SHARK FIN ECG PATTERN IN A PATIENT WITH TAKOTSUBO SYNDROME - CASE STUDY AND LITERATURE REVIEW.

Shark fin or triangular QRS-ST-T waveform ECG pattern, also known as lambda-wave ST elevation or giant R wave syndrome, is a particular ECG presentation where QRS complex, ST-segment and T-wave are fused in a unique complex. Originally described in some patients with ST-segment elevation myocardial infarction (STEMI) during the acute phase, it has been found to be associated with a high risk of ventricular fibrillation and cardiogenic shock as well as with a high in-hospital mortality. However, shark fin ECG pattern has also been reported in patients with non-acute coronary syndrome related ST-elevation (NASTEP), including stress-induced takotsubo syndrome (TTS). Fourteen such cases (all females) have been reported so far. The authors present a case of a 56-year-old male with shark fin ECG pattern associated with TTS triggered by burn injuries of head, back, upper, lower limbs and the respiratory tract. Due to respiratory insufficiency and heart failure with hemodynamic compromise, he required mechanical ventilation and catecholamines use. Echocardiography showed apical and midventricular akinesia with left ventricular ejection fraction and global longitudinal strain reduced to 30% and -6.8%, respectively and a high segmental post-systolic index. Shark fin pattern maintained within 2 days, then ST-T evolution was observed. Echocardiographic improvement followed by almost normalization were seen after 6 and 9 days, respectively. No cardiac arrhythmias were recorded as in most of the described cases with shark fin ECG and TTS.

BRUGADA-LIKE ECG PATTERN AND TUMORS INVOLVING RIGHT VENTRICULAR OUTFLOW TRACT - CASE SERIES AND LITERATURE REVIEW.

Mechanical heart compression, including that from mediastinal tumor, may cause Brugada-like ECG pattern. Such ECG pattern might also be observed in intracardiac tumor obstructing the right ventricular out"ow tract (RVOT). Eight cases with Brugada-like ECG and tumors involving RVOT have been described so far; 4 growing in the mediastinum (with one example of in"ammatory mass), 3 with intracardiac location, and 1 being an organized pericardial hematoma. The authors present other 3 cases of intracardiac metastatic tumors in RVOT and Brugada-like ECG pattern with coved ST-segment elevation in the right precordial leads. All patients had negative history of cardiovascular disease or familiar malignant arrhythmia occurrence. ECG were done routinely; none of the patients had chest pain or an increased level of cardiac troponins. In all patients, neoplastic disease was at advanced stage. A 76-year-old male, had a history of four neoplasms: bladder cancer was being treated with chemotherapy, while prostate, tongue, and lung cancers had been resected years ago and no signs of local relapse were found. A 78-year-old female, was diagnosed with colon cancer 1 month after an episode of venous thromboembolism. Six months after the resection of cancer, second focus of adenocarcinoma was found in the rectum. Third patient, a 65-year-old-male had undergone nephrectomy for renal cancer a year before cardiac metastasis diagnosis.

TAKOTSUBO SYNDROME AND CORONARY ARTERY FISTULA: CASE REPORT AND LITERATURE REVIEW.

Takotsubo syndrome (TTS) has been reported in various clinical conditions. Coronary artery fistula (CAF) is diagnosed in 0.2- 0.4% of patients undergoing coronary angiography. Pathologic communication between coronary artery (e.g., left anterior de¬scending coronary artery - LAD) and cardiac chambers (e.g., left ventricle - LV) is cameral type of CAF which particularly predis¬pose to myocardial ischemia due to a steal syndrome. Eight cases of coexistent TTS and CAF have been reported so far; in 6 of them LAD cameral fistulas drained LV, in 2 others communications between coronary arteries and pulmonary artery were found. The authors describe a case of a 75-year-old female, admitted due to chest pain and dyspnea. Her clinical picture with ST-segment elevation in ECG, moderately increased troponin I and apical ballooning in echocardiography, was more typical for TTS than for myocardial infarction; besides that, color doppler imaging was suggestive of multiple CAF to LV. Coronary angiography showed communication between all (normal) coronary arteries and LV. Throughout the conservative therapy, first, an improve¬ment and then normalization of LV function were observed after 2 and 6 days, respectively. Chest x-ray and computed tomogra¬phy revealed mediastinal tumor (eventually diagnosed as lung cancer). Cardiac magnetic resonance performed after one month did not show late gadolinium enhancement. During the course of 24 months follow-up, she was taking bisoprolol and ramipril and her cardiologic state remained stable, even during chemotherapy and radiotherapy. The authors collected the clinical data of all 9 cases with concomitant TTS and CAF. Specific TTS triggering factors/predisposing conditions were present in all patients, which has indicated that coexistence of TTS and CAF is rather coincidental.

