Rivaroxaban Failure Presenting With Renal Infarction in a Patient With Persistent Atrial Fibrillation: A Case Report.

Direct oral anticoagulants (DOAC) are the preferred choice of anticoagulation for patients with atrial fibrillation. DOACs are always preferred over vitamin K antagonists due to their better safety profile in terms of life-threatening bleeding and decreased need for INR (international normalised ratio) monitoring. Although the most commonly used anticoagulation, failure to DOAC has been reported. Here we present a rare case of rivaroxaban failure presenting with left renal infarction in a patient who had dense spontaneous echocardiographic contrast in the left atrium visualised by transthoracic echocardiography.

Effect of Azilsartan on clinical blood pressure reduction compared to other angiotensin receptor blockers: a systematic review and meta-analysis.

Background: Hypertension has significantly contributed to morbidity and mortality, necessitating effective management. Angiotensin receptor blockers (ARBs) have emerged as a cornerstone in hypertension treatment. Azilsartan, a relatively recent addition to the ARB family, offers unique characteristics, including prodrug activation. This systematic review and meta-analysis aimed to evaluate Azilsartan's role in reducing clinical blood pressure compared to other ARBs and determine the most effective dosage. Methods: Following PRISMA guidelines, a comprehensive literature search was conducted in Medline, Web of Science, Cochrane Library, and clinicaltrials.gov. Eligible studies included adult hypertensive patients receiving Azilsartan compared to other ARBs, with clinical systolic blood pressure (SBP) and diastolic blood pressure (DBP) outcomes. Data extraction and quality assessment were performed, and statistical analysis employed comprehensive meta-analysis (CMA) software. Results: Eleven randomized controlled trials encompassing 18 studies involving 6024 patients were included. Azilsartan demonstrated significant reductions in clinical SBP (mean difference=-2.85 mmHg) and DBP (mean difference=-2.095 mmHg) compared to other ARBs. Higher doses of Azilsartan showed greater efficacy, with 80 mg exhibiting the most substantial reduction in SBP. The analysis emphasized the need for more studies investigating lower Azilsartan doses (10 and 20 mg). Conclusion: This systematic review and meta-analysis underscore Azilsartan's effectiveness in reducing SBP and DBP. Dose-dependent effects emphasize the importance of optimal dosing when prescribing Azilsartan. These findings provide valuable insights for clinicians in managing hypertension effectively and call for further research, primarily focusing on lower Azilsartan doses and a more diverse patient population.

Identification and Validation of Functional miRNAs and Their Main Targets in Sorghum bicolor.

MicroRNAs (miRNAs) are typically non-coding RNAs of 18-26 nucleotides (nts) that are produced endogenously and regulated post-transcriptionally through degradation or translational repression. Since miRNAs are evolutionarily conserved, their preservation is essential for important regulatory functions in plant development, growth, and responses to environmental stress. Sorghum bicolor (sbi) is a valuable food and fodder crop which is grown worldwide. A range of sbi miRNAs were identified so far as being connected to plant development and stress responses. Herein, we employed a variety of bioinformatics tools for miRNA profiling in sbi and a PCR-based platform for the validation of these miRNAs. In total, 74 new conserved sbi miRNAs from 52 miRNA families have been predicted. Using the psRNA Target method, 10613 different protein targets of these predicted miRNAs have been attained. These targets include 54 GO-terms which have substantial targets in the biological, molecular, and cellular processes. We particularly found that the sbi-miR1861c and sbi-miR5050 are involved to regulate sulphur compound biosynthetic process, while the significant spliceosomal complex is regulated by sbi-miR815b and sbi-miR7768b. Also, we report that the pre-ribosome, electron transport chain, cell communication, cellular respiration, protein localization, and photosynthesis are controlled by sbi-miR2907b, sbi-miR530, sbi-miR7749, sbi-miR1858a, sbi-mi7729a, and sbi-miR417, respectively. The identification and validation of these novel sbi miRNAs shall contribute a lot in improving the crop yield and ensure sustainable agriculture.

