Unruptured non-coronary sinus of Valsalva aneurysm – case report

Introduction: Sinus of Valsalva aneurysm (SVA) is an abnormal dilatation of the aortic root located between the aortic valve annulus and the sinotubular junction. The estimated rate of SVA is approximately 0.09% of the general population and involve up to 3.5% of all congenital heart defects1. Aneurysm predominantly originates from the right coronary sinus and may rupture up to 35% of the time commonly to the right cardiac chambers2. We present an unusual case of a patient with SVA originating from the non-coronary sinus. Case report: 63-old-year male with no history of prior cardiovascular disease was presented to department with shortness of breath and chest pain. Physical examination showed blood pressure of 140/80mmHg, respiratory rate of 18/min and heart rate of 84 beats/min. Electrocardiogram revealed complete right bundle-branch block. A routine transthoracic echocardiography showed the enlargement of the left ventricle with large aneurysm originating from non-coronary sinus measuring 3.6x4cm. Echocardiography also revealed a trileaflet aortic valve with moderate aortic regurgitation and normal systolic function of the left ventricle. TEE demonstrated a non-coronary SAV protruding into the left atrium cavity with no signs of rupture. Selective angiography showed normal epicardial coronary arteries, and SAV with dilatation of ascending aorta measuring up to 40 mm. Moderate aortic insufficiency was also detected. The patient was referred to the cardiothoracic surgery ward for further operative treatment. Conclusion: Although rare, SAV can be a cause of sudden death. Therefore, a combination of transthoracic echocardiography with other imaging techniques, such as TEE, 3D echocardiography, CT angiography and aortic angiography is recommended to obtain comprehensive information and to improve diagnostic accuracy3

Percutaneous occlusion of malignant left atrial appendage in patient with recurrent ischemic stroke

Introduction: The left atrial appendage (LAA) is the most common place of thrombosis in patients with atrial fibrillation (AF). Numerous studies have shown that oral anticoagulation (OAC) significantly reduces the risk of thromboembolism. However, there are no recommendations regarding how to treat cardioembolic recurrent strokes when patients are well anticoagulated.1-3 Case report: 68-years-old male with permanent non-valvular AF, currently taking apixaban, was hospitalized for the second time due to recurrent ischemic cerebrovascular stroke. At the time of his first presentation six months ago, he was well anticoagulated with warfarin (international normalized ratio was 3.56) and have had a CHA2DS2VASc score 2. He had no significant carotid disease or mobile aortic arch atheroma. Transesophageal echocardiography (TEE) revealed a significantly dilated left atrium (LA) with dense spontaneous echo contrast (SEC). There was no organized thrombus in the LA nor in the LAA. The contractile function of the LAA was severely decreased, with peak systolic velocity of 33 cm/s on Doppler evaluation. Despite taking effective anticoagulant medications for both times our patient experienced recurrent ischemic stroke and yet again had dense SEC in the LA and LAA. In order to prevent upcoming cardioembolic event, we decided to preform percutaneous LAA closure with Amplatzer Amulet device under TEE guidance. Successful LAA closure was confirmed by color Doppler imaging and a single postocclusion angiography. The patient was discharged with OAC (warfarin) in addition of 100 mg/day of acetylsalicylic acid to prevent thrombus formation on device. Follow up TEE was performed one month after the procedure. Good position of LAA occluding device was confirmed with no evidence of thrombus formation on the left atrial face of the device. Conclusion: In general, after implantation of LAA occluding device, OAC is not indicated. However, combination therapy with indefinite OAC plus LAA closure in patients with AF with recurrent strokes despite good anticoagulation should be considered in order to prevent a new stroke

Influence of compressed air diving on pulmonary alveocapillary membrane and right ventricular systolic function

