Mediastinal schwannomas primarily originate from the intercostal and sympathetic nerves located in the posterior mediastinum. Tumors originating from the vagus nerve in the middle mediastinum are extremely rare, accounting for 2% of all intrathoracic schwannomas. Although schwannomas are typically asymptomatic and discovered by accident, they can produce symptoms when they compress adjacent structures, which may lead to severe complications and are hard to manage. These cardiovascular risk factors include superior vena cava syndrome, cardiac tamponade, heart failure, and pulmonary hypertension. Due to their widespread cystic degeneration, they are often misinterpreted as bronchogenic or pericardial cysts. Multimodality imaging can help differentiate diagnoses, determine the location and extent of the mass, and assess the involvement of other structures, which is essential for guiding surgical procedures and improving patient outcomes. The management approach is based on tumor size, location, concern for underlying malignant pathology, and potential complications related to tumor infiltration into surrounding structures. We report a case of a giant mediastinal tumor with a successful surgical resection under cardiopulmonary bypass. It was diagnosed as a schwannoma by pathological examination, more than 1 year postoperatively, with neither symptoms of postoperative neurological disorders nor signs of recurrence.
The aim of this study was to investigate the relationship between coronary microvascular dysfunction (CMD) and left ventricular multi-directional deformation in patients with angina with no obstructive coronary artery disease (ANOCA).
This study retrospectively analyzed patients who were clinically diagnosed with ANOCA in our hospital from September 2018 to September 2024. Coronary flow velocity reserve (CFVR) was measured using adenosine stress echocardiography to evaluate CMD. Patients were divided into two groups: the CMD group (CFVR ≤ 2.0) and the control group (CFVR > 2.0). The global longitudinal strain (GLS), global circumferential strain (GCS), and global radial strain (GRS) of the left ventricle were analyzed by two-dimensional speckle tracking imaging (2D-STI).
This study included 69 patients in the CMD group and 75 individuals in the control group. Compared to the control group, the CMD group showed a lower absolute value of GLS and a higher absolute value of GCS. After adjusting for confounding factors, multivariate logistic regression analysis revealed that GLS (β: −1.119, OR: 0.327, 95% CI: 0.223–0.478, p < 0.001), GCS (β: 0.464, OR: 1.591, 95% CI: 1.239–2.042, p < 0.001) were independent predictors of CMD in ANOCA patients. The areas under the ROC curve of GLS, GCS, GRS, and the combination of GLS and GCS were 0.858, 0.687, 0.519, and 0.901, respectively. The results of Pearson correlation analysis showed that CFVR was negatively correlated with GCS, with r values of −0.264 (p < 0.001). The correlation coefficient between CFVR and GLS was positive, with r values of 0.562 (p < 0.001).
The findings showed that when ANOCA patients developed CMD, the absolute value of GLS decreased, and the absolute value of GCS increased. The combination of GLS and GCS demonstrated strong predictive value and diagnostic efficiency for CMD in ANOCA patients. Our study is beneficial for the early detection of CMD in ANOCA patients and the development of intervention strategies.
The objective of our study was to establish the prevalence of ischemia during exercise stress echocardiography (ESE) in patients with anomalous aortic origin of coronary arteries (AAOCA).
A cohort of 46 patients with AAOCA was retrospectively included in this study. Treadmill/bike exercise stress echo tests for ischemia assessment were performed and analyzed according to ESC guidelines. Computed tomography coronary angiography (CTCA), cardiac magnetic resonance, myocardial perfusion scintigraphy and invasive angiography with intravascular ultrasound if needed were used for coronary artery (CA) morphology and myocardial perfusion assessment. Most patients (70%) were overall symptomatic at rest, 57% reported chest pain and 2% had cardiac arrest before the ESE. By contrast, only 2% of patients reported chest pain during ESE. CTCA revealed that 70% of patients had an inter-arterial course, 17% were found to have an intramural course and 24% had a slit-like ostium of their anomalous CA. Other high-risk features were less frequent findings. All myocardial perfusion studies were negative and only one patient with AAOCA developed ischemia during ESE. Following investigations, four patients were eligible for surgical interventions and were operated on while the remaining patients were followed up for a median of 3 years with no adverse cardiovascular events.
Incidence of ischemia on exercise stress echo is extremely low among middle-aged patients with AAOCA despite symptoms at rest and malignant anatomical features. A good short-term outcome in unoperated AAOCA patients following negative exercise stress echocardiography has been shown.
To understand prognostic differences between sexes in (subtypes of) secondary mitral valve regurgitation (SMR) and to identify avenues for improvement.
In this retrospective study, all consecutive patients diagnosed with moderate or severe SMR by echocardiographic assessment between January 1, 2014, and June 1, 2021 were included. Sex-specific analyses were performed using Cox proportional hazards analysis, adjusted for significant covariates. A total of 1245 patients with SMR (43% female) were included. Females more often had atrial SMR (233 (29%) females vs. 200 (21%) males, p < 0.01), males more often ischemic SMR (100 females (12%) vs. 245 males (25%), p < 0.01), and there were no significant differences between sexes in the proportion of non-ischemic SMR (199 (25%) females vs. 268 (28%) males, p = 0.99). The estimated 5-year survival was 70% (CI = 68%, 73%). Median follow-up was 4.3 years [2.7–6.2], 236 males and 128 females died during follow-up. Females had a better survival than males in a multivariable Cox model (HR = 0.67, p < 0.01).
Overall survival in patients with SMR was low with an estimated 5-year survival of 70%. Females had a better survival in patