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Gastroduodenal artery (GDA) aneurysms are exceptionally rare. Although rare, providers should have a sufficient understanding of the causes, symptoms, and treatment options due to there being a high risk of mortality if these aneurysms rupture. It is important to understand the need for close management and follow-up in patients with this diagnosis, especially in the outpatient setting. Various treatment options are available and should be immediately discussed with every patient diagnosed with this aneurysm. We report a patient with a previously diagnosed gastroduodenal aneurysm who presented to the clinic with new-onset symptoms.

The low prevalence of scimitar syndrome along with its varied clinical presentation poses a diagnostic dilemma to the treating clinicians. It usually falls under a large spectrum of conditions called venolobar syndrome. Scimitar involves the partial venous drainage of the right lung to the inferior vena cava (IVC). We share our experience of two cases that were diagnosed as partial anomalous pulmonary venous connection/drainage (PAPVC/PAPVD) on echocardiography but CT scan revealed the underlying scimitar syndrome. Perioperative pulmonary arterial hypertension, intraoperative ventilation strategies for managing associated lung hypoplasia, and postoperative right ventricular dysfunction are a few challenges faced in the perioperative period.

Background In patients with resectable esophageal adenocarcinoma (EAC), the decision for neoadjuvant treatment depends on clinical staging with endoscopic ultrasound (EUS) and positron-emission tomography (PET) scan. Patients with locally advanced EAC pathology misclassified as early EAC by clinical staging are missing the opportunity to receive neoadjuvant therapy. We aim to identify predictors of locally advanced pathology in EAC to determine more accurately those who benefit from neoadjuvant therapy. Methods Retrospective study of patients who underwent upfront endoscopic or surgical resection for EAC without neoadjuvant therapy from January 2011 to December 2017 was performed. Clinical characteristics, EUS, PET scan and histologic findings were analyzed. Multivariable analysis of predictors of locally advanced stage was performed and a risk prediction score was developed. Results A total of 97 patients were included; 68 patients were staged as early EAC (pT1 or pT2 and pN0) and 29 patients were staged as locally advanced EAC (pT1 or pT2 with pN1 and pT3 or pT4 irrespective of N status). In a predictive model of EAC, patients presenting with dysphagia, tumor size >2 cm, exophytic mass appearance on endoscopy and absence of hiatal hernia were more likely to be have locally advanced pathology with a probability of 70% (C-statistic 0.766). Conclusions A risk prediction model based on the presence of dysphagia, tumor size >2 cm, exophytic mass appearance and absence of hiatal hernia can be used to identify locally advanced pathology in EAC patients.

Background Thoracic epidural analgesia (TEA) and thoracic paravertebral block (TPVB) are commonly used in geriatric patients for pain management after thoracotomy. In this study, we aimed to investigate the effect of TEA and TPVB on postoperative analgesia in geriatric patients who underwent thoracotomy. Methodology Postoperative analgesia follow-up files of patients over 65 years of age who underwent thoracotomy were analyzed retrospectively. Patient’s demographic data, diagnosis, type of surgery, postoperative 24-hour mean arterial pressure (MAP), heart rate, respiratory rate, peripheral oxygen saturation, static/dynamic visual analog scale (VAS) scores, need for additional analgesics, global pain assessment, and side effects such as nausea, vomiting, hypotension, bradycardia, and respiratory depression were examined. The patients were divided into two groups: those treated with TEA (Group 1) and those treated with TPVB (Group 2). Results There was no statistically significant difference between the groups in terms of demographic data (p > 0.05). MAP in the TEA group was statistically significantly lower than in the second and sixth-hour TPVB group (p = 0.008, p < 0.001). VAS static scores in the TEA group were statistically significantly lower at 30 minutes (p = 0.001), and at one, two, six, twelve, and twenty-four hours compared to the TPVB group (p < 0.001, except at 30 minutes). VAS dynamic scores were statistically significantly lower in the TEA group at 30 minutes, and at one, two, six, twelve, and twenty-four hours compared to the TPVB group (p < 0.001). There was no statistically significant difference between the groups in terms of nausea, vomiting, hypotension, and bradycardia (p > 0.05). The use of additional analgesics in the TEA group was statistically significantly lower than in the TPVB group (p < 0.001). Conclusions More effective postoperative analgesia results with stable hemodynamic conditions were observed in geriatric patients who underwent TEA for thoracotomy compared to TPVB. Regarding side effects, although there was a lower incidence in TPVB, this was not statistically significant when compared to TEA. TEA, as a component of the multimodal analgesia approach, can be accepted as a safe and effective method in the elderly patient group who underwent thoracotomy.

