Cardiovascular Diseases

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• Recurrent high-risk pulmonary thromboembolism treated with repeated thrombolytic therapy could be helpful for certain patients: a case report and review of the literature Leila Bigdelu, Negar Ebrahimi, Ossama Maadarani Views: 429 HTML: 51 PDF: 334

  Acute pulmonary thromboembolism (PTE) is considered the third most frequent acute cardiovascular syndrome behind myocardial infarction and stroke, with annual incidence rates ranging from 39 to 115 per 100,000 people and ranking high among the causes of cardiovascular mortality. High-risk PTE is characterised by haemodynamic instability and encompasses clinical manifestations such as cardiac arrest, obstructive shock and persistent hypotension. The European Society of Cardiology (ESC) recommends a reperfusion strategy with systemic thrombolytic therapy for high-risk PTE under class I, level B if there are no contraindications. Overall, unsuccessful thrombolytic therapy and recurrent PTE have been reported in 8% of patients with high-risk PTE. The guidelines recommend surgical pulmonary embolectomy if thrombolysis is contraindicated or has failed. The position of repeated thrombolytic therapy as a treatment option in patients with recurrent high-risk PTE, especially in situations with a lack of surgical expertise or resources, was not mentioned in the guidelines. We report the case of a patient who suffered a recurrent high-risk PTE and was treated with repeated thrombolytic therapy that was effective and resulted in excellent outcomes.

• Haemorrhagic pericardial effusion as the presenting symptom of scurvy Hajar Joulal, Jaouad Yousfi, Laïla Benjilali, Mouna Zahlane, Lamiaa Essaadouni Views: 274 HTML: 33 PDF: 287

  Introduction: Vitamin C deficiency (or scurvy) usually takes weeks to become apparent as cutaneous signs and impaired wound healing. Haemorrhagic pericarditis remains a rare complication of scurvy, which has never been reported as an isolated condition. We report the case of a haemorrhagic pericarditis revealing a vitamin C deficiency in a 56-year-old patient.
  Case description: A 56-year-old woman presented with a 2-week history of worsening chest pain and dyspnoea, with no significant medical history. Upon admission, the patient exhibited tachycardia, tachypnoea, low blood pressure, elevated jugular venous pressure, muffled heart sounds and multiple petechiae on her lower limbs. An ultrasound revealed a large pericardial effusion, and an emergency pericardiocentesis was performed, which yielded haemorrhagic fluid without atypical cells. An initial workup including haemoculture, PT and PTT, tuberculosis workup, autoantibodies, tumour markers and infectious disease was negative. A whole-body CT scan showed no evidence of tuberculosis or lymphoma. Additional testing showed that her vitamin C level was <3 umol/L. Following stabilisation, high-dose vitamin C therapy was initiated. Subsequently, she showed continued clinical improvement and remained asymptomatic upon her discharge.
  Discussion: While uncommon, it is crucial to investigate vitamin C deficiency when confronted with an unexplained haemorrhagic pericardial effusion, particularly in patients with risk factors.
  Conclusion: Our case highlights the significance of early detection of this condition in promptly addressing the diverse complications of scurvy, thereby enhancing the prognosis of a potentially fatal condition.

• Deep vein thrombosis revealing a "silent" coeliac disease Sofia Miranda, Patrícia Clara, Joana Rua, Miriam Cimbron, Fernando Salvador Views: 380 HTML: 81 PDF: 333

  Introduction: We present a clinical case of a 45-year-old man with recurrent deep vein thrombosis (DVT) and multiple hospital admissions due to severe infectious conditions. A newfound hypoalbuminemia raised the suspicion of a protein-losing condition, with an upper endoscopy revealing lesions at the D2 level compatible with coeliac sprue and HLA typing positive for both DQ-2 and DQ-8.
  Methods: A gluten free diet was started and apixaban was suspended.
  Results: No new complications were reported.
  Discussion: Multiple mechanisms are believed to be behind the association between DVT and coeliac disease. However, to this date, no consensus exists regarding the ideal duration of anticoagulation.

• Seizure and bilateral external jugular vein distention: a rare manifestation of Stanford type A aortic dissection Mohamad Zbidat, Botros Msheiil, Nasra Idilbi Views: 300 HTML: 36 PDF: 264

  Introduction: Seizure as a sole sign of Stanford Type A aortic dissection (AAD) is mentioned in the medical literature. In this case, AAD was manifested by external bilateral jugular vein distention and generalized seizure.
  Patients and Methods: A 47-year-old woman presented to the Emergency Department with convulsions in the upper and lower extremities. She was diagnosed with AAD and transferred to a hospital with cardio-thoracic capabilities for surgery.
  Conclusion: Seizure resulting from aortic dissection has been explained by general cerebral hypoperfusion. However, jugular vein distention could be secondary to increased thoracic pressure, due to compression of the pulmonary artery by the ascending aorta.

• Spontaneous recovery of isolated advanced heart block in patient with celiac disease by starting a strict gluten free diet: a case report and review of the literature Ossama Maadarani, Leila Bigdelu, Zouheir Bitar, Mohammad Alhabibi, Hosni Kabbara Views: 405 HTML: 61 PDF: 312

  Cardiac conduction disorder may have a wide range of aetiology and can manifest with symptomatic bradycardia and syncope. Celiac disease is a malabsorptive long-term autoimmune disorder where the small intestine is the primarily affected organ due to gluten intolerance in genetically predisposed individuals. The associations between celiac disease and cardiac pathology are uncommon. We report a case of a 50-year-old woman with a known case of celiac disease who presented with a symptomatic cardiac conduction abnormality that improved with a gluten-free diet.

