ST-T Wave Research Articles

Electrocardiogram Abnormalities in Children With Lyme Arthritis.

Classically, Lyme disease follows a staged illness pattern with carditis occurring in early disseminated disease and arthritis in late-stage disease. A more comprehensive understanding of Lyme suggests that clinical stages may intersect. Little is known regarding the overlap of electrocardiogram (ECG) abnormalities in children with Lyme arthritis. This study aimed to estimate the prevalence of ECG changes in pediatric patients presenting with Lyme arthritis. In this retrospective, cross-sectional study was conducted at a tertiary care children's hospital in a Lyme endemic area; patients were identified based on Lyme testing performed from January 2012 to August 2022. Children diagnosed with Lyme arthritis by 2-tiered serology with ECGs obtained within 2 days of antibiotic initiation were included. A study cardiologist reviewed all ECGs for evidence of carditis defined as atrioventricular block, ST-T wave changes, QTc interval prolongation, accelerated junctional rhythm or right bundle branch block. Two hundred thirty-three patients were diagnosed with Lyme arthritis; 90 (38.6%) had ECGs completed. Five patients (5.6%) had ECG abnormalities: 3 were diagnosed with first-degree atrioventricular block, 1 with QTc prolongation, and 1 with ST-T wave changes. No clinical or laboratory features in patients with Lyme arthritis were associated with an increased likelihood of having an abnormal ECG. All patients with ECG abnormalities were treated with oral antibiotics, and none had clinically significant cardiac disease. ECG abnormalities in children with Lyme arthritis rarely occur and, when present, are not reflective of clinically significant cardiac disease. These results do not support routine screening ECGs on asymptomatic pediatric patients with Lyme arthritis.

Prevalence and Risk Factors of Heart Failure with Preserved Ejection Fraction in Middle-Aged Maintenance Haemodialysis Patients on a Twice-Weekly Schedule: Experience from a Single Indian Centre.

Background. Data on the prevalence of cardiac failure with preserved ejection in the haemodialysis population, which impacts treatment strategy, mortality, and morbidity, are scarce. Aims and Objectives. Estimate the prevalence of heart failure with preserved ejection fraction (HFpEF) in haemodialysis patients Classify cardiac failure and ascertain the risk factors influencing HFpEF in haemodialysis patients. Methods. All consenting individuals on haemodialysis over 18 years of age were included. Lung ultrasound was performed as per the LUST study protocol, and the labs were documented. Echocardiographic parameters were measured using two-dimensional (2D ECHO). Results. A total of 102 patients consented to participate in the study, which included 63 males (61.8%) and 39 females (38.2%). The mean patient age was 53 ± 13.1 years. The dialysis vintage of the participants was 38.92 ± 6.947 months. 47 (46.1%) patients had diabetes and 88 (80.4%) had hypertension. ECG findings included sinus rhythm (51/102, 50%), sinus tachycardia (22/102, 21.6%), ST-T wave abnormalities (18/102, 17.6%), and atrial fibrillation (11/102, 10.8%). Heart failure with preserved ejection fraction (HFpEF) was present in 44/102 (43.14%), heart failure with mid-range EF in 14/102 (13.72%), and heart failure with reduced EF in 13/102 (12.7%) patients. The ejection fraction was positively associated with haemoglobin (r = 0.23; p = 0.044), and calcium levels (r = 0.25; p =0 .03). E/lateral e' ratio was positively correlated with NT pro-BNP (r = 0.63; p < 0.001), systolic blood pressure (r = 0.44; p = 0.003) and age (r = 0.353; p = 0.003) and negatively correlated with transferrin saturation (r = -0.353; p = 0.027) and diastolic blood pressure (r = -0.31; p = 0.040). Binary logistic regression analysis revealed that the odds of diastolic dysfunction increased by 2.3 times with each unit increase of creatinine, and diabetics have 7.66 times higher risk for diastolic dysfunction. Binary logistic regression involving ejection fraction (EF) and all laboratory and clinical parameters revealed odds of HFpEF increased by 1.93 times with each unit increase in age, odds of HFpEF increases by 1.53 times with each unit increase in phosphorous and odds of HFpEF increased by 1.1 times with a unit increase of systolic blood pressure. Conclusion. HFpEF is the predominant form of heart failure in haemodialysis patients. Haemoglobin and calcium were positively associated with ejection fraction. Advancing age, elevated creatinine and diabetes mellitus levels are independent predictors of diastolic dysfunction in haemodialysis patients.

The Relationship between Job Strain and Ischemic Heart Disease Mediated by Endothelial Dysfunction Markers and Imaging.

