ST-segment Elevation In V1 Research Articles

THE APEX TALKS…CARDIAC METASTASIS MIMICKING ST SEGMENT ELEVATION MYOCARDIAL INFARCTION

Abstract A 78–year–old man with a recent diagnosis of lung squamous cell carcinoma was referred to our cardiology department for marked ECG abnormalities (ST segment elevation in V2–V4 and T waves inversion in the antero–lateral leads, Fig.1) in the absence of ischemic symptoms and for the detection of an intramyocardial mass at the apical segments on the CT scan. He had no significant previous cardiovascular history. A transthoracic echocardiogram (TTE) was performed and showed an isoechoic mass at the LV apical segments measuring 3 x 4 cm apparently incorporating the myocardial wall without a clear cleavage plane (Fig.2a). The EF was normal. No pericardial effusion present. The contrast echocardiography with Sonovue revealed a late uptake of the contrast (Fig.2b). Cardiac magnetic resonance (CMR) showed an ovular image in the para–apical area of 40 x 23 cm consistent with a secondary lesion (Fig.3). Unfortunately, the exam was interrupted early due to a patient’s claustrophobic crisis, without having acquired the post–contrast images. Due to infiltrative appearance of the mass and the oncology history, this formation was highly suspicious for metastasis. No complicated ventricular arrhythmias were detected on ECG monitoring. No symptoms of heart failure were reported. Due to the marked EKG repolarization abnormalities the patient underwent coronary angiography which excluded significant stenosis. FDG PET/CT showed areas of increased metabolism also at liver and adrenal left gland. Finally, the patient was transferred to the oncology department for specific management. Cardiac metastases are more common than primary cardiac malignancy and are more frequently related to primary lung cancer, followed by breast cancer and hematologic malignancies. Typical presentation includes arrhythmias or conduction disturbances. The imaging findings of cardiac metastases are non–specific but mostly infiltrative, heterogeneous, and multiple masses may be present. Echocardiography is the initial imaging test for the detection of cardiac metastasis, although CMR, CT and PET/CT may be helpful. Herein we described a case of cardiac metastasis with EKG mimicking acute coronary syndrome. This finding is not uncommon among these patients. EKG findings of myocardial ischemia or injury, particularly localized and prolonged ST elevation, in the absence of ischemic symptoms have been reported in previous studies as high specificity for cardiac metastasis in patients with malignancy.

Anesthesia management in a patient who diagnosed with brugada syndrome in third preoperative evaluation

Brugada Syndrome (BS) is a rare genetic disease that can be fatal with malignant arrhythmias. It has been stated that drugs, which are frequently used in anesthesia practice, electrolytic or autonomic imbalance, fever, and infections can trigger cardiac arhythm and sudden cardiac death even in asymptomatic patients. Here we describe a patient who diagnosed with Brugada Syndrome in third preoperative evaluation. A 60-year-old male patient was scheduled for an infected knee prosthesis. The patient's preoperative laboratory findings were normal except for ECG changes. There was ST segment elevation in V1 and V2 leads in the ECG. The patient was consulted with the cardiology clinic and was evaluated as Brugada Syndrome ECG type 1. There is no consensus regarding the application and technique of anesthesia for these patients. We decided to apply general anesthesia because we could provide better hemodynamic stabilization. The patient was transferred to the intensive care unit. There were no adverse events observed during the anesthetic management and discharged from the hospital on the second postoperative day. We emphasize the importance of detailed preoperative evaluation each time, even in patients with a known anesthesia history.

