Temporal Trends of Cardiac Chambers Function with Trastuzumab in Human Epidermal Growth Factor Receptor II-Positive Breast Cancer Patients.

BACKGROUND: Trastuzumab has substantially improved overall survival and reduced the risk of disease recurrence in patients with human epidermal growth factor receptor type II (HER-II)-positive breast cancer. However, this benefit may be at the increased risk of cardiotoxicity. We aimed to explore the early subclinical left and right ventricular as well as atrial dysfunction, in trastuzumab-treated patients with HER-II-positive breast cancer, using velocity vector imaging. METHODS: Echocardiography images were acquired in 50 patients with HER-II-positive breast cancer undergoing trastuzumab therapy. All patients had baseline and 3-6 months and 12-15 months of follow-up echocardiograms after initiation of trastuzumab therapy. Subendocardial borders of all the cardiac chambers were traced from the apical views to obtain volumetric and deformation indices. RESULTS: Mean age was 60 ± 13 years. Left ventricular (LV) ejection fraction as well as conventional indices of right ventricular (RV) function did not change with trastuzumab. The RV peak systolic global longitudinal strain (GLε) significantly decreased (-24.53 ± 6.03 vs. -21.28 ± 5.11 vs. -21.84 ± 5.15, baseline vs. first and second follow-ups, P = 0.01). LV peak systolic GLε was reduced by 1.19 at early follow-up (P < 0.05). Left atrial reservoir and booster pump functions as well as right atrial reservoir function were reduced through follow-up as well. CONCLUSIONS: The RV exhibited greater change in strain after trastuzumab treatment when compared to the LV. Atria function was reduced by trastuzumab as well. The repercussion of these findings and their potential implication will warrant further study.

Predictors of incipient dysfunction of all cardiac chambers after treatment of metastatic renal cell carcinoma by tyrosine kinase inhibitors.

PURPOSE: We aimed to explore the hypothesis that early subclinical cardiac chamber dysfunction secondary to tyrosine kinase inhibitors (TKIs) in patients with metastatic renal cell carcinoma could be signaled by abnormal cardiac mechanics demonstrated by velocity vector imaging. METHODS: Echocardiographic images were acquired from the apical views in 23 metastatic renal cell carcinoma patients. All patients had baseline and at least a 3-month follow-up echocardiogram after receiving TKI therapy. Subendocardial borders of all the cardiac chambers were traced to obtain volumetric and deformation indices. RESULTS: Mean age was 67 ± 9 years with 92% men. The right ventricle peak systolic global longitudinal strain (GLɛ) and strain rate were significantly lower after TKIs (-23.49 ± 5.1 versus -19.81 ± 5.5, p = 0.002 and -1.52 ± 0.52 versus -1.24 ± 0.35 p = 0.02, respectively). LV GLɛ was not statistically different. Volumetric and deformation indices showed a minimal decrease of the right atrium reservoir and conduit functions, and no significant changes of left atrial function. CONCLUSIONS: The right heart exhibited greater strain changes than the left heart after TKI treatment. The implications of these findings and their potential significance warrant further work.

Right and Left Atrial Dissimilarities in Normal Subjects Explored by Speckle Tracking Echocardiography.

BACKGROUND: Atrial function is an important contributor of ventricular function and has a prognostic role in various cardiovascular diseases. We tested the hypothesis that right and left atrial (RA & LA) function may not be equal despite their accommodating identical cardiac output. METHODS: Two-dimensional (2D) speckle tracking echocardiography was acquired from the apical four-chamber view in 100 normal subjects. Both RA/LA subendocardial borders were traced to obtain atrial volumes, strain (ε) and strain rate (SR). Reservoir, conduit, and booster pump functions were evaluated. Consequently, εNeg (corresponding to pump function) and εPos (corresponding to conduit function) were gauged. The SR parameters (SRLateNeg, SRPos, and SREarlyNeg), corresponding respectively to atrial systole, inception of ventricular systole, and inception of ventricular diastole, were measured. RESULTS: Mean age was 39 ± 15 years with 50 men (50%). Volumetric indices revealed that reservoir (Filling Volume = 35.1 ± 10.4 mL for LA vs. 27.47 ± 11.93 mL for RA, expansion index = 52.18 ± 16.89% for LA vs. 45.03 ± 16.49% for RA and diastolic emptying index = 52.85 ± 16.85 for LA vs. 45.62 ± 16.5 for RA, P < 0.001) and conduit (passive emptying (%) of total emptying = 34.49 ± 10.4 for LA vs. 26.82 ± 11.98 for RA and passive emptying index = 52.63 ± 16.86 for LA vs. 45.39 ± 16.5 for RA, P < 0.001) functions were significantly higher in the LA compared to the RA. Nevertheless, deformation indices demonstrated an opposite pattern (SRpos = 1.88 ± 0.74 for RA vs. 1.56 ± 0.54 for LA, P = 0.03 and εPos = 59.56 ± 30.63 for RA vs. 45.94 ± 16.67 for LA, P < 0.001). Reservoir, conduit, and booster pump functions showed no statistical significance among both genders. CONCLUSIONS: Evaluation of global and regional RA/LA function by speckle tracking echocardiography is feasible. The current report provides insights regarding dissimilarities between both atria in healthy individuals. The significance of these findings and their potential application will warrant further work.

