Finger ischemia in a young lady: an unusual presentation of papillary fibroelastoma with intraventricular location.

An otherwise healthy 32-year-old woman suffered from finger ischemia. An echocardiogram and computed tomography scan revealed a mobile mass in the left ventricle that was attached to the anterior papillary muscle and did not involve the valve leaflets. The tumor was resected, and histopathology confirmed it to be a papillary fibroelastoma. Our case emphasizes the significance of a comprehensive diagnostic work-up for a peripheral ischemic lesion. This resulted in the discovery of an unusual intra-ventricular origin for a commonly benign tumor.

Differentiating typical Tako-tsubo syndrome from extensive anterior STEMI: Look behind the anterior wall.

BACKGROUND: Tako-tsubo syndrome (TTS) in its most typical form shares common features with anterior ST-segment elevation myocardial infarction (AMI) during acute presentation. Differential diagnosis between the two conditions is often challenging especially if ST-segment elevation is associated with extensive apical akinesis. METHODS: We sought to systematically analyze ECG and echocardiographic parameters including LV longitudinal strain and two new indexes: the inferior-apex ratio (IAR) and the inferior-lateral-apex ratio (ILAR), to assess if ventricular involvement may be different in TTS and AMI. RESULTS: A retrospective cohort study was conducted with two groups: patients with TTS (n = 22) and patients with extensive anterior STEMI (n = 22). Lack of ST elevation in V1 was associated with TTS with sensitivity and specificity of 86%, positive and negative predictive value of 86%. Longitudinal strain in mid inferior and mid inferior-lateral segments were more compromised in TTS: -4.3 ± 6.4% and -5.4 ± 5.4% in TTS versus -10.2 ± 5.5% and -9.9 ± 4.9% in AMI, respectively (p < .01 for all). By multivariate analysis, both longitudinal strain values, inferior-apical ratio (IAR) < 1 and inferior-lateral-apical ratio (ILAR) < 1 were independently associated with diagnosis of TTS during acute phase. CONCLUSIONS: Our results suggest that impaired contractility extending beyond apex to mid inferior and inferior-lateral walls can be easily assessed by IAR and ILAR, and these indexes facilitate non-invasive differentiation of TTS from extensive anterior STEMI.

Acute heart failure due to COVID-19 related myocardial injury and de novo hypertensive cardiomyopathy: a challenging diagnosis.

We report a COVID-19 case with acute heart and kidney failure in a healthy young male. Echocardiography showed severe systolic and diastolic left ventricle dysfunction, with diffuse myocardial thickening. Cardiac MRI showed aspects of focal myocarditis, and hypertensive cardiomyopathy. Renal biopsy demonstrated limited acute tubular injury, and hypertensive kidney disease. Coronary angiography excluded critical stenoses. Unlike what we initially suspected, myocardial inflammation had a limited extent in our patient; severe hypertension causing cardiomyopathy and multi-organ damage, not diagnosed before, was primarily responsible for severe illness. Correct diagnosis and guidelines-directed treatment allowed a favorable course.

Dyspnea following thoracostomy closure after right pneumonectomy: An uncommon echocardiographic diagnosis and therapeutic approach.

Dyspnea and hypoxemia are common postoperative problems after pneumonectomy. One of the rarer causes of respiratory distress after right pneumonectomy is the development of a significant right-to-left shunt across a patent foramen ovale (PFO), which can evolve at a variable interval of time after the operation. We report here our experience with a patient who underwent right pneumonectomy, followed by several complications, and who presented severe dyspnea 7 months later, after the closure of a right thoracostomy. This report outlines the management of this challenging clinical condition; transesophageal echocardiography (TOE) provided a clear diagnosis and guided an effective percutaneous treatment.

Severe Aortic Regurgitation of Early Degenerated Mitroflow Bioprosthesis: From Echocardiographic Diagnosis to Treatment with Valve-in-Valve Transcatheter Aortic Valve Implantation.

Valve-in-Valve transcatheter aortic valve implantation (ViV TAVI) is emerging as an effective therapeutic option for bioprosthetic valve failure. Recently, concern has been raised for early valve deterioration of Mitroflow (Sorin) aortic bioprosthesis, with the development of prevalent stenosis. We report cases of pure severe aortic regurgitation (AR) due to early and mid-term prosthesis degeneration. From June 2018 to October 2019, three patients were treated in our division for the new appearance of severe intraprosthetic regurgitation. Patient 1 (man, 85-year-old) and patient 3 (woman, 83-year-old) had a Mitroflow n. 25 and n. 21 implanted, respectively, in 2012 and 2013 for severe aortic stenosis. Patient 2, a 67-year-old woman with Marfan syndrome underwent a Mitroflow n. 25 implant in 2008 for severe AR and presented chronic type-B aortic dissection. Patient 1 was diagnosed with severe AR in the ambulatory setting, while the other patients presented acute heart failure, requiring inotrope support and high doses intravenous diuretics, and in case 3, temporary extracorporeal ultrafiltration. All patients appeared at high surgical risk and were successfully treated with ViV TAVI, through the right axillary artery in patient 2, and through the femoral artery in patients 1 and 3. Results were good at short- and mid-term follow-up. In conclusion, early and midterm bioprosthesis degeneration with the development of severe AR is a possible complication of the Mitroflow aortic valve. ViV TAVI has been confirmed as a safe and effective therapeutic option in our cases.

