Cardiac Silhouette Research Articles

Pericardial Constriction Caused by a Giant Lipoma

We report the case of a 52-year-old woman who was referred to our center for an unusually large constrictive pericardial mass. Her medical and surgical history included obstructive sleep apnea, reduction mammoplasty, breast cancer, obesity (body mass index = 44.63 kg/m2), and latex allergy. She complained of exercise intolerance and progressive dyspnea (New York Heart Association class III) for 6 months. Physical examination revealed low heart sounds without paradoxal pulse. Her chest x-ray showed an enlarged cardiac silhouette (Figure 1A), and her ECG was in sinus rhythm with low QRS voltage in leads aVL and III (Figure 1C). On cardiac CT scan, we observed a very large, well-delimited, noninvasive lipidic mass (20×17×15 cm) surrounding a normal-size heart (Figure 2A). No additional anomaly was found. Transthoracic echocardiography was challenging, with obesity and the fatty mass limiting echocardiographic windows. Therefore we performed a cardiac MRI, which showed normal biventricular size and function and no significant valvular disease. Cardiac MRI depicted a well-delimited intrapericardial mass with high signal intensity on T1-weighted images (Figure 3). The mass signal was fully nulled with application of fat saturation, confirming a diagnosis of giant intrapericardial lipoma. There was no gadolinium enhancement in the myocardium, …

Female With Severe Shock

A 51-year-old woman presented to the emergency department (ED) with severe shock, unresponsiveness, and motor restlessness. She had been found unconscious in an open field with horses. Primary survey revealed a self-maintained airway and spontaneous breathing without external blood loss. Glasgow Coma Scale score was 7. Complete physical examination revealed parasternal bruising resembling a horseshoe print (Figure 1). Initial systolic blood pressure was between 70 and 90 mm Hg, with a pulse rate of 130 beats/min, with no improvement despite volume replacement with 0.9% normal saline solution. After intubation, a markedly elevated jugular venous pressure was observed and sinus tachycardia persisted. A pulsus paradoxus was not observed. Chest radiograph showed an enlarged cardiac silhouette (Figure 2). Abdominal ultrasonography result was normal. Bedside cardiac ultrasonography was not available in the ED.Figure 2Chest radiograph showing enlarged cardiac silhouette.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Cardiac tamponade caused by a blunt thoracic trauma. Initial diagnosis of traumatic cardiac tamponade is difficult, especially in blunt chest injury. Clinical suspicion increases when sinus tachycardia, elevated jugular venous pressure, or pulsus paradoxus is present and irresponsive to volume replacement.1Spodick D.H. Acute cardiac tamponade.N Engl J Med. 2003; 349: 684-690Crossref PubMed Scopus (530) Google Scholar Blood in the pericardial sac causes pressure on the cardiac ventricles and reduces diastolic compliance, and then causes a decrease in systemic and venous return, and eventually death from cardiogenic shock, ie, cardiac tamponade.1Spodick D.H. Acute cardiac tamponade.N Engl J Med. 2003; 349: 684-690Crossref PubMed Scopus (530) Google Scholar, 2Von Wachenfelt H, Nilsson C, Ventorp M. Measurement of kick loads from horses on stable fittings and building elements. 2013. Available at: http://pub.epsilon.slu.se/10949/7/wachenfelt_etal_131220.pdf. Accessed April 2, 2015.Google Scholar, 3Fitzgerald M. Spencer J. Johnson F. et al.Definitive management of acute cardiac tamponade secondary to blunt trauma.Emerg Med Australas. 2005; 17: 494-499Crossref PubMed Scopus (47) Google Scholar Our patient immediately underwent needle pericardiocentesis at the ED (Figure 3), where 150 mL of blood was drained, resulting in hemodynamic stability. After the pericardiocentesis, right-sided cardiac failure developed, which was successfully treated with diuretics. The patient fully recovered and was discharged home after 9 days.

