Electrocardiogram Revealed Sinus Tachycardia Research Articles

Grave's disease in a 4 years old Saudi girl; a case report

Background: Graves' disease is rarely diagnosed in children under 5 years. It can lead to serious developmental and growth problems if it is not early diagnosed and properly managed. Case presentation: A case of 4-year-old Saudi female was presented with family history of hyperthyroidism and unremarkable past medical history. She was presented to the emergency department with on and off fever, irritability, thyroid swelling and bilateral eye protrusion with no other positive clinical findings. Her thyroid-stimulating hormone (TSH) was low (0.005 uIU/ml), and free thyroxine (T4) was normal (18.78 pmol/L). Thyroid ultrasound showed diffused enlargement of both lobes. Electrocardiogram revealed sinus tachycardia and incomplete bundle branch block. The patient was diagnosed with Graves' disease and started carbimazole and B-blocker treatment. Although it is usually a disease of older patients, Graves' disease should be considered in cases of tachycardia in children. As relapses are common in such cases, an appropriate management plan and follow up should be counted to achieve long term remission. Conclusion: Tachycardia in children should be taken seriously where hyperthyroidism to be considered. Treatment options are variable to achieve control and long-term remissions.

Emergency decompressive craniotomy with scalp block and closed-loop TCI sedation for acute ischemic stroke in a patient with incidental diagnosed large left ventricular mass, presenting with severe LV dysfunction.

Dear Editor, An average built 35-year-old male presented to the emergency-department with a history of a sudden onset of left-sided weakness and bi-frontal headache, with a chronic history of ischemic cardiomyopathy, and acute myocardial infarction one year back, with current functional status New York Heart Association classification (NYHA) class III. Patient underwent thrombolytic therapy with 0.9 mg/kg alteplase (r-TPA) over 60 minutes after evaluating risk factors during the precious golden hour period. Over the next 12 hours, the GCS deteriorated. There was cerebral swelling with a midline shift of 8 to 12 mm, although the patient was not intubated or ventilated. In a repeat scan and the neurosurgeon planned to proceed with emergency decompressive craniotomy. Complete hemogram was normal, electrocardiogram revealed sinus tachycardia with left anterior hemiblock. Routine trans-thoracic echocardiogram suggested global left ventricular (LV) dysfunction with an ejection fraction of 20%, large left ventricular mass (query myxoma or thrombus attached to LV apex measuring 44 mm × 36 mm), and grade III mitral regurgitation with eccentric jet. [Figure 1] Computerized tomography showed Acute Ischemic Stroke (AIS) in the right middle cerebral artery territory. After explaining due appropriate risks and benefits of surgery to the patient relatives and interdisciplinary consensus, the team decided to proceed with craniotomy under Monitored Anesthesia Care using scalp block and manual closed-loop TCI Propofol sedation under spectral entropy monitoring.Figure 1: Echocardiography (ECHO) Revealing Large Left Ventricular Mass Attached LV Apex Measuring 44 Mm × 36 Mm (A) Parasternal Long Axis View, (B) Apical Four Chamber ViewBilateral scalp anesthesia was given using 24-gauge short bevel needle with 40 ml 0.2% Ropivacaine. After assessing for adequate block by pin prick method, entropy leads were attached and secured with 1-inch plaster tape. TCI sedation with Propofol was started with the initial effect site concentration of 1 microgram/ml, later escalated to 3 microgram/ml to maintain spectral entropy between 60-80 and hemodynamic parameters. Decompressive craniotomy was completed in 2 hours 10 minutes, with no complications; patient recovery was rapid and was obeying verbal comments when effect-site concentration reached 0.5 microgram/ml. After this emergency surgery, the patient was operated for his cardiac mass after 9 months and it was found to be thrombus on histopathological diagnosis. Thrombus, tumor, and vegetation are the most common causes of intracardiac mass and must be distinguished from normal variants such as papillary muscles, false tendons, sigmoid septum, and apical trabeculation.[1] Our patient was at high risk with associated large left ventricular mass, severe left ventricular dysfunction, and ischemic cardiomyopathy and grade III mitral regurgitation for emergency craniotomy. Anesthetic management in this clinical scenario could be associated with risk of complications ranging from peri-operative myocardial infarction, pulmonary edema, LV outlet obstruction and sudden cardiac arrest, new thrombo-embolic episodes, and hemorrhagic changes in infraction.[2] Scalp block with TCI Propofol sedation prevents hemodynamic perturbances associated with general anesthesia with intubation and cardio depressant effects of anesthetic agents. Manual closed loop TCI Propofol sedation with deep anesthesia control offers optimal titration with stable hemodynamic sedation and eliminates the need for unintended protection of the airway.[3] Considering the risk and benefit ratio, craniotomy with closed loop TCI Propofol sedation outweighed the risks of general anesthesia in our patient. Though awake craniotomy with TCI sedation is safe but has a few limitations like difficulty to alter ventilation in case of intraoperative cerebral edema and airway securement may be difficult in case requirement occur intraoperatively due to positioning of patient. In spite of appropriate anticoagulation, a thrombus traveling across the cardiac cycle has a high potential to embolize. It is imperative LV masses should be surgically removed as early as possible, owing to risk of recurrent thrombo-embolic phenomenon. We conclude that craniotomy under scalp block may be performed even in an emergency craniotomy in patients with high peri-operative risk. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

579 ACUTE ISCHEMIC HEART FAILURE: PHARMACOLOGICAL AND INTERVENTIONAL MANAGEMENT OF A FRAIL PATIENT

Abstract An 87-year-old male patient with worsening dyspnea was admitted to our institution. The patient had a history of acute myocardial infarction treated with coronary stenting of the left descending artery (LAD), diagonal (Diag), right coronary artery (RCA), and chronic kidney disease. For acute pulmonary edema, the patient was admitted to our cardiac intensive care unit and rapidly treated with non-invasive positive-pressure ventilation with continuous positive airway pressure (C-PAP), IV high dosage diuretic therapy, inotropes, and vasoactive agents. Chest X-ray revealed cardiomegaly (cardiothoracic ratio, 56%) and pulmonary congestion. Electrocardiogram revealed sinus tachycardia and diffuse ST-segment abnormalities. An echocardiogram demonstrated left ventricular apical akinesia, with a left ventricular ejection fraction (LVEF) of 25% and severe mitral regurgitation. Blood tests revealed very high levels of NT-pro-brain natriuretic peptide (NT-proBNP) (>30000 pg/ml) and myocardial necrosis markers (hs-Trop 5055 ng/l; CK-MB 72 ng/ml). After 24 hours, the patient was placed on intra-aortic balloon pump (IABP) support to further hemodynamic support through the right femoral artery, nonetheless, he showed no improvement in symptoms or urine output. Because of a state of hypoxemic and hypercapnic respiratory failure, non-invasive ventilation (NIV) was given to the patient with a gradual improvement in blood gas analysis. The optimization of diuretic therapy allowed to treat the state of acute oliguric kidney disease, avoiding dialytic treatment. After 48 hours, because of a new worsening in hemodynamic state, we decided for a percutaneous left ventricular assist device (Impella CP, Denver, Massachusetts, USA). After placing the Impella device, coronary angiography was performed, showing critical stenosis of the left main (LM), involving the origin of the left anterior descending artery and a collateralized chronic occlusion of the circumflex artery and the LAD, after the origin of a large first diagonal branch. Because of the high procedural risk, we decided to perform only percutaneous coronary intervention and stent implantation of LM. After 3 days his symptoms improved, the required dose of inotropic agents and furosemide decreased and Impella was removed. After 12 days the patient was admitted to the cardiological ward and discharged after 21 days because of a urinary infection requiring antibiotic therapy. The management of acute heart failure in very old patients is challenging, limiting in many cases the use of invasive procedures such as coronary angiography or left ventricular assist devices. In this case, although the patient presented a very high-risk profile considering age and comorbidities, the use of Impella resulted to be safe and guaranteed hemodynamic support during the procedure of revascularization and in the immediate post-operative phase.

