1
|
Bettella N, De Lazzari M, Zorzi A, Vessella T, Cipriani A, Motta R, Perazzolo Marra M, Corrado D. Relationship between papillary muscles abnormalities and apparently unexplained infero-lateral T-wave inversion in athletes. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.3132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Aims
To evaluate by cardiac magnetic resonance (CMR) if left ventricle papillary muscle abnormalities, such as hypertrophy and abnormal location, may be the anatomo-functional substrates responsible for TWI inversion in lateral or infero-lateral leads in otherwise healthy athletes.
Methods
We included competitive athletes with TWI in lateral or infero-lateral leads in the absence of cardiac diseases detected by CMR. The control population included healthy athletes with normal ECG, matched for age and gender. We compared thickness, volume (both absolute and relative to the cardiac mass) and position of the papillary muscles between cases and controls.
Results
We included 53 athletes with apparently unexplained TWI in the lateral or infero-lateral leads (median age 20 years (17–42), 86.8% males) and 53 athletes with no TWI matched for age and gender. 4 patients (7.6%) had family history for cardiomyopathy or sudden cardiac death. Athletes with TWI showed more hypertrophic papillary muscles compared to controls, with statistically significant difference in diameter, area and volume (p<0.01). The median ratio between the papillary muscles and the left ventricular mass was 4.4% among athletes with TWI versus 3% among those without TWI (p<0.001). Papillary muscles showed apical displacement in 47% of cases, compared to 17% in the control group (p=0.001).
Conclusions
Idiopathic TWI in lateral or infero-lateral leads is associated with left ventricle papillary muscle hypertrophy and their apical displacement detected by CMR. The comprehension of clinical and prognostic significance of papillary muscle abnormalities responsible for these ventricular repolarization alterations requires further studies.
Example
Funding Acknowledgement
Type of funding source: None
Collapse
Affiliation(s)
- N Bettella
- University of Padova, Department of Cardiac, Thoracic and Vascular sciences, Padua, Italy
| | - M De Lazzari
- University of Padova, Department of Cardiac, Thoracic and Vascular sciences, Padua, Italy
| | - A Zorzi
- University of Padova, Department of Cardiac, Thoracic and Vascular sciences, Padua, Italy
| | - T Vessella
- Center for Sports Medicine, ULSS2 Marca Trevigiana, Treviso, Italy, Treviso, Italy
| | - A Cipriani
- University of Padova, Department of Cardiac, Thoracic and Vascular sciences, Padua, Italy
| | - R Motta
- University of Padua, Department of medicine, Padova, Italy
| | - M Perazzolo Marra
- University of Padova, Department of Cardiac, Thoracic and Vascular sciences, Padua, Italy
| | - D Corrado
- University of Padova, Department of Cardiac, Thoracic and Vascular sciences, Padua, Italy
| |
Collapse
|
2
|
Bettella N, Previtero M, Ruocco A, Muraru D, Iliceto S, Badano LP. P167 The burden of post-actinic heart disease: a case of severe valvular and coronary artery disease in a cancer survivor. Eur Heart J Cardiovasc Imaging 2020. [DOI: 10.1093/ehjci/jez319.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
A 47-year old female complaining of exertional dyspnoea (NYHA class III) was admitted at our Cardiology department. She had a history of nodular sclerosis Hodgkin lymphoma (HL), treated with chemo- and radiotherapy, and complicated by post-actinic pneumopathy and cardiopathy. At the age of 39, she had undergone coronary artery bypass grafting with left internal mammal artery (LIMA) to left anterior descendent artery and saphenous vein to obtuse marginal branch, and aortic valve replacement with a mechanical prosthesis due to severe aortic stenosis. Some years later, she had undergone percutaneous stenting of the left main (LM) due to occlusion of the LIMA bypass graft.
At admission, the patient was hemodynamically stable, with signs of right-sided congestive heart failure. Both 2D and 3D transthoracic echocardiogram (TTE) showed preserved biventricular function, normal function of the aortic prosthesis, and diffuse calcification of the whole mitral valve apparatus, involving the leaflets, the annulus, the tendinous chords and the anterolateral papillary muscle (Figure Panels A-B), causing severe mitral stenosis (mean gradient 10 mmHg, 3D planimetric area 0.9 cm2, Wilkins score 12) and moderate organic insufficiency (Panel C). The tricuspid valve was also affected, with thickened, hypomobile leaflets, causing mild stenosis (mean gradient 4 mmHg, 3D planimetric area 3.8 cm2) and severe insufficiency (Panel D). Transesophageal echocardiogram (TOE) couldn"t be performed because of actinic oesophagitis. Percutaneous valvuloplasty was contraindicated due to moderate mitral insufficiency, high Wilkins score and a huge amount of calcium affecting the whole valve apparatus but sparing the commissures.
The patient was scheduled to PCI on the LM due to intrastent restenosis, but died during the procedure as a consequence of an intrastent massive thrombosis leading to cardiac arrest.
