Acute Isolated Right Ventricular Infarction: Unusual Presentation of Anterior ST-Segment-Elevation Myocardial Infarction.

Acute right ventricular infarction presenting with ST-segment elevation in the anterior precordial electrocardiographic leads is an unusual event. Anterior ST-segment elevation typically suggests occlusion of the left anterior descending coronary artery. It should be recognized, however, that occlusion of a right coronary artery branch can cause isolated ST-segment elevation in leads V1 and V2 on a standard 12-lead electrocardiogram. We describe the cases of 2 patients who presented with acute chest syndrome with isolated ST-segment elevation in leads V1 and V2. Emergency coronary angiograms revealed that acute thrombotic occlusion of the right ventricular marginal branch of the dominant right coronary artery caused the clinical manifestations in the first patient, whereas occlusion of the proximal nondominant right coronary artery was the culprit lesion in the second patient. Both lesions caused right ventricular myocardial infarction. The patients underwent successful primary percutaneous coronary intervention. These cases illustrate the importance of carefully reviewing angiographic findings to accurately diagnose an acute isolated right ventricular myocardial infarction, which may mimic the electrocardiographic features of an anterior-wall myocardial infarction.

Haemodynamic and structural correlates of the first and second heart sounds in pulmonary arterial hypertension: an acoustic cardiography cohort study.

OBJECTIVE: To examine the relationship between acoustic characteristics of the first and second heart sounds (S1 and S2) and underlying cardiac structure and haemodynamics in patients with isolated pulmonary arterial hypertension (PAH) and controls. DESIGN: Prospective multicentre cohort study. SETTING: Tertiary referral and community hospitals. PARTICIPANTS: We prospectively evaluated 40 PAH patients undergoing right-heart catheterisation with contemporaneous digital acoustic cardiography (intensity and complexity) and two-dimensional transthoracic echocardiography. To normalise for differences in body habitus, acoustic variables were also expressed as a ratio (S2/S1). 130 participants (55 also had haemodynamic and/or echocardiographic assessment) without clinical or haemodynamic evidence of PAH or congestive heart failure acted as controls. RESULTS: Patients with PAH had higher mean pulmonary artery pressure (mPA; 40±13 vs 16±4 mm Hg, p<0.0001) and pulmonary vascular resistance (9±6 vs 1±1 Wood Units, p<0.0001) compared with controls, but cardiac index and mean pulmonary capillary wedge pressure were similar. More PAH patients had evidence of right ventricular (RV) dilation (50% vs 19%) and RV systolic dysfunction (41% vs 9%) in the moderate-severe range (all p<0.05). Compared with controls, the acoustic profiles of PAH patients were characterised by increased S2 complexity, S2/S1 complexity and S2/S1 intensity (all p<0.05). In the PAH cohort, S2 complexity was inversely related to S1 complexity. mPA was the only independent multivariate predictor of S2 complexity. The severity of RV enlargement and systolic impairment had reciprocal effects on the complexity of S2 (increased) and S1 (decreased). Decreased S1 complexity was also related to evidence of a small left ventricular cavity. CONCLUSIONS: Acoustic characteristics of both S1 and S2 are related to the severity of PAH and are associated with RV enlargement and systolic dysfunction. The reciprocal relationship between S2 and S1 complexity may also reflect the underlying ventricular interaction associated with PAH.

Isolated thigh pain in myocardial infarction.

The referred pain of angina to upper half of the body is well known. However, isolated pain in the thigh as a presenting symptom in myocardial infarction is neither considered nor discussed at all. Here, we report a middle-aged man without demonstrable risk factors who presented to the emergency department for isolated bilateral anteromedial thigh pain. He was diagnosed with acute inferior wall myocardial infarction. After thrombolysis, the thigh pain improved. The probable mechanism for this is attributable to radiation of pain via sensory cardiac fibers that is present in the lumbar sympathetic ganglia, which resulted in pain.

Defective T wave combined with incomplete right bundle branch block: a new electrocardiographic index for diagnosing atrial septal defect.

