Left Ventricular Hypokinesis Research Articles

Occult coronary artery disease in global severe left ventricular hypokinesia

AimGlobal hypokinesia of left ventricle (GHLV) is uncommon in ICMP that delays the proper treatment because of confusion with DCMP as the closest differential diagnosis. The aim of this study is to evaluate the role of coronary angiogram in unexplained dilated and significant GHLV of with no prior documentation of CAD. Materials and methodsIt is short term prospective study which included 100 consecutive patients during the period Jan-2012 to Feb-2013. The study group consists of patients having dilated and GHLV with significant left ventricular dysfunction without documented CAD before. EF% was computed by Simpson's method. Epidemiological data and details of risk factors were studied. CAG was done in all patients. Viability study was done in 3 cases. Treatment plan was modified after CAG and viability study results depending upon the CAD status. Follow up results at the end of one month were analysed. ResultsOut of 100 patients with dilated and GHLV with severe left ventricular dysfunction, 73 patients had normal CAG and 16 (16%) patients had significant CAD. Three patients underwent CABG and thirteen patients had undergone angioplasty. Only 4 patients developed mild renal dysfunction and improved on follow up. Three patients died during one month follow up with normal coronaries. ConclusionCAD was seen in 27% of patients with dilated and GHLV. CAG is safe even up to LVEF of as low as 20%. The triad of low EF, significant CAD and viable myocardium provides favourable prognosis. Mild CAD needs optimised medication.

Left ventricular apical aneurysm in chronic Chagas cardiomyopathy—A case report

A 56-year-old female, who immigrated to the USA from Honduras, presented with worsening shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and decreased exercise tolerance over the previous 2 months. She was diagnosed 1 year previously with non-ischemic dilated cardiomyopathy and non-sustained monomorphic ventricular tachycardia. An implantable cardioverter defibrillator was placed. Cause for her dilated cardiomyopathy was unknown at that time. On admission, her electrocardiogram showed low voltage complexes, with frequent premature ventricular contractions. Transthoracic two-dimensional echocardiogram (2D ECHO) showed severely reduced ejection fraction of 20%, severe mitral regurgitation with left ventricular (LV) hypokinesis, and inferolateral and inferior wall akinesis. On review of her records, a contrast 2D ECHO from the previous year revealed an aneurysm of the LV apical region. Live three-dimensional (3D) ECHO on her present admission showed persistent LV apical aneurysm. Computed tomography angiogram showed no atherosclerotic lesions. Multiple episodes of non-sustained ventricular tachycardia were recorded on telemetry. Based on these findings, the diagnosis of Chagas cardiomyopathy was entertained. Serological tests for Trypanosoma cruzi antibodies were done and returned positive. We report a case of chronic Chagas cardiomyopathy that was initially missed but ultimately diagnosed based on the finding of LV apical aneurysm.<Learning objective: Chagas cardiomyopathy is becoming increasingly prevalent in non-endemic countries. One hallmark finding associated with Chagas cardiomyopathy is left ventricle apical aneurysm. We were able to identify this finding with transthoracic contrast 2D ECHO and live 3D ECHO.>

Dissociation of Early Shock in Takotsubo Cardiomyopathy from either Right or Left Ventricular Systolic Dysfunction

Takotsubo cardiomyopathy (TTC) is often associated with hypotension and shock. However, development of hypotension/shock in TTC is not closely related to extent of left ventricular (LV) hypokinesis. We sought to determine whether additional right ventricular (RV) involvement in TTC might contribute to hypotension and shock development and thus to prolonged hospital stay (PHS). We evaluated 102 consecutive TTC patients with acute transthoracic echocardiography (TTE) to detect RV hypokinesis. Correlates of hypotension, shock and PHS were identified by univariate and multivariate analyses. Of the 102 patients evaluated, 33% had RV hypokinesis but only 9% had extensive RV involvement. Within the first 24 hours of admission, severe hypotension (systolic blood pressure (SBP) ≤ 90 mmHg) occurred in 21% of the patients and shock (hypotension + peripheral organ hypo-perfusion) in 16.6% of cases. RV involvement was a univariate but not a multivariate correlate of either hypotension or shock and did not result in PHS. On the other hand, RV involvement predicted more extensive LV hypokinesis and LV systolic dysfunction. In TTC, RV hypokinesis occurs in approximately 33% of cases and correlates with more severe LV wall motion abnormality but not with development of hypotension or shock. These data therefore reinforce previous findings that hypotension/shock in TTC are not purely by impaired cardiac output.