Promjena obrazaca disanja u obliku porasta respiratorne brzine do pretjerane hiperventilacije često se pojavljuje tijekom i nakon SCUBA ronjenja. Povezana je s preopterećenjem pluća intersticijskom i alveolarnom tekućinom. Također je poznata pojavnost cirkulirajućih venskih plinskih mjehurića (VPM) u ronilaca i njihov utjecaj na plućnu funkciju, porast plućnog arterijskog tlaka (PAT-a) i hemodinamiku desne klijetke (DK). Ova studija je provedena radi procjene učinkovitosti disanja nakon ronjenja i utvrđivanja povezanosti promjena disanja s oštećenjem alveokapilarne membrane. Drugi cilj našeg istraživanja bio je procijeniti moguće učinke zarona na funkciju DK-a pomoću dvodimenzionalne (2D) "Speckle tracking" ehokardiografije kao nove slikovne metode. Ispitivanje je provedeno na 12 profesionalnih muških ronilaca (39,5 ± 10,5 godina), a ronjenje se sastojalo od jednog brzog urona u morsku vodu do 18 metara dubine, trajanja 47 minuta i izravnog uspona na površinu. Analizirana je učinkovitost ventilacije (VE/VCO2) tijekom maksimalnog spiroergometrijskog testa prije i dva sata nakon standardnog protokola ronjenja. Nadalje, u razdoblju 30 minuta od izrona, ispitanici su podvrgnuti uzimanju uzoraka krvi za određivanje proteina surfaktanta (SPs). U razdobljima 30, 60, 90 i 120 minuta od izrona, učinjen je ultrazvuk pluća zbog detektiranja ultrazvučnih kometa (UK). U istim intervalima rađen je i ultrazvuk srca zbog detekcije VPM-a, procjene srednjeg plućnog arterijskog tlaka (sPAT) i procjene sistoličke funkcije srca s fokusom na DK-a. Ehokardiografski je praćen novi pokazatelj sistoličke funkcije DK-a, odnosno, mjerena je dvodimenzionalna longitudinalna deformacija slobodne stijenke DK (2D GLS) uz uobičajene ehokardiografske pokazatelje sistoličke funkcije DK-a: amplituda sistoličkog pomaka trikuspidalnog prstena (TAPSE), vršna sistolička brzina lateralnog trikuspidalnog prstena (RV S`) i promjena frakcije površine (FAC). Spiroergometrijsko testiranje je pokazalo očuvanu funkcionalnu sposobnost i učinak vježbanja, ali s povećanjem VE/VCO2, tj. smanjenjem učinkovitosti disanja nakon ronjenja (21,4 ± 2,9 prema 22,9 ± 3,3, p < 0,05). Zreli SP-B se povećao za 13 % dok su ostali SP-i bili nepromijenjeni. Ultrazvučne plućne komete (UK) i VPM bili su značajno prisutni u prvoj evaluaciji nakon ronjenja sa značajnom, progresivnom, ali ne i potpunom, redukcijom nakon 120 min. po izronu. Srednji plućni arterijski tlak (sPAT) povećao se nakon ronjenja sa 13,3 mmHg na maksimalno 23,5 mmHg (p = 0,002), što ukazuje na porast opterećenja DK-a nakon ronjenja. Utvrđen je porast sistoličke funkcije lateralne stijenke zida DK-a, tj. 2D GLS s početnih -24,26 % na -28,44 % (p = 0,003) i to u sva tri segmenta uz porast 26 % (bazalno), 15,4 % (medijalno) i 16,3 % (apikalno), a što su potvrdili i standardni pokazatelji sistoličke funkcije DK: TAPSE (11,6 %), RV FAC (19,2 %), RV S' (12,7 %). Ispitivanjem smo pokazali da se nakon jednog zarona nakupila intersticijska i alveolarna tekućina u plućima sa smanjenom učinkovitosti ventilacije. Selektivan porast samo zrelog oblika SP-B moguće predstavlja funkcionalno oštećenje alveokapilarne membrane. Naši rezultati su pokazali da uz značajni porast VPM-a u srcu i UK-a u plućima raste PAT i opterećenje DK-a, na koje srce odgovara porastom sistoličke funkcije i longitudinalne deformacije DK-a kao mogućim kompenzatornim mehanizmom.Changing breathing patterns in the form of increased respiratory rate to excessive hyperventilation often occurs during and after SCUBA diving and is associated with overloading the lung with interstitial and alveolar fluid. Also known is the occurrence of circulating venous gas embolism (VGE) in diver and their effect on pulmonary function, pulmonary arterial pressure (PAP) and hemodynamics of the right ventricle (RV). This study was conducted to assess the effectiveness of breathing after diving and to establish the association of respiratory changes with damage to the alveolocapillary membrane. Another aim of our study was to evaluate the potential effects of dive on RV function using two-dimensional (2D) "Speckle tracking" echocardiography as new image method. The survey was carried out on 12 professional male divers (39,5 ± 10,5 years), and diving consisted of one fast dive in sea water up to 18 meters deep, 47 minutes duration and direct rises to the surface. Ventilation efficiency (VE/VCO2) was analyzed during the maximum spiroergometric test two and a half hours after the standard diving protocol. Furthermore, within 30 minutes of the ascend, subjects were subjected to blood samples for surfactant protein (SPs) determination. In the 30, 60, 90 and 120 minutes after ascend, ultrasonography was performed for the detection of ultrasound lung comets (ULC). At the same intervals, cardiac ultrasound was performed for VGE detection, mean pulmonary arterial pressure (m PAP) measurement and heart systolic estimation with RV focus. Echocardiographic measurements were performed of a new indicator of the systolic function of the RV, two-dimensional longitudinal deformation of the free wall RV (2D GLS) with the usual echocardiographic indicators of the systolic function of the RV: systolic shift of tricuspid ring (TAPSE), peak systolic velocity of the lateral tricuspid ring (RV S') and fractional area change (FAC). Spiroergometric testing has shown conserved functional ability and exercise effect but with increased VE/VCO2 and decreased breathing efficiency after diving (21.4 ± 2.9 vs. 22.9 ± 3.3, p < 0.05). The mature SP-B increased 13 % while the other SPs were unchanged. The ultrasound long comets (ULC) and VGE were significantly present in the first evaluation after diving with a significant, progressive but not complete reduction after 120 min. The mean pulmonary arterial pressure (mPAP) increased after diving from 13.3 mmHg to a maximum of 23.5 mmHg (p = 0.002), indicating an increase in RV load after diving. The increase of the systolic function of the RV lateral wall, 2D GLS from the initial -24.26 % to -28.44 % (p = 0.003), was established in all three segments with an increase of 26 % (basal), 15.4 % ( medial) and 16.3 % (apical), as confirmed by standard echocardiographic indicators: TAPSE (11.6 %), RV FAC (19.2 %), RV S' (12.7 %). In conclusion, we showed that after one dive there was an accumulation of interstitial and alveolar fluid in the lungs with reduced ventilation efficiency. Selective growth of only one form of SP-B indicates possible functional damage of the alveo-capillary membrane. Our results showed that with significant increases in VGE in the heart and the UK in the lungs increase PAP and the load of RV, with increased systolic function and longitudinal deformation of RV as possible compensatory mechanism

