Inferior Wall Research Articles

Midface Trauma - a Clinical Case of Complex Fracture of the Zygomatic-Alveolar Complex

Traumatic injuries of the maxillofacial region occupy one of the leading places in terms of prevalence among traumas. Injuries of this localization belong to the category of the most severe and complex injuries, posing a significant threat to the health and life of the patient, due to the fact that fractures of the bones of the facial skeleton are often accompanied by various injuries of the organs of vision, sinuses and brain. Injuries of the zygomatic bone isolated and in more than half of cases fractures of the zygomatic bone accompanied by injuries of the walls of the maxillary sinus, nasal and orbital bones, and the eyeball. Of these, 15% accompanied in combination with fractures of the maxillary sinus walls. The article presents a clinical case of transportation trauma of a patient because of a traffic accident as a passenger. Upon admission to the hospital, after a comprehensive examination, the diagnosis: Fracture with displacement of the anterior lateral wall of the right Maxillary sinus, the inferior and lateral wall of the right Orbit. Fracture of the Zygomatic arch with angular deformation. Contusion and abrasions of soft tissues of the right half of the face, right para-orbital tissue. Then successfully performed the operation - Repositioning of bone fragments in fractures Operation repositioning of the zygomatic bone fracture and Osteosynthesis of the anterior wall of the Maxillary sinus on the right side with a titanium perforated plate and isolated from the PRP membrane.

FREQUENCY OF COMPLETE HEART BLOCK IN PATIENTS PRESENTING WITH INFERIOR WALL MYOCARDIAL INFARCTION

Objective: To determine the frequency of complete heart block in patients with acute inferior wall myocardial infarction Methods: Descriptive cross-sectional study conducted in Cardiology Department Khyber Teaching hospital Peshawar from 23 Dec, 2019 to 23 Jun, 2020. Diagnosis of acute inferior wall MI was made. Presence or absence of complete heart block was made with standard 12 lead ECG and continues cardiac monitoring during hospital stay. Results: A total of 233 patients meeting the inclusion criteria were studied. Mean age ±SD of studied population was 63.86±7.180. Patients were divided into two groups based of age. The number of patients less than 60 years of age were 58 (24.9%) while those 60 years and above were 175 (75.1%). 158 (67.8%) patients were males while 75 (32.2%) patients were females. Complete Heart Block (CHB) was recorded in (18.5%) of patients with Acute Myocardial Infarction (AMI). There was no effect of CV risk factors on CHB except age where elderly patients showed significantly higher rates of CHB Conclusion: CHB is a common complication in patients with inferior wall myocardial high. Aging increases the risk of CHB in inferior STEMI.

Mitral valve prolapse in sudden cardiac arrest survivors - coincidence or causal relationship?

Sudden cardiac arrest (SCA) risk stratification in patients with mitral valve prolapse (MVP) may be complicated by other potential causes of arrhythmia. We aimed to characterize SCA survivors with isolated (iMVP) and non-isolated MVP (non-iMVP) and to assess their long-term follow-up. This ambispective study included 75 patients with MVP who experienced SCA and were treated in our center between 2009-2024. They were divided into three groups depending on probability of relation between SCA and comorbidities. The control group comprised 112 subjects with MVP but without a history of SCA. We analyzed all available electrocardiograms, Holter ECG monitoring and echocardiograms, including longitudinal strain. A novel parameter, the systolic atrial-directed notch (SADN) was tested. SCA survivors with iMVP (n=28) had higher prevalence of mitral annular disjunction (MAD) (80% vs. 35.7%, P=0.006), Pickelhaube sign (60% vs. 8.3%, P=0.008), SADN > 2 mm (69.6% vs. 14.3%, P=0.001) as well as higher absolute longitudinal strain values in basal and mid segments of inferior and inferolateral wall than patients with SCA and non-iMVP without other defined structural heart diseases (SHD(-)) (n=14). The differences were also observed in comparison to control group. The cumulative incidence of appropriate implantable cardioverter-defibrillator shocks within 6 years was 62% in patients with iMVP and 23% in the group with non-iMVP SHD(-). Echocardiographic findings such as MAD, SADN, Pickelhaube sign and increased segmental strain may be useful in the assessment of relation between SCA and MVP. Malignant arrhythmias often recur in SCA survivors with iMVP.

