Diagnostic and therapeutic challenge: A case of right ventricular thrombus.

Right ventricular thrombus is a rare finding found in 4% of people diagnosed with pulmonary embolism. Although right ventricular thrombi are usually associated with atrial fibrillation, deep venous vein thrombi, or intracardiac procedures, isolated right ventricular thrombi are rare. Right ventricular thrombus has also been reported in patients with right ventricular infarction, as hypokinesis of the right ventricle causes blood stasis and promotes thrombosis as per Virchow's triad. However, we present a case of isolated RV thrombus in a patient without evidence of deep vein thrombosis or right ventricular hypokinesis who presented with dyspnea on exertion.

The curious case of Kounis syndrome: exploring clinical manifestations and management in the presence of nonobstructive coronary arteries.

Kounis syndrome, an allergic hypersensitivity coronary disorder, is a rare but potentially life-threatening condition triggered by various allergens, including medications. We present the case of a 41-year-old male with no prior cardiac history, who developed Kounis syndrome following vancomycin administration for suspected cellulitis. The patient initially presented with rash, fever, and malaise, which progressed to chest discomfort associated with diaphoresis and elevated troponin levels. Diagnostic evaluations, including electrocardiographic changes and coronary angiography, confirmed a diagnosis of type I Kounis syndrome. This case adds to the limited literature on vancomycin-induced Kounis syndrome, and underscores the importance of considering this diagnosis in patients with myocardial damage following exposure to potential allergens.

Transfusion-associated acute lung injury following albumin treatment in liver disease.

BACKGROUND AND OBJECTIVES: Transfusion-related acute lung injury is an infrequent adverse reaction observed in patients receiving blood products. The lung injury can range in severity and can be associated with both mortality and mortality. All blood products except albumin have been linked to cases of transfusion-related acute lung injury. In fact, albumin may be used as a salvage modality in severe transfusion-related acute lung injury. We report an alcoholic patient who developed lung injury following treatment with albumin in the setting of hypoalbuminaemia. MATERIALS AND METHODS: A 41-year-old male with alcoholic liver disease was admitted for severe ascites and alcoholic hepatitis. Chest x-ray showed small pleural effusions at the lung bases with no overt pulmonary oedema. He received high doses of furosemide for lower extremity oedema. The patient received a total of two albumin infusions to augment the diuresis effect. RESULTS: He subsequently developed acute hypoxic respiratory failure with imaging showing interstitial and airspace abnormalities concerning for pulmonary oedema. He showed no additional signs of volume overload and was treated supportively until the condition improved. CONCLUSION: This is the first reported case of albumin-associated lung injury proximally related to albumin infusion. We aim to increase awareness of this possible sequelae among physicians.

Sodium-glucose cotransporter-2 inhibitor-associated euglycemic diabetic ketoacidosis in COVID-19-infected patients: A systematic review of case reports.

