Dehiscent Prosthetic Aortic Valve and Aortic Root Pseudoaneurysm Complicated by Left Main Coronary Artery Compression.

Prosthetic aortic valve dehiscence is an uncommon complication of prosthetic valve endocarditis that may occur in patients who have undergone aortic valve replacement (AVR). The concurrent presence of aortic root pseudoaneurysm may further complicate the clinical presentation through the external compression of coronary arteries. Thus, patients may present with clinical features of coronary ischemia. Echocardiogram and coronary angiography are useful in establishing diagnosis. Treatment involves a multidisciplinary approach involving cardiologists, infectious disease specialists, and cardiothoracic surgeons. The authors of this study discuss a 51-year-old male who presented with anginal chest pain and was found to have a new left bundle branch block, elevated troponins, and left main coronary artery compression complicating aortic root aneurysm. He ended up requiring a re-do AVR, repair of the pseudoaneurysm, and coronary artery bypass graft.

A Novel Case of Acquired Isolated Left Ventricular Non-compaction in a Primigravida: Revisiting the Diagnostic Criteria of Left Ventricular Non-compaction.

Left ventricular non-compaction (LVNC) is rare cardiomyopathy characterized by the presence of a two-layered myocardium with prominent trabeculations. It has high rates of mortality and morbidity. Clinical presentation could vary from asymptomatic patients to developing ventricular arrhythmias, thromboembolism, heart failure, and even sudden cardiac death. We present a 23-year-old primigravida with a childhood history of dilated cardiomyopathy secondary to post-viral myocarditis presenting at 32 weeks gestation with dyspnea on exertion. Initial 2-D echocardiogram revealed a mildly dilated left ventricle with apical trabeculation and a 2-layer distinction between compacted and noncompacted myocardium indicating non-compaction of the left ventricle. This case presents a peculiar confluence of cardiac genetics, normal physiology, and infection. We describe a rare form of acquired LVNC that transformed from another type of cardiomyopathy to LVNC during pregnancy drawing attention to the causality pathways of LVNC.

Crescendo Angina Secondary to Congenital Absence of the Left Circumflex Coronary Artery: A Case Report.

Congenital coronary artery abnormalities (CAAs) are very rare in the general population. Among these congenital anomalies, left circumflex artery (LCx) anomaly is the most common. Although many are asymptomatic, a small percentage of patients with this anomaly present with angina-like symptoms. Usually, a majority of these cases are found incidentally during coronary angiography. We present a 71-year-old male with crescendo angina with a positive chemical stress test. Coronary angiography showed an absent LCx and a superdominant right coronary artery (RCA). Although congenital LCx absence is a benign finding, the coexistence of this abnormality with significant atherosclerotic disease in the coronary artery can lead to significant morbidity and mortality in this population. Understanding the embryological and morphological significance of these anomalies is important in adequately diagnosing and managing these patients.

Untying the Knot: A Rare Case of Formation of a Life-Threatening Intracardiac Knot Following the Placement of a Temporary Transvenous Pacemaker.

The implantation of a temporary pacemaker lead is a very common procedure performed in most hospitals and is known to be relatively safe, but there can be serious complications in rare circumstances. Reported complications including arrhythmias, infection, thromboembolic phenomena, and perforation of the vessel or the heart are all extensively described. However, an unusual and life-threatening complication that is not frequently discussed is the formation of intracardiac knots. We present a case of a rare complication of a temporary pacemaker placement with the formation of a knot in the distal lead requiring expert technique for removal.

Unsterile Subcutaneous Insulin Injections Causing Psoas and Spinal Epidural Abscesses.

Spinal epidural and psoas abscesses have been found to occur together. Most cases described in the literature have been secondary to either hematogenous spread or direct invasion. Risk factors include intravenous drug use and immunosuppression. This case highlights the risk of the use of unsterile subcutaneous insulin injections leading to psoas abscess, which can be complicated by a spinal epidural abscess.

The Destabilized Artery: A Case of Spontaneous Coronary Artery Dissection Presenting as Unstable Angina.

Spontaneous coronary artery dissection (SCAD) is increasingly being recognized as a cause of acute coronary syndrome (ACS). This increased recognition of SCAD has been noted in patients with and without traditional cardiovascular risk factors such as diabetes mellitus, hyperlipidemia, and cigarette smoking. The increasing incidence is believed to be due to recent advances in diagnostic and coronary imaging modalities. The most common presenting feature is chest pain or discomfort. Normal troponin level does not rule out SCAD as the definitive diagnosis is made on coronary angiography. Percutaneous intervention (PCI) for SCAD has been associated with lower success rates compared to PCI for atherosclerotic coronary artery disease. Medical management is, therefore, the initial treatment of choice.

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.

Opioid-Induced Hyperalgesia in a Cancer Patient on High-Dose Methadone Maintenance Therapy: A Case for Subspecialty Opioid Use Disorder Primary Care.

As opioid use disorder (OUD) reaches epidemic levels in the United States, medication-assisted treatment (MAT) plays a central role in its treatment. Methadone, a long-acting mu-opioid receptor agonist has been shown to be effective in managing OUD. It is also known that chronic opioid therapy may have the paradoxical effect of increased sensitivity to pain, a phenomenon called opioid-induced hyperalgesia (OIH). This presents a conundrum when a patient such as ours, on MAT presents with acute pain and OIH. This case report illustrates the current challenges health care providers encounter when treating patients on chronic MAT for non-opioid-related conditions. As this patient population ages, these encounters will become more common. These patients will need appropriate health care screening and chronic care management. This case serves two purposes; to highlight the difficulty in treating acute pain in patients on long-term high-dose methadone coupled with the missed opportunity for primary care for OUD patient population, and proposes that education reforms in this area be implemented now.