Ventricular Wall Motion Research Articles

Sex differences related changes in cardiac structure and function after ST-segment elevation myocardial infarction

Abstract Background Sex disparities in presentation, treatment, and outcomes after ST-segment Elevation Myocardial Infarction (STEMI) are well recognized. However, little is known about sex related changes in cardiac structure and function following a STEMI in this contemporary era of early PCI. Purpose To compare sex differences in change of echocardiographic parameters of structure and function following a first-time STEMI. Methods This echocardiographic study involved 380 non-diabetic first-time STEMI patients. Structural and functional parameters were evaluated during initial hospitalization (median 1 day after presentation) and at 4-months. Adverse remodelling was defined as a 20% increase in left ventricular end-diastolic volume (LVEDV) at 4 months compared to the hospitalisation echo. Functional parameters included left ventricular ejection fraction (LVEF) and wall motion score index (WMSI). According to current guidelines, eccentric hypertrophy was defined as left ventricular mass index (LVMI) >95 g/m2 for women and >115 g/m2 for men with a relative wall thickness (RWT) ≤0.42; concentric hypertrophy was defined as LVMI >95 g/m2 for women and >115 g/m2 for men with RWT >0.42. The different patterns in geometry were assessed at 4-months. Results Among 380 patients, comprising 285 males and 95 females, females had a higher prevalence of hypertension (42% vs. 25.6%, p=0.004), lower hemoglobin levels (8.40 mmol/l vs. 9.10, p<0.001), and higher plasma NT-proBNP concentrations upon admission (132 ng/L vs 67, p<0.001) and after 24 hours (1322 ng/l vs 784, p<0.001). During the initial echocardiogram conducted upon hospitalization, as well as during the echocardiogram at 4 months, women had significantly lower LV diameters, LV volumes, LV mass, LAVI and wall thickness compared to man. However, during both evaluations women showed higher E/e’ ratio’s and LVEF. The change in echocardiographic variables between both timepoints did not differ significantly between sexes. Furthermore, no significant difference in LV geometry patterns (eccentric or concentric) were observed between sexes and adverse LV remodelling was similar between both groups at approximately 22-23% (p=0.991). Conclusions Although differences exist between sexes in patient characteristics and individual echocardiographic parameters, no disparity is observed in geometry patterns, adverse LV remodelling, or the change in echocardiographic parameters after STEMI.

Initial experience with a 5G cellular network and robotic arm-based remote echocardiographic system in an all-comers setting

Abstract Background Echocardiography is the test-of-choice for the initial evaluation of many cardiac diseases and requires expertise that is often limited in rural area. Robotic arm-assisted remote echocardigram has been attampted for teleconsultation but was limited to heart failure patients(ref), primarily due to the network delay in telecommunication and the subsequent incoordination in robotic arm control. Purpose We aim to assess the feasibility and diagnostic accuracy of a 5G cellular network and robotic arm-based remote echocardiographic system in an all-comers setting. Methods 51 pts were enrolled from the outpatient cardiology clinic of our institute. All pts underwent standard comprehensive echocardiography on a 5G cellular network and robotic arm-based remote echocardiographic system (the robotic part was deployed at our hospital and the control part was located at another campus 20 kilometers away) (Figure 1)and a conventional echocardiographic platform (at our hospital) successively. The order in which patients were examined on the remote and conventional instruments was randomly determined. There was no interval between the two examinations, and examinations of the same patient were performed by experienced but different cardiologists, who were blinded to each other’s diagnosis. The doctor who used the remote system was also randomly allocated and had not been previously specifically trained. The exams were real-time and diagnoses were made right after the exams. Results Of the 51 pts, the image quality was sufficient for diagnosis in 50 patients (48% female, 40±18 years). 1 pt was excluded because some key views could not be obtained using the remote system (98% of exams successful). 17 pts had positive findings, including 10 with a primary diagnosis of valvulopathy (1 Barlow's syndrome, 1 bicuspid aortic valve and 8 less-than-moderate regurgitation), 2 cardiac surgery follow-ups (1 case of aortic valve replacement and septal myectomy, and 1 case of mitral valve replacement and tricuspid annuloplasty), and 2 hypertrophic cardiomyopathy (including 1 case of obstruction at papillary muscle level), 2 with abnormal left ventricular wall motion(including 1 case of apical mural thrombus) (Figure 2), and 1 with congenital heart disease (secumdum atrial septal defect). The main diagnosis was consistent in 98% of cases (papillary muscle level obstruction was missed in one case), using conventional echocardiographic findings as the standard. Time for image acquision using remote echocardiography was significantly longer than conventional one (24 minutes 36 seconds ± 4 minutes 52 seconds vs. 16 minutes 15 seconds ± 1 minute 54 seconds, p<0.0001, paired t-test). Conclusions Comprehensive echocardiographic exam with a 5G cellular network and robotic arm-based remote system is feasible with relatively good diagnostic accuracy.Figure 1Figure 2

Thromboembolic Complications in Takotsubo Cardiomyopathy.

