Background: Although diastolic dysfunction is common among patients treated with cancer therapy, no clear evidence has been shown that it predicts systolic dysfunction. This study evaluated the correlation of longitudinal diastolic strain time (Dst) with the routine echocardiography diastolic parameters and to estimated its role in the early detection of cardiotoxicity among patients with active breast cancer. Methods: Data were collected as part of the Israel Cardio-Oncology Registry (ICOR), a prospective registry enrolling all adult patients referred to the cardio-oncology clinic. All patients with breast cancer, planned for Doxorubicin therapy were included. Echocardiography, including Global longitudinal systolic strain (GLS) and Dst, was assessed at baseline before chemotherapy (T1), during Doxorubicin therapy (T2) and after the completion of Doxorubicin therapy (T3). Cardiotoxicity were determined by GLS relative reduction of ≥15%. Dst was assessed as the time measured (ms) of the myocardium lengthening during diastole. =diastolic time (ms) measured. Results: Among 69 patients, 67 (97.1%) were females with a mean age 52±13years. Diastolic strain timeDst measurement was significantly associated with the standard routine diastolic parameters. Significant GLS reduction was observed in 10 (20%) patients at T3 . Both in a univariate and a multivariate analyses the change in Ds basal time from T1 to T2 emerged to be significantly associated with GLS reduction at T3 (p<0.04). Conclusions: Among breast cancer patients, Dst time showed high correlation to standard the routine diastolic echocardiography parameters. Relative reductionChange in Ds basal time emerged associated with clinically significant systolic dysfunction as measured by GLS reduction.
We present a late presentation of saddle pulmonary embolism and thrombus-in-transit straddle the patent foramen on patient who successfully recovered from severe acute respiratory syndrome coronavirus-2 (COVID-19) pneumonia. Seven days post-discharge (i.e. 28 days after initial COVID-19 symptom onset), she was readmitted to hospital for severe dyspnea. Computer tomography angiogram and echocardiography confirmed the diagnosis. Severe pro-inflammatory and pro-thrombotic states with endothelial involvement have been reported associated with severe COVID-19 infection. However the duration of hypercoagulable state has not yet known. This case highlights the risk of thromboembolic phenomena for prolonged periods of times after recovering from COVID-19 pneumonia.
B-LINES IN COVID-19: “UNSPECIFICITY” IS NOT “MEANINGLESS”Luigi Vetrugno1,2 MD, Prof, Tiziana Bove1,2 MD, Prof, Daniele Orso1 MD, Federico Barbariol2 MD, Flavio Bassi2 MD, Enrico Boero3 MD, Giovanni Ferrari4 MD, Robert Kong5MD, FRCA, EDIC,1Department of Medicine, University of Udine, ItalyAnesthesia and Intensive Care ClinicVia Colugna n° 50, 33100 Udine, Italy2University-Hospital of Udine, ItalyDepartment of Anesthesia and Intensive CareP.le S. Maria della. Misericordia n° 15, 33100 Udine, Italy3Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Torino, Italy4SC Pneumologia ad Indirizzo Semi Intensivo, Azienda Ospedaliera Ordine Mauriziano. Largo Turati 62 – Torino, Italy5 Cardiac Anaesthesia & Intensive Care, Brighton & Sussex University Hospital, Brighton BN2 5BE United KingdomShort title: lung ultrasound and B-lines*Corresponding author:Prof. Luigi Vetrugno, MDDepartment of Medicine, University of Udine, ItalyAnesthesia and Intensive Care ClinicVia Colugna n° 50, 33100 Udine, ItalyPhone: +39 0432 559509Fax: +39 0432 559502Financial Support and Sponsorship: None.Conflict of Interest: Luigi Vetrugno received travel support for Congress Lecture by Cook Medical.The other authors declare no conflict of