Role of Cardiac Magnetic Resonance Imaging and Troponin T in Definitive Diagnosis of Myocardial Infarction With Nonobstructive Coronary Arteries (MINOCA).

BACKGROUND: It is unknown whether the degree of high-sensitivity troponin T (hsTropT) elevation in patients with suspected myocardial infarction without obstructive coronary arteries (MINOCA) presentations can help predict the likelihood of an abnormal cardiac magnetic resonance (CMR) scan. In this study we describe the diagnostic utility of CMR in patients with MINOCA and assesses the effect of peak hsTropT levels at presentation on CMR diagnostic yield. METHODS: Records of consecutive patients (n = 1407) referred for CMR at a tertiary referral hospital between January 2016 and September 2021 were reviewed. A total of 70 patients met the criteria of MINOCA including ischemic chest pain, elevated peak hsTropT, and nonobstructive coronary artery disease (< 50% stenosis). The peak hsTropT levels within 72 hours of admission were identified. CMR images were generated using a 3.0 T Siemens scanner. Predictors of having an abnormal CMR were evaluated. RESULTS: CMR established a diagnosis in 71% (n = 50) of patients, with the most common CMR diagnosis being myopericarditis (n = 27; 39%). Time to CMR was an independent predictor of a normal CMR scan (odds ratio, 0.98; 95% confidence interval, 0.97-0.999). Peak hsTropT had a high diagnostic accuracy for identifying patients with an abnormal CMR scan (area under the receiver operator characteristic curve, 0.81; P < 0.001). The optimal hsTropT cutoff was 166 ng/L, with 72% sensitivity and specificity. A troponin value ≥ 166 ng/L was independently predictive of an abnormal CMR scan (odds ratio, 4.76; 95% confidence interval, 1.32-17.11). CONCLUSIONS: HsTropT and early CMR imaging are independently predictive of an abnormal CMR scan in patients with MINOCA. Additionally, the use of a hsTropT cutoff provides incremental predictive value to clinical parameters and time to CMR scanning in determining an abnormal scan.

A Caseating Tricuspid Mass in an Adult With Eisenmenger Syndrome Secondary to Aorto-Pulmonary Window.

We present the case of a 55-year old Caucasian man with Eisenmenger syndrome secondary to uncorrected aorto-pulmonary window, whose clinical course has been complicated by recurrent cerebral abscesses and dynamic tricuspid annular caseation with probable pulmonary embolization. (Level of Difficulty: Intermediate.).

Multivessel Giant Coronary Artery Aneurysms Incidentally Demonstrated During Angiography for Acute Myocardial Infarction.

Giant coronary artery aneurysms are a rare manifestation of coronary artery disease and are defined by an aneurysmal diameter of >20 mm. Multimodal invasive and noninvasive imaging is required for accurate assessment We describe a case of multivessel giant coronary artery aneurysms noted during angiography for myocardial infarction. (Level of Difficulty: Intermediate.).

Cardiac manifestations of IgG4-related disease: a case series.

Background: IgG4-related disease (IgG4-RD) is an autoimmune condition affecting almost every organ system, with an early inflammatory phase and later fibrotic consequences. Vascular manifestations, particularly, large-vessel involvement in IgG4-RD, are well described. However, important IgG4-related effects on medium-sized arteries and the pericardium are less well recognized. These less frequently reported cardiovascular effects of IgG4-RD include coronary artery stenosis, pericardial disease, cardiac masses, and valvular heart disease. Case summary: This case series focuses on three patients that demonstrate the cardiovascular effects of IgG4-RD and the pitfalls and importance of early diagnosis. Cases 1 and 2 presented with cardiac manifestations prior to more typical organ systems being affected which led to a delay in diagnosis. Case 1 presented with an acute myocardial infarction secondary to IgG4-RD of the coronary arteries and Case 2 presented with pericarditis which progressed to pericardial constriction due to IgG4-RD. Case 3 already had a diagnosis of IgG4-RD from a prior renal biopsy which raised the index of suspicion that his pericardial disease and thoracic mass were also related to IgG4-RD. Discussion: Cardiac manifestations of IgG4-RD remain under-recognized and include coronary artery and pericardial disease. These manifestations often precede more typical manifestations in other organ systems. Recognizing cardiac manifestations of IgG4-RD on cardiac imaging can raise clinical suspicion and act as a catalyst to ascertain a confirmatory diagnosis. Early diagnosis and treatment are crucial to prevent potentially fatal outcomes and irreversible fibrosis.