Apical ballooning syndrome, commonly known as Takotsubo syndrome, is a distinct cardiomyopathy often resembling acute myocardial infarction in presentation. Takotsubo syndrome patients exhibit varied patterns of left ventricular wall motion abnormalities, most frequently apical dyskinesis with basal hyperkinesis, that are characteristically transient. Although emotional or physical stressors precipitate Takotsubo syndrome in most cases, a significant proportion presents without identifiable triggers, with a pronounced female predominance. Despite recovery of left ventricular function, Takotsubo syndrome may lead to serious complications akin to acute coronary syndromes. The pathophysiology remains incompletely understood, with catecholamine surge implicated in the genesis of myocardial injury, although direct causation remains debated. Diagnosis involves integrating clinical history, imaging modalities like echocardiography, and cardiac MRI. Psychiatric disorders, particularly anxiety and depression, are frequently associated with Takotsubo syndrome, suggesting a role of chronic stress in disease susceptibility. Management includes supportive care, with anticoagulation considered in cases of apical thrombus, alongside close monitoring for complications and recovery of left ventricular function. This article reviews the current understanding, challenges in diagnosis, and management strategies for Takotsubo syndrome.

Type I Kounis syndrome in a young woman without chest pain: a case report

BackgroundKounis syndrome is defined as the concurrence of acute coronary syndromes in the setting of allergic or anaphylactic reactions. It primarily affects men aged 40–70 years and is often associated with chest pain. This syndrome is often unrecognized and undiagnosed in clinical practice due to a low level of awareness. Herein, we present a case of type I Kounis syndrome in a young woman without chest pain.Case presentationA 28-year-old Japanese woman with a history of atopic dermatitis received a glycyrrhizin, glutathione, and neurotropin preparation (a preparation of inflamed skin extract from rabbits inoculated with vaccinia virus) at a dermatology clinic to treat pruritus caused by atopic dermatitis. Immediately after the administration, the patient developed abdominal pain and generalized body wheals. The patient was diagnosed with anaphylaxis and was transported to our hospital. She had no chest pain on arrival at our hospital; however, a 12-lead electrocardiogram showed ST elevation in leads I, aVL, V2, and V3, and an echocardiogram showed decreased wall motion in the anterior and lateral walls of the left ventricle. Sublingual nitroglycerin administration improved ST-segment elevation and left ventricular wall motion abnormalities. The patient underwent emergency coronary angiography, which revealed no significant stenosis, and was diagnosed with type I Kounis syndrome.ConclusionKounis syndrome without chest pain is rare in young women. Since it can be fatal in cases with severe allergic symptoms such as anaphylaxis, the possibility of concurrent acute coronary syndrome should be considered when treating systemic allergic reactions, regardless of age, sex, or the presence or absence of chest symptoms.

Left Ventricular Wall Motion as an Additional Valuable Parameter in Diabetic Patients with Normal Myocardial Perfusion Imaging.

Gated SPECT is an established technique for assessment of left ventricular function in cardiovascular disease patients. However, there is little information about the influence of diabetes mellitus on gated SPECT parameters. This study was established to assess gated SPECT parameters in Diabetes Mellitus (DM) and non-diabetes mellitus (non-DM) patients with normal Myocardial Perfusion Imaging (MPI). In this analytical cross-sectional study, 314 patients (157 DM, 157 non-DM) with normal MPI were enrolled. Prevalence of risk factors for CAD like hypertension (HTN), and dyslipidemia were found to be significantly higher (p <0.01) in DM patients compared to non-DM. No statistically significant difference was observed among the TID, ESV, EDV, PFR, TTPF, and Wall Thickness (WT) parameters between DM and non-DM patients. Wall motion (Wm) in DM patients was significantly higher compared to non-DM patients. (3.9 ± 0.51 vs. 2.69 ± 0.48 for DM and non-DM patients, respectively, p-value:0.01). Also, there was no significant difference in Wm in the two groups with and without HTN. This shows the independent effect of DM on the Wm. This study believes that the Wm parameter should be noted for the early diagnosis or prevention of heart disease in DM patients. These findings can indicate the gradual changes in the movements of the left ventricle and the beginning of the progression of diabetic cardiomyopathy.

