Ischemic rupture of the anterolateral papillary muscle.

We describe the case of a 59-year-old man who presented with chest pain and ST-segment elevation in the inferior leads, R>S in V1 and ST depression in the anterior leads due to proximal occlusion of the first obtuse marginal. Primary coronary angioplasty and stenting of this artery were performed. Twelve hours later the patient became hemodynamically unstable and severe mitral regurgitation due to rupture of one of the heads of the anterolateral papillary muscle was diagnosed. Emergency surgery was performed (papillary muscle head reimplantation, mitral annuloplasty with a rigid ring, tricuspid annuloplasty and coronary artery bypass grafting). On surgical inspection, it was observed that the detached muscle head had become trapped in the left ventricle by a secondary cord attached to the other head. This case is unusual in presenting two uncommon features of ischemic papillary muscle: rupture of the anterolateral muscle in myocardial infarction involving the inferoposterior walls, and the fact that the ruptured muscle head did not prolapse because it had become trapped in the left ventricle by secondary cord attachment.

Transesophageal Echocardiogram: Still a Powerful Tool in the 21st Century for the Diagnosis of Aortic Dissection.

A 63-year-old woman with a history of previous anaphylactic reaction to iodate contrast presented with sudden back pain during exertion associated with elevated D-dimer levels. Transthoracic echocardiogram was unremarkable. She was unable to perform a computerized tomography for further evaluation of the aorta due to her allergic background. Transesophageal echocardiogram disclosed a type B aortic dissection. This case report recalls the importance of transesophageal echocardiography in the algorithm for diagnosing aortic dissection in scenarios where CT is not possible.

Unveiling an Unusual Cause of Cardiac Tamponade.

This case presents a 48-year-old woman initially diagnosed with an ostium secundum atrial septal defect (ASD) at the age of 36. Twelve years post-intervention, she presented to the emergency department with cardiac tamponade. This case highlights the importance of maintaining prolonged follow-up for individuals undergoing percutaneous ASD closure, given the possibility of potentially fatal late complications of ASD occlusion devices.

Caseous calcification of the mitral annulus: a multi-modality imaging perspective.

Mitral annulus calcification is a common echocardiographic finding, particularly in the elderly and in end-stage renal disease patients under chronic dialysis. Caseous calcification or liquefaction necrosis of mitral annulus calcification is a rare evolution of mitral annular calcification. Early recognition of this entity avoids an invasive diagnostic approach, since it is benign and, unlike intracardiac tumors and abscesses, has a favorable prognosis. The authors present the case of an 84-year-old woman with a suspicious large, echodense mass at the level of the posterior mitral leaflet with associated severe mitral regurgitation. Cardiac magnetic resonance imaging demonstrated a hypoperfused mass with strong peripheral enhancement 10 minutes after gadolinium administration. Multislice computed tomography showed the calcified nature of the mass. A multi-modality imaging approach confirmed the diagnosis of caseous calcification of the posterior mitral annulus. The patient refused surgical treatment.

Infective endocarditis: Epidemiology and prognosis.

INTRODUCTION: Infective endocarditis (IE) is associated with high morbidity and mortality, despite advances in diagnosis and treatment. OBJECTIVE: To assess changes in the epidemiological profile of IE, to perform a time-trend analysis and to define short-term and long-term prognostic predictors of IE. METHODS: Retrospective analysis of 173 patients admitted with a diagnosis of IE to a Portuguese level II Hospital between January 1998 and December 2013. The patients were divided into two groups according to the period of occurrence of the IE episode (1998-2007 vs. 2008-2013). The clinical event studied was the occurrence of death or the need for urgent surgery during hospitalization, and death in the follow-up period. Independent predictors of short-term and long-term prognosis were identified. RESULTS: In the first portion of the study, IE occurred in younger individuals, often drug addicts, users of intravenous drugs and with gastrointestinal disease, human immunodeficiency virus and hepatitis B infection. In the second portion of the study, IE occurred more frequently in individuals of an older age with concomitant cardiovascular disease; enterococcus was isolated more frequently. The independent predictors of in-hospital death or need for urgent valve surgery were septic shock and the occurrence of peri-annular complications. The independent predictors of long-term mortality were age, chronic kidney disease and IE due to multidrug-resistant microorganisms. CONCLUSION: Differences were found in the epidemiological profile of IE during the study period. Referral for valve surgery increased slightly, but mortality remained high.

