Jugular Venous Pressure Research Articles

Abstract 4136566: Primary Pericardial Mesothelioma: Diagnostic dilemma and rapid decline

Description of case: A 33-year-old man with no medical history or environment exposures, presented with dyspnea, nausea, and vomiting. He was tachycardic, with jugular venous distension, pulsus paradoxus, low voltage QRS and echocardiogram (TTE) showed a large pericardial effusion with ventricular interdependence. He underwent pericardiocentesis with negative fluid studies, including cytology. Two months later he represented with dyspnea and pleuritic chest pain, was diagnosed with pericarditis, and found to have recurrent pericardial effusion without tamponade. He was treated with aspirin and colchicine and discharged, with surveillance TTE showing a stable pericardial effusion but with significant adhesions and constrictive physiology (confirmed on right heart catheterization). Negative QuantiFERON was obtained and Anakinra started. Two months later he remained symptomatic with new pleural effusions and was sent for positron emission tomography scan which revealed diffuse intensely hypermetabolic pericardial thickening/fluid, up to 3.8 cm in maximal thickness and increased uptake in mediastinal nodes. Next, a cardiac MRI showed extensive circumferential thickening of the pericardial space approximately 2.5 cm in thickness. Both the visceral and parietal pericardium exhibited extensive scattered delayed hyperenhancement. Subsequent pericardial biopsy showed markedly fibrotic pericardium and pathology showed biphasic malignant pericardial mesothelioma. Immunosuppressive medications were stopped, and he underwent thoracentesis. After multidisciplinary discussions, he was started on nivolumab every two weeks and ipilimumab with a plan for surgery based on response to therapy. However, progressive symptoms and worsening constriction physiology led to palliative consultation and comfort care transition, with him dying shortly after. Discussion: Recurrent pericarditis and pericardial effusion, along with negative typical pericardial fluid studies, raised suspicion for a non-benign etiology. Multimodality imaging was employed and led to a pericardial biopsy. Constrictive pericarditis is an uncommon presentation of primary pericardial mesothelioma. Biphasic mesotheliomas from pleural or peritoneal origins are normally treated with systemic therapy with preference for combined immunotherapy. Primary pericardial mesothelioma is associated with a late presentation and high mortality rate, with surgery, if able to be done early appearing to be the recommended approach.

Abstract 4138449: High Output Heart Failure from an Aortocaval Fistula

Introduction: High output heart failure (HOHF) due to a post-traumatic aortocaval fistula is a rare entity. This case seeks to explore the presentation as well as complexities of management of these patients. Case Presentation: A 50-year-old male with a prior right abdominal stab wound requiring exploratory laparotomy 20 years ago presented with worsening dyspnea on exertion and palpitations. Physical examination was remarkable for jugular venous distention, lower extremity edema, and a pulsatile mass in the right abdomen with an audible bruit. A 12-lead ECG showed rapid atrial flutter. A transthoracic echocardiogram (TTE) showed a reduced left ventricular ejection fraction (LVEF) of 30-35%, severely dilated atria and inferior vena cava (IVC) with high velocity flow. Abdominal computed tomography venogram showed dilation of the IVC up to 8cm and an aortocaval fistula at the level of the right renal vessels, resulting in an atrophic right kidney. Cardiac catheterization was notable for a cardiac output (CO) of 12L/min, cardiac index (CI) of 7L/min/m2 and reduced systemic vascular resistance (SVR). He was managed with beta blockers and diuretics, followed by TEE-guided cardioversion for atrial flutter to restore sinus rhythm. Vascular surgery performed a successful, first of its kind endovascular repair of the abdominal aorta with stenting of the right common iliac artery and placement of a 20mm Amplatzer Septal Occluder device in the right renal artery. He tolerated the procedure well, and post-operative TTE showed a recovered LVEF of 55-60% and CO of 6L/min. Discussion: HOHF is defined by a CO more than 8L/min or CI more than 4L/min/m2 along with clinical symptoms. Decreased SVR leads to sympathetic activation and stimulation of the renin-angiotensin-aldosterone system, leading to fluid retention, cardiac remodeling, and exacerbation of symptoms. Challenges present in the management of HOHF and the use of vasodilatory agents should be avoided, as they can exacerbate the problem. In our case, limitations were also faced in the use of many traditional HF therapies due to renal dysfunction as a result of the fistula. Therefore, repair was the only viable long-term solution. Conclusion: This case displays an uncommon etiology of HOHF, emphasizing the need for meticulous evaluation to ensure proper management. Early detection of aortocaval fistulas is crucial to prevent worsening cardiac dysfunction, with symptoms resolving rapidly post-repair.