Best management of patients with malignant pericardial effusion: A comparative study between imaging-guided pericardiocentesis and surgical pericardial window.

Background: The clinical course of malignancies is frequently complicated by third spacing in body cavities, including pericardial effusion. What remains the optimal management for malignant pericardial effusion is a dilemma. Aim: We aimed to compare 30-day outcomes of imaging-guided pericardiocentesis and surgical pericardial window in patients with malignant pericardial effusion. Methods: A retrospective observational study was done at a tertiary care hospital. We reviewed hospital record files of 91 consecutive patients admitted with malignant pericardial effusion from January 2010 to December 2019 and requiring imaging-guided pericardiocentesis or pericardial window. Results: A total of 71 patients were included in the final analysis. Most patients were male (68%). The mean age was 45 years. Hypertension was the most common comorbid condition. Lymphoma or leukemia (39%) was the most common cause of malignant pericardial effusion followed by lung cancer (28%). About 57.7% of patients underwent pericardiocentesis, and the remainder underwent surgical pericardial window (42.3%). The overall procedural success was 97.2%, and the overall mortality was 5.6%. The success rate was similar when pericardiocentesis was compared with the surgical pericardial window (p = 0.22). The length of hospital stay was higher in patients undergoing pericardial window (p = 0.007), whereas the re-accumulation rate was higher in the pericardiocentesis group (0% versus 34%, p < 0.001). Patients undergoing pericardial window had higher odds of major bleeding requiring transfusions. Conclusion: There is a higher rate of recurrence following isolated pericardiocentesis but a comparable mortality difference between the two procedures. Complication rates can be reduced by improving surgical technique and peri-operative management. Meticulous surgical care, infection precautions, and good glycemic control in this immunocompromised subset can preserve the pericardial window as a better management option. Relevance to Patients: Pericardial window is a promising and effective management option for patients with recurrent malignant pericardial effusion, but it comes at the cost of bleeding and infection. More extensive trials are needed to understand better the long-term outcomes of pericardial window or pericardiocentesis in patients with malignant effusion.

Efficacy of Pemafibrate Versus Fenofibrate Administration on Serum Lipid Levels in Patients with Dyslipidemia: Network Meta-Analysis and Systematic Review.

BACKGROUND: Pemafibrate is a novel fibrate class drug that is a highly potent and selective agonist of peroxisome proliferator-activated receptor α (PPARα). We performed the first ever network meta-analysis containing the largest ever group of patients to test the efficacy of pemafibrate in improving lipid levels compared with fenofibrate and placebo in patients with dyslipidemia. METHODS: Potentially relevant clinical trials were identified in Medline, PubMed, Embase, clinicaltrials.gov, and Cochrane Controlled Trials registry. Nine randomized controlled trials met the inclusion criteria out of 40 potentially available articles. The primary effect outcome was a change in the levels of triglycerides (TG), high-density lipoproteins (HDL), or low-density lipoproteins (LDL) before and after the treatment. RESULTS: A total of 12,359 subjects were included. The mean patient age was 54.73 (years), the mean ratio for female patients was 18.75%, and the mean examination period was 14.22 weeks. The dose for pemafibrate included in our study was 0.1, 0.2, or 0.4 mg twice daily, whereas the dose for fenofibrate was 100 mg/day. Data showed a significant reduction in TG and a mild increase in HDL levels across the pemafibrate group at different doses and fenofibrate 100 mg group (with greatest effect observed with pemafibrate 0.1 mg twice daily). A mild increase in LDL was also observed in all groups, but the increase in LDL in the 0.1 mg twice daily dose group was statistically insignificant. CONCLUSION: Pemafibrate 0.1 mg twice daily dose led to highest reduction in TG levels and the highest increase in HDL levels compared with other doses of pemafibrate, fenofibrate, and placebo.