Reversible non‐ischaemic cardiomyopathy and left ventricular dysfunction after liver transplantation: a single‐centre experience

Non-ischaemic cardiomyopathy (NIC) is an early complication of liver transplantation (LT). Our aims were to define the prevalence, associated clinical factors, and prognosis of this condition. A retrospective study was performed on patients undergoing LT at our institution from January 2005 to December 2012. Patients who developed NIC were identified. Data collected included demographic and clinical data. A total 1460 transplants were performed in this period and seventeen patients developed NIC. Pretransplant median QTc interval was 459 (range, 405-530), and median E/A ratio was 1 (range, 0.71-1.67). Fourteen patients (82%) were severely malnourished and required nutritional support. Thirteen patients (76%) had renal insufficiency. Median time to onset was 2days post-transplant (range, 0-20). Echocardiograms showed global left ventricular hypokinesis and a decrease in ejection fraction (EF) from a median of 65% (range, 50-81) pretransplant to a median of 21% (range, 15-32). Median raw model for end-stage liver disease (MELD) score was 29 in patients with NIC vs. 18 in patients without cardiomyopathy (P=0.01). There was no significant difference between recipients with NIC vs. recipients without cardiomyopathy regarding donor age, donor risk index, and cold and warm ischaemia time. Recovery of cardiac function occurred in 16 patients, with a median EF of 44% (range, 25-65%) at the time of discharge. The last echocardiogram available showed a median EF of 59% (range, 49-73%). One-year survival of NIC patients was 94.1%. Non-ischaemic cardiomyopathy is a rare complication after LT. Patients with NIC are critically ill, with high MELD score, and severe malnutrition.

Cerebral microembolism in patients with segmental left ventricular wall motion abnormalities

Background and purposeThe significance of segmental heart wall motion abnormalities for stroke is unknown. The aims of the study included (1) comparison of the frequency and type of embolic signals in the middle cerebral artery in patients with segmental left ventricular wall hypokinesis due to coronary heart disease with and without stroke, and (2) determination of the relationship between inflammatory parameters, fibrinogen level, dyslipidemia and microembolic signals in the middle cerebral artery in patients with segmental heart hypokinesis. Material and methodsThe study included 68 patients with segmental heart hypokinesis (33 without stroke [group I] and 35 with stroke [group II]), as well as 37 healthy volunteers and a reference group of 30 patients. Echocardiography and carotid/transcranial Doppler with detection of microembolic signals were performed. Patients from group I and II had erythrocyte sedimentation rate, leucocyte count, triglycerides, total cholesterol, HDL, and LDL examined. ResultsEmbolic signals were detected in patients with segmental heart hypokinesis significantly more frequently than in the control and reference groups. The high number of embolic signals, signals of high intensity, hypokinesis of the distal part of the intraventricular septum, increased cholesterol levels, LDL and triglycerides were all found more frequently in patients from group II than in group I. Embolic signals were detected more frequently in patients with high fibrinogen levels and leukocytosis. ConclusionsEmbolic signals in the middle cerebral artery in patients with segmental left ventricular hypokinesis have to be considered as a risk factor of stroke. The following changes are observed in patients with cardiogenic stroke: hypokinetic intraventricular septum, high intensity embolic signals, increased serum fibrinogen levels and leucocyte count. It may indicate the importance of these factors in the aetiology of stroke.

Subclinical Hypothyroidism

A 77-year-old male former smoker with hypertension, dyslipidemia, and diabetes mellitus was admitted to our institution for recurrent syncope. He had a history of previous non–Q-wave inferior myocardial infarction in 1980, which had never been investigated by coronary angiography. Echocardiogram showed left ventricular dilation, inferior akinesia, and hypokinesia of the remaining segments with severe left ventricular dysfunction (left ventricular ejection fraction, 30%). Twenty-four–hour Holter ECG recording revealed 3 episodes of self-terminating sustained ventricular tachycardia. The patient underwent a coronary angiography that evidenced multivessel disease with chronic total occlusion of the proximal right coronary artery and of the mid left circumflex artery and diffuse disease of the left anterior descending artery without critical stenosis. Collateral flow ran from left anterior descending artery to left circumflex artery via diagonal branches (Rentrop 2); mid-distal right coronary artery was supplied by homo- contralateral vessel circulation via left circumflex artery collateral channels (Rentrop 3). No revascularization therapy was performed because both mid-distal right coronary artery and left circumflex artery were supplied by valid collateral flow and the patient was asymptomatic for …