Peripheral intravenous cannulation is a routine in the medical field with the rarity of complications in expert hands. However, at times, complications arise including the fracture of the cannula inside the vein, which is a rare but potentially serious complication with the possibility of pulmonary embolism. We have reported a case of a broken piece of a cannula in the cephalic vein removed with the help of a Fogarty catheter with the emphasis on preoperative imaging studies to localize it and use of a tourniquet to avoid distal migration during retrieval. There are varied reports about the conservative vs operative approaches for foreign bodies in vasculature. It should be removed in the first place where expertise allow so that the rare but potentially serious complications can be avoided.

With our population getting older and sicker, we are witnessing a steady increase in the volume of cardiothoracic procedures performed. As the role of anesthesiologists continues to shift towards being perioperative physicians, it is crucial to tailor the anesthetic to manage the surgical pain in both intraoperative and postoperative periods. In cardiac surgery, poorly controlled surgical pain can lead to opioid-induced hyperalgesia as well as chronic pain syndrome. As current practice encourages early extubation and decreased length of stay, clinicians have increasingly steered away from heavy intraop narcotic therapy over the past two decades. To blunt the sympathetic response and postoperative pain control, some have been using various fascial plane nerve blocks to reduce opioid use during surgery. These blocks are considered very safe to perform and do not lead to hemodynamic changes seen in neuraxial blockades. In this review article, we provide a brief overview of each of the commonly used blocks and summarize and discuss the latest clinical data for each of the common blocks and their efficacy in the setting of cardiothoracic surgery.

Introduction Managing chronic empyema thoracis (CET) due to tuberculosis (TB) in debilitated patients is complicated. Open window thoracostomy (OWT) is one of the ways to manage these high-risk patients. Closure of OWT is sometimes difficult to attain. The purpose of this study is to compare the outcome of OWT in terms of chest wall closure in two similar groups. The only difference between these groups was the circumference of the OWT created. This study will benefit patients of CET with OWT to attain early chest wall closure without being subjected to another surgical trauma. Methods This is a prospective comparative study, conducted in the Department of Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi, from August 2019 to July 2020. A total of 48 patients, 22 and 26 patients in group A and group B, respectively, were included in this study. Both groups were matched for age, gender, diagnosis, body mass index, and stage of empyema, with the difference only in the OWT circumference. Results Both groups had a history of multiple chest tube intubations. Among group A patients, a smaller circumference of OWT (20-24 cm; mean 22 cm) was created as compared to group B (30-34 cm; mean 33 cm). Spontaneous OWT closure was seen in 21 (95.5%) patients in group A and seven (26.9%) patients in group B in a time period of 6.2 ± 1.5 and 11.4 ± 0.5 months, respectively (p-value: ≤ 0.001). Pleural cavity clearance was attained in 21 (95.5%) patients in group A and 24 (92.35%) patients in group B in a time duration of 4 ± 1.4 months and 4 ± 4.1 months, respectively (p-value: ≤ 0.97). Complete lung expansion was found in 21 (95.5%) patients in group A and 24 (92.3%) patients in group B in a time duration of 5 ± 1.7 months and 4.7 ± 1.6 months, respectively (p-value: ≤ 0.62). Conclusion This prospective single-center study shows that successful spontaneous early closure of OWT primarily depends on the size of the OWT created. A smaller-sized OWT, if created judiciously, not only closes spontaneously but also facilitates the clearance of purulent discharge and potentially helps in the definitive healing of bronchopleural fistulae and consequent lung expansion, thereby avoiding more invasive procedures like decortication in a debilitated patient. Furthermore, there is no need for a second surgery for closure of OWT.

There is abundant evidence demonstrating the association between gut dysbiosis and neurogenic diseases such as hypertension. A common characteristic of resistant hypertension is the chronic elevation in sympathetic nervous system (SNS) activity accompanied by increased release of norepinephrine (NE), indicating a neurogenic component that contributes to the development of hypertension. Factors that modulate the sympathetic tone to the cardiovascular system in hypertensive patients are still poorly understood. Research has identified an interaction between the brain and the gut, and this interaction plays a possible role in the mechanism of heart damage-induced hypertension. Data, however, remain scarce, and further study is required to define the role of microbiota in sympathetic neural function and its relationship with heart damage and blood pressure (BP) control. Experimental evidence has pointed toward a bidirectional relationship between alterations in the types of bacteria present in the gut and neurogenic diseases, such as hypertension. Our published data showed that miR-204, a microRNA that plays an important role in the CNS function, is affected by gut dysbiosis. Therefore, miR-204 could be a key element that regulates normal sinus rhythm and neuronal hypertension. In this review, we will shed light on the potential mechanism by which microbiota affects hypothalamic miR-204, which in turn, could hinder the sympathetic nerve drive to the cardiovascular system leading to arrhythmia and hypertension.

