Apical Aneurysm Research Articles

593 Spontaneous coronary artery dissection in young

Abstract Aims We present the case of a 25 years-old patient, presented to the Emergency Department for chest pain and epigastralgia complicated by vomiting. Symptoms started about 30 h before, afterwards an effort. The patient did not have any known cardiovascular risk factors (except for sporadic consumption of cannabis) and family medical history was negative for premature cardiovascular disease or sudden cardiac death. His past medical history was unremarkable. Methods and results Clinical examination was normal. ECG was suggestive for subacute anterior ST-elevation myocardial infarction (QS in V1–V4 leads with ST segment elevation and biphasic T-waves in V4–V6) and was accompanied by significant elevation of myocardial necrosis biomarkers (hsTnT 3416 ng/l, n.v. <15). Echocardiography revealed a severely reduced left ventricular ejection fraction (LVEF = 30%) with regional wall motion abnormalities (apical and septal akinesia, and anterior mid-ventricular segment hypokinesia). Coronary angiography was suggestive for a dissection of the proximal-to-mid left anterior descending artery. Dissection flap, subocclusion of the first septal branch, and intramural thrombosis were noted. Direct stenting with drug-eluting stent was successful, with thrombolysis in myocardial infarction (TIMI) flow grade 3. The patient was started on dual antiplatelet treatment (aspirin and ticagrelor), ACE-inhibitors, beta blockers, and spironolactone. Further testing ruled out other conditions that may be associated with spontaneous coronary artery dissection (autoimmune diseases, including vasculitis, connective tissue disease, coagulative disorders). The clinical course was complicated by pericarditis and the development of LV apical thrombus. So, patient was started on anticoagulation (warfarin) with subsequently downgrading from ticagrelor to clopidogrel. Echocardiographic follow-up documented a progressive improvement of LVEF (50%), and global longitudinal strain (GLS −15%) with persistence of wall motion abnormalities in the apical and septal segments. Partial resolution of intracavitary thrombi was documented. CMR revealed LV apical aneurysm. Moreover, the use of dedicated sequences showed transmural late gadolinium enhancement in akinetic segments, and fatty metaplasia of the apical portion of the anterior wall and anterior septal wall. Finally, early gadolinium enhancement imaging, confirmed the persistence of LV stratified apical thrombus. Conclusions Spontaneous coronary artery dissection (SCAD) is an underdiagnosed and frequent cause of acute coronary syndrome (ACS) in young-to-middle aged patients, particularly women; therefore, even in young people, a chest pain episode suggestive for an ischaemic cause should never be underestimated. Cardiac magnetic resonance is the most accurate method to evaluate the sequelae of myocardial infarction (including LV size and function, presence of fatty metaplasia, extent and transmurality of ischaemic scar, presence of thrombi), to aid in differential diagnosis and to define prognosis and guide the therapeutic management.

477 Three cases of Kawasaki disease developed at young age and with a long term follow-up

Abstract Kawasaki disease is a relatively new disease and it took years since its first discovery to find and establish precise diagnostic and therapeutic indications. We report three cases of Kawasaki disease diagnosed between 1976 and 1993, which developed vascular complications and which were followed up for more than 20 years. The first case involved a 45-year-old woman who was first diagnosed with Kawasaki disease at age 3 years old. Her condition was complicated in the acute phase by a myocardial infarction and by the development of an apical aneurysm. The second case involved a 30-years-old woman who was first diagnosed with Kawasaki disease at age 6 months. The disease was complicated by coronary aneurysms and by right coronary artery occlusion. The third case involved a 29-year-old male who received a diagnosis of Kawasaki disease at age 1 year old. Echocardiography in the acute phase showed coronary aneurysms. One year later a new echocardiography revealed a thrombosis of the right coronary artery without myocardial infarction. The coronarography confirmed the coronary aneurysms and the thrombosis. All three cases were treated with a medical therapy and were followed up with periodic imaging exams, stress tests, 24-h Holter monitorings and cardiological check-ups. With these three case reports we have highlighted the possibility of finding a population of adult patients who may come to medical attention for acute events, such as myocardial infarction, presenting complicated, and disastrous angiographic pictures: it is plausible that such a population, in addition to cardiovascular risk factors, may have developed a KD in the years of lacking diagnostic and therapeutic options.

