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A 65-year-old man presented with acute decompensated heart failure. He was found to have severe prosthetic aortic valve regurgitation caused by a fractured strut of a sutureless prosthetic aortic valve that embolized to the distal portion of the aorta. We highlight the importance of multimodality imaging in diagnosis and management. (Level of Difficulty: Intermediate.).
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Recent reports linked acute COVID-19 infection in hospitalized patients to cardiac abnormalities. Studies have not evaluated presence of abnormal cardiac structure and function before scanning in setting of COVD-19 infection. We sought to examine cardiac abnormalities in consecutive group of patients with acute COVID-19 infection according to the presence or absence of cardiac disease based on review of health records and cardiovascular imaging studies. We looked at independent contribution of imaging findings to clinical outcomes. After excluding patients with previous left ventricular (LV) systolic dysfunction (global and/or segmental), 724 patients were included. Machine learning identified predictors of in-hospital mortality and in-hospital mortality + ECMO. In patients without previous cardiovascular disease, LV EF < 50% occurred in 3.4%, abnormal LV global longitudinal strain (< 16%) in 24%, and diastolic dysfunction in 20%. Right ventricular systolic dysfunction (RV free wall strain < 20%) was noted in 18%. Moderate and large pericardial effusion were uncommon with an incidence of 0.4% for each category. Forty patients received ECMO support, and 79 died (10.9%). A stepwise increase in AUC was observed with addition of vital signs and laboratory measurements to baseline clinical characteristics, and a further significant increase (AUC 0.91) was observed when echocardiographic measurements were added. The performance of an optimized prediction model was similar to the model including baseline characteristics + vital signs and laboratory results + echocardiographic measurements.
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COVID-19/complicações , Cardiopatias/etiologia , Cardiopatias/mortalidade , Hospitalização/estatística & dados numéricos , Adolescente , Adulto , Idoso , COVID-19/diagnóstico , COVID-19/mortalidade , COVID-19/terapia , Regras de Decisão Clínica , Ecocardiografia , Oxigenação por Membrana Extracorpórea , Feminino , Cardiopatias/diagnóstico por imagem , Mortalidade Hospitalar/tendências , Humanos , Aprendizado de Máquina , Masculino , Pessoa de Meia-Idade , Modelos Teóricos , Prognóstico , Curva ROC , Estudos Retrospectivos , Adulto JovemRESUMO
Coronary artery fistulae are rare abnormalities of the coronary arteries that are usually discovered incidentally on coronary angiogram. Most patients remain asymptomatic, and significant hemodynamic consequences are rarely observed. The following report describes the case of a patient presenting with symptoms of congestive cardiac failure due to multiple coronary artery fistulae.
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Fístula Artério-Arterial/complicações , Anomalias dos Vasos Coronários/complicações , Insuficiência Cardíaca/etiologia , Artéria Pulmonar/anormalidades , Fístula Artério-Arterial/diagnóstico por imagem , Fístula Artério-Arterial/fisiopatologia , Fístula Artério-Arterial/terapia , Angiografia por Tomografia Computadorizada , Angiografia Coronária/métodos , Anomalias dos Vasos Coronários/diagnóstico por imagem , Anomalias dos Vasos Coronários/fisiopatologia , Anomalias dos Vasos Coronários/terapia , Feminino , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/fisiopatologia , Hemodinâmica , Humanos , Pessoa de Meia-Idade , Artéria Pulmonar/diagnóstico por imagem , Artéria Pulmonar/fisiopatologiaRESUMO
OBJECTIVES: This study sought to identify Doppler parameters useful for the assessment of left ventricular filling pressure (LVFP) in patients with mitral annular calcification (MAC) and to develop and validate a decision algorithm for assessing LVFP in such patients. BACKGROUND: Predicting LVFP in the presence of MAC is problematic. METHODS: Prospectively, 50 patients with MAC (mean 72 ± 11 years of age) underwent a complete Doppler echocardiographic study and right or left heart catheterization. Standard and nonstandard parameters of ventricular filling and relaxation were correlated with LVFP. Classification and regression tree analysis was used to develop a decision tree for prediction of LVFP. Validation was performed prospectively using an additional cohort with MAC and invasive hemodynamics (n = 21). RESULTS: In the initial study group, 26 patients had mild MAC, and 24 had moderate or severe MAC. Mean LVFP was 17.0 ± 8.1 mm Hg (range 4 to 50 mm Hg). Of the variables tested, the best predictor of LVFP was the ratio of early-to-late diastolic filling velocity (mitral E/A) (r = 0.66; p < 0.001). This finding was observed in subjects with mild as well as moderate-to-severe MAC. Importantly, the ratio of early diastolic filling velocity-to-mitral annulus velocity (E/e') demonstrated weak correlation (r = 0.42; p = 0.003). A clinical algorithm using mitral E/A and isovolumic relaxation time (IVRT) was associated with good specificity (100%) and positive predictive value (100%), and moderate sensitivity (81%) and negative predictive value (67%) for high LVFP. Validation of the clinical algorithm in a separate prospective cohort yielded a diagnostic accuracy of 94%. CONCLUSIONS: The E/e' ratio should not be used to estimate LVFP in subjects with significant MAC. However, mitral E/A ratio and IVRT are useful predictors of LVFP in this patient population. The proposed decision algorithm combining these Doppler parameters is accurate in estimating LVFP in patients with MAC.
