Calcified left ventricular apical aneurysm with intramural thrombus: a case report.

Background: Left ventricular aneurysms (LVAs) are a well-appreciated complication of acute myocardial infarction. Ventricular aneurysms involving the left ventricle (LV) typically evolve as a result of anterior myocardial infarction and are associated with greater morbidity, complication rates, and hospital resource utilization. Incidence of LVA is decreasing with advent of modern reperfusion therapies; however, in the setting of excess morbidity, clinicians must maintain an appreciation for their appearance to allow timely diagnosis and individualized care. Case summary: This case report describes the clinical history, investigation, appearance, and management of a patient with calcified apical LVA with history of previous anterior ST-elevation myocardial infarction. The patient was initially admitted for elective coronary angiography in the setting of worsening exertional dyspnoea and subsequently underwent coronary artery bypass graft, aneurysm resection, and LV reconstruction. Discussion: Left ventricular aneurysms are an uncommon complication experienced in the modern era of acute myocardial infarction and current reperfusion therapies, but remain an important cause of excess morbidity and complication. Evidence-based guidelines for the diagnosis, workup, and subsequent management of LVAs are lacking. The imaging findings presented in this case serve as an important reminder of the appearance of LVAs so that timely diagnosis and individualized care considerations can be made.

Pericardial decompression syndrome with acute right ventricular failure: a case series.

Background: Pericardial decompression syndrome (PDS) is an uncommon complication of pericardial drainage of large pericardial effusions and cardiac tamponade characterized by paradoxical haemodynamic instability following drainage. Pericardial decompression syndrome may occur immediately, or in the days following pericardial decompression, and presents with signs and symptoms suggestive of uni-/biventricular failure or acute pulmonary oedema. Case summary: This series describes two cases of this syndrome which demonstrates acute right ventricular failure as a mechanism of PDS and provides insights into the echocardiographic findings and clinical course of this poorly understood syndrome. Case 1 describes a patient who underwent pericardiocentesis, whilst Case 2 describes a patient who underwent surgical pericardiostomy. In both patients, acute right ventricular failure was observed following the release of tamponade and is favoured to be the cause of haemodynamic instability. Discussion: Pericardial decompression syndrome is a poorly understood, likely underreported complication of pericardial drainage for cardiac tamponade associated with high morbidity and mortality. Whilst a number of hypotheses exist as to the aetiology of PDS, this case series supports haemodynamic compromise being secondary to left ventricular compression following acute right ventricular dilatation.

The role of imaging in pulmonary hypertension.

Pulmonary hypertension (PH) is a debilitating and potentially life threatening condition in which increased pressure in the pulmonary arteries may result from a variety of pathological processes. These can include disease primarily involving the pulmonary vasculature, but more commonly PH may result from left-sided heart disease, including valvular heart disease. Chronic thromboembolic pulmonary hypertension (CTEPH) is an important disease to identify because it may be amenable to surgical pulmonary artery endarterectomy or balloon pulmonary angioplasty. Parenchymal lung diseases are also widespread in the community. Any of these disease processes may result in adverse remodeling of the right ventricle and progressive right heart (RH) failure as a common final pathway. Because of the breadth of pathological processes which cause PH, multiple imaging modalities play vital roles in ensuring accurate diagnosis and classification, which will lead to application of the most appropriate therapy. Multimodality imaging may also provide important prognostic information and has a role in the assessment of response to therapies which ultimately dictate clinical outcomes. This review provides an overview of the wide variety of established imaging techniques currently in use, but also examines many of the novel imaging techniques which may be increasingly utilized in the future to guide comprehensive care of patients with PH.

Reduced Exercise Capacity in Diabetes Mellitus Is Not Associated with Impaired Deformation or Twist.

