Anomalous Coronary Arteries: A Cause for Malignant Arrhythmias.

Anomalous aortic origin of a coronary artery (AAOCA) is a congenital condition that can lead to sudden cardiac death (SCD), particularly among young individuals. The cause of SCD is thought to be ischemia, primarily related to the course of the anomalous coronary artery. Surgical intervention, such as unroofing or coronary revascularization, is the preferred management modality for patients with evidence of ischemia or concomitant fixed obstruction. Herein, we presented a case of a 24-year-old male admitted to the emergency department with a history of palpitations, dyspnea, diaphoresis, and syncope. The patient had no prior medical diseases and was eventually diagnosed with an anomalous right coronary artery (ARCA) originating from the left coronary sinus. The patient underwent surgical unroofing of the ARCA to prevent further episodes of ischemia and ventricular arrhythmias. The case highlights that coronary artery anomalies can be life-threatening and lead to SCD, especially in young individuals with no risk factors. Investigating coronary anomalies in medically free patients presenting with cardiac symptoms and arrhythmias is crucial.

Clinically Amyopathic Dermatomyositis With Rapid Progressive Interstitial Lung Disease Diagnosed in a Patient on Extracorporeal Membrane Oxygenation.

Clinically amyopathic dermatomyositis (CADM) is characterized by skin manifestations with minimal to no muscle involvement. It is a unique subset of dermatomyositis, which may create a diagnostic challenge due to its vague presentation. Establishing the diagnosis is crucial as CADM is highly associated with rapidly progressive interstitial lung disease (RP-ILD), and patients who suffer from thereof have an abysmal prognosis. Herein, we described a case of a 46-year-old male who presented with a history of skin rash and then started to experience shortness of breath. His respiratory symptoms were progressing swiftly and affected his daily life activities. The initial blood tests were normal, but his chest imaging revealed fibrotic nonspecific interstitial pneumonia. The patient required intubation due to a critical respiratory condition, and later, he needed extracorporeal membrane oxygenation (ECMO). While the patient was connected to an ECMO machine, a bedside open lung biopsy (BOLB) was performed, and the results were in keeping with RP-ILD and CADM. The patient was started on cyclophosphamide without a response, and his chest computed tomography showed acute respiratory distress syndrome. His hospital course was complicated with pneumonia, severe kidney dysfunction requiring dialysis, and candidemia, which resulted in the patient's death.

Self-Expandable Transcatheter Aortic Valve Implantation Outcomes: Findings From the Western Region of Saudi Arabia.

Background and objective The prevalence of aortic stenosis in Saudi Arabia is expected to increase owing to the rise in the life expectancy of the population. Such increase is expected to be met with higher demand for interventions including transcatheter aortic valve implantation (TAVI). In this study, we aimed to identify the outcomes of this procedure among the population of the Western region of Saudi Arabia. Methods This was a retrospective observational study involving patients who underwent TAVI at the King Faisal Cardiac Center (KFCC), Jeddah, Saudi Arabia from June 2018 to January 2020. All patients who had undergone TAVI were included, and patients who were lost to follow-up for more than 90 days were excluded. The collected data included sociodemographic characteristics, peri-procedural assessment, and outcomes within 90 days. Results The study included a total of 52 patients. There were 28 males (53.8%) and 24 females (46.2%). The mean age of the cohort was 78 years. Type two diabetes mellitus was present in 67.3%, and hypertension and dyslipidemia were seen in 80.8% of patients. Coronary diseases were seen in 55.8%. The majority had prior percutaneous coronary intervention (PCI) (53.8%) and 3.8% had coronary artery bypass grafting (CABG). Twenty patients (38.5%) had heart failure. Atrial fibrillation was encountered in 13 patients (25%). Chronic kidney disease was described in nine (17.3%) patients, and four (7.7%) were on regular hemodialysis. The median Society of Thoracic Surgery (STS) risk score was 2.4 (IQR: 1.97-5). High STS scores (>8) were only seen in 9% of the patients. The success rate was 98%, and the in-hospital mortality rate was 3.8%. Vascular complications were seen in eight patients (15.4%), and the majority of them were minor. One patient (1.9%) had a major vascular complication. There was a tendency toward high blood transfusions (19.2%). Clinically manifest stroke was seen in three patients (5.8%). Eight patients (15.4%) had post-procedure complete heart block (CHB). Endocarditis was seen in two patients (3.8%). Thirty-day cardiac readmission was observed in 17.3% of patients, and acute kidney injury was seen in eight patients (15.4%). Mild aortic regurgitation was seen in 51.9% of the patients, but moderate or severe aortic insufficiency (AI) was not encountered. Conclusion Transfemoral TAVI using a self-expandable valve is a safe and feasible procedure at KFCC, an intermediate-sized center. Our data is comparable to local and international centers of similar size. Program sustainability depends on the development of robust referral networks and implementing regulatory quality and patient safety standards.

