Cases reported "Myocardial Ischemia"

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1/51. The nondiagnostic ECG in the chest pain patient: normal and nonspecific initial ECG presentations of acute MI.

    The 12-lead electrocardiogram (ECG) is a powerful clinical tool used in the evaluation of chest pain patients, assisting in the selection of the proper therapy. Unfortunately, the ECG is diagnostic of acute myocardial infarction (AMI) in only one-half of such patients at initial hospital evaluation. In the remaining group of patients with the nondiagnostic 12-lead electrocardiogram, the ECG may be entirely normal, show nonspecific sinus tachycardia (ST) segment-T wave abnormalities, or obvious ischemic changes. In adult chest pain patients treated in the emergency department (ED), 1% to 4% of such patients with an absolutely normal ECG had a final hospital diagnosis of AMI; furthermore, patients with nonspecific electrocardiographic abnormalities experienced AMI in 4% of cases. These findings reinforce the teaching point that the history is the most important tool used in the evaluation of chest pain patients. Furthermore, overreliance on a normal or nonspecifically abnormal ECG in a patient with a classic description of anginal chest pain is dangerous.
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2/51. Prolonged perioperative myocardial ischemia in a young male: due to topical intranasal cocaine?

    We present a case of prolonged myocardial ischemia in a young healthy male presenting for nasal polypectomy and tonsillectomy. Induction of anesthesia proceeded uneventfully. Immediately after surgical incision, the patient developed a sinus tachycardia with ST-segment depression in leads II and III, and ST elevation in leads aVR, aVL, aVF, and V. Depth of anesthesia was increased, esmolol was administered, which slowed the heart rate, and the procedure was terminated. However, myocardial ischemia only gradually resolved, leaving residual T-wave flattening in lead III by day 3 postoperatively. After extensive investigation to rule out other causes of ischemia, we considered cardiotoxicity due to intranasally administered cocaine with epinephrine to be the most likely precipitant. Nasal packing with gauze soaked in a solution containing cocaine 3 mg/kg and epinephrine 1 mg occurred just 40 minutes prior to induction of anesthesia. Topical intranasal cocaine is rapidly and reliably absorbed systemically, with peak plasma concentrations occurring within 30 to 60 minutes, corresponding to the time course of cocaine administration and surgical stimulation in this patient. Systemic absorption of topical intranasal cocaine has previously been reported to cause adverse cardiac sequelae, including myocardial infarction. This report reinforces the need for caution regarding the use of topical intranasal cocaine, particularly if used in combination with epinephrine.
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3/51. pneumopericardium mimicking acute myocardial ischemia after laparoscopic cholecystectomy.

    pneumopericardium occurred after laparoscopic cholecystectomy in a 57-year-old woman. The patient had chest pain accompanied by T-wave inversion on electrocardiogram, with signs and symptoms suggestive of acute myocardial ischemia. Evaluation for myocardial infarction, however, was negative and clinical findings resolved spontaneously. Although pneumopericardium after laparoscopic procedures has been previously reported, this case illustrates how associated findings may mimic those of acute myocardial ischemia or infarction.
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4/51. epicardial mapping and radiofrequency catheter ablation of ischemic ventricular tachycardia using a three-dimensional nonfluoroscopic mapping system.

    Endocardial radiofrequency catheter ablation of ischemic left ventricular tachycardia has been of variable success due to multiple factors. Two such factors include the location of the reentrant circuit in the deep myocardium or on the epicardial surface and the inherent limitations of fluoroscopy as a guide for target localization. We report a patient in whom successful epicardial mapping and radiofrequency catheter ablation of an ischemic left ventricular tachycardia was performed using pericardial access and the CARTO electroanatomic mapping system.
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5/51. ICD hardware failure associated with multiple internal shocks.

    The delivery of 37 shocks by an ICD within 20 minutes, in response to T wave oversensing during atrial flutter, resulted in several manifestations of undesirable device behavior. The generator reverted to backup mode, and disabled automatic capacitor reformation, therapy delivery, and automatic gain control. Postexplant analysis of the device revealed damage to the high voltage output section of the circuitry consistent with excessive electrical stress. In rare circumstances, multiple internal discharges can result in serious clinical anomalies in ICD behavior, and possibly in an increase in susceptibility to circuitry damage.
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6/51. Severe transmyocardial ischemia in a patient with tension pneumothorax.

