M. Samir Arnaout

Guidelines for the Use of Echocardiography in the Evaluation of a Cardiac Source of Embolism

Embolism from the heart or the thoracic aorta often leads to clinically significant morbidity and mortality due to transient ischemic attack, stroke or occlusion of peripheral arteries. Transthoracic and transesophageal echocardiography are the key diagnostic modalities for evaluation, diagnosis, and management of stroke, systemic and pulmonary embolism. This document provides comprehensive American Society of Echocardiography guidelines on the use of echocardiography for evaluation of cardiac sources of embolism. It describes general mechanisms of stroke and systemic embolism; the specific role of cardiac and aortic sources in stroke, and systemic and pulmonary embolism; the role of echocardiography in evaluation, diagnosis, and management of cardiac and aortic sources of emboli including the incremental value of contrast and 3D echocardiography; and a brief description of alternative imaging techniques and their role in the evaluation of cardiac sources of emboli. Specific guidelines are provided for each category of embolic sources including the left atrium and left atrial appendage, left ventricle, heart valves, cardiac tumors, and thoracic aorta. In addition, there are recommendation regarding pulmonary embolism, and embolism related to cardiovascular surgery and percutaneous procedures. The guidelines also include a dedicated section on cardiac sources of embolism in pediatric populations.

Unusual Manifestation of an Ampullary Tumor Presenting with Severe Upper Gastrointestinal Bleeding

Ampullary tumors can occasionally ulcerate and present as frank gastrointestinal bleeding. The most common clinical presentation is jaundice like in other tumors of the biliary tree. We report on a 68-year-old man who presented with severe upper gastrointestinal hemorrhage secondary to an asymptomatic mass of the ampulla of Vater. An endoscopic biopsy specimen revealed a villous adenoma with moderate dysplasia. A curative resection was performed, and pathological work-up revealed the presence of an infiltrating, moderately differentiated ampullary adenocarcinoma.

Hypertension and its management in countries in Africa and the Middle East, with special reference to the place of β-blockade

Abstract Background: The prevalence and clinical consequences of hypertension in countries in Africa and the Middle East have not been studied as well as in other regions. Scope: We have reviewed the literature on the epidemiology and management of hypertension and related cardiovascular complications in countries within Africa and the Middle East. A PubMed search for countries in the region and ‘hypertension’ was supplemented by articles identified from reviews, and by literature suggested by the authors. Findings: The prevalence of hypertension is >20% in some countries in the Middle East and Africa, despite an average population age that is some 10–15 years lower than those of developed countries. Hypertension in these countries is associated with an increased risk of cardiovascular risk factors and cardiovascular disease, as elsewhere. Awareness rates of hypertension are low. Hypertension and its complications are undertreated, and mortality rates from cardiovascular disease are higher than in developed countries. Conclusion: Available resources should be brought to bear on the management of hypertension in these countries. In particular, a recent downgrading of the importance of β-blockers in hypertension management guidelines needs to be reassessed. These agents are as effective as other antihypertensive classes both on blood pressures and on cardiovascular event rates. General concerns over an increased rate of new-onset diabetes with β-blockers have been overstated, although these agents should be avoided in metabolic syndrome.

Giant right ventricular fibroma co-existing atrial septal defect in a 15 year old girl.

The most common benign cardiac tumours are the myxomas, the rhabdomyomas, and the fibromas, with the latter 2 variants being the most common tumours encountered in children. The size and location of tumours within the heart create a variety of clinical findings, such as murmurs, chest pain, tachyarrythmias, and congestive cardiac failure. Nowadays, the tumours are usually diagnosed by echocardiography, magnetic resonance imaging and cardiac catheterization. Surgical excision is the treatment of choice if the tumour causes either arrhythmia or cavitary obstruction. In this report, we describe a giant ventricular fibroma co-existing with an atrial septal defect in a girl aged 15 years.

Massive pulmonary embolism in a Lebanese patient doubly heterozygous for MTHFR and Factor V Leiden presenting with syncope and treated with tenecteplase

A 54-year-old man, with a past history of hypertension and non-insulin-dependent diabetes, presented to the emergency department following a collapse at home. The patient had reported to his family left calf pain after driving for several hours. The patient denied the presence of history of varicose veins, history suggestive of episodes of thrombotic events in the legs or strokes and family history was negative for thrombotic events. Thereafter the patient fell down after standing up and developed severe shortness of breath with chest compressive feeling. On examination, he was plethoric and diaphoretic, but apyrexial. His pulse rate was 115 per min and regular, with a systolic blood pressure of 60 mmHg. His respiratory rate was 28 per min, and oxygen saturation was 91% on room air. Auscultation of his lungs and heart was unremarkable, as was the examination of his abdomen. His left lower leg was noted to be 3 cm larger in diameter than the right, 3 cm below the level of the anterior tibial tuberosity. A large bore intravenous cannula was sited in each antecubital fossae. Arterial blood gas analysis (performed at the above level of oxygen supplementation) revealed a pH of 7.36, with a pCO2 of 30.6, pO2 of 60.5, and HCO3 of 17. An electrocardiogram demonstrated sinus tachycardia, with minor anterolateral ST segment depression, with T wave inversion in lead V I, an ‘SI, QIII, TIII’ pattern, and an incomplete right bundle branch block (IRBBB) (figure 1). Chest X-ray was unremarkable. A bedside ultrasound scan revealed left popliteal vein thrombosis, and a bedside echocardiography

Unusual thrombotic cardiac complications of Pemphigus vulgaris: a new link?

