Multi-Modality Imaging Approach to a rare form of Biventricular Ring-Shaped Constrictive Pericarditis.

A 48-year-old man with AIDS/HIV and a previous history of tuberculous pericarditis 25 years earlier was admitted to our department of infectious diseases because of P. carinii pneumonia. A CT (computed tomography) scan described diffuse pericardial thickening with extensive pericardial calcifications on both ventricles. A transthoracic echocardiogram showed all the typical hemodynamic features of pericardial constriction. A review of the CT with 3D reconstruction revealed the presence of ring-shaped pericardial calcification at the basal segments of right and left ventricles extending over the inferior atrioventricular groove, the inferior interventricular groove and the cranial wall of the right atrium. Only a few cases of ring-shaped constrictive pericarditis have been reported and both global ventricular constriction and localized segmental constriction have been described. Our case wants to underline how important a comprehensive multi-modality imaging approach is to this rare form of constrictive pericarditis.

The Importance of Being Aware of Intrinsic Methods' Limitation in Low-Density Lipoprotein Cholesterol Determination to Correctly Identify Cardiovascular Risk: Is Direct Determination Obtained with the Roche System Systematically Overestimating LDL in Very High-Risk Patients with Triglycerides Concentration of Less than 2.25 mmol/L?

BACKGROUND: low-density lipoprotein cholesterol (LDL-C) is a strong cardiovascular risk factor, but the methods used to correctly determine it are is still questioned. The aim of this study was to compare the direct determination of LDL-C levels, obtained with the Roche cobas c system, with LDL-C values calculated through Sampson's and Friedewald's equations in very high-risk patients with triglycerides concentrations of less than 2.25 mmol/L (<200 mg/dL). METHODS: in 127 consecutive patients with a recent diagnosis of acute coronary syndrome and triglycerides of less than 2.25 mmol/L, plasma LDL-C was measured directly and calculated with Sampson's and Friedewald's equations before hospital discharge, and the data were compared. RESULTS: median LDL values obtained with the Friedenwald and Sampson equations and with direct determination were 2.31 (IQR 1.59-3.21), 2.36 (IQR 1.66-3.26) and 2.64 (IQR 1.97-3.65) mmol/L, respectively. Direct measurements were higher by 0.35 and 0.40 mmol/L when compared to the levels calculated with Sampson's or Friedewald's equations, respectively (p < 0.01). The correlation between the two equations was almost perfect (rho 0.997) but decreased when the directly determined data were compared to those calculated with Sampson's equation (rho 0.954) or Friedewald's method (rho 0.939). CONCLUSION: direct determination generated higher values of LDL-C concentration through a probable systematic overestimation.

Reverse Remodeling and Functional Improvement of Left Ventricle in Patients with Chronic Heart Failure Treated with Sacubitril/Valsartan: Comparison between Non-Ischemic and Ischemic Etiology.

Sacubitril/valsartan (SV) has been demonstrated to reduce cardiovascular mortality, hospitalization for heart failure and to induce reverse ventricular remodeling. The present study was designed to confirm the effects of SV in a selected population of patients with HFrEF and to evaluate the different responses between patients with an ischemic or a non-ischemic etiology. A total of 79 patients with indication of SV were recruited prospectively during a timelapse of 4 years. SV was overall associated to a reduction of end-diastolic and end-systolic volume, of NT-proBNP levels, furosemide dosage and NYHA functional class, together with an increase in EF. These changes were more evident in patients with non-ischemic dilated cardiomyopathy, who showed a significant improvement in ventricular volumes, ejection fraction, TAPSE and blood levels of NT-proBNP. Kaplan-Meier curves confirmed a greater benefit in terms of ejection-fraction improvement in non-ischemic patients compared to the ischemic group. The results of the present study confirm the positive effect of SV on NYHA functional class, NT- proBNP, left ventricular volumes and EF in HFrEF patients, showing evidence of association of SV with ventricular remodeling in patients with dilated cardiomyopathy of non-ischemic etiology compared to the ischemic group.

Large Serpiginous Thrombus Crossing a Patent Foramen Ovale.

Transesophageal iconic image of a large serpiginous thrombus crossing a patent foramen ovale.

Role of three-dimensional echocardiography in structural complications after acute myocardial infarction.

