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Clinical Medicine Insights. Cardiology 2023Regional right ventricular dysfunction with akinesia of the mid-free wall with normal apical motion known as McConnell's sign is an under-reported echocardiographic...
Regional right ventricular dysfunction with akinesia of the mid-free wall with normal apical motion known as McConnell's sign is an under-reported echocardiographic finding in the setting of pulmonary embolism. We conducted a literature review and systematic analysis, while describing 2 cases of pulmonary embolism with findings of reverse McConnell's sign.
PubMed: 37312974
DOI: 10.1177/11795468231178665 -
The American Journal of Case Reports Jun 2023BACKGROUND Left ventricular thrombus is a serious complication of numerous cardiovascular conditions. Anticoagulation with oral vitamin K antagonists such as warfarin is...
BACKGROUND Left ventricular thrombus is a serious complication of numerous cardiovascular conditions. Anticoagulation with oral vitamin K antagonists such as warfarin is a standard treatment for left ventricular thrombus and is recommended to reduce the risk of embolization. Patients with cardiac conditions share comorbidities with patients with end-stage renal disease, and patients with advanced kidney disease are predisposed to atherothrombotic and thromboembolic complications. The efficacy of direct oral anticoagulants in patients with left ventricular thrombus has not been well studied. CASE REPORT A 50-year-old man had prior myocardial infarction, heart failure with reduced ejection fraction, diabetes, hypertension, atrial fibrillation, treated hepatitis B infection, and end-stage renal disease on hemodialysis. On regular outpatient follow-up with the cardiology clinic, a transthoracic echocardiogram was requested and revealed akinesia of the mid to apical anterior wall, mid to apical septum, and left ventricular apex, and large apical thrombus measuring 20×15 mm. Apixaban 5 mg orally twice daily was started. A transthoracic echocardiogram was done after 3 months and after 6 months, and the thrombus did not resolve. The apixaban was shifted to warfarin. The international normalized range was maintained at the therapeutic range (INR 2.0-3.0). After 4 months of receiving warfarin, echocardiography showed a resolution of the left ventricular thrombus. CONCLUSIONS We report a case of left ventricular thrombus that was successfully dissolved by warfarin after treatment with apixaban failed. This case challenges the general assumption of apixaban's effectiveness in patients with end-stage renal disease on dialysis.
Topics: Male; Humans; Middle Aged; Warfarin; Renal Dialysis; Anticoagulants; Thrombosis; Kidney Failure, Chronic; Vitamin K
PubMed: 37310921
DOI: 10.12659/AJCR.940199 -
Cureus May 2023In addition to the well-known convex ST-segment elevation myocardial infarction (STEMI) pattern associated with acute occlusive myocardial infarction (OMI), there are...
In addition to the well-known convex ST-segment elevation myocardial infarction (STEMI) pattern associated with acute occlusive myocardial infarction (OMI), there are other cases that are recognized as OMI without fulfilling the established characteristic STEMI criteria. Over one-fourth of the patients initially classified as having non-STEMI can be re-classified as having OMI by recognizing other STEMI equivalent patterns. We report a case of a 79-year-old man with multiple comorbidities who was brought to the ED by paramedics with a two-hour history of ongoing chest pain. During transport, the patient suffered a cardiac arrest associated with ventricular fibrillation (VF) that required electric defibrillation and active cardiopulmonary resuscitation. Upon ED arrival, the patient was unresponsive, with a heart rate of 150 beats/min and ECG evidence of wide-QRS tachycardia that was misinterpreted as ventricular tachycardia (VT). He was further managed with intravenous amiodarone, mechanical ventilation, sedation, and unsuccessful defibrillation therapy. Upon persistence of the wide-QRS tachycardia and clinical instability, the cardiology team was emergently consulted for bedside assistance. On further review of the ECG, a shark fin (SF) OMI pattern was identified, indicative of an extensive anterolateral OMI. A bedside echocardiogram revealed a severe left ventricular systolic dysfunction with marked anterolateral and apical akinesia. The patient underwent a successful percutaneous coronary intervention (PCI) to an ostial left anterior descending (LAD) culprit occlusion with hemodynamic support but ultimately died due to multiorgan failure and refractory ventricular arrhythmias. This case illustrates an infrequent OMI presentation (<1.5%) formed by the fusion of the QRS, ST-segment elevation, and T-wave resulting in a wide triangular waveform, giving the appearance of an SF that can also potentially lead to ECG misinterpretation as VT. It also highlights the importance of recognizing STEMI-equivalent ECG patterns to avoid delays in reperfusion therapy. The SF OMI pattern has also been associated with a large amount of ischemic myocardium (such as with left main or proximal LAD occlusion) with a higher mortality risk from cardiogenic shock and/or VF. This high-risk OMI pattern should lead to a more definite reperfusion treatment, such as primary PCI and the possible need for backup hemodynamic support.
