Predictors of severe tricuspid regurgitation in patients with permanent pacemaker or automatic implantable cardioverter-defibrillator leads.

Patients with permanent pacemaker or automatic implantable cardioverter-defibrillator (AICD) leads have an increased prevalence of tricuspid regurgitation. However, the roles of cardiac rhythm and lead-placement duration in the development of severe tricuspid regurgitation are unclear. We reviewed echocardiographic data on 26 consecutive patients who had severe tricuspid regurgitation after permanent pacemaker or AICD placement; before treatment, they had no organic tricuspid valve disease, pulmonary hypertension, left ventricular dysfunction, or severe tricuspid regurgitation. We compared the results to those of 26 control subjects who had these same devices but no more than mild tricuspid regurgitation. The patients and control subjects were similar in age (mean, 81 ±6 vs 81 ±8 yr; P = 0.83), sex (male, 42% vs 46%; P = 0.78), and left ventricular ejection fraction (0.60 ±0.06 vs 0.58 ± 0.05; P = 0.4). The patients had a higher prevalence of atrial fibrillation (92% vs 65%; P=0.01) and longer median duration of pacemaker or AICD lead placement (49.5 vs 5 mo; P < 0.001). After adjusting for age, sex, and right ventricular systolic pressure by multivariate logistic regression analysis, we found that atrial fibrillation (odds ratio=6.4; P = 0.03) and duration of lead placement (odds ratio=1.5/yr; P = 0.001) were independently associated with severe tricuspid regurgitation. Out study shows that atrial fibrillation and longer durations of lead placement might increase the risk of severe tricuspid regurgitation in patients with permanent pacemakers or AICDs.

Left anterior descending coronary artery stenosis: in a patient with takotsubo cardiomyopathy.

Takotsubo cardiomyopathy is characterized by chest pain, electrocardiographic abnormalities such as ST-segment elevation or depression, and elevated cardiac enzyme levels. Left ventriculography reveals transient akinesis of the involved segment of the myocardial wall (usually the left ventricular apex) and compensatory hyperkinesis of the noninvolved myocardium, which appears as apical ballooning during systole. Existing criteria for the diagnosis of takotsubo cardiomyopathy include the absence of obstructive coronary artery disease. Indeed, previous investigators have found incidental stenosis in only a minority of patients.Herein, we present the unusual case of an 84-year-old woman who sustained 4 episodes of takotsubo cardiomyopathy in 18 years. At the time of the initial episode, coronary angiography revealed no substantial stenosis. Concomitant with the 2nd episode, stenosis in the 1st obtuse marginal branch was treated with stenting. No new lesions were apparent after the patient's 3rd presentation, and the previously placed stent was patent. During the 4th (current) presentation, we detected and percutaneously treated severe stenoses in the patient's left anterior descending coronary artery and 2nd obtuse marginal branch.Although this report is of a single patient only, it definitively illustrates that severe coronary artery disease can occur in patients who have takotsubo cardiomyopathy. We recommend the thorough evaluation of possible coronary artery disease in high-risk patients, even upon the strong clinical suspicion of takotsubo cardiomyopathy.

Predictors for the development of severe tricuspid regurgitation with anatomically normal valve in patients with atrial fibrillation.

BACKGROUND AND AIMS: Atrial fibrillation (AF) may be a risk factor for severe functional tricuspid valve regurgitation (FTR). We aimed to determine the predictors of severe FTR in patients with AF. METHODS AND RESULTS: From our echocardiographic laboratory database, we searched for and reviewed the medical records of consecutive patients with severe FTR and AF seen at Mayo Clinic in Arizona from 2002 through 2009. Our search identified 42 patients who met all inclusion criteria. These patients (cases) with severe FTR and AF were compared with 38 patients (controls) with AF who had no greater than mild tricuspid regurgitation. Case patients with severe FTR were older than controls (mean, 81 years vs. 76 years; P < 0.001) and more frequently had chronic AF (69% vs 26%; P < 0.001). Mean right atrial volume (86 mL/m(2) vs 46 mL/m(2) ; P < 0.001), right ventricular volume (42 mL ± 33 mL vs 22 mL ±8 mL; P < 0.001) and tricuspid annular diameter (3.6 cm vs 3.0 cm; P < 0.001) were larger in cases than in controls. Patients with severe FTR also had a higher prevalence of right-sided heart failure (69% vs 16%; P < 0.001). After adjusting for age and gender, right atrial and right ventricular volumes were independent predictors for the development of severe FTR in patients with AF (odds ratio, 1.7 [95% CI, 1.3-2.8] for every 10 mL/m(2) increase in right atrial volume; P = 0.0002 and odds ratio, 3.1 [95% CI, 1.5-8.9] for every 10 mL increase in right ventricular volume; P = 0.0002). CONCLUSIONS: Severe FTR occurs in older patients with chronic AF as a result of marked right atrial and right ventricular dilatation; and enlargement of the tricuspid annulus in the absence of pulmonary hypertension. More importantly, severe FTR leads to increased prevalence of right-sided heart failure underscoring the nonbenign nature of chronic AF.

Atypical presentation of takotsubo cardiomyopathy.

Midventricular ballooning syndrome, an atypical variant of takotsubo cardiomyopathy (TCM), is characterized by transient wall motion abnormalities of the midsegment of the left ventricle with apical sparing. In contrast to the typical form of TCM, apical contractility is preserved and may even be hyperkinetic in midventricular TCM. We present a case of atypical TCM in an 86-year-old woman who had chest pain while accompanying her husband in the emergency department as he was evaluated for chest pain.