The importance of the evolution of ST-T wave changes for differentiating acute pericarditis from myocardial ischemia

A 28-year-old, moderately obese man with dyslipidemia (low-density lipoprotein 163 mg/dL, high-density lipoprotein 33 mg/dL), hypertension, active tobacco use (1 pack per day), and a family history for premature coronary artery disease (CAD) initially presented with burning, nonexertional chest discomfort exacerbated by deep inspiration. His initial electrocardiogram (ECG; Fig. 1A) was interpreted as pericarditis because of the diffuse mild ST-segment elevation and PR-segment depression. An echocardiogram demonstrated normal left ventricular systolic function and a trivial pericardial effusion. He was treated with nonsteroidal antiinflammatories and his symptoms resolved. Follow-up ECG performed the next morning (Fig. 1B) demonstrated sinus rhythm, persistent mild ST elevation, and biphasic T waves in leads V3-V4 as well as in leads III and aVF. Four months later, the patient returned with similar symptoms of chest discomfort and was admitted with the diagnosis of unstable angina. The admission ECG was unremarkable showing no persistent PR or ST-T abnormalities. He was ruled out for myocardial infarction by serial enzymes. An exercise myocardial perfusion imaging study was obtained. The patient exercised for 7 minutes 33 seconds on a standard Bruce protocol, obtained 9.4 METs, and reached 69% of maximum predicted heart rate. His exercise ECG revealed up to 2.5 mm of ST-segment elevation in leads V3-V5 accompanied by chest discomfort. The patient's chest pain resolved with cessation of exercise and 1 sublingual nitroglycerin. The ECG returned to baseline within 3 minutes of recovery. He was referred for coronary angiography and was found to have a proximal left anterior descending (LAD) stenosis and underwent percutaneous coronary intervention with stenting. He was discharged home on postprocedure day 3.     

Tumor encasement of the heart simulating pericardial effusion

A 56-year-old woman with breast carcinoma was referred for an urgent two-dimensional echocardiogram. An anterior and posterior echo-free space suggesting pericardial effusion and a new right atrial mass were detected. A few hours later the patient died suddenly. Necropsy revealed neoplastic encasement of the heart without pericardial effusion.     

Coronary angiographic, echocardiographic, and electrocardiographic studies on a patient with variant angina due to coronary artery spasm.

A 45-year-old Caucasian female patient with a clinical rehistory and ECG's conforming to the syndrome of variant angina as characterized by Prinzmetal is presented. ECG's recorded during spontaneous pain demonstrated ST-segment elevation and symmetrical peaking of the T-waves in the lateral precordial leads and short runs of ventricular tachycardia. Similar ECG changes were recorded during treadmill exercise- and hand-grip exercise-induced chest pain. An echocardiogram recorded during angina induced by hand-grip exercise demonstrated progressive flattening of septal motion. Multiple views of the coronary system by selective coronary cineangiography were normal with the patient at rest. Angina was then induced by hand-grip exercise and a repeat right anterior oblique view of the left coronary system revealed marked spasm of the left anterior descending artery proximal to the first septal perforator.     

Rupture of a giant saccular aneurysm of coronary arteriovenous fistulas

A 58-year-old Japanese woman was admitted to our hospital because of chest pain. A continuous murmur was detected at the left parasternal area. Electrocardiogram showed ST elevation in leads V2, V3 and V4. Chest computed tomography and echocardiography demonstrated pericardial effusion and a large mass which was adjacent to the pulmonary artery. An abnormal blood flow was detected in the mass by Doppler echocardiography. Coronary angiography confirmed that the mass was a giant aneurysm of coronary arteriovenous fistula arising from both the left and right coronary arteries. This patient had no symptoms until rupture of the fistula. Rupture of a coronary arteriovenous fistula is very rare but can be a cause of chest pain and pericardial effusion.     

How much harm can be caused by a badly recorded or badly interpreted ECG! (author's transl)

Two cases are presented which support the sentence of the title. In a 38 years old man a life insurance company proposed an extra charge on the basis of a pseudoischemic ECG due to exceeding pressure of the writing pen on the ECG paper. In a 28 years old asymptomatic female an abnormal ECG was interpreted as due to ischemic heart disease. Physical activity was restricted and three pregnancies were interrupted. 18 years later an angiography showed normal coronary vessels. Some months later an echocardiogram showed an abnormal pericardial pattern, giving a possible explanation for the abnormal ECG.     

