Finger ischemia in a young lady: an unusual presentation of papillary fibroelastoma with intraventricular location

An otherwise healthy 32-year-old woman suffered from finger ischemia. An echocardiogram and computed tomography scan revealed a mobile mass in the left ventricle that was attached to the anterior papillary muscle and did not involve the valve leaflets. The tumor was resected, and histopathology confirmed it to be a papillary fibroelastoma. Our case emphasizes the significance of a comprehensive diagnostic work-up for a peripheral ischemic lesion. This resulted in the discovery of an unusual intra-ventricular origin for a commonly benign tumor.

Differentiating typical Tako-tsubo syndrome from extensive anterior STEMI: Look behind the anterior wall

BACKGROUND

Tako-tsubo syndrome (TTS) in its most typical form shares common features with anterior ST-segment elevation myocardial infarction (AMI) during acute presentation. Differential diagnosis between the two conditions is often challenging especially if ST-segment elevation is associated with extensive apical akinesis.

METHODS

We sought to systematically analyze ECG and echocardiographic parameters including LV longitudinal strain and two new indexes: the inferior-apex ratio (IAR) and the inferior-lateral-apex ratio (ILAR), to assess if ventricular involvement may be different in TTS and AMI.

RESULTS

A retrospective cohort study was conducted with two groups: patients with TTS (n = 22) and patients with extensive anterior STEMI (n = 22). Lack of ST elevation in V1 was associated with TTS with sensitivity and specificity of 86%, positive and negative predictive value of 86%. Longitudinal strain in mid inferior and mid inferior-lateral segments were more compromised in TTS: -4.3 ± 6.4% and -5.4 ± 5.4% in TTS versus -10.2 ± 5.5% and -9.9 ± 4.9% in AMI, respectively (p < .01 for all). By multivariate analysis, both longitudinal strain values, inferior-apical ratio (IAR) < 1 and inferior-lateral-apical ratio (ILAR) < 1 were independently associated with diagnosis of TTS during acute phase.

CONCLUSIONS

Our results suggest that impaired contractility extending beyond apex to mid inferior and inferior-lateral walls can be easily assessed by IAR and ILAR, and these indexes facilitate non-invasive differentiation of TTS from extensive anterior STEMI.

Differentiating typical tako tsubo syndrome from extensive anterior ST-elevation myocardial infarction: look behind the anterior wall

Funding Acknowledgements

Type of funding sources: None.

Tako-Tsubo Syndrome (TTS) consists in transient left ventricular dysfunction resembling in its typical form acute anterior ST-elevation myocardial infarction (STEMI). Early non-invasive differential diagnosis, crucial for therapeutic purposes, appears difficult according to available data.

Purpose

to systematically analyze LV function and ECG changes in patients with acute anterior STEMI and TTS, to identify parameters possibly useful for differential diagnosis.

Methods

this is a retrospective cohort study, with 2 groups: patients with anterior STEMI and extensive apical involvement at echocardiography (n = 22); patients with TTS (n = 22) and ECG changes diagnostic for anterior STEMI at presentation (n = 22). They underwent a comprehensive clinical and echocardiographic evaluation in acute phase, including 2D speckle tracking longitudinal strain. We created new indexes based on wall motion impairment of inferior and inferior-lateral walls: the Inferior apex ratio (IAR) and inferior-lateral apex ratio (ILAR) (see picture).

