Interesting Electrophysiological Findings in a Patient With Coincidental Right Ventricular Outflow Tract and Atrioventricular Nodal Reentrant Tachycardia

Tachycardia induced tachycardias are not common in clinical practice, and it is believed that most cases of double tachycardia are coincidental. The existence of two different tachycardias in the same patient almost always poses problems in the electrophysiology laboratory. However, in rare instances, the emergence of a second tachycardia can actually provide invaluable information about the first one. In this report, we describe a 30-year-old woman who presented with palpitations. Electrophysiological study revealed that atrial programmed stimulation at baseline induced right ventricular outflow tract (RVOT) tachycardia and supraventricular tachycardia. The study also showed that each of the tachycardias was able to induce the other. A short run of RVOT tachycardia during supraventricular tachycardia was able to entrain the latter. This finding provided important information about the nature of the supraventricular tachycardia, which proved to be atrioventricular nodal reentrant tachycardia. Both of these tachycardias were successfully ablated, and the patient’s palpitations disappeared

Przepływ w gałęzi przedniej zstępującej lewej tętnicy wieńcowej u pacjentów z marskością wątroby

Introduction. Although cardiac function appears normal in patients with cirrhosis at rest, cardiac function deteriorates in these patients under stress conditions. Decreased cardiac function against stress may be due to coronary microvascular dysfunction in these patients. In this study, we aimed to evaluate coronary microvascular dysfunction in patients with cirrhosis by measuring coronary flow reserve (CFR) by transthoracic echocardiography. Materials and methods. Thirty-eight patients with cirrhosis and 32 healthy subjects (as control group) were examined. In addition to standard two-dimesional (2D) and Doppler echocardiography, coronary flow velocity was measured by pulsed-wave Doppler from the middle to the distal part of the left anterior descending artery at the beginning and after dipyridamole infusion in the hyperemic state. CFR was measured as the ratio of hyperemic peak diastolic flow rate to basal peak diastolic flow rate. Results. CFR was significantly lower in the cirrhosis group than in the control group (2.01 ± 0.31 and 2.84 ± 0.62; p < 0.0001). Increasing age, increasing myocardial mass, high aspartate aminotransferase and alanine aminotransferase, low hemoglobin, high C-reactive protein, decreased cholesterol and platelet levels were found to be associated with the reduction in CFR. Among all these factors only, the hemoglobin level and age were independent determinants of impaired CFR. Conclusions. Impaired CFR in patients with cirrhosis promotes coronary microvascular dysfunction. The coronary microvascular dysfunction can potentially contribute to the development of cirrhotic cardiomyopathy.Wstęp. Chociaż czynność serca u pacjentów z marskością wątroby oceniana w spoczynku wydaje się prawidłowa, to w warunkach wysiłku fizycznego lub obciążenia farmakologicznego ulega ona pogorszeniu. Zaburzenie czynności serca podczas obciążenia może być spowodowane dysfunkcją mikrokrążenia wieńcowego u tych chorych. Celem badania była ocena dysfunkcji mikrokrążenia wieńcowego u pacjentów z marskością wątroby przez pomiar rezerwy przepływu wieńcowego (CRF) za pomocą echokardiografii przezklatkowej. Materiał i metody. Do badania włączono 38 chorych z marskością wątroby i 32 osoby zdrowe (grupa kontrolna). Oprócz standardowej echokardiografii dwuwymiarowej (2D) i echokardiografii doplerowskiej prędkość przepływu wieńcowego w odcinkach środkowym i dystalnym gałęzi przedniej lewej tętnicy zstępującej zmierzono za pomocą badania dopplerowskiego metodą fali pulsacyjnej bezpośrednio przed wlewem dipirydamolu i po nim. Rezerwę przepływu wieńcowego mierzono jako stosunek maksymalnego przepływu rozkurczowego w obciążeniu do maksymalnego przepływu rozkurczowego w spoczynku. Wyniki. Rezerwa przepływu wieńcowego była istotnie niższa w grupie z marskością wątroby niż w grupie kontrolnej (2,01 ± 0,31 i 2,84 ± 0,62; p &lt; 0,0001). Stwierdzono, że ze zmniejszeniem CFR wiązały się: wiek, zwiększenie masy mięśnia sercowego, wysoka aktywność aminotransferaz asparaginianowej i alaninowej, niskie stężenie hemoglobiny, wysokie stężenie białka C-reaktywnego, obniżone stężenie cholesterolu i zmniejszona liczba płytek krwi. Jednak tylko stężenie hemoglobiny i wiek były niezależnymi determinantami zmniejszonej CFR. Wnioski. Zmniejszenie CFR u chorych z marskością wątroby sprzyja dysfunkcji mikrokrążenia wieńcowego, która może prowadzić do rozwoju kardiomiopatii wątrobowej (marskiej)

