Case Reports in Cardiology The latest articles from Hindawi © 2017 , Hindawi Limited . All rights reserved. Pneumomediastinum and Mediastinal Hematoma Secondary to Right Brachiocephalic Vein Thrombectomy Mimicking STEMI Tue, 18 Jul 2017 08:15:11 +0000 A 50-year-old male with a history of hemodialysis dependent chronic kidney disease presented to our emergency department with acute midsternal crushing chest pain. Patient was diagnosed with acute anterolateral wall Myocardial Infraction due to the presence of corresponding ST segment elevations in EKG and underwent emergent cardiac catheterization which revealed normal patent coronaries without any disease. He continued to have chest pain for which CT of the chest was done which revealed pneumomediastinum with mediastinal hematoma, due to the recent attempted thrombectomy for thrombus in his right brachiocephalic vein. Prem Shukla, Prudence Dy, Rishi Raj, Sayee Sundar Alagusundaramoorthy, and Noel Nivera Copyright © 2017 Prem Shukla et al. All rights reserved. Acute Myocardial Infarction Caused by an Anomalous Right Coronary Artery Occlusion Presenting with Precordial ST Elevation Sun, 16 Jul 2017 07:03:57 +0000 Acute coronary syndrome with precordial ST segment elevation is usually related to left anterior descending artery occlusion, although isolated right ventricular infarction has been described as a cause of ST elevation in V1–V3 leads. We present a case of a patient with previous inferior wall infarction and new acute ST elevation myocardial infarction (STEMI) due to proximal right coronary thrombotic occlusion resulting in right ventricular infarction with precordial ST elevation and sinus node dysfunction. The patient was treated with successful rescue angioplasty achieving resolution of acute symptoms and electrocardiographic abnormalities. Bruno da Silva Matte and Alexandre Damiani Azmus Copyright © 2017 Bruno da Silva Matte and Alexandre Damiani Azmus. All rights reserved. Fulminant Myocarditis Managed by Extracorporeal Life Support (Impella® CP): A Rare Case Wed, 12 Jul 2017 07:37:55 +0000 Background. Treating myocarditis can be difficult, as clear criteria for diagnosis and management are lacking for heterogeneous clinical presentations. Case Description. We report a case of a 49-year-old female who presented with cardiogenic shock and subsequent cardiac arrest. Extracorporeal life support was instituted, and after eight days with Impella CP the patient recovered and at six months presented with normal cardiac function. Conclusion. Fulminant myocarditis remains a challenging disease in daily clinical practice, not only for diagnosis, but also for treatment. With this report we emphasize that myocardial failure due to fulminant myocarditis may be reversible if treated with extracorporeal life support, which thus plays an important and life-saving role. Henrik Fox, Martin Farr, Dieter Horstkotte, and Christian Flottmann Copyright © 2017 Henrik Fox et al. All rights reserved. Isolated Major Aortopulmonary Collateral as the Sole Pulmonary Blood Supply to an Entire Lung Segment Wed, 12 Jul 2017 07:13:57 +0000 Congenital systemic-to-pulmonary collateral arteries or major aortopulmonary collaterals are associated with cyanotic congenital heart disease with decreased pulmonary blood flow. Though it is usually associated with congenital heart diseases, there is an increased incidence of isolated acquired aortopulmonary collaterals in premature infants with chronic lung disease. Interestingly, isolated congenital aortopulmonary collaterals can occur without any lung disease, which may cause congestive heart failure and require closure. We present a neonate with an echocardiogram that showed only left-sided heart dilation. Further workup with a CT angiogram demonstrated an anomalous systemic artery from the descending thoracic aorta supplying the left lower lobe. He eventually developed heart failure symptoms and was taken to the catheterization laboratory for closure of the collateral. However, with the collateral being the only source of blood flow to the entire left lower lobe, he required surgical unifocalization. Isolated aortopulmonary collaterals without any other congenital heart disease or