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Calcinose/diagnóstico por imagem , Ecocardiografia Doppler , Doenças das Valvas Cardíacas/diagnóstico por imagem , Valva Mitral/diagnóstico por imagem , Função Ventricular Esquerda , Pressão Ventricular , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Calcinose/fisiopatologia , Árvores de Decisões , Feminino , Doenças das Valvas Cardíacas/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/fisiopatologia , Variações Dependentes do Observador , Valor Preditivo dos Testes , Estudos Prospectivos , Reprodutibilidade dos Testes , Índice de Gravidade de DoençaRESUMO
Noncompaction cardiomyopathy (NCCM) is a unique cardiomyopathy with a diverse array of genotypic and phenotypic manifestations. Its hallmark morphology consists of a bilayered myocardium with a compact epicardial layer and prominent trabeculations that comprise the noncompacted endocardial layer. The controversial diagnostic criteria for NCCM have been frequently discussed in the literature. This review touches on those diagnostic criteria, delves further into the evolving use of advanced imaging techniques within the major imaging modalities (echocardiography, computed tomography, and cardiac magnetic resonance imaging), and proposes an alternative algorithm incorporating these techniques for aiding with the diagnosis of NCCM.
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Ecocardiografia/métodos , Miocárdio Ventricular não Compactado Isolado/diagnóstico por imagem , Imageamento por Ressonância Magnética/métodos , Imagem Multimodal/métodos , Tomografia Computadorizada por Raios X/métodos , Ventrículos do Coração/diagnóstico por imagem , HumanosRESUMO
PURPOSE OF REVIEW: Chest pain and myocardial ischemia are common features in patients with hypertrophic cardiomyopathy (HCM). This review addresses diagnostic roles of computed tomography and nuclear stress testing (NST) in patients with HCM. RECENT FINDINGS: Current evidence showed the limitation of NST in the diagnosis of epicardial coronary artery stenosis due to the prevalent microvascular dysfunction. In this context, the excellent negative predictive value of coronary computed tomography angiography (CCTA) makes it very attractive to serve as a gatekeeper to invasive angiography in low-risk symptomatic patients, either as the first noninvasive imaging test of choice or after the presence of perfusion defect seen in NST. Furthermore, the identification of coronary atherosclerosis process in the absence of obstructive lesion could have impacts on the management of risk factors for coronary artery disease. We also propose an algorithm for evaluation of ischemia in HCM patients based on the recent evidence. SUMMARY: In low-intermediate-risk symptomatic patients with HCM, both NST and CCTA are acceptable diagnostic tools for the evaluation of myocardial ischemia. In the presence of nuclear perfusion defect, CCTA can be used to rule out significant epicardial stenosis. Presence of significant major epicardial artery stenosis on CCTA or high-risk patients could be considered for invasive angiography.
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Cardiomiopatia Hipertrófica , Dor no Peito , Isquemia Miocárdica , Cardiomiopatia Hipertrófica/complicações , Cardiomiopatia Hipertrófica/fisiopatologia , Dor no Peito/diagnóstico , Dor no Peito/etiologia , Dor no Peito/fisiopatologia , Angiografia Coronária/métodos , Diagnóstico Diferencial , Teste de Esforço/métodos , Humanos , Microvasos/fisiopatologia , Isquemia Miocárdica/diagnóstico , Isquemia Miocárdica/etiologia , Isquemia Miocárdica/fisiopatologia , Imagem de Perfusão do Miocárdio/métodos , Tomografia Computadorizada por Raios X/métodosAssuntos
Angiografia por Tomografia Computadorizada , Ecocardiografia Doppler em Cores , Contusões Miocárdicas/diagnóstico por imagem , Insuficiência da Valva Tricúspide/diagnóstico por imagem , Valva Tricúspide/diagnóstico por imagem , Acidentes de Trânsito , Adulto , Biópsia , Anuloplastia da Valva Cardíaca , Implante de Prótese de Valva Cardíaca , Humanos , Masculino , Contusões Miocárdicas/etiologia , Contusões Miocárdicas/cirurgia , Resultado do Tratamento , Valva Tricúspide/lesões , Valva Tricúspide/cirurgia , Insuficiência da Valva Tricúspide/etiologia , Insuficiência da Valva Tricúspide/cirurgiaRESUMO
