Compression of a giant pseudomeningocele causing transient anoxic seizures-a case report.

Transient anoxic seizure upon application of pressure on a giant pseudomeningocele has never been reported in the literature; such abrupt changes in intracranial pressure due to large volume of cerebrospinal fluid (CSF) translocation, if left untreated may lead to permanent cerebral hypoxic injury and death. Here we describe a case of a 26-year-old woman who had undergone lumbar disc surgery in another unit few months ago and developed a large lump around her back. Any pressure on the lump resulted in headaches and at times episodes of seizures. Clinical examination revealed a very large fluid-filled lump consistent with a giant pseudomeningocele, confirmed by an MRI. A video EEG while applying pressure on the lump was recorded. The patient developed a typical seizure attack with a characteristic pattern of cerebral anoxia, and a paired ECG showed irregular rhythm with junctional and ventricular ectopic beats during the latter part of the attack, raising a suspicion of asystole. Upon relieving the pressure off the lump, the patient gradually regained consciousness with no permanent neurological deficit. We then discuss the pathophysiology of anoxic seizures and highlight the need to be vigilant in managing patients with such lesions in order to prevent permanent cerebral hypoxic injury and death.

Trigeminia de la bigeminia ventricular por mecanismo reentrante: reentrada de la reentrada / Trigeminy of ventricular bigeminy caused by reentrant mechanism: reentry of reentry

El proceso post-infarto agudo de miocardio genera el sustrato apropiado para la formación de circuitos de reentrada, los cuales son considerados como el mecanismo más frecuente de las extrasístoles y taquiarritmias ventriculares. Presentamos el trazado electrocardiográfico de un paciente con infarto agudo de miocardio en quien se observó la inusual concurrencia de una trigeminia ventricular acoplada a extrasístoles ventriculares bigeminadas, que originó una secuencia de trigeminia sobre la bigeminia, evidenciando la existencia de dos circuitos reentrantes (reentrada de la reentrada); después de una dupla de la extrasístole bigeminada se genera un aleteo ventricular.

The process that follows an acute myocardial infarction generates an appropriate substrate for the formation of reentry circuits, considered to be the most frequent mechanism of ventricular extrasystoles and tachyarrhythmias. We present the case of a patient with an acute myocardial infarction unusually concurring with ventricular trigeminy coupled to ventricular bigeminated extrasystoles giving rise to a trigeminy sequence over the bigeminy, which indicates the existence of two reentry circuits (reentry of reentry) that trigger ventricular flutter.

[Effect of bronchoalveolar lavage on the heart rhythm and conduction of the children with severe pneumonia].

OBJECTIVE: To observe the effect of bronchoalveolar lavage on the heart rhythm and conduction of children with severe pneumonia through monitoring the electrocardiogram change of different step of the bronchoalveolar lavage, for proving the safety of the operation of bronchoalveolar lavage from the perspective of cardiac electrophysiology. METHOD: From July 2011 to March 2012, 30 patients who were hospitalized in pneumology department of Dalian Children's Hospital and met the inclusion criteria and therapeutic indications of bronchoalveolar lavage were chosen. They were 3 to 12 years old, the average age was 5.3 years, including 17 boys and 13 girls, the ratio of boys and girls is 1.3: 1. Continuous sampling the electrocardiogram before and during the process including anesthesia, entering into glottis, lavage, aspiration, and revive, and recording the heart rate, rhythm amplitude and width of P wave, the PR interval, the form and width of QRS complex were also measured. The recorded data were analyzed and statistical analysis to reflect the change of the cardiac electrophysiology. RESULT: The incidence of heart rate increase was 100.0%, 26 (86.7%) patients began to emerge after anesthesia, the rest of the patients also developed heart rate increase after the start of bronchoscopic operation. All patients had sinus tachycardia, and were most obvious in the progress of lavage and revive. In the process of entering into glottis, lavage, aspiration, 13 (43.3%) patients had arrhythmia episodes. Types of arrhythmia included sinus bradycardia, atrioventricular block and premature beat. Incidences of intraoperative arrhythmia compared with the pre- and post-operation were all statistically significantly different (P = 0.00). The most common arrhythmia were premature beat, in 17 of the 30 cases there were premature beat including 9 cases with atrial premature beats and 8 cases ventricular premature contraction. Two patients had III° atrioventricular block accompanied by serious sinus bradycardia. All kinds of arrhythmias except sinus tachycardia disappeared after the operation was ended. Five patients (16.7%) had PR interval prolongation. Five patients (16.7%) had incomplete right bundle branch block (IRBBB) . Incidences of IRBBB compared with the pre-operation and post-operation were all not significantly different [13.3% (n = 4) vs. 0(n = 0) and 3.3% (n = 1), all P > 0.05]. Different operating progress made no significant difference in the measurement value of electrocardiogram[13.3% (n = 4) vs. 0(n = 0) and 3.3% (n = 1), all P > 0.05], but showed the most notable effect on heart rate. CONCLUSION: Bronchoalveolar lavage can influence the heart rhythm and conduction, but most of the influence with pathological significance are transient. Cardiac electrophysiological changes were the most obvious in endotracheal operation with the risk of malignant arrhythmia but the risk is low, the bronchoalveolar lavage technique is safe. The contingency plans for dealing with all kinds of adverse reactions must be ready before the operations of bronchoalveolar lavage. During the procedure, the patient's ECG changes should be closely monitored to reduce the incidence of adverse reactions.

