Camel-Hump T-Wave, Tee-Pee Sign, and Wavy Triple Sign (Yasser’s Sign) with Hypocalcemia and Hyperkalemia in Covid-19 Pneumonia with Lacunar Infarction

Rationale: A novel COVID-19 is a multi-systemic critical worldwide pandemic infection. Certainly, associated multiple electrolytes imbalance in COVID-19 pneumonia is a remarkable decisive event. Camel-hump T-wave, Tee-Pee sign, and Wavy triple sign (Yasser’s sign)are novel highly significant descriptive electrocardiographic signs that are seen in calcium and potassium disturbance. There is an established and strong relationship between and electrocardiographic abnormalities and electrolytes imbalance. COVID-19 pneumonia and cerebrovascular stroke are commonly seen in a patient with Coronavirus infection. Patient concerns: A 69-year-old married worker Egyptian male patient was presented to the emergency department with COVID-19 pneumonia and cerebrovascular stroke. Diagnosis: COVID-19 pneumonia with lacunar infarction, hypocalcemia, and hyperkalemia. Interventions: Chest CT scan, brain CT scan, electrocardiography, oxygenation, and echocardiography. Outcomes: Initial bad and deterioration outcome but, the dramatic outcome had happened after later management. Lessons: The understanding of electrocardiographic signs regarding metabolic disorders such as electrolytes imbalance and other associated systemic diseases is very important. Elderly male sex, heavy smoker, COVID-19 pneumonia, cerebrovascular stroke, chronic renal impairment, ischemic heart disease, hypokalemia, hypocalcemia, and hypernatremia represent bad prognostic points and is indicating a high-risk condition.

ECG Changes Through Immunosuppressive Therapy Indicate Cardiac Abnormality in Anti-MDA5 Antibody-Positive Clinically Amyopathic Dermatomyositis

Anti-melanoma differentiation-associated gene 5 (MDA5) antibody, a dermatomyositis (DM)-specific antibody, is strongly associated with interstitial lung disease (ILD). Patients with idiopathic inflammatory myopathy (IIM) who are anti-MDA5 antibody positive [anti-MDA5 (+)] often experience chest symptoms during the active disease phase. These symptoms are primarily explained by respiratory failure; nevertheless, cardiac involvement can also be symptomatic. Thus, the aim of this study was to investigate cardiac involvement in anti-MDA5 (+) DM. A total of 63 patients with IIM who underwent electrocardiography (ECG) and ultrasound cardiography (UCG) during the active disease phase from 2016 to 2021 [anti-MDA5 (+) group, n = 21; anti-MDA5-negative (-) group, n = 42] were enrolled in the study, and their clinical charts were retrospectively reviewed. The ECG and UCG findings were compared between the anti-MDA5 (+) and anti-MDA5 (-) groups. All anti-MDA5 (+) patients had DM with ILD. The anti-MDA5 (+) group showed more frequent skin ulcerations and lower levels of leukocytes, muscle enzymes, and electrolytes (Na, K, Cl, and Ca) than the anti-MDA5 (-) group. According to the ECG findings obtained during the active disease phase, the T wave amplitudes were significantly lower for the anti-MDA5 (+) group than for the anti-MDA5 (-) group (I, II, and V4–6 lead; p < 0.01; aVF and V3, p < 0.05). However, the lower amplitudes were restored during the remission phase. Except for the E wave, A wave and Sep e’, the UCG results showed no significant differences between the groups. Four patients with anti-MDA5 (+) DM had many leads with lower T wave and cardiac abnormalities (heart failure, diastolic dysfunction, myocarditis) on and after admission. Though anti-MDA5 (+) patients clinically improved after immunosuppressive therapy, some of their ECG findings did not fully recover in remission phase. In conclusion, anti-MDA5 (+) DM appears to show cardiac involvement (electrical activity and function) during the active phase. Further studies are necessary to clarify the actual cardiac condition and mechanism of these findings in patients with anti-MDA5 (+) DM.