BACKGROUND: Arterial and venous thrombosis may share common pathophysiology involving the activation of platelets and inflammatory mediators. A growing body of evidence suggests prothrombotic effect of renin angiotensin system (RAS) including vascular inflammation and platelet activation. We hypothesized that the use of angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) plays a role in protecting against venous thromboembolism (VTE) in patients atherosclerosis. METHODS: We conducted a retrospective study, reviewing 1,100 consecutive patients admitted to a teaching hospital with a diagnosis of either myocardial infarction or ischemic stroke from 2005 to 2010. Patients who had been treated with anticoagulation therapy before or after the first visit were excluded. The occurrence of VTE during the follow up period, risk factors for VTE on admission, and the use of ACEIs or ARBs during the follow up period were recorded. RESULTS: The mean age of the entire study population was 68.1 years. 52.0% of the patients were female and 76.5% were African American. 67.3% were on RAS inhibitors. The overall incidence of VTE was 9.7% (n = 107). Among the RAS inhibitor users, the incidence of VTE events was 9.0% (54/603) for the ACEI only users, 7.1% (8/113) for the ARB only users, and 0% (0/24) for the patients taking combination of ACEI and ARB. Among patients on RAS inhibitors, 8.4% (62/740) developed a VTE, compared with 12.5% (45/360) in the nonuser group [HR (hazard ratio), 0.58; 95% CI (confidence interval), 0.39-0.84; P<0.01]. Even after controlling for factors related to VTE (smoking, history of cancer, and immobilization, hormone use) and diabetes, the use of RAS inhibitors was still associated with a significantly lower risk of developing VTE (AHR, 0.59; 95% CI, 0.40-0.88; P = 0.01). CONCLUSIONS: The use of RAS inhibitors appears to be associated with a reduction in the risk of VTE.
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Inibidores da Enzima Conversora de Angiotensina/administração & dosagem , Aterosclerose/tratamento farmacológico , Sistema Renina-Angiotensina/efeitos dos fármacos , Tromboembolia Venosa/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Aterosclerose/complicações , Isquemia Encefálica/complicações , Isquemia Encefálica/tratamento farmacológico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/complicações , Infarto do Miocárdio/tratamento farmacológico , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/tratamento farmacológico , Tromboembolia Venosa/etiologiaRESUMO
AIMS: Cardiac calcification is associated with coronary artery disease, arrhythmias, conduction disease, and adverse cardiac events. Recently, we have described an echocardiographic-based global cardiac calcification scoring system. The objective of this study was to evaluate the severity of cardiac calcification in patients with permanent pacemakers as based on this scoring system. METHODS AND RESULTS: Patients with a pacemaker implanted within the 2-year study period with a previous echocardiogram were identified and underwent blinded global cardiac calcium scoring. These patients were compared to matched control patients without a pacemaker who also underwent calcium scoring. The study group consisted of 49 patients with pacemaker implantation who were compared to 100 matched control patients. The mean calcium score in the pacemaker group was 3.3 ± 2.9 versus 1.8 ± 2.0 (P = 0.006) in the control group. Univariate and multivariate analysis revealed glomerular filtration rate and calcium scoring to be significant predictors of the presence of a pacemaker. CONCLUSION: Echocardiographic-based calcium scoring correlates with the presence of severe conduction disease requiring a pacemaker.
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Arritmias Cardíacas/complicações , Arritmias Cardíacas/diagnóstico por imagem , Calcinose/complicações , Calcinose/diagnóstico por imagem , Ecocardiografia/métodos , Interpretação de Imagem Assistida por Computador/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Sensibilidade e EspecificidadeRESUMO
We investigated whether there is an increased risk of coronary heart diseases (CHD) in those with common allergic symptoms using the NHANES III, which is a representative sample of the United States population in 1988 to 1994. CHD was defined by Rose questionnaire and history of heart attack. Allergic symptoms were categorized into no symptoms (NO), rhinoconjunctivitis without wheezing (RC), and wheezing (WZ) based on symptoms. Multivariate logistic regression was used to obtain odds ratios (ORs) of CHD. Eight thousand six hundred fifty-three nonpregnant subjects ≥20 years old with overnight fasting ≥8 hours were included. CHD was present in 5.9% of the population; 36.5% did not have allergic symptoms (NO), 45.9% had RC, and 17.6% had WZ. The prevalence of CHD was 3.9% in NO, 4.8% in RC, and 12.8% in WZ (p <0.001). Compared to NO, unadjusted ORs of CHD were 1.24 (95% confidence interval 0.94 to 1.62) in RC and 3.58 (2.68 to 4.78) in WZ and ORs adjusted for sociodemographic factors and co-morbidities were 1.40 (1.02 to 1.92) in RC and 2.64 (1.79 to 3.90) in WZ. Only the group of women <50 years of age had significantly increased ORs in RC and WZ. In conclusion, common allergic symptoms were significantly associated with an increased risk of CHD.