Myocarditis Presenting as ST-Elevation Myocardial Infarction.

When evaluating a patient with ST-segment elevation on ECG and acute chest pain, providers often rapidly arrive at the diagnosis of ST-elevation myocardial infarction (STEMI). As myocardial infarction is deadly and time is of the essence in establishing reperfusion, it is reasonable to place it at the top of the differential. However, doing so should not come at the expense of conducting a thorough clinical evaluation, considering all causes of ST-segment elevation, and creating a comprehensive differential. Myocarditis, in particular, can present similarly to myocardial infarction and misdiagnosis can lead to unnecessary and sometimes harmful interventions such as thrombolytic therapy, vasodilator therapy, or coronary angiography. We present a case of myocarditis mimicking STEMI and discuss diagnosis and treatment of myocarditis.

The Year in Perioperative Echocardiography: Selected Highlights from 2018.

This article is the third of an annual series reviewing the research highlights of the year pertaining to the subspecialty of perioperative echocardiography for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board for the opportunity to continue this series. In most cases, these will be research articles targeted at the perioperative echocardiography diagnosis and treatment of patients after cardiothoracic surgery; but in some cases, these articles will target the use of perioperative echocardiography in general.

High-Dose Vincristine Sulfate Liposome Injection, for Advanced, Relapsed, or Refractory Philadelphia Chromosome-Negative Acute Lymphoblastic Leukemia in an Adolescent and Young Adult Subgroup of a Phase 2 Clinical Trial.

PURPOSE: A study of vincristine sulfate (VCR) liposome injection (VSLI) was conducted in patients with advanced, relapsed, or refractory, Philadelphia chromosome-negative acute lymphoblastic/lymphocytic leukemia (ALL). A retrospective subgroup analysis of the results was performed to evaluate the safety and efficacy of VSLI in the adolescent and young adult (AYA) patients. METHODS: Of the 65 patients treated in the pivotal Phase 2 Study HBS407 (NCT00495079), 44 patients were aged ≤39 years (median 27 [range 19-39] years) and were included in this analysis. Patients received VSLI (2.25 mg/m2 intravenously every 7 ± 3 days) without dose capping or concurrent steroid administration in continuous 28-day cycles. RESULTS: VSLI was well tolerated in the AYA patients over a median of 5 (range 1-15) doses administered. One-third of patients (36%) experienced treatment-related serious adverse events (AEs) with peripheral neuropathy (7%), tumor lysis syndrome (7%), and febrile neutropenia (5%) in >1 patient. Neuropathy-associated AEs occurred in 82% patients; no neuropathy-related deaths occurred. The rate of complete remission (CR) (with or without complete blood count recovery) by investigator assessment was 25% in AYA patients, and the overall response rate was 39%. Median leukemia-free survival in AYA patients attaining CR was 135 (range 32-463) days, and median overall survival was 141 (range 13-620) days. CONCLUSION: VSLI provided a meaningful clinical benefit to AYA patients with ALL, and its safety profile was comparable to that of VCR despite the delivery of higher doses (individual and cumulative).

Remote second-hand tobacco exposure in flight attendants is associated with systemic but not pulmonary hypertension.

BACKGROUND: Second-hand tobacco smoke has been associated with cardiopulmonary dysfunction. We sought to examine the residual effects of remote second-hand smoke exposure on resting and exercise cardiopulmonary hemodynamics. We hypothesized that remote secondhand smoke exposure results in persistent cardiopulmonary hemodynamic abnormalities. METHODS: Participants were non-smoking flight attendants who worked in airline cabins prior to the in-flight tobacco ban. Participants underwent clinical evaluations and completed smoke exposure questionnaires. We used Doppler echocardiography to measure pulmonary artery systolic pressure (PASP) and pulmonary vascular resistance (PVR) at rest and during supine bicycle ergometer exercise, using the validated formula TRV/VTIRVOT x 10 + 0.16, where VTIRVOT is the velocity time integral at the right ventricular outflow tract and TRV is the tricuspid regurgitation velocity. The group was divided into quartiles according to the degree of smoke exposure. Analysis of variance was used to determine the differences in hemodynamic outcomes. RESULTS: Seventy-nine flight attendants were included in our analysis. Baseline characteristics among participants in each quartile of smoke exposure were similar except for history of systemic hypertension, which was more prevalent in the highest quartile. Peak exercise PASP rose to the same degree in all test groups (mean PASP 44 mm Hg, p = 0.25), and PVR increased by approximately 27% in all quartiles. There was no significant difference in pulmonary artery systolic pressure or pulmonary vascular resistance among quartiles of smoke exposure. CONCLUSIONS: We found that remote heavy second-hand smoke exposure from in-flight tobacco is associated with systemic hypertension but does not have demonstrable pulmonary hemodynamic consequences.

