Jugular Venous Pressure Research Articles

Bilateral optic disc edema as the presenting sign of brain metastasis

To report a rare case of bilateral optic disc edema as a presentation of brain metastasis. Case report. A 51-year-old healthy woman presented with complaints of headache, diplopia, and distortion of peripheral vision for the past one month. Examination of both the eyes showed massive optic disc edema, multiple radial hemorrhages, hard exudates at the disc margin, and absent venous pulsation. Magnetic resonance imaging (MRI and MRA) showed leptomeningeal enhancement with raised intracranial pressure: a sign of metastasis. She had undergone mastectomy and had received eight cycles of systemic chemotherapy and radiation for breast carcinoma two years ago. She was urgently referred to an oncologist for further management. This case highlights the importance of neuroimaging in patients presenting with bilateral disc edema and prior history of breast carcinoma to rule out metastasis.

Implication of Right Atrial Pressure Estimated by Echocardiography in Patients with Severe Tricuspid Regurgitation

Little is known about how tightly right atrial pressure (RAP) is associated with prognosis in patients with severe tricuspid regurgitation (TR). The aim of this study was to investigate the association of RAP estimated by echocardiography (RAP-echo) with cardiovascular events in patients with severe TR. Two hundred forty outpatients (median age, 75years; 130 women) who underwent two-dimensional transthoracic echocardiography and were diagnosed with severe TR were retrospectively studied. According to RAP-echo using the diameter of the inferior vena cava and its response to a sniff, patients were classified into two groups: low or middle and high RAP-echo. Cardiovascular events were defined as cardiovascular death and admission for heart failure. During follow-up (median, 428 days; range, 87-1,229 days), 64 patients experienced cardiovascular events. By multivariate analysis, high RAP-echo was independently associated with cardiovascular events (hazard ratio, 2.46; 95% CI, 1.17-5.18). Also, jugular venous distention and leg edema were not independently associated with cardiovascular events. The significant and stronger association of RAP-echo with clinical outcome compared with estimates of RAP on physical examination suggests that recognition of high RAP-echo can be a valuable surrogate for the clinical management of severe TR patients.

A simple pleural effusion or not?

A 60-year-old man presented with a 2-week history of progressive dyspnea and bilateral leg edema. He had undergone a prosthetic mitral valve replacement 9 years earlier. The patient was in respiratory distress (respiratory rate 32/min, oxygen saturation 86% on air, heart rate 124/min, blood pressure 109/56 mmHg). Examination revealed bilateral lung crackles and reduced air entry with dullness to percussion and elevated jugular venous pressure. The electrocardiogram showed sinus tachycardia. A chest X-ray (CXR) (Figure 1) and bedside lung ultrasonography were performed (Figure 2A). A diagnosis of a large pleural effusion was made and urgent thoracocentesis was considered in view of the patient’s respiratory distress. A repeat ultrasonographic scan with adjusted angulation to identify the most suitable entry point for the chest drain (Figure 2B) yielded new results that led to the cancellation of the thoracocentesis.

#5787 ALBUMINURIA IN PATIENTS ADMITTED WITH HEART FAILURE IS ASSOCIATED WITH MORE SYSTEMIC CONGESTION ASSESSED BY ULTRASOUND

