SEPTIC CARDIOMYOPATHY

Septična kardiomiopatija reverzibilna je disfunkcija miokarda u septičnih bolesnika. Smanjenje kontraktilnosti miokarda prisutno je u više od 40 % bolesnika s teškom sepsom ili sa septičnim šokom. Sepsom inducirana disfunkcija miokarda (SIDM) jedan je od glavnih prediktora lošeg ishoda septičnih bolesnika. Smrtnost septičnih bolesnika sa SIDM je od 70-% do 90 %, a bez SIDM je oko 20 %. SIDM karakterizira dilatacija klijetki, sniženje istisne frakcije klijetki, slabiji odgovor na nadomjestak tekućine i na vazoaktivnu terapiju te reverzibilnost promjena unutar 7-10 dana. Za nastanak SIDM odgovorni su brojni izvanstanični i stanični mehanizmi uz interakciju brojnih čimbenika koji sudjeluju u regulaciji radne muskulature srca i u sustavu međustaničnog prijenosa signala. Rezultat interakcije je poremećaj u povezanosti između unutarstaničnog citoskeleta i izvanstaničnog matriksa i slabljenje prijenosa snage kontrakcije miokarda. Za dijagnosticiranje SIDM koriste se hemodinamski monitoring, EKG, transtorakalna i transezofagusna ehokardiografi ja i laboratorijski testovi. U liječenje SIDM spada kontrola infekcije, optimizacija hemodinamskih parametara, nadomjestak tekućine, vazopresori, inotropna terapija, primjena krvnih pripravaka i statini. Adekvatnu i učinkovitu terapiju septične kardiomiopatije za sada još nemamo. Koristimo kardioprotektivnu terapiju, uzročno liječenje sepse ili septičnog šoka uz suportivne mjere.Septic cardiomyopathy is a reversible myocardial dysfunction in patients with sepsis. Depression in myocardial contractility is detected in more than 40% of patients with severe sepsis or septic shock. Sepsis-induced myocardial dysfunction (SIMD) is one of the main predictors of poor outcome in patients with sepsis. Mortality rate in patients with sepsis and SIMD is 70%-90%, while it is only 20% in patients without SIMD. SIMD is characterized by ventricular dilatation, decreased ejection fraction, less response to fl uid replacement and catecholamines. It is reversible within 7-10 days. Many extracellular and intracellular mechanisms and mediators included in the regulation of the heart muscle cell contraction may contribute to septic cardiomyopathy. The underlying cause is disorder in communication between the intracellular contractile apparatus and extracellular matrix, resulting in attenuation of the myocardial contraction. Hemodynamic monitoring, ECG, transthoracic and transesophageal echocardiography, and various laboratory tests are used in the diagnostic work-up. There are several therapeutic interventions such as infection control, optimization of hemodynamic parameters, adequate volume resuscitation, inotropic drugs, transfusion of blood derivatives, and statins. However, for now, there is no effi cient therapy for septic cardiomyopathy. The management of SIMD includes cardioprotective therapy, etiologic treatment of sepsis and septic shock, and supportive measures

Multimodality imaging of cor triatriatum sinister

Introduction: Cor triatriatum sinister (CTS) is a very rare congenital cardiac malformation in which the left atrium (LA) is divided into two chambers by a fold of tissue, a membrane, or a fibromuscular band. The anomaly is usually diagnosed in childhood, but in adult age is less common. Clinical symptoms can mimic mitral stenosis.1-5 Case report: We report a case of 54-year-old woman referred to our hospital for transesophageal echocardiography (TEE). She had in history of dyspnea, headache, dizziness and effort intolerance for five years. Physical examination and laboratory values were unremarkable. Two-dimensional and threedimensional transesophageal echocardiography revealed fibromembranous structure in the dilated LA (Figure 1 and Figure 2). The membrane attached laterally to the junction of the left upper pulmo-nic vein and left atrial appendage, and medially to the interatrial septum. The membrane divided LA into two chambers (proximal chamber and distal chamber). Proximal chamber was receiving the pulmonary veins, and distal chamber contained left atrial appendage and mitral valve orifice. We found few fenestrations connecting the two chambers (Figure 3). Multislice computed tomography (MSCT) confirmed diagnosis of CTS (Figure 4). Coronary angiography revealed normal coronary arteries. The patient was referred to surgery following a TEE and MSCT diagnosis of CTS. The atrial membrane was excised around its periphery. Recovery from the surgery was uneventful and she was asymptomatic on further hospital stay and follow-up. Conclusion: The diagnosis of cor triatriatum sinister is paramount because of possibility of surgical repair with excellent long-term prognosis. 3D TEE is noninvasive method for comprehensive imaging and correct diagnosis of this rare congenital cardiac malformation. Surgical repair is an easy and definitive treatment choice of CTS should be considered in patients with left heart chamber obstruction symptoms

