Robert C. Lichtenberg

American College of Cardiology/European Society of Cardiology Clinical Expert Consensus Document on Hypertrophic Cardiomyopathy: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents and the European Society of Cardiology Committee for Practice Guidelines

A 29-year-old Dominican man with a history of intravenous heroin use and hepatitis C presented with a 5-day history of fever, dyspnoea, haemoptysis, pleuritic chest pain, abdominal pain, haematochezia and haematemesis. Initial physical examination was significant for scleral icterus, generalised abdominal tenderness to palpation, melaena and blood-tinged sputum. Blood cultures grew Fusobacterium species. CT scan of the chest revealed multiple bilateral cavitary features in lung fields. At the same time, a neck ultrasound performed demonstrated thrombophlebitis in the right internal jugular vein, confirming the diagnosis of ‘Lemierre’s syndrome’. Treatment was with antibiotics and supportive care for 6 weeks.

American College of Cardiology/ European Society of Cardiology Clinical Expert Consensus Document on Hypertrophic Cardiomyopathy A Report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents and the European Society of Cardiology Committee for Practice Guidelines

This document has been developed as a Clinical Expert Consensus Document (CECD), combining the resources of the American College of Cardiology Foundation (ACCF) and the European Society of Cardiology (ESC). It is intended to provide a perspective on the current state of management of patients with hypertrophic cardiomyopathy. Clinical Expert Consensus Documents are intended to inform practitioners, payers, and other interested parties of the opinion of the ACCF and the ESC concerning evolving areas of clinical practice and/or technologies that are widely available or new to the practice community. Topics chosen for coverage by expert consensus documents are so designed because the evidence base, the experience with technology, and/or the clinical practice are not considered sufficiently well developed to be evaluated by the formal American College of Cardiology/American Heart Association (ACC/AHA) Practice Guidelines process. Often the topic is the subject of considerable ongoing investigation. Thus, the reader should view the CECD as the best attempt of the ACC and the ESC to inform and guide clinical practice in areas where rigorous evidence may not yet be available or the evidence to date is not widely accepted. When feasible, CECDs include indications or contraindications. Some topics covered by CECDs will be addressed subsequently by the ACC/AHA Practice Guidelines Committee. The Task Force on Clinical …

Cardiovascular effects of lightning strikes

OBJECTIVES The purpose of this study was to investigate the effects of lightning strikes on the cardiovascular system. BACKGROUND A lightning strike can attack its victims in one of three ways: direct hit, splash or ground strike. The cardiovascular system can be affected directly by mechanical or electrical trauma during a direct hit or can be indirectly affected through effects on the total body with extensive catecholamine release or autonomic stimulation. Reported effects include hypertension, tachycardia, nonspecific electrocardiographic (ECG) changes including prolongation of the corrected QT (QTc) interval, transient T wave inversion and myocardial necrosis with creatine kinase-MB (CK-MB) fraction release. METHODS Nineteen victims from five separate lightning strikes were studied over a 2-month period. Each patient was evaluated by serial ECG, CK-MB determinations and echocardiography. RESULTS The early (0 to 72 h) effects of lightning were demonstrated on the ECG by ST segment elevation consistent with acute current of injury, prolonged QTc interval with direct hits and nonspecific ST and T wave changes. On echocardiography, segmental or global ventricular dysfunction was seen, and pericardial effusion was also detected. During the intermediate (3- to 14-day) period, new and often marked ECG changes consistent with pericarditis or ischemia were seen. No new echocardiographic changes were detected, however, and the early abnormalities including severe left ventricular dysfunction with cardiogenic shock have reversed. The late (1 to 12 months) period revealed only one patient with long-term sequelae (recurrent pericarditis that persisted for 5 months). CONCLUSIONS Unless both entrance and exit sites are limited to the lower limbs, direct and splash lightning strikes cause myocardial damage as assessed by abnormal serum enzyme determinations or abnormal echocardiographic findings. Only direct hits resulted in echocardiographic abnormalities or a prolonged QTc interval. The degree of myocardial injury can be severe with left and right ventricular ejection fraction < 15% and can be reversible.

Decreased gluconeogenesis and increased glucose disposal without hyperinsulinemia in 10-day-old rats with endotoxic shock

Glucose dyshomeostasis is a common and life-threatening sign of endotoxic shock in the newborn. In this study, liver gluconeogenesis was evaluated in 10-day-old rats with endotoxic shock using the isolated perfused liver. Phosphoenolpyruvate carboxykinase (PEPCK) activity and PEPCK mRNA abundance were measured to confirm altered gluconeogenesis. Glucose disposal was also evaluated by a glucose tolerance test. Twenty-four-hour-fasted rats were studied to enhance gluconeogenesis and decrease glucose disposal. Rats received an intraperitoneal (IP) injection as follows: group 1 (fed-saline), 0.2 mL saline in fed rats; group 2 (fed-LPS), 0.1 mg/kg Salmonella enteritidis lipopolysaccharide (LPS) in fed rats; group 3 (fasted-saline), 0.2 mL saline in fasted rats; and group 4 (fasted-LPS), 0.1 mg/kg LPS in fasted rats. Isolated liver perfusion, determination of liver PEPCK activity and liver PEPCK mRNA abundance, and a glucose tolerance test were performed at 4 hours in fed rats and at 6 hours in fasted rats. LPS induced hypoglycemia (1.62 +/- 0.33 mmol/L, P < .05) at 6 hours in group 2 (fed-LPS), but not in group 4 (fasted-LPS). Hyperinsulinemia was not observed in either group 2 (fed-LPS) or group 4 (fasted-LPS). In group 2 (fed-LPS), liver gluconeogenesis decreased (3.0 +/- 0.3 mg/g liver, P < .01). PEPCK activity decreased from 0.65 +/- 0.07 (group 1) to 0.23 +/- 0.02 U (P < .01). PEPCK mRNA abundance also decreased from 100% +/- 10% to 40% +/- 10%. The glucose disappearance rate (t1/2) increased (P < .05) in group 2 (fed-LPS) and group 4 (fasted-LPS).(ABSTRACT TRUNCATED AT 250 WORDS)

ACCF/AHA/CDC conference report on emerging infectious diseases and biological terrorism threats: the clinical and public health implications for the prevention and control of cardiovascular diseases.

### American College of Cardiology Foundation ### American Heart Association View this table: ACCF/AHA/CDC Consensus Conference Report on Emerging Infectious Diseases and Biological Terrorism Threats—Participants’ Relationships With Industry

Disruption of sutured pulmonary valve in fontan operation

Two patients who had undergone a Fontan operation presented late with considerable disruption of a sutured pulmonary valve. Both patients had increasing ascites, decreased exercise tolerance, atrial arrhythmias, high right atrial pressure, and a large ratio of pulmonary blood flow to systemic blood flow. At operation, the main pulmonary artery was closed either by suturing the anterior and posterior walls together immediately distal to the pulmonary valve or by reinforcing the resutured pulmonary valve with a polytetrafluoroethylene patch. Both patients had an uneventful postoperative course, with disappearance of the symptoms and return of sinus rhythm. Although it is tempting to simply suture the usually thickened pulmonary valve in the Fontan operation, approximation of the pulmonary artery walls or patch reinforcement is necessary to minimize disruption.