Tako-tsubo cardiomyopathy (TTC) is increasingly being recognised as transient left ventricular dysfunction following various hyperadrenergic states such as emotional or physical stressors. The association of this rare clinical entity with myasthenia gravis (MG) has been reported only twice in the literature, both following plasmapheresis for MG crisis. Here we describe a unique case of TTC in a 40-year-old woman with MG admitted with MG crisis managed conservatively. This case suggests that plasmapheresis is unlikely to have a causative role in the development of TTC in these patients. Patients with MG crisis may be at potential risk of developing TTC and careful clinical and electrocardiographic monitoring is necessary while treating them. The possible role of stress as the common precipitating factor in both conditions is also discussed.
narrow QRS tachycardia, ventricular tachycardia, fascicular tachycardia, radiofrequency ablation, tachycardiomyopathy
Case PresentationA 38-year-old woman presented with recurrent sustained episodes of palpitation, each episode lasting more than 3 weeks. The symptoms were unresponsive to amiodarone 400 mg/day. Echocardiogram revealed mildly dilated left ventricle with global left ventricular hypokinesia and ejection fraction of 30%. The electrocardiogram (ECG) during palpitation showed a narrow QRS tachycardia with ventriculoatrial (VA) dissociation and mild variations in RR interval (Fig. 1A). The QRS complex during the tachycardia was relatively narrow (100 ms), and exhibited left anterior fascicular (LAF) block morphology and leftward (−45 • ) axis. During sinus rhythm, ECG was unremarkable, except for mildly prolonged QTc (480 ms) (Fig. 1B). Baseline electrophysiology study showed sinus rhythm (cycle length 700 ms), normal atrial-His (AH; 76 ms) and His-ventricular (HV; 48 ms) intervals, and absence of VA conduction on pacing from right ventricular (RV) apex at 600 ms. Programmed atrial stimulation showed no dual atrioventricular (AV) nodal physiology. Atrial and ventricular burst and extrastimulation pacing induced the clinical tachycardia easily and reproducibly ( Fig. 2A). During the tachycardia (cycle length around 370 ms, HV interval +6 ms), His Bundle (HB) and right bundle (RB) were activated sequentially with a HB-RB interval of 20 ms, which was similar to the HB-RB interval measured during sinus rhythm. Rapid pacing from the RV apex and basal RV septum at cycle length of 360 ms, during the tachycardia, resulted in constant fusion beats, with postpacing intervals exceeding the tachycardia cycle lengths by 154 and 76 ms, respectively. Intravenous bolus of adenosine 18 mg did not affect the
The allelic variants of peroxisome proliferator-activated receptor alpha (PPARα) can influence the risk of coronary artery disease (CAD) by virtue of its effect on lipid metabolism. However, the role of PPARα intronic polymorphism with CAD has received little attention. The association of allelic variants G/C at intron 7 of the PPAR-alpha gene with CAD was examined in a hospital-based Indian population.
PPAR genotyping was performed in 110 male patients with CAD and 120 age and ethnically matched healthy males by PCR amplification of the gene followed by restriction digestion. Presence of C allele showed a positive association with CAD (OR = 2.9; 95% CI [1.65–4.145]; P = .009) and also with dyslipidaemia (OR = 2.95, 95% CI (1.5–4.39); P < .05).
Impaired lipid metabolism in carriers of the PPARα Intron 7C allele is possibly responsible for the predilection to CAD.
Endomyocardial fibrosis (EMF) is characterized by fibrous tissue deposition on the endocardial surface leading to impaired filling of one or both ventricles, resulting in either right or left heart failure or both. Although Sinus node dysfunction and tachyarrhythmia - atrial fibrillation, ventricular tachycardia, have been commonly reported, complete heart block (CHB) necessitating a pacemaker is rare in EMF. Transvenous pacing is technically limited by fibrotic obliteration of the affected ventricle that results in poor lead parameters, and alternative pacing strategy like epicardial pacing may be required in many. We report three cases of EMF, who were treated with an alternative pacing strategy.
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