A Curious Case of an Anomalous Right Coronary Artery

Single coronary artery (SCA) is an unusual congenital anomaly, seen by diagnostic coronary angiography. Absence of the right coronary artery (RCA) is one of the rarest coronary artery anomalies occurring when the artery fails to develop in the right atrioventricular (AV) groove. Herein, we describe the case of a 58-year-old man presenting with new onset decompensated congestive heart failure found to have a congenitally absent right coronary ostium. The AV groove extended such that the left circumflex artery supplied the domain of the RCA. Such coronary artery anomalies are rare, and we aim to shed further insight into these congenital processes so that operators may remain vigilant of them in their practice.

Use of Lumason Contrast Echocardiography in Post-myocardial Infarction Ventricular Septal Defect

We report herein the case of an elderly female who presented with myocardial infarction complicated by ventricular septal defect (VSD) that was evident on cardiac auscultation and contrast echocardiography using Lumason® (Bracco Diagnostics Inc, Monroe Township, USA). Patient underwent surgical repair for her VSD post-infarct along with coronary artery bypass grafting after being treated for cardiogenic shock. We also highlight the management strategies in patients with similar complications. In this report, we shed the light on the importance of using Lumason contrast for the identification of shunt and for the diagnosis of VSD. Lumason contrast is widely available and licensed.

Giant Coronary Artery Aneurysm: A Successful Diagnosis

Coronary artery aneurysms (CAAs) are rare, with giant CAAs being even rarer. The precise pathophysiology of this phenomenon is still unknown. CAAs are seldom reported life-threatening abnormalities of the cardiovascular system. We herein present a case of a 74-year-old man who presented at the hospital complaining of chest pain. An adenosine thallium scan revealed a small, reversible defect in the inferior wall of the left ventricle extending into the apex, consistent with ischemia. Echocardiography uncovered a large right coronary artery (RCA) aneurysm, measuring 5.6 × 7.5 cm. Diagnostic coronary angiography confirmed the presence of a large RCA aneurysm and aneurysmal dilation of the left anterior descending and circumflex arteries with no flow-limiting lesions. A reversed saphenous vein interposition graft was placed from the ascending aorta to the right posterior descending artery. The RCA aneurysmal sac was resected and sent to pathology, which uncovered myxoid degeneration of the media as well as thrombus formation. No complications were encountered during the procedure. Early diagnosis is vital to avoid fatal complications of CAAs, and therapeutic approaches are currently individualized in view of absence of evidence-based management strategies. 

Current Practice of Percutaneous Coronary Intervention in Patients With Coagulation Disorders

Acute coronary artery disease represents the leading cause of death worldwide. Some studies have shown that coagulation disorders can play a protective role against ischemic heart disease, presumably due to hypocoagulable state and decrease thrombin formation. However, autopsy reports showed atherosclerotic lesions in some patients with hemophilia. Since the introduction of clotting factors and replacement therapies, the life expectancy of patients with coagulation disorders has increased significantly. As a result, the incidence of cardiovascular diseases became higher making their treatment more challenging. Door to balloon strategy applies in ST-elevation myocardial infarction (STEMI), and percutaneous coronary intervention should not be delayed. While in non-STEMI (NSTEMI) and unstable angina, a hematology consult is essential. Prophylactic coagulation factor replacement is crucial in these patients in order to avoid bleeding complications, but on the other hand, these factors were also associated with thrombotic complications. Historically, bare-metal stents were preferred over drug-eluting stents in view of the shorter duration of dual antiplatelets therapy (DAPT). Currently, some trials have demonstrated the safety of new-generation drug-eluting stents in patients with elevated bleeding risk, where DAPT use is limited to four weeks. The radial artery is the preferred access and was found to have less bleeding complications when compared to the femoral access. Anticoagulation with heparin is the safest in view of antidote availability and shorter half-life. Bivalirudin has also been used in some case reports, while GP2b3a inhibitors are usually avoided except in a high thrombus burden. Close peri procedural follow-up is important with patient education about symptoms of bleed. Carefully and individually tailored antithrombotic and factor replacement therapy is required to overcome these clinically challenging situations. Early screening for cardiovascular risk factors and considering early intervention and management might help to improve the general health status of this population and reduce morbidity.