Seizures in activating calcium-sensing receptor antibodies positive autoimmune hypoparathyroidism and preponderance of steroids therapy: A case report.

A 55-year-old female patient presented with generalized tonic-clonic seizures. Laboratory evaluation revealed low calcium (4.9 mg/dl), low PTH (0.9 pg/ml), and positive activating CaSR antibodies. The condition was diagnosed as autoimmune hypoparathyroidism. Calcium and vitamin D supplements did not correct the patient's hypocalcemia. The addition of prednisone to vitamin supplements showed a better response and corrected the hypocalcemia. The patient remained in seizure-free for one year.

Idiopathic unilateral third nerve palsy with pupillary sparring in 10-year-old child -a case report.

Introduction and importance: Aneurysm, diabetes mellitus, central nervous system (CNS) infections, pituitary tumors, and ischemia alterations are all potential causes of unilateral oculomotor nerve palsy, a common clinical disease. Case presentation: A 10-year-old child presented with right eyelid ptosis and restricted eye movements associated with diplopia and pain in the right eye. Brain imaging and laboratory tests revealed no obstruction, infection, or hypercoagulable state. The condition was labeled as idiopathic. A patient was diagnosed with ptosis through a sling procedure and after 2 and 4 weeks of follow-up was told he had mild anemia. The patient was prescribed ferrous sulfate 8mg once daily for 4 months and his condition improved. Clinical discussion: Surgery can correct the appearance of crossed eyes, but it seldom restores or significantly improves binocular function. Amblyopia and the loss of binocular vision can occur in children with third nerve palsy due to the excessive angle of incitant strabismus and the resulting ptosis. Conclusion: Patients with idiopathic third nerve palsy must be informed of their prognosis so that they can make an informed decision about whether or not to undergo surgery. Clinical examination is the only way to identify a child's condition and proper investigations and a full history of prenatal and antenatal courses are required.

Diagnostic dilemma of celiac disease presenting with weight loss and secondary amenorrhea: A case report.

RATIONALE: Celiac disease (CD) is autoimmune enteropathy affecting the proximal small intestinal mucosa. It is caused by insensitivity to gluten, a protein predominantly presented in wheat. CD is classically associated with gastrointestinal symptoms. The non-classic clinical presentation of CD can present with other organ involvement. Non-human leukocyte antigens genes are associated with atypical forms. PATIENTS CONCERN: We reported a case of 30-year-old female who presented with progressive pallor, amenorrhea, and unexplained weight loss with generalized body weakness. Her body mass index was 20. The patient was having no other systemic manifestations. DIAGNOSIS: This paper reports a case of a female patient having CD without its typical features. Her laboratory evaluation revealed microcytic anemia. Anti-TTg IgA and Anti-TTG IgG antibodies were raised, ferritin and folate were low, and there was mild hyperbilirubinemia. However, follicle-stimulating hormone, luteinizing hormone, and serum estradiol levels were normal. She was diagnosed with a case of anemia resulting from malabsorption caused by CD. INTERVENTIONS: A management plan was devised based on a strict gluten-free diet. The patient received supplements containing folates, iron, calcium, zinc, and vitamins A, D, E, B6, and B12. OUTCOMES: After 3 months of treatment with strict gluten-free diet patient showed remarkable improvement. Her hemoglobin level raised with weight gain. Her normal menstrual cycle was restored with complete resolution of symptoms at 1 year follow-up. LESSONS: The pathogenesis of the atypical CD is multifactorial, but impaired uptake of micronutrients from the duodenum is the most likely cause, even if other common features of classical forms, such as bloating and diarrhea, are absent. Lack of awareness about atypical forms may lead to under-diagnoses of the disease. The physicians should consider the atypical presentations of CD to avoid the under-diagnoses of this multisystem disorder.

Role of point-of-care arterial blood potassium in diagnosing pseudohyperkalemia.