Extended myectomy for apical hypertrophic cardiomyopathy: a case report

BackgroundApical hypertrophic cardiomyopathy is a variant of hypertrophic cardiomyopathy that predominantly affects the apex of the left ventricle and rarely involves the right ventricular apex or both apexes. Heart transplantation is the traditional treatment for apical hypertrophic cardiomyopathy. Although surgical myectomy approaching the apex has been available for decades, its safety and accuracy greatly depend on the surgeon’s skills and experience.Case presentationThe first case involved a 63-year-old man with apical hypertrophic cardiomyopathy, wherein preoperative contrast computed tomography findings revealed apical hypertrophy and complete apical cavity obliteration. The patient underwent extended myectomy, which revealed the apex cavity filled with abnormal muscles. Using the transaortic approach, the location of the bilateral papillary muscle was confirmed, thereby providing the required orientation. The abnormal muscle mass was successfully resected, and the postoperative end-diastolic volume was extremely increased. The second case involved a 43-year-old man with an apical left ventricular aneurysm and mid-hypertrophic cardiomyopathy obstruction. The thin-walled apical aneurysm contained a large apical-basal band. Upon detecting the bilateral papillary muscle, mid-ventricular myectomy was performed from the apex. During postoperative catheterization, there was no pressure gradient between the left ventricle and aorta.ConclusionsWe reviewed two cases of apical hypertrophic cardiomyopathy, efficiently treated using extended apical myectomy. Although it is an uncommon procedure, the cases presented show how it can be used to successfully manage cases of apical hypertrophic cardiomyopathy. However, it is important to secure the postoperative left ventricular end-diastolic volume.

Beware of the octopus trap: A case of mid-ventricular hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is an autosomal dominant inherited disorder characterised by a genetic defect resulting in mutation of the sarcomere and consequently myocardial dysfunction. It has a prevalence of 1 in 500 and an important cause of sudden cardiac death. HCM has several variations, with asymmetric septal hypertrophy being most prevalent (90%) while mid-ventricular hypertrophy with apical aneurysm has rarely been reported.

Abstract 13829: Association Between E-wave Propagation Index and Left Ventricular Thrombus Formation in Systolic Heart Failure

Background: The E-wave propagation index (EPI) is a measure of apical blood flow and has been proposed as a risk marker of left ventricular thrombus (LVT) formation. We sought to investigate the association between EPI and LVT in patients with heart failure with reduced ejection fraction (HFrEF). Methods: This was a retrospective cohort study of patients with HFrEF. Follow-up echocardiograms were investigated for development of LVT. EPI was measured at baseline investigation as the velocity time integral of the transmitral E-wave divided by the left ventricular length. Logistic regression was used to investigate the association between EPI and LVT. Multivariable adjustments were made for age, significant mitral regurgitation, apical aneurysm, prior myocardial infarction, and left ventricular ejection fraction (LVEF). Results: Of 785 patients, 24 (3%) developed LVT. Mean age was 66 years, 73% were men, and LVEF was 28%. Those who developed LVT had significantly lower EPI (1.12 vs. 1.36, p=0.02). EPI was significantly associated with LVT in univariable logistic regression (OR=1.16 (1.03-1.31), per 0.1 decrease) (figure). These findings were unchanged after multivariable adjustments (OR=1.15 (1.00-1.31), per 0.1 decrease). The EPI provided an area under the curve of 0.68 with an optimal cutoff of 1.2. This cutoff had a sensitivity of 75%, specificity of 60%, positive predictive value of 6%, and negative predictive value of 99%. A low EPI was associated with a more than 4-fold increased risk of LVT (OR=4.56 (1.79-11.62), p=0.001). Conclusion: Decreasing EPI is associated with a higher risk of LVT. While a low EPI poses a markedly increased risk of LVT, a high EPI may be used to rule out LVT.

Abstract 13758: Right Ventricular Dysfunction Contributes to Left Ventricular Thrombus Formation After Myocardial Infarction

Introduction: Thromboembolic events such as stroke due to left ventricular thrombus (LVT) formation accompany acute myocardial infarction (MI). Risk factors for the development of LVT after MI have been identified based on limited data, including MI location, severe ventricular wall motion abnormalities or aneurysm, and reduced left ventricular ejection fraction (LVEF). Hypothesis: The purpose of this study was to define additional determinants of LVT formation following acute anterior MI through comparing clinical and echocardiographic characteristics between patients with and without LVT formation during the first 3 months after MI. Methods: This case-control-study comprised acute anterior MI patients with and without LVT, who were selected from a cohort of 1327 consecutive patients with ischemic heart failure in our hospital. The cases and controls were matched for age, sex, and LVEF. LVT was detected by routine/contrast echocardiography or cardiac magnetic resonance imaging during the first 3 months following MI. Results: Formation of apical aneurysm after MI was independently associated with LVT formation (72.0% vs. 43.5%, odds ratio [OR]=5.06, P=0.005). Echocardiographic risk factors associated with LVT formation included reduced mitral annular plane systolic excursion (MAPSE<7mm, OR=4.69), moderate-severe diastolic dysfunction (OR=2.71), and right ventricular (RV) dysfunction [reduced tricuspid annular plane systolic excursion (TAPSE)<17mm (OR=5.48), reduced RV factional area change (RV_FAC)<0.35 (OR=3.32), and enlarged RV diameters (OR=1.62)]. Subgroup analysis showed reduced TAPSE (OR=5.12, P=0.010) associated with increased risk of LVT formation in anterior MI patients without apical aneurysm, independent of clinical and other echocardiographic covariates. Conclusions: RV dysfunction as determined by reduced TAPSE and RV_FAC is independently associated with LVT formation in acute anterior MI patients, especially in the setting of MI patients without the formation of an apical aneurysm. This suggests that besides assessment of left ventricular abnormalities, assessment of concomitant RV dysfunction is of importance in risk stratification of LVT formation in patients with acute anterior MI.