Abstract Background and Aims Albuminuria is frequently observed in patients with heart failure (HF) and is associated with worse outcomes. New instrumental methods of congestion assessment in HF are superior in accuracy to physical examination and, therefore, are becoming the new standards for congestion registration. The relationship of albuminuria with congestion assessed by ultrasound in HF population is unclear. We aimed to investigate the relationship between albuminuria level and congestion measured by lung ultrasound (LUS) and Venous Excess Ultrasound (VExUS) at admission in patients with ADHF. Method In this prospective study we included 58 patients which were admitted with ADHF (typical signs and symptoms with NT-proBNP > 300 pg/ml). Patients with end-stage chronic kidney disease (CKD), malignancy were excluded. Routine clinical examination and laboratory tests, echocardiography, eight-zone LUS, and VExUS assessment of veins: cava inferior, hepatic, portal, and renal were performed. Patients were divided into two groups according to albumin/creatinine ratio at hospitalization: without albuminuria (uACR<30 mg/gCr) and with albuminuria (uACR>30 mg/gCr). Results 72% were male, mean age was 72 (55;79) (Me (IQR) years, 52% (n = 30) had reduced ejection fraction (EF), 77% - hypertension (HTN), 66% - atrial fibrillation (AF), 37% - diabetes mellites (DM), 58% - coronary artery disease (CAD), 17% (n = 10) - previously known CKD. On physical examination at admission 67% (n = 39) patients had orthopnea,69% (n = 40) - exertional dyspnea, 53.4% (n = 31) - elevated jugular venous pressure, 91.4% (n = 53) - ankle edema, 50% (n = 29) - hepatomegaly and 82.8% (n = 48) pulmonary crepitations. Mean NT-proBNP was 2062 (13443248) (Me (IQR)) pg/ml. 49 (84%) had pulmonary congestion assessed by LUS (mean number of B-lines 34 (25;48)), 86% (n = 50) – congestion by VExUS, from which the majority of patients had the most severe, 3rd, grade (1st – 32%, 2nd – 16%, 3rd – 52%). The prevalence of albuminuria was 65.5% (n = 38): 92% (n = 35/38) patients had albuminuria categories A2 and 8% (n = 3/38) had A3 category. Groups with and without albuminuria were similar in gender, age, prevalence of EF<40%, comorbidities, exertional dyspnea, orthopnea, elevated jugular venous pressure, hepatomegaly, pulmonary crepitations, levels of NT-proBNP and serum creatinine. Differences between groups with and without albuminuria were detected in the frequency of ankle swelling (100%(n = 38/38) vs 75% (n = 15/20), p = 0.003). Patients with albuminuria had a trend to more frequently having pulmonary congestion than without albuminuria (89% (n = 34/38) and 75% (n = 15/20), p = 0.15 respectively). The prevalence of congestion assessed by VExUS was higher in patients with albuminuria (95% (n = 36/38) and 70% (n = 14/20), p = 0.009 respectively). Conclusion In patients hospitalized with ADHF albuminuria is associated with systemic congestion assessed by VExUS. The relationship between pulmonary congestion by LUS and albuminuria should be a matter of future studies.

Demystifying Cardiac Amyloidosis with Cardiac MRI: A case report

Amyloidosis refers to the accumulation of amyloid fibrils in different organs of the body that may result in the dysfunction of the organ systems. Cardiac amyloidosis (CA) is an accumulation of amyloid fibrils in cardiac tissue that leads to an increase in the thickness and mass of the ventricular wall inducing progressive and restrictive infiltrative cardiomyopathy. We present here a case of 62-year-old male with complaints of shortness of breath on exertion, abdominal distention, and leg edema, had elevated jugular venous pressure, pedal edema, and ascites. Echo findings showed biventricular wall thickening, restrictive left ventricular inflow pattern in pulse wave Doppler, and strain pattern characteristic of an infiltrative process. He was thus referred for a cardiac MRI for further evaluation with the suspicion of restrictive cardiomyopathy. Based on the CMR findings and the clinical scenario, the patient underwent a rectal mucosal biopsy that was confirmative of systemic amyloidosis.

End-tidal carbon dioxide's change to fluid challenge versus internal jugular vein dispensability index for predicting fluid responsiveness in septic patients: A prospective, observational study.

The prediction of fluid responsiveness is crucial for the fluid management of septic shock patients. This prospective, observational study was conducted to compare end-tidal carbon dioxide (ETCO2) change due to fluid challenge (FC-induced ΔETCO2) versus internal jugular vein distensibility index (IJVDI) as predictors of fluid responsiveness in such patients. Septic hypoperfused mechanically ventilated patients were classified as fluid responders (Rs) and non-responders (NRs) according to the improvement of left ventricular outflow tract-velocity time integral (ΔLVOT-VTI) after fluid challenge (FC). The receiver operating characteristic (ROC) curves of FC-induced ΔETCO2, pre-(FC) IJVDI and their combination for prediction of fluid responsiveness were compared to that of ΔLVOT-VTI% as a gold standard. Of 140 patients who completed the study, 51 (36.4%) patients were classified as Rs and 89 (63.6%) patients as NRs. With regard to the prediction of fluid responsiveness, no significant difference (P. 0. 384) was found between the diagnostic accuracy of FC-induced ΔETCO2 >2 mmHg (area under the ROC curve [AUC] 0.908, P < 0.001) and that of pre-(FC) IJVDI >18% (AUC 0.938, P < 0.001), but a prediction model combining both markers, ΔETCO2 ≥3 mmHg and IJVDI ≥16%, achieved significantly higher accuracy (AUC 0.982, P < 0.001) than each independent one (P < 0.05). Under stable ventilatory and metabolic conditions, the predictivity of FC-induced ΔETCO2 >2 mmHg can be comparable to that of pre-(FC) IJVDI >18%. A predictive model combining both FC-induced ΔETCO2 ≥3 mmHg and IJVDI ≥16% can provide higher accuracy than that recorded for each one independently.

