Severe Mitral Valve Regurgitation Secondary to Fulminant Myocarditis in the Setting of a Lupus Flare.

Systemic Lupus Erythematosus represents a chronic autoimmune disorder characterized by multiorgan involvement. Lupus myocarditis is a rare presentation of one of the cardiac complications of lupus with an incidence of 3-9%. It usually presents with non-specific symptoms such as dyspnea, orthopnea, chest pain, pedal edema, fever, diaphoresis, paroxysmal nocturnal dyspnea, nausea, vomiting, or palpitations. Even though endomyocardial biopsy is considered the gold standard diagnostic approach, other non-invasive diagnostic alternatives including cardiac magnetic resonance (CMR) have been studied. Therapeutic interventions may range from high-dose steroids, and IVIG, to the most advanced strategies such as mechanical circulatory support including VenoArterial Extracorporeal Membrane Oxygenation (VA-ECMO), and Impella, among others.

Myocardial Infarction Presenting as Both Left Ventricular Aneurysm and Ventricular Septal Defect.

Acute myocardial infarction can result in various mechanical complications, although they have become rare with the advent of reperfusion therapies. Among these complications, ventricular septal rupture (VSR) and left ventricular aneurysm (LVA) are infrequent but life-threatening conditions associated with high morbidity and mortality. We present a rare case of a 67-year-old male with acute myocardial infarction who developed concomitant apical LVA and ventricular septal rupture. LEARNING POINTS: Mechanical complications of myocardial infarction, such as a ventricular septal rupture (VSR) and left ventricular aneurysm (LVA), are rare but life-threatening.Early diagnosis is critical. A ventricular septal defect (VSD) requires immediate surgical closure, while surgery for LVA is only considered in specific cases such as chest pain or thromboembolism.Diagnostic tools such as echocardiography and left ventriculography play a vital role in identifying and characterising these complications, enabling timely treatment decisions.

Red cell distribution width (RDW) correlates with markers of diastolic dysfunction in patients with impaired left ventricular systolic function.

OBJECTIVE: Red-cell distribution width (RDW) has been identified as a novel prognostic marker in a heterogeneous group of heart failure patients. In this group, diastolic dysfunction is associated with worse outcome. As the evidence is limited, the aim of the present study was to assess the relationship of RDW to diastolic markers in patients with left ventricular dysfunction (LVD) diagnosed during cardiac catheterization. METHODS: Clinical and angiographic data were collected retrospectively on a total of 291 stable patients (mean age 62 years, 199 males) with systolic dysfunction documented during cardiac catheterization in a regional medical center between January 2006 and December 2010. RESULTS: Positive association was seen between RDW and Left ventricular end diastolic pressure (LVEDP), estimated systolic pulmonary arterial pressure(sPAP), and left atrial dimension (LAD) (r: 0.18, 0.24, 0.28, respectively; p:<0.05).Three year retrospective survival analysis for 108 patients admitted in the first 2 years showed a statistically significant decrease in survival patients with high RDW(> 14.5) vs. normal RDW (73%vs.88%;log rank p:0.03). This was seen even in the asymptomatic subgroup (71% vs. 94%; log rank p: 0.01). CONCLUSION: RDW correlates with markers of diastolic dysfunction in patients with LVD. Additionally, in patients asymptomatic LVD, high RDW is still associated with lower survival.

Electrocardiographic abnormalities in patients presenting with intracranial parenchymal haemorrhage.

OBJECTIVES: The electrocardiographic abnormalities associated with ischaemic stroke and subarachnoid haemorrhage have been described frequently and studied systematically; however, these changes were not investigated thoroughly in patients with intracranial parenchymal haemorrhage (IPH). METHODS: We retrospectively reviewed the electrocardiograms (ECGs) and medical records of all patients who had been diagnosed with acute intraparynchemal haemorrhage (IPH) between 2006 and 2009. RESULTS: We included 160 patients (56% males). The median age was 71 years (interquartile range (IQR) 59 to 80) and 69% were above the age of 60 years. Most patients were hypertensive (81%).The majority of patients (86%) had at least one ECG abnormality. Sixty-eight (43%) patients had T-wave inversion and 65 (41%) had QTc interval prolongation. There was a significant association between QTc prolongation and the bleeding size and the presence of midline shift; odd ratios were 2.8 (CI 1.4 to 5.5; P 0.003) and 2.2 (CI 1.1 to 4.2; P 0.04), respectively. In addition, sinus tachycardia was found to be significantly associated with the presence of hydrocephalus (OR 4.1; CI 1.3 to 12.8; P 0.02). CONCLUSIONS: ECG abnormalities are a common finding in patients with IPH. Repolarizaion abnormalities occur the most frequently. QTc prolongation was associated with bleeding size and midline shift. Patients who had hydrocephalus were more likely to have sinus tachycardia at presentation.

The role of postexercise measurements in the diagnosis of peripheral arterial disease in HIV-infected patients.

