Ankush Moza

Intravenous lipid emulsion in wide complex arrhythmia with alternating bundle branch block pattern from cocaine overdose.

We describe the management of a young patient who had experienced a cocaine overdose. The patient presented with altered mental status and seizures and subsequently developed a wide complex arrhythmia with a rare alternating bundle branch block pattern. Intravenous lipid emulsion was administered following initial resuscitation and endotracheal intubation, because conservative methods of treating the persistent cardiac arrhythmias failed.

Emergent echocardiography and extracorporeal membrane oxygenation: Lifesaving in massive pulmonary embolism

Massive pulmonary embolism is a life-threatening emergency that results in circulatory failure. The main challenges in management are early diagnosis and maintenance of hemodynamic stability. We present a case of a 63-year-old male who was in cardiac arrest. After resuscitation, massive pulmonary embolism was diagnosed with the help of bedside echocardiography and extracorporeal membrane oxygenation (ECMO). We were able to maintain hemodynamic stability and improve hypoxia until the patient underwent embolectomy. This case demonstrates a common presentation of massive pulmonary embolism highlighting the main challenges in its management and the role of echocardiography and ECMO in improving outcomes in such scenarios.

Effect of Transradial Catheterisation on Patency Rates of Radial Arteries Used as a Conduit for Coronary Bypass

BACKGROUND Transradial catheterisation is known to be associated with occlusion of the radial artery with an estimated incidence of 2-10% (1). There are very few studies looking at the patency of radial artery as a bypass graft after utilisation for catheterisation. METHODS We conducted a retrospective review of patients undergoing coronary artery bypass grafting (CABG) utilising a radial artery graft. RESULTS Long term patency rates were 59% in radial artery grafts utilised for catheterisation prior to CABG, compared to 78% if it were not (p= 0.035). CONCLUSION Patency rates of radial artery grafts are significantly lower when the same radial artery was utilised for angiography prior to coronary artery bypass grafting (CABG).

Anomalous Origin of Right Coronary Artery Associated With Hypertrophic Obstructive Cardiomyopathy

A 29-year-old man with anginal chest pain and recurrent syncopal attacks was observed with invasive and noninvasive cardiodiagnostic techniques, which disclosed an anomalous origin of right coronary artery from the left coronary cusp and hypertrophic obstructive cardiomyopathy. The authors report a very rare coexistence of these 2 clinical entities, both of which are well known to independently increase the likelihood of sudden cardiac death under strenuous physical stress.

Reverse Takotsubo Cardiomyopathy: A Story of a Critically Ill Man with Transient Cardiac Dysfunction

Reverse Takotsubo cardiomyopathy (TCM) is a recently described variant of classic TCM. In contrast to classic TCM, the regional wall motion abnormalities are localized in the basal segments. The condition can be triggered by acute stressful events, including acute medical illnesses. The wall motion abnormalities and left ventricular dysfunction are usually completely reversible. We present a case of an 84-year-old man with a complicated postoperative course after laparoscopic cholecystectomy with multiple laparotomies and recurrent sepsis. Echocardiographic evaluation demonstrated left ventricular dysfunction and wall motion abnormalities in a pattern resembling reverse TCM. He had no significant coronary disease on angiography and follow-up echocardiography showed complete resolution of left ventricular systolic dysfunction and regional wall motion abnormalities.

Another cause of chest pain: Staphylococcus aureus sternal osteomyelitis in an otherwise healthy adult

Chest pain requires a detailed differential diagnosis with good history-taking skills to differentiate between cardiogenic and noncardiogenic causes. Moreover, when other symptoms such as fever and elevated white blood cell count are involved, it may be necessary to consider causes that include infectious sources. A 53-year-old female with no significant past medical history returned to the hospital with recurrent complaints of chest pain that was constant, substernal, reproducible, and exacerbated with inspiration and expiration. The chest pain was thought to be noncardiogenic, as electrocardiography did not demonstrate changes, and cardiac enzymes were found to be negative for signs of ischemia. The patient’s blood cultures were analyzed from a previous admission and were shown to be positive for Staphylococcus aureus. The patient was started empirically on vancomycin, which was later switched to ceftriaxone as the bacteria were more sensitive to this antibiotic. A transthoracic echocardiogram did not demonstrate any vegetation or signs of endocarditis. There was a small right pleural effusion discovered on X-ray. Therefore, computed tomography as well as magnetic resonance imaging of the chest were performed, and showed osteomyelitis of the chest. The patient was continued on intravenous ceftriaxone for a total of 6 weeks. Tests for HIV, hepatitis A, B, and C were all found to be negative. The patient had no history of childhood illness, recurrent infections, or previous trauma to the chest, and had had no recent respiratory infections, pneumonia, or any underlying lung condition. Hence, her condition was thought to be a case of primary sternal osteomyelitis without known cause.

