ABSTRACT
We present the case of a 63-year-old woman with a remote history of supraventricular tachycardia and hyperlipidemia, who presented with recurrent episodes of acute-onset chest pain. An electrocardiogram showed no evidence of acute coronary syndrome. A chest radiograph revealed a prominent right-sided heart border. A suspected congenital pericardial cyst was identified on a computed tomographic chest scan, and stranding was noted around the cyst. The patient was treated with nonsteroidal anti-inflammatory drugs, and the pain initially abated. Another flare-up was treated similarly. Cardiac magnetic resonance imaging was then performed after symptoms had resolved, and no evidence of the cyst was seen. The suspected cause of the patient's chest pain was acute inflammation of a congenital pericardial cyst with subsequent rupture and resolution of symptoms.
Subject(s)
Acute Pain/etiology , Chest Pain/etiology , Mediastinal Cyst/complications , Pericarditis/etiology , Acute Pain/diagnosis , Acute Pain/drug therapy , Anti-Inflammatory Agents, Non-Steroidal/therapeutic use , Chest Pain/diagnosis , Chest Pain/drug therapy , Electrocardiography , Female , Humans , Magnetic Resonance Imaging , Mediastinal Cyst/congenital , Mediastinal Cyst/diagnostic imaging , Middle Aged , Pericarditis/diagnostic imaging , Pericarditis/drug therapy , Rupture, Spontaneous , Syndrome , Tomography, X-Ray Computed , Treatment OutcomeABSTRACT
Therapeutic ionizing radiation, such as that used in the treatment of Hodgkin's lymphoma, can cause cardiac valvular damage that may take several years to manifest as radiation-associated valvular heart disease. Treatment can be complicated by comorbid radiation injury to other cardiac and mediastinal structures that lead to traditional surgical valve replacement or repair becoming high-risk. A representative case is presented that demonstrates the complexity of radiation-associated valvular heart disease and its successful treatment with percutaneous transcatheter valve replacement. The prevalence and pathophysiologic mechanism of radiation-associated valvular injury are reviewed. Anthracycline adjuvant therapy appears to increase the risk of valvular fibrosis. Left-sided heart valves are more commonly affected than right-sided heart valves. A particular pattern of calcification has been noted in some patients, and experimental data suggest that radiation induction of an osteogenic phenotype may be responsible. A renewed appreciation of the cardiac valvular effects of therapeutic ionizing radiation for mediastinal malignancies is important, and the treatment of such patients may be assisted by the development of novel, less-invasive approaches.
Subject(s)
Aortic Valve Insufficiency/etiology , Aortic Valve Stenosis/etiology , Aortic Valve/pathology , Aortic Valve/radiation effects , Calcinosis/etiology , Hodgkin Disease/radiotherapy , Radiation Injuries/etiology , Aortic Valve/diagnostic imaging , Aortic Valve/physiopathology , Aortic Valve Insufficiency/diagnosis , Aortic Valve Insufficiency/physiopathology , Aortic Valve Insufficiency/therapy , Aortic Valve Stenosis/diagnosis , Aortic Valve Stenosis/physiopathology , Aortic Valve Stenosis/therapy , Calcinosis/diagnosis , Calcinosis/physiopathology , Calcinosis/therapy , Cardiac Catheterization , Echocardiography, Doppler, Color , Echocardiography, Transesophageal , Electrocardiography , Heart Valve Prosthesis Implantation/methods , Humans , Male , Middle Aged , Radiation Injuries/diagnosis , Radiation Injuries/physiopathology , Radiation Injuries/therapy , Radiotherapy/adverse effects , Treatment OutcomeABSTRACT
INTRODUCTION: Acute anterior myocardial infarctions caused by proximal left anterior descending (LAD) artery occlusions are associated with a higher morbidity and mortality. Early identification of high-risk patients via the 12-lead electrocardiogram (ECG) could assist physicians and emergency response teams in providing early and aggressive care for patients with anterior ST-elevation myocardial infarctions (STEMI). Approximately 25% of US hospitals have primary percutaneous coronary intervention (PCI) capability for the treatment of acute myocardial infarctions. Given the paucity of hospitals capable of PCI, early identification of more severe myocardial infarction may prompt emergency medical service routing of these patients to PCI-capable hospitals. We sought to determine if the 12 lead ECG is capable of predicting proximal LAD artery occlusions. METHODS: In a retrospective, post-hoc analysis of the Pre-Hospital Administration of Thrombolytic Therapy with Urgent Culprit Artery Revascularization pilot trial, we compared the ECG findings of proximal and nonproximal LAD occlusions for patients who had undergone an ECG within 180 minutes of symptom onset. RESULTS: In this study, 72 patients had anterior STEMIs, with ECGs performed within 180 minutes of symptom onset. In patients who had undergone ECGs within 60 minutes (n = 35), the mean sum of ST elevation (STE) in leads V1 through V6 plus ST depression (STD) in leads II, III, and aVF was 19.2 mm for proximal LAD occlusions and 11.7 mm for nonproximal LAD occlusions (P = 0.007). A sum STE in V1 through V6 plus STD in II, III, and aVF of at least 17.5 mm had a sensitivity of 52.3%, specificity of 92.9%, positive predictive value of 91.7%, and negative predictive value of 56.5% for proximal LAD occlusions. When the ECG was performed more than 60 minutes after symptom onset (n = 37), there was no significant difference in ST-segment deviation between the 2 groups. CONCLUSION: The sum STE (V1-V6) and STD (II, III, aVF) on a 12-lead ECG can be used to predict proximal LAD occlusions if performed within the first hour of symptom onset. This should be considered a high-risk finding and may prompt prehospital direction of such patients to PCI-capable hospitals.
