.hindawi.com/journals/cric/2016/3175798/ Unligated side branches of the left internal mammary artery (LIMA) have been described in the literature as a cause of coronary steal resulting in angina. Despite a number of studies reporting successful side branch embolization to relieve symptoms, this phenomenon remains controversial. Hemodynamic evidence of coronary steal using angiographic and intravascular Doppler techniques has been supported by some and rejected by others. In this case study using an intracoronary Doppler wire with adenosine, we demonstrate that a trial occlusion of the LIMA thoracic side branch with selective balloon inflation can confirm physiologic significant steal and whether coil embolization of the side branch is indicated. Fadi J. Sawaya, Henry Liberman, and Chandan Devireddy Copyright © 2016 Fadi J. Sawaya et al. All rights reserved. A Practical Method for No-Reflow Treatment Thu, 11 Feb 2016 16:26:58 +0000 http://www.hindawi.com/journals/cric/2016/9596123/ No-reflow is an undesirable result of percutaneous coronary interventions. Vasoactive drug administration at the distal part of the coronary artery is suggested as a therapeutic option for no-reflow treatment. Here, we represent two cases of successful no-reflow management with previously used monorail balloon at the same procedure as a hand-made distal infusion catheter. Mustafa Cetin, Emrullah Kiziltunc, Zehra Güven Cetin, Harun Kundi, Birsen Gulkan, and Hülya Cicekcioglu Copyright © 2016 Mustafa Cetin et al. All rights reserved. A Retained Bullet in Pericardial Sac: Penetrating Gunshot Injury of the Heart Wed, 10 Feb 2016 06:39:25 +0000 http://www.hindawi.com/journals/cric/2016/2427681/ Penetrating cardiac trauma is rarely seen but when present there is a short time lag to keep the patients alive. Cardiac gunshot injuries are exceptional and it occurs mostly during interpersonal disagreements casualties or a mistakenly fired gun nowadays. Here we present a case of cardiac gunshot injury from the war of Kobani, Syria. The patient was mistakenly diagnosed to have a sole bullet in the left shoulder while he had a penetrating cardiac trauma with a bullet in the heart and pericardial effusion possibly giving rise to pericardial tamponade. Luckily the cardiac gunshot injury was noticed one day later and the patient was referred to a tertiary hospital. Intrapericardial bullet was conservatively followed up. The patient was discharged one week later after resection of the bullet in the shoulder. Adnan Kaya, Emine Caliskan, Mustafa Adem Tatlisu, Mert Ilker Hayiroglu, Ahmet Ilker Tekessin, Yasin Cakilli, Sahin Avsar, Ahmet Oz, and Osman Uzman Copyright © 2016 Adnan Kaya et al. All rights reserved. Stenting of Variant Left Carotid Artery Using Brachial Artery Approach in a Patient with Unusual Type of Bovine Aortic Arch Thu, 28 Jan 2016 11:35:15 +0000 http://www.hindawi.com/journals/cric/2016/9512318/ Bovine aortic arch is the most frequently encountered variation in human aortic arch branching. A 63-year-old Asian male presented with symptomatic severe stenosis of left carotid artery originating from the brachiocephalic trunk. Selective engagement to the left carotid artery was unsuccessful using transfemoral approach. We reported on a successful left carotid artery stenting case using right brachial artery approach in a bovine aortic arch. This paper is worthy of reporting in terms of guiding physicians for interventional procedures in these types of challenging cases. Emre Gürel, Zeki Yüksel Günaydın, Ahmet Karagöz, Osman Bektaş, Adil Bayramoğlu, Abdullah Çelik, and Aslı Vural Copyright © 2016 Emre Gürel et al. All rights reserved. Bortezomib-Induced Complete Heart Block and Myocardial Scar: The Potential Role of Cardiac Biomarkers in Monitoring Cardiotoxicity Thu, 28 Jan 2016 09:24:34 +0000 http://www.hindawi.com/journals/cric/2016/3456287/ Bortezomib is a proteasome inhibitor used to treat multiple myeloma and mantle cell lymphoma. Traditionally, bortezomib was thought to have little cardiovascular toxicity; however, there