Left Ventriculography Research Articles

Prospective evaluation of an AI algorithm for real-time LVEF assessment in acute coronary syndrome using left coronary angiograms: the CathEF multicenter study

Abstract Background Acute assessment of Left Ventricular Ejection Fraction (LVEF) is critical at time of percutaneous coronary intervention to optimize clinical management. The CathEF artificial intelligence algorithm offers a novel approach for real-time, intra-procedural LVEF assessment using routinely obtained left coronary artery angiograms without additional dye use[1]. Our objective was to evaluate the real-time application of the CathEF algorithm for LVEF measurement during coronary angiogram procedures in patients with acute coronary syndrome (ACS) and to compare its performance with transthoracic echocardiography (TTE) and left ventriculography. Methods The CathEF study is a prospective multi-center study that recruited ACS patients undergoing coronary angiography at two institutions from July 2022 to July 2023. Using the CathEF algorithm and the PACS-AI software, we analyzed 2 to 4 left coronary angiogram videos per procedure for LVEF assessment to compare to ventriculography (if indicated) and echocardiography performed during the same hospitalization. Operators were blinded to the CathEF AI-generated results. The primary measure was the algorithm's area under the receiving-operating characteristic curve (AUC) in identifying LVEF <40% or ≥40% compared to TTE-LVEF. Results 240 patients (32% female, average age 66 ± 12 years) were enrolled, with 207 undergoing TTE during index hospitalization (coronary angiogram to TTE mean delay of 0.8±6.3 days). The CathEF algorithm analyzed 881 coronary angiogram videos, averaging 3.12±1.66 per patient. Indications for angiography included unstable angina (18%), NSTEMI (47%), and STEMI (35%). The algorithm took under one minute to apply. CathEF’s performance yielded an AUC of 0.90 (95% CI, 0.840-0.96) and an MAE of 6.81% ± 0.43, with a Spearman correlation of 0.52. Conclusions This study provides proof-of-concept for prospective deployment of an AI algorithm at point-of-care with reliable LVEF measurement in real-time during ACS. This innovation holds the potential to ensure all ACS patients can receive prompt and appropriate care based on their LVEF.CathEF algorithm applied to an angiogramPACS-AI : Platform used to apply CathEF

'Color Doppler stripes’ make it difficult to diagnose the severity of valvular heart diseases: a report of two cases

BackgroundEchocardiography remains the reference-standard imaging technique for assessing valvular heart disease (VHD), but artifacts like the ‘color Doppler stripe’ can complicate diagnosis. This artifact is not widely recognized and can mimic severe VHD, leading to potential misdiagnoses. We present two cases where color Doppler stripes mimicked severe VHD, highlighting the need for awareness and accurate interpretation in echocardiographic assessments.Case presentationsCase 1: An 85-year-old patient was referred for mitral valve surgery due to suspected severe mitral regurgitation (MR). Upon evaluation, transthoracic echocardiography (TTE) showed mitral valve prolapse (P3) and a high-echoic, vibrating structure attached to the mitral valve, indicative of chordal rupture. Color Doppler echocardiography revealed strong systolic signals in the left atrium, mimicking severe MR. Transesophageal echocardiography (TEE) also detected the vibrating structure and color Doppler stripes in the left atrium, left ventricle, and outside the cardiac chambers. The PISA method on TEE indicated moderate MR and left ventriculography showed Sellers grade II MR. The artifact was identified as color Doppler stripes caused by the vibrating high-echoic structure from the ruptured chorda. Case 2: A 64-year-old patient with severe aortic stenosis, end-stage kidney disease requiring hemodialysis, and a history of coronary bypass grafting presented for routine follow-up. B-mode echocardiography showed a severely calcified tricuspid aortic valve with a vibrating calcified nodule and restricted opening, corresponding to severe aortic stenosis. During systole, color Doppler signals were observed around the aortic, pulmonary, and tricuspid valves, mimicking significant pulmonary stenosis and tricuspid regurgitation. However, pulmonary stenosis was ruled out as the pulmonary valve opening was normal. Mild tricuspid regurgitation was confirmed in the apical view.ConclusionsThese cases highlight the diagnostic challenges posed by color Doppler stripes. Recognizing and understanding this artifact are crucial for the accurate diagnosis and management of VHD, ensuring appropriate treatment and patient outcomes.