Left ventricular aneurysms (LVA) occur after an infarcted area of the myocardium necrotizes, fibroses, and expands, forming a dyskinetic cavity. Most ventricular aneurysms are asymptomatic and go unrecognized unless found incidentally. Symptoms commonly reported include angina, heart failure, syncope, and even sudden cardiac death. Late complications from left ventricular aneurysms are infrequently reported. This case reports an elderly woman who presented with new-onset angina from an expanding 18-year-old true left ventricular aneurysm that was successfully treated with surgical repair.

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2), was initially discovered in December 2019 in China and rapidly spread all over the world to become a pandemic. The most common symptoms of a disease are fever, cough, generalized body ache, weakness, dyspnoea, nausea, vomiting, and diarrhea. Among vascular complications of COVID-19, the venous thrombotic complications, like pulmonary embolism and lower limb deep veins thrombosis, are not uncommon. But data about arterial thrombotic complications of COVID-19, especially carotid thrombosis, are still limited. We are describing a case of stroke due to thrombosis of the right carotid arteries, in a patient who had recovered from asymptomatic COVID-19. A 66-year-old male with arterial hypertension presented to the emergency department with a history of repeated collapse, dysarthria, weakness in the left extremities, and a drop in the left angle of his mouth (National Institutes of Health Stroke Scale [NIHSS]-4). The patient was swabbed for COVID-19 which was negative. A computed tomography angiography (CTA) was obtained which showed thrombosis in the branching point of the brachiocephalic trunk (BCT) continuing into the right subclavian artery (SA) and also into the right common carotid artery (CCA), with a subtotal occlusion of the right CCA, extending into the internal carotid artery (ICA) as well. From the apical lung tissue caught during the CT scan, bilateral, irregular widespread ground-glass opacifications, as well as consolidations and small reticular changes were seen in the lungs, which is typical for COVID-19 infection. A quantitative antibody test for COVID-19 infection was performed with the results showing a strong positivity for IgG antibodies, indicating previous COVID-19 infection. The patient was indicated for a standard carotid thrombectomy, which was performed without complications. It seems that one of the important factors that led to the formation of the thrombus in the carotid arteries was COVID-19 infection-induced inflammation in the atherosclerotic carotid vessels and generalized hypercoagulability as well as hyperviscosity. COVID-19 infection is an independent and important risk factor for the formation of an arterial thrombus during the acute illness and in the early post-COVID-19 period also, regardless of the severity of its course. Prophylactic anticoagulation is needed not only at the time of acute illness but also at the early post-COVID-19 time.

Lower lumbar spine burst fractures make up only 1% of all lumbar spine fractures. A burst fracture with neurological compromise, ligamentous injury, severe kyphotic deformity, or loss of anterior column support typically requires surgical stabilization. Treatment options at the L4 and L5 levels are challenging and often require an anterior/posterior approach. Very little has been reported on anterior approaches to the L4 and L5 levels when a corpectomy is required. Hence, we present a patient with a complex burst fracture of L4 and L5. She underwent a corpectomy of L4 and L5 and placement of an expandable cage through a window created between the aorta and the inferior vena cava via an anterior transperitoneal abdominal approach followed by posterior stabilization and fusion from L2 to the pelvis.

This case presents an infant boy with neonatal respiratory distress and sepsis, who was eventually diagnosed with and treated for superior vena cava (SVC) syndrome after three months of fluctuating head and neck edema. While SVC syndrome is uncommon in pediatrics and is usually caused by malignancy-associated external compression, the growing use of central venous catheters in these patients makes catheter-related thrombosis a potential cause of this serious complication. This case of delayed diagnosis highlights the importance of investigating SVC syndrome as a potential cause of respiratory distress and edema in any patient with a history of central venous catheter placement or similar procedures.

