Giordano Zampi

Takotsubo Syndrome After Mitral Valve Replacement: Case Report and Brief Review of the Literature

RANSIENT LEFT VENTRICULAR apical ballooningsyndrome, also known as Takotsubo or stress-inducedcardiomyopathy, is a cardiac disease characterized by transientleft ventricular dysfunction, electrocardiographic changes mim-icking an acute coronary syndrome, and release of myocardialcellular necrosis enzymes in the absence of significant lesionsof coronary arteries.

Early Doppler-echocardiography evaluation of Carpentier-Edwards Standard and Carpentier-Edwards Magna aortic prosthetic valve: comparison of hemodynamic performance

ObjectivesThis study was designed to describe Doppler-echocardiography values of Carpentier-Edwards Perimount Standard (CEPS) and Carpentier-Edwards Perimount Magna (CEPM) aortic prosthetic valves, evaluated by a single, experienced echo-laboratory, early in the postoperative phase.MethodsThree-hundred-seventy-seven consecutive patients, who had had a CEPS or a CEPM implanted in our Hospital due to aortic stenosis and/or insufficiency, underwent baseline Doppler echocardiography evaluation within 7 days after surgery. Hemodynamic performances of CEPS and CEPM were accurately described, evaluating flow-dependent (transprosthetic velocities and gradients) and flow-independent (effective orifice area, indexed effective orifice area and Doppler velocity index) Doppler-echocardiography parameters.ResultsOut of the 377 patients 48.8% were men (n = 184), mean age was 74.63 ± 6.77 years, mean BSA was 1.78 ± 0.18 m2, mean ejection fraction was 57.78 ± 8%. Two-hundred and sixty two CEPS and 115 CEPM were implanted. Comparing size-by-size CEPS with CEPM, both prostheses showed a good hemodynamic profile, with fairly similar values of pressure gradients (PGmax and mean, in mmHg, = 37,18 ± 11.57 and 20.81 ± 7.44 in CEPS n°19 compared to 32,47 ± 7,76 and 17,67 ± 4.63 in CEPM n°19 and progressively lower in higher sized prostheses, having PGmax and mean 15 ± 3,16 and 9.15 ± 1,29 in CEPS n°29 compared to 15,67 ± 1,53 and 9 ± 1 in CEPM n°29) and EOAi (being 0,65 ± 0,33 cm²/m² in CEPS n°19 compared to 0,77 ± 0,29 cm²/m² in CEPM n°19 and progressively higher in higher sized prostheses, being 1,28 ± 0,59 cm²/m² in CEPS n°29 compared to 1,07 ± 0,18 cm²/m² in CEPM n°29), the latter resulting, however, basically less flow obstructive.ConclusionsOur data confirm the good hemodynamic performance of both aortic bioprostheses and the more favourable hemodynamic profile of CEPM compared to CEPS, pointing out the need to perform routinely an accurate baseline Doppler-echocardiography evaluation early after surgery to allow an adequate interpretation of data at follow-up.

Liposarcoma metastasis of the heart: burst shoots to reveal it

A 36-year-old male in chemotherapy treatment for a surgically removed liposarcoma of the shoulder underwent transthoracic echocardiography to evaluate cardiac function. The echo showed a great dishomogeneous mass of ∼6 …

An unrepaired persistent truncus arteriosus in a 62-year-old adult.

: In this image focus, we describe the case an old woman with persistent unrepaired truncus arteriosus type III and Eisenmenger syndrome.

The pressure/volume relationship during dobutamine stress echocardiography in transplanted heart: comparison with quality of life and coronary anatomy

BackgroundCardiac allograft vasculopathy (CAV) is a major late complication in cardiac transplant recipients and has a relevant impact on outcome of these patients. Aims of this study: to compare, in cardiac transplant recipients patients, the diagnostic value of pressure/volume relationship (ESPVR) during dobutamine stress echocardiography (DSE) for coronary artery disease, assessed by Multislice Computed Tomography (MSCT), and by coronary angiography (CA). We also analyzed any possible relationship between ESPVR and the Health Related Quality of Life of the patients (HRQoL), evaluated by SF–36 questionnaire.Methods25 consecutive patients underwent DSE within 24 hours after MSCT coronary angiogram and then they underwent CA. The HRQoL questionnaire was administered to the patients in the settings of DSE. They were followed-up for 6 months.ResultsDSE has a sensitivity in detecting CAV of 67%, specificity of 95%, positive predictive value of 67% and negative predictive value of 95%; DSE with ESPVR has a sensitivity of 100%, specificity of 95%, positive predictive value of 75%, negative predictive value of 100%; MSCT has a sensitivity of 100%; specificity of 82%; positive predictive value of 43%; negative predictive value of 100%. Htx recipients with a flat-biphasic ESPVR, although asymptomatic, perceived a worst HRQoL compared with the up-sloping ESPVR population, and this is statistically significant for the general health (p 0.0004), the vitality (p 0.0013) and the mental health (p 0.021) SF-36 subscale.ConclusionsEvaluation with DSE and ESPVR is accurate in the clinical control of heart transplant recipients reserving invasive evaluation only for patients with abnormal contractility indexes.

Left atrial myxoma: two sides of the same coin.

In this clinical picture we present two cases of left atrial myxoma that differed very much in their clinical presentation.

