Case Reports in Cardiology The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Metastatic Calcinosis of Aortic Valve Secondary to Renal Failure Mimicking Infective Endocarditis Sun, 25 Sep 2016 09:01:43 +0000 End stage renal disease has a list of consequences, cardiovascular being the most common. Inefficient dialysis can cause significant deposition of calcium all over the body, including heart valves making heart function impaired. We illustrate a case of 38-year-old female with end stage renal disease on peritoneal dialysis. The patient had been complaining of pain and swelling of the right hand for the last few months and had been seen by hand surgeon and was admitted electively for the biopsy of hand lesions. Before her planned surgery, she developed severe shortness of breath. Urgent echocardiogram revealed severe aortic regurgitation and large vegetation on the aortic valve. Infective endocarditis was suspected but blood cultures were negative for any microorganism and the patient did not meet the Duke criteria. Because of her hemodynamic instability immediate mechanical valve replacement surgery was performed. The pathology report showed extensive calcification and myxoid degeneration. No infectious agent was found. Later on, biopsy of her hand lesions showed extensive calcification with macrophages and giant cells. No atypia or malignancy was identified. This is a rare case of the metastatic calcinosis of aortic valve secondary to renal failure mimicking aortic valve infective endocarditis. Noman Ahmed Jang Khan, Masroor A. Khan, and Guillermo Juan Morell Chardon Copyright © 2016 Noman Ahmed Jang Khan et al. All rights reserved. Aortic Dissection in a Healthy Male Athlete: A Unique Case with Comprehensive Literature Review Wed, 21 Sep 2016 11:40:20 +0000 A young otherwise healthy 27-year-old male who has been using anabolic steroids for a long time developed Type I aortic dissection associated with heavy weightlifting. The patient did not have a recent history of trauma to the chest, no history of hypertension, and no illicit drug use. He presented with severe chest pain radiating to back and syncopal event with exertion. Initial vitals were significant for blood pressure of 80/50 mmHg, pulse of 80 beats per minute, respirations of 24 per minute, and oxygen saturation of 92% on room air. Physical exam was significant for elevated jugular venous pressure, muffled heart sounds, and cold extremities with diminished pulses in upper and absent pulses in lower extremities. Bedside echocardiogram showed aortic root dilatation and cardiac tamponade. STAT computed tomography (CT) scan of chest revealed dissection of ascending aorta. Cardiothoracic surgery was consulted and patient underwent successful repair of ascending aorta. Hemodynamic stress of weightlifting can predispose to aortic dissection. Aortic dissection is a rare but often catastrophic condition if not diagnosed and managed acutely. Although rare, aortic dissection needs to be in the differential when a young weightlifter presents with chest pain as a delay in diagnosis may be fatal. Balraj Singh, Jennifer M. Treece, Ghulam Murtaza, Samit Bhatheja, Steven J. Lavine, and Timir K. Paul Copyright © 2016 Balraj Singh et al. All rights reserved. Pseudopheochromocytoma Associated with Domestic Assault Wed, 21 Sep 2016 09:45:40 +0000 Pseudopheochromocytoma has a clinical presentation that is similar to pheochromocytoma. It manifests itself with paroxysmal hypertension crises, associated with various symptoms such as headaches, chest pain, nausea, palpitations, and dizziness. Patients are usually asymptomatic in between the crises. Unlike pheochromocytoma, there is no catecholamines overproduction in this pathology: hypertensive peaks are caused by a hyperactivation of the sympathetic nervous system, which is often triggered by a psychological trauma in the past. Treatment of pseudopheochromocytoma can be challenging due to normal blood pressure values in between the hypertensive peaks; it includes alpha- and beta-blockers for moderate crises and prevention and must be combined with psychopharmacologic agents such as anxiolytics or antidepressant drugs. Psychotherapy