Vinod Namana

Adult Onset Dysphagia: Right Sided Aortic Arch, Ductus Diverticulum, and Retroesophageal Ligamentum Arteriosum Comprising an Obstructing Vascular Ring

A 49-year-old African American male patient with no past medical history was admitted because of 3 months of difficulty swallowing solid and liquid foods. He had constant retrosternal discomfort and appeared malnourished. The chest radiograph revealed a right sided aortic arch with tracheal deviation to the left. A swallow study confirmed a fixed esophageal narrowing at the level of T6. Contrast enhanced Computed Tomography (CT) angiogram of the chest and neck revealed a mirror image right aortic arch with a left sided cardiac apex and a prominent ductus diverticulum (measuring 1.7 × 1.8 cm). This structure extended posterior to and indented the mid esophagus. A left posterolateral thoracotomy was performed and the ductus diverticulum was resected. A retroesophageal ligamentum arteriosum was found during surgery and divided. This rare combination of congenital anatomical aberrations led to severe dysphagia in our patient. Successful surgical correction in the form of resection of the ductus diverticulum and division of the retroesophageal ligamentum arteriosum led to complete resolution of our patients symptoms.

Electrocardiogram helmet sign: an adverse clinical prognosis.

A 90-year-old male with a history of hypertension, diabetes mellitus type II and coronary artery disease status-post coronary artery bypass graft surgery in 2001 presented with a new onset seizure. On examination he was stuporous, afebrile, had a heart rate 85 beats per minute and blood pressure 148/70 mm of Hg. His pupils were reactive to light, had a supple neck and no focal neurological deficits. Had elevated jugular venous pressure 14 cm of H2O, diffuse bilateral rales on lung auscultation and …

Saddle pulmonary embolism: right ventricular strain an indicator for early surgical approach

Current mainstay treatment for pulmonary embolism (PE) includes oral anticoagulation, thrombolytic therapy, catheter embolectomy and acute surgical embolectomy. Surgical embolectomy is reserved for hemodynamically unstable patients (cardiogenic shock, cardiac arrest) and contraindication to thrombolytic therapy. We report a case of saddle PE in a young female with echocardiographic signs of right ventricular (RV) dysfunction who underwent early acute surgical embolectomy with a positive outcome. It would be beneficial to use bedside echocardiography even in hemodynamically stable patients to determine RV strain as this could act as an early indicator suggesting the escalation of therapy.

Right Ventricular Infarction

Coronary Heart Disease is a leading cause of morbidity and mortality worldwide. A great amount is known about left ventricular myocardial infarction. It was not until much later (1974) that right ventricular myocardial infarction was studied as a separate entity. Isolated right ventricle myocardial infarction is rare. Around one-third of patients with acute infero-posterior ST-segment elevation myocardial infarction, will present with concomitant right ventricular infraction. The aim of this paper is to review the literature on the importance of early recognition of right ventricular infarction, clinical presentation, pathophysiology, diagnostic evaluation, differential diagnosis, treatment, complications and prognosis.

Electrocardiogram Changes with Acute Alcohol Intoxication: A Systematic Review

Background: Acute alcohol intoxication has been associated with cardiac arrhythmias but the electrocardiogram (ECG) changes associated with acute alcohol intoxication are not well defined in the literature. Objective: Highlight the best evidence regarding the ECG changes associated with acute alcohol intoxication in otherwise healthy patients and the pathophysiology of the changes. Methods: A literature search was carried out; 4 studies relating to ECG changes with acute alcohol intoxication were included in this review. Results: Of the total 141 patients included in the review, 90 (63.8%) patients had P-wave prolongation, 80 (56%) patients had QTc prolongation, 19 (13.5%) patients developed T-wave abnormalities, 10 (7%) patients had QRS complex prolongation, 3 (2.12%) patients developed ST-segment depressions. Conclusion: The most common ECG changes associated with acute alcohol intoxication are (in decreasing order of frequency) P-wave and QTc prolongation, followed by T-wave abnormalities and QRS complex prolongation. Mostly, these changes are completely reversible.

