Ronstan Lobo

The use of conscious sedation in elective external direct current cardioversion: a single centre experience

Abstract External direct current (DC) cardioversion is a commonly used method of terminating atrial arrhythmias. The chance of procedural success is inversely related to the duration of the arrhythmia. In many hospitals, the procedure is carried out under general anaesthesia, necessitating the presence of anaesthetic as well as medical staff. Frequently, it may be difficult to coordinate the availability of the two teams, causing delays to each patient, waste of staff time, an inefficient service and increased costs. The primary aim of the study was to determine the safety and tolerability of conscious sedation using intravenous midazolam in elective external DC cardioversion of patients with atrial flutter or atrial fibrillation attending University Hospital Limerick, Ireland. Patients who were electively admitted for DC cardioversion for atrial fibrillation or atrial flutter were recruited. A pre-defined sedation protocol using intravenous midazolam was used. The midazolam was given by the cardiology registrar without the presence of an anaesthetist. DC cardioversion was then performed according to the hospital protocol. Any complications arising during the procedure were noted. Prior to discharge, patients were given a questionnaire to determine their awareness of the procedure and if they would have the procedure done again in the future if needed. A total of 100 patients were recruited. The median number of shocks was one (highest number of shocks being four). The median dose of midazolam was 7.5 mg, with the highest dose being 20 mg. All of patients surveyed were not aware of the shock that was administered to them. All of the patients surveyed were happy with the service and would be happy to return for a repeat cardioversion in the future if required. The use of conscious sedation for DC cardioversion of patients with atrial fibrillation / atrial flutter was found to be safe and tolerable.

Spontaneous intracranial hypotension presenting as a chronic daily headache.

A 51-year-old male was referred by his general practitioner with a 9-month history of chronic daily headache, affecting the frontal and vertex areas of the head. T1-weighted MRI with gadolinium enhancement showed diffuse pachymeningeal enhancement (figures 1 and 2). He subsequently had a lumbar puncture, and the opening pressure was 3.5 cm in the cerebrospinal fluid (CSF), confirming intracranial hypotension. The CSF constituents were normal. When the history was revisited, it was noted that the patient had for the first 2 months postural-related headaches; however, …

A commentary on the disparate perspectives of clinical microbiologists and surgeons: ad hoc antimicrobial use.

Prosthetic joints and other orthopedic implants have improved quality of life for patients world-wide and the use of such devices is increasing. However, while infection rates subsequent to associated surgery are relatively low (<3%), the consequences of incidence are considerable, encompassing morbidity (including amputation) and mortality in addition to significant social and economic costs. Emphasis, therefore, has been placed on mitigating microbial risk, with clinical microbiologists and surgeons utilizing rapidly evolving molecular laboratory techniques in detection and diagnosis of infection, which still occurs despite sophisticated patient management. Multidisciplinary approaches are regularly adopted to achieve this. In this commentary, we describe an unusual case of Actinomyces infection in total hip arthroplasty and, in that context, describe the perspectives of the clinical microbiology and surgical teams and how they contrasted. More specifically, this case demonstrates an ad hoc approach to structured eradication of biofilms and intracellular bacteria related to biomaterials, as reflected in early usage of linezolid. This is a complex topic and, as described in this case, such accelerated treatment can be effective. This commentary focuses on the merits of such inadvisable use of potent antimicrobials amid the risk of diminishing valuable antimicrobial efficacy, albeit resulting in desirable patient outcomes.

Confusion and altered behaviour? Cause.

We describe the case of a 65-year-old man who presented with confusion and change in behaviour, and describe the investigative steps that were taken before a diagnosis was made. This patient was eventually diagnosed with leptomeningeal carcinomatosis secondary to a previously undiagnosed oesophageal carcinoma.

Parkinsonism can be cured

This case describes a woman with a history of rheumatoid arthritis with secondary vasculitic skin ulcers, Sicca syndrome and idiopathic Parkinsons disease that was diagnosed by a neurologist in 2005. The patients parkinsonian symptoms were difficult to control, despite the use of antiparkinsonian medications. During a regular clinical review in 2011, the patients rheumatologist had prescribed cyclophosphamide infusions to help with the vasculitic skin ulcers. Over the following 2 months, the patients parkinsonian symptoms completely resolved.

