Case Reports in Cardiology The latest articles from Hindawi © 2017 , Hindawi Limited . All rights reserved. Chagas Cardiomyopathy Presenting as Symptomatic Bradycardia: An Underappreciated Emerging Public Health Problem in the United States Wed, 16 Aug 2017 06:31:22 +0000 Chagas cardiomyopathy (CCM) is traditionally considered a disease restricted to areas of endemicity. However, an estimated 300,000 people living in the United States today have CCM, of which its majority is undiagnosed. We present a case of CCM acquired in an endemic area and detected in its early stage. A 42-year-old El Salvadoran woman presented with recurrent chest pain and syncopal episodes. Significant family history includes a sister in El Salvador who also began suffering similar episodes. Physical exam and ancillary studies were only remarkable for sinus bradycardia. The patient was diagnosed with symptomatic sinus bradycardia and a pacemaker was placed. During her hospital course, Chagas serology was ordered given the epidemiological context from which she came. With no other identifiable cause, CCM was the suspected etiology. This case highlights the underrecognized presence of Chagas in the United States and the economic and public health importance of its consideration in the etiological differential diagnosis of electrocardiographic changes among Latin American immigrants. While the United States is not considered an endemic area for Chagas disease, the influx of Latin American immigrants has created a new challenge to identify at-risk populations, diagnose suspected cases, and provide adequate treatment for this disease. Richard Jesse Durrance, Tofura Ullah, Zulekha Atif, William Frumkin, and Kaushik Doshi Copyright © 2017 Richard Jesse Durrance et al. All rights reserved. Spontaneous Coronary Artery Dissection: A Rare Manifestation of Alport Syndrome Mon, 14 Aug 2017 06:35:40 +0000 Alport syndrome (AS) is a genetic disorder due to inheritance of genetic mutations which lead to production of abnormal type IV collagen. AS has been associated with renal, auditory, and ocular diseases due to the presence of abnormal alpha chains of type IV collagen in the glomerulus, cochlea, cornea, lens, and retina. The resulting disorder includes hereditary nephritis, corneal opacities, anterior lenticonus, fleck retinopathy, temporal retinal thinning, and sensorineural deafness. Aortic and aortic valve pathologies have been described as extrarenal manifestations of AS in multiple case reports. One case report described intramural hematoma of the coronary artery. We report the first case of true spontaneous coronary artery dissection (SCAD) with an intimal flap as a very rare manifestation of AS. The patient is a 36-year-old female with history of AS with chronic kidney disease, hypertension, and obesity who presented to the emergency room with acute onset of substernal chest pain radiating to her neck and arms. Troponin was elevated, and ECG showed transient 1 mm ST-segment elevation in the inferior leads. Subsequent coronary angiography revealed localized dissection of the left circumflex artery. Percutaneous coronary angioplasty was performed and her symptoms improved. This case illustrates that SCAD may be a manifestation of AS patients with chest pain. Amornpol Anuwatworn, Prince Sethi, Kelly Steffen, Orvar Jonsson, and Marian Petrasko Copyright © 2017 Amornpol Anuwatworn et al. All rights reserved. The Use of a Novel Heart Failure Agent in the Treatment of Pregnancy-Associated Cardiomyopathy Mon, 14 Aug 2017 06:16:17 +0000 Peripartum cardiomyopathy is an uncommon, pregnancy-related form of dilated cardiomyopathy that is associated with development of new-onset left ventricular dysfunction. Its etiology is presently unknown, but current standard of care involves the use of typical drug therapy for the treatment of heart failure. Pregnancy-associated cardiomyopathy (PACM) is a similar condition that refers to patients who develop such symptoms prior to the last month of pregnancy. We report the case of a nulliparous Caucasian female who develops early, severe PACM during her first pregnancy with postpartum persistence of New York Heart Association class II-III symptoms despite medical therapy. The use of the novel heart failure agent, sacubitril/valsartan (Entresto), is initiated with near-complete resolution of her symptoms. Vamsi C. Gaddipati, Aarti A. Patel, and Adam J. Cohen Copyright © 2017 Vamsi