Structural right ventricular (RV) abnormalities are present in a substantial proportion of patients with hypertrophic cardiomyopathy (HCM), but the trigger for RV hypertrophy remains unclear. The aim ...of this study was to assess the relationship between RV and left ventricular (LV) remodeling and the impact of biventricular involvement on clinical status in this setting.
Ninety-nine patients with HCM and 30 normal subjects with a similar age and gender distribution were prospectively enrolled. Comprehensive echocardiography was performed in all, including the assessment of LV and RV function by tissue Doppler and speckle-tracking echocardiography. Measurement of RV free wall thickness (RVWT) was performed at end-diastole, in a zoomed subcostal view, focusing on the RV midwall.
Patients with HCM had increased RVWT (6.4 ± 1.9 vs 3.6 ± 0.8 mm, P < .001) and lower values of RV global longitudinal strain (-19.4 ± 4.4% vs -23.8 ± 2.7%, P < .001) compared with control subjects. RVWT was independently related to LV mass and LV global longitudinal strain. Increased RVWT was correlated with New York Heart Association class (r = 0.20, P = .04) and calculated sudden cardiac death risk score (r = 0.52, P < .001) and was independently related to the presence of ventricular arrhythmias (odds ratio, 2.02; 95% CI, 1.28-3.19; P = .002).
In patients with HCM, the presence of RV hypertrophy was associated with increased LV mass and reduced LV longitudinal strain, correlated with increased calculated sudden cardiac death risk score, and independently related to the presence of ventricular arrhythmias. These data suggest more severe disease in patients with biventricular HCM.
Appropriateness of use criteria (AUC) for transthoracic echocardiography (TTE) have been developed by American cardiology associations to help avoid unnecessary scans by formalizing indications for ...imaging. There are 98 indications classified as either appropriate (A), inappropriate (I), or uncertain (U). AUC may allow better targeting of limited resources, but they have not been tested systematically outside the USA.
To test AUC in Wales, one of the four countries of the UK.
We collected requests for TTE and the corresponding TTE reports from all Welsh hospitals during 1 week in June 2012 and analysed them according to appropriateness, specialty, and location (secondary vs. tertiary services) of the referring physician.
We analysed 1070 pairs of echocardiography requests and TTE reports from 14 hospitals mean age 66.5 (16.1) years; 579 (51%) M: A-922 (86%); I-115 (11%), and U-33 (3%); 287 (25%) studies were from two tertiary centres and 338 (29.5%) were of inpatients. Main indications were the evaluation of: cardiac structure and function (489, 45.7%), valvular function (267, 25%), and hypertension, heart failure, or cardiomyopathy (149, 13.9%). In-patient requests (main indication--'initial evaluation of left ventricle ejection fraction post acute coronary syndrome'--44 studies, 13.7%) were more often appropriate than outpatients (main indication--'symptoms/conditions potentially related to suspected cardiac aetiology'--142 studies, 19.8%): 94.4 vs. 83.5%, P < 0.05. The most common inappropriate indication was 'initial evaluation for a murmur/click without symptoms/signs of structural heart disease' (29 studies, 2.7%). The proportion of appropriate requests by specialty was 89% for medical, 87% for GPs, 85.3% for cardiologists, 80.8% for surgical, and 60% for cardiac surgeons (P < 0.05 for cardiac surgeons); 47.8% of requests were generated by cardiologists, and abnormalities were detected in 82% of all scans (37% minor findings and 45% major findings), least often in those requested by general practitioners.
Application of AUC yields results similar to those reported from the USA; ∼1 in 10 scans could be avoided.
