Supercritical Carbon Dioxide and Microwave-Assisted Extraction of Functional Lipophilic Compounds from Arthrospira platensis.

Arthrospira platensis biomass was used in order to obtain functional lipophilic compounds through green extraction technologies such as supercritical carbon dioxide fluid extraction (SFE) and microwave-assisted extraction (MAE). The temperature (T) factor was evaluated for MAE, while for SFE, pressure (P), temperature (T), and co-solvent (ethanol) (CS) were evaluated. The maximum extraction yield of the obtained oleoresin was (4.07% ± 0.14%) and (4.27% ± 0.10%) for SFE and MAE, respectively. Extracts were characterized by gas chromatography mass spectrometry (GC-MS) and gas chromatography flame ionization detector (GC-FID). The maximum contents of functional lipophilic compounds in the SFE and MAE extracts were: for carotenoids 283 ± 0.10 µg/g and 629 ± 0.13 µg/g, respectively; for tocopherols 5.01 ± 0.05 µg/g and 2.46 ± 0.09 µg/g, respectively; and for fatty acids 34.76 ± 0.08 mg/g and 15.88 ± 0.06 mg/g, respectively. In conclusion, the SFE process at P 450 bar, T 60 °C and CS 53.33% of CO2 produced the highest yield of tocopherols, carotenoids and fatty acids. The MAE process at 400 W and 50 °C gives the best extracts in terms of tocopherols and carotenoids. For yield and fatty acids, the MAE process at 400 W and 70 °C produced the highest values. Both SFE and MAE showed to be suitable green extraction technologies for obtaining functional lipophilic compounds from Arthrospira platensis.

Large Right Atrial Myxoma: A Rare Presentation.

We present a case of a 74-year-old female with a large right atrial myxoma who initially presented to her primary care physician with nonspecific constitutional and abdominal symptoms. Her presenting symptoms were initially thought to originate from her gastrointestinal tract, but her workup for a gastrointestinal disorder was nondiagnostic. It was not until this patient developed symptoms of overt right heart failure that a cardiac condition was suspected. Our case highlights the importance of understanding the potential of cardiac myxomas to mimic many diseases, including cardiac, infective, neurologic, immunologic, pulmonary, and malignant diseases. Therefore, clinicians must always maintain a high index of suspicion for cardiac myxomas when evaluating patients with cardiac and non-cardiac-related symptoms that may be due to these tumors.

A Patient With Athlete's Heart Syndrome: When the Abnormal Is Normal.

Long-term athletic training can result in structural and conduction changes within the heart, leading to Athlete's heart syndrome (AHS). This syndrome is characterized by increased left ventricle (LV) dimensions, thickness, and mass. Dynamic exercise significantly contributes to these alterations, with sinus bradycardia being a common conduction abnormality, often accompanied by first-degree atrioventricular (AV) block. However, higher degrees of AV conduction abnormalities, such as second- and third-degree blocks, though rare, might occur due to parasympathetic hypertonia. Prompt evaluation is necessary to rule out underlying structural or infiltrative heart diseases. We present the case of a 66-year-old lifelong long-distance runner with marked sinus bradycardia, AV dissociation, and junctional escape rhythm, alongside left ventricular hypertrophy (LVH) and T-wave repolarization abnormalities. Subsequent studies ruled out possible pathologies, and the patient was diagnosed with AHS, characterized by cardiac remodeling and bradycardia due to prolonged cardiac loading. This case underscores the importance of clinical assessment, cardiac imaging, and exclusion of pathologic causes to distinguish normal physiological adaptations from potentially concerning conditions.

A Case of Left Ventricular Pseudoaneurysm as a Complication of Late-Presenting ST-Segment Elevation Myocardial Infarction.

This case report delineates the clinical trajectory and management strategies of a 59-year-old Hispanic male diagnosed with a left ventricular pseudoaneurysm (LVPA) following a delayed presentation of ST-segment elevation myocardial infarction (STEMI), for which reperfusion treatment was not administered. Initially, an echocardiogram demonstrated an extensive anterolateral myocardial infarction, severe left ventricular systolic dysfunction, and an early-stage left ventricular apical aneurysm with thrombus, leading to the initiation of warfarin. Metabolic myocardial perfusion imaging via positron emission tomography indicated a substantial myocardial scar without viability, guiding the decision against revascularization. Post discharge, the patient, equipped with a wearable cardioverter defibrillator for sudden cardiac death prevention, experienced symptomatic ventricular tachycardia, which was resolved with defibrillator shocks. Subsequent imaging revealed an acute LVPA adjacent to the existing left ventricular aneurysm. Given the high surgical risk, conservative management was elected, resulting in thrombosis and closure of the pseudoaneurysm after two weeks. The patient eventually transitioned to home hospice, surviving an additional five months. This report underscores the complexities and therapeutic dilemmas in managing post-MI LVPA patients who are ineligible for surgical intervention.