New Echo parameters for Detection of the Culprit Lesion Site and Evaluation of its Severity in Acute Inferior wall Myocardial Infarction

New Echo parameters for Detection of the Culprit Lesion Site and Evaluation of its Severity in Acute Inferior wall Myocardial Infarction

Reverse Takotsubo Cardiomyopathy mimicking inferior wall STEMI– A case report

Takotsubo syndrome is a disease of uncertain aetiology characterized by transientregional wall motion abnormality without associated coronary artery disease. Though the classical variant or the apical ballooning syndrome is most commonly seen in post-menopausal women atypical variants like reverse Takotsubo cardiomyopathy can occur in younger patients. Reverse Takotsubo cardiomyopathy more frequently presents with ST-segment depression and presentation as STEMI is rare. Here we are presenting a case of a39-year-old lady who presented as STEMI inferior wall but eventually diagnosed to have reverse Takotsubo cardiomyopathy based on clinical, echocardiographic and angiographic findings.

Combined Supine-Prone Myocardial Perfusion Imaging: Enhancing Diagnostic Accuracy.

The combined supine-prone imaging protocol for SPECT myocardial perfusion imaging offers significant advantages over supine imaging alone. By comparing supine and prone images, one can distinguish attenuation artifacts in the inferior and anterior walls from true perfusion defects, thus improving specificity and diagnostic accuracy. The recommended protocol is to perform prone imaging after supine stress imaging when perfusion defects are noted. The additional prone imaging time is 20%-40% less than the standard supine imaging time. Implementing prone imaging can optimize patient care and provide substantial benefits for nuclear cardiology labs, especially those without attenuation correction.

Imaging and clinical significance of tubular cell in lateral facial recess

Objective:To observe the position and morphology of tubular cell in lateral facial recess by CT scanning and surgical finding, and its clinical significance. Methods:Thirty patients（32 ears） with cholesteatoma and/or adhesive otitis media requiring radical mastoidectomy and tympanoplasty were included in this study. To observe the morphology of the tubular cell in the lateral facial recess cavity through temporal bone HRCT and surgery, and to analyze its relationship with the facial nerve. Results:Tubular cell were found in 59.4%（19/32） ears by temporal bone HRCT and through surgeon. The length ranged from 1.5-6.5 mm, with median length of 2.5 mm. All of them opened in the facial recess, ran on the posterior wall of the facial recess, and even reached the bottom of the inferior tympanic cavity or the level of the inferior wall of the external auditory canal（sagittal view and surgical findings）. Probing from the inside out, the tubular cell located between the second genu of the facial nerve and the chorda tympani, which was a part of the lateral wall of the facial nerve（facial crest）. When the tubular cell is occupied by granulation tissue, it is easy to be regarded as the facial nerve. Fully drilling out the tubular cell is helpful to cut down the facial nerve crest. In the study, the follow-up and/or postoperative no facial paralysis happens during the operation and in the follow up. Conclusion:Preoperative temporal bone HRCT can clearly show the tubular cell in the lateral facial recess cavity. Comprehensive and accurate identification of these structures is helpful to fully cut down the facial nerve crest and remove the hidden lesions in the posterior tympanic cavity.

