A Rare Case of Left Ventricular Thrombus in a Normal Heart in a Patient With Factor V Leiden Disease.

Left ventricular thrombus (LVT) is mostly associated with anterior wall myocardial infarction and reduced ejection fraction. It can also be associated with cardiomyopathy, myocarditis, and hypercoagulable states such as cancer, antiphospholipid syndrome, and protein C or protein S deficiency. Factor V Leiden (FVL) disease is one of the hypercoagulable states where mutant factor V is insensitive to natural anticoagulation factor protein C, and FVL disease increases the risk of peripheral thromboembolism such as pulmonary embolism (PE) and deep vein thrombosis (DVT). We report a 60-year-old female patient with a history of heterozygous factor V Leiden and a remote history of deep vein thrombosis who presented with left-sided weakness and intermittent chest pain. Computed tomography (CT) of the brain ruled out stroke, electrocardiogram (EKG) showed sinus rhythm and some new T-wave inversion, and troponin was mildly elevated. Other laboratory results were unremarkable. A transthoracic echocardiogram showed a left ventricular mass with left ventricular outflow tract (LVOT) obstruction in systole with normal systolic and diastolic function and no wall motion abnormalities. Emergent surgery proved to be a thrombus. The learning objectives of our case are that a normal-sized and functional left ventricle does not preclude left ventricular thrombosis, long-term anticoagulation therapy in patients with factor V Leiden and a first episode of thromboembolism with additional risk factors may prevent further serious thromboembolic event, and timely diagnosis and treatment of cardiac thrombosis may reduce morbidity and mortality.

Left ventricle pedunculated thrombi risks and outcomes: a case report and literature review.

A 42-year-old male with ischemic cardiomyopathy presented with acute bilateral femoral artery embolization. After management with embolectomy and fasciotomy in both femoral arteries, transthoracic echocardiography revealed two pedunculated highly mobile left ventricle (LV) thrombi. Given the procedural risk, anticoagulation therapy was recommended over surgery. However, the bleeding risk impeded the continuation of anticoagulation, which increased the thrombus size. Multiorgan failure and disseminated intravascular coagulopathy followed and the patient died. We also systematically reviewed the PubMed and Scopus databases for pedunculated LV thrombi cases and retrieved 74 and 63 reports respectively. Of these, 37 relevant reports (45 cases) plus 11 reports from the manual search were included for data extraction, a total of 56 cases besides our case. Based on the etiologies and risks, LV thrombi are predictable and preventable, especially after ischemic events. A clear diagnostic algorithm and vigilant follow-up are needed as well as multidisciplinary management once a diagnosis is confirmed.

Relatamos o caso de um homem de 42 anos com cardiomiopatia isquêmica que apresentou embolização aguda bilateral das artérias femorais. Embolectomia das artérias femorais e fasciotomia foram realizadas bilateralmente e, posteriormente, o ecocardiograma transtorácico revelou a presença de dois trombos pedunculados altamente móveis no ventrículo esquerdo (VE). Diante do risco associado à abordagem cirúrgica, recomendou-se terapia anticoagulante. No entanto, o risco de sangramento impediu a continuação da anticoagulação, o que levou ao aumento dos trombos. Posteriormente, o paciente evoluiu com falência de múltiplos órgãos e coagulação intravascular disseminada, vindo a óbito. Além do relato de caso, realizamos buscas sistemáticas nas bases de dados PubMed e Scopus por casos de trombos pedunculados no VE. Foram recuperados 74 e 63 relatos, respectivamente, dos quais 37 relatos relevantes (45 casos) e 11 da busca manual foram selecionados para extração de dados, totalizando 56 casos além do nosso. Com base nas etiologias e nos riscos, os trombos no VE são previsíveis e evitáveis, especialmente após eventos isquêmicos. Isso requer um algoritmo diagnóstico claro e acompanhamento vigilante, bem como manejo multidisciplinar após confirmação do diagnóstico.

Concentric remodeling and the metabolic-associated steatotic liver disease in patients with type 1 diabetes: an exploratory study.