Results

TTS and STEMI patients were similar for age (74.7 ± 9.1 vs 73.4 ± 14.1 y), sex, and main biochemical data except for higher peak troponin I in STEMI (1323 ± 622 vs 377 ± 220 ng/L, p = 0.01). ST segment elevation in V1 (V1e) was significantly less common in TTS (p &lt; 0.001) while increased ratio of ST segment elevation in V4-V6 to V1-V3 (∑Ste V4-V6/∑Ste V1-V3≥1) was more common in TTS (p &lt; 0.001). Among ECG parameters, absence of V1e had the best sensitivity (86%) and specificity (86%) in predicting TTS. LVEF values were similar (means: 45% in both groups) with EDVI greater in TTS (55.5 ±12.3 vs 46.6 ± 11.0 ml/m2, p = 0.02). WMSI was greater in TTS patients (2.2 ± 0.1 vs 1.9 ± 0.1, p &lt; 0.0001), mainly for greater scores of mid segments.  Global longitudinal strain was impaired in TTS (-8.1 ± 2.5 %) and in anterior STEMI (-7.9 ± 2.7, p = 0.8). By analyzing the single segments, strain was significantly more compromised in TTS in mid inferior (MI) (-4.3 ± 6.4 vs -9.9 ± 5.5 % in STEMI, p = 0.003) and mid inferior-lateral (MIL) segments (-5.4 ± 5.4 vs -9.6 ± 4.9 %, p = 0.009). Mean IAR was 0.7 ± 0.3 in TTS vs 1.8 ± 0.6 in STEMI, p &lt; 0.0001; mean ILAR was 0.7 ± 0.1 in TTS vs 2.0 ± 0.9 in STEMI, p &lt; 0.0001. ILAR was &lt; I in all TTS patients, and &gt; 1 in all STEMI cases. IAR &lt; 1 showed 90% sensitivity and 95% specificity in predicting TTS. By multivariate linear regression analysis, strain values of MI and MIL segments were significantly associated with TTS (Beta: -0.98 and -0.97 respectively, p &lt; 0.0001), independently from age, sex, and EDVI. IAR and ILAR values were significantly associated with TTS (Beta: -0.81 and -0.76 respectively, p &lt; 0.0001) independently from the same co-variates as above.

Conclusions

evidence of impaired contractility extending beyond apex to mid inferior and inferior-lateral walls, assed by longitudinal strain or by IAR and ILAR, can help to discriminate TTS from extensive anterior STEMI, more accurately than ECG parameters. Abstract Figure. Examples of ILAR index  Abstract Figure. IAR and ILAR distributions

Acute heart failure due to COVID-19 related myocardial injury and de novo hypertensive cardiomyopathy: a challenging diagnosis

We report a COVID-19 case with acute heart and kidney failure in a healthy young male. Echocardiography showed severe systolic and diastolic left ventricle dysfunction, with diffuse myocardial thickening. Cardiac MRI showed aspects of focal myocarditis, and hypertensive cardiomyopathy. Renal biopsy demonstrated limited acute tubular injury, and hypertensive kidney disease. Coronary angiography excluded critical stenoses. Unlike what we initially suspected, myocardial inflammation had a limited extent in our patient; severe hypertension causing cardiomyopathy and multi-organ damage, not diagnosed before, was primarily responsible for severe illness. Correct diagnosis and guidelines-directed treatment allowed a favorable course.

Severe Aortic Regurgitation of Early Degenerated Mitroflow Bioprosthesis: From Echocardiographic Diagnosis to Treatment with Valve-in-Valve Transcatheter Aortic Valve Implantation

Valve-in-Valve transcatheter aortic valve implantation (ViV TAVI) is emerging as an effective therapeutic option for bioprosthetic valve failure. Recently, concern has been raised for early valve deterioration of Mitroflow (Sorin) aortic bioprosthesis, with the development of prevalent stenosis. We report cases of pure severe aortic regurgitation (AR) due to early and mid-term prosthesis degeneration. From June 2018 to October 2019, three patients were treated in our division for the new appearance of severe intraprosthetic regurgitation. Patient 1 (man, 85-year-old) and patient 3 (woman, 83-year-old) had a Mitroflow n. 25 and n. 21 implanted, respectively, in 2012 and 2013 for severe aortic stenosis. Patient 2, a 67-year-old woman with Marfan syndrome underwent a Mitroflow n. 25 implant in 2008 for severe AR and presented chronic type-B aortic dissection. Patient 1 was diagnosed with severe AR in the ambulatory setting, while the other patients presented acute heart failure, requiring inotrope support and high doses intravenous diuretics, and in case 3, temporary extracorporeal ultrafiltration. All patients appeared at high surgical risk and were successfully treated with ViV TAVI, through the right axillary artery in patient 2, and through the femoral artery in patients 1 and 3. Results were good at short- and mid-term follow-up. In conclusion, early and midterm bioprosthesis degeneration with the development of severe AR is a possible complication of the Mitroflow aortic valve. ViV TAVI has been confirmed as a safe and effective therapeutic option in our cases.

