Kanji Iga

Deep negative T waves associated with reversible left ventricular dysfunction in acute adrenal crisis

We report two cases of reversible left ventricular dysfunction associated with deep negative T waves during acute adrenal crisis due to isolated deficiency of adrenocorticotrophic hormone. There were no symptoms suggestive of heart disease in either case and left ventricular wall motion abnormalities, present mainly around the left ventricular apex, returned to normal in 1–2 weeks. Deep negative T waves normalized 4 weeks after corticosteroid administration. Acute adrenal crisis should be considered when deep negative T waves are associated with left ventricular dysfunction without cardiac symptoms.

Increased thrombin–antithrombin III complex during an episode of paroxysmal atrial fibrillation

Thrombin-antithrombin III complex (TAT) is a marker of thrombin generation, indicating increased coagulability. To investigate whether paroxysmal atrial fibrillation (PAf) is associated with an increased coagulation system, we measured TAT within 24 h after the documentation of PAf in 50 patients with structurally normal hearts. The mean age of the study population was 62 years old. In 32 patients, PAf was documented during routine physical examinations, electrocardiograms or echocardiograms and in the remaining 18 patients, it was reproducibly documented on more than two Holter electrocardiograms. Group I consisted of 38 TAT data sets from 38 patients who did not receive anticoagulant therapy during PAf episodes. At least one week after starting anticoagulant therapy, TAT was measured again in ten patients in whom there was evidence of PAf on the day of measurement. In the remaining 12 patients, PAf occurred while the patients were receiving anticoagulation. Group II consisted of 22 TAT data sets from 22 patients who received anticoagulation during PAf episodes. The average TAT value was 5.8 ng/ml in group I, while it was 2.8 ng/ml in group II (P<0.0001). TAT was greater than 5 ng/ml in 15 of the 38 patients in group I, and in four of the 22 patients in group II. In 20 symptomatic patients, we measured TAT again when the patients maintained sinus rhythm under the same anticoagulant therapy; four patients were receiving and 16 patients were not receiving anticoagulation therapy. TAT decreased from 6.4 to 2.3 ng/ml on average when PAf disappeared and sinus rhythm was maintained (P=0.0009). Increase in the coagulation system occurred transiently during or shortly after PAf episodes in about 40% of PAf patients. As patients with prior anticoagulation had a relatively low TAT value, anticoagulant therapy might be useful in patients with PAf.

Rapid growth of a left atrial myxoma. Serial two-dimensional echocardiographic observation over eighteen months.

We encountered a patient with rapid progressing left atrial myxoma in whom two-dimensional echocardiography was serially obtained over eighteen months. The horizontal and longitudinal diameters showed a linear 2.5 fold increase, while the size of the base attached to the left atrial wall remained unchanged. Therefore, the last echocardiogram obtained just before surgery showed the characteristic pendular motion of left atrial myxoma.

Reversible left ventricular dysfunction secondary to rapid atrial fibrillation

We present the cases of four patients with reversible left ventricular dysfunction associated with severe congestive heart failure presumably induced by rapid atrial fibrillation. The mean heart rate was 159 beats/min and the mean left ventricular end-diastolic dimension was 58.5 mm with diffusely impaired left ventricular motion. None of the patients had a history of preceding upper respiratory infection before the acute episode and no signs of inflammation at onset, and all patients were New York Heart Association Class I or II before the acute episode. Left ventriculography, done about 1 month when congestive heart failure and ventricular rate were controlled with digitalis and diuretics, still showed diffusely decreased left ventricular motion; the mean end-diastolic volume was 165 ml and the mean ejection fraction was 30%. Coronary angiography was normal in three patients and one showed moderate left anterior descending artery stenosis. Right ventricular biopsy, done in three patients showed no evidence of myocarditis. Left ventricular wall motion normalized in 5-36 months on follow-up echocardiography. These findings suggest that persistent rapid atrial fibrillation can cause reversible left ventricular dysfunction which can take a considerable period of time to normalize.

Intracardiac thrombi in both the right atrium and right ventricle after acute inferior-wall myocardial infarction

We present a case of inferior-wall myocardial infarction associated with thrombi in both the right ventricle and right atrium. Routine transthoracic echocardiography could not detect these thrombi while transesophageal echocardiography provided an excellent image of the thrombi. The right atrium or right ventricle may be the site for thrombi, presumably due to both right ventricular and right atrial infarction in acute inferior-wall infarction.

Abnormal venous connection between the left upper pulmonary vein and the left brachiocephalic vein, associated with rheumatic combined valvular heart disease

SummaryA case of partial anomalous pulmonary venous return (PAPVR) associated with mitral stenosis and aortic regurgitation is described. The diagnostic clue was radiocardiography using radioiodide serum albumin (RISA), our routine procedure before cardiac catheterization. The abnormal vessel connected with both the left upper pulmonary vein (PV) and the left brachiocephalic vein, without a stenotic lesion. Aortic valve replacement, open mitral commissurotomy, and simple ligation of the anomalous vein were successfully performed.

