Thrombus-in-transit involving all four chambers of the heart in a patient presenting with acute pulmonary embolism.

A 43-year-old male with history of pulmonary embolism defaulted on anti-coagulation and presented with recurrent massive pulmonary embolism. Echocardiography revealed a serpiginous freely floating right atrial thrombus prolapsing through the tricuspid valve into the right ventricle. Thrombus was also seen crossing the interatrial septum into the left atrium and prolapsing into the left ventricle. Right-sided chambers were dilated with right ventricular dysfunction. Left ventricle was functioning normally. After evaluation by the pulmonary embolism response team, thrombolysis was done with alteplase which resulted in dramatic improvement of the symptoms and complete resolution of the intra-cardiac thrombus. Regular follow-up and counselling are advised henceforth to ensure drug compliance. Learning objectives: 1.In patients with right heart thrombus crossing an intracardiac communication into left-sided chambers carries an additional risk.2.Pulmonary embolism response team is essential for clinical decision-making.3.Echocardiography plays a critical role to diagnose and assess the extent of the intracardiac thrombus and ventricular function.4.On computed tomography, right ventricular (RV)/left ventricular diameter ratio of >0.9 and the presence of septal bowing signifies the presence of RV strain.5.Adequate counselling ensuring patient compliance and regular follow up is of utmost importance.

A Case of Delayed Non-infective Cystic Swelling at the Pacemaker Pocket Site.

With the expanding indications for device implantation, the number of cardiac implantable electrophysiological devices (CIED) being implanted has increased drastically. In a patient presenting with swelling at the pacemaker pocket site several years after the implantation, an infective collection due to device seeding by blood-borne microorganisms is the first diagnosis that is commonly considered. Once the diagnosis of CIED infection is made, complete removal of all the hardware is usually performed. We are describing an unusual case of a 70-year-old male with a permanent pacemaker implanted 8 years ago, who came with insidiously growing swelling at the pacemaker pocket site. He was afebrile. On examination, the swelling was soft and mobile and had no signs of inflammation. Blood cultures after 3 days of incubation did not show any growth. Ultrasound examination revealed a cystic swelling with thick septations. CT showed features suggestive of a seroma measuring 6.7 x 9.4 x 11 cm. Antibiotics were given empirically. A total of 100ml of serosanguinous fluid was drained and the pocket wall was excised. Pulse Generator (PG) was placed back into the pocket and the leads were reconnected. Culture and sensitivity testing of the drained fluid and excised tissue did not show any growth and microscopy revealed no abnormal cells. The patient was followed up on a regular basis for six months. There was no recurrence of swelling at the pacemaker site. Even though an infective abscess is the commonest cause of pacemaker pocket swelling, a non-infective swelling, however rare, must be considered as a non-infective swelling does not require complete removal of the hardware.

Diagnostic accuracy of MicroRNA 208b level with respect to different types of atrial fibrillation.

MicroRNAs (miRNA) are prerequisite for cardiovascular functions. miRNA miR-208 b is a cardio-specific miRNA with tissue (atrial) levels elevated in atrial fibrillation (AFib) and blood levels significantly elevated in myocardial infarction. We calculated serum levels of miR-208 b in paroxysmal and persistent AFib, embolic cerebrovascular accident patients with AFib as possible etiology and controls. There was a statistically significant change of miR-208 b levels in paroxysmal (p = 0.044) and persistent (p = 0.040) AFib patients, but not for embolic CVA patients. miR-208 b could serve as a new serum marker for paroxysmal AFib.

Troubleshooting a pacemaker output failure: A case report.

The indications for permanent pacemaker (PM) implantation are rapidly expanding resulting in an increasing number of patients receiving PMs. Such PM patients need a good quality medical care. The follow up of these patients and their devices places a heavy burden on cardiology clinics with significant implications for the already stretched hospital resources. This has resulted in increased reliance on the options of automatic and continuous adjustments that the modern PMs offer. One such feature is the 'automatic sensitivity function' or 'AutoSense' which when turned on, monitors the amplitude of the intrinsic R wave and P wave and continuously adjusts the sensitivity, as a function of measured amplitudes, to avoid undersensing or oversensing. We are describing a case in which oversensing occurred even though the pacemaker's 'AutoSense' function was kept on and hence was misunderstood to be a lead problem and was advised ventricular lead replacement.

The prognostic value of dispersion of repolarization in stress cardiomyopathy.

