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a McMaster University, Department of Medicine, Hamilton, Ontario, Canada b University of Ottawa, Department of Epidemiology and Community Medicine, Faculty of Medicine, Ottawa, Ontario, Canada c McMaster University, Department of Pathology and Molecular Medicine, Hamilton, Ontario, Canada d Stephenson Cardiovascular Magnetic Resonance Centre, University of Calgary, Alberta, Canada e Universite de Sherbrooke, Department of Cardiology, Quebec, Canada f McMaster University, Department of Medicine, Division of Cardiology, Hamilton, Ontario, Canada

A 76-year-old male with a pacemaker presented with acute pulmonary oedema requiring invasive mechanical ventilation. Transthoracic echocardiography (TTE) revealed a partially flail anterior mitral leaflet, severe mitral regurgitation (MR), and pulmonary hypertension, not present on previous TTEs. Transoesophageal echocardiography (TEE) demonstrated an elongated anterior mitral valve leaflet (AMVL) with a flail A2 …

Significant hypoxemia can result from right-to-left intracardiac shunting through a patent foramen ovale, an atrial septal defect or a ventricular septal defect. Pulmonary embolus, congenital heart disease and pericardial tamponade are well-recognized causes of right-to-left shunting. However, right-to-left shunting can also follow pericardiocentesis. A case of profound hypoxemia caused by right ventricular hypokinesis precipitated by pericardial tap is reported. This under-recognized entity can be responsible for significant morbidity in the critical care setting. The clinical presentation, natural history, diagnosis and treatment of hypoxemia caused by intracardiac shunt following pericardiocentesis are discussed.

A 51-year-old man with a history of ischemic cardiomyopathy who underwent a recent three-vessel coronary artery bypass graft and Dor procedure was admitted to a tertiary care hospital with ventricular tachycardia and congestive heart failure. He underwent a transthoracic echocardiogram, which demonstrated a noticeable aneurysm at the left ventricular apex (A) with patch closure (arrow) in the apical four-chamber view, consistent with a previous Dor procedure (Figure 1). Doppler flow studies suggested a patch leak with communication between the left ventricular cavity and apical aneurysm. A cardiac computed tomography scan demonstrated a communication across the patch closure (arrow in Figure 2), between the left ventricular cavity (LV) and the aneurysm (A). Figure 1 Figure 2 The Dor procedure was first performed in 1984 (1). It is a reasonable surgical ventricular restoration option for patients with severe left ventricular dysfunction and aneurysm. The Dor procedure involves endoventricular patch plasty closure of an apical aneurysm to reduce left ventricular cavity size, resulting in improved left ventricular function and cardiac output (2). The present patient, however, had disruption of the repair procedure, resulting in worsening cardiac function and heart failure without appreciable benefit. He eventually underwent successful cardiac transplantation and remained well two years later.

Staphylococcus aureus is a relatively common pathogen causing pneumonia in the community, hospital ward and intensive care unit. Although pneumonia is responsible for significant morbidity and mortality, especially in elderly and immunocompromised patients, it is usually uncomplicated and resolves without complications. The case of a woman who developed a para-aortic abscess after a community-acquired S aureus pneumonia infection is presented. A number of diagnostic imaging modalities were used to reach the diagnosis. This complication has not been reported previously and it is likely secondary to suppurative lymphadenitis of a station 5 or 6 node. The patient was successfully managed nonsurgically with computed tomography-guided drainage and intravenous antibiotics.

Apical hypertrophic cardiomyopathy (AHCM), first described by Sakamoto et al (1), is typically characterized by ‘giant negative T waves’ (larger than 10 mm), particularly in the precordial leads, asymmetrical left ventricular (LV) apical hypertrophy on echocardiogram and spade-shaped LV configuration on left ventriculography (2). An asymptomatic 55-year-old woman had repolarization abnormalities noted on a routine preoperative electrocardiogram (Figure 1A). The initial echocardiogram was normal, with no evidence of LV hypertrophy or segmental wall motion abnormalities. Subsequent investigations, including coronary catheterization and cardiac magnetic resonance imaging, led to the diagnosis of AHCM with LV apical aneurysm (Figures 1B and ​and1C1C). Figure 1) A Resting 12-lead electrocardiogram demonstrating voltage criteria for left ventricular hypertrophy and negative T waves of 2 mm to 4 mm in leads II, III, aVF and V3 to V6. B Left ventricular angiogram demonstrating apical aneurysm. C Left ventricular ... The present case illustrates that although the electrocardiogram and echocardiogram are commonly used in clinical practice, these tests may not be sufficient to exclude the diagnosis of AHCM. Further investigations, including cardiac magnetic resonance imaging, are essential to the diagnosis of this rare condition (3,4). The second point illustrated by the present case is that patients with AHCM are at risk of developing an aneurysm at the LV apex, which can potentially lead to increased incidence of embolic complications, arrhythmias and congestive heart failure (5).