Diagnostic and therapeutic dilemma due to new pattern electrocardiographic change in myocardial infarction: a case report from a remote island

Acute myocardial infarction results due to acute disruption of coronary blood flow, commonly presented with chest pain. Electrocardiogram showing ST-segment elevation in consecutive leads is a classical ST-elevation myocardial infarction; however, atypical ST-segment elevation also can occur. We report an elderly lady who presented to the island health centre with intractable central chest pain. Electrocardiogram showed ST-segment elevation in V1 and aVR; whereas ST-depression in V4-6. With primary management, she was referred to a regional hospital. Repeat electrocardiogram showed ST-segment elevation in V1, aVR, and III; whereas ST-depression in V4-6, aVL, and I. Therefore, considering Aslanger's pattern of ECG change myocardial infarction, she was referred to the cardiac centre where coronary angiography revealed severe diffuse triple vessel disease. Primary PCI was performed on the right coronary artery initially as it is the primary culprit vessel with stenosis of other vessels. Therefore, staged angioplasty was performed on the left coronary system. Uncommon and atypical electrocardiographic presentations may be encountered in daily practice, associated with severe multiple-vessel diseases. So, it can be challenging for a cardiologist as well during interventions.

ACUTE ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION IN A YOUNG PATIENT WITH IGA NEPHROPATHY: A RARE CASE REPORT


 Cardiovascular events are less commonly described in glomerular disease. However, thromboembolic events are quite commonly reported in glomerular disease with nephrotic range proteinuria. Here, we report a case of a 29 years old male with IgA nephropathy present with central chest pain radiating to the jaw. He was under mycophenolate, prednisolone and losartan with remission of proteinuria for two months. ECG showed extensive ST segment elevation in V1- V6 leads. His cardiac troponins were elevated. Coronary angiography showed complete thrombotic occlusion of mid left anterior descending artery which was successfully recanalized after primary percutaneous intervention. Though less commonly reported in literature, such incidence of coronary events in IgA nephropathy can rarely present with acute myocardial infarction.

434 TAKOTSUBO SYNDROME AFTER PACEMAKER IMPLANTATION

Abstract Introduction Takotsubo syndrome is a clinical syndrome characterized by typical anamnestic features together with typical ECG and echocardiographic findings. Comparing with the available literature not so many cases of takotsubo syndrome after pacemaker implantation can be found. Furthermore, there are only few articles talking about ECG features in these patient. The case we described allows to observe dynamic ECG alterations in a patient with electro-induced ventriculograms Case Description A 90-year-old male was admitted to the emergency room for important fatigue associated with severe bradycardia (25/min). His cardiovascular history was silent, and his past medical history was characterized by high blood pressure, chronic pulmonary obstructive disease and anemia due to iron deficiency. The ECG showed second degree AVB type 2, with phases of 2:1 AVB and paroxysmal third degree AVB on continuous monitoring. The routine blood tests showed normal T troponin and BNP was 420 pg/mL. The echocardiogram revealed normal biventricular dimensions and systolic function with moderate aortic valve stenosis. The patient underwent urgent permanent DDD pacemaker implantation without previous isoproterenol administration. During the procedure he referred important pain on the site of the wound, and he became confused and agitated. The procedure was complicated by massive pneumothorax that needed quick decompression. On the 2nd day after pacemaker implantation the ECG revealed electro-induced atrium-guided ventriculograms and began to modify with only mild ST-segment elevation in V2 and initial T-wave inversion from V3 to V6 and in I - II - aVF. On the next days, T-waves became deeper and QTc prolonged to 540 ms. These abnormalities were then gradually resolved on the 11th day. Mild transient attenuation of the amplitude of the QRS complexes in V2 – V3 leads on day 1 could be reported. Another echocardiogram was then performed, which showed new apical akinesis with “apical ballooning” aspect and EF of 40%. TnT and BNP values increased. Coronary angiogram was not performed due to patient rejection, so that coronaropathy could not be excluded with certainty. Nevertheless, the patient had only high blood pressure as cardiovascular risk factor and that the probability of the diagnosis of takotsubo cardiomyopathy was assessed of 76,9% by InterTAK diagnostic score, so that we considered Takotsubo syndrome the most likely diagnosis. Therefore, the patient's therapy was then optimized with an increase in the dosage of ACE inhibitors. At one month follow-up the ECG remained stable, and the echocardiogram showed a preserved ejection fraction (EF = 55%), without alterations of the segmental contractility. BNP and TnT values were normal. Therapy was left unmodified. Conclusions Takotsubo syndrome should be consider a rare but possible complication of pacemaker implantation. This is true especially for patients affected by frailty and cognitive impairment. There are no specific ECG criteria for takotsubo syndrome in patients with electro-induced ventriculograms, but anomalies of the repolarization are similar to those in patients with spontaneous ventricular activity. Transient attenuation of the QRS complexes voltages could be seen even just in the precordial leads and it is generally present in the very acute phase.

