Fibrosing Mediastinitis Causing High Degree AV Block in a Young Female Patient

A 30-year-old woman presented with presyncopal episodes and was found to have high degree atrioventricular block. Computed tomography imaging demonstrated pericardial thickening extending from the main pulmonary artery to the aortic cusps. Here we present a rare case of fibrosing mediastinitis causing high-degree atrioventricular block. (Level of Difficulty: Intermediate.).

Cystic Tumor of the Atrioventricular Node Causing Rapid-Onset and Reversible Complete Heart Block

Cystic tumors of the atrioventricular node are rare primary cardiac neoplasms, frequently reported as a postmortem diagnosis during autopsy. Despite their small size, they can present with complete heart block or sudden cardiac death. Herein, we present a case of rapidly progressing high-grade atrioventricular block that improved after surgery. (Level of Difficulty: Intermediate.).

Ventriculoatrial Block and His-His Changes During Supraventricular Tachycardia: Diagnostic and Mechanistic Implications

Supraventricular tachycardia (SVT) with ventriculoatrial (VA) block can represent a diagnostic challenge. We present a case of SVT where His-His interval shortening was repeatedly observed during episodes of VA block. This novel observation is more diagnostically suggestive of atrioventricular nodal re-entrant tachycardia, as opposed to orthodromic re-entry using a nodofascicular or nodoventricular pathway where a constant His-His is recorded during episodes of VA block. (Level of Difficulty: Intermediate.).

Narrow Complex Tachycardia With Intermittent 2:1 Atrioventricular Relationship

Narrow QRS complex tachycardia has a broad differential diagnosis. We present a series of rhythm strips with representative onset, transition from 2:1 AV conduction to 1:1 AV conduction, and offset of tachycardia. By analyzing these rhythm strips, we can identify the electrophysiologic mechanism and diagnosis. (Level of Difficulty: Intermediate.).

Left ventricular vortex analysis by high-frame rate blood speckle tracking echocardiography in healthy children and in congenital heart disease

Background

High-frame rate blood speckle tracking (BST) echocardiography is a new technique for the assessment of intracardiac flow. The purpose of this study was to evaluate the characteristics of left ventricular (LV) vortices in healthy children and in those with congenital heart disease (CHD).

Methods

Characteristics of LV vortices were analyses based on 4-chamber BST images from 118 healthy children (median age 6.84 years, range 0.01-17 years) and 43 children with CHD (median age 0.99 years, range 0.01-14 years). Both groups were compared after propensity matching. Multiple linear regression was used to identify factors that independently influence vortex characteristics.

Results

Feasibility of vortex imaging was 93.7% for healthy children and 95.6% for CHD. After propensity matching, there were no overall significant differences in vortex distance to apex, distance to interventricular septum (IVS), height, width, sphericity index, or area. However, multiple regression analysis revealed significant associations of LV morphology with vortex characteristics. Furthermore, CHD involving LV volume overload and CHD involving LV pressure overload were both associated with vortices localized closer to the IVS.

Conclusions

LV vortex analysis using high-frame rate BST echocardiography is feasible in healthy children and in those with CHD. As they are associated with LV morphology and are modified in some types of CHD, vortices might yield diagnostic and prognostic value. Future studies are warranted to establish applications of vortex imaging in the clinical setting.

ECG in an Athlete With Syncope: Innocuous Incomplete Right Bundle Branch Block or Brugada Pattern?

Abnormalities of an athlete's electrocardiogram may be the result of an underlying heart disease and may carry a risk of sudden death. It is important that electrocardiographic abnormalities are correctly distinguished. We present the case of a young marathon athlete presenting with syncope and incomplete right bundle block pattern suggestive of a type 2 Brugada pattern. (Level of Difficulty: Advanced.).

Epicardial Connections as Intra-Atrial Conduction Routes in a Patient With Advanced Atrial Remodeling

In a patient with long-standing persistent atrial fibrillation, elimination of an epicardial connection between the right-sided pulmonary venous carina and the right atrium during catheter ablation resulted in intra-atrial conduction injuries in the presence of advanced atrial remodeling. (Level of Difficulty: Advanced.).