Significance of High-Sensitivity Troponin T After Elective External Direct Current Cardioversion for Atrial Fibrillation or Atrial Flutter

External transthoracic direct current (DC) cardioversion is a commonly used method of terminating cardiac arrhythmias. Previous research has shown that DC cardioversion resulted in myocardial injury as evidenced by increased levels of cardiac troponin, even though only minimally. Many of these studies were based on the outdated monophasic defibrillators and older, less sensitive troponin assays. This study aimed to assess the effect of external transthoracic DC cardioversion on myocardial injury as measured by the change in the new high-sensitivity cardiac troponin T (hs-cTnT) using the more modern biphasic defibrillators. Patients who were admitted for elective DC cardioversion for atrial fibrillation or atrial flutter were recruited. Hs-cTnT levels were taken before cardioversion and at 6 hours after cardioversion. A total of 120 cardioversions were performed. Median (twenty-fifth to seventy-fifth interquartile range) cumulative energy was 161 J (155 to 532 J). A total of 49 (41%) patients received a cumulative energy of 300 J or higher. The median hs-cTnT level before cardioversion was 7 ng/L (4 to 11 ng/L) and that after cardioversion was 7 ng/L (4 to 10 ng/L). A Wilcoxon signed-rank test showed no significant difference between pre- and post-cardioversion hs-cTnT levels (Z = -0.940, p = 0.347). In conclusion, external DC cardioversion did not result in myocardial injury within the first 6 hours as measured by high-sensitivity troponin T. Patients who are cardioverted and are found to have a significant increase in cardiac troponin after cardioversion should be assessed for causes of myocardial injury and not assumed to have myocardial injury due to the cardioversion itself.

25 Stemi patients with ejection fraction 35 percent or less; percent improvement, average time to improvement and outcomes 2014–2017, 2017

Introduction Left ventricular ejection fraction (LVEF) is an independent risk factor for adverse cardiac outcomes post ST elevation myocardial infarction (STEMI). Post-STEMI patients can have lower than expected LVEF due to reasons other than myocardial necrosis owing to physiological aspects such as hibernation and stunning of myocardium. Much interest in the literature focuses on the months post infarction. This project attempts to assess the acute window in the weeks post STEMI where it is hypothesised there can be considerable improvement in LVEF. Methods This retrospective study assessed follow up data on STEMI patients presenting to University Hospital Limerick (UHL) between January 2014 and January 2017. The study was initially presented to the UHL ethics committee and having being vetted was approved. An existing STEMI heartbeat database and PCI clinic database were used to identify the patient cohort estimated to be ten percent of STEMI cases based on an extensive literature review. Patients who had STEMI and had an inpatient transthoracic echocardiogram (TTE) showing LVEF of 35% or less were selected. Patients were excluded if they did not attend follow up in UHL or they did not have a repeat TTE done between 28 to 48 days post STEMI. Basic demographics, culprit vessel, time to follow up TTE as well as percentage improvement were recorded by accessing the patients electronic cardiology record comprising of TTE and coronary angiography reports via McKeeson Cardiology Software. Results There were 634 STEMI cases presenting to UHL for primary percutaneous intervention (pPCI) during the study period. A total of 44 patients were identified to have a post-pPCI LVEF of 35% or less. 9 patients were excluded as they did not have repeat TTE within the requisite 48 day follow up period. 2 patients suffered fatal outcomes of death. 4 patients had not attended UHL for repeat TTE with repeat imaging at tertiary hospitals in Ennis and Nenagh respectively. Of the 29 patients with sufficient data, 83% (n=24) were male with the average age of 60.3 ±13.1 years. Culprit vessels were the left anterior descending artery in 83% (n=25) of patients, right coronary artery in 14% (n=4) patients and left circumflex artery in 3% (n=1). Average LVEF at baseline was 29.2% ±4.77%. Average time to repeat measurement was 37.4 ±5.3 days. There was an improvement in 20 patients, with an increase in LVEF of between 2.5% to 17.5%. 7 patients showed no improvement. 2 patients disimproved. This represents 69% of the cohort showing improvement within 48 days with a median increase in LVEF of 5% (interquartile range 15%). Conclusions This small sample of STEMI patients shows promise for improvement in LVEF within 48 days post STEMI. This shows potential for improved cardiac function in the weeks rather than months post STEMI in line with concepts of stunning and hibernation of myocardium post myocardial infarction. It also provides an estimate on post STEMI low LVEF patients that may be candidates for alternative novel or research therapies.

