Case Reports in Cardiology The latest articles from Hindawi © 2018 , Hindawi Limited . All rights reserved. Giant Left Ventricular Thrombus in a Patient with Acute Ischemic Stroke: A Case Report and Minireview Sun, 14 Jan 2018 00:00:00 +0000 A 56-year-old healthy male with no obvious risk factors or significant past medical history was admitted to the emergency room with acute ischemic stroke. On his transthoracic echocardiography (TTE), an extremely large thrombus was detected at the apex involving the distal anterior wall. The thrombus was predominantly adherent but with a mobile tip. The patient was subsequently managed with dual antiplatelet therapy. In this report, we present an interesting case of an acute ischemic stroke secondary to a giant left ventricular thrombus in a patient with no past significant cardiac or neurologic medical history. Fan Ye, Burton V. Silverstein, Matheen A. Khuddus, Christopher L. Bray, and Arthur C. Lee Copyright © 2018 Fan Ye et al. All rights reserved. Successful Rotational Atherectomy for an Angulated Calcified Lesion in an Anomalous Right Coronary Artery Using the “Mother-and-Child” Technique Sun, 14 Jan 2018 00:00:00 +0000 Percutaneous coronary intervention (PCI) involving the anomalous coronary artery is challenging with respect to difficulty in achieving stable catheterization. Rotational atherectomy (RA) can facilitate severely calcified lesions to improve stent delivery and stent expansion; however, its utility in tortuous and angulated coronary arteries is limited with difficulty in delivery of the RA burr. The mother-and-child technique is effective for complex PCIs with increased backup force for device delivery in such complicated cases. We report a case of successful rotational atherectomy using the “mother-and-child” technique with a Dio thrombus aspiration catheter for an angulated calcified lesion in an anomalous origin of the right coronary artery. Manabu Ogita, Satoru Suwa, Taketo Sonoda, Shuta Tsuboi, Katsumi Miyauchi, and Hiroyuki Daida Copyright © 2018 Manabu Ogita et al. All rights reserved. Multiple Culprit Coronary Artery Thrombosis in a Patient with Coronary Ectasia Sun, 14 Jan 2018 00:00:00 +0000 We here report a case of ST-elevation myocardial infarction (STEMI) due to simultaneous acute coronary artery occlusions of two major coronary arteries in a patient with coronary ectasia. The patient had been previously submitted to percutaneous coronary angioplasty with bare metal stent implantation in both culprit vessels. Very late stent thrombosis could be the cause of the first occlusion, triggering the event in the other vessel. In addition, concomitant embolic sources were not identified. Although routine aspiration thrombectomy in STEMI was not proven to be beneficial in randomized clinical trials, it was of great value in this case. We also discuss the relation between coronary ectasia, chronic inflammatory status, and increased platelet activity which may have caused plaque disruption in another already vulnerable vessel. Bruno da Silva Matte, Gustavo Neves de Araujo, Felipe Homem Valle, and Ana Maria Rocha Krepsky Copyright © 2018 Bruno da Silva Matte et al. All rights reserved. Thrombosis in the Surgically Corrected Anomalous Right Coronary Artery after Reimplantation in Aorta Sun, 31 Dec 2017 00:00:00 +0000 A 32-year-old African American female presented with dyspnea, and after several cardiac diagnostic tests, the diagnosis of an anomalous origin of the RCA from the pulmonary trunk was established by multislice coronary CT angiography. She underwent surgical correction with reimplantation of the RCA, from the pulmonary artery to the aortic root. However, 10 days after surgery, she developed frequent episodes of chest pain, and repeat coronary CTA showed a partially occlusive thrombus in the surgically reimplanted RCA. Anticoagulation with warfarin resulted in complete resolution of the patient’s symptoms. Ata Bajwa, Bhanu Gupta, Lina Ya’qoub, Steven B. Laster, and Randall Thompson Copyright © 2017 Ata Bajwa et al. All rights reserved. A Case of Cardiac Calcified Amorphous Tumor Presenting with