Myocardial Contrast Echocardiography for the Detection of Coronary Artery Disease in Patients with Global Hypokinesis Admitted for First-Onset Acute Heart Failure: Pilot Study

BackgroundThe non-invasive differentiation of ischemic and nonischemic acute heart failure (AHF) not resulting from acute myocardial infarction is difficult and has therapeutic and prognostic implications. The aim of this study was to assess whether resting myocardial contrast echocardiography (MCE) can detect coronary artery disease (CAD) in patients with decreased left ventricular (LV) systolic function and global hypokinesis presenting with AHF.MethodsTwenty-one consecutive patients underwent low-power real-time MCE based on color-coded pulse inversion Doppler. Standard apical LV views were acquired during contrast IV infusion of Definity®. Following transient microbubbles destruction, the contrast replenishment rate (β), reflecting myocardial blood flow velocity, was derived by plotting signal intensity vs. time and fitting data to the exponential function: y (t) = A (1 - e-β(t-t0)) + C.ResultsOf the 21 (mean age 56.6 ± 13.6 years) patients, 5 (23.8%) demonstrated flow-limiting CAD (> 70% of luminal diameter narrowing). The mean ± standard deviation of LV ejection fraction was 29.6 ± 8.6%. Quantitative MCE analysis was feasible in 258 of 378 segments (68.3%). There were no significant difference in "β" and "Aβ" in patients without and with CAD (0.48 ± 0.27 vs. 0.45 ± 0.25, p = 0.453 for β and 2.99 ± 2.23 vs. 3.68 ± 3.13, p = 0.059 for Aβ, respectively). No contrast-related side effects were reported.ConclusionResting quantitative MCE analysis in patients with AHF was feasible, however, the parameters did not aid in detecting of CAD.

Possible space flight-induced catecholamine cardiomyopathy: Neil Armstrong&amp;#39;s last 20 lunar minutes

Possible space flight-induced catecholamine cardiomyopathy: Neil Armstrong&#39;s last 20 lunar minutes William J RoweFormer Assistant Clinical Professor of Medicine, Medical University of Ohio at Toledo, Ohio, USAAbstract: The hypothesis underpinning this paper is that space flight may predispose to catecholamine cardiomyopathy. Catecholamine levels in space are twice those of the supine levels on Earth. Serum magnesium levels are significantly reduced, with potential vicious cycles triggered by elevation of catecholamines. These are conducive to coronary vasospasm with clot formation from oxidative stress and calcium overload, and ultimately, temporary impairment of left ventricular function could occur. Experimental animals in space have shown a significant increase in norepinephrine levels with various microcirculatory disorders and serious myocardial pathology. During extravehicular activity (space walks), astronauts show heart rates of 150&ndash;174 beats per minute. Before exposure to the iron-laden dust brought into the habitat on his space suit, Neil Armstrong&#39;s heart rates on the lunar surface were 130&ndash;160 beats per minute, and accompanied by dyspnea on two occasions during his last 20 minutes on the moon. A stress test done on the day after splashdown was consistent with &quot;ischemic left ventricular dysfunction&quot;. To support this hypothesis, echocardiography on the international space station might show left ventricular hypokinesia. Alpha adrenergic blockade, correction of invariable significant magnesium deficits, along with correction of invariable atrial natriuretic peptide deficits, may counteract the vasoconstrictive action of norepinephrine.Keywords: space flight, catecholamines, cardiomyopathy, magnesium, oxidative stress, heat intolerance, calcium

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.

Non-ischemic Cardiomyopathy Secondary to Pegylated Interferon in a Patient with Chronic Hepatitis C

