Cutaneous T-cell Lymphoma Predisposing to Recurrent Infective Endocarditis by Methicillin-resistant Staphylococcus Aureus (MRSA) in a Patient with Intracardiac Defibrillator (ICD).

Cutaneous T-cell lymphoma (CTCL) is a rare group of extra-nodal non-Hodgkin's lymphomas resulting in infiltration of the skin by the malignant cells. Sézary syndrome (SS) and mycosis fungoides (MF) are the most common subtypes, and infectious complications are the major cause of death in such patients. The presence of implantable cardiac devices (ICD) and CTCL make the patient more vulnerable to the device-related infective endocarditis (IE) caused by methicillin-resistant staphylococcus aureus (MRSA). The need for reimplantation of ICD should be assessed in detail and non-cardiac conditions should be considered while making such decisions. Herein, we report a unique case of non-ischemic cardiomyopathy with an implantable cardiac defibrillator (ICD), who later developed CTCL, complicated by the recurrent right-sided IE which is caused by MRSA. Key Words: Cutaneous T-cell lymphoma, Methicillin-resistant staphylococcus aureus (MRSA), Infective endocarditis.

Covid-19 Infection During Pregnancy With Acute Heart Failure, Venous Thrombosis And Pneumonia.

The COVID-19 infection has spread rampantly, attaining pandemic status within three months of its first appearance. It has been classically associated with respiratory signs and symptoms. However, unusual presentations have also been reported in multiple literatures. We are reporting a case of acute heart failure in a pregnant patient diagnosed with Covid-19 infection. Her hospital course has been complicated by pneumonia and venous thrombosis during the postpartum period. Her laboratory investigations showed evidence of myocardial injury, acute heart failure, and COVID-19 infection in second PCR sample taken during postpartum period. Echocardiography exhibited features of severe left ventricle systolic dysfunction. She had successful delivery through caesarean-section, nevertheless, her postpartum period was complicated by pneumonia and right femoral venous thrombosis. CT scan of the chest and pulmonary arteries revealed infiltrations in the left lower lobe and right middle lobe, suggestive of consolidation, with no evidence of pulmonary embolism. Cardiac MRI displayed severe global LV and RV systolic dysfunction, but no evidence of myocardial infarction, myocardial infiltration, or abnormal myocardial delayed enhancement. Her condition improved and she was discharged on heart failure medications. During follow-up at the heart failure clinic, her symptoms continued to ameliorate, except the LV and RV systolic dysfunction which persisted. Multiple unusual presentations of Covid-19 infection have been reported in various literatures and screening of the COVID-19 infection should be practiced on regular basis especially among high-risk patients. Prompt identification of COVID-19 infection will lead to proper isolation and mitigation of infection spread among hospitalized patients and health care workers. Covid-19 PCR should be repeated in cases having clinical indication and negative first sample. A proper history and cardiac MRI can differentiate between different aetiologies of heart failure during pregnancy and peripartum COVID-19 infection. Adequate anticoagulation should be considered in COVID-19 patients due to the high risk of thromboembolism. Among patients with COVID-19 infection, CT chest helps demonstrate the extent of pulmonary involvement.

Durable Left Ventricular Assist Device with Mechanical Mitral and Aortic Valves.

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Sensitivity and Specificity of Pulmonary Artery Pressure Measurement in Echocardiography and Correlation with Right Heart Catheterization.