Concomitant ST-Elevation Myocardial Infarction and Occipital Stroke and a Brief Review of the Literature Sun, 24 Dec 2017 00:00:00 +0000 Cardiac calcified amorphous tumor (CAT) is an extremely rare benign intracavitary tumor of the heart. It may mimic other cardiac tumors and can present with signs or symptoms of systemic embolization. There are limited data regarding CAT in the literature. We report a case of a 68-year-old woman with a cardiac CAT and mitral annular calcification (MAC), who presented with acute ST-elevation myocardial infarction (STEMI) and occipital stroke. After extensive review of the literature, we believe that this case is possibly the first description of a cardiac CAT presenting with STEMI. The CAT was surgically removed, and the diagnosis was confirmed by histology. The patient tolerated the surgery and reported no events at 6-month follow-up. Kyaw Kyaw, Htun Latt, Sammy San Myint Aung, and Chanwit Roongsritong Copyright © 2017 Kyaw Kyaw et al. All rights reserved. Anomalous Coronary Artery Origin in a Young Patient with Marfan Syndrome Thu, 21 Dec 2017 00:00:00 +0000 Marfan syndrome is an autosomal dominant genetic disorder that affects connective tissue and is caused by mutations in the fibrillin 1 gene present at chromosome 15. Aortic aneurysm is its main complication, and along the dilation of the aorta root and its descending portion (60–100%), with secondary aortic insufficiency, it increases risk of acute aortic dissection and death. Coronary artery anomalies affect between 0.3% and 1.6% of the general population and are the second leading cause of sudden death in young adults, especially if the anomalous coronary passes through aorta and pulmonary artery. The anomalous origin of the left main coronary artery in the right Valsalva sinus has a prevalence of 0.02%–0.05% and is commonly related to other congenital cardiac anomalies, such as transposition of great vessels, coronary fistulas, bicuspid aortic valve, and tetralogy of Fallot. Its association with Marfan syndrome is not known, and there is no previous report in the literature. We describe here a case of a female with Marfan syndrome diagnosed with symptomatic anomalous origin of the left coronary artery in the right Valsalva sinus. S. B. C. P. Duarte, D. O. Beraldo, L. A. M. Cesar, A. P. Mansur, and J. Y. Takada Copyright © 2017 S. B. C. P. Duarte et al. All rights reserved. Ticagrelor-Induced Angioedema: A Rare and Unexpected Phenomenon Sun, 17 Dec 2017 00:00:00 +0000 Angioedema can cause potentially life-threatening airway obstruction. This case report describes an exceedingly rare episode of ticagrelor-induced hypersensitivity reaction, manifesting as angioedema with periorbital and likely respiratory involvement. The heart team should be vigilant for this precarious condition which may require emergent airway management. Desensitization protocols and alternative regimens (e.g., clopidogrel, prasugrel, and addition of an adjunctive anticoagulant) should be considered when there is an absolute indication for antiplatelet therapy. Rajeev Seecheran, Valmiki Seecheran, Sangeeta Persad, Sasha Lalla, and Naveen Anand Seecheran Copyright © 2017 Rajeev Seecheran et al. All rights reserved. Detection of the “Crossed Aorta Sign” during Echocardiography before Angiography Thu, 14 Dec 2017 09:43:28 +0000 We report the case of an anomalous circumflex (Cx) origin from the right sinus of Valsalva with retroaortic course observed in a modified apical four-chamber view during transthoracic study (TTE). This finding is known as the “crossed aorta sign.” Usually, the diagnosis of this congenital anomaly of coronary circulation is established during coronary angiography. In this case, the diagnosis was performed by echocardiography before angiography. We believe that recent improvements in echocardiography increase the potential of this imaging technology also in the diagnosis of coronary artery anomalies. Laura Massobrio, Alberto Valbusa, Giovanni Bertero, Fabrizio Montecucco, Gian Marco Rosa, Gian Paolo Bezante, and Claudio Brunelli Copyright © 2017 Laura Massobrio et al. All rights