Large Left Atrial Thrombus in a Patient With Severe Mitral Stenosis and Atrial Fibrillation Despite Anticoagulant Therapy: A Case Report.

This case report highlights a patient with atrial fibrillation, severe mitral stenosis, and left atrial dilatation who developed a large thrombus, despite being on anticoagulant therapy. The complexity of thrombus formation in patients with multiple risk factors is described, emphasising the need for regular echocardiographic assessments to detect and monitor thrombi, even in patients undergoing anticoagulant treatment. The interplay between atrial fibrillation, mitral stenosis, and left atrial dilatation contributes to thrombus formation, requiring a multidisciplinary approach to the management of these patients. Further research is needed to improve our understanding of the optimal treatment strategies for such cases. Timely identification and intervention are critical to mitigate the risk of thromboembolic complications in these high-risk patients.

Imaging of Cardiac Masses: An Updated Overview.

Studying cardiac masses is one of the most challenging tasks for cardiac imagers. The aim of this review article is to focus on the modern imaging of cardiac masses proceeding through the most frequent ones. Cardiac benign masses such as myxoma, cardiac papillary fibroelastoma, rhabdomyoma, lipoma, and hemangioma are browsed considering the usefulness of most common cardiovascular imaging tools, such as ultrasound techniques, cardiac computed tomography, cardiac magnetic resonance, and in the diagnostic process. In the same way, the most frequent malignant cardiac masses, such as angiosarcoma and metastases, are highlighted. Then, the article browses through nontumoral masses such as cysts, mitral caseous degenerative formations, thrombi, and vegetations, highlighting the differential diagnosis between them. In addition, the article helps in recognizing anatomic normal variants that should not be misdiagnosed as pathological entities.

Effects of Metformin and Exercise Training, Alone or in Combination, on Cardiac Function in Individuals with Insulin Resistance.

INTRODUCTION: In patients affected by insulin resistance (IR), metformin (MET) therapy has been shown to exert its positive effects by improving glucose tolerance and preventing the evolution to diabetes. Recently, it was shown that the addition of metformin to physical training did not improve sensitivity to insulin or peak oxygen consumption (peak VO2). The purpose of this study was to establish the effect of metformin and exercise, separately or in combination, on systolic left ventricular (LV) function in individuals with IR. METHODS: Seventy-five patients with IR were enrolled and subsequently assigned to MET, combination MET and exercise, or exercise alone. The LV systolic and diastolic functions were evaluated with standard echocardiography tissue Doppler imaging (TDI) and speckle tracking echocardiography at baseline and after 12 weeks of treatment. RESULTS: MET, administered alone or in association with exercise, improved longitudinal LV function, as evidenced by an increase in systolic (S) wave on TDI, alongside increases in longitudinal global strain and strain rate in comparison to the group undergoing physical training alone. The traditional echocardiographic parameters showed no statistically significant differences among the three groups before or after the different cycles of therapy. CONCLUSIONS: Treatment with MET, either with or without exercise, but not exercise alone, produced a significant increase in global longitudinal LV systolic function at rest. These findings validate the observation that the use of MET alone or in association with exercise has a crucial role to counteract the negative effects of IR on cardiovascular function.

Effects of an aquatic-based exercise program to improve cardiometabolic profile, quality of life, and physical activity levels in men with type 2 diabetes mellitus.

BACKGROUND: The role of structured exercise in improving cardiometabolic profile and quality of life in patients with type 2 diabetes mellitus (2DM) has been widely demonstrated. Little is known about the effects of an aquatic-based exercise program in patients with 2DM. OBJECTIVE: To evaluate the effects of a supervised aquatic-based exercise program on cardiometabolic profile, quality of life, and physical activity levels in patients with 2DM. DESIGN AND SETTING: Observational study, community pre-post aquatic-based exercise program, primary care intervention. PATIENTS: Eighteen men diagnosed with 2DM (52.2 ± 9.3 years). METHODS: and MAIN OUTCOME MEASUREMENTS: Cardiometabolic profile, quality of life, and physical activity levels were assessed before and after 12 weeks of an aquatic-based exercise program. RESULTS: The results show a significant improvement of cardiometabolic assessments (maximum oxygen consumption: 24.1 versus 21.1 mL/kg/min, P < .05; blood pressure: 125.4/77 versus 130.7/82.5 mm Hg, P < .05; fasting blood glucose: 119.6 versus 132.5 mg/dL, P < .05; body mass index: 29.9 versus 31.1 kg/m², P < .005; low-density lipoprotein cholesterol: 95.2 versus 104.9 mg/dL, P < .05; and diastolic function: E/E' 9.1 versus 10.1, P < .005) and an increase in quality of life and physical activity levels (Medical Outcome Study 36-item Short Form Health Survey mental component summary: 72.3 versus 67, P < .05; Problems Area About Diabetes: 20.1 versus 33.2, P < .005) and energy expenditure in general physical activity (physical activity: 3888.7 versus 1239.5 kcal/wk, P < .05). CONCLUSIONS: These findings demonstrate that an aquatic-based exercise program produces benefits for the cardiovascular system and metabolic profile and appears to be safe and effective in improving quality of life and increasing physical activity levels in patients with 2DM.