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.

Atrial Function as an Independent Predictor of Postoperative Atrial Fibrillation in Patients Undergoing Aortic Valve Surgery for Severe Aortic Stenosis.

BACKGROUND: Postoperative atrial fibrillation (POAF) is a common, clinically relevant, but hardly predictable complication after surgical aortic valve replacement. The aim of this study was to test the role of preoperative left atrial longitudinal strain as a predictor of POAF in clinical practice. METHODS: Sixty patients scheduled for aortic valve replacement for severe isolated aortic stenosis, in stable sinus rhythm, were prospectively enrolled and underwent full clinical, biochemical, and transthoracic echocardiographic assessment on the day before surgery. Left atrial strain-derived peak atrial longitudinal strain (PALS) and peak atrial contraction strain (PACS) were obtained. The occurrence of POAF was evaluated during the hospital stay after the intervention. RESULTS: POAF was present in 26 of 60 patients (43.3%). Among all clinical variables examined, age showed a significant correlation with POAF (P = .04), while no significant differences were noted regarding preoperative symptoms, cardiovascular risk factors, medications, and biochemical data. As for the echocardiographic parameters, only PALS and PACS showed strong, significant correlations with the occurrence of arrhythmia (P < .0001 on univariate analysis), with areas under the curve of 0.87 ± 0.04 (95% CI, 0.76-0.94) for PALS and 0.85 ± 0.05 (95% CI, 0.73-0.93) for PACS. In two comprehensive multivariate models, PALS and PACS remained significant predictors of POAF (odds ratio, 0.73 [95% CI, 0.61-0.88; P = .0008] and 0.72 [95% CI, 0.59-0.87; P = .0007]). No significant interaction was detected between PALS or PACS and other clinical and echocardiographic variables, including age, E/E' ratio, and left atrial enlargement. CONCLUSIONS: PALS and PACS indexes are routinely feasible and useful to predict POAF in patients with severe isolated aortic stenosis undergoing surgical aortic valve replacement.

Frame rate required for speckle tracking echocardiography: A quantitative clinical study with open-source, vendor-independent software.

OBJECTIVES: To determine the optimal frame rate at which reliable heart walls velocities can be assessed by speckle tracking. BACKGROUND: Assessing left ventricular function with speckle tracking is useful in patient diagnosis but requires a temporal resolution that can follow myocardial motion. In this study we investigated the effect of different frame rates on the accuracy of speckle tracking results, highlighting the temporal resolution where reliable results can be obtained. MATERIAL AND METHODS: 27 patients were scanned at two different frame rates at their resting heart rate. From all acquired loops, lower temporal resolution image sequences were generated by dropping frames, decreasing the frame rate by up to 10-fold. RESULTS: Tissue velocities were estimated by automated speckle tracking. Above 40 frames/s the peak velocity was reliably measured. When frame rate was lower, the inter-frame interval containing the instant of highest velocity also contained lower velocities, and therefore the average velocity in that interval was an underestimate of the clinically desired instantaneous maximum velocity. CONCLUSIONS: The higher the frame rate, the more accurately maximum velocities are identified by speckle tracking, until the frame rate drops below 40 frames/s, beyond which there is little increase in peak velocity. We provide in an online supplement the vendor-independent software we used for automatic speckle-tracked velocity assessment to help others working in this field.

Nonalcoholic Fatty Liver Disease Is Associated With Ventricular Arrhythmias in Patients With Type 2 Diabetes Referred for Clinically Indicated 24-Hour Holter Monitoring.