Abstract 14332: Syncope, Storm, and Shock: Fulminant Myocarditis

A 46-year-old female with prediabetes and recent hysterectomy three weeks prior presented to the hospital for syncope. Patient reported no chest pain or dyspnea but complained of intermittent palpitations. The patient developed runs of non-sustained ventricular tachycardia which quickly escalated into incessant ventricular tachycardia (VT). Unresponsive to maximal medical therapy, the patient was cardioverted, intubated and sedated. Electrocardiogram was obtained which showed ST segment elevation in V1 and V2 without reciprocal changes. Bedside point-of-care ultrasound was negative for wall motion abnormalities. Laboratory results were significant for normal electrolytes, elevated troponins peaking at 7.14 ng/mL the following morning, and lactic acid of 3.2 mmol/L. Patient was initiated on vasopressor and ionotropic support for suspected shock. Left heart catheterization was negative for obstructive coronary artery disease. Right heart catheterization revealed mild pulmonary hypertension and biventricular failure. Formal echocardiogram revealed mid-range ejection fraction with a small pericardial effusion. The patient’s clinical status was deteriorating and revealed multiorgan failure. In conjunction with advanced heart failure and mechanical circulatory support teams, veno-arterial extracorporeal membrane oxygenation was initiated with subsequent implantation of intra-aortic balloon pump. High-dose steroids were given while awaiting transfer to a quaternary center. The patient is currently being evaluated for endomyocardial biopsy and evaluation of left ventricular assist device or heart transplantation due to fulminant myocarditis (FM). FM requires early recognition, intensive support, and further investigation for optimal management.

Abstract 14888: Arrhythmogenic Right Ventricular Cardiomyopathy-Brugada Syndrome Overlap: A Rare Clinical Entity

Introduction: Arrhythmogenic right ventricular cardiomyopathy (ARVC) and Brugada syndrome (BS) are inherited disorders that predispose individuals to arrhythmic sudden cardiac death. ARVC is a heart muscle disorder of intercellular junctions resulting from mutations of desmosomal (DS) genes, often leading to heart failure, and monomorphic ventricular tachycardia (VT). BS is a channelopathy due to sodium channel mutations, usually presenting as polymorphic VT without cardiomyopathy. Case presentation: A 35-year-old male with history of migraines presented with syncope resulting in a fall. No family history of arrhythmias or sudden cardiac death. Initial EKG showed wide complex monomorphic VT. Repeat EKG (figure 1), revealed coved ST-segment elevations in V1, V2 consistent with Brugada type 1 pattern. Emergent coronary angiography was unremarkable, and echocardiogram showed left ventricular ejection fraction of 55-60%, right ventricle (RV) outflow tract proximal diameter measured 3.5cm and normal RV function. An implantable cardioverter-defibrillator (ICD) was implanted for secondary prevention. Device interrogation on follow-up showed 11 shocks for recurrent episodes of monomorphic VT and patient was started on quinidine maintenance therapy. He remained symptom-free on subsequent visits. Genetic testing was positive for DSC2, DSP, and TMEM43 mutations associated with ARVC, but negative for genes associated with BS. Cardiac MRI results are pending. Discussion: Our patient has overlapping features of ARVC (genotype and monomorphic VT) and BS (EKG with coved ST elevations in V1, V2). Emerging evidence supports the theory that defects in DS proteins may affect the integrity of voltage-gated sodium channels in cardiac intercalated discs, leading to BS like phenotype. Conclusion: ARVC and BS could be related to the same disease spectrum, but further studies are required to understand pathophysiology, to guide treatment decisions.

Dealing With Failure.

Dealing With Failure.