We are reporting a case of Pemphigus vulgaris with extensive thrombosis of deep veins, pulmonary veins, and cardiac chambers complicated by myocardial infarction. The extensive skin lesions prohibited the administration of thrombolytics and coronary intervention. The patient was treated conservatively with heparin, and oral anticoagulation in addition to steroids and cyclosporine with significant resolution of thrombosis.

An Attempt to Halt the Ever-Increasing Prevalence of Morbidities Resulting from Excess Dietary Sodium Intake the Lebanese Experience

zation (WHO) on hypertension, one billion adults worldwide have been estimated to be affected, with an annual mortality of 9 million. Being the most common modifiable risk factor for cardiovascular disease and death, several worldwide initiatives are underway to prevent the fulfillment of the 2025 projections of 1.5 billion cases of hypertension [1,2]. A solid approach that has witnessed worldwide action and is still progressing with great momentum is the reduction of excess dietary sodium intake. Countless studies and trials have shown a positive relation between high sodium intake and risk of cardiovascular and renal disease [3-5]. Moreover, direct, independent relation to stroke [6], left ventricular hypertrophy [7], and proteinuria [5] have been documented, in addition to indirect relation to stomach cancer [8], obesity [9], increased risk of renal stones and osteoporosis [10], and severity of asthma [11]. To that effect, several health authorities have set guidelines for the optimal level of dietary sodium intake. The WHO have set the target intake at less than 5 g of salt or 2 g of sodium [12] while the Institute of Medicine (IOM) recommends an intake of 1.5 to 2.3 g [13] and 1.5 to 2.4 g of sodium per day as per the American Heart Association (AHA) [14]. On a global scale, implementation of the above guidelines has been ongoing for decades now by countries such as Finland and the United Kingdom through massmedia health campaigns, food reformulation by the food industry, and implementation of clear food labeling strategies [15]. The outcome of reducing 33% of sodium intake of the entire population of Finland was a staggering 80% drop in mortality due to stroke and coronary heart disease, concomitant with a fall of over 10-mm Hg in the population’s average blood pressure [16]. In the UK, similar measures and outcomes were observed and several governmental and non-governmental bodies such as the Consensus Action on Salt and Health (CASH), UK Food Standards Agency (FSA), and World Action on Salt and Health (WASH) were founded to implement and maintain the developed strategies [17]. In the last decade, dozens of countries have followed the trend, such as Canada, Australia, the United States, a dozen European countries, and many developing countries in Asia and Africa. In the Middle East, Kuwait is currently at the forefront of this endeavor as it has already reduced the amount of sodium added to bread during production by 20% in the last year. In Lebanon, the Lebanese Action on Sodium and Health (LASH) group was founded in 2012 as part of the Vascular Medicine Program (VMP) at the American University of Beirut (AUB). With the guidance of the WASH organization, LASH established its strategy to optimize sodium intake in the Lebanese population based on four pillars, namely, research, awareness raising, advocacy, and monitoring. The research was done in order to determine the current dietary sodium intake in the Lebanese population, estimated to be between 2.9 and 3.1 g, thus exceeding all set guidelines and upper limits [18]. On September 10-12, 2013, LASH participated in the workshop held by the World Health Organization Eastern Mediterranean Regional Office (WHO-EMRO) on salt and fat reduction and setting up protocols for measuring salt and fat intake and content in food, in Amman, Jordan. Research findings presented included the determination of the main contributors of salt in the Lebanese diet, which were found to be bread (26%), processed meat (12%). The average Lebanese intake of sodium was estimated to be between 2.9 and 3.1 g/day. Results of questionnaires about knowledge, attitudes, and behaviors (KAB) of Lebanese consumers regarding salt intake were also presented and reflected a poor knowledge of the effects of sodium on health and its sources in the diet and an unfavorable behavior of the consumers towards reducing their dietary intake. LASH also presented the obstacles Lebanon was facing at the time, primarily involving the government and the industry in planning a gradual reduction in salt levels in bread and other high-sodium processed foods that are widely consumed. This obstacle was starting to unfold when LASH held a press conference on March 11, 2014, on the occasion of World Salt Awareness Week, to announce the launch of the national campaign under the patronage of