Case report: A patient with transient sigmoid septum in takotsubo syndrome with left ventricular outflow tract obstruction.

Left ventricular outflow tract obstruction is now recognized as a common complication of takotsubo syndrome, resulting in more serious acute and long-term outcomes. We describe a case of takotsubo syndrome where a transient sigmoid septum produced left ventricular outflow obstruction and explore the mechanisms leading to this occurring. This phenomenon has not been previously described. .

Incidentally identified coronary artery calcium on non-contrast CT scan of the chest predicts major adverse cardiac events among hospital inpatients.

BACKGROUND: Coronary artery calcium (CAC) identified on non-gated CT scan of the chest is predictive of major adverse cardiac events (MACE) in multiple studies with guidelines therefore recommending the routine reporting of incidental CAC. These studies have been limited however to the outpatient setting. We aimed to determine the prognostic utility of incidentally identified CAC on CT scan of the chest among hospital inpatients. METHODS AND RESULTS: Consecutive patients (n=740) referred for inpatient non-contrast CT scan of the chest at a tertiary referral hospital (January 2011 to March 2017) were included (n=280) if they had no known history of coronary artery disease, active malignancy or died within 30 days of admission. Scans were assessed for the presence of CAC by visual assessment and quantified by Agatston scoring. Median age was 69 years (IQR: 54-82) and 51% were male with a median CAC score of 7 (IQR 0-205). MACE occurred in 140 (50%) patients at 3.5 years median follow-up including 98 deaths. Half of all events occurred within 18 months. Visible CAC was associated with increased MACE (HR) 6.0 (95% CI: 3.7 to 9.7) compared with patients with no visible CAC. This finding persisted after adjusting for cardiovascular risk factors HR 2.4 (95% CI: 1.3 to 4.3) and with both absolute CAC score and CAC score ≥50th percentile. CONCLUSION: Incidental CAC identified on CT scan of the chest among hospital inpatients provides prognostic information that is independent of cardiovascular risk factors. These patients may benefit from aggressive risk factor modification given the high event rate in the short term.

Haemoptysis: just another case of endocarditis? A case report.

BACKGROUND: Pulmonary arteriovenous malformations (PAVM) are rare, and most cases are congenital. They require prompt recognition and management particularly in patients presenting with hypoxia and haemoptysis. We describe a unique case of recurrent endocarditis causing pulmonary artery aneurysms (PAAs) and formation of PAVM. CASE SUMMARY: A 60-year-old woman presented with dyspnoea, haemoptysis, and severe hypoxia. Her background was significant for previous pacemaker lead infection, refractory heart failure secondary to severe tricuspid valve distortion by her pacemaker lead, tricuspid and mitral valve replacements complicated by recurrent endocarditis over several years. Two years prior to her current presentation computed tomography (CT) scanning revealed new small PAAs thought possibly to be mycotic in origin. After her current presentation, prompt high-resolution CT scanning of her chest with contrast revealed significant pulmonary haemorrhage and new clusters of PAVM. Urgent pulmonary angiography confirmed PAVM and was successfully treated with coil embolization. Her dyspnoea, pulmonary haemorrhage, and hypoxia resolved. DISCUSSION: Acquired causes account for a very small percentage of PAVM and the mechanism of their development is unknown. As she had recurrent right-sided endocarditis and her PAAs developed following this, with new PAVM developing 2 years later; we hypothesize that they were causally related. We believe this is the first case of recurrent left- and right-sided endocarditis leading to formation of PAAs and development of PAVM presenting with significant hypoxia and haemoptysis requiring prompt intervention.

