Infarct Size Reduction in an Anterior ST-Elevation Myocardial Infarction Following "Optimized" Supersaturated Oxygen Therapy.

This comprehensive case report documents the treatment of a 37-year-old female patient who presented with anterior ST-elevation myocardial infarction (STEMI). The patient underwent percutaneous coronary intervention (PCI), followed by an innovative therapy - optimized supersaturated oxygen therapy (SSO2). This therapy was chosen due to its potential to enhance myocardial salvage, particularly in severe MI cases like the patient. The report meticulously details the patient's clinical course, including the diagnostic procedures and the rationale behind opting for SSO2 therapy. It highlights the significant improvements observed post-therapy: enhanced left ventricular (LV) function and a remarkable reduction in the size of the LV apical aneurysm. These outcomes suggest a direct benefit of SSO2 in reducing myocardial damage. Finally, the report discusses the broader implications of these findings. It underscores the potential of optimized SSO2 therapy in clinical settings, particularly for patients with anterior MI. The case exemplifies how advanced therapeutic interventions like SSO2 can play a pivotal role in improving clinical outcomes post-MI, thereby advocating for its consideration in similar clinical scenarios.

Association of New-Onset Atrial Fibrillation With All-Cause Mortality in COVID-19 Patients.

Background The COVID-19 pandemic has brought about unprecedented global health challenges, with its impact extending beyond respiratory manifestations to encompass cardiovascular complications, including arrhythmias. Dysrhythmias in COVID-19 are multifactorial, ranging from direct myocardial insult due to the cytokine storm to metabolic derangements. Objective In this study, we aim to examine the incidence of new-onset atrial fibrillation and to study its association with all-cause mortality of COVID-19. Methods A cross-sectional study was conducted at Cabell Huntington Hospital, West Virginia, utilizing electronic medical records of COVID-19 patients from 2020 to 2021. Inclusion criteria comprised patients aged >18 years with COVID-19 diagnosis and cardiac arrhythmias during hospitalization. Logistic regression analysis was employed to examine the relationship between demographic and clinical variables and in-hospital mortality. Results Of the 264 eligible patients, those aged >66 years had lower odds of in-hospital mortality (p < 0.001), while gender, ejection fraction, and diabetes mellitus did not significantly predict mortality. Atrial fibrillation (p = 0.011) and heart failure (p = 0.030) were associated with increased odds of mortality, while hypertension showed no significant predictive power (p = 0.791). Conclusion This study highlights the significance of atrial fibrillation and heart failure as predictors of in-hospital mortality in COVID-19 patients. Our findings underscore the importance of recognizing and managing arrhythmias in COVID-19 and call for further research on the mechanisms and long-term effects of these cardiac complications in the context of the pandemic. These insights can guide clinical practice and interventions to optimize patient outcomes.

Novel Intracoronary Infusion of Supersaturated Oxygen Therapy in Patients Presenting With Acute ST Elevation Myocardial Infarction: Does It Help?

Supersaturated oxygen (SSO2) is one of the emerging therapies that has shown benefit for patients suffering from acute ST elevation myocardial infarction (STEMI) in terms of reducing infarct size, which has been used as a prognostic indicator for future heart failure and hospitalizations. Trials investigating SSO2 therapy have shown improvement in infarct size when used as an adjunct therapy to percutaneous trans-luminal coronary angioplasty (PTCA) or percutaneous coronary intervention (PCI) in patients presenting with acute myocardial infarction (aMI).  Here we present a patient with a mid left anterior descending artery (mLAD) STEMI who underwent SSO2 therapy. The patient presented with new onset angina and ST elevations on EKG. He underwent emergent coronary angiography, which confirmed an mLAD complete vessel occlusion. Successful PCI was done with a drug-eluting stent followed by supersaturated oxygen therapy. On follow-up evaluation, the patient had improved left ventricular (LV) ejection fraction from 35% to 60%. This case highlights the safety and efficacy of SSO2 therapy for patients suffering from acute anterior wall myocardial infarction. We recommend further investigation of this therapy for its routine use, safety, and prognostic utility. We also recommend routine use of adjunctive SSO2 therapy for patients suffering acute anterior STEMI.

