A Lost Bullet in the Coronary Sinus: A Cautionary Tale.

We present a case of venous bullet embolism to the right atrium following a gunshot wound (GSW) to the abdomen. A 53-year-old male presented after a GSW to the abdomen. His workup included a computed tomography (CT) scan demonstrating an aortic injury with aortocaval fistula. A radio-opaque object consistent with a bullet was visualized in the right atrium. First, this case details an important decision, choice of surgery versus an interventional approach. After repair of the aortocaval fistula, the patient underwent a planned attempt to extract the bullet through a right lateral thoracotomy approach utilizing cardiopulmonary bypass to facilitate a right atriotomy. Intraoperatively, the team was not able to localize the bullet in the right atrium despite fluoroscopic evaluation. A postoperative CT scan demonstrated that the bullet had migrated into the coronary sinus. Lastly, this case demonstrates successful positioning maneuvers to dislodge the bullet out of the heart and into the inferior vena cava, allowing for the endovascular extraction of the bullet.

Complete postsurgical left ventricular-aortic discontinuity and pseudoaneurysm formation.

BACKGROUND: Left ventricular outflow tract pseudoaneurysm is a rare but potentially fatal complication of aortic valve replacement, infective endocarditis (IE), and suture dehiscence. Left ventricular-aortic discontinuity is a severe and uncommon manifestation of IE. For patients who have a long-standing history of endocarditis, periannular lesions in the aortic valve may rupture, leading to the rare occurrence of complete, or total, left ventricular-aortic discontinuity. METHODS: We present a case of complete postoperative left ventricular-aortic discontinuity and massive circumferential left ventricular outflow tract pseudoaneurysm discovered during a 3-month follow-up visit. Appropriate consent was obtained from all parties before submission of this case report. RESULTS: Postoperative cardiac computed tomography of a patient demonstrated dehiscence of a recently placed surgical aortic valve from the left ventricular outflow tract, with massive circumferential pseudoaneurysm formation. Only a small remnant of the membranous interventricular septum connected the aortic root to the heart, informing the diagnosis of complete left ventricular-aortic discontinuity. CONCLUSION: The clinical presentation of a left ventricular outflow tract pseudoaneurysm with concomitant left ventricular-aortic discontinuity is commonly nonspecific or clinically silent; thus, it requires a high index of suspicion and use of multimodality imaging for diagnosis and management.

Swiss cheese interventricular septum presenting with catastrophic stroke: the potential role of ECG-gated CTA.

Ventricular septal defect is a common congenital cardiac condition that presents in a variety of morphologies. Less commonly, when an individual patient is found to have multiple ventricular septal defects, the term "Swiss cheese ventricular septal defect" is applied. Although not routinely utilized in clinical practice, electrocardiogram (ECG)-gated computed tomographic angiography (CTA) has been shown to provide utility in detecting intracardiac shunts, demonstrating promise in preventing acute strokes secondary to a paradoxical embolus from occurring; this is especially important when atypical cardiac septa are suspected. This case seeks to illustrate how usage of ECG-gated CTA can assist in early detection and prevention of adverse outcomes resulting from an atypical presentation of a ventricular septal defect.

Rapid 3D reconstruction guided embolization for catastrophic bleeding following vacuum assisted breast biopsy; A case report and review of the literature.

The most clinically significant complication associated with stereotactic core needle biopsy of the breast is hematoma formation, which only occurs in less than 1% of biopsies and may require treatment. Cases of uncontrollable bleeding, refractory to repeated compression, resulting from biopsy are exceedingly rare. We present a case of catastrophic, uncontrollable bleeding and large hematoma formation resulting from stereotactic vacuum-assisted breast biopsy of a breast mass identified in screening mammography. Percutaneous embolization was planned and guided using 3D reconstructions from computed tomographic angiography, and bleeding was successfully controlled with micro-coil embolization.

Myocardial Ischemia and Anomalous Origin of the Right Coronary Artery From the Pulmonary Artery in the Adult: Management Implications and Follow-Up.