Pulmonary thromboembolism in adults: Experience from a tertiary care center

BackgroundVenous thromboembolism (VTE) includes deep vein thrombosis (DVT) and pulmonary embolism (PE). We aimed to analyze the risk factors, clinical presentations, evaluation and management strategies as well as outcomes of adult pulmonary thromboembolism cases at a tertiary care center. MethodsIn a retrospective observational study, all consecutive adult pulmonary thromboembolism cases admitted from January 2019 to September 2020 at our center were enrolled in this study. ResultsForty-eight patients were included in the present study. The commonest presenting features were dyspnea (93.8%) and cough (79.2%). The risk factors included hypertension 11 (23%), diabetes 6 (12%), recent trauma and recent surgery 3 (6%) each, and malignancy in 2 (4%). DVT was present in 12 (25%) cases while history of smoking was significant, 31 present in (64.6%). Tuberculosis was also found to be an important risk factor for PE in 8 (16.7%). The current COVID-19 pandemic has come up as an important risk factor for PTE which was also true in our case with 13 (27%) patients being cases of moderate to severe COVID-19 pneumonia. Electrocardiogram revealed sinus tachycardia (56.25%), precordial lead T-wave changes (6.3%), and S1Q3T3 pattern (16.67%). Diagnosis was confirmed by computed tomographic pulmonary angiography (CTPA) in 81% of cases. Treatment options included low molecular weight heparin (LMWH) in 91%, newer oral anticoagulants (NOACs) in 2% of the patients and thrombolysis was needed in 12.5% of patients. There was no in-hospital mortality; however one patient had major bleeding. ConclusionThe clinical presentation of PE varied from dyspnea to cough, though the commonest feature of dyspnea remains unchanged compared to prior studies. CTPA has been modality of choice for diagnosis, however few patients with high probability for PTE were diagnosed clinically along with suggestive echocardiography and ECG findings. Thus, a high index of suspicion and timely therapeutic anticoagulation with various agents led to effective management and better outcome in the studied patients.

Enigma of Huge mass filling the apical wall of the left ventricle. Is it thrombus, tumor or endomyocardial fibrosis?

Background: Cardiac masses have a wide range of etiologies with the most common being thrombi and less commonly tumors. Certain areas of the heart have specific tumor predilections. We present an interesting case in which the diagnosis of the ventricular mass was difficult given the initial symptomatology and the patient's phobia. Case summary: A 45-year-old male patient with medical history of smoking, was admitted to the emergency room complaining of severe breathlessness, However, the patient declined any chest discomfort or pain. On physical examination he was dyspneic, with vital signs revealed heart rate of 110 beats/min, blood pressure of 125/90 mmHg. Cardiovascular examination showed regular heart rhythm and normal heart sounds. Electrocardiogram revealed sinus tachycardia, chest X-ray was suggestive of cardiomegaly. Transthoracic Echocardiography demonstrated a dilated left ventricle with severely reduced ejection fraction and diffuses kinetic disturbances. The presence of a huge mass filling the apical wall of the left ventricle, hyperechogenic in appearance and very adherent to the ventricle. In front of this doubtful appearance at the echocardiography the patient was programmed for a cardiac magnetic resonance imaging which could not be carried out because of the claustrophobic state of the patient. In the meantime, the patient had a cardiac arrest due to refractory ventricular fibrillation successfully resuscitated. In front of this complication, he benefited from an automatic implantable defibrillator as a secondary prevention. Subsequently, a coronary angiography was performed in the context of the patient's smoking habits and kinetic disorders, to our surprise showed a complete occlusion of the left anterior descending artery knowing that the patient is not diabetic and he never complained of any painful symptomatology, primary coronary intervention was successfully performed to the left anterior descending artery. The patient was started on therapeutic anticoagulation and heart failure therapy. Follow-up imaging after 6months showed a significant improvement of the left ventricular systolic function and thrombus regression to apical segment without embolic events. Conclusion: The diagnosis of a ventricular mass remains difficult, the orientation can be done initially by the ground of the patient while being helped by the transtoracic echography and the multimodality imagery at the end to specify the nature of the intra-cardiac mass for an adequate and fast management. Keywords: Thrombus, ventricular mass, coronary angiography, heart failure, oral anticoagulation. DOI: 10.7176/JHMN/98-05 Publication date: March 31 st 2022

Left Atrial Appendage Confusion: A Mobile Echodensity in a Patient With Endocarditis

A 50-YEAR-OLD, 70- kg, 172- cm man with known bicuspid aortic valve disease and severe aortic insufficiency presented to the authors’ institution with a 3-day history of “pulsating” chest pain, dyspnea with exertion, and bilateral lower extremity swelling. The patient previously was hospitalized on several occasions for the treatment of recurrent Streptococcus cristatus bacteremia originating from poor dentition. He also was receiving apixaban for the treatment of a cephalic vein thrombosis. The physical examination was notable for sinus tachycardia (122 beats/min), grade III/VI systolic and diastolic murmurs heard best at the left sternal border, bilateral lower extremity pitting edema, and red petechiae on both hands and feet. The patient was anemic (hemoglobin of 8.0 g/dL) and had renal insufficiency (serum creatinine concentration of 1.66 mg/dL). Leukocytosis was present (11.8 103/µL). The plasma brain natriuretic peptide level was markedly elevated (20,063 pg/mL). An increase in high-sensitivity troponin concentration also was observed. An electrocardiogram revealed sinus tachycardia and low-voltage QRS complexes, but acute ST-segment changes were absent. Transthoracic echocardiogram revealed vegetations on both the aortic and mitral valves, resulting in severe regurgitation. Transesophageal echocardiography (TEE) also was performed as part of the diagnostic evaluation, and the following images were obtained (Fig. 1-3; Videos 1-3). What is the diagnosis?

