The Unrepaired Tetralogy of Fallot: A Tale of Delayed Presentation and Limited Access to Care.

Tetralogy of Fallot (TOF) is a common cyanotic congenital heart disease characterized by four distinct anatomical features. While surgical repair has significantly improved long-term outcomes, some individuals, particularly those from low socioeconomic backgrounds who lack access to medical care, may suffer from complications such as pulmonary hypertension (pHTN) and heart failure. We present a case report of a young female with unrepaired TOF who presented with acute-on-chronic hypoxic respiratory failure and heart failure, highlighting the complex nature and challenges associated with this condition.

Recurrent Spontaneous Pneumothorax in a Young Male With Duchenne Muscular Dystrophy Following COVID-19 Infection.

Duchene muscular dystrophy (DMD) is a genetic disorder primarily affecting males. It is characterized by progressive muscle tissue degeneration. Patients with DMD are at an increased risk of respiratory infections, including coronavirus disease 20019 (COVID-19), due to weakened respiratory muscles. We present a case of a young male with DMD who experienced recurrent pneumothorax 10 months after recovering from a COVID-19 infection. The patient required prompt medical intervention, including a chest tube, multiple surgeries, and mechanical pleurodesis. This case highlights the importance of recognizing recurring pneumothorax as a potential complication of COVID-19, particularly in patients with underlying neuromuscular disorders, as it is a medical emergency requiring prompt treatment to prevent respiratory compromise.

Role of ECG in the Accidental Finding of an Atrioventricular Septal Defect in an Asymptomatic Patient Undergoing Cosmetic Surgery.

Electrocardiogram (ECG) is an important diagnostic tool in identifying congenital heart disease (CHD), as demonstrated by this case of a 48-year-old female who presented for a preoperative evaluation for cosmetic surgery. ECG showed a right bundle branch block (RBBB) and first-degree atrioventricular (AV) block, and further testing revealed a primum atrial septal defect (ASD) with mitral valve anterior leaflet cleft and a membranous ventricular septal defect (VSD). She underwent successful surgical repair and was discharged home without complications. This case highlights the importance of performing additional tests like echocardiography or other imaging modalities in cases of abnormal ECG findings to accurately diagnose the underlying heart condition and ensure proper treatment.

COVID-19 Unveiling Heart Failure in the Realm of Rheumatic Heart Disease.

The global coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has resulted in various clinical manifestations, including cardiovascular complications. This case report focuses on a unique instance where COVID-19 infection exacerbated heart failure and induced atrial fibrillation in a previously asymptomatic young male with undiagnosed rheumatic heart disease (RHD). RHD, a prevalent cause of valvular abnormalities in developing countries, poses an additional risk for severe outcomes when coexisting with COVID-19 infection, highlighting the need for prompt and tailored interventions.

Continuous Positive Airway Pressure vs Mandibular Advancement Devices in the Treatment of Obstructive Sleep Apnea: An Updated Systematic Review and Meta-Analysis.

INTRODUCTION: Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder which has various treatment options, however, continuous positive airway pressure (CPAP) remains the gold standard. The aim of this meta-analysis is to compare the current first-line treatment of OSA, i.e., the continuous positive airway pressure (CPAP) with mandibular advancement devices (MADs) in mild to severe OSA. OBJECTIVE: This meta-analysis is a comparison of the efficacy of continuous positive airway pressure vs mandibular advancement devices in patients with mild to severe obstructive sleep apnea. The primary objective of the meta-analysis is to compare the efficacy of CPAP vs MADs in the treatment of OSA. This meta-analysis includes randomized control and cross-over studies that compare the efficacy of CPAP and MAD and outcomes are reported in terms of apnea-hypopnea index (AHI), lowest oxygen saturation, and Epworth sleepiness scale both pre- and post-treatment. DATA SOURCES AND STUDY SELECTION: A PubMed and Cochrane database search was conducted in May 2021 and study bibliographies were reviewed. Randomized clinical trials comparing the effect of CPAP and MAD on AHI, lowest oxygen saturation, and ESS in patients with obstructive sleep apnea were selected. Of the 436 studies initially identified, eight were selected for analysis after screening. The quantitative measures used for comparing the efficacy of CPAP and MAD were post-treatment apnea-hypopnea index (AHI), lowest oxygen saturation, and post-treatment Epworth score scale (ESS). DATA EXTRACTION AND SYNTHESIS:  A network of meta-analyses was performed using RevMan (Copenhagen, Denmark: Nordic Cochrane Center) where multivariate random-effects models were used to generate pooled estimates. Data were analyzed using generic inverse variance method and P < 0.05 is regarded as statistically significant. Combined summary statistics of standardized (STD) paired difference in mean for individual studies and combined studies was calculated. A chi-square-based test of homogeneity was performed and the inconsistency index (I2) statistic was determined. RESULTS: Compared the AHI, lowest oxygen saturation, and ESS from baseline to follow-up pre- and post-treatment in both CPAP and MAD groups; after the database search 436 records were identified, eight studies were included in the RCT, and three were RCT crossover studies. The duration of treatment varies in each group. AHI, ESS, and lowest oxygen saturation are calculated pre- and post-treatment. Compared with MAD, CPAP was associated with decrease in AHI with a mean difference of -5.83 (95% CI, -8.85, -2.81, P < 0.01). The lowest oxygen saturation was also decreased in CPAP group compared to MAD group with a mean difference of 0.72 (95% CI, 0.51, 0.94, P < 0.01). However, there was no statistically significant difference in ESS between CPAP and MAD group with a mean difference of 0.23 (95% CI, -0.24, 0.70, P = 0.34). The meta-analysis states that among patients with obstructive sleep apnea, both CPAP and MADs are effective in reducing the AHI and lowest oxygen saturation, however, no significant difference was found in ESS pre- and post-treatment. CONCLUSIONS: CPAP still remains the gold standard for the treatment of OSA and should continue to be recommended as a treatment for OSA. MAD can be used as adjunctive treatment or as a treatment for those who cannot readily access or do not prefer CPAP.

