Spontaneous coronary and vertebral artery dissections are rare events occurring most commonly in otherwise healthy women during pregnancy or the post-partum period.
This report describes a 35-year-old female who presented with an acute inferior ST elevation myocardial infarction 7 months post-partum secondary to spontaneous dissection of the left obtuse marginal coronary artery. Despite appropriate medical therapy with dual anti-platelet therapy, the patient presented four weeks later with a spontaneous dissection of the right vertebral artery.
We review the presentation, diagnosis, and management of spontaneous dissections of the vasculature in the peri-partum period.
Spontaneous dissection; Vasculature; Pregnancy; Imaging
Ventricular septal rupture (VSR), a mechanical complication following an acute myocardial infarction (MI), is thought to result from coagulation necrosis due to lack of collateral reperfusion. Although the gold standard test to confirm left-to-right shunting between ventricular cavities remains invasive ventriculography, two-dimensional transthoracic echocardiography (TTE) with color flow Doppler and cardiac MRI (CMR) are reliable tests for the non-invasive diagnosis of VSR.
A 62-year-old Caucasian female presented with a late case of a VSR post inferior MI diagnosed by multimodality cardiac imaging including TTE, CMR and ventriculography.
We review the presentation, diagnosis and management of VSR post MI.
Echocardiography; Cardiac Mri; Ventricular septal rupture
Peripartum cardiomyopathy (PPCM) is a rare cardiac disorder characterized by the development of heart failure in the last month of pregnancy or up to 5 months postpartum in women without other identifiable causes of cardiac failure. The combination of left ventricular (LV) systolic dysfunction and hypercoaguability can cause thromboembolic complications including intra-cardiac thrombi.
A 25-year-old Caucasian female with PPCM demonstrated multiple thrombi in the LV on transthoracic echocardiography. Following anticoagulation with parenteral heparin, a cardiac MRI four days later demonstrated near resolution of the thrombi.
We review the presentation, diagnosis and management of LV thrombi in the clinical setting of PPCM.
Peripartum cardiomyopathy; Multimodality cardiac imaging; Thrombus
Double chambered right ventricle (DCRV) is a relatively rare congenital heart disease, characterized by the abnormal division of the right ventricle into a high-pressure inlet and low-pressure outlet by anomalous muscle bundles. Extra-cardiac right-to-left shunts may present with clinical symptoms in adulthood and should be sought in patients with previous cavo-pulmonary shunt procedures.
We report a case of DCRV in a 29 year old Caucasian male presenting in adulthood with a right-to-left shunt secondary to venous collaterals, following cavopulmonary anastomosis for congenital pulmonary atresia and hypoplastic right ventricle.
Multimodality cardiac imaging using echocardiography, cardiac CT, cardiac MRI and cardiac catheterization is often required for complete characterization of complex congenital heart anomalies in adulthood.
Echocardiography; Cardiac CT; Cardiac MRI; Cardiac catheterization; Double chambered right ventricle; Aortopulmonary shunt
Several studies have correlated elevations in cardiac biomarkers of injury post marathon with transient and reversible right ventricular (RV) systolic dysfunction as assessed by both transthoracic echocardiography (TTE) and cardiovascular magnetic resonance (CMR). Whether or not permanent myocardial injury occurs due to repeated marathon running in the aging population remains controversial.
To assess the extent and severity of cardiac dysfunction after the completion of full marathon running in individuals greater than 50 years of age using cardiac biomarkers, TTE, cardiac computed tomography (CCT), and CMR.
A total of 25 healthy volunteers (21 males, 55 ± 4 years old) from the 2010 and 2011 Manitoba Full Marathons (26.2 miles) were included in the study. Cardiac biomarkers and TTE were performed one week prior to the marathon, immediately after completing the race and at one-week follow-up. CMR was performed at baseline and within 24 hours of completion of the marathon, followed by CCT within 3 months of the marathon.
All participants demonstrated an elevated cTnT post marathon. Right atrial and ventricular volumes increased, while RV systolic function decreased significantly immediately post marathon, returning to baseline values one week later. Of the entire study population, only two individuals demonstrated late gadolinium enhancement of the subendocardium in the anterior wall of the left ventricle, with evidence of stenosis of the left anterior descending artery on CCT.
