Coronary-Bronchial Fistula: Coil the Steal.

Coronary artery fistula is a rare coronary anomaly with communication between the coronary artery and either the cardiac chamber or other vessels. We present a case of coronary-to-bronchial artery fistula that resulted in likely coronary artery steal and was treated with coil embolization. (Level of Difficulty: Beginner.).

Descending Aortic Thrombus Hanging by a Thread: Three-Dimensional Echocardiogram.

Aortic thrombus is a rarely identified source of distal embolization. A conservative approach with anticoagulation alone carries a significant risk of embolization. Various open surgical approaches have been suggested as therapeutic options, but all of them carry a significant morbidity and mortality risk in this population subgroup. Contemporary endovascular approaches aimed at exclusion of the floating thrombus are now increasingly performed, and have significantly lower periprocedural complications compared with an open surgical approach.

Right-Sided Aortic Arch With Symptomatic Aberrant Left Subclavian Artery-Kommerell Diverticulum: An Isolation Procedure.

Right-sided aortic arch is a rare anomaly (incidence 0.05%), commonly associated with an aberrant subclavian artery (35% of cases) with a Kommerell diverticulum at the origin. This aberrant artery passes posterior to the esophagus and can cause compression syndrome. We present such a case, treated with a hybrid endovascular repair. (Level of Difficulty: Advanced.).

Secular Trend in the Use and Implementation of Impella in High-Risk Percutaneous Coronary Intervention and Cardiogenic Shock: A Real-World Experience.

OBJECTIVES: Cardiogenic shock carries high mortality despite advancements in therapeutic interventions. Impella (Abiomed) is a mechanical circulatory support device that is being increasingly used in cardiogenic shock patients. Impella is also utilized in high-risk patients undergoing percutaneous coronary intervention (PCI). We review the trend of Impella use at a single tertiary-care center, retrospectively analyze the outcomes, and discuss the increasing use of this device in the United States. METHODS: This a retrospective, observational study of Impella use for two indications, cardiogenic shock and high-risk PCI, at a tertiary-care center. The primary endpoint was the yearly implant rate of Impella and the secondary endpoint was periprocedural complications and major adverse cardiovascular events at 30 days. RESULTS: Forty-four Impella devices were implanted between 2008 and June of 2017. The rate of Impella implantation has significantly increased since its introduction in our facility in 2008. The most common complication was acute renal dysfunction (23%) followed by vascular complications (20%). Mortality at 30 days was 75% in the cardiogenic shock group and 11% in the high-risk PCI group. CONCLUSION: The use of the Impella device as a mechanical circulatory support has increased since its introduction, although its acceptance rate remains low. Despite its theoretical hemodynamic advantage, the outcome in cardiogenic shock patients remains poor.

Iatrogenic Transient Complete Heart Block in a Preexisting LBBB.

Catheter induced cardiac arrhythmia is a well-known complication encountered during pulmonary artery or cardiac catheterization. Injury to the cardiac conducting system often involves the right bundle branch which in a patient with preexisting left bundle branch block can lead to fatal arrhythmia including asystole. Such a complication during central venous cannulation is rare as it usually does not enter the heart. The guide wire or the cannula itself can cause such an injury during central venous cannulation. The length of the guide wire, its rigidity, and lack of set guidelines for its insertion make it theoretically more prone to cause such an injury. We report a case of LBBB that went into transient complete heart block following guide wire insertion during a central venous cannulation procedure.

A Benign Cardiac Growth but Not So Indolent.

Cardiac lipomatous hypertrophy is a rare benign condition that usually involves the interatrial septum. Due to its benign nature it rarely requires intervention. Its presence outside the interatrial septum is reported infrequently. We present a case of lipomatous hypertrophy in the intraventricular septum that was complicated by a severe, symptomatic, and disabling dynamic left ventricular outflow tract obstruction. The symptoms significantly improved following the excision of the mass. In our case transthoracic echocardiogram was used to visualize the mass and measure the severity of the obstruction; Cardiac Magnetic Resonance Imaging was used to characterize the mass and histopathology confirmed the diagnosis.

Spontaneous intercostal lung herniation complicated by rib fractures: a therapeutic dilemma.

Lung herniation has been defined as a protrusion of lung tissue through its bounding structure. We present a case of spontaneous intercostal lung herniation following bouts of cough, which was complicated by multiple rib fractures, in which we had to adopt a non-surgical approach due to the clinical circumstance. Its understanding in the field of internal medicine is important as appropriate therapeutic judgment, and long-term follow-up is essential for full recovery.