ЭЛЕКТРОКАРДИОГРАФИЧЕСКИЕ ПАТТЕРНЫ ВНЕЗАПНОЙ СЕРДЕЧНОЙ СМЕРТИ У ПАЦИЕНТА С ИНФАРКТОМ МИОКАРДА И ВНЕБОЛЬНИЧНОЙ ПНЕВМОНИЕЙ, ВЫЗВАННОЙ НОВОЙ КОРОНАВИРУСНОЙ ИНФЕКЦИЕЙ

Abstract. Introduction. Sudden death remains a major public health problem causing death in 25–50% of patients with a previous myocardial infarction. Studying and searching for new prognostic risk factors for sudden cardiac death are an extremely difficult task. Atrioventricular dissociation may be one of the significant cardiac complications of acute myocardial infarction in a patient diagnosed with a new coronavirus infection. Aim was to present a clinical case of patient G. born in 1936 with sudden cardiac death registered during 24-hour electrocardiography monitoring, which was preceded by arrhythmogenic myocardial activity and atrioventricular dissociation. Materials and Methods. Literature was reviewed, and patient G.’s medical background was studied. Results and Discussion. Changes are shown that took place in the in arrhythmogenic myocardial activity preceding asystole in patient G. born in 1936, who was hospitalized with a diagnosis of coronary heart disease. Repeated myocardial infarction of the inferior wall of the left ventricle dated November 11, 2023. Post-infarction cardiosclerosis (1986). Rhythm and conduction disturbances are a paroxysmal form of atrial fibrillation. First-degree atrioventricular block, complete right bundle branch block. Hypertension stage 3, risk 4. Controlled arterial hypertension. Target blood pressure 120-129/70-79 mm Hg. Hypertrophy of the walls and dilatation of the cavities of the left ventricle and of the left and right atria. Chronic heart failure 2B (Simpson ejection fraction 29%). Functional class III. Bilateral hydrothorax. Community-acquired right-sided pneumonia, severe. Respiratory failure 1-2. Type 2 diabetes mellitus, target glycated hemoglobin level below 8%. Chronic kidney disease C3a (glomerular filtration rate 55 ml/min/1.73 m²). New coronavirus infection (PCR SARS-COV-2 diagnosed on November 21, 2023). Conclusions. In the presented case report, electrophysiological instability of the myocardium preceding asystole in patient G. was recorded on a long-term electrocardiogram recording, the patient having the verified leading risk factors for sudden cardiac death, such as hemodynamically significant ventricular arrhythmias, myocardial infarction, episodes of atrioventricular dissociation, heart failure with the reduced left ventricular ejection fraction, and coronavirus infection.

An Interesting Uncanny Clinical Presentation of Acute Myocardial Infarction

Myocardial infarction can present to the emergency room in the form of various complications. Anterior wall MI is notorious for producing mechanical complications like ventricular free wall rupture, ventricular septum rupture, and papillary muscle rupture. Inferior wall MI is usually associated with conduction abnormalities like heart blocks. Here, reperfusion of the myocardium and concurrent management of the complication should go hand in hand. We had a patient presenting to the ER with an ECG that was confusing between a PSVT and VT which when reverted revealed an anterior wall MI. The patient was salvaged with prompt revascularization.

Ablation index value for transmural lesions based on unipolar electrograms in patients with paroxysmal atrial fibrillation undergoing pulmonary vein isolation.

It remains unclear whether the current recommended ablation index (AI) value is suitable for individualized catheter ablation. Prior research has established that the elimination of the negative component of the unipolar electrogram (UP-EGM) applications reflects the formation of transmural lesion during radiofrequency ablation. The aim of this study was to explore the relationship between AI values when UP-EGM turns positive during pulmonary vein isolation and recommended AI values. A total of 50 patients with drug-refractory PAF who underwent index RFCA were consecutively included from September 2022 to January 2023. All the patients underwent AI-guided ablation. UP-EGM was also recorded during the procedure. The difference in the AI between the value when the UP-EGM turned completely positive [AIUP-EGM(+)] and the recommended value at the end of ablation (AIEND) was compared. A total of 2 954 lesion points were detected in 50 patients. The average values of AIUP-EGM(+) at the anterior wall and the posterior wall were 420.9 and 267.4, respectively. The average AIEND values were 524.3 and 393.9 at the anterior wall and the posterior wall, respectively. The percentage of increase in the AI between the AIUP-EGM(+) and AIEND groups was 22%, 28% at the anterior wall and 47%, 49% at the posterior wall (P < 0.001). After a mean follow-up duration of 11.30 ± 2.10 months, 44 patients (88%) remained in sinus rhythm without antiarrhythmic drugs. The AIUP-EGM(+) was lower than the recommended value for all the pulmonary vein regions. The recommended AI value seems to be too high for the posterior and inferior walls, but this remains to be proven in future research.

