Ethical Dilemma: Should Continuous Intravenous Drug Use Affect Appropriate Management in Prosthetic Valve Endocarditis?

Drug use is a major challenge that negatively impacts many aspects of health. The issue of drug use is growing with every passing day. Efforts to mitigate its use are countered by even more people succumbing to the intravenous drug use due to their relatively easy availability and patients' poor insight into their medical condition. Infective endocarditis (IE) is a condition with high mortality and morbidity. It requires prolonged treatment with antibiotics, and, under some special circumstances, surgical management is also necessitated. Intravenous drug users who get valve replacement after index IE episode may continue to use drugs despite our utmost efforts to prevent it. They can subsequently develop prosthetic valve endocarditis (PVE), which is one of the indications for surgical valve replacement, hence requiring a redo surgery. However, their irregular behavior can create reservations while considering a repeat valvular surgery and delay the appropriate treatment. This can increase morbidity and mortality from PVE in intravenous drug users with otherwise no or few comorbidities.

Rare Presentation of Pulmonary Embolism Amidst Coronavirus Disease 2019 Era: Utility of Multiorgan Ultrasonography

Coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) is the underlying cause of a global crisis that the entire world is facing. It is a highly contagious viral infection, which is why social distancing seems to be effective. Its ability to survive on various surfaces and aerosolize necessitates very meticulous precautions, including airborne isolation for severely ill patients requiring mechanical ventilation. However, these patients may need routine diagnostic investigations including chest computed tomography and chest tomography angiogram scans (CT and CTA) to rule out other potential differential diagnoses and guide management. In this case, we focus on the utility of multiorgan ultrasonography (MOU) at the bedside to diagnose and manage pulmonary embolism (PE) in COVID-19 patients.

Heyde’s Syndrome Complicating Management in a Patient With High Bleeding and Thrombotic Risks

The association of severe aortic stenosis and gastrointestinal (GI) bleeding is a well-known phenomenon. The pathogenesis involves an acquired deficiency of von Willebrand factor (vWF) due to shear stress resulting in alteration of vWF morphology. This results in in-appropriate cleavage of vWF multimers into smaller dysfunctional fragments. Patients with atrial fibrillation and high thrombotic risk require anticoagulation for stroke prophylaxis. We describe a case of severe intermittent GI bleeding in a patient with atrial fibrillation while being on warfarin and other novel anticoagulants. This case highlights the role of severe aortic stenosis and resultant acquired vWF deficiency in complicating decision making in patients with a need for anticoagulation due to high thrombotic risk.

The Role of Revascularization in Chronic Stable Angina: Do We Have an Answer?

Coronary artery disease is one of the leading causes of death in the United States. The utility of revascularization in patients presenting with acute coronary syndrome is well elucidated, both in reducing death and re-infarction. However, in patients with chronic stable angina, the optimal management strategy is less clear. While medical management with aggressive control of risk factors and lifestyle changes are the cornerstones of treatment, the utility of revascularization in this subset of patients has always been a topic of debate.

Extensive coil embolization of a giant coronary artery aneurysm in an octogenarian: a case report

Background

Coronary artery aneurysms (CAA) are often diagnosed incidentally on coronary angiography or imaging modalities done for other reasons. ‘Giant’ CAA by definition exceeds 20 mm in diameter or four times the diameter of normal coronary artery. The management of patients with CAAs is challenging due to poorly understood mechanism, variable presentation, and lack of clear-cut societal recommendations. Though conservative management is preferred in asymptomatic patients, massive size or interval growth may make intervention necessary.

Case summary

We describe a case of successful coil embolization of a giant coronary aneurysm in an elderly 84-year-old male. Patient, who presented for a follow-up computed tomography angiography to evaluate a previously repaired abdominal aortic aneurysm 2 years back, was found to have interval growth of right coronary artery aneurysm from 4 cm in diameter to 7 × 8 cm in its greatest dimensions. The rationale for treatment was to prevent sudden death from continued growth and eventual rupture of aneurysm in addition to potential risk of thromboembolism and compression of adjacent structures.

