Advances in the diagnosis of myocarditis in idiopathic inflammatory myopathies: an overview of diagnostic tests.

Cardiac involvement in idiopathic inflammatory myopathies (IIM) purports to worse clinical outcomes, and therefore early identification is important. Research has focused on blood biomarkers and basic investigations such as ECG and echocardiography, which have the advantage of wide availability and low cost but are limited in their sensitivity and specificity. Imaging the myocardium to directly look for inflammation and scarring has therefore been explored, with a number of new methods for doing this gaining wider research interest and clinical availability. Cardiovascular magnetic resonance (CMR) with contemporary multiparametric mapping techniques and late gadolinium enhancement imaging, is an extremely valuable and increasingly used non-invasive imaging modality for the diagnosis of myocarditis. The recently updated CMR-based Lake Louise Criteria for the diagnosis of myocarditis incorporate the newer T1 and T2 mapping techniques, which have greatly improved the diagnostic accuracy for IIM myocarditis.18F-FDG-PET/CT is a well-utilized imaging modality in the diagnosis of malignancies in IIM, and it also has a role for the diagnosis of myocarditis in multiple systemic inflammatory diseases. Endomyocardial biopsy, however, remains the gold standard technique for the diagnosis of myocarditis and is necessary for the diagnosis of specific cases of myocarditis. This article provides an overview of the important tests and imaging modalities that clinicians should consider when faced with an IIM patient with potential myocarditis.

Atypical Presentation of a Giant Hemorrhagic Ovarian Cyst.

Hemorrhagic ovarian cysts (HOCs) are frequently seen in reproductive age women, developing in the luteal phase of ovulatory cycles. Giant HOCs are rare, as bleeding inside a closed space causes acute pain leading to early diagnosis. Anovulation or oligoovulation is a defining feature of polycystic ovarian syndrome (PCOS), and hence, functional cysts are uncommon in PCOS patients. This report describes a young girl with PCOS and amenorrhea, presenting with a giant hemorrhagic ovarian cyst. Most hemorrhagic cysts undergo spontaneous resolution with follow-up. Our patient presented as a surgical emergency following torsion and rupture with hemoperitoneum. Torsion causes an obstruction in the blood flow leading to infarction and loss of ovarian viability. Early diagnosis and detorsion may help to preserve ovarian function.

Microwave assisted synthesis of guar gum based biopolymeric macromolecule optimized as a flocculant for mineral ore processing.

The research endeavour to synthesize a novel, non-toxic, eco-friendly guar gum based biopolymeric macromolecule, [2-(methacryloyloxy) ethyl] trimethyl ammonium chloride grafted guar gum (GG-g-P (MAETMAC)) that has been optimized as a flocculant for mineral ore processing. The synthesis was performed using non-radiation and microwave assisted technique to compare and ensure the superiority of the latter. The intended grafting of monomer[2-(methacryloyloxy) ethyl] trimethyl ammonium chloride on to the biological macromolecule (guar gum) was confirmed through standard physico-chemical characterization techniques namely X-ray diffraction (XRD), scanning electron microscopy (SEM), thermal gravimetric analysis (TGA), Fourier transform infrared (FTIR) spectroscopy, ultraviolet-visible (UV-visible) spectroscopy, intrinsic viscosity study, etc. The flocculation efficacy of the synthesized novel graft copolymer was thoroughly investigated in kaolin, coal fine, and iron ore suspensions. We have explored a graft copolymer, [2-(methacryloyloxy) ethyl] trimethyl ammonium chloride grafted guar gum that has not been studied yet to the best of our knowledge. To establish the superiority of the synthesized biomaterial, the flocculation study revealed that the best grade of the synthesized novel graft copolymer showed flocculation efficacy of 90 % in kaolin, 69 % in Iron ore, and 29 % in coal fine suspensions which was significantly higher than using alum as a coagulant which provided 36 % efficacy in kaolin, 29 % in iron ore and 10 % in coal fine suspensions.

Anterior STEMI complicating acute aortic syndrome: mechanistic insight and bridge to surgery with intravascular ultrasound-guided primary PCI.

Stanford type A acute aortic syndromes (AAS) can be complicated with acute coronary closure and ST segment elevation myocardial infarction (STEMI) leading to significant additional morbidity and mortality. The recommended treatment for type A AAS is emergency cardiac surgery. We present the case of a patient with intramural haematoma involving the ascending and descending aorta complicated with anterior wall STEMI after CT imaging. Coronary angiography and intravascular ultrasonography (IVUS) revealed the dissection spiralling into the media of the left main stem (LMS) and left anterior descending (LAD) coronary artery. In the setting of acute vessel closure and ongoing myocardial ischaemia primary percutaneous coronary intervention (PCI) was performed to the LMS, LAD and second diagonal branch prior to successful emergency cardiac surgery with an aortic-arch interposition graft. Emergency IVUS-guided stenting to relieve acute coronary occlusion in the context of aortic dissection can be performed in selected cases to safely bridge the patient for cardiac surgery.

Images of the month 1: Histoacryl glue embolisation to the right ventricle following treatment for gastric varices.

