Sofia Cabral

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.

Hyponatremia – an unusual trigger of Takotsubo cardiomyopathy

Takotsubo cardiomyopathy is an acute cardiac entity with clinical manifestations similar to myocardial infarction, accounting for 1-2% of acute coronary syndrome admissions. Its underlying pathophysiology is not yet well established. It is usually associated with acute physical or emotional stress, but the list of potential triggers has grown as the condition attracts the attention of the medical community. In order to diagnose the condition correctly and to gain new insights into it, we need to know its potential triggers as well as its clinical presentation and diagnostic criteria. We report a case of takotsubo cardiomyopathy triggered by hyponatremia.

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.

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.

Documento de Consenso e Recomendações para a realização de Ecocardiografia Transtorácica em Portugal

Echocardiography is the most widely used imaging technique in modern cardiological clinical practice, since it is readily available, portable and safe, and provides a comprehensive morphological and functional assessment at low cost compared to other imaging modalities. Recent technological advances have introduced new echocardiographic techniques and widened the clinical applications of echocardiography. However, these developments have also led to an increase in information, rendering interpretation of the data provided by the exam more complex; this may result in assessment errors by less experienced operators. Standardization of procedures and training in echocardiography is therefore essential to ensure quality and safety for patients. The present document aims to contribute to this end, recommending quality requirements for operators and echocardiography laboratories in Portugal.

Late left atrioventricular disruption: an unusual complication of mitral valve replacement after endocarditis

Late development of left ventricular (LV) rupture after mitral valve (MV) replacement is a rare clinical condition associated with a poor prognosis. The diagnosis of this complication may be difficult, and a multimodality imaging approach is extremely useful for its characterisation. We report a case of a 35-year-old man who presented with heart failure due to an acute native MV endocarditis. Echocardiography showed a ruptured anterior MV leaflet with severe mitral regurgitation, and a periannular abscess in anatomical relation with left atrial appendage. Antibiotic therapy was started and an urgent surgery was performed, in which the MV was replaced with a mechanical prosthetic valve. After an uneventful year, the patient was admitted again with an acute pericarditis. Echocardiography evaluation (transthoracic and transoesophageal) revealed a large cavity (39 × 33 mm) with systolic expansion in the basal segment of anterolateral LV wall, immediately below the prosthetic mitral annulus plane, communicating with the LV through a neck of 13 mm (Fig. 1A–C, asterisk), suggesting the presence of a late left atrioventricular groove disruption. In addition, two paraprosthetic leaks were visualised, leading to at least moderate regurgitation (Fig. 1D). During follow-up, LV ejection fraction decreased slightly to 58% and mild LV dilatation developed. An additional anatomical characterisation with cardiac computed tomography (CT) was performed, confirming left atrioventricular groove rupture adjacent to the prosthetic MV (Fig. 1E–G, asterisk), leading to a slightly antero-superior displacement of the left coronary artery, and in close relationship with the circumflex artery (pointed out with an arrow in Fig. 1G). This CT anatomical characterisation of the surrounding structures was essential in surgical treatment planning. The patient was successfully submitted to LV repair and prosthetic MV replacement with improvement in clinical status.

Partial Papillary Muscle Rupture after Myocardial Infarction and Early Severe Obstructive Bioprosthetic Valve Thrombosis: an Unusual Combination

Mailing Address: Inês Silveira • Largo Prof. Abel Salazar, 4099-001 Porto Portugal E-mail: Ines.c.silveira@gmail.com Manuscript receivde December 02, 2017, revised manuscript April 04, 2018, accepted April 25, 2018

Left ventricular noncompaction or hypertrophic cardiomyopathy? Both!

Left ventricular noncompaction (LVNC) is a rare condition defined by prominent trabeculation of the myocardial wall and deep intertrabecular recesses communicating with the LV cavity. Hypertrophic cardiomyopathy (HCM) is the most common genetic cardiac disorder and is characterised by ventricular hypertrophy in the absence of another identifiable cause. LVNC and HCM are heterogeneous and yet poorly characterised entities but increasing evidence suggests an overlap of genetic and clinical features. A 70-year-old man, without relevant personal or familiar pathological history, was referred to our Emergency Department with sudden palpitations and light-headedness. Objectively, the patient was hypotensive (85/55mmHg) and with a rhythm of monomorphic ventricular tachycardia, therefore, an urgent electrical cardioversion was performed. As part of the aetiological investigation, electrocardiogram revealed sinus rhythm with non-specific ventricular repolarization abnormalities in V4-V6. Transthoracic echocardiogram showed preserved biventricular systolic function but LV presented with significant apical hypertrophy (maximum thickness of 16mm) and hypertrabeculation of the antero-lateral wall. Ultrasound contrast injection confirmed hypertrabeculation and deep recesses in the left ventricular wall with areas of almost nonexistent normal myocardium (non-compacted layer/compacted layer ratio above 2.3). Cardiac magnetic resonance revealed typical findings of LVNC and apical HCM supporting both diagnosis in this patient (Figure 1). Hospitalization was uneventfully, a cardioverterdefibrillator was implanted and the patient was discharged with beta-blocker. After twelve months of follow-up, there were no signs of heart failure or lifethreatening arrhythmias. To our knowledge, this is the first reported case of simultaneous presentation of LVNC and HCM in such an advanced age.