A Rarely Reported Case of Enterococcus faecalis Bacteremia Causing Infective Endocarditis and Osteomyelitis.

Infective endocarditis (IE) is an infection of the heart valves or endocardium, usually due to the spread of infection through the blood. It can cause a varied range of symptoms, from being asymptomatic to reduced heart function, valvular abnormalities, embolization, or death. Enterococci are usually present as normal gut flora but can also cause bacteremia, urinary tract infections, or IE, especially in the elderly population. The source of enterococcal spread in most of the cases is unidentifiable and sometimes associated with the genitourinary tract or damage to the gut mucosa due to trauma, malignancy, and infection, among others. Very few cases have been reported so far on Enterococcus faecalis (E. faecalis) endocarditis and even rarer for such cases complicated by osteomyelitis. Here, we describe the case of a 63-year-old male patient with a recent history of cardiac arrest, a percutaneous endoscopic gastrostomy tube placement, and endotracheal tube placement. He presented with back pain and was found to have osteomyelitis on magnetic resonance imaging and aortic valve vegetations on transthoracic echocardiography (TTE). His blood cultures were positive for E. faecalis. Repeat TTE showed growth in the vegetation, and the patient underwent bioprosthetic aortic valve replacement.

Bilateral Internal Carotid Artery Occlusion, an Unusual Clinical Entity in a Young Adult.

Bilateral internal carotid artery occlusion (BICAO) is a rare disease leading to serious cerebrovascular disease and complications including recurrent ischemic stroke or death. There are very few cases reported on BICAO, especially among young adults. The clinical presentation can range from asymptomatic to fatal ischemic stroke depending upon the presence of adequate collateral blood flow. Here we report a case of BICAO in a 31-year-old female who presented with intermittent left-sided hemiparesis for one day and was subsequently found to have complete occlusion of the bilateral intracranial internal carotid arteries on CT angiography (CTA). Magnetic resonance imaging (MRI) brain showed sub-acute right middle cerebral artery (MCA), acute left middle cerebral artery, and anterior cerebral artery infarcts (ACA). Being outside the window for thrombolysis, she was successfully treated with balloon angioplasty of the left internal carotid artery (ICA) and started on dual antiplatelet therapy. The case illustrates the importance of evaluating for cerebrovascular disease when someone presents with stroke-like symptoms even in the young adult population, as prompt treatment can be lifesaving.

A Rare Case Report of ST-Segment Elevation Myocardial Infarction and Recurrent Chest Pain in Polyarteritis Nodosa.

Polyarteritis nodosa (PAN) is a type of vasculitis that mainly affects small and medium-sized blood vessels. The clinical presentation can be nonspecific as weight loss, abdominal pain, and hypertension, or fatal as myocardial infarction (MI) and bowel perforation depending upon the organ involved. Cardiac involvement of PAN usually manifests as congestive heart failure, aneurysms, or MIs and is mostly identified during postmortem studies of autopsied patients. Here, we report a case of anterior MI as a sequela of PAN in a 40-year-old female who was diagnosed with PAN two weeks before her MI. She presented with intermittent chest pain for one day. At the time of admission, an electrocardiogram revealed anterior MI, and she was subsequently found to have 95-99% stenosis of the proximal left anterior descending artery during cardiac catheterization. The patient was successfully treated with percutaneous coronary intervention and was started on dual antiplatelet therapy. Her treatment was continued with steroids and cyclophosphamide. The case illustrates the importance of recognizing MI as a sequela of PAN as timely treatment could be lifesaving.