Myocardial ischemia in the setting of extrinsic coronary compression: two case reports.

Background: Myocardial ischemia occurs in the setting of inadequate or complete cessation of blood supply to the myocardium. While atherosclerosis is the most common cause; other causes have been identified. Rare cases can be caused by extrinsic compression of the coronaries by a dilated pulmonary artery (PA) or by mechanical obstruction from nearby chest tubes or drains. We present two cases of myocardial ischemia-driven malignant arrhythmia leading to cardiac arrest caused by obstruction of the coronary blood flow from external compression. Case Description: In the first case, venous bypass graft compression from a chest tube postoperatively was noted and in the second case left main coronary artery (LMCA) compression from a dilated PA secondary to pulmonary artery hypertension (PAH) was seen. Diagnosis of these two cases was made via emergent coronary angiogram and intravascular ultrasound (IVUS) and treated by placing a drug eluting stent (DES) in LMCA compression and by adjusting the chest tube and placing a DES in the venous bypass graft with the restoration of flow. We also review the available literature regarding the incidence, diagnosis, and management of this rare entity. Conclusions: Overall, extrinsic compression of the coronaries is rare, therefore clinicians need to be aware of this infrequent process, to allow for appropriate diagnosis, management, and to prevent excess morbidity and mortality from this rare complication.

Venous Stent Migration of the Right Ventricle.

Peripheral migration of a venous stent to the heart is a rare but known complication, with the heart being the most common site of landing. Echocardiographic modalities are essential in clinical diagnosis and management, particularly with limited data and consensus regarding the best management approach. (Level of Difficulty: Intermediate.).

Isolated accessory tricuspid valve leaflet in asymptomatic adult.

Accessory tricuspid valve (ATV) is a rare congenital anomaly that is often seen in complex congenital anomalies in children with very few reported cases in adults. We report a case of isolated ATV in an asymptomatic adult with no other congenital defects along with illustrative transesophageal echocardiographic 2D, 3D, high-resolution photo-realistic images.

Influence of Polypropylene and Steel Fibers on the Performance and Crack Repair of Self-Compacting Concrete.

The research reported in this paper aims to evaluate the epoxy injection technique used to strengthen fiber-reinforced self-compacting concrete (FRSCC) with high strength. This method is carried out on ruptured concrete specimens to assess the efficiency of the epoxy resin adhesive injection retrofitting technique for strength and stiffness. Five FRSCC mixes were designed and placed using different types (steel and polypropylene) and contents (0%, 0.25%, and 0.45% by volume) of fibers. The fresh and mechanical properties in addition to the microstructure of produced mixes were evaluated to assess the impact of fibers on the behavior of FRSCC. Results showed that the workability of FRSCC is reduced by increasing steel or polypropylene fiber content; however, the rheological characteristics of placed mixes satisfied the European Guidelines for Self-Compacting Concrete recommendation for fresh concrete. Also, splitting tensile, flexural, and shear strengths were enhanced by increasing fiber content. The simultaneous application of epoxy injection in FRSCC for repairing damaged concrete beams was shown to be highly effective.

The Impact of Cardiology Consultation on Medical Intensive Care Unit Patients with Elevated Troponin Levels.

BACKGROUND: Cardiac troponin (cTn) is mainly used to diagnose acute coronary syndrome (ACS). However, cTn can also be elevated in critically ill patients secondary to demand ischemia or myocardial injury. The impact of cardiology consultation on the clinical outcomes of patients admitted to medical intensive care unit (ICU) with elevated cTn is unclear. METHODS: A retrospective analysis of medical ICU patients with elevated cTn without evidence of ACS between January 2013 through December 2018. Patients were stratified based on documentation of cardiology consultation. The primary outcome was 1-year mortality. Secondary outcomes were in-hospital and 30-day mortality, the length of stay (LOS), further cardiac testing, 30-day readmission rate, new prescription of cardiac medications, and the predictors of a cardiology consultation. RESULTS: Of 846 patients screened, 766 patients were included, of whom 63.2% had cardiology consultation. Cardiology consultation group had longer median LOS (7 vs. 5 days, P = 0.007), additional cardiac testing (90.3% vs. 67.7%, P < 0.001), and more new cardiac medications (52.1% vs. 16.3%, P < 0.001). No difference was noted in-hospital mortality (adjusted odds ratio [aOR], 0.6, 95% CI, 0.4-1.1, P = .117), 30-day mortality (aOR = 0.8, 95% CI, 0.5-1.4, P = .425), 1- year mortality (aOR, 1.4, 95% CI, 0.9-2.2, P = .193), or cardiac-specific 30-day readmission rate (aOR, 7.0, 95% CI, 0.7-14.9, P = .137). History of coronary artery disease (CAD) was the most independent predictor for a cardiology consult (aOR, 2.2, 95% CI, 1.3-3.8, P < .001). CONCLUSION: Cardiology consultation for elevated cTn in medical ICU patients was associated with increased cardiac testing and LOS, without significant impact on mortality.

Acute ischemic stroke as initial manifestation of undiagnosed iron deficiency anemia: case-report and literature review.

Cerebrovascular disease is the second leading cause of death in the United States in adults aged 65 years and older and is most commonly caused by atherosclerosis. More so, cryptogenic strokes account for one-third of all ischemic strokes. At the same time, iron deficiency anemia is prevalent worldwide and mostly affects females of childbearing age. Here we report a case of a 42-year-old female who presented with symptoms of acute ischemic stroke and was found to have severe iron deficiency anemia. After prompt investigation of other secondary causes, it was determined that her stroke was likely secondary to her iron deficiency anemia. Upon review of the literature, a few case reports showed an association between iron deficiency anemia and strokes in the adult population, but little evidence exists supporting a direct relationship between the two entities. In this case, we aim to evaluate the complex relationship between iron deficiency anemia and stroke and to define a new potential cause of ischemic stroke, which would have been considered earlier as cryptogenic. However, further studies in the future are warranted to validate our observation.