Electrophysiological Manifestations of Cardiac Amyloidosis: JACC: CardioOncology State-of-the-Art Review

Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy caused by the extracellular deposition of amyloid fibrils in the myocardium. Although cardiac amyloidosis patients primarily present with heart failure symptoms, arrhythmias and conduction system disease are frequently encountered. Atrial fibrillation (AF) is observed in up to 70% of patients at the time of diagnosis, and patients typically have controlled ventricular rates caused by concomitant conduction system disease. Thromboembolic risk is particularly high in patients with CA and AF, and left atrial thrombi have been observed even in the absence of clinically diagnosed AF. Atrioventricular nodal and infra-Hisian disease are common, and permanent pacemakers are frequently required. The use of implantable cardioverter-defibrillators in this population is controversial. This review summarizes the published data and therapeutic strategies surrounding arrhythmias and conduction system disease with the goal of aiding clinicians managing the clinical complexities of CA.

Acute Coronary Syndrome Requiring Coronary Artery Bypass Grafting in a Patient With Sotos Syndrome

Sotos syndrome, characterized by cerebral gigantism with neurologic disorders, is an overgrowth syndrome caused by mutations of the NSD1 gene, with an estimated prevalence of 1:10,000-1:50,000. We herein describe the first case of Sotos syndrome complicated by acute coronary syndrome, for which emergency coronary artery bypass grafting was performed. (Level of Difficulty: Intermediate.)

Patient With Presyncope and Variable PR Interval and QRS Morphology

We describe the case of a 72-year-old female patient, presenting with presyncope and variable PR Interval and changing QRS morphology on the electrocardiogram. Differential diagnosis is discussed. (Level of Difficulty: Beginner.).

Chest Pain and Hemodynamic Instability in a Young Woman

We report the case of an 18-year-old female admitted to the hospital for severe hemodynamic instability and fatal outcome within 6 hours following admission. Significant electrocardiographic modifications were noted and are presented with diagnostic options. (Level of Difficulty: Intermediate.)

Wide Complex Tachycardia in Patient With Cardiac Device

Electrocardiographic clues for a differential diagnosis of wide complex tachycardia in a patient with a pacemaker are presented. (Level of Difficulty: Intermediate.).

Heart Block in Unpalliated Complex Adult Congenital Heart Disease: Massive Collateral Burden Precludes Epicardial Pacemaker

Complete heart block is a common complication for adults with congenital heart disease (CHD). Epicardial pacing is preferred in patients with septal shunting due to risk of thromboembolism. Anatomic changes in complex CHD may preclude surgical epicardial lead placement. Thromboembolism risk reduction in such patients requiring endocardial pacing remains questionable. (Level of Difficulty: Advanced.)

Epicardial Ablation of Persistent Junctional Reciprocating Tachycardia in an Infant With Tachycardia-Induced Cardiomyopathy

A 3-month-old infant who developed persistent junctional reciprocating tachycardia (PJRT)–induced cardiomyopathy that was successfully treated with radiofrequency ablation. To our knowledge this is the youngest reported patient with a successful epicardial lesion placed in a diverticulum off the coronary sinus and also the first report of a PJRT connection located at an epicardial site distinct from the mitral and tricuspid valve annulus. We use this case to highlight how low-power lesions in the coronary sinus in the youngest of patients can achieve results safely. (Level of Difficulty: Advanced.)

Catheter-Based Cardio-Neural Ablation for Refractory Vasovagal Syncope: First U.S. Report

We highlight the feasibility and efficacy of a new application for catheter ablation to target atrial ganglionated plexi in a patient with refractory vasovagal syncope. We describe a physiologically guided technique and demonstrate 18-month freedom from syncope with 2 tilt-table tests to objectively assess reproducible elimination of symptomatology and underlying pathophysiology. (Level of Difficulty: Beginner.)

Supraventricular Tachycardia in Situs Inversus Totalis and Congenitally Corrected Transposition of the Great Arteries

We share a rare case of an older adult patient with situs inversus totalis (mirror image of all viscera, including dextrocardia) and congenitally corrected transposition of the great arteries who presented with supraventricular tachycardia. We highlight the unique electrocardiographic characteristics of these rare conditions and the importance of electrocardiogram interpretation skills. (Level of Difficulty: Advanced.)

