Online-only Data Supplement Movie Research Articles

Giant Aorto–Right Ventricular Fistula With Single Coronary Artery

A 15-year-old boy with symptoms of dyspnea and fatigue since early childhood was referred to our institution for evaluation. Physical examination of the patient showed long, slender extremities and a pectus carinatum deformity of the chest (Figure 1A). His arm span–to-height ratio was 1.03, and his upper segment–to–lower segment ratio was 0.82. He had blood pressure of 126/70 mm Hg, with a heart rate of 96 bpm; a grade 4/6 continuous murmur was present in the right lower parasternal area. A 12-lead ECG showed right bundle-branch block (Figure 2), and chest radiography (posteroanterior view) revealed mild cardiomegaly. Radiography of the thoracolumbar spine of the patient disclosed a mild degree of scoliosis (inset, Figure 1A). Two-dimensional echocardiography (parasternal long-axis view) showed a large fistula (2 cm in diameter) arising from the right aortic sinus (Figure 1B; online-only Data Supplement Movie I). A tilted apical 4-chamber view showed a turbulent jet (velocity 3.5 m/s) at the free wall of the right ventricle (Figure 1C; online-only Data Supplement Movie II). Three-dimensional echocardiography in a tilted apical 5-chamber view showed a broad tunnel arising from the aorta (Figure 1D; online-only Data Supplement Movie III). Computed tomographic cardiac angiography revealed the presence of a …

A Rare Complication of Infective Endocarditis

A 65-year-old man with a permanent pacemaker placed for atrioventricular block presented to the emergency department with 4 days of fever, gastrointestinal complaints, and back pain. On presentation, he was febrile, tachycardic, and hypotensive, with a significant leukocytosis. Urine and blood cultures grew methicillin-sensitive staphylococcus aureus in 6/6 bottles. The patient was initiated on appropriate antibiotic coverage, including nafcillin, resulting in sterilization of blood cultures. Transesophageal echocardiography revealed a vegetation on the pacing wire, likely involving the tricuspid valve, necessitating removal of the pacing lead (online-only Data Supplement Movies I and II). Four weeks into his antibiotic course, continued fevers along with a new holosystolic murmur at the apex of his heart prompted repeat echocardiography, which revealed a persistent mobile echodensity on the tricuspid valve and a new mobile echodensity on the …

Get Closer to the Diagnosis in a Flash

A 15-year-old girl of Middle East origin was seen by a pediatrician because of suspected pituitary nanismus. That diagnosis was quickly ruled out; however, a supposedly innocent systolic cardiac murmur resulted in referral to echocardiography. She had no cardiopulmonary symptoms, but the examination revealed a large nonobstructive, mobile, and apparently multicystic mass in the right ventricle (Figure 1). The mass was located close to the tricuspid valve with a stalk to a papillary muscle. Color Doppler imaging did not show any flow in the tumor (Figure 2; also see online-only Data Supplement Movie clips). Figure 1. Echocardiography. A , Apical 5-chamber view showing the attachment of the mass (M) to a papillary muscle in the right ventricle. B and C are parasternal long-axis and short-axis views, respectively. In these views, the multicystic appearance of the mass is clearly seen. AO indicates aorta; LA, left atrium; LV, left ventricle; and RA, right atrium. Figure 2. Echocardiographic image with color Doppler. The velocity scale is adjusted to 49 cm/s. There is no flow in the cardiac mass. Lower color flow velocities gave aliasing artifacts in …

Chest Pain, Shortness of Breath, and Palpitations Unmask an Unexpected Diagnosis

A 48-year-old white man was admitted to our hospital because of a sustained wide-complex tachycardia (160 bpm). He presented with chest discomfort, dyspnea, palpitations, and dizziness. Because medical cardioversion with intravenous amiodarone failed, intravenous ajmaline was administered, which successfully resulted in conversion to sinus rhythm. Physical examination and laboratory results revealed no significant abnormalities. The patient reported no discomfort until the morning of admission, and there was no history of disease except for tuberculosis, successfully treated 20 years earlier. Although serial cardiac troponin T analysis was negative, the patient complained of ongoing angina. Cardiac catheterization showed subtotal stenosis of the right coronary artery (Figure 1A), which was successfully treated by percutaneous coronary intervention and placement of a bare-metal stent (Figure 1B). Notably, the coronary arteries showed no high-grade lesions in the other main coronary vessels. Echocardiography revealed an echodense mass at the right ventricular lateral wall, the interatrial and interventricular septum, and the left atrial wall. A magnetic resonance imaging scan (Figures 2A and 2B; online-only Data Supplement Movies I–IV) calculated a tumor volume of ≈130 mL …

