case report

Background: Subclavian venous access for pacemaker lead insertion is a common procedure and is normally considered safe in the hands of an expert. However, subclavian venepuncture is not without complications, starting from mild subcutaneous hematoma to pneumothorax. We here present a case of hemoptysis occurring after difficult subclavian vein puncture, which subsequently improved on conservative management only. Case Summary: A 65-year-old gentleman, post aortic valve replacement had persistent high-grade AV block and was taken up for a dual chamber pacemaker implantation. Immediately following venous access, he had a bout of hemoptysis, which recovered on its own. Post procedure chest x-ray was suggestive of alveolar hemorrhage which cleared gradually in next three-four days. Discussion: Post subclavian venepuncture hemoptysis is known; but it is a rare complication, arising either because of lung parenchyma injury or arterial injury. This is mostly benign and improves on conservative management only; however rarely it may be massive and life threatening where transcatheter arterial embolization may be required.

Wegener’s granulomatosis is a systemic granulomatous focus on small to medium sized vessels. It typically affects sinuses, lungs and kidneys due to necrotizing granulomatous vasculitis. Less commonly, cardiac involvement is reported up to 8%-44% of cases [1-3]. It often rises to supraventricular arrhythmia, left ventricular systolic dysfunction, pericarditis, myocarditis, and valvulitis [4,5]. Cardiac conducting tissue involvement is rare and associated with increased mortality. It was only reported in fourteen previous cases, some of them were reversible to medical treatment [6]. 

A 56-year-old man was admitted to our hospital because of sudden onset of right-sided thoracic pain. The ECG showed inferior ST segment elevations. He has been treated with aspirin, clopidogrel, unfractionated heparin and tenecteplase, and his symptoms resolved after 30 minutes. About half an hour later, the patient developed again left-sided thoracic pain and the signs of an anterior myocardial ST-segment elevation infarction. 90 minutes after receiving the initial medications, the performed coronary angiography revealed a long dissection of a large ramus circumflexus. Furthermore, the left anterior descending coronary artery was occluded at about the mid-level. The left ventriculography showed a reduced ventricular function and a Stanford type A aortic dissection. Immediate patient transfer for emergency surgical intervention was arranged. However, ventricular fibrillation occurred during transport and he required endotracheal intubation and prolonged cardiopulmonary resuscitation. Unfortunately, he died during further transport. In a patient with massive thoracic pain of initially uncommon localization in combination with fluctuation of ST-segment elevations, aortic dissection should be seriously taken into the differential diagnosis as well as into therapeutic management decisions (in particular antiplatelet and thrombolytic therapy).

A 60-year-old female patient presented with typical anginal pain on exertion and relieved by rest for about one month. Percutaneous coronary angiography was done and showed an abnormal left circumflex coronary artery connecting to intercostal artery. Embolization of that abnormal connection was done successfully and the patient discharged from hospital after 24 hours. This case shows a new form of coronary steal syndrome. This cause could be missed if not put under the differential diagnosis of typical anginal pain with normal coronary arteries.

Permanent pacemaker implantation is conventionally done via upper limb veins. But in 1% - 6% cases, usual sub clavicular approach is either not possible or contraindicated due to complete occlusion of superior vena cava (SVC) or bilateral subclavian vein and/or bilateral implant site infection or thin skin [1]. Alternative approaches are warranted, including leadless pacemaker or complex lead extraction techniques, before considering surgical epicardial lead placement as a last resort because it has own hazards. We report a patient with complete heart block, total SVC obstruction, and a previously implanted malfunctioning epicardial lead presenting with pacemaker end of life. In view of exhaustion of the surgical option and in a resource constrained situation for lead extraction or leadless pacemaker, transiliac endocardial pacemaker implantation was done and a repeat surgery was averted. Learning objective: Complete venous occlusion is not very often encountered after pacemaker/ICD implantation. Apart from the risk of general anesthesia and invasive surgery, epicardial leads increase battery drain, and have a shorter operating life compared to an endocardial lead. The sparingly utilized iliac venous approach for permanent pacemaker implantation is a valuable, safe and minimally invasive alternative, when the conventional percutaneous access is unavailable, and surgery is undesirable or not possible. 