Bronchial artery embolization leading to acute myocardial infarction: a case report on bronchial artery-coronary artery fistula

A 22-year-old woman presented with hemoptysis for three days, averaging 150 ml of blood per day. She had no history of childhood chest disease. On admission, a chest scan suggested a potential lung infection, and laboratory results showed no significant abnormalities. Despite continuous infusion of posterior pituitary hormone, her symptoms persisted. We performed bronchial arteriography and embolization using 150–350 μm microsphere particles. During the procedure, the patient developed chest pain. An electrocardiogram (ECG) showed abnormal Q-waves and ST-T elevation, with vital signs indicating hypotension and elevated myocardial enzymes suggesting acute myocardial infarction (AMI). Repeated arteriography revealed a bronchial artery-right coronary artery fistula, likely worsened by a dislodged gelatin sponge blocking coronary microvessels. The embolization was halted, and treatment with low molecular weight heparin and aspirin was initiated. By the fifth postoperative day, the patient’s ECG indicated an abnormal Q wave in the inferior leads, and myocardial enzymes were gradually returning to normal. One week later, coronary angiography revealed no blockage, and the patient was discharged after stabilization. The cardiovascular magnetic resonance (CMR) indicated myocardial necrosis and edema in the inferior wall of the heart. During subsequent follow-up, the patient reported no significant chest pain or recurrence of hemoptysis.

A Prospective Observational Study on the Clinical Profile Assessment of Myocardial Infarction Patients in a Tertiary Care Teaching Hospital

Background: Cardiovascular Diseases (CVDs) are the single largest contributor to the global burden of disease and are recognized as the leading cause of death globally. CHD has various clinical manifestations ranging from asymptomatic to acute conditions, namely acute coronary syndrome. Cardiovascular risk factors for acute coronary syndrome (ACS) are on the rise in people of Indian origin. Myocardial Infarction (MI) also called as heart attack, infarction means the death of an area of tissue because of interrupted blood supply. Myocardial Infarction has become a growing concern among the cardiovascular diseases, hence the study is conducted in order to assess the clinical profile of patients suffering from MI. Aim: To assess the clinical presentations, risk factors, short-term complications and management of patients with MI. Methodology: A prospective observational study was conducted in a tertiary care teaching hospital over six months. A total of 121 patients were selected based on inclusion and exclusion criteria. Results: Among the 121 patients included, the predominant were males (63.63%). Most of the patients fell under the age group of 51-60 (n=46). The common presenting symptoms were chest pain (42.32%), followed by breathlessness (26.04%) and sweating (15.34%). Most patients had NSTEMI (62.80%) and STEMI (37.19%). Alcohol (23.44%) was major risk factor followed by smoking (22.48%) and diabetes (14.35%). The elevated biomarkers noted were Troponin I (42.14%), Troponin T (37.19%) and CK-MB (6.61%) respectively. The majority of infarctions occurred on inferior wall (30.57%). The most prevalent complication observed was heart failure (14.8%) followed by sinus tachycardia (6.61%), and sinus bradycardia (5.78%). The majority of patients received key medications like anti-platelet agents, statins and anti-coagulants during hospital stay. Conclusion: The risk of men developing myocardial infarction is more compared to women due to various reasons. It is more likely that the diagnosis of myocardial infarction is neglected due to certain presenting symptoms like epigastric pain, syncope, vomiting, sweating etc., hence this study was conducted with an overview of creating awareness regarding the severity of myocardial infarction along with the advantages of early diagnosis.