Abstract We128: Effect of Coronavirus Disease 2019 on the Incidence of Stress-induced Cardiomyopathy; A Single Center Experience

Introduction: Takotsubo Syndrome, or stress-induced cardiomyopathy (SIC) is a transient dysfunction of the left ventricle. Emerging data has shown a rise in the number of cases in recent times. In January of 2020 the Centers for Disease Control and Prevention (CDC) declared Coronavirus disease 2019 (COVID-19) a public healthcare emergency. Given the impact of the COVID-19 on economic and psychosocial factors in individuals across the globe, we sought to study the effect of COVID-19 on the incidence of SIC at our institution. Research Question: Has economic and psychosocial stress associated with COVID-19 led to an increase in the incidence of stress-induced cardiomyopathy? Aim: To study the impact of COVID-19 on the incidence of stress-induced cardiomyopathy. Methods: A retrospective review of cardiac catheterization laboratory data was performed from January 2011 to August 2022. We identified a total of (n=121) cases of stress induced cardiomyopathy. Diagnosis was adjudicated based on the findings on cardiac catheterization, left ventriculography, and echocardiography. Clinical and demographic data of interest was obtained from individual patient electronic medical records into a secure database management tool. Additional data of interest was obtained by performing a post-discharge questionnaire via a telephone survey. Results: The mean age of the population was 69 years (SD± 11.5). 93% (112) of the study population were females. A preceding physical stressor as a triggering factor was present in 59% (72) of individuals, 25% (31) individuals reported a preceding emotional stressor. An increase in the number of cases of SIC was noticed from January of 2020. Only 11% (8) of the patients who were admitted from Janurary 2020 had COVID-19 [Figure 1]. 36% (44) patients participated in the survery. Patients graded their disability from SIC as the following: Mild in 11% (4) , moderate in 7% (3) and severe in 2% (1) of the individuals [Figure 2]. All the patients were referred to Cardiac Rehabilitation at the Medical Center; a American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) certified program that provides patients with educational, preventional and rehabilitative resources. Conclusion: A rise in the incidence of SIC was noted in our single center retrospective study when the CDC declared COVID-19 a healthcare emergency. This suggests an indirect economic and psychosocial stress related process from COVID-19; the "Long COVID" that is not talked about.

Complete Heart Block without Ventricular Escape Rhythm during Left Ventriculography

Complete Heart Block without Ventricular Escape Rhythm during Left Ventriculography

Myocardial Infarction Presenting as Both Left Ventricular Aneurysm and Ventricular Septal Defect.

Mechanical complications of myocardial infarction, such as a ventricular septal rupture (VSR) and left ventricular aneurysm (LVA), are rare but life-threatening.Early diagnosis is critical. A ventricular septal defect (VSD) requires immediate surgical closure, while surgery for LVA is only considered in specific cases such as chest pain or thromboembolism.Diagnostic tools such as echocardiography and left ventriculography play a vital role in identifying and characterising these complications, enabling timely treatment decisions.

Abstract 12525: Acute Pulmonary Edema, Mid-Ventricular Stress Cardiomyopathy and Cardiogenic Shock Following Intranasal Lidocaine/Epinephrine Administration During Septorhinoplasty

Case Presentation: A 19-year-old female presented for elective septorhinoplasty for nasal septal deviation and turbinate hypertrophy. After induction of anesthesia, and orotracheal intubation, pledgets soaked in 4% topical lidocaine with 1:1,000 epinephrine were placed in bilateral nares. Next, 1% lidocaine with 1:100,000 epinephrine was locally injected in the nasal mucosa to obtain hemostasis and analgesia. This resulted in transient hypertensive emergency, followed by undifferentiated shock requiring the initiation of norepinephrine. No signs of ischemia were seen on EKG. Chest X-ray revealed acute pulmonary edema. TTE showed reduced left ventricular systolic function, EF 30%, with mid-segment akinesis, consistent with mid-ventricular stress cardiomyopathy. Coronary angiography identified normal anatomy and patent arteries, supporting the diagnosis. Surveillance TTE after extubation and empiric treatment with metoprolol and losartan, showed improvement of EF to 45-50% and resolution of regional wall motion abnormalities. Discussion: Stress cardiomyopathy, also known as Takotsubo (TCM), is a rare form of cardiomyopathy accounting for 2-3% of ACS. The syndrome mainly affects the LV, causing a regional, transient, systolic dysfunction visualized on TTE or left ventriculography, that occurs in the absence of obstructive epicardial coronary lesions. Pathogenesis is poorly understood. Postulated mechanisms include catecholamine excess, coronary artery spasm and microvascular dysfunction. A systematic review found elevated norepinephrine levels in 74.3% of patients diagnosed with TCM, as was the case for our patient. Rapid systemic absorption of epinephrine can cause diffuse microvascular spasm and myocardial stunning. Catecholamine surge may also afflict direct myocardial toxicity, leading to disorganized cytoskeletal structures, excess extracellular matrix proteins and dysfunctional contractile properties of the myocardium.

