The Use of Systematic Clinical Approach in Diagnosing Rare Cases of Secondary Hypertension: A Case Report of Mid Aortic Syndrome in a Young Patient.

Mid aortic syndrome (MAS) is a rare disease that occurs in children and young adults. The most important clinical feature reflecting vascular involvement is the presence of systemic hypertension. The diagnosis is usually made during the imaging assessment of secondary hypertension when routine echocardiography fails to identify the characteristic morphological or Doppler flow patterns associated with thoracic arch coarctation in the presence of the clinical features of aortic vascular obstruction. In this report, we present a case of a 22-year-old male who presented with systemic hypertension not responding to medical treatment, and whose systematic diagnostic workup revealed the diagnosis of MAS involving both renal arteries.

Therapeutic Hypothermia With Progesterone Improves Neurologic Outcomes in Ventricular Fibrillation Cardiac Arrest After Electric Shock.

Trauma by electricity imposes mechanical, electrical, and thermal forces on the human body. Often, the delicate cardiac electrophysiology is disrupted causing dysrhythmia and subsequent cardiac arrest. Anoxic brain injury (ABI) is the most severe consequence and the main cause of mortality following cardiac arrest. Establishing a working protocol to treat patients who are at risk for ABI after suffering a cardiac arrest is of paramount importance. There has yet to be sufficient exploration of combination therapy of therapeutic hypothermia (TH) and progesterone as a neuroprotective strategy in patients who have suffered cardiac arrest after electric shock. The protocol required TH initiation upon transfer to the ICU with a target core body temperature of 33°C for 18 hours. This was achieved through a combination of cooling blankets, ice packs, chilled IV fluids, nasogastric lavage with iced saline, and intravascular cooling devices. Progesterone therapy at 80-100 mg intramuscularly every 12 hours for 72 hours was initiated shortly after admission to the ICU. We present a case series of three patients (mean age = 29.3 years, mean presenting Glasgow Coma Score = 3) who suffered ventricular fibrillation (VF) cardiac arrest from non-lightning electric shock, and who had considerably improved outcomes following the TH-progesterone combination therapy protocol. The average length of stay was 13.7 days. The cases presented suggest that there may be a role for neuroprotective combination therapy in post-resuscitation care of VF cardiac arrest. While TH is well documented as a neuroprotective measure, progesterone administration is a safe therapy with promising, albeit currently inconclusive, neuroprotective effect. Future protocols involving TH and progesterone combination therapy in these patients should be further explored.

The Grave Consequences of Late Presentation and Management of Rare Double Left Ventricle Chamber With Cardiomyopathy.

A double­chambered left ventricle is a rare congenital anomaly. We present the case of a 26-year-old man with such anomaly who presented with congestive heart failure. After this diagnosis was confirmed with echocardiography, surgical removal of the anomalous band and replacement of the regurgitant deformed mitral valve were performed. Postoperatively, the patient deteriorated, and no corrective response was associated with surgery. Herein we discuss what we have learned from this rare case and how it may apply to the management of similar cases in the future.

Acute Myocardial Ischemia Secondary to Embolization of Left Atrial Myxoma to Coronary Artery.

Cardiac myxoma is the most common primary cardiac tumor. Rarely it can present with systemic or coronary embolization due to fragmentation of the tumor mass. We present a case of a young male who presented with an acute myocardial ischemia secondary to embolization of a left atrial myxoma originating from the left atrium. The patient underwent successful emergency surgical management of both the myxoma and the occlusion of the coronary artery. In this scenario, the surgery is the only effective treatment. The case also highlights the significance of performing emergency echocardiography in the setting of acute myocardial ischemia to look for possible associated pathology which can inform management plan.

Surgical Management of Cardiac Hydatid Cyst and the Residual Intramural Ectocyst.

The cardiac hydatid cyst (HC) is a rare pathology and mostly is endemic in livestock raising countries. Patients do not have a specific presentation so it is mainly a diagnosis based on imaging. Finding HC anywhere in the body warrants looking for another hydatid in other organs. This is a case report of a young male who presented with nonspecific symptoms and during diagnostic workup, it happened that he has combined hepatic and cardiac HCs. The cardiac cyst was located intramurally in the interventricular septum and expanding down mostly to the left side of the diaphragmatic surface of the heart and partly crossing intramurally to the diaphragmatic surface of the right ventricle. Emergency open-heart surgery was performed; the endocyst was removed while intramural ectocyst was drained to prevent potential future residual space.

A Case Report of a Ventral Hernia Containing a Liver Cyst in a Patient with Autosomal Dominant Polycystic Kidney Disease.

Autosomal dominant polycystic kidney disease (ADPKD) is the most commonly inherited renal disorder and the fourth most common cause of end-stage renal disease. ADPKD is a systemic disease with multiple extrarenal manifestations, including cystic involvement of other organs, such as the liver and pancreas, and connective tissue abnormalities. The prevalence of hernias is higher in patients with ADPKD. It has been hypothesized that these hernias are the result of abnormal extracellular matrix production and/or increased intra-abdominal pressure from the cyst burden. We present a case of a 56-year-old female with polycystic kidney disease who was admitted for an incarcerated ventral hernia. The patient presented with obstructive symptoms concerning for bowel impingement. The patient underwent operative management, and during the procedure, an incarcerated liver cyst was identified in the hernia sac. This was successfully reduced, and the hernia was repaired with mesh.

