An Acute Large Pericardial Effusion in a Scleroderma Renal Crisis.

This case report describes a patient with systemic sclerosis (SSc) who presented with a large pericardial effusion and a scleroderma renal crisis (SRC). The patient's clinical presentation, diagnostic workup, and treatment plans are reviewed. The coexistence of these complications presents a challenging clinical scenario requiring an interdisciplinary approach. The management of pericardial effusion in SSc and SRC is discussed, emphasizing the need for early detection and prompt treatment. Further research is needed to better understand and manage these complex complications in SSc patients.

Heart Block and Sinus Pause Following Abdominal Surgery: A Case Requiring Temporary Pacemaker Insertion.

This case report presents the clinical course of a 70-year-old female with a history of hypertension who developed sinus pauses following abdominal surgery, ultimately requiring the placement of a pacemaker. The patient initially presented with altered mental status preceded by abdominal pain, which progressed to confusion and obtundation. Examination revealed signs of toxicity, tachycardia, tachypnea, and a distended abdomen with absent bowel sounds. A computed tomography (CT) scan of the abdomen indicated closed-loop small bowel obstruction with free air and ascites. The patient underwent exploratory laparotomy, revealing purulent fluid and a necrotic, perforated appendix, leading to appendectomy and peritoneal irrigation. Subsequent surgeries addressed the coagulative necrosis of the omentum and wound closure. During the recovery period, the patient exhibited bradycardia with sinus pauses, including episodes of complete heart block. Cardiology consultation attributed this to increased parasympathetic tone following surgery and recommended the placement of a temporary transvenous pacemaker. As the patient's condition improved, the sinus pacing function progressively returned, leading to the removal of the pacemaker. This case underscores the potential development of sinus pauses after abdominal surgery and highlights the importance of prompt recognition, appropriate management, and collaboration between surgical and cardiology teams to ensure patient recovery.

Torsades De Pointes in a 71-Year-Old Female With Normal Qt Interval After Azithromycin Use.

A 71-year-old female visiting from Colombia presented to the emergency room with a productive cough, subjective fever, and chills for the past three days. Baseline EKG demonstrated a QT interval of 385 milliseconds with left ventricular hypertrophy and T wave inversions in leads V4, V5, and V6. Azithromycin was administered, and she was subsequently found to have torsades de pointes (TdP) on telemetry. In high-risk individuals, medications with reduced effects on cardiac conduction should be considered to avoid potentially lethal reactions. This case highlights the importance of clinical history prior to the administration of medications that have a propensity to cause abnormalities in cardiac conduction. Our patient had a grossly normal QT interval prior to the administration of azithromycin; however, she subsequently developed torsades de pointes. The patient was on telemetry monitoring, and cardiopulmonary resuscitation was quickly initiated as she was in a hospitalized setting; however, in an outpatient community setting, she likely would not have survived. By examining all the elements which contribute to QT prolongation, clinicians can have a deeper understanding of the complexities, particularly in individuals with multiple co-morbid conditions prior to the administration of medications that have a propensity to affect the QT interval.

Intrinsic cardiac elastography in patients with primary mitral regurgitation: predictive role after mitral valve repair.

AIMS: Chronic volume-overload can impair systolic and diastolic myocardial properties. We tested the hypothesis that Intrinsic Cardiac Elastography may detect alterations in passive myocardial elasticity in patients with chronic severe mitral regurgitation (MR) and predict worsening left ventricular (LV) function after mitral valve repair (MVr). METHODS AND RESULTS: Comprehensive transthoracic echocardiography and cardiac elastography were performed in 80 patients with primary MR (prolapse and/or flail leaflets) of varying severity and compared with 40 normal subjects. In patients who underwent MVr (n = 51), elastography measurements were related to changes in left ventricular ejection fraction (LVEF) at short-term (3-4 days post-op) and mid-term (1 year) follow-up. Most patients were asymptomatic or mildly symptomatic and had preserved LVEF (>60%). Intrinsic velocity propagation (iVP) of myocardial stretch, a direct measure of myocardial stiffness, was higher in patients with severe MR {median 2.0 [interquartile range (IQR) 1.5-2.2] m/s, range 1.1-3.4 m/s; n = 56} compared to normal subjects [median 1.7 (IQR 1.5-1.8) m/s; n = 40; P = 0.0005], but not in those with mild or moderate MR [median 1.7 (IQR 1.4-1.9) m/s; n = 24]. A higher iVP was associated with more severe LV volume-overload and LV and left atrial enlargement (P < 0.05 for all). In patients undergoing MVr, a higher iVP independently predicted a larger drop in LVEF post-intervention (short-term, P = 0.001; 1 year, P = 0.007), incrementally to pre-operative LVEF (P < 0.05). CONCLUSION: Non-invasive measurements of myocardial stiffness were able to predict functional deterioration after MVr for chronic primary MR. Further studies should investigate the mechanisms and practical utility of this novel measurement.

