Lone Hepatocellular Carcinoma: An Isolated Chest Wall Malignancy

Herein we describe the case of an elderly diabetic gentleman presenting with a two-week history of dyspnea and nonproductive cough, found to have a large left anterolateral chest wall mass. Further characterization through computed tomography (CT) of the chest revealed a soft tissue mass in the left anterior lower hemithorax found to be hepatocellular carcinoma (HCC). The liver, spleen, and pancreas were unremarkable. Diagnostic labs were unremarkable. The patient had no history of hepatitis, alcohol abuse, or illicit substance use. Pathological examination and immunohistochemical staining of the chest mass biopsy were consistent with metastatic hepatocellular carcinoma (HCC). The patient opted to pursue no further medical intervention and expired two weeks later. To the authors’ knowledge, this is one of very few descriptions of isolated hepatocellular carcinoma found in the absence of a primary liver lesion and classical risk factors for hepatocarcinogenesis. This case highlights that HCC may present independently of liver lesions seen on imaging in a patient without clear signs or symptoms of liver. HCC should be considered in cases of isolated tumors with unclear primaries as ectopic carcinogenesis and occult primary malignancy are possibilities

Acute chest pain in a patient with left bundle branch pacing

We present a patient with left bundle branch (LBB) electronic ventricular pacing with chest pain. ECG showed ventricular pacing and ST elevation in the inferolateral leads. At first it was felt that the Sgarbossa criteria for STEMI in electronic ventricular pacing are not met. However, as symptoms persisted, emergency coronary angiography was performed showing complete occlusion of the left circumflex artery. As LBB pacing results in narrow QRS complexes with incomplete right bundle branch block, ST-segment deviation should not be ignored and the Sgarbossa criteria for patients with LBB block or right ventricular electronic pacing should not be applied.Non peer reviewe

Heart Failure in Thyrotoxic Cardiomopathy: Extracorporeal Membrane Oxygenation Treatment for Graves’ Disease

Thyrotoxicosis-induced cardiomyopathy and consequent heart failure is one of the most grave complications of uncontrolled hyperthyroidism. In such patients, early recognition of thyrotoxicosis, and directed antithyroid therapy can lead to rapid normalization of left ventricular function. Herein, we present a case of a 29-year-old male with Graves’ disease who developed heart failure with severe deterioration of left ventricular function and eventually, circulatory collapse. Height and weight of the patient were 1.8 m and 84 kg, respectively. The patient was placed on venoarterial extracorporeal membrane oxygenation for immediate circulatory support, with restoration of cardiac function after 6 days

Pathophysiology, diagnosis, and management of the no-reflow phenomenon

Successful reperfusion of an infarct-related coronary artery by primary percutaneous intervention or fibrinolysis during acute ST-elevation myocardial infarction (STEMI) does not always restore myocardial tissue perfusion, a phenomenon termed “no-reflow.” Herein we discuss the pathophysiology of this highly prevalent phenomenon and highlight the most salient aspects of its clinical diagnosis and management as well as the limitations of presently used methods. There is a great need for understanding the dynamic nature of no-reflow, as its occurrence is associated with poor cardiovascular outcomes. The no-reflow phenomenon may lend an explanation to the lack of further improvements in in-hospital mortality in STEMI patients despite decreases in door-to-balloon time. Hence, no-reflow potentially presents an important target for investigators interested in improving outcomes in STEMI. In the era of reperfusion, much effort has been made to decrease myocardial infarct (MI) size by implementing early reperfusion with primary percutaneous coronary intervention (P-PCI) or thrombolytic agents. Door-to-balloon times have improved substantially while concomitant in-hospital mortality improvements lag behind [1]. It is plausible that outcomes after successfully reperfused MI are determined by the initial size of myocardial ischemia, time from onset of ischemia to reperfusion, potential reperfusion injury, patency of the epicardial infarct-related artery, distal thromboembolization, adverse remodeling after infarction, and the microvascular no-reflow phenomenon (NRP). Herein we describe the dynamic pathophysiology of the NRP. Additionally, we present a comparison of clinical diagnostic and therapeutic strategies

What is the cause of hypotension? A rare complication of percutaneous coronary intervention of a chronic total occlusion: a case report.

Background In the last few years, complex techniques and advanced equipment became available to treat chronically occluded coronary arteries. Such procedures portend a series of possible complications that operators should be ready to quickly recognize and deal with. Case summary A 75-year-old lady with uncontrolled stable angina underwent percutaneous treatment of a chronically occluded right coronary artery. After balloon angioplasty and stenting, she developed a severe hypotension, refractory to fluid resuscitation and vasopressors. Computerized tomography scan demonstrated an intramural haematoma (IMH) of the right atrioventricular groove resulting in life-threatening pseudotamponade (or dry tamponade), as further confirmed by cardiac magnetic resonance imaging (MRI). The decision was for conservative management and haemodynamic support by intra-aortic balloon pump. Clinically, the patient improved and was discharged a few days later. Follow-up MRI confirmed resolution of the IMH. Discussion Severe hypotension during percutaneous treatment of chronically occluded coronary arteries may be related to various causes. Differential diagnosis is thus important in this setting and should include IMH, a rare but potentially fatal complication as it may cause compression of cardiac chambers and lead to pseudotamponade. A high index of suspicion is required to diagnose IMH but there are no clear guidelines for management of such cases