Discussion

This case demonstrates the safe and successful use of extensive coil embolization technique to treat a ‘giant’ CAA in an elderly patient when surgical risks were prohibitive.

Axillary Approach for Venoarterial Extracorporeal Membrane Oxygenation Cannulation

Extracorporeal membrane oxygenation support (ECMO) is a form of mechanical circulatory support that is used in patients with severe dysfunction of heart or lung or both. Depending on whether it is venovenous or venoarterial support, it can temporarily substitute for circulation and ventilation while the underlying cause is addressed. Traditional approach for cannulation usually involves the femoral vessels. This is due to the easy accessibility, larger lumen of vessels, and physician expertise and training in femoral approach. However, in certain circumstances like critical lower extremity ischemia, crush injury or trauma to lower extremity, and lower extremity infections (like necrotizing fasciitis), this approach is not practical. In these situations, axillary vasculature provides a good substitute for ECMO cannulation. 

Microbiological quality analysis of different types of popular dried food items

The study was carried out to investigate the microbiological quality of dried foods which are very popular among kids. Moreover, people from all age groups like it, although adults do not take it on a regular basis, the total consumed amount among the adults are not negligible. Chips, biscuits, muesli, salted peanuts all are dried foods, and all of these can undergo microbial contamination due to the remaining water activity, environmental condition, production processing faults, humidity, temperature etc. In the current study, twenty-four samples were analyzed for microbial quality analysis. Six samples from each category of dried food were subjected to study for the presence of mesophilic organisms, coliforms, molds and other specific food pathogens. Of the samples studied, almost all were found to be contaminated with the mesophilic bacteria (104 -107CFU/g) and fungus (105 -107CFU/g). Survival of Vibrio spp. was absent and Salmonella spp. was found in only one sample. Escherichia coli, Pseudomonas spp., Staphylococcus spp. and Shigella spp. were found in many of the samples indicating the poor quality of the dried food items. Overall, the present study revealed that potato chips were highly contaminated by bacteria and fungi. Consuming such contaminated chips may cause foodborne illness that is a great threat to our health.

Imaging Modalities to Delineate Sequelae of Spontaneous Coronary Artery Dissection Managed with Percutaneous Coronary Intervention

Patients with spontaneous coronary artery dissection (SCAD) often present as clinically unstable, requiring management with percutaneous coronary intervention. Complications from persistent dissection and initial percutaneous management can present with later challenges. Intravascular and non-invasive imaging modalities are adjunct modalities to coronary angiography to delineate coronary anatomy and guide therapeutic strategies. Herein, we describe the case of a 23-year-old female patient who presented with heart failure and severe mitral regurgitation eight months after an index SCAD event during which she underwent extensive stenting of the left anterior descending artery. The multimodal imaging used in this case and how it helped in formulating the management rationale is also reviewed.

Mitral Valve Replacement Under Venoarterial Extracorporeal Membrane Oxygenation Support for Severe Streptococcus Mitis Endocarditis

Streptococcus mitis is an alpha-hemolytic species of Streptococcus and is the most prevalent organism of the oral flora. In patients with dental procedures or trauma and underlying damaged heart valves, it can cause infection of the valves (endocarditis). It has a propensity to affect the left-sided heart valves (mitral and aortic valves) in non-intravenous drug users (IVDU), whereas right-sided heart valves (tricuspid and pulmonic valves) in IVDU. We describe a case of a patient who presented with mitral valve endocarditis that was treated with antibiotics. He was lost to follow-up and then presented four years after his index presentation in cardiogenic shock from severe streptococcal mitis endocarditis causing severe mitral regurgitation. His course deteriorated to the point where the patient required a valve replacement surgery under hemodynamic support. 

