Twiddlers syndrome presenting as life threatening electrical storm

A 75-year-old man underwent implantation of a single chamber implantable cardioverter defibrillator (ICD) for primary prevention of his underlying severe non-ischaemic cardiomyopathy. Thirteen months later, he presented to the emergency room(ER) with inappropriate ICD shocks as a result of over sensing of the right ventricular lead and double counting of the right atrial signals. The chest X-ray (CXR) revealed a right ventricular ICD lead displaced into the right atrium with coiling in the pocket. The right ventricular shocking coil was noted at the tricuspid annulus. The lead was removed from the pocket and was replaced with a new lead. This case represents the classical Twiddler\u27s syndrome in an ICD with potential lethal consequences

Mahaim Tachycardia Induced Cardiomyopathy

We present the case report of a 22-year man, with incessant palpitations, chest pain, shortness of breath, and pulsations in his neck for the past 7 months. He was referred to the cardiology unit for workup of wide complex tachycardia (WCT). His echocardiography, 6 months earlier, had demonstrated severe left ventricular (LV) systolic dysfunction, severe global hypokinesia, mild tricuspid regurgitation (TR), and mild mitral regurgitation (MR) which resolved with medical therapy including beta-blockers. He underwent electrophysiological study, which revealed a decremental right sided atriofascicular pathway causing a WCT with left bundle branch block (LBBB) morphology and left axis deviation (LAD, Mahaim tachycardia). This was successfully ablated by radiofrequency ablation (RF) with abolition of the tachycardia. This case report highlights Mahaim tachycardia induced cardiomyopathy, a rare but curable cause of cardiomyopathy

Two Congenital Left-to-Right Shunt Anomalies in a Septuagenarian: ARare Occurrence

Atrial septal defect (ASD) and patent ductus arteriosus (PDA) are common congenital anomalies presenting in childhood. Life expectancy of an uncorrected PDAis shortened to half; and ASD of a significant size has increased morbidity and mortality. Their co-existence in an elderly patient with first presentation at 70 years of age is a rarity. We present the case of a 70-year woman with one-week history of dyspnea with high blood pressure and signs of heart failure. She was found to have a PDA and an ASD with left-to-right shunt. She was managed conservatively. She was offered cardiac catheterization, but she refused. This is the first documented case in local literature with two such congenital heart defects presenting in a septuagenarian. In a country where average life expectancy is in the 60\u27s, the survival of the patient with two heart defects, beyond-average survival age, is interesting

Antidromic Atrioventricular Reentrant Tachycardia Dependent on a Unidirectional Left Anterior Accessory Pathway Mimicking Peri-mitral Ventricular Tachycardia: Successful Ablation via a Transseptal Approach

Antidromic atrioventricular reentrant tachycardia (aAVRT) is rare compared to orthodromic atrioventricular reentrant tachycardia (oAVRT). An aAVRT that is dependent on a unidirectional, decremental accessory pathway (AP) is even rarer. Idiopathic ventricular tachycardias (iVT) that have benign prognoses and respond well to medical therapy can be confused with aAVRTs dependent on APs having ventricular insertion sites close to the iVT focus and have a real risk of sudden death. The preferred approach of ablation for such tachycardias with anterograde conduction only is a retrograde aortic approach, which facilitates the mapping of the earliest ventricular activation during atrial pacing or tachycardia from the ventricular side. This, however, necessitates access to the arterial system with accompanying complications. We describe herein the case of a wide complex tachycardia, which was treated initially as VT with intravenous lidocaine. The baseline electrocardiogram (ECG) did not show preexcitation. An electrophysiology study (EPS) revealed a left anterior AP that conducted anterograde only. AVRT was easily inducible at a cycle length of 290 ms. Successful ablation was undertaken via the transseptal approach without recurrence

Are BP readings taken after a patient-physician encounter in a real-world clinic scenario the lowest of all the readings in a clinic visit.

