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   Table of Contents - Current issue
April-June 2019
Volume 29 | Issue 2
Page Nos. 45-87

Online since Friday, July 19, 2019

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The Intrusive nature of epicardial adipose tissue as revealed by cardiac magnetic resonance p. 45
Laura Anna Leo, Vera Lucia Paiocchi, Susanne Anna Schlossbauer, Siew Yen Ho, Francesco F Faletra
The epicardial adipose tissue (EAT) refers to the deposition of adipose tissue fully enclosed by the pericardial sac. EAT has a complex mixture of adipocytes, nervous tissue, as well as inflammatory, stromal and immune cells secreting bioactive molecules. This heterogeneous composition reveals that it is not a simply fat storage depot, but rather a biologically active organ that appears playing a “dichotomous” role, either protective or proinflammatory and proatherogenic. The cardiac magnetic resonance (CMR) allows a clear visualization of EAT using a specific pulse sequence called steady-state free precession. When abundant, the EAT assumes a pervasive presence not only covering the entire epicardial surface but also invading spaces that usually are almost virtual and separating walls that usually are so close each other to resemble a single wall. To the best of our knowledge, this aspect of cardiac anatomy has never been described before. In this pictorial review, we therefore focus our attention on certain cardiac areas in which EAT, when abundant, is particularly intrusive. In particular, we describe the presence of EAT into: (a) the interatrial groove, the atrioventricular septum, and the inferior pyramidal space, (b) the left lateral ridge, (c) the atrioventricular grooves, and (d) the transverse pericardial sinus. To confirm the reliability in depicting the EAT distribution, we present CMR images side-by-side with corresponding anatomic specimens.
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Left Atrial Fractional Shortening: A Simple and Practical “Strain” for Everyone Highly accessed article p. 52
Giulia Elena Mandoli, Matteo Cameli, Edoardo Lisi, Simona Minardi, Valentina Capone, Maria Concetta Pastore, Sergio Mondillo
Background: The function of the left atrium (LA) is reduced in many cardiac diseases even with normal size. The assessment of its compliance could represent an added value in an echocardiographic report in case the gold standard technique (speckle-tracking echocardiography [STE]) is not available. We sought to test a simple and quick method as surrogate of STE: the dynamic measurement of the LA anteroposterior diameter (APD) that we called LA fractional shortening (LAFS). Materials and Methods: A total of 153 consecutive patients underwent a transthoracic echocardiography in our echo laboratory between January and June 2017. The only inclusion criteria were the presence of an acoustic window and the informed consent. We chose to not apply exclusion criteria to assess LAFS feasibility. The LAFS was calculated as (maxAPD−minAPD)/(maxAPD) × 100 in parasternal long-axis view. We evaluated the correlation of its value with the peak atrial longitudinal strain (PALS) and the LA emptying fraction (EF). Results: Mean execution time was 32.1 ± 5 s for LAFS, 2.3 ± 0.7 min for LAEF, and 2 ± 1 min for PALS. LAFS, with a feasibility of about 97%, was moderately correlated with PALS and LAEF (R between 0.20 and 0.30, P < 0.05). LAFS fractional shortening also emerged as surrogate for PALS via the relationship PALS = 21.07 + 0.364x (LAFS). Conclusions: LAFS demonstrated a correlation with PALS, a short execution time, a high feasibility, and the possibility to be used as a surrogate of PALS, applying a specific formula.
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Aortic regurgitation as a risk factor for coronary embolization from complex atheromatous aortic plaques: A clinical case p. 58
Vito Maurizio Parato, Alfredo Cardinali, Michele Scarano
Patients with mobile aortic arch atheroma and severe aortic regurgitation may be at higher risk of systemic embolism. We report the case of a 68-year-old male patient with complex aortic arch plaque with superimposed thrombus, in which an acute inferior ST-elevation myocardial infarction occurred. In the reported case, coronary embolism may have been caused by flaked aortic plaque and/or superimposed thrombus, which was possibly carried by aortic regurgitation flow. It is a very rare mechanism by which a coronary embolism is possible from an aortic complex plaque.
