Bassam Omar

Cardioprotection by Cu, Zn-superoxide dismutase is lost at high doses in the reoxygenated heart

Limited dose-response curves for superoxide dismutase (SOD) were assessed in isolated and in vivo hearts. SOD at 2.3, 7, 20, or 50 mg/L suppressed CK release in Langendorff rat hearts by 61%, 63%, 72%, and 30%, respectively. SOD at 0.5, 1, 5, and 50 mg/L suppressed LDH release in Langendorff rabbit hearts by 32%, 48%, 54%, and -12%, respectively. In rabbit hearts subjected to coronary artery ligation and reperfusion in vivo, SOD at 2, 5, or 15 mg/kg reduced infarct size by 10%, 30% or 19%, respectively, while 50 mg/kg increased infarct size by 28%. In conclusion, while SOD was protective at low doses in all models, protection was lost at higher doses in the isolated rat and rabbit hearts, and exacerbation of damage was seen in the in vivo rabbit hearts.

ST-Elevation Myocardial Infarction in the Presence of Biventricular Paced Rhythm

BACKGROUND In the diagnosis of acute myocardial infarction (AMI), the presence of baseline left bundle branch block or a permanent pacemaker rhythm poses a challenge. OBJECTIVE We present a case report highlighting this challenge, along with a review of pertinent literature. CASE REPORT A 70-year-old female with known severe idiopathic dilated cardiomyopathy and moderate coronary artery disease who was status post-biventricular pacemaker/implantable cardioverter defibrillator insertion was brought to our institution via Emergency Medical Services with recurrent firing of her implantable cardioverter defibrillator and syncope. After stabilization in the Emergency Department and treatment with intravenous amiodarone, the patient admitted to having ongoing chest pains. The electrocardiogram revealed evidence of biventricular pacing with superimposed ST-segment elevations in the anterolateral leads indicative of myocardial injury. She underwent prompt angiography, thrombectomy, and bare-metal stent insertion to a totally occluded proximal left anterior descending coronary artery, with resolution of her chest pain and improvement in the ST-segment changes. CONCLUSIONS Despite proposed criteria that aid in the recognition of AMI with underlying left bundle branch block and paced rhythm; the advent of new pacing modalities and the potential variability of pacing sites impose additional diagnostic challenges requiring higher level of suspicion and better physician awareness.

Ciprofloxacin-induced torsade de pointes

A 65-year-old man with recently diagnosed urinary tract infection treated with ciprofloxacin (Cipro) presented to our institution with recurrent seizure-like activity. His rhythm revealed torsade de pointes, which required defibrillation. Subsequent electrocardiogram revealed severely prolonged QT interval, which near-completely resolved 7 days later off Cipro. This case highlights a rare but potentially fatal side effect of quinolone antibiotics, especially in combination with other QT-prolonging medications. Review of the literature with regard to prevalence, mechanism, and assessment and treatment of this potentially fatal incidence is provided.

Iatrogenic Aortic Insufficiency Following Mitral Valve Replacement: Case Report and Review of the Literature

We report a 28-year-old white female who suffered significant aortic insufficiency (AI) following mitral valve (MV) replacement for endocarditis. The patient had history of rheumatoid arthritis and presented to our emergency department with a 3-month history of dyspnea, orthopnea, fevers and weight loss, worsening over 2 weeks, for which she took intermittent acetaminophen. On admission, vital signs revealed blood pressure of 99/70 mm Hg, heart rate of 120 beats/minute, and temperature of 98.8 °F; her weight was 100 lbs. Physical exam revealed a thin and pale female. Cardiac auscultation revealed regular tachycardic rhythm with a third heart sound, and a short early systolic murmur at the left lower sternal border without radiation. Lungs revealed right lower lobe rhonchi. Initial pertinent laboratory evaluation revealed hemoglobin 9.6 g/dL and white blood cell count 17,500/μL. Renal function was normal, and hepatic enzymes were mildly elevated. Chest radiogram revealed right lower lobe infiltrate. Blood cultures revealed Enterococcus faecalis. Two-dimensional echocardiogram revealed large multilobed vegetation attached to the anterior MV leaflet with severe mitral regurgitation (MR), otherwise normal left ventricular systolic function. She was started on appropriate antibiotics and underwent MV replacement with 25-mm On-X prosthesis. She was noted post-operatively to have prominent systolic and diastolic murmurs. Repeat echocardiogram revealed normal mitral prosthesis function, with new moderately severe AI. Transesophageal echocardiogram revealed AI originating from a tethered non-coronary cusp, due to a suture preventing proper cusp mobility. The patient declined further surgery. She recovered slowly and was discharged to inpatient rehabilitation 4 weeks later. This case highlights the importance of vigilance to this potential serious complication of valve surgery with regard to diagnosis and treatment to prevent long-term adverse consequences.