Hyperkalemia is a life-threatening emergency, but it needs to be differentiated from pseudohyperkalemia to avoid unnecessary treatment. We present a case of pseudohyperkalemia in a chronic lymphocytic leukemia patient with severe leukocytosis, highlighting the role of point-of-care potassium. Laboratory workup showed persistent hyperkalemia on analysis of venous blood samples even after treatment for hyperkalemia. Point-of-care potassium checks on whole arterial blood immediately after sampling were consistently in the normal range. Treatments for hyperkalemia were stopped to avoid life-threatening hypokalemia.

Non-Hodgkin's lymphoma masquerading as splenic abscess: A case report.

Background: Non-Hodgkin's lymphoma (NHL) is a monoclonal proliferation of lymphoid cells from B lineage. Although NHLs are primarily hematological tumors of lymph nodes but rarely can involve extranodal sites such as the spleen. Case report: A 29-year-old female patient presented with low-grade fever, cough, anemia, weight loss, tender left hypochondrium, and splenomegaly. A hypodense lesion in the spleen with central necrosis, having strong positivity for common leukocyte antigen (LCA), CD 20, and CD 10, led to a diffuse large B cell lymphoma diagnosis. The patient had an excellent clinical post-splenectomy response to combination chemotherapy and immunotherapy. Conclusion: NHL can present with symptomatic extra-nodal involvement without enlarged lymph nodes.

Prevalence and Outcomes of Myocarditis in Dengue-Infected Patients Admitted to a Tertiary Care Hospital of Low-Middle Income Country.

Background: Myocarditis is a challenging diagnosis due to the heterogeneity of clinical presentations. Myocarditis can present with a mildly raised cardiac enzyme to severe myocarditis leading to congestive heart failure, arrhythmias, cardiogenic shock, and death. It is a predictor of morbidity and mortality in dengue-infected patients. The exact prevalence of dengue myocarditis and its outcomes are unknown in Pakistan. Objectives: We aim to study the prevalence and association of myocarditis with the length of stay in the hospital and mortality of dengue-infected patients. Methods: A retrospective observational study done at a tertiary care hospital. We reviewed hospital record files of 1008 consecutive patients with dengue viral infection admitted from November 2018 to November 2019. Results: Out of 1008 dengue-infected patients, 55.4% of patients were older than 35 years and 68.4% were males. Hypertension (HTN) was the most common comorbid condition. The prevalence of myocarditis in hospitalized dengue-infected patients was 4.2%. All (100%) of dengue myocarditis patients had raised cardiac troponin I (cTn-I), 59.5% of patients had at least one electrocardiography (ECG) change, and 24% had reduced ejection fraction (EF) (defined as EF < 55%). On multivariable analysis, patients with raised cTn-I levels (adjusted odds ratios = 5.29; [95% confidence interval (CI): 2.16-12.96]) and abnormal echocardiography (ECHO) [aOR = 4.38; 95% CI: 1.26-15.27)] had a prolonged hospital stay (>3 days). Raised cTn-I levels (aOR = 8.2; [95% CI: 1.83-36.84]) was significantly associated with in-hospital mortality. Conclusions: Raised cTn-I is the predictor of length of stay and in-hospital mortality in dengue-infected patients. Atrial fibrillation, diabetes mellitus, hypertension, low serum bicarbonate, high serum creatinine, and any abnormality on echocardiography were associated with adverse outcomes in dengue-infected patients.

COVID-19 Vaccination-Induced Cardiomyopathy Requiring Permanent Left Ventricular Assist Device.

Myocarditis was identified as a rare but serious adverse event that can occur after mRNA-based coronavirus disease 2019 (COVID-19) vaccination, particularly in young males. During the COVID-19 pandemic, we report a case of a young obese male without multiple comorbidities who presented with abdominal pain and was found to have severe myocarditis/cardiomyopathy, which was likely due to mRNA-based COVID-19 vaccination. The patient had left ventricular assist device (LVAD) implantation during hospitalization. Myocarditis/cardiomyopathy may be a rare complication of the mRNA-based COVID vaccine; however, one should maintain a high index of suspicion that these vaccines may cause irreversible cardiomyopathy if the patient had prior COVID-19 infection.