Background and Objectives: Job strain is a psychological, physical, and behavioral stress that occurs at the workplace. Job strain is associated with more than double the normal risk of coronary artery disease (CAD). The main aim of this study was to determine the association between job strain and the following parameters: high-sensitivity C-reactive protein (hs-CRP), the albumin urine excretion rate (AUER), and secondary-level testing. Materials and Methods: This study was a descriptive cross-sectional study conducted on patients who underwent cardiological assessment between October 2023 and February 2024 at the Promedicanon Cardiology Center. This study comprised 210 participants, with two groups: 105 chronic coronary syndromes (CCS) patients and 105 no-CCS patients. The baseline characteristics collected were age, gender, education, rural/urban environment, traditional CAD risk factors, hs-CRP, and AUER. The secondary-level testing included an electrocardiogram (ECG), echocardiography, and enhanced contrast computed tomography (ECCT). Psychological questionnaires comprised the tertiary-level testing, including the PHQ-9 depression questionnaire, and the satisfaction with work scale (SWWS) for job strain (Likert score). Results: The baseline characteristics were all significantly different between the groups (p < 0.05) except for total cholesterol. The hs-CRP level had a mean value of 0.4837 ± 0.19082 in the CCS group; for the no-CCS group, the hs-CRP mean value was 0.2289 ± 0.11009; p-value < 0.001. The AUER had a mean value of 42.770 ± 12.8658 for the CCS group and 26.432 ± 9.7338 for the no-CCS group; p-value < 0.001. For the associations between secondary-level testing and job strain: p < 0.001 for ST depression, negative T-waves, and q-waves; p = 0.415 for atrial fibrillation (AF); p = 0.018 for wall motion studies; p = 0.005 for ECCT. The association between job strain and AF had no statistical significance. The contractility of left ventricle walls and coronary calcification score were associated with job strain, with statistical significance. The p-value was 0.013 for the relationship between depression and the ECCT; for the association between depression and CCS status, the p-value was 0.021. Depression is usually diagnosed in job strain. The association between depression, and coronary calcification, as well as depression and CCS status had statistical significance. Conclusions: Job strain increased the hs-CRP level and AUER in both the CCS and no-CCS patients. The primary and secondary prevention of CHD could also include interventions to reduce job strain.

Electrocardiographic abnormalities in patients with microtia

The main objective of this study was to investigate the incidence and characteristics of electrocardiographic abnormalities in patients with microtia, and to explore cardiac maldevelopment associated with microtia. This retrospective study analyzed a large cohort of microtia patients admitted to Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, from September 2017 to August 2022. The routine electrocardiographic reports of these patients were reviewed to assess the incidence and characteristics of abnormalities. The study included a total of 10,151 patients (5598 in the microtia group and 4553 in the control group) who were admitted to the Plastic Surgery Hospital of Peking Union Medical College. The microtia group had a significantly higher incidence of abnormal electrocardiographies compared to the control group (18.3% vs. 13.6%, P < 0.01), even when excluding sinus irregularity (6.1% vs. 4.4%, P < 0.01). Among the 1025 cases of abnormal electrocardiographies in the microtia group, 686 cases were reported with simple sinus irregularity. After excluding sinus irregularity as abnormal, the most prevalent abnormalities was right bundle branch block (37.5%), followed by sinus bradycardia (17.4%), ST-T wave abnormalities (13.3%), atrial rhythm (9.1%), sinus tachycardia (8.3%), and ventricular high voltage (4.7%). Less common ECG abnormalities included atrial tachycardia (2.1%), ventricular premature contraction (2.4%), and ectopic atrial rhythm (1.8%). atrioventricular block and junctional rhythm were present in 1.2% and 0.9% of the cases, respectively. Wolff Parkinson White syndrome and dextrocardia had a lower prevalence, at 0.6% and 0.9%, respectively. The occurrence of electrocardiographic abnormalities in microtia patients was found to be higher compared to the control group. These findings highlight the potential congenital defect in cardiac electrophysiology beyond the presence of congenital heart defect that coincide with microtia.

Wearable electrocardiogram devices in patients with congenital long QT syndrome: The SMART-QT study

BackgroundIn patients with congenital long QT syndrome (LQTS), the risk of ventricular arrhythmia is correlated with the duration of the corrected QT interval and the changes in the ST-T wave pattern on the 12-lead surface electrocardiogram (12L-ECG). Remote monitoring of these variables could be useful. AimTo evaluate the abilities of two wearable electrocardiogram devices (Apple Watch and KardiaMobile 6L) to provide reliable electrocardiograms in terms of corrected QT interval and ST-T wave patterns in patients with LQTS. MethodsIn a prospective multicentre study (ClinicalTrials.gov identifier: NCT04728100), a 12L-ECG, a 6-lead KardiaMobile 6L electrocardiogram and two single-lead Apple Watch electrocardiograms were recorded in patients with LQTS. The corrected QT interval and ST-T wave patterns were evaluated manually. ResultsOverall, 98 patients with LQTS were included; 12.2% were children and 92.8% had a pathogenic variant in an LQTS gene. The main genotypes were LQTS type 1 (40.8%), LQTS type 2 (36.7%) and LQTS type 3 (7.1%); rarer genotypes were also represented. When comparing the ST-T wave patterns obtained with the 12L-ECG, the level of agreement was moderate with the Apple Watch (k=0.593) and substantial with the KardiaMobile 6L (k=0.651). Regarding the corrected QT interval, the correlation with 12L-ECG was strong for the Apple Watch (r=0.703 in lead II) and moderate for the KardiaMobile 6L (r=0.593). There was a slight overestimation of corrected QT interval with the Apple Watch and a subtle underestimation with the KardiaMobile 6L. ConclusionsIn patients with LQTS, the corrected QT interval and ST-T wave patterns obtained with the Apple Watch and the KardiaMobile 6L correlated with the 12L-ECG. Although wearable electrocardiogram devices cannot replace the 12L-ECG for the follow-up of these patients, they could be interesting additional monitoring tools.

