[Left atrium remodeling after catheter ablation of atrial fibrillation]. / Remodelado reverso de aurícula izquierda posablación de fibrilación auricular.

Atrial fibrillation (AF) is the most common cardiac arrhythmia. It has a high association with cardiovascular embolic events and heart failure. Structural and functional changes are a fundamental part of the pathophysiological process, leading to left atrial myopathy and progressive left ventricular dysfunction that modifies the prognosis of patients. We present the case of a 75-year-old patient with symptomatic paroxysmal AF with good functional class who was referred for pulmonary vein ablation after antiarrhythmic therapy failure. The initial echocardiogram showed preserved biventricular systolic function, mild diastolic dysfunction, and normal left atrium (LA) volumes. However, functional LA impairment was observed with decreased reservoir phase strain. Pulmonary vein isolation was successfully performed without evidence of new arrhythmic events, in addition to improvement in LA reservoir strain, left ventricular (LV) global longitudinal strain, and myocardial work index at three months follow-up. The patient has remained asymptomatic and is under clinical follow-up. LA and LV strain as new advanced echocardiography techniques is useful in the assessment of reverse remodeling of atrial myopathy and LV structural assessment.

Insights of tricuspid regurgitation mechanisms in patients with right ventricular apical pacing by three-dimensional echocardiography.

OBJECTIVE: Device lead-induced tricuspid regurgitation (LITR) mechanisms are well-defined by 3D transthoracic echocardiography (3D-TTE). There is a lack of data on the Latin-American population. The objective of this study was to describe the prevalence of several mechanisms and insights in patients with permanent right ventricular (RV) implanted devices by 3D-TTE examination. METHODS: We performed a cross-sectional analysis of 101 patients with permanent cardiac devices such as pacemakers or defibrillators. 3D-TTE was obtained on all patients in RV-focused apical views to perform a complete tricuspid valve (TV) evaluation: leaflets, subvalvular apparatus, precise lead location, and functional assessment to evaluate possible mechanisms of tricuspid regurgitation (TR). RESULTS: In a total of 101 patients, the leads did not interfere with TV function in 53 p. (59%), while LITR was observed in 38 (41%) patients. Adherent, impinging, entangled, and mixed lead-induced mechanisms were observed. Time in years since device implantation was significantly higher in patients with LITR. CONCLUSIONS: LITR was present in a high proportion of our population. LITR is the result of damage to the TV as well as its subvalvular apparatus due to the fibrotic and inflammatory response over time when leads are situated in unfavorable locations.

[Cardiac progression of systemic light chain amyloidosis]. / Progresión cardiaca de amiloidosis sistémica de cadera ligera.

Systemic light chain amyloidosis is a disease characterized by the accumulation of amyloid protein in multiple organs and systems. We present the case of a 52-year-old male patient with a diagnosis of systemic light chain amyloidosis associated with cardiac and renal involvement. A renal biopsy showed the presence of renal amyloidosis associated with proteinuria, and the patient was referred for cardiovascular evaluation. The baseline electrocardiogram showed micro voltage in frontal leads that were discordant with the left ventricular hypertrophy evidenced in the transthoracic echocardiogram (TTE). Cardiac magnetic resonance imaging (CMR) confirmed the presence of cardiac amyloid infiltration with a pattern of extensive ventricular late-gadolinium enhancement. Despite being referred and receiving specific systemic chemotherapy treatment, the evolution was not favorable after four months of follow-up with worsening cardiac infiltration, increasing values of biomarkers, and progression of dyspnea. The TTE was useful in revealing the unfavorable evolution and worsening of diastolic function parameters and increased wall thickness in the context of infiltration. The electrocardiogram and echocardiogram were easily accessible tools that allowed the monitoring of the response to treatment.

Cardiac Multimodality Imaging Assessment of Dystrophic Myocardial Calcification in a Human Immunodeficiency Virus-Infected Patient With Dilated Cardiomyopathy.

