Browsing by Author "Takata, Theodore"
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Item A Rare Occurrence of Cardiogenic Shock after Cardioversion: A Case Report(2023) Jain, Kunal; Fajkus, Austin; Takata, TheodoreBackground: Atrial fibrillation (AF) is a common cardiac arrhythmia that affects the health and lifespan of people and has been growing in prevalence with the aging population. AF leads to atrial remodeling, which increases the likelihood of developing treatment resistant AF. Risk factors for AF include obstructive sleep apnea, alcohol use, obesity, hypertension, and diabetes. Treatment consists of rhythm control, rate control, and thromboembolism prevention. If a patient fails to convert to sinus rhythm or remains symptomatic despite pharmacological treatment, the next step in management may include Direct Current Cardioversion (DCCV) or catheter ablation. DCCV restores sinus rhythm (SR) by using controlled shocks to the heart and is considered a safe and effective procedure for treating AF. Complications include arrhythmias, skin burns, and cardiac tissue damage. Following the restoration of SR, cardiac output (CO) generally improves. Cardiogenic shock is a rare occurrence after DCCV. This case report details one of these rare occurrences, where a patient with multiple comorbidities developed cardiogenic shock after DCCV for AF. Case Information: A 65-year-old male with a history of heart failure with reduced ejection fraction, AF with prior ablation, atrial flutter, dilated cardiomyopathy, obstructive sleep apnea, chronic kidney disease, and implantable cardioverter defibrillator (ICD), presented to the emergency department (ED) with symptoms of dyspnea and shortness of breath. ECG showed atrial flutter with rapid ventricular response (RVR). Urgent DCCV was performed, restoring SR but precipitating cardiogenic shock, which required intubation and vasopressors. Since stroke volume remains constant in patients with dilated cardiomyopathy, the ICD was reprogrammed to raise the HR. Thereby improving the CO and resolving the cardiogenic shock. The patient remained stable for one month but had recurrent decompensated heart failure. ECG showed AF with RVR with a HR greater than 130 bpm. The patient was cardioverted again to sinus rhythm. However, the patient's condition soon deteriorated, wherein he developed shortness of breath, orthopnea, diaphoresis, and cold extremities. He was intubated due to his respiratory distress and started on milrinone, norepinephrine, furosemide, and an amiodarone drip. He nonetheless converted to AF with RVR, compromising his CO. This was evident clinically by his decrease in urine output, despite furosemide treatment. Urgent AV node ablation with a biventricular ICD upgrade was thus recommended. Postoperatively, as his condition improved, the patient was extubated and switched to oral diuretics. Amiodarone was discontinued, and his heart failure medications were slowly reinstated. Upon discharge, the patient was referred to another facility that specializes in heart failure and transplants. Conclusion: Although DCCV is generally considered a safe and effective procedure, there are still risks associated with it. This case highlights the importance of considering underlying cardiac dysfunction in patients undergoing cardioversion for AF and the need for close monitoring and follow-up in these patients. Since not many cases showcasing these potential complications have been documented, this warrants further research to identify risk factors, complications, and ways to prevent harm to patients who may undergo DCCV.Item Upper Gastrointestinal Bleed with an Unusual Etiology: A Difficult Case with Unclear Imaging Findings.(2024-03-21) Wazir, Ali; Ngyuen, Michael; Takata, TheodoreBackground: Atrial fibrillation (AF) is a cardiac arrhythmia which can be managed with AF ablations, used to control aberrant electrical activity. A serious complication of ablations includes atrioesophageal fistulas (AEF), with clinical manifestations of hematemesis, fever, neurological deficits, and mental status changes. A majority of documented cases utilize computed tomography (CT) scans which demonstrate the presence of a fistula, but there remains a paucity of AEF cases with unclear imaging findings. Case Presentation: A 63-year-old Caucasian male with symptomatic persistent AF underwent radiofrequency ablation with PVs and left atrial posterior wall isolation on December 12, 2016. The patient tolerated the procedure well. On January 11, 2017, the patient returned to the emergency department with hematemesis one day prior. The patient reported chills, nausea, mild headache and a temperature of 103.2F. Patient reported taking ibuprofen with no relief. Vital signs at admission: T 98.5 F, BP 107/57, HR 62 bpm, and oxygen saturation of 100% on room air. PE: normal with no neurologic deficits. Labs: CBC indicated leukocytosis with neutrophilic shift and bandemia, thrombocytopenia, and low hemoglobin. CMP: low serum albumin and total protein. Coagulation studies: elevated aPTT and INR. Serum troponin I: minimally elevated. ECG: nonspecific T wave changes. CXR: no evidence of cardiopulmonary disease. Cranial CT scan: nonspecific bilateral subcortical frontal lobe white matter changes. Chest CTA with contrast was recommended by the EP to assess for an AEF and revealed no atrial wall defects. Gastroenterology was consulted for an upper GI bleed (UGIB) caused by NSAID usage based on imaging findings. Patient further experienced vision changes, confusion, chills, and myalgias. Blood Gram stain was positive for gram-positive cocci. Patient was started on a course of piperacillin-tazobactam and vancomycin. Magnetic Resonance Imaging illustrated bihemispheric ischemic infarctions. EGD revealed a protuberance with a small opening thirty centimeters from the incisors. Patient continued to deteriorate, and a repeat CT angiogram displayed a possible atrial wall defect but no overt fistula, pneumomediastinum, or contrast media within the esophagus. Based on high clinical suspicion of an AEF, a cardiothoracic surgery consult was requested. A cardiothoracic surgery was performed with repair of the left atrium and esophageal fistula. A 2-3 millimeter punctate defect was present between the left and right inferior pulmonary veins. Fibrinous adhesions were present on the anterior esophagus at the level of the left atrium. A punctate mucosal perforation was present in the esophageal wall measuring 2-3 millimeters in diameter. A pericardial patch was placed. The patient tolerated the procedure well and was transferred to the cardiovascular ICU. Post-operatively, the patient developed sepsis, delirium, and difficulty swallowing and was placed on tube feeding. Over the following days, mental status improved. Final culture results on postoperative day seven confirmed Streptococcus oralis, Streptococcus mitis, and Granulicatella adiacens and were treated with IV ceftriaxone outpatient. On postoperative day nine, the patient was discharged with no neurological deficits. Conclusion: This case highlights the importance of including AEFs within differential diagnoses of UGIB given recent AF ablations when imaging results are inconclusive.