Cardiovascular Diseases

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• Angina pectoris as a manifestation of ALCAPA syndrome in a 20-year-old female: a case report and review of literature Leila Bigdelu, Ossama Maadarani, Ali Azari, Ali Heidari-Bakavoli, Zouheir Bitar Views: 492 HTML: 61 PDF: 381

  Anomalous left coronary artery from the pulmonary artery (ALCAPA) is considered a rare congenital heart disease where the take-off of the left coronary artery abnormally originates from the pulmonary artery instead of left aortic sinus. It is associated with a high mortality rate in the first year of life and sudden death in adults if left untreated. We report an adult form of ALCAPA syndrome in a 20-year-old female who presented with anginal pain for the previous few months. Unfortunately, the patient was hesitant to have surgery at the time.

• Tracheoesophageal prosthesis malfunction - a case report Gaurav Mohan, Ashika Ajitkumar, Sivanaga Yarrarapu, Karthik Ashok, Doantrang Du, Douglas Livornese Views: 404 HTML: 71 PDF: 349

  Tracheoesophageal prosthesis (TEP) is an artificial connection between the trachea and esophagus allowing air into the upper esophagus from the trachea thereby vibrating it. TEPs give patients who lose their vocal cords to laryngectomies a tracheoesophageal voice. A potential complication of this is silent aspiration of gastric content. We present a case of a 69-year-old female with a TEP placed after a laryngectomy for laryngeal cancer who presented to the hospital with shortness of breath and hypoxia. She was initially treated for a presumed diagnosis of chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) exacerbations but continued to be hypoxic despite aggressive medical management. Further evaluation revealed silent aspirations as a consequence of TEP malfunction. Through our case report we urge clinicians to consider this differential diagnosis, as the clinical presentation of silent aspiration among patients with a TEP can be easily mistaken for a COPD exacerbation. A large number of patients with TEPs are smokers with underlying COPD.

• Resolution of sickle cell crisis following administration of amiodarone Paul Silaghi, Daniel T. Eitzman Views: 437 HTML: 31 PDF: 392

  Sickle cell disease is a prevalent hematologic condition, but some of the factors that lead to erythrocyte sickling are not fully known. A 58-year-old male patient with a history of sickle cell disease (SCD) and paroxysmal atrial fibrillation was transferred from an outside hospital for further management of refractory sickle cell crisis with acute chest syndrome. Before transfer, the patient received antibiotics and multiple packed red blood cell (pRBC) transfusions, with minimal effect on symptoms or anemia. After transfer, the patient developed rapid supraventricular tachycardia and atrial fibrillation (rates >160) with a drop in blood pressure. He was started on IV amiodarone. His heart rate was subsequently better controlled and converted to sinus rhythm the following day. Three days following initiation of amiodarone, the patient, with a hemoglobin count of 6.4 g/dl, required one additional unit of pRBC. On the fourth day, the patient’s hemoglobin count rose to 9.4 g/dl, and he reported a marked improvement in symptoms. The improvements in symptoms and hemoglobin count were sustained, and the patient was discharged two days later. This remarkable improvement in anemia and symptoms triggered a search for potential causes. Amiodarone is a complex drug shown to have effects on multiple cell types, including erythrocytes. A recent preclinical study demonstrated reduced sickling and improved anemia in a murine model of SCD. This case report raises the possibility that amiodarone may have contributed to the rapid improvement in anemia and should be further explored in clinical trials.

• Cardiac arrest due to out-of-hospital pulmonary embolism during pregnancy: successful thrombolysis Mårten Söderberg, Erika Smedberg, Pelle G. Lindqvist Views: 590 HTML: 75 PDF: 506

  Introduction: Pulmonary embolism (PE) is a rare, severe complication in pregnancy, in which case thrombolysis can be lifesaving but has risks. We aim to highlight actions specific to pregnant women.
  Case Description: A 24-week pregnant woman developed shortness of breath and experienced sudden cardiac arrest. Cardiopulmonary resuscitation (CPR) was begun immediately in the ambulance and a perimortem caesarean section was performed upon arrival at hospital, but the new-born died. After 55 minutes of CPR, bedside echocardiography revealed right ventricular strain and thrombolysis was given. The uterus was bandaged to minimize blood loss. After massive transfusions and correction of haemostasis, a hysterectomy was performed due to inability of the uterus to contract. After 3 weeks, the patient was discharged in good health and placed on continuous anticoagulant treatment with warfarin.
  Discussion: Approximately 3% of all out-of-hospital cardiac arrest cases are due to PE. Among the few patients who survive at the scene, thrombolysis can be lifesaving and should be considered in pregnant women with unstable PE. Prompt collaborative diagnostic work-up in the emergency room is necessary. In a pregnant woman with cardiac arrest, a perimortem caesarean section improves the chances of both maternal and fetal survival.
  Conclusion: Thrombolysis should be considered for patients with PE in pregnancy with the same indications as in a non-pregnant woman. In case of survival, there is profuse bleeding with need for massive transfusions and haemostasis correction. Despite being in very poor condition, the above patient survived and was fully restored to health.

• Cardiac hydatid disease with palpitations as the only presenting complaint: the egg in the nest Ali Azari, Leila Bigdelu, Ossama Maadarani, Zouheir Bitar Views: 379 HTML: 30 PDF: 303

  Hydatid disease, also known as cystic echinococcosis, is a parasitic infection caused by the larval stage of Echinococcus granulosus. It usually invades organs such as the liver and the lungs but can affect any organ. Isolated cardiac involvement is a rare manifestation. We present a case of isolated left ventricle hydatid cyst with negative serological tests, which was treated with surgical removal and confirmed by histopathological examination.