A Broken Heart Coexisting with Obstructive Coronary Artery Disease: Double Trouble

Background. Takotsubo is a syndrome characterized by transient regional systolic dysfunction of the left ventricle (LV). The most common clinical presentation mimics acute myocardial infarction without angiographic evidence of obstructive coronary artery disease or acute plaque rupture.1-3 The diagnosis and management became a challenge when it presented as atypical symptoms and significant obstructive coronary artery. Thus, this case report highlights the diagnosis and management of Takotsubo Cardiomyopathy with obstructive coronary artery disease.Case illustration. A 71 years old woman came to the emergency room with a chief complaint of dyspnea from one week ago and worsened in the last three days. The initial electrocardiogram showed slight ST-elevation, and thorax Rontgen showed the congestion and elongation of the aorta. Increased high-sensitive Cardiac Troponin T and The NT-Pro BNP levels were present, along with apical ballooning of the LV and reduced RV function. Physiological stress was found to be the death of her husband one week ago. Although the left ventriculography of this patient was classically depicted as the octopus trap, we did find obstructive coronary artery disease in the left anterior descending artery.
 Keywords: Takotsubo Cardiomyopathy, Uncommon presentation, Coronary artery disease, apical ballooning, acute heart failure

Peripheral VA-ECMO and pericardial drainage connected to the ECMO circuit for cardiac tamponade from blowout rupture: a case report

BackgroundLeft ventricular free wall rupture, particularly the blowout type, is still one of the most lethal complications of myocardial infarction and can cause catastrophic cardiac tamponade. Extracorporeal membrane oxygenation (ECMO) is often used to treat haemodynamic instability due to cardiac tamponade. However, elevated pericardial pressure can cause collapse of the right atrium, resulting in inadequate ECMO inflow and preventing the stabilisation of the circulation. Further, it can interfere with the venous return from the superior vena cava (SVC), increasing the intracranial pressure and reducing cerebral perfusion levels.Case presentationA 65-year-old man was hospitalised for out-of-hospital cardiac arrest. We used ECMO for cardiopulmonary resuscitation. After the establishment of ECMO, transthoracic echocardiography and left ventriculography revealed massive pericardial effusion. The treatment was supplemented with pericardial drainage since ECMO flow was frequently hampered by suction events. However, the blowout rupture led to the requirement of constant drainage from the pericardial catheter. To tend to this leak, we connected the venous cannula of ECMO and the pericardial drainage catheter. The surgery was performed with stable circulation without suction failure of ECMO. During the course of the intensive care management, the neurological prognosis of the patient was revealed to be poor, and the patient was shifted to palliative care. Unfortunately, the patient died on day 10 of hospitalisation.ConclusionWe present a case wherein the combination of pericardial drainage and ECMO was used to maintain circulation in a patient with massive pericardial effusion due to cardiac rupture.

Presumed Takotsubo syndrome is associated with high in-hospital mortality in very elderly frail females: a case series.

Given the aging of general population, very elderly females with Takotsubo syndrome (TTS) are not rarely encountered in clinical practice. Although coronary angiography with left ventriculography is the gold standard diagnostic tool to exclude or confirm TTS, currently, this invasive procedure is less frequently performed in older patients with several comorbidities, such as renal failure, anemia, infections, neurological disorders, malignancy, and severe frailty. In these patients, a "presumed" TTS is diagnosed on the basis of clinical presentation, electrocardiogram, cardiac biomarkers, and echocardiographic findings without coronary angiography. While, in younger patients, TTS is generally a benign condition, in very elderly females, it is associated with higher in-hospital mortality and poor prognosis. Herein, we present four cases of ultra-octogenarian females diagnosed with "presumed TTS", who did not undergo coronary angiography due to severe frailty and multiple comorbidities and who exhibited poor outcome. This could arise the question if an early more aggressive approach could have changed final results. Probably, the solution could only be a personalized decision deriving from a profound and detailed discussion of each case through a multidisciplinary team approach.

