Patrizia Grimaldi

Left ventricular thrombus formation and cardioembolic complications in patients with Takotsubo-like syndrome: A systematic review

BACKGROUND Though a severe left ventricular systolic dysfunction has been described in most patients with Takotsubo-like (or Apical Ballooning) syndrome, the occurrence of intra-cavitary thrombus formation seems to be such an exceptional finding. However, no large studies but single case descriptions of this complication are available over the last decade in the literature. METHODS By searching for the PubMed-Medline database we selected 14 studies that met our eligibility criteria. RESULTS Demographic, clinical and morphofunctional characteristics of 15 patients who where described to have left ventricular thrombosis as a complication of the Takotsubo-like syndrome are comprehensively described in this review. Cardioembolic complications (stroke in 3 cases, renal infarction or popliteal artery thrombosis in other two) occurred in 33.3% out of them. The incidence of thrombus formation and related systemic embolisms in the general population with this syndrome were established on the basis of such available historical data and reviews on this subject. CONCLUSION Left ventricular thrombus formation has been reported in at least 14 studies (15 patients) over the last decade until the end of 2007. This approximately results in about 2.5% of all the patients with documented Takotsubo-like syndrome. Cardioembolic complications occurred in 5/15 cases, corresponding to 0.8% of the whole known population.

Evidence of cardiovascular autonomic impairment in mitochondrial disorders

ObjectiveTo investigate autonomic nervous system (ANS) function in mitochondrial disorders (MD).BackgroundMD are characterized by a wide range of clinical features, including heart abnormalities and peripheral and central nervous systems involvement. Rarely autonomic symptoms have been reported.Methods22 patients with MD underwent a battery of cardiovascular reflex tests including five tests of parasympathetic function and four tests of sympathetic function. Power spectral analyses (PSA) of heart rate variability in the supine and upright positions were also evaluated. Plasma levels of adrenaline, noradrenaline and dopamine were determined in the standing and lying positions.ResultsOnly 4/22 patients referred symptoms related to ANS dysfunction. 46% of patients had a definite autonomic damage (i. e. an autonomic score ≥ 4). 36% showed moderate alterations with an autonomic score in the range 2–3 and 18 % had a normal autonomic function. MD patients had a significantly (p <0.03) lower increase of adrenaline level after standing.ConclusionsOur data indicate an autonomic dysfunction in more than 80% of MD patients, even in the absence of a clinically manifested autonomic involvement. Cardiovascular autonomic investigation might be systematically employed in the characterization of MD.

Extrinsic pulmonary stenosis in primary mediastinal B-cellular lymphoma

We describe the case of a 34‐year‐old man with a history of asthenia and excessive fatigability. Transthoracic echocardiography showed a mass in the right ventricular outflow tract with a peak systolic gradient of 52 mmHg. Contrast‐enhanced CT confirmed the presence of a lobulated mass, which extensively filled the anterior mediastinum, infiltrating the pulmonary artery trunk up to occupying the right ventricular outflow tract. CT‐guided biopsy revealed primary mediastinal B‐cellular lymphoma. The patient underwent chemotherapy, achieving complete remission of the disease at the 12‐month follow‐up, while the gradient across the pulmonary artery dropped from 52 mmHg to 14 mmHg.

Echocardiographic assessment of subclinical left ventricular eccentric hypertrophy in adult-onset GHD patients by geometric remodeling: an observational case-control study

BackgroundMost patients with growth hormone deficiency (GHD) show high body mass index. Overweight subjects, but GHD patients, were demonstrated to have high left ventricular mass index (LVMi) and abnormal LV geometric remodeling. We sought to study these characteristics in a group of GHD patients, in an attempt to establish the BMI-independent role of GHD.MethodsFifty-four patients, 28 F and 26 M, aged 45.9 ± 13.1, with adult-onset GHD (pituitary adenomas 48.2%, empty sella 27.8%, pituitary inflammation 5.5%, cranio-pharyngioma 3.7%, not identified pathogenesis 14.8%) were enrolled. To minimize any possible interferences of BMI on the aim of this study, the control group included 20 age- and weight-matched healthy subjects. The LV geometry was identified by the relationship between LVMi (cut-off 125 g/m2) and relative wall thickness (cut-off 0.45) at echocardiography.ResultsThere was no significant between-group difference in resting cardiac morphology and function, nor when considering age-related discrepancy. The majority of patients had normal-low LVM/LVMi, but about one fourth of them showed higher values. These findings correlated to relatively high circulating IGF-1 and systolic blood pressure at rest. The main LV geometric pattern was eccentric hypertrophy in 22% of GHD population (26% of with severe GHD) and in 15% of controls (p = NS).ConclusionThough the lack of significant differences in resting LV morphology and function, about 25% of GHD patients showed high LVMi (consisting of eccentric hypertrophy), not dissimilarly to overweight controls. This finding, which prognostic role is well known in obese and hypertensive patients, is worthy to be investigated in GHD patients through wider controlled trials.