Acute Esophageal Necrosis Early after Renal Transplantation.

BACKGROUND: Acute esophageal necrosis (AEN) is defined as a diffused black discoloration of the esophageal mucosa involving mainly the distal part of the esophagus. It is considered a rare clinical entity with a high mortality rate. The etiology of AEN is unknown, but it has been correlated to many causes such as malignancies, infections, and hemodynamics instability. Here, we report a case of a patient developing AEN a few days after kidney transplantation. Case Presentation. A 57-year-old male was admitted electively for kidney transplantation that he received from his son. The surgery was complicated with a significant drop in blood pressure but otherwise was uneventful. The patient was showing good signs of recovery but then suffered from significant hematemesis. An urgent upper esophagogastroduodenoscopy revealed black discoloration of the esophageal mucosa in keeping with AEN. The patient was treated with proton pump inhibitors infusion and started empirically on antivirals and antifungals. The patient's condition improved in regards to the AEN; nonetheless, the complications resulted in graft loss, and the patient returned to hemodialysis. CONCLUSION: AEN is a critical condition that mandates early intervention. Identifying high-risk populations may aid in early anticipation and diagnosis. Patients with chronic kidney disease are at risk of atherosclerosis leading to a low flow state which is exacerbated during renal transplantation surgery, especially if the procedure was complicated with a drop in blood pressure.

A Case of Systemic Lupus Erythematosus in a Patient Presenting with Libman-Sacks Endocarditis.

BACKGROUND: Libman-Sacks endocarditis (LSE) is a rare cardiovascular manifestation of systemic lupus erythematosus/antiphospholipid syndrome that is described as a sterile verrucous nonbacterial vegetative lesion. These lesions can cause progressive damage to the heart valves leading to valve surgery. The most common valves to be affected are the aortic and mitral valves. Libman-Sacks endocarditis is associated with malignancies, other systemic diseases like systemic lupus erythematosus (SLE) and antiphospholipid antibody syndrome (APS). The majority of LSE patients are usually asymptomatic. Case Summary. We describe a 39-year-old male patient who presented with increasing shortness of breath and pulmonary congestion. He was found to have severe mitral valve regurgitation and mitral stenosis. Transesophageal echocardiogram confirmed the diagnosis of Libman-Sacks endocarditis with thickened mitral valve leaflets with symmetrical mass-like structure causing a restriction in the valve function during both cardiac phases later diagnosed with systemic lupus erythematosus by immunology. The patient was started on diuretics, anticoagulants, angiotensin inhibitors, beta-blockers, and hydroxychloroquine. He underwent successful mechanical mitral valve replacement with a 27 mm St. Jude valve. The mitral valve was found to be grossly thickened with friable tissue and complete amalgamation of the leaflets with subvalvular apparatus. The patient suffered some warfarin adverse effects a year later but did well otherwise. CONCLUSION: This case demonstrates that Libman-Sacks endocarditis can be the first manifestation of systemic lupus erythematosus. Early and prompt diagnosis of LSE can prevent and lessen the many side effects associated with thromboembolism. Additionally, addressing the underlying disease is key to successful treatment.

Leclercia adecarboxylata Bacteremia without a Focus in a Non-Immunosuppressed Patient.

BACKGROUND Leclercia adecarboxylata is a gram-negative rod, which is normally found in water and food. It is an emerging pathogen that affects immunocompromised patients, including patients with hematological malignancies or those receiving chemotherapy. Generally, L. adecarboxylata is considered a low-virulence pathogen with an excellent susceptibility profile, but some strains may be resistant to multiple antibiotics, such as b-lactams. Moreover, L. adecarboxylata is usually isolated as a part of polymicrobial cultures in immunocompetent individuals, but there have been cases where it was the only isolate. CASE REPORT A 74-year-old woman who was non-immunosuppressed and had multiple comorbidities was admitted with acute decompensated heart failure due to pneumonia. She was treated with multiple courses of antibiotics including amoxicillin-clavulanate and ciprofloxacin for pneumonia, but her infection worsened, and she had cardiopulmonary arrest. After resuscitation, she was stable for several days but suddenly became confused and hypotensive. The septic screen showed L. adecarboxylata bacteremia without a clear source, which was treated successfully with meropenem for 14 days. After the meropenem course, the patient developed diarrhea and was found to have severe Clostridium difficile infection. She did not respond to oral vancomycin and intravenous metronidazole and died. CONCLUSIONS This case illustrated an infection in a non-immunosuppressed individual by an organism that is considered an opportunistic pathogen, mainly affecting immunocompromised patients. The patient's blood culture grew L. adecarboxylata, which was sensitive to all antibiotics but resolved with meropenem treatment. Owing to increasing L. adecarboxylata infections, we recommend further studies to understand the organism's pathogenesis, risk factors, and resistance pattern.

