A case of transcatheter prosthetic aortic valve endocarditis.

Transcatheter aortic valve implantation (TAVR) constitutes an established treatment in inoperable or high perioperative risk patients with severe aortic stenosis. Prosthetic valve endocarditis after ΤΑVR occurs with an incidence of 0.3-1% per patient-year. Infective endocarditis may stem from hematogenous dissemination or contact with infected adherent tissue. Few cases of infective endocarditis after TAVR have been reported. We present an interesting case of a 79-year-old male with a history of severe aortic stenosis status post TAVR greater than one year ago, and pulmonary vein isolation for atrial fibrillation six weeks ago was found to have infective endocarditis with a vegetation on the prosthetic valve leading to multiple embolic strokes as a result of Enterococcus faecalis bacteremia. The patient was not a surgical candidate with his Society of Thoracic Surgery (STS) risk score being 18%; therefore, he was managed conservatively on intravenous antibiotics. Our case had endocarditis from enterococcus bacteremia; however, the patient never had any gastrointestinal or genitourinary procedure.

A rare case of adult congenital heart disease: single ventricular chamber with anomalous right coronary artery in an octogenarian.

Patients with single-ventricle physiology encompass a wide array of anatomic subtypes, including but not limited to: tricuspid atresia, hypoplastic left heart syndrome, double-outlet or double-inlet ventricles. The outcomes for patients with single ventricle born before 1990 are relatively poor. An 81-year-old female presented to the hospital as non-ST elevation myocardial infarction. She was started on antiplatelet and anticoagulation. Echocardiogram revealed a single ventricle which was thought to be left ventricle with possible transposition of great vessels. Angiography was performed that identified the single ventricle and anomalous origin of the right coronary artery (RCA). She was also found to have double vessel coronary artery disease with diffuse stenosis of mid-RCA at 80% and proximal circumflex at 95%. She was managed conservatively as was high risk for CABG given her rare congenital condition. Patients with single ventricle are at risk of long-term morbidity, including heart failure, neurological injury, and early death. The mortality risk of these patients is high as most of the patients without corrective surgery do not proceed to adulthood. Our case had multivessel coronary artery stenosis along with a rare presentation of congenital heart disease in adulthood. The patient was offered percutaneous coronary intervention, but she declined and chose to be treated conservatively with only medical management. We present a rare case of an elderly female surviving with a single ventricular chamber. The patient is an exception to the usual process of the pathology as most patients without corrective surgery seldom survive into adulthood.

An entire coronary system arising from right coronary cusp: a rare anomaly.

The prevalence of coronary artery anomalies is approximately 0.6% in individuals undergoing angiography. Most of the anomalies are benign, but some can lead to myocardial infarction, cardiomyopathy, and sudden cardiac death. It is very rare to have an entire coronary circulation that arises from the right coronary cusp. We present a case of a 57-year-old male who presented with complaints of chest pain and dyspnea on exertion. An invasive angiogram revealed all the three coronary arteries originating from the right coronary cusp. It is crucial to define coronary anatomy as anomalies dictate which cardiac intervention should be attempted in cases of ischemia.

Congenital anomaly of coronary artery: absence of left circumflex artery.

The prevalence of congenital coronary artery anomalies is approximately 1% in the general population. They are a common cause of sudden death in younger persons. Congenital absence of the left circumflex artery is usually a benign condition but can cause symptoms of exertional angina. We present a case of a 59-year-old female who presented with complaints of chest pain. She was evaluated by the cardiology service. An invasive angiogram identified the absence of the circumflex artery, a large right coronary artery, and large septal and diagonal branches of the left main coronary artery possibly as a compensatory mechanism to supply blood to the LCx territories. It is important to define coronary anatomy as anomalies dictate which cardiac intervention should be attempted in cases of ischemia.

Spontaneous Coronary Artery Dissection Masquerading as Coronary Artery Stenosis in a Young Patient.

BACKGROUND Spontaneous coronary artery dissection (SCAD) is primarily found in females. SCAD can have many precipitating factors such as exercise, trauma, pregnancy, drugs, and connective tissue disease. Prognosis is poor for left main stem, left anterior descending (LAD) artery, and multivessel involvement, especially for females. CASE REPORT We present a case of young African American male with sickle cell disease who presented with chest pain associated with shortness of breath. He was found to have non-ST elevation myocardial infarction (NSTEMI). He was diagnosed with SCAD during catheterization with the help of intravascular ultrasound imaging. Three drug-eluting stents were placed to cover the proximal LAD vessel along its whole length until resolution of the lesion. The patients' hospital course was complicated by an additional finding of left ventricular thrombus, possibly a complication of NSTEMI, which was treated with anticoagulation to complete resolution. CONCLUSIONS SCAD is fatal, it can proceed to cause myocardial infarction as in this particular patient's case, and sudden death if not recognized early. It can be missed on angiography alone; further intracoronary imaging such as intravascular ultrasound and optical computed tomography should be used to confirm the diagnosis of SCAD so that early and appropriate treatment can ensue.

