Giant left atrial thrombus: an unexpected finding.

The incidence of left atrial thrombi is higher in patients with mitral valve stenosis. Its presence and location have important implications in deciding on the therapeutic approach, particularly the need for valve repair. We describe the case of a 63-year-old patient, with asymptomatic moderate mitral stenosis, hospitalized due to community-acquired pneumonia, in whom investigation to exclude pulmonary thromboembolism revealed a giant left atrial thrombus, which required urgent surgery.

Effusive-constrictive pericarditis: the role of noninvasive imaging.

Effusive-constrictive pericarditis is a rare entity in which clinical suspicion is of paramount importance, and although cardiac catheterization remains the gold standard for diagnosis, noninvasive imaging techniques are very useful in consolidating the diagnosis prior to confirmation by invasive means. The authors describe the case of a 52-year-old man, who had undergone heart surgery in the past, with a long history of heart failure refractory to medical therapy and chronic recurrent pericardial effusion, in whom noninvasive imaging techniques were decisive in arriving at the correct diagnosis of effusive-constrictive pericarditis, which was later confirmed by cardiac catheterization, thus enabling the correct therapeutic approach to be adopted and leading to improvement in clinical status.

Stress-induced intraventricular gradients in symptomatic athletes during upright exercise continuous wave Doppler echocardiography.

The development of significant intraventricular gradients (IVGs) during exercise has been described anecdotally in athletes. However, the prevalence and clinical effect of this observation are unclear. In addition, the most appropriate exercise technique (upright vs semisupine) for eliciting IVGs also remains unknown. The present study had 2 main aims: (1) to identify the prevalence of exercise IVGs in athletes whose preparticipation cardiovascular screening result for sports practice, according to the European Society of Cardiology guidelines, was positive; and (2) to evaluate the influence of performing exercise echocardiography, as described, on the detection of IVGs. We enrolled 139 consecutive athletes (135 amateurs and 4 professionals, mean age 22 ± 9.9 years; 30 women) who underwent treadmill exercise echocardiography. In each athlete, the IVG was evaluated by continuous wave Doppler during 5 conditions: left lateral decubitus at rest; upright at rest; upright at peak treadmill exercise; upright in the recovery phase; and left lateral decubitus in the recovery phase. All patients had normokinetic regional wall motion at rest and during exercise. According to the detection of IVG during treadmill echocardiography (IVG was considered significant if >30 mm Hg at rest or >50 mm Hg during/after exercise), 2 groups were identified: a group (n = 52), with significant IVG and a group (n = 87) without significant IVG. The IVG was greater in the upright position, both at rest (only 2 athletes from group with IVG) and after exercise (52 athletes, all from group with IVG). The IVG was lower in the recovery phase in the left lateral decubitus position (55 ± 15 mm Hg in 30 athletes, all from group with IVG) than in the upright position in the recovery phase (95 ± 35 mm Hg in 52 athletes, all from group with IVG) and at peak exercise (66 ± 24 mm Hg in 41 athletes from group with IVG). We observed systolic anterior movement of the mitral valve in 33 of the 52 athletes in the group with IVG and in none of the athletes in the group without IVG. In conclusion, in athletes, exercise-induced symptoms and/or ischemia-like electrocardiographic signs are often associated with significant IVG, developing in the absence of wall motion abnormalities. IVG was more evident during post-treadmill upright imaging.

[Value of exercise echocardiography in aortic recoarctation--case report]. / Utilidade da ecocardiografia de esforço na recoarctação da aorta--caso clínico.

In this article the authors present a case study of a young man with coarctation of the aorta that underwent surgical correction at 4 months old, for whom the exercise echocardiogram was important in determining the functional importance of recoarctation and the decision of the timing for re-intervention, demonstrating the importance of this technique to discriminate the functional significance of this pathology.

The importance of cardiac magnetic resonance imaging in the diagnosis of myocarditis--a case report.