Spontaneous Fontan Physiology in Burnt-Out Endomyocardial Fibrosis

A 42-year-old man presented with congestive heart failure and atrial fibrillation. He had been diagnosed with endomyocardial fibrosis 8 years earlier and was stable on diuretics. He had congested neck veins, pedal edema, and massive ascites and a loud third heart sound. ECG confirmed atrial fibrillation. The chest radiograph showed massive cardiomegaly with a cardiothoracic ratio of 90%. Two-dimensional echocardiography revealed features of endomyocardial fibrosis with predominant right ventricular involvement (online-only Data Supplement Movie I; Figure, A). The right atrium was aneurysmally dilated with dense spontaneous echo contrast. The right ventricular cavity was obliterated. The inferior vena cava measured 28 mm with no respiratory variation, suggesting high systemic venous pressures. Hepatic vein flow showed loss of a wave reversal and increased antegrade flow in inspiration. Low-pressure tricuspid regurgitation was reflected in the …

Unusual Location for a Large Cardiac Fibroma

A 37-year-old woman with palpitations and chest discomfort was referred to our institution for assessment of a right ventricular (RV) mass seen on echocardiography (Figure 1). Cardiovascular magnetic resonance confirmed the presence of a large oval mass (6×7 cm) within the basal RV free wall (online-only Data Supplement Movies I and II). The mass was causing compression of the RV inlet but no invasion of the tricuspid annulus or valve (Figure 2). The mass had a low signal on T1- and T2-weighted images, no increase in signal during first-pass perfusion, but diffuse delayed hyperenhancement after gadolinium injection, with some central areas of relatively low signal (Figure 2, B through D). These features are typical of cardiac fibroma. On surgery, a large, lobulated solid mass was excised from the …

Multimodality Imaging in an Unusual Case of Palpitations and Right Heart Failure

A 73-year-old woman presented with palpitations and right heart failure. Physical examination revealed elevated jugular venous pulse with a pansystolic murmur. ECG showed atrial flutter with a right bundle-branch block (Figure 1). A chest X-ray revealed normal cardiac size with a superior mediastinal opacity consistent with a goitre (Figure 2). Transthoracic and transoesophageal echocardiography demonstrated a large intramyocardial mass in the right ventricular freewall measuring up to 7.5×5 cm associated with right ventricular and right atrial dilatation, and systolic dysfunction (Figure 3A and B and online-only Data Supplement Movie I). The tricuspid valve was thickened with impaired leaflet mobility, resulting in severe tricuspid regurgitation (online-only Data Supplement Movie II). Tests to characterize the mass and to investigate other primary tumors were undertaken. A computed tomography scan confirmed a cardiac mass, a goitre, a small adrenal …

Left Ventricular Outflow Tract Obstruction Caused by Tamponade

A transthoracic echocardiogram of a 72-year-old woman who was admitted to the hospital complaining of dyspnea at rest and peripheral edema showed severe pericardial effusion with right chamber and left atrial collapse, as well as left ventricular hypertrophy with systolic anterior movement of the septal mitral leaflet and systolic gradient through the left ventricular outflow tract (peak gradient of 70 mm Hg; online-only Data Supplement Movie I and Figure 1). A grade 3/6 systolic murmur was heard. The ECG showed sinus rhythm and respiratory phasic changes in QRS amplitude (Figure 2). The patient was referred to the …

Severe Aortic Regurgitation Secondary to Antisynthetase Syndrome

A 47-year-old woman with hypertension and a history of antisynthetase syndrome (ASS) diagnosed in 2002 (positive anti-PL-7 antibodies) and on long-term immunosuppressive therapy was admitted to the hospital in 2008 for worsening chest pain, shortness of breath, hypoxemia, and diffuse muscle weakness. Plain chest radiograph showed bilateral lower-lobe infiltrates and computed tomography confirmed bilateral patchy infiltrates consistent with interstitial lung disease. After being treated aggressively with high-dose immunosuppressive therapy, the patient improved and was discharged home. She was subsequently readmitted a few days later with progressive dyspnea. A transthoracic echocardiogram (TTE) showed moderate to severe aortic regurgitation (Figure 1A; online-only Data Supplement Movie IA and IB) that was not present in a prior TTE performed 4 months before admission (requested to screen for left ventricular hypertrophy; patient was asymptomatic at that time; Figure 1B and online-only Data Supplement Movie IIA and IIB). During the next 4 weeks, …