is increasing evidence that bortezomib can lead to cardiac complications including left ventricular dysfunction and atrioventricular block. We present the case of a 66-year-old man with multiple myeloma and persistent asymptomatic elevations of cardiac biomarkers who developed complete heart block and evidence of myocardial scar after his eighth cycle of bortezomib, requiring permanent pacemaker placement. In addition to discussing the cardiovascular complications of bortezomib therapy, we propose a potential role for biomarkers in the prediction and monitoring of bortezomib cardiotoxicity. Sachin Diwadkar, Aarti A. Patel, and Michael G. Fradley Copyright © 2016 Sachin Diwadkar et al. All rights reserved. Reversibility of High-Grade Atrioventricular Block with Revascularization in Coronary Artery Disease without Infarction: A Literature Review Tue, 26 Jan 2016 16:14:14 +0000 http://www.hindawi.com/journals/cric/2016/1971803/ Complete atrioventricular (AV) block is known to be reversible in some cases of acute inferior wall myocardial infarction (MI). The reversibility of high-grade AV block in non-MI coronary artery disease (CAD), however, is rarely described in the literature. Herein we perform a literature review to assess what is known about the reversibility of high-grade AV block after right coronary artery revascularization in CAD patients who present without an acute MI. To illustrate this phenomenon we describe a case of 2 : 1 AV block associated with unstable angina, in which revascularization resulted in immediate and durable restoration of 1 : 1 AV conduction, thereby obviating the need for permanent pacemaker implantation. The literature review suggests two possible explanations: a vagally mediated response or a mechanism dependent on conduction system ischemia. Due to the limited understanding of AV block reversibility following revascularization in non-acute MI presentations, it remains difficult to reliably predict which patients presenting with high-grade AV block in the absence of MI may have the potential to avoid permanent pacemaker implantation via coronary revascularization. We thus offer this review as a potential starting point for the approach to such patients. Rhanderson Cardoso, Carlos E. Alfonso, and James O. Coffey Copyright © 2016 Rhanderson Cardoso et al. All rights reserved. Hypereosinophilic Syndrome: A Case of Fatal Löffler Endocarditis Thu, 21 Jan 2016 07:12:33 +0000 http://www.hindawi.com/journals/cric/2016/2359532/ Hypereosinophilic syndrome (HES) is a rare disorder with unknown global prevalence, barely reported in Hispanic population, and characterized by persistent eosinophilia in association with organ dysfunctions directly attributable to eosinophilic infiltration. Cardiac involvement may be present in 50 to 60% of the patients. This is known as Löffler endocarditis. We present a case of a 36-year-old Hispanic man with signs of heart failure. Laboratory studies showed eosinophilia (23,100/μL). Thoracic computer tomography showed bilateral pleural effusion and a large left ventricular mass. Transthoracic echocardiography showed left ventricle apical obliteration and a restrictive pattern. Pulmonary angiography demonstrated a thrombus in the lingular and middle lobe. Despite treatment, the patient deceased seven days after admission. Autopsy confirmed the diagnosis of Löffler endocarditis. Mario Enrique Baltazares-Lipp, Juan Ignacio Soto-González, Carlos Manuel Aboitiz-Rivera, Héctor A. Carmona-Ruíz, Benito Sarabia Ortega, and Ruben Blachman-Braun Copyright © 2016 Mario Enrique Baltazares-Lipp et al. All rights reserved. Midventricular Hypertrophic Cardiomyopathy with Apical Aneurysm: Potential for Underdiagnosis and Value of Multimodality Imaging Wed, 20 Jan 2016 16:07:55 +0000 http://www.hindawi.com/journals/cric/2016/9717948/ We illustrate a case of midventricle obstructive HCM and apical aneurysm diagnosed with appropriate use of multimodality imaging. A 75-year-old African American woman presented with a 3-day history of chest pain and dyspnea with elevated