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The usefulness of a multimodality approach in a case of subtle iatrogenic aortic dissection: Sometimes is better to look and wait p. 62
Ignazio Salamone, Maria Ludovica Carerj, Ugo Barbaro, Vittorio Virga, Concetta Zito, Antonio Bracco, Alfredo Blandino, Sergio Racchiusa
We report a rare case of iatrogenic right coronary artery (RCA) dissection complicated by a retrograde subtle aortic dissection, which occurred during a primary percutaneous transluminal coronary angioplasty (PTCA). A 65-year-old female, with acute anterior ST-elevation myocardial infarction (STEMI), promptly underwent primary PTCA in the left anterior descending artery. After 5 h, the patient's condition becomes worse with recurrence of chest pain and new electrocardiogram modifications suggestive of inferior STEMI. A second coronary angiography revealed a spiral dissection extending from the ostium to the medium tract of the RCA. At the same time, a contrast media extravasation due to coronary ostium fissure occurred. Coronary stents were implanted from the medium tract of the right coronary to the ostium, to promptly arrest the active bleeding and to treat the dissection. After cardiosurgical advice, the patient was referred to the radiology department, where she underwent computed tomography angiography (CTA), which showed a small hematoma in the anterior wall of the ascending aorta. The stable clinical conditions of the patient suggested a conservative therapeutic approach. During the following 6 weeks CTA and transesophageal echocardiography were performed to rule out any other complication, and the patient was fortunately discharged with almost complete resolution of the hematoma.
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Anomalous right coronary artery origin from left main stem: Role of cardio-computed tomography in the diagnosis and therapeutic Approach p. 65
Matteo Gravina, Grazia Casavecchia, Alessandro Martone, Mario Sollitto, Stefano Zicchino, Andrea Cuculo, Luca Macarini, Matteo Di Biase, Natale Daniele Brunetti
Anomalous coronary arteries (ACAs) are rare but potentially life-threatening abnormalities of coronary circulation. Most of the variants are benign; however, some may lead to myocardial ischemia and/or sudden cardiac arrest. We report the case of a 75-year-old male complaining of exertion chest discomfort. Admission electrocardiogram on presentation showed sinus bradycardia with a slight elevation of ST-T in inferior leads. Troponin levels, however, were normal. Coronary angiography showed an anomalous right coronary artery (RCA) originating from the left main stem without significant stenosis. Cardio-CT confirmed the anomalous origin of the RCA from the left main stem and showed its anomalous course between the aorta and the pulmonary artery. The patient was deemed a candidate for surgery and transferred to a cardiac surgery center. Only the exact definition of the anatomic and clinical features of ACAs may allow the identification of the most appropriate and effective treatment. Multislice computed tomography may play a fundamental role in the diagnosis and treatment of ACAs.
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Giant right ventricular mass protruding into the pulmonary artery during systole p. 68
Yavuzer Koza, Umit Arslan, Bilgehan Erkut, Enise Armagan Koza
Myxomas are the most common primary cardiac tumors in adults and mainly originate in the left atrium with a slight female predominance. Only 3%–4% of myxomas are detected in the right ventricle. Although these tumors are histologically benign, they can lead to several catastrophic complications such as embolization or obstruction of blood flow at the mitral or tricuspid valve orifices. We report a rare case of right ventricular myxoma presented with near-syncope attacks and worsening dyspnea.