reserved. Rare Case of Cocaine-Induced Aortic Aneurysm: A Near Dissection Event Thu, 14 Dec 2017 00:00:00 +0000 Cocaine use has been associated with cardiovascular complications such as coronary atherosclerosis, coronary artery spasm, cardiac arrhythmias, acute myocardial infarction, myocarditis, and dilated cardiomyopathies. Aortic dissection is a rare but life-threatening complication of cocaine use. Cocaine and stimulant use can cause aortic aneurysm by increasing the aortic wall stress, and the most feared complications are dissection, rupture, and death. There are no clear guidelines about screening cocaine abusers with CT scan of the chest. We do not know if the number of years of cocaine use or the amount of cocaine use can be associated with higher incidence of aortic aneurysm or dissection. Cocaine-induced aortic aneurysm does not have any specific clinical feature. Common presentation is chest discomfort or chest pain. This common presentation is bewildering enough for clinicians to think of more common causes of chest pain like myocardial infarction and myocarditis. The sudden onset of severe, sharp, stabbing chest or back pain is suggestive of aortic dissection. Here, we present a young otherwise healthy patient with chronic cocaine use presenting with chest pain and found to have significant size aortic aneurysm. Ranju Kunwor and AnnMarie Canelas Copyright © 2017 Ranju Kunwor and AnnMarie Canelas. All rights reserved. ST Segment Elevation Is Not Always Myocardial Infarction: A Case of Focal Myopericarditis Wed, 29 Nov 2017 00:00:00 +0000 Protocols exist on how to manage STEMI patients, with well-established timelines. There are times when patients present with chest pain, ST segment elevation, and biomarker elevation that are not due to coronary artery disease. These conditions usually present with normal coronary angiography. We present a case that was clinically indistinguishable from STEMI and that was diagnosed with focal myopericarditis on cardiac MRI. Cyrus M. Munguti, Samuel Akidiva, Jacob Wallace, and Hussam Farhoud Copyright © 2017 Cyrus M. Munguti et al. All rights reserved. Ventricular Fibrillation following Varicella Zoster Myocarditis Thu, 23 Nov 2017 00:00:00 +0000 Varicella-zoster virus (VZV) infection can rarely lead to serious cardiac complications and life-threatening arrhythmias. We present a case of a 46-year-old male patient who developed VZV myocarditis and presented with recurrent syncopal episodes followed by a cardiac arrest. He had a further collapse eight years later, and cardiac magnetic resonance imaging (MRI) demonstrated mild mid-wall basal and inferolateral wall fibrosis. He was treated with an implantable cardioverter defibrillator (ICD) and represented two years later with ICD shocks, and interrogation of the device revealed ventricular fibrillation episodes. This case demonstrates the life-threatening long-term sequelae of VZV myocarditis in adults. We suggest that VZV myocarditis should be considered in all patients who present with a syncopal event after VZV infection. In these patients, ICD implantation is a potentially life-saving procedure. Adam Ioannou, Irene Tsappa, Sofia Metaxa, and Constantinos G. Missouris Copyright © 2017 Adam Ioannou et al. All rights reserved. Anticoagulation for the Pregnant Patient with a Mechanical Heart Valve, No Perfect Therapy: Review of Guidelines for Anticoagulation in the Pregnant Patient Wed, 22 Nov 2017 00:00:00 +0000 Heart valve replacement with a mechanical valve requires lifelong anticoagulation. Guidelines currently recommend using a vitamin K antagonist (VKA) such as warfarin. Given the teratogenic effects of VKAs, it is often favorable to switch to heparin-derived therapies in pregnant patients since they do not cross the placenta. However, these therapies are known to be less effective anticoagulants subjecting the pregnant patient to a higher chance of a thrombotic event. Guidelines currently recommend pregnant women requiring more than 5 mg a day of warfarin be switched to alternative therapy during the first trimester. This case report highlights a patient who was