Abstract 4124313: An unusual case of pericardial mass

A 30-year-old male electrician presented with two days of fever and positional left shoulder pain and was found to have elevated inflammatory markers and a large pericardial effusion with echocardiographic evidence of tamponade for which he underwent pericardiocentesis. He was discharged on a course of anti-inflammatory therapy with presumed diagnosis of idiopathic pericarditis based on negative cytology. He returned 6 months later with several weeks of upper respiratory infection symptoms as well as new abdominal discomfort and emesis. On presentation, his vital signs were notable for tachycardia to 113 and cardiac exam was notable for tachycardia, regular rhythm, no rubs or murmurs, nondisplaced precordial impulse, normal jugular venous pressure with Kussmaul sign, and pulsus paradoxus of 6. An electrocardiogram showed sinus tachycardia with diffuse ST segment changes (Figure A). His cardiac biomarkers were unremarkable (troponin 21). His labs revealed normocytic anemia with hemoglobin of 11 and erythrocyte sediment rate above assay. Echocardiogram demonstrated a circumferential complex pericardial effusion with echocardiographic evidence of early tamponade (Figure B, C). A pericardiocentesis was attempted with inability to advance wire within pericardial space. A malignancy workup was initiated. CT demonstrated multi-station thoracic and lower cervical lymphadenopathy, moderate left pleural effusion, and an intrapericardial mass with associated pericardial effusion (Figure D). Cardiac magnetic resonance imaging demonstrated a circumferential intrapericardial non-mobile mass measuring up to 22 mm in thickness posteriorly and the mass was isointense to myocardium indicating low-fat content (Figure E). A supraclavicular lymph node biopsy was obtained with immunohistochemical staining positive for WT1 and calretinin, consistent with metastatic epithelioid mesothelioma of pericardial versus pleural etiology (Figure F). A PET-CT subsequently showed a FDG-avid circumferential anterior pericardial mass and multiple pleural-based lesions concerning for metastatic mesothelioma. He was initiated on pemetrexed/carboplatin systemic chemotherapy. With systemic therapy, his disease has been stable for 6 months. Pericardial mesothelioma is a rare malignancy. This case underscores the diagnostic challenges associated with pericardial mesothelioma and the importance of cancer workup as part of the pericardial effusion workup.

Abstract 4112944: A diagnostic challenge overcome with persistent clinical suspicion in a case of cardiac AL amyloidosis

Case: A 62-year old male with a history of chronic kidney disease and paroxysmal atrial fibrillation presented with several months of fatigue, a progressive decline in functional status (NYHA IIIb-IV), weight loss, and intermittent lower extremity swelling. Blood pressure was 92/72 mmHg on presentation, and heart rate was 90 bpm. Physical examination revealed a jugular venous pressure of 12-14 cm H2O and 2+ bilateral lower extremity edema with mild wheezing. Methods/workup: Laboratories are shown in Table 1 and were notable for a serum free light chain ratio of 0.14. Transthoracic echocardiogram (figure 1) revealed a left ventricular (LV) ejection fraction of 33% with increased LV wall thickness and severe bi-atrial enlargement. Bone marrow biopsy revealed 2% lambda restricted plasma cells without evidence of amyloid deposits; metastatic bone survey was negative. A fat pad biopsy and endomyocardial biopsy stained negative for amyloid with Congo red. Cardiac MRI showed diffuse, circumferential subendocardial late gadolinium enhancement, most compatible with cardiac amyloidosis (figure 2). The patient also had a chest CT scan that demonstrated a few patchy nodular pulmonary infiltrates. Given his extensive negative workup, he was referred to pulmonary and endobronchial biopsy was positive for amyloid on Congo red staining (figure 3). Biopsy tissue typing revealed Lambda subtype AL amyloidosis. Management: The patient was started on Daratumumab, Cyclophosphamide, Bortezomib, and Dexamethasone by Hematology. Unfortunately, about a month after his diagnosis, he developed worsening heart failure despite treatment. He was admitted to an outside hospital with refractory cardiogenic shock and passed away during that admission. Discussion: The diagnosis of AL amyloidosis requires a high index of suspicion for prompt diagnosis and treatment. We present a case in which cardiac amyloidosis was suspected based on the patient’s clinical picture and cardiac imaging; however, multiple initial biopsies were negative. An expedited, multimodal and interdisciplinary diagnostic assessment is imperative as prognosis with chemotherapy is highly dependent on extent of AL disease, patient functional status, and presence of cardiac compromise. Elevated natriuretic peptides, troponins, autonomic dysfunction, and hypotension are negative prognostic features.