Influence of compressed air diving on pulmonary alveocapillary membrane and right ventricular systolic function

Promjena obrazaca disanja u obliku porasta respiratorne brzine do pretjerane hiperventilacije često se pojavljuje tijekom i nakon SCUBA ronjenja. Povezana je s preopterećenjem pluća intersticijskom i alveolarnom tekućinom. Također je poznata pojavnost cirkulirajućih venskih plinskih mjehurića (VPM) u ronilaca i njihov utjecaj na plućnu funkciju, porast plućnog arterijskog tlaka (PAT-a) i hemodinamiku desne klijetke (DK). Ova studija je provedena radi procjene učinkovitosti disanja nakon ronjenja i utvrđivanja povezanosti promjena disanja s oštećenjem alveokapilarne membrane. Drugi cilj našeg istraživanja bio je procijeniti moguće učinke zarona na funkciju DK-a pomoću dvodimenzionalne (2D) "Speckle tracking" ehokardiografije kao nove slikovne metode. Ispitivanje je provedeno na 12 profesionalnih muških ronilaca (39,5 ± 10,5 godina), a ronjenje se sastojalo od jednog brzog urona u morsku vodu do 18 metara dubine, trajanja 47 minuta i izravnog uspona na površinu. Analizirana je učinkovitost ventilacije (VE/VCO2) tijekom maksimalnog spiroergometrijskog testa prije i dva sata nakon standardnog protokola ronjenja. Nadalje, u razdoblju 30 minuta od izrona, ispitanici su podvrgnuti uzimanju uzoraka krvi za određivanje proteina surfaktanta (SPs). U razdobljima 30, 60, 90 i 120 minuta od izrona, učinjen je ultrazvuk pluća zbog detektiranja ultrazvučnih kometa (UK). U istim intervalima rađen je i ultrazvuk srca zbog detekcije VPM-a, procjene srednjeg plućnog arterijskog tlaka (sPAT) i procjene sistoličke funkcije srca s fokusom na DK-a. Ehokardiografski je praćen novi pokazatelj sistoličke funkcije DK-a, odnosno, mjerena je dvodimenzionalna longitudinalna deformacija slobodne stijenke DK (2D GLS) uz uobičajene ehokardiografske pokazatelje sistoličke funkcije DK-a: amplituda sistoličkog pomaka trikuspidalnog prstena (TAPSE), vršna sistolička brzina lateralnog trikuspidalnog prstena (RV S`) i promjena frakcije površine (FAC). Spiroergometrijsko testiranje je pokazalo očuvanu funkcionalnu sposobnost i učinak vježbanja, ali s povećanjem VE/VCO2, tj. smanjenjem učinkovitosti disanja nakon ronjenja (21,4 ± 2,9 prema 22,9 ± 3,3, p < 0,05). Zreli SP-B se povećao za 13 % dok su ostali SP-i bili nepromijenjeni. Ultrazvučne plućne komete (UK) i VPM bili su značajno prisutni u prvoj evaluaciji nakon ronjenja sa značajnom, progresivnom, ali ne i potpunom, redukcijom nakon 120 min. po izronu. Srednji plućni arterijski tlak (sPAT) povećao se nakon ronjenja sa 13,3 mmHg na maksimalno 23,5 mmHg (p = 0,002), što ukazuje na porast opterećenja DK-a nakon ronjenja. Utvrđen je porast sistoličke funkcije lateralne stijenke zida DK-a, tj. 2D GLS s početnih -24,26 % na -28,44 % (p = 0,003) i to u sva tri segmenta uz porast 26 % (bazalno), 15,4 % (medijalno) i 16,3 % (apikalno), a što su potvrdili i standardni pokazatelji sistoličke funkcije DK: TAPSE (11,6 %), RV FAC (19,2 %), RV S' (12,7 %). Ispitivanjem smo pokazali da se nakon jednog zarona nakupila intersticijska i alveolarna tekućina u plućima sa smanjenom učinkovitosti ventilacije. Selektivan porast samo zrelog oblika SP-B moguće predstavlja funkcionalno oštećenje alveokapilarne membrane. Naši rezultati su pokazali da uz značajni porast VPM-a u srcu i UK-a u plućima raste PAT i opterećenje DK-a, na koje srce odgovara porastom sistoličke funkcije i longitudinalne