Transient global amnesia after ablation of premature ventricular beats arising from the right coronary cusp.

A 58-year-old female underwent PVC ablation within the right coronary cusp for symptomatic PVCs and suspected PVC-induced cardiomyopathy. Immediately after the procedure, she started to complain about feelings of impending doom, disorientation to time and place, and amnesia regarding the procedure. No sensory or motor deficits could be elicited. A thromboembolic event was suspected and she was evaluated by a neurologist. CT scan of her brain was negative. She was diagnosed with transient global amnesia and her mentation returned to baseline within 4 hours after the procedure.

A novel approach to differentiating orthodromic reciprocating tachycardia from atrioventricular nodal reentrant tachycardia.

BACKGROUND: Various diagnostic maneuvers have been proposed to help differentiate orthodromic reciprocating tachycardia (ORT) from atrioventricular nodal reentrant tachycardia (AVNRT) prior to ablation. However, not all criteria are applicable in every situation as each has limitations. OBJECTIVE: The purpose of this study was to determine whether the behavior of tachycardia during onset of right ventricular (RV) pacing would help differentiate ORT from AVNRT. METHODS: We retrospectively reviewed 72 cases (42 typical AVNRT, 7 atypical AVNRT, 15 left free-wall pathways, 6 septal pathways, 2 right free-wall pathways). We assessed the number of beats required to accelerate the tachycardia cycle length (TCL) to the paced cycle length (PCL) once a fully RV paced complex was achieved during supraventricular tachycardia. RESULTS: In the AVNRT group, delta cycle length (DCL = PCL-TCL) was 29 +/- 16 ms compared to 29 +/- 10 ms in ORT group (P = NS). In the AVNRT group, the average number of fully RV paced beats required to reset the tachycardia was 3.7 +/- 1.1 compared to 1 +/- 0 in the ORT group (P <.0001). Using a cutoff >1 beat yielded both positive and negative predictive values of 100% for diagnosing AVNRT versus ORT. During entrainment attempts, AVNRT terminated 51% of the time and ORT terminated 65% of the time but still allowed application of the new criterion. CONCLUSION: Assessing timing and type of response of supraventricular tachycardia to RV pacing can help differentiate ORT from AVNRT with high certainty and prevent the need for other pacing maneuvers and measurements.

Rotational atherectomy to facilitate stent expansion after deployment in ST-segment-elevation myocardial infarction.

We describe successful rotational atherectomy performed in the setting of two relative contraindications to the procedure. A 77- year-old female presented with ST-segment-elevation myocardial infarction due to 100% right coronary artery thrombosis. With high pressure dilatation (22 atmospheres) and cutting balloon angioplasty, the lesion dissected but did not fully dilate. After stenting and high-pressure post-dilatation at 25 atmospheres the dissection resolved, but a 70% waist remained. Rotational atherectomy allowed full dilatation of the lesion at 22 atmospheres. In this case, after stenting removed angiographically evident thrombus and dissection, rotational atherectomy effectively and safely treated residual stenosis at an undilatable lesion.

Immediate impact of participation in the electronic residency application service on a fellowship program.

OBJECTIVE: This study sought to evaluate the immediate impact of participation in the Electronic Residency Application Service (ERAS) on a single cardiology fellowship program. METHOD: The study reviewed all applications (n = 1824) made to the Geisinger Medical Center cardiology fellowship program over a 4-year period (2004-2007). The aggregate data for the first 2 years (pre-ERAS, 2004 and 2005) was compared to that of the last 2 years (post-ERAS, 2006 and 2007). RESULTS: Compared to the pre-ERAS period, the total number of applications in the post-ERAS period increased by 49% (732 versus 1092; p<.05) and the number of complete applications increased by 70% (577 versus 983; p<.05). Other significant differences (p<.05) included a higher percentage of applications from female candidates (81 of 732 [11%] versus 186 of 1092 [17%]), and a greater geographic distance from applicants' internal medicine residency institutions (420 ± 454 miles versus 585 ± 559 miles]. Comparison of applicants' age, citizenship status, graduation origin, years since medical school graduation, and United States Medical Licensing Examination scores yielded no significant differences between pre-ERAS and post-ERAS periods. CONCLUSION: Participation in ERAS resulted in an immediate increase in the total number of applications, higher proportion of applications with complete data, a higher number and proportion of female applicants, and a wider geographic distribution of applications. This likely reflects ease of application submission through a central electronic service. However, the administrative burden on fellowship programs and the effects of wider geographic distribution of applications on the fellowship-matching process merit further evaluation.

Emphysematous urinary tract infections: diagnosis, treatment and survival (case review series).

BACKGROUND: Emphysematous urinary tract infections are rare conditions, usually occurring in diabetic patients. Mortality rates in medically managed patients are reported to be as high as 70% to 90%. Growth of the diabetic population warrants heightened attention to these potentially fatal infections. We report a series of 5 cases with favorable outcomes. CASE REPORTS: All patients were diabetic. Presenting symptoms included fever, chills, nausea, vomiting, and abdominal pain. On physical examination, two patients had costovertebral angle tenderness; a third was dehydrated; a fourth had dehydration and an abdominal mass; and a fifth patient had suprapubic tenderness. All cases had leukocytosis and impaired renal function. Computed tomography (CT) scan disclosed emphysematous pyelonephritis in 3 cases (gas within renal parenchyma and/or perirenal tissue), emphysematous pyelitis in 1 case (gas in collecting system), and emphysematous cystitis in 1 patient (gas within bladder wall). Urine culture of 1 case grew Enterococci, whereas in the other cases cultures yielded gas-producing organisms. All patients received intravenous antibiotics. Two patients underwent CT-guided abscess drainage; 2 cases had J-stent placement, and one patient was readmitted with septic shock and underwent nephrectomy. All the patients' conditions improved and they were discharged. DISCUSSION: Emphysematous urinary tract infections are usually caused by gas-producing organisms. They should be suspected in diabetic patients with urinary tract infections and worsening of renal function. CT scan is the method of choice for diagnosis and follow up. None of our patients died, mainly due to early diagnosis, sequential radiologic assessment, and timely surgical intervention when needed.

Comparison of blood pressure control with amlodipine and controlled-release isradipine: an open-label, drug substitution study.

An open-label drug substitution study showed that controlled-release isradipine (Dynacirc-CR) can be safely substituted for amlodipine on a mg-for-mg basis in patients with mild-to-moderate hypertension. When controlled-release isradipine was substituted for amlodipine, blood pressure was more effectively controlled, and edema rates were reduced. When subjects resumed amlodipine therapy, the previous gain in blood pressure reduction and lessening of edema vanished. The basis for this more favorable pattern of efficacy and side-effects with controlled-release isradipine, although mechanistically unresolved, may relate to a lesser degree of sympathetic nervous system activation.