P177 COR TRIATRIATUM DEXTER: THE ROLE OF TRANSTHORACIC ECHOCARDIOGRAPHY

Abstract Introduction Cor triatriatum dexter (CTD) is an extremely rare congenital cardiac abnormality and its prompt recognition by transthoracic echocardiography (TTE) is essential for a correct diagnosis. Case presentation An 82–years–old woman was admitted to our cardiologic ward for worsening dyspnoea. The physical examination revealed a bilateral lower extremity oedema with elevated jugular venous pressure and hepatomegaly. The ECG showed atrial fibrillation with a heart rate of 70 bpm already treated with beta–blockers and direct–acting oral anticoagulant. TTE revealed a left ventricle with normal dimensions and function, a dilated right ventricle with a mild systolic dysfunction and increased wall thickness, a marked dilation of the right atrium and a tricuspid severe regurgitation. A deeper analysis of the right atrium revealed the presence of membrane partitioning the chamber into two compartments (Figure 1). The separation was incomplete as demonstrated by the flow across the membrane with Color–Doppler technique (Figure 2). The patient was treated using high doses of diuretics with a subsequent clinical improvement. A percutaneous intervention on the tricuspid valve was planned by the Heart Time. Discussion CTD derives from the persistence of the right valve of the sinus venosus resulting in a complete or incomplete fibromuscular band which separates the right atrium into two cavities. The spectrum of clinical manifestations is broad, based upon the degree of separation. In older patients CTD is often asymptomatic and incidentally found during diagnostic imaging examinations. TTE plays a key role in the identification of CTD, as a first–line diagnostic imaging tool. It, also, allows a differential diagnosis with a prominent eustachian valve, chiari network, and thebesian valve. However, in difficult cases a multiparametric approach is required including transoesophageal echocardiogram or cardiac magnetic resonance. Echocardiography has a pivotal role in the prompt recognition of other cardiac abnormalities associated with CTD such as atrial septal defect or patent foramen ovale, right ventricular hypoplasia and Ebstein’s anomaly. In our case, none of these were documented. Atrial fibrillation should be investigated due to severe atrial chamber dilation. A multiplane evaluation of the right atrium and the Color–Doppler technique are helpful to visualize the configuration of the membrane and evaluate the absence of flow disturbances.

PO-04-084 LOW SHOCK IMPEDANCE OF SUBCUTANEOUS IMPLANTABLE CARDIAC DEFIBRILLATOR (S-ICD) IN THE SETTING OF ACUTE DECOMPENSATED HEART FAILURE

Shock impedance represents the resistance between the coil and generator of subcutaneous ICDs. It is an important metric to predict device defibrillation success. Several factors have been implicated in determining system impedance of S-ICDs such as generator-lead distance, body habitus as well as generator position (subcutaneous vs. intermuscular pocket). We present a case report highlighting the impact of volume status on shock impedance. N/A A 60-year-old female presents to the office. She has a past medical history of obesity, Heart Failure with Preserved Ejection Fraction (HFpEF), ventricular fibrillation followed by implantation of transvenous ICD. This was complicated by device infection requiring device extraction and implantation of S-ICD. She has been having progressive shortness of breath with minimal exertion weeks prior to presentation. She denied chest pain, palpitations or dizziness but endorsed generalized fatigue as well as significant weight gain. She usually weighs around 165-170 lbs, but was 220 lbs on presentation. Her physical exam was remarkable for elevated jugular venous pressure, anasarca with crackles in the lung bases as well as abdominal ascites and lower extremity edema. Interrogation of her device was performed which showed no significant arrythmias. However, device detected low system impedance of <30 ohms. Her previous interrogation about 3 months earlier showed impedance of 50 Ohms. She was admitted for inpatient intravenous diuresis. Chest radiograph demonstrated normal position of the generator in the posterolateral chest wall and normal lead position in the parasternal area. Serial device interrogations were performed during the hospitalization showing gradual improvement in system impedance up to 45 Ohms once euvolemia was achieved (Figure 1). Due to improvement in shock impedance with diuresis, defibrillation threshold testing (DFT) was deferred and patient was discharged home in stable condition. Her repeat interrogation at follow up showed an impedance of 60 ohms. In the setting of heart failure exacerbation, excess fluid accumulation in the chest and abdominal cavities may result in a decrease in S-ICD shock impedance. Interpretation of device impedance should factor in patient’s volume status. Further studies are needed to ascertain if low impedance caused by fluid overload can impact device defibrillation success rate.