Aortic Root Abscess Presenting As Chest Pain and Ischemic EKG Changes: Importance of Timely Diagnosis.

The occurrence of perivalvular abscess, a purulent infection that affects the myocardium and endocardium of natural or artificial valve tissues, can result from either the spread of bacteria from a distant source via bacteremia, or from the expansion of an existing infectious cardiac focus, such as infective endocarditis (IE). The aortic abscess should be suspected in patients with infective endocarditis who fail to improve despite being on appropriate antibiotics. Sometimes aortic abscesses can present as PR interval lengthening or heart block due to the extension of infection. We present an atypical presentation of aortic root abscess with chest pain and ischemic EKG changes. A 45-year-old intravenous drug user presented with chest pain episodes with EKG showing ST depression in V2-V6 and ST elevation in avR. The coronary angiographic study showed no significant coronary artery disease, but the patient complained of chest pain. Transthoracic echo in the catheterization lab showed severe aortic regurgitation. The patient became hemodynamically unstable, worsened his respiratory status, and had to be intubated. He had a bedside transesophageal echo that revealed an aortic root abscess. The patient's condition continued deteriorating, and he passed away the same day. This case focuses on the timely diagnosis of aortic root abscess, and Transesophageal echocardiography (TEE) is the gold standard for diagnosing aortic root abscesses. This case also focuses on keeping perivalvular abscess among our differentials in a patient presenting with chest pain and abnormal EKG, especially in a high-risk population.

Prevalence of Substance Abuse Among Trauma Patients in Rural West Virginia.

BACKGROUND:  Substance abuse poses considerable clinical, economic, and social challenges. West Virginia is hailed as the epicenter of the substance abuse in the United States, the prevalence and pattern of different trauma mechanisms in a rural context or in patients with different forms of substance abuse remain unclear. OBJECTIVE:  We performed the following analysis to understand the prevalence of substance abuse in patients with different trauma mechanisms in the rural setting with high substance abuse in the West Virginia. METHODS:  We performed a cross-sectional retrospective analysis of adult trauma patients (motor vehicle, fall, assault, firearm suicide, brawl/rape and machinery) hospitalized in two tertiary care hospitals in West Virginia between 2006 and 2016. We identified all patients who had a urine drug screen (UDS) test and extracted the data related to the substance and trauma. RESULTS:  Among 8734 patients screened using UDS, 5940 (68.1%) patients were tested positive for the substance. Opiates, alcohol, benzodiazepines, and cannabis were the four most common substances identified in trauma victims. In all instances, the prescribed drug was less than 20%. Fatal outcome was observed in 366 patients in the sample, with 44% (n=162) testing positive for UDS, 12% (n=45) testing positive for only alcohol, and 15% (n=56) testing positive for both alcohol and UDS. Regarding the trauma mechanism, the motor vehicle accident (MVA) was the most prominent with a clear association of substance abuse with fatal outcome. CONCLUSION:  The most prevalent trauma mechanism was a MVA, with a strong link between drug usage and mortality. Due to the high incidence of positive substance abuse screens, UDS tests may need to be more widely implemented in trauma in the West Virginia region. The findings of this study might help in establishing regional or national policies to reduce acute substance abuse.

The Jailed Sinoatrial Node: An Interesting Case of Cardiogenic Shock Secondary to Sinus Arrest Following Percutaneous Intervention.