BACKGROUND: Incomplete right bundle branch block (ICRBBB) is commonly associated with atrial septal defect (ASD), but lacks sufficient diagnostic test characteristics. An abnormal T wave is also often observed in ASD, with horizontal or inverted displacement of the proximal T wave limb in the right precordial leads, termed "defective T wave" (DTW). METHODS: We examined the diagnostic test characteristics of combining ICRBBB with DTW as a new index to diagnose ASD. A total of 132 consecutive patients with ASD and 132 cases of age/gender-matched controls without ASD were enrolled. RESULTS: Sensitivities of DTW, ICRBBB, and both were 87.1% - 87.9%. Specificities were 97.0%, 96.2%, and 100%, respectively. Positive predictive values were 1.3%, 1.1%, and 100.0% respectively, while negative predictive values were 99.9% for each. CONCLUSION: Combining ICRBBB with DTW in electrocardiogram (ECG) as a new index significantly increased the specificity and positive predictive values while maintaining a high sensitivity in diagnosing ASD.

Contemporary use of adjunctive thrombectomy during primary percutaneous coronary intervention for ST-elevation myocardial infarction in the United States.

OBJECTIVES: We sought to examine the contemporary use of thrombectomy during primary percutaneous coronary intervention (PCI) in the United States. BACKGROUND: Adjunctive thrombectomy during primary PCI for patients with ST-segment elevation myocardial infarction (STEMI) has demonstrated mixed results. While earlier studies showed either unfavorable or neutral effects with rheolytic thrombectomy, recent clinical trials have shown benefits with manual or rheolytic thrombectomy when compared to PCI alone. METHODS: We analyzed data from 122,449 patients undergoing primary PCI for STEMI from 1,181 centers reported to the CathPCI Registry® between July 2009 and December 2010. We used logistic regression analysis to examine factors associated with the use of manual and rheolytic thrombectomy. RESULTS: Thrombectomy was performed in 23,195 patients (18.9%): 22,404 (18.3%) had manual thrombectomy and 791 (0.6%) had rheolytic thrombectomy. The use of manual thrombectomy increased over time (P < 0.05). The use of rheolytic thrombectomy did not change. There was significant variation in the use of thrombectomy across hospitals. The strongest predictors of manual versus no thrombectomy included TIMI 0/1 flow (odds ratio 1.69), younger age (OR 0.90 per 10 year increase), saphenous vein graft (OR 2.22), glycoprotein IIb/IIIa inhibitor (OR 1.34), single-vessel disease (OR 1.13), and year of admission (OR 1.20 per year; all P < 0.001). The strongest predictor of manual versus rheolytic thrombectomy was year of admission (OR 1.23, P < 0.001). CONCLUSIONS: Our data show that thrombectomy is performed infrequently in the US during primary PCI for STEMI. There is significant variation in the use of thrombectomy across US hospitals.

Potential of delayed gadolinium enhancement magnetic resonance imaging for quantification of reverse remodeling of the peri-infarct zone in patients with ischemic cardiomyopathy treated with chronic vasodilator therapy: initial experience.

PURPOSE: The peri-infarct zone represents the morphologic substrate for reentry ventricular tachycardia after myocardial infarction, and its extent is a strong predictor of major cardiac events. Although delayed gadolinium enhancement magnetic resonance imaging (DGE-MRI) was shown to allow for detailed characterization of myocardial infarction by quantifying infarct core zone and peri-infarct zone volume, potentials of DGE-MRI for measuring changes in peri-infarct zone volume are unknown. Therefore, we aimed to assess changes in volume of the peri-infarct zone among patients with ischemic cardiomyopathy treated with chronic vasodilator therapy. MATERIALS AND METHODS: Core and peri-infarct zone volumes as assessed with DGE-MRI were measured in 5 patients at baseline and after 6 months treatment with sustained-release dipyridamole. RESULTS: Core zone volume remained stable during follow-up [median (range), 19 mL (9 to 42) vs. 16 mL (11 to 46); P=0.785]. The ratio between the peri-infarct zone and the core zone volume decreased significantly at 6 months compared with baseline [median (range), 0.22 (0.19 to 0.42) vs. 0.18 (0.09 to 0.32); P=0.043], and a trend toward reduction in peri-infarct zone volume was found [median (range), 5 mL (2 to 8) vs. 3 mL (2 to 6); P=0.059]. The peri-infarct zone volume decreased in all but 1 patient over the follow-up. CONCLUSIONS: This initial experience suggests that reverse remodeling of the peri-infarct zone with reduction in peri-infarct zone volume may take place in patients with ischemic cardiomyopathy. Quantification of this process may be feasible with DGE-MRI, but further studies are needed to confirm this hypothesis and to further clarify the role of DGE-MRI for the assessment of changes in peri-infarct zone volume in patients with ischemic cardiomyopathy.

