Isolated accessory tricuspid valve leaflet in asymptomatic adult.

Accessory tricuspid valve (ATV) is a rare congenital anomaly that is often seen in complex congenital anomalies in children with very few reported cases in adults. We report a case of isolated ATV in an asymptomatic adult with no other congenital defects along with illustrative transesophageal echocardiographic 2D, 3D, high-resolution photo-realistic images.

Reversible bradycardia secondary to myxedema coma: case-report.

Myxedema coma occurs mostly in patients with long-standing untreated or undertreated hypothyroidism. Bradycardia is a well-known cardiac manifestation for myxedema coma; however, not all bradycardia with hypothyroidism are sinus bradycardia. Sick sinus syndrome is a group of arrhythmias caused by the malfunction of the natural pacemaker of the heart. Tachy-Brady syndrome is considered to be a type of sick sinus syndrome, where the heart alternates between tachycardia and bradycardia, and it is usually treated with pacemaker implantation along with rate slowing medical therapy. Here we report a case of an 83-year-old female who presented with myxedema coma and atrial fibrillation with tachycardia and intermittent slow ventricular response. We attempt to review the relationship between these two diseases and conclude that appropriate diagnosis of myxedema coma, may be beneficial in reducing the need for pacemaker implantation.

Myocardial ischemia in the setting of extrinsic coronary compression: two case reports.

Background: Myocardial ischemia occurs in the setting of inadequate or complete cessation of blood supply to the myocardium. While atherosclerosis is the most common cause; other causes have been identified. Rare cases can be caused by extrinsic compression of the coronaries by a dilated pulmonary artery (PA) or by mechanical obstruction from nearby chest tubes or drains. We present two cases of myocardial ischemia-driven malignant arrhythmia leading to cardiac arrest caused by obstruction of the coronary blood flow from external compression. Case Description: In the first case, venous bypass graft compression from a chest tube postoperatively was noted and in the second case left main coronary artery (LMCA) compression from a dilated PA secondary to pulmonary artery hypertension (PAH) was seen. Diagnosis of these two cases was made via emergent coronary angiogram and intravascular ultrasound (IVUS) and treated by placing a drug eluting stent (DES) in LMCA compression and by adjusting the chest tube and placing a DES in the venous bypass graft with the restoration of flow. We also review the available literature regarding the incidence, diagnosis, and management of this rare entity. Conclusions: Overall, extrinsic compression of the coronaries is rare, therefore clinicians need to be aware of this infrequent process, to allow for appropriate diagnosis, management, and to prevent excess morbidity and mortality from this rare complication.

Laterality of Radiation Therapy in Breast Cancer is Not Associated With Increased Risk of Coronary Artery Disease in the Contemporary Era.

Purpose: External beam radiation therapy (EBRT) is a critical component of breast cancer (BC) therapy. Given the improvement in technology in the contemporary era, we hypothesized that there is no difference in the development of or worsening of existing coronary artery disease (CAD) in patients with BC receiving left versus right-sided radiation. Methods and Materials: For the meta-analysis portion of our study, we searched PubMed, Web of Science, and Scopus and included studies from January 1999 to September 2022. CAD was identified using a homogenous metric across multiple studies included. We computed the risk ratio (RR) for included studies using a random effects model. For the institutional cohort portion of our study, we selected high cardiovascular-risk patients who received diagnoses of BC between 2010 and 2022 if they met our inclusion criteria. We performed a Cox proportional hazards model with stepwise adjustment. Results: A pooled random effects model with 9 studies showed that patients with left-sided BC receiving EBRT had a 10% increased risk of CAD when compared with patients with right-sided BC receiving EBRT (RR, 1.10; 95% CI, 1.02-1.18; P = .01). However, subgroup analysis of 6 studies that included patients diagnosed after 1980 did not show a significant difference in CAD based on BC laterality (RR, 1.07; 95% CI, 0.95-1.20; P = .27). For the institutional cohort portion of the study, we found that patients with left-sided BC who received EBRT did not have a significantly higher risk of CAD when compared with their right-sided counterparts (hazard ratios [HR], 0.73; 95% CI, 0.34-1.54; P = .402). Conclusions: Our study suggests a historical trend of increased CAD in BC patients receiving left-sided EBRT. Data from patients diagnosed after 2010 in our institutional cohort did not show a significant difference, emphasizing that modern EBRT regimens are safe, and laterality of BC does not affect CAD outcomes in the short term after a BC diagnosis.

Intracoronary Brachytherapy for Drug-Eluting Stent Restenosis: Outcomes and Clinical Correlates.

