An Itchy Lead: First Reported Case of Ventricular Pacemaker Lead Self-Extraction.

We present a particularly rare case and the first ever report of a ventricular self-extraction in a 98-year old female. Our patient had a past medical history significant for severe Alzheimer's dementia, paroxysmal atrial fibrillation, and sick sinus syndrome who was admitted in clinically stable condition following the unwitnessed self-extraction the ventricular lead of her dual chamber pacemaker. This case highlights the potential risks and other clinical challenges of pacemaker and ICD placement in elderly patients and in patients with cognitive impairment.

Aortic valve endocarditis complicated by ST-elevation myocardial infarction.

Infective endocarditis complicated by abscess formation and coronary artery compression is a rare clinical event with a high mortality rate, and diagnosis requires a heightened degree of suspicion. We present the clinical, angiographic, and echocardiographic features of a 73-year-old woman who presented with dyspnea and was found to have right coronary artery compression that was secondary to abscess formation resulting from diffuse infectious endocarditis. We discuss the patient's case and briefly review the relevant medical literature. To our knowledge, this is the first reported case of abscess formation involving a native aortic valve and the right coronary artery.

When catastrophe strikes - a case of atrial myxoma with distal embolization.

Primary tumors of the heart are rare, with an incidence between 0.0017 and 0.19 percent in unselected patients at autopsy. About three-quarters of these tumors are benign, and nearly half of these benign tumors are myxomas. First described in 1845, myxomas were diagnosed posthumously until the 1950s. The clinical features are determined by their size, locations and mobility. Embolism occurs in one-third of patients, but it is rare for patients to initially present with multiple, simultaneous widespread emboli.

Complete resolution of acute renal failure after left renal artery angioplasty and stent placement for total renal artery occlusion.

A 25-year-old female, 17 weeks pregnant presented to our hospital with complaints of progressively increasing dyspnea. She was hypertensive with creatine of 1.0; she was transferred to ICU with multiple medications to control her blood pressure, without success. The patient continued to decompensate, which required intubation. The patient developed acute renal failure, part of her work-up suggested bilateral renal artery stenosis. She was taken to the catheterization lab and was found to have bilateral total renal artery occlusion. The left renal artery was successfully opened. The patient recovered and her blood pressure was controlled after the procedure. In the past, surgery was the preferred treatment in cases of acute renal artery occlusion. This approach has been replaced increasingly by renal artery angioplasty, which is less invasive and is at least as effective as surgical reconstruction. Our case demonstrates a percutaneous approach can be tried for totally occluded renal artery with a successful outcome.

Severe dilatation of saphenous vein grafts: a late complication of coronary surgery in which the diagnosis is suggested by chest x-ray.

Aneurysmal dilatation of saphenous vein graft (SVG), first reported in 1975, is secondary to true aneurysm or pseudoaneurysm. We report 1 case and review 107 cases published since 1975. Severe SVG dilatations are large (6 +/- 3 cm), occur remote from surgery (12 +/- 4 years) and are life threatening, with 15.7% in-hospital mortality. Symptoms are nonspecific and the abnormality is initially observed by chest X-ray in 57% of cases. The chest X-ray abnormalities have a distinctive appearance that may suggest both diagnosis and which SVG is involved. Diagnosis is made clinically by imaging, i.e. computed tomography, echocardiography, magnetic resonance and/or surgical observation (66 cases), or most accurately by tissue evaluation by the pathologist (42 cases). Aneurysm is more common than pseudoaneurysm by a 6:1 ratio.

Implementation of the ACC/AHA guidelines for preoperative cardiac risk assessment in a general medicine preoperative clinic: improving efficiency and preserving outcomes.

BACKGROUND: The American College of Cardiology/American Heart Association (ACC/AHA) publishes recommendations for cardiac assessment of patients undergoing noncardiac surgery with the intent of promoting evidence-based, efficient preoperative screening and management. We sought to study the impact of guideline implementation for cardiac risk assessment in a general internal medicine preoperative clinic. METHODS: The study was an observational cohort study of consecutive patients being evaluated in an outpatient preoperative evaluation clinic before and after implementation of the ACC/AHA guideline. Data was gathered by retrospective abstraction of hospital and clinic charts using standard definitions. 299 patients were reviewed prior to guideline implementation and their care compared to 339 consecutive patients after the guideline was implemented in the clinic. RESULTS: Guideline implementation led to a reduction in exercise stress testing (30.8% before, 16.2% after; p<0.001) and hospital length of stay (6.5 days before, 5.6 days after; p=0.055). beta-Blocker therapy increased after the intervention (15.7% before; 34.5% after; p<0.001) and preoperative test appropriateness improved (86% before to 94.1% after; p<0.001). CONCLUSIONS: Implementation of the ACC/AHA guidelines for cardiac risk assessment prior to noncardiac surgery in an internal medicine preoperative assessment clinic led to a more appropriate use of preoperative stress testing and beta-blocker therapy while preserving a low rate of cardiac complications.

Prognostic significance of an elevated creatine kinase in the absence of an elevated troponin I during an acute coronary syndrome.

In patients with troponin-negative acute coronary syndromes, creatine kinase (CK)-MB elevation predicts a significantly higher risk of death and major acute cardiac events compared with CK-MB negative patients. This risk is accentuated in troponin-negative, CK-MB positive patients who do not demonstrate ST elevation by electrocardiogram.