Marathon running in individuals over the age of 50 is associated with a transient, yet reversible increase in cardiac biomarkers and RV systolic dysfunction. The presence of myocardial fibrosis in older marathon athletes is infrequent, but when present, may be due to underlying occult coronary artery disease.
Marathon running; Cardiac biomarkers; Echocardiography; Cardiac computed tomography; Cardiovascular magnetic resonance
Left ventricular free wall rupture (LVFWR) is one of the most lethal complications following myocardial infarction. It accounts for approximately 12% to 21% of all in-hospital deaths following myocardial infarction. The majority of patients die shortly after LVFWR from instantaneous pericardial tamponade and hemodynamic collapse. However, up to one-third of cases are subacute in nature, allowing limited time for emergent surgical repair to prevent sudden death. A high index of suspicion and timely use of diagnostic tests are important in recognizing cases. The present report describes the case of a 69-year-old man who initially presented with acute pericardial tamponade and was subsequently diagnosed with LVFWR in the operating room as the cause of his hemopericardium. The pathology, diagnosis and management of LVFWR are reviewed.
Echocardiography; Hemopericardium; Mechanical complications; Myocardial infarction
Spontaneous coronary dissections are a well described entity which are often difficult to treat. Intramural hematoma is one type of coronary dissection. Previous case reports have described the treatment for angiographically visible dissection. We describe the first report of diffuse intramural hematoma visualized only on intravascular ultrasound with no angiographically obvious evidence of dissection treated with multivessel drug eluting stenting. This case highlights the importance of a high level of suspicion and atypical presentations of coronary dissection, and the use of multimodality imaging with intravascular ultrasound and computerized tomography for both diagnosis and therapy.
PCI; IVUS; CT; intramural hematoma.
Congenital pericardial cysts are benign lesions that arise from the pericardium during embryonic development. The diagnosis is based on typical imaging features, but atypical locations and signal magnetic resonance imaging sequences make it difficult to exclude other lesions. Diffusion-weighted magnetic resonance imaging is a novel method that can be used to differentiate tissues based on their restriction to proton diffusion. Its use in differentiating pericardial cysts from other pericardial lesions has not yet been described.
We present three cases (a 51-year-old Caucasian woman, a 66-year-old Caucasian woman and a 77-year-old Caucasian woman) with pericardial cysts evaluated with diffusion-weighted imaging using cardiac magnetic resonance imaging. Each lesion demonstrated a high apparent diffusion coefficient similar to that of free water.
This case series is the first attempt to investigate the utility of diffusion-weighted magnetic resonance imaging in the assessment of pericardial cysts. Diffusion-weighted imaging may be a useful noninvasive diagnostic tool for pericardial cysts when conventional imaging findings are inconclusive.
In Canada, breast cancer is the leading cause of cancer-related death in women. Approximately 25% to 30% of breast cancers overexpress the human epidermal growth factor receptor 2. Trastuzumab (Trz), which is a monoclonal antibody against epidermal growth factor receptor 2, reduces recurrence and mortality by 50% and 33%, respectively. Other clinical studies have shown that 5% to 10% of patients who receive Trz following doxorubicin treatment develop cardiac dysfunction. This reviews discusses the various mechanisms that may account for doxorubicin and Trz-induced cardiac dysfunction.
Trastuzumab (Trz) is a monoclonal antibody against the human epidermal growth factor receptor 2 that is found to be overexpressed in 25% to 30% of breast cancer patients. In spite of the therapeutic benefits of Trz, cardiotoxic side effects are still an issue. This effect is potentiated particularly when Trz is administered following doxorubicin (DOX) treatment. Among the various mechanisms that may account for DOX and Trz-induced cardiotoxicity, the role of oxidative stress has gained significant support. The present review discusses the evidence supporting the hypothesis that oxidative stress comes from multiple sources through an increase in the production of reactive oxygen species and/or a decrease in antioxidant defense systems. The adjuvant use of Trz can potentiate cardiomyocyte damage through a ‘dual-hit’ mechanism, which includes inhibition of the neuregulin-1 survival signalling pathway and angiotensin II-induced activation of NADPH oxidase, with the ability to further increase reactive oxygen species production. Preventive therapies for DOX- and Trz-induced cardiac dysfunction have eluded investigators, but may include the prophylactic use of angiotensin-converting enzyme inhibitors, beta-blockers and use of antioxidants. Thus, a better understanding of the mechanisms leading to this characteristic drug-induced cardiomyopathy, as well as potential cardioprotective strategies is required.