PubMed: 37292562
DOI: 10.7759/cureus.38708 -
Saudi Journal of Anaesthesia 2023To evaluate the efficacy, safety, and satisfaction for the use of adjuvant; magnesium sulfate (MgSO) in sub-Tenon anesthesia for cataract surgery.
PURPOSE
To evaluate the efficacy, safety, and satisfaction for the use of adjuvant; magnesium sulfate (MgSO) in sub-Tenon anesthesia for cataract surgery.
METHODS
This single centered randomized, double blind trial was held in 2021 after approval of ethical committee at the Eye Hospital, Riyadh, Saudi Arabia. Cataract patients to be operated using local anesthesia were randomly assigned to two groups; Group magnesium sulfate (MS) received 50 mg/0.5 ml of magnesium sulfate and Group normal saline (NS) received 0.5 ml of normal saline added to the standard mixture, respectively. Absence of eyelid dropping and akinesia of the globe at different time after anesthesia were considered as ineffective anesthesia. The age and sex-adjusted generalized estimating equation (GEE) analysis was carried out. Complications, patient's and surgeon's satisfaction were also compared.
RESULTS
Each group had 100 cataract patients. Effectiveness of block was not significantly different in two groups (adjusted odds ratio, 0.90; 95% confidence interval [CI], 0.62, 1.31; = 0.594). The likelihood of "no eye-opening" significantly increased with time (adjusted odds ratio, 1.26; 95% CI, 1.18-1.34; < 0.001). Subconjunctival bleeding was significantly higher in the MS versus NS Group (36 of 98 [36.7%] vs. 11 of 102 [10.8%], < 0.001). Chemosis was not significantly different between the groups ( = 0.95). Patient's satisfaction score was very good (9/10) but slightly higher in NS group than MS ( = 0.001) while surgeon's satisfaction score was similar in both groups ( = 0.149).
CONCLUSIONS
Although safe, adding 50 mg of magnesium sulfate did not improve the effect of sub-Tenon anesthesia for cataract surgery. Risk of subconjunctival bleeding was higher in cataract patients operated using MgSO compared to those managed with the conventional sub-Tenon anesthetic.
PubMed: 37260671
DOI: 10.4103/sja.sja_532_22 -
Brain Sciences Apr 2023Data on the use of device-aided therapies (DATs) in people with Parkinson's disease (PwP) are scarce. Analyzing data from the Care4PD patient survey, we (1) evaluated...