OBJECTIVE: Echocardiography is helpful in assessment of pulmonary hemodynamic, however its correlation with Right heart catheterization (RHC) is conflicting. We conducted a study to evaluate sensitivity and specificity of pulmonary hemodynamic parameters measured in echocardiography. Furthermore its correlation with the values measured in RHC was assessed. METHOD: Retrospective, cross-sectional study conducted at King Fahad medical City, Riyadh, Saudi Arabia. 95 adult patients referred for right heart catheterization were enrolled in the study. All the patients had echocardiography and RHC within one week of each other. RESULT: Diabetes mellitus, hypertension and dyslipidemia were present among 55%, 66% and 41% of patients respectively. 85% of the study participants were diagnosed to have pulmonary hypertension and 79% of the study participants had postcapillary pulmonary hypertension. Sensitivity of pulmonary artery systolic pressure (PAPs), mean pulmonary artery pressure (PAPm) using PAPs and pulmonary artery acceleration velocity (PAcT) were 86%, 93% and 89% respectively. Correlation of PAPs, PAPm using PAPs and PAcT on echo with invasive hemodynamic in RHC were 0.56, 0.43 and 0.24 respectively. Among patients with moderate to severe Tricuspid Regurgitation (TR) and tricuspid annular plane systolic excursion (TAPSE) <1.5cm correlation of PAPs, PAPm using PAPs and PAcT on echocardiography with right heart catheterization were 0.31, 0.24 and 0.42 respectively. CONCLUSION: Echocardiographic assessment of PAPs and PAPm has high sensitivity and weak to moderate correlation with hemodynamic data in RHC. PAPs measurement on echocardiogram has best correlation with invasive measurement followed by PAPm measurement using PAPs. Among patients with moderate to severe TR and TAPSE <1.5cm PAPm measurement using PAcT has better correlation than using PAPs.

Spontaneous Coronary Artery Dissection in Relation to Physical and Emotional Stress: A Retrospective Study in 4 Arab Gulf Countries.

Spontaneous coronary artery dissection (SCAD) has emerged as an important cause of acute coronary syndrome and sudden cardiac death. The triggers for SCAD often do not include traditional atherosclerotic risk factors. The most commonly reported triggers are extreme physical or emotional stress. The current study compared in-hospital and follow-up events in patients with SCAD with and without reported stress. Data from 83 patients with a confirmed diagnosis of SCAD were collected retrospectively from 30 centers in 4 Arab Gulf countries (KSA, UAE, Kuwait, and Bahrain) from January 2011 to December 2017. In-hospital myocardial infarction (MI), percutaneous coronary intervention (PCI), ventricular tachycardia/ventricular fibrillation, cardiogenic shock, death, ICD placement, dissection extension) and follow-up (MI, de novo SCAD, death, spontaneous superior mesenteric artery dissection) events were compared between those with and without reported stress. Emotional and physical stress was defined as new or unusually intense stress, within 1 week of their initial hospitalization. The median age of patients in the study was 44 (37-55) years. Foty-two (51%) were women. Stress (emotional, physical, and combined) was reported in 49 (59%) of all patients. Sixty-two percent of women with SCAD reported stress, and 51 % of men with SCAD reported stress. Men more commonly reported physical and combined stress. Women more commonly reported emotional stress (P < 0.001). The presence or absence of reported stress did not impact on overall adverse cardiovascular events (P = 0.8). In-hospital and follow-up events were comparable in patients with SCAD in the presence or absence of reported stress as a trigger.

STEMI and COVID-19 Pandemic in Saudi Arabia.

The COVID-19 pandemic had significant impact on health care worldwide which has led to a reduction in all elective admissions and management of patients through virtual care. The purpose of this study is to assess changes in STEMI volumes, door to reperfusion, and the time from the onset of symptoms until reperfusion therapy, and in-hospital events between the pre-COVID-19 (PC) and after COVID-19 (AC) period. All acute ST-segment elevation myocardial infarction (STEMI) cases were retrospectively identified from 16 centers in the Kingdom of Saudi Arabia during the COVID-19 period from January 01 to April 30, 2020. These cases were compared to a pre-COVID period from January 01 to April 30, 2018 and 2019. One thousand seven hundred and eighty-five patients with a mean age 56.3 (SD ± 12.4) years, 88.3% were male. During COVID-19 Pandemic the total STEMI volumes was reduced (28%, n = 500), STEMI volumes for those treated with reperfusion therapy was reduced too (27.6%, n= 450). Door to balloon time < 90 minutes was achieved in (73.1%, no = 307) during 2020. Timing from the onset of symptoms to the balloon of more than 12 hours was higher during 2020 comparing to pre-COVID 19 years (17.2% vs <3%, respectively). There were no differences between the AC and PC period with respect to in-hospital events and the length of hospital stay. There was a reduction in the STEMI volumes during 2020. Our data reflected the standard of care for STEMI patients continued during the COVID-19 pandemic while demonstrating patients delayed presenting to the hospital.

Echocardiographic parameters associated with recovery in heart failure with reduced ejection fraction.