Background Acute mesenteric ischemia (AMI) is a vascular emergency with a quite low incidence, but it is associated with disproportionately more severe morbidity and mortality. The aim of this study was to assess the current trend in the treatment of AMI and to see if endovascular intervention is an effective treatment modality in the selected group of patients. Methods A retrospective review of patients admitted with AMI between 2007 and 2018 was performed. Outcome measures were length of stay (LOS) at hospital and intensive care unit (ICU), and post-treatment mortality. Results A total of 98 patients with AMI were admitted during the study period. Patients undergoing endovascular treatment compared with surgery were younger (62.9 ± 13.7 years vs. 69.5 ± 12.8 years; p = 0.01). Shorter LOS in hospital and ICU was observed for those treated with endovascular approach (6.8 ± 3.4 and 3.25 ± 0.5 days) compared to the surgical group (25 ± 8.6 and 12.8 ± 26.8 days; p < 0.001). Out of 39 patients requiring ICU admission, 48.7% were surgically treated and 10.2% underwent endovascular intervention (p < 0.001). Mortality associated with surgery was 30.6% compared to only 6.6% with endovascular intervention (p < 0.001). Between 2007 and 2012, only one patient underwent endovascular intervention and 20 underwent surgery compared to 14 patients treated with endovascular approach and 16 with surgery between 2013 and 2018. Conclusion In this non-randomized, retrospective case series, patients with endovascular treatment fared clinically better and the intervention was found to be safe and feasible in the selected group of patients. We suggest a preference for this modality where possible. At our hospital, a trend favoring this approach is apparent during the last six years.

Myxomas, being the most common primary benign tumor among all cardiac tumors, occur rarely with a very low incidence rate. Myxomas can cause various clinical manifestations or can be diagnosed incidentally. Some patients with cardiac myxomas are completely asymptomatic. Cardiac myxomas cause life-threatening complications, thus early diagnosis is imperative. We are reporting a case of atrial myxoma in a 38-year-old female without any significant past medical history, who came to our clinic for cardiology evaluation prior to plastic surgery. The elliptical mobile mass, located in the left atrium with its attachment to the interatrial septum, was diagnosed by transthoracic echocardiography. The patient was referred for surgery and a minimally invasive surgical approach was chosen. A histological report confirmed the diagnosis of myxoma. The patient recovered well. Three years of follow-up did not reveal any signs of recurrence of the tumor. We are also analyzing 20 previously published cases of asymptomatic myxomas and myxomas treated with a minimally invasive surgical approach, reported in the PubMed database for the last 20 years (2001-2021) in the adult patient population (age 19 and over). The aim of this study is to highlight the asymptomatic presentation of cardiac myxomas and to underline the advantages of a minimally invasive surgical approach. In summary, asymptomatic cardiac myxomas are rare incidental findings. Attention to subtle symptoms during a physical exam and scrupulous history-taking can provide a clue to this diagnosis. Early diagnosis of cardiac myxomas is crucial to prevent life-threatening complications. Minimally invasive surgery is a promising alternative approach to standard open-heart surgery for treating cardiac myxomas, providing faster recovery and higher patient satisfaction with surgical care.

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.

Infective endocarditis (IE), commonly caused by Staphylococcus aureus, can affect multiple cardiac structures and lead to significant morbidity and mortality. We present a case of IE with extensive mitral valve involvement causing perforation and hemodynamic compromise. A 66-year-old Caucasian female presented to the emergency department for progressive altered mental status and lethargy. The patient and family denied history of intravenous drug use (IVDU) on interview. Physical exam revealed tachypnea, tachycardia, lethargy, and fluctuance in the right antecubital fossa draining serous fluid. Initial studies revealed a urinary tract infection, patchy bilateral opacities on chest x-ray, hypoxic respiratory failure, elevated lactate and cardiac markers, leukocytosis, and positive urine toxicology for opioid and benzodiazepine. She was intubated and admitted to the ICU, and later developed acute respiratory distress syndrome with requirement for vasopressors. Antibiotics were started, and blood cultures ultimately grew methicillin-sensitive S. aureus. Coronavirus disease 2019 (COVID-19) results were negative. Cardiology was consulted for elevated cardiac markers that were due to myocardial injury in the setting of septic shock. A transthoracic echocardiogram showed a large mobile mass on the anterior mitral leaflet. Further evaluation with transesophageal echocardiogram revealed a large, mobile, and centrally necrotic vegetation on the medial portion of the mitral annulus extending to both the anterior and posterior leaflets. Doppler of the valve showed holosystolic retrograde ejection into the left atrium confirming a perforation. The patient was transferred urgently to a cardiothoracic surgery capable center for operative intervention on the mitral valve. IE is most commonly caused by S. aureus and seen in highest rates among patients with a prosthetic valve, congenital heart disease, and intracardiac device. However, roughly 50% of IE occurs in patients without any valvular disease. Other risk factors include IVDU, valvular disease, and prior history of endocarditis. Clinical diagnosis of IE is made using the Duke’s criteria, with echocardiogram and bacteremia playing a major role. The initial management involves empiric antibiotics until a pathogen is identified. Surgical consult is also suggested, and indications for surgery include heart failure due to valve dysfunction, uncontrolled infection, prevention of embolism, and hemodynamic compromise. Prompt recognition and intervention is crucial in the prevention of mortality in patients with IE leading to mitral perforation and hemodynamic compromise.