Left ventricular ejection fraction and long-term outcomes in women presenting with signs and symptoms of ischaemia

BackgroundAlthough women are known to have a relatively higher left ventricular ejection fraction (LVEF) compared with men, a sex-neutral LVEF threshold continues to be used for clinical management. We sought...

Mitral annulus disjunction detected by left ventriculography

Mitral annulus disjunction detected by left ventriculography

Takotsubo Syndrome Occurring after mRNA COVID-19 Vaccination in a Patient with Graves’ Disease

Cardiovascular events such as myocarditis following mRNA COVID-19 vaccination are increasing. We present a 67-year-old postmenopausal woman with Takotsubo Syndrome and Graves' disease after mRNA COVID-19 vaccination. She developed chest pain and shortness of breath one week after vaccination. An electrocardiogram revealed ST elevation in the precordial leads. Coronary angiography revealed the absence of obstructive coronary artery disease, and the left ventriculography showed a typical feature with apical ballooning. Laboratory workup showed the elevation of free T4 and thyrotropin receptor antibodies. It was presumed that Takotsubo Syndrome and Graves' disease were probably related to the COVID-19 mRNA vaccination. The patient was treated with low-dose bisoprolol, diuretics, carbimazole, and steroid and discharged uneventfully. The mRNA COVID-19 vaccination is still safe and effective to defend against COVID-19 pandemic. However, clinicians should be aware of the possible cardiovascular adverse events other than myocarditis following vaccination.

643 THE HEART WAS MADE TO BE BROKEN: RECURRENT TAKOTSUBO SYNDROME IN AMYOTROPHIC LATERAL SCLEROSIS

Abstract Takotsubo syndrome (TTS) is a rare cardiac disease, characterized by transient regional wall motion abnormalities without evidence of obstructive coronary artery stenoses, mainly triggered by emotion or physical stressors. Reverse Takotsubo syndrome (rTTS), an atypical variant with basal segments involvement, is frequently associated with neurological disorders, including patients with amyotrophic lateral sclerosis (ALS). We reported the case of a 54 years old woman who experienced two consecutive episodes of TTS with different wall motion patterns, complicated by a recurrent episode and arrhythmic events. A Caucasian woman, affected by ALS, was hospitalized in our department due to anemia and recurrent episodes of hematochezia. Following a week of relative clinical stability, the patient experienced acute deterioration with generalized malaise and worsening dyspnea. CT scan excluded pulmonary causes, whereas EKG (ST segment depression in the lower and lateral leads), blood test (increase in high-sensitive cardiac troponins) and TTE (severe impairment of LVEF, with akinesia of basal segments) revealed a cardiac etiology. Coronary angiography and left ventriculography were performed, documenting a wall motion pattern consistent with rTTS. After an initial management in intensive care unit, clinical stability was obtained with a complete recovery of left ventricular systolic function. The patient was discharged but one month later, due to bacterial pneumonia, she was readmitted in our ward and antibiotic therapy was started. Two days later an acute deterioration of clinical status occurred, characterized by dyspnea, altered state of consciousness and marked hypotension. TTE revealed a severe left ventricular systolic dysfunction with apical akinesia and preserved contractility of basal segments, so a diagnosis of typical TTS was made. Three weeks later the clinical scenario became more complicated due to advanced atrioventricular block, with phases of atrioventricular dissociation and ventricular escape-rhythm. Therefore, in light of the increased risk of infectious complications, she underwent implantation of a leadless pacemaker (PMK). This clinical case represents the first report of recurrent episodes of TTS, one of which as rTTS, in a patient affected by ALS. It is worth noting that the first episode of TTS had atypical clinical presentation (dyspnea without chest pain), the EKG showed diffuse ST-segment depression (totally different from classical TTS typical electrocardiographic alterations), and TTE confirmed a different phenotype of segment involvement (unsurprisingly InterTAK Diagnostic Score was low). TTS recurrence is an extremely rare event, even if in this case there were two well defined triggers such as anemia and pneumonia. On the other hand it is reasonable to think that non-use of BBs after the first episode may have contributed to the occurrence of the next event, affecting different segments compared to the previous episode. Furthermore, advanced atrioventricular (AV) block represents a rare complication of TTS, most probably due to catecholamine stress or increased vagal tone, often requiring PMK implantation. In conclusion TTS represents an important frequent cardiac complication in patients affected by ALS, often still underdiagnosed. Therefore clinicians must keep their guard up with TTS, especially in the cases with atypical clinical presentation.

