Extensive Coronary Thrombosis as a Sequelae of COVID-19 Presenting as a STEMI.

Thrombotic complications, in particular ST-elevation myocardial infarction (STEMI), have been described in active Coronavirus disease 2019 (COVID-19) cases. This is a result of systemic inflammation that often leads to endothelial activation, microvascular thrombosis and a hypercoagulable state. However, it is unknown how long patients who have cleared the COVID-19 infection remain at risk for coronary thrombosis as a sequela of disease burden. We present a case of a patient who presented three to four weeks following the initial infection.

Percutaneous management of RetroFlex 3 balloon rupture and separation of the Edwards Sapien delivery system.

We report the case of an 85-year-old woman with severe aortic stenosis who underwent transcatheter aortic valve replacement with use of the Edwards Sapien(®) valve system. The procedure was complicated by rupture of the valve-deployment balloon, with separation and retention of the nose cone of the RetroFlex 3(®) delivery system in the iliac artery. Our endovascular retrieval of the equipment was successful, and we achieved access-site hemostasis by deploying a covered stent. To our knowledge, this is the first report of the endovascular retrieval of a malfunctioning delivery system during transcatheter aortic valve replacement.

Reverse Takotsubo cardiomyopathy in the setting of anaphylaxis treated with high-dose intravenous epinephrine.

BACKGROUND: Takotsubo cardiomyopathy is seen, though rarely, in anaphylaxis treated with epinephrine. Stress cardiomyopathy is most likely to occur in middle-aged women. The underlying etiology is believed to be related to catecholamine release in periods of intense stress. Catecholamines administered exogenously, and those secreted by neuroendocrine tumors (e.g., pheochromocytoma) or during anaphylaxis have been reported to cause apical ballooning syndrome, or takotsubo syndrome. However, reverse takotsubo stress cardiomyopathy is rarely seen or reported in anaphylaxis treated with epinephrine. OBJECTIVES: To report a case illustrating that high-dose intravenous epinephrine can trigger stress cardiomyopathy, and that the risk is heightened with inappropriate dosing in the treatment of anaphylaxis. CASE REPORT: We report a rare case of iatrogenic reverse takotsubo syndrome in a young woman who was inappropriately treated with high-dose intravenous epinephrine for mild anaphylaxis. CONCLUSION: Inappropriately high doses of intravenous epinephrine can trigger stress cardiomyopathy. Emergency physicians should be familiar with the diagnosis, grading, and appropriate treatments of anaphylaxis to avoid this unnecessary complication.

Entrapment of a looped/kinked catheter in the brachial artery and its successful retrieval during transradial coronary catheterization.

Transradial access for cardiac catheterization is widely accepted as a safe and viable approach with markedly decreased incidence of major accessrelated complications compared to the transfemoral approach. Minor catheter looping or kinking during catheter manipulation is common and can be managed with gentle rotation, and thus goes unnoticed without complications. Rarely, this looped/kinked catheter can get entrapped and require an invasive approach for retrieval. To our knowledge, there is only one such case described for the transradial approach, where the authors had to use a 6 Fr Amplatz gooseneck snare kit via right femoral approach to remove the entrapped catheter. We present a case of entrapped looped/kinked 5 Fr catheter during transradial catheterization in the brachial artery and describe a novel approach of removing this entrapped catheter through the same radial access without any complications.

Drug-eluting stent thrombosis after 2029 days of placement: longest ever reported interval between drug-eluting stent placement and very late thrombosis.

In this era of very wide-spread use of percutaneous coronary intervention for the management of coronary artery disease, the appropriate duration of antiplatelet therapy after drug-eluting stent implantation still remains a subject of debate. Current recommendations from the American College of Cardiology/American Heart Association (2007) is to continue treatment with aspirin and clopidogrel for 1 year and then continue with aspirin only. However, cases of very late stent thrombosis (more than 12 months postimplantation) are being increasingly reported in literature. In this article we report a case of thrombosis as a result of drug-eluting stent placement after almost 67 months (2029 days), which to our knowledge, is the longest reported duration between the implantation of drug-eluting stent and occurrence of vascular event associated with very late stent thrombosis.

Acute hepatitis in a woman following excessive ingestion of an energy drink: a case report.

INTRODUCTION: The consumption of energy drinks has increased significantly. We report the case of a patient who presented to our hospital with jaundice, abdominal pain, and markedly increased liver transaminases likely due to the increased consumption of an energy drink. To the best of our knowledge, this is the first case report in the literature linking the development of acute hepatitis to the consumption of an energy drink. CASE PRESENTATION: A 22-year-old Caucasian woman presented to our hospital with epigastric pain, nausea, vomiting, and low-grade fever. She had been drinking 10 cans of an energy drink daily for two weeks prior to presentation. Her physical examination revealed mild epigastric tenderness. Her initial blood tests revealed elevated alanine aminotransferase, aspartate aminotransferase, and total bilirubin. A computed tomographic scan of the abdomen and pelvis was normal, and the patient was discharged to home. She returned to the Emergency Department of our hospital with worsening pain and new-onset jaundice. This time her physical examination revealed epigastric tenderness and icteric sclera. Her aspartate aminotransferase, alanine aminotransferase, and international normalized ratio were markedly elevated. Further radiological studies were non-specific, and she was admitted to our hospital with a diagnosis of acute hepatitis. Her viral serology and toxicology screens were negative. The patient was treated supportively and was discharged after resolution of her symptoms and a marked decrease in her liver enzymes. CONCLUSION: The development of acute hepatitis in this patient was most likely due to the excessive ingestion of an energy drink, and we speculate that niacin was the culprit ingredient.

Left atrial appendage lipoma: an unusual location of cardiac lipomas.

