Effects of medically generated electromagnetic interference from medical devices on cardiac implantable electronic devices: A review.

As cardiac implantable electronic devices (CIED) become more prevalent, it is important to acknowledge potential electromagnetic interference (EMI) from other sources, such as internal and external electronic devices and procedures and its effect on these devices. EMI from other sources can potentially inhibit pacing and trigger shocks in permanent pacemakers (PPM) and implantable cardioverter defibrillators (ICD), respectively. This review analyzes potential EMI amongst CIED and left ventricular assist device, deep brain stimulators, spinal cord stimulators, transcutaneous electrical nerve stimulators, and throughout an array of procedures, such as endoscopy, bronchoscopy, and procedures involving electrocautery. Although there is evidence to support EMI from internal and external devices and during procedures, there is a lack of large multicenter studies, and, as a result, current management guidelines are based primarily on expert opinion and anecdotal experience. We aim to provide a general overview of PPM/ICD function, review documented EMI effect on these devices, and acknowledge current management of CIED interference.

Takotsubo cardiomyopathy: A comprehensive review.

Takotsubo cardiomyopathy (TCM), also known as stress cardiomyopathy, occurs in the setting of catecholamine surge from an acute stressor. This cardiomyopathy mimics acute myocardial infarction in the absence of coronary disease. The classic feature of TCM is regional wall motion abnormalities with characteristic ballooning of the left ventricle. The etiology of the stressor is often physical or emotional stress, however iatrogenic causes of TCM have been reported in the literature. In our review, we discuss medications, primarily the exogenous administration of catecholamines, and a wide array of procedures with subsequent development of iatrogenic cardiomyopathy. TCM is unique in that it is transient and has favorable outcomes in most individuals. Classically, beta-blockers and ACE-inhibitors have been prescribed in individuals with cardiomyopathy; however, unique to TCM, no specific treatment is required other than temporary supportive measures as this process is transient. Additionally, no improvement in mortality or recurrence have been reported in patients on these drugs. The aim of this review is to elucidate on the iatrogenic causes of TCM, allowing for prompt recognition and management by clinicians.

Esophageal Rupture Presenting with ST Segment Elevation and Junctional Rhythm Mimicking Acute Myocardial Infarction.

Esophageal rupture is a rare but potentially fatal cause of chest pain. The presentation is variable and can mimic other conditions such as aortic dissection, pulmonary embolism, and myocardial infarction (MI). A 71-year-old male with a history of coronary artery disease presented to the ED with complaints of acute chest pain and respiratory distress. Over the next 48 hours, the patient developed dynamic ST segment changes on surface electrocardiogram mimicking an inferolateral ST segment elevation MI accompanied by a junctional rhythm. Curiously, his cardiac enzymes remained negative during this time, but his clinical status continued to deteriorate. A subsequent CT scan demonstrated a lower esophageal rupture, and the patient underwent successful endoscopic stenting. While rare, prompt recognition of esophageal rupture is imperative to improving morbidity and mortality. While esophageal rupture has been noted to cause ST segment elevation before, this appears to be the first case associated with a junctional rhythm.

Recurrent Stress Cardiomyopathy: A Rare Variant in a Young Patient with Undiagnosed Pheochromocytoma.

Biventricular stress cardiomyopathy is one of several known anatomical variants of reversible cardiomyopathies to occur. We present a case of a young patient with recurrent stress cardiomyopathy complicated by cardiogenic shock in the perioperative period. The cardiomyopathy observed was in a patient with neurofibromatosis type I and undiagnosed pheochromocytoma who presented for intervention of hydrocephalus. This case demonstrates the importance of vigilance in the young patient who develops shock in the perioperative period.

Safety of Phosphodiesterase-5 Inhibitors in Valvular Heart Disease.

ABSTRACT: Erectile dysfunction is a common entity in clinical practice. Primary erectile dysfunction, not related to vasculopathy or psychiatric disorder, can be readily treated with phosphodiesterase inhibitors. These drugs have many physiologic effects that can alter a patient's hemodynamic profile considerably, especially in the presence of concomitant structural heart disease, specifically valvular heart disease. Although some contraindications to the use of PDE5 inhibitors in patients with cardiovascular disease are defined, the effect of these drugs in the presence of valvular heart disease is not well documented. The purpose of this review is to analyze the data regarding the safety of PDE5 inhibitors in patients with valvular heart disease.

Sweet-Tasting Ionic Conjugates of Local Anesthetics and Vasoconstrictors.

