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Intercostal artery aneurysms are rare entities usually seen in connective tissue disorders and inflammatory conditions and syndromes like Ehlers-Danlos syndrome, Kawasaki’s disease, and neurofibromatosis. Spontaneous development of intercostal aneurysm is rare and the presence of multiple aneurysms/aneurysmosis is exceedingly rare. Although there have been a few case reports on aortic aneurysm, coronary artery aneurysms and many on ruptured cerebral aneurysms, we could not find a single case of spontaneous intercostal artery aneurysm secondary to chronic cocaine abuse. We report an exceedingly rare case of intercostal artery aneurysmosis presumably secondary to long-term cocaine abuse. Intercostal artery aneurysm is the least common visceral aneurysm and given the very limited literature on this subject, the pathogenesis is poorly understood.

Deep venous thrombosis (DVT) is the most common cause of unilateral lower limb swelling. Common differential diagnosis includes superficial thrombophlebitis and ruptured Baker's cyst. DVT is one of the most common complications diagnosed following lower extremity orthopedic surgery. However, many less frequent causes are often easily overlooked. Here we present a case of a 65-year-old man with a previous hip replacement who developed left-sided progressive leg swelling for years, which was managed initially with anticoagulation for provoked DVT and with compression stockings for post-thrombotic syndrome with no improvement. There was arterialization and spectral broadening of the venous waveform in the Doppler study. Computed tomography angiogram of the lower limbs showed evidence of arteriovenous fistula (AVF) with opacification of the deep left leg veins. Angioplasty and embolization of the fistula resulted in the resolution of leg swelling. We also discussed similar cases found in the literature. AVF needs to be considered in patients presenting with unilateral leg swelling following lower extremity orthopedic surgery.

Background Chronic mesenteric ischaemia (CMI) and median arcuate ligament syndrome (MALS) have similar clinical presentations with surgical intervention as the mainstay of treatment. However, surgical response varies and is unpredictable. Therefore, we aim to evaluate the technical and clinical success rates of selective revascularisation in older patients with CMI and younger patients with MALS undergoing arcuate ligament decompression with celiac sympathectomy. Methods We conducted a retrospective single-centre longitudinal comparative study of all the patients who underwent surgery for symptoms of CMI and MALS from December 2002 to 2020 at our tertiary referral vascular centre. Our primary outcome was symptom-free survival post-intervention. The secondary outcomes were perioperative mortality, technical success, and all-cause mortality at 17 years. Results We operated on 28 patients; 17 patients with CMI (revascularisations with bypass) and 11 with MALS (decompression and celiac sympathectomy). All (100%) patients had technical success. There was no perioperative mortality. All the MALS patients had symptom-free survival following the procedure throughout follow-up. In contrast, three patients with CMI complained of recurring abdominal pain even after one year of the surgery. However, there was no further weight loss and none of them required any intervention. Conclusion Stratified management of CMI with revascularisation and open surgical decompression with celiac sympathectomy in MALS are effective treatments with favourable long-term outcomes.

A 67-year-old man presented to the emergency department for two weeks of progressive shortness of breath with orthopnea and new-onset back pain. On admission, vital signs were normal, and physical exam was remarkable for jugular vein distention with the rest of the cardiovascular exam in normal limits. A bedside transthoracic echocardiogram showed a large circumferential pericardial effusion with M-mode analysis revealed diastolic collapse of the right ventricle (RV) and > 40% tricuspid inflow respiratory variation in Doppler. Emergency pericardiocentesis yielded 800 cm3 of yellow-colored fluid. Subsequently, the patient underwent lymph node biopsy showing tumor cells consistent with squamous cell carcinoma of unknown origin. This case highlights the use of bedside echocardiogram and M-mode imaging for the diagnosis of cardiac tamponade.

Introduction Paraplegia is a serious complication after thoracic and thoracoabdominal aortic aneurysm surgery. The aortic cross-clamp blocks blood flow to the intercostal artery as a feeding blood vessel, so the spinal cord is at risk of being exposed to ischemia. Hypothermia with systemic cooling is a useful means of avoiding spinal ischemia caused by aortic blockade but has various side effects. Theoretically, local cooling by epidural cooling catheter is an effective method to reduce the side effects. However, the use of needle sensors to measure the temperature of the human spinal cord is not ethically applicable in the real clinical field. The purpose of the study is to build computer modeling of human-sized spinal cords and a basic platform for simulating spinal cord cooling. This is being done to prove that local cooling can cool the human spinal cord in the same way, even in human spinal cords larger than laboratory animals. Methods We tried to model a horizontal cross-section of tissue near the spinal cord at a size equivalent to that of an adult human. The tissue around the spinal cord was decomposed into many small matrices for analysis using the finite element method. Next, the analysis was performed using a high-speed computer on the assumption that the matrix exchanges heat with the adjacent matrix over time according to Pennes' bio-heat equation. Repeated calculations were performed on a high-speed computer to calculate temperature changes in the central part of the spinal cord. Result By setting the temperature of the cooling catheter to 20°C, temperatures at the center of the spinal cord after 5, 10, 15, 20 and 25 minutes were 34.08°C, 33.64°C, 33.48°C, 33.40°C, and 33.36°C, respectively. After stopping the cooling, the temperature at the center of the spinal cord recovered to baseline temperature within 10 minutes. Conclusion Results were similar to those of previous animal studies using our local cooling system, suggesting that evaluation of cooling catheter's performance by computational simulation (CS) is effective.

Tumor lysis syndrome (TLS) occurring after surgical resection of right atrium (RA) and inferior vena cava (IVC) tumor thrombus is a very rare but insidious condition. We report a case of hepatocellular carcinoma who developed TLS after uneventful excision of RA+IVC tumor thrombus under median sternotomy and cardiopulmonary bypass (CPB). Although the procedure was not expected to arouse massive tumor cell necrosis, post-operative course was complicated by metabolic acidosis, hypocalcemia, and progressive hyperkalemia indicative of TLS. Unfortunately, laboratory diagnosis of TLS was delayed under conditions of continuous renal replacement therapy (CRRT) for peri-operative acute renal failure. Despite all efforts, the patient died 36 hours after surgery due to lethal arrhythmia and disseminated infarction of the kidneys, spleen, and liver.

