Inferior Wall Of Left Ventricle Research Articles

Crypt of the left ventricular apex.

A 61-year-old Japanese woman was introduced our hospital because of abnormality in electrocardiography (ECG). She had no symptom, and no past and family history. Three years ago, ECG showed sinus rhythm, negative T waves in I, aVL, V2 to V6 leads, and no left ventricular hypertrophy (Panel A). Echocardiography showed normokinesis (ejection fraction, 64%). Contrast enhanced computed tomography (CECT) showed normal coronary arteries but crypts (arrows) at left ventricular apex with mild hypertrophy (Panel B, C). At this time, ECG showed new negative T waves in II and aVF in addition to progression of negative T waves in I, aVL, V2 to V6 leads (Panel D). CECT showed almost disappearing crypt (arrow) due to progression of apical hypertrophy (Panel E, F). Left ventricular crypts are congenital fissure-like protrusion penetrating more than 50% of the thickness of adjoining compacted myocardium. They are commonly seen in the basal inferior wall of left ventricle and interventricular septum in hypertrophic cardiomyopathy (HCM) and HCM carriers who have not yet hypertrophy. Apical crypt may be one of the markers of progression to apical HCM that is more seen in Japanese.

Additional value of CMR feature tracking parameters for the evaluation of the risk of complex ventricular arrhythmias and sudden cardiac death in patients with Mitral Valve Prolapse

Abstract Funding Acknowledgements Type of funding sources: None. Background Mitral valve prolapse (MVP) with mitro-annular disjunction (MAD) has been associated with complex ventricular arrhythmias (c-VA) and sudden cardiac death (SCD) but risk stratification in this subset of patients remains insufficiently characterized. The aim of this study was to investigate the association between deformation parameters assessed by feature tracking (FT) cardiac magnetic resonance (CMR) in patients with MVP and MAD (MVP-MAD) and c-VA and/or SCD. Methods We included 23 patients (47 ± 13 years; 43 % males) with MVP-MAD, of whom 17 (74 %) presented with c-VA and 6 (26%) with SCD, as well as 20 age- and sex-matched controls (50 ± 18 years; 57% males). All patients underwent CMR with assessment of MAD length, late gadolinium enhancement (LGE), extracellular volume (ECV), global and regional longitudinal (LS), and circumferential strain (CS). RATIO-CS was defined as the ratio between regional CS in the basal inferolateral and mid-inferolateral walls (fig.1). Results In MVP-MAD patients, non-ischemic LGE of the LV inferior and inferolateral wall was observed in 21 patients (50%). As compared to controls, MVP-MAD patients showed lower global LS (-18.7 ±4.1 vs -24.7 ± 5.7 p < 0.001), higher native T1 relaxation time and ECV of the left ventricle (LV) inferolateral wall (1104 ± 63ms vs 1083 ± 66ms p < 0.029 and 0.31 ± 0.03 vs 0.27 ± 0.04 p 0.003), lower CS and LS of the LV mid and inferolateral segments (p < 0.005). Logistic univariate regression analysis showed an increased risk of c-VA in case of LGE presence (OR: 9.52 [2.28-39.7] p = 0.002), a high number of LV segments with LGE (OR: 1.78 [1.21-2.63] p = 0.004), GLS (OR: 1.58 [1.21-2.07] p < 0.001), decreased inferolateral mid ventricular wall CS (OR: 1.41 [1.16-1.72] p < 0.001), decreased basal and mid-ventricular inferolateral wall LS (OR: 1.11 [1.00-1.23] p = 0.047 and OR: 1.62 [1.22-2.13] p < 0.001 respectively), increased native T1 times (OR: 1.01 [1.00-1.02] p = 0.039), increased ECV of the basal infero-lateral wall (OR: 4.93e + 07 [1.22-1.98e + 15] p = 0.047) and decreased RATIO-CS (OR: 7.48 [1.87-30.00] p = 0.005) (table 1). In multivariate analysis the presence of a lower LS in the basal inferolateral wall remained an independent predictor of c-VA (OR: 1.62 [1.22-2.13.00] p = 0.0007) and RATIO-CS remained an independent predictor of SCD (OR: 7.73 [1.78-33.60] p = 0.006). Conclusion Lower inferolateral LS and RATIO CS are respectively associated with c-VA and SCD in MVP-MAD patients. FT may provide additional value for risk stratification on top of standard CMR parameters in this subset of patients. Abstract Figure. fig.1 Abstract table 1