Immune thrombocytopenic purpura (ITP) is an autoimmune pathology that causes thrombocytopenia. This can become extremely troublesome when dealing with the rare clinical scenario of having to operate a highly invasive procedure on patients with thrombocytopenia. We report a case of a 66-year-old male with multiple comorbidities, including ITP, who underwent coronary artery bypass grafting (CABG) with an aortic valve replacement (AVR). He deteriorated rapidly, prompting urgent procedures. Little to no literature exists on the treatment plan for a critical patient with ITP who is about to undergo an open heart surgery. Our goal was to aggressively treat the patient with prednisolone, azathioprine, and platelets in the short preoperative time in order to maximize the prognosis. Our patient remained stable postoperatively, developed no complications, and was discharged successfully.

Background and objective The prevalence of aortic stenosis in Saudi Arabia is expected to increase owing to the rise in the life expectancy of the population. Such increase is expected to be met with higher demand for interventions including transcatheter aortic valve implantation (TAVI). In this study, we aimed to identify the outcomes of this procedure among the population of the Western region of Saudi Arabia. Methods This was a retrospective observational study involving patients who underwent TAVI at the King Faisal Cardiac Center (KFCC), Jeddah, Saudi Arabia from June 2018 to January 2020. All patients who had undergone TAVI were included, and patients who were lost to follow-up for more than 90 days were excluded. The collected data included sociodemographic characteristics, peri-procedural assessment, and outcomes within 90 days. Results The study included a total of 52 patients. There were 28 males (53.8%) and 24 females (46.2%). The mean age of the cohort was 78 years. Type two diabetes mellitus was present in 67.3%, and hypertension and dyslipidemia were seen in 80.8% of patients. Coronary diseases were seen in 55.8%. The majority had prior percutaneous coronary intervention (PCI) (53.8%) and 3.8% had coronary artery bypass grafting (CABG). Twenty patients (38.5%) had heart failure. Atrial fibrillation was encountered in 13 patients (25%). Chronic kidney disease was described in nine (17.3%) patients, and four (7.7%) were on regular hemodialysis. The median Society of Thoracic Surgery (STS) risk score was 2.4 (IQR: 1.97-5). High STS scores (>8) were only seen in 9% of the patients. The success rate was 98%, and the in-hospital mortality rate was 3.8%. Vascular complications were seen in eight patients (15.4%), and the majority of them were minor. One patient (1.9%) had a major vascular complication. There was a tendency toward high blood transfusions (19.2%). Clinically manifest stroke was seen in three patients (5.8%). Eight patients (15.4%) had post-procedure complete heart block (CHB). Endocarditis was seen in two patients (3.8%). Thirty-day cardiac readmission was observed in 17.3% of patients, and acute kidney injury was seen in eight patients (15.4%). Mild aortic regurgitation was seen in 51.9% of the patients, but moderate or severe aortic insufficiency (AI) was not encountered. Conclusion Transfemoral TAVI using a self-expandable valve is a safe and feasible procedure at KFCC, an intermediate-sized center. Our data is comparable to local and international centers of similar size. Program sustainability depends on the development of robust referral networks and implementing regulatory quality and patient safety standards.

Transthyretin amyloid cardiomyopathy disease burden is increasing daily due to advancements in diagnostic and imaging modalities in the modern world. Tafamidis is one of many therapeutic options. The main objective of this review is to study the role of Tafamidis in slowing the progression of transthyretin cardiomyopathy (TTR-CM) by analyzing randomized controlled trials (RCTs) and non-RCTs of Tafamidis. We searched for published papers of Tafamidis in the English language in electronic databases like Google Scholar, PubMed, Cochrane Library, and PubMed Central. We imported the resulting articles from our search to Mendeley software. Four reviewers removed the duplicates and performed title and abstract screening of the articles. The same reviewers obtained the full-text of relevant articles and did full-text screening based on eligibility criteria. Finally, five reviewers performed a quality assessment of RCTs using the Cochrane risk of bias assessment and of non-RCTs by a checklist prepared by Downs and Black. Any disagreements about any process were resolved by a discussion with other authors. One RCT and five non-RCTs of Tafamidis were included in this systematic review. From the non-RCTs, stability was observed in different parameters like echocardiographic findings, cardiac biomarkers, and ECG in patients with transthyretin cardiomyopathy during the study duration with Tafamidis. ATTR-ACT (Tafamidis in Transthyretin Cardiomyopathy Clinical Trial) trial demonstrated reduction of cardiovascular events and all-cause mortality in the Tafamidis group in comparison to placebo. In both RCT and non-RCTs, Tafamidis was established as a safe and tolerable drug for patients with TTR-CM. Our study proved the role of Tafamidis in reducing cardiovascular events, all-cause mortality, and the progression of cardiac disease in TTR-CM patients. In addition to five non-RCTs, current evidence is based on the findings of only one RCT of Tafamidis. Hence, evidence from additional RCTs is required to strongly support the stability of parameters like echocardiographic findings, cardiac biomarkers, and ECG with Tafamidis use.

