Transhepatic approach of patent foramen ovale closure in the setting of congenital inferior vena cava anomaly.

Patent foramen ovale (PFO) is the most common interatrial septal abnormality. The indications for PFO device closure are still being evaluated, with the most common reason being to prevent cerebrovascular accidents (CVA) caused by paradoxical embolism of deep vein thrombosis (DVT) in the lower extremities. This procedure is usually performed through percutaneous intervention using femoral vein access. Here, we present a case of PFO closure using a transhepatic approach, as femoral vein access was not feasible due to an interrupted inferior vena cava (IVC). The patient had a prominent left-sided IVC, larger than the right-sided IVC, and the left-sided IVC served as the main draining conduit via the hemiazygous system, which then connected to the azygous vein and emptied into the right atrium (RA). Cardiac MRI confirmed these findings, including the continuation of the suprahepatic IVC to the right atrium. With the assistance of interventional radiologist, transhepatic access was achieved, and the PFO was successfully closed. Hemostasis was achieved using coil embolization, and there were no post-procedural complications.

Novel predictors of permanent pacemaker implantation following transcatheter aortic valve replacement.

BACKGROUND: Conduction and rhythm abnormalities requiring permanent pacemakers (PPM) are short-term complications following transcatheter aortic valve replacement (TAVR), and their clinical outcomes remain conflicting. Potential novel predictors of post-TAVR PPM, like QRS duration, QTc prolongation, and supraventricular arrhythmias, have been poorly studied. AIM: To evaluate the effects of baseline nonspecific interventricular conduction delay and supraventricular arrhythmia on post-TAVR PPM requirement and determine the impact of PPM implantation on clinical outcomes. METHODS: A retrospective cohort study that identified patients with TAVR between January 1, 2012 to December 31, 2019. The group was dichotomized into those with post-TAVR PPM and those without PPM. Both groups were followed for one year. RESULTS: Out of the 357 patients that met inclusion criteria, the mean age was 80 years, 188 (52.7%) were male, and 57 (16%) had a PPM implantation. Baseline demographics, valve type, and cardiovascular risk factors were similar except for type II diabetes mellitus (DM), which was more prevalent in the PPM cohort (59.6% vs 40.7%; P = 0.009). The PPM cohort had a significantly higher rate of pre-procedure right bundle branch block, prolonged QRS > 120 ms, prolonged QTc > 470 ms, and supraventricular arrhythmias. There was a consistently significant increase in the odds ratio (OR) of PPM implantation for every 20 ms increase in the QRS duration above 100 ms: QRS 101-120 [OR: 2.44; confidence intervals (CI): 1.14-5.25; P = 0.022], QRS 121-140 (OR: 3.25; CI: 1.32-7.98; P = 0.010), QRS 141-160 (OR: 6.98; CI: 3.10-15.61; P < 0.001). After model adjustment for baseline risk factors, the OR remained significant for type II DM (aOR: 2.16; CI: 1.18-3.94; P = 0.012), QRS > 120 (aOR: 2.18; CI: 1.02-4.66; P = 0.045) and marginally significant for supraventricular arrhythmias (aOR: 1.82; CI: 0.97-3.42; P = 0.062). The PPM cohort had a higher adjusted OR of heart failure (HF) hospitalization (aOR: 2.2; CI: 1.1-4.3; P = 0.022) and nonfatal myocardial infarction (MI) (aOR: 3.9; CI: 1.1-14; P = 0.031) without any difference in mortality (aOR: 1.1; CI: 0.5-2.7; P = 0.796) at one year. CONCLUSION: Pre-TAVR type II DM and QRS duration > 120, regardless of the presence of bundle branch blocks, are predictors of post-TAVR PPM. At 1-year post-TAVR, patients with PPM have higher odds of HF hospitalization and MI.

Acute Hypoxia From Different Clinical Entities Can Potentially Break the Heart: Takotsubo Cardiomyopathy.

Takotsubo syndrome is characterized by transient regional left ventricular wall motion abnormalities and elevated troponin levels like those seen in classic myocardial infarction but without evidence of obstructive coronary artery disease. We present two uncommon cases of Takotsubo syndrome. In Case 1, a 64-year-old man presented with chronic obstructive pulmonary disease exacerbation who later developed chest pain and acute hypoxic respiratory failure. In Case 2, a 77-year-old woman with myasthenia gravis was admitted for acute hypoxic hypercapnic respiratory failure requiring mechanical ventilation following a myasthenic crisis. In both cases, serum high sensitivity troponin was elevated, electrocardiograph showed findings suggestive of infarction, and coronary angiogram did not show evidence of obstructive coronary artery disease. Echocardiogram in both patients revealed abnormal left ventricular wall motion, likely secondary to Takotsubo syndrome. Takotsubo syndrome is uncommon in the setting of chronic obstructive pulmonary disease exacerbation or myasthenic crisis, and proposed mechanisms for the disease include catecholamine surge, vasospasm of coronary arteries, and microvascular dysfunction. Takotsubo syndrome is reversible; thus, it is important to remove any trigger leading to catecholamine surge. Identification of such triggers and early diagnosis could help optimize pharmacotherapy.

