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A man in his 80s presented with recurrent presyncope and bradycardia. An electrocardiogram showed atrial fibrillation with an irregular ventricular rate of around 60 beats per minute, right bundle branch block, and left posterior fascicular block. What would you do next?
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Fibrilación Atrial , Bloqueo de Rama , Humanos , Bloqueo de Rama/diagnóstico , Sistema de Conducción CardíacoRESUMEN
We describe a previously unreported and potentially fatal complication of colonic perforation following the implantation of a subcutaneous implantable cardioverter-defibrillator in a young patient with nonischemic cardiomyopathy. We discuss the importance of technique and postprocedural evaluation for subdiaphragmatic complications. This description emphasizes presenting complaints, early recognition, and management strategies. (Level of Difficulty: Beginner.).
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We describe the case of a young female patient with hypertrophic cardiomyopathy (HCM) with a dual chamber implantable cardioverter defibrillator (ICD), and complete heart block from a prior septal ablation procedure. Due to persistent left ventricular outflow tract (LVOT) obstruction and symptoms, she underwent surgical myectomy. Her exertional symptoms continued despite improved LVOT flow parameters. A comprehensive evaluation, including ICD interrogation, helped arrive at the correct diagnosis and treatment plan.
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Cardiomiopatía Hipertrófica , Ablación por Catéter , Cardiopatías Congénitas , Disfunción Ventricular Izquierda , Obstrucción del Flujo Ventricular Externo , Humanos , Femenino , Tabiques Cardíacos/cirugía , Cardiopatías Congénitas/cirugía , Resultado del TratamientoAsunto(s)
Bloqueo Atrioventricular , Marcapaso Artificial , Reemplazo de la Válvula Aórtica Transcatéter , Bloqueo Atrioventricular/diagnóstico , Bloqueo Atrioventricular/etiología , Bloqueo Atrioventricular/terapia , Bradicardia/diagnóstico , Bradicardia/etiología , Bradicardia/terapia , Electrocardiografía , Humanos , Marcapaso Artificial/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversosAsunto(s)
Cardiomiopatías/terapia , Muerte Súbita Cardíaca/prevención & control , Taquicardia por Reentrada en el Nodo Atrioventricular/diagnóstico , Taquicardia por Reentrada en el Nodo Atrioventricular/fisiopatología , Adulto , Diagnóstico Diferencial , Electrocardiografía , Humanos , Masculino , Prevención Primaria , Taquicardia por Reentrada en el Nodo Atrioventricular/cirugía , Taquicardia Ventricular/diagnósticoAsunto(s)
Bloqueo Atrioventricular , Bloqueo de Rama , Electrocardiografía/métodos , Prueba de Esfuerzo/métodos , Marcapaso Artificial , Síncope , Anciano , Bloqueo Atrioventricular/diagnóstico , Bloqueo Atrioventricular/fisiopatología , Bloqueo Atrioventricular/terapia , Bloqueo de Rama/diagnóstico , Bloqueo de Rama/fisiopatología , Bloqueo de Rama/terapia , Humanos , Masculino , Implantación de Prótesis/instrumentación , Implantación de Prótesis/métodos , Recurrencia , Síncope/etiología , Síncope/terapia , Resultado del TratamientoRESUMEN
Aging results in loss of subcutaneous body fat as well as lean body mass. Elderly patients are also more likely to require cardiac implantable electronic devices (CIED) due to rising cardiovascular disease prevalence. A majority of the currently available devices require placement in a pocket created in the subcutaneous space between the subcutaneous fat tissue and the underlying chest wall muscle. Deficient subcutaneous fat tissue can result in device protrusion and even erosion through the skin. This can lead to significant morbidity and mortality especially when associated with device infection and need for device system extraction. This article reviews the scope of the problem and some of the strategies that can be employed to address the lack of subcutaneous soft tissue at the time of device implant.
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BACKGROUND: In the era of an expanding use of transcatheter aortic valve replacement (TAVR), conduction disturbances and the requirement for permanent pacemaker (PPM) implantation remains a clinical concern. HYPOTHESIS: Using a single-center experience, we sought to identify predictors of ventricular pacing burden after TAVR in patients who required PPM implantation. METHODS: We conducted a retrospective study of 359 consecutive patients with symptomatic severe aortic valve stenosis who underwent TAVR at our institution between September 2013 and July 2019. Thirty patients (8.4%) required a PPM within 30 days after TAVR. Pre and post-TAVR electrocardiograms, pre-TAVR echocardiograms and computed tomography (CT), TAVR procedural details and post-TAVR device interrogation records at 1, 3, and 6 months were reviewed. RESULTS: Mean percentage of ventricular pacing (VP%) at 1, 3, and 6 months was 58%, 59%, and 56% respectively. Using univariate logistic regression analysis, patients who had low VP% < 5% at 6 months were more likely to have a prosthesis/echocardiography-derived left ventricular outflow tract (LVOT) diameter ratio < 1.3 (OR 7.00, P-value .048), prosthesis/CT-derived aortic annulus diameter ratio < 1.02 (OR 7.11, P-value .047), post-TAVR new-onset LBBB (OR 16.80, P-value .019), time to PPM implantation greater than 2 days post-TAVR (OR 9.38, P-value .026) and pre-TAVR use of a beta blocker (OR 9.40, P-value .026). CONCLUSIONS: In patients who required a PPM implantation post-TAVR, a lower TAVR prosthesis/LVOT or aortic annulus diameter ratio, post-TAVR new-onset LBBB and later time of PPM implantation showed a trend toward predicting a low VP% at 6 months.
