Gabriella Locorotondo

Reversible coronary microvascular dysfunction: a common pathogenetic mechanism in Apical Ballooning or Tako-Tsubo Syndrome

AIMS To study coronary microvascular dysfunction as possible pathogenetic mechanism in Apical Ballooning Syndrome (ABS). METHODS AND RESULTS Fifteen ABS patients (all women, 68 +/- 14 years) underwent myocardial contrast echocardiography at baseline during adenosine infusion (140 microg/kg/min) and at 1-month follow-up and compared with a group of anterior ST-elevation myocardial infarction (STEMI) patients with similar clinical characteristics. Myocardial perfusion was assessed by contrast score index (CSI) and endocardial length of contrast defect (contrast defect length, CDL), whereas myocardial dysfunction by wall motion score index (WMSI), endocardial length of contractile dysfunction (wall motion defect length, WMDL), and LV ejection fraction (LVEF). At baseline, no difference in myocardial perfusion and dysfunction were present between the two groups. During adenosine challenge, while no changes were observed in STEMI group, in ABS patients CSI, CDL, WMSI, and WMDL significantly decreased compared with baseline (P < 0.001 vs. baseline for all parameters) and LVEF significantly increased (P = 0.01 vs. baseline). At 1-month follow-up, myocardial perfusion and dysfunction completely recovered in ABS patients (P < 0.001 vs. baseline for all parameters), whereas no significant changes were observed in STEMI group. CONCLUSION Our data strongly suggest that in ABS, irrespectively of its underlying aetiology, acute and reversible coronary microvascular vasoconstriction could represent a common pathophysiological mechanism.

Characterization of microvascular and myocardial damage within perfusion defect area at myocardial contrast echocardiography in the subacute phase of myocardial infarction

AIMS The anatomical correlates of perfusion defect (PD) at myocardial contrast echocardiography (MCE) in the subacute phase of ST-elevation myocardial infarction (STEMI) are currently unknown. The study aimed at assessing whether, in the subacute phase of STEMI, within MCE PD microvessels are anatomically damaged or if some vasodilation can be still elicited and if the PD correlates with the extent of myocardial necrosis. METHODS AND RESULTS Twenty-two post-percutaneous coronary intervention (PCI) patients underwent MCE 7 ± 1 days after STEMI, at baseline and after adenosine (ADN) administration. An area of completely non-opacified myocardium, corresponding to the area of the PD, was quantitated by planimetry. The area of the PD on MCE was compared with biochemical and imaging measures of myocardial necrosis: cardiac Troponin T peak (cTnT peak) and hyperenhanced area at gadolinium-enhanced cardiac magnetic resonance (Gd-CMR), respectively. After vasodilator stimulus, the area of the PD remained significantly unchanged when compared with the baseline value (P = 0.09 vs. baseline). The MCE index correlated at baseline with cTnT peak and Gd-CMR assessments of myocardial necrosis (P < 0.001). Also after ADN infusion, correlations between PD and extent of myocardial necrosis were similar to that assessed at baseline. CONCLUSION When assessed in the subacute phase of STEMI, the extent of the PD on MCE represents an area of both myocardial and microvascular necrosis.

Effects of late REopening of Coronary total Occlusion on micRovascular perfusion and myocarDial function: the RECORD study