Massive Right Heart Thrombus Causing Complete Cardiac Obstruction Relieved by Thrombolysis: A Case Report.

BACKGROUND: Right heart thrombus (RHT) is a medical condition associated with acute pulmonary embolism and congestive cardiac failure. Rapid recognition is essential for instituting early treatment and preventing adverse outcomes. CASE SUMMARY: A 55-year-old male presented with symptoms of congestive cardiac failure complicated by cardiac arrest. Initial transthoracic echocardiography (TTE) demonstrated moderate impairment of both ventricles and a moderately dilated right ventricle (RV). After initial improvement with heart failure treatment, the patient subsequently had a second cardiac arrest. Bedside TTE revealed complete RV obstruction by thrombus, and intravenous thrombolysis was immediately instituted, with complete dissolution of the thrombus and haemodynamic recovery 15 minutes after treatment. Unfortunately, the patient suffered significant hypoxic brain injury and did not survive. DISCUSSION: RHT can manifest acutely in a dramatic fashion with cardiac arrest. Bedside TTE is key to making a rapid diagnosis in this setting to allow early administration of thrombolytic therapy. LEARNING POINTS: Right heart thrombus (RHT) may manifest acutely as cardiac arrest in patients with underlying cardiomyopathy.Echocardiography is essential for rapid diagnosis of RHT.Thrombolysis can lead to rapid thrombus dissolution and haemodynamic improvement.

Feeding Induces Left Atrial Compression and Impedes Cardiac Filling in Patients With Large Hiatal Hernia.

BACKGROUND: Patients with large hiatal hernias (HH) frequently experience postprandial dyspnea. The aim of this study was to evaluate whether feeding induced cardiac compression in these patients using echocardiography. METHODS: Transthoracic echocardiography was performed during fasting and 30 min after feeding (300 g rice pudding) in patients with HHs (n = 32; mean age, 72 ± 9 years). A subset of patients (n = 15; mean age, 76 ± 6 years) were evaluated postoperatively. RESULTS: Preoperatively, feeding decreased left atrial (LA) volumes (maximal 27.4 ± 11.3 vs 19.2 ± 9.7 mL/m2, P < .001; minimal 13.1 ± 7.0 vs 6.9 ± 5.1 mL/m2, P < .001), and increased LA inflow velocities (systolic wave 0.62 ± 0.14 vs 0.77 ± 0.17 m/sec, P < .01; diastolic wave 0.46 ± 0.13 vs 0.59 ± 0.13 m/sec, P < .01), mitral inflow velocities (E wave 0.79 ± 0.17 vs 0.94 ± 0.19 m/sec, P < .01; A wave 0.93 ± 0.20 vs 1.05 ± 0.22 m/sec, P < .01), and E/E' ratio (12.1 ± 2.7 vs 13.7 ± 3.9, P < .01). Cardiac output (6.3 ± 1.6 vs 7.24 ± 2.0 L, P < .01) increased postprandially by marked heart rate augmentation (68.8 ± 7.0 vs 84.2 ± 8.4 beats/min, P < .01), with modest stroke volume increase (88.5 ± 16.7 vs 94.3 ± 19.5 mL, P = .03). After HH surgery, feeding did not change LA volumes (maximal 52.9 ± 13.6 vs 53.4 ± 12.5 mL, P = .89; minimal 28.6 ± 12.2 vs 27.4 ± 8.7 mL, P = .59) or E/E' ratio (10.9 ± 2.1 vs 11.3 ± 2.3) and induced more modest alterations in LA inflow (systolic wave 0.58 ± 0.17 vs 0.68 ± 0.16 m/sec, P = .01; diastolic wave 0.41 ± 0.12 vs 0.47 ± 0.13 m/sec, P = .01) and mitral inflow (E wave 0.69 ± 0.15 vs 0.80 ± 0.13 m/sec, P < .01; A wave 0.92 ± 0.13 vs 1.01 ± 0.18 m/sec, P = .02). Postoperatively, feeding increased cardiac output by substantial stroke volume augmentation (81.9 ± 16.5 vs 90.8 ± 16.0 mL, P = .01), with only modest increase in heart rate (69.8 ± 9.1 vs 75.9 ± 10.5 beats/min, P < .01). CONCLUSIONS: Feeding produces marked LA compression in patients with HHs, inducing compensatory exaggerated responses in cardiac inflow and hemodynamic status. These compensatory mechanisms improve postoperatively following resolution of LA compression, likely explaining the debility noted preoperatively.