BACKGROUND: Diabetic ketoacidosis (DKA) manifests as hyperglycemia, metabolic acidosis, and ketosis. However, euglycemic DKA (eu-DKA) conceals severe DKA with glucose levels below 200 mg/dL. Sodium-glucose cotransporter-2 (SGLT2) inhibitors can induce eu-DKA in diabetic patients. Notably, coronavirus disease 2019 (COVID-19) -infected individuals with diabetes using SGLT2 inhibitors face an augmented risk of eu-DKA due to the direct toxic impact of the virus on pancreatic islets. This study aims to comprehensively investigate the association between SGLT2 inhibitors and eu-DKA in COVID-19 patients through meticulous case report analysis. Additionally, we endeavor to examine the outcomes and treatment approaches for COVID-19-infected diabetics receiving SGLT2 inhibitors, providing indispensable insights for healthcare professionals managing this specific patient population. AIM: To investigate the connection between SGLT2 inhibitors and euglycemic DKA in COVID-19 patients through a meticulous analysis of case reports. METHODS: We conducted an exhaustive search across prominent electronic databases, including PubMed, SCOPUS, Web of Science, and Google Scholar. This search encompassed the period from December 2019 to May 2022, incorporating published studies and pre-prints. The search terms employed encompassed "SGLT2 inhibitors", "euglycemic DKA", "COVID-19", and related variations. By incorporating these diverse sources, our objective was to ensure a thorough exploration of the existing literature on this subject, thereby augmenting the validity and robustness of our findings. RESULTS: Our search yielded a total of seven case reports and one case series, collectively comprising a cohort of twelve patients. These reports detailed instances of eu-DKA in individuals with COVID-19. Crucially, all twelve patients were utilizing SGLT2 as their primary anti-diabetic medication. Upon admission, all oral medications were promptly discontinued, and the patients were initiated on intravenous insulin therapy to effectively manage the DKA. Encouragingly, eleven patients demonstrated a favorable outcome, while regrettably, one patient succumbed to the condition. Subsequently, SGLT2 were discontinued for all patients upon their discharge from the hospital. These findings provide valuable insights into the clinical management and outcomes of eu-DKA cases associated with COVID-19 and SGLT2, underscoring the critical importance of prompt intervention and vigilant medication adjustments. CONCLUSION: Our study sheds light on the possibility of diabetic patients developing both drug-related and unrelated DKA, as well as encountering adverse outcomes in the context of COVID-19, despite maintaining satisfactory glycemic control. The relationship between glycemic control and clinical outcomes in COVID-19 remains ambiguous. Consequently, this systematic review proposes that COVID-19-infected diabetic patients using SGLT2 should contemplate alternative treatment protocols until their recovery from the disease.

Dipyridamole-induced STEMI: case report and review of the literature.

Dipyridamole nuclear myocardial perfusion imaging is a safe and useful modality for assessing myocardial ischemia. It is the modality of choice for cardiac risk stratification in patients who are unable to exercise. Intravenous dipyridamole causes coronary vasodilation and may result in heterogeneity of coronary blood flow in significant coronary artery disease. Ischemic electrocardiographic changes following pharmacological stress testing are less likely to occur compared with exercise stress tests. Ischemia is more likely to be present in the form of ST depression, with ST-segment elevation being exceedingly rare. We present the case of a 73-year-old patient who developed ST-segment elevation myocardial infarction following pharmacologic stress testing.

Effect of fibrinolytic therapy on ST-elevation myocardial infarction clinical outcomes during the COVID-19 pandemic: A systematic review and meta-analysis.

BACKGROUND: ST-elevation myocardial infarction (STEMI) is the result of transmural ischemia of the myocardium and is associated with a high mortality rate. Primary percutaneous coronary intervention (PPCI) is the recommended first-line treatment strategy for patients with STEMI. The timely delivery of PPCI became extremely challenging for STEMI patients during the coronavirus disease 2019 (COVID-19) pandemic, leading to a projected steep rise in mortality. These delays were overcome by the shift from first-line therapy and the development of modern fibrinolytic-based reperfusion. It is unclear whether fibrinolytic-based reperfusion therapy is effective in improving STEMI endpoints. AIM: To determine the incidence of fibrinolytic therapy during the COVID-19 pandemic and its effects on STEMI clinical outcomes. METHODS: PubMed, Google Scholar, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials were queried from January 2020 up to February 2022 to identify studies investigating the effect of fibrinolytic therapy on the prognostic outcome of STEMI patients during the pandemic. Primary outcomes were the incidence of fibrinolysis and the risk of all-cause mortality. Data were meta-analyzed using the random effects model to derive odds ratios (OR) and 95% confidence intervals. Quality assessment was carried out using the Newcastle-Ottawa scale. RESULTS: Fourteen studies including 50136 STEMI patients (n = 15142 in the pandemic arm; n = 34994 in the pre-pandemic arm) were included. The mean age was 61 years; 79% were male, 27% had type 2 diabetes, and 47% were smokers. Compared with the pre-pandemic period, there was a significantly increased overall incidence of fibrinolysis during the pandemic period [OR: 1.80 (1.18 to 2.75); I2= 78%; P = 0.00; GRADE: Very low]. The incidence of fibrinolysis was not associated with the risk of all-cause mortality in any setting. The countries with a low-and middle-income status reported a higher incidence of fibrinolysis [OR: 5.16 (2.18 to 12.22); I2 = 81%; P = 0.00; GRADE: Very low] and an increased risk of all-cause mortality in STEMI patients [OR: 1.16 (1.03 to 1.30); I2 = 0%; P = 0.01; GRADE: Very low]. Meta-regression analysis showed a positive correlation of hyperlipidemia (P = 0.001) and hypertension (P < 0.001) with all-cause mortality. CONCLUSION: There is an increased incidence of fibrinolysis during the pandemic period, but it has no effect on the risk of all-cause mortality. The low- and middle-income status has a significant impact on the all-cause mortality rate and the incidence of fibrinolysis.