Accuracy and reliability of focused echocardiography in patients with Chagas disease from endemic areas: SaMi-Trop cohort study.

Chagas disease remains a major cause of cardiovascular death in endemic areas. Focused echocardiography (FoCUS) is a point-of-care means of assessing cardiac function which can be useful for the diagnosis of cardiac involvement. This study aims evaluating the characteristics of validity and reliability of FoCUS applied on Chagas disease patients. Patients with Chagas disease coming from an endemic area were selected from a large cohort (SaMi-Trop). A simplified echocardiogram with only three images was extracted from the conventional echocardiogram performed in this cohort. The images were evaluated by an observer who was blinded to the clinical and echocardiographic data, to determine the accuracy and reliability of FoCUS for cardiac assessment. The analysis constituted of 5 prespecified variables, dichotomized in absence or presence: left ventricular (LV) size and systolic function, right ventricular (RV) size and systolic function, and LV aneurysm. We included 725 patients with a mean age of 63.4 ± 12.3 years, 483 (67%) female. Abnormal electrocardiogram was observed in 81.5% of the patients. Left and right ventricular dysfunctions were found in 103 (14%) and 49 (7%) of the patients, respectively. Sensitivity, specificity, positive predictive value and negative predictive value were 84%, 94%, 70% and 97% for LV enlargement and 81%, 93%, 68% and 97% for LV systolic dysfunction, respectively, and 46%, 99%, 60% and 98% for RV dilatation, and 37%, 100%, 100% and 96% for RV dysfunction, respectively. Inter and intraobserver agreement were 61% and 87% for LV enlargement and 63% and 92% for LV dysfunction, respectively, and 50% and 49% for RV size and 46% and 79% for RV dysfunction, respectively. LV apical aneurysm was found in 45 patients (6.2%) with the lowest sensitivity of FoCUS study (11%; 95% CI 2-28%). FoCUS showed satisfactory values of validity and reliability for assessment of cardiac chambers in patients with Chagas disease, except for apical aneurysm. This tool can identify heart disease with potential impact on patient management in the limited-resource setting.

Akut Anterior Miyokard İnfarktüsü Geçiren ve Primer Perkütan Koroner Girişim Uygulanan Hastalarda Sol Ventrikül Apikal Trombüs Oluşumunun Öngördürücüleri: SYNTAX Skorunun Önemi

Aim: Left ventricular (LV) apical thrombus development is one of the important advers event patients with anterior ST elevation myocardial infarction (STEMI) and accompanies with LV apical aneurysm and systolic dysfunction. SYNTAX score is an important determinant of cardiovascular morbidity and mortality in patients with coronary artery disease. We aimed that the relationship between LV apical thrombus and SYNTAX score and other clinical risk factors patients with anterior STEMI Methods: A total of 205 consecutive anterior STEMI patients undergoing primary PCI (35 female/ 170 male mean age: 55.8 ± 9.6 years) were included in our study. We assessed the severity and complexity of coronary artery disease by using SYNTAX score. The patients were divided into two groups; patients with apical thrombus (n=19) and patients without apical thrombus(n=186). Results: We found that systolic and diastolic blood pressure were lower patients with apical thrombus groups. (p<0.001 for both). Syntax score was higher and LV ejection fraction (LVEF) is lower in patients with apical thrombus (p<0.001 for both). We also showed that LV apical thrombus formation was independently associated with lower systolic blood pressure (p=0.006), SYNYAX score (p=0.003), and depressed LVEF (p=0.001). Conclusion: In this study, impaired LVEF, lower systolic blood pressure and SYNTAX score have been found to be predictors of LV thrombus generation. Patients presenting with anterior myocardial infarction who have high SYNTAX scores (> 18.25) at PPCI should be followed up closely.

