Atypical presentation of cardiac sarcoidosis: role of multimodality imaging and review of literature.

Cardiac sarcoidosis (CS) is challenging to determine, consequently is under-recognised in clinical practice. The accurate prevalence of CS is possibly underestimated due to unspecific symptoms, subclinical illness and the dearth of universally accepted diagnostic criteria. Totally, non-invasive diagnosis of CS was proposed in 2015 by the Japanese Ministry of Health and Welfare using positron emission tomography and cardiac MRI findings as major criteria and substituting histological verification. We present a case of a 60-year-old woman with pulmonary sarcoidosis presenting with progressively worsening palpitations and recurrent syncope. Her initial evaluation at another hospital facility revealed normal cardiac testing. A detailed evaluation with echocardiography and cardiac MRI helped us arrive at the diagnosis of CS, which resulted in appropriate treatment and resolution of symptoms. We discuss CS in general, the clinical disease, diagnostic algorithms, latest guidelines and management.

Think before you leap: cutaneous hypersensitivity to polytetrafluoroethylene arteriovenous graft masquerading as infection.

Polytetrafluoroethylene (PTFE) graft is a synthetic graft commonly used in chronic haemodialysis patients. Expected complications of synthetic grafts include infection, thrombosis, oedema and pain. PTFE is a non-textile graft that is chemically inert, electronegative and hydrophobic. Due to their chemical properties, PTFE grafts have lower risks of these adversities. We present a patient with a rare case of cutaneous hypersensitivity to a PTFE graft.

Unusual complication of an Alaskan cruise: thinking outside the box.

A 69-year-old man with a medical history of hypertension and diabetes presented with altered mental status once he returned from a 14-day Alaskan cruise. An extensive workup for stroke was negative. His physical examination was normal without any focal motor deficits, but he had developed memory loss and paresthesia. He admitted to eating a lot of fish when he was in Alaska. The whole-blood mercury level was found to be elevated. He was managed conservatively and his symptoms resolved completely in a few days. This led to a diagnosis of organic mercury toxicity.

Actinomycotic endocarditis of the eustachian valve: a rare case and a review of the literature.

Eustachian valve endocarditis caused by Actinomyces species is extremely rare. A literature review revealed only one reported case-caused by Actinomyces israelii in an intravenous drug abuser. Our patient, a 30-year-old woman who at first appeared to be in good health, presented with fever, a large mobile mass on the eustachian valve, and extensive intra-abdominal and pelvic masses that looked malignant. Histopathologic examination of tissue found in association with an intrauterine contraceptive device revealed filamentous, branching microorganisms consistent with Actinomyces turicensis. This patient was treated successfully with antibiotic agents. In addition to presenting a new case of a rare condition, we discuss cardiac actinomycotic infections in general and eustachian valve endocarditis in particular: its predisposing factors, clinical course, sequelae, and our approaches to its management.

Comparison of patients with peripartum heart failure and normal (≥55%) versus low (<45%) left ventricular ejection fractions.

The current definition of peripartum cardiomyopathy (PC) is restricted to patients with left ventricular systolic dysfunction (ejection fraction [EF]<45%). Data on peripartum heart failure (HF) with normal EF are sparse. We describe clinical characteristics of patients with normal (≥55%) and patients with low (<45%) left ventricular ejection fractions (LVEFs). Electronic medical records (2006 to 2013) of our tertiary care center were retrospectively screened to identify peripartum HF with normal EF, defined as an entity meeting Framingham criteria for HF with symptom onset during the last month of pregnancy or up to 5 months after delivery and with an EF of ≥55%. Clinical characteristics, echocardiographic parameters, and outcomes of these patients were compared with age-matched control patients with traditionally defined PC (EF<45%). A total of 25 patients with PC and EF≥55% were identified. Exclusion of hypertension (n=9), preeclampsia (n=1), and diabetes mellitus (n=2) yielded 13 patients with PC and EF≥55%. Age-matched patients with traditional PC (EF<45%) constituted controls (n=16). Compared with patients with PC and low LVEF, patients with PC and normal LVEF had lower B-type natriuretic peptide levels, systolic and diastolic left ventricular dimensions, left atrial size, and incidence of decompensated HF during delivery (p<0.05). Compared with historical age-matched controls, patients with normal LVEF exhibited attenuated E' mitral annular velocities. On follow-up, these patients were associated with a lower New York Heart Association functional class. In conclusion, peripartum HF with normal LVEF appears to be a distinct entity.

Two-dimensional strain profiles in patients with physiological and pathological hypertrophy and preserved left ventricular systolic function: a comparative analyses.

OBJECTIVE: This study was designed to examine the utility of two-dimensional strain (2DS) or speckle tracking imaging to typify functional adaptations of the left ventricle in variant forms of left ventricular hypertrophy (LVH). DESIGN: Cross-sectional study. SETTING: Urban tertiary care academic medical centres. PARTICIPANTS: A total of 129 subjects, 56 with hypertrophic cardiomyopathy (HCM), 34 with hypertensive left ventricular hypertrophy (H-LVH), 27 professional athletes with LVH (AT-LVH) and 12 healthy controls in sinus rhythm with preserved left ventricular systolic function. METHODS: Conventional echocardiographic and tissue Doppler examinations were performed in all study subjects. Bi-dimensional acquisitions were analysed to map longitudinal systolic strain (automated function imaging, AFI, GE Healthcare, Waukesha, Wisconsin, USA) from apical views. RESULTS: Subjects with HCM had significantly lower regional and average global peak longitudinal systolic strain (GLS-avg) compared with controls and other forms of LVH. Strain dispersion index, a measure of regional contractile heterogeneity, was higher in HCM compared with the rest of the groups. On receiver operator characteristics analysis, GLS-avg had excellent discriminatory ability to distinguish HCM from H-LVH area under curve (AUC) (0.893, p<0.001) or AT-LVH AUC (0.920, p<0.001). Tissue Doppler and LV morphological parameters were better suited to differentiate the athlete heart from HCM. CONCLUSIONS: 2DS (AFI) allows rapid characterisation of regional and global systolic function and may have the potential to differentiate HCM from variant forms of LVH.

A novel approach to ICD lead revision in a patient with extensive vascular thrombosis.

Chronic extensive thrombosis of the venous system is a commonly encountered problem in end stage renal disease (ESRD) patients undergoing transvenous device implantation, lead extraction or lead revision. We describe a case of an ESRD patient with an implantable cardioverter defibrillator (ICD) that failed to deliver therapy due to lead fracture. Patient needed revision of the ICD lead system, but had extensive axillary-subclavian-superior vena cava occlusion. Patient refused a thoracotomy approach as well as lead extraction as he had a complicated course of lead extraction in the past. We successfully improvised a novel technique to revise the ICD system.