Multiparametric assessment of decongestion in patients admitted with acute heart failure: dynamic changes and correlation with natriuresis

Abstract Background Heart Failure (HF) is a major public health problem, expected to increase in the next few decades. The vast majority of acute HF (AHF) episodes are precipitated by congestion with volume overload and/or fluid redistribution. Current Guidelines stress on the importance of relieving congestion before discharge, recommending anyway only daily assessment of signs and symptoms. Lung ultrasound (LUS) B-lines and other ultrasound markers of congestion has emerged as valuable tools to improve diagnostic accuracy and help clinicians in fluid management. Purpose To assess the dynamic changes of B-lines and other markers of congestion and their relationship with the clinical evaluation, chest X-ray (CXR) and natriuretic peptides in patients admitted for AHF. Methods Fifty-eight patients (age 72±11 ys, 35% women) admitted with acute HF were enrolled. Patients underwent clinical evaluation (Clinical Congestion Score, CCS, including rales, pathological S3 heart sound, pedal oedema, jugular vein distension; range 0-4), and CXR (CXR score, including enlargement and loss of definition of hilar structures, peribronchial and perivascular cuffing, cardiomegaly, pleural effusion; range 0-4). An integrated multiorgan ultrasound exam including LUS B-lines, echocardiography, and venous excess ultrasound (VExUS) score was performed at admission (T0), between 24 and 48 hours from T0 (T1), and at discharge (T2). Follow-up data at 30 days were collected. Results Mean CCS was 1.52±0.99 at T0, with a reduction at T1 (0.86±0.66; p<0.01), and at T2 (0.34±0.66; p<0.01). Sixteen percent of patients with a CCS=0 at T0 showed, however, persistent B-lines on LUS (mean B-lines 19±6). The mean number of B-lines was 26±12 at T0 with a reduction at T1 (17±11; p<0.001), and at T2 (13±11; p<0.001). Other echocardiographic non-invasive hemodynamic parameters, such as pulmonary artery systolic pressure (PASP) and E/e’ showed a reduction only at T2, but not at T1 (figure). The number of B-lines correlated at all time points with CCS, CXR score, VExUS score, and NT-proBNP values (all p<0.05). We divided patients into two groups: "responders" (with ≥15 reduction of B-lines between T0 and T2) and "non-responders" (with <15 reduction of B-lines between T0 and T2). Responders had higher chlorine and sodium urinary excretion at T1 compared to non-responders. The number of B-lines at all time points was associated to 30-days cardiovascular mortality at univariable analysis. Neither CCS nor CXR score were associated with 30-day events. Conclusions In patients with acute HF, B-lines quantification is related to standard congestion assessment based on clinical evaluation, CXR and NT-proBNP, showing, however, a more dynamic behaviour in the assessment of decongestion. B-lines variations are also related to diuresis and chlorine urinary output, a recognized predictor of diuretic response. Persistent congestion is related to an increased risk of hospitalization and death.

Prognostic Significance of Right Ventricular Free Wall Longitudinal Strain and Angiographic Correlation in Acute Inferior Wall ST-elevation MI

Background: In this study, we assessed the prognostic significance of right ventricular free wall longitudinal strain (RVfwLS) in patients with acute inferior wall MI and investigated its association with angiographic characteristics and adverse outcomes. Methods: A prospective observational study was conducted with 200 patients admitted with acute inferior wall MI who underwent primary angioplasty. 2D speckle tracking echocardiography was used to measure the RVfwLS at the time of admission. Angiographic characteristics were collected, and patients were followed up for adverse outcomes until discharge. Categorical data were compared using the χ2 test or Fisher’s exact test. Logistic regression analysis was used to identify adverse cardiovascular outcomes independently associated with RVfwLS. A p-value of <0.05 was considered statistically significant for all analyses. Results: Compared with patients with normal strain (n=88, 44%), patients with diminished strain (n=116, 56%) had significantly lower blood pressure (56.52% versus 43.58%; p=0.03), reduced tissue velocities (93.3% versus 6.7%; p<0.01), elevated jugular venous pressure (58.93% versus 41.07%; p=0.04), and higher right ventricular systolic pressure (52.04% versus 47.96%; p=0.04). Additionally, patients with diminished strain had a higher incidence of triple vessel disease (80% versus 20%; p=0.026) and arrhythmias necessitating inotropic support (66.67% versus 37.33%; p=0.02), as well as a longer hospital stay (78.7% versus 21.3%; p<0.01) compared with patients with normal strain. In multivariate analysis, arrhythmias (p=0.046; OR 2.05; 95% CI [0.93–8.10]) and right heart failure (p=0.035; OR 3.64; 95% CI [1.35–11.53]) were independently associated with RVfwLS. The optimal RVfwLS cut-off value for predicting adverse outcomes was −14.8% (AUC=0.915; 95% CI [0.876–0.954]; p<0.001), with a sensitivity of 81.3% and specificity of 86.8%. Conclusion: RVfwLS can be used to categorise the severity of infarction and predict adverse outcomes.

