International Journal of the Cardiovascular Academy

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Sinus venous atrial septal defect (SVD) is highly difficult to diagnose because of its location. Below, we report a case of SVD which is misdiagnosed as pulmonary hypertension and anomalous pulmonary venous return. A 57-year-old female patient was referred to congenital disease outpatient clinic of a tertiary center. She was admitted to the hospital with complaints of fatigue and exercise dyspnea which had started a year ago. She had transthoracic echocardiography (TTE) examination done in another hospital which showed dilated right heart chambers and pulmonary hypertension. She underwent transesophageal echocardiography (TEE) examination with the suspicion of atrial septal defect (ASD), but no defect was seen. As her symptoms persisted, we repeated the TTE and TEE examination in our center. TEE revealed 0.6 cm ASD on the upper side of the interatrial septum. All four pulmonary veins were draining into the left atrium. Right heart catheterization (RHC) confirmed the diagnosis. A left-to-right shunt was detected and localized by a significant step-up in blood oxygen saturation found between mid and upper segments of the right atrium. According to our TEE and RHC results, we planned the surgical closure of the defect. Sinus venous ASD is deficiency of the superior portion of atrial septum adjacent to superior vena cava. Diagnosis of SVD is often more difficult than other forms of ASD and may require special imaging such as TEE, magnetic resonance imaging, or computed tomographic scanning. In conclusion, cardiologists must be aware about the possibility of SVD patients who have unexplained exertional dyspnea and fatigue, dilated right atrium and ventricle, pulmonary hypertension, paradoxical embolism, or atrial arrhythmias in their respective populations.

In this case, we report a successful closure of secundum atrial septal defect in a 32-year-old female patient with an interrupted inferior vena cava (IVC). Interrupted IVC was detected coincidentally during right heart catheterization. The defect was successfully closed through transjugular vein approach as an alternative to surgery.

Pulmonary thromboembolism (PTE) is usually caused by deep vein thrombosis (DVT) in the lower extremities; which can be as varied clinical spectrum as asymptomatic embolism detected incidentally to serious disease with massive embolism causing death. A 44 year-old female patient was admitted to emergency department with complaints of general condition impairment, hypotension and marked dyspnea. She had a fracture on the right femur proximal region after falling a month ago. Lower extremity Doppler ultrasonography revealed findings consistent with acute deep vein thrombosis in the right lower extremity. Emergency pulmonary CT angiography revealed bilateral massive pulmonary thromboembolism extending especially from the main pulmonary artery to the right pulmonary artery. IV thrombolytic was contraindicated as a result of head trauma and subdural hematoma history a month ago. The patient was taken to the catheter laboratory and we performed a selective thrombus aspiration and fragmentation. The vital signs and hemodynamics of the patient improved rapidly after the procedure. This case report is important for demonstrating rapid percutaneous management of a young female patient with a life-threatening condition and favourable outcome of percutaneous intervention despite many comorbid conditions.

A 56-year-old male patient was admitted to our clinic due to persistent fever despite the use of antibiotics for 2 weeks, chest pain, and presyncope. His medical history revealed that the patient underwent modified Bentall-De Bono procedure 2 months ago due to ascending aortic aneurysm and severe aortic insufficiency. Transthoracic apical 5 chamber view showed that mobile vegetation prolapsed into the left ventricular outflow tract during ventricular diastole and that mechanical prosthetic valve was superior to the aortic annulus. Transesophageal echocardiography revealed normal aortic mechanical prosthetic valve function; however, the valve was positioned more superior to the annular plane and a dense vegetation was observed. Moreover, a complete dehiscence of the prosthetic valve was attached to aortic annulus with a single stitch in an area between noncoronary sinus and left coronary sinus. Dense thrombus formation was observed in the perivalvular region. Many cases with prosthetic valve endocarditis and partial dehiscence as its complication have been reported in the literature. However, to the best of our knowledge, there is no reported case of complete dehiscence secondary to infective endocarditis following complete ascending aortic graft and prosthetic aortic valve replacement (modified Bentall-De Bono procedure).

Objective: We aimed to determine the prevalence, predictors, and mortality rate of premature clopidogrel discontinuation within 30 days of successful coronary stenting. Methods: All consecutive patients who underwent successful coronary stent implantation at our hospital between December 2006 and December 2007 were prospectively included in this study. Patients were interviewed by telephone 30 days after stent implantation. Premature clopidogrel discontinuation was defined as follows: patients who did not continue clopidogrel after discharge were defined as “never used” and patients who received clopidogrel for <20 days or interrupted therapy for at least 5 successive days within the first 30 days were defined as “partially used.” Results: Follow-up data were available for 381 patients and 58 (15.2%) patients reported premature clopidogrel discontinuation. No mortality and only 1 (0.3%) stent thrombosis occurred in adherent patients, whereas there were 2 (3.4%) mortalities and 6 (10.3%) stent thrombosis in the patients who prematurely discontinued clopidogrel. Those who discontinued clopidogrel therapy were older (P = 0.02), more likely to be female (P = 0.02), single (P = 0.03), of lower economic (P < 0.05) and educational status (P < 0.01), more likely to have chronic disease (P = 0.04), less likely to have undergone previous stenting (P = 0.01), and were more likely to be receiving a larger number of drugs (P < 0.05). In multivariate analysis, low- or intermediate-economic status, no history of previous stent implantation, and total number of prescribed drugs using were factors independently associated with premature clopidogrel discontinuation. Conclusion: This study demonstrates several predictors of premature clopidogrel discontinuation. This data may help clinicians pay particular attention to these patients in an attempt to improve the outcomes of coronary stenting.

Online since 14^th February 2018.