Data on the use of device-aided therapies (DATs) in people with Parkinson's disease (PwP) are scarce. Analyzing data from the Care4PD patient survey, we (1) evaluated application frequency and type of DAT in a larger, nationwide, cross-sectoral PwP sample in Germany; (2) analyzed the frequency of symptoms indicative for advanced PD (aPD) and need for DAT amongst the remaining patients and (3) compared the most bothersome symptoms and need for professional long-term care (LTC) of patients with and without suspected aPD. Data from 1269 PwP were analyzed. In total, 153 PwP (12%) received DAT, mainly deep brain stimulation (DBS). Of the remaining 1116 PwP without DAT, >50% fulfilled at least one aPD criterion. Akinesia/rigidity and autonomic problems were most bothersome for PwP with and without suspected aPD, with more tremor in the non-aPD and more motor fluctuations and falls in the aPD group. To recapitulate, the German DAT application rate is rather low, although a large proportion of PwP fulfills aPD criteria indicating a need for intensified treatment strategies. Many reported bothersome symptoms could be overcome with DAT with benefits even for LTC patients. Thus, precise and early identification of aPD symptoms (and therapy-resistant tremor) should be implemented in future DAT preselection tools and educational trainings.
PubMed: 37239208
DOI: 10.3390/brainsci13050736 -
Cureus Apr 2023An 85-year-old woman presented with altered mental status and appeared to be actively agitated due to her medications. During her hospitalization, troponins trended up...
An 85-year-old woman presented with altered mental status and appeared to be actively agitated due to her medications. During her hospitalization, troponins trended up and an electrocardiogram (ECG) showed diffuse ST elevation. Echocardiogram showed an estimated ejection fraction of 40% with hypokinesis of the apex, suggestive of Takotsubo cardiomyopathy. After several days of supportive care, the patient showed significant clinical improvement with normalization of ECG, cardiac enzymes, and echocardiographic findings. Although Takotsubo cardiomyopathy has been associated with diverse forms of physical or emotional stress, this report discusses a rare case of delirium state causing Takotsubo cardiomyopathy.
PubMed: 37223164
DOI: 10.7759/cureus.37941 -
Frontiers in Cardiovascular Medicine 2023Takotsubo syndrome (TTS) is mainly characterized by chest pain, left ventricular dysfunction, ST-segment deviation on electrocardiogram (ECG) and elevated troponins in...
BACKGROUND
Takotsubo syndrome (TTS) is mainly characterized by chest pain, left ventricular dysfunction, ST-segment deviation on electrocardiogram (ECG) and elevated troponins in the absence of obstructive coronary artery disease. Diagnostic features include left ventricular systolic dysfunction shown on transthoracic echocardiography (TTE) with wall motion abnormalities, generally with the typical "apical ballooning" pattern. In very rare cases, it involves a reverse form which is characterized by basal and mid-ventricular severe hypokinesia or akinesia, and sparing of the apex. TTS is known to be triggered by emotional or physical stressors. Recently, multiple sclerosis (MS) has been described as a potential trigger of TTS, especially when lesions are located in the brainstem.
CASE SUMMARY
We herein report the case of a 26-year-old woman who developed cardiogenic shock due to reverse TTS in the setting of MS. After being admitted for suspected MS, the patient presented with rapidly deteriorating clinical condition, with acute pulmonary oedema and hemodynamic collapse, requiring mechanical ventilation and aminergic support. TTE found a severely reduced left ventricular ejection fraction (LVEF) of 20%, consistent with reverse TTS (basal and mid ventricular akinesia, apical hyperkinesia). Cardiac magnetic resonance imaging (MRI) performed 4 days later showed myocardial oedema in the mid and basal segments on T2-weighted imaging, with partial recovery of LVEF (46%), confirmed the diagnosis of TTS. In the meantime, the suspicion of MS was also confirmed, based on cerebral MRI and cerebral spinal fluid analyses, with a final diagnosis of reverse TTS induced by MS. High-dose intravenous corticotherapy was initiated. Subsequent evolution was marked by rapid clinical improvement, as well as normalization of LVEF and segmental wall-motion abnormalities.
CONCLUSION
Our case is an example of the brain-heart relationship: it shows how neurologic inflammatory diseases can trigger a cardiogenic shock due to TTS, with potentially serious outcomes. It sheds light on the reverse form, which, although rare, has already been described in the setting of acute neurologic disorders. Only a handful of case reports have highlighted MS as a trigger of reverse TTS. Finally, through an updated systematic review, we highlight the unique features of patients with reversed TTS triggered by MS.
