A Rare Case of Isolated Cardiac Sarcoidosis With Negative Biopsy: Diagnosis by Clinical Criteria.

Cardiac sarcoidosis (CS) is a potentially life-threatening condition that can cause sudden, fatal conduction abnormalities, arrhythmias, and heart failure. The diagnosis of CS is challenging due to nonspecific symptoms and an unclear diagnostic criterion. Although biopsy is the gold standard method, the sensitivity of biopsy is low. About a portion of CS cases are detected through imaging. A unique aspect of our case is that our definitive diagnosis was made based on clinical and imaging criteria alone despite a negative biopsy. Our diagnosis was confirmed further on follow-up with improvement in cardiac function on imaging after a treatment course with corticosteroids. This case highlights the need to have a broad differential and more awareness of this rare etiology and the value of clinical criteria to make a definitive diagnosis.

Outcomes of Transcatheter Mitral Valve Repair Using the MitraClip System in Patients With Atrial Fibrillation. A Meta-Analysis.

Transcatheter mitral valve repair (TMVR) with the MitraClip system is now approved for degenerative and functional mitral regurgitation (MR). Atrial fibrillation (AF) is commonly seen in MR. In our study, we perform a pooled analysis of the existing data to investigate the outcomes of MitraClip in patients with versus without AF. We conducted a systematic search of PubMed, Google Scholar, and SCOPUS databases through December, 2022 for studies comparing the outcomes of TMVR using the MitraClip in patients with preexisting AF versus those without AF. A meta-analysis was performed to investigate the primary outcomes of all-cause mortality and heart failure (HF) hospitalization. Secondary outcomes were cardiovascular mortality, in-hospital mortality, stroke, New York Heart Association class I or II at follow-up, length of hospital stay, and procedural time. A total of 10 studies (n = 24,111; AF = 12,789; no AF = 11,322) were included in the final analysis. Preexisting AF was associated with higher overall all-cause mortality (odds ratio 1.55, 95% confidence interval 1.32 to 1.83, p <0.0002) and higher overall HF hospitalization rate (odds ratio 1.3, 95% confidence interval 1.08 to 1.56, p <0.0154). There was no statistically significant difference in cardiovascular mortality, in-hospital mortality, stroke, length of hospital stay, procedural time, or New York Heart Association class I/II at follow-up comparing AF versus no AF. The presence of AF in patients who underwent TMVR with MitraClip is associated with higher all-cause mortality and HF hospitalization. This should be taken into consideration in the management of MR patients.

Extracorporeal Membrane Oxygenation (ECMO) Cannula Stimulation of the Carotid Sinus Causing Bradycardic Pauses in a Patient With COVID-19.

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) cannulation is a potential cause of episodic bradycardia during an intensive care course because of the proximal cannula insertion site being in the vicinity of the carotid sinus. Herein, we report the case of episodic bradycardia throughout a multi-week intensive care stay of a VV-ECMO recipient due to a severe coronavirus disease 2019 (COVID-19) infection that did not emerge for the rest of the patient's hospitalization after decannulation.

A rare variant of a ruptured sinus of valsalva aneurysm forming an aorto-atrial fistula: a case report and review of literature.

Background: Sinus of valsalva aneurysms (SOVAs) are infrequent findings and generally diagnosed incidentally. A SOVA may be at risk for rupture, which would lead to an aorto-cardiac shunt. These patients present similarly to decompensated heart failure. Case Presentation: We present a case of a 44-year-old female with a ruptured non-coronary SOVA diagnosed by echocardiogram during evaluation for exertional dyspnoea. A trans-oesophageal echocardiogram (TEE) revealed a 2.1 cm non-coronary SOVA with windsock communication to the right atrium. The patient refused surgery, and two years later, presented with florid right heart failure with preserved left ventricular function. The right ventricle was severely dilated and hypokinetic with right atrial enlargement. After finally agreeing to surgery, a pre-operative catheterization revealed non-obstructive coronaries and a significant left to right shunt with elevated pulmonary pressure. The patient had suboptimal response to diuretic therapy and was sent for successful repair of the aneurysm with the closure of the aorto-atrial fistula via bovine pericardial patch and resolution of the left to right shunt as demonstrated by intra-operative TEE. Her right-sided heart failure symptoms subsequently resolved. Discussion: SOVA is a rare finding but should still be considered in the differential in young and middle-aged patients with symptoms of acute heart failure, hemodynamic compromise, and a new continuous heart murmur. Early surgical repair is highly recommended to prevent acute and long-term complications.

