Multimodality Cardiac Imaging in COVID-19 Infection.

COVID-19 infection often produces cardiovascular complications, which can range from mild to severe and influence the overall prognosis. Imaging is the cornerstone for diagnosing initial COVID-19 cardiovascular involvement as well as treatment guidance. In this review, we present the current state of the literature on this subject while also emphasizing possible algorithms for indicating and executing these investigations.

The Impact of Atrial Fibrillation on All Heart Chambers Remodeling and Function in Patients with Dilated Cardiomyopathy-A Two- and Three-Dimensional Echocardiography Study.

Atrial fibrillation is frequently seen in patients with dilated cardiomyopathy (DCM), and its presence impacts the function of the heart, with clinical and prognostic consequences. In this prospective single-center study, we aimed to assess the impact of atrial fibrillation on cardiac structure and function, using comprehensive two- and three-dimensional echocardiography. We included 41 patients with DCM and persistent or permanent atrial fibrillation (38 male, age 58.8 ± 11 years), as well as 47 patients with DCM and in sinus rhythm (35 male, age 58 ± 12.5 years). Cardiac chambers and mitral and tricuspid valves' structure and function were assessed via standard two-dimensional, speckle-tracking, and three-dimensional echocardiography (3DE). Patients with DCM and atrial fibrillation had a more impaired left ventricular global longitudinal strain, higher 3DE left atrial volumes, and reduced function compared to patients in sinus rhythm in the presence of similar left ventricle volumes. Mitral annulus configuration was altered in atrial fibrillation DCM patients. Also, right heart volumes were larger, with more severe atrial and ventricular dysfunction, despite similar estimated pulmonary artery pressures and severity of tricuspid regurgitation. Using advanced echocardiography techniques, we demonstrated that atrial fibrillation induces significant remodeling in all heart chambers.

The Dysfunctional Right Ventricle in Dilated Cardiomyopathies: Looking from the Right Point of View.

Dilated cardiomyopathies (DCMs) are a heterogenous group of primary myocardial diseases, representing one of the leading causes of heart failure, and the main indication for heart transplantation. While the degree of left ventricular dilation and dysfunction are two key determinants of adverse outcomes in DCM patients, right ventricular (RV) remodeling and dysfunction further negatively influence patient prognosis. Consequently, RV functional assessment and diagnosing RV involvement by using an integrative approach based on multimodality imaging is of paramount importance in the evaluation of DCM patients and provides incremental prognostic and therapeutic information. Transthoracic echocardiography remains the first-line imaging modality used for the assessment of the RV, and newer techniques such as speckle-tracking and three-dimensional echocardiography significantly improve its diagnostic and prognostic accuracy. Nonetheless, cardiac magnetic resonance (CMR) is considered the gold standard imaging modality for the evaluation of RV size and function, and all DCM patients should be evaluated by CMR at least once. Accordingly, this review provides a comprehensive overview of the anatomy and function of the RV, and the pathophysiology, diagnosis, and prognostic value of RV dysfunction in DCM patients, based on traditional and novel imaging techniques.

Echocardiography Assessment of Cardiac Function in Adults Living with HIV: A Speckle Tracking Study in the Era of Antiretroviral Therapy.

Adults living with HIV (human immunodeficiency virus) infection (ALHIV) have high rates of cardiovascular events. New approaches are needed to detect subclinical cardiac dysfunction. We used conventional and speckle tracking echocardiography to investigate whether ALHIV display latent cardiac dysfunction. We analyzed 85 young subjects with HIV infection and free from cardiovascular risk factors (31 ± 4 years) and 80 matched healthy volunteers. We measured left ventricular (LV) layered global longitudinal strain, circumferential strain, peak longitudinal strain in the reservoir and contraction phases of the left atrium (LASr respectively LASct). In the HIV group, LV ejection fraction and s' TDI (tissue doppler imaging) were slightly lower but still in the normal ranges. Layered longitudinal strain showed no significant difference, whereas circumferential global strain was significantly lower in the HIV group (−20.3 ± 3.9 vs. −22.3 ± 3.0, p < 0.001). LASr (34.3% ± 7.3% vs. 38.0% ± 6.9%, p < 0.001) was also lower in ALHIV and multivariate analysis showed that age (ß = −0.737, p = 0.01) and infection duration (ß = −0.221, p = 0.02) were independently associated with LASr. In the absence of cardiovascular risk factors, adults living with HIV display normal LV systolic function. Left atrial reservoir strain, is, however, decreased and suggests early diastolic dysfunction.