The time administration and cost burden of intravenous immunoglobulin (IVIG) therapy in a 4-year-old girl with Kawasaki disease: A case report

Kawasaki disease (KD) is an acute systemic vasculitis frequently affecting children under five years old. KD can cause severe complications. It can lead to coronary aneurysms in 15-25% of untreated cases. Intravenous immunoglobulin (IVIG) treatment within ten days of initial onset can reduce the rate of coronary artery aneurysms. However, IVIG administration in Indonesia is currently limited due to its high cost. The case reported a 4-year-old girl with a chief complaint of fever. She complained about a high fever seven days before hospitalization. She also complained about vomiting, cough, joint pain, diarrhea, skin peeling, and rash on her body, palms, and soles. On examination, she looked irritable and sluggish. The temperature was 39.9o C. There were red eyes without discharge, strawberry tongue, oral thrush, and red, dry, cracked lips, swollen neck lymph nodes, and skin rash on her body, palms, and soles. Laboratory testing showed microcytic hypochromic anemia with Hb 7.9 g/dL and leukocytosis 24.230/mm3. Chest X-ray showed perihilar and paracardial infiltrates. Electrocardiogram revealed sinus tachycardia. An echocardiogram showed left ventricle dilatation with trivial mitral regurgitation and no coronary abnormalities were found. She was diagnosed with Kawasaki Disease. She was treated by IVIG 30 gr single dose during 12 hours on day 7 of initial onset, methylprednisolone injection 10 mg/8 hours, paracetamol 150 mg/8 hours, and aspirin 400 mg/8 hours orally and discharged from the hospital with improvement. There weren’t any coronary artery abnormalities found. IVIG administration within ten days of initial onset in KD patients can reduce the risk of coronary artery complications. IVIG administration after day 10 of initial onset can achieve resolution of inflammation but can be insufficient for preventing coronary artery lesions (CALs).

A rare complication of acute severe ulcerative colitis.

A 21-year-old female with ulcerative colitis presented with abdominal pain and bloody diarrhea. Laboratory studies revealed markedly elevated C-reactive protein and thrombocytosis. Flexible sigmoidoscopy revealed severe endoscopic activity with ulceration and spontaneous bleeding along rectum and sigmoid colon. Ulcerative colitis had been diagnosed 3 years before, presenting as severe and extensive disease (pancolitis). She had previously failed therapy with infliximab and vedolizumab and had recently started induction therapy with golimumab. She responded well to intravenous corticosteroids but, when switched to oral corticosteroids, there was symptomatic recurrence. Intravenous corticosteroids were re-started and she was evaluated for surgery. At this time, she developed new-onset tachycardia. Electrocardiogram revealed sinus tachycardia with heart rate of approximately 120 bpm. Because tachycardia could result from worsening colitis with potential serious complications, abdominal computerized tomography scan was performed and demonstrated mild lumen dilation and wall thickening consistent with acute colitis without evidence of pneumoperitoneum or toxic megacolon. Surprisingly, thoracic planes revealed the presence of free air dissecting mediastinal space (Figure 1). What is your diagnosis?