troponins. Her electrocardiogram showed sinus rhythm, left atrial enlargement, left ventricular hypertrophy, prolonged QT, and occasional ectopy. After medical therapy optimization, she underwent coronary angiography for an initial diagnosis of non-ST segment elevation myocardial infarction. Her coronaries were unremarkable for significant disease but her left ventriculogram showed hyperdynamic contractility of the midportion of the ventricle along with a large dyskinetic aneurysmal apical sac. A subsequent transthoracic echocardiogram provided poor visualization of the apical region of the ventricle but contrast enhancement identified an aneurysmal pouch distal to the midventricular obstruction. To further clarify the diagnosis, cardiac magnetic resonance imaging with contrast was performed confirming the diagnosis of midventricular hypertrophic cardiomyopathy with apical aneurysm and fibrosis consistent with apical scar on delayed enhancement. The patient was medically treated and subsequently underwent elective implantable defibrillator placement in the ensuing months for recurrent nonsustained ventricular tachycardia and was initiated on prophylactic oral anticoagulation with warfarin for thromboembolic risk reduction. Archana Sivanandam and Karthik Ananthasubramaniam Copyright © 2016 Archana Sivanandam and Karthik Ananthasubramaniam. All rights reserved. Anomalous Origination of Right Coronary Artery from Left Sinus in Asymptomatic Young Male Presenting with Positive Ischemic Response on Treadmill Test Thu, 14 Jan 2016 14:03:03 +0000 http://www.hindawi.com/journals/cric/2016/7652869/ Anomalous origination of coronary artery from the opposite sinus (ACAOS) is a rare coronary artery anomaly. Right ACAOS with interarterial course is a type of ACAOS, which conveys a high risk for myocardial ischemia or sudden death. We reported a case of right ACAOS with interarterial course in otherwise healthy young male. He was asymptomatic, until an obligatory medical check-up with treadmill test showed a sign of positive ischemic response. Further work-up revealed that he had right ACAOS with interarterial course. Watchful observation was applied to him, while strenuous physical activity and competitive sport were absolutely prohibited. Budi Yuli Setianto, Anggoro Budi Hartopo, Putrika Prastuti Ratna Gharini, and Nahar Taufiq Copyright © 2016 Budi Yuli Setianto et al. All rights reserved. Left Atrial Myxoma Hypervascularized from the Right Coronary Artery: An Interesting Cath Lab Finding Tue, 12 Jan 2016 13:52:10 +0000 http://www.hindawi.com/journals/cric/2016/4865439/ Primary cardiac tumors are rare and approximately half of them are atrial myxomas. They rarely remain asymptomatic, especially if large. The imaging of a myxoma by contrast dye during coronary angiography is an infrequent sign, which clarifies the vascular supply of the tumor. We report herein an interesting and rare case of a left atrial myxoma hypervascularized from the right coronary artery. Marcos Danillo Peixoto Oliveira, Adriano Ossuna Tamazato, Fernando Roberto de Fazzio, Luiz J. Kajita, Expedito E. Ribeiro, and Pedro Alves Lemos Copyright © 2016 Marcos Danillo Peixoto Oliveira et al. All rights reserved. A Striking Coronary Artery Pattern in a Grown-Up Congenital Heart Disease Patient Wed, 06 Jan 2016 12:22:43 +0000 http://www.hindawi.com/journals/cric/2016/5482578/ Left ventricular noncompaction (LVNC) is a myocardial disorder probably due to the arrest of normal embryogenesis of the left ventricle. It could be isolated or associated with other extracardiac and cardiac abnormalities, including coronary artery anomalies. Despite the continuous improvement of imaging resolution quality, this cardiomyopathy still remains frequently misdiagnosed, especially if associated with other heart diseases. We report a case of LVNC association with both malposition of the great arteries and a very original coronary artery pattern. Fortunato Iacovelli, Martino Pepe, Gaetano Contegiacomo, Vito Alberotanza, Filippo Masi, Alessandro Santo Bortone, and