Cardiac Angiosarcoma Presenting as Large Pericardial Effusion With Effusive-Constrictive Pericarditis.

Pericardial angiosarcoma is an extremely rare malignant tumor originating from the endothelial cells of blood vessels within the pericardium. We present a case of a 49-year-old male who presented with symptoms of pericardial effusion and was subsequently diagnosed with pericardial angiosarcoma. This case report highlights the diagnostic challenges and management options associated with this rare entity.

Sinus Venosus Atrial Septal Defect as an Overlooked Source of Shortness of Breath Among Patients With Pulmonary Arterial Hypertension.

Sinus venosus atrial septal defects (SVASD) associated with partial anomalous pulmonary venous return (PAPVR) can be overlooked as a source of dyspnea in adult patients with pulmonary hypertension. We present the case of a 61-year-old male with exertional dyspnea initially attributed to pulmonary hypertension, who was subsequently diagnosed with SVASD and right superior PAPVR. This case underscores the critical importance of maintaining high clinical awareness and utilizing multimodal imaging techniques in cardiology to accurately diagnose and manage pulmonary hypertension secondary to congenital heart disease. Timely surgical correction can significantly improve morbidity and mortality outcomes.

Optimizing Valve Selection in Valve-in-Valve Transcatheter Aortic Valve Replacement: A Case Study on Addressing Patient-Prosthesis Mismatch and Early Structural Valve Deterioration in a Morbidly Obese Patient.

Transcatheter aortic valve replacement (TAVR) has increasingly become a fundamental approach for treating aortic valve stenosis (AVS), especially in high surgical risk patients. This case study underscores the criticality of meticulous procedural planning and precise valve selection in patients with severe AVS compounded by obesity. We report a case of a patient who, after receiving a 26 mm Edwards Sapiens 3 valve, presented with worsening exertional dyspnea and a declining indexed effective orifice area (EOAi). This deterioration indicated early structural valve deterioration (SVD), presumably due to patient-prosthesis mismatch (PPM). A subsequent valve-in-valve (ViV) TAVR using a 29 mm Medtronic Evolut Fx valve was successfully executed, leading to a notable improvement in EOAi. This case study emphasizes the complexities inherent in valve choice and sizing in TAVR, particularly highlighting the impact of PPM on obese patients and its potential to precipitate early SVD. The report further explores the emerging strategies in addressing TAVR valve dysfunctions via ViV interventions, shedding light on the nuanced and dynamic nature of TAVR management in obese patients. It advocates for tailored treatment strategies in managing such intricate cases, demonstrating the evolving landscape of TAVR procedures.

Successful Rescue Transaortic Valve Replacement Using Edwards Sapien 3 Following Failed Evolut R Implantation in a Degenerated Surgical Bioprosthesis: A Case Report.

This study examines a complex scenario of structural valve degeneration (SVD) in a high surgical-risk patient with a previously implanted 25 mm Carpentier-Edwards (CE) Perimount Magna Ease 3300 (Irvine, CA: Edwards Lifesciences) surgical bioprosthetic valve (SAV), the patient presented with both paravalvular leak (PVL) and central prosthetic valve insufficiency (PVI). The patient was considered for a transaortic valve-in-valve (ViV) intervention with a self-expanding 29 mm Evolut R valve (Minneapolis, MN: Medtronic). The case describes a ViV intervention complicated by the malpositioning of the Evolut R valve secondary to micro-dislodgement into the left ventricular outflow tract (LVOT) after deployment and subsequent migration into the LVOT during an attempted bioprosthetic valve fracture (BVF) of the SAV that aimed to decrease transvalvular gradients. The resulting acute severe PVL resulted in significant hemodynamic deterioration, necessitating emergent intervention by implanting a balloon-expandable 26 mm Edwards SAPIEN 3 valve (Irvine, CA: Edwards Lifesciences), effectively averting the need for a surgical valve explant. This study illuminates the intricacies and emergency management strategies in transcatheter aortic valve replacement (TAVR) procedures, particularly in high-risk patients with SVD, and offers critical insights into the challenges and solutions in ViV implantations.