Reticent uneventful rupture of right coronary sinus of valsalva aneurysm into right ventricle.

Aneurysms of sinus of Valsalva are rare congenital or acquired cardiac anomalies. They most commonly involve the right or non-coronary sinuses. Herein we report a very rare case of a ruptured congenital right sinus of Valsalva aneurysm into the right ventricular outflow tract followed conservatively for at least 10 years without any events.

Unforeseen cardiac involvement in McArdle's disease.

McArdle's disease (glycogen storage disease type V) is a rare autosomal recessive metabolic myopathy due to myophosphorylase deficiency. It classically manifests by exercise intolerance, leg cramps, muscle pain and occasionally exercise induced myoglobinuria. The onset of exercise intolerance is typically in the second or third decades of life. It has a specific predilection to skeletal muscle involvement, yet cardiac muscle involvement is very rare. This report describes an unusual case of a 33 year-old man with known McArdle's disease who presented with an incidental finding of severe obstructive hypertrophic cardiomyopathy.

Mitral valve surgery for marantic endocarditis and multiple cerebral embolisation.

Valvular involvement is common in antiphospholipid syndrome (APS) with increased risk of thrombo-embolic events. We report a patient with APS and multiple cerebral infarcts. Echocardiography demonstrated verrucous vegetations of the mitral valve in keeping with marantic endocarditis. The patient underwent successful mitral valve replacement. Post-operative clinical and echocardiographic follow-up showed excellent short term results.

Unexpected sequel of chronic Q-fever endocarditis.

We report a patient with chronic Q-fever endocarditis who was treated with Bentall procedure on two occasions due to persistent endocarditis. A chronic pseudoaneurysm of the aortic root was discovered incidentally by cardiac magnetic resonance and computed tomography eight years post-operatively. Due to chronicity of the pseudoaneurysm and great risk of re-intervention, conservative management was recommended.

Patent ductus arteriosus with Eisenmenger syndrome.

Herein we report a 21 year-old woman with a previously documented patent ductus arteriosus and Eisenmenger physiology. She presented with increasing cyanosis and exercise intolerance which could be explained by a new finding of right to left shunting through an interatrial communication. She was started on Bosentan therapy aiming to reduce the pulmonary pressure with consideration for heart-lung transplantation should any further deterioration occur.

Mitral annular geometry in normal and myxomatous mitral valves: three-dimensional transesophageal echocardiographic quantification.

BACKGROUND AND AIM OF THE STUDY: The mitral annulus (MA) has a complex dynamic geometry that is difficult to visualize in two dimensions; hence, novel real-time three-dimensional transesophageal echocardiography (RT-3D-TEE) provides insights into its dynamic nature. The study aim was to investigate changes in MA geometry in normal subjects and to explore differences in patients with myxomatous mitral valve disease (MMVD), using 3D quantitation with RT-3D-TEE. METHODS: Thirty-five participants (18 with MMVD, 17 normal subjects as controls) were enrolled into the study. The following geometric measurements were obtained at end-systole (ES) and end-diastole (ED): surface area, circumference, perimeter, height, commissure-to-commissure (C-C) diameter, anterior-to-posterior (A-P) diameter, and the ratio of A-P diameter to C-C diameter (circularization). To detect the effect of the severity of mitral regurgitation (MR) on MA dynamics, patients with MMVD were allocated to two subgroups with mild (n = 7) or moderate/severe (n = 11) MR. RESULTS: Control subjects demonstrated a saddle-shaped, elliptical MA configuration with slightly larger ES parameters. The MA shape was changed during the cardiac cycle, being more circular at ES and flatter at ED (p < 0.05). In MMVD patients, the MA retained a saddle shape but became dilated and circular with larger ED parameters compared to controls (p < 0.05). The degree of MA geometric changes was more prominent in moderate/severe MR patients (p < 0.001), while mild MR patients displayed MA geometry and dynamics similar to those of controls. CONCLUSION: The MA geometry is altered in MMVD patients, with the extent of changes being determined by the severity of the MR. RT-3D-TEE provides high-quality images that permit a precise quantitative analysis of the 3D geometry of the MA.

Prediction of incipient left ventricular dysfunction in patients with chronic primary mitral regurgitation: a velocity vector imaging study.