Validation of an electrocardiographic marker of low voltage areas in the right ventricular outflow tract in patients with idiopathic ventricular arrhythmias.

Previous studies have reported the presence of subtle abnormalities in the right ventricular outflow tract (RVOT) in patients with apparently normal hearts and ventricular arrhythmias (VAs) from the RVOT, including the presence of low voltage areas (LVAs). This LVAs seem to be associated with the presence of ST-segment elevation in V1 or V2 leads at the level of the 2nd intercostal space (ICS). Our aim was to validate an electrocardiographic marker of LVAs in the RVOT in patients with idiopathic outflow tract VAs. A total of 120 patients were studied, 84 patients referred for ablation of idiopathic VAs with an inferior axis by the same operator, and a control group of 36 patients without VAs. Structural heart disease including arrhythmogenic right ventricular cardiomyopathy was ruled out in all patients. An electrocardiogram was performed with V1-V2 at the 2nd ICS, and ST-segment elevation ≥1 mm and T-wave inversion beyond V1 were assessed. Bipolar voltage map of the RVOT was performed in sinus rhythm (0.5-1.5 mV color display). Areas with electrograms <1.5 mV were considered LVAs, and their presence was assessed. We compared three groups, VAs from the RVOT (n = 66), VAs from the LVOT (n = 18) and Control group (n = 36). ST-elevation, T-wave inversion and left versus right side of the VAs were tested as predictors of LVAs, respective odds ratio (ORs) (95% confidence interval [CI]) and p values, were calculated with univariate logist regression. Variables with a p < .005 were included in the multivariate analysis. ST-segment elevation, T-wave inversion and LVAs were present in the RVOT group, LVOT group and Control group as follows: (62%, 17%, and 6%, p < .0001), (33%, 29%, and 0%, p = .001) and (62%, 25%, and 14%, p < .0001). The ST-segment elevation, T-wave inversion and right-sided VAs were all predictors of LVAs, respective unadjusted ORs (95% CI), p values were, 32.31 (11.33-92.13), p < .0001, 4.137 (1.615-10.60), p = .003 and 8.200 (3.309-20.32), p < .0001. After adjustment, the only independent predictor of LVAs was the ST-segment elevation, with an adjusted OR (95% CI) of 20.94 (6.787-64.61), p < .0001. LVAs were frequently present in patients with idiopathic VAs. ST-segment elevation was the only independent predictor of their presence.

Differentiating typical tako tsubo syndrome from extensive anterior ST-elevation myocardial infarction: look behind the anterior wall