Spinal cord infarction caused by extensive aortic intramural hematoma.

We report the case of a 62-year-old Caucasian man, an ex-smoker, who presented to the emergency room complaining of intense lower back pain followed by immediate bilateral loss of inferior limbs motor function. Clinical examination showed complete paralysis and paranesthesia in both legs, while pain and temperature sensory examination revealed a sensory level at dermatome T6, with normal touch, vibration, and position senses. His blood pressure was 190∕100 mmHg. Computed tomography demonstrated dilated thoracic aorta (maximum diameter 44 mm) and abdominal aorta (maximum 58 mm), with extended intramural hematoma (IMH), thus establishing the diagnosis of type A aortic IMH complicated with paraplegia through spinal perfusion deficit. Due to the extension of the lesions, surgical intervention for aortic repair was considered at high risk while cerebrospinal fluid drainage was not recommended by the neurologist. The patient remained stable while hospitalized and was released from the hospital with mild improvement of neurological deficiencies.

Assessment of Epinephrine and Norepinephrine in Gastric Carcinoma.

The aim of our study was to assess the sympathetic nervous system's involvement in the evolution of gastric carcinoma in patients by analyzing the mediators of this system (epinephrine and norepinephrine), as well as by analyzing the histological expression of the norepinephrine transporter (NET). We conducted an observational study including 91 patients diagnosed with gastric carcinoma and an additional 200 patients without cancer between November 2017 and October 2018. We set the primary endpoint as mortality from any cause in the first two years after enrolment in the study. The patients were monitored by a 24-h Holter electrocardiogram (ECG) to assess sympathetic or parasympathetic predominance. Blood was also collected from the patients to measure plasma free metanephrine (Meta) and normetanephrine (N-Meta), and tumor histological samples were collected for the analysis of NET expression. All of this was performed prior to the application of any antineoplastic therapy. Each patient was monitored for two years. We found higher heart rates in patients with gastric carcinoma than those without cancer. Regarding Meta and N-Meta, elevated levels were recorded in the patients with gastric carcinoma, correlating with the degree of tumor differentiation and other negative prognostic factors such as tumor invasion, lymph node metastasis, and distant metastases. Elevated Meta and N-Meta was also associated with a poor survival rate. All these data suggest that the predominance of the sympathetic nervous system's activity predicts increased gastric carcinoma severity.

Alpha-lipoic acid and vitamin B complex slow down the changes in mice diabetic cardiomyopathy.

AIM: The aim of our study was to assess histologically and by cardiac ultrasound the effects of alpha-lipoic acid (ALA) and vitamin B complex, as pathogenic therapies, in diabetic cardiomyopathy (DCM) in mice. MATERIALS AND METHODS: We performed an experimental animal study, in which we analyzed from a structural and functional point of view the changes produced in DCM. To produce DCM, we induced diabetes mellitus (DM) in C57BL∕6 mice by intraperitoneal injection of a single 150 mg∕kg body weight dose of streptozotocin (STZ). We formed a sham group (animals without DM), a control group (animals with DM but without treatment, DM_Control) and a group of animals with DM that were treated with ALA and vitamin B complex (DM_Treated). RESULTS: At six weeks after STZ administration, there was no decrease in left ventricular ejection fraction (LVEF) in the sham group, while in the control group there was a significant decrease in LVEF, about 43.75±3.37%, compared to the group that received treatment with ALA and vitamin B complex, in which LVEF decreased to 49.6±5.02% (p=0.0432). Also, the degree of interstitial myocardial fibrosis was higher in animals with DM compared to animals without DM, but the applied therapeutic protocol considerably improved the accumulation of interstitial collagen. The same observation was maintained regarding the evaluation of polysaccharide deposits. CONCLUSIONS: We can say that the administration of ALA and vitamin B complex in mice with STZ-induced DM, improves the degree of myocardial fibrosis, the accumulation of polysaccharides, and prevents severe deterioration of systolic and diastolic function of the heart.

Myocardial Function Assessed by Multi-Layered Two-Dimensional Speckle Tracking Analysis in Asymptomatic Young Subjects with Diabetes Mellitus Type 1.