Background: Infants of diabetic mothers (IDMs) are at increased risk of developing congenital anomalies including cardiac defects. Pathological left ventricular hypertrophy, asymmetrical septal hypertrophy and outflow tract obstruction is a rare but known cardiac comorbidity in infants of diabetic mothers. The severity of this condition in IDMs can vary from an incidental finding on echocardiography to an infant with severe symptoms of congestive heart failure and specific management of the condition varies. Aim: The aim of this article is to report this clinical entity in a Nigerian infant born to a mother with poor glycaemic control in pregnancy and highlight management. Case report: We report a term neonate who was diagnosed as a case of pathological left ventricular hypertrophy, asymmetrical septal hypertrophy and outflow tract obstruction delivered to a mother with gestational diabetics with poor glycaemic control in pregnancy. Child was treated successfully with β-adrenergic blocker and showed resolution of hypertrophy in follow-up echocardiography. Conclusion: Infants of diabetic mothers are very high risk infants. Pathological left ventricular hypertrophy in IDM have good prognosis. Early recognition and prompt intervention is advocated.

Post-extrasystolic potentiation (PESP) is a marker of contractile reserve and refers to the augmentation of left ventricular contractility due to preload recruitment and rise in intracellular calcium following a premature beat. In this case report we show that PESP might be a safe and helpful aid to evaluate low flow, low gradient aortic stenosis and contractile reserve in the cathlab, thereby reducing the potential risk of complications associated with intravenous dobutamine evaluation and reducing unnecessary testing.

Ventricular assist device is a portable machine which is also called an artificial heart for the patients who have terminal heart failure. The device maintains the heart’s vital functions until the suitable donor is found for the heart transplantation. It can be applied to either ventricles or both (biventricular). Although the device provides independence for the patient, it also has life-threatening complications. Such as infection, stroke secondary to thromboembolism, hemorrhage depending on anticoagulant use, right heart failure… and most of the time it is really hard to manage those complications. We will present a case, who had ischemic stroke as a complication of VAD even though he has been using aspirin, warfarin and had effective INR value.

Introduction: Atrioventricular nodal reentrant tachycardia (AVNRT) is the most frequent supraventricular tachycardia, commonly manifesting as autolimited paroxysmal episodes of rapid regular palpitations that exceed 150 beats per minute (bpm), dizziness and pounding neck sensation. Case presentation: We present a case of a male patient, 70 years old, with ischemic heart disease and slow-fast AVNRT treated with radiofrequency catheter ablation (RFCA) in March 2019, with regular 6-months follow-ups. He was readmitted in our department in November 2020 for rest dyspnea and incessant fluttering sensation in the neck, without palpitations. The event electrocardiogram (ECG) was initially interpreted by general cardiologist as accelerated junctional rhythm, 75 bpm. Due to the persistence of symptoms and ECG findings, a differential diagnosis between reentry and focal automaticity was imposed. The response to vagal maneuvers and Holter ECG monitoring characteristics provided valuable information. We suspected recurrent slow ventricular rate typical AVNRT, which was confirmed by electrophysiological study and we successfully performed the RFCA of the slow intranodal pathway. Conclusion: AV nodal reentry tachycardia may have an unusual presentation, occurring in elder male patients with structural heart disease. Antiarrhythmic drugs can promote reentry in this kind of patients. In cases of slow ventricular rate, vagal maneuvers and Holter ECG monitoring can help with the differential diagnosis. The arrhythmia can be successfully treated with RFCA with special caution regarding the risk of AV block.

We describe successful percutaneous coronary intervention (PCI) of significantly diseased ostial left main (LM) and distal LM bifurcation (Medina 1,1,1) in a patient with a reduced left ventricular ejection fraction and a recent valve-in-valve balloon-expandable TAVR using the DK-Crush technique with the support of a percutaneous left ventricular assist device.