Early diastolic mitral regurgitation in left ventricular aneurysm.

Diastolic mitral regurgitation is a type of functional mitral regurgitation that develops via a reversal of the left atrioventricular pressure gradient during diastole. This study aimed to explore the mechanism underlying early diastolic mitral regurgitation (EDMR) in patients with left ventricular (LV) aneurysms after anterior myocardial infarction (AMI) by assessing the intraventricular pressure difference using vector flow mapping. We enrolled 23 consecutive patients with LV aneurysms (with and without EDMR) and 15 healthy men as controls. In the control group, LV suction began from the apex during early diastole. In contrast, the blood that pooled in the apical aneurysm during systole generated a relatively higher pressure at the apex than at the basal LV during early diastole; consequently, the pressure reversal phenomenon occurred in the LV. Compared to the EDMR- group, the EDMR + group (n = 7) exhibited a significantly higher diastolic time ratio ([time from the second heart sound to the pressure inversion point]/[total diastolic time]) (P < 0.001). The diastolic time ratio was significantly correlated with log BNP, but not with E/A, E/E', or the left atrial expansion index. In conclusion, EDMR in LV aneurysm may be due to a prolonged diastolic time ratio leading to prolonged pressure inversion in the LV during early diastole.

Multi-modality imaging in hypertrophic cardiomyopathy: intermodal discrepancies in key prognostic parameters

Abstract Background/Introduction Multi-modality imaging is crucial for confirming diagnosis and assessing prognosis in patients with hypertrophic cardiomyopathy (HCM). However, inter-modality discrepancies in key parameters are commonly reported. Purpose To assess real-world inter-modal reporting discrepancies between transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) imaging in the measurement of four key parameters in HCM patients. Methods Consecutive HCM patients with TTE and CMR performed within 6 months of each other at a tertiary centre were retrospectively assessed for reported maximum wall thickness (MWT), left atrial diameter (LAd), left ventricular ejection fraction (LVEF) and presence of left ventricular apical aneurysm (LVAA). The CMR report was considered gold standard. Data are reported as mean ± standard deviation (SD) or median and interquartile range (IQR) as appropriate. Results 353 consecutive HCM patients (72% male, median age 60.9 years, IQR 49.8–71.6 years) with TTE and CMR within 6 months (median difference 1.7 months, IQR 1.1–3.4 months) were assessed between 4th January 2018 and 9th April 2019. Of 284 patients with paired MWT data, median difference was 0.0 mm (IQR −1.0 to 3.0 mm, p=0.02), likely representing a difference in distributions of MWT. TTE both over and underestimated MWT (in 36% and 46% cases respectively). Of the 94 patients with paired LAd data, mean difference was 0.4±5.7 mm (95% CI −0.8010 to 1.546, p=0.5). N=320 patients with paired LVEF data (after excluding patients with atrial fibrillation (n=20)). Median difference in LVEF was 12% (IQR 5–19% p&amp;lt;0.0001). TTE underestimated LVEF in 88% of cases. CMR and TTE both identified 14 (5%) patients as having LVEF &amp;lt;50%. There were however 8 cases of disagreement in classification of LVEF &amp;lt;50%, due to over (n=4) or underestimation (n=4) by TTE. LVAA was accurately identified by TTE in only 9/30 (30%) of those patients with demonstrable LVAA by CMR (p=0.0008). TTE evidence of a discreet apical chamber (paradoxical jet on spectral or colour Doppler) was present in 16/21 (76%) cases where TTE failed to overtly identify LVAA. However, apical or mid-cavity obliteration was reported in 15/21 (71%) cases where TTE failed to identify LVAA. Conclusion(s) Echocardiography and CMR measurements are often used interchangeably in clinical practice but inter-modality discrepancies can affect diagnosis and sudden cardiac death (SCD) risk assessment. This is particularly important for binary risk factors such as LVEF&amp;lt;50% or LVAA which are considered major SCD risk factors in the latest American Heart Association guidelines. 25 (7%) patients in our cohort had major risk factors identified by CMR that were not identified on TTE. CMR is an important, recommended tool where TTE imaging is suboptimal, but attention to more subtle elements of abnormal intracavity blood flow may be able to increase LVAA detection during TTE. Funding Acknowledgement Type of funding sources: None.

