Case #20 — Tall R Waves in Precordial Electrocardiogram Leads

by Maygen del Castillo, MD, Ihab Hamzeh, MD, FACC, and Yochai Birnbaum, MD, FACC

A 55-year-old man with a history of coronary artery bypass grafting and severe biventricular failure presented with several weeks of shortness of breath and associated chest pain. He needed an Impella® heart pump (Abiomed, Inc.) as mechanical circulatory support for volume overload and cardiogenic shock. His mildly elevated cardiac troponin I level (1.35 ng/mL on admission) was attributed to demand ischemia from decompensated heart failure; the level decreased after diuresis. He was referred for advanced heart failure evaluation. Figure 1 shows his electrocardiogram (ECG) on presentation.

Case #19 — Osborn Waves: Differential Diagnosis

by Akriti G. Jain, MD, Hammad Zafar, MD, Sanjay Jain, MD, and Jason D’Souza, MD

A 56-year-old man with schizoaffective disorder, type 2 diabetes mellitus, and no cardiac history was sent from a psychiatric facility for evaluation of a left foot wound. He was disoriented to time, place, and person. The patient’s core body temperature was 87.4 °F, and his pupils were equally reactive to light. His left foot had an ulcer with a dirty base and much foreign material, and his 2nd and 3rd toes were black with clear demarcation. Laboratory results included a normal white blood cell count (8 ×10⁹/L, 23% band neutrophils), a hemoglobin level of 7.4 g/dL, normal electrolyte levels except for calcium elevation (11.8 mg/dL; 12.8 mg/dL after correction for albumin), and no detected cardiac troponin. Urine toxicology results were positive for tricyclic antidepressants (TCAs). An electrocardiogram (ECG) showed junctional rhythm with J waves (Osborn waves); a corrected QT interval (QTc) of 468 ms; a PR interval of 188 ms; and a heart rate of 60 beats/min (Fig. 1).

Case #18 — ST-Segment Elevation Soon after Coronary Artery Bypass Grafting

by Sanket Borgaonkar, MD, and Yochai Birnbaum, MD, FACC

A 59-year-old woman with hypertension, hyperlipidemia, and gastroesophageal reflux reported exertional angina that resolved with rest and nitroglycerin. Nuclear stress test results revealed a small, reversible inferior-wall defect and a left ventricular ejection fraction (LVEF) of 0.67. A coronary angiogram showed diffuse 3-vessel disease. The patient underwent elective 4-vessel coronary artery bypass grafting (CABG) with no complications and was extubated the next day. On postoperative day 2, a routine electrocardiogram (ECG) showed an rSr′ pattern in leads V₁ and V₂, and ST-segment elevation (STE) in leads V₂ through V₄ (Fig. 1).

Case #17 — Tachycardia in the Presence of Ventricular Pacing

by Toug Tanavin, MD, Mark Pollet, MD, and Yochai Birnbaum, MD, FACC

A 61-year-old man with coronary artery disease presented with volume overload caused by medication noncompliance. His medical history included percutaneous coronary intervention; ischemic cardiomyopathy (left ventricular [LV] ejection fraction, <0.15); and placement of a biventricular implantable cardioverter-defibrillator (ICD), model and programming unknown. Chest radiographs showed properly positioned ventricular and right atrial leads. Figure 1 shows the patient’s electrocardiogram (ECG) on presentation.

Case #16 — Cocaine-Induced Electrocardiographic Phenomenon

by Sundeep Kumar, MD, Luis Sanchez, MD, Ruthvik Srinivasamurthy, MD, and Patrick F. Mathias, MD, FACC

A 27-year-old white man presented at the hospital after recent cocaine use, reporting intermittent left-sided chest pain, diaphoresis, and dizziness. His vital signs were normal; results of physical examination were not noteworthy. Chest radiographic and cardiac enzyme test results were normal. His urine was positive for cocaine. An electrocardiogram (ECG) during a pain-free state revealed findings not present one month earlier: a prolonged QTc interval, new T-wave inversions, and biphasic T waves in leads V₂ and V₃ (Fig. 1, arrows).

Case # 15 — Chest Radiograph Clarifies an Electrocardiographic Abnormality

by Alexander Postalian, MD, Yochai Birnbaum, MD, FACC, and Mohammad Saeed, MD, FACC

A 69-year-old man with severe aortic stenosis underwent transcatheter aortic valve replacement with a 29-mm Edwards Sapien 3 Transcatheter Heart Valve (Edwards Lifesciences LLC). During the procedure, he had transient 3rd-degree atrioventricular block, followed by sinus rhythm with PR prolongation, right bundle branch block, and left anterior fascicular block. Our electrophysiology team was consulted.

We decided to implant a dual chamber pacemaker (Medtronic) in DDDR mode. The day after implantation, the following surface electrocardiogram (ECG) was obtained (programmed atrioventricular [AV] delay, 160 ms).

Case #14 — Slow, But Dangerous

by Kelvin N.V. Bush, MD, and Gregg G. Gerasimon MD

A 70-year-old man with ischemic heart disease, chronic heart failure, and a left ventricular ejection fraction of 0.25 presented with recurrent palpitations and diaphoresis. His single-chamber implantable cardioverter-defibrillator had recently been upgraded to a Dynagen™ X4 Cardiac Resynchronization Therapy Defibrillator (Boston Scientific Corporation), and he had been taking β-blockers and amiodarone. Physical examination results were notable for hemodynamic stability, jugular venous distention, a jugular venous pressure of 12 cm H₂O, and no evidence of pulmonary or hepatic congestion. The patient’s resting electrocardiogram (ECG) revealed a wide-complex rhythm (Fig. 1).