s S119 pericardial effusion (PeriE), and in severe cases cardiac tamponade. Echocardiograms are routinely obtained following PVI to rule out PeriE. The V-Scan unit is a novel handheld ultrasound unit capable of limited echocardiographic imaging. It is lighter,more portable and less expensive to function than a traditional echocardiogram. We aimed to learn if V-Scan can safely be used to rule out PeriE in post PVI patients when compared to traditional echocardiogram. METHODS: Seventeen consecutive patients undergoing PVI for AF treatment at the Kingston General Hospital were included. All patients underwent limited echocardiogram protocol immediately following PVI with both VScan and traditional echocardiogram devices. Limited imaging protocol included 5 imaging planes in 4 chamber, 2 chamber, parasternal long-axis, parasternal short axis and subcostal views. A total of 34 sets (17 2) of patient and device specific images were obtained. All images were edited to eliminate deviceidentifying features and randomized for the evaluating cardiologist. Image quality and diagnostic power were compared. RESULTS: Quality: Among images rated excellent quality, 28.6% were from VScan, compared to 71.4% from traditional echocardiogram. Among all images rated poor quality, 75.0% were from VScan, compared to 25.0% from traditional echocardiogram. 82.4% of VScan images were rated adequate diagnostic quality or better. Among studies in which all 5 imaging planes could be satisfactorily obtained, 40% were obtained from VScan, compared to 60% from traditional echocardiogram. Diagnostic Power: There were 3 non-diagnostic studies, all of which are from VScan images. VScan images identified 2 pericardial effusions that did not match with the conclusion from the traditional echocardiogram images, in that no pericardial effusions were identified in the traditional echo images. CONCLUSION: 1 Traditional echocardiogram is superior in imaging quality and in ability to obtain multiple diagnostic imaging planes. 2 VScan led to more non-diagnostic studies and a tendency to over-diagnose pericardial effusion. 3 Nevertheless, VScan was able to obtain satisfactory diagnostic quality images in over 82.4% of patients. 079 THE UTILITY OF PORTABLE ECHOCARDIOGRAPHY AS A CLINICAL TOOL IN INTERNATIONAL MEDICINE: AN EXPLORATORY STUDY IN UGANDA DS Wright, MB Tsang, Z Khalid, J Schwalm, J Kayima, A Mulji, O Salehian

Fourteen patients with atrial fibrillation or flutter and a ventricular rate of greater than or equal to 120 beats/min occurring after cardiac surgery entered a double-blind placebo-controlled conditional crossover trial of intravenous propafenone. Patients randomly received either propafenone (2 mg/kg body weight) or placebo during a 10 minute intravenous infusion. If 20 minutes after the initiation of this infusion there was no conversion to sinus rhythm, the patient received a second intravenous infusion over 10 minutes (either propafenone or placebo, whichever was not given first). The electrocardiogram was recorded continuously throughout the study. Fourteen patients received propafenone and 10 received placebo. No patient's rhythm converted to sinus rhythm after placebo. In six patients (43%) (p less than 0.001), the arrhythmia converted to sinus rhythm between 5 and 10 minutes after the end of the propafenone infusion. After propafenone, the ventricular response to atrial fibrillation or flutter decreased significantly from 141.6 +/- 15.2 to 116.0 +/- 15.5 beats/min. Ventricular rate did not change after placebo. The mean propafenone plasma concentration was 3.46 +/- 2.17 mg/liter. The only side effect of propafenone noted was a decrease in systolic blood pressure of 9 +/- 9 mm Hg. Propafenone was useful for management of atrial fibrillation after cardiac surgery both for control of rapid ventricular response and for conversion to sinus rhythm.