Cardiac Sarcoidosis With Prominent Epsilon Waves: A Perfect Phenocopy of ARVC

Cardiac sarcoidosis (CS) overlaps in clinical presentation with arrhythmogenic right ventricular cardiomyopathy and shares phenotypic classification, including the presence of epsilon waves. The presence of conduction disease is seen exclusively in CS, as an important phenotypic difference. We present a case of ventricular tachycardia and epsilon waves due to CS, without conduction disease. (Level of Difficulty: Intermediate.).

Pacemaker Treatment for Apical Hypertrophic Cardiomyopathy in the Setting of an Apical Ventricular Aneurysm

We describe the case of a patient with apical hypertrophic cardiomyopathy with concomitant apical aneurysm. We measured the aneurysmal cavity pressure using the pressure guidewire system. The patient underwent implantable cardioverter-defibrillator treatment successfully to reduce the pressure gradient between the aneurysmal cavity and the true left ventricle. (Level of Difficulty: Intermediate.)

A curious case of Lyme carditis in an urban hospital

Lyme carditis (LC), a manifestation of early disseminated Lyme disease, most commonly presents with cardiac conduction abnormalities. It is a transient condition with good prognosis but in extremely rare cases may be life-threatening. We describe a 42-year-old man who presented with progressively worsening generalized weakness, presyncope and dyspnea on exertion for 2 weeks after sustaining a tick bite. He subsequently developed a ‘bull’s eye rash’ on his flank 2 days before his presentation. He was found to have symptomatic third-degree AV conduction blockade with a ventricular escape rhythm resulting in a brief cardiac arrest. Intravenous (IV) ceftriaxone was commenced empirically and a temporary transvenous pacemaker was placed. In a few days he showed dramatic, rapid improvement; the pacemaker was removed, and the patient was discharged on oral doxycycline to complete a 24-day course. This case is unique due to its occurrence in an urban hospital where such cases are uncommon. Cardiac arrest, although brief in this case, is a rare occurrence. Lyme carditis was a surprise diagnosis in our hospital due to the patient’s geographical dislocation during the COVID-19 pandemic.

The Longer the Block, the Harder You Fall: Extrinsic Idiopathic Atrioventricular Block Masquerading as Seizures

History and physical examination are the diagnostic cornerstones of transient loss of consciousness (TLOC). However, details can be scarce and examination unrevealing, thus making the diagnosis elusive. In a case of convulsive TLOC, the initial diagnosis was incorrect, but a fortuitously captured event on telemetry yielded the diagnosis: extrinsic idiopathic atrioventricular block. (Level of Difficulty: Beginner.)

Virtual reality three-dimensional echocardiographic imaging for planning surgical atrioventricular valve repair

OBJECTIVES

To investigate how virtual reality (VR) imaging impacts decision-making in atrioventricular valve surgery.

METHODS

This was a single-center retrospective study involving 15 children and adolescents, median age 6 years (range, 0.33-16) requiring surgical repair of the atrioventricular valves between the years 2016 and 2019. The patients' preoperative 3-dimesnional (3D) echocardiographic data were used to create 3D visualization in a VR application. Five pediatric cardiothoracic surgeons completed a questionnaire formulated to compare their surgical decisions regarding the cases after reviewing conventionally presented 2-dimesnional and 3D echocardiographic images and again after visualization of 3D echocardiograms using the VR platform. Finally, intraoperative findings were shared with surgeons to confirm assessment of the pathology.

RESULTS

In 67% of cases presented with VR, surgeons reported having "more" or "much more" confidence in their understanding of each patient's pathology and their surgical approach. In all but one case, surgeons were at least as confident after reviewing the VR compared with standard imaging. The case where surgeons reported to be least confident on VR had the worst technical quality of data used. After viewing patient cases on VR, surgeons reported that they would have made minor modifications to surgical approach in 53% and major modifications in 7% of cases.

CONCLUSIONS

The main impact of viewing imaging on VR is the improved clarity of the anatomical structures. Surgeons reported that this would have impacted the surgical approach in the majority of cases. Poor-quality 3D echocardiographic data were associated with a negative impact of VR visualization; thus. quality assessment of imaging is necessary before projecting in a VR format.

