Torsades de Pointes with QT prolongation related to donepezil use.

An 83-year-old female, who had a history of anterior myocardial infarction, was treated for Alzheimer's disease with donepezil. She suffered from repeated diarrhea and vomiting, and experienced syncope. She was admitted to our hospital and was diagnosed with acute colitis and syncope. On admission, her heart rate was 54 beats/min with regular rhythm. Laboratory data showed a low plasma potassium level. Electrocardiogram (ECG) showed poor R progression, ST elevation, negative T in precordial leads, and marked QT prolongation. Transthoracic echocardiogram showed the enlargement of the left atrium and aneurysmal area at the apex. Torsades de Pointes (TdP) with syncope and convulsion were confirmed on ECG monitoring twice after admission. We treated her with potassium chloride and started magnesium sulfate and lidocaine, and then added isoprenaline injection. After these treatments, her heart rate increased and we did not detect TdP again. With the aging population in Japan, prescriptions for donepezil are increasing. We have to be vigilant for syncope in patients taking donepezil, which is possibly related to QT prolongation and TdP.

Usefulness of transesophageal echocardiographic observation during chemotherapy for cardiac metastasis of non-Hodgkin lymphoma complicated with left ventricular diastolic collapse.

A 53-year-old man, who had been treated for penile origin diffuse large B cell type non-Hodgkin lymphoma (NHL), suffered from right femoral pain and dyspnea. Positron emission tomography (PET) revealed abnormal accumulation in his right femur and cardiac segments. Transthoracic echocardiography revealed massive localized pericardial effusion with the collapse of both ventricles and the mass-like echo in the left atrium. We performed emergent pericardiocentesis and diagnosed this case as a recurrence of NHL with cardiac metastasis. With the use of transesophageal echocardiography (TEE), we confirmed the mass-like echo around the inter-atrial septum, which directly invaded to the aortic ring and the right atrial wall. In order to evaluate the effect of chemotherapy, we performed TEE and observed the precise changes of intra-cardiac tumor size. With the use of TEE monitoring, we could select the appropriate chemotherapeutic regimen, and the tumor became smaller and finally diminished. The femoral accumulation detected by PET also disappeared. We experienced a case of cardiac metastasis of NHL complicated with left ventricular diastolic collapse due to the massive localized pericardial effusion. TEE is a useful tool to evaluate precisely the efficacy of chemotherapy for intra-cardiac tumors.

Mitral regurgitation resulting from the consecutive multiple perforations by infective endocarditis mimicking the isolated anterior mitral cleft.

A 60-year-old man, suffering from sustained cough and dyspnea on effort, was diagnosed as congestive heart failure. He did not yield the history of having fever or other inflammatory events. His physical examination disclosed a pan-systolic murmur at the apex. Transthoracic color Doppler echocardiography showed moderate to severe mitral regurgitation originated from the linear tear of the anterior mitral leaflet. The tear reached to the mid-portion of the leaflet just within the postero-medial commissure and the regurgitant flow convergence was not hemispheric, but box-like shaped, suggesting that the linear tear was the isolated mitral cleft. Transesophageal echocardiography showed the almost same findings and we found no other anomalies. Surgical treatment was selected to repair the mitral regurgitation. Under operation, we found three consecutive perforations located linearly in the anterior mitral leaflet. The mitral valve replaced with the prosthetic one. The pathological examination of the resected valve showed mucinous degeneration of the chordae tendineae and fibrinoid change without inflammatory cellular infiltration. These findings were compatible with the healed infective endocarditis. Here we experienced a curious case of mitral regurgitation, caused by consecutive three mitral perforations mimicking the isolated anterior mitral cleft.