switched to alternative therapy during her first pregnancy and suffered a devastating cerebrovascular accident (CVA). Further complicating her situation was during a subsequent pregnancy; this patient continued warfarin use during the first trimester and experienced multiple transient ischemic attacks (TIAs). This case highlights the increased risk of thrombotic events in pregnant patients with mechanical valves. It also highlights the difficulty of providing appropriate anticoagulation for the pregnant patient who has experienced thrombotic events on multiple anticoagulants. Aaron Richardson, Stuart Shah, Ciel Harris, Garry McCulloch, and Patrick Antoun Copyright © 2017 Aaron Richardson et al. All rights reserved. Subacute Right Ventricular Perforation by Pacemaker Lead Causing Left-Sided Hemothorax and Epicardial Hematoma Thu, 16 Nov 2017 10:24:25 +0000 We report a case of right ventricular wall perforation by a pacemaker lead in a 78-year-old female 18 days after a permanent pacemaker insertion. This injury necessitated explant of the perforating lead and implantation of a new one with surgical backup. We review the literature and discuss the possible risk and protective factors including lead models that were associated with higher incidence of perforation. We review the traditional pacing parameters and their lack of reliability to diagnose perforation and the need for low threshold to utilize imaging in appropriate clinical scenarios. The authors believe this case is of educational value to all health care professionals, especially emergency medicine and internal medicine residents, who routinely see patients with pacemakers complaining of chest pain, shortness of breath, or dizziness. Abdelrahman Ahmed, Mohamed Shokr, and Randy Lieberman Copyright © 2017 Abdelrahman Ahmed et al. All rights reserved. The Use of Adenosine to Enable Safe Implantation of Transcatheter Tricuspid Valve Thu, 16 Nov 2017 00:00:00 +0000 High precision is necessary during percutaneous transcatheter heart valve implantation. The precision of the implantation has been established by increasing the heart rate (usually to 200 beats per minute) to the point of significantly reduced cardiac output and thus minimizing valve movement. Routinely, this tachycardia is induced by rapid pacing. Here we report a case of failure to pace during valve-in-valve (VIV) Edwards Sapien XT implantation in the tricuspid valve position. Transient cardiac arrest was induced by intravenous adenosine injection enabling accurate valve implantation. Vicki Zeniou, Shmuel Chen, Mony Shuvy, David Luria, Chaim Lotan, and Haim D. Danenberg Copyright © 2017 Vicki Zeniou et al. All rights reserved. AngioVac System Used for Vegetation Debulking in a Patient with Tricuspid Valve Endocarditis: A Case Report and Review of the Literature Tue, 07 Nov 2017 00:00:00 +0000 AngioVac is a vacuum-based device approved in 2014 for percutaneous removal of undesirable materials from the intravascular system. Although numerous reports exist with regard to the use of the AngioVac device in aspiration of iliocaval, pulmonary, upper extremity, and right-sided heart chamber thrombi, very few data are present demonstrating its use in treatment of right-sided endocarditis. In this case report, we describe the novel device used in debulking a large right-sided tricuspid valve vegetation reducing the occurrence of septic embolisation and enhancing the efficacy of antibiotics in clearance of bloodstream infection. Further research is needed in larger RSIE patient populations to confirm the benefits and the potential of improved outcomes associated with the AngioVac device as well as identify its potential complications. Hossam Abubakar, Ahmed Rashed, Ahmed Subahi, Ahmed S. Yassin, Mohamed Shokr, and Mahir Elder Copyright © 2017 Hossam Abubakar et al. All rights reserved. Congenital Absence of Left Circumflex Artery: A Case Report and Review of the Literature Mon, 30 Oct 2017 00:00:00 +0000 Congenital absence of the left circumflex artery is a rare coronary anomaly with few reported cases in the literature. These patients are usually diagnosed