Real-Time 3-Dimensional Transesophageal Echocardiography of the Atrioventricular Septal Defect

Being able to view the morphological details of the heart malformation in any patient with the diagnosis of atrioventricular septal defect (AVSD) is invaluable in surgical planning, especially in the current era of modified 1-patch versus 2-patch techniques. Real-time 3-dimensional transesophageal echocardiography (RT 3D TEE) is a recently developed technique that allows real-time high-quality images akin to viewing the heart specimen. We present the principal pathomorphological features of AVSD as visualized by RT 3D TEE. The hallmark of AVSD is a common atrioventricular junction guarded by a common atrioventricular valve.1 In the normal heart, when seen from atrial perspective, the aortic valve is wedged between the mitral and tricuspid valve. In AVSD, because of the common AV junction, the aortic valve is in an “unwedged” position (Figure 1). The valve consists of 5 leaflets: the superior and inferior bridging leaflets, each of which overrides the ventricular septum, a left mural leaflet, a right anterior, and a right inferior leaflet (Figure 2). Whether the bridging leaflets are joined together distinguishes the complete form from the partial form. In partial AVSD (also termed “ostium primum ASD”), a tongue of leaflet tissue connects the bridging leaflets and the undersides of these leaflets …

Radiofrequency Catheter Ablation of Life-Threatening Ventricular Arrhythmias Caused by Left Ventricular Metastatic Infiltration

Metastases to the cardiac ventricles are rare and, unfortunately, often follow a rapidly fatal course.1,2 Occasionally, they cause symptomatic ventricular arrhythmias (VAs) for which limited therapeutic options exist, such as antiarrhythmic drugs, whereas the use of catheter ablation, to our knowledge, has never been reported to date. We present the case of a 27-year-old man with a metastatic tumor in the left ventricle and intractable malignant VAs. In February 2009, the patient had been diagnosed with a gluteal sarcoma and initially treated with combined chemotherapy (including anthracyclines) and radiation. Since December 2009, a mild reduction in left ventricular ejection fraction (45%) was detected, and since January 2010, frequent monomorphic premature ventricular contractions (PVCs) and nonsustained ventricular tachycardias (VTs) were documented. Treatment with amiodarone proved helpful, and no life-threatening VAs could be induced on standard electrophysiological study.3 Since April 2010, however, the patient suffered from multiple drug-refractory episodes of sustained VT and ventricular fibrillation, requiring several direct current shocks (Figure 1). His left ventricular ejection fraction had remained stable. Electrical storm resulted in immediate hemodynamic instability and dramatically affected his quality of life. The patient was referred to our institution, where multiple antiarrhythmic drug combinations were tested, both orally and intravenously, allowing a relative stabilization of cardiac rhythm. Cardiac MRI showed a T2-hyperintense, weakly gadolinium-enhanced area at the basis of the anterior papillary muscle, compatible with metastatic infiltration (Figure 2, online-only Data Supplement Movie 1). An oncology consultation hypothesized a life expectancy of <6 months. After about 2 weeks, the recurrence of multiple episodes of VT and ventricular fibrillation required intensive care treatment with deep sedation and assisted ventilation, but still VAs could not be controlled. Thus, a repeat electrophysiological evaluation and radiofrequency …

Imaging Phenotype Versus Genotype in Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is a common monogenetic cardiac disease with a prevalence of 0.2%1 that usually is inherited as an autosomal dominant trait with variable penetrance and expression. Clinically, HCM is defined by the presence of left ventricular (LV) hypertrophy (LVH) unexplained by abnormal loading conditions.1 The natural history varies from an asymptomatic course to drug-refractory angina/dyspnea, sudden cardiac death (SCD), and end-stage heart failure. The incidence of HCM-related SCD is approximately 1% to 2% in children and adolescents and 0.5% to 1% in adults.2,3 In this review, we examine the impact of advanced diagnostic imaging technologies on HCM, with particular emphasis on the detection of particular genetic subtypes. In ≈60% of cases, HCM is inherited as an autosomal dominant trait caused by mutations in genes coding for cardiac sarcomere proteins (Figure 1).4–7 Mutations in genes encoding Z-disc proteins and proteins involved in calcium regulation account for <5% of cases. The absence of sarcomeric gene mutations can be explained by limitations of current mutation detection techniques or mutations in as yet unidentified genes, but in some cases, hypertrophy is caused by other diseases that mimic the phenotype of sarcomeric protein disease. Table 1 lists genetic disorders associated with HCM. Figure 1. A schematic illustration of a cardiac sarcomere. View this table: Table 1. Currently Known Genes Implicated in HCM More than 600 different sarcomeric gene mutations are reported in patients with HCM.8–16 The majority are missense mutations, but nonsense, frameshift, and in-frame insertion/deletion mutations also occur. Most mutations are characterized by incomplete penetrance and variable clinical expression likely due to locus heterogeneity and the effect of mutations at different locations within the same gene. Most mutations probably have a dominant negative effect on sarcomere function, but in some cases, haploinsufficiency (ie, only a single functional …