Ventricular fibrillation after exposure to air freshener-death just a breath away.

A case of ventricular fibrillation due to butane toxicity after unintentional inhalation of air freshener is reported for its rarity and to create awareness among practitioners and the public. A 25-year-old woman collapsed in the supermarket after unintended exposure to air freshener sprayed into her nostrils. Her husband started cardiopulmonary resuscitation immediately, and she was brought to the hospital. She had coarse ventricular fibrillation. Defibrillation with 360 J was given, and the rhythm reverted to normal sinus rhythm after the third shock. Epinephrine was not administered, and she was treated with esmolol infusion for ventricular ectopy. The patient recovered completely without any sequelae and was discharged on the fifth hospital day. On thin layer chromatography, the chemical content of the spray was identified to be isobutane. Avoiding epinephrine and administering ß-adrenergic blockers may protect the catecholamine-sensitized heart early during resuscitation in butane exposure cases.

Acute ST-segment elevation myocardial infarction from a centipede bite.

Acute myocardial infarction (AMI) following a centipede bite has been very rarely reported. Here, we describe a 22 year-old man who had ST-segment elevation AMI after a centipede bite. He presented with typical chest pain, electro and echocardiographic abnormalities, and elevated cardiac enzymes with normal coronary angiography. The probable mechanisms were described. Practitioners treating centipede bites shall not consider it lightly, as centipede envenomation may produce a variety of systemic and local manifestations in susceptible individuals.

Electrocardiographic changes during inhalational oleander toxicity.

Inhalational oleander toxicity was considered in a family of 4 by history of exposure to smoke from burning oleander twigs. Electrocardiography revealed first- and second-degree atrioventricular block with digoxin-like ST-T-wave changes, suggestive of oleander toxicity in the absence of exposure to digoxin or other herbal medicines, and without systemic illness. Complete blood count, biometabolic profile, chest x-ray, and echocardiography did not reveal any abnormalities. Electrocardiographies normalized within 4 days when kept away from offending agents. Because oleander plant materials are used for burning, people are exposed to inhalational oleander toxicity. Hence, practitioners shall consider such poisonings in them.

Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association.

Venous thromboembolism (VTE) is responsible for the hospitalization of >250 000 Americans annually and represents a significant risk for morbidity and mortality. Despite the publication of evidence-based clinical practice guidelines to aid in the management of VTE in its acute and chronic forms, the clinician is frequently confronted with manifestations of VTE for which data are sparse and optimal management is unclear. In particular, the optimal use of advanced therapies for acute VTE, including thrombolysis and catheter-based therapies, remains uncertain. This report addresses the management of massive and submassive pulmonary embolism (PE), iliofemoral deep vein thrombosis (IFDVT),and chronic thromboembolic pulmonary hypertension (CTEPH). The goal is to provide practical advice to enable the busy clinician to optimize the management of patients with these severe manifestations of VTE. Although this document makes recommendations for management, optimal medical decisions must incorporate other factors, including patient wishes, quality of life, and life expectancy based on age and comorbidities. The appropriateness of these recommendations for a specific patient may vary depending on these factors and will be best judged by the bedside clinician.

Acoustic cardiographic indices of transmyocardial ischemia during percutaneous coronary intervention.