Трудности диагностики инфаркта миокарда нижней стенки левого желудочка с вовлечением правого желудочка

The article presents a clinical observation of myocardial infarction (MI) of the inferior wall of the left ventricle (LV) with ST-segment elevation in combination with damage to the right ventricle (RV). Unfortunately, there is often a delay in the timely diagnosis of RV involvement in the process. This is because, at the beginning of the symptoms, it may not differ clinically from the typical manifestations of MI of the inferior-diaphragmatic region of the LV. However, the combination of LV inferior wall MI with RV MI is an important, negative predictor of increased mortality in these patients. In this case, RV MI was diagnosed after stenting of the right coronary artery, only when signs of hypotension and increased pressure of the jugular veins appeared. Based on the analysis of this clinical case, the authors discuss the need to record an ECG of the right heart in most patients with inferior MI, especially in the presence of hypotension without signs of acute left ventricular failure.

1116 Atypical, cardiac location of melanoma

Abstract A 66 – year – old woman, never treated because of any cardiac illnesses in the past, suffering from the chest pain evoked by physical activity, came to the outpatient clinic on January, 12 th 2019 for the diagnostics. Clinical examination, apart from an elevated blood pressure – 180/100 mmHg, showed no changes. In the ECG – SR 55 bpm. Performed TTE revealed an abnormal structure, having the dimensions 41x29 mm. Heart chamber dimensions, except for moderately enlarged LA, were in the normal range; ejection fraction was preserved. The patient was referred to the Department of Cardiology aiming at further diagnostics. In the course of hospitalization CT of the heart was done, during which the presence of hipodensic, mobile tissue change, having irregular borders, coming out of left ventricle wall was confirmed. PET examination excluded the existence of other remote changes. TEE corroborated the diagnosis of a tumor, originating from the inferior wall of left ventricle. Performed angiography ruled out significant changes in coronary arteries. Subsequently, the patient underwent the removal of the left ventricle tumor on February, 2 nd 2019 in the Department of Cardiosurgery. Histopathological examination result after the surgery wasn’t unequivocal – differential diagnosis should have included melanoma, myoepithelial cancer and MPNST ‘high – grade’ sarcoma. Immunohistochemical examination was continued. In the meantime, a control TTE was performed, which detected a tumor 14x10 mm. After the immunohistochemical examination results a woman was qualified to immunotherapy with the usage of pembrolizumab, initiated on March In TTE done on March, 30th 2109 the dimensions of tumor 30x20 mm suggested the disease progression. Therapy was continued. Next echocardiography didn’t visualise the presence of tumor. The patient was after the second cycle of chemotherapy. Abstract 1116 Figure.