Clinical Outcome of TAVR vs. SAVR in Patients With Cardiac Amyloidosis.

Data regarding the clinical outcomes of transcatheter aortic valve replacement (TAVR) vs. surgical aortic valve replacement (SAVR) in cardiac amyloidosis are lacking. Our study aimed to look at the clinical outcomes of TAVR vs. SAVR in patients with cardiac amyloidosis. METHOD: We queried the National Inpatient Sample database for the years 2009-2014 using validated ICD-9-CM codes for TAVR and SAVR. Propensity score matching (1:1; PSM) was performed and in-hospital outcomes were compared between matched cohorts. RESULTS: Before PSM, the TAVR group had a higher hospitalization cost ($59,192 vs. $56,171.1, p = 0.001) and in-hospital mortality (4.24% vs. 3.27%, p = 0.001) compared to the SAVR group. After PSM, mortality (41.3% vs. 5.81%, p = 0.001) and hospitalization cost ($5907 vs. $6280, p = 0.001) was higher in the SAVR group. Length of stay was shorter in the TAVR group compared to SAVR group before (8.7 vs 11.4 p = 0.001) and after (8.7 vs 0.13.7, p = 0.001) PSM. After PSM, the incidence of acute myocardial infarction (10.10% vs. 17.57%, p = 0.001), acute kidney injury (20.67% vs. 31.40%, p = 0.001) and major bleeding (39.18% vs. 47.90%, p = 0.001) were higher in the SAVR group while the TAVR group had a higher incidence of the stroke (12.47% vs. 11.97%, p = 0.001), vascular complication (14.59% vs. 12.97%, p = 0.001), and permanent pacemaker implantation (10.45% vs. 8.48%, p = 0.001). CONCLUSION: In CA patients, in-hospital mortality and hospitalization costs were higher in the SAVR group than in the TAVR group, while the length of stay was shorter in the TAVR group.

Clinical In-Hospital Outcomes of Acute Myocardial Infarction in Patients With Hematological Malignancies.

Introduction The purpose of our study is to determine in-hospital outcomes of acute myocardial infarction in patients with hematological malignancies and their subtypes. Method Patient data were obtained from the nationwide inpatient sample (NIS) database between the years 2009-2014. Patients with hematological cancer subtypes and acute MI (non-ST segment elevation myocardial infarction and ST-segment elevation myocardial infarction (NSTEMI/STEMI) were identified using validated international classification of diseases (ninth revision) and clinical modification (ICD-9-CM) codes. Statistical analysis using the chi-square test was performed to determine the hospital outcomes of acute MI in patients with hematological cancers and subtypes. Results The prevalence of acute myocardial infarction was 2.4% in patients with hematological neoplasms (N=3,027,800). Amongst the subtypes of blood cancers, the highest prevalence of acute MI was seen in lymphocytic leukemia (2.9%). The mortality of MI in patients with hematological malignancies was 16.8% vs 8.8% in patients with non-hematological malignancies, in-hospital costs were $25469 ± 36763 vs. $20534 ± 24767, and length of in-hospital stay was 8.3 ± 10 vs 6.3 ± 7.8 days. Amongst the hematological cancer subtypes, the highest mortality of acute MI was found in myeloid leukemia (23%) followed by multiple myeloma (MM) (17.9%), lymphocytic leukemia (15.9%), and lymphoma (14.4%). The length of stay and hospitalization cost was highest for myeloid leukemia, followed by MM, lymphocytic leukemia, and lymphoma. Conclusion This study showed that acute MI in patients with hematological malignancies has higher in-hospital mortality, length of stay, and cost. Amongst the blood neoplasm subtypes the highest mortality, length of hospital stay, and hospitalization cost were found in myeloid leukemia.