A cluster of grapes: Right atrial masses of uncertain origin.

Implanted ports have provided clinicians with long term venous accessibility, while maintaining comfort and convenience for their patients. One of the most commonly used implanted ports for oncological access is a Mediport (Norfork Medical, Skokie, IL). Guidelines (INS2021) strongly recommend placing central catheter tips at the cavo-atrial junction. In fact, too deep atrium position may be associated with micro-traumatism, possibly leading to a catheter associated right atrial thrombosis (CRAT). No significant literature discusses the possibility of such port masses being seeded by a bacteria, as in the case for endocarditis, which was seen in our patient. In the following case report, we will explore the case of a 41-year-old female with metastatic urothelial carcinoma who developed multiple right atrial masses possibly associated with a deeply seated totally implanted vascular access device (TIVAD) tip within the right atrial wall. These right atrial masses were of unknown origin, and in the setting of MRSA bacteremia, multiple possible etiologies would be discussed. We will also explore ways in which similar complications can be easily prevented in the future.

Major Complications and Failure Modes of the Angiosculpt Scoring Balloon Catheter: Analysis of the MAUDE Database.

Since its Food and Drug Administration approval in January 2007, the Angiosculpt scoring balloon catheter has been widely utilized in severely calcified stenotic vascular lesions. We sought to characterize the complication rates, failure modes, and outcomes associated with the Angiosculpt catheter. Using queried events from October 2013 to December 2020 from the Food and Drug Administration Manufacturer and User Facility Device Experience database, we analyzed the Angiosculpt scoring balloon catheter complication rates and mode of failure. A total of 248 complications were reported. Most reported complications occurred in the superficial femoral artery (SFA) (19.4%, n = 48), followed by the left anterior descending artery (8.1%, n = 20). Severe vessel calcifications were reported in (26.6%, n = 66) of the complications. Most complications occurred with damage to the device, such as tip break (44.8%, n = 111) and balloon rupture (26.6%, n = 66). Some complications were due to difficulties in the withdrawal of the catheter (23.8%, n = 59). Balloon rupture is observed at a significantly higher rate amongst calcified vessels (60.6% vs 14.8%), P = < 0.001, and in cases involving the SFA (39.4% vs 11.3%), P = < 0.001. All-cause complications in calcified vessels are associated with the SFA (39.4% vs 12.5%), P = < 0.001, and left anterior descending artery (16.7% vs 5.1%), P = < 0.001. The Angiosculpt scoring balloon catheter has a relatively low complication rate. Most complications were associated with a device tip break, balloon rupture, and difficulties in withdrawal in severely calcified vessels.

Correlation between Echocardiographic Diastolic Parameters and Invasive Measurements of Left Ventricular Filling Pressure in Patients with Takotsubo Cardiomyopathy.