Clinical significance of atrial kick

A 68-year-old man with a history of diabetes mellitus type II, hypertension and active smoking was transferred to our hospital from a nearby hospital for coronary artery bypass graft (CABG) surgery after suffering a complicated inferior wall myocardial infarction (IWMI). Post the initial angioplasty, the patient developed in-stent thrombosis and became hypotensive with a systolic blood pressure < 90 mmHg. After hemodynamic stability was achieved he was transferred to our hospital. During his stay, the cardiac monitor showed fluctuations in his blood pressure with a drop in systolic blood pressure by 10 to 15 mmHg and diastolic blood pressure by 10 mmHg when he developed atrioventricular (AV) dissociation during an idioventricular rhythm. Atrial kick, the fourth phase of ventricular diastole in the cardiac cycle is where the atria contributes to the ventricular end diastolic volume by atrial contraction. The significance of the atrial kick in the hemodynamics of the patient was captured on the cardiac monitor during the patients stay in the cardiac intensive care unit.

A Case of Hyperacute Severe Thrombocytopenia Occurring Less than 24 Hours after Intravenous Tirofiban Infusion

Thrombocytopenia is defined as a condition where the platelet count is below the lower limit of normal (<150 G/L), and it is categorized as mild (100–149 G/L), moderate (50–99 G/L), and severe (<50 G/L). We present here a 79-year-old man who developed severe thrombocytopenia with a platelet count of 6 G/L, less than 24 hours after intravenous tirofiban infusion that was given to the patient during a percutaneous transluminal coronary angioplasty procedure with placement of 3 drug-eluting stents. The patients baseline platelet count was 233 G/L before the procedure. Based on the timeline of events during hospitalization and laboratory evidence, it was highly likely that the patients thrombocytopenia was the result of tirofiban-induced immune thrombocytopenia, a type of drug-induced immune thrombocytopenia (DITP) which occurs due to drug-dependent antibody-mediated platelet destruction. Anticoagulant-mediated artefactual pseudothrombocytopenia was ruled out as no platelet clumping was seen on the peripheral blood smears. The treatment of DITP includes discontinuation of the causative drug; monitoring of platelet count recovery; or treatment of severe thrombocytopenia with glucocorticoids, IVIG, or platelet transfusions depending on the clinical presentation. The most likely causative agent of this patients thrombocytopenia—tirofiban—was discontinued, and the patient did not develop any signs of bleeding during the remainder of his hospital stay. His platelet count gradually improved to 24 G/L, and he was discharged on the sixth hospital day.

Isolated Diffuse Supravalvular Aortic Stenosis with Severe Aortic Narrowing in a 41-Year-Old Man

Isolated supravalvular aortic stenosis in adults is a rare form of left ventricular outflow tract obstruction. We describe a case in a 41-year-old man in whom the supravalvular aorta had narrowed to approximately the size of the left anterior descending coronary artery. The patient underwent aortic surgery with replacement of the ascending aorta and repair of supravalvular aortic stenosis with a pantaloon graft. A postoperative echocardiogram showed substantial improvement: the mean gradient across the aorta had fallen from 48 to 8 mmHg. Surgery is the definitive treatment in symptomatic patients with supravalvular aortic stenosis.

The Giant Rheumatoid Nodule: A Case Report

Rheumatoid arthritis is one of the most common debilitating rheumatological disorders. A subcutaneous rheumatoid nodule usually occurs in advanced cases of rheumatoid arthritis and is also a hallmark of the chronicity of the disease. They are also the most common extra-articular manifestation of rheumatoid arthritis. We present a case of a giant rheumatoid nodule, developed on the left elbow.

Cor Triatriatum Sinistrum

Figure 1 – A) Transthoracic echocardiogram showing cor triatriatum: proximal and distal left atrium separated by a membrane (Pointing white arrow), LA: left atrium; LV: left ventricle; RV: right ventricle; RA: right atrium. B) Transesophageal echocardiogram showing cor triatriatum: proximal and distal left atrium separated by a membrane (Pointing white arrow), LA: left atrium; LV: left ventricle. A 25-year-old male presented to clinic with complaints of palpitations. Transthoracic echocardiogram (TTE) showed presence of a membrane in left atrium suggestive of cor triatriatum [Figure 1A]. This finding was confirmed with transesophageal echocardiogram (TEE), which revealed a membrane in the left atrium attaching at the Coumadin ridge and the atrial septum, just caudal to the fossa ovalis [Figure 1B].