A uterine/ovarian artery pseudoaneurysm is a rare complication of pelvic surgical interventions such as oocyte retrieval. This complication can be life-threatening due to the risk of rupture and blood extravasation. We report the case of a 30-year-old, nulliparous, married woman with a rare uterine/ovarian artery pseudoaneurysm due to in vitro fertilization. The patient has a history of sickle cell disease and primary infertility with multiple failed ovulation induction. She presented to the emergency department (ED) with hypotension following ovum retrieval for in vitro fertilization. Upon examination, we noted that the patient had tense ascites. A focused assessment with sonography in trauma (FAST) in the ED revealed internal bleeding. The diagnosis of a uterine artery pseudoaneurysm was established. She underwent an exploratory laparotomy to control bleeding due to her instability. Computed tomography and FAST scans help make an accurate diagnosis, and this case highlights that early intervention by embolization is essential to stabilize the patient and improve patient outcomes.

Coronary artery aneurysms (CAAs) are rare, with giant CAAs being even rarer. The precise pathophysiology of this phenomenon is still unknown. CAAs are seldom reported life-threatening abnormalities of the cardiovascular system. We herein present a case of a 74-year-old man who presented at the hospital complaining of chest pain. An adenosine thallium scan revealed a small, reversible defect in the inferior wall of the left ventricle extending into the apex, consistent with ischemia. Echocardiography uncovered a large right coronary artery (RCA) aneurysm, measuring 5.6 × 7.5 cm. Diagnostic coronary angiography confirmed the presence of a large RCA aneurysm and aneurysmal dilation of the left anterior descending and circumflex arteries with no flow-limiting lesions. A reversed saphenous vein interposition graft was placed from the ascending aorta to the right posterior descending artery. The RCA aneurysmal sac was resected and sent to pathology, which uncovered myxoid degeneration of the media as well as thrombus formation. No complications were encountered during the procedure. Early diagnosis is vital to avoid fatal complications of CAAs, and therapeutic approaches are currently individualized in view of absence of evidence-based management strategies.

Retroperitoneal hematomas are a rare and fatal complication of endovascular embolization. We report a case of an 89-year-old woman who was referred to interventional radiology for percutaneous embolization for intractable epistaxis as a result of a left nasal cavity mucosal melanoma. After successful embolization of the left sphenopalatine artery, the patient became hypotensive and was transferred to the intensive care unit. Post-operative CT abdomen and pelvis angiogram showed a large right perinephric hematoma, which is an extremely uncommon complication of endovascular embolization for epistaxis. Practitioners should be aware of this life-threatening complication in weighing the risks and benefits of embolization versus direct surgical ligation, and they should identify and intervene promptly if a retroperitoneal hematoma should occur.

Atherosclerosis of the internal mammary artery (IMA) is an uncommon disease. We present a case report of a patient with stable angina who had a history of coarctation repair. After meticulous investigation and discussion, a coronary artery bypass graft (CABG) was planned. During the surgery, we found that the left internal mammary artery (LIMA) was severely atherosclerotic without any blood flow, and a fragment of LIMA was taken for histopathological examination for further insight into pathogenesis. Vein grafts were alternatively used. Furthermore, relevant literature review and management were discussed for the use of LIMA in patients with a history of aortic coarctation.

Long-segment pulmonary atresia (PA), non-confluent branch pulmonary arteries, ventricular septal defect, tricuspid valve atresia (type 1A), and single ventricle physiology is a relatively rare and extremely heterogeneous form of congenital heart disease. This subset of patients having pulmonary atresia, ventricular septal defect, and major aortopulmonary collateral arteries (MAPCAs) have to undergo multiple unifocalization staging operations before a complete repair is attempted. Most of the patients were deemed inoperable. We report a rare case of a concomitant single-stage unifocalization and cavopulmonary anastomosis (bi-directional Glenn procedure) in an adolescent cyanotic girl with tricuspid valve atresia (type 1 A), long-segment pulmonary atresia, non-confluent branch pulmonary arteries, bilateral patent ductus arteriosus, MAPCAs, and single-ventricle physiology. Reconstruction of the absent central pulmonary artery and non-confluent branch pulmonary arteries was achieved by dividing the bilateral patent ductus arteriosus feeding the bilateral pulmonary arteries.

Intracranial aneurysms are pathological dilatations of intracranial arteries and prevail in around 3.2% of the general population. The worst outcome of an aneurysm is its rupture. Its prevention and management can be accomplished by two broad modalities: surgical clipping and endovascular coiling. This review has explored each of these approaches individually and has then directly compared them to provide a good understanding of their respective advantages and disadvantages over one another. Clipping is associated with a higher rate of occlusion of the aneurysm and lower rates of residual and recurrent aneurysms, whereas coiling is associated with lower morbidity and mortality and a better postoperative course. The risks and benefits of each of these procedures must be thoroughly examined in each case. This article has stressed the need to consider all contributing patient, procedure-related, surgeon-related, and hospital factors before arriving at a final decision to manage a specific case.

Main bronchus stenosis as a sequel of pulmonary tuberculosis is infrequent and should raise suspicion of other presentations of the infection. Given its non-specific symptomatology and the absence of a specific diagnostic method, tracheobronchial tuberculosis is usually not suspected and diagnosed despite its great impact on quality of life due to the high incidence of stenosis as a consequence. Ogilvie's syndrome, an uncommon condition, requires careful management and surveillance given the risk of ischemia and colonic perforation intrinsic to the disease. We present a case of a patient with main bronchus stenosis secondary to tuberculosis infection and Ogilvie's syndrome post-surgery.