THE ULTRASONOGRAPHIC FINDINGS OF THE LIVER, GALL BLADDER AND THEIR RELATED VASCULATURES IN HEALTHY EGYPTIAN BUFFALOES (BUBALUS BUBALIS)

This study provided a full description of the normal ultrasonographic findings of the hepatobiliary system and its blood vessels in Egyptian buffaloes. The reported results particularly those of ultrasonography were compared with the normal reference values of cattle that had been previously recorded. This study was carried out on thirty healthy buffaloes. Complete clinical examination, hematological pictures profiling, blood biochemical analysis of total blood serum proteins, albumins, globulins, aspartate aminotransferase (AST), alkaline phosphatase (AP), γ-glutamyltranspeptidase (GGT), triglycerides and cholesterol, radiography and ultrasonographic examination were conducted with all these animals. The results showed that the clinical findings, blood pictures and blood biochemical levels agreed with the previously reported reference values of healthy buffaloes. The outlines of cranial abdomen, line of diaphragm and the cardiac silhouette were displayed normally on the radiographs. The acoustic windows for ultrasonographic examination of the hepatobilliary system was the right 11th intercostal space. The gall bladder could not be imaged from the right 12th intercostal space. The description of these normal ultrasonographic findings of the aforementioned organs will be valuable in detection of the abnormalities of these organs.

Total anomalous pulmonary venous return

TAPVR typically presents in early infancy due to excessive pulmonary blood flow and mild cyanosis. Presentation is earlier when there is obstruction to pulmonary venous flow where neonates present with severe cyanosis and cardiogenic shock, surgical repair must be planned immediately. Mixing of well oxygenated blood through the anomalous connection of pulmonary veins with the systemic blood in the right atrium results in similar oxygen saturation in all cardiac chambers and arteries, therefore pre and post ductal oxygen saturations are equal. Increased blood flow across the right heart causes delay in closure of the pulmonary valve, presenting as fixed splitting of second heart sound as well as systolic flow murmur over the pulmonic region. Supra-cardiac drainage of anomalous pulmonary veins to the superior vena cava result in figure-eight or snow man appearance of the cardiac silhouette on CXR.

THE EFFECT OF DEXMEDETOMIDINE ON RADIOGRAPHIC CARDIAC SILHOUETTE SIZE IN HEALTHY CATS.

Dexmedetomidine, an alpha2 -adrenergic agonist, may be used in companion animals for chemical restraint, including cardiac evaluation. Echocardiographic changes associated with alpha2 -adrenergic agonists have been described; however reports of radiographic changes in cats were not found at the time of this study. Aims of this observational, prospective, experimental study were to describe the effects of dexmedetomidine on the radiographic appearance of the cardiac silhouette in healthy, adult cats. Fourteen healthy adult cats received dexmedetomidine 40 mcg/kg IM. Right lateral, left lateral, ventrodorsal, and dorsoventral thoracic radiographs were obtained for each cat at three time points: presedation, intrasedation, and postsedation (≥ two hours after reversal with atipamezole). Radiographs were evaluated in a blinded, randomized fashion by two independent observers using the vertebral heart score on all four views, the number of intercostal spaces on lateral projections, and the percent width of thorax on ventrodorsal and dorsoventral projections. Median vertebral heart score on right lateral view was significantly increased intrasedation (median = 7.8; range = 7.25-8.25) compared to presedation (median = 7.5; range = 7-8 [P = 0.001]). Median percentage width was significantly higher intrasedation (70% on VD; range 65-80 [P = 0.001], and 75% on DV; range 65-80 [P = 0.006]) compared to presedation (65%; range 65-75 on both projections). Dexmedetomidine was associated with a small but significant increase in cardiac silhouette size on right lateral (vertebral heart score), ventrodorsal (percentage width), and dorsoventral (percentage width) radiographs in healthy adult cats. This effect should be taken into consideration for future interpretation of thoracic radiographs in dexmedetomidine-sedated cats.