• A case of severe cardiomyopathy due to COVID-induced myocarditis, completely resolved after colchicine and immunoglobulin therapy Su Khine, Srujan Edupuganti, Ghassan Bachuwa Views: 605 PDF: 470 HTML: 96

  Coronavirus 19 (COVID-19) is well known for causing acute respiratory distress syndrome. Among other systemic complications, myocarditis is a frequently reported presentation as well as complication. One systematic review reported a 14% mortality rate in patients with COVID-19 myocarditis. Endomyocardial biopsy is a definitive diagnostic test but has been a challenge to perform in most cases of COVID myocarditis due to the contagious nature of the disease. Patients presenting with new cardiomyopathy with troponin leak and arrhythmias, supported by recent COVID-19 diagnosis should be suspected for COVID-induced myocarditis. Supportive treatment has been the mainstay of treatment with limited data on immunotherapy and colchicine. Our case is about a male in his 50s who had a cardiac arrest due to ventricular fibrillations, with a positive COVID-19 test. Further workup showed severe non-ischaemic cardiomyopathy with an EF of 15–20%. He was treated with intravenous immunotherapy and colchicine. A repeat echocardiogram 3 days later showed resolution of cardiomyopathy. Our case report highlights the possible beneficial effects of immunotherapy and colchicine in viral myocarditis.

• Caseous calcification of the mitral annulus: mimicking a cardiac mass. Zouheir Bitar, Ossama Sajeh Maadarani, Harikrishna Rajendran, Rashed Juma Al Hamdan, Mohamed Elhabibi Views: 341 PDF: 301 HTML: 59

  Mitral annulus calcification is a common incidental finding in echocardiography examination of predisposed populations. On the other hand, caseous calcification of the mitral annulus is a rare variant that challenges the physician to differentiate it from different causes of cardiac masses. We describe a case of incidentally discovered caseous calcification confirmed with CT cardiac and cardiac magnetic resonance.

• Persistent cardioactive glycosides intoxication related to gastric phytobezoar of oleander leaves Michel Pescia, Marco Conti, Romina Contratto Views: 271 PDF: 340 HTML: 30

  Nerium oleander is a plant containing cardiac glycosides, and intoxication with its leaves is a medical emergency. We report the case of a 73-year-old man who took a decoction of oleander leaves for a reckless purpose. Upon arrival in the emergency room, he presented an altered state of consciousness, drooling and vomiting. He was bradycardic with intermittent third- degree atrioventricular block and typical downsloping ST-segment depression related to glycosides toxicity. Despite initial treatment with atropine, isoprenaline and repeated bolus of digoxin-specific antibody (Fab) fragments, symptoms were persistent 12 hours after admission. Suspecting that the patient not only drank the decoction but also ingested the leaves and had slow gastric emptying, we performed gastric lavage without benefit. We subsequently performed a gastroscopy that showed an oleander phytobezoar, and its removal permitted a rapid clinical improvement.

  Treatment with digoxin-specific antibodies for intoxication is well described and dosage should be adapted to the plasmatic level. Such an examination is useless in oleander intoxication because it does not represent the real quantity of toxin. The dosage of antibodies is empiric and should be guided by the clinical severity.
  In such intoxication, the presence of a phytobezoar from oleander leaves cannot be excluded so we believe that a gastroscopy for its mechanical removal should always be considered to avoid persistent release of toxin.

• Rumpel-Leede phenomenon following radial artery catheterisation Floyd A. Pirtle, Dylan Maldonado , Pitchaporn Yingchoncharoen, Jerapas Thongpiya, Natnicha Leelaviwat, Annia Cavazos, Cloyce L. Stetson Views: 591 HTML: 263 PDF: 320

  Rumpel-Leede phenomenon is a rarely diagnosed entity that can be seen in patients following the application of tourniquet-like forces to the extremities. This phenomenon describes petechiae and purpura secondary to venous compression and congestion, with its underlying aetiology involving the fragility of capillary vessels within the dermis. This condition is associated with chronic medical conditions such as diabetes mellitus, hypertension, dyslipidemia, peripheral vascular disease and systemic inflammatory diseases, including infections. In addition, patients with coagulopathy including thrombocytopenia or platelet dysfunction from antiplatelet use, or those with thrombotic thrombocytopenic purpura and idiopathic thrombocytopenic purpura, are predisposed to capillary haemorrhage and petechiae formation. In this report, we present a case of a patient who developed Rumpel-Leede phenomenon following catheterisation of the right radial artery with spontaneous resolution – where only five cases have been reported to date – with the aim to make clinicians aware of this condition and to avoid unnecessary interventions.

• A rare case of stroke as a complication after percutaneous mechanical thrombectomy in a patient with intermediate-high risk pulmonary embolism and patent foramen ovale Marina López-Rubio, Aurora Gómez-Tórtola, Iago Sousa-Casasnovas, Jorge García-Carreño, Marta Vales-Montero, Crhistian Mario Oblitas, Pablo Demelo-Rodríguez, Francisco Galeano-Valle Views: 273 HTML: 65 PDF: 313

  We present an extremely rare case of a patient with intermediate-high risk pulmonary embolism treated with percutaneous mechanical thrombectomy, complicated with stroke as a form of paradoxical embolism through a previously unknown patent foramen ovale. We reviewed the literature for indications, efficacy, and safety of this procedure, as well as for experience on this technique in patients with patent foramen ovale.