C. Gaddipati et al. All rights reserved. Sequential Venous Percutaneous Transluminal Angioplasty and Balloon Dilatation of the Interatrial Septum during Percutaneous Edge-to-Edge Mitral Valve Repair Wed, 09 Aug 2017 00:00:00 +0000 Percutaneous edge-to-edge mitral valve repair (PMVR) is widely used for selected, high-risk patients with severe mitral valve regurgitation (MR). This report describes a case of 81-year-old woman presenting with severe and highly symptomatic mitral valve regurgitation (MR) caused by a flail of the posterior mitral valve leaflet (PML). PMVR turned out to be challenging in this patient because of a stenosis and tortuosity of both iliac veins as well as sclerosis of the interatrial septum, precluding the vascular and left atrial access by standard methods, respectively. We managed to achieve atrial access by venous percutaneous transluminal angioplasty (PTA) and balloon dilatation of the interatrial septum. Subsequently, we could advance the MitraClip® system to the left atrium, and deployment of the clip in the central segment of the mitral valve leaflets (A2/P2) resulted in a significant reduction of MR. Rezo Jorbenadze, Johannes Patzelt, Meinrad Gawaz, Peter Seizer, and Harald F. Langer Copyright © 2017 Rezo Jorbenadze et al. All rights reserved. Detection of a Left Superior Vena Cava during a Pacemaker Implantation in Cotonou Tue, 08 Aug 2017 06:48:14 +0000 Persistent left superior vena cava (LSVC) is a rare congenital anomaly. Its prevalence in the general population is 0.1 to 0.5%. LSVC is 5 times rarer when accompanied by an absence of the right superior vena cava (RSVC). We present the case of a 54-year-old man who carries a persistent LSVC without RSVC. Clinically, this patient presented a regular bradycardia at 40 per minute associated with a heart failure syndrome. The electrocardiogram diagnosed a complete atrioventricular block and transthoracic echocardiography showed dilated left heart cavities and a left ventricular ejection fraction of 50%. During the procedure of pacemaker implantation, the probe followed an unusual LSVC-coronary sinus-right atrium path and it was not easy to pass through the tricuspid orifice. We propose a review of the literature on this subject, focusing on the clinical implications of this malformation in cardiac stimulation and in other areas of cardiology. A. Sonou, M. Hounkponou, L. Codjo, P. M. Adjagba, C. Houehanou, H. Dohou, S. Assani, Y. Tchabi, and M. Houenassi Copyright © 2017 A. Sonou et al. All rights reserved. Leukemic Ischemia: A Case of Myocardial Infarction Secondary to Leukemic Cardiac Involvement Mon, 07 Aug 2017 00:00:00 +0000 We report a case of a 39-year-old male who presented to the emergency department with acute chest pain while being in remission from T-cell acute lymphoblastic leukemia (T-ALL). Cardiac markers were elevated and EKG revealed ischemic changes compatible with acute myocardial ischemia. Coronary computed tomography angiography (CCTA) showed calcium-free coronary arteries and soft tissue myocardial infiltration suggestive of cardiac leukemia. A bone marrow biopsy confirmed recurrence of T-ALL, and patient was successfully treated with chemotherapy. We discuss the prospective diagnosis of myopericardial leukemic involvement and the role of CCTA in diagnosis and perform a literature review. Dzmitry Fursevich, Colin Zuchowski, Joseph Limback, Melissa Kendall, Ashley Ramirez, Naim Fanaian, and Jeremy Burt Copyright © 2017 Dzmitry Fursevich et al. All rights reserved. Alveolar Soft Part Sarcoma with Unusual Cardiac Metastasis: A Case Report and Review of the Literature Sun, 06 Aug 2017 08:33:21 +0000 Alveolar soft part sarcoma is a very uncommon soft tissue malignancy which accounts for <1% of soft tissue sarcoma. It is a malignant and highly vascular tumor arising most commonly in the musculature of the lower extremities, with metastasis primarily to the lungs, bones, and brain. Cardiac metastasis is very rare and only 5 cases have been reported in the literature so far. We report a case of a young woman with a history of surgically resected alveolar soft part sarcoma of left thigh who presented with persistent dry cough and was found to have a cardiac mass, which on biopsy proved to be alveolar soft part sarcoma. Abhinav Tiwari, Bhavana Siddegowda Bangalore, Himani Sharma, Zaid Ammari, Mohammad S. Khan, Zubair Khan, and Hermann Simo Copyright © 2017 Abhinav Tiwari et al. All rights