598 PREVALANCE AND PREDICTORS OF LONG-TERM CARDIAC SYMPTOMS IN PATIENTS WITH TAKOTSUBO SYNDROME

Abstract Background Takotsubo syndrome (TTS) is characterized by an acute and transient left ventricular dysfunction, usually involving the apical and midventricular segments, associated with troponin elevation and often triggered by either emotional or physical stressors. Once considered a benign condition, it is now clear that TTS patients have increased long-term mortality compared with the general population. Prevalence and the determinants of long-term cardiac symptoms in TTS patients have been scarcely investigated. Methods We enrolled consecutive patients admitted to our Centre with a diagnosis of TTS . All patients underwent invasive coronary angiography with left ventriculography at admission and only those fulfilling both the Mayo Clinic and Heart Failure Association criteria for a TTS diagnosis were selected for this study. Clinical, biochemical, and instrumental data were collected at admission and before discharge, and patients were followed-up for: symptoms recurrence (i.e., presence of effort angina and/or dyspnoea in the absence of other obvious causes) and all-cause mortality. The prevalence of long-term symptoms was further compared with a control group of unselected patients admitted for acute coronary syndromes (ACS) in the same period, matched for sex, age, and left ventricular ejection fraction (LVEF) at discharge. Results We eventually enrolled 118 patients (aged 73±10 years, 91% of whom were female). Acute chest pain was the most common presenting symptom (73%), followed by dyspnoea (32%), acute heart failure (16%), cardiogenic shock (9%), and syncope (8%). Most of cases (82%) were classified as having a typical (apical) LV dysfunction. Either a physical or an emotional stressor was identified in 37 (31%) and 31 (26%) of the patients, respectively. At admission, patients showed moderate systolic dysfunction (LVEF 40±9%), which was often improved at discharge (LVEF 52±8%). Over a median follow-up of 21 (interquartile interval 11-53) months, 35% of patients complained of some cardiac symptom: 32% of patients complained of effort dyspnoea and 7% (partially overlapping with the former) complained of effort angina. When compared with ACS patients (n=55, aged 71±10 years, 94% women, LVEF 53±9%), TTS patients featured a similar mortality rate, a lower (non-significant) prevalence of angina, and a significantly higher prevalence of dyspnoea (p=0.02). Notably, while a lower age at presentation (p=0.017) and a physical trigger (p=0.015) were significantly associated with the risk of recurrent angina, the absence of chest pain (p=0.044), a lower LVEF at admission (p=0.019), and a higher troponin T concentration at discharge (p=0.018) were associated with the presence of dyspnoea at follow-up. Finally, older age, male sex, renal dysfunction, cardiogenic shock, and concomitant coronary artery disease were all associated with a higher risk of death. Prescription of ACE-inhibitors and/or beta-blockers were associated with reduced risk (p<0.05, for all), in line with previous reports. Conclusion TTS is associated with a high risk of recurrent cardiac symptoms, mostly dyspnoea, over time. Selected clinical, biochemical, and instrumental characteristics may help identify patients more at risk, who may deserve a closer follow-up and potentially tailored therapies, to be investigated in future studies.

439 TRANSIENT SEVERE MITRAL REGURGITATION IN REVERSED TAKOTSUBO SYNDROME

Abstract A 65-years old Caucasian woman was referred to the emergency department for chest pain, dyspnoea and high systolic blood pressure. In the previous days she complained a constant state of anxiety and worries due to family troubles. At the admission 12 – lead EKG showed sinus rhythm, ST-T segment depression >1 mm in the lateral and anterior leads (from V2 to V6). Laboratory exams showed elevated values of high sensivity troponin levels (high-sensitive troponin: 41 pg/mL – maximum laboratory cut off value: 12 pg/mL). Bedside echocardiogram showed an LVEF of 40% due to apical hyperkinesis, akynesis of the basal segments and hypokinesis of the mid segments of the left ventricle; a severe double jet MR (Fig.1); a type II diastolic dysfunction (E/A: 1,5; E/e’: 14). Several B lines (> 3) were present in all pulmonary regions assessed by lung POCUS. Cardiac angiography demonstrated non obstructive coronary artery disease. Left ventriculography showed an hyperdynamic apex and severe basal hypokinesis. Clinical and functional status rapidly improved. Daily EKGs were registered with a progressive resolution of the ST-T segment depression. She was discharged on the 7th days and the TTE in pre-discharge showed an LVEF of 60%, without wall motion abnormalities and complete recovery of mitral regurgitation. We report a case of reversible severe mitral regurgitation in a patient with basal ballooning TTS. Mital regurgitation is generally described in the contest of classical apical TTS. The potential mechanisms for severe MR are similar to those of acute myocardial infarction. Admission and daily echocardiographic evaluation is crucial in this subset of patients, with a tailored therapy following the severity of mitral valve disease. Fig. 1

