A Rare Case of Severe Mitral Stenosis Presenting As Cardiogenic Shock.

We report a case of severe mitral stenosis (MS) in a 58-year-old female from Guyana. Though rheumatic MS continues to be less prevalent in third-world countries, it poses a significant threat as far as morbidity and mortality are concerned. The modern definition of "Third World" is used to classify countries that are poor or developing. Countries that are part of the "third world" are generally characterized by (1) high rates of poverty, (2) economic and/or political instability, and (3) high mortality. The standard method of diagnosing MS in patients has been established as transthoracic echocardiograms (TTE), along with pertinent historical and physical exam findings. Specifically, with TTE, criteria include a mitral valve area ≤1.5 cm2, severe left atrial enlargement, and elevated pulmonary artery systolic pressure >50 millimeters of mercury (mmHg). Once diagnosed with severe MS, treatment options for patients range from non-surgical percutaneous mitral balloon valvuloplasty to surgical mitral valve commissurotomy. In our case, she was a 58-year-old female with a past medical history of seizures of unknown etiology, not on any home medication regimen, presenting to the emergency department with shortness of breath, malaise, weight loss, and bilateral lower leg edema. Vitals were significant for tachycardia at 153 bpm, tachypnea at 24 breaths per minute, and saturating at 96% on room air. On the physical exam, there was an irregularly irregular rhythm, bilateral crackles at the bases, right upper quadrant tenderness to palpation, bilateral pitting edema, and no calf tenderness. Lab findings were significant for elevated brain natriuretic peptide, but three electrocardiograms were performed in the emergency department, all confirming the new onset of atrial fibrillation. A CT angiogram of the chest was performed, which ruled out pulmonary embolus but additionally found marked reflux of contrast noted within the inferior vena cava and hepatic veins, along with right atrial dilation reflective of right heart strain; additionally, mitral valve calcifications were noted. The cardiologist on duty confirmed the diagnosis using point-of-care ultrasound (POCUS) followed by TTE; the patient was rapidly transferred to a hospital with appropriate services for surgical management within the same day of arrival at the emergency department. This case highlights the importance of bedside POCUS as an additional diagnostic tool for cardiologists, along with pertinent history, physical examination findings, and laboratory findings. Proper utilization of POCUS can allow for the immediate diagnosis of severe pathologies and prevent the delay of appropriate treatment, as seen in our case. Wider adoption of POCUS practices as a part of the general initial evaluation of patients has not yet been recommended by the American Heart Association but can offer clinical benefit in morbidity/mortality with expedited progression to appropriate treatment.

Navigating Diagnostic Challenges: Severe Pulmonary Hypertension in Acute Exacerbation of Chronic Obstructive Pulmonary Disease vs. Pulmonary Embolism.

A 63-year-old male with an unremarkable medical history presented to the emergency room (ER) with shortness of breath and bilateral lower extremity edema. In the ER, he was found to be hypoxic and hypercapnic on an arterial blood gas. CT angiography of the chest revealed severe emphysematous changes and large right apical bullae. A bedside point-of-care ultrasound demonstrated many bilateral B-lines as well as normal ejection fraction (EF). An echocardiogram revealed a small left ventricular cavity with an EF of 65%, severely dilated right ventricle, severe right ventricular dysfunction, "D" shaped interventricular septum, severely dilated right atrium, and severe pulmonary arterial hypertension (PAH) with a calculated pulmonary artery systolic pressure of 72 mmHg. The patient was initiated on bilevel positive airway pressure, glucocorticoids, bronchodilator nebulization, and diuretics with symptomatic improvement. Herein, this case report discusses similarities and differences between presentations and echocardiographic manifestations of severe PAH in the setting of acute exacerbation of chronic obstructive pulmonary disease and pulmonary embolism in the acute setting.

Idiopathic Ventricular Tachycardia in the Presence of Triple-Vessel Coronary Artery Disease: A Case Report.

Exercise-induced ventricular tachycardia undergoes ischemia evaluation; however, it is important to identify idiopathic ventricular tachycardia in patients with concomitant coronary artery disease and radiofrequency ablations can be lifesaving. We report a case of exercise-induced right and left ventricular outflow tract ventricular tachycardia in a patient with triple vessel coronary artery disease.

Transthyretin Cardiac Amyloidosis Presenting as Bradycardia, Renal Failure, Atrioventricular-Nodal Blockade, Shock, and Hyperkalemia (BRASH) Syndrome: A Case Report.