Native heart valve thrombosis associated with COVID-19 - a report of 4 cases.

Native heart valve thrombosis (NHVT) is a rare valvular pathology, usually associated with prothrombotic state or disturbed intracardiac blood flow related to structural valve abnormalities. While different venous and arterial thromboembolic complications of COVID-19 have been widely described, so far NHVT has not been reported in the context of the disease. The authors describe 4 cases of NHVT associated with COVID-19, revealed on aortic, mitral (2 patients) and tricuspid valve. In a 29-yearold male with mild pneumonia, large thrombus developed on bicuspid aortic valve (BAV), which resulted in fatal brain emboli. In a 76-yearold male with a history of rheumatoid arthritis (RA) being in a recovery period after COVID-19, central retinal artery occlusion (CRAO) was the first sign of mitral valve thrombus, which disappeared after 3 weeks, during apixaban use. Such therapy was also successful in a 46-yearold female with multiple cardiovascular risk factors in whom mitral valve thrombus was found in a routine echocardiography after she got COVID-19 the third time. In a 75-year-old man with moderate COVID-19 pneumonia and bacterial coinfection, coexistent transient focal LV dysfunction and tricuspid valve thrombus were observed. The patient was treated with apixaban as well; however, in this case only reduction in the thrombus size was seen after 4 months therapy. The authors indicate that in patients with COVID-19 and NHVT, other prothrombotic conditions can usually be found. This complication may involve different valves and occur irrespective of COVID-19 severity. Interdisciplinary evaluation of such patients is necessary.

Acute femoral artery occlusion in a male with Duhring disease and COVID-19 pneumonia treated with baricitinib.

Arterial thromboembolic events (ATE) in COVID-19, similarly as venous thromboembolism (VTE), are observed mainly in severely ill patients. ATE include brain, heart, aortic, and peripheral ischemic complications which usually aggravate a course of the disease leading to lifethreatening conditions. A CASE REPORT: The authors describe a case of a 53-year-old male with Duhring disease in the remission period admitted due to severe COVID-19 pneumonia. The patient was treated with ceftriaxone (2000 mg once daily), dexamethasone (8 mg once daily), enoxaparin (60 mg twice daily), baricitinib (4 mg once daily), and remdesivir (200 mg on the first day, followed by 100 mg within 4 consecutive days); he required high flow oxygen therapy. On day 5 of hospitalization, he began to suffer from pain of the right lower extremity; in physical examination the limb was cold with absent femoral, popliteal, and pedal pulses. Urgent computed tomography angiography revealed total occlusion of the right superficial femoral artery (SFA) in the absence of any atherosclerotic plaques in the aorta. The patient was intubated and transferred to department of vascular surgery, where a giant clot was removed from SFA. Unfortunately, the patient outcome was unfavorable due to respiratory failure progression. The authors underline that ATE may occur even in anticoagulated patients and that association of some therapeutic options of COVID-19, like janus kinase (JAK) inhibitors use with an increased risk of ATE, should not be excluded.

Retroperitoneal hematoma in COVID-19 patients - case series.

