Myositis Ossificans: A Mimicker of an Intramuscular Tumour

Teaching point: Myositis ossificans is a do not touch lesion of which the radiological findings can be misleading in the early stages due to possible features mimicking a malignant process

Cardioversion of persistent atrial fibrillation is associated with a 24-hour relapse gap:Observations from prolonged postcardioversion rhythm monitoring

BackgroundMany recurrences occur after electrical cardioversion (ECV) of atrial fibrillation (AF). Assessment of extent of remodeling and continuous prolonged rhythm monitoring might reveal actionable recurrence mechanisms. HypothesisAfter ECV of AF specific patterns of arrhythmia recurrence can be distinguished. MethodsAll patients who underwent successful ECV due to persistent AF were included. Tissue velocity echocardiography during AF was performed before ECV to study atrial fibrillatory cycle length and fibrillatory velocity. After ECV, the heart rhythm of all patients was monitored 3 times daily during 4weeks, and timing of recurrence was noted. ResultsIn total, 50 patients (68% male) were included; mean age was 689years. Median duration of the current AF episode was 102 (range, 74-152) days. Twenty-one (42%) patients showed recurrence of persistent AF. No recurrences occurred during the first 24hours. There were no differences in clinical characteristics between patients with or without recurrence of AF. However, patients with early recurrence of AF had significantly higher precardioversion wall-motion velocity compared with patients who remained in sinus rhythm (2.8 [1.6-3.6] vs 1.4 [0.9-3.3] cm/s; P=0.017), whereas atrial fibrillatory cycle length did not differ. ConclusionsIn this study on 50 patients successfully cardioverted for persistent AF, there was a relapse gap of 24hours. This phenomenon has not been well appreciated before and offers an AF-free window of opportunity for electrocardiographically triggered cardiac imaging or complex electrophysiological procedures. Echocardiographic tissue velocity imaging may visualize atrial remodeling relevant to AF recurrence

Tissue velocity imaging of the left atrium predicts response to flecainide in patients with acute atrial fibrillation

BACKGROUND Acute atrial fibrillation (AF) is often treated with the administration of intravenous flecainide; however, this treatment may not always be successful and is potentially hazardous. Previous studies suggest that electro-echocardiographic tissue velocity imaging (TVI) of the atrial wall may reflect atrial remodeling. OBJECTIVE To study whether atrial TVI can be used to identify nonresponders of flecainide administered intravenously in patients with acute AF. METHODS We used atrial TVI to measure atrial fibrillatory cycle Length determined by using tissue velocity imaging (AFCL-TVI) and atrial fibrillatory wall motion velocity determined by using tissue velocity imaging (AFV-TVI) in the left atrium in 52 (55%) patients presenting with acute AF in the emergency department. These 2 parameters reflect electrical and structural remodeling, respectively. Standard baseline characteristics were recorded. RESULTS Patients were predominantly men (76%) and 64 7 11 years old. Thirty-six (69%) patients had successful cardioversion after flecainide infusion. There were no significant differences in baseline characteristics between responders and nonresponders. Patients with a successful cardioversion had a longer mean AFCL-TVI and higher median (interquartile range) AFV-TVI compared with patients with failed cardioversion: 172 L- 29 ms vs 137 L- 35 ms (P CONCLUSIONS Electro-echocardiographic atrial TVI measurement is a promising noninvasive tool for predicting outcome of pharmacological cardioversion. A short AFCL-TVI and a low AFV-TVI are related to failure of cardioversion of AF using flecainide. tj (C) 2014 Heart Rhythm Society. All rights reserved

Poor anticoagulation relates to extended access times for cardioversion and is associated with long-term major cardiac and cerebrovascular events

AbstractBackgroundPatients undergoing elective electrical cardioversion (ECV) for atrial fibrillation have a temporarily increased risk of thromboembolism. Current guidelines recommend adequate anticoagulation for ≥3 consecutive weeks precardioversion, i.e. consecutive INR values 2.0–3.0 in patients with vitamin K antagonists (VKA). We aimed to evaluate the occurrence and impact of subtherapeutic INRs precardioversion and to study factors associated with these unwanted fluctuations.MethodsWe recruited 346 consecutive patients undergoing elective ECV in the Maastricht University Medical Centre between 2008 and 2013. Predictors of subtherapeutic INR values were identified and incorporated into a logistic regression model.ResultsA subtherapeutic INR precardioversion occurred in 55.2% of patients. The only statistically significant predictor was VKA-naivety (Odds Ratio (OR) 4.78, 95% Confidence Interval (CI) 2.67–8.58, p<0.001). In patients with ≥1 subtherapeutic INR precardioversion, time from referral until cardioversion was 91.1±42.8days, compared to 41.7±26.6days (p<0.001) in patients without subtherapeutic INRs.No thromboembolic events occurred <30days after the ECV. Independent predictors for the combined endpoint of cardiovascular death, ischemic stroke and the need of blood transfusion (n=30, median follow-up of 374days) were coronary artery disease in the history (OR 3.35, 95%CI 1.54–7.25, p=0.002) and subtherapeutic INR precardioversion (OR 3.64, 95%CI 1.43–9.24, p=0.007).ConclusionsThe use of VKA often results in subtherapeutic INRs precardioversion and is associated with a significant delay until cardioversion, especially in patients with recent initiation of VKA therapy. Furthermore, subtherapeutic INR levels prior to ECV are associated with the combined endpoint of cardiovascular death, ischemic stroke and the need of blood transfusion