Aspirin hypersensitivity in patients with coronary artery disease: linking pathophysiology to clinical practice.

Dual antiplatelet therapy, consisting of aspirin and a P2Y12 receptor antagonist, has been the cornerstone of management in those undergoing percutaneous coronary intervention, reducing stent thromboses and cardiovascular events. Given the pivotal role of aspirin in cardiovascular disease management, patients with aspirin hypersensitivity pose complex clinical challenges. Allergy to aspirin is reported in 1.5-2.6% of patients presenting with cardiac disease. Identification of the subtype of aspirin hypersensitivity will determine suitability for aspirin desensitization, dictate choice of desensitization protocol and inform risk management. Aspirin desensitization is an effective and viable clinical strategy, although it remains underutilised in clinical practice. Collaboration between cardiologists and immunologists should be strongly encouraged to facilitate optimal management of such patients. This review describes the complexity of managing patients with aspirin hypersensitivity in cardiac disease, the indications and risks of aspirin desensitization, and the approach to management of the minority of patients who are unsuitable for desensitization.

Left atrial compression and right ventricular outflow tract diameter on echocardiography are independently associated with exercise capacity in patients with large hiatal hernia.

INTRODUCTION: Large hiatal hernia (HH) is often associated with left atrial (LA) compression, anteroposterior cardiac compression (manifesting as reduced right ventricular outflow tract (RVOT) diameter), and left ventricular (LV) compression (manifesting as systolic paradoxical outward motion (LV-PM) of the posterobasal LV segment). Exercise impairment, also common in this population, improves following HH surgery. We aimed to identify echocardiographic parameters independently associated with exercise impairment due to HH-mediated cardiogenic compression. METHODS: Patients with a large HH (>30% intra-thoracic stomach, n = 163) referred for cardiac evaluation were included. Echocardiographic parameters were retrospectively analyzed in relation to HH-related LA compression severity and the presence of LV-PM. Echocardiographic parameters independently associated with exercise capacity were identified by multivariable analysis. RESULTS: Mean baseline metabolic equivalents were reduced (70 ± 28% predicted). Moderate-severe LA compression and LV-PM were present in 91 of 163 (56%) and 65 of 162 (40%) patients, respectively. Patients with moderate-severe LA compression and LV-PM had decreased LA and LV dimensions. Moderate-severe LA compression was also associated with reduced RVOT diameter while LV-PM predicted a greater reduction in LV volumes. LA compression and RVOT diameter were independently associated with baseline exercise capacity and increased following HH surgery performed in a subgroup (n = 72, LA diameter: 14 ± 5 vs 20 ± 4 mm/m2 ; RVOT diameter: 17 ± 3 vs 19 ± 3 mm/m2 , P < .001 for both). Conversely, LV-PM was not independently associated with exercise capacity. CONCLUSION: Hiatal hernia-related cardiac compression reduces LA and RVOT dimensions. These parameters are independently associated with baseline exercise capacity and improve following HH surgery. LV-PM is associated with decreased LV volumes but not exercise capacity in this population.

Valsalva maneuver exacerbates left atrial compression in patients with large hiatal hernia.