Myocardial Stiffness by Intrinsic Cardiac Elastography in Patients with Amyloidosis: Comparison with Chamber Stiffness and Global Longitudinal Strain.

BACKGROUND: The aim of this study was to test the hypothesis that intrinsic cardiac elastography can detect diastolic tissue abnormalities produced by cardiac amyloid infiltration and that measurements may have incremental value beyond traditional echocardiographic measures. The specific aims were (1) to evaluate the relationship between left ventricular myocardial stiffness (by elastography) and measures of diastolic chamber stiffness and systolic strain in patients with amyloidosis and (2) to compare their prognostic potential. METHODS: We prospectively studied 67 patients with amyloidosis (cardiac amyloidosis, n = 48; noncardiac amyloidosis, n = 19) and 40 normal subjects. Patients underwent comprehensive echocardiography including measurement of left ventricular global longitudinal strain (GLS) by speckle-tracking. Intrinsic velocity propagation of myocardial stretch (iVP), a direct measure of myocardial elasticity, was quantified using intrinsic cardiac elastography. Chamber stiffness was evaluated from the end-diastolic pressure-volume relationships (P = αVß). The major end point at follow-up was the composite of death, cardiac hospitalization, worsening heart failure, and stroke. RESULTS: The iVP of myocardial stretch was highest in patients with cardiac amyloidosis compared with those with noncardiac amyloidosis and normal subjects (3.2 ± 1.0, 1.8 ± 0.4, and 1.6 ± 0.2 m/sec, respectively; P < .0001) and correlated with chamber stiffness, function, and structure (ß coefficient, operating chamber stiffness, GLS, wall thickness; P ≤ .001 for all). At follow-up (median, 2.6 years), measures of left ventricular and myocardial stiffness, GLS, diastolic dysfunction grade, and N-terminal pro-brain natriuretic peptide were associated with excess events. At multivariate analysis, iVP of myocardial stretch remained an independent predictor of adverse events, incremental to GLS and N-terminal pro-brain natriuretic peptide. CONCLUSIONS: Measurements by cardiac elastography correlate with functional and structural derangements produced by cardiac amyloid infiltration but provide unique information that is incremental to conventional echocardiography.

Intrinsic Wave Propagation of Myocardial Stretch, A New Tool to Evaluate Myocardial Stiffness: A Pilot Study in Patients with Aortic Stenosis and Mitral Regurgitation.

BACKGROUND: Left ventricular (LV) filling following atrial contraction generates LV myocardial stretch that propagates from base to apex with a speed proportional to myocardial elasticity. The aim of this study was to test the hypothesis that intrinsic velocity propagation of myocardial stretch (iVP) would be altered in patients with valvular disease and chronic LV pressure overload or volume overload, which may adversely affect mechanical properties of the LV tissue. A second aim was to compare iVP with flow propagation velocity in the chamber. METHODS: Sixty subjects were prospectively recruited: 20 with severe aortic stenosis (AS), 20 with severe degenerative mitral regurgitation (MR), and 20 normal control subjects. LV iVP was measured using ultrahigh-frame rate tissue Doppler (350-460 frames/sec) and flow propagation velocity by color flow M-mode imaging. Follow-up data (up to 2 years) were retrieved from medical records. RESULTS: iVP was highest in patients with AS (2.2 ± 0.7 m/sec), intermediate in those with MR (1.6 ± 0.5 m/sec), and lowest in control subjects (1.4 ± 0.2 m/sec; P < .0001). Fourteen patients with AS and eight with MR had iVP > 1.8 m/sec. Overall, iVP correlated with age, LV morphology, severity of aortic valve obstruction, and measures of LV preload and afterload. At follow-up, patients with high iVP had lower survival free of major adverse cardiac events (P = .002). Flow propagation velocity was similar between groups and correlated poorly with iVP (r = 0.26, P = .10). CONCLUSIONS: A significant number of patients with severe AS and severe MR had rapid transmission of myocardial stretch, indicating increased myocardial stiffness. This information was not conveyed by measurement of flow propagation. Larger studies are needed to investigate the clinical utility of this novel measurement.