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Intravenous immunoglobulin (IVIG) is a therapeutic preparation of pooled polyspecific IgG used effectively in immune thrombocytopenic purpura (ITP), autoimmune diseases, and inflammatory diseases. We present a case of a 67-year-old male who presented with diffuse petechiae and was diagnosed with immune thrombocytopenic purpura with platelet count less than 10,000 per milliliter. Treatment was initiated with IVIG. When the third dose of IVIG was being administered he developed hypertensive urgency and non-ST segment elevation myocardial infarction. He was deemed not to be a candidate for cardiac catheterization and was treated conservatively. IVIG can cause major thrombotic adverse events such as deep vein thrombosis, myocardial infarction and stroke, which are attributed to thrombosis and hyperviscocity. Decreasing the dosage of IVIG, administration of anticoagulants are proposed treatments for such events. We propose that patients receiving high-dose IVIG with previous coronary artery disease require meticulous cardiac monitoring. Further research is needed to determine the true adverse effects of high-dose IVIG and prophylaxis regimens to decrease the risk.
Assuntos
Síndrome Coronariana Aguda/induzido quimicamente , Hipertensão/induzido quimicamente , Imunoglobulinas Intravenosas/efeitos adversos , Fatores Imunológicos/efeitos adversos , Púrpura Trombocitopênica Idiopática/tratamento farmacológico , Síndrome Coronariana Aguda/sangue , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/tratamento farmacológico , Idoso , Anti-Hipertensivos/uso terapêutico , Relação Dose-Resposta a Droga , Eletrocardiografia , Humanos , Hipertensão/sangue , Hipertensão/diagnóstico , Hipertensão/tratamento farmacológico , Masculino , Contagem de Plaquetas , Púrpura Trombocitopênica Idiopática/sangue , Púrpura Trombocitopênica Idiopática/imunologia , Tomografia Computadorizada por Raios XRESUMO
Evolution of plaque that is prone to rupture is characterized by inflammation and physical changes. Accumulation of low-density lipoprotein in the sub-intima provides esterified cholesterol (ESC) to macrophages and smooth muscle cells that convert it into free cholesterol (FRC) by cholesteryl ester hydrolases (CEHs). Membrane-bound cholesterol carriers transport FRC to high-density lipoprotein (HDL). Impaired HDL transport function and altered composition can lead to extracellular accumulation of FRC, whereas impaired membrane carrier activity can lead to intracellular FRC accumulation. Saturation of FRC can result in cholesterol crystallization with cell death and intimal injury. Disequilibrium between ESC and FRC can impact foam cell and cholesterol crystal (CC) formation. Cholesterol crystals initiate inflammation via NLRP3 inflammasome leading to interleukin-1ß (IL-1ß) production inducing C-reactive protein. Eventually, crystals growing from within the plaque and associated inflammation destabilize the plaque. Thus, inhibition of inflammation by antagonists to IL-1ß or agents that dissolve or prevent CC formation may stabilize vulnerable plaques.
Assuntos
Arterite , Colesterol , Células Espumosas , Humanos , Lipoproteínas HDL , Placa AteroscleróticaRESUMO
Atypical antipsychotics are very widely used for various psychiatric ailments because of their less extrapyramidal side effects. Various reports of disturbances in glucose metabolism in the form of new onset diabetes mellitus, exacerbation of preexisting diabetes mellitus, diabetic ketoacidosis, hyperosmolar nonketotic coma, acute pancreatitis, and increased adiposity have been reported. We present a case of new onset diabetic ketoacidosis in a patient without a history of glucose intolerance who was being treated with olanzapine for bipolar disorder. He presented in hyperglycemic, hyperosmolar, hyperketotic state with hyperkalemia, and peaked T waves on electrocardiogram. He was treated with vigorous intravenous hydration, insulin, and kaexylate which stabilized his metabolic profile. He was discontinued off of his olanzapine and started on resperidol for his bipolar disorder. Over the course of 6 months, the patient was discontinued off of his insulin and has been doing well on his follow-up appointments. This case highlights the necessity of close blood glucose monitoring of patient on atypical antipsychotic medications irrespective of their diabetic status.
