P-wave voltage and peaking on electrocardiogram in patients undergoing head-up tilt testing for history of syncope.

BACKGROUND: Only scanty data are available in the literature on P-wave (PW) morphology at ECG in patients with history of vasovagal syncope undergoing diagnostic functional testing. In this study, we evaluated resting and head-up tilt testing (HUTT) related changes in PW voltage (PWV) and duration (PVD) and their relationship with triggered syncope. METHODS: 55 patients, mean aged 41 ± 19 y (35 F), without patent heart disease or neuropathy, underwent potentiated HUTT according to the Italian protocol. Heart rate (HR), blood pressure (BP), PR-interval, PWV and PWD were measured at rest, 15 min from passive position (15-min) and after nitroglycerine (peak-HR). PW peaking (PWP) was calculated as percent increase in PWV than baseline values. Patients were divided into 2 groups based on tilt-positive (group-A) or negative (group-B) response. RESULTS: 20 patients (36%) entered the group-A, whereas 35 (64%) the group-B. Higher PWV was observed at baseline in group-A (0.147 ± 0.034 mV vs 0.114 ± 0.036 mV in group-B, p=0.001), with no differences in the remaining ECG measurements. BP was lower in group-A than in B, both at 15-min and peak-HR. HUTT-related PWP in lead II (the most significant among all inferior leads) was 31 ± 30% in group-A vs 95 ± 54% in group-B (p<0.0001) at 15-min, and 52 ± 44% vs 112±72% at peak-HR, respectively (p=0.002). 75% of patients with PWP ≤ 50% experienced HUTT-triggered syncope, vs 5% of those with PWP ≥ 100% (p<0.0001). CONCLUSIONS: This study shows a potential relationship between HUTT-triggered syncope and low or absent PWP, suggesting a role for atrial chamber functional involvement in the mechanisms underlying the vasovagal syncope.

Detraining-related changes in left ventricular wall thickness and longitudinal strain in a young athlete likely to have hypertrophic cardiomyopathy.

One of the diagnostic criteria in order to differentiate between physiological and pathological left ventricular hypertrophy is the wall thickness reduction after at least 3-month detraining period, which is considered a marker of the athlete's heart. This report describes detraining-related regression of LV hypertrophy and improvement in myocardial deformation in a junior athlete likely to have hypertrophic cardiomyopathy. Key pointsHypertrophic cardiomyopathy in adolescent athletes can be discovered by 12-lead ECGPhysical training is an important trigger for the clinical presentation of hypertrophic cardiomyopathyReverse LV remodeling (wall thickness reduction) with detraining is a common echocardiographic finding in athletes with physiological hypertrophyThis report demonstrates that reverse remodeling can also be found in adolescent athletes likely to have hypertrophic cardiomyopathy.

Semiautomatic quantification of left ventricular function by two-dimensional feature tracking imaging echocardiography. A comparison study with cardiac magnetic resonance imaging.

OBJECTIVE: To evaluate the accuracy of a semiautomatic quantification of left ventricular (LV) volumes and ejection fraction (EF) using two-dimensional (2D) feature tracking imaging (FTI). METHODS: Thirty-four consecutive subjects (11 patients with dilated cardiomyopathy, 13 with hypertrophic cardiomyopathy, and 10 subjects with no cardiac disease) underwent, on the same day, trans-thoracic echocardiography (TTE) examination, FTI, and cardiac magnetic resonance imaging (MRI), as gold standard, in order to quantify LV volumes and EF. The echocardiographic quantification of LV volumes and EF was determined from four- and two-chamber views using both standard TTE Biplane Simpson's method and a semiautomatic border detection based on FTI. Furthermore, the time for data analysis for each method was measured. RESULTS: The time required for semiautomatic analysis of volumes and EF was significantly lower (P < 0.0001) by FTI (71 seconds) in comparison with standard biplane Simpson's method (93 seconds). LV volumes obtained by FTI were significant underestimated (P < 0.001) in comparison with MRI. Bland-Altman analysis of EDV and ESV using FTI and cardiac MRI showed a low level of agreement for EDV (mean difference = 40.8; SD = 39) and ESV (mean difference = 38.1; SD = 42). On the contrary, no significant difference between FTI and MRI in assessing the LVEF was found; furthermore, a very low bias (2 ± 12) by Bland-Altman analysis was found between FTI and cardiac MRI for the quantification of EF. CONCLUSION: Semiautomatic quantification of LV volumes using FTI allows an accurate, rapid, easy and reliable assessment of LV EF and a rough estimation of LV volumes.

Myocardial deformation in acute myocarditis with normal left ventricular wall motion--a cardiac magnetic resonance and 2-dimensional strain echocardiographic study.