P-wave voltage and peaking on electrocardiogram in patients undergoing head-up tilt testing for history of syncope

BACKGROUND Only scanty data are available in the literature on P-wave (PW) morphology at ECG in patients with history of vasovagal syncope undergoing diagnostic functional testing. In this study, we evaluated resting and head-up tilt testing (HUTT) related changes in PW voltage (PWV) and duration (PVD) and their relationship with triggered syncope. METHODS 55 patients, mean aged 41 ± 19 y (35 F), without patent heart disease or neuropathy, underwent potentiated HUTT according to the Italian protocol. Heart rate (HR), blood pressure (BP), PR-interval, PWV and PWD were measured at rest, 15 min from passive position (15-min) and after nitroglycerine (peak-HR). PW peaking (PWP) was calculated as percent increase in PWV than baseline values. Patients were divided into 2 groups based on tilt-positive (group-A) or negative (group-B) response. RESULTS 20 patients (36%) entered the group-A, whereas 35 (64%) the group-B. Higher PWV was observed at baseline in group-A (0.147 ± 0.034 mV vs 0.114 ± 0.036 mV in group-B, p=0.001), with no differences in the remaining ECG measurements. BP was lower in group-A than in B, both at 15-min and peak-HR. HUTT-related PWP in lead II (the most significant among all inferior leads) was 31 ± 30% in group-A vs 95 ± 54% in group-B (p<0.0001) at 15-min, and 52 ± 44% vs 112±72% at peak-HR, respectively (p=0.002). 75% of patients with PWP ≤ 50% experienced HUTT-triggered syncope, vs 5% of those with PWP ≥ 100% (p<0.0001). CONCLUSIONS This study shows a potential relationship between HUTT-triggered syncope and low or absent PWP, suggesting a role for atrial chamber functional involvement in the mechanisms underlying the vasovagal syncope.

Cardiac allograft vasculopathy

Cardiac allograft vasculopathy (CAV) is an accelerated form of coronary artery disease affecting both intramyocardial and epicardial coronary arteries and is observed in patients during long-term survival after cardiac transplantation. We report a case of CAV complicated with silent transmural myocardial infarction and massive left ventricular thrombus formation associated with silent pericarditis and with ischemic and non-ischemic scar tissue, as detected by cardiac magnetic resonance imaging (CMRI). The authors suggest CMRI as an additional technique along with echocardiography during follow-up of heart transplant recipients. CMRI may contribute to the early identification of areas of myocardial wall abnormalities suggestive of CAV, thus guiding diagnosis and prompt percutaneous treatment.ZusammenfassungDie kardiale Allotransplantat-Vaskulopathie („cardiac allograft vasculopathy“, CAV) ist eine rasch progrediente Form der koronaren Herzkrankheit (KHK), die intramyokardiale und epikardiale Koronararterien betrifft und bei Langzeitüberlebenden nach Herztransplantation auftreten kann. Wir berichten über einen Patienten mit CAV und klinisch asymptomatischem transmuralem Myokardinfarkt. Kompliziert wurde das Krankheitsbild durch eine massive linksventrikuläre Thrombusbildung mit stummer Perikarditis sowie ischämischem und nichtischämischem Narbengewebe, wie mittels kardialer Magnetresonanztomographie (MRT) nachgewiesen werden konnte. Die Autoren empfehlen, die kardiale MRT zusätzlich zur Echokardiographie als bildgebende Technik in der Lanzeitbetreuung nach Herztransplantation einzusetzen. Sie kann dazu beitragen, myokardiale Wandbewegungsstörungen aufgrund einer CAV früh zu entdecken und damit die Diagnostik sowie die zur Behandlung erforderliche perkutane Intervention zu beschleunigen.

Cardiac allograft vasculopathy@@@Kardiale Allotransplantat-Vaskulopathie: Complications and imaging studies@@@Komplikationen und bildgebende Diagnostik

Cardiac allograft vasculopathy (CAV) is an accelerated form of coronary artery disease affecting both intramyocardial and epicardial coronary arteries and is observed in patients during long-term survival after cardiac transplantation. We report a case of CAV complicated with silent transmural myocardial infarction and massive left ventricular thrombus formation associated with silent pericarditis and with ischemic and non-ischemic scar tissue, as detected by cardiac magnetic resonance imaging (CMRI). The authors suggest CMRI as an additional technique along with echocardiography during follow-up of heart transplant recipients. CMRI may contribute to the early identification of areas of myocardial wall abnormalities suggestive of CAV, thus guiding diagnosis and prompt percutaneous treatment.ZusammenfassungDie kardiale Allotransplantat-Vaskulopathie („cardiac allograft vasculopathy“, CAV) ist eine rasch progrediente Form der koronaren Herzkrankheit (KHK), die intramyokardiale und epikardiale Koronararterien betrifft und bei Langzeitüberlebenden nach Herztransplantation auftreten kann. Wir berichten über einen Patienten mit CAV und klinisch asymptomatischem transmuralem Myokardinfarkt. Kompliziert wurde das Krankheitsbild durch eine massive linksventrikuläre Thrombusbildung mit stummer Perikarditis sowie ischämischem und nichtischämischem Narbengewebe, wie mittels kardialer Magnetresonanztomographie (MRT) nachgewiesen werden konnte. Die Autoren empfehlen, die kardiale MRT zusätzlich zur Echokardiographie als bildgebende Technik in der Lanzeitbetreuung nach Herztransplantation einzusetzen. Sie kann dazu beitragen, myokardiale Wandbewegungsstörungen aufgrund einer CAV früh zu entdecken und damit die Diagnostik sowie die zur Behandlung erforderliche perkutane Intervention zu beschleunigen.