Left Atrial Thrombus Mimicking Myxoma Secondary to Rebound Hypercoagulable State

Novel oral anticoagulants (NOACs) have made the use of anticoagulation in patients with atrial fibrillation (AFib) much more convenient and predictable. It is a very common practice to hold anticoagulation either in anticipation of surgical procedures (to prevent excessive bleeding) or in case of acute bleeding episodes. This abrupt withdrawal of anticoagulation tilts the balance in favor of pro-thrombotic state in the body. We present a case of a 60-year-old man with past medical history of AFib who abruptly discontinued his apixaban (Eliquis). This patient presented to emergency room with the complaint of weakness and numbness of left arm and left half of the face. Stroke code was activated, and patient received tissue plasminogen activator (t-PA). This resulted in significant improvement of symptoms within hours of receiving treatment. Later during the same day, patient developed numbness and tingling of fingers of left hand. On physical exam, left hand was cold to touch and radial pulse was absent. Arterial duplex revealed occluded ulnar and radial arteries. Vascular surgery performed embolectomy to establish blood flow in the radial and ulnar arteries. Transthoracic echocardiogram revealed large left atrial mass attached to the atrial septum. Most likely t-PA infusion in the setting of atrial mass led to distal showering of emboli resulting in stenosis of radial and ulnar arteries. The left atrial mass was most likely thrombus as patient had cardiac imaging including transthoracic echocardiogram and computed tomography of heart prior to these events which did not reveal any mass in left atrium. In short, as clinicians we should be aware of the hypercoagulability associated with withdrawal of anticoagulation. In addition, we should be wary of the challenges associated with differentiating cardiac masses of different etiology.

Prevalence of Myocardial Infarction in Patients With Chronic Pancreatitis

OBJECTIVE

We conducted this study to ascertain whether chronic inflammation secondary to chronic pancreatitis (CP) has any association with myocardial infarction(MI).

METHODS

Data were collected from a commercial database (Explorys, Inc, IBM Watson, Ohio). Adults with the diagnosis of "chronic pancreatitis," based on Systematized Nomenclature of Medicine-Clinical Terms, were included in the CP group, and the rest of the patients were included in the non-CP group. The prevalence of MI was compared in both groups, and statistical multivariate model was performed.

RESULTS

A total of 28,842,210 patients were included in the study. The overall prevalence of MI was 14.22% in the CP group as compared with 3.23% in the non-CP group (P < 0.0001). In the multivariate analysis, the odds ratio (OR) for MI in CP group was 1.453 (95% confidence interval, 1.418-1.488, P < 0.0001). Hypertension was a strong predictor for MI in the CP group with an OR of 3.2 (95% confidence interval, 3.0-3.5), followed by chronic kidney disease, older than 65 years, dyslipidemia, diabetes mellitus, obesity, alcohol abuse, smoking, White race, and male sex.

CONCLUSIONS

This study showed that CP is associated with comorbidities, which can increase the prevalence and OR of MI.

Long-term results of endovenous laser ablation of saphenous vein reflux: Up to nine years of follow-up

INTRODUCTION

Endovenous laser ablation (EVLA) has become the gold standard for the treatment of saphenous vein reflux. We report the long-term clinical and ultrasound results of EVLA.

METHODS

This study is a retrospective review of patients who underwent EVLA of saphenous vein over four years. Clinical results were assessed using venous clinical severity score (VCSS), and ultrasound results were classified according to Bush classification.

RESULTS

Over a median follow-up time of 4.4 years, 168 EVLA-treated patients showed a drop in VCSS from 4.38 to 1.39. Ultrasound results of 140 treated great saphenous veins showed that 64% had one or more cause of recurrence. The presence of neovascularization correlated well with the lack of improvement of VCSS.

CONCLUSION

EVLA resulted in drop in VCSS from 4.38 to 1.39. Among 140 treated great saphenous veins, reflux in the anterior accessory saphenous vein was the primary cause (23.5%) of recurrence.

Extremely Late In-Stent Thrombosis 12 Years After Implantation of a Drug-Eluting Stent

Stent thrombosis is one of the most feared complications of percutaneous coronary intervention. Most commonly it occurs within the first few days after the deployment of the stent. Once the stent is completely endothelialized, this complication becomes extremely rare. Few cases of very late stent thrombosis were reported in the literature with the longest interval being around 11 years after the initial intervention. We report here the case of a 78-year-old male patient who presented with acute onset chest pain found to have acute inferior ST-segment elevation myocardial infarction due to thrombotic occlusion of a prior paclitaxel drug-eluting stent placed 12 years prior. This is, to our knowledge, the first case of stent thrombosis occurring after this long duration since stent implantation.