Complete occlusion of the sinoatrial node artery can be a complication of percutaneous intervention (PCI) to the right coronary artery (RCA). When this happens, dysfunction of the sinus node may follow resulting in sinus arrest. When this occurs, it is usually transient and as such, is typically not accompanied by hemodynamic instability. Permanent sinus arrest and shock state may, however, occur on rare occasions. The presence of junctional rhythms on the electrocardiogram (ECG) may predict the occurrence of these permanent arrhythmias and cardiogenic shock. In this case report, we present a 78-year-old woman who developed cardiogenic shock secondary to sinus arrest following PCI to RCA. Her ECG showed junctional rhythm, and she went on to require permanent ventricular pacing. This illustrates a known but rare complication of PCI to RCA.

Spontaneous Coronary Artery Dissection of an Anomalous Right Coronary Artery in a Young Male.

Spontaneous coronary artery dissection (SCAD) is a tear in the coronary artery layers that presents clinically as an acute coronary syndrome (ACS), ventricular arrhythmias, or sudden cardiac death (SCD). It is uncommon for young healthy males with no comorbid conditions to have SCAD. We report an interesting case of SCAD in an anomalous right coronary artery (RCA) in a young 33-year-old male. The patient presented with episodes of midsternal chest pain and had elevated troponins on laboratory workup. A left heart catheterization revealed anomalous RCA, originating from the left aortic sinus. The left heart catheterization also demonstrated a SCAD of the anomalous RCA. Cardiothoracic surgery was consulted, and the patient had placement of saphenous vein graft to the proximal RCA. While this patient's presentation of ACS in the setting of SCAD is relatively common, it was atypical due to gender and lack of precipitating stressors. One of the risk factors this patient did have was the anomalous RCA arising from the left aortic sinus. There is scarce literature involving guidance for therapeutic intervention for RCA ostial lesion, let alone an anomalous one. Although coronary artery bypass grafting (CABG) remains the most clinically sound decision, in this case, further development of guidelines for RCA lesions would aid in decision-making.

Protective effect of allopurinol in preventing contrast-induced nephropathy among patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis.

Introduction: Contrast-induced nephropathy (CIN) is the third most common cause of iatrogenic acute renal failure and is triggered by administration of radiopaque contrast media. Periprocedural hydration is imperative in prevention of CIN, and uric acid has been recognized to have an integral role in development of renal disease. The aim of our study is to understand the efficacy of allopurinol in preventing CIN among patients undergoing percutaneous coronary intervention. Material and methods: A literature search was performed on PubMed (Medline), Science Direct and Cochrane Library using a combination of Mesh terms. We limited our search to randomized controlled trials (RCTs) and articles published in the English language. The PRISMA protocol was utilized to conduct this meta-analysis. Results: Six studies were included in the final analysis. All included studies were clinical trials conducted between 2013 and 2019. A total of 853 patients were included. There was a significant reduction in the risk of CIN among patients who were pretreated with adequate hydration plus allopurinol (100 to 600 mg) compared to hydration only before undergoing percutaneous coronary angiography (RR = 0.39, 95% CI: 0.21-0.73). A sensitivity analysis of studies using 300 mg of allopurinol only reported a significant reduction in CI-AKI compared to hydration alone (RR = 0.26, 95% CI: 0.11-0.57). Conclusions: Our study demonstrates that Allopurinol is effective in preventing contrast-induced nephropathy in patients undergoing percutaneous coronary intervention. Larger clinical trials are warranted to better understand this effect.

A Comprehensive Systemic Literature Review of Pericardial Decompression Syndrome: Often Unrecognized and Potentially Fatal Syndrome.

