A Case of Sudden Cardiac Death due to Pilsicainide-Induced Torsades de Pointes

An 84-year-old male received oral pilsicainide, a pure sodium channel blocker with slow recovery kinetics, to convert his paroxysmal atrial fibrillation to a sinus rhythm; the patient developed sudden cardiac death two days later. The Holter electrocardiogram, which was worn by chance, revealed torsade de pointes with gradually prolonged QT intervals. This drug is rapidly absorbed from the gastrointestinal tract, and most of it is excreted from the kidney. Although the patient's renal function was not highly impaired and the dose of pilsicainide was low, the plasma concentration of pilsicainide may have been high, which can produce torsades de pointes in the octogenarian. Although the oral administration of class IC drugs, including pilsicainide, is effective to terminate atrial fibrillation, careful consideration must be taken before giving these drugs to octogenarians.

Valsalva Aneurysm Filled with Thrombi Mimicking a Cardiac Tumor

A Valsalva aneurysm filled with thrombi can be difficult to diagnose, because it mimics a cardiac tumor. Both cardiac magnetic resonance imaging (MRI) and transesophageal echocardiogram (TEE) were performed on a patient who showed a low-echoic mass located between the atrial septum and the non-coronary sinus. Based on MRI findings allowing tissue characterization and the accurate location of the mass and the TEE findings of an irregular surface of the mass and a partial defect in the edge of the non-coronary sinus, we diagnosed the mass as a thrombosed Valsalva aneurysm that had perforated the inter-atrial septum. The operative findings coincided with the preoperative diagnosis. Both MRI and TEE are useful for diagnosing this condition.

Transesophageal Echocardiographic Evaluation of Atherosclerosis

Transesophageal echocardiography (TEE) is a promising method for evaluating thoracic aortic atherosclerosis and coronary atherosclerosis. The highest impact of TEE as a clinical tool is in searching for cardiac embolic sources in patients with stroke and atrial fibrillation and in conducting detailed evaluations in patients with valvular disease, especially those with mitral valvular disease. However, it is also clinically useful in the evaluation of thoracic aortic atherosclerosis and coronary atherosclerosis. TEE is capable of evaluating thoracic aortic atherosis (intima- media complex thickness) and sclerosis (stiffness parameter beta) simultaneously. In addition, TEE can evaluate coronary atherosclerosis by non-invasively revealing narrowing or occlusion of the coronary arteries and providing information about coronary flow reserve. TEE imaging has improved with the advent of harmonic imaging, multiplane probes, contrast agents, and three-dimensional TEE. Future technology, including integrated backscatter (IBS), tissue Doppler, and strain imaging, will lead to further improvements in TEE. Thoracic aortic atherosclerosis and coronary atherosclerosis assessment should be performed in any patient undergoing TEE.