To the Editor:We enjoyed reading the case, authored by Janus and Hoit, of a 67-year-old woman with a subarachnoid hemorrhage (SAH) who presented with three different variants of takotsubo (TT).[i] We congratulate the authors on their interesting contribution to the literature. We would like to share some comments and questions on the chronology and management of the events between the first two episodes, which occurred a few days apart. Although fascinating, this is not the first case of TT with a rapidly evolving pattern. We previously described a case of mid-ventricular takotsubo which replaced apical ballooning in 6 hours.[ii] A recent meta-analysis showed that almost 80% of TT recurrences exhibit a ballooning pattern different from the first presentation.[iii] In this regard, regional cardiac sympathetic innervation remodeling or denervation could hypothetically justify why the same territory is usually spared from further relapses. Even though images were not provided, the authors stated that “echocardiographic wall motion abnormalities quickly resolved after each acute stressor”. One could therefore argue that this was not a case of multiple TT variants during the same episode, as noted by Madias,iii but rather an example of early recurrences. Additionally, if cardiac innervation remodeling were responsible for the different locations of the ballooning, we believe that the change in pattern would have taken longer to manifest. This would not support the observation of two distinct ballooning patterns emerging within days, let alone hours.i, ii In this case, a short-term change from the mid-ventricular to apical pattern could be reasonably explained by different β adrenergic-receptor (β-AR) subtype downregulation. We know that norepinephrine can downregulate β1-AR after a few hours. Beta1-ARs are markedly lower on biopsied patients with acute TT compared to healthy controls,[iv] whilst in the same study β2-ARs expression—which is predominant in the apical and mid-ventricular segments and thought to be involved in typical takotsubo pathogenesis[v]—was equivalent to normal. Thus, the sequence of events could be interpreted as a relative local β2 prevalence due to dynamic β1 downregulation (β1:β2 mismatch), following a base:mid-ventricle, and ultimately a mid-ventricle:apex progression. What do the authors think about this theory? Is it possible that multi-faceted presentations might simply be under-recognized? Should this be the case, how do they think we could better understand this phenomenon in a noninvasive fashion? Could dobutamine stress echocardiography have utility to identify areas of β-AR downregulation and sympathetic denervation? It would also be interesting to know more about the patient’s medical therapy. Did she receive nonselective β-blockers, such as labetalol or carvedilol, usually prescribed after SAH? If so, this might indicate that β-blockers do not prevent recurrences,[vi] but rather create a maladaptive imbalance in regional β1:β2 distribution favoring early relapse(s), as this case suggests.References[i] Janus SE, Hoit BD. The three faces of takotsubo cardiomyopathy in a single patient. Echocardiography. 2020 Jan;37(1):135-138. doi: 10.1111/echo.14560. Epub 2019 Dec 16.[ii] Casavecchia G, Zicchino S, Gravina M, et al. Fast 'wandering' Takotsubo syndrome: atypical mixed evolution from apical to mid-ventricular ballooning. Future Cardiol. 2017 Nov;13(6):529-532. doi: 10.2217/fca-2017-0018. Epub 2017 Oct 12.[iii] Madias JE. Comparison of the first episode with the first recurrent episode of takotsubo syndrome in 128 patients from the world literature: Pathophysiologic connotations. Int J Cardiol. 2020 Mar 3. pii: S0167-5273(20)30215-1. doi: 10.1016/j.ijcard.2020.03.003.[iv] Nakano T, Onoue K, Nakada Y, et al. Alteration of β-Adrenoceptor Signaling in Left Ventricle of Acute Phase Takotsubo Syndrome: a Human Study. Sci Rep 8, 12731 (2018). https://doi.org/10.1038/s41598-018-31034-z.[v] Paur H, Wright PT, Sikkel MB, et al. High levels of circulating epinephrine trigger apical cardiodepression in a β2-adrenergic receptor/Gi-dependent manner: a new model of Takotsubo cardiomyopathy. Circulation. 2012 Aug 7;126(6):697-706. doi: 10.1161/CIRCULATIONAHA.112.111591. Epub 2012 Jun 25.[vi] Santoro F, Ieva R, Musaico F, et al. Lack of efficacy of drug therapy in preventing takotsubo cardiomyopathy recurrence: a meta-analysis. Clin Cardiol. 2014 Jul;37(7):434-9. doi: 10.1002/clc.22280. Epub 2014 Apr 3.