BACKGROUND: Pericardial Decompression Syndrome (PDS) is defined as paradoxical hemodynamic deterioration and/or pulmonary edema, commonly associated with ventricular dysfunction. This phenomenon was first described by Vandyke in 1983. PDS is a rare but formidable complication of pericardiocentesis, which, if not managed appropriately, is fatal. PDS, as an entity, has discrete literature; this review is to understand its epidemiology, presentation, and management. METHODOLOGY: Medline, Science Direct and Google Scholar databases were utilized to do a systemic literature search. PRISMA protocol was employed. Abstracts, case reports, case series and clinical studies were identified from 1983 to 2019. A total of 6508 articles were reviewed, out of which, 210 were short-listed, and after removal of duplicates, 49 manuscripts were included in this review. For statistical analysis, patient data was tabulated in SPSS version 20. Cases were divided into two categories surgical and percutaneous groups. t-test was conducted for continuous variable and chi-square test was conducted for categorical data used for analysis. RESULTS: A total of 42 full-length case reports, 2 poster abstracts, 3 case series of 2 patients, 1 case series of 4 patients and 1 case series of 5 patients were included in the study. A total of 59 cases were included in this manuscript. Our data had 45.8% (n=27) males and 54.2% (n=32) females. The mean age of patients was 48.04 ± 17 years. Pericardiocentesis was performed in 52.5% (n=31) cases, and pericardiostomy was performed in 45.8% (n=27). The most common identifiable cause of pericardial effusion was found to be malignancy in 35.6% (n=21). Twenty-three 23 cases reported pre-procedural ejection fraction, which ranged from 20%-75% with a mean of 55.8 ± 14.6%, while 26 cases reported post-procedural ejection fraction which ranged from 10%-65% with a mean of 30% ± 15.1%. Data was further divided into two categories, namely, pericardiocentesis and pericardiostomy. The outcome as death was significant in the pericardiostomy arm with a p-value of < 0.00. The use of inotropic agents for the treatment of PDS was more common in needle pericardiocentesis with a p-value of 0.04. Lastly, the computed recovery time did not yield any significance with a p-value of 0.275. CONCLUSION: Pericardial decompression syndrome is a rare condition with high mortality. Operators performing pericardial drainage should be aware of this complication following drainage of cardiac tamponade, since early recognition and expeditious supportive care are the only therapeutic modalities available for adequate management of this complication.

The Self Sabotaging Vessel: A Case Report and Literature Review of Spontaneous Coronary Artery Dissection.

Spontaneous coronary artery dissection (SCAD) is a very rare cause of acute coronary syndrome. Despite the recent advances in the management of cardiovascular diseases, the diagnoses and management of SCAD remain a dilemma. It has been described to majorly affect females of childbearing age, immediately post-partum or on oral contraceptives. Recent cases have also identified underlying connective tissue disease as a risk factor. Since its discovery, only a limited number of cases affecting males have been reported in the literature. This makes our case unique. In this, we present a 31-year-old male without any traditional risk factors who presented with atypical chest pain. Electrocardiogram showed ST-segment changes with echocardiogram revealing apical left ventricular akinesis. A diagnostic left heart catheterization showed multiple lumens in the distal left anterior descending artery (LAD). The patient was managed conservatively and discharged home on guideline-directed medical therapy.

Rare Manifestation of Idiopathic Tracheobronchopathia Osteochondroplastica: Misdiagnosed and Untreated Entity?

Tracheobronchopathia osteochondroplastica (TBPO) is a rare benign disease of unknown cause, in which multiple cartilaginous or bony submucosal nodules project into the trachea and proximal bronchi. It usually occurs in men in their fifth decade and can cause airway obstruction, bleeding and chronic cough; patients are more prone to post-obstructive pneumonia and chronic lung infection in some instances. We report a case of a 69-year-old female who presented with shortness of breath and lower extremity swelling over the past couple of weeks. Echocardiography (ECHO) was consistent with heart failure with preserved ejection fraction, and she was treated with diuretics accordingly. Imaging revealed persistent pleural effusions bilaterally, more pronounced on the right side. During the course of her hospitalization, the patient coded once and had to be resuscitated. She had bronchoscopy done and pathology was consistent with TBPO. In this condition, there are numerous osseous or cartilaginous submucosal nodules in the trachea and the main bronchus and nodules are formed due to the deposition of calcium phosphate that results in the proliferation of osseous and cartilaginous structures resulting in the obstruction of large airways. Treatment for the most part is supportive and resolves around bronchodilators for symptomatic relief.