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Estenosis de la Válvula Aórtica/cirugía , Arritmias Cardíacas/terapia , Estimulación Cardíaca Artificial/métodos , Electrocardiografía , Complicaciones Posoperatorias/terapia , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Anciano , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/diagnóstico , Arritmias Cardíacas/etiología , Arritmias Cardíacas/fisiopatología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Estudios Retrospectivos , Tomografía Computarizada por Rayos XRESUMEN
Recent studies have shown conflicting data regarding left ventricular (LV) function in patients with neurocardiogenic syncope, with some investigators reporting a marked decrease in LV end-systolic wall stress and stress-corrected fractional shortening. We sought to determine the characteristics of resting LV deformation in patients with neurocardiogenic syncope by selective motion tracking of subendocardial and subepicardial regions using speckle tracking echocardiography. We assessed resting LV function in 82 patients undergoing head-up tilt-table (HUTT) testing. Patients were divided into 3 groups based on a positive HUTT test with associated co-morbid conditions (n = 30), no associated co-morbid conditions (n = 30), or negative HUTT results (n = 22). LV longitudinal, circumferential, and radial strains were obtained by speckle tracking echocardiography of subendocardial and subepicardial regions in each group and compared with resting LV deformation in 20 healthy control subjects. Compared with endocardial longitudinal strain in control subjects, that in patients with positive HUTT results was attenuated, irrespective of co-morbid conditions (p <0.05). Circumferential and radial strains did not differ among groups. On multivariate logistic regression analysis, endocardial longitudinal strain was an independent predictor (odds ratio, 1.16; p = 0.01) of positive HUTT test results. In conclusion, resting LV longitudinal strain is attenuated in patients with positive HUTT test results. Overall, these results may suggest that an increase in resting LV contractility is not a prerequisite for development of neurocardiogenic syncope.
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Ventrículos Cardíacos/fisiopatología , Síncope Vasovagal/diagnóstico , Pruebas de Mesa Inclinada/instrumentación , Función Ventricular Izquierda/fisiología , Adulto , Anciano , Diagnóstico Diferencial , Ecocardiografía , Diseño de Equipo , Femenino , Estudios de Seguimiento , Ventrículos Cardíacos/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Reproducibilidad de los Resultados , Estudios Retrospectivos , Síncope Vasovagal/fisiopatologíaRESUMEN
Cardiac arrhythmias comprise of a heterogeneous group of disorders which manifest in a wide range of clinical presentations. They can be associated with underlying cardiac disease and portend a grave prognosis, with some arrhythmias being rapidly fatal. Other arrhythmias, however are relatively benign and can be asymptomatic or may be a mere inconvenience for the patient. All primary care physicians can expect to encounter some forms of arrhythmias during the course of their practice. This review article provides a brief overview of the commonly seen tachyarrhythmias for the general practitioner and provides relevant updates on the recent developments in our understanding of their mechanisms and management.
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Arritmias Cardíacas/fisiopatología , Arritmias Cardíacas/terapia , Fármacos Cardiovasculares/uso terapéutico , Fibrilación Atrial/fisiopatología , Fibrilación Atrial/terapia , Aleteo Atrial/fisiopatología , Aleteo Atrial/terapia , Fármacos Cardiovasculares/administración & dosificación , Fármacos Cardiovasculares/efectos adversos , Ablación por Catéter , Cardioversión Eléctrica , Electrocardiografía , Ventrículos Cardíacos/fisiopatología , Humanos , Factores de Riesgo , Taquicardia/fisiopatología , Taquicardia/terapiaRESUMEN
After a gap of almost 60 years following the development of warfarin, 2 new categories of oral anticoagulant agents have been approved for clinical use - the direct thrombin inhibitors and factor Xa inhibitors. These agents promise to be more convenient to administer with fixed dosing but still have equivalent efficacy and improved bleeding risk compared to warfarin. The clinical community is looking forward to the widespread usage of these agents but there is also some apprehension regarding bleeding risks, non-availability of specific reversal strategies and lack of specific monitoring parameters. This review article will attempt to educate the reader about three representative drugs from these classes: Dabigatran, Rivaroxaban and Apixaban. We will discuss the historical perspective to the development of these drugs, available research data and pharmacology of these agents. The best strategies for monitoring and reversal of these drugs in special situations will also be touched upon.