Right ventricular strain for detecting subclinical dysfunction of the right ventricle in systemic sclerosis

Introduction: Right ventricular (RV) function and cardiac involvement in systemic sclerosis (SSc) is important factor for the prognosis of SSc but often remains undetectable despite echocardiographic screening. 1,3 Speckle derived strain (2D-STE) of the right ventricle (RV GLS) was utilized to detect subclinical abnormalities in regional and global contractility in SSc patients with no echocardiographic signs of pulmonary arterial hypertension. Aim of pilot study was to study the advantages of 2D speckle-tracking echocardiographic derived parameters in identifying RV dysfunction in SSc patients for quantifying myocardial deformation and conventional RV indexes in patients with SSc and to investigate whether these could be indicative of right heart failure or can be used as non-invasive methods of screening in SSc. Methods and Results: 27 SSc patients (mean age, 54.3 years; 96% female) with technically adequate echocardiograms were studied. Standard morphological measurements of RV chamber function, tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), tricuspid tissue Doppler annular velocities (TDIs,), right ventricular myocardial performance index (RIMP) and global longitudinal right ventricular free wall strain (RV FW GLS) were obtained. Twenty-two patients without pulmonary arterial hypertension (PAH) due to systemic sclerosis were studied. When we used the cutoff value recommended by the American Society of Echocardiography Guidelines to identify abnormal RV function4, patients were determined to have normal RV function, TAPSE 21.9 (±2.21), RV FAC 49.4 (±3.45), RIMP 0.44 (±0.08) respectively. Global longitudinal strain (LS) of the RV was calculated by averaging the LS value of 3 segments of the RV free wall in RV focused apical 4-chamber view (Figure 1). 40.9% of those patients had abnormal RV FW GLS (-14.8%) more pronounced in the basal regional longitudinal strain. Conclusion: Right ventricular strain reveals a diverse pattern of regional strain in SSc that is not detected by conventional measures of function, suggestive of subclinical RV myocardial disease and could be used as non-invasive method in screening for PAH in SSc to select patients eligible for right heart catheterization or to monitor the effects of PAH therapy.1-

Ehokardiografija u otkrivanju endokarditisa izazvanog ugradnjom elektrode implantabilnog kardioverter defibrilatora: prikaz slučaja

Lead endocarditis is an infrequent but potentially lethal complication of implantable cardioverter defibrillator (ICD) implantation. We report a case of a 53-year-old man with ICD who was admitted to our hospital because of fever, chills, shivering, headache and malaise. Transthoracic echocardiography detected a structure highly suspect of vegetation located on the ICD lead. Transesophageal echocardiography showed a 20x12 mm mobile vegetation attached to the ICD lead in the right atrium. The infection was caused by methicillin-resistant Staphylococcus epidermidis (MRSE), which was isolated from blood cultures. Treatment consisted of surgical removal of the ICD lead and placement of new epicardial ICD leads. Three years afterwards, the patient remained asymptomatic. To our knowledge, this is the first such case reported from Croatia.Endokarditis elektrode je rijetka no potencijalno smrtonosna komplikacija ugradnje implantabilnog kardioverter defibrilatora (ICD). Prikazujemo slučaj 53 godine starog muškarca s implantiranim ICD-om koji je hospitaliziran zbog febriliteta, groznice, tresavice i općeg lošeg stanja. Transtorakalnim ultrazvukom srca je otkrivena tvorba vrlo sumnjiva na vegetaciju na elektrodi ICD-a, da bi transezofagusnim ultrazvukom bila prikazana vegetacija veličine 20x12 mm pričvršćena za elektrodu ICD-a u desnom atriju. Uzročnik endokarditisa je bio meticilin rezistentni Staphylococcus epidermidis (MRSE) koji je izoliran u hemokulturi. Liječenje se sastojalo od kirurškog odstranjenja elektrode ICD-a i njene zamjene novim, epikardijalnim elektrodama. Tri godine kasnije bolesnik je i dalje bez tegoba. Prema našim saznanjima, ovo je prvi ovakav slučaj dosad opisan u Hrvatskoj