Peripheral arterial disease (PAD) is a marker of atherosclerosis, which is not well studied in the population with human immunodeficiency virus (HIV). We prospectively enrolled HIV-infected patients who had normal resting ankle-brachial index (rABI) readings. All participants performed either a treadmill walking test (TT) or pedal plantar flexion test (PFT). Patients were divided into 2 groups according to postexercise changes; PAD and No-PAD group. The 2 groups were compared with regard to established cardiovascular disease risk factors and other HIV infection parameters. Peripheral arterial disease was present in 30 (26.5%) of 113 consecutive HIV-infected patients included in the study. Mean age was 47 ± 10 years. The risk factors studied did not differ significantly among the 2 groups except for male gender, which was significantly associated with PAD (RR: 4.15; CI: 1.6 to 11.1: P < .0008). The prevalence of PAD, diagnosed by significant drop in postexercise ABI and ankle pressure in patients with HIV is high.

Coronary anomaly and coronary artery fistula as cause of angina pectoris with literature review.

Coronary artery fistulas are rare anomalies of the coronary arteries that may sometimes cause symptoms by shunting blood flow away from the myocardial capillary network. We report the case of a 46-year old lady which shows the right coronary cusp giving rise to left main coronary artery called anomalous origin of a coronary artery (AOCA), and also a fistula between the left coronary artery and pulmonary artery. We describe our diagnostic approach and review the literature on the epidemiology, pathophysiology, the diagnostic modalities, and treatment options.

Fractional excretion of sodium predicts worsening renal function in acute decompensated heart failure.

BACKGROUND: Renal impairment (RI), defined as an increase in creatinine level of greater than 26.5 mmol/L, develops in more than 30% of acute decompensated heart failure (ADHF) patients. Fractional excretion of sodium (FeNa) reflects sodium handling by the kidneys during diuresis. AIM: To study the relationship between FeNa and RI in patients admitted with ADHF. METHOD: The hospital course and renal function of all ADHF patients admitted to the hospital were prospectively observed. Patients were included if their admission creatinine level was 176 mmol/L or lower, they had been on a low-salt diet since admission, had urine sodium and creatinine samples collected more than 6 h after a furosemide dose in the first few days of admission, and they were on daily intravenous furosemide doses of 20 mg or more. RESULTS: Over six months, 51 patients met the inclusion criteria; the average daily dose of intravenous furosemide was 58.8 mg. RI developed in 39% of patients. A FeNa cut-off point of 0.4% was determined using ROC curve analysis; patients with a FeNa of greater than 0.4% (28 patients) were compared with patients with a lower FeNa (23 patients). Admission creatinine level and furosemide dose were higher in the first group (P=0.01 and P=0.06, respectively). The first group developed RI more frequently (OR=6.3; 95% CI 1.7 to 23.5; P=0.0047; adjusted OR for admission creatinine = 6.18; 95% CI 1.6 to 24.5; P=0.0096; and adjusted OR for furosemide dose = 4.7; 95% CI 1.3 to 16.7; P=0.016). They had a longer hospitalization course (median nine days [interquartile range 6.3 to 13.5 days] versus seven days [interquartile range 4.0 to 9.0 days]; P=0.036) and they were admitted to the cardiac care unit more frequently (OR=6.8; 95% CI 1.3 to 34.9; P=0.02). CONCLUSION: A FeNa of greater than 0.4% more than 6 h after a dose of diuretics predicts RI and a complicated hospital course in ADHF patients.

Viral load and CD4+ cell count as risk factors for prolonged QT interval in HIV-infected subjects: a cohort-nested case-control study in an outpatient population.

BACKGROUND: QTc interval prolongation is a serious ECG finding which has frequently been reported in HIV-infected patients, but associated risk factors have not been determined in this population. METHODS: Data were collected from the charts of a cohort of 135 consecutive HIV-infected patients from our HIV outpatient clinic. The cohort was divided into two groups, patients with prolonged QTc and those with normal QTc interval. Multiple variables and potential risk factors were analyzed, including the CD4+ cell count and viral load (VL), which were assessed on the same day or within several days of the initial ECG. RESULTS: 23 patients were found to have prolonged QTc (17%). No significant difference in baseline characteristics was observed between the groups; however, statistically significant differences were observed with regard to the CD4+ cell count and VL. CONCLUSION: A low CD4 cell count and a high VL may be risk factors potentially related to QT prolongation in HIV patients in the outpatient setting.

Case report and literature review: acute pneumonitis and alveolar hemorrhage after subcutaneous injection of liquid silicone.

Lay (non-medical) injection of silicone may lead to serious clinical consequences. Most reports of illicit cosmetic procedures have dealt with failed, lay attempts at breast augmentation. Although these procedures have resulted in severe pneumonitis and alveolar hemorrhage, reports of similar complication after lay attempts at buttock augmentation have been sparse. We describe one of these rare cases and review the literature on clinicopathologic sequelae of lay attempts at cosmetic procedures using commercially available silicone preparations.

"Buddy wire" technique to overcome proximal coronary tortuosity during rotational atherectomy.

We report a case in which rotational atherectomy was planned for the treatment of a severely calcified obstructive lesion in the middle right coronary artery. Severe proximal vessel tortuosity prevented the advancement of the Rotablator burr. We utilized the "buddy wire" technique, allowing facilitated advancement of the Rotablator and successful atherectomy and stenting. We propose this old technique as an alternative method to allow advancement of the Rotablator burr through tortuous and calcified vessels.