interest.Key works: Lung Ultrasound; interstitial syndrome, COVID-19, B-lines.Authors’ contributions LV and DO concept, design and drafting the manuscript. TB, FB, EB, FB, GF critical revision of the manuscript for important intellectual content. RK critical review and editing the manuscript. All authors read and approved the final manuscript.We thank Prof. Trovato and Dr Sperandeo for commenting on our article.1 We agree with them that lung ultrasound (LU) imaging is useful and our aim was to provide readers with a succinct overview of how LU was used in the care of COVID-19 patients at two centres in Italy.2 The frequent finding in COVID-19 patients of lung consolidation at the inferior and basal regions means that one of the limitations of LU, which is to perform a complete assessment of the periphery of the lungs, is mitigated, as affected regions are not obscured by the scapula. Other authors have shown that in COVID-19 patients, LU provided results similar to those of computed tomography (CT) of the lung and superior to those of standard chest x-rays.3-5 Therefore, LU provides clinicians with another mode of lung imaging that can be performed non-invasively and without the logistic challenges of obtaining CT lung scan in these patients, as is well-known to centers who have been faced with a large caseload.6 As stated in our article, we have not identified an LU finding that is pathognomonic of COVID-19.1-7 However, the presence of B lines in several different clinical situations does not decrease their significance. In medicine, many signs are frequent in various diseases, like fever, but this is not a good reason to underestimate or not consider them at all. Furthermore, emerging ultrasound image analysis based on artificial intelligence and deep learning has the potential to further enhance the utility of LU.8-9 Although caution is needed in terms of exaggerating the power of LU, we hope it will continue to be used widely after the pandemic.ReferencesSperandeo M, Trovato G. Usefulness of lung ultrasound imaging in Covid-19 pneumonia: the persisting need of safety and evidences. Echocardiography. in press (ECHO-2020-0386)Vetrugno L, Bove T, Orso D, et al. Our Italian experience using lung ultrasound for identification, grading and serial follow-up of severity of lung involvement for management of patients with COVID-19. Echocardiography. 2020;37:625‐627. doi:10.1111/echo.14664Huang Y, Wang S, Liu Y. A Preliminary Study on the Ultrasonic Manifestations of Peripulmonary Lesions of Non-Critical Novel Coronavirus Pneumonia (COVID-19). SSRN. 2020. doi: 10.21203/rs.2.24369/v1Jin YH, Cai L, Cheng ZS, et al. A rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-nCoV) infected pneumonia (standard version). Mil Med Res. 2020;7:4. doi: 10.1186/s40779-020-0233-6Convissar D, Gibson LE, Berra L, Bittner EA, Chang MG. Application of Lung Ultrasound during the COVID-19 Pandemic: A Narrative Review [published online ahead of print, 2020 Apr 30]. Anesth Analg. 2020;10.1213/ANE.0000000000004929. doi:10.1213/ANE.0000000000004929Wang E, Mei W, Shang Y, et al. Chinese Association of Anesthesiologists Expert Consensus on the Use of Perioperative Ultrasound in Coronavirus Disease 2019 Patients [published online ahead of print, 2020 Apr 10]. J Cardiothorac Vasc Anesth. 2020;S1053-0770(20)30325-6. doi:10.1053/j.jvca.2020.04.002Vetrugno L, Bove T, Orso D, Bassi F, Boero E, Ferrari G. Lung Ultrasound and the COVID-19 ”Pattern”: Not All That Glitters Today Is Gold Tomorrow [published online ahead of print, 2020 May 8]. J Ultrasound Med. 2020;10.1002/jum.15327. doi:10.1002/jum.15327Corradi F, Brusasco C, Vezzani A, et al. Computer-aided quantitative ultrasonography for detection of pulmonary edema in mechanically ventilated cardiac surgery patients. Chest 150:640‐651, 2016 doi:10.1016/j.chest.2016.04.013Gullett J, Donnelly JP, Sinert R, et al. Interobserver agreement in the evaluation of B-lines using bedside ultrasound. J Crit Care. 2015;30:1395-1399 doi:10.1016/j.jcrc.2015.08.021