Effects of Aortic Valve Replacement on Left Ventricular Diastolic Function in Patients With Aortic Valve Stenosis

The afterload increase imposed by severe aortic valve stenosis (AS) creates concentric left ventricular (LV) remodeling and diastolic dysfunction (DD), which are both markers of poor clinical outcome. Ideally, a correctly timed surgery for isolated AS can reverse the LV remodeling. However, data on LV DD after aortic valve replacement (AVR) are sparse and contrasting. Aims of the study are to define the markers of a favorable evolution of the DD at follow-up. Patients with severe isolated AS, scheduled for AVR were prospectively enrolled. Transthoracic echocardiography with DD assessment was performed before surgery, and at 12 months after surgery. Global LV longitudinal and circumferential strain, peak atrial longitudinal and contraction strain (PALS, PACS) were obtained at baseline. LV septal biopsy to assess fibrosis was performed at the time of AVR. Sixty-seven patients were enrolled, age 72 ± 8 years, 66% female, ejection fraction 61 ± 8%, E/e' 13 ± 6, PALS 23 ± 7%. Normal estimated left atrial pressure was detected in 19/67 (28%) versus 43/67 (64%) at follow-up (p <0.0001). In the 37 patients with biopsy available, fibrosis was 24 ± 12%. PALS and AS severity were correlated with LV fibrosis (R² = 0.19; p = 0.006, and R² = 0.15; p = 0.02, respectively). PALS (odds ratio: 1.19 [1.05 to 1.41], p = 0.02) and PACS (odds ratio: 1.24 [1.06 to 1.50], p = 0.006) were the only baseline noninvasive parameters independently associated with normal left atrial pressure at follow-up. Mean follow-up time was 791 ± 245 days, and 8 (12%) patients had cardiovascular events (death, hospital admission due to heart failure or ischemic disease, and onset of atrial fibrillation). Myocardial fibrosis (p = 0.05), baseline PALS (p = 0.004), and PACS (p = 0.03) were associated with cardiovascular events. In conclusion, LV diastolic function generally improves after AVR for severe AS. Baseline PALS, PACS, and LV fibrosis were related to the DD and clinical outcome at follow-up; these parameters might cue a better diastolic response to the afterload correction.

Giant Right Coronary Artery Aneurysm Detected by Transthoracic Echocardiography

Coronary artery aneurysms (CAAs) are rare findings caused by atherosclerosis in about 50% of cases. They are usually diagnosed using coronary angiography, cardiac computed tomography, or magnetic resonance imaging. In this report, we present a rare case of giant, isolated right CAA, detected by transthoracic echocardiography in an adult patient with unstable angina. Diameters of the aneurysm were 3.6 cm × 2.7 cm. Anterior-septal hypokinesia of the left ventricle was also noted. A comprehensive echocardiographic examination, including contrast study, excluded alternative diagnoses and supported the hypothesis of a coronary ectasia. The coronary angiography confirmed the diagnosis of giant coronary aneurysm and revealed a severe three-vessel disease. The patient was treated with cardiac surgery a few days later: two coronary artery bypass grafts and exclusion of the aneurysm by surgical legation were successfully performed.

Dyspnea following thoracostomy closure after right pneumonectomy: An uncommon echocardiographic diagnosis and therapeutic approach

Dyspnea and hypoxemia are common postoperative problems after pneumonectomy. One of the rarer causes of respiratory distress after right pneumonectomy is the development of a significant right-to-left shunt across a patent foramen ovale (PFO), which can evolve at a variable interval of time after the operation. We report here our experience with a patient who underwent right pneumonectomy, followed by several complications, and who presented severe dyspnea 7 months later, after the closure of a right thoracostomy. This report outlines the management of this challenging clinical condition; transesophageal echocardiography (TOE) provided a clear diagnosis and guided an effective percutaneous treatment.

Nonalcoholic Fatty Liver Disease Is Associated With Ventricular Arrhythmias in Patients With Type 2 Diabetes Referred for Clinically Indicated 24-Hour Holter Monitoring

OBJECTIVE

Recent studies have suggested that nonalcoholic fatty liver disease (NAFLD) is associated with an increased risk of heart rate-corrected QT interval prolongation and atrial fibrillation in patients with type 2 diabetes. Currently, no data exist regarding the relationship between NAFLD and ventricular arrhythmias in this patient population.

