Euglycemic Diabetic Ketoacidosis in a Sedated Patient after Coronary Artery Bypass Grafting: A Case Report and Literature Review.

Euglycemic diabetic ketoacidosis (EDKA) is a rare and serious adverse effect of sodium-glucose cotransporter 2 inhibitors (SGLT-2i). The diagnosis is challenging due to the rarity, nonspecific symptoms, and absence of the alarmingly high blood glucose levels, and thus, it could be initially missed resulting in delayed treatment. This is particularly important for sedated patients, as the absence of typical clinical signs and symptoms can obscure the diagnosis. We present the case of a patient with type 2 diabetes mellitus on empagliflozin who developed EDKA while sedated after coronary artery bypass grafting (CABG) despite stopping the medication 24 hours prior to surgery. We also summarize the current literature on EDKA after CABG. Physicians must be aware and maintain a high index of suspicion for the illness, especially in patients with T2DM taking SGLT-2i and undergoing a major operation such as CABG. Emergent treatment and multidisciplinary follow-up are needed to improve patient outcomes and mitigate complications. Physicians should also consider identifying the optimal time to discontinue SGLT-2i before major surgeries and possible ketone studies in such patients, especially those sedated following the surgery.

Organized intrapericardial haematoma: a rare cause of heart failure after 2 years of trauma.

Intrapericardial organized haematoma secondary to blunt chest trauma is an extremely rare cause of constrictive pericarditis. We report a 30-year-old male who presented with heart failure for 12 months and was found to have an organized intrapericardial haematoma secondary to blunt chest trauma in a road traffic accident 2 years prior. The use of multiple imaging modalities including two-dimensional (transthoracic and transoesophageal) echocardiogram and cardiac magnetic resonance imaging established the diagnosis. Surgical excision of the haematoma and removal of the constricting pericardium relieved his symptoms.

Aspergillus cyst of aortic valve bioprosthesis.

Aspergillus endocarditis (AE) is an ominous complication of cardiac surgery with a dismal prognosis. We present a 35-year-old female who developed AE 4 months after her aortic and mitral valve replacement. Transesophageal echocardiography revealed an aortic root abscess and a cystic mass attached to the aortic bioprosthesis. Intraoperatively, the cyst was filled with fungal material. The aortic bioprosthesis was replaced and the patient was treated with amphotericin B. Six weeks later her condition suddenly deteriorated and she died on the same day. Early performance of transesophageal echocardiography and extended blood culture is mandatory in suspected cases of AE.

An incidental finding of mitral valve network.

A 63-year-old male presented with a 6-month history of worsening exertional dyspnea and was found to have three-vessel coronary artery disease. Transesophageal echocardiography revealed a filamentous structure attached to the anterior mitral valve leaflet, which was confirmed during surgery as filamentous network. To our knowledge, this is the first report to describe such a network attached to the mitral valve.

Right atrial myxoma associated with an atrial septal defect by real-time three-dimensional echocardiography.

A 40-year-old woman presented with a 1 month history of shortness of breath and easy fatigability. Two-dimensional echocardiography and real-time three-dimensional echocardiography (RT3DE) showed a large right atrial mass protruding into the right ventricle and an atrial septal defect (ASD). Successful excision of the mass, which proved to be a myxoma, and closure of the ASD completely relieved her symptoms. To our knowledge, this is the first report of RT3DE in a patient with right atrial myxoma associated with an ASD.

Partial anomalous pulmonary venous connection associated with Lutembacher's syndrome.

Lutembacher's syndrome is a rare combination of congenital atrial septal defect and mitral stenosis (almost always rheumatic). The hemodynamic effect of this combination makes the clinical diagnosis difficult due to a wide variation of clinical presentation. Echocardiography and cardiac catheterization are useful tools for proper diagnosis and planning of the therapeutic strategy. We present a 28-year-old female with Lutembacher's syndrome associated with partial anomalous pulmonary venous connection (PAPVC), which was surgically corrected. To our knowledge, this combination has never been reported in the literature.

Treating heparin-induced thrombocytopenia. The unconventional way!

Heparin-induced thrombocytopenia HIT is a potentially devastating complication of heparin therapy. The severe form of HIT has been associated with both venous and arterial thrombosis manifested by myocardial infarction, cerebrovascular occlusion, skin necrosis or limb ischemia. Several agents are now available as alternatives to heparin in patients with suspected HIT, including the thrombin specific inhibitors lepirudin and argatroban as well as the low molecular weight heparinoid known as danaparoid. When lacking these agents, here we report the use of plasmapheresis to create an artificial state of anticoagulation; exchanging patient's plasma with albumin rather than fresh frozen plasma, to allow the safe introduction of warfarin.

Biatrial aspergillosis in a patient with immunocompetency.

A 24-year-old man presented with a 24-hour history of pain and numbness in his left arm. The patient's clinical presentation of peripheral embolism was corroborated by angiography. Echocardiographic study showed masses in both right and left atria. Pathologic specimen from the embolus confirmed the diagnosis of aspergillosis.

Aorto-right atrial fistula.

We report a child in whom a fistula connected the descending thoracic aorta to the right atrium. This is a previously unreported cardiac malformation. The patient was initially misdiagnosed as having a patent ductus arteriosus (PDA). On clinical examination and auscultation, the problem was different from PDA in that the continuous machinery murmur was better heard on the right parasternal area and posteriorly on the left. Surgical ligation of the fistula through a left thoracotomy abolished the murmur.

Detection of intracoronary air embolism by echocardiography.

We report the diagnosis of intracoronary air embolism by transesophageal echocardiography in 2 patients undergoing open heart surgery. The sudden appearance of inferior wall akinesis with increased brightness of the area immediately after removal of the aortic cross clamp and spontaneous resolution of the abnormalities support the diagnosis of intracoronary air embolism.