BRASH syndrome involves the chain of events resulting from the collective effects of Bradycardia, Renal failure, Atrioventricular (AV)-nodal blockade, Shock, and Hyperkalemia. BRASH syndrome can rapidly progress to cardiac arrest. Early recognition is crucial. We present a case of transthyretin cardiac amyloidosis (ATTR-CA) in an elderly woman who presented with BRASH syndrome shortly after an AV-nodal blocker was prescribed for atrial fibrillation.

A Case Report on Takotsubo Cardiomyopathy.

A 71-year-old female with a past medical history of hypertension, seizure disorder, chronic obstructive pulmonary disease, coronary artery disease, chronic kidney disease, open abdominal aortic aneurysm repair complicated by spinal cord infarction resulting in lower extremity paraparesis with chronic urinary retention, and sacral decubitus ulcer initially presented to the emergency department (ED) complaining of a one-week history of chest pain. During her inpatient stay, acute myocardial infarction and pulmonary embolism were ruled out and the patient was hemodynamically stable for discharge until she started experiencing new-onset nausea and dyspnea. Bedside electrocardiogram demonstrated ST elevations in the anterior leads with concomitant T-wave inversions in the inferolateral leads as well as a prolonged QTc. Troponin-HS was elevated at 907.69. Bedside transthoracic echocardiogram (TTE) demonstrated a severely decreased left ventricular ejection fraction of 10%-15% (representing an acute decrease from a left ventricular ejection fraction of 55%-60% from a TTE performed seven days prior). Cardiac catheterization demonstrated mild non-obstructive coronary artery disease and no interventions were conducted. Such signs and symptoms of acute myocardial infarction, without demonstrable coronary artery stenosis, are consistent with stress induced or Takotsubo cardiomyopathy. This phenomenon occurs in approximately 1%-2% of patients presenting with troponin-positive suspected acute coronary syndrome (ACS) or suspected ST-elevation myocardial infarction (STEMI).

Echocardiographic Evaluation of Cardiac Masses.

PURPOSE OF REVIEW: Cardiac masses encompass a broad range of etiologies and are often initially revealed by echocardiography. The differential may change depending on the location of the mass and patients' medical history or presentation. It is important for clinicians to be aware of subtle visual characteristics on echocardiography in order to correctly diagnose the pathology. METHODS: Patients who underwent transthoracic echocardiography and were found to have one or more cardiac masses between January 1, 2020, and May 15, 2023, were reviewed. Their demographic data, clinical presentation, medical history, imaging, and follow-up information were collected from hospital electronic medical records, de-identified, and used to complete this review paper. A detailed review of cardiac masses divided by cardiac chamber accompanied by real-world echocardiographic images from patients in a large inner city public hospital. We hope that this systematic review of cardiac masses with real-world echocardiographic images will help clinicians note subtle echocardiographic characteristics to aid in the diagnosis and treatment of cardiac masses.

Tuberculous Pericarditis Presenting as Cardiac Tamponade: Role of Echocardiography.

Tuberculous pericarditis, a rare but potentially lethal manifestation of tuberculosis, poses diagnostic and therapeutic challenges in clinical practice. Its nonspecific clinical presentation often mimics other conditions, leading to delayed or missed diagnoses. We report a 25-year-old male with no past medical history, who presented with nonspecific symptoms such as fatigue, weight loss, body aches, and dyspnea. An electrocardiogram showed low voltage QRS complex with electrical alternans, and transthoracic echocardiography (TTE) showed large pericardial effusion with tamponade physiology with right ventricular diastolic collapse, the collapse of the right atrium and the inferior vena cava was dilated with a respiratory variation of less than 50%. The diagnosis of tuberculous pericarditis was made based on clinical presentation, imaging, and laboratory findings, including a positive QuantiFERON-TB gold test and pericardial fluid analysis, despite negative cultures. This case highlights the significance of considering tuberculosis in the differential diagnosis of pericardial effusion and underscores the role of imaging and laboratory investigations in diagnosis. Management of tuberculous pericarditis involves a combination of antituberculous chemotherapy, pericardiocentesis, and corticosteroids. Despite its rarity, tuberculous pericarditis carries a high mortality rate and can present as cardiac tamponade, as illustrated in our case. This underscores the need for high clinical suspicion, especially in high-risk populations, for timely diagnosis and initiation of treatment.

Reversible severe pulmonary hypertension and right heart failure with cardiogenic shock due to scurvy: a case report.

