Dual Left Anterior Descending Artery: Clinical Overview and Interventional Management.

Congenital coronary artery anomalies are relatively rare, occurring in approximately 0.6%-1.3% of cases undergoing coronary angiography. Among these anomalies, a unique cardiac abnormality known as a dual left anterior descending artery (LAD) stands out. A dual LAD is characterized by the presence of 2 LADs in the anterior interventricular sulcus. This structural deviation consists of a shorter LAD that terminates high in the anterior interventricular sulcus and a longer LAD that extends to the distal sulcus, supplying blood to the cardiac apex. Percutaneous procedures on dual LADs are even less frequent. We describe a 53-year-old woman with typical burning chest pain, ST-elevation in leads I and aVL, and positive troponin I enzyme. Coronary angiography revealed a thrombotic lesion with 99% stenosis at the proximal part of the LAD. The main LAD originated properly from the left coronary cusp, and the remainder of its course was supplied by a second branch originating from the right coronary cusp. Computed tomography angiography and echocardiography were performed for the LAD course. The patient was discharged after an uneventful 1-week hospital stay. Our case is particularly noteworthy for several reasons. Firstly, this dual LAD anomaly is uncommon, and patients with dual LADs less frequently have a ramus artery. Secondly, there have been only a few documented cases of percutaneous transluminal coronary angioplasty performed on short LADs. The key takeaway from this scintillating case study is the significance of identifying the artery responsible for blood supply to the cardiac apex.

Conventional and two-dimensional strain echocardiography in predicting postoperative atrial fibrillation after coronary artery bypass grafting surgery.

Background: Atrial fibrillation (AF) is a common complication after heart surgeries. Advances in imaging technologies and an understanding of the pathophysiology of preoperative left atrial (LA) dysfunction can lead to more definitive potential therapeutic approaches. This study aimed to determine the role of conventional echocardiography and LA two-dimensional (2D) strain echocardiography in assessing LA function and predicting POAF after CABG surgery. Methods: All patients with sinus rhythm who underwent CABG surgery were enrolled. All the patients had undergone conventional echocardiography and LA 2D-strain echocardiography 24 hours before surgery. In addition to demographic, clinical, and perioperative features, electrocardiogram (ECG) and Holter monitoring were recorded. Results: Of the 105 patients included, 85 patients (81%) were men with a mean age of 60.26±10.61 years. POAF was seen in 22.9% of patients during hospitalization, and AF duration was 10 hours (median; IQR: 2.0-19.5). AF patients had a higher LA volume index (LAVI) than patients with sinus rhythm (p=0.018). Patients with sinus rhythm had higher rates of LA reservoir (26.97±6.87 VS. 20.46±4.27, p<0.001), LA contractile (14.98±3.68 VS. 12.76±3.72, p =0.012) and LA global strain (24.28±6.57 VS. 17.71±4.11, p<0.001) than AF patients. The results of the multivariate logistic regression showed that LAVI (p=0.014) and LA global strain (p=0.027) were independent predictors of AF detection. Conclusion: Compared to conventional echocardiography, 2D-strain echocardiography is a more effective diagnostic method to predict the possibility of post-CABG AF.

Accessory Mitral Valve Misdiagnosed as Vegetation: A Case Report.

An accessory mitral valve (AMV) is a rare anomaly of the mitral valve (MV) that often causes left ventricular outflow tract (LVOT) obstruction. We describe a young woman presenting with infrequent palpitations to our outpatient clinic. She was evaluated for mid-systolic murmur at the left sternal border. At the initial transthoracic echocardiography, vegetation on the MV was suspected. The patient was referred to our advanced echocardiography lab, where transesophageal echocardiography revealed an AMV with mild LVOT obstruction. The findings, along with extensive laboratory tests, ruled out vegetation. Additionally, she had a bicuspid aortic valve. At follow-up after 1 year, the patient was asymptomatic regarding the AMV with LVOT obstruction, and the repeat echocardiography depicted no changes compared with the previous echocardiography. Distinguishing AMVs from other MV masses, including vegetation, sometimes poses a challenge and can lead to unnecessary diagnostic and therapeutic measures. This rare MV anomaly is associated with bicuspid aortic valves.

