Caseous calcification of the mitral annulus (CCMA) is a rare variant of mitral annular calcification, and a multimodality approach is advised to ensure an accurate diagnosis. We report a case of a patient with CCMA, associated with severe mitral regurgitation. An 82-year-old woman was admitted due to worsening heart failure. Transthoracic echocardiography revealed a fixed, hyperechogenic mass, accompanied by restriction of the posterior mitral leaflet, and subsequent severe mitral regurgitation. Transesophageal echocardiography demonstrated a restricted motion of the posterior mitral leaflet, because of a large, echogenic mass (15 mm × 11 mm), attached to the mitral annulus, vacuolated with a central echolucent aspect, lacking acoustic shadowing. Contrast-enhanced cardiac computed tomography identified a distinct oval mass (18 mm × 11 mm × 19 mm) presenting a central hypodense content and peripheral calcification, strongly suggestive of CCMA. Considering the patient's profile, surgical valvular replacement was considered unsuitable. Therefore, a transcatheter edge-to-edge repair was performed, resulting in mild residual regurgitation.
In the evaluation of cardiomyopathies, cardiac computed tomography (CCT) is predominantly used for assessing congenital or acquired coronary artery diseases as a potential etiology underlying the observed myocardial abnormalities. However, its utility is expected to expand. We present a case of an asymptomatic patient with claustrophobia who sought medical attention due to frequent ventricular beats. The resting electrocardiogram revealed repolarization abnormalities characterized by flattened T-waves in the lateral leads and low QRS voltages in the peripheral leads, whereas transthoracic echocardiography was normal. CCT accurately identified hypodense areas indicative of fibrofatty infiltration within the inferolateral and anterior walls of the left ventricle. Furthermore, late iodine contrast-phase imaging revealed subepicardial late enhancement striae in the same regions. These imaging findings were pivotal in establishing a diagnosis of left-dominant arrhythmogenic cardiomyopathy. This clinical vignette underscores the potential of CCT in tissue characterization, particularly when cardiac magnetic resonance imaging is contraindicated or unavailable.
Abstract Background Arrhythmogenic cardiomyopathy (AC) is a genetically determined heart muscle disease characterized by myocyte necrosis and consequent fibro-fatty replacement. The recognition of fibrosis is a relevant finding with important diagnostic and prognostic implications. Speckle tracking echocardiography (STE) may be more accurate than conventional echocardiography in detecting early myocardial alterations that need to be confirmed with the gold standard technique, cardiac magnetic resonance (CMR). Purpose The aim of our study is to evaluate if STE-derived strain analysis can predict the presence of fibrosis on CMR in the corresponding segment. Methods 86 patients with AC (including right/left dominant and biventricular forms) underwent advanced echocardiography with STE-derived strain analysis and CMR. Using a 17-segment Bull's-eye model, the cut-off value that best predicts the presence of gadolinium enhancement on CMR was determined for each wall segment using ROC curve analysis. Results The medium age was 45 (32-58) years, male gender was prevalent 71%. Among our patients, 44.1% had a biventricular form, 26.7% had a right-dominant form, 26.7% had a left-dominant form, and 2.3% had a borderline diagnosis. Regarding cardiovascular risk factors, 11.6% of patients had arterial hypertension, 15.1% had dyslipidemia, 2% had diabetes, 1% were smokers and 1% had coronary artery disease with previous percutaneous revascularization. The mean left ventricle (LV) ejection fraction (EF) was preserved 59% (54-64), while the medium LV global longitudinal strain (GLS) was slightly reduced, -18.2% (-20.1 to -15.2). A detailed analysis of regional wall strain was performed, and ROC curve analysis was used to determine a cut-off value for each segment to predict the presence of fibrosis on CMR in the corresponding segment, as shown in Table 1. Lower-than-average values demonstrated good accuracy in predicting the presence of fibrosis on CMR. Conclusions STE-strain analysis is a clinically accessible tool that enhances the sensitivity of echocardiography in detecting myocardial tissue alterations in AC, which would otherwise be identifiable only through CMR. Notably, even when GLS is within normal limits, regional strain sub-analysis can additionally reveal myocardial involvement. Table 1
Heart failure (HF) remains a critical global health challenge, necessitating advancements in diagnostic and therapeutic strategies. This review explores the evolution of imaging technologies and their impact on HF management, focusing on three-dimensional echocardiography (3DE), myocardial strain imaging, and vortex dynamics imaging. Three-dimensional echocardiography enhances traditional echocardiography by providing more accurate assessments of cardiac structures, while myocardial strain imaging offers the early detection of subclinical myocardial dysfunction, crucial in conditions such as chemotherapy-induced cardiotoxicity and ischemic heart disease. Vortex dynamics imaging, a novel technique, provides insights into intracardiac flow patterns, aiding in the evaluation of left ventricular function, valve diseases, and congenital heart anomalies. The integration of these advanced imaging modalities into clinical practice facilitates personalized treatment strategies, enabling the earlier diagnosis and more precise monitoring of disease progression. The ongoing refinement of these imaging techniques holds promise for improving patient outcomes and advancing the field of precision medicine in HF care.