Aortic Papillary Fibroelastoma as an Unusual Cause of Angina

A 61-year-old woman with no risk factors for cardiovascular disease presented to her local hospital with symptoms of exertional angina. The resting ECG was unremarkable, but during exercise treadmill testing, the patient had her usual symptoms associated with >2-mm downsloping ST-segment depression in the inferolateral leads, which took 13 minutes to resolve. Urgent coronary angiography revealed a normal left main stem, left anterior descending artery, and circumflex artery (Figure 1; online-only Data Supplement Movie I), but right coronary artery cannulation proved impossible. The patient had chest pain during the procedure, and an aortogram was performed both to exclude dissection and to attempt to identify the right coronary artery (Figure 1; online-only Data Supplement Movie II). There was no dissection, but the right coronary artery was still not seen. As a result, contrast-enhanced 64-slice computed tomography coronary angiography was requested. This showed a small, anomalous right coronary artery but also revealed a well-defined low-attenuation filling defect consistent with a mass adjacent to the left coronary cusp of the aortic valve (Figure 1). To obtain better tissue characterization of this mass, cardiovascular magnetic resonance was performed. This demonstrated a mobile, noncalcified spherical structure attached to the aortic valve with intermediate signal intensity …

Resistant Pericardial Tamponade

An 87-year-old woman with critical aortic stenosis and preserved left ventricular (LV) systolic function (ejection fraction 50%) was admitted with pulmonary edema. She stabilized with medical therapy, and a decision was made to perform balloon aortic valvuloplasty as a bridge to potential transcatheter aortic valve implantation. Initially, a temporary pacemaker was inserted from the right femoral vein to the right ventricle to allow rapid pacing during aortic valvuloplasty. The heavily calcified aortic valve was crossed with an Amplatz left 1 6F catheter and a straight Amplatz 0.035-inch Super Stiff wire (Boston Scientific Corp, Natick, MA), but difficulties were experienced gaining a stable wire position at the LV apex. The patient complained of chest pain, with rapid hemodynamic deterioration, and a clinical diagnosis of pericardial tamponade was confirmed with transthoracic echocardiography (Figure 1A; online-only Data Supplement Movie I). On color Doppler imaging, a jet from the lateral wall of the LV into the pericardial space could be identified (Figure 1B; …

