A 65-year-old woman was brought to Coney Island Hospital emergency room (ER) with a history of orthopnea for 3 days associated with retrosternal chest pain, cough, and palpitations. She had undergone CABG 7 years ago with metallic mitral valve replacement for critical MS at another hospital. Her medications include Coumadin and aspirin. She claimed to not have taken Coumadin for 6 years. Her exercise tolerance was about 3 blocks. The patient denied any use of tobacco, alcohol, or drugs. On physical examinations, the patient is noted to have a pulse of 86 beats per minute, respiratory rate of 20 breaths per min, temperature of 97.78F, and a blood pressure 106/60 mm Hg. Pulse oximetry on room air was 95%. She did not have jugular venous distention, but she had reduced bilateral air entry at the bases and bilateral rales in the lower third of her lung fields. The patient was noted to have a systolic murmur without a metallic click in the mitral area. She had 2+ pulses and her abdomen was soft, nontender, and without organomegaly. The patient had no calf asymmetry and no pedal edema and her neurologic exam was grossly intact. Laboratory data revealed a normal total white blood cell count and hematocrit. Serum chemistry including electrolytes and liver function tests were within normal limits. Coagulation profile revealed a PT 12.4, PTT 31.8, INR 1.2; CPK and troponin were normal. Chest x-ray revealed cardiomegaly. There was evidence of bilateral congestion and bilateral small pleural effusion. In addition, metallic valve and metallic clips were evident on the x-ray. The electrocardiogram revealed right bundle branch block and pulmonary hypertension. In the emergency room the patient was treated as having congestive heart failure and given intravenous furosemide, beta-blockers, nitroglycerin, and heparin. The patient was admitted to the Arrhythmia Unit in Coney Island Hospital. A transthoracic echocardiogram showed inadequate tilt motion of the metallic valve and severe pulmonary hypertension. TEE revealed a mitral valve thrombus with minimal LV filling. The patient was transferred for emergency mitral valve replacement and recovered well postsurgery.Teaching PointIn any patient with a metallic valve, complete occlusion by a clot must be suspected if the patient presents with heart failure.
ObjectiveThe objective of the project is to study the spectrum of indications for permanent pacemaker (PPM) implantation in a community hospital. The study also analyzed the type of pacemaker implanted, median age, and the indication for the procedure and whether a Holter exam diagnosed the indication for the pacemaker. In addition, we collected data to analyze how many patients had a temporary pacemaker placed before implantation of a permanent pacemaker.MethodsA retrospective study of all patients who had a permanent pacemaker placement in Coney Island Hospital in Brooklyn, New York from January 2000 to January 2004. Data were collected regarding the indication for the permanent pacemaker placement, age and sex of the patient, clinical presentation, and diagnostic utility of Holter.Results214 patients (111 males and 103 females) underwent PPM implantation at the Coney Island hospital in the period of 2002-2004. The age of patients ranged from 43 to 94 years with a median age of 78 years. The indication for PPM implantation was sick sinus syndrome for 103 patients (48%), third-degree AV block or high second-degree AV block for 99 patients (46%), and trifascicular block for 12 patients (5%). Presenting symptom was fall in 40% patients, syncope in 12%, dizziness in 10%, chest pain in 13%, and cardiac arrest in 2 patients; the remaining 23% patients presented with various other noncardiac illnesses like pneumonia, respiratory arrest, altered mental status, and diabetic ketoacidosis. Thirty-four percent of patients received a single-chamber PPM while 66% received a dual-chamber PPM. The diagnosis was established in only 4% of patients with the help of Holter exam. Fifty-four percent of patients had a temporary pacemaker wire inserted before a PPM. Acute myocardial infarction was diagnosed on 10% of patients.ConclusionsSick sinus syndrome and high-grade AV block appear to be major indications for permanent pacing in the elderly. Fall is an important symptom and warrants an electrocardiogram in the elderly. Utility of Holter monitoring in diagnosis to aid permanent pacing was low.
A 69-year-old Hispanic male came to the Coney Island Hospital emergency room with complaints of dyspnea for 2 days, reduced exercise tolerance, orthopnea, and paroxysmal nocturnal dyspnea. The patient denied any cough, loss of weight, night sweat, chest pain, palpitations, diaphoresis, or fever. The patient said his private physician had diagnosed a murmur a year ago but no work-up was done. He had no prior history of valvular heart disease or prior myocardial infarction. In the ER, the patient was noticed to have a temperature of 98 degrees Fahrenheit, a pulse of 112 beats per minute, regular, a blood pressure of 130/80 mm Hg with no Kussmaul's sign, and a respiratory rate of 30 per minute. He had jugular venous distention with regular S1 and S2 hear sounds. A systolic murmur 4/6 was appreciated in mitral area radiating to the axilla. A systolic murmur in the tricuspid area 4/6 was also appreciated radiating to the carotids. Peripheral pulses were regular. Lung field auscultation revealed bibasal rales. The chest x-ray revealed acute pulmonary edema and no pleural effusion. The electrocardiogram showed sinus tachycardia and P pulmonale. Arterial blood gas showed oxygen saturation of 98% on 3 liters of oxygen. Serum chemistry including electrolytes and renal and liver function tests were normal. Urine toxicology was negative. Serial creatinine phosphokinase was normal. The patient was admitted to a monitored unit and a transesophageal echocardiogram (TEE) was performed. It documented mitral and tricuspid valve prolapse with moderate to severe mitral regurgitation and moderate tricuspid regurgitation with pulmonary hypertension. There was thickened, myxomatous, and prolapsing mitral valve posterior leaflets into the left atrium with flail segment. The chordae were intact. Interior leaflets are slightly thickened but otherwise normal in structure. The tricuspid valve posterior leaflet was also thickened, redundant, and myxomatous. Posterior leaflet was also prolapsing into the left atrium with flail segment. Tricuspid valve leaflet chordae are also intact. Left ventricle was mild to moderately dilated with global hypokinesis. Left ventricular ejection fraction was moderately compromised and visually estimated 35%. Left atrium was severely enlarged. The patient was transferred to cardiac care unit and was given diuretics, ACE inhibitors, digoxin, and prophylaxis for infective endocarditis. The patient underwent emergency mitral valve replacement. He recovered well postoperatively and noted to be stable on discharge and on follow-up.ConclusionMyxomatous prolapsing mitral valve may present late in a patient's life as acute pulmonary edema.
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