Learning points
Hodgkin lymphoma survivors are at increased cardiovascular and intraoperative risk. Old radiotherapy protocols for HL may cause severe post-actinic valvular and coronary disease. Post-actinic valvular heart disease often affects aortic and mitral valve more than a decade after irradiation, and may manifest as stenosis, insufficiency or both. Organic regurgitation and stenosis of tricuspid valve are uncommon, but may also occur and lead to worse patient outcome. Despite TOE may bring additional valuable informations in challenging cases, the coexistence of oesophageal sequelae from post-actinic oesophagitis may limit its applicability. TTE is the first line and often the only diagnostic tool available for identifying the characteristic valvular lesions in cancer survivors exposed to radiotherapy. 3D TTE may be particularly useful to identify subtle signs of primary involvement of tricuspid apparatus and quantify the anatomical area of a stenotic tricuspid valve, when severe regurgitation coexists and transvalvular gradients may be unreliable.
Abstract P167 Figure
Collapse
Affiliation(s)
- N Bettella
- University of Padova, Cardiac, Thoracic, Vascular Sciences and Public Health, Padua, Italy
| | - M Previtero
- University of Padova, Cardiac, Thoracic, Vascular Sciences and Public Health, Padua, Italy
| | - A Ruocco
- University of Padova, Cardiac, Thoracic, Vascular Sciences and Public Health, Padua, Italy
| | - D Muraru
- Italian Institute for Auxology IRCCS, Cardiology, Milan, Italy
| | - S Iliceto
- University of Padova, Cardiac, Thoracic, Vascular Sciences and Public Health, Padua, Italy
| | - L P Badano
- Italian Institute for Auxology IRCCS, Cardiology, Milan, Italy
| |
Collapse
|
3
|
Ruocco A, Previtero M, Bettella N, Muraru D, Iliceto S, Badano LP. P190 Chest pain and syncope in Turner"s syndrome: going beyond the obvious to not miss the critical diagnosis. Role of multimodality imaging approach. Eur Heart J Cardiovasc Imaging 2020. [DOI: 10.1093/ehjci/jez319.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Clinical Presentation: a 18-year-old woman with Turner’s syndrome (TS), with history of hypothyroidism treated with L-thyroxin, asymptomatic moderately stenotic bicuspid aortic valve (AV) and without any known cardiovascular risk factor, was admitted to our emergency department (ED) because of syncope and typical chest pain after dinner associated with dyspnea. Chest pain lasted for an hour with spontaneous regression. In the ED the patient (pt) was normotensive. An ECG showed sinus rhythm (88 bpm), nonspecific repolarization anomalies (T wave inversion) in the inferior and anterior leads. Myocardial necrosis biomarkers were negative. A 3D transthoracic echocardiography showed normal biventricular systolic function with left ventricular hypertrophy, dilatation of the ascending aorta, unicuspid AV with severe aortic stenosis (peak/mean gradient 110/61 mmHg, aortic valve area 0,88 cm2-0,62 cm2/m2), mild pericardial effusion (Figure Panel A, B, C). Five days after, the pt had a new episode of typical chest pain without ECG changes. A computerized tomography (CT) was performed to rule out the hypothesis of aortic dissection and showed a dilation of the ascending aorta and pericardial effusion localized in the diaphragmatic wall, no signs of dissection or aortic hematoma. However, CT was of suboptimal quality because of sinus tachycardia (120 bpm) and so the pt underwent a coronary angiography and aortography that ruled out coronary disease, confirmed the dilatation of ascending aorta (50 mm) and showed images of penetrating atherosclerotic ulcer of the ascending aorta (Figure panel D). The pt underwent urgent transesophageal echocardiography (TOE) that confirmed the severely stenotic unicuspid AV and showed a localized type A aortic dissection (Figure Panel E, F, G). The pt underwent urgent AV and ascending aorta replacement (Figure Panel H).
Learning points
Chest pain and syncope are challenging symptoms in pts presenting in ED. AV pathology and aortic dissection should be always suspected and ruled out. TS is associated with multiple congenital cardiovascular abnormalities and is the most common established cause of aortic dissection in young women. 30% of Turner’s pts have congenitally AV abnormalities, and dilation of the ascending aorta is frequently associated. However, unicuspid AV is a very rare anomaly, usually stenotic at birth and requiring replacement. The presence of pericardial effusion in a pt with chest pain and syncope should raise the suspicion of aortic dissection, even if those symptoms usually accompany severe aortic stenosis. Even if CT is the gold standard imaging technique to rule out aortic dissection, the accuracy of a test is critically related to the image quality. When the suspicion of dissection is high and the reliability of the reference test is low, it’s reasonable to perform a different test to rule out the pathology. Aortography and TOE were pivotal to identify the limited dissection of the ascending aorta.
Abstract P190 Figure.
Collapse
Affiliation(s)
- A Ruocco
- University Hospital of Padova, Department of Cardio-Thorax-Vascular Sciences and Public Health, Padua, Italy
| | - M Previtero
- University Hospital of Padova, Department of Cardio-Thorax-Vascular Sciences and Public Health, Padua, Italy
| | - N Bettella
- University Hospital of Padova, Department of Cardio-Thorax-Vascular Sciences and Public Health, Padua, Italy
| | - D Muraru
- University Hospital of Padova, Department of Cardio-Thorax-Vascular Sciences and Public Health, Padua, Italy
| | - S Iliceto
- University Hospital of Padova, Department of Cardio-Thorax-Vascular Sciences and Public Health, Padua, Italy
| | - L P Badano
- University Hospital of Padova, Department of Cardio-Thorax-Vascular Sciences and Public Health, Padua, Italy
| |
Collapse
|