A curious Takotsubo cardiomyopathy after COVID-19.

We present the case of a 66-year-old woman undergoing chronic dialysis who developed pneumonia and enteritis after being infected with COVID-19 and had severe wall motion reduction similar to a left ventricular aneurysm. There was concern that the condition might worsen due to left ventricular wall thinning and curious wall motion abnormalities, but echocardiography one month later showed normalization. After four months, simultaneous binuclear myocardial scintigraphy of thallium and BMIPP showed that the mismatch had disappeared. We considered that there may be other factors specific to COVID-19 infection in addition to the stress associated with infection and reviewed the literature.

Successful conservative treatment for left ventricular free wall rupture after acute myocardial infarction.

Left ventricular free wall rupture (LVFWR) is a rare but fatal complication of acute myocardial infarction (AMI). An 81-year-old female patient with several cardiovascular risk factors presented to the emergency department with symptoms of developing a chronic stomachache and cold sweat. An echocardiograph showed wall motion abnormalities from the lateral to posterior wall, as well as pericardial effusion containing clots of up to 17 mm in the posterior wall that indicated LVFWR after AMI. Although she was conscious after being brought to the initial care unit, she suddenly lost consciousness and fell into electromechanical dissociation (EMD). Endotracheal intubation was immediately initiated and her pericardial drainage and intra aortic balloon pump (IABP) placement, and hemodynamics recovered. Although she had 100% obstruction in the left circumflex artery (LCX) #12 on coronary angiography (CAG), she was discharged to the Intensive Care Unit (ICU) without percutaneous coronary intervention (PCI). Conservative treatment such as intubation, sedation, pericardiocentesis and strict blood pressure management as well as treatment by IABP long-term support led to the patient being uneventfully discharged after 60 days.

The impact that myocarditis for post-acute COVID-19 syndrome may be dermatomyositis-like myocarditis: A case report.

Myocarditis is often reported as a complication of COVID-19 infection or post-vaccination, but there are few reports of "myocarditis for Post-acute COVID-19 syndrome", and many unknowns still remain. Apart from that, an association between COVID-19 infection and dermatomyositis has also been reported. We describe the clinical presentation of acute myocarditis in a patient who had developed COVID-19 syndrome one-month earlier. A healthy 49-year-old man experienced typical COVID-19 symptoms. Thirty-two days later, he was admitted because of fever and severe fatigue, chest pain and bradycardia. Blood tests showed major inflammation. PCR for SARS-CoV-2 on nasopharyngeal swab (ID NOW™) was positive, but diagnosed as a previous infection due to a high CT value. Because of haemodynamic worsening with both an increase in cardiac troponin I and NT-pro BNP levels and reduced wall motion on echocardiography, acute myocarditis was suspected. Myocardial biopsy revealed severe lymphocytic infiltration and interstitial edema between myocardial fibers. These findings led to the diagnosis of fulminant myocarditis. Interestingly, myocardium was also stained with human myxovirus resistance protein 1 (MxA). We consider that there may be an aspect of "dermatomyositis-like myocarditis with SARS-CoV-2" in our case. This is the first case of fulminant myocarditis for Post-acute COVID-19 syndrome in which diagnosis of active myocarditis was proven by pathological examination following myocardial biopsy and strong association with dermatomyositis was suggested pathologically.

With M-protein positive, could transthyretin amyrodosis be easily excluded? Not necessarily! Wild-type transthyretin amyrodosis with Waldenström's macroglobulinaemia: a case report.

Background: Generally, it is said that amyloid light-chain (AL) develops not only in multiple myeloma but also in Waldenström's macroglobulinemia. We experienced a case of M-protein positive and diagnosed as wild-type transthyretin amyrodosis (ATTRwt) accompanied with Waldenström's macroglobulinemia. Case summary: The patient was 72-year-old male, and the main complaint was dyspnoea in April 2020 and visited a nearby doctor. He was introduced to the Department of Haematology at our hospital for high levels of serum immunoglobulin M, M-protein positivity, and cardiac hypertrophy with a suspect of AL amyloidosis. Duodenal mucosal biopsy and abdominal skin biopsy showed no amyloid deposits, and left iliac bone marrow biopsy diagnosed Waldenström's macroglobulinemia and with no amyloid, and Kumamoto criteria score 1. Last of all, ATTRwt was diagnosed for endocardial biopsy. Discussion: This is a very rare case of ATTRwt with Waldenström's macroglobulinaemia.

