Systemic hypertension counteracts potential benefits of growth hormone replacement therapy on left ventricular remodeling in adults with growth hormone deficiency.

BACKGROUND: Systemic Hypertension (SH) is the main cause of left ventricular (LV) hypertrophy in the general population, but only scanty data are available on LV geometric remodeling (LVGR) in hypertensive patients with GH deficiency (GHD). AIM: We investigated hypertensive LVGR in adult-onset GHD patients, before (T0) and after 55±16 months (T1) of individualized GH replacement therapy (GHRT). SUBJECTS: Fifty-one patients, aged 45±15 yr, 29 women, were enrolled. Fifteen patients met criteria for SH (group A) whereas 36 were normotensive (group B). METHODS: An echocardiogram was performed on all patients, at least twice (at T0 and T1). LV geometric remodeling as a relationship between LV mass (LVM) index and relative wall thickness (RWT), LV volumes, and ejection fraction were measured. RESULTS: At T0, group A showed higher LV mass and LVM index values than group B; LV hypertrophy was found in 40% and 22% of patients, respectively (p=0.06). At T1, IGF-I levels had increased significantly in both groups. LV hypertrophy rate consistently increased in group A (from 40 to 60%, p<0.05), whereas slightly decreased in group B (from 22 to 19%, ns). Body surface area (p<0.001), age (p<0.05), and systolic blood pressure (p<0.05) were main determinants of LVM at multivariate analysis. CONCLUSIONS: Along with body surface area and age, SH was significantly related to abnormal LVGR (LV hypertrophy) in GHD patients. As a result, blood pressure management and caloric intake restrictions are deemed necessary for this subset of patients.

Calcified disease of the mitral annulus: a spectrum of an evolving disease.

Mitral annulus calcification may appear under different forms depending from its evolution stage: mitral annulus calcification; homogeneous calcified mass of the mitral valve; liquefaction necrosis of the mass; reduction or stability of the mass dimension. We report a large calcified mass located in between the posterior mitral valve leaflet and adjacent left ventricular myocardium suggesting the homogeneous calcified phase of the disease.

Atrial lipomatous hypertrophy causing reduction in systemic venous return.

Lipomatous hypertrophy of the interatrial septum (LHIAS) is a benign condition characterized by an abnormal deposition of adipose tissue in the interatrial septum which appears as a pseudomass with a bilobed shape. We present the case of a 68-year-old obese female patient. LHIAS is an infrequent finding, but with recent improvements in imaging it is increasingly recognized. Cardiac MRI may prove useful in its diagnosis in terms of tissue characterization, as well as for the evaluation of disease extension and haemodynamic compromise.

Quadricuspid morphology of the aortic valve.

Quadricuspid aortic valve is a rare congenital heart defect. It may be isolated or associated to other cardiac anomalies. It may cause aortic valve dysfunction, commonly aortic regurgitation. Management of patients with quadricuspid aortic valve is represented by strict follow-up, because they may require aortic valve replacement in later life. We report the case of a 37-year old male patient, occasionally diagnosed to have quadricuspid aortic valve. Diagnosis and management are discussed.

Cardiac allograft vasculopathy : complications and imaging studies.

Cardiac allograft vasculopathy (CAV) is an accelerated form of coronary artery disease affecting both intramyocardial and epicardial coronary arteries and is observed in patients during long-term survival after cardiac transplantation. We report a case of CAV complicated with silent transmural myocardial infarction and massive left ventricular thrombus formation associated with silent pericarditis and with ischemic and non-ischemic scar tissue, as detected by cardiac magnetic resonance imaging (CMRI). The authors suggest CMRI as an additional technique along with echocardiography during follow-up of heart transplant recipients. CMRI may contribute to the early identification of areas of myocardial wall abnormalities suggestive of CAV, thus guiding diagnosis and prompt percutaneous treatment.

Prevalence of atrial septal aneurysm in patients with migraine: an echocardiographic study.

OBJECTIVE: To evaluate the prevalence of atrial septal aneurysm in patients with migraine. BACKGROUND: Migraine has long been considered a risk factor for stroke. Atrial septal aneurysm is often observed in young patients with ischemic stroke and is frequently associated with other conditions potentially leading to embolism. METHODS: We performed a transthoracic echocardiogram in 90 consecutive patients (65 women and 25 men; mean age, 35.3 years [standard deviation, 9]) with migraine but free from cerebral and cardiovascular disease and in 53 control subjects (37 women and 16 men; mean age, 34 years [standard deviation, 10]). The diagnosis of atrial septal aneurysm was performed according to Olivares-Reyes criteria. A transesophageal echocardiogram also was performed in 75 patients with migraine (83.3%). RESULTS: The prevalence of isolated atrial septal aneurysm was higher in patients with migraine with aura (28.5%) than in patients with migraine without aura (3.6%) (P <.005) or in control subjects (1.9%) (P <.005). CONCLUSIONS: Our data suggest a role of atrial septal aneurysm in the genesis of aura in patients with migraine.