Electrocardiography score based on the Minnesota code classification system predicts cardiovascular mortality in an asymptomatic low-risk population

Background The use of a single abnormal finding on electrocardiography (ECG) is not recommended for stratifying the risk of cardiovascular (CV) events in low-risk general populations because of its low discriminative power. However, the value of a scoring system containing multiple abnormal ECG findings for predicting CV death has not been sufficiently evaluated. Methods In a prospective community-based cohort study, 8417 participants without atherosclerotic CV diseases (ASCVDs) and any related symptoms were followed for 18 years. The standard 12-lead ECGs were recorded at baseline and the ECG findings were categorized using the Minnesota code classification. CV deaths were defined as death from myocardial infarction (MI), chronic ischemic heart disease, heart failure, fatal arrhythmia, cerebrovascular event, pulmonary thromboembolism, peripheral vascular disease and sudden cardiac arrest and identified using the Korean National Statistical Office (KOSTAT) database. Results In a multivariate Cox proportional hazard (CPH) model, major and minor ST-T wave abnormalities, atrial fibrillation (AF), Q waves in the anterior leads, the lack of Q waves in the posterior leads, high amplitudes of the left and right precordial leads, left axis deviation and sinus tachycardia were associated with higher risks of CV deaths. The ECG score consisted of these findings showed modest predictive values represented by C-statistics that ranged from 0.632 to 760 during the follow-up and performed better in the early follow-up period. The ECG score independently predicted CV death after adjustment for relevant covariates in a multivariate model, and improved the predictive performance of the 10-year ASCVD risk estimator and a model of conventional risk factors including age, diabetes and current smoking. The combined ECG score (Harrell’s C-index: 0.852, 95% confidence interval [CI], 0.828–0.876) composed of the ECG score and the conventional risk factors outperformed the 10-year ASCVD risk estimator (Harrell’s C-index: 0.806; 95% CI, 0.780–0.833) and the model of the conventional risk factors (Harrell’s C-index: 0.841, 95% CI, 0.817–0.865) and exhibited an excellent goodness of fit between the predicted and observed probabilities of CV death. Conclusions The ECG score could be useful to predict CV death independently and may add value to the conventional CV risk estimators regarding the risk stratification of CV death in asymptomatic low-risk general populations.

Abstract B043: Challenges in managing cancer patients with congenital coronary artery anomalies: A case report

Abstract Introduction: Congenital coronary artery anomalies are rare cardiac abnormalities that can increase the risk of sudden cardiac death, particularly during exercise. Patients with cancer and concurrent coronary artery disease face higher mortality risks, as they often receive delayed percutaneous coronary intervention. Additionally, anthracycline chemotherapy, commonly used in cancer treatment, can cause cardiotoxicity and worsen pre-existing cardiac abnormalities. Despite the complexity of managing cancer patients with coronary artery anomalies, there is a lack of clear guidelines and consensus on optimal approaches. This report presents a unique case of a patient with a malignant inter-arterial course of the right coronary artery and newly diagnosed Human T-lymphotropic virus type I-associated adult T-cell leukemia/lymphoma, discussing the challenges and implications of chemotherapy in such cases. Case Presentation: A 38-year-old male presented with weakness and palpitations, exhibiting abnormal laboratory findings. CT angiography revealed a malignant inter-arterial course of the right coronary artery with severe narrowing. Electrocardiograms showed ST elevations and subsequent T-wave inversions. Despite the increased risk of cardiomyopathy due to the coronary anomaly, the patient required chemotherapy for life-threatening tumor lysis syndrome and refractory lactic acidosis. Anthracycline-based chemotherapy was initiated, and a follow-up echocardiogram after six months showed no acute changes. Conclusion: Managing cancer patients receiving anthracycline chemotherapy remains challenging due to limited guidelines. Anthracycline-induced cardiotoxicity is a concern, especially in patients with pre-existing cardiac anomalies like the malignant inter-arterial course of the right coronary artery. This case emphasizes the importance of recognizing and managing such anomalies in cancer patients to reduce the risk of sudden cardiac death. The higher mortality risk in cancer patients with coronary artery disease highlights the need for guidelines in managing anomalous coronary vessels in cancer patients. Further research is necessary to develop evidence-based strategies for managing cardiac complications in cancer patients, particularly those with pre-existing cardiac anomalies. Citation Format: Aliya M. Khan, Sophia Navajas Urisote, Danish A. Sheikh. Challenges in managing cancer patients with congenital coronary artery anomalies: A case report [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr B043.

