Nuno Antunes

Intramyocardial dissecting haematoma: a rare complication of acute myocardial infarction

Intramyocardial dissecting haematoma (IDH) is a rare complication of myocardial infarction, with very scarce reports in medical literature. Before the advent of non-invasive imaging techniques, the diagnosis of IDH was only made by necropsy. It can develop in the left ventricular free wall, the right ventricle, or the interventricular septum. We present a case of a patient with an IDH after acute anterolateral myocardial infarction, focusing on the utility of echocardiography in the diagnosis and follow-up of this unusual complication. By this imaging modality, it was possible to see the various acoustic densities of the progressive clotting of the intramyocardial haematoma, its extension through the haemorrhagic dissection, as well as its independency in relation to ventricular cavities and extracardiac space by confirming intact epicardial and endocardial layers. Based on this report, we believe that serial two-dimensional echocardiography, added, when necessary, by the use of contrast agents is the non-invasive method ideally suited to confirm the diagnosis and monitor its evolution at the patients bedside.

Stunned Myocardium following Ischemic Stroke

Neuromediated stunned myocardium is a well-known complication of subarachnoid hemorrhage but has rarely been reported in association with other central nervous system disorders. The pathophysiology of this entity remains unclear, but a catecholamine-induced neurocardiogenic injury has been proposed as a causal factor. Typically, patients have rapid full cardiovascular recovery within a few days. We report a case of ischemic stroke, coexisting with ischemic electrocardiographic changes, increased cardiac-specific necrosis biomarkers, regional wall motion abnormalities and a cardiac SPECT consistent with inferior myocardial infarction despite normal coronary arteries. Interestingly, left-ventricular dysfunction in this case persisted longer than usually described despite full neurologic recovery. This case also illustrates the diagnostic challenges posed by this entity which frequently mimics acute myocardial infarction and emphasizes the investigation needed in this area.

Coronary artery fistula presenting as unstable angina

A 74-year-old man, with a history of heavy smoking, presented with unstable angina (Figure 1). Dobutamine stress echocardiography showed ischemia in the right coronary artery territory. Coronary angiography revealed no obstructive epicardial disease in the left dominant circulation (Figure 2A); the right coronary artery (RCA) was a small caliber and tortuous vessel, with only minor atheroma. However, an abnormal vessel arising from the proximal RCA was noted (Figure 2B and C), confirmed as a fistulous connection to the left atrium by multislice computed tomography, which also excluded other vascular anomalies (Figure 3). This was deemed to be causing a coronary steal phenomenon. Exercise myocardial perfusion imaging under anti-ischemic therapy excluded residual ischemia and the patient was successfully conservatively managed (Figure 4). Coronary-pulmonary artery fistulas (CPAF) are rare, often incidental findings of coronary angiography, thought to

Renal cell carcinoma presenting as a stress cardiomyopathy

A 76-year-old woman was admitted to the emergency department with a squeezing severe chest pain starting at rest, 1h before. Previous medical history was unremarkable. An electrocardiogram showed rapidly evolving ST-segment changes ( Panels A–C ). The rapid troponin I assay was positive (1.4 ng/mL). Unknown renal dysfunction was also noted (creatinine of 1.7 mg/dL). Apical akinesia was present on bedside echocardiogram (TEE). Urgent coronary angiography due to unremitting chest pain and hypotension excluded obstructive coronary disease. Ventriculography showed a striking pattern of apical akinesia ( Panels D and E …

Aortocoronary dissection complicating percutaneous angioplasty

A 56-year-old man was admitted to our hospital for elective coronary angioplasty of a chronic total occlusion (CTO) of the right coronary artery (RCA). After insertion of a right femoral sheath, the RCA was engaged with a 6 French Amplatz AL-2 (Cordis, Miami, Fl, USA) guiding catheter. Recanalization was begun using a 0.014-inch Miracle 3 guidewire (Asahi Intecc, Japan). At this stage, an ostial dissection flap of the RCA with immediate retrograde extension to the ascending aorta was noticed (Figure 1). Stenting of the RCA ostium with a Xience Prime 3.0 × 15 mm stent (Abbott Vascular, Santa Clara, California, USA) was performed, followed by a PTFE-covered 3.0 × 19 mm Jostent graft

Mitral valve aneurysm: A serious complication of aortic valve endocarditis

Mitral valve aneurysms are rare and occur most commonly in association with aortic valve endocarditis. Transesophageal echocardiography is the most sensitive imaging modality for the diagnosis of this entity and its potential complications, such as leaflet rupture and mitral regurgitation, which mandate prompt surgical intervention. We present the case of a 70-year-old male patient with aortic valve endocarditis complicated with a ruptured aneurysm of the anterior mitral valve leaflet and associated severe mitral regurgitation, diagnosed by transesophageal echocardiography, with impressive images. We hypothesized that the aneurysm developed through direct extension of infection from the aortic valve or from a prolapsing aortic vegetation, with abscess formation and subsequent rupture and drainage. This case highlights the importance of appropriate imaging for early detection and timely surgical intervention (repair or replacement) to prevent fatal outcomes.