Background: The systemic complications of vitamin C deficiency, otherwise known as scurvy, have been well-documented in history. Few case reports have documented severe cardiopulmonary complications such as right heart failure (RHF) and pulmonary hypertension (PH). Case summary: A 25-year-old female presented to the hospital with two weeks of progressive fatigue, dyspnoea, myalgias, and arthralgias. She was admitted for symptomatic anaemia requiring transfusion. Her symptoms persisted and she developed severe PH and RHF, complicated by cardiogenic shock and multiple episodes of cardiac arrest. She was found to have severe vitamin C deficiency secondary to a severely self-restricted diet. After repletion of vitamin C, the patient had complete resolution of RHF and PH. Discussion: This case adds to the sparse literature documenting severe cardiopulmonary complications of vitamin C deficiency. We believe that this is the first adult case of scurvy causing RHF and PH leading to cardiogenic shock and episodes of cardiac arrest. There are multiple hypotheses on the pathogenesis of scurvy-associated PH and RHF, including overactivation of hypoxia-inducible transcription factors and deficiency of vitamin C's vasodilatory effect that acts through increased nitric oxide production in endothelial cells. When recognized, early vitamin C repletion may prevent severe cardiopulmonary complications of scurvy.

A Rare Case of Massive Left Atrial Myxoma Presenting as Syncope.

We report a rare case of a large left atrial myxoma that manifested as syncope in a patient who presented to the hospital following a syncopal episode. Our patient had a history of hypertension and anemia with reported two months of dyspnea on exertion. He was found to have a large left atrial myxoma. Atrial myxomas are the most common benign primary cardiac tumors. Patients may be asymptomatic or experience shortness of breath, palpitations, syncope, or sudden death. Cases of syncope caused by left atrial myxoma have been rarely documented. Our case report adds to the growing literature documenting this phenomenon. Larger observational studies are needed to properly define the incidence of left atrial myxoma causing syncope.

A Rare Case of Central Retinal Artery Occlusion in the Setting of Patent Foramen Ovale.

Patent foramen ovale (PFO) is a congenital heart anomaly with persistent non-closure of the atrial septum that generally closes six to 12 months after birth in the majority of adults. While remaining asymptomatic in the majority of cases, PFO could lead to paradoxical embolism and cryptogenic strokes in most symptomatic cases. The incidence of small arterial occlusion due to paradoxical emboli is quite uncommon. In this report, we present a case of a 51-year-old man who presented with acute left-sided painless visual loss due to central retinal artery occlusion (CRAO). Stroke work-up and hypercoagulability evaluations were negative. The patient was found to have PFO with the initial presentation as CRAO, a rather rare presentation in the setting of PFO. In this report also, we discuss the clinical presentation, pathogenesis, and the current evidence-based therapeutic options in the management of PFO in adults, highlighting the importance of considering this diagnostic entity in the setting of acute visual loss, as with our case presentation.

A Rare Case of Coexisting Mutation in Desmin and Thioredoxin Reductase 2 Genes Causing Dilated Cardiomyopathy.

Desmin (DES) maintains the overall structure of cardiomyocytes and cytoskeletal organization within striated muscle cells. Mitochondrial thioredoxin reductase 2 (TXNRD-2) is essential for mitochondrial oxygen radical scavenging. We describe a rare case of dilated cardiomyopathy (DCM) in an 18-year-old female with a heterozygous mutation involving both DES and TXNRD-2 genes.

A Rare Case of Congestive Heart Failure due to Isolated Aortic Valve Disease in a Middle-Aged Man Secondary to Rheumatic Fever.

Rheumatic heart disease (RHD) is commonly seen in people from developing and low-income countries. More cases are being recorded in developed countries due to migration and globalization. RHD develops in people with a history of rheumatic fever; it is an autoimmune response to group A streptococcal infection due to similarities at the molecular level. Congestive heart failure, arrhythmia, atrial fibrillation, stroke, and infective endocarditis are a few of the many complications associated with RHD. Here we present a case of a 48-year-old male with a past medical history of rheumatic fever at the age of 12 years, who presented to the emergency room (ER) complaining of bilateral ankle swelling, dyspnea on exertion, and palpitations. The patient was tachycardic with a heart rate of 146 beats per minute and tachypneic with a respiratory rate of 22 breaths per minute. On physical exam, there was a harsh systolic and diastolic murmur at the right upper sternal border. A 12-lead electrocardiogram (EKG) revealed atrial flutter with a variable block. Chest X-ray revealed an enlarged cardiac silhouette with a pro-brain natriuretic peptide (proBNP) of 2,772 pg/mL (normal ≤ 125 pg/mL). The patient was stabilized with metoprolol and furosemide and was admitted to the hospital for further investigation. Transthoracic echocardiogram showed left ventricular ejection fraction (LVEF) of 50-55% with severe concentric hypertrophy of the left ventricle with a severely dilated left atrium. Increased thickness of the aortic valve with severe stenosis and a peak gradient of 139 mm Hg and a mean gradient of 82 mm Hg was noted. The valve area was measured to be 0.8 cm2. Transesophageal echocardiogram showed a tri-leaflet aortic valve with commissural fusion of valve cusps with severe leaflet thickening consistent with rheumatic valve disease. The patient underwent tissue aortic valve replacement with a bioprosthetic valve. The pathology report showed extensive fibrosis and calcification of the aortic valve. The patient came in for a follow-up visit 6 months later and expressed feeling better and more active.