[Thrombo-embolic risk evaluation in patients with atrial fibrillation. Role of echocardiography]. / Stratificazione del rischio tromboembolico nel paziente con fibrillazione atriale. Ruolo dell'ecocardiografia.

Atrial fibrillation (AF) is the most common observed cardiac arrhythmia and is the most frequent condition associated with thromboembolic events in patients with or without mitral valve disease. The source of cardiac emboli is the left atrium, the left atrial appendage or, less frequently, the left ventricle. Emboli may also originate from aortic atherosclerotic plaques. It is important to identify patients at risk in order to perform the appropriate therapy. Risk stratification is multiparametric, being based on clinical, laboratory, and echocardiographic data. Several trials have pointed out the role of echocardiography in the evaluation of anatomic and functional parameters associated with thromboembolic risk. Transthoracic echocardiography (TTE) does not provide sufficient information regarding posterior cardiac structures, being its sensitivity in detecting thrombi relatively low (33-72%). Transesophageal echocardiography (TEE) in contrast, has an almost 100% sensitivity; this technique is, therefore, mandatory in patients with AF for an adequate prevention of thromboembolism. The echocardiographic information joined with clinical features allow to stratify, in a proper way, the risk of every single patient.

Cardiovascular autonomic control in Becker muscular dystrophy.

Although autonomic symptoms are not prominent in dystrophinopathies, a reduced vagal activity and an enhanced sympathetic tone have been found in Duchenne muscular dystrophy. Twenty patients with Becker muscular dystrophy (BMD) were investigated by a battery of six cardiovascular autonomic tests (beat-to-beat variability during quiet breathing and deep breathing, heart rate responses to Valsalva maneuver and standing, blood pressure responses to standing and sustained handgrip) and power spectral analysis (PSA) of heart rate variability. Although 11 patients revealed abnormal findings at some cardiovascular tests, none of them had a definite autonomic damage, as indicated by two or more abnormal tests. The mean results of the single tests did not differ from normal controls, except for the beat-to-beat variability during quiet breathing, which was significantly higher in BMD (p<0.05). Such finding was confirmed by a significantly higher total variance (p<0.05), indicating an increased parasympathetic activity. Spectral components were not significantly different from normal controls. PSA values were not influenced by age, functional ability score or presence of heart abnormalities. Our data suggest that autonomic involvement does not represent a major finding in BMD.

[Reversal left diastolic ventriculo-atrial flow induced by asynchronism in a patient with dilated cardiopathy and VVI pacemaker]. / Reflusso diastolico ventricolo-atriale sinistro indotto dall'asincronismo atrio-ventricolare in paziente con cardiopatia dilatativa portatore di pacemaker VVI.

We studied a case of reversal atrioventricular diastolic flow in a 74-year-old patient suffering from chronic heart failure for six years, following double myocardial infarction on the inferior (in 1985) and the anterior wall (in 1992). During his last hospitalization, he had an arrhythmic complication (advanced atrioventricular block) that required a definitive implantation of a VVI-pacemaker. The patient, a working man in good hemodynamic condition over the past several years, acknowledged symptoms of progressive functional decline three to six months prior to coming to our observation for a medical check-up. The surface electrocardiogram showed normal electrical PM activity. Echo-Doppler examination beyond the improved systolic function of left ventricle showed a variable E/A velocity ratio of mitral valve flow, due to the casual relationship between spontaneous atrial electrical activity and ventricular stimulation. In addition, at the surface ECG we frequently observed a retrograde atrioventricular flow during mean phase of diastole each time the P wave occurred at the end of T wave. This event did not occur when the T-P interval was longer (a few more milliseconds) and was thus similar to a normal atrioventricular ECG sequence. To summarize, we can affirm that in patients with dilated cardiomyopathy and improved systolic function requiring pacemaker implantation, the sequential mode of ventricular stimulation must be preferred, especially if there is normal electrical activity in the right atrium.

Longitudinal dissociation within the reentry pathway of ventricular tachycardia.

Two cases of nonsustained, repetitive ventricular tachycardia are analyzed. In both, the episodes of tachycardia do not contain random numbers of beats, but the complexes in each phase of tachycardia are either always in even numbers (case 1) or always in odd numbers (case 2). This indicates longitudinal dissociation within the reentry circuit: i.e., there are two functionally separate pathways in some part of the reentry circuit, and the reciprocating impulse runs alternatively through the two pathways. Tachycardia ends due to block of the impulse always in the same pathway, thus, the number of beats in each episode of tachycardia is always either in odd or even numbers.

Parasystolic ventricular tachycardia with variable exit block.

This case is an example of ventricular parasystolic tachycardia associated with variable expressions of ectopic-ventricular (E-V) exit block. The exit block manifested with 2:1, 3:2, 4:3 and higher ratios of E-V conductions, interspaced with periods of 1:1 conduction. Concealed E-V conduction of the ectopic impulse could also be deduced.