Perry Fisher is an Internal Medicine resident at the Mount Sinai Beth Israel Medical Center in New York. Born and raised in Queens, New York, Fisher attended an accelerated B.S./ M.D. program at the Sophie Davis School of Biomedical Education. He completed his clinical medical school training at Albany Medical College. Along the way, Fisher performed clinical research, presented at multiple conferences and lectures, published works, and amassed several awards honoring his work. Fisher now practices inpatient medicine at Beth Israel Hospital, and maintains outpatient privileges at the Ryan NENA Community Health Center – serving the underserved population of New York City’s Lower East Side. He has a passion for the art of Cardiology, and aspires to specialize in Cardiovascular Medicine.

Angioimmunoblastic T-Cell Lymphoma (AITL) is an uncommon lymphoma with rare cardiac manifestations. We present a clinical example where non-contrast and contrast enhanced echocardiograms demonstrated remarkably different myocardial compositions, particularly in our patient identifying infiltrating lymphoma in the myocardium. Case: A 68-year-old African American man with past medical history of AITL presented with weakness and fatigue for 2 weeks. Transthoracic echocardiogram (TTE) without contrast was performed that showed a pericardial effusion and an echolucency of the left ventricle concerning for pseudoaneurysm. Repeat TTE was performed using IV contrast revealed the presence of multiple non-communicating hypodensities within the myocardium. Pericardial fluid analysis did not reveal evidence of lymphoma, however pleural fluid cytology exhibited abnormal cells consistent with T-cell lymphoma. Discussion: In our patient, contrast enhanced echocardiography identified infiltrating lymphoma in the myocardium that was not seen with standard 2D imaging. Echocardiographic contrast agents are excellent tools for the evaluation of the LV endocardium especially in the detection and classification of intracardiac masses, including thrombi and tumors. Most malignant tumors, secondary to neovascularization, have an abnormally concentrated and dilated vasculature and concordantly, will display increased contrast enhancement compared to the adjacent myocardium. Contrary to the norm, we found metastatic lesions in our patient with deceased pixel intensity. The use of contrast agents should be considered when evaluating patients with non-cardiac diseases that have the potential for infiltrating the myocardium, but the level of contrast enhancement may be variable with certain types of tumors.: Angioimmunoblastic T-Cell Lymphoma (AITL) is an uncommon lymphoma with rare cardiac manifestations. We present a clinical example where non-contrast and contrast enhanced echocardiograms demonstrated remarkably different myocardial compositions, particularly in our patient identifying infiltrating lymphoma in the myocardium.

To be updated soon..

Oxygen free radicals associated with ischemia-reperfusion (IR) injury in cardiomyocytes is known to cause mitochondrial damage. However, the exact mechanism of how the oxygen free radicals develop in the mitochondria due to IR stress is currently unclear. In the current study, we focus upon understanding the role of frataxin (FXN) in regulating mitochondrial damage associated with IR injury. FXN, a nuclear encoded mitochondrial matrix protein, has been observed to regulate mitochondrial iron homeostasis and thus mitochondrial energy regulation. Loss of FXN, in Friedreich’s ataxia, is associated with mitochondrial iron overload and increased ROS formation and cellular damage. In this study, we hypothesized that FXN protects cardiomyocytes against IR injury by preventing the dysregulation of myocardial bioenergetics. We identified that FXN expression is increased in response to IR injury and that increase is mediated by hypoxia inducible factor (HIF-1) which results in regulation of mitochondrial iron homeostasis and the ensuing mitochondrial ROS formation. Most surprisingly, we observed that enhanced FXN expression displayed elevated levels of glutathione (GSH) and superoxide dismutase (SOD). Furthermore, these findings were supported in our FXN over-expressing and knock down cells under the same IR condition. Together, these results demonstrate that increased expression of FXN is cardio-protective against IR injury through its anti-oxidant effect and by improving mitochondrial energetics.

Leandro Augusto Franco Nascimento has completed his medical school from Faculdade de Medicina de Petrópolis and Post-graduation studies in cardiology from Real e Benemérita Associação Portuguesa de Beneficência de São Paulo – Hospital São Joaquim.