Stefano Favale Copyright © 2016 Fortunato Iacovelli et al. All rights reserved. An Unusual Case of Biatrial Myxoma in a Young Female Sun, 03 Jan 2016 14:16:39 +0000 http://www.hindawi.com/journals/cric/2016/3545480/ Myxoma, a rare type of intracardiac tumor, forms a very small percentage of the cardiac cases. Reports of biatrial myxoma are rarer, with cases of single tumor reaching both atria being more common. Here, we present an unusual case of two independently growing atrial myxoma in a 29-year-old female. We emphasize that early recognition of symptoms, confirmation of diagnosis by transesophageal echocardiography, and prompt surgical excision remain vital in the management of such patients. The patient in the present case was managed successfully with no evidences of recurrence at the last follow-up. Vikrant Vijan, Anjith Vupputuri, and Rajiv Chandrasekharan Nair Copyright © 2016 Vikrant Vijan et al. All rights reserved. Electrical Injury-Induced Complete Atrioventricular Block: Is Permanent Pacemaker Required? Tue, 29 Dec 2015 13:32:49 +0000 http://www.hindawi.com/journals/cric/2015/158948/ A considerable percentage of electrical injuries occur as a result of work activities. Electrical injury can lead to various cardiovascular disorders: acute myocardial necrosis, myocardial ischemia, heart failure, arrhythmias, hemorrhagic pericarditis, acute hypertension with peripheral vasospasm, and anomalous, nonspecific ECG alterations. Ventricular fibrillation is the most common arrhythmia resulting from electrical injury and is the leading cause of death in electrical (especially low voltage alternating current) injury cases. Asystole, premature ventricular contractions, ventricular tachycardia, conduction disorders (various degrees of heart blocks, bundle-brunch blocks), supraventricular tachycardia, and atrial fibrillation are the other arrhythmic complications of electrical injury. Complete atrioventricular block has rarely been reported and permanent pacemaker was required for the treatment in some of these cases. Herein, we present a case of reversible complete atrioventricular block due to low voltage electrical injury in a young electrical technician. Osman Beton, Tolga Han Efe, Hakki Kaya, Murat Bilgin, Lale Dinc Asarcikli, and Mehmet Birhan Yilmaz Copyright © 2015 Osman Beton et al. All rights reserved. Ruptured Sinus of Valsalva Aneurysm into the Left Atrium with Multiple Fistulous Communications: A Rare Cause of Heart Failure Sun, 27 Dec 2015 08:32:24 +0000 http://www.hindawi.com/journals/cric/2015/627946/ Ruptured noncoronary sinus of valsalva aneurysm with fistulous connections to multiple cardiac chambers has not been reported previously. We report a 66-year-old man who presented with worsening cough and exertional dyspnea. Transesophageal echocardiogram confirmed a large aneurysm involving the noncoronary cusp of the aortic sinus with aneurysmal extension to the left atrium. There were also two fistulous communications with the left atrium and one small fistulous connection with the right atrium. Open-heart surgery with aortic root replacement and reimplantation of coronary arteries along with primary closure and repair of aorta to the left atrial fistula was performed. Yashwant Agrawal, Rakshita Chandrashekhar, Jerry W. Pratt, Maria D. Cole, Sreenivas Kamath, and Jagadeesh K. Kalavakunta Copyright © 2015 Yashwant Agrawal et al. All rights reserved. Rare Cause of Wide QRS Tachycardia Tue, 15 Dec 2015 08:11:03 +0000 http://www.hindawi.com/journals/cric/2015/151269/ Cardiac involvement is a well-known feature of neuromuscular diseases. Most commonly cardiac manifestations occur later in the course of the disease. Occasionally severe cardiac disease, including conduction disturbances, life-threatening arrhythmias, and cardiomyopathy, with its impact on prognosis, may be dissociated from peripheral myopathy. We report a case of bundle branch reentrant ventricular tachycardia as primary manifestation of myotonic dystrophy and discuss associated diagnostic and treatment challenges. Nikolay