Satya S. Vittala

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)

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.

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 …

Effect of migraine treatment on heart

A 59-year-old woman presented for evaluation of palpitations, orthopnoea, and dyspnoea on exertion. On examination, the patient was found to have an apical holosystolic murmur suggestive of mitral regurgitation. She had no history of rheumatic heart disease but had experienced migraine headaches for which she started taking methysergide when she was 51 years old. She stopped using the methysergide at age 53, when …

Early bioprosthetic valve failure due to carcinoid heart disease

A 78-year-old woman with a patent foramen ovale (PFO) and carcinoid heart disease (CHD) underwent PFO closure and replacement of the tricuspid valve (TV) and pulmonary valve (PV) with bioprostheses [27 and 21 mm, respectively (Carpentier Edwards Perimount; Edwards Lifesciences, LLC, Irvine, CA, USA)]. Pre-surgically, she had markedly elevated serotonin (472 ng/mL), urinary 5-hydroxyindoleacetic acid (5–HIAA) (37 mg/24 h), and chromogranin A (3010 ng/mL). Intraoperative transoesophageal echocardiography (TOE) showed normal function, with minimal regurgitation …

Diagnosis of pulmonary arteriovenous malformation using a transesophageal echocardiography bubble study

A 42-year-old woman underwent transthoracic echocardiography with agitated saline contrast injection after an ischaemic stroke; a right-to-left shunt was observed ( Figure A ). Transesophageal echocardiography with agitated saline contrast injection (‘bubble study’) was then performed; bubbles were apparent in the left atrium after four …