ARTICLES IN PRESS | YEAR-2025 | VOLUME-1

Arteriovenous coronary malformations are rare in the adult patient population with challenging diagnosis and management. This is a complex case of a left circumflex artery to coronary sinus fistula in a patient with history of bioprosthetic aortic valve replacement presenting with new onset of shortness of breath.

Background: In-hospital cardiac arrest (IHCA) is a common clinical event with extremely poor outcomes associated with cardiovascular disease. Although IHCA, associated with a high mortality rate, has received little attention compared to other cardiovascular conditions such as myocardial infarction and stroke [1]. The survival rate of IHCA to discharge is approximately 25% [2]. We report a case of cardiac arrest survival in a patient with a history of old MI (anterior), SVD, and uncontrolled DM and HTN. The patient was initially treated with resuscitation according to guidelines due to the unavailability of consent for PCI.
Case Presentation: A 55-year-old South Asian woman presented with massive acute anterior MI with uncontrolled DM and HTN. After proper management of acute MI in the hospital, she was discharged with advice and a suggestion for coronary angiography. Before angiography, an ECHO was done, revealing an LVEF of only 46%, regional wall motion abnormality, and grade II diastolic dysfunction. She was strongly advised to undergo coronary angiography as early as possible. Angiography revealed a massive occlusion of 99% in the mid-LAD. When the cardiac team decided to perform PCI, the patient’s guardian did not give immediate consent. During this time, the patient suffered a cardiac arrest, and an emergency event occurred. ROSC was established through CPR for 30 minutes, followed by intubation and mechanical ventilation. The patient was transferred to the CCU [3]. In the CCU, the patient remained on mechanical ventilation for about 48 hours. After correcting biochemical imbalances, the patient regained hemodynamic stability. She is now undergoing cardiac rehabilitation and has provided consent for PCI.
Conclusion: Cardiac arrest is a sudden event that occurs mostly due to cardiac causes. It is difficult to manage and has a high mortality rate. The key elements of treatment during cardiac arrest include chest compressions, ventilation, early defibrillation when applicable, and immediate attention to potentially reversible causes such as hyperkalemia or hypoxia. There is limited evidence to support more advanced treatments. PCI remains the mainstay of treatment for cardiac arrest caused by thrombus-mediated flow limitation.

The patient is a 70-year-old male who developed back pain in May 2021. He was diagnosed with a ureteral stone and type 2 diabetes (T2D) with an HbA1c of 9.3% in 2021. After a successful operation, he continued treatment for T2D. Pulse wave velocity (PWV) showed an ankle-brachial index (ABI) of 0.78/0.83 (R/L) and a cardio-ankle vascular index (CAVI) of 12.9/13.9, suggesting arteriosclerosis and peripheral artery disease (PAD). Computed tomography (CT) showed a movable lesion adjacent to the right heart, suggesting a pericardial cyst. HbA1c had been stable after that but increased during the summer of 2024; he then started imeglimin (Twymeeg), which was associated with clinical efficacy and without gastrointestinal adverse effects (GI-AE).

The patient was an 81-year-old man with type 2 diabetes (T2D), hypertension, and hyperuricemia for several years. He was treated with a low-carbohydrate diet (LCD), sitagliptin, nifedipine, and febuxostat. Pulse wave velocity (PWV) showed an ankle-brachial pressure index (ABI) of 1.29/1.33 and a cardio-ankle vascular index (CAVI) of 10.1/10.2 (right/left), which were within the normal range for his age. Biochemical examinations were unremarkable, with low coefficients of variation (CV) observed in red blood cell (RBC) count, hemoglobin (Hb), HbA1c, platelet count, creatinine, and HDL, ranging from 2.6% to 6.3%. The probable reasons for his stable clinical progress include a highly regular lifestyle and psychologically satisfying interpersonal relationships, following the principles of Hinohara-ism.