The authors describe the case of a 16-year-old male, who went to the emergency department with a clinical setting characterized by chest pain, electrocardiographic pattern of inferoposterior acute myocardial infarction and elevated markers of myocardial necrosis. Cardiac catheterization revealed no significant coronary lesions and the transthoracic echocardiogram showed no segmental abnormalities. Myocarditis was suspected, and this diagnosis was confirmed by magnetic resonance imaging. This case demonstrates the difficulty of establishing a definitive diagnosis of myocarditis and the increasing importance of cardiac magnetic resonance imaging in this area.

Efficacy of beta-blocker therapy in symptomatic athletes with exercise-induced intra-ventricular gradients.

BACKGROUND: Upright exercise stress echocardiography (SE) induces significant intraventricular gradient (IVG) and systolic anterior motion (SAM) in a large proportion of symptomatic athletes, who may therefore benefit from a negative inotropic therapy.The purpose of the present study was to assess the effect of chronic oral ß blocker therapy on the occurrence of exercise-induced IVG and mitral valve SAM, in symptomatic athletes. METHODS: We enrolled 35 symptomatic athletes (age = 23 ± 11 years) with IVG (>30 mmHg) during SE off therapy. All repeated SE on chronic oral beta-blocker therapy (atenolol up to 50 mg, bisoprolol up to 10 mg, or metoprolol up to 100 mg daily according to physician-driven choice). RESULTS: On therapy, there was during SE a reduction in IVG (35 off vs 17 on beta blocker, p < 0.01), decrease of IVG (102 ± 34 mmHg off vs 69 ± 24 mmHg on beta blocker, p < 0.01), peak heart rate (178 ± 15 bpm off vs 157 ± 9 bpm on beta blocker), SAM (24 off vs 9 on beta blocker, p < 0.001), symptoms during SE (17 off vs 2 on beta blocker p < 0.001), ST segment depression (13 off vs 2 on beta blocker, p < 0.001). CONCLUSIONS: In athletes with positive screening on medical evaluation for sports practice and IVG on exertion, treatment with oral beta blockers improved symptoms in the large majority of patients. Symptomatic benefit was mirrored by objective evidence of improvement of echocardiographic signs of obstruction (IVG and SAM) and reduction of ischemia-like electrocardiographic changes.

Intraventricular gradients and acute coronary syndromes: a case report.

Left ventricular outflow tract obstruction (LVOTO) has traditionally been associated with hypertrophic obstructive cardiomyopathy, but can occur in other clinical scenarios such as acute myocardial infarction (AMI). In some patients, LVOTO is absent at rest, being detectable only with provocation tests such as stress echocardiography. Timely diagnosis of this phenomenon is very important, as it has therapeutic implications, and relies on clinical suspicion and on recognizing substrates in which LVOTO can occur. We report a case of syncope and AMI associated with LVOTO with systolic anterior motion of the mitral valve and a significant intraventricular gradient.

Acute severe mitral regurgitation as an early complication of pacemaker implantation.

A 70-year-old man developed drug refractory acute pulmonary oedema secondary to acute severe mitral regurgitation (MR) immediately after implantation of a dual-chamber pacemaker for complete heart block. Clinical improvement occurred after allowing the patient to resume his native rhythm. A new lead was positioned within the right ventricular outflow tract (RVOT). The echocardiogram during pacing at RVOT showed minimal MR.

Cardiac syndrome X, intraventricular gradients and, beta-blockers.

