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Objective: LVADs are surgically implanted mechanical pumps that improve survival rates of individuals with advanced heart failure. LVAD therapy is associated with high morbidity, which can be partially attributed to challenges with detecting LVAD complications before adverse events occur. Current methods used to monitor for complications with LVAD support require frequent clinical assessments at specialized LVAD centers. Analysis of recorded precordial sounds may enable real-time, remote monitoring of device and cardiac function for early detection of LVAD complications. The dominance of LVAD sounds in the precordium limits the utility of routine cardiac auscultation of LVAD recipients. In this work, we develop a signal processing pipeline to mitigate sounds generated by the LVAD. Methods: We collected in vivo precordial sounds from 17 LVAD recipients, and contemporaneous echocardiograms from 12 of these individuals, to validate heart valve closure timings. Results: We characterized various acoustic signatures of heart sounds extracted from in vivo recordings, and report preliminary findings linking fundamental heart sound characteristics and level of LVAD support. Conclusion: Mitigation of LVAD sounds from precordial sound recordings of LVAD recipients enables analysis of intrinsic heart sounds. Significance: These findings provide proof-of-concept evidence of the clinical utility of heart sound analysis for bedside and remote monitoring of LVAD recipients.

Shielding the precordium can effect manifestation of haemodynamically significant patent ductus arteriosus (hsPDA). Preterm neonates born at ≤ 32 weeks of gestation if needed phototherapy within 72 h of birth and had no echocardiographically proven hsPDA were eligible to be enrolled in this open-label randomised controlled trial. In chest shielding group, in addition to the standard care, left side of the chest was covered using food grade aluminium foil during phototherapy while control group received standard care. Mean gestational age (weeks; 30.1 ± 1.5 vs 30.1 ± 1.6) was comparable in the two groups. However, neonates in the chest shield group had lower birth weight (g; 1281 ± 259 vs 1422 ± 307) and were more likely to be small-for-gestational age (21.6% vs 8.0%). It was seen that 4 (7.8%) babies in the chest shield group and 5 (10%) babies in the standard group developed hsPDA after starting phototherapy with relative risk (RR) of 0.78 (95% CI 0.22–2.75). The left atrium to aortic ratio was significantly different in the two groups with 1.5 ± 0.1 in the chest shield group and 1.8 ± 0.2 in standard group (p value 0.03). Conclusion: Chest shielding of preterm babies during phototherapy has no effect on the incidence of haemodynamically significant patent ductus arteriosus. Trial registration: Trial was registered with Clinical trial registry of India (CTRI/2018/01/011069).

Right pulmonary artery (RPA) to left atrium fistula (LA) is an extremely rare congenital malformation with less than 100 cases of PA-to-LA fistula reported. It causes central cyanosis and may present with heart failure. This is the first case to be closed under 2D and 3D TEE guidance inside cath lab. We present a case of a 12-year-old student who complained of exertional dyspnea and easy fatigability over the past few months. His mother reported mild cyanosis since birth which increased with exertion. On examination, he had central cyanosis with grade II clubbing in both fingers and toes, silent precordium with no audible murmur over his back). ECG showed normal sinus rhythm with no abnormality. CXR showed an abnormal shadow related to right cardiac border with prominent pulmonary artery and otherwise normal pulmonary vasculature. His complete blood count showed erythrocytosis with hemoglobin concentration of 16.4 g/dl and hematocrit value of 69.2%. Transthoracic echocardiography showed dilated left atrium with dilated right pulmonary artery. Patient was diagnosed to have a right pulmonary AV malformation. Invasive cardiac catheterization was done to identify size and number of this pulmonary AV malformation. Right pulmonary angiography showed a right pulmonary artery to left atrium fistula (type I) measuring 11 mm in its narrowest diameter with free shunting of blood. TEE guidance inside our cath lab showed normal pulmonary venous drainage into the left atrium, dilated right pulmonary artery opening into left atrium through an opening 10 mm with systolic flow across of low gradient (15 mmHg). A balloon was advanced across the fistula for sizing. Stretched diameter of fistula measured 13 mm. An Amplatzer ventricular septal occluder 14 was successfully positioned across the fistula. Right pulmonary angiography assured patent right lower pulmonary artery. TEE assured normal pulmonary veins flow into the left atrium. Patient saturation rose from 75% to 95%. Complete cure can be accomplished by transcatheter closure of direct pulmonary artery to left atrium communication. Systematic approach in assessment of patients with rare congenital anomalies can help their management despite of difficult clinical diagnosis. 2D and 3D TEE can guide RPA to LA fistula transcatheter closure as in ASD closure.

A 71-year-old woman with cardiac sarcoidosis underwent an implantable cardioverter-defibrillator implantation in the left precordium to prevent fatal arrhythmias. Two weeks later, she presented with dyspnea. Chest X-ray revealed right pneumothorax due to the active atrial lead perforation. Subsequently, air was detected surrounding the heart. Although it was difficult to differentiate pneumopericardium from pneumomediastinum, postural conversion computed tomography (CT) in the supine and prone positions documented air migration in the pericardial cavity and diagnosed pneumopericardium. This rare case of pneumopericardium combined with pneumothorax contralateral to the venous access site highlights the utility of postural conversion CT for diagnosis of pneumopericardium.

