Intermittent Palpitations Research Articles

Initiation of tachycardia with longitudinal dissociation: What is the mechanism?

Case presentation A 61-year-old man with hypertension, diabetes, and obstructive sleep apnea had a history of intermittent palpitations for 30 years that progressively increased in frequency and duration. The patient underwent an invasive electrophysiologic study, during which pacing from the right ventricular apex demonstrated earliest retrograde atrial activation along the posterior paraseptal region. Administration of intravenous adenosine (12 mg) during ventricular pacing is shown in Figure 1. There was no evidence of anterograde dual atrioventricular (AV) nodal physiology or anterograde preexcitation. Sustained supraventricular tachycardia (SVT) at a cycle length of 370 ms was induced in the baseline state with a single premature ventricular extrastimulus (Figure 2). An example of tachycardia response to a premature extrastimulus is shown in Figure 3A. What is the mechanism of the tachycardia?

Non-functioning paraganglioma occurring in the urinary bladder: A case report and review of the literature.

Paraganglioma, also termed extra-adrenal pheochromocytoma, may be observed at the base of the skull and neck as well as within the mediastinum and periaortic region. The clinical symptoms of paraganglioma of the urinary bladder include intermittent hypertensive attacks, micturition, headaches and palpitations due to high catecholamine levels; these types of paragangliomas are extremely rare. However, certain bladder paragangliomas do not present with any of these symptoms; thus, surgeons are not pre-warned on how to prepare for their resection. Surgery to remove pheochromocytomas may therefore result in an intraoperative hypertensive crisis and increase the mortality rate. This infrequent type of paraganglioma is only recognized through histological examination following surgery. The current study reports the case of a 61-year-old male with urinary bladder paraganglioma. The patient presented with hypertension, which was controlled to within a normal range using diovan and norvasc treatment; in addition, the patient's blood pressure was not altered with urination or postural changes. The patient was not administered an α-blocking agent or a blood volume expander prior to the surgery, and during the partial cystectomy no hypertensive crisis occurred.

ECG Challenge: February 3, 2015.

HomeCirculationVol. 131, No. 5ECG Challenge: February 3, 2015 Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBECG Challenge: February 3, 2015 Originally published3 Feb 2015https://doi.org/10.1161/CIRCULATIONAHA.114.015197Circulation. 2015;131:513A 21-year-old male college student without any known cardiac problems presents to his college health service with concerns of intermittent palpitations that occur sporadically. They generally last only for a few minutes, although he did have 1 more prolonged episode 1 week before. This episode also terminated spontaneously. The results of his physical examination are unremarkable. An ECG is obtained.Download figureDownload PowerPointWhat is the diagnosis?To submit your diagnosis, go to http://circ.ahajournals.org/letters/submit/circulationaha;131/5/513. The diagnosis will follow in next week's issue (February 10).Please go to the journal’s Facebook page for more ECG Challenges: http://goo.gl/cm4K7. Challenges are posted on Tuesdays and Responses on Wednesdays.FootnotesCorrespondence to Philip J. Podrid, MD, West Roxbury VA Hospital, Section of Cardiology, 1400 VFW Pkwy, West Roxbury, MA 02132. E-mail [email protected] Previous Back to top Next FiguresReferencesRelatedDetails February 3, 2015Vol 131, Issue 5 Advertisement Article InformationMetrics © 2015 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.114.015197PMID: 30525998 Originally publishedFebruary 3, 2015 PDF download Advertisement SubjectsElectrocardiology (ECG)

Extranodal Rosai-Dorfman Disease Involving the Left Atrium: Cardiac MRI, CT, and PET Scan Findings.