Abstract 4120573: Abrupt cardiac rupture of the patient with ATTR amyloidosis

A Japanese male in his 80s was admitted to our emergency department with chest pain. His prior history was syncope and ventricular tachycardia. Transthoracic echocardiography (TTE) revealed thickening of the basal part of the antero-septal wall and thinning of the basal part of the inferior wall. Coronary angiography (CAG), cardiac MRI and blood test revealed no specific abnormalities. The day before his emergency admission, he visited the cardiology outpatient department for a periodic examination of cardiac hypertrophy. ECG, chest X-ray, and TTE were unchanged from his prior examination. However, that night, he experienced chest pain and was transferred to our hospital. On arrival, his vital signs were critical, with a blood pressure of 70/59 mmHg. ECG indicated ST elevation in antero-lateral leads. TTE detected pericardial effusion, and contrast-enhanced CT identified two focal areas of non-enhancement in the myocardium and pericardial effusion without signs of aortic dissection. CAG revealed no significant stenosis or obstructive lesion. During coronary angiography, the patient deteriorated to asystole. Cardiopulmonary resuscitation and percutaneous pericardial drainage were initiated. Hemorrhagic pericardial effusion was aspirated. Immediate surgical hemostasis was undergone, revealing about 2 cm lacerations and hematoma in the anterior and inferior wall. After surgery, he complained of abdominal discomfort. Esophageal gastrointestinal endoscopy was undergone to investigate the abdominal discomfort, and he was diagnosed with early gastric cancer. Endoscopic submucosal dissection (ESD) was undergone, and histopathological examination revealed adenocarcinoma and eosinophilic amorphous materials deposited in the submucosal vessels. Congo red staining of the submucosal vessels revealed orange-red areas. A technetium-99m pyrophosphatase scintigraphy showed Grade 2 uptake in the heart. Transthyretin (TTR) staining was positive in the specimen from ESD, leading to a diagnosis of TTR amyloidosis. Genetic test for TTR was negative, which led to a diagnosis of wild-type TTR amyloidosis and tafamidis was started. In cases of acute pericardial effusion and/or cardiac rupture, it is imperative to consider cardiac amyloidosis as a potential etiology, in addition to myocardial infarction and aortic dissection, especially in patients with left ventricular wall thickening, neuropathy, or abnormal ECG, also known as “red flag”.

Abstract 4120434: A Rare Case Of Localized Ventricular Tachycardia Due To Mitral Annular Disjunction And a Subvalvular Aneurysm

Introduction: Mitral annular disjunction (MAD) is an abnormality of the mitral valve where a portion of the mitral annulus and valve leaflets insert into the left atrium away from the fibrous annulus. Since its identification in 1981 its diagnosis has increased due to the advancements in cardiac imaging. It’s association with ventricular arrythmia (VA) and sudden cardiac death (SCD) underscores the importance of its identification. We present a case of ventricular tachycardia (VT) that is attributed to MAD with associated sub-mitral valve left ventricular aneurysm (SMA) formation. Case: A 51-year-old African American male with history of posterior papillary muscle premature ventricular contractions (PVC), PVC induced cardiomyopathy, and family history of sudden cardiac death in his mother who presented to the emergency department due to palpitations. Electrocardiogram (ECG) showed sustained monomorphic VT at a rate of 160 bpm. This converted to normal sinus rhythm with intravenous amiodarone and metoprolol. Further work up included cardiac magnetic resonance which identified a 4 x 1.8 x 1.4 cm SMA on the basal inferior and inferolateral walls. There was near transmural late gadolinium enhancement (LGE) of the aneurysm and an associated 7 mm of MAD with posterior mitral valve prolapse (MVP). He underwent left heart catheterization which was normal. ECG showed a superior right axis with associated right bundle branch block which correlated to a basal inferolateral exit and to the location of the SMA. Ultimately the patient underwent implantation of secondary prevention implantable cardioverter-defibrillator and initiation of sotalol. Discussion: The prevalence of MAD is approximately 30% in those with MVP and 8% in the general population. Those patients with MAD and MVP appear to be at higher risk for VA and SCD. The most likely mechanism for this association is the fibrotic changes that occur in the basal inferolateral left ventricle because of mechanical stretch on the papillary muscles by the prolapsing leaflets. The scar and aneurysm that develop can serve as substrate for reentrant VA. Treatment for this involves surgical repair of the mitral valve annulus and correction of the MAD distance which has been shown to improve arrythmia. Conclusion: This case illustrates an important but poorly understood arrhythmogenic entity that will increase in incidence as cardiac imaging advances. Its implications in VA and SCD warrant further research.