A life-threatening reverse Takotsubo syndrome in a young breastfeeding woman: a case report.

BACKGROUND: Takotsubo syndrome (TTS) is characterized by transient left ventricular (LV) dysfunction and is usually triggered by emotional, physical, or combined stress. This syndrome has been increasingly recognized, although it remains a challenging and often misdiagnosed disorder. CASE SUMMARY: A 36-year-old breastfeeding woman was admitted with sudden dyspnoea and oppressive chest pain. On admission, she was lethargic, hypotensive, and tachycardic. The electrocardiogram showed rapid atrial fibrillation and diffuse ST-segment depression. The transthoracic echocardiogram (TTE) revealed severe LV systolic dysfunction, with midventricular and basal akinesis, compensatory apical hyperkinesia, and without intraventricular gradient. Emergent coronary angiogram showed normal coronary arteries. A presumptive diagnosis of reverse TTS with cardiogenic shock (CS) was made. The patient was transferred to the intensive care unit after intubation and inotropic and vasopressor support was initiated. During hospitalization, rapid clinical improvement was observed. In 3 days, the patient was weaned from haemodynamic support and extubated. Furthermore, ß-blocker and angiotensin receptor blocker were initiated and tolerated. Cabergoline was also administered to inhibit lactation. The presumptive diagnosis was further strengthened by cardiac magnetic resonance and all triggering factors were excluded. At hospital discharge she was asymptomatic and the follow-up TTE was normal, which confirmed the diagnosis of reverse TTS. DISCUSSION: We present a case of a young woman, 8 months after delivery, which developed a life-threatening reverse TTS without triggering factor identified. Reverse TTS is a rare variant of TTS with different clinical features and is more likely to be complicated by pulmonary oedema and CS.

Prognostic impact of iron deficiency in acute coronary syndromes.

BACKGROUND: Iron deficiency (IDef) is a prevalent condition in patients with heart disease and in those with heart failure (HF). Evidence has shown that this deficit is associated with worse prognosis. Data in literature are scarce on the prognostic impact of IDef in acute coronary syndromes (ACS), which is the main objective of this study. METHODS: Observational, retrospective study which included 817 patients admitted for ACS. Two groups were defined according to the presence (n=298) or absence of IDef (n=519) on admission. The clinical event under study was the occurrence of death or severe HF in the long term. Independent predictors of prognosis were determined with logistic regression analysis. RESULTS: Thirty-six percent of patients had IDef. There was higher mortality (p=0.004), higher incidence of HF (p=0.011) during follow-up and a higher rate of hospital readmissions (p=0.048) in this group. IDef was an independent predictor of death or severe HF in follow-up, along with anemia, left ventricular dysfunction, renal dysfunction and the absence of revascularization. IDef also enabled us to further stratify the prognosis of patients without anemia based on the occurrence of death or severe HF and those with lower Killip classes (≤2) based on the occurrence of death. CONCLUSION: IDef was an independent predictor of death or severe HF in patients admitted with ACS and enabled additional stratification for those without anemia on admission and in those with Killip classes ≤2.

Echocardiographic assessment of a cardiac lymphoma: beyond two-dimensional imaging.

