[Acute right heart failure after intravenous application of heroin and flunitrazepam]. / Akutes Rechtsherzversagen nach intravenöser Applikation von Heroin und Flunitrazepam.

HISTORY: A 32-year-old woman was admitted to the emergency department because of acute dyspnea and syncope. A few minutes before the onset of symptoms, she had self-administered an intravenous injection of one gram of heroin combined with grinded flunitrazepam tablets. INVESTIGATIONS: Signs of acute cor pulmonale were detected on transthoracic echocardiography despite lack of pulmonary embolism in computed tomography. It was assumed that microembolisms were the cause of acute pulmonary hypertension after intravenous injection of heroin and flunitrazepam. TREATMENT AND COURSE: Because of lack of thrombus in CT scan therapeutic anticoagulation with unfractionated heparin and oxygen insufflation was initiated resulting in rapid improvement of oxygen saturation and blood pressure. On the following day pulmonary pressure in transthoracic echocardiography was already decreased significantly. Without signs of deep venous thrombosis in duplex scan and only a marginal sub segmental perfusion deficit in ventilation-perfusion-scintigraphy therapeutic anticoagulation was recommended for three months. CONCLUSION: The most likely cause of micro embolisms in this case are particles of talc, which are often used to cut heroin, or the microcrystalline cellulose used in tablets. There have been reports of tissue necrosis due to arterial embolism/vasospasm by crystalloid or oily substances (embolia cutis medicamentosa) in the extremities after intraarterial injection of grinded flunitrazepam tablets. Therefore it seems plausible that intravenous application may cause a serve but transient deficit of perfusion in pulmonary circulation.

The impact of foreshortening on regional strain--a comparison of regional strain evaluation between speckle tracking and tissue velocity imaging.

PURPOSE: The conventional parameter of systolic function is global left ventricular (LV) ejection fraction (EF), but this parameter will be replaced by global strain because it seems to be more robust. However, regional strain differences can have a significant impact on global strain. Thus, the aim of the present study was to evaluate the effect of non-standardized scanning on regional strain values determined by 2D speckle tracking and tissue velocity imaging (TVI). Regional longitudinal peak systolic strain (PSS) was measured in standardized data sets of the apical 4-chamber view (ChV) and in a standardized oblique foreshortened view in patients with normal wall motion patterns. MATERIALS AND METHODS: A standardized 4ChV and a foreshortened 4ChV - defined by distinct cardiac structures - were acquired using a Vivid E9 system in 54 patients. All regional PSS values measured in monoplane 2D loops in lateral and septal regions were analyzed to detect the differences between regional strain measured in the standard and the foreshortened view. RESULTS: Significant PSS differences due to FS were detected in patients using 2D speckle tracking for the basal septal regions (p < 0.001). No significant differences due to FS were detected in patients during the analysis of TVI-based strain values (p > 0.05, paired sample T-test). CONCLUSION: To our knowledge this is the first study focusing on methodological aspects - especially standardization - using speckle tracking and TVI. Due to the lower accuracy of strain calculation based on TVI in basal regions, foreshortening has no significant impact on quantitative parameters of TVI-derived strain values in normal contracting hearts. Using speckle tracking, however, foreshortening induces significant differences of basal septal strain in normal contracting hearts. In the presence of regional wall motion defects, a lack of standardization of the views will cause inhomogeneous patterns of regional strain depending on the scan planes through the center of the infarction or its penumbra. Thus, non-standardization will have a significant impact on deformation parameters in 2D echocardiography.

Recurrent strokes under anticoagulation therapy: Sticky platelet syndrome combined with a patent foramen ovale.

The sticky platelet syndrome (SPS) is a congenital disorder characterized by platelet hyperaggregability to epinephrine and/or adenosine diphosphate; this predisposes affected individuals to acute myocardial infarction, ischemic optic neuropathy, recurrent venous thromboembolism, and transient ischemic cerebral attacks and strokes. Here, we describe an unusual case with recurrent cerebrovascular accidents due to SPS, in the presence of a patent foramen ovale (PFO). We report an unusual case of a 56-year-old female patient with a PFO, who suffered from recurrent strokes despite long-term medication with clopidogrel for SPS. The patient underwent successful transcatheter closure of the PFO, and, in addition, she has been placed on low-dose acetylsalicylic acid. After 18-month follow-up, she demonstrated an intact atrial septum without any vegetations on the percutaneous device until today. She has had no further thromboembolic events.

[35-year old patient with severe thromboembolism]. / 35-jähriger Patient mit ausgeprägter Thromboembolie.

We report a case of a 35 year old male with severe deep vein thrombosis of the lower limb on both sides and pulmonary embolism. A Klinefelter's mosaic (47,XXY [81%]/48,XXXY [19%]) was diagnosed. Because no other cause for this thromboembolism was found, we assume that in part, it was caused by the Klinefelter's mosaic. In all male patients presenting with thromboembolism, especially those with an unusual habitus, a Klinefelter's syndrome should be considered as differential diagnosis. Testosterone substitution therapy should be started in all patients with Klinefelter's syndrome to prevent further disease.