lung disease are rare. Our patient is the first reported case to have an isolated aortopulmonary collateral being the sole pulmonary blood supply to an entire lung segment. Due to its rarity, there is still much to learn about the origin and development of these collaterals that possibly developed prenatally. Hannah S. Kim, R. Mark Grady, and Shabana Shahanavaz Copyright © 2017 Hannah S. Kim et al. All rights reserved. Combination of Carbon Dioxide Angiography and Outback® Elite for Revascularization of a Patient with Renal Insufficiency with Bilateral Femoropopliteal Chronic Total Occlusions Sun, 09 Jul 2017 00:00:00 +0000 A new reentry device (Outback Elite) system has been available in Japan since June 2016. This new device enables easier treatment of chronic total occlusion (CTO) in the lower extremities. We report a case of a woman in her 70s who underwent revascularization using this new device twice to treat both of her femoropopliteal CTO lesions. She was referred to our hospital complaining of intermittent claudication in both legs. She had a long history of diabetes mellitus complicated with severe chronic kidney disease. Her estimated glomerular filtration rate was <20. She refused surgical revascularization; therefore, we performed our treatment without iodine contrast medium. First, magnetic resonance imaging was performed to confirm that the CTO lesions had caused severe claudication before intervention. Subsequently, the Outback Elite device and carbon dioxide (CO2) angiography made it possible to revascularize both of her legs without iodine contrast medium. At 6 months after the procedures, we did not observe exacerbation of claudication in her legs. Yuhei Nojima, Shinsuke Nanto, Hidenori Adachi, Madoka Ihara, and Tetsuya Kurimoto Copyright © 2017 Yuhei Nojima et al. All rights reserved. Lyme Carditis Buried Beneath ST-Segment Elevations Wed, 21 Jun 2017 00:00:00 +0000 Lyme disease is caused by the spirochete Borrelia burgdorferi and is carried to human hosts by infected ticks. There are nearly 30,000 cases of Lyme disease reported to the CDC each year, with 3-4% of those cases reporting Lyme carditis. The most common manifestation of Lyme carditis is partial heart block following bacterial-induced inflammation of the conducting nodes. Here we report a 45-year-old gentleman that presented to the hospital with intense nonradiating chest pressure and tightness. Lab studies were remarkable for elevated troponins. EKG demonstrated normal sinus rhythm with mild ST elevations. Three weeks prior to hospital presentation, patient had gone hunting near Madison. One week prior to admission, he noticed an erythematous lesion on his right shoulder. Because of his constellation of history, arthralgias, and carditis, he was started on ceftriaxone to treat probable Lyme disease. This case illustrates the importance of thorough history taking and extensive physical examination when assessing a case of possible acute myocardial infarction. Because Lyme carditis is reversible, recognition of this syndrome in young patients, whether in the form of AV block, myocarditis, or acute myocardial ischemia, is critical to the initiation of appropriate antibiotics in order to prevent permanent heart block, or even death. Basia Michalski and Adrian Umpierrez De Reguero Copyright © 2017 Basia Michalski and Adrian Umpierrez De Reguero. All rights reserved. Development of New Deep Venous Thrombosis While on Apixaban Tue, 20 Jun 2017 09:33:48 +0000 The efficacy of novel oral anticoagulants (NOACs) in preventing deep venous thrombosis (DVT) has been established in large multicenter trials. Predictable pharmacokinetics, avoidance of routine laboratory monitoring, and lesser drug interactions have made NOACs safer and more tolerable treatment option in comparison to warfarin. However, cases of treatment failure mainly due to interindividual variation in plasma drug levels can be seen rarely. In this report we describe a case of acute DVT of right lower extremity in a patient who was on apixaban for prevention of venous thromboembolism (VTE) due to underlying nonvalvular atrial fibrillation (NVAF). Munish Sharma, Sabarina Ramanathan, and Koroush Khalighi Copyright © 2017 