Khawaja Afzal Ammar

THE INCREASING BURDEN OF AMYLOIDOSIS FROM APEX TO BASE: NEW INSIGHTS FROM TECHNETIUM-99M PYROPHOSPHATE IMAGING

Background: Two-dimensional speckle-tracking strain echocardiography (2D STE) in cardiac amyloidosis (CA) patients has shown relatively preserved left ventricle apical systolic function as measured by longitudinal strain (LS). Technetium-99m pyrophosphate (99mTc-PYP) myocardial imaging has gained

Cardiac Amyloidosis Presenting as Severe Mitral Regurgitation

Although mild to moderate mitral regurgitation is common in cardiac amyloidosis (CA), severe mitral regurgitation as the primary presenting finding is rare [(1)][1]. We present 3 such cases of patients with severe mitral regurgitation who on further workup were discovered to have CA [(2)][2] ([

Multivariate Criteria Most Accurately Distinguish Cardiac from Noncardiac Causes of Dyspnea

Cardiopulmonary exercise testing provides oxygen pulse as a continuous measure of stroke volume, which is superior to other stress-testing methods in which systolic function is measured at baseline and at peak stress. However, the optimal peak oxygen pulse criterion for distinguishing cardiac from noncardiac causes of exercise limitation is unknown. In comparing several peak oxygen pulse criteria against the clinical standard of cardiopulmonary exercise testing, we retrospectively studied 54 consecutive patients referred for cardiopulmonary exercise testing. These exercise tests included measurement of oxygen consumption, carbon dioxide production, breathing reserve, arterial blood gases at baseline and at peak stress, exercise electrocardiogram, heart rate, and blood pressure response. Results were blindly interpreted and patients were categorized as members either of our Cardiac Group (abnormal result secondary to cardiac causes of exercise limitation) or of our Noncardiac Group (normal or abnormal result secondary to any noncardiac cause of exercise limitation). The accuracy of the peak oxygen pulse criteria ranged from 50% for univariate criterion (≤15 mL/beat), to 61% for oxygen pulse curve pattern, to 63% for bivariate criterion (≤15 mL/beat for men, ≤10 mL/beat for women), to as high as 81% for a multivariate criterion. All multivariate criteria outperformed oxygen pulse curve pattern, univariate, and bivariate criteria. This is the first study to evaluate the optimal peak oxygen pulse criterion for differentiating cardiac from noncardiac causes of exercise limitation. Multivariate criteria (especially a criterion incorporating age, sex, height, and weight) should be used preferentially, as opposed to the commonly used univariate and bivariate criteria.

Synovial sarcoma invades the left atrium: visualization with three-dimensional trans-oesophageal echocardiography

A 36-year-old male presented with right hemiplegia and aphasia. Computed tomography imaging showed showered infarcts with multi-organ involvement including left carotid filling defect and left upper lung mass encasing the left upper pulmonary vein ( Panels A and B ). Trans-thoracic echocardiogram revealed a left atrial mass oscillating into the left ventricle. Two-dimensional trans-oesophageal echocardiogram (TEE) …

Metastatic breast cancer diagnosed by rubidium-82 positron emission tomography myocardial perfusion imaging

CASE PRESENTATION A 71-year-old man presented with dyspnea. Rb PET MPI at rest and after intravenous regadenoson was negative for myocardial ischemia but showed increased uptake anterolateral and superior to the heart (Figure 1A). Reconstructed transaxial Rb PET images confirmed abnormal uptake (Figure 1B). Computed tomography (CT) imaging of the chest showed enlarged blood vessels in the left side of the chest wall (Figure 1C). F18-fluorodeoxyglucose (FDG)-PET scan superimposed on the CT scan revealed a 1.5-cm, metabolically active pulmonary nodule (Figure 1D), confirmed to be adenocarcinoma of breast origin on biopsy (Figure 2). DISCUSSION Rb is a potassium analogue that is taken up by hyperactive tumor cells, which display increased Na?/ K? adenosine triphosphatase activity in the cell membrane. This is similar to enhanced FDG uptake that occurs with increased glucose-6-phosphatase activity in the cytoplasm. Abnormal activity seen on Rb imaging corresponded to abnormally enlarged blood vessels that are usually not visible on CT scan. One explanation could be the induced blood vessel growth secondary to angiogenesis-stimulating hormonal factors released by the tumor. Such tumor blood vessels are abnormally dilated and distorted in shape, as seen in our patient. In summary, Rb may have a potential adjunctive role in cancer diagnosis. Our study underscores the importance of carefully reviewing the PET emission and CT transmission images for both cardiac and extracardiac findings, and using both normalized cardiac and noncardiac hybrid PET-CT displays to aid in identifying important extracardiac abnormalities that may prompt further diagnostic evaluation.