Objectives: This study aimed to analyze all the reported cases of definitive infective endocarditis, based on the modified Duke criteria in a tertiary hospital over the past five years, focusing on the causative organism/s, predisposing factors, and outcomes. Methods: This is a cross-sectional retrospective study. Patients with a confirmed diagnosis of infective endocarditis using modified Duke criteria were included. The demographic data, predisposing factors, the causative microorganisms, laboratory and echocardiography results, and treatment were collected. Results: In total, 37 patients were identified, 22 were male, and the median age was 59 years. Native valve endocarditis was found in 29 (78.3%) patients. The most frequently involved valves were the mitral valve in eight (42.1%) and aortic valve in six (31.6%) patients. Fever occurred in 22 patients (59.5%). The most frequent organisms were Staphylococcus aureus in 14 (37.4%) patients, coagulase-negative staphylococci in seven (18.9%) patients, and streptococci in seven (18.9%) patients. The majority (n=27) of the patients (72.97%) were treated medically, with 10 (27.02%) requiring in-hospital surgical intervention. The in-hospital mortality rate was 24.3%. Late presentation, reluctance to undergo surgery, and the past history of rheumatic fever were the contributing factors. Conclusion: Native valve endocarditis is the major type of infective endocarditis. The most frequent organisms were Staphylococcus aureus, Streptococcus, and coagulase-negative staphylococci. In our study, infective endocarditis was more common among males, surgical intervention was low, and a high in-hospital mortality rate was noted in our series.

Type A aortic dissection is a surgical emergency occurring when an intimal tear in the aorta creates a false lumen in the ascending aorta. The authors report the case of an older woman with a medical history of arterial hypertension, atrial fibrillation, dyslipidemia, heart failure, and osteoarticular spinal pathology, presenting with sudden and persistent retrosternal pain, who was initially misdiagnosed with a lower airway infection and was discovered to have an acute type A aortic dissection. The authors intend to draw attention to medical errors and emphasize the importance of early diagnosis in pathology with a potentially fatal prognosis.

The anterior cervicothoracic spine is a challenging region to approach given the various vascular, osseous, nervous, and articular structures, which prevent adequate exposure. This region is susceptible to lesions ranging from tumors, degenerative disease, infectious processes, and traumatic fractures. Our objective was to critically evaluate the sternotomy approach in spine surgery to give the technical implications of its usage. The safety and efficacy of the transsternal approach are discussed as well as the advantages, disadvantages, indications, and contraindications. The transsternal approach is the most direct access to pathologies in the upper anterior cervicothoracic spine and enables the spine surgeon to gain direct exposure to the cervicothoracic junction for ideal visualization. Anatomical considerations must be kept in mind while performing a sternotomy to prevent complications such as denervation or bleeding. This technique is useful for the armamentarium of spinal surgeons.

Amyloidosis is a clinical condition characterized by amyloid fibril deposition into different organ systems. The most common types are light chain (AL) amyloidosis and transthyretin amyloidosis (ATTR) amyloidosis. Amyloidosis involves the heart with an incidence of 1.38 to 3.69 per 100,000 person-years and a prevalence of 14.85 per 100,000 person-years between 2004 and 2018. Diagnosis of cardiac amyloidosis can be made through cardiac imaging, including cardiac magnetic resonance imaging (CMR) and 99mTc-labeled pyrophosphate (PYP) cardiac scan. However, a tissue biopsy is frequently needed to confirm the diagnosis. Herein, we report such a case of cardiac amyloidosis. The patient presented with pericardial effusion and acute kidney injury as the initial presentation. The presumptive diagnosis was ATTR amyloidosis, but the endomyocardial biopsy confirmed the diagnosis of AL amyloidosis. The patient was started on bortezomib, cyclophosphamide, and dexamethasone therapy. We aimed to highlight the different diagnostic modalities of cardiac amyloidosis and the importance of obtaining tissue biopsy to confirm the amyloidosis type before starting the treatment.

Background Transcatheter aortic valve replacement (TAVR) is increasingly utilized for most patients with symptomatic severe aortic stenosis. TAVR is linked to enhanced long-term cardiac hemodynamics, reversal of left ventricle (LV) hypertrophy, and improved aortic valve gradients. We present a retrospective observational study assessing cardiac remodeling and valvular flow patterns post-TAVR. Methods Retrospective echocardiographic data were collected, evaluating cardiac function and valvular flow patterns before and after TAVR at a single institution. Data was compiled and statistically analyzed using a paired t-test evaluating variations at approximately 30 days and one-year post-TAVR. Results On echocardiogram 30 days and one-year post-TAVR, there was a reduction in LV mass index from 132 g/m² to 110 g/m² (95%CI: 98-122; p=0.01) and 118 g/m² (95%CI: 102-133; p=0.03), and a reduction in relative wall thickness from 0.54 to 0.49 (95%CI: 0.46-0.52; p=0.05) and 0.44 (95%CI: 0.38-0.49; p=0.03), respectively. Doppler velocity indices (DVI) increased from 0.24 to 0.61 (95%CI: 0.49-0.73; p

Innominate artery occlusion is a rare entity, particularly when coupled with severe left common carotid artery stenosis. Innominate artery disease may present with varying degrees of symptomatology and can place patients at risk for both posterior fossa and hemispheric ischemic events. We present a symptomatic case of innominate artery occlusion with severe left common carotid disease. We reviewed the literature and current options for the treatment of innominate artery disease. The patient underwent successful hybrid repair with left carotid artery retrograde stenting and left carotid artery to right carotid artery bypass. She has been symptom and re-intervention free during her one-year follow-up. We describe a successful hybrid repair of symptomatic innominate artery occlusion with concomitant severe left carotid artery stenosis in a patient with a prohibitive open thoracic surgical risk.