Exercise-induced left ventricular outflow tract obstruction. A potential cause of symptoms in the elderly.

We describe a 79-year-old male patient with no significant risk factors for coronary heart disease besides age and gender. He was referred for cardiology consultation because of effort dyspnea. Diagnostic exams including laboratory tests, chest X-ray, ECG and resting echocardiogram showed no abnormalities. He underwent exercise stress echocardiography, which revealed reduced exercise tolerance and a dynamic left ventricular outflow tract obstruction with an intraventricular gradient of over 50 mmHg. No segmental wall motion abnormalities were observed. He was treated with the beta-blocker bisoprolol 5 mg qd, with significant clinical improvement. Two years later exercise stress echocardiography was repeated and better functional capacity was apparent, with no intraventricular gradient during peak exercise. The authors discuss the clinical importance of this unsuspected cause of symptoms in the elderly.     

Echocardiographic evaluation of pericardial effusion in myxedema. Incidence and biochemical and clinical correlations.

Pericardial effusion is a recognized consequences of myxedema. Its incidence is unknown, primarily because of past difficulties in establishing the diagnosis. We studied 33 hypothyroid patients by echocardiography. Ten of the 33 patients (30%) had positive echoes for pericardial effusion. Seven of these ten patients had enlarged hearts on chest X-ray. Five patients had cardiac enlargement but no echo evidence of pericardial effusion. Serum concentrations of thyroxine, 1.8+/-0.3 vs 1.5+/-0.1 mcg/dl and of thyroid stimulating hormone, 34+/-4 vs 38+/-5 muU/ml did not differ in the groups with and without pericardial effusion, respectively. However, the pericardial effusion group had significantly slower heart rates on ECG than those without pericardial effusion: 53+/-8 vs 68+/-2 beats/min, P less than 0.05. Low voltage was present in five of the ten patients with pericardial effusion and five of the 23 nonpericardial effusion patients. None of the patients with pericardial effusion developed tamponade. Seven patients with pericardial effusion were restudied after periods of thyroxine replacement therapy ranging from six months to two years. All were euthyroid and had negative echoes on follow-up, but two still showed cardiomegaly on chest X-ray (both had associated coronary artery disease). We conclude that pericardial effusion occurs frequently in patients with myxedema. Tamponade is uncommon and the effusions disappear with thyroid replacement therapy. Cardiomegaly on chest X-ray and low voltage on ECG are not reliable indicators of pericardial effusion.     

Two cases of acute coronary occlusion after successful coronary angioplasty associated with a treadmill stress testing

We presented two cases of acute coronary occlusion after successful percutaneous transluminal coronary angioplasty (PTCA) associated with a treadmill stress testing. Case 1: A 54-year-old man with effort angina was referred to our hospital for cardiac catheterization. At the time of cardiac catheterization, the proximal RCA had a 99% diameter narrowing, and the proximal LCX had a 90% diameter narrowing. PTCA was performed and both lesions were successfully dilated. Eight days after PTCA, he had a symptom-limited treadmill stress testing, using the Bruce protocol. The exercise was terminated at a peak heart rate of 173/min (103% of aged-predicted maximal heart rate), and at a maximal systolic blood pressure of 140 mmHg. A few minutes after the end of exercise, he developed a severe chest pain and ECG changes, which showed ST elevation in leads II, III, aVF and ST depression in leads V4-V6. Emergency coronary angiography disclosed an acute coronary occlusion of RCA at the site of PTCA. Emergency PTCA was performed and the lesion was successfully re-dilated. Case 2: A 68-year-old man was referred to our hospital for cardiac catheterization a month after subendocardial anterior myocardial infarction. At the time of cardiac catheterization, the proximal LAD have a 99% diameter narrowing. PTCA was performed and the lesion was successfully dilated. 18 days after PTCA, he had a symptom-limited treadmill stress testing, using the Bruce protocol. The exercise was terminated at a peak heart rate of 158/min (102% of aged-predicted maximal heart rate), and at a maximal systolic blood pressure of 218 mmHg. Ten minutes after the one of 218 mmHg.(ABSTRACT TRUNCATED AT 250 WORDS)     

Two cases of primary cardiac lymphoma presenting with pericardial effusion and cardiac tamponade