BackgroundAbstract:The unprecedented COVID situation has led to a steep learning curve. This is a case report of a patient who previously known to have a diagnosis of innocent murmur was re-investigated and found to have a rare congenital heart disease – aorto-pulmonary window (AP window).ObjectivesIntroduction:‘No question is simple’. Alert parents and an astute GP aided in the re-investigation of a murmur which led to the re-visiting the diagnosis from an innocent murmur to Aorto-pulmonary window (APW).APW is a rare congenital heart defect occuring as an isolated cardiac lesion or with other cardiac anomalies and rarely with abnormal coronary arteries. Its clinical presentation is dependent on the size of the defect and the associated lesions.MethodsCase report:A 4.5-year-old boy referred to PEC(Paediatrician with expertise in cardiology) clinic due to the query raised by parents - ‘ What are the implications of the pandemic on my child with a murmur?’This murmur had which was previously investigated when he was a toddler and found to be innocent, was assessed by the GP during the pandemic. Apart from mild difficulty breathing at rest on occasion, the parents posed no other concerns. Parents on reflection comprehend why he did not enjoy physical sports like his peers.On clinical examination, he had frontal bossing, prominence of the left chest wall and engorged vein in the upper part of chest. He had visible apical impulse, hyperdynamic impulse, gallop rhythm. The P2 was loud and 4/6 pansystolic murmur that radiated all over the precordium and back, loudest at the left lower sternal edge. Rest of his examinations were normal.ResultsA further ECHO confirmed AP window with pulmonary hypertension. He had an initial device closure but a residual shunt was identified following a diagnostic cardiac catheterization. He has now had corrective surgery was performed with no intraoperative complication and good echo results. Pulmonary hypertension has persisted and he will be under continued to be followed up in cardiac clinic.He is going to be followed up in 4–6 weeks in a cardiology clinic.ConclusionsDiscussion:No question is simple and although it has been an unprecedented time last year, it led to re-visiting the child’s clinical condition and thus a rare diagnosis.APW consists of a communication between the ascending aorta and the pulmonary trunk and/or the right pulmonary artery. Some literature suggests a majority of the APW is associated with other cardiac anomalies. Our patient was a case of isolated APW.1Literature also suggests APW can be confused with other defects. Clinical findings associated with an adequate echocardiogram can provide the information for the correct diagnosis.APW has similar hemodynamic features to a patent ductus arteriosus or, even more so, to a common truncus arteriosus (CTA).Referencehttps://www.scielo.br/pdf/abc/v73n1/a06v73n1.pdf- Aortopulmonary Window. Clinical and Surgical Assessment of 18 Cases. Andressa Mussi Soares, Edmar Atik, Tâmara Martins Cortez, Angela Maria T. Albuquerque, Claudia P. Castro, Miguel Barbero-Marcial, Munir Ebaid Sao Paulo, SP - Brazil

Introduction: Patients presenting with cardiac injuries from gunshot wounds and blunt chest trauma have high mortality, without any observed survival benefit when presenting with cardiac tamponade. Cardiac tamponade is a life-threatening hemodynamically significant compression of the heart by a sudden or gradual accumulation of collections in the pericardial space that incites and overrides the body’s compensatory mechanism. Clinical Case: We present and discuss the successful management and survival of two patients with traumatic cardiac tamponade from gunshot wounds to the precordium who underwent successful lifesaving median sternotomy at a Teaching Hospital in Ghana with a new Cardiovascular and Thoracic Surgery Unit. Discussion: Usually the diagnosis of cardiac tamponade from traumatic haemopericardium is made by clinical findings which though may not always be present especially after blunt chest trauma. EFAST is a reliable tool for diagnosing and following cardiac tamponade. Median sternotomy is the standard procedure in these patients to access and repair cardiac injury either with or without cardiopulmonary bypass. Conclusion: Emergency median sternotomy in patients with cardiac tamponade from chest trauma especially after EFAST diagnosis can be lifesaving even in less resourced centres.

Nonpenetrating blunt force trauma to the front of the chest can lead to commotio cordis, a cardiac rhythm disturbance, which can result in cardiac arrest and death. The condition is particularly noted during sport. No series of such cases has been published in the UK. This study is a retrospective analysis of a database of 6000 cases of sudden cardiac death examining commotio cordis in the setting of collapse and death shortly following a blow to the precordium where no structural heart disease was identified at autopsy. Of the 17 cases, 16 were male, and 11 were 18 years old or younger. Eleven occurred whilst playing sport while 6 involved physical interaction including assault. The most common circumstance of death involved a youth being struck in the chest by a ball during sporting activity. In conclusion, this study demonstrates that cases of commotio cordis in the UK follow a similar circumstantial and age profile to those reported in the United States, and indicates that ball sports such as football, cricket, and rugby expose young participants to a similar risk. There is currently no nation-wide registry of deaths occurring during sporting activity in the UK, and although the true incidence of this condition is not currently known, it is most probably under-recognised and underdiagnosed.

A 79-year-old man with dilated cardiomyopathy and severe functional mitral regurgitation presented with general fatigue and dyspnea. Auscultation revealed a systolic regurgitant murmur with a minimized second heart sound due to a low output. On the other hand, the third heart sound was ultimately enhanced, being visible and palpable as a pulsatile knock of the precordium. Phonocardiography and echocardiography successfully confirmed early-diastolic rapid distension of the left ventricle along with rapid ventricular filling and abrupt deceleration of the atrioventricular blood flow to be the precise etiology of the ultimate third heart sound, indicating critically deteriorated hemodynamics due to massive mitral regurgitation combined with a low output.

A cardiac apex impulse sensing based on a singlemode-multimode-singlemode (SMS) fiber structure has been demonstrated experimentally to monitor heart pulse in the human body. The sensor was placed onto the sample’s skin at the precordium area. By detecting the power output variation due to vibration applied to the SMS fiber structure by cardiac apex impulse, the heart condition could be observed. The pulse wave signal pattern which was obtained had the similar signal pattern with the apex cardiography reference signal graph. The proposed method can be used to measure vital signs with several advantages, such as real-time and accuracy, high sensitivity, reproducible, low cost and convenient operation.

