Symptomatic unicuspid aortic valve.

A 22-year-old man with typical angina was seeking medical attention at primary health clinics for a couple of months. Owing to his young age and the absence of coronary artery disease risk factors, he was assured of no serious problem. Proper examination at a referral centre revealed weak peripheral pulses with diminished and delayed carotid upstroke. A normal S1 with a soft S2 were audible. A 3/6 late peaking systolic murmur was best heard in the aortic area radiating to the neck. Symptomatic bicuspid aortic valve disease was suspected. Diagnosis of unicuspid aortic valve was established by transoesophageal and three-dimensional echocardiography. The valve was successfully replaced with a mechanical prosthesis. The patient remains asymptomatic at 1 year follow-up.

'Mechanical thrombectomy alone' as a definite therapy for rescue angioplasty.

Coronary reperfusion strategies for acute ST segment elevation myocardial infarction (STEMI) include primary percutaneous coronary intervention (PCI), intravenous thrombolytic agents and recently mechanical thrombectomy alone during PCI, the latter reserved for those without significant residual disease post-thrombectomy. We describe the success of 'mechanical thrombectomy alone' in two young patients undergoing rescue angioplasty at our institution. Both patients were thrombolysed for inferior STEMI. During rescue PCI, post-thrombus aspiration, mild underlying atherosclerotic burden was detected in both patients, thus possibly obviating the need for further balloon angioplasty or stenting. Cost and compliance with long-term dual antiplatelet therapy (DAPT) was an additional factor to avoid stenting. Both patients received aspirin, clopidogrel, heparin and additional standard therapy for myocardial infarction (MI). Medication compliance was ensured by providing 1 month DAPT at no extra cost. Short-term follow-up at 1 and 3 months, for both patients was uneventful. Two-year, long-term follow-up, available for one patient has been uneventful.

Splenic abcess owing to brucellosis.

Brucellosis, caused by aerobic Gram-negative coccabacilli, is prevalent worldwide. It occurs mainly because of the consumption of unpasteurised milk and contact with animals. The disease is particularly hyperendemic in the Mediterranean region and Arabian Peninsula. Its high prevalence in the UAE continues to be a major health problem, causing significant morbidity and mortality. According to the Ministry of Health, 119 cases were reported in 2010, and most of those cases were patients aged over 45. Even though an effective treatment is available for this disease, treatment failure frequently occurs owing to delay in diagnosis, relapses and its prolonged clinical course. We present a 33-year-old man who was admitted to our internal medicine teaching unit service with non-specific symptoms. A workup revealed Brucella in the blood cultures. An abdominal ultrasound showed multiple splenic abscesses. After treatment with triple therapy, the patient has remained asymptomatic at 2 years follow-up.

Brugada syndrome with elevated cardiac biomarkers.

A 45-year-old man presented to our hospital with a history of palpitations, presyncope and chest pain. Vital signs and physical examination were unremarkable. Initial ECG  revealed sinus rhythm with non-specific ST changes. Subsequent ECGs showed rsr' in V1 and saddle-back pattern of ST elevation in lead V2, indicative of type 2 Brugada ECG pattern. Telemetry monitoring revealed multiple runs of asymptomatic non-sustained polymorphic ventricular tachycardia. Ajmaline challenge test confirmed the diagnosis of Brugada syndrome. The subsequent rise and fall of cardiac biomarkers was suggestive of acute myocardial infarction which was refuted by having normal coronaries by cardiac catheterisation. Echocardiogram showed normal cardiac structures and function without any evidence of myopericarditis. Automated intracardiac defibrillator was recommended which the patient declined.

"Personality traits and heart disease in the Middle East". Is there a link?