and dietetic treatment are also crucial in pseudopheochromocytoma management. H. M. Le, G. Carbutti, D. Ilisei, E. Bouccin, and X. Vandemergel Copyright © 2016 H. M. Le et al. All rights reserved. An Obstructed Anomalous Left Anterior Descending Coronary Artery Arising from the Right Coronary Artery Requiring Surgical Intervention Mon, 19 Sep 2016 14:16:03 +0000 A 47-year-old female presented to our hospital with symptoms of stable angina. Cardiac catheterization revealed a rare coronary artery anomaly of the left anterior descending (LAD) artery branching off the right coronary artery ostium. Furthermore, the anomalous LAD artery exhibited significant atherosclerotic obstruction. Our review of the literature found only nine such previously described cases. Due to the unique nature of coronary artery anomalies and their complications, we would like to contribute our case to the medical literature. Alexander Mironov, Sean Galligan, Aleksandre Kakauridze, and Jonathan D. Marmur Copyright © 2016 Alexander Mironov et al. All rights reserved. Successful Intravascular Ultrasound-Guided Transradial Coronary Intervention with a 4Fr Guiding Catheter Thu, 08 Sep 2016 18:04:14 +0000 Minimizing the catheter size can reduce vascular access complications and contrast dye usage in coronary angiography. The small diameter of the 4Fr guiding catheter has limited the use of several angioplasty devices such as intravascular ultrasound (IVUS) in the past. However, the combination of a novel IVUS catheter and a 0.010 guidewire makes it possible to perform IVUS-guided percutaneous coronary intervention (PCI) with a 4Fr guiding catheter. We herein report the case of a 51-year-old man with silent myocardial ischemia who underwent IVUS-guided transradial PCI with a 4Fr guiding catheter. Yasuhiro Nakano and Kenji Sadamatsu Copyright © 2016 Yasuhiro Nakano and Kenji Sadamatsu. All rights reserved. Interventricular Septal Hematoma and Coronary-Ventricular Fistula: A Complication of Retrograde Chronic Total Occlusion Intervention Wed, 07 Sep 2016 16:51:00 +0000 Interventricular septal hematoma is a rare complication of retrograde chronic total occlusion (CTO) percutaneous coronary interventions (PCI) with a typically benign course. Here we report two cases of interventricular septal hematoma and coronary-cameral fistula development after right coronary artery (RCA) CTO-PCI using a retrograde approach. Both were complicated by development of ST-segment elevation and chest pain. One case was managed actively and the other conservatively, both with a favorable outcome. Abdul-rahman R. Abdel-karim, Minh Vo, Michael L. Main, and J. Aaron Grantham Copyright © 2016 Abdul-rahman R. Abdel-karim et al. All rights reserved. Successful Retrieval of a Dismembered Central Venous Catheter Stuck to the Right Pulmonary Artery Using a Stepwise Approach Wed, 07 Sep 2016 16:46:13 +0000 Recent advances in anticancer chemotherapy have resulted in an increase in the number of patients requiring a central venous port catheter, and the incidence of catheter pinch-off syndrome has been increasing. Catheter pinch-off syndrome is a rare and unusual complication. It is difficult to retrieve dislodged catheters from the pulmonary artery, especially if the catheter is stuck to the peripheral pulmonary artery. We herein describe the successful removal of a catheter stuck in the pulmonary artery with a stepwise approach. First, a pigtail catheter was used to tug the dislodged catheter in order to free the unilateral end. Then, a gooseneck snare was used to catch and pull the catheter out of the patient. The key to success is to free the end of the catheter. Keisuke Nakabayashi, Hidekimi Nomura, Daichi Isomura, Ryo Sugiura, and Toshiaki Oka Copyright © 2016 Keisuke Nakabayashi et al. All rights reserved. Comment on “A Rare Case of Renal Infarct due to Noncompaction Cardiomyopathy: A Case Report and Literature Review” Thu, 01 Sep 2016 09:41:03 +0000 Josef Finsterer and Sinda Zarrouk-Mahjoub Copyright © 2016 Josef Finsterer and Sinda Zarrouk-Mahjoub. All rights reserved. The Role of TEE in Diagnosing Hepatopulmonary Syndrome and Cryptogenic Cirrhosis Wed, 31 Aug 2016 07:34:46 +0000 In the vast majority of cases, ongoing hypoxemia in a cirrhotic patient is usually hepatopulmonary syndrome (HPS) until proven otherwise; in this case, HPS was suspected prior to any known diagnosis of cirrhosis. This is the first reported case in the literature whereby HPS and cirrhosis were diagnosed after the fact, rather than with the preexisting knowledge of liver cirrhosis. Joel Scott-Herridge, Kapil Bhagirath, Surinder Janda, and Davinder S. Jassal Copyright © 2016 Joel Scott-Herridge et al. All rights reserved. Delayed Tamponade after Traumatic Wound with Left Ventricular Compression Mon, 29 Aug 2016 12:00:11 +0000 Delayed cardiac tamponade after a penetrating chest injury is a rare complication. The clinical diagnosis of tamponade is facilitated with imaging. We present a case report of a 23-year-old male who was brought to emergency after multiple stab wounds to the chest. After resuscitation and repair of laceration of right internal mammary artery and right ventricle, he was discharged but later returned with shortness of breath. Echocardiography revealed a rare case of delayed pericardial tamponade causing left ventricular collapse. The pericardial effusion was treated with emergent pericardiocentesis and later required a thoracoscopy guided pericardial window for definitive management. Fahad Almehmadi, Mark Chandy, Kim A. Connelly, and Jeremy Edwards Copyright © 2016 Fahad Almehmadi et al. All rights reserved. Ultrasound Assisted Catheter Directed Thrombolysis in the Management of a Right Atrial Thrombus: A New Weapon in the Armamentarium? Sun, 28 Aug 2016 09:25:20 +0000 Catheter related thrombosis (CRT) is a commonly encountered entity fraught with substantial risk for mortality secondary to various complications including pulmonary embolism (PE), tricuspid regurgitation, endocarditis, right sided heart failure, and cardiogenic and septic shock. CRT carries a mortality rate of 18% in hemodialysis patients and more than 40% in nonhemodialysis patients. Management strategies include systemic anticoagulation, systemic thrombolysis, surgical evacuation, and percutaneous retrieval with no established guidelines. Ultrasound assisted catheter directed thrombolysis emerges as promising modality with a relatively lower risk of hemorrhage compared to systemic thrombolysis. We report a case of a 75-year-old man with dialysis catheter related thrombosis without PE for which ultrasound assisted catheter directed thrombolysis was used successfully as an alternative therapy. Mohamed Shokr, Ramanjit Kaur, Kevin Belgrave, Arshad Javed, Mahir Elder, Shaun Cardozo, Luis Afonso, and Amir Kaki Copyright © 2016 Mohamed Shokr et al. All rights reserved. Endoscopic Ultrasound for the Detection of Left Atrial Appendage Thrombus: A Useful Technique in Patients with Transesophageal Echocardiography Contraindication Thu, 25 Aug 2016 06:21:18 +0000 Endoscopic ultrasound is a diagnostic and therapeutic technique used in specialized centers for patients that have undergone digestive procedures. This technique enables highly precise real-time imaging of the digestive tract wall and surrounding organs. Endoscopic ultrasound is also useful in patients with cardiovascular diseases such as atrial fibrillation. In patients with contraindication for transesophageal echocardiography due to high risk of esophageal bleeding or complications that may require immediate intervention, endoscopic ultrasound may be a safer option for visualizing atrial chambers to rule out the presence of left atrial appendage thrombi before cardioversion. Manuel Marina-Breysse, Alfonso Jurado-Román, Bartolomé López-Viedma, Jesús Piqueras-Flores, and María T. López-Lluva Copyright © 2016 Manuel Marina-Breysse et al. All rights reserved. A Patient with a Right Atrium Mass and Congenital Heart Disease: A Challenging Diagnosis of a Stubborn Disease Sun, 21 Aug 2016 09:07:06 +0000 Cardiac lymphoma is extremely rare. An intracardiac mass has rarely been reported to be the cardiac involvement of extranodal lymphoma. It is difficult to establish a final diagnosis via routine examinations. The ability of an echocardiogram to characterize tissue is limited; systemic (18)F-FDG