Zia Ur Rahman

Speckle Tracking Echocardiography of the Right Atrium: The Neglected Chamber

The right atrium (RA) plays a pivotal role in electromechanical and endocrine regulation of the heart. Its peculiar anatomical features and phasic mechanical function make it distinct from ventricles. Various invasive and noninvasive techniques have been used to elucidate RA structure and function. Of these modalities, echocardiography has distinct advantages over others. Several conventional measures of RA function through echocardiography have been described in the literature, but they are load dependent. A relatively new technique is speckle tracking–derived strain, which is relatively less dependent on loading conditions. Speckle tracking echocardiography tracks acoustic scatters (speckles) of myocardium frame‐by‐frame to calculate strain or deformation of the myocardium. Speckle tracking echocardiography has been used extensively for strain assessment of the right and left ventricle to detect subtle disease pathology, to gain mechanistic insight, as a marker of ischemic metabolic memory, as an endpoint in clinical trials, and as a functional assessment tool. The RA is a relatively neglected chamber, as it is mostly studied for assessment of atrial mass lesions, for electrophysiological studies, and in animal models for physiological assessment. However, its role in the systolic and diastolic function of the right heart, pulmonary vascular pathology, congenital heart diseases, and combined electromechanical activation phenomena has been less explored or unexplored. Speckle tracking echocardiography is an ideal tool for the assessment of the RA because of its regional and global functional characterization, angle independence, and high temporal resolution.

Feature tracking cardiac magnetic resonance imaging: A review of a novel non-invasive cardiac imaging technique

Cardiovascular disease is a leading cause of morbidity and mortality globally. Early diagnostic markers are gaining popularity for better patient care disease outcomes. There is an increasing interest in noninvasive cardiac imaging biomarkers to diagnose subclinical cardiac disease. Feature tracking cardiac magnetic resonance imaging is a novel post-processing technique that is increasingly being employed to assess global and regional myocardial function. This technique has numerous applications in structural and functional diagnostics. It has been validated in multiple studies, although there is still a long way to go for it to become routine standard of care.

Breathless at the point of a sword

Context: Scimitar syndrome is a congenital anomaly of pulmonary venous return where right pulmonary artery drains into right side other heart, instead of the left side, causing pulmonary hypertension resulting in shortness of breath, recurrent lower respiratory tract infections, chest pain, and fatigue. Early diagnosis and surgical intervention would correct this congenital anomaly reducing morbidity and complications in otherwise healthy young patients. Case Report: We present a case of an 18-year-old female who presented with exertional shortness of breath, fatigue, and recurrent lower respiratory tract infections. She had unremarkable physical examination but chest x-ray showed an abnormal opacity next to right heart border. Computed tomography (CT) chest was performed that showed possible scimitar syndrome. Transesophageal echocardiogram (TEE) and right heart catheterization (RHC) confirmed the diagnosis. Conclusion: Scimitar syndrome is a very rare congenital anomaly of pulmonary venous return. It is usually diagnosed in early childhood but the diagnosis may be delayed until later in adulthood. The consequences are pulmonary hypertension, right-sided heart failure, and frequent pulmonary infections resulting in increased morbidity, mortality, and frequent doctor visits for otherwise healthy young patients.

Cardiomyopathy Associated With Targeted Therapy for Breast Cancer

Background: Chemotherapeutic agents directed against human epidermal growth factor receptor 2 (HER‐2) have significantly improved the prognosis of patients who are positive for this receptor. However, cardiomyopathy remains as a common adverse effect of using these agents. Materials and Methods: Literature search was conducted via PubMed using the keywords of “Trastuzumab Cardiomyopathy,” “Lapatinib Cardiomyopathy” and “Pertuzumab Cardiomyopathy,” which provided 104 results. These articles were then screened for relevance to the targeted subject based on their title and abstracts. Case reports and articles that were not discussing any aspect of cardiomyopathy secondary to targeted therapy for breast cancer and articles not in English were eliminated. After elimination, a bibliography search among selected articles was done and a total of 46 articles were identified. The collected articles were then meticulously analyzed and summarized. Results: The use of human epidermal growth factor receptor 2 (HER‐2) receptor targeted chemotherapy in breast cancer is limited because of a higher incidence (19–22%) of cardiomyopathy. The incidence of cardiomyopathy is not dose dependent and in most cases it is reversible after discontinuation of the drug and treatment with heart failure medications. Severe adverse outcomes including death or permanent disability are rare. Conclusion: HER‐2 targeted chemotherapy for breast cancer has a higher incidence of associated reversible cardiomyopathy. Patients should be monitored by serial echocardiography starting at the beginning of the treatment and followed by every 3 months until the completion of chemotherapy. Co‐ordination between oncologists and cardiologists is needed to develop evidence‐based protocols to prevent, identify, monitor and treat trastuzumab‐induced cardiomyopathy.