Abstract 13153: Non-Rheumatic Streptococcal Myocarditis Manifesting as Acute Non-ST-Elevation Myocardial Infarction

Case presentation: A 24-year-old healthy man presented with acute, constant, non-radiating, chest pain with pleuritic quality. Three days prior, he had developed fever, sore throat, cervical lymphadenopathy, and tachycardia. Amoxicillin was given for a positive rapid streptococcal test. He was afebrile and bradycardic at 50 bpm. Lab showed leukocytosis (WBC 20,000/μL, neutrophil 80%), elevated ESR 70 mm/hr, CRP 23 mg/dL, and rising hs-cTn from 800 to 1,700 ng/L. Anti-streptolysin O and anti-DNase-B were normal. Tests for adenovirus, EBV, CMV, and other respiratory viruses were negative. Initial EKG showed sinus bradycardia with ST depression and T-wave inversion in V1-V2 and III. CXR and echo were unremarkable. He received intravenous penicillin G and indomethacin. Chest pain resolved on the following day. Repeat EKG showed resolution of bradycardia, ST depression, and T-wave inversion in V2. Indomethacin, colchicine, and amoxicillin were given upon discharge. Discussion: In contrast to acute rheumatic fever (ARF), a condition caused by molecular mimicry leading to cross-reactive humoral and cellular immune responses between cardiac and Streptococcus pyogenes antigens, the pathophysiology of non-rheumatic streptococcal myocarditis is presumably toxin-mediated. Although the revised Jones criteria were fulfilled in our patient, the temporal relationship between pharyngitis and the onset of carditis must be taken into account to distinguish these two entities. Concurrent myocarditis and pharyngitis suggest non-rheumatic streptococcal myocarditis, as opposed to a delayed presentation in ARF. Latency from pharyngitis to chest pain was reportedly around 3 days. The absence of valvular heart disease and streptococcal antibodies, such as anti-streptolysin O and anti-DNase B, are a clue to diagnosis. A recent case-series also suggested male-predominance. There has been an increase in a diagnosis of non-rheumatic streptococcal myocarditis due to a widespread use of diagnostic modalities such as MRI. Clinicians should consider this condition in a differential diagnosis of acute coronary syndrome, particularly in any young individuals with chest pain, elevated cardiac biomarkers, EKG changes, and simultaneous streptococcal pharyngitis.

Polypharmacy, Gender Disparities, and Ethnic and Racial Predispositions in Long QT Syndrome: An In-Depth Review.

Long QT syndrome (LQTS) is a complex disorder of cardiac electrophysiology. It is characterized by delayed myocardial polarization leading to QT prolongation and alterations on the ST segment and Twave visible on electrocardiogram (ECG). Syncope is a common manifestation, and torsade de pointes (TdP) can lead to sudden cardiac death. Three major LQTS genes (KCI31, KCNH2, and SCN5) lead to most of the cases of LQTS. Lifestyle modifications, beta blockers, and implantable cardioverterdefibrillator(ICD) placement are the main treatments for LQTS. Polypharmacy, including QT-prolonging drugs, has been shown to worsen LQTS. The impact on potassium channels and the human ether-a-go-go-related gene (hERG) is the mechanism behind the QT interval prolongation caused by these medications. There is an increased incidence of LQTS among African-American men and women as compared to Caucasians. Women with LQTS tend to have a higher mortality rate from the condition, especially during menstruation and shortly after giving birth. Genetic testing is reserved to those patientswho exhibit either a strong clinical index of suspicion or experience persistent QT prolongation despite their lack of symptoms. Knowing the genetics, racial, and gender discrepancies can help improve patient management and a better comprehension on each case. Proper understanding of how ion channels function and their interaction with medications will lead to a better comprehension and to develop effective forms to treat those patients.

Ophthalmological and radiological findings in patients of hypertensive crisis reporting to an intensive care setting

Background: The term “hypertensive crisis (HC)” is used to describe both hypertensive emergencies and hypertensive urgencies. Hypertensive emergencies are characterized by the presence of target organ damage, whereas hypertensive urgencies do not involve such organ damage. Methods: The main objective of this research was to evaluate all prevalence and clinical profiles of HC in an intensive care unit (ICU). A consecutive type of nonprobability sampling was followed during the study period for the selection of the study sample. A total of 50 patients fulfilling the criteria of eligibility were used for this research with proper informed consent. Results: Of the 50 patients reporting to the ICU with hypertensive emergencies and urgency, the most common systemic involvement was neurological, followed by cardiac. On Electrocardiographic (ECG), ST-T wave changes were seen in 46% of cases, whereas left ventricular hypertrophy was reported in 22% of cases. Conclusions: Hypertensive retinopathy was the most common ophthalmological finding, SR-T wave changes were the most common ECG finding, and intracerebral hemorrhage was the most common computed tomography finding in patients of HC.

Significance of electrocardiogram abnormalities in children presenting to the emergency department with acute COVID-19 infection

ObjectivesAcute COVID-19 infection may be associated with electrocardiogram (EKG) abnormalities in pediatric patients. We have anecdotally observed EKG abnormalities in patients without MIS-C or significant cardiac disease requiring intervention or further follow-up. Our aim was to determine the incidence of abnormal EKG findings and correlate with evidence of significant cardiac pathology in pediatric patients who present to the emergency department during an acute COVID-19 infection. MethodsWe conducted a retrospective chart review of 209 pediatric patients diagnosed in the emergency department with acute COVID-19 infection and had an EKG during the same encounter; patients with MIS-C were excluded. Primary objectives included determination of the incidence of EKG abnormalities in patients presenting to the emergency department (ED) with acute COVID-19 infection who did not require hospitalization. Secondary objectives included correlation of these findings with other concomitant testing of possible cardiac pathology (echocardiograms, biomarkers), and clinical outcomes. ResultsEKG abnormalities were identified in 84 (40%) patients. Echo was performed in 28 (13.4%) patients; only 1 was abnormal, and considered an incidental finding. The most common EKG abnormality involved nonspecific ST-T wave patterns, suggestive of but not diagnostic for underlying pericardial or myocardial disease. Serum troponin and BNP values were normal in all patients tested, either with a normal or abnormal EKG. A normal EKG had a 100% sensitivity and negative predictive value in predicting a normal echocardiogram. No patients were hospitalized and there was normalization of EKG abnormalities during short-term follow up. ConclusionsDespite a high incidence of abnormal EKG repolarization patterns in pediatric patients presenting with acute (non-MIS-C) COVID-19 infections, these patients generally do not have abnormal cardiac biomarkers or echocardiograms, and the risk for adverse cardiac events is low.

The Case Files

The Case Files

Whether and what abnormalities we find in ECG records and 24-hour Holter ECG in patients after COVID-19 without hospitalization with cardiac damage

Abstract Funding Acknowledgements Type of funding sources: None. Cardiac arrhythmias and cardiac damage (CD) are more common in hospitalized patients with COVID-19. Many studies have shown that arrhythmias are an independent risk factor for death and the course of COVID-19 in these patients. However, there are no publications on the impact of the SARS CoV-2 on patients with a domestic course of COVID-19 without a previous history of cardiovascular disease. The aim of the study was to assess whether and what arrhythmias occur in patients in the early period after the course of COVID-19 without hospitalisation and to assess which of them may be predictors of heart damage after COVID-19. Methods In patients, in the post-COVID period (mean 12 ± 6 weeks) a standard 12-lead ECG (ECG) and 24-h Holter ECG (Holter) were performed. Following parameters were analysed: 1. in ECG: mean heart rate (mHR); PQ interval (PQ), QRS duration (QRSd); corrected QT interval (QTc); atrial fibrillation (AF); inappropriate sinus tachycardia (ITS), QRS duration &amp;gt; 120ms (QRS&amp;gt;120); LBBB, RBBB, QRS fragmentation (QRSf); STT wave abnormalities (STTabn); presence of premature supraventricular (SVES) and ventricular (VES) complexes; 2. in 24-h Holter ECG: sinus tachycardia (STach), new atrial fibrillation (AFHolter), SVES &amp;gt; 1000/24h (SVES&amp;gt;1000); supraventricular tachycardia (TSV), VES &amp;gt; 1000/24h (VES&amp;gt;1000), Couplet VES (VEScouplet), non-sustained ventricular tachycardia (nsVT); ventricular tachycardia (VT), block A-V 2nd typ 2 and/or block A-V 3rd grade (AVdist). Cardiac damage (CardD) was defined as EF&amp;lt;50% and/or any contraction abnormalities in ECHO and/or MRI examination. Patients were divided into two groups depending on the cardiac damage: Gr 1 without CardD and Gr 2 with CardD. Next ECG and Holter parameters were compared between both groups. Results A total of 1032 patients, (64% women and 36% men), mean age was 47.8± 16.5 were included in the analysis, of whom 91 pts (9,28%) met the cardiac damage criteria. The most frequent ECG abnormalities QRS fragmentations in 17,3% pts – noted in 17,3%. In no one pts VT and or VF was found. Comparison between groups in analysed parameters are shown IN Table 1 and Table 2 Multivariate regression analysis showed that: age (OR 1.02, 95%Cl 1.00-1.104; p=0.028), LBBB (OR 30.82; 95%Cl 1.99-475.80; p=0,014), VES&amp;gt;1000/24h (OR 7.97; 95%Cl 1.68 -37.78; p=0,008), nsVT (OR 6.20; 95%Cl 1.22-31.62; p=0,028) were associated with a higher risk of cardiac injury in the post COVID period However female were lower risk of cardiac damage (OR 0,27, 95%Cl 0.14-0.41; p&amp;lt;0.001) Conclusions Based on the obtained results, it can be concluded that the most common cardiac arrhythmias which predict cardiac damage in patients in the early period after the course of COVID-19 without hospitalization were LBBB, ventricular extrasystoles VES&amp;gt;1000/24h and non-sustained ventricular tachycardia. In addition, age (elderly people) and sex (male) predispose to myocardial damage after COVID-19.

Long-term outcome of interventional approaches for treatment of coronary artery fistulas: a retrospective cohort study in a great referral center

BackgroundDespite the spontaneous regression of many cases of coronary artery fistulas (CAFs), symptomatic patients or cases with severe shunting may require therapeutic interventions. In the present study, we aimed to assess the outcome of treatment of CAFs using interventional approaches.MethodsThis retrospective cohort study was performed on 29 patients with CAFs that were referred to our tertiary center between 2009 and 2019. Baseline characteristics were collected by reviewing the hospital files, and the patients were followed up to assess long-term outcomes with a mean follow-up of 3.3 years.ResultsOverall, in 29 patients in our cohort study, 82.9% suffered from isolated CAFs and in the remaining cases, concurrent congenital abnormalities did exist. For treatment, coils (Cook, Pfm, Ev3) were used in 79.3%, ADO II(AGA) in 18.3%, vascular plug (AGA) in 3.4%, and a combination of coil/ vascular plug/amplatzer in 3.4%. Postoperative complications were reported in 4 patients as external iliac artery thrombosis, transient PSVT, ST-T wave changes and mild pericardial effusion that were all managed successfully with no adverse sequels. No coronary artery injury, device dislocation, dissection, ischemia or coronary dilatation occurred, and there was no death. As larger fistulas were treated by a retrograde approach through the right side of the heart, there was significant correlation between residual shunts and the mode of closure approach; the majority of the residual shunts occurred in patients in the retrograde approach group.ConclusionsTrans-catheter approach for treating CAFs leads to appropriate long-term outcome with minimal potential side effects.