A case in which SGLT2 inhibitor is a contributing factor to takotsubo cardiomyopathy and heart failure.

SGLT2 inhibitors are reported to have advantages in protecting against heart failure events. However, there are also reports of concerns when given to older persons or persons with geriatric syndrome. Our case is an example of a patient with a history of chronic thyroiditis where the SGLT2 inhibitor triggered a thyroid crisis, and blood catecholamine overload caused takotsubo cardiomyopathy and heart failure. .

Non-Invasive Central Venous Pressure Measurement Using Enclosed-Zone Central Venous Pressure (ezCVPTM).

BACKGROUND: Central venous pressure (CVP) is measured to assess intravascular fluid status. Although the clinical gold standard for evaluating CVP is invasive measurement using catheterization, the use of catheterization is limited in a clinical setting because of its invasiveness. We developed novel non-invasive technique, enclosed-zone (ezCVPTM) measurement for estimating CVP. The purpose of this study was to assess the feasibility of ezCVP and the relationship between ezCVP and CVP measured by a catheter.Methods and Results:We conducted 291 measurements in 97 patients. Linear regression analysis revealed that ezCVP was significantly correlated with CVP (r=0.65, P<0.0001). The Bland-Altman analysis showed that ezCVP had an underestimation bias of -2.5 mmHg with 95% limits of agreement of -14.1 mmHg and 9.6 mmHg for CVP (P<0.0001). The areas under the curves of receiver operating curve with ezCVP to detect the CVP ≥12 cmH2O (8.8 mmHg) and CVP >10 mmHg were 0.81 or 0.88, respectively. The sensitivity, specificity and positive likelihood ratio of ezCVP for the CVP ≥8.8 mmHg and CVP >10 mmHg were 0.59, 0.96 and 14.8 with a cut-off value of 11.9 and 0.79, 0.97 and 26.3 with a cut-off value of 12.7. CONCLUSIONS: These findings suggest that ezCVP measurement is feasible and useful for assessing CVP.

Associations of left ventricular shape with left ventricular volumes and functions assessed by ECG-gated SPECT in patients without significant perfusion abnormality.

Left ventricular (LV) remodeling often results from conditions with an elevated LV hemodynamic load or after myocardial infarction. The present study was undertaken to investigate the associations of LV shape with LV volumes and functions in patients without significant perfusion abnormality. One hundred and sixty-seven patients without significant perfusion abnormality on ECG-gated SPECT were enrolled. LV ejection fraction (LVEF) was obtained for assessing LV systolic function. Peak filling rate (PFR) and one-third mean filling rate (1/3 MFR) were obtained for assessing LV diastolic function. LV shape index (LVSI) was defined as the ratio of the maximum three-dimensional short- and long-axis LV dimension, and varies from 0 (line) to 1 (sphere). There were 125 male and 42 female patients with a mean age of 70 ± 8 years. End-systolic LVSI was 0.49 ± 0.07 (0.34-0.65). End-systolic LVSI was associated with LV end-diastolic volume (r = 0.51, p < 0.001) and LV end-systolic volume (LVESV) (r = 0.64, p < 0.001), and was inversely associated with LVEF (r = - 0.69, p < 0.001), PFR (r = - 0.45, p < 0.001) and 1/3 MFR (r = - 0.26, p = 0.008). End-systolic LVSI was increased with increased LVESV, and was not any more with LVESV of > 40 ml. Multivariate liner regression analysis showed that age (ß = 0.16, p = 0.01), LVESV (ß = 0.20, p = 0.03) and LVEF (ß = - 0.53, p < 0.001) were significantly associated with end-systolic LVSI. Our data suggest that end-systolic LVSI, a measurement of LV shape, has close correlations with LV volumes and functions in patients without significant perfusion abnormality.

Diagnostic value of peak filling rate derived from ECG-gated myocardial perfusion SPECT for detecting myocardial ischaemia in patients with non-obstructive coronary artery disease.