• Successful thrombolytic therapy using ultraslow low-dose infusion during pregnancy for mitral mechanical valve thrombosis: a case series and review of the literature Leila Bigdelu, Ossama Maadarani, Asal Yadolh, Zouheir Bitar, Nadia Azadi Views: 452 HTML: 84 PDF: 371

  According to the modified World Health Organization (WHO) classification, pregnant women with mechanical valves face a very high risk of complications (Risk Category III). Mechanical valve thrombosis is a serious complication that significantly increases during pregnancy due to multiple mechanisms. Thrombolytic therapy has recently been used as a first-line treatment for mechanical valve thrombosis during pregnancy. However, the consensus regarding the optimal treatment strategy, type, dose and route of administration was unclear. We present three cases of mechanical mitral valve thrombosis during pregnancy treated successfully with repeated doses of ultraslow infusion of low-dose tissue-type plasminogen activator (t-PA) alteplase. We also present a review of the literature on this subject.

• Hepatic coma secondary to Fontan Conduit thrombosis João Luís Cavaco, Ana Rita Ferreira, Constança Abecasis Jalles, Inês Matias Lopes, Armando Braz, Ana Oliveira Pedro, António Pais de Lacerda Views: 638 HTML: 68 PDF: 362

  Introduction: The Fontan procedure is used to treat congenital heart defects and has improved long-term survival. Long-term complications include liver disease due to congestive hepatopathy. Fontan-related cirrhosis can manifest with ascites, gastrointestinal bleeding and encephalopathy.

  Case description: A 43-year-old man with history of Fontan surgery was admitted with COVID-19 pneumonia. There was rapid clinical and neurological deterioration, with coma and shock. CT imaging showed thrombosis of the Fontan conduit. The patient was successfully subjected to recanalization of the Fontan circulation, with progressive improvement of coma.

  Discussion: Fontan-associated liver disease is a major complication following the Fontan procedure. Clinicians must be aware of this pathology during patient follow-up.

• Epipericardial fat necrosis Yumi Otaka, Yukinori Harada, Ren Kawamura, Taro Shimizu Views: 398 HTML: 33 PDF: 342

  Introduction: Epipericardial fat necrosis (EFN) is a relatively rare benign disease that causes acute chest pain.

  Case Description: A woman in her 20s presented with acute left shoulder and epigastric pain. One day before presentation, she had visited a cardiologist and an acute coronary syndrome had been ruled out. The pain worsened with deep inspiration. Chest computed tomography (CT) showed a soft-tissue attenuation lesion containing a fatty centre located in the epipericardial fat at the left cardiophrenic angle. Hence, EFN was diagnosed and the pain was resolved with loxoprofen. The lesion had disappeared on a follow-up chest CT scan.

  Discussion: EFN is a rare benign disease that causes acute chest pain. Approximately 70–90% of EFN cases are misdiagnosed by clinicians as other diseases.

  Conclusion: In patients with acute chest pain, the correct diagnosis of EFN avoids unnecessary invasive investigations and reassures patients.

• Chatterjee Phenomenon: A Demonstration of Cardiac Memory in Paced Rhythms Jason Kuniyoshi, Maggie Kwock, Krixie Silangcruz, Witina Techasatian, Yoshito Nishimura Views: 433 HTML: 165 PDF: 375

  Introduction: While T-wave inversions (TWI) are associated with various pathologies, they are rarely associated with cardiac memory, termed the Chatterjee phenomenon.

  Case: A 76-year-old man with sick sinus syndrome with a pacemaker presented with chest tightness and new onset TWI in his precordial leads. On admission, he tested positive for COVID-19, but remained stable and only required minimal supplemental oxygen. His troponin was only slightly elevated, and EKG showed TWI throughout his precordial leads. A previous EKG had shown normal sinus rhythm without a paced rhythm or ST wave abnormalities. Interrogation of his pacemaker revealed an AV-paced rhythm. Given his chest tightness without dynamic changes in his troponin or EKG, the symptoms were considered more likely related to his COVID-19 infection, and he was discharged home.

  Discussion: Aberrancies in normal cardiac conduction can result in altered electrical activation, especially for those with AV pacemakers, leading some patients to develop cardiac memory, manifesting as TWI.

  Conclusion: AV-paced rhythm and narrow QRS complexes with TWI localized to precordial leads without evidence of active cardiac ischaemia may suggest cardiac memory, termed the Chatterjee phenomenon, requiring no invasive interventions.

• EBUS-TBNA-induced Purulent Pericarditis: A Rare Complication of a Common Procedure Joana Alfaiate, Andreia Brito, Ana Matos Views: 398 HTML: 42 PDF: 245

  Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a diagnostic tool used to investigate mediastinal lesions. It has a good safety profile, but there are rare accounts of potentially deadly complications. The present article describes one such complication: pericardial empyema.
  A 70-year-old man underwent EBUS-TBNA for the differential diagnosis of a pulmonary mass with multiple mediastinal adenopathies. Two weeks after the procedure he developed chest pain, shortness of breath and fever, with rapid progression to hypotension, tachycardia and low peripheral saturation. He was diagnosed with purulent pericarditis with cardiac tamponade. Pericardial drainage and antibiotic therapy were employed with successful recovery from obstructive disease and septic shock.