Complete Atrioventricular Block: A Rare Complication of MitraClip Implantation

MitraClip (Abbott Vascular, Inc., Santa Clara, California) has emerged as a viable alternative for treatment of symptomatic severe mitral regurgitation. Conduction abnormalities are not a known complication of this procedure. We report a case of complete heart block without a ventricular escape rhythm immediately following MitraClip placement near the medial leaflets (A3-P3) in a patient with underlying trifascicular block. (Level of Difficulty: Intermediate.).

Recurrent Atrial Flutter Requiring Multiple Cardioversions in a Preterm Infant

We describe the first case of atrial flutter requiring multiple cardioversions in a preterm infant. Direct current cardioversion is one of the best-understood treatment options, with a first-time success rate higher than 96%. The electrocardiograms provided reveal a second run of atrial flutter occurring after successful cardioversion. (Level of Difficulty: Intermediate.).

Left ventricular global longitudinal strain in identifying subclinical myocardial dysfunction among patients hospitalized with COVID-19

Background

The incidence of acute cardiac injury in COVID-19 patients is very often subclinical and can be detected by cardiac magnetic resonance imaging. The aim of this study was to assess if subclinical myocardial dysfunction could be identified using left ventricular global longitudinal strain (LV-GLS) in patients hospitalized with COVID-19.

Methods

We performed a search of COVID-19 patients admitted to our institution from January 1st, 2020 to June 8th, 2020, which revealed 589 patients (mean age = 66 ± 18, male = 56%). All available 60 transthoracic echocardiograms (TTE) were reviewed and off-line assessment of LV-GLS was performed in 40 studies that had sufficient quality images and the views required to calculate LV-GLS. We also analyzed electrocardiograms and laboratory findings including inflammatory markers, Troponin-I, and B-type natriuretic peptide (BNP).

Results

Of 589 patients admitted with COVID-19 during our study period, 60 (10.1%) underwent TTE during hospitalization. Findings consistent with overt myocardial involvement included reduced ejection fraction (23%), wall motion abnormalities (22%), low stroke volume (82%) and increased LV wall thickness (45%). LV-GLS analysis was available for 40 patients and was abnormal in 32 patients (80%). All patients with LV dysfunction had elevated cardiac enzymes and positive inflammatory biomarkers.

Conclusions

Subclinical myocardial dysfunction as measured via reduced LV-GLS is frequent, occurring in 80% of patients hospitalized with COVID-19, while prevalent LV function parameters such as reduced EF and wall motion abnormalities were less frequent findings. The mechanism of cardiac injury in COVID-19 infection is the subject of ongoing research.

Atrioventricular Node Ablation to Enhance Resynchronization Therapy Response in a Patient With Complete Atrioventricular Block

Up to one-third of patients who undergo cardiac resynchronization therapy do not obtain clinical benefit. A systematic approach can identify treatable causes in many nonresponding patients. We present a case of nonresponse to cardiac resynchronization therapy that resolved by ablation of the atrioventricular node in a patient with complete atrioventricular block. (Level of Difficulty: Advanced.)

Chloroquine Cardiotoxicity Leading to Cardiogenic Shock

A patient with a history of heart block and longstanding chloroquine use presented in cardiogenic shock refractory to medical therapy and mechanical circulatory support. Autopsy supported antimalarial-induced cardiomyopathy (AMIC). Progression of AMIC may be halted with early recognition and cessation of antimalarial therapy, highlighting importance of screening and timely diagnosis. (Level of Difficulty: Beginner.)

Rare Case of Fetal Permanent Junctional Reciprocating Tachycardia Refractory to Prenatal Antiarrhythmic Therapy