PET/CT scans provide important information for both staging and response assessment in patients with lymphoma. A 68-year-old Chinese male with a second patent foramen ovale (PFO) and an interventricular septal defect presented at our institute with persistent fever, shortness of breath, repeated paroxysmal supraventricular tachycardia (PSVT) attack, and rapidly progressing superior vena cava syndrome. The patient also presented with a mass located in the upper right atrium and superior vena cava which was detected by echocardiogram. (18)F-FDG PET/CT scan revealed a pathological increase of (18)F-FDG uptake in the atrial mass and several other extracardiac lymph nodes. Lymph node biopsy was positive for large B-cell lymphoma. Immunohistochemistry revealed intense and diffuse expression of CD20, CD10, BCL-6, and Ki-67. The patient died without any chemotherapy 18 days after hospital discharge. Wenyan Wang, Huaicong Long, and Zhiying Zhao Copyright © 2016 Wenyan Wang et al. All rights reserved. Platypnea-Orthodeoxia Syndrome after Transcatheter Aortic Valve Implantation Wed, 17 Aug 2016 11:08:54 +0000 Progressive dyspnea and hypoxaemia in the subacute phase after transcatheter aortic valve implantation (TAVI) are uncommon and warrant immediate assessment of valve and prosthesis leaflet function to exclude thrombosis, as well as investigation for other causes related to the procedure, such as left ventricular dysfunction, pulmonary embolism, and respiratory sepsis. In this case, we report the observation of a patient presenting two weeks after TAVI with arterial hypoxaemia in an upright position, relieved by lying flat, and coupled with an intracardiac shunt detected on echocardiography in the absence of pulmonary hypertension, raising the suspicion of Platypnea-Orthodeoxia Syndrome (POS). Invasive intracardiac haemodynamic assessment showed a significant right-to-left shunt (Qp/Qs = 0.74), which confirmed the diagnosis, with subsequent closure of the intracardiac defect resulting in immediate relief of symptoms and hypoxaemia. To our knowledge, this is the first reported case of an interatrial defect and shunt causing Platypnea-Orthodeoxia Syndrome after transcatheter aortic valve implantation, resolved by percutaneous device closure. Andrew K. Roy, Jerome Garot, Antoinette Neylon, Marco Spaziano, Fadi J. Sawaya, and Thierry Lefèvre Copyright © 2016 Andrew K. Roy et al. All rights reserved. Severe Bioprosthetic Mitral Valve Stenosis and Heart Failure in a Young Woman with Systemic Lupus Erythematosus Wed, 17 Aug 2016 09:18:04 +0000 A 23-year-old African American woman with a past medical history of systemic lupus erythematous (SLE), secondary hypertension, and end stage renal disease (ESRD) on hemodialysis for eight years was stable until she developed symptomatic severe mitral regurgitation with preserved ejection fraction. She underwent a bioprosthetic mitral valve replacement (MVR) at outside hospital. However, within a year of her surgery, she presented to our hospital with NYHA class IV symptoms. She was treated for heart failure but in view of her persistent symptoms and low EF was considered for heart and kidney transplant. This was a challenge in view of her history of lupus. We presumed that her stenosis of bioprosthetic valve was secondary to lupus and renal disease. We hypothesized that her low ejection fraction was secondary to mitral stenosis and potentially reversible. We performed a dobutamine stress echocardiogram, which revealed an improved ejection fraction to more than 50% and confirmed preserved inotropic contractile reserve of her myocardium. Based on this finding, she underwent a metallic mitral valve and tricuspid valve replacement. Following surgery, her symptoms completely resolved. This case highlights the pathophysiology of lupus causing stenosis of prosthetic valves and low ejection cardiomyopathy. Siddharth Wartak, Isaac Akkad, Adnan Sadiq, Gregory Crooke, Manfred Moskovits, Robert Frankel, Gerald Hollander, and Jacob Shani Copyright © 2016 Siddharth Wartak et al. All rights reserved. Comment on “Symptomatic Trifascicular Block in Steinert’s Disease: Is It Too Soon for a Pacemaker?” Mon, 15 