Rosai-Dorfman disease (RDD) is a rare entity that usually involves the lymph nodes but extranodal involvements have been seen in numerous cases, although RDD with cardiovascular involvement is extremely rare. We describe a case of a young male who presented with intermittent palpitations and was found to have a left atrium mass. Our case not only emphasizes the rarity of the above lesion but also highlights the importance of modern-day imaging like computed tomography, Cardiac Magnetic Resonance Imaging (CMRI), and PET scan in characterizing such nonspecific lesions and directing appropriate line of treatment. RDD should be considered as one of the differentials even for isolated cardiac lesions.

The unexpected pitter patter: new-onset atrial fibrillation in pregnancy.

Background. Atrial fibrillation is a relatively uncommon but dangerous complication of pregnancy. Emergency physicians must know how to treat both stable and unstable tachycardias in late pregnancy. In this case, a 40-year-old female with a cerclage due to incompetent cervix and previous preterm deliveries presents in new-onset atrial fibrillation. Case Report. A previously healthy 40-year-old African American G2 P1 female with a 23-week twin gestation complicated by an incompetent cervix requiring a cervical cerclage presented to the emergency department with intermittent palpitations and shortness of breath for the past two months. EMS noted the patient to have a tachydysrhythmia, atrial fibrillation with rapid ventricular response. She was placed on a diltiazem drip, which was titrated to 15 mg/hr without successful rate control. Her heart rate remained in the 130s and the rhythm continued to be atrial fibrillation with RVR. Digoxin was then added as a second agent, and discussions about the potential risks of cardioversion in pregnancy ensued. Fortunately, the patient converted to sinus rhythm before cardioversion became necessary. The digoxin was discontinued; the diltiazem was also discontinued after the patient subsequently developed hypotension. “Why Should Emergency Physicians Be Aware of This?” New-onset atrial fibrillation is rare in pregnancy but can increase the mortality and morbidity of the mother and fetus if not treated promptly.

Huge Intravascular Tumor Extending to the Heart: Leiomyomatosis.

Intravenous leiomyomatosis (IVL) is a rare neoplasm characterized by histologically benign-looking smooth muscle cell tumor mass, which is growing within the intrauterine and extrauterine venous system. In this report we aimed to present an unusual case of IVL, which is originating from iliac vein and extended throughout to right cardiac chambers. A 49-year-old female patient, who was treated with warfarin sodium due to right iliac vein thrombosis, was admitted to our department with intermittent dyspnea, palpitation, and dizziness. Physical examination was almost normal except bilateral pretibial edema. On magnetic resonance venography, there was an intravenous mass, which is originated from right internal iliac vein and extended into the inferior vena cava. Transthoracic echocardiography and transesophageal echocardiography revealed a huge mass extending from the inferior vena cava through the right atrium, with obvious venous occlusion. Thoracic, abdominal, and pelvic MR showed an intravascular mass, which is concordant with leiomyomatosis. Surgery was performed through median sternotomy. A huge mass with 25-cm length and 186-gr weight was excised through right atrial oblique incision, on beating heart with cardiopulmonary bypass. Histopathologic assessment was compatible with IVL. Exact strategy for the surgical treatment of IVL is still controversial. We used one-stage approach, with complete resection of a huge IVL extending from right atrium to right iliac vein. In such cases, high recurrence rate is a significant problem; therefore it should be kept in mind.

