How we dealt with the double whammy! Acute pulmonary embolism with abdominal aortic clot and renal infarcts.

Pulmonary embolism (PE) is the third most common cause of cardiovascular mortality in the United States, and the submassive PE accounts for 20%-25% of all acute PE. In the last decade, endovascular therapy with catheter-directed thrombolysis (CDT) intervention has shown great success in the treatment of submassive PE. There is limited data regarding using these devices to treat patients with concomitant abdominal aortic and renal vessel clots. Herein, we present a case of a 23-year-old male who presented with submassive PE associated with abdominal aortic thrombosis and renal infarcts. The patient was successfully treated with CDT with complete resolution of pulmonary and bilateral renal artery clots.

The great invasion, a case of lung mass invading the heart through the pulmonary veins.

The heart is a rare site of metastatic lesions of malignancies. Cardiac metastasis may go unrecognized till autopsy, and about half of all newly diagnosed lung cancer patients have metastasis to another organ. Due to the absence of early symptoms, the clinical diagnosis of cardiac metastasis is challenging. Even when they are symptomatic, these symptoms may be masked by the clinical features of primary cancer. Noncardiac neoplasms may spread to the heart through lymphatic or hematogenous dissemination, local extension, or a transvenous route. Here, we report a case of a 56-year-old male with lung mass extending from the right upper lobe to the left atrium was associated with mass effect on superior vena cava and left brachiocephalic vein.

Stemi mimicking post COVID: a case of focal myopericarditis post COVID infection.

Since the beginning of the coronavirus disease 2019 (COVID19) pandemic, several cases of myocarditis related to COVID-19 infection have been reported. These cases range from asymptomatic disease to fulminant heart failure or sudden cardiac death. Cardiac injury has also been found in asymptomatic patients and patients who recovered from the disease. Data regarding cardiovascular involvement due to COVID-19 infection are still limited, and the actual prevalence of myocarditis due to COVID-19 infection is still unknown. We present a case of focal myopericarditis in a patient recently recovered from COVID-19 pneumonia with electrocardiogram showing ST elevation in inferior and lateral leads. This case highlights the need for studying the long-term cardiovascular complications of COVID-19 and reinforces the use of cardiac magnetic resonance (CMR) and cardiac biomarkers in the diagnosis of COVID-19-related myocarditis.

Heart broken. An unusual case of biventricular takotsubo cardiomyopathy complicated by STEMI and Left ventricular thrombi. A case report.

Takotsubo cardiomyopathy (TCM) is a rare occurrence in patients with troponin-positive acute coronary syndrome (ACS). It usually manifests as transient apical ballooning of the left ventricle with concomitant occurrence of right ventricular involvement in only one-third of cases. Biventricular TCM is associated with more hemodynamic instability as compared to left sided alone. Depressed ventricular systolic function and localized ventricular dyskinesis can facilitate clot formation in ventricular cavity. We present a case of 80-year-old man who presented to the ED for evaluation of hypotension. An electrocardiogram suggested acute anterior wall myocardial infarction. He underwent emergent coronary angiography and was found to have mid to apical akinesis and basal hyperkinesis with normal left coronaries and chronic total right coronary artery occlusion with excellent collaterals from left. A transthoracic echocardiography (TTE) revealed left ventricular ejection fraction 25-30% and akinesis of left and right ventricle except in the basal region. TTE with definity showed sessile thrombus. In our patient, sepsis was the most important triggering factor given initial presentation of hypotension with leukocytosis. Broad spectrum antibiotics including vancomycin and Zosyn were started considering a combination of septic and cardiogenic shock. Repeat EKG showed resolution of ST-T segment elevation but our patient remained hemodynamically unstable even with two pressure support and, ultimately, died 72 hours after admission. Herein, we emphasize on the importance right ventricular involvement and its relation to hemodynamic instability. This case highlights the importance of anticipating hemodynamic instability and clot formation in patients with biventricular Takotsubo cardiomyopathy.

Acute-Hypoxemia-Induced Right-To-Left Shunting in the Presence of Patent Foramen Ovale.

Patent foramen ovale (PFO) is a common congenital abnormality of the heart. It results from incomplete closure of foramen ovale that persists in adulthood. Most individuals with PFO are asymptomatic and are discovered incidentally. The left atrial pressure is generally higher than the right atrial pressure, which prevents blood flow against the gradient; however, any medical condition that increases the pulmonary artery pressure can lead to reversal of blood flow from right to left by elevating right atrial pressure. We present a case of a 59-year-old female who presented with complaints of shortness of breath associated with bilateral lower-extremity edema and was found to have acute decompensated heart failure and atrial fibrillation. Transesophageal echocardiogram (TEE) with cardioversion was performed. Propofol was given for conscious sedation; however, the procedure was terminated as patient became hypoxemic and was noted to have moderately dilated right ventricle (RV) with hypokinesia and PFO with right-to-left shunting. It also demonstrated mild mitral regurgitation, mild left ventricular hypertrophy, and a left ventricular ejection fraction of 55-60%. In contrast to TEE findings, while the patient was having normal oxygen saturation, transthoracic echocardiogram showed left-to-right shunting instead of right-to-left and no RV hypokinesia was noted. In conclusion, this case draws attention to the relationship between acute hypoxemia and right-to-left shunting in a patient with PFO. This case illustrates and highlights the need for more prospective studies to establish a relationship between acute hypoxemia and right-to-left shunting in the presence of PFO.