PubMed: 37206102
DOI: 10.3389/fcvm.2023.1175644 -
European Heart Journal. Case Reports May 2023This is a case report of a patient with Anderson-Fabry disease (AFD) due to the D313Y variant on the a-galactosidase A () gene on migalastat treatment and severe chronic...
BACKGROUND
This is a case report of a patient with Anderson-Fabry disease (AFD) due to the D313Y variant on the a-galactosidase A () gene on migalastat treatment and severe chronic kidney disease referred to our unit to assess possible cardiac involvement.
CASE SUMMARY
A 53-year-old man with chronic kidney disease due to AFD and a medical history of revascularized coronary artery disease, chronic atrial fibrillation, and arterial hypertension was referred to our unit for evaluation of possible cardiac involvement in the context of AFD. Biochemical evaluation reported reduced serum alpha-galactosidase A activity and borderline abnormal serum lyso-Gb enzyme activity. The patient had also history of acroparesthesias, dermatological presentation of multiple angiokeratomas, severe kidney impairment with an estimated glomerular filtration rate (eGFR) of 30 mL/min/1.73m² by the age of 16, and microalbuminuria that cumulatively set the diagnosis of AFD. Transthoracic echocardiogram showed left ventricular concentric hypertrophy with left ventricular ejection fraction of 45%. Cardiac magnetic resonance showed findings in keeping with ischaemic heart disease (IHD), i.e. akinesia and subendocardial scarring of the basal anterior and the entirety of the septum and the true apex; in addition, there was severe asymmetrical hypertrophy of the basal anteroseptum (max 18 mm), evidence of low-grade myocardial inflammation, and mid-wall fibrosis of the basal inferior and inferolateral wall, suggesting a cardiomyopathic process-myocardial disease which could not be explained solely by IHD or well-controlled hypertension.
DISCUSSION
This is the first case of possible cardiac involvement in a patient with AFD due to the D313Y variant. This case demonstrates the diagnostic challenges of cardiac involvement in AFD, especially in the presence of a concomitant underlying pathology.
PubMed: 37201153
DOI: 10.1093/ehjcr/ytad224 -
Journal of Vitreoretinal Diseases 2023To compare retrobulbar anesthesia injection (RAI) with hyaluronidase and without hyaluronidase in vitreoretinal surgery using clinical efficacy measures and orbital...
To compare retrobulbar anesthesia injection (RAI) with hyaluronidase and without hyaluronidase in vitreoretinal surgery using clinical efficacy measures and orbital manometry (OM). This prospective randomized double-masked study enrolled patients who had surgery using an 8 mL RAI with or without hyaluronidase. Outcome measures were clinical block effectiveness (akinesia, pain scores, need for supplemental anesthetic or sedative medications) and orbital dynamics assessed by OM before and up to 5 minutes after RAI. Twenty-two patients received RAI with hyaluronidase (Group H+), and 25 received RAI without hyaluronidase (Group H-). Baseline characteristics were well matched. No differences in clinical efficacy were found. OM showed no difference in preinjection orbital tension (4 ± 2 mm Hg in both groups) or calculated orbital compliance (0.6 ± 0.3 mL/mm Hg, Group H+; 0.5 ± 0.2 mL/mm Hg, Group H-) ( = .13). After RAI, the peak orbital tension was 23 ± 15 mm Hg in Group H+ and 24 ± 9 mm Hg in Group H- ( = .67); it declined more rapidly in Group H+. Orbital tension at 5 minutes was 6 ± 3 mm Hg in Group H+ and 11 ± 5 mm Hg in Group H- ( = .0008). OM showed faster resolution of post-RAI orbital tension elevation with hyaluronidase; however, there were no clinically evident differences between groups. Thus, 8 mL RAI with or without hyaluronidase is safe and can achieve excellent clinical results. Our data do not support the routine use of hyaluronidase with RAI.
PubMed: 37188214
DOI: 10.1177/24741264231160934