A 53-year-old man presented with shortness of breath for 10 days. Due to the ongoing COVID-19 pandemic, he delayed seeking medical attention. ECG showed sustained monomorphic ventricular tachycardia (figure 1A). He converted to normal sinus rhythm with intravenous lidocaine. A holosystolic murmur was heard on auscultation of precordium. Repeat ECG showed ST-segment elevation in inferior leads (figure 1B). Serum troponin was 0.09 ng/mL (normal 0.00–0.04 ng/mL). Figure 1 (A) Initial EKG showing monomorphic ventricular tachycardia. (B) EKG after cardioversion showing sinus rhythm and persistent ST elevation in inferior leads. A transesophageal echocardiogram showed left ventricular (LV) ejection fraction of …

Purpose There is no concrete evidence to support the association between the amount of subcutaneous fat area (SFA) in the central venous port-insertion site (precordium) and port-related complications. We aimed to investigate the relationship between SFA in the midclavicular line and postoperative infectious complications in patients undergoing port-insertion surgery. Methods This was a single-institute and historical cohort study of 174 patients who underwent first central venous port implantation surgery for chemotherapy between January 2014 and December 2018. SFA in the midclavicular line was measured using preoperative computed tomography scans. The patients were divided into three groups according to SFA amount tertiles, and we investigated the association of SFA with infectious and all-cause complication events within 1 year. Results Within a median follow-up of 306 days, the patients with intermediate SFA had significantly higher infection-free survival than those with low and high SFA (low vs. intermediate vs. high: 80.4% vs. 97.7% vs. 83.4%, respectively, p=0.034). In contrast, there was no significant difference in the overall complication-free survival among the groups (low vs. intermediate vs. high: 80.4% vs. 88.9% vs. 81.8%, respectively, p=0.29). Low SFA was independently associated with high risk of infectious complications (hazard ratio, 9.45; 95% confidence interval, 1.07–83.22, p=0.043). Conclusion Low SFA in the midclavicular line was an independent risk factor for infectious complications in the chemotherapy setting. This practical indicator can be useful for optimizing patients’ nutritional status and when considering other types of vascular access to support administration of intravenous chemotherapy.

A 74-year old female patient presented with a 3-week history of fever, general weakness, and later developed complete heart block. On admission, the patient was febrile (temperature of 39°C) and tachypnoeic (respiratory rate of 29/min) with oxygen saturation of 95% on 2 L of oxygen. Her heart rate was 60 beats/min (VVI pacing), arterial blood pressure was 135/60 mm Hg and the Glasgow Coma Scale was 15. On chest auscultation, she had a harsh systolic murmur over her left precordium and bilateral rales. Blood tests demonstrated moderate anemia (hemoglobin of 95 g/L), leucocytosis (white blood cell count of 13.13 x 10^9/L), hypoalbuminemia (albumin concentration of 18 g/L), normal liver function tests and creatinine clearance of 45 ml/min. Computed tomography aortography demonstrated an irregular mass arising from the aortic root that extended into the right atrium (RA) and a fistulous tract (the Gerbode defect) between the left ventricular outflow tract (LVOT) and the right ventricle (RV). Transoesophageal echocardiography showed large vegetation in the RA and left to right cardiac shunt through the Gerbode defect from the LVOT to the RA and the RV. Using cardiopulmonary bypass, the patient underwent resection of the aortic cusps, debridement of the aortic root, septal and anterior leaflets of the tricuspid valve, and the membranous septum. The Gerbode defect was closed with an autologous pericardial patch, then a sliding annuloplasty of the septal leaflet of the tricuspid valve was performed. Finally, the aortic root was replaced with a 23 mm Freestyle xenograft.

Ebstein's disease is a rare malformation of the tricuspid valve, accounting for approximately 1% of all cardiac malformations. It is an anomaly of the tricuspid valve where most often the 3 sheets are involved, to varying degrees, preventing the tricuspid valve from working properly. A 32 years old women was addressed to the hospital for palpitations, chronic dyspnea, edema of the lower limbs, and cyanosis. She has no history, nor known cardiovascular risk factors. The initial somatic examination showed signs of right heart failure with blood pressure at 132/75 mmHg, and heart rate at 130 beat per minute. At cardiac auscultation, we noted a systolic murmur on all the precordium, maximum at the tricuspid focus, without signs of left heart failure. The electrocardiogram revealed a common flutter. The echography showed an enormous dilation of the right cavities with atrialization of the ventricule by a low insertion of the tricuspid valve towards the right ventricule tip with offset between the mitral and tricuspid valve above 20mm. The Doppler revealed severe tricuspid regurgitation with a pulmonary hypertension estimated at 86 mmHg. After optimal treatment by converting enzyme inhibitor, digitalics, and diuretics, the patient was referred for tricuspid valve replacement associated to an atrialized plication of the right ventricule. Ebstein's disease is a rare malformation of the tricuspid valve. The risk of sudden death remains high and unpredictable even in operated subjects with post-operative clinical improvement.

A 26-year-old man with a history of a perimembranous ventricular septal defect (VSD) was admitted to the orthopaedic service after sustaining a tibial fracture in a motor vehicle accident. He was lost to cardiology follow-up after age 10, at which time his echocardiogram demonstrated a restrictive VSD (gradient of 80 mm Hg across) and mild flow acceleration without obstruction through the right ventricular outflow tract (RVOT). Cardiac examination on admission was notable for a palpable RV lift and a harsh 3/6 systolic ejection murmur audible throughout the precordium. An echocardiogram was obtained, demonstrating new …

In case of suicide, the presence of multiple entrance wounds is always suspicious. We report the case of a man who committed suicide by shooting himself three times in the chest and the skull with a submachine gun. The weapon seems to have been initially pointed in the precordium area with a lethal lesion of the proximal aorta. Two other projectiles were fired by the weapon and hit the neck and the skull of the deceased. The presence of three entrance wounds despite a first fatal wound could finally be explained by the characteristics of the weapon and wounds. Most suicides related to multiple gunshot wounds are explained by a first nonlethal shot but the use of an automatic weapon can also be found. In these last cases, medicolegal and criminalistics aspects become important in differentiating suicide and homicide.

A young boy presented with cyanosis and shortness of breath since childhood. Clinically, he has a single second sound, a quiet precordium, and no murmurs. Further investigations reveal a ventricular septal defect and Eisenmenger syndrome. The steps of clinical evaluation from history to examination and investigations are discussed. The management given and potential complications and their management are discussed.