Polycystic Liver With Cardiac Compression Leading to Atrial Fibrillation: Case Report and Review of the Literature

Polycystic liver disease (PCLD) is a rare condition that most often occurs in patients with polycystic kidney disease and less commonly as an isolated liver disease. Complications include cyst rupture, infection, hemorrhage, and compression of surrounding organs by large cysts. We present the case of a patient with a history of PCLD who presented to our hospital with palpitations and was found to have atrial fibrillation. Imaging and echocardiograph revealed a dominant large cyst compressing the right atrium. Other etiologies including thyroid disease, ischemic heart disease, and electrolytes abnormalities were excluded. The patient refused surgical intervention and was conservatively treated with rate control and anticoagulation. To the best of our knowledge, this is the first case of new-onset atrial fibrillation secondary to right atrial compression by a liver cyst. Compression of cardiac chambers resulting in new-onset arrhythmia should be considered when evaluating patients with PCLD.

Incidence and Risk Factors for Atrial Fibrillation Recurrence after Ablation of Nodal and Atrioventricular Reentrant Tachycardia: A Meta-analysis

Introduction

Atrioventricular nodal reentrant tachycardia (AVNRT) and atrioventricular reentrant tachycardia (AVRT) are frequently associated with atrial fibrillation (AF). Targeting the slow or accessory pathways has been advocated as therapy for coexisting AF. But in practice, AF has frequently recurred after ablation, possibly because of various risk factors. The objective of this study is to investigate these risk factors and check for their significance in AF recurrence.

Materials and methods

A systematic review of Medline, Cochrane, and ClinicalTrials.gov databases was conducted. Articles that studied AF recurrence after either AVNRT or AVRT ablation were reviewed. Publication bias was adequately assessed, and the random method was applied for all dichotomous values. Finally, the odds ratio (OR) and confidence intervals (CI) were calculated for each risk factor.

Results

Four studies were included, with a total of 1,308 participants. Only 218 participants had dual tachycardia (AF with either AVNRT or AVRT). The mean follow-up time was 29 +/- 3.3 months. The mean age was 56 +/- 15 years. Age constituted the only significant risk factor for AF recurrence (OR: 3.4, CI: 2.1-5.3, p<0.001). Atrial vulnerability did not significantly correlate with a higher risk of AF recurrence (OR: 4.8, CI: 0.7-29, p<0.008). Again, neither male gender (OR: 1.5, CI: 0.8-2.8, p<0.16) nor left atrial diameter (OR: 1.5, CI: 0.2-10, p<0.67) were significant risk factors for recurrence of AF.

Conclusion

Older age was the only significant predictor of AF recurrence after ablation of AVNRT or AVRT. Further studies are needed to determine the age cut-off at which concomitant pulmonary vein isolation would be beneficial in patients undergoing ablation of AVNRT/AVRT.

Relevance of B-Lines on Lung Ultrasound in Volume Overload and Pulmonary Congestion: Clinical Correlations and Outcomes in Patients on Hemodialysis

BACKGROUND

Volume overload in patients on hemodialysis (HD) is an independent risk factor for cardiovascular mortality. B-lines detected on lung ultrasound (BLUS) assess extravascular lung water. This raises interest in its utility for assessing volume status and cardiovascular outcomes.

METHODS

End-stage renal disease patients on HD at the Island Rehab Center being older than 18 years were screened. Patients achieving their dry weight (DW) had a lung ultrasound in a supine position. Scores were classified as mild (0-14), moderate (15-30), and severe (>30) for pulmonary congestion. Patients with more than 60 were further classified as very severe. Patients were followed for cardiac events and death.

RESULTS

81 patients were recruited. 58 were males, with a mean age of 59.7 years. 44 had New York Heart Association (NYHA) class 1, 24 had class 2, and 13 had class 3. In univariate analysis, NYHA class was associated with B-line classes (<0.001) and diastolic dysfunction (0.002). In multivariate analysis, NYHA grade strongly correlated with B-line classification (0.01) but not with heart function (0.95). 71 subjects were followed for a mean duration of 1.19 years. 9 patients died and 20 had an incident cardiac event. A Kaplan-Meier survival analysis demonstrated an interval decrease in survival times in all-cause mortality and cardiac events with increased BLUS scores (p = 0.0049). Multivariate Cox regression analysis showed the independent predictive value of BLUS class for mortality and cardiac events with a heart rate of 2.98 and 7.98 in severe and very severe classes, respectively, compared to patients in the mild class (p = 0.025 and 0.013).

CONCLUSION

At DW, BLUS is an independent risk factor for death and cardiovascular events in patients on HD.

Sudden cardiac death in isolated right ventricular hypertrabeculation/noncompaction cardiomyopathy

Hypertrabeculation/noncompaction of the myocardium is a rare disorder that involves most commonly the left ventricle of the heart and it has been recognized as a distinct cardiomyopathy by the World Health Organization. However, it is extremely rare for this condition to involve exclusively the right ventricle. We report the cases of three patients who presented with ventricular tachyarrhythmia and sudden cardiac death. They were found to have isolated right ventricular hypertrabeculation/noncompaction on echocardiography. This supports the hypothesis that this condition is highly arrhythmogenic and is associated with high mortality similarly to the left ventricular hypertrabeculation/noncompaction cardiomyopathy.

