The Simultaneous Occurrence of Acute ST-Elevation Myocardial Infarction, Acute Ischemic Stroke, and Pulmonary Embolism.

Acute ST-elevation myocardial infarction (STEMI), acute ischemic stroke (AIS), and acute pulmonary embolism (PE) are life-threatening conditions, each posing a high risk of morbidity and mortality. When all three of these acute conditions occur simultaneously, the overall prognosis for the patient becomes considerably worse. We report a case of a 70-year-old woman who presented to the emergency department (ED) with a triad of acute STEMI, AIS, and PE as a consequence of atherosclerotic heart disease, atrial fibrillation, and a prolonged transatlantic flight. The diagnoses were promptly confirmed through emergent coronary and cerebral angiography, along with a computerized tomography pulmonary angiogram (CTPA). The patient underwent a combination of medical therapy and endovascular thrombectomy. However, she later developed a subarachnoid hemorrhage and eventually progressed to brain death.

Pseudoaneurysm Formation After "Preclose"-Assisted Impella Insertion in a Patient With Cardiogenic Shock.

The use of mechanical support devices such as the Impella CP (Abiomed, Danvers, MA) is a growing form of treatment for patients with cardiogenic shock (CS). Despite the increase in usage, there remains a dearth in literature regarding potential complications. Vascular complications such as pseudoaneurysms (PAs) are rare but important potential complications that can occur with use of the Impella. We present Impella-assisted percutaneous coronary intervention (PCI) in a patient with CS, "Preclosed" with the Perclose ProGlide (Abbott, Plymouth, MN) device complicated by development of a PA. A 62-year-old male patient with a history of diabetes and hypertension presented to our emergency room (ER) with chest pain and electrocardiogram (ECG) findings consistent with an acute anterior wall ST-elevation myocardial infarction (STEMI). This was further complicated by refractory CS. The patient was urgently taken to the cardiac catherization laboratory. After exchange of sequential dilators, a single Perclose device was used prior to the insertion of the Impella sheath. The patient then underwent a successful Impella-assisted PCI of his left anterior descending artery. Upon stabilization of hemodynamics, the patient was taken to the catheterization laboratory for Impella removal. After removal of Impella, imaging detected extravasation of contrast, without development of hematoma, later confirmed to be a PA via computed tomography (CT) scans and ultrasound Doppler imaging. The PA was successfully managed with injection of thrombin. The PA was likely caused by shearing forces of the dilators, the 14-F Impella sheath and foot of the device. We propose deploying the Perclose device earlier in the process of dilating the access site to avoid such complication. This is one of the first case reports that detail the occurrence and management of a PA with Impella insertion.

Pulmonary Embolism Complicated With Cardiopulmonary Arrest Treated With Combination of Thrombolytics and Aspiration Thrombectomy.

Systemic thrombolytic therapy is frequently used in the treatment of massive pulmonary embolism. We describe a case of pulseless electrical activity arrest, refractory obstructive shock in the setting of massive pulmonary embolism despite tissue plasminogen activator that was successfully treated with catheter-directed aspiration thrombectomy. (Level of Difficulty: Intermediate.).

Pathophysiologic mechanisms of lupus-induced myocardial injury elucidated by cardiovascular magnetic resonance imaging.

Various pathophysiologic mechanisms may account for lupus-induced myocardial injury. Understanding the distinctions in the underlying disease process helps recognize variable clinical presentations and implement appropriate therapies. This report describes lupus-induced myocardial injury in three men less than 40 years old with diverse pathophysiologic mechanisms and presentations including acute myopericarditis with microvascular obstruction, acute coronary syndrome (ACS) and chronic myocarditis with systolic heart failure. Cardiovascular magnetic resonance (CMR) helped define the mechanism of disease, which included evidence of coronary microvascular obstruction in a patient without epicardial coronary artery disease. These findings highlight the cardiovascular effects of lupus, reveal coronary microvascular obstruction as potential consequence of acute myocarditis, and demonstrate the application of CMR in assessing the extent of disease.

Left Ventricular Free Wall Rupture in Broken-Heart Syndrome: A Fatal Complication.

Takotsubo cardiomyopathy is usually a transient condition and is treated conservatively. It is rarely associated with ventricular free wall rupture, a fatal complication of the disease described in this report. Cardiothoracic surgery performed emergent ventricular wall repair; however, treatment was unsuccessful, and the patient expired.

Dengue fever as a cause of perimyocarditis and low-pressure cardiac tamponade.

We describe a case of dengue shock syndrome, perimyocarditis, and low-pressure cardiac tamponade following a trip to the Caribbean. The case was managed in the critical care unit and 6 weeks after discharge the patient was asymptomatic with a normal ejection fraction. Dengue fever presenting as cardiac tamponade is exceedingly rare and emphasizes the importance of taking a thorough travel history as well as being aware of atypical manifestations of rare diseases to make a correct diagnosis.