Non-functioning adrenal incidentalomas (NFAIs) have been placed in relationship with a higher risk of glucose profile anomalies, while the full-blown typical picture of Cushing’s syndrome (CS) and ...associated secondary (glucocorticoid-induced) diabetes mellitus is not explicitly confirmed in this instance. Our objective was to highlight the most recent data concerning the glucose profile, particularly, type 2 diabetes mellitus (T2DM) in NFAIs with/without mild autonomous cortisol secretion (MACS). This was a comprehensive review of the literature; the search was conducted according to various combinations of key terms. We included English-published, original studies across a 5-year window of publication time (from January 2020 until 1 April 2024) on PubMed. We excluded case reports, reviews, studies on T1DM or secondary diabetes, and experimental data. We identified 37 studies of various designs (14 retrospective studies as well 13 cross-sectional, 4 cohorts, 3 prospective, and 2 case–control studies) that analysed 17,391 individuals, with a female-to-male ratio of 1.47 (aged between 14 and 96 years). T2DM prevalence in MACS (affecting 10 to 30% of NFAIs) ranged from 12% to 44%. The highest T2DM prevalence in NFAI was 45.2% in one study. MACS versus (non-MACS) NFAIs (n = 16) showed an increased risk of T2DM and even of prediabetes or higher fasting plasma glucose or HbA1c (no unanimous results). T2DM prevalence was analysed in NFAI (N = 1243, female-to-male ratio of 1.11, mean age of 60.42) versus (non-tumour) controls (N = 1548, female-to-male ratio of 0.91, average age of 60.22) amid four studies, and two of them were confirmatory with respect to a higher rate in NFAIs. Four studies included a sub-group of CS compared to NFAI/MACS, and two of them did not confirm an increased rate of glucose profile anomalies in CS versus NFAIs/ACS. The longest period of follow-up with concern to the glycaemic profile was 10.5 years, and one cohort showed a significant increase in the T2DM rate at 17.9% compared to the baseline value of 0.03%. Additionally, inconsistent data from six studies enrolling 1039 individuals that underwent adrenalectomy (N = 674) and conservative management (N = 365) pinpointed the impact of the surgery in NFAIs. The regulation of the glucose metabolism after adrenalectomy versus baseline versus conservative management (n = 3) was improved. To our knowledge, this comprehensive review included one of the largest recent analyses in the field of glucose profile amid the confirmation of MACS/NFAI. In light of the rising incidence of NFAI/AIs due to easier access to imagery scans and endocrine evaluation across the spectrum of modern medicine, it is critical to assess if these patients have an increased frequency of cardio-metabolic disorders that worsen their overall comorbidity and mortality profile, including via the confirmation of T2DM.
Myxomatous mitral valve disease (MVD) is a common disorder in which the entire mitral valve apparatus seems to be involved. Mitral valve repair is nowadays the method of choice for the correction of ...mitral regurgitation but the optimal shape and flexibility of the annuloplasty ring remain controversial. Considering that myxomatous MVD covers a wide spectrum from limited fi bro-elastic deficiency to extensive Barlow disease, we presume that the mitral annulus morphological and functional changes are likely different in different types of myxomatous MVD. We analyze the 3-dimensional geometry and the dynamics of the mitral annulus in 110 patients with significant mitral regurgitation due to different types of myxomatous mitral valve disease and 40 normal subjects using 3D transesophageal echocardiography. The mitral annulus differs in patients with limited MVD, extensive MVD and in normal controls in terms of size, shape, and dynamics. Patients with limited MVD have larger, flatter, dysfunctional and more mobile mitral annulus compared to normal, while patients with extensive MVD have even larger, flatter and more dysfunctional mitral annulus, with reduced mobility. The non-planar dynamics has different patterns during systole, according to the extension of MV disease. Our data may be important for the appropriate choose of annuloplasty mitral annulus in mitral valve repair, the current trend being to choose the ring according to the underlying pathology.
Purpose
Left ventricular hypertrophy (LVH) is as an independent risk factor. Discrepancies were reported between LV mass (LVM) estimated by echocardiography and electrocardiography (ECG) findings. We ...hypothesized that QRS voltage criteria may reflect not only anatomical changes (LVM) but also changes in LV function and we tested the relationship between QRS voltage and echocardiographic parameters of LV function in patients (pts) with different types of LVH.
Methods
We prospectively enrolled pts with LVH and preserved ejection fraction (LVEF >50%): 20 pts with isolated arterial hypertension, HTN, 20 pts with severe aortic stenosis, AS (indexed aortic valve area <0.6 cm2/m2), and 20 pts with symmetric hypertrophic cardiomyopathy, HCM. Standard 12‐lead ECG (including Sokolow and Cornell voltage indices) and a comprehensive two‐dimensional (2D) echocardiography were performed in all. Left ventricular mass was calculated according to Devereux formula. Global longitudinal strain (GLS) was assessed by speckle tracking echocardiography.