Three-dimensional echocardiography (3DE) is a unique cardiovascular imaging modality in terms of: ability to provide realistic anatomical views of cardiac structures in the beating heart and possibility to visualize cardiac structures from any desired perspective. Therefore, 3DE is emerging as an accurate imaging modality for a prompt diagnosis and detailed anatomical description of structural complications (SC) of acute myocardial infarction (AMI). We report 3 emblematic cases which show how both the transthoracic (TTE) and transesophageal (TEE) 3D imaging can provide precise anatomic information useful to address management of SC in AMI patients: (1) detailed assessment of size, location, and morphology of an apical ventricular septal defect (VSD) obtained with 3DTTE was pivotal in referring the patient to percutaneous closure of it; (2) size and location of a complex inferior VSD with irregular margins advised against percutaneous closure; and (3) 3DTEE assisted surgeons to choose between reparative or replacement surgery for an acute mitral regurgitation due to complete papillary muscle rupture.

Comprehensive analysis of left ventricular geometry and function by three-dimensional echocardiography in healthy adults.

BACKGROUND: Recent European Association of Echocardiography and American Society of Echocardiography guidelines on three-dimensional echocardiography state that normal values of left ventricular (LV) parameters for age and body size remain to be established. METHODS: In 226 consecutive healthy subjects (125 women; age range, 18-76 years), comprehensive three-dimensional echocardiographic analyses of LV parameters were performed, and values were compared with those obtained by conventional echocardiography. RESULTS: Upper reference values (mean+ 2 SDs) for three-dimensional LV end-diastolic and end-systolic volumes were 85 and 34 mL/m(2) in men and 72 and 28 mL/m(2) in women, respectively. Indexing LV volumes to body surface area did not eliminate gender differences. Lower reference values (mean - 2 SDs) for ejection fraction were 54% in men and 57% in women and for stroke volume were 25 and 24 mL/m(2), respectively. Upper reference values for LV mass were 97 g/m(2) in men and 90 g/m(2) in women and for end-diastolic sphericity index were 0.49 and 0.48, respectively. Significant age dependency of LV parameters was identified and reported across age groups. Three-dimensional echocardiographic LV volumes were larger, ejection fraction was similar, and LV stroke volume and mass were significantly smaller in comparison with the corresponding values obtained by conventional echocardiography. CONCLUSIONS: The investigators report a comprehensive analysis of LV geometry and function using three-dimensional echocardiography in a relatively large cohort of healthy Caucasian subjects with a wide age range. These may serve to establish age-specific and gender-specific reference ranges, which are crucial for the routine implementation of three-dimensional echocardiography to detect LV remodeling and dysfunction in clinical practice.

Right atrial size and function assessed with three-dimensional and speckle-tracking echocardiography in 200 healthy volunteers.

AIMS: Right atrial (RA) size predicts the outcome in some pathological conditions but reference values for RA volumes and myocardial function remain to be defined. Thus, we used two-dimensional speckle-tracking echocardiography (2D-STE) and three-dimensional echocardiography (3DE) to define normative reference values of RA volumes and function. METHODS AND RESULTS: Two hundreds healthy volunteers (43 ± 15 years, range 18-75; 44% men) underwent two-dimensional echocardiography (2DE) to obtain RA volumes and longitudinal strain (LS) of RA wall using 2D-STE, and 3DE to measure maximal (Vmax), minimal, and preA volumes to calculate total, passive, and active emptying volumes (TotEV, PassEV, and ActEV) and emptying fractions (TotEF, PassEF, and ActEF). Three-dimensional echocardiography volumes (Vmax, 52 ± 15 mL vs. 41 ± 14 mL), EVs (TotEV, 33 ± 10 mL vs. 24 ± 9 mL), and EFs (TotEF, 63 ± 9 vs. 58 ± 9%) were larger than 2DE ones (all P < 0.0001). Indexed 3D volumes were significantly larger in men than in women. RA TotEF correlated with total LS (r = 0.24, P = 0.025) and PassEF with positive LS (LSpos; r = 0.34, P < 0.0001). Ageing was associated with a decrease in passive (LSpos, r = -041; PassEV, r = -0.26; PassEF, r = -0.38; all P < 0.0001) and an increase in active RA function (negative LS, r = 0.34; ActEV, r = 0.25; all P < 0.0001; and ActEF, r = 0.15; P = 0.035) in order to maintain TotEV (r = -0.14, P = 0.05). CONCLUSION: Our study provides normative values for RA volumes and function measured by 3DE and 2D-STE in a relatively large cohort of healthy subjects with a wide age range. These data will help clinicians to identify RA remodelling and dysfunction.