Clinically isolated aortitis presenting as inferior ST-elevation myocardial infarction due to an unruptured sinus of Valsalva aneurysm: a rare and forgotten cause of acute coronary syndrome in a young patient with no evidence of systemic vasculitis.

A 21-year-old man presented with chest pain, diaphoresis and dyspnoea. Electrocardiogram (ECG) showed inferior ST-elevation myocardial infarction. Troponin I was positive. Patient underwent left heart catheterisation, which revealed normal epicardial coronary arteries except for right coronary artery which could not be engaged. CT coronary angiogram was done, which revealed large right sinus of Valsalva aneurysm giving rise to a pinched out right coronary artery. Patient underwent composite graft replacement of aortic valve, aortic root and ascending aorta along with a saphenous vein graft to right coronary artery. He was discharged in stable condition on fifth postoperative day. Biopsy of the aneurysmal tissue was suggestive of vasculitic aetiology. There was no evidence of systemic vasculitis and Magnetic Resonance Angiography (MRA) screen was negative for Takayasu's arteritis. Our patient was, hence, diagnosed with clinically isolated aortitis leading to ST elevation myocardial infarction due to an unruptured sinus of Valsalva aneurysm.

Periprocedural and In-Hospital Outcomes Among Percutaneous Coronary Intervention in Saphenous Vein Graft: A Retrospective Observational Study at a Tertiary Care Hospital in South Asian Country.

Background Saphenous vein graft (SVG) may occlude either early or several months to years after coronary artery bypass graft (CABG) surgery. Doing re-do CABG surgery is associated with higher complication and mortality rate as compared to percutaneous coronary intervention (PCI) in SVG. However, PCI of SVG is associated with more periprocedural and in-hospital complications as compared to PCI of native coronary arteries. Due to the scarcity of local data in this regard, this study was designed to estimate the periprocedural and in-hospital outcomes among PCI in SVG. Objectives We aim to study the periprocedural and in-hospital outcomes among patients who underwent PCI in SVG. Methods It is a retrospective observational study. We reviewed hospital record files of 167 consecutive patients, admitted to Aga Khan University Hospital, Karachi, from January 2010 to December 2019, who underwent PCI in SVG. Results Out of 167 patients, 145 (86.8%) were male with a mean age of 72.26 (±8.46) years. Hypertension was the most common comorbid condition. Majority of 141(84.4%) patients presented within 6-10 years since the last CABG done. Seventy-eight (46.7%) patients presented with non-ST elevation myocardial infarction (NSTEMI). Patients who presented with acute coronary syndrome (ACS), 51 (36.9%), and 21 (15.2%) had congestive heart failure and cardiogenic shock on presentation respectively. Coronary angiography was performed in the majority of 155 (92.8%) patients through the femoral artery. The body of the SVG was the most common site affected by the disease. In 88 (52.7%) patients stents were deployed in SVG to obtuse marginal (OM). Drug-eluting stents (DES) were used in 124 (74.3%) patients. 22 (13.2%) of patients developed periprocedural complications, predominantly slow flow and 7 (4.2)% patients had in-hospital complications. Conclusions PCI of SVG is associated with a high procedural success rate and acceptable risk for periprocedural and in-hospital complications. PCI of SVG may be considered as a safe and efficacious option for the percutaneous intervention of SVG lesions.

Multi Vessel Coronary Artery Disease Presenting as a False Negative Myocardial Perfusion Imaging and True Positive Exercise Tolerance Test: A Case of Balanced Ischemia.