INTRODUCTION: Development of intraventricular gradients (IVG) on exertion seldom occurs in an unselected population. We performed exercise stress echocardiography (SE) in a 23-year-old athlete with a positive treadmill ECG and normal resting echocardiogram, but without angiographically demonstrable coronary disease (cardiac syndrome X), during which he developed an IVG of 102 mmHg and systolic anterior motion (SAM) of the mitral valve. Subsequently, we performed SE in 91 patients, 44 of whom were women, mean age 51.4 +/- 12.1 years (20-72), under similar circumstances--positive treadmill testing and no angiographically demonstrable coronary disease. In 33 (36%) of these, SE disclosed IVG with a mean end-systolic peak of 86 +/- 34 mmHg (30-165), together with mitral valve SAM in 23. The 20 patients who repeated SE under beta-blocker therapy constitute the study population. Seven (35%) of them were women, mean age 50.7 +/- 13.4 years (23 to 72). OBJECTIVE: To assess the effect of beta-blockers on the occurrence of IVG and mitral valve SAM in patients with cardiac syndrome X. METHODS: We repeated SE in 20 of the 33 patient that developed IVG on exertion, under beta-blocker therapy. They all underwent 2D and Doppler echocardiographic assessment before, during and after treadmill exercise. RESULTS: Mean IVG in the 20 patients in the study population was 971 +/- 31 mmHg on the first SE assessment. In the assessment performed under beta-blocker therapy, 11 did not develop IVG, and in 9 the gradient was significantly reduced, to a mean of 46 +/- 13 mmHg. Mean heart rate at peak exercise was 161 +/- 17 bpm in the first SE assessment and 143 +/- 12 bpm under treatment with beta-blockers (p < 0.0001). Fifteen of these patients showed clinical improvement during follow-up, while no change in clinical status was seen in the other five. CONCLUSIONS: In patients with cardiac syndrome X and IVG on exertion, treatment with oral beta-blockers prevented the occurrence of IVG or significantly reduced their magnitude. These changes were associated with significant reduction in heart rate at peak exercise and with clinical improvement in 75% of the study population.

Three cases of pregnancy in patients with severe pulmonary arterial hypertension: experience of a single unit.

Pregnancy in patients with severe pulmonary arterial hypertension is a high risk situation, which makes pregnancy prevention or termination in the first trimester advisable. For this reason, patients of reproductive age with this pathology are referred for gynecology consultation. Since our unit began operating in 1999, we have had three pregnant patients with severe pulmonary arterial hypertension--one our patient and the other two referred from other centers. In this article we describe these three cases and review the literature on pregnancy and pulmonary arterial hypertension.

Value of treadmill exercise echocardiography in the evaluation of symptomatic hypertrophic cardiomyopathy with latent obstruction. Impact on therapeutic decisions.

The authors report the case of a 64-year-old patient with hypertrophic cardiomyopathy with latent obstruction. The patient complained of fatigue but the left ventricular outflow gradient at rest was not significant. He underwent exercise echocardiography that was stopped after 3 minutes due to exhaustion. The gradient at peak workload was 150 mmHg accompanied by a fall in arterial pressure. After the patient refused surgery, a double chamber pacemaker was implanted. A month later, exercise echocardiography lasted for 12 minutes and the gradient at peak workload was 60 mmHg. The authors highlight the importance of exercise echocardiography in the evaluation of symptomatic patients with hypertrophic cardiomyopathy without significant left ventricular outflow gradient at rest and the possible therapeutic role of pacing in these patients.

The role of echocardiography in assessing parachute mitral valve.

Treadmill exercise echocardiography with Doppler evaluation during effort has been used for several years in our department. The usefulness of this methodology in the management of patients with coronary heart disease is recognized but it is being increasingly used in patients with valvular heart disease. We report the case of a 44-year-old man with parachute mitral valve, in which transesophageal echocardiography characterized the pathology and exercise stress echocardiography was important for accurate functional assessment and clinical decisions.

Echocardiography during treadmill exercise testing in a patient with mitral stenosis.

Treadmill exercise echocardiography with Doppler during effort has been used for several years in our department. This form of echocardiography is used mainly in evaluation of patients with coronary heart disease and it is being increasingly used in valvular heart disease. We report the case of a 49-year-old woman with moderate mitral stenosis, in which stress echocardiography was important in making correct clinical decisions.

The usefulness of contrast during exercise echocardiography for the assessment of systolic pulmonary pressure.