Predictors of Permanent Pacemaker Implantation in Patients After Transcatheter Aortic Valve Replacement in a Chinese Population

Background: Permanent pacemaker (PPM) implantation is the main complication of transcatheter aortic valve replacement (TAVR). Few studies have evaluated the requirement for PPM implantation due to ECG changes following TAVR in a Chinese population.Objective: Our study aimed to evaluate the incidence and predictors of PPM implantation in a cohort of Chinese patients with TAVR.Methods: We retrospectively evaluated 39 consecutive patients with severe native aortic stenosis referred for TAVR with a self-expandable prosthesis, the Venus A valve (Venus MedTech Inc., Hangzhou, China), from 2019 to 2021 at the Heart Center of Affiliated Zhongshan Hospital of Dalian University. Predictors of PPM implantation were identified using logistic regression.Results: In our study, the incidence of PPM implantation was 20.5%. PPM implantation occurs with higher risk in patients with negative creatinine clearance (CrCl), dyslipidemia, high Society of Thoracic Surgeons (STS) Morbimortality scores, and lead I T wave elevation. TAVR induced several cardiac electrical changes such as increased R wave and T wave changes in lead V5. The main independent predictors of PPM implantation were new-onset left bundle branch block (LBBB) (coef: 3.211, 95% CI: 0.899–7.467, p = 0.004) and lead I T wave elevation (coef: 11.081, 95% CI: 1.632–28.083, p = 0.016).Conclusion: New-onset LBBB and lead I T wave elevation were the main independent predictors of PPM implantation in patients undergoing TAVR. Clinical indications such as negative CrCl, dyslipidemia, high STS Morbimortality scores, and an increased T wave elevation before TAVR should be treated with caution to decrease the need for subsequent PPM implantation.

Wellens Syndrome: A Review Article

Wellens syndrome is a pre-infarct stage of coronary syndrome and a clinical condition associated with left descending proximal anterior artery stenosis. Diagnostic criteria for Wellens syndrome include clinical history, ECG changes, and laboratory results. The pathognomonic ECG of Wellens syndrome is anterior inverted T-wave in precordial leads, which can be seen during pain-free period, accompanied by isoelectric or minimally elevated ST segment (<1 mm), no precordial Q waves, and normal or slightly elevated cardiac serum markers. Early diagnosis leads to early management and a better prognosis. Early management of Wellens syndrome involves maintaining an airway, breathing, circulation, monitoring vital signs, and medical management. Still, the only definitive management is urgent cardiac angiography to prevent further myocardial ischemia. The combination of early diagnostic and appropriate management will reduce complications and mortality rates. Keywords: Wellens Syndrome, Acute Coronary Syndromes, pre-Infarct MI.

The relationship of hs-CRP, vitronectin and NT-proBNP serum levels with the extent and severity of cardiac complications in patients with organophosphate pesticide poisoning

Acute organophosphate poisoning kills tens of thousands of people annually around the world. These substances are widely used as insecticides in homes, industry, and agricultural environments. Due to the ease of access, they can cause accidental or intentional risks of exposure through the skin or respiratory contact. This study aimed to evaluate the serum levels of hs-CRP, Vitronectin, and NT-proBNP and their relationship with the extent and severity of cardiac complications in patients with organophosphate pesticide poisoning. In this descriptive-comparative study, 160 patients were studied with acute organophosphate poisoning. Also, for better comparison, 40 healthy individuals participated in this study. Diagnosis of organophosphate poisoning was based on clinical findings of serum butyrylcholinesterase levels. The hs-CRP measurement was performed by an autoanalyzer (Abbott, model Alcyon 300, USA) with the ELISA hs-CRP kit (The apDia Company, Belgium). Vitronectin (VN) measurements were performed by ELISA method and Glory science human VN kit with Catalog No: 11668. NT-ProBNP serum levels were analyzed by ProBNP assay kit (Roche, Germany) by ECLIA method using Elecsys 2010 Analyzer. The most important variables studied in this study were the electrical activity and conduction system of the heart, PR distance, QTC interval, and T-wave changes. In this study, most of the patients were women and girls (60.78%). The highest percentage of organophosphate poisoning was in the age group of 15-24 years (37.25%). In most cases (78.43%), poisoning was intentional or suicidal. Evaluation of electrophysiological abnormalities of the heart showed that 89 patients (55.62%) had long QTC interval (>450 msec), 43 cases (26.87%) had possible long QTC (431-450 msec), and 28 cases (17.5%) had normal QTC (<430 msec). Only 9.37% of cases (n = 15) showed an increase in P-R distance, which is characteristic of the first-degree ventricular atrial block. Sinus bradycardia occurred in 57 cases (35.62%) and sinus tachycardia in 43 cases (26.87%); in 60 cases (37.5%), the pulse rate was normal. Smooth T-wave changes were observed in 9.8% of patients and reverse T-wave was observed in 17.6%. A long T-wave was not reported in any case. In only two cases (1.25%) was grade 1 ventricular atrial block and grade 2 and 3 blocks were not observed. In general, there was a significant difference in the hs-CRP, vitronectin, and NT-proBNP serum levels between the patient and control groups in all studied variables. These parameters were also related to the extent and severity of the disease.