incidentally when they undergo coronary angiography or coronary CT to rule out underlying coronary artery disease. In this article, we report a case of a 46-year-old man who was incidentally found to have a congenitally absent left circumflex artery with a superdominant right coronary artery after a workup was initiated for frequent premature ventricular contractions and regional wall motion on echocardiogram. A review of the clinical presentation, symptoms, and diagnostic modalities used to diagnose this entity is presented. Setri Fugar, Lydia Issac, Alexis Kofi Okoh, Christelle Chedrawy, Nadia El Hangouche, and Neha Yadav Copyright © 2017 Setri Fugar et al. All rights reserved. Deglutition Syncope: Two Case Reports Attributed to Vagal Hyperactivity Wed, 25 Oct 2017 09:57:03 +0000 Deglutition syncope is a relatively rare cause of syncope that belongs to the category of neurally mediated reflex syncopal syndromes. The phenomenon is related to vagal reflex in context to deglutition causing atrioventricular block and acute reduction in cardiac output leading to dizziness or syncope. We present case series of two cases of deglutition syncope, of which first was managed medically and second with pacemaker implantation. Sukhdeep Bhogal, Pooja Sethi, Yasir Taha, Muralidhar Papireddy, Akhilesh Mahajan, Syed Imran M. Zaidi, Vijay Ramu, and Timir Paul Copyright © 2017 Sukhdeep Bhogal et al. All rights reserved. A Rare Manifestation of Asymptomatic Ebstein’s Anomaly with Tricuspid Valve Endocarditis Wed, 25 Oct 2017 00:00:00 +0000 Ebstein’s anomaly is a rare congenital heart disease that presents with apical displacement of the septal and posterior leaflets of the tricuspid valve. It has a wide spectrum of clinical presentations and has been shown to manifest itself any time from birth to adulthood. Our patient is a 43-year-old male with a history of intravenous heroin abuse who presented to the emergency department with worsening shortness of breath and lower extremity edema. He denied any prior cardiac history. A transthoracic echo showed normal left ventricular function, but a large 2.2 × 2.1 cm echodensity on the septal leaflet of the tricuspid valve consistent with vegetation with severe tricuspid regurgitation and probable leaflet perforation. It also demonstrated severe right heart enlargement with atrialization of the right ventricle and apical displacement of the tricuspid valve consistent with Ebstein’s anomaly. This is a rare case of an adult who presented with asymptomatic Ebstein’s anomaly. There have been few reports of tricuspid valve endocarditis with Ebstein’s anomaly in the literature. To our knowledge, this represents the fifth reported case of a new diagnosis of Ebstein’s anomaly in the setting of endocarditis and the second case of Ebstein’s anomaly and endocarditis in an intravenous drug abuser. Carmel Moazez, Vicken Zeitjian, Christian Breburda, and Ranjini Roy Copyright © 2017 Carmel Moazez et al. All rights reserved. Right Atrial Fibroelastoma Presenting as Typical Atrial Flutter: Rare Disease in Unusual Location Tue, 10 Oct 2017 00:00:00 +0000 Typical atrial flutter as initial presentation of papillary fibroelastoma involving the cavotricuspid isthmus is not described before in literature. To our knowledge only 14 cases have been reported in literature involving the right atrium. Very unusual location is at the junction between inferior vena cava (IVC) and right atria as only 1 case has been reported. Ahmad Abuarqoub, Ghada Elshimy, Muhammed Shittu, Aiman Hamdan, and Fayez Shamoon Copyright © 2017 Ahmad Abuarqoub et al. All rights reserved. D-Shaped Left Ventricle, Anatomic, and Physiologic Implications Sun, 08 Oct 2017 00:00:00 +0000 Right ventricular loading/pressure influences left ventricular function because the two ventricles pump in series and because they are anatomically arranged in parallel, sharing the common ventricular septum. Flattening of the interventricular septum detected during echocardiographic examination is called D-shaped left ventricle. We present a case of an elderly male of African descent, who presented with increased