BACKGROUND: The systolic pulmonary artery pressure (PAPs) can be accurately estimated, non-invasively, using continuous-wave Doppler (CWD) ultrasound measurement of the peak velocity of a tricuspid regurgitant (TR) jet. However, it is often difficult to obtain adequate tricuspid regurgitation signals for measurement of PAPs, what could lead to its underestimation. Therefore, utilization of air-blood-saline contrast has been implemented for the improvement of Doppler signal in several clinical contexts. It is now recommended in the evaluation of patients with pulmonary hypertension. Physical activity is severely restricted in patients with PAH, being exertional dypnea the most typical symptom. Exercise stress echo-Doppler imaging allows assessment of the response to exercise. It is an excellent screening test for patients with suspected PAH. Our purpose was to evaluate the value and accuracy of agitated saline with blood contrast echocardiography, in the improvement of the Doppler signal, to quantify PAPs during treadmill exercise-echocardiography. PURPOSE: To evaluate the value of contrast echocardiography, using agitated saline with blood, in the improvement of the Doppler signal used to quantify the pulmonary artery systolic pressure during exercise. METHODS: From a total of 41 patients (pts), we studied 38 pts (93%), 35 women, aged 54 +/- 12 years-old. 27 with the diagnosis of systemic sclerosis, 10 with history of pulmonary embolism and one patient with a suspected idiopathic PAH, who were referred to the Unity of Heart Failure and Pulmonary Hypertension for screening of PAH. According to the Unity protocol, a transthoracic echocardiogram was made, in left decubitus (LD), with evaluation of right ventricle-right atria gradient (RV/RAg). A peripheral venous access was obtained, with a 3-way stopcock and the patients were placed in orthostatism (O), with a new evaluation of RV/RAg. Exercise echocardiography (EE) was begun, with evaluation of RV/RAg at peak exercise (P) and afterwards agitated saline (8 cc with 1 cc of air and 1 cc of blood) was injected, followed by a new evaluation of RV/RAg (PC) and then the interruption of the EE. Pulmonary Hypertension was diagnosed when RV/RAg at the end of the exercise was superior to 40 mmHg. RESULTS: The quality of Doppler signal was deteriorated in 5 pts, maintained in 6 pts and improved in 26 pts, with the use of contrast. In one patient, an interventricular septal defect was diagnosed. In 6 pts, a Doppler signal was only obtained with the use of contrast. In 15 pts, a RV/RAg superior to 40 mmHg was only obtained with the use of contrast. Of these, 9 have already been submitted to right heart cathetherism, that confirmed the diagnosis of pulmonary hypertension in 5 of them (56%). RV/RAg (P) was 44 +/- 11 mmHg and RV/RAg (PC) was 54 +/- 11 mmHg, p < 0,001. CONCLUSION: 1. The method is applicable in a large number of patients. 2. RV/RA gradients obtained at peak exercise are higher with the use of contrast, and the clinical meaning of this difference should be evaluated in a larger number of pts submitted to right heart cathetherism. The high number of false positives should lead to a higher diagnostic threshold. 3. This method seems to have relevant clinical value in the diagnosis of pulmonary arterial hypertension.

Echocardiography during treadmill exercise testing for evaluation of pulmonary artery systolic pressure: advantages of the method.