Retained peripherally inserted central catheter guidewire with vegetation.

Sir, Central venous cannulation is often a necessity for patients in intensive care units or in patients with difficult peripheral access. Loss of the guidewire is a serious and potentially life-threatening complication with reports of fatalities in up to 20% of cases, when the complete guide wire is lost.[1] A 2-year 3-month-old female child presented to our institute with chief complaints of poor weight gain, abdominal discomfort, and decrease in appetite. Chest X-ray of the patient showed a radio-dense wire extending into inferior vena cava (IVC) and right atrium [Figure 1]. Patient had a history of hospital admission at the age of 8 months for jaundice. Peripherally inserted central catheter (PICC) was inserted at that hospital in right femoral vein due to difficult peripheral venous cannulation. PICC line was kept for 12 days and later it was removed. Later on, patient presented to our institute with above mentioned complaints. Computerised tomography (CT) scan showed evidence of a linear radio-dense wire extending from infrarenal IVC into the right ventricle. Its tip was seen in the superior vena cava suggestive of foreign material [Figure 1b]. Transthoracic echocardiography showed a hyperechoic mobile structure of size 20 × 10 mm (possibly a vegetation) in the right atrium having attachment to the superior vena cava and IVC with to-and-fro movement across tricuspid valve and near total occlusion of IVC by hyperechoic structure till mid abdomen level [Video 1]. Moderate to severe tricuspid regurgitation (TR) was seen on transthoracic echocardiography. Surgical removal of PICC guidewire was planned. Complete blood count, serum electrolytes, coagulation profile, liver, and kidney function tests were done preoperatively. Preoperative electrocardiogram showed sinus tachycardia and nonspecific ST-T wave changes. The open surgical repair was planned under hypothermic cardiopulmonary bypassFigure 1: (a) Chest X-.Ray PA view showing a radio dense wire extending into inferior vena cava and right atrium. (b) Computerised tomography scan showing evidence of a linear Ra: Right atrium dense wire extending from infrarenal IVC, extending into right ventricle and the tip is seen in superior vena cava suggesting foreign material. (c) Guidewire with vegetation. (d) Right atrium opened with blocked IVC. IVC: Inferior vena cava {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video Clip 1","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_0bc3rv32"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Patient was induced with general anaesthesia and endotracheal intubation carried out after injecting fentanyl 5 mg/kg, midazolam 0.1 mg/kg, and vecuronium 0.1 mg/kg. Five lead electrocardiogram, invasive arterial blood pressure, central venous pressure, temperature, end tidal carbon dioxide, pulse oximetry, and urine output were monitored intraoperatively. Cardiopulmonary bypass (CPB) was established after cannulating ascending aorta and right atrium. Total circulatory arrest was initiated. Right atrium was opened and removal of guidewire with vegetation from right atrial wall and tricuspid valve leaflet were done [Figure 1c and 1d]. Tricuspid valve was checked for tricuspid regurgitation and anteroseptal commissuroplasty was done. Post repair, moderate to severe tricuspid regurgitation was present. CPB was instituted again, and tricuspid valve was repaired. After complete rewarming, patient was weaned off CPB uneventfully. 180 ml of packed red blood cells was transfused intraoperatively. Total duration of surgery was four hours. Patient was shifted to paediatric intensive care unit and was extubated on second postoperative day. Complications pertaining to the retained guide wire include complete loss of wire, injury to the vessel from the wire, fracture of the wire, and bleeding.[1–5] Patients undergoing foreign body removal pose a challenge for the anaesthesiologist as there can be risk of arrhythmia, bleeding causing haemodynamic instability, prolonged aortic cross clamp time, and postbypass myocardial dysfunction. Percutaneous retrieval was not possible in this case due to the extent of guide wire with associated vegetation and risk of its embolisation. Therefore, decision was made for surgical plan to remove guide wire under cardiopulmonary bypass. This case highlights the importance of formulating a plan for the anaesthetic management of patients undergoing guidewire removal and preparedness for postoperative management. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Cardiovascular profile and electrocardiographic findings of hospitalized adult patients during the surge of delta and omicron variants of COVID-19 in a COVID-19 tertiary referral center