AIMS: Progressive left ventricular (LV) dilatation and irreversible myocardial damage are important causes of morbidity and mortality in patients with chronic primary mitral regurgitation (MR) due to myxomatous mitral valve disease. We assessed the hypothesis that early subclinical LV dysfunction secondary to chronic primary MR could be signalled by abnormal LV rotation mechanics, utilizing velocity vector imaging (VVI). METHODS AND RESULTS: Forty-three with chronic primary MR and 41 normal subjects were evaluated. All had normal LV systolic function. Peak endocardial and epicardial rotations in systole were measured in apical and basal short-axis images. LV twist was defined as the net difference between apical and basal angles of rotation while LV torsion was calculated as LV twist divided by LV diastolic longitudinal length. To explore the effects of MR severity on LV rotation, patients were divided into three groups: mild, moderate, and severe MR. The peak twist and torsion of the LV endocardium displayed significant differences across the study groups (P = 0.005 and 0.015, respectively). Subjects with moderate MR revealed the highest LV rotation profile (2.26 ± 0.66°/cm and 17.83 ± 5.2° for torsion and twist, respectively), implicating hyperdynamic LV function. However, severe MR group showed the lowest LV rotation profile (1.39 ± 0.8°/cm and 11.43 ± 6.09° for torsion and twist, respectively), suggesting incipient LV dysfunction. There were no significant differences in epicardial LV rotations. CONCLUSION: Evaluation of global LV function by VVI is a novel reproducible index for detecting subnormal latent LV dysfunction in chronic MR patients, which may aid in the optimal timing of surgery.

Global left atrial dysfunction and regional heterogeneity in primary chronic mitral insufficiency.

AIMS: We assessed the hypothesis that global and regional left atrial (LA) function is altered in patients with chronic primary mitral regurgitation (MR) secondary to myxomatous mitral valve disease (MMVD). METHODS AND RESULTS: Velocity vector imaging of the LA was acquired from apical four- and two-chamber views in 41 normal and 43 subjects with chronic MR due to MMVD. All had normal left ventricular systolic function. The LA subendocardium was traced to obtain atrial volumes, ejection fraction, velocities, and strain (ε)/strain rate (SR) measurements. To explore the effects of MR severity on LA function, subjects were divided into two groups: mild vs. moderate/severe MR. Reservoir (expansion and diastolic emptying indices), booster pump (active emptying index) functions, and LA ejection fraction were markedly impaired in subjects with MR (P < 0.001). Mean LA ε was reduced in moderate/severe MR compared with control subjects (P < 0.01). A consistent pattern of differences in atrial regional function was noted with the anterior wall having a lower peak systolic ε/SR, which is more evident in the moderate/severe MR group (P < 0.01) when compared with controls and mild MR groups. CONCLUSION: LA filling during ventricular systole (reservoir function), LA contraction (booster pump function), and ejection fraction were significantly impaired in patients with chronic MR. Regional differences in LA contractility at the anterior wall were noted presumably due to the eccentricity of the systolic anteriorly directed MR jet hitting the anterior wall and altering local wall mechanics.

Real-time three-dimensional transesophageal echocardiography assessment of the mitral valve: perioperative advantages and game-changing findings.

Real-time three-dimensional transesophageal echocardiography (RT-3D-TEE) represents a unique perioperative cardiovascular imaging tool which, without any need for off-line reconstruction, has been shown to be highly valuable for evaluating mitral valve and other intracardiac structures. It is highly probable that, in the near future, RT-3D-TEE will have a positive effect on the perioperative assessment of complex 3D mitral valve structures, as it provides important approaches to the pathophysiology of various mitral valve diseases, including prosthetic valves, and will become incorporated into everyday perioperative practice. The clinical applications and therapeutic implications of perioperative RT-3D-TEE in the thorough assessment of the mitral valve are briefly summarized in this review.

Cardiac abnormalities in primary hyperoxaluria.

BACKGROUND: In patients with primary hyperoxaluria (PH), oxalate overproduction can result in recurrent urolithiasis and nephrocalcinosis, which in some cases results in a progressive decline in renal function, oxalate retention, and systemic oxalosis involving bone, retina, arterial media, peripheral nerves, skin, and heart. Oxalosis involving the myocardium or conduction system can potentially lead to heart failure and fatal arrhythmias. METHODS AND RESULTS: A retrospective review of our institution's database was conducted for all patients with a confirmed diagnosis of PH between 1/1948 and 1/2006 (n=103). Electrocardiogram (ECG) and echocardiography were used to identify cardiac abnormalities. Ninety-three patients fulfilled the inclusion criteria, 58% were male. Mean follow-up was 11.9 (median 8.8) years. In 38 patients who received an ECG or echocardiography, 31 were found to have any cardiac abnormalities. Cardiac findings correlated with decline in renal function. CONCLUSIONS: Our data suggests that physicians caring for patients with PH should pay close attention to cardiac status, especially if renal function is impaired.