Yu. Mironov, Natalia A. Mironova, Marina A. Saidova, Olga V. Stukalova, and Sergey P. Golitsyn Copyright © 2015 Nikolay Yu. Mironov et al. All rights reserved. Rapid Switch from Intra-Aortic Balloon Pumping to Percutaneous Cardiopulmonary Support Using Perclose ProGlide Wed, 09 Dec 2015 11:04:48 +0000 http://www.hindawi.com/journals/cric/2015/407059/ We present a case of a patient who needed rapid switch from intra-aortic balloon pumping (IABP) to percutaneous cardiopulmonary support (PCPS)/venoarterial extracorporeal membrane oxygenation. It is difficult to switch from IABP to PCPS, because 0.035-inch guidewires cannot pass the IABP guidewire lumen (0.025-inch compatible), and the IABP sheath needs to be removed together with the IABP catheter. First, a 0.025-inch guidewire was inserted into the IABP wire lumen, and then the IABP catheter together with the 8 Fr IABP sheath was removed, leaving the 0.025-inch guidewire in place. We used the Perclose ProGlide for safe and rapid exchange of the 0.025-inch guidewire for a 0.035-inch guidewire. This allowed insertion of a PCPS cannula and the prompt initiation of PCPS. Kenichi Sakakura, Yusuke Adachi, Yousuke Taniguchi, Hiroshi Wada, Shin-ichi Momomura, and Hideo Fujita Copyright © 2015 Kenichi Sakakura et al. All rights reserved. An Atypical Case of Apical Hypertrophic Cardiomyopathy: Absence of Giant T Waves in spite of Extreme Apical Wall Hypertrophy Tue, 08 Dec 2015 07:40:29 +0000 http://www.hindawi.com/journals/cric/2015/980971/ Apical hypertrophic cardiomyopathy is an uncommon variant of hypertrophic cardiomyopathy, with hypertrophy mainly affecting the apex of the left ventricle. We hereby describe a case of an octogenarian female patient who was randomly diagnosed with AHCM due to other comorbidities. Elias Sanidas, Maria Bonou, Georgios Anastasiadis, Georgios Tzanis, and John Barbetseas Copyright © 2015 Elias Sanidas et al. All rights reserved. Acute Myocarditis in a Patient with Newly Diagnosed Granulomatosis with Polyangiitis Mon, 07 Dec 2015 11:14:28 +0000 http://www.hindawi.com/journals/cric/2015/134529/ A 22-year-old woman recently diagnosed with granulomatosis with polyangiitis (GPA) was admitted to the department of cardiology due to chest pain and shortness of breath. The ECG showed widespread mild PR-segment depression, upwardly convex ST-segment elevation, and T-wave inversion. The troponin T level was elevated at 550 ng/L. Transthoracic echocardiography showed basal inferoseptal thinning and hypokinesis, mild pericardial effusion, and an overall preserved left ventricular ejection fraction of 55%. Global longitudinal strain, however, was clearly reduced. Cardiac magnetic resonance imaging (MRI) showed findings consistent with myocarditis but the etiology of the apical hypokinesis could not be determined with certainty and may well have been due to a myocardial infarction, a notion supported by a coronary angiogram displaying slow flow in the territory of the left anterior descending artery. Finally, an endomyocardial biopsy confirmed the diagnosis of myocarditis. The cardiac symptoms subsided upon treatment with high-dose prednisolone and rituximab. Anne Munch, Jens Sundbøll, Søren Høyer, and Manan Pareek Copyright © 2015 Anne Munch et al. All rights reserved. Aneurysm of the Left Coronary Artery in Postoperative Bland-White-Garland Syndrome Sun, 06 Dec 2015 11:24:12 +0000 http://www.hindawi.com/journals/cric/2015/568014/ We report a case of anomalous left coronary artery from the pulmonary artery (ALCAPA) or Bland-White-Garland syndrome, present the challenges of performing a differential diagnosis, and discuss the treatment of the syndrome. Although ALCAPA is a rare congenital heart disease, it is one of the most common causes of myocardial ischemia in childhood and presents a diagnostic challenge. A four-year-old girl was referred to a pediatric cardiologist for evaluation of mitral valve regurgitation murmur and heart failure. The transthoracic echocardiogram demonstrated the left coronary artery (LCA) not arising from the