INTRODUCTION: Diabetic cardiomyopathy in young patients with type 1 diabetes (T1D) usually presents as asymptomatic diastolic heart dysfunction with left ventricle (LV) remodeling. Its prevalence seems to be underestimated. One of the factors seemingly influencing LV remodeling is a metabolic-associated steatotic liver disease (MASLD), which was extensively investigated in patients with type 2 diabetes but not with T1D. This study aimed to describe the correlation between MASLD risk and relative wall thickness (RWT) in young patients with T1D without heart failure symptoms or treatment. MATERIALS AND METHODS: Study participants were recruited at the inpatient diabetology department, in admission order. Patients underwent a set of laboratory tests and echocardiographic examinations. The risk of MASLD was estimated using fatty liver index (FLI). Acquired data was then statistically analyzed. RESULTS: The study group consisted of 55 patients. 25 participants had RWT > 0.42, suggesting LV remodeling. Study participants did not differ in HbA1c, NT-proBNP, HDL, LDL, non-HDL, and uric acid concentrations. However, patients with RWT > 0.42 had higher FLI (40.97 vs. 13.82, p < 0.01) and BMI (27.3 vs. 22.5, p < 0.01) and differed in transaminase concentrations. Moreover, patients with RWT > 0.42 had significantly higher LV mass index (85.6 vs. 68.2 g/m2) and altered mitral ring velocities. In univariable logistic regression, FLI correlated with LV remodeling risk (OR 1.028, p = 0.05). The optimal cutoff point for FLI predicting the RWT > 0.42 was 26.38 (OR 10.6, p = 0.04, sensitivity 0.857, specificity 0.657). CONCLUSIONS: FLI correlates with RWT in patients with T1D independently of diabetes metabolic control and hypothetically may support recognizing T1D patients with a higher risk of LV remodeling.

Double Outlet Left Ventricle with Intact Ventricular Septum: A Rare Prenatally Diagnosed Case Report.

INTRODUCTION: Double outlet left ventricle (DOLV) is a rare congenital heart anomaly, and cases of DOLV with an intact ventricular septum are uncommon. To date, only four such cases have been reported in the medical literature. CASE PRESENTATION: This report presents a case of prenatally diagnosed DOLV. A fetal echocardiogram at 21 weeks of gestation demonstrated both great arteries, aorta and pulmonary artery, arising from the left ventricle with severely dysplastic tricuspid valve and severe hypoplasia of the right ventricle. Subsequent echocardiograms demonstrated no ventricular septal defect. The patient required balloon atrial septostomy in the first week of life, underwent pulmonary artery banding at 5 weeks of life, and is currently status post-bidirectional Glenn, and is awaiting final Fontan palliation. CONCLUSION: Prenatal diagnosis aided in predicting and guiding postnatal management.

Cardiac Point-Of-Care Ultrasound: An Emergency Medicine Review.

Cardiac point-of-care ultrasound (POCUS) can make critical diagnoses and monitor the response to interventions. In contrast with consultative echocardiography, cardiac POCUS serves to answer a specific clinical question. This imaging modality can be used to evaluate for left ventricular systolic and diastolic dysfunction, pericardial effusion and tamponade, acute and chronic right ventricular dysfunction, valvular dysfunction, and cardiac activity in cardiac arrest.

Comparison between Handheld Echocardiography and Cardiac Magnetic Resonance for Stroke Volume and Left Ventricular Ejection Fraction Quantification.

Background: Reliable quantification of stroke volume (SV) and left ventricular ejection fraction (LVEF) is essential for point-of-care assessment in hemodynamically compromised patients. Handheld echocardiography (HHE) equipment has entered the market a few years ago and is now available for clinical use. However, the performance of HHE for SV and LVEF quantification in comparison to cardiac magnetic resonance (CMR) imaging as golden standard is yet unknown. Methods: Twenty volunteers were scanned with HHE, standard echocardiography (SE), and CMR. LVEF and SV were measured with each modality, and their accuracy and precision were evaluated. Results: Bias and limits of agreement (LOA) between HHE and CMR were -0.21% (-2.89: 2.48) and 11.24% (-15.79: 15.59) for LVEF and 29.85 ml (22.13: 37.57) and 32.34 ml (-15.01: 44.86) for SV, respectively. Bias and LOA between SE and CMR were -0.60% (-3.74:2.55) and 13.16% (-18.85:18.26) for LVEF and 32.08 ml (24.61:39.54) and 31.34 ml (-11.29:43.37) for SV, respectively. Conclusion: HHE versus CMR showed comparable accuracy and precision compared to SE versus CMR.

Computational modeling of left ventricular flow using PC-CMR-derived four-dimensional wall motion.

