Right Atrial Thrombus Masquerading as Myxoma.

Introduction: In-situ right atrial (RA) thrombus is a rare occurrence typically associated with heightened inflammatory or hypercoagulable states. Here, we present a case of in-situ RA thrombus mimicking atrial myxoma in a patient with sepsis and bacteraemia. Case description: A 41-year-old man presented with septic arthritis and bacteraemia caused by methicillin-resistant Staphylococcus aureus (MRSA). A transoesophageal echocardiogram revealed a large pediculated mass resembling atrial myxoma, which was not visible on transthoracic echocardiography performed four days earlier. Cardiac magnetic resonance (CMR) imaging strongly suggested a thrombus, leading to the patient undergoing transcatheter aspiration. Subsequent pathology confirmed an organised fibrin thrombus without evidence of infection. Discussion: The patient's in-situ RA thrombus likely developed in response to a heightened inflammatory state associated with sepsis. Limited data exist on in-situ RA thrombi in the absence of atrial fibrillation, though some reports suggest a correlation between heightened inflammation and a hypercoagulable state. Conclusion: CMR imaging is invaluable for characterising such masses and can aid in distinguishing a thrombus from a myxoma. LEARNING POINTS: Differentiating right atrial (RA) thrombus from myxoma: cardiac magnetic resonance imaging is essential for distinguishing RA thrombus from myxoma, preventing unnecessary surgeries.Hypercoagulable and inflammatory states: spontaneous in-situ RA thrombi can occur without deep vein thrombosis (DVT) or atrial fibrillation, especially in hypercoagulable and inflammatory conditions.Transcatheter aspiration: this less invasive alternative to surgery is effective for large, mobile RA thrombi, reducing embolisation risk.

Menopause, epicardial adiposity and preserved ejection fraction heart failure.

Postmenopausal women are overrepresented in the preserved ejection heart failure population. Expansion of visceral and epicardial adipose tissue during the menopause transition leads to local and low-grade systemic inflammation that in turn contributes to left ventricular concentric remodeling, diastolic dysfunction and the development and progression of preserved ejection fraction. In contrast to visceral adipose tissue imaging, epicardial adipose tissue can be inexpensively imaged on low radiation coronary calcium score computerized tomography examination. The menopause transition provides a unique time frame to evaluate the contribution of epicardial adipose tissue expansion to the pathogenesis of preserved ejection heart failure.

Mitral Annular Calcification-Related Valvular Disease: A Challenging Entity.

Mitral valve annular calcification-related valvular disease is increasingly common due to the rising prevalence of age-related mitral annular calcifications. Mitral annular calcification alters the structure and function of the mitral valve annulus, which in turn causes mitral valve regurgitation, stenosis, or both. As it frequently coexists with comorbid conditions and overlapping symptoms, mitral annular calcification-related valvular disease poses significant diagnostic and therapeutic challenges. For instance, left ventricular diastolic dysfunction hinders the assessment of mitral valvular disease. Detection of mitral annular calcifications and assessment of related mitral valve disease hinge on two-dimensional echocardiography. Comprehensive assessment of mitral annular calcifications and related mitral valve disease may require multidetector computed tomography and three-dimensional echocardiography. Invasive hemodynamic testing with exercise helps identify the cause of symptoms in patients with comorbid conditions, and transcatheter interventions have emerged as a viable therapeutic option for older patients. After an outline of the normal mitral annulus, we examine how mitral annular calcifications lead to mitral valve disease and how to accurately assess mitral regurgitation and stenosis. Lastly, we review surgical and transcatheter approaches to the management of mitral annular calcification-related mitral valve regurgitation, stenosis, or both.

Predictability of Inpatient Mortality of Different Comorbidities in Both Types of Acute Decompensated Heart Failure: Analysis of National Inpatient Sample.

BACKGROUND: Several prediction models have been proposed to assess the short outcomes and in-hospital mortality among patients with heart failure (HF). Several variables were used in common among those models. We sought to focus on other, yet important risk factors that can predict outcomes. We also sought to stratify patients based on ejection fraction, matching both groups with different risk factors. METHODS: We conducted a retrospective cohort study utilizing the Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS) 2016 database. RESULTS: There were totally 116,189 admissions for acute decompensated heart failure (ADHF). Of these, 50.9% were for heart failure with reduced ejection fraction (HFrEF) group (n = 59,195), and 49.1% were for heart failure with preserved ejection faction (HFpEF) group (n = 56,994). Overall, in-hospital mortality was 2.5% of admissions for ADHF (n = 2,869). When stratified by HF types, admissions for HFrEF had higher mortality rate (2.7%, n = 1,594) in comparison to admissions for HFpEF (2.2%, n = 1,275) (P < 0.001). Significantly associated variables in univariate analyses were age, race, hypertension, diabetes mellitus, chronic kidney disease (CKD), atrial fibrillation/flutter, obesity, and chronic ischemic heart disease (IHD), while gender and chronic obstructive pulmonary disease (COPD) did not achieve statistical significance (P > 0.1). CONCLUSIONS: To our knowledge, this is the first study to stratify HF patients based on ejection fraction and utilizing different predictors and in-hospital mortality. These and other data support the need for future research to utilize these predictors to create more accurate models in the future.