Munish Sharma et al. All rights reserved. Pulmonary Hemorrhage following Edge-to-Edge Mitral Valve Repair Mon, 19 Jun 2017 07:58:36 +0000 Mitral valve repair with the MitraClip device has emerged as an effective treatment option for patients with severe mitral regurgitation and contraindications for surgical interventions. While the procedure is not known to cause pulmonary complications, we describe two cases of pulmonary hemorrhage following percutaneous mitral valve repair. The patients did well with supportive care and reinitiation of anticlotting agents was well tolerated after resolution of bleeding. Mirna B. Ayache, Myttle A. Mayuga, Chantal ElAmm, Guilherme Attizzani, and Jordan Kazakov Copyright © 2017 Mirna B. Ayache et al. All rights reserved. When Is the Optimal Timing of Surgical Intervention for Severe Functional Tricuspid Regurgitation? Mon, 19 Jun 2017 00:00:00 +0000 Functional tricuspid regurgitation (TR) is a serious pathology to be noted for severe right heart failure (HF) and poor prognosis; however, the conventional assessment of TR has some limitations and the optimal timing of surgical intervention remains unclear. A 79-year-old Japanese female was admitted to our hospital to undergo cardiac surgery, because edema gradually got worse despite the increase in diuretics. She had a history of atrial fibrillation (AF) and chronic HF due to severe TR and had been treated with a furosemide for leg edema 4 years ago. A transthoracic echocardiogram (TTE), transesophageal echocardiogram, cardiac magnetic resonance imaging, and cardiac pool scintigraphy demonstrated severe functional TR with tricuspid annular dilation, insufficient tricuspid valve coaptation, and reduced right ventricular ejection fraction (EF) but preserved left ventricular EF. In addition, Swan-Ganz catheter study showed normal pulmonary arterial wedge pressure and mean pulmonary arterial pressure. Tricuspid ring annuloplasty was performed with MC3 ring. Postoperative TTE showed trivial TR, and she had no edema with normal sinus rhythm two months later. Annuloplasty to severe functional TR caused by tricuspid annular dilation due to AF dramatically improved right HF. Cardiologist should pay strict attention to the optimal timing of surgical intervention for TR. Nobuhiro Nakanishi, Masanobu Ishii, Koichi Kaikita, Ken Okamoto, Yasuhiro Izumiya, Eiichiro Yamamoto, Seiji Takashio, Seiji Hokimoto, Toshihiro Fukui, and Kenichi Tsujita Copyright © 2017 Nobuhiro Nakanishi et al. All rights reserved. First Reported Case of Hemopericardium Related to Dabigatran Use Reversed by New Antidote Idarucizumab Wed, 14 Jun 2017 00:00:00 +0000 Dabigatran, the first novel oral anticoagulant (NOAC) with a reversal agent, heralded a paradigm shift in the treatment of nonvalvular atrial fibrillation. The potential for life-threatening hemorrhagic events with the use of NOACs has been highly debated since the effectiveness of reversal agents such as idarucizumab is based primarily on pharmacologic data. It is known that cancer patients are at an increased risk of bleeding with anticoagulation, though specific studies demonstrating the risks or efficacy of NOACs in this population are lacking. We provide the first report of hemopericardium resulting in multiorgan failure related to dabigatran use that was successfully reversed by idarucizumab in a man with prostate cancer on chemotherapy. Steven Song, Joselle Cook, Clive Goulbourne, Matthew Meade, Louis Salciccioli, and Jason Lazar Copyright © 2017 Steven Song et al. All rights reserved. Cardiac Dysrhythmias and Neurological Dysregulation: Manifestations of Profound Hypomagnesemia Mon, 05 Jun 2017 09:07:39 +0000 Magnesium is the second most common intracellular cation and serves as an important metabolic cofactor to over 300 enzymatic reactions throughout the human body. Among its various roles, magnesium modulates calcium entry and release from sarcoplasmic reticulum and regulates ATP pumps in myocytes and neurons, thereby regulating cardiac and neuronal excitability. Therefore, deficiency of this essential mineral may result in serious cardiovascular and neurologic derangements. In this case, we present the clinical course of a 76-year-old woman