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A 55-year-old woman with a history of chronic bronchitis, Clostridium difficile colitis, and alcohol and tobacco abuse was admitted with altered mentation, hyponatremia, and necrotizing right-upper-lobe pneumonia. She was started on cefepime and vancomycin; metronidazole was added for colitis. A resting electrocardiogram (ECG) showed sinus tachycardia with a QS pattern in the precordial leads, normal intervals, and small T-wave inversions in leads V5 and V6. Four days later, significant changes in her baseline telemetry rhythm prompted a repeat 12-lead ECG; the patient's pulse rate was 75 beats/min with a QT interval of 720 ms and QTc of 746 ms (Fig. 1). Her troponin T level was

Author(s): Mojadidi, Mohammad Khalid; Zhang, Lili; Chugh, Yashasvi; Eshtehardi, Parham; Hovnanians, Ninel; Gevorgyan, Rubine; Mojaddedi, Sanaullah; Nezami, Nariman; Zaman, Muhammad Omer; Rafique, Asim; Villablanca, Pedro A; Tobis, Jonathan M | Abstract: BackgroundTranscranial Doppler (TCD) with agitated saline has been shown to be an alternative for the detection of right-to-left shunts (RLS) with similar diagnostic accuracies as transesophageal echocardiography (TEE). It is hypothesized that the addition of blood to agitated saline increases the sensitivity of TCD for the detection of RLS. The aim of this meta-analysis was to determine whether agitated saline with blood increases the sensitivity of TCD for the detection of RLS compared to agitated saline alone and other contrast agents.MethodA systematic review of Medline, Cochrane, and Embase was performed to look for all prospective studies assessing intracardiac RLS using TCD compared with TEE as the reference; both tests were performed with a contrast agent and a maneuver to provoke RLS in all studies.ResultsA total of 27 studies (29 comparisons) with 1,968 patients met the inclusion criteria. Of 29 comparisons, 10 (35%) used echovist contrast during TCD, 4 (14%) used a gelatin-based solution, 12 (41%) used agitated saline, and 3 (10%) utilized 2 different contrast agents. The addition of blood to agitated saline improved the sensitivity of TCD to 100% compared to agitated saline alone (96% sensitivity, P = 0.161), echovist (94% sensitivity, P = 0.044), and gelatin-based solutions (93% sensitivity, P = 0.041).ConclusionThe addition of blood to agitated saline improves the sensitivity of TCD for the detection of RLS to 100% when compared to other conventional contrast agents; these findings support the addition of blood to agitated saline during TCD bubble studies.

Platypnea-orthodeoxia (POD) is a rare syndrome described by dyspnea and hypoxemia while upright that improves on recumbence. It is associated with an intracardiac shunt, pulmonary AVM, ventilation-perfusion mismatch or a combination of these. A 53-year-old woman was referred for unexplained hypoxia

It is well established that primary prophylactic ICD (P-ICD) implantation for heart failure (HF) for patients with a sustained left ventricle ejection fraction (LVEF) ≤ 35% has a significant survival benefit. However, data regarding rates of P-ICD implantation is scant especially in underserved

Macroscopic T-wave alternans (MTWA) is beat to beat variability in the vector or amplitude of T-waves on surface ECG. Often linked with acquired long-QT syndrome, MTWA is a sign of electrical instability and impending reentrant arrhythmias. This is a case of medication related QT-prolongation with