Search Results (53)

Left ventricular (LV) apical obliteration represents a convergent imaging phenotype arising from diverse cardiac conditions, including thrombotic, hypertrophic, infiltrative, congenital, and neoplastic diseases. These conditions, despite sharing overlapping morphological features, require profoundly different management strategies. In this context, an accurate characterization of the LV apex is a cornerstone point, and can be performed through various techniques. Advances in multimodality imaging have substantially improved diagnostic precision, allowing clinicians to differentiate true obliteration from mimicking conditions such as hypertrabeculation, apical hypertrophy, or subendocardial fibrosis. This review provides a comprehensive overview of the anatomical variability of the LV apex and its implications for imaging interpretation. We appraise the role of echocardiography, including contrast-enhanced and speckle-tracking studies—alongside cardiac magnetic resonance (CMR), computed tomography (CT), and selective nuclear imaging in the evaluation of apical pathology. For each principal cause of apical obliteration—LV thrombus, apical hypertrophic cardiomyopathy, left ventricular non-compaction, endomyocardial fibrosis, cardiac amyloidosis, and intracardiac tumors—we outline key diagnostic clues, imaging red flags, and distinguishing tissue characteristics. Special emphasis is given to the incremental value of CMR for tissue characterization, thrombus detection, and fibrosis mapping, as well as to the interpretative challenges posed by apical foreshortening, near-field artefacts, and suboptimal acoustic windows. A practical, stepwise imaging framework is proposed to guide clinicians through the differential diagnosis of apical obliteration using an integrated multimodality approach. Future directions include the incorporation of 4D flow, advanced mapping techniques, and artificial intelligence-powered analysis to refine apical phenotyping and identify early disease signatures. Recognizing the full spectrum of apical pathology and its imaging manifestations is essential to prevent misdiagnosis, enable timely therapeutic decisions, and improve risk stratification. Full article

Extremely premature newborns are predisposed to cardiovascular complications due to a number of factors, including myocardial immaturity, hemodynamic changes, and iatrogenic effects. There are few studies on myocardial strain in extremely premature infants during the early neonatal period. The objective of study was to assess the left ventricular (LV) segmental strain in extremely premature newborns during the early neonatal period by employing speckle-tracking echocardiography (STE). This prospective study examined 65 newborns with no signs of hemodynamic impairment during the first 72 h of life. The cohort had a range of birth weights (600–1500 g) and gestational ages (24–35 weeks). The peak strain in 18 LV segments during systole (peak S and time to peak S), and throughout the cardiac cycle (peak G and time to peak G), and during early systolic pre-stretch (peak P and time to peak P) were assessed in the longitudinal, circumferential, and radial directions. We obtained percentile tables of segmental strain characteristics in the longitudinal, circumferential, and radial directions. No dependence of segmental strain on the birth weight, gestational age, or arterial duct closure was found. A positive gradient of the longitudinal strain magnitude was observed from the base to the apex. The highest circumferential and radial strain were observed in LV septum. This study is the first to register and compare the longitudinal, circumferential, and radial LV strain using STE in extremely premature infants with no signs of hemodynamic disturbances during the first 72 h of life. Reference values for segmental strain were established. Full article

Background and objectives: In cases of acute type A aortic dissection, including iatrogenic cases following transcatheter procedures, the choice of arterial cannulation site has a critical influence on early haemodynamics, organ protection and the risk of malperfusion. Transapical left ventricular cannulation has been suggested as a ‘central’ approach for rapidly establishing cardiopulmonary bypass with antegrade true-lumen flow. This review summarises the current evidence on TAC in acute type A dissection, focusing on indications, technical aspects and clinical outcomes. Materials and methods: We conducted a narrative review of observational studies and technical reports describing TAC for the surgical repair of acute type A aortic dissection. Particular attention was paid to patient selection, operative technique, perioperative complications, and early and mid-term results. Results: Across the published series, TAC is primarily employed in haemodynamically unstable patients or when the peripheral arteries are dissected, diseased, or unsuitable. A long arterial cannula is introduced through the left ventricular apex, crosses the aortic valve and is positioned in the true lumen of the ascending aorta under echocardiographic guidance. This configuration enables the rapid initiation of CPB, shortens skin-to-pump times, and provides reliable antegrade inflow. Early mortality and stroke rates are comparable to those associated with other cannulation strategies. Reported complications include malperfusion requiring site conversion, apical bleeding and rare local structural damage. These can be minimised through standardised technique and systematic imaging. Conclusions: TAC is a valuable bail-out option and, in selected patients, a primary cannulation option for acute type A aortic dissection when conventional arterial access is unsafe or ineffective. Although it offers fast and reproducible establishment of antegrade true-lumen flow, it requires specific expertise in apical exposure and intraoperative echocardiography. It should therefore be integrated into a structured perfusion and repair strategy. Full article

