Bilateral Atria Research Articles

A CASE OF ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS WITH INFILTRATING EOSINOPHILIC MYOCARDITIS

TOPIC: Allergy and Airway TYPE: Medical Student/Resident Case Reports INTRODUCTION: Eosinophilic myocarditis (EM) is associated with myriad clinical presentations. With both chronic and acute forms, there exists a wide range of cardiac dysfunction and etiologies, including hyper-eosinophilia, hypersensitivity reaction, and parasitic or fungal infections. Chronic EM is associated with congestive heart failure, a lower mortality rate when compared to acute EM, and clinical response to corticosteroids. Here we present a case of a 57-year-old male with suspected long standing undiagnosed allergic bronchopulmonary aspergillosis, presenting as asthma, leading to infiltrative eosinophilic myocarditis. CASE PRESENTATION: Our patient was diagnosed with asthma at age 45 and he had pansinusitis with recurrent polypectomies. He presented with 10 days of dyspnea, chest tightness, palpitations, and orthopnea. He had no history of cardiac disease. CXR on admission showed bilateral patchy opacities and pleural effusions. CT of the chest demonstrated upper lobe bronchiectasis and pulmonary edema. His EKG was significant for a right axis deviation and new Q waves in V1-V4, consistent with myocardial scarring. An ejection fraction of 30-34% with global hypokinesis was seen on transthoracic echocardiogram.Based on the clinical presentation, he was thought to have allergic bronchopulmonary aspergillosis. When his previous laboratory was reviewed, he had significant eosinophilia that had been persistent over time. Since he had persistent eosinophilia and new cardiomyopathy with possible myocarditis, the diagnosis of eosinophilic myocarditis was suspected. He had no evidence of coronary artery disease on left heart catheterization and cardiac MRI showed scarring of the septal and infero-septal walls, and bilateral atria, consistent with chronic EM. Prednisone therapy was begun and his eosinophil count returned to normal in 5 days and improved to discharge with prednisone therapy. Two weeks later, he had an endomyocardial biopsy (EMB), which showed fibrosis, but no eosinophilic infiltration. He was asymptomatic at his last clinic appointment. DISCUSSION: EM can result in irreversible and fatal myocardial dysfunction. For diagnosis, EMB is considered the gold standard, for which serum eosinophil concentration, echocardiography, and cardiac MRI may assist. Though biopsy in this case showed fibrosis without eosinophilic infiltration, this can be attributed to previous corticosteroid treatment, in addition to variation with tissue sampling. CONCLUSIONS: Our patient had a misdiagnosis of asthma, associated with recurrent nasal polyps, persistent eosinophilia, positive aspergillus IgE and bronchiectasis, consistent with allergic bronchopulmonary aspergillosis. In this case, corticosteroid administration resolved his respiratory and cardiac symptoms. To date, there is no gold standard for treatment; however, regimens typically include corticosteroids, cytotoxic agents, and immunosuppressive therapy. REFERENCE #1: Barry, J.; Gadre, A.; Akuthota, P.; Hypersensitivity pneumonitis, allergic bronchopulmonary aspergillosis and other eosinophilic lung diseases. Current Opinion in Immunology, 2020, 66:129–135. https://doi.org/10.1016/j.coi.2020.10.005 REFERENCE #2: Ralapanawa et al. A young female presenting with heart failure secondary to eosinophilic myocarditis: a case report and review of the literature. BMC Res Notes, 2018, 11(168). https://doi.org/10.1186/s13104-018-3273-1 REFERENCE #3: Sheikh, H.; Siddiqui, M.; Uddin, S. et al. The Clinicopathological Profile of Eosinophilic Myocarditis. Cureus, 2018, 10(12): e3677. doi:10.7759/cureus.3677 DISCLOSURES: No relevant relationships by Kendall Creed, source=Web Response No relevant relationships by Navkiran Randhawa, source=Web Response No relevant relationships by Sabrina Siddiqui, source=Web Response No relevant relationships by Victor Test, source=Web Response

