Image in Cardiology
A rare cause of subendocardial ischemia
Uma causa rara de isquemia subendocárdica
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It can present clinically as heart failure, hemolytic anemia or infective endocarditis. The diagnosis is normally suspected following transthoracic echocardiography.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 78-year-old woman with paroxysmal atrial fibrillation had undergone aortic valve replacement with a mechanical prosthesis 10 years previously and was under oral anticoagulation. She had recently been hospitalized for chest pain with anterior ST elevation. Coronary angiography revealed no epicardial coronary disease but showed what appeared to be a thrombus in the distal anterior descending artery; aortography showed moderate aortic regurgitation. Echocardiography revealed elevated transvalvular gradients, suggestive of mismatch and/or increased flow, and mild regurgitation (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). The setting was interpreted as embolic infarction. The patient was discharged with indication for close monitoring of INR, and transesophageal echocardiography was scheduled to assess valve function.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">She was re-admitted two weeks later for recurrence of intense chest pain, together with autonomic symptoms and marked ST depression (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>), which did not respond to medical therapy. Repeat cardiac catheterization excluded coronary artery disease and showed good disc opening of the prosthetic valve and severe aortic regurgitation (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>). Thoracic computed tomography angiography excluded acute aortic syndrome. Transesophageal echocardiography showed severe periprosthetic regurgitation (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>). The patient was referred for cardiac surgery.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Diagnosing periprosthetic regurgitation can be a challenge when the clinical presentation is atypical and transthoracic echocardiography fails to clarify the situation. The resulting decrease in diastolic coronary perfusion pressure can lead to severe subendocardial ischemia. In the case presented, due consideration of the symptoms and use of various imaging techniques confirmed the diagnosis and enabled appropriate treatment to be planned.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical disclosures</span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Protection of human and animal subjects</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Confidentiality of data</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Right to privacy and informed consent</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:3 [ "identificador" => "sec0005" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0015" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0020" "titulo" => "Right to privacy and informed consent" ] ] ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-10-17" "fechaAceptado" => "2015-01-02" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Almeida I, Madeira M, Caetano F, et al. Uma causa rara de isquemia subendocárdica. Rev Port Cardiol. 2015;34:429–431.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 861 "Ancho" => 2673 "Tamanyo" => 249361 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Transthoracic echocardiography showing: (A) mechanical aortic valve (21-mm Medtronic<span class="elsevierStyleSup">®</span> with mild regurgitation, possibly periprosthetic; (B) elevated transvalvular gradients (maximum 51 mmHg and mean 24 mmHg); acceleration time 89 ms, left ventricular outflow tract velocity time integral/aortic velocity time integral 0.29 and area index 0.83 cm<span class="elsevierStyleSup">2</span>/m<span class="elsevierStyleSup">2</span>, suggestive of mismatch and/or increased flow.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2160 "Ancho" => 3257 "Tamanyo" => 1090325 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Electrocardiogram: (A) baseline; (B) during episode of chest pain, showing diffuse ST depression with a maximum of 7 mm in V4.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1064 "Ancho" => 995 "Tamanyo" => 87947 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Aortography showing severe aortic regurgitation, for which the cause could not be identified.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 858 "Ancho" => 1300 "Tamanyo" => 208757 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiography: (A and B) short-axis view (40°), showing valve dehiscence in the region of the non-coronary cusp, affecting 25–30% of the perimeter of the prosthesis (yellow arrows); (C) (in systole) and (D) (in diastole), long-axis view (120°), showing turbulent regurgitant jet, wide at its source, filling the entire left ventricular outflow tract.</p>" ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003400000006/v1_201506200223/S2174204915001130/v1_201506200223/en/main.assets" "Apartado" => array:4 [ "identificador" => "9915" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Images in cardiology" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003400000006/v1_201506200223/S2174204915001130/v1_201506200223/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204915001130?idApp=UINPBA00004E" ]
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| 2021 June | 35 | 22 | 57 |
| 2021 May | 39 | 43 | 82 |
| 2021 April | 77 | 31 | 108 |
| 2021 March | 89 | 17 | 106 |
| 2021 February | 73 | 19 | 92 |
| 2021 January | 41 | 15 | 56 |
| 2020 December | 44 | 10 | 54 |
| 2020 November | 60 | 9 | 69 |
| 2020 October | 31 | 11 | 42 |
| 2020 September | 65 | 10 | 75 |
| 2020 August | 59 | 5 | 64 |
| 2020 July | 42 | 4 | 46 |
| 2020 June | 56 | 8 | 64 |
| 2020 May | 67 | 5 | 72 |
| 2020 April | 58 | 7 | 65 |
| 2020 March | 96 | 11 | 107 |
| 2020 February | 110 | 26 | 136 |
| 2020 January | 46 | 6 | 52 |
| 2019 December | 64 | 4 | 68 |
| 2019 November | 49 | 7 | 56 |
| 2019 October | 58 | 4 | 62 |
| 2019 September | 135 | 8 | 143 |
| 2019 August | 47 | 7 | 54 |
| 2019 July | 68 | 16 | 84 |
| 2019 June | 83 | 7 | 90 |
| 2019 May | 90 | 6 | 96 |
| 2019 April | 88 | 11 | 99 |
| 2019 March | 76 | 10 | 86 |
| 2019 February | 93 | 7 | 100 |
| 2019 January | 95 | 6 | 101 |
| 2018 December | 109 | 13 | 122 |
| 2018 November | 66 | 8 | 74 |
| 2018 October | 139 | 8 | 147 |
| 2018 September | 79 | 13 | 92 |
| 2018 August | 55 | 5 | 60 |
| 2018 July | 30 | 2 | 32 |
| 2018 June | 52 | 5 | 57 |
| 2018 May | 89 | 7 | 96 |
| 2018 April | 65 | 5 | 70 |
| 2018 March | 122 | 10 | 132 |
| 2018 February | 53 | 5 | 58 |
| 2018 January | 87 | 3 | 90 |
| 2017 December | 118 | 2 | 120 |
| 2017 November | 58 | 7 | 65 |
| 2017 October | 63 | 12 | 75 |
| 2017 September | 48 | 12 | 60 |
| 2017 August | 67 | 9 | 76 |
| 2017 July | 46 | 14 | 60 |
| 2017 June | 51 | 10 | 61 |
| 2017 May | 72 | 15 | 87 |
| 2017 April | 59 | 9 | 68 |
| 2017 March | 75 | 13 | 88 |
| 2017 February | 56 | 3 | 59 |
| 2017 January | 56 | 2 | 58 |
| 2016 December | 52 | 10 | 62 |
| 2016 November | 39 | 3 | 42 |
| 2016 October | 66 | 7 | 73 |
| 2016 September | 60 | 7 | 67 |
| 2016 August | 16 | 6 | 22 |
| 2016 July | 23 | 5 | 28 |
| 2016 June | 26 | 3 | 29 |
| 2016 May | 27 | 2 | 29 |
| 2016 April | 34 | 14 | 48 |
| 2016 March | 56 | 20 | 76 |
| 2016 February | 63 | 28 | 91 |
| 2016 January | 59 | 16 | 75 |
| 2015 December | 47 | 19 | 66 |
| 2015 November | 59 | 14 | 73 |
| 2015 October | 58 | 18 | 76 |
| 2015 September | 54 | 22 | 76 |
| 2015 August | 110 | 36 | 146 |
| 2015 July | 141 | 56 | 197 |
| 2015 June | 67 | 33 | 100 |
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