Unusual Presentation of De Winter's Sign Due to Bezold-Jarisch Reflex in a Patient With Severe Aortic Valve Stenosis.

The de Winter electrocardiogram (ECG) pattern, marked by upsloping ST depression in leads V2-V6, ST elevation in lead aVR, and tall symmetric T waves, typically indicates left anterior descending artery (LAD) occlusion. Traditionally linked to LAD occlusion, it is rare in severe aortic stenosis and the Bezold-Jarisch reflex (BJR). We report an 83-year-old man with severe aortic stenosis who developed hypotension due to bleeding and exhibited the de Winter ECG pattern. This case highlights how severe aortic stenosis and BJR can lead to significant hemodynamic instability and ischemic ECG changes, resolving after hemodynamic stabilization.

High-Degree Atrioventricular Block and Torsades De Pointes in Severe Aortic Stenosis Treated With Transcatheter Aortic Valve Replacement.

Severe aortic stenosis (AS) significantly elevates cardiovascular risk, predisposing patients to high-degree atrioventricular (AV) block and life-threatening tachyarrhythmias, including torsades de pointes (TdP). This case report presents a patient with severe AS who developed high-degree AV block and, subsequently, TdP, highlighting the interplay between bradycardia and mechanisms that trigger ventricular tachycardias. The case underscores the importance of identifying and managing these risk factors to improve patient outcomes.

The Critical Role of Lambda-Shaped QRS-ST-T Wave Fusion ST-Elevation in Diagnosing and Managing Takotsubo Cardiomyopathy: A Case Report and Review of Literature.

Stress-induced cardiomyopathy, commonly known as Takotsubo cardiomyopathy (TCM), is a clinical syndrome characterized by acute and transient ventricular systolic dysfunction that often presents with chest pain and may resemble an acute coronary syndrome. This case report discusses a complex clinical scenario involving an adult female with severe depression who attempted suicide through drug overdose, subsequently developing serotonin syndrome. Her clinical presentation was further complicated by the emergence of a unique lambda-shaped triangular QRS-ST-T waveform fusion ST-elevation electrocardiographic (ECG) pattern closely mimicking an anterolateral occlusive myocardial infarction. The study delves into the clinical implications of this unique ECG pattern in TCM, providing valuable insights into diagnosing and treating such complex cases. This case underscores the importance of recognizing diverse manifestations of TCM and its potential for severe cardiovascular complications.

Unveiling the Heart of the Matter: Intravascular Ultrasound in Acute Myocardial Infarction.

Intravascular ultrasound (IVUS) has become crucial in contemporary percutaneous coronary interventions (PCIs), offering detailed two-dimensional (2D) arterial wall visualization. Current guidelines consider it valuable for guiding coronary stent placement, especially in complex cases like the left main (LM) artery, allowing a comprehensive assessment of vessel characteristics and stent performance. There are some studies that highlight the potential impact of IVUS on acute myocardial infarction (AMI) management, notably improving outcomes. This case involves a 37-year-old man who experienced an AMI, necessitating the use of IVUS to ascertain the underlying cause of his acute coronary syndrome (ACS). This approach was essential for guiding appropriate treatment and ultimately led to successful stent implantation.

An Unusual Presentation of Apical Hypertrophic Cardiomyopathy in an Orthotopic Heart Transplant Recipient.

In this case study, we present the evaluation of an orthotopic heart transplant (OHT) patient who presented with persistent shortness of breath and dizziness upon standing. The investigation uncovered the presence of progressive hypertrophic cardiomyopathy (HCM) in the transplanted heart, a condition first detected 11 years after the transplantation. Utilizing echocardiography with global longitudinal strain (GLS), we determined that the HCM likely originated from genetic predominance inherited from the heart donor rather than hypertensive disease. This finding highlights the significance of genetic factors in post-transplant complications and warrants further investigation into the long-term effects of heart transplantation on recipient health.

A Rare Case of Kounis Syndrome Secondary to Infliximab.

Kounis syndrome (KS) is an acute coronary syndrome triggered by allergic or anaphylactic reactions. It manifests as coronary artery vasospasm, acute myocardial infarction, or coronary stent thrombosis, resulting from inflammatory cytokine release and inappropriate activation of platelets and mast cells. We present a case of an 85-year-old male with Crohn's disease who suffered anaphylaxis during infliximab infusion, culminating in non-ST myocardial infarction (NSTEMI). The patient's symptoms were effectively managed with epinephrine and diphenhydramine, and KS secondary to infliximab was diagnosed. Diagnosing KS can be challenging due to the overlapping signs of an allergic reaction and myocardial infarction. Timely recognition and appropriate management of KS are crucial to enhance patient outcomes. Therefore, healthcare providers should maintain a high index of suspicion for KS in patients with acute coronary syndromes linked to allergic reactions to optimize care and minimize potential risks. This case report underscores the significance of prompt intervention and awareness of Kounis syndrome in clinical practice.