Abstract 11377: Takotsubo Syndrome Among Patients With Spontaneous Coronary Artery Dissection: A Report of the ISCAD Registry

Introduction: Association of takotsubo syndrome (TTS) with spontaneous coronary artery dissection (SCAD) has been described previously. Characteristics and in-hospital prognosis of SCAD patients with concomitant TTS remain unclear. Methods: Patients with angiography-confirmed SCAD were selected from the iSCAD Registry and underwent core lab adjudication of left ventriculography (LVG) and coronary angiography including assessment of SCAD lesion characteristics, TIMI Flow Grade (TFG), and TIMI Myocardial Perfusion Grade (TMPG). Classic TTS was defined as wall motion abnormality (WMA) presenting as apical ballooning. TTS variants were defined as non-apical WMA discordant to dissected coronary territory with apical sparing. In-hospital event was defined as composite of recurrent myocardial infarction (MI), cerebrovascular accident, heart failure requiring diuretics, or new arrhythmia. Results: On blinded review of LVG from 216 patients, TTS was identified in 38 (17.6%) patients (classic, midventricular, and focal pattern: 86.8%, 2.6%, and 10.5%, respectively). There was no significant difference in age, cardiovascular risk factors, history of anxiety or depression, recreational substance use, emotional or physical stressors, extracoronary vascular abnormalities, peak troponin levels, or TFG of dissected arteries between TTS and non-TTS groups. TTS patients were more likely to present with ST-segment elevation MI (47.4% vs 27.5%; p=0.02), left anterior descending artery (LAD) involvement (89.5% vs 59.0%; p=0.0004), and TMPG < 3 (68.4% vs 48.3%; p=0.02) compared to non-TTS patients. TTS patients had a greater risk of in-hospital events (32.4% vs 15.1%; p=0.01), mainly attributed to new arrhythmia (27.0% vs 6.5%; p=0.0009) and heart failure (11.4% vs 3.0%; p=0.03). Conclusion: Coexistence of TTS and SCAD was associated with ST-elevation MI, LAD involvement, impaired microvascular myocardial perfusion, and adverse in-hospital outcomes.

Abstract 15140: Post-Myocardial Infarction Ventricular Septal Defect in a Patient With Mixed Connective Tissue Disorder

Mixed connective tissue disorder (MCTD) is associated with a broad range of cardiovascular abnormalities, including coronary artery disease (CAD). It has been proposed that chronic systemic inflammation plays a key role in the development of atherosclerotic disease. A 66-year-old female with a history of MCTD and hypertension presented with mild dyspnea and pleuritic chest pain after one week of persistent flu-like symptoms. Her blood pressure was 108/77 mmHg, pulse 92 bpm, saturating 98% on room air. She was comfortable and denied other risk factors such as diabetes, hyperlipidemia, or prior smoking history. On exam she was found to have a soft holosystolic murmur across her precordium. EKG showed sinus rhythm with small Q waves and ST elevation in V1-V6. She was taken for cardiac catheterization which revealed a thrombotic occlusion in the proximal left anterior descending artery (LAD) and a severe lesion in the left circumflex artery. She underwent angioplasty with one drug eluted stent placed to LAD. Left ventriculography revealed a VSD near the apex, and transthoracic echocardiogram showed a 7.6 mm muscular VSD with left to right shunt, ejection fraction of 35% and hypokinesis of the anterior wall. She became hypotensive and required vasopressors prior to coronary artery bypass grafting and primary closure of her apical VSD. Intraoperatively, a 2 cm VSD with 5 cm of necrotic surrounding tissue was noted. Post-operative complications included asystolic cardiac arrest, marked cardiogenic shock and multiorgan failure to which she ultimately succumbed. Post-myocardial infarction VSD is a rare complication of MI occurring in approximately 0.2% of cases. However, patients with MCTD can develop atypical symptoms, resulting in delayed presentation and therefore higher risk of mechanical complications. We highlight the importance of a thorough physical exam and high suspicion for mechanical complications in these patients even when hemodynamically stable.

