Left Ventricular Twist and Torsion

Abstract

A 52-year-old white man visited his physician because he started experiencing shortness of breath on walking short distances at ground level. He had smoked half a packet of cigarettes daily for 40 years. Physical examination revealed a blood pressure of 147/95 mm Hg. Chest examination and chest x-ray were unremarkable, and ECG showed left atrial abnormality. The patient had normal serum electrolytes, blood sugar, and kidney function tests. A stress echocardiogram was ordered to exclude potential coronary artery disease. His resting echocardiography showed an ejection fraction (EF) of 60%, normal septal and posterior wall thickness, and mild diastolic dysfunction (septal early diastolic mitral annular velocity [e′] of 7 cm/s, early diastolic [E wave] to late diastolic [A wave] transmitral Doppler flow velocity ratio [E/A] of 1.4, E-wave deceleration time of 210 ms, E/e′ ratio of 9, and left atrial volume index of 44 mL/m2; Figure 1A). There were no resting segmental wall motion abnormalities suggestive of ischemia. The patient exercised on a treadmill using Bruce protocol for 4 minutes and 43 s, and achieved 6.6 metabolic equivalent of task and maximum heart rate of 148 bpm (88% of his maximum age predicted heart rate). At peak exercise, the patient developed severe dyspnea and his blood pressure was 213/90 mm Hg. Post exercise echocardiography was acquired within 1 minute of exercise termination and showed EF of 69% and no segmental wall motion abnormalities, with Doppler recordings obtained at recovering heart rate of 125 bpm; showing a septal e′ velocity of 7.3 cm/s, E/A of 1.9, E-wave deceleration time of 110 ms, and E/e′ of 13.7, left atrial volume index of 35 mL/m2 (Figure 1B). Ten minutes into the recovery period, the blood pressure returned to basal level (145/80 mm Hg). Compared with resting levels, the increased E/A ratio, shortened E-wave deceleration …