Surgical management of mycotic aneurysm of the left anterior descending artery.

Mycotic aneurysms of the coronary artery with underlying infective endocarditis are rare. The present report discusses the case of a 53-year-old woman with acute ST elevation myocardial infarction in the setting of native aortic valve endocarditis. Percutaneous transluminal coronary angioplasty was performed. Approximately four weeks after hospital admission, the patient had systemic embolization to the extremities with resulting cyanosis of the left toes. She was evaluated for replacement of the aortic valve and underwent a repeat angiogram, which demonstrated a mycotic aneurysm at the site of the angioplasty. She subsequently underwent successful excision of the aneurysm with coronary artery bypass grafting and replacement of the aortic valve with a 21 mm St Jude aortic valve prosthesis. The remaining hospital course was unremarkable.

Transcatheter closure of atrial septal defect (secundum type): the role of echocardiography in evaluating interatrial defects.

Atrial septal defects are among the most common congenital heart defects seen in the adult population. The diagnosis is usually made in children and closure is attempted before they are school age. In other cases, where the diagnosis is missed until adulthood, atrial arrhythmias and congestive heart failure are commonly seen. We report the case of an atrial septal defect (secundum type), which was diagnosed in a 72-year-old woman with paroxysmal atrial fibrillation. She also had a history of hypertension and hyperlipidemia. Transthoracic and transesophageal findings were consistent with right-sided volume overload and an atrial septal defect of approximately 1 cm in size. This was corroborated by the findings on cardiac catheterization with a shunt ratio of 1.8. The pulmonary artery pressures were within normal limits. The patient was referred for closure of the atrial septal defect. Presently, the options for septal defect closure are direct suture repair, Dacron patch repair depending on the size of the defect, and percutaneous transcatheter closure. Transcatheter closure is also available in treating selected patients with patent foramen ovale.

Current diagnosis and treatment of infective endocarditis.

The incidence of infective endocarditis continues to rise with a yearly incidence of around 15,000 to 20,000 new cases in the USA. As a result, rapid diagnosis, effective treatment and prompt recognition of complications are essential to desirable clinical outcomes. Recent guidelines such as the Duke criteria have incorporated echocardiography for diagnosis of infective endocarditis, making this diagnostic test mandatory for patients with suspected infective endocarditis. The diversity of pathogens that can cause infective endocarditis, some of which cannot be cultured easily, makes diagnosis even more difficult. Coagulase-negative staphylococci and viridans streptococci groups continue to be the major causative microorganisms of infective endocarditis. In the case of culture-negative endocarditis or infective endocarditis caused by fastidious microorganisms, the polymerase chain reaction and probe-based diagnostic methods are available to clinical reference laboratories.

Myocardial infarction in a patient with thrombotic thrombocytopenic purpura.

A 63-year-old male with a prior history of thrombotic thrombocytopenic purpura was admitted with sudden onset of syncope. He denied chest pain. His initial blood chemistries were consistent with acute relapse of thrombotic thrombocytopenic purpura as indicated by microangiopathic hemolytic anemia and thrombocytopenia. The patient had evidence of myocardial injury as indicated by elevation of cardiac enzymes. A 12-lead electrocardiogram demonstrated ST elevation (up to 5 mm) in leads V(2) to V(6). The patient was treated with plasma exchange with fresh frozen plasma in addition to nitroglycerin, metoprolol and prednisone in a tapering dose. After reviewing the literature, we believe that the etiology of myocardial damage remains elusive, but may be secondary to an autoimmune phenomenon resulting in microthrombosis and myocarditis. We were unable to find any documentation about any specific treatment in such patients. Further studies are awaited regarding appropriate treatment of patients with thrombotic thrombocytopenic purpura and acute electrocardiographic changes.

Left atrial mass: thrombus mimicking myxoma.

A 31-year-old woman underwent elective transthoracic echocardiography for paroxysmal atrial fibrillation, which showed a large left atrial mass. A two-dimensional echocardiogram showed a large left atrium mass. Subsequent transesophageal echocardiography showed a 3 cm x 3 cm circular mass with smooth contours. The differential diagnosis included myxoma versus thrombus, but because of morphology and mobility of the mass, it was difficult to differentiate one from the other. The patient had been on chronic coumadin therapy for paroxysmal atrial fibrillation. An operation was performed and the intracardiac mass resected. On pathologic examination the mass was diagnosed as an organized thrombus. A brief review of the literature has been presented to discuss the differential diagnosis of the mass in the left atrium.

Thrombotic occlusion of Bjork-Shiley prosthetic aortic valve.

Thrombotic occlusion of a prosthetic Bjork-Shiley valve is a potentially fatal complication. We present the case of a male, 62 years of age, diagnosed with thrombotic occlusion of prosthetic Bjork-Shiley aortic valve approximately 17 years post implantation. A brief review of the literature focusing on potential risk factors associated with the development of this condition and currently available diagnostic modalities used for evaluation and treatment are presented.

Role of magnetic resonance imaging in visualizing coronary arteries.

Ischemic heart disease is the leading cause of death worldwide. At present, coronary angiography is the gold standard for the diagnosis of coronary artery disease. Conventional coronary angiography is an invasive procedure with a small, yet inherent risk of myocardial infarction, stroke, potential arrhythmias, and death. Other noninvasive diagnostic tools, such as electrocardiography, echocardiography, and nuclear imaging are now widely available but are limited by their inability to directly visualize and quantify coronary artery stenoses and predict the stability of plaques. Coronary magnetic resonance angiography (MRA) is a technique that allows visualization of the coronary arteries by noninvasive means; however, it has not yet reached a stage where it can be used in routine clinical practice. Although coronary MRA is a potentially useful diagnostic tool, it has limitations. Further research should focus on improving the diagnostic resolution and accuracy of coronary MRA. This review summarizes results from several studies comparing coronary MRA with conventional coronary angiography. Current two-dimensional and three-dimensional coronary MRA techniques and their limitations are also discussed.