RESEARCH DESIGN AND METHODS

We retrospectively analyzed the data of 330 outpatients with type 2 diabetes without preexisting atrial fibrillation, end-stage renal disease, or known liver diseases who had undergone 24-h Holter monitoring for clinical reasons between 2013 and 2015. Ventricular arrhythmias were defined as the presence of nonsustained ventricular tachycardia (VT), >30 premature ventricular complexes (PVCs) per hour, or both. NAFLD was diagnosed by ultrasonography.

RESULTS

Compared with patients without NAFLD, those with NAFLD (n = 238, 72%) had a significantly higher prevalence of >30 PVCs/h (19.3% vs. 6.5%, P < 0.005), nonsustained VT (14.7% vs. 4.3%, P < 0.005), or both (27.3% vs. 9.8%, P < 0.001). NAFLD was associated with a 3.5-fold increased risk of ventricular arrhythmias (unadjusted odds ratio [OR] 3.47 [95% CI 1.65-7.30], P < 0.001). This association remained significant even after adjusting for age, sex, BMI, smoking, hypertension, ischemic heart disease, valvular heart disease, chronic kidney disease, chronic obstructive pulmonary disease, serum γ-glutamyltransferase levels, medication use, and left ventricular ejection fraction (adjusted OR 3.01 [95% CI 1.26-7.17], P = 0.013).

CONCLUSIONS

This is the first observational study to show that NAFLD is independently associated with an increased risk of prevalent ventricular arrhythmias in patients with type 2 diabetes.

Frame rate required for speckle tracking echocardiography: A quantitative clinical study with open-source, vendor-independent software

OBJECTIVES

To determine the optimal frame rate at which reliable heart walls velocities can be assessed by speckle tracking.

BACKGROUND

Assessing left ventricular function with speckle tracking is useful in patient diagnosis but requires a temporal resolution that can follow myocardial motion. In this study we investigated the effect of different frame rates on the accuracy of speckle tracking results, highlighting the temporal resolution where reliable results can be obtained.

MATERIAL AND METHODS

27 patients were scanned at two different frame rates at their resting heart rate. From all acquired loops, lower temporal resolution image sequences were generated by dropping frames, decreasing the frame rate by up to 10-fold.

RESULTS

Tissue velocities were estimated by automated speckle tracking. Above 40 frames/s the peak velocity was reliably measured. When frame rate was lower, the inter-frame interval containing the instant of highest velocity also contained lower velocities, and therefore the average velocity in that interval was an underestimate of the clinically desired instantaneous maximum velocity.

CONCLUSIONS

The higher the frame rate, the more accurately maximum velocities are identified by speckle tracking, until the frame rate drops below 40 frames/s, beyond which there is little increase in peak velocity. We provide in an online supplement the vendor-independent software we used for automatic speckle-tracked velocity assessment to help others working in this field.

Hyperuricemia is associated with an increased prevalence of atrial fibrillation in hospitalized patients with type 2 diabetes

PURPOSE

Hyperuricemia/gout and atrial fibrillation (AF) are two pathological conditions that are highly prevalent in type 2 diabetes and share multiple cardiovascular risk factors. However, the relationship between elevated levels of serum uric acid and risk of AF in type 2 diabetes is currently poorly known.

METHODS

We studied a hospital-based sample of 842 (male/female = 463/379) patients with type 2 diabetes discharged from our Division of Endocrinology during 2007-2011. Hyperuricemia was defined as a serum uric acid level >7 mg/dl for men and >6 mg/dl for women or allopurinol use. The diagnosis of AF was confirmed in affected participants on the basis of ECGs and medical history by experienced cardiologists.

RESULTS

Overall, 243 (28.9 %) patients had hyperuricemia and 91 (10.8 %) patients had persistent or permanent AF. Compared with those with normal serum uric acid levels, patients with hyperuricemia had a remarkably greater prevalence of AF (20.6 vs. 7.1 %; p < 0.001). Hyperuricemia was significantly associated with an increased risk of prevalent AF (odds ratio 3.41, 95 % CI 2.19-5.32; p < 0.001). Adjustments for age, sex, smoking, hemoglobin A1c, hypertension status, chronic kidney disease, chronic obstructive pulmonary disease and previous histories of hyperthyroidism, ischemic heart disease and valvular heart diseases did not weaken this association (adjusted-odds ratio 6.27, 95 % CI 1.82-21.5; p < 0.01).