COVID-19-associated MRSA infective endocarditis and mitral valve perforation: a case report.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has emerged as a global pandemic, leading to significant morbidity and mortality. The interplay between COVID-19 and other medical conditions can complicate diagnosis and management, necessitating further exploration. CASE PRESENTATION: This case report presents a patient with COVID-19 who developed infective endocarditis (IE) and mitral valve perforation caused by methicillin-resistant Staphylococcus aureus on a native mitral valve. Notably, the patient did not exhibit typical IE risk factors, such as intravenous drug use. However, he did possess risk factors for bacteremia, including a history of diabetes mellitus and recent steroid use due to the COVID-19 infection. The diagnosis of IE was crucially facilitated by transesophageal echocardiography. CONCLUSIONS: This case highlights the potential association between COVID-19 and the development of infective endocarditis. Prompt evaluation using transesophageal echocardiography is vital when there is a high suspicion of IE in COVID-19 patients. Further research is required to elucidate the precise relationship between COVID-19 and IE.

When images don't explain reality: A case of an intravascular extension of an endometrial tumor.

Endometrial stromal sarcoma is a rare mesenchymal tumor with the potential for intravascular metastases. We present the case of a 52-year-old female patient with a history of previously resected endometrial sarcoma who was found to have an inferior vena cava thrombus with intracardiac extension. Pathological assessment following resection revealed intravascular extension of an underlying endometrial stromal sarcoma. This case demonstrates the aggressive nature and intracardiac metastatic potential of endometrial sarcomas.

Delayed presentation of biopsy-proven eosinophilic myocarditis following COVID-19 mRNA vaccine.

Myopericarditis associated with COVID-19 mRNA vaccines has been recognized as an uncommon adverse reaction, especially among young, healthy adult males. Eosinophilic myocarditis is a rare form of inflammation reflecting a hypersensitivity reaction following an inciting event commonly caused by drugs including vaccines. Eosinophilic myocarditis, a subtype of myocarditis, is characterized by eosinophilic myocardial infiltrates. It is usually accompanied by systemic eosinophilia in the form of a drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome and is rarely associated with myocyte fibrosis and/or necrosis. In this report, we present a case of biopsy-proven eosinophilic myocarditis in a 24-year-old male patient, likely secondary to COVID-19 mRNA vaccination. To our knowledge, this is the first report to describe delayed eosinophilic myocarditis following the COVID-19 mRNA vaccine. Clinicians should be aware of possible delayed presentation to avoid associated morbidity.

Polypill Therapy in Cardiovascular Disease: A Meta-Analysis of Randomized Controlled Trials.