reserved. Symptomatic Long Pauses and Bradycardia due to Massive Multinodular Goiter Sun, 06 Aug 2017 08:19:38 +0000 Sinus node dysfunction with symptomatic bradycardia or chronotropic incompetence is generally an indication for pacemaker implantation. However, in patients with symptomatic sinus bradycardia, the identification and treatment of underlying pathologies may avoid the need for permanent pacemaker implantation. We present a case of carotid sinus syndrome and severe obstructive sleep apnea due to a massive multinodular goiter in a patient who presented with recurrent sinus pauses and syncope. The patient was managed without pacemaker implantation but instead with thyroidectomy resulting in decompression of the carotid sinus and airway and resolution of bradycardic episodes. Amrish Deshmukh and Cevher Ozcan Copyright © 2017 Amrish Deshmukh and Cevher Ozcan. All rights reserved. Acute Heart Failure Exacerbation with Cardiogenic Shock and Elevated Systemic Vascular Resistance Treated with a Combination of Nicardipine and Dobutamine Therapy Sun, 06 Aug 2017 06:33:51 +0000 Acute heart failure is a common reason for hospital admission and is usually caused by decreased cardiac output either as a result of an intrinsic cardiac issue or as a result of severe hypertension with elevated afterload. We present a patient with a history of HFrEF who presented with acute heart failure, found to have hypotension requiring Dobutamine support and an elevated systemic vascular resistance requiring Nicardipine drip, with subsequent recovery of cardiac function. Lydia E. Issac, Setri Fugar, Naser Yamani, and Burhan Mohamedali Copyright © 2017 Lydia E. Issac et al. All rights reserved. Neuropsychological Outcome following Resuscitation after Out-of-Hospital Cardiac Arrest: A One-Year Follow-Up Sun, 06 Aug 2017 00:00:00 +0000 A 61-year-old woman survived resuscitation after out-of-hospital cardiac arrest. The heterogeneity of the resulting cognitive impairments and the recovery over a one-year period are presented, highlighting the need for standardized neuropsychological testing even after short cardiac arrests and for effective treatment both out of hospital and in hospital. Jeannette Overbeck and Frank-Michael Schweers Copyright © 2017 Jeannette Overbeck and Frank-Michael Schweers. All rights reserved. Cobalt Cardiomyopathy Secondary to Hip Arthroplasty: An Increasingly Prevalent Problem Sun, 06 Aug 2017 00:00:00 +0000 A forty-year-old man experienced worsening heart failure four years following bilateral complicated total hip replacement. His condition was extensively worked up but no underlying pathology was immediately evident. Given the cobalt-chromium alloy component present in the hip arthroplasties, the raised cobalt blood levels, and a fitting clinical picture coupled with radiological findings, the patient underwent right hip revision. Evidence of biotribocorrosion was present on direct visualisation intraoperatively. The patient subsequently experienced symptomatic improvement (NYHA class III to class I) and echocardiography showed recovery of ejection fraction. Cobalt exists as a bivalent and trivalent molecule in circulation and produces a cytotoxicity profile similar to nanoparticles, causing neurological, thyroid, and cardiological pathology. Blood levels are not entirely useful as there is no identifiable conversion factor for levels in whole blood, serum, and erythrocytes which seem to act independently of each other. Interestingly cobalt cardiomyopathy is frequently compounded by other possible causes of cardiomyopathy such as alcohol and a link has been postulated. Definitive treatment is revision of the arthroplasty as other treatments are unproven. Russel Tilney, Melanie Roberta Burg, and Mark Adrian Sammut Copyright © 2017 Russel Tilney et al. All rights reserved. Surgery Averted Using a Novel, Minimally Invasive Approach to Treat Very Severe Radial Artery Spasm Wed, 02 Aug 2017 07:59:26 +0000 A 42-year-old male admitted with a non-ST elevation myocardial infarction was referred for invasive angiographic assessment. Based on preprocedural assessment, the right radial artery approach was selected. Despite possessing none of the consensus risk factors for radial artery spasm, in addition to receiving standard arterial spasm prophylaxis and conscious sedation, the patient suffered very severe radial artery spasm with initial catheter placement, resulting in entrapment