Diffuse Left Ventricular Hypokinesis Research Articles

P310 CARDIOPULMONARY EXERCISE TEST IN THE EVALUATION OF A PATIENT WITH HFREF: THE IMPORTANCE IN THE ANALYSIS OF GAS KINETICS

Abstract Introduction exertional dyspnea is a symptom present in several diseases, identifying the origin is of fundamental diagnostic and therapeutic importance. Cardiorespiratory exercise testing (CPET) is a valuable tool not only to assess functional capacity but also for diagnostic and prognostic purposes. Clinical case 55–year–old patient with a history of episode of acute pulmonary edema. Echocardiogram showed FE 35% with diffuse left ventricular (LV) hypokinesis and mild–to–moderate mitral insufficiency (MI). Diagnostic coronarography showed lesion–free coronary tree. An interrupted CPET at 140W showed peak O2 consumption of 23.6 mL/kg/min that excluded indication for cardiac transplantation. An echocardiogram from us confirmed dilated cardiomyopathy (CMPD) with FE=32%, diffuse VS hypokinesia and mild–to–moderate functional MI. CPET was repeated, maximal for respiratory quotient (1.42) interrupted due to muscle exhaustion, indicative of moderate reduction in functional capacity with peak VO2 at 64% of predicted, preserved anaerobic threshold at 51% of VO2 max and reduced VO2/W and Pulse Oxygen Ratio (VO2/HR) values from cardiogenic limitation. Also evident drop in VO2/HR during the final stages of the test and associated change in slope of the VO2/Work relationship a sign of decline in stroke volume and cardiogenic efficiency. Absent signs of ventilatory limitation, pulmonary vascular (Ve/VCO2=20.8 in normal range), or exercise desaturation. In the final phase of the test increase in VCO2 and Ve/VCO2 and Ve/VO2 equivalents. In order to find the explanation to the data collected by CPET, exercise echocardiogram was performed, which revealed the development of severe mitral valvular insufficiency and subsequent pulmonary hypertension justifying the behavior of the parameters collected by CPET. Discussion The oxygen pulse represents a metabolic surrogate for stroke volume. Normally during the active phases of exertion there is a progressive increase followed by a plateau. The evident flattening of the VO2/Work curve during the final phases of exercise and the concomitant decrease in oxygen pulse denote inadequate cardiac performance relative to the increased energy demands during exercise. Conclusions CPET proves to be a valuable clinical tool to guide the diagnostic–therapeutic pathway, particularly in the presence of complex heart disease (CMPD or IM).

765 Is acute response to calcium sensitizers drugs predictive of response to cardiac contractility modulation in NYHA IV patients?

Abstract A 53-years old man presented to our institution with a diagnosis of decompensated heart failure NYHA Class IV. He had a history of ischaemic heart disease with severe biventricular dysfunction, diabetes, hypertension, dyslipidaemia, advanced chronic kidney disease, previous explanation of dual-chamber implantable electronic device (ICD) due to endocarditis and subsequent implantation of subcutaneous ICD in primary prevention. Home therapy included uptitrated angiotensin-converting enzyme inhibitor, β-blocker, loop-diuretic, spironolactone, acetylsalicylic acid, and oral hypoglycemics. Clinical examination showed signs and symptoms of systemic and pulmonary congestion with pleural effusion and ascites. Echocardiography revealed diffuse left ventricular (LV) hypokinesis with an ejection fraction (EF) of 25%, severe right ventricular dysfunction and increased filling pressures. He was treated with high dose of i.v. diuretics with mild improvement of dyspnoea. However, haemodynamic stability was labile with worsening of symptoms as soon as mild down-titration of iv diuretics was attempted. Levosimendan, a calcium-sensitizer inodilator, indicated for short-term treatment of acutely decompensated severe chronic heart failure (HF), was administered with good clinical response. Thus, we thought that the patient could have benefited from contractility modulation therapy (CCM) which acts on intramyocardial calcium handling. CCM is a novel therapeutic option for patients with classes III–IV HF with EF ≥ 25% to ≤ 45% and narrow QRS complex that acts on intramyocardial calcium-handling. CCM proved effective in alleviating symptoms, improving exercise tolerance and quality of life, and reducing hospitalization rates in HF. It improves myocardial contractility, reverses the foetal myocyte gene program associated with HF and facilitates cardiac reverse remodelling. Therefore, an Optimizer Smart System (Impulse Dynamics) was implanted. Two pacing electrodes were placed on the interventricular septum in apical and mid-septal position, respectively. The leads were connected to a pulse-generator in a right pectoral pocket. In the following days, we observed a progressive improvement in clinical status, with gradual resolution of peripheral oedema, dyspnoea and fatigue and significant weight loss. Six-month echocardiography showed a stable value of EF and significant improvement in stroke volume (35.2 ml from 24.8 ml at baseline). The patient did not undergo further hospitalization for decompensated HF and was in stable ambulatory NYHA Class IV. We believe CCM is an option in patients with advanced HF in which avoiding recurrent hospitalizations, with their overt increase mortality, is often a challenging therapeutic goal. 765 Figure