Abstract Background: Cystic fibrosis may lead to left ventricular dysfunction. This dysfunction can be documented by methods such as tissue doppler echocardiographic imaging and two-dimensional speckle tracking echocardiography in early stage. Patients and Methods: A total of 34 patients diagnosed with cystic fibrosis (mean age and SD 9.9±4.9 years) and 37 healthy control subjects with a comparable gender and age distribution (mean age 9.8±4.3) were studied. The results for the two groups were compared along with the results of published reports. Result: Control group had higher diastolic and systolic dimentions compared to the patient group in M-mode measurements of left ventricle by conventional echocardiography (p <0.05). There was no significant relationship between the groups in terms of the dimensions of systolic and diastolic measurements of interventricular septum and posterior wall of left ventricle, and ejection fraction. Pulmonary artery systolic pressure was significantly higher in the patient group (p<0.001). Myocardial performance indices of left ventricle free wall and interventricular septum were increased in the patient group compared to the control group (p<0.05). ). As measured by speckle tracking echocardiography, 7 segments in left ventricular myocardial longitudinal strain and 3 segments in left ventricular myocardial circumferential strain showed significant reductions in patients with cystic fibrosis compared to controls (p <0.05). Conclusions: Tissue doppler echocardiographic imaging and speckle tracking echocardiography may help identifying subclinical left ventricular dysfunction in cystic fibrosis patients with unremarkable conventional echocardiography. Its may be considered for the routine follow-up of cystic fibrosis patients.
SARS-CoV-2 not only causes viral pneumonia but has major implications for the cardiovascular system. Nevertheless, we assisted to a drastic reduction in the number of ACS during this period. Telemedicine and telecardiology, intended as integration to the traditional management appear precious tools especially in Covid-19 era. Given the decrease in new Covid-19 cases worldwide20, now we are approaching the so-called “Phase 2” challenge of a gradual return to pre-Covid-19 life. The epidemiological and clinical situation is rapidly evolving and practice patterns with policies depend on institutions and local availability.
A 35-year-old male with history of recurrent arrhythmias presented for pulmonary vein isolation. He underwent pre-procedural screening for thromboembolism risk with transesophageal echocardiogram. He had an incidental finding of a rare fenestrated membrane overlying his left atrial appendage. Additional work-up throughout his clinical course revealed genetic mutations in the LMNA and SNTA1 genes. There have been no previous reported genetic mutations reported in cases with LAA membranes.
Introduction: Chagas disease is one of the main diseases in Latin America and heart involvement is its main characteristics, and the main cause of death. The aim of this study is to evaluate if there is any parameter of Doppler Tissue Imaging (DTI) which can be used as a predictor for later events in chronic Chagas disease. Methods: we analyses DTI variables of 543 patients with chronic Chagas disease for the evaluation of predicting factors of events. Major adverse cardiovascular events (MACE) were considered as stroke, heart failure resistant to treatment, sustained ventricular tachycardia, implantable cardioverter-defibrillator, sudden death, and cardiovascular death. The following findings were also included in total evens: heart failure, bradycardia, ventricular arrhythmia, new conduction system abnormalities and new echocardiographic abnormalities. Multivariate analysis with logistic regression was used in order to assess the Doppler and DTI parameters predicting events. Variables with a p-value ≤ 0.10 in the univariate analysis were included in the multivariate analysis. Results: In patients with chronic Chagas disease, the analysis of DTI parameters showed that S’ wave and E’ wave of the lateral wall of the left ventricle were significant predictors of MACE (OR: 0.83; 95% CI: 0.71-0.96; p value: 0.015 and OR: 0.80; 95% CI: 0.66-0.98; p value: 0.031, respectively). Conclusions: This study found that patients with chronic Chagas disease who had events showed significantly lower parameters in the DTI. What is more, this study showed that even lower DTI parameters are significant predictors of events.