Prognosis of apical hypertrophic cardiomyopathy in patients with an implantable cardioverter defibrillator

Abstract Background Prophylactic use of implantable cardioverter-defibrillators (ICDs) to prevent sudden cardiac death (SCD) is widely spread all over the world in patients with hypertrophic cardiomyopathy (HCM). Apical HCM is a phenotype variant of HCM, with hypertrophy predominantly affecting apex, that was initially described 30 years ago. Apical HCM patients may have different clinical prognosis compared with other subsets of HCM. In previous studies, apical HCM patients seem to have a more benign prognosis than other types of HCM. However, little is known about the long-term outcomes of apical HCM and there are many unclear points. Moreover, there are few reports about the clinical prognosis in apical HCM patients with an ICD. Objective The aim of this study is to identify the difference between the prognosis of apical and the other HCM patients with an ICD. Methods We retrospectively analyzed the database of our ICD clinic. All subjects had been implanted with an ICD from October 2006 to August 2017. We classified HCM patients into LV outflow tract obstruction (LVOTO) and midventricular obstruction (MVO), apical HCM and other non-obstructive types. We divided all the patients into apical and other types of HCM, and examined their background, incidence of appropriate ICD therapies, hospitalization for heart failure, electrical storm and death. Results A total of consecutive 62 Japanese HCM patients with an ICD (follow-up period, 86±25 months; age, 67±14 years; male sex, 85%; left ventricular ejection fraction, 57±12%; LV max wall-thickness, 19±5mm; LV apical aneurysm, 9.7%; HCM Risk-SCD, 4.4±3.0) were enrolled in this study. We classified them into 14 apical HCM and 48 other types of HCM patients. The clinical characteristics and major events of these patients are shown in the Figure. During the follow-up periods, there were no significant differences in the incidence of hospitalization for heart failure, electrical storm and death between the 2 groups (p=0.40; p=0.22; p=0.23). Appropriate therapies occurred in 5 of 14 (36%) patients with apical HCM and 4 of 48 (8.3%) patients with other types of HCM (p=0.022). Conclusions Appropriate ICD therapy was more prevalent in patients with apical HCM, compared to patients with other types of HCM. However, the incidences of hospitalization for heart failure, electrical storm and death were not significantly different between two groups. Funding Acknowledgement Type of funding sources: None.

Sudden cardiac death risk stratification in hypertrophic cardiomyopathy: discrepancies persist among guidelines

Abstract Background Differing criteria have been provided on sudden cardiac death (SCD) risk stratification in hypertrophic cardiomyopathy (HCM) by current guidelines. Recently, AHA/ACC proposed an algorithm with novel clinical markers. It remains to be established the impact of this new approach. Purpose Evaluate the impact of the 2020 AHA/ACC guideline on the 2014 ESC and 2011 ACCF/AHA criteria regarding SCD risk assessment and primary prevention implantable cardioverter-defibrillator (ICD) in HCM. Methods The database of a HCM center non-referred cohort was accessed for SCD risk profile between March 2007 and March 2020. The agreement for primary prevention ICD recommendations among guidelines was assessed with the Cohen's and Fleiss' Kappa coefficient, P&amp;lt;0.05. SCD or appropriate ICD shock were defined as the primary end-point. Results A total of 100 patients, age 60±13 years, 55 (55%) females, were followed by 5±3 years. The maximal left ventricular (LV) wall thickness was 18±4 mm, 38 (38%) patients showed a family history of SCD, 22 (22%) syncope, 6 (6%) ejection fraction ≤50%, 2 (2%) LV apical aneurysm, 1 (1%) massive LV hypertrophy, 26 (26%) non-sustained ventricular tachycardia, and 23 (23%) extensive late gadolinium enhancement. An ICD was placed in 17 (17%) patients. According to the 2020 AHA/ACC guideline, 57 (57%) patients met class IIa recommendation, 27 (27%) class IIb, and 16 (16%) class III. The 2014 ESC model classified 14 (14%) in class IIa, 18 (18%) in class IIb, and 68 (68%) in class III. The 2011 ACCF/AHA considered 66 (66%) in class IIa, 6 (6%) in class IIb, and 28 (28%) in class III. The Cohen's Kappa was 0.200 (95% CI 0.292–0.107), P=0.0005, between the 2020 AHA/ACC and the 2014 ESC, and 0.520 (95% CI 0.651–0.388), P=0.0005, between the North American approaches. The Fleiss' Kappa was 0.219 (95% CI 0.303–0.135) P=0.0005 among the three guidelines, whereas it reached 0.221 (95% CI 0.334–0.108) for class IIa, 0.244 (95% CI 0.357–0.131) for class IIb and 0.202 (95% CI 0.315–0.089) for class III, P=0.0005. Figure 1 shows the patient's reclassification with the new guideline. The primary end-points occurred in 7 (7%) patients in a median follow-up of 6 (17–0.4) years. All of them were classified as IIa with the 2011 ACCF/AHA guideline, but only 4 (4%) met this class under the 2020 AHA/ACC, and none in the 2014 ESC model. Conclusion A low agreement was found among guidelines, especially between the 2020 AHA/ACC and the 2014 ESC criteria. The North American systems differed moderately, but the new approach has reduced the cases in class IIa and III recommendation for primary prevention ICD. In contrast, the recent 2020 guideline has increased the number of patients in class IIa in relation to the European model, but both strategies have not protected the totality of patients with SCD or appropriate shock. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Hospital de Clínicas de Porto Alegre Figure 1