40-Year-Old Woman With Breathlessness and Fatigue

40-Year-Old Woman With Breathlessness and Fatigue

Isolated Multiple Subepicardiac and Epicardiac Echinococcosis

To the Editor : We are describing an extremely rare case of isolated pericardial and subepicardial Echinococcosis (EC) associated with pericardial effusion. The cardiac locations of these cysts in our case are extremely rare (subepicardiac region). An 11-y-old girl was admitted for evaluation of new onset fever, cough, dyspnea on exertion and chest pain for 1 mo. Chest radiograph showed enlarged cardiac silhouette suggestive of pericardial effusion. Transthoracic echocardiography showed large pericardial effusion and multiple, well defined cysts in the pericardial space and subepicardium (Fig. 1). Chest CT, brain CT and abdominal ultrasound were normal. Albendazole was started and then successful surgical excision of the pericardial cyst and evacuations of the subepicardial cysts with removal of most of the walls were performed. Perioperative course was free of complications. The patient was discharged home on Albendazole. Further follow up showed no further cyst formation, no pericardial or pleural effusion. EC most commonly involves the liver (60–70 %) followed by lungs (10–15 %). Cardiac and pericardial EC are rare (0.5–2 %) and are usually associated with liver and lungs involvement. Only few cases with isolated cardiac involvement were reported in the literature. The most affected sites of the heart are the left ventricle (LV) (75 %), right ventricle (RV) (18 %), and the interventricular septum, whereas the pericardium as well as left and right atria are the least affected [1–4]. Rupture of intracardiac cysts can lead to multiple significant complications. Anaphylaxis is one of the most serious complications. Other possible complications include, acute pulmonary hypertension and systemic arterial embolization which may occur secondary to embolization of parts of the EC cysts into the pulmonary and systemic circulations, respectively. In addition, acute pericarditis and tamponade may result from rupture of cysts into the pericardial space. Morbidity and mortality in these cases arise primarily from the complications in the perioperative period. Although surgical mortality is relatively high, the surgery risk should be evaluated in the face of high mortality rate of untreated patients that reaches up to 27 % [5]. In general, treatment of cardiac Echinococcosis requires a combined medical and surgical approach. Early diagnosis and management is associated with a favorable outcome. * Bassel Mohammad Nijres basselmn@yahoo.com

Surgical Correction of Esophageal Stenosis by Right Aortic Arch Persistence in Two Cats

Background: Vascular ring anomaly is considered a hereditary change. It occurs when the fourth right aortic arch persists instead of the fourth left aortic arch, forming a vascular ring that compress the esophagus causing esophageal dilatation cranial to the compression site. Diagnosis is based upon anamnesis, physical examination, clinical signs and complementary exams (radiograph, complete blood count and biochemical tests). The clinical treatment is inadequate, since the dilatation persists and tends to progress causing irreversible tissue injury. Surgical correction is indicated and consists of the arterial ligament resection and correction of the esophageal stenosis.Case: The objective of the current study is to report two case of persistence of right aortic arch in two cats referred to the Veterinary Hospital of the Federal University of Santa Maria. On physical examination the patients were alert, in good nutritional status, adequately hydrated and presented normal colored mucous membranes. Each animal underwent radiog­raphy and esophagogram with barium sulphate. The exam demonstrated partial esophageal dilation cranial to the cardiac silhouette, suggestive of vascular ring anomaly. An exploratory thoracotomy was performed in order to achieve the definitive diagnosis. The arterial ligament was resected and esophageal stenosis corrected. Anesthesia, surgery and the postoperative period undergo without any complications. Patients remained hospitalized in the first 24 h for observation and were dis­charged after this period. Ten days surgery they returned for revaluation and removal of the skin suture. Four months after the surgical correction the animals underwent a new radiography and esophagogram examination. Radiographic findings evidenced persistence of esophageal dilation and narrowing of the esophageal lumen. Patients were evaluated periodically up to 10 months after surgery, verifying excellent quality of life and remission of clinical signs.Discussion: Vascular ring anomalies affects both dogs and cats, occurring more commonly in purebred dogs than in mixed breed. The literature reports cases in young Siamese and Persian cats, although the absolute numbers are insufficient to make conclusions about the racial predisposition. This case report enrolled two cases of PRAA in adult mixed breed cats (one male and one female from the same litter). Surgical correction is the recommended treatment for PRAA, either con­ventional or minimally invasive techniques. To assist the dissection of the fibrous ring and correction of esophageal stenosis we utilized a 22 Fr Foley catheter, introduced through the oral cavity to the esophageal stenotic area. The inflation of the balloon on the constricted area allows visualization of residual fiber rings and facilitates its dissection and removal. The PRAA mortality is associated with late diagnosis and the coexistence of aspiration pneumonia. Therefore, surgery should be performed as soon as possible after the onset of clinical signs, in order to reduce damage to the esophageal muscles and nerves. It is estimated that 80% of cases survived the postoperative period. In both cases, no clinical signs were observed, and there was a reduction of the esophageal diameter compared with the previous dilation, as well as better esophageal transit. Ten months after surgery, the animals returned for revaluation, presenting adequate body development and good quality of life. As shown in this case report, surgical intervention allowed for the accurate diagnosis and correction of PRAA in cats, with remission of clinical signs and full recovery of the animal.Keywords: cat, regurgitation, megaesophagus, thoracotomy, anomaly.