COVID-19 patients, particularly those with severe pulmonary involvement, are at an increased thromboembolic risk related, among various causes, to the cytokine storm and excessive activation of the coagulation cascade and platelets. Different intensity of anticoagulation for them is proposed, mainly with low molecular weight heparins (LMWHs); in a confirmed pulmonary embolism (PE) the therapeutic dose of LMWH is routinely used. Some authors suggest that hemorrhagic complications in COVID-19 patients are rare. At the same time, one can find reports on internal bleeding, including retroperitoneal hematoma (RPH) and other abdominal hematomas. CASE REPORTS: The authors describe 5 cases (3 of those aged more than 80 years) with giant RPHs and with moderate/severe COVID-19 pneumonia, treated before RPH diagnosis with different enoxaparin doses. The therapeutic dose was given to the male with verified PE limited to the segmental/subsegmental pulmonary arteries and initially to the female in whom echocardiography was strongly suggestive of PE, yet this diagnosis was excluded on CT angiography. In one patient, the enoxaparin dose was escalated from 40 mg bd to 60 mg bd after the D-dimer increase. Two patients had bleeding complications despite the enoxaparin dose restricted to 40 mg/daily or bd. Two males had a coexistent psoas hematoma while in only one female there was a coexistent femoral hematoma. RPHs occurred between day 4 and 14 of hospitalization and all were treated conservatively. Three patients who died were particularly charged, so their deaths were not merely directly associated with RPH, which was closely analyzed in one autopsy performed. The authors underline that the choice of anticoagulation intensity in patients with COVID-19 pneumonia without venous thromboembolism seems sometimes difficult but recent publications indicate the low prophylactic enoxaparin dose as an optimal option. Anticoagulation dose escalation based only on the D-dimer level may not be appropriate for certain patients; moreover, the D-dimer increase is commonly observed during internal bleeding.

Bradycardia during optical timolol therapy: its delayed remission after timolol discontinuation and unexpected further relapse.

Optical betablockers (BBs), including nonselective BB timolol, are commonly used for the management of primary open angle glaucoma and ocular hypertension. About 80% of topically administered timolol is systemically absorbed, which can rarely induce such complications as bradycardia, bronchospasm and depression. A CASE REPORT: The authors describe a case of a 67-year-old female referred because of significant bradycardia and a suggestion of pacemaker implantation. She had no cardiovascular history besides hyperlipidemia and mild hyperglycemia, so her previous treatment was focused on glaucoma due to which she had been using optical timolol for several years. Moreover, she suffered from depression which was treated with venlafaxine and sertraline. Over a few months, she started feeling weak and dizzy. Her daily heart rate (HR) markedly decreased to 40-45/min. 24-hour ECG monitoring revealed multiple episodes of nodal rhythm and of sinoatrial block and the lowest HR of 33/min; bradycardia defined as HR less than 45/min constituted over 40% of the time recorded. Close observation with repeated 24-hour ECG monitoring after timolol discontinuation showed lasting several-daylong gradual bradycardia remission; after 2, 9, 16 and 23 days, bradycardia constituted 19.9%, 13.9%, 0.2% and 0% of the time recorded, respectively. Genetic testing of cytochrome P450 2D6 revealed the presence of the c.506 -1G>A variant with one non-functional allele (CYP2D6 *4/-) which might have slowed down timolol metabolism in the context of simultaneous antidepressants use, so venlafaxine and sertraline were reduced. However, during follow-up, incremental bradycardia relapse, suggestive of an underlying sinus node dysfunction, was observed.

Concomitance of COVID-19 and legionnaires' disease - a case series.

Coronavirus disease-2019 (COVID-19) and legionnaires disease (LD) caused by Gram-negative water-born bacteria Legionella pneumophila show certain similarities, including a predisposition to pulmonary involvement and extrapulmonary manifestations in some of the patients infected. One disease can mimic the other, both can rarely coexist. CASE SERIES REPORT: The authors describe 7 such cases (5 females), aged 51-90 years (mean 69.7 years) detected while screening 133 subjects with moderate to severe pneumonia and confirmed COVID- 19, which constituted 5.3% of the patients in whom urinary antigen test (UAT) for L. pneumophila was performed. The patients had multiple concomitant disorders: hypertension (6), heart failure (4), diabetes (4), obesity (4), coronary heart disease (3), chronic kidney disease (3), chronic obstructive pulmonary disease (3), anemia (3). Positive UAT was obtained at admission in 4 patients, and on 3rd, 11th and 14th days of hospitalization in the remaining 3 patients. One patient also had positive UAT for Streptococcus pneumoniae. We analyzed: radiological imaging, laboratory data (CRP, interleukin-6, procalcitonin, troponin I, BNP), ECG, echocardiography, treatment and outcome. Three patients required a modification of initial antibiotic therapy, two developed Clostridioides difficile infection. The duration of hospitalization ranged from 13 to 59 days (mean 24.3 days); two patients died. CONCLUSIONS: The authors suggest that the coexistence of COVID- 19 and LD may result in prolonged hospitalization, in increased mortality risk and in subsequent cardiovascular complications, including takotsubo syndrome (TTS) which was found in 2 cases, both presented as focal TTS (fTTS).