AN ALREADY SICK HEART: A CASE OF FATAL SARS-COV-2 MYOCARDITIS

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) myocarditis has recently been described in case reports. A systematic review in early 2021 found fourteen case reports of myocarditis or myopericarditis secondary to this viral infection. We describe an interesting case of proven non-ischemic cardiac dysfunction in the setting of acute infection. Despite steroid treatment, which has been suggested to have favorable outcomes, our patient did not survive. CASE PRESENTATION: We present a case of a 77-year-old man with extensive electrophysiologic and ischemic cardiac disease who presented to the hospital for generalized weakness, malaise, and shortness of breath. The patient's cardiac history was significant for atrial flutter s/p ablation, coronary artery disease s/p coronary artery bypass graft in the distant past, peripheral artery disease s/p right lower extremity revascularization, and carotid stenosis s/p carotid endarterectomy. SARS-CoV-2 PCR test was positive. The patient had increasing hypoxia which required non-invasive ventilation and eventually, tracheal intubation and mechanical ventilation. The hospital course was complicated by the development of persistent chest pain associated with elevated cardiac enzymes. EKG showed diffuse ST-segment depressions. An echocardiogram revealed diffuse left ventricular hypokinesis and a reduced ejection fraction of 20% which was not present previously. In this setting, the patient was ruled in for acute coronary syndrome and underwent cardiac catheterization. Cardiac catheterization demonstrated patent grafts and no significant obstructive disease. A presumptive diagnosis of myocarditis was made. The patient's clinical status deteriorated despite optimal medical treatment, and he developed hemodynamically unstable atrial fibrillation that did not respond to pharmacologic treatment or cardioversion and resulted in cardiogenic shock and, ultimately, his death. DISCUSSION: SARS-CoV-2 myocarditis has been described in select case reports internationally. Many of these cases are described in patients with no previously identified comorbid conditions. This case suggests that in patients with underlying electrophysiologic dysfunction, SARS-CoV-2 myocarditis is associated with poor outcomes. CONCLUSIONS: The mechanism of the effect of SARS-CoV-2 on the heart is unclear and includes myocarditis or myopericarditis. In our patient, cardiac catheterization which was performed during his hospitalization confirmed no ischemic disease and suggested the presence of myocarditis which was ultimately fatal in the setting of refractory cardiogenic shock. Further research is needed into the optimal management of myocarditis associated with SARS-CoV-2. REFERENCE #1: Sawalha K, Abozenah M, Kadado AJ, et al. Systematic Review of COVID-19 Related Myocarditis- Insights on Management and Outcome. Cardiovasc Revasc Med. Feb 2021;23:107-113. REFERENCE #2: Purdy A, Ido F, Sterner S, et al. Myocarditis in COVID-19 presenting with cardiogenic shock: a case series. Eur Heart J Case Rep. Feb 2021;5(2):ytab028. REFERENCE #3: Fried JA, Ramasubbu K, Bhatt R, et al. The Variety of Cardiovascular Presentations of COVID-19. Circulation. 2020;141(23):1930-1936. DISCLOSURES: No relevant relationships by Sravani Gajjala, source=Web Response No relevant relationships by Stacey Jou, source=Web Response No relevant relationships by Zein Kattih, source=Web Response No relevant relationships by Rosaline Ma, source=Web Response No relevant relationships by Akhilesh Mahajan, source=Web Response No relevant relationships by Vinayak Shenoy, source=Web Response