Effect of patent complete revascularization on the akinetic myocardial segments.

The aims of the study were (i) to examine the changes in echocardiographic parameters and (ii) to compare the fate of myocardial segments with akinesia and without akinesia on preoperative echocardiography after coronary artery bypass grafting. One hundred one patients who underwent complete revascularization, who were assessed by preoperative, before discharge, postoperative 3- and 12-month echocardiographic examinations, and who showed all patent grafts at postoperative 1-year angiograms were included. Echocardiographic left ventricular ejection fraction was assessed, and a 16-segment model was adopted for regional analysis of the left ventricle. A total of 1616 segments were analysed based on a 6-point scale: 1 = normal (N = 1083), 2 = mild hypokinesia (N = 2), 3 = moderate hypokinesia (N = 74), 4 = severe hypokinesia (N = 150), 5 = akinesia without thinning (N = 259) and 6 = akinesia with thinning (N = 48). The serial left ventricular ejection fraction measured preoperatively, before discharge, at postoperative 3- and 12-months were 0.48 ± 0.14, 0.49 ± 0.12, 0.49 ± 0.10 and 0.54 ± 0.10, respectively. The left ventricular ejection fraction significantly increased over time during the postoperative 12 months (P < 0.001). Wall motion scores tended to decrease over time in both segment groups with akinesia and without akinesia (P < 0.001), and improvement of the wall motion was significantly higher in the segment group with akinesia than in the segment group without akinesia (P < 0.001). The left ventricular ejection fraction and regional wall motion improved over time during the postoperative 12 months, regardless of the presence of an akinetic segment. Complete revascularization including akinetic myocardium should be considered when performing coronary artery bypass grafting.

A study to observe the association of left ventricular ejection fraction and wall motion score index with duration of early systolic lengthening in patients with non-ST-elevation acute coronary syndrome

Background: Management of non-ST elevation myocardial infarction acute coronary syndrome (NSTEMI ACS) patients is not well defined as that of ST elevation myocardial infarction. The accuracy of results of conventional echocardiography is significantly compromised when imaging is suboptimal, myocardial damage is in small areas, and compensatory hyperkinesias of healthy segment. Aims and Objectives: Duration of early systolic lengthening (DESL) may be employed to identify early myocardial ischemia and thus, may help to prepare treatment strategies for NSTEMI patients. Materials and Methods: A total of 57 patients with NSTEMI ACS attending the cardiology department were included in the study group. Results: More than 80% of patients of NSTEMI have normal or near normal ejection fraction and wall motion score index. In our study, the DESL is prolonged in a significant number of non-ST-elevation acute coronary syndrome patients. Conclusion: As DESL is afterload independent, it is superior to global longitudinal strain in assessing myocardial damage. Several studies including ourselves show that DESL of &lt;50 ms may be the cutoff value to reveal minimal myocardial damage.

Embryonic alcohol exposure in zebrafish predisposes adults to cardiomyopathy and diastolic dysfunction.

Fetal alcohol spectrum disorders (FASDs) impact up to 0.8% of the global population. However, cardiovascular health outcomes in adult patients, along with predictive biomarkers for cardiac risk stratification, remain unknown. Our aim was to utilize a longitudinal cohort study in an animal model to evaluate the impact of embryonic alcohol exposure (EAE) on cardiac structure, function, and transcriptional profile across the lifespan. Using zebrafish, we characterized the aftereffects of embryonic alcohol exposure (EAE) in adults binned by congenital heart defect (CHD) severity. Chamber sizes were quantified on dissected adult hearts to identify structural changes indicative of cardiomyopathy. Using echocardiography, we quantified systolic function based on ejection fraction and longitudinal strain, and diastolic function based on ventricular filling dynamics, ventricular wall movement, and estimated atrial pressures. Finally, we performed RNA sequencing on EAE ventricles and assessed how differentially expressed genes (DEGs) correlated with cardiac function. Here, we demonstrate that embryonic alcohol exposure (EAE) causes cardiomyopathy and diastolic dysfunction through persistent alterations to ventricular wall structure and gene expression. Following abnormal ventricular morphogenesis, >30% of all EAE adults developed increased atrial-to-ventricular size ratios, abnormal ventricular filling dynamics, and reduced myocardial wall relaxation during early diastole despite preserved systolic function. RNA sequencing of the EAE ventricle revealed novel and heart failure-associated genes (slc25a33, ankrd9, dusp2, dusp4, spry4, eya4, and edn1) whose expression levels were altered across the animal's lifespan or correlated with the degree of diastolic dysfunction detected in adulthood. Our study identifies EAE as a risk factor for adult-onset cardiomyopathy and diastolic dysfunction, regardless of CHD status, and suggests novel molecular indicators of adult EAE-induced heart disease.