Persistence of Late Gadolinium Enhancement in Post-Acute Myocarditis Imaging

Background: Diagnosis of acute myocarditis (AM) is based on combining ECG and seromarkers, but endomyocardial biopsy (EMB) remains the gold standard. Cardiac Magnetic Resonance (CMR) has been established as a reference standard for the non-invasive diagnosis. CMR is useful for follow-up since it is able to non-invasively delineate the presence and extent of myocardial edema and myocardial left ventricle (LV) lesions, represented by late gadolinium enhancement (LGE). The follow-up depends on the individual scenario. The aim of this study is to correlate CMR findings with cardiac enzymes and inflammatory markers in patients with AM and to evaluate the utility of CMR follow-up, even after the resolution of the symptomatology.Methods: Between 2008 to 2016 thirty-three consecutive patients with clinical and laboratory suspicion of AM referred for CMR within seven days from the beginning of the symptoms. The final analysis included 24 patients with AM CMR-confirmed. The follow-up was performed between 3 and 24 months from the diagnosis. CMR was performed using a standard protocol. Presence of edema and extent of myocardial LGE were examined. The comparison between the proportion of patients affected by edema at onset and that of patients affected at the various follow-up was conducted through the test of Mc Nemar. The effect of the predictors on the outcome was evaluated with a nonparametric two-sample Wald test.Results: All patients showed edema and LGE at baseline CMR. The LV lateral wall resulted the most affected by edema (in particular the 12th segment), inferior and lateral wall of LV were the most involved by LGE. There was a highly significant effect (P<0.001) of the Troponin peak on the number of areas involved by LGE. At CMR follow-up, edema has resolved in all patients, LGE persisted in 23/24 patients.Conclusions: There is a correlation between the levels of troponin and myocardial LGE extension in baseline CMR but not between clinical conditions of the patients and post-myocarditis imaging. The presence and the extent of LGE in CMR follow-up are not predictive of outcome in patients without severe hemodynamic compromise, but it can be considered rather an early sign of poor prognosis.

Infective Endocarditis of the Mitral Valve in a Patient with Congenital RCA to LV Fistula

A 26-year-old female recent nursing graduate from the Philippines presented to the Emergency Department with 4-week history of intermittent fevers. This occurred following dental root canal and filling 5 months earlier. Physical examination revealed a pansystolic murmur in the left sternal edge. Blood cultures were positive for Streptococcus anginosus (one of the Milleri group Streptococci) with penicillin MIC of 0.125. Transthoracic echocardiography (TTE) demonstrated markedly dilated right coronary artery (RCA) with RCA fistula noted between the distal RCA and entering the basal inferior LV wall. Left ventricle (LV) was mildly dilated with normal systolic function (EF 58%). A transoesophageal echocardiogram revealed a strand-like echodensity (3.3 mm length) associated with the posterior mitral valve leaflet tip. There was significant dilation of the RCA (ostial RCA 1.5 cm) visualised traversing over the RV outflow tract and connecting into the basal inferior LV cavity. High turbulent diastolic flow was demonstrated consistent with RCA to LV fistula. Cardiac MRI revealed RCA to LV fistula flow representing 28% of aortic flow. A partial anomalous pulmonary venous drainage of the right upper lobe to the superior vena cava was detected. The patient was treated with 42 days of intravenous penicillin. Repeat TTE showed mild posterior mitral valve leaflet thickening with grade 0-1/4 mitral regurgitation. A 3D printed model (Fig. 1) was presented at a multidisciplinary team meeting. As LV fistulae pose a risk for rupture, a decision was made for elective percutaneous closure six months after demonstration of clearance from infection and normal inflammatory markers.

PP-027 A Patient Presented with Acute Inferior Myocardial Infarction and Left Anterior Descending Artery Stenosis and Thrombus Formation