The heart as the primary site of lesion in malignant lymphoma is extremely rare. We experienced 2 cases of malignant lymphoma whose initial presentation was massive pericardial effusion with cardiac tamponade. The first case was a 75-year-old man who had shortness of breath for 1 week. Chest X-ray showed cardiomegaly (CTR 65%), and his condition was diagnosed as congestive heart failure at first and thereafter echocardiogram revealed pericardial effusion. The second case was a 76-year-old man who complained of exertional dyspnea which worsened over 2 weeks. His condition was diagnosed as congestive heart failure at first and echocardiogram revealed pericardial effusion. Pericardial drainage tapped bloody fluid and cytological examination revealed malignant lymphoma. After treatment, the first case lived for eleven months with no recurrence of pericardial effusion. The second case has lived for 4 years. We present these 2 cases can be defined as primary cardiac lymphoma according to McALLISTER and FENOGLIO, i.e., a lymphoma that involves only the heart and pericardium. More cases of primary cardiac lymphoma will be found in the future because of the ease with which the echocardiogram can detect pericardial effusion.     

Oozing type of left ventricular rupture via subepicardial aneurysm diagnosed 5 months after myocardial infarction

A 71-year-old man visited our hospital complaining of increasing fatigue and exertional dyspnea. He had had severe epigastric pain for the past 5 months. On admission, chest radiogram showed marked cardiac dilatation and echocardiogram massive pericardial effusion with a small subepicardial aneurysm at the posterior wall of the left ventricle. An urgent pericardiocentesis removed 1300 ml of bloody effusion. The red blood cell count of the pericardial effusion was similar to that of the peripheral blood, and there were no abnormal findings on cytologic and bacteriological examinations. Coronary angiography showed a blunt occlusion of the mid-portion of the circumflex artery. Left ventricular angiogram revealed aneurysmal deformity of the left ventricular posterior wall. These findings suggested that an oozing type of left ventricular rupture via a subepicardial aneurysm had occurred after the onset of myocardial infarction (MI), resulting in massive accumulation of pericardial effusion. The patient is presently doing well without any clinical symptoms 18 months after pericardiocentesis. This is the first case report in which a subepicardial aneurysm with massive pericardial effusion was detected in the chronic stage of MI and successfully managed without surgical repair.     

Infarct rupture of the heart. A clinical case operated on with success

A 48-year-old woman was admitted for acute myocardial infarction with a normal clinical course. On the fifth day a new chest pain occurred, with low cardiac output and high central venous pressure; a pericardial effusion was present at the echocardiogram. The clinical picture improved with intensive medical care but, on the tenth day, there was a relapse with a life-threatening heart tamponade. An emergency operation was performed without previous heart catheterization. The pericardium was tense and contained about 300 ml of clots; in a wide infarcted area of the lateral wall of the left ventricle two small perforations were evident. Primary reconstruction was accomplished with interrupted stitches supported by Teflon felt strips. The bypass weaning was easy and the postoperative clinical course uneventful. We believe that the cardiac rupture is a surgical emergency; the non-invasive diagnosis is possible; the coronary angiography and revascularization must be postponed.     

Myocardial infarction and coronary artery ventricular fistulas due to blunt chest trauma

Myocardial infarction and coronary artery ventricular fistulas due to blunt chest trauma. HISTORY AND CLINICAL FINDINGS: An 18-year-old previously healthy, cigarette smoking man with no other risk factors for ischaemic heart disease, was admitted to hospital after being kicked in the chest by a horse. On arrival he complained about pain in the lower mediastinum. INVESTIGATIONS: The ECG showed sinus rhythm, right bundle branch block and convex bowed ST elevation in leads V1-V3. Sixty minutes after the incident the cardiac enzymes (creatinekinase-MB fraction, troponin I) were significantly raised. Despite an only slightly reduced left ventricular function documented by transthoracic echocardiography, SPECT-thallium scan showed large scintigraphic defects. Coronary heart disease was excluded by coronary angiography. Four small coronary-ventricular fistulas were identified. Laevocardiography showed a hypokinesia in the antero-septal region. DIAGNOSIS, TREATMENT AND COURSE: We assumed traumatic myocardial infarction of the anterior wall and rupture of multiple small coronary vessels, leading to coronary-ventricular fistulas. No interventional or surgical therapy was performed. Later on the left ventricular function became normal. Echocardiography merely outlined an akinetic scar in the middle of the septum. At exercise ECG test sixteen months later, the patient remained asymptomatic and was able to exercise without any signs of ischaemia up to a work load of 175 W. Furthermore, the fistulas could be seen by echocardiography. CONCLUSION: Cardiac involvement should be considered in all cases of blunt chest trauma. In addition to a traumatic myocardial infarction fistulas may also, though rarely, occur. Myocardial scintigraphy after cardiac contusion is not suitable for diagnosing myocardial ischaemia or vitability.     