Background: Left ventricular (LV) diastolic dysfunction represents an earlier step of the ischaemic cascade. We tested the hypothesis that the index of LV diastolic function from electrocardiogram (ECG)-gated single photon emission computed tomography (SPECT) is useful in detecting myocardial ischaemia in patients with non-obstructive coronary artery disease (CAD).Methods: One-hundred-ten patients with non-obstructive CAD and summed redistribution score of zero were enrolled. Summed difference score (SDS) of ≥2 was considered as the presence of myocardial ischaemia. Peak filling rate (PFR) defined as the maximum dV/dt divided by LV end-diastolic volume was obtained as the index of LV diastolic function.Results: Of 110 patients with non-obstructive CAD, 51 patients had myocardial ischaemia. SDSs in patients with myocardial ischaemia and those without were 3.5 ± 1.8 and 0.4 ± 0.5, respectively (p < 0.001). PFRs after stress (r = -0.22, p = 0.02) and at redistribution (r = -0.24, p = 0.01) were inversely correlated with SDS. Multivariate logistic regression analysis showed that PFR at redistribution was an independent predictor of the presence of myocardial ischaemia in patients with non-obstructive CAD (odds ratio: 0.15, 95% confidence interval: 0.04-0.51, p = 0.002).Conclusion: Our data suggest that PFR, the index of LV diastolic function from ECG-gated SPECT, helps to find myocardial ischaemia in patients with non-obstructive CAD.

Effects of Myocardial Perfusion Defect on the Frontal QRS-T Angle in Anterior Versus Inferior Myocardial Infarction.

Objective The frontal QRS-T angle on a 12-lead electrocardiogram (ECG) has recently become accepted as a variable of ventricular repolarization. We compared the effects of myocardial perfusion defect (MPD) on the frontal QRS-T angle between anterior and inferior myocardial infarction (MI) using single-photon emission computed tomography. Methods The frontal QRS-T angle was defined as the absolute value of the difference between the frontal plane QRS axis and T-wave axis. A QRS-T angle more than 90° was considered abnormal. Patients Forty-two patients with anterior MI and 42 age- and sex-matched patients with inferior MI were enrolled. For controls, 42 age- and sex-matched patients with no MPD were selected. Results The mean frontal QRS-T angles in anterior MI, inferior MI and control subjects were 94.7±46.2°, 26.7±22.1° and 27.0±23.2°, respectively. Compared with controls, the frontal QRS-T angle was larger in anterior MI subjects (p<0.001), and similar in value to that in inferior MI subjects (p=0.69). An abnormal QRS-T angle was frequent in the anterior MI subjects than the inferior MI subjects (55% vs. 2%, p<0.001). In anterior MI subjects, MPD was significantly associated with the T-wave axis (ρ=0.46, p=0.002) and QRS-T angle (ρ=0.47, p=0.002), but was not with the QRS axis (ρ=0.07, p=0.66). In inferior MI subjects, there were no associations between MPD and the ECG variables. Conclusion Our data suggest that the frontal QRS-T angle in inferior MI subjects is not increased as evidently as that in anterior MI subjects.

Delivery balloon rupture during transcatheter heart valve alignment procedure in extreme descending aorta tortuosity.

A 79-year-old man with a history of partial resection of the lung and the bladder due to cancer, hypertension, dyslipidemia, and heart failure, underwent transcatheter aortic valve replacement with a SAPIEN 3 (S3) valve (Edwards Lifesciences, Irvine, CA, USA). Preprocedural examination showed a bicuspid aortic valve and severe calcification of the leaflets. Computed tomography showed great tortuosity of the descending aorta. A 29-mm S3 valve prosthesis was advanced into the aorta, but a high degree of resistance was encountered in the middle of the descending aorta. The prosthesis was advanced to the level of aortic valve and an attempt was made to deploy the valve. However, the valve balloon did not expand. A balloon rupture was suspected. The balloon catheter was pulled back into the eSheath (Edwards Lifesciences), and the catheter and eSheath were removed together. Rupture of the balloon was confirmed. A new eSheath and prosthesis were prepared, with delivery supported with a Lunderquist guidewire (Cook Medical, Bloomington, IN, USA). The valve alignment procedure was performed in a straighter portion of the descending aorta. The new 29-mm S3 valve was then successfully implanted. .

Coronary Artery Calcium Is Associated with Left Ventricular Diastolic Function Independent of Myocardial Ischemia.