BACKGROUND: The aim of our study was to assess longitudinal (L), circumferential (C) and radial (R) strain (S) of the left ventricle (LV) in patients with acute myocarditis and preserved LV wall motion. METHODS AND RESULTS: Of the 26 male patients that were enrolled, 13 patients (26+/-8 years) suffered from acute myocarditis and 13 (25+/-2 years) were healthy participants (controls). Both patients and controls underwent cardiac magnetic resonance (CMR) and 2-dimensional S imaging (2D-S) echocardiography on the same day. Myocardial strains (RS, LS and CS) were quantified by 2D-S. In patients with myocarditis, a delayed enhancement (DE) CMR study was performed to identify damaged myocardial segments. In the myocarditis group there was a significant LS reduction compared with controls (-25+/-7 vs -20+/-7, P<0.0001), whereas no difference was found between the 2 groups concerning CS and RS. Subepicardial DE areas were found in 12 of 13 patients. Segments with DE showed a significantly lower LS in comparison with segments without DE (-19+/-4 vs -23+/-6, P<0.0001). In contrast, no difference in CS and RS was found when comparing segments with DE vs segments without DE. CONCLUSIONS: In patients with acute myocarditis, evidence of subepicardial damage and no wall motion abnormalities, longitudinal deformation is diffusely impaired, whereas circumferential impairment is regionally sited in the areas of subepicardial damage.

Left ventricular diverticulum and previous rhabdomyoma: an occasional detection.

A 35-year-old patient previously operated when a child for right ventricular (RV) rhabdomyoma was submitted to cardiac magnetic resonance (CMR) that showed a dilated RV and a small contractile cavity in the inferior left ventricular (LV) wall suggestive for diverticulum. This report shows the first description of a simultaneous evidence of LV diverticulum and previous rhabdomyoma, and furthermore highlights the important role of CMR for an easy detection of this congenital abnormality.

Right ventricular outflow tract obstruction in hypertrophic cardiomyopathy.

Recently, new cardiac imaging techniques as cardiac magnetic resonance have shown to play a primary role for a recognition of unusual mechanisms of right and left ventricular obstruction. However, echocardiography remains the most widely used technique and the first step to recognize myocardial hypertrophy, blood flow velocity, and pressure gradients in real time (2). We describe a rare case of hypertrophic cardiomyopathy with isolated obstruction of right ventricular out flow where transthoracic echocardiography was able to detect right ventricular hypertrophy and obstruction.

Patent foramen ovale: comparison among diagnostic strategies in cryptogenic stroke and migraine.

OBJECTIVE: The aim of this study was to compare transthoracic echocardiography (TTE) and transcranial Doppler ultrasonography (TCD) with transesophageal echocardiography (TEE) in order to define the best clinical approach to patent foramen ovale (PFO) detection. METHODS: In total, 72 consecutive patients (33 men) with a mean age of 49 +/- 13 years were prospectively enrolled. The TEE indication was cryptogenic stroke (36 patients) or migraine (36 patients, 22 with aura). All patients underwent standard TTE, TCD, and TEE examination. For any study, a contrast test was carried on using an agitated saline solution mixed with urea-linked gelatine (Haemaccel), injected as a rapid bolus via a right antecubital vein. A prolonged Valsalva maneuver was performed to improve test sensitivity. RESULTS: TEE identified a PFO in 65% of the whole population: 56.5% in the migraine cohort and 43.5% in the cryptogenic stroke cohort. TTE was able to detect a PFO in 55% of patients positive at TEE (54% negative predictive value, 100% positive predictive value, 55% sensitivity, and 100% specificity). TCD was able to identify a PFO in 97% of patients positive at TEE (89% negative predictive value, 98% positive predictive value, 94% sensitivity, and 96% specificity). CONCLUSIONS: In patients with cryptogenic stroke and migraine, there is a fair concordance (k = 0.89) between TCD and TEE in PFO recognition. Accordingly, TCD should be recommended as a simple, noninvasive, and reliable technique, whereas TEE indication should be restricted to selected patients. TTE is a very specific technique, whose major advantage is the ability to detect a large right-to-left shunt, particularly if associated with an atrial septal aneurysm.

Lipomatous metaplasia in ischemic cardiomyopathy.

Lipomatous metaplasia is characterized by substitution of muscle fibers with adipose tissue in the context of a myocardial scar. Cardiac magnetic resonance is an accurate cardiac imaging technique with high tissue spatial resolution that can easily characterize scar tissue, adipose tissue and lipomatous metaplasia. We report a case of lipomatous metaplasia in a 68-year-old man with a 14-year history of anterior myocardial infarction admitted to our cardiac department for dyspnea and palpitations.

Heart failure diagnosis: the role of echocardiography and magnetic resonance imaging.

