Fulminant Influenza A myocarditis in a patient presenting with cardiogenic shock and biventricular thrombi: a case report.

BACKGROUND: Acute myocarditis is a common condition, with viral infections being the most common aetiology in North America and Europe. Influenza A myocarditis is however rare. As clinical manifestation may be fulminant, early recognition and management are paramount and may impact overall prognosis by hindering complications such as thromboembolism. A brief review of the literature, diagnostic modalities, work-up and treatment are discussed. CASE SUMMARY: We present the case of a 42-year-old, previously healthy woman with recent flu-like symptoms, developing decompensated heart failure (HF) and cardiogenic shock within a week, due to Influenza A myocarditis. Biventricular thrombi were identified. Pharmacological haemodynamic support, followed by HF therapy, allowed full recuperation of heart function. Intracavitary thrombi disappeared under unfractionated heparin with bridging to rivaroxaban. DISCUSSION: Fulminant myocarditis due to Influenza A is rare and, to the best of our knowledge, has not been associated with intracardiac thrombi formation. Echocardiography is the essential first-line imaging modality. Cardiac magnetic resonance plays a major role in the diagnosis of myocarditis and may preclude the need for an endomyocardial biopsy in selected cases. Coronary angiography may be required to rule out ischaemic aetiology. First-line therapy in fulminant disease is pharmacological and, if required, mechanical haemodynamic support. Standard HF therapy complete the therapeutic options and should be introduced as soon as possible. Complications such as intracardiac thrombi formation, require targeted treatment. Specific drug therapies targeting Influenza A have no proven benefit in myocarditis.

Clinical Predictors and Prognostic Impact of Recovery of Wall Motion Abnormalities in Takotsubo Syndrome: Results From the International Takotsubo Registry.

Background Left ventricular (LV) recovery in takotsubo syndrome (TTS) occurs over a wide-ranging interval, varying from hours to weeks. We sought to investigate the clinical predictors and prognostic impact of recovery time for TTS patients. Methods and Results TTS patients from the International Takotsubo Registry were included in this study. Cut-off for early LV recovery was determined to be 10 days after the acute event. Multivariable logistic regression was used to assess factors associated with the absence of early recovery. In-hospital outcomes and 1-year mortality were compared for patients with versus without early recovery. We analyzed 406 patients with comprehensive and serial imaging data regarding time to recovery. Of these, 191 (47.0%) had early LV recovery and 215 (53.0%) demonstrated late LV improvement. Patients without early recovery were more often male (12.6% versus 5.2%; P=0.011) and presented more frequently with typical TTS (76.3% versus 67.0%, P=0.040). Cardiac and inflammatory markers were higher in patients without early recovery than in those with early recovery. Patients without early recovery showed unfavorable 1-year outcome compared with patients with early recovery (P=0.003). On multiple logistic regression, male sex, LV ejection fraction <45%, and acute neurologic disorders were associated with the absence of early recovery. Conclusions TTS patients without early LV recovery have different clinical characteristics and less favorable 1-year outcome compared with patients with early recovery. The factors associated with the absence of early recovery included male sex, reduced LV ejection fraction, and acute neurologic events. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT01947621.

Prevalence and significance of notched T-waves in elite professional cyclists.

OBJECTIVES: To identify the frequency and significance of notched T-waves (NTW) in elite endurance athletes. METHODS: Professional cyclists were followed for 4 years with a clinical, electrocardiographic and echocardiographic assessment. Electrocardiograms were classified according to the presence or absence of NTWs; clinical and echocardiographic correlates were assessed. RESULTS: 42 Caucasian male cyclists were included. NTW were detected in 8 (19%) cyclists who showed significantly longer QT (461 ±â€¯15 vs 422 ±â€¯33 ms, p < 0.01) and QTc intervals (434 ±â€¯19 vs 383 ±â€¯21 ms, p < 0.01), a larger left ventricular end-diastolic volume (163 ±â€¯27 vs 137 ±â€¯23 mL, p = 0.014), end-diastolic volume index (84 ±â€¯13 vs 73 ±â€¯11 mL, p = 0.037) and end-diastolic apex-to-base length (9.9 ±â€¯0.7 vs 9.3 ±â€¯0.5 mm. p = 0.035). There were no detected arrhythmic events, and echocardiography did not reveal any abnormalities. CONCLUSIONS: This is to our knowledge the first study reporting a high prevalence of NTW in athletes. In our small cohort of cyclists NTW were associated with QT interval prolongation and left ventricular changes. This may be indicative of underlying inhomogeneity of repolarisation. Expanding on this research could reveal a role for NTW in identifying ventricular morphological changes.

Multimodality imaging evaluation of a mitro-aortic fibrosa pseudoaneurysm fistulizing into both atria.

To our knowledge, we describe the first case of a pseudoaneurysm of the mitro-aortic intervalvular fibrosa fistulizing into both atria, following an aortic bacterial endocarditis and valve replacement.

Electrophysiological abnormalities in patients with paroxysmal atrial fibrillation in the absence of overt structural heart disease.

PURPOSE: The aim of the present study was to define the atrial electrical substrate in patients with paroxysmal atrial fibrillation (AF) occurring in the absence of overt structural heart disease and to assess if electrophysiological parameters could predict AF recurrence after radiofrequency ablation in this population. METHODS AND RESULTS: 45 consecutive patients (39 male, age 59 ± 10 years) with paroxysmal AF and without overt structural heart disease, referred for radiofrequency catheter ablation, were prospectively enrolled. A cohort of 12 age-matched patients without a history of AF, served as a control group. Atrial electrical substrate was assessed by P-wave signal-averaging, intracardiac conduction delays and refractory periods. Total P wave duration during signal-averaging was longer in patients with paroxysmal AF than in controls (140 ± 19 ms vs 123 ± 13 ms, p = 0.004). Patients with paroxysmal AF showed an increase in right intra-atrial (40.2 ± 11.3 ms vs 31.7 ± 11.8 ms, p = 0.02) and inter-atrial conduction delays (87.93 ± 22.0 ms vs 65.3 ± 15.6 ms, p = 0.001) in sinus rhythm. Refractory periods in the right atrium were longer in patients with paroxysmal AF (265 ± 44 ms vs 222 ± 32 ms, p = 0.002). After ablation, 22 patients had AF recurrence but showed no differences in electrophysiological parameters compared to patients without recurrence. CONCLUSION: Electrophysiological abnormalities are present in patients with paroxysmal AF without overt structural heart disease. Neither signal-averaged P-wave duration nor intracardiac atrial electrophysiology could predict arrhythmia recurrence after pulmonary vein isolation.

When inappropriate becomes beneficial.

We report the case of a young man who accidentally received a prolonged electric discharge from electrical wires and released the electric source with the help of an inappropriate shock from his implantable cardioverter-defibrillator (ICD), after misinterpretation of the electrical signal by the device as a ventricular tachycardia. This case illustrates the "electrical noise" phenomenon, and underscores the need for precautions for patients with an ICD and their physicians.