Hypoventilation syndrome is defined as a decrease in alveolar ventilation leading to hypercapnia (PaCO2 > 35-45 mmHg) and hypoxemia. There are multiple causes of hypoventilation syndrome described in the literature, of which central and obesity-related causes are more prevalent. Other causes such as neuromuscular disorders and chest wall deformities are relatively less common. Multiple defects in the normal functioning of the respiratory function are implicated in the pathophysiological mechanism of hypoventilation syndrome, such as a hypoactive central ventilatory drive, decreased airway function, ventilation-perfusion mismatch, defective pulmonary mechanics, and respiratory muscle fatigue. Patients often present with dyspnea, headache, lethargy, repeated pulmonary infections, hypoxia that usually improves with low flow oxygen, and hypercapnia that may alter mental function. Nocturnal or diurnal assisted mechanical ventilation is proven to be an effective therapy for patients suffering hypoventilation syndromes. We describe a case of a 47-year-old woman with hypoventilation syndrome resulting from a rare chest wall deformity with inward protrusion of the costochondral junction of the ribs with ossification of the costal cartilage on CT who presented with dyspnea and hypercapnia.

Background Knowledge about oral anticoagulant treatment can impact treatment outcomes in patients with atrial fibrillation. However, evidence is scarce regarding the knowledge of oral anticoagulants among Saudi patients with atrial fibrillation. Hence, this study aimed to assess the level of anticoagulation knowledge among patients with atrial fibrillation taking oral anticoagulants. Methodology A survey using a cross-sectional study design was conducted among patients with a confirmed diagnosis of atrial fibrillation in a tertiary care setting. The Oral Anticoagulation Knowledge Tool (AKT), a 33-item, self-administered questionnaire, was used to assess the knowledge of anticoagulation. Results A total of 290 patients with a median age of 67 years participated in the survey. More than half of those surveyed (56.2%) were females. Overall, 195 (67.2%) patients had an overall adequate anticoagulation knowledge. The median knowledge score of participants on warfarin was significantly higher than those on direct-acting oral anticoagulants (p < 0.001). Only age was found to be a predictor of AKT. Increasing age was associated with fewer odds of adequate AKT. For every one-year increase in age, the knowledge score decreased by 0.08 (95% confidence interval: -0.13 to -0.04). Conclusions This study found significant knowledge gaps among Saudi patients with atrial fibrillation taking oral anticoagulants. Advancing age was inversely associated with oral anticoagulation knowledge.

Perioperative acute cardiac tamponade associated with perforation from pulmonary vein isolation (PVI) and radiofrequency catheter ablation (RFCA) for the treatment of refractory atrial fibrillation (AF) is rare. If not identified early and managed promptly, it can lead to decreased ejection fraction, hypotension, and ultimately death. We report a case of acute tamponade that was diagnosed and successfully managed following PVI and RFCA. A 49-year-old woman with a past medical history of paroxysmal AF and sick sinus syndrome presented to our hospital with intermittent episodes of palpitations and recurrent episodes of syncope. Given the drug-refractory AF, our patient underwent PVI and RFCA. A loop recorder was implanted for recurrent episodes of syncope, which revealed that she had sick sinus syndrome. During the current visit, transthoracic ECG revealed mild tricuspid regurgitation and trace pericardial effusion. Her left ventricle (LV) ejection fraction was 60%. A CT angiography of the pulmonary vessels and the aorta showed no evidence of pulmonary embolism, aortic aneurysm, or aortic dissection. However, there was an enlarged heart size and small bilateral pleural effusions. During a second PVI and RFCA, while in the operating room, the patient became hypotensive. A transesophageal echocardiogram (TEE) showed diastolic volume reduction in the right atrium and right ventricular and pericardial effusion. Intravenous (IV) resuscitation with lactated Ringer's solution and saline solution was rapidly given to the patient while performing percutaneous pericardiocentesis. In addition, packed red blood cells were transfused into the patient, and phenylephrine was given IV. There was 400 mL of blood drained from the pericardial sac, confirming the presence of acute cardiac tamponade. Following the pericardiocentesis, the patient became normotensive. A drainage tube was inserted into the pericardial space, which drained a total of 250 mL of sanguineous fluid over the next 48 hours after the procedure, after which it was removed without signs of persistent bleeding, and the patient was discharged. We conclude that her previous PVI and RFCA, and the anatomical distortion that might have resulted from her enlarged heart size, may have predisposed her to perforation and thus acute cardiac tamponade in this PVI and RFCA. Although perforation leading cardiac tamponade is rare during PVI and RFCA, the future focus when performing this procedure should be to (i) have a high index of suspicion for acute cardiac tamponade, (ii) use TEE and intracardiac echocardiography for early detection, and (iii) promptly manage the acute cardiac tamponade with pericardiocentesis, while giving IV fluid resuscitation and positive inotropes to hemodynamically stabilize the patient.

Kartagener's syndrome is a rare autosomal recessive disorder characterized by the situs inversus, bronchiectasis, and chronic sinusitis. It is found in about half of the individuals with primary ciliary dyskinesia, a disorder of dynein arms in the cilia which renders the mucociliary apparatus inefficient. One of the manifestations of this disorder is the inability to clear secretions from the respiratory pathway leading to recurrent infections and their complications. We present a case of a 16-year-old female with the classical triad of Kartagener's syndrome who developed left-sided empyema thoracis and needed video-assisted thoracoscopic decortication for her condition.

Ventricular fibrillation (VF) is a lethal cardiac arrhythmia that leads to cardiac arrest and death. It is especially deadly when it fails to respond to conventional treatment with electrical defibrillation. This arrhythmia is often triggered by acute myocardial ischemia, but in rare cases, it can be precipitated by direct myocardial trauma. Most patients with traumatic cardiac arrest do not survive, but in a minority of patients, an emergency thoracotomy may improve survival by addressing reversible causes such as haemorrhage control, relief of cardiac tamponade, and direct wound closure. We present an unusual case of a traumatic cardiac arrest, presenting with refractory ventricular fibrillation due to a cardiac laceration in a young trauma patient with an isolated chest injury.

Chondromyxoid fibroma (CMF) is a benign cartilaginous tumor that typically occurs in the long bones of young adult males, with the clinical presentation varying from asymptomatic to localized pain, swelling, and movement restriction. We report an unusual presentation of CMF involving a rib, along with a literature review of the management of CMF. Although benign, local recurrence is not uncommon, and malignant transformation has been reported on rare occasions. En bloc surgical excision, with adequate tumor-free resection margins, of radiologically suspected chondromyxoid fibroma is crucial for the treatment and confirmation of diagnosis. A high index of suspicion, adequate treatment, and follow-up are critical for the successful management of these uncommon benign chondroid tumors.