OBJECTIVE: Recent studies have suggested that nonalcoholic fatty liver disease (NAFLD) is associated with an increased risk of heart rate-corrected QT interval prolongation and atrial fibrillation in patients with type 2 diabetes. Currently, no data exist regarding the relationship between NAFLD and ventricular arrhythmias in this patient population. RESEARCH DESIGN AND METHODS: We retrospectively analyzed the data of 330 outpatients with type 2 diabetes without preexisting atrial fibrillation, end-stage renal disease, or known liver diseases who had undergone 24-h Holter monitoring for clinical reasons between 2013 and 2015. Ventricular arrhythmias were defined as the presence of nonsustained ventricular tachycardia (VT), >30 premature ventricular complexes (PVCs) per hour, or both. NAFLD was diagnosed by ultrasonography. RESULTS: Compared with patients without NAFLD, those with NAFLD (n = 238, 72%) had a significantly higher prevalence of >30 PVCs/h (19.3% vs. 6.5%, P < 0.005), nonsustained VT (14.7% vs. 4.3%, P < 0.005), or both (27.3% vs. 9.8%, P < 0.001). NAFLD was associated with a 3.5-fold increased risk of ventricular arrhythmias (unadjusted odds ratio [OR] 3.47 [95% CI 1.65-7.30], P < 0.001). This association remained significant even after adjusting for age, sex, BMI, smoking, hypertension, ischemic heart disease, valvular heart disease, chronic kidney disease, chronic obstructive pulmonary disease, serum γ-glutamyltransferase levels, medication use, and left ventricular ejection fraction (adjusted OR 3.01 [95% CI 1.26-7.17], P = 0.013). CONCLUSIONS: This is the first observational study to show that NAFLD is independently associated with an increased risk of prevalent ventricular arrhythmias in patients with type 2 diabetes.

Nonalcoholic Fatty Liver Disease Is Independently Associated with Early Left Ventricular Diastolic Dysfunction in Patients with Type 2 Diabetes.

Accumulating evidence suggests that nonalcoholic fatty liver disease (NAFLD) is associated with left ventricular diastolic dysfunction (LVDD) in nondiabetic individuals. To date, there are very limited data on this topic in patients with type 2 diabetes and it remains uncertain whether NAFLD is independently associated with the presence of LVDD in this patient population. We performed a liver ultrasonography and trans-thoracic echocardiography (with speckle-tracking strain analysis) in 222 (156 men and 66 women) consecutive type 2 diabetic outpatients with no previous history of ischemic heart disease, chronic heart failure, valvular diseases and known hepatic diseases. Binary logistic regression analysis was used to examine the association between NAFLD and the presence/severity of LVDD graded according to the current criteria of the American Society of Echocardiography, and to identify the variables that were independently associated with LVDD, which was included as the dependent variable. Patients with ultrasound-diagnosed NAFLD (n = 158; 71.2% of total) were more likely to be female, overweight/obese, and had longer diabetes duration, higher hemoglobin A1c and lower estimated glomerular filtration rate (eGFR) than those without NAFLD. Notably, they also had a remarkably greater prevalence of mild and/or moderate LVDD compared with those without NAFLD (71% vs. 33%; P<0.001). Age, hypertension, smoking, medication use, E/A ratio, LV volumes and mass were comparable between the two groups of patients. NAFLD was associated with a three-fold increased odds of mild and/or moderate LVDD after adjusting for age, sex, body mass index, hypertension, diabetes duration, hemoglobin A1c, eGFR, LV mass index and ejection fraction (adjusted-odds ratio 3.08, 95%CI 1.5-6.4, P = 0.003). In conclusion, NAFLD is independently associated with early LVDD in type 2 diabetic patients with preserved systolic function.

Heart valve calcification in patients with type 2 diabetes and nonalcoholic fatty liver disease.

PURPOSE: Aortic valve sclerosis (AVS) and mitral annulus calcification (MAC) are two powerful predictors of adverse cardiovascular outcomes in patients with type 2 diabetes, but the etiology of valvular calcification is uncertain. Nonalcoholic fatty liver disease (NAFLD) is an emerging cardiovascular risk factor and is very common in type 2 diabetes, but whether NAFLD is associated with valvular calcification in this group of patients is presently unknown. METHODS: We undertook a cross-sectional study of 247 consecutive type 2 diabetic outpatients with no previous history of heart failure, valvular heart diseases (aortic stenosis, mitral stenosis, moderate or severe aortic and mitral regurgitation) or hepatic diseases. Presence of MAC and AVS was detected by echocardiography. NAFLD was diagnosed by ultrasonography. RESULTS: Overall, 139 (56.3%) patients had no heart valve calcification (HVC-0), 65 (26.3%) patients had one valve affected (HVC-1) and 43 (17.4%) patients had both valves affected (HVC-2). 175 (70.8%) patients had NAFLD and the prevalence of this disease markedly increased in patients with HVC-2 compared with either HVC-1 or HVC-0 (86.1% vs. 83.1% vs. 60.4%, respectively; p < 0.001). NAFLD was significantly associated with AVS and/or MAC (unadjusted-odds ratio 3.51, 95% CI 1.89-6.51, p < 0.001). Adjustments for age, sex, waist circumference, smoking, blood pressure, hemoglobin A1c, LDL-cholesterol, kidney function parameters, medication use and echocardiographic variables did not appreciably weaken this association (adjusted-odds ratio 2.70, 95% CI 1.23-7.38, p < 0.01). CONCLUSIONS: Our results show that NAFLD is an independent predictor of cardiac calcification in both the aortic and mitral valves in patients with type 2 diabetes.