who presented with marked cardiac and neurological signs and symptoms which developed as a result of severe hypomagnesemia. The patient promptly responded to magnesium replacement once the diagnosis was established. We herein discuss the clinical presentation, pathophysiology, diagnosis, and management of severe hypomagnesemia and emphasize the implications of magnesium deficiency in the cardiovascular and central nervous systems. Furthermore, this case highlights the importance of having high vigilance for hypomagnesemia in the appropriate clinical setting. Sagger Mawri, Edward Gildeh, Namita Joseph, Bobak Rabbani, and Bryan Zweig Copyright © 2017 Sagger Mawri et al. All rights reserved. Torsade de Pointes Induced by Hypokalemia from Imipenem and Piperacillin Tue, 30 May 2017 08:47:13 +0000 Imipenem-cilastatin and piperacillin-tazobactam are two antibiotics with broad antimicrobial coverage. Besides the many well established adverse effects of these drugs, there have been few case reports of hypokalemia. Here we present an interesting case of resistant hypokalemia caused by these drugs leading to Torsades de Pointes which has never been reported in the past. Hypokalemia resolved with discontinuation of piperacillin. Varun Kumar, Sandeep Khosla, and Monica Stancu Copyright © 2017 Varun Kumar et al. All rights reserved. False Positive Transit Time Flowmetry Graft Failure in Multivessel Coronary Spasm following Off-Pump Coronary Artery Bypass Grafting Sun, 28 May 2017 07:55:01 +0000 Intraoperative Transit Time Flowmetry is currently recommended to assess graft patency during coronary artery bypass grafting (CABG), especially in presence of haemodynamic instability or inability to wean the patient from cardiopulmonary bypass, new regional wall motion abnormalities, or significant ventricular arrhythmias. The VeriQ™ system is one of the currently available systems, which detects imperfections that may be corrected by graft revision. In this case report, multivessel coronary spasm (CS) post-CABG interferes with these intraoperative parameters misleading initially into false results. Cardiac surgeons should bear in mind the limit of VeriQ in distinguishing between graft failure and CS. Angiography may be considered in patients with decreased graft flow despite revision of anastomosis and vasodilatory treatment for the definitive diagnosis. George Kassimis and George Krasopoulos Copyright © 2017 George Kassimis and George Krasopoulos. All rights reserved. Acute Lymphoblastic Leukemia with Infective Endocarditis Presented with Unusual Intracardiac Mass Sun, 28 May 2017 07:17:59 +0000 Acute lymphoblastic leukemia (ALL) is a systemic disease that is presented with different symptoms and signs. Cardiac manifestation is rare in ALL, but it is very important and needs appropriate management. It usually presents as leukemic myocardial infiltration and in the presence of cardiac mass comprehensive evaluation for other etiologies is mandatory. We reported on a 6-year-old boy in remission phase of ALL and large cardiac mass in the right atrium with obscure early symptoms and signs, in whom infective endocarditis (IE) was diagnosed and appropriate medical treatment was performed. Because the mass was sustained, surgical resection was considered for the patient. Ali Sadeghpour Tabaei, Leili Koochakzadeh, Mohammadrafie Khorgami, and Sepehr Sadeghpour Tabaei Copyright © 2017 Ali Sadeghpour Tabaei et al. All rights reserved. A Rare Case of Pneumopericardium in the Setting of Tuberculous Constrictive Pericarditis Sun, 28 May 2017 00:00:00 +0000 A 28-year-old Filipino male was admitted due to high-grade fevers and dyspnea on a background of chronic cough and weight loss. Due to clinical and echocardiographic signs of cardiac tamponade, emergency pericardiocentesis was performed on his first hospital day. Five days after, chest radiographs showed new pockets of radiolucency within the cardiac shadow, indicative of pneumopericardium. On repeat echo, air microbubbles admixed with loculated effusion were visualized in the anterior pericardial space. Constrictive physiology was also supported by a thickened pericardium, septal bounce, exaggerated respiratory variation in AV valve