Spiked Helmet Sign in the Inferior Leads.

This case report describes a patient in their 80s who was admitted to the critical care unit with pulseless electrical activity cardiac arrest.

Marked QTc Reduction Immediately Following Direct Current Cardioversion of Atrial Fibrillation: Clinical Implications and Mechanisms.

BACKGROUND: The QTc in sinus rhythm (SR) following direct current cardioversion (DCCV) of atrial fibrillation (AF) is commonly used as a baseline QTc for patients who require initiation of antiarrhythmic drugs for rhythm control. Inaccurate baseline QTc may cause drug-induced torsades de pointes. OBJECTIVES: This study sought to assess time-dependent QTc changes following DCCV. METHODS: We prospectively assessed QTc changes with Bazett's QTc and Fridericia's QTc formulas in 65 patients following conversion of AF to SR. Among these 65 patients, 48 underwent DCCV and 17 spontaneously converted to SR. RESULTS: There was a large and statistically significant decrease in QTc in SR immediately following DCCV in 40 patients, which occurred with an abrupt reduction in heart rate postcardioversion. This finding excluded 8 patients with ventricular-paced QRS. The mean decrease from QTc in AF was 70.7 ± 37.2 milliseconds in the QTc interval for heart rate using Bazett's formula and 33.8 ± 17.9 milliseconds in the QTc interval for heart rate using Fridericia's formula at 1-minute post-DCCV. In 17 patients with spontaneous conversion from AF to SR, the QTc reduction was comparable to those in patients with DCCV. The QTc increased with time and reached a steady state at 5 minutes following conversion. Initiation of Class III drugs based on the "shortened" baseline QTc following DCCV was associated with drug-induced torsades de pointes. CONCLUSIONS: In patients with AF following conversion, regardless spontaneous or DCCV, the QTc shortened significantly with decreases in heart rate, likely via the mechanism of time-dependent rate adaption of ventricular repolarization. A steady-state QTc at 5-minutes following DCCV should be used as real baseline for guidance of pharmacotherapy in patients with AF.

Anatomical characteristics of the membranous septum are predictive of pacemaker requirement in patients undergoing transcatheter aortic valve replacement.

PURPOSE: We aimed to study the characteristics of the membranous septum (MS) and its relationship with the aortic valve (AoV) and aortic annulus (AA) in patients who required PPM post-TAVR. METHODS: We performed a retrospective case-control study of 144 patients undergoing TAVR from 2016 to 2018. Thirty-four patients, requiring PPM implantation, were compared with 34 matched controls who did not require pacing. The total MS length, supra-annular MS (SA-MS) length, infra-annular MS (IA-MS) length, angle between the plane of the AA and MS (AA-MS), and degree of AoV calcifications (AVC) were obtained from preoperative CT. AoV prosthesis implantation depth was obtained from intra-operative fluoroscopy. RESULTS: There were no significant differences in valve type (self-expandable: 23 cases vs 25 controls, and balloon-expandable: 11 vs 9, p = 0.79), degree of AVC (0.65 cm3 vs 0.82 cm3, p = 0.62), or implantation depth (7.76 mm vs 7.28 mm, p = 0.83). Compared to controls, there was no difference in total MS length (6.68 mm vs 6.06 mm, p = 0.97), but the IA-MS was significantly shorter (3.64 mm vs 4.56 mm, p = 0.02) and the SA-MS was significantly longer (2.73 mm vs 1.67 mm, p = 0.02) in patients requiring PPM. Patients requiring PPM also had a larger AA-MS angle (103.5° vs 96.7°, p = 0.01). CONCLUSION: The position of the MS with respect to the AA and MS distance below the annular plane were more closely associated with post-TAVR conduction abnormalities requiring PPM than the absolute length of the MS. Patients undergoing TAVR with such anatomy have a higher risk of requiring PPM and should be monitored for developing these complications.

Catheter-based interventions versus medical and surgical approaches in acute pulmonary embolism.

OBJECTIVE: Catheter-based intervention (CBI) has become an increasingly popular option for treating pulmonary embolism (PE); however, the real benefits are unknown. The purpose of the present study was to compare the outcomes of patients treated with CBI with the outcomes of those treated with medical or surgical approaches. METHODS: We performed a retrospective analysis of patients admitted from October 2015 to December 2017 with a diagnosis of acute PE. We compared patients aged ≥18 years with a diagnosis of acute PE treated with CBI against a control group identified by propensity score matching. The control group was divided into those who had undergone surgical pulmonary embolectomy (SPE) as the surgical group and those who had not undergone SPE as the medical group. The primary outcome was mortality (in-hospital and overall mortality). The secondary outcomes were major bleeding, length of hospital stay, thrombus resolution, right ventricle improvement in systolic function and dilatation, and recurrent PE. RESULTS: Of the 108 patients, 30 were in the CBI group and 78 were in the control group (62 in the medical group and 16 in the surgical group). The patient characteristics on admission were similar, except for the body mass index, which was greater in the CBI group (P = .03). No difference was found in clinical severity, clot burden, right ventricle function, or biomarkers. Recurrent PE was less frequent in the CBI group than in the medical group (0% vs 6.4%). Otherwise, no significant differences were found in the outcomes between the CBI and medical groups. When CBI was compared with the surgical group, SPE was associated with improved mortality (0% vs 16.6%) but a longer median length of hospital stay (median, 7 days; interquartile range, 3-12 days; vs median, 8 days; interquartile range, 6.5-17 days). CONCLUSIONS: The use of CBI reduced the number of recurrent PE events compared with the medically treated patients; however, the mortality was higher than that in the surgical group.

A Tale of 2 Hearts: Simultaneous Dual Tachycardias Occurring 22 Years After Orthotopic Heart Transplantation.

At 22 years following heart transplantation, a patient presented with incessant atrial flutter. During electrophysiologic study, 2 simultaneous atrial arrhythmias were mapped, 1 from the donor and 1 from the recipient's heart. High-density mapping allowed for rapid identification of electrically abnormal areas, which were successfully ablated, thus restoring sinus rhythm. (Level of Difficulty: Advanced.).