The present study reports the case of a female patient, black, 32, born in the city of Mogi das Cruzes / SP, referred for examination of coronary angiography in hemodynamics service in Real e Benemérita Associação Portuguesa de Beneficência São Paulo - São Joaquim Hospital due to symptoms of exercise intolerance and palpitations with exercise test showing criteria for myocardial ischemia. During the hemodynamic examination she was diagnosed with Bland-White-Garland Syndrome, a rare congenital defect, estimating its incidence at 1:300,000 live births. We decided to admit her to perform complementary tests and therapeutic decision. After detailed study of the case, we accompany the patient in clinical and drug treatment for 5 months when she presented partial improvement of symptoms, but with myocardial scintigraphy showing drug induced ischemia, moderate/large extension, which led us to indicate the surgical treatment. After 3 months, patient is asymptomatic with myocardial scintigraphy showing lesser extension of ischemia. Her heart shows no signs of permanent ischemic damage, such dilatation or akinetic areas.

To be updated soon..

The present study reports the case of a female patient, black, 32, born in the city of Mogi das Cruzes / SP, referred for examination of coronary angiography in hemodynamics service in Real e Benemérita Associação Portuguesa de Beneficência São Paulo - São Joaquim Hospital due to symptoms of exercise intolerance and palpitations with exercise test showing criteria for myocardial ischemia. During the hemodynamic examination she was diagnosed with Bland-White-Garland Syndrome, a rare congenital defect, estimating its incidence at 1:300,000 live births. We decided to admit her to perform complementary tests and therapeutic decision. After detailed study of the case, we accompany the patient in clinical and drug treatment for 5 months when she presented partial improvement of symptoms, but with myocardial scintigraphy showing drug induced ischemia, moderate/large extension, which led us to indicate the surgical treatment. After 3 months, patient is asymptomatic with myocardial scintigraphy showing lesser extension of ischemia. Her heart shows no signs of permanent ischemic damage, such dilatation or akinetic areas.

To be updated soon..

The present study reports the case of a female patient, black, 32, born in the city of Mogi das Cruzes / SP, referred for examination of coronary angiography in hemodynamics service in Real e Benemérita Associação Portuguesa de Beneficência São Paulo - São Joaquim Hospital due to symptoms of exercise intolerance and palpitations with exercise test showing criteria for myocardial ischemia. During the hemodynamic examination she was diagnosed with Bland-White-Garland Syndrome, a rare congenital defect, estimating its incidence at 1:300,000 live births. We decided to admit her to perform complementary tests and therapeutic decision. After detailed study of the case, we accompany the patient in clinical and drug treatment for 5 months when she presented partial improvement of symptoms, but with myocardial scintigraphy showing drug induced ischemia, moderate/large extension, which led us to indicate the surgical treatment. After 3 months, patient is asymptomatic with myocardial scintigraphy showing lesser extension of ischemia. Her heart shows no signs of permanent ischemic damage, such dilatation or akinetic areas.

To be updated soon..

The present study reports the case of a female patient, black, 32, born in the city of Mogi das Cruzes / SP, referred for examination of coronary angiography in hemodynamics service in Real e Benemérita Associação Portuguesa de Beneficência São Paulo - São Joaquim Hospital due to symptoms of exercise intolerance and palpitations with exercise test showing criteria for myocardial ischemia. During the hemodynamic examination she was diagnosed with Bland-White-Garland Syndrome, a rare congenital defect, estimating its incidence at 1:300,000 live births. We decided to admit her to perform complementary tests and therapeutic decision. After detailed study of the case, we accompany the patient in clinical and drug treatment for 5 months when she presented partial improvement of symptoms, but with myocardial scintigraphy showing drug induced ischemia, moderate/large extension, which led us to indicate the surgical treatment. After 3 months, patient is asymptomatic with myocardial scintigraphy showing lesser extension of ischemia. Her heart shows no signs of permanent ischemic damage, such dilatation or akinetic areas.