Fulminant myocarditis associated with severe fever with thrombocytopenia syndrome: a case report

BackgroundSevere fever with thrombocytopenia syndrome (SFTS) is an emerging viral infectious disease with high mortality. It causes multiple organ dysfunction; however, myocarditis has never been reported as a complication with SFTS.Case presentationA 62-year-old previously healthy woman developed fever, fatigue, diarrhea, and a mild consciousness disorder. She visited a local clinic, and laboratory data showed leukocytopenia, thrombocytopenia, and elevation of the aspartate aminotransferase level. She was transferred to Kagoshima University Hospital and diagnosed as having SFTS by real-time reverse transcription polymerase chain reaction. Subsequently, her blood pressure gradually decreased despite fluid resuscitation and vasopressor administration. Based on elevated toroponin I levels in serum, a transient diffuse left ventricular hypokinesis and wall thickening in echocardiography, diffuse ST elevation in electrocardiography, and exclusion of other heart diseases, she was diagnosed as having fulminant myocarditis. After hemodynamic support with inotropic agents, she recovered near normal cardiac function. She was discharged to home on day 28.ConclusionsWe report the first case of fulminant myocarditis associated with SFTS.

Chest Pain and ST-Segment Elevation in an 18-Year-Old Man

An 18-year-old man came to the hospital because of 1 day of chest pain typical of pericarditis. He had had an upper respiratory infection 10days earlier. His electrocardiograms indicated evolving pericarditis. His echocardiogram showed mild, diffuse left ventricular hypokinesia, and his troponin I level peaked at 47.5ng/ml. Thus, he had myopericarditis.

A Case of Cardiac Amyloidosis With Dilated Left Ventricular Chamber and Improvement of Electrocardiogram After Standard Heart Failure Treatment

A 40-years-old man presented with orthopnea, lower limb edema and exertional dyspnea, markedly worsening over last 1 month. He was diagnosed as severe heart failure (NYHA4) and admitted to our hospital in April 2016. An electrocardiogram showed low QRS voltage in the limb leads and poor R progression in the precordial leads (V1-4). Prominent left ventricular (LV) dilation with diffuse LV hypokinesis (LVDd/Ds 68.5/64.2 mm), severe impairment of LV systolic function (LVEF 14%) and left atrium dilatation (55.3 mm) were revealed by echocardiography. Thickness of interventricular septum was 12.3 mm in diastole, without “granular sparkling sign”. Immediately after the admission, medical therapies with intravenous dobutamine, carperitide, furosemide were initiated. His body weight was decreased to 61 kg (−20.4 kg), serum BNP concentration was improved from 1970 pg/dl to 26 pg/dl. On X-ray coronary angiography, there was no significant coronary arterial stenosis. Both myocardial biopsy and subcutaneous fat biopsy demonstrated amyloid deposition, diagnosing him as having AL cardiac amyloidosis. Interestingly, after medical treatment, low QRS voltage were disappeared in limb leads, and the range of QS pattern in the precordial leads became small (only in V1-2). We've reported a case of cardiac amyloidosis with dilated LV chamber and significant improvement of low QRS voltage in limb lead after standard medical therapy.

Takotsubo and surroundings. Step by step postpartum stress-induced cardiomyopathy shows its facet. A peculiar case of atypical takotasubo in the peripartum period

Takotsubo syndrome is an acquired cardiomyopathy with transient and reversible left ventricular dysfunction that can mimic an acute coronary syndrome. It is characterized by ECG abnormalities, including minimal ST-segment elevation and T-wave changes, mild troponin elevation, typical left ventricular regional wall motion abnormalities (apical ballooning) and atypical forms (midventricular or reverse apical ballooning) without significant coronary artery stenosis. Its etiology and pathophysiology remain unclear. The sympathetic system seems to play a central role: its exaggerated response to emotional or physical stress triggers may induce microvascular dysfunction and catecholamine-induced cardiotoxicity due to cyclic AMP-mediated calcium overload. We report our experience highlighting the possible pathophysiological and clinical overlap of emotional-triggered catecholamine cardiotoxicity, arterial hypertension and physiological cardiovascular overload in pregnancy describing an atypical case of takotsubo cardiomyopathy with diffuse left ventricular hypokinesia at onset and subsequent evolution to apical ballooning.