of a 5 Fr pigtail catheter within the left ventricle. After exhausting traditional methods for resolution of radial artery spasm, surgical intervention appeared to be the only remaining option for removal of the entrapped catheter. Prior to committing to surgery, use of an axillary nerve block to hinder sympathetic vascular tone was suggested and attempted. This intervention resulted in atraumatic catheter removal. We present a case of very severe radial artery spasm refractory to customary interventions, alleviated with a novel, minimally invasive technique, which spared surgical intervention. Anthony A. Cochet Jr. and Daniel A. Bellin Copyright © 2017 Anthony A. Cochet Jr. and Daniel A. Bellin. All rights reserved. Case Report of First Angiography-Based On-Line FFR Assessment during Coronary Catheterization Tue, 01 Aug 2017 00:00:00 +0000 Fractional flow reserve (FFR), an index of the hemodynamic severity of coronary stenoses, is derived from hyperemic pressure measurements and requires a pressure-monitoring guide wire and hyperemic stimulus. Although it has become the standard of reference for decision-making regarding coronary revascularization, the procedure remains underutilized due to its invasive nature. is a novel technology that uses the patient’s hemodynamic data and routine angiograms to generate a complete three-dimensional coronary tree, with color-coded display of the FFR values at each point along the vessels. After being proven to be as accurate as invasive FFR measurements in an off-line study, this case report presents the first on-line application of the system in the catheterization lab. Here too, a high concordance between and invasive FFR was observed. In light of the demonstrated capabilities of the system, it should emerge as an important tool for clinical decision-making regarding revascularization in patients with coronary artery disease. Ran Kornowski and Hana Vaknin-Assa Copyright © 2017 Ran Kornowski and Hana Vaknin-Assa. All rights reserved. Incomplete Resolution of Deep Vein Thromboses during Rivaroxaban Therapy Sun, 30 Jul 2017 08:17:35 +0000 We present the case of a patient with a deep vein thrombosis (DVT) who failed rivaroxaban therapy. Our patient initially presented with left lower extremity edema, erythema, and pain. He was subsequently started on rivaroxaban therapy for a combined treatment period of 12 months, during and after which he persisted to have evidence of a DVT. The patient’s prescribed drug regimen was changed from rivaroxaban to warfarin, which demonstrated a rapid resolution of the DVTs as determined by ultrasound assessment of our patient’s lower extremity veins. Rivaroxaban, a factor Xa inhibitor, is a well-known oral anticoagulant that is used for a variety of indications and has become a mainstay in the treatment of deep vein thrombosis. With the introduction and emergence of this medication in the clinic, postmarketing reports of efficacy or lack thereof are important to review. In conclusion, we anticipate that it is likely that there are other patients with DVTs who may not respond to rivaroxaban and for whom alternative anticoagulation therapies should be explored. Jonathan M. Yaghoubian, Jacob Adashek, Bahareh Yaghoubian-Yazi, Menachem Nagar, Nojan Toomari, Richard J. Pietras, and Uri M. Ben-Zur Copyright © 2017 Jonathan M. Yaghoubian et al. All rights reserved. Incidental Finding of an Undiagnosed Coarctation of the Aorta Causing Dilated Cardiomyopathy in an Adult Thu, 27 Jul 2017 00:00:00 +0000 31-year-old male with no past medical history apart from high blood pressure noted by GP one week prior to admission presented with a three-week history of a flu-like illness and symptoms of heart failure with severe global left ventricular dilation and dysfunction on Transthoracic Echocardiography (TTE). Two weeks following admission he complained of left arm pain and CT upper limb confirmed embolic occlusion of the left brachial artery and incidental severe coarctation of the proximal descending aorta after the origin of the left subclavian artery. Follow-up TTE suggested the presence of coarctation of the aorta on a suprasternal view which was not performed at the time of his first TTE. His heart failure and blood pressure responded very well to medical therapy and he has been referred for surgical correction of his aortic coarctation. Abdalla Ibrahim, Zahir Satti, and Ronan Curtin Copyright © 2017 Abdalla Ibrahim