ABSTRACT
Aortic stenosis is the most common heart valve disease, especially among the elderly. Symptomatic aortic valve stenosis is linked to a poor prognosis and a high mortality rate if left untreated. The only effective treatment for severe symptomatic aortic stenosis is aortic valve replacement using either a mechanical or a biological prosthesis. Mechanical valve prostheses, while highly durable, are thrombogenic, necessitating lifelong anticoagulation with oral anti-vitamin K agents, such as acenocoumarol. Conversely, bioprosthetic valves, though less durable, carry a minimal thrombogenic risk and do not require anticoagulation. Currently, there is no proven role for direct-acting oral anticoagulants (DOACs) in patients with mechanical heart valves due to insufficient clinical trial data regarding their safety in this patient population. Herein, we present the case of a 59-year-old female known to have aortic stenosis, who underwent surgical treatment with mechanical aortic valve replacement eight years ago. Post-surgery, acenocoumarol was initiated. However, 18 months prior to presenting at our institution, the patient started taking rivaroxaban (a DOAC) instead of acenocoumarol due to the unavailability of acenocoumarol during the ongoing economic crisis in Lebanon, without consulting her cardiologist. Although she was followed up by her general practitioner and reported having a mechanical valve, her son contradicted this, claiming she had a biological valve. After thorough investigations, including chest X-ray, echocardiography, and fluoroscopy, it was confirmed that the patient indeed had a normally functioning mechanical aortic valve. Immediate corrective measures were taken, starting with IV unfractionated heparin and acenocoumarol, targeting an International Normalized Ratio (INR) between 2.5 and 3, while educating the patient about her condition and the importance of adhering to acenocoumarol therapy.
ABSTRACT
The diagnosis of atrial septal defect (ASD) may be delayed until adulthood or even later in life as it is a well-tolerated congenital heart disease. If patients are not examined and investigated well in childhood, the diagnosis may be delayed until later in adulthood when patients present with palpitations and sometimes dyspnea due to the right chambers dilatation from right ventricular volume overload. In this report, we present a case of a 50-year-old female patient with symptoms of heart failure and atrial fibrillation who was found to have dilated right cardiac chambers, dilated pulmonary artery, severe tricuspid regurgitation, pulmonary hypertension, and a pulmonary-to-systemic flow ratio (Qp/Qs) of more than 1.5 by transthoracic echocardiography and Doppler, indicating left to right shunt at the atrial level. However, transthoracic echocardiography could not visualize the defect, and two-dimensional (2D) transesophageal echocardiography was done in this patient and documented the presence of a sinus venosus ASD with an incomplete cor triatriatum dexter membrane; all four pulmonary veins were identified going to the left atrium. Since the presence of an incomplete cor triatriatum dexter membrane (despite causing no symptoms) makes the percutaneous closure of the sinus venosus ASD and the percutaneous repair of tricuspid regurgitation very difficult, we decided to advise surgical ASD closure and tricuspid valve repair for the patient.
ABSTRACT
Imaging the superior vena cava (SVC) during two-dimensional (2D) transthoracic echocardiographic examination is challenging and should be performed routinely. Here, we present a case where a lower (juxta-atrial) SVC mass was seen prolapsing into the right atrium by 2D transthoracic echocardiography; in this case, the imaging of the lower (juxta-atrial) SVC was done from the subcostal window. It was not possible to image the SVC from the suprasternal, right supraclavicular, left parasternal, or apical windows. CT scan of the chest with intravenous contrast was done in this case and showed an anterior mediastinal mass invading the SVC and prolapsing into the right atrium. CT-guided biopsy proved the mass to be a type B2 thymoma.
ABSTRACT
Acute myeloid leukemia (AML), the most common form of acute leukemia, is an aggressive lethal hematological malignancy that mainly occurs in older adults with a slightly higher predominance in males. It is prompted by the clonal expansion of immature myeloid blasts in the bone marrow, peripheral blood, and/or extramedullary tissues. Leukostasis in AML is a critical medical condition mainly affecting the lungs and brain and arises when tissue perfusion is compromised due to the clustering of white blood cells (WBCs) within the microvasculature. Cardiac involvement in this condition is exceptionally uncommon. Here, we present a case of a 56-year-old man, recently diagnosed with acute myelogenous leukemia M4 and leukostasis, who developed acute anterior ST-elevation myocardial infarction six days after presentation and in whom emergent coronary angiography showed proximal left anterior descending (LAD) artery lesion with a large clot obstructing the flow and thrombolysis in myocardial infarction (TIMI) I flow, and urgent percutaneous coronary intervention (PCI) was done; thromboaspiration and drug-coated balloon angioplasty were performed with good angiographic results. Antiplatelet (aspirin and clopidogrel) and anticoagulation (enoxaparin) were started immediately before PCI. Emergent leukapheresis was initiated in addition to hydroxyurea with complete resolution of chest pain. Four days post PCI, the patient developed right-sided hemiparesis with an evident infarct on a CT scan of the brain, and he also developed acute limb ischemia involving the distal right foot. Five days post PCI, the patient had a sudden sustained ventricular tachycardia followed immediately by asystole, and cardio-pulmonary resuscitation was done for 25 minutes but with no response.
ABSTRACT
Pneumococcal disease affects people across all ages but is more prevalent in young children and the elderly. Despite the availability of the pneumococcal vaccine for adults, the disease burden and mortality associated with it remains a challenge. A few studies conducted in Lebanon have reported epidemiology of pneumococcal disease, concurring the high burden among adults and older adults in the region. The pneumococcal vaccine is a part of the routine immunization schedule for children, but there are no recommendations for adult vaccination. A medical advisory board was hence conducted in September 2020 to discuss the burden of pneumococcal disease (PD) among adults in Lebanon. The participants were experts from the fields of internal medicine, family medicine, hematology, cardiology, oncology, endocrinology, pulmonology, and infectious diseases. The experts reached a consensus that there is a need to take steps to increase the rate of adult vaccination uptake and create awareness among physicians, pharmacists, caregivers, and patients. The physicians should be trained on adult immunization and should actively discuss the importance of the pneumococcal vaccine, especially with high-risk adult patients. Implementing adult vaccination as a routine practice and involving various stakeholders to address the gaps can help in reducing the burden of pneumococcal disease in adults.
ABSTRACT
We report the case of a 41-year-old woman who developed thrombosis of a CarboMedics prosthetic valve in the mitral position despite adequate anticoagulation. This report provides further supportive data to recently published studies suggesting an increased thrombogenicity of the CarboMedics prosthetic valve in the mitral position and it underscores the importance of conducting large prospective, randomized trials for further evaluation of the thromboembolic complications of this valve.