Cyclophosphamide as a Treatment for Focal Segmental Glomerular Sclerosis Recurrence in a Kidney Transplant Patient.

BACKGROUND Primary focal segmental glomerular sclerosis (FSGS) frequently causes recurrence after kidney transplantation, leading to graft loss in half of the patients. Conservative treatment of FSGS is the main acceptable method due to the lack of randomized clinical trials. A few strategies are known to treat FSGS recurrence, such as plasmapheresis and intravenous immunoglobulin (IVIG), but failure to achieve remission may occur. In addition, some of these treatment strategies are more established in pediatric patients and lack evidence in adult patients. CASE REPORT We describe the case of a 24-year-old woman who had a kidney transplant due to FSGS and was admitted to the hospital for an evaluation of lower-limb and facial swelling. Her kidney biopsy showed segmental glomerulosclerosis compatible with recurrence of FSGS. Her FSGS relapses were further confirmed by increase in serum creatinine and proteinuria. The patient had several FSGS relapses that were treated by different combinations of plasmapheresis, pulse steroid, mycophenolic acid, tacrolimus, prednisolone, IVIG, and IV rituximab. She did not respond to conventional therapy and was eventually treated successfully using cyclophosphamide and remained in remission afterward. CONCLUSIONS FSGS has a high recurrence rate after kidney transplantation. A few options to achieve remission have been investigated. In this report, we present the case of a young woman with FSGS recurrence after a kidney transplant, achieving remission successfully with cyclophosphamide. Cyclophosphamide can be used a treatment of FSGS recurrence in a transplanted kidney when all other options have been exhausted. Additional research is needed to assess the efficacy and safety profile of cyclophosphamide in such cases.

Late Complications After Previous Surgical Repair for Coarctation With Extra-Anatomic Bypass Graft: Report on Two Cases.

Surgical correction of aortic coarctation (CoA) has been the standard treatment in infants and adolescents to prevent late consequences related to obstruction and distal hypoperfusion. Several surgical techniques for CoA repair have traditionally been applied. However, late complications, including re-CoA and pseudoaneurysm formation, are not uncommon. The incidence of complications is highly related to the type of initial surgery. Here, we are reporting two cases of late complications related to an infrequently used surgical technique, the extra-anatomical aortic bypass graft (EABG). The first case presented with pseudoaneurysm at the distal anastomosis site with the descending aorta and treated by endovascular stent graft. The second case presented with stenosis at the proximal anastomosis site with the left subclavian artery (LSCA) and treated medically upon the request of the patient.

Relentless Hypoxia in a Patient With Carcinoid Syndrome.

Patent foramen ovale (PFO) in patients with carcinoid heart disease (CHD) may result in hypoxia due to the presence of large right (R) to left (L) intracardiac shunts leading to hypoxia and worsening clinical condition. Percutaneous closure of the PFO can normalize oxygen saturation, relieve symptoms, and lessens left-sided heart valves involvement. We describe a case of a 70-year-old female patient with a history of small bowel neuroendocrine tumor on monthly octreotide infusion presented with worsening exertional dyspnea and hypoxia secondary to R to L intracardiac shunt through the PFO. The decision was made to close the PFO percutaneously with Amplatzer (Plymouth, MN: Abbott) PFO occluder device which resulted in immediate normalization of oxygen saturation and relief of her dyspnea.

Flexible Fiberoptic Bronchoscopy: Indications, Diagnostic Yield and Complications.

Objective Flexible fiberoptic bronchoscopy (FFB) has become an essential procedure for diagnosing and managing various respiratory conditions. We aimed to assess the main indications, diagnostic yield, and safety of FFB in our institute. Methods A total of 216 patients who underwent FFB between July 2009 and June 2012 at King Abdul-Aziz Medical City, Jeddah, Saudi Arabia, were reviewed retrospectively. Indications of the procedure, the diagnostic yield of variable respiratory diseases, and complications were reported. Result Out of 216 patients, 210 (97.2%) completed FFB. One hundred and ninety-eight (91.7%) bronchoscopies were for diagnostic purposes, and the remaining 12 (5.6%) were for therapeutic aim. The mean age of patients was 50 years ± 20 years and patients. Respiratory infection, malignancy, pulmonary infiltrate in febrile neutropenia (FN), and hemoptysis in order of frequency were the main indications. The overall diagnostic yield was 46%. Mycobacterium tuberculosis (MTB) was the most common indication (26.8%) and was identified in 37.7%, whereas pneumonia was confirmed in 46.3% of the patients. Malignancy was established in 35.3% of suspected cases, while eosinophilic pneumonia was diagnosed in 100%. The diagnostic yield in pulmonary infiltrates of human immunodeficiency viral (HIV) was 85.7%. Alveolar hemorrhage was the most common cause of hemoptysis. Out of therapeutic bronchoscopy, lung collapse was the main indication. There is no mortality and complications occurred in 1.5% of the cases. Conclusion MTB was the most common indication of FFB, followed by malignancy. It has a high diagnostic yield in eosinophilic pneumonia and pulmonary infiltrates in HIV patients. FFB is shown to be a safe modality for diagnostic and therapeutic purposes.