et al. All rights reserved. “Spice” (Synthetic Marijuana) Induced Acute Myocardial Infarction: A Case Series Wed, 26 Jul 2017 07:10:39 +0000 Marijuana is the most widely abused “recreational” substance in the United States, with highest prevalence in young adults. It is reported to cause ischemic strokes, hepatitis, anxiety, and psychosis. Although it is associated with dose dependent tachycardia and can lead to coronary vasospasm, it has not been directly related to acute myocardial infarction (AMI). Marijuana induced coronary vasospasm can result in endothelial denudation at the site of a vulnerable atherosclerotic plaque in response to hemodynamic stressors, potentially causing an AMI. Spice refers to herbal mixture with composition and effects similar to that of marijuana and therefore is referred to as “synthetic marijuana.” Herein, we report 3 cases of spice induced ST-segment elevation myocardial infarction. All patients were relatively young and had few or absolutely no risk factors for cardiovascular disease. All patients underwent emergent coronary angiography, with two needing stent placement and the third requiring only aspiration thrombectomy. Our case series emphasizes the importance of suspecting and investigating synthetic marijuana use in low risk young adults presenting with AMI. E. Ul Haq, A. Shafiq, A. A. Khan, A. A. Awan, S. Ezad, W. J. Minteer, and B. Omar Copyright © 2017 E. Ul Haq et al. All rights reserved. Recurrent Wheezing and Cough Caused by Double Aortic Arch, Not Asthma Tue, 25 Jul 2017 06:42:07 +0000 Introduction. Double aortic arch is a congenital vascular abnormality in which the connected segments and their branches course between and compress the trachea and esophagus, often resulting in invariable airway compression. Case Presentation. A 4-year-old boy with a history of recurrent wheezing was admitted to our hospital for evaluation of asthma based on his past medical history, persistent cough, wheezing, and airway hyperresponsiveness by lung function test. Double aortic arch was diagnosed with computed tomography angiogram. After surgery, the respiratory infection improved strikingly. Early diagnosis and treatment may prevent chronic, irreversible complications. Conclusion. We present a case of double aortic arch masquerading as asthma. Qiao Zhang, Zhou Fu, Jihong Dai, Gang Geng, Wenlong Fu, and Daiyin Tian Copyright © 2017 Qiao Zhang et al. All rights reserved. Seizure Associated Takotsubo Syndrome: A Rare Combination Mon, 24 Jul 2017 00:00:00 +0000 Takotsubo cardiomyopathy (TC) is increasingly recognized in neurocritical care population especially in postmenopausal females. We are presenting a 61-year-old African American female with past medical history of epilepsy, bipolar disorder, and hypertension who presented with multiple episodes of seizures due to noncompliance with antiepileptic medications. She was on telemetry which showed ST alarm. Electrocardiogram (ECG) was ordered and showed ST elevation in anterolateral leads and troponins were positive. Subsequently Takotsubo cardiomyopathy was diagnosed by left ventriculography findings and absence of angiographic evidence of obstructive coronary artery disease. Echocardiogram showed apical hypokinesia, ejection fraction of 40%, and systolic anterior motion of mitral valve with hyperdynamic left ventricle, in the absence of intracoronary thrombus formation in the angiogram. Electroencephalography showed evidence of generalized tonic-clonic seizure. She was treated with supportive therapy. This case illustrates importance of ECG in all patients with seizure irrespective of cardiac symptoms as TC could be the cause of Sudden Unexpected Death in Epilepsy (SUDEP) and may be underdiagnosed and so undertreated. Htay Htay Kyi, Nour Aljariri Alhesan, Sunil Upadhaya, and Samer Al Hadidi Copyright © 2017 Htay Htay Kyi et al. All rights reserved. Pneumomediastinum and Mediastinal Hematoma Secondary to Right Brachiocephalic Vein Thrombectomy Mimicking STEMI Tue, 18 Jul 2017 08:15:11 +0000 A 50-year-old male with a history of hemodialysis dependent chronic kidney disease presented to our emergency department with acute midsternal crushing chest pain. Patient was diagnosed with acute anterolateral wall Myocardial Infraction due to the presence of corresponding ST segment elevations in EKG and underwent emergent cardiac catheterization which revealed normal patent coronaries without any disease. He