Echocardiographic Evaluation of Cardiac Masses.

PURPOSE OF REVIEW: Cardiac masses encompass a broad range of etiologies and are often initially revealed by echocardiography. The differential may change depending on the location of the mass and patients' medical history or presentation. It is important for clinicians to be aware of subtle visual characteristics on echocardiography in order to correctly diagnose the pathology. METHODS: Patients who underwent transthoracic echocardiography and were found to have one or more cardiac masses between January 1, 2020, and May 15, 2023, were reviewed. Their demographic data, clinical presentation, medical history, imaging, and follow-up information were collected from hospital electronic medical records, de-identified, and used to complete this review paper. A detailed review of cardiac masses divided by cardiac chamber accompanied by real-world echocardiographic images from patients in a large inner city public hospital. We hope that this systematic review of cardiac masses with real-world echocardiographic images will help clinicians note subtle echocardiographic characteristics to aid in the diagnosis and treatment of cardiac masses.

Crab vs. Mushroom: A Review of Crustacean and Fungal Chitin in Wound Treatment.

Chitin and its derivative chitosan are popular constituents in wound-treatment technologies due to their nanoscale fibrous morphology and attractive biomedical properties that accelerate healing and reduce scarring. These abundant natural polymers found in arthropod exoskeletons and fungal cell walls affect almost every phase of the healing process, acting as hemostatic and antibacterial agents that also support cell proliferation and attachment. However, key differences exist in the structure, properties, processing, and associated polymers of fungal and arthropod chitin, affecting their respective application to wound treatment. High purity crustacean-derived chitin and chitosan have been widely investigated for wound-treatment applications, with research incorporating chemically modified chitosan derivatives and advanced nanocomposite dressings utilizing biocompatible additives, such as natural polysaccharides, mineral clays, and metal nanoparticles used to achieve excellent mechanical and biomedical properties. Conversely, fungi-derived chitin is covalently decorated with -glucan and has received less research interest despite its mass production potential, simple extraction process, variations in chitin and associated polymer content, and the established healing properties of fungal exopolysaccharides. This review investigates the proven biomedical properties of both fungal- and crustacean-derived chitin and chitosan, their healing mechanisms, and their potential to advance modern wound-treatment methods through further research and practical application.

Waste-Derived Low-Cost Mycelium Nanopapers with Tunable Mechanical and Surface Properties.

Mycelium, the vegetative growth of filamentous fungi, has attracted increasing commercial and academic interest in recent years because of its ability to upcycle agricultural and industrial wastes into low-cost, sustainable composite materials. However, mycelium composites typically exhibit foam-like mechanical properties, primarily originating from their weak organic filler constituents. Fungal growth can be alternatively utilized as a low-cost method for on-demand generation of natural nanofibrils, such as chitin and chitosan, which can be grown and isolated from liquid wastes and byproducts in the form of fungal microfilaments. This study characterized polymer extracts and nanopapers produced from a common mushroom reference and various species of fungal mycelium grown on sugarcane byproduct molasses. Polymer yields of ∼10-26% were achieved, which are comparable to those of crustacean-derived chitin, and the nanopapers produced exhibited much higher tensile strengths than the existing mycelium materials, with values of up to ∼25 MPa (mycelium) and ∼98 MPa (mushroom), in addition to useful hydrophobic surface properties resulting from the presence of organic lipid residues in the nanopapers. HCl or H2O2 treatments were used to remove these impurities facilitating tuning of mechanical, thermal, and surface properties of the nanopapers produced. This potentially enables their use in a wide range of applications including coatings, membranes, packaging, and paper.

Quality factor effect on the wireless range of microstrip patch antenna strain sensors.

Recently introduced passive wireless strain sensors based on microstrip patch antennas have shown great potential for reliable health and usage monitoring in aerospace and civil industries. However, the wireless interrogation range of these sensors is limited to few centimeters, which restricts their practical application. This paper presents an investigation on the effect of circular microstrip patch antenna (CMPA) design on the quality factor and the maximum practical wireless reading range of the sensor. The results reveal that by using appropriate substrate materials the interrogation distance of the CMPA sensor can be increased four-fold, from the previously reported 5 to 20 cm, thus improving considerably the viability of this type of wireless sensors for strain measurement and damage detection.