BACKGROUND: Diabetes mellitus type 1 (DM1) is associated with a high risk for cardiovascular disease, and early detection of myocardial dysfunction is crucial for the prevention of cardiac complications. OBJECTIVES: The aim of this study was to evaluate left ventricular (LV) and right ventricular (RV) function by using both conventional echocardiography as well as multi-layered speckle tracking echocardiography (STE) in young adults with DM1. METHODS: We included 50 young asymptomatic adults diagnosed with DM1 (mean interval from diagnosis 9 ± 6 years) and 80 healthy controls. STE was acquired using the GE Vivid S60 equipment. The LV longitudinal strain (LS), layer-specific strains of the endocardium, myocardium, and epicardium (global longitudinal strain [GLS]endo, GLSmyo, GLSepi) as well as RV strain were obtained using the EchoPAC BT13 workstation. RESULTS: No significant intergroup differences in LV ejection fraction were noted. GLSendo and GLSmyo were reduced in the DM1 group (-20.6 ± 2.7 vs. -22.0 ± 2.3 and -18.0 ± 2.4 vs. -19.1 ± 1.9, respectively, p < 0.05) compared to controls. Mechanical dispersion was higher in the diabetes group (34 ± 11 vs. 29 ± 7, p < 0.05). RV strain measurements showed no significant difference between the groups. CONCLUSIONS: Young adults with DM1 and without known heart disease have subclinical myocardial dysfunction with lower LV endocardium and myocardium LS and higher mechanical dispersion demonstrated by multi-layered STE.

NT-proBNP and Echocardiographic Parameters in Liver Cirrhosis - Correlations with Disease Severity.

determined. Liver disease severity in patients with cirrhosis was established by Child-Pugh class, MELD score and presence/absence of ascites. Results: Plasma levels of NT-proBNP were significantly higher in cirrhotic patients than in the healthy subjects. NT-proBNP levels were also significantly elevated in Child-Pugh class C patients compared to those in class B and A. Left atrium size, diastolic function, left ventricular wall thickness and left ventricular ejection fraction were significantly altered in cirrhotic patients compared to controls. Advanced cirrhosis and high levels of NT-proBNP were significantly associated with increased left atrium volume and signs of cardiac diastolic dysfunction. We also observed significant differences between quartile groups of MELD score for the following: NT-proBNP, Troponin I, left atrium volume, left ventricle wall thickness, lateral wall and septum systolic tissue doppler velocities and global longitudinal strain. Conclusion: NT-proBNP is increased in patients with cirrhosis and is correlated with the severity of liver disease as established by Child-Pugh class, MELD score and presence of ascites.

Longitudinal strain analysis allows the identification of subclinical deterioration of right ventricular function in patients with cancer therapy-related left ventricular dysfunction.

BACKGROUND: This study was designed to assess right ventricular systolic function in cancer patients. METHODS AND RESULTS: 68 consecutive patients receiving potentially cardiotoxic agents were followed for 6 months in a single-center, observational, cohort-study. Left ventricle and free-wall right ventricular longitudinal strain were analyzed prior and after 6 months of treatment, using a vendor-independent software, together with left ventricle ejection fraction, tricuspid annulus plane systolic excursion and right ventricular fractional area change. Cancer therapy-related cardiac dysfunction was defined as a left ventricle ejection fraction drop of >10% to <53%. Both left ventricle ejection fraction (59±7% vs. 55±8%, p<0.0001) and left ventricle longitudinal strain (-19.7±2.5% vs. -17.1±2.6%, p<0.0001) were reduced at follow up, along with free-wall right ventricular longitudinal strain (-24.9±4.5% vs. -21.6±4.9%, p<0.0001). Cancer therapy-related cardiac dysfunction was detected in 20 patients (29%). In 15 out of these 20 patients (75%), a concomitant relative reduction in free-wall right ventricular longitudinal strain magnitude by 17±7% was detected. Moreover, there was a significant correlation between left ventricle and free-wall right ventricular longitudinal strain at follow-up examinations (r=0.323, p<0.0001). A relative drop of right ventricular longitudinal strain >17% had a sensitivity of 55% and a specificity of 70% (AUC=0.75, 0.7-0.8, 95% CI) to identify patients with cancer treatment related cardiac dysfunction. Neither tricuspid annulus plane systolic excursion (24±5 vs. 23±4 mm, p=0.07), nor right ventricular fractional area change (45±8% vs. 44±7%, p=0.6) showed any significant change between examinations. CONCLUSIONS: Longitudinal strain analysis allows the identification of subclinical right ventricular dysfunction appearing in the course of cancer treatment when conventional indices of right ventricular dysfunction function are unaffected.

