Marco Cerrito

Anatomical M-Mode: An Old–New Technique

The M‐mode (motion mode) technique has improved the diagnostic possibilities of echocardiography due to its high temporal resolution. The use of a two‐dimensional (2D) image as a basis for M‐mode analysis at a defined line, independent of the transducer orientation, namely the anatomic M‐mode (AMM), has been proposed from the beginning of 2D echocardiography. For several years, however, this could not be accomplished due to several reasons including the limited digital memory, the relatively rough pixels of 2D images, and the low temporal resolution of the screen. The AMM has been improved by the “fully digital” machines. These are able to provide a series of digital data (direction, position, and timing) relative to any single echo received from any point of the tissue. AMM analysis, thus, can be performed in any direction, as a “normal” monodimensional echocardiogram. With respect to traditional M‐mode, AMM permits a more detailed analysis of cardiac chambers diameters obtained by linear measurements, regional wall motion of the left ventricle (both at rest and during stress), and location of accessory pathways. In particular, the assessment of left ventricular regional wall motion represents the most important goal of this new technique, which results in marked reduction or even elimination of the limitations due to the subjective character of wall motion evaluation with 2D echocardiography. (ECHOCARDIOGRAPHY, Volume 20, May 2003)

Citalopram-induced long QT syndrome and torsade de pointes: Role for concomitant therapy and disease

Abstract Although citalopram is considered to be a safe antidepressant drug, some cases of arrhythmic disorders, syncope, or intoxication leading to lethal outcomes have been described over the last few years. We report the case of citalopram-induced long QT syndrome complicated by torsade de pointes in a young woman, in whom the role for antihypertensive treatment with diuretics and intercurrent flu-like syndrome is discussed.

Systemic embolism in takotsubo syndrome

A 57-year-old woman with acute left leg ischemia due to popliteal artery occlusion and deep T-wave inversion at ECG revealed she had suffered, the day before, from typical chest pain after a confrontational argument; yet, she had not sought medical assistance. Echocardiography showed left ventricular wall motion abnormalities consistent with the diagnosis of emotional stress-induced takotsubo syndrome. Coronary angiography ruled out obstructive atherosclerotic disease and left ventriculography confirmed apical ballooning with evolving thrombosis. Left leg angiography demonstrated diffuse embolisation of the popliteal artery. Ventricular thrombosis is a complication of takotsubo syndrome and has been associated with adverse events supposed to be due to a cardioembolic mechanism, in particular cerebro-vascular accidents. To the best of our knowledge, this is the first direct visualization of systemic cardiogenic embolism in takotsubo syndrome. Physicians should be aware that ventricular thrombosis may be present in the earliest stages of the disease and that emboli dislocation can occur even before wall motion normalization.

Capsaicin, arterial hypertensive crisis and acute myocardial infarction associated with high levels of thyroid stimulating hormone

Chili peppers are rich in capsaicin. The potent vasodilator calcitonin gene-related peptide (CGRP) is stored in a population of C-fiber afferents that are sensitive to capsaicin. CGRP and peptides released from cardiac C fibers have a beneficial effect in myocardial ischemia and reperfusion. It has been reported that capsaicin pretreatment deplete cardiac C-fiber peptide stores. Furthermore, it has also been reported that capsaicin-treated pigs significantly increase mean arterial blood pressure compared with controls and that the decrease in CGRP synthesis and release contributes to the elevated blood pressure. It has also been reported that sub-clinical hypothyroidism is associated with a significant risk of coronary heart disease (CHD). We present a case of arterial hypertensive crisis and acute myocardial infarction in a 59-year-old Italian man with high levels of thyroid stimulating hormone and with an abundant ingestion of peppers and of chili peppers which occurred the day before.

Supraventricular Tachycardia in Infants: Epidemiology and Clinical Management

Supraventricular tachycardias (SVTs) are observed in 0,1-0,4% of the paediatric population and represent an important clinical problem with related significant health and social issues. Most tachycardias are paroxysmal, being associated with sudden onset and termination, and only a relatively small number of them is permanent, namely chronic. Paroxysmal tachycardias, in addition, can be either sustained (lasting > 30 seconds) or non-sustained whenever their duration is less. Most SVTs are due to re-entry, and only atrial tachycardia and and junctional ectopic tachycardia are caused by enhanced automaticity. Atrial tachycardia, however, can also be due, although rarely, to re-entry or to triggered activity. A prompt recognition of these arrthmias in children by pediatric cardiologist is essential for a correct clinical managemet of the patients. In this review, the epidemiologic data regarding the SVTs in pediatric age are reported along with the description of the pathophysiological mechanisms and the analysis of electrocardiographic findings to be considered for a correct clinical diagnosis and a rational therapeutic approach to these arrhythmias.