Schistosomiasis is an endemic disease commonly found in areas of Africa and the Middle East. It is a prevalent parasitic infection in the southern region of Saudi Arabia and Yemen. The most common species found are Schistosoma mansoni and Schistosoma haematobium. Schistosomiasis can manifest in the urinary bladder, liver, and gastrointestinal system. The occurrence of the infection in the lungs is very rare and usually appears after years of initial infection. We report a case of a 23-year-old Yemeni male who presented to the emergency department complaining of sudden, right-sided chest pain with shortness of breath of one day. Examination and chest X-ray revealed the presence of pneumothorax, and a chest tube was inserted accordingly. As the pneumothorax did not resolve and a continuous air leak was present, the patient was taken to the operation theatre on suspicion of a fistula. The diagnostic procedure found the presence of bullae and patterns of inflammatory infection. A resected lung wedge revealed the presence of Schistosoma eggs, and schistosomiasis was diagnosed. In conclusion, spontaneous pneumothorax secondary to infection can present in young healthy males. Meanwhile, schistosomiasis infection must be kept in mind when dealing with patients coming from endemic areas even if they present with no recent visit to endemic areas.

A 55-year-old woman with stage IV breast cancer was diagnosed with heart failure. Her left ventricular ejection fraction (LVEF) had decreased to 37.2%. Chemotherapy-related cardiac dysfunction (CTRCD) was suspected, and standard treatment for heart failure was initiated. After five months, her LVEF remained below 50% since she could not tolerate beta-blockers. Ivabradine was introduced, which remarkably improved her LVEF to 72.6% in only three months. Her myocardium was not dilated, which may be the reason that ivabradine was effective. Ivabradine has shown to be safe and effective in the treatment of CTRCD, and improved activities of daily living of an advanced-stage cancer patient.

Vagal paraganglioma is a rare finding that develops from paraganglionic tissue found around the vagus nerve; it has a prevalence of 0.012% of all tumors. It is the third most common paraganglioma of the head and neck but still accounts for less than 5% of these tumors, and it has a well-established female prevalence. It is a difficult tumor to identify early based on its symptoms alone and only a thorough investigation can help solidify its diagnosis. In this report, we discuss a presentation of this phenomenon that is not only unique in its manifestation but also a very difficult diagnosis due to its deceptive presentation and multiple extensions. These masses need a good surgical regime to be removed properly and postoperative complications are very frequent in most of these cases.

Low back pain is very common and the vast majority of cases are related to non-specific etiologies. Low back pain due to serious pathologies is very rare. We present the case of a 66-year-old man with progressively worsening low back pain. His past medical history was remarkable for poorly controlled hypertension, diabetes mellitus, and dyslipidemia. He had several visits to the outpatient clinics and was diagnosed as having low back pain due to musculoskeletal etiology. He was prescribed multiple oral non-steroidal anti-inflammatory drugs and underwent multiple sessions of physiotherapy. However, his condition progressed, and did not show any clinical improvement. He underwent a plain radiograph of the lumbosacral spine which revealed decreased intervertebral disc spaces with multiple osteophytes. However, aneurysmal dilatation of the abdominal aorta was noted with atheromatous calcification. Computed tomography angiography confirmed the diagnosis of abdominal aortic aneurysm. The patient underwent endovascular repair of the aneurysm. The patient had complete resolution of his low back pain and remained symptom-free after six months of follow-up. The present case highlighted that those common presentations such as low back pain can be indicative of serious underlying pathology. Early diagnosis and management of abdominal aortic aneurysms can improve the prognosis and survival.

Rhabdomyolysis (RML) is a disease that results from the death of muscle fibers and the release of intracellular contents into the bloodstream as a result of traumatic or non-traumatic muscle injury. Postoperative RML is a rare complication that may result from improper patient positioning, extended surgery time, or unique patient risk factors. We describe a case of a 43-year-old obese male who presented with postoperative bilateral shoulder RML after undergoing cardiothoracic surgery for aortic valve disease. To our knowledge, after a thorough review of the literature using PubMed, Medline, and Google Scholar, no previous studies have reported positioning injuries specific to obese cardiac surgical patients and their relation to RML.

Hematologic paraneoplastic syndromes with extreme neutrophilia and eosinophilia are very rarely associated with adenocarcinoma of the lung. We describe a case of a 57-year-old female who presented with neutrophil- and eosinophil-predominant hyperleukocytosis and hypoxic respiratory insufficiency. Bone marrow biopsy confirmed metastatic adenocarcinoma, similar to the biopsy-proven adenocarcinoma of the lung. She was administered one dose of cytotoxic chemotherapy with carboplatin and pemetrexed and started on leukoreductive therapy with hydroxyurea. Molecular testing revealed a BRAF V600E mutation and she was started on dabrafenib and trametinib with significant clinical improvement. This is the first reported case of metastatic BRAF V600E mutated non-small cell lung cancer presenting with extreme neutrophilia and eosinophilia treated with a combination BRAF and mitogen-activated extracellular kinase (MEK) inhibitor.

A 35-year-old female with sarcoidosis sought medical attention due to palpitations. The ECG showed an atrial tachycardia (AT), apparently originating in the left atrium. A 24-hour Holter monitoring revealed AT to be present during the entire day. Cardiac magnetic resonance exhibited no cardiac involvement by sarcoidosis but registered a mildly depressed left ventricular ejection fraction (LVEF). Atrial electroanatomical mapping showed the earliest activation zone on the distal portion of the left atrial appendage (LAA). Considering the high risk for perforation with catheter ablation in this region, she was sent to thoracoscopic surgical LAA exclusion with a clip device; it was possible to witness the termination of the arrhythmia during the procedure. She was safely discharged two days after surgery and has completed a one-year follow-up without recurrence of AT or symptoms, and with normalization of LVEF.