The effectiveness of polypill therapy in the prevention and treatment of cardiovascular disorders is still unclear. This meta-analysis aimed to assess the efficacy of polypill therapy in reducing cardiovascular risk factors. We conducted a systematic search of PubMed, Cochrane CENTRAL, SCOPUS, and Google Scholar for randomized controlled trials (RCTs) that evaluated polypill therapy for cardiovascular diseases, hypertension, or dyslipidemia. We included 18 RCTs with a total of 20,463 participants in our analysis. Pooled effect estimates were reported as Odds ratios (ORs) with a 95% confidence interval (CI) using a random-effects model. Polypill therapy was associated with a statistically significant reduction in systolic blood pressure (SBP) (OR: -0.33, 95% CI [-0.64, -0.03]; P-value = 0.03), diastolic blood pressure (DBP) (OR: -0.70, 95% CI [-1.20, -0.21]; P-value = 0.005), and total cholesterol level (OR: -1.25, 95% CI [-1.82, -0.68]; P-value < 0.0001). Polypill therapy also showed improved adherence (OR 2.18, 95% CI [1.47, 3.24]; P-value = 0.0001). However, there was no statistically significant benefit in the reduction of all-cause mortality, major cardiovascular events, and LDL-c levels. The use of polypill therapy is associated with a statistically significant reduction in SBP, DBP, and total cholesterol levels, as well as improved adherence. Further research is needed to determine its impact on hard clinical outcomes such as mortality and major cardiovascular events.

Chagas disease-induced ventricular tachycardia: A case report.

Chagas disease is a protozoal infection caused by Trypanosoma cruzi (T. cruzi) that can affect many organ systems. Chagas cardiomyopathy tends to affect 30% of infected individuals. Cardiac manifestations include myocardial fibrosis, conduction defects, cardiomyopathy, ventricular tachycardia, and sudden cardiac death. In this report, we discuss a 51-year-old male who presented with recurrent episodes of non-sustained ventricular tachycardia refractory to medical therapy.

The vicious cycle of BRASH syndrome: A case report.

First described in 2016, BRASH syndrome is an underreported clinical entity characterized by bradycardia, renal dysfunction, atrioventricular nodal blockade (AVNB), shock, and hyperkalemia. The recognition of BRASH syndrome as a clinical entity is crucial for early and effective management. Patients with BRASH syndrome present with symptomatic bradycardia that is resistant to treatment with standard agents such as atropine. In this report, we present the case of a 67-year-old male patient who presented with symptomatic bradycardia with an ultimate diagnosis of BRASH syndrome. We also shed light on predisposing factors and challenges encountered during the management of affected patients.

MINOCA mimic: Type 2 myocardial infarction due to severe aortic stenosis complicated by cardiogenic shock.

Acute myocardial infarction without significant obstructive coronary disease presents a challenging clinical entity that requires timely intervention. The term myocardial infarction with nonobstructive coronary arteries (MINOCA) describes a working diagnosis attributed to varying etiologies in patients with a presumed ischemic cardiac condition. Several overlapping etiologies can be classified as type 2 myocardial infarction (MI). The 2019 AHA statement established diagnostic criteria and clarified the associated confusion, aiding in appropriate diagnosis. In this report, we present a case of demand-ischemia MINOCA and cardiogenic shock in a patient with severe aortic stenosis (AS).

Inari large-bore mechanical thrombectomy in intermediate-high risk submassive PE patients: Case series and literature review.

Pulmonary embolism (PE) is one of the most common causes of cardiovascular (CV) mortality worldwide. Owing to the associated morbidity and mortality with other treatment modalities, including systemic thrombolysis, a discernible change in the era of acute pulmonary embolism management has been reported. Catheter-directed thrombectomy using the FlowTriever system (Inari Medical; Irvine, CA, USA) was shown to reduce endpoints of interest in patients with acute intermediate-high risk PE and was associated with rapid hemodynamic improvement. In this report, we describe our experience with three cases of patients presenting with submassive PE, whereby immediate pulmonary artery pressure improvement was evident in all cases after successful mechanical thrombectomy. Our experience supports the use of FlowTriever mechanical thrombectomy for the treatment of submassive PE in clinical practice, with a call for further research to establish associated benefits.