Heterotaxy syndrome is characterized by a tendency for bilaterally symmetric arrangement (isomerism) of inner organs. It is frequently associated with complex congenital heart defects (CHDs). In “heterotaxic” hearts, the tendency for isomerism is confined to the atria. The ventricular segment always shows asymmetric arrangements (D-hand or L-hand topology). This study aimed to determine the statistical distribution of ventricular topology among patients with CHDs associated with heterotaxy and to identify possible associations between ventricular topology and cardiovascular disorders and survival. It is a retrospective cross-sectional study on 192 patients treated at a single center between 2000 and 2023. Our cohort had 115 patients of left atrial isomerism (LAI) and 77 of right atrial isomerism (RAI). The whole cohort (n = 192) showed a bias towards ventricular D-hand topology (67%), which was statistically significant in LAI (74%). In contrast, RAI showed an almost equal distribution (57% D-hand, 43% L-hand). No significant associations were found between ventricular topology and major CHDs or mortality. Significant associations were observed between ventricular topology and cardiac apex position, direction of p-wave axis, and aortic arch sidedness. We conclude that, in the setting of heterotaxy, especially RAI, ventricular topology and aortic arch sidedness both behave as binary anatomical variables showing a tendency for randomized occurrence. This tendency for statistically symmetric distribution is interpreted as reflecting the syndrome-specific tendency for bilateral symmetry. Full article

Right ventricular apex (RVA) pacing has historically been the default approach for cardiac pacing; however, it is associated with the development of progressive left ventricular dysfunction and heart failure (HF), particularly in patients with high pacing burdens. While advances in device programming and modern algorithms have sought to mitigate these effects, preserving physiological activation has proven to be more critical than reducing ventricular pacing. Conduction system pacing (CSP) techniques—namely, His-bundle pacing (HBP) and particularly left bundle branch area pacing (LBBAP)—have emerged as superior alternatives, enabling improved left ventricular function and reduced rates of pacing-induced cardiomyopathy (PICM). Nevertheless, despite the clinical advantages of these procedures over RVA, they face limitations including variable implantation success rates, increased pacing thresholds and lead revision rates, technical challenges, and occasional procedure prolongation. Thus, while CSP approaches represent the future of physiological pacing, RVA pacing continues to provide a necessary and reliable option in the current clinical practice. Full article

Dilated cardiomyopathy affects greater than 1 in 2500 patients worldwide, including those with the neuromuscular disorder Duchenne muscular dystrophy (DMD). While inflammation within skeletal muscle is strongly associated with DMD pathology, the key biomarkers for inflammation and possible targets for therapy within cardiac tissue in DMD-associated dilated cardiomyopathy remain to be identified. One such potential target is the myocardial ghrelin-growth hormone secretagogue receptor (GHSR) system, which is associated with cardiomyocyte survival and inhibition of inflammation. We sought to determine alterations in myocardial GHSR together with markers of cardiac inflammation using mdx:utrn^−/− mice as a model for DMD-associated dilated cardiomyopathy. With traditional histopathology, we determined that the pathology of DMD in mdx:utrn^−/− mice was characterized by disruption of myofiber organization, lymphocytic infiltration, and extensive cardiomyocyte vacuolization and necrosis surrounding areas of fibrosis in the left ventricular wall and apex. Using a fluorescent ghrelin analog, Cy5-ghrelin (1–19), to visualize GHSR with fluorescence confocal microscopy, we demonstrate that GHSR is elevated in mdx/utrn^−/− myocardial tissues and correlates strongly with both F4-80 (activated macrophages) and IL-6 (pro-inflammatory cytokine), and negatively with cardiac function. We also show that GHSR can be visualized in pro-inflammatory macrophages, suggesting a direct role for GHSR in the inflammatory progression of DMD. Full article

