Commonly reported complications of hepatic cysts include compression of biliary tree, rupture into peritoneal cavity, spontaneous hemorrhage and infection, however cardiac complications are rare. An 89 year old lady with history of hypertension, sick sinus syndrome, hyperlipidemia and pulmonary

Background: Acute Aortic dissection is a critical etiology of chest pain with very high mortality. 1% to 2% of patients die per hour during the initial 24 to 48 hours. Case: A 62 year old lady with history of diabetes, hypertension, hyperlipidemia, hypothyroidism, smoking and no pertinent family history presented with atypical chest pain. She remained hemodynamically stable with no discrepancy of BP between arms. Labs: troponin 0.64, 0.63 ng/ml. EKG: sinus bradycardia. Chest x-ray: no mediastinal widening or signs of aortic aneurysm. Coronary angiogram showed 20-30 % stenosis in left anterior descending and right coronary arteries. An aortogram showed dilated aortic root over 6 cm with aortic regurgitation. Decision-making: An emergent echocardiogram confirmed acute aortic regurgitation and dissection. CT angiogram showed DeBakey type I aortic dissection extending from aortic annulus to infra renal aorta, supra aortic great vessels, celiac axis and left renal artery. She had no signs of malperfusion syndrome. She was started on iv Esmolol and emergently airlifted to tertiary care facility for surgical repair. Intra operative TEE showed findings consistent with acute aortic dissection. She had successful modified Bentall procedure with replacement of aortic valve, aortic root, ascending aorta and hemi arch. She had excellent recovery and continues to do well at follow up visits in our clinic. Conclusion: An early diagnosis of acute aortic dissection requires high index of suspicion due to variable symptoms and clinical manifestations. DeBakey type I aortic dissection may have better chance of survival in the absence of malperfusion syndrome if treated early as in this case.

Introduction: Spontaneous Coronary Artery Dissection (SCAD) is an uncommon condition. In patients taking prescription amphetamine or with methamphetamine abuse, SCAD has been reported in some case reports. We describe a case of a young female patient who had recurrent SCAD on prescription amphetamine with multisite involvement. Case presentation: A 48-year-old woman with history of active tobacco use, hypertension presented with substernal chest pain radiating to both arms. Her home medications included prescription amphetamine (Amphetamine, Dextroamphetamine) for reported history of ADHD (Attention Deficit Hyperactivity Disorder, diagnosed in childhood). The patient’s electrocardiogram showed ST elevations in V2,V3 and V4 and with reciprocal changes in leads II, III and aVF. On emergent cardiac catheterization we noted dominant left system with 99% occlusion with thrombus of mid LAD with radiolucent lumens and contrast dye extravasation into the arterial wall suggesting type 1 SCAD. Otherwise we noted normal RCA, LCx and OM branches. An IVUS was not used during the procedure. This lesion was revascularized with a drug eluding stent with containment of the dissection and achievement of TIMI 3 flow. We noted that the patient presented similarly two separate times in the past 2 years and cardiac catheterizations at that time revealed type 2B SCAD involving OM3, which appeared angiographically normal on current angiogram and 90% distal LAD occlusion from type 1 SCAD. The patient was treated with aspirin and ticagrelor and discharged 2 days post procedure in stable condition. Conclusions: Spontaneous Coronary Artery Dissection (SCAD) has been reported in patients with prescription amphetamine and methamphetamine use, but it is imperative to rule out alternative etiologies and amphetamine related SCAD should be a diagnosis of exclusion. We opted to intervene on the mid LAD dissection and the distal dissections were treated medically.

Rituximab is a chimeric monoclonal antibody against the protein CD20 which is predominantly found on the surface of B cells. Malignant B cells express higher levels of CD20. Rituximab not only induces cellular apoptosis but also down regulates the B cell receptor and mediates antibody dependent

Cardiac Memory (CM) is a rare but clinically significant electrocardiogram (ECG) finding consisting of persistent T-wave changes that mimic ischemia. This phenomenon is most often encountered after normal ventricular conduction has been restored after pacing or any period of wide QRS activation.

IgG4 related disease (IgG4-RD) is a newly recognized etiology for inflammation and chronic structural changes to large vessels. The disease is characterized by a lymphoplasmacytic infiltrate of the adventitial layer rather than inflammatory changes of the media as seen is other vasculitities. While

Background Micra transcatheter pacing systems were first brought onto the market in 2016. Currently the Micra pacemaker is indicated for VVIR mode in patients that experience symptomatic high-grade AV block, tachy-brady syndrome and individuals considered high risk for right atrial lead dislodgement. Our institution has utilized Micra pacing successfully in various clinical applications: limited transvenous access due to superior vena cava syndrome, right ventricular pacemaker lead induced tricuspid regurgitation, pacemaker infection and as described below, atrial fibrillation ablation shortly after pacemaker insertion. Case We report a case of a 72-year-old male with a history of symptomatic paroxysmal atrial fibrillation, mechanical aortic valve and morbid obesity who presented to our outpatient clinic for evaluation of his symptomatic atrial fibrillation. Despite increased Sotalol dosing, the patient continued to have symptomatic paroxysmal atrial fibrillation with symptoms of dizziness and near syncope. Outpatient monitoring revealed greater than 5-6 second pauses during atrial fibrillation episodes and greater than 1 second pauses during sinus rhythm. Clinical Decision Making Due to the patient's need for both a pacemaker and an atrial fibrillation ablation, the electrophysiologist felt the patient would be high risk for atrial lead dislodgment. Another concern was the patient's long-term anticoagulation secondary to his mechanical aortic valve. After a multidisciplinary discussion, the consensus was for a Micra pacemaker to be inserted with atrial fibrillation ablation to be performed shortly after. This was performed successfully and in outpatient follow up, the patient has been free of any further syncope, dizziness or atrial fibrillation. Conclusions This case focuses on creating awareness that Micra transcatheter pacing can be utilized in high risk patients with excellent results in an ever-expanding list of clinical indications.

His Bundle pacing has reemerged as an alternative to ventricular pacing in hopes to resynchronize the ventricles, narrow the QRS complex and improve clinical symptoms of congestive heart failure. Multiple case reports have documented the benefit of HIS bundle pacing; however, severe tricuspid

Key Teaching Points•Intracardiac echocardiography (ICE) can safely be used in the left atrium.•ICE in the left atrium in conjunction with mapping software can give the electrophysiologist better anatomical views of vital structures.•If conduction block cannot be demonstrated via the endocardial approach, ICE in the left atrium may assist in visualization of thickened tissue, requiring an epicardial approach. •Intracardiac echocardiography (ICE) can safely be used in the left atrium.•ICE in the left atrium in conjunction with mapping software can give the electrophysiologist better anatomical views of vital structures.•If conduction block cannot be demonstrated via the endocardial approach, ICE in the left atrium may assist in visualization of thickened tissue, requiring an epicardial approach.

Nonbacterial thrombotic endocarditis (NBTE) is a rare subset of endocarditis that requires a high index of suspicion to diagnose. NBTE is usually caused by advanced malignancy or systemic lupus erythematosus however we present an even more uncommon etiology of NBTE, antiphospholipid syndrome. We