OBJECTIVE: The study aims to determine the clinical and echocardiographic parameters of patients with recovered heart failure (HFrecEF). METHODOLOGY: Sixty-seven patients (cases) were identified as heart failure with recovered ejection fraction (HFrecEF), defined as improvement in EF ≥ 10%. Sixty-nine patients (controls) were randomly selected by convenience sampling with no or <10% improvement in EF (HFrEF non-recovered). RESULTS: The mean interval between baseline and follow-up echocardiography was 10.5 months in cases and 11.2 months in the control group. HFrecEF showed a 22.7% improvement in mean ejection fraction, and HFrEF non-recovered group also showed a minor increment of 5.5%. HFrecEF patients were significantly younger (49.51 vs 57.54 years, P .001) with non-ischemic cardiomyopathy (86.6% vs 52.2%). Patients with HFrecEF had significantly less left ventricular end-diastolic and end-systolic volumes (LVEDV: 162.51 mL vs 208.54 mL, P < .001; LVESV: 119.81 mL vs 157.13 mL, P < .001) and index left atrial volume (37.66 mL vs 47.09 mL, P < .001) than patients with non-recovered EF. The right ventricle (RV) and inferior vena cava were significantly dilated with higher mean tricuspid annular plane systolic excursion (TAPSE) among patients with HFrecEF than HFrEF non-recovered. CONCLUSION: Based on univariate analysis, younger age, non-ischemic etiology, LVEDV, LVESV, deceleration time, better TAPSE, dilated right ventricle, dilated IVC, and smaller left atrial volumes were found significant, but on multivariate logistic regression model only left ventricle end-diastolic volume, left atrial volume, and TAPSE were linked to the recovery of ejection fraction.

Situs ambiguousin an Adult with Congenital Cardiovascular and Musculoskeletal Defect.

Situs ambiguous(SA) is an abnormality in which the thoracic and abdominal organs are not clearly lateralized. Situs ambiguous with polysplenia is usually associated with complex cardiovascular abnormalities and rarely found among adults due to high mortality at younger age. We are reporting a rare cluster of Situs ambiguous with polysplenia (left isomerism) in an adult with congenital hand deformity and cardiovascular pathology, who presented with ascites and decompensated congestive cardiac failure due to dilated cardiomyopathy. He had congenital agenesis of left hand fingers and hypoplastic left thumb. Electrocardiogram and imaging findings were consistent with dextrocardia, Situs inversus and features of left isomerism. Echocardiography showed severe biventricular failure with prominent coronary sinus. Such a combination of musculoskeletal and cardiovascular pathologies was not reported in the literature. His coronary arteries were normal. He had successful single chamber Implantable Cadioverter Defibrillator (ICD) insertion.

Prediction of 10-year risk of hard coronary events among Saudi adults based on prevalence of heart disease risk factors.

AIM: Cardiovascular disease is becoming the lead cause of mortality and morbidity worldwide, and developing countries are the main contributors to this trend. Saudi Arabia, which is considered a rapidly developing country, faces progressive urbanization and the adoption of a westernized lifestyle, factors which contribute to the rising burden of cardiovascular disease. Our study evaluates the prevalence of coronary risk factors and predicts hard coronary artery events over 10 years in an urban Saudi cohort. METHODS: A cross-sectional observational study was conducted on a Saudi population. The study involved Saudi subjects aged more than 20 years without a history of coronary heart disease. Demographic variables and hard coronary events (HCE) risk factors were measured. Each subject's 10-year HCE risk was estimated by means of the Framingham Risk Score (FRS). RESULTS: A total of 4932 subjects (2215 men and 2717 women) were examined, the majority (85%) of whom were less than 40 years old. The risk of developing HCE within the next 10 years was low in 92.6% of subjects, intermediate in 3.2% and high in 4.1%. On considering diabetes as coronary heart disease (CHD) risk-equivalent, 26% of subjects were at high risk for hard coronary events in 10 years. The HCE risk progressively increased with age and was higher in men. CONCLUSIONS: Our study, the first to estimate the 10-year risk of HCE among adults in an emerging country, determined that a significant proportion of a younger aged population is at risk for the development of hard coronary events. Public awareness programs to control risk factors are warranted.