BACKGROUND: Exercise capacity is frequently reduced in people with diabetes mellitus (DM) and may be due to subclinical cardiac dysfunction. Speckle-tracking echocardiography is now widely available; however, the clinical utility and significance of left ventricular (LV) strain and twist parameters remain uncertain. We hypothesized that LV strain and twist would be reduced in DM subjects during exercise. METHODS: Adults with type 1 or type 2 DM and age- and sex-matched controls performed cardiopulmonary exercise testing (VO2 peak) and supine bicycle exercise echocardiography. Detailed echocardiographic assessment of biventricular function was performed at baseline and repeated during incremental exercise to maximal intensity. RESULTS: Of the 60 participants completing the study protocol, 51 (34 DM, 17 controls; mean age, 42 ± 13 years; 69% male; DM duration, 16 ± 10 years) had sufficient image quality to assess LV deformation and twist mechanics at rest. Of these, 38 (25 DM, 13 controls) were able to be assessed immediately after exercise. Baseline LV systolic and diastolic function using standard echocardiography measurements were similar between groups. Resting LV global longitudinal strain, twist, twist rate and untwist rate, and the corresponding peak exercise and reserve measures did not differ significantly. As compared with the control subjects, exercise capacity was reduced in the DM cohort (VO2 peak 33 ± 10 vs 41 ± 12 mL/minute/kg; P = .02); however, no correlation was observed between VO2 peak and LV twist reserve (R = 0.28, P = .09), LV twist rate reserve (R = 0.14, P = .39), or LV untwist rate reserve (R = 0.24, P = .14). CONCLUSIONS: Despite reduced VO2 peak, LV twist mechanics at rest and after maximal intensity exercise did not differ significantly in a cohort of asymptomatic DM subjects with normal resting LV systolic and diastolic function compared with age- and sex-matched controls. This would suggest that exercise capacity can be reduced in the absence of subclinical cardiac dysfunction and that noncardiac factors should be considered as alternative explanations.

An Unusual Case of Shock Following an Elective Caesarean Delivery.

BACKGROUND: The differential diagnosis of peripartum chest pain and cardiogenic shock is broad and includes pulmonary embolism, amniotic fluid embolism, peripartum and Takotsubo cardiomyopathy, myocardial infarction, and anaesthetic complications. CASE: A 31-year-old woman with Addison's disease underwent an elective caesarean section that was complicated by chest pain and cardiogenic shock. After initial resuscitation, she was transferred to a tertiary hospital, and urgent transthoracic echocardiography revealed severe systolic dysfunction. She was treated with an increased dose of hydrocortisone and intravenous furosemide and improved. Follow-up imaging showed improvement of left ventricular systolic function. CONCLUSION: In patients with cardiogenic shock after delivery, early transthoracic echocardiography is a non-invasive tool that can rapidly narrow the differential diagnosis.

Echocardiographic Assessment of the Right Ventricle-State of the Art.

Assessment of right ventricular (RV) structure and function by echocardiography has largely been qualitative in the past. More recent approaches emphasise the quantification of RV structure from multiple echocardiographic views and quantification of multiple parameters of RV function. Current echocardiographic examinations should include at least two quantitative measures of RV function. This paper will highlight commonly used measures along with their strengths and weaknesses. With further technical developments in three-dimensional and myocardial deformation imaging and as more outcome data become available it is likely that further quantitative assessment will become routine and be used to guide diagnosis and treatment choices.

Sildenafil enhances central hemodynamic responses to exercise, but not V̇o2peak, in people with diabetes mellitus.