Integration of cardiac monitoring with video to enable service transformation

The future of digital care will be significantly enhanced by the integration and interoperation of systems and services. Collaboration between clinicians and service providers will allow combined services to be shaped such that the whole is greater than the sum of the parts. In future services need to enable people to continue with their lives whilst being supported, rapidly and appropriately when required. We present the results of a project to use an innovative cardiac event loop recorder (ELR) and screening service in cooperation with the use of video consultations. The ELR service detects and records abnormal ECG traces. The connected consultant can choose to receive a PDF of any abnormal trace within seconds or have the trace pre-screened by a cardiac physiologist. The consultant can then initiate a video call to the person and discuss the event. The patient might then attend a consultation in person. The goal is to significantly improve the detection of abnormal events and offer immediacy of support and diagnosis i.e. quality improvement by early diagnosis and potential cost saving in the immediate term by reducing surveillance appointments and in the long term by reducing burden of disease e.g. stroke reduction by earlier AF detection This approach facilitates two modes of care delivery that are innovative: The first is the capture of infrequent events. An example case involved a 66-year-old hypertensive female who suffered from 2 years history of palpitations and had been treated for anxiety and ventricular ectopic beats. Physical examination was normal. Echocardiography showed structurally normal heart. Her electrocardiogram showed normal sinus rhythm with normal PR and QT segments Since several 24 hours Holter monitoring episodes had proved to be unsuccessful in the past it was decided to monitor the patient with the smart event ELR. The patient was equipped with a one-channel smart ELR that was used over a period of 2 weeks of continuous monitoring. The recorder was programmed to automatically send both manually triggered cardiac events as well as automatically triggered events for atrial fibrillation (AF). For the latter, the automatic AF detection algorithm had been activated. All events were automatically transferred using GPRS (tele-ECG option) and in virtually real time. International Digital Health and Care Congress, The King’s Fund, London, September 10-12 2014. International Journal of Integrated Care – Volume 14, 01 November – URN:NBN:NL:UI:10-1-116508– http://www.ijic.org/ Over the course of the next days the recorder sent in ECGs, which showed clear evidence of paroxysmal atrial fibrillation (PAF) as a cause of her intermittent palpitation. During these episodes, she felt unwell with erratic heart rate and light-headedness. The episodes lasted between 30 seconds and up to 2 minutes, confirming the diagnosis of PAF. For patients with long-term conditions that include cardiovascular disease the approach offers a pro-active and supportive way to manage people in their own homes. Both approaches address several of the NHS Outcomes Framework domains, specifically: • reducing premature mortality. • ensuring people feel supported to manage their condition. • reducing the amount of time spent in hospital. • improving people’s experience of outpatient care. • improving hospital’s responsiveness to patient’s needs. During the presentation there will be a live demonstration of the cardiac monitoring and the video service.

Extraadrenal Biatrial Cardiac Paraganglioma: Diagnosis, Histological Criteria and Surgical Management

Primary cardiac paragangliomas are rare heart tumors that originate from the neural crest. We report a case of successful surgical treatment of a noncatecholamine-producing cardiac paraganglioma in a 25-year-old white male patient with dyspnea on exertion and intermittent palpitations. Echocardiography revealed solid 4.6- × 4.3-cm tumor mass located in close relation to the left and right atria. A magnetic resonance image of the heart demonstrated the solid tumor mass adjacent mainly to the right atrium and in part to the left atrium with an early and strong arterial uptake of the contrast medium (see arrow in Fig 1).

An Unusual Cause of ST Elevations in a Young Man

A 24-year-old healthy young man presented with intermittent chest pain and palpitations for three days and an episode of syncope on the day of presentation. He had similar episodes of palpitations and near syncope during the past few months. He had no family history of cardiac diseases and denied any history of substance abuse. His initial vital signs, physical exam and lab work were unremarkable. However, his presentation electrocardiogram (ECG) was significant for a pseudo-right bundle branch block pattern with ST elevations in the precordial leads (Fig. 1). A diagnosis of Type I Brugada syndrome (BS) was made based on his clinical presentation and ECG pattern. An implantable cardioverter defibrillator (ICD) was implanted for primary prevention of sudden cardiac death (SCD). Figure 1 Presentation ECG of the patient with ST elevations in leads V1–V3, pseudo-right bundle branch pattern and a terminal S wave in the lateral leads. Clinical spectrum of BS ranges from asymptomatic to SCD. Symptoms such as syncope are usually related to ventricular arrhythmias. BS is responsible for up to 4–12 % of all SCD worldwide, and is more common in young adults and in men.1 Symptomatic patients with BS (history of VT/VF or syncope) have a class I indication for ICD implantation to prevent SCD.1 Genetic testing and ECG screening of family members are also recommended for management of this disease.