Abstract Funding Acknowledgements Type of funding sources: None. Background COVID-19 has been reported to cause cardiac injury. It can be detected by an electrocardiogram (ECG), which may show markers that may predict clinical outcome. Robust data on the ECG abnormalities among COVID-19 patients affected by the alpha, beta, and gamma variants have been reported, but there is paucity of data among patients affected by the delta and omicron variants. Purpose This study aims to describe the cardiovascular profile, ECG findings, and clinical course of adult patients with COVID-19, and to determine the association between certain ECG findings and clinical outcomes among these patients. Methods We evaluated 547 COVID-19 patients admitted from June 2021 to June 2022. Clinical profiles were extracted from electronic records. Admission ECGs were independently read and adjudicated by three cardiologists. Logistic regression analysis was done to determine the association between ECG abnormalities and adverse outcomes, including in-hospital mortality, ICU admission, need for mechanical ventilation, acute respiratory distress syndrome (ARDS), shock, acute kidney injury (AKI), myocardial infarction (MI), myocarditis, venous thromboembolism (VTE), and stroke. Results A Total of 547 COVID-19 patients (mean age 54; men 51.2%) were included. The most common comorbidities were hypertension, diabetes, and dyslipidemia. Majority of patients had severe COVID-19 infection (36%). On admission, 6.4% needed intubation and 14.6% died. The most common ECG abnormalities were non-specific ST-T wave changes (41.1%) and sinus tachycardia (25.6%). Other findings were ST segment depression (3.3%), T wave inversion (1.6%), and ST segment elevation (1.3%). On logistic regression analysis, intraventricular conduction delay (IVCD), T wave inversion, and poor R wave progression were significantly associated with mortality; sinus tachycardia, atrioventricular (AV) block, ST segment elevation, and T wave inversion were significantly associated with the development of VTE; left axis deviation, ST segment elevation, and T wave inversion were significantly associated with the development of ARDS; sinus tachycardia, ST segment depression, and T wave inversion were significantly associated with the development of shock; and sinus tachycardia, ST segment elevation, and early repolarization changes were significantly associated with ICU admission. No associations were established for AKI, MI, myocarditis, and need for mechanical ventilation due to the low prevalence of these outcomes. Conclusion A baseline ECG in patients with COVID-19 may help predict patients who may warrant hospitalization or even intensive care monitoring. In our cohort, certain ECG abnormalities, especially sinus tachycardia, left axis deviation, ST segment elevation, ST segment depression, T wave inversion, AV block, IVCD, poor R wave progression, and early repolarization changes, were associated with adverse clinical outcomes, including in-hospital mortality.

The Prevalence of Pathologic Q Waves on Electrocardiograms of Pediatric Patients with Confirmed Hypertrophic Cardiomyopathy: A Systematic Review of the Literature

Objectives The electrocardiogram (ECG) of patients with hypertrophic cardiomyopathy (HCM) ranges from normal to exhibiting evidence of ventricular hypertrophy, including pathologic Q waves and ST-T wave changes. Deep Q waves in the inferior and lateral leads are one of the classic ECG findings associated with HCM. The prevalence or frequency of this finding in pediatric HCM patients, however, is not well-established. Furthermore, other pediatric health conditions have also been associated with pathologic and non-pathologic Q waves and an awareness of those conditions is important to consider when Q waves are observed. The primary goal of this systematic review of the literature is to describe the prevalence of pathologic Q waves in the ECGs of pediatric patients with echocardiogram proven HCM. A secondary goal is to review other pediatric conditions that can present with pathologic and non-pathologic Q waves. Methods The databases PubMed, Web of Science, Scopus and cumulative index to nursing and allied health literature (CINAHL) were searched utilizing the preferred reporting items for systematic reviews and meta-analyses (PRISMA) format. The Rayyan systemic review software was used to screen articles for final review. The initial search (Search 1) consisted of the following terms: “dagger Q wave”, “dagger-like Q waves”, “dagger shape Q waves”. Subsequently, a broader search (Search 2) was conducted to determine if viable articles were omitted in the first search. This broader search strategy eliminated the term “HCM”. The authors then performed detailed review of the articles these two searches yielded, as well as a review of the references of these articles to find other relevant articles as well as produce a list of other pediatric conditions that may be associated with pathologic or nonpathologic Q waves. Results Of the articles found via the three searches, a total of nine English language articles that specifically addressed the prevalence of pathological Q waves in pediatric HCM patients were ultimately included in our systematic review. These nine articles described a total of 845 pediatric patients with HCM. Of these, 258 (30.5%) demonstrated pathological Q waves on their electrocardiograms. The range of percentages reported for pathological Q waves was 12.5 to 66.7%. Additionally, our review found fifteen different pediatric conditions reported to be associated with pathologic or non-pathologic Q waves. Conclusion Our systematic review confirmed that pathologic Q waves are a common and early electrocardiographic finding in children with HCM and may, in fact, be the only ECG finding. In addition, our review provided an extensive list of other pediatric diseases and conditions associated with pathologic or non-pathologic Q waves on the electrocardiogram.

Conduction system disorders and electrocardiographic findings in COVID-19 deceased patients in 2021, Shiraz, Iran.