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症例 びまん性左室壁運動の低下を伴ったrigid spine症候群の1例

Eosinophilic Myocarditis due to Churg-Strauss Syndrome With Markedly Elevated Eosinophil Cationic Protein

A 67-year-old woman with asthma visited our hospital with increasing dyspnea and new-onset paresthesia and purpura in her legs. Physical examination showed a wheeze, pretibial edema, and surrounding purpura. Chest X-rays showed cardiac decompensation and an electrocardiogram revealed a new ST-T change. Laboratory data showed leukocytosis, hypereosinophilia (10,450/μL), troponin T(+), elevated BNP, and markedly elevated eosinophil cationic protein (ECP) (> 150 ng/mL). Echocardiography revealed diffuse left ventricular hypokinesis (ejection fraction 30%) with increased wall thickness. Coronary angiography was normal. Cardiac magnetic resonance imaging implied diffuse myocardial edema and subendocardial late gadolinium enhancement. Skin biopsy of purpura showed superfi cial perivascular dermatitis with remarkable eosinophilic infiltrations. No evidence of drug allergies, parasitic infection, or myeloproliferative disorder was detected. Based on these findings, a diagnosis of eosinophilic myocarditis due to Churg-Strauss syndrome was considered. She was administered prednisolone at a dose of 1 mg/kg, cyclophosphamide, and diuretics. Several markers of eosinophilic myocarditis and heart failure gradually improved, including ECP. She was discharged 30 days later with no cardiac event. Eosinophilic myocarditis is characterized by predominantly eosinophilic infi ltration. Eosinophilic granule proteins, such as ECP and major basic protein, play important roles in the pathogenesis of eosinophilic myocarditis. We experienced a rare case of eosinophilic myocarditis due to Churg-Strauss syndrome. Markedly elevated ECP played an important role in the early diagnosis and subsequent reduction in ECP served as a marker of monitoring. In an asthmatic patient with dyspnea, hypereosinophilia, and vasculitis, Churg-Strauss syndrome with eosinophilic myocarditis should be considered.

Pseudoinfarto agudo do miocárdio devido à síndrome da disfunção ventricular apical transitória (síndrome de Takotsubo)

Takotsubo syndrome is characterized by predominantly medial-apical transient left ventricular dysfunction, which is typically triggered by physical or emotional stress. The present article reports the case of a 61-year-old female patient presenting with dizziness, excessive sweating, and sudden state of ill feeling following an episode involving intense emotional stress. The physical examination and electrocardiogram were normal upon admission, but the troponin I and creatine kinase-MB concentrations were increased. Acute myocardial infarction without ST segment elevation was suspected, and coronary angiography was immediately performed, which showed severe diffuse left ventricular hypokinesia, medial-apical systolic ballooning, and a lack of significant coronary injury. The patient was referred to the intensive care unit and was successfully treated with supportive therapy. As this case shows, Takotsubo syndrome might simulate the clinical manifestations of acute myocardial infarction, and coronary angiography is necessary to distinguish between both myocardial infarction and myocardial infarction in the acute stage. The present patient progressed with spontaneous resolution of the ventricular dysfunction without any sequelae.

An Unusual Cause for an Irregularly Irregular Pulse

70-YEAR-OLD woman with metastatic cancer (later deemed pancreatic) came urgently to surgery because of large bowel obstruction. Approximately 1.5 L of ascitic fluid was initially present. The blood loss during exploration, debulking, and construction of an ileostomy was 700 mL. The preoperative electrocardiogram indicated a right bundle-branch block and a left anterior hemiblock. A recent preoperative echocardiogram showed a small pericardial effusion, normal valvular function, and diffuse left ventricular hypokinesis (ejection fraction of 38%). The initial decompression and drainage of the abdomen appeared well tolerated, but the problem shown in Figure 1 occurred during the progress of the surgery. At an FIO2 of 0.7, an arterial blood sample exhibited a pH of 7.43, a pO2 of 273 mmHg, a pCO2 of of 46 mmHg, and a hemoglobin level of 12.9 g/dL. Ionized calcium, sodium, and potassium were 1.08, 134, and 4.2 mmol/L, respectively. Capnograph contour and ventilation pressure patterns were unremarkable, but the pulse oximetry waveform mimicked the arterial trace. What arrhythmia is responsible for the observed arterial pressure waveform?