Permanent junctional reciprocating tachycardia (PJRT) is a rare form of atrioventricular reentrant tachycardia that is commonly resistant to most antiarrhythmic medication therapy and over an extended duration can result in tachycardia-induced cardiomyopathy. The prenatal presentation of PJRT is typically similar to that of other types of fetal supraventricular tachycardia (SVT), making it difficult to distinguish from other forms of SVT in utero by fetal echocardiography. Surface electrocardiography after delivery is typically required to make a definitive diagnosis of PJRT. We report a case of fetal SVT at 19 weeks’ gestation refractory to maternal transplacental treatment with digoxin, amiodarone, flecainide, sotalol, metoprolol, intraumbilical amiodarone, and fetal intramuscular digoxin over the course of 12 weeks. Repeat cesarean delivery was performed at 30 2/7 weeks’ gestation for tachycardia-induced cardiomyopathy with hydrops fetalis. Postnatal electrocardiogram and continuous rhythm monitoring confirmed the diagnosis of PJRT. Combined neonatal treatment with amiodarone, digoxin, and propranolol was successful in reestablishment of sinus rhythm, with radiofrequency ablation planned if medical therapy eventually fails or once early childhood is reached. To our knowledge, this is the first described case of fetal PJRT refractory to multiple standard in utero antiarrhythmic modalities and highlights the importance of inclusion in the differential diagnosis.

Predictors of pacemaker dependency in patients implanted with a pacemaker after Transaortic valve replacement

Introduction and objectives

The development of complete AV block and the need for pacemaker implantation (PM) is the most frequent complication after Transaortic valve replacement (TAVR). In other PM clinical contexts, a higher percentage of ventricular stimulation has been associated with worse prognosis. The objective was to study the existence of predictors of PM dependence.

Methods

We identified 96 consecutive patients who had received a PM post-TAVR (all Core-Valve). We retrospectively analyzed this cohort with the aim of identifying predictors of a high and very high percentage of ventricular pacing (VP), PM dependency and survival.

Results

The mean age was 82.3 years, with a mean logistic EuroSCORE of 17.1, 53% were women and 12% of patients had LVEF < 50%. The indication was complete AV block in 40.5%, and LBBB in 59.5%. Mean survival was 62.7 months, IQR [54.4-71]. The only independent predictor of mortality was the pre-TAVR logistic Euro-SCORE (RR = 1,026, p = 0.033), but not LVEF < 50%, VP > 50%, VP > 85% or PM dependence. In 73 patients PM rhythm was documented at the end of follow-up. Of these, 14 (19.2%) were considered dependent, and 37 (50.7%) presented VP > 50%. The post-TAVR complete AV block recovery rate was 67.8%. In multivariate analysis, female sex (HR = 5.6, p = 0.005), and indication of complete AV block vs. LBBB (HR = 15.7, p = 0.017) were independently associated with PM dependency.

Conclusions

Female sex and indication due to complete AV block were independent predictors of PM dependency during follow up. In our series of patients with mostly normal LVEF, a high percentage of stimulation does not influence prognosis.

Marked Sinus Bradycardia Associated With Remdesivir in COVID-19: A Case and Literature Review

Remdesivir has seen extensive use during the coronavirus disease-2019 pandemic given its clinically proven efficacy against severe acute respiratory syndrome coronavirus type 2. There has been little cited regarding adverse effects. Here we present the case of a patient with marked sinus bradycardia that began acutely on initiation of remdesivir and resolved almost immediately on cessation of the drug. (Level of Difficulty: Beginner.)

Septal Reduction Using Transvenous Intramyocardial Cerclage Radiofrequency Ablation: Preclinical Feasibility

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Surgical myectomy is morbid and transcoronary alcohol septal ablation can result in geographic miss or occasional nontarget injury.

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We developed a transvenous intraseptal radiofrequency ablation technique (cerclage ablation method) to overcome the shortcomings of surgical myectomy and alcohol septal ablation.

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We delivered dedicated intraseptal radiofrequency ablation catheter into the ventricular septum through the coronary sinus and a septal vein. The ablated volume of myocardium was larger at higher electrode temperatures and using an irrigated-ablation mode in vitro. Cerclage ablation was successful in all in vivo attempts and induced a focal regional wall motion abnormality at later follow-up.

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This study presents in vivo evidence of the feasibility, effectiveness, and safety of cerclage ablation method to debulk interventricular septal myocardium.

