Left internal mammary artery to pulmonary artery fistula causing coronary steal syndrome: A review of literature on therapy, intervention, and management.

Coronary artery anomalies (CAA) are anatomical aberrations in the origin, structure, and course of the epicardial arteries. Literature has detailed common anomalies or fistulas formed because of coronary artery bypass grafting (CABG) manipulation of intrathoracic vessels. Despite the commonality of the CABG procedure, there are a few CAA and fistula findings which remain extremely rare. We present a case of left internal mammary artery to pulmonary artery fistula causing coronary steal syndrome that presented symptomatically as a malignant arrhythmia. Following a literature review of therapy, intervention, and management we recommend a team based approach when faced with this extremely rare case presentation. The goal of management should to reduce symptoms, and ischemia, by reducing or stopping flow through the fistula and out of the coronary blood supply.

Intra-Atrial Right Coronary Artery and Anomalous Origin of Left Circumflex Artery Found Concurrently.

Coronary artery anomalies (CAAs) are known to be anatomical aberrations in the origin and structure. Due to the diverse anatomical variants, surgeons and angiographers have struggled when faced with patients who have CAA. To frame the complicated issues surrounding CAA, we present a case of a young patient found to have two CAAs, concurrently on coronary computed tomography angiography (CCTA), while in the emergency room being evaluated for chest pain. Patient was medically observed without any invasive procedure since he was deemed to have low cardiovascular risk. Subsequently, literature on prevalence, as well as high risk findings are reviewed. Further studies to evaluate pharmacological, angiographic, and surgical interventions may have additional benefit for both patients and practitioners. Our aim is to help shed the light on difficulties cardiologists are facing during angiography. Additionally, our paper offers some guidance for how to evaluate and follow patients with similar findings into the future.

Trends and predictors of coronary revascularization in patients with coronary artery anomalies and acute myocardial infarction: a nationwide analysis of 8131 patients.

OBJECTIVE: Acute myocardial infarction (AMI) is rarely associated with coronary artery anomalies (CAA). This confluence makes it difficult to identify and treat the culprit lesion with percutaneous coronary intervention (PCI). Our objective was to evaluate trends and predictors of revascularization in patients with CAA and AMI using a large national database. METHODS: We included adult patients with CAA presenting as ST segment elevation myocardial infarction (STEMI) or non-ST segment elevation myocardial infarction (NSTEMI) and undergoing coronary angiography from Nationwide Inpatient Sample from 2000 to 2011, using ICD-9 diagnosis code of 746.85 for CAA. Chi-square test for trend was used to compare revascularization rates over time. Multivariate logistic regression was used to identify predictors of revascularization. RESULTS: There were almost 4.7 million subjects with AMI undergoing coronary angiography from 2000 to 2011. Of these, there were 8131 patients with CAA, including 3425 STEMI and 4706 NSTEMI patients. Mean age of the CAA population was 59 years with 63.6% males. Overall PCI rate was 47.8% and coronary artery bypass grafting rate was 8.8%. In STEMI patients with CAA, PCI rate increased from 49.9% in 2000 to 77.8% in 2011 (P < 0.001). In NSTEMI patients with CAA, PCI rate remained unchanged from 33.3% in 2000 to 37.3% in 2011 (P = 0.34). Revascularization trends in AMI patients with CAA mirrored those in AMI patients without CAA. CONCLUSION: Despite the technical challenges associated with PCI in CAA, PCI rates in STEMI patients with CAA continue to increase over time. On the contrary, PCI rates continue to remain low in CAA patients with NSTEMI, reflecting overall contemporary NSTEMI treatment trends.

Complete atrioventricular block caused by pulmonary embolism: A case report and review of literature.