AIMS The effects of the reopening of a coronary total occlusion (CoTO) on microvascular perfusion in subacute or chronic coronary syndromes are actually unclear. We aimed at evaluating the microvascular perfusion pattern by myocardial contrast echocardiography (MCE), in addition to contractile function, before and after CoTO reopening. METHODS Twenty four patients with subacute and chronic coronary syndromes and CoTO datable >7 days underwent evaluation of microvascular perfusion and left ventricular (LV) function by MCE (Acuson Sequoia, with Sonovue, Bracco) before the reopening of the CoTO and at 9 ± 3 months of follow-up. Microvascular perfusion was semi-quantitatively assessed by the contrast score index (CSI), whereas the endocardial length of the perfusion defect [contrast defect length (CDL)], measured in three apical views and averaged, was expressed as a percentage of the total LV endocardial border. The wall motion score index (WMSI), LV volumes, and ejection fraction were also calculated. RESULTS At baseline, a mild impairment of LV contractile function was observed, which corresponded to a similar impairment of the coronary microvascular perfusion in the overall study population. At follow-up, a significant reduction of CDL% [8.23 (0-19.63) vs. 0 (0-3.68), P = 0.005], improvement of the CSI (1.41 ± 0.29 vs. 1.12 ± 0.17, P = 0.001) and the WMSI (1.73 ± 0.41 vs. 1.33 ± 0.34, P = 0.0004), and increase in the ejection fraction (47.48% ± 8.66 vs. 55.60% ± 8.29, P = 0.0001) were found. CONCLUSION Reopening of a CoTO in patients with clinical indications to myocardial revascularization is associated with the improvement of coronary microvascular perfusion and the recovery of contractile function.

Influence of left ventricular hypertrophy on microvascular dysfunction and left ventricular remodelling after acute myocardial infarction

AIMS To ascertain whether the presence of left ventricular (LV) hypertrophy in patients with ST-segment elevation myocardial infarction (STEMI) influences microvascular dysfunction and LV remodelling at 6 months of follow-up. METHODS AND RESULTS Fifty-six consecutive STEMI patients successfully treated with primary or rescue percutaneous coronary intervention underwent conventional two-dimensional and myocardial contrast echocardiography within 24 h and at 6 months. Left ventricular mass, end-diastolic volume (EDV), end-systolic volume (ESV), ejection fraction, and wall motion score index (WMSI) were measured. Left ventricular hypertrophy was defined as LV mass index >116 g/m(2) in men and >104 g/m(2) in women. In order to evaluate the potential influence of microvascular dysfunction on LV remodelling, myocardial perfusion was semiquantitatively scored by contrast score index (CSI). Patients with LV hypertrophy had higher EDV and ESV both at 24 h and at 6 months, compared with patients without LV hypertrophy (P < 0.05). No significant changes over time were observed in both groups. Both WMSI and CSI were similar between groups at 24 h and at follow-up, but improved in both groups over time (P < 0.05). CONCLUSION Left ventricular hypertrophy does not appear to influence the development of post-acute myocardial infarction LV remodelling. Hypertrophic and non-hypertrophic left ventricles showed the same extent and temporal improvement in regional contractile function and microvascular perfusion.

Intramural atrial hematoma: a rare complication of a common procedure

In a 79-year-old woman admitted to another hospital for acute coronary syndrome and treated by urgent percutaneous coronary intervention (PCI) of right coronary artery (RCA), a left atrium (LA) formation, not previously seen at echocardiography, was surprisingly identified about 12 hours after revascularization. The patient was still asymptomatic, but, to better characterize such mass, she was early transferred to our department. Transthoracic echocardiography (TTE) (Philips iE33, Philips, Amsterdam, The Netherlands), performed at admission and within 24 hours from PCI, confirmed the presence of an anechoic formation (7.1 9 3.9 cm) with a thin hyperechoic wall, adhering to the free LA wall and protruding within the LA, with no valvular contact and transmitral medium gradient of 4 mmHg. No blood was found to flow inside the mass at color Doppler mode, neither any communication with atrial cavity could be identified. Presence of pericardial effusion was surely excluded and no other fluid was detected around the heart (Fig. 1A,B). Soon after admission, the patient developed high levels of systemic blood pressure associated with chest pain, dyspnea, and ST segment depression on lateral leads at electrocardiography. Then, an urgent coronary angiography (INNOVA, GE, Fairfield, CT, USA), that denied the onset of new coronary lesions, was performed. Interestingly, a leak and accumulation of contrast medium, which was not present at the time of PCI, was noted at RCA posterolateral side branch (Fig. 2A,B). Prompt optimization of antihypertensive therapy resolved chest pain and electrocardiographic changes and no elevation of cardiac necrosis biomarkers was further found. Shortness of breath, instead, was resolved resting on bed and was