A Patient Presented with Acute Inferior Myocardial Infarction and Left Anterior Descending Artery Stenosis and Thrombus Formation. Cengiz Ozturk, Mustafa Aparci, Ali Osman Yildirim, Sait Demirkol, Murat Unlu, Zekeriya Arslan, Sevket Balta, Mustafa Demir, Turgay Celik, Atila Iyisoy. Department of Cardiology, Gulhane Medical Faculty, Ankara, Turkey; Department of Cardiology, Eskisehir Military Hospital, Eskisehir, Turkey; Department of Cardiology, Kasimpasa Military Hospital, Istanbul, Turkey; Department of Cardiology, Mevki Military Hospital, Ankara, Turkey. Acute inferior myocardial infarction is characterized infarction of inferior wall of left ventricle that is territory of right or circumflex coronary artery, frequently occurs with abrupt obstruction of any else of these arteries. We report a case of inferior myocardial infarction that diagnosed clinically and electrocardiographically but angiographically no any culprit lesion in right or circumflex coronary artery but serious lesion and thrombus without complete obstruction in proximal left anterior descending artery. A 38 years old man without previous cardiac history and risk factories is admitted to our coronary care unit with typical chest pain last as 20 minutes as in last 24 hours. The patient feels chest discomfort during moderate exercise last a month. Physical examination revealed blood pressure and heart rate were 117/70mmHg and 80/beat per minute. Heart sounds were normal with no any murmur. Respiratory sounds were normal. His ECG revealed sinus rhythm, ST segment elevation and pathological Q wave in lead 2,3 and aVF and posterior leads (figure1). Echocardiographic findings included left ventricular ejection fraction %60, left ventricular apical hypokinesia and left ventricular diastolic dysfunction (grade 1). Laboratory findings revealed maximum troponin I:0,684 ng/ml, maximum CKMB:54U/l and other routine biochemical parameters were normal. The patient was taken to catheter laboratory for coronary angiography and PCI. In coronary angiography, right and circumflex coronary artery were normal but there is serious stenosis and thrombus formation in the proximal of left anterior decsending artery(figure2). We decided to perform intravascular ultrasonography to evaluate the degree of lesion severity. Intravascular ultrasonography showed serious stenosis and thrombus (figure3). The patient was referred to cardiovascular surgery for coronary artery bypass grafting. Acute STEMI is a condition required emergency revascularization. Our case confirms clinically acute inferior myocardial infarction. We performed coronary angiography but we did not see any culprit lesion in right or circumflex coronary artery and their branches. However, there is severly stenosis and hazy view in proximal segment of left anterior descending artery. Because of inflamatory markers are normal, miyocarditis is low probability. Both echocardiographically left ventricle apical hypokinesia and seriously stenosis and thrombus (see figure 2-3) in the proximal segment of LAD was associated acute coronary syndrome. We referred the patients to cardiovascular surgery for CABG.

Anectodal Report of Anomalous Circumflex Associated with Pathological Scintigraphy in a Patient with Atypical Chest Pain.

The incidence of Coronary Artery Anomalies (CAA) in routine Coronary Angiography(CAG) is between 0.6% and 1.5%. Most anomalies are not of clinical significance, but some are related to angina, dyspnoea, syncope, acute myocardial infarction andsudden death. Diagnosis and adequate imaging of CAA are crucial for appropriate patient management, especially in patient candidates for Percutaneous Coronary Intervention (PCI) and cardiac surgery. This report describes the anomalous origin of the Left Circumflex Artery (LCX), arising by the right sinus of Valsalva and associated with the presence of hypoplasicLeft Anterior Descending Coronary Artery (LAD) that correlates with myocardial scintigraphy findings of reduced uptake in the anterior and inferior wall of left ventricle.

Subclinical Cardiotoxicity Detected by Strain Rate Imaging up to 14 months After Breast Radiation Therapy

Strain rate imaging (SRI) is a new echocardiographic modality that enables accurate measurement of regional myocardial function. We investigated the role of SRI and troponin I (TnI) in the detection of subclinical radiation therapy (RT)-induced cardiotoxicity in breast cancer patients. This study prospectively included 75 women (51 left-sided and 24 right-sided) receiving adjuvant RT to the breast/chest wall and regional lymph nodes. Sequential echocardiographs with SRI were obtained before RT, immediately after RT, and 8 and 14 months after RT. TnI levels were measured on the first and last day of RT. Mean heart and left ventricle (LV) doses were both 9 ± 4 Gy for the left-sided patients and 4 ± 4 Gy and 1 ± 0.4 Gy, respectively, for the right-sided patients. A decrease in strain was observed at all post-RT time points for left-sided patients (-17.5% ± 1.9% immediately after RT, -16.6% ± 1.4% at 8 months, and -17.7% ± 1.9% at 14 months vs -19.4% ± 2.4% before RT, P<.01) but not for right-sided patients. When we considered left-sided patients only, the highest mean dose was given to the anterior left ventricular (LV) wall (25 ± 14 Gy) and the lowest to the inferior LV wall (3 ± 3 Gy). Strain of the anterior wall was reduced after RT (-16.6% ± 2.3% immediately after RT, -16% ± 2.6% at 8 months, and -16.8% ± 3% at 14 months vs -19% ± 3.5% before RT, P<.05), whereas strain of the inferior wall showed no significant change. No changes were observed with conventional echocardiography. Furthermore, mean TnI levels for the left-sided patients were significantly elevated after RT compared with before RT, whereas TnI levels of the right-sided patients remained unaffected. In contrast to conventional echocardiography, SRI detected a regional, subclinical decline in cardiac function up to 14 months after breast RT. It remains to be determined whether these changes are related to clinical outcome. In the meantime, we encourage the use of radiation techniques that minimize the exposure of the anterior LV wall in left-sided patients.