inflow, and IVC plethora. A chest CT scan confirmed the presence of an air-fluid level within the pericardial sac. The patient was started on a quadruple antituberculosis regimen and IV piperacillin-tazobactam to cover for superimposed acute bacterial pericarditis. Pericardiectomy was performed as definitive management, with stripped pericardium measuring 5–7 mm thick and caseous material extracted from the pericardial sac. Histopathology was consistent with tuberculosis. This report highlights pneumopericardium as a rare complication of pericardiocentesis. We focused on the utility of echocardiography for diagnosing and monitoring this condition on a background of tuberculous constrictive pericarditis, ultimately convincing us that pericardiectomy was necessary, instead of the usual conservative measures for pneumopericardium. Lauro L. Abrahan IV, Stephanie Martha O. Obillos, Jaime Alfonso M. Aherrera, Jose Donato A. Magno, Celia Catherine C. Uy-Agbayani, Ulysses King G. Gopez, and Jobelle Joyce Anne R. Baldonado Copyright © 2017 Lauro L. Abrahan IV et al. All rights reserved. Mitochondrial Cardiomyopathy Presenting as Dilated Phase of Hypertrophic Cardiomyopathy Diagnosed with Histological and Genetic Analyses Tue, 23 May 2017 08:26:04 +0000 We report a case with 46-year-old man diagnosed with mitochondrial cardiomyopathy in the dilated phase of hypertrophic cardiomyopathy. Since cardiac magnetic resonance imaging, beta-methyl-p--iodophenyl-pentadecanoic myocardial scintigraphy, and positron emission tomography/computed tomography revealed no remarkable findings, we performed electron microscopic examination, which aided in diagnosing mitochondrial cardiomyopathy. Muscle biopsy was also compatible with mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes and DNA analysis also concluded it. Since muscle biopsy is less invasive for patients compared to endomyocardial biopsy, cardiologists need to consider it. The diagnosis of mitochondrial cardiomyopathy is helpful because it is a genetic condition and also for consideration of device therapy, as well as management for acute crisis. Toshiki Kuno, Syohei Imaeda, Yohei Asakawa, Hiroshi Nakamura, Genzou Takemura, Daisuke Asahara, Akira Kanamori, Tomoyuki Kabutoya, and Yohei Numasawa Copyright © 2017 Toshiki Kuno et al. All rights reserved. Aneurysm of the Pulmonary Artery in Fallot’s Tetralogy Mon, 22 May 2017 00:00:00 +0000 Introduction. Pulmonary artery aneurysms are a rare entity. Etiologies of these findings are multiple, but they are exceptionally associated with Fallot’s Tetralogy. In this study, we present an unusual case of an important aneurysm of the left pulmonary artery associated with Fallot’s Tetralogy disease. Case Presentation. A 30-year-old woman has been admitted for dyspnea and cyanosis. The data which had been obtained from echocardiography, cardiac catheterization, and angio-magnetic resonance imaging (MRI) suggested the existence of an important aneurysm of the left pulmonary artery associated with a regular Fallot’s disease with a pulmonic stenosis. We have noticed the presence of a small restrictive patent ductus arteriosus (PDA). Therefore, the patient was referred to surgical correction. Conclusion. Pulmonary artery aneurysms associated with Fallot’s Tetralogy are rarely reported. The natural history of these rare arterial aneurysms has to be clarified. Kawtar Afrikh, Loua Hattach, Nadia Fellat, Mustapha El Bakkali, and Halima Benjelloun Copyright © 2017 Kawtar Afrikh et al. All rights reserved. Type A Quadricuspid Aortic Valve Infective Endocarditis Complicated by Multiple Aortocardiac Fistulae: Case Report and Brief Literature Review Thu, 18 May 2017 00:00:00 +0000 Aortocardiac fistulae (ACF) are exceptionally due to infective endocarditis; they are usually congenital, posttraumatic, or complicate aortic dissection. In infective endocarditis setting, their presence should prompt urgent surgery as patients can deteriorate rapidly. We report the case of a 78-year-old female patient with the first ever reported quadricuspid aortic valve infective endocarditis complicated by multiple aortocardiac fistulae. Additionally, we provide a brief review of ACF, in infective endocarditis