Peripartum cardiomyopathy (PPCM) is a relatively rare cardiac disease that manifests in the final stage of pregnancy and in the first months after delivery in women with no preexisting heart disease. Many etiological processes have been suggested: viral myocarditis, abnormal immune response to pregnancy, excessive prolactin excretion, prolonged tocolysis and a familiar predisposition to PPCM. Its diagnosis is often delayed because its symptoms, which include fatigue, dyspnea and palpitations are nonspecific. For this reason the diagnosis of PPCM is still made by exclusion of other etiologies. The long-term prognosis, once the acute phase is over, is a function of myocardial damage, this varies from complete functional recovery to chronic HF. The outcome of PPCM is highly variable with an alevated risk of fetomaternal morbidity and mortality. We report a serious case of a 40 years old female with biamniotic bicorionic twin pregnancy (PMA) who delivered by caesarean section and developed acute PPCM on post-operative. Symptoms occurred two hours after an intramuscular injection of two vials of methylergonovine the same day of cesarean delivery. These manifested in sudden tachypnoe, tachycardia and the appearance itchy maculopapular rash on her chest. On further evaluation, ECHO revealed cardiomegaly with reduced ejection fraction (< 15%). The case was successfully managed by a multidisciplinary team, using drugs like levosimendan and cabergoline, which rapresent emerging strategy in this clinical context.

This report provides an insight into a very unusual problem in the first trimester of pregnancy, and describes the unfolding of a series of potential blunders. We all know that most problems in gynecologic oncology become terribly magnified when the patient is pregnant. HB had a routine ultrasound in the first trimester of pregnancy, and a large, extremely vascular mass occupying most of the lower anterior abdominal wall, was found (Figure 1). Because she had received methotrexate two years earlier for a persistent elevation of the hCG titer following surgery for an ectopic pregnancy, she was referred to the gynecologic-oncology service with the working diagnosis of metastatic gestational trophoblastic disease (GTD). An MRI showed a vascular mass in the subcutaneous tissue invading the rectus sheath and muscle, but not attached to the uterus (Figure 2). The report stated, in no uncertain terms, that the mass was strongly indicative of a metastasis from GTD. However, the hCG level was consistent with the estimated gestational age, and a mass such as this would represent an extremely unusual way for this disease to present. She had been told that she would need the have the pregnancy terminated, followed by chemotherapy to reduce the size of the mass prior to its removal.

We describe here the case of a 23-year old woman with small cell carcinoma of the ovary of the hypercalcemic type (SCCOHT) with SMARC-A4 mutation who benefited from surgery in two steps leading to a total hysterectomy with bilateral salpingo-oophorectomy, omentectomy, pelvic and lombo-aortic lymph nodes dissection. She also received 6 courses of poly-chemotherapy after the surgery. A close follow-up was then performed by clinical examination every three months with determination of serum calcium and CA125 level as well as imaging with thoraco-abdominal CT scan. To date, the patient has a disease-free survival of more than 9 years. We also reviewed the literature on this topic and discuted the new diagnostic and prognostic genetic tool SMARC-A4 mutation.

A malignant tumor has the capacity to grow rapidly and to metastasize to the other parts of the body. Ovary has been a common organ for secondaries caused by hematological spread of the tumor and exhibits the same histopathology as that of the primary tumor. Very rarely, it has been found that the patients suffer from two or more histologically distinct, simultaneously detected malignancies, which are called as synchronous tumors or multiple primaries [1]. These multiple primaries can have an impact on cancer treatment (e.g., surgery) and affect the overall prognosis of the patient. Although there is no consensus on the definition of synchronous cancer, commonly two or more primary tumors that occur in a patient closely with respect to the time interval are termed as synchronous tumors [2]. Simultaneous diagnosis of gall bladder carcinoma with ovarian carcinoma with distinct histopathology is rare. A very few cases have been reported so far in literature. We discuss here a rare case that presented with synchronous tumor of gall bladder and the ovary.

In gamma-ray spectrometry, the analysis of the environmental radioactivity samples (soil, sediment and ash of a living organism) needs to know the linear attenuation coefficient of the sample matrix. This coefficient is required to calculate the self-absorption correction factor through the sample bulk. In addition, these parameters are very important because the unidentified samples can be different in the composition and density from the reference liquid sources which are usually used for efficiency calibration in the radioactive monitoring process. The present work is essentially concerned to introduce a mathematical method to calculate the linear attenuation coefficient without using any collimator. This method was based mainly on the calculations of the effective solid angle subtended by the source-to-the detector configurations, the efficiency transfer technique and the average path lengths through the samples itself. The method can be used as a tool for the calculation of the linear attenuation coefficient of unidentified materials with good facility to use it in the calibration process of γ-ray detectors, particularly in the study of soil samples. The results are compared with the data from NIST-XCOM to show how much the results are in close agreement and to give the validity of the approach.