Background: Quantitative evaluation of myocardial function traditionally relies on parameters such as ejection fraction and strain. Strain, reflecting the relative change in the length of a myocardial segment over the cardiac cycle, has been extensively studied in various cardiac pathologies over the past two decades. However, the absolute length change, or longitudinal displacement, of myocardial segments during the cardiac cycle has received limited attention. This study aims to evaluate longitudinal displacement in two separate groups: healthy athletes and patients with left ventricular dysfunction, providing new insights into myocardial function assessment. Methods: Echocardiographic examinations were performed on 30 healthy football players and 30 patients with left ventricular dysfunction using speckle-tracking imaging analysis. Global and regional peak longitudinal displacement values were calculated and compared with corresponding global and regional peak longitudinal strain measurements. A manual alternative for calculating global longitudinal strain was also proposed. Results: An inverse correlation was found between regional longitudinal displacement and regional longitudinal strain. Longitudinal displacement was maximal in the basal segments and lowest in the apex of the left ventricle, exhibiting a reversed basal-to-apical gradient (17.6 ± 3.5 mm vs. 11.5 ± 2.9 mm vs. 4.22 ± 1.7 mm in basal, mid, and apical segments, respectively; p < 0.000001). Maximal longitudinal displacement was observed in the inferior and posterior walls of the left ventricle. In the 30 patients with left ventricular dysfunction, global longitudinal displacement was significantly lower than in healthy individuals (4.4 ± 1.7 mm vs. 11.7 ± 1.5 mm, p < 0.000001). Global longitudinal displacement and global longitudinal strain showed a strong negative correlation (r = −0.72, p < 0.000001). Manually calculated global longitudinal strain demonstrated good agreement with speckle-tracking-based global longitudinal strain. Conclusions: Peak longitudinal displacement can be used to evaluate both regional and global myocardial function, similarly to peak longitudinal strain. Unlike strain, longitudinal displacement exhibits a reversed basal-to-apical gradient, with the highest values at the base of the left ventricle and the lowest at the apex. Global and regional longitudinal displacement is significantly reduced in patients with left ventricular dysfunction. Global longitudinal strain can be manually calculated using displacement measurements. Further studies are needed to evaluate peak longitudinal displacement in various cardiac pathologies. Full article

A 2-month-old Shiba Inu was presented to an emergency veterinary clinic with decreased activity and was diagnosed with pulmonary hypertension secondary to a ventricular septal defect. The dog was referred to the TUAT Veterinary Medical Center for further evaluation. During treatment, a diverticulum was incidentally identified at the apex of the left ventricle. While the diverticulum caused no clinical symptoms, a cardiac synchronous computed tomography (CT) scan was performed to accurately assess its anatomical location and size. This case highlights the value of advanced imaging techniques in diagnosing complex congenital cardiac anomalies. Full article

Background and Objectives: Left ventricular aneurysm (LVA) causes geometric changes, including reduced systolic function and a more spherical shape, which is quantified by the sphericity index (SI), the ratio of the short to long axis in the apical four-chamber view. This study aimed to assess SI’s value in A-LVA and B-LVA, identify influencing factors, and evaluate its clinical relevance. Materials and Methods: This clinical study included 54 patients with post-infarction LVA and used echocardiography to determine LVA locations (A-LVA near the apex and B-LVA in the basal segments), with SI and other echocardiographic measures assessed in both systole and diastole for the entire cohort and stratified by A-LVA and B-LVA groups. Results: Among the 54 patients, 41 had A-LVA and 13 had B-LVA. The mean SI was 0.55 in diastole and 0.47 in systole for the cohort. Patients with A-LVA had a mean SI of 0.51 in diastole and 0.44 in systole, while B-LVA patients exhibited significantly higher SI values, with 0.65 in diastole and 0.57 in systole, due to lower long-axis (L) values in both phases. The mean left ventricular ejection fraction (EF) was 23.95% in A-LVA and 30.85% in B-LVA, with no significant difference. However, apical aneurysms were larger (greater LVAV and LVAA) and more significantly reduced functional myocardium. LVEDV, LVESV, LVEDA, and LVESA did not differ significantly between A-LVA and B-LVA. In cases of severe mitral regurgitation (MR), SI was notably higher (0.75 in diastole) due to a marked reduction in the L axis. Conclusions: SI is key in differentiating A-LVA and B-LVA on echocardiography. B-LVA has lower volume and area values, but similar aneurysm and left ventricular volumes and EF. Higher SI in B-LVA is due to a reduced L-axis, and is worsened by severe mitral regurgitation (MR). Surgical ventricular reconstruction (SVR) compensates for L-axis reduction, with preservation of the L axis critical for achieving a more physiological shape. SI thus serves as a marker for left ventricular geometry and surgical outcomes. Full article