Abstract #1412763: Hustle for The Muscle: A Rare Case of Non-traumatic Rhabdomyolysis Secondary to Thyrotoxicosis

Rhabdomyolysis (RM) is a rare potentially life-threatening condition characterized by breakdown of striated muscle which can lead to progressive acute kidney injury. Common etiologies include trauma, infection, drugs, or surgery. Rarely, endocrinopathies including thyrotoxicosis have been associated with RM. Here, we present a case of non-traumatic and non-exertional RM secondary to thyrotoxicosis. A 50-year-old man recently diagnosed with Graves’ disease a month ago presented to the hospital with fever for 3 days. A week prior to presentation, thyroid function tests (TFT) showed normalizing FT4 (1.13ng/dL) and T3 (112ng/dL) levels with low TSH (<0.005ulU/m) which prompted his endocrinologist to decrease the methimazole dose from 20mg thrice daily to 10mg once daily. His fever was associated with nausea, vomiting, chills, and non-bloody diarrhea. On admission, the following vital signs were obtained: temperature 101.6F, blood pressure 140/85 mmHg, pulse rate 108 bpm, respiratory rate 16 bpm, and oxygen saturation 99% on room air. He was found to be alert, conscious, and coherent. Physical examination was notable for exophthalmos, absence of jugular vein distention, diffusely enlarged non-tender thyroid, clear breath sounds, no jaundice, and no peripheral edema. His calculated Burch-Wartofsky score was 40. Laboratory evaluation showed leukocytosis, elevated FT4 (4.01ng/dL), elevated FT3 (5.87pg/mL), and low TSH (<0.015uIU/mL) levels. He was also found to have acute kidney injury with creatinine of 1.33 mg/dL associated with hemoglobinuria. Further testing revealed a significantly elevated creatinine kinase (CK) at 98,760 U/L. On imaging, chest x-ray and CT scan were consistent with left lower lobe pneumonia. During the hospital stay, the patient was treated with methimazole 20mg daily together with antibiotics, aggressive hydration, and propranolol. His kidney function initially rapidly worsened but eventually improved as the CK levels normalized. FT4 levels were monitored and it gradually trended back to normal after 5 days. He was discharged stable and advised to follow up with his endocrinologist after a week. This is a case of a thyrotoxicosis complicated by rapidly worsening renal function. With a markedly elevated CK level accompanied by hemoglobinuria, absence of trauma or physical exertion, patient developed a concomitant non-traumatic RM. Non-traumatic RM is a rare complication of thyrotoxicosis and/or hyperthyroidism. Due to increased metabolic rate and energy consumption, rapid depletion of myocyte energy storage and substrates escalates, ultimately leading to necrosis. Based on literatures, only four cases were reported regarding the similar condition. In these cases, CK levels reported was less than 10 times the normal range. Our patient is unique that without history of trauma or exertion, a non-traumatic, non-drug-induced rhabdomyolysis transpired in the setting of acute thyrotoxicosis, with CK levels almost 580 times the upper normal limit. Management wise, aggressive hydration remains the treatment of choice to provide adequate renal perfusion and prevent renal damage.

Jugular Venous Pulse Waveform Extraction From a Wearable Radio Frequency Sensor.

Many prevalent heart diseases can be indicated by the features of the jugular venous pulse (JVP), an efficacious indicator of right heart health. However, JVP dynamics are not widely utilized in clinical settings as its observation and sensing remain cumbersome. Non-invasive measures of cardiac behavior, including the JVP, are of growing interest to enable continuous and at-home monitoring of cardiac disorders. In this work, we propose a wearable near-field radio-frequency (RF) sensor affixed with a neck collar on the clavicle over the internal jugular vein to enable non-invasive JVP sensing. We employed a complex vector injection signal processing method to extract repeatable JVP waveform features in multiple postures. With a 21-subject human study, we demonstrated morphologically consistent JVP sensing with consistent a-, c-, and v-wave feature timings, benchmarked by synchronous electrocardiogram and phonocardiogram. Further, inter-postural experiments demonstrated the capability of the proposed system to quantify morphological changes to the JVP which are present in many cardiac disorders. The results of this work suggest the proposed near-field RF sensor is capable of non-invasive JVP monitoring, potentially enabling improved sensing in both clinical and ambulatory environments.