13 High sensitive troponin t levels following elective external direct current cardioversion for atrial fibrillation and atrial flutter

Introduction External transthoracic direct current (DC) cardioversion is a commonly used method of terminating arrhythmias, emergently or electively. It is known that external DC cardioversion can result in a rise in creatine kinase (CK). Previous research has shown that DC cardioversion resulted in subtle myocardial injury as evidenced by CK-MB, troponin I and troponin T increase, even though only minimally. These studies were based on the outdated monophasic defibrillators and older troponin assays. Since early 2010, the new high sensitive troponin T (Hs-trop T) assays have been used to diagnose myocardial injury and have been found to be highly sensitive and specific. This study aimed to assess the effect of external transthoracic DC cardioversion on myocardial injury as measured by the change in Hs-trop T using the more modern biphasic defibrillators in an elective setting. Methods Patients who were admitted for a day-case elective DC cardioversion for atrial fibrillation or atrial flutter were asked to participate in the study. DC cardioversion was performed using the Phillips Heartstart XL biphasic defibrillator. For cardioversions that failed at 200 Joules, the Physio-Control Lifepak 20e 360 J biphasic defibrillator was used. Hs-trop T levels were taken pre-cardioversion and at 6 h post-cardioversion (in keeping with the Third Universal Definition of Myocardial Infarction guidelines on biomarker detection of myocardial injury with necrosis). The assay used was the Roche Elecsys Troponin T hs (high sensitive) immunoassay. Quantitative analysis for haemolysis, icterus and lipaemia (which could result in interference with the Hs-trop T assay) were measured in each blood sample that was taken using the Abbott Architect c16000. Results A total of 120 cardioversions were done on 101 patients. Analysis of each of the blood sample taken showed no raised haemolytic, icteric or lipaemic indices above the recommendations for the Hs-trop T assay. Median number of shocks was 1, and the maximum number of shocks was 6. Median cumulative energy was 150 Joules (interquartile range = 387.5 Joules) with the minimum being 50 Joules and maximum being 1730 Joules. A total of 49 (40.8%) patients received a cumulative defibrillation energy of 300 Joules or higher. The highest energy delivered per shock was 360 Joules and median peak impedance levels was 80.80 Ohms (interquartile range = 19.05 Ohms). Median Hs-trop T levels pre-cardioversion was 7 ng/L (interquartile range = 7) and post-cardioversion was 7 ng/L (interquartile range = 6). A Wilcoxon signed-rank test showed no significant difference between pre-and-post cardioversion Hs-Trop T levels (Z = -0.940, p = 0.347). Conclusions External DC cardioversion did not result in myocardial injury as measured by high sensitive troponin T. The implications of this study is important as patients who are cardioverted and are found to have a significant troponin rise post-cardioversion should be assessed for causes of myocardial injury and not assumed to have myocardial injury due to the cardioversion itself.

Woman with chest pain and shortness of breath since age 18

We present an interesting case of a 38-year-old woman who presented with a history of left-sided chest pain, dyspnoea and palpitations. The symptoms have been occurring since age 18, and were previously diagnosed as costochondritis. Because of the suspicious history, the patient underwent further cardiac investigations. The echocardiogram demonstrated an abnormal structure adjacent to the aortic valve. A diagnostic coronary angiogram revealed a large left circumflex artery fistulating into the right atrium. Surgery was performed to ligate the fistula. The patient recovered well and has been asymptomatic since.

Fever of unknown origin, with a twist.

The authors present a case of an 81-year-old man with fever of unknown origin. The case report is illustrated with the images which clarified the diagnosis in this challenging case. The cardiac MR images were of critical importance in arriving at a diagnosis of aortic root mycotic pseudoaneurysm with rupture into the right ventricle.