INTRODUCTION: Hiatal hernia (HH) can cause left atrial (LA) compression and impair LA filling. We evaluated the cardiac effects of preload reduction and abdominal strain induced by Valsalva maneuver (VM) in large HH patients. METHODS: LA and left ventricular (LV) dimensions were measured using 2D transthoracic echocardiography at rest and during VM in HH patients (n=55, 70±10 years) and controls (n=22, 67±6 years). Biplane LV volumes (n=39) and mitral inflow pulse-wave Doppler parameters (n=27) were also evaluated. In HH patients, resting LA compression was graded qualitatively (none-mild or moderate-severe). RESULTS: In both controls and HH patients, VM significantly decreased LA (controls, 19±2 vs 16±3 mm/m2 ; HH, 16±5 vs 9±5 mm/m2 ) and LV diameters (22±3 vs 19±3 mm/m2 ; 21±3 vs 17±3 mm/m2 ) and LV volume (38±8 vs 26±10 mL/m2 ; 31±8 vs 19±9 mL/m2 ) (P<.001 for all). VM decreased LA diameter significantly more in HH patients than controls (-42% vs -16%, P<.001). HH patients with none-mild resting LA compression exhibited significantly greater LA diameter reduction than controls (-38±23% vs -16±13% P=.0003) despite similar resting LA diameters. LV volumes were similarly decreased by VM in HH patients and controls irrespective of resting LA compression severity indicating relative preservation of LV filling. LA diameter correlated inversely with early diastolic filling velocity during VM in HH patients (R=-.43, P=.03) but not controls (R=.18, P=.43). CONCLUSION: VM can markedly exacerbate LA compression in HH patients; however, LV filling is relatively less affected possibly due to augmented early diastolic filling. Conditions associated with decreased preload and increased intra-abdominal pressure may exacerbate the cardiac effects of large HH.

Changes in lung volumes and gas trapping in patients with large hiatal hernia.

BACKGROUND AND AIMS: Studies assessing hiatal hernia (HH)-related effects on lung volumes derived by body plethysmography are limited. We aimed to evaluate the effect of hernia size on lung volumes (including assessment by body plethysmography) and the relationship to functional capacity, as well as the impact of corrective surgery. METHODS: Seventy-three patients (70 ± 10 years; 54 female) with large HH [mean ± standard deviation, intra-thoracic stomach (ITS) (%): 63 ± 20%; type III in 65/73] had respiratory function data (spirometry, 73/73; body plethysmography, 64/73; diffusing capacity, 71/73) and underwent HH surgery. Respiratory function was analysed in relation to hernia size (groups I, II and III: ≤50, 50%-75% and ≥75% ITS, respectively) and functional capacity. Post-operative changes were quantified in a subgroup. RESULTS: Total lung capacity (TLC) and vital capacity (VC) correlated inversely with hernia size (TLC: 97 ± 11%, 96 ± 13%, 88 ± 10% predicted in groups I, II and III, respectively, P = 0.01; VC: 110 ± 17%, 111 ± 14%, 98 ± 14% predicted, P = 0.02); however, mean values were normal and only 14% had abnormal lung volumes. Surgery increased TLC (93 ± 11% vs 97 ± 10% predicted) and VC (105 ± 15% vs 116 ± 18%), and decreased residual volume/total lung capacity (RV/TLC) ratio (39 ± 7% vs 37 ± 6%) (P < 0.01 for all). Respiratory changes were modest relative to the marked functional class improvement. Among parameters that improved following HH surgery, decreased TLC and forced expiratory volume in 1 s and increased RV/TLC ratio correlated with poorer functional class pre-operatively. CONCLUSIONS: Increasing HH size correlates with reduced TLC and VC. Surgery improves lung volumes and gas trapping; however, the changes are mild and within the normal range.

Fixed left ventricular outflow tract obstruction mimicking hypertrophic obstructive cardiomyopathy: pitfalls in diagnosis.

We present a case series that highlights the diagnostic challenges with left ventricular hypertrophy (LVH) and left ventricular outflow tract obstruction (LVOTO). Fixed structural lesions causing LVOTO with secondary LVH may mimic hypertrophic obstructive cardiomyopathy (HOCM). Management of these two entities is critically different. Misdiagnosis and failure to recognize fixed left ventricular outflow tract (LVOT) lesions may result in morbidity as a result of inappropriate therapy and delay of definitive surgical treatment. It is thus necessary to identify the correct type and level of obstruction in the LVOT by careful correlation of clinical examination, Doppler evaluation, and advanced imaging findings.