Brugada phenocopy in pulmonary embolism - clinicopathological case study and literature review.

Brugada syndrome (BrS) is an inherited channelopathy characterized on ECG by coved (type 1) or saddle-back (type 2) ST-segment elevation (STE) of 2 or more mm in the right precordial leads and is associated with an increased risk of malignant ventricular arrhythmias. The term Brugada phenocopy (BrPh) indicates conditions that may reversibly induce Brugada-like ECG pattern in patients without true BrS; e.g.: metabolic abnormalities, mechanical heart compression, ischemia, myocarditis/pericarditis, and pulmonary embolism (PE). Only 9 cases of BPh associated with PE have been described so far. The authors present another case of a 41-year-old-male and analyze the clinical data of all 10 subjects (7 males and 3 females). Type 1 of ECG Brugada pattern was present in 7 patients (including ours), type 2 was found in 2 persons; in 1 case ECG pattern was not defined. In 7 patients STE was prominent (5 mm or more in at least 1 lead). STE was limited to V1-V2 leads in 4 persons, extended to V3 in 3 patients and even to V4 in 3 other patients, which correlated with the significant right ventricular (RV) dilatation. Concomitant left ventricular (LV) systolic dysfunction was reported only in 1 patient, which suggested that paradoxical embolization of coronary artery was not the mechanism of BrS-like STE. Clinical course of PE was usually severe (5 individuals were treated with thrombolysis) and in 3 cases it ended with death. The autopsy was only performed on our patient. It showed diffuse (ischemic) injury of RV and LV secondary to RV overload, decreased cardiac output and severe oxygen deficiency in myocardium, which could have led to BrS pattern in ECG.

Amiodarone-induced musical hallucinations.

Musical hallucinations (MHs), a kind of auditory hallucinations (AHs), are a rarely observed phenomenon of abnormal perception of sound in the absence of an external auditory source. MHs are characterized by perception of melodies, music, or songs. AHs/MHs can be associated with hypoacusis, psychiatric or neurological diseases, intoxication and adverse reactions of different medications (e.g., propranolol, amantadine, voriconazole). A CASE REPORT: The authors present a case of a 77-year-old male with advanced heart failure, recurrent episodes of atrial fibrillations and moderate hypoacusis, who mistakenly overdosed oral amiodarone (6 pills 200 mg each daily within 3 days). After administration of 12 pills during 2 days, he started hearing music and songs not heard by others. One day later, when the number of ingested pills increased to 18, he decided to discontinue amiodarone and consulted a cardiologist; no signs of physical, ECG or laboratory deterioration were observed. MHs disappeared next day and returned only as a single episode when he tried to restart amiodarone at a dose of 1 pill daily 2 weeks later. Finally, following complete removal of the medication, he experienced no MHs whatsoever. Amiodarone is known to seldom cause neurological or mental complications; however, MHs after the drug have never been reported so far.

Marked self-limiting sinus bradycardia in COVID-19 patients not requiring therapy in the intensive care unit - case series report.

