Case Reports in Cardiology https://www.hindawi.com The latest articles from Hindawi © 2017 , Hindawi Limited . All rights reserved. Lyme Carditis Buried Beneath ST-Segment Elevations Wed, 21 Jun 2017 00:00:00 +0000 http://www.hindawi.com/journals/cric/2017/9157625/ 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 http://www.hindawi.com/journals/cric/2017/2842935/ 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 http://www.hindawi.com/journals/cric/2017/4854736/ 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 http://www.hindawi.com/journals/cric/2017/9232658/ 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 http://www.hindawi.com/journals/cric/2017/6458636/ 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 http://www.hindawi.com/journals/cric/2017/6250312/ 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 http://www.hindawi.com/journals/cric/2017/4565182/ 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 http://www.hindawi.com/journals/cric/2017/3186047/ 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 http://www.hindawi.com/journals/cric/2017/1528416/ 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 http://www.hindawi.com/journals/cric/2017/4257452/ 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 http://www.hindawi.com/journals/cric/2017/9473917/ 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 http://www.hindawi.com/journals/cric/2017/1384905/ 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 http://www.hindawi.com/journals/cric/2017/2865305/ 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 http://www.hindawi.com/journals/cric/2017/8101489/ 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 http://www.hindawi.com/journals/cric/2017/9878049/ 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 http://www.hindawi.com/journals/cric/2017/6956298/ 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 http://www.hindawi.com/journals/cric/2017/5086586/ 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 http://www.hindawi.com/journals/cric/2017/7065759/ 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 http://www.hindawi.com/journals/cric/2017/3850646/ 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 http://www.hindawi.com/journals/cric/2017/9734795/ 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 http://www.hindawi.com/journals/cric/2017/8510160/ 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 http://www.hindawi.com/journals/cric/2017/9894215/ 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 http://www.hindawi.com/journals/cric/2017/8710135/ 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 http://www.hindawi.com/journals/cric/2017/8694652/ 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 http://www.hindawi.com/journals/cric/2017/6287015/ 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. Surgical Repair of Subacute Right Ventricular Perforation after Pacemaker Implantation Thu, 06 Apr 2017 00:00:00 +0000 http://www.hindawi.com/journals/cric/2017/3242891/ We report an 84-year-old woman who presented with right ventricular perforation 4 days after pacemaker implantation for syncope due to sick sinus syndrome. Median sternotomy revealed no pericardial effusion, but the pacing lead had penetrated the right ventricle and pericardium. When the pleura was opened, the tip of the lead was seen in the visceral pleura. The lead was cut in the pericardial cavity and extracted from the left subclavian wound together with the generator. The right ventricular perforation was sutured and a temporary pacing lead was placed on the right ventricular wall intraoperatively. Ten days after the surgery, a new pacemaker lead was placed in the ventricular septum via the right axillary vein. Right ventricular perforation is a rare complication after pacemaker implantation. Typically, it occurs at the time of implantation or within 24 hours after implantation. In the present case, the perforation of the right ventricle which needed urgent surgery occurred 4 days after implanting the pacing lead at the right ventricular apex. Great care should have been taken not to overlook this life-threatening complication even more than 24 hours after pacemaker implantation. Takeshi Oda, Takanori Kono, Keiichi Akaiwa, Yasushi Takahara, Chie Yasuoka, and Katsuhiko Nakamura Copyright © 2017 Takeshi Oda et al. All rights reserved. Life-Threatening Hemopericardium Associated with Rivaroxaban Wed, 05 Apr 2017 07:32:09 +0000 http://www.hindawi.com/journals/cric/2017/4691325/ Rivaroxaban is a novel oral anticoagulant used in the treatment of venous thromboembolism. The use of this medication has expanded over the recent years with resultant expansion of side effect profile. We present a case of a 56-year-old female who presented with shortness of breath and chest pain 12 weeks after starting rivaroxaban for left upper extremity deep vein thrombosis. She was later diagnosed with spontaneous hemopericardium requiring pericardial fluid drainage. Rarer side effects like this will be encountered more often with the increasing use of novel oral anticoagulants. The clinicians should be cognizant of this entity among patients with shortness of breath and chest pain for timely diagnosis and intervention. Sijan Basnet, Niranjan Tachamo, Biswaraj Tharu, Rashmi Dhital, Sushil