Abstract Coronary computed tomography angiography (CCTA) has emerged as a pivotal non-invasive imaging modality for detailed assessment of coronary anatomy and plaque characteristics, playing a significant role in diagnosing and managing ischemic heart disease (IHD). Traditional approaches, such as the Segment Stenosis Score, Segment Involvement Score, and Leaman score, offer semi-quantitative evaluations of plaque burden. However, they are limited by their inability to quantify plaque volume precisely. Recent advancements in CCTA software have enabled more accurate, quantitative assessments that strongly correlate with invasive methods like intravascular ultrasonography and optical coherence tomography. These software tools also allow for detailed plaque characterization, categorizing plaques by composition and identifying high-risk features that may predict future cardiovascular events. The emerging photon-counting CT technique further enhances plaque analysis by individually measuring photons to assess plaque structure. Additionally, perfusion CT offers a functional imaging approach to evaluate myocardial blood flow, complementing CCTA by detecting microcirculatory dysfunction and providing insights into myocardial tissue, especially in fibrosis cases. The peri-coronary Fat Attenuation Index (pFAI), a 3D tool analyzing peri-coronary fat, has emerged as a significant prognostic marker, improving risk stratification in IHD. The evaluation of pFAI, particularly in patients with non-obstructive coronary disease, provides valuable information on inflammation and cardiovascular risk, making it a critical component of comprehensive IHD assessment. The advancement of CCTA-derived plaque analysis represents a significant change in cardiovascular imaging, enhancing diagnostic precision and risk assessment. As precision medicine advances, the integration of CCTA plaque analysis is set to transform the treatment of complex cardiovascular diseases.
Arrhythmogenic cardiomyopathy (ACM) is a genetic disorder characterized by fibrofatty replacement of myocardial tissue, predominantly affecting the right ventricle (RV), but often involving the left ventricle (LV) as well. The early detection of fibrosis, crucial for risk stratification, has been enhanced by advanced imaging techniques. Global longitudinal strain (GLS) has shown promise as a surrogate marker for late enhancement (LE) in identifying myocardial fibrosis, yet precise cut-off values for strain are lacking. The aim of the study is to evaluate LV strain as a predictor of LE in ACM and to define strain cut-offs for early fibrosis detection, enhancing non-invasive diagnostic accuracy.
Coronary artery disease (CAD) is the leading global cause of mortality, accounting for approximately 30% of all deaths. It is primarily characterized by the accumulation of atherosclerotic plaques within the coronary arteries, leading to reduced blood flow to the heart muscle. Early detection of atherosclerotic plaques is crucial to prevent major adverse cardiac events. Notably, recent studies have shown that 15% of myocardial infarctions occur in patients with non-obstructive CAD, underscoring the importance of comprehensive plaque assessment beyond merely identifying obstructive lesions. Cardiac Computed Tomography Angiography (CCTA) has emerged as a cost-effective and efficient technique for excluding obstructive CAD, particularly in patients with a low-to-intermediate clinical likelihood of the disease. Recent advancements in CCTA technology, such as improved resolution and reduced scan times, have mitigated many technical challenges, allowing for precise quantification and characterization of both calcified and non-calcified atherosclerotic plaques. This review focuses on two critical physiological aspects of atherosclerotic plaques: the burden of calcifications, assessed via the coronary artery calcium score (CACs), and perivascular fat attenuation index (pFAI), an emerging marker of vascular inflammation. The CACs, obtained through non-contrast CT scans, quantifies calcified plaque burden and is widely used to stratify cardiovascular risk, particularly in asymptomatic patients. Despite its prognostic value, the CACs does not provide information on non-calcified plaques or inflammatory status. In contrast, the pFAI, derived from CCTA, serves as an indirect marker of coronary inflammation and has shown potential in predicting adverse cardiac events. Combining both CACs and pFAI assessment could offer a comprehensive risk stratification approach, integrating the established calcification burden with novel inflammatory markers to enhance CAD prevention and management strategies.
Abstract Introduction Aortitis includes both infectious and non-infectious inflammation of the arterial wall. Infectious forms have a worse prognosis, necessitating immediate diagnosis and treatment. We report a case of a patient with prosthetic valve endocarditis complicated with infectious aortitis and multiple embolic lesions, ultimately leading to death. Case presentation An 81-year-old man with an aortic valve bioprosthesis (Intuity 27 mm) presented with fever, dysuria, and ankle swelling. Laboratory showed leukocytosis, anemia, elevated NT-proBNP, and C-reactive protein. Echocardiography revealed a hyperechogenic mass on the bioprosthesis, confirmed as prosthetic endocarditis by transesophageal echocardiography, which also showed an aortic bulb aneurysm and a 9 mm arterial wall thickening. Blood cultures were positive for Staphylococcus aureus , and intravenous antibiotics were started. Thoracic computed tomography confirmed aortic root dilation and mural thickening, indicating infectious aortitis with multiple embolic lesions in the spleen and kidneys. The patient then suffered an intestinal sub-occlusion. The Heart Team decided against cardiovascular surgery due to frailty and high surgical risk. Despite initial hemodynamic stability, his condition deteriorated, leading to death. Conclusion This case presents a challenging scenario of prosthetic valvular endocarditis complicated by infectious aortitis, aortic aneurysm, and multiple thromboembolic lesions in a high-risk patient, ultimately resulting in death.
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