Results
A significant correlation was found between both ECG indices and LVM assessed by echocardiography. Moreover, significant correlations were found between Sokolow–Lyon voltage and LVEF (r = 0.26; P = 0.03), GLS (r = 0.59; P < 0.001) and E/e' average (r = 0.43; P < 0.001). Cornell voltage index correlated significantly only with GLS. In multivariable analysis GLS emerged as the only independent correlate of both Sokolow–Lyon (ß = 0.6, P < 0.001) and Cornell voltage indices (ß = 0.45, P < 0.001).
Conclusion
These findings suggest that in pts with LVH, ECG should no longer be used only as a surrogate method for LVM estimation (structural changes only), but rather as an investigation complementary to imaging, incorporating information on overall LV remodeling (changes in structure and function).
Coarctation of the aorta (CoA) is a relatively frequent congenital defect. Its natural evolution is marked by serious complications including aortic dissection, heart failure, coronary artery ...disease, infective endocarditis, or cerebral haemorrhages. Correction of CoA before complications arise is associated with a favorable long-term outcome. Timely diagnosis of CoA is therefore of utmost importance in the prognosis of these patients. Non-invasive imaging techniques, ranging from chest radiography to echocardiography, Cardiac Computed Tomography (CCT), and Cardiac Magnetic Resonance (CMR) have evolved to the extent where they can not only suggest but also precisely characterize the lesion and guide further management. We present a series of 3 case reports, highlighting the diagnostic approach and treatment for this pathology.
A TURN IN THE WRONG DIRECTION. WHAT IS MISSING? Casian, Mihnea; Gurzun, Maria Magdalena; Ionita, Iulia Theodora ...
Journal of hypertension,
06/2022, Letnik:
40, Številka:
Suppl 1
Journal Article
Recenzirano
Odprti dostop
Objective: The case highlights the importance of specific non-traditional cardiovascular risk factors in a patient with premature severe cardiovascular disease, despite an apparently adequate control ...of traditional cardiovascular risk factors. Design and method: Clinical Case. Results: We present the case of a 38 year-old female with Turner syndrome, with cardiovascular risk factors (mild dislypidemia, type 2 diabetes, grade 1 ESC/ ESH hypertension) who presents to the emergency department for newly-onset constrictive chest pain. Her chronic treatment consisted of a low-dose ACEi and metformin. Clinical exam was unremarkable, except for specific clinical phenotype, with normal BP values in both arms and without any signs of congestion. The electrocardiogram showed sinus rhythm of 65 beats/min, narrow QRS, negative T waves in inferior leads, as well a Q wave in lead III. Hs- troponin (1046pg/ml, ULN: 10pg/ml) and NT-proBNP levels (820,9pg/ml) were elevated. Echocardiography revealed a normal ejection fraction, with localized hypokinesia of the inferior wall and no significant valvular disease. The aortic valve was tricuspid and no signs of aortic coarctaction were observed from the suprasternal view. Coronarography was performed, showing significant CAD, with multiple lesions on ADA, LCXA and RCA. The two suboclusive lesions from the RCA were addressed using two drug eluting stents. The evolution was favourable under specific treatment. The baseline levels of LDLc (117 mg/dl) and glycosylated haemoglobin (5,7%) were not as high as we initially expected, given the severe CAD. Furthermore, the ambulatory 24 h BP monitoring after discharge confirmed that the previous treatment with low-dose ACEi was efficient in maintaining the target BP values. Conclusions: Turner syndrome is associated with a variety of cardiovascular manifestations, such as aortic coarctation, which leads to secondary hypertension, as well as an increased risk of cardiovascular events. In our patient, the hypertension was essential, without any arguments for secondary hypertension, as we would have expected. Furthermore, despite the fact the patient exhibited several traditional cardiovascular risk factors, they were controlled within the recommended targets (with the exception of LDLc, slightly higher than 100 mg/dl). The disease duration appears to be critical, as the patient was diagnosed with hypertension more than 15 years ago. We concluded that the advanced premature CAD is most likely the result of the hormonal imbalance and lack of hormone replacement therapy, for which the patient was no longer eligible. Drastic control of traditional cardiovascular risk factors in this case will probably prove to be insufficient.
