Cardiac troponin I elevation after orogenital sex during pregnancy.

BACKGROUND: Venous air embolism due to orogenital sex in pregnancy is an uncommon clinical event. CASE: A previously healthy, 29-week pregnant woman presented to the emergency room unconscious 1 hour after engaging in orogenital sex with her partner. The cardiology service was consulted due to troponin elevation. Assessment was that the patient had likely suffered an air embolism with associated troponin leak. CONCLUSION: Although a rare clinical event, air embolism from air insufflation of the vagina can result in troponin elevation and should be considered in the differential diagnosis in pregnant patients with a history of orogenital sex.

Morquio's syndrome: severe aortic regurgitation and late pulmonary autograft failure.

A 44-year-old woman underwent a Ross procedure for severe aortic regurgitation at the age of 32 years. She had been diagnosed in childhood with spondyloepiphyseal dysplasia and a bicuspid aortic valve. At surgery, a tricuspid aortic valve with chondroid metaplasia and fibrosis was reported. Biochemical and genetic evaluation in this patient confirmed the diagnosis of mucopolysaccharidosis IV type B (MPS IV), otherwise known as Morquio's syndrome. This autosomal-recessive inherited syndrome is characterized by the accumulation of keratin sulfate in connective tissue and various other organs. Cardiac (notably valvular) involvement has been well described in the literature. To the authors' knowledge, this is the first reported case of valve replacement or Ross procedure for this condition. This woman presented 12 years after her initial valve surgery with progressive dyspnea. Echocardiographic examination revealed severe pulmonic autograft regurgitation without a dilated aortic root, together with severe stenosis of the pulmonary homograft. It is postulated that the underlying metabolic abnormality may have led to progressive pulmonary autograft failure and to accelerated dysfunction and stenosis of the pulmonary homograft. It is likely that a mechanical prosthesis would have been a better therapeutic option if the preoperative diagnosis of MPS IV had been made.

The bicuspid aortic valve.

The bicuspid aortic valve affects 1 to 2% of the population and may be complicated by aortic stenosis or aortic insufficiency and infective endocarditis. The bicuspid aortic valve is associated with abnormalities of the aortic wall such as coarctation of the aorta, aortic dissection, and aortic aneurysm. Most patients with a bicuspid aortic valve will develop some complication during life. Individuals with a bicuspid valve may be unaware of its presence and are at risk for unsuspected complications. Aortic wall abnormalities associated with bicuspid aortic valve are due to cystic medial necrosis. This process is associated with increased metalloproteinase activity and apoptosis of vascular smooth muscle cells. The clinical correlates of aortopathy in the bicuspid aortic valve include significant enlargement of the ascending aorta with aneurysm formation and dissection. This process continues after valve replacement. The person with bicuspid aortic valve requires continuous surveillance to treat associated lesions and prevent complications.

Systemic amyloidosis associated with pleomorphic sarcoma of the spleen and remission of nephrotic syndrome after removal of the tumor.

We report a case of a 57-year-old woman who was diagnosed with a systemic AA amyloidosis associated with a pleomorphic sarcoma of the spleen. Although the association and causality between chronic inflammatory states and systemic AA amyloidosis have been well established, the evidence linking solid malignancies to reactive AA amyloidosis is scarce. Our patient had a significant systemic amyloid deposition including biopsy-proven renal and cardiac AA amyloidosis. Subsequent evaluation uncovered the presence of a large splenic mass, which was treated by splenectomy. Histologically the splenic tumor was classified as pleomorphic sarcoma. The removal of the tumor resulted in a marked decline in proteinuria, stable renal and cardiac functions, and symptomatic improvement at 1-year follow-up. Based on the noted improvements, we speculate that the pleomorphic sarcoma of the spleen caused secondary amyloidosis in our case. Stromal tumors, although rare, may be associated with and should be considered in the differential diagnosis of the cause of AA amyloidosis.

Noninvasive evaluation of a cutting balloon entrapped in a left main coronary artery using transesophageal echocardiography.

There are reports in the literature describing the utility of transesophageal echocardiography (TEE) in the evaluation of the coronary arteries. Studies have also shown the value of TEE in patients undergoing coronary intervention such as assessing coronary anatomy and flow following angioplasty. We report an interesting case where TEE helped to establish the location of a fractured cutting balloon device lodged in the left main coronary artery and obviated the need for cardiac surgery to remove the fractured balloon catheter. To our knowledge, this is the first case report of this type of complication utilizing a cutting balloon device.

Infective endocarditis resulting from CardioSEAL closure of a patent foramen ovale.

Patent foramen ovale and atrial septal aneurysm are associated with an increased risk of cryptogenic stroke and recurrent thromboembolic events. Percutaneous closure is a therapeutic option to medical therapy and surgical closure. We present the first case of endocarditis associated with a CardioSEAL device closing a patent foramen ovale.