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Anticoagulantes/administración & dosificación , Bencimidazoles/administración & dosificación , Morfolinas/administración & dosificación , Pirazoles/administración & dosificación , Piridonas/administración & dosificación , Tiofenos/administración & dosificación , beta-Alanina/análogos & derivados , Administración Oral , Dabigatrán , Inhibidores del Factor Xa , Humanos , Rivaroxabán , Tromboembolia/prevención & control , beta-Alanina/administración & dosificaciónRESUMEN
OBJECTIVE: The aim of this study is to evaluate the relationship between polarity of left ventricular (LV) pacing and the resultant regional, global, and transmural mechanical sequence of contraction. BACKGROUND: Cardiac resynchronization therapy (CRT) is widely utilized in patients with drug refractory congestive heart failure with systolic dysfunction (EF <35 %) and intraventricular conduction delay (QRS duration >120 ms). However, little is known about polarity of pacing stimulation and the resultant differences in LV mechanics. METHODS: The polarity of pacing was altered sequentially in 20 patients (73 ± 13, 16 males) with preexisting biventricular devices with potential choice of multiple vectors for pacing stimulation. Initial unipolar or extended bipolar configurations were switched to bipolar configuration or vice versa, and echocardiographic images were acquired for off-line analysis. Regional and global LV longitudinal and radial mechanics were assessed selectively from the subendocardial and subepicardial regions with 2D speckle-tracking echocardiography. Left ventricular capture by each vector configuration was confirmed by local lead capture and appropriate QRS alteration. RESULTS: Unipolar pacing resulted in increased dispersion of LV regional endocardial strains with a higher base-to-apex gradients of longitudinal shortening strains (P < 0.05). LV longitudinal shortening strain magnitude was higher at LV base with bipolar stimulation in comparison with unipolar stimulation (-10.5 ± 10.5 vs. -4.2 ± 6.3, P = 0.02). CONCLUSION: There is a difference in the mechanical activation sequence of the LV between unipolar vs. bipolar pacing stimulation. This may have important implications for CRT.
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Terapia de Resincronización Cardíaca/métodos , Insuficiencia Cardíaca/terapia , Ventrículos Cardíacos/fisiopatología , Contracción Miocárdica/fisiología , Anciano , Electrocardiografía , Femenino , Humanos , Masculino , Resultado del TratamientoRESUMEN
The presence of coronary artery calcium is closely associated with the presence of atherosclerotic lesions in the coronary vasculature. Detection of coronary calcium by imaging techniques has evolved over the last few decades and has become especially more sophisticated with advanced imaging technology. Whereas the status of coronary artery calcium as a marker of increased cardiovascular risk is well established, the indication for testing continues to be a topic of debate.
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Enfermedad de la Arteria Coronaria/patología , Grupos Raciales , Calcificación Vascular/patología , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Atención Ambulatoria/economía , Enfermedades de la Aorta/etnología , Enfermedades de la Aorta/mortalidad , Enfermedades de la Aorta/patología , Calcio/metabolismo , Angiografía Coronaria/métodos , Enfermedad de la Arteria Coronaria/etnología , Enfermedad de la Arteria Coronaria/mortalidad , Vasos Coronarios/metabolismo , Costos y Análisis de Costo , Servicio de Urgencia en Hospital/economía , Femenino , Humanos , Masculino , Síndrome Metabólico/etnología , Síndrome Metabólico/mortalidad , Síndrome Metabólico/patología , Persona de Mediana Edad , Pronóstico , Factores de Riesgo , Factores Sexuales , Calcificación Vascular/etnología , Calcificación Vascular/mortalidad , Adulto JovenRESUMEN
Echocardiography can be used for rapid and accurate risk stratification of patients with pulmonary embolism to appropriately direct the therapeutic strategies for those at high risk. Echocardiography is an ideal risk stratification tool in this regard because of its easy portability to the emergency room or to the bed side. It can be performed at a relatively low cost and at no risk to the patient. Furthermore, echocardiography allows repetitive noninvasive assessment of the cardiovascular and hemodynamic status of the patient and the response to the therapeutic interventions. Right ventricular hypokinesis, persistent pulmonary hypertension, a patent foramen ovale, and a free floating right heart thrombus are echocardiographic markers that identify patients at a higher risk for morbidity and mortality. Such patients warrant special consideration for thrombolysis or embolectomy.