Objective: The case highlights the importance of diagnosing secondary hypertension and adequate treatment in the setting of a patient with classical cardiovascular risk factors which would otherwise ...make primary hypertension the most likely diagnosis. Design and method: Clinical Case Results: A 57 year-old male with cardiovascular risk factors (smoking, dislypidemia), grade 2 essential hypertension (ESC/ESH) and G3a stage chronic kidney disease (CKD) presents to our clinic with fatigue and persistent high blood pressure values despite treatment with ACEi. Clinical exam was unremarkable except for a 10mmHg difference between the arm and foot systolic blood pressure. The 24-hour ambulatory blood pressure monitoring revealed a non-dipping profile, with a mean blood pressure value of 150/100mmHg. TTE was performed and the following were observed: bicuspid aortic valve with tight aortic stenosis (mean AV PG > 40mmHg, AVA = 1.12cm2) and LV systolic dysfunction (LVEF = 35%). TEE was also performed and confirmed the bicuspid aortic valve. Given the context of the patient, computed tomography angiography (CTA) was the investigation of choice in order to visualize the aorta. Postductal coarctation was detected with a hypoplastic thoracic aorta and multiple collateral vessels. The coronary angiogram was normal. The ACEi was stopped and the patient received a dihydropyridine calcium channel blocker in combination with an adolsterone receptor antagonist with a favourable course. Aortic valve replacement surgery with mechanical valve implantation was recommended. Considering the multiple collateral vessels and complex vascular morphology, surgical correction of the coarctation was considered no longer feasible Conclusions: CoA was the actual cause for the persistent high blood pressure values in an adult male with cardiovascular risk factors who was believed to have essential hypertension. In the setting of aortic stenosis with impaired LV systolic function, high blood pressure values are not typical. Taking into account the BAV, the clinical suspicion of CoA was high and prompted further investigations. The CKD is the result of the the underperfusion of the kidneys secondary to the CoA and the use of ACEi.
Mitral regurgitation (MR) represents the second most frequent valvular heart disease. The appropriate management of organic MR remains unclear in many aspects, especially in several specific clinical ...scenarios. This review aims to discuss the current guideline recommendations regarding the management of organic MR, while highlighting the controversial aspects encountered in daily clinical practice. The role of imaging is essential in establishing the most appropriate type of surgical treatment (repair or replace), which is based on morphological mitral valve (MV) characteristics (reparability of the valve) and local surgical expertise in valve repair. The potential advantages of 3-dimensional echocardiography in assessing the MV are discussed. Other modern imaging techniques (tissue Doppler and speckle tracking) may provide additional useful information in borderline cases. Exercise echocardiography (evaluating MR severity, pulmonary pressure, or right ventricular function) may have an important role in the management of difficult cases. Finally, the moment when surgery is no longer an option and alternative solutions should be sought is also discussed. Although in everyday clinical practice the timing of surgery is not always straightforward, some newer clinical and echocardiographic indicators can guide this decision and help improve the outcome of these patients.
Simultaneous or sequential combination of prosthetic valve (PV) thrombosis and infectious endocarditis is a rare clinical finding. The management of these patients involves a complex ...multidisciplinary strategy using clinical judgment and imaging techniques. Transesophageal echocardiography (TEE) and especially 3D transesophageal echocardiography is essential. Moreover, positron emission tomography with fluorodeoxyglucose (F18-FDG PET/CT) can be a valuable tool to diagnose and manage these complicated clinical scenarios.
We present the case of a 65-year-old patient who was admitted in our clinic for paroxysmal nocturnal dyspnea and chills for one week. He had multiple surgical interventions for rheumatic mitral valve disease (percutaneous mitral valvuloplasty in 2008, and mitral valve replacement and tricuspid annuloplasty in October 2019).
At admission, the diagnosis of prosthetic valve thrombosis was established taking into account the clinical context (low INR values for the last two months), the patient symptoms and the echocardiographic findings. IV unfractionated heparin was administered. One week after admission the patient’s clinical status further deteriorated. TEE reevaluation showed partial thrombus regression with elements suggestive for concomitant infectious endocarditis. The diagnosis key is the clinical evolution and repeated TEE evaluations. In our case, they enabled the probable diagnosis of a sequential association of thrombosis and infectious endocarditis on mechanical PV. The therapeutic approach requires a high clinical suspicion and a prompt management, emergent surgery being the only lifesaving strategy in unstable patients with obstructive mechanical pathology.
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