Variability of right ventricular global and segmental longitudinal strain measurements.

OBJECTIVES: We evaluated intra-observer, test-retest, and inter-observer reproducibility of right ventricular (RV) longitudinal strain (LS) measurements derived from two-dimensional speckle tracking echocardiography. BACKGROUND: The assessment of RV deformation has demonstrated to hold valuable prognostic and diagnostic data in clinical practice. Data about the reproducibility of the measurements, however, are missing. METHODS: In 200 subjects, apical modified four-chamber view focused on the right ventricle (RV) was obtained. In 150 subjects (75%), a second set of images was acquired for test-retest analysis. Global RV LS (RVGLS-4C), free wall strain (RVFW-4C), and segmental maximum peak strain (base, mid, and apex) were calculated (EchoPac vBT13, GE Vingmed Ultrasound, Horten, Norway). Additionally, the reliability and feasibility of RV free wall strain derived from single wall tracking (RVFW-SWT) were tested. The absolute difference between repeated measurements and inter-class correlation coefficients (ICC) for consistency was calculated. RESULTS: RVGLS-4C and RVFW-4C measurement could be obtained in all subjects. RVGLS-4C demonstrated lower intra-observer, test-retest, and inter-observer absolute difference compared to RVFW-4C (1.4 ± 1.2%, 1.8 ± 1.5%, and 1.7 ± 1.9%, respectively, vs 2.4 ± 2.4, 2.2 ± 1.9, and 2.6 ± 3.0, respectively, P < 0.01). ICC ranged between 0.83 and 0.90 for RVGLS-4C measurements and between 0.76 and 0.79 for RVFW-4C measurements. RVFW-SWT was feasible in 82.5% of the subjects and showed noninferior reproducibility compared to RVFW-4C. Basal and apical segments demonstrating the highest variability. CONCLUSIONS: The measurement of RVGLS-4C appears to be reliable in clinical practice and demonstrates better reproducibility compared to RV free wall LS measurements. Segmental LS measurements presented high variability and such parameters should be interpreted with caution.

Variability of longitudinal strain measurements: levelling the playing field.

Speckle tracking echocardiography offers a unique opportunity to evaluate myocardial function, and global longitudinal strain (GLS) is currently recommended as a measurement of global left ventricular function. To facilitate clinical applicability of the method, collective efforts have been made to standardise strain measurements and to raise awareness of the potential sources of variability. The purpose of this review is to familiarise the reader with the most common sources of variability of longitudinal strain measurements and detail the possible measures to increase the accuracy and reproducibility of strain parameters.

Right atrium floating thrombus and bilateral pulmonary embolism in a patient with pancreatic pseudocyst.

Pulmonary embolism in the context of pancreatitis is a rare condition and even fewer cases of pulmonary embolism associated with pancreatic pseudocyst and chronic pancreatitis have been reported in the literature. We present the case of a patient diagnosed with chronic pancreatitis due to alcohol ingestion complicated with pancreatic pseudocyst, with no classic thrombogenic risk factors, who developed right atrial thrombus and massive bilateral pulmonary embolism. .

Left and right ventricular morphology and function in athletes with elevated pulmonary systolic arterial pressure.