Local anesthetics are widely utilized in dentistry, cosmetology, and medicine. Local anesthesia is essential to providing a pain-free experience during dental and local surgeries as well as cosmetic procedures. However, the injection itself may produce discomfort and be a source of aversion. A novel approach toward the taste modulation of local anesthetics is proposed, in which the anesthetics of the "-caine" family serve as cations and are coupled with anionic sweeteners such as saccharinate and acesulfamate. Ionic conjugates of vasoconstrictor epinephrine such as epinephrine saccharinate and epinephrine acesulfamate have also been synthesized. Novel ionic conjugates were developed using anion exchange techniques. Reported compounds are sweet-tasting and are safe to use both topically and as injections.

The incidental finding of a persistent left superior vena cava: implications for primary care providers-case and review.

Persistent left superior vena cava (PLSVC) is the most common thoracic venous anomaly and is a persistent congenital remnant of the vena caval system from early cardiac development. Patients with congenital anomalous venous return are at increased risk of developing various cardiac arrhythmias, due to derangement of embryologic conductive tissue during the early development of the heart. Previously this discovery was commonly made during the placement of pacemakers or defibrillators for the treatment of the arrhythmias, when the operator encountered difficulty with proper lead deployment. However, in today's world of various easily obtainable imaging modalities, PLSVC is being discovered more and more by primary care providers during routine testing or screening for other ailments. Given the known association between anomalous venous return and the propensity for cardiac arrhythmias, we review the embryology of PLSVC and the mechanisms by which it leads to conduction abnormalities. We also provide the practitioner with recommendations for certain baseline cardiac observations and suggestions for proper surveillance in hopes that better understanding will reduce unnecessary and potentially harmful testing, premature subspecialty referral, and unneeded patient anxiety.

ECG diagnosis: The effect of ionized serum calcium levels on electrocardiogram.

High and low levels of ionized serum calcium concentration can produce characteristic changes on the electrocardiogram. These changes are almost entirely limited to the duration of the ST segment, with no change in the QRS complexes or T waves. High ionized serum calcium shortens the ST segment, and low ionized serum calcium prolongs the ST segment. Two common clinical scenarios are presented.

Iatrogenic Aortocoronary Arteriovenous Fistula following Coronary Artery Bypass Surgery: A Case Report and Complete Review of the Literature.

The case of a patient who presented with angina following a coronary artery bypass (CABG) operation during which the left internal mammary artery was inadvertently anastomosed to a cardiac vein is presented. The literature concerning previously reported cases of aortocoronary arteriovenous fistulas (ACAVF) due to inadvertent grafting of a coronary vein is reviewed and the significance of this complication is discussed. ACAVF due to inadvertent grafting of a coronary vein is a rare complication of CABG and may be a more common cause of graft failure than has previously been recognized. Distortion of cardiac anatomy, the presence of epicardial fat, and an intramyocardial course of the artery intended for grafting are predisposing factors. Some patients present with angina pectoris and heart failure whereas others have no symptoms. The diagnostic test of choice is coronary angiography. Cardiac MRI and CT have a limited role due to the smaller size and the more clearly defined course of these fistulas. Asymptomatic patients are simply observed since spontaneous closure of these fistulas is reported. Symptomatic patients can be treated with combined medical management and percutaneous methods.

The D-dimer assay: a possible tool in the evaluation of atrial thrombosis.

Atrial fibrillation (AF) is a common arrhythmia seen in clinical practice, and affects more than 4% of the population older than 60 years of age. Peripheral thromboembolism contributes significantly to the observed morbidity and mortality. Symptomatic AF, before cardioversion to normal sinus rhythm, requires either exclusion of atrial thrombi using transesophageal echocardiography (TEE) or the conventional use of three weeks of adequate anticoagulation. The exclusion of atrial thrombi by TEE, a nontomographic technique but comparable with conventional treatment of AF in outcomes, has inherent limitations due to the complex three-dimensional multilobed anatomy of the left atrial appendage, where the majority of atrial thrombi arise. Also, the conventional treatment of three weeks of therapeutic anticoagulation before cardioversion reportedly does not always eliminate atrial thrombi. Plasma D-dimer constitutes an antigen-antibody reaction to the dimeric final degradation product of a mature clot. An elevated fibrin D-dimer has a high sensitivity for intravascular thrombosis and, hence, may improve the evaluation of a patient with AF before cardioversion in addition to a TEE. A case is presented in which a positive D-dimer resulted in performing TEE to document atrial thrombosis and the complications of previous bacterial endocarditis. In the present case, this involved aortic root abscess formation and acute aortic regurgitation because of flailing of the noncoronary cusp that resulted in recurrent pulmonary edema.