Alcohol-Induced Cardiomyopathy Presenting with Left Ventricular Apical Thrombus

Background: Chronic excessive alcohol consumption has been strongly associated with alcohol-induced cardiomyopathy (AC) in patients with no evidence of coronary artery disease (CAD). AC may cause cardiovascular complications and significant impact on the quality of life. We discuss an interesting case of dilated cardiomyopathy, associated complication, diagnostic work-up and management. Case Report: A young male presented to our service with worsening dyspnea, orthopnea, and scrotal and lower extremity edema. On average, he consumed a pack of 12 beers every day and had a 30-pack-years smoking history. He was found to be in acute heart failure with evidence of pulmonary edema and cardiomegaly on chest imaging. He had biventricular dilatation and severely reduced left ventricular ejection fraction (LVEF) 15% in addition to a thrombus in the LV apex. The cardiac catheterization was unremarkable for CAD. He was diuresed appropriately resulting in significant weight loss and resolution of symptoms. LV thrombus was treated with unfractionated heparin infusion that was transitioned to warfarin. He was maintained on guidelines-directed medical therapy for heart failure. Extensive counseling was provided regarding alcohol and tobacco cessation. On follow-up echocardiogram, his LVEF improved and there was no evidence of LV thrombus. We think, the readership will benefit from our experience of treating a case of AC, and the importance of clinical history. Conclusion: Chronic excessive alcohol use is detrimental to cardiac function leading to alcohol-induced cardiomyopathy. A careful approach to clinical history of alcohol consumption and prompt diagnostic workup negative for ischemic causes may confirm the diagnosis. Cardiac function improves with guidelines-directed medical therapy for heart failure and abstinence from alcohol.

Transcatheter Aortic Valve Replacement in High-Risk Surgical Patient with Severe Aortic Insufficiency

Background: Transcatheter aortic valve replacement (TAVR) is approved by the FDA for severe aortic stenosis (AS) in patients of all surgical risk categories but has yet to be studied for its utility in aortic insufficiency (AI), despite the need for a safe alternative to surgery for prohibitive surgical risk patients. Case Report: We describe a case of a female patient who presented with acute decompensated congestive heart failure (CHF) with New York Heart Association (NYHA) Class IV symptoms. She was found to have severe AI leading to acute decompensation. Two years prior to this, she had aortic valve endocarditis that had potentially resulted in severe AI. Considering her underling comorbidities including diabetes mellitus, hypertension, morbid obesity and multiple myeloma on active chemotherapy at the time of evaluation, the patient was a high-risk surgical candidate for surgical aortic valve repair (SAVR) in view of elevated risk of mortality, infection, and poor wound healing. After critical and comprehensive assessment, transcatheter aortic valve intervention was considered to be an appropriate choice of treatment. TAVR was successfully performed that resulted in immediate improvement of aortic valve function. On subsequent follow-ups, she demonstrated markedly improved symptoms and reduced status to NYHA Class II HF symptoms. Conclusion: TAVR is a potential treatment modality for patients with severe AI who are poor surgical candidates for SAVR. We hope our case contributes to the growing pool of studies investigating the utility of TAVR procedure in patients with severe AI.

Oval-Shaped Radiographic Opacity Mimicking a Lung Mass

Phantom tumor of the lung is an infrequent presentation of volume overload in congestive heart failure. This finding is often mistaken for a lung mass that leads to extensive workup and unnecessary treatments. A 75-year-old male was evaluated for a right lower lobe rounded opacity. A transthoracic echocardiogram showed normal left ventricular function. Biopsy of the mass was unremarkable. Patient was managed with diuretics, and subsequent lung imaging revealed resolution of the opacity.

The Single Cusp of Life: A Case Report

Background: Anomalous coronary artery (CAA) is a rare condition occurring in less than 1% of individuals. The most common form consists of the left circumflex artery (LCx) arising from the right coronary sinus. These vascular anomalies have been associated with an increased risk of sudden cardiac death. We present a rare case of an anomalous coronary artery in a patient with all three coronary arteries arising from a shared ostium. Case presentation: A 67-year-old transgender Caucasian male with medical history of dyslipidemia and hypertension presented for ischemic workup due to occasional chest pain prior to undergoing male to female gender reassignment surgery. A Regadenosan stress test with SPECT myocardial perfusion imaging revealed moderate sized, moderate intensity perfusion defect reversible in inferolateral wall and fixed in inferior wall. Coronary angiography revealed anomalous origin of the coronary arteries, with all three major coronary arteries arising from a shared, single, ostium originating from the right coronary cusp. Coronary computed tomographic angiography (CCTA) showed a “malignant course” of LAD running between the pulmonary artery and aorta. A conservative management was pursued in view of mild symptoms with close follow ups. Conclusion: It is important to evaluate all coronary artery anomalies (CAA) for a “malignant” course due to its associated risk for various cardiac events including sudden cardiac death. Surgical management is indicated in high-risk patients with malignant courses. However, asymptomatic patients and those with mild symptoms with or without malignant course can be followed closely.

A Troika of Tricuspid Valve Thrombus, Bilateral Upper Extremity Deep Venous Thrombosis and Pulmonary Embolism

Background: Tricuspid valve thrombus with concomitant bilateral pulmonary embolism (PE) and right heart strain poses a significant risk of hemodynamic instability and increased mortality. Case Report: We report the unique case of a female who presented with dyspnea and tachycardia, and was subsequently found to have a structure attached to the tricuspid valve. Concomitantly, she also had bilateral upper extremity deep venous thrombosis (UEDVT) and bilateral sub-massive PE. Thorough clinical assessment, and diagnostic and risk stratification tools were applied to guide the management and disposition. Tricuspid valve thrombus resolved after unfractionated heparin therapy followed by oral anticoagulation as seen on repeat transthoracic echocardiography. We think the readership will benefit from our experience of managing an uncommon and critical clinical presentation of tricuspid valve thrombus in the setting of extensive venous thromboembolism. Conclusion: Careful clinical assessment, risk stratification tools, and close monitoring are needed to guide the management of tricuspid valve thrombus with concomitant bilateral PE and UEDVT.