Intracardiac hemodynamics plays a crucial role in the onset and development of cardiac and valvular diseases. Simulations of blood flow in the left ventricle (LV) have provided valuable insight into assessing LV hemodynamics. While fully coupled fluid-solid modelings of the LV remain challenging due to the complex passive-active behavior of the LV wall myocardium, the integration of imaging-driven quantification of structural motion with computational fluid dynamics (CFD) modeling in the LV holds the promise of feasible and clinically translatable characterization of patient-specific LV hemodynamics. In this study, we propose to integrate two magnetic resonance imaging (MRI) modalities with the moving-boundary CFD method to characterize intracardiac LV hemodynamics. Our method uses the standard cine cardiac magnetic resonance (CMR) images to estimate four-dimensional myocardial motion, eliminating the need for involved myocardial material modeling to capture LV wall behavior. In conjunction with CMR, phase contrast-MRI (PC-MRI) was used to measure temporal blood inflow rates at the mitral orifice, serving as an additional boundary condition. Flow patterns, including velocity streamlines, vortex rings, and kinetic energy, were characterized and compared to the available data. Moreover, relationships between LV wall kinematic markers and flow characteristics were determined without myocardial material modeling and using a non-rigid image registration (NRIR) method. The fidelity of the simulation was quantitatively evaluated by validating the flow rate at the aortic outflow tract against respective PC-MRI measures. The proposed methodology offers a novel and feasible toolset that works with standard PC-CMR protocols to improve the clinical assessment of LV characteristics in prognostic studies and surgical planning.

Molecular and physiological mechanisms of aging are distinct in the cardiac right and left ventricles.

Aging is the primary risk factor for heart disease, the leading global cause of death. Right ventricular (RV) function predicts survival in several age-related clinical contexts, yet no therapies directly improve RV function, in large part due to a poor mechanistic understanding of RV aging and how it is distinct from the widely studied left ventricle (LV). To address this gap, we comprehensively quantified RV functional and morphological remodeling with age. We further aimed to identify molecular mechanisms of RV aging thus we performed RNAseq on RV and LV from male and female young (4 months) and aged (19-21 months) C57BL6 mice. Contrary to the concentric hypertrophic remodeling and diastolic dysfunction that occurs in the LV, the aging RV underwent eccentric remodeling with significant dilation and impaired systolic function. Transcriptomic data were also consistent with ventricle-specific aging, with few genes (13%) similarly shared between ventricles with aging. KEGG analysis identified shared aging genes in inflammatory and immune cell pathways that were confirmed by flow cytometry that demonstrated higher percent of GR1+ myeloid cells in both ventricles. Unique RV aging genes enriched in the biosynthesis of saturated fatty acids, PPAR signaling, and butanoate metabolism, and we identified putative novel RV-specific aging genes. Together, we suggest that the RV and LV are unique cardiac chambers that undergo distinct remodeling with age. These robust differences may explain why therapies designed from LV-based studies fail to improve RV function and suggest that future efforts emphasizing ventricular differences may elucidate new therapies for healthy cardiac aging.

Relationship between left atrial/left ventricular diameter ratio and outcomes in patients with hypertrophic cardiomyopathy.

BACKGROUND: Although diastolic dysfunction is the main pathophysiological feature of hypertrophic cardiomyopathy (HCM), it remains to be clarified whether parameters of diastolic function can reliably determine HCM prognosis. In patients with reduced left ventricular (LV) distensibility, chronic elevation of LV diastolic pressure is seen with a smaller than expected LV size. Accordingly, patients with HCM with severe LV diastolic dysfunction typically demonstrate left atrial (LA) dilation and a disproportionately smaller left ventricle. Therefore, we investigated the relationship between LA/LV diameter ratio, as a potential indicator of disease progression, and outcomes in patients with HCM. METHODS: We included 468 patients in whom LA and LV end-diastolic diameter were successfully evaluated by echocardiography at the initial assessment. We divided the patients into two groups: those with an LA/LV diameter ratio > 1 and those with an LA/LV diameter ratio ≤ 1. We compared the HCM-related death rates between the two groups. RESULTS: Of the 468 patients, 96 patients (20.5 %) with HCM showed an LA/LV diameter ratio > 1. In the univariate analysis, patients with an LA/LV diameter ratio > 1 had a significantly greater likelihood of HCM-related death than patients with an LA/LV diameter ratio ≤ 1 (log-rank p = 0.002). In the multivariate Cox proportional hazards analysis, when including LA/LV diameter ratio > 1 and imbalanced baseline variables, an LA/LV diameter ratio > 1 was an independent determinant of HCM-related death (adjusted hazard ratio: 1.87, 95 % confidence interval: 1.08-3.24; p = 0.024). CONCLUSION: LA/LV diameter ratio can be easily evaluated and may be useful for risk stratification of HCM-related death in patients with HCM.