INTRODUCTION: Although abnormalities of ventricular repolarization are a hallmark of SC, their clinical impact on management remains to be determined. This study sought to evaluate the prognostic value of dispersion of repolarization in stress cardiomyopathy (SC) with regards to major cardiac events (MCE), recovery time, and recurrence. METHODS: This study analyzed data from258 patients with SC, from January 2009 to January 2018. Standard 12 lead ECG recordings during the acute, subacute, and recovery phases were collected for each eligible patient. Logistic regression was used to identify independent predictors of MCE, a composite of 30 day all-cause mortality, cardiogenic shock, life-threatening ventricular arrhythmias, and stroke. RESULTS: Among the 101 eligible patients (80.2% females, mean age 45.8 ± 11.5 years) in the study cohort, MCE occurred in 16 patients (15.8%). Cox regression analysis identified two independent predictors of MCE: increased ΔQT dispersion ≥ 40 ms (HR 1.31, 95% CI 1.05-9.77, p = 0.029) and increased Δnegative T wave amplitude dispersion ≤ -2.0 mV (HR 1.25, 95% CI 1.11-11.93, p = 0.018) during the subacute phase. The final regression model had good accuracy (sensitivity 81.3%, specificity 96.5%) and discriminative power (AUC 0.89, 95% CI 0.83-0.95). Kaplan-Meier analysis revealed that there was increasing MCE in patients with zero, one, or two predictors (log rank p < 0.001). In addition, patients with increased dispersion also had a significantly longer time to achieve complete recovery (21.4 ± 6.8 vs. 8.5 ± 4.3 days, p = 0.012) and a higher incidence of recurrence (31.3% vs. 2.4%, p = 0.011) of SC. CONCLUSION: Evaluation of dynamic changes of dispersion of repolarization is a simple bed-side tool with high predictive accuracy for prognostication of short term adverse outcomes, delayed recovery, and recurrence in patients with SC.

Fragmented QRS on electrocardiography as a predictor of myocardial scar in patients with hypertrophic cardiomyopathy.

Background: Fragmented QRS (fQRS) and Q waves are ECG findings in patients with myocardial scar. fQRS is more sensitive than pathological Q waves in detecting myocardial fibrosis in patients with coronary artery disease (CAD). Cardiac magnetic resonance (CMR) imaging is used for the diagnosis and for quantifying scar tissue in patients with HCM. Our aim was to correlate ECG parameters like fQRS and Q waves with the presence of late gadolinium enhancement (LGE) assessed by contrast CMR imaging to elucidate ECG markers which might predict scar tissue in HCM.Methods: This study is a retrospective analysis which included 39 patients who were diagnosed/suspected to have HCM on echocardiography and referred for contrast CMR imaging at our centre between 2010 and 2016. Presence of fQRS was correlated with scar demonstrated by LGE on CMR.Results: Twenty four (66.67%) patients had asymmetrical septal hypertrophy, 7 (19.44%) patients had apical involvement while 5 (13.89%) had concentric pattern. Only 4 (11.11%) patients had pathological Q waves in contiguous leads on surface ECG while fQRS in two contiguous leads was present in 23 (63.89%) patients. Presence of fQRS was more in patients with LGE on CMR than those without (84.61 versus 10%, p<.001). When presence of LGE in specific segments (anterior, lateral and inferior) was correlated with corresponding ECG leads, all the three segments showed significant correlation. The overall sensitivity, specificity, PPV and NPV of fQRS for predicting scar tissue were 84.6, 90.0, 95.6 and 69.2%, respectively.Conclusion: fQRS on surface ECG can be used as an indirect marker to predict the presence of fibrosis in HCM.

A novel prediction model for risk stratification in patients with a type 1 Brugada ECG pattern.

BACKGROUND: Risk stratification in Brugada syndrome remains a controversial and unresolved clinical problem, especially in asymptomatic patients with a type 1 ECG pattern. The purpose of this study is to derive and validate a prediction model based on clinical and ECG parameters to effectively identify patients with a type 1 ECG pattern who are at high risk of major arrhythmic events (MAE) during follow-up. METHODS: This study analysed data from 103 consecutive patients with Brugada Type 1 ECG pattern and no history of previous cardiac arrest. The prediction model was derived using logistic regression with MAE as the primary outcome, and patient demographic and electrocardiographic parameters as potential predictor variables. The model was externally validated in an independent cohort of 42 patients. RESULTS: The final model (Brugada Risk Stratification [BRS] score) consisted of 4 independent predictors (1 point each) of MAE during follow-up (median 85.3 months): spontaneous type 1 pattern, QRS fragments in inferior leads≥3,S wave upslope duration ratio ≥ 0.8, and T peak - T end ≥ 100 ms. The BRS score (AUC = 0.95,95% CI 0.0.92-0.98) stratifies patients with a type 1 ECG pattern into low (BRS score ≤ 2) and high (BRS score ≥ 3) risk classes, with a class specific risk of MAE of 0-1.1% and 92.3-100% across the derivation and validation cohorts, respectively. CONCLUSIONS: The BRS score is a simple bed-side tool with high predictive accuracy, for risk stratification of patients with a Brugada Type 1 ECG pattern. Prospective validation of the prediction model is necessary before this score can be implemented in clinical practice.

A rare infective endocarditis caused by Vagococcus fluvialis.