Comparative Study of the Vertebral Heart Scale (VHS) and the Cardiothoracic Ratio (CTR) in Healthy Poodle Breed dogs

Background: Veterinary cardiology has been widely divulged, especially because of the search for diagnostic methods that allow early identification of heart disease in companion animals. Several techniques are available, such as digital radiography (DR), computerized tomography (CT) and magnetic resonance (MR) that are being applied to patients with various diseases. VHS has been widely used in clinical practice in veterinary medicine as a way to diagnose heart size increases in lateral thoracic radiography in small animals. Cardiothoracic ratio (CTR) is a predictive factor for cardiac insufficiency in humans. In veterinary medicine, this index is still little used. The objective of the present study was to compare the vertebral heart scale (VHS) and cardiothoracic ratio (CTR) to assess changes in the size of the cardiac silhouette dogs in thoracic radiographs.Materials, Methods & Results: The VHS and CTR of forty healthy poodle breed dogs (20 males and 20 females) from University Veterinary Hospital at the Federal University of Piauí were assessed. The animals were placed in supine and lateral decubitus, to obtain radiographic images in dorsoventral (DV) and right and left laterolateral projections of the thoracic region. The images acquired on the photosensitive radiographic chassis were analyzed by digital radiographic image system installed in the Image Diagnosis Service of the University Veterinary Hospital -HVU/UFPI. VHS (Vertebral Heart Scale) measurements were taken using the sum of the heart length and heart width at its greatest diameter, comparing with the vertebral bodies from the fourth thoracic vertebra (T4). The CTR was assessed by comparing the greatest width of the heart silhouette and the distance between the thoracic walls at height T8. The heart width was measured from the two greatest distances (ML and MR), from the vertical line that divides the limit between the right and left sides of the heart, at the point of its greatest diameter. Similarly, the thoracic width was measured at the point of greatest thoracic diameter (MTD). The mean of the VHS and CTR in the males was 9.83 ± 0.85v and 0.48 ± 0.05, respectively. The females showed values of 9.65 ± 0.65v and 0.50 ± 0.03, respectively (P > 0.05). The mean of the VHS and CTR, considering males and females, was 9.72 ± 0.73v and 0.48 ± 0.04, respectively. VHS and weight correlated positively (r = 0.96), as the CTR and weight (r = 0.94). VHS and age showed high correlation (r = 0.96) as CTR and age (r = 0.93). VHS and CTR showed high correlation (r = 0.96).Discussion: Although congenital malformations and genetic diseases can occur, the acquired heart diseases correspond to most of the complications found in dogs. VHS increases considerably 6 to 12 months before the development of congestive heart failure (CHF). The poodles studied, considering the universe of males and females (P < 0.05), presented mean VHS values of 9.72 ± 0.73v. Similarly, there was no significant difference between genders for VHS measured in right and left decubitus in normal dogs. The cardiothoracic ratio measured for the poodles studied showed mean values of 0.48 ± 0.05. In humans, values below 0.5 are considered normal, while values above this may indicate the presence of cardiomegaly. The CTR is intimately related to the volume of the left ventricle and CTR values above 0.5 in humans are pathological. Our results demonstrated that VHS and CTR showed strong correlation in their measurements, suggesting that CTR, constantly used in humans, could be considered as a tool to assess the size of the heart silhouette in dogs of the poodle breed.

