Overcoming a stubborn patent foramen ovale.

Transesophageal echocardiography (TEE) with agitated saline contrast ("bubble study") is the gold standard for detection of patent foramen ovale (PFO). Standard provocative maneuvers help facilitate right-to-left shunting necessary for diagnosing PFO but may be difficult to implement during TEE. Hypovolemia related to preprocedural fasting may challenge detection of PFO in TEE, and additional optimization measures such as fluid replenishment with passive leg raise (PLR) can enhance PFO detection. We present a 57-year-old male with history of cryptogenic stroke and stubborn PFO which during TEE bubble study responded only to ample fluid replenishment with PLR following a period of prolonged preprocedural fasting.

A case of variant parachute mitral valve associated with mitral annular disjunction arrhythmic syndrome.

Parachute mitral valve (PMV) is a rare congenital cardiac valvular anomaly often associated with other congenital cardiac defects, particularly Shone's complex, but may infrequently occur in isolation. PMV and its variants are predominantly associated with mitral stenosis (MS) or rarely mitral regurgitation (MR). We present the case of a middle-aged female who was evaluated for a syncopal episode and found to have an atypical variant PMV with disproportionately long anterior mitral leaflet, bileaflet mitral valve prolapse, and mitral annular disjunction, without associated MS or MR. This is the first case report to highlight this particular constellation of findings.

Plasminogen Activator Inhibitor-1 4G/5G Polymorphism Presenting as Recurrent Ischemic Stroke: The Microthrombi Shower.

Certain clinical scenarios should alert a physician to take a deeper look into causative pathological processes. This was evident in the case of a 41-year-old man who presented for recurrent micro thromboembolic strokes, which is atypical for the patient's age. Our desire to explain the pathological process led to the rare finding of a plasminogen activator inhibitor-1 polymorphism, which has been associated with an increased risk of cerebrovascular thrombosis. A defect in this pathway leads to the inhibition of the tissue plasminogen activator protein. This genetic polymorphism has relatively been unexplored in recent medical literature, and we are hoping that our case may inspire future research that could help potential targets of risk factor stratifications as well as the development of novel pharmacological options.

Role of Cardiac Magnetic Resonance in Detecting Biventricular Apical Hypertrophic Cardiomyopathy.

Apical Hypertrophic Cardiomyopathy (ApHCM) is a rare variant of hypertrophic cardiomyopathy with a low prevalence in the general population. ApHCM with right ventricular involvement (BiApHCM) is largely unreported and may not be detected with conventional transthoracic echocardiogram (TTE) alone. Cardiac Magnetic Resonance (CMR) has been demonstrated to be a proficient imaging modality to diagnose BiApHCM. We present a case of BiApHCM that was diagnosed with TTE and further characterized by CMR. This imaging modality may be utilized more in the future to help diagnose and detect the prevalence of BiApHCM.

Clinical Impact of Atrial Fibrillation on Short-Term Outcomes and In-Hospital Mortality in Patients with Takotsubo Syndrome: A Propensity-Matched National Study.

INTRODUCTION: Takotsubo Syndrome (TS) patients are at high risk of developing atrial fibrillation. We sought to investigate the outcomes and economic impact of atrial fibrillation on TS patients utilizing the National Inpatient Sample. METHODS: Patients with TS were identified in the National Inpatient Sample (NIS) database between 2010 and 2014 using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), and subsequently were divided into two groups, those with and without atrial fibrillation. The primary outcome was all-cause in-hospital mortality in the two groups. Secondary outcomes were in-hospital complications. We also evaluated the length of hospital stay and the cost of hospitalization. Propensity score-matched analysis was performed to address potential confounding factors. RESULTS: Among the study population, the prevalence of atrial fibrillation was 17.57%. After matching, the atrial fibrillation group had no significant increase of in-hospital mortality (OR: 1.13; 95% CI: 0.94-1.35, p = 0.211). However, atrial fibrillation patients were more likely to develop cardiac arrest and ventricular arrhythmias (OR: 1.51, 95% CI: 1.26-1.80, p < 0.0001), have higher rate of major cardiac complications when combined as a single endpoint in-hospital complication (OR: 1.16, 95% CI: 1.04-1.29, p: 0.006), also they were more likely to stay longer in hospital (OR: 1.13, 95% CI: 1.08-1.19, p < 0.0001), and have increased cost of hospitalization (OR: 1.13, 95% CI 1.07-1.20, p < 0.0001). CONCLUSION: Atrial fibrillation does not increase in-hospital mortality in patients presenting with TS. However atrial fibrillation is associated with an increased risk of ventricular arrhythmias, length of stay, non-routine discharges and cost of hospitalization.

Hepatic Sinusoidal Obstruction Syndrome in a Patient With Multiple Myeloma Treated With CyBorD.

Hepatic sinusoidal obstruction syndrome (SOS) is a life-threatening state generally occurring as a complication of conditioning regimens used for hematopoietic stem cell transplant. Hepatic SOS after a standard dose of chemotherapy in malignancies is rare, and there are only a few cases in pediatric literature. We report a 56-year-old man with multiple myeloma who experienced SOS after being initiated on chemotherapy including cyclophosphamide, dexamethasone, and bortezomib and who experienced a delay in treatment with defibrotide, because it is currently approved by the Food and Drug Administration for only patients who develop SOS after hematopoietic stem cell transplant.

Do zebrafish Rh proteins act as dual ammonia-CO2 channels?

Transfer of the small gaseous molecules CO2 and NH3 across biological membranes, long thought to occur solely by simple diffusion, is now known to be facilitated by members of two multigene families: aquaporins (AQP) and rhesus (Rh) proteins. Although it is accepted that AQP1 and Rh proteins are involved in CO2 and NH3 transfer, respectively, the idea that a single channel can exhibit selectivity for both gases is controversial. Indeed, studies using the same in vitro model (human red blood cells) have provided evidence both for and against a role for Rh proteins as CO2 channels. Thus, this study was initiated to provide in vivo evidence for a dual function of Rh proteins as ammonia and CO2 channels. Here, we show that in zebrafish (Danio rerio), direct ammonia-CO2 competition experiments in adults or translational knockdowns of Rh proteins in larvae affects both ammonia and CO2 excretion. These results suggest that Rh proteins in zebrafish may be common pathways for transport of ammonia and CO2.