Cardiovascular complications of the COVID-19 comprise cardiac arrhythmias, including sinus bradycardia (SB). CASE REPORTS: The authors present clinical data of 19 hospitalized patients (12 males), aged 20-73 years, with marked (less than 45/min during daily hours) self-limiting SB. None of them had SB at admission or earlier, none had used cardiovascular medications potentially decreasing the heart rate. Pulmonary involvement was severe in 4, moderate in 13 and mild in 2 patients; 14 needed oxygen therapy (4 using high flow oxygen equipment), none required treatment in the intensive care unit. All patients were given low molecular weight heparin in a prophylactic dose, 13 intravenous ceftriaxone, 12 dexamethasone, 8 convalescent plasma. Before SB appearance, 12 patients were treated with remdesivir (3 patients did not receive a full planned dose) and 2 with tocilizumab. SB appeared suddenly on day 5-14 from the onset of the disease, with a minimal heart rate of 32-44/min and in 3 cases it was mildly symptomatic; 2 of those received ad-hoc atropine, one orciprenaline. Interleukin-6 (Il-6) and C-reactive protein (CRP) concentrations at SB onset were significantly lower than at admission (9.3 vs 70.0 pg/ml and 16.8 vs 98.5 mg/l, respectively). Cardiac troponin I was slightly elevated in 2 patients. ECG morphology abnormalities (transient negative T waves or ST depression) were found in 4 males. All subjects had normal left ventricular ejection fraction; in 5 echocardiography revealed small pericardial effusion; in 10 patients, longitudinal strain was also studied: reginal abnormalities were found in all of them, particularly in basal segments. SB lasted 3-11 days and was reversible in all patients; none required temporary stimulation. The COVID-19 course was favorable in all patients; they were stable at discharge. During 4-12 months of posthospital observation, including clinical features, control ECG and 24-hour Holter monitoring, none of the patients was qualified for pacemaker implantation.

Tablet-based limited echocardiography at COVID-19-dedicated hospital during the pandemic in the context of takotsubo syndrome.

In the course of COVID-19 pandemic, many patients with diagnosed or suspected disease do require echocardiography. At the same time, when it comes to the echocardiographers, there is a fear of their being exposed to contamination. At COVID-19-dedicated hospital examinations are bedside, and in some patients hand-held or tablet-based echocardiography should be preferred; the echocardiographer routinely puts on a complete protective uniform. The prevalence of stress-induced takotsubo syndrome (TTS) during the Covid-19 pandemic is higher than previously reported. The authors present the images obtained using tabletbased limited echocardiography in patients with different forms of TTS. The time of the examination of patients and decontamination of the equipment was short (5-7 min and less than 2 min, respectively); the images were of fairly good quality.

Multimodality imaging of mitral annular disjunction.

Mitral valve prolapse (MVP) is diagnosed by auscultation and echocardiography in about 2-3% of the general population and takes rather a benign course. However, in some patients, ventricular arrhythmia and sudden cardiac death (SCD) occur, which is linked to mitral annular disjunction (MAD). MAD is defined as distinct separation of the mitral valve annulus-left atrial wall continuum and the basal region of the posterolateral left ventricular (LV) myocardium. MAD results in disturbed inferior-posterior LV wall and posteromedial papillary muscle stretch giving rise to local fibrosis presenting in cardiac magnetic resonance (CMR) as late gadolinium enhancement (LGE) and posing a substrate for malignant arrhythmia. Multidetector-row computed tomography (MDCT) in MAD patients is still rarely used. A CASE REPORT: Mitral valve prolapse (MVP) is diagnosed by auscultation and echocardiography in about 2-3% of the general population and takes rather a benign course. However, in some patients, ventricular arrhythmia and sudden cardiac death (SCD) occur, which is linked to mitral annular disjunction (MAD). MAD is defined as distinct separation of the mitral valve annulus-left atrial wall continuum and the basal region of the posterolateral left ventricular (LV) myocardium. MAD results in disturbed inferior-posterior LV wall and posteromedial papillary muscle stretch giving rise to local fibrosis presenting in cardiac magnetic resonance (CMR) as late gadolinium enhancement (LGE) and posing a substrate for malignant arrhythmia. Multidetector-row computed tomography (MDCT) in MAD patients is still rarely used.

Takotsubo syndrome after nimodipine-induced hypotension treated with norepinephrine in a female with subarachnoid hemorrhage.