Background: This study aimed to report outcomes of intracoronary brachytherapy (ICBT) in treating drug-eluting stent (DES) in-stent restenosis (ISR) and identify correlated factors. Methods: Patients who underwent ICBT for DES ISR from 2010 to 2021 were included in this single-institution retrospective PCI registry. Patients were treated with balloon angioplasty, laser atherectomy, and/or rotational atherectomy, followed by ICBT at a dose of 18.4-25 Gy delivered at the site of ISR with dose determined by the reference vessel size. The primary outcome was 3-year target lesion failure rate (TLF). Secondary end points were 1-year TLF, target lesion revascularization (TLR), all-cause mortality, and cardiac mortality. Results: In total, 330 consecutive patients presented with 345 treated lesions; 70% were male, age was 66 ± 11 years, 55% were diabetic patients, 62% underwent previous bypass surgery, and 89% were placed with at least 2 stent layers at the treated site. The rate of TLF was 18% at 1 year and 46% at 3 years. All-cause mortality and cardiac mortality rates were 19.8% and 12.3% at 3 years. The number of stent layers was associated with 3-year TLF (1 layer, 33.3%; 2 layers, 47.0%, >3 layers, 60.2%; P = .045). Diabetes, repeat ICBT, final percent stenosis, lesion length, and intravascular imaging use were not correlated with the primary outcome. Lower ICBT dose (P = .035) and restenosis <1 year from previous percutaneous coronary intervention (P = .044) were correlated with early (1-year) TLF. Conclusion: ICBT for recurrent DES ISR provided low recurrence rates at 1 year, which increased substantially by 3 years. Outcomes were most closely correlated with the number of stent layers, but early restenosis and lower ICBT dose adversely affected early TLF.

Venous Stent Migration of the Right Ventricle.

Peripheral migration of a venous stent to the heart is a rare but known complication, with the heart being the most common site of landing. Echocardiographic modalities are essential in clinical diagnosis and management, particularly with limited data and consensus regarding the best management approach. (Level of Difficulty: Intermediate.).

Influence of Polypropylene and Steel Fibers on the Performance and Crack Repair of Self-Compacting Concrete.

The research reported in this paper aims to evaluate the epoxy injection technique used to strengthen fiber-reinforced self-compacting concrete (FRSCC) with high strength. This method is carried out on ruptured concrete specimens to assess the efficiency of the epoxy resin adhesive injection retrofitting technique for strength and stiffness. Five FRSCC mixes were designed and placed using different types (steel and polypropylene) and contents (0%, 0.25%, and 0.45% by volume) of fibers. The fresh and mechanical properties in addition to the microstructure of produced mixes were evaluated to assess the impact of fibers on the behavior of FRSCC. Results showed that the workability of FRSCC is reduced by increasing steel or polypropylene fiber content; however, the rheological characteristics of placed mixes satisfied the European Guidelines for Self-Compacting Concrete recommendation for fresh concrete. Also, splitting tensile, flexural, and shear strengths were enhanced by increasing fiber content. The simultaneous application of epoxy injection in FRSCC for repairing damaged concrete beams was shown to be highly effective.

The Impact of Cardiology Consultation on Medical Intensive Care Unit Patients with Elevated Troponin Levels.

BACKGROUND: Cardiac troponin (cTn) is mainly used to diagnose acute coronary syndrome (ACS). However, cTn can also be elevated in critically ill patients secondary to demand ischemia or myocardial injury. The impact of cardiology consultation on the clinical outcomes of patients admitted to medical intensive care unit (ICU) with elevated cTn is unclear. METHODS: A retrospective analysis of medical ICU patients with elevated cTn without evidence of ACS between January 2013 through December 2018. Patients were stratified based on documentation of cardiology consultation. The primary outcome was 1-year mortality. Secondary outcomes were in-hospital and 30-day mortality, the length of stay (LOS), further cardiac testing, 30-day readmission rate, new prescription of cardiac medications, and the predictors of a cardiology consultation. RESULTS: Of 846 patients screened, 766 patients were included, of whom 63.2% had cardiology consultation. Cardiology consultation group had longer median LOS (7 vs. 5 days, P = 0.007), additional cardiac testing (90.3% vs. 67.7%, P < 0.001), and more new cardiac medications (52.1% vs. 16.3%, P < 0.001). No difference was noted in-hospital mortality (adjusted odds ratio [aOR], 0.6, 95% CI, 0.4-1.1, P = .117), 30-day mortality (aOR = 0.8, 95% CI, 0.5-1.4, P = .425), 1- year mortality (aOR, 1.4, 95% CI, 0.9-2.2, P = .193), or cardiac-specific 30-day readmission rate (aOR, 7.0, 95% CI, 0.7-14.9, P = .137). History of coronary artery disease (CAD) was the most independent predictor for a cardiology consult (aOR, 2.2, 95% CI, 1.3-3.8, P < .001). CONCLUSION: Cardiology consultation for elevated cTn in medical ICU patients was associated with increased cardiac testing and LOS, without significant impact on mortality.

Successful Fibrinolytic Therapy in a Challenging Obstructive Prosthetic Mitral Valve Thrombosis.

