Obscured meshwork structure after treatment for heart failure: a case study.

An 87-year-old man with heart failure was admitted to our hospital. A transthoracic echocardiography showed diffuse mild left ventricular (LV) hypokinesis and LV noncompaction at the apex. A three-dimensional transthoracic echocardiography confirmed a trabecular meshwork. After treatment for heart failure, LV end-systolic dimension decreased and trabeculae seemed to converge and became obscure in end-systole. This is a rare case suggesting mechanism of obscured LV noncompaction after treatment for heart failure.

Simultaneous pressure recording in mid-ventricular obstructive hypertrophic cardiomyopathy.

A 70-year-old man was diagnosed with mid-ventricular obstructive hypertrophic cardiomyopathy (MVOHCM) with apical aneurysm and paradoxic jet flow. At cardiac catheterization, pressure study showed that there was a markedly high pressure-gradient of 90 mmHg between the apex and the base in systole. Apical pressure was 350 mmHg after premature ventricular contraction. The apical aneurysm was already dilated and spherical in late systole; the absence of active relaxation was considered to be the cause of the paradoxic jet flow. In this report, we suggest the pathogenesis of left ventricular apical aneurysm and paradoxic jet flow in MVOHCM.

Triphasic mitral inflow documented by Doppler echocardiography and cardiac catheterization: a case study.

An 85-year-old woman with hypertension was referred to our hospital for the management of chest pain. Echocardiography showed left ventricular (LV) hypertrophy with impaired systolic function (ejection fraction, 40%) and mitral regurgitation. Pulsed Doppler echocardiography for checking mitral inflow showed triphasic mitral inflow velocity. Simultaneous recording of the LV and pulmonary artery wedge (PAW) pressures showed a high mean PAW pressure with a prominent v wave. The LV pressure showed a temporary elevation in early diastole; it was unusually decreased in mid-diastole, and finally was elevated to such an extent that it exceeded PAW pressure. In this patient, the mid-diastolic decrease in LV pressure, despite the presence of simultaneous LV filling flow, cannot be explained by conventional pressure-volume relation; rather it can be attributed to the abrupt increase in the inflow volume due to the impaired diastolic function. This case shows the characteristics of triphasic mitral inflow in patients with diastolic dysfunction.

Prominent isovolumic relaxation flow in a patient with cardiac tamponade.

We present herein the case of a 72-year-old man who presented with orthopnea and was diagnosed with cardiac tamponade due to carcinomatous pericarditis. Pulsed Doppler echocardiogram showed prominent isovolumic relaxation flow (IVRF) directed from the cardiac base toward the apex. Such flow is rare in pericardial effusion and may be due to enhanced early diastolic untwisting, sphericalization of apex, and restriction of wall motion by epicardial fibrous tissue. We describe herein a rare case of prominent IVRF with interesting underlying mechanisms.

Triphasic mitral inflow in acute coronary syndrome: A case study.

An 86-year-old woman was referred to our hospital for the management of rapid onset of chest pain. Blood analysis showed increased levels of cardiac enzymes and B-type natriuretic peptide. An electrocardiogram showed poor R wave in precordial leads and a QS wave in lead V4. A chest roentgenogram showed mild pulmonary congestion. An echocardiogram showed hypokinesis of the broad anterior wall of the left ventricle (LV). A pulsed Doppler echocardiogram of mitral inflow revealed an abnormal relaxation pattern. After increasing the preload by leg elevation, an intermittent triphasic mitral inflow pattern emerged. The patient underwent emergent cardiac catheterization for acute coronary syndrome (ACS). A pressure study after leg elevation disclosed an elevation in LV diastolic pressure and a "dip-up-down pattern." The patient underwent percutaneous coronary intervention of the left anterior descending artery. This case showed that a triphasic mitral inflow pattern is observed not only in hypertrophic diastolic heart failure but also in ACS. The triphasic pattern may be observed in the case of low LV distensibility and markedly increased preload. This is the first case report describing triphasic mitral inflow in ACS and demonstrating the pathophysiology of a triphasic mitral inflow pattern.

Atrioventricular block and diastolic dysfunction in a patient with Sanfilippo C.

A 39-year-old woman with Sanfilippo C syndrome was referred to our department for the treatment of bradycardia. An electrocardiogram revealed a second degree atrioventricular block, and pacemaker implantation was performed with the patient under general anesthesia. A transthoracic echocardiogram showed normal left ventricular systolic function, moderate mitral regurgitation due to mitral valve prolapse, and a high E/e' ratio, indicating left ventricular diastolic dysfunction. The present patient exhibited a rare case of Sanfilippo syndrome complicated with conduction disturbances, mitral regurgitation, and diastolic dysfunction.

Coronary spasm as a cause of takotsubo cardiomyopathy and intraventricular obstruction.

A 79-year-old man presented to the emergency room because of chest pain on 3 successive mornings. An electrocardiogram (ECG) showed ST segment elevation in leads II, III, and aVF. Laboratory findings including cardiac enzymes, were within normal limits, except a positive result for the troponin T test. Two-dimensional echocardiography revealed akinesis of the left ventricular apex and hyperkinesis of the basal wall. Doppler echocardiography revealed a significant subaortic pressure gradient. Emergent coronary angiography showed no significant coronary artery stenosis, but the ergonovine test induced a right coronary artery spasm with exaggeration of the ST segment elevation in II, III, and aVF leads. The computed tomography performed 2 weeks later showed normal left ventricular wall motion with sigmoid septum. The patient was diagnosed with takotsubo cardiomyopathy and intraventricular obstruction due to coronary spasm; he was treated with calcium channel blockers and nitrates. This case suggests the importance of differential diagnosis of the pathogenesis of takotsubo cardiomyopathy.