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Background Cardiac lipoma and lipomatous hypertrophy of interatrial septum (LHIS) are very rare disorders with distinct pathological features. While cardiac lipoma is a well-circumscribed encapsulated tumor of mature adipocytes, LHIS is due to entrapment of fat cells in the interatrial septum during embryogenesis. Although a biopsy is the definitive diagnostic test, these disorders can be differentiated by a cardiac magnetic resonance imaging (MRI). Treatment of LHIS is not warranted in asymptomatic patients. In symptomatic patients, surgical resection is the only recommended treatment, which has shown to improve good long-term prognosis. Case summary A 63-year-old Caucasian woman with past medical history significant for hypertension, hypothyroidism, right breast ductal cell carcinoma treated with mastectomy and breast implant, platelet granule disorder, asthma requiring chronic intermittent prednisone use, presented to the outpatient cardiology office with recent onset exertional dyspnea, palpitations, weight gain and weakness. Initial workup with electrocardiogram and holter monitor did not reveal significant findings. During the subsequent hospitalization for community acquired pneumonia, the patient developed symptomatic paroxysmal atrial fibrillation. Transthoracic echocardiogram showed a right ventricular mass. A biopsy was not pursued given the high risk of bleeding due to platelet granule disorder. Cardiac MRI showed characteristic features consistent with cardiac lipoma and LHIS. Prednisone was discontinued. Genetic testing for arrhythmogenic right ventricular dysplasia and 24-h urine cortisol test was negative. As multiple attempts at rhythm control failed with sotalol and flecainide, pulmonary vein isolation and right atrial isthmus radiofrequency ablation were done. She is in follow-up with symptomatic relief and no recurrence of atrial fibrillation for 10 mo. Conclusion Benign fatty lesions in heart include solitary lipoma, lipomatous infiltration and lipomatous hypertrophy of interatrial septum. Although transvenous biopsy provides a definitive diagnosis, Cardiac MRI is superior to computed tomography and aids in differentiating benign from malignant lesions. Surgical excision of cardiac lipoma along with capsule and pedicle removal generally prevents recurrence, but with our patient's unusual tumor features and comorbidities proscribed a surgical approach. Symptom management with antiarrhythmics and ablation techniques were successfully utilized.

A 69-year-old man with past medical history of coronary artery disease, status postcoronary artery bypass, ischaemic cardiomyopathy with ejection fraction of 15%, status postautomatic implantable cardioverter defibrillator since 2013, known case of ventricular tachycardia (VT), on sotalol, irritable

Biventricular pacing uses passive fixation to position a left ventricular lead (LVL) in the coronary sinus (CS). Early LVL dislodgement (< 1 month) is common but idiopathic late LVL dislodgement causing pulmonary embolism (PE) is rare and potentially fatal. A 55 year old male with non-ischemic

Objectives Our purpose was to determine the effect of interatrial block (IAB, P-wave duration ≥120 ms) on left atrial (LA) dynamics. IAB is associated with LA enlargement (LAE). LA dysfunction is associated with decreased left ventricular filling, a propensity for LA appendage thrombus formation, and reduced atrial natriuretic peptide levels. We evaluated LA function in patients with and without IAB matched for LA size. Methods Echocardiograms with LA enlargement were analyzed. Twenty-four patients had IAB, and 16 patients without IAB formed the control group. LA volumes, A-wave acceleration times (At), LA stroke volume (LASV), ejection fraction (LAEF), and kinetic energy (LAKE) were calculated. Results The control group and patients with IAB had comparable maximal LA volume and diameter (P >.05). Patients with IAB had significantly longer At (115 ± 39 ms vs 83 ± 24 ms, P

Background Prior studies of active pectoral implantable defibrillator (ICD) lead systems demonstrated a lowering of defibrillation thresholds (DFTs) with the addition of a superior vena cava (SVC) coil. These studies were done on fixed-tilt waveforms where a large reduction in impedance leads to large phase duration changes. Objective The present study was designed to evaluate the SVC coil benefit and intercoil spacing on DFTs with a "tuned" waveform. Methods This prospective, multicenter study included 113 patients randomized at implant to a 17-cm and a 21-cm intercoil spacing ICD lead. DFTs were measured with SVC coil turned ON versus OFF in a random order, using an optimized binary search method. Results DFT voltage (423 ± 120 vs. 438 ± 118 V; P = .042) and stored energy (9.8 ± 5.6 vs. 10.2 ± 5.8 J; P = .043) were significantly reduced with the SVC coil ON. However, intercoil distance had no significant effect on DFT voltage (437.3 ± 115.1 vs. 407.7 ± 123.8 V; P = .19) or stored energy (10.3 ± 5.4 vs. 9.2 ± 5.8 J; P = .31). Subgroup analyses showed that the dual-coil leads were most effective when placed in the high position (innominate vein-SVC junction) or when the single-coil shock impedance was ≥58 Ω, regardless of intercoil spacing. Conclusion With a tuned waveform, the addition of an SVC coil to the shocking pathway reduces DFTs, although this difference was smaller than reported previously. Intercoil distance had no significant effect on the defibrillation parameters.