Objective:Identification of patients who are nonresponders to cardiac resynchronization therapy (CRT) with the use of simple and objective parameters may be helpful in tailoring treatment. The aim of this study is to investigate whether E/(Ea×Sa) could be a predictor of CRT nonresponders (E=early diastolic transmitral velocity, Ea=early diastolic mitral annular velocity, Sa=systolic mitral annular velocity). Methods:In total, 53 heart failure patients were evaluated for this study, and 33 patients were included according to the study criteria. Before and six months after CRT-D(CRT with a defibrillator) implantation, E, Ea, and Sa were determined at the medial and lateral mitral annular sites, and the average values were obtained. E/(Ea×Sa) was calculated (medial, lateral, average). The patients were followed for six months to monitor their CRT response. A responder was defined as a patient with a reduction in end-systolic volume of <15% and an increase in six-minute walking distance of 50 meters. Results:At a six-month follow-up, 24(72.7%) of the 33 patients responded to CRT. At the six-month follow-up, in the responder group, the E/Ea ratio, lateral mitral, and average E/(Ea×Sa) indices were significantly reduced (p<0.01 for all). The baseline lateral mitral, medial mitral, and average E/(Ea×Sa) indices were significantly lower in the responder group than in the nonresponder group (p≤0.01 for all). The ROC analysis showed that all the E/(Ea×Sa) indices predict the CRT nonresponder patients. The AUC values were 0.89(lateral E/(Ea×Sa)), 0.85(average E/(Ea×Sa)), and 0.77(medial E/(Ea×Sa))(p≤0.01 for all). Conclusion:We found that the E/(Ea×Sa) index is a novel predictor of CRT nonresponder patients.
Diastolic dysfunction (DD) is reported to affect up to 35% of the adult general population. The consequence of progressive DD is heart failure with preserved ejection fraction (HFpEF). Coronary microvascular dysfunction (CMD) has been suggested as one of the pathologic mechanisms leading to HFpEF. We investigated whether there was an association between coronary microvascular function and echocardiographic indices of left ventricular diastolic function in patients with chest pain and unobstructed coronary arteries (CPUCA). This retrospective observational study recruited patients referred to cardiology clinics assessment of chest pain who subsequently underwent assessment via CT coronary angiogram (CTA). Coronary microvascular dysfunction was determined by myocardial blood flow reserve (MBFR; <2.0) using myocardial contrast echocardiography. Echocardiographic indices of diastolic function (septal mitral annular e’; septal mitral annular E/e’) were measured from baseline transthoracic echocardiogram. 149 patients (52% men) with a mean age 59.7(9.5) years were recruited. Mean (standard deviation) MBFR was 2.2 (0.51). 37% (55/149) had MBFR<2.0. Median [interquartile range] septal mitral annular e’ velocity and septal mitral annular E/e’ were 7.6 cm/s [6.2, 8.9] and 9.5 [7.5, 10.8] respectively. Univariate regression analysis showed only age was a significant predictor of increasing septal mitral annular E/e’ (=+0.20 95% CI 0.13, +0.28, p<0.001) but not MBFR. Multivariable analysis also showed no association between these septal mitral annular E/e’ and MBFR after adjustment for cardiovascular risk factors. There was no relationship found between echocardiographic indices of left ventricular diastolic function and coronary microvascular function.