Exercise capacity is frequently reduced in people with diabetes mellitus (DM), and the contribution of pulmonary microvascular dysfunction remains undefined. We hypothesized that pulmonary microvascular disease, measured by a novel exercise echocardiography technique termed pulmonary transit of agitated contrast (PTAC), would be greater in subjects with DM and that the use of pulmonary vasodilator agent sildenafil would improve exercise performance by reducing right ventricular afterload. Forty subjects with DM and 20 matched controls performed cardiopulmonary exercise testing and semisupine exercise echocardiography 1 h after placebo or sildenafil ingestion in a double-blind randomized crossover design. The primary efficacy end point was exercise capacity (V̇o2peak) while secondary measures included pulmonary vascular resistance, cardiac output, and change in PTAC. DM subjects were aged 44 ± 13 yr, 73% male, with 16 ± 10 yr DM history. Sildenafil caused marginal improvements in echocardiographic measures of biventricular systolic function in DM subjects. Exercise-induced increases in pulmonary artery systolic pressure and pulmonary vascular resistance were attenuated with sildenafil, while heart rate (+2.4 ±1.2 beats/min, P = 0.04) and cardiac output (+322 ± 21 ml, P = 0.03) improved. However, the degree of PTAC did not change (P = 0.93) and V̇o2peak did not increase following sildenafil as compared with placebo (V̇o2peak: 31.8 ± 9.7 vs. 32.1 ± 9.5 ml·min-1·kg-1, P = 0.42). We conclude that sildenafil administration causes modest acute improvements in central hemodynamics but does not improve exercise capacity. This may be due to the mismatch in action of sildenafil on the pulmonary arteries rather than the distal pulmonary microvasculature and potential adverse effects on peripheral oxygen extraction. NEW & NOTEWORTHY This is one of the largest and most comprehensive studies of cardiopulmonary exercise performance in people with diabetes mellitus and to our knowledge the first to assess the effect of sildenafil using detailed echocardiographic measures during incremental exercise. Sildenafil attenuated the rise in pulmonary vascular resistance while augmenting cardiac output and intriguingly heart rate, without conferring any improvement in exercise capacity. The enhanced central hemodynamic indexes may have been offset by reduced peripheral O2 extraction.

Measurement of microvascular function in patients presenting with thrombolysis for ST elevation myocardial infarction, and PCI for non-ST elevation myocardial infarction.

BACKGROUND: In this prospective study, we compared the invasive measures of microvascular function in two subsets: patients with pharmacoinvasive thrombolysis for STEMI, and patients undergoing percutaneous coronary intervention (PCI) for NSTEMI. METHODS: The study consisted of 17 patients with STEMI referred for cardiac catheterisation post thrombolysis, and 20 patients with NSTEMI. Coronary physiological indexes were measured in each patient before and after PCI. RESULTS: The median pre-PCI index of microcirculatory function (IMR) at baseline was significantly higher in the STEMI group than the NSTEMI group (26 units vs. 15 units, p = 0.02). Following PCI, IMR decreased in both groups (STEMI 20 units vs. NSTEMI 14 units, p = 0.10). There was an inverse correlation between post PCI IMR and left ventricular ejection fraction (LVEF) (r = -0.52, p = 0.001). Furthermore, post PCI IMR was an independent predictor of index admission LVEF in the total population (ß = -0.388, p = 0.02). CONCLUSION: Invasive measures of microvascular function are inferior in a pharmacoinvasive STEMI group compared to a clinically stable NSTEMI group. In the STEMI population, the IMR following coronary intervention appears to predict LVEF.

Exercise capacity in diabetes mellitus is predicted by activity status and cardiac size rather than cardiac function: a case control study.

BACKGROUND: The reasons for reduced exercise capacity in diabetes mellitus (DM) remains incompletely understood, although diastolic dysfunction and diabetic cardiomyopathy are often favored explanations. However, there is a paucity of literature detailing cardiac function and reserve during incremental exercise to evaluate its significance and contribution. We sought to determine associations between comprehensive measures of cardiac function during exercise and maximal oxygen consumption ([Formula: see text]peak), with the hypothesis that the reduction in exercise capacity and cardiac function would be associated with co-morbidities and sedentary behavior rather than diabetes itself. METHODS: This case-control study involved 60 subjects [20 with type 1 DM (T1DM), 20 T2DM, and 10 healthy controls age/sex-matched to each diabetes subtype] performing cardiopulmonary exercise testing and bicycle ergometer echocardiography studies. Measures of biventricular function were assessed during incremental exercise to maximal intensity. RESULTS: T2DM subjects were middle-aged (52 ± 11 years) with a mean T2DM diagnosis of 12 ± 7 years and modest glycemic control (HbA1c 57 ± 12 mmol/mol). T1DM participants were younger (35 ± 8 years), with a 19 ± 10 year history of T1DM and suboptimal glycemic control (HbA1c 65 ± 16 mmol/mol). Participants with T2DM were heavier than their controls (body mass index 29.3 ± 3.4 kg/m2 vs. 24.7 ± 2.9, P = 0.001), performed less exercise (10 ± 12 vs. 28 ± 30 MET hours/week, P = 0.031) and had lower exercise capacity ([Formula: see text]peak = 26 ± 6 vs. 38 ± 8 ml/min/kg, P < 0.0001). These differences were not associated with biventricular systolic or left ventricular (LV) diastolic dysfunction at rest or during exercise. There was no difference in weight, exercise participation or [Formula: see text]peak in T1DM subjects as compared to their controls. After accounting for age, sex and body surface area in a multivariate analysis, significant positive predictors of [Formula: see text]peak were cardiac size (LV end-diastolic volume, LVEDV) and estimated MET-hours, while T2DM was a negative predictor. These combined factors accounted for 80% of the variance in [Formula: see text]peak (P < 0.0001). CONCLUSIONS: Exercise capacity is reduced in T2DM subjects relative to matched controls, whereas exercise capacity is preserved in T1DM. There was no evidence of sub-clinical cardiac dysfunction but, rather, there was an association between impaired exercise capacity, small LV volumes and sedentary behavior.

