Asymptomatic Left Ventricular Dysfunction: Is There a Role for Screening in General Population?

Stage A and B heart failure (HF) include asymptomatic patients without and with structural cardiac disorder, respectively. Asymptomatic left ventricular (LV) dysfunction represents an early stage of HF that should be recognized to prevent overt HF development. Echocardiography plays a pivotal role in assessment of cardiac structure and function and represents the ideal imaging technique for screening in the general population, thanks to its availability, feasibility, and low cost. Traditional echocardiography, with LV systolic and diastolic function and cardiac remodeling assessment, is usually performed. Development of new technologies may offer additional information and insights in detection of early LV dysfunction.

Images in cardiovascular medicine: caseous calcification of the mitral annulus.

A 78-year-old woman was admitted to our emergency department for subarachnoid hemorrhage. Since a month ago, she was taking warfarin after diagnosis, on transthoracic echocardiogram (TTE), of a suspected large atrial thrombus. The patient, referred to our institution for further investigation, presented asymptomatic; electrocardiogram showed sinus rhythm. TTE revealed an echo dense spherical mass located in the mitral periannular posterior region with moderate mitral regurgitation. Transesophageal echocardiography and cardiac computed tomography confirmed a calcified round mass (2.0 × 2.9 cm) with central areas of echolucency-like liquefaction surrounded by a hyperechogenic structure without systolic flow inside the cavity. The mass was diagnosed as caseous calcification of the mitral annulus (CCMA), a rare finding associated with a benign prognosis, requiring surgery only in the presence of mitral valve dysfunction. The diagnosis of CCMA is, often, misconstrued as thrombus, tumor, or abscess, leading to unnecessary investigations or interventions. Our patient was discharged after discontinuation of warfarin.

Rapid Onset Idiopathic Pulmonary Hypertension: A Case Report with a Review of Echocardiographic Parameters.

Pulmonary hypertension (PHT) is an emerging issue. The prognosis in PHT is usually poor, independently from the etiology, with progressive right ventricle failure. Despite right Heart Catheterism is the gold standard for diagnosis of PHT, echocardiography provides important information about prognosis and is helpful in both follow-up and first evaluation of PHT patients, showing a good correlation with invasively measured parameters by right heart catheterization. However, it is important to understand the limits of this method, particularly in some settings, where transthoracic echocardiography has shown a lack of accuracy. In this case report we documented a case of rapid onset (3 months) idiopathic PHT and we provided a critical analysis of echocardiographic role in PHT.

Nonbacterial Thrombotic Endocarditis with Atypical Presentation as Overt Congestive Heart Failure.

Nonbacterial thrombotic endocarditis (NBTE) is a form of endocarditis associated with malignancy or autoimmune disorders. Diagnosis remains a challenge as patients are often asymptomatic up to embolic events or rarely, valve dysfunction. We report a case of NBTE with uncommon clinical presentation and identified with multimodal echocardiography. An 82-year-old man presented to our outpatient clinic reporting dyspnea. Past medical history included hypertension, diabetes, kidney disease, and unprovoked deep-vein thrombosis. On physical examination, he was apyretic, mildly hypotensive, and hypoxemic, had a systolic murmur and lower limbs edema. Transthoracic echocardiography revealed severe mitral regurgitation due to verrucous thickening of the free margin of both leaflets, increased pulmonary pressure, and dilated inferior vena cava. Multiple blood cultures were negative. Transesophageal echocardiography confirmed "thrombotic" thickening of mitral leaflets. Nuclear investigations were highly suggestive of multi-metastatic pulmonary cancer. We did not further proceed with the diagnostic workup and prescribed palliative care. Lesions seen on echocardiography were suggestive of NBTE: they involved both sides of mitral leaflets, close to the edges, had irregular shape and echo density, a broad base, and no independent motion. Criteria for infective endocarditis were not met and the final diagnosis was paraneoplastic NBTE due to underlying lung cancer. We remark the lack of definitive recommendations about the treatment of NBTE and the only role of anticoagulation to prevent systemic embolism. We have reported a case of NBTE presenting with atypical symptoms and likely related to the prothrombotic state induced by underlying lung cancer. Provided the unconclusive microbiological tests, multimodal imaging has played a crucial role in the final diagnosis.