Perry Fisher is an Internal Medicine resident at the Mount Sinai Beth Israel Medical Center in New York. Born and raised in Queens, New York, Fisher attended an accelerated B.S./ M.D. program at the Sophie Davis School of Biomedical Education. He completed his clinical medical school training at Albany Medical College. Along the way, Fisher performed clinical research, presented at multiple conferences and lectures, published works, and amassed several awards honoring his work. Fisher now practices inpatient medicine at Beth Israel Hospital, and maintains outpatient privileges at the Ryan NENA Community Health Center – serving the underserved population of New York City’s Lower East Side. He has a passion for the art of Cardiology, and aspires to specialize in Cardiovascular Medicine.

Angioimmunoblastic T-Cell Lymphoma (AITL) is an uncommon lymphoma with rare cardiac manifestations. We present a clinical example where non-contrast and contrast enhanced echocardiograms demonstrated remarkably different myocardial compositions, particularly in our patient identifying infiltrating lymphoma in the myocardium. Case: A 68-year-old African American man with past medical history of AITL presented with weakness and fatigue for 2 weeks. Transthoracic echocardiogram (TTE) without contrast was performed that showed a pericardial effusion and an echolucency of the left ventricle concerning for pseudoaneurysm. Repeat TTE was performed using IV contrast revealed the presence of multiple non-communicating hypodensities within the myocardium. Pericardial fluid analysis did not reveal evidence of lymphoma, however pleural fluid cytology exhibited abnormal cells consistent with T-cell lymphoma. Discussion: In our patient, contrast enhanced echocardiography identified infiltrating lymphoma in the myocardium that was not seen with standard 2D imaging. Echocardiographic contrast agents are excellent tools for the evaluation of the LV endocardium especially in the detection and classification of intracardiac masses, including thrombi and tumors. Most malignant tumors, secondary to neovascularization, have an abnormally concentrated and dilated vasculature and concordantly, will display increased contrast enhancement compared to the adjacent myocardium. Contrary to the norm, we found metastatic lesions in our patient with deceased pixel intensity. The use of contrast agents should be considered when evaluating patients with non-cardiac diseases that have the potential for infiltrating the myocardium, but the level of contrast enhancement may be variable with certain types of tumors.: Angioimmunoblastic T-Cell Lymphoma (AITL) is an uncommon lymphoma with rare cardiac manifestations. We present a clinical example where non-contrast and contrast enhanced echocardiograms demonstrated remarkably different myocardial compositions, particularly in our patient identifying infiltrating lymphoma in the myocardium.

Aileen D M Divinagracia-Alban has completed her Doctor of Medicine and Internship from the University of Santo Tomas. She took up Residency Training in Internal Medicine from Makati Medical Center. She is currently a third year Cardiology Fellow in Makati Medical Center, Philippines.

Background: Eosinophilic myocarditis is a rare and under-recognized subtype of myocarditis. The signs and symptoms are non-specific, most often mimicking other diseases, leading to a late, and sometimes, incorrect diagnosis. This disease can be self-limiting, however, if not detected early, can progress to a fatal outcome. Case Presentation: A 33-year-old female, known asthmatic was admitted due to recurrent chest pain, dyspnea and abdominal pain. ECGs showed transient ST segment elevation. The cardiac enzymes, WBC and eosinophil counts were significantly elevated. Coronary angiogram was normal. 2D echocardiogram showed concentric hypertrophy with segmental hypokinesia, normal LVEF, severe mitral regurgitation and with signs of diastolic dysfunction. Cardiac MRI showed mild diffuse myocardial edema and a patchy subendocardial enhancement. After initiation of steroid therapy, there was dramatic improvement in the symptoms and peripheral eosinophilia. 2D echocardiogram was again performed after several months was normal. Early discontinuation of steroids resulted in recurrence of cardiac events. Conclusion: Eosinophilic myocarditis, though uncommon, should be considered as a differential diagnosis in patients with acute coronary syndrome-like symptoms, history of asthma and allergies, a normal coronary angiogram, with or without peripheral eosinophilia. An echocardiogram and a cardiac MRI can support the diagnosis, however, endomyocardial biopsy remains to be the gold standard. Prompt recognition and immediate steroid therapy are important keys in managing this rare disease.