The Management Dilemma: Concomitant Acute Hip Fracture and Severe Asymptomatic Aortic Stenosis

Acute hip fractures (AHF) are common in elderly patients. A combination of age-related osteoporosis and increased fall risk makes this population group most susceptible to different fractures including acute fracture of the hip. AHF is a disabling condition that warrants immediate attention. It has a huge impact on the already compromised baseline functional status of elderly patients rendering them more susceptible to different morbidities and even mortality. Similarly, age-related degeneration of the aortic valve with resulting calcification also makes elderly patients prone to aortic stenosis (AS). Severe asymptomatic AS when diagnosed in these patients with AHF in the perioperative period makes the management options very challenging. Severity of AS usually translates into worse postoperative outcomes. The management rationale of concomitant presence of these two conditions is unclear. There is a lack of clear-cut recommendations and societal guidelines in such scenario. 

Metabolic maturation in the first 2 years of life in resource-constrained settings and its association with postnatal growths

Malnutrition continues to affect the growth and development of millions of children worldwide, and chronic undernutrition has proven to be largely refractory to interventions. Improved understanding of metabolic development in infancy and how it differs in growth-constrained children may provide insights to inform more timely, targeted, and effective interventions. Here, the metabolome of healthy infants was compared to that of growth-constrained infants from three continents over the first 2 years of life to identify metabolic signatures of aging. Predictive models demonstrated that growth-constrained children lag in their metabolic maturity relative to their healthier peers and that metabolic maturity can predict growth 6 months into the future. Our results provide a metabolic framework from which future nutritional programs may be more precisely constructed and evaluated.

Cardiovascular Risk Profile of Chimeric Antigen Receptor T-cell Therapy

Chimeric antigen receptor (CAR) T-cell therapy is a novel form of immunotherapy that has been recently introduced in clinical practice for the treatment of leukemias and lymphomas after being approved by United States Food and Drug Administration (USFDA). The risk profile of this treatment modality is not yet fully explored. As the survival of cancer patients is expected to rise due to new therapies being brought into practice, physicians are going to encounter side effects of these therapies. This may include both short-term and long-term effects. Having a good knowledge of these side effects can help the physicians recognize in advance the at-risk population and risk stratify them accordingly. Cardiac oncology is a growing field that involves the study of interaction between novel immunotherapies and their cardiac side effects. Knowing the cardiotoxicity profile of CAR T-cell therapy will help us choose the most appropriate patient population (those who can benefit the most without being at risk of harmful effects including cardiotoxicity) for the therapy. It will also help us recognize various cardiac complications, as they arise later during the lifetime of these cancer survivors. 

Triple Valve Replacement in a Patient with Severe Combined Aortic and Mitral Stenosis

With recent advancements and evidence in favor of transcatheter approach for valve replacements including valve-in-valve procedures, it has become a favorable choice particularly in critically ill patients. Additionally, transcatheter mitral valve-in-valve replacement (TMViVR) is emerging as a less invasive substitute for patients with early dysfunctional bioprosthetic valve. We describe the clinical course of a 52-year-old male whose initial presentation to the hospital for dyspnea on exertion secondary to combined severe aortic and mitral stenosis got complicated requiring three valvular replacement procedures with favorable outcomes.

The Mystery of Low Phosphate: Marijuana is the Smoking Gun

Hypophosphatemia is a rarely reported side-effect of cannabis use. The potential mechanisms of hypophosphatemia include enteric malabsorption/loss, excessive urinary excretion, or rapid trans-cellular shifts. Severe hypophosphatemia from daily marijuana use is a rare side-effect. A trans-cellular shift is the most likely proposed mechanism. Although it tends to self-correct fairly rapidly, close observation for the dreaded consequences related to hypophosphatemia is required. Both the users and providers must be aware of this rare association of hypophosphatemia with daily marijuana use.

Fill Two Needs With One Deed! Single-Access Protected Percutaneous Coronary Intervention With Impella Hemodynamic Support

This report describes the case of a 64-year-old man who presented with acute coronary syndrome, depressed left ventricular function, and triple vessel disease on angiogram. The patient refused surgery and underwent high-risk percutaneous coronary intervention through the Impella sheath (Abiomed, Danvers, MA). This is one of the first known cases of single-access protected percutaneous coronary intervention, an innovative technique that brings into consideration the importance of dual vascular access via the Impella sheath.