and quadricuspid aortic valve. Amine Ghalem, Mohammed Bachrif, Anass Hbali, Mostapha Beghi, Nabila Ismaili, and Noha El Ouafi Copyright © 2017 Amine Ghalem et al. All rights reserved. Saphenovenous Graft Aneurysm: A Rare Complication of CABG Thu, 18 May 2017 00:00:00 +0000 Saphenovenous graft aneurysm is a rare complication of coronary artery bypass grafts that is likely underdiagnosed. It is typically asymptomatic, slow growing, and often diagnosed incidentally on angiography or following catastrophic rupture. There is no consensus on best management but PCI and surgery appear to have more favourable mortality outcomes relative to conservative management. We present the case of a 48-year-old male with a cardiovascular risk profile hallmarked by diabetes mellitus, end stage renal failure, recalcitrant hyperlipidaemia, and IHD previously treated with CABG. 11 years following his CABG, he was retrieved from remote Australia to a tertiary cardiology centre with stabbing chest pain. Serial cardiac enzymes were negative. Echocardiogram identified a mass compressing the right ventricular wall. Noncontrast coronary angiogram ultimately identified a large aneurysm at the proximal end of SVG to PDA. He was managed with aggressive risk factor modification prior to planned surgical intervention once medically optimized. His case supports the role of aggressive medical management combined with surgical intervention. James Thomas Connell Copyright © 2017 James Thomas Connell. All rights reserved. Anomalous Papillary Muscle Insertion Causing Dynamic Left Ventricular Outflow Tract Obstruction without Hypertrophic Obstructive Cardiomyopathy Mon, 15 May 2017 00:00:00 +0000 Anomalous papillary muscle insertion directly into the surface of the mitral valve leaflet is rare, especially in a subject without apparent evidence of hypertrophic cardiomyopathy. We present a case of this isolated congenital malformation producing two hemodynamic sequelae of dynamic left ventricular outflow tract obstruction and severe mitral regurgitation. Ravi Korabathina, Katherine Chiu, Hugh M. van Gelder, and Arthur Labovitz Copyright © 2017 Ravi Korabathina et al. All rights reserved. Pyridostigmine Induced Prolonged Asystole in a Patient with Myasthenia Gravis Successfully Treated with Hyoscyamine Sun, 14 May 2017 08:10:34 +0000 Reversible acetylcholinesterase inhibitors are used as first-line treatment for myasthenia gravis. They improve symptoms by increasing concentration of acetylcholine at the neuromuscular junction and stimulating nicotinic receptors. Serious bradyarrhythmias can occur from muscarinic stimulation in heart, which in rare cases may progress to asystole. These patients can initially be managed with hyoscyamine, a muscarinic antagonist. Persistence of bradyarrhythmias even after hyoscyamine treatment may warrant pacemaker placement. We present a case of 65-year-old female patient who presented with diplopia, dysphagia, and muscle weakness who was diagnosed with myasthenia gravis. She developed significant sinoatrial node block with prolonged asystole after starting treatment with pyridostigmine which was successfully treated with hyoscyamine, thus avoiding pacemaker placement. Mohammad Saud Khan, Abhinav Tiwari, Zubair Khan, Himani Sharma, Mohammad Taleb, and Jeffrey Hammersley Copyright © 2017 Mohammad Saud Khan et al. All rights reserved. Failed TAVI in TAVI Implantation: TAVI Dislocation Followed by Ensuing Surgical Graft Resection Sun, 30 Apr 2017 00:00:00 +0000 We are presenting a case report of failed valve-in-valve treatment of severe aortic stenosis. A control ultrasonography after TAVI implantation revealed a severe aortic regurgitation of the graft which was subsequently unresolved with postimplantation dilatation. Second TAVI was implanted with cranial dislocation to the aortic root. Patient underwent a CT examination to clarify the TAVI in TAVI position. Patient underwent a surgical resection of TAVI with implantation of biological aortic valve prosthesis. In situations where TAVI treatment fails or is complicated beyond the possibility of endovascular repair, surgical intervention despite its higher risks is the preferred choice. Róbert Novotný, Jaroslav