Relationship between dietary sodium and sugar intake: A cross-sectional study of the National Health and Nutrition Examination Survey 2001-2016.

Dietary sodium intake and cardiovascular outcomes have a reported J-shaped curve relationship. This study analyzes the relationship between dietary sodium and sugar intake as a potential mechanism to explain this association. The authors examined cross-sectional data from the National Health and Nutrition Examination Survey (NHANES) 2001-2016 where dietary sodium, carbohydrate, fat, cholesterol, and sugar intakes were assessed by 24-hour dietary recall and were standardized to a total daily intake of 2000 calories. Sodium intake was categorized into sodium quintiles (SQ) as follows: SQ1(0.06-2.6 g/d); SQ2(2.6-3.0 g/d); SQ3(3.0-3.4 g/d); SQ4(3.4-4.0 g/d); and SQ5(4.0-29.3 g/d). Simple and multivariate linear regression using SQ3 as reference were used to assess associations between daily sodium intake and the other nutrients. Our results showed that among 38 722 participants that met our study criteria, the mean age was 43.6 years (SD 16.8 years) and sex was equally distributed (48.8% male vs 51.2% female). Sugar intake went down across increasing SQs and was significantly higher in SQ1 (141.2 g/d) and SQ2 (118.6 g/d) and significantly lower in SQ4 (97.9 g/d) and SQ5 (85.6 g/d) compared to SQ3 (108.6 g/d; all P < .01). These same trends remained unchanged and significant in the fully adjusted multivariate model. In conclusion, NHANES study participants reporting low sodium intake on 24-hour dietary recall have a higher consumption of sugar. The negative impact of low sodium diet on cardiovascular health may be explained at least partially by the associated high sugar intake.

Brugada Phenocopy Type 1 Secondary to Synthetic Cannabinoids.

Brugada phenocopies (BrP) are clinical entities that have EKG tracings similar to the congenital Brugada syndrome (BrS) but without ventricular tachyarrhythmias or sudden cardiac death. BrP is caused by various factors such as metabolic disturbances (electrolyte imbalance), drugs, mechanical compression of the mediastinum, and inflammatory conditions such as myocarditis or pericarditis. We present a very rare case of a young patient who had a Brugada phenocopy Type 1 suspected to be secondary to synthetic cannabinoids.

Operator-Controlled Comparison Between 5 French and 6 French Guiding Catheters for Percutaneous Intervention Using Transradial Approach.

Objective To compare 5 French (Fr) and 6 Fr guiding catheters regarding the volume of contrast administered, fluoroscopy time, and total procedure time during transradial percutaneous coronary intervention (PCI). Background Previous studies had compared 5 Fr and 6 Fr catheters and deemed 5 Fr catheters safe and effective. In this study, we retrospectively compared the 5 Fr catheter to 6 Fr catheter with an attempt to eliminate the effect of inter-operator skill level variability. Methods In a single-center, retrospective cohort study, we randomly selected patients who had received PCI through transradial access using 5 Fr or 6 Fr catheters. The study involved two groups of 100 patients each. These groups were comprised of an equal number of cases from each operator. The primary endpoint was contrast medium volume. Secondary endpoints were fluoroscopy time and procedure time. Results Less contrast was used in the 5 Fr group vs. 6 Fr catheter group (140.2 ± 45.7 mL vs. 158.2 ± 66.7 mL, p=0.004). PCI using 5 Fr catheters was associated with shorter fluoroscopy time (13.7 ± 7.3 mins vs. 15.2 ± 8.2 mins, p=0.584) and shorter procedure time (43.7 ± 22.2 mins vs. 46.5 ± 19.7 mins, p=0.890), but this was not statistically significant. Conclusion Transradial PCI using 5 Fr guiding catheters was associated with less contrast medium usage, but there was no advantage regarding procedure time or fluoroscopy time when compared to 6 Fr catheters. Similar to 6 Fr catheters, 5 Fr catheters achieved high PCI success rates through radial access when compared in the treatment of coronary lesions with the same level of complexity.