Debulking of left ventricular septal mass is typically accomplished using surgical myectomy, which is morbid, or using transcoronary alcohol septal ablation, which can result in geographic miss and occasional catastrophic nontarget coronary injury. The authors developed and tested operational parameters in vitro and vivo for a device to accomplish transvenous intraseptal radiofrequency ablation to reduce ventricular septal mass using a technique derived from mitral cerclage, which the authors call cerclage ablation. Cerclage ablation appeared feasible in vitro and safe and effective in vivo. Cerclage ablation is an attractive new approach to debulk the interventricular septum in obstructive hypertrophic cardiomyopathy. These data support clinical investigation.

Catheter Ablation of Atrioventricular Block: From Diagnosis to Selection of Proper Treatment

A 39-year-old man presented with recurrent syncope. A 12-lead electrocardiogram and a 24-h Holter recording demonstrated atypical persistent Mobitz type I and high-degree atrioventricular block, respectively. The functional nature of the atrioventricular block was confirmed by atropine challenge, exercise testing, and electrophysiological study. The patient was successfully treated with a cardioneuroablation procedure. (Level of Difficulty: Intermediate.).

Alternating QRS Morphologies and PR Intervals After Transcatheter Aortic Valve Replacement

Alternating bundle branch block pattern on electrocardiogram (ECG) is a concerning finding with important prognostic implications. This ECG challenge explores the electrophysiological mechanism of a case of alternating bundle branch block with alternating PR intervals. (Level of Difficulty: Beginner.).

Differential Effects of Vagal Activation on the Sinus and Atrioventricular Nodes: Report of 2 Cases

Vagal activation usually affects both sinus and atrioventricular (AV) nodes, manifesting as sinus slowing accompanied by varying degrees of AV block. AV block accompanying sinus acceleration as during treadmill testing is usually considered pathologic. We report 2 cases of vagally mediated reflex AV block accompanied by sinus tachycardia and acceleration. (Level of Difficulty: Intermediate.)

de Winter Electrocardiographic Pattern Caused by Diagonal Branch Lesion

A woman in her 50s developed acute coronary syndrome with de Winter pattern electrocardiogram (ECG). A coronary angiography revealed diagonal branch lesion caused by spontaneous coronary artery dissection, whereas the left-anterior descending artery was intact. The ECG change was transient and returned to normal without treatment 2 h later. (Level of Difficulty: Beginner.)

Complete Heart Block, Severe Ventricular Dysfunction, and Myocardial Inflammation in a Child With COVID-19 Infection

A young child presented with severe ventricular dysfunction and troponin leak in the setting of coronavirus disease-2019. He developed intermittent, self-resolving, and hemodynamically insignificant episodes of complete heart block that were diagnosed on telemetry and managed conservatively. This report is the first description of coronavirus disease-2019-induced transient complete heart block in a child. (Level of Difficulty: Intermediate.).

Transcatheter Aortic Valve Replacement of a Bicuspid Aortic Valve in a Heart Transplant Recipient

Patients with heart transplants who present with severe aortic stenosis may be deemed high-risk surgical candidates due to immunosuppression and multiple comorbid conditions. Appropriately selected patients may be successfully treated with transcatheter aortic valve replacement. (Level of Difficulty: Advanced.)

Heart Brake: An Unusual Cardiac Manifestation of COVID-19

A 49-year-old man presented with worsening high-grade fevers, dry cough, and shortness of breath. He tested positive for severe acute respiratory syndrome-coronavirus-2 and was noted to have bradycardia with intermittent high-degree atrioventricular block. However, cardiac biomarkers and echocardiographic findings were normal, thus making this an unusual and interesting manifestation of myocardial involvement of this novel coronavirus. (Level of Difficulty: Beginner.)

Primary Cardiac Lymphoma Manifesting as an Atrioventricular Block in a Renal Transplantation Recipient

Our report illustrates an atrioventricular block due to primary cardiac lymphoma attached to the right atrial septum that was rapidly reversible by surgical debulking and effective chemotherapy without the need for a permanent pacemaker. (Level of Difficulty: Beginner.)

Left Atrial Intramural Hematoma Post-Ablation of Supraventricular Tachycardia: A Rare Complication Treated Successfully

We report successful management of left atrial hematoma after ablation of supraventricular tachycardia. A 43-year-old female patient experienced chest pain immediately after radiofrequency ablation of a symptomatic left posterolateral accessory pathway. Transthoracic echocardiography demonstrated a large mass occupying the left atrium. Computed tomography and transesophageal echocardiography results were consistent with posterolateral intramural hematoma. She became hemodynamically unstable, requiring emergent surgery. The mass resolved completely by 6 weeks. (Level of Difficulty: Beginner.)