The assessment of left ventricular (LV) function in the setting of mitral stenosis (MS) has been critically examined for decades. Accurate assessment of aberrations in diastolic function is important as these subjects often present with signs and symptoms of heart failure and pulmonary congestion that cannot be solely explained by the severity of mechanical obstruction. Echocardiographic evaluation of diastolic dysfunction includes an evaluation of reduced LV compliance, diminished restoring forces and enhanced stiffness, which are challenging in the setting of MS owing to altered hemodynamic loading. Conventional echocardiographic and Doppler measures offer limited information. Novel assessments employing speckle tracking echocardiography are relatively less studied. A more comprehensive assessment including clinical evaluation, identification of concomitant disorders and comorbidities is particularly warranted in older subjects with degenerative MS to suspect diastolic dysfunction and arrive at optimal medical therapy or intervention. This review provides an overview of etiological, pathophysiological, echocardiographic and invasive assessment of diastolic dysfunction in the setting of MS, with specific focus on strengths and limitations of available echocardiographic and Doppler techniques.
Pericardial cysts are considered rare incidental findings, which are generally asymptomatic in nature. Occasionally, patients may represent with chest discomfort, dyspnea or palpitations. Pericarditis related to a ruptured pericardial cyst has not been previously reported in the literature. Here, we report the case of a 62-year-old male who developed acute pericarditis as a result of a ruptured enlarging pericardial cyst.
We report a case of 41-year-old woman who presented with chest tightness and shortness of breath. Transthoracic echocardiogram (TTE) showed left ventricular (LV) pseudo-aneurysm of the inferior wall with preserved LV systolic function. Coronary angiogram was normal. Surgical repair of the pseudo-aneurysm with a pericardial patch was performed, and pathological results confirmed rupture of an isolated congenital LV diverticulum.as the most likely etiology.
The aim of the study is to investigate the impairment of diastolic function of the left ventricle (LV) and the right ventricle (RV) in arterial hypertension outpatients. Materials and methods. Arterial hypertension patients (n=299) and practically healthy people (n=62) were examined on an outpatient basis. Echocardiographically, diastolic dysfunctions of both ventricles were evaluated. Results. All the arterial hypertension patients had a pattern of diastolic dysfunction (DD) of the RV of different grades (grade I RVDD and grade II RVDD), regardless of the presence or absence of pulmonary arterial hypertension. Patterns of grade I LVDD and grade I RVDD were detected in 84 patients. Patterns of grade I LVDD and grade II RVDD were detected in 77 patients. Patterns of grade II LVDD and grade II RVDD were detected in 41 patients. A pattern of grade II RVDD with normal left ventricular diastolic function was detected in 97 patients with a short duration of disease (3.92±0.48 years) versus the other groups with more than 15 years of hypertension. 175 arterial hypertension patients had grade I or II LVDD only in 18.3% of cases according to the recommendations of the American and European societies of echocardiographers (2016). Conclusion. The patients with a short period of hypertensive disease have only the pseudonormal pattern of RVDD, which can be an early diagnostic marker of heart failure. Echocardiographic diagnosis of diastolic function made according to various criteria can both increase the number of chronic heart failure patients and significantly decrease it.
Controversy surrounds the cause of the pressure gradient in patients with hypertrophic obstructive cardiomyopathy (HOCM). Left ventricular cavity obliteration (LVCO) was first described as the cause of the gradient but subsequently systolic anterior motion (SAM) of the mitral valve has been established as the cause. Nevertheless, the two gradients, though different in origin and significance, share similar characteristics. They both have a similar “dagger” profile, are obtained from the cardiac apex, are associated with a hyperdynamic left ventricle, and the gradients are worsened by Valsalva. The distinction has clinical relevance, because treating the intra cavitary gradient (ICG) of LVCO as if it were a SAM associated gradient associated with HOCM would be inappropriate and possibly harmful. To clarify the cause and characteristics of the ICG in patients with LVCO in patients without HOCM we assessed the extent and duration of cavity obliteration and for differentiation we compared the spectral profiles with patients with HOCM and severe aortic stenosis (AS). Higher ICG is associated with greater extent and more prolonged apposition of LV walls. The spectral profile of patients with AS, HOCM and LVCO are differentiated by the peak/mean gradient ratios of 2 or less, 2-3, and 3 or greater, respectively in > 90% of patients. Most patients with LVCO without HOCM or severe LVH have an ICG < 36 mmHg. The magnitude of ICG is quantitatively associated with extent and duration of LVCO. Spectral profiles of severe AS, HOCM, and LVCO can be differentiated by the peak/mean gradient ratio.