shortness of breath. Transthoracic echocardiogram showed flattening and left sided deviation of interventricular septum causing a decreased size in left ventricle, secondary to volume/pressure overload in the right ventricle. While patient received hemodialysis therapy and intravascular volume was removed, patient blood pressure was noted to increase, paradox. Repeated transthoracic echocardiogram demonstrated less left deviation of interventricular septum compared with previous echocardiogram. We consider that it is important for all physicians to be aware of the anatomic and physiologic implication of D-shaped left ventricle and how right ventricle pressure/volume overload affects its function and anatomy. Eder Hans Cativo Calderon, Tuoyo O. Mene-Afejuku, Rachna Valvani, Diana P. Cativo, Devendra Tripathi, Hans A. Reyes, and Savi Mushiyev Copyright © 2017 Eder Hans Cativo Calderon et al. All rights reserved. Parachute-Like Mitral Valve Tuberculoma: A Rare Presentation Sun, 08 Oct 2017 00:00:00 +0000 There have been anecdotal reports of tuberculous cardiac involvement, mainly in cases of military tuberculosis or immune deficient individuals. The spectrum of clinical presentations of tuberculous cardiac involvements includes incidental detection of single and multiple well-circumscribed tuberculomas, symptomatic obstructive lesions, AV conduction abnormalities, and even sudden death. We present a case of cardiac tuberculoma in an immune-competent person who presented with worsening dyspnea. The unique morphology of this mass posed an imaging challenge that required 4-dimensional (4D) echocardiography and cardiac magnetic resonance (CMR) detail to differentiate the mass from an anterior mitral leaflet (AML) aneurysm. Histological examination after surgical resection confirmed its tuberculous etiology. Arslan Masood, Gul Zaman Khan, Irfan Bashir, and Zubair Akram Copyright © 2017 Arslan Masood et al. All rights reserved. Postintervention Dyspnea after Radiofrequency Catheter Ablation: Think of a Phrenic Nerve Injury Wed, 04 Oct 2017 00:00:00 +0000 Phrenic nerve injury (PNI) is a rare complication of catheter ablation therapy, most commonly observed in cryoablation of the right side pulmonary veins. We present a case of PNI after radiofrequency catheter ablation that developed acute dyspnea 24 hours after the intervention. Dyspnea is the main symptom of PNI, so the diagnosis should always be suspected if it appears after any type of catheter ablation involving the trajectory of the phrenic nerve. There is no specific treatment for PNI. The only maneuver that has been reported to accelerate the recovery of PNI is early stopping of the ablation therapy. Liliana E. Ramos-Villalobos, Luis Colin Lizalde, Manlio F. Márquez, Pedro Iturralde, and Francisco Castillo Copyright © 2017 Liliana E. Ramos-Villalobos et al. All rights reserved. Coronary Artery Hematoma Treated with Fenestration Using a Novel NSE Alpha® Scoring Balloon Mon, 02 Oct 2017 05:52:59 +0000 The optimal management of coronary intramural hematoma has not been defined. We described a case in which coronary occlusion developed due to an intramural hematoma after percutaneous coronary intervention for mid left circumflex artery (LCX). Intravascular ultrasound (IVUS) demonstrated the progression of the intramural hematoma and a totally compressed true lumen. Our approach was based on fenestration with a scoring balloon (NSE Alpha, Goodman, Japan), which allowed the deployment of an additional stent to be avoided. In conclusion, this management can be effectively and safely performed. Naohiro Funayama, Takao Konishi, Tadashi Yamamoto, and Daisuke Hotta Copyright © 2017 Naohiro Funayama et al. All rights reserved. Epoetin Alfa: A Cause of Coronary Artery Thrombosis Sun, 01 Oct 2017 08:02:57 +0000 Introduction. Epoetin alfa is an erythrocyte-stimulating factor. We here present a case of an anemic patient, who was given epogen before a coronary artery bypass (CABG) surgery and developed periprocedural myocardial infarction. To our knowledge, there has been no previous case reported of epogen causing myocardial infarction. Case Presentation. 