Navigating Diagnostic Challenges: Severe Pulmonary Hypertension in Acute Exacerbation of Chronic Obstructive Pulmonary Disease vs. Pulmonary Embolism.

A 63-year-old male with an unremarkable medical history presented to the emergency room (ER) with shortness of breath and bilateral lower extremity edema. In the ER, he was found to be hypoxic and hypercapnic on an arterial blood gas. CT angiography of the chest revealed severe emphysematous changes and large right apical bullae. A bedside point-of-care ultrasound demonstrated many bilateral B-lines as well as normal ejection fraction (EF). An echocardiogram revealed a small left ventricular cavity with an EF of 65%, severely dilated right ventricle, severe right ventricular dysfunction, "D" shaped interventricular septum, severely dilated right atrium, and severe pulmonary arterial hypertension (PAH) with a calculated pulmonary artery systolic pressure of 72 mmHg. The patient was initiated on bilevel positive airway pressure, glucocorticoids, bronchodilator nebulization, and diuretics with symptomatic improvement. Herein, this case report discusses similarities and differences between presentations and echocardiographic manifestations of severe PAH in the setting of acute exacerbation of chronic obstructive pulmonary disease and pulmonary embolism in the acute setting.

A Rare Case of Severe Mitral Stenosis Presenting As Cardiogenic Shock.

We report a case of severe mitral stenosis (MS) in a 58-year-old female from Guyana. Though rheumatic MS continues to be less prevalent in third-world countries, it poses a significant threat as far as morbidity and mortality are concerned. The modern definition of "Third World" is used to classify countries that are poor or developing. Countries that are part of the "third world" are generally characterized by (1) high rates of poverty, (2) economic and/or political instability, and (3) high mortality. The standard method of diagnosing MS in patients has been established as transthoracic echocardiograms (TTE), along with pertinent historical and physical exam findings. Specifically, with TTE, criteria include a mitral valve area ≤1.5 cm2, severe left atrial enlargement, and elevated pulmonary artery systolic pressure >50 millimeters of mercury (mmHg). Once diagnosed with severe MS, treatment options for patients range from non-surgical percutaneous mitral balloon valvuloplasty to surgical mitral valve commissurotomy. In our case, she was a 58-year-old female with a past medical history of seizures of unknown etiology, not on any home medication regimen, presenting to the emergency department with shortness of breath, malaise, weight loss, and bilateral lower leg edema. Vitals were significant for tachycardia at 153 bpm, tachypnea at 24 breaths per minute, and saturating at 96% on room air. On the physical exam, there was an irregularly irregular rhythm, bilateral crackles at the bases, right upper quadrant tenderness to palpation, bilateral pitting edema, and no calf tenderness. Lab findings were significant for elevated brain natriuretic peptide, but three electrocardiograms were performed in the emergency department, all confirming the new onset of atrial fibrillation. A CT angiogram of the chest was performed, which ruled out pulmonary embolus but additionally found marked reflux of contrast noted within the inferior vena cava and hepatic veins, along with right atrial dilation reflective of right heart strain; additionally, mitral valve calcifications were noted. The cardiologist on duty confirmed the diagnosis using point-of-care ultrasound (POCUS) followed by TTE; the patient was rapidly transferred to a hospital with appropriate services for surgical management within the same day of arrival at the emergency department. This case highlights the importance of bedside POCUS as an additional diagnostic tool for cardiologists, along with pertinent history, physical examination findings, and laboratory findings. Proper utilization of POCUS can allow for the immediate diagnosis of severe pathologies and prevent the delay of appropriate treatment, as seen in our case. Wider adoption of POCUS practices as a part of the general initial evaluation of patients has not yet been recommended by the American Heart Association but can offer clinical benefit in morbidity/mortality with expedited progression to appropriate treatment.

A Rare Encounter With Unusual Metastasis: Metastatic Right Ventricular Tumor Secondary to Cervical Cancer.