Abstract Funding Acknowledgements Type of funding sources: None. Tako-Tsubo Syndrome (TTS) consists in transient left ventricular dysfunction resembling in its typical form acute anterior ST-elevation myocardial infarction (STEMI). Early non-invasive differential diagnosis, crucial for therapeutic purposes, appears difficult according to available data. Purpose to systematically analyze LV function and ECG changes in patients with acute anterior STEMI and TTS, to identify parameters possibly useful for differential diagnosis. Methods this is a retrospective cohort study, with 2 groups: patients with anterior STEMI and extensive apical involvement at echocardiography (n = 22); patients with TTS (n = 22) and ECG changes diagnostic for anterior STEMI at presentation (n = 22). They underwent a comprehensive clinical and echocardiographic evaluation in acute phase, including 2D speckle tracking longitudinal strain. We created new indexes based on wall motion impairment of inferior and inferior-lateral walls: the Inferior apex ratio (IAR) and inferior-lateral apex ratio (ILAR) (see picture). Results TTS and STEMI patients were similar for age (74.7 ± 9.1 vs 73.4 ± 14.1 y), sex, and main biochemical data except for higher peak troponin I in STEMI (1323 ± 622 vs 377 ± 220 ng/L, p = 0.01). ST segment elevation in V1 (V1e) was significantly less common in TTS (p &amp;lt; 0.001) while increased ratio of ST segment elevation in V4-V6 to V1-V3 (∑Ste V4-V6/∑Ste V1-V3≥1) was more common in TTS (p &amp;lt; 0.001). Among ECG parameters, absence of V1e had the best sensitivity (86%) and specificity (86%) in predicting TTS. LVEF values were similar (means: 45% in both groups) with EDVI greater in TTS (55.5 ±12.3 vs 46.6 ± 11.0 ml/m2, p = 0.02). WMSI was greater in TTS patients (2.2 ± 0.1 vs 1.9 ± 0.1, p &amp;lt; 0.0001), mainly for greater scores of mid segments. Global longitudinal strain was impaired in TTS (-8.1 ± 2.5 %) and in anterior STEMI (-7.9 ± 2.7, p = 0.8). By analyzing the single segments, strain was significantly more compromised in TTS in mid inferior (MI) (-4.3 ± 6.4 vs -9.9 ± 5.5 % in STEMI, p = 0.003) and mid inferior-lateral (MIL) segments (-5.4 ± 5.4 vs -9.6 ± 4.9 %, p = 0.009). Mean IAR was 0.7 ± 0.3 in TTS vs 1.8 ± 0.6 in STEMI, p &amp;lt; 0.0001; mean ILAR was 0.7 ± 0.1 in TTS vs 2.0 ± 0.9 in STEMI, p &amp;lt; 0.0001. ILAR was &amp;lt; I in all TTS patients, and &amp;gt; 1 in all STEMI cases. IAR &amp;lt; 1 showed 90% sensitivity and 95% specificity in predicting TTS. By multivariate linear regression analysis, strain values of MI and MIL segments were significantly associated with TTS (Beta: -0.98 and -0.97 respectively, p &amp;lt; 0.0001), independently from age, sex, and EDVI. IAR and ILAR values were significantly associated with TTS (Beta: -0.81 and -0.76 respectively, p &amp;lt; 0.0001) independently from the same co-variates as above. Conclusions evidence of impaired contractility extending beyond apex to mid inferior and inferior-lateral walls, assed by longitudinal strain or by IAR and ILAR, can help to discriminate TTS from extensive anterior STEMI, more accurately than ECG parameters. Abstract Figure. Examples of ILAR index Abstract Figure. IAR and ILAR distributions

ST-Segment Elevation Mimicking STEMI Due to Hypercalcemia: A Case Report

ST-segment elevation myocardial infarction (STEMI) is an important, life-threatening diagnosis that requires quick diagnosis and treatment, characteristic ECG of which shows ST-segment elevation. Unfortunately, ST-segment elevation is nonspecific, which can be misleading if not careful to be interpreted, as in this case of hypercalcemia seen by us. A 48-year-old male was admitted to our emergency department with recurrent chest pain, nausea and vomiting. Medical history includes hypertension and diabetes. ST-segment elevation in V1 - V4 mimicking STEMI was present on admission. However, immediate coronary angiography revealed nearly normal coronary arteries, his troponin was negative in 6 hours and calcium was 2.95 mmol/L. It was thought that the ECG changes were not indicative of cardiac ischemia but hypercalcemia. He was managed with calcium reduction treatment such as intravenous normal saline and furosemide, with subsequent resolution of ST-segment changes.

Clinical presentation and electrocardiographic features of Brugada syndrome in Iraq