To the Editor:We enjoyed reading the case, authored by Janus and Hoit, of a 67-year-old woman with a subarachnoid hemorrhage (SAH) who presented with three different variants of takotsubo (TT).[i] We congratulate the authors on their interesting contribution to the literature. We would like to share some comments and questions on the chronology and management of the events between the first two episodes, which occurred a few days apart. Although fascinating, this is not the first case of TT with a rapidly evolving pattern. We previously described a case of mid-ventricular takotsubo which replaced apical ballooning in 6 hours.[ii] A recent meta-analysis showed that almost 80% of TT recurrences exhibit a ballooning pattern different from the first presentation.[iii] In this regard, regional cardiac sympathetic innervation remodeling or denervation could hypothetically justify why the same territory is usually spared from further relapses. Even though images were not provided, the authors stated that “echocardiographic wall motion abnormalities quickly resolved after each acute stressor”. One could therefore argue that this was not a case of multiple TT variants during the same episode, as noted by Madias,iii but rather an example of early recurrences. Additionally, if cardiac innervation remodeling were responsible for the different locations of the ballooning, we believe that the change in pattern would have taken longer to manifest. This would not support the observation of two distinct ballooning patterns emerging within days, let alone hours.i, ii In this case, a short-term change from the mid-ventricular to apical pattern could be reasonably explained by different β adrenergic-receptor (β-AR) subtype downregulation. We know that norepinephrine can downregulate β1-AR after a few hours. Beta1-ARs are markedly lower on biopsied patients with acute TT compared to healthy controls,[iv] whilst in the same study β2-ARs expression—which is predominant in the apical and mid-ventricular segments and thought to be involved in typical takotsubo pathogenesis[v]—was equivalent to normal. Thus, the sequence of events could be interpreted as a relative local β2 prevalence due to dynamic β1 downregulation (β1:β2 mismatch), following a base:mid-ventricle, and ultimately a mid-ventricle:apex progression. What do the authors think about this theory? Is it possible that multi-faceted presentations might simply be under-recognized? Should this be the case, how do they think we could better understand this phenomenon in a noninvasive fashion? Could dobutamine stress echocardiography have utility to identify areas of β-AR downregulation and sympathetic denervation? It would also be interesting to know more about the patient’s medical therapy. Did she receive nonselective β-blockers, such as labetalol or carvedilol, usually prescribed after SAH? If so, this might indicate that β-blockers do not prevent recurrences,[vi] but rather create a maladaptive imbalance in regional β1:β2 distribution favoring early relapse(s), as this case suggests.References[i] Janus SE, Hoit BD. The three faces of takotsubo cardiomyopathy in a single patient. Echocardiography. 2020 Jan;37(1):135-138. doi: 10.1111/echo.14560. Epub 2019 Dec 16.[ii] Casavecchia G, Zicchino S, Gravina M, et al. Fast 'wandering' Takotsubo syndrome: atypical mixed evolution from apical to mid-ventricular ballooning. Future Cardiol. 2017 Nov;13(6):529-532. doi: 10.2217/fca-2017-0018. Epub 2017 Oct 12.[iii] Madias JE. Comparison of the first episode with the first recurrent episode of takotsubo syndrome in 128 patients from the world literature: Pathophysiologic connotations. Int J Cardiol. 2020 Mar 3. pii: S0167-5273(20)30215-1. doi: 10.1016/j.ijcard.2020.03.003.[iv] Nakano T, Onoue K, Nakada Y, et al. Alteration of β-Adrenoceptor Signaling in Left Ventricle of Acute Phase Takotsubo Syndrome: a Human Study. Sci Rep 8, 12731 (2018). https://doi.org/10.1038/s41598-018-31034-z.[v] Paur H, Wright PT, Sikkel MB, et al. High levels of circulating epinephrine trigger apical cardiodepression in a β2-adrenergic receptor/Gi-dependent manner: a new model of Takotsubo cardiomyopathy. Circulation. 2012 Aug 7;126(6):697-706. doi: 10.1161/CIRCULATIONAHA.112.111591. Epub 2012 Jun 25.[vi] Santoro F, Ieva R, Musaico F, et al. Lack of efficacy of drug therapy in preventing takotsubo cardiomyopathy recurrence: a meta-analysis. Clin Cardiol. 2014 Jul;37(7):434-9. doi: 10.1002/clc.22280. Epub 2014 Apr 3.
SARS-CoV-2 not only causes viral pneumonia but has major implications for the cardiovascular system. Nevertheless, we assisted to a drastic reduction in the number of ACS during this period. Telemedicine and telecardiology, intended as integration to the traditional management appear precious tools especially in Covid-19 era. Given the decrease in new Covid-19 cases worldwide20, now we are approaching the so-called “Phase 2” challenge of a gradual return to pre-Covid-19 life. The epidemiological and clinical situation is rapidly evolving and practice patterns with policies depend on institutions and local availability.
