Adnan Sadiq

Paradoxical Arterial Emboli Causing Acute Limb Ischemia in a Patient with Essential Thrombocytosis

Acute arterial occlusion can be the result of acute thrombosis or systemic embolism. Paradoxical embolism of a venous thrombosis through a right-to-left shunt is an important cause of acute limb ischemia. We describe a young patient with acute limb ischemia who was found to have multiple deep venous thromboses causing arterial embolization through a patent foramen ovale. Essential thrombocytosis was found to be the risk factor for venous thromboses in this patient. The patient was managed with embolectomy and anticoagulation along with chemotherapeutic cytoreduction of platelet count. This case illustrates the importance of considering the systemic embolism as a cause of acute arterial occlusion. The presence of a hypercoagulable status such as chronic myeloproliferative disorder does not eliminate the possibility of systemic embolism in the event of acute arterial occlusion. Patients presenting with acute limb ischemia should be evaluated for embolic sources. The presence of deep venous thrombosis in such a patient should prompt the evaluation for a patent foramen ovale.

Superior vena cava and right atrium wall infective endocarditis in patients receiving hemodialysis

Infective endocarditis is significantly more common and causes greater morbidity and mortality in patients receiving hemodialysis than in the general population. Episodes of bacteremia during hemodialysis are primarily the result of frequent vascular access through an arteriovenous fistula, a vascular graft, or an indwelling vascular catheter. This leads to dialysis access infection and secondary bacteremia. We describe 4 cases of patients receiving hemodialysis, with an indwelling intravascular dialysis catheter, who developed right-sided endocarditis with vegetations located exclusively on the superior vena cava and right atrium wall. All patients had persistent bacteremia with Staphylococcus, secondary to an indwelling intravascular hemodialysis catheter, which led to seeding of the right-sided cardiac wall, causing infective endocarditis. The rates of acceptance for hemodialysis are increasing, along with improved survival in this group of patients. This will probably lead to an increase in the incidence of infective endocarditis, with atypical presentations such as superior vena cava and right-sided cardiac wall endocarditis.

Complete heart block in takotsubo cardiomyopathy.

Tako-tsubo cardiomyopathy is a relatively recently recognized clinical entity, which presents similar to an acute myocardial infarction but there is no evidence of obstructive coronary artery disease on cardiac catheterization. It mostly affects postmenopausal women and an episode of acute illness or stress can often be identified preceding the presentation. Tako-tsubo cardiomyopathy (TCM) usually has a favorable outcome and an excellent prognosis but, in rare instances, it can be associated with life threatening complications. We report a unique case of TCM where the patient presented with a transient complete heart block.

Radiation induced cardiac valve disease in a man from Chernobyl.

A young man presented with a new heart murmur. History revealed that the patient was from Ukraine, which was affected by the Chernobyl nuclear plant explosion in 1986. Physical examination revealed murmurs of mitral regurgitation and aortic stenosis. Transesophageal echocardiography revealed severely calcified mitral and calcified tricuspid aortic valves with mitral and aortic regurgitation and aortic stenosis. Following valve replacement surgery, pathologic examination of the valves showed severe dystrophic calcifications and changes suggestive of a chronic inflammatory process such as radiation-induced valve disease. In the absence of another etiology explaining such severe valve disease in a young man, it can only be surmised that heavy radiation exposure from the nuclear plant caused this significant valve damage.

Medication-induced Takotsubo Cardiomyopathy presenting with cardiogenic shock—utility of extracorporeal membrane oxygenation (ECMO): case report and review of the literature

Takotsubo cardiomyopathy (TTC) is a transient condition that affects the myocardium and is seen mostly in post-menopausal women secondary to an emotional or physical stressor; however, certain drugs have been described as cause of this syndrome. We report the case of a young female with medication--induced TTC, who presented with cardiogenic shock as initial manifestation, treated successfully with extracorporeal membrane oxygenation (ECMO). To our knowledge, this is the first case in the literature describing the use of ECMO in cardiogenic shock due to medication-induced TTC.

Echocardiography: a case of coronary sinus endocarditis.