Heart failure (HF) is the final common pathway of any heart disease, being a major cause of cardiovascular morbidity and mortality. Echocardiography is the most useful tool in the diagnosis of HF: echocardiographic evidence of left ventricular (LV) systolic dysfunction is generally associated with a dilated left ventricle (LV) and a reduced LV ejection fraction (EF). In many patients (pts) with symptoms of HF, however, EF and LV volumes are normal. Quantitative assessment of global and/or regional LV and right ventricle (RV) function is, therefore, necessary, and some emerging techniques, as Tissue Doppler Imaging (TDI) and Strain Imaging (SI), can provide such information. Moreover, cardiac magnetic resonance imaging (MRI) has emerged as an extremely useful technique in the investigation of pts with HF. Cardiac MRI permits calculation of myocardial mass, volumes and EF with Simpson's algorithm from three-dimensional data and with no geometric assumptions. The integration of conventional echocardiographic measurements, new echocardiographic parameters, and cardiac MRI is a very promising approach for an accurate evaluation of pts with HF.

Simultaneous recognition of myocardial, pleural and pulmonary parenchyma inflammation by cardiac magnetic resonance.

Magnetic resonance imaging (MRI) showed high accuracy in the diagnosis of many inflammatory cardiac diseases. We report a case of a patient where cardiac MRI was able to identify inflammation of myocardium, pleura and pulmonary parenchyma.

Acute myocardial infarction and Kounis syndrome.

Kounis syndrome is the concurrence of acute coronary syndromes with conditions associated with mast cell activation including allergic or hypersensitivity and anaphylactic or anaphylactoid insults. We present a case of acute myocardial infarction associated with an allergic reaction in a 73-year-old Italian woman with recent implantation of stents.

Capsaicin, arterial hypertensive crisis and acute myocardial infarction associated with high levels of thyroid stimulating hormone.

Chili peppers are rich in capsaicin. The potent vasodilator calcitonin gene-related peptide (CGRP) is stored in a population of C-fiber afferents that are sensitive to capsaicin. CGRP and peptides released from cardiac C fibers have a beneficial effect in myocardial ischemia and reperfusion. It has been reported that capsaicin pretreatment deplete cardiac C-fiber peptide stores. Furthermore, it has also been reported that capsaicin-treated pigs significantly increase mean arterial blood pressure compared with controls and that the decrease in CGRP synthesis and release contributes to the elevated blood pressure. It has also been reported that sub-clinical hypothyroidism is associated with a significant risk of coronary heart disease (CHD). We present a case of arterial hypertensive crisis and acute myocardial infarction in a 59-year-old Italian man with high levels of thyroid stimulating hormone and with an abundant ingestion of peppers and of chili peppers which occurred the day before.

An unusual diagnosis of atrial shunt defect by magnetic resonance imaging.

Paroxysmal atrial arrhythmias especially atrial fibrillation are frequently encountered in adult patients with atrial septal defect. However, the diagnosis of atrial defect can be difficult. Thransthoracic echocardiography, the mostly utilized cardiac technique, has shown a limited ability to identify small atrial defects. Transesophageal echocardiography has shown high accuracy to identify but it isn't well tolerated of the patients. Recently, the utility of multislice computed tomography in the evaluation of direction, location, and size of shunt flow in congenital heart disease has been demonstrated. Cardiac magnetic resonance imaging (MRI) is a recent imaging technique that permits with high spatial resolution and without ionising radiation an accurate identification of many cardiovascular diseases. We report an unusual detection of an atrial defect by phase-contrast cine MRI in a patient clinically suspected of arrhitmogenic right ventricular displasia.

Cerebral transient ischemic attack due to left ventricular thrombus formation in a young patient with silent myocardial infarction and normal coronary arteries.

Among many cardiac diseases related to cerebral stroke, left ventricular thrombus formation due to silent myocardial infarction with normal coronary arteries represents a rare cause of cerebral ischemia. We describe an unusual case of cerebral ischemia due to cardiac thrombus formation in a young patient with silent myocardial infarction and normal coronary arteries in which echocardiography and cardiac MR imaging clearly showed the embolic source.

Isolated supravalvular pulmonary stenosis in a 25-day-old newborn infant: an occasional and early diagnosis.

Pulmonary stenosis comprises variable pathologic features from the right ventricular outflow tract to the peripheral pulmonary arteries. Most frequently, the obstruction occurs at the level of the pulmonary valve; however, it occurs less frequently at the infindibular level. It can occur as part of more congenital cardiac malformations such as tetralogy of Fallot, complete transposition of great arteries, or atrial septal defect. Proximal pulmonary artery stenosis has also been reported as an acquired lesion in infants treated for congenital heart disease. Primary isolated supravalvular pulmonary stenosis is less common. We present a case of primary isolated pulmonary artery stenosis in an asymptomatic 25-day-old newborn infant.

An integrated imaging approach with magnetic resonance imaging can reveal pitfall pleural effusion at echocardiography.

We report an echocardiographic pitfall, where a hypoecogenic area mimicking a pleural effusion was detected by CMR as an area of normal pulmonary parenchyma between the posterior left atrial wall and the dilated right pulmonary vein.