Pulmonary Embolism Management Audit and Machine Learning Analysis of Delayed Anticoagulation in a Swiss Teaching Hospital.

Background/Objectives: Diagnosing acute pulmonary embolism (PE) is challenging due to its wide range of symptoms and numerous differential diagnoses. Medical professionals must balance performing all essential examinations and avoiding unnecessary testing. This study aimed to retrospectively audit the diagnosis and treatment of acute PE at a Swiss public teaching hospital to determine the adherence to current guidelines and to identify the factors associated with the delayed initiation of anticoagulation in PE patients. Methods: In this retrospective observational cohort study, we included all adult patients hospitalized with PE at the Cantonal Hospital Baselland (KSBL) between November 2018 and October 2020, where the diagnosis was made within the first twelve hours of their arrival to the emergency department (ED). LASSO regression was employed to identify clinical characteristics associated with delayed anticoagulation initiation. Results: A total of 197 patients were included (mean age: 70 years, 54% female). The audit revealed that diagnostic workup was conducted according to guidelines in 57% of cases. Often, D-dimer levels were measured although not strictly necessary (70%). Pretest probability was assessed and documented using the Wells or Geneva score in only 3% of patients, and risk assessment via the Pulmonary Embolism Severity Index (PESI) score was documented in 21% of patients. The median time from ED arrival to CT scan was 120 min (IQR 89.5-210.5), and the median time to anticoagulation initiation was 193 min (IQR 145-277). Factors identified by LASSO associated with delayed anticoagulation included prolonged time from ED arrival to CT scan, the presence of distended jugular veins on examination, ED arrival in the morning, and presenting symptoms of weakness or tiredness. Complementary leg ultrasound was performed in 57% of patients, with 38% of these cases lacking prior clinical examination for deep vein thrombosis. The duration of the anticoagulation treatment was not specified in the discharge report for 17% of patients. A medical follow-up after discharge was recommended in 75% of the patients. Conclusions: In conclusion, while the management of PE at the KSBL generally adheres to high standards, there are areas for improvement, particularly in the morning performance, the use of a pretest probability assessment, D-dimer measurement, risk assessment via the PESI score, the performance of complementary leg ultrasounds, clarification of the anticoagulation duration, and follow-up management.

In vivo volumetric analysis of retinal vascular hemodynamics in mice with spatio-temporal optical coherence tomography.

Microcirculation and neurovascular coupling are important parameters to study in neurological and neuro-ophthalmic conditions. As the retina shares many similarities with the cerebral cortex and is optically accessible, a special focus is directed to assessing the chorioretinal structure, microvasculature, and hemodynamics of mice, a vital animal model for vision and neuroscience research. We aim to introduce an optical imaging tool enabling in vivo volumetric mouse retinal monitoring of vascular hemodynamics with high temporal resolution. We translated the spatio-temporal optical coherence tomography (STOC-T) technique into the field of small animal imaging by designing a new optical system that could compensate for the mouse eye refractive error. We also developed post-processing algorithms, notably for the assessment of (i) localized hemodynamics from the analysis of pulse wave-induced Doppler artifact modulation and (ii) retinal tissue displacement from phase-sensitive measurements. We acquired high-quality, in vivo volumetric mouse retina images at a rate of 113Hz over a lateral field of view of . We presented high-resolution en face images of the retinal and choroidal structure and microvasculature from various layers, after digital aberration correction. We were able to measure the pulse wave velocity in capillaries of the outer plexiform layer with a mean speed of 0.35mm/s and identified venous and arterial pulsation frequency and phase delay. We quantified the modulation amplitudes of tissue displacement near major vessels (with peaks of 150nm), potentially carrying information about the biomechanical properties of the retinal layers involved. Last, we identified the delays between retinal displacements due to the passing of venous and arterial pulse waves. The developed STOC-T system provides insights into the hemodynamics of the mouse retina and choroid that could be beneficial in the study of neurovascular coupling and vasculature and flow speed anomalies in neurological and neuro-ophthalmic conditions.