Arrhythmogenic right ventricular cardiomyopathy/dysplasia (Naxos disease) in a case of rheumatic heart disease – A rare occurrence

We report a case of chronic RHD with severe Rheumatic mitral valve stenosis who had undergone closed mitral commissurotomy (CMC) a few years back. The 20-year-old male continued to be symptomatic with dyspnea and intermittent palpitations even after the procedure (CMC). ECG during one of such an episode revealed ventricular tachycardia, which was promptly cardioverted. His physical examination revealed palmoplantar keratoderma and woolly hair. ECG revealed an epsilon wave in lead V1 and 2D ECHO revealed dilated right atrium and right ventricle, a low LVEF and aneurysmal RVOT. MRI revealed fibrofatty replacement of right ventricular apex and free wall associated with areas of fibrosis and fatty replacement in scattered areas of left ventricle.

ECG Response: February 11, 2014

ECG Challenge: A 59-year-old woman has a history of lupus with renal involvement for which she is taking glucocorticoids. She has no known heart disease. She presents to her rheumatologist with concerns of intermittent palpitations that first began ≈1 month ago. She was referred to a cardiologist and an ECG was obtained. The ECG shows a regular rhythm with 2 different rates. The initial portion of the ECG shows a regular rhythm with a rate of 72 bpm. The second part of the ECG shows a regular rhythm at a rate of 160 bpm. All the QRS complexes (except for the 8th QRS complex; ↓) have the same morphology. The QRS complex duration is normal (0.08 s), and there is a normal morphology and a normal axis between 0° and +90° (positive QRS complex in leads I and aVF). The …

ECG Challenge: February 4, 2014

HomeCirculationVol. 129, No. 5ECG Challenge: February 4, 2014 Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBECG Challenge: February 4, 2014 Originally published4 Feb 2014https://doi.org/10.1161/CIRCULATIONAHA.113.008536Circulation. 2014;129:613Download figureDownload PowerPointA 59-year-old woman has a history of lupus with renal involvement for which she is taking glucocorticoids. She has no known heart disease. She presents to her rheumatologist with complaints of intermittent palpitations that first began about 1 month ago. She was referred to a cardiologist, and an ECG was obtained.What is the diagnosis?To submit your diagnosis, go to http://circ.ahajournals.org/letters/submit/circulationaha;129/5/613. The diagnosis will follow in next week’s issue (February 11).Please go to the journal’s Facebook page for more ECG Challenges: http://goo.gl/cm4K7. Challenges are posted on Tuesdays and Responses on Wednesdays.FootnotesCorrespondence to Philip J. Podrid, MD, West Roxbury VA Hospital, Section of Cardiology, 1400 VFW Pkwy, West Roxbury, MA 02132. E-mail [email protected] Previous Back to top Next FiguresReferencesRelatedDetails February 4, 2014Vol 129, Issue 5 Advertisement Article InformationMetrics © 2014 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.113.008536 Originally publishedFebruary 4, 2014 PDF download Advertisement SubjectsElectrocardiology (ECG)

