Acquired aortopulmonary fistula: a case report.

BACKGROUND: Aortopulmonary fistula is a rare complication of ascending aorta pathology. Presentation is most commonly dramatic with acute onset chest pain or heart failure secondary to left to right shunting. We describe a patient with acquired aortopulmonary fistula who had an insidious onset of heart failure as his presenting complaint. We also highlight the utility of multimodality cardiac imaging in establishing the diagnosis. CASE SUMMARY: A 79-year-old male patient with a history of coronary artery bypass graft surgery and mechanical aortic valve replacement, 23 years prior, presented with exertional dyspnoea of 7 months duration. An initial workup that included transthoracic and transoesophageal echocardiography as well as coronary and bypass graft angiography failed to diagnose an acquired aortopulmonary fistula complicating an ascending aortic pseudoaneurysm. Upon referral to our institution, the correct diagnosis was suspected on off-axis transthoracic echocardiography. The fistula was subsequently confirmed, and the extent of ascending aorta pathology defined via a multimodality imaging approach that consisted of transoesophageal echocardiography and cardiac computed tomography. The patient underwent successful surgical repair and was discharged in a stable condition. DISCUSSION: Acquired aortopulmonary fistula is a rare clinical entity. We describe a patient who had an insidious presentation of heart failure and found to have a large ascending aortic aneurysm that eroded into the main pulmonary artery creating a fistulous communication. The diagnosis was delayed and required a high index of suspicion and multimodality cardiac imaging.

Regadenoson administration and QT interval prolongation during pharmacological radionuclide myocardial perfusion imaging.

The objective of our study is to assess change in QTc interval with Regadenoson administration during myocardial perfusion imaging (MPI). We conducted a retrospective, observational analysis of 1497 consecutive patients who underwent pharmacological radionuclide MPI. On multivariate logistic regression analyses, there was no statistical significance of QTc prolongation when adjusted for ischemia/fixed perfusion defect on MPI and QT prolonging medications being taken prior to stress testing. However, a positive stress ECG after Regadenoson injection had a statistical significance (p value 0.0004). Regadenoson is a safe drug for use in MPI with little, if any, side effects of major clinical significance.

Coronary intervention and arteria lusoria-Not simple as it may seem.

We reviewed the letter from Dr. Walter W. Woody and would like to thank him for showing his interest in our article and providing his opinion and point of view. However, we respectfully disagree with few points that have been raised. Switching to a femoral approach was considered to be a safer alternative for percutaneous intervention due to the presence of arteria lusoria. Risks and possible complications would include increased contrast use, increased radiation exposure, aortic dissection and even cerebral stroke, all of which have been reported extensively in literature. One single procedural methodology cannot be applied to a particular clinical scenario, whether simple or challenging. We have multiple different catheters and multiple different interventional approaches at our disposal to help and guide us through a case, in the best interest of the patient.

Incidental finding of arteria lusoria during transradial coronary catheterization: Significance in interventional cardiology.

Arteria lusoria is the most common anomaly of the aortic arch with an incidence of 0.5%-2.5%. It is mostly diagnosed incidentally while performing imaging for evaluation of other unrelated medical conditions. The aberrant right subclavian artery arises beyond the origin of the left subclavian artery from the aortic arch. This results in a complex right-subclavian-aortic anatomy which leads to difficulty in transradial coronary angiography. This can lead to prolonged procedure time and increased use of catheters by unaware interventionists. This is even more important if this is encountered in the setting of an acute myocardial infarction. Our review takes into account clinical significance of this uncommon anomaly in the field of interventional cardiology.

Cardiac Evaluation and Monitoring of Patients Undergoing Noncardiac Surgery.

Surgical management of disease has a tremendous impact on our health system. Millions of people worldwide undergo surgeries every year. Cardiovascular complications in the perioperative period are one of the most common events leading to increased morbidity and mortality. Although such events are very small in number, they are associated with a high mortality rate making it essential for physicians to understand the importance of perioperative cardiovascular risk assessment and evaluation. Its involves a detailed process of history taking, patient's medical profile, medications being used, functional status of the patient, and knowledge about the surgical procedure and its inherent risks. Different risk assessment tools and calculators have also been developed to aid in this process, each with their own advantages and limitations. After such a comprehensive evaluation, a physician will be able to provide a risk assessment or it may all lead to further testing if it is believed that a change in management after such testing will help to reduce perioperative morbidity and mortality. There is extensive literature on the significance of multiple perioperative testing modalities and how they can change management. The purpose of our review is to provide a concise but comprehensive analysis on all such aspects of perioperative cardiovascular risk assessment for noncardiac surgeries and provide a basic methodology toward such assessment and decision making.

Failing phrenics: an obscure cause of exertional dyspnea: Case report and literature review.

INTRODUCTION: Idiopathic phrenic nerve palsy is a rare cause of exertional dyspnea. We present a case of a patient presenting with worsening dyspnea of an unknown etiology found to be related to bilateral phrenic nerve palsy. DISCUSSION: Forty-two-year-old man presented to our emergency department with exertional dyspnea, orthopnea, and a left lower lobe consolidation treated initially as bronchitis by his primary physician as an outpatient, then subsequently as pneumonia at another institution, with no improvement in symptomatology. After admission to our hospital, CT chest demonstrated only supradiaphragmatic atelectatic changes. Echocardiography was normal. Bronchoscopy was contemplated however the patient could not lie flat. A fluoroscopic sniff test demonstrated diaphragmatic dysfunction and pulmonary function tests revealed restrictive pulmonary disease with evidence of neuromuscular etiology. Nerve conduction studies confirmed bilateral phrenic neuropathy. He was referred to a specialized neuromuscular disease center where subsequent workup did not demonstrate any specific etiology. A sleep study confirmed sleep disordered breathing suggestive of diaphragmatic paralysis and he was discharged on bi-level positive pressure ventilation. CONCLUSION: This is a unique case of exertional dyspnea and orthopnea from diaphragmatic paresis caused by bilateral phrenic nerve palsy where the initial workup for pulmonary and cardiovascular etiologies was essentially unremarkable. Shortness of breath and orthopnea caused by phrenic neuropathy is a rare condition, yet has a variety of etiologies. Our case suggests a template to the diagnostic approach, management, and follow up of bilateral phrenic nerve palsy.