Background Case reports of cardiac arrest in temporal proximity to Conducted Electrical Weapon(CEW) exposure raise legitimate concerns about this as a rare possibility. In this pilot study, we respectfully navigate the oversight and regulatory hurdles and demonstrate the intra-shock electrocardiographic effects of an intentional transcardiac CEW discharge using subcutaneous probes placed directly across the precordium of patients with a previously implanted intracardiac EKG sensing lead. Methods Adults scheduled to undergo diagnostic EP studies or replacement of an implanted cardiac device were enrolled. Sterile subcutaneous electrodes were placed at the right sternoclavicular junction and the left lower costal margin at the midclavicular line. A standard police issue TASER Model X26 CEW was attached to the subcutaneous electrodes and a 5 s discharge was delivered. Continuous surface and intracardiac EKG monitoring was performed. Results A total of 157 subjects were reviewed for possible inclusion and 21 were interviewed. Among these, 4 subjects agreed and completed the study protocol. All subjects tolerated the 5 s CEW discharge without clinical complications. There were no significant changes in mean heart rate or blood pressure. Interrogation of the devices after CEW discharge revealed no ventricular pacing, dysrhythmias, damage or interference with the implanted devices. Conclusions In this pilot study, we have successfully navigated the regulatory hurdles and demonstrated the feasibility of performing intracardiac EKG recording during intentional precordial CEW discharges in humans. While no CEW-associated dysrhythmias were noted, the size of this preliminary dataset precludes making conclusions about the risk of such events. Larger studies are warranted and should consider exploring variations of the CEW electrode position in relation to the cardiac silhouette.

Introduction Stress has been associated with acute heart failure syndrome, with significant morbidity and mortality. Methodology Case report and non-systematic review of relevant literature. Case report A 65-year-old woman with a history of untreated generalised anxiety disorder who, after the violent death of a child, suffered oppressive pain in the precordium, neck and upper left limb that lasted more than 30 min; the initial clinical suspicion was acute coronary syndrome. Literature review Takotsubo cardiomyopathy is characterised by left ventricular dysfunction, reversible in most cases, and altered ventricular wall motion in the absence of coronary abnormalities, associated with high plasma concentrations of catecholamines, which in most cases coincide with an acute physical or emotional stressor. Conclusions Takotsubo cardiomyopathy is a differential diagnosis that physicians treating patients with suspected coronary syndrome should consider, especially in postmenopausal women with a history of psychiatric comorbidities such as generalised anxiety disorder.

Commotio cordis is an increasingly reported fatal mechano-electric syndrome and is the second most common cause of sudden cardiac death in young athletes. It is most commonly associated with a sports-related injury, wherein, there is a high-velocity impact between a projectile and the precordium. By virtue of this impact, malignant arrhythmias consequently develop leading to the individual’s immediate demise, accompanied by a relatively normal post-mortem analysis. The importance of an autopsy remains paramount to exclude other causes of sudden death. With increasing awareness and reporting, survival rates are beginning to improve; however, prevention of the development of this condition remains the best approach for survival.

The article contains data pertaining to the reconstruction of an 8-lead ECG from 2 subcutaneous implantable cardioverter defibrillator vectors. The location of electrodes on the precordium required for the data collection are detailed; the flow chart for patient selection and exclusion is shown; the summary data of the root mean square error (RMSE) (in microvolts) and Pearson r for the ECG transformation all cases and the pearson correlation for all the leads measured and reconstructed leads are also shown. Detailed background, methodology and discussion can be found in the linked research article.

The first human electrocardiogram (ECG) ever recorded is accredited to the British physiologist Augustus D. Waller who, in 1887, published a paper depicting several beats of a one-lead ECG using a refined Lipmann capillary electrometer. The recordings were obtained with one electrode placed in the back and the other over the precordium. Subsequently, in 1895, Willem Einthoven, a Dutch physician and physiologist, further improved the capillary electrometer and mathematically corrected human ECG tracings to allow for inertia and friction in the capillary. For the corrected curves, and based on the mathematical tradition initiated by Descartes more than two centuries earlier, he labeled the successive deflections PQRST, labels that we still use today. Furthermore, Einthoven later improved the sensitivity of the capillary electrometer, developed the string galvanometer, and, in 1903, published recordings of human ECGs as we know them these days. For these extraordinary and related achievements, including the demonstration of its clinical application, he received the Nobel Prize in Medicine in 1924.

Reported here is a rare respiratory complication in a young primiparous woman in a remote community hospital in the Northern Territory, Australia. A Caucasian primiparous woman aged 23 years presented with chest pain following a very prolonged second stage of labour. On clinical examination a crunching and crackling sound was heard over the precordium, synchronous with the heartbeat (Hamman's sign). A chest radiograph confirmed the presence of pneumomediastinum. Complete resolution of symptoms and signs was achieved with supportive management.

A 26-year-old man presented to our emergency department with a dull, pleuritic chest pain after being shot on the chest during a football match. The pain radiated to the back and was exacerbated by coughing. Shortness of breath was noted. On examination, the patient was found to have a high-pitched voice and crepitus over the neck and clavicles. Chest expansion was symmetrical and the lung was clear bilaterally. There was no hyper-resonance on percussion. A crunching sound during systole was auscultated over the precordium. The …

Heart surgeries, such as cardiac ablations, require an extremely accurate estimate of the location of the myocardium in millimeters. This paper develops the use of a UWB radar system to track the position of the myocardium in real time. We construct a phantom to simulate the dielectric propagation path from the precordium to the myocardium which includes an obstacle to simulate the chest wall and a motion stage to simulate cardiac motion. We use a commercially available radar system operating in the 6–10 GHz frequency range, however, this large bandwidth is still inadequate. Therefore, we utilize the high available sampling rate to interpolate, using the Gaussian transmitted signal, to obtain finer resolution. We test our approach by tracking the phantom position with the motion stage simulating sinusoidal and chirp movements. The results show that the radar system can provide adequate resolution to track a cardiac wall phantom. The next paper will report the experiments on a live cardiac wall with ethics approval.