Hlubocký, Tomáš Kovárník, Petr Mitáš, Zuzana Hlubocka, Jan Rulíšek, Sevim Ismihan Gulmez, Shubjiwan Kaur Ghotra, and Jaroslav Lindner Copyright © 2017 Róbert Novotný et al. All rights reserved. Sorafenib-Associated Heart Failure Complicated by Cardiogenic Shock after Treatment of Advanced Stage Hepatocellular Carcinoma: A Clinical Case Discussion Thu, 27 Apr 2017 00:00:00 +0000 Background. Sorafenib, an oral tyrosine kinase inhibitor (TKI), targets multiple tyrosine kinase receptors (TKRs) involved in angiogenesis and tumor growth. Studies suggest that inhibition of TKR impacts cardiomyocyte survival. Inhibition of VEGF signaling interrupts angiogenesis and is associated with the development of hypertension and compensatory hypertrophy. Compensated hypertrophy ultimately leads to heart failure. Case Description. A 76-year-old man with a past medical history of systolic heart failure due to ischemic cardiomyopathy and stage IIIC hepatocellular carcinoma (HCC) presented with symptoms of decompensated heart failure. Four months prior to admission, he was started on sorafenib. Results. Our patient was treated with intravenous furosemide and guideline directed therapy. Clinical status was complicated by the development of low cardiac output and shock requiring inotropic support. Careful titration of heart failure medication led to hemodynamic improvement and discontinuation of dobutamine. Conclusion. Greater awareness of sorafenib cardiotoxicity is essential. As TKI usage grows for treatment of cancers, heart failure-related complications will increase. In our patient, routine heart failure management and cessation of sorafenib led to clinical improvement. Future studies on the treatment of sorafenib cardiotoxicity should be explored further in this unique patient population. Candace Wu and Kamal Shemisa Copyright © 2017 Candace Wu and Kamal Shemisa. All rights reserved. A Novel, Modified Reverse Controlled Antegrade and Retrograde Subintimal Tracking Technique for Bypassing the Calcified Proximal Cap of Coronary Total Occlusions Wed, 26 Apr 2017 08:08:55 +0000 Antegrade crossing is the most common approach to chronic total occlusions (CTOs). However, it is sometimes difficult to penetrate the proximal hard cap with guidewires, especially in the case of CTOs of anomalous coronary arteries because of a lack of support. Herein, we describe a novel, modified reverse controlled antegrade and retrograde subintimal tracking (CART) technique in which the dissection reentry was intentionally created in the proximal segment of the vessel, not within the occluded segment, using retrograde guidewire and the aid of an antegrade balloon. This technique facilitated retrograde crossing of CTOs by avoiding the proximal hard cap and may provide a viable option for patients in which conventional reverse CART is not possible. Tsuyoshi Isawa, Masahiko Ochiai, Masato Munehisa, and Tatsushi Ootomo Copyright © 2017 Tsuyoshi Isawa et al. All rights reserved. Cryoablation for Ventricular Tachycardia Originating from Anterior Papillary Muscle of Left Ventricle Guided by Intracardiac Echocardiography Thu, 20 Apr 2017 06:59:36 +0000 Papillary muscles (PMs) were reported to be origin of ventricular arrhythmia (VA). Radiofrequency (RF) ablation was reported to be acutely effective in eliminating VA. However, the recurrence rate is high. Recently, cryoablation guided by intracardiac echocardiography, 3-dimensional mapping system, and image integration was introduced as alternative strategy for this challenging ablation. We present a case of ventricular tachycardia originating from anterior PM of left ventricle treated by cryoablation guided only by intracardiac echocardiography. Ibrahim Marai, Nizar Andria, and Osnat Gurevitz Copyright © 2017 Ibrahim Marai et al. All rights reserved. Left Atrial Myxoma in Pregnancy: Management Strategy Using Minimally Invasive Surgical Approach Sun, 16 Apr 2017 08:24:47 +0000 This case report concerns a young woman who, during her pregnancy, suffered severe mitral regurgitation. It was discovered at the same time that she had a left atrial myxoma. During the early postpartum period she successfully underwent an anterior minithoracotomy to remove the left