Repeated Syncope Following COVID-19 Infection.

A 74-year-old woman presented to our hospital with syncope after a coronavirus disease 2019 (COVID-19) infection. Upon admission, she passed out, and an 8 second sinus arrest was detected during telemetry monitoring. During the next syncope episode, telemetry monitoring showed that her heart rate decreased from 80 to 36 bpm, accompanied by a 2.4 second pause. A permanent pacemaker was implanted; however, the patient still experienced syncope. The head-up tilt test revealed a vasodepressor reflex syncope. The need for permanent pacemakers in patients with syncope following COVID-19 therefore remains controversial.

Clinical Characteristics of the Patient With Unmeasurable Ankle-Brachial Index in Endovascular Treatment.

Introduction Ankle-brachial index (ABI) is an important indicator to diagnose lower extremity arterial disease (LEAD). However, patients with unmeasurable ABI are sometimes excluded from the analysis and their clinical characteristics are poorly understood. Methods One hundred twenty-two consecutive Japanese subjects (mean age, 72 years), who underwent successful endovascular treatment (EVT) for lower extremity arteries at our hospital were retrospectively studied. Results Of the 122 patients, 23 (19%) patients presented an unmeasurable ABI before EVT. Five of 23 (22%) had still an unmeasurable ABI one day after EVT. Comorbidities including hypertension, diabetes, dyslipidemia, hemodialysis, smoking, ischemic heart disease, atrial fibrillation, and past-EVT history were not different between ABI measurable and unmeasurable patients. However, patients with unmeasurable ABI presented a significantly higher degree of Rutherford category and a smaller number of tibial vessel runoff than patients with measurable ABI before EVT (p<0.05 and p<0.01, respectively). There was no difference in the lesion site between the two groups. The event rate including all-cause mortality, re-EVT, lower limb amputation, and bypass surgery did not differ between two groups four years after EVT. ABI after four years of initial EVT did not differ between pre-EVT measurable and unmeasurable patients (0.96 vs. 0.84, p=0.48). Conclusions Patients with unmeasurable ABI before EVT were characterized by higher degree of Rutherford categorization and a small number of tibial vessel runoff, but there was no significant difference in outcomes during the follow-up period.

Subcutaneous-implantable cardioverter defibrillator lead dislodgement in a juvenile catecholamine-induced polymorphic ventricular tachycardia patient.

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a relatively rare inherited arrhythmic disease that causes sudden cardiac death, and is caused by mutations in the cardiac ryanodine receptor (RyR2) or sarcoplasmic reticulum protein calsequestrin 2 gene (CASQ2). A 16-year-old man was diagnosed with CPVT and was implanted with a Subcutaneous-implantable Cardioverter Defibrillator (S-ICD), but defibrillation electrode detachment occurred early after placement. We suspected that a two-incision technique was the possible cause. We also report on changes in surface ECG in remote monitoring of the device. TAKE HOME MESSAGE  Although two-incision techniques are becoming the mainstream method of S-ICD implantation, we should consider that the three-incision technique may be advantageous in highly active patients. Remote monitoring may also be useful for early detection of S-ICD dislodgement.

Septic Shock Due to Urinary Tract Infection in an Immunosuppressed Patient Prescribed Dapagliflozin.

Urinary tract infection (UTI) is one of the adverse effects of sodium-glucose cotransporter 2 (SGLT2) inhibitors. We describe a rare case of septic shock due to UTI in an immunosuppressed patient prescribed dapagliflozin. A 69-year-old woman was admitted to our hospital for the treatment of pyelonephritis. She was prescribed immunosuppressive drugs for systemic lupus erythematosus and was newly prescribed dapagliflozin for heart failure two weeks prior. One hour after admission, the patient developed hypotension and was diagnosed with septic shock due to UTI. She was administered norepinephrine, hydrocortisone and meropenem. Afterward, she underwent emergent transurethral lithotomy for her right urinary tract stones. The following clinical course was uneventful, and she was discharged on day 17. She had no recurrence of UTI or exacerbation of heart failure without dapagliflozin administration. This case report emphasizes the importance of considering the possibility of UTIs and cases in which SGLT2 inhibitors should be used. If a patient is female and immunocompromised, dapagliflozin should be prescribed more carefully after considering the increased risk of UTIs.

Multiple Cardiac Calcified Amorphous Tumors.

A 61-year-old woman who underwent hemodialysis presented with heart failure. Echocardiography revealed multiple mobile masses in the left atrium. The masses were excised, and histopathologic examination revealed calcified amorphous tumors. Here, we present several echocardiography images, including 3-dimensional transesophageal echocardiography, demonstrating the revolving masses in the left atrium. (Level of Difficulty: Intermediate.).

Delayed-onset constrictive pericarditis associated with trauma.

A 59-year-old man presented with exertional dyspnoea and pretibial oedema that had lasted 6 months. He was referred to our hospital with suspected constrictive pericarditis (CP). Several examinations, including CT, echocardiography and cardiac catheterisation, indicated heart failure associated with CP that had been induced by trauma 13 years prior. The CP and heart failure were unresponsive to medical treatment, therefore, a surgical pericardiectomy was performed, which is considered the only definitive treatment. Pathological examination of the resected pericardium revealed a fatty texture and dense fibrous connective tissues, which are associated with old haemorrhage and focal calcification. The patient's symptoms were improved to New York Heart Association Class I, and his peripheral oedema disappeared 6 months after leaving hospital.