A. Khanna

A RARE CASE OF “YO-YO”-LIKE LEFT ATRIAL APPENDAGE THROMBUS CAUSING FUNCTIONAL MITRAL STENOSIS.: 60

Background Intracardiac thrombi are a common entity seen in clinical practice. The predisposing factors are atrial fibrillation, low cardiac output, and a low flow state as seen in patients with severely compromised systolic function and dilatation of the cardiac chambers. Anticoagulation in a patient with structural heart disease and atrial fibrillation is strongly recommended. Case Report We present a case of a 62-year-old lady seen in the ER with complaints of worsening shortness of breath over the past 2 weeks. Her past medical history was significant for hypertension, diabetes mellitus, atrial fibrillation, severe LV systolic dysfunction with NYHA class III heart failure s/p AICD insertion, and mitral regurgitation s/p mitral valve repair. Physical examination revealed a chronically ill-appearing woman in moderate respiratory distress. The first and second heart sounds were soft with a 2/6 pan systolic murmur at apex and left sternal border radiating to the left axilla. A short diastolic murmur was heard inconsistently at the apex. There was evidence of biventricular heart failure. The INR was 1.6. A transthoracic echocardiogram (TTE) revealed enlargement of all four cardiac chambers. There was global hypokinesis of the left ventricle with severely reduced left ventricular systolic function (LVEF 10%). An echo dense mass was visualized originating in the left atrium and intermittently protruding through the mitral valve. The color Doppler examination revealed moderate mitral regurgitation and moderate tricuspid regurgitation. The transesophageal echocardiogram revealed a large left atrial thrombus occupying the left atrial appendage and prolapsing back and forth through the mitral valve (like a “yo-yo”), causing an intermittent functional mitral stenosis. The patient was treated for heart failure and adequately anticoagulated. A few weeks later, a repeat TTE at another hospital revealed no evidence of the prolapsing thrombus. The INR at this time was therapeutic. Discussion Subtherapeutic anticoagulation is a common clinical problem. In some patients, such as ours, the thrombi can grow to a large size and cause functional obstruction of the valves. The mobile nature of these thrombi put the patients at a very high risk for systemic embolic events. Adequate and therapeutic anticoagulation is highly recommended to prevent such devastating complications. Although some thrombi may require surgical removal, a large percentage can be treated with adequate anticoagulation with either unfractionated or low-molecular-weight heparin and warfarin.

48 INDICATION SPECTRUM OF PERMANENT PACEMAKER IMPLANTATION IN A COMMUNITY HOSPITAL IN NEW YORK CITY.

Objective The objective of the project is to study the spectrum of indications for permanent pacemaker (PPM) implantation in a community hospital. The study also analyzed the type of pacemaker implanted, median age, and the indication for the procedure and whether a Holter exam diagnosed the indication for the pacemaker. In addition, we collected data to analyze how many patients had a temporary pacemaker placed before implantation of a permanent pacemaker. Methods A retrospective study of all patients who had a permanent pacemaker placement in Coney Island Hospital in Brooklyn, New York from January 2000 to January 2004. Data were collected regarding the indication for the permanent pacemaker placement, age and sex of the patient, clinical presentation, and diagnostic utility of Holter. Results 214 patients (111 males and 103 females) underwent PPM implantation at the Coney Island hospital in the period of 2002-2004. The age of patients ranged from 43 to 94 years with a median age of 78 years. The indication for PPM implantation was sick sinus syndrome for 103 patients (48%), third-degree AV block or high second-degree AV block for 99 patients (46%), and trifascicular block for 12 patients (5%). Presenting symptom was fall in 40% patients, syncope in 12%, dizziness in 10%, chest pain in 13%, and cardiac arrest in 2 patients; the remaining 23% patients presented with various other noncardiac illnesses like pneumonia, respiratory arrest, altered mental status, and diabetic ketoacidosis. Thirty-four percent of patients received a single-chamber PPM while 66% received a dual-chamber PPM. The diagnosis was established in only 4% of patients with the help of Holter exam. Fifty-four percent of patients had a temporary pacemaker wire inserted before a PPM. Acute myocardial infarction was diagnosed on 10% of patients. Conclusions Sick sinus syndrome and high-grade AV block appear to be major indications for permanent pacing in the elderly. Fall is an important symptom and warrants an electrocardiogram in the elderly. Utility of Holter monitoring in diagnosis to aid permanent pacing was low.