Background Severe patient prosthesis mismatch (sPPM) after surgical aortic valve replacement is associated with worse outcomes. Limited data exists on the impact of sPPM on outcomes after transcatheter aortic valve replacement (TAVR), especially regarding the newer generation valves. The aim of this study was to evaluate the incidence, determinants, and outcomes of sPPM in patients undergoing TAVR with Edwards SAPIEN XT (ES XT) and Edwards SAPIEN 3 (ES3) valves (Edwards Lifesciences, Irvine, CA, USA). Methods We retrospectively reviewed 366 patients who underwent TAVR with ES XT (n = 114) or ES3 (n = 252) valves between July 2012 and June 2018. sPPM was defined as indexed effective orifice area (iEOA)

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that can involve any organ system. Vasculitides are classified according to the predominant vessel involved such as large vessel, medium vessel, or small vessel vasculitis. Of these, Takayasu arteritis, Behcet's disease, relapsing polychondritis, and immunoglobulin G4 (IgG4)-related disease predominantly involve large vessels. The most common form of vasculitis seen in SLE is small vessel vasculitis. Aortitis in SLE is an extremely rare complication. This is a case report of a 21-year-old female patient with a history of SLE with overlap syndrome of primary biliary cirrhosis and autoimmune hepatitis associated with antiphospholipid syndrome (APS), who presented with a one-week history of left-back burning lumbar pain, radiating to the flank, which increased with changes in position associated with intermittent claudication. In the angiography images and the positron emission tomography (PET) scan, a hypometabolic left para-aortic oval image was noted, corresponding to the presence of a contained hematoma in an abdominal aorta rupture. Later, she underwent vascular surgery and hemodynamics, performing thoracoabdominal aortic reconstruction together with aortorenal bypass and left nephrectomy. Pathology fundings of the left kidney correspond with class IV lupus nephritis, and the resection sample of the thoracoabdominal aneurysm showed a marked thinning and fragmentation of elastic fibers, areas of fibrosis of the wall with severe IgG4 negative lymphoplasmacytic infiltrate in the immunohistochemical study, establishing the diagnosis of aortitis.

Visceral artery pseudoaneurysms are rare but potentially life-threatening. Among visceral artery pseudoaneurysm (VAPA), the superior mesenteric artery (SMA) pseudoaneurysm is the rarest type. VAPAs are usually related with infection, inflammatory disease, trauma, or arises as a postoperative complication. Early diagnosis and endovascular or surgical intervention are key in lowering the risk of intestinal infarction and death due to potentially fatal hemorrhage. A 49-year-old man presented with cough, shortness of breath, weight loss, and an incidental finding of spontaneous SMA pseudoaneurysm with localized bleed on CT angiography. An urgent endovascular embolization was performed of the pseudoaneurysm, with an adequate outcome and recovery. SMA pseudoaneurysms associated with infective endocarditis are rare but carry a high risk of rupture and related morbidity and mortality. Direct oral anticoagulants like apixaban (Eliquis) have also been reported to cause pseudoaneurysm formation by slow and constant bleeding, which may have contributed here as a cause of pseudoaneurysm along with infective endocarditis, which was diagnosed later after endovascular embolization. The treatment can be either an endovascular, endoscopic, or open surgical approach.

