[Caseous calcification of the mitral annulus: case report and review of the literature]. / Calcificazione caseosa dell'anulus mitralico: caso clinico e revisione della letteratura.

Caseous calcification of the mitral annulus is an uncommon variant of mitral annular calcification. It appears as a round echodense mass containing central areas of echolucencies resembling liquefaction and with no flow in the central zone on color Doppler. In most cases it involves the posterior mitral annulus region, particularly in female subjects. The pathogenesis remains unclear: hypercholesterolemia and the dissolution of lipid-rich macrophages may be implicated in liquefaction necrosis. Transthoracic and transesophageal echocardiography represents the most reliable technique for diagnosis, whereas cardiac magnetic resonance imaging is the choice in doubtful cases. We report the case of an 82-year-old female patient describing different aspects of this particular clinical condition.

Giant Right Coronary Artery Aneurysm Detected by Transthoracic Echocardiography.

Coronary artery aneurysms (CAAs) are rare findings caused by atherosclerosis in about 50% of cases. They are usually diagnosed using coronary angiography, cardiac computed tomography, or magnetic resonance imaging. In this report, we present a rare case of giant, isolated right CAA, detected by transthoracic echocardiography in an adult patient with unstable angina. Diameters of the aneurysm were 3.6 cm × 2.7 cm. Anterior-septal hypokinesia of the left ventricle was also noted. A comprehensive echocardiographic examination, including contrast study, excluded alternative diagnoses and supported the hypothesis of a coronary ectasia. The coronary angiography confirmed the diagnosis of giant coronary aneurysm and revealed a severe three-vessel disease. The patient was treated with cardiac surgery a few days later: two coronary artery bypass grafts and exclusion of the aneurysm by surgical legation were successfully performed.

Anatomy of a wrong diagnosis: false sinus venosus atrial septal defect.

In contrast with transthoracic echocardiography, transesophageal echocardiography provides a sure way to make the diagnosis of sinus venosus atrial septal defect; on the other hand this abnormality is more complex than that seen with the secundum atrial septal defect, and inexperienced operators may fail to recognize properly the defect. In front of a high reported sensitivity using transesophageal echocardiography, specificity is difficult to assess, due to possible underreporting of diagnostic errors. We describe a false positive diagnosis of sinus venosus atrial septal defect, in the setting of enlarged right chambers of the heart because of pressure overload. Modified anatomy of the heart, together with the presence of a prominent linear structure(probably Eustachian Valve) and an incomplete examination in this case made image interpretation very prone to misinterpretation. In this anatomical setting transesophageal longitudinal "bicaval" view may be sub-optimal for examining the atrial septum, potentially showing false images that need to be known for correct image interpretation. Nonetheless, a scan plane taken more accurately at the superior level would have demonstrated/excluded the pathognomonic feature of sinus venosus atrial septal defect in the high atrial septum, between the fatty limbus and the inferior aspect of the right pulmonary artery; moreover TEE allows morphological information about the posterior structures of the heart that need to be investigated in detail for a complete diagnosis.

[Long QRS tachycardia secondary to Aconitum napellus alkaloid ingestion]. / Tachicardia a QRS largo da ingestione alimentare di alcaloidi di Aconitum napellus.

The roots and seeds of the aconite (Aconitum napellus) contain alkaloids with modulatory activity on the sodium voltage-dependent channels; most fatal cases have been determined by ventricular tachycardia and respiratory paralysis. The only established treatment is supportive. We report a case of poisoning from Aconitum napellus, ingested by a husband and wife who thought the plant was "mountain chicory". They both had tachyarrhythmias, but the husband had more malignant episodes of hemodynamically unstable wide QRS tachycardia and respiratory paralysis requiring mechanical ventilation.