Objective: To determine the difference in Blood Pressure (BP) readings taken before, during and after the clinic encounter. Study Design: Descriptive study. Place and Duration of Study: Cardiology Clinic, The Aga Khan University Hospital, Karachi, from January to August 2013. Methodology: Hypertensive and normotensive participants aged ≥ 18 years were recruited. Pre-clinic BP was measured by a nurse and in-clinic BP by a physician. After 15 minutes, two post-clinic BP readings were taken at 1 minute interval. All readings were taken using Omron HEM7221-E. Results: Out of 180 participants, males were 57% and 130 (71%) were hypertensive. Mean SBP (Systolic BP) taken preclinic, in-clinic, post-clinic 1 and post-clinic 2 were: 126 ± 20 mmHg, 131 ± 23 mmHg, 126 ± 20 mmHg and 121 ± 21 mmHg respectively (p \u3c 0.001). Mean DBP (Diastolic BP) taken pre-clinic, in-clinic, post-clinic 1 and post-clinic 2 were 77 ± 12 mmHg, 81 ± 13 mmHg, 79 ± 12 mmHg and 79 ± 11 mmHg respectively (p \u3c 0.001). Conclusion: BP taken in the post-clinic setting may significantly be the lowest reading in a clinic encounter, making in-clinic BP unreliable to diagnose or manage hypertension

White coat hypertension is not a benign entity: a cross-sectional study at a tertiary care hospital in Pakistan

OBJECTIVES: To determine the frequency of White Coat Hypertension in patients undergoing ambulatory blood pressure monitoring at a tertiary care center and to compare ambulatory blood pressure profiles of normotensives, white coat hypertensives and hypertensives.METHODS: A descriptive cross-sectional study was conducted which included all adult patients undergoing ambulatory blood pressure monitoring over a 3-year period. Those patients with incomplete data, less than 85% successful BP readings and inadequate number of daytime and nighttime readings were excluded from the study. The data on ambulatory blood pressure monitoring comprised of demographics, blood pressure, pulse pressure and mean arterial pressure readings at every 30 minutes interval and also a graphical representation of patients\u27 24-hour blood pressure recording. SPSS was used for data analysis. Chi-square test and analysis of variance (ANOVA) was used for qualitative and quantitative variables respectively.RESULTS: A total of 277 patients with a mean age of 48.98 +/- 17.52 years were included. There were 189 (58%) males included in the study. Out of the total, 46 (16.6%) patients had White Coat Hypertension, 59 (21.3%) were Normotensive and 172 (62.1%) had Hypertension. The mean age of Normotensives was 40.80 +/- 14.11 years, White Coat Hypertensives was 37.72 +/- 14.58 years and Hypertensives was 54.80 +/- 16.76 years (

Defining the hemodynamic response of hypertensive and normotensive subjects through serial timed blood pressure readings in the clinic

Background: Every third patient in the clinic is misdiagnosed due to white-coat phenomenon, necessitating needless and costly treatment. We aimed to study the hemodynamic response of the physician\u27s visit on hypertensive and normotensive patients by investigating the trend of blood pressure (BP) before, during and 15 min after the physician-patient encounter.Methods: A descriptive, cross-sectional study was conducted over a period of 8 months in the cardiology clinics at the Aga Khan University Hospital, Karachi. Both hypertensive and normotensive patients, aged ≥18 years, were recruited. Pregnant females or those with a history of volume loss were excluded. BP readings were taken using an automated, validated device (Omron-HEM7221-E) at three points: pre-clinic BP by the assessment nurse, in-clinic BP by the attending physician and post-clinic BP 15-min after the physician-patient encounter by a research assistant. Independent samples t-test was used to calculate the statistical difference between hypertensive and normotensive BP values.Results: Of 180 participants, 71% (n = 128) were hypertensive and 57% (n = 103) of all were males. The mean age of the participants was 57 ± 15 years. The mean and standard deviation(±SD) systolic BP (SBP) taken pre-clinic, in-clinic and 15-min post-clinic for hypertensive population was 128.7 ± 20 mmHg, 137.1 ± 21 mmHg and 127.9 ± 19 mmHg. The mean and standard deviation(±SD) SBP taken pre-clinic, in-clinic and 15 min post-clinic for normotensive population was 112 ± 16 mmHg, 115.8 ± 20 mmHg and 111.8 ± 15 mmHg. The hypertensive SBP values showed statistically significant difference from the normotensive values (difference in pre-clinic SBP: 16.7 mmHg, p-value \u3c 0.001; in-clinic SBP: 21.3 mmHg, p-value \u3c 0.001; and 15 min post-clinic: 16.1 mmHg, p-value \u3c 0.001).Conclusions: Hypertensive and normotensive patients display congruent hemodynamics upon visiting the physician, the alert response being accentuated amongst the hypertensive group. In-clinic BP readings are higher for both hypertensive and normotensive patients making them unreliable for screening and management of hypertension amongst both the groups