Differential Prognostic Impact of Clinical Congestion between Preserved versus Reduced Ejection Fraction in Patients Hospitalized for Acute Decompensated Heart Failure: Findings from the Japanese Kyoto Congestive Heart Failure Registry

Most patients hospitalized for heart failure (HF) present with signs of congestion. Prognostic significance of clinical congestion may vary depending on left ventricular ejection fraction (LVEF). This study aims to investigate the prognostic impact of congestion across different LVEF categories. Composite congestion scores (CCSs; 0-9) derived from the severity of edema, jugular venous pressure, and orthopnea, were analyzed on admission and at discharge in 3787 patients hospitalized for HF (LVEF ≥ 40%: n = 2347, LVEF < 40%: n = 1440). The median admission CCS was 4 in both LVEF strata (P = .64). Adjusted hazard ratios (HRs; 95% confidence interval [CI]) of the moderate (CCS 4-6) and severe congestion [7-9] groups relative to the mild congestion [0-3] group on admission for a composite of all-cause death or HF rehospitalization were 1.20 (1.04-1.39, P = .01) and 1.54 (1.27-1.86, P < .001) in the LVEF ≥ 40% stratum, and 1.20 (1.01-1.44, P = .04) and 0.82 (0.61-1.07, P = .14) in the LVEF < 40% stratum, respectively (Pinteraction< .001). A total of 16% of the patients with LVEF ≥40% and 14% with LVEF <40% had residual congestion (CCS ≥ 1) at discharge, which was associated with a respective adjusted HR of 1.40 (1.18-1.65, P < .001) and 1.25 (0.98-1.58, P = .07) for postdischarge death or HF rehospitalization (Pinteraction = 0.63). The severity of clinical congestion on admission was associated with adverse clinical outcomes in patients with LVEF ≥ 40%, but not in those with LVEF < 40%. These findings warrant further studies to better understand the detailed profile of congestion across the LVEF spectrum.

A histology and immunochemistry study comparing open versus close and open-method endoscopic saphenous vein harvesting.

The introduction of endoscopic saphenous vein harvesting (ESVH) has been reported to reduce wound pain and infection, compared with open saphenous vein harvesting (OSVH) techniques. There are still controversies regarding this technique. The aim of our study is to investigate the endothelial preservation of saphenous vein (SV) grafts harvested by different techniques. Further observations were made for harvesting and closure time, incision length and effect of pressure distension of the veins to the vein endothelium. Prospective observational study of sixty human saphenous vein grafts was performed to evaluate endothelial preservation by haematoxylin-eosin and Cluster of Differentiation 31 (CD 31) staining. Saphenous vein was harvested endoscopically either by closed CO2 (carbon dioxide) ESVH, open CO2 ESVH or OSVH harvesting technique. Demographic data and intra-operative data were collected. Two saphenous vein samples were collected from each patient to compare differences before and after distension of the veins. Both haematoxylin-eosin and immunohistochemistry slides were imaged by a high-resolution slide scanning system. Open CO2 ESVH group showed the highest number of endothelial detachments. Mean scoring of the immunohistochemistry method using the CD31 antibody was much lower in the open CO2 ESVH group (33.25% ± 28.71, P < 0.0003). This represents a more poorly preserved endothelial cells in the Open CO2 ESVH than the closed CO2 ESVH. Closure time and incision lengths were significantly shorter in both ESVH groups compared to the OSVH group. Significant low scores of immunohistochemistry for samples were seen in distended veins (39.0% ± 30.08, p = 0.004). The OSVH in random sample B, which represents the conduit that will be used, had a far better endothelium preservation and less endothelial detachment when compared to ESVH. We observed more endothelial detachment in the open CO2 ESVH group, due to lack of subcutaneous tissue separation, poor visualization and traction stress across the wall of the saphenous vein. The closed CO2 ESVH group had more endothelial cells preserved, but the OSVH group fared the best with the least number of endothelial cell detachment and a higher score of CD31 antibody. The online version contains supplementary material available at 10.1007/s12055-024-01752-3.

Facial Venous Tumour Thrombus from Submandibular Gland Mucoepidermoid Carcinoma: An Atypical Tumour Spread in Head and Neck Cancer.

