Mitral Annulus Disjunction: A Comprehensive Cardiovascular Magnetic Resonance Phenotype and Clinical Outcomes Study.

BACKGROUND: Clinical importance of mitral annulus disjunction (MAD) is not well established. PURPOSE: Characterize a population of MAD all-comers diagnosed by cardiac magnetic resonance imaging (MRI). STUDY TYPE: Retrospective. POPULATION: MAD confirmed in 222 patients, age of 49.2 ± 19.3 years, 126 (56.8%) males. FIELD STRENGTH/SEQUENCE: 1.5 T and 3 T/steady-state free precession and inversion recovery. ASSESSMENT: Clinical history, outcomes, imaging, and arrhythmia data. MAD defined as a separation ≥2 mm between left ventricular myocardium and mitral annulus. Presence and pattern of late gadolinium enhancement (LGE) were analyzed. LGE in the papillary muscles and adjacent to MAD were identified as MAD related. Ventricular arrhythmias (VA) were grouped into non-sustained ventricular arrhythmias (NSVA) or sustained. Cardiovascular death assessed. STATISTICAL TESTS: Differences between baseline characteristics were compared. Univariate regression was used to investigate possible associations between ventricular arrhythmia and cardiovascular death with characteristics associated with the severity of MAD. A multivariable logistic regression included significant variables from the univariate analysis and was performed for MAD-related and global LGE. RESULTS: MAD extent 5.0 ± 2.6 mm. MV annulus expanded during systole for MAD ≥6 mm. Systolic expansion associated with prolapse, billowing, and curling. LGE present in 82 patients (36.9%). Twenty-three patients (10.4%) showed MAD-related LGE by three different observers. No association of LGE with MAD extent (P = 0.545) noted. Follow-up 4.1 ± 2.4 years. No sustained VA observed. In univariable analysis, NSVA was more prevalent in patients with MAD ≥6 mm (33.3% vs. 9.9%), but this was attenuated on multivariate analysis (P = 0.054). The presence of NSVA was associated with global LGE but not MAD-related LGE in isolation (P = 0.750). Three patients died of cardiovascular causes (1.4%) and none had MAD-related LGE. None died of sudden cardiac arrest. CONCLUSION: In patients referred for cardiac MRI, mitral valve dysfunction was associated with MAD severity. Scar was not related to the extent of MAD, but associated with NSVA. The risk of sustained arrhythmias and cardiovascular death was low in this population. EVIDENCE LEVEL: 4 TECHNICAL EFFICACY: Stage 2.

Impact of the use of cusp-overlap projection on the incidence of permanent pacemaker implantation post-transcatheter aortic valve implantation with self-expanding valves.

INTRODUCTION: Current rates of permanent pacemaker implantation (PPMI) after transcatheter aortic valve implantation (TAVI) range between 3.4% and 25.9%. PPMI is associated with a worse prognosis. A lower valve implantation depth is associated with an increased risk of conduction disturbances. Theoretically, cusp-overlap projection (COP) has the potential to enable higher valve deployment. OBJECTIVE: To compare the 30-day PPMI incidence post-TAVI using self-expanding valves according to the fluoroscopic guidance technique. METHODS: This retrospective single-center study assessed consecutive patients undergoing TAVI with CoreValve™ valves between April 2019 and November 2021, grouped according to the fluoroscopic guidance technique (COP vs. coplanar implantation technique [CIT]). RESULTS: A total of 122 patients were included, predominantly women (52.5%), with a mean age of 81.6±5.5 years. COP was used in 49.2% of the sample. The CIT group had a significantly higher prevalence of previous beta-blocker use (p<0.01), lower baseline left ventricular ejection fraction (p=0.04) and a higher EuroSCORE II (p=0.02). The 30-day PPMI rate was 27.9% (n=34), with no significant difference between the COP and CIT groups (26.7% vs. 29.0%, p=0.77). Complete atrioventricular block was the main cause (38.5%). Likewise, mean fluoroscopy time (p=0.14) and contrast volume (p=0.35) used were similar between the two groups. Radiation dose was lower in the COP group (p=0.02). There was no significant difference between post-TAVI grades III and IV aortic valve regurgitation (p=0.27) and there were no cases of periprocedural acute coronary occlusion. CONCLUSIONS: This study shows that the COP technique, although safe and not associated with increased complexity, did not significantly reduce the 30-day PPMI rate compared to the traditional CIT view.