32. HYPERTENSION AND DILATED CARDIOMYOPATHY IN PEDIATRIC PATIENT: THE ROLE OF L-CARNITINE

Background: Carnitine is an essential compound for cellular metabolism, and plays an important role in blood pressure (BP) regulation and cardiac development. Carnitine deficiency is a disorder that relate to pediatric hypertension and dilated cardiomyopathy, with possibilities of rapid reversal after carnitine replacement. Objective: This report describes a child suffering from hypertension and dilated cardiomyopathy with suspected carnitine deficiency. Case description: A 4-year-old boy came to emergency department on August 2018 with shortness of breath. BP was 140/80 mmHg, electrocardiogram revealed sinus tachycardia 150 bpm, echocardiography demonstrated stretch PFO, moderate TR, mild AR, and dilated cardiomyopathy with EF 31.14%. He was diagnosed with grade II hypertension and congestive heart failure. Antihypertensive and heart failure treatment were administered. There was no vascular disorder found, kidney function test and urinalysis were within normal limit. He was also found to have malnutrition, stunting, and suspected to suffer from carnitine deficiency, hence L-carnitine and vitamin B6 were commenced since day 16. Patient's condition was gradually improved and discharged on the 26th day. Unfortunately, he stopped L-carnitine 1 year afterwards, but still continue to take vitamin B6. The last follow-up evaluation on January 2021 showed improvement of BP control (112/70 mmHg) and reversal of cardiac dysfunction with EF 68.9%. Discussion: Carnitine deficiency is a rare but treatable cause of pediatric hypertension and cardiomyopathy. Although previous case reports showed complete improvement within a few months, however that was not happened in this case, that may be caused by L-carnitine withdrawal.

Electrocardiographic manifestations in a large right-sided pneumothorax

BackgroundPneumothorax is an extrapulmonary air accumulation within the pleural space between the lung and chest wall. Once pneumothorax acquires tension physiology, it turns into a potentially lethal condition requiring prompt surgical intervention. Common symptoms are chest pain and dyspnea; hence an electrocardiogram (ECG) is often performed in emergent settings. However, early diagnosis of pneumothorax remains challenging since chest pain and dyspnea are common symptomatology in various life-threatening emergencies, often leading to overlooked or delayed diagnosis. While the majority of left-sided pneumothorax-related ECG abnormalities have been reported, right-sided pneumothorax-related ECG abnormalities remain elucidated.Case presentationA 51-year-old man presented to the emergency department with acute-onset chest pain and dyspnea. Upon initial examination, the patient had a blood pressure of 98/68 mmHg, tachycardia of 100 beats/min, tachypnea of 28 breaths/min, and oxygen saturation of 94% on ambient air. Chest auscultation revealed decreased breath sounds on the right side. ECG revealed sinus tachycardia, phasic voltage variation of QRS complexes in V4–6, P-pulmonale, and vertical P-wave axis. Chest radiographs and computed tomography (CT) scans confirmed a large right-sided pneumothorax. The patient’s symptoms, all the ECG abnormalities, and increased heart rate on the initial presentation resolved following an emergent tube thoracostomy. Moreover, we found that these ECG abnormalities consisted of two independent factors: respiratory components and the diaphragm level. Besides, CT scans demonstrated the large bullae with a maximum diameter of 46 × 49 mm in the right lung apex. Finally, the patient showed complete recovery with a thoracoscopic bullectomy.ConclusionsHerein, we describe a case of a large right-sided primary spontaneous pneumothorax with characteristic ECG findings that resolved following re-expansion of the lung. Our case may shed new light on the mechanisms underlying ECG abnormalities associated with a large right-sided pneumothorax. Moreover, ECG manifestations may provide useful information to suspect a large pneumothorax or tension pneumothorax in emergent settings where ECGs are performed on patients with acute chest pain and dyspnea.

Clot in Transit: Point-of-Care Ultrasound Diagnosis of Acute Pulmonary Embolism.

A 64-year-old man, who underwent a stent placement in his left external iliac vein 5 days prior, presented to the Emergency Department complaining of acute-onset shortness of breath. He denied any chest pain or leg swelling. Initial vital signs revealed a blood pressure of 115/70 mm Hg, heart rate of 130 beats/min, respiratory rate of 18 breaths/min, and O2 saturation of 92%, improving to 99–100% with nasal cannula and non-rebreather oxygen at flush rate (>40 L/min). Electrocardiogram revealed sinus tachycardia at 132 beats/min, poor R-wave progression, and ST depressions in V4–V6.

Lamotrigine Toxicosis Treated with Intravenous Lipid Emulsion Therapy in a Dog

A female spayed dachshund/mixed-breed dog was evaluated following ingestion of lamotrigine tablets with subsequent rapid onset of vomiting, diarrhea, and generalized tremoring. On initial examination, the dog was moderately obtunded and nonambulatory with intermittent myoclonus and hyperesthesia. Electrocardiogram revealed sinus tachycardia with prolongation of the QT interval. Intravenous lipid emulsion (ILE) infusion was initiated, with reduction in tremoring and improved patient mentation being noted after ∼20 min of therapy. An elevated cardiac troponin I value measured at 1.02 ng/mL the day after presentation. Serum toxicological assay revealed marked reduction in serum lamotrigine levels following ILE and continued reduction during hospitalization. The dog's clinical signs resolved, corrected QT interval returned to normal, and the patient was discharged 38 hr after presentation. Individual cases of lamotrigine toxicosis have not been fully reported in veterinary literature. This case report documents the rapid onset of clinical signs including neurologic dysfunction, cardiac arrhythmias, and transient corrected QT prolongation. Serial serum concentrations of lamotrigine showed a rapid reduction with ILE therapy and corresponded with clinical recovery, suggesting efficacy of ILE treatment in this case.

