"Circumnavigation": A Worthy Descriptor to Depict Torrential Mitral Regurgitation and a Reverence to Ferdinand Magellan.

"Circumnavigation" is never used as a verb in cardiology. Hypertrophic obstructive cardiomyopathy is a complex entity that often involves the mitral valve leading to eccentric mitral regurgitation. Utilizing multimodality imaging, assessing the severity of mitral regurgitation, and phenotyping the type of myocardial hypertrophy are achievable with certainty. We describe a case of a 42-year-old male who presented with palpitations and was ultimately diagnosed with hypertrophic obstructive cardiomyopathy with a mitral regurgitation. The torrential mitral regurgitation jet was so severe that it was "circumnavigating" the left atrium. In addition, we also draw historical parallelism with Magellan's heroic "circumnavigation" of the globe as we celebrate 500 years of his journey. Furthermore, we also describe the multimodality assessment of hypertrophic obstructive cardiomyopathy utilizing transthoracic echocardiography and cardiac magnetic resonance imaging. We discuss the challenges in quantifying such severe mitral regurgitation with any individual imaging modality.

Acute Decompensated Heart Failure Due to Combined Ischemic Cardiomyopathy and Cardiac Amyloidosis.

There are no established guidelines for the management of concurrent ischemic cardiomyopathy and cardiac amyloidosis due to the rarity of this phenomenon. We present the case of an African American woman in her 70s who was found to be in acute decompensated heart failure after she presented with progressive dyspnea. Initial workup revealed severe left ventricular systolic dysfunction with an ejection fraction of 20% and severe multivessel coronary artery disease, including severe left main disease. Multimodality imaging with cardiac MRI and technetium-99m pyrophosphate scintigraphy (PYP) during this hospital course revealed concurrent cardiac amyloidosis. Her systolic dysfunction was attributed to a combination of cardiac amyloidosis and ischemic cardiomyopathy. A multidisciplinary team comprised of interventional cardiology, cardiac surgery, and advanced heart failure amyloid specialists worked collaboratively to formulate an optimal treatment plan based on their collective clinical experiences and the limited literature, which ultimately resulted in a positive clinical outcome. Further investigation is needed to define treatment strategies specific to this patient population.

The Infectious Tale of Aerococcal Aortic Endocarditis: Cardiac Pacing in Acute Aortic Insufficiency With Complete Heart Block as a Bridge to Aortic Valve Replacement.

Here, we describe a rare case of Aerococcus endocarditis causing aortic insufficiency and paravalvular abscess presenting as complete heart block and shock. A 76-year-old man with diabetes mellitus presented to the emergency department with fever and dyspnea. His temperature was 102.4°F, heart rate 59 beats per minute, blood pressure 105/44 mmHg, and oxygen saturation was 98% on 6L oxygen. Examination revealed bounding carotid pulses, a 2/6 early blowing diastolic murmur at the left lower sternal border, and diminished lung sounds at the bases. Laboratory data showed leukocytosis of 19.65 k/µL, blood urea nitrogen 72 mg/dL, creatinine 2.92 mg/dL, lactic acid 3.1 mmol/L, pro-B-type natriuretic peptide 15,342 pg/mL, high-sensitivity troponin 136 ng/L, aspartate aminotransferase 129 U/L, and alanine aminotransferase of 115 U/L. An electrocardiogram showed complete heart block, and a transvenous pacemaker was placed. A transesophageal echocardiogram revealed an aortic root abscess and severe aortic insufficiency secondary to Aerococcus urinae. Ventricular pacing was used to decrease aortic insufficiency and optimize computed tomography with gating to view the coronary arteries due to wall motion abnormalities seen on the transthoracic echocardiogram. His aortic valve was replaced, and a pacemaker was planned. Aortic valve Aerococcus endocarditis is rare and can lead to complete heart block and aortic insufficiency. Cardiac pacing improves hemodynamics by increasing heart rate and decreasing left ventricular end-diastolic pressure.