Lutembacher’s syndrome: a case report

Lutembacherov sindrom je kombinacija kongenitalnog atrijskog septalnog defekta (ASD) i stečene mitralne stenoze (MS). Prvi put ga je opisao francuski liječnik Lutembacher 1916. godine. Ovaj sindrom je vrlo rijedak i smatra se da mu je incidencija 0.001/10,00000. Hemodinamski efekti ovog sindroma posljedica su relativnog utjecaja težine MS i veličine ASD. Prikazujemo 54-godišnju pacijenticu kojoj je bio indiciran transtorakalni ehokardiografski pregled (TTE) zbog evaluacije prijašnjeg nalaza srednje teške MS u sklopu progresije zaduhe unatrag mjesec dana. Prije dvije godine prilikom hospitalizacije uslijed srčanog popuštanja, primjenom TTE registrirana je srednje teška MS uz urednu sistoličku funkciju lijeve klijetke. Sada se primjenom TTE i transezofagijske ehokardiografije registrira srednje teška MS te ASD koji nije bio opisan u prijašnjim ultazvučnim nalazima pa je postavljena dijagnoza Lutembacherova sindroma. Ovaj prikaz slučaja pokazuje kako je ehokardiografija nezaobilazna dijagnostička metoda u otkrivanju mnogih kardioloških entiteta uključujući i ovaj rijetko prisutan sindrom.Lutembacher’s syndrome refers to a con- genital atrial septal defect (ASD) complicated by aquired mitral stenosis (MS). It was first described by Lutembacher, a French physician, in 1916. This syndrome is a very rare disease, it is found that the incidence of Lutembacher’s syndrome is 0.001/10,00000. The hemodynamic effects of this syndrome are a result of the inter- play between the relative effects of the ASD and MS. We present a 54-year-old female referred to hospital for echocardiographic evaluation of previously diagnosed mild MS. She reported progression of dyspnea over the last month. Two years ago, she was admitted to another hospital because of heart failure and transthoracic echo- cardiography (TTE) revealed moderate MS with perserved left ventricular systolic function. We performed TTE and transesophageal echocardiogram and found severe MS with ASD that was previously unrecognised. The diagnosis of Lutembacher’s syndrome was established. This case demonstrates the presence of this rare disease in our population, but we would also like to stress the importance of the role of echocardiography in identifying many clinical syndromes including this one

Akutni infarkt miokarda u 58-godišnje žene s anomalnim polazištem lijeve koronarne arterije iz desnog Valsalvina sinusa

We report a case of a 58-year-old female with a history of hypertension, hypercholesterolemia and diabetes type 2, who was admitted to the coronary care unit with continuous substernal severe chest pain persisting for two hours. Her electrocardiogram showed ST-elevation acute myocardial infarction. ST-segment elevation was noted in leads I and aVL and ST-segment depression in leads II, III and V3-V5. The troponin-I level was elevated (1.97 ng/L). Coronary angiography showed anomalous origin of the left coronary artery from the right sinus of Valsalva and subocclusion in the proximal portion of the diagonal branch. In conclusion, primary percutaneous coronary intervention (PCI) of diagonal branch was performed with balloon dilatation and thrombolysis in myocardial infarction TIMI 3 flow was achieved. After PCI, she had no chest pain. At 5-year clinical follow-up, the patient was asymptomatic.Prikazujemo slučaj 58-godišnje žene koja boluje od hipertenzije, hiperkolesterolemije i dijabetesa melitusa tip 2 te koja je primljena u koronarnu jedinicu s bolovima u prsima u trajanju od dva sata. Elektrokardiogram je pokazivao infarkt miokarda sa ST elevacijom. Elevacija ST-segmenta bila je prisutna u I odvodu i aVL odvodu, a depresija ST-segmenta u odvodima II, III i V3-V5. Zabilježene su povišene vrijednosti troponina-I (1,97 ng/L). Koronarografija je pokazala anomalno polazište lijeve koronarne arterije iz desnog Valsalvina sinusa i subokluziju u proksimalnom dijelu dijagonalne grane. U zaključku, primarna perkutana intervencija (PCI) dijagonalne grane izvedena je balonskom dilatacijom uz postignut TIMI 3 protok. Nakon PCI bolesnica je bez bolova i u kliničkom praćenju od pet godina asimptomatska