Uncovering an Easily Overlooked Cause of Dyspnea: Partial Anomalous Pulmonary Venous Connection of the Right Pulmonary Vein to the Superior Vena Cava Leading to Right Heart Enlargement.

This case report describes a rare variant of partial anomalous pulmonary venous connections (PAPVCs) in a patient who presented with an insidious progression of dyspnea on exertion as an adult, leading to the diagnosis of PAPVC. The patient had an anomalous right upper pulmonary vein connecting to an anomalous pulmonary-azygos trunk that connected to the cranial superior vena cava (SVC), producing a large left-to-right extracardiac shunt. The diagnosis of PAPVC was made after evaluating for causes of right heart chamber enlargement. This case highlights the importance of considering PAPVC as a potential cause of unclear etiology for exertional dyspnea, right-sided chamber enlargements, and intact atrial septum. The onset and severity of symptoms in patients with PAPVC depend on various factors, including the number of pulmonary veins, site of connection, pulmonary vascular resistance, atrial compliance, and the presence of other congenital heart defects. Therefore, clinicians should maintain a high level of suspicion for PAPVC in patients with these types of symptoms.

Multivitamin-Induced Pharmacobezoar: A Rare Entity of Large Bowel Obstruction.

The term bezoar refers to a foreign object found like a mass of concretion in the gastrointestinal tract that results from an accumulation of undigested material. When the composition of the ingested material is a medication, it is known as a pharmacobezoar. A rare complication from pharmacobezoar is large intestinal obstruction. Here we present the case of a 77-year-old male who presented with progressive abdominal distension, involuntary guarding, and large bowel obstruction. Abdominal imaging studies were remarkable for radiopaque objects of uncertain etiology in the transverse colon and rectal ampulla. The patient underwent colonic decompression by sigmoidoscopy, where the pills were identified by direct visualization. He later underwent endoscopic removal of the pharmacobezoars. A detailed medication review identified the culprit to be multivitamins. This case portrays an unusual etiology of large bowel obstruction. At this moment, no cases have been reported of multivitamins as the culprit of pharmacobezoar with subsequent development of large bowel obstruction.

Índice de inmunidad-inflamación sistémica (IIS) como marcador pronóstico de mortalidad en pacientes con COVID-19.

OBJECTIVE: To determine if the systemic immune-inflammation index (SII) is a prognostic marker of mortality in COVID-19 patients. METHOD: Retrospective study that included patients admitted to a general hospital in Mexico City with diagnostic of COVID-19, confirmed by quantitative polymerase chain reaction from nasopharyngeal swab specimens in addition to characteristic symptomatology and computerized thoracic tomography imaging. Upon admission an hematic biometry was taken to calculate the SII (neutrophils × platelets/lymphocytes). The optimal cut-off point was determined from a ROC curve; the chi-square test was used to evaluate the association of SII with mortality, the strength of the association was estimated through the odds ratio (OR) and, finally, a multivariate binary logistic regression analysis was performed. RESULTS: 140 individuals were included, 86 (61.4%) men and 54 women (38.6%), the mean age of patients was 52 (± 13.81) years old. The best prognostic cut-off point found was 2332.30 × 109 (area under the curve: 0.68; 95% confidence interval [95% CI]: 0.59-0.77; p < 0.05). The OR was 3.78 (95% CI: 1.83-7.82; p < 0.05). CONCLUSIONS: We demonstrated that the SII is an easily available tool, effective and a prognostic marker of mortality in hospitalized COVID-19 patients.

