Patient With Missed Right Ventricular Rupture From Blunt Trauma Remains Hemodynamically Stable for 3 Days.

Cardiac chamber rupture from blunt trauma is rare but can be fatal. Surprisingly, in some subsets of patients, it can be subtle and rather easily missed. Rapid recognition and management are essential. Percutaneous closure can be successful in iatrogenic chamber perforation (during pericardiocentesis) but possibly not in traumatic chamber rupture. (Level of Difficulty: Intermediate.).

A Rare Case of Intracavitary Cardiac Metastasis of Endometrial Carcinosarcoma.

A 59-year-old female, with past medical history including endometrial carcinosarcoma with a port-a-cath device, presented due to shortness of breath. Transesophageal echocardiogram demonstrated a mass extending from the right atrium, involving the tricuspid valve, and extending into the right ventricle. Our differential diagnosis included thrombus as well as endocarditis and malignancy; a thrombus was considered to be the most likely etiology due to the port-a-cath device. Use of the novel AngioVac mechanical aspiration device (AngioDynamics, 2021) allowed removal of the mass as well as evaluation by pathology, establishing the unlikely diagnosis of metastatic endometrial carcinosarcoma.

Anomalous Origin of the Right Coronary Artery From the First Septal Perforator.

A 68-year-old white male presented to the clinic for chest pain and shortness of breath with exertion. Through coronary angiography, the patient was found to have an anomalous origin of the right coronary artery off the first septal perforator branch of the left anterior descending artery. The patient was treated with conservative medical therapy as symptoms had resolved, and the patient did not wish to undergo further procedures.

Massive Mural Thrombus Masquerading as Myxoma.

A 75-year-old Caucasian female with a past medical history including insulin-dependent diabetes mellitus, hypertension, and dyslipidemia, presented to the emergency room for having palpitations for three weeks. Echocardiography revealed a very large left atrial mass mimicking myxoma. Mass was excised and examined by pathology, revealing a mural thrombus. A mural thrombus is not an uncommon mass found in the left atrium. However, it does not often present symptomatically, strongly mimics an atrial myxoma on cardiac imaging, and has rarely ever been reported to be greater than seven centimeters in any dimension. We present a case of a 75-year-old Caucasian woman with a massive, symptomatic cardiac thrombus masquerading as a myxoma on imaging.

Bidirectional Ventricular Tachycardia in Acute Multivessel Myocardial Infarction.

Bidirectional ventricular tachycardia (BVT) is a rare and unusual ventricular dysrhythmia that is characterized by a beat-to-beat alternation of the QRS axis. This can sometimes manifest as alternating left and right bundle branch blocks. To the best of our knowledge, there are two previous cases of BVT in the setting of type I myocardial infarction. Our case would be the third and showed a subtle change in the anterior-posterior axis that can be seen in lead V2. The coronary angiography of our patient demonstrated severe multivessel coronary artery disease with complete total occlusion of the proximal dominant right coronary artery, 100% in-stent restenosis of the ostial left circumflex, 40% stenosis of left main, and 90% stenosis of mid left anterior descending artery (LAD). The BVT resolved after two amiodarone boluses followed by a drip. We attempted to transition to oral mexiletine, however, the patient was unable to tolerate the medication due to intractable nausea and vomiting. The patient subsequently underwent high risk coronary artery bypass graft surgery with no further episodes of BVT following revascularization and was discharged after six weeks of hospitalization. Although rare, type I myocardial infarction is an important differential diagnosis of BVT.

A Unique Case of a Right Atrial Myxoma Infected With Escherichia coli.

A 70-year-old white male, with past medical history of coronary artery disease, peripheral arterial disease status-post bilateral femoral artery stents, insulin-dependent diabetes mellitus, hypertension, hyperlipidemia, arthritis, tobacco use, and alcohol use, presented with shortness of breath and an abnormal finding on a recent transesophageal echo. This had revealed a large, fixed mass in the right atrium. Our differential diagnosis had included thrombus, endocarditis, myxoma, papillary fibroelastoma, sarcoma, and metastatic tumor. The cardiothoracic surgeon excised this mass, which upon culturing, revealed what we found to be the only reported case of an atrial myxoma infected with Escherichia coli. In addition to surgical excision, the patient was treated with six weeks of intravenous cefepime.

Rapidly enlarging mycotic coronary artery aneurysm caused by bacterial seeding involving methicillin-sensitive Staphylococcus aureus and Klebsiella pneumoniae.

Coronary artery aneurysms are uncommon. A rare subcategory caused by infectious etiologies are called mycotic coronary artery aneurysms (MCAA), which have an exceedingly high mortality rate. In this report, we present a rare case of a rapidly expanding MCAA involving Staphylococcus aureus and Klebsiella pneumoniae affecting the left circumflex artery. Per our literature review, MCAA involving K. pneumoniae co-infection or superinfection have rarely, if ever, been documented. The aneurysm was discovered when the patient underwent coronary angiography for non-ST-elevation myocardial infarction. She was treated for bacteremia and upon reevaluation the aneurysm had grown approximately three times the original size. The patient had an aneurysmectomy with coronary artery bypass grafting due to the enlargement and size of the aneurysm. By highlighting this life-threatening disease, we hope to shed light on rare causes of MCAA and the importance of appropriate treatment. .

AngioVac Removal of an Isolated Infected Pulmonary Valve Papillary Fibroelastoma.