Feasible stenting of a large septal perforator providing a sizeable coronary collaterals.

While coronary artery disease involving the septal perforator branches presents similar to diseases of major coronary arteries, management can present a challenge. Owing to their relatively small size, performing interventional procedures is often impractical in terms of selecting appropriate devices. Although larger septal perforator branches have been managed percutaneously, similar to major vessels, long-term sequelae and clinical effectiveness have been indeterminate. We present our experience in managing a patient with a stenosed septal perforator branch and challenging comorbidities.

The overestimation of concentric hypertrophy in patients with HFpEF as determined by 2D-echocardiography.

Background: Heart failure with preserved ejection fraction continues to pose multiple challenges in terms of accurate diagnosis, treatment, and associated morbidity. Accurate left ventricular (LV) mass calculation yields essential prognostic information relating to structural heart disease. Two-dimensional (2D) echocardiography-based calculations are solely limited to LV geometric assumptions of symmetry, whereas three-dimensional (3D) echocardiography could overcome these limitations. This study aims to compare the performance of 2D and 3D LV mass calculations. Methods: A prospective review of echocardiography findings at the University of Louisville, Kentucky, was conducted and assessed. Normal ejection fraction (EF) was defined as >=52% in males and >=54% in females. The following calculations were performed: relative wall thickness (RWT) = 2x posterior wall thickness/LV internal diastolic dimension (LVIDd) and 2D LV mass = 0.8{1.04([LVIDd + IVSd +PWd]3 - LVIDd3)} + 0.6. Concentric hypertrophy was RWT >0.42 and LV mass >95 kg/m2 in females or >115 kg/m2 in males. The same cut-offs were used for 2D and 3D echocardiography. Results: Echocardiographic findings for a total number of 154 patients in the study were investigated. There was a weak positive correlation between 2D and 3D LV mass indices (R = 0.534, r2 = 0.286, p = 0.001). Seventy patients had 3D EF >=45% with clinical heart failure (HFpEF). Among HFpEF patients, LV hypertrophy (LVH) was present in 74% of patients by 2D echocardiography and 30% by 3D echocardiography (McNemar test p = 0.001). Using 3D echocardiography as the reference, 68% of normal patients were misdiagnosed with LV hypertrophy by 2D echocardiography. Two-thirds of the patients with concentric remodeling by 3D echocardiography were misclassified as having concentric hypertrophy by 2D echocardiography (p = 0.001). Conclusion: Adapting necropsy-proven LV mass index cutoffs, 2D over-diagnosed LV hypertrophy through overestimation of the mass, compared to 3D echocardiography. In turn, the majority of HFpEF patients showed no structural hypertrophy of the LV on 3D imaging. This suggests that the majority of patients with HFpEF may qualify for pharmacological prevention to prevent further progression to LV remodeling or LVH.

The curious case of an isolated right coronary artery aneurysm complicated by thrombosis and distal embolization.

A 40-year-old male patient with no significant medical history was admitted with an inferior ST-segment elevation myocardial infarction. Primary percutaneous coronary intervention revealed a right coronary artery aneurysm, with no evidence of significant coronary disease. We support the hypothesis of aneurysmal thrombus formation with distal embolization.

The undesirable communication: A case of cerebral air emboli in the setting of atrio-esophageal fistula following atrial fibrillation catheter ablation.

Atrial-esophageal fistula is an extremely rare condition but is often a deleterious complication following catheter ablation for atrial fibrillation. The associated iatrogenic communication acts as a conduit for air and bacterial translocation, which may lead to cerebral air embolism and polymicrobial sepsis, respectively. Coupled with a history of invasive procedures, the diagnosis is largely based on the accompanying neurological symptoms. In this report, we present the case of a 73-year-old female who presented with neurological deficits attributed to cerebral vascular emboli three weeks after catheter ablation for the treatment of chronic atrial fibrillation.