Assuntos
Antipsicóticos/efeitos adversos , Benzodiazepinas/efeitos adversos , Transtorno Bipolar/tratamento farmacológico , Cetoacidose Diabética/induzido quimicamente , Coma Hiperglicêmico Hiperosmolar não Cetótico/induzido quimicamente , Quelantes/uso terapêutico , Cetoacidose Diabética/tratamento farmacológico , Humanos , Coma Hiperglicêmico Hiperosmolar não Cetótico/tratamento farmacológico , Hiperpotassemia/induzido quimicamente , Hiperpotassemia/tratamento farmacológico , Hipoglicemiantes/uso terapêutico , Insulina/uso terapêutico , Masculino , Pessoa de Meia-Idade , Olanzapina , Poliestirenos/uso terapêuticoRESUMO
Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy or "broken heart syndrome," is a rare and reversible condition characterized by transient left ventricular dysfunction. It is typically triggered by acute emotional or physical stressors. Here, we present a unique case of TCM occurring in a 77-year-old woman following cardioversion for persistent and symptomatic atrial fibrillation. The patient underwent uncomplicated cardioversion with recent imaging showing intact global systolic function. She presented four days post-procedure for chest pain, shortness of breath, and peripheral edema. A repeat echocardiogram showed a marked decrease in cardiac function evidenced by an ejection fraction of 20-25%. The patient was readmitted and managed with IV diuretics. Symptoms resolved within three days and the patient showed improved cardiac function on imaging prior to discharge.
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Background: Left atrial appendage occlusion (LAAO) performed percutaneously has emerged as a widely accepted method for stroke prevention, offering a viable alternative to anticoagulation. Numerous studies have demonstrated the effectiveness and safety of this procedure. However, in certain cases, the use of a single LAAO device may not adequately achieve optimal closure due to variations in the anatomy of the left atrial appendage (LAA). Case summary: In this manuscript, we highlight the successful closure of a bilobed LAA with a large ostium utilizing two WATCHMAN™ FLX devices and using the double sheath technique. The aim was to achieve optimal closure and address the unique anatomical characteristics of the patient's LAA. Discussion: The utilization of two LAAO devices in bilobed appendage anatomy, where a single device may not be sufficient, is possible, although it poses a challenge because of the lack of technical expertise and limited published evidence. Transoesophageal imaging can serve as a valuable tool for assessing the precise anatomy of the LAA and guide the selection and placement of the occlusion devices.
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Although Percutaneous Coronary Intervention (PCI) has revolutionized the management of CAD, the deliverability of devices including balloons, specialty balloons, stents, atherectomy catheters, thrombectomy devices, and intravascular lithotripsy devices has become a common challenge faced by interventional cardiologists. Guide Extension Catheters (GECs) have been developed and are now widely used to create improved backup support to allow the advancement of interventional equipment required for the PCI. Improved lesion preparation, plaque modification (e.g., with atherectomy), and Guide Extension Catheters (GEC), also called as Mother-Child Technique, has proven critical to procedural success in complex cases. In this review, we discuss the role and limitations of current guide extension devices, with a brief discussion of next-generation GEC.
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Melanoma is considered a masquerader of many diseases owing to its potential to metastasize to many organs. Several malignancies can metastasize to the heart including malignant melanoma. Historically, antemortem diagnosis of cardiac involvement of melanoma is not common, but with significant improvement in imaging modalities, the diagnosis can now be made early and accurately, aiding in treatment and improved survival. We present a case of a 36-year-old man with brief neurological symptoms and subsequent diagnosis of cerebrovascular accident (CVA). Cardiac imaging revealed incidental findings of right and left ventricular masses and lymph node biopsy, confirming metastatic melanoma. Cardioembolic etiology was suspected for his CVA. Prompt immunotherapy was initiated with improvement in his clinical condition.
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BACKGROUND: Percutaneous coronary intervention (PCI) of saphenous vein grafts (SVG) can be challenging due to no reflow phenomenon from distal embolization of debris and microvascular vasoconstriction, resulting in myocardial injury post-procedure. Guidelines promote the use of distal embolic protection devices (EPD) to protect the distal arterial bed during SVG PCI. However, this approach has shown less-than-optimal results in many studies. We report our data using the Borgess protocol [prophylactic intracoronary (IC) nicardipine injection and direct stenting], as an alternative to EPDs in a large series of SVG interventions. METHODS: This is a retrospective, cohort study of our single center experience with SVG interventions between 2017 and 2021. The primary outcome of the study was major adverse cardiovascular events (MACE) [a composite of death, emergent coronary artery bypass graft surgery (CABG), myocardial infarction (MI), and target vessel revascularization (TVR)] at 30 days post-procedure. RESULTS: There were 424 consecutive SVG interventions performed during the study period, and 76% of cases presented with acute coronary syndrome. Full adherence to the Borgess protocol was observed in 36% of cases; IC nicardipine was utilized in 72% of cases. MACE rate was 3.5% at 30 days driven primarily by MI (2.6%). CONCLUSION: The Borgess protocol approach to vein graft interventions proved good outcomes when compared to SVG PCI in randomized trials utilizing EPDs. Our study is limited by the retrospective nature and single center experience.
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Atrial fibrillation (AF) is a common complication in patients who underwent transcatheter aortic valve implantation. Some of these patients have preexisting AF as well. The management of these patients is complex, especially after the procedure, when there is a sudden change in hemodynamics. There are no established guidelines about the management of the patients who underwent transcatheter aortic valve replacement with preexisting or new-onset AF. This review article discusses the management of these patients with rate and rhythm control strategies with medications. This article also highlights the role of newer oral anticoagulation medications and left atrial occlusion devices to prevent stroke after the procedure. We will also discuss new advances in the care of this patient population to prevent the occurrence of AF after transcatheter aortic valve implantation. In conclusion, this article is a synopsis of both pharmacologic and device interventions for the management of AF in patients who underwent transcatheter aortic valve replacement.
Assuntos
Estenose da Valva Aórtica , Fibrilação Atrial , Acidente Vascular Cerebral , Substituição da Valva Aórtica Transcateter , Humanos , Substituição da Valva Aórtica Transcateter/efeitos adversos , Fibrilação Atrial/tratamento farmacológico , Estenose da Valva Aórtica/complicações , Resultado do Tratamento , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Valva Aórtica/cirurgiaAssuntos
Antiarrítmicos/efeitos adversos , Flecainida/efeitos adversos , Insuficiência Cardíaca/tratamento farmacológico , Taquicardia Ventricular/induzido quimicamente , Idoso , Amiodarona/uso terapêutico , Eletrocardiografia , Feminino , Humanos , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/tratamento farmacológicoRESUMO
Cardiac masses pose diagnostic challenges. We present a 62-year-old woman presented for evaluation of chest pain and palpitations. Transthoracic echocardiography showed left atrial mass, which was subsequently identified as hiatal hernia by cardiac magnetic resonance imaging.
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We report a case of coronary artery fistula arising from the left main coronary artery in a 62-year-old patient presenting with atrial fibrillation. He underwent a transthoracic echocardiogram which suggested a possible coronary artery fistula. Cardiac computed tomographic angiography and cardiac catheterization confirmed the diagnosis. Coronary artery fistula originated from the left main coronary artery, which is rare and terminated in the coronary sinus. Multi-modality imaging helps to delineate anatomy and decide treatment options. Small asymptomatic fistulas do not require treatment, and large or symptomatic fistulas need closure. Our patient was asymptomatic, and we opted for conservative management with close outpatient echocardiographic monitoring.
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Ticagrelor (BRILINTA®) is a very commonly used oral antiplatelet agent in acute coronary syndrome and after percutaneous coronary intervention (PCI). It is a reversible, direct inhibitor of the adenosine diphosphate (ADP) P2Y12 receptor. Most of the patients tolerate the drug well but it is known to cause brady arrhythmias and ventricular pauses, the exact mechanism of which is unclear. We present a case of acute coronary syndrome/unstable angina in a 58-year-old Caucasian gentleman requiring cardiac catheterization and PCI with drug eluting stent deployment and syncope following Ticagrelor loading from long ventricular pauses.
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A patient presenting with worsening dyspnea and left-sided chest pain underwent heart catheterization, found to have a rare connection between the right and left coronary arteries draining into the left ventricle, consistent with dual coronary-cameral fistula.