E014 Severe myocarditis with cardiogenic shock in adult-onset Still’s disease after mRNA COVID-19 vaccination: a case of atypical presentation

Abstract Background/Aims Adult-onset Still’s disease is a systemic inflammatory disease of unknown aetiology. Post-COVID-19 vaccine adult-onset Still’s disease has been reported and was associated with only mild myocarditis. Here we report the first case of adult-onset Still’s disease after mRNA COVID-19 vaccination presenting with severe myocarditis with acute heart failure and cardiogenic shock. Methods We described the case history of the patient. Results A 72-year-old Chinese woman developed gradual onset of fever, shortness of breath, sore throat, generalised arthralgia, malaise and poor appetite 15 days after receiving the first dose of BNT162b2 mRNA COVID-19 vaccine. Physical examination revealed fever, bilateral ankle oedema and elevated jugular venous pressure. Significant investigation results are shown in Table 1. Extensive viral panel tests (including enterovirus, influenza and cytomegalovirus) were all negative. Echocardiography showed severely reduced left ventricular ejection fraction of 20%. The acute heart failure was complicated by cardiogenic shock requiring intensive care unit admission. Myocarditis was later diagnosed. Although the heart condition subsequently improved, there were persistent fever and arthralgia, as well as the development of generalised maculopapular skin rash. In view of that, series of investigations were performed, which revealed persistent neutrophilic leucocytosis, hyper-ferritinaemia and liver function derangement, while autoimmune panel was grossly unremarkable and septic/viral workup was negative (Table 1). Contrast PET-CT scan showed no features of malignancy. Adult-onset Still’s disease was diagnosed, and the patient was treated with oral prednisolone 40mg daily. The patient’s condition responded to the treatment; the fever subsided and the leucocyte count and inflammatory markers were normalised, and she was subsequently discharged. Three months after discharge, the patient was clinically well with prednisolone tapered down to 5mg daily. Reassessment echocardiogram showed full recovery with LVEF 60%. Conclusion Severe myocarditis with acute heart failure and cardiogenic shock is a possible initial presentation of adult-onset Still’s disease after mRNA COVID-19 vaccination. After exclusion of more common aetiologies, it is important to consider adult-onset Still’s disease as one of the differential diagnoses in the presence of compatible features following COVID-19 vaccination, such that appropriate and timely workup and treatment can be offered. Disclosure A. Kan: None. W. Yeung: None. C. Lau: None. P.H. Li: None.

Which congestion presentation pattern on the physical findings is associated with future adverse events? A cluster analysis in the multicenter acute heart failure registry.

Clinical congestion is the most frequent reason for hospital admission in patients with acute heart failure (AHF). However, few studies have investigated the patterns and prognostic implication of the physical congestion using unbiased and robust statistical methods. A hierarchical agglomerative clustering analysis was performed in the multicenter Japanese AHF registry (N = 3151) with the distance calculated by Jaccard's distance for jugular vein distention (JVD), leg edema, S3, crackles, and orthopnea. The primary outcome was a composite of cardiac death and heart failure readmission within 1-year. At the time of admission, the median number of prevalent congestive signs was 2. We identified three phenogroups: 'no physical congestions' (N = 251); 'congestion without JVD' (N = 1415); and 'congestion with JVD' (N = 1495). Patients in 'no physical congestion' were the youngest (median 75 [62, 83] years) with the lowest systolic blood pressure (122 [106, 142] mmHg). Patients in 'congestion without JVD', and 'congestion with JVD' were similar in terms of age (77 [67, 84] vs. 78 [69, 84] years) and systolic blood pressure (138 [118, 160] vs. 137 [118, 158] mmHg). While 30-day mortality was similar (4.0%, 3.7%, and 4.3% in 'no physical congestion,' 'congestion without JVD,' and 'congestion with JVD', respectively), the patients in 'congestion with JVD' were at the highest risk for the primary outcome (adjusted hazard ratio 1.79, 95% CI 1.26-2.55 when 'no physical congestion' was a reference). Our clustering analysis demonstrated that congestion signs, particularly JVD, allowed identification of AHF phenogroups with distinct clinical characteristics and long-term outcomes.

Clinical Profile and Outcomes of Epidemic Dropsy Patients Attending a Tertiary Care Centre in Assam, India.