Tumour thrombus of the facial vein is an exceedingly rare complication arising from mucoepidermoid carcinoma of the salivary glands. Early detection is pivotal for appropriate management, as delays can lead to metastatic disease, worsening the prognosis. We present a case involving a 76-year-old male with a history of mucoepidermoid carcinoma of the right submandibular gland, previously treated with surgical resection and radiotherapy. The patient, a long-term worker in a rubber factory, presented with a painless, firm swelling in the right cheek, persisting for three months. Contrast-enhanced computed tomography (CECT) showed distended facial vein with enhancing thrombus confirmed by sonographic correlation demonstrating intralesional vascularity. Cannon ball pulmonary nodules were also noted. Radiological findings led to a core biopsy, confirming tumor thrombosis of the facial vein due to mucoepidermoid carcinoma. However, the patient declined a biopsy of the pulmonary nodules, and has been referred to oncology for further management. This case highlights the critical importance of considering venous tumour thrombus in patients with previous salivary gland malignancies presenting with new or persistent facial swellings. It emphasises the role of advanced imaging techniques in the early identification of this rare entity. Additionally, it stresses the need for healthcare providers to engage in thorough discussions with patients about the potential consequences of forgoing recommended treatments, reinforcing the need for vigilance in monitoring such patients. Tumours of head and neck may cause thrombosis of veins by direct invasion resulting in a tumour thrombus, or indirectly by exerting a mass effect and vein compression.These can be distinguished by contrast-enhanced computed tomography (CECT) or magnetic resonance imaging (MRI).Doppler ultrasound may show patchy neovascularisation in a tumour thrombus, which would be absent if thrombosis was caused by compression.

Can venous pulse transit time at supracardiac level predict clinical deterioration in early-onset preeclampsia? Report of two cases

Can venous pulse transit time at supracardiac level predict clinical deterioration in early-onset preeclampsia? Report of two cases

Extraction of the Jugular Venous Pulse and carotid profile using a cervical contact plethysmography system

The Jugular Venous Pulse (JVP) is considered a reliable parameter for the assessment of Central Venous Pressure (CVP). Here, the functionality of a cervical contact plethysmography system designed for non-invasive and operator-independent acquisition of the JVP signal, is shown. To validate the signal, it was recorded in supine and sitting positions, together with the reference Electrocardiography (ECG), on 26 healthy subjects. In the supine acquired signal, the characteristic JVP waves (a, c, v) and the negative deflections (x, y) are well recognizable. In the sitting recorded signal, the systolic peak b and the d incisura of the Common Carotid Artery (CCA) waveform are recognized. For each signal, we calculated the Fraction of the Cardiac Cycle (ccf) represented by the time intervals between the JVP peaks and the ECG peaks, in the form: ΔtaP, ΔtcR, ΔtxP, ΔtvT, Δtyv, Δtvx, and Δtxa. The same was done for the CCA waveform, in the form: ΔtbS, ΔtbT, Δtdb, ΔtdS, and ΔtdT. This system could mitigate risks and costs associated with central venous catheterization and its potential extends to applications in telemedicine, sports medicine, and space medicine.

Cardiac biomarkers as tools in the prediction and diagnosis of traumatic pericarditis and traumatic reticuloperitonitis in cattle and buffaloes

BackgroundIn the livestock industry, Foreign Body Syndrome is a devastating disease condition. Feeding management, lacking of food discrimination, and eating chopped food increase the risk of swallowing sharp foreign bodies in bovine species. In addition to the honeycomb cells shape of the reticulum, the contractions of the reticular wall, gravid uterine pressure, and parturition efforts, foreign bodies can penetrate the reticular wall, causing cascade of problems including traumatic reticulitis, traumatic reticuloperitonitis, and traumatic pericarditis. The present study was carried out to evaluate the diagnostic significance of cardiac troponin I rapid test cassette and other cardiac biomarkers including serum cardiac troponin I (cTn I), creatine kinase-myocardial band (CK-MB), lactate dehydrogenase (LDH), and aspartate aminotransferase enzyme (AST), in confirmed cases of traumatic pericarditis (TP) and/or traumatic reticuleoperitonitis (TRP) in cattle and buffaloes.MethodsA total number of 30 animals (22 cattle and 8 buffaloes) with different signs such as anorexia, jugular distension, brisket edema, and signs of pain (reluctance to move, arching back, and abduction of the forelimbs) were included in the present study. Based on case history, clinical signs, ferroscopic, pericardiocentesis, radiographic and ultrasonographic examinations, TP were confirmed in cattle (n = 10) and buffaloes (n = 8) while TRP were confirmed only in cattle (n = 12). Additionally, 20 clinically healthy animals (n = 10 cattle and 10 buffaloes) were used as a control group. Blood samples were collected for determination of blood level of Tn-I, and activity of CK-MB, LDH, and AST.ResultsThe obtained results revealed a highly significant increase in serum cTn I in diseased cattle with TP and TRP (P = 0.00), while buffaloes with TP showed no significant changes in serum cTn I (P = 0.111). Both diseased cattle and buffaloes showed increased serum activities of CK-MB, AST, and LDH enzyme. On the other hand, cardiac troponin I rapid test cassette failed to detect cTn I in diseased animals.ConclusionThe study concluded that the cardiac troponin I rapid test cassette did not have a diagnostic significance and could not be used as a point-of-care under field condition for diagnosis of TP and TRP in large ruminants. However, the serum troponin I level is helpful in diagnosis of TP and TRP in cattle. Although cardiac biomarkers have some diagnostic values in TP and TRP, the traditional diagnostic methods (clinical, radiography and ultrasonography examinations) are crucial for thorough evaluation of TP/TRP cases in bovine.