A Rare Cause of Endocarditis: Streptococcus pyogenes

Although group A β-hemolytic streptococcus is an uncommon cause of infective endocarditis, an increase in the incidence of invasive group A streptococcus infections including bacteremia has been reported in the last two decades. Herein we report Streptococcus pyogenes endocarditis in a previously healthy adult patient who was hospitalized to investigate the etiology of fever. Because of a suspicion of a new vegetation appeared in the second (aortic) valve in the 14th day of high dose penicillin G treatment, the mitral and aortic valves were replaced by mechanical prosthesis on the 22nd day of treatment. He was discharged from hospital after the 6 week course of antibiotic treatment

Longitudinal Strain and Strain Rate for Estimating Left Ventricular Filling Pressure in Heart Transplant Recipients

Traditional parameters have limited value to estimate left ventricular filling pressure (LVFP) in orthotropic heart transplant (OHT) recipients. We hypothesized that global longitudinal strain (GLS), diastolic, and systolic strain rate (SR) would be depressed in OHT recipients with elevated LVFP and could overcome the limitations of traditional parameters. We studied consecutively OHT patients at the time of endomyocardial biopsies and retrospectively pretransplantation studies conforming to the same protocol. Comprehensive echocardiography with strain measurements was performed. Results were compared with pulmonary capillary wedge pressure (PCWP) obtained from right heart catheterization that was performed just after the echocardiography study. In all, 74 studies were performed in 50 OHT recipients. Mean PWCP was 11.8 +/- 4.3 mm Hg (range: 4 to 25 mm Hg). Several parameters, but not left atrial volume index, mitral inflow velocities, annular velocities, and their ratio (E/e'), were different between studies with normal (n = 47) and elevated PCWP (n = 27). Area Under Curve for GLS (0.932*), E/e'SR (0.849*), and systolic SR (0.848*) (*p 0.0001) were more accurate than traditional parameters for predicting PCWP 12 mm Hg. GLS, systolic SR and E/e'SR remained accurate regardless of LV ejection fraction and allograft vasculopathy. Meanwhile, E/e' was accurate to predict PWCP in native failing hearts before transplantation. Changes in GLS and E/e'SR tracked accurately changes in PCWP. In conclusion, traditional indices of diastolic function perform poorly in OHT recipients, whereas GLS and E/e'SR provide reliable means of LVFP, irrespective of ejection fraction and allograft vasculopathy. These parameters also track reasonably well the changes in LVFP. (c) 2020 Elsevier Inc. All rights reserved

Treatment-associated change in apelin concentration in patients with hypertension and its relationship with left ventricular diastolic function

OBJECTIVE: We examined the change in apelin concentration and its relationship with left ventricular diastolic function in patients treated for hypertension. METHODS: Ninety treatment-naive patients with newly diagnosed hypertension and 33 age- and sex-matched control subjects were prospectively enrolled. Patients with hypertension were randomized to treatment either with telmisartan 80 mg or amlodipine 10 mg. Apelin concentration was measured and echocardiography was performed at baseline and after 1 month of treatment. RESULTS: The data of 77 patients and 33 controls were analyzed. Mean age, gender, baseline blood pressure, apelin levels, and echocardiographic measurements were similar between the treatment groups (p>0.05 for all). Apelin concentration was significantly lower in patients with hypertension than in controls. There was a significant increase in apelin level after 1 month of treatment in both groups (0.32 +/- 0.17 vs. 0.38 +/- 0.17 ng/dL in telmisartan group, p=0.009, and 0.27 +/- 0.13 vs. 0.34 +/- 0.18 ng/dL in amlodipine group, p=0.013). Diastolic function improved significantly in both groups (p<0.05) but was not significantly associated with change in apelin concentration. CONCLUSION: Apelin concentration increased significantly after 1 month of effective treatment with telmisartan or amlodipine to a similar extent. Change in apelin concentration was not associated with improvement in diastolic functio

Multiparametric assessment of right ventricular function in heart transplant recipients by echocardiography and relations with pulmonary hemodynamics