Reversible QRS fragmentation in Takotsubo cardiomyopathy.

An 80-year-old lady with a history of diabetes mellitus presented to the emergency room with palpitations. Electrocardiogram revealed ST-segment elevation over the inferior and lateral leads. Notably, the QRS complexes across precordial leads V4-6 and aVR were fragmented. A positive deflection was seen in lead V1, embedded within the QRS complex, which is resemblant to the Epsilon wave morphology (Figure 1, left columns). Despite such findings and raised serum troponin, she was free from chest pain. Transthoracic echocardiography showed left ventricular (LV) apical ballooning with severe hypokinesis, corroborated by invasive left ventriculography. Coronary angiography revealed no occlusive lesion. The diagnosis was Takotsubo cardiomyopathy (TTC). (Figure 2). The finding of fragmented QRS in TTC is of electrophysiological interest. Arrhythmic manifestations complicating TTC affects up to one-quarter of patients, and half is life-threatening (13.5%).1 Symptomatic atrioventricular block and less commonly sinus nodal dysfunction may mandate cardiac pacing and are due to a secondary increase in vagal tone in sympathetic overdrive. The origin of ventricular tachycardia (VT)/ fibrillation remained controversial in TTC. While QT prolongation is well-recognized in TTC that provided a substrate for polymorphic VT, the origin of monomorphic VT was believed to be catecholaminergic or automatic, and unlikely reentrant based on classical lack of myocardial fibrosis detectable as late gadolinium MRI enhancement in TCC.2, 3 However, latest research provided revoking evidence by identifying diffuse fibrosis/ micronecrosis through T1-mapping in TTC.4 QRS fragmentation, a marker of myocardial fibrosis, is predictive of sudden cardiac death in patients with ischemic and non-ischemic cardiomyopathy. Its presence in the inferior leads, in particular, was identified as an ominous sign in patients with known cardiomyopathy for subsequent sudden death,5 while lateral lead predominance conferred excess risks in subjects without structural heart disease. Whether fragmented QRS has a prognostic role in Takotsubo cardiomyopathy remained unclear. Furthermore, myocardial edema during a hyperacute phase in TTC may predispose to transient electrical inhomogeneity.2 On the contrary, the Epilson wave, an electrocardiographic finding characteristic of arrhythmogenic right ventricular cardiomyopathy, together with QRS fragmentation are both indicators of delayed ventricular depolarization. While the Epilson wave has been reported in myocarditis, how it is related to myocardial edema in the hyperacute phase of TTC and whether it may have a prognostic role remained obscure. In our patient, no significant nodal dysfunction or ventricular tachyarrhythmia occurred. She was treated with aspirin (80 mg daily), lisinopril (2.5 mg daily), bisoprolol fumarate (1.25 mg daily), and atorvastatin (20 mg daily). Three months later, reassessment echocardiography showed recovered LV systolic function with an ejection fraction of 65%, and resolution of apical ballooning. These were accompanied by a complete reversal of QRS fragmentation and the disappearance of the Epsilon wave-like morphology (Figure 1, rights columns). Ambulatory Holter assessment showed nil evidence of electrical instability. This succinct Spotlight thus re-capitulates the fundamental electro-pathophysiological basis implicated in the natural course of TTC, in which further research is needed. Li Shu Fan Medical Fellowship for Internal Medicine 2021/22 (Y.H.C.) None declared.

Shark Fin Electrocardiogram in the Intensive Care Unit.

Shark Fin Electrocardiogram in the Intensive Care Unit.

THE EFFECT OF BETA BLOCKAGE IN PATIENTS FOLLOWING ACUTE CORONARY SYNDROME - STRATIFIED ACCORDING TO LEFT VENTRICULAR EJECTION FRACTION.

THE EFFECT OF BETA BLOCKAGE IN PATIENTS FOLLOWING ACUTE CORONARY SYNDROME - STRATIFIED ACCORDING TO LEFT VENTRICULAR EJECTION FRACTION.