Small cell carcinoma presenting as a biatrial mass with obstructive physiology: a case report

BackgroundSmall cell carcinoma is a highly aggressive and often fatal cancer that most commonly arises in the lung, although it can occasionally arise from other sites, such as the gastrointestinal tract, prostate or cervix. Cardiac involvement, however, is extremely uncommon and therefore has been poorly documented in the literature.Case presentationWe describe a rare case of a 31-year-old male with small cell carcinoma presenting as a massive, 15-cm cardiac tumor invading the bilateral atria, interatrial septum, and pericardium without an apparent primary malignancy on PET CT and cardiac MRI. With extensive tissue necrosis, traditional methods of obtaining a right atrial endomyocardial biopsy via internal jugular venous access failed and a diagnosis was made via endoscopic ultrasound guided transesophageal fine needle aspiration of the left atrial mass. Due to the extensive tumor invasion, the patient was not a suitable candidate for surgical resection, debulking, or heart transplant. The patient was treated with etoposide, carboplatin, atezolizumab, and radiation therapy with initial monitoring in the intensive care unit due to concern that tumor lysis may cause rapid cardiac decompensation. Unfortunately, 4 months after chemoradiation therapy, the malignancy progressed and the patient passed away 6 months after the initial diagnosis.ConclusionWe describe a rare occurrence of small cell carcinoma presenting as a massive cardiac tumor without apparent primary malignancy. This case demonstrates useful alternative diagnostic strategies and treatment considerations for patients presenting with a rare cardiac mass.

Unique Atrial Tachycardia From the Right Inferior Pulmonary Vein Mimicking Multiple Focal Patterns in the Bilateral Atria and Aorta

Unique Atrial Tachycardia From the Right Inferior Pulmonary Vein Mimicking Multiple Focal Patterns in the Bilateral Atria and Aorta

Cardiac mucormycosis: a case report.

BackgroundMucormycosis is an invasive fungal infection (IFI) most commonly seen in immunocompromised patients. Diabetic ketoacidosis, haematopoietic transplantation, iron overload states, and deferoxamine therapy are considered to be some of the classical risk factors. While cutaneous and rhino-sinusoidal forms may be seen in immunocompetent (IC) individuals, cardiac and mediastinal involvement is rare. In this report, we describe a young patient without predisposing factors who presented as mediastinal mucormycosis with extensive cardiac involvement.Case summaryA 19-year-old male presented with complaints of dry cough and dyspnoea on exertion over the last 4 months. Echocardiography showed diffuse infiltration of both atria along with multiple pedunculated freely mobile masses. A computed tomography chest was done to further delineate the true extent of the disease and revealed diffuse infiltration of the mediastinum, bilateral atria and interatrial septum, pulmonary veins, and superior vena cava. A fine needle aspiration cytology from a mediastinal mass revealed broad aseptate fungal hyphae with right angled branching consistent with Mucor. Extensive evaluation could not find any predisposing factors. The patient was started on Amphotericin B and surgical debridement was contemplated. However, owing to the diffuse infiltration around the heart and mediastinal vasculature, debridement could not be performed and the patient eventually succumbed to the illness.DiscussionMediastinal mucormycosis though rare in IC patients, is a rapidly progressive condition with a high fatality. A high index of suspicion needs to be maintained in individuals presenting with infiltrative disorders of the mediastinum for early diagnosis and prompt treatment.

Optimal Cardiac Magnetic Resonance Contrast-Enhanced Timing Robust Angiography (CMR-CENTRA) for the Three-Dimensional Reconstruction of the Bilateral Atria in the Electroanatomic Mapping (EAM) of Atrial Fibrillation

Optimal Cardiac Magnetic Resonance Contrast-Enhanced Timing Robust Angiography (CMR-CENTRA) for the Three-Dimensional Reconstruction of the Bilateral Atria in the Electroanatomic Mapping (EAM) of Atrial Fibrillation

Positional Relationship Between the Pulmonary Venous Confluence-Vertical Vein and Atria in Infracardiac Total Anomalous Pulmonary Venous Connection.

