Aliakbar Arvandi

Intracardiac thrombus-in-transit characterized on 3-dimensional transesophageal echocardiography.

A 60-year-old woman presented with fever and shortness of breath of one weeks duration. Physical examination disclosed a right-lower-quadrant abdominal mass and pretibial edema. A chest computed tomogram showed bilateral pulmonary embolism, and venous Doppler ultrasonographic imaging of the lower extremities revealed acute deep vein thrombosis (DVT) of the right common femoral vein. Abdominal ultrasonograms showed a large right ovarian mass. A 2-dimensional transthoracic echocardiogram (2D TTE) showed an echogenic mass in the atria. Two-dimensional transesophageal echocardiograms (TEE) revealed an aneurysmal interatrial septum and a large, mobile mass in the right atrium. The mass was in transit through a patent foramen ovale and extended into the left atrium (Fig. 1). Three-dimensional (3D) TEE helped to characterize the mass as a thrombus-intransit that extended through the interatrial septum (Fig. 2). Upon sequential cropping of the images, echolucent components seen inside the mass were consistent with an intracardiac thrombus.1 The ovarian mass was found to be malignant. The patient was prescribed long-term anticoagulation. After 6 months, 2D TTE revealed complete resolution of the thrombus and no evidence of left-sided emboli. Fig. 1 Two-dimensional transesophageal echocardiograms show an aneurysmal interatrial septum and the large intracardiac thrombus (arrows) in A) apical 4-chamber view and B) short-axis view at the aortic valve level. Fig. 2 Three-dimensional transesophageal echocardiograms show the intracardiac thrombus-in-transit (arrows) at the levels of A) the interatrial septum and B) the mitral valve.

Isolated Pulmonary Valve Endocarditis Complicated With Septic Emboli to the Lung Causing Pneumothorax, Pneumonia, and Sepsis in an Intravenous Drug Abuser

Intravenous drug users are at increased risk for developing right-sided infective endocarditis involving the tricuspid and pulmonary valves. Isolated pulmonary valve endocarditis in intravenous drug users is very rare, and these patients often have more complications, such as pulmonary embolism, sepsis, and pneumonia. We report a case with pulmonary valve endocarditis and extensive pulmonary complications, including sepsis, septic emboli, pneumonia, and pneumothorax. Early identification of pulmonic valve endocarditis and treatment with appropriate antibiotics with or without surgical management should provide better outcomes, and clinicians need to think about pulmonary valve endocarditis in patients with complex respiratory presentations.

Klippel-Trenaunay syndrome and radial artery coronary graft spasm.

A 75-year-old woman with known diagnosis of Klippel-Trenaunay syndrome presented with acute onset of chest pain, dyspnea and elevated cardiac enzymes. She had triple vessel coronary artery disease on subsequent coronary angiography. Given the unavailability of venous conduits secondary to lower extremity varicosities, coronary artery bypass grafting with radial and internal mammary arterial grafts was carried out. The radial artery graft went into spasm two days later and required intracoronary vasodilators to relieve the spasm. The patient remained hypotensive and finally expired.

Venous Stent Migration into Right Ventricle

Venous stents (VS) are used to treat central and peripheral stenoses. Stent embolization into a cardiac chamber is a rare, yet serious complication. We present a case of a 61-year-old man with a recently stented arteriovenous graft venous stenosis who developed VS migration into the right ventricle, associated with S. aureus bacteremia.

Left Atrial Slow Flow and Its Potential Complication

It has been estimated that 2.2 million people in United States have paroxysmal or persistent atrial fibrillation. The incidence has increased 13% over the past 20 years and it seems to be on the rise. The most feared complication of atrial fibrillation is systemic thromboembolic events. Mitral stenosis and atrial fibrillation is risk factors for cardiac thrombus formation. We report an interesting case in which a 69-year-old male with rheumatic mitral stenosis, atrial fibrillation and congestive heart failure developed rapidly worsening dyspnea on anticoagulation. Subsequent investigation demonstrated impaired left ventricular systolic function, severe mitral valve stenosis and a large left atrial thrombus. Since the patient’s symptoms had worsened rapidly during a relatively short period of time, we hypothesize that the thrombus was obstructing blood flow through the left atrium and was causing the patient’s symptoms. Mitral valve stenosis, itself, is a risk factor for thromboembolic events. Combined with atrial fibrillation and left ventricular systolic dysfunction, slow flow in the left atrium may contribute to thrombus formation. Even though, our patient was anticoagulated, the stability of oral anticoagulation therapy is essential. We want to highlight one particular group of patients, classified as high risk, in which close clinical follow-up and more intense anticoagulation might be of benefit. Also, the possibility of thrombus formation in the left atrium should be considered when there is a sudden change in symptoms

Effect of Alcohol Intake in Patients with Hypertension Currently on Medication Treatment

Regular alcohol use is a risk factor for hypertension and is associated with decreased rate of blood pressure control. The authors conducted a retrospective study of alcohol intake and number of hypertensive medications used in patients with hypertension visiting cardiology clinic from 2011 to 2012. The authors found that a history of alcohol consumption was not associated with number of antihypertensive medication or blood pressure control. However, diastolic blood pressure in normal-weighed drinker subgroup was higher than the nondrinker counterpart. Patients with higher body mass index and Black race tended to use more number of different classes of antihypertensive medication.

Giant coronary artery aneurysm seen on blood-pool study.

An 81-year-old man was incidentally found to have a large pericardial cyst on a chest computed tomography. Before surgical removal, an echocardiogram demonstrated that the cyst was more likely a large (7.5 cm) right coronary arterial aneurysm. A cardiac blood-pool study demonstrated a blood-filled structure adjacent to the heart, roughly the same size as the combined size of both the right and left ventricles. Coronary angiography confirmed the presence of a large right coronary artery aneurysm. A coronary aneurysm should be considered when a blood-filled structure is seen adjacent to the heart on a multigated acquisition scan.

Effects of Alcohol and Illicit Substance Consumption in Patients with Infective Endocarditis

Alcohol and illicit drug use seem to compound every aspect of health, with cardiac and infectious complications as no exceptions. Not spared from the influence of alcohol and illicit drug use is the subject of infective endocarditis. This study assesses the prevalence of disease and risk of complications in patients with infective endocarditis who used alcohol, illicit drugs, or illicit drugs and alcohol. Medical records of the patients diagnosed with infective endocarditis were retrospectively reviewed. The study showed no causation between alcohol intake and prevalence of infective endocarditis but demonstrated significant decreased cardiac function, increased vegetation size, and incidence of embolic complications among drug and/or alcohol users compared to nondrug/alcohol users.