Septic arthritis of the shoulder joint is rare and might affect around 3% of the general population [1]. A delay in diagnosis may increase morbidity and lead to bone and cartilage destruction [2]. Septic arthritis is an unusual complication of pregnancy and can progress to permanent arthropathy and disability [3]. Septic arthropathy in pregnancy requires multidisciplinary team involvement for prompt recognition and treatment to improve both maternal and fetal outcomes. High index of suspicion is vital when clinical and laboratory findings suggest septic arthritis. There are multiple predisposing factors reported previously for septic arthritis of the shoulder in pregnancy such as medical conditions, pyelonephritis and trauma. We report a 37 year old lady who presented at 26 weeks gestation with acute left shoulder pain and high temperature following minor left palm trauma. She also had left mastectomy with axillary clearance ten years earlier. She underwent arthroscopic wash out of her left shoulder joint and was covered with antibiotics with rapid improvement and recovery. We reinforce the importance of early multidisciplinary involvement when septic arthritis of the shoulder in pregnancy is suspected especially in women who have had previous mastectomy and axillary clearance which could be a predisposing factor for such a rare and serious joint condition in pregnancy.

A 21-y-old recreationally active male lacking the last 30° of elbow extension from a fractured and dislocated elbow sustained while wakeboarding came to our clinic November of 2015. A regimen was applied of 20-minutes of pulsed shortwave diathermy (PSWD) treatments delivered at 100 watts to heat the affected tissue prior to approximately 40°C followed by 10 minutes of joint mobilizations. This was followed by application of an ice pack to the area for 30 minutes. Measurements and treatments were given on Nov 3,5 and 10. The changes in AROM extension were as follows: Nov 3, from 30° to 20°; Nov 5, from 24° to 10°; Nov 10, from 10° to 0°. Over the course of the treatment the PSWD/ joint mobilizations improved extension AROM of the elbow 30° (full AROM) in just 3 treatments. There was also no post-treatment pain.

The absorption parameters such as total mass attenuation coefficients, molecular, atomic, and electronic cross sections, effective atomic numbers and electron densities were calculated for some selected enzyme inhibitors in the photon energy range from 1 keV up to 100 GeV. The changes in the absorption parameters were interpreted with the photoelectric effect, Compton scattering and pair production processes. It is observed that the 2-Imino-1-imidazolidineacetic acid enzyme inhibitor has more radiation shielding feature when compared to other chosen enzyme inhibitors. The present investigation is anticipated to be useful for researchers studying with radiation in several fields and cancer researchers.

Chondromyxoid fibroma (CMF) is a very rare benign cartilaginous tumor representing less than 0.5% of all bone tumors while also being the rarest cartilaginous bone tumor. Common locations of occurrence include the metaphysial region of the proximal tibia and distal femur. We report a case of a 10-year-old female affected by a CMF of the left lower tibia. The radiological features demonstrated by X-ray and magnetic resonance imaging (MRI) are discussed.

The linear no-threshold hypothesis (LNT)-the basis of radiation regulatory policy-extrapolates from observed high-dose harm to assumed low-dose harm, entailing that all ionizing radiation is harmful, by denying any biological response to damage and asserting cumulative lifetime harm, regardless of dose or dose rate. All aspects of LNT are demonstrably false. There are evolved biological responses that repair or remove radiogenic damage from low doses and dose rates, thereby averting acute harm and precluding the alleged cumulative damage. LNT and its offspring, the “as low as reasonably achievable” principle, do not err on the side of caution; neither is truly conservative. The public needs protection from radiophobia, rather than from low-dose radiation exposure. Neither radiation regulations nor medical practice should be based on LNT, but rather, at least as a first step, on a linear (down to a) threshold (LT) model.