Thymoma - diagnostics options.

Various types of tumors (either benign or malignant) can be found in mediastinum. Early diagnosis and treatment may help to improve survival and quality if life in these patients. Compared to direct mediastinoscopy, used for obtaining a specimen for histological analysis in previous decades, modern imaging methods, specifically the CT navigated biopsy, represent an effective and less invasive approach to the diagnosis. In our publication, we present a patient with thymoma, rather rare type of anterior mediastinum tumor.

Cardiac resynchronisation therapy optimisation of interventricular delay by the systolic dyssynchrony index: A comparative, randomised, 12-month follow-up study.

BACKGROUND: The aim of our study was to compare the effect of interventricular (VV) delay optimisation in CRT recipients on the basis of systolic dyssynchrony index (SDI) derived from the three-dimensional echocardiography (3DE) versus QRS width assessment on left ventricle volume reduction at the 12-month follow-up. METHODS: We included 63 patients with recently implanted CRT in this randomised, open-label trial. Patients were randomised to VV delay optimisation according to QRS complex width measurement in group 1 (n = 31) to obtain the narrowest QRS complex and SDI in group 2 (n = 32) to achieve its lowest possible value. We evaluated left ventricular end-systolic volume (LVESv), left ventricular ejection fraction (LVEF) and SDI by 3DE before CRT implantation and at a 12-month follow-up in all the patients. We also obtained the New York Heart Association functional class, the 6-minute walk test, the quality of life questionnaire and the level of NT-proBNP. RESULTS: The number of volumetric responders was similar in both groups (17 vs. 20, P = 0.786). There were also no significant differences in the reduction of LVESv (-41 ± 55 mL vs. - 61 ± 51 mL, P = 0.111), improvement in LVEF (+10.1 ± 10.6% vs. + 13.0 ± 9.9%, P = 0.213) or differences in clinical outcomes between both groups at the 12-month follow-up. CONCLUSION: CRT optimisation of interventricular delay using SDI compared with QRS width assessment did not reveal any significant difference in terms of volumetric and clinical response at the 12-month follow-up.

Real time 3-dimensional transesophageal echocardiography is more specific than 2-dimensional TEE in the assessment of left atrial appendage thrombosis.

BACKGROUND: In patients indicated for detection of intraatrial thrombus (T), 2-dimensional transesophageal echocardiography (2DTEE) is routinely used but differentiation between T and trabeculae or artifacts in the left atrial appendage (LAA) is often difficult. AIMS: To compare the diagnostic value of real time 3D-transesophageal echocardiography (RT3DTEE) and 2DTEE in the assessment of LAA thrombosis. PATIENTS AND METHODS: One hundred and ten consecutive patients (73M, aged 64+-13) were examined by 2DTEE. In terms of possible T, individual pts were diagnosed as negative (N2), uncertain trabecular finding (U2), other/artifacts (O2), and clearly positive (T2). The RT3DTEE was then applied and the categorization repeated (N3,U3,O3 and T3, resp.). Finally, the operator decided whether the RT3DTEE. A: had an additional diagnostic value, and/or B: changed the definite diagnosis of thrombosis. RESULTS: N2:71; U2:17; O2:19; T2:3; N3:97; U3:1; O3:12; T3:0. Ad A/ RT3DTEE enabled us to refine or change the diagnosis in 26/110 cases. 17 pts were switched from group U2 to N3, 7:O2-N3 and 2:T2-N3. 12 pts from O2 and 1 pt from T2 remained unclarified. Ad B/ Diagnoses were changed in 6 patients after RT3DTEE. A very suspicious T2 was found in 3 patients. In 1, the finding was requalified definitely as musculi pectinati. In the second patient, the finding was re-categorized as just a spontaneous echocontrast without T. In another 4 patients, T in LAA was definitely excluded after RT3DTEE (1 patient switched from U2 to N3, 3 from O2 to N3). In another 13, the findings remained unclear, mostly because of poor quality image. No real thrombus was found in this study. CONCLUSION: RT3DTEE provides additional information, which may be helpful in the differentiation of thrombus from other findings. It is particularly useful in the identification of muscular trabeculae in the left atrial appendage.

Prolonged burst as a new method for cardioverter-defibrillator testing.