Anomalous origin of the right coronary artery from the pulmonary artery (ARCAPA) is a very rare and potentially fatal congenital heart defect due to myocardial ischemia secondary to coronary steal phenomenon. We present a case of an adult presenting with a myocardial infarction who was found to have ARCAPA. Three-dimensional (3D) reconstructed computed tomography angiography (CTA) was utilized preoperatively for surgical planning. Surgical technique as well as pre- and postoperative 3D CTA are described and literature reviewed.

Egg-and-Banana Sign: A Novel Diagnostic CT Marker for Pulmonary Hypertension.

OBJECTIVE: The purpose of this study was to retrospectively determine whether the egg-and-banana sign, defined as the visualization of the main pulmonary artery (PA) at the level of the aortic arch, is a sensitive and specific diagnostic marker for pulmonary hypertension. MATERIALS AND METHODS: A total of 186 patients who, between January 2014 and July 2017, received right heart catheterizations and underwent CT studies that included the aortic arch within 140 days of catheterization were evaluated in this retrospective study. Of these patients, 127 had pulmonary hypertension (PH), and 59 who did not have PH served as control subjects. Two blinded radiologists reviewed each study for the egg-and-banana sign. The diameters of the main PA and ascending aorta were also measured. Contingency tables, ROC curves, and a t test were used for statistical analysis. RESULTS: The egg-and-banana sign was associated with a higher mean PA pressure, a higher ratio of the diameter of the PA to the diameter of the ascending aorta (Ao) (hereafter referred to as the "PA-to-Ao ratio"), and a larger PA diameter (p < 0.006). It had a specificity of 85% and a positive predictive value of 85%. When the egg-and-banana sign was used in combination with a main PA diameter larger than 29 mm and a PA-to-Ao ratio greater than 1, its specificity increased to 91% and 93%, respectively. When considered as individual markers, the PA diameter had a high sensitivity (80%; AUC value, 0.74) and the PA-to-Ao ratio had a high specificity (81%; AUC value, 0.73) for PH. Moderate correlations were noted between PA pressure and PA diameter (r = 0.37) and between PA pressure and PA-to-Ao ratio (r = 0.43). CONCLUSION: The egg-and-banana sign has a high specificity and PPV for PH. Specificity increased when the sign was used in combination with other classic CT markers.

Primary spontaneous pneumothorax in conjunction with Marfan syndrome.

A 25-year-old man with a history of Marfan syndrome, asthma and smoking presented with worsening dyspnoea and right-sided chest pain worsened with deep breathing after a fall 2 days prior. Diagnostic imaging revealed a spontaneous right-sided pneumothorax due to ruptured subpleural bullae in the apex of the right lung. Smaller subpleural bullae were also noted in the apex of the left lung. A chest tube was placed to reduce the right pneumothorax successfully.

Incidental finding of tracheal bronchus complicating the anesthetic management of a left video-assisted thoracoscopic procedure.

Congenital abnormalities of the large airways are uncommon, but may occasionally pose significant difficulties for anesthesiologists. The tracheal bronchus is an anatomical variant in which an accessory bronchus originates directly from the trachea rather than distal to the carina, as a takeoff from the right mainstem bronchus. Anesthesiologists should be aware of this uncommon anomaly, its different variants, and its management in order to successfully establish one lung ventilation (OLV) for surgical isolation. In this article, we report the challenges encountered in establishing OLV in a patient with a previously undiagnosed aberrant right upper lobe bronchus arising directly from the trachea.

Nephrolithiasis in "back-to-back" kidneys.

A 57-year-old woman presented with a 1-week history of left lower quadrant pain and nausea and vomiting. Computed tomography without contrast demonstrated a left 2.3-cm calculus at the ureteropelvic junction and a 6-mm lower pole calculus. The kidneys were in the pelvis and oriented "back-to-back," with the lateral portions of the kidneys fused in the midline. To our knowledge, this is the first description of this renal fusion anomaly. The patient underwent robotic pyelolithotomy of the ureteropelvic junction calculus and subsequent flexible ureteroscopic laser lithotripsy of the lower pole calculus and ureteral stent placement through the assistant working port.