Background The clinical condition of epidemic dropsy is caused by the consumption of edible oils contaminated with Argemone mexicana oil. Two of the most toxic alkaloids found in argemone oil are sanguinarine and dehydrosanguinarine, which cause capillary dilation, proliferation, and increased permeability. Extreme cardiac decompensation leading to congestive heart failure and glaucoma resulting in blindness are the most serious consequences of epidemic dropsy. Materials and methods All patients attending the medicine department of Tezpur Medical College and Hospital with clinical features of epidemic dropsy were included in the study after obtaining informed consent. All patients, after a complete history, underwent a thorough clinical examination, and findings were recorded using a pre-formed proforma. Along with routine blood examination, patients were also evaluated with echocardiography, ECG, and chest X-ray. Cooking oil samples obtained from patients were investigated for the presence of sanguinarine in a standardized laboratory with the help of the district authority. The statistical analysis was done using MS Excel 2017. Results Out of 38 patients, 36 were male (94.7%), and only two were female (5.2%). Male to female ratio was 18:1. This difference in sex ratio may be due to the fact that only severely ill patients attended our tertiary care hospital. In contrast, moderate and mildly ill patients were treated in local hospitals. The mean age of patients was 28.1 years, and the mean length of hospital stay was eight days. Bilateral pitting type of ankle edema was the most common clinical manifestation, and all 38 patients (100%) exhibited edema. A total of 76% of patients had dermatological manifestations. Sixty-two percent of patients had gastrointestinal manifestations. In cardiovascular manifestation, persistent tachycardia was seen in 52% of patients, pansystolic murmur was best heard in the apical area in 42% of patients, and 21 percent had evidence of a raised jugular venous pressure (JVP). Five percent of patients had pleural effusion. Sixteen percent of patients had ophthalmological manifestations. Eight patients (21%) required ICU care. The in-hospital fatality rate was 10.53% (n=4). Of the expired patients, 100% were male. The most common cause of death was cardiogenic shock (75%), followed by septic shock (25%). Conclusion From our study, it was found that most of the patients were male, with an age group of 25-45 years. The most common clinical manifestation was dependent edema, along with signs of heart failure. Other common manifestations were dermatological and gastrointestinal. The severity and outcome were directly related to the delay in seeking medical consultation and diagnosis.

Empirical retinal venous pulse wave velocity using modified photoplethysmography

ObjectiveUsing the novel imaging method of high-speed modified photoplethysmography we measured the retinal venous pulse wave velocity in a single case.ResultsA healthy 30-year-old subject underwent high-speed modified photoplethysmography (120 frames per second) with simultaneous ophthalmodynamometry at 26 Meditron units. A video of the optic nerve was analyzed using custom software. A harmonic regression model was fitted to each pixel in the time series and used to quantify the retinal vascular pulse wave parameters. Retinal venous pulsation at the optic disc was observed as a complex dynamic wall motion, whereas contraction commenced at a point in the vein at the center of the optic disc, and progressed centrifugally. The empirically estimated retinal venous pulse wave velocity at this segment was approximately 22.24694 mm/s. This measurement provides an estimate for future studies in the field.

24-year-old obese woman with dilated cardiomyopathy: a case report of obese cardiomyopathy

Background: Dilated cardiomyopathy is a disease characterized by enlargement of the heart ventricles with impaired left ventricular or biventricular systolic function. Obesity is a risk factor for changes in the structure and function of the heart, known as obese cardiomyopathy. The purpose of writing this case report is to holistically discuss obesity as a risk factor for dilated cardiomyopathy based on a literature review. Case presentation: A 24-year-old woman complained of shortness of breath 2 months ago, appeared during activities and while she slept at night, and improved when sitting and resting. Other complaints are palpitations, swollen feet, nausea, and vomiting. Childhood history of obesity. Blood pressure 160/95 mmHg, respiratory rate 22 times/minute, and body mass index 33.8 kg/m2 (obesity II). The jugular venous pressure is increased. Auscultation revealed a systolic murmur at ICS 4 grade 3/6 and pulmonary crackles, with pitting edema in the legs. Electrocardiography revealed sinus tachycardia. Laboratory tests showed high triglycerides and total cholesterol, and other laboratories were within normal limits. Echocardiographic examination showed decreased left ventricular systolic function, severe left ventricular dilatation, and an ejection fraction of 27.9%. No significant lesions were found during the angiographic examination. A magnetic resonance imaging examination revealed non-ischemic cardiomyopathy, moderate left ventricular dysfunction, and severe right ventricular dysfunction. Patients were given heart failure therapy according to guidelines. On routine control, the patient's condition was stable. Conclusion: Obesity is believed to be a risk factor for dilated cardiomyopathy through an increased hemodynamic load, neurohormonal dysregulation, inflammation, and lipotoxicity. Modalities such as the electrocardiogram, echocardiography, and magnetic resonance imaging can support the results of examinations for diagnosing dilated cardiomyopathy due to obesity. The management of obese cardiomyopathy involves changing lifestyles and administering drugs according to the clinical manifestations of heart failure.