Non-invasive investigations play an important role in the early diagnosis of coronary artery disease. Although the stress test is an easily available investigation for the diagnosis of obstructive coronary artery disease, its results are affected by the pretest probability. Myocardial perfusion imaging (MPI) is one of the commonly performed non-invasive cardiac imaging. The common reasons for false-negative exercise MPI are reported to be inadequate exercise, a lower dose of radio-tracer, small area of perfusion defect, and ischemia caused by left circumflex or its branches. Balanced ischemia is one of the rare causes of false-negative MPI. In this case report, we present a 73-year-old gentleman who presented with chest pain and shortness of breath. An exercise electrocardiogram (ECG) at five metabolic equivalents was positive for symptoms and electrocardiographic evidence of ischemia, but the myocardial perfusion image did not show ischemia. An invasive coronary angiogram was done due to high-risk exercise ECG, which revealed severe three-vessel coronary artery disease. Although the false-negative myocardial perfusion scan in the presence of a positive exercise electrocardiogram is unusual, it should not be ignored. Positive exercise ECG with the reproduction of symptoms indicates a high probability of critical coronary artery disease, irrespective of perfusion defects.

Pericardiocentesis Indications and Complications: A Retrospective Observational Study in a Tertiary Care Hospital in Karachi, Pakistan.

INTRODUCTION: Pericardiocentesis is crucial for the diagnosis and management of diseases responsible for significant pericardial effusions. Pericardiocentesis was performed the first time by Riolanus for cardiac tamponade. He described the process of trephination of the sternum to remove the abnormally accumulated fluid from the pericardial space. However, with the advancement of expertise in echocardiography assisted procedures, echocardiography-guided diagnostic and therapeutic pericardiocentesis is now considered standard clinical practice in the treatment of pericardial effusions. OBJECTIVES: We aim to study different causes of pericardial effusion and indications of pericardiocentesis as well as complications associated with it in our population. METHODS: This is a retrospective observational study done at Aga Khan University Hospital, Karachi. We reviewed hospital record files of 66 patients admitted to Aga Khan University Hospital from January 2010 to December 2019 who underwent pericardiocentesis. RESULTS: Out of 66 patients, 43 (65.2%) were male. The mean age of the study population was 48.59±18.9 years and 41 (62.1%) of them had underlying active malignancy with hematological malignancies being most common followed by lung carcinoma. In the majority of patients (71.2%), pericardiocentesis was performed at the bedside, and the rest of them (28.8%) underwent pericardiocentesis in the cardiac catheterization laboratory. Of all the patients, 46 (69.7%) underwent pericardiocentesis under echocardiography guidance and 18 (27.3%) required fluoroscopy. Successful pericardiocentesis was performed in 65 (98.5%) of the patients, two (3%) patients developed access site infection and only one (1.5%) patient became hemodynamically unstable while undergoing pericardiocentesis Conclusion: Malignancy, predominantly lymphoma, is the most common cause of pericardial effusion requiring pericardiocentesis. Dyspnea is the most common symptom of presentation with cardiac tamponade. Echocardiography is the commonly used imaging modality for pericardiocentesis. Bedside setting is the most common setting used for pericardiocentesis. Imaging guided pericardiocentesis has a very high success and low complication rate.

It's Not Always Occam's Razor - The Case of a Young Man with Subaortic Membrane with Superimposed Pulmonary Thromboembolism and Left Main Coronary Artery Disease.

Subaortic membrane (SAM) is a discrete fibromuscular structure which causes left ventricular outflow tract obstruction and leads to the symptomatology of valvular aortic stenosis. It is known to be associated with other congenital cardiac defects in around 30% of cases. However, it has not been associated with chronic pulmonary thromboembolism in the past. We present a case of a middle-aged Pakistani man who presented with dyspnea and hemoptysis. He was found to have a SAM and severe pulmonary hypertension on transthoracic echocardiogram. A coronary angiogram revealed non-obstructive left main coronary artery disease. A computed tomography (CT) scan chest was done to evaluate the cause of severe pulmonary hypertension unexplained by SAM which revealed chronic pulmonary thromboembolism. Surgical resection was deferred due to high risk. Hence, he was kept on anticoagulation for pulmonary thromboembolism, and aspirin and a statin for non-obstructive coronary artery disease. Over the course of two months, his symptoms improved. This case highlights the importance of evaluating different causes of pulmonary hypertension in patients with SAM.