Ghimire, and Dilli Ram Poudel Copyright © 2017 Sijan Basnet et al. All rights reserved. Peeled Guidewire Coating with Debulked Plaque Obtained by Directional Coronary Atherectomy Wed, 05 Apr 2017 00:00:00 +0000 http://www.hindawi.com/journals/cric/2017/2397183/ Percutaneous directional coronary atherectomy (DCA) is a plaque debulking method performed in Japan, and recently a renewed DCA device has been launched. We present a case with a tight left anterior descending lesion undergoing percutaneous coronary intervention with application of DCA. After several sessions of DCA, white plaques accompanied by green, stringed materials were obtained from the device; some materials were considerably long (approximately 15 mm in length). A drug-eluting stent was subsequently implanted, and the procedure was completed successfully without any complications. The extracted plaques and artificial materials were pathologically examined, and no inflammatory changes were detected on plaques adjacent to the material. Assessing pathological findings and structure of the DCA catheter, the obtained artificial materials were considered as peeled guidewire, possibly resulting from the friction between the guidewire and metallic bearing in the housing of DCA catheter. Of note, this phenomenon has been recognized even in other DCA cases in which guidewires of the other kind are used. We report this phenomenon for the first time, warning of theoretically possible distal embolization of artificial materials caused by any debulking devices. Rikuta Hamaya, Taishi Yonetsu, Sadamitsu Ichijo, Makoto Araki, Tadashi Murai, Yoshihisa Kanaji, Eisuke Usui, Junji Matsuda, Masahiro Hoshino, Masahiro Hada, Takayuki Niida, Yoshinori Kanno, and Tsunekazu Kakuta Copyright © 2017 Rikuta Hamaya et al. All rights reserved. Pulmonary Embolism and Intracardiac Type A Thrombus with an Unexpected Outcome Sun, 02 Apr 2017 08:04:56 +0000 http://www.hindawi.com/journals/cric/2017/9092576/ Detection of right heart thrombi (RHT) in the context of pulmonary thromboembolism (PE) is uncommon (4–18%) and increases the risk of mortality beyond the presence of PE alone. Type A thrombi are serpiginous and highly mobile and are thought to be originated from large veins and captured in-transit within the right heart. Optimal management of RHT is still uncertain. A 79-year-old woman, with a history of recent total hysterectomy with adnexectomy and a Wells procedure, presented to the emergency department following an episode of syncope. Computed tomography revealed bilateral PE and the presence of a right atrial thrombus. Transthoracic echocardiography demonstrated a free-floating type A thrombus in the right atrium, protruding into the right ventricle, and signs of pulmonary hypertension and right ventricle dysfunction. Considering the recent surgery and clinical stability, treatment with heparin alone was decided. Subsequent clinical improvement was observed and echocardiographic follow-up revealed complete thrombus dissolution and complete recovery of right ventricle function. Most authors recommend treatment of PE with RHT with thrombolysis or embolectomy followed by anticoagulation, although evidence is scarce. Individual risk of hemorrhage and operatory-related mortality should be taken into account when defining the treatment strategy especially when benefit is not firmly established. João Português, Lucy Calvo, Margarida Oliveira, Vítor Hugo Pereira, Joana Guardado, Mário Rui Lourenço, Olga Azevedo, Francisco Ferreira, Filipa Canário-Almeida, and António Lourenço Copyright © 2017 João Português et al. All rights reserved. Papillary Fibroelastoma as a Cause of Cardiogenic Embolic Stroke in a β-Thalassemia Patient: Case Report and Literature Review Sun, 26 Mar 2017 07:40:39 +0000 http://www.hindawi.com/journals/cric/2017/8185601/ We describe a case of a young male without stroke risk factors who presented with a sudden onset of left-sided weakness, left hand numbness, and left eye blurriness. CT scan of the head without contrast and diffusion-weighted MRI of the brain with contrast revealed an ischemic stroke in the right middle cerebral artery distribution. Transesophageal echocardiography (TEE) revealed a mobile pedunculated mass on the posterior surface of the mitral valve. This mass was resected and pathology showed a cardiac papillary fibroelastoma (CPFE), which was determined to be the cause of the patient’s cardioembolic stroke. Further workup also found that patient had microcytic anemia secondary to β-thalassemia intermedia, a rare hematologic disorder due to defective hemoglobin synthesis. Recently, another case report suggested β-thalassemia major may underlie the pathogenesis of CPFE. β-Thalassemia major causes a state of chronic inflammation and endothelial damage, which can mediate CPFE formation. Based on literature review, this is the first case report of a CPFE in a patient with β-thalassemia intermedia. This hypothesis-generating case report calls attention to the need for elucidating the relationship between CPFE and β-thalassemia in future studies to better understand the diagnosis and management of a rare cardiac tumor. Re-I Chin, John J. Monda, Maulik Sheth, William Ogle, Gloria Merenda, and Debapriya De Copyright © 2017 Re-I Chin et al. All rights reserved.