Amier Ahmad

Nutcracker Syndrome and Sickle Cell Trait: A Perfect Storm for Hematuria

We describe the case of a 27-year-old woman with a history of sickle cell trait (SCT) who presented with several months of hematuria and was found to have nutcracker syndrome (NCS). While SCT is a common cause of hematuria resulting from renal papillary necrosis, our patient had concomitant abdominal pain and anemia, prompting further evaluation and the subsequent diagnosis of NCS. Interestingly, the anoxia in the left renal vein from NCS predisposes patients with SCT to sickling. Our case highlights key clinical features of both NCS and SCT and the relationship between the two disease processes.

Hypertension in Women: Recent Advances and Lingering Questions

Cardiovascular disease (CVD) is the leading cause of death in women in every major developed country and most emerging countries.1,2 Hypertension, the most common modifiable risk factor for CVD, is estimated to occur in 85.7 million adults in the United States (44.9 million women and 40.8 million men).3 Elevated blood pressure (BP) >140/90 mm Hg is associated with a shorter life expectancy overall, shorter life expectancy free of CVD, and more years lived with CVD.3–5 Hypertension is less common in women, compared with men, in those younger than 65 years of age, but is more common in elderly (65 years and older) women than men. In the United States, between 2011 and 2014, the prevalence of hypertension in women and men by age group was 8% versus 11% (20–34 years), 23% versus 23% (35–44 years), 33% versus 36% (45–54 years), 56% versus 58% (55–64 years), 66% versus 64% (65–74 years), and 81% versus 73% (≥75 years).3 Globally, the prevalence of hypertension differs between sexes. Mills et al6 conducted a systematic analysis of population-based studies from 90 countries with 968 419 individuals to estimate the prevalence of hypertension in various countries grouped by income. Women in middle-/low-income countries, across all age groups, had a higher prevalence of hypertension compared with high-income countries. Awareness rates were higher in women than in men in both high-income countries (72% women versus 62% men) and middle-/low-income countries (45% women versus 31% men). Furthermore, women in both high-income countries (62% women versus 49% men) and middle-/low-income countries (36% women versus 22% men) reported a higher rate of antihypertensive medication use compared with men, and hypertension control rates (BP <140/90 mm Hg) were higher in women than in men in both high-income countries (52% women versus 49% men) and middle-/low-income countries …

Usefulness of three-dimensional echocardiography in the assessment of valvular involvement in Loeffler endocarditis

Loeffler endocarditis is a complication of hypereosinophilic syndrome resulting from eosinophilic infiltration of heart tissue. We report a case of Loeffler endocarditis in which three‐dimensional transthoracic and transesophageal echocardiography provided additional information to what was found by two‐dimensional transthoracic echocardiography alone. Our case illustrates the usefulness of combined two‐ and three‐dimensional echocardiography in the assessment of Loeffler endocarditis. In addition, a summary of the features of hypereosinophilic syndrome and Loeffler endocarditis is provided in tabular form.

Usefulness of live/real time three/four-dimensional transesophageal echocardiography in the percutaneous closure of an iatrogenic aorto-right ventricular fistula

The development of an aorto‐right ventricular fistula is a rare complication of cardiac surgery. The most common treatment is surgical closure of the fistula, but percutaneous closure of the fistula has become an attractive alternative option. We present a case of successful utilization of live/real time three/four‐dimensional transoesophageal echocardiography (3/4DTEE) to select the correct device size for percutaneous closure of an adult patient presenting with an aorto‐right ventricular (AO‐RV) fistula following aortic valve replacement. To the best of our knowledge, this is the first case in which 3/4DTEE was used to select the device size and guide percutaneous closure of an iatrogenic AO‐RV fistula.

Psoriasis and Cardiomyopathy: A Review of the Literature

Abstract Psoriasis is an idiopathic chronic immune-mediated skin condition in which the body’s immune system undergoes several derangements, including increased antigen presentation by T cells and increased T-helper cell type 1 cytokines, resulting in skin lesions as well as arthritis. Despite that cardiovascular involvement in psoriasis is common and reported in up to 47% of cases, this association is not well recognized by physicians, dermatologists, and cardiologists. Psoriasis is considered the most prevalent autoimmune disease in the United States and affects approximately 7.4 million people. Although its exact etiology is unclear, inflammatory response to infectious agents has been proposed as one of the mechanisms. We present a concise review of the literature associating psoriasis with dilated cardiomyopathy and the proposed pathophysiologic processes for the main goal of increased awareness.

