Usefulness of speckle myocardial imaging modalities for differential diagnosis of left ventricular non-compaction of the myocardium.

BACKGROUND/OBJECTIVES: Current diagnostic criteria for left ventricular non-compaction (LVNC) may result in over-diagnosis of the disease. We evaluate the role of speckle imaging in differential diagnosis of LVNC. METHODS AND RESULTS: We included all patients who, between January 2012 and May 2015, fulfilled currently accepted criteria for LVNC (28 patients). A control group of 28 healthy individuals and a third group of 13 patients with dilated cardiomyopathy (DCM) were created. Speckle-tracking echocardiography was performed in all groups. Thirteen patients with LVNC had an ejection fraction (EF) <50% (33.5%, SD 10). When compared to controls, patients with LVNC and EF<50% had a larger LV, larger left atrial diameter (LA), reduced e', and reduced global longitudinal strain (GLS). All but one patient with LVNC and EF<50% showed an abnormal LV rotation. This abnormal pattern was observed in 4 LVNC patients (27%) with EF≥50% and in none of the controls. In patients with LVNC, EF ≥50%, and abnormal rotation, GLS was lower than in controls, (-17 (SD 3) vs -21 (SD 3)). Rigid body rotation (RBR) was also observed in 2 DCM patients, with significant differences in EF, GLS, LV diameters relative to the rest of the DCM group. CONCLUSIONS: In patients who fulfil the morphologic criteria for LVNC, speckle myocardial imaging techniques could be useful in differentiating between healthy individuals (functionally normal LV) and patients with LVNC (with functional abnormalities in the myocardium in spite of a preserved EF).

Multicystic/cavitated giant left atrial myxomas: a matter of technology?

We present the case of a rare echocardiographic image of a giant cavitated myxoma and the pathologic findings of the cystic mass. The new echocardiographic equipment not only has improved the sensitivity for diagnosis of different pathologies but also has redefined its visual and morphologic characteristics. Although most myxomas are solid masses and some cystic myxomas have been reported, the presence of multiple cavities on echocardiographic exam has exceptionally been described. While cystic changes have been described at autopsy in 14% of cardiac myxomas, its identification with echocardiography is rare. Nowadays, the new echocardiographic equipment has improved the quality and the accuracy to detect and describe intracardiac masses, showing myxomas with cystic cavities in vivo that in the past was a pathologic finding.

Multicavitated left atrial myxoma mimicking a hydatid cyst.

A 67 year-old asymptomatic patient was referred to our echo-lab because of hypertension. Transthoracic 2D-echocardiogram showed a non-prolapsing ovoid mass attached to the left side of the interatrial septum. Transesophageal echocardiography evidenced an ovoid cavitated mass with internal areas of calcification. Color Doppler revealed flow inside the cavities. At surgery, a multicavitated mass was observed attached to interatrial septum. Macroscopically revealed cavities filled with blood, as well as partially calcified areas. Microscopically there were collections of "lipidic" cells embedded in the myxoid matrix, typical of cardiac myxoma. Cardiac hydatid cysts usually have a rounded shape. Most myxomas are solid masses without a cystic architecture or cavitations. Calcification is usually identified at a microscopic level. The combination of a polycystic appearance of the mass and macroscopic areas of calcification is more frequently observed in hydatid cysts than in cardiac myxomas. This appearance of the mass leads us to consider a cardiac echinococcal cyst as the first diagnostic possibility. This peculiar structure of cardiac myxoma, to the best of our knowledge, has never been documented. Transthoracic echocardiography and particularly transesophageal imaging, enable us to delineate this kind of tumors. Surgical resection is the appropriate treatment for these tumors, even in asymptomatic patients.

Incomplete myocardial rupture after coronary embolism of an isolated single coronary artery.

An 82-year-old female was admitted to the coronary care unit with an anterior wall myocardial infarction and cardiogenic shock. She was in chronic atrial fibrillation without oral anticoagulation. Coronary angiography showed occlusion of the left main coronary artery which originated together with a normal right coronary artery from the right sinus of Valsalva. The advanced age, the presence of chronic atrial fibrillation not anticoagulated and the normal appearance of the remaining coronary arteries suggested a thromboembolic origin. Transthoracic echocardiography showed an abrupt interruption of the myocardial wall, in the apical portion of the interventricular septum, not communicating with the pericardial sac or right ventricular cavity suggesting the presence of an incomplete contained rupture of the myocardial wall at this location. She died in cardiogenic shock due to the extensive left ventricular damage.