The Post Clinic Ambulatory Blood Pressure (PC-ABP) study correlates Post Clinic Blood Pressure (PCBP) with the gold standard Ambulatory Blood Pressure

Objectives: Our previous study showed that post-clinic blood pressure (BP) taken 15 min after a physician-patient encounter was the lowest reading in a routine clinic. We aimed to validate this reading with 24 h Ambulatory Blood Pressure Monitoring (ABPM) readings. A cross-sectional study was conducted in the cardiology clinics at the Aga Khan University, Pakistan. Hypertensive patients aged ≥ 18 years, or those referred for the diagnosis of hypertension were included.Results: Of 150 participants, 49% were males. 76% of all participants were hypertensive. Pre-clinic BP reading was measured by a nurse, in-clinic by a physician and 15 min post-clinic by a research assistant using a validated, automated BP device (Omron-HEM7221-E). All patients were referred for 24 h ABPM. Among the three readings taken during a clinic visit, mean (± SD) systolic BP (SBP) pre-clinic, in-clinic, and 15 min post-clinic were 153.2 ± 23, 152.3 ± 21, and 140.0 ± 18 mmHg, respectively. Mean (± SD) diastolic BP (DBP) taken pre-clinic, in-clinic and 15 min post-clinic were 83.5 ± 12, 90.9 ± 12, and 86.4 ± 11 mmHg respectively. Mean (± SD) daytime ambulatory SBP, DBP and pulse readings were 134.7 ± 15, 78.7 ± 15 mmHg, and 72.6 ± 12/min, respectively. Pearson correlation coefficients of pre-clinic, in-clinic and post-clinic SBP with daytime ambulatory-SBP were 0.4 (p value: \u3c 0.001), 0.5 (p value: \u3c 0.001) and 0.6 (p value: \u3c 0.001), respectively. Post-clinic BP has a good correlation with ambulatory BP and may be considered a more reliable reading in the clinic setting

Echocardiography And Multimodal Imaging Advancements In Cardiac Imaging

One of the technological sectors that has advanced and evolved the fastest in recent decades is echocardiography. As a non-invasive technique at a reasonable price, it also lends itself in the future to increasingly integrated use at the patient's bedside in any clinical approach situation, from emergencies to interventional environments, operating rooms, clinical routine, outpatient clinics, diagnostics, and monitoring of therapies. The equipment's downsizing will enable a deeper and more comprehensive integration with the clinical physical examination (clinical echocardiography), not only by cardiologists but also by the wide range of clinical specialties in medicine and surgery. This poses significant organizational and training issues to effectively incorporate multimodal imaging and ultrasound diagnostic techniques into the diagnostic and treatment paths of the various subspecialties. Additional developments in portable and miniaturized technologies are also required to achieve reliability at least on par with the highest level of equipment. This collaborative approach to multimodality imaging in cardiology may benefit from artificial intelligence

COVID-19 BBIBP-CorV vaccine and transient heart block - A phenomenon by chance or a possible correlation - A case report

Importance: Bradyarrhythmia during COVID19 illness carries prognostic significance. Electrophysiological side effects of COVID19 vaccine remain largely unknown. It is imperative to report nature of cardiovascular side effects of the vaccine.Case presentation: An 80 years-old-man presented with complains of dizziness, trepidation and shortness of breath following his first shot of COVID-19 BBIBP-CorV (Sino-pharm). ECG on arrival showed 2:1 atrioventricular block with an underlying old left bundle branch block. The AV block changed into Mobitz type-I over the course of next 2 days and into a sinus 1:1 conduction on fourth day of presentation. However, our patient underwent permanent pacemaker implantation due to the underlying conduction tissue disease and intermittent 2:1 AV block during the hospital stay.Clinical discussion: It is likely that patients with an already diseased conduction system are at an increased risk of worsening of AV block following inoculation of the vaccine. Vaccine associated AV blocks are likely to be reversible. Presence of prior coronary artery disease and electrical abnormalities are important considerations.Conclusion: COVID-19 vaccine may have added side effects in subjects with known heart disease. Humoral response towards the vaccine might interfere with the conduction system of the heart and more so in patients with diseased and scarred myocardium