SUBMASSIVE PULMONARY EMBOLISM IN THE SETTING OF HEPARIN-INDUCED THROMBOCYTOPENIA

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Heparin-induced Thrombocytopenia (HIT) is an immunoglobulin-mediated response against platelet factor 4-heparin complexes leading to thrombotic events carrying a mortality rate of 5-10%. HIT with pulmonary embolism (PE) although rare, is the most common life-threatening event occurring in 25% of all HIT cases. Treatment is controversial as heparin products are contraindicated and no best practices have been described. We present a case of a middle-age man with recent exposure to heparin presenting with syncope. CASE PRESENTATION: A 54 year-old male with type 2 diabetes and a recent hospitalization 10 days prior for diabetic ketoacidosis receiving prophylactic heparin presented for syncope. On arrival he was normotensive but tachycardic and hypoxemic. Laboratory studies revealed thrombocytopenia to 90k, a drop from baseline 150k, which was confirmed by repeat testing. Troponin and BNP were elevated. Electrocardiogram revealed sinus tachycardia and S1Q3T3 pattern. Given concern for submassive PE patient was started on a heparin drip since confirmatory computer tomography angiography could not be performed due to renal failure. Cardiology was consulted for possible catheter directed tissue plasminogen activator or thrombectomy, however both these interventions were unavailable at our institution. Given suspicion of HIT patient was switched from heparin to argatroban drip. Ventilation/perfusion scan demonstrated high probability of bilateral PE and transthoracic echocardiogram revealed right heart strain. Dopplers confirmed popliteal and left brachial vein thrombosis. Patient’s platelet count improved after discontinuation of heparin products to 140k. Platelet factor 4 and serotonin release assay were both positive. The patient was eventually transitioned to warfarin to be continued for 3 months and then re-evaluated. DISCUSSION: Treatment of submassive and massive PE in patients with HIT remains controversial. Several modalities of treatment have been described in the literature with varied success including non-heparin anticoagulation like argatroban, thrombolytic agents, catheter-based thrombus aspiration, and surgical embolectomy. Multiple cases using direct thrombin inhibitors like danaparoid, bivalirudin, lepirudin and argatroban have been reported however given argatroban is hepatically cleared, it tends to be used the most. Hemodynamic stability continues to be the prime factor when deciding between parenteral anticoagulation versus more invasive techniques. In the setting of HIT-associated PE with significant hemodynamic compromise, non-heparin anticoagulation with catheter-directed thrombolysis has been used with good outcomes. CONCLUSIONS: HIT associated PE is a rare phenomenon, however, when it occurs there are available treatment options. Although no clear study has demonstrated superiority, treatment primarily depends on hemodynamic stability and institutional resources. Reference #1: Mark Prince, Tim Wenham. “Heparin-induced thrombocytopenia” Postgraduate Medical Journal, Volume 94, Issue 1114 Reference #2: Hourmouzis, Z., et al. (2015). "Pulmonary embolism and heparin-induced thrombocytopenia successfully treated with tissue plasminogen activator and argatroban.” Am J Emerg Med 33(5): 739 e735-736 Reference #3: Warkentin TE, Kelton JG. “A 14-year study of heparin-induced thrombocytopenia” Am J Med. 1996;101(5):502 DISCLOSURES: No relevant relationships by Ayesha Azmeen, source=Web Response No relevant relationships by Anil Magge, source=Web Response no disclosure on file for Viraj Modi; No relevant relationships by Mario Perez, source=Web Response

Atrial Fibrillation in a Patient With an Accessory Pathway.