Aug 2016 13:54:07 +0000 Josef Finsterer and Claudia Stöllberger Copyright © 2016 Josef Finsterer and Claudia Stöllberger. All rights reserved. Adult ADHD Medications and Their Cardiovascular Implications Mon, 08 Aug 2016 05:47:49 +0000 Attention-deficit/hyperactivity disorder (ADHD) is a chronic neurobiological disorder exhibited by difficulty maintaining attention, as well as hyperactivity and impulsive behavior. Central nervous system (CNS) stimulants are the first line of treatment for ADHD. With the increase in number of adults on CNS stimulants, the question that arises is how well do we understand the long-term cardiovascular effects of these drugs. There has been increasing concern that adults with ADHD are at greater risk for developing adverse cardiovascular events such as sudden death, myocardial infarction, and stroke as compared to pediatric population. Cardiovascular response attributed to ADHD medication has mainly been observed in heart rate and blood pressure elevations, while less is known about the etiology of rare cardiovascular events like acute myocardial infarction (AMI), arrhythmia, and cardiomyopathy and its long-term sequelae. We present a unique case of AMI in an adult taking Adderall (mixed amphetamine salts) and briefly discuss the literature relevant to the cardiovascular safety of CNS stimulants for adult ADHD. A. Sinha, O. Lewis, R. Kumar, S. L. H. Yeruva, and B. H. Curry Copyright © 2016 A. Sinha et al. All rights reserved. Ventricular Septal Defect from Takotsubo Syndrome Wed, 03 Aug 2016 11:42:13 +0000 Takotsubo Syndrome is a transient condition characterized by left ventricular systolic dysfunction with apical akinesis/dyskinesis and ballooning. Although the prognosis with medical management is excellent in most cases, rare cases of serious complications can occur. We present here a case of a 71-year-old woman presenting with acute decompensated heart failure with initial findings consistent with a myocardial infarction, who was found instead to have an acute ventricular septal defect as a complication of Takotsubo Syndrome. Daniel Y. Lu, Julie Caplow, Neha Quatromoni, Rhondalyn Forde-McLean, and Anjali Tiku Owens Copyright © 2016 Daniel Y. Lu et al. All rights reserved. Cardiac Fibroelastoma versus Thrombus: Echocardiographic Evidence Can Be Misleading Sun, 31 Jul 2016 17:09:43 +0000 We present a case of a young female with stroke symptoms who underwent valve sparing resection of a presumed fibroelastoma based on echocardiographic findings. After confirming embolic stroke, she underwent excision of the lesion, which on pathology revealed a nonbacterial thrombus. Ultimately, this led to a more extensive work-up leading to the discovery of a papillary serous ovarian carcinoma, the underlying cause of her hypercoagulable state. The initial echocardiographic findings painted the clear picture of a papillary tumor on the aortic valve which was likely the source of the emboli resulting in ischemic stroke. This unique case presentation illustrates that imaging, including echocardiography, may not always coincide with the clinical diagnosis. Thus, understanding the differential diagnoses of cardiac masses is of vital clinical significance. The distinction of fibroelastoma versus the much less common finding of aortic thrombus may lead to early diagnosis of malignancy and prevention of life threatening events due to stroke or undiagnosed disease. John P. O’Laughlin, Gautam Verma, and Iosif Gulkarov Copyright © 2016 John P. O’Laughlin et al. All rights reserved. The Presence of a Large Chiari Network in a Patient with Atrial Fibrillation and Stroke Sun, 31 Jul 2016 08:04:15 +0000 The Chiari network is an embryological remnant found in the right atrium, mostly without any significant pathophysiological consequences. However, several cardiac associations are reported in the literature including supraventricular tachyarrhythmias. We present a case of a 96-year-old body donor with a stroke episode and intermittent atrial fibrillations. The dissection of the heart revealed the presence of an immense Chiari network with a large central thrombus. The role of a Chiari network in the pathogenesis of stroke