[Left atrium remodeling after catheter ablation of atrial fibrillation]

Atrial fibrillation (AF) is the most common cardiac arrhythmia. It has a high association with cardiovascular embolic events and heart failure. Structural and functional changes are a fundamental part of the pathophysiological process, leading to left atrial myopathy and progressive left ventricular dysfunction that modifies the prognosis of patients. We present the case of a 75-year-old patient with symptomatic paroxysmal AF with good functional class who was referred for pulmonary vein ablation after antiarrhythmic therapy failure. The initial echocardiogram showed preserved biventricular systolic function, mild diastolic dysfunction, and normal left atrium (LA) volumes. However, functional LA impairment was observed with decreased reservoir phase strain. Pulmonary vein isolation was successfully performed without evidence of new arrhythmic events, in addition to improvement in LA reservoir strain, left ventricular (LV) global longitudinal strain, and myocardial work index at three months follow-up. The patient has remained asymptomatic and is under clinical follow-up. LA and LV strain as new advanced echocardiography techniques is useful in the assessment of reverse remodeling of atrial myopathy and LV structural assessment.

Cardiac magnetic resonance as a risk re-stratification tool in apical hypertrophic cardiomyopathy

Apical hypertrophic cardiomyopathy (ApHCM) can result in the formation of a left ventricular apical aneurysm and progressive myocardial fibrosis, which is associated with a worse prognosis. We present the case of a 76-year-old man previously diagnosed with ApHCM seven years ago, who has been under clinical follow-up. Serial cardiac magnetic resonance (CMR) imaging was performed in 2013 and 2020 due to suspected apical aneurysm formation based on echocardiographic evaluation. The 2020 CMR imaging revealed an increase in myocardial fibrosis observed through late-gadolinium enhancement images and, for the first time, a small apical aneurysm that was not clearly visualized on two-dimensional echocardiography. The time course leading to the development of an ApHCM aneurysm is not well-defined and may impact the clinical course.

Cardiac Multimodality Imaging Assessment of Dystrophic Myocardial Calcification in a Human Immunodeficiency Virus-Infected Patient With Dilated Cardiomyopathy

Dystrophic myocardial calcification represents the sequelae of local tissue damage and cellular necrosis. We present the case of a 72-year-old man who presented with exertional chest pain. He had a medical history of human immunodeficiency virus (HIV) infection and chronic dilated cardiomyopathy with severe left ventricular (LV) systolic dysfunction and wall motion abnormalities at the inferior and lateral LV walls. A cardiac magnetic resonance (CMR) examination from 16 years ago showed a subendocardial late gadolinium enhancement (LGE) distribution consistent with prior myocardial infarction (MI). Recently, a pharmacological stress myocardial perfusion imaging by CMR had been positive for myocardial ischemia in the left descending coronary artery (LAD) territory. A cardiac CT angiography (CCTA) showed non-significant LAD obstruction <50% consistent with microvascular ischemia and the presence of dystrophic myocardial calcification as an unusual progression of a prior MI. Conservative approach and optimal medical therapy were employed in our patient, and there was no symptom progression during the two-month follow-up period.

[Different phenotypes of mitral regurgitation in patients with right apical ventricular pacing: an echocardiographic approach in a heterogeneity of clinical scenarios]

The presence of mitral regurgitation (MR) in patients with right ventricular apical pacing can be the result of multiple phenomena. On the one hand, this stimulation causes an asynchronous activation of the left ventricle (LV) and the papillary muscles, leading to a deterioration of the LV ejection fraction and causing an inadequate closure of the valve apparatus. However, there is a wide heterogeneity of ischemic and non-ischemic myocardial conditions that can coexist with mechanical alteration of the LV and the mitral valve leading to or worsening MR in these patients, which can make the etiological determination of valvular regurgitation difficult. Transthoracic echocardiography study allows comprehensive evaluation of mitral valve regurgitation and ventricular function parameters and mechanical asynchrony as a result of artificial pacing. The comprehensive study of these phenomena is relevant in clinical decision-making to define those patients who benefit from cardiac resynchronization therapy to alleviate symptomatic MR.

Cardiac Computed Tomography as an Alternative Technique in the Assessment of Acute Myocardial Ischemia in the Context of COVID-19 Infection

Coronavirus disease 2019 (COVID-19) has been shown to result in coagulation abnormalities and predisposes patients to thrombotic status, both in the venous and arterial circulations. Herein, we report the case of a 60-year-old patient with COVID-19 pneumonia confirmed by polymerase chain reaction (PCR) who experienced signs and symptoms of myocardial ischemia. A cardiac computed tomography (CT) demonstrated an extensive coronary artery multivessel disease and ischemic dilated cardiomyopathy in a non-invasively approach allowing to define the coronary obstructive involvement in the acute stage of the disease.

Prolapse and regurgitation of the four heart valves in a patient with Ehlers-Danlos Syndrome: a case report

Background

The Ehlers–Danlos Syndrome (EDS) is part of a group of connective tissue diseases that affect the synthesis and processing of collagen leading to alterations in the structure of many tissues and organs.

Case summary

Herein, we reported a case of a patient with prolapse of the four cardiac valves. Non-significant regurgitation of the mitral, aortic, and tricuspid valves was observed. The pulmonary regurgitation (PR) was considered significant. Dilatation of the right ventricle with preserved systolic function was also noted. A cardiac magnetic resonance confirmed the findings of the echocardiogram and determined a severe PR (regurgitant fraction of 41%). The physical examination revealed hyperlaxity of the joints, skin hyperelasticity, defects in wound healing, and abdominal hernias suggesting EDS. The stress test did not develop any symptoms or complex arrhythmias. In this patient, the heart team initially decided medical treatment and evolutionary control. At the moment, he remains asymptomatic.

Discussion

Valvular involvement in EDS is an infrequent event and the compromise of the four cardiac valves is exceptional. The existence of severe PR with a marked increase in ventricular volumes, even in the absence of symptoms, in most cases requires an intervention on the valve. However, in patients with EDS, there are a high rate of complications and interventions should be avoided as much as possible.