Pneumomediastinum is defined as free air or gas within the mediastinum, and in case of spontaneous pneumomediastinum there is no evidence of trauma, invasive procedures or previously diagnosed lung diseases. Spontaneous emphysema is a rare condition at urgent care centers. Hammam’s syndrome or spontaneous pneumomediastinum is more frequent in young adults. The more frequent symptoms are chest pain and dyspnea. Hammam’s sign, a pathognomonic sign of mediastinal emphysema, is a crunching, rasping sound, synchronous with heartbeat, heard over the precordium. Pneumomediastinum is diagnosed with the aid of chest X-rays and chest CT scans. It is usually a benign self-limited condition. Treatment is conservative and symptom alleviating. The purpose of this study was to describe a case of Hammam’s syndrome and the importance of clinical evaluation and early diagnosis of this disease

A 76-year-old woman loses a close friend. Several hours later, she has chest pain, diaphoresis, and shortness of breath. She presents to the emergency department, where an ECG shows deep T wave inversion across the precordium. Cardiac troponin is elevated. This presentation is classic for myocardial ischemia and for stress cardiomyopathy. Recognition of stress cardiomyopathy, and its distinction from acute coronary syndrome (ACS), is crucial for the clinician, since their pathophysiology and treatment are quite different. Stress cardiomyopathy is an acute reversible syndrome with characteristic wall motion abnormalities, consisting of apical hypokinesis or dyskinesis with sparing of the basal ventricular segments. Although the final outcome is generally good, early in their clinical course, patientsmay have cardiogenic shock (4 %), malignant ventricular arrhythmias (1–2 %), and death (1–1.5 %) [1]. Stress cardiomyopathy can complicate other conditions in the ICU, notably including subarachnoid hemorrhage. Patients with these more complex presentations often present clinical challenges. This manuscript aims to increase understanding of the identification and pathophysiology of stress cardiomyopathy to help practitioners manage this interesting syndrome.

The vibrations produced by the cardiovascular system that are coupled to the precordium can be noninvasively detected using accelerometers. This technique is called seismocardiography. Although clinical applications have been proposed for seismocardiography, the physiology underlying the signal is still not clear. The relationship of seismocardiograms of on the back-to-front axis and cardiac events is fairly well known. However, the 3-D seismocardiograms detectable with modern accelerometers have not been quantified in terms of cardiac cycle events. A major reason for this might be the degree of intersubject variability observed in 3-D seismocardiograms. We present a method to quantify 3-D seismocardiography in terms of cardiac cycle events. First, cardiac cycle events are identified from the seismocardiograms, and then, assigned a number based on the location in which the corresponding event was found. 396 cardiac cycle events from 9 healthy subjects and 120 cardiac cycle events from patients suffering from atrial flutter were analyzed. Despite the weak intersubject correlation of the waveforms (0.05, 0.27, and 0.15 for the x-, y-, and z-axes, respectively), the present method managed to find latent similarities in the seismocardiograms of healthy subjects. We observed that in healthy subjects the distribution of cardiac cycle event coordinates was centered on specific locations. These locations were different in patients with atrial flutter. The results suggest that spatial distribution of seismocardiographic cardiac cycle events might be used to discriminate healthy individuals and those with a failing heart.

Introduction Seismocardiography (SCG) includes vibration signals propagated to the chest surface from cardiac valve movement, blood flow and myocardial muscle contraction. SCG feature analysis may prove useful in the early non-invasive detection of HF deterioration. In this study, the propagation and coupling of cardiac surface motion to the anterior chest surface was modeled using computer simulations. Objective Develop a computational model of SCG propagation to enhance understanding of SCG genesis, and SCG's spatial amplitude and spectrographic distribution over the anterior chest wall. Methods The computational geometry was extracted from short-axis cardiac cine MRI imaging of a healthy participant. Cardiac wall motion was captured by applying a 3D motion tracking algorithm to the cine MRI images. The propagation of cardiac motion to the chest surface was simulated using Finite Element Method (FEM). A mechanical model was also developed where the displacements at a simulated heart wall were coupled to a mechanical chest surface model using an array of linear actuators. Results Common SCG feature points (e.g., MC-mitral valve closure; IM- Isovolumic contraction; AO- aortic valve opening; AC- aortic valve closure; and MO- mitral valve opening) were predicted by the model. Furthermore, the timing of these feature points was validated against the left ventricle volume variation extracted from short-axis cine MRI images. The maximum SCG amplitude (in the dorso-ventral direction) was observed in the 4th intercoastal space near the left lower sternal border. The pilot results of the mechanical model were in a qualitative agreement. Conclusions The computer model predicted the feature points observed in real SCG measurements. The current model may be utilized in the future to study the distribution of SCG over precordium and to analyze the effect of the properties of cardiac and contiguous chest structures, including great vessels, chest wall ribs, muscles and articulations, lungs, and cutaneous soft tissue. Further model development may deepen understanding of SCG generation and propagation, increasing its potential utility for diagnosis and monitoring of cardiac pathologies.