Abstract 4136412: Quantitative Cardiac Magnetic Resonance Standardized Signal Intensity Comparison in Dilated Cardiomyopathy versus Cardiac Sarcoidosis

Introduction/Background: Dilated cardiomyopathy (DCM) and cardiac sarcoidosis (CS) manifest unique late gadolinium enhancement (LGE) patterns on cardiac magnetic resonance (CMR), indicative of differing distributions of myocardial scar tissue. Nevertheless, these LGE patterns lack specificity, leading to significant overlap between the two conditions. Goals/Aims: This study seeks to introduce a novel quantitative method employing z-score analysis of LGE-CMR signal intensity to objectively evaluate and compare the spatial distribution of LGE intensity between DCM and CS. Methods/Approach: The retrospective cohort included 22 NICM patients (13 DCM, 9 CS) that underwent pre-procedural CMR prior to ventricular tachycardia (VT) ablation between November 2018 to May 2023. LGE images were delineated into sub-endocardial, mid-myocardial, and sub-epicardial layers, categorized into anterior, lateral, inferior, and septal walls based on the AHA 17 segment model for LV myocardial segmentation. CMR signal intensities were standardized as z-scores: z = (x−μ)/σ, where x is the MRI signal intensity for a specific myocardial segment and layer, and μ and σ are the mean and standard deviation across all myocardial segments and layers of the LV, to characterize regional intensity variations. Results/Data: Compared to patients with DCM, those with CS exhibited significantly higher CMR signal intensity z-scores in the septum (β=0.32, p=0.009), particularly in the endocardial third of the right ventricular side (β=0.56, p=0.001). A z-score greater than 0.40 in this area was associated with a CS diagnosis, with an area under the ROC curve of 0.692 in 5-fold cross-validation. Conclusions: Patients with CS exhibit higher affinity for contrast in the septum, particularly on the RV endocardium. Standardized analysis of CMR signal intensities provides a novel, quantitative method for distinguishing CS from DCM, with the former exhibiting higher CMR signal intensity z-scores in the septum.

Abstract 4119267: Diagnosing An Uncommon Presentation of Cardiac Sarcoidosis with Isolated Bi-Atrial Involvement: A Case Report

Background: Sarcoidosis, a systemic granulomatous inflammatory disorder can involve various organs, including the heart but isolated bi-atrial cardiac involvement is rare. Advanced cardiac imaging especially in atypical presentations, can aid in early diagnosis. Case: A 59 year-old man with history of biopsy-proven pulmonary sarcoidosis presented with non exertional chest pain for 2 months. EKG, cardiac enzymes, and Initial echocardiogram(TTE) was unremarkable. Stress echocardiogram ruled out myocardial ischemia. CT scan noted mediastinal lymphadenopathy consistent with known sarcidosis. In absence of other explainable etiolgies for chest pain, Cardiac MRI was done and showed preserved biventricular function, subepicardial enhancement in the basal inferior, inferolateral, and anterolateral walls. The enhancement raised suspicion for CS. However, symptoms resolved spontaneously, cardiac workup paused and he was monitored conservatively with serial Echocardiogram(TTE) until onset of dyspnea 3 years later. Repeat TTE and EKG then noted newly enlarged left atrium and atrial tachycardia. Further testing with Cardiac positron emission tomographic imaging with F-18 fluorodeoxyglucose (FDG-PET CT) showed abnormal myocardial uptake in both atrial posterior walls but no ventricular involvement, indicative of isolated bi-atrial inflammation in CS. He was treated with prednisone and methotrexate. Successful symptom and inflammation resolution on FDG-PET CT occurred in 3 months Discussion: CS is rare and seen clinically in about 5% and diagnosed postmortem in 25% of sarcoidosis cases. Symptoms vary widely, with potential for severe heart complications. Left ventricle and interventricular septum are commonly involved, but isolated bi-atrial involvement is rare. Early diagnosis aided by Cardiac MRI and FDG-PET CT is crucial. Prednisone is mainstay of treatment, often combined with methotrexate. Cases of concurrent atrial CS involvement and bi-atrial fibrosis with Left ventricular hyperenhancement are documented, but this is the first known report of isolated bi-atrial hyperenhancement on FDG-PET CT for CS. This case highlights the need for symptom correlation with clinical and imaging follow-up, especially in atypical presentations.