Perforated ventricular aneurysm in a male suffering from pneumonia

In a 49-year-old male with fever, dyspnea, and chest pain, thoracic x-ray revealed pneumonia with enlarged heart silhouette. Antibiotics were successful, pneumonia healed and complaints disappeared. Yet, during the following 3 months, echocardiography showed mild persistent pericardial effusion while in ECG both sinus tachycardia and ST-T changes were found suggesting chronic pericarditis. Magnetic resonance imaging, however, revealed an extensive posterobasal aneurysm with pericardial effusion substantiated by ventriculography. Coronary angiography showed diffuse three-vessel disease. Surgery revealed aneurysm with distinct perforation of the left ventricle and pericardial thrombi, thus aneurysmectomy as well as bypass grafts were performed. One year postoperatively, magnetic resonance imaging confirmed the absence of aneurysm with only a small irreversible posterobasal perfusion defect remaining as shown by thallium scintigraphy.     

Correct diagnosis and successful treatment for pericardial effusion due to toothpick injury： A case report and literature review

We reported a 55-year-old man who suffered from chest pain and dyspnea on exertion for two weeks associated with night sweating, general malaise, poor appetite, and body weight loss. Physical examination revealed friction rub with distant heart sound, bilateral clear breathing sound, no abdomen tenderness, and normal bowel sound. Subsequent chest X-ray revealed cardiomegaly and cardiac echo showed massive pericardial and pleural effusion with normal left ventricular function. Constrictive pericarditis was diagnosed based on clinical information. Tuberculosis (TB), malignancy, autoimmune disease, infection, hypothyroidism, and idiopathic could be the causes but excluded by further study. High-resolution lung CT scan after reconstruction revealed a moderate amount pericardial effusion with possible superimposed infection. Thickness of pericardium and left lobe liver abscess were found. A straight tubular structure about 6 cm in length transverses the lateral segment of liver to pericardial space and unknown foreign body was suspected. Laparotomy was performed, 6.5 cm toothpick was found through the liver into pericardium. Post-operative course was uneventful and he discharged one week later. The patient could not remember swallowing the toothpick before. He had no chest pain and dyspnea on exertion during a 6-mo follow-up period.     

Efficacy of percutaneous balloon pericardiotomy and intrapericardial instillation for the management of refractory pericardial effusion: a case report

Percutaneous balloon pericardiotomy and intrapericardial instillation seemed to be less invasive and effective treatments for refractory pericardial effusion. A 65-year-old man who suffered from refractory pericardial effusion associated with gastric cancer and had been hospitalized three times for pericardiocentesis, complained of dyspnea at rest and visited our emergency room. Echocardiography showed a large amount of pericardial effusion all around the heart and signs of cardiac tamponade. Percutaneous balloon pericardiotomy was performed and pericardial effusion turned to pleural effusion. We performed left thoracocentesis. One week later, massive pericardial effusion localized only around the right heart appeared, and pericardiocentesis was performed again. After another month, pericardial effusion around right heart appeared again and intrapericardial instillation with OK-432 (Picibanil) was tried. After the procedure, the pericardial effusion did not increase, and he has had few symptoms for 2 months as an outpatient.     

Aspiration thrombectomy for acute myocardial infarction resulting from the sequential occlusions of two major coronary arteries in a short time

A 49-year-old man was admitted to our hospital due to chest oppressive sensation. Coronary angiography showed total occlusion in the proximal right coronary artery even after intracoronary nitroglycerin, but no stenosis in the left coronary artery. He was treated with aspiration thrombectomy and stent deployment. After 23 hours, he suddenly had severe chest pain, and ECG showed marked ST elevation in leads I, aVL and V2-6. Surprisingly, coronary angiography showed total occlusion in the proximal left anterior descending artery even after intracoronary nitroglycerin where there had been no stenosis on first angiogram just 23 hours earlier. He was treated with aspiration thrombectomy.     