Role of sarcolemmal BK(Ca) channels in stretch-induced extrasystoles in isolated chick hearts.

BACKGROUND: It remains unclear whether sarcolemmal BK(Ca) channels in post-hatch chick ventricular myocytes contribute to stretch-induced extrasystoles (SIE), and whether they are stretch-activated BK(Ca) (SAK(Ca)) channels or a non-stretch-sensitive BK(Ca) variant. METHODS AND RESULTS: To determine the role of sarcolemmal BK(Ca) channels in SIE and their stretch sensitivity, an isolated 2-week-old Langendorff-perfused chick heart and mathematical simulation were used. The ventricular wall was rapidly stretched by application of a volume change pulse. As the speed of the stretch increased, the probability of SIE also significantly increased, significantly shortening the delay between SIE and the initiation of the stretch. Application of 100 nmol/L of Grammostola spatulata mechanotoxin 4, a cation-selective stretch-activated channel (SAC) blocker, significantly decreased the probability of SIE. The application of Iberiotoxin, however, a BK(Ca) channel blocker, significantly increased the probability of SIE, suggesting that a K(+) efflux via a sarcolemmal BK(Ca) channel reduces SIE by balancing out stretch-induced cation influx via SACs. The simulation using a cardiomyocyte model combined with a new stretch sensitivity model that considers viscoelastic intracellular force transmission showed that stretch sensitivity in BK(Ca) channels is required to reproduce the present wet experimental results. CONCLUSIONS: Sarcolemmal BK(Ca) channels in post-hatch chick ventricular myocytes are SAK(Ca) channels, and they have a suppressive effect on SIE.

Protective effects of estrogen against reperfusion arrhythmias following severe myocardial ischemia in rats.

BACKGROUND: Female sex hormones may have protective effects against arrhythmias, including reperfusion arrhythmias (RAs), but the mechanisms are still not completely known. METHODS AND RESULTS: Serial changes in rat hearts (rhythm, apoptosis and the its infuencing factors; cardiac vinculin mRNA expression and connexin43 (Cx43) dephosphorylation) were examined during periods of ischemia-reperfusion with and without estrogen treatment. After reperfusion, although the incidence of arrhythmias became higher in both the vehicle-group and estrogen-group, compared with the ischemia period, estrogen prevented reperfusion-induced upregulation of the incidence of arrhythmias, especially ventricular premature beats (VPB) and ventricular tachycardia (VT). The duration of VT and fibrillation, and the number of VPB and VT, were all significantly decreased in the estrogen-group. The expression of cardiac vinculin mRNA decreased significantly in the vehicle-group but not in the estrogen-group. Cx43 dephosphorylation and myocyte apoptosis increased in both groups, but the values for the estrogen-group were all markedly lower than those for the vehicle-group. A selective estrogen receptor (ER) beta agonist prevented reperfusion-induced upregulation of the incidence of both VPB and VT significantly; a selective ERalpha agonist had no significant influence. CONCLUSIONS: Estrogen can protect the heart against RAs, at least in part, mediated through gap junctions. Upregulation of ERbeta but not ERalpha mediated most of the estrogen-induced cardioprotection against RA.

Cardiovascular toxicity of cryopreserved cord blood cell infusion.