and pulmonary embolism is discussed. Nneka Schwimmer-Okike, Johannes Niebuhr, Grit Gesine Ruth Schramek, Stefan Frantz, and Heike Kielstein Copyright © 2016 Nneka Schwimmer-Okike et al. All rights reserved. Noncompaction and Dilated Cardiomyopathy in a Patient with Schizophrenia Sun, 31 Jul 2016 06:32:09 +0000 Objectives. Psychosis and left ventricular hypertrabeculation (or noncompaction) (LVHT) have not been described in the same patient. Here we report a patient with a long-term history of schizophrenia who was later diagnosed with dilated cardiomyopathy (dCMP) and LVHT. Case Report. A 47-year-old Caucasian male developed nondifferentiated schizophrenia at the age of 26 y. Since the age of 33 y he was regularly drinking alcohol. At the age of 47 y he developed heart failure. Transthoracic echocardiography showed an enlarged left ventricle, reduced systolic function, and surprisingly LVHT in the apical segment. Additionally, the left atrium was enlarged, the right ventricular cavities were mildly enlarged, and there were pulmonary hypertension and a small pericardial effusion. Cardiac MRI confirmed the echocardiographic findings. Since coronary angiography was normal, dilated cardiomyopathy was additionally diagnosed. Since he was taking clozapine during years, dilated cardiomyopathy could be due to not only alcohol consumption but also the long-term neuroleptic medication. Conclusions. LVHT may be associated with nondifferentiated psychosis. Management of LVHT is challenging in patients with psychosis due to poor compliance and adherence of these patients. Patients with LVHT and psychosis need particular attention since they usually take cardiotoxic drugs for a long time, which may further deteriorate the prognosis of LVHT. Josef Finsterer and Claudia Stöllberger Copyright © 2016 Josef Finsterer and Claudia Stöllberger. All rights reserved. Takotsubo Cardiomyopathy and Catatonia in the Setting of Benzodiazepine Withdrawal Thu, 28 Jul 2016 11:36:00 +0000 We report two serious and unusual complications of benzodiazepine withdrawal in a single patient: takotsubo cardiomyopathy and catatonia. This 61-year-old female patient was brought to the emergency department with lethargy and within hours had declined into a state of catatonia. Although there was never a complaint of chest pain, ECG showed deep anterior T-wave inversions and cardiac enzymes were elevated. An echocardiogram was consistent with takotsubo cardiomyopathy. She later received 1 mg of midazolam and within minutes had resolution of catatonic symptoms. Careful history revealed that she had omitted her daily dose of lorazepam for 3 days prior to admission. To our knowledge, the case presented herein is the first report of simultaneous catatonia and takotsubo cardiomyopathy in the setting of benzodiazepine withdrawal. The pathogenesis of both conditions is poorly understood but may be indirectly related to the sudden decrease in γ-aminobutyric acid (GABA) signaling during benzodiazepine withdrawal. Teng J. Peng, Nicholas D. Patchett, and Sheilah A. Bernard Copyright © 2016 Teng J. Peng et al. All rights reserved. Refractory Hypotension as an Initial Presentation of Bilateral Subclavian Artery Stenosis Thu, 28 Jul 2016 10:59:48 +0000 Bilateral subclavian stenosis is a rare clinical condition. An interbrachial pressure difference of 15 mm Hg can raise suspicion for unilateral subclavian artery stenosis, but the diagnosis of bilateral subclavian artery stenosis can be challenging. We present a case of a 75-year-old woman who presented with refractory hypotension after surgery. Initial vitals revealed blood pressure in the 60s/50s mm Hg in both arms. Cardiopulmonary examination was remarkable for diminished pulses in all 4 extremities and audible carotid bruits. She continued to be hypotensive despite aggressive fluid resuscitation. Troponin T peaked at 0.24 ng/mL (reference < 0.04), and an echocardiogram revealed a reduction in ejection fraction (37% from 50%). Left and right heart catheterization demonstrated normal filling pressures and cardiac output. During the procedure, however, it was noted that the patient’s central blood pressure was 70–80 mm Hg higher