An Electrifying Case of a Broken Heart Syndrome.

Takotsubo syndrome (TTS) describes an acute and transient left ventricular (LV) dysfunction that, although not obligatory, is many times associated with an underlying emotional, physical, or combined trigger. We describe a rare case of an 80-year-old female who developed TTS after pacemaker implantation in the context of a complete atrioventricular block (CAVB). During the patient's workup, right ventricular (RV) lead dislodgment was found. She developed acute heart failure symptoms 12 hours after device implantation with transthoracic echocardiogram showing de novo severe systolic biventricular dysfunction with dyskinesia of the apical segments and hyperdynamic contractility of the basal segments of both ventricles. Coronarography was normal, and left ventriculography demonstrated apical ballooning. TTS was then considered the most probable diagnosis. The patient received supportive care with diuretics, beta-blocker, and angiotensin-converting enzyme inhibitor (ACEI); an RV lead repositioning was also done. After four weeks, left ventricular function had fully recovered, confirming the diagnosis. This is a rare case of a post-pacemaker implantation TTS with concomitant lead dislodgment that can be assumed as a likely contributing factor. This report emphasizes that, although rare, TTS should be considered in the differential diagnosis of patients with acute heart failure development after pacemaker implantation.

Never Too Old for Congenital Heart Disease: A Case of Cor Triatriatum Sinistrum and Mitral Valve Prolapse.

Cor triatriatum is a congenital atrial abnormality, which comprises a membrane that divides the atrium into two chambers. Symptoms can arise either due to the obstructive nature of this membrane or related to other associated anomalies, such as atrial septal defects or abnormal pulmonary venous return. The authors report the case of an adult male, in whom an incidental finding of cor triatriatum sinistrum was documented in association with mitral valve prolapse. However, both the late diagnosis and the association with mitral valve disease are uncommon. Multimodality imaging evaluation can prove very helpful in these cases to better define the anatomy of the left atrium and appropriately plan for intervention when indicated.

Hypomania Symptoms Across Psychiatric Disorders: Screening Use of the Hypomania Check-List 32 at Admission to an Outpatient Psychiatry Clinic.

Introduction: Hypomania symptoms are best described as a continuum, ranging beyond Bipolar Spectrum Disorders (BSD). Other nosological entities, such as major depressive disorder, schizoaffective disorder, or borderline personality disorder, may also share symptoms with BSD, raising challenges for differential diagnosis. While the Hypomania Checklist-32 is one of the most widely used tools for screening hypomania, there is limited evidence describing its use in a real-world outpatient psychiatric clinical setting. Methods: Here we tested the psychometric properties of a European Portuguese adaptation of the HCL-32, establishing its factor structure, reliability and construct validity. Furthermore, we analyzed differences in hypomanic symptoms among several clinical groups and in a non-clinical sample. Data was obtained retrospectively in an ecological setting from a clinical sample of an outpatient psychiatry and psychology clinic, comprising 463 Portuguese individuals, 326 of whom had a psychiatric diagnosis, namely BSD (n = 66), major depressive disorder (n = 116), or other psychiatric disorders (n = 144). A separate non-clinical sample was also collected among healthy volunteers (n = 62). A battery of self-report measures of affective symptoms was applied, and in a subset of patients, diagnosis was established using a structured diagnostic interview. Results: Psychometric properties of the HCL-32 were adequate, with good internal consistency (Cronbach's α = 0.86) and test-retest stability (ICC = 0.86), and two subscores ("active/elated" and "risk-taking/irritable") defined by Principal Component Analysis. Receiver Operating Characteristic curve analysis demonstrated that the test score discriminated moderately between patients with BSD and other clinical samples as well as healthy volunteers, with a cut-off score of 17 for the total score of the HCL-32 rendering the best combination of sensitivity and specificity. When compared to the HCL-32 total score, the risk-taking/irritable subscore seems to provide additional benefit in discriminating between different clinical groups, namely regarding specificity in the discrimination from patients with a diagnosis of major depressive disorder that was low for the full scale and the alternate subscale. Conclusions: HCL-32 can be used as a screening tool for BSD among adult patients presenting in an outpatient psychiatric clinical setting.

