G. Wong

Cardiac metastatic melanoma.

We describe the case of a 55-year-old woman presenting with a recent onset of mild cough and no other specific cardiovascular symptoms, and with a normal examination. Salient past medical history included BRAF-positive melanoma resected from the small bowel with abdominal, left inguinal and pulmonary metastases, 2u2005years prior. Following immunotherapy with combined dabrafenib and trametinib for 6u2005months and subsequently, ipilimumab, complete remission was achieved. The only other significant history was of type 2 diabetes mellitus with metformin therapy.nnPlain radiographs of the chest were unremarkable, and a subsequent fluorodeoxyglucose positron emission tomography (FDG PET) demonstrated focal uptake in the anterior left ventricle (figure 1). Transoesophageal echocardiography (TOE) demonstrated a large, voluminous intracavitary left ventricular mass (45×25u2005mm) attached to the mid anterior wall without evidence of obstruction (figure 2, video 1). Cardiac MRI confirmed a mass with increased signal intensity on T1-weighted imaging suggestive of metastatic melanoma in …

A narrow QRS tachycardia with changing rate: What is the mechanism(s)?

1Department of Cardiology, RoyalMelbourneHospital andUniversity ofMelbourneGrattan Street, Parkville, VIC 3050, Australia 2KasturbaMedical College,Manipal University,Manipal, Karnataka, 576104, India Correspondence JonathanKalman,MBBS,PhD,DirectorofHeartRhythmServices, RoyalMelbourneHospital,DepartmentofCardiology, Suite1,MelbourneHeartCentre, Royal MelbourneHospital, Royal Parade, Parkville, VIC3050,Australia. Email: jon.kalman@mh.org.au

Paediatric chronic recurrent multifocal osteomyelitis.

A previously healthy girl aged 15 years presented with a 3-month history of low back pain, lethargy, morning stiffness and nocturnal back discomfort. She had no significant history of weight loss, infective symptoms or neurological symptoms, including bladder or bowel incontinence. There was no recent travel history.nnExamination revealed normal temperature and mild focal tenderness over the midline lumbar spine, with normal range of motion. There was isolated weakness in left hip flexion, and no other neurological findings. Blood tests showed a normal white cell count (6.6×109/L), elevated erythrocyte sedimentation rate (38u2005mm/hour) and slightly elevated C reactive protein (11u2005mg/L, normal<10u2005mg/L). X-rays were unremarkable. A limited CT of L3 showed diffuse sclerosis of its spinous process with areas of lytic destruction and mild effacement of the paravertebral fat pads (figure 1). Serial blood cultures were negative for microorganisms. Subsequent empirical antibiotics with intravenous flucloxacillin were initiated for presumed infective osteomyelitis.nnnnFigurexa01 nCT lumbar spine. Axial view. Bone …

Catheter ablation for atrial fibrillation in congestive heart failure: consider the upside, consider the downside

This editorial refers to ‘Catheter ablation of atrial fibrillation in patients with heart failure: impact of maintaining sinus rhythm on heart failure status and long-term rates of stroke and death’ by W. Ullah et al. , 2016;18(5):679–686. nnWhen patients present with deteriorating heart failure (HF) symptoms associated with atrial fibrillation (AF) development, there is understandably considerable clinical momentum to deal definitively with the arrhythmia. The adverse impact of AF on HF symptoms and outcomes including mortality has been extensively documented. However, whether this trend can be successfully reversed by rhythm management has not yet been clearly established. Definitive evidence that return of sinus rhythm results in improved outcomes including stroke risk and mortality has been lacking. Indeed, a randomized study of pharmacologic rhythm control vs. rate control demonstrated no benefit, possibly in part due to relative drug inefficacy and in part to pro-arrhythmia.1 A number of small randomized studies with 6- to 12-month follow-up have shown that compared with a medical rate control strategy, catheter ablation of AF in HF patients results in improved NYHA class2 and increase in ejection fraction.3 However, the latter finding has not been universal,4 and the studies were too small to consider stroke or mortality outcomes.5 Further complicating this picture is the recent STAR AF (Substrate and Trigger Ablation for Reduction of Atrial Fibrillation) 2 study6 finding that there is no proven ablative approach to substrate management in persistent AF. Yet pulmonary vein antral isolation alone for persistent …