Prosthetic valve thrombosis is a rare and severe complication of the mechanical prosthetic valve. Management can be challenging due to varying clinical presentation, overlapping features of differential diagnosis, and lack of randomized controlled trials on the therapeutic options. In this article, we report the case of a patient with a mechanical prosthetic mitral valve presented with symptoms of heart failure, and an echocardiography showing increased mean pressure gradient across the prosthesis along with a fixed posterior leaflet and a partially restricted anterior leaflet with no visible mass. That raised the concern for an obstructed prosthesis. After multimodality imaging and multidisciplinary team discussions, prosthetic valve thrombosis diagnosis was favored over other different diagnoses that included but not limited to pannus ingrowth. Fibrinolytic therapy was administrated, and the patient was discharged on optimal anticoagulation. Repeated echocardiography a month later showed normal mean gradient and normal functioning prosthetic mitral valve without the need for repeat mitral valve surgery.

Rapidly Growing Squamous Cell Carcinoma of the Tongue.

The tongue can be a guide for different normal findings/variants, pathological lesions, or signs for systemic diseases. And oral cancer can be among the differentials, which can be detected early by a thorough oral exam. The early detection of oral cancer is particularly important, as the stage of oral cancer at the time of the diagnosis is the most critical factor determining the five-year survival. We present a case of a high-risk patient for oral cancers presented with a rapidly growing tongue lesion over six months that was diagnosed as a squamous cell carcinoma of the tongue on the biopsy. The case highlights an alarming rapid growth nature of oral cancers and alerts the clinicians of the importance of the physical exam as a cost-effective and potentially life-saving measure against oral cancers. It also demonstrates a brief review of risk factors and high-risk features of oral cancers.

The Association of Hypophosphatemia With Resistant Lactic Acidosis in Critical Care Illness.

Critically ill patients are known to have a variety of electrolyte abnormalities. Lactic acidosis can frequently be seen secondary to shock states and is usually treated with aggressive volume resuscitation. Interestingly, hypophosphatemia is a potential cause of resistant lactic acidosis, which may not be as commonly identified or considered. We present a case of a 42-year-old man admitted twice over a span of 6 months with an elevated lactate level that did not resolve with volume resuscitation. It was ultimately determined that his lactic acidosis was due to hypophosphatemia after ruling out other potential causes. Phosphate replacement therapy resulted in the normalization of his lactate. In the literature, multiple theories have indicated the association of hypophosphatemia with lactic acidosis though no prior cases exist supporting a direct relationship. In this case, we set forth to evaluate the complicated relationship between all of these factors and to highlight the importance of early detection and treatment of hypophosphatemia, which may be beneficial in treating lactic acidosis.

Acute ischemic stroke as initial manifestation of undiagnosed iron deficiency anemia: case-report and literature review.

Cerebrovascular disease is the second leading cause of death in the United States in adults aged 65 years and older and is most commonly caused by atherosclerosis. More so, cryptogenic strokes account for one-third of all ischemic strokes. At the same time, iron deficiency anemia is prevalent worldwide and mostly affects females of childbearing age. Here we report a case of a 42-year-old female who presented with symptoms of acute ischemic stroke and was found to have severe iron deficiency anemia. After prompt investigation of other secondary causes, it was determined that her stroke was likely secondary to her iron deficiency anemia. Upon review of the literature, a few case reports showed an association between iron deficiency anemia and strokes in the adult population, but little evidence exists supporting a direct relationship between the two entities. In this case, we aim to evaluate the complex relationship between iron deficiency anemia and stroke and to define a new potential cause of ischemic stroke, which would have been considered earlier as cryptogenic. However, further studies in the future are warranted to validate our observation.

Review of Cases of E-Cigarette or Vaping Product Use-Associated Lung Injury (EVALI) and Brief Review of the Literature.

Since the appearance of the E-Cigarette in the early 2000s, its industry, popularity, and prevalence have risen dramatically. In the past, E-Cigarette use with the vaping of nicotine or cannabis products had been associated with a few reported cases of lung injury. However, in 2019, thousands of cases of E-Cigarette or vaping product use-associated lung injury (EVALI) were reported in the United States. Evidence linked this outbreak with vaping of tetrahydrocannabinol (THC). We report two confirmed cases of EVALI and their associated clinical, radiologic, and pathologic features. This report supports the growing body of information regarding EVALI. It also discusses various substances, particularly vitamin E acetate, which has been suggested as a causative agent.

Transient Asymptomatic Sinus Bradycardia and Sinus Pauses with Bevacizumab: Case Report and Literature Review.

Systemic side effects of anti-cancer therapy remain a major limiting factor for patients, even with targeted therapy. Bevacizumab is an example of targeted cancer therapy which targets the vascular endothelial growth factor receptor (VEGFR) that has been approved for the treatment of various cancers and has been evaluated in metastatic urothelial carcinoma (MUC). We report a case of MUC on bevacizumab containing regimen who developed temporary asymptomatic sinus bradycardia with sinus pauses. That adverse event was thought to be related to the bevacizumab in her cancer regimen. Her Holter monitoring recording for a total duration of 28 days and 14 h after discharge did not show recurrence of sinus pauses. This case indicates the necessity for observation for the cardiac conduction defects as side effects in patients receiving bevacizumab, especially since they might be asymptomatic and transient.