Disfunción ventricular y edema agudo de pulmón asociado a crisis hipertensiva intraoperatoria. Evaluación clínica y ecocardiográfica

A 39-year-old obese woman underwent surgery to open an obstructed tear duct under general anesthesia. After reversal of the neuromuscular block, the patient had a sudden, severe increase in blood pressure related to nonsustained monomorphic ventricular tachycardia. Acute pulmonary edema and cardiogenic shock developed minutes after treatment with propranolol, labetalol, and nitroglycerin. Intraoperative transesophageal echocardiography showed severe diffuse left ventricular hypokinesis with an ejection fraction under 15%. Hemodynamic stability was achieved with inotropic infusions. Angiography ruled out coronary artery injury and echocardiographic follow-up revealed progressive improvement of ventricular function. We analyze diagnostic possibilities and describe the benefits of echocardiography in the diagnosis and treatment of intraoperative acute heart failure.

A Case of Cardiac Sarcoidosis with Complete Atrioventricular Block Revealed by Gastric Biopsy

A 67-year old woman was emergently admitted because of fainting spells. Electrocardiography showed complete atrioventricular block, and echocardiography demonstrated reduced left ventricular systolic function. Decreased uptake was observed in multiple areas on thallium myocardial scintigraphy; however, coronary angiography showed no significant stenosis. Diffuse left ventricular hypokinesis and complete AV block strongly suggested cardiac sarcoidosis or amyloidosis, but a definitive diagnosis could not be established because histological evidence was lacking. Giant multinucleated cells were incidentally detected on gastric biopsy, and the diagnosis of sarcoidosis was made.

Left ventricular apical cystic thrombus mimicking a hydatid cyst

A 69-year-old man was admitted to the emergency department with dyspnea. His medical history was remarkable for smoking (75 pack-years), chronic obstructive pulmonary disease and ischemic cardiomyopathy. On physical examination, his blood pressure was 100/80 mmHg, his pulse rate was 104 beats/min and he had bilateral moderate pretibial edema. Cardiac auscultation revealed a 2/6 systolic murmur at the apex with distant heart sounds. Auscultation of the lungs revealed bilateral rales with diffuse rhonchi in the lower lobes. On a 12-lead electrocardiogram, poor progression of the pre-cordial R wave and P mitrale were noticed. Two-dimensional echocardiography displayed diffuse left ventricular hypokinesia with an estimated ejection fraction of 15%. A cystic thrombus that did not have a germinative membrane was found at the apex of the left ventricle (Figure 1). Pulmonary computed tomography angiography showed a filling defect in the left ventricle. Tests for Echinococcus granulosus were negative. Heparin, warfarin and heart failure treatment were started. One week later, echocardiography showed that the size of the thrombus had decreased by 25%. The patient did not have any complication related to the thrombus. Figure 1) Left ventricular apical cystic thrombus Left ventricular thrombus is a common complication of severe heart failure. Therapeutic options for such thrombi include anti-thrombotics, anticoagulant therapy, thrombolysis or surgical removal of the thrombus. Clinicians should also consider hydatid cysts in the differential diagnosis, when history and laboratory tests could be used to confirm the diagnosis. But overall, until the diagnosis is established, treatment should also be initiated for a probable diagnosis of thrombus (1,2).

Tc-99m Depreotide SPECT/CT Depicts Myocardial Involvement in a Case of Thrombotic Thrombocytopenic Purpura

We report a case of thrombotic thrombocytopenic purpura (TTP) with cardiac involvement, imaged with Tc-99m depreotide. A 56-year-old man presented with fever, hematuria, and chest pain. Laboratory findings (angiopathic hemolytic anemia, thrombocytopenia, and uremia) were suggestive of TTP. Cardiac enzymes were elevated and diffuse left ventricular hypokinesis was demonstrated by echocardiography. Serum rheumatologic and virologic analysis were negative. A Tc-99m depreotide SPECT/CT study showed diffuse uptake in the myocardium, indicating inflammatory reaction to thrombotic/hemorrhagic myocardial damage. We suggest that Tc-99m depreotide imaging may reveal myocardial involvement in TTP; this could prompt further investigation for potential applications in myocarditis of other etiologies.