54 UNEXPLAINED CARDIAC TAMPONADE.

A 28-year-old Hispanic woman came to the Coney Island Hospital ER with gradually progressive distention of the abdomen, shortness of breath, puffiness of the face, and swelling of her feet for 1 month. There was loss of appetite with a weight loss of approximately 20 pounds occurring over 1 month. In the ER, the patient had a temperature of 988F, a pulse of 90 to 100 per minute, regular but thready, a blood pressure 110/70 mm Hg with no Kussmauls sign, and a respiratory rate of 18-20 per minute. She had jugular venous distention with distant soft heart sounds but no murmurs or pericardial rub. Lung fields were clean and the abdomen revealed a mild ascites. There was no calf asymmetry. Peripheral pulses were feeble. Laboratory data revealed a normal total white count with normal differential. Serum chemistry including electrolytes, renal and liver function tests were normal. ESR, amylase, and lipase were normal. CPK was normal and pregnancy test was negative. The electrocardiogram was low voltage with electrical alternans at a rate of 86 bpm, normal axis, P-R interval 134 ms, Q-T 336/402 ms, and QRS was 78 ms.Chest x-ray revealed an enlarged, globular heart. A CT scan of the chest was done, which showed a large pericardial effusion. A bedside echocardiogram revealed a large pericardial effusion with diastolic collapse of the right ventricle. The patient was admitted to the cardiac intensive care unit and a pericardiocentesis was done; 1.5 L of bloody fluid drained in pericardial tap, which was hemorraghic, with 44% PMN, 55% lymphocytes, a negative gram and acid-fast stains, and adenosine deaminase of 16. The histopathology was acellular fluid negative for malignancy. Serum for ECHO and coxsackievirus 1-6 were negative. A pericardiectomy with pericardial window was done to prevent reaccumulation of the pericardial effusion. The pericardial biopsy showed acute fibrinous and chronic nonspecific pericarditis. PPD was negative. The pericardial tissue culture was negative for bacteria including Mycobacterium tuberculosis. A search for occult malignancy was begun and the patient was found to have a raised CA 125. Her Pap smear showed grade 1 CIN and cone biopsy, which showed squamous metaplasia but no dysplastic changes. A CT abdomen showed bilateral ovarian cysts, which were biopsied laparoscopically and found negative for malignancy. Collagen vascular work-up and HIV testing were negative. The patient recovered from the acute illness and was followed up by pulmonary, oncology and gynecology but no malignancy could be detected.

20 SYMPTOMATIC BRADYARRHYTHMIA LIKELY RELATED TO USE OF HERBAL MEDICINE

Case Report A 39 year old lady presented to the ER with multiple episodes of dizziness associated with sweating and breathlessness for three days. An episode of near syncope prompted her to visit the ER. On examination, her pulse was 66/min, regular with a blood pressure of 100/60 mm Hg and no postural drop. She was afebrile with a respiratory rate of 18/min. Examination of the cardiovascular system revealed a S1 and S2 of normal intensity and absence of any murmurs. The rest of the clinical examination was normal. ECG showed a sinus pause with narrow complex escape junctional rhythm with a ventricular rate of 68/min, which was regular with retrograde conduction of P wave seen overlying the ST segment. The axis was normal. Patients clinical findings were suggestive of episodes of low cardiac output state most likely due to bradycardia, which on electrocardiogram seemed to be caused by sinus node dysfunction. Laboratory data including electrolytes and TSH were within normal limits. Connective tissue diseases workup was unremarkable. A detailed history revealed that the patient was taking an herbal medicine supplement named “Focus Factor” for the past three months in order to enhance her memory, as marketed by the company. “Focus Factor” contains natural vitamins, minerals, antioxidants and omega-3 fatty acids and in addition, three herbal extracts, namely bacopa, huperzine and vinpocetine. A meticulous research revealed that huperzine is known to have cholinesterase inhibition effects that enhance the parasympathetic system, which likely explains the sinus node dysfunction. This alternative medication was stopped and the patient was observed in a telemetry unit. The patient continued to be in junctional rhythm but gradually reverted to sinus rhythm in 48 hours. Since then, the patient has remained asymptomatic on outpatient follow-up and continues to refrain from this herbal product. The cause of this patients symptomatic bradycardia was attributed to the use of the herbal medication. To our knowledge this is the first case report linking the product “Focus Factor” to symptomatic bradycardia. The potentially life-threatening side effects of some unregulated herbal supplements warrant careful review of their use and marketing.