It has been shown in several studies that coronary artery calcium (CAC) burden or CAC progression is associated with heart failure. We tested the hypothesis that the extent of CAC is associated with left ventricular (LV) diastolic parameters derived from gated myocardial perfusion single-photon emission computed tomography (SPECT) in patients with no evidence of myocardial ischemia.157 patients undergoing coronary computed tomography (CT), gated SPECT, and transthoracic echocardiography (TTE) were enrolled in this study. The CAC score was calculated according to the Agatston method. The peak filling rate (PFR) and the one-third mean filling rate (1/3MFR) were obtained as LV diastolic parameters.There were 139 patients with CAC and 18 patients without. The CAC score ranged from 0 to 4,976. There were no significant differences in the LV end-diastolic volume (LVEDV) (61 ± 21 mL versus 62 ± 22 mL, P = 0.79) and LV ejection fraction (LVEF) (66 ± 9% versus 68 ± 9%, P = 0.43). Patients with CAC had lower PFR than those without (2.2 ± 0.5 EDV/s versus 2.6 ± 0.7 EDV/s, P = 0.03). Multivariate linear regression analysis showed that ln (CAC score + 1) was significantly associated with PFR (ß = -0.20, P = 0.01) and 1/3MFR (ß = -0.18, P = 0.049).Our data suggest that the extent of CAC is inversely associated with LV diastolic parameters derived from gated SPECT independent of myocardial ischemia.

Effects of deep inspiration on QRS axis, T-wave axis and frontal QRS-T angle in the routine electrocardiogram.

The frontal QRS-T angle on the electrocardiogram has been described as a variable of ventricular repolarization. We evaluated how deep inspiration affected QRS axis, T-wave axis and frontal QRS-T angle. We also assessed the effects on left ventricular volume on the association using myocardial perfusion SPECT. Fifty patients undergoing ECGs both in resting state and in deep inspiration and subsequent SPECT were enrolled. Frontal QRS-T angle was defined as the absolute value of the difference between the frontal QRS axis and T-wave axis. Change in frontal QRS-T angle was calculated using (QRS-T angle in deep inspiration-QRS-T angle in resting state). In resting state, QRS axis and T-wave axis were 20.9° ± 30.0° and 40.9° ± 36.1°, respectively. Frontal QRS-T angle was 35.9° ± 36.1°. Deep inspiration caused rightward shifts of QRS axis (42.3° ± 29.5°, p < 0.001) and T-wave axis (49.5° ± 39.7°, p < 0.001). However, deep inspiration did not affect frontal QRS-T angle (33.9° ± 35.8°, p = 0.44). Frontal QRS-T angle in deep inspiration had good correlation (r = 0.87, p < 0.001) and agreement with that in resting state. Left ventricular (LV) end-diastolic volume had a significant association with change in frontal QRS-T angle (r = 0.29, p = 0.04). Our data suggest that frontal QRS-T angle in deep inspiration has a good correlation with that in resting state, and the agreement is acceptable. In patients with dilated LV, QRS-T angle in deep inspiration may be susceptible to the overestimation.

Myocardial perfusion defect assessed by single-photon emission computed tomography and frontal QRS-T angle in patients with prior anterior myocardial infarction.

The frontal QRS-T angle is one of the markers of ventricular repolarization. We sought to assess the effects of myocardial perfusion defect on QRS-T angle in patients with prior anterior myocardial infarction (MI). Seventy-one patients with prior anterior MI and 71 age- and sex-matched control subjects having no myocardial perfusion defect were selected. Frontal QRS-T angle was defined as the absolute value of the difference between the frontal plane QRS axis and T-wave axis. The extent of myocardial perfusion defect was determined using myocardial perfusion single-photon emission computed tomography (SPECT). The extent of myocardial perfusion defect of patients with prior anterior MI was 21.8 ± 13.7%. Frontal QRS-T angle was significantly larger in patients with prior anterior MI than control subjects (82° ± 49° vs 30° ± 26°, p < 0.001). Prevalence of abnormal frontal QRS-T angle defined as more than 90° was significantly higher in patients with prior anterior MI than control subjects (42% vs 4%, p < 0.001). Multivariate linear regression analysis showed that age (ß=0.18, p = 0.02) and myocardial perfusion defect (ß = 0.46, p = 0.02) were independent determinants of frontal QRS-T angle. Our results suggest that the extent of myocardial perfusion defect is an independent determinant of frontal QRS-T angle in patients with prior anterior MI.