Research on the duration of electrocardiogram components in pregnant goats

The electrocardiogram is a graph recording of heart’s electric activity, so it is used in medical practice mainly in order to observe the heart’s activity. The values of the main components of the electrocardiogram in pregnant goats were determined within the current research. All of these were performed in three different stages of pregnancy (the beginning, the middle and the ending), being focused on the variation of these values during the pregnancy. The gestation diagnosis was confirmed by ultrasound-exam. During the pregnancy, the following values for the duration of the main ECG’s components were found: the P wave (0.045-0.044 s), the P-R segment (0.061-0.048 s), of the P-R range (0.105-0.086 s), of the QRS complex (0.042-0.040 s), of the Q-T range (0.242-0.218 s), of the P-T range (0.377-0.368 s), of the R-R range (0.465-0.431 s), the T wave (0.091-0.104 s) and of the T-P segment (0.097-0.101 s). Our results show that during the pregnancy the duration of: the P wave, the P-R segment, the P-R range, the QRS complex, the Q-T range, the P-T range and the R-R range, decrease, while the duration of the T wave and the T-P segment increase.

The type 2 myocardial infarction following hypertension:a case report

A 60-years-old patient with sustained chest pain was referred to hypertension.The tertiary Troponin-I concentrations,namely the biomarker of myocardial injury,were 0.19ng per milliliter,1.288ng per milliliterand 16.698ng per milliliter,respectively.Electrocardiogram showed ST-segment and T wave dynamic changes.Type 2 MI was confirmed.

A Fully-Coupled Electro-Mechanical Whole-Heart Computational Model: Influence of Cardiac Contraction on the ECG

The ECG is one of the most commonly used non-invasive tools to gain insights into the electrical functioning of the heart. It has been crucial as a foundation in the creation and validation of in silico models describing the underlying electrophysiological processes. However, so far, the contraction of the heart and its influences on the ECG have mainly been overlooked in in silico models. As the heart contracts and moves, so do the electrical sources within the heart responsible for the signal on the body surface, thus potentially altering the ECG. To illuminate these aspects, we developed a human 4-chamber electro-mechanically coupled whole heart in silico model and embedded it within a torso model. Our model faithfully reproduces measured 12-lead ECG traces, circulatory characteristics, as well as physiological ventricular rotation and atrioventricular valve plane displacement. We compare our dynamic model to three non-deforming ones in terms of standard clinically used ECG leads (Einthoven and Wilson) and body surface potential maps (BSPM). The non-deforming models consider the heart at its ventricular end-diastatic, end-diastolic and end-systolic states. The standard leads show negligible differences during P-Wave and QRS-Complex, yet during T-Wave the leads closest to the heart show prominent differences in amplitude. When looking at the BSPM, there are no notable differences during the P-Wave, but effects of cardiac motion can be observed already during the QRS-Complex, increasing further during the T-Wave. We conclude that for the modeling of activation (P-Wave/QRS-Complex), the associated effort of simulating a complete electro-mechanical approach is not worth the computational cost. But when looking at ventricular repolarization (T-Wave) in standard leads as well as BSPM, there are areas where the signal can be influenced by cardiac motion of the heart to an extent that should not be ignored.

Catecholamines are key modulators of ventricular repolarization patterns in the ball python (Python regius)

Ectothermic vertebrates experience daily changes in body temperature, and anecdotal observations suggest these changes affect ventricular repolarization such that the T-wave in the ECG changes polarity. Mammals, in contrast, can maintain stable body temperatures, and their ventricular repolarization is strongly modulated by changes in heart rate and by sympathetic nervous system activity. The aim of this study was to assess the role of body temperature, heart rate, and circulating catecholamines on local repolarization gradients in the ectothermic ball python (Python regius). We recorded body-surface electrocardiograms and performed open-chest high-resolution epicardial mapping while increasing body temperature in five pythons, in all of which there was a change in T-wave polarity. However, the vector of repolarization differed between individuals, and only a subset of leads revealed T-wave polarity change. RNA sequencing revealed regional differences related to adrenergic signaling. In one denervated and Ringer’s solution–perfused heart, heating and elevated heart rates did not induce change in T-wave polarity, whereas noradrenaline did. Accordingly, electrocardiograms in eight awake pythons receiving intra-arterial infusion of the β-adrenergic receptor agonists adrenaline and isoproterenol revealed T-wave inversion in most individuals. Conversely, blocking the β-adrenergic receptors using propranolol prevented T-wave change during heating. Our findings indicate that changes in ventricular repolarization in ball pythons are caused by increased tone of the sympathetic nervous system, not by changes in temperature. Therefore, ventricular repolarization in both pythons and mammals is modulated by evolutionary conserved mechanisms involving catecholaminergic stimulation.