AIM: To find out whether it is possible to anaesthetize patients safely without analgesia and sedation, using burst pacing prolonged until the patient becomes unconscious. METHODS: One hundred and four patients undergoing implantation or reimplantation of a cardioverter-defibrillator were included. Patients randomized into Group B underwent prolonged burst pacing without analgesia and sedation. Patients in Group T underwent a T-wave shock under analgesia and sedation. Blood samples for measurement of serum neuron-specific enolase were taken before surgery and 6, 24, and 48 h after the procedure. RESULTS: From the 104 patients, 51 were randomly assigned to Group B and 53 to Group T. Four patients from Group B were switched to Group T (ventricular fibrillation not induced by burst pacing). The clinical characteristics of both groups were similar. The mean total time of cardiac arrest was significantly longer in Group B (23.0 ± 4.4 s, median 22.7) vs. Group T (10.3 ± 3.0 s, median 10.0), P < 0.0001 (Mann-Whitney U-test). The effectiveness of both induction methods was similar (92.1% in Group B and 100% in Group T). The mean neuron-specific enolase levels after 6, 24, and 48 h were similar in Groups B and T (13.1 ± 6.3 and 11.6 ± 5.8 mg/L, 14.5 ± 7.5 and 13.4 ± 6.0 mg/L, and 14.9 ± 5.9 and 12.2 ± 6.0 mg/L, respectively) as were these levels compared with baseline neuron-specificenolase levels (14.0 ± 5.9 and 13.4 ± 4.0 mg/L, respectively), P = NS for all. CONCLUSION: Despite a longer time of total cardiac arrest, prolonged burst pacing appears to be a safe and effective method for induction of ventricular fibrillation during cardioverter-defibrillator testing, which enables omission of analgesia and sedation or general anaesthesia.

Prediction of long-term reverse left ventricular remodeling after revascularization or medical treatment in patients with ischemic cardiomyopathy: a comparative study between SPECT and MRI.

Patients with ischemic heart disease and depressed left ventricular (LV) ejection fraction (LVEF) develop varying degrees of LV remodeling after cardiac surgical revascularization. Fifty-three patients with stable ischemic heart disease and impaired LV function (LVEF 34.9 ± 4%) were prospectively followed up for 24 months. Thirty-seven patients underwent coronary artery bypass grafting (CABG), 16 patients were treated conservatively. Cardiac magnetic resonance imaging (MRI) and SPECT were performed at baseline and after 12 and 24 months of follow-up. The patients were divided into responders and non-responders depending on the degree of LVEF improvement at 24 months follow-up (>5%-responders). MRI with ≤5 segments with DE/wall thickness ratio (DEWTR) ≥50% predicted LV reverse remodeling with a sensitivity of 86% and a specificity of 75% (AUC 0.81). An MRI finding of ≤2 segments with the DEWTR ≥75% had a corresponding sensitivity of 71% and specificity of 67% (AUC 0.75) while fixed perfusion defect on SPECT <16.5% of LV predicted reverse remodeling with a sensitivity of 64% and a specificity of 69% (AUC 0.64). A preoperative number of segments with the DE/wall thickness ratio of ≥50 and ≥75% obtained by MRI, was found to be a better predictor of left ventricular reverse remodeling than fixed perfusion defect by SPECT. No other MRI or SPECT parameter predicted LVEF improvement at 24 months after CABG.

The prevalence of eustachian valve on transoesophageal echo examination.

BACKGROUND: The Eustachian valve (EV) is an embryonic structure redirecting the blood flow from the inferior vena cava through the foramen ovale. It may persist in adults as a floating membrane in the right atrium. A large EV can be associated with thrombosis, embolization, bacterial endocarditis, etc. The prevalence of EV in the normal population is unknown. AIM: to assess the prevalence and size of EV in unselected patients examined by transoesophageal echo. Methods. 1100 consecutive patients were examined for various reasons by a single operator and interpreter. Routine check was made for the presence of EV in the right atrium. Only patients with a mobile EV and not with a simple rigid rim were counted. Three measurements of the EV length at the level of the aortic valve (i.e. 90°C) were made off-line and the longest distance considered. If the EV was not visualized and recorded as a straight line because of its chaotic movement, the picture of the valve was segmented into several separated valve portions and the sum taken as the true length. RESULTS: 46 patients (24 males) with EV were identified out of total 1100 pts examined. The average length of the EV was 23.6 ± 9.7 mm (7-47 mm, median 23 mm). CONCLUSIONS: The finding of a persisting Eustachian valve on transoesophageal echo examination is not rare. The prevalence was similar in men and in women. Bearing in mind the possible complications associated with a large valve, we recommend that a proper description of persistent EV is included in routine transoesophageal echo reports.

