Persistent right superior vena cava in a patient with dextrocardia: Case report and review of the literature.

INTRODUCTION: Systemic venous circulation anomalies are uncommon; they are often incidental findings during echocardiography. CASE: A 56-year-old man, with dextrocardia, was evaluated for dyspnea. The patient's medical history included diabetes mellitus requiring insulin treatment, hypertension, and tobacco use. Physical examination revealed normal jugular venous pulsations and clear lungs. Cardiac examination revealed normal heart sounds, and grade II/VI systolic ejection murmur over the right precordium. Echocardiography revealed normal chamber size and systolic function, without significant valvular lesions. The coronary sinus was dilated. It was evaluated using intravenous agitated saline contrast to rule out anomalous venous drainage or shunting. When injected into the left antecubital vein, contrast appeared initially in the right atrium followed by the right ventricle. However, when injected into the right antecubital vein, contrast appeared initially in the dilated coronary sinus followed by the right atrium and right ventricle. There was no evidence of intracardiac shunting. These findings were consistent with persistent right superior vena cava in the setting of situs inversus dextrocardia, with normally draining left superior vena cava. CONCLUSION: Persistent superior vena cava connection to the coronary sinus is often incidental but an important finding which helps in planning safe invasive procedures..

Pacemaker-mediated angina.

Angina is a clinical syndrome characterized by discomfort in the chest, jaw, shoulder, back or arm. It is typically aggravated by exertion or emotional stress and relieved by nitroglycerin. Atherosclerotic coronary artery disease is the most common cause of angina. Dual-chamber pacemakers track the atrial electrical activity by pacing the ventricle. The present article reports the first case in the literature involving pacemaker-mediated angina. A 78-year-old man complained of chest pain shortly after the placement of a permanent dual-chamber pacemaker and experienced immediate relief of his pain after the pacemaker mode was switched from tracking the atrium and pacing the ventricle to sensing and pacing the ventricle. The pain was identified as angina pectoris. The comprehensive history-taking performed before pacemaker placement helped to quickly identify the cause of the patient's pain.

Cocaine-induced coronary stent thrombosis.

Cocaine is the most commonly abused drug in patients presenting to emergency rooms. Compliance with medical instructions and medications is poor in patients who use cocaine. A case involving a 41-year-old cocaine user who developed subacute stent thrombosis is described. The patient underwent bare metal stent implantation three days before presentation and had confirmed compliance with dual antiplatelet therapy. The stent thrombosis was treated with a manual and mechanical thrombectomy, in addition to percutaneous transluminal coronary angioplasty. Given the issue of compliance and the increased evidence of cocaine-induced thrombosis in native vessels and stents, it is recommended that balloon angioplasty alone should be the treatment of choice when intervention is required.

Exercise-induced ST-segment elevation during the recovery phase of an exercise stress test.

To the authors' knowledge, the present report represents the first case in the medical literature in which an ST-segment elevation during the recovery phase of an exercise stress test indicated significant left main coronary artery stenosis. Although the patient did not complain of chest pain during the test, the ST-segment elevation persisted 20 min into recovery.

Safety of ß-blockers in the acute management of cocaine-associated chest pain.

BACKGROUND: Cocaine is the most commonly abused illegal drug in patients presenting to emergency departments (EDs) because of chest pain and accounts for almost 40% of all drug-related visits. It is not known whether all ß-blockers (BB) and ß1-selective agents or mixed α1/ß-adrenergic antagonists (α1/ß-BB) are safe in the acute management of cocaine-associated chest pain, due to concerns of unopposed α-receptor activity resulting in coronary artery spasm and hypertensive urgency. METHODS: Patients who presented to the EDs of 2 large inner city hospitals because of chest pain and who tested positive for cocaine were identified by retrospective chart review. Demographic characteristics, symptoms, vital signs, electrocardiographic abnormalities, medication use, comorbidities, and troponin values were documented. The presence and type of BB used were studied in relation to peak elevation in troponin T and troponin I. Troponin elevation was defined as a troponin I greater than 0.6 ng/mL and troponin T greater than 0.1 ng/mL if serum creatinine was less than 2 mg/dL. RESULTS: A total of 378 patients were included in the study; of these, 78% (n = 296) were black; 12% (n = 44), white; and 10% (n = 38), of other race. Twelve percent (n = 46) of the patients had typical chest pain, 22% (n = 84) had coronary artery disease, 56% (n = 213) had hypertension, and 21% (n = 79) had diabetes mellitus. The admission electrocardiogram showed changes (ST elevation, ST depression, or T-wave inversion) in 43% (n = 163) of the patients. ß-Blockers were used in 43% (n = 162) of the encounters. Troponin elevation occurred in 11% (n = 42) of patients. There was no difference in the number of patients with troponin rise in the BB and non-BB groups, 22 of 162 vs 20 of 213 (P = .2). There was no difference in mean peak troponin levels in patients with troponin rise who were treated with BB vs no BB, 6.7 vs 5.7 ng/mL (P = .6). There was no difference in mean peak troponin levels in patients with troponin rise who were treated with a ß1-selective agents vs a α1/ß-BB, 7.5 vs 4.1 ng/mL (P = .4). No cases of hypertensive urgency were identified after taking any BB. CONCLUSION: Troponin rise is not uncommon in patients with cocaine-associated chest pain and occurred in 11% of the patients. In patients with cocaine-associated chest pain, BBs did not appear to change the incidence of troponin rise. ß1-Selective BBs did not appear to worsen troponin levels compared with mixed α1/ß-BB.

Ciprofloxacin-induced torsade de pointes.

A 65-year-old man with recently diagnosed urinary tract infection treated with ciprofloxacin (Cipro) presented to our institution with recurrent seizure-like activity. His rhythm revealed torsade de pointes, which required defibrillation. Subsequent electrocardiogram revealed severely prolonged QT interval, which near-completely resolved 7 days later off Cipro. This case highlights a rare but potentially fatal side effect of quinolone antibiotics, especially in combination with other QT-prolonging medications. Review of the literature with regard to prevalence, mechanism, and assessment and treatment of this potentially fatal incidence is provided.

Biatrial myxoma and cerebral ischemia successfully treated with intravenous thrombolytic therapy and surgical resection.

We report what we believe is the 1st case in the medical literature in which an intravenous thrombolytic agent was used successfully--without massive intracranial bleeding--to treat acute stroke induced by atrial myxoma. Our patient, who had biatrial myxomas with a dual blood supply from the right coronary artery, presented with cerebral ischemia. Transesophageal echocardiography was essential in clarifying the diagnosis and in helping to direct surgical treatment.