Percutaneous Intervention With Balloon-Expandable Covered Stent for the Treatment of Traumatic Aortic Pseudoaneurysm in a Paediatric Patient.

In this report, we describe the case of a 13-year-old male who presented to our hospital after sustaining injuries from a motor vehicle accident (MVA). A full-body CT scan revealed multiple injuries, including subgaleal hematoma, hemorrhagic brain contusion, moderate-size aortic pseudoaneurysm with associated mediastinal hematoma, and multiple stable visceral organ lacerations. Additionally, there were numerous fractures, including in the right femur associated with large hematoma. The patient was deemed at high risk for systemic anticoagulation required for an urgent operative aortic repair. Available percutaneous endograft sizes were deemed too large for his descending aortic diameter, and the associated potential risk of vessel injury from the large sheath required to implant the endograft removed this option from consideration. The decision was made to use a balloon-expandable covered stent, which is routinely used to treat coarctation of the aorta (CoA) as a life-saving alternative. A BeGraft aortic stent (Bentley InnoMed, Hechingen, Germany) measuring 16x38 mm was successfully implanted percutaneously with complete exclusion of the pseudoaneurysm without any procedural complications.

The Perception of Coronary Artery Disease and Cardiac Catheterization in Saudi Arabia: "What the Public Know".

Objective Coronary artery disease (CAD) constitutes a significant health hazard in middle-aged individuals in Saudi Arabia. We sought to assess the level of knowledge of cardiovascular risk factors and describe the perception of coronary intervention among the general population in the city of Jeddah in the western part of Saudi Arabia. Methods A cross-sectional study was conducted in the city of Jeddah during the period from April 2019 to September 1, 2019, by using a structured online questionnaire to assess the participants' awareness of risk factors for CAD and coronary intervention. The survey included questions about socio-demographic data, risk factors of cardiovascular diseases, symptoms of heart attack, knowledge of coronary catheterizations, as well as resources of knowledge about coronary heart disease. Results The study included 984 participants. The majority of the participants had university diplomas (78.1%). Only 38.5 % were healthcare workers. Dyslipidemia and smoking were identified by 70.5% and 66.7%, respectively, as a recognized risk factor for CAD. Diabetes was mentioned by 32.1%. Participants without CAD risk factors had a significantly lower level of knowledge regarding the strong association between diabetes mellitus (DM) II and CAD (p-value=0.02). Healthcare professionals had a significantly lower level of knowledge regarding cardiac catheterization as compared to non-healthcare professionals. A higher percentage of healthcare professionals would agree to have cardiac catheterization if indicated (p-value=0.003). Awareness campaigns were the most common source of information for the public. Conclusion The current level of knowledge of CAD in the western part of Saudi Arabia is fair. National awareness campaigns are required to improve the level of healthcare education.

Etiology of Pericardial Effusion and Outcomes Post Pericardiocentesis in the Western Region of Saudi Arabia: A Single-center Experience.

Background Pericardial effusion is the accumulation of blood or excess fluid in the cavity between the heart and the pericardium sac. Pericardial effusion can be caused by several etiologies, including malignant and non-malignant causes. Pericardiocentesis is the gold standard assessment method for pericardial effusion etiology. The aim of this study was to identify the long-term outcome of patients who presented with massive pericardial effusion and underwent pericardiocentesis at King Abdulaziz Medical City, Jeddah, a large tertiary hospital in the western part of Saudi Arabia. Methods This is a single-center retrospective cross-sectional study conducted at King Abdulaziz Medical City Jeddah, Saudi Arabia, between January 2013 to December 2018. Data were collected from patient's charts; the clinical and echocardiographic findings, alongside with pericardial fluid analysis, were collected. Procedure and patients outcomes were obtained and reported. Results Of the 107 patients with pericardial effusion, 39 patients had moderate to severe pericardial effusion requiring pericardiocentesis. The mean age was 52 years, and 56.4% were females. The most common chronic disease was hypertension and the presence of metastasis. The most common cause of pericardial effusion was a malignancy. A majority of patients had severe pericardial effusion. Many patients had tamponade (69.6%). Patients with malignant pericardial effusion had a median survival of 54 days. Conclusion Etiologies of pericardial effusion requiring drainage depend on the population studied. Patients with malignant effusions have worse outcomes than non-malignant effusion. Pericardiocentesis is required to ascertain the cause and risk-stratify patients.