Takayasu's arteritis is a rare form of chronic inflammatory disorder involving large vessels, with an unclear etiology. Common early signs and symptoms are weakness, malaise, and fever. Takayasu's arteritis mainly involves the aorta and its branches as well as the subclavian and carotid arteries. While radiologic methods can identify diseased vessels, they can't tell the difference between active and chronic lesions. This study reviews the characteristics of Takayasu's arteritis to identify any possible changes in the prevalence of symptoms of the disease. We conducted a literature review of case reports on Takayasu arteritis from PubMed and Google Scholar. Variables of interest were age, gender, symptoms, blood pressure (BP) measurement, diminished pulses, and radiological findings. Data were transferred to an Excel spreadsheet (Microsoft Corporation, Redmond, WA), and mean, median, and standard deviation, frequencies, and proportions were calculated using R version 1.1.456 (RStudio: Integrated Development for R. RStudio, PBC, Boston, MA). There were 43 cases, and females accounted for 88.3% of the presentations. The average age was 25 years, SD 12.5 years. Fever was the most frequent symptom (20.93%), followed by chest pain (13.95%), claudication (13.95%), and headache (13.95%). Less frequent complaints included shortness of breath (11.62%), weight loss (9.30%), syncope (6.98%), and night sweats (4.65%). On the right side, the average BP was 142/87 mmHg, and the left-sided finding averaged 115/72 mmHg. Decreased pulses were primarily seen in the radial artery with 15 cases. Radiological findings showed narrowing of the vessels in the following order: aorta (22), carotid (11), renal (10), subclavian (9), celiac (2), mesenteric (2), axillary (2), and tibial (1). The characteristics of Takayasu's arteritis were analyzed in this study. It identified several findings, ranging from fever symptoms to the signs of claudication, as well as the involvement of major vessels, such as the aorta and its branches, and a summary of radiological findings. This depicts the picture of Takayasu's arteritis and what physicians should expect when dealing with the disease.

Takayasu’s arteritis is a rare chronic granulomatous vasculitis that predominantly affects the aorta and its branches. It is estimated to affect 2.6/million/annum, predominantly women in the second or third decade of their lives. This case report describes the case of a 21-year-old female, who initially only had low-grade fever and acrodynia, which over a few months, progressed to arm and leg claudication, weight loss, nausea, headache, and dizziness. A year later, the patient experienced impalpable radial pulses bilaterally, and her CT angiogram revealed multi-level arterial stenosis. A diagnosis of Takayasu’s arteritis was made and the patient was started on steroids and methotrexate. A consult was made with vascular surgery but no intervention was deemed necessary and the patient responded well to the medical treatment given. Though Takayasu’s arteritis is a very rare disease, a detailed history, clinical examination, and investigations can help with early diagnosis.

Like many other countries at the moment, the United Kingdom (UK) is currently under national lockdown due to the coronavirus disease 2019 (COVID-19) pandemic. An unfortunate consequence of such social isolation measures is that patients with genuine acute medical emergencies may not present to a hospital in a timely manner. We present such a scenario, whereby a patient had a delayed presentation of ST-elevation myocardial infarction (STEMI) due to fear of breaching COVID-19 lockdown rules. As a result of the patient presenting well outside the optimal treatment window, her STEMI was complicated by a severe ventricular septal defect (VSD). We discuss how the COVID-19 pandemic has influenced the nature and management of STEMIs and associated issues.

Celiac artery compression syndrome (CACS), also known as median arcuate ligament syndrome, can sometimes represent a diagnostic challenge. Here, we present the case of a 29-year-old man who presented with recurrent diabetic ketoacidosis (DKA), abdominal pain, and vomiting thought to be due to cyclical vomiting syndrome. However, the lack of a clear precipitant for DKA, the presence of chronic gastrointestinal symptoms, and a revealing physical examination of abdominal bruit led to clinical suspicion of CACS and its diagnosis after appropriate investigations. While angiography has traditionally been considered the gold standard diagnostic test, hemodynamic and geometric ultrasound criteria can, however, be diagnostic. The patient was managed by releasing the celiac artery through robotic surgery and serial monitoring as an outpatient revealed resolution of his symptoms and no further readmissions for DKA. This case highlights how a presumptive and erroneous diagnosis (cyclical vomiting syndrome) can misguide clinicians, especially when dealing with a rare diagnosis of exclusion.

Infective endocarditis (IE) is an infection of the endothelium of the heart, that typically affects heart valves. While echocardiography remains crucial in the diagnosis and management of IE, multimodality cardiac imaging helps obtain additional information for the management of complex cases. Alternative imaging modalities such as computed tomography (CT), computed tomography angiography (CTA), and magnetic resonance imaging (MRI) are playing an increasing role in the diagnosis and management of IE, especially for patients with prosthetic valve endocarditis (PVE). Here we present a case of a 60-year-old Caucasian male who was diagnosed with IE, complicated by aortic root abscess, and multiorgan failure. In this challenging case, multimodality cardiac imaging helped in the precise understanding of the extent of endocarditis, cannulation strategy, and direct the course of the surgical procedure that resulted in successful patient management.