Positron Emission Tomography in Acute Coronary Syndromes

Several imaging techniques have been used to assess cardiac structure and function, to understand pathophysiology, and to guide clinical decision making in the setting of acute coronary syndromes (ACS). Over the last years, cardiac positron emission tomography (PET) has affirmed its role in this setting. Indeed, the combined quantitative assessment of myocardial metabolism and perfusion has allowed to better understand the functional status of infarcted and non-infarcted myocardium, thus improving our knowledge of myocardial response to necrosis. More recently, several studies, taking advantage of previous observations in patients with cancer, have shown that PET could also provide important information on the mechanisms of vascular instability through the early identification of activated inflammatory cells in the atherosclerotic plaque. These findings are opening the way to more effective forms of prevention of acute vascular syndromes in high-risk patients; furthermore, new more sensitive and specific tracers for the identification of vascular inflammation are under development. In this review, we describe the potential and limitations of PET in the assessment of ACS.

Multiple vertebral fractures precipitate a platypnea-orthodeoxia syndrome in a patient with atrial septal defect and aortic root dilatation: When the upright position becomes intolerable

Platypnea-orthodeoxia syndrome is a rare disease characterized by dyspnea and oxygen desaturation induced by the upright position and relieved by recumbency. We report a case of a 65-year-old woman with a recent history of traumatic hip and multiple vertebral fractures referred to our institute due to onset of severe acute dyspnea. Transthoracic and transesophageal echocardiography, conducted by intravenous administration of agitated saline contrast solution, revealed the presence of atrial septal defect (ASD) associated with an important bidirectional shunting that was right-to-left directed when the patient was in a sitting position. Surgical closure of ASD resulted in resolution of the syndrome.

Intramyocardial Spontaneous Hematoma Mimicking an Acute Myocardial Infarction

An 80-year-old man affected by rheumatoid arthritis and chronic myeloid leukemia who was a smoker and hypertensive was admitted to the coronary care unit for first ST-elevation myocardial infarction. The diagnosis was suspected on the basis of the presence of chest pain associated with ST-segment elevation in leads III and aVF and a cardiac troponin T level of 0.30 ng/dL. At coronary angiography, performed 2 hours after pain onset, a 50% stenosis of the proximal right coronary artery with a translucent filling defect that suggested a parietal thrombus at the cardiac crux was found (see online-only Data Supplement Movie I); the left coronary artery had diffuse atherosclerosis in the absence of significant stenosis. Therefore, no interventional procedure was performed and the patient was treated with aspirin and clopidogrel. The …

Letter by Locorotondo et al Regarding Article, "Association Between Midwall Late Gadolinium Enhancement and Sudden Cardiac Death in Patients with Dilated Cardiomyopathy and Mild and Moderate Left Ventricular Systolic Dysfunction"

We read with great interest the article by Halliday and colleagues1 that was published in the May 30, 2017, issue of Circulation . The authors demonstrated that patients with mild-to-moderate left ventricular (LV) dysfunction and late gadolinium enhancement (LGE) during cardiac magnetic resonance imaging are at increased risk of sudden cardiac death and may benefit from implantation of a defibrillator. Similarly, a recent meta-analysis2 reported that ventricular arrhythmias and sudden cardiac death more frequently occur in patients with LGE, regardless of LV ejection fraction ( 35%). Recently, …

Cardiac thrombi mistaken for metastasis in recurrent melanoma.

Intra-cardiac thrombi can be incidentally found in recurrent melanoma and need careful assessment. An 81-year-old woman, with a history of malignant nasopharyngeal melanoma, was evaluated by echocardiography and cardiac magnetic resonance due to the detection of undefined masses localized both in right atrium and ventricle during contrast-enhanced thoraco-abdominal computed tomography.