Rituximab Induced Left Bundle Branch Block

Rituximab (a monoclonal antibody directed against CD 20) therapy can be acutely complicated by infusion reactions and cardiac arrhythmia on rare occasions. We report the first case of a new onset left bundle branch block (LBBB) after rituximab therapy for Wegener′s vasculitis.

Pulmonary hypertension in renal transplant candidates: A systematic review and meta-analysis of the available evidence and a proposed algorithm for pre-transplant management

Background: Pulmonary hypertension (PHT) is common in patients with end stage renal disease (ESRD). Moderate to severe PHT is a strong independent predictor of mortality in hemodialysis (HD) patients, and in those undergoing noncardiac surgery. The studies which have evaluated the association of PHT with renal transplant outcomes have shown conflicting results. We performed a systematic review and meta-analysis of the current available evidence examining the effect of existing PHT on relevant clinical outcomes following renal transplantation. Materials and methods: Major databases (Pubmed, Embase, Cochrane, Web of Science, and Scopus) were searched for studies of patients undergoing renal transplantation that reported pulmonary pressures and transplantation outcomes. Data were extracted from the original publications. Results: Out of 259 publications, only 3 (with a total of 502 patients) were eligible for inclusion in the current analysis. Our meta-analysis of these three studies suggests a three-fold increase in mortality after renal transplantation in patients with PHT compared to those without PHT (OR 3.15, 95% confidence interval 1.42-6.97; p = 0.005). A qualitative review indicates that PHT is associated with both early graft dysfunction and worse renal function at 12 months post-transplant. Conclusions: There is paucity of clinical trial data examining the effect of pulmonary hypertension and its management on renal transplant outcomes. In this metaanalysis we found that there is an increased risk of mortality in patients with pulmonary hypertension who undergo renal transplantation. Correspondence to: George V. Moukarbel, MD, Division of Cardiovascular Medicine, Department of Medicine, University of Toledo Medical Center, 3000 Arlington Avenue, Toledo, OH 43614, USA, Tel: (419) 383-6094; Fax (419) 3833041; E-mail: george.moukarbel@utoledo.edu

Tacrolimus as a rare cause of pericardial effusion in a renal transplant recipient

Pericardial effusion in a renal transplant recipient represents a diagnostic conundrum with a variety of differential diagnoses. Immunosuppressive medications such as sirolimus have been linked to pericardial effusions in the reported literature. Tacrolimus has been reported to be associated with pleural effusions and ascites. We present a case of a patient with tacrolimus as the likely cause of a recurrent pericardial effusion.

Effectiveness of Ultrafiltration in Patients with Congestive Heart Failure

Among all cardiac diseases, congestive heart failure (CHF) is the leading cause of patient rehospitalization. Fluid overload and lung congestion are the major reasons for these recurrent admissions. This disease can be associated with worsening renal function, a phenomenon called cardiorenal syndrome (CRS), which is challenging to manage. Conventional diuretic therapy of both CRS and diuretic resistance has offered limited efficacy. Compared with conventional therapy, hemodiafiltration (HDF) has shown promising results for fluid removal in some clinical trials, with inconclusive effects on all-cause mortality and rehospitalizations. Nonetheless, the results are inconsistent because of the high heterogeneity among these studies. In this chapter, we shed light on the role of different methods of ultrafiltration, including peritoneal ultrafiltration, sustained slow efficiency dialysis, and HDF, in the management of CHF, and review the current literature.