Scombroid fish poisoning illness and coronary artery vasospasm.

We present an interesting case of a young man with coronary artery vasospasm complicating scombroid fish poisoning illness. The initial presentation included tachycardia and significant hypotension. A 12-lead ECG showed sinus tachycardia with marked widespread ST segment depression and ST elevation in aVR. Symptoms subsequently improved with intravenous fluid rehydration, antihistamines, and glyceral trinitrate. The underlying pathogenesis and treatment of this rarely described manifestation of the fish poisoning illness is discussed.

Exertional fat embolism after hip joint replacement: a case report.

INTRODUCTION: We present the case of a patient with exertional fat embolism on isolated exercise of his right leg two and four months after right total hip joint replacement. His immediate post-operative period had also been complicated by an acute episode of chest pain and hypotension, treated as acute coronary syndrome. To the best of our knowledge, this is the first reported case of exertional fat embolism following orthopedic surgery. CASE PRESENTATION: A 71-year-old Caucasian man underwent elective cementless total right hip joint replacement. His acute post-operative period was complicated by an episode of chest pain and hypotension. This was treated as acute coronary syndrome. Two months later, a routine stress echocardiography demonstrated a shower of small, echodense bubbles in his right heart, reproduced on exercise of his right leg but not his left. Computed tomography pulmonary angiography excluded pulmonary thromboemboli. A technetium-99m colloid scan confirmed pulmonary fat emboli. Similar findings occurred again four months after the operation but had resolved at six months. CONCLUSIONS: Fat embolism is a well-described phenomenon in the acute setting after long-bone trauma or intramedullary manipulation, and the rare fat embolism syndrome can be fatal. Exertional fat embolism months after joint replacement, however, is an undescribed phenomenon that may have implications in the sub-acute post-operative phase. This may be of particular interest to those involved in orthopedics, cardiology and rehabilitation, but the large volume of patients undergoing joint replacements may broaden the clinical scope of this unusual presentation far beyond these specialties.

Isolated hypertrophy of the basal ventricular septum: characteristics of patients with and without outflow tract obstruction.

BACKGROUND: Isolated basal septal hypertrophy (IBSH) of the left ventricle (LV) is not a well understood phenomenon, particularly in the presence of concomitant left ventricular outflow tract obstruction (LVOTO). We evaluated the prevalence of IBSH and compared those with and without LVOTO. METHODS: Retrospective observational study of 4104 consecutive patients undergoing echocardiography at a community cardiology practice and a hospital without specialized Hypertrophic Cardiomyopathy (HCM) service to determine prevalence of IBSH, defined as isolated hypertrophy (>15 mm) of the basal LV septum (BS) without hypertrophy elsewhere. Clinical, ECG and echocardiographic characteristics were compared in IBSH with and without LVOTO. RESULTS: Prevalence of IBSH was 5.8% (240/4104): mean (SD) age was 76.0y (10.4) with equal gender distribution. Prevalence increased with age (p<0.001 for trend), reaching 7.8% over 70y. None had a family history of HCM, and HCM-associated ECG changes were uncommon. Mean BS thickness (SD) was 17.8mm (0.24) with a BS/posterior wall ratio (SD) of 1.76 (0.31). Resting peak LVOT gradient (>20mmHg) was present in 8/240 (3.3%), mean (SD) 69.6mmHg (59.3). Patients with LVOTO had hypercontractile LV function (fractional shortening [SD] 51.8% [9.5] vs. 40.5% [10.9], p=0.012) compared to those without LVOTO, but had similar BS thickness [SD] (17.8mm [3.0] vs. 17.8mm [2.8], p=0.996) and ECG characteristics. Greater apical and septal displacements of the mitral valve co-aptation point characterized those with IBSH and LVOTO. CONCLUSIONS: IBSH is common in elderly patients referred for echocardiography. LVOTO occurs only when concomitant mitral valve co-aptation and LV hypercontractility facilitate development of a gradient, rather than through differences in the degree of BS myocardial hypertrophy.