Case Report: Stemi With Covid-19

BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV‑2) causing coronavirus disease 2019 (COVID-19) has reached pandemic levels by March 2020. Patients with cardiovascular disease, particularly with cardiac injury represent a vulnerable population and increased risk of mortality and morbidity. There is still no guidelines for management of cardiovascular disease during the COVID-19 pandemic. CASE ILLUSTRATION An unconscious 52-year-old male brought to ER with complaints of abdominal discomfort and nausea. The patient had a cardiac arrest in ER and ROSC was obtained. The patient was intubated ECG showed anterior STEMI and primary PCI was performed. The endotracheal tube was changed due to blockage of excessive and thick slime. Tracheostomy was performed. Bronchoscopy was performed and found tracheal mucosal edema, hyperemic and easily bleed; mucous plug and blood clots in the tip of tracheostomy cannula. Thoracic CT-Scan showed ground-glass appearance and fibrosis of the 6th thoracic dextra segment. PCR SARS-CoV-2 showed reactive. The patient was discharged from our hospital after three weeks with clinically stable and referred to COVID-19 center hospital nearby his home for another two weeks. After PCR SARS CoV-2 was performed twice showed negative results, the patient was discharged. CONCLUSION SARS-CoV‑2 infection may lead to acute myocardial injury through viral systemic inflammation, although specific mechanism remained uncertain. A thick mucus plaque and stool cell may be a specific clinical features in COVID-19 patients. Tracheostomy has a continuing role in managing weaning from extended periods of mechanical ventilation during the COVID-19 pandemic.

Outcomes of Tricuspid Regurgitation after Percutaneous Mitral Commissurotomy

PURPOSE The gap in evidence in the management of multivalvular lesions can be addressed by providing more data on clinical and echocardiographic outcomes after Percutaneous Mitral commissurotomy (PMC). METHODS Participants were Filipinos aged >/= 19 years old, admitted due to severe mitral stenosis with moderate to severe tricuspid regurgitation (TR). The outcome of PMC was divided into 2 groups: Significant TR which included the progression of moderate to severe TR or persistence of severe TR and Insignificant TR group which included those with mild TR, regression to moderate to mild TR, severe to moderate, or persistence of moderate TR. These groups were compared from baseline, 24th hour, 1st month, and 6th month using the same echocardiographic parameters. The numerical data between significant and nonsignificant tricuspid regurgitation were compared using non-parametric Mann Whitney U test and categorical data using the Chi-Square test. RESULTS A total of 38 participants were analyzed. On the 24th-hour post- PTMC, the Significant TR group had significantly higher RAVI (42.3 vs 26.1, p=.004), RVD mid (3.81 vs 2.92, p=.001), SPAP (60.5 vs 38.5, p=.003), and RVOT (2.8 vs 2.2, p=.001) and lower MV planimetry (1.25 vs 1.58, p=.009); On the 1st-month RVD mid (3.4 vs 2.8, p=.02) and TV annulus (3.35 vs 2.76, p=0.10) were significantly higher in the Significant TR group; On the 6th month RAVI (59 vs 24.7, p=.001), RVD mid (4 vs 2.73, p=.006), and TV annulus (4.5 vs 2.67 p=.001) were significantly higher in the Significant TR group when compared to Insignificant TR group. CONCLUSION PMC improved baseline parameters of SPAP, MV planimetry, MV gradient, and functional class on short-term follow-up on both groups of TR. Majority of outcomes after the procedure had insignificant TR. However, those with significant TR had higher RVD mid and TV annulus from the 24th hour to 6 months when compared to the insignificant TR group.

Takayasu Arteritis Presenting as Severe Pulmonary Hypertension

Takayasu arteritis is an inflammatory disease of large- and medium-sized arteries, with a predilection for the aorta and its branches. Advanced lesions demonstrate a panarteritis with intimal proliferation. It can affect the aorta, subclavian artery, renal artery, iliac artery, coronary artery, and other blood vessels. Pulmonary arteritis is very uncommon in TA. We describe a case of TA, who primarily presented with pulmonary hypertension.

Successful Decannulation of Hybrid ECMO Circuitry: The First Philippine Experience

We report the first VA-VAV-VV ECMO conversion in a 57-year-old Filipino female with persistent coronary insufficiency from toxic shock syndrome due to Streptococcus pyogenes bacteremia, acute respiratory distress syndrome, and Harlequin syndrome with progressive acute limb ischemia from cone snail venom poisoning. The patient came in via air ambulance transport because deteriorating clinical status after having stepped on a cone snail 3 days prior and developing severe dehydration from vomiting and passage of voluminous watery stools after eating a local delicacy. The patient was admitted at the ICU where after 3 days of treatment, the patient developed cardiac tamponade and underwent stat pleuropericardial windowing with pericardiocentesis. Due to increasing pressor requirements from the combined shock, Swan-Ganz catheterization was inserted and a VA-ECMO system was set up. There was gradual improvement in cardiac hemodynamics, however oxygen requirement was increasing and both lower extremities became progressively violaceous with decreasing pulses. Harlequin syndrome was ruled in, the multidisciplinary team decided to convert to VAV hybrid circuit by adding a venous access by way of the right internal jugular vein. Improvement in oxygenation lead to eventual conversion from VAV to purely VV dedicated circuit. Ultrafiltration via ECMO was likewise done because of worsening azotemia and oliguria. The patient was then gradually weaned off from ECMO and was successfully decannulated after 8 days. Below knee amputation was done to address the progressive acute limb ischemia. The patient was nutritionally built up and physically rehabilitated and was eventually discharged improved on the 28th hospital day.

