electrocardiogram showed sinus rhythm with first degree atrioventricular (AV) block. A left heart catheterization revealed non-obstructive coronary artery disease. An echocardiogram revealed a normal left ventricular function, without structural abnormalities, and the distal tip of the tunneled catheter in the right atrium. While hospitalized, he had multiple episodes of chest pain and hypotension associated with dialysis. In these scenarios, telemetry showed intermittent runs of ventricularly paced rhythm. Interestingly, the symptoms and the paced rhythm would resolve with repositioning to an upright position and fluid resuscitation. Maintaining the patient in upright position with the head of bed at 45 degrees, in addition to decreasing the rate of ultrafiltration resulted in no further episodes for the remainder of his hospitalization.
in patients on hemodialysis, this patient was at increased risk due to his pacemaker. This leadless pacemaker functions by sensing atrial mechanical signals instead of electrical signals which is seen in more traditional pacemakers. The fluid dynamic changes during rapid fluid removal in hemodialysis, distally placed tunneled CVC, and his preference for hunched over positioning are factors contributing to altered atrial mechanical signal, leading to AV dyssynchrony. This dyssynchrony is termed pacemaker syndrome in which devices pace the ventricles in isolation, leading to improper or mistimed atrial and ventricular contractions and reduced cardiac output. Although commonly seen in many undergoing HD, this patient was more at risk due to the presence of a single chamber leadless pacemaker. With increased use of leadless pacemakers, IDH rates may increase.
Discussion: Although IDH is a common complication
PLEURAL EFFUSION RESULTING IN RV COLLAPSE AND PRE-TAMPONADE PHYSIOLOGY Roxanne Nemati, Meredith Hickman, James Crowe, Vishal Vyas, Ibrahim El- Abbassi; Leonard J Chabert Medical Center, Houma, LA.
Introduction: Patients with pleural effusions often present with dyspnea but tend to be hemodynamically stable.
Notably, the TTE showed compression of the right ventricle (RV) with partial collapse noted in early diastole secondary to the pleural effusion. Pre- tamponade physiology was suggested by tricuspid valve inflow respirophasic variation. The patient underwent thoracentesis and chest tube placement. Post-procedurally, she developed re-expansion pulmonary edema and a small pneumothorax. Pleural fluid was transudative, with the etiology presumed secondary to a hepatic hydrothorax. A repeat TTE demonstrated resolution of the right ventricular compression with mild reaccumulation of the pleural effusion. Diuretics were also initiated. After discharge, she required subsequent thoracenteses for recurrent symptoms and ultimately passed away. Discussion: This patient uniquely presented with pre-tamponade physiology despite only a small pericardial effusion (not amenable to pericardiocentesis); rather, cardiovascular
Case: A 61-year-old female with HIV, hepatitis C with cirrhosis, chronic obstructive pulmonary disease, type II diabetes mellitus, hypertension, hyperlipidemia and polysubstance abuse presented with progressive shortness of breath for 1 month. She reported associated 3-pillow orthopnea, lower extremity swelling, paroxysmal nocturnal dyspnea, and dry cough. She endorsed a 43-pack-year smoking history and cocaine use twice monthly. On evaluation, she was hemodynamically stable and saturating 95-97% on room air. A physical exam revealed absent lung sounds over the right midlung and pretibial edema. Labs were notable for hyperkalemia
and hypoalbuminemia. A electrocardiogram demonstrated a normal sinus rhythm with low- voltage QRS complexes. A chest x-ray revealed a large right pleural effusion. A CT of the chest confirmed a pleural effusion with compressive atelectasis of the right middle and lower lobes. A transthoracic echocardiogram (TTE) revealed an ejection fraction of 60% and small localized posterior effusion.
compromise occurred secondary to a massive pleural effusion. Cardiac tamponade results from impaired diastolic filling secondary to extrinsic compression of the heart. It may present with tachycardia, muffled heart sounds, elevated central venous presssures, 44
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