A case of cor triatriatum sinister during pregnancy.

Cor triatriatum sinister rijetka je prirođena srčana greška, koja obično biva otkrivena u djetinjstvu. Donosimo prikaz slučaja mlade bolesnice kojoj je cor triatriatum sinister otkriven u odrasloj dobi te njegovo praćenje tijekom trudnoće i uspješno konzervativno liječenje sve do poroda. Obzirom na sličnu patofiziologiju odlučili smo se bolesnicu pratiti kao umjereno tešku asimptomatsku mitralnu stenozu. Kliničko praćenje i redoviti ehokardiografski pregledi zauzimaju pri tome centralno mjesto. Prema našem saznanju, ovaj slučaj pacijentice predstavlja prvi slučaj majčinskoga cor triatriatum sinister u trudnoći u Hrvatskoj.Cor triatriatum sinister is a rare congenital cardiac malformation, usually diagnosed in childhood. We describe a case of maternal cor triatriatum diagnosed in adult age and its successful conservative management throughout pregnancy until postpartum. Due to hemodynamic similarities, we decided to treat the cor triatriatum sinister like a moderate asymptomatic functional mitral stenosis in this case. Clinical controls, regular echocardigraphic controls have a central place in the follow up of gravida with congenital cardiac anomalies. To the best of our knowledge, this case is the first case of maternal cor triatriatum sinister in Croatia

An unexpected cause of right ventricular failure – an intruder in the right ventricular outflow tract

Case report: 56-year-old male patient was admitted due to fever of unknown origin. Upon admission, the patient was in bad general condition with high values of inflammatory markers in laboratory results and signs of right side heart failure. 12-lead ECG showed nonspecific conduction disorders. No signs of systemic disease have been found with extensive internal and diagnostic treatment. Scintigraphy with labeled leukocytes, as attempt to find origin of infection did not show any pathological accumulation. Coronarography excludes atherosclerotic changes in epicardial vessels. Transthoracic (TTE) and transesophageal (TEE) echocardiography described a visible hyperechogenic formation in a right ventricular outflow tract (RVOT), oriented towards pulmonic valve, 1.6 cm long and 0.3 cm wide (Figure 1). Right ventricle (RV) showed milder reduced systolic function, with signs of right-side congestion. There was moderate pulmonary valve regurgitation (PR 2+), and mild tricuspid regurgitation with estimation of right ventricular systolic pressure of 27 mmHg. Preserved left ventricular fraction of 58% was observed. MSCT of thorax identified a strange metal body, resembling to sewing needle in the RV area. The patient initially refused the surgical procedure of foreign body extraction, until the clinical condition deteriorated. He was hospitalized again with fever, hem culture positive on Escherichia coli. Transthoracic echocardiography now showed a formation of 8 mm, possibly vegetation, on the ventricular surface of the pulmonary valve with severe pulmonary insufficiency, severe tricuspid regurgitation and moderate right-side heart failure. Diagnosis of pulmonary valve endocarditis has been established. The patient was successfully operated, the bioprosthetic pulmonary valve was implanted combined with tricuspid valve repair and the foreign body was removed from the right ventricle. Postoperative recovery went well, and control echocardiography showed a good function of the bioprosthetic pulmonary valve and tricuspid valve repair. Foreign body was a sewing needle, but the patient could not remember how did it get there. Conclusion: Isolated right ventricular heart failure can be caused by pulmonary valve insufficiency1,2, as in our case by foreign body in RVOT finally complicated by endocarditis of pulmonary valve