Quadricuspid Aortic Valve: An Incidental Finding in an Elderly Man.

Quadricuspid aortic valve (QAV) is a very rare congenital abnormality. Here, we present a rare case of QAV incidentally noted in a patient at an advanced age during transthoracic echocardiography (TTE). A 73-year-old man with a history of hypertension, hyperlipidemia, diabetes, and treated prostate cancer was admitted to the hospital with palpitations. An electrocardiogram (ECG) showed T-wave inversion in V5-V6, with initial troponin levels mildly elevated. Acute coronary syndrome was ruled out by serial ECGs that were unchanged, and troponins downtrended. TTE showed a rare and incidental finding of type A QAV with four equal cusps with mild aortic regurgitation.

Statin-Induced Necrotizing Autoimmune Myositis.

Statins are the most frequently prescribed medications for primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD). The United States Preventative Services Task Force recommends that clinicians selectively offer a statin for the primary prevention of ASCVD for adults aged 40 - 75 years with one or more cardiovascular disease risk factors and an estimated 10-year risk of a cardiovascular event of 10% or greater. Despite their ubiquity, it is estimated that approximately 6-10% of patients remain intolerant due to muscle aches. Here, we present a case of a 71-year-old female that was taking atorvastatin for a year and presented to the emergency room with proximal muscle aches and weakness. Laboratory values were significant for an elevated creatinine kinase of 4,166 U/L (reference range, 20 - 180). Her magnetic resonance imaging was significant for edema in bilateral lower extremity proximal muscles. Serology revealed a high anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase antibody, confirming the diagnosis of statin-induced necrotizing autoimmune myositis. A muscle biopsy of the right vastus lateralis revealed necrotic muscle fibers. During her hospital course, she was treated with intravenous methylprednisolone, mycophenolate mofetil, and tacrolimus. Her symptoms gradually improved, and she was discharged after 14 days with a rheumatology follow-up. This is an exceedingly rare complication of statin use and has only recently received increasing attention. Here we present our experience with this disease.

Liquid metal polymer composite: Flexible, conductive, biocompatible, and antimicrobial scaffold.

Gallium and its alloys, such as eutectic gallium indium alloy (EGaIn), a form of liquid metal, have recently attracted the attention of researchers due to their low toxicity and electrical and thermal conductivity for biomedical application. However, further research is required to harness EGaIn-composites advantages and address their application as a biomedical scaffold. In this research, EGaIn-polylactic acid/polycaprolactone composites with and without a second conductive filler, MXene, were prepared and characterized. The addition of MXene, into the EGaIn-composite, can improve the composite's electrochemical properties by connecting the liquid metal droplets resulting in electrically conductive continuous pathways within the polymeric matrix. The results showed that the composite with 50% EGaIn and 4% MXene, displayed optimal electrochemical properties and enhanced mechanical and radiopacity properties. Furthermore, the composite showed good biocompatibility, examined through interactions with fibroblast cells, and antibacterial properties against methicillin-resistant Staphylococcus aureus. Therefore, the liquid metal (EGaIn) polymer composite with MXene provides a first proof-of-concept engineering scaffold strategy with low toxicity, functional electrochemical properties, and promising antimicrobial properties.

Clotting of Hemodialysis Access in Patients with COVID-19 in an Inner-City Hospital.