Introduction: Chagas disease is one of the main diseases in Latin America and heart involvement is its main characteristics, and the main cause of death. The aim of this study is to evaluate if there is any parameter of Doppler Tissue Imaging (DTI) which can be used as a predictor for later events in chronic Chagas disease. Methods: we analyses DTI variables of 543 patients with chronic Chagas disease for the evaluation of predicting factors of events. Major adverse cardiovascular events (MACE) were considered as stroke, heart failure resistant to treatment, sustained ventricular tachycardia, implantable cardioverter-defibrillator, sudden death, and cardiovascular death. The following findings were also included in total evens: heart failure, bradycardia, ventricular arrhythmia, new conduction system abnormalities and new echocardiographic abnormalities. Multivariate analysis with logistic regression was used in order to assess the Doppler and DTI parameters predicting events. Variables with a p-value ≤ 0.10 in the univariate analysis were included in the multivariate analysis. Results: In patients with chronic Chagas disease, the analysis of DTI parameters showed that S’ wave and E’ wave of the lateral wall of the left ventricle were significant predictors of MACE (OR: 0.83; 95% CI: 0.71-0.96; p value: 0.015 and OR: 0.80; 95% CI: 0.66-0.98; p value: 0.031, respectively). Conclusions: This study found that patients with chronic Chagas disease who had events showed significantly lower parameters in the DTI. What is more, this study showed that even lower DTI parameters are significant predictors of events.
The assessment of left ventricular (LV) function in the setting of mitral stenosis (MS) has been critically examined for decades. Accurate assessment of aberrations in diastolic function is important as these subjects often present with signs and symptoms of heart failure and pulmonary congestion that cannot be solely explained by the severity of mechanical obstruction. Echocardiographic evaluation of diastolic dysfunction includes an evaluation of reduced LV compliance, diminished restoring forces and enhanced stiffness, which are challenging in the setting of MS owing to altered hemodynamic loading. Conventional echocardiographic and Doppler measures offer limited information. Novel assessments employing speckle tracking echocardiography are relatively less studied. A more comprehensive assessment including clinical evaluation, identification of concomitant disorders and comorbidities is particularly warranted in older subjects with degenerative MS to suspect diastolic dysfunction and arrive at optimal medical therapy or intervention. This review provides an overview of etiological, pathophysiological, echocardiographic and invasive assessment of diastolic dysfunction in the setting of MS, with specific focus on strengths and limitations of available echocardiographic and Doppler techniques.
Pericardial cysts are considered rare incidental findings, which are generally asymptomatic in nature. Occasionally, patients may represent with chest discomfort, dyspnea or palpitations. Pericarditis related to a ruptured pericardial cyst has not been previously reported in the literature. Here, we report the case of a 62-year-old male who developed acute pericarditis as a result of a ruptured enlarging pericardial cyst.
We report a case of 41-year-old woman who presented with chest tightness and shortness of breath. Transthoracic echocardiogram (TTE) showed left ventricular (LV) pseudo-aneurysm of the inferior wall with preserved LV systolic function. Coronary angiogram was normal. Surgical repair of the pseudo-aneurysm with a pericardial patch was performed, and pathological results confirmed rupture of an isolated congenital LV diverticulum.as the most likely etiology.
The aim of the study is to investigate the impairment of diastolic function of the left ventricle (LV) and the right ventricle (RV) in arterial hypertension outpatients. Materials and methods. Arterial hypertension patients (n=299) and practically healthy people (n=62) were examined on an outpatient basis. Echocardiographically, diastolic dysfunctions of both ventricles were evaluated. Results. All the arterial hypertension patients had a pattern of diastolic dysfunction (DD) of the RV of different grades (grade I RVDD and grade II RVDD), regardless of the presence or absence of pulmonary arterial hypertension. Patterns of grade I LVDD and grade I RVDD were detected in 84 patients. Patterns of grade I LVDD and grade II RVDD were detected in 77 patients. Patterns of grade II LVDD and grade II RVDD were detected in 41 patients. A pattern of grade II RVDD with normal left ventricular diastolic function was detected in 97 patients with a short duration of disease (3.92±0.48 years) versus the other groups with more than 15 years of hypertension. 175 arterial hypertension patients had grade I or II LVDD only in 18.3% of cases according to the recommendations of the American and European societies of echocardiographers (2016). Conclusion. The patients with a short period of hypertensive disease have only the pseudonormal pattern of RVDD, which can be an early diagnostic marker of heart failure. Echocardiographic diagnosis of diastolic function made according to various criteria can both increase the number of chronic heart failure patients and significantly decrease it.