Duplex ultrasound in the evaluation of venous and arterial thoracic outlet syndrome.

We are reporting a case of thoracic outlet syndrome and the value of duplex in the diagnosis of this syndrome.

A review of the pivotal role of cardiac MRI in mitral valve regurgitation.

Cardiac imaging is the cornerstone of defining the etiology, quantification, and management of mitral regurgitation (MR). This continues to be even more so the case with emerging transcatheter techniques to manage MR. Transthoracic echocardiography remains the first-line imaging modality to assess MR but has limitations. Cardiac MRI(CMR) provides the advantages of quantitative nonvisual estimation, 3D volumetric data, late gadolinium, T1, and extracellular volume measurements to comprehensively assess mitral valvular pathology, cardiac remodeling, and the prognostic impact of therapies. This review describes the superiority, technical aspects and growing evidence behind CMR, and lays the roadmap for the future of CMR in MR.

Usefulness of Malignancy as a Predictor of WorseIn-Hospital Outcomes in Patients With Takotsubo Cardiomyopathy.

Takotsubo cardiomyopathy (TC) is a form of dilated cardiomyopathy often associated with physical or emotional stress. Association with cancer has been reported, however, in-hospital outcomes in TC patients with history of malignancy have not been fully characterized. We conducted a retrospective chart review of hospitalized patients with diagnosis of TC between January 2006 and January 2017. Patients were divided into 2 groups based on the previous history of malignancy. Presenting symptoms, cardiac imaging and short-term events including in-hospital complications and mortality, were compared. Of 318 patients with TC, 81 (25.4%) had a previous diagnosis of cancer. Mean age was 67.5 (SD 12.6), 151 (47.5%) were African American, 122 (38.4%) Caucasian, and 10 (3.1%) of other ethnicities. Patients with history of malignancy were older (70.0 [SD 10.6] vs 66.6 [SD 13.1] years, p = 0.03), had higher heart rate on presentation (93 [SD 19] vs 87 [SD 25] beats/minute, p = 0.03), higher prevalence of severely decreased cardiac function (left ventricular ejection fraction <25%) (29.6% vs 16%, p = 0.01), longer hospitalization (7 (4-13) vs 4 (3-8) days, p = 0.001) and experienced more in-hospital cardiac arrests (6 [7.4%] vs 5 [2.1%], p = 0.035) compared with patients without malignancy history. Higher percentage of longer hospitalization and left ventricular ejection fraction <25% in the cancer group persisted after controlling for sepsis, chemotherapy exposure, and metastatic disease. In conclusion, in a racially diverse hospitalized population of TC, prevalence of cancer history is high, and diagnosis of previous malignancy is associated with adverse in-hospital outcomes.

Medical marijuana: A panacea or scourge.

Marijuana (Cannabis sativa) has been used for recreational and medical purposes since ages. Marijuana smoking is an evil, which is on the rise with about 180.6 million active users worldwide. The recent legalization of marijuana in Uruguay has generated global interest. The purpose of this short review is to describe the various preparations, uses and adverse effects of medical marijuana. It also deals with the adverse effects of marijuana smoking when used for recreational purposes. ased on the current literature, medical use of marijuana is justified in certain conditions as an alternative therapy.

Electronic cigarettes: facts and myths.

E-cigarettes are devices designed to deliver nicotine to users without burning tobacco. These are being marketed globally as a healthier substitute to the conventional cigarettes and as smoking quitting aids. The use of these devices has increased recently in developed countries with approximately 1.3 million users reported in the United Kingdom in 2013. Perception of these products as a safe alternative, appealing advertisements, and lax regulatory policies have helped gain popularity among the public. Despite all these claims, a debate is on-going because of insufficient scientific data regarding safety and efficacy of e-cigarettes as well as awareness of the potential health hazards. To solve the dilemma, more scientific studies in this field are required. Prompt regulatory response with strict vigilance on marketing and advertising may be desirable in the interest of users and public at large.