BACKGROUND: An increased incidence of thrombotic complications in patients with coronavirus disease 2019 (COVID-19) has been reported. Severe acute kidney injury (AKI) is one of the major clinical manifestations of COVID-19 with the need for renal replacement therapy. It was observed that hemodialysis (HD) accesses tended to thrombose more often in the COVID-19 population than in non-COVID-19 patients. We hypothesize that the hypercoagulable state of COVID-19 is associated with higher incidence of access clotting. METHOD: In this retrospective single-centered study at Kings County Hospital in New York City, 1,075 patients with COVID-19 were screened, and 174 patients who received HD from January 3, 2021 to May 15, 2020 were enrolled to examine the risk factors of dialysis access clotting in patients with COVID-19. RESULTS: Of the 174 patients, 109 (63%) were COVID-19 positive. 39 (22.6%) patients had dialysis access clotting at least once during their hospitalization, and they had significantly higher body mass index (BMI) (p = 0.001), higher rates of COVID-19 (p = 0.015), AKI (p < 0.001), higher platelet counts (p = 0.029), higher lactate dehydrogenase levels (p = 0.009), and lower albumin levels (p = 0.001) than those without access malfunctions. Low albumin levels (p = 0.008), AKI (p = 0.008), and high BMI (p = 0.018) were risk factors associated with HD access clotting among COVID-19 patients. CONCLUSION: Patients with COVID-19 who receive HD for AKI with high BMI are at a higher risk of clotting their HD access.

COVID-19 Pneumonia Precipitating Acute Anterior Wall Myocardial Infarction With Large Left Ventricular Apical Thrombus.

Initial reports suggest an increased thrombotic risk in coronavirus disease 2019 (COVID-19). We present a case of COVID-19 pneumonia that precipitated chest pain, an acute anterior wall ST-elevation myocardial infarction on the fifth day of hospitalization resulting in large left ventricular apical thrombus.

Additive Manufacturing of Polymer Materials: Progress, Promise and Challenges.

The use of additive manufacturing (AM) has moved well beyond prototyping and has been established as a highly versatile manufacturing method with demonstrated potential to completely transform traditional manufacturing in the future. In this paper, a comprehensive review and critical analyses of the recent advances and achievements in the field of different AM processes for polymers, their composites and nanocomposites, elastomers and multi materials, shape memory polymers and thermo-responsive materials are presented. Moreover, their applications in different fields such as bio-medical, electronics, textiles, and aerospace industries are also discussed. We conclude the article with an account of further research needs and future perspectives of AM process with polymeric materials.

Crab vs. Mushroom: A Review of Crustacean and Fungal Chitin in Wound Treatment.

Chitin and its derivative chitosan are popular constituents in wound-treatment technologies due to their nanoscale fibrous morphology and attractive biomedical properties that accelerate healing and reduce scarring. These abundant natural polymers found in arthropod exoskeletons and fungal cell walls affect almost every phase of the healing process, acting as hemostatic and antibacterial agents that also support cell proliferation and attachment. However, key differences exist in the structure, properties, processing, and associated polymers of fungal and arthropod chitin, affecting their respective application to wound treatment. High purity crustacean-derived chitin and chitosan have been widely investigated for wound-treatment applications, with research incorporating chemically modified chitosan derivatives and advanced nanocomposite dressings utilizing biocompatible additives, such as natural polysaccharides, mineral clays, and metal nanoparticles used to achieve excellent mechanical and biomedical properties. Conversely, fungi-derived chitin is covalently decorated with -glucan and has received less research interest despite its mass production potential, simple extraction process, variations in chitin and associated polymer content, and the established healing properties of fungal exopolysaccharides. This review investigates the proven biomedical properties of both fungal- and crustacean-derived chitin and chitosan, their healing mechanisms, and their potential to advance modern wound-treatment methods through further research and practical application.

Waste-Derived Low-Cost Mycelium Nanopapers with Tunable Mechanical and Surface Properties.

Mycelium, the vegetative growth of filamentous fungi, has attracted increasing commercial and academic interest in recent years because of its ability to upcycle agricultural and industrial wastes into low-cost, sustainable composite materials. However, mycelium composites typically exhibit foam-like mechanical properties, primarily originating from their weak organic filler constituents. Fungal growth can be alternatively utilized as a low-cost method for on-demand generation of natural nanofibrils, such as chitin and chitosan, which can be grown and isolated from liquid wastes and byproducts in the form of fungal microfilaments. This study characterized polymer extracts and nanopapers produced from a common mushroom reference and various species of fungal mycelium grown on sugarcane byproduct molasses. Polymer yields of ∼10-26% were achieved, which are comparable to those of crustacean-derived chitin, and the nanopapers produced exhibited much higher tensile strengths than the existing mycelium materials, with values of up to ∼25 MPa (mycelium) and ∼98 MPa (mushroom), in addition to useful hydrophobic surface properties resulting from the presence of organic lipid residues in the nanopapers. HCl or H2O2 treatments were used to remove these impurities facilitating tuning of mechanical, thermal, and surface properties of the nanopapers produced. This potentially enables their use in a wide range of applications including coatings, membranes, packaging, and paper.