Takako Iino

Two Cases of Calcified Amorphous Tumor Mimicking Mitral Valve Vegetation

The term cardiac calcified amorphous tumor (CAT) was coined in 1997 by Reynolds et al,1 who described 11 cases with nonneoplastic cardiac masses characterized by a pedicle and diffuse calcification. Additionally, CAT could originate in any of the 4 chambers. Once the mass is excised, its unique histological features such as the presence of calcified nodules in an amorphous background of fibrin with degeneration and focal inflammation allow an accurate diagnosis of cardiac CAT. However, in cases when CAT has arisen close to the cardiac valves and is mobile, it is not always easy to distinguish between CAT and mitral valve vegetation preoperatively. Here, we report 2 cases of CAT arising from mitral annular calcification (MAC) and propose imaging features that can be used to distinguish CAT from mitral valve vegetation. Case 1. A 58-year-old man with end-stage renal disease secondary to diabetic nephropathy was referred to our hospital. He had been maintained on hemodialysis for the past 4 years. Transthoracic echocardiography revealed 2 cardiac tumors adherent to the posterior MAC (Figure 1A). One was a highly mobile, …

Candesartan improves impaired endothelial function in the human coronary artery.

BackgroundEndothelial dysfunction is closely related to cardiovascular events. Several studies have documented that angiotensin II type 1 receptor blockers (ARB) improve peripheral endothelial dysfunction. However, the effect of ARB on coronary endothelial function remains elusive. The purpose of this study was to ascertain the beneficial effects of ARB on human coronary artery endothelial function. Methods and ResultsTwenty-seven patients were randomly assigned to either the candesartan group (n=14) or the control group (n=13) and followed for 12 months. Coronary blood flow velocity was measured in the left anterior descending artery without stenosis using an intracoronary Doppler-tipped guide-wire. We evaluated coronary endothelial function as the coronary blood flow velocity reserve (CFR), which was defined as the percent change in the coronary blood flow velocity after an intracoronary acetylcholine infusion. At baseline, the CFR in both groups was below 300%, implying that these patients had endothelial dysfunction. After treatment with candesartan for 6 months, the CFR increased significantly from 199±20 to 337±27% (P<0.001), whereas the CFR did not change in the control group (194±32 vs. 185±41%, P=0.52). During 12 months of observation, the cardiovascular event-free survival rate of the patients with an increased CFR was significantly greater than the rate in patients with a decreased CFR (P=0.02). Moreover, the cardiovascular event-free survival rate was greater in the candesartan group than in the control group (P=0.04). ConclusionOur results suggest that candesartan improves coronary endothelial dysfunction of human coronary arteries and may prevent cardiac events.

Renal paradoxical embolism in a hypertensive young adult without acute ischemic symptoms

A 22-year-old woman, who often carried heavy books, was admitted for evaluation of hyperreninemic hypertension. Two months prior to admission, she noted leg edema. Radiological examinations revealed bilateral renal infarction with no other abnormal findings. An echocardiography showed a patent foramen ovale (PFO). Hypertension was considered secondary to renal infarction caused by paradoxical embolism through PFO. Antihypertensive and anticoagulant therapy led to improvement of hypertension. In previously reported cases of renal paradoxical embolism, multiorgan involvement was usually observed. Our case is unique in that embolism was confirmed only in the kidneys, and that clinical characteristics of renal embolism were not observed.

Blood Balloon Induced by an Atrial Myxoma in the Heart

A 75-year-old male with a left atrial (LA) mass was referred to our hospital. The patient had been healthy until 5 months prior, when dyspnea on exertion developed. A chest radiograph showed mild enlargement of the cardiac silhouette. An ECG showed sinus rhythm with P mitrale (Figure 1A). Transthoracic echocardiography (TTE) revealed a 5.4×3.9-cm hypoechoic tumor that had prolapsed through the mitral valve causing left ventricular inflow obstruction (Figure 1B; Movie I in the online-only Data Supplement). The tumor appeared to be soft with smooth surface and had a stalk originating from the interatrial septum. Transesophageal echocardiography (TEE) revealed dynamic smoke-like echoes, indicative of spontaneous echo contrast, inside the tumor (Figure 1C; Movie I in the online-only Data Supplement). M-mode showed multiple echoes and unique tumor behavior with subtle motion, in which the tumor rebounded into LA cavity twice during systole, producing an M-shaped signal (Figure 1D; Movie II in the online-only Data Supplement). These echocardiographic findings implied that the inside of tumor was filled with liquid, rather than clotted blood, giving it a blood-balloon–like appearance. Moreover, color Doppler revealed afferent flow entering the tumor (Figure 2A) and efferent flow draining from the tumor (Figure 2C). Both flows occurred …

Right Atrial Giant Myxoma Occupying the Right Ventricular Cavity

We report a case of a giant right atrial myxoma mimicking the right ventricular tumor. The 75-year-old patient underwent cardiac surgery, and the tumor was excised along with the stalk. Tricuspid valve annuloplasty was performed before closure of the right atriotomy. The tumor may have caused intraventricular stenosis, hepatic dysfunction, and progressive fatigue as a result of low cardiac output. This case is of special interest because the myxoma was very large compared with those ever reported, and a right atrial myxoma occupying the right ventricular cavity is rare.