Postpartum Sudden Cardiac Death After Spontaneous Coronary Artery Dissection in a Patient With Fibromuscular Dysplasia.

Spontaneous coronary artery dissection (SCAD) is a rare entity that can cause acute myocardial infarction and sudden cardiac death (SCD) which often goes unrecognized. We report a case of SCAD in a young postpartum female who presented with sudden cardiac arrest. The patient was managed medically and found to have fibromuscular dysplasia (FMD). After being stabilized in the critical care unit, coronary angiography was performed which showed dissection of the left main artery, intramural hematoma, and the culprit lesion. Further investigation showed dissection of the left vertebral artery which was all consistent with a diagnosis of FMD. The patient was followed as an outpatient and a repeated coronary angiography demonstrated healed dissection site. In conclusion, this case exemplifies that prompt diagnosis along with medical management without the need of coronary artery bypass graft, and percutaneous coronary intervention can improve survival in SCAD.

Loperamide Induced Life Threatening Ventricular Arrhythmia.

Loperamide is over-the-counter antidiarrheal agent acting on peripherally located µ opioid receptors. It is gaining popularity among drug abusers as opioid substitute. We report a case of a 46-year-old male that was presented after cardiac arrest. After ruling out ischemia, cardiomyopathy, pulmonary embolism, central nervous system pathology, sepsis, and other drug toxicity, we found out that patient was using around 100 mg of Loperamide to control his chronic diarrhea presumably because of irritable bowel syndrome for last five years and consumed up to 200 mg of Loperamide daily for last two days before the cardiac arrest. We hypothesize that the patient's QTc prolongation and subsequent cardiac arrest are due to Loperamide toxicity. Patient experienced gradual resolution of tachyarrhythmia and gradual decrease in QTc interval during hospitalization which supports the evidence of causal relationship between Loperamide overdose and potentially fatal arrhythmias. It also provided the clue that patient may have congenital long QT syndrome which was unmasked by Loperamide causing ventricular arrhythmias. This case adds one more pearl in the literature to support that Loperamide overdose related cardiac toxicity does exist and it raises concerns over Loperamide abuse in the community.

ST segment elevation myocardial infarction of a rare aetiology: an unexpected diagnosis.

A 43-year-old man presenting with acute coronary syndrome with ST segment elevation myocardial infarction underwent urgent coronary angiography. During the intervention, the patient was found to have several multiple filling defects with dynamic obstruction in the left coronary circulation. Thrombectomy was performed on distal left anterior descending artery and 2nd diagonal artery lesions with balloon angioplasty, which was unsuccessful. Considering the dynamic obstruction in the angiogram, immediate imaging was performed for structural evaluation of the heart. Cardiac CT revealed a circumferential groove on the heart, suggesting an external compression leading to dynamic obstruction of the coronary arteries on angiogram. Cardiac hernia, a very rare aetiology, was suspected to be the culprit for the ST segment elevation myocardial infarction. Thoracoscopy was performed, which revealed congenital cardiac hernia and a fibrous pericardial band encircling the apex. A left mini thoracotomy was performed to release the constriction imposed over the heart, with improvement in circulation.

Real-time ultrasound guidance facilitates transradial access: RAUST (Radial Artery access with Ultrasound Trial).

OBJECTIVES: This study sought to assess the utility of ultrasound (US) guidance for transradial arterial access. BACKGROUND: US guidance has been demonstrated to facilitate vascular access, but has not been tested in a multicenter randomized fashion for transradial cardiac catheterization. METHODS: We conducted a prospective multicenter randomized controlled trial of 698 patients undergoing transradial cardiac catheterization. Patients were randomized to needle insertion with either palpation or real-time US guidance (351 palpation, 347 US). Primary endpoints were the number of forward attempts required for access, first-pass success rate, and time to access. RESULTS: The number of attempts was reduced with US guidance [mean: 1.65 ± 1.2 vs. 3.05 ± 3.4, p < 0.0001; median: 1 (interquartile range [IQR]: 1 to 2) vs. 2 (1 to 3), p < 0.0001] and the first-pass success rate improved (64.8% vs. 43.9%, p < 0.0001). The time to access was reduced (88 ± 78 s vs. 108 ± 112 s, p = 0.006; median: 64 [IQR: 45 to 94] s vs. 74 [IQR: 49 to 120] s, p = 0.01). Ten patients in the control group required crossover to US guidance after 5 min of failed palpation attempts with 8 of 10 (80%) having successful sheath insertion with US. The number of difficult access procedures was decreased with US guidance (2.4% vs. 18.6% for ≥5 attempts, p < 0.001; 3.7% vs. 6.8% for ≥5min, p = 0.07). No significant differences were observed in the rate of operator-reported spasm, patient pain scores following the procedure, or bleeding complications. CONCLUSIONS: Ultrasound guidance improves the success and efficiency of radial artery cannulation in patients presenting for transradial catheterization. (Radial Artery Access With Ultrasound Trial [RAUST]; NCT01605292).