Effects of metformin and exercise training, alone or in association, on cardio-pulmonary performance and quality of life in insulin resistance patients.

BACKGROUND: Metformin (MET) therapy exerts positive effects improving glucose tolerance and preventing the evolution toward diabetes in insulin resistant patients. It has been shown that adding MET to exercise training does not improve insulin sensitivity. The aim of this study was to determine the effect of MET and exercise training alone or in combination on maximal aerobic capacity and, as a secondary end-point on quality of life indexes in individuals with insulin resistance. METHODS: 75 insulin resistant patients were enrolled and subsequently assigned to MET (M), MET with exercise training (MEx), and exercise training alone (Ex). 12-weeks of supervised exercise-training program was carried out in both Ex and MEx groups. Cardiopulmonary exercise test and SF-36 to evaluate Health-Related Quality of Life (HRQoL) was performed at basal and after 12-weeks of treatment. RESULTS: Cardiopulmonary exercise test showed a significant increase of peak VO2 in Ex and MEx whereas M showed no improvement of peak VO2 (∆ VO2 [CI 95%] Ex +0.26 [0.47 to 0.05] l/min; ∆ VO2 MEx +0.19 [0.33 to 0.05] l/min; ∆ VO2 M -0.09 [-0.03 to -0.15] l/min; M vs E p < 0.01; M vs MEx p < 0.01; MEx vs Ex p = ns). SF-36 highlighted a significant increase in general QoL index in the MEx (58.3 ± 19 vs 77.3 ± 16; p < 0.01) and Ex (62.1 ± 17 vs 73.7 ± 12; p < 0.005) groups. CONCLUSIONS: We evidenced that cardiopulmonary negative effects showed by MET therapy may be counterbalanced with the combination of exercise training. Given that exercise training associated with MET produced similar effects to exercise training alone in terms of maximal aerobic capacity and HRQoL, programmed exercise training remains the first choice therapy in insulin resistant patients.

Altered transmural contractility in postmenopausal women affected by cardiac syndrome X.

BACKGROUND: Cardiac syndrome X (CSX) is characterized by typical angina and abnormal exercise test results, with normal coronary arteries. Cardiovascular magnetic resonance imaging has shown subendocardial hypoperfusion in patients with CSX after adenosine. The aim of this study was to investigate the contribution of separate myocardial layers to global function under stress in women with CSX. METHODS: Twenty-two postmenopausal women with CSX were studied and compared with 20 healthy women matched for age and body mass index. All subjects underwent clinical evaluations and exercise echocardiography. Left ventricular systolic and diastolic parameters were evaluated at rest and at peak exercise. Layer-specific global longitudinal strain (GLS) and strain rate (SR) were assessed from the endocardium, midmyocardium, and epicardium using two-dimensional speckle-tracking echocardiography. RESULTS: All subjects showed normal contractile function at rest and at peak exercise. Significant increases in GLS and SR in all myocardial layers were observed at peak exercise in the control group, whereas patients with CSX showed significantly lower increases in endocardial GLS and SR compared with the control group (endocardial ΔSR, 0.17 ± 0.19 vs 0.33 ± 0.13 [P < .01]; endocardial ΔGLS, 1.33 ± 2.93 vs 6.64 ± 2.62 [P < .001]). Moreover, significantly impaired diastolic function (ΔE', 1.1 ± 3.3 vs 4.0 ± 2.03) was observed in patients with CSX. CONCLUSIONS: The results of this study show subendocardial impairment of contractile function during exercise in patients with CSX, confirming the existence of reduced myocardial perfusion reserve in patients with CSX and suggesting layer-targeted exercise echocardiography as a sensitive diagnostic tool in the assessment of suspected CSX.