[Correlation of intracardiac pressures and electrical atrial potentials with morphology and function of overloaded atria assessed by echocardiography]. / Korelace intraatriálních elektrických potenciálu a tlaku s morfologickými a funkcními ukazateli pretízených síní stanovenými echokardiografií.

BACKGROUND: In patients with chronic complete heart block or single chamber pacing and preserved sinus depolarization, left and right atria (LA, RA) may suffer from increased intraatrial pressure resulting from atrioventricular dyssynchrony (AVDys), dilate and lose their contractile function. The purpose of the study was to find out whether any correlation exists between the echocardiographically measured LA, RA morphological and functional parameters on one hand and the intracardiac RA pressures and electrical potentials on the other hand in patients with chronic AVDys. METHODS: In 26 pts (77 +/- 10 years, 16 males), where a chronic AVDys was the most important patophysiological mechanism of atrial overloading, the intraatrial pressures (atrial, right ventricular, pulmonary arterial and wedge pressure/PWP/) and electrical potentials (upper, middle, lower part of RA and RA appendage) were correlated with atrial diameters, volumes, ejection fraction and filling parameters. RESULTS: There was a moderate inverse correlation between the LA ejection fraction and PWP: r = -0,489, p = 0,025 at a level of significance 0.05, but no relationship between PWP and LA size/volumes. No correlation between RA potentials or intracardiac pressures and RA morphologic or functional features were documented. CONCLUSIONS: In this study, an inverse correlation between the capillary wedge pressure and left atrial ejection fraction in pts with chronic atrioventricular dyssynchrony was documented. No other correlation between echocardiographic parameters and intracardiac pressures or electrical potentials was found.

Acute aortic dissection complicated by fistula from aorta to right ventricle through ventricular septum.

A case report of aortic dissection (AoD) complicated by a shunt to the right ventricle is presented. Complications, treatment options, and survival of patients with Type A and Type B AoD are reviewed.

The effects of candesartan on left ventricular hypertrophy and function in nonobstructive hypertrophic cardiomyopathy: a pilot, randomized study.

Hypertrophic cardiomyopathy is caused by mutations in the genes that encode sarcomeric proteins and is primarily characterized by unexplained left ventricular hypertrophy, impaired cardiac function, reduced exercise tolerance, and a relatively high incidence of sudden cardiac death, especially in the young. The extent of left ventricular hypertrophy is one of the major determinants of disease prognosis. Angiotensin II has trophic effects on the heart and plays an important role in the development of myocardial hypertrophy. Here in a double-blind, placebo-controlled, randomized study, we show that the long-term administration of the angiotensin II type 1 receptor antagonist candesartan in patients with hypertrophic cardiomyopathy was associated with the significant regression of left ventricular hypertrophy, improvement of left ventricular function, and exercise tolerance. The magnitude of the treatment effect was dependent on specific sarcomeric protein gene mutations that had the greatest responses on the carriers of ss-myosin heavy chain and cardiac myosin binding protein C gene mutations. These data indicate that modulating the role of angiotensin II in the development of hypertrophy is specific with respect to both the affected sarcomeric protein gene and the affected codon within that gene. Thus, angiotensin II type 1 receptor blockade has the potential to attenuate myocardial hypertrophy and may, therefore, provide a new treatment option to prevent sudden cardiac death in patients with hypertrophic cardiomyopathy.

Mistakes in dealing with aortic dissection. Lessons from three warning cases.

BACKGROUND: Aortic dissection is a dangerous condition with a high mortality in the acute stage. Aortic dissection requires early diagnosis and treatment. METHODS AND RESULTS: This short review discusses and focuses on known complications of aortic dissection and its natural mortality applying data from already published reports and from cohorts and registers, especially IRAD. Survival data of patients with type A and type B of dissection are presented and treatment options are proposed. The review presents three interesting cases from our database pointing out mistakes made in the diagnostic process and in dealing with the patient even after establishing the correct diagnosis. In one case, a patient with chest pain + "immeasurable" BP was suspected to suffer from an acute myocardial infarction and cardiogenic shock instead of AoD + aortic branch obstruction. In another patient with chest pain + V1V2 ST elevation, again the acute coronary syndrome was suspected. In fact, AoD with a perforation to cardiac chambers through the interventricular septum was the explanation. In the third case, the correct diagnosis of AoD was established. This patient was at a significant risk of aortic rupture because of his uncontrolled blood pressure. Instead of sedation administration and effective BP lowering, the patient was stressed even more by detailed information about this life threatening disease. This led to an aortic rupture with cardiac tamponade. Other mistakes made when dealing with all these presented cases are also discussed. CONCLUSION: The high mortality in patients suffering from aortic dissection is often potentiated by misdiagnosing and mishandling of these patients in clinical scenario.