Rare case of asymptomatic spontaneous coronary artery dissection.

We present a case of a 46-year-old woman who presented to the emergency room after a syncopal episode. Most of her initial workup did not lead to any diagnosis. However, the transthoracic echocardiogram showed new onset left ventricular dysfunction. Further, cardiac evaluation showed a chronic coronary artery dissection in the proximal left anterior descending artery. Syncope was related to vasovagal event but rapid plasma reagin being positive led to the question of whether the coronary artery dissection was secondary to vasculitic manifestation of prior syphilis infection. More research is needed to answer this question and to find such an association. .

Boerhaave Syndrome, Pneumothorax, and Chylothorax in a Critically Ill Patient with Tuberous Sclerosis Complex.

Tuberous sclerosis complex (TSC) is an autosomal dominant, variably expressed multisystem disease. The predominant pulmonary features of TSC are identical to those of lymphangioleiomyomatosis (LAM). Pneumothorax, multifocal micronodular pneumocyte hyperplasia, and chylothorax are rare complications of TSC. We report a young male with pneumothorax, lung nodules, and chylous effusion who developed empyema thoracis after esophageal rupture. Hospital course was complicated by respiratory failure. Family opted to transfer to hospice care. Chylothorax is a rare complication of TSC with few scattered reports mostly in female patients. Patients with TSC are usually managed by multispecialists and it is important to be aware of the rare pulmonary manifestations of this disease. A male patient with TSC having lung nodules presenting with chylothorax and empyema thoracis from Boerhaave syndrome makes our case unique.

Gastro-Hepatic Fistula with Liver Abscess: A Rare Complication of a Common Procedure.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is a procedure used most commonly for enteral access for nutrition and continuation of treatment in patients when oral nutrition is not possible. It is a safe, cost-effective procedure; however, has its own complications and adverse effects that can be life threatening. CASE REPORT: Here, we present the case of a 76-year-old woman who was sent to a long-term skilled nursing facility after discharge from a hospital a month before, initially admitted for seizures after a fall and diabetic ketoacidosis. She underwent tracheostomy for prolonged respiratory support on mechanical ventilation and also underwent PEG tube placement. She presented in our Emergency Department (ED) with septic shock and multi-organ failure initially attributed to urinary tract infection and possible Clostridium difficile colitis. However, on further evaluation she was found to have a dislodged PEG tube, which led to development of gastro-hepatic fistula and multiple liver abscesses with liver necrosis. Comfort measures were implemented and she died due to her critical condition. CONCLUSIONS: To the best of our knowledge, this is the first case of a PEG tube, with no post-procedure complications, that dislodged and resulted in formation of a gastro-hepatic fistula and multiple liver abscesses. It is the first case that describes liver injury resulting from dislodgement rather than the liver being injured during the procedure of PEG tube placement itself.

Atypical hemolytic-uremic syndrome: a case report and literature review.

BACKGROUND: Atypical hemolytic uremic syndrome (aHUS) is a rare disease characterized by hemolysis, thrombocytopenia, and renal dysfunction. It is a disease related to genetic mutations in the alternative complement pathway and has a distinct pathophysiology but is difficult to differentiate from other thrombotic microangiopathies. CASE REPORT: We present a case of a 59-year-old female patient who presented with accelerated hypertension, acute renal failure, hemolysis, and encephalopathy. She was managed with antihypertensive medication, but her encephalopathy did not improve. Evaluation resulted in our impression of the disease being atypical hemolytic-uremic syndrome. The patient continued to be managed with good blood pressure control and later was started on eculizumab, but evaluation of response to therapy was hindered by the patient's non-compliance with therapy and follow-up appointments. CONCLUSIONS: We have a very limited understanding of the genetics and epidemiology of atypical HUS, and the overlapping clinical features sometimes delay diagnosis and initiation of appropriate treatment of this rare disease.

Collapsing focal segmental glomerulosclerosis in a patient with systemic lupus erythematosus.

We present a case of a 36-year-old female from Ghana who presented with atypical chest pain and shortness of breath and was found to have bilateral transudative pleural effusion and trivial pericardial effusion. Further work-up revealed serological markers consistent with active lupus and negative HIV. She developed rapid deterioration of her renal function requiring dialysis. Her renal biopsy showed collapsing focal segmental glomerulosclerosis with diffuse mesangial proliferative glomerulonephritis, consistent with lupus nephritis class II along with tubular degenerative changes. She was started on high dose steroids and later on mycophenolate mofetil. Her renal function slowly recovered to baseline.

The enigmatic kikuchi-fujimoto disease: a case report and review.

We report this case of a 33-year-old African American woman who presented to the clinic with preauricular and submandibular masses that she had noticed 6 weeks earlier. She gave a remote history of noticing bilateral cervical masses 3 years prior to this presentation that had not been investigated at the time and resolved spontaneously. Excisional biopsies of the cervical lymph nodes showed morphologic and immunophenotypic findings suggestive of Kikuchi Fujimoto disease (KFD). KFD is an uncommon, self-limited, and perhaps an underdiagnosed entity with an excellent prognosis. It mimics malignant lymphoma in presentation and therefore an accurate clinicopathological differentiation is crucial.