Double-chambered left ventricle misdiagnosed as ventricular septal defect.

A 35-year-old woman was initially misdiagnosed with a muscular ventricular septal defect but was later correctly diagnosed with a double-chambered left ventricle following evaluation by echocardiography and cardiac computed tomography.

Is cardiac function associated with the clinical course of disease in patients with gout? A prospective study.

OBJECTIVE: To analyze the function of the left heart in patients with different courses of gout, the independent influencing factors for left heart functional changes, and interactions between left atrial and left ventricular functions. METHODS: Patients with gout (n = 171) were selected; 87 patients with a disease course <10 years were included in Group I, and 84 patients with a disease course ≥10 years were included in Group II. Ninety-four healthy volunteers comprised the control group. RESULTS: The intergroup differences in cardiac strain parameters were statistically significant (p < .05). Moreover, the differences gradually declined with disease progression. Multivariate logistic regression analysis showed that uric acid was an independent predictor of decreased left ventricular global longitudinal strain (LVGLS). Moreover, LVGLS had a positive effect on the left atrial systolic rate (LASr) and the left atrial systolic contraction time (LASct) but no interaction with the left atrial systolic contraction duration (LAScd). CONCLUSION: The course of the disease significantly affected the function of the left heart in gout patients, and uric acid was observed to be an independent predictor of decreased LVGLS in gout patients.

Load Dependency of Ventricular Pump Function: Impact on the Non-Invasive Evaluation of the Severity and the Prognostic Relevance of Myocardial Dysfunction.

Ventricular pump function, which is determined by myocyte contractility, preload and afterload, and, additionally, also significantly influenced by heart rhythm, synchrony of intraventricular contraction and ventricular interdependence, explains the difficulties in establishing the contribution of myocardial contractile dysfunction to the development and progression of heart failure. Estimating myocardial contractility is one of the most difficult challenges because the most commonly used clinical measurements of cardiac performance cannot differentiate contractility changes from alterations in ventricular loading conditions. Under both physiological and pathological conditions, there is also a permanent complex interaction between myocardial contractility, ventricular anatomy and hemodynamic loading conditions. All this explains why no single parameter can alone reveal the real picture of ventricular dysfunction. Over time there has been increasing recognition that a load-independent contractility parameter cannot truly exist, because loading itself changes the myofilament force-generating capacity. Because the use of a single parameter is inadequate, it is necessary to perform multiparametric evaluations and also apply integrative approaches using parameter combinations which include details about ventricular loading conditions. This is particularly important for evaluating the highly afterload-sensitive right ventricular function. In this regard, the existence of certain reluctance particularly to the implementation of non-invasively obtainable parameter combinations in the routine clinical praxis should be reconsidered in the future. Among the non-invasive approaches used to evaluate ventricular function in connection with its current loading conditions, assessment of the relationship between ventricular contraction (e.g., myocardial displacement or deformation) and pressure overload, or the relationship between ejection volume (or ejection velocity) and pressure overload, as well as the relationship between ventricular dilation and pressure overload, were found useful for therapeutic decision-making. In the future, it will be unavoidable to take the load dependency of ventricular function much more into consideration. A solid basis for achieving this goal will be obtainable by intensifying the clinical research necessary to provide more evidence for the practical importance of this largely unsolved problem.

Assessment of left ventricular myocardial systolic dysfunction in premature ovarian insufficiency patients using echocardiographic layer-specific myocardial strain imaging.

