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).

Case #13 — Confusion, Ataxia, and Wide-Complex Tachycardia: What Caused This Arrhythmia?

by Justin Price, MD, Jinesh Shah, MD, Michael Q. Bui, MD, and Christopher D. Chiles, MD, FACC

A previously healthy 36-year-old woman presented at the emergency department with gradual-onset confusion, ataxia, and aphasia. Her vital signs were normal. On physical examination, she reacted to painful stimuli but was nonverbal and unable to follow commands. Initial laboratory results revealed no abnormalities. Computed tomograms of the head and results of a lumbar puncture were nondiagnostic. During hospitalization, the patient decompensated and needed emergency intubation and vasopressor support. An electrocardiogram (ECG) was obtained (Fig. 1). An echocardiogram revealed an acute reduction of left ventricular ejection fraction (range, 0.35–0.40) and anterior wall-motion abnormalities. Notable laboratory results included troponin I, 17.1 ng/mL; normal thyroid values; and negative toxicology screening.