Periorbital edema from apixaban treatment

A 70-year-old female with nonvalvular atrial fibrillation presented with 2 weeks of progressive bilateral periorbital swelling and pruritus limited to her eyes. Her symptoms started 2 days after her oral anticoagulation was changed from warfarin to apixaban. She denied rash, shortness of breath, and tongue or lip swelling. She had made no other medication changes and had used no new facial products within that time period. Examination revealed bilateral eyelid edema with chemosis, tearing, and conjunctival hyperemia (Fig. 1). Her apixaban was discontinued and she was referred to ophthalmology. There were no visual changes on formal ophthalmologic examination, and the patient was instructed to apply triamcinolone cream locally for symptomatic relief. Within 1 week, her symptoms had resolved (Fig. 2). She was subsequently started on rivaroxaban without issue. Apixaban is a direct inhibitor of factor Xa for which no hypersensitivity reactions have been reported in the literature (other than product information reporting a frequency of 0.1– 1%). The underlying mechanism resulting in periorbital edema remains unclear and is not established in the literature. Ours is the first report of bilateral periorbital edema likely from the use of apixaban with complete resolution of symptoms after cessation of the drug.

Incremental value of live/real time three‐dimensional transesophageal echocardiography in the assessment of ventricular septal rupture following acute myocardial infarction

Ventricular septal rupture is a serious complication following acute myocardial infarctions and is associated with a significant mortality rate. Classically, two‐dimensional transthoracic echocardiography has been used to diagnose this complication and visualize its location. Two‐dimensional transesophageal echocardiography has supplemented the transthoracic approach by providing more accurate assessment of the defect size and in guiding closure both percutaneously and intraoperatively. This modality, however, is limited to two‐dimensional views only, and a greater breadth of information is instead available through the use of three‐dimensional transesophageal echocardiography. We present a series of 11 patients in which live/real time three‐dimensional transesophageal echocardiography offered incremental benefits over two‐dimensional imaging alone.

Usefulness of two- and three-dimensional transesophageal echocardiography in the assessment of proximal left coronary system compression by a paraprosthetic aortic valve abscess

Paraprosthetic aortic valve abscess represents a rare, but lethal complication of infective endocarditis. We report a case of proximal left coronary system compression by a paraprosthetic aortic valve abscess whose detection was augmented using live/real time three‐dimensional transesophageal echocardiography. Our case illustrates the usefulness of combined two‐ and three‐dimensional transesophageal echocardiography in detecting this finding.

Incremental benefit of three‐dimensional transesophageal echocardiography in the assessment of left main coronary artery stent protrusion

Ostial lesions represent a challenging clinical scenario and percutaneous intervention (PCI) of left main coronary artery ostial lesions has been associated with postintervention complications, including protrusion of deployed stents into a sinus of Valsalva or aortic root. We report a case of stent protrusion into the aortic root following aorto‐ostial left main coronary artery PCI, in which three‐dimensional transesophageal echocardiography (3DTEE) provided incremental benefit over standard two‐dimensional images. Specifically, 3DTEE confirmed the presence of stent protrusion by allowing clear visualization of the stent scaffold, in addition to characterizing the relationship between the stent and surrounding structures.

Does three-dimensional transesophageal echocardiography provide incremental value in percutaneous closure of ascending aortic pseudoaneurysm?

Ascending aortic pseudoaneurysms (AO PSAs), if left untreated, are complicated by a high rate of rupture resulting in significant morbidity and mortality. New transcatheter modalities have emerged as acceptable surgical alternatives for their management. We present a case of an ascending aortic PSA in which intraoperative two‐ and three‐dimensional transesophageal echocardiography (2DTEE and 3DTEE) provided a comprehensive assessment of the PSA in pre‐ and postclosure settings.