Influence of myocardial viability on responsiveness to cardiac resynchronization in ischemic dilated cardiomyopathy: a prospective observational cohort study

OBJECTIVE To understand whether patients with post-ischemic dilated cardiomyopathy and myocardial viability (MV) could benefit from cardiac resynchronization therapy (CRT) in terms of clinical, echocardiographic and neuro- hormonal parameters compared to patients without MV. METHODS One hundred and four consecutive patients were enrolled in a prospective observational cohort study. Using dobutamine stress echocardiography, 2 groups were identified: group A of 51 patients with MV and group B of 53 patients without MV. All patients were implanted with biventricular pacing devices combined with an internal cardioverter-defibrillator. Clinical, echocardiographic and neuro-hormonal parameters were evaluated at baseline and at six month follow-up. Analysis of variance for repeated measures on each variable suggestive of remodeling was performed. We considered responder every patient with: decrease of > 15% in left ventricular volumes and/or improvement in left ventricular ejection fraction of > 5% in addition to NYHA class improvement. RESULTS All the variables improved in both groups (time effect). Comparing the two groups (group effect), the following variables were significantly better in group A: N-terminal pro-B-type natriuretic peptide (p=0.02), NYHA class (p=0.003), reverse remodeling (RR) (p=0.007), dP/dt (p=0.005), left ventricular ejection fraction (p=0.009), 3rd sound (p=0.01), and left ventricular end-systolic volume after the first week (p=0.035). RR occurred at the first week after CRT only in Group A and was maintained for all the time of this study. The maximum difference of the decrease of left ventricular volumes between the two groups occurred after the first week (p<0.001). CONCLUSION Patients with MV responded better than patients without MV with a significant improvement after the first week from CRT.

Abdominal ascitic fluid: tricky concealing of the electrocardiogram

A 75-year-old Caucasian woman was referred to our Emergency Department (ED) with swollen legs and exertional dyspnoea. Additionally, she had a pancreatic adenocarcinoma with diffuse metastatic involvement and peritoneal carcinosis. Her physical exam revealed a blood pressure of 110/60 mm Hg, pulse 130/min, jugular venous distention not associated with pulsus paradoxus, muffled heart sounds, ascites, and ankle oedema. Upon her arrival at the ED blood saturation was 75% and arterial blood gas analysis revealed severe respiratory acidosis. An electrocardiogram (ECG) was promptly performed showing a sinus tachycardia and very low voltage on peripheral leads and on V4–V6 leads (Fig. 1A). Transthoracic echocardiography was performed due to suspicion of a pericardial effusion. However, the ultrasound examination was unreliable due to diffuse anechoic interposition of a large abdominal effusion altering the correct identification of cardiac chambers. Thoracic echoscopy showed no pleural or pericardial effusion. Chest X-ray demonstrated consistent elevation of the diaphragm resulting in heart displacement due to a huge ascitic effusion (Fig. 2A). Paracentesis was eventually performed, subtracting about three litres of ascitic fluid and resulting in improvement of the haemodynamic parameters and of dyspnoea. The procedure enabled the correct visualisation of cardiac structures by means of cardiac ultrasound examination, and the presence of pericardial effusion or constrictive pericarditis was definitely ruled out (Fig. 3A, B). Notably, three months before the referral the patient underwent a comprehensive medical evaluation with normal ECG (Fig. 1B) and X-ray (Fig. 2B) findings, demonstrating how impending abdominal effusion can consistently change ECG registration and interpretation.

Inverted left appendage: an unexpected echocardiographic image finding after left ventricular assist device implantation

The inverted left atrial appendage (LAA) is a rare cause of a left atrial mass and often leads to misdiagnoses [1, 2], and the natural history and incidence of subsequent complications are, as yet, undefined. When an inverted LAA is discovered postoperatively, it invariably presents as an echogenic, left atrial mass on transesophageal or transthoracic echocardiography. Differential diagnoses include atrial myxoma, vegetation, or thrombus, with the last being more likely in a patient immediately postsurgery [3]. We present the case of a 61-year-old male with a history of anterior left ventricle and infarction and depressed low ejection fraction (EF 0.20), who suffered from postischemic dilated cardiomyopathy. He was admitted for left ventricular assist device (LVAD) implantation in our department (INTERMACS Class 2). Preoperative transesophageal echocardiography (TEE) revealed a mild mitral valve regurgitation, dilated left atrium, and severe akinesia of extended left ventricle segments without endocardial thrombotic apposition, no atrial mass, and normal LAA shape (Fig. 1a, b). The patient underwent LVAD implantation (axial flow device) by standard cardiopulmonary bypass and through median sternotomy access. Postoperative transthoracic echocardiography revealed a long, large, and ellipsoidal hyperechoic image (18 9 14 mm) inside the left atrium, upper and nearer the mitral valve orifice. TEE confirmed the presence of the hyper echoic mass arising from the lateral left atrial wall (Fig. 1c) and fixed near the mitral annulus during cardiac diastole without signs of obstruction associated with increased flow velocity into the left superior pulmonary vein (Fig. 1d, e, Movie 1). Afterwards, we recognized that the cardiac structure was the left atrial appendage but inverted and mimicking a left atrial mass. We present an unusual and unexpected echocardiography image resulting in unpredictable hemodynamic changes (the negative pressure during placement or removal of the left atrial vent or during deairing manoeuvres, or

Combined venoarterial extracorporeal membrane oxygenation and transcatheter aortic valve implantation for the treatment of acute aortic prosthesis dysfunction in a high-risk patient

We describe the case of a patient with acute bioprosthesis dysfunction in cardiogenic shock, in whom hemodynamic support was provided by venoarterial extracorporeal membrane oxygenation, and successfully treated by transcatheter aortic valve implantation.