Influence of gravity on pulmonary venous flow velocity patterns: Analysis of left and right pulmonary venous flow velocities in left and right decubitus positions

BACKGROUND The pulmonary venous flow signal measured by transesophageal echocardiography is generally recorded from the left upper pulmonary vein in the left lateral decubitus position, whereas that by transthoracic echocardiography is from the right upper pulmonary vein in the left semi-lateral decubitus position. The purpose of this study was to evaluate the influence of the postural change on the peak flow velocities of the left and right pulmonary veins and whether the parameters of the left and right pulmonary venous flow can be used interchangeably. METHODS AND RESULTS The study group consisted of 37 patients with normal left ventricular filling pressure and in whom the systolic forward flow signals from both pulmonary veins recorded in the left and right lateral decubitus positions were clear enough to differentiate as biphasic. The peak early systolic (peak S1) and diastolic velocities were significantly increased when the pulmonary vein was on the recumbent subjects upper side, whereas the peak late systolic velocity (peak S2) was significantly increased when the pulmonary vein was on the recumbent subjects lower side. The peak S1 was higher than the peak S2 when the pulmonary vein was on the recumbent subjects upper side, whereas the reverse relation was seen when the pulmonary vein was on the recumbent subjects lower side. CONCLUSIONS We should take into consideration the body position and the side on which the pulmonary vein is situated in evaluating the peak flow velocities of the pulmonary veins.

Unroofed coronary sinus syndrome: Diagnostic consideration by contrast echocardiography and usefulness of transesophageal echocardiography and magnetic resonance imaging

We present two cases of unroofed coronary sinus syndrome without a left superior vena cava [1]; one is associated with mitral stenosis and the other is an isolated form. The diagnostic clue was a markedly enlarged coronary sinus with color flow within it detected by transthoracic echocardiography. Contrast echocardiography with injection of contrast medium through the left antecubital vein [2] showed a negative jet from the coronary sinus in the right atrium, indicating the presence of a left-to-right shunt through the enlarged coronary sinus. This enlarged coronary sinus was clearly seen lying behind the left atrium by transesophageal echocardiography (TEE) and a communication between the left atrium and the coronary sinus was documented. Echo Doppler gave us additional information about the presence of the flow across the fenestrations. Spin echo magnetic resonance imaging (MRI) demonstrated the fenestration present between the coronary sinus and the left atrium, and cine mode confirmed the flow across these fenestrations. When the coronary sinus is enlarged on transthoracic echocardiography and cannot be filled by contrast echocardiography via the left antecubital vein, further examination for the presence of an unroofed coronary sinus is necessary. T E E and MRI give us useful information in this situation.

Intermittently audible the “third heart sound” as a sign of complete atrio-ventricular block in patients with a VVI pacemaker

BACKGROUND It is not known that an S3 can be audible intermittently. We have recognized this in patients with VVI pacing in whom sinus rhythm has been preserved. SUBJECTS AND METHODS Subjects consisted of consecutive 39 patients with VVI pacemaker implantation and preservation of sinus rhythm. We tried to find out what percentage of these patients have an intermittent S3 and also to elucidate the mechanism of this sound by Doppler echocardiography. The PP interval and RR intervals were measured and ¿PP-RR¿/RR was calculated. One doctor carried out auscultation from the left sternal border to the apex for 5-6 consecutive beats while the patients held their breath. Transmitral flow velocity was measured by pulsed Doppler echocardiography with a paper speed of 100 cm/sec. A wave velocity was measured when a P wave coincided with late diastole. E wave velocity was measured when no A wave was present in early diastole. The maximal summation of E and A waves (E+A) velocity was measured. RESULT An intermittent S3, being audible in 21 patients (group A) and not audible in 18 patients (group B), coincided with maximal E+A velocity. There was no statistical age difference between the two groups. Both maximal E+A velocity, and A velocity were higher in group A than group B (116.2 cm/sec Vs 90.8 cm/sec P<0.0001, 80.6 cm/sec Vs 56.4 cm/sec P<0.0001 respectively), while E velocity was not statistically different (68.3 cm/sec Vs 60.3 cm/sec). In 5 of 9 cases in whom an intermittent S3 was not audible regardless of more than 100 cm/sec of E+A velocity, the calculated ¿PP-RR¿/RR was less than 0.1. CONCLUSION An intermittently audible S3 is one of the physical signs of complete atrio-ventricular block. It occurs when a strong atrial contraction develops exactly at the time of rapid left ventricular filling. However, when the PP and RR intervals are too close, the S3 may be difficult to discern.

Formation of a left atrial ball thrombus from a large mural thrombus 4 days after an embolic episode

We present a case of basilar artery embolism originating from a left atrial mural thrombus. The thrombus was large and attached to the posterior left atrial wall, but decreased in size and detached forming a ball type thrombus over the next 4 days without anticoagulant and/or antifibrinolytic therapy.