Cardiac lipomas are benign neoplasms of the heart and accounts for 8.4% of all primary tumors. They can occur sporadically at any age with no sex preference. The tumor originates mostly in the subendocardium and subepicardium but very rarely within the myocardium. Clinically this tumor is asymptomatic and found incidentally in the vast majority of cases. On occasion large lesions can lead to mechanical obstruction and pericardial effusions if located in the epicardium. Although lipomas can occur at different atrial or ventricular locations, it was never reported at the level of the left atrial appendage (LAA). Usually a mass in the LAA represents a thrombus, however there are few case reports of LAA tumors mainly representing fibroelastomas, myxomas, hemangiomas, and malignant tumors. To our knowledge there are no reported cases of left atrial appendage lipomas (LAAL) in the medical literature. We report the first case of LAAL discovered incidentally on transesophageal echocardiogram during off pump coronary artery bypass grafting.

Acute complication due to impella 2.5 device (superficial femoral artery thrombosis): managed successfully with novel aspiration thrombectomy catheter (pronto v3).

The Impella recover LP 2.5 is a percutaneous left ventricular assist device (LVAD) recently approved for use in patients undergoing high risk percutaneous coronary intervention (PCI) and also in cases of cardiogenic shock. There is limited evidence available in literature about its safety, especially with regards to the incidence of local vascular complications, their management and long-term implications. We report here the first case of a serious local vascular complication-superficial femoral artery thrombus formation during Impella recover LP 2.5 use in a high risk PCI which was managed successfully with novel aspiration thrombectomy catheter (Pronto V3), which in itself is the first reported use of Pronto V3 in such a vascular complication.

Dietary intake in hemodialysis patients does not reflect a heart healthy diet.

OBJECTIVE: Cardiovascular disease is highly prevalent and has a major effect on morbidity and mortality in patients undergoing maintenance hemodialysis (MHD). Dietary factors that may contribute to cardiovascular disease have not been well studied in this population. We hypothesize that dietary intake in this population does not meet the guidelines for cardiovascular risk reduction. DESIGN: A cross-sectional study was completed using the validated "Block Dialysis 1 Food Frequency Questionnaire" to assess dietary intake of MHD patients. SETTING AND PATIENTS: A total of 70 patients undergoing MHD at our outpatient dialysis center completed the questionnaire under the supervision of a trained dietitian. The population consisted of 38 men and 32 women. MAIN OUTCOME MEASURE: Dietary intake was the main outcome measure, with a focus on calories, soluble fiber, saturated fatty acid (SFA), unsaturated fatty acid intake (UFA), and protein. RESULTS: The mean fiber intake was 10.77 (±5.87) g/day, and only 2 of 71 (2.9%) were in compliance with the recommended daily intake of >25 g/day. As percentage of total calories, of the 70 patients, 5 (7.1%) had a fat intake of <30%, 22 (31.4%) had SFA intake of <10%, 64 (91.4%) had a UFA of ≤30%, 22 (31.4%) had a protein-based diet of ≥15%, and 66 (94.3%) had a carbohydrate diet of <60%. CONCLUSIONS: Most patients did not meet the dietary guidelines for reducing the risk of cardiovascular disease. Substituting UFA or soluble fiber for SFA improves low density lipoprotein (LDL) cholesterol levels without negative effects on other lipid parameters.

Characteristics and outcomes of methicillin-resistant Staphylococcus aureus surgical-site infections in patients with cancer: a case-control study.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) infections remain a significant cause of morbidity and mortality. We experienced an increased incidence of MRSA surgical-site infections (MRSA SSIs) at our institution. However, to our knowledge, no studies have evaluated the risk factors and outcomes of MRSA SSIs in cancer patients. METHODS: We conducted a case-control study and identified all patients who had developed MRSA SSIs at our institution from July 1, 2002 to July 30, 2003, and all patients who had undergone surgery by the same surgical team during the same time period but who had not developed MRSA SSIs. Cases and controls were age-matched at 1:2 ratio. RESULTS: The study included 29 cases and 58 controls. Mean interval between surgery and MRSA SSI onset was 17.8 days (range 3-75 days). Cases were more likely than controls to have progressive cancer (72 versus 38%), have received antibiotics (mainly quinolones) within 24 h of surgery (17 versus 2%), have had ongoing infection (10 versus 0%), and have had longer hospital and intensive care unit stays (11.0 versus 7.8 days and 3.4 versus 1.5 days) (all P < 0.05). In a multivariate logistic regression analysis, significant predictors of MRSA SSI in cancer patients were antibiotics use <24 h of surgery and progressive cancer. No surgical factors (i.e., procedure time or timing of perioperative antibiotics) were associated with increased risk of MRSA SSI. CONCLUSIONS: Several clinical and postoperative factors were associated with increased risk of MRSA SSI in cancer patients, but antibiotic use before surgery (especially quinolones) and progressive cancer were the only independent predictors.

Hypercalcemia, metabolic alkalosis and renal failure secondary to calcium bicarbonate intake for osteoporosis prevention--'modern' milk alkali syndrome: a case report.

We report a case of a patient presenting with a triad of hypercalcemia, metabolic alkalosis and renal failure secondary to calcium bicarbonate intake for osteoporosis prevention. It is the classical presentation of the "modern" milk alkali syndrome that presents several characteristics distinguishing it from the "old" syndrome described secondary to peptic ulcer disease treatment. Milk alkali syndrome affects middle-aged female patients taking over-the-counter calcium carbonate. Clinically, these patients present in an acute hypercalcemia crisis, responding rapidly to hydration. The phosphorus level is normal to low. Bisphosphonate should be used cautiously due to the risk of symptomatic hypocalcemia.