Wall motion assessment by feature tracking in pediatric patients with coronary anomalies undergoing dobutamine stress CMR.

Left ventricular (LV) wall motion assessment is an important adjunct in addition to perfusion defects in assessing ischemic changes. This study aims to investigate the feasibility and utility of performing feature tracking (FT) in pediatric patients with coronary anomalies undergoing dobutamine stress CMR to assess wall motion abnormalities (WMA) and perfusion defects. This is a retrospective study where 10 patients with an inducible first-pass perfusion (FPP) defect and 10 without were selected. Global LV circumferential strain/strain rate (GCS/GCSR) was measured at rest and at peak stress (systole and diastole) using a commercially available feature tracking software. Peak GCS and GCSR were compared to indexed wall motion score (WMSI) between groups with and without FPP defect and in subjects with and without WMA. The median age of patients was 13.5 years (Q1, 11 years; Q3, 15 years). Five subjects had qualitatively WMA at peak stress. A moderate correlation of GCS with WMSI at peak stress (0.48, p = 0.026) and a significant difference between GCS at rest and stress in patients with no inducible WMA (p = 0.007) were seen. No significant difference was noted in GCS between rest and stress in patients with WMA (p = 0.13). There was a larger absolute GCS/GCSR at peak stress in subjects with no inducible FPP defect or WMA. Smaller absolute GCS and a lack of significant change in GCS at peak stress in those with inducible WMA or perfusion defect are suggestive of compromised LV deformation in subjects with inducible WMA. Given these findings, GCS derived from CMR-FT may be used to objectively assess WMA in pediatric patients undergoing stress CMR.

Periostin regulates lysyl oxidase through ERK1/2 MAPK-dependent serum response factor in activated cardiac fibroblasts.

Collagen crosslinking, mediated by lysyl oxidase, is an adaptive mechanism of the cardiac repair process initiated by cardiac fibroblasts postmyocardial injury. However, excessive crosslinking leads to cardiac wall stiffening, which impairs the contractile properties of the left ventricle and leads to heart failure. In this study, we investigated the role of periostin, a matricellular protein, in the regulation of lysyl oxidase in cardiac fibroblasts in response to angiotensin II and TGFβ1. Our results indicated that periostin silencing abolished the angiotensin II and TGFβ1-mediated upregulation of lysyl oxidase. Furthermore, the attenuation of periostin expression resulted in a notable reduction in the activity of lysyl oxidase. Downstream of periostin, ERK1/2 MAPK signaling was found to be activated, which in turn transcriptionally upregulates the serum response factor to facilitate the enhanced expression of lysyl oxidase. The periostin-lysyl oxidase association was also positively correlated in an in vivo rat model of myocardial infarction. The expression of periostin and lysyl oxidase was upregulated in the collagen-rich fibrotic scar tissue of the left ventricle. Remarkably, echocardiography data showed a reduction in the left ventricular wall movement, ejection fraction, and fractional shortening, indicative of enhanced stiffening of the cardiac wall. These findings shed light on the mechanistic role of periostin in the collagen crosslinking initiated by activated cardiac fibroblasts. Our findings signify periostin as a possible therapeutic target to reduce excessive collagen crosslinking that contributes to the structural remodeling associated with heart failure.

