Arrhythmias of the Left Atrial Appendage: Approaches to the Definitive Management of Atrial Tachycardia from the LAA Stump.

The left atrial appendage (LAA) is now recognized as a significant contributor to arrhythmia and thromboembolism in patients with a history of atrial fibrillation. Thoracoscopic exclusion of the LAA is made possible with the AtriClip device. In this report, we describe the case of a 65-year-old man with history of multiple left atrial ablation procedures and LAA clipping. He developed a microreentrant atrial tachycardia originating from the anterior base of the LAA stump, underwent complete isolation of the LAA, and had subsequent resolution of arrhythmogenic activity from the residual LAA stump.

Inferior Wall ST-Elevation Myocardial Infarction Complicated by Left Ventricular Pseudoaneurysm, Cardiac Tamponade, and Partial Papillary Muscle Rupture.

Papillary muscle rupture (PMR) is a rare complication of myocardial infarction. Its incidence has been decreasing nowadays because of improved early revascularization techniques. When it occurs, surgical treatment is the only therapeutic lifesaving approach. We report a case of an 85-year-old female patient who presented to the emergency room with chest pain. An electrocardiogram showed inferior wall ST-elevation myocardial infarction. The patient was revascularized emergently with a drug-eluting stent to the obtuse marginal artery. An intra-aortic balloon pump was inserted for hemodynamic support. Six hours later, the patient developed shortness of breath with persistent hypotension. A transthoracic echocardiogram (TTE) showed a large pericardial effusion with a pseudoaneurysm in the infero-septal apex. Immediate drainage of pericardial fluid was performed. Seventy-two hours later, the patient had flash pulmonary edema. A new severe eccentric mitral regurgitation was discovered on transesophageal echocardiography (TEE). Findings revealed a partial posteromedial papillary muscle tear and prolapse of the A2 scallop. The patient was not a candidate for surgical replacement or percutaneous repair due to the high surgical risk and poor functional status, and she passed away on day fifteen of her hospital stay. Limited case series have shown promising benefits of percutaneous edge-to-edge mitral valve repair in selected high surgical risk patients and as a bridge to definitive mitral valve replacement. A diagnosis of PMR should be in the differential diagnosis, especially when evaluating hemodynamically unstable patients who present with prolonged symptoms.

Patient-nephrologist prognostic awareness and discordance in end stage renal disease on renal replacement therapy.

PURPOSE: The 1-year mortality rate of patients with end-stage renal disease (ESRD) on renal replacement therapy (RRT) is 20-25% comparable to many cancers. Studies have shown that cancer patients commonly overestimate their likelihood of survival relative to their physicians. It is unclear if this translates into other terminal illnesses. METHODS: Adult and elderly patients with ESRD on RRT without cognitive defect were interviewed to evaluate their prognostic estimates at 1 and 5 years. Past medical history and demographic data was abstracted from their medical charts. Each patient's proper nephrologist was then interviewed regarding his proper prognostic estimate for this patient. Both the patient and the nephrologist's estimates were compared and a difference of greater than 20% was defined as the threshold for prognostic concordance. RESULTS: 77% of patients were found to be in prognostic discordance with their nephrologists. This group was older, had more comorbidities, a lower albumin level and a poorer prognosis. The majority of patients were in disagreement with their nephrologists regarding whether a discussion about prognosis had taken place. The choice of end of life care for 55% of patients was focused on relieving pain and discomfort. CONCLUSION: Communication of prognosis and discussions related to life expectancy and end of life care are lacking in the routine care of ESRD patients. ESRD patients therefore tend to overestimate their prognosis which might lead to overutilization of invasive procedures with increased acute healthcare costs as well as a delay in instigation of palliative or hospice measures.

Purulent Pericarditis Caused by Bacteroides fragilis: A Rare Complication of Cholangitis.

Bacterial infection is a rare cause of pericarditis especially in the post-antibiotic era. When compared to viral or idiopathic etiologies, purulent pericarditis carries a higher risk for complications. While most cases are due to Staphylococcus aureus, we present a rare case of pericarditis due to Bacteroides fragilis originating from a liver abscess and leading to pericardial effusion. Our case highlights the need to maintain a high clinical suspicion of bacterial infection when patients present with sepsis and have evidence of pericarditis.

A Plasma Cell Dyscrasia Presenting as Amyloid Cardiomyopathy and Autonomic Dysfunction in a Healthy Patient.