412 Polytetrafluoroethylene(PTFE) Pledgets Masquerading As A Pseudo-Aneurysm Of Left Ventricle Apex. A Case Report

Abstract Background TransCatheter Aortic Valve Implantation (TAVI) is now established as an alternative for open aortic valve replacement in high-risk patients with severe calcified degenerative aortic stenosis. Case presentation Here we report a case of a 78 tears old female patient who presented six months following transapical TAVI with a pulsatile mass over the left anterior mini thoracotomy wound. Transthoracic echocardiography showed suspicion of a left ventricular apical aneurysm with no evidence of free pericardial fluid.Contrast enhanced CT reported a large pseudo-aneurysm arising from the apex of the left ventricle extending through the left anterior thoracic wall. She was scheduled for emergency surgical exploration via median sternotomy. Upon median sternotomy there were dense pericardial adhesions limiting the mobilization of the heart specially the apex, which necessitated establishment of cardiopulmonary bypass. The heart was arrested, and the dissection was completed. The cavity in connection with the ventricular apex had purulent contents and the site of the TAVI ventriculotomy was secure with the PTFE pledgets in place with no evidence of leakage. Samples of the cavity fluids had pus cells, but no organisms were grown. The patient made an uneventful recovery and was discharged home 6 days postoperatively. Discussion PTFE pledgets are frequently used in cardiac surgery to support surgical closure. These pledgets on a contrast enhanced CT scan can make it difficult to correctly diagnose and may mimic anastomotic leaks as both give similar hyper-dense appearance on contrast enhanced CT scan

Spatial metabolomics identifies localized chemical changes in heart tissue during chronic cardiac Chagas Disease.

Chagas disease (CD), caused by the parasite Trypanosoma cruzi, is one of nineteen neglected tropical diseases. CD is a vector-borne disease transmitted by triatomines, but CD can also be transmitted through blood transfusions, organ transplants, T. cruzi-contaminated food and drinks, and congenital transmission. While endemic to the Americas, T. cruzi infects 7–8 million people worldwide and can induce severe cardiac symptoms including apical aneurysms, thromboembolisms and arrhythmias during the chronic stage of CD. However, these cardiac clinical manifestations and CD pathogenesis are not fully understood. Using spatial metabolomics (chemical cartography), we sought to understand the localized impact of chronic CD on the cardiac metabolome of mice infected with two divergent T. cruzi strains. Our data showed chemical differences in localized cardiac regions upon chronic T. cruzi infection, indicating that parasite infection changes the host metabolome at specific sites in chronic CD. These sites were distinct from the sites of highest parasite burden. In addition, we identified acylcarnitines and glycerophosphocholines as discriminatory chemical families within each heart region, comparing infected and uninfected samples. Overall, our study indicated global and positional metabolic differences common to infection with different T. cruzi strains and identified select infection-modulated pathways. These results provide further insight into CD pathogenesis and demonstrate the advantage of a systematic spatial perspective to understand infectious disease tropism.

Prognostic implications of different clinical profiles in hypertrophic cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) is a myocardial genetic disease relatively common in the general population with heterogenous clinical presentation, natural history and prognosis. About 60% of HCM patients have a stable clinical course, while others may experience a variety of HCM-related complications which follows relatively independent pathways, and that can be distinguished in different subgroups. These subgroups are represented by patients with left ventricular outflow tract obstruction; patients with end-stage disease and reduced or preserved systolic function; patients with apical hypertrophy; patients with apical aneurysm; patients with atrial fibrillation, patients at high risk of sudden death and patients with preclinical HCM. The purpose of this review was to describe each of these clinical profiles with its prognostic implications.

Supplementary role of left ventricular global longitudinal strain for predicting sudden cardiac death in hypertrophic cardiomyopathy.