INTRODUCTION: Acute electrocardiogram abnormalities are common in patients afflicted with pulmonary embolism (PE). Rarely, a patient with acute pulmonary embolism and electrocardiogram changes may have an underlying conduction abnormality that complicates their course. CASE PRESENTATION: We describe a patient with known history of left bundle branch block who presented with acute PE and developed a right bundle branch block, which devolved into complete third degree heart block without ventricular escape rhythm and led to concomitant hemodynamic compromise. DISCUSSION: Given the rarity of this clinical scenario, we call for clinicians to be aware of PE-associated conduction pathology as well as the possibility that malignant cardiac conduction blocks may occur in the setting of PE particularly if the patient is known to have underlying conduction system disease. We emphasize the importance of continuous telemetry monitoring in patients presenting with PE as these types of arrhythmic complications and hemodynamic decompensation has been observed.

Purulent Pericarditis Caused by Bacteroides fragilis: A Rare Complication of Cholangitis.

Bacterial infection is a rare cause of pericarditis especially in the post-antibiotic era. When compared to viral or idiopathic etiologies, purulent pericarditis carries a higher risk for complications. While most cases are due to Staphylococcus aureus, we present a rare case of pericarditis due to Bacteroides fragilis originating from a liver abscess and leading to pericardial effusion. Our case highlights the need to maintain a high clinical suspicion of bacterial infection when patients present with sepsis and have evidence of pericarditis.

Small Septal Branch Artery Thrombus Inducing Ventricular Fibrillation: To Intervene or Not to Intervene.

A 64-year-old woman presented for chest pain and was diagnosed with anteroseptal ST segment elevation myocardial infarction (STEMI). Emergent angiography showed 95% stenosis at the ostium of the second septal branch, consistent with thrombus, and no other significant lesions. The lesion was not amenable to intervention due to small caliber. Post angiography, the patient's electrical rhythm deteriorated into ventricular fibrillation. Following resuscitation, repeat angiography confirmed same findings. Electrophysiology study at 3 months was positive for inducing fibrillation. Due to patient risk factors, she had placement of a dual chamber defibrillator. A 5-month follow-up echocardiogram showed a small area of ventricular septal wall bowing, consistent with blood supply from septal territory.

Snow and Reindeer: Large Tricuspid Valve Mobile Vegetation.

A 20-year-old female with history of polysubstance abuse presented with fevers and lightheadness. Blood cultures grew out Streptococcus constellatus, which is known to form purulent infections when introduced in the body. Evaluation with transesophageal echocardiogram showed a definite large, irregular, loosely organized, highly mobile vegetation.

Takotsubo Cardiomyopathy precipitated by opiate withdrawal.

INTRODUCTION: Takotsubo Cardiomyopathy is a transient non-ischemic cardiomyopathy usually characterized by apical ballooning of the left ventricle, with electrocardiographic changes and enzyme release, without evidence of obstructive coronary artery disease. Typically seen in stress induced situations, in post-menopausal females, this condition may have a predilection for patients with dependency disorders. CASE: The following is a case in which Takotsubo Cardiomyopathy was induced by withdrawal from opiate medications. Followed by resolution of symptoms after restarting maintenance opioid therapy. DISCUSSION: We feel health care professionals should be aware of this possibility in such a patient population especially when they have demonstrated cardiovascular symptomatology. Given the prevalence of opiate use both recreational and iatrogenic, the index of suspicion for opiate-withdrawal induced cardiomyopathy should be high in the presence of cardiac symptomatology.

Takotsubo Cardiomyopathy Precipitated by Tapering of Anxiolytic Medication: A Case Report.

Takotsubo cardiomyopathy is a transient apical ballooning of the left ventricle typically with electrocardiographic changes and enzyme release without evidence of obstructive coronary artery disease. It typically occurs in postmenopausal women and may have a predilection for patients with anxiety disorders. The following is a case in which we believe takotsubo cardiomyopathy was induced by the tapering of antianxiety medications. We feel that health care professionals should be aware of this possibility in such a patient population especially when they have demonstrated cardiovascular symptomatology.