Echo-Guided Pericardiocentesis

HomeCirculationVol. 123, No. 4Echo-Guided Pericardiocentesis Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsFree AccessResearch ArticlePDF/EPUBEcho-Guided PericardiocentesisLet the Bubbles Show the Way Craig D. Ainsworth, MD, FRCPC and Omid Salehian, MSc, MD, FRCPC, FACC, FAHA Craig D. AinsworthCraig D. Ainsworth From the Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada. Search for more papers by this author and Omid SalehianOmid Salehian From the Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada. Search for more papers by this author Originally published1 Feb 2011https://doi.org/10.1161/CIRCULATIONAHA.110.005512Circulation. 2011;123:e210–e211A 75-year-old man with coronary artery disease, atrial fibrillation, sick sinus syndrome with permanent pacemaker, hypertension, dyslipidemia, and previous exertional dyspnea related to moderately severe mitral regurgitation from myxomatous degeneration and bileaflet prolapse presented with progressively worsening dyspnea several weeks after undergoing successful mitral and tricuspid valve repair with insertion of annuloplasty rings in addition to 2-vessel coronary artery bypass surgery. On presentation to the hospital he was found to have dyspnea at rest, hypotension, and jugular venous distension. A transthoracic echocardiogram demonstrated normal left ventricular function, no significant valvular stenosis, or regurgitation and a moderate sized pericardial effusion measuring 1.4 cm anteriorly and 2.7 cm posteriorly (Figure A through C). Significant inferior vena cava dilatation was noted, but no convincing chamber collapse to suggest overt cardiac tamponade. His symptoms persisted with no alternate cause discovered; therefore, therapeutic pericardiocentesis was requested. The location and distribution of pericardial fluid was reestablished, and a lateral apical approach provided the best window to access the effusion. Under echocardiographic guidance, a sheathed needle was inserted into the pericardial space with aspiration of sanguineous fluid. Agitated saline bubbles confirmed that the needle tip was in the pericardial space (Figure D and online-only Data Supplement Movie I). The needle was removed and the sheath advanced. Prior to dilatation, repeat injection of agitated saline revealed bubbles in the right ventricle; therefore, the procedure was stopped (Figure E and online-only Data Supplement Movie II). A subsequent attempt was performed using the same technique, and this resulted in entry of the catheter sheath into the left ventricle (Figure F and online-only Data Supplement Movie III). The procedure was abandoned, and serial echocardiograms showed no worsening of the pericardial effusion.Download figureDownload PowerPointFigure. Transthoracic echocardiogram images obtained before and during attempted pericardiocentesis. (A and B) apical 4-chamber views detailing size and location of pericardial effusion. (C) subcostal view showing posterior fluid collection. (D) agitated saline contrast injected through needle inserted in apical area seen entering pericardial space as imaged from subcostal window. (E and F) subcostal views depicting agitated saline entering right and left ventricular cavities respectively.DiscussionEchocardiography-guided pericardiocentesis has been performed since the late 1970s, when it was first performed at the Mayo Clinic in Rochester, Minnesota. Echocardiographic guidance for placement of a sheathed catheter into pericardial effusions has supplanted the previously performed blind subxiphoid approach as the preferred procedure for the diagnosis and management of most large or hemodynamically significant pericardial effusions. The blind technique used for years prior to the introduction of echocardiography was associated with exceedingly high rates of morbidity and mortality.1 The echocardiography-guided technique involves indentifying the location and distribution of pericardial fluid and entering with a needle at a point on the chest wall where the largest fluid accumulation is closest to the skin while avoiding vital structures.2 Once the sheathed needle is inserted into the pericardial space, only the sheath is advanced, and the steel needle is removed. Sheath position is routinely verified by instillation of agitated saline through the sheath and imaging from another window. In large, symptomatic, or hemodynamically significant pericardial effusions, this technique is associated with near perfect procedural success rates and low incidence of minor complications (3.5%) or major adverse events requiring intervention (1.2%).2 Our attempted pericardiocentesis initially revealed saline bubbles in the pericardial space but subsequently showed bubbles entering the right and left ventricular cavities. No intervention was required after these inadvertent entries into cardiac chambers. Ultimately, the procedure was abandoned and further attempts were not performed. Although not attempted in our case, real-time echocardiography-guided pericardiocentesis with a probe-mounted needle has been studied and appears to be very safe, and may be useful for smaller or difficult-to-access effusions.3 The authors of this study argue that constant visualization of the needle during insertion reduces the likelihood of perforating cardiac chambers.This case highlights the importance of administering agitated saline after attempted needle insertion into the pericardial space as to help avoid inadvertently dilating into a ventricular cavity or other undesired space.DisclosuresNone.FootnotesThe online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/123/4/e210/DC1.Correspondence to Omid Salehian, MD, Division of Cardiology, Department of Medicine, McMaster University, 1200 Main Street West, Room 3U8, Hamilton, Ontario, Canada, L8N 3Z5. E-mail [email protected]ca

Multidetector Computerized Tomography Can Guide and Document Alcohol Septal Ablation in Hypertrophic Obstructive Cardiomyopathy

Cardiac imaging is of special value in the diagnosis and management of hypertrophic obstructive cardiomyopathy.1 Echocardiography2 and magnetic resonance imaging,3 in particular, have been used to diagnose the disorder, to elucidate its pathophysiology, and to guide and document the results of treatment.4 A 41-year-old woman was evaluated for treatment of symptomatic hypertrophic obstructive cardiomyopathy. Because of a strong family history of hypertrophic and dilated cardiomyopathies, in some cases associated with sudden death, an automatic implantable cardioverter defibrillator was implanted. Despite treatment with metoprolol succinate, verapamil, and finally metoprolol plus diltiazem, she had New York Heart Association Class III dyspnea and fatigue; symptoms were worse after a meal. Echocardiography showed asymmetrical septal hypertrophy, systolic anterior motion of the mitral valve, and moderate tricuspid and mitral valves regurgitation (right ventriclular systolic pressure 50 to 60 mm Hg) (online-only Data Supplement Movies I to III). A multidetector computerized tomography (MDCT) study of the heart and coronary arteries was done to delineate 1) the degree and exact location of interventricular septal hypertrophy; 2) the presence and degree of systolic anterior motion of the mitral valve and mitral valve leaflet-septal contact; and 3) the anatomy of the coronary arterial supply to the hypertrophied interventricular septum. Electrocardiogram (ECG)-gated contrast enhanced MDCT scan was performed using a Siemens SOMATOM Definition AS 128-slice computerized tomography scanner (Siemens Medical Solutions, Forchheim, Germany). Imaging was performed from the ascending thoracic aorta to the level of the upper abdomen during a 6-second breath hold at end inspiration. We used a triphasic IV regimen: 60 mL of iodinated contrast (Isovue [Iopamidol] 370 mg …