Although infusion of cryopreserved bone marrow or peripheral blood stem cell is associated with a variety of symptoms, there have been no reports detailing the data of infusion-related toxicities of cryopreserved cord blood (CB) units. We prospectively evaluated the incidence and significance of infusion-related toxicities in 34 adult patients undergoing unrelated CB transplantation. Cryopreserved CB units were thawed and immediately infused, unfiltered, through a central intravenous catheter without further manipulation. Heart rate, blood pressure, oxygen saturation and clinical symptoms were recorded during and after infusion. Twenty-four percent of patients experienced non-cardiovascular toxicities related to infusion. The incidence of systolic and diastolic hypertension and bradycardia was 58, 64 and 32%, respectively. Although three patients (9%) with severe systolic hypertension after the infusion required treatment with antihypertensive agents, no patients experienced life-threatening side effects or needed discontinuation of CB unit infusion. Patient or transplant characteristics had no effect on the hypertension and bradycardia related to the infusion of CB. These data suggest that infusion of cryopreserved CB without further manipulation after thawing is safe and well tolerated. However, cardiovascular toxicities including hypertension and bradycardia were frequently observed.

[The use of heart rate variability analysis to determine changes in autonomic nervous system activity induced by laryngoscopy and endotracheal intubation]. / Zastosowanie analizy zmiennosci rytmu serca do oceny zmian aktywnosci autonomicznego ukladu nerwowego wywolanych laryngoskopia i intubacja dotchawicza.

BACKGROUND: Laryngoscopy and intubation are associated with marked autonomic system activation that can be assessed by heart rate variability analysis (HRV)--a new method, comparing R-R intervals in 12-lead continuous ECG recording. METHODS: Fifty-two ASA I and II adults patients of both sexes were enrolled in the study. Patients were induced with fentanyl and thiopental, paralysed with vecuronium, and intubated. Continuous ECG was recorded and selected time-domain parameters (RMSSD, SDNN, NN50 and pNN50) were analyzed before and after intubation at 5- min intervals. RESULTS: Endotracheal intubation resulted in transient supraventricular and ventricular extrasystoles in six patients. Seven patients developed transient bigeminy. Equivocal changes of RMSSD, SDNN, NN50 and pNN50 were observed. CONCLUSION: Because of the large incidence of cardiac rhythm disturbances, the HRV proved to be useless for assessment of autonomic system changes.

[Chronic progressive external ophthalmoplegia: clinical and electromyographic manifestations in a series of cases]. / Oftalmoplejía externa progresiva crónica: manifestaciones clínicas y electromiográficas en una serie de casos.

INTRODUCTION: Chronic progressive external ophthalmoplegia (CPEO) is a common mitochondrial disease. The different conditions in this group of diseases overlap clinically, enzymatically and genetically. There is no effective treatment. Ptosis improves with corrective surgery involving tarsorrhaphy as a palliative measure. CASE REPORTS: Code numbers were examined in a retrospective study conducted in order to search for patients with ptosis or ophthalmoplegia who had either visited or been admitted to the neurology department over the last 10 years. Data concerning these patients' clinical features and results of complementary tests were collected. Six patients with CPEO were identified, five of whom were females. Ages ranged from 44 to 72 years. All the patients had ptosis, although 50% were asymmetric. Half of them reported mild dysphagia while swallowing liquids. Levels of creatine phosphokinase and acetylcholine antireceptor antibodies were normal. Half the patients showed increased jitter and a muscle biopsy revealed that five of them had ragged red fibres. The most frequent enzyme deficit was complex I and IV deficiency. There were no familial forms; the most common genetic anomaly was single deletion in the mitochondrial deoxyribonucleic acid. CONCLUSIONS: In cases of ptosis and ophthalmoplegia that do not respond to anticholinesterases, knowledge of this condition makes it possible to avoid the use of immunosuppressant drugs, which have important side effects.

Frequency of arrhythmic events during head-up tilt testing in patients with suspected neurocardiogenic syncope or presyncope.

Head-up tilt testing (HUT) is a useful diagnostic tool for evaluating suspected neurocardiogenic syncope. Although arrhythmic events during HUT have been occasionally reported, their incidence in a large number of patients is unknown. We aimed to assess the incidence and clinical significance of arrhythmic events in patients with suspected neurocardiogenic syncope who underwent HUT with isoproterenol provocation. For 2,242 patients who underwent HUT, the incidence of total arrhythmic events was 31%: bradyarrhythmias 24%, premature beats 4%, and tachyarrhythmias 3%. For 547 patients who developed bradyarrhythmias during HUT, the incidence of junctional arrhythmias was 92%. For 702 arrhythmic events, the incidence of arrhythmic events during the first phase of HUT was significantly lower than the second phase (p <0.001). The incidence of arrhythmic events in patients with positive HUT responses was significantly higher than in those with negative responses (p <0.001). In patients with positive responses, bradyarrhythmias were noted in 85%, and junctional arrhythmia was the most common arrhythmic event. Of the positive responses, 353 patients (61%) had the vasodepressive type, 181 (32%) patients the mixed type, and the remaining 39 (7%) the cardioinhibitory type. Of 2,242 patients, ventricular fibrillation occurred in 1 patient (0.04%). Thus, bradyarrhythmias were the most common arrhythmic events during HUT with isoproterenol provocation. Serious ventricular tachyarrhythmia rarely occurred.