SCARY ECG IN TAKOTSUBO CARDIOMYOPATHY

Abstract Takotsubo cardiomyopathy (TTC) is characterized by a transient ventricular wall motion abnormality and shares common features with acute coronary syndrome (ACS) with a wide spectrum of triggers, such as both emotional or physical, activating common toxic catecholamines–mediated pathways. TTC might be associated with severe clinical complications. We report a case of a 74–year female patient with circulatory shock with mixed phenotype, distributive due to sepsis and cardiogenic due to TTC. The patient presented to the emergency department with severe hypotension, pathological qSOFA score and clinical and laboratory findings consistent with severe sepsis. ECG showed diffuse lambda ST–segment elevation, also called “shark fin”(fig.1). According to hemodynamically unstable scenario and ECG pattern, emergency coronary angiography was performed, showing absence of coronary artery disease(fig. 2). Echocardiography revealed severe LV systolic disfunction (EF 20–25%) with apical ballooning and severe systolic anterior motion (SAM) of the anterior mitral leaflet eliciting dynamic LVOTO with peak gradient greater than 90 mmHg; fig. 3) and severe MR. Patient was treated with cautious fluid administration, hemotrasfusion and empiric large spectrum antibiotic therapy. According to TTC working diagnosis, even if septic state was thought to contribute to cardiogenic shock, norepinephrine was not administered due to concerns for LVOTO and SAM. After overcoming of dramatic first phase and after hemodynamic steadiness was achieved, beta blockade and ACEi were progressively administered. Seriate transthoracic echocardiogram revealed progressive improvement of LV systolic function, regression of apical ballooning, SAM and LVOTO. ECG monitoring showed regression of ischemic ST elevation. ST elevation has been described in about 56% of TTC cases, however with amplitude tipically lower than in STEMI. Lambda–wave ST elevation has been rarely reported. Vasospasm, local intermittent microvascular constriction, catecholamine–induced metabolic toxicity, transmural systolic wall tension and its the mechano–electric feedback can explain scaring ECG–pattern. Despite its rare prevalence in TTC “shark fin” pattern appears to relate to adverse outcome and it should be used as an early marker of potential further clinical deterioration, suggesting more intensive monitoring to avoid delays in possible therapy escalation.

Donor heart dysfunction and graft survival in liver and kidney transplants-A register-based study from Sweden.

Stress cardiomyopathy in donors can potentially affect graft function and longevity. This study aims to investigate the association between echocardiographic left ventricular ejection fraction (LVEF)<50%, and/or the presence of left ventricular regional wall motion abnormalities (RWMA) in organ donors, and short- and long-term liver and kidney graft survival. Our secondary aim was to link graft survival with donor and recipient characteristics. All donors considered for liver and kidney donation with echocardiographic records at Sahlgrenska University Hospital between 2006 and 2016 were matched with their recipients through the Scandiatransplant register. The studied outcomes were graft survival, re-transplantation, and recipient death. Kaplan-Meier curves were used to plot time to event. Multivariate Cox-regression was used to test independence. There were 370 liver donors and 312 kidney donors (matched with 458 recipients) with echocardiographic records at Sahlgrenska University Hospital between June 2006 and November 2016. Of patients with LV dysfunction by echocardiography, there were 102 liver- and 72 kidney donors. Univariate survival analyses showed no statistical difference in the short- and long-term graft survival from donors with LV dysfunction compared to donors without. Donor age>65 years, recipient re-transplantation and recipient liver tumor were predictors of worse outcome in liver transplants (p<.05). Donor age>65, donor hypertension, recipient re-transplantation, and a recipient diagnosis of diabetes or nephritis/glomerulonephritis had a negative association with graft survival in kidney transplants (p<.05). We found no significant association between donor LV dysfunction and short- and long-term graft survival in liver and kidney transplants, suggesting that livers and kidneys from such donors can be safely transplanted.

Pulmonary Embolism in Patients Admitted With Takotsubo Cardiomyopathy: Prevalence and Associated In-Hospital Adverse Events.