Parâmetros fisiológicos, características de pelame e gradientes térmicos em novilhas nelore no verão e inverno em ambiente tropical / Physiological parameters, hair coat characteristics and thermal gradients in nellore heifers in summer and winter in tropical environment

Investigou-se a influência da estação do ano sobre as características termorreguladoras e de pelame bem como os gradientes térmicos em novilhas da raça Nelore. Utilizaram-se quinze animais com idade inicial e final de 12 e 18 meses, respectivamente. Foram avaliadas as temperaturas retal (TR), da epiderme (TEP) e da superfície corporal (TSC), bem como as frequências cardíaca (FC) e respiratória (FR), taxa de sudação (TS), comprimento do pelo, peso e número dos pelos e os gradientes térmicos entre temperaturas retal e do ar (TR-TAR), temperaturas da superfície corporal e do ar (TSC-TAR) e temperaturas retal e da superfície corporal (TR-TSC). No inverno, as médias de TR, TEP e TSC foram de 39,6ºC; 36,4ºC e 35,9ºC, respectivamente, e no verão foram de 39,1ºC; 37,6ºC e 37,3ºC, respectivamente. A média da FR, FC e TS no inverno foram de 33,6 mpm, 68,9 bpm e 82 g.m-2h-1, respectivamente, e no verão foram de 31,4 mpm, 74,7 bpm e 210,7 g.m-2h-1, respectivamente. No inverno o número médio (601,13 pelos/cm2) e o comprimento (1,04 mm) de pelos foram maiores em relação ao verão que foram, respectivamente, 289,2 pelos/cm2 e 0,59 mm. No verão, o gradiente TSC-TAR (10,20) foi superior ao inverno (8,63) e o gradiente TR-TSC no verão (1,85) foi inferior ao inverno (3,74). Os parâmetros fisiológicos, gradientes térmicos e características do pelame se encontraram dentro da normalidade, ou seja, novilhas da raça Nelore não tiveram dificuldade em manter o equilíbrio térmico, o que confirma que são adaptadas ao ambiente tropical.

The influence of season on thermo regulators traits and hair coat characteristics was investigated, as well as the thermal gradients in Nellore heifers. Fifteen animals with initial and final age of 12 and 18 months, respectively, were used. The rectal (RT), skin (ST) and body surface (BST) temperatures, heart (HR), respiratory (RR) and sweating (SR) rates, the length, weight and number of hairs, the thermal gradients between rectal and air temperatures (RT-AT), body surface and air temperatures (BST-AT) and rectal and body surface temperatures (RT-BST) were evaluated. In winter, the RT, ST and BST averages were 39.6ºC, 36.4ºC and 35.9°C, respectively, and in summer were 39.1°C, 37.6°C and 37.3°C respectively. The RR, HR and SR averages in winter were 33.6 mpm, 68.9 bpm and 82 g.m-2h- 1, respectively, and in summer were 31.4 mpm, 74.7 bpm and 210.7 g.m-2/h-1, respectively. In winter the average number (601.13 hairs/cm2) and the hair length (1.04 mm) were higher than in summer, that were respectively 289.2 hairs/cm2 and 0.59 mm. In summer, the BST-AT gradient (10.20) was higher than in winter (8.63) and RT-BST gradient in summer (1.85) was lower than in winter (3.74). The physiological parameters, thermal gradients and hair coat characteristics are normal, in other words, the Nellore heifers had no difficulty in maintaining the thermal balance, which indicates that they are adapted to the tropical environment.