[Cardiac arrhythmias during pregnancy--what to do?]. / Rhythmusstörungen während der Schwangerschaft--was tun?

METHODS: Atrial premature beats are frequently diagnosed during pregnancy, supraventricular tachycardia (atrial tachycardia, AV nodal reentrant tachycardia, circus movement tachycardia) less frequently. For acute therapy, electrical cardioversion with 50-100 J is indicated in all unstable patients. In stable supraventricular tachycardia, initial therapy includes vagal maneuvers to terminate breakthrough tachycardias. For short-term management, when vagal maneuvers fail, intravenous adenosine is the drug of first choice and may safely terminate the arrhythmia. For long-term therapy, beta-blocking agents with beta(1) selectivity are first-line drugs; class Ic agents or the class III drug sotalol represent effective and therapeutic alternatives. Ventricular premature beats are also frequently present during pregnancy and benign in most of the unstable patients; however, malignant ventricular tachyarrhythmias (sustained ventricular tachycardia, ventricular flutter, ventricular fibrillation) are less frequently observed. Electrical cardioversion is necessary in all patients with hemodynamically unstable situation and life-threatening ventricular tachyarrhythmias; in hemodynamically stable patients, initial therapy with ajmaline, procainamide or lidocaine is indicated. If prophylactic therapy is needed, beta-blocking agents with beta(1) selectivity are regarded as drugs of first choice. If this therapy proves ineffective, class Ic agents or sotalol can be considered. In patients with syncopal ventricular tachycardia, ventricular fibrillation, ventricular flutter or aborted sudden death, an implantable cardioverter-defibrillator is indicated. In patients with symptomatic bradycardia, a pacemaker can be implanted using echocardiography at any stage of pregnancy. CONCLUSIONS: The treatment of the pregnant patient with cardiac arrhythmias requires important modifications of the standard practice of arrhythmia management. The goal of therapy is to protect the patient and fetus through delivery, after which chronic or definitive therapy can be administered.

Ambulatory electrocardiographic evaluation of the heart in patients treated by megachemotherapy and bone marrow transplantation.

The aim of the study was evaluation of the frequency of conduction defects and cardiac arrhythmias before and one month (once a week) after bone marrow transplantation (BMT). It was evaluated by 24-hour electrocardiography based on the Holter's method. There were 50 patients (mean age 29.0 years) examined who were treated with megachemotherapy based on BuCy2, BuCy4 (busulphan and cyclophosphamide), BEAM (carmustine, etoposide, cytarabine, melphalan) and dexaBEAM (dexa-dexamethason) programs before BMT. No heart conduction defects occurred. The mean heart rate increased after BMT. Tachycardia (> 100/min) was observed in 92.5-98.1% of patients and bradycardia (< 60/min) in 41.6-68.0% patients. In 6% of patients bradycardia below 40/min occurred. The heart rate was increased in patients who previously used anthracycline antibiotics, had anaemia or fever, and in patients after autologous BMT (p < 0.05). The complex ventricular extrasystoles were detected in 20% of patients before megachemotherapy. They were more frequently observed in patients with hypokalemia (p < 0.05). After therapy these extrasystoles were observed in a total of 24% patients. There was a statistically significant correlation between this kind of extrasystole and age. The extrasystoles developed mainly in young men. In 10% they occurred de novo and also mainly in men. The heart failure (III degrees, IV degrees according to NYHA) occurred in 14% of patients and death caused by heart (or multiorgan) damage in 18%. Older patients and those who had higher mean heart rate during the first month after BMT were dying more frequently (p < 0.05).

Opening of K(ATP) channel attenuates the increase in QT dispersion produced by the first balloon inflation during coronary angioplasty.