Cardiac granulocytic sarcoma (chloroma): in vivo diagnosis with transesophageal echocardiography.

Granulocytic sarcoma, or chloroma, is an uncommon presentation of acute leukemia. Cardiac involvement is very rare and usually diagnosed at autopsy. We present a case that discloses the essential role of transesophageal echocardiography for its in vivo diagnosis. The principal features with this imaging technique are finely described.

[Tako-tsubo syndrome associated with a long course of the left anterior descending coronary artery along the apical diaphragmatic surface of the left ventricle]. / Asociación del síndrome take-tsubo con la arteria coronaria descendente anterior con extensa distribución por el segmento diafragmático.

INTRODUCTION AND OBJECTIVES: Tako-tsubo-like transient left ventricular apical ballooning has been described in Japan, but few cases have been reported in Western countries. We report one of the first series outside Japan, which provides new information on the coronary anatomy of this disorder. PATIENTS AND METHODS: From January 1998 to February 2003 we observed 11 patients with a clinical suspicion of acute myocardial infarction, normal coronary arteries, and transient tako-tsubo-like systolic left ventricular apical ballooning. We compared the coronary artery anatomy in these 11 patients with that in 44 controls matched for age and sex: 22 with normal coronary arteries and 22 with acute myocardial infarction related with an obstructive thrombus in the left anterior descending coronary artery. RESULTS: As in Japanese patients, tako-tsubo syndrome in Caucasian patients frequently occurs in women in their seventh or eighth decades of life, and is usually preceded by emotional or physical stress. The left anterior descending in our patients with tako-tsubo syndrome was longer overall, and its recurrent diaphragmatic segment was longer, than in controls. To compare these groups we designed a measure termed recurrent segment index (left anterior descending recurrent segment length/total left anterior descending length x 100). In tako-tsubo syndrome this index was 22.3 (1.5)%, vs 10.9 (6.7)% in normal controls (P<.001), and 11.3 (7.7)% in acute myocardial infarction patients (P<.001). Patients with acute myocardial infarction and a high recurrent segment index (> or =16%) had ventriculographic findings of systolic apical ballooning identical to those in patients with tako-tsubo syndrome. CONCLUSIONS: All our patients with tako-tsubo syndrome had a left anterior descending with a long recurrent segment. The identical ventriculographic findings in patients with tako-tsubo syndrome and those with acute myocardial infarction with a long recurrent segment may be due to a common etiology.

Prosthetic valve endocarditis due to Listeria monocytogenes. Report of two cases and reviews.

INTRODUCTION: Endocarditis due to Listeria monocytogenes is a rare but serious disease often leading to valve dysfunction and heart failure. Two cases of listerial prosthetic valve endocarditis are reviewed along with 66 cases previously reported. RESULTS: The mean age of patients with listerial endocarditis increased from 47.1 years in the decades from 1955-1984 to 65.5 years from 1985-2000. Chronic debilitating diseases, solid tumours and immunosuppression associated with organ transplantation, hematologic neoplasia or AIDS were found in 41.1% of cases. Listerial endocarditis was a vegetative and destructive process, with dehiscense of the prosthesis and occasionally, abscess formation, fistulization and pericarditis. Treatment with penicillin or ampicillin alone or combined with gentamicin was adequate therapy in most cases. Vancomycin together with gentamicin may be a reasonable alternative therapy. CONCLUSIONS: Despite problems associated with microbial persistence and relapses in other forms of human listeriosis, antimicrobial therapy alone may be a successful treatment for listerial endocarditis, including cases occurring on prosthetic valves. Valve replacement may be reserved for complicated cases with valve dehiscense, cardiac failure or myocardial abscess. Overall mortality was 35.3%, although most patients who died did so before 1985 and since then mortality has been significantly reduced to 12%.