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Case #28

You are on call and your next admission is here. You are on the phone with the admitting resident and get a quick one liner about the patient, "19 yo male with syncope". You think to yourself, "great another worthless vasovagal syncope admission." You get down to the ER and it seems there is a bunch of comotion. You here "Clear" and it turns out they are shocking your patient. The Er doc says "OK we got him back". You try to see what the heck is going on but there are too many people around his bed. So you grab the chart and try to get some history.

The patient is 19 years old lost conciousness while waiting for the bus with friends to go to his college. He fell to the floor and in a matter of minutes regained conciousness. No witnessed loss of bowel control, no witnessed seizure activity and his friends caught him before he could hit his head on the ground. The patient admitted to the admitting resident that after awakening he knew where he was and than he felt some retrosternal chest pain, was very sweaty and short of breath which subsided in 3 minutes. His friends also said he looked really pale. WHile in the ER the chest pain returned with similair symptoms. He also admitted that a week ago he felt some Chest pain, sob and diaphoresis which subsided in a couple of minutes but did not follow up with a doctor because "I thought it went away." He has no significant medical history and is adopted. Physical exam was only significant for a grade IV harsh systolic murmur which was not fully described becasue of "too much background ER noise". The paper work is incomplete because of what ever is going on now happened while the resident was writing his ER H+P. The Labs were drawn and pending. The only thing you have are two EKG's below.What are your interpretations of the following EKG's?

Click here for better quality image of EKG#1

EKG #1 with chest pain in ER

Click here for better Quality image of EKG #2

EKG #2 while in ER

 

This time it turns out the "syncope" turned out to be something else.

Really quickly going over the interpretation because the reads are strait forward and than what this patient turned out to have.

EKG #1 is chuck full of diagnosis. Left atrial enlargement for the all negative defllection >1mm in v1 for the pwave. 1st degree AV block for .20 sec p-r interval. LVH for voltage criteria in the precordial leads (which may be normal for young patients or really thin patients) with T wave "strain pattern" in II, II , AVF. Borderline Right axis which I did not put in the answers. Antero-septal st elevation possibly representing acute infarction (aVr and v1-v2 usualy represent aterior and septal distribution with lateral (v3-v6) st-depression possibly representing reciprical depression vs lateral ischemia. Lot of stuff.

EKG #2

Strait forward classic Polymorphic VTach that looks like it spinning around on a string, hence Torsade des pointes. Which lead him to being shocked.

Now for what happened to the patient.

First of all the second EKG lead him to being shocked. He returned to a similair EKG tracing of the first EKG when he was converted. The labs came back and turned out he was positive for Troponins and Ck's. He was admitted to the CCU and was prepared to go the cathlab. While awaiting the cathlab to open he had an echo performed which revealed the following images.

Click here for larger image

Turns out, as you can see from the Echo there is assymetric hypertrophy of the septum. This is diagnostic for Hypertrophic Cardiomyopathy which can explain the syncope, the age and some of the EKG findings. But how does that explain the Rhythm and the acute coronary syndrome?

The answer came in the cathlab as shown below. Turns out the patients coronaries where patent however, he had Mycoardial Mocyte Bridging. Which is basically when the muscle grows so much that when the heart contracts it actually compressess the Coronaries closed. In a normal heart, the coronaries are still open during systole, even though the majority of flow in the coronaries is in diastole (relaxation). The images below are from the cath lab and the first is diastole the second in from systole. Notice the compression of the coronaries.

So now with the diagnosis of Hypertrophic cardiomyopathy and myocyte bridging with positive troponins and infarction it was decided to treat this with bi-pass surgery and subsequent placement of an ICD for the Polymorphic V-Tach. The images from surgery (below) explain how he developed Polymorhic V-Tach. Old Infarcted scar tissue (areas of white pointed out by white arrows) was found on the heart which set him up for the developement of V-Tach. Old scar can act as sort of a re-entry circuit creator and if the right circumstances arise around the tissue V-Tach can develope. So in the end it turned out to be a not so easy case of syncope.