Headache, vision changes and cranial nerve palsy after head trauma.

A 43-year-old female was brought to the hospital after a ground level fall and her Glasgow Coma Scale was 15. Non-contrast head computed tomography (CT) scan showed small bilateral subdural hematomas, left traumatic subarachnoid hemorrhage, left occipital bone and left longitudinal temporal bone fractures. She was managed conservatively. Interval repeat non-contrast head CT scans showed resolution of the hemorrhage. Two and a half months later she presented to the hospital with headaches, intermittent diplopia, blurry vision and a right lateral gaze palsy. Non-contrast head CT scan showed mild hyperattenuation in the cavernous sinus. Subsequently, a CT angiogram of the head was obtained that showed opacification of the bilateral cavernous sinus and distention of the orbital veins (Figure 1A,B). Evaluation with diagnostic cerebral angiogram showed direct bilateral carotid-cavernous fistulas (CCFs) (Figures 2 and 3). She underwent staged embolization of the CCFs. Direct CCF is the abnormal connection between the internal carotid artery and the cavernous sinus.1, 2 CCFs can present with the classic triad of chemosis, pulsatile proptosis and ocular bruit.3, 4 Other symptoms include orbital pain, abducens nerve palsy, deterioration of visual acuity and ophthalmoplegia.4, 5 Causes of CCF formation are traumatic, iatrogenic, connective tissue disorders and spontaneous.2, 6-9 Traumatic CCFs formation occurs in up to 1.25% of patients with traumatic brain injury or facial and skull base fractures.10, 11 Bilateral CCF formation is rare after trauma and symptoms develop in a delayed fashion.10-15 Treatment options include conservative management, open surgery, endovascular procedures and radiosurgery.16-18

An elderly female with a history of hiatal hernia and respiratory distress.

An 81-year-old female with a past medical history of hiatal hernia presented to the emergency department with respiratory distress. The patient was afebrile, tachycardic, hypoxic, and tachypneic with cyanosis, retractions, and significant jugular venous distention. Point-of-care ultrasound revealed no pericardial effusion and bilateral lung sliding, though the inferior vena cava was not visualized. Chest x-ray revealed a massive hiatal hernia (Figure 1A). Nasogastric tube placement was attempted unsuccessfully by multiple clinicians. Subsequent computed tomography (Figures 2 and 3) demonstrated the mass effect of the stomach on the heart. Fluid resuscitation and broad-spectrum antibiotics were administered; however, the patient continued to decompensate. A nasogastric tube was successfully placed by the most experienced nurse in the department, with 2 L of gastric contents rapidly evacuated (Figure 1B) and immediate improvement in the patient's hemodynamic and respiratory status. The patient underwent surgical consultation but ultimately decided against surgery and was admitted for non-operative management. Here, we present a case of tension gastrothorax, an emergent, life-threatening condition leading to acute, severe respiratory distress and obstructive shock secondary to mass effect from the stomach herniating into the chest. The incidence is more common in children with congenital diagphragmatic hernia and patients with acute trauma.1, 2 Immediate decompression of the gastric lumen can lead to physiologic improvement in symptoms as a temporizing measure.3 Surgical consultation for reduction of gastric contents into the abdomen should be obtained for definitive care.3

