Dysphagia, Hyperglycemia, and Presyncope.

There have been over 80 documented cases of swallow syncope-a rare form of reflex or neurally mediated syncope-with most cases associated with an underlying esophageal disorder. Here, we describe the first reported case of swallow syncope or presyncope caused by an infectious esophagitis. Our 65-year-old patient initially developed dysphagia, odynophagia, and presyncope with swallowing. This lead to nutrition and medication avoidance behavior, which was followed by the development of diabetic ketoacidosis. The diagnosis of swallow presyncope was confirmed with a provocative swallow study demonstrating 8 s sinus arrest, and an underlying cause of Candida esophagitis was found by upper endoscopy. Symptoms completely resolved after treatment with micafungin.

Usefulness of transesophageal echocardiography to confirm clinical utility of CHA2DS2-VASc and CHADS2 scores in atrial flutter.

The CHA(2)DS(2)-VASc and CHADS(2) risk stratification schemes are used to predict thromboembolism and ischemic stroke in patients with atrial fibrillation. However, limited data are available regarding the utility of these risk stratification schemes for stroke in patients with atrial flutter. A retrospective analysis of 455 transesophageal echocardiographic studies in patients with atrial flutter was performed to identify left atrial (LA) thrombi and/or spontaneous echocardiographic contrast (SEC). The CHA(2)DS(2)-VASc (Congestive heart failure, Hypertension, Age ≥75 years [doubled risk weight], Diabetes mellitus, previous Stroke/transient ischemic attack [doubled risk weight], Vascular disease, Age 65 to 74 years, Sex) and CHADS(2) (Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, previous Stroke/transient ischemic attack [double risk weight]) scores were calculated to stratify the risk of stroke or transient cerebrovascular ischemic events. Transesophageal echocardiography revealed LA thrombi in 5.3% and SEC in 25.9% of patients. Using CHADS(2), LA thrombus was found in 2.2% of the low-intermediate-risk group and 8.3% of the high-risk group (p = 0.005). SEC was found in 19.8% of the low-intermediate-risk group and 32% of the high-risk group (p = 0.004). Using CHA(2)DS(2)-VASc, LA thrombus was found in 1.7% of the low-intermediate-risk group and 6.5% of the high-risk group (p = 0.053). SEC was found in 11.8% of the low-intermediate-risk group versus 30.9% of the high-risk group (p = 0.004). The sensitivity for LA thrombus/SEC with a high CHADS(2) and CHA(2)DS(2)-VASc score was 64.8% and 88.7%, respectively (p = 0.0001). The specificity for LA thrombus/SEC with high CHADS(2) and CHA(2)DS(2)-VASc scores was 52.6% and 28.9%, respectively (p = 0.0001). In conclusion, both CHA(2)DS(2)-VASc and CHADS(2) scores are useful for stroke risk stratification in patients with atrial flutter. CHA(2)DS(2)-VASc had greater sensitivity for LA thrombus and SEC detection at the cost of reduced specificity.

Intercostal muscle twitching from right ventricular apical pacing.

A patient with a dilated cardiomyopathy underwent successful implantation of a cardiac resynchronization therapy defibrillator. The device system included an active fixation lead placed at the right ventricular (RV) apex. Pacing from the RV apex unexpectedly led to left-sided intercostal muscle stimulation and twitching. This intercostal muscle twitching resolved completely with movement of the lead to the RV outflow tract.

Successful percutaneous cardiac resynchronization despite an occlusive Thebesian valve.

We report the case of a patient with symptomatic heart failure referred after an unsuccessful attempt at cardiac resynchronization therapy. An occlusive Thebesian valve prevented entry into the coronary sinus ostium. Careful analysis of the patient's cardiovascular physiology and anatomy revealed the "fortuitous" presence of a persistent left superior vena cava. Cannulation of this vessel permitted percutaneous retrograde placement of a left ventricular lead into a posterolateral cardiac venous branch resulting in successful cardiac resynchronization. This unique case provides strong evidence that thorough knowledge of cardiac embryology, anatomy, and physiology plays a pivotal role in percutaneous electromechanical intervention for drug-refractory heart failure.