66-year-old female presented with substernal chest pain. EKG showed ST segment elevations in aVf and L-III. Patient underwent left heart catheterization (LHC) and had triple vessel disease. A bare metal stent was placed in RCA. Patient continued to have symptoms after discharge and presented to the ED again with these complaints. She underwent coronary artery bypass surgery (CABG). Before the procedure, patient’s hemoglobin was 11.1 grams/deciliter and was given epogen to raise hemoglobin level. Postoperative day (POD) #1 patient had ST elevations in inferior and anterolateral leads. She was diagnosed with periprocedural myocardial infarction. Patient underwent repeat LHC, which identified obstruction of saphenous vein graft (SVG). Hypercoagulable workup was negative for any disease and the patient was diagnosed with epogen induced early graft occlusion. Conclusion. Epogen administration can cause myocardial infarction and coronary artery thrombosis. We suggest that physicians use epogen very cautiously, especially in population who has underlying coronary artery disease. Muhammad Umer Siddiqui, Yelena Galumyan, James Klein, Zunaira Naeem, and Aron Schwarcz Copyright © 2017 Muhammad Umer Siddiqui et al. All rights reserved. Case Report of Multiembolic Cerebrovascular Event Associated with Ramp Study Echocardiogram Thu, 28 Sep 2017 08:43:45 +0000 The incidence of ramp test echocardiogram-associated embolic events in the setting of therapeutic anticoagulation is likely rare and has not been reported. We present such a case in a patient with a HeartMate II left ventricular assist device (LVAD) whose serial head computed tomography images, deteriorating clinical course, and the multiembolic nature of the event suggest causality. If the pretest probability of pump thrombosis in an individual LVAD patient is sufficiently high, the potential risks of performing a ramp study echocardiogram may not be warranted, even in the setting of adequate anticoagulation. Brian C. Butera, Luanda P. Grazette, Tracy Lawrence, Michael E. Bowdish, and Andrew J. Yoon Copyright © 2017 Brian C. Butera et al. All rights reserved. Aorto-Right Ventricular Shunt after TAVR: Rare Complication of Common Procedure Thu, 28 Sep 2017 07:19:05 +0000 Background. The primary treatment of symptomatic aortic stenosis is aortic valve replacement. Instead of open chest surgery, transcatheter aortic valve replacement (TAVR) is an alternative intervention for high-risk surgical candidates. Clinical Case. A 92-year-old male presented with progressive exertional dyspnea and recurrent syncopal attacks secondary to severe AS. The patient underwent successful transfemoral TAVR with 29 mm Edwards SAPIEN XT valve. His postoperative course was complicated by aorto-right ventricular shunt. The patient’s clinical course was followed up for one year. Conclusion. This case reports the incidence and clinical course of one of the rare complications of TAVR, aorto-right ventricular fistula. Conservative medical management is appropriate in hemodynamically stable patients with this specific complication. Abdelkader Almanfi, Ahmad Qurie, and Neil Strickman Copyright © 2017 Abdelkader Almanfi et al. All rights reserved. A Rare Association of Takotsubo Cardiomyopathy with High-Degree Atrioventricular Block Wed, 20 Sep 2017 07:03:41 +0000 Here we present a case of a patient who got trapped in an elevator; on initial evaluation patient was found with bradycardia; on further evaluation electrocardiogram (EKG) showed new onset 2nd-degree Mobitz type 2 AV block. On admission patient developed ischemic changes on EKG and troponin elevation. Transthoracic echocardiogram showed reduced ejection fraction as well as apical inferior, anterior, lateral, and septal hypokinesia. Coronary angiography showed nonobstructive coronary artery disease and ventriculogram demonstrated anterolateral and apical hypokinesia suggesting takotsubo cardiomyopathy (TCM). Atrioventricular block (AV) is rarely seen as initial presentation of TCM and has a prevalence of about 2.9%. AV block during early presentation of TCM poses