“Spice” (Synthetic Marijuana) Induced Acute Myocardial Infarction: A Case Series

Marijuana is the most widely abused “recreational” substance in the United States, with highest prevalence in young adults. It is reported to cause ischemic strokes, hepatitis, anxiety, and psychosis. Although it is associated with dose dependent tachycardia and can lead to coronary vasospasm, it has not been directly related to acute myocardial infarction (AMI). Marijuana induced coronary vasospasm can result in endothelial denudation at the site of a vulnerable atherosclerotic plaque in response to hemodynamic stressors, potentially causing an AMI. Spice refers to herbal mixture with composition and effects similar to that of marijuana and therefore is referred to as “synthetic marijuana.” Herein, we report 3 cases of spice induced ST-segment elevation myocardial infarction. All patients were relatively young and had few or absolutely no risk factors for cardiovascular disease. All patients underwent emergent coronary angiography, with two needing stent placement and the third requiring only aspiration thrombectomy. Our case series emphasizes the importance of suspecting and investigating synthetic marijuana use in low risk young adults presenting with AMI.

Anomalous Origin of Left Anterior Descending Artery and Left Circumflex Artery from Right Coronary Sinus with Malignant Left Anterior Descending Artery Course: Role of Coronary CT Angiography Derived Fractional Flow Reserve in Decision Making

Congenital coronary anomalies are uncommon and are mostly asymptomatic; however, patients may have symptoms depending on the origin and course of anomalous artery. Very rarely, coronary anomalies can also lead to life-threatening complications especially in young athletes. A malignant course of the left main (LM) or left anterior descending (LAD) artery between aorta and pulmonary artery is considered the most significant risk factor for such complications. Various noninvasive tests are available to evaluate myocardial ischemia due to anomalous coronary artery. Coronary computed tomography (CT) angiogram derived fractional flow reserve (CT-FFR) is a noninvasive diagnostic test which has shown promising results in the hemodynamic assessment of obstructive coronary artery disease. However, its role in coronary anomalies has not been studied. We present a case of a 22-year-old male who presented with atypical chest pain and was found to have anomalous origin of left anterior descending (LAD) artery and left circumflex (LCX) artery from right coronary sinus. LAD had a malignant course for which CT-FFR was done which was hemodynamically nonsignificant. The decision was made to manage the patient conservatively.

Correlation of Weight and LDL Level Changes with Age in Males vs. Females

Results: Weight in young patients (mean age 50; n = 157) was 236 ± 70 lbs, and in Older patients (mean age 69; n = 243) was 198 ± 53 lbs (38 lbs difference; P < 0.05). Weight in young males decreased from 241 ± 70 lbs to 204 ± 44 lbs with age (37 lbs difference, P < 0.05), while weight in females decreased from 206 ± 65 lbs to (12 lbs difference, P = NS). LDL in young patients was 97 ± 41 mg/dL and in older patients was 81 ± 33 mg/dL (16 mg/dL difference, P < 0.05). LDL in young males decreased from 92 ± 33 mg/dL to 81 ± 34 mg/dL with age (11 mg/dL difference, P < 0.05), while LDL in young females decreased from 104 ± 49 mg/dL to 81 ± 32 mg/dL with age (23 mg/dL difference, P < 0.05). Abstract

Persistent right superior vena cava in a patient with dextrocardia: Case report and review of the literature