BACKGROUND: The extent of diastolic dysfunction is of clinical importance in the risk stratification and management of patients with Takotsubo cardiomyopathy (TC). Standard echocardiographic indices of diastolic dysfunction have robust predictive ability in assorted disease states, but have not been validated in TC. The aim of this study was to compare Doppler metrics of diastolic function against catheterization-measured filling pressures in TC. METHODS: Patients with TC who met inclusion and exclusion criteria were evaluated using echocardiography and catheterization performed within 24 hours. Both left ventricular (LV) end-diastolic pressure and LV pre-A diastolic pressure were obtained from catheterization tracings. The echocardiographic parameters for diastolic function were extracted using the American Society of Echocardiography recommendations and a previously validated regression equation for mean left atrial pressure (mLAP). RESULTS: A total of 51 patients with TC were included. Patients were predominantly women (72.5%), with a mean age of 58 ± 13 years and a mean ejection fraction of 24 ± 10 %. E/e' ratio (septal, average, and lateral) and calculated mLAP correlated positively with catheterization LV pre-A, with fair to moderate correlation (coefficient range, 0.38-0.44). The t-test mean difference between LV pre-A pressure and calculated mLAP was 0.77 ± 7.34 mm Hg (95% CI, ±14.68 mm Hg) suggesting inconsistent measures. mLAP also exhibited poor diagnostic ability to discriminate elevated LV pre-A diastolic pressure, with an area under the receiver operating characteristic curve of 0.69 (95% CI, 0.50-0.88). CONCLUSIONS: Commonly used echocardiographic parameters for diastolic function demonstrated less-than-optimal correlation, with poor sensitivity and specificity, compared with invasively measured LV end-diastolic pressure or LV pre-A wave diastolic pressure in patients with TC. Precise characterization of LV filling pressure in patients with TC using contemporary noninvasive echocardiographic parameters appears challenging. Invasive measurements of filling pressure should remain the gold standard for optimal risk stratification and management of patients with TC.

Inspirations from a Complicated Pediatric Heart Transplantation.

It takes only 1 profound experience to change someone's life. We invite you to read about how an experience of struggle led to a motivation in medicine. Through a first-person perspective, the author details the sequence of diagnosis and treatment of his own case of cardiac transplantation secondary to viral cardiomyopathy.

The Ominous Triad of Severe Takotsubo Cardiomyopathy.

QT prolongation is present in 26-52% of cases of Takotsubo cardiomyopathy (TCM). It has been postulated to result from reduced cardiac repolarization reserve and reflects the transient myocardial insult observed in TCM. Bradycardia-induced QT interval prolongation is amplified by the occurrence of TCM, a combination that potentially carries a significant risk for torsade de pointes (TdP). We present a unique case of an 80-year-old female with TCM-related cardiac arrest. The patient had acquired long QT syndrome in which TCM myocardial insult led to the precipitation of a third-degree atrioventricular (AV) block and subsequent bradycardia-induced TdP. Due to the lack of robust literature, there is no clear guideline in the management of third-degree AV block in the setting of TCM. In our case, because of recurrent ventricular tachycardia (VT) and ventricular fibrillation (VF) arrest, we opted for temporary pacing at a high ventricular rate, followed by a biventricular implantable cardioverter-defibrillator (BiV/ICD). Follow-up 3 months later revealed improvement of left ventricular (LV) dysfunction and resolution of QT prolongation. However, the noticed AV conduction defects persisted. In the available literature, we identified five reported cases that bear similarity with our patient's presentation. The identified cases were middle-aged to elderly females with no significant cardiac history, who exhibited a similar triad of TCM associated with high-grade AV block, acquired long QT syndrome, and a rapid progression of bradycardia-induced TdP, resulting in a near cardiac arrest within the first 24 - 48 h of admission. It is crucial to monitor corrected QT (QTc), correct electrolyte abnormalities, and minimize QT-prolonging medications in patients with TCM. The recognition of AV conduction defects in patients with TCM is critical, especially if it is associated with significant QT prolongation. Such situations are underrecognized, and are potentially fatal, necessitating close monitoring and timely intervention.

Daptomycin-Associated Diarrhea: A Case Report and Review of the Literature.

