Paravalvular Leak Closure After Transcatheter Tricuspid Valve-in-Ring Implantation: A Case Report.

Transcatheter tricuspid valve intervention (TTVI) has emerged as a promising alternative for patients with severe tricuspid regurgitation who are deemed high-risk for surgery. With advancements in device design and delivery systems, TTVI has shown promising outcomes in reducing tricuspid regurgitation severity and improving symptoms in selected patients. Paravalvular leaks (PVLs) are one of the most common complications faced, which can significantly contribute to patients' morbidity and mortality. Percutaneous PVL closure represents a minimally invasive approach to address this issue, but its efficacy and safety in the context of transcatheter tricuspid valve-in-ring implantation require further elucidation. We describe the case of a 44-year-old lady with a history of rheumatic valve disease status post-tricuspid valve annuloplasty with an incomplete ring who presented to cardiology clinics with symptomatic torrential tricuspid regurgitation. Due to the high risk of surgical reintervention secondary to severe right ventricular (RV) failure, she was denied surgical intervention. Therefore, she underwent transcatheter tricuspid valve-in-ring (TVIR) implantation with a 26 mm MyVal (Meril Life Sciences Pvt Ltd., Vapi, GJ, IND), which was complicated by a residual severe tricuspid paravalvular regurgitation. The defect was subsequently closed by a dedicated Occlutech PVL device (Occlutech, Helsingborg, SWE) measuring 18 mm x 10 mm. Post which, the patient had trivial tricuspid regurgitation and significant improvement in signs and symptoms with subsequent follow-up.

First Report of Supra-Annular Atrially Placed Bioprosthetic Mitral Valve Leak Closure Through Percutaneous Approach.

An 81-year-old man underwent mitral valve replacement in 2015 for severe calcific mitral stenosis with multiple subsequent hospitalizations for pulmonary edema. TEE in 2019 revealed severe paravalvular regurgitation. This is the first reported case of suprannular atrially placed mitral paravalvular leak closure.

Myocardial infarction masquerading as myocarditis in a patient with factor V Leiden: unmasked with MR.

We present a case of a 21-year-old man presenting with sharp left-sided chest pain. A CT pulmonary angiogram was negative, ECG was unremarkable and a mild troponin rise was observed. Myocarditis was suspected as the most likely diagnosis, particularly in view of the patient's previous diagnosis of myocarditis 3 years prior. A cardiac MRI was indicative of an acute mid-anterior myocardial infarction (MI) and an old inferior MI with an associated aneurysm. A subsequent angiogram revealed a subtotal occlusion in the second diagonal artery, likely precipitated by homozygous factor V Leiden.This case illustrates the value of MRI in differentiating acute MI from myocarditis when clinical suspicion is low, as in this young patient with atypical chest pain. Further, it demonstrates the value of MRI in detecting previous MIs and reinforces the importance of searching for precipitants of MI in young patients.

Isolated Left Ventricular Diastolic Collapse Due to Extra-Thoracic Compression.

Isolated collapse of the left ventricle (LV) in diastole is not a very common finding on two-dimensional echocardiography. Reported cases in the literature were due to either loculated postoperative pericardial effusion/hematoma or left pleural effusion. To our knowledge, this is the first case report of LV diastolic collapse secondary to extra-thoracic compression.

First Report of Nocardia asiatica Presenting as an Anterior Mediastinal Mass in a Patient with Myasthenia Gravis: A Case Report and Review of the Literature.

The spectrum of infections with Nocardia spp. is heterogeneous. It has classically been associated with lung, brain, or skin involvement. We describe an unusual presentation of Nocardia asiatica (N. asiatica) in an Iraqi patient with myasthenia gravis suffering from a disseminated infection and presenting with an anterior mediastinal cystic mass. N. asiatica has only been three times described outside Japan and Thailand, and the rarity of this entity deserves this communication.

Asymptomatic spontaneous coronary artery dissection.

Spontaneous coronary artery dissection (SCAD) is a rare cause of myocardial ischemia that could present as angina, acute myocardial infarction, or even sudden death. It occurs more commonly in women and it has been associated with autoimmune and collagen vascular diseases. The management and prognosis in these patients depend on the initial clinical presentation and the extent of dissection. In this article, we report 2 cases of asymptomatic SCAD that were diagnosed on routine preoperative evaluation. The management options and clinical implications are discussed.

The interaction of gender and clinical risk profile in patients referred for exercise nuclear imaging versus exercise echocardiography.