CONCLUSIONS

These results indicate that hyperuricemia is associated with an increased prevalence of AF in hospitalized patients with type 2 diabetes, independently of multiple risk factors and potential confounders.

Nonalcoholic Fatty Liver Disease Is Independently Associated with Early Left Ventricular Diastolic Dysfunction in Patients with Type 2 Diabetes

Accumulating evidence suggests that nonalcoholic fatty liver disease (NAFLD) is associated with left ventricular diastolic dysfunction (LVDD) in nondiabetic individuals. To date, there are very limited data on this topic in patients with type 2 diabetes and it remains uncertain whether NAFLD is independently associated with the presence of LVDD in this patient population. We performed a liver ultrasonography and trans-thoracic echocardiography (with speckle-tracking strain analysis) in 222 (156 men and 66 women) consecutive type 2 diabetic outpatients with no previous history of ischemic heart disease, chronic heart failure, valvular diseases and known hepatic diseases. Binary logistic regression analysis was used to examine the association between NAFLD and the presence/severity of LVDD graded according to the current criteria of the American Society of Echocardiography, and to identify the variables that were independently associated with LVDD, which was included as the dependent variable. Patients with ultrasound-diagnosed NAFLD (n = 158; 71.2% of total) were more likely to be female, overweight/obese, and had longer diabetes duration, higher hemoglobin A1c and lower estimated glomerular filtration rate (eGFR) than those without NAFLD. Notably, they also had a remarkably greater prevalence of mild and/or moderate LVDD compared with those without NAFLD (71% vs. 33%; P<0.001). Age, hypertension, smoking, medication use, E/A ratio, LV volumes and mass were comparable between the two groups of patients. NAFLD was associated with a three-fold increased odds of mild and/or moderate LVDD after adjusting for age, sex, body mass index, hypertension, diabetes duration, hemoglobin A1c, eGFR, LV mass index and ejection fraction (adjusted-odds ratio 3.08, 95%CI 1.5–6.4, P = 0.003). In conclusion, NAFLD is independently associated with early LVDD in type 2 diabetic patients with preserved systolic function.

Heart valve calcification in patients with type 2 diabetes and nonalcoholic fatty liver disease

PURPOSE

Aortic valve sclerosis (AVS) and mitral annulus calcification (MAC) are two powerful predictors of adverse cardiovascular outcomes in patients with type 2 diabetes, but the etiology of valvular calcification is uncertain. Nonalcoholic fatty liver disease (NAFLD) is an emerging cardiovascular risk factor and is very common in type 2 diabetes, but whether NAFLD is associated with valvular calcification in this group of patients is presently unknown.

METHODS

We undertook a cross-sectional study of 247 consecutive type 2 diabetic outpatients with no previous history of heart failure, valvular heart diseases (aortic stenosis, mitral stenosis, moderate or severe aortic and mitral regurgitation) or hepatic diseases. Presence of MAC and AVS was detected by echocardiography. NAFLD was diagnosed by ultrasonography.

RESULTS

Overall, 139 (56.3%) patients had no heart valve calcification (HVC-0), 65 (26.3%) patients had one valve affected (HVC-1) and 43 (17.4%) patients had both valves affected (HVC-2). 175 (70.8%) patients had NAFLD and the prevalence of this disease markedly increased in patients with HVC-2 compared with either HVC-1 or HVC-0 (86.1% vs. 83.1% vs. 60.4%, respectively; p < 0.001). NAFLD was significantly associated with AVS and/or MAC (unadjusted-odds ratio 3.51, 95% CI 1.89-6.51, p < 0.001). Adjustments for age, sex, waist circumference, smoking, blood pressure, hemoglobin A1c, LDL-cholesterol, kidney function parameters, medication use and echocardiographic variables did not appreciably weaken this association (adjusted-odds ratio 2.70, 95% CI 1.23-7.38, p < 0.01).

CONCLUSIONS

Our results show that NAFLD is an independent predictor of cardiac calcification in both the aortic and mitral valves in patients with type 2 diabetes.