aorta, presence of coronary collateral circulation, and moderate mitral valve regurgitation. ALCAPA was confirmed using angiotomography. The LCA was surgically reimplanted into the aorta. After 3 years of postoperative follow-up, the patient developed an LCA aneurysm. Diagnosis of cardiac ischemia in childhood remains a challenge, and careful evaluation of coronary arteries on the echocardiogram is an important tool. In this report, we present a case of ALCAPA with an uncommon postoperative outcome. Nathalie Jeanne Magioli Bravo-Valenzuela and Guilherme Ricardo Nunes Silva Copyright © 2015 Nathalie Jeanne Magioli Bravo-Valenzuela and Guilherme Ricardo Nunes Silva. All rights reserved. A Heart Stopping Case of the Bezold-Jarisch Reflex Tue, 01 Dec 2015 13:55:34 +0000 http://www.hindawi.com/journals/cric/2015/359401/ The Bezold-Jarisch reflex is a parasympathetic reflex induced by intense mechanical stimulation of the ventricular myocytes. Exceptionally, cases have been described in patients receiving dobutamine infusion during a stress echocardiography. All were healthy middle-aged women and recovered without sequelae. A healthy 60-year-old woman suffered two 5.9-second episodes of asystole during her 20 mcg/kg/min infusion of dobutamine. Recovery was quick and without sequelae. Echocardiography and coronary angiography were both normal. In conclusion, this is the fourth documented case of a severe Bezold-Jarisch reflex causing asystole during dobutamine infusion. Diagnosis can only be made after excluding all other possible diagnoses, most importantly ischemia. This serves as a reminder of the importance of close monitoring during dobutamine infusion. Marc-Etienne Parent and Serge Lepage Copyright © 2015 Marc-Etienne Parent and Serge Lepage. All rights reserved. Acute Coronary Syndrome: An Unusual Consequence of GERD Tue, 24 Nov 2015 08:27:06 +0000 http://www.hindawi.com/journals/cric/2015/939641/ We report a case of an 83-year-old man with history of coronary artery disease and gastroesophageal reflux disease (GERD) who presented with sudden onset nocturnal dyspnea. He was diagnosed with non-ST elevation myocardial infarction based on the electrocardiographic changes and cardiac biomarker elevation. Cardiac catheterization revealed chronic three-vessel coronary artery disease, with 2 patent grafts and 2 chronically occluded grafts. While at the hospital, the patient experienced a similar episode of nocturnal dyspnea, prompting a barium esophagram, which was suggestive of a stricture in the distal esophagus from long-standing GERD. We hypothesized that he had myocardial ischemia due to increased oxygen demand from uncontrolled GERD symptoms. He had no further ischemic episodes after increasing the dose of antireflux medication over a 6-month follow-up. After presenting our case, we review the literature on this atypical presentation of GERD causing acute coronary syndrome and discuss potential mechanisms. Chui Man Carmen Hui, Santosh K. Padala, Michael Lavelle, Mikhail T. Torosoff, Xinjun Cindy Zhu, and Mandeep S. Sidhu Copyright © 2015 Chui Man Carmen Hui et al. All rights reserved. Recurrent Postmyocardial Infarction Ventricular Tachycardia: An Unusual Culprit Sun, 22 Nov 2015 11:09:36 +0000 http://www.hindawi.com/journals/cric/2015/564394/ Although temporary transvenous pacing is life-saving in patients with myocardial infarction who develop bradyarrhythmias, the electrical complications resulting from it can be fatal and are rarely reported. We report here a patient with acute inferior wall myocardial infarction who required temporary transvenous pacing due to second-degree atrioventricular block accompanied with hypotension. Following coronary angiography and successful revascularisation, the patient developed multiple episodes of monomorphic and polymorphic ventricular tachycardia as well as ventricular fibrillation which on careful inspection were found to be initiated by fusion of the intrinsic and paced complexes. The problem of malignant ventricular tachycardia was solved by simple removal