Aileen D M Divinagracia-Alban has completed her Doctor of Medicine and Internship from the University of Santo Tomas. She took up Residency Training in Internal Medicine from Makati Medical Center. She is currently a third year Cardiology Fellow in Makati Medical Center, Philippines.

Background: Recurrent ST elevation myocardial infarction (STEMI) with different culprit lesions in a single patient occurring few days apart is very rare with limited similar cases reported. Case Presentation: We present a case of a 53-year-old male who presented to the Emergency Department with left upper quadrant abdominal pain and an initial electrocardiogram showing ST elevation MI in the anterolateral leads. He underwent successful primary angioplasty of the culprit lesion (LAD) with placement of a single Everolimus drug-eluting stent with plans for staged intervention within a month of the remaining severe lesion in the left circumflex (LCx) artery (non-infarct related vessel). Two days after the initial STEMI, the patient experienced recurrence of abdominal pain with hypotension, and a repeat ECG revealed new ST segment elevation in the inferior leads. A repeat coronary angiogram demonstrated a widely patent stent in the LAD and the previously noted diseased LCx. No other new lesions were noted and the RCA was also patent. The patient then underwent a successful second primary PCI of the previously untreated severe lesion in the LCx. Conclusion: Consecutive episodes of acute myocardial infarction in different coronary arteries occurring within hours to a few days after primary PCI for STEMI is very rare and can be catastrophic if not detected early. The preferred interventional treatment strategy as to whether we need to perform “culprit-lesion only” versus “preventive” PCI of all significant lesions in STEMI patients with multi-vessel disease remains controversial.

Giuseppe Petrone has completed his degree in Medicine and Surgery from Second University of Naples (Italy) and is specialist in Cardiovascular Surgery since May 2015. He has worked as a Registrar and Clinical Fellow in Hammersmith Hospital (Imperial College, London) for a year (from May 2014 to April 2015). He is a Resident in the Cardiovascular department of “Heart Centre-City of Alessandria”. He has been invited to discuss his research projects in occasion of important meeting (59th annual conference of the Israel Heart society, Tel Aviv 2012; 61st annual conference of the Israel Heart society, Tel Aviv 2014, Heart Valve Society meeting, New York 2014; Mitral Valve Conclave, New York 2015; and EACTS, Amsterdam 2015). He has published 4 papers in reputed journals.

Background & Objective: Since 1996, we have developed an innovative technique of ventriculoplasty, the “twist technique” (TT). The procedure performed has the purpose of preserving not only the volume and the shape of the LV but, above all, to restore the physiologic counterclockwise (CCW) twist of the cardiac apex through a rearrangement of its fibers, rebuilding the natural apical vortex of the LV. We present our experience in LV remodeling. Methods: From 1996 to 2015, 289 patients with post-infarction LV aneurysm underwent reconstructive procedures. Mean age was 56.4±7.3 years. Average LV ejection fraction (EF) was 38.9% ±11.6%. LV reconstruction was performed by using the TT in 265 patients (91.7%). Jatene technique was also performed. Afterwards, the orifice closure was obtained performing the TT: a running 2-0 polypropylene suture orients cardiac fibers remodeling heart apex in a cone shape; stitches are outdistanced of 1 cm on the lateral side of the endocardial wall and of 1/2 cm on the endocardial septum. The distal and akinetic portion of the septum is folded and therefore excluded. In 257 patients (88.9%) concomitant myocardial revascularization was performed. Results: Perioperative mortality was 2.4%. Mean follow-up was 8.45±4.2 years. Actuarial survival rate at 13 years was 73%. The physiological movement of the new apex that unfolds in a natural CCW twist has considerably improved LVEF. Mean post-operatively EF was 46.1±9.3%. Conclusion: LV remodeling using the TT reproduces physiological CCW torsion of the cardiac apex; it is a safe surgical procedure with low perioperative mortality and excellent long-term survival.