deformacije DK-a kao mogućim kompenzatornim mehanizmom.Changing breathing patterns in the form of increased respiratory rate to excessive hyperventilation often occurs during and after SCUBA diving and is associated with overloading the lung with interstitial and alveolar fluid. Also known is the occurrence of circulating venous gas embolism (VGE) in diver and their effect on pulmonary function, pulmonary arterial pressure (PAP) and hemodynamics of the right ventricle (RV). This study was conducted to assess the effectiveness of breathing after diving and to establish the association of respiratory changes with damage to the alveolocapillary membrane. Another aim of our study was to evaluate the potential effects of dive on RV function using two-dimensional (2D) "Speckle tracking" echocardiography as new image method. The survey was carried out on 12 professional male divers (39,5 ± 10,5 years), and diving consisted of one fast dive in sea water up to 18 meters deep, 47 minutes duration and direct rises to the surface. Ventilation efficiency (VE/VCO2) was analyzed during the maximum spiroergometric test two and a half hours after the standard diving protocol. Furthermore, within 30 minutes of the ascend, subjects were subjected to blood samples for surfactant protein (SPs) determination. In the 30, 60, 90 and 120 minutes after ascend, ultrasonography was performed for the detection of ultrasound lung comets (ULC). At the same intervals, cardiac ultrasound was performed for VGE detection, mean pulmonary arterial pressure (m PAP) measurement and heart systolic estimation with RV focus. Echocardiographic measurements were performed of a new indicator of the systolic function of the RV, two-dimensional longitudinal deformation of the free wall RV (2D GLS) with the usual echocardiographic indicators of the systolic function of the RV: systolic shift of tricuspid ring (TAPSE), peak systolic velocity of the lateral tricuspid ring (RV S') and fractional area change (FAC). Spiroergometric testing has shown conserved functional ability and exercise effect but with increased VE/VCO2 and decreased breathing efficiency after diving (21.4 ± 2.9 vs. 22.9 ± 3.3, p < 0.05). The mature SP-B increased 13 % while the other SPs were unchanged. The ultrasound long comets (ULC) and VGE were significantly present in the first evaluation after diving with a significant, progressive but not complete reduction after 120 min. The mean pulmonary arterial pressure (mPAP) increased after diving from 13.3 mmHg to a maximum of 23.5 mmHg (p = 0.002), indicating an increase in RV load after diving. The increase of the systolic function of the RV lateral wall, 2D GLS from the initial -24.26 % to -28.44 % (p = 0.003), was established in all three segments with an increase of 26 % (basal), 15.4 % ( medial) and 16.3 % (apical), as confirmed by standard echocardiographic indicators: TAPSE (11.6 %), RV FAC (19.2 %), RV S' (12.7 %). In conclusion, we showed that after one dive there was an accumulation of interstitial and alveolar fluid in the lungs with reduced ventilation efficiency. Selective growth of only one form of SP-B indicates possible functional damage of the alveo-capillary membrane. Our results showed that with significant increases in VGE in the heart and the UK in the lungs increase PAP and the load of RV, with increased systolic function and longitudinal deformation of RV as possible compensatory mechanism