A rare presentation of transient hypothermia in HIV infection: A case report and systematic review of cases.

Hypothermia defined as a core body temperature less than 35°C causes hundreds of deaths annually in the United States. It can occur in a variety of clinical settings, including environmental exposure, shock, infection, metabolic disorders, alcohol, or drug toxicity, and malnutrition. This condition can affect many different organ systems and may lead to serious complications including cardiac arrhythmia. Hypothermia is extremely rare in people living with HIV but can be seen in severely malnourished patients or those who are not receiving antiretroviral therapy (ART). It is a life-threatening situation that should be treated aggressively. To the best of our knowledge, there are only a few cases that have been reported for people living with HIV presenting with hypothermia and sinus bradycardia. Herein, we are reporting a very rare case of people living with AIDS who presented with hypothermia complicated by sinus bradycardia. In addition, we also performed a systematic review of cases based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline, to investigate the clinical characteristics and outcomes associated with this rare complication. This systematic review of cases hopefully can increase the awareness of this rare entity and help improve its outcome.

COVID-19 and Diabetic Ketoacidosis: A Single Center Experience.

BACKGROUND AND OBJECTIVES:  To describe the clinical characteristics and outcomes of hospitalized coronavirus disease 2019 (COVID-19) patients with diabetic ketoacidosis (DKA) -- a single center tertiary hospital experience. MATERIALS AND METHODS:  A retrospective study was conducted among patients admitted to our hospital in the United States between March 1st and June 15th, 2020 with DKA and severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection known as COVID-19. We compared the baseline characteristics, laboratory data, and clinical course between survivors and nonsurvivors to identify the risk factors associated with mortality in the patients with DKA. RESULTS:  A total number of 43 patients were included in this study. The median age was 52 years. Thirty-three (76.7%) patients were male. Median value of initial glucose on presentation was 553 mg/dL (300.0-1927.0 mg/dL). On admission, 33 (76.7%) patients had glycated hemoglobin (HbA1c) ≥ 8% (64 mmol/mol) and HbA1c was not obtained in 10 (23.3%) patients. Acute kidney injury (AKI) was seen in 37 (86.0%) patients, 6 (14%) patients required renal replacement therapy and 22 (51.2%) required mechanical ventilation. Among the 43 patients, 25 (58.1%) died. Out of 25 patients who died 15 (60.0%) were Hispanics, 6 (24.0%) were White, 3 (12.0%) were African American, 1 (4%) was Arabic, and 1 (4%) was Asian. The patients who died were older in age than who survived (mean age 58 ± 6.13 vs 46 ± 9.39; p = 0.023). Some 95% of the patients requiring mechanical ventilation died (odds ratio [OR]: 89.25; 95% confidence interval [CI]: 9.10-874.96); p = 0.001). Compared to survivors, nonsurvivors had significantly higher d-dimer (13.00 ± 3.20 mcg/mL vs 6.15 ± 3.66 mcg/mL; p< 0.006) and peak ferritin values (2763.66 ± 1105.32 ng/mL vs 835.16 ± 257.07 ng/mL; p= 0.016).  Conclusion: Our retrospective study shows COVID-19 infection may present as DKA in patients with diabetes mellitus (DM). Older age, mechanical ventilation, elevated d-dimer, and ferritin are associated with poor prognosis in these patients. Our study shows that COVID-19 is associated with substantial mortality in DKA patients and adds to the limited literature available regarding poor risk factors associated with mortality in these patients.

Enigma of recurrent strokes with literature review.

Metastatic tumors are the most common tumors affecting the heart. Primary tumors are rare, with myxomas being the most common of the primary cardiac tumors. The incidence of primary cardiac tumors is 0.02%, about 200 cases has been reported in 1 million autopsies. Most of primary cardiac tumors have been detected incidentally on diagnostic modalities: computed tomography (CT), cardiac magnetic resonance imaging (MRI), or echocardiography. Majority of primary-origin cardiac tumors are benign, of which the most common type of primary tumor is cardiac myxoma. Fibroelastoma is a rare benign tumor and the 2nd most common cause of primary cardiac tumors. In the past fibroelastoma has been detected on autopsy findings. With the development of more advanced imaging modalities fibroelastoma is more frequently detected as a cause of stroke, myocardial infarction (MI), angina episodes, and systemic embolization. Echocardiogram is the best diagnostic modality to diagnose primary cardiac tumors although transthoracic echocardiogram (TTE) can miss primary cardiac tumors; transesophageal echocardiography (TEE) has been more labeled more accurate in the diagnosis of primary cardiac tumors. We present here a case of a 21-year-old male with the history of multiple strokes secondary to cardiac papillary fibroelastoma (CPF).