Giuseppe Oreto

Left Ventricular Function in Hypertension: New Insight by Speckle Tracking Echocardiography

Background: Conventional transthoracic echocardiography (TTE) and tissue Doppler imaging (TDI) are usually unable to reveal very early subtle abnormalities in left ventricular (LV) systolic function caused by hypertension, prior to manifestation of hypertrophy (LVH). This study was undertaken to assess whether speckle tracking echocardiography (STE) provides more insight into early hypertension‐induced LV systolic dysfunction, with the purpose of identifying patients at higher risk for heart failure (HF). Methods: Fifty‐one patients (56.5 ± 14 years) and 51 controls (52 ± 12.6 years) were enrolled. According to the presence or absence of LVH, patients were classified as LVH(+) and LVH(–), respectively. Global longitudinal function was calculated by TDI, global strains [longitudinal (LS), radial (RS), and circumferential (CS)] and twist were assessed by STE. Results: Conventional TTE showed a LV diastolic dysfunction with normal systolic function in all patients. TDI was able to detect a systolic dysfunction only in the LVH(+) group (P < 0.001) whereas STE revealed an impairment of systolic LS in all patients, including those without hypertrophy (P = 0.02). Furthermore, in the LVH(+) group, STE showed reduced RS and increased CS and twist. These last alterations were observed with respect to both controls (RS: P = 0.02; CS: P = 0.05; twist: P < 0.001) and LVH(–) patients (RS: P = 0.01; CS: P = 0.003; twist: P = 0.001). Conclusion: In hypertensive patients, STE provides more detailed information than conventional echocardiography and TDI, since it reveals a systolic dysfunction before hypertrophy occurs (Stage A of ACC/AHA classification of HF) and identifies some early LV mechanic changes that might improve the clinical management of these patients. (Echocardiography 2011;28:649‐657)

Persistent left-sided superior vena cava: integrated noninvasive diagnosis.

Persistent left superior vena cava (PLSVC) is a rare finding. We describe 5 patients with PLSVC diagnosed by a noninvasive approach, including two‐dimensional (2D) echocardiogram, nuclear magnetic resonance and multislice computed tomography (MCT). In 4 cases the PLSVC was isolated (“alone PLSVC”), and in 1 case associated with a right superior vena cava.

Inappropriate sinus tachycardia after radiofrequency ablation of para-Hisian accessory pathways.

Inappropriate Sinus Tachycardia After Catheter Ablation. Introduction: Inappropriate sinus tachycardia (IST) has been observed following radiofrequency ablation (RFA) of the AV nodal fast pathway. This study was aimed to prospectively analyze the incidence and clinical significance of IST following RFA of para‐Hisian accessory pathways (APs).

Right Bundle Branch Block on Alternate Beats during Acute Pulmonary Embolism

The electrocardiogram of a patient with acute pulmonary embolism showed right bundle branch block (RBBB) on alternate beats; following thrombolysis, the pattern evolved to persistent RBBB and eventually to normal conduction. Analysis of serial tracings suggested that the mechanism of RBBB alternans was tachycardia‐dependent bidirectional bundle branch block, caused by prolongation of both anterograde and retrograde refractory periods (RPs) of the right bundle branch (RBB). The sinus impulse found the RBB refractory, and was conducted over the left bundle branch only, depolarizing the left ventricle and then attempting to penetrate retrogradely the RBB; at that time, however, the RBB was still refractory. When a QRS complex had a RBBB configuration, therefore, the RBB was not depolarized; the ensuing sinus impulse found the RBB fully responsive as a consequence of the long period intervening between two successive depolarizations, and resulted in normal intraventricular conduction.

Permanent Cardiac Pacing for Severe Pallid Breath-Holding Spells

We report the case of an infant affected by frequent episodes of loss of consciousness with the clinical features of pallid breath‐holding attacks. Prolonged asystole, up to 26 seconds, was demonstrated by Holter monitoring. The patient was treated with permanent pacemaker implantation, followed by complete symptom resolution during a 26‐month follow‐up.

Electrocardiographic and Electrophysiological Characteristics of Atrial Tachycardia With Early Activation Close to the His-Bundle.

Radiofrequency (RF) ablation of atrial tachycardia (AT) with earliest activation at the His‐bundle may be associated with the risk of AV block, and detection of this AT origin using the electrocardiogram (ECG) would be helpful in planning ablation. Aim of this study was to characterize the P‐wave morphology and intracardiac electrograms at the successful ablation site for this group of ATs.

ST Segment Depression in the Inferior Leads in Brugada Pattern: A New Sign

Brugada pattern (BP) is characterized by J wave and elevated ST segment in the right precordial leads. At times the ECG signs are present only with the electrodes displaced 1 or 2 intercostal spaces above.

Images in Cardiovascular Medicine: Caseous Calcification of the Mitral Annulus

A 78‐year‐old woman was admitted to our emergency department for subarachnoid hemorrhage. Since a month ago, she was taking warfarin after diagnosis, on transthoracic echocardiogram (TTE), of a suspected large atrial thrombus. The patient, referred to our institution for further investigation, presented asymptomatic; electrocardiogram showed sinus rhythm. TTE revealed an echo dense spherical mass located in the mitral periannular posterior region with moderate mitral regurgitation. Transesophageal echocardiography and cardiac computed tomography confirmed a calcified round mass (2.0 × 2.9 cm) with central areas of echolucency‐like liquefaction surrounded by a hyperechogenic structure without systolic flow inside the cavity. The mass was diagnosed as caseous calcification of the mitral annulus (CCMA), a rare finding associated with a benign prognosis, requiring surgery only in the presence of mitral valve dysfunction. The diagnosis of CCMA is, often, misconstrued as thrombus, tumor, or abscess, leading to unnecessary investigations or interventions. Our patient was discharged after discontinuation of warfarin.

QRS Complex Voltage Changes Associated with Supraventricular Tachycardia

QRS Voltage Changes in SVT. u2028 Introduction: The aim of this study was to evaluate the changes in ventricular complex voltage associated with narrow QRS supraventricular tachycardia (SVT).

Salbutamol‐Induced Narrow QRS Tachycardia: What Is the Mechanism?

The electrocardiogram of Figure 1 shows a narrow QRS tachycardia, recorded from a 3-year-old female patient without history of heart disease, admitted following accidental ingestion of 24 mg of salbutamol (a dose more than 6 times higher than the maximal one recommended at this age). Tachycardia rate is 195 per minute. The QRS complexes are narrow, and each of them is preceded by a P wave that is negative in leads I and aVL and positive in the inferior leads and in lead V1. What is the mechanism of tachycardia?