Double‐Chambered Left Ventricle in Echocardiography

In this article, we describe a double-chambered left ventricle (LV) in a 37-year-old man. Its accessory chamber attached to the inferior and posterior wall of LV, and had normal systolic contraction without any regional wall motion abnormality. A double-chambered LV was suspected on echocardiography and confirmed by cardiac computed tomography scanning and cardiac magnet resonance imaging. Our aim is to accentuate the value of echocardiography in this rare anomaly

Diagnostic accuracy of supine and prone thallium-201 stress myocardial perfusion single-photon emission computed tomography to detect coronary artery disease in inferior wall of left ventricle

Prone thallium-201 ((201)Tl) myocardial perfusion single-photon emission computed tomography (SPECT) reduces false-positive rates when evaluating inferior wall abnormalities by minimizing diaphragmatic attenuation. The present study investigates the diagnostic validity of prone (201)Tl stress myocardial perfusion SPECT for detecting coronary artery disease in the inferior wall of the left ventricle in Japanese patients. Of the 104 consecutive patients who underwent (201)Tl stress myocardial perfusion SPECT to diagnose coronary artery disease, we evaluated 46 who underwent image acquisition in both the supine and prone positions, and coronary angiography within 3 months thereafter. Images were acquired in the routine supine position immediately following (201)Tl (111 MBq) injection and 4 h following early acquisition. Images were acquired in the prone position only during the early phase following supine acquisition. We evaluated the SPECT images of the inferior half segments of the left ventricle using a five-point defect scoring system. According to the coronary angiographic findings, we investigated the diagnostic accuracy of stress-rest supine, stress supine, stress prone, and combined supine-prone images. Reduced uptake in the stress supine image of the combined images was considered as attenuation when uptake was normal in the prone image. The sensitivity of the stress-rest supine, stress supine, stress prone, and stress-combined supine-prone images was 77%, 86%, 55%, and 55%, and the specificity was 71%, 54%, 79%, and 83%, respectively. Diagnostic accuracy was the highest in stress-rest supine images. Prone images tended to improve the specificity of detecting coronary artery disease in the inferior wall, but not diagnostic accuracy compared with stress-rest supine images because of decreased sensitivity.

Scintigraphic Evaluation of Cardiac Metabolism and Sympathetic Nerve Function in Alcoholic Cardiomyopathy

A 70-year-old man with alcoholic cardiomyopathy underwent 99mtechnetium-sestamibi (MIBI), iodine-123-labeled metaiodobenzylguanidine (MIBG) scintigraphy and Iodine-123-labeled beta-methyl-iodophenyl pentadecanoic acid (BMIPP) scintigraphy. 99mtechnetium-MIBI identified myocardial damage in the inferior wall of left ventricle. (123)I BMIPP showed low uptake in the inferior wall of the myocardium, concordant to perfusion. (123)I BMIPP and (123)I MIBG showed reduced uptake in the inferior segment of the myocardium, indicating impairment of fatty acid metabolism and sympathetic abnormalities. Damaged myocardium was demonstrated in alcoholic cardiomyopathy. Beta blocker (carvedilol) and angiotensin-receptor blocker (valsartan) were started at low doses, then increased gradually, leading to the improvement of cardiac performance. Cardiac sympathetic nerve function, impaired due to alcoholic cardiomyopathy, was improved with beta-blocker therapy. Cardiac scintigraphy may be useful to assess the extent of myocardial improvement and the response to therapy.