A 46-year-old woman presented with decompensated liver disease. Upper gastrointestinal endoscopy demonstrated a gastric fundal varix with stigmata of recent bleeding. She was treated with Histoacryl glue and lipiodol injection. As a part of a clinical trial, a transthoracic echocardiography was performed. This showed an echogenic mass in the right ventricle. The mass was initially assumed to be thrombus, but as the clinical story did not fit with this, she had further investigations. Computed tomography found the mass to be very radio-opaque with embolisation into the right lung. This is a rare appearance of glue embolisation, a recognised complication of treatment with Histoacryl glue.

Laminopathies: should Wenckebach be a cause for concern? A case report.

BACKGROUND: LMNA cardiomyopathy is a cause of dilated cardiomyopathy (DCM) characterized by aggressive heart failure, high risk of arrhythmias, and sudden cardiac death. We present a case of a male presenting with an LMNA mutation with an aggressive DCM leading to sudden cardiac death (SCD). CASE SUMMARY: A 42-year-old male presented with the feeling of lethargy and intermittent dizziness. Electrocardiogram demonstrated atrioventricular block in keeping with Mobitz type 1, at a rate of 40 b.p.m. and cardiac monitoring showed non-sustained ventricular tachycardia. Cardiac magnetic resonance imaging showed preserved left ventricular (LV) ejection function (59%) but features suggesting DCM. These included mild LV dilatation with an end diastolic volume (EDV) of 213 mL and late enhancement showing a single mid myocardial focus of high signal over the distal right ventricular insertion point inferiorly and a linear area of high signal over the basal septum. After discussion at the cardiology multi-disciplinary meeting, a pacemaker was implanted so that beta-blockers could be initiated to suppress the ventricular arrhythmias. A laminopathy was suspected and if this was confirmed from genetic testing the plan was to upgrade to an implantable defibrillator. Due to stability, this was decided to be done in an outpatient setting. He unfortunately had an out-of-hospital VF arrest and died. Post-mortem showed subtle cardiomyopathy in keeping with a DCM. Genetic tests results were returned a few months later which confirmed a pathogenic variant in LMNA. DISCUSSION: Because of the complexity of LMNA-related cardiac disease, they should be managed and followed up in centres with special expertise in inherited cardiomyopathy.

Splenic rupture as the presenting symptom in infective endocarditis: a rare and dangerous complication.

Infective endocarditis remains a dangerous condition and carries a mortality risk of approximately 20%. Splenic rupture is a rare complication of endocarditis. A 60-year-old woman with a history of atrial fibrillation, mitral valve repair and severe mitral regurgitation was admitted with a fall and abdominal pain. Emergency laparotomy was performed leading to a diagnosis of splenic rupture, for which splenectomy was performed. Four months later, the patient represented with symptoms of a transient ischaemic attack. Transthoracic and transoesophageal echocardiogram confirmed a large vegetation on the anterior mitral valve leaflet. Treatment with antibiotics and re-do mitral valve surgery was performed. The cause of the initial splenic rupture was felt to have been secondary to undiagnosed infective endocarditis. It is imperative to consider endocarditis in a case of spontaneous splenic rupture particularly in high-risk patients such as those with previous valve surgery.

Young stroke due to pulmonary arteriovenous malformation.

Young patients presenting with cryptogenic stroke should be investigated for cardiac and extra-cardiac sources of emboli. We present a patient who was investigated for a cardiac source of emboli, following multiple ischaemic strokes and migraine with aura over a period of 17 years. The events were initially thought to be related to a patent foramen ovale (PFO) on bubble contrast echocardiography, however, due to an unusual flow pattern to the left heart, she underwent a CT angiogram to exclude intrapulmonary shunting. This confirmed the presence of a moderate sized congenital pulmonary arteriovenous fistula in the left lung. Transcatheter occlusion of the vascular malformation has resolution of her symptoms. Bubble contrast echocardiography is routinely used to diagnose a PFO in these cases, but extreme caution is required during the procedure to differentiate the pattern of flow seen in patients with a pulmonary arteriovenous malformation.

A case of the crossed coronaries.

Coronary artery anomalies are rare; however, can be a potential cause of significant morbidity and even mortality. Crossed left anterior descending and left circumflex arteries is a rare finding, and therefore the significance of this finding is not well understood. CT coronary angiography is an excellent non-invasive modality which enables the diagnosis of such abnormalities, and it is likely that with the increased use of CT coronary angiography in cardiology, other similar cases will be diagnosed.

Cardiac arrest in a patient with trichorhinophalangeal syndrome and dilated cardiomyopathy.

A 44-year-old woman with known trichorhinophalangeal syndrome presented with an unheralded out of hospital cardiac arrest. Transthoracic echocardiography showed severe left ventricular systolic dysfunction with an ejection fraction <25% and cardiac MRI confirmed a diagnosis of congenital non-ischaemic dilated cardiomyopathy. The case highlights a very rare syndrome, it is previously unknown association with dilated cardiomyopathy and the possible benefit of cardiac screening for patients with known trichorhinophalangeal syndrome.

Hyper-dominance of the left anterior descending artery-a large territory.

Coronary artery anomalies are rare and a potential cause of significant morbidity and mortality. A hyper-dominant left anterior descending artery is extremely rare with only 17 cases reported in the literature. Occlusion of a hyper-dominant left anterior descending artery can cause a massive myocardial infarction affecting a large myocardial territory and therefore clinicians should be aware of its importance.