Early-Stage Loeffler's Endocarditis with Isolated Right Ventricular Involvement: Management, Long-Term Follow-Up, and Review of Literature.

Loeffler's endocarditis is a clinical condition characterized by combination of three key findings: unexplained prolonged and marked eosinophilia (>1500 eosinophils/mm(3) ), absence of a primary cause of hypereosinophilia, and evidence of eosinophil-mediated organ damage. We report a case of a 55-year-old African American male with symptoms of heart failure. Hematology showed white blood cell count of 17 670/mm(3) with 63% eosinophils and an absolute eosinophil count of 11 133/mm(3) . Echocardiogram and computed tomography showed near complete obliteration of right ventricular cavity. Endomyocardial biopsy showed diffuse myocyte necrosis with extensive eosinophilic infiltration without fibrosis consistent with early Loeffler's endocarditis. Molecular and cytogenetic analyses of bone marrow cells were negative for FIP1L1-PDGFRA fusion, PDGFRB mutation, abnormal myeloid maturation, or a lymphoproliferative disorder. Flow cytometry showed no clonality excluding chronic eosinophilic leukemia. There was a complete resolution of symptoms and eosinophilia after 1 month of steroid therapy.

Ischemia from extrinsic compression of the brachial artery by a stent in the venous outflow of a brachio-basilic arterio-venous graft.

Distal artery embolization is a well-known complication after mechanical thrombectomy, manifesting as limb ischemia. We describe a case of ischemia that developed after mechanical thrombectomy and stent placement in the venous anastomosis of a brachio- basilic arterio-venous graft. Subsequent investigations revealed that the stent had extrinsically compressed the adjacent brachial artery. Although balloon angioplasty of the artery initially restored flow, the patient needed surgical removal of the graft and stent to prevent persistent ischemia.

Unusual Response of Subclavian In-Stent Restenosis to Balloon Angioplasty in a Patient with HIV.

Human Immunodeficiency Virus (HIV) infection and use of protease inhibitors have been associated with accelerated atherosclerosis. Increased rates of coronary in-stent restenosis are reported in these patients. There is limited data available on peripheral vascular disease interventions on these patients. Herein we report an aggressive subclavian in-stent restenosis with an unexpected response to balloon angioplasty treatment with a large, mobile tissue flap formation and its treatment with another stent.

Retroperitoneal hematoma: an unexpected complication during intervention on an occluded superficial femoral artery via a retrograde popliteal artery approach.

Peripheral arterial disease involvement of the superficial femoral artery (SFA) is common. Different endovascular techniques are used successfully for revascularization of this artery. A retrograde approach to chronic total occlusion (CTO) of the SFA through the ipsilateral popliteal artery has been used occasionally if an antegrade approach is not feasible or has failed. Some of the known complications encountered during this approach are arteriovenous fistula formation at the access site, occlusion of the popliteal artery if closure devices are used, and bleeding. There are no reports of perforation or bleeding of the SFA or the external iliac artery (EIA) during a popliteal approach, probably due to lack of flow in the occluded segment of the SFA. We report a case in which a retroperitoneal hematoma occurred due to retrograde blood flow through the established true channel in the proximal SFA and subsequently to the dissection plane with a wire tip perforation in the EIA, which was treated by stopping retrograde filling with prolonged balloon inflation in the distal SFA before the CTO.

Recrudescent digoxin toxicity treated with plasma exchange: a case report and review of literature.

A 53-year-old woman presented with digitalis toxicity caused by acute overdose that manifested as atrial tachycardia with block, sinus pauses, and competing AV junctional rhythm with atrial fibrillation. Patient admitted to overdosing with digoxin 15-20 h before presentation with intent to commit suicide. Serum digoxin level was 35.6 ng/ml and renal function was normal. Patient was treated with 1,040 mg of digoxin-specific antibody Fab fragment with prompt resolution of arrhythmias and restoration of sinus rhythm. Four hours after digoxin antibody administration, serum digoxin level declined to 0.2 ng/ml. Eighteen hours after treatment with Fab fragment, patient developed premature ventricular complexes, atrial tachycardia with and without atrioventricular block, and non-sustained ventricular tachycardia followed by ventricular fibrillation from which she was successfully resuscitated. Electrocardiogram showed no evidence of acute myocardial infarction, and emergent coronary angiogram did not reveal significant coronary artery disease. Repeat digoxin level was 20.4 ng/ml. A diagnosis of recrudescent digoxin toxicity was made and the patient was treated with one session of plasma exchange with resolution of arrhythmias. Immediately after plasma exchange, digoxin level decreased to 10.4 ng/ml, and after 10 h, the level further decreased to 6.6 ng/ml. The following day, digoxin level had decreased to 2.9 ng/ml. Our experience with this case would suggest that plasma exchange should be considered as a treatment modality for recrudescent digoxin toxicity.