Dystrophic myocardial calcification represents the sequelae of local tissue damage and cellular necrosis. We present the case of a 72-year-old man who presented with exertional chest pain. He had a medical history of human immunodeficiency virus (HIV) infection and chronic dilated cardiomyopathy with severe left ventricular (LV) systolic dysfunction and wall motion abnormalities at the inferior and lateral LV walls. A cardiac magnetic resonance (CMR) examination from 16 years ago showed a subendocardial late gadolinium enhancement (LGE) distribution consistent with prior myocardial infarction (MI). Recently, a pharmacological stress myocardial perfusion imaging by CMR had been positive for myocardial ischemia in the left descending coronary artery (LAD) territory. A cardiac CT angiography (CCTA) showed non-significant LAD obstruction <50% consistent with microvascular ischemia and the presence of dystrophic myocardial calcification as an unusual progression of a prior MI. Conservative approach and optimal medical therapy were employed in our patient, and there was no symptom progression during the two-month follow-up period.

[Different phenotypes of mitral regurgitation in patients with right apical ventricular pacing: an echocardiographic approach in a heterogeneity of clinical scenarios]. / Distintos fenotipos de insuficiencia mitral en pacientes con estimulación apical del ventrículo derecho: un abordaje ecocardiográfico en una heterogeneidad de escenarios clínicos.

The presence of mitral regurgitation (MR) in patients with right ventricular apical pacing can be the result of multiple phenomena. On the one hand, this stimulation causes an asynchronous activation of the left ventricle (LV) and the papillary muscles, leading to a deterioration of the LV ejection fraction and causing an inadequate closure of the valve apparatus. However, there is a wide heterogeneity of ischemic and non-ischemic myocardial conditions that can coexist with mechanical alteration of the LV and the mitral valve leading to or worsening MR in these patients, which can make the etiological determination of valvular regurgitation difficult. Transthoracic echocardiography study allows comprehensive evaluation of mitral valve regurgitation and ventricular function parameters and mechanical asynchrony as a result of artificial pacing. The comprehensive study of these phenomena is relevant in clinical decision-making to define those patients who benefit from cardiac resynchronization therapy to alleviate symptomatic MR.

Cardiac Computed Tomography as an Alternative Technique in the Assessment of Acute Myocardial Ischemia in the Context of COVID-19 Infection.

Coronavirus disease 2019 (COVID-19) has been shown to result in coagulation abnormalities and predisposes patients to thrombotic status, both in the venous and arterial circulations. Herein, we report the case of a 60-year-old patient with COVID-19 pneumonia confirmed by polymerase chain reaction (PCR) who experienced signs and symptoms of myocardial ischemia. A cardiac computed tomography (CT) demonstrated an extensive coronary artery multivessel disease and ischemic dilated cardiomyopathy in a non-invasively approach allowing to define the coronary obstructive involvement in the acute stage of the disease.

Prolapse and regurgitation of the four heart valves in a patient with Ehlers-Danlos Syndrome: a case report.

BACKGROUND: The Ehlers-Danlos Syndrome (EDS) is part of a group of connective tissue diseases that affect the synthesis and processing of collagen leading to alterations in the structure of many tissues and organs. CASE SUMMARY: Herein, we reported a case of a patient with prolapse of the four cardiac valves. Non-significant regurgitation of the mitral, aortic, and tricuspid valves was observed. The pulmonary regurgitation (PR) was considered significant. Dilatation of the right ventricle with preserved systolic function was also noted. A cardiac magnetic resonance confirmed the findings of the echocardiogram and determined a severe PR (regurgitant fraction of 41%). The physical examination revealed hyperlaxity of the joints, skin hyperelasticity, defects in wound healing, and abdominal hernias suggesting EDS. The stress test did not develop any symptoms or complex arrhythmias. In this patient, the heart team initially decided medical treatment and evolutionary control. At the moment, he remains asymptomatic. DISCUSSION: Valvular involvement in EDS is an infrequent event and the compromise of the four cardiac valves is exceptional. The existence of severe PR with a marked increase in ventricular volumes, even in the absence of symptoms, in most cases requires an intervention on the valve. However, in patients with EDS, there are a high rate of complications and interventions should be avoided as much as possible.