Metastasis of cervical cancer to the heart is rare. Cervical carcinoma typically spreads to the lungs, liver, bones, and lymph nodes via hematogenous, lymphatic, transvenous, or direct extension. Cardiac metastasis from cervical carcinoma is uncommon and portends a dismal prognosis, with mean survival under six months post-diagnosis. A high index of suspicion and multimodal imaging is imperative for prompt diagnosis and improved outcomes in these patients. Here, we report a rare case where a 41-year-old African American female with stage IIIB cervical squamous cell carcinoma (SCC) presented with exertional dyspnea and chest pain concerning pulmonary embolism (PE). Computed tomography angiography showed no PE but revealed a right ventricular (RV) mass and diffuse pulmonary nodules. Echocardiography suggested an RV tumor versus a thrombus. Cardiac magnetic resonance imaging demonstrated a large RV infiltrative mass favoring metastasis over thrombus. A biopsy of one of the pulmonary nodules confirmed metastatic SCC. Despite treatment, the prognosis was poor.

Treatment of Type 2 Diabetes Mellitus in Advanced Chronic Kidney Disease for the Primary Care Physician.

Diabetes mellitus (DM) is a common cause of chronic kidney disease (CKD), leading to the need for renal replacement therapy (RRT). RRT includes hemodialysis (HD), peritoneal dialysis (PD), kidney transplantation (KT), and medical management. As CKD advances, the management of DM may change as medication clearance, effectiveness, and side effects can be altered due to decreasing renal clearance. Medications like metformin that were safe to use early in CKD may build up toxic levels of metabolites in advanced CKD. Other medications, like sodium-glucose co-transporter 2 inhibitors, which work by excreting glucose in the urine, may not be able to work effectively in advanced CKD due to fewer working nephrons. Insulin breakdown may take longer, and both formulation and dosing may need to be changed to avoid hypoglycemia. While DM control contributes to CKD progression, effective DM control continues to be important even after patients have been placed on RRT. Patients on RRT are frequently taken care of by a team of providers, including the primary care physician, both in and outside the hospital. Non-nephrologists who are involved with the care of a patient treated with RRT need to be adept at managing DM in this population. This paper aims to outline the management of type 2 DM in advanced CKD.

Octreotide Causing Hyperkalemia: A Case Report and Review of the Literature.

Octreotide, a synthetic analog of somatostatin, is widely utilized for its inhibitory effects on various hormones, including growth hormone, insulin, and glucagon. Its applications span conditions such as acromegaly, carcinoid tumors, and gastrointestinal bleeding due to its ability to reduce portal venous pressure. Additionally, it serves a crucial role in nuclear medicine imaging and the management of hepatorenal syndrome. We report a case of a 44-year-old man with type 2 diabetes mellitus (T2DM) and stage 5 chronic kidney disease (CKD), not yet on hemodialysis, who presented with persistent severe hypoglycemia. Despite multiple oral glucose administrations, his blood glucose levels remained critically low. The patient was treated with octreotide for sulfonylurea-induced hypoglycemia. However, he developed hyperkalemia as a side effect of octreotide treatment. Traditional therapies for sulfonylurea-induced hypoglycemia often involve intravenous and oral dextrose and glucagon, which may lead to recurrent hypoglycemia due to their stimulatory effects on insulin release. Octreotide directly inhibits insulin release from the pancreas, thus preventing rebound hypoglycemia. However, its administration in patients with renal impairment poses a risk of hyperkalemia due to its suppression of insulin-mediated cellular potassium uptake, and it should be used with caution. This case highlights the potential for life-threatening hyperkalemia induced by octreotide in non-dialysis CKD patients. Physicians must be vigilant about this side effect, particularly in patients with underlying renal impairment. Close monitoring of potassium levels and appropriate management strategies are essential to ensure the safe use of octreotide. This case aims to raise awareness and contribute to a better understanding of octreotide-induced hyperkalemia in CKD patients.

Idiopathic Ventricular Tachycardia in the Presence of Triple-Vessel Coronary Artery Disease: A Case Report.

Exercise-induced ventricular tachycardia undergoes ischemia evaluation; however, it is important to identify idiopathic ventricular tachycardia in patients with concomitant coronary artery disease and radiofrequency ablations can be lifesaving. We report a case of exercise-induced right and left ventricular outflow tract ventricular tachycardia in a patient with triple vessel coronary artery disease.

Navigating Aspirin Hypersensitivity in Patients Undergoing Percutaneous Coronary Intervention.