BACKGROUND: Exercise myocardial perfusion imaging (E-MPI) and exercise echocardiography (E-Echo) are thought to be compatible for the non-invasive evaluation of patients with suspected coronary artery disease (CAD). The interaction of gender and clinical risk profile in the referral of patients to either of these two imaging modalities has not been well studied. METHODS AND RESULTS: This was a prospective study of 922 consecutive patients who were referred for either E-MPI (331 patients) or E-Echo (591 patients) at the American University of Beirut Medical Center in the year of 2008. Men undergoing E-MPI had a higher risk profile than those undergoing E-Echo. They were older (58±12 years versus 55±12 years, p=0.002) and had a higher prevalence of multiple (>2) CAD risk factors (55% versus 37%, p<0.001) as well as a higher prevalence of prior PCI (22% versus 15%, p=0.017) or CABG (12% versus 7%, p=0.016). Furthermore, they achieved lower METS in their exercise (9.4±2.0 versus 10.4±2.3, p<0.001) and had a higher incidence of ischemia and on their scans (16% versus 9.1%, p=0.008). In contrast, women undergoing E-MPI had a similar profile to those undergoing E-Echo in terms of prevalence of risk factors, prior history of coronary events and the prevalence of ischemia or impaired ejection fraction on their scans. CONCLUSION: There is an important interaction between gender and clinical risk profile in patients undergoing E-MPI versus E-Echo. In men, E-MPI seems to be the preferred test for the higher risk profile patients, whereas in women the two tests are interchangeable.

Variations in the referral patterns to stress nuclear imaging and stress echocardiography scans.

BACKGROUND: Stress myocardial perfusion imaging (MPI) and stress echocardiography (Echo) are commonly used for the noninvasive evaluation of patients with suspected coronary artery disease (CAD). Very few studies have compared the referral patterns to these imaging modalities in terms of the clinical profile of patients, reasons for referral, and type of referring physicians. METHODS AND RESULTS: This was a prospective study of 1,020 consecutive patients who were referred for stress MPI (429 patients) or stress Echo (591 patients) at the American University of Beirut Medical Center in the year of 2008. Patients referred to MPI were older and had a higher prevalence of diabetes, hypertension, hypercholesterolemia, smoking, and previous myocardial infarction, coronary angioplasty, or bypass surgery. There were more abnormal scans in the stress MPI group (24% vs 15%, P < 0.001), as well as a higher prevalence of ischemia (15% vs 7.6%, P < 0.001) and impaired left ventricular function with an ejection fraction <50% (11% vs 1.7%, P < 0.001). A higher percentage of stress Echo studies were self-referred by physicians who themselves interpret the scans (31% vs 19%, P < 0.001). CONCLUSION: Patients referred for stress MPI are at a higher risk than those referred for stress Echo having more CAD risk factors, more prior history of coronary events, and an older age. These findings have important implications in the interpretation of studies that compare the diagnostic and prognostic power of these two imaging modalities.

Cardiac tamponade caused by polymicrobial gram-negative organisms.

Polymicrobial gram-negative pericarditis is a rare entity. We describe the first case of suppurative pericarditis with Citrobacter diversus and Proteus mirabilis.

Comparison of the systemic levels of inflammatory markers after percutaneous coronary intervention with bare metal versus sirolimus-eluting stents.

BACKGROUND: Percutaneous coronary intervention (PCI) with bare metal stent (BMS) deployment causes plaque disruption and a rise in systemic levels of C-reactive protein (CRP), interleukin (IL)-6, and monocyte chemoattractant protein (MCP)-1. Our aim is to study whether PCI with sirolimus-eluting stent (SES) use attenuates this response. METHODS: Patients with stable angina undergoing single-vessel PCI were enrolled in a randomized, open-label fashion into a BMS group or an SES group. Blood samples were drawn pre-PCI, 24 hours post-PCI, and 30 days post-PCI. Systemic concentrations of CRP, IL-6, and MCP-1 were measured at all time points. RESULTS: In total, 41 patients were enrolled (21 in the BMS group and 20 in the SES group). The baseline plasma concentrations of all markers were comparable between groups. At 24 hours, the mean plasma CRP concentration in the SES group was 20.21 mg/dL versus 8.95 mg/dL in the BMS group (P = 0.15). The mean plasma IL-6 concentration at 24 hours was 25.41 pg/mL in the SES group versus 17.44 pg/mL in the BMS group (P = 0.17). The mean plasma MCP-1 concentration at 24 hours was 382.38 pg/mL in the SES group versus 329.04 pg/mL in the BMS group (P = 0.2). At 30 days, plasma concentrations of all three markers decreased to similar values between groups. CONCLUSIONS: The use of SES did not inhibit the rise in systemic concentrations of CRP, IL-6, and MCP-1 at 24 hours or 30 days post-PCI, compared with BMS. Moreover, at 24 hours, there was a trend for higher systemic levels of all proinflammatory markers in the SES group compared with the BMS cohort.

Ventricular late potentials among thalassemia patients.