Incomplete Removal and Accidental Retention of Temporary Epicardial Pacing Wires in the Chest after Heart Surgery: A Case Report.

Temporary pacemaker wires are commonly used for the diagnosis and treatment of arrhythmias in the acute postoperative period. We herein describe a 65-year-old woman with a history of coronary artery bypass graft surgery who was referred to the hospital with a purulent discharge in the lower third of the sternal region while on antibiotics. Two years later, following treatment failure, 2 sternal wires were removed. Several years after the surgery, the patient developed a purulent discharge. On suspicion of rib osteomyelitis, the last left cartilage attached to the sternum was excised and removed together with an infectious tract. During the operation, the right ventricle was torn, and tampons were used to control bleeding. The patient was placed under cardiopulmonary bypass via the cannulation of the left femoral artery and the right femoral vein. The sternum was opened, and the rupture site was repaired. A temporary epicardial pacing wire was found at the site of the right ventricular rupture. Several days later, the patient was taken from the intensive care unit to the operating room due to a pulsatile hematoma in the left groin and a diagnosis of a pseudoaneurysm of the femoral artery. After a week, the purulent discharge at the lower sternum improved, and the patient was discharged. At 1 month's post-discharge follow-up, the infection was eradicated.

Percutaneous Balloon Mitral Valvuloplasty and Early Right Atrial Clot Formation: A Case Report.

Percutaneous balloon mitral valvuloplasty (PBMV) has recently become the treatment of choice for many patients suffering from mitral stenosis. In the current report, we introduce a 26-year-old woman who presented to us with palpitation and exertional dyspnea but without any remarkable medical history. ECG illustrated the sinus rhythm, transthoracic echocardiography (TTE) showed severe rheumatic mitral stenosis and (2+) mitral regurgitation, and transesophageal echocardiography (TEE) demonstrated severe mitral stenosis and no thrombus. Accordingly, the patient underwent percutaneous transvenous mitral commissurotomy (PTMC). On the following day, TTE showed a fresh mobile thrombus in the right atrium attached to the atrial septum, which was confirmed by TEE. As a result, the patient received 1 mg/kg (60 mg) of enoxaparin subcutaneously twice daily plus 5 mg of warfarin daily. Subsequent TTE revealed no mass 4 days after the treatment. Evidence suggests that endocardial surface injury and trans-septal puncture during PTMC may be associated with clot formation, which is aggravated by low blood flow in the right atrium and the catheter as a foreign body. This case report emphasizes the importance of post-PTMC anticoagulant therapy.

Higher Frequency of Nocturnal Blood Pressure Dipping but Not Heart Rate Dipping in Inflammatory Bowel Disease.

BACKGROUND: Masked hypertension (MHTN) and lack of nocturnal dipping in blood pressure (BP) have been linked to the state of inflammation. AIMS: We aimed to assess the frequency of nocturnal patterns of BP and heart rate (HR) in patients with IBD. METHODS: Sixty-three normotensive patients with confirmed IBD during remission and 63 healthy subjects were enrolled in a case-control study. All subjects were monitored for BP and HR over a period of 24 h under ambulatory setting. Means for BP and HR were calculated for nighttime and daytime periods. Daytime BP ≥ 135/85 mmHg, nighttime BP ≥ 120/70 mmHg, and 24-h average BP ≥ 130/80 mmHg were defined as MHTN. The main end points of this study were lack of >10% nocturnal decrease in the systolic BP (NDP-BP) and in HR (NDP-HR). RESULTS: After exclusion of 8 patients with IBD from analysis, 55 patients and 63 control subjects (49% men) with a mean age of 37.5 ± 11.0 years were enrolled. NDP-BP was more common in the IBD group compared to controls (55 vs. 33%; P = 0.026). MHTN was detected in 24% of IBD patients compared to 8% among controls (P = 0.017). Meanwhile, NDP-HR was observed in 22% of the IBD patients and 30% of the control group (P = 0.402). IBD remained a significant predictor of NDP-BP (odds ratio 2.60, 95% confidence interval 1.19-5.51) following an adjustment for age and gender. CONCLUSIONS: IBD is associated with higher frequency of NDP-BP and MHTN; however, nocturnal changes in HR were similar in both groups.