An unusual interventricular communication after acute myocardial infarction

An 82-year-old woman was admitted to our hospital with a 9-day history of intermittent chest pain. Electrocardiography showed abnormal Q waves in leads II, III, and aVF and ST-segment elevation in leads II, III, aVF, V4, V5, and V6 ( Panel A ). Echocardiography showed not only inferoposterior wall akinesis but also an …

Morphological Determinants of Obstructive Hypertrophic Cardiomyopathy Obtained Using Echocardiography

The morphological determinants of left ventricular outflow tract (LVOT) obstruction in hypertrophic cardiomyopathy (HCM) are not completely understood. We aimed to identify the anatomical risks of the obstruction using echocardiography.Fifty patients with untreated HCM were classified into two groups: those with LVOT pressure gradient (LVOTPG) ≥ 30 mmHg (obstructive HCM [HOCM] group) and those with LVOTPG < 30 mmHg (HNCM group). The echocardiographic morphological variables were analyzed to determine whether they were predictive of LVOT obstruction. Systolic anterior motions of the mitral valve were observed in 100% of patients in the HOCM group but only in 58% in the HNCM group. There were no significant differences in wall thickness, end-systolic LV dimension (LVDs), or LVOT diameter between the two groups. However, HOCM subjects had a shorter distance from papillary muscles to the inter-ventricular septum (5.97 ± 2.3 versus 9.20 ± 1.9 mm, respectively, P < 0.0001) and a longer anterior mitral leaflet (AML) length (24.7 ± 5.8 versus 20.1 ± 5.4 mm, respectively, P < 0.01) compared to the HNCM group. The AML length/LVDs ratio was significantly higher in the HOCM group compared to the HNCM group (1.02 ± 0.34 versus 0.78 ± 0.26, P < 0.01), and an LVOT obstruction was predicted with an area under the curve of 0.71 (P < 0.05). Multiple linear regression revealed that only the AML length/LVDs ratio was independently associated with LVOTPG (P < 0.01).The AML length/LVDs ratio has a significant predictive value for LVOT obstruction and a strong relationship with LVOTPGs. The AML length/LVDs ratio determines the anatomical risk of LVOT obstruction in HCM.

In vivo visualization of the blood separation in the left ventricular chamber: a case of fulminant myocarditis requiring venoarterial extracorporeal membrane oxygenation

A 33-year-old woman was admitted with a clinical diagnosis of fulminant myocarditis. Echocardiography showed severe left ventricular (LV) hypokinesis, with diffuse wall motion abnormalities (ejection fraction, 20 %) (Fig. 1a). The patient developed rapidly worsening hemodynamics with hypoxia and an unmeasurable blood pressure; we therefore performed venoarterial extracorporeal membrane oxygenation (VA-ECMO), intubation with use of an intra-aortic balloon pump, and intravenous heparin infusion. The VA-ECMO flow was maintained at 3–4 L/ min. The activated partial thromboplastin time was 98 s. Only 3 h after initiating VA-ECMO, echocardiography revealed aortic valve closure and sedimentation in the LV chamber. The sedimentation was clearly separated into supernatant and sludge components as a result of the difference in specific gravity, mimicking blood separation (Fig. 1b, c, Video 1). Despite the aortic valve closure, blood movement through the mitral valve was still observed (Fig. 1d); this might have prevented sludge formation in the LV inflow tract. Despite thrombectomy and implantation of an LV assist device, the patient developed fatal multiorgan failure. Pathology autopsy confirmed myocarditis (Fig. 1e). In patients with severe myocardial dysfunction, VA-ECMO circulation in a nonphysiological

An unusual cause of superior vena cava syndrome after pacemaker implantation

An 81-year-old woman with a history of aortic valve replacement and DDD pacemaker implantation 5 years earlier was admitted to our hospital. She had had the ventricular lead with a VDD pacemaker re-inserted 3 years prior because the pacing threshold had increased in both the atrial and …

Steroid-induced metamorphosis of the heart: a case of cardiac sarcoidosis

A 35-year-old man was admitted for acute heart failure. Electrocardiography showed epsilon waves in leads V1 and V2 ( Panel A ). Echocardiography showed asymmetric septal hypertrophy mimicking hypertrophic cardiomyopathy ( Panel B and see Supplementary data online, Video S1 ). Enlargement of the mediastinal lymph nodes ( Panel C ) and multiple low-density nodules in both the …