To explore the positional relationship between the pulmonary venous confluence-venous vein (PVC-VV) and both the atria in infracardiac total anomalous pulmonary venous connection (iTAPVC), using two-dimensional (2D) computerized tomography (CT) reconstruction. Through the 2D reconstruction of enhanced cardiac CT images of patients with iTAPVC, the projection of PVC-VV on coronal axial images was acquired and its location on the bilateral atrial splice was analyzed. Sagittal axial reconstruction was used to identify which atrium had a precise anterior-posterior positional relationship with PVC-VV. The type of iTAPVC, where the projection of PVC-VV was lying on the left atrium, and the left atrium had a precise anterior-posterior positional relationship with PVC-VV, was classified as the left atrial type. If the projection of PVC-VV was lying on the right atrium and the right atrium had a precise anterior-posterior positional relationship with PVC-VV, it was classified as the right atrial type. Finally, if the projection of PVC-VV was lying in the middle of the bilateral atria, and both the atria had precise anterior-posterior positional relationship with PVC-VV, it was referred to as the bilateral atrial type. Upon analysis of the 22 enhanced cardiac CT images, 6 were the left atrial type (27.27 %), 9 were right atrial type (40.91 %), while 7 were of the bilateral atrial type (31.82 %). The positional relationship between PVC-VV and the bilateral atria are variable, and iTAPVC classification using 2D CT reconstruction is an invaluable tool in designing the surgical approaches in iTAPVC.

Heterotaxy syndrome: an autopsy case report and review of the literature

Heterotaxy, also referred to as atrial isomerism or situs ambiguous, is a rare group of heterogeneous developmental disorders of lateralization, characterized by disruption of the normal left-right axis orientation of visceral organs, including the heart, lungs, stomach, spleen, and liver. Lateralization disorders are divided into incomplete (i.e., heterotaxy), and complete (i.e., situs inversus totalis). Heterotaxy is defined by abnormal assembly of the thoracic and abdominal organs from the normal situs solitus, occurring during early embryonic development. Complex cardiac malformations are a major component of heterotaxy syndrome, with consequent significant morbidity and mortality. Atrial appendage isomerism, with either bilateral right atria (right atrial isomerism) or paired left atria (left atrial isomerism) are a pivotal feature, as well as either asplenia or polyspenia. These two features are the cornerstones of the morphologic classification of these disorders. This case study reports autopsy findings in a 39 week old neonate with heterotaxy syndrome, born to a 25 year old G2 P1 mother with no family history of anomalies, with a review of the literature.

Aggressive Atrial Volume Reduction for Bilateral Giant Atria Improves Respiratory Function

Giant bilateral atria with mitral and tricuspid regurgitation can cause postoperative respiratory dysfunction. In this article, we describe a case of giant atria with poor respiratory function that was improved by atrial volume reduction. A 79-year-old woman was referred to our institution for valve surgery. Her vital capacity was 1,080 mL. The mitral and tricuspid valves were repaired during surgery. We removed a circular section of the left atrial wall. The right atrial wall and interatrial septum were removed; this improved her vital capacity to 1,370 mL. We conclude that aggressive volume reduction of both atria improves respiratory function.

Extensive Extranodal Involvement of Rare Sites in Non Hodgkin's Lymphoma Detected on (18)F- FDG PET-CT: A Case Report.

We present a case of a 23year-old male treated for Hodgkin's lymphoma who developed diffuse large B-cell lymphoma (DLBCL) 8years after achieving remission. (18)F-fluorodeoxyglucose positron emission tomography computed tomography ((18)F-FDG PET-CT) was done, which revealed extensive extranodal involvement of bilateral atria, bilateral kidneys, ileo-caecal junction and left testis along with mesenteric and retroperitoneal lymph nodal involvement. Renal and cardiac lesions were not detected by contrast-enhanced CT. Simultaneous lymphomatous involvement of rare sites such as heart, kidneys and testis in a single patient has not been reported before.