Here we present a young asymptomatic male incidentally diagnosed to have aortic regurgitation (AR). The patient had a history of a blunt trauma to the thorax two years back but did never have any symptoms. Transthoracic echocardiography showed a moderately dilated left ventricle with normal systolic function and severe AR with normal nondilated aortic root and tri-leaflet aortic valve. To diagnose the etiology of the AR a trans-esophageal echocardiogram (TEE) was done, which revealed a perforation in the non-adjacent leaflet (NAL) and confirmed severe AR with two AR jets being clearly visualised, one through the point of incomplete coaptation and other one through the perforated area in the NAL. The patient was treated with aortic valve replacement and was doing well on follow-up.
Heart failure with preserved ejection fraction (HFpEF) is a complex clinical entity associated with significant morbidity and mortality. Common comorbidities including hypertension, coronary artery disease, diabetes, chronic kidney disease, obesity, and increasing age predispose to preclinical diastolic dysfunction that often progresses to frank HFpEF. That said, clinical HFpEF is typically associated with some degree of diastolic dysfunction or can occur in the absence of many conventional diastolic dysfunction indices. The exact biologic links between risk factors, structural changes, and clinical manifestations are not clearly apparent. Innovative approaches including deformation imaging have enabled deeper understanding of HFpEF cardiac mechanics beyond conventional metrics. Furthermore, predictive analytics through data driven platforms have allowed for a deeper understanding of HFpEF phenotypes. This review focuses on the changes in cardiac mechanics that occur through preclinical myocardial dysfunction to clinically apparent HFpEF.
Objective: Atrial fibrillation (AF) after coronary artery bypass grafting (CABG) is a factor that causes an increase in mortality and morbidity. Therefore, predicting post-CABG AF development is important for treatment management. In this study, we investigated the value of the ratio E/(Ea × Sa) as a combined systolic-diastolic index in predicting post-CABG AF development. Methods: This prospective study included 102 patients who underwent only isolated coronary bypass. Preoperative demographic features, biochemical and hematological parameters, and the electrocardiographic data of all patients were recorded. The E/(Ea × Sa) indices were calculated from the echocardiographic measurements. Those who retained their postoperative sinus rhythm were defined as group 1, and those who developed AF were defined as group 2. Results: Group 2 had significantly higher lateral (group 1: 1.14 ± 0.61 vs. group 2: 1.47 ± 0.87; p = 0.02), medial (group 1: 1.61 ± 0.70 vs. group 2: 1.99 ± 0.91; p = 0.02), and mean (group 1: 1.30 ± 0.58 vs. group 2: 1.62 ± 0.74; p = 0.001) E/(Ea×Sa) indices than group 1. In the univariate analysis, age, CHA2DS2-VASc score, sPAP, and mean E/(EaxSa) index were found to be significant predictors of post-CABG AF development. However, only the mean E/(EaxSa) index was found to be a significant predictor of post-CABG AF development in the multivariate analysis (OR: 2.31 95% CI 1.02–5.24; p = 0.04). Conclusions: The combined systolic-diastolic index predicted the development of post-CABG AF.
Cardiac computed tomography (CT) is increasingly used to plan transcatheter structural heart interventions, however, intra-operative guidance relies on trans-esophageal echocardiography (TEE) and fluoroscopy. This study sought to develop the methods of stepwise CT multi-planar reconstruction manipulation to mimic TEE thus bridging the gap between preoperative planning and intra-operative guidance tools. This CT manipulation successfully reproduces similar configurations as TEE views in mid-esophageal left ventricle (LV) views, transgastric LV 2-chamber views for mitral apparatus, and other miscellaneous views. Stepwise cardiac CT manipulation to mimic TEE is the final piece of the puzzle in the mental co-registration of these three crucial imaging modalities. With it, we are enabled to foresee the TEE images and fluoroscopy projections in a preoperative rehearsal thus improving the intra-operative accuracy of interventions.
Ortner's syndrome is a really rare complication that manifest by hoarseness of voice. It is usually due to left recurrent laryngeal nerve compression. Cardiac causes of Ortner's syndrome are rarely encountered and it is usually due to left atrial enlargement as a complication of valvular lesions affecting mitral valve but other rare causes include ascending aortic aneurysm or pulmonary artery aneurysm. Hereby, we present the 3rd case in the literature to report Ortner's syndrome due to pulmonary artery aneurysm in a 38-year old female patient with previous history of bilharziasis.