The Effectiveness of Laparoscopic-assisted Percutaneous Endoscopic Gastrostomy in Patients with Unfavorable Anatomy: A Single-center Retrospective Cohort Study.

Percutaneous endoscopic gastrostomy (PEG) is an easy means to provide enteral access in patients unable to maintain adequate nutrition via the oral route. In patients with morbid obesity, altered intra-abdominal anatomy due to prior abdominal surgery, the interposition of the colon or other factors precluding endoscopy, feeding tube placement by laparoscopic means (LAPEG) can provide a potentially safe alternative. The objective of this study was to examine the efficacy and outcomes of laparoscopic-assisted placement of PEG in adult patients. This is a retrospective cohort analysis of adult patients, who underwent PEG and/or laparoscopic-assisted percutaneous endoscopic gastrostomy placement (LAPEG) by two surgeons at a single institution. A total of 36 patients underwent PEG and/or LAPEG. No significant differences were found in the total and postoperative length of stay and mortality. There were no procedure-related complications in the LAPEG group versus two in the PEG group (8.7%), but this did not reach statistical significance. LAPEG was 100% successful in gaining enteral feeding access in patients that had failed PEG. The most common reason for PEG placement failure was colonic interposition (39%), followed by intra-abdominal adhesions and gastric displacement by hiatal hernia (each 23%). 38.5% of LAPG procedures could be done via 5-mm single port access, 38.5% required two-port and 23% required three-port access. In conclusion, LAPEG is a feasible minimally invasive alternative to gain enteral feeding access in patients that have failed PEG that does not increase the length of stay, morbidity or mortality.

Asynchronous Bilateral Obturator Hernias: A Suggested Approach to Reduce Morbidity of Obturator Hernias.

Obturator hernias (OHs) are rare pelvic hernias that involve the protrusion of intraperitoneal or extraperitoneal organs or tissues through the obturator foramen. Risk factors for OH patients include female gender, chronic disease, age, malnourishment, history of multiple pregnancies, anatomical enlargement of obturator foramen, increased intraabdominal pressure, and defective collagen metabolism. Since OHs have the highest mortality rate of all abdominal hernias, prompt diagnosis and treatment are critical. Prior research has demonstrated an increased likelihood of bilateral OHs relative to unilateral. We present the case of a 79-year-old female who presented with an obstructed OH six months after an operation for an OH on the contralateral side. Due to the potential morbidity and mortality associated with OHs and delay in discovery, we suggest evaluation and treatment of the contralateral side in patients who present with unilateral OHs.

Combined Extra- and Intrapleural Hematoma After Blunt Chest Injury in an Anticoagulated Patient.

The objective of this study was to describe the atypical presentation of combined intrapleural and extrapleural hematomas in patients on anticoagulant therapy and explain the best workup and treatment for this pathology. This case report details the presentation, initial treatment, initial workup, and subsequent final treatment and workup of an elderly female patient that arrived at our trauma facility after suffering a blunt force trauma. The patient received anticoagulation therapy for her comorbidities prior to this incident. The outcome of interest was to better understand the best diagnostic and treatment modalities for treating combined intrapleural and extrapleural hematomas.

Abdominal Apoplexy: A Case Study of Idiopathic Spontaneous Lesser Sac Hematoma.

Idiopathic spontaneous intraperitoneal hemorrhage (ISIH) is a rare event associated with high mortality. There have been multiple case reports of spontaneous rupture of middle colic pseudoaneurysms in the literature. Herein, we present a case of a 51-year-old female that presented with spontaneous rupture of the middle colic artery and associated massive intraabdominal hematoma without findings of a pseudoaneurysm. The patient underwent a computed tomography (CT) scan as an outpatient 24 hours prior to the onset of the bleeding due to abdominal pain without findings of hematoma or aneurysm of the mesenteric vessels. Subsequently, the patient underwent emergent exploratory laparotomy with findings of a massive hematoma in the lesser sac and spontaneous bleeding from the middle colic artery that was ligated. The patient had an uneventful postoperative course and fully recovered. To our knowledge, this is the second reported case of idiopathic bleeding from the middle colic artery without evidence of a pseudoaneurysm based on a current review of the literature.

Diaphragmatic Hernia Repair Using Biosynthetic Tissue Reinforcement Patch: A Case Series Experience.

Diaphragmatic hernias are commonly encountered by general surgeons. However, repair is often fraught with complications and recurrence. The use of extracellular matrix scaffolds for repair of damaged tissues through constructive remodeling is an effective surgical adjunct. Herein, we describe the repair of diaphragmatic hernias using GORE® BIO-A® Tissue Reinforcement patch in a series of patients.

Combined Coronary Artery Bypass Grafting and Extra-anatomic Ascending Aorta to Bifemoral Grafting Through Median Sternotomy.

