Blue toe syndrome caused by emboli from anomalous left atrial septal pouch thrombus: a case report.

BACKGROUND: Left atrial septal pouches (LASPs) are a relatively newly described but common anatomical cardiac variant thought to be associated with atrial fibrillation (AF) and cardio-embolic stroke. Blue toe syndrome (BTS) describes ischemic changes in the toes due to microembolisation of the digital arteries. Establishing the etiology of BTS is vital so that the underlying cause can be treated. Here we describe the first case of BTS arising due to emboli from LASP thrombus arising on a background of new-onset AF. CASE PRESENTATION: A 65-year-old man presented with a two-day history of progressive painful swelling and bluish-purple discoloration of the second and fourth toes of his left foot and new-onset AF. Tests for hypercoagulability disorders were negative. Duplex ultrasound and CT angiography excluded deep venous thrombosis and an absence of embolus, thrombus, or occlusion in the arterial tree in the lower extremities bilaterally, so BTS was diagnosed. While transthoracic echocardiography and chest CT initially showed no cardiac abnormalities or mural thrombus, subsequent transesophageal echocardiography revealed a LASP with an associated pedunculated thrombus. The affected toes were amputated due to wet gangrene, but the patient recovered well with thrombus resolution after anticoagulation. CONCLUSION: The presence of a LASP in the absence of any other identifiable cause of BTS should trigger careful investigation of the interatrial septum, preferably using a multimodality imaging approach. The possibility that LASPs may not merely be an innocent bystander but a causative mechanism for peripheral ischemia must be considered.

Anomalous right coronary artery with interarterial course depicting an unusual case of an electrical storm: a case presentation.

BACKGROUND: The condition of anomalous aortic origin of the right coronary artery (AAORCA) with an interarterial course leads to few, if any, clinical problems. Malignant presentation of the often non-significant AAORCA associated with conduction system abnormalities is a rare finding. Surgical repair, even for highly symptomatic patients, is still controversial. However, in this case, the surgery brought a paradigm shift in treatment modality, improving the symptoms of this patient. CASE PRESENTATION: We report a case of a 52-year-old man with severe chest pain and recurrent electrical storms with an implanted cardiac resynchronization therapy defibrillator (CRT-D) device. Coronary angiography and computed tomography (CT) revealed the rare anomalous aortic origin of the right coronary artery (AAORCA) with a high interarterial course between the aorta and the pulmonary trunk. As symptoms typically develop on exertion, placing the patient at an increased risk of ischemic distress, a stress myocardial perfusion imaging study helped to identify his high-risk status. Although patient-specific, a surgical repair was the only concrete step agreed upon after multiple collaborative discussions with the cardiac surgeons. Surgery significantly improved the symptoms, with the patient reporting resolution of his chest pain, as well as no documented inappropriate defibrillator activity on follow-up appointments. CONCLUSION: One purpose of reporting the case study was to underscore the risk factors associated with AAORCA, challenging claims of its benign nature. This case complements existing findings demonstrating that ischemic distress consequent to the right coronary artery (RCA) compression may precede the rare incidence of an electrical storm. Importantly, the case-study emphasizes the significance of integrated multimodality imaging in clinical practice as well as providing real-world evidence for the efficacy of surgical repair in highly symptomatic patients with AAORCA with an interarterial course.

The Analysis of Surgical Outcomes in Operable Gastric Cancer Patients Presenting With or Without Sarcopenia.

We aimed to identify the patients with increased risk of post-operative complications using pre-operative sarcopenia as an indicator of adverse outcome in gastric cancer patients undergoing resection. This study was a prospective observational cohort study including patients with adenocarcinoma of stomach, undergoing gastric resection with curative intent. All the patient underwent pre-operative evaluation of sarcopenia including skeletal muscle index (SMI) measurements and hand grip strength (HGS) analysis. The post-operative parameters assessed were the time to initiate enteral feeding, the time to pass first flatus, post-operative complications, post-operative hospital stay, and histopathological staging of the resected specimen. All these parameters were compared between the sarcopenia and non-sarcopenia arms to obtain the final results. The total number of patients enrolled was 72 (46 male, 26 female). The mean SMI of the study cohort was 47.1 cm2/m2 and the mean HGS was 29.35 kg. Thirty-six patients (24 male, 12 female) were sarcopenic pre-operatively. Sixty-two patients underwent subtotal gastrectomy with D2 lymphadenectomy, and 10 patients underwent total gastrectomy with D2 lymphadenectomy. The median time to pass flatus was 4 days, the median time to initiation of enteral feeding was 4 days, and the median post-operative hospital stay was 12 days. Majority of the study patients had a pT3N1-2 disease. Sarcopenia was significantly associated with worsening ECOG performance status (p = 0.001), delay in passage of first flatus post-operatively (p = 0.017), higher post-operative complications (p = 0.012), higher T stage (p = 0.040), and higher N stage (p = 0.001). But there was no significant association between sarcopenia and time to initiation of enteral feeding and post-operative hospital stay. Sarcopenia is an independent prognostic factor for adverse short-term post-operative outcomes in patients undergoing curative intent resection of gastric cancer.

A valuable cardiac magnetic resonance investigation after MINOCA/takotsubo Syndrome: a case report.

Myocardial infarction with non-obstructive coronary arteries is a working diagnosis that includes takotsubo cardiomyopathy/syndrome (TTS). Cardiac magnetic resonance (CMR) is useful for establishing the underlying aetiology of myocardial infarction with non-obstructive coronary arteries during the acute phase, but its role in follow-up is less well established. A 35-year-old man with several cardiac risk factors presented 3 days after his sister's death with biochemical and clinical features of acute myocardial infarction without coronary artery obstruction on angiography but with diagnostic features of TTS on CMR, including oedema but no late gadolinium enhancement. Subsequent CMR 3 months later revealed left ventricular late gadolinium enhancement suggesting previous acute myocardial infarction. Although the initial diagnosis of TTS was robust according to established criteria, it remained uncertain whether the later ischaemic injury was related to an ischaemic event at presentation or occurred in the intervening period. Nevertheless, CMR may have an extended role in the follow-up of these patients and may reveal additional, actionable pathology.

Kounis syndrome induced by amoxicillin following vasospastic coronary event in a 22-year-old patient: a case report.

This article reports the case of a 22-year-old male patient presented with electrocardiographic ST elevation and elevated cardiac biomarkers. The clinical cascade set into events within an hour of administration of a single-dose of amoxicillin on being diagnosed with acute tonsillitis. The case was preliminarily diagnosed and treated according to the acute coronary syndrome protocol, but on performing coronary angiography no abnormalities in the coronary artery were found. Acute myocarditis was excluded in cardiac MRI. Considering possible hypersensitive reaction of amoxicillin in the absence of major cardiovascular risk in the young patient, diagnosis of Kounis syndrome (KS) was inferred. A thorough clinical observation of the patient after stopping the administration of amoxicillin revealed that there was a resolution of ST-elevation towards baseline. It coincided with falling cardiac biomarkers concomitant with subsided pain. The asymptomatic patient was discharged after 5 days of hospital stay. Telephonic follow-up one week after discharge from the hospital confirmed his pain-free and overall normal clinical status. Aim of the present report is to emphasize the need for increased awareness of KS induced by amoxicillin.