Impairment of elastic properties of the aorta in bicuspid aortic valve: relationship between biomolecular and aortic strain patterns.

Aims: Bicuspid aortic valve (BAV) is associated with aortic wall alterations. We aimed to detect any correlation between aortic elasticity and genetic and biomolecular patterns of elastin. Methods and results: Forty-nine BAV patients (mean age: 38 ± 17.05) were prospectively enrolled. A blood sample was drawn for analysis of a single nucleotide polymorphism of elastin gene (ELN rs2071307) responsible for misfolding of elastin, and for the amount of elastin soluble fragments (ESF) in the plasma. Aortic dimensions and elastic properties were determined by echocardiography, aortic stiffness (AS) by M-mode analysis, and longitudinal strain (LS) of the ascending aorta (AA) by speckle-tracking echocardiography; values of aortic strain were compared with 45 age-matched subjects (mean age: 33 ± 9.67) with tricuspid aortic valve (TAV). BAV patients had greater aortic dimensions [Valsalva sinus (P = 0.004), sinotubular junction (P = 0.013), AA (P < 0.001)] and stiffness (P = 0.002) but lower LS (P = 0.04) than those with TAV. Results from comparisons of mutated genotype patients (AA, n = 10) with heterozygous (GA, n = 21) and wild-types ones (GG, n = 16) revealed that the presence of mutation was associated with increased ESF (P = 0.010 GG vs. GA; P = 0.035 GA vs. AA), larger AA (P = 0.019 GG vs. GA; P = 0.001 GG vs. AA), and lower LS (P = 0.032 GG vs. AA). Patients with a dilated AA showed greater ESF (P < 0.001), greater AS (P = 0.007), and lower LS of the AA (P = 0.002) than those with a normal AA. The same parameters were not significantly different comparing patients with moderate or severe aortic valve disease and patients with less than moderate valve disease. Conclusions: Our results show a close correlation between genetic and biomolecular patterns of elastin and mechanical properties of the aorta in patients with BAV.

The Diagnostic Challenge of Dipyridamole-atropine Stress Echocardiography in a Patient with Myocardial Bridge.

A 60-year-old male patient was submitted to dipyridamole-atropine stress echocardiography (DSE) for chest pain during exertion. At rest, no electrocardiographic (ECG) and transthoracic echocardiographic (TTE) abnormalities were observed. After dipyridamole infusion, the patient complained a mild chest discomfort, without ECG changes and TTE wall-motion abnormalities. Subsequently, worsening of the anginal symptoms combined with descending ST-depression and T-negative waves occurred after atropine and unexpectedly, aminophylline administration. Coronary angiography was performed showing a myocardial bridge (MB) of the left anterior descending artery. The occurrence, during DSE, of worsening ischemic abnormalities after atropine and aminophylline administration may be a particular diagnostic feature of MB.

Left atrial function in cardiac amyloidosis.