OBJECTIVES: The objective of the study was to evaluate the prevalence and potential impact of elevated pulmonary arterial systolic pressure (PASP) on left and right cardiac morphology and function in young elite athletes. METHODS: In total, 85 professional athletes (40 endurance, 20 strength, and 25 mixed training, mean age 17.8 ± 4.0) and 50 sedentary controls (mean age 18.6 ± 3.3) underwent transthoracic echocardiographic examination. Two-dimensional measurements of the right (RV) and left ventricle (LV) were obtained. PASP was estimated from the peak tricuspid regurgitant velocity (TRV). Speckle tracking-derived longitudinal LV and RV strain measurements (RV_LS) were calculated for function estimation. RESULTS: Maximum TRV (2.2 ± 0.3 vs 2.0 ± 0.2 m/s, P < .01) and PASP (26 ± 5 vs 22 ± 5 mm Hg, P < .01) were higher in athletes compared to controls. PAPS above 30 mm Hg (35 ± 3 mm Hg, range 31-40 mm Hg) was identified in 11 athletes (12.9%). Athletes with elevated PASP demonstrated higher LV mass (P < .01), LV stroke volume indexed (P < .01), larger RV-end-systolic area (ESAi), RV-end-diastolic area (EDAi), right atrium ES volume and ED volume, and decreased RV fractional area change (FAC) (P < .01) when compared to matched controls and higher RV-EDAi (13.0 ± 1.6 vs 11.1 ± 1.5, P < .01), RV-ESAi (8.2 ± 1.5 vs 6.1 ± 0.9, P < .01), and significantly reduced RV FAC (38.1 ± 5.8 vs 44.6 ± 2.5, P < .01) when compared to matched athletes. LV global longitudinal strain and RV_LS showed no differences between the groups. CONCLUSIONS: Pulmonary arterial systolic pressure elevation in young athletes is associated with pronounced right ventricular enlargement, even when compared to matched athletes. Conventional and speckle tracking echocardiography showed preserved right ventricular function.

Collagen I and III, MMP-1 and TIMP-1 immunoexpression in dilated cardiomyopathy.

The extracellular matrix (ECM) remodeling represents the pathological substrate of dilated cardiomyopathy (DCM). In this study, we statistically analyzed the immunoexpression of collagen I and III, matrix metalloproteinase-1 (MMP-1) and its tissue inhibitor-1 (TIMP-1) in the myocardial tissue in 18 cases of DCM compared to a control group. We observed a significant increase in the immunoexpression of collagen I and III in patients with DCM and a significant reduction in the immunoexpression of MMP-1 compared with the control group. Also, the collagen I and TIMP-1 expression indicated a positive linear correlation and respectively a negative linear relationship with collagen III and MMP-1. The analyzed markers in this study can be used to quantify the degree of collagen sclerosis from the ECM of DCM.

Changes of desmin expression pattern in the myocardium of patients with alcoholic dilated cardiomyopathy.

INTRODUCTION: It has been suggested that desmin cytoskeleton remodeling may contribute to the progression of dilated cardiomyopathy and might affect long-term prognosis. This study is aiming at evaluating desmin expression in cardiomyocytes from patients with dilated cardiomyopathy of alcoholic etiology in advanced stages of the disease and comparing the results with measurements of normal heart tissue from control patients. MATERIALS AND METHODS: For immunohistochemistry, sections from 36 myocardium fragments taken from left ventricle of dilated cardiomyopathy patients were immunolabeled with an anti-desmin antibody and negative control slides were obtained by omitting the primary antibody. We calculated the ratios between the areas of myocardiocytes and the length and number of A dark disks and assessed the desmin expression level as the integrated optical density (IOD) and, respectively, the total areas of the signal given by immunolabeling. A Student's t-test has been utilized to assess the differences, p<0.05 deemed significant data. RESULTS: We identified significant decrease in numerical density of dark disks in our cases group compared with controls (p<0.05). Also, the ratios between total cellular area and total length of dark disks and number of dark disks was significantly different between cases and controls (p=0.04). IOD was significantly different between dilative cardiomyopathy cases and controls and also, overall desmin expression area was increased in dilatative cardiomyopathy patients. CONCLUSIONS: The identification of different desmin expression and standardization in diseased myocardium may be helpful in stratifying patients and in understanding their evolution, but also in finding new therapeutic targets that aim the alterations in desmin expression.

Rare case of single coronary artery in a patient with liver cirrhosis.

We report here the case of a 58-year-old male presented with atypical chest pain, dyspnea and fatigue, with a medical history of liver cirrhosis and undergoing treatment with beta-blocker. The clinical exam was normal. The 12-lead electrocardiogram (ECG) showed normal heart rate, without repolarization changes. Transthoracic echocardiography revealed no wall motion abnormalities of the left ventricle, moderate tricuspid regurgitation with mild pulmonary hypertension and left ventricular hypertrophy. The biochemical markers for myocardial infarction were negative. He underwent coronary angiography that revealed a single coronary artery originating from the right coronary sinus of Valsalva.