Background Despite ample evidence of continuing preoperative aspirin to improve coronary artery bypass surgery outcomes, practice for the routine continuation of preoperative aspirin is inconsistent due to concern for increased postoperative bleeding. The purpose of this study was to investigate preoperative aspirin use and its effect on postoperative bleeding after off-pump coronary artery bypass grafting (OPCABG). Methodology This cohort study involved patients (n = 74) who underwent OPCABG at a single center between August 2017 and January 2018. After considering the inclusion and exclusion criteria, the patients were divided into two groups: one (n = 37) received tablet aspirin 75 mg till the day of the surgery, and for the other group (n = 37) aspirin was stopped five days before the surgery. Postoperative bleeding was recorded in both groups. After considering preoperative, intraoperative, and postoperative variables, statistical analysis was performed. Results There was no significant difference between the two groups concerning peroperative and postoperative variables. In addition, no significant difference was observed between the two groups in chest tube drainage at one, two, three, twenty-four, forty-eight, and seventy-two hours (p = 0.845, 0.126, 0.568, 0.478, 0.342, and 0.717, respectively). No significant difference was seen in the transfusion requirement of blood and fresh frozen plasma (FFP). Conclusions Continuation of preoperative aspirin till the day of the surgery is neither associated with an increase in chest tube drainage, reoperation for bleeding complications nor transfusion of blood and FFP.

Vasculitis involving the gastrointestinal (GI) tract typically occurs in association with multisystem disease. Isolated superior mesenteric artery (SMA) vasculitis is a rare disorder that has a high degree of morbidity and mortality. Patients often present with nonspecific symptoms, and this condition can lead to varying degrees of intestinal ischemia, significant gastrointestinal bleeding, and bowel infarction, leading to perforation, peritonitis, and sepsis from bacterial translocation. Diagnosing this condition can be very challenging. High clinical suspicion and early diagnosis using both laboratory workup and appropriate vascular imaging are pivotal in improving outcomes in such patients. Herein, we describe the case of isolated yet multifocal SMA vasculitis with coexisting superior mesenteric vein (SMV) thrombosis. Medical therapy alone resulted in clinical and radiographic improvements. To our knowledge, there have not been any previous reports of this unique coexistence.

COVID-19, which is caused by the novel severe acute respiratory syndrome coronavirus (SARS-CoV-2), is known to cause a myriad of complications along with the typical lower respiratory tract involvement. One of the emerging complications is a hypercoagulable state leading to venous or arterial thromboembolism. These complications are more common in those presenting with a severe disease with significantly elevated inflammatory markers. Although co-morbid illnesses play a role in worsening such complications, yet they are not the main determinants as these complications also occur in those without any co-morbid illness. Here, we report a case of a 64-year-old male with severe COVID-19 pneumonia presenting with acute limb ischemia with a non-salvageable limb who required subsequent amputation of the affected limb.

Acute aortic dissection (AAD) is a cardiovascular emergency that requires emergent surgical, endovascular, or medical intervention depending on the portion of the aorta implicated, as dictated by the Stanford classification, and the extent of aortic involvement. Acute chest pain radiating to the back is typically seen in AAD and may be associated with radial pulse deficits. A high index of suspicion is required to diagnose and initiate management of this emergency as early as possible. This is a report of an atypical presentation of an extensive aortic dissection identified in a young man without most of the typical risk factors, but which was promptly diagnosed and treated.

Chronic venous ulcers, often complicated by late diagnosis and persistent infections, present major clinical and financial challenges. Recently, photobiomodulation therapy (PBMT) has been shown to be effective in overcoming physiological impairments such as hemostasis and inflammation, accelerating the wound healing process. This case series summarises our experience in the treatment of two Asian patients with lower-extremity chronic venous ulcers using PBMT with blue light. Case 1 was a 71-year-old male with a history of hypertension, chronic venous insufficiency and previous deep vein thrombosis. Prior to blue light therapy, the average duration of treatment until wound closure with compression dressings used to be 10-12 weeks. Complete wound closure with the blue light therapy was eight weeks, with a total reduction of 67% of wound size by week 4. Case 2 was a 77-year-old male with a background of hypertension and ischaemic heart disease. Prior to blue light therapy, the patient had also underwent iliac venoplasty and stenting for his recurring bilateral malleolus venous ulcers. By week 4, the right malleolus wound had healed, while the left malleolus wound had a size reduction of 38%. Complete closure of both the wounds was noted at week 6. Blue light was administered to the wounds of both patients for 120 seconds per session, as an adjunct to compression therapy. Both patients reported no additional wound pain during the administration of blue light therapy, with an overall reduction of wound pain at three weeks. The cases demonstrated that PBMT with blue light was well-tolerated, safe, and efficacious in improving wound healing with an adjunct to standard treatment of chronic venous ulcers.

Left atrial myxomas are rare tumors that arise in the left atrium of the heart. As they become larger, they tend to grow into the atrial lumen and disrupt cardiac hemodynamics. Commonly reported symptoms include dyspnea, orthopnea, cough, peripheral edema, and fatigue. On physical examination, a characteristic "tumor plop" may be heard in some patients early in diastole. Left atrial myxomas may cause emboli to be released into the systemic circulation, which can lead to acute cardiovascular events, including strokes. We present the case of a 43-year-old female with sudden-onset slurred speech, left facial droop, and left-sided hemiplegia. CT angiography of the brain revealed a right middle cerebral artery infarct, and the patient underwent emergent mechanical thrombectomy. Upon workup for secondary causes of stroke, echocardiogram revealed an incidental 8 cm left atrial myxoma. After stabilization in the ICU, the patient was taken to surgery and the tumor was successfully removed. Over the course of admission, the patient's left-sided hemiplegia gradually improved, and she was eventually transferred to inpatient rehabilitation care. A multidisciplinary effort involving medicine teams, neurology, cardiology, cardiothoracic surgery, neuro-interventional radiology, pain management, and endocrinology was essential in reaching the diagnosis. This case highlights the importance of considering a primary cardiac tumor such as a left atrial myxoma in the differential diagnosis when evaluating for secondary causes of acute ischemic stroke.