We investigated the prognostic role of left ventricular global longitudinal strain (LV-GLS) and its incremental value to established risk models for predicting sudden cardiac death (SCD) in patients with hypertrophic cardiomyopathy (HCM). LV-GLS was measured with vendor-independent software at a core laboratory in a cohort of 835 patients with HCM (aged 56.3 ± 12.2 years) followed-up for a median of 6.4 years. The primary endpoint was SCD events, including appropriate defibrillator therapy, within 5 years after the initial evaluation. The secondary endpoint was a composite of SCD events, heart failure admission, heart transplantation, and all-cause mortality. Twenty (2.4%) and 85 (10.2%) patients experienced the primary and secondary endpoints, respectively. Lower absolute LV-GLS quartiles, especially those worse than the median (-15.0%), were associated with progressively higher SCD event rates (P = 0.004). LV-GLS was associated with an increased risk for the primary endpoint, independent of the LV ejection fraction, apical aneurysm, and 2014 European Society of Cardiology (ESC) risk score [adjusted hazard ratio (aHR) 1.14, 95% confidence interval (CI) 1.02-1.28] or 2011 American College of Cardiology/American Heart Association (ACC/AHA) risk factors (aHR 1.18, 95% CI 1.05-1.32). LV-GLS was also associated with a higher risk for the composite secondary endpoint (aHR 1.06, 95% CI 1.01-1.12). The addition of LV-GLS enhanced the performance of the ESC risk score (C-statistic 0.756 vs. 0.842, P = 0.007) and the 2011 ACC/AHA risk factor strategy (C-statistic 0.743 vs. 0.814, P = 0.007) for predicting SCD. LV-GLS is an important prognosticator in patients with HCM and provides additional information to established risk stratification strategies for predicting SCD.

Echocardiographic risk factors of left ventricular thrombus in patients with acute anterior myocardial infarction.

AimsThis study aimed to identify echocardiographic determinants of left ventricular thrombus (LVT) formation after acute anterior myocardial infarction (MI).Methods and resultsThis case–control study comprised 55 acute anterior MI patients with LVT as cases and 55 acute anterior MI patients without LVT as controls, who were selected from a cohort of consecutive patients with ischemic heart failure in our hospital. The cases and controls were matched for age, sex, and left ventricular ejection fraction. LVT was detected by routine/contrast echocardiography or cardiac magnetic resonance imaging during the first 3 months following MI. Formation of apical aneurysm after MI was independently associated with LVT formation [72.0% vs. 43.5%, odds ratio (OR) = 5.06, 95% confidence interval (CI) 1.65–15.48, P = 0.005]. Echocardiographic risk factors associated with LVT formation included reduced mitral annular plane systolic excursion (<7 mm, OR = 4.69, 95% CI 1.84–11.95, P = 0.001), moderate–severe diastolic dysfunction (OR = 2.71, 95% CI 1.11–6.57, P = 0.028), and right ventricular (RV) dysfunction [reduced tricuspid annular plane systolic excursion < 17 mm (OR = 5.48, 95% CI 2.12–14.13, P < 0.001), reduced RV fractional area change < 0.35 (OR = 3.32, 95% CI 1.20–9.18, P = 0.021), and enlarged RV mid diameter (per 5 mm increase OR = 1.62, 95% CI 1.12–2.34, P = 0.010)]. Reduced tricuspid annular plane systolic excursion (<17 mm) significantly associated with increased risk of LVT in anterior MI patients (OR = 3.84, 95% CI 1.37–10.75, P = 0.010), especially in those patients without apical aneurysm (OR = 5.12, 95% CI 1.45–18.08, P = 0.011), independent of body mass index, hypertension, anaemia, mitral annular plane systolic excursion, and moderate–severe diastolic dysfunction.ConclusionsRight ventricular dysfunction as determined by reduced TAPSE or RV fractional area change is independently associated with LVT formation in acute anterior MI patients, especially in the setting of MI patients without the formation of an apical aneurysm. This study suggests that besides assessment of left ventricular abnormalities, assessment of concomitant RV dysfunction is of importance on risk stratification of LVT formation in patients with acute anterior MI.

Clinical characteristics of hypertrophic cardiomyopathy and restricted cardiomyopathy patients complicating with intracardiac thrombosis