Cardiac conduction disorders and electrocardiographic (ECG) changes may occur as a manifestation of coronavirus disease 2019 (COVID-19), especially in severe cases. To describe conduction system disorders and their association with other electrocardiographic parameters in patients who died of COVID-19. In this cross-sectional study, electrocardiographic and clinical data of 432 patients who expired from COVID-19 between August 1st, 2021, and December 1st, 2021, in a tertiary hospital were reviewed. Among 432 patients who died from COVID-19, atrioventricular block (AVB) was found in 40 (9.3%). Among these 40 patients, 28 (6.5%) suffered from 1st degree AVB, and 12 (2.8%) suffered from complete heart block (CHB). Changes in ST-T wave, compatible with myocardial infarction or localized myocarditis, appeared in 189 (59.0%). Findings compatible with myocardial injury, such as fragmented QRS and prolonged QTc, were found in 91 patients (21.1%) and 28 patients (6.5%), respectively. In patients who died of COVID-19, conduction disorder was unrelated to any underlying medical condition. Fragmented QRS, axis deviation, and ST-T changes were significantly related to conduction system disorder in patients who died of COVID-19 (P value < 0.05). Conduction system disorders are associated with several other ECG abnormalities, especially those indicative of myocardial ischemia or inflammation. Most patients (73.14%) who died of COVID-19 demonstrated at least one ECG abnormality parameter. Since a COVID-19 patient's ECG gives important information regarding their cardiac health, our findings can help develop a risk stratification method for at-risk COVID-19 patients in future studies.

A Rare Case Report of Ruptured Sinus of Valsalva Aneurysm

&lt;p&gt;主動脈竇動脈瘤是一種罕見的心臟結構病變，因具非特異性表徵及困難診斷，容易導致高死亡風險。本案例是一位53歲男性患者，因急性胸痛入院治療，藉由實驗室檢查發現心肌酵素升高、D-二聚體升高，心電圖檢查為aVR導程ST段上升、於第I、II、V4~6導程出現ST-T波段變化，初步診斷為左冠狀動脈主幹心肌梗塞，立即行冠狀動脈攝影檢查發現無異常。個案出現胸痛合併心因性休克之症狀，從中排除主動脈剝離、肺栓塞、心包填塞等診斷，深入檢視病史紀錄及影像報告，發現心臟超音波、胸部電腦斷層及冠狀動脈血管攝影檢查有由左流向右心室的瘻管分流，最終確診為主動脈竇動脈瘤破裂。患者緊急接受右冠狀竇動脈瘤修補及主動脈瓣置換手術治療後，胸痛、休克狀況改善且左心室功能恢復，術後預後良好。在面對急性胸痛合併血液動力學不穩定的患者時，除了須考慮症狀相關的疾病診斷外，當聽診發現S1及S2連續性心雜音時，建議將主動脈竇動脈瘤破裂列入考慮，以掌握治療處置之重要時機。&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;&lt;p&gt;Aneurysm of the sinus of Valsalva is a rare cardiac anomaly due to the nonspecific symptoms and dif-ficult confirmation of diagnosis leading to high mortality. This report describes the case of a 53-year-old man who had suffered from acute chest pain. The electrocardiogram showed the ST segment ele-vation in lead aVR and ST-T wave changes in leads I, II and V4-6. Elevated D-dimer levels and cardi-ac enzymes were also observed. Acute myocardial infarction caused by the left main coronary artery obstruction was initial diagnosed. Coronary angiogram was performed immediately and the result indicated non-obstructive coronary artery. However, cardiogenic shock with persistent chest pain was discovered. Aortic dissection, pulmonary thromboembolism and cardiac tamponade were gradually excluded. Through detailed review and analysis of medical history, physical assessment and image ex-aminations with echocardiography, chest computed tomography and coronary angiogram, a ruptured sinus of Valsalva aneurysm was eventually diagnosed based on image examinations which revealed left-to-right shunt communicating with the right-sided heart chambers. The patient received emergen-cy right coronary sinus aneurysm repairment and aortic valve replacement surgery. Symptoms with chest pain and shock gradually disappeared and left ventricular function was restored postoperatively. The patient demonstrated excellent recovery. In facing relevance diagnostics for patients with acute chest pain and hemodynamic instability, a ruptured sinus of Valsalva aneurysm must be considered to endure best treatment timing if heart auscultation reveals S1 and S2 continuous murmurs.&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

Acil Servise Başvuran Covid-19 Hastalarında sık görülen EKG Değişiklikleri ve EKG Bulgularının Prognostik Önemi

Aim: &#x0D; It is known that cardiac involvement may occur in patients with COVID-19 infection. And one of the best diagnostic tools of cardiac involvement is the ECG. The aim of this study is to investigate the common ECG findings in COVID-19 infection and the effect of these findings on the prognosis.&#x0D; Material and Method:&#x0D; 215 patients who applied to our emergency department between 04.06.2022 and 04.08.2022 and met the criteria for inclusion in the study were included in this study. All patient results and ECG images were accessed from the hospital data recording system. The results were used for statistical analysis.&#x0D; Results:&#x0D; Of 215 patients, 118 were female and 97 were male, and the mean age was 58±21 years. Of these patients, 52 were hospitalized in the service and 17 were hospitalized in intensive care units, and 146 patients were discharged from the emergency department. The most common ECG finding was ST-T wave change. It was observed that there was a correlation between the detection of VT in the ECG and the intensive care unit admission. It was observed that the ECG findings of the patients had no effect on the prognosis.&#x0D; Conclusion: &#x0D; All ECG findings can be seen in patients admitted to the emergency department with COVID-19 infection. The most common ECG finding is ST-T wave change. In addition, long QTc, sinus tachycardia and AF are also common. However, no correlation was found between ECG findings and disease prognosis.