A 25-year-old woman with no cardiovascular risk factors was admitted to our hospital with dyspnea and palpitations during the last two months. Physical examination showed blood pressure of 150/50 mm Hg and a continuous murmur across the precordium in cardiac auscultation was observed. The 12 leads electrocardiogram was normal. Chest X-ray showed a slight cardiomegaly. The transthoracic echocardiography revealed dilatation of the right cavities and a rupture of right sinus of Valsalva aneurysm (SVA) into the right atrium (Fig. 1A). The Doppler study (Fig. 1B) and transesophageal echocardiography confirmed the shunt between the right SVA and the right atrium (Fig. 1C and D, Supplementary movie 1 and 2). The rupture of right sinus of Valsalva was also demonstrated by real time 3D transesophageal echocardiography (Fig. 2A, Supplementary movie 3). Unlike transthoracic and transesophageal echocardiography which shows shunt between right SVA and right atrium, computed multidetector tomography, showed a communication between the right SVA and right cardiac chambers (right atrium and right ventricle) (blue circle, Fig. 2B). These findings were confirmed during surgery (blue arrow, Fig. 2C), and the fistula was closed (Fig. 2D). The patient's postoperative course was uneventful. The patient was discharged on the sixth post-operative day. At two years follow-up, the patient remains asymptomatic. Fig. 1 A: Transthoracic echocardiography, parasternal short axis view at level of great vessels, revealed rupture of right sinus of Valsalva into the right atrium (asterisk). B, C, and D: Transesophageal echocardiography and color Doppler study confirming the ... Fig. 2 A: Real time 3D transesophageal echocardiography, in zoom mode, showing rupture of right sinus of Valsalva into the right atrium (blue arrow). B: Computed multidetector tomography showing communication between the right sinus of Valsalva and right cardiac ... SVA are rare but well known congenital anomalies. They occur three times more often in males with highest incidence in Asian populations. They commonly rupture into the right ventricle or right atrium,1) rarely into the both right cardiac chambers as was observed in case presented herein. Moreover, in Africa the main complication of the SVA is the dissection into ventricular septum.2) Since the first echocardiographic description of SVA by Rothbaum et al.3) in 1974, the echocardiography plays a pivotal role in the definitive diagnosis aneurysm of the sinus of Valsalva. However, in recent years several papers have been published emphasizing the use of other imaging modalities for diagnosis of this heart condition.4),5) According to several reports, the diagnosis of SVA was made at echocardiography in 90% of cases. In present case the multidetector tomography gave more precise information showing a rare type of rupture of SVA-rupture into right cardiac chambers, and the role of multidetector tomography as additional tool for the precision of the diagnosis. In present case the detailed anatomic and functional information obtained by these non-invasive tests were enough to guide the surgical planning without recourse to invasive studies. Invasive tests must be reserved for patients in whom the percutaneous closure of the fistula is possible, or the suspicion of coronary disease is present. Finally, given the widespread use of these new noninvasive tests, cardiologists and radiologists should be able to recognize this rare disease.

An 11-year-old boy was admitted to hospital with symptoms of nausea, edema, fatigability, and inability to lie down, which slowly developed over the past 4 months. Transthoracic echocardiography and an ECG were performed and showed the diagnosis of double-chambered left ventricle (DCLV). A physical examination showed protrusion of the precordium, soft heart sounds, cardiomegaly, a grade 3/6 systolic murmur at the cardiac apex, and enlargement of the liver to 3 cm below the right costal margin. ECG showed a sinus rhythm with left ventricular hypertrophy. Transthoracic echocardiography demonstrated that the left ventricle was divided into basal and apical chambers by an incomplete fibromuscular septum (Figure 1A). The basal chamber, which communicated with the left atrium and the normally positioned aorta, was severely enlarged with an end-diastolic diameter of 80.7 mm. This chamber was abnormally configured to the shape of a ball. The basal and midventricular septum expanded toward the right ventricle. The left ventricular wall and septum had impaired contraction with severe reduction of the left ventricular ejection fraction to 35%. Systolic pressure of the 2 chambers was similar, and the diameter of communication between them was 16.0 mm. There was thinning of the wall of the apical chamber. A DCLV was also shown by cardiac magnetic resonance imaging (Figure 1B). The patient’s ECG showed sinus rhythm, T-wave changes, and enlargement of the left ventricle and left atrium (Figure 1C). Figure 1. Clinical feathers of the DCLV proband. A , Apical 4-chamber view of transthoracic echocardiography of the proband. B , Cardiac magnetic resonance imaging shows the diagnosis. C , ECG result of the proband. white arrow, fibromuscular septum. LA indicates left atrium; LV1, basal chamber of the left ventricle; LV2, apical chamber of the left ventricle; RA, right atrium; …

Clinical data: Heart murmur was identified at auscultation in childhood, but the diagnosis of aortic coarctation associated with atrial septal defect was attained when the patient was 15 years old. The patient practiced regular physical activity and did not report symptoms for up to 5 years, when he became sedentary. He received specific anti-hypertensive medication. Physical examination: patient was eupneic, acyanotic, obese, ample pulses in the upper limbs and decreased in the lower limbs. Weight: 113 kg; height: 177 cm; Body Mass Index (BMI): 36.1 kg/m2; RUL BP was the same in the LUL, 149/89 mmHg; right inferior limb BP = 113/77 mmHg; Heart rate (HR): 82 bpm; oxygen saturation of 95%. The aorta was clearly palpable at the suprasternal notch. The apex beat was not palpable in the precordium and there were no systolic impulses in the left sternal border (LSB). Normal heart sounds; constant split second sound and rough systolic murmur + / ++ / 4, was heard in the upper LSB. The liver was not palpable.

In rare circumstances, hemodynamically stable patients can harbor serious penetrating cardiac injuries. We hypothesized that chest computed tomography (CCT) is potentially useful in evaluation. The records of all patients admitted to our center with wounds to the precordium or who sustained a hemothorax or pneumothorax after penetrating torso injuries over a 48-month period were reviewed. Those having an admission CCT were studied. The potential diagnostic value of hemopericardium (HPC) and pneumopericardium (PPC) on CCT was examined. Most of the 333 patients were male [293 (88.0 %)] with a roughly equal distribution of gunshot [189 (56.8 %)] and stab [144 (43.2 %)] wounds. Mean age was 28.7 ± 12.6 years. Thirteen (3.9 %) patients had cardiac injuries that were operatively managed. Eleven (3.3 %) CCT studies demonstrated HPC and/or PPC. Ten of these patients had an injury with one false positive. Retained hemothorax and proximity findings on the three false negative CCT studies led to video-assisted thoracoscopic surgery or subxiphoid exploration with diagnosis of the injury. HPC and/or PPC on CCT had a sensitivity of 76.9 %, specificity of 99.7 %, positive predictive value of 90.9 %, and negative predictive value (NPV) of 99.1 % for cardiac injuries. However, including all findings that changed management, CCT had a sensitivity and NPV of 100 %. CCT is a potentially useful modality for the evaluation of cardiac injuries in high-risk stable patients. The presence of HPC and/or PPC on CCT after penetrating thoracic trauma is highly indicative of a significant cardiac injury.