The prevalence of takotsubo syndrome (TTS) in patients with subarachnoid hemorrhage (SAH) is much higher than in the general population. Clinical and experimental observations confirm secondary to brain damage catecholamine-mediated cardiac injury resulting in reversible left ventricular (LV) dysfunction. However, other triggers can also be involved in TTS development e.g. manipulations during surgical or endovascular treatment of a bleeding intracranial aneurysm, concomitant hyponatremia or infection, intubation, blood transfusion and pharmacologic treatment. Nimodipine is recommended in SAH to prevent cerebral arteries vasospasm but can cause hypotension, so vasopressors, e.g. norepinephrine (NE) are commonly used to reach target blood pressure. A CASE REPORT: The authors present a case of a 72-year-old woman with SAH in whom the disease began with a headache, syncope, decreased level of consciousness and vomiting; there were no cardiac symptoms at admission. Endovascular coiling of internal carotid artery aneurysm was performed. On day 2, she developed TTS presenting in echocardiography as apical ballooning; immediately before TTS onset, NE was started to treat nimodipine-induced hypotension. Despite severe heart failure (HF), the patient's neurological status did not deteriorate. HF symptoms remitted after a few days and LV function returned to normal after a week. Negative T waves in ECG which appeared at TTS onset disappeared after 50 days. At that moment no neurological deficits were observed. CONCLUSIONS: The authors underline that in SAH patients nimodipine administration should be cautious to avoid an excessive blood pressure decrease especially in view of further catecholamines use.

Asymptomatic cardiac and gallbladder involvement at initial presentation of Legionnaires' disease.

Extrapulmonary manifestations of Legionnaires' disease (LD) include, inter alia cardiac, brain, abdominal, joints and skin involvement. A CASE REPORT: The authors describe a case of a 41-year-old immunocompetent female admitted due to a high fever, chills and fatigue. She negated cough and chest or abdominal pain. Initial chest X-ray was normal. Among laboratory abnormalities were: elevation of C-reactive protein, procalcitonin, transaminases and creatinine, hyponatremia, low white blood cell and platelet count and a moderate proteinuria. ECG showed subtle ST elevation. Echocardiography revealed normal left ventricular (LV) contractility and near normal longitudinal strain, mild myocardial thickening, and a small pericardial effusion; additionally, in subcostal view, gallbladder wall thickening (GBWT) was found. Positive L. pneumophila urinary antigen test confirmed LD diagnosis. Control Xray and CT showed development of pleural effusion and bilateral pulmonary infiltrations. Clinical and radiologic improvement of the disease was achieved with ciprofloxacin therapy started from admission. ECG abnormalities persisted for only 5 days, GBWT resolved after 9 days, pericardial effusion disappeared after 10 days; normalization of LV thickness and an increase in longitudinal strain was found within 2 weeks. However, cardiac magnetic resonance (CMR) performed after a month revealed focal midmyocardial and linear subepicardial late gadolinium enhancement (LGE). CONCLUSIONS: The authors underline the fact that being aware of extrapulmonary LD, also silent, may allow to diagnose the disease, especially when pulmonary involvement is initially absent.

Transient left ventricular hypertrophy in a 30-year-old female with chronic emotional stress and depression treated with venlafaxine.

Transient left ventricular hypertrophy or thickening (TLVH/T) is a phenomenon rarely observed in some patients with myocarditis and stress-induced takotsubo syndrome (TTS). Initial presentation on echocardiography can mimic hypertrophic cardiomyopathy (HCM), sometimes with a decreased ejection fraction (EF). A CASE REPORT: The authors describe TLVH/T in a 30-year-old female with a history of chronic emotional stress and depression treated with venlafaxine (75 mg twice a day). She suffered from spinocerebellar ataxia (SCA) and, because of a family conflict, was living alone with a daughter who was diagnosed with maple syrup urine disease (MSUD). At admission, she presented with advanced heart failure with pulmonary congestion, moderately elevated blood pressure, ECG signs of LV hypertrophy (with negative T waves in leads: I-III, aVF, V4- 6) and with mild troponin I and high BNP elevation. Echocardiography revealed hypertrophy of the LV myocardium, systolic dysfunction and a small pericardial effusion. She denied any chest pain; there were no clinical features of infection or connective tissue disorder. Genetic nature of the patient's SCA and of her daughter's MSUD gave rise to a suspicion that she had coexistent HCM. She received therapy with ramipril, carvedilol and diuretics; venlafaxine was not discontinued. Cardiac magnetic resonance (CMR) performed a month later showed LV thickening to be a little smaller, absence of late gadolinium enhancement and an improvement of EF; T2-weighted images were not studied. Unexpectedly, after several months, LV hypertrophy disappeared in subsequent ECG, echocardiography and CMR; simultaneously, EF as well as regional and longitudinal strain returned to normal values.

Severe transient left ventricular dysfunction in a patient with Legionella pneumophila pneumonia.