Abstract 4136480: A Rare Cause of a Classic Presentation of NSTEMI: Case of 39-Year-Old Female with Hypothyroidism Induced Myocarditis

Background: Myocarditis is a cause of non-ischemic cardiomyopathy (NICM) and troponin elevation. There are many causes including uncontrolled thyroid disorder (TD). A thorough history, cardiac MRI (cMRI) followed by an endomyocardial biopsy (EMB) is necessary for diagnosis. This case illustrates a classic presentation of NSTEMI with a rare cause of myocarditis due to uncontrolled hypothyroidism. Description of Case: A 39-year-old female with history of congenital hypothyroidism and tobacco use disorder presented to the Emergency Department with sudden onset of unprovoked sub-sternal chest pain. She stated she had stopped taking her levothyroxine years ago due to side effects such as abdominal discomfort. On admission, work up included high sensitivity troponin (Hs-cTn), EKG, urine drug screen (UDS), and thyroid panel. There was no evidence of ischemic changes on EKG, Hs-cTn was 3600 (normal: 3-54) which up-trended to 43,742, and UDS was negative. She was placed on appropriate medical therapy for NSTEMI and taken for urgent coronary angiography wbich showed normal epicardial arteries. A transthoracic echocardiogram (TTE) was unremarkable with a normal ejection fraction (EF). However, she continued to complain of chest discomfort and palpitations. Her vital signs remained stable but her thyroid panel revealed a TSH of 127 (normal: 0.27-4.2), T4 of 0.18 (normal: 0.92 – 1.6) and T3 of 1.0 (normal: 2.3-4.2). Inflammatory markers were also elevated. A cMRI was obtained revealing gadolinium enhancement in the anterior septal wall with extension into the subepicardium of the inferior wall suggestive of possible myocarditis. An EMB was performed to elucidate etiology. Pathology results were only remarkable for edema but newly reduced EF of 30-35% was noted on TTE at time of biopsy. Endocrinology was consulted for untreated hypothyroidism and patient was initiated on levothyroxine leading to improvement of her symptoms. Discussion: Our patient's history and work up were consistent with myocarditis induced by severe hypothyroidism. TD is a rare cause of reversible NICM and symptoms improve once TD is controlled. While there are several cases reported on hyperthyroidism associated myocarditis, there are only a few cases of myocarditis associated with uncontrolled hypothyroidism. Clinicians should maintain a broad differential to ensure a thorough work up in a patient presenting with NSTEMI, and a thyroid panel should be included especially if myocarditis is suspected.

Marfan's Syndrome with Acute Inferior Wall ST-segment Elevation Myocardial Infarction in A Combined Family of 13 Cases