Aspirin hypersensitivity continues to be a major clinical challenge in patients with coronary artery disease (CAD), particularly in those requiring percutaneous coronary intervention (PCI) in the absence of a validated alternative antiplatelet regimen. Although true aspirin allergies are uncommon, they can manifest with severe reactions such as angioedema or anaphylaxis, highlighting the critical role of diagnostic challenge tests and tolerance induction strategies. Here, a 61-year-old female with end-stage renal disease (ESRD) on hemodialysis presented with new-onset heart failure and elevated troponins in the setting of a hypertensive emergency. A subsequent left heart catheterization revealed severe multivessel disease, but PCI was deferred due to her history suggestive of aspirin-induced angioedema and the absence of a known optimal approach in this scenario. Given the feasibility of completing a desensitization protocol, aspirin desensitization was pursued, facilitating the successful placement of a drug-eluting stent. This case highlights the need for validated protocols to manage aspirin hypersensitivity, as the current treatment paradigm necessitates a highly individualized approach by the treating clinician.

Towards Optimal Cardiovascular Health: A Comprehensive Review of Preventive Strategies.

Heart disease remains a prominent global health concern, with cardiovascular disease (CVD) standing as a leading cause of death worldwide. Preventing heart disease not only decreases the risk of premature death but also mitigates complications like heart attacks, strokes, and arrhythmias, thereby enhancing overall health and quality of life. The economic burden of heart disease treatment highlights the importance of implementing preventive measures, such as lifestyle changes and early interventions, which can alleviate healthcare costs. These strategies, targeting risk factors like hypertension (HTN), diabetes mellitus (DM), dyslipidemia, and obesity, not only prevent heart disease but also reduce the risk of other health issues. Herein, this review covers various preventive measures, including dietary interventions, exercise, controlling HTN, DM, cholesterol, and weight, smoking cessation, and pharmacological interventions. By critically analyzing the guidelines and leveraging robust data alongside variations in recommendations, this review aims to elucidate effective primary prevention strategies for CVD.

Severe Hypertrophic Cardiomyopathy Associated With Hydroxychloroquine in a Young Woman With Systemic Lupus Erythematosus: A Case Report and Review of the Literature.

The use of the antimalarial drug hydroxychloroquine is a standard treatment in patients with systemic lupus erythematosus. It helps reduce disease-associated damage, prevents disease flare, and improves overall survival. The mechanism of action of hydroxychloroquine includes interference with lysosomal degradation of cells leading to the accumulation of vacuoles. Retinopathy is a well-described adverse effect of hydroxychloroquine, thus requiring screening with an ophthalmologist after prolonged use. Although rarely reported, cardiac adverse effects of hydroxychloroquine can also occur. In this report, we present a case of a 23-year-old woman with systemic lupus erythematosus on hydroxychloroquine who presented with stroke possibly due to Libman-Sacks endocarditis and was found to have severe hypertrophic cardiomyopathy on transthoracic echocardiogram.

Crisis in the Chest: Acute Chest Syndrome as a Sequela of Tricuspid Valve Endocarditis.

The management of acute chest syndrome (ACS) in sickle cell disease occurring concurrently with pulmonary embolism resulting from tricuspid valve endocarditis poses an atypical challenge. We present a case in which this complex interaction occurs and the prompt interventions that were utilized to give the best possible outcome.

A Rare Case of Coexisting Mutation in Desmin and Thioredoxin Reductase 2 Genes Causing Dilated Cardiomyopathy.

Desmin (DES) maintains the overall structure of cardiomyocytes and cytoskeletal organization within striated muscle cells. Mitochondrial thioredoxin reductase 2 (TXNRD-2) is essential for mitochondrial oxygen radical scavenging. We describe a rare case of dilated cardiomyopathy (DCM) in an 18-year-old female with a heterozygous mutation involving both DES and TXNRD-2 genes.

A Case Report on Takotsubo Cardiomyopathy.