Case: A 23-year-old female with history of hypertension and end-stage renal disease requiring hemodialysis (HD) presented with fever. She had been undergoing HD via a tunneled catheter for a year and presented 3 months prior to this admission for bacteremia with Enterococcus faecalis. At that time she was treated with vancomycin and gentamycin as well as HD catheter replacement and implantation of an arteriovenous (AV) fistula. She was discharged to complete 10 days of intravenous vancomycin during HD and ciprofloxacin orally. She now presented with fever of 102°F during HD, laboratory findings showed a white blood cell count of 30 9 10/L, hemoglobin of 10.2 g/dL, hematocrit of 31%, and platelets of 31 9 10. Basic metabolic panel showed sodium of 134 mEq/L, potassium 5.4 mEq/L, chloride 97 mmol/L, carbon dioxide 25 mmol/L, blood urea nitrogen 81 mg/dL, creatinine 15.1 mg/dL, glucose 203 mg/dL, and calcium 8 mg/dL. Blood cultures were positive for Acinetobacter baumanii. Her fever persisted despite antimicrobial coverage with ampicillin sulbactam and gentamicin intravenously. As her AV fistula was not yet matured a HD catheter was replaced. Transthoracic echocardiogram (Philips iE33, Philips Medical Systems, Andover, MA, USA) performed revealing a mobile structure of 1.4– 0.4 cm in the right atrium, originating from the ostium of the coronary sinus (CS) consistent with vegetation. No valvular involvement was seen (Figs. 1 and 2; Videos S1–S3). With persistent fever and echocardiographic findings, antibiotics were changed from ampicillin sulbactam to meropenem intravenously according to susceptibility. Since the diagnosis of endocarditis was established by echocardiography and her symptoms improved upon treatment of antibiotics, transesophageal echocardiogram was not required. She was discharged with 6 weeks of ceftazidime and gentamicin to be given after dialysis. Her blood cultures turned negative, fever subsided, and her white blood cell count normalized. On outpatient follow-up after completion of antibiotics, the patient had no further febrile events and no further imaging was required. Several months later, the patient underwent removal of her tunneled catheter as her AV fistula was matured for HD access. Address for correspondence and reprint requests: Clara Kwan, M.D., Department of Medicine, Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, NY 11219. Fax: 718-283-8498; E-mail: clara.kayla@gmail.com Figure 1. An apical four-chamber view with posterior angulation showing a vegetation measuring 1.4 9 0.4 cm is seen in the right atrium, attached to the ostium of the coronary sinus (white arrow) consistent with a vegetation. RA = right atrium; RV = right ventricle; LV = left ventricle.

Sinus of Valsalva aneurysm: a rare presentation with ventricular tachycardia.

![Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4][![Graphic][5] ][5] An 82-year-old male with of a history of hypertension presented to the emergency department with complaints of intermittent palpitations. Electrocardiogram results showed monomorphic ventricular

A Multidisciplinary Approach to Anesthetic Management of a Parturient with Severe Aortic Stenosis.

In order to optimize anesthetic management and avoid adverse maternal and fetal outcomes, a clear understanding of the changes in cardiovascular physiology that occur during pregnancy is paramount. The effects of normal gestation on the cardiovascular system are particularly significant in a parturient with cardiac valvular pathology. We present a case of a 27-year-old G2P0 at 37 weeks with a past medical history of diabetes, macrosomia, congenital bicuspid aortic valve with severe stenosis (valve area 0.7 cm2) who was scheduled for elective C-section. A multidisciplinary discussion involving cardiologists, cardiac surgeons, obstetric surgeons, neonatal intensivists, perfusion staff, anesthesiologists, and nursing staff was held to formulate a plan for the perioperative management of this parturient. Also, contingency plans were formulated and discussed with the care providers, in the event of acute decompensation of the mother and baby and possible need for emergency aortic valvuloplasty and/or aortic valve replacement.

Unusual Endocarditis: “Rare Bug, Rare Site”

A 27-year-old man was diagnosed with infective endocarditis due to Streptococcus agalactiae. Large vegetations were seen on the anterior mitral valve leaflet and also on the right ventricular side of a membranous ventricular septal defect. Streptococcus agalactiae is a rare cause of endocarditis, and it is very rare to find large vegetations around ventricular septal defect. The authors present this interesting case of unusual endocarditis with vegetations in both the right and left heart. This case is the first reported case of infective endocarditis involving the left and the right sides of the heart at the same time in a nonintravenous drug user.

Systolic aortic regurgitation: A rare phenomenon

We describe a case of an elderly man admitted to our hospital with syncope and a slow pulse rate. An echocardiogram showed both diastolic as well as systolic aortic regurgitation. Careful analysis of the clinical data, electrocardiogram and echocardiogram revealed that systolic aortic regurgitation was related to syncope in a very interesting fashion.