Reversible bradycardia secondary to myxedema coma: case-report.

Myxedema coma occurs mostly in patients with long-standing untreated or undertreated hypothyroidism. Bradycardia is a well-known cardiac manifestation for myxedema coma; however, not all bradycardia with hypothyroidism are sinus bradycardia. Sick sinus syndrome is a group of arrhythmias caused by the malfunction of the natural pacemaker of the heart. Tachy-Brady syndrome is considered to be a type of sick sinus syndrome, where the heart alternates between tachycardia and bradycardia, and it is usually treated with pacemaker implantation along with rate slowing medical therapy. Here we report a case of an 83-year-old female who presented with myxedema coma and atrial fibrillation with tachycardia and intermittent slow ventricular response. We attempt to review the relationship between these two diseases and conclude that appropriate diagnosis of myxedema coma, may be beneficial in reducing the need for pacemaker implantation.

Review of Cases of E-Cigarette or Vaping Product Use-Associated Lung Injury (EVALI) and Brief Review of the Literature.

Since the appearance of the E-Cigarette in the early 2000s, its industry, popularity, and prevalence have risen dramatically. In the past, E-Cigarette use with the vaping of nicotine or cannabis products had been associated with a few reported cases of lung injury. However, in 2019, thousands of cases of E-Cigarette or vaping product use-associated lung injury (EVALI) were reported in the United States. Evidence linked this outbreak with vaping of tetrahydrocannabinol (THC). We report two confirmed cases of EVALI and their associated clinical, radiologic, and pathologic features. This report supports the growing body of information regarding EVALI. It also discusses various substances, particularly vitamin E acetate, which has been suggested as a causative agent.

The Association of Hypophosphatemia With Resistant Lactic Acidosis in Critical Care Illness.

Critically ill patients are known to have a variety of electrolyte abnormalities. Lactic acidosis can frequently be seen secondary to shock states and is usually treated with aggressive volume resuscitation. Interestingly, hypophosphatemia is a potential cause of resistant lactic acidosis, which may not be as commonly identified or considered. We present a case of a 42-year-old man admitted twice over a span of 6 months with an elevated lactate level that did not resolve with volume resuscitation. It was ultimately determined that his lactic acidosis was due to hypophosphatemia after ruling out other potential causes. Phosphate replacement therapy resulted in the normalization of his lactate. In the literature, multiple theories have indicated the association of hypophosphatemia with lactic acidosis though no prior cases exist supporting a direct relationship. In this case, we set forth to evaluate the complicated relationship between all of these factors and to highlight the importance of early detection and treatment of hypophosphatemia, which may be beneficial in treating lactic acidosis.

Successful Fibrinolytic Therapy in a Challenging Obstructive Prosthetic Mitral Valve Thrombosis.

Prosthetic valve thrombosis is a rare and severe complication of the mechanical prosthetic valve. Management can be challenging due to varying clinical presentation, overlapping features of differential diagnosis, and lack of randomized controlled trials on the therapeutic options. In this article, we report the case of a patient with a mechanical prosthetic mitral valve presented with symptoms of heart failure, and an echocardiography showing increased mean pressure gradient across the prosthesis along with a fixed posterior leaflet and a partially restricted anterior leaflet with no visible mass. That raised the concern for an obstructed prosthesis. After multimodality imaging and multidisciplinary team discussions, prosthetic valve thrombosis diagnosis was favored over other different diagnoses that included but not limited to pannus ingrowth. Fibrinolytic therapy was administrated, and the patient was discharged on optimal anticoagulation. Repeated echocardiography a month later showed normal mean gradient and normal functioning prosthetic mitral valve without the need for repeat mitral valve surgery.

Rapidly Growing Squamous Cell Carcinoma of the Tongue.

The tongue can be a guide for different normal findings/variants, pathological lesions, or signs for systemic diseases. And oral cancer can be among the differentials, which can be detected early by a thorough oral exam. The early detection of oral cancer is particularly important, as the stage of oral cancer at the time of the diagnosis is the most critical factor determining the five-year survival. We present a case of a high-risk patient for oral cancers presented with a rapidly growing tongue lesion over six months that was diagnosed as a squamous cell carcinoma of the tongue on the biopsy. The case highlights an alarming rapid growth nature of oral cancers and alerts the clinicians of the importance of the physical exam as a cost-effective and potentially life-saving measure against oral cancers. It also demonstrates a brief review of risk factors and high-risk features of oral cancers.

Transient Asymptomatic Sinus Bradycardia and Sinus Pauses with Bevacizumab: Case Report and Literature Review.

Systemic side effects of anti-cancer therapy remain a major limiting factor for patients, even with targeted therapy. Bevacizumab is an example of targeted cancer therapy which targets the vascular endothelial growth factor receptor (VEGFR) that has been approved for the treatment of various cancers and has been evaluated in metastatic urothelial carcinoma (MUC). We report a case of MUC on bevacizumab containing regimen who developed temporary asymptomatic sinus bradycardia with sinus pauses. That adverse event was thought to be related to the bevacizumab in her cancer regimen. Her Holter monitoring recording for a total duration of 28 days and 14 h after discharge did not show recurrence of sinus pauses. This case indicates the necessity for observation for the cardiac conduction defects as side effects in patients receiving bevacizumab, especially since they might be asymptomatic and transient.