Mian Yousuf

A 58-Year-Old Woman With ST-Segment Elevation, Seizures, and Altered Mental Status in the Setting of Opiate Withdrawal*

(CHEST 2009; 135:1098–1101) A 58-year-old woman with history of fibromyalgia and opiate dependence presented after being unable to obtain prescription opiates for 1 week. She had been experiencing dysphoria, rhinorrhea, diaphoresis, nausea, and vomiting, and was brought to the emergency department in a post-ictal state after having a witnessed seizure. She was intubated on arrival for airway protection. Physical examination and laboratory evaluation were unremarkable. Findings on ECG, noncontrast computerized axial tomographic scan of the head, and lumbar puncture were unrevealing. She was empirically started on IV vancomycin, ceftriaxone, and fentanyl based on a working diagnoses of meningoencephalitis, toxin-induced seizures, and opiate withdrawal. She was triaged to the medical ICU. Eight hours later in the medical ICU, a repeat ECG (Fig 1) showed diffuse STsegment elevation in precordial leads V2 through V6. Laboratory evaluation revealed elevated cardiac biomarker levels: creatine kinase, 4,294 units/L; creatine kinase MB, 30.6 ng/mL; relative index, 0.7%; and troponin, 10.2 ng/mL. A diagnosis of ST-segment elevation myocardial infarction was entertained and treated initially with aspirin, metoprolol, simivastatin, heparin, and an IV eptifibatide. Emergent coronary angiography was performed, which revealed patent

Does left atrial volume affect exercise capacity of heart transplant recipients

BackgroundHeart transplant (HT) recipients demonstrate limited exercise capacity compared to normal patients, very likely for multiple reasons. In this study we hypothesized that left atrial volume (LAV), which is known to predict exercise capacity in patients with various cardiac pathologies including heart failure and hypertrophic cardiomyopathy is associated with limited exercise capacity of HT recipients.MethodsWe analyzed 50 patients [age 57 ±2 (SEM), 12 females] who had a post-HT echocardiography and cardiopulmonary exercise test (CPX) within 9 weeks time at clinic follow up. The change in LAV (ΔLAV) was also computed as the difference in LAV from the preceding one-year to the study echocardiogram. Correlations among the measured parameters were assessed with a Pearsons correlation analysis.ResultsLAV (n = 50) and ΔLAV (n = 40) indexed to body surface area were 40.6 ± 11.5 ml·m-2 and 1.9 ± 8.5 ml·m-2·year-1, data are mean ± SD, respectively. Indexed LAV and ΔLAV were both significantly correlated with the ventilatory efficiency, assessed by the VE/VCO2 slope (r = 0.300, p = 0.038; r = 0.484, p = 0.002, respectively). LAV showed a significant correlation with peak oxygen consumption (r = -0.328, p = 0.020).ConclusionsAlthough our study is limited by a retrospective study design and relatively small number of patients, our findings suggest that enlarged LAV and increasing change in LAV is associated with the diminished exercise capacity in HT recipients and warrants further investigation to better elucidate this relationship.

Use of bicycle exercise echocardiography for unexplained exertional dyspnea.

Unexplained exertional dyspnea is a common and perplexing clinical problem. Myocardial ischemia and left ventricular systolic dysfunction are important cardiac causes, but are often not detected in these patients. Recently, exercise‐induced left ventricular diastolic dysfunction and exercised‐induced pulmonary hypertension have emerged as common alternative mechanisms. While conventional exercise treadmill echocardiography effectively diagnoses left ventricular systolic dysfunction and myocardial ischemia, it has limited ability to detect exercise‐induced diastolic dysfunction or pulmonary hypertension. The latest advances in exercise echocardiography, including utilization of tissue Doppler imaging and harmonic imaging, make noninvasive evaluation of both conventional and alternative cardiac causes of exertional dyspnea possible. These advancements, when coupled with newly designed supine exercise platforms for bicycle exercise echocardiography (BE), facilitate the detection of exercise‐induced diastolic dysfunction and pulmonary hypertension. Moreover, BE using supine ergometry additionally permits the dynamic evaluation of valvular function and interatrial shunting and detection of pulmonary arteriovenous fistula, uncommon but important causes of unexplained exertional dyspnea. Therefore, we propose that because of its superior diagnostic capabilities, BE should be included as part of a comprehensive cardiac evaluation of patients with unexplained exertional dyspnea. Copyright

A rare case of Klebsiella pneumoniae myocardial abscess

Myocardial abscess of the left ventricular free wall in the absence of infective endocarditis (IE) is very unusual. Most cases are discovered during autopsies and are due to Gram-positive cocci. We present a rare case of Klebsiella pneumoniae causing myocardial abscess of the left ventricular free wall. The patient had no evidence of valvular endocarditis or bacteremia, and the abscess was discovered during coronary artery bypass grafting surgery (CABG).

Hemodynamically significant atrial septal defect after atrial fibrillation ablation: A hole to remember

Case Report A 67-year-old woman was referred for cryoablation after flecainide therapy for symptomatic paroxysmal atrial fibrillation (PAF) was unsuccessful. A transesophageal echocardiogram performed immediately before the ablation was unremarkable. Double-transseptal puncture with a Brockenbrough needle through 8F SL0 and SL2 sheaths was performed. A Lasso catheter was advanced through the SL2 sheath into the left atrium and used to map all 4 pulmonary veins. The SL0 sheath was exchanged for a 15F FlexCath (Medtronic, Minneapolis, MN), and a 28-mm Arctic Front Cardiac CryoAblation Catheter (Medtronic) was used to isolate all pulmonary veins. A hockey stick maneuver was required to engage the right inferior pulmonary vein. The next day, color flow interrogation with a transthoracic echocardiogram demonstrated a small interatrial defect and left-to-right shunt (Figure 1). Over the next 3 months, the patient continued to have episodes of PAF, and she was eventually brought back for radiofrequency ablation (RFA). An echocardiogram performed before the procedure demonstrated mild right ventricular (RV) dilation, ventricular septum diastolic flattening, and a stable shunt. During the RFA, the interatrial septum was crossed through the iatrogenic atrial septal defect (iASD) with two 8.5F sheaths, and all the electrically reconnected veins were isolated successfully. Within days after the procedure, the patient began experiencing increasing dyspnea on exertion and fatigue. Workup with transthoracic echocardiogram and cardiac magnetic resonance imaging (Figure 2) showed moderate right atrial and RV dilation, an RV systolic pressure of 40 mm Hg, and a large atrial septal defect with a rim up to 1.1 cm (Figure 3). There was a significant left-to-right interatrial

RIGHT HEART FAILURE FROM PERSISTENT IATROGENIC ATRIAL SEPTAL DEFECT FOLLOWING ATRIAL FIBRILLATION ABLATION

Persistent iatrogenic atrial septal defect (iASD) has been reported in patients with a transseptal puncture performed for access to the left atrium. Majority of these resolve spontaneously and their clinical significance remains unknown. Here, we report a rare case of a symptomatic, persistent iASD