Electrocardiographic pattern combined with echocardiographic wall motion abnormalities in stress related cardiomyopathies: clinical and pathophysiological insights.

We report five cases of stress related cardiomyopathies that occurred in post-menopausal women (age range from 49 to 90) consecutively admitted to our Department in the last year in different clinical settings: typical anginal pain, carotid endarterectomy, pulmonary edema, cardiogenic shock, and severe asthenia. Apical left ventricular involvement was observed in three patients in conjunction with ECG mild ST segment elevation in anterior precordial leads resembling acute anterior myocardial infarction; isolated mid ventricular dysfunction was present in two patients in conjunction with ST segment depression in the anterior precordial leads. The ECG evolved showing T wave inversion in four cases and normalized in one. In all cases, blood chemistry showed mild elevation of CK-MB and TN. The observed wall motion abnormalities were reversible in four of five cases during hospital stay. Stress echocardiography was performed in two patients (dobutamine in the patient with persistent mid-ventricular hypokinesis, exercise in another case) and correctly predicted the absence of coronary artery disease. We conclude that wall motion analysis at echocardiography combined with ECG ST segment changes and serum markers of myocardial necrosis (CK-MB and TN) may allow recognition of stress cardiomyopathies in different clinical settings. Echo stress may be proposed in those patients in whom some suspicion of coronary artery disease persists.

Kounis syndrome in a patient with ovarian cancer and allergy to iodinated contrast media: report of a case of vasospastic angina induced by chemotherapy.

We report the case of a 71-year-old woman with previous coronary angioplasty, ovarian cancer with multiple metastases and allergy to iodinated contrast media, who developed vasospastic angina after several treatments with cisplatin and cyclophosphamide, so that we considered this as a case of "allergic angina" or Kounis syndrome (type II variant). The patient underwent standard anti-ischemic therapy with nitrates, calcium blocking agents and enoxaparin so having an uneventful outcome.

Tako-tsubo syndrome: report of a case with mild electrocardiographic changes but with multiple wall motion abnormalities.

We report the case of a 60-year-old woman admitted to our hospital for typical chest pain with only mild ST segment depression in the anterior precordial leads but with left ventricular akinesia of the mid-infero-postero-lateral segments with sparing of the base and of the apical septum. Coronary angiography was normal and the patient was dismissed from our hospital after echocardiographic normalization in spite of persistent ECG repolarization changes. We conclude that echocardiographic examination allows recognition of atypical forms of "tako-tsubo" disease in presence of only subtle and non-specific repolarization changes.

Pulmonary embolism after brain hemorrhage in a hypertensive patient: the therapeutic dilemma.

Massive pulmonary embolism is a life-threatening condition to be treated with anticoagulants or even thrombolytic agents in selected cases. However, these drugs are controindicated after a recent hemorrhagic episode. We report the case of a 46-year-old patient with uncontrolled systemic hypertension who was affected by severe spontaneous cerebral hemorrhage and left hemiparesis. After some days of rehabilitation care he developed sudden dyspnea, tachycardia and hypotension secondary to bilateral pulmonary embolism. Owing to controindication to the use of thrombolytic agents, anticoagulant therapy with high-dose intravenous unfractionated heparin followed by oral warfarin was begun, with a successful and uncomplicated outcome. The therapeutic approach to similar not uncommon cases is debated and some hypotheses are made about the aetiology of pulmonary embolism in these patients.

Is transesophageal echocardiography useful in planning surgery of mediastinal thymomas? Transesophageal investigation of a mediastinal thymoma.

Thymomas are the commonest tumors arising in the anterior mediastinum, sometimes representing an incidental finding at radiological examination. Surgery of these neoplasms must be planned after accurately assessing the invasive or non-invasive nature of the mass. In the present case this could be achieved also by submitting the patient to transesophageal echocardiography which could accurately exclude infiltration of heart walls. We therefore think that this technique can be considered a useful complement to radiological ones in defining the surgical strategy of mediastinal thymomas.

Regression of warfarin-resistant left atrial appendage thrombus after ablation of atrial fibrillation and permanent pacing.

Atrial fibrillation is the most common rhythm disturbance and can also occur in absence of true cardiac disease. However, also in these cases, it can generate left atrial appendage thrombi with systemic embolic potential. A regular and well conducted anticoagulant therapy with dicoumarol derivatives, as indicated in these patients, is not always successful. We report the case of a patient with lone atrial fibrillation and a left atrial appendage thrombus resistant to anticoagulant therapy with warfarin, which disappeared after catheter ablation of atrial fibrillation by electrical disconnection of the pulmonary veins, restoration of sinus rhythm and dual-chamber pacemaker implantation.

Congestive heart failure secondary to right ventricular metastasis of colon cancer. A case report and review of the literature.

Although metastatic tumors of the heart occur more frequently than primary ones, infiltration of the right heart by a metastatic colon cancer has rarely been reported. We report the case of a woman previously operated on for colon cancer, presenting with symptoms of congestive heart failure due to metastatic invasion of the right ventricular cavity. Both transthoracic and transesophageal echocardiography were useful in detecting the mass, but not in defining its nature. The patient underwent a palliative surgical resection of the neoplastic mass but died soon after the intervention.

Transesophageal investigation of surgically ligated left atrial appendage.

Surgical ligation of the left atrial appendage is often performed during heart surgery for various diseases like mitral prosthesis implantation, mitral valve repair, and even coronary artery revascularization, mainly to prevent thrombus formation and systemic embolism in patients with atrial fibrillation. However surgical ligation is sometimes incomplete, thereby exposing the patient to residual embolic risk. We report two cases of surgical ligation of the left atrial appendage focusing on the transesophageal echographic aspects of complete or incomplete closure of the appendage.

Transesophageal echocardiographic evidence of atrial fibrillation with systolic flow in the right atrial appendage and systolic reversal pulmonary flow in a patient with DDD permanent pacing.

We report the case of a patient with atrial fibrillation on standard electrocardiogram who underwent transesophageal echocardiography to rule out presence of thrombi in heart cavities. Pulsed-wave Doppler investigation revealed multiphasic waves consistent with atrial fibrillation in the left atrial appendage, while in the right atrial appendage, a biphasic flow was registered after QRS depolarization. Some hypotheses are made about the origin of this signal.