Distribution of the Origin Far from His Bundle Area in Adenosine Triphosphate Sensitive Atrial Tachycardia

Introduction: The origin of adenosine-triphosphate (ATP)-sensitive atrial tachycardia (AT) is reported to be adjacent to the His bundle (HB). However, different origins of the AT foci have been reported in previous studies.Methods: We performed electrophysiological study of AT with catheters placed in a normal fashion (high right atrium, HB, coronary sinus, and right ventricle) along with electroanatomical mapping of both atria and aortic cusps. ATs in which earliest activation was recorded at the HB electrode and which were terminated by rapid infusion of ATP (4.7±3.0 mg) were included. We reviewed the data in 10 consecutive cases.Results: All tachycardias were abolished by focal radiofrequency catheter ablation. The successful ablation sites were the non-coronary cusp (n=5), tricuspid annulus (n=3), right atrial septal wall (n=1), and left atrial septal wall (n=1). These successful ablation sites were earlier than that of the HB by 28.2±20.0 msec, 25.0±16.0 msec, 35.0 msec, and 74.0 msec, respectively. In 4 cases (40%, both side of atrial septum, tricuspid annulus) of these 10 cases, the distance between the sites and the HB were greater than 10 mm.Conclusion: When treating ATP-sensitive AT, it is important to perform detailed mapping that includes electroanatomical mapping not only near HB but of the bilateral atria even if the earliest atrial activation is recorded at the HB.

血管撮影装置からのＸ線がペースメーカに影響した例

We performed an experimental study of the influence on pacemakers (PM) of X-rays from the angiocardiography equipment. (1) We used one PM of DDD mode in this study. (2) The PM was irradiated under two exposure levels: one the standard dose and the other the maximum dose in the angiocardiography study situation. (3) We set the pacing lead wires to the bilateral atria and ventricles in Irnich's human body model. (4) We set two irradiation fields, one with a lead block on the PM and the other without the lead block. The result showed that when the PM was included in the irradiation field and the exposure level was of the maximum dose, the influence of irradiation on the PM was that of level 2 as classified by a research report by the Ministry of Internal Affairs and Communications. The absorbed dose of the PM was 93.4 mGy under these conditions. We confirmed that radiation dose does not affect a pacemaker with pacing lead wire. However, it acts on the generator of the PM owing to the direct photoelectric effect. When there were many dose rates (or total radiation dose), an obstacle occurred.

Right-to-Left Shunt Evaluated at the Aortic Arch by Contrast-Enhanced Transesophageal Echocardiography

The right-to-left shunt (RLS) is diagnosed by contrast-enhanced transesophageal echocardiographic monitoring of the bilateral atria (cTEE-BA). However, the procedure is often disturbed by nonsmoke spontaneous individual contrast (NSSIC) with fast motion, which appears in the left atrium after respiratory maneuvers without administration of a contrast medium and moves past in several seconds. We attempted to perform cTEE monitoring of the aortic arch (cTEE-AA) for evaluation of the RLS and compared the findings with those of cTEE-BA. Both cTEE-BA and cTEE-AA were performed in 168 patients with ischemic stroke (133 men and 35 women; mean age +/- SD, 62.0 +/- 14.4 years). The frequency of NSSIC in the left atrium was compared with that in the aortic arch during the respiratory maneuver. When contrast much brighter than the NSSIC was visualized in the left atrium and the aortic arch during the respiratory maneuver with administration of the contrast medium, we considered the RLS to be positive in the cTEE-BA and cTEE-AA, respectively. Findings were then compared between the 2 examinations. Nonsmoke spontaneous individual contrast was more frequently observed in the left atrium than the aortic arch (61.3% versus 14.9%; chi2 test, P < .0001). The RLS was positive in 34 patients in the cTEE-BA and in 39 patients in the cTEE-AA. The sensitivity and specificity of the cTEE-AA for the cTEE-BA were 100% and 96.3%, respectively. The cTEE-AA may be an alternative method for detection of an RLS, especially in patients with a large amount of NSSIC in the left atrium.

