Abnormal Electrocardiogram, Echocardiogram, and Miscellaneous Imaging




Case 1



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A 30-year-old man with a history of deep vein thrombosis and pulmonary embolism came to the hospital with a complaint of left facial numbness for 5 days with associated hearing loss in the left ear and ataxia. Echocardiography was done, and the results are shown in Figure 10.1.1.




Figure 10.1.1


Echocardiography finding: Left ventricular thrombus.





Key Points




  • Thrombus in the left side of the heart is very dangerous because it can lead to stroke and systemic embolism.



  • Low ejection fraction, akinetic cardiac chambers, and hypercoagulable states can all lead to the occurrence of left ventricular (LV) thrombus.



  • Anticoagulation with warfarin is approved for treatment of LV thrombus. Novel oral anticoagulants are not yet approved for treatment of LV thrombus.





Case 2



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A 68-year-old woman with medical history of hypertension, diabetes mellitus, and obstructive airway disease came to the hospital with complaints of chest pain. ECG did not reveal ischemic changes. Troponins were negative, and acute coronary syndrome was ruled out. Echocardiography was done, and the results are shown in Figure 10.2.1.




Figure 10.2.1


Echocardiography with contrast finding: Dilated ballooned apex and hyper contractile base—Classical of Takosubo cardiomyopathy.





Key Points




  • Takotsubo cardiomyopathy, also called stress-induced cardiomyopathy, is characterized by regional systolic dysfunction.



  • In the most common form, there is ballooning and dilatation of the apex and hypercontractility of the base.



  • Takotsubo cardiomyopathy is believed to be caused by catecholamine-induced microvascular spasm.



  • It is a close mimicker of acute coronary syndrome.





Case 3



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A 38-year-old man with a medical history of end-stage renal disease who is currently on hemodialysis came to the emergency department with complaints of shortness of breath. ECG showed low-voltage complexes. Echocardiography was done, and the results are shown in Figure 10.3.1.




Figure 10.3.1


Echocardiogram finding: Picture showing moderate pericardial effusion, right ventricular diastolic collapse with evidence of cardiac tamponade.





Key Points




  • The Beck clinical triad in cardiac tamponade includes elevated jugular venous pulsation, muffled heart sounds, and low blood pressure.



  • ECG findings include low-voltage QRS complex, electrical alternans, and sinus tachycardia. However, these findings are nonspecific for cardiac tamponade.



  • Echocardiography findings include right atrial systolic collapse, right ventricular diastolic collapse, inferior vena cava plethora, and increased flow variation across mitral and tricuspid valves.





Case 4



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A 53-year-old woman with medical history of hypertension, diabetes mellitus, and chronic obstructive pulmonary disease came to the emergency department with severe shortness of breath for 1 day. ECG did not show any ischemic changes. Bedside echocardiography was done, and the results are shown in Figure 10.4.1.




Figure 10.4.1


Echocardiography finding: Positive Mc. Connell’s sign is seen in echo- cardiography.





Key Points




  • Mc Conell’s sign is characterized by akinesia of the mid free wall and hypercontractility of the apex.



  • It is a highly specific finding for pulmonary embolism but not as sensitive.





Case 5



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A 47-year-old woman with a medical history of hypertension, nonischemic cardiomyopathy, and status post aortic and mitral valve replacement 5 years ago came to the hospital with fever and shortness of breath. Echocardiography was done, and the results are shown in Figure 10.5.1.




Figure 10.5.1


Echocardiography finding: Large mobile mass which may be consistent with vegetation on noncoronary cusp.





Key Points




  • Patients with prosthetic heart valves are at high risk of developing infective endocarditis.



  • Early treatment of infective endocarditis is important to reduce morbidity and mortality.



  • Sensitivity of transthoracic echocardiography ranges from 40% to 63% for infective endocarditis and from 90% to 100% for transesophageal echocardiogrpahy.





Case 6



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A 28-year-old man with a medical history of asthma came to the hospital complaining of shortness of breath accompanied of retrosternal chest pain that was nonradiating. He rated the pain as 8/10 and indicated it was sudden in onset. He had unequal pulses in the extremities and had elevated blood pressure. CT of the chest was done, and the results are shown in Figures 10.6.1a, 10.6.1b.




Figure 10.6.1a


CT chest findings: Intimal flap is visible involving the ascending and proximal descending thoracic aorta consistent with a Stanford type A dissection.






Figure 10.6.1b


Echocardiogram findings: Aortic dissection flap in ascending aorta.





Key Points




  • In the CT scan, an intimal flap is seen separating a false lumen from a true lumen.



  • Sensitivity of transesophageal echocardiography (TEE) is as high as 98%, whereas specificity of TEE is 63% to 96%.



  • CT scan has a sensitivity of 83% to 95% and a specificity of 87% to 100% for the diagnosis of acute aortic dissection.





Case 7



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An 87-year-old woman was brought to the emergency department after she passed out at home. She had a device placed for the syncope. Identify the device in the chest x-ray in Figure 10.7.1.




Figure 10.7.1


X-ray finding: The above patient has dual chamber pacemaker with 2 leads with one in the right atrium and one in the right ventricle.





Key Points




  • Pacemakers consist of 2 components—a pulse generator and leads.



  • Pacemakers are most commonly placed in the prepectoral position and are connected to 1 or more endocardial leads transvenously.



  • In most pacemakers, leads are located in the endocardium, whereas in others, leads are located in the epicardium.


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Nov 19, 2019 | Posted by in CARDIOLOGY | Comments Off on Abnormal Electrocardiogram, Echocardiogram, and Miscellaneous Imaging
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