Temporary central venous hemodialysis (HD) catheters are commonly used in end-stage renal disease (ESRD) patients while awaiting peritoneal dialysis catheter, arterio-venous fistula or graft placement and maturation. Catheter-related right atrial thrombus (CRAT) is a common finding in patients with central venous catheters (CVCs) and can cause CVC to malfunction. The incidence of CRAT is about 29% with a mortality of 18.3% or greater if not identified and managed appropriately. Two major types of right atrial (RA) thrombi have been identified. Type A thrombus usually originates in the peripheral veins embolizing to the RA. Type B originates within a structurally abnormal RA and is usually attached to the chamber walls or foreign bodies like CVC or intra-cardiac wires. There is a high risk of thrombi embolization leading to pulmonary embolism as in our patient, systemic embolization if a right to left shunt is present and potential hemodynamic compromise. The optimal therapeutic approach is still a subject of discussion, but timely catheter removal with prompt initiation of systemic anticoagulation is key. Surgical management is pursued when medical therapy fails or if the thrombus is greater than 6 cm. Our case is that of a 30-year-old male with CRAT successfully treated with surgical embolectomy after the failure of systemic anticoagulation. This case highlights the importance of early detection of CRAT, initiation of optimal medical therapy and the need for surgical intervention when medical therapy fails.

Thoracoabdominal aortic aneurysm (TAAA) is primarily a disorder of the elderly; the condition, however, is rare in children, for whom the misdiagnosis is not uncommon. It is one of the leading causes of death in the older age group worldwide, with a 4:1 male to female ratio. There are no real data about the incidence of aortic aneurysms in childhood. Although rare, an aortic aneurysm can be an important cause of mortality in children and adolescents. We present a case of an adolescent boy with a left coronary artery aneurysm, left axillary artery aneurysm, and TAAA type-IV caused by the metabolic disease homocysteinemia. He was referred to our facility when the complicated picture of the disease was discovered.

Cardiac calcified amorphous tumor (CAT) is a rare, non-neoplastic, intra-cavity cardiac mass. Only a few cases have been described in the literature. A 46-year-old Indian female presented with decompensated heart failure. On echocardiography, 1.9 x 1.7 cm pedunculated mobile mass in the left ventricle attached to the intraventricular septum was seen. On cardiac magnetic resonance imaging (MRI), the lesion was isointense. Histopathology of the excised mass revealed fibrin deposition with eosinophilic amorphous material in the center with the periphery of the lesion showing calcification without any myxomatous tissue. A final diagnosis of CAT of the heart was established. CAT is composed of calcium deposits in the background of amorphous degenerating fibrinous material. It presents as a pedunculated mass in any chamber of the heart with a very high preponderance of distal embolization. Differentiation from calcified atrial myxoma, calcified thrombi, or other cardiac neoplasms is very difficult. Histopathological examination is the mainstay of diagnosis. Treatment is emergency excision to prevent distal embolization. CAT is a rare non-neoplastic tumor, which is mainly a tissue diagnosis after its resection.

This is a case report of a child who had acyanotic congenital heart disease - ventricular septal defect (VSD) and a patent ductus arteriosus (PDA) with severe pulmonary arterial hypertension. The child underwent open-heart surgery - VSD closure with PDA ligation - and six months later was re-admitted for congenital lobar emphysema of the right middle lobe. He underwent successful right middle lobectomy of the lung six months after cardiac surgery under a one-lung ventilation technique in which application of fiber-optic bronchoscope made the surgery safer and more suitable.

Here, we describe a rare case of Aerococcus endocarditis causing aortic insufficiency and paravalvular abscess presenting as complete heart block and shock. A 76-year-old man with diabetes mellitus presented to the emergency department with fever and dyspnea. His temperature was 102.4°F, heart rate 59 beats per minute, blood pressure 105/44 mmHg, and oxygen saturation was 98% on 6L oxygen. Examination revealed bounding carotid pulses, a 2/6 early blowing diastolic murmur at the left lower sternal border, and diminished lung sounds at the bases. Laboratory data showed leukocytosis of 19.65 k/µL, blood urea nitrogen 72 mg/dL, creatinine 2.92 mg/dL, lactic acid 3.1 mmol/L, pro-B-type natriuretic peptide 15,342 pg/mL, high-sensitivity troponin 136 ng/L, aspartate aminotransferase 129 U/L, and alanine aminotransferase of 115 U/L. An electrocardiogram showed complete heart block, and a transvenous pacemaker was placed. A transesophageal echocardiogram revealed an aortic root abscess and severe aortic insufficiency secondary to Aerococcus urinae. Ventricular pacing was used to decrease aortic insufficiency and optimize computed tomography with gating to view the coronary arteries due to wall motion abnormalities seen on the transthoracic echocardiogram. His aortic valve was replaced, and a pacemaker was planned. Aortic valve Aerococcus endocarditis is rare and can lead to complete heart block and aortic insufficiency. Cardiac pacing improves hemodynamics by increasing heart rate and decreasing left ventricular end-diastolic pressure.

Introduction COVID-19 has manifested a striking disarray in healthcare access and provision, particularly amongst patients presenting with life-threatening ischemic heart disease (IHD). The paucity of data from low-middle income countries has limited our understanding of the consequential burden in the developing world. We aim to compare volumes, presentations, management strategies, and outcomes of IHD amongst patients presenting in the same calendar months before and during the COVID-19 pandemic. Methods We conducted a retrospective cross-sectional analysis at the Aga Khan University Hospital, one of the premier tertiary care centres in Pakistan. Data were collected on all adult patients (>18 years) who were admitted with IHD (acute coronary syndrome (ACS) and stable angina) from March 1 to June 30, 2019 (pre-COVID) and March 1 to June 30, 2020 (during-COVID), respectively. Group differences for continuous variables were evaluated using student t-test or Mann-Whitney U test. The chi-squared test or Fisher test was used for categorical variables. Values of p less than 0.05 were considered statistically significant. P-value trend calculation and graphical visualization were done using STATA (StataCorp, College Station, TX). Results Data were assimilated on 1019 patients, with 706 (69.3%) and 313 (30.7%) patients presenting in each respective group (pre-COVID and during-COVID). Current smoking status (p=0.019), admission source (p