Introduction Takotsubo cardiomyopathy (TCM) is a poorly understood condition typically characterized by abnormal left ventricular wall motion without causative coronary artery disease and typically presents in post-menopausal women after the experience of a physical or emotional stressor. The pathophysiology of TCM is complex and multifactorial, resulting in complications with varied severity; one of the most concerning complications is thromboembolism, specifically, pulmonary embolism (PE), which is understudied in its relation to TCM.The purpose of this study was to characterize and evaluate the real-world prevalence and outcomes of PE in TCM. Methods Data were derived from the National Inpatient Sample database from January 2016 to December 2019. The primary outcomes assessed were baseline and hospital admission characteristics and comorbidities for patients with TCM with and without PE. Outcomes for TCM patients with PEand predictors of mortality in TCM were also analyzed. Results PE developed in 788 of 40,120 patients with TCM (1.96%). After multivariate adjustment, PE was found to be independently associated with intracardiac thrombus (adjusted odds ratio (aOR) 2.067; 95% confidence interval (CI): 1.198-3.566; p = 0.009) and right heart catheterization (RHC) (aOR: 1.971; 95% CI: 1.160-3.350; p = 0.012). Mortality in patients with TCM was associated with, among other factors, age in years at admission (aOR: 1.104; 95% CI: 1.010-1.017; p = 0.001), African American race (aOR: 1.191; 95% CI: 1.020-1.391; p = 0.027), Asian or Pacific Islander race (aOR: 1.637; 95% CI: 1.283-2.090; p = 0.001), coagulopathy (aOR: 3.393; 95% CI: 2.889-2.986; p = 0.001), liver disease (aOR: 1.446; 95% CI: 1.147-1.824; p = 0.002), atrial fibrillation (aOR: 1.460; 95% CI: 1.320-1.615; p = 0.001), and pulmonary embolism (aOR: 2.217; 95% CI: 1.781-2.760; p = 0.001). Conclusion In a large cohort of patients admitted with TCM,we found the prevalence of PE to be 1.96%. PE, along with comorbidities such as coagulopathy and atrial fibrillation, was found to be a significant predictorof mortality in this patient cohort.

Takotsubo cardiomyopathy after solid organ transplantation: a scoping review.

Takotsubo syndrome (TTS) is a stress-induced cardiomyopathy that causes temporary left ventricular wall motion abnormalities and abrupt reversible heart failure. The incidence of perioperative TTS is proportional to the severity of surgical trauma, the duration of the procedure, and the degree of apparent sympathetic activity. A growing number of articles have discussed TTS after a solid organ transplant (SOT), which is one of the circumstances in which physical and emotional stress are at their highest levels. The majority of published cases involved patients who had received an orthotopic liver transplant (OLT). TTS occurred in 0.3-1.7% of liver transplant recipients, but a limited number of cases of TTS in patients who had received kidney, heart, or lung transplants have also been documented. In this study, we analyzed the TTS instances that developed after SOT, highlighting the symptoms and causes as well as the various treatment approaches that were applied. Most TTS cases following OLT and kidney transplant cases occurred in the first week of the surgery. However, the majority of cases occurred years after heart transplantation. Dizziness, dyspnoea, and chest discomfort are the most typical symptoms. Patients may also experience syncope and generalized weakness. In spite of this, the symptoms differ depending on the transplanted organ. Dyspnoea is a common symptom after lung transplants, whereas chest discomfort and dizziness are a common symptom after liver and kidney transplants. Yet, chest pain is not a typical symptom after a heart transplant.

Imaging Features of Arrhythmogenic Cardiomyopathies.

Arrhythmogenic cardiomyopathy (ACM) is a genetic disease characterized by replacement of ventricular myocardium with fibrofatty tissue, predisposing the patient to ventricular arrhythmias and/or sudden cardiac death. Most cases of ACM are associated with pathogenic variants in genes that encode desmosomal proteins, an important cell-to-cell adhesion complex present in both the heart and skin tissue. Although ACM was first described as a disease predominantly of the right ventricle, it is now acknowledged that it can also primarily involve the left ventricle or both ventricles. The original right-dominant phenotype is traditionally diagnosed using the 2010 task force criteria, a multifactorial algorithm divided into major and minor criteria consisting of structural criteria based on two-dimensional echocardiographic, cardiac MRI, or right ventricular angiographic findings; tissue characterization based on endomyocardial biopsy results; repolarization and depolarization abnormalities based on electrocardiographic findings; arrhythmic features; and family history. Shortfalls in the task force criteria due to the modern understanding of the disease have led to development of the Padua criteria, which include updated criteria for diagnosis of the right-dominant phenotype and new criteria for diagnosis of the left-predominant and biventricular phenotypes. In addition to incorporating cardiac MRI findings of ventricular dilatation, systolic dysfunction, and regional wall motion abnormalities, the new Padua criteria emphasize late gadolinium enhancement at cardiac MRI as a key feature in diagnosis and imaging-based tissue characterization. Conditions to consider in the differential diagnosis of the right-dominant phenotype include various other causes of right ventricular dilatation such as left-to-right shunts and variants of normal right ventricular anatomy that can be misinterpreted as abnormalities. The left-dominant phenotype can mimic myocarditis at imaging and clinical examination. Additional considerations for the differential diagnosis of ACM, particularly for the left-dominant phenotype, include sarcoidosis and dilated cardiomyopathy. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Saddle Pulmonary Embolus Treated With Bilateral Emergent Aspiration Pulmonary Thrombectomy