Diagnostic utility of echocardiography and ultrasonography in buffaloes suffering from pericarditis

Pericarditis remains a serious problem faced by bovine producers in the developing countries. This study was designed to evaluate the echocardiographic and ultrasonographic changes in dairy buffaloes affected with pericarditis presented to Large Animal Clinic, Teaching Veterinary Hospital of Guru Angad Dev Veterinary and Animal Sciences University (GADVASU), Ludhiana, India. 49 buffaloes were included and selected on the basis one or more of the clinical signs viz., brisket edema, dyspnoea, muffled heart sounds and distended jugular veins. Animals were subjected to clinical examination, thoracic and abdominal ultrasonography and M- mode echocardiography. The CVS examination revealed normal intensity of heart sounds in 17 and muffled in 32 cases with splashing/pericardial rub in 9 cases. Ultrasonography revealed spleenic congestion, liver was congested in majority of the cases with visible dilatation of the caudal vena cava. Heart was normal in 7 and visibly compressed in 42 cases due to the pericardial fluid. Massive pleural fluid was seen in 28 cases. Buffaloes in our study had pericardial effusions (n=49), pleural and pericardial effusions (n=45) and pleural, pericardial and peritoneal effusions (n=19). The predominant echocardiographic findings were significantly decreased dimensions of the heart chambers in both systole and diastole. The left ventricular contractility indices (FS% and EF%) were significantly high. The clinical findings alone do not allow a definitive diagnosis of pericarditis as characteristic signs were not present in all the cases. The combined use of ultrasonography and echocardiography provides a comprehensive idea about such cases and aids in early diagnosis of pericarditis.

A 70-year-old man with a drooping eyelid and distended chest veins

A 70-year-old man with a drooping eyelid and distended chest veins

Diphteric Myocarditis: A Case Report on Ecg and Cardiac Imaging Findings with the Levels of Cardiac Enzymes in a 17-Year-Old

Background: Diphtheria, caused by Corynebacterium diphtheriae, remains a life-threatening infectious disease in regions with low vaccination uptake. Myocarditis, a severe cardiac complication of diphtheria, is a leading cause of mortality. Despite the success of vaccines in reducing diphtheria cases, sporadic cases continue to occur, leading to significant health complications. Objective: This case report aims to present the clinical course, electrocardiogram (ECG) and cardiac imaging findings, and serial levels of serum troponin in a 17-year-old patient with diphtheritic myocarditis, and to discuss the management and outcomes. Methods: This study was conducted at Lady Reading Hospital, Peshawar, Pakistan. Ethical approval was obtained from the hospital's ethical review board, and informed consent was acquired from the patient and guardians. A comprehensive diagnostic workup was performed, including clinical examination, laboratory tests, ECG, transthoracic echocardiography (TTE), and cardiac magnetic resonance imaging (MRI). The patient’s vital signs, blood pressure, pulse rate, and jugular venous pressure were recorded. Laboratory tests included leukocyte count, erythrocyte sedimentation rate (ESR), and serial serum troponin measurements. ECG findings were documented, and TTE was used to assess left ventricular ejection fraction (LVEF). Cardiac MRI was performed to identify myocardial edema and delayed enhancement. Treatment included intravenous diuretics, ACE inhibitors, SGLT2 inhibitors, benzylpenicillin, and corticosteroids. Data were analyzed using SPSS version 25.0. Results: The patient presented with a blood pressure of 110/70 mmHg and a pulse rate of 88 bpm. Initial laboratory tests showed a normal leukocyte count, ESR of 45 mm/hr, and troponin levels of 25 ng/ml, which decreased to 21.85 ng/ml and then to 8 ng/ml. ECG revealed ST segment depressions in the precordial leads. TTE showed an initial LVEF of 50%, declining to 35% and then to 28% within a week. Post-treatment, LVEF improved to 44% and subsequently to 55% at four weeks. Cardiac MRI indicated myocardial edema in the apical anterior and apical septal walls, with intramyocardial and subepicardial delayed enhancement. Conclusion: Diphtheritic myocarditis can lead to rapid and severe deterioration of cardiac function. Early diagnosis and aggressive treatment, including the use of advanced imaging techniques and comprehensive medical therapy, can result in significant improvement in cardiac function and patient outcomes. Public health initiatives to improve vaccination coverage are essential to prevent such life-threatening complications.