A high proportion of patients with severe systemic atherosclerotic disease present with the involvement of both the coronary and aortoiliac arteries. For these patients with multiple comorbidities and high surgical risk, it is critical to minimize the overall physiologic burden of the operation when possible. Furthermore, with severe or complete occlusion of vascular supply to the lower extremities, it is beneficial to avoid two-stage surgeries because of the high risk of irreversible ischemia necessitating amputation. In select cases, a single combined operation without entering the abdominal cavity may be a reliable option. We present a case with excellent results using the technique of coronary artery bypass grafting (CABG) and extra-anatomic ascending aorta to bifemoral grafting through median sternotomy and subcutaneous tunneling. Furthermore, there is a wide variation in anticoagulation reversal practices among surgeons after performing these combined grafting operations. We administered only half of the ideal calculated protamine dose for reversal of heparinization, which achieved favorable results in our patient. Overall, with symptomatic occlusion of the coronary and aortoiliac arteries, combined CABG and extra-anatomic aortobifemoral grafting with subcutaneous tunneling is a reliable surgical option. The indication for this approach should be tailored to the anatomy of the lesion and the urgency of the clinical scenario.

Pneumomediastinum After Dental Filling: A Rare Case Presentation.

Pneumomediastinum and subcutaneous emphysema is an uncommon potentially life-threatening complication of dental procedures. Common causes of pneumomediastinum after dental procedures include tooth extraction, preparation, restorative treatment, endodontic treatment, and subgingival curettage that are associated with the use of handpieces and high-pressure air/water syringes. Herein, we present a case of pneumomediastinum with subcutaneous emphysema in a 40-year-old female who underwent two dental fillings and presented to our hospital with chief complain of facial swelling and odynophagia. The patient was managed conservatively, had an uneventful hospital course, and fully recovered. This case underlines the need for prompt diagnosis and management because of the risk of airway compromise, air embolism, and infection. The mechanism, clinical presentation, differential diagnosis, and complications are also reviewed.

Combined Myocardial Bridge and Coronary Vessel Disease Requiring Coronary Artery Bypass Grafting and Myotomy of the Myocardial Bridge.

Myocardial bridging (MB) describes a band of myocardium that covers the epicardial surface of the coronary artery. This band can vary both in thickness and distance to which it covers the artery. It is broadly classified as superficial or deep, depending on the thickness of the covering muscle layer. It can be asymptomatic, or it could present with different complications. Reported complications have included ischemia and acute coronary syndromes, coronary spasm, ventricular septal rupture, and arrhythmias. MB is most commonly found in the middle segment of the left anterior descending (LAD) coronary artery. There is controversy with regard to therapy for symptomatic patients who are refractory to medical management. Percutaneous coronary intervention and surgical myotomy (unroofing) have been proposed; yet, each one has its pros and cons. MB can be associated with the development of atherosclerosis proximal to the MB segment in the involved coronary artery, and patients can present having both pathologies. We present a case series of six patients with atherosclerotic coronary lesions requiring coronary artery bypass grafting (CABG) with an accidental perioperative finding of MB, which required myotomy.

Hepatic Artery Aneurysm in the Setting of Acute Pancreatitis and Giant Cell Arteritis.

Visceral artery aneurysms are rare with an incidence of 0.1%-0.2%. Of these, 20% are hepatic artery aneurysms (HAAs). Despite the potential of remaining asymptomatic for long periods of time, the risk of rupture for HAAs is 20%-80%. Treatment includes operative management with open or endovascular techniques. HAA in the setting of pancreatitis has been reported in two prior cases outside of the United States. However, there have been no cases describing the association of HAA and giant cell arteritis (GCA). We present a rare case of an 80-year-old male with a history of GCA who was found to have developed HAA following an episode of acute pancreatitis that was repaired surgically with an open technique. To our knowledge, the association between HAA with acute pancreatitis and GCA has not been reported before.

Persistent Shoulder Pain Due to a Suprascapular Nerve Injury in the Setting of Trauma.

Suprascapular neuropathy is a rare cause of shoulder pain with an injury to the nerve intrinsically related to the anatomy and course of the suprascapular nerve. The common etiologies of a suprascapular nerve injury include repetitive overhead activity, rotator cuff pathology, and compression of the nerve at either the suprascapular or the spinoglenoid notch secondary to space-occupying lesions. Although uncommon, suprascapular nerve damage has been associated with scapular fractures previously. However, there is a scarcity of literature describing a suprascapular nerve injury as the etiology of persistent shoulder pain after trauma. We present the case of a 52-year-old male who was struck by a motor vehicle, suffered a scapular fracture, and developed persistent shoulder pain secondary to a suprascapular nerve injury diagnosed 15 months post trauma.

An Unusual Presentation of a Cardiac Foreign Body in a Pediatric Patient.

Cardiac foreign bodies (FBs) are rare. Their etiology can be attributed to penetrating injuries although they are also often found incidentally. The approach for removal of these FBs is variable and patient dependent. Although there is debate regarding indications for removal, there is a general consensus that symptomatic FBs presenting acutely, as well as asymptomatic FBs posing a greater risk of complication to the patient, should be removed. We present the case of a 14-year-old patient with a cardiac FB and a step-wise approach for removal.