Lymphoma is usually recognized as the third most frequent metastatic malignancy involving the heart. In recent years, the incidence of cardiac lymphoma has increased, mainly because of HIV-infected patients. We present a case of secondary cardiac lymphoma in an HIV patient presenting with heart failure. Transthoracic echocardiography showed increased left ventricular (LV) wall thickness and an extensive mass in the right cavities with involvement of the tricuspid annulus (Figure 1). Doppler tissue imaging (DTI) showed reduced systolic and diastolic velocities at mitral and tricuspid annulus, compatible with systolic and diastolic myocardial dysfunction, likely owing to infiltration. After 2 weeks of chemotherapy, repeated exam showed significant reduction of the tumour mass and of the LV wall thickness, as well as normalized systolic and diastolic velocities at mitral and tricuspid annulus, as assessed by DTI. Use of transthoracic echocardiography, mostly two-dimensional imaging, has been described for several years for the diagnosis of cardiac involvement as well as for the assessment of tumour regression in response to chemotherapy. The present case report highlights the potential utility of other echocardiographic modalities, particularly DTI, for the assessment of cardiac lymphoma but also for monitoring the tumour response to adequate therapy.

Coexistence of coronary cameral fistulae and cor triatriatum sinister in an elderly patient.

Coronary cameral fistulae are unusual congenital or acquired anomalous communications between an epicardial coronary artery and a cardiac chamber. There are no reported cases of the association of coronary cameral fistulae and cor triatriatum, a rare congenital cardiac anomaly in which a fibromuscular membrane divides the left atrium into two chambers. We report the case of an 82-year-old man presenting with recurrent anterior chest pain. Echocardiographic examination identified non-obstructive cor triatriatum, mitral valve prolapse resulting in significant mitral regurgitation, dilated coronary arteries, and established the entry site of coronary artery fistulae at the apex of the left ventricle (Figure 1). Coronary angiography confirmed the existence of a plexiform fistula between the left anterior descending coronary artery and the left ventricle. Tetrofosmine scintigraphy revealed the presence of stress-induced ischaemia in the apex. To our knowledge, we report the oldest person with coronary cameral fistulae presenting with angina only at this stage, and the interesting case of the coexistence of two, although unconnected, congenital conditions in an elderly patient. In addition, this report highlights the important role of transthoracic and transoesophageal echocardiography to the characterization of these unusual anomalies, and the complementary information offered by three-dimensional transthoracic echocardiography.

Thrombosed aneurysm of the left sinus of Valsalva.

The authors present the case of a 57-year-old asymptomatic woman, in whom a large left coronary sinus of Valsalva aneurysm was incidentally diagnosed on a routine echocardiogram in 1998. The case was initially presented to cardiac surgery consultants, and since there were no signs of rupture and the patient was asymptomatic, it was decided to keep her in close clinical and echocardiographic follow-up. Eight years later, and with no clinical manifestation in the meantime, a transesophageal echocardiogram (TEE) showed that the aneurysm was filled with swirling spontaneous echo contrast ("smoke") overlying a thrombus, which was not detected by transthoracic echocardiography. The patient then underwent surgical treatment with aortic root and aortic valve replacement and coronary reimplantation, with an excellent result. Although the need for early surgical intervention in patients with ruptured sinus of Valsalva aneurysms is well established, the optimal management of an asymptomatic, unruptured aneurysm is less clear, due to the absence of a precise natural history. The follow-up of our patient clearly demonstrated that it is mandatory to assess unruptured sinus of Valsalva aneurysms by TEE, particularly to exclude thrombotic complications. Such complications are one of the possible paths of the natural history of unruptured sinus of Valsalva aneurysms, and support the indication for early surgical treatment to avoid future complications.

Transient left ventricular apical ballooning--characterization of an increasingly common new diagnostic entity. Another case report.