Antibiotic-associated diarrhea (AAD) describes any unexplained diarrhea associated with the use of antibiotics. AAD develops through diverse mechanisms, ranging from pharmacologic effects on gut motility to disturbance of the function and carbohydrate metabolism of the indigenous intestinal flora and overgrowth by pathogenic micro-organisms. Clostridioides difficile-associated diarrhea (CDAD) is a subset of AAD; however, it accounts only for a small percentage of diarrhea caused by antibiotics. Diarrhea has been reported as a side effect of daptomycin use, nevertheless, it's thought to be mild and carries significantly less risk of diarrhea than other alternative treatments of S. aureus bacteremia, i.e., vancomycin or cefazolin. The authors present an interesting case of daptomycin-associated diarrhea presenting with a protracted and severe course. Patient symptoms didn't improve with empiric Clostridioides difficile therapy and CDAD testing was negative. Diarrhea promptly resolved after discontinuation of daptomycin. Furthermore, a thorough literature review was conducted and discussed in this article to raise awareness of this under-recognized complication. Clinicians should be mindful of daptomycin-associated diarrhea along with its presentation and treatment. Further studies are needed to identify the pathophysiology of daptomycin-associated diarrhea and other forms of AAD. Understanding their mechanism could help prevent, treat, and reduce the significant medical costs associated with antibiotic adverse events.

Turnpike Catheter failure, causes and mechanisms: Insights from the MAUDE database.

Background: The Turnpike catheters (Teleflex, Wayne, PA, USA) is a microcatheter that was approved by the Food and Drug Administration in November 2014 to be used to access discrete regions of the coronary and peripheral vasculature. Methods: The Manufacturer and User Facility Device Experience (MAUDE) database was queried for reports of the Turnpike catheters from March 2015 through August 2021. Results: A total of 216 reports were found during the study period. After excluding duplicate reports (n = 21), our final cohort included 195 reports. The most common failure mode was catheter tip break or detachment (83%, n = 165) which was significantly associated with over-torquing (p-value = 0.025). The most common clinical consequence was the entrapment of the catheter (33%, n = 65), followed by vessel injury (7.8% n = 15) and vessel occlusion (3.6%, n = 7). Most patients had no consequences (47.0%, n = 93) or recovered (11%, n = 22). A total of 4 deaths were reported. 35.8% of reports (n = 69) specified the presence of severe calcification in the target vessel. Over torquing by interventionists was reported in 33.2% of events (n = 64). Conclusion: Despite clinical trials demonstrating the safety of the Turnpike catheters, complications can still occur. These data serve to inform operators about potentional risks and complications associated with the use of the device. Physicians should avoid over-torqueing which seems to be the most common mechanism for device complications.

Plasminogen Activator Inhibitor-1 4G/5G Polymorphism Presenting as Recurrent Ischemic Stroke: The Microthrombi Shower.

Certain clinical scenarios should alert a physician to take a deeper look into causative pathological processes. This was evident in the case of a 41-year-old man who presented for recurrent micro thromboembolic strokes, which is atypical for the patient's age. Our desire to explain the pathological process led to the rare finding of a plasminogen activator inhibitor-1 polymorphism, which has been associated with an increased risk of cerebrovascular thrombosis. A defect in this pathway leads to the inhibition of the tissue plasminogen activator protein. This genetic polymorphism has relatively been unexplored in recent medical literature, and we are hoping that our case may inspire future research that could help potential targets of risk factor stratifications as well as the development of novel pharmacological options.

Antiphospholipid Syndrome in a Patient With Autosomal Dominant Polycystic Kidney Disease: The Surface of the Moon.

Antiphospholipid syndrome (APS) is a rare coagulopathic disorder diagnosed with a combination of clinical/imaging findings with specific antibody titer elevations over a period of 12 weeks. The following case report will discuss the unusual and challenging hospital course of a patient with extensive autosomal dominant polycystic kidney disease (ADPKD) being treated for a multi-drug resistant urinary tract infection (UTI). The patient later developed multiple deep vein thrombosis (DVT) and was found to have antiphospholipid syndrome. Warfarin, the anticoagulant of choice for antiphospholipid syndrome, has a higher likelihood of intracerebral hemorrhage than direct oral anticoagulants. This is particularly challenging since patients with autosomal dominant polycystic kidney disease have a higher propensity to develop intracranial aneurysms (ICA).