Cardiac arrest following anaesthetic induction in a world-class bodybuilder

This is a report of a 41-year-old professional male bodybuilder with a history of active anabolic-androgenic steroid abuse and a normal echocardiogram two years prior to admission who experienced a near-fatal arrhythmia during anaesthetic induction for elective orthopaedic surgery.The patient had severe concentric left ventricular hypertrophy, diffuse left ventricular hypokinesis, decreased ejection fraction and inducible monomorphic ventricular tachycardia. A single-chamber cardioverter/defibrillator was inserted.

Successful Resuscitation from Prolonged Ventricular Fibrillation Using a Portable Percutaneous Cardiopulmonary Support System

From the Departments of Anesthesiology and Intensive Care Medicine and Gastroenterological Surgery, Kawasaki Medical School, Okayama, Japan.TWO cases of ventricular fibrillation (VF) under general anesthesia during noncardiac surgery are presented. Although both patients were refractory to conventional cardiopulmonary resuscitation (CPR), they were rescued using a percutaneous cardiopulmonary support (PCPS) system without any complications. We emphasize the importance of emergency extracorporeal circulation with PCPS as a life-saving measure in prolonged CPR during intraoperative cardiac arrest.A 75-yr-old man was scheduled for gastrectomy under general anesthesia with a diagnosis of early gastric cancer. He had had dilated cardiomyopathy for 5 yr. His medications included an angiotensin-converting enzyme inhibitor, digitalis, and a β-blocker. His physical status was New York Heart Association class II. Preoperative echocardiography revealed mild mitral regurgitation and diffuse left ventricular hypokinesis with an ejection fraction of 34%. Coronary angiography performed 1 month earlier showed mild luminal irregularities in the right and left coronary arteries but no significant stenotic changes.Anesthesia was induced with midazolam, fentanyl, and vecuronium, and the trachea was intubated. Anesthesia was maintained with sevoflurane–oxygen and nitrous oxide. Radial artery and pulmonary artery catheters were inserted, and their pressures were 120/80 mmHg and 25/12 mmHg, respectively. Ten milliliters 1% lidocaine was administered through an epidural catheter inserted from Th8 to Th9, followed by continuous infusion at a rate of 4 ml/h of a mixture of 40 ml 1% lidocaine and 500 μg fentanyl.The surgery proceeded uneventfully with stable hemodynamics and arterial oxygen saturation. When the epigastric artery was ligated 1 h after the surgery was begun, however, VF occurred after ventricular extrasystoles. Closed-chest compression was immediately started by the surgeons, sevoflurane was switched off, and the lungs were manually ventilated with oxygen. For resuscitation, 1.0 mg ephedrine, 3.0 mg epinephrine in total, 80 mg lidocaine, and 20 ml sodium bicarbonate were administered. The findings of arterial blood gas/pH and electrolyte analysis during CPR revealed pH 7.41, 29 mmEq/l pco2, 477 mmHg po2, 131 mEq/l Na, and 4.3 mEq/l K, with a hematocrit of 38%. A peak arterial pressure of 80 mmHg was maintained by closed-chest compression during CPR. The patient could not be defibrillated with direct current shocks despite six attempts (200 J × 3, 300 J, 400 J × 2). The decision to use PCPS was made 25 min after the onset of VF. A 16.5-French, 15-cm perfusion cannula (CX-EB16ASH; TERUMO, Tokyo, Japan) was inserted through the left femoral artery, and a 21-French, 50-cm draining cannula (CX-EB21VSH, TERUMO) was inserted in the right atrium through the right internal jugular vein. Placement of perfusion and draining cannulae was performed using a modified Seldinger technique as follows. After skin preparation and draping, we advanced an 18-gauge needle into the vessels, replaced it with a guidewire, and incised the skin. The percutaneous tract was