BACKGROUND: Due to the lack of oestrogen, premature ovarian insufficiency (POI) is an independent risk factor for ischaemic heart disease and overall cardiovascular disease. This study aimed to apply layer-specific myocardial strain for early quantitative evaluation of subclinical left ventricular myocardial systolic function changes in patients with POI. METHODS: Forty-eight newly diagnosed, untreated patients with POI (POI group) and fifty healthy female subjects matched for age, height and weight (control group) were enrolled. Standard transthoracic echocardiography was used to measure conventional parameters and layer-specific strain parameters.The layer-specific strain parameters included subendomyocardial global longitudinal strain (GLSendo), mid-layer myocardial global longitudinal strain (GLSmid), subepimyocardial global longitudinal strain (GLSepi), subendomyocardial global circumferential strain (GCSendo), mid-layer myocardial global circumferential strain (GCSmid), and subepimyocardial global circumferential strain (GCSepi). RESULTS: There were no significant differences in age, body mass index (BMI), blood pressure, or left ventricular ejection fraction (LVEF) between the two groups. The end-diastolic interventricular septal thickness (IVST) was greater in the POI group (8.29 ± 1.32 vs. 7.66 ± 0.82, P = 0.008), and the POI group had lower E, E/A, and lateral e' (all P < 0.05). As for systolic functions,the POI group had lower GLSendo, GLSmid, GLSepi, GCSendo, GCSmid, and GCSepi (all P < 0.05).The intraobserver and interobserver coefficients of GLSendo, GLSmid, GLSepi, GCSendo, GCSmid, and GCSepi were greater than 0.900. CONCLUSIONS: POI patients with normal LVEF may suffer from subclinical left ventricular myocardial systolic dysfunction. Echocardiography of layer-specific myocardial strain could more sensitively detect subclinical impairment of left ventricular systolic function in POI patients.

The preferable position for quantifying left ventricular diameter by transthoracic echocardiography.

BACKGROUND: In quantifying left ventricular (LV) diameter, which position for echocardiographic measurements, mitral valve tip level (MV-tip) or LV mid level (LV-mid), more accurately represents the LV volume is unclear. Furthermore, which factor affects the measurement error also has not been elucidated. METHODS: We enrolled 150 patients without myocardial infarction and local asynergy who underwent echocardiography and cardiac magnetic resonance imaging (CMRI). Echocardiographic LV diastolic diameter (LVDD) and LV systolic diameter (LVDS) were measured at both MV-tip and LV-mid, and the LV end-diastolic volume (LVEDV) and end-systolic volume (LVESV) were quantified using CMRI. We quantified the degree of aortic wedging as the angle between the anterior wall of the aorta and the ventricular septal surface (ASA). RESULTS: The average LVDD was smaller and average LVDS larger when measured at the MV-tip than at the LV-mid. In regression analyses, the correlation coefficient between LVDD and LVEDV was larger at LV-mid (R = 0.89) than at MV-tip (R = 0.82), and the correlation coefficient between LVDS and LVESV also larger at LV-mid (R = 0.93) than MV-tip (R = 0.87). ASA, Valsalva diameter, left atrial diameter, patient height, and LV mass significantly affected the echocardiographic measurement error, but no factor affected the measurement error when quantifying LVDD at the LV-mid level. CONCLUSIONS: The echocardiographic LV diameter measured at LV-mid has a stronger correlation with LV chamber size derived from CMRI than measurements at MV-tip. The LVDD measured at the LV-mid level is not affected by other factors.

Smaller Left Ventricular Size But Preserved Function in Adolescents and Adults Born Preterm.

BACKGROUND: Prematurely born adults have increased risk for cardiovascular disease. There are limited cardiac data on US-born preterm individuals. We aimed to determine whether adolescents and adults born prematurely have altered left ventricular (LV) structure and function, and to interrogate diastolic function using isometric handgrip exercise. METHODS AND RESULTS: Adolescents and adults born moderately to extremely preterm (≤32 weeks gestation or <1500 g birth weight) were recruited from the Parkland Health Neonatal Intensive Care Unit Registry. Full-term participants were recruited from the local area. Study procedures included anthropometrics and vitals, handgrip testing, and echocardiography performed at rest and during isometric handgrip exercise. Data were reported as mean±SD. The study enrolled 107 preterm and 48 term participants. Preterm participants (gestational age: 29.5±2.5 weeks) were shorter with higher body mass index (P<0.001) compared with term participants. Preterm participants exhibited smaller LV end-diastolic volume index (50.8±10.1 versus 56.9±10.0 mL/m2, P<0.001), LV stroke volume index (29.6±6.0 versus 34.1±6.5 mL/m2, P<0.001), and LV mass index (67.2±13.1 versus 73.3±14.2 g/m2, P=0.002) compared with term individuals. Preterm participants also had subclinical reductions in LV peak systolic tissue velocity and peak early diastolic tissue velocity lateral at rest. Isometric handgrip exercise promoted a reduction in diastolic function and an increase in hemodynamic measures, but changes during isometric handgrip exercise were similar between groups. CONCLUSIONS: Adolescents and adults born preterm exhibit overall normal cardiac function despite smaller cardiac volumes and mass compared with individuals born full term. Effects are most pronounced at the lowest gestational ages.