of the pacing lead. To the best of our knowledge, malignant ventricular tachycardia of both monomorphic and polymorphic types initiated by fusion complexes in a paced patient has not been reported in literature. Akhil Kumar Sharma, Nirdesh Jain, Safal Safal, Vikas Kumar, and Sudhanshu Kumar Dwivedi Copyright © 2015 Akhil Kumar Sharma et al. All rights reserved. Left Ventricular Thrombus as a Complication of Clozapine-Induced Cardiomyopathy: A Case Report and Brief Literature Review Wed, 18 Nov 2015 07:11:11 +0000 http://www.hindawi.com/journals/cric/2015/835952/ A 48-year-old male with history of schizoaffective disorder on clozapine presented with chest pain, dyspnea, and new left bundle branch block. He underwent coronary angiography, which revealed no atherosclerosis. The patient’s workup was unrevealing for a cause for the cardiomyopathy and thus it was thought that clozapine was the offending agent. The patient was taken off clozapine and started on guideline directed heart failure therapy. During the course of hospitalization, he was also discovered to have a left ventricular (LV) thrombus for which he received anticoagulation. To our knowledge, this is the first case report of clozapine-induced cardiomyopathy complicated by a LV thrombus. Shahbaz A. Malik, Sarah Malik, Taylor F. Dowsley, and Balwinder Singh Copyright © 2015 Shahbaz A. Malik et al. All rights reserved. Valvular Excrescences: A Possible Transient Phenomenon Mon, 16 Nov 2015 14:29:22 +0000 http://www.hindawi.com/journals/cric/2015/380765/ The thrombogenic potential of Lambl excrescences (LE) is minimal unlike the benign tumour fibroelastoma wherefrom thrombi often originate. We present a patient with multiple strokes within a six-year period. A possible locus on the aortic valve was found and diagnosed as fibroelastoma. Before aortic valve substitution prior finding could not be visualized and surgery was aborted. Due to review of earlier Transesophageal Echocardiography (TEE) and the transient component, LE was accepted as the most plausible diagnosis. This illustrates the need for TEE just before surgery. Peter Marstrand, Maiken Brit Jensen, and Nikolaj Ihlemann Copyright © 2015 Peter Marstrand et al. All rights reserved. Giant Saphenous Venous Graft Aneurysm with Compression of the Pulmonary Artery: A Rare Cause of Heart Failure Mon, 16 Nov 2015 13:58:20 +0000 http://www.hindawi.com/journals/cric/2015/854296/ We report a case of a 74-year-old man who presented with dyspnea on exertion and pedal edema. He had five-vessel coronary artery bypass graft (CABG) surgery twenty-six years ago and redo three-vessel CABG done thirteen years later. Computed tomographic angiography (CTA) of the heart and coronary vessels demonstrated a giant aneurysm arising from the saphenous venous graft (SVG) to the first obtuse marginal of the left circumflex artery compressing the pulmonary artery (PA). He underwent coronary angiography, confirming the CTA findings. Surgical and percutaneous interventions were offered, but the patient opted for conservative management due to the high risk of morbidity and mortality. Jagadeesh K. Kalavakunta, Yashwant Agrawal, Alicia Williams, Jerry W. Pratt, and Frank Saltiel Copyright © 2015 Jagadeesh K. Kalavakunta et al. All rights reserved. Cushing’s Disease Presented by Reversible Dilated Cardiomyopathy Mon, 16 Nov 2015 13:14:10 +0000 http://www.hindawi.com/journals/cric/2015/980897/ Introduction. Dilated cardiomyopathy is rarely reported among CS patients especially without hypertension and left ventricular hypertrophy. Materials and Methods. We hereby report a Cushing’s syndrome case presenting with dilated cardiomyopathy. Results. A 48-year-old female patient was admitted to our clinic with severe proximal myopathy and dilated cardiomyopathy without ventricular hypertrophy. Cushing’s disease was diagnosed and magnetic-resonance imaging of the pituitary gland revealed a microadenoma. Under diuretic and ketoconazole treatments, she underwent a successful transnasal/transsphenoidal adenomectomy procedure. Full