The stress clot: Mid-cavitary variant takotsubo cardiomyopathy with left ventricular thrombus.

Pregnancy and the post-partum period are known hypercoagulable states. Mid-cavitary variant Takotsubo cardiomyopathy (TCM) is uncommon and seen in only about 14% of all Takotsubo cases. Left ventricular thrombus (LVT) in the setting of mid-cavitary TCM is extremely rare, occurring in approximately 1% of cases. We describe a case of a young female, 1-week post-partum, with an acute LVT in the setting of mid-ventricular TCM, and we discuss the striking images and clinical management of this uncommon presentation.

Emergency department approach to QTc prolongation.

QTc prolongation has been associated with increased risk of developing ventricular tachydysrhythmias, particularly Torsades de Pointes (TdP). QTc prolongation is influenced by many factors including congenital causes, heart rate, metabolic imbalances, and pharmacotherapy. Several commonly used medications in the emergency department (ED), such as antipsychotics and antiemetics, are known to prolong the QT interval. In addition, ED patients may present with conditions that may predispose them to QTc prolongation, such as drug overdose or hypokalemia, which can further complicate management. ED providers should not only be aware of which medications have these effects, but must also thoroughly investigate any pertinent patient history that may contribute to QTc prolongation. This review discusses commonly encountered medications that are associated with QTc prolongation, the mechanisms by which they prolong the QTc interval, and other factors that may influence ED medication administration and management.

Multiple symptomatic giant coronary aneurysms.

We describe a rare case of coronary artery aneurysms due to Kawasaki disease in an elderly patient. Our case presents multiple giant coronary artery aneurysms affecting the left coronary system which is less common compared with right coronary aneurysms. Giant coronary artery aneurysms are uncommon; even more rare is their association with ischemic symptoms, and treatment can be challenging. We describe a case of symptomatic multiple coronary artery aneurysms with symptom relief after coronary artery bypass grafting in an elderly patient.

Strangulation: A Cause or Mimicker of Global Myocardial Hypoxia on ECG.

ST segment changes are often associated with myocardial ischemia but may be mimickers. We present a 21-year-old male who suffered a cardiac arrest following a suicide attempt by strangulation. Initial ECG revealed diffuse ST depressions and ST elevation in augmented vector right (aVR), concerning myocardial ischemia. However, repeat ECG revealed normal ST segments and an echocardiogram revealed no wall motion abnormalities. This case highlights the effects of systemic hypoxia on cardiac muscle and the need for a broad differential diagnosis when interpreting an ECG. This is invaluable when ST segment changes mimic acute myocardial infarction, but the clinical scenario suggests global hypoxia.

Massive Device-Related Thrombus After LAA Occlusion: Intraoperative Insights Into Mechanism.

In patients with a contraindication to oral anticoagulation, the left atrial appendage occlusion devices are an approved alternative. Device-related thrombus is a recognized complication, but underlying mechanisms are incompletely understood. In this case series, the authors describe potentially the same mechanism of thrombosis with intraoperative images of incomplete endothelialization. (Level of Difficulty: Intermediate.).

Kyphosis - A risk factor for positioning brachial plexopathy during spinal surgeries.

OBJECTIVE: The aim of this study was to evaluate the differences in transcranial electric motor-evoked potentials - TceMEP on upper limbs and the incidences of postoperative brachial plexopathy between patients with kyphotic and scoliotic trunk shapes. METHODS: In the period of January 2011-January 2017, 61 consecutive patients (mean age: 18.4 years ± 4.4 years (range: 10-32)) with pediatric spinal deformity underwent surgery in our Department. Eight of them had a kyphotic trunk deformity (Scheuermann kyphosis, neurofibromatosis, posterior thoracic hemivertebra), and the rest of the 53 patients had a scoliotic trunk deformity (mostly adolescent idiopathic scoliosis - AIS, lateral hemivertebra). The TceMEP recordings in all four limbs were analyzed every 30 min, or upon the surgeon's command. Upper limb TceMEP recordings were used as a control of systemic and anesthetic related changes, and as the indicator of positioning brachial plexopathy. RESULTS: Four out of 8 patients (50.0%) from the kyphotic group experienced noteworthy decreases in TceMEP amplitude (≥65%) in one or both arms, and only 2 out of 53 patients (3.8%) from the scoliotic group, confirming significant statistical difference (Chi-square 16.75, p < 0.05). Two out of 8 patients with decreases in TceMEP amplitude suffered from transitory postoperative brachial plexopathy, and both of them were from the kyphotic group. CONCLUSION: It seems that kyphotic trunks have a higher risk for positioning-related brachial plexopathy, probably due to distribution of trunk's weight onto only four points (two iliac bones and two shoulders), compared to the scoliotic trunks that have wider weight-bearing areas. We emphasize the importance of proper patient positioning and close intraoperative neuro-monitoring of all four limbs in more than one channel per limb. LEVEL OF EVIDENCE: Level IV Therapeutic Study.