Objective: To investigate the clinical characteristics of patients with hypertrophic cardiomyopathy (HCM) and restrictive cardiomyopathy (RCM) complicating with intracardiac thrombosis. Methods: This is a retrospective observational study. Consecutive patients diagnosed with HCM or RCM and complicated with intracardiac thrombosis (including left and right atrium or ventricular thrombosis), who were admitted to the Heart Failure Care Unit of Fuwai Hospital, Chinese Academy of Medical Sciences, from September 2008 to September 2018, were enrolled in this study. Patients with myocardial infarction were excluded. The general clinical data of the enrolled patients, including demographic data, major complications, laboratory indicators, echocardiographic indicators, drug application and distribution of intracardiac thrombosis, were collected from electronic medical record system and analyzed. Results: A total of 98 patients were enrolled in this study, including 52 patients (53.1%) with HCM and 46 patients (46.9%) with RCM. The most common comorbidity was atrial fibrillation/flutter: 40 patients (76.9%) in HCM group and 36 patients (78.3%) in RCM group. Majority of patients received oral anticoagulants treatment: 43 patients (82.7%) in HCM group and 35 patients (76.1%) in RCM group. Intracardiac thrombosis was mainly located in the left atrium in both HCM group (39 cases (75.0%)) and RCM group (32 cases (69.6%)). Thrombosis was found in ≥ 2 chambers in 7 patients (7.1%). Rate of left atrial thrombosis was the highest (81.6% (62/76)) in HCM and RCM patients complicating with atrial fibrillation/flutter. Intra-aneurysmal thrombosis occurred in 4 out of 5 patients complicated with apical left ventricular aneurysm. The rate of left ventricular thrombosis in patients with left ventricular ejection fraction≥50% was 7.4% (4/54), which was significantly lower than that in patients with left ventricular ejection fraction<50% (34.5%(10/29)) (P<0.01). Conclusion: There are certain distribution characteristics of HCM and RCM patients with intracardiac thrombosis, and the left atrium is the most common site of thrombosis, more attention should be paid in HCM and RCM patients on the diagnosis and treatment of intracardiac thrombosis.

Left Ventricular Apical Aneurysms in Hypertrophic Cardiomyopathy: Equivalent Detection by Magnetic Resonance Imaging and Contrast Echocardiography

Left ventricular (LV) apical aneurysm is a unique morphological entity and novel adverse risk marker existing within the broad phenotypic spectrum of hypertrophic cardiomyopathy (HCM). Its true prevalence in the HCM population is likely underestimated because of inherent limitations of conventional noncontrast echocardiography. The authors hypothesized that contrast echocardiography is a reliable imaging technique compared with cardiovascular magnetic resonance (CMR) for the detection of apical aneurysms. The aim of this study was to assess the effectiveness of contrast echocardiography in the detection of LV apical aneurysms in patients with HCM in comparison with the gold standard, CMR. One hundred twelve patients with HCM identified from an institutional clinical database, who underwent echocardiographic and CMR examinations within 12months and had LV apical aneurysms identified on either or both imaging modalities, were retrospectively analyzed. Discordant cases were reviewed by an expert panel, and a consensus was reached regarding the presence or absence of an apical aneurysm. The reason for any discrepancy was recorded. The mean age of the patients was 59±13years, and 73% were men. Sixty-four (57%) underwent contrast echocardiography. The median interval between echocardiography and CMR was 118days (interquartile range, 61-237days). Thirty-nine patients (35%) had discordance between echocardiographic and CMR findings, of whom 20 had aneurysms reported on echocardiography but not CMR and 19 vice versa. Upon reanalysis by the expert panel, aneurysms were initially missed on CMR in 16 patients (80%), largely because of interpretation error secondary to small aneurysms, with a mean aneurysm size of 0.82±0.38cm in these cases. Before secondary review by the expert panel, contrast echocardiography had sensitivity of 97% compared with 85% for CMR (P=.0198) and 64% for noncontrast echocardiography (P=.0001). After secondary review, contrast echocardiography had sensitivity of 98% compared with 67% for noncontrast echocardiography (P=.0001) and 97% for CMR (P=1.00). Contrast echocardiography has high sensitivity for detecting LV apical aneurysms and should beused routinely in the evaluation and risk stratification of patients with HCM.

Numerical Simulation Study on the Mechanism of Formation of Apical Aneurysm in Hypertrophic Cardiomyopathy With Midventricular Obstruction.

Apical aneurysm was observed to be associated with midventricular obstruction (MVO) in hypertrophic cardiomyopathy (HCM). To investigate the genesis of the apical aneurysm, the idealized numerical left ventricular models (finite-element left ventricle models) of the healthy left ventricle, subaortic obstruction, and midventricular obstruction in HCM of left ventricle were created. The mechanical effects in the formation of apical aneurysm were determined by comparing the myofiber stress on the apical wall between these three models (healthy, subaortic obstruction, and midventricular obstruction models). In comparing the subaortic obstruction model and MVO model with HCM, it was found that, at the time of maximum pressure, the maximum value of myofiber stress in MVO model was 75.0% higher than that in the subaortic obstruction model (654.5 kPa vs. 373.9 kPa). The maximum stress on the apex of LV increased 79.9, 69.3, 117.8% than that on the myocardium around the apex in healthy model, subaortic obstruction model, and MVO model, respectively. Our results indicated that high myofiber stress on the apical wall might initiate the formation process of the apical aneurysm.