UNLABELLED: The significant role of psychosocial factors as a contributing factor to an increased risk of having a myocardial infarction has been extensively studied in the western world. This era of economic crises has seen an exponential rise in heart disease at a relatively earlier age. Whether these dynamics are equally associated, in the younger ethnically diverse population of UAE, which contributes to more than 50% of the population is not very well known. OBJECTIVES: No studies have examined the role of psychosocial variables and personality traits as a contributing factor to CAD in the UAE. The objective of this case controlled study was to explore relationships between demographics, socioeconomic status, personality types, stress-handling abilities, emotional intelligence, and cardiac risk factors. METHODS: The participants of this case controlled study included 90 MI patients admitted to a govt hospital in UAE during the period of 2011-2012, which were matched to 90 healthy individual. A analysis of their personality types, emotional intelligence and stress handling skills was performed using specific questionnaires. RESULTS: The results showed a significantly higher incidence of Type A personality in the MI group. In addition, these individuals were also much more likely to have diabetes, hypertension, and a history smoking, when compared to controls. Moreover a significant relationship between the presence of Type A personality and the presence of CAD was identified. Associations among variables were examined followed by analysis, discussion, and recommendation for prevention and treatment of CAD in UAE.

"Lone aspiration thrombectomy" without stenting in young patients with ST elevation myocardial infarction.

UNLABELLED: Plaque rupture with thrombotic occlusion without severe underlying coronary atherosclerosis is frequently observed during primary percutaneous coronary intervention (pPCI) for ST-segment elevation myocardial infarction (STEMI). These lesions are stented even if post thrombectomy mild underlying coronary artery disease (CAD) is noted. The value of mechanical thrombus aspiration alone "lone aspiration thrombectomy" (LAT) without stenting is not well studied. We present a retrospective analysis of patients receiving LAT as the only pPCI therapy for STEMI. Between January 2008 and March 2012, 202 young patients underwent pPCI for acute STEMI at our institution. From this group 10 patients had LAT as definitive therapy. LAT was favored if post thrombectomy minimal underlying CAD was noted, and concerns regarding long term treatment cost and compliance with dual antiplatelet therapy (DAPT) was an issue. All patients received ASA, clopidogrel, heparin and eptifibatide. DAPT was maintained for at least 1 month. One patient was lost to follow-up. At one month, all remaining 9 patients were free of MACE. At six weeks one patient had recurrent STEMI after abruptly discontinuing all his medications. Re-occlusion at the site of prior plaque rupture was stented, and treatment compliance was urged. Short term follow up at 2 months available for 5 patients and 2 years for 3 patients revealed no adverse consequences, the remaining patients had returned to their home countries. CONCLUSION: In selected young patients presenting with acute STEMI, LAT without balloon angioplasty or stenting is feasible and is associated with favorable short and long-term outcome.

Risk factor assessment of young patients with acute myocardial infarction.

UNLABELLED: The Middle East represents an attractive area for young individuals to seek employment, where they are exposed to numerous environmental conditions. The pursuit of a better standard of living has driven hundreds to the Middle East over the recent decades. This influx has also resulted in a predisposition to premature coronary artery disease (CAD). The aim of this study was to provide an overview of the risk factors in patients younger than 45 years, presenting with acute myocardial infarction (AMI). Out of the 148 patients analyzed, 137 were males and 11 females. 119 were from South Asia and 29 were Arabs. Their mean age was 36 ± 4.2 years. Smoking was the most prevalent risk factor in both groups at 67.6%. This was followed by hypertension, family history of CAD, hyperlipidemia and Diabetes mellitus. There was no significant difference in the clinical risk factor profile between these two groups. ST elevation myocardial infarction (STEMI) was noted in 67.6%, while 32.4% patients suffered a Non ST elevation myocardial infarction (NSTEMI). 84.5% received coronary stents, 8.8% had lone thrombus aspiration or balloon angioplasty only, while the rest were treated by conservative medical management or referred for coronary artery bypass surgery. CONCLUSION: There is no significant difference in the CAD risk profile between young South Asian and Arab patients. Preventive strategies focused on risk factor reduction, especially smoking cessation, should be implemented to protect young adults in the most productive years of their life.