Influence of compressed air diving on pulmonary alveocapillary membrane and right ventricular systolic function

Promjena obrazaca disanja u obliku porasta respiratorne brzine do pretjerane hiperventilacije često se pojavljuje tijekom i nakon SCUBA ronjenja. Povezana je s preopterećenjem pluća intersticijskom i alveolarnom tekućinom. Također je poznata pojavnost cirkulirajućih venskih plinskih mjehurića (VPM) u ronilaca i njihov utjecaj na plućnu funkciju, porast plućnog arterijskog tlaka (PAT-a) i hemodinamiku desne klijetke (DK). Ova studija je provedena radi procjene učinkovitosti disanja nakon ronjenja i utvrđivanja povezanosti promjena disanja s oštećenjem alveokapilarne membrane. Drugi cilj našeg istraživanja bio je procijeniti moguće učinke zarona na funkciju DK-a pomoću dvodimenzionalne (2D) "Speckle tracking" ehokardiografije kao nove slikovne metode. Ispitivanje je provedeno na 12 profesionalnih muških ronilaca (39,5 ± 10,5 godina), a ronjenje se sastojalo od jednog brzog urona u morsku vodu do 18 metara dubine, trajanja 47 minuta i izravnog uspona na površinu. Analizirana je učinkovitost ventilacije (VE/VCO2) tijekom maksimalnog spiroergometrijskog testa prije i dva sata nakon standardnog protokola ronjenja. Nadalje, u razdoblju 30 minuta od izrona, ispitanici su podvrgnuti uzimanju uzoraka krvi za određivanje proteina surfaktanta (SPs). U razdobljima 30, 60, 90 i 120 minuta od izrona, učinjen je ultrazvuk pluća zbog detektiranja ultrazvučnih kometa (UK). U istim intervalima rađen je i ultrazvuk srca zbog detekcije VPM-a, procjene srednjeg plućnog arterijskog tlaka (sPAT) i procjene sistoličke funkcije srca s fokusom na DK-a. Ehokardiografski je praćen novi pokazatelj sistoličke funkcije DK-a, odnosno, mjerena je dvodimenzionalna longitudinalna deformacija slobodne stijenke DK (2D GLS) uz uobičajene ehokardiografske pokazatelje sistoličke funkcije DK-a: amplituda sistoličkog pomaka trikuspidalnog prstena (TAPSE), vršna sistolička brzina lateralnog trikuspidalnog prstena (RV S`) i promjena frakcije površine (FAC). Spiroergometrijsko testiranje je pokazalo očuvanu funkcionalnu sposobnost i učinak vježbanja, ali s povećanjem VE/VCO2, tj. smanjenjem učinkovitosti disanja nakon ronjenja (21,4 ± 2,9 prema 22,9 ± 3,3, p < 0,05). Zreli SP-B se povećao za 13 % dok su ostali SP-i bili nepromijenjeni. Ultrazvučne plućne komete (UK) i VPM bili su značajno prisutni u prvoj evaluaciji nakon ronjenja sa značajnom, progresivnom, ali ne i potpunom, redukcijom nakon 120 min. po izronu. Srednji plućni arterijski tlak (sPAT) povećao se nakon ronjenja sa 13,3 mmHg na maksimalno 23,5 mmHg (p = 0,002), što ukazuje na porast opterećenja DK-a nakon ronjenja. Utvrđen je porast sistoličke funkcije lateralne stijenke zida DK-a, tj. 2D GLS s početnih -24,26 % na -28,44 % (p = 0,003) i to u sva tri segmenta uz porast 26 % (bazalno), 15,4 % (medijalno) i 16,3 % (apikalno), a što su potvrdili i standardni pokazatelji sistoličke funkcije DK: TAPSE (11,6 %), RV FAC (19,2 %), RV S' (12,7 %). Ispitivanjem smo pokazali da se nakon jednog zarona nakupila intersticijska i alveolarna tekućina u plućima sa smanjenom učinkovitosti ventilacije. Selektivan porast samo zrelog oblika SP-B moguće predstavlja funkcionalno oštećenje alveokapilarne membrane. Naši rezultati su pokazali da uz značajni porast VPM-a u srcu i UK-a u plućima raste PAT i opterećenje DK-a, na koje srce odgovara porastom sistoličke funkcije i longitudinalne deformacije DK-a kao mogućim kompenzatornim mehanizmom.Changing breathing patterns in the form of increased respiratory rate to excessive hyperventilation often occurs during and after SCUBA diving and is associated with overloading the lung with interstitial and alveolar fluid. Also known is the occurrence of circulating venous gas embolism (VGE) in diver and their effect on pulmonary function, pulmonary arterial pressure (PAP) and hemodynamics of the right ventricle (RV). This study was conducted to assess the effectiveness of breathing after diving and to establish the association of respiratory changes with damage to the alveolocapillary membrane. Another aim of our study was to evaluate the potential effects of dive on RV function using two-dimensional (2D) "Speckle tracking" echocardiography as new image method. The survey was carried out on 12 professional male divers (39,5 ± 10,5 years), and diving consisted of one fast dive in sea water up to 18 meters deep, 47 minutes duration and direct rises to the surface. Ventilation efficiency (VE/VCO2) was analyzed during the maximum spiroergometric test two and a half hours after the standard diving protocol. Furthermore, within 30 minutes of the ascend, subjects were subjected to blood samples for surfactant protein (SPs) determination. In the 30, 60, 90 and 120 minutes after ascend, ultrasonography was performed for the detection of ultrasound lung comets (ULC). At the same intervals, cardiac ultrasound was performed for VGE detection, mean pulmonary arterial pressure (m PAP) measurement and heart systolic estimation with RV focus. Echocardiographic measurements were performed of a new indicator of the systolic function of the RV, two-dimensional longitudinal deformation of the free wall RV (2D GLS) with the usual echocardiographic indicators of the systolic function of the RV: systolic shift of tricuspid ring (TAPSE), peak systolic velocity of the lateral tricuspid ring (RV S') and fractional area change (FAC). Spiroergometric testing has shown conserved functional ability and exercise effect but with increased VE/VCO2 and decreased breathing efficiency after diving (21.4 ± 2.9 vs. 22.9 ± 3.3, p < 0.05). The mature SP-B increased 13 % while the other SPs were unchanged. The ultrasound long comets (ULC) and VGE were significantly present in the first evaluation after diving with a significant, progressive but not complete reduction after 120 min. The mean pulmonary arterial pressure (mPAP) increased after diving from 13.3 mmHg to a maximum of 23.5 mmHg (p = 0.002), indicating an increase in RV load after diving. The increase of the systolic function of the RV lateral wall, 2D GLS from the initial -24.26 % to -28.44 % (p = 0.003), was established in all three segments with an increase of 26 % (basal), 15.4 % ( medial) and 16.3 % (apical), as confirmed by standard echocardiographic indicators: TAPSE (11.6 %), RV FAC (19.2 %), RV S' (12.7 %). In conclusion, we showed that after one dive there was an accumulation of interstitial and alveolar fluid in the lungs with reduced ventilation efficiency. Selective growth of only one form of SP-B indicates possible functional damage of the alveo-capillary membrane. Our results showed that with significant increases in VGE in the heart and the UK in the lungs increase PAP and the load of RV, with increased systolic function and longitudinal deformation of RV as possible compensatory mechanism

Atypical presentation of thrombosis of a permanent pacemaker lead

Pacemaker related infective endocarditis (PMIE) and pacemaker lead thrombosis (PMLT) are infrequent but potentially lethal complications of pacemaker (PM) therapy. Differences in clinical presentation, echocardiographic appearance and laboratory findings are usually helpful in making a confident diagnosis. On the other hand, atypical clinical and echocardiographic findings may complicate their differentiation and result in a therapeutic dilemma. We present a 70-year-old man with a permanent PM hospitalized because of a 7-day history of fever and weakness. Elevated inflammatory parameters and atypical echocardiographic findings resulted in a diagnostic dilemma between PMIE and PMLT. In this paper, we discuss the pathogenesis of these entities, their clinical presentation and therapy