Objective: Right ventricular (RV) dilatation and dysfunction are usually present in heart transplant (HTx) patients and worsened with residual pulmonary hypertension (PH). We aimed to determine the ability of different echocardiographic modalities to evaluate RV function in comparison with cardiac magnetic resonance (CMR) and their relations with pulmonary hemodynamics in HTx patients. Methods: A total of 62 data sets [echocardiographic, hemodynamic, and CMR] were acquired from 35 HTx patients. Comprehensive echocardiography, including two-dimensional (2D) transthoracic echocardiography, speckle tracking echocardiography, and three-dimensional (3D) echocardiography, was performed. Mean pulmonary artery pressure (mPAP) was obtained invasively from right heart catheterization. The correlations between all echocardiographic parameters and CMR imaging data and the differences between patients with and without residual PH were evaluated. Results: Diastolic and systolic RV volumes and RV ejection fraction (RVEF) by 3D echocardiography correlated strongly with CMR-derived volumes and RVEF (r =.91, r =.79, r =.64; p <.0001 for each, respectively). Among other parameters, RV fractional area change (r =.439; p <.001) and RV free wall longitudinal strain (RVFW-LS) (r = −.34; p <.05) correlated moderately with CMR-RVEF, whereas tricuspid annulus S’ velocity (r =.29; p <.05) and tricuspid annular systolic plane excursion (r =.27; p <.05) correlated weakly with CMR-RVEF. Additionally, 3D-RVEF and RVFW-LS were significantly decreased in studies with mPAP ≥ 20 mm Hg in comparison to those with mPAP < 20 mm Hg (47.7 ± 3.7 vs. 50.9 ± 5.3, p =.04 and −15.5 ± 3.1 vs. −17.5 ± 3, p =.03, respectively). Conclusion: The best method for the evaluation of RV function in HTx recipients is 3D echocardiography. Besides, the subclinical impact of residual PH on RV function can be best determined by RVFW-LS and 3D-RVEF in these patients

Three-Dimensional Color Doppler Echocardiography for Direct Measurement of Vena Contracta Area in Mitral Regurgitation In Vitro Validation and Clinical Experience

ObjectivesOur goal was to prospectively compare the accuracy of real-time three-dimensional (3D) color Doppler vena contracta (VC) area and two-dimensional (2D) VC diameter in an in vitro model and in the clinical assessment of mitral regurgitation (MR) severity.BackgroundReal-time 3D color Doppler allows direct measurement of VC area and may be more accurate for assessment of MR than the conventional VC diameter measurement by 2D color Doppler.MethodsUsing a circulatory loop with an incorporated imaging chamber, various pulsatile flow rates of MR were driven through 4 differently sized orifices. In a clinical study of patients with at least mild MR, regurgitation severity was assessed quantitatively using Doppler-derived effective regurgitant orifice area (EROA), and semiquantitatively as recommended by the American Society of Echocardiography. We describe a step-by-step process to accurately identify the 3D-VC area and compare that measure against known orifice areas (in vitro study) and EROA (clinical study).ResultsIn vitro, 3D-VC area demonstrated the strongest correlation with known orifice area (r = 0.92, p < 0.001), whereas 2D-VC diameter had a weak correlation with orifice area (r = 0.56, p = 0.01). In a clinical study of 61 patients, 3D-VC area correlated with Doppler-derived EROA (r = 0.85, p < 0.001); the relation was stronger than for 2D-VC diameter (r = 0.67, p < 0.001). The advantage of 3D-VC area over 2D-VC diameter was more pronounced in eccentric jets (r = 0.87, p < 0.001 vs. r = 0.6, p < 0.001, respectively) and in moderate-to-severe or severe MR (r = 0.80, p < 0.001 vs. r = 0.18, p = 0.4, respectively).ConclusionsMeasurement of VC area is feasible with real-time 3D color Doppler and provides a simple parameter that accurately reflects MR severity, particularly in eccentric and clinically significant MR where geometric assumptions may be challenging

Approach to optimal assessment of right ventricular remodelling in heart transplant recipients: insights from myocardial work index, T1 mapping, and endomyocardial biopsy

International audienceAims Right ventricular (RV) dysfunction is an important cause of graft failure after heart transplantation (HTx). We sought to investigate relative merits of echocardiographic tools and cardiac magnetic resonance (CMR) with T1 mapping for the assessment of functional adaptation and remodelling of the RV in HTx recipients. Methods and results Sixty-one complete data set of echocardiography, CMR, right heart catheterization, and biopsy were obtained. Myocardial work index (MWI) was quantified by integrating longitudinal strain (LS) with invasively measured pulmonary artery pressure. CMR derived RV volumes, T1 time, and extracellular volume (ECV) were quantified. Endomyocardial biopsy findings were used as the reference standard for myocardial microstructural changes. In HTx recipients who never had a previous allograft rejection, longitudinal function parameters were lower than healthy organ donors, while ejection fraction (EF) (52.0 +/- 8.7%) and MWI (403.2 +/- 77.2 mmHg%) were preserved. Rejection was characterized by significantly reduced LS, MWI, longer T1 time, and increased ECV that improved after recovery, whereas RV volumes and EF did not change MWI was the strongest determinant of rejection related myocardial damage (area under curve: 0.812, P &lt; 0.0001, 95% CI: 0.69-0.94) with good specificity (77%), albeit modest sensitivity. In contrast, T1 time and ECV were sensitive (84%, both) but not specific to detect subclinical RV damage. Conclusion Subclinical adaptive RV remodelling is characterized by preserved RV EF despite longitudinal function abnormalities, except for MWI. While ultrastructural damage is reflected by MWI, ECV, and T1 time, only MWI has the capability to discriminate functional adaptation from transition to subclinical structural damage