Pacemaker and Defibrillator Implantation and Programming in Patients with Deep Brain Stimulation.

The need for cardiac device implantation in patients receiving deep brain stimulation (DBS) is increasing. Despite the theoretical risk of the two systems interacting, there are no clear guidelines for cardiologists carrying out cardiac device implantation in this population. We performed a review of the literature and describe 13 case reports in which patients have both DBS and a cardiac pacemaker or ICD implanted.

Improving rates of implantable cardioverter defibrillator deactivation in end-of-life care.

Implantable cardioverter defibrillators (ICDs) save lives in selected patients at risk of sudden cardiac death. However, in patents suffering with terminal illness, ICD therapy could pose a risk of unnecessary futile shocks which could lead to undignified discomfort in their final days of life. National guidelines advise that patients approaching the end of their natural life should be offered a compassionate choice of having their defibrillator deactivated.

Multidisciplinary surgical team approach for excision of squamous cell carcinoma overlying pacemaker site.

We report an unusual case of an elderly man presenting with a fast-growing large malignant tumour involving the skin overlying his permanent pacemaker site. The fast-growing cutaneous squamous cell carcinoma appeared 2 years after pacemaker implantation. Joint specialist input was required to tackle this complex problem as a wide surgical excision would expose the pacemaker generator risking device infection particularly if the skin graft reconstruction failed.

Pulmonary oedema, think beyond the heart even in the presence of severe left ventricular systolic dysfunction.

We submit a case of a young patient with known severe left ventricular (LV) systolic impairment who presented with recurrent flash pulmonary oedema (FPO) requiring multiple high-dependency care admissions. Despite extensive optimisation of his underlying heart failure, the presentations remained frequent. Investigations for alternative diagnosis were not approached due to the presence of LV impairment and compliance being questioned.

Syncope secondary to left ventricular outflow tract obstruction, an interesting presentation of infective endocarditis.

We describe a case of a 74-year-old woman who presented with symptoms of fever and lethargy, associated with an episode of cardiac syncope and exertional shortness of breath (SOB). She was diagnosed with Staphylococcus aureus infective mural endocarditis (IE) and subsequent transoesophageal echocardiogram (TOE) confirmed this diagnosis. As the vegetative mass arose from the septal wall, an unusual location, it caused left ventricular outflow tract (LVOT) obstruction and therefore behaved similarly to a subaortic valvular stenosis.

Undiagnosed cardiac sarcoidosis presenting as complete heart block and ventricular arrhythmia.

Cardiac involvement in sarcoidosis has been reported to be as high as 50% of cases and it is well documented that it is associated with a poorer prognosis. Early recognition and treatment is key to reducing the risk of fatal arrhythmias and heart failure. We report a case of undiagnosed systemic sarcoidosis in a young man who initially presented to the emergency department with complete heart block in the context of preserved biventricular systolic function, and then again with ventricular tachycardia and moderately impaired left ventricular systolic function.

Chest pain symptom scoring can improve the quality of referrals to Rapid Access Chest Pain Clinic.

Typical stable angina is a clinical diagnosis based on history. The challenge for GPs in primary care is to identify those patients who are presenting with either possible or typical angina symptoms and refer onwards for specialist assessment in the local Rapid Access Chest Pain Clinic (RACPC). Our initial information gathering study suggested that referring GPs may be cautiously overdiagnosing angina in primary care, potentially resulting in avoidable or unnecessary referrals to RACPC.

An unusual cause of sustained ventricular tachycardia in a 27-year-old man.

We present an interesting, unusual and complex case of a young man who initially presented with symptoms suggestive of tuberculosis and later developed malignant ventricular arrhythmias. A diagnosis of cardiac sarcoidosis was made only after histological evidence was paired with his presentation of monomorphic ventricular tachycardia. In this case we highlight the current challenges faced in the choice of investigations and diagnostic criteria.

Wellens' syndrome in a 24-year-old woman.

Wellens' syndrome refers to specific ECG abnormalities in the precordial T-wave segment, which are associated with critical stenosis of the proximal left anterior descending (LAD) coronary artery culminating in an acute anterior wall myocardial infarction (MI) if the patient is not urgently revascularised. We describe the youngest reported presentation of Wellens' syndrome in a 24-year-old woman with unstable chest pain, characteristic ECG changes and slight troponin biomarker elevation. This was initially unrecognised by the emergency department as unstable coronary syndrome and she subsequently progressed to an anterior non-ST elevation MI (NSTEMI).

Rare vascular perforation complicating radial approach to percutaneous coronary angioplasty.

A transradial arterial approach to coronary angiography and percutaneous coronary intervention has become increasingly embraced by cardiologists as it is associated with decreased vascular complications and allows early mobilisation of patients when compared with transfemoral arterial access. Major vascular complication post-transradial access is uncommon. We describe a very rare case of perforation of the costocervical trunk (a branch of the right subclavian artery at the site of the thoracic inlet) presenting shortly after percutaneous transradial coronary intervention.