Background: Brugada syndrome is a clinical entity composed of twelve leads electrocardiographic changes of coved or saddle shaped ST-segment elevation in V1 and V2 with serious ventricular arrhythmias which may cause sudden cardiac death. Objectives: The objectives of this study is to highlight the clinical presentation and the types of ECG changes of Brugada syndrome cases seen in Iraq and to orient physicians about this fatal condition. Patients and Methods: Patients presented with symptoms of palpitation, dizzy attacks or syncope and diagnosed as Brugada syndrome were included in this case series study. The diagnosis of Brugada syndrome based mainly on the typical coved or saddle shaped or variant ST-Segment elevation in electrocardiographic leads V1, V2. Results: Eighteen patients were included in this case series study. All are males. Age ranged from 15-45 Y. The presenting symptoms were palpitation in 12 patients, syncope in 8, dizzy spells and pre syncope in 14 and chest pain seen in 2. The arrhythmic events were clinically documented in 10. Monomorphic VT seen in 4, VF in 2, atrial fibrillation in 2 and atrial flutter in 2. Induced VF by EP study seen in 2. Type I Brugada ECG pattern was seen in 6 patients, type II in 4 and three of type III. Five showed a variant type of the syndrome. Family history of sudden cardiac death was seen in 8 patients while in 10 it was negative. ICD was implanted in 6 patients. In 12 patients (67%) the diagnosis of Brugada syndrome was missed during the provisional medical contacts. Conclusion: Brugada syndrome is not uncommon in Iraq but needs a high diagnostic suspicion through appreciating the symptomologies and electrocardiographic features of this fatal syndrome to plan management to prevent sudden cardiac death. Key words: Brugada syndrome, Iraq

Electrocardiographic findings in true acute left main coronary total occlusion a subanalisys from ATOLMA registry

IntroductionAcute total occlusion of the left main coronary artery (ATOLMA) usually leads to a catastrophic presentation. Prediction of ATOLMA by electrocardiogram (ECG) may contribute to early detection and reperfusion. Limited data have been reported previously. This study aims to identify the admission 12‑leads ECG features that can predict the presence of ATOLMA and in-Hospital mortality in these patients. MethodsThe admission ECGs findings in 24 patients from the previously reported ATOLMA multicenter registry were compared to the ECGs findings in 15 patients with an acute subtotal occlusion of the left main (ASOLMA) and to 15 patients with anterior ST-elevation myocardial infarction of the proximal left anterior descending (LADp-STEMI). ResultsSome ECG features at presentation can predict an ATOLMA: QRS left axis deviation (−61.17 ± 9 degrees); ST-segment elevation in aVL (1.9 ± 0.65 mm); absence of ST-segment elevation in V1 (0.0 ± 0.6 mm); bifascicular block (58%); fragmented QRS (62.5%); prolongation of QTc interval (465 ± 19 ms) and of QRS interval (136 ± 12 mm). The multivariate analysis found that the independent predictors to distinguish ATOLMA from ASOLMA were aVL ST-segment deviation (OR 5.6(95% CI 1.5–21), p = 0.01) and absence of V1 ST-segment elevation (OR 27(95% CI 1.4–52), p = 0.01); and from LADp-STEMI was QRS width (OR 1.1(95% CI 1.02–1.2), p = 0.02). Fragmented QRS was the only independent predictor of in-hospital mortality in ATOLMA (OR 0.125(95% CI 0.01–0.81), p = 0.03). ConclusionsaVL ST-segment elevation, the absence of V1 ST-segment elevation, left axis deviation, the presence of bifascicular block, and prolongation of QRS and QTc interval are predictors of ATOLMA. Fragmented QRS predicts in-hospital mortality in ATOLMA.

Ventricular repolarization abnormalities: the electrocardiographic track of cardiac tumoural involvement in an infant with tuberous sclerosis complex. A case report.

BackgroundPrimary cardiac tumours are rare in children. Against this backdrop, Doppler echocardiogram is the main diagnostic procedure, while electrocardiogram (ECG) usually plays a secondary role, by detecting tumoural consequences as cardiac arrhythmias and chambers overload. We describe a case where an electrocardiographic sign was the cornerstone to diagnosis and surveillance of an infant with a cardiac rhabdomyoma.Case summaryA female infant was referred for cardiac evaluation to elucidate an electrocardiographic abnormality, detected during investigation of seizures. She had recently been diagnosed with epilepsy and was under three different anticonvulsants for appropriate control. Cardiovascular symptoms were absent. Skin inspection revealed hypochromic macules. Respiratory and cardiovascular examinations were normal, as well as laboratorial tests and chest radiography. Electrocardiogram (ECG) showed dome-shaped ST-segment elevation in V2 and V3. Transthoracic echocardiogram unveiled a single hyper-echogenic node (0.4 cm2) in the interventricular septum. Cardiac chambers had normal size and function and Doppler analysis was also normal. No specific medication was used to treat the tumour. During follow-up, she remained free of cardiac symptoms. Eighteen months after her first visit to the cardiologist, routine clinical assessment, ECG, and transthoracic Doppler echocardiogram normal results stated the spontaneous and complete involution of the tumoural lesion.DiscussionConvex ST-segment elevation, generally related to myocardial injury, is unusual in paediatric patients. Once it occurs in asymptomatic individuals within this age bracket, exclusion of cardiac tumours is mandatory. However, data regarding the accuracy of such electrocardiographic marker in this clinical setting are still to be defined.