Lutembacher Syndrome in a 35-Year-Old Filipino Woman: A Case Report

INTRODUCTION: Lutembacher syndrome (LS) is an uncommon cardiac abnormality characterized by any association of a congenital or iatrogenic atrial septal defect (ASD) and a congenital or acquired mitral stenosis (MS). The hemodynamic effects of this syndrome are a result of the interplay between the relative effects of the ASD and MS. CASE REPORT: A 35-year-old woman presented to the cardiology clinic with a 1-month history of easy fatigability, exertional dyspnea, and productive cough with whitish phlegm. She has no edema, orthopnea, paroxysmal nocturnal dyspnea, or fever. Two weeks before admission, she developed palpitation and still with persistence of symptoms. She sought consultation and was prescribed with clopidogrel 75 mg one tablet once a day, sildenafil 100 mg one tablet once a day, and verapamil 40 mg one tablet once a day, which provided relief. She has no history of hypertension, diabetes, cerebrovascular disease, coronary artery disease, or thyroid or renal disease. She is a nonsmoker and an occasional alcoholic drinker. On general physical examination, blood pressure was 120/80 mm Hg; cardiac rate, 72 beats per minute; and respiratory rate, 20 cycles per minute. She was afebrile and had distended jugular veins with rales at the left lung base. Abdominal examination revealed neither organomegaly nor shifting dullness. There was neither cyanosis nor pedal edema.

Multifaced risk factors and clinical impact of a deep Y descent in patients with heart failure irrespective of RV-PA coupling

BackgroundA deep Y descent in the jugular venous pulse (JVP) is associated with diseases such as a decrease in right ventricular (RV) preload reserve. The present study investigated the relationship between RV-pulmonary arterial (PA) coupling and a deep Y descent, examined risk factors for a deep Y descent and clarified whether a deep Y descent was an independent risk factor for cardiac events irrespective of RV-PA coupling in patients with heart failure (HF). MethodsWe enrolled 350 patients with HF who underwent echocardiography and JVP examination. A deep Y descent was identified by a deeper ‘Y’ descent than ‘X’ descent in the JVP waveform. We defined cardiac events of HF as follows: sudden death, death from HF, the emergent infusion of loop diuretics, or hospitalization for decompensated HF. Results and ConclusionsA deep Y descent and cardiac events were observed in 129 and 83 patients, respectively. The prevalence of a deep Y descent increased with decreases in the tricuspid annular plane systolic excursion (TAPSE)/systolic pulmonary arterial pressure (SPAP) ratio. Not only the TAPSE/SPAP ratio (odds ratio,0.756 per0.1 mm/mmHg, 95 %confidence interval [CI], 0.660–0.866, p < 0.001), but also age, atrial fibrillation, and the use of beta-blockers were independent factors for a deep Y descent in multivariate logistic model. Multivariate Cox hazard model demonstrated that a deep Y descent was for cardiac events in patients with HF (Hazard ratio,2.682, 95 %CI, 1.599–4.497, p < 0.001) irrespective of the TAPSE/SPAP ratio. The development of therapeutic strategies based on central venous waveform may be needed for patients with HF.

Use of Jugular Venous Pressure to Optimize Outcomes of Vestibular Schwannoma Resection: A Review of the Literature and Proof of Concept

Abstract Background Surgical resection of vestibular schwannoma (VS) and other benign posterior fossa tumors is often curative if gross total resection is achieved; however, these lesions pose unique challenges due to their intricate location and proximity to critical structures. Approaches for resection often utilize lateral head rotation and neck flexion to optimize the surgical field. However, this may inadvertently occlude cerebral venous drainage, elevating intracranial pressure (ICP) and increasing intraoperative bleeding, potentially increasing the operative risk to patients. Methods We review relevant literature regarding the effects of head rotation and neck flexion on internal jugular vein (IJV) occlusion and ICP and highlight the notion that head rotation and flexion may occlude the ipsilateral IJV, increasing ICP. Subsequently, we propose a novel technique using continuous, real-time monitoring of jugular bulb pressure (JBP) to detect obstructions in jugular venous flow and guide optimal head positioning prior to VS resection. Results As proof of concept, we present a single-patient case in which JBP monitoring was employed to optimize head positioning prior to a VS resection, which shows a significant reduction in JBP compared with traditional positioning. Conclusion This innovative approach offers promise in enhancing the safety and efficacy of intracranial surgery for VS and other neurosurgical procedures.