Marfan's syndrome (MFS) is a rare autosomal dominant connective tissue disorder, often associated with genetic mutations and most patients have a family history of the disease. Its clinical manifestations are mainly skeletal, ocular and cardiovascular pathologies. We report a case of a 34-year-old male diagnosed with Marfan's syndrome at the age of 22 and presenting with ocular symptoms. Following an episode of sudden chest pain, he was admitted to the hospital with an acute inferior wall ST-segment elevation myocardial infarction, and was diagnosed with a mid-right coronary artery occlusion by coronary angiography. He underwent coronary artery balloon dilatation to restore grade 3 flow, and a stent was implantated 4 months later. In a subsequent epidemiologic survey of 26 family members from 4 generations, 13 members were diagnosed with Marfan's syndrome, all of them presented with ocular signs. After more than 3 years of follow-up of the entire family, there is currently no one with coarctation of the aorta and no sudden death. Since some patients with Marfan's syndrome can present with acute chest pain complicated by aortic coarctation, if the coarctation involves the aortic root it can lead to severe stenosis or occlusion of the coronary arteries, resulting in electrocardiograms showing typical changes for a ST-segment elevation myocardial infarction. Considering the complexity and life-threatening nature of Marfan's syndrome, it is important consider the various etiologies of chest pain in patients with Marfan's syndrome.

Percutaneous Closure of Postmyocardial Infarction Ventricular Septal Rupture – A Single Center Experience from the Eastern Part of India

Abstract Background: Postinfarction ventricular septal rupture (VSR) is a rare but lethal mechanical complication of an acute myocardial infarction (AMI). It results in 90%–95% mortality within 2 months of diagnosis without any kind of intervention. Given high surgical mortality, transcatheter closure has emerged as a potential strategy and as an alternative to high-risk surgical closure. Indian data on percutaneous device closure of post-AMI VSR are limited; hence, we report our resource-limited single-center experience with different kinds of occluder devices for closure of post-AMI VSR. Methods and Results: In this single-center, retrospective cohort study, patients who underwent transcatheter closure of postmyocardial infarction (MI) VSR between 2018 and 2024 at Health World Hospitals in Durgapur, West Bengal, were included. The primary outcome was a mortality rate of 30 days. The study population was eleven primary cases of post-MI VSR. The mean age of the population was 61 years. The majority of the patients had anterior wall MI (54.5%), and the remaining had inferior wall MI. Different kinds of devices (Amplatzer atrial septal occlude, post-MI VSD device, and Konar-Multifunctional Occluder) were used to close VSR. Successful closure was performed in 9 patients (81%) with minimal residual shunt in 2 patients. Of 9 cases, 3 patients expired; one was lost to follow-up, and the rest are doing well at 30-day follow-up. Conclusion: Transcatheter closure of PMI VSRs can be performed with different kinds of devices with high technical success, relatively low procedural complication rates, and a good 30-day survival even in a setup outside the metropolis with limited availability of devices, as an alternative to very high-risk surgical closure.

Accuracy of the Image Interpretation Capability of ChatGPT-4 Vision in Analysis of Hess Screen and Visual Field Abnormalities.

OpenAI, the owner of ChatGPT, publicly released the GPT-4 Vision in September 2023. This multimedia chatbot has the capability to receive and analyze various images presented to it by the user. We assessed the accuracy of its interpretation of 2 of the images commonly used in neuro-ophthalmology, namely Hess screen and automated visual field images. We separately uploaded typical images of 5 abnormal Hess screen charts related to third, fourth, and sixth cranial nerve palsy, Brown syndrome, and inferior orbital wall fracture with entrapment of the inferior rectus muscle. Likewise, 5 classic images of automated visual field grayscale maps related to lesions of the optic nerve, the chiasma, the optic tract, the optic radiations, and the occipital lobe were presented. The chatbot was instructed to select the best option among the 5 choices presented in each question. The GPT-4 Vision was able to select the right choice in 2/5 questions on Hess screens and 3/5 of the visual field questions. Despite selection of the correct option, qualitative evaluation of GPT-4 responses revealed flawed analysis of certain aspects of some image findings, such as the side of involvement or the misinterpretation of the physiologic blind spot as a central scotoma. The performance of GPT-4 Vision in the interpretation of abnormalities of Hess screen and visual field involvement was highly variable, even with simple typical cases of classic disorders. As the chatbot's image recognition is currently evolving, its capacity to accurately interpret ophthalmologic images is still limited at this time.