Purpose: Since non-provocative dive profiles are no guarantor of protection against decompression sickness, novel means including pre-dive "preconditioning" interventions, are proposed for its prevention. This study investigated and compared the effect of pre-dive oxygenation, pre-dive whole body vibration or a combination of both on post-dive bubble formation. Methods: Six healthy volunteers performed 6 no-decompression dives each, to a depth of 33 mfw for 20 min (3 control dives without preconditioning and 1 of each preconditioning protocol) with a minimum interval of 1 week between each dive. Post-dive bubbles were counted in the precordium by two-dimensional echocardiography, 30 and 90 min after the dive, with and without knee flexing. Each diver served as his own control. Results: Vascular gas emboli (VGE) were systematically observed before and after knee flexing at each post-dive measurement. Compared to the control dives, we observed a decrease in VGE count of 23.8 ± 7.4% after oxygen breathing (p < 0.05), 84.1 ± 5.6% after vibration (p < 0.001), and 55.1 ± 9.6% after vibration combined with oxygen (p < 0.001). The difference between all preconditioning methods was statistically significant. Conclusions: The precise mechanism that induces the decrease in post-dive VGE and thus makes the diver more resistant to decompression stress is still not known. However, it seems that a pre-dive mechanical reduction of existing gas nuclei might best explain the beneficial effects of this strategy. The apparent non-synergic effect of oxygen and vibration has probably to be understood because of different mechanisms involved., SCOPUS: ar.j, info:eu-repo/semantics/published

Coronary cameral fistula is a rare congenital cardiac abnormality. An 18-year-old boy presented with features of right heart volume overload. Clinical examination was suggestive of hyperdynamic circulation with continuous murmur in precordium. 2D echocardiography showed dilated right coronary artery, and 3D echocardiography added information in tracing the track of the fistula which was consistent with the diagnosis of right coronary cameral fistula draining into the right ventricle. Coronary angiograms revealed an unusually dilated right coronary artery giving the appearance of an "elephant trunk" and with a fistulous tract into the right ventricle. Considering the higher risks of surgery in such difficult cases, we performed a successful transcatheter closure of the fistula using an Amplatzer vascular plug.

Epicardial mapping and ablation via subxiphoid percutaneous ablation has advanced the field of ventricular tachycardia ablation in the setting of structural heart disease. Significant pericardial adhesions are well recognized in the setting of post cardiac surgery and recurrent pericarditis. We present a rare complication that resulted during dissection of pericardial adhesions during a percutaneous approach in a patient without prior history of cardiac surgery or pericarditis. A sixty-seven-year-old woman presented with a history of palpitations and presyncope over a 2 month period. During hospitalization, she had an episode of paroxysmal ventricular tachycardia with right bundle branch block morphology and R wave–dominant precordium (Figure 1). Ejection fraction was 70% without wall motion abnormalities. She did not have a history of myocardial infarction, myocarditis, or tuberculosis. She underwent …

Venous air embolism is a devastating and potentially life-threatening complication that can occur during neurosurgical procedures. We report the development and use of the "inter-mammary sticky roll,"a technique to reliably secure a precordial Doppler ultrasonic probe to the chest wall during neurosurgical cases that require lateral decubitus positioning. We have found that this noninvasive technique is safe, and effectively facilitates a constant Doppler signal with no additional risk to the patient.

Instantaneous death after a relatively minor hit on the precordium is known as commotio cordis (CC). Mechanical stimulation of the heart by a nonpenetrating, impulse-like impact is sufficient to induce ventricular fibrillation (VF) in an otherwise normal heart, but not forceful enough to make structural damage to the myocardium or the thoracic cage. It is second to hypertrophic cardiomyopathy as a cause of sudden death in young individuals engaged in sport. When the blow on the chest coincide with the vulnerable period in the cardiac cycle produce a phenomenon similar to ‘R on P’ in premature ventricular complexes (PVC) resulting in VF. Two thirds of the events are sports related. Timing of the impact, hardness and speed of the projectile plays an important role in the pathophysiology of CC. Higher velocity projectiles may produce more severe injury resulting in tissue trauma but not CC. The site of impact on the chest is also crucial. It is the portion ofthe chestwall exactly overlying the letventricle on the left of sternum which has to be struck to produce CC. Training persons involved in sports related activities in cardiopulmonary resuscitation and making defibrillators immediately available may prevent some deaths related to CC. Designing softer balls and protective devices may prevent although not eliminate CC.

Clinical data: The patient reports that a heart murmur had been heard at childhood; however, the diagnosis of coarctation of the aorta was made 1 month ago by echocardiogram and CT scan, performed due to recent complaints of tired legs. She performed physical activities on a regular basis and did not report headache. She was not receiving any specific medication. Physical examination: Normal breathing; acyanotic; brisk pulses in upper limbs, absent in lower limbs. Weight: 58 kg; height: 166 cm; blood pressure (BP) in right arm equal to that in left arm = 140/80 mmHg, BP in legs: 80 mmHg; heart rate (HR): 78 bpm; oxygen saturation: 96%. Aorta clearly palpable on the suprasternal notch. Thrill and grade 1/4 mild systolic murmur on the suprasternal notch. The apical impulse was not palpable in the precordium, and there were no systolic impulses on the left sternal border. Normal heart sounds; grade 1/4 systolic murmur in the aortic area and back, both on the right and left sides. Liver not palpable.