BACKGROUND: Transmyocardial ischemia is manifested as ST-segment elevation (STE). We examined acoustic cardiographic indices of STE that occur during percutaneous coronary intervention (PCI). METHODS: Of 83 patients undergoing coronary angiography, 25 underwent PCI, including 5 who developed STE. Continuous 12-lead ECG and computerized acoustic cardiographic heart sound analysis were performed during PCI. Intensities of the heart sounds (S1 to S4), diastolic time (from S2 to S1), and systolic time intervals (S1 to S2) were recorded. RESULTS: As STE increased, there was no change in heart rate or systolic time. Contractility decreased, with an increase in S3 intensity and a reduction in S1/S2 ratio. Left ventricular stiffness increased, reflected by an increase in S4 intensity. CONCLUSIONS: As transmyocardial ischemia worsened during progressive STE, acoustic cardiographic indices reflected impaired contractility and increased ventricular stiffness. In particular, the S4 was most predictive of increasing degrees of STE. These findings have implications for assessment of transmyocardial ischemia in patients with ECG findings that confound ST segment interpretation.

Significance of the intima-media thickness of carotid and thoracic aorta in coronary artery disease in the South Indian population.

BACKGROUND: Ultrasound detected intima-media thickness (IMT) of the carotid artery and thoracic aorta are possible screening tests to assess the risk of coronary artery disease (CAD) in asymptomatic individuals. OBJECTIVE: Aim of the study was to assess the utility of carotid and aortic IMT as a predictor of CAD and to assess the extent of IMT with severity of CAD in a South Indian population. PATIENTS AND METHODS: A cross-sectional and analytical study was carried out among 40 cases, who had angiographic evidence of CAD against 30 healthy control subjects with a normal treadmill test. At plaque-free regions, the carotid IMT was evaluated by B-mode ultrasonography and thoracic aorta IMT was evaluated by trans-esophageal echocardiography (TEE). The significance of difference in means between two groups was analyzed using one-way ANOVA F-test and the significance of difference in proportions by Chi-square test. Multiple comparisons were done by Bonferroni t test. The correlation between IMT and severity of CAD was assessed by Spearman's method. RESULTS: There were 38 males and 2 females among cases with age 51.7 ± 8.3 years, and 28 males and 2 females among control subjects with age 52.2 ± 7.1 years. Increased carotid IMT was noted among 24 cases and 2 control subjects, and the association was significant for CAD [P < 0.001, Chi-square = 20.89, odds ratio (OR) = 21.00, and 95% confidence interval (CI) = 4.78-89.59]. Similarly, 19 cases and one control subject had abnormal IMT with positive correlation for CAD (P < 0.001, Chi-square = 16.39, OR = 28.24, and 95% CI = 4.06-163.21). There was no association between IMT and diabetes, hypertension, or smoking; however, IMT was significantly associated with age and dyslipidemia. Also, there was no correlation between extent of IMT and severity of CAD. CONCLUSIONS: IMT of the carotid and thoracic aorta is strongly associated with risk of CAD in a South Indian population, and may be used as a non-invasive screening tool for coronary atherosclerosis in resource-limited settings. The presence of dyslipidemia influenced IMT and may be used as a tool to follow patients on hypolipidemic drugs.

Cardiovascular Complications in Ciguatera Fish Poisoning: A Wake-up Call.

Ciguatera fish poisoning occurs with ingestion of fish containing ciguatoxin. It causes a clinical syndrome that comprises classic gastrointestinal, neurological and cardiovascular symptoms. Ciguatoxin is a sodium channel agonist with cholinergic and adrenergic activity. Although cardiovascular symptoms are rare with ciguatoxin, we report two cases with bradycardia and hypotension. Fatality and long-term sequelae are not uncommon with ciguatoxin poisoning and educating the general population is essential.

Ex vivo hemodynamic assessment of mechanical aortic valve gradients using a high-fidelity pressure wire.