Polyglandular Autoimmune Syndrome Type 2 Presenting With Ventricular Tachycardia

Introduction: Polyglandular autoimmune syndrome (PGA) describes a condition where dysfunction of two or more endocrine glands occurs in association with circulating organ-specific antibodies directed against the involved glands. Case Presentation: A 36 year old female, known type 1 diabetic presented with a 3 week-history of heat intolerance and intermittent palpitations, associated with dyspnea and light-headedness. On examination, a cachexic, lethargic woman with an unrecordable pulse and blood pressure was found. She was found to have sustained monomorphic ventricular tachycardia on cardiac monitor at a rate of 186 beats per minute, confirmed on 12-lead electrocardiogram. The patient was immediately cardioverted, with restoration of sinus rhythm and pulse. Further examination revealed generalized hyperpigmentation with patches of depigmentation, alopecia, a goiter, proptosis and lid lag. Thyroid function test was consistent with thyrotoxicosis and co-syntropin test confirmed adrenal insufficiency. Complete blood count was significant for a macrocytic anemia; with low level of vitamin B12 on testing. A diagnosis of sustained ventricular tachycardia in a patient with PGA type 2 was made and the patient was admitted to the intensive care unit. She was treated with hydrocortisone, fludrocortisone, carbimazole, propanolol and cyanocobalamin. The patient was maintained on amiodarone for one week and she remained in sinus rhythm for the remainder of her hospitalization. Discussion: PGA type 2 is characterized by the occurrence of adrenal insufficiency with thyroid autoimmune disease (hypo or hyperthyroidism) and insulin-dependent diabetes mellitus. Electrolyte abnormalities are frequently found in adrenal insufficiency and may predispose to arrhythmias on a background of increased adrenergic effect of thyrotoxicosis. Conclusion: The presence of an immunoendocrinopathy warrants the search for other endocrine hypofunction. In situations where a life-threatening arrhythmia is present, urgent identification and treatment of the arrhythmia is top priority.

間欠的な動悸・脈の不規則感へのアプローチ

間欠的な動悸・脈の不規則感へのアプローチ

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Introduction: Introduction Pheochromocytoma in pregnancy is a rare but potentially life threatening condition to both mother and fetus. Early diagnosis and appropriate management reduces possible maternal and fetal complications, however it is a challenge to diagnose as its ambiguous presentation often mimics preeclampsia, especially when associated with proteinuria and hypertension. A 33 year old Chinese woman presented at 38 weeks gestational age with a BP 200/110 and mild proteinuria on urine dipstick. She had 2 previous uncomplicated pregnancies by normal vaginal delivery. She complains of intermittent palpitations and mild occipital headache for the past 2 years. On admission, she was asymptomatic, afebrile, BP 136/96. Physical exam was unremarkable. Urine dipstick was positive for protein, fetal movements were positive with fetal heart rate of 150. Patient was diagnosed with preeclampsia. She was started on Magnesium sulfate, and labor induced with delivery of a healthy baby. Six hours later her BP increased to 210/116 with a peak troponin of 5.08. ECHO showed mild systolic dysfunction with hypokinesia of the anteroseptal wall and moderate mitral regurgitation. Patient had a cardiac cath showing normal coronaries. During the procedure her BP increased to 310/140 and she was started on cardizem. Ultrasound was performed that showed a soft tissue mass abutting the posterior aspect of the left kidney. Ct scan of pelvis confirmed a heterogeneous soft tissue mass 6.3x5.6x5.7 cm replacing the adrenal gland. The patient was started on phenoxybenzamine and lopressor and after 30 days of treatment had the mass resected uneventfully. Discussion Our case highlights the importance of early awareness and recognition of the presence of pheochromocytoma in a pregnant patient with hypertension. Pheochromocytoma in pregnancy demands special attention, since both maternal and fetal outcomes are historically poor. Distinguishing pheochromocytoma from pre-eclampsia is extremely challenging, especially in the presence of proteinuria and a history of normal past pregnancies. Although clinical course is complex and diagnosis often challenging, results are rewarding with complete resolution of symptoms in most cases after tumor resection.