A 77 year old man with recurrent lower extremity thrombosis presented with acute onset shortness of breath and new onset hypoxemia three days after prostatectomy for adenocarcinoma of the prostate. He had been off anticoagulation during the perioperative period. In addition to his new diagnosis of prostate cancer he also had a remote history of treated non-invasive melanoma. Based on this presentation he was at high risk of developing thromboembolic disease. Computed tomography angiogram (CTA) of his chest confirmed a large saddle pulmonary embolus, echocardiogram was positive for new right ventricular wall motion dyskinesis and lower extremity ultrasound revealed bilateral acute and chronic deep vein thrombosis. Given his high bleeding risk, hypoxia and elevated troponin I, he underwent emergent successful aspiration pulmonary thrombectomy. This case is of interest to hospitalists and intesivists as it provides an overview of the current invasive management of pulmonary embolus in the acute setting when systemic anticoagulation is contraindicated. Emergent Aspiration Pulmonary Thrombectomy can restore pulmonary artery flow and cardiopulmonary hemodynamics. A collaborative team based approach that involves the emergency department, intensive care unit, interventional teams and hospitalists is favored.

Ultrasound Targeted Microbubble Cavitation (UTMC) for the treatment of Myocardial Microvascular Obstruction (MVO)

Congestive heart failure following acute myocardial infarction is increasing due to microvascular obstruction (MVO), for which there is no effective therapy. We have been developing ultrasound-targeted microbubble cavitation (UTMC) as a potential treatment. Rapacz familial hypercholesterolemic (RFH) pigs were used in this study. MVO was created in the left anterior descending (LAD) microcirculation. UTMC therapy was applied during infusion of Definity®. Left ventricular (LV) segmental wall motion and microvascular perfusion were assessed with ultrasound. Cardiac MRI was obtained to measure infarct size and area of MVO; ultrasound imaging and coronary angiography were performed at 48h. LAD angiographic flow was improved at 48 h post-treatment in comparison to control. UTMC treatment significantly improved echo-based LV systolic performance. UTMC was also found to significantly enhance LAD blood volume at 48h versus control. MRI-derived LV segmental wall motion and ejection fraction also improved post-treatment. Infarct size was reduced as assessed by both Evans Blue/TTC staining and MRI. In conclusion, we demonstrated that UTMC significantly reduced infarct size, enhanced LAD microvascular perfusion and improved LV systolic performance.

Resting strain analysis to identify myocardial ischemia in patients with advanced chronic kidney disease.

Chronic kidney disease (CKD) is associated with higher incidence of cardiovascular death. Screening for coronary artery disease in asymptomatic or mildly symptomatic patients is challenging. The aim of this study was to investigate the incremental value of resting deformation analysis in predicting positive results for myocardial ischemia during stress transthoracic echocardiography in patients with end-stage CKD. Sixty-one patients (mean age: 62.3 ± 11.8, 65.7% men) with end-stage CKD were included in the study. Patients underwent a resting transthoracic echocardiogram and a dobutamine stress contrast echo (DSE) protocol. Positive results of DSE were defined as stress-induced left ventricular (LV) wall motion abnormalities. The study cohort had normal or mildly impaired systolic function: mean LV ejection fraction (EF) was 49.2% (±10.4) and mean LV global longitudinal strain (GLS) was 14.4% (±4.5). Half of our population had impaired left atrial (LA) strain: mean LA reservoir, conduit, and contractile reserve were 24.1% (±12.6), 10.6% (±5.9), and 13.6% (±9.2), respectively. DSE was positive for ischemia in 55.7%. A significant negative association with DSE results was found for LV EF, LV GLS and the conduit phase of LA strain. Both LV and LA dimensions showed positive correlation with presence of ischemia in DSE. Multivariate logistic regression analysis showed that LV GLS was independently associated with DSE (p = 0.007), after controlling for covariates, with high diagnostic accuracy. Resting LV deformation could predict positive results during DSE, thus may be useful to better identify renal patients who might benefit from coronary artery screening.

Exploratory Review of the Takotsubo Syndrome and the Possible Role of the Psychosocial Stress Response and Inflammaging.