Doppler Tissue, Strain, and Strain Rate Imaging in Pediatric Patients with Alström Syndrome: Are There Regional Functional Abnormalities?

We sought to determine the potential additive usefulness of Doppler tissue imaging (DTI), strain (epsilon), and epsilon rate (SR) imaging in assessing systolic function in pediatric patients with Alström syndrome. We conducted a case-control study at a pediatric hospital with 5 patients (age 5-18 years) with Alström syndrome living in Atlantic Canada and 21 age- and sex-matched healthy control subjects. Standard echocardiographic examination was followed by DTI of the interventricular septum (IVS) and left ventricle (LV) lateral wall, longitudinal epsilon, and SR at the basal, mid, and apical segments of the LV lateral, inferior, and anterior walls, and the IVS. We also imaged radial epsilon and SR of the interventricular posterior wall. For patients versus control subjects, conventional ejection fraction (0.65 vs 0.72) and fractional shortening (0.30 vs 0.35) did not distinguish between groups. DTI-derived s-waves consistently demonstrated significant differences in systolic function (LV lateral wall 0.073 vs 0.100; IVS 0.064 vs 0.080; LV anterior wall 0.066 vs 0.096; LV inferior wall 0.069 vs 0.092 [P < .05 in all positions]). Epsilon differences were observed in the movement of the mid-LV lateral (-10.4 vs -15.2, P = .035), basal LV anterior wall (-16.3 vs -22.9, P = .004), and the apical IVS (-6.3 vs -13.8, P = .015). SR at the midposition of the LV lateral wall (-0.7 vs -1.4, P = .000) also differed between the groups. Substantial diastolic function differences were also observed between patients and control subjects. Detection of systolic and diastolic function abnormalities in patients with Alström syndrome can potentially be enhanced by the use of DTI, epsilon, and SR imaging.

Implications of inferior ST-segment elevation accompanying anterior wall acute myocardial infarction for the angiographic morphology of the left anterior descending coronary artery morphology and site of occlusion

Inferior ST-segment elevation during anterior wall acute myocardial infarction (AMI) due to left anterior descending (LAD) coronary artery occlusion is unusual and was not previously investigated. This study tested the hypothesis that inferior ST-segment elevation during anterior AMI predicts a specific angiographic morphology that satisfies 2 necessary conditions: (1) mass of ischemic anterior wall myocardium is relatively small, resulting in a weaker anterior injury current and less reciprocal inferior ST-segment depression; and (2) there is concomitant inferior wall transmural ischemia that further shifts the inferior ST segments upward. The study group consisted of 42 consecutive patients with anterior AMI undergoing angiography at 4.1 days (range 0 to 14). Coronary angiograms were examined for 3 features: (1) site of LAD artery occlusion (a distal obstruction implying a smaller mass of ischemic anterior wall myocardium), (2) LAD artery extension onto inferior wall of left ventricle (termed a “wrap around” vessel), and (3) collateral flow from LAD artery to inferior wall. The latter 2 features would be expected to contribute to inferior wall transmural ischemia. Acute inferior ST-segment elevation (sum of ST-segment deviation in leads II, III and aVF ≥3.0 mm) was seen in 7 patients (16%). A greater number of LAD artery branches proximal to the site of occlusion was significantly correlated with less inferior ST-segment depression (r = 0.59, p < 0.01). The 33 patients with an LAD artery that “wrapped around” the cardiac apex to the inferior wall had less total inferior ST-segment depression than that of the 9 with a shorter artery (0.2 ± 4.0 vs -3.0 ± 2.8 mm; p < 0.05). Of the 7 patients with inferior ST-segment elevation, 5 had a wrap around artery with the culprit lesion distal to 3 major branches. This combination of angiographic findings occurred in only 2 of the other 35 patients (odds ratio 44, 95% confidence interval 4 to 632; p < 0.001). These results support the hypothesis that inferior ST-segment elevation during anterior AMI results from a smaller mass of ischemic anterior myocardium combined with simultaneous inferior transmural ischemia (i.e., a distal occlusion in a wrap around LAD coronary artery).