Kounis Syndrome Induced by Protamine Sulfate.

Protamine sulfate is considered a "life-saving" antidote for heparinized patients with major bleeds. Although the beneficial attributes and application of protamine sulfate in various clinical settings cannot be argued, it also has an impressive side-effect profile. Kounis syndrome (KS) is an acute coronary syndrome in the setting of an allergic reaction, which can be induced by numerous allergens. Herein, we report a case of KS secondary to the use of protamine sulfate after cryoablation for atrial fibrillation.

Management of Cardiogenic Shock due to Thyrotoxicosis: A Systematic Literature Review.

BACKGROUND: A grave complication of thyrotoxicosis, or thyroid storm, is the development of heart failure and cardiomyopathy. Recognizing this condition is imperative in preventing further left ventricular dysfunction and cardiogenic shock. This manuscript aims to review the literature on cardiogenic shock associated with thyrotoxicosis and present management recommendations on this rare condition. METHODS: A literature search was performed in December of 2018, using the PubMed medical search engine. A systematic search was carried out using the keywords Thyroid Storm AND Cardiogenic Shock and Thyrotoxicosis AND Shock. MANAGEMENT: Decrease of thyroid hormone levels using therapeutic plasma exchange LV Unloading and ventilation by Impella and Extracorporeal Mechanical Ventilation (ECMO). CONCLUSION: Patients presenting with thyroid storm-induced shock may not be suitable candidates for traditional management with ß -adrenergic blockers (ß-blockers). The use of ß-blockers could exasperate their condition. Through extensive literature review on this rare condition, the most effective management was found to be therapeutic plasma exchange in order to decrease thyroid hormone levels, which have direct toxic effect on the heart. Furthermore, the use of ECMO and Impella is advised to reduce pressure on the heart and ensure the patient's organs are well oxygenated and perfused while the left ventricle is recovering.

Transradial Versus Transfemoral Approach for Coronary Angiography in Females with Prior Bypass Surgery.

Background Multiple studies have shown that trans-radial access (TRA) for women undergoing coronary angiography/intervention (CA/I) has a lower risk of vascular access site complications as compared with trans-femoral access (TFA). In patients who had previously undergone coronary artery bypass grafting (CABG), studies also showed no significant difference between TRA and TFA in terms of contrast amount (CA), procedure time (PT), and fluoroscopy time (FT). However, those studies mainly included men. Limited information is available on the relative merits of TRA as compared with TFA for cardiac catheterization in females who previously undergone CABG. The purpose of this study was to determine the efficacy and safety of TRA versus TFA in women with prior CABG surgery who are undergoing CA/I in regard to CA, PT, and FT. Methods In this single-center retrospective cohort study, females with a history of CABG who underwent CA/I in the period from January 2013 to September 2016 were included. A total of 584 patients were included and divided into two groups: TRA group (49 patients) and TFA group (535 patients). The primary endpoints were CA, PT, and FT. The means for the primary outcomes were compared between the two using the independent t-score test. Results A total of 584 female patients with a history of CABG had cardiac catheterization from January 2013 to September 2016 at our center. Trans-femoral access accounted for 91.6% (n=535) of the patients while trans-radial access accounted for 8.4% (n=49) of the patients. A comparison of procedural variables between TRA and TFA revealed that there was no statistical significance in procedure time, fluoroscopy time, or the contrast volume. The access site crossover rate was 6.12% (n=3) from radial to femoral while there was a 0% rate in the femoral to radial access. Conclusion The key findings of this study suggest that in female patients with a prior history of CABG, TRA is an equally reliable and efficacious approach for both diagnostic angiography and intervention compared to TFA.