UNUSUAL PRESENTATION OF LUPUS NEPHRITIS IN A 22 YEAR OLD MALE : A CASE REPORT

Systemic lupus erythematosus (SLE) is an autoimmune disease in which organ and cell undergo damage initially mediated by tissue binding autoantibodies &amp; immune complexes.In most patients, autoantibodies are present for a few years before the rst clinical symptoms appears. It is ve to six times more prevalent in women than in men .Nephritis is usually the most serious manifestation of SLE, particularly because nephritis and infection are the leading cause of mortality in the rst decade of disease. We present a case of a 22 yr old male who came with complaint of bilateral pedal oedema and pufness of face since 1 month . On examination, patient was stable hemodynamically with pulse of 88 per minute, blood pressure of 110/80 millimeter of mercury with room air saturation of 99 percent and jugular venous pressure of 6-7 millimeters of water. He also had pallor in lower palpebral conjunctiva and bilateral pitting pedal oedema.There was no clubbing, icterus,cyanosis or lymphadenopathy. His routine blood investigations showed anaemia , leucocytosis , elevated creatinine, hyperkalaemia , hypoalbuminemia, iron deciency ,urine routine microscopy suggestive of RBC cast 60-70/high power eld . Complement C3 and C4 were low, ANA positive grade 3(1:1000) homogeneous and cytoplasmic speckled, ANA BLOT positive for dsDNA, nucleosome, Histones, Sm/RNP,Mi2b.His ultrasound (USG) revealed bilateral bulky kidney and heterogeneous with raised cortical echogenicity and normal size. His renal biopsy was done which showed diffuse lupus nephritis(ISN/RPS2018 modication)class IV and indices(modied NIH) of activity 15/24 and chronicity 2/12, necrotizing vascular lesions along with evidence of vascular immune deposits in diffuse immunoorescence studies and associated inammatory cells are noted. Patient received intravenous pulse therapy of methyl prednisolone 1gram for 5 days with monitoring of kidney function test. Patient was put on cyclophosphamide with hemodialysis for immunosuppression because patient was not responding to steroids, as seen by rising serum creatinine and urea levels and declining urine output. The patient improved dramatically, urine output increased and serum creatinine and urea decreased, therefore haemodialysis was discontinued, and the patient was managed conservatively and discharged on oral prednisolone with a monthly cyclophospmide injection.

Impact of mitral regurgitation in patients with acute heart failure: insights from the RELAX-AHF-2 trial.

The impact of mitral regurgitation (MR) in patients hospitalized for acute heart failure (AHF) is not well established. We assessed the role of MR in patients enrolled in the Relaxin in Acute Heart Failure 2 (RELAX-AHF-2) trial. Patients enrolled in RELAX-AHF-2 with available data regarding MR status were included in this analysis. Baseline characteristics, in-hospital data, and clinical outcomes through 180-day follow-up were evaluated. The impact of moderate/severe MR was assessed. Among 6420 AHF patients with known MR status, 1810 patients (28.2%) had moderate/severe MR. Compared to patients with no/mild MR, those with moderate/severe MR were more likely to have history of heart failure (HF), prior HF hospitalization, more comorbidities, symptoms/signs of HF, lower left ventricular ejection fraction and higher N-terminal pro-B-type natriuretic peptide levels. Moderate/severe MR was associated with longer length of hospital stay, higher rates of residual dyspnoea, increased jugular venous pressure through the index hospitalization and a higher unadjusted risk of the composite of cardiovascular (CV) death or rehospitalization for HF/renal failure (RF) through 180 days (crude hazard ratio [HR] 1.15, 95% confidence interval [CI] 1.03-1.27, p=0.01). The association between moderate/severe MR and poorer outcomes was not maintained in a multivariable model including several covariates of interest (adjusted HR 1.03, 95% CI 0.91-1.17, p=0.65). Similar findings were observed for HF/RF rehospitalization alone. In patients with AHF, moderate/severe MR was associated with a worse clinical profile but did not have an independent prognostic impact on clinical outcomes.

Point-of-care ultrasound in diagnosis and management of congestive nephropathy.

Congestive nephropathy is kidney dysfunction caused by the impact of elevated venous pressures on renal hemodynamics. As a part of cardiorenal syndrome, the diagnosis is usually made based on history and physical examination, with findings such as jugular venous distension, a third heart sound, and vital signs as supporting findings. More recently, however, these once though objective measures have come under scrutiny for their accuracy. At the same time, bedside ultrasound has increased in popularity and is routinely being used by clinicians to take some of the guess work out of making the diagnosis of volume overload and venous congestion. In this mini-review, we will discuss some of the traditional methods used to measure venous congestion, describe the role of point-of-care ultrasound and how it can ameliorate a clinician's evaluation, and offer a description of venous excess ultrasound score, a relatively novel scoring technique used to objectively quantify congestion. While there is a paucity of published large scale clinical trials evaluating the potential benefit of ultrasonography in venous congestion compared to gold standard invasive measurements, more study is underway to solidify the role of this objective measure in daily clinical practice.