than cuff pressures obtained in either arm. Selective angiography revealed 90% left subclavian ostial stenosis as well as 70% stenosis of the right subclavian artery. Maxwell Eyram Afari, John V. Wylie Jr., and Joseph P. Carrozza Jr. Copyright © 2016 Maxwell Eyram Afari et al. All rights reserved. Loperamide Induced Life Threatening Ventricular Arrhythmia Thu, 28 Jul 2016 06:04:39 +0000 Loperamide is over-the-counter antidiarrheal agent acting on peripherally located μ opioid receptors. It is gaining popularity among drug abusers as opioid substitute. We report a case of a 46-year-old male that was presented after cardiac arrest. After ruling out ischemia, cardiomyopathy, pulmonary embolism, central nervous system pathology, sepsis, and other drug toxicity, we found out that patient was using around 100 mg of Loperamide to control his chronic diarrhea presumably because of irritable bowel syndrome for last five years and consumed up to 200 mg of Loperamide daily for last two days before the cardiac arrest. We hypothesize that the patient’s QTc prolongation and subsequent cardiac arrest are due to Loperamide toxicity. Patient experienced gradual resolution of tachyarrhythmia and gradual decrease in QTc interval during hospitalization which supports the evidence of causal relationship between Loperamide overdose and potentially fatal arrhythmias. It also provided the clue that patient may have congenital long QT syndrome which was unmasked by Loperamide causing ventricular arrhythmias. This case adds one more pearl in the literature to support that Loperamide overdose related cardiac toxicity does exist and it raises concerns over Loperamide abuse in the community. Ankit Upadhyay, Vijaykumar Bodar, Mohammad Malekzadegan, Sharanjit Singh, William Frumkin, Aditya Mangla, and Kaushik Doshi Copyright © 2016 Ankit Upadhyay et al. All rights reserved. GuideLiner Catheter Use for Percutaneous Intervention Involving Anomalous Origin of a Single Coronary Trunk Arising from the Ascending Aorta Wed, 27 Jul 2016 09:25:45 +0000 Cases in which an anomalous single coronary trunk arises from the ascending aorta are extremely rare. In percutaneous coronary intervention for the lesion of a coronary artery anomaly, several problems may occur, including selection of a guide catheter, insufficient backup force, and difficulties of stent delivery. The GuideLiner catheter, which is a coaxial guide extension having the advantage of rapid exchange, facilitates coronary intervention for complex lesions. We report a case of angina having a lesion in the left anterior descending artery of a single coronary trunk arising from the ascending aorta. We successfully performed revascularization by using the GuideLiner catheter. Mitsunari Matsumoto, Yusuke Tamanaha, Yoshimasa Tsurumaki, and Tomohiro Nakamura Copyright © 2016 Mitsunari Matsumoto et al. All rights reserved. Fractional Flow Reserve Assessment of a Significant Coronary Stenosis Masked by a Downstream Serial Lesion Wed, 27 Jul 2016 08:33:49 +0000 Fractional flow reserve (FFR) has been recognized as an effective tool to determine functional significance in intermediate coronary lesions and FFR-guided percutaneous coronary intervention (PCI) improves clinical outcomes. However, hemodynamic interaction between serial stenoses within one coronary artery complicates the assessment of functional severity of each individual lesion. We present a case in which FFR measurement by intracoronary bolus injection of adenosine helps to make appropriate revascularization decision in serial stenoses when the procedures are performed systemically and properly. Lawrence Yu-Min Liu, Hsu-Ping Wu, and Po-Lin Lin Copyright © 2016 Lawrence Yu-Min Liu et al. All rights reserved. Sepsis-Induced Takotsubo Cardiomyopathy Leading to Torsades de Pointes Wed, 20 Jul 2016 14:21:23 +0000 Background. Takotsubo cardiomyopathy (TCM) is sudden and reversible myocardial dysfunction often attributable to physical or emotional triggers. Case Report. We describe a 51-year-old man presented to emergency department with sepsis from urinary tract infection (UTI). He was placed on cefepime for UTI and non-ST-elevation myocardial infarction