Primary Cardiac Lymphoma: Case Report and Brief Review of the Literature

Primary cardiac lymphoma is defined as a non-Hodgkin's lymphoma mainly located in the heart and/or the pericardium. It is rare and affects elderly men. Common manifestations are pericardial effusion and heart failure. Diagnosis is usually late and prognosis is poor. We report a case of a patient with a large primary cardiac lymphoma who presented with chest pain and negative T-waves in electrocardiogram. Transthoracic echocardiogram showed a large mass in the right atrium and right ventricle while transesophageal echocardiogram also revealed the presence of large mobile masses in the right atrium, which were considered to be thrombi. Tissue biopsy showed a high-grade B-cell diffuse lymphocytic lymphoma. The patient was treated with chemotherapy and radiation with complete remission and prolonged survival.     

An autopsied case with a bicuspid aortic valve who had progressive angina pectoris and heart failure during follow-up of 27 years

A Japanese man who died at age 85 had been followed since the age of 59, when he first presented. He had hypertension of 162/102 mmHg and a loud systolic murmur on his first visit. He had had an active daily life without any medication for the next 10 years. At the age of 72 he complained of mild chest discomfort on exercise. Although electrocardiography showed no abnormalities, echocardiogram showed calcified bicuspid aortic valve with mild stenosis. At the age of 81 the dyspnea and chest oppression were exacerbated, associated with marked ST depression on exercise electrocardiogram and restriction of aortic valve opening on echocardiograms. In the following years a gradual increase in QRS voltage and ST depression with T wave inversion were recorded on resting electrocardiograms and sharp increases in both left ventricular end-diastolic diameter and flow velocity at the aortic root were observed on echocardiograms. At the age of 85 he died of intractable heart failure with massive pleural effusion. Autopsy revealed marked hypertrophy and moderate dilatation of the heart (weight: 580 g). The bicuspid aortic valve had anterior-posterior cusps with a raphe on the anterior cusp. The mobility of the cusps was almost lost because of severe calcification and thickening. Severe stenosis was found near the orifice of the right coronary artery, but there were no significant ischemic myocardial lesions.     

Myocardial and pericardial staining by transradial Optitorque Jacky shape catheter during left ventriculogram

A 69-year-old male presented with inferior wall ischemia. Transradial coronary angiogram with an Optitorque Jacky shape catheter showed unobstructed coronary arteries (Terumo Medical Corporation). Left ventriculography was complicated with myocardial and pericardial contrast staining. The catheter was pulled back. The patient experienced sharp chest pain that resolved in 20 minutes. Stat transthoracic echocardiogram was unremarkable. The patient remained hemodynamically stable. Transthoracic echocardiogram the next morning revealed trivial pericardial effusion. Patient was asymptomatic on outpatient follow-up. The Optitorque transradial catheter, with Jacky and Tiger tip shapes, is the preferred multipurpose catheter for transradial coronary angiogram. Potential complications of ventriculogram catheters are myocardial staining, myocardial rupture, cardiac tamponade, and arrhythmias caused by improper position of the catheter tip. It is imperative to check the position of the catheter tip with a small amount of contrast injection prior to left ventriculography (even though we checked our position with a small test injection) to avoid these types of complication. This case illustrates the value of careful manipulation and placement of transradial catheter during left ventriculography.     

Echocardiographic and roentgenographic determination of left ventricular size after coronary arterial bypass graft surgery.

In 38 patients undergoing elective coronary arterial bypass graft surgery, the radiographic dimension of the left side of the heart was determined and echocardiographic studies were performed before and after surgery. On the plain chest x-ray film one week after surgery, all patients showed an increase in the size of the left side of the heart, which usually was not accompanied by an increase in the echocardiographic left ventricular end-diastolic dimension; however, in 25 patients, pericardial fluid was detected soon after surgery, which would explain the enlarged cardiac silhouettes. Several months after surgery, the radiographic size of the heart returned to the preoperative value in most patients, and pericardial fluid was no longer demonstrated on the echocardiogram. Thus, pericardial fluid frequently is found in the first week following coronary arterial bypass graft surgery and may give the impression of increased cardiac size on plain chest x-ray films; however, echocardiographic studies provide a more accurate estimate of left ventricular size and reveal the presence of pericardial effusion.