Multiple spinal curvatures in a captive African dwarf crocodile <i>Osteolaemus tetraspis</i> (Cope, 1861)

A 4 year old African dwarf crocodile that had been domiciled at the Zoological Gardens, University of Ibadan for 2 years was presented with a history of anorexia of two weeks’ duration and reluctance to move for about a week prior to presentation. Physical examination revealed body curvatures and radiography was requested. Dorsoventral, ventrodorsal and left lateral views were done and these revealed multiple curvatures of the cervical, thoracic and caudal vertebrae. There appeared to be a generalized reduction in bone density although there were no visible fractures. There was a lateral compression of the right lung and a downward displacement of the cardiac silhouette. There were also several mineral opacities within the stomach which are suspected to be stones. Metabolic Bone Disease is a non-infectious disease common to reptiles in captivity. It is a consequence of improper diet and husbandry. A diet of flesh without bone or calcium supplements can cause an imbalance leading to the signs and symptoms seen. This can also be worsened by lack of, or insufficient, Vitamin D. It has severe effects in young animals as they require a higher nutritional plane to meet growth requirements. It is essential that reptiles in captivity receive calcium supplementation to maintain calcium: phosphorus balance and adequate exposure to sunlight or artificial ultraviolet light to encourage the synthesis of Vitamin D in the skin. These will prevent the production of parathyroid hormone which causes bone resorption and leads to swollen misshapen bones, fractures, twisting of the spine and kidney damage. Keywords: African dwarf crocodile, Metabolic bone disease, Radiography, Spinal curvatures

Childhood allergic bronchopulmonary aspergillosis presenting as a middle lobe syndrome

Allergic bronchopulmonary aspergillosis (ABPA) is infrequently documented in children with asthma. Although collapse is not uncommon, middle lobe syndrome (MLS) as a presentation of ABPA is rather a rarity. A 9-year-old female child with asthma presented with increase in intensity of symptoms along with a right midzone patchy consolidation on a chest radiograph. In addition, an ill-defined opacity abutting the right cardiac border with loss of cardiac silhouette was noted. A right lateral view confirmed a MLS, which was further corroborated by high resolution computed tomography. Central bronchiectasis was also observed, which prompted a work-up for ABPA. The child met 7/8 major diagnostic criteria for ABPA. She was then initiated on oral prednisolone that resulted in a marked clinical improvement within a fortnight. Radiological clearance occurred at 3 months with inflation of the middle lobe. ABPA presenting with MLS in a child is yet to be reported. A high index of suspicion is required to establish the diagnosis of ABPA in a child presenting with MLS. This would obviate the invasive investigations usually done to ascertain the cause of MLS.

Invasive meningococcal disease with pericarditis and pneumonia: A rare presentation in childhood