AIMS: Left atrium can be involved by amyloid deposition in familial amyloid polyneuropathy (FAP). The aim of our study is to assess left atrium function in atrial amyloidosis. METHODS: Twenty-eight FAP patients (53 ±â€Š12 years) and a control group of 22 asymptomatic individuals (49 ±â€Š11 years) underwent strain echocardiography and cardiac magnetic resonance (CMR). CMR by late gadolinium enhancement (LGE) was used to assess the left atrium amyloid deposition, whereas strain echocardiography was used to quantify the left atrium deformation. The following atrial longitudinal strain (ALS) parameters were assessed: peak at the end of ventricular systole (peak-ALS), peak at early diastole (early-ALS), negative peak in late diastole, precontraction (prec)-ALS (difference between peak-ALS and early-ALS), and late ALS (sum of negative peak and prec-ALS). RESULTS: CMR showed atrial LGE in 14 FAP patients (LGE-atrial group), whereas 14 FAP patients showed no LGE (no-LGE-atrial group). Peak-ALS was significantly lower in the LGE-atrial group (22.8 ±â€Š13%) compared with the no-LGE-atrial group (59.6 ±â€Š33.1%; P = 0.001) and controls (47.4 ±â€Š16.4%; P = 0.001). Early-ALS was lower in the LGE-atrial group (10.2 ±â€Š6.2%) compared with the controls (26.3 ±â€Š11.9%; P = 0.02) and the no-LGE-atrial group (30.2 ±â€Š22.4%; P = 0.01). Prec-ALS was lower (P = 0.001) in the LGE-atrial group (12.6 ±â€Š7.8%) compared with the no-LGE-atrial group (26.2 ±â€Š15%). Conversely, late-ALS was higher (P = 0.04) in the no-LGE-atrial group (22.8 ±â€Š12.3%) compared with the controls (13.9 ±â€Š9%); no significant differences were found in the negative peak among groups. CONCLUSIONS: Patients with atrial amyloidosis have an adverse left atrium remodeling associated with left atrium dysfunction. Left atrium assessment may provide useful information in the clinical and prognostic stratification of amyloidotic patients.

Multimodalities Imaging in Diagnosis of Pericardial Cyst.

Pericardial cysts, an uncommon benign congenital anomaly belonging to the category of mediastinal masses. Cysts are usually detected incidentally on chest radiography or echocardiography, being most patients asymptomatic. In some cases, however, symptoms and complications occur, like dyspnea, chest pain, or persistent cough. Computed tomography and magnetic resonance imaging are the imaging techniques of choice to diagnose pericardial cysts. The removal of pericardial cysts is restricted to the cases with an uncertain diagnosis or in the presence of symptoms.

Role of imaging in assessment of atrial fibrosis in patients with atrial fibrillation: state-of-the-art review.

Atrial fibrillation (AF) is the most common arrhythmia in the world. Despite the large number of studies focused on the causes and mechanisms of AF, it remains a clinical challenge. Atrial electrical and structural remodelling caused by AF is responsible for the perpetuation of the arrhythmia. However, a validated noninvasive method for assessment of atrial fibrosis in clinical practice is lacking. In this review, we aim to present an update about the origins and mechanisms of atrial remodelling, particularly focusing on atrial fibrosis, and compare imaging techniques that can detect atrial changes and greatly contribute to the clinical management of patients with AF.

Early identification of vascular damage in patients with systemic sclerosis.

Vascular involvement in systemic sclerosis (SSc) plays a key role in the pathogenesis of fibrosis. We assessed arterial stiffness using a new echo-tracking technique in patients with SSc asymptomatic for cardiovascular diseases. We enrolled 22 patients (21 female, 63 ± 14 years) and 20 controls (12 female, 62 ± 3 years). Carotid intima-media thickness (IMT) was comparable between the 2 groups (1.1 ± 0.3 vs 1.0 ± 0.4 mm, P = ns), whereas the stiffness parameters were significantly increased in patients (ß: 9.5 ± 4.2 vs 5.8 ± 1.1, P = .001; pulse wave velocity [PWV]: 6.5 ± 1.5 vs 5.2 ± 0.6 m/sec, P = .003). A correlation between stiffness parameters, anti-Scl-70 antibodies (ß: r = .46, P = .03; PWV: r = .50, P = .02), and anticentromere antibodies (ß: r = -.54, P = .020; PWV: r = -.53, P = .023) was found. Echo-tracking technique may be valuable in early identification of vascular involvement in patients with SSc.