Purpose: Reversible cardiomyopathy is a side effect of interferon treatment, typically described as being associated with high-dose standard interferon. Pegylated INF has a polyethylene glycol molecule attached to the protein, which results in a reduction in its rate of absorption, renal clearance, and immunogenicity following subcutaneous injection. We present a rare case of PEG interferon-induced dilated cardiomyopathy. A 65-year-old female with hepatitis C (HCV), mononeuritis multiplex, mixed cryoglobulinemia, and hypertension presented with complaints of shortness of breath with minimal exertion, which was gradually worsening. She denied any chest pain, palpitations, fever, chills, blood loss, weight loss, or history of smoking. She was started on treatment for HCV in June of 2012, with telapravir, PEG interferon, and ribavirin. Her viral load was detectable at week four, and undetectable at weeks 12 and 24. Her renal function was normal at the start of treatment. During the therapy, her renal function started to deteriorate. Doses of ribavirin and interferon were reduced secondary to her anemia and neutropenia, respectively. Despite dose reduction, treatment was stopped at week 33 due to treatment intolerance. Prior to treatment, the patient had a cardiac catheterization, which showed an ejection fraction (EF) of 50% and non-obstructive coronary artery disease. An echocardiogram done in following treatment showed an EF of 30-35%, with moderate mitral regurgitation (MR) and global left ventricular hypokinesia, stage three diastolic dysfunction, left ventricular dilatation, moderate left atrial dilatation, trace tricuspid regurgitation, and a pulmonary artery pressure of 40 mmHg. A transesophageal echocardiogram (TEE) confirmed the global hypokinesia, and the EF had decreased to 15-20%, with moderate MR. Repeat cardiac catheterization showed global hypokinesia, patent coronary arteries, and an EF of 25-30%. The right ventricular systolic pressure was 41 mmHg. Cryoglobulins were absent, and the rheumatoid factor had decreased to 45 from 200 prior to treatment. An autoimmune work-up was negative. The patient denied any flu-like illness during treatment. A myocardial biopsy was not performed to confirm the diagnosis; however, after ruling out other causes of cardiomyopathy, we attributed the cardiomyopathy to interferon therapy. We believe that the deterioration in renal function may have caused elevated concentrations of interferon, resulting in cardiotoxicity. The sudden worsening of the cardiomyopathy and its chronology in relation to the use of pegylated interferon and deteriorating renal function further support our impression.

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

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

Abstract 334: Hypertensive Crisis Combined with Acute Myocardial Ischemic Injury after Glatiramer Acetate Subcutaneous Injection: A Case Presentation and Literature Review

Introduction Hypertensive crisis (HC) affects more than a half million Americans each year, and leave many with irreversible injury. Despite extensive studies on HC and its complications, there remain many unrecognized risk factors and prognosticators. Physicians should perform comprehensive evaluation, including a current medication list review of patients who present with HC to effectively identify the cause and intervene accordingly. We present a case of HC with acute myocardial damage after subcutaneous injection of glatiramer acetate Case presentation A 47 year-old Caucasian male with history of multiple sclerosis (MS) who presented to the emergency room with complaints of headache, chest discomfort, and cough with frothy bloody secretions approximately 30 minutes after subcutaneous injection of glatiramer acetate. For the past 5 years, the patient had reported occasional hot flashes, headache, and palpitations after injection of glatiramer acetate. On examination, blood pressure was 260/160mmHg and heart rate was 120bpm. Chest X-ray showed acute pulmonary edema. EKG showed significant ST elevations in leads I and AVL and ST depressions in leads II, III, and AVF. Troponin levels were elevated during first 24 hours (0.1, 3.7, and 3.5 μg/L). Echocardiography revealed an ejection fraction of 45% with left ventricular wall hypokinesis. Blood pressure was controlled with intravenous nitroprusside and labetalol and after 48hours, repeat EKG was normal, and stress test with myoview was negative for ischemic changes. Discussion Hypertensive crisis is associated with significant morbidity and mortality. Myocardial damage often results from HC and causes subsequent heart failure which leads to death of sufferers. Glatiramer acetate (Copaxone) is an immunomodulator currently used to reduce symptomatic episodes in patients with relapsing-remitting MS. During the post-marketing period, there have been reports of patients with hypertension, chest pain, and others symptoms that received emergency medical care; however, HC combined with acute myocardial damage has been never reported. Whether an immunologic or non-immunologic mechanism mediates these episodes is unknown.