7 INDICATIONS SPECTRUM FOR TEMPORARY CARDIAC PACEMAKER THERAPY IN A COMMUNITY HOSPITAL

Background We sought to study the indications, complications and course of patients admitted to a community hospital and needed temporary pacemaker. Method We studied 181 consecutive patients who needed a temporary pacemaker between 04/2001 and 04/2003. Results A total of 181 patients were studied. The average age was 76.1 ± 12.3, 100 males, 81 females. The commonest site of insertion was right subclavian (45%) followed by right femoral vein (27%), right internal jugular vein in 18%, left femoral vein in 9%. The commonest indication for temporary pacemaker was sick sinus syndrome and symptomatic bradycardia (56%) as a bridge for permanent pacemaker. 47 (25.9%) needing temporary pacemaker had an acute coronary syndrome as their cause, 14 (29%) of which died of cardiac complications, 9 had persistent conduction defect needing permanent pacemaker. 25 of these patients had infarction involving the inferior wall. Non essential medications causing symptomatic bradycardia needing temporary pacemaker was found in 29 (16%) of patients. 20 (11%) patients had hyperkalemia (medication induced or renal failure) and 3 patients had digoxin toxicity as the cause of conduction disturbance. 6 patients needed temporary pacemaker as their permanent pacemaker generator had reached end of life. Conclusion Temporary support of conduction system prior to placement of permanent pacemaker was the commonest cause of temporary pacemaker in our study. Myocardial infarction needing temporary pacemaker is a high risk group patient with a high mortality. Iatrogenic cause of conduction disturbance is a frequent cause for need of temporary pacemaker.

45 EVALUATION OF RISK FACTORS FOR PROGRESSION OF AORTIC SCLEROSIS TO AORTIC STENOSIS

Background Aortic sclerosis is found in approximately 25% of elderly people in the United States. Aortic stenosis develops in only 2% to 3% of people older than 75 years. Calcific aortic stenosis is thought to result from aging and “wear and tear” of the aortic valve. However, aortic sclerosis may represent an early stage in the progression to aortic stenosis, in the presence of risk factors. We sought to study the risk factor profile of patients with aortic stenosis and compare them with the risk factors in patients with aortic sclerosis. Method 31 consecutive patients with echocardiographic findings of aortic sclerosis were screened for atherosclerotic risk factors, namely hypertension (HTN), diabetes mellitus (DM), smoking, lipid profiles, family history of premature coronary artery disease (CAD) and for clinical presence of atherosclerosis, stroke and peripheral arterial disease (PAD). 31 consecutive patients with clinical and echocardiographic findings of aortic stenosis were evaluated for comparison. Result The average age of patients with aortic stenosis and aortic sclerosis were 78 and 77.6 years respectively. 14 were males in each group. HTN, DM, smoking were present in 25, 9, 8 and 22, 10, 2 patients in aortic stenosis and aortic sclerosis group respectively. PAD, stroke and CAD were present in 3, 6, 15 and 2, 4, 13 patients in the respective groups. Lipid profile is shown below. (table) Conclusion In this small study, patients with aortic stenosis had higher LDL levels, which was statistically significant compared with patients of similar age with aortic sclerosis. Though more patients with aortic stenosis were smokers, it was not statistically significant. Lowering LDL levels may play a role in reducing the progression of aortic sclerosis to aortic stenosis.