protocol given elevated troponins with chest pain. Subsequently, patient was pulseless with torsades de pointes (TdP) and then converted to sinus rhythm with cardioversion. An echocardiogram revealed low ejection fraction with hypokinesis of the apical wall. Over 48 hours, the patient was extubated and stable on 3 L/min nasal cannula. He underwent a cardiac catheterization to evaluate coronary artery disease (CAD) and was found to have mild nonobstructive CAD with no further findings. Conclusion. TCM is a rare disorder presenting with symptoms similar to acute coronary syndrome. Though traditionally elicited by physical and emotional triggers leading to transient left ventricular dysfunction, our case suggests that it may also be triggered by a urinary tract infection and lead to severe QT prolongation and a malignant ventricular arrhythmia in TdP. Nirav Patel, Abhishek Shenoy, George Dous, Haroon Kamran, and Nabil El-Sherif Copyright © 2016 Nirav Patel et al. All rights reserved. Amphetamine Containing Dietary Supplements and Acute Myocardial Infarction Tue, 19 Jul 2016 12:50:29 +0000 Weight loss is one of the most researched and marketed topics in American society. Dietary regimens, medications that claim to boost the metabolism, and the constant pressure to fit into society all play a role in our patient’s choices regarding new dietary products. One of the products that are well known to suppress appetite and cause weight loss is amphetamines. While these medications suppress appetite, most people are not aware of the detrimental side effects of amphetamines, including hypertension, tachycardia, arrhythmias, and in certain instances acute myocardial infarction. Here we present the uncommon entity of an acute myocardial infarction due to chronic use of an amphetamine containing dietary supplement in conjunction with an exercise regimen. Our case brings to light further awareness regarding use of amphetamines. Clinicians should have a high index of suspicion of use of these substances when young patients with no risk factors for coronary artery disease present with acute arrhythmias, heart failure, and myocardial infarctions. Julio Perez-Downes, Abdulwahab Hritani, Candice Baldeo, and Patrick Antoun Copyright © 2016 Julio Perez-Downes et al. All rights reserved. Successful Percutaneous Coronary Intervention through a Severely Bent Artificial Ascending Aorta Using the DIO Thrombus Aspiration Catheter Tue, 19 Jul 2016 12:09:29 +0000 A 66-year-old man was admitted to our institute because of chest pain. He had undergone replacement of the ascending aorta due to aortic dissection 9 years previously. We made a diagnosis of acute coronary syndrome, and coronary artery angiography was performed. Although the right coronary artery was successfully cannulated, a severe bend of the artificial aorta made it very difficult to advance the catheter into the left coronary artery. Ultimately, a DIO thrombus aspiration catheter was used to enter the left coronary artery, and a stent was implanted successfully. The DIO catheter is very useful when the selection of a guiding catheter is complicated, such as in the case of severe vessel tortuosity or a bend of the ascending aorta. Akinori Fujikake, Takaaki Komatsu, and Isao Taguchi Copyright © 2016 Akinori Fujikake et al. All rights reserved. Dexamethasone Associated ST Elevation Myocardial Infarction Four Days after an Unremarkable Coronary Angiogram—Another Reason for Cautious Use of Steroids: A Case Report and Review of the Literature Mon, 18 Jul 2016 13:33:00 +0000 Drug induced myocardial infarction is a known entity with different forms of steroids linked to coronary artery disease (CAD) either through promoting its traditional risk factors, inducing coronary spasm, or by other unidentified mechanisms. Dexamethasone is known to promote an atherogenic and hypercoagulable state. We report a case of a 75-year-old woman who had ST elevation myocardial infarction (STEMI) associated with dexamethasone use just 4 days following an angiogram showing minor luminal irregularities. Mohamed Shokr, Ahmed Rashed, Kusum Lata, and Ashok Kondur Copyright © 2016 Mohamed Shokr et al. All rights reserved.