Prosthetic mitral valve Aspergillus fumigatus endocarditis.

Aspergillus endocarditis is a fatal source of valvular infection with a near 100 % mortality rate if pharmacotherapy and valve-replacement surgery are not initiated swiftly after diagnosis. Complicating its diagnosis is the low yield for growth on standard blood culture and time requirements for molecular diagnostic tools to return a result. Aspergillus endocarditis of the mitral valve presents as valvular vegetations that reduce the caliber of the mitral valve and can cause syncope as in the case of mitral stenosis with subsequent valve failure, left atrial enlargement, and prospective cardiovascular failure. Reports of the management of Aspergillus endocarditis after serial mitral valve replacement are not prominent in the literature. We report the case of a 41-year-old female with previous mitral valve prosthesis who received a second prosthetic mitral valve after a syncopal episode. Vegetations resembling thrombi were noted on transesophageal echocardiogram, diagnosed as Aspergillus fumigatus endocarditis, and successfully treated with antifungal therapy in conjunction with removal of her dysfunctional prosthesis.

ST Elevation Myocardial Infarction as Presenting Feature of C-ANCA Vasculitis: A Case of a Diagnostic Dilemma.

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS). Although uncommon, it should be included in the differential diagnosis for middle-aged patients without elevated atherosclerotic vascular disease risk or a family history of cardiovascular disease. SCAD is associated with postpartum women; however, reports noting its association with autoimmune disease and vasculopathy in other populations have recently gained prominence. We report a case of a 41-year-old male who was found to have SCAD after presenting with ST segment elevation myocardial infarction in the context of episodic vision loss, and who later underwent work-up for C-ANCA vasculitis and was successfully treated with corticosteroids. LEARNING POINTS: SCAD is most common in middle-aged females. However, it can present in male patients, and it should raise suspicion of underlying vasculopathy.Eosinophilic vasculitis may mimic parasitic infection.C-ANCA vasculitis can be associated with SCAD.

Influenza: National Trends Using the National Inpatient Sample Database from 1993 to 2015.

Background There is a significant impact of influenza on individuals, families, and societies both economically and clinically. This significant impact is a result of hospital admissions, medication expenses, side effects, secondary bacterial infections, and more days off from work or other forms of reduced productivity for the patients or their caretakers. Our objective is to present the trends in the rate of hospital discharges per 100,000 population from the years 1993 through 2015, the mean age, and the inpatient mortality rate. Methods This is a retrospective study utilizing the National Inpatient Sample (NIS) from 1993 through 2015. Discharges due to influenza from 1993 to 2015 were identified, and the rate of discharges per 100,000 population, inpatient mortality, and mean age of discharged patients were trended. Linear regression was used to assess if the deviation from horizontal was statistically significant for the trends of the rate of discharges per 100,000 population, mean age, and percentage of the inpatient mortality. Result The mean age and inpatient mortality vary from year to year. The linear regression analysis for the trends was not statistically significant, and for the percentage of the inpatient mortality, the deviation from horizontal was not significant, P-value 0.75 and F-value: 0.09. Similarly, for the mean age, the deviation from horizontal was not significant with a P-value of 0.97 and an F-value of 0.001. However, the linear regression analysis for the rate of discharges per 100,000 population was remarkable for a statistically significant deviation from the horizontal with a P-value of 0.0002 and an F value of 19.5. Conclusion Recent advancements in influenza detection have made the detection feasible, quick, and cost-effective. However, the role of these advanced modalities on the outcome is still controversial. Our analysis revealed a significant increase in the rate of discharges due to influenza, but there was no significant change in the parentage of the inpatient mortality over the years between 1993 - 2015. Advanced influenza virus detection tests are now recommended in both outpatient (including emergency department) and inpatient admissions. The recent increase in inpatient admissions could be due to better detection modalities. However, no change in the percentage of inpatient mortality makes the impact of these detection tests on the outcome questionable. A further prospective study is warranted to assess the impact of these tests on the outcome.

Emphysematous Gastritis in the Setting of Chronic Abdominal Pain.

Emphysematous gastritis is a rare but fatal variant of gastritis. It is caused by gastric wall invasion by gas-forming organisms. It follows disruption of gastric mucosal integrity by a variety of factors, most commonly caustic ingestion and alcohol abuse. Patients typically present with abdominal symptoms with features of septic shock. Emphysematous gastritis carries a high mortality rate warranting early intervention with supportive measures and broad-spectrum antibiotics. It is essential to consider this rare entity in the differential diagnosis of a patient presenting with abdominal pain as timely intervention is crucial for survival. LEARNING POINTS: Emphysematous gastritis is rare but important to keep in mind when evaluating patients with acute abdominal pain.Emphysematous gastritis is a serious condition which has a high mortality rate if not diagnosed early.