Premature ventricular contractions of the right ventricular outflow tract: Upward displacement of the ECG unmasks ST elevation in V1 associated with the presence of low voltage areas

Introduction and AimsFrequent premature ventricular contractions (PVCs) originating from the right ventricular outflow tract (RVOT) are usually considered a benign entity and the ECG is typically normal. The aim of this study was to assess whether upward displacement of the ECG to the second intercostal space (ICS) would reveal any abnormal pattern. MethodsA total of 18 consecutive patients with apparently normal hearts were studied, mean age 44±16 years, 12 women, who underwent catheter ablation of the RVOT due to frequent PVCs. A 12-lead ECG was performed in the standard position and repeated in a higher position, at the level of the second ICS. Three-dimensional bipolar electroanatomical voltage mapping (EVM) was performed in all patients and low voltage areas (LVAs) were defined as areas with amplitude <1.5 mV. ResultsThe ECG in the second ICS was normal in eleven patients but in seven (39%) it revealed a pattern of ST-segment elevation in V1. EVM revealed the presence of LVAs in six patients (33%) which included the earliest activation site (EAS) in five. The ST elevation was associated with the presence of LVAs (p<0.0001) and with the LVAs at the EAS (p=0.002). ConclusionIn this group of patients with apparently normal hearts and with frequent PVCs of the RVOT, upward displacement of the ECG revealed the presence of ST elevation in more than one third of patients, and the ST elevation was associated with the presence of LVAs in the RVOT.

Interpretation of electrocardiogram in an ultra-marathon athlete: a case report

The electrocardiogram (ECG) of athletes, especially in those that are endurance-trained, frequently shows some alterations; however, abnormalities of athlete’s ECG may be an expression of an underlying heart disease, which carries a risk of sudden death during sport. It is important that ECG abnormalities are correctly distinguished. We report a case of an ultramarathon athlete who arrived in Emergency Department, after a 100-kilometer race, showing ECG alterations that required further investigations to rule out a cardiac disease. ECG trace showed anterior repolarization abnormalities with ST-segment elevation in V1 to V3 leads. He was admitted to the Cardiology Department and underwent a coronary study that was normal. A cardiac magnetic resonance was also performed. The final diagnosis was athlete’s heart.

Hepatocellular Carcinoma Presenting as ST Elevation in V1 and V2 (Brugada Pattern)