Slaying Monster with Catheter: A Case Report

This is a case of successful treatment of secondary hypertension with catheter intervention in a 62 years old gentleman who has severe aortoiliac occlusive disease, severe coronary artery disease and other comorbidities. Early recognition, diagnosis and treatment of secondary causes of hypertension lead to good clinical outcomes, possible reversal of end-organ damage and better blood pressure control. Blood pressure control is essential prior to coronary intervention in patients with resistant hypertension and concomitant coronary artery disease to prevent haemorrhagic stroke and other unwanted complications. This gentleman has triple vessels and left main stem disease which surgeons refused for coronary artery by pass graft (CABG) in view patient has severe aorto-iliac occlusive disease with resistant hypertension. We have done successful revascularization to aorto-iliac followed by coronary intervention. Keywords secondary/resistant hypertension, coronary artery disease, aortoiliac occlusive disease, catheter (endovascular) intervention

A Rare Case of an Ascending Aorta and Aortic Arch Aneurysm with an Aberrant Right Common Carotid Artery

Ascending aortic aneurysms are asymptomatic and are usually discovered as an incidental finding on chest imaging. However, larger aneurysms can present with symptoms resulting from compression of surrounding structures including the trachea, bronchi, and the esophagus which can result in hoarseness, cough chest pain or back pain. The presence of an aortic arch anomaly, specifically an aberrant right common carotid artery, in a background of an aortic arch aneurysm is extremely rare with a worldwide incidence of <1%. They are usually asymptomatic but can result to catastrophic life threatening events and pose significant challenges to surgical or endovascular treatment. This is a case of a 63-year old Filipino male who presented with a sudden onset of dull back pain radiating to the left anterior chest. Workup revealed an ascending and aortic arch aneurysm with an aberrant right common carotid artery arising directly from the transverse aorta. Surgical aortic arch debranching was done to repair the aberrant vessels prior to Thoracic Endovascular Aortic Repair (TEVAR) wherein a custom-made Thoracic Valiant graft was deployed on the aneurysm. The patient was discharged on the 4th day after TEVAR without any complaints of dyspnea, back pain nor chest pain with no neurologic and visceral organ dysfunction. This case has emphasized that knowledge on the anatomy of the aortic arch is imperative in planning out thoracic surgery and endovascular interventions especially on rare anatomic anomalies such as seen in this case. Keywords aortic aneurysm, aberrant right common carotid artery, TEVAR

Cardiology Fellowship Training One Year into COVID 19 Pandemic: The Philippine General Hospital Experience

The previous year, 2020, was one challenging year for everyone, most especially to the healthcare workers. We experienced a pandemic no one ever imagined that would happen in our lifetime. Medical frontliners, the People Giving Hope, were called and were given the responsibility of taking care and defending the patients from the unfamiliar enemy, the COVID 19 virus. With the changes brought about the pandemic, transformation of the cardiology fellowship training also happened. Three Cardiology fellows in training gives us a sneak peek of how the pandemic affected their lives after a year of battling the virus. KEYWORDS Covid 19, Cardiology, Training

Percutaneous Pulmonary Valve Implantation in a Bangladeshi Center: A Case Series

INTRODUCTION Incidence of congenital heart disease is 25 per thousand live birth in Bangladesh which is much higher than other countries. Tetralogy of Fallot, the commonest cyanotic heart disease (5%) and some other complex diseases with right ventricular outflow tract abnormality demand surgical correction and revision in many occasions including percutaneous intervention. As a resource constraint country, it was a difficult task to introduce percutaneous pulmonary valve implantation (PPVI) with MelodyTM. However, it was started on 12th December 2012 in Combined Military Hospital Dhaka, Bangladesh and cases performed till October 2019 were included in this series. METHODS Retrospective analysis of six cases who had PPVI with MelodyTM in Combined Military Hospital, Bangladesh. Patient with dysfunctional conduit between right ventricle (RV) and pulmonary artery causing (a) Symptoms of exceptional dyspnoea of various grade (NYHA II,III, IV) (b) RVEVD >150 ml/m2 ±regurgitant fraction >40% (c) RVOT peak instantaneous gradient > 30 mm Hg. (d) RV dysfunction (RVEF<40%) were accepted for the procedure and outcome were analyzed. RESULTS Mean age was 9.56 ± 2.96 years, weight was 28.75 ± 8.61 kg, height was 137.5 ± 17.52 cm. Mean age at surgery was 4.25 ± 2.72 years. Female were 66.66%. Aortic homograft was used in 66.66% cases. Eighteen mm Ensemble was used in four (66.66%) cases and 20 mm and 22 mm in one each. Immediate result was excellent with no residual PS in two cases and negligible residual flow acceleration across pulmonary valve in four cases. No PR seen in all except one. One patient developed Bacterial endocarditis after 3 years and was treated. CONCLUSION Aim of PPVI is to prolong the life expectancy of conduits which were placed surgically from right ventricle to pulmonary artery. In our case series, we found that Melody valve is functioning well without any complications like infective endocarditis or stent fracture. KEYWORDS PPVI, MelodyTM, RVOT, Outcome