The AngioVac (Angiodynamics) system is indicated for the removal of right-sided venous soft thrombi and emboli. This is the first report that demonstrates the AngioVac system can be extended to the extraction of right-sided cardiac tumors, in the current case, a pulmonary valve papillary fibroelastoma infected with Streptococcus salivarius and Rothia species. (Level of Difficulty: Advanced.).

Vasospastic Angina and Role of Cardiac Catheterization.

Prinzmetal angina, also known as vasospastic or variant angina, is defined as an intermittent focal coronary artery spasm often associated with an atherosclerotic lesion near the site of spasm. It is caused by a focal or diffuse spasm of the smooth layer of the arterial wall of an epicardial coronary artery. Acute infarctions or malignant arrhythmias may develop during spasm-induced ischemia. Evaluation includes observation of echocardiogram (EKG) for transient ST elevations during discomfort; diagnosis is confirmed with coronary angiography using provocative testing. We describe two cases of patients who presented for non-cardiac complaints, but had episodes of vasospastic angina during their hospitalization. Both underwent cardiac catheterization with differing results, demonstrating the importance of catheterization in patients who experience vasospastic angina.

Intermittent outpatient nesiritide infusion reduces hospital admissions in patients with advanced heart failure.

Recombinant B-type natriuretic peptide (BNP) is a therapeutic modality in patients with decompensated congestive heart failure. Retrospectively tested are the effects of intermittent outpatient nesiritide infusion on symptoms, hospital readmission rates, endogenous BNP, and renal function in patients with advanced heart failure. Twenty-four patients in heart failure in New York Heart Association (NYHA) classes III-IV received a 6- to 8-hour intermittent nesiritide outpatient infusion (0.01 mcg/kg/min continuously intravenously) once weekly for a total duration of 3 months in addition to standard medical therapy. Data were analyzed retrospectively to compare hospital readmission rates, endogenous BNP levels, blood urea nitrogen, and creatinine levels 1 year before and up to 12 months after starting treatment. All patients tolerated nesiritide infusions well with no significant adverse events. At the end of the observation period, NYHA classes had improved 1 class in 16 patients and 2 classes in 4 patients and remained unchanged in 4 patients. There was a significant reduction in hospital readmissions within 1 year with nesiritide treatment compared with the year before (0.94 +/- 0.8 vs 3.6 +/- 2.2, P < .005). No significant changes were seen regarding endogenous BNP levels (1002 +/- 870 vs 1092 +/- 978 pg/mL, P = .95), blood urea nitrogen levels (45 +/- 28 vs 45 +/- 26 mg/dL, P = .96), and a tendency of slightly elevated creatinine levels that did not differ significantly compared with prior levels (1.76 +/- 0.85 vs 1.1 +/- 0.56 mg/dL, P = .5). Intermittent outpatient nesiritide treatment resulted in improved symptoms and reduced hospital readmission rates without a significant decline in renal function in patients with advanced heart failure but did not alter endogenous BNP levels.

Ultrasound at 27 kHz increases tissue expression and activity of nitric oxide synthases in acute limb ischemia in rabbits.

Transcutaneous low-frequency ultrasound (US) preserves myocardial and skeletal muscle viability by increasing tissue perfusion through an undefined nitric oxide (NO)-dependent mechanism. We have examined whether US increases tissue expression and activity of the three nitric oxide synthase (NOS) isoforms: endothelial (eNOS), neuronal (nNOS) and inducible (iNOS). The two femoral arteries of four New Zealand rabbits were ligated for a total of 120 min. After 60 min of ligation, transcutaneous low-frequency US (27 kHz, 0.13 W/cm2) was applied for 60 min to one thigh, while the contra-lateral artery served as a control (total ischemia time=120 min). Calcium-dependent (cNOS) and -independent (ciNOS) NOS activity, and concentration of total eNOS, ser-1177 phosphorylated eNOS (P-eNOS), nNOS and iNOS were then determined in the gracilis muscle. Compared with the control, US application significantly increased cNOS activity [3.34+/-0.28 versus 3.87+/-0.10x1000 counts per minute (cpm), respectively, p=0.031] and ciNOS activity (1.99+/-0.09 versus 3.26+/-0.68 cpm, respectively, p<0.001). Western immunoblotting revealed a significant increase in protein content of both iNOS (184.5+/-1.08%; p<0.0001) and P-eNOS (381.5+/-2.47%; p<0.001), with only a small increase in total eNOS and nNOS expression. In conclusion, application of transcutaneous low-frequency US to ischemic muscular tissue significantly increases both cNOS and ciNOS activity by increasing eNOS phosphorylation and iNOS expression, respectively.

Unusual evolution of ST elevation acute myocardial infarction.

We report a case of acute ST-segment elevation myocardial infarction with an unusual evolution of ST-segment elevation. Several possible explanations of this progression are discussed with supportive evidence for each explaination. The clinical, electrocardiographic, and angiographic features of this case are also illustrated.

Congenital bicuspid aortic valve enodocarditis with multiple subvalvular complications and an acquired membranous ventricular septal defect.

We report a case with echocardiographic demonstration of native congenital bicuspid aortic valve endocarditis with multiple subaortic complications. Transesophageal echocardiography in this case revealed large vegetations with multiloculated aortic paravalvular abscess around the cusps; a high-acquired restrictive membranous ventricular septal defect with vegetations extending to the tricuspid leaflets and paravalvular aortic regurgitation caused by aortic leaflet perforation.