BACKGROUND: Iron induced cardiac abnormalities remain the number one cause of death among thalassemia major (TM) patients. Signal averaged ECG (SAECG) was suggested to predict ventricular tachycardia as the underlying substrate for up to 5% incidence of sudden cardiac death among TM patients. The prevalence of ventricular late potentials (VLP) among different TM populations varied (3-31%); therefore to further clarify this we here describe the incidence of VLP among TM patients over a 7 year follow up period (1997 to 2004). METHODS: 26 TM patients were randomly selected from a group of 240 TM patients. SAECG, regular ECG, echocardiography-Doppler were analyzed during the study period. Ferritin levels and cardiac complaints were registered from an interview and chart review. RESULTS: Mean QRS duration increased from 89.23 (+/-10.60) ms in 1997 to 94.27 (+/-10.91) in 2004 (p<0.01), mean late amplitude signal (LAS) duration increased from 23.04 (+/-7.68) ms in 1997 to 27.69 (+/-6.82) ms in 2004 (p=0.01), whereas mean root mean square voltage RMS decreased from 80.85 (+/-51.19) mV in 1997 to 45.12 (+/-21.42) mV in 2004 (p<0.01). Changes in QRS duration and RMS voltage were found to be linearly correlated with average of ferritin over years (r=0.38, p=0.03 and r=-0.47, p=0.01 respectively); and only 1 patient developed VLP over 7 years. CONCLUSION: The incidence of VLP is 3.8% in the TM population over 7 years, despite the presence of significant changes in all SAECG criteria. RMS voltage and QRS duration changes over time seem to be related to iron overload measured by ferritin level.

Echocardiographically detected mass "in transit" in early amniotic fluid embolism.

BACKGROUND: Amniotic fluid embolism is a catastrophic illness related to the passage of fetal material into the pulmonary circulation causing cardiovascular collapse. CASE: A 29-year-old female sustained cardiopulmonary arrest during delivery presumably due to amniotic fluid embolism. A right atrial mass "in transit" was detected by echocardiography. It had an appearance and pattern of motion that was suggestive of a gelatinous consistency and is likely to have been an amniotic fluid embolus. There was also evidence of acute right ventricular overload. CONCLUSION: We recommend that echocardiography be considered early on such conditions to gain more insight into the pathogenesis of this complication.

Acute myocardial infarction: clinical characteristics, management and outcome in a university medical centre in a developing Middle Eastern country.

BACKGROUND: The management and outcome of acute myocardial infarction (AMI) have not been well studied in developing countries, although demographic data from the World Health Organization indicate that developing countries contribute a major share to the global burden of cardiovascular disease. OBJECTIVES: To analyze the clinical characteristics, management and outcome of patients hospitalized with AMI in a university medical centre in a developing Middle Eastern country. METHODS: The study population comprised all patients hospitalized with AMI at the American University of Beirut between January 1, 1997, and December 30, 1998. The medical records of the patients were reviewed to determine their clinical characteristics, the diagnostic and invasive procedures used during the hospitalization, and any in-hospital complications, including death. RESULTS: The population comprised 184 patients with a mean age of 60+/-13 years. Fifty-two per cent of the infarcts were anterior and 76% developed Q waves. Fifty-one per cent of the patients received thrombolytic therapy. At discharge, 80% of the patients were given acetylsalicylic acid, 35% were given beta-blockers, 34% were given angiotensin-converting enzyme inhibitors and 30% were given statins. Seventy-two per cent of the patients underwent coronary angiography, 23% underwent percutaneous transluminal coronary angioplasty and 13% had coronary artery bypass grafting. The in-hospital mortality was 13%. The predictors of in-hospital mortality were advanced age (over 60 years), diabetes, prior AMI, Killip class greater than I and ejection fraction less that 40%. In contrast, the predictors of coronary angiography were younger age (less than 60 years), absence of diabetes or no history of AMI, Killip class I and ejection fraction greater than 40%. CONCLUSIONS: Coronary angiography after AMI was performed more frequently than expected in a university medical centre in a developing country, and it seemed to be selectively used in the low- risk patients rather than the high-risk ones. Furthermore, the underuse of medical therapy with beta-blockers and statins was evident. These findings should prompt cardiac societies in these countries to initiate educational campaigns focusing on the cost-effectiveness of therapy in AMI to optimize the use of their limited resources.

Sequential use of thrombolytic agents for thrombosed mitral valve prosthesis during pregnancy.

Thrombolytic therapy has gained popularity as an alternative to surgery in the treatment of prosthetic heart valve thrombosis. We report on the sequential use of streptokinase followed by recombinant tissue type plasminogen activator (rt-PA) for the treatment of a thrombosed prosthetic mitral valve in a pregnant woman at 26 weeks of gestation. Although thrombolysis was unsuccessful, the patient carried till 34 weeks of gestation and delivered by cesarean section a live newborn with an uneventful postpartum course. Based on our case and on what has been previously described in the literature, thrombolytic therapy should be considered as an option in the management of hemodynamically unstable pregnant patients with prosthetic valve thrombosis. When a single agent proves insufficient, combination therapy should be considered as it might provide hemodynamic stability and improvement in cardiac function that would allow patients at a high surgical risk to carry their pregnancy to viability.