Doxorubicin; Epidermal growth factor; Heart failure; Oxidative stress; Renin-angiotensin system
Tissue Doppler imaging (TDI) is a noninvasive echocardiographic method for the diagnosis of diastolic dysfunction in patients with varying degrees of aortic stenosis (AS). Little is known however, on the utility of TDI in the serial assessment of diastolic abnormalities in AS.
The aim of the current proposal was to examine whether treatment with rosuvastatin was successful in improving diastolic abnormalities in patients enrolled in the Aortic Stenosis Progression Observation Measuring Effects of Rosuvastatin (ASTRONOMER) study.
Conventional Doppler indices including peak early (E) and late (A) transmitral velocities, and E/A ratio were measured from spectral Doppler. Tissue Doppler measurements including early (E') and late (A') velocities of the lateral annulus were determined, and E/E' was calculated.
The study population included 168 patients (56 ± 13 years), whose AS severity was categorized based on peak velocity at baseline (Group I: 2.5-3.0 m/s; Group II: 3.1-3.5 m/s; Group III: 3.6-4.0 m/s). Baseline and follow-up hemodynamics, LV dimensions and diastolic functional parameters were evaluated in all three groups. There was increased diastolic dysfunction from baseline to follow-up in each of the placebo and rosuvastatin groups. In patients with increasing severity of AS in Groups I and II, the lateral E' was lower and the E/E' (as an estimate of increased left ventricular end-diastolic pressure) was higher at baseline (p < 0.05). However, treatment with rosuvastatin did not affect the progression of diastolic dysfunction from baseline to 3.5 year follow-up between patients in any of the three predefined groups.
In patients with mild to moderate asymptomatic AS, rosuvastatin did not attenuate the progression of diastolic dysfunction.
Partial anomalous pulmonary venous connection (PAPVC) is an extremely rare congenital condition where one or more of the pulmonary veins are connected to the venous circulation. Although initially suspected with unexplained right ventricular enlargement on transthoracic echocardiography (TTE), cardiac MRI is able to delineate the anatomical variant. We present a case of a 65-year-old male diagnosed with left sided PAPVC using multimodality cardiac imaging.
A patient with hypertrophic cardiomyopathy (HCM) and transfusion-dependent sideroblastic anemia, who presented with decompensated heart failure, is described. The present case demonstrates the usefulness of cardiac magnetic resonance imaging as a noninvasive imaging modality to assess the etiology of new systolic dysfunction in the setting of HCM. Cardiac magnetic resonance imaging is able to differentiate between the dilated ‘burned-out’ phase of HCM and a concomitant dilated cardiomyopathy secondary to myocarditis or hemosiderosis.
Cardiac MRI; Hemochromatosis; Hypertrophic cardiomyopathy
Duchenne muscular dystrophy (DMD) leads to structural heart disease, including dilated cardiomyopathy, in 90% of patients >18 years of age. Despite the ubiquity of cardiomyopathy associated with DMD, ventricular aneurysms in these patients have rarely been reported. We present a case of a basal inferoposterior aneurysm of the left ventricle in a 23-year-old male patient with DMD.
A 63-year-old woman with no known cardiac history presented with pulmonary edema accompanied by electrocardiographic evidence of ischemia. Echocardiography demonstrated normal cardiac dimensions, normal wall motion and mild diastolic dysfunction. Despite repeat attempts at extubation following aggressive diuresis, the patient required ongoing ventilatory support. Although cardiac catheterization revealed normal coronary arteries, computed tomography revealed a 4 cm × 9 cm multinodular goiter extending into the mediastinum and compressing the trachea. A diagnosis of negative pressure pulmonary edema should be considered in the differential diagnosis of any patient presenting with acute heart failure.
Computed tomography; ECG; Echocardiography; Heart failure
Breast cancer, a leading cause of increased morbidity and mortality among women, overexpresses the human epidermal growth factor receptor 2 in approximately 20% to 30% of cases. Trastuzumab (Trz), a monoclonal antibody against the human epidermal growth factor receptor 2, improves survival in breast cancer patients in both the adjuvant and metastatic settings. Despite the therapeutic benefits of Trz, there is an increased incidence of cardiotoxicity, particularly when administered following anthracycline-based chemotherapy. The pathogenesis underlying Trz-mediated cardiotoxicity remains poorly understood. The present review focuses on the current understanding of Trz-mediated cardiotoxicity from both the basic and clinical science perspectives.