Controversy surrounds the cause of the pressure gradient in patients with hypertrophic obstructive cardiomyopathy (HOCM). Left ventricular cavity obliteration (LVCO) was first described as the cause of the gradient but subsequently systolic anterior motion (SAM) of the mitral valve has been established as the cause. Nevertheless, the two gradients, though different in origin and significance, share similar characteristics. They both have a similar “dagger” profile, are obtained from the cardiac apex, are associated with a hyperdynamic left ventricle, and the gradients are worsened by Valsalva. The distinction has clinical relevance, because treating the intra cavitary gradient (ICG) of LVCO as if it were a SAM associated gradient associated with HOCM would be inappropriate and possibly harmful. To clarify the cause and characteristics of the ICG in patients with LVCO in patients without HOCM we assessed the extent and duration of cavity obliteration and for differentiation we compared the spectral profiles with patients with HOCM and severe aortic stenosis (AS). Higher ICG is associated with greater extent and more prolonged apposition of LV walls. The spectral profile of patients with AS, HOCM and LVCO are differentiated by the peak/mean gradient ratios of 2 or less, 2-3, and 3 or greater, respectively in > 90% of patients. Most patients with LVCO without HOCM or severe LVH have an ICG < 36 mmHg. The magnitude of ICG is quantitatively associated with extent and duration of LVCO. Spectral profiles of severe AS, HOCM, and LVCO can be differentiated by the peak/mean gradient ratio.
Here we present a young asymptomatic male incidentally diagnosed to have aortic regurgitation (AR). The patient had a history of a blunt trauma to the thorax two years back but did never have any symptoms. Transthoracic echocardiography showed a moderately dilated left ventricle with normal systolic function and severe AR with normal nondilated aortic root and tri-leaflet aortic valve. To diagnose the etiology of the AR a trans-esophageal echocardiogram (TEE) was done, which revealed a perforation in the non-adjacent leaflet (NAL) and confirmed severe AR with two AR jets being clearly visualised, one through the point of incomplete coaptation and other one through the perforated area in the NAL. The patient was treated with aortic valve replacement and was doing well on follow-up.
Heart failure with preserved ejection fraction (HFpEF) is a complex clinical entity associated with significant morbidity and mortality. Common comorbidities including hypertension, coronary artery disease, diabetes, chronic kidney disease, obesity, and increasing age predispose to preclinical diastolic dysfunction that often progresses to frank HFpEF. That said, clinical HFpEF is typically associated with some degree of diastolic dysfunction or can occur in the absence of many conventional diastolic dysfunction indices. The exact biologic links between risk factors, structural changes, and clinical manifestations are not clearly apparent. Innovative approaches including deformation imaging have enabled deeper understanding of HFpEF cardiac mechanics beyond conventional metrics. Furthermore, predictive analytics through data driven platforms have allowed for a deeper understanding of HFpEF phenotypes. This review focuses on the changes in cardiac mechanics that occur through preclinical myocardial dysfunction to clinically apparent HFpEF.
Ortner's syndrome is a really rare complication that manifest by hoarseness of voice. It is usually due to left recurrent laryngeal nerve compression. Cardiac causes of Ortner's syndrome are rarely encountered and it is usually due to left atrial enlargement as a complication of valvular lesions affecting mitral valve but other rare causes include ascending aortic aneurysm or pulmonary artery aneurysm. Hereby, we present the 3rd case in the literature to report Ortner's syndrome due to pulmonary artery aneurysm in a 38-year old female patient with previous history of bilharziasis.