Aortoesophageal Fistula: A Fatal Complication of Thoracic Endovascular Aortic Stent-Graft Placement.

BACKGROUND Hemetemesis is rarely caused by an aorta-esophageal fistula with thoracic aorta aneurysm in patients. This uncommon etiology, AEF/TAA, can potentially rupture and cause death if left untreated. Thoracic endovascular aorta repair places a stent-graft to seal the aneurysm and cover the fistulous track. Open surgical repair is associated with high risk of morbidity and mortality; therefore, TEVAR is a much safer alternative to it. However, recurrent or persistent infection remains a major concern with TEVAR for AEF. CASE REPORT We present a rare case of an 80-year-old woman who presented with complaints of hemetemesis and epigastric pain. The patient underwent a computerized tomography scan, highlighting a TAA and AEF. A stent was placed in the descending thoracic aorta via endovascular approach and a subsequent EGD was negative for any residual bleeding. Methicillin-resistant Staphylococcus aureus was isolated from the patient's sputum cultures and she was treated with a prolonged course of antibiotics. She presented to the hospital a few weeks later with new-onset hematemesis. Workup identified an AEF. The patient was high risk for open surgical repair due to her comorbid conditions; therefore, an esophageal stent was placed. She was diagnosed with AEF secondary to an infected endovascular thoracic aorta stent. CONCLUSIONS Patients who are high risk for open surgical repair from immediate rupture of TAA with AEF can benefit from use of the TEVAR approach. The stent itself is a foreign body; therefore, the risk of infection persists. AEF is a rare but potentially fatal complication of the infected thoracic aortic stent itself.

Anomalous Origin of a Right Coronary Artery from Pulmonary Artery.

Congenital defects of the coronary arteries are noted in 0.2-1.4% of the general population. The first case of an anomalous origin of right coronary artery from pulmonary artery (ARCAPA) was described by Brooks in 1885. ARCAPA has an overall incidence of 0.002% in the general population. Most of the cases are asymptomatic; however, it can lead to serious complications such as heart failure, ischemia, and sudden death. A 57-year-old man presented to the cardiologist's office with complaints of shortness of breath and fatigue. The patient also had a previous history of coronary stents and heart failure. Initially, he was evaluated with a stress test which was reported as abnormal. The patient then underwent an invasive coronary angiography that revealed anomalous origin of the right coronary artery (RCA) and multivessel disease. Cardiothoracic surgery evaluated the patient and coronary artery bypass graft was performed. During the surgery, the anomalous origin of RCA from the pulmonary artery was identified and was successfully corrected by reimplanting the RCA into the ascending aorta. The anomalous origin of RCA is a rare yet life-threatening condition. The RCA due to its location of origin from the pulmonary artery tends to be a low-pressure vessel with a very thin and fragile wall. It also serves as a retrograde venous conduit from the left coronary circulation into the pulmonary artery. This connection results in a left-to-right shunt that explains the increase in oxygen saturation in the pulmonary artery and the high cardiac output which is normally seen in these cases. The clinical presentation can vary from coronary ischemia to heart failure or sudden death. Therefore, surgical correction is recommended even in asymptomatic patients. We present a case of an anomalous origin of RCA from the pulmonary artery which, unlike the origin of left coronary from pulmonary artery, is very rare. Patients with this condition should have early correction even if they are asymptomatic in order to prevent long-term complications.

CASE REPORT Anomalies Associated With Congenitally Corrected Transposition of Great Arteries: Expect the Unexpected.

OBJECTIVE: Congenitally corrected transposition of great arteries (CCTGA) is characterized by atrioventricular and ventriculoarterial discordance. Characterizations of these anomalies are important because they may influence surgical approach and management. METHODS: We present a case of newly diagnosed CCTGA at the age of 50. He presented with sudden onset of shortness of breath for the first time and was diagnosed with CCTGA. Echocardiogram, magnetic resonance imaging, and cardiac catheterization were utilized to elucidate the pathology. RESULTS: Intraoperatively, patient's CCTGA and ventricularization of the right ventricle were confirmed. The severe systemic atrioventricular valve regurgitation was replaced with a bioprosthetic valve (Medtronic Mosaic No. 29) with placement of epicardial ventricular leads for possible future placement of automatic implantable cardioverter defibrillators. Pathology report confirmed a degeneration of the systemic atrioventricular valve. CONCLUSIONS: Significant coronary artery anomalies have also been described in literature with CCTGA. The variances encountered in this case are excellent examples of the intricacies associated in diagnosis and surgical care in patients with CCTGA.