OBJECTIVES: Accurate assessment of prosthetic mechanical valve malfunction is challenging for non-invasive and invasive techniques. We evaluated a 0.014-inch pressure-sensing coronary guidewire to assess mechanical valve dysfunction. BACKGROUND: Several case reports have shown that transaortic pressure gradients can be recorded using a 0.014-inch guidewire during cardiac catheterization. METHODS: We performed an ex vivo study measuring the effects of sequentially crossing the center of each valve with a 6 French coronary angiographic catheter, a 0.035-inch guidewire, and a 0.014-inch pressure-sensing guidewire on valve dysfunction using the following 23 mm bileaflet and tilting-disc aortic valves: St. Jude Regent™, CarboMedics, Medtronic Hall™, and Björk-Shiley Monostut. A left heart model pulse duplicator recorded 10 consecutive cycles. RESULTS: For all valves, the greatest increase in valve regurgitation occurred with the 6 French catheter, causing a reduction in aortic valve back pressure and cardiac output, with an increase in leakage rate, regurgitant fraction, and energy loss. In comparison to the 0.035-inch guidewire, the 0.014-inch guidewire had greater regurgitation for St. Jude, lower for Medtronic Hall, and equivalent for CarboMedics and Björk-Shiley valves. For the CarboMedics valve, the 0.035-inch guidewire caused a significant increase in regurgitant fraction and energy loss, while the pressure wire had no change compared to baseline. CONCLUSIONS: The degree of regurgitation caused by the 0.014-inch guidewire varies with the type of mechanical aortic valve. While prior case reports have shown that valve hemodynamics may be measured using a pressure-sensing guidewire, valve regurgitation occurs when crossing a St. Jude, Medtronic Hall, or Björk-Shiley aortic valve.

Percutaneous patent foramen ovale closure using Helex and Amplatzer devices without intraprocedural echocardiographic guidance.

OBJECTIVES: We compared procedural outcomes of patients undergoing patent foramen ovale (PFO) closure using Helex (W.L. Gore & Assoc., Flagstaff, AZ, USA) and Amplatzer (AGA Medical Corp., Plymouth, MN, USA) devices using intracardiac echocardiographic (ICE) versus fluoroscopic-only guidance. BACKGROUND: Use of transesophageal or ICE to guide PFO closure is associated with patient discomfort and cost. While fluoroscopic guidance of septal closure using Amplatzer is well established, there is no published experience for Helex. METHODS: We performed a single-center, single-operator analysis of patients undergoing PFO closure using Helex or Amplatzer occluders. Device and guidance strategy was selected by the operator. RESULTS: Of the 132 PFO patients, 23 were closed with Helex, and 109 were closed with Amplatzer (103 Cribriforms, 4 PFO occluders, and 2 atrial septal occluders). Fluoroscopic guidance was used for 15 (65%) Helex and 102 (94%) Amplatzer cases. Successful device placement was achieved in all patients with a 1.5% complication rate (1 arrhythmia and 1 device embolization). Procedure time was shorter for fluoroscopic guidance of Amplatzer cases compared to ICE guidance (P = 0.023), and for Amplatzer versus Helex cases (P = 0.0004). Among the Helex cases, there were no differences in procedure or fluoroscopy time comparing ICE to fluoroscopic guidance. There was no residual shunting by transthoracic echocardiographic bubble study in 93% of Helex and 95% of Amplatzer cases at 6 months. CONCLUSIONS: Use of right atrial angiography and fluoroscopic-only guidance for PFO closure using Helex and Amplatzer devices provides an efficient alternative to ICE guidance. While procedure and fluoroscopy times were significantly shorter for Amplatzer versus Helex cases, these times were similar for Helex comparing fluoroscopy versus ICE guidance.

Can echocardiographic evaluation of cardiopulmonary hemodynamics decrease right heart catheterizations in end-stage heart failure patients awaiting transplantation?