Frontal QRS-T angle and World Health Organization classification for body mass index.

BACKGROUND: The frontal QRS-T angle, defined as the absolute value of the difference between QRS axis and T-wave axis on 12­lead electrocardiogram (ECG), is the difference in orientation between ventricular depolarization and repolarization. We tested the hypothesis that QRS-T angle is affected by obesity. METHODS: A total of 177 patients undergoing both ECG and echocardiography within one month were recruited from outpatient clinic. Using the World Health Organization (WHO) classification of body mass index (BMI), the patients were classified into the four groups: underweight (<18.5 kg/m2, n = 25), normal weight (18.5-24.9 kg/m2, n = 79), overweight (25-29.9 kg/m2, n = 38) and obese (≥30 kg/m2, n = 35). RESULTS: Obese patients were significantly younger than those in other groups. As for echocardiographic variables, left ventricular internal dimension and left ventricular mass (LVM) increased with increased WHO classification of BMI. QRS axis and T-wave axis decreased with increased WHO classification of BMI, whereas QRS-T angle increased. Multivariate linear regression analysis showed that BMI (ß = 0.23, p = 0.01) and LVM (ß = 0.19, p = 0.046) were independent determinants of QRS-T angle. CONCLUSIONS: Our results suggest that BMI is an independent determinant of QRS-T angle.

Influenza infection presenting with pulmonary congestion: influenza myocarditis.

Influenza myocarditis is a rare but life-threatening complication of influenza infection. Pneumonitis is a well-known complication of influenza infection, and chest computed tomography (CT) is useful for diagnosing pneumonitis. In addition, myocarditis should be considered in cases of pulmonary congestion observed on chest CT.

Implications of electrocardiographic frontal QRS axis on left ventricular diastolic parameters derived from electrocardiogram-gated myocardial perfusion single photon emission computed tomography.

BACKGROUND: Current electrocardiographic (ECG) machines report various variables including frontal QRS axis automatically. We tested the hypothesis that QRS axis is associated with left ventricular (LV) diastolic parameters derived from ECG-gated myocardial perfusion single photon emission computed tomography (SPECT) independent of myocardial ischemia. METHODS: Ninety-three patients with preserved LV ejection fraction and no evidence of myocardial ischemia were enrolled based on ECG-gated SPECT. Peak filling rate (PFR), one-third mean filling rate (1/3 MFR) and time to peak filling (TTPF) were obtained as LV diastolic parameters. RESULTS: There were 82 male and 11 female patients with a mean age of 69 ± 9 years. QRS axis ranged from - 40° to 85° (36° ± 31°). QRS axis was correlated with PFR (r = 0.28, p < 0.01), 1/3 MFR (r = 0.25, p = 0.02) and TTPF (r = - 0.21, p = 0.04). QRS axis was also correlated with age (r = - 0.23, p = 0.03), body mass index (BMI) (r = - 0.36, p < 0.01) and LV mass index (LVMI) (r = - 0.27, p < 0.01). Linear regression analysis showed that QRS axis was associated with PFR, 1/3 MFR and TTPF for LV diastolic function, but was not associated with these LV diastolic parameters after adjustment of various confounders. CONCLUSIONS: Our data suggest that QRS axis depends on age, BMI or LVMI, and serves as a surrogate marker of LV diastolic function.

Effects of atrial fibrillation on myocardial washout rate of thallium-201 on myocardial perfusion single-photon emission computed tomography.