Identification of a Novel Human Ankyrin-Repeated Protein Homologous to CARP

We cloned a novel ankyrin repeat protein, Arpp, by immunoscreening a cDNA library constructed from a human esophageal carcinoma cell line, TE1, with an antibody directed to a hypothetical protein encoded by antisense p53 mRNA. Arpp protein is composed of 333 amino acids and contains four ankyrin-like repeat motifs in the middle portion of the protein, a PEST-like sequence and a lysine-rich sequence similar to a nuclear localization signal in the N-terminal region, and a proline-rich region containing consensus phosphorylation sites in the C-terminal region. Protein sequence analysis revealed that Arpp is homologous (52.7% identity) to Carp which is shown to be involved in the regulation of the transcription of the cardiac ventricular myosin light chain 2 gene. Arpp mRNA was found to be expressed in normal skeletal and cardiac muscle. Interestingly, Arpp expression was detectable in bilateral ventricles, but undetectable in bilateral atria and large vessels, suggesting that Arpp may play a specific function in cardiac ventricles as well as skeletal muscles.

A family with idiopathic dilatation of bilateral atria

A family with idiopathic dilatation of bilateral atria

Marked electrocardiographic enlargement of bilateral atria in two cases of juvenile hypertrophic cardiomyopathy

Marked electrocardiographic enlargement of bilateral atria in two cases of juvenile hypertrophic cardiomyopathy

HNK-1 expression pattern in normal and bis-diamine induced malformed developing rat heart: three dimensional reconstruction analysis using computer graphics.

The spatiotemporal distribution of the immunoreactivity of monoclonal antibody HNK-1 was investigated immunohistochemically in normal and bis-diamine-induced malformed rat embryonic hearts using three-dimensional reconstruction with computer graphics. First recognized in the primitive heart 11.5 days after conception, HNK-1 immunoreactivity was distributed in the atrio-ventricular and bulbo-ventricular junctional areas with incomplete ring-like appearance in the early embryonic stages. In the late embryonic stages the immunoreactive sites were rearranged and localized in the sites topographically corresponding to almost the entire pathway of the conduction system, including the three major internodal tracts connecting the right sinoatrial node and atrioventricular node. Immunoreactivity gradually decreased after the completion of the conduction system, and only a faint reactivity in the atrio-ventricular node region remained in the new-born heart. These results indicate that HNK-1 is expressed temporarily in the pathways corresponding to the conduction system during the development of the heart. In bis-(dichloroacethyl)-octamethylen-diamine (bis-diamine)-induced malformed hearts, localization of HNK-1 immunoreactivity was not remarkably altered in the early embryonic heart. In the late embryo, immunoreactive sites in the sino-atrial node region and atrio-ventricular node region deviated dorsocaudally with the poorly developed internodal tracts, and abnormal distribution was observed in the bilateral atria. We consider that these abnormalities may occur in conjunction with abnormal morphological development such as insufficient absorption of the sinus venosus.

Immunohistochemical localization of atrial natriuretic polypeptide (ANP) in human atrial and ventricular myocardiocytes.

To date, there have been few immunohistochemical investigations of atrial natriuretic polypeptide (ANP) in human cardiac tissue, especially the ventricles. In this study, myocardial tissue was obtained from two sources: the bilateral atria and ventricles at autopsy; and biopsy tissues from the right auricle and left ventricle of a patient with myocardial infarction undergoing surgery. These tissues were examined by the avidin-biotin immunoperoxidase technique using three kinds of primary ANP-antibodies. ANP-immunoreactivity was observed in the perinuclear region of myocytes of all tissues examined. The intensity of the reaction was stronger in atrial tissue, weaker in ventricular tissue. In the later tissue, the positive-staining myocytes were not part of the pulse-conducting system. Although the tissues we studied were not obtained from normal hearts, our data demonstrates that ANP-reactivity can be detected in ventricular myocytes outside the pulse-conducting system.

