Susan Wilansky

Anteroapical Stunning and Left Ventricular Outflow Tract Obstruction

Dynamic left ventricular outflow tract (LVOT) obstruction is typically observed in the setting of hypertrophic cardiomyopathy. It has also been reported with concentric LV hypertrophy, excessive sympathetic stimulation, and acute myocardial infarction. We describe 3 patients with chest discomfort after emotional stress, who had pronounced abnormalities on electrocardiograms, insignificant obstructive coronary disease and hemodynamic instability with LVOT obstruction, and regional wall motion abnormalities. Suppression of contractility with beta-blockers resulted in resolution of the gradient and in clinical improvement. On follow-up, functional recovery was excellent, and ventricular function had normalized. The conditions and mechanisms that may produce this sequence of events are discussed. The most probable scenario is that an acute ischemic insult secondary to vasospasm, LV stunning, and acute geometric remodeling produced a substrate for LVOT obstruction that was exacerbated by basal LV hypercontractility. The importance of this observation is that routine treatment of cardiogenic shock cannot be used and that conservative management results in excellent prognosis.

Left Ventricular Diastolic Function in Normal Human Pregnancy

BACKGROUND Little information is available about changes in left ventricular diastolic function during pregnancy. We used mitral inflow and pulmonary venous flow profiles to evaluate left ventricular diastolic function in 37 healthy pregnant women 26 to 41 years old (mean, 32 years). METHODS AND RESULTS Echocardiographic studies were performed at the end of each trimester. Eight subjects (control group) underwent similar testing 1 to 3.5 months (mean, 1.7 months) postpartum. During pregnancy, the cardiac output increased significantly as a result of an increased heart rate and, to a lesser degree, stroke volume. Significantly decreased systemic vascular resistance and increased left ventricular mass were also noted. Peak mitral flow velocity in early diastole (E) increased 13. 3% during the first trimester and remained at the high end of normal throughout pregnancy. Peak A-wave velocity (A) increased maximally in the third trimester. Compared with control subjects, first-trimester subjects had a significantly increased E/A ratio. The ratio subsequently decreased, reflecting the augmented A-wave velocity. Pulmonary venous peak systolic forward flow velocity increased, peaking in the second trimester (nonsignificant), but returned to baseline levels postpartum. The pulmonary venous diastolic time-velocity integral decreased significantly from the first to the third trimester. Peak pulmonary venous reverse flow velocity at atrial contraction increased significantly, without being markedly changed in duration. CONCLUSIONS Pregnancy, a chronic, natural volume-overload state, has important effects on hemodynamic and echocardiographic variables. Based on pulmonary venous flow and left ventricular inflow velocities, our results provide a standard reference concerning diastolic filling dynamics by trimester.

Left ventricular outflow tract obstruction and hemolytic anemia after mitral valve repair with a duran ring

We report a case of mitral valve repair with a Duran ring that was complicated by left ventricular outflow tract obstruction, mitral regurgitation, and hemolytic anemia. A 59-year-old man with severe mitral valve regurgitation underwent mitral valve repair, including a Duran ring annuloplasty. Postoperatively, left ventricular outflow tract obstruction developed and echocardiography revealed severe systolic anterior motion of the mitral valve. The patient then underwent mitral valve replacement with a 29-mm St. Jude valve.

Images in cardiovascular medicine. An unusual case of right-sided heart failure.

A 57-year-old man with a history of coronary artery disease and chronic obstructive pulmonary disease was admitted to another hospital with progressive dyspnea, ascites, edema, and mild jaundice. He was transferred to St. Lukes Episcopal Hospital for further evaluation. Biplane transesophageal echocardiography (TEE) revealed an extensive tumor mass in the right atrium and left atrium (Fig 1, A) with obstruction of the superior vena cava. TEE-guided biopsy of the superior vena cava mass revealed histology of large-cell lymphoma (B-cell type). At 6-month follow-up, after appropriate chemotherapy, repeat TEE showed almost total resolution of the tumor bulk, with only a small residual mass seen in the right atrium (Fig 1, B).

Carcinoid Heart Disease

A 37-year-old black woman presented with watery diarrhea, facial flushing, and progressive right heart failure. CT-guided biopsy of a liver mass revealed a neuroendocrine tumor. Elevated levels of 5-hydroxyindoleacetic acid confirmed the diagnosis of metastatic carcinoid syndrome. A …

Unusual Atrial Thrombi Discovered by Transesophageal Echocardiography

### Case 1 A 58-year-old man was transferred to St Luke’s Episcopal Hospital in January 1996 with persistent pleuritic chest pain. His medical history included a pulmonary embolus that had been treated with anticoagulation in December 1994. Three months later, in March 1995, multiple emboli to the right brachial, carotid, and renal arteries were discovered; at that time, an inferior vena caval filter was placed. In September 1995, an atrial septal defect was diagnosed and surgically closed. In the …