Acute Limb Ischemia: A rare and devastating complication of infective Endocarditis

Introduction@#In contrast to embolic events to the brain, lungs and spleen which have been comprehensively discussed in literature, acute limb ischemia (ALI) due to septic embolism (SE) from infective endocarditis (IE) are uncommonly reported. There have been no reported cases of ALI as a complication of IE among Filipinos to date making this case report the first in our country@*Case Presentation@#We report two cases of communityacquired native valve endocarditis caused by streptococcus spp. and enterococcus faecalis. Both patients had large and mobile vegetations in the mitral valve and aortic valve respectively on transthoracic echocardiography. The first one developed ALI (IIa) on the R leg after the initiation of antibiotics. The second case presented with ALI (IIa) on the R leg on admission. They were given the appropriate antibiotics and received systemic anticoagulation with heparin. The first case underwent successful emergency embolectomy on the R leg but developed new-onset ALI on the L leg and refused further intervention. Embolectomy was also recommended on the second patient who also re-fused any intervention. Despite maximal medical management, both patients subsequently expired@*Conclusion@#Infective endocarditis (IE) patients are at risk to develop SE before or during the initiation of appropriate antibiotics. ALI is a life threatening extra cardiac complication of IE. Early recognition and prompt aggressive management are therefore imperative.

Left Ventricular Non-Compaction in an adult with Patent Ductus Arteriosus

Introduction@#Left ventricular non-compaction (LVNC) is a rare form of cardiomyopathy that may occur in isolation or with an associated cardiac anomaly. It presents with a wide array of manifestations, prompting early recognition to be imperative to prevent progression of symptoms.@*Case presentation@#We report a case of a 46-year-old male complaining of palpitations for 10 years who survived sudden cardiac arrest on the same year as symptom onset. Consult was advised but was not done until he had heart failure symptoms. Carvedilol, furosemide and digoxin were given. Initially, some improvement was noted but he later developed dyspnea on exertion prompting consult at our institution. Pertinent physical examination findings include a dynamic precordium, apex beat at sixth left intercostal space-anterior axillary line (LICS AAL), right ventricular heave, distinct heart sounds, normal rate, irregularly irregular rhythm, a grade 4/6 continuous murmur heard best at the left upper sternal border, suggestive of patent ductus arteriosus (PDA), and a grade 3/6 holosystolic murmur at the apex radiating to the axilla, suggestive of mitral regurgitation. Transthoracic echocardiography confirmed presence of a PDA (0.8cm) with left to right shunt and Qp/Qs of 2.7:1. Incidental finding of LVNC was noted characterized by prominent ventricular trabeculations and deep intertrabecular recesses. Optimal medical treatment for heart failure was given with symptomatic relief. Surgical closure of the PDA was contemplated after hemodynamic studies can confirm the absence of irreversible pulmonary hypertension.@*Discussion@#Patients with LVNC may be asymptomatic or may present with heart failure, sudden cardiac death or arrhythmias. The diagnosis of LVNC poses a diagnostic challenge. Echocardiography is a cost-effective diagnostic tool that will allow early diagnosis. Cardiac magnetic resonance (CMR) imaging is an alternative diagnostic modality. Once the diagnosis has been confirmed, prompt initiation of guideline-directed medical treatment for heart failure may prevent progression of disease.@*Conclusion@#Left ventricular non-compaction may occur in isolation or in association with other congenital heart diseases such as patent ductus arteriosus. Closure of a PDA is indicated in the presence of a significant shunt and with confirmation of acute reversibility in the presence of pulmonary hypertension to prevent the possibility of decompensation in a patient with heart failure.

Acute Myocardial Infarction in very young Filipino adults

Introduction@#Acute myocardial infarction (AMI) is rare in “very young” patients and studies among Filipinos are scarce. The objective of this study is to determine the prevalence, clinical, echocardiographic and angiographic features, and outcome of this population.@*Methods@#A retrospective study of patients aged 19 to 30 years old who were diagnosed with AMI at the Philippine Heart Center from 2012 to 2016 was done.@*Results@#The prevalence of AMI in very young Filipino adults at our institution was 0.93% (11/1182). The mean age was 26.5±3.4 years with a male predominance (82%). Chest pain was the most common symptom (91%). More than half of the patients did not have heredofamilial diseases. Eight patients were smokers (72%). There was one case of illegal drug use (methamphetamine) (9%). There were only two cases of non-ST elevation myocardial infarction (NSTEMI) (18%). ST elevation myocardial infarction (STEMI) of the anterior wall was seen in four cases (36%), inferior wall in three cases (27%) and anterolateral wall in two cases (18%). Six patients (45%) had left anterior descending artery (LAD) involvement. Two patients (18%) had right coronary artery (RCA) involvement. Two patients (18%) had both LAD and RCA involvement. The youngest patient, a 19-year-old female with Takayasu arteritis, had three-vessel involvement. Five patients (45%) underwent percutaneous coronary involvement (PCI) of the LAD while two had PCI of the RCA (18%). All patients were discharged improved.@*Discussion@#Acute myocardial infarction (AMI) in the young has not been extensively studied among Asians. Chest pain is the most common clinical presentation with STEMI being more frequent than NSTEMI in this age group. Male gender and smoking were the most common risk factors.@*Conclusion@#Early recognition and prompt management of AMI, particularly revascularization (if indicated), are of paramount importance to optimize outcomes.