Diagnosis and Significance of Pulmonary Microvascular Disease in Diabetes.

OBJECTIVE: To determine whether pulmonary microvascular disease is detectable in subjects with diabetes and associated with diminished exercise capacity using a novel echocardiographic marker quantifying the pulmonary transit of agitated contrast bubbles (PTAC). RESEARCH DESIGN AND METHODS: Sixty participants (40 with diabetes and 20 control subjects) performed cardiopulmonary (maximal oxygen consumption [VO2peak]) and semisupine bicycle echocardiography exercise tests within a 1-week period. Pulmonary microvascular disease was assessed using PTAC (the number of bubbles traversing the pulmonary circulation to reach the left ventricle, categorized as low PTAC or high PTAC). Echocardiographic measures of cardiac output, pulmonary artery pressures, and biventricular function were obtained during exercise. RESULTS: Subjects with diabetes and control subjects were of similar age (44 ± 13 vs. 43 ± 13 years, P = 0.87) and sex composition (70% vs. 65% male, P = 0.7). At peak exercise, low PTAC was present in more participants with diabetes than control subjects (41% vs. 12.5%, χ2P = 0.041) and, in particular, in more subjects with diabetes with microvascular complications compared with both those without complications and control subjects (55% vs. 26% vs. 13%, χ2P = 0.02). When compared with high PTAC, low PTAC was associated with a 24% lower VO2peak (P = 0.006), reduced right ventricular function (P = 0.015), and greater pulmonary artery pressures during exercise (P = 0.02). CONCLUSIONS: PTAC is reduced in diabetes, particularly in the presence of microvascular pathology in other vascular beds, suggesting that it may be a meaningful indicator of pulmonary microvascular disease with important consequences for cardiovascular function and exercise capacity.

Systemic Mastocytosis, Kounis Syndrome and Coronary Intervention: Case Report and Systematic Review.

A 72-year-old male reported a long-standing history of unexplained syncope. Stress echocardiography demonstrated inducible anterior hypokinesis, and he proceeded to percutaneous coronary intervention for an 80% stenosis of the left anterior descending artery. Thirty minutes post-procedure, he experienced a pulseless electrical activity (PEA) cardiac arrest. Urgent repeat angiography demonstrated profound coronary artery spasm consistent with Kounis syndrome. Three days later, a second PEA arrest occurred. Systemic mastocytosis was ultimately diagnosed as the cause of his recurrent syncopal episodes and cardiac arrests. Our patient was discharged 56days after his cardiac arrest on appropriate immunotherapy, and has made an excellent event-free recovery. Systemic mastocytosis is the pathological accumulation of mast cells in organs, and it may cause life-threatening syncope and cardiac arrests. It is estimated to affect up to 1 in 10,000 people, however is often underdiagnosed. No previous reviews have examined cardiac manifestations of systemic mastocytosis. We undertook a structured systematic review of cardiac presentations of systemic mastocytosis in adults, screening 619 publications. Twenty-three cases met inclusion criteria; our review suggests that short-term mortality is high (22%), and patients with cardiac presentations are predominantly male (83%). Unexplained cardiac arrest (26%) may be the first presentation of this haematological disorder. From our review of the literature, we have also derived suggested management approaches for cardiologists encountering or suspecting systemic mastocytosis in a variety of clinical scenarios.