Restoration of normal left ventricular geometry after percutaneous mitral annuloplasty: case report and review of literature.

Surgical mitral valve intervention is not considered suitable in patients with severe functional mitral regurgitation due to severe dilated cardiomyopathy and severe systolic dysfunction. In such patients percutaneous mitral valve intervention is the next best alternative. We are presenting case report of a patient who presented with severe dyspnea progressing to orthopnea and paroxysmal nocturnal dyspnea. He was found to have severe functional mitral regurgitation and severe left ventricle systolic dysfunction. Surgical mitral intervention was not considered suitable and percutaneous mitral annuloplasty was done. At one month follow-up significant improvement in symptoms were noted with improvement in severity of mitral regurgitation severity. At 6 months follow-up further improvement in symptoms were noted along with significant improvement in the severity of mitral regurgitation and normalization of left ventricle geometry. At 1 year follow-up his symptoms further improved, left ventricle geometry remained normal and mitral regurgitation severity remained mild to moderate. Our case demonstrate that in patient with severe LV systolic dysfunction, severe mitral regurgitation and left bundle branch block percutaneous mitral annuloplasty can obviate the need for CRT-D due to significant improvement in LV function and geometry along with regression in severity of mitral regurgitation. Improvement in mitral regurgitation severity and LV geometry started early and kept improving with excellent result at 6 and 12 months.

Transcatheter closure of residual postinfarction ventricular septal defect after dehiscence of surgical patch repair.

Ventricular septal defect (VSD) is a life-threatening complication of transmural myocardial infarction. Urgent surgical repair and concomitant revascularization are the standard of care. Percutaneous catheter-based closure techniques have been reserved for patients with a high-risk surgery or a failed surgical procedure with residual shunting. This case report demonstrates the successful transcatheter closure of residual VSD using the Amplatzer muscular VSD device (Amplatzer, Minnesota, USA) after surgical patch dehiscence for postinfarction VSD and 3-and-a-half years' post-intervention follow-up.

Metastatic adenocarcinoma presenting as choroidal mass and recurrent cardiac tamponade.

Cardiac tamponade is an unusual earliest presentation of undiagnosed metastatic adenocarcinoma of unknown origin. Malignant pericardial effusion requiring drainage is also a poor prognostic marker with reported median survival of 6.1 months. A choroidal mass may be the presenting sign of systemic malignancy; the diagnosis of metastatic ocular tumour is important as it portends poor prognosis. We are reporting an unusual presentation of an undiagnosed metastatic adenocarcinoma presenting in an elderly male primarily with loss of vision due to choroidal mass causing retinal detachment and repeated episodes of dyspnea due to recurrent pericardial effusion causing cardiac tamponade. Fluid analysis from pleura and breast biopsy revealed evidence of metastatic adenocarcinoma. Immunohistochemistry finding were suggestive of possible lung or gastrointestinal tract as a primary source. Imaging studies showed widely spread malignancy involving abdominal viscera, mediastinum, lung, pericardium, choroid and brain. He showed features of pericardial constriction on echocardiography after fluid drainage due to pericardial infiltration. He expired before he could have received palliative chemotherapy.

Stenting for huge coronary artery aneurysm and stenosis in a patient with Behçet's disease presenting with non-ST segment elevation myocardial infarction.

Coronary artery aneurysms in patients with Behçet's disease are rare and associated with fatal complications. Covered stents have been used in the management of coronary aneurysms but not in patients with Behçet's disease. We are reporting a rare case of Behçet's disease, admitted with non-ST segment elevation myocardial infarction, whose coronary angiogram revealed huge aneurysm involving proximal left anterior descending artery followed by severe stenosis. The stenosis was treated by drug-eluting stent and the aneurysm was successfully sealed with a covered stent. He remained asymptomatic at 3-month follow-up and repeat angiogram showed patent stents. .

Percutaneous coronary intervention for acute coronary syndrome in dextrocardia and situs inversus.

A 55-year-old male presented with Non-ST Elevated Myocardial Infarction (NSTEMI). He was a known case of dextrocardia. His standard ECG showed finding consistent with dextrocardia. Coronary angiogram was performed after due manipulation and then successful Percutaneous Coronary Intervention (PCI) of right coronary artery was done.