Pulmonary Valve Replacement in an Adult Jehovah's Witness with Tetralogy of Fallot

The refusal of Jehovah's Witnesses to use blood products can limit access to cardiac surgery, as patients may not be offered surgery for complex disease, especially revision surgery. We report a successful, complex adult congenital heart disease (ACHD) surgery with intraoperative and perioperative optimization. We have tried to highlight through this case that complex ACHD surgeries can be performed in Jehovah's Witness patients with skilled perioperative and intraoperative management. The role of bovine hemoglobin in this population is being defined and was found helpful in this case.

Heart Failure with Preserved Ejection Fraction: Can Device Therapy Be Our Option?

Heart failure with preserved ejection fraction (HFpEF) comprises half of the total heart failure (HF) population. It is a unique class of patients whose systolic heart function is preserved but have impaired diastolic function leading to symptoms typical of HF. In the era of 1980s and 1990s, ‘congestive heart failure’ was used to refer to all the HF patients. With a better understanding of pathophysiology of ‘diastolic HF’, the term ‘HFpEF’ got widespread acceptance in early 2000s. Despite the increasing awareness of pathophysiology and diagnostic modalities for this group of HF patients, it is unfortunate to say that the therapies that we can provide are limited when compared to their counterpart HF with reduced ejection fraction (HFrEF) group. This review will focus on the use of device therapy in patients with HFpEF, particularly implantable cardioverter defibrillator and cardiac resynchronization therapy.

Is Testosterone Replacement Safe in Men with Cardiovascular Disease?

Testosterone is an anabolic hormone that is responsible for the development of male sex organs. It also increases muscle mass and fortifies bone density. In addition to being responsible for primary sexual characteristics at birth and puberty (development and changes of sexual organs such as uterus, vagina, penis, and testes), testosterone is also involved in maintaining secondary sexual characteristics. Patients with low testosterone who are symptomatic should be treated with testosterone replacement therapy (TRT) once the diagnosis has been confirmed. The goal of treatment is to improve the symptoms including the physical, sexual, and cognitive health with the aim being to keep the testosterone in the mid-normal limit of the reference range. Male hypogonadism has been increasingly diagnosed and treated in elderly males since the last decade. A proportionate increase in the prescription of testosterone has been seen as well. The relationship of testosterone levels with cardiovascular (CV) outcomes is challenging and has shown conflicting results. Moreover, in patients with established CV disease, those with high CV risk factors including diabetes, or those with significant risk factors for atherosclerotic CV disease (ASCVD), the benefits of TRT should be weighed against the risks of replacement. Risks and benefits of TRT should be discussed with every patient prior to starting or restarting the procedure.

Acute Paraspinal Compartment Syndrome in an Unconscious Patient

Compartment syndrome can be a limb-threatening emergency that may require immediate intervention. It usually involves the extremities but any closed compartment of the body is susceptible to it. Paraspinal compartment extends on both sides of the spine. Prolonged lying on the back in unconscious patients leads to muscle edema which eventually leads to increase pressure in the compartment. Neurovascular comprise is a dreaded complication of compartment syndrome. Paraspinal compartment is a potential site of compartment syndrome particularly in unconscious patients and it requires prompt diagnosis, careful monitoring, immediate medical attention and even warranting surgical intervention in certain cases.

A Novel Case of Idiopathic Restrictive Cardiomyopathy

Restrictive cardiomyopathy (CM) usually develops and progresses slowly, over a course of years. The rapid development of idiopathic restrictive CM immediately following a liver transplant is unusual. We describe the case of a patient who developed idiopathic restrictive CM fairly rapidly following a liver transplant. It progressed within a few months to the point where the patient required scheduled paracenteses and dialysis. The morphological definition of restrictive CM consists of bi-atrial dilation with non-dilated and non-hypertrophic ventricles. A cardiac biopsy may be needed when the underlying cause is not evident. When a cardiac biopsy is not able to identify a specific cause, then the word "idiopathic" is used to describe the CM.