Incidence of pericardial effusion in females stimulated in "in vitro fertilization" program.

AIMS: To evaluate the incidence of pericardial irritation in females after hormonal stimulation in in vitro fertilization program, and to set its clinical significance as a symptom of ovarian hyperstimulation syndrome (OHSS). PATIENTS: Thirty-nine females, aged 30 +/- 5 years (20-46), with a normal echo finding prior to hormonal stimulation. METHODS: Serial echocardiography: baseline A, in hCG application B, embryo-transfer C. RESULTS: Thirty-nine, 39, and 35 echocardiography examinations were done on A, B, and C respectively. On B, in 7 (17.9%) of 39 patients either new pericardial effusion "1," increased pericardial echogenicity "2," or both "3" were detected (4 patients, 2 patients, and 1 patient, i.e., 10.3%, 5.1%, and 2.6% respectively.). On C, in 8 of 35 patients (22.8 %) abnormalities were detected: "1" in 2 patients (5.7 %), "2" in 1 patient (2.9 %), and "3" in 5 patients (14.2 %). No clinical symptoms related to these findings were present. No OHSS occurred in these patients. On the contrary, clinical OHSS developed later in 2 patients, classified as medium degree (1 patient) and severe degree (1 patient)-both patients had negative echo during follow-up. CONCLUSION: Echocardiographic signs of mild pericardial irritation may appear also in patients with no clinical signs of OHSS. The incidence of these changes increases during stimulation procedure. Development of OHSS may not be preceded by the incidence of these warning signs. Consequently, routine echocardiographic examination during stimulation is not indicated, since significant pericardial effusion is rather a late sign of OHSS.

Unusual cause of femorofemoral cardiopulmonary bypass failure.

A case of femorofemoral cardiopulmonary bypass failure in a patient undergoing an emergent operation because of acute aortic dissection is described. The importance of the accurate deduction of preoperative transesophageal echocardiography findings is emphasized.

Acute severe mitral regurgitation with cardiogenic shock caused by two-step complete anterior papillary muscle rupture during acute myocardial infarction.

BACKGROUND: Rupture of a papillary muscle is an infrequent but often fatal mechanical complication of acute myocardial infarction. AIM: The aim of this paper is to present a case report of a 65-year old women with acute severe mitral regurgitation with cardiogenic shock caused by two-step complete anterior papillary muscle rupture during acute myocardial infarction. The transthoracic echocardiography was obtained at the bedside and showed a posterior mitral valve prolapse with a severe mitral regurgitation. During this examination the patient developed acute pulmonary oedema and a consequent cardiogenic shock. Transthoracic echocardiography was then reevaluated and completed. New findings of bi-leaflet mitral flail and progression of massive mitral regurgitation were documented. The complete rupture of a papilary muscle was then considered as a cause of an acute clinical deterioration. Intraoperative findings showed a complete transection of both heads of anterolateral and necrotic regions of basis of posteromedial papillary muscle. CONCLUSIONS: This case confirms the importance of immediate echocardiography in confirming a diagnosis of acute mechanical complications of acute coronary syndromes and this examination is important for the management of a hemodynamically unstable patient. Echocardiography should be done immediately on any patient in whom the diagnosis of mechanical complication of acute coronary syndromes is suspected.

Dramatically improved left ventricular function after biventricular pacemaker implantation--a case report.

A case study of a patient suffering from severe chronic congestive heart failure resulting from ischemic cardiomyopathy in whom a biventricular (BiV) pacing system was implanted is reported. After a 1-year follow-up, left ventricular (LV) ejection fraction improved dramatically from an initial 15% to 60%, left ventricular end-diastolic diameter decreased, as did left atrial dimension. Tissue Doppler data and acute hemodynamic measurements taken during the biventricular pacemaker implantation procedure are presented. The case represents an exceptional example of left ventricular reverse remodeling with practically normalized left ventricular function after 1 year of synchronized pacing.