Mohammad Q. Najib

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)

Symptomatic pericardial cyst: a case series

Pericardial cysts are most commonly located at the cardiophrenic angle or, rarely, in the posterior or anterior superior mediastinum. The majority of pericardial cysts are asymptomatic and are found incidentally. Symptomatic pericardial cysts present with dyspnoea, chest pain, or persistent cough. We describe four patients with symptomatic pericardial cysts who were treated with either echocardiographically guided percutaneous aspiration or video-assisted thoracoscopic surgery, or both; thoracotomy; or conservative therapy.

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.

Valvular heart disease in patients with osteogenesis imperfecta.

Osteogenesis imperfecta (OI) or “brittle bone disease” is a rare connective tissue hereditary disorder. The most common clinical presentation of OI is bone fractures. OI also involves extraskeletal structures; however, cardiovascular manifestations are rare. In this report, we describe the cardiovascular anomalies of patients with OI who underwent valve surgery and review the literature on this subject. doi: 10.1111/jocs.12064 (J Card Surg 2013;28:139–143)

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.

An unusual presentation of left ventricular assist device thrombus

A 41-year-old man with non-ischaemic dilated cardiomyopathy and morbid obesity was hospitalized with shortness of breath, abdominal pain, and haematochezia. At the age of 39 years, he underwent a left ventricular assist device (LVAD) placement (HeartMate II; Thoratec Corporation, Pleasanton, CA) for destination therapy and tricuspid valve annuloplasty. Initial evaluation revealed ischaemic colitis, elevated left heart filling pressures, and severe haemolysis. LVAD readings were not definitive but suggested a thrombus. Colour flow Doppler transesophageal echocardiography (TEE) demonstrated a normal flow in the left ventricular inflow ( Panel A ; see Supplementary data online, Movie S1 ) and outflow …

Takotsubo cardiomyopathy in a patient with pulmonary embolism

Takotsubo cardiomyopathy is an acute cardiac syndrome characterized by transient regional wall motion abnormalities of the left ventricular apex or midventricle. Patients often present with chest pain or dyspnoea, ST-segment elevation, and minor elevations of cardiac enzyme levels. Takotsubo cardiomyopathy has been associated with severe emotional or physical stress such as severe burns, spinal cord injury, subarachnoid haemorrhage, and multiple traumas. We report a case of takotsubo cardiomyopathy in a 79-year-old woman with pulmonary embolism. Although pulmonary embolism has been listed as a potential cause of takotsubo cardiomyopathy, this is the first case reported with this association.

Multiple Papillary Fibroelastomas

A 53-year-old woman who had a history of mitral valve prolapse was referred to our institution after an incidental finding of small masses on the mitral, tricuspid, and pulmonary valves on transthoracic echocardiography. She had no symptoms suggestive of endocarditis with negative blood cultures. Complete blood cell count and erythrocyte sedimentation rate were within normal limits. The patient underwent transesophageal echocardiography, which showed a pedunculated, papillary mass on the tricuspid valve (Figure 1 and Movie I in the online-only Data Supplement) with mild tricuspid regurgitation. In addition, 2 sessile masses were noted on the pulmonary valve (Figure 2 and Movie I in the online-only Data Supplement) and the posterior mitral …

Coronary Arteriovenous Fistula in a Patient with Aortic Valve Regurgitation

Case Report: A 25-year-old man with a 3-month history of infective endocarditis (streptococcal organism) successfully treated with 6 weeks of intravenous antibiotics was evaluated for known aortic valve regurgitation. Transthoracic echocardiography (Sonos 7500, Hewlett Packard, Palo Alto, CA, USA) demonstrated healed aortic valve vegetations, with severe regurgitation and moderate to severe left ventricular enlargement and normal left ventricular systolic function. An echolucent structure in the posterior atrioventricular groove in the region of coronary sinus with abnormal Doppler flow (Fig. 1A–D; movie clips S1–S3) indicated probable coronary fistula or coronary anomaly.