continued to have chest pain for which CT of the chest was done which revealed pneumomediastinum with mediastinal hematoma, due to the recent attempted thrombectomy for thrombus in his right brachiocephalic vein. Prem Shukla, Prudence Dy, Rishi Raj, Sayee Sundar Alagusundaramoorthy, and Noel Nivera Copyright © 2017 Prem Shukla et al. All rights reserved. Acute Myocardial Infarction Caused by an Anomalous Right Coronary Artery Occlusion Presenting with Precordial ST Elevation Sun, 16 Jul 2017 07:03:57 +0000 Acute coronary syndrome with precordial ST segment elevation is usually related to left anterior descending artery occlusion, although isolated right ventricular infarction has been described as a cause of ST elevation in V1–V3 leads. We present a case of a patient with previous inferior wall infarction and new acute ST elevation myocardial infarction (STEMI) due to proximal right coronary thrombotic occlusion resulting in right ventricular infarction with precordial ST elevation and sinus node dysfunction. The patient was treated with successful rescue angioplasty achieving resolution of acute symptoms and electrocardiographic abnormalities. Bruno da Silva Matte and Alexandre Damiani Azmus Copyright © 2017 Bruno da Silva Matte and Alexandre Damiani Azmus. All rights reserved. Fulminant Myocarditis Managed by Extracorporeal Life Support (Impella® CP): A Rare Case Wed, 12 Jul 2017 07:37:55 +0000 Background. Treating myocarditis can be difficult, as clear criteria for diagnosis and management are lacking for heterogeneous clinical presentations. Case Description. We report a case of a 49-year-old female who presented with cardiogenic shock and subsequent cardiac arrest. Extracorporeal life support was instituted, and after eight days with Impella CP the patient recovered and at six months presented with normal cardiac function. Conclusion. Fulminant myocarditis remains a challenging disease in daily clinical practice, not only for diagnosis, but also for treatment. With this report we emphasize that myocardial failure due to fulminant myocarditis may be reversible if treated with extracorporeal life support, which thus plays an important and life-saving role. Henrik Fox, Martin Farr, Dieter Horstkotte, and Christian Flottmann Copyright © 2017 Henrik Fox et al. All rights reserved. Isolated Major Aortopulmonary Collateral as the Sole Pulmonary Blood Supply to an Entire Lung Segment Wed, 12 Jul 2017 07:13:57 +0000 Congenital systemic-to-pulmonary collateral arteries or major aortopulmonary collaterals are associated with cyanotic congenital heart disease with decreased pulmonary blood flow. Though it is usually associated with congenital heart diseases, there is an increased incidence of isolated acquired aortopulmonary collaterals in premature infants with chronic lung disease. Interestingly, isolated congenital aortopulmonary collaterals can occur without any lung disease, which may cause congestive heart failure and require closure. We present a neonate with an echocardiogram that showed only left-sided heart dilation. Further workup with a CT angiogram demonstrated an anomalous systemic artery from the descending thoracic aorta supplying the left lower lobe. He eventually developed heart failure symptoms and was taken to the catheterization laboratory for closure of the collateral. However, with the collateral being the only source of blood flow to the entire left lower lobe, he required surgical unifocalization. Isolated aortopulmonary collaterals without any other congenital heart disease or lung disease are rare. Our patient is the first reported case to have an isolated aortopulmonary collateral being the sole pulmonary blood supply to an entire lung segment. Due to its rarity, there is still much to learn about the origin and development of these collaterals that possibly developed prenatally. Hannah S. Kim, R. Mark Grady, and Shabana Shahanavaz Copyright © 2017 Hannah S. Kim et al. All rights reserved. Combination of Carbon Dioxide Angiography and Outback® Elite for Revascularization of a Patient with Renal Insufficiency with Bilateral Femoropopliteal Chronic Total Occlusions Sun, 09 Jul 2017 00:00:00 +0000 A new reentry device (Outback Elite) system has been available in Japan since June 2016. This new device enables easier treatment of chronic total occlusion (CTO) in the lower extremities. We report a case of a woman in her 70s who underwent revascularization