Incomplete Kawasaki Disease in an Infant: A Case Report and Literature Review.

The term "incomplete Kawasaki Disease (IKD)" was first used to describe patients with coronary complications who did not fulfill the classical diagnostic criteria for Kawasaki Disease (KD). The risk of coronary artery involvement is similar if not greater in cases of IKD. However, the recognition of IKD is challenging and often delayed, especially in infants. Multiple algorithms have been formulated to identify cases of IKD utilizing supplemental clinical, echocardiographic, and laboratory features. Although fever is not required for a diagnosis of KD in the Japanese guideline, most of the current guidelines, including those of the American Heart Association (AHA), consider the presence of fever for at least seven days a requirement for the diagnosis of both KD and IKD in infants. We present a case of IKD in a four-month-old female who presented with fever for less than three days and did not follow the current AHA algorithm for IKD. An echocardiogram obtained 10 days later revealed a coronary artery aneurysm, and a retrospective diagnosis of IKD was made. A review of the literature identified similar cases with a growing consensus on the need to redefine the role of fever. Pediatricians should search for coronary artery lesions in cases of high clinical suspicion, even if the fever period is short, particularly in those less than six months. Additionally, further innovative research is directly needed to identify immunological and cellular markers that could be tested early in the course of the disease and guide the management.

A Case of Quadricuspid Aortic Valve Regurgitation: The Cardiac Clover.

A quadricuspid aortic valve is a very rare congenital heart condition that can present as aortic regurgitation in the 5th and 6th decade of life. The following case report will describe a patient who presented with symptoms of severe aortic regurgitation and was found to have a quadricuspid aortic valve on echocardiography. The case will describe the clinical manifestations in which the patient presented and the subsequent diagnosis of the quadricuspid aortic valve. The rationale for the surgical approach will also be discussed, along with the patient's clinical response.

Ruptured Bullae: A Case of Transthyretin Cardiac Amyloidosis.

Amyloidosis is a rare disease with an incidence of only 16.6 per 100,000 patients per year. A high grade of clinical suspicion is required to suspect an atypical cause of left ventricular hypertrophy or new-onset heart failure. A transthoracic echocardiogram (TTE) is the initial evaluation that may yield clues pointing towards an etiology of cardiac amyloidosis. Due to the subjective nature of TTE interpretations, suspicion for cardiac amyloidosis may be missed. Once suspicion arises, additional tests, such as serum and urine electrophoresis and technetium-99m pyrophosphate myocardial perfusion imaging, can further aid in establishing a diagnosis. The pathophysiology in transthyretin amyloidosis (ATTR) involves the misfolding of the transthyretin/prealbumin protein, which leads to an inherent propensity to aggregate. These proteins can accumulate in the extracellular space between cardiac myocytes, which may thicken sections of the heart, leading to ventricular restriction. Here, we explore the case of an 83-year-old man with chronic, treatment-resistant heart failure with preserved ejection fraction, New York Heart Association class III, who presented with multiple ruptured bullae in the bilateral lower extremity, leading to a new diagnosis of ATTR cardiac amyloidosis.

Perpetually Positive: Post-COVID Interstitial Lung Disease in an Immunocompromised Patient With Diffuse Large B-cell Lymphoma.

As more patients recover from COVID-19 infection, long-term complications are beginning to arise. Our case report will explore a debilitating long-term complication, Post-COVID Interstitial Lung Disease (PC-ILD). We will introduce a patient who developed PC-ILD in the setting of diffuse large B-cell lymphoma, outlining a difficult hospital course, including a positive COVID-19 polymerase chain reaction (PCR) for more than 3 months. We will then discuss the human body's physiological response to the virus and how our patient was not able to adequately mount an immune response. Finally, the pathophysiology of PC-ILD will be explored and correlated with the patient's subsequent computed tomographic images obtained over a 3-month period. The difficult hospital course and complex medical decision-making outlined in this case report serve as a reminder for health care providers to maintain vigilance in protecting our most vulnerable patient population from such a devastating disease process.