Myocardial Ultrasonic Tissue Characterization In A Case Of Myocardial Contusion

Myocardial ultrasonic tissue characterization has been used recently for evaluating myocardial disease. However, it has been unknown whether myocardial ultrasonic tissue characterization is useful for detection of myocardial cotusion. We treated a patient with myocardial contusion in whom we observed changes in cyclic variation of myocardial ultrasonic integrated backscatter. A 61-year-old male was transported to Osaka Prefectural Nakakawachi Medical Center of Acute Medicine after suffering blunt anterior chest trauma due to motor vehicle accident. Second hospital day after the trauma, myocardial contusion showing diffuse left ventricular hypokinesia was diagnosed by electrocardiogram and echocardiogram. After diagnosing myocardial contusion, we evaluated the myocardial ultrasonic tissue characterization with an integrated backscatter imaging system. We analyzed cyclic variation of the integrated backscatter. Cyclic variation was measured in both the anterior and posterior myocardium at the left ventricle. The values of cyclic variation were consistent with recovery of left ventricular function. Thus, we conclude that integrated backscatter examination is a new technique that may be useful in the evaluating myocardial contusion.

Echocardiographic determinants of mitral early flow propagation velocity

Transmitral color Doppler early diastolic flow propagation velocity (Vp) has been correlated with the left ventricular (LV) relaxation time constant τ in dilated cardiomyopathy and ischemic heart disease. The aim of this study was to investigate the independent influence of LV systolic function and geometry, and of LV relaxation, on Vp in an unselected outpatient population. We studied 30 normal subjects and 130 patients (hypertensive LV hypertrophy, aortic valve stenosis or prosthesis, hypertrophic cardiomyopathy, coronary artery disease, dilated cardiomyopathy, aortic or mitral valve regurgitation). In all, we noninvasively measured LV geometry, mass, systolic function, wall motion dyssynergy, and diastolic function (abnormal relaxation or restrictive LV Doppler filling patterns). The Vp was similar in normal subjects and in patients (51 ± 14 vs 53 ± 25 cm/s). In normal subjects, the determinants of Vp at multiple regression analysis were isovolumic relaxation time, 2-dimensional cardiac index, and mitral E-wave velocity-time integral. In all, the main determinants were LV ejection fraction, percent of segmental wall dyssynergy, and isovolumic relaxation time and age. The Vp was highest in hypertrophic (75 ± 25 cm/s, p <0.05 vs normal subjects) and lowest in dilated (35 ± 13 cm/s, p = NS) cardiomyopathy. During multivariate analysis of variance, percent of wall dyssynergy (but not diffuse LV hypokinesia) independently reduced Vp (p = 0.02). The latter was not influenced by the LV filling pattern. Thus, in an unselected clinical population, prolonged relaxation per se does not influence Vp if LV systolic dyfunction and/or wall dyssynergy is absent—the latter factors are important independent determinants of Vp, which is determined by multiple factors.

‘Reversible cardiomyopathy’ in patients with severe scorpion envenoming by Tityus serrulatus: evolution of enzymatic, electrocardiographic and echocardiographic alterations

Severe scorpion envenoming is characterized by cardiocirculatory failure which may lead to pulmonary oedema. These are the major causes of death among victims of scorpion stings. Involvement of the heart has been attributed to the massive release of catecholamines and/or to a direct toxic effect of the venom on cardiac fibres, while pulmonary oedema has been considered to be of cardiogenic or non-cardiogenic origin. We present here the clinical, laboratory, electrocardiographic and echocardiographic data of 12 victims of severe Tityus serrulatus stings. These patients had important echocardiographic evidence of moderate to severe left ventricular (LV) dysfunction with diffuse LV hypokinesia and reduced ejection fraction. Seven developed pulmonary oedema. The clinical course of all the patients was satisfactory and the laboratory, electrocardiographic and echocardiographic changes returned to normal, usually within 1 week of the sting. The important alterations detected by echocardiography as early as during the 1st few hours after the sting, taken together with the enzymatic and electrocardiographic data, confirm that LV dysfunction is responsible, either alone or in combination with other factors, for the cardiac insufficiency and pulmonary oedema encountered in scorpion envenoming.