OBJETIVO: Determinar si el índice de inmunidad-inflamación sistémica (IIS) es un marcador pronóstico de mortalidad en pacientes con COVID-19. MÉTODO: Estudio retrospectivo que incluyó pacientes que ingresaron con diagnóstico de COVID-19 a un hospital general de la Ciudad de México, confirmado mediante prueba de reacción cuantitativa en cadena de la polimerasa con transcriptasa inversa de muestras de hisopado nasofaríngeo, además de la sintomatología característica y los hallazgos de la tomografía computarizada de tórax. A su ingreso se les realizó biometría hemática para el cálculo del IIS (neutrófilos × plaquetas/linfocitos). Mediante una curva ROC se determinó el punto de corte óptimo del IIS. Para evaluar la asociación del IIS con la mortalidad se utilizó la prueba de ji al cuadrado, la fuerza de la asociación con la razón de momios (OR, odds ratio) y se realizó un análisis multivariado de regresión logística binaria. RESULTADOS: Se incluyeron 140 individuos, de los cuales 86 (61.4%) eran hombres y 54 (38.6%) mujeres, con una media de edad de 52 (± 13.81) años. El mejor punto de corte pronóstico fue 2332.30 × 109 (área bajo la curva: 0.68; intervalo de confianza del 95% [IC95%]: 0.59-0.77; p < 0.05). La OR fue de 3.78 (IC95%: 1.83-7.82; p < 0.05). CONCLUSIONES: El IIS mostró ser una herramienta de fácil disponibilidad y un marcador pronóstico de mortalidad al ingreso en pacientes hospitalizados con COVID-19.

Cardiac Platypnea-Orthodeoxia Syndrome: A Rare Case of Flow-Directed, Right-to-Left Shunt via a Patent Foramen Ovale Exacerbated by Aortic Root Enlargement.

Cardiac platypnea-orthodeoxia is a unique clinical syndrome characterized by dyspnea and deoxygenation when moving from a supine to an upright position. In this case report, we detail the experience of a 78-year-old male with persistent hypoxemia following a paradoxical embolic ischemic stroke. Despite proper management of his respiratory symptoms, the patient continued to be affected by marked dyspnea and hypoxemia, particularly when upright or in a right-sided decubitus position. Subsequent investigation revealed that his hypoxemia was a result of cardiac platypnea-orthodeoxia syndrome (POS). This condition was attributed to the enlargement of his aortic root and ascending aorta, coupled with a counterclockwise rotation of the heart axis. These factors facilitated a flow-directed, right-to-left interatrial shunt through a patent foramen ovale, even in the absence of elevated right heart pressures.

Unusual Case of Acute Coronary Syndrome Due to Compression of the Left Main Coronary Artery From a Contained Aortic Root Perforation.

We present an intriguing and rare case of a 71-year-old male who presented with a non-ST elevation myocardial infarction (NSTEMI). Initial coronary angiography revealed severe and unusual systolic extrinsic compression of the left main coronary artery (LM), warranting further advanced imaging investigations. Computed tomography angiography (CTA) and transesophageal echocardiography (TEE) were employed to determine the underlying cause, which was identified as a contained aortic rupture leading to the formation of a pseudoaneurysm in the left coronary sinus of Valsalva and aortic root. This condition was found to be a sequela of previously undiagnosed endocarditis, likely secondary to lower extremity osteomyelitis and bacteremia, for which the patient received prolonged intravenous (IV) antibiotic therapy. This case highlights the critical role advanced imaging techniques play in accurately diagnosing and characterizing complex cardiovascular abnormalities, enabling early intervention and optimizing patient outcomes. Healthcare providers should remain vigilant for such atypical presentations to ensure timely and appropriate management.

Impact of accountable care organizations on acute cholecystitis outcomes in the Rio Grande Valley.

BACKGROUND: Accountable care organizations through the Affordable Care Act are to improve Medicare beneficiaries' health while reducing costs. We hypothesize that this model may shift care, disease burden, and costs to nonaffiliated hospital facilities in patients with acute cholecystitis. METHODS: A retrospective difference-in-differences analysis was performed to compare severity, postoperative complications, diagnostic modality, length of stay, and costs in patients with acute cholecystitis from a post-accountable care organization implementation period (January 2014 through December 2015) to a pre-accountable care organization period (January 2011 through December 2012). RESULTS: Analysis of 400 patients with acute cholecystitis revealed the post-accountable care organization patients had significantly (P < .0001) higher disease severity (14.4% vs 8.4%), emergency admissions (90.1 vs 74.2%), computed tomography scans (55.5% vs 27.8%), prolonged length of stay (5.2 vs 3.9 days), and a 30% (P < .0003) increase in total costs. CONCLUSION: These data are consistent with the hypothesis that the introduction of accountable care organizations resulted in a higher morbidity, more emergency admissions, more extensive management, a prolonged length of stay, and increased cost in patients with acute cholecystitis. These data support the position that accountable care organizations may shift costs from the primary care setting to nonaffiliated accountable care organization hospitals, provide a lesser level of care, and thus potentially failing their primary mandates.