Triple, simultaneous, very late coronary stent thrombosis

Coronary artery stent thrombosis is an uncommon but potentially catastrophic complication. The risk of very late stent thrombosis (VLST) raises important safety issues regarding the first generation of drug-eluting stents (DES). Although several complex mechanisms for VLST have been suggested and various predictors have been described, its pathophysiology is not completely understood and it is not known whether longer-term dual antiplatelet therapy reduces the risk. We present a rare case of simultaneous very late DES thrombosis in the three vascular territories, following discontinuation of antiplatelet therapy seven years after stent placement, presenting as cardiogenic shock.

Pulmonary embolism with thromboembolus in transit.

An 88-year-old woman was admitted with syncope and rapidly evolved with shock. Her medical history was notable for recent orthopedic surgery. The electrocardiogram showed ST-segment depression in the precordial and inferior leads (Figure 1). Rapid troponin I assay was positive. Bedside echocardiography revealed a dilated and dysfunctional right ventricle, with akinesia of the lateral wall and paradoxical interventricular septal motion (Figure 2A). Remarkably, a large, worm-like, mobile, freefloating right atrial mass was noted, insinuating through the tricuspid valve during systole (Figure 2B--D). Acute pulmonary embolism (PE) with right heart thromboembolus was strongly suspected, so prompt resuscitation and anticoagulant therapy were started, while emergency thoracic computed tomography angiography confirmed bilateral central emboli (Figure 3A--C). Despite the high bleeding risk, thrombolysis was undertaken, given the life-threatening condition, with gradual improvement in clinical status and no major bleeding complications. No right heart thromboembolus was found in the follow-up echocardiogram and the patient had an uneventful hospital course. Right heart thromboemboli in transit are an incidental finding in up to 20% of patients with acute high-risk

Pseudoaneurisma gigante do ventrículo esquerdo - catástrofe silenciosa

P declare that no experiments were performed on humans or animals for this investigation. Pseudoaneurysms are a serious complication of myocardial infarction but can be asymptomatic and only detected by chance in patients with previous subclinical events. The images presented are of a 62-year-old man, a smoker, with no history of heart disease, admitted to our hospital for community-acquired pneumonia. The chest X-ray on admission showed cardiomegaly and the electrocardiogram showed Q waves in the inferior leads. Transthoracic echocardiography revealed mild left chamber dilatation and severe left ventricular systolic dysfunction, with an aneurysmal sac, 8 cm in diameter, involving the basal portion of the posterior, inferior and lateral walls and containing a thrombus (Figures 1 and 2). Since unequivocal differential diagnosis between aneurysm and pseudoaneurysm was not possible with this technique, magnetic resonance imaging was performed, which revealed an old extensive inferior infarction, extending to the adjacent portion of the right ventricle, with inferior myocardial wall rupture. A diagnosis was thus established of pseudoaneurysm in the inferior and posterior walls, containing an organized thrombus (Figures 3 and 4). Cardiac catheterization showed single-vessel disease with chronic occlusion of the mid segment of the right coronary artery. Surgical repair was proposed but the patient refused. He remained clinically stable in NYHA class II for 10 months after discharge, but was then lost to follow-up.

Origem anómala da coronária direita e enfarte agudo do miocárdio: causa ou coincidência?

Congenital coronary artery anomalies are one of the causes of myocardial ischemia and sudden death in the young, mainly during sports. Origin of the right coronary artery from the left anterior descending artery is very rare, with a prevalence of 0.015%, corresponding to 1.2% of all coronary artery anomalies. The authors present the case of a 22-year-old man, with a history of cocaine use, admitted to hospital with a non-ST elevation acute myocardial infarction. Coronary angiography revealed the presence of this rare coronary anomaly and the absence of atherosclerotic luminal stenosis, and so it was assumed to be a type II infarction caused by cocaine-induced vasospasm of the anomalous vessel.