Cardiac MRI; Cardiomyopathy; Echocardiography; Renin-angiotensin system; Trastuzumab
Cardiac tamponade is the phenomenon of hemodynamic compromise caused by a pericardial effusion. Following a myocardial infarction, the most common causes of pericardial fluid include early pericarditis, Dressler's syndrome, and hemopericardium secondary to a free wall rupture. On transthoracic echocardiography, pericardial fluid appears as an echo-free space in between the visceral and parietal layers of the pericardium. Pericardial fat has a similar appearance on echocardiography and it may be difficult to discern the two entities. We present a case of a post-MI patient demonstrating pseudo tamponade physiology in the setting of excessive pericardial fat.
A 35 year-old asymptomatic Caucasian female with a family history of hypertrophic cardiomyopathy (HCM) was referred for cardiologic evaluation. The electrocardiogram and transthoracic echocardiogram were normal. Cardiovascular magnetic resonance (CMR) was performed for further assessment of myocardial function and presence of myocardial scar. CMR showed normal left ventricular systolic size, measurements and function. However, there was extensive, diffuse late gadolinium enhancement (LGE) throughout the left ventricle. This finding was consistent with extensive myocardial scarring and was highly suggestive of advanced, non-ischemic cardiomyopathy. Genotyping showed a heterozygous mis-sense mutation (275G>A) in the cardiac troponin T (TNNT2) gene, which is causally associated with HCM. There have been no previous reports of such extensive, atypical pattern of myocardial scarring despite an otherwise structurally and functionally normal left ventricle in an asymptomatic individual with HCM. This finding has important implications for phenotype screening in HCM.
Echocardiography is widely used in the management of patients with cardiogenic shock (CS). Left ventricular ejection fraction (EF) has been shown to be an independent predictor of survival in CS. Tissue Doppler Imaging (TDI) is a sensitive echocardiographic technique that allows for the early quantitative assessment of regional left ventricular dysfunction. TDI derived indices, including systolic velocity (S'), early (E') and late (A') diastolic velocities of the lateral mitral annulus, are reduced in heart failure patients (EF < 30%) and portend a poor prognosis. In CS patients, the application of TDI prior to revascularization remains unknown.
To characterize TDI derived indices in CS patients as compared to patients with chronic CHF.
Between 2006 and 2007, 100 patients were retrospectively evaluated who underwent echocardiography for assessment of LV systolic function. This population included: Group I) 50 patients (30 males, 57 ± 13 years) with chronic CHF as controls; and Group II) 50 patients (29 males, 58 ± 10 years) with CS. Spectral Doppler indices including peak early (E) and late (A) transmitral velocities, E/A ratio, and E-wave deceleration time were determined. Tissue Doppler indices including S', E' and A' velocities of the lateral annulus were measured.
Of the entire cohort, the mean LVEF was 25 ± 5%. Cardiogenic shock patients demonstrated significantly lower lateral S', E' and a higher E/E' ratio (p < 0.01), as compared to CHF patients. The in-hospital mortality in the CHF cohort was 5% as compared to the CS group with an in hospital mortality of 40%. In the subset of CS patients (n = 30) who survived, the mean S' at presentation was higher as compared to those patients who died in hospital (3.5 ± 0.5 vs. 1.8 ± 0.5 cm/s).
Despite similar reduction in LV systolic function, CS patients have reduced myocardial velocities and higher filling pressures using TDI, as compared to CHF patients. Whether TDI could be a reliable tool to determine CS patients with the best chance of recovery following revascularization is yet to be determined.
A 44-year-old man with no known cardiac history presented with worsening dyspnea on minimal exertion. During follow-up, computed tomography angiography and echocardiography confirmed the incidental finding of cor triatriatum. As improvements in spatial and temporal resolution continue, cardiac computed tomography may become better suited to the dynamic imaging of anatomical defects in the heart, including, but not limited to, coronary artery disease.
Computed tomography coronary angiography; Cor triatriatum; Echocardiography