The Index of Microcirculatory Resistance Postpercutaneous Coronary Intervention Predicts Left Ventricular Recovery in Patients With Thrombolyzed ST-Segment Elevation Myocardial Infarction.

BACKGROUND: The index of microcirculatory resistance (IMR), an invasive measure of microvascular function, has been shown to correlate with clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI). The aim of this study is to evaluate the predictive value of IMR on left ventricular recovery in patients undergoing a pharmacoinvasive strategy for STEMI. METHODS: The index of microcirculatory resistance was assessed following percutaneous coronary intervention (PCI) in 31 patients with STEMI who were initially managed with thrombolysis. Other markers of microvascular function such as coronary flow reserve (CFR), TIMI flow grade, corrected TIMI frame count (cTFC), and ST-segment resolution were also recorded. All indices were evaluated against measures of left ventricular function and recovery 3 months postindex event. RESULTS: The IMR correlated with left ventricular function, as assessed by wall motion score and ejection fraction at 3-month follow-up (r = 0.652, P = 0.005; r = -0.452, P = 0.011, respectively). The traditional methods of assessing microvascular function, such as CFR, TIMI flow grade, cTFC, and ST-segment resolution did not correlate with wall motion score and ejection fraction at 3 months. Post-PCI IMR was significantly lower in those patients with left ventricular recovery at 3 months (18 U vs 39 U, P < 0.001). The optimal cut-off value for post-PCI IMR and left ventricular recovery was 32 U. In patients in whom the IMR was greater than 32 U, the percent change in ejection fraction was significantly lower than in those patients in whom the IMR was less than 32 U (2 ± 11 vs 12 ± 8, P = 0.012). CONCLUSIONS: In patients presenting with STEMI initially managed with thrombolysis and subsequently undergoing PCI, IMR correlates with measures of left ventricular function and has the potential to predict left ventricular recovery at 3 months.

Abnormal right ventricular relaxation in pulmonary hypertension.

Left ventricular diastolic dysfunction is a well-described complication of systemic hypertension. However, less is known regarding the effect of chronic pressure overload on right ventricular (RV) diastolic function. We hypothesized that pulmonary hypertension (PHT) is associated with abnormal RV early relaxation and that this would be best shown by invasive pressure measurement. Twenty-five patients undergoing right heart catheterization for investigation of breathlessness and/or suspected PHT were studied. In addition to standard measurements, RV pressure was sampled with a high-fidelity micromanometer, and RV pressure/time curves were analyzed. Patients were divided into a PHT group and a non-PHT group on the basis of a derived mean pulmonary artery systolic pressure of 25 mmHg. Eleven patients were classified to the PHT group. This group had significantly higher RV minimum diastolic pressure ([Formula: see text] vs. [Formula: see text] mmHg, [Formula: see text]) and RV end-diastolic pressure (RVEDP; [Formula: see text] vs. [Formula: see text] mmHg, [Formula: see text]), and RV τ was significantly prolonged ([Formula: see text] vs. [Formula: see text] ms, [Formula: see text]). There were strong correlations between RV τ and RV minimum diastolic pressure ([Formula: see text], [Formula: see text]) and between RV τ and RVEDP ([Formula: see text], [Formula: see text]). There was a trend toward increased RV contractility (end-systolic elastance) in the PHT group ([Formula: see text] vs. [Formula: see text] mmHg/mL, [Formula: see text]) and a correlation between RV systolic pressure and first derivative of maximum pressure change ([Formula: see text], [Formula: see text]). Stroke volumes were similar. Invasive measures of RV early relaxation are abnormal in patients with PHT, whereas measured contractility is static or increasing, which suggests that diastolic dysfunction may precede systolic dysfunction. Furthermore, there is a strong association between measures of RV relaxation and RV filling pressures.

Acute myocardial infarction due to coronary artery embolus associated with atrial fibrillation.

Coronary artery embolus is a rare and potentially under- recognised cause of acute myocardial infarction. We describe the case of an 80-year-old woman presenting with an acute coronary syndrome secondary to coronary artery embolus associated with atrial fibrillation, which was successfully treated with the use of a thrombectomy aspiration catheter.

