Alberto Cecconi

Cause and Long-Term Outcome of Cardiac Tamponade

Cardiac tamponade is a life-threatening condition, whose current specific cause and outcome are unknown. Our purpose was to analyze it. We performed a retrospective observational study with prospective follow-up data including 136 consecutive patients admitted with diagnosis of cardiac tamponade, from 2003 to 2013. We thoroughly recorded variables as clinical features, drainage/pericardiocentesis, fluid characteristics, and long-term events (new cardiac tamponade ± death). The median age was 65 ± 17 years (55% men). In the baseline characteristics, 70% were no smokers, 12% were on anticoagulation, and 13 had suffered a previous myocardial infarction. In the preceding month, 15 patients had undergone a cardiac catheterization, 5 cardiac surgery, and 5 pacemaker insertion. Fever was observed in 16% of patients and 21% displayed other inflammatory symptoms. In 81% of patients, pericardiocentesis was needed. The fluid was hemorrhagic or a transudate in the majority, with positive cytology in 15% and bacteria in 3.7%. Main causes were malignancy (32%), infection (24%), idiopathic (16%), iatrogenic (15%), postmyocardial infarction (7%), uremic (4%), and other causes (2%). After a maximum follow-up of 10.4 years, cardiac tamponade recurred in 10% of the cases (62% in the neoplastic group) and the 48% of patients died (89% in the neoplastic cohort). In conclusion, most cardiac tamponades are due to malignancy, having this specific cause a poorer outcome, probably as a manifestation of an advanced disease. The rest of causes, after an aggressive intensive management, have a good prognosis, especially the iatrogenic.

Acute Pericarditis Secondary to Hydatid Cyst Rupture Diagnosis by Multimodality Imaging

A 37-year-old man, a construction worker, presented to the emergency department with chest pain. He was a smoker with no other relevant clinical history, with the exception of a liver hydatidosis treated successfully by surgery 20 years before. The pain was substernal, started at rest, had a relatively rapid onset, and worsened by lying down and with deep breathing. There was no history of recent respiratory tract infection or fever. On arrival, the vital parameters were normal. At physical examination, a friction rub was audible, and no signs of cardiac tamponade were present. The ECG showed diffuse ST-segment elevation with upward concavity (Figure 1). Chest radiography revealed a mild enlargement of the cardiac silhouette. Hemogram, creatine kinase, and troponins were normal; erythrocyte sedimentation rates were markedly increased (80 mm/h). The diagnosis of acute pericarditis was made, and treatment with nonsteroidal anti-inflammatory drugs was initiated. Figure 1. Twelve-lead ECG. Diffuse ST-segment elevation with upward concavity is seen. Two-dimensional echocardiography detected moderate pericardial effusion …

Anterior ST-segment elevation secondary to right coronary occlusion: The sheep in wolf's clothing

We present a case of an anterior ST-segment elevation acute coronary syndrome secondary to occlusion of a non-dominant right coronary artery. Usually, an anterior ST-segment elevation corresponds to a left anterior descending artery occlusion; however, in rare cases it can be secondary to a non-dominant right coronary artery occlusion. The two causal entities may be adequately differentiated by the detailed analysis of the ECG. The electrocardiographic criteria that allow the proper prediction of the culprit artery in anterior ST-segment elevation acute coronary syndrome are reviewed.

Wide QRS Complex Tachycardia: What the Algorithms Fear

A 70-year-old man was admitted to the emergency department for several hours of palpitations, dizziness, and dyspnea. The patient had a history of hypertension, diabetes mellitus, dyslipidemia, chronic obstructive pulmonary disease, and paroxysmal atrial fibrillation. His medications included eprosartan, amlodipine, atorvastatin, sitagliptin, indacaterol, and acenocoumarol. On arrival, his heart rate was 170 bpm and blood pressure was 110/50 mm Hg. The following 12-lead ECG was obtained (Figure 1). Figure 1. ECG obtained at admission in the emergency department. Based on the ECG, what is the most likely diagnosis? Please turn the page to read the diagnosis. The ECG in Figure 1 shows a wide QRS complex tachycardia at 170 bpm. Wide QRS complex tachycardia can be originated by 3 main mechanisms1: 1. Ventricular tachycardia (VT). 2. Supraventricular tachycardia (SVT) …

Spike or not a spike? That is the question in a patient with single lead pacemaker

Dual-chamber pacing is feasible via the floating atrial sensor electrodes of a single-pass VDD lead but the atrial lead threshold is higher than the accepted clinical standard. Furthermore, due to the floating nature of the system, atrial sensing and pacing thresholds may vary during the follow up. For these reasons this strategy is seldom considered a common pacing solution in routine clinical practice. Alternatively, this phenomenon is likely to be observed as a result of incorrect generator configuration. As shown in our case, this inadequate setting can be suspected just by the analysis of the surface ECG and the post implantation chest X-ray.