The complementary nature of tissue Doppler to 99m Tc-PYP imaging in diagnosis of right ventricular cardiac amyloidosis

A 69-year-old woman with a history of hypertension, dyslipidemia, atrial fibrillation, dual-chamber implantable device therapy for bradycardia, and liver transplantation in 2006 for familial amyloidosis (transthyretin-related cardiac amyloidosis [ATTRm]) presented with progressive dyspnea, edema, and abdominal distention. Her electrocardiogram (Figure 1) revealed right bundle branch block, inferior and anterior infarcts, and borderline low-voltage QRS complexes. Transthoracic echocardiography (Figure 2, Movies 1-3) revealed diffuse biventricular thickening with increased echogenicity, decreased ejection fraction, and pericardial and pleural effusions. Peak systolic tissue Doppler velocity in the right ventricle (Figure 3A) and early relaxation Doppler velocity of the left ventricular septal annulus were severely reduced (Figure 3B), consistent with biventricular involvement. Two-dimensional speckle-tracking echocardiography showed a typical bull’s-eye pattern with progressively reduced segmental longitudinal strain from the base to the apex of the LV (Figure 4). Technetium pyrophosphate (Tc-PYP) planar (Figure 5A and B) and single-photon positive emission computed tomography cardiac imaging (Figure 5C) confirmed increased uptake consistent with cardiac amyloid deposition. Non-invasive diagnostic modalities for cardiac amyloidosis—including echocardiography, electrocardiography, and magnetic resonance imaging—are limited by poor specificity with a positive predictive value (PPV) of less than 50%. The Tc-PYP scan has been suggested as a promising method of screening for cardiac amyloidosis, with PPV approaching 100% in certain scenarios. This case demonstrates the promise

Contemporary practice pattern of revascularization in a large tertiary care referral center in non-ST elevation myocardial infarction: A propensity-matched 10-year experience

We sought to compare the effects of early versus delayed percutaneous coronary intervention (PCI) on the outcomes at 1 year in patients presenting with non‐ST‐segment elevation myocardial infarction (NSTEMI).

NORMAL DIAMETER OF THE ASCENDING AORTA IN ADULTS: THE IMPACT OF STRICTER CRITERIA ON SELECTION OF SUBJECTS FREE OF DISEASE

Background: The American Society of Echocardiography 2015 guidelines for measurement of the aorta utilized studies, including one by Devereaux et al., that suffered from smaller sample sizes and lax criteria for selection of normal subjects, using absence of clinical etiologies of aortic aneurysm

Dilated mid-ascending aorta in hypertrophic cardiomyopathy is associated with dynamic left ventricular outflow tract obstruction and not with genetic abnormalities

Background: Prior studies have suggested a relationship between aortic dilatation and hypertrophic cardiomyopathy (HCM). There are no data evaluating the relative strength of association between dilated aorta and HCM in terms of whether the dilatation was mediated by left ventricular outflow tract (

Non Invasive Imaging (Echocardiography, Nuclear, PET, MR and CT)GABAPENTINOIDS THERAPY IS ASSOCIATED WITH HIGHER DOSES OF ATROPINE AND DOBUTAMINE IN STRESS ECHOCARDIOGRAPHY

Background: Anecdotal observation by a stress technician suggested that patients on gabapentinoids required longer protocols to achieve the target heart rate (HR) during stress echocardiography. In addition, recent randomized clinical trials have shown attenuation of reflex tachycardia and