a therapeutic dilemma with regard to the timing and the need to place a temporary or permanent pacemaker. The decision to place a permanent pacemaker may be on a case-by-case basis and more research is needed on formulating standardized recommendations in patients with TCM and conduction tissue abnormalities. Eder Hans Cativo, Rachna Valvani, Tuoyo O. Mene-Afejuku, Diana P. Cativo, and Savi Mushiyev Copyright © 2017 Eder Hans Cativo et al. All rights reserved. H. capsulatum: A Not-So-Benign Cause of Pericarditis Thu, 07 Sep 2017 07:54:27 +0000 The common causes of pericarditis and its course are benign in the majority of cases. Thus, further testing is usually not pursued and treatment for a presumptive viral etiology with nonsteroidal agents and steroids has been an accepted strategy. We present a patient with pericarditis who was unresponsive to first-line therapy and was subsequently found to have necrotizing granulomas of the pericardium with extensive adhesions and fungal elements seen on tissue biopsy. Serologic testing confirms active H. capsulatum infection, and he responded well to Itraconazole treatment. In patients with pericarditis who fail standard therapy with NSAIDs and steroids, it is suggested that they undergo thorough evaluation and that histoplasmosis be considered as an etiology, especially in endemic regions. Paolo K. Soriano, Muhammad Iqbal, Shakthishri Kandaswamy, Sami Akram, Abhishek Kulkarni, and Tamer Hudali Copyright © 2017 Paolo K. Soriano et al. All rights reserved. Revascularization of Chronic Total Occlusion of the Infrarenal Aorta in a Patient with Triple Vessel Disease: Report of a Case Treated by Endovascular Approach Wed, 06 Sep 2017 10:03:45 +0000 Surgical management of advance aortoiliac occlusive disease is time-tested and a widely practiced strategy, particularly when there is significant coronary artery disease associated with aortoiliac occlusive disease. The technological advances in the field of percutaneous techniques have facilitated the use of nonsurgical endovascular alternatives for peripheral arterial disease in patients with significant comorbidities at high surgical risk, as illustrated in our case report. We report a case of chronic total occlusion of the aorta that was treated percutaneously with endovascular stenting. We also discuss the specific technique used in this procedure. Mahek Shah, Soumya Patnaik, Rahul Sinha, Issac Opoku-Asare, Khalid Chaudhry, and Sean Janzer Copyright © 2017 Mahek Shah et al. All rights reserved. Persistent Unexplained Dyspnea: A Case of Hepatopulmonary Syndrome Tue, 29 Aug 2017 00:00:00 +0000 Regarding a patient with dyspnea, the history and physical examination often lead to the correct diagnosis. In some circumstances, when more than one underlying disease is present, the diagnostic process can be more challenging. We describe an unusual case of dyspnea and persistent hypoxemia related to a hepatopulmonary syndrome in a 53-year-old patient with known heart failure and chronic liver disease. Initially managed with intravenous diuretic therapy, due to signs of lung and peripheral congestion, our patient did not improve as expected; therefore we performed more advanced studies with a chest-abdomen CT scan and a right heart catheterization. They showed, respectively, no signs of parenchymal and vasculature lung disease, a cirrhotic liver disease, splenomegaly, signs of portal hypertension, and high cardiac output with normal pulmonary vascular resistance. These results, along with the association of hypoxemia and chronic liver disease, suggested a hepatopulmonary syndrome. The diagnosis was confirmed by the demonstration of an intrapulmonary vascular dilatation with right to left shunt during a microbubble transthoracic echocardiography and a lung perfusion scan. Liver transplantation is the only successful treatment for this syndrome; however, the patient became soon unsuitable for this strategy, due to a rapid clinical deterioration. Alfonso Campanile, Alessandro Colombo, Maurizio Del Pinto, and Claudio Cavallini Copyright © 2017 Alfonso Campanile et al. All rights reserved.