Early impairment of contractility reserve in patients with insulin resistance in comparison with healthy subjects.

BACKGROUND: Insulin resistance (IR) is currently considered a crucial cardiovascular (CV) risk factor, which seems to play a dominant role in the evolution toward cardiac and vascular impairment. Early IR-induced cardiac dysfunction can be assessed by Doppler-derived myocardial systolic strain rate (SR) index, measured at baseline and after dobutamine stress echocardiography (DSE). METHODS: Thirty IR patients (HOMA-IR = 7 ± 5.2, age 52.6 ± 2.1 years), and 20 healthy, age and sex matched controls were studied. IR had been diagnosed in all patients in the 3 months preceding the study. Dobutamine echocardiography was performed in all subjects to exclude ischemic heart disease, and left ventricular contractile reserve (LVCR) was then assessed. LVCR was evaluated as an increase in the peak of an average longitudinal SR, measured in the basal and mid segments of 2 and 4 chamber ventricular walls. RESULTS: No significant differences between the 2 groups were revealed by baseline echocardiography. In contrast, after DSE a significant decrease of Delta SR was found in the IR group in comparison to the controls (0.54 ± 0.31 s⁻¹ vs 1.14 ± 0.45 s⁻¹; p < 0.0001). CONCLUSIONS: Our results show that IR, even if isolated and arising within a short time period, not only represents the initial phase of future diabetes, but may adversely affect heart function, as evidenced by the depressed LVCR. Our data strengthen the need for attention to be paid to IR state and for an early therapeutic approach.

Inverted takotsubo cardiomyopathy induced by dobutamine stress echocardiography with atypical presentation.

A 48-year-old woman was scheduled by our lab to perform a standard dobutamine/atropine stress echocardiogram. During the test, the patient referred to a slight chest discomfort and developed a progressive left ventricle akinesia of all midbasal LV segments, thus mimicking a midbasal ballooning. ECG persisted without significant abnormalities and with no raise of Troponin I. Coronary angiography showed normal coronary arteries and ventriculography a severe EF reduction and apical hypercontractility. Echocardiography showed a progressive improvement with a complete recovery 48 hours later. This is a rare case of inverted takotsubo syndrome induced by dobutamine stress echocardiography that occurred with atypical presentation.

Cardiovascular modulation during vagus nerve stimulation therapy in patients with refractory epilepsy.

To evaluate the effects of permanent vagal stimulation on cardiovascular system, 10 patients, affected by drug-resistant epilepsy with no primitive cardiovascular pathologies, were assessed prior to VNS surgery. A complete echocardiographic study [conventional and tissue Doppler imaging (TDI)], 24-h blood pressure (BP) monitoring and HRV evaluation were performed. The above mentioned parameters were investigated without any substantial changes to drug treatment during a check-up subsequent to VNS activation [mean: 7.7 months]. The results obtained show that while the anthropometrical data and both conventional and TDI echocardiography were unvaried compared to baseline, BP showed a significant increase of both systodiastolic values. Moreover, a close scrutiny of the most affected period of the BP increase (zenith between 16:31 and 17:30 pm) (systolic BP 114.7 mmHg vs 95.3 mmHg, P < 0.0001; diastolic BP 70.9 mmHg vs 56.9 mmHg, P < 0.001) showed a significant increase of the high frequencies components (HF) (28.4 ± 2.7 vs 36 ± 5.3, P < 0.05) and a significant reduction in low frequency/HF ratio (2.3 ± 0.3 vs 1.7 ± 0.3, P < 0.0001). The present study confirms the intrinsic cardiovascular safety and reliability of VNS procedures on both BP and HF and LF profiles and suggests that a primitive VNS-mediated central impingement on vagal efferents, independently by the antiepileptic mechanism, correlated to an moderate increase of parasympathetic activity, which in turn might play a protective role in seizure-triggered alterations of cardiovascular dynamic.

Echocardiographic accidental finding of asymptomatic cardiac and pulmonary embolism caused by cement leakage after percutaneous vertebroplasty.

Percutaneous vertebroplasty (PVP) is a therapeutic, interventional radiological procedure involving bone cement injection into a vertebral body. Although PVP is considered a minimally invasive procedure, cement leakage into the perivertebral venous system can occur with its migration towards the right heart and the pulmonary circulation. We report a case of accidental finding of asymptomatic cardiac and pulmonary embolism caused by cement leakage after PVP.