A 24-year-old man with history of unspecified arrhythmia presented with palpitations and chest pain. Initial electrocardiogram (ECG) revealed irregular tachycardia with varying QRS width: 150 to 200 beats per minute for narrow complexes and 300 beats per minute for wide complexes. Following cardioversion, ECG revealed sinus tachycardia with a preexcitation pattern of positive delta waves in the anterolateral leads and negative delta waves in inferior leads. The patient remained in sinus rhythm and underwent successful ablation of a right posteroseptal accessory pathway. Subsequent ECG showed upright T waves in the leads I, aVL, and V2-6, large inverted T waves in leads III and aVF, and no delta waves. This case serves as an important reminder that atrial fibrillation (AF) in the presence of an accessory pathway may present with confounding ECG features, potentially leading to incorrect diagnoses and treatments that may be life threatening. Despite 10% to 30% prevalence of AF in the presence of an accessory pathway and the relative awareness of Wolff-Parkinson-White syndrome among general internal medicine providers, the clinical recognition of Wolff-Parkinson-White syndrome may be hindered in the presence of preexcited AF.

Optimal management of Brugada syndrome

Brugada syndrome can induce malignant ventricular arrhythmias in the absence of structural heart disease. The hallmark of the condition is the ’’coved’’ (type I) or ’’saddle-back’’ (types II and III) ST segment elevation in the right precordial leads. The definite diagnosis requires the documentation of the type I morphology. The electrocardiographic pattern is often dynamic, but it can be unmasked by sodium channel blockers such as flecainide. We report the case of a 33-year old male, with family history significant for sudden cardiac death, who underwent successful cardio-pulmonary resuscitation for ventricular fibrillation-associated cardiac arrest. The 12 lead electrocardiogram performed after the resuscitation maneuvers showed intermittent type 1 Brugada pattern. General physical examination and routine laboratory evaluation were unremarkable. A repeated electrocardiogram revealed sinus tachycardia with right bundle branch block. We performed a flecainide challenge test which reproduced the initial coved-type ST segment elevation in V1 and V2. We decided to implant a ventricular single chamber cardioverter-defibrillator with one therapeutical window for ventricular fibrillation (at 300 ms), high energy shocks without antitachycardia pacing. The device was successful in preventing another episode of ventricular fibrillation just 2 days after the procedure. Implantable cardioverter-defibrillators are the most effective secondary prophylaxis therapeutic options for individuals with Brugada Syndrome, but they subject the patient to complications related to device implantation and inappropriate shocks.

The Case Files

The Case Files

Cardiac Vignette: Ruptured Coronary Sinus of Valsalva

A 35-year-old male with no significant past cardiac history presented to our institution with chest pain, dyspnoea and palpitations. On presentation, he was hypotensive and tachycardic. Examination revealed a Grade IV pansystolic murmur, loudest over the left parasternal region. Electrocardiogram revealed sinus tachycardia, right-axis deviation and right bundle branch block morphology. Blood tests showed a high sensitivity troponin leak of 900. Computed tomographic pulmonary angiography revealed right lower lobe segmental pulmonary embolus. Bedside transthoracic echocardiogram revealed a severely dilated right ventricle (RV) with severe impairment of systolic function. Left ventricular (LV) function was normal. Colour Doppler showed presence of a shunt between the LV and right atrium (RA) in the superior aspect of the septal leaflet. Transoesophageal echocardiography demonstrated a dilated RA and RV with a small peri-membranous ventricular septal defect located high in the interventricular septum with turbulent flow from the LV to the RV. An additional shunt was observed from the LV into the RA. Overall findings were consistent with a ruptured coronary sinus of Valsalva. The patient had a complicated clinical course with cardiogenic shock, acute liver injury and renal impairment. Decision was made for cardiothoracic intervention. Repair of sinus of Valsalva from the aortic non-coronary sinus to the right atrium with repair of the aortic valve and closure of secundum atrial septal defect. The patient had an uneventful intra-operative and postoperative course. Aneurysm of the coronary sinus of Valsalva is a rare congenital cardiac anomaly. Multimodality imaging is essential for accurate diagnosis and management.

An Interesting Case of Left Ventricular Diverticulum

Left ventricular (LV) diverticulum is defined as a protrusion of the free wall of the ventricle, including endocardium, myocardium, and pericardium. It is classified into fibrous and muscular types. Most of the patients are asymptomatic. It is mainly diagnosed by echocardiography, magnetic resonance imaging, and ventriculography. Surgery is the treatment of choice if the patient is symptomatic associated with other cardiac anomalies. In asymptomatic patient with isolated LV diverticulum, the treatment is controversial. Our patient is a 35-year-old male presented with progressive dyspnea on exertion for the past 1 month. Clinical examination was normal. His electrocardiogram revealed sinus tachycardia. There was no evidence of ischemic changes. Echocardiogram revealed aneurysmal outpouching of the posterolateral basal segment of the left ventricle adjacent to the posterior mitral leaflet [Figure 1]. Ejection fraction was 50% with trivial mitral regurgitation. His coronary angiogram showed normal epicardial coronaries. The patient was treated with furosemide, enalapril, metoprolol, and spironolactone. Then, the patient was referred to the cardiothoracic surgery department for further management.