Tuberculous endocarditis: valvular and right atrial involvement.

Valvular endocarditis due to Mycobacterium tuberculosis is a rare clinical entity. It is usually manifest in the context of disseminated tuberculosis in immunocompromised patients. This report describes a unique case of a 30-year-old immunocompetent man with an incidental finding of tuberculous valvular endocarditis. The patient had a large mass on the anterior mitral leaflet and severe mitral regurgitation. He underwent mitral valve replacement and Mycobacterium tuberculosis was cultured from the valve vegetation and the right atrial masses. Post-operative recovery has been uneventful without relapse for 24 months.

Rheumatic tricuspid valve disease: an evidence-based systematic overview.

BACKGROUND AND AIM OF THE STUDY: Right-sided valve abnormalities are less common than their left-sided counterparts. Furthermore, whilst organic rheumatic involvement of the tricuspid valve is not uncommon, it receives less attention than left-sided heart valves. An evidence-based systematic overview was carried out to assess the epidemiology, diagnosis and management of organic rheumatic tricuspid valve disease (RTVD) over the past half century. METHODS: A computed search spanning more than four decades was conducted to identify articles on various aspects of RTVD. The bibliographies of all relevant articles were also searched. RESULTS: A total of 2,497 rheumatic heart disease patients (mean age 25.5 years; female:male ratio 1.3:1) was included. RTVD was detected in 193 patients (7.7%). Echocardiography was used to detect tricuspid valve involvement in all patients. Associated mitral valve disease was present in 99.3% of the patients with RTVD. A total of 1,092 patients (mean age 45.4 years) was included from six studies on surgical correction of the tricuspid valve. Of these patients, 278 (25.4%) underwent tricuspid valve replacement, while 814 (74.5%) had tricuspid valve repair. The in-hospital mortality was 9.9%, and late mortality 33.2% CONCLUSION: RTVD is not uncommon among patients with rheumatic heart disease, but attracts less attention and might, therefore, be overlooked. Echocardiography is the most common diagnostic tool. Although indications for surgical intervention are not well defined, valve repair may have a better outcome than replacement.

Fatal migratory pulmonary thromboembolism following successful pericardiocentesis.

Echocardiography-guided pericardiocentesis is relatively safe with minimal risk in experienced hands. However, complications can occur because of the procedure. This report describes a unique case of an 84-year-old man with unanticipated fatal pulmonary thromboembolism following a successful pericardiocentesis.

Prevention of late postmyocardial infarction left ventricular remodeling: an update.

Cardiac remodeling remains an important primary therapeutic target in patients with myocardial infarction (MI) and chronic heart failure. It also has utility as a reliable surrogate for clinical outcomes. The past three decades of research have demonstrated the importance of cardiac remodeling as a basic mechanism in the progression of heart failure. Novel therapeutic advances have allowed more patients to survive acute MI. Strategies to prevent or halt adverse left ventricular remodeling have included pharmacotherapy, percutaneous interventions, device-based therapies, and surgical procedures. More recently, experimental research has added opportunities for novel approaches to prevent and reverse cardiac remodeling. This review summarizes the effects of current and future therapeutic strategies on left ventricular remodeling and dysfunction after MI.

Infectious pericarditis: an experience spanning a decade.

BACKGROUND: Although recent literature suggests a changing spectrum for infectious pericarditis (IP), this view has not been proven. In this report, we aim to review the features of IP in cases from a large tertiary centre. METHODS: A retrospective review of our institution's database was conducted to identify cases with IP between January 1994 and December 2004. All pericardial biopsy tissue results from the same period were also reviewed. RESULTS: One hundred and thirty-eight cases were identified, of which 14 cases were identified by pathology. The mean age was 53 +/- 18 years, and 74% were men. The most frequently identified causative organisms were Propionibacterium acnes (P. acnes), staphylococci and streptococci. A common predisposing factor was an immune-compromised state, followed by cardiac surgery. Fifty-five patients were treated with antibiotics (medical group) while 63 cases (surgical group) underwent surgical drainage (pericardial window) and/or pericardiectomy. In comparison to the medical group, the surgical group was more critically ill and immunocompromised (40% versus 24%, respectively). There were 52 late deaths during follow-up. Mortality in the medical group was 67% while in the surgical group it was 24% (P < 0.0001). CONCLUSIONS: In contradistinction to the literature reports, the most prevalent organism for IP was P. acnes. Patients managed aggressively with both antibiotics and surgery, demonstrated lower mortality rates. Therefore, clinicians should maintain a high index of suspicion for IP so that timely and appropriate mortality-reducing strategies can be offered.