Previously healthy 2-year-old boy presented with a 3-day history of fever, irritability and vomiting. There was no cutaneous rash. Ceftriaxone (100 mg/kg/day) and Dexamethasone 5.5 mg 6/6 h (on the first 3 days) were started and lumbar puncture was performed. Cerebral spinal fluid (CSF) showed 3.696 WBCs/μL with 99% neutrophils, glucose 1 mg/dL and total protein 578.0 mg/dL. CSF Gram stain showed extracellular and intracellular Gram-negative diplococci. Latex agglutination was reactive for N. meningitidis group C. The CSF culture was negative. After 6-day of antibiotic treatment patient started with dyspnea, dry cough and hypotension. Cardiorespiratory examination revealed an elevated jugular venous pressure, normal heart sounds, with no pericardial rub, coarse sounds with crackles over left base were heard. New CSF analyses showed 336 WBCs/μL with 61% neutrophils, 39% lymphocytes, protein 99.5 g/L and glucose 26 mg/dL (serum glucose 75 mg/dL). The CSF and blood cultures were negative. Chest X-ray showed an enlarged cardiac silhouette, consolidation in the left lung and pleural effusion. The antimicrobial treatment was changed to meropenem. Computed tomography of the chest showed moderate pleural effusion, consolidation in the left lobe. The cardiac echography revealed a pericardial effusion. There was no sign of imminent cardiac tamponade. Pericardiocentesis was performed and a total of 115 ml hemorrhagic pericardial fluid was aspirated. The fluid analysis demonstrated 1.460 WBC/mm3, with 85% polymorphonuclear neutrophils and 15% lymphocytes, total proteins of 4.5 g/dL, 836 U/L LDH and glucose 60 mg/dL. No microorganism was observed by Gram and Ziehl-Nielsen stain. The pericardial fluid culture to aerobic and mycobacteria was negative. Methylprednisolone was administered for five days. Patient was discharged after 14 days of antibiotic therapy with full recovery. We present a case of meningococcal meningitis that developed two rare manifestations associated in children: pericarditis and pneumonia (Fig. 1, Fig. 2, Fig. 3). Occurrence of cardiac tamponade in reactive pericarditis is most often associated in serogroup C infections [1], [2], serogroup predominant in Amazon [3]. Meningococcal pneumonia is more associated with serogroup Y [4]. The forms of presentation of pericardial involvement include: disseminated meningococcal infection with pericardial, primary meningococcal pericarditis and reactive meningococcal pericarditis [1]. The hypersensitivity reaction type 3 tends to occur during the convalescent period (4–10 days after the start of antibiotic therapy) [5]. Thought to be due to a hypersensitivity reaction to previously damaged pericardial tissue, which acts as an antigen stimulus to antibody formation [5]. If the effusion is large treatment is done with high doses corticoids [1]. Fig. 1 Chest X-ray showed an enlarged cardiac silhouette, consolidation in the inferior lobe of left lung and pleural effusion. Fig. 2 Computed tomography of the chest (CTC) showed left lung atelectasis, moderate pleural effusion and consolidation in the left upper lobe. CTC mediastinal window shows moderate pericardial effusion. Fig. 3 The cardiac echography revealed a pericardial effusion. There was no sign of cardiac tamponade.

Chagas Heart Failure in Patients from Latin America.

Physicians working in Europe and the United States should suspect Chagas heart failure in every patient coming from Latin America with chronic heart failure. Diagnosis should be confirmed by positive serology. Right bundle branch block and left anterior fascicular block on 12-lead electrocardiogram, enlarged cardiac silhouette with no pulmonary congestion on chest X-ray and left ventricular apical aneurysm on echocardiography are the distinctive features of this condition. The clinical course is poorer than that of non-Chagas heart failure; however, medical treatment is similar. Implantable cardioverter-defibrillators are useful in the primary and secondary prevention of sudden cardiac death. Cardiac resynchronisation therapy can be given to patients on optimal medical therapy and with lengthened QRS complex. Heart transplantation is the treatment of choice for patients with end-stage Chagas heart failure.

Sanguineous Pericardial Effusion and Cardiac Tamponade in the Setting of Graves' Disease: Report of a Case and Review of Previously Reported Cases.

Introduction. Pericardial effusion in the setting of hyperthyroidism is rare. We present a patient with Graves' disease who developed a sanguineous pericardial effusion and cardiac tamponade. Case Description. A 76-year-old man presenting with fatigue was diagnosed with Graves' disease and treated with methimazole. Two months later, he was hospitalized for uncontrolled atrial fibrillation. Electrocardiography showed diffuse low voltage and atrial fibrillation with rapid ventricular rate. Chest radiograph revealed an enlarged cardiac silhouette and left-sided pleural effusion. Thyroid stimulating hormone was undetectable, and free thyroxine was elevated. Diltiazem and heparin were started, and methimazole was increased. Transthoracic echocardiography revealed a large pericardial effusion with cardiac tamponade physiology. Pericardiocentesis obtained 1,050 mL of sanguineous fluid. The patient progressed to thyroid storm, treated with propylthiouracil, potassium iodine, hydrocortisone, and cholestyramine. Cultures and cytology of the pericardial fluid were negative. Thyroid hormone markers progressively normalized, and he improved clinically and was discharged. Discussion. We found 10 previously reported cases of pericardial effusions in the setting of hyperthyroidism. Heparin use may have contributed to the sanguineous nature of our patient's pericardial effusion, but other reported cases occurred without anticoagulation. Sanguineous and nonsanguineous pericardial effusions and cardiac tamponade may be due to hyperthyroidism.