Lymphocytic variant of Hypereosinophilic syndrome complicated by myocarditis

A 26 year-old-male with nil significant past medical history presented to us with swelling of left lower limb since 2 weeks. He has tachyapnea and tachycardia. His JVP was normal and cardiac auscultation was normal. Examination was suggestive of deep vein thrombosis (DVT) of the left lower limb. Doppler of lower limb confirmed this and patient was appropriately placed on anti-coagulation. He had persistently elevated blood eosinophil counts. Bone marrow biopsy was and mutational analysis confirmed presence of lymphocytic variant of hypereosinophilic syndrome (HES). He continued to have tachycardia and cardiac enzymes were positive. Electrocardiogram revealed sinus tachycardia and echo was normal. After ruling out the possibility of pulmonary thromboembolism with CT pulmonary angiogram, myocarditis was attributed to HES. He was promptly treated glucocorticoids which were later tapered gradually in lieu of improvement of his clinical condition and declining eosinophil counts. He was discharged and was under regular follow-up. Key words: Hypereosinophilic syndrome, Persistent eosinophilia, Deep vein thrombosis, Myocarditis.

Cardiac Tamponade: An Uncommon Presentation of Granulomatosis With Polyangiitis

SESSION TITLE: Pulmonary Manifestations of Systemic Disease Case Report Posters SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM INTRODUCTION: Cardiac tamponade is a life-threatening condition requiring pericardial drainage to restore hemodynamic balance. We describe a case of tamponade as the presenting manifestation of granulomatosis with polyangiitis (GPA). CASE PRESENTATION: A 58 year-old farmer acutely developed chest pain and dyspnea. He was tachycardic, tachypneic and diaphoretic. He described a productive cough, recurrent sinusitis, malaise, polyarthralgias, night sweats and a 50 pound weight loss. On examination he appeared ill. Jugular venous pulsations were elevated, heart tones were distant and trace pretibial pitting edema was present. Labs demonstrated leukocytosis, anemia, thrombocytosis and normal renal function. Troponin-T was negative. Electrocardiogram revealed sinus tachycardia. Computed tomography ruled out pulmonary embolism but showed a pericardial effusion [image 1] with pericardial enhancement. Irregular nodules were noted in the right lung [image 2], as well as a left pleural effusion and mediastinal lymphadenopathy. Echocardiogram revealed right ventricular and atrial collapse and respirophasic flow reversal in the inferior vena cava, consistent with tamponade. Pericardiocentesis yielded 500 mL of sero-sanguineous fluid. Further studies revealed microscopic hematuria, erythrocyte sedimentation rate of 130 mm/hr, C-reactive protein of 203 mg/L, cytoplasmic anti-neutrophil cytoplasmic antibodies (c-ANCA) titer of 1:256 and markedly elevated proteinase (PR-3). Pericardial cytology and cultures were negative. Treatment for GPA was initiated with prednisone and cyclophosphamide, in addition to colchicine and indomethacin. Four months after diagnosis he is in remission. DISCUSSION: The reported frequency of cardiac involvement with GPA ranges from 6-44% (1); the largest GPA case series found a 10% overall incidence of pericarditis (2). To our knowledge this is the first description of tamponade leading to the diagnosis of GPA, though four cases of tamponade in the setting of established GPA have been previously described. This patient was successfully treated with pericardiocentesis and immunosuppression. CONCLUSIONS: Pericarditis is not uncommon in GPA and can rarely result in tamponade. Reference #1: Grant et al. Wegener's granulomatosis and the heart. Br Heart J. 1994 Jan;71(1):82-6. Reference #2: Hoffman et al. Wegener granulomatosis: an analysis of 158 patients. Ann Intern Med. 1992 Mar 15;116(6):488-98. Reference #3: Schiavone et al. Unusual cardiac complications of Wegener's granulomatosis. Chest. 1985 Nov;88(5):745-8. DISCLOSURE: The following authors have nothing to disclose: Erin Sullivan, Rodrigo Cartin-Ceba, Fabien Maldonado No Product/Research Disclosure Information