    OBJECTIVE: To report tension pneumothorax (TP) as a cause of severe myocardial ischemia. DESIGN: Clinical case report. SETTING: Medical intensive care unit of a university hospital. patients: One patient with severe shock attributable to right TP after unsuccessful percutaneous central venous catheterization. INTERVENTIONS: blood pressure, electrocardiogram (ECG), chest radiograph, and echocardiography during and after shock. MEASUREMENTS AND MAIN RESULTS: On admission the patient was in profound state of shock (heart rate 140 beats/min, blood pressure 65/30 mm Hg). Twelve-lead ECG showed pronounced ST segment elevation in leads II, III, aVF, and V4-V6. Chest radiograph revealed right TP with complete displacement of the mediastinum and the heart to the left side. Immediate right-sided tube thoracostomy resulted in reexpansion of the lung followed by instantaneous hemodynamic and respiratory improvement as well as nearly complete resolution of the ECG changes. Peak value of the creatine phosphokinase was 4140 U/L without significant elevation of the MB isoenzyme at any time. Moreover, the initial hypokinesia of the posterior and lateral left ventricular wall resolved completely, as demonstrated by echocardiography. CONCLUSION: The specific condition of TP may lead to impaired systolic and diastolic coronary artery blood flow affecting ventricular repolarization and T-wave configuration in ECG indicative of transmyocardial ischemia. General symptoms, namely hypotension, tachycardia, and hypoxemia, are likewise typical for cardiogenic shock attributable to myocardial infarction. Yet any therapeutic measure directed toward revascularization, such as thrombolysis or even percutaneous transluminal coronary angioplasty, would have had devastating consequences. Therefore, thorough physical examination of our patient was pivotal in disclosing the true origin of profound shock.
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7/51. Ineffective subthalamic nucleus stimulation in levodopa-resistant postischemic parkinsonism.

    The authors report a patient with postischemic parkinsonism who responded neither to levodopa nor to bilateral subthalamic nucleus (STN) stimulation. MRI revealed bilateral lesions of the substantia nigra, the striatum, the external pallidum, and part of the internal pallidum. PET showed reduced striatal dopa-decarboxylase activity, D2 receptor binding, and glucose metabolism. Perioperative microrecording showed low-frequency activity of STN cells. This case suggests that parkinsonian patients who do not have a good response to levodopa or in whom a postsynaptic dopaminergic lesion can be shown may not be good candidates for STN surgery.
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8/51. Biosense mapping for ablation of ventricular tachycardia in cardiomyopathy.

    Using conventional technology, radiofrequency ablation of ventricular tachycardia in cardiomyopathy is frequently unsuccessful because of hemodynamic instability, multiple foci and recurrences. The Biosense CARTO nonfluoroscopic mapping and navigation system, when used to locate the area of the scar or reentry circuit, has the potential to improve the successful ablation, and reduce the rate of recurrence. We report 2 cases here of ventricular tachycardia in cardiomyopathy in which Biosense mapping was useful to identify the area of scar in 1 case, and the area of microreentry circuits in another. Radiofrequency ablation was possible and successful, while the use of conventional mapping was impossible or had recurrence.
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9/51. Effectiveness of an antiplatelet agent for coronary artery ectasia associated with silent myocardial ischemia.

    A 74-year-old Japanese male was referred to our hospital because of an abnormal electrocardiogram. The electrocardiogram revealed tall P waves in leads II, III, and aV(F). echocardiography disclosed hypokinesis extending from the anteroseptal region to the apex. iodine-123 15-(p-iodophenyl)-3-(R,S)-methylpentadecanoic acid (123-BMIPP) scintigraphy revealed reduced uptake from the anteroseptal region to the apex. Coronary arteriography demonstrated diffuse dilatation of the right and left coronary arteries without organic stenosis, and left ventriculography showed hypokinesis at the same area. Furthermore, the coronary flow reserve in the left anterior descending artery was decreased. He was treated with an antiplatelet agent. Ten months later, the left ventriculography, 123I-BMIPP scintigraphy findings and coronary flow reserve were normalized. These findings demonstrate that antiplatelet therapy may be useful in the preservation of left ventricular function in patients with coronary artery ectasia.
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10/51. Unusual ECG responses to exercise stress testing.

    We describe the case of a patient with coronary artery disease who developed transient ST-segment depression, right bundle branch block (RBBB), left anterior hemiblock, ST-segment elevation ST), and "giant" T-waves in her electrocardiogram (ECG), an assortment of ECG patterns heretofore unreported in conjunction with exercise stress testing (EST). The amplitude of the ST was modulated by the superimposed RBBB, as was shown by its augmentation after the abrupt disappearance of RBBB. Following recession of the latter "giant" T-waves, which usually are encountered in the hyperacute phase of myocardial infarction, developed and persisted late in the recovery period. Cardiac enzymes after EST were negative, and arteriography revealed a stenotic left anterior descending coronary artery. The present case indicates that a variety of ECG expressions of severe transmural ischemia or myocardial infarction can also be manifest in the course of EST; this also suggests a common pathophysiological mechanism in severe EST-triggered ischemia and the early phase of myocardial infarction.
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