SINUS OF VALSALVA RUPTURE IN A PATIENT WITH A BICUSPID AORTIC VALVE

Bicuspid aortic valve (AV) is the most common congenital heart defect occurring in 0.9-2% of the general population; however, aneurysm of the sinus of Valsalva occurs in only 0.1-to-3.5% of all congenital heart defects and may occur in the presence of a bicuspid AV. Rupture of a sinus of Valsalva

Fibrosing Mediastinitis: Uncommon Life-threatening Complication of Histoplasmosis

Histoplasmosis involving mediastinum is very rare which can present as a mediastinal mass or fibrosing mediastinitis. Fibrosing mediastinitis can be life-threatening if left untreated due to the involvement of the surrounding visceral and vascular structures. We present an interesting case of fibrosing mediastinitis due to histoplasmosis presented with palpitations, chest pain and dyspnea. The patient had mediastinal and hilar lymphadenopathy with calcification on chest imaging. The patient was diagnosed on lymph node biopsy and treated with antifungals.

Diagnostic Value of Noninvasive Computed Tomography Perfusion Imaging and Coronary Computed Tomography Angiography for Assessing Hemodynamically Significant Native Coronary Artery Lesions

Background: The objective of this study is to determine the diagnostic performance of computed tomography perfusion (CTP) with and without computed tomography angiography (CTA) in assessment of hemodynamically significant coronary artery lesions in comparison to invasive fractional flow reserve (FFR). Materials and Methods: PubMed and Cochrane Center Register of Controlled Trials from January 2010 searched through December 2014. Nine original studies were selected evaluating the diagnostic performance of CTP with and without CTA to invasive coronary angiography in evaluation of hemodynamic significance of coronary lesions (n = 951). Results: The sensitivity, specificity, LR+ and LR‐ and DOR of CTA+CTP were 0.85 [95% confidence interval (CI: 0.79‐0.89)] 0.94 (CI: 0.91‐0.97), 15.8 (CI: 7.99‐31.39), 0.146 (CI: 0.08‐0.26), and 147.2 (CI: 69.77‐310.66). Summary Receiver Operating Characteristics (SROC) results showed area under the curve (AUC) of 0.97 indicating that CTA+CTP may detect hemodynamically significant coronary artery lesions with high accuracy. The sensitivity, specificity, LR+ and LR‐ and DOR of CTP were 0.83 (CI: 0.78‐0.87), 0.84 (CI: 0.80‐0.87) 5.26 (CI: 2.93‐9.43), 0.209 (CI: 0.12‐0.36), and 31.97 (CI: 11.59‐88.20). Conclusions: This result suggests that CTP with CTA significantly improves diagnostic performance of coronary artery lesions compared to CTA alone and closely comparable with invasive FFR.

The Mystery of Multiple Masses: A Case of Anaplastic Astrocytoma

Though most primary brain gliomas present as a single mass lesion in the brain, this potential diagnosis must be considered in the differential diagnosis when faced with a case of multifocal brain mass lesions. Among the most common brain tumors in humans, glioblastomas can be classified into four classes, one of which consists of anaplastic astrocytomas (AA). Due to its significant malignant potential, a prompt stereotactic brain biopsy should be considered to allow for early diagnosis. Karyotypic analysis of the specimen may allow for the discovery of 1p12q and IDH132 gene mutations. This knowledge can be used to best determine prognosis and guide therapy.

Valvular Hemolysis Masquerading as Prosthetic Valve Stenosis

The evaluation of prosthetic valves can provide a unique challenge, and a thoughtful approach is required. High output states like anemia should be kept in the differential when evaluating elevated gradients across prosthetic valves. We present the case of a 69-year-old man with a Starr-Edwards prosthetic aortic valve who presented with symptoms of congestive heart failure and high transvalvular pressure gradients. These symptoms indicate a potential prosthetic valve stenosis. His laboratory evaluation results were consistent with valve-related hemolysis. Resolving his anemia led to a resolution of the symptoms and lowered the pressure gradient on follow-up.

The Importance of a Complete Differential: Case Report of a Tuberculoma in a Patient without Pulmonary Involvement

Patients with a tuberculoma typically present with pulmonary involvement of tuberculosis and have risk factors for tuberculosis (TB). The risk factors for tuberculosis include bacillary load, proximity to infectious case, immunosuppressive conditions, malnutrition, young age, diabetes mellitus, working in healthcare, recent incarceration, alcohol use, and tobacco use. Although rare, it is possible for a patient to present with a tuberculoma despite the absence of risk factors for tuberculosis other than diabetes and without pulmonary involvement.