Killian-Jamieson diverticulum (KJD) is a rare presentation of esophageal diverticulum. It is located beneath the cricopharyngeal muscle and arises laterally from the Killian-Jamieson space. The pathogenesis is postulated to be from increased intraluminal pressure. Most patients with KJD are typically asymptomatic; however, a common clinical presentation is dysphagia. Demographics of patients with KJD are typically elderly, in which the majority are female and over 50 years old. Due to less frequent diagnosis of KJD, there are a limited number of case studies compared to Zenker’s diverticulum, the more common presentation of esophageal diverticulum. In this case study, we discuss an atypical case presentation in a young, African-American female.

Primary cardiac tumors (PCTs) are rare and represent a heterogeneous group of tumors, potentially arising from various parts of the heart. The majority of these tumors are benign (90%), with myxoma being the most common subtype. Cardiac hemangiomas are rare vascular tumors that constitute 1-2% of all benign heart neoplasms. We present a rare case of a 79-year-old woman presented with multifocal embolic brain infarcts secondary to cavernous hemangioma of the mitral valve (MV). Cavernous hemangioma was successfully resected with follow-up imaging at six months, demonstrating no regrowth. There are no pathognomonic signs or findings to suggest cavernous hemangioma of the MV on clinical examination or imaging studies. Surgical resection and histopathologic analysis remain the gold standard for diagnosis and treatment, respectively. Following complete resection, the prognosis is generally favorable with a low recurrence rate, but periodic echocardiography is recommended to detect any potential recurrence.

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.

The severe acute respiratory syndrome coronavirus-2 (SARS-CoV2) virus has been known to manifest various non-pulmonary complications in the affected patient, including both venous and less frequently, arterial thrombosis. Ongoing research is necessary to determine who might benefit from therapeutic anticoagulation as well as potentially develop an algorithm to predict thromboembolic events in this patient population. We present a case of a 65-year-old man with a past medical history of hypertension, diabetes type 2, and a previous cerebrovascular accident who was admitted with acute hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19). On admission to the hospital, the patient was initiated on therapeutic anticoagulation. Subsequently, he developed left lower limb ischemia. Imaging discovered arterial thrombosis in the bilateral deep femoral and left popliteal arteries. Consequently, the patient required catheter directed thrombolysis for partial reperfusion. Unfortunately, the patient succumbed to the complications of COVID-19. This case is notable in that it highlights the arterial thrombophilia associated with COVID-19 despite early intervention with therapeutic anticoagulation.

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.

COVID-19, also known as severe acute respiratory distress syndrome coronavirus 2, mostly affects the respiratory system causing acute respiratory syndrome. It not only targets lungs but also causes vascular endothelial disruption, which can lead to arterial or venous thrombosis causing ischemia, which increases the morbidity and mortality in some patients, if not recognized and treated in a timely manner. We present an interesting case of a patient recovering from COVID-19 pneumonia , who developed bilateral foot ischemia due to thrombosis of bilateral profunda femoris, bilateral anterior tibial, and tibioperoneal arteries. A 44-year-old gentleman presented to the emergency department complaining of severe bilateral foot pain, which progressively got worse. Upon examination he had blue toes bilaterally with absent dorsalis pedis and posterior tibial pulse. CT angiogram was performed, which showed severe multilevel lower limb arterial occlusions involving bilateral profunda femoris, bilateral anterior tibial, and tibioperoneal arteries. The patient was initially thrombolyzed and later underwent thrombectomy with the assistance of interventional radiologist. Hospital course was uneventful, and the patient was discharged on warfarin following complete resolution of symptoms.

Ischemic heart disease (IHD) is the leading cause of death worldwide, and it is defined as an imbalance between myocardial oxygen supply and demand. Coronary artery disease (CAD) and left ventricular hypertrophy (LVH) are two common causes of IHD that independently result in myocardial ischemia. CAD decreases myocardial blood and oxygen supply whereas LVH increases myocardial oxygen demand. The coexistence of both CAD and LVH results in a significant increase in oxygen demand while simultaneously lowering oxygen supply. Since hypertension is a shared predisposing condition for both CAD and LVH, the left ventricular (LV) mass on noninvasive echocardiography can reflect on the severity of coronary artery stenosis. In clinical practice, it can help physicians decide whether to perform invasive cardiac catheterization to visualize the extent of the coronary block. Although, both CAD and LVH are directly proportional to mortality risk, the addition of eccentric LVH can further increase morbidity and mortality due to myocardial infarction. Therefore, the latest management of both the acute and chronic phases of CAD places an increased emphasis on controlling the predisposing factors to prevent or reverse LVH. For example, angiotensin-converting enzyme inhibitors and diuretics reduce LV mass by lowering the cardiac preload and afterload. This article aims to investigate the deleterious effects of the collaboration between CAD and LVH, establish a causal relationship, and explore the new prevention and management strategies.