João Almeida

Massive right atrial myxoma presenting as syncope and exertional dyspnea: case report

Primary heart neoplasms are rare occurring with an estimated incidence of 0.0017-0.19%. Myxoma is the most prevalent primary heart tumor. The right atrium is an unusual localization, occurring only in 15-20% of myxoma cases. We report a rare case of a massive right atrial myxoma causing tricuspid valve obstruction and presenting as syncope and exertional dyspnea. This case illustrates the influence of myxomas size, position and mobility as well as patients body posture and respiration to the development of signs and symptoms. Three-dimensional echocardiography proved useful in surgery planning, allowing a better definition of the tumor outline and attachment.

Comparison of Coronary Artery Disease Consortium 1 and 2 Scores and Duke Clinical Score to Predict Obstructive Coronary Disease by Invasive Coronary Angiography

The first step in evaluating a patient with suspected stable coronary artery disease (CAD) is the determination of the pretest probability. The European Society of Cardiology guidelines recommend the use of the CAD Consortium 1 score (CAD1), which contrary to CAD Consortium 2 (CAD2) score and Duke Clinical Score (DCS), does not include modifiable cardiovascular risk factors.

Mitral and aortic valve aneurysms secondary to infective endocarditis: impressive images of a rare echocardiographic finding

Mitral and aortic valve aneurysms are uncommon, but the coexistence of both mitral and aortic valve aneurysms in the same patient is a rather unusual finding in the literature. We report a rare clinical case of a patient with both mitral and aortic valve aneurysms and a rupture of the mitral valve aneurysm, as the main echocardiographic manifestations of infective endocarditis. This clinical case emphasizes infective endocarditis as the most frequent cause of valve aneurysms, reminding that this diagnosis should be suspected even in the absence of vegetations. This case demonstrates that transoesophageal echocardiography plays a major role on diagnosis of valve aneurysms, revealing the rupture of the mitral valve aneurysm and defining this rupture as the main mechanism of mitral valve regurgitation. This case also underlines the role of transoesophageal echocardiography on management decisions, allowing a morphological evaluation of the mitral valve and selection of the appropriate surgical strategy.

Cardiomyopathy and Kidney Disease in a Patient with Maternally Inherited Diabetes and Deafness Caused by the 3243A>G Mutation of Mitochondrial DNA

Cardiomyopathy is a manifestation of mitochondrial cytopathies, but rarely constitutes the dominant feature, especially in adults. We report the case of a 59-year-old male with a personal and maternal history of diabetes and deafness, who presented with cardiomyopathy and kidney disease. We diagnosed the patient as having a mitochondrial cytopathy resulting from the 3243A>G mutation on the tRNALeu(UUR) gene in the mitochondrial DNA. The family history, broad spectrum of clinical manifestations and fluctuant clinical course provided clues to the diagnosis. We discuss the possible mechanisms underlying the phenotypic variability and fluctuant clinical course of mitochondrial disorders and the potential usefulness of coenzyme Q10 and L-carnitine in 3243A>G mutation patients.

Impact of the 2016 ASE/EACVI recommendations on the prevalence of diastolic dysfunction in the general population

Aims Diastolic dysfunction (DD) is frequent in the general population; however, the assessment of diastolic function remains challenging. We aimed to evaluate the impact of the recent 2016 American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging (EACVI) recommendations in the prevalence and grades of DD compared with the 2009 guidelines and the Canberra Study Criteria (CSC). Methods and results Within a population-based cohort, a total of 1000 individuals, aged ≥45 years, were evaluated retrospectively. Patients with previously known cardiac disease or ejection fraction <50% were excluded. Diastolic function was assessed by transthoracic echocardiography. DD prevalence and grades were determined according to the three classifications. The mean age was 62.0 ± 10.5 years and 37% were men. The prevalence of DD was 1.4% (n = 14) with the 2016 recommendations, 38.1% (n = 381) with the 2009 recommendations, and 30.4% (n = 304) using the CSC. The concordance between the updated recommendations and the other two was poor (from k = 0.13 to k = 0.18, P < 0.001). Regarding the categorization in DD grades, none of the 14 individuals with DD by the 2016 guidelines were assigned to Grade 1 DD, 64% were classified as Grade 2, 7% had Grade 3, and 29% had indeterminate grade. Conclusion The application of the new 2016 ASE/EACVI recommendations resulted in a much lower prevalence of DD. The concordance between the classifications was poor. The updated algorithm seems to be able to diagnose only the most advanced cases.