Acute Myocarditis Mimicking Reverse Takotsubo Cardiomyopathy

A 48 year-old man with type 1 diabetes mellitus was admitted to our hospital with diabetic ketoacidosis precipitated by a persistent 7-day febrile illness related to a viral upper respiratory infection. Two days after admission he had an episode of chest pain with a rise of troponin I up to 29 ng/mL but no ECG changes. Coronary angiography demonstrated minor plaque but no flow-limiting disease. Left ventriculography showed severe hypokinesis of basal and mid segments but preserved contractility of apical segments, consistent with a pattern of inverted Takotsubo cardiomyopathy (Figure 1A and 1D and online-only Data Supplement Movie I). The patient was then referred for cardiovascular magnetic resonance (CMR) imaging to determine the underlying cause of left ventricular impairment. Cine CMR imaging confirmed left ventricular wall …

Real-Time 3-Dimensional Transesophageal Echocardiography in the Evaluation of a Patient With Concomitant Double-Orifice Mitral Valve, Bicuspid Aortic Valve, and Coarctation of the Aorta

A 35-year-old woman was referred for further cardiovascular assessment after an incidental finding of a systolic murmur and symptoms of exertional chest tightness. On examination, she had an anacrotic pulse with an aortic ejection systolic murmur. Two-dimensional (2D) transthoracic echocardiogram (TTE) demonstrated normal left ventricular (LV) size and systolic function with a thickened and calcified bicuspid aortic valve. The mean gradient was 47 mm Hg, and valve area was 0.8 cm2, consistent with severe aortic stenosis. There was mild coarctation of the aorta with a peak velocity of 2.5 m/s. The mitral valve appeared structurally abnormal (Figures 1 and 2⇓ and online-only Data Supplement Movies I and II). However, 2D TTE images were suboptimal. Therefore, 2D transesophageal echocardiography (TEE) was performed. This confirmed a bicuspid aortic …

Huge Prosthetic Mitral Valve Thrombosis in a Pregnant Woman

A 42-year-old woman in her 30th week of pregnancy who had undergone a mitral valve replacement with a 29-mm St. Jude Medical mechanical prosthetic valve (St. Jude Medical, St. Paul, Minn) 2 years earlier was referred to our hospital with severe dyspnea. She had a history of irregular and subtherapeutic use of enoxaparin 6000 IU/d until admission. Transthoracic echocardiography revealed a mean diastolic mitral transvalvular gradient of 29 mm Hg, mitral valve area of 0.6 cm2, and a giant thrombus with mobile components on the prosthetic valve (Figure 1; online-only Data Supplement Movie I). In spite of the large prosthetic mitral valve thrombosis, she had no history …

Recurrent Syncope Due to Torsades de Pointes in a 41-Year-Old Woman With an Empty Sella, Anterior Pituitary Insufficiency, and a Long-QT Interval

A 41-year-old woman was admitted to our emergency room (ER) because of recurrent syncope. ECG monitoring in the ER showed episodes of sustained but self-limiting torsades de pointes ventricular tachycardia (Figure 1). Two more episodes of syncope occurred in the ER. Intravenous magnesium was administered. Echocardiography revealed a severely impaired left ventricular (LV) function (online-only Data Supplement Movie I). The patient was immediately transferred to the cardiac catheterization laboratory for further assessment. Coronary artery disease was excluded by coronary angiography. LV angiography confirmed global hypokinesia (online-only Data Supplement Movie II). The calculated LV ejection fraction was 30%. During the procedure a temporary pacemaker was placed in the right ventricle. Pacing was initiated at a rate of 80 bpm, and the patient was transferred to the coronary care unit. No more episodes …