With the awareness of health problems related to obesity, weight reducing diets have become very popular. However, if these meal supplements are not taken as recommended, they can cause considerable harm in high risk individuals. We report a case of a young obese man who developed diabetic ketoacidosis (DKA) followed by rhabdomyolysis and acute renal failure (ARF) after excessive intake of a high carbohydrate containing weight-reducing meal. DKA associated with excessive intake of weight reducing diets has not been reported previously. In people with obesity and insulin resistance improper use of these supplements can cause severe metabolic complications.

Sarcoid granulomas usually involve the myocardium with rare focal extensions into the pericardium and endocardium with resultant conduction defects, ventricular arrhythmias, and ventricular systolic and diastolic dysfunction. Primary involvement of valvular leaflets resulting in valvular regurgitation or stenosis is not known. We present a case of a wastewater consultant who developed tricuspid regurgitation and symptomatic atrioventricular block secondary to infiltration of tricuspid leaflets and conduction system from sarcoid granulomas. The patient later developed severe dilated cardiomyopathy as a result of extensive cardiac sarcoidosis necessitating cardiac transplantation. Valvular regurgitation should be included as one of the presenting manifestations of cardiac sarcoidosis.

A persistent left superior vena cava has been observed in 0.3% of the general population on autopsy. Its presence can complicate left-sided device implantation. Commonly, a LSVC connects to the right atrium via the coronary sinus. A LSVC-accessory hemiazygous-hemiazygous-inferior vena caval communication has not been described previously. The presence of such a congenital venous anomaly will prohibit a left-sided device implant.

A 50-year-old man with an ischemic cardiomyopathy underwent ICD implantation for inducible ventricular fibrillation (VF). Sixteen months later he experienced inappropriate ICD therapy due to atrial fibrillation with a rapid ventricular response. The initial shock resulted in the initiation of VF (proarrhythmia) and the patient received an additional shock converting his rhythm to an idioventricular rhythm with a cycle length of 490 ms (122 beats/min). Due to lead hyperpolarization, the device oversensed ventricular events and the patient subsequently received additional shocks.

Background: Cardiac resynchronization therapy (CRT) is effective in improving cardiac function and symptoms in patients (pts) with advanced heart failure (HF) and ventricular conduction abnormalities. These results are thought to be secondary to reduction in ventricular dyssynchrony and mitral regurgitation (MR). However, effects of CRT on left atrial (LA) function and interatrial conduction (IAC) are unknown. LA dysfunction and prolonged IAC are associated with decreased left ventricular (LV) filling and atrial fibrillation (AF). Accordingly, we studied the effects of CRT on LA function and IAC. Methods: Fifty-six pts (39m, 17f, 67 10 yr) with NYHA III-IV CHF, LV ejection fraction 35%, a QRS interval 130 msec on optimal medical therapy for HF underwent CRT (Medtronic InSync or Guidant Contak CD). P max (maximum P wave duration on any lead) and P disp (difference between P max and minimum P wave duration) were measured on a 12-lead ECG at baseline and at 6 months post CRT. Echocardiograms were recorded in a subset of 27 pts at baseline and at 6 months post CRT. Using the biplane area-length method, LA volumes at mitral opening, onset of P wave and mitral closure were determined. Based on Simpson’s formula, LA stroke volume (LASV), ejection fraction (LAEF) and kinetic energy (LAKE) were calculated. Peak A wave velocity (Avel) and A wave acceleration time (At) were also measured. Results: While LA volumes, At and Avel were similar at baseline and post CRT, there was a marked reduction in P max (143 23 msec vs. 132 27 msec, p 0.01)) and P disp (35 13 msec vs. 22 13 msec, p 0.01) 6 months post CRT. There was also a significant improvement in LASV (7.5 4 ml vs. 20 15 ml, p 0.01), LAEF (19 6% vs. 29 20%, p 0.01) and LAKE (28 20 Kdyne/cm/s vs. 70 40 Kdyne/cm/s, p 0.01) at 6 months. Conclusions: CRT results in marked reduction in IAC delay and significant improvement in LA systolic function. Although LA volumes did not change, LASV, LAEF, and LAKE improved at 6 months. Enhanced LA electromechanical function may result in improved LV filling and contribute to the hemodynamic and symptomatic improvement observed with CRT and has implications for reduction in the propensity for AF.

We report telemetry recording of an extreme non-fatal tachyarrhythmia noted in a hospitalized quadriplegic male with history of atrial fibrillation where the average ventricular conduction rate was found to be about 600 beats per minute and was associated with transient syncope. A medical literature review suggests that the fastest human ventricular conduction rate reported to date in a tachyarrhythmia is 480 beats per minute. We therefore report the fastest human heart rate noted in a tachyarrhythmia and the most probable mechanism of this arrhythmia being a rapid atrial fibrillation with 1:1 conduction in the setting of probable co-existing multiple bypass tracts.