Coronary artery dissection: a fatal complication following blunt chest trauma

A 21-year-old male driver of a Suzuki motorcycle going at low speed (speed upon impact 40 km/h) grazed the wire fencing of a house tangentially. He then went off the road, hit a small tree, drove into a stream bed, and ended up lying on its bank. When the ambulance arrived at the scene of the accident, the rider had no obvious signs of injury, but was somnolent. His blood pressure was 85/50 mmHg, his pulse was 50 beats per minute, his respiratory rate was 16 per minute, and his oxygen saturation was 75 %. The man was intubated immediately. With pharmacological support of noradrenalin, the patient was transported to hospital by air. Chest and abdomen ultrasounds ruled out any internal injuries. The heart ultrasound showed left ventricular hypokinesis. An initial ECG showed ST elevation for the anterior leads. Shortly after hospitalization the man went into cardiac arrest. Despite 40 min of continuous CPR with repeated defibrillation, the heart could not be restarted and the patient was pronounced dead. The time between the accident and death was 2 h. An autopsy was performed 8 h after his death. The deceased male was 175 cm tall and weighed 81 kg. On external examination, abrasions of the skin at the knees and the lower limbs were found and a contused lacerated wound extending into the dermis was found above the inner ankle of the right foot, surrounded by bruising. Internal examination revealed swelling of the brain, soft tissue contusion of the anterior thoracic wall, thoracic bone fracture, a fracture of the 2nd and 3rd ribs in the midclavicular line on the left, contusion of both lungs, and a shallow lacerated wound at the lower pole of the spleen. Cardiac autopsy showed traumatic dissection of the left main and the proximal left anterior descending coronary artery with complete obstruction of their lumen in a total length of 4 cm (Figs. 1, 2). Macroscopically, the cardiac muscle did not show any changes. There were only small hemorrhages underneath the endocardium of both cardiac atria. Histological examination of the heart confirmed interstitial swelling in the area of anterior and anteroseptal part of the left ventricle. In this area, stretching and ruffling of a group of muscle fibers was found as one of the first signs of ischemia of the cardiac muscle (Fig. 3a, b). Nevertheless, cardiomyocyte necrosis or leukocyte infiltration of the cardiac muscle was not found. The cardiac muscle architecture was normal. Histological examination of the coronary arteries in the range of the common trunk of the left coronary artery and in the initial section of the descending segment of the left coronary artery demonstrated traumatic dissection (level 4/5–5/5 tunica media) with evident external compression of the artery lumen with intramural hematoma (Fig. 3c, d). The walls of the coronary arteries, including their elastic lamellae, were of normal structure. There were no signs of mural (medial or adventitial) or periadventitial M. Dobias Faculty of Medicine and University Hospital in Olomouc, Institute of Forensic Medicine and Medical Law, Palacky University in Olomouc, I. P. Pavlova 6, Olomouc, Czech Republic

Decreased stroke volume–brachial pulse pressure ratio in patients with type 2 diabetes over 50 years: The role of peripheral neuropathy

Background and aimsTo document the stroke volume to pulse pressure ratio (SV/PP, an index of total arterial compliance) and its correlates in patients with type 2 diabetes (T2DM) aged over 50 years whose peripheral neuropathy and silent myocardial ischemic (SMI) status were known. Methods and resultsA total of 360 patients with T2DM aged ≥50 years, without cardiac history or symptom, left ventricular systolic dysfunction, dilatation and hypokinesia, were retrospectively enrolled. The SV/PP was calculated from echocardiographic left ventricular measurements and brachial blood pressure at rest. Peripheral neuropathy was defined as the presence of any two or more of the following: neuropathic symptoms, decreased distal sensation, or decreased or absent ankle reflexes. SMI was defined as an abnormal stress myocardial scintigraphy and/or stress echocardiography. A low SV/PP ratio (<0.53 ml/m²/mmHg, first tertile) was associated with age, creatinine clearance, 24 h urinary albumin excretion rate, peripheral neuropathy, hypertension, serum total cholesterol and triglycerides levels (p < 0.05–0.0001). In multivariate analysis, age (OR 1.1 [1.0–1.2], p < 0.01), triglycerides (OR 1.5 [1.2–2.0], p = 0.01) and peripheral neuropathy (OR 2.2 [1.2–3.9], p = 0.009) were independently associated with a low SV/PP. The patients with peripheral neuropathy had lower SV (p < 0.01) and higher PP (p < 0.05) than those without, and only lower SV after adjustment for age and nephropathy. Similar results were obtained in the patients with and without SMI. ConclusionPeripheral neuropathy was independently associated with decreased SV/PP, mainly through decreased SV, in patients with T2DM over 50 years.