Coronary artery fistulas (CAFs) are rare congenital anomalies, presenting in 0.05–0.9% of cases, characterized by an aberrant connection between a coronary artery and a cardiac chamber or great vessel. Clinical manifestations can include heart failure, myocardial ischemia due to coronary steal, arrhythmias, or infective endocarditis. We report a case of a 39-year-old man initially evaluated in 2016 for peripheral edema and suspected right ventricular (RV) abnormality. Earlier assessments indicated a left anterior descending (LAD) coronary artery–RV fistula, but initial catheterization was nondiagnostic. Transthoracic echocardiography (TTE) revealed a dilated left coronary artery (LCA) and an RV apex aneurysm, confirmed by CT and coronary angiography, showing a 14 mm LAD fistula with large aneurysmal sacs (45.6 × 37.3 mm). Cardiac MRI demonstrated a tortuous LAD fistula draining into RV aneurysmal sacs with preserved biventricular function. Surgical intervention was recommended, but the patient declined and was lost to follow-up until 2022, being asymptomatic. Re-evaluation showed progression in aneurysm size (47 × 45 mm and 16 × 18 mm) without ventricular functional change. Follow-up TTE in 2023 indicated stable findings. This case emphasizes the necessity of multimodal imaging (TTE, CT, MRI, angiography) for CAF diagnosis and management planning. Given the variability in CAF presentation and outcomes, individualized management—including surgical, percutaneous, or conservative strategies—is crucial. Persistent follow-up is essential for monitoring potential complications and guiding treatment, even in asymptomatic patients refusing intervention. Full article

Left ventricular hypertrabeculation (LVHT) used to be a rare phenotypic trait. With advances in diagnostic imaging techniques, LVHT is being recognised in an increasing number of people. The scientific data show the possibility of the overdiagnosis of this cardiomyopathy in a population of people who have very high levels of physical activity. We describe the case of a young athlete with no medical history, who presented with syncope during a marathon running race. Initial evaluation showed elevated troponin I; transthoracic echocardiography showed a trabeculated ventricle and subsequent cardiac magnetic resonance (CMR) revealed left ventricular hypertrabeculation (LVHT). During subsequent evaluation by tilt table testing, vasovagal syncope was identified as the likely aetiology of the syncope. The patient was advised to cease sports and stimulants like caffeine use. At the 29-month follow-up, CMR showed the normalisation of the non-compacted to compacted myocardial ratio and an improvement in left ventricular function, with no further syncopal episodes reported. This is an example of the physiological hypertrabeculation of the LV apex in a recreational endurance athlete, with the normalisation of the non-compacted to compacted myocardial layer ratio after detraining. Physiological hypertrabeculation, a benign component of exercise-induced cardiac remodelling, must be differentiated from non-compaction cardiomyopathy and other pathologies causing syncope. This case underscores the importance of distinguishing physiological hypertrabeculation from pathological LVHT in athletes, highlighting that exercise-induced cardiac remodelling can normalise with detraining. Full article