BACKGROUND: Myocardial perfusion single-photon emission computed tomography (SPECT) with thallium (Tl)-201 is an established modality for evaluating myocardial ischemia. We assessed the effects of atrial fibrillation (AF) on the myocardial washout rate (WR) of Tl-201 on myocardial perfusion SPECT. PATIENTS AND METHODS: A total of 231 patients with no evidence of myocardial ischemia were enrolled retrospectively in this study. Patients were divided into two groups on the basis of the ECG at the time of myocardial perfusion SPECT. The mean myocardial WR of Tl-201 was calculated from the stress and the redistribution Bull's eye maps. RESULTS: There were 34 patients with AF and 197 patients with sinus rhythm. There were no significant differences in clinical variables, except for older age and higher heart rate in patients with AF. Myocardial WR of Tl-201 was significantly lower in patients with AF than those with sinus rhythm (46±12 vs. 51±8%, P=0.03). Multivariate analysis including these factors showed that female sex (ß=0.18, P=0.02), AF (ß=-0.14 P=0.03), hemoglobin (ß=-0.18, P<0.01), and serum creatinine (ß=0.24, P<0.01) were determinants of myocardial WR of Tl-201. CONCLUSION: Our data suggest that AF is associated with reduced myocardial WR of Tl-201 on myocardial perfuison SPECT.

Effect of fibrillatory wave amplitude on coronary blood flow as assessed by thrombolysis in myocardial infarction frame count in patients with atrial fibrillation.

Atrial fibrillation (AF) is the most common arrhythmia, characterized by a lack of atrial contraction and an irregular ventricular rhythm. We assessed the effect of fibrillatory wave amplitude on coronary blood flow in patients with AF using the thrombolysis in myocardial infarction (TIMI) frame count. Sixty-one patients with AF persisting for longer than 30 days were included. For controls, 61 age- and sex-matched patients with sinus rhythm were selected. Coarse AF was defined as any fibrillatory wave ≥ 1 mm and fine AF as any fibrillatory wave < 1 mm. Mean TIMI frame count was significantly higher in patients with AF than in those with sinus rhythm (18 ± 4 vs 30 ± 11, p < 0.001). Multivariate analysis showed that AF was the only determinant of mean TIMI frame count (ß = 0.48, p < 0.001). Among patients with AF, 32 had coarse AF and 29 had fine AF. Left atrial volume index (54 ± 14 vs 64 ± 21 ml/m2, p = 0.03) was significantly larger, and mean TIMI frame count (26 ± 7 vs 35 ± 12, p < 0.001) was significantly higher in patients with fine AF than in those with coarse AF. Multivariate analysis showed that hypertension (ß = - 0.29, p = 0.01) and a fine fibrillatory wave (ß = 0.33, p = 0.007) were determinants of mean TIMI frame count. Our data suggest that coronary blood flow is reduced in patients with AF compared with those with sinus rhythm, and that a fine fibrillatory wave is a major determinant of reduced coronary blood flow in patients with AF.

Predictive value of plaque morphology assessed by frequency-domain optical coherence tomography for impaired microvascular perfusion after elective stent implantation: the intracoronary electrocardiogram study.

Aims: This study was undertaken to assess the association between plaque features at culprit lesions assessed by frequency-domain optical coherence tomography (FD-OCT) and impaired microvascular perfusion estimated by intracoronary electrocardiogram (IcECG) after elective percutaneous coronary intervention (PCI). Furthermore, we investigated whether IcECG could predict future cardiac events. Methods and results: This study consisted of 84 patients who underwent both FD-OCT and IcECG during PCI. Patients were classified into two groups based on ST-segment elevation (ST-E) on IcECG after the procedure; ST-E (-) group (n = 53) and ST-E (+) group (n = 31). Minimum fibrous cap thickness was significantly thinner in the ST-E (+) group than in the ST-E (-) group (240 µm [IQR 180 to 310] vs. 100 µm [IQR 60 to 120], P < 0.001). Plaque rupture (7.5% vs. 35.5%, P = 0.001), lipid-rich plaque (75.5% vs. 100%, P < 0.001), the thin cap fibroatheroma (0% vs. 25.8%, P < 0.001) on pre-FD-OCT, protrusion (18.9% vs. 56.7%, P < 0.001), and intra-stent dissection (15.1% vs. 50.0%, P < 0.001) on post-FD-OCT were significantly more frequently found in the ST-E (+) group than in the ST-E (-) group. The incidence of MACE (cardiac death, myocardial infarction, revascularization, hospitalization for heart failure) during 1-year was significantly higher in the ST-E (+) group than in the ST-E (-) group (5.7% vs. 19.4%, P < 0.05). Conclusion: Plaque features assessed by FD-OCT might be associated with impaired microvascular perfusion and ST-segment elevation on IcECG after the procedure could predict 1-year cardiac events after elective PCI.