A Clinical Challenge Overcome by His Bundle Pacing

We highlight a diagnostic challenge in a patient with dyspnea on exertion due to radiation therapy-induced severe first-degree atrioventricular block and how permanent His bundle pacing was helpful in overcoming these symptoms. (Level of Difficulty: Intermediate.).

Beta-blockers in cirrhosis: Evidence-based indications and limitations

Non-selective beta-blockers (NSBBs) are the mainstay of treatment for portal hypertension in the setting of liver cirrhosis. Randomised controlled trials demonstrated their efficacy in preventing initial variceal bleeding and subsequent rebleeding. Recent evidence indicates that NSBBs could prevent liver decompensation in patients with compensated cirrhosis. Despite solid data favouring NSBB use in cirrhosis, some studies have highlighted relevant safety issues in patients with end-stage liver disease, particularly with refractory ascites and infection. This review summarises the evidence supporting current recommendations and restrictions of NSBB use in patients with cirrhosis.

A Rare Case of Mad Honey Disease: A Reversible Cause of Complete Heart Block

This case describes a patient with hypotension, bradycardia, and third-degree atrioventricular block following ingestion of a grayanotoxin-containing Pieris species, or lily of the valley bush. Although unlikely in metropolitan environments, physicians should be aware of the possibility of grayanotoxin ingestion when confronted with new-onset heart block even in nonendemic areas. (Level of Difficulty: Beginner.)

Quadravalvular Noninfectious Endocarditis

Nonbacterial thrombotic endocarditis is characterized by sterile thrombi on cardiac valves. This report describes the case of nonbacterial endocarditis without pathologic findings of fibrin or platelet deposition. Quadrivalvular endocarditis was found to be due to immunoglobulin M heavy chain deposition. This was a case of nonbacterial, nonthrombotic quadrivalvular endocarditis, which was termed noninfective endocarditis. (Level of Difficulty: Intermediate.)

Fontan Liver Lesions: Not Always HCC

A 24-year-old Fontan procedure patient underwent surveillance liver cardiac magnetic resonance imaging. Findings were suggestive of hepatocellular carcinoma (HCC). Currently, HCC is diagnosed based on imaging alone. Given her otherwise reassuring clinical profile, she underwent liver biopsy. Pathology demonstrated focal nodular hyperplasia. This raises concern for overdiagnosis of HCC in Fontan patients without tissue confirmation. (Level of Difficulty: Advanced.)

Clinical Manifestations, Diagnosis, and Treatment of Sarcoidosis

The focus of this review is current knowledge about the epidemiology, clinical manifestations, diagnosis, and treatment of both pulmonary sarcoidosis and extrapulmonary sarcoidosis. Although intrathoracic involvement is the hallmark of the disease, present in over 90% of patients, sarcoidosis can affect virtually any organ. Clinical presentations of sarcoidosis are diverse, ranging from asymptomatic, incidental findings to organ failure. Diagnosis requires the presence of noncaseating granuloma and compatible presentations after exclusion of other identifiable causes. Spontaneous remission is frequent, so treatment is not always indicated unless the disease is symptomatic or causes progressive organ damage/dysfunction. Glucocorticoids are the cornerstone of treatment of sarcoidosis even though evidence from randomized controlled studies is lacking. Glucocorticoid-sparing agents and biologic agents are often used as second- and third-line therapy for patients who do not respond to glucocorticoids or experience serious adverse effects.

Leadless Dual-Chamber Pacing: A Novel Communication Method for Wireless Pacemaker Synchronization

Contemporary leadless pacemakers only feature single-chamber pacing capability. This study presents a prototype of a leadless dual-chamber pacemaker. Highly energy-efficient intrabody communication was implemented for wireless pacemaker synchronization. Optimal communication parameters were obtained by in vivo and ex vivo measurements in the heart and blood. The prototype successfully performed dual-chamber pacing in vivo. The presented wireless communication method may in the future also enable leadless cardiac resynchronization therapy.