using this new device twice to treat both of her femoropopliteal CTO lesions. She was referred to our hospital complaining of intermittent claudication in both legs. She had a long history of diabetes mellitus complicated with severe chronic kidney disease. Her estimated glomerular filtration rate was <20. She refused surgical revascularization; therefore, we performed our treatment without iodine contrast medium. First, magnetic resonance imaging was performed to confirm that the CTO lesions had caused severe claudication before intervention. Subsequently, the Outback Elite device and carbon dioxide (CO2) angiography made it possible to revascularize both of her legs without iodine contrast medium. At 6 months after the procedures, we did not observe exacerbation of claudication in her legs. Yuhei Nojima, Shinsuke Nanto, Hidenori Adachi, Madoka Ihara, and Tetsuya Kurimoto Copyright © 2017 Yuhei Nojima et al. All rights reserved. Lyme Carditis Buried Beneath ST-Segment Elevations Wed, 21 Jun 2017 00:00:00 +0000 Lyme disease is caused by the spirochete Borrelia burgdorferi and is carried to human hosts by infected ticks. There are nearly 30,000 cases of Lyme disease reported to the CDC each year, with 3-4% of those cases reporting Lyme carditis. The most common manifestation of Lyme carditis is partial heart block following bacterial-induced inflammation of the conducting nodes. Here we report a 45-year-old gentleman that presented to the hospital with intense nonradiating chest pressure and tightness. Lab studies were remarkable for elevated troponins. EKG demonstrated normal sinus rhythm with mild ST elevations. Three weeks prior to hospital presentation, patient had gone hunting near Madison. One week prior to admission, he noticed an erythematous lesion on his right shoulder. Because of his constellation of history, arthralgias, and carditis, he was started on ceftriaxone to treat probable Lyme disease. This case illustrates the importance of thorough history taking and extensive physical examination when assessing a case of possible acute myocardial infarction. Because Lyme carditis is reversible, recognition of this syndrome in young patients, whether in the form of AV block, myocarditis, or acute myocardial ischemia, is critical to the initiation of appropriate antibiotics in order to prevent permanent heart block, or even death. Basia Michalski and Adrian Umpierrez De Reguero Copyright © 2017 Basia Michalski and Adrian Umpierrez De Reguero. All rights reserved. Development of New Deep Venous Thrombosis While on Apixaban Tue, 20 Jun 2017 09:33:48 +0000 The efficacy of novel oral anticoagulants (NOACs) in preventing deep venous thrombosis (DVT) has been established in large multicenter trials. Predictable pharmacokinetics, avoidance of routine laboratory monitoring, and lesser drug interactions have made NOACs safer and more tolerable treatment option in comparison to warfarin. However, cases of treatment failure mainly due to interindividual variation in plasma drug levels can be seen rarely. In this report we describe a case of acute DVT of right lower extremity in a patient who was on apixaban for prevention of venous thromboembolism (VTE) due to underlying nonvalvular atrial fibrillation (NVAF). Munish Sharma, Sabarina Ramanathan, and Koroush Khalighi Copyright © 2017 Munish Sharma et al. All rights reserved. Pulmonary Hemorrhage following Edge-to-Edge Mitral Valve Repair Mon, 19 Jun 2017 07:58:36 +0000 Mitral valve repair with the MitraClip device has emerged as an effective treatment option for patients with severe mitral regurgitation and contraindications for surgical interventions. While the procedure is not known to cause pulmonary complications, we describe two cases of pulmonary hemorrhage following percutaneous mitral valve repair. The patients did well with supportive care and reinitiation of anticlotting agents was well tolerated after resolution of bleeding. Mirna B. Ayache, Myttle A. Mayuga, Chantal ElAmm, Guilherme Attizzani, and Jordan Kazakov Copyright © 2017 Mirna B. Ayache et al. All rights reserved. When Is the Optimal Timing of Surgical Intervention for Severe Functional Tricuspid Regurgitation? Mon, 19 Jun 2017 00:00:00 +0000 Functional tricuspid regurgitation (TR) is a serious pathology to be noted for severe right heart failure (HF) and poor prognosis; however, the conventional assessment of TR has some limitations and the optimal timing