ABSTRACT
Hypertrophic cardiomyopathy (HCM) can involve the right ventricle (RV), although RV hypertrophy usually exists with left ventricular (LV) hypertrophy and the severity of hypertrophy is milder in the RV than in the LV. We report a case of isolated extreme RV hypertrophy with a maximum RV wall thickness of 40 mm. A 72-year-old man presented with an abnormal electrocardiogram and isolated hypertrophy of the RV apex was found on echocardiography. A diagnosis of HCM was made based on myocardial features on multiple imaging modalities such as the similar myocardial characteristics to LV hypertrophy and systolic thickening. The isolated hypertrophy of the RV apex exhibited partial calcification, which was surrounded by hypoperfused areas of the myocardium on multidetector computed tomography.
ABSTRACT
Thoracic duct injury is a rare mechanical complication during the insertion of a central venous cannula via the left internal jugular vein. We report a case of thoracic duct injury during the insertion of a temporary pacing lead via the right internal jugular vein. A 92-year-old woman presented with third-degree atrioventricular block. Temporary ventricular pacing was attempted via the right internal jugular venous route, but a guidewire and sheath migrated into the vessel structure that was not directly connected to the right ventricle. Considering the characteristics of the fluid obtained from the vessel and the anatomical components of the mediastinum, a diagnosis of thoracic duct injury was made. The system inserted incorrectly was removed and a pacing lead was placed in the right ventricular apex through the right internal jugular vein. Her clinical course was uneventful without developing pneumothorax, hemothorax, or chylothorax, and 5 days later, a permanent pacemaker was implanted via the left subclavian venous route.
ABSTRACT
Simplifying jugular venous pressure (JVP), visibility of the right internal jugular vein above the right clavicle in the sitting position, has been proposed in the management of heart failure (HF) because of its convenience. However, this method may be undervalued for the detection of mildly to moderately increased JVP. Increased JVP on inspiration, known as Kussmaul sign, may be a useful physical finding in this condition. This study consisted of 138 patients who were admitted for the management of HF. Using this simple method, JVP was assessed at rest in the sitting position before discharge; its response to inspiration was also examined if no high JVP was noted at rest. The primary outcome was a composite of cardiac death and hospitalization for worsening HF. Among all the patients, 16 patients (12%) had high JVP at rest and another 16 patients (12%) had high JVP not at rest but on inspiration. During a follow-up period of 249 ± 182 days, a primary outcome event occurred in 63 patients (46%). The incidence of adverse cardiac events was higher in patients with a high JVP at rest (69%; hazard ratio 3.31, 95% confidence interval 1.64 to 6.67, p = 0.0009) and in patients with a high JVP on inspiration (56%; hazard ratio 2.18, 95% confidence interval 1.02 to 4.63, p = 0.043) than in patients without a high JVP in both conditions (41%). In conclusion, a high JVP not only at rest but also on inspiration was associated with a poor prognosis. The response of JVP to inspiration using this simple technique of physical examination may be a new approach in the management of HF.