A Plasma Cell Dyscrasia Presenting as Amyloid Cardiomyopathy and Autonomic Dysfunction in a Healthy Patient

Systemic amyloidosis is a rare multisystem disease caused by incorrectly folded proteins that deposit pathologically in different tissues and organs of the human body. It has a very wide spectrum of clinical presentations according to the affected organ(s), and its diagnosis is commonly delayed. Cardiac involvement is the leading cause of morbidity and mortality and carries a poor prognosis, especially in primary light chain amyloidosis. Therefore any delay in the diagnosis can result in devastating outcomes for the patient. We report the case of a 65-year-old man who presented with dizziness and lightheadedness. He was found to have orthostatic hypotension and further investigations revealed the diagnosis of amyloid cardiomyopathy complicating a plasma cell dyscrasia. What is worth noting, in this case, is that the patient had cardiac amyloidosis presenting primarily as autonomic dysfunction and orthostatic hypotension, without any cardiac-specific symptoms such as heart failure or angina. This is a very unusual presentation of advanced-stage cardiac amyloidosis. This article highlights the variety of clinical presentations of cardiac amyloidosis, and focuses on the recent progress such as novel diagnostic and surveillance approaches using imaging, biomarkers, and new histological typing techniques. Current and future promising treatment options are also discussed, including methods directly targeting the amyloid deposits.

Asystole caused by Hydroxycut Hardcore: A case report and literature review

Obesity is a rising epidemic worldwide driving people to search for remedy through nonconventional therapies. Hydroxycut products are popular supplements used as weight loss aids. Many reports revealed serious adverse effects related to their ingestion. We report the case of a 37-year-old healthy male patient who presented following an episode of syncope. On telemetry, he manifested recurrent sinus node arrests, including a symptomatic 24 s sinus pause. The patient admitted to taking Hydroxycut Hardcore for 10 days previously. After discontinuation of the drug, his symptoms completely resolved. This is the first case of Hydroxycut-associated syncope secondary to bradyarrhythmia.

Is kidney function affecting the management of myocardial infarction? A retrospective cohort study in patients with normal kidney function, chronic kidney disease stage III-V, and ESRD

Patients with chronic kidney disease (CKD) are three times more likely to have myocardial infarction (MI) and suffer from increased morbidity and higher mortality. Traditional and unique risk factors are prevalent and constitute challenges for the standard of care. However, CKD patients have been largely excluded from clinical trials and little evidence is available to guide evidence-based treatment of coronary artery disease in patients with CKD. Our objective was to assess whether a difference exists in the management of MI (ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction) among patients with normal kidney function, CKD stage III–V, and end-stage renal disease (ESRD) patients. We conducted a retrospective cohort study on patients admitted to Staten Island University Hospital for the diagnosis of MI between January 2005 and December 2012. Patients were assigned to one of three groups according to their kidney function: Data collected on the medical management and the use of statins, platelet inhibitors, beta-blockers, and angiotensin converting enzyme inhibitors/angiotensin receptor blockers were compared among the three cohorts, as well as medical interventions including: catheterization and coronary artery bypass graft (CABG) when indicated. Chi-square test was used to compare the proportions between nominal variables. Binary logistic analysis was used in order to determine associations between treatment modalities and comorbidities, and to account for possible confounding factors. Three hundred and thirty-four patients (mean age 67.2±13.9 years) were included. In terms of management, medical treatment was not different among the three groups. However, cardiac catheterization was performed less in ESRD when compared with no CKD and CKD stage III–V (45.6% vs 74% and 93.9%) (P<0.001). CABG was performed in comparable proportions in the three groups and CABG was not associated with the degree of CKD (P=0.078) in binary logistics regression. Cardiac catheterization on the other hand carried the strongest association among all studied variables (P<0.001). This association was maintained after adjusting for other comorbidities. The length of stay for the three cohorts (non-CKD, CKD stage III–V, and ESRD on hemodialysis) was 16, 17, and 15 days, respectively and was not statistically different. Many observations have reported discrimination of care for patients with CKD considered suboptimal candidates for aggressive management of their cardiac disease. In our study, medical therapy was achieved at high percentage and was comparable among groups of different kidney function. However, kidney disease seems to affect the management of patients with acute MI; percutaneous coronary angiography is not uniformly performed in patients with CKD and ESRD when compared with patients with normal kidney function.