Currently, there is minimal guidance to antiepileptic dose adjustment for a patient requiring either venoarterial (VA) extracorporeal membrane oxygenation (ECMO) or plasma exchange (PLEX) therapy, and to our knowledge, there are rare guidances for a patient requiring both. Given the dangers with non-therapeutic concentrations of phenytoin, it is critical for the intensive care unit (ICU) practitioner to understand how the pharmacokinetic parameters of phenytoin change in critically ill patients requiring extracorporeal support. This case study presents a 41-year-old female transferred to the cardiovascular ICU requiring VA ECMO and PLEX for the treatment of systemic lupus erythematosus (SLE)-induced catastrophic antiphospholipid syndrome (CAPS). Free phenytoin concentrations were measured to assess the removal of phenytoin. There was no significant decrease in the free phenytoin concentrations post-PLEX and while on ECMO. Free phenytoin concentrations are not influenced in the setting of PLEX and while on ECMO.

Aortic dissection is relatively uncommon, but often presents with acute severe chest or back pain and acute hemodynamic compromise and is associated with high mortality. We present a case of aortic dissection with an atypical presentation in a heart failure patient and the challenges encountered to make the diagnosis. The patient was a 54-year-old African American female who presented with progressively worsening exertional dyspnea and orthopnea for three days and sensation of indigestion and bloating. The patient denied any recent history of chest pain and she was initially admitted for heart failure exacerbation. Her admission chest x-ray showed severe cardiomegaly with a prominence of pulmonary vascular but there was a borderline widening of mediastinum measuring 8.2 cm. Physical exam showed unequal dorsalis pedis pulses (fainter on the right side) and systolic blood pressure difference of more than 20 mmHg between bilateral upper extremities. Computed tomography angiography (CTA) of chest, abdomen, and pelvis confirmed the diagnosis of dissection of thoracic and abdominal aorta extending from the left subclavian artery to the femoral artery. The patient was managed with labetalol drip and later transferred to a tertiary center for an elevated level of care where the endovascular intervention was performed. The patient then followed up with a vascular clinic for serial CTA and heart failure clinic for optimization of core measures. In conclusion, this case highlights the importance of clinical suspicion of aortic dissection and discusses the various clinical presentations of aortic dissection and its management. Being a highly fatal condition, prompt diagnosis is extremely important and is often life-saving. Therefore, it is important for physicians to be aware of atypical presentations of aortic dissection to initiate timely interventions to avoid catastrophic complications.

Introduction Abdominal aortic aneurysms (AAA) are uncommon in young adults ≤55 years of age. There is a lack of literature on clinical characteristics, risk factors, and therapeutic outcomes so we present a case series of 11 patients of AAA aged ≤55 years. Methods We included single-center retrospective case series between 2013 to 2020. We reviewed 44 patients who were operated for AAA in a tertiary care center in India. We identified 13 patients who were ≤55 years; two patients with incomplete records were excluded. A patient information sheet was used to retrieve demographic data, clinical presentation, outcomes, and follow-up. Results Out of 11 patients, 10 were men. Nine patients (81.8%) had symptomatic AAA. The majority (45.4%) exhibited an infrarenal aneurysm and the median size of the aneurysm was 5.8 cm (IQR: 5.5-6.4 cm). Eight patients (72.7%) had a history of smoking. Hypertension was observed in six patients and one patient had associated coronary artery disease. Clamping time was > 45 minutes among three patients; all smokers. Blood loss was > 500 ml in five patients. The median length of hospital stay was 10 days (7-40); more among patients with metabolic equivalents (METS) score < 4, 14.5 (8-19) days. No grade III-IV complications and mortality were noted with a median follow-up of 15 months, with all patients living. Conclusion The aneurysm was symptomatic in the majority of participants. An association of smoking in increasing both the median clamping time and length of hospital stay was seen. No mortality and good disease-free follow-up suggested good outcomes.

A peripheral pulmonary arterial aneurysm (PAA) is an abnormal dilatation of the distal pulmonary artery consisting of all three vessel wall layers (the intima, media, and adventitia). It is a rare, potentially life-threatening entity. There is no defined standard for an abnormal amount of dilation of the distal pulmonary vasculature, however, the most common criteria used is a diameter greater than 1.5 times the upper limit of a normal or proximal portion. Despite the rarity of peripheral PAAs, the ability to recognize and diagnose them is important for both radiologists and clinicians. Early recognition is needed because of the high mortality associated with rupture. Consistent guidelines still need to be developed to help clinicians determine when intervention is appropriate. In the interim, endovascular coil embolization has become a mainstay of treatment due to its minimally invasive nature and lower risk of complications when compared to open surgical approaches.

Here, we present a case of partial anomalous pulmonary venous return with the superior type of sinus venosus atrial septal defect. This case also had unusually persistent left-sided superior vena cava, which could not be diagnosed well in preoperative transthoracic echocardiography and required contrast-enhanced cardiac computed tomography scanning for proper diagnosing, operative planning, and avoidance of intraoperative problems. Postoperative, cardiac computed tomography scanning was also done to confirm adequate management.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or COVID-19 is the virus responsible for the 2019 global pandemic. Pulmonary complications of COVID-19 are well established in the literature. However, the virus causes numerous extrapulmonary manifestations, notably acute aortic occlusion (AAO). COVID-19 creates a hypercoagulable state via the upregulation of numerous procoagulant cytokines in endothelial cells of blood vessels. We present a case of a 63-year-old patient without a previous history of prothrombotic disorders who developed AAO in the distal abdominal aorta and bilateral common iliac arteries after contracting COVID-19. The patient was a poor surgical candidate and was treated with fibrinolytics that were administered via an EkoSonic™ Endovascular System (EKOS) catheter using a bilateral transfemoral approach. This case highlights a unique treatment option for non-surgical candidates with AAO.