Multifaceted highly targeted sequential multidrug treatment of early ambulatory high-risk SARS-CoV-2 infection (COVID-19).

The SARS-CoV-2 virus spreading across the world has led to surges of COVID-19 illness, hospitalizations, and death. The complex and multifaceted pathophysiology of life-threatening COVID-19 illness including viral mediated organ damage, cytokine storm, and thrombosis warrants early interventions to address all components of the devastating illness. In countries where therapeutic nihilism is prevalent, patients endure escalating symptoms and without early treatment can succumb to delayed in-hospital care and death. Prompt early initiation of sequenced multidrug therapy (SMDT) is a widely and currently available solution to stem the tide of hospitalizations and death. A multipronged therapeutic approach includes 1) adjuvant nutraceuticals, 2) combination intracellular anti-infective therapy, 3) inhaled/oral corticosteroids, 4) antiplatelet agents/anticoagulants, 5) supportive care including supplemental oxygen, monitoring, and telemedicine. Randomized trials of individual, novel oral therapies have not delivered tools for physicians to combat the pandemic in practice. No single therapeutic option thus far has been entirely effective and therefore a combination is required at this time. An urgent immediate pivot from single drug to SMDT regimens should be employed as a critical strategy to deal with the large numbers of acute COVID-19 patients with the aim of reducing the intensity and duration of symptoms and avoiding hospitalization and death.

Nonbacterial Thrombotic Endocarditis With Embolic Phenomena Diagnosed by Transesophageal Echocardiogram.

Nonbacterial thrombotic endocarditis (NBTE) is a valvular disorder commonly associated with malignancy and connective tissue diseases. While the disorder is often discovered during autopsy, it is sometimes diagnosed in patients who present with systemic embolization. Here, we discuss the case of a 52-year-old female, with connective tissue disease and malignancy, who presented with symptoms of systemic embolization and was diagnosed with NBTE by transesophageal echocardiogram (TEE). This case highlights the utility of TEE in diagnosing NBTE and its influence in guiding the subsequent management of patients.

Giant aneurysms of coronary arteries and saphenous vein grafts: angiographic findings and histopathological correlates.

INTRODUCTION: Giant aneurysms that develop in native coronary arteries or saphenous vein grafts are morphologically defined as abnormally expanded outpouching vascular structures >4 cm in diameter. The location, morphology, and content of giant aneurysms account for adverse cardiovascular effects. METHODS: Two cases of giant aneurysms were studied comprehensively by noninvasive and invasive cardiac methods and subsequent histopathology. The first patient had a giant aneurysm that developed over a course of several years in a saphenous vein graft whereas the second patient had a giant aneurysm occurring within a native coronary artery. Accompanying clinical and angiographic findings are described. RESULTS: Atherosclerosis and thrombosis were among the prominent histopathological findings. CONCLUSIONS: Atherosclerosis and associated thrombosis within giant aneurysms result in obstruction of flow, distal embolization, and development of acute coronary syndromes including recurrent ischemic chest pain, unstable angina, and acute myocardial infarction. The options for clinical management of giant coronary or vein graft aneurysms include surgical excision, percutaneous coil occlusion and stent deployment, or medical approach.

Beware of the B(e)all valve: mistaken valve identity, 30-year survival, and valve replacement.

Effective management of patients after the implantation of mechanical cardiac valves includes correct recognition of each valve and its related complications. Herein, we present the case of a patient who had undergone implantation of a floating-disc Beall-Surgitool mitral valve in 1976 and developed multiple valve-related complications. Over 30 years and in multiple medical centers, the device was mistakenly assumed to be a "ball" valve. The correct identification of the prosthesis led to the recognition of valvular failure, and the patient underwent its replacement with an On-X bileaflet carbon valve. Pathologic and microscopic examination of the explanted Beall valve showed massive pannus formation that extended over the sewing cuff on the atrial and ventricular side, preventing complete disc closure; disrupted fabric coating of the sewing ring, with exposure of the underlying metal; and a marked inflammatory reaction. We report one of the longest intervals on record between the implantation and replacement of a Beall-Surgitool valve.