Combined cerebral and lower-limb revascularization

Brachiocephalic atherosclerosis and aortoiliac occlusive disease are often encountered concomitantly, The authors report a technique of combined brachiocephalic and femoral revascularization in which a single transthoracic approach is used.

Renal artery pseudoaneurysm after blunt abdominal trauma

Renal artery pseudoaneurysms are rare after blunt abdominal trauma; only 11 cases have been previously reported. Pseudoaneurysms are caused by decelerating injuries of the renal artery after major falls or automobile accidents. Patients may be asymptomatic for many years, and the pseudoaneurysm may expand and rupture before diagnosis or treatment. The patients in four untreated cases died. The diagnosis of renal artery pseudoaneurysm can be made by Doppler sonography, computerized tomography, renal perfusion imaging, or contrast angiography. Treatment requires either surgical or percutaneous intervention. Renal salvage was possible in five of the seven patients treated. We report two additional patients with successful outcomes after surgical intervention.

Mycotic aneurysm of the popliteal artery secondary to tuberculosis. A case report and review of the literature

Mycotic aneurysms of the popliteal artery are rare; 33 cases have been reported in the literature. The treatment of choice is a large excision with extra-anatomic revascularization. In situ revascularization is sometimes possible. To the best of our knowledge, tuberculosis has never been reported as a causal factor of mycotic aneurysms of the popliteal artery. We report a case of a recurrent tuberculous false aneurysm of the popliteal artery. After 2 attempts at in situ revascularization, the femoral artery was ligated with no distal ischemia.

Concomitant cerebral, brachiocephalic trunk, and cardiac revascularization. An unusual case

Extensive transthoracic brachiocephalic revascularization is rarely performed. Instances of this operation performed concomitantly with cardiac revascularization and carotid endarterectomy have been reported in fewer than 10 cases in the literature. We report the case of a patient requiring complex brachiocephalic revascularization associated with coronary bypass grafting and a left carotid endarterectomy.

Arteritis due to Salmonella with aneurysm formation: two cases

Although arterial infection due to Salmonella is rare, it remains one of the most common causes of primary mycotic aneurysms. The presentation is one of sepsis, cultures positive for Salmonella and rapid expansion or rupture of the aneurysm. The authors' experience at Victoria Hospital, London, Ont., includes two cases of aneurysms infected with Salmonella--one aneurysm of the aorta and the other of the common femoral artery. Both patients were treated by excision of the aneurysm, extra-anatomic reconstruction in an area remote from the infected field and long-term administration of appropriate antibiotics. One patient was alive and well 36 months after resection. The other died of multiple organ failure 10 days after resection. From a review of the English and French literature since 1948, 64 cases of abdominal aortic aneurysms infected with Salmonella were found; half of the patients survived the perioperative period. The diagnosis of mycotic aneurysm must be considered in any patient with an aneurysm and culture specimens positive for Salmonella. The authors favour wide débridement of the infected aneurysm with extra-anatomic reconstruction. This view is supported by a review of the literature. The appropriate antibiotic therapy is bactericidal rather than bacteriostatic.

Antibiotic prophylaxis for surgery in morbidly obese patients

The rate of wound infections in morbidly obese patients who underwent gastroplasty surgery at our institution was 16.5% compared with a rate of 2.5% in normal-weight patients who underwent clean-contaminated surgery. Both groups received 1 gm of cefazolin intramuscularly before surgery was performed. We hypothesized that this regimen of prophylaxis did not provide adequate tissue levels in the morbidly obese. Morbidly obese patients who were undergoing gastroplasty were randomly selected to receive 1 gm cefazolin in the buttock fat, buttock muscle, or by intravenous injection. A fourth group of morbidly obese patients received 2 gm of cefazolin intravenously. Normal-weight patients who were undergoing upper abdominal surgery received 1 gm of cefazolin intravenously. At incision and closure, both blood and tissue levels of cefazolin were significantly (p less than 0.001) lower for all morbidly obese patients who received 1 gm cefazolin when compared with the blood and tissue levels of the drug found in normal-weight patients. The cefazolin levels obtained were below the minimal inhibitory concentrations of greater than 2 micrograms/ml for gram-positive cocci and of greater than 4 micrograms/ml for gram-negative rods. Only when the morbidly obese patient received 2 gm cefazolin were both the serum and adipose tissue levels adequate. For a 4-month period, all morbidly obese patients received 2 gm cefazolin prophylaxis, and the wound infection rate dropped to 5.6% compared with the previous rate of 16.5% (p less than 0.03). We conclude that antibiotic prophylaxis must be specially tailored to the needs of these obese patients.