Sternal osteomyelitis caused by Gordonia bronchialis in an immunocompetent patient following coronary artery bypass surgery.

Skin commensals, especially gram-positive cocci, are the usual microbial organisms that cause post-operative sternal wound infections. Rarely, environmental bacteria such as Gordonia spp. have been implicated as etiological agents in post-cardiac procedure surgical site infections. We report a case of a patient who presented with post-coronary artery bypass sternal osteomyelitis caused by this uncommon pathogen, and review relevant medical literature to identify commonalities in presentation, diagnosis and management. Repeat isolation of Gordonia bronchialis in the setting of post-procedure wound infection should raise suspicion for a real pathogenicity. Definitive identification requires a broad range of bacterial PCR DNA amplification and sequencing followed by susceptibility testing as treatment may require a prolonged course of antibiotics.

ST Segment Elevation Myocardial Infarction in the COVID-19 Era: Appraisal of the Evidence.

The COVID-19 pandemic continues to present a public health challenge and has had a significant impact on the presentation, time-dependent management, and clinical outcomes of ST elevation myocardial infarction (STEMI). Patients with COVID-19 and pre-disposing cardiovascular risk factors like hypertension, hyperlipidemia, and diabetes mellitus are at a higher risk of developing STEMI, and global trends have highlighted delayed management of STEMI, which may contribute to worse clinical outcomes. Prolonged time to intervention has also resulted in an increased rate of no reflow, which is an independent risk factor for worse outcomes in these patients. Timely primary percutaneous coronary intervention (PCI) remains standard of care for STEMI and can be attained within the recommended 90 minutes timeline from hospital presentation. A coordinated, safe, standardized, algorithmic approach among emergency medical services, emergency departments, and cardiac catheterization laboratory is needed to ensure optimal patient outcome during and after the COVID-19 pandemic. The focus of this case report is to highlight the challenges of PCI for ST elevation myocardial infarction in the COVID-19 era.

Encephalopathy of Unclear Etiology: A Diagnostic Dilemma.

INTRODUCTION: Drug reaction with eosinophilia and systemic symptoms (DRESS) is a potentially fatal condition caused by drug exposure resulting in hypersensitivity reaction with involvement of different organ systems. CASE PRESENTATION: We present a case of a 65-year-old man with a recent history of right total knee arthroplasty complicated by wound infection on a regimen of vancomycin who was transferred to our hospital for further management of fever, rigors, altered mental status, acute hypoxic respiratory failure, acute kidney injury, and development of an erythematous rash. DISCUSSION: DRESS syndrome was considered definite in this patient according to the European Registry of Severe Cutaneous Adverse Reaction Criteria, also known as RegiSCAR. To our knowledge, metabolic encephalopathy associated with multiorgan dysfunction resulting from vancomycin-induced DRESS syndrome has not been reported. CONCLUSION: A thorough analysis of recent medication history is essential for the prompt identification and management of this condition.

Acute Levetiracetam-Induced Thrombocytopenia in an Anticoagulated Immunocompetent Patient.

Levetiracetam (LEV) is a commonly prescribed anti-seizure medication for the prophylaxis and treatment of focal and generalized seizures. However, a few significant LEV-associated adverse effects have been reported in the literature. Here, we describe a case of significant thrombocytopenia within 24 hours of IV LEV administration for generalized seizures in an anticoagulated immunocompetent patient that completely resolved following discontinuation of the medication. Increased awareness of this uncommon thrombocytopenic side effect of LEV especially in the setting of anticoagulation is important for clinicians providing care to patients with a history of seizures due to the heightened risk of clinically significant bleeding.

Hemorrhagic Pleural Effusion: A Rare Presentation of Vitamin K Deficiency in an Adult Patient.

Nutritionally acquired vitamin K deficiency is a rare condition in adults and can uncommonly present as hemorrhagic pleural effusion. We discuss the case of A 44-year-old apparently healthy man who presented with left-sided pleuritic chest pain two months after experiencing upper respiratory tract symptoms. Imaging revealed a loculated left-sided effusion, and a corresponding thoracentesis yielded exudative hemorrhagic fluid with no microbial growth. Laboratory work-up showed prolonged clotting time with low factors II, VII, and X activity, absence of clotting factor inhibitors, and very low serum vitamin K levels. A five-day course of oral vitamin K and nutritional optimization normalized the clotting profile. Acquired vitamin K deficiency from poor micronutrient intake is rare in adults and can result in hemorrhagic pleural effusion. Vitamin K supplementation can normalize the clotting profile while nutritional counseling helps prevent a recurrence. Malnutrition-induced vitamin K deficiency can occur in the setting of a major depressive disorder in adults. Thorough patient history and physical examination are necessary to promptly identify and reverse the coagulopathy.