atrial myxoma in conjunction with repair of the mitral valve. The thoracotomy approach in this specific patient was chosen as it would give a better chance of successful mother-child bonding because the patient would be able to avoid the precautions which would have been necessary following a sternotomy, especially the limitation of her ability to hold her child during the first 4–6 weeks postoperatively. Noppon Taksaudom, Kuntharee Traisrisilp, and Rungsrit Kanjanavanit Copyright © 2017 Noppon Taksaudom et al. All rights reserved. Retrieval of Embolized Amplatzer Patent Foramen Ovale Occlusion Device: Issues Related to Late Recognition Sun, 16 Apr 2017 08:12:31 +0000 Embolization of a percutaneous patent foramen ovale (PFO) closure device is a rare but serious complication. While early, periprocedural device embolization can normally be managed with snare and percutaneous retrieval, late embolization requires a different management strategy due to inability of the device to deform to allow passage into a large caliber sheath. We present a case of asymptomatic device embolization recognized six months following implantation and discuss the challenges encountered in successfully retrieving the device. Allan J. Davies, Nicholas Collins, and Nicole Organ Copyright © 2017 Allan J. Davies et al. All rights reserved. Absence of Left Circumflex Artery: A Rare Congenital Disorder of Coronary Arteries Sun, 16 Apr 2017 07:50:50 +0000 Congenital absence of left circumflex artery is a rare occurrence and very few cases have been reported in literature. It is a benign incidental finding; however some patients present with sudden onset chest pain mimicking acute coronary syndrome often resulting in detection of this rare anatomy on coronary angiography. Coronary computed tomography angiography is a relatively new noninvasive imaging modality which can be used to confirm this suspicion and diagnose this unique morphology reliably. Saad Ullah, Muzammil Khan, Noman Ahmed Jang Khan, Hassan Zeb, and Roshan Patel Copyright © 2017 Saad Ullah et al. All rights reserved. Severe Dilatation of Coronary Artery Ostium Complicating Sinus of Valsalva Aneurysm: Differential Diagnosis and Review of the Literature Thu, 13 Apr 2017 10:13:49 +0000 Coronary artery dilatation may be due to various aetiologies including congenital anomalies, atherosclerotic coronary disease, and Kawasakis disease. We describe a case characterised by apparent severe dilatation of the right coronary artery ostium in an asymptomatic male. Subsequent imaging and surgical intervention documented the presence of a sinus of Valsalva aneurysm extending into the ostium of the right coronary artery. This represents an unusual manifestation of a sinus of Valsalva aneurysm. The underlying pathophysiology, differential diagnosis, role of surgical management, and outcomes are discussed. Paul Bamford and Nicholas Collins Copyright © 2017 Paul Bamford and Nicholas Collins. All rights reserved. Reversible Myocardial Injury and Intraventricular Thrombus Associated with Aluminium Phosphide Poisoning Sun, 09 Apr 2017 10:45:14 +0000 Aluminium phosphide (ALP) is widely used as a fumigant pesticide. In case of ALP poisoning, it is responsible for myocardial dysfunction, related to toxic myocarditis, and hemodynamic disorders. We report a case of a 28-year-old female who had intentionally ingested ALP and was admitted with cardiogenic shock. The transthoracic echocardiography (TTE) at the time of admission showed severe global myocardial hypokinesia with the presence of a giant left ventricular thrombus. Cardiovascular magnetic resonance (CMR) revealed extensive toxic myocarditis with a left ventricular systolic dysfunction. All cardiac lesions were reversible after symptomatic treatment, within 6 months. We aim, by reporting this case, to evidence the complete reversibility of cardiac injury due to aluminium phosphide poisoning documented by transthoracic echocardiography and cardiovascular magnetic resonance. Abdelkader Jalil El Hangouche, Hala Fennich, Oumaima Alaika, Taoufiq Dakka, Zaineb Raissouni, Latifa Oukerraj, Nawal Doghmi, and Mohamed Cherti Copyright © 2017 Abdelkader Jalil El Hangouche et al. All rights reserved.