Incidence and predictors of vascular access site complications following transfemoral transcatheter aortic valve implantation

INTRODUCTION AND OBJECTIVES Vascular access site complications in transfemoral (TF) transcatheter aortic valve implantation (TAVI) are associated with increased morbidity and mortality; however, their incidence and predictors are conflicting between studies. This study sought to assess the incidence and predictors of vascular access site complications in patients undergoing TF TAVI. METHODS A total of 140 patients undergoing TF TAVI were included in the study. Minimum iliofemoral diameter and iliofemoral calcium score (CS) were estimated from contrast-enhanced multidetector computed tomography imaging, using different thresholds according to aortic luminal attenuation. To assess the impact of the learning effect, the first 50% of TF TAVI procedures were compared to the remainder. RESULTS Fifty-one patients presented access site complications (7.1% major, 29.3% minor), most of which were local bleeding or hematoma (11.4%), pseudoaneurysm (7.9%) or closure device failure (5.0%). In a multivariate logistic regression analysis that included sheath-to-iliofemoral artery ratio (SIFAR) (the ratio between the sheath outer diameter and minimum iliofemoral diameter), iliofemoral CS and center experience, SIFAR was the sole independent predictor of access site complications (hazard ratio 14.5, confidence interval [CI] 95% 1.75-120.12, p=0.013). The SIFAR threshold with the highest sum of sensitivity (71.4%) and specificity (53.4%) for access site complications was 0.92 (area under the curve 0.66, 95% CI 0.56-0.75, p=0.002). CONCLUSIONS Vascular access site complications are frequent in patients undergoing TF TAVI. SIFAR was the only independent predictor of access site complications and therefore should be systematically assessed during pre-procedural imaging study.

Comparison of self-expanding and balloon-expandable transcatheter aortic valves morphology and association with paravalvular regurgitation: Evaluation using multidetector computed tomography

Compare final morphology of self‐expanding and balloon‐expandable prosthesis and association with paravalvular regurgitation (PVR).

Three‐dimensional proximal flow convergence automatic calculation for determining mitral valve area in rheumatic mitral stenosis

Management of patients with mitral stenosis (MS) depends heavily on the accurate quantification of mitral valve area (MVA) using echocardiography. All currently used two‐dimensional (2D) methods have limitations. Estimation of MVA using the proximal isovelocity surface area (PISA) method with real time three‐dimensional (3D) echocardiography may circumvent those limitations. We aimed to evaluate the accuracy of 3D direct measurement of PISA in the estimation of MVA.

Reply to the Letter to the Editor: “Quinolone-induced hypersensitivity reactions and the Kounis syndrome”

We would like to thank Koniari et al. for the interest demonstrated in our manuscript. We have reported the case of an 85-year-old male who developed type 1 Kounis syndrome (coronary spasm) after administration of ciprofloxacin. The authors pointed out the potential role of the combined effect of the drugs the patient was taking (hydroxyzine and alprazolam). Indeed, they cited case reports of cutaneous manifestations of allergy to hydroxyzine and alprazolam. However, our patient was chronically medicated with both drugs and never developed any manifestation of allergic reaction to them. Therefore, we think that a possible synergistic effect is less likely. Also, the temporal association with the intravenous administration of ciprofloxacin, in a patient previously sensitized to quinolones, is highly suggestive of reaction to that drug. Nevertheless, we think this concept is very interesting and we thank the authors for mentioning the possibility, since clinicians should be aware that a mix of antigens can bring about an additive allergic reaction and even Kounis syndrome. The reference to the potential adverse effect that administration of morphine could have had in our case was also relevant and important. True opioid allergies are rare and

Tachycardiomyopathy and Extracorporeal Membrane Oxygenation: A Case Report

Tachycardiomyopathy (TCM) is a rare, but potentially reversible cause of cardiomyopathy and cardiogenic shock. It is defined by a global left ventricular systolic dysfunction secondary to persistent tachyarrhythmia, with partial (in patients with previous structural disease), or total recovery (in patients without previous structural disease) after cardiac rhythm normalization.1 The most commonly implicated arrhythmia is atrial fibrillation. The hemodynamic changes that characterize the patient with TCM include: increase in ventricular telediastolic and telesystolic volumes, global hypokinesis, increase in ventricular and pulmonary artery filling pressures, and, finally, decrease in ejection fraction (EF).1,2 It manifests clinically by congestive heart failure, and, in some cases, it may develop into cardiogenic shock. There are no specific methods to identify the presence of TCM. The diagnosis is usually attained retrospectively with normalization or improvement of left ventricular dysfunction, through tachyarrhythmia reversion or control. The most frequent complications of TCM are embolic events, complications due to the evolution of arrhythmia severity with degeneration to Ventricular Tachycardia (VT)/Ventricular Fibrillation (VF) and cardiogenic shock.3