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   2013| July-September  | Volume 23 | Issue 3  
    Online since December 30, 2013

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Severe midventricular hypertrophic obstructive cardiomyopathy and apical aneurysm
Giuseppe Gibelli, Salvatore Biasi, Valeria Buonamici
July-September 2013, 23(3):81-83
A 40-year-old man was found to have hypertrophic cardiomyopathy (HCM) with severe mid ventricular obstruction. The obstruction produced two distinct left ventricular chambers with an estimated 60 mmHg continuous wave (CW) Doppler intraventricular gradient. Pulsed wave (PW) Doppler showed high velocity systodiastolic flow from apex to base and flow from base to apex confined mostly to the second half of diastole. Cardiac magnetic resonance (CMR) showed midventricular obstruction, due to septal, parietal, and to an hypertrophic, double posteromedial papillary muscle; an apical aneurysm was detected. Aneurysm is underdiagnosed by echocardiography in HCM and an accurate anatomic definition is needed if surgery is planned; thus, a CMR should always be obtained in these patients.
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Early detection of left ventricular dysfunction in diabetes mellitus patients with normal ejection fraction, stratified by BMI: A preliminary speckle tracking echocardiography study
Lorenzo Conte, Iacopo Fabiani, Valentina Barletta, Cristina Bianchi, Ciccarone Anna Maria, Cuono Cucco, Marianna De Filippi, Roberto Miccoli, Stefano Del Prato, Carlo Palombo, Vitantonio Di Bello
July-September 2013, 23(3):73-80
Background: Diabetes mellitus (DM) represents by itself a major risk factor for cardiovascular events and the coexistence of obesity with consequent left ventricular volumetric overload could be responsible for further damages on left ventricular function. Aim of this study was to demonstrate the effect of body mass index (BMI) on left ventricular function in diabetes patients with no cardiovascular complications and with normal ejection fraction (EF). Materials and Methods: We evaluated 71 stable asymptomatic diabetes patients in optimal medical treatment and 24 healthy controls (C) (45% females; mean age: 58.4 +/− 9.4 years; BMI: 23.5 +/− 1.5). We stratified diabetes patients into two groups according to BMI: BMI <30 kg/m 2 (A: 44 patients; 47% females; mean age: 60.9 +/− 6.6 years; BMI: 25.7 +/− 1.9; Diabetes duration: 9.1 +/− 9.5 years); BMI >30 kg/m 2 (B: 27 patients; 37% females; mean age: 56.2 +/− 7.8 years; BMI: 33.0 +/− 2.1; Diabetes duration: 8.5 +/− 5.2 years). The following parameters were evaluated by conventional two dimensional (2D) echocardiography (GE VIVID 7) and tissue Doppler imaging (TDI): left ventricular dimensions (LVIDd; PWTd; IVSd), Left Ventricular Volumes (EDV, ESV), EF (by biplane Simpson's method), Left Ventricular Mass (by ASE formula), peak mitral annular velocity at septal and lateral levels (Sm and Sl). Global longitudinal strain (GLS) was obtained off line by Speckle tracking imaging method using Echopac 10 software. Results: Groups A, B were comparable for diabetes duration and glycated hemoglobin level, history of hypertension, and lipid profile. The EF was similar in the three groups, (A: 64 +/− 6%; B: 63 +/− 4%; C: 61 +/−5%; P= NS). LVMass 2.7 indexed for height was significantly higher in A and B in comparison with C (A: 45.2 +/− 8.1 g/m 2.7 ; B: 46.1 +/− 9.6 g/m 2.7 ; C: 39.5 +/− 4.9 g/m 2.7 ; P < 0.05). The stroke volume index (SVi) was significantly lower in B vs A (B: 35.3 +/− 5.7 ml/m 2 ; A: 39.3 +/ 7.1 ml/m 2 ; P = 0.033). GLS was significantly lower in group B respect A and C (C: 20.9 +/− 1.3%; A: -20.3+/−2.6%; B: -19 +/− 2; P < 0.05; P < 0.01). Conclusions: In uncomplicated asymptomatic DM patients, the presence of first degree obesity plays an incremental role in adversely affecting left ventricular function and remodeling. The conventional echocardiographic methods such as the EF and the TDI are not so sensitive to identify the early LV dysfunction such as the evaluation of GLS by Speckle Tracking echocardiography. The longitudinal subendocardial fibers dysfunction in diabetes/obese patients could be derived by the complex interaction between metabolic (diabetes) and hemodynamic/endocrine abnormalities.
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A Rare complication of aorto-left atrial fistula after aortic valve replacement and its management with intraoperative transoesophageal echocardiography
Tanveer Ahmad, Satish Chithiraichelvan, Thimmangouda Ayangouda Patil, Vivek Jawali
July-September 2013, 23(3):88-90
Aorto-atrial fistula is a rare complication of prosthetic aortic valve replacement and most of them have been diagnosed as a late complication. We present a case of this unusual complication after aortic valve replacement which was diagnosed intraoperatively and this potentially disastrous complication was corrected promptly. Early recognition and diagnosis of this rare surgical complication with intraoperative transoesophageal echocardiography (TEE) is imperative for prompt surgical repair of this lethal defect.
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Direct left ventricular metastasis reduction: 3D-echo monitoring for management of clinical case
Leggio Stefano, Buccheri Sergio, Soto-Parra Hector, Monte Ines
July-September 2013, 23(3):84-87
A 52-year-old woman with a lung carcinoma metastatic to bone was admitted to the Cardiology Department for acute chest pain after 1 week of the oncologic therapy. Electrocardiographic examination (ECG) revealed ischemic picture with ST-T wave abnormalities in DI and aVL leads and poor progression of R wave in V1-V4 leads. Two- and three-dimensional transthoracic echocardiography (2D/3D TTE) showed myocardial involvement with infiltration of the anterolateral left ventricular (LV) wall from the epicardial to the endocardial layer, apical hypokinesia, LV ejection fraction (LVEF) and global 3D longitudinal strain reduction, but was absent pericardial effusion. Three months from the beginning of erlotinib, the patient showed a significant reduction in myocardial involvement with no ECG-ST elevation. Echo showed a mild regression of the wall infiltration and a slightly improvement of LVEF and strain. A computed tomography (CT) scan showed partial remission of the primary lung lesion, intracavitary and intramyocardial mass.
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