of surgical intervention remains unclear. A 79-year-old Japanese female was admitted to our hospital to undergo cardiac surgery, because edema gradually got worse despite the increase in diuretics. She had a history of atrial fibrillation (AF) and chronic HF due to severe TR and had been treated with a furosemide for leg edema 4 years ago. A transthoracic echocardiogram (TTE), transesophageal echocardiogram, cardiac magnetic resonance imaging, and cardiac pool scintigraphy demonstrated severe functional TR with tricuspid annular dilation, insufficient tricuspid valve coaptation, and reduced right ventricular ejection fraction (EF) but preserved left ventricular EF. In addition, Swan-Ganz catheter study showed normal pulmonary arterial wedge pressure and mean pulmonary arterial pressure. Tricuspid ring annuloplasty was performed with MC3 ring. Postoperative TTE showed trivial TR, and she had no edema with normal sinus rhythm two months later. Annuloplasty to severe functional TR caused by tricuspid annular dilation due to AF dramatically improved right HF. Cardiologist should pay strict attention to the optimal timing of surgical intervention for TR. Nobuhiro Nakanishi, Masanobu Ishii, Koichi Kaikita, Ken Okamoto, Yasuhiro Izumiya, Eiichiro Yamamoto, Seiji Takashio, Seiji Hokimoto, Toshihiro Fukui, and Kenichi Tsujita Copyright © 2017 Nobuhiro Nakanishi et al. All rights reserved. First Reported Case of Hemopericardium Related to Dabigatran Use Reversed by New Antidote Idarucizumab Wed, 14 Jun 2017 00:00:00 +0000 Dabigatran, the first novel oral anticoagulant (NOAC) with a reversal agent, heralded a paradigm shift in the treatment of nonvalvular atrial fibrillation. The potential for life-threatening hemorrhagic events with the use of NOACs has been highly debated since the effectiveness of reversal agents such as idarucizumab is based primarily on pharmacologic data. It is known that cancer patients are at an increased risk of bleeding with anticoagulation, though specific studies demonstrating the risks or efficacy of NOACs in this population are lacking. We provide the first report of hemopericardium resulting in multiorgan failure related to dabigatran use that was successfully reversed by idarucizumab in a man with prostate cancer on chemotherapy. Steven Song, Joselle Cook, Clive Goulbourne, Matthew Meade, Louis Salciccioli, and Jason Lazar Copyright © 2017 Steven Song et al. All rights reserved. Cardiac Dysrhythmias and Neurological Dysregulation: Manifestations of Profound Hypomagnesemia Mon, 05 Jun 2017 09:07:39 +0000 Magnesium is the second most common intracellular cation and serves as an important metabolic cofactor to over 300 enzymatic reactions throughout the human body. Among its various roles, magnesium modulates calcium entry and release from sarcoplasmic reticulum and regulates ATP pumps in myocytes and neurons, thereby regulating cardiac and neuronal excitability. Therefore, deficiency of this essential mineral may result in serious cardiovascular and neurologic derangements. In this case, we present the clinical course of a 76-year-old woman who presented with marked cardiac and neurological signs and symptoms which developed as a result of severe hypomagnesemia. The patient promptly responded to magnesium replacement once the diagnosis was established. We herein discuss the clinical presentation, pathophysiology, diagnosis, and management of severe hypomagnesemia and emphasize the implications of magnesium deficiency in the cardiovascular and central nervous systems. Furthermore, this case highlights the importance of having high vigilance for hypomagnesemia in the appropriate clinical setting. Sagger Mawri, Edward Gildeh, Namita Joseph, Bobak Rabbani, and Bryan Zweig Copyright © 2017 Sagger Mawri et al. All rights reserved. Torsade de Pointes Induced by Hypokalemia from Imipenem and Piperacillin Tue, 30 May 2017 08:47:13 +0000 Imipenem-cilastatin and piperacillin-tazobactam are two antibiotics with broad antimicrobial coverage. Besides the many well established adverse effects of these drugs, there have been few case reports of hypokalemia. Here we present an interesting case of resistant hypokalemia caused by these drugs leading to Torsades de Pointes which has never been reported in the past. Hypokalemia resolved with discontinuation of piperacillin. Varun Kumar, Sandeep Khosla, and Monica Stancu Copyright © 2017 Varun Kumar et al. All rights reserved.