SAPHO syndrome associated with acne conglobata successfully treated with etanercept

A 42-year-old Taiwanese male presented to our dermatology department with complaint of chronic acne on the face, back and buttocks with severe sinus tracts and depressed scar formation for 20 years (Fig. 1A). Long-term oral minocycline provided some relief, but new crops of lesions continued to develop periodically. He started to suffer from intermittent chest pain and palpitation during the past 5 years. Repeated 24-hour-electrocardiography monitoring and echocardiography were unremarkable. In addition, episodic polyarthralgia over the bilateral temporomandibular joint, left shoulder, and left ankle were noted in recent years. Laboratory studies revealed a mild increase in the erythrocyte sedimentation rate (11 mm, normal: <10 mm) and mild decreases in immunoglobulin G (656 mg/dL, normal: 751e1560 mg/dL), immunoglobulin M (44.4 mg/dL, normal: 46e304 mg/dL), and complement 3 (72.7 mg/dL, normal: 79e152 mg/dL). X-ray of the chest, left ankle, and skull, as well as computed tomography of the head and anterior chest wall were all unremarkable. Bone scintigraphy showed uptake in the left parietal skull,

Evaluation of Patients for Paroxysmal Atrial Fibrillation After Ischemic Stroke

An 84-year-old woman with a medical history significant for hypertension and hyperlipidemia presented with aphasia and was found to have a left parietal subacute infarct with hemorrhagic conversion and a remote right parietal lobe infarct, not previously recognized on computed tomography of the head. Workup included a transthoracic echocardiogram that showed normal left ventricular size, an ejection fraction >65%, and abnormal left ventricular diastolic filling. The left atrium was mild to moderately dilated. There was mild mitral regurgitation, mild pulmonary hypertension, and no evidence of patent foramen ovale with agitated saline. She complained of intermittent palpitations (every few weeks) and was placed on telemetry during her inpatient stay, with no significant arrhythmia detected. After her inpatient admission, she was treated with aspirin and had a 30-day event monitor that showed no episodes of atrial fibrillation. One year later, she presented at the office of her primary care physician with complaints of palpitations and shortness of breath. She was found to be in atrial fibrillation and was subsequently treated with warfarin. Atrial fibrillation is a common cause of ischemic stroke; overall, one sixth of cerebral infarcts are attributed to atrial fibrillation. As patients age, that proportion increases. Between 50 and 59 years of age, 1.5% of strokes are attributed to atrial fibrillation, but between 80 and 89 years of age the proportion increases to 23.5%.1 In patients with rheumatic heart disease, the incidence is even higher, 17× that of patients without atrial fibrillation.2 Atrial fibrillation can be persistent (lasting >7 days) or paroxysmal (spontaneously terminating in <7 days). Diagnosing paroxysmal atrial fibrillation can be a challenge but an important endeavor in patients suspected of cardioembolic stroke. All patients with prior stroke, transient ischemic attack, or thromboembolism receive at …

Ventricular tachycardia – an atypical initial presentation of sarcoidosis: a case report

IntroductionSymptomatic cardiac involvement is seen in less than 5% of all cases of sarcoidosis. Although clinically apparent cardiac sarcoidosis is an uncommon entity, ventricular tachyarrhythmias as the first presenting symptom are very rare.Case presentationWe discuss the case of a 41-year-old Asian woman who presented to our hospital with intermittent palpitation and on evaluation was diagnosed to have systemic sarcoidosis with cardiac involvement. She was started on multiple antiarrhythmic drugs and corticosteroids without any satisfactory response.ConclusionsOur case report indicates that sarcoidosis can manifest as ventricular tachycardia without any detectable systemic findings. This makes sarcoidosis an important diagnostic consideration in patients with ventricular tachycardia of unknown origin given the high mortality associated with ventricular tachyarrhythmias.

Right atrial paraganglioma, a rare primary cardiac tumour

We present a Case report of 45 years old otherwise fit female patient diagnosed with Right atrial mass following short history of flu like symptoms later complicated by hot flushes and intermittent palpitations. She underwent successful resection of her cardiac tumour and histopathology revealed it to be Paraganglioma of the heart. We present a summary of management of this rare primary cardiac tumour.

Intracardiac foreign body caused by cement leakage as a late complication of percutaneous vertebroplasty

Intracardiac foreign body caused by cement leakage as a late complication of percutaneous vertebroplasty