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Renal cell carcinoma (RCC) can invade locally through the renal vein and into the inferior vena cava (IVC) with tumor-thrombus formation reported in 5%-15% of patients. From the IVC, RCC can grow intravascularly and extend into the right atrium. We present a rare case with two uncommon findings: tumor-thrombus extension leading to a right atrial mass and initial presentation of RCC as heart failure. A 69-year-old woman presented with signs and symptoms of heart failure. Electrocardiogram was normal and the initial troponin level was mildly elevated to 0.09 ng/mL. Echocardiography revealed a dilated right atrium with a 6.9 cm x 3.8 cm echogenic mass consistent with a tumor impinging on the tricuspid valve leading to a functional stenosis. Computed tomography (CT) of the abdomen revealed a large right-sided renal mass with enlargement of the renal vein suggestive of tumor thrombus. Although the initial presentation of RCC with cardiac symptoms is surprising, this case highlights the importance of maintaining a comprehensive differential diagnosis. It also signifies the need for further imaging as not all atrial masses are cardiac tumors. Many other primary tumors - kidney, liver, lung, and thyroid - can directly invade or metastasize into the atrium by way of the vena cava.
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Cardiogenic cerebral embolism is believed to be responsible over 25% of all ischemic strokes. Since 1856, Lambl's description of small excrescences on the aortic valves has attracted widespread attention and controversy. With the increasing use of transesophageal echocardiography, ever-increasing valvular strands are being detected. The case is presented of a cardioembolic stroke secondary to Lambl's excrescences in a 59-year-old man. In addition, the current concepts regarding the importance of recognizing these valvular strands are discussed, and a brief review of the topic is provided.
Assuntos
Valva Aórtica/diagnóstico por imagem , Valva Aórtica/patologia , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologia , Anticoagulantes/uso terapêutico , Ecocardiografia Transesofagiana , Humanos , Masculino , Pessoa de Meia-Idade , Prevenção Secundária , Acidente Vascular Cerebral/prevenção & controle , Varfarina/uso terapêuticoRESUMO
Clozapine is a dibenzodiazepine antipsychotic used for treatment-resistant schizophrenia. Its association with several side effects such as agranulocytosis, seizure, and insulin resistance is well known. Cardiac side effects such as myocarditis and cardiomyopathy are less common and have been seldom reported. Here we report an unusual case of clozapine-induced nonischemic dilated cardiomyopathy. A 50-year-old female with treatment-resistant schizophrenia on clozapine presented with gradually worsening shortness of breath, productive cough, and pleuritic chest pain. She was found to have non-ischemic dilated cardiomyopathy due to clozapine use as no other causative factor was found. Clozapine was gradually tapered and then discontinued. Repeat echocardiogram in three months revealed improvement in ejection fraction. This case is unique as it outlines clozapine as a rare cause of nonischemic cardiomyopathy, as discontinuation of the drug showed improvement in symptoms and heart function.
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Gastrointestinal pathology can cause cardiac symptoms and disorders. We present a case of a patient who had worsening of her palpitations with food intake. She was found to have a high burden of premature ventricular contractions in the setting of hiatal hernia and gastro-oesophageal reflux disease. After extensive investigations and ruling out cardiac causes, her arrhythmia resolved with the surgical correction of hiatal hernia.
Assuntos
Refluxo Gastroesofágico/diagnóstico , Hérnia Hiatal/diagnóstico , Obesidade/complicações , Complexos Ventriculares Prematuros/etiologia , Antagonistas Adrenérgicos beta/uso terapêutico , Diagnóstico Diferencial , Eletrocardiografia , Endoscopia do Sistema Digestório , Feminino , Fundoplicatura , Refluxo Gastroesofágico/etiologia , Hérnia Hiatal/complicações , Hérnia Hiatal/cirurgia , Humanos , Pessoa de Meia-Idade , Síndrome , Complexos Ventriculares Prematuros/diagnóstico , Complexos Ventriculares Prematuros/tratamento farmacológicoRESUMO
Asymptomatic cardiac masses are often diagnosed incidentally. Massive lipomatous hypertrophy can be confused for other cardiac masses and need careful evaluation including multimodality imaging to manage appropriately.
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Median arcuate ligament syndrome (MALS) is a rare benign condition typically affecting young females. It usually presents with abdominal symptoms of pain, nausea, and unintentional weight loss. They are usually diagnosed incidentally on CT of the abdomen done for abdominal pain. Here we present a rare case of MALS which presented with an anginal type of chest pain without any abdominal symptoms leading to an extensive workup and incidental diagnosis.