A 71-year-old female with a past medical history of hypertension, seizure disorder, chronic obstructive pulmonary disease, coronary artery disease, chronic kidney disease, open abdominal aortic aneurysm repair complicated by spinal cord infarction resulting in lower extremity paraparesis with chronic urinary retention, and sacral decubitus ulcer initially presented to the emergency department (ED) complaining of a one-week history of chest pain. During her inpatient stay, acute myocardial infarction and pulmonary embolism were ruled out and the patient was hemodynamically stable for discharge until she started experiencing new-onset nausea and dyspnea. Bedside electrocardiogram demonstrated ST elevations in the anterior leads with concomitant T-wave inversions in the inferolateral leads as well as a prolonged QTc. Troponin-HS was elevated at 907.69. Bedside transthoracic echocardiogram (TTE) demonstrated a severely decreased left ventricular ejection fraction of 10%-15% (representing an acute decrease from a left ventricular ejection fraction of 55%-60% from a TTE performed seven days prior). Cardiac catheterization demonstrated mild non-obstructive coronary artery disease and no interventions were conducted. Such signs and symptoms of acute myocardial infarction, without demonstrable coronary artery stenosis, are consistent with stress induced or Takotsubo cardiomyopathy. This phenomenon occurs in approximately 1%-2% of patients presenting with troponin-positive suspected acute coronary syndrome (ACS) or suspected ST-elevation myocardial infarction (STEMI).

A Rare Case of Massive Left Atrial Myxoma Presenting as Syncope.

We report a rare case of a large left atrial myxoma that manifested as syncope in a patient who presented to the hospital following a syncopal episode. Our patient had a history of hypertension and anemia with reported two months of dyspnea on exertion. He was found to have a large left atrial myxoma. Atrial myxomas are the most common benign primary cardiac tumors. Patients may be asymptomatic or experience shortness of breath, palpitations, syncope, or sudden death. Cases of syncope caused by left atrial myxoma have been rarely documented. Our case report adds to the growing literature documenting this phenomenon. Larger observational studies are needed to properly define the incidence of left atrial myxoma causing syncope.

Reversible severe pulmonary hypertension and right heart failure with cardiogenic shock due to scurvy: a case report.

Background: The systemic complications of vitamin C deficiency, otherwise known as scurvy, have been well-documented in history. Few case reports have documented severe cardiopulmonary complications such as right heart failure (RHF) and pulmonary hypertension (PH). Case summary: A 25-year-old female presented to the hospital with two weeks of progressive fatigue, dyspnoea, myalgias, and arthralgias. She was admitted for symptomatic anaemia requiring transfusion. Her symptoms persisted and she developed severe PH and RHF, complicated by cardiogenic shock and multiple episodes of cardiac arrest. She was found to have severe vitamin C deficiency secondary to a severely self-restricted diet. After repletion of vitamin C, the patient had complete resolution of RHF and PH. Discussion: This case adds to the sparse literature documenting severe cardiopulmonary complications of vitamin C deficiency. We believe that this is the first adult case of scurvy causing RHF and PH leading to cardiogenic shock and episodes of cardiac arrest. There are multiple hypotheses on the pathogenesis of scurvy-associated PH and RHF, including overactivation of hypoxia-inducible transcription factors and deficiency of vitamin C's vasodilatory effect that acts through increased nitric oxide production in endothelial cells. When recognized, early vitamin C repletion may prevent severe cardiopulmonary complications of scurvy.

Quadricuspid Aortic Valve: An Incidental Finding in an Elderly Man.

Quadricuspid aortic valve (QAV) is a very rare congenital abnormality. Here, we present a rare case of QAV incidentally noted in a patient at an advanced age during transthoracic echocardiography (TTE). A 73-year-old man with a history of hypertension, hyperlipidemia, diabetes, and treated prostate cancer was admitted to the hospital with palpitations. An electrocardiogram (ECG) showed T-wave inversion in V5-V6, with initial troponin levels mildly elevated. Acute coronary syndrome was ruled out by serial ECGs that were unchanged, and troponins downtrended. TTE showed a rare and incidental finding of type A QAV with four equal cusps with mild aortic regurgitation.

Transthyretin Cardiac Amyloidosis Presenting as Bradycardia, Renal Failure, Atrioventricular-Nodal Blockade, Shock, and Hyperkalemia (BRASH) Syndrome: A Case Report.

BRASH syndrome involves the chain of events resulting from the collective effects of Bradycardia, Renal failure, Atrioventricular (AV)-nodal blockade, Shock, and Hyperkalemia. BRASH syndrome can rapidly progress to cardiac arrest. Early recognition is crucial. We present a case of transthyretin cardiac amyloidosis (ATTR-CA) in an elderly woman who presented with BRASH syndrome shortly after an AV-nodal blocker was prescribed for atrial fibrillation.