The chicken or the egg? Mycoplasma pneumoniae complicated by left ventricle thrombus and anterior myocardial infarction: a case report.

Background: Mycoplasma pneumoniae can be associated with extrapulmonary manifestations, including vasculitis, myocarditis, and thrombosis. In rare cases, it has also been implicated in intracardiac thrombus formation. Case Summary: A previously healthy 25-year-old male presented with worsening abdominal pain, an episode of acute chest pain, new lightheadedness, and gait instability in the setting of M. pneumoniae. Initial blood tests were notable for mild coagulopathy, thrombocytosis, transaminitis, and elevated high-sensitivity troponin. Further, workup revealed systematic emboli to the cerebellum, kidneys, spleen, anterior myocardial infarction, and a left ventricular multilobular mural mass. Due to the unknown composition of the mass with concern for further embolic events, the patient underwent successful surgical excision with the mass ultimately defined as a thrombus. Hypercoagulable workup was notably inconclusive and intraoperative myocardial biopsies revealed organizing infarction without inflammation or healed myocarditis. Post-operative course was complicated by left ventricular dysfunction and acute kidney injury, both with eventual improvement. Patient has remained on guideline-directed medical therapy and prophylactic anticoagulation. Discussion: We presume that the formation of the ventricular thrombus in this case was a result of transient thrombophilia in the setting of M. pneumonia resulting in coronary obstruction and subsequent myocardial injury. This case underscores the challenge of determining the pathophysiological sequence of events in patients with mycoplasma who develop systemic embolism and the management of a large residual thrombus, particularly in regard to surgical consideration.

Automatic segmentation of echocardiographic images using a shifted windows vision transformer architecture.

Echocardiography is one the most commonly used imaging modalities for the diagnosis of congenital heart disease. Echocardiographic image analysis is crucial to obtaining accurate cardiac anatomy information. Semantic segmentation models can be used to precisely delimit the borders of the left ventricle, and allow an accurate and automatic identification of the region of interest, which can be extremely useful for cardiologists. In the field of computer vision, convolutional neural network (CNN) architectures remain dominant. Existing CNN approaches have proved highly efficient for the segmentation of various medical images over the past decade. However, these solutions usually struggle to capture long-range dependencies, especially when it comes to images with objects of different scales and complex structures. In this study, we present an efficient method for semantic segmentation of echocardiographic images that overcomes these challenges by leveraging the self-attention mechanism of the Transformer architecture. The proposed solution extracts long-range dependencies and efficiently processes objects at different scales, improving performance in a variety of tasks. We introduce Shifted Windows Transformer models (Swin Transformers), which encode both the content of anatomical structures and the relationship between them. Our solution combines the Swin Transformer and U-Net architectures, producing a U-shaped variant. The validation of the proposed method is performed with the EchoNet-Dynamic dataset used to train our model. The results show an accuracy of 0.97, a Dice coefficient of 0.87, and an Intersection over union (IoU) of 0.78. Swin Transformer models are promising for semantically segmenting echocardiographic images and may help assist cardiologists in automatically analyzing and measuring complex echocardiographic images.

Impact of an Exercise-Based Cardiac Rehabilitation Program on Cardiopulmonary Test Parameters.