Legionella pneumophila infection (legionellosis) usually presents as a multisystemic disease, predominantly affecting the lungs (Legionnaires' disease - LD). Immunodeficiency, chemotherapy or chronic steroids use increase the risk of developing LD. Extrapulmonary manifestations of LD include cardiac complications: myocarditis, pericarditis or endocarditis. A CASE REPORT: The authors describe a case of a 51-year-old female with a history of cryoglobulinemic vasculitis, Sjögren syndrome and chronic lymphocytic leukemia who was admitted due to a high fever, fatigue, tachycardia, dyspnea and cough. Chest X-ray and CT showed bilateral pulmonary infiltrations and pleural effusion. LD was diagnosed on positive L. pneumophila urinary antigen test. Echocardiography revealed severe left ventricular (LV) dysfunction with substantially decreased ejection fraction and global longitudinal strain (GLS), with a pattern resembling reverse takotsubo syndrome (rTTS). The coronary arteries in non-invasive coronary angiography were normal. During therapy with levofloxacin and intravenous immunoglobulins as well as with carvedilol, ramipril and diuretics, gradual clinical improvement with complete normalization of LV function was observed within 5 weeks. Cardiac magnetic resonance (CMR) performed on day 35 revealed only small intramural foci of late gadolinium enhancement (LGE) with localization not corresponding to the most decreased regional longitudinal strain in the initial echocardiographic examination. The authors suggest that the mechanism of transient LV dysfunction in the case presented may have been of complex nature, including LD myocarditis and stress-induced cardiomyopathy (with the prevalence of the latter) which has not so far been reported in the literature.

Daily longitudinal strain evaluation for left ventricular function monitoring in a 65-year-old female with reverse syndrome takotsubo and multiple triggering factors.

Among patients with takotsubo syndrome (TTS), reverse TTS (rTTS) constitutes 1-23% of all cases reported in the literature. The highest prevalence of rTTS is observed in intracranial hemorrhage, pheochromocytoma and severe infections. A CASE REPORT: The authors describe a case of a 65-year-old female with advanced multiple myeloma in whom rTTS was recognized on admission due to streptococcal sepsis. Other possible triggering factors included: anemia, blood transfusion, transient acute renal failure with electrolyte imbalance. ECG showed ST-segment depression in precordial leads and echocardiography revealed severe left ventricular (LV) dysfunction with apical sparing and with decreased ejection fraction (EF) and global longitudinal strain (GLS): 30 % and -10 %, respectively. Daily echocardiography showed gradual normalization of GLS as well as of regional longitudinal strain (RLS) within 8 days. The authors confirm the distinctness of rTTS including clinical, ECG, echocardiographic and laboratory findings and suggest the usefulness of daily longitudinal strain evaluation for LV function recovery monitoring.

Takotsubo syndrome triggered by emotional and physical stress due to coincidental immobilization resembling the experimental model of the disease - a case report.

The term takotsubo syndrome (TTS) is derived from a comparison of left ventricular (LV) appearance in its apical form to the shape of the pot which is a trap used for octopus catching. In the classical animal model on rats, its occurrence can be triggered by experimental immobilization (IMO). Former observations of capture myopathy, seen in animals after extreme exertion, showed coexistence of rhabdomyolysis related to skeletal muscle injury and myocardial damage. The authors describe a case of a 66-year-old obese female in whom TTS was triggered by an uncommonly stressful event when she had been trapped in the bathtub for several hours. The woman lives alone and has impaired functionality due to degenerative disease of the spine and hips. On this unlucky day, she decided to have a bath after which she was unable to get out of the bathtub despite repeated efforts. She was very frustrated and helpless having to spend all the evening and night in that cul-de-sac-like situation. She was rescued in the morning by neighbors and firemen who transferred her to hospital. On admission she was exhausted and suffering from dyspnea, she negated any chest pain; there were bloody abrasions on her elbows. Due to negative T waves in ECG and elevated troponin I, echocardiography was performed which revealed LV apical ballooning. The high level of creatine phosphokinase (CPK) was suggestive of rhabdomyolysis. Following heart failure therapy, the patient's clinical state, as well as echocardiographic parameters, improved gradually. Normalization of LV function and CPK values was observed after 11 days.