Isolated Left Ventricular Noncompaction

(ECHOCARDIOGRAPHY, Volume 21, July 2004)

Multislice computed tomography demonstration of a coronary-to-pulmonary artery fistula.

MSCT-coronary angiography demonstrated a threevessel CAD; no critical stenosis was apparent, but the images were not conclusive owing to severe vascular calcifications. Moreover, a coronary-to-pulmonary artery fistula was disclosed. The fistula came out (Fig. 1a) frontwards, downwards and rightwards from the proximal segment of the left anterior descending artery (LAD). The fistula then inverted its course and formed two ‘U-shaped’ curves – the former larger and the latter narrower – crossed the LAD itself and reached the left wall of the main pulmonary trunk (Fig. 1b), into which it drained after having become ectasic (Fig. 2).

Bifid T waves in leads V2 and V3 in children: a normal variant

IntroductionThe T wave is rarely bifid, apart from patients with long QT syndrome or subjects treated with antiarrhythmic drugs. At times, a U wave partially superimposed upon the T wave is responsible for an apparently bifid T wave. Bifid T waves, in contrast, have been described in normal children in the past, but the phenomenon has not received any attention in recent years, to the extent that it is not mentioned in current textbooks of paediatric cardiology. Aim of the present study was to determine the incidence and clinical counterpart of bifid T waves in a paediatric population.MethodsWe selected 604 consecutive children free from clinically detectable heart disease; subjects whose electrocardiogram showed a bifid T wave underwent a complete clinical and echocardiographic examination. In addition, the electrocardiograms of 110 consecutive adults have also been analyzed. A T wave was considered as bifid whenever it was notched, being the 2 peaks separated from each other by a notch with duration ≥ 0.02 sec and voltage ≥ 0.05 mV. Moreover, in 7 children with bifid T wave in lead V2 further precordial recordings were obtained: a small electrode was gradually moved from V1 to V3, and 4 additional leads were recorded: 2 between V1 an V2, and 2 between V2 and V3.ResultsA bifid T wave was observed in 110 children (18,3%), with a relatively age-related incidence; the highest rate of bifid T waves (53%) occurred in the group of 5-year-old children. The bifid T wave was detected only in lead V2 in 51 cases (46,4%), only in lead V3 in 5 cases (4,6%), in both leads V2 and V3 in 50 cases (45,4%), and in leads other than V2 and V3 in 4 cases (3,6%). In the adult group, none of the examined electrocardiograms showed bifid T waves in any lead.In the bifid T wave paediatric population, the echocardiogram did not reveal any abnormality, apart from 3 subjects which had an asymptomatic mitral valve prolapse; a trivial mitral and/or tricuspid regurgitation detected by color Doppler, as well as a patent foramen ovale in infants, were not considered as abnormal findings. The QTc interval was normal in all of the subjects; the average QTc interval was not different in the bifid T wave population (402 ± 46 msec) with respect to the control group (407 ± 39 msec).ConclusionThe incidence of bifid T waves in leads V2 and V3 in normal children is high, and awareness of this phenomenon avoids possible misinterpretations leading to a diagnosis of ECG abnormalities.

Very early recurrence of Takotsubo syndrome.

Recurrence of the Takotsubo syndrome is possible, and in the majority of cases it occurs within 4 years. The present report is focused on a case of the Takotsubo syndrome recurrence after 10 years. The patient had been admitted for the first time in 1999 with a diagnosis of “non‐q wave acute anterolateral myocardial infarction.” Ten years later, she was readmitted for suspected acute myocardial infarction; coronary arteries, however, were normal, and the left ventricular angiogram demonstrated apical ballooning typical for the Takotsubo syndrome. It is worth noting that the clinical presentation and the ECG were the same on both occasions; in addition, both events were triggered by an emotional stress.

Left ventricular pseudodiverticulum.

The differential diagnosis between left ventricular aneurysm and diverticulum remains a matter of debate. Cardiac magnetic resonance is dramatically helpful in the anatomical and functional characterization of the walls of any angiographical left ventricular outpouching.