INTRODUCTION: Exercise-based cardiac rehabilitation programs (CRPs) represent a multidisciplinary therapeutic approach tailored to improve cardiorespiratory fitness and overall health-related quality of life, while reducing cardiovascular hospitalizations and mortality. Our aim was to determine changes in exercise capacity and cardiac events according to the left ventricular ejection fraction (LVEF) following a CRP. METHODS: This single-center cohort study included 131 patients who completed a center-based CRP from 2015 to 2022. Cardiopulmonary exercise testing (CPET), transthoracic echocardiography, and laboratory analysis were performed before and after program completion. RESULTS: Of 232 enrolled patients, 131 were included in our cohort analysis, with 36.6% having a reduced LVEF. These patients exhibited higher rates of atrial fibrillation (p = 0.019) and NT-proBNP values (p < 0.001). Patients with reduced LVEF had lower peak VO2 (pVO2) (p = 0.046), percentage of predicted oxygen consumption (ppVO2) (p < 0.001), and VO2 at anaerobic threshold (p = 0.015) during baseline CPET. Completion of the CRP led to comparable improvements in exercise performance between groups, assessed through Δ pVO2 (p = 0.990), Δ ppVO2 (p = 0.610), and Δ VE/VCO2 slope (p = 0.200). In the study population, male gender and hypertension independently predicted variation in VE/VCO2 slope (p = 0.017) and oxygen uptake efficiency slope (p = 0.048), respectively, post-CRP. During follow-up, 9.2% of all patients had hospital admissions for cardiac events, and 3.8% died, with no significant differences between groups. CONCLUSION: Patients with reduced LVEF admitted to our CRP showed lower functional status based on specific CPET parameters. After CRP, both reduced and preserved LVEF groups experienced similar functional improvements. Therefore, strategies to increase participation of patients with reduced LVEF in such programs are warranted.

Serial evaluation of biventricular function in COVID-19 recovered patients using speckle tracking echocardiography.

OBJECTIVES: The persistence and outcomes following myocardial injury subsequent to coronavirus disease-2019 (COVID-19) infection has not been properly elucidated. We assessed sub-clinical bi-ventricular dysfunction using speckle tracking echocardiography (STE) in post COVID-19 patients. METHODS: A total of 189 subjects following recovery from COVID-19 infection were enrolled. Detailed echocardiography including STE along with clinical, hematological, biochemical and inflammatory parameters were assessed for all. Patients were divided into four groups (asymptomatic, mild, moderate and severe) based on severity of COVID-19 infection. Additionally, 90 healthy individuals were enrolled as controls. All these patients were followed up for one year following enrolment. RESULTS: Subclinical LV and right ventricle (RV) dysfunction were seen in 58 (30.7 %) and 55 (29.1 %) patients respectively at baseline. Significant difference was observed in mean LVGLS values among the three groups (mild: -21.5 ± 2.8 %; moderate: -17 ± 7.1 %; severe: -12.1 ± 4 %; P < 0.0001). Over a year of follow-up, significant improvement in LVGLS from baseline (-19.1 ± 5.8 %) was observed (-19.9 ± 4.6 %; P < 0.0001). Similarly, RVFWS (-23.5 ± 6.3 % vs -23.8 ± 5.8 %; P = 0.03) had significant improvement from baseline to one year of follow-up. Reduced LVGLS was reported in 12 (6.3 %) subjects while impaired RVFWS was documented in 10 (5.3 %) subjects at one year of follow-up. CONCLUSIONS: Subclinical LV and RV dysfunction were seen in nearly a third of recovered COVID-19 patients. Over a year of follow-up, significant improvement in subclinical LV and RV dysfunction was noted.

Post-Myocardial Infarction (MI) Left Ventricular Free Wall Rupture Managed Conservatively.

Left ventricular free wall rupture (LVFWR) is an uncommon but often fatal complication of acute myocardial infarction. LVFWR is managed with hemodynamic stabilization and is typically followed by surgical intervention with varying approaches depending on the type of LVFWR. A 78-year-old male with a history of coronary artery bypass graft (CABG) was admitted with ST-segment elevation myocardial infarction. Left heart catheterization showed complete occlusion of the saphenous vein graft to the 1st obtuse marginal artery. The patient was not a candidate for percutaneous coronary intervention or CABG. The patient later developed atrial fibrillation with a rapid ventricular response which was managed with beta blockers. Computed tomography pulmonary angiogram was done to rule out pulmonary embolus; however, it demonstrated findings of a lateral LVFWR. The patient was deemed a poor surgical candidate for cardiothoracic surgery, and the LVFWR was managed conservatively with metoprolol succinate and bed rest. He later required amiodarone and direct current cardioversion due to the recurrence of atrial fibrillation. Two months following the LVFWR, the patient remained stable with no apparent complications. In a certain subset of LVFWR patients, surgical management may not be possible given patient anatomy and other high-risk factors. In these cases, conservative management with bed rest and beta blockers and treatment of ventricular and atrial arrhythmias may be a viable therapeutic option.