Transient left ventricular apical ballooning syndrome (ABS) is characterized by chest pain, electrocardiographic alterations mimicking acute myocardial infarction (MI), transient left ventricular apical dyskinesis and normal coronary angiogram. It usually has a favorable prognosis. We present the case of a 71-year-old female patient, with a history of respiratory infection, who was admitted to the emergency department with chest discomfort, electrocardiographic alterations suggesting anterolateral MI, and shock. The admission echocardiogram revealed apical dyskinesis and dilatation, basal hypercontractility and a left intraventricular gradient of 75.27 mmHg. Elevation of cardiac biomarkers was disproportionately low. Coronary angiography was normal and the echocardiographic abnormalities disappeared after the tenth day of hospitalization. We describe the diagnostic criteria and characteristics of ABS. It is more prevalent in post-menopausal women and has a recognized association with stress. Its incidence will probably rise with increasing awareness of this entity, aging populations, and wider access to echocardiography and cardiac catheterization.

Impact of cardiac rehabilitation on quality of life and depression after acute coronary syndrome.

OBJECTIVE: To evaluate the impact of cardiac rehabilitation programs (CRP) on quality of life (QL) and depression at one-year follow-up after acute coronary syndrome (ACS). METHODS: Two hundred and three patients, without previous cardiological follow-up and referred to the outpatient clinic after hospitalization for ACS between 9/1/2001 and 12/31/2002, were randomly allocated to a 12-week, 3-times-a-week CRP or standard cardiology follow-up only, after giving their informed consent. Baseline population characteristics were recorded and, in patients with more than 4 years' education, QL and depression were evaluated during hospitalization and at one-year follow-up by self-reported responses to the SF-36 QL survey and the Beck Depression Inventory (BDI) respectively. Analysis was by intention-to-treat. RESULTS: 31 patients randomized to CRP, mean age 56 years (31-80), 84% male (group A) and 95 patients, mean age 58 years (33-86), 83 % male, allocated to standard follow-up (group B), responded to the questionnaires. There were no significant differences between the two groups in any of the variables evaluated by the questionnaires during hospitalization. At one-year evaluation, the average BDI score was lower in the CRP group (8 vs. 11, p = 0.05). The prevalence of depressive symptoms (37.5 vs. 56.1%) or severe depression (3.1% vs. 12.2%) was also lower, in this group, although not significantly. SF-36 found significant differences in the evaluation of Vitality (average 62 points in A vs. 47 in B, p < 0.02) and General Health (57 points in A vs. 46 points in B, p < 0.02); there were no differences in the other parameters evaluated. When the physical and mental health components were analyzed, a significant difference favoring CRP was found in mental health (70.6 vs. 56.9, p = 0.02) but not in physical health (62.9 in A vs. 56.4 in B, NS). CONCLUSIONS: Despite the small sample size, significant differences favorable to CRP after ACS were found. After one-year follow-up, patients referred to CRP have a better BDI score; the Vitality and General Health parameters, as well as the mental health component evaluated by SF-36, are also significantly improved after CRP.

Impact of pre-hospital emergency in the management and prognosis of acute myocardial infarction.

