Non-atherosclerotic multiple coronary artery aneurysms.

A 52-year-old man underwent two-dimensional echocardiogram which showed moderate to severe aortic regurgitation (AR) and dilated ascending aorta. CT angiography (CTA) showed dilated ascending aorta (5 cm) and transoesophageal echocardiogram revealed bicuspid aortic valve. He underwent cardiac catheterisation which revealed triple vessel aneurysmal disease of the left anterior descending, left circumflex and right coronary artery. The patient underwent aortic graft placement for ascending aortic aneurysm and aortic valve replacement with a Saint Jude valve for severe AR. There was no history or stigmata of Kawasaki disease and workup for coronary artery aneurysm including vasculitis and connective tissue disorders was negative. Histopathology did not reveal evidence of active aortitis or dissection. His aneurysms are being observed by a yearly coronary CTA. We present a rare case of multiple coronary artery aneurysms associated with bicuspid aortic valve and ascending aortic aneurysm.

Electrocardiographic impacts of lung resection.

INTRODUCTION: Electrocardiographic (ECG) changes accompanying lung resection have not been well investigated previously in a large controlled series of human adults. Thus, our current investigation was undertaken for a better understanding of the ECG changes associated with lung resection. MATERIALS AND METHODS: Medical records of 117 patients who underwent lung resection (segmentectomy, lobectomy, or pneumonectomy) were reviewed. Their clinical course and ECGs were compared during early, intermediate and late postoperative course (<1 month, 1 month to 1 year and >1 year post-op respectively). RESULTS: Patients in the acute postoperative phase had higher heart rate, increased maximum P-duration and P-dispersion, increased incidence of atrial arrhythmias and frequent ST-T changes. P-vector and QRS-vector were significantly affected after the lung resections; the correlation being most consistent between the anatomical displacements and the QRS-vector in the majority of patients. The axial shifts also demonstrated a characteristic temporal relationship after left pneumonectomy (a leftward deviation in the acute, normal or slight rightward deviation in the intermediate and a rightward deviation in the late postoperative course). The precordial R/S transition is often affected due to the mediastinal shifts and the ECGs in patients after left lung resection may simulate acute anteroseptal myocardial infarction due to a delayed R/S transition. CONCLUSION: The understanding and recognition of the expected ECG findings after lung resection are imperative to avoid confusing these changes with other acute cardiopulmonary events which would prevent unnecessary further investigational work-up. These ECG changes are often dynamic and may bear a temporal relationship to the dynamic post-surgical changes in the thoracic anatomy.

P-wave indices in patients with pulmonary emphysema: do P-terminal force and interatrial block have confounding effects?

INTRODUCTION: Pulmonary emphysema causes several electrocardiogram changes, and one of the most common and well known is on the frontal P-wave axis. P-axis verticalization (P-axis > 60°) serves as a quasidiagnostic indicator of emphysema. The correlation of P-axis verticalization with the radiological severity of emphysema and severity of chronic obstructive lung function have been previously investigated and well described in the literature. However, the correlation of P-axis verticalization in emphysema with other P-indices like P-terminal force in V1 (Ptf), amplitude of initial positive component of P-waves in V1 (i-PV1), and interatrial block (IAB) have not been well studied. Our current study was undertaken to investigate the effects of emphysema on these P-wave indices in correlation with the verticalization of the P-vector. MATERIALS AND METHODS: Unselected, routinely recorded electrocardiograms of 170 hospitalized emphysema patients were studied. Significant Ptf (s-Ptf) was considered ≥40 mm.ms and was divided into two types based on the morphology of P-waves in V1: either a totally negative (-) P wave in V1 or a biphasic (+/-) P wave in V1. RESULTS: s-Ptf correlated better with vertical P-vectors than nonvertical P-vectors (P = 0.03). s-Ptf also significantly correlated with IAB (P = 0.001); however, IAB and P-vector verticalization did not appear to have any significant correlation (P = 0.23). There was a very weak correlation between i-PV1 and frontal P-vector (r = 0.15; P = 0.047); however, no significant correlation was found between i-PV1 and P-amplitude in lead III (r = 0.07; P = 0.36). CONCLUSION: We conclude that increased P-tf in emphysema may be due to downward right atrial position caused by right atrial displacement, and thus the common assumption that increased P-tf implies left atrial enlargement should be made with caution in patients with emphysema. Also, the lack of strong correlation between i-PV1 and P-amplitude in lead III or vertical P-vector may suggest the predominant role of downward right atrial distortion rather than right atrial enlargement in causing vertical P-vector in emphysema.

Optimal electrocardiographic limb lead set for rapid emphysema screening.

BACKGROUND: Pulmonary emphysema of any etiology has been shown to be strongly and quasidiagnostically associated with a vertical frontal P wave axis. A vertical P wave axis (>60 degrees) during sinus rhythm can be easily determined by a P wave in lead III greater than the P wave in lead I (bipolar lead set) or a dominantly negative P wave in aVL (unipolar lead set). The purpose of this investigation was to determine which set of limb leads may be better for identifying the vertical P vector of emphysema in adults. METHODS: Unselected consecutive electrocardiograms from 100 patients with a diagnosis of emphysema were analyzed to determine the P wave axis. Patients aged younger than 45 years, those not in sinus rhythm, and those with poor quality tracings were excluded. The electrocardiographic data were divided into three categories depending on the frontal P wave axis, ie, >60 degrees, 60 degrees, or <60 degrees, by each criterion (P amplitude lead III > lead I and a negative P wave in aVL). RESULTS: Sixty-six percent of patients had a P wave axis > 60 degrees based on aVL, and 88% of patients had a P wave axis > 60 degrees based on the P wave in lead III being greater than in lead I. CONCLUSION: A P wave in lead III greater than that in lead I is a more sensitive marker than a negative P wave in aVL for diagnosing emphysema and is recommended for rapid routine screening.

Rapidly progressing mycotic aortic aneurysm masquerading as acute coronary syndrome.

Mycotic aortic aneurysms are rare. The most common cause of a mycotic aortic aneurysm is bacterial seeding in a diseased or injured aortic intima with subsequent arteritis. Because the clinical presentation of mycotic aortic aneurysms can be quite variable, the diagnosis hence can often be quite challenging. We herewith report an interesting case study in which the patient with a mycotic aortic aneurysm presented with the clinical picture masquerading as an acute coronary syndrome. The scenario reiterates the fact that despite the availability of accurate noninvasive imaging techniques, strong clinical suspicion might be imperative for the diagnosis of mycotic aneurysms.