Background and Objectives: The incidence of left ventricular thrombus has decreased in recent years due to advancements in reperfusion strategies for acute myocardial infarction and the use of medications to reduce ventricular remodeling. However, the accurate detection of thrombus remains crucial. Echocardiography is a primary diagnostic tool for thrombus detection, but in cases where the apex of the left ventricle is not clearly visualized, contrast injection is often required for diagnosis. We developed a postprocessing Left Ventricular Thrombus Detection Method (LVTDM) to enhance image details in the region of interest, enabling diagnosis without additional contrast injection. A purpose of our study is the evaluation of Left Ventricular Thrombus Detection Method. Materials and Methods: We analyzed echocardiography video files from 29 patients with apical wall motion abnormalities using LVTDM to identify the presence or absence of thrombus in the left ventricular apex. The results were verified with diagnoses obtained from the same echocardiography examinations following contrast injection. Our method demonstrated a sensitivity of 100% and a specificity of 83%, with a negative predictive value of 100% for ruling out thrombus. There was a strong correlation in thrombus detection/ruling out between LVTDM and contrast echocardiography. The Left Ventricular Thrombus Detection Method can be integrated into routine echocardiography examinations to effectively rule out thrombus when the apex is not clearly visualized. The implementation of this method has the potential to reduce the need for contrast injection by approximately half for detecting left ventricular thrombus. Full article

Those using the mouse for the purposes of electrophysiological research presume that the morphology of the conduction axis is comparable with the human arrangement. As yet, however, to the best of our knowledge, no direct comparison has been made between the species. By comparing our extensive histological findings in the human heart with comparable serially-sectioned datasets prepared from adult murine hearts, we aimed to provide this information. When comparing the gross anatomy, we used three-dimensional datasets of neonatal mice hearts prepared using episcopic microscopy. The overall cardiac architecture is comparable, although the mouse has a persistent left superior caval vein draining via the coronary sinus. An inferior pyramidal space and an infero-septal recess are both present in the murine heart, although they are not as well developed as in the human heart. The overall arrangement of the conduction axis is similarly comparable, albeit with subtle differences reflecting the incomplete wedging of the subaortic outflow tract in the murine heart. Most significantly, the findings in both species reveal the presence of extensive superior septal pathways, which perhaps explain the finding of base-to-apex activation of the ventricular mass known to occur in the murine heart. Full article

Apical sparing is an echocardiographic pattern where myocardial strain is preserved at the apex compared to the basal segments. In a normal heart, longitudinal strain shows a gradient with lower values at the base and higher at the apex. This gradient becomes more pronounced in pathological states, such as cardiac amyloidosis, resulting in a relative apical sparing effect. This study explores cardiac conditions associated with apical sparing and the underlying mechanisms. We reviewed echocardiography examinations reporting apical sparing from 2021 to 2024 in our hospital database. Relevant echo exams and clinical data were retrieved and analyzed. Apical sparing was identified in 74 patients. Cardiac amyloidosis was diagnosed in 12 patients (16.2%). Other cardiac pathologies potentially contributing to apical sparing included hypertrophic cardiomyopathy, left ventricular hypertrophy due to hypertension, end-stage renal disease, coronary artery disease (involving the right coronary artery and left circumflex), reversed Takotsubo syndrome, and chemotherapy-induced cardiomyopathy. The clinical context of echocardiography was crucial in guiding the diagnostic work-up. Apical sparing is a nonspecific echocardiographic finding associated with various cardiac conditions. Its diagnostic value depends heavily on the clinical context. Understanding the broader clinical picture is essential for accurate interpretation and diagnosis. Full article

Left ventricular (LV) longitudinal function is mechanically coupled to the elasticity of the ascending aorta (AA). The pathophysiologic link between a stiff AA and reduced longitudinal strain and the subsequent deterioration in longitudinal LV systolic function is likely relevant in heart failure with preserved ejection fraction (HFpEF). The proposed therapeutic effect of freeing the LV apex and allowing for LV inverse longitudinal shortening was studied in silico utilizing the Living Left Heart Human Model (Dassault Systémes Simulia Corporation). LV function was evaluated in a model with (A) an elastic AA, (B) a stiff AA, and (C) a stiff AA with a free LV apex. The cardiac model simulation demonstrated that freeing the apex caused inverse LV longitudinal shortening that could abolish the deleterious mechanical effect of a stiff AA on LV function. A stiff AA and impairment of the LV longitudinal strain are common in patients with HFpEF. The hypothesis-generating model strongly suggests that freeing the apex and inverse longitudinal shortening may improve LV function in HFpEF patients with a stiff AA. Full article