Candidacy for heart transplantation is influenced by the severity of pulmonary hypertension. In this study, invasive hemodynamics from right-sided cardiac catheterization were compared with values obtained by validated equations from Doppler 2-dimensional transthoracic echocardiography. This prospective study was conducted in 40 patients with end-stage heart failure evaluated for heart transplantation or ventricular assist device implantation. Transthoracic echocardiography and right-sided cardiac catheterization were performed within 4 hours. From continuous-wave Doppler of the tricuspid regurgitation jet, pulmonary artery systolic pressure was calculated as the peak gradient across the tricuspid valve plus right atrial pressure estimated from inferior vena cava filling. Mean pulmonary artery pressure was calculated as (0.61 × pulmonary artery systolic pressure) + 2. Pulmonary vascular resistance (PVR) was calculated as (tricuspid regurgitation velocity/right ventricular outflow tract time-velocity integral × 10) + 0.16. Pulmonary capillary wedge pressure was calculated as 1.91 + (1.24 × E/E'). Pearson's correlation and Bland-Altman analysis of mean differences between echocardiographic and right-sided cardiac catheterization measurements were statistically significant for all hemodynamic parameters (pulmonary artery systolic pressure: r = 0.82, p < 0.05, mean difference 3.1 mm Hg, 95% confidence interval [CI] -0.2 to 6.3; mean pulmonary artery pressure: r = 0.80, p < 0.05, mean difference 2.5 mm Hg, 95% CI 0.3 to 4.6; PVR: r = 0.52, p < 0.05, mean difference 0.8 Wood units, 95% CI 0.3 to 1.4; pulmonary capillary wedge pressure: r = 0.65, p < 0.05, mean difference 2.2 mm Hg, 95% CI 0.1 to 4.3). Compared with right-sided cardiac catheterization, PVR by Doppler echocardiography identified all patients with PVR > 4 Wood units (n = 4), 73% of patients with PVR <2 Wood units (n = 8), and 52% of patients with PVR from 2 to 4 Wood units (n = 10). In conclusion, echocardiographic estimation of cardiopulmonary hemodynamics is reliable in patients with end-stage cardiomyopathy. The noninvasive assessment of hemodynamics by echocardiography may be able to decrease the number of serial right-sided cardiac catheterizations in selected patients awaiting heart transplantation. However, in patients with borderline PVR, right-sided cardiac catheterization is indicated to assess eligibility for transplantation.

Noninvasive prediction of left ventricular systolic dysfunction in patients with clinically suspected heart failure using acoustic cardiography.

The signs and symptoms of systolic heart failure are frequently insensitive and nonspecific, making an accurate bedside diagnosis of left ventricular systolic dysfunction (LVSD) challenging. B-type natriuretic peptide (BNP) is often used, but is not diagnostically useful when in the indeterminate range. The authors investigated the diagnostic test characteristics of acoustic cardiographic parameters to identify patients with LVSD. Four hundred thirty-three patients with contemporaneous measurements of computerized acoustic cardiography, BNP, and echocardiography were included. The acoustic cardiographic model outperformed BNP alone at detecting reduced left ventricular ejection fraction (C statistic, 0.88 vs 0.67; P<.0001). The acoustic model with BNP did not perform better than the acoustic model alone (P=.14). Within the indeterminate BNP range, the acoustic model outperformed BNP (C statistic, 0.89 vs 0.64; P<.0001). Noninvasive computerized acoustic cardiography predicted LVSD in a diverse population. This acoustic cardiographic model outperformed BNP alone for predicting LVSD.

Retrograde left-ventricular hemodynamic assessment of mechanical aortic and mitral valve gradients using a high-fidelity pressure wire: a case series.

Noninvasive assessment of mechanical heart valve function with echocardiography is challenging. There are important safety issues when considering placing a standard catheter across a mechanical valve with for invasive hemodynamic measurements. The feasibility of using a high-fidelity micromanometer coronary pressure guide wire to assess hemodynamics across mechanical valves has been reported. Although this method appears feasible, safe, and free of major complication, its application and utility remains obscure and underappreciated. We report a series of two patients with mitral and aortic (St. Jude and Björk-Shiley) mechanical valves in which we successfully used this pressure wire technique to assess valvular function in patients evaluated for repeat surgical valve replacement. We include the first report of this guide wire technique to assess hemodynamics across a Björk-Shiley single-tilting disk valve.

Utility of intracardiac echocardiography for atrial baffle leak closure in repaired transposition of the great arteries.

A 27-year-old male with dextro-transposition of great arteries had Senning atrial switch repair in childhood and dual-chamber pacemaker placement for sinus node dysfunction in adulthood. Transthoracic echocardiography showed a lead in the systemic (anatomic right) ventricle. Multidetector computed tomography showed the lead perforating the baffle in the region of the body of the systemic venous atrium into the systemic ventricle. The lead was extracted, and a new lead was placed in the pulmonary (anatomic left) ventricle. A bidirectional baffle shunt persisted. The iatrogenic baffle leak was percutaneously closed with an Amplatzer septal occluder device using both intracardiac echocardiography (ICE) and three-dimensional transesophageal echocardiography (3D-TEE). We report the first use of ICE for baffle leak closure, which provided a good definition of the complex anatomy and guided the procedure.