Systemic amyloidosis is a rare multisystem disease caused by incorrectly folded proteins that deposit pathologically in different tissues and organs of the human body. It has a very wide spectrum of clinical presentations according to the affected organ(s), and its diagnosis is commonly delayed. Cardiac involvement is the leading cause of morbidity and mortality and carries a poor prognosis, especially in primary light chain amyloidosis. Therefore any delay in the diagnosis can result in devastating outcomes for the patient. We report the case of a 65-year-old man who presented with dizziness and lightheadedness. He was found to have orthostatic hypotension and further investigations revealed the diagnosis of amyloid cardiomyopathy complicating a plasma cell dyscrasia. What is worth noting, in this case, is that the patient had cardiac amyloidosis presenting primarily as autonomic dysfunction and orthostatic hypotension, without any cardiac-specific symptoms such as heart failure or angina. This is a very unusual presentation of advanced-stage cardiac amyloidosis. This article highlights the variety of clinical presentations of cardiac amyloidosis, and focuses on the recent progress such as novel diagnostic and surveillance approaches using imaging, biomarkers, and new histological typing techniques. Current and future promising treatment options are also discussed, including methods directly targeting the amyloid deposits.

Utilization of the Impella for hemodynamic support during percutaneous intervention and cardiogenic shock: an insight.

INTRODUCTION: Impella is a catheter-based micro-axial flow pump placed across the aortic valve, and it is currently the only percutaneous left ventricular assist device approved for high-risk percutaneous coronary intervention and cardiogenic shock. Areas Covered: Even though several studies have repeatedly demonstrated the excellent hemodynamic profile of Impella in high-risk settings, it remains underutilized. Here we aim to provide an up-to-date summary of the available literature on Impellas use in High risk settings as well as the practical aspects of its usage. Expert Commentary: Percutaneous coronary interventions in high rsk settings have always been challenging for a physician. Impella 2.5 and CP, have been proven safe, cost effective and feasible in High Risk Percutaneous coronary Interventions with an excellent hemodynamic profile.

Persistence of a Cervical Neck Mass, Not Just the Lymphoma.

Actinomycosis is a rare, chronic granulomatous infection caused by gram-positive, anaerobic to microaerophilic branching filamentous bacteria. In the cervicofacial region, it usually presents as an enlarging neck mass. It remains a diagnostic challenge due to the fact that cultures show no growth in more than 50% of cases. We report a case of a 67-year-old patient known to have a neck mass secondary to lymphoma in which the neck mass persisted despite therapy. Upon evaluation, the diagnosis of culture-negative actinomycosis was based on histopathology findings, and the patient received antibiotic therapy. We will discuss the diagnosis and pathology of actinomycosis, attempting to explore the relationship between actinomycosis and lymphoid malignancy.

Surgical Treatment of an Isolated Metastatic Myocardial Neuroendocrine Tumor.

We describe a patient diagnosed with a neuroendocrine tumor of the small intestine metastatic to the heart who underwent successful cardiac metastasectomy. The tumor was located on the right ventricle free wall, obstructing the right ventricular outflow tract. There was no valvular involvement.

Charge separation and photocurrent polarity-switching at CdS quantum dots assembly in polyelectrolyte interfaced with hole scavengers.

Significant charge separation and potential-dependent photocurrent polarity switching are reported at multilayers of polyacrylate-capped CdS quantum dots (Q-CdS, d = 3.6 +/-0.5 nm) assembled in poly(diallydimethylammonium chloride) with an alkaline sulfide solution interface. The films were deposited by dip self-assembly or dip-spin self-assembly, and photocurrents were enhanced up to 2-fold by the latter method and reached a maximum at 4-6 bilayers. The monochromatic incident-photon-to-current-conversion efficiency equalled 6.5% at 340 nm and 2.1% at 440 nm at a 6-bilayer film in the sulfide electrolyte. The photocurrent magnitude and direction were found to depend on the assembly method, number of bilayers, film history, electrode potential and solution redox species. While significant anodic and cathodic photocurrents were measured in sulfide, the film acted predominantly as a photocathode in the presence of another hole scavenger, ascorbic acid. Charge separation leading to a cathodic photocurrent in the presence of hole scavengers is possibly mediated by a photo-oxidized species in the multilayers, which facilitates net photogenerated hole transfer to the electrode at reducing potentials.