Impact of right atrial pressure on decision-making using fractional flow reserve (FFR) in elective percutaneous intervention.

BACKGROUND: We undertook a prospective study to assess the impact of routine incorporation of right atrial pressure into the calculation of FFR in a real world elective PCI cohort. METHODS: 42 patients with stenoses in 2 separate epicardial vessels at coronary angiography were studied. Using a temperature and pressure sensing guidewire (TPSG) FFR and FFRRAP were performed in the target vessel pre and post PCI and in a non-target vessel. FFR was defined as Pd/Pa, FFRRAP as Pd-Pv/Pa-Pv where Pv was right atrial pressure and Pd/Pa were the hyperemic distal and proximal arterial pressures respectively. RESULTS: Mean RAP was 9.1 ± 0.7 mmHg. Mean FFR was significantly lower when RAP was included in the calculation (FFRRAP 0.77 ± 0.19 vs. FFR 0.80 ± 0.16, p<0.001). In the target vessel pre PCI, incorporating RAP into the calculation of FFR resulted in a significant difference in the FFR value (FFR Pre-PCI 0.69 ± 0.02 vs. FFRRAP Pre-PCI 0.63 ± 0.03, p<0.0001). 21 patients had an FFR ≤ 0.8 in the group. If right atrial pressure were utilized to calculate FFR prior to PCI, an additional 9 patients would have been re-categorised to an FFR ≤ 0.8. Following PCI, mean FFR was lower when RAP was incorporated (Post PCI FFRRAP 0.93±0.05 vs. Post PCI FFR 0.95 ± 0.06, p<0.001). CONCLUSION: Incorporation of right atrial pressure into the calculation of FFR significantly alters FFR values and may potentially reclassify lesions below ischaemic thresholds.

The index of microvascular resistance identifies patients with periprocedural myocardial infarction in elective percutaneous coronary intervention.

BACKGROUND: This study was designed to assess whether measurement of the index of microvascular resistance (IMR) could help prospectively identify patients who develop periprocedural myocardial infarction (PPMI). METHODS AND RESULTS: IMR was measured in 54 patients before and following percutaneous coronary intervention (PCI) in a culprit vessel with a PressureWire using the equation IMR = Pa(Hyp) × Tmn(Hyp) (Pd(Hyp)-Pw/Pa(Hyp)-Pw). IMR was also measured in an angiographically normal reference vessel. The relative pre-IMR ratio (rPIMR) defined as IMR Culprit divided by IMR Non-Culprit was also calculated. Troponin was sequentially sampled up to 24 h following PCI. Mean troponin post-PCI was 0.37±0.8 ng/ml. 33 (61%) patients fulfilled the criteria for PPMI. IMR pre-PCI was the most significant correlate of post-PCI troponin (r=0.43 p=0.001), however, the number of balloon inflations (r=0.3, p=0.02) and rPIMR (r=0.33 p=0.017) were also correlated. IMR pre-PCI was higher in patients with periprocedural myocardial infarction compared with patients without PPMI (IMR pre-PCI 21.2±2.1 PPMI vs 15.6±1.8 No PPMI, p=0.02). The strongest predictor of troponin post-PCI was IMR pre-PCI (ß 0.7, p=0.02). Both IMR pre- and rPIMR were predictive of PPMI (OR 11 (1.3 to 90.5) p=0.026, OR 1.09 (1 to 1.19) p=0.03, respectively). CONCLUSION: Microvascular function prior to PCI is an important determinant of PPMI. Measuring IMR pre-PCI and rPIMR may allow prospective identification of patients at risk of periprocedural myocardial infarction. Future studies in a larger cohort are required to establish the predictive ability of IMR in PPMI.

Successful application of a PressureWire retrogradely across an ATS prosthetic aortic valve to diagnose constrictive pericarditis.

Assessment of the left ventricular pressure measured across an aortic valve prosthesis is occasionally necessary when noninvasive imaging and Doppler echocardiographic data are inconclusive or differ from the clinical findings for specific scenarios, such as diagnosing constrictive or restrictive physiology. We present a case in which we safely and effectively replicate the previous successful application of a PressureWire in diagnosing constrictive pericarditis in a patient with a bileafltet mechanical aortic and mitral valves.