Background Sudden death due to low-energy blunt trauma to the precordium (commotio cordis) has been described with a variety of sporting objects. However, the risk of ventricular fibrillation (VF) relative to the shape of the impact object is not known. Objective The objective of the current experiment is to test whether the impact object shape is a clinical variable that affects the risk for commotio cordis. Methods In a juvenile swine model, impacts were given in random order with two different spherical shapes (72 mm diameter, equivalent to a baseball; 42 mm diameter, equivalent to a golf ball) and a flat round object 72 mm in diameter. Objects were equal in weight (150 g), thrown at 30 mph, and gated to the vulnerable portion of the cardiac cycle. Results Sixteen swine received 144 impacts. The flat object did not cause VF ( P = .01 compared with the two spherical objects), nonsustained VF, ST elevation, or bundle branch block. The smaller diameter sphere caused VF in nine of 48 impacts (19%), and the larger diameter sphere caused VF in five of 48 impacts (10%; P = .25). The smaller diameter sphere was associated with a greater increase in left ventricular pressure ( P P = .001 compared with larger sphere only) and a higher likelihood of ST segment elevations ( P P = .08 compared with larger sphere only) and bundle branch block (Fisher's exact P = .008, and Fisher's exact P = .18 compared with larger sphere only). Conclusion The shape of the projectile markedly influences the risk of VF from chest wall impact. This effect is likely mediated via a greater increase in left ventricular pressure with smaller diameter objects. Spreading the impact force over a larger area may decrease the risk of sudden death and has implications for the design of protective athletic equipment.

In this paper, we present a case review of a 58-year-old female who presented to our emergency department with pyrexia, dyspnoea, dehydration and pain in her left breast six months following coronary artery bypass grafting (CABG). Although her sternotomy wound had healed well, examination revealed fluctuance of the whole precordium and left breast. She underwent antibiotic treatment and subsequent surgical debridement, followed by the application of vacuum-assisted dressings. Surgical reconstruction was deemed unsuitable and therefore the patient continued to be managed with vacuum dressings followed by routine dressings to allow the wound to heal by secondary intention. The patient was discharged three months after initial presentation in a good condition. The wound had completely healed four months later.

The acute management of Takotsubo cardiomyopathy remains incompletely understood despite an increasing incidence. A 63 year old woman presented with chest pain. Her medical history included hypertension and active tobacco use. Physical exam noted a 3/6 holosystolic murmur throughout the precordium

Action potential duration alternans (APDA) can vary regionally in magnitude and phase. The influence of APDA heterogeneity on T-wave alternans (TWA) has not been defined.Our objectives were: (1) to determine how APDA affects the magnitude and spatial distribution of TWA, and (2) to optimize electrocardiographic (ECG) lead configuration accordingly to improve TWA detection.Global, regional, and discordant APDA were simulated in a 257-node heart model. Using a forward solution, body surface potentials were derived at 300 points on the thorax and TWA was computed at each point. In 22 patients with cardiomyopathy (left ventricular ejection fraction 28% +/- 6%), TWA was measured from a 114-electrode body surface map using the spectral method during atrial pacing at 110 beats/min.An increase in global APDA from 4 to 12 ms resulted in an increase in maximum TWA from 10 to 30 microV. TWA magnitude varied with the size and location of the alternating myocardium, but was largest with discordant APDA compared with regional or global APDA. Irrespective of the location or phase of APDA, TWA was largest over the precordium and correlated with T-wave amplitude in the simulation (R(2) = 0.56 +/- 0.24, P.01) and clinical study (R(2) = 0.45 +/- 0.23, P.02). A novel lead configuration (12 precordial leads + limb leads) significantly improved maximum TWA detection compared with the conventional 12-lead ECG+ Frank lead configuration.TWA magnitude is dependent on the interaction of concordant and discordant alternating sources within the heart. Maximum TWA consistently localizes to the precordium and a novel lead configuration using 12 precordial leads improves TWA quantification.

Pectus excavatum is a common congenital musculoskeletal disease occurring in approximately 1 in 800 births.1 Indications for surgical repair include pain, exercise intolerance, abnormal pulmonary function, right ventricular (RV) dysfunction, tricuspid valve compression, and cosmetic enhancement.2 We present an unusual case of endocarditis after pectus repair. A 14-year-old girl presented to the emergency room with a 2-week history of intermittent fever, chills, and pain in the lower parasternum 2 months after pectus excavatum repair. The modified Ravitch technique was used, inserting an 18-cm vitallium strut for stabilization. Physical examination revealed a 3/6 holosystolic midfrequency murmur heard throughout the precordium and an early, short diastolic murmur. Initial laboratory studies demonstrated a mild left shift and elevated inflammatory markers. Chest radiograph demonstrated a normal cardiac silhouette with inferior and posterior displacement of the pectus bar at the level of the …

Contains fulltext : 69906.pdf (Publisher’s version ) (Open Access) Of all patients with Noonan syndrome, 50-90% have one or more congenital heart defects. The most frequent occurring are pulmonary stenosis (PS) and hypertrophic cardiomyopathy. The electrocardiogram (ECG) of a patient with Noonan syndrome often shows a characteristic pattern, with a left axis deviation, abnormal R/S ratio over the left precordium, and an abnormal Q wave. The objective of this study was to determine if these ECG characteristics are an independent feature of the Noonan syndrome or if they are related to the congenital heart defect. A cohort study was performed with 118 patients from two university hospitals in the United States and in The Netherlands. All patients were diagnosed with definite Noonan syndrome and had had an ECG and echocardiography. Sixty-nine patients (58%) had characteristic abnormalities of the ECG. In the patient group without a cardiac defect (n = 21), ten patients had a characteristic ECG abnormality. There was no statistical relationship between the presence of a characteristic ECG abnormality and the presence of a cardiac defect (p = 0.33). Patients with hypertrophic cardiomyopathy had more ECG abnormalities in total (p = 0.05), without correlation with a specific ECG abnormality. We conclude that the ECG features in patients with Noonan syndrome are characteristic for the syndrome and are not related to a specific cardiac defect. An ECG is very useful in the diagnosis of Noonan syndrome; every child with a Noonan phenotype should have an ECG and echocardiogram for evaluation.