Takotsubo syndrome (TTS) is a cardiomyopathy that clinically presents as a transient and reversible left ventricular wall motion abnormality (LVWMA). Recovery can occur spontaneously within hours or weeks. Studies have shown that it mainly affects older people. In particular, there is a higher prevalence in postmenopausal women. Physical and emotional stress factors are widely discussed and generally recognized triggers. In addition, the hypothalamic-pituitary-adrenal (HPA) axis and the associated glucocorticoid-dependent negative feedback play an important role in the resulting immune response. This review aims to highlight the unstudied aspects of the trigger factors of TTS. The focus is on emotional stress/chronic unpredictable mild stress (CUMS), which is influenced by estrogen concentration and noradrenaline, for example, and can lead to changes in the behavioral, hormonal, and autonomic systems. Age- and gender-specific aspects, as well as psychological effects, must also be considered. We hypothesize that this leads to a stronger corticosteroid response and altered feedback of the HPA axis. This may trigger proinflammatory markers and thus immunosuppression, inflammaging, and sympathetic overactivation, which contributes significantly to the development of TTS. The aim is to highlight the importance of CUMS and psychological triggers as risk factors and to make an exploratory proposal based on the new knowledge. Based on the imbalance between the sympathetic and parasympathetic nervous systems, transcutaneous vagus nerve stimulation (tVNS) is presented as a possible new therapeutic approach.

Analysis and insights of cardiac amyloidosis: novel perception of rare diseases in cardiology.

Amyloidosis is a rare systemic disease, while cardiac amyloidosis (CA) is nothing more than a chronic disease that causes fatal damage to the structure and function of the heart. The pathogenesis of CA is elusive, the clinical manifestations are diverse and lack of specificity, and the treatment and prognosis of different subtypes vary widely. It is of great practical significance to deepen the understanding of CA. The clinical data of 39 patients with CA admitted to the First Affiliated Hospital of Gannan Medical University and Fujian Medical University Union Hospital from January 1, 2018 to March 1, 2024 were collected and retrospectively studied, and the clinical features, diagnosis, differentiation, treatment effects and prognosis of CA patients were analyzed. The Kaplan-Meier method was used for survival analysis. Meanwhile, the latest literature from PubMed was retrieved to systematically discuss the research progress in the diagnosis and treatment of CA. This paper is expected to provide novel and valuable references for the clinical and basic research of CA. A total of 39 patients with CA were included in this study, including 23 males (58.97%) and 16 females (41.03%). The average age at diagnosis was 60.51±10.28 years old. In this study, 24 patients (61.54%) had anemia of different degrees, 19 patients (48.72%) were accompanied by abnormal elevation of cardiac troponin T (cTnT), and all patients (100%) had abnormal elevation of N-terminal pro-brain natriuretic peptide (NT-proBNP), and 28 patients (71.79%) had renal impairment. Typical electrocardiogram (ECG) findings in CA patients in this study show low voltage in limb leads, various types of atrioventricular block, various types of tachycardia, atrial fibrillation and poor R-wave progression. The representative results of ultrasonic cardiogram (UCG) showed: 1. Atrium were enlarged, and ventricular wall motion was weakened. 2. Septum and posterior walls of the ventricle were symmetrically thickened, and the myocardium showed speckled strong echo. 3. Mitral regurgitation (moderate to severe) and tricuspid regurgitation. 4. Widening of the pulmonary artery and pulmonary hypertension. Typical results of cardiac magnetic resonance imaging (MRI) of CA patients in this study showed that delayed gadolinium enhancement of the ventricular wall, with ventricular wall thickening to varying degrees and ventricle or atrium enlargement. The pathological manifestations of CA patients in this study were mostly Congo red staining (+) and deposition of eosinophilic amyloid in the affected organs or tissues. All CA patients included in this study received standardized treatment, the median follow-up time was 29.5 (range, 6.5-71) months, and at the latest follow-up, only 12 cases of 39 patients with CA were still alive, and 27 patients died in our study, all of which were due to uncontrollable progression of the disease and failed treatment. Our study showed that there is no statistical significance in the different age groups of the CA patients (P>0.05), while it was surprising that male CA patients had significantly worse overall survival (OS) than female patients. Correspondingly, patients who received chemotherapy and were accompanied with renal impairment had a worse prognosis than those who did not receive chemotherapy and had normal renal function (all P<0.05). CA is a rare disease caused by systemic amyloidosis, the pivotal points of CA diagnosis and treatment as well as the premise for improving the long-term prognosis of CA patients are clear diagnosis and accurate typing. The treatment of CA also requires targeted individual treatment according to the subtype and etiology of CA patients, so as to maximize the prognosis of CA patients.