Increased QT dispersion predicts the occurrence of lethal ventricular arrhythmias complicating percutaneous transluminal coronary angioplasty (PTCA). Moreover, these arrhythmias occur more frequently at the first balloon inflation. Activation of the K(ATP) channel may influence QT dispersion and ventricular arrhythmias during coronary angioplasty, so 40 consecutive patients with stable angina were randomized to receive 3 mg/h of nicorandil infusion or placebo and QT dispersion and the incidence of ventricular ectopy were investigated before and throughout PTCA. There were no significant differences in QT dispersion at baseline between the nicorandil group (42+/-8 ms) and placebo (42+/-12ms). At the first balloon inflation, the QT dispersion in the nicorandil group (51+/-13 ms) was significantly less than that observed with placebo (76+/-16ms, p<0.001). However, the QT dispersion at the second inflation was similar in both groups (nicorandil: 45+/-12ms; placebo: 52+/-14ms). Ventricular ectopy was observed in 1 patient receiving nicorandil and 5 patients in the placebo group during the first inflation, and none in the nicorandil and 1 patient in the placebo group during the second balloon inflation. Activation of the K(ATP) channel may inhibit the development of ventricular arrhythmias during PTCA, particularly at the first balloon inflation.

Arrhythmia/ischemia management during minimally invasive cardiac operation.

We present a case of severe arrhythmia and hemodynamic compromise in a patient undergoing minimally invasive coronary artery bypass grafting without cardiopulmonary bypass. This was successfully treated via an extracorporeal shunt from a femoral artery cannula.

Alteraciones electrocardiográficas inducidas por paclitaxel (taxol) / Electrocardiographic alterations induced by paclitaxel (taxol)

Objetivo. Identificar repercusiones clínicas y alteraciones electrocardiográficas inducidas por la infusión de placlitaxel durante 24 horas. Pacientes y métodos. De enero de 1993 a enero de 1996, en los Departamentos de Medicina Interna del Hospital ABC y de Oncología del Hospital General de México, se estudiaron a 35 pacientes entre 18 y 75 años de edad, con diversas neoplasias karnofsky > 60 por ciento, que previamente habrían recibido uno o más esquemas de quimioterapia. Todos recibieron paclitaxel en infusión continua de 24 horas, cada 21 días, con dosis de 125-225 mg/m², y profilaxis para tratamiento de hipersensibilidad con dexametasona, ranitidina y clorfeniramina. Se practicó electrocardiograma antes y después de cada infusión del taxano. El grado de cardiotoxicidad se calificó de acuerdo con los criterios del national Cancer Institute. Resultados. Treinta y cinco pacientes con edad promedio de 50 ñ 8.8 años, 28 mujeres (80 por ciento) y siete hombres (20 por ciento), recibieron 110 ciclos. Diecinueve pacientes (54.2 por ciento) habían recibido doxorrubicina previamente y 10 habían sido sometidos a radioterapia mediastinal. Un paciente presentó infarto agudo al miocardio un año antes del tratamiento. Se encontró disminución de la frecuencia cardiaca en 37.1 por ciento de los pacientes y 26.3 por ciento de los ciclos con dosis de 125 y 150 mg/m². En 25.7 por ciento de los pacientes y 19 ciclos se detectó prolongación del intervalo QTc con dosis mayores de 150 mg/m². Hubo extrasístoles supraventriculares en cuatro pacientes durante ocho ciclos de tratamiento y extrasístoles ventriculares, en un paciente, durante un ciclo. Se detectó disminusión del voltaje del complejo QRS en 3.6 por ciento de los ciclos y en 5.7 por ciento de los pacientes con dosis de 135 y 175 mg/m². La inversión de la onda T se presentó en tres casos durante cuatro ciclos, sin repercusión hemodinámica ni traducción enzímatica. Se registró aumento de la frecuencia cardiaca en 28.5 por ciento de los pacientes y 18.1 por ciento de los ciclos con dosis superiores a 175 mg/m². Hubo un caso de taquicardia supraventricular con dosis de 225 mg/m². Todas las alteraciones se calificaron como grado I, sin repercusión hemodinámica ni significancia estadística...

[Arrhythmogenic right ventricular dysplasia disclosed by ventricular extrasystole]. / Dysplasie ventriculaire droite arythmogène révélée par une extrasystolie ventriculaire.

Arrhythmogenic right ventricular dysplasia is one of the principal causes of sudden cardiac death in young subjects. In the absence of ventricular tachycardia, the disease can be revealed by simple ventricular extrasystole. In the light of such a case, the authors discuss the value of various complementary investigations for the diagnosis of these clinical forms with little or no symptoms. Detailed examination of the electrocardiogram followed by a search for late ventricular potentials are decisive steps before proceeding to invasive investigations which often remain essential to confirm the diagnosis. The prognosis remains uncertain, and is always dominated by the risk of sudden death, even in these apparently minor forms of the disease. This point further emphasizes the need for detection, which should be facilitated by the recent establishment of a list of diagnostic criteria.