Myocarditis after thymoma resection, with left ventricular hypokinesia mimicking acute coronary syndrome

Myocarditis after thymoma resection, with left ventricular hypokinesia mimicking acute coronary syndrome

Abstract WP131: Correlation of Cardiac Derangement in Patients with Right-Sided Ischemic Stroke and the Severity of Insular Damage

Objective: Although it is known that neurogenic cardiac damage can occur after an ischemic stroke, the mapping of the neuroanatomic correlation of ischemic stroke-related myocardial injury remains to be defined. Our previous animal study found a higher incidence of myocardial damage from left-sided insular infarction comparing to the right side. However, the results from various clinical studies have been inconclusive. This clinical study aims to identify a quantitative correlation between adverse cardiac outcomes and insular infarction, left-sided versus right-sided, as well as potential prognostic factors that may be used to aid in assessing patient outcomes and making treatment decisions. Methods and Results: A serial measurements of cardiac troponin T (cTnT) and creatine phosphokinase-MB (CK-MB), 12-lead EKG, and two- dimensional echocardiography were performed in 42 patients with MRI-confirmed ischemic stroke involving the insular cortex. The severity of insular damage was measured with diffusion-weighted imaging studies (DWI). Patients with renal failure, recent cardiac ischemic events, or congestive heart failure were excluded. Twenty-two patients (52.4%) had left-sided middle cerebral artery (MCA) infarcts with insular involvement, whereas 20 (47.6%) had a right-sided MCA infarcts involving the insular cortex. When compared to patients with left MCA infarcts involving the insular cortex, patients with right MCA infarcts with insular involvement had significantly higher levels of cTnT elevation. By using the linear regression analysis we also identified a statistically significant correlation between cTnT elevation and severity of right insular damage, instead of the NIH stroke score (NIHSS) as commonly assumed. Moreover, two patients were found to have transient left ventricular wall hypokinesis which mimics Takotsubo cardiomyopathy. Conclusions: This study showed that patients with right MCA ischemic stroke involving the insular cortex, comparing to those with left-sided insular stroke, tend to have more severe cardiac insult leading to higher levels of cTnT. The study also identified severity of insular damage as a potential prognostic factor in assessing cardiac derangement as a complication of insular infarction.

Stress Cardiomyopathy Associated with Diffuse Alveolar Hemorrhage after Colonoscopy

Stress cardiomyopathy (SCM) is usually precipitated by a physiologically or psychologically stressful event. Although it occurs only rarely, hypoxia- and hypercapnia-induced sympathetic activation may also cause SCM. We present the case of a 37-year-old woman affected with SCM after a routine colonoscopy. During the procedure, she aspirated residual polyethylene glycol from her stomach. Hypotension, resting dyspnea, and hemoptysis were subsequently observed. Laboratory findings revealed elevated cardiac enzymes, and a transthoracic echocardiogram revealed left ventricular (LV) global hypokinesia. She was ultimately diagnosed with diffuse alveolar hemorrhage-associated SCM. After successful treatment with a ventilator and corticosteroids, her LV systolic function and dimensions normalized and she was discharged without complications.

Systemic Lupus Complicated by Myocardial Vasculitis

A 20-year-old woman was admitted to the intensive care unit due to heart failure. Her past medical history included only systemic lupus erythematosus (SLE) with multiple complications. She had been suffering from asthenia, fever and abdominal pain, followed by dyspnea, global heart failure and a persistent fever. Electrocardiogram (ECG) showed sinus tachycardia and echocardiography showed dilated cardiomyopathy with significant systolic alteration and an estimated left ventricular ejection fraction (LVEF) of 40%. The level of troponin I was elevated. A total body scan excluded the presence of any deep abscesses. The treatment consisted of intravenous corticosteroids, cyclophosphamide and finally plasma exchange, which achieved clinical and echographic improvement. Mycophenolate mofetil and rituximab were later introduced. We herein report a rare case of multiple infarcts in an apparently healthy young woman. SLE is known to be a cardiovascular risk factor in this population; however, we report a rare case of multiple infarcts and vasculitis in a young woman suffering from severe LED, in spite of the use of immunosuppressive treatment. A cardiac MR scan confirmed the presence of left ventricular global hypokinesia (Picture A, arrows). Several areas of late gadolinium enhancement (LGE) were visible, indicating small and patchy subendocardial infarcts, without a relationship with coronary segmentation (Picture B, arrows). Furthermore, a diagnosis of myocarditis was excluded based on the lack of delayed enhancement in the subepicardial layers. Altogether, the clinical and MR scan findings were in suggested a diagnosis of myocardial vasculitis, supported by the fact that the coronary arteries were normal.

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.

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.