INTRODUCTION: In recent decades pre-hospital emergency plans have been developed in Portugal, in order to improve the quality and efficiency of medical care in acute situations. However, the real impact of these measures in the treatment of acute coronary patients has not been thoroughly studied. OBJECTIVE: To evaluate the impact of pre-hospital emergency care (PHE) in the management and prognosis of patients admitted to hospital with acute myocardial infarction (AMI). POPULATION: Three hundred and eighty-one consecutive patients admitted to our hospital with AMI between 7/1/2001 and 12/31/2002. METHODS: The patients referred to the Emergency Department (ED) after PHE care were prospectively compared with other patients admitted with AMI (controls), in terms of clinical and demographic characteristics, initial ECG, time of symptoms-to-ED, symptoms-to-ECG, and door-to-needle/balloon, Killip class, in-hospital morbidity and mortality, ejection fraction (EF) at discharge, morbidity and mortality during the first year and EF after one year. RESULTS: Of the 51 patients (mean age 66, 57% male) of the PHE group, 55% (mean age 66, 64% male) presented ST elevation on admission ECG. Of the 330 patients (mean age 63 years, 70% male) of the control group, ST elevation was present in 41% (p = 0.05), mean age 59 years (p < 0.02), 77% male (NS). There were no significant differences between the groups when cardiovascular risk factors, cardiac event history and comorbidity were studied. Time of symptoms-to-ED (124 vs. 256 min) and symptoms-to-ECG (138 vs. 292 min) were shorter in the PHE group (p < 0.005 and < 0.003, respectively). Door-to-ECG time was 14 min vs. 36 min in the control group (p < 0.02). In patients with ST elevation, door-to-needle (77 vs. 105 min) and door-to-balloon (79 vs. 132 min) times were shorter after PHE (NS, p = 0.08). Overall, the time of symptoms-to-reperfusion was shorter in the PHE group. There were no differences in Killip class, in-hospital mortality or one-year mortality/morbidity. The prevalence of EF < 45% was lower in the PHE group, both at discharge (39 vs. 58%, p = 0.08) and on the first year echocardiogram (8.3 vs. 46%, p < 0.04). CONCLUSIONS: Compared to other patients with AMI, those admitted to the ED after PHE are older and more frequently present ST elevation. PHE has a significant impact in reducing the time between first symptoms and admission to the ED, first ECG and reperfusion therapy. In patients with ST elevation at admission, the prevalence of heart failure after one year was found to be significantly lower in the PHE group, revealing the positive impact of PHE care in AMI that persists after one-year follow-up.

Balloon mitral valvuloplasty during pregnancy--our experience.

INTRODUCTION: Mitral stenosis is the most common valvular heart lesion found in pregnancy. When severe, it leads to significant maternal and fetal morbidity and mortality, since the hemodynamic adaptations to pregnancy are badly tolerated. Pregnancy can lead to development of heart failure in patients with asymptomatic or even unknown mitral stenosis, as a result of the increased mitral valve pressure gradient caused by the physiologic increase in heart rate and blood volume in pregnancy. When symptoms persist despite optimal medical therapy, the poor prognosis justifies the correction of mitral stenosis during pregnancy. OBJECTIVE: To present our experience in treating severe mitral stenosis in women who develop severe heart failure during pregnancy, using percutaneous balloon mitral valvuloplasty. PATIENTS: From 1996 to March 2002, in our department, 47 balloon mitral valvuloplasties were successfully performed in women, three of them pregnant. These were patients with congestive heart failure, New York Heart Association (NYHA) functional class III or IV, at the end of the second trimester of pregnancy, who did not respond positively to drug treatment with diuretics and digitalis. INTERVENTIONS: We performed percutaneous balloon mitral valvuloplasty using the Inoue technique in the three pregnant patients, with success, at around 25 weeks of gestation. RESULTS: After the procedure, the patients showed clinical improvement, returning to the NYHA functional class that they were in before becoming pregnant (I-II). The previous mitral valve area was 0.9-1.2 cm2, nearly doubling after valvuloplasty. Mean left atrial pressure decreased on average by 42%, and the maximum pressure (V wave) decreased on average by 40%. The mitral valve pressure gradient decreased from 15, 10 and 28 mmHg to 7, 5 and 5 mmHg after valvuloplasty. During the procedure there were no maternal or fetal complications. All patients were discharged 24 to 48 h after valvuloplasty, continuing their pregnancies without complications. One woman had vaginal delivery, and the other two had cesarean sections at 35 weeks of gestation, all without complications with healthy newborns that developed normally. In follow-up, one patient who had moderate mitral regurgitation after valvuloplasty developed severe mitral regurgitation, requiring surgical correction after two years. CONCLUSION: In pregnant patients who have severe mitral stenosis and persistent congestive heart failure symptoms despite conventional medical treatment, when feasible, percutaneous balloon mitral valvuloplasty is the best treatment.