Peripheral Bronchial Carcinoid Tumor Presenting as a Right Cardiophrenic Angle Mass.

A 50-year-old woman presented for evaluation of an enlarging right cardiophrenic angle mass. Two years prior she complained of intermittent nausea, diarrhea, and flushing. Initial chest radiography and computed tomography (CT) suggested a pericardial cyst. Due to the onset of increasing dyspnea on exertion, lower extremity edema, and weight gain repeat CT was performed revealing a solid tumor. An Indium-111 octreotide scan showed somatostatin activity limited to the pericardiac mass. Histology after resection confirmed the diagnosis of peripheral bronchial carcinoid. The traditional differential diagnosis for a right cardiophrenic angle mass was misleading in this patient.

Doppler evaluation of the descending aorta in patients with hypertrophic cardiomyopathy: potential for assessing the functional significance of outflow tract gradients and for optimizing pacemaker function.

UNLABELLED: We evaluated whether analysis of aortic flow could be useful for determining the functional significance of left ventricular outflow gradients and for optimizing pacing therapy in patients with hypertrophic cardiomyopathy (HOCM). METHODS: Doppler echocardiography was performed in 32 patients with HOCM. Eleven patients with pacemakers (PPM) also underwent treadmill and quality-of-life (QOL) testing in a randomized crossover trial (1 month of backup pacing (AAI at 30 beats per minute), 1 month with an atrioventricular interval (AVI) of 30 ms (DDD30), and 1 month with an "optimized" AVI (DDDop) that maximized the descending aortic Doppler velocity time integral. RESULTS: Patients with HOCM displayed a notch in the aortic Doppler flow profile. The location of the notch in systole corresponded with the development of the peak left ventricular outflow gradient. Aortic flow after the notch was variable ranging from 6-48% of the total flow. In patients with pacemakers, improved response to pacing was noted in those patients that developed the notch early in systole and had subsequent attenuation of aortic flow. Optimizing the AVI was associated with improved exercise tolerance (AAI: 4.6 +/- 2.3 min., DDD30: 5.5 +/- 2.2 min., and DDDop: 7.7 +/- 2.5 min.; p < 0.05) and improved QOL. CONCLUSIONS: Patients with HOCM have a notch in their aortic Doppler flow profile. The location of the notch correlates with the development of the peak left ventricular outflow gradient and flow after the notch is variable. Patients with an early notch and attenuated flow after the notch appear to have the greatest response to pacing therapy.

The use of the Doppler pulmonary artery velocity time integral to optimize placement of a ventricular pacing lead in a patient with Ebstein's anomaly.

Ebstein's anomaly is a rare congenital heart defect. Patients with severe symptomatic tricuspid regurgitation requiring surgical correction often have conduction system disease. We present a case of a 14 year-old girl with Ebstein's malformation and bioprosthetic tricuspid valve who required permanent pacing for symptomatic bradycardia. The placement of the right ventricular pacing lead was facilitated by the use of the Doppler pulmonary artery velocity time integral as a surrogate for stroke volume. This case demonstrates the importance of site-specific pacing and the utility of Doppler echocardiography to optimize lead placement and cardiac performance in patients with Ebstein's anomaly and advanced conduction system disease.

AIDS associated with severe cor pulmonale and large pericardial effusion with cardiac tamponade.

Cardiac involvement in patients with advanced HIV/AIDS is common, including pericardial effusion and pulmonary hypertension. Although there is an increased incidence of pericardial effusion in patients with AIDS, most are small and asymptomatic. The presence of a pericardial effusion and/or pulmonary hypertension is associated with shortened survival. We present a case of a 43-year-old man with AIDS and advanced cardiovascular involvement who developed severe cor pulmonale and a large pericardial effusion with cardiac tamponade.

Use of intracardiac echocardiography in guiding radiofrequency catheter ablation of atrial tachycardia in a patient after the senning operation.

A patient with D-transposition of the great arteries developed drug refractory atrial tachycardia 12 years after a Senning operation. Electrophysiological study confirmed the presence of atrial baffle-tricuspid valve isthmus dependent reentrant intraatrial tachycardia. Intracardiac echocardiography facilitated initial identification of structures, catheter positioning, and identification of the atrial baffle-tricuspid valve isthmus.