Karyne L. Vinales

Predictors for the development of severe tricuspid regurgitation with anatomically normal valve in patients with atrial fibrillation.

Background and Aims: Atrial fibrillation (AF) may be a risk factor for severe functional tricuspid valve regurgitation (FTR). We aimed to determine the predictors of severe FTR in patients with AF. Methods and Results: From our echocardiographic laboratory database, we searched for and reviewed the medical records of consecutive patients with severe FTR and AF seen at Mayo Clinic in Arizona from 2002 through 2009. Our search identified 42 patients who met all inclusion criteria. These patients (cases) with severe FTR and AF were compared with 38 patients (controls) with AF who had no greater than mild tricuspid regurgitation. Case patients with severe FTR were older than controls (mean, 81 years vs. 76 years; P < 0.001) and more frequently had chronic AF (69% vs 26%; P < 0.001). Mean right atrial volume (86 mL/m2 vs 46 mL/m2; P < 0.001), right ventricular volume (42 mL ± 33 mL vs 22 mL ±8 mL; P < 0.001) and tricuspid annular diameter (3.6 cm vs 3.0 cm; P < 0.001) were larger in cases than in controls. Patients with severe FTR also had a higher prevalence of right‐sided heart failure (69% vs 16%; P < 0.001). After adjusting for age and gender, right atrial and right ventricular volumes were independent predictors for the development of severe FTR in patients with AF (odds ratio, 1.7 [95% CI, 1.3–2.8] for every 10 mL/m2 increase in right atrial volume; P = 0.0002 and odds ratio, 3.1 [95% CI, 1.5–8.9] for every 10 mL increase in right ventricular volume; P = 0.0002). Conclusions: Severe FTR occurs in older patients with chronic AF as a result of marked right atrial and right ventricular dilatation; and enlargement of the tricuspid annulus in the absence of pulmonary hypertension. More importantly, severe FTR leads to increased prevalence of right‐sided heart failure underscoring the nonbenign nature of chronic AF. (Echocardiography 2012;29:140‐146)

Atypical presentation of takotsubo cardiomyopathy

Midventricular ballooning syndrome, an atypical variant of takotsubo cardiomyopathy (TCM), is characterized by transient wall motion abnormalities of the midsegment of the left ventricle with apical sparing. In contrast to the typical form of TCM, apical contractility is preserved and may even be hyperkinetic in midventricular TCM. We present a case of atypical TCM in an 86-year-old woman who had chest pain while accompanying her husband in the emergency department as he was evaluated for chest pain.

Anterolateral papillary muscle rupture: An unusual complication of septic coronary embolism

In most cases, acute mitral valve regurgitation in the setting of infective endocarditis is caused by the destruction of either the mitral valve leaflets or the chordal apparatus. A 54-year-old woman had development of respiratory failure due to pulmonary oedema from severe acute mitral valve regurgitation in the setting of acute bacterial endocarditis. She was found to have a ruptured anterolateral papillary muscle from occlusion of the circumflex artery by embolic vegetations arising from the aortic valve. Although this occurrence is uncommon, an embolic phenomenon resulting in myocardial infarction and subsequent rupture of papillary muscle must be considered as a cause of acute severe mitral valve regurgitation.

Occurrence of left-sided heart valve involvement before right-sided heart valve involvement in carcinoid heart disease

Carcinoids are rare neuroendocrine tumours that occur primarily in the gastrointestinal tract. Carcinoid heart disease is characterized by fibrous plaque deposition on the endocardial surface of the cardiac valves and chambers. It affects the right heart valves in 85% of cases and the left heart valves in 15%. We present an unusual case of a patient with metastatic carcinoid heart disease in whom typical carcinoid aortic and mitral valve lesions developed 2 years prior to the development of severe right-sided carcinoid valvular heart disease.

Unusual Case of Nonbacterial Thrombotic Endocarditis Attributable to Primary Antiphospholipid Syndrome

A 54-year-old man was referred for cardiac evaluation before renal transplantation because of chronic renal failure. His medical history was remarkable for diabetes mellitus, hypertension, and 3 episodes of transient ischemic attack (the most recent was 3 years earlier). A transthoracic echocardiogram showed a large, mobile mass on the anterior leaflet of the mitral valve, with trivial mitral regurgitation (Figure 1; Movie I in the online-only Data Supplement). The mass was originally believed to be a fibroelastoma; endocarditis was not considered initially because of the absence of systemic symptoms. Transesophageal echocardiography showed a 1×2-cm mobile, echodense region on the A2 segment of the mitral valve leaflet (Figure 2 and Movie II in the online-only Data Supplement are 2-dimensional images; Figure 3 and …

Predictors of Elevated Cardiac Enzyme Levels in Hospitalized Patients with Atrial Fibrillation and No Known Coronary Artery Disease

We retrospectively studied the predictive capabilities of elevated cardiac enzyme levels in terms of the prognosis of patients who were hospitalized with atrial fibrillation and who had no known coronary artery disease. Among 321 patients with atrial fibrillation, 60 without known coronary artery disease had their cardiac enzyme concentrations measured during hospitalization and underwent stress testing or cardiac catheterization within 12 months before or after hospitalization. We then compared the clinical and electrocardiographic characteristics of the 20 patients who had elevated cardiac enzyme levels and the 40 patients who had normal levels. Age, sex, and comorbidities did not differ between the groups. In the patients with elevated cardiac enzyme levels, the mean concentrations of troponin T and creatine kinase-MB isoenzymes were 0.08 ± 0.08 ng/mL and 6.49 ± 4.94 ng/mL, respectively. In univariate analyses, only peak heart rate during atrial tachyarrhythmia was predictive of elevated enzyme levels (P <0.0001). Mean heart rate was higher in the elevated-level patients (146 ± 22 vs 117 ± 29 beats/min; P=0.0007). Upon multivariate analysis, heart rate was the only independent predictor of elevated levels. Coronary artery disease was found in only 2 patients who had elevated levels and in one patient who had normal levels (P=0.26). Increased myocardial demand is probably why the presenting heart rate was predictive of elevated cardiac enzyme levels. Most patients with elevated enzyme levels did not have coronary artery disease, and none died of cardiac causes during the 6-month follow-up period. To validate our findings, larger studies are warranted.

Takotsubo cardiomyopathy complicated by left-ventricular apical thrombus.

A 68-year-old woman presented with pneumonia and was found on chest radiographs to have bilateral lung nodules. She was very anxious because of the possibility of lung cancer. She underwent a CT-guided lung biopsy, which revealed squamous-cell carcinoma of the lung. On the same day, inferolateral ST elevation was noted on electrocardiogram. The patient denied any chest pain. Troponin T was elevated. Cardiac angiogram showed no coronary artery disease. Transthoracic …