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Multimodality imaging diagnosis of multiple ventricular thrombosis and massive stroke after gemcitabine and cisplatin chemotherapy for Urothelial Cancer p. 71
Pier Paolo Bassareo, Daniele Cocco, Christian Cadeddu, Giuseppe Mercuro
Cancer and chemotherapy are known to be risk factors for developing coagulative disorders, venous thrombosis, adverse cardiovascular events, and cardiotoxicity. Combined modality gemcitabine–cisplatin chemotherapy is often administered to treat a few solid tumors. We report the unusual case of a man suffering from urothelial cancer and admitted for chemotherapy, who developed an ischemic stroke after the last chemotherapeutical cycle. During his hospital stay, at echocardiographic examination, left ventricular transient hypokinesia and two intraventricular thrombi were detected, without evidence of acute coronary syndrome. Multimodality imaging approach (i.e., transthoracic echo, transoesophageal echo, computed tomography, and cardiac magnetic resonance imaging) played a pivotal role for a clear diagnosis and prompt decision-making. This is the first report of an intraventricular-related arterial thromboembolic event in a patient treated with the combination gemcitabine–cisplatin.
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Challenges with managing delayed presentation of persistent truncus arteriosus with torrential pulmonary blood flow in a Resource-Limited setting p. 75
Igoche David Peter, Damilola M Oladele, Gurama Kefas, Olamide V Kayode, Iseko I Iseko
Embryologically, incomplete conotruncal septation with resultant single aortopulmonary trunk and defective ventricular septation defines the congenital cardiac lesion known as persistent truncus arteriosus (PTA). Torrential pulmonary blood flow is inevitable when this rare lesion is further compounded by patency of the arterial ductus. Such was the case of a patient who presented with fast breathing, reduced suck, darkening of the tongue, and extremities. Urgent echocardiographic diagnosis was PTA (Type A1) with patent ductus arteriosus and pulmonary hypertension and left ventricular systolic dysfunction.
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The additional value of three-dimensional transesophageal echocardiography in the diagnosis of unusual complication of bioprosthetic mitral valve p. 78
Martina Evangelista, Marta Barletta, Anca Irina Corciu, Valnetina Mantovani, Lucrezia Delli Paoli, Marco Guazzi, Maurizio Tusa
Primary tissue failure of bioprosthetic mitral valves due to cusp perforations or ruptures is an unusual complication on short-term follow-up. An 88-year-old male with a known history of mitral regurgitation (MR) treated with bioprosthetic valve replacement in 2016 was referred to our center for recurrent heart failure. The two-dimensional (2D) transthoracic echocardiography documented an intraprosthetic jet of regurgitation without identifying a clear morphological mechanism, nor quantifying precisely the mitral insufficiency. 3D transesophageal echocardiography (TOE) with the tool FlexiSlice added relevant information by providing insights into the pathophysiological mechanisms of MR. The present case emphasizes the importance of 3D TOE as a fundamental tool for the diagnostic algorithm of bioprosthetic valves failure, even in the more demanding cases.
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“where is the heart?” When cardiac magnetic resonance imaging helps if echocardiography is inconclusive p. 82
Alessandro Caretta, Laura Anna Leo, Vera Lucia Paiocchi, Lorenzo Grazioli Gauthier, Francesco Fulvio Faletra, Tiziano Moccetti
Cardiovascular magnetic resonance (CMR) is the gold standard technique to comprehensively assess cardiac structure and function. A 64-year-old male, planned for surgical coronary revascularization, underwent transthoracic and transesophageal echocardiography for a mitral regurgitation, with an eccentric jet of unclear mechanism; these examinations were inconclusive because of the lack of adequate visualization of the cardiac structures. A CMR was then performed to quantify mitral regurgitation and, additionally, it documented a giant hiatus hernia with gastric sliding into the thorax. In this case, CMR helped to better define the severity of a valvular disease and provided ancillary information from the extracardiac findings.
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High-risk NSTEMI due to subclavian artery atherothrombosis in a prior coronary artery bypass graft patient p. 86
Michele Coceani, Francesco Sbrana, Marco Ciardetti, Beatrice Dal Pino, Cataldo Palmieri, Sergio Berti, Alberto Giannoni, Michele Emdin, Tiziana Sampietro
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