Large Pleural Effusion and Mediastinal Mass: An Unusual Connection!

Question: A 50-year-old Hispanic man with history of smoking, chronic obstructive pulmonary disease, chronic pancreatitis, congestive heart failure, and recurrent deep vein thrombosis on anticoagulation therapy was admitted with worsening shortness of breath and upper abdominal and chest pain for 3 days. The patient had chronic abdominal pain, occasional productive cough and had lost 50-lb weight over the last 6 months. He denied fever, night sweats, difficulty swallowing, vomiting, or diarrhea. Initial vital signs were temperature 97.7 F, blood pressure 90/58 mm Hg, heart rate 89 bpm, respiratory rate 24/min, and SPO2 90% on 15 L oxygen via nonrebreather mask. The breath sounds were diminished and there was dullness to percussion on the left side of chest. Electrocardiogram showed a normal sinus rhythm at 100 bpm. A portable chest radiograph revealed a large left pleural effusion, small right pleural effusion, congestive heart failure, and globular cardiac silhouette (Figure A). Left thoracentesis was performed and 2 L of cloudy fluid was drained leading to improvement in patient’s symptoms and vital signs. A repeat chest radiograph confirmed interval decrease in size of left pleural effusion (Figure B). Initial laboratory tests showed hemoglobin of 12 g/dL (normal, 13–17), white blood cells of 19,000/mL (normal, 4000–11,000), pro-brain natriuretic peptide of 1100 pg/mL (normal, <450), and normal basic metabolic panel, liver tests, troponin, and serum lipase. Empiric antibiotics were initiated for presumed para-pneumonic effusion. A 2-D echocardiogram demonstrated normal ventricular ejection fraction, minimal pericardial effusion and a mass in the left pleural space compressing on the left atrium (Figure C, arrow). Non–contrast-enhanced computed tomography (CT) of the thorax revealed a large, predominantly cystic appearing middle mediastinal mass extending from the upper abdomen to the subcarinal level (Figure D, asterisk). What is the diagnosis? Look on page 319 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Fluoroscopic position of the second-generation cryoballoon during ablation in the right superior pulmonary vein as a predictor of phrenic nerve injury.

Phrenic nerve injury (PNI) is the most frequently observed complication during pulmonary vein isolation procedure using the second-generation cryoballoon (CB). Our objective was to analyse the correlation between the fluoroscopic position of the 28 mm CB during ablation in the right superior pulmonary vein (RSPV) and the occurrence of PNI. A total of 165 patients having undergone the large 28 mm CB ablation were retrospectively reviewed. Positioning of the CB relative to the cardiac silhouette was classified under fluoroscopic guidance in antero-posterior projection during RSPV ablation. Regarding the lower half of the balloon, CB positioning was defined as follows: (A) completely inside the cardiac shadow; (B1) <1/3 outside the cardiac shadow; and (B2) ≥1/3 outside the cardiac shadow. Phrenic nerve injury occurred in 9.7% (16/165) during ablation in the RSPV. The occurrence of PNI was 0.9, 10.6, and 90.1% in positions A, B1, and B2, respectively (A vs. B1, P = 0.01; B1 vs. B2, P < 0.0001). Among other pre-procedural and procedural variables, the B2 position was the strongest independent determinant for predicting PNI at RSPV (P = 0.001, odds ratio: 119.9; 95% confidence interval: 11.6-1234.7) after multivariable analysis. The incidence of PNI at the RSPV significantly increased in case of more distal positioning of the CB relative to the cardiac shadow. This simple and straightforward intra-procedural indicator might prone the operators to attempt occluding the RPSV more proximally in order to avoid PNI.