A 70-year-old male with a past history of coronary artery bypass grafting, presented with high-grade fever and rapidly progressive dyspnea for 3 days. He was febrile and a prominent diastolic murmur was noted in the aortic area. Transesophageal echocardiography showed severe aortic regurgitation with multiple mobile vegetations attached to both supra- and infravalvular surfaces of aortic valve. Blood cultures grew Vagococcus fluvialis which was confirmed with identification and antibiotic susceptibility test testing and S16 RNA sequencing. The patient underwent aortic valve replacement with a bioprosthetic valve. Repeat blood culture was sterile. He was continued on vancomycin injections for a total period of six weeks. Vagococcus is a unique genus of Gram-positive, catalase-negative, facultatively anaerobic cocci that was identified in 1989. The only other documented case of vagococcal endocarditis involving mitral and aortic valves had a similar rapidly progressive presentation with extensive valvular damage. V. fluvialis infection appears to have fulminant course with sudden deterioration requiring surgical intervention. .

Familial atrioventricular nodal re-entrant tachycardia: A case seriers and a systematic review.

Multiple reports of familial clustering suggest that genetic factors may contribute in the pathogenesis of atrioventricular nodal re-entrant tachycardia (AVNRT). We report three cases of AVNRT in a father and his two sons along with a review of literature of other similar cases. Electrophysiological studies induced typical AVNRT, which was successfully eliminated by radiofrequency ablation in all of them. Of the 22 reported cases, 96% had typical (slow-fast) variant of AVNRT. The predominant pattern of inheritance appears to be autosomal dominant, though other patterns may exist. Further research is needed to understand the genetic influence of AVNRT and its pathophysiology.

The Utility of Exercise Testing in Risk Stratification of Asymptomatic Patients With Type 1 Brugada Pattern.

INTRODUCTION: Risk stratification of asymptomatic patients with a Brugada type 1 ECG pattern remains an unresolved clinical conundrum. In contrast to provocative pharmacological testing in Brugada syndrome, there is limited data on the role of exercise stress testing as a risk stratification modality. The objective of this study was to evaluate the utility of exercise testing in asymptomatic patients with type 1 Brugada pattern to prognosticate major arrhythmic events (MAE) during follow-up. METHODS AND RESULTS: Treadmill exercise testing was conducted for 75 asymptomatic patients with type 1 Brugada pattern and for 88 healthy control subjects. The clinical end point of MAE was defined as the occurrence of sudden cardiac death (SCD) or resuscitated ventricular fibrillation (VF). During a follow-up of 77.9 ± 28.9 months, eight MAE occurred (five VF and three SCD). Multivariate Cox regression analysis showed that the following were independent predictors of MAE in asymptomatic patients with a type 1 Brugada pattern: increase in S wave upslope duration ratio >30% at peak exercise (HR 1.35, 95% CI 1.08-10.97, P = 0.023), augmentation of J point elevation in lead aVR >2 mm in late recovery (HR 1.88, 95% 1.21-15.67, P = 0.011), and delayed HR recovery (HR 1.14, 95% CI 1.06-18.22, P = 0.042). A high-risk cohort was identified by the final step-wise regression model with good accuracy (specificity = 98.4%, sensitivity = 62.5%) and discriminative power (AUC = 0.93, 95% CI 0.89-0.96, P = 0.002). Kaplan-Meier analysis revealed increasing MAE in subjects with one, two, or three predictors, respectively (log rank P < 0.001). CONCLUSIONS: Exercise testing in asymptomatic patients with type 1 Brugada pattern aids in identification of high-risk patients and provides a unique window of opportunity for early intervention.

An unusual type of accessory pathway in tricuspid atresia.

The occurrence of pre-excitation in tricuspid atresia (TA) is slightly more common than that in normal children. The accessory pathway (AP), when it occurs in the setting of congenital atrioventricular valvar disease, is usually ipsilateral to the side of the abnormal valve. This report describes a patient with TA who had pre-excitation due to a left-sided AP that masked and modified the typical electrocardiographic features. The electrophysiological study confirmed an epicardial left posterior AP that was successfully ablated with radiofrequency energy, through the coronary sinus. Left-sided APs including epicardial ones may rarely be seen in TA and can potentially cause difficulties due to lack of vascular access to the heart after the Fontan surgery if arrhythmias occur. They are amenable to successful radiofrequency ablation and need to be dressed prior to Fontan surgery. .

Permanent pacing in a patient with tricuspid prosthesis--widening therapeutic use of coronary sinus.

Unconventional sites are being used for pacing in patients with inaccessible right ventricle like single ventricle, atresia of tricuspid valve and in anomalous venous drainage. Here we report a case in which the right ventricle could not be accessed due to the metallic prosthesis. A 41-year-old lady required triple valve replacement for rheumatic involvement. Permanent pacemaker implantation was done with epicardial lead for bradycardia post operatively. Pulse generator change was needed within 3 years as the pacemaker reached end of life due to high lead threshold. Subsequent pacemaker implantation was done with a left ventricular lead in coronary sinus by percutaneous approach. One year after implantation, the threshold remains stable. Coronary sinus can be utilized for permanent pacing in patients with inaccessible right ventricle due to prosthetic tricuspid valve.