Simultaneous measurement of atrial natriuretic polypeptide (ANP) messenger RNA and ANP in rat heart — Evidence for a preferentially increased synthesis and secretion of ANP in left atrium of spontaneously hypertensive rats (SHR) —

Tissue levels of atrial natriuretic polypeptide (ANP) messenger RNA (ANPmRNA) and ANP in the rat heart were measured simultaneously. In Wistar rats, ANPmRNA of the same size (approximately 0.95 kbp) was detected in all four chambers of the rat heart. The ANPmRNA level was the highest in the right atrium, and the left atrial level was slightly lower than the right atrial level. Ventricular levels were more than two orders of magnitude lower than atrial levels. Tissue ANP concentrations of four chambers were roughly parallel to ANPmRNA levels. In spontaneously hypertensive rats (SHR) with the elevated plasma ANP level, the ANPmRNA level in the left atrium was substantially increased. The left/right ratio of atrial ANPmRNA level in SHR (150%) was higher than that in control Wistar Kyoto rats (WKY) (90%). In contrast, the left/right ratio of atrial ANP concentration was decreased in SHR (44%) compared with that in WKY (84%). The ratio of ANP to ANPmRNA levels in the left atrium of SHR was about three times smaller than that in the right atrium of SHR, and those in bilateral atria of WKY. These results indicate that the biosynthesis and secretion of ANP from the left atrium is preferentially increased in SHR. Thus, simultaneous determination of ANPmRNA and ANP levels is a refined strategy of investigation for the biosynthesis, storage and secretion of ANP.

Quantitative studies on the ultrastructural differentiation and growth of mammalian cardiac muscle cells. The atria and ventricles of the cat.

Ultrastructural differentiation of cardiac muscle cells in the bilateral atria and ventricles of the cat at 1, 16, 25 and 40 days and 6 months after birth was studied by morphometry on electron micrographs. At the newborn stage, no T-tubule was found in the ventricular muscle cells, but specific granules were already noted in the atrial myocytes. The cell diameter of the ventricular myocardium was greater than that of the atrium at this stage. The T-tubule was first recognized in the ventricular muscle cells at day 16, at which stage the area occupied by the mitochondria and glycogen in the atrial muscle cells was definitely found to differ from that in the ventricular muscle cells. Thereafter, the differences in the ultrastructure between the atria and ventricles became more remarkable, particularly in the cell diameter and in the mitochondrial area. The cat cardiac muscle cells are characterized by numerous lipid droplets within the cytoplasm in contrast to those of the rat and the guinea pig.

Quantitative studies on the ultrastructural differentiation and growth of mammalian cardiac muscle cells. I. The atria and ventricles of the rat.

The postnatal development of myocardial cells in the bilateral atria and ventricles of rats at days 1, 10, 20, 30 and 60 was studied by means of an ultrastructural quantitative method. No clear differences between the right and left myocardium were found throughout the developmental period or in the adult stage. The myocardial cells increased in thickness more rapidly up to day 20 than during the subsequent period. Myofibrils occupied about 50-60% of the cytoplasm of almost all kinds of cardiac muscle cells except those of the newborn atrium. The fraction of mitochondria increased after day 10, whereas that of glycogen conversely decreased. Although the presence of specific granules characterized the atrial myocardial cells even in newborns (day 1), no differences in other cellular components or fiber thickness between the atrium and the ventricle were seen at this stage. The distinction between atrial and ventricular muscle cells, in terms of fiber thickness, mitochondrial and glycogen content, began to appear at day 10 and became increasingly prominent with age until virtually all muscle fibers reached an almost mature state at day 20.