Extralobar pulmonary sequestration: a case report

We described the case of a 36-year-old Turkish female with an extralobar pulmonary sequestration who suffered from chest and back pain for five years without any evidence of pulmonary infection. A chest X-ray showed an area of opacity behind the cardiac silhouette in the lower area of the left hemithorax. A CT scan of the thorax with intravenous contrast showed a 9 x 7 cm in size ovoid mass with necrosis in the lower left lobe. It revealed two aortic branches directed toward the pulmonary opacity. She subsequently underwent surgery and the anomalous tissue was removed by mass excision. The patient was diagnosed with extralobar pulmonary sequestration.

Abstract 13951: Right Anterior Oblique in Addition to Left Anterior Oblique Projections Are Useful to Implant Right Ventricular Pacemaker Lead Into Mid-Septum and Achieve More Physiological Pacing

Introduction: It has been reported that it is difficult to implant right ventricular (RV) leads to the true mid-septum using conventional fluoroscopic criteria. Thus, we investigated which is the best method to achieve the true RV mid-septum using 3 dimensions (3D) reconstruction of 64-slice multidetector computed tomography (64 MDCT). Methods and Results: We retrospectively analyzed 33 patients in whom we intended to place RV lead into the septum using conventional fluoroscopic criteria, 40 degree left anterior oblique (LAO40), and performed 64 MDCT later. 3D reconstruction of 64 MDCT revealed that the right ventricular lead was anchored on the true mid-septum in 10 patients (only 30%; MS group, n=10), anterior wall in 19 patients, and free wall in 4 patients (non-MS group, n=23). After implantation of the pacemaker, we evaluated the predictive value of MS group when we used electrocardiography criteria (q wave or negative QRS complex in lead I), 90 degree left lateral (LL90) view and 30 degree right anterior oblique (RAO30) view using 3D reconstruction of 64 MDCT in addition to LAO view. As shown in a table, the method using both LAO and RAO views was the best to achieve the true RV mid-septum among these methods. MS group had significantly shorter paced QRS duration and ΔQRS (paced QRS-own QRS) than non-MS group (139±21.9ms vs. 155.3±10.9ms, p=0.03 and 24.2±21.2ms vs. 55.5±9.1ms, p=0.0001). Conclusions: The true mid-septum RV pacing could achieve more physiological pacing. Not only confirming rightward orientation in LAO view but also aiming the middle of the cardiac silhouette in the RAO view may be a simple and accurate way to achieve the true RV mid-septum positioning.

Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 13: Commotio Cordis: A Scientific Statement From the American Heart Association and American College of Cardiology.

Commotio cordis is defined as sudden cardiac death triggered by a relatively innocent blow to the precordium.1 Although initially thought to be extremely rare, it is now increasingly reported in the United States and worldwide.2,3 Enhanced recognition of commotio cordis, rather than an increase in event frequency, likely accounts for the greater visibility of those events. Commotio cordis is one of the most common causes of sudden cardiac death in recreational and competitive sports, instantaneously resulting in a potentially fatal arrhythmia.4 Commotio cordis is distinct from cardiac contusion, in which structural damage to the heart with resultant arrhythmias develops within 24 hours after severe chest impact.5 Risk factors for a commotio cordis have been defined by a Commotio Cordis Registry of clinical events and an experimental swine model. Human cases occur largely in adolescent males (95% of cases), with a mean age of 14 years.2 Impacts occur over the left chest wall and are generally sustained with a hard spherical object such as a baseball, hockey puck, lacrosse ball, or softball. Collapse is instantaneous or within a few seconds; when a defibrillator is used rapidly, the arrhythmia is typically ventricular fibrillation (VF). An experimental model of commotio cordis has confirmed the arrhythmia induced by a chest blow is VF.6 Impact must occur over the cardiac silhouette, and harder balls are more likely to induce VF.6–8 In addition, this model has demonstrated the critical importance of timing in that only those blows that occur during a narrow time segment of the T-wave upstroke reliably produce VF.6 These laboratory experiments have also shown the importance of size and shape of the object.9 Blows must occur directly perpendicular to the chest wall to produce VF, and impact velocities optimal to …

Uncovering the diagnosis

JBS (Medicine Resident): A 63-year-old African-American woman presented to the emergency department with progressive dyspnoea of 2-weeks’ duration. She denied chest pain, palpitations or syncope. Her medical history was significant...