Introduction Systemic venous circulation anomalies are uncommon; they are often incidental findings during echocardiography. Case A 56-year-old man, with dextrocardia, was evaluated for dyspnea. The patients medical history included diabetes mellitus requiring insulin treatment, hypertension, and tobacco use. Physical examination revealed normal jugular venous pulsations and clear lungs. Cardiac examination revealed normal heart sounds, and grade II/VI systolic ejection murmur over the right precordium. Echocardiography revealed normal chamber size and systolic function, without significant valvular lesions. The coronary sinus was dilated. It was evaluated using intravenous agitated saline contrast to rule out anomalous venous drainage or shunting. When injected into the left antecubital vein, contrast appeared initially in the right atrium followed by the right ventricle. However, when injected into the right antecubital vein, contrast appeared initially in the dilated coronary sinus followed by the right atrium and right ventricle. There was no evidence of intracardiac shunting. These findings were consistent with persistent right superior vena cava in the setting of situs inversus dextrocardia, with normally draining left superior vena cava. Conclusion Persistent superior vena cava connection to the coronary sinus is often incidental but an important finding which helps in planning safe invasive procedures.<Learning objective: Understand the importance of identifying anomalous venous connections with regard to catheter-based procedures. Appreciate the incidence of these vascular anomalies in the normal population and in congenital heart disease. Understand how echocardiography with intravenous agitated saline contrast can be helpful in the diagnosis of such anomalous venous connections.>.

Chest pain associated with rate-related left bundle branch block and cardiac memory mimicking ischemia

Background Intermittent left bundle branch block (LBBB) has been linked to chest pain, and causes cardiac memory electrocardiographic (ECG) changes mimicking ischemia. Purpose To present a case of chest pain with ECG abnormalities suggestive of ischemia, both likely caused by LBBB. Case A 33-year-old hypertensive female evaluated for chest pain and LBBB by ECG was treated with lisinopril and metoprolol, and scheduled for stress testing. A 12-lead ECG performed prior to the stress test, due to recurrence of the chest pain the preceding night, showed resolution of the LBBB with a lower heart rate, and T-wave inversions in the precordial leads suggestive of ischemia. She developed chest pains with reappearance of LBBB during stress testing, which prompted cardiac catheterization. This revealed normal coronaries and left ventricular systolic function. The ECG abnormalities were in retrospect likely due to cardiac memory. Her chest pains may have been caused by the intermittent, rate-related LBBB, as control of her heart rate and blood pressure with metoprolol and lisinopril improved her symptoms on follow-up. Conclusion Intermittent LBBB causes chest pain and electrocardiographic abnormalities suggestive of ischemia in the absence of obstructive coronary disease. Certain clinical and electrocardiographic features may provide clues to a non-ischemic etiology.<Learning objective: In the absence of obstructive coronary disease, rate-related left bundle branch block is associated with chest pain described as local, non-radiating, with palpitations and walk-through phenomenon. It can also cause electrocardiographic (ECG) changes of cardiac memory, which mimic myocardial ischemia, but with T waves that are positive in lead aVL, positive or isoelectric in lead I, and more inverted in the precordial leads compared with lead III. These clinical and ECG features may provide clues to non-coronary etiology of chest pain.>.

Traumatic Tension Pneumothorax as a Cause of ICD Failure: A Case Report and Review of the Literature

Background. Tension pneumothorax can infrequently cause ventricular arrhythmias and increase the threshold of defibrillation. It should be suspected whenever there is difficulty in defibrillation for a ventricular arrhythmia. Purpose. To report a case of traumatic tension pneumothorax leading to ventricular tachycardia and causing defibrillator failure. Case. A 65-year-old African-American female was brought in to our emergency department complaining of dyspnea after being forced down by cops. She had history of mitral valve replacement for severe mitral regurgitation and biventricular implantable cardioverter defibrillator inserted for nonischemic cardiomyopathy. Shortly after arrival, she developed sustained ventricular tachycardia, causing repetitive unsuccessful ICD shocks. She was intubated and ventricular tachycardia resolved with amiodarone. Chest radiograph revealed large left sided tension pneumothorax which was promptly drained. The patient was treated for congestive heart failure; she was extubated on the third day of admission, and the chest tube was removed. Conclusion. Prompt recognition of tension pneumothorax is essential, by maintaining a high index of suspicion in patients with an increased defibrillation threshold causing ineffective defibrillations.