recovery of symptoms and echocardiographic features was achieved after six months of surgery. Conclusion. Cushing’s syndrome must be kept in mind as a reversible cause of dilated cardiomyopathy. Recovery of cardiomyopathy is achieved with successful surgery. Berna İmge Aydoğan, Demet Menekşe Gerede, Asena Gökçay Canpolat, and Murat Faik Erdoğan Copyright © 2015 Berna İmge Aydoğan et al. All rights reserved. Insights into the Mechanism of Severe Mitral Regurgitation: RT-3D TEE Guided Management with Pathological Correlation Thu, 12 Nov 2015 09:53:26 +0000 http://www.hindawi.com/journals/cric/2015/961565/ Mitral valve perforation is an uncommon but important complication of infective endocarditis. We report a case of a 65-year-old man who was diagnosed to have infective endocarditis of his mitral valve. Through the course of his admission he had a rapid development of hemodynamic instability and pulmonary edema secondary to acutely worsening mitral regurgitation. While the TEE demonstrated an increase in the size of his bacterial vegetation, Real Time 3D TEE was ultimately the imaging modality through which the valve perforation was identified. Through this case report we discuss the advantages that RT-3D TEE has over traditional 2D TEE in the management of valve perforation. Senthil Anand, Naktal Hamoud, Jess Thompson, and Rajesh Janardhanan Copyright © 2015 Senthil Anand et al. All rights reserved. Multiple Coronary Artery Microfistulas Associated with Apical Hypertrophic Cardiomyopathy: Left and Right Coronary Artery to the Left Ventricle Wed, 11 Nov 2015 12:04:32 +0000 http://www.hindawi.com/journals/cric/2015/819839/ A 76-year-old woman underwent coronary angiography for chest pain. On the coronary angiogram, no significant coronary artery atherosclerotic stenosis was observed. Multiple coronary artery microfistulas, draining from the left anterior descending artery to the left ventricle and from the posterior descending artery of the right coronary artery to the left ventricle, were observed. Apical wall thickening and fistula flow from the left anterior descending artery were demonstrated by using transthoracic echocardiography. We describe a rare case of multiple coronary artery microfistulas from the left and right coronary artery to the left ventricle combined with apical hypertrophic cardiomyopathy. Jeong-Woo Choi, Kyehwan Kim, Min Gyu Kang, Jin-Sin Koh, Jeong Rang Park, and Jin-Yong Hwang Copyright © 2015 Jeong-Woo Choi et al. All rights reserved. Mitral Subvalvular Aneurysm in a Patient with Chagas Disease and Recurrent Episodes of Ventricular Tachycardia Sun, 08 Nov 2015 13:16:20 +0000 http://www.hindawi.com/journals/cric/2015/213104/ Subvalvular left ventricular aneurysm is a rare disease of obscure origin suggesting unique causes such as congenital, traumatic, and inflammatory or infectious diseases. Its mortality is closely related to heart failure, mitral insufficiency, thromboembolic phenomena, and cardiac arrhythmias. Although association with coronary artery disease is not described, the compression of epicardial vessels by the aneurysm may lead to ischemic manifestations. We report here a case of mitral subvalvular left ventricular aneurysm of probable chagasic origin, in a patient with normal left ventricular function evolving with repeated episodes of monomorphic ventricular tachycardia, despite noninducible electrophysiological testing and the use of optimal medical treatment, including amiodarone. The indication for implantable cardioverter-defibrillator in patients with Chagas cardiomyopathy and segmental wall motion abnormalities but without global systolic dysfunction remains unclear in literature, even in the presence of complex ventricular arrhythmias. A brief review of the literature on morphological features, diagnosis, prognosis, and treatment will be also discussed. Tereza Augusta Grillo, Guilherme Rafael S. Athayde, Ana Flávia L. Belfort, Reynaldo C. Miranda, Andrea Z. Beaton, and Bruno R. Nascimento Copyright © 2015 Tereza Augusta Grillo et al. All rights reserved.