10-Year community prevalence and trends of severe asymptomatic hypertension among patients with hypertension in the USA: 2007-2016.

BACKGROUND: Severe asymptomatic hypertension (SAH) is associated with significant health cost, morbidity and mortality. AIM: Establish the nationwide prevalence, trends and associated sociodemographic characteristics of SAH among patients with hypertension in the USA. METHODS: We utilized the National Health and Nutrition Examination data collected over five survey cycles (2007-2016). Included were participants aged 20-80 years with self-reported diagnosis of hypertension. SAH was defined as having a mean systolic blood pressure (SBP) ≥180 mmHg and/or mean diastolic blood pressure (DBP) ≥120 mmHg at the time of examination. The Chi square test was used to compare prevalence across different categories. Associations between sociodemographic variables and SAH were assessed using multivariate binary logistic regression. RESULTS: The prevalence of SAH among patients with hypertension is 2.15% (95% CI 1.80-2.56), mainly explained by isolated mean SBP≥180 mmHg (86% of all cases), with no statistically significant change between 2007: 2.66% (95% CI 2.10-3.36) and 2016:2.61% [95% CI 1.73-3.94), p-trend = 0.17. Increasing age (OR 1.07, 95% CI 1.04-1.09), NH Blacks (OR 2.20, 95% CI 1.37-3.54), BMI< 25 (OR 2.52, 95% CI 1.48-4.28), lack of health insurance OR 4.92% (95% CI 2.53-9.54) and never married individuals (OR = 2.59%, 95% CI 1.20-5.60) were more likely to have SAH, comparatively. There was no significant association between duration of hypertension and SAH. CONCLUSION: The prevalence of SAH in the USA is 2.15% and has been stable over the past decade. Our study underscores the importance of identifying barriers to screening and treatment of hypertension which is a major treatable risk factor for cardiovascular disease.

Ultrasound-Guided Vascular Access Is an Important Tool to Prevent Catastrophes: Transinferior Epigastric Artery Cardiac Catheterization.

We report a case of cardiac catheterization that was done entirely by accidentally accessing the inferior epigastric artery (IEA) through an unintentional puncture of the U-shaped portion of the inferior epigastric artery. Luckily the patient did not have any trauma to the IEA and was d/c home with no complications. A 48-year-old female with history of hypertension and CAD S/P left circumflex stent many years ago who presented to our facility with persistent crescendo angina for which decision was made to proceed with LHC. The cardiac catheterization showed no significant CAD with patent stent so it was decided that there is no further intervention needed. Femoral angiogram was done and showed that the stick was high and the tip of the sheath was about to come out of the CFA; at the same time, it came into our minds that the sheath could be passing through the IEA by sticking the U portion of the IEA, but due to the high risk, an immediate access was obtained through the contralateral groin then a balloon over the wire was passed beyond the original sheath tip, then the sheath was slowly pulled back while contrast was injected. Angiogram showed that the sheath was inserted through the U-shaped portion of the IEA. Conclusion. Ultrasound guidance should be the first-line standard for arterial access in any cardiac catheterization procedure. US is a proven tool that can increase success and decrease complications in a wide variety of vascular access procedures.

Loeys-Dietz Syndrome Complicated by Right Coronary Artery Pseudoaneurysm.

Loeys-Dietz syndrome is a rare autosomal dominant connective tissue disorder notable for rapidly progressive vascular aneurysmal disease and craniofacial defects. Patients are at an increased risk for aneurysm rupture and dissection at younger ages compared to other aneurysmal syndromes. Early surgical intervention is important for prevention of ruptures and/or dissection. The coronary arterial tree is mostly involved as a result of postoperative complications of an aortic root repair. This fact has been sparsely reported. We report a unique case of LDS2 presenting with chest pain that was later diagnosed as a pseudoaneurysm as a result of a right coronary artery graft dehiscence.