Introduction: Hepatocellular carcinoma (HCC) is usually discovered on routine ultrasound screening in patients with chronic liver disease or when symptomatic enough to warrant investigation. However, initial presentation of HCC as ST—segment elevation in V1 and V2 (Brugada pattern) has never been previously reported. Case Presentation: We report a 63—year—old African American male with past medical history of hypertension, tobacco abuse, and schizophrenia, who presented with 3 weeks of right upper quadrant and epigastric abdominal pain, which was worse when bending over. EKG on admission showed new ST elevation in V1 and V2 with reciprocal changes in inferior leads when compared to previous EKG in June 2016, which was concerning for acute STEMI (Fig. 1). Cardiology was consulted, and the patient underwent cardiac catheterization, which was negative. Following negative cardiac catheterization, he was transferred back to the General Medicine service for workup of his abdominal pain. Abdominal ultrasound was negative for cholecystitis or stones. Due to continued symptoms he received a CT abdomen (Fig. 2), which showed a large mass in the left lobe of the liver, as well as gastric wall thickening and large left upper quadrant varices. The patient at this time acknowledged being diagnosed with hepatitis C infection more than 20 years ago. Gastroenterology was consulted, and the patient underwent EGD, MRCP, and colonoscopy. MRI (Fig. 3) showed 2 focal masses within the left lobe of the liver, findings concerning for infiltrative neoplastic process. Tumor markers, including AFP, CA19—9, and CEA, as well as hepatitis serologies were drawn. AFP was significantly elevated to approximately 10,000 ng/mL, and the diagnosis of hepatocellular carcinoma was considered highly likely. Initial read of triple—phase CT was atypical for hepatocellular carcinoma; therefore, liver biopsy was scheduled with Interventional Radiology. Final read of the CT showed left hepatic lobe mass with invasion and occlusion of the left portal vein, most consistent with hepatocellular carcinoma. Pathology from liver core biopsy was consistent with HCC.3025_A.tif Figure 1: EKG showing ST segment elevation in V1 and V2 (Brugada pattern)3025_B.tif Figure 2: CT abdomen showing a large mass in the left lobe of the liver3025_C.tif Figure 3: MRI abdomen showing 2 focal mass—like areas within medial segment of left lobe of the liverDiscussion: HCC is the ninth most commonly diagnosed cancer worldwide. HCC is usually discovered either during routine screening or when symptomatic. In our case, HCC was presented in a patient with acute epigastric pain and EKG findings of ST—segment elevation. This case shows that intra—abdominal tumors, such as HCC, may present as ST elevation.

Crossover between low molecular weight heparin and unfractionated heparin in patients with acute coronary syndrome undergoing percutaneous coronary intervention: Clinical case report

Objective: Describe of Crossover between low molecular weight heparin (LMWH) and unfractionated heparin (UFH) in patient with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). Method: Descriptive study, report clinical case has acute coronary syndrome undergoing percutaneous coronary intervention, the patient was crossover of LMWH and UFH. Results: A patientas female, 75 years old, admitted to Vietnam National Heart Institute on April, 2018. Reason for hospitalizationas left chest pain, shortness of breath. Medical examination showed the patient with acute coronary syndrome by left chest pain, ST segment elevation in V1 and V2, troponin T increased, suggest the Bloked of the Righ coronary artery (RCA) is the main cause. The result of scan of coronary arteries through radial artery was showed that RCA II is 80% blocked, RCA III is 99% blocked with blood clots. Left anterior descending (LAD) is completely bloked. LCX I is 95% bloked. Beside, collateral circulation is developed, which helps to nurture normal function of left heart muscles. We were conducted to the first PCI for two stent at RCA II and RCA III, the second PCI for the one stent at LCX I. We used crossover between LMW and UFH during PCI, undergoing two times PCI, the patient were conscious and no chest pain, estimate for the LAD by CTO-PCI method on the next time. Conclusion: Crossover between LMWH and UFH in patient with acute coronary syndrome undergoing percutaneous coronary intervention can make safe and more effective.

Takotsubo cardiomyopathy in a young women after cosmetic laser treatment for facial mole removal

Takotsubo cardiomyopathy (TCM), also known as stress cardiomyopathy, is a type of nonischemic cardiomyopathy, in which there is a sudden temporary weakening of the muscular portion of the heart. It is usually the result of severe emotional or physical stress, such as a sudden illness, the loss of a loved one, or a serious accident. The most commonly discussed possible mechanism is stress-induced catecholamine release, with toxicity to and subsequent stunning of the myocardium. We describe a rare case of TCM in a young woman after receiving cosmetic facial mole removal under local laser therapy. She denied history of systemic disease. The patient had chest pain, shortness of breath, elevated cardiac enzymes, and ST-segment elevations in V1–V4. There is absence of significant coronary artery disease in emergent cardiac catheterization. Left ventriculography revealed apical ballooning akinesis with basal hyperkinesis during systole. Takotsubo cardiomyopathy was impressed under above findings. The patient was successfully treated with medical conservative treatment without complication.

Optimal management of Brugada syndrome

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