INTRODUCTION: Determination of pulmonary artery systolic pressure by Doppler echocardiography (based on the pressure gradient between the right ventricle and right atrium - DeltaP RV/RA) or by right heart catheterization is useful in evaluating the severity and prognosis of cardiac disease. The aim of the study was to evaluate DeltaP RV/RA non-invasively during treadmill exercise in patients with tricuspid regurgitation and without coronary artery disease. METHODS: Of a total of 149 patients referred to our echo laboratory, we completed the study in 142 (95%), of whom 120 were women, mean age 52+/-13 years (23 to 82). We studied 68 patients with valvular heart disease (of whom 56 had mitral valve stenosis and sinus rhythm on ECG), 42 with systemic sclerosis, 10 with severe pulmonary hypertension, 12 with a history of pulmonary embolism and 10 healthy controls. The DeltaP RV/RA was determined from the tricuspid regurgitation jet using continuous wave Doppler in left lateral decubitus (LLD) before exercise testing (BLLD), in a standing position (SP), at peak workload (PW) before termination of the test, and in the first 60 seconds of the recovery period in LLD (RLLD). RESULTS: The DeltaP RV/RA in BLLD was 36+/-21 mmHg (range 18 to 147); the SP [symbol: see text]P RV/RA was 32+/-24 mmHg (range 12 to 137), p<0.001 vs. BLLD DeltaP RV/RA; the PW DeltaP RV/RA was 58+/-26 mmHg (range 28 to 177), p<0.0001 vs. SP DeltaP RV/RA; and the RLLD DeltaP RV/RA was 47+/-25 mmHg (range 20 to 152), p<0.001 vs. PW DeltaP RV/RA. The differences between PW DeltaP RV/RA and RLLD DeltaP RV/RA changed therapeutic decisions in 10 patients (18%) with mitral stenosis, and modified the management of 13 patients (30%) with systemic sclerosis (who then underwent right heart catheterization). CONCLUSIONS: Echocardiography during treadmill exercise testing was feasible in most patients. The DeltaP RV/RA decreases in response to the standing position. The DeltaP RV/RA rises considerably with exercise in the majority of patients and is significantly higher at peak workload than in the recovery period. The differences between PW DeltaP RV/RA and RLLD DeltaP RV/RA influenced patient management.

Five cases of transient left ventricular apical ballooning--the experience of a Portuguese center.

Transient left ventricular apical dyskinesia (apical ballooning syndrome, ABS) is characterized by transient alterations in regional wall motion, involving the mid and apical segments of the left ventricle, as well as electrocardiographic alterations, mimicking ST-elevation acute myocardial infarction, in the absence of obstructive disease of the epicardial coronary arteries. In this article, we present a series of five cases of ABS and a theoretical review of the syndrome.

Syncope caused by severe hypotension and intraventricular gradient during dobutamine stress echocardiography.

Dobutamine stress echocardiography is widely used for the evaluation of coronary artery disease. This form of stress echocardiography is safe but not without complications. We report a case of hypotension and syncope during dobutamine stress echocardiography in which a severe intraventricular gradient of over 200 mmHg and systolic anterior movement of the mitral valve were observed.

Evaluation of left ventricular outflow tract gradient during treadmill exercise and in recovery period in orthostatic position, in patients with hypertrophic cardiomyopathy.

BACKGROUND: Left ventricular outflow tract obstruction is an independent predictor of adverse outcome in hypertrophic cardiomyopathy (HCM). The classical quantification of intraventricular obstruction is performed in resting conditions in supine position, but this assessment does not reflect what happens in HCM patients (pts) in their daily activities, neither during effort nor during orthostatic recovery. AIM: To assess intraventricular gradients with echocardiography during treadmill exercise and in the recovery period in upright position, in HCM pts. METHODS: We studied 17 HCM pts (9 males, mean age 53 +/- 16 years, 11 with obstructive HCM). Each pt had 2 echocardiographic evaluations at rest (left lateral decubitus (LLD) and orthostatic position). The pts then underwent a treadmill exercise test and intraventricular gradients were measured at peak exercise and during recovery in orthostatic position. RESULTS: 3 pts with non-obstructive HCM at rest developed intraventricular gradients during exercise. 1 pt developed this gradient only during orthostatic recovery. The mean intraventricular gradient in LLD was 49 +/- 24 mmHg; in orthostatic position was 62 +/- 29 mmHg (p < 0.001 versus in LLD); at peak exercise was 83 +/- 35 mmHg (p < 0.001 versus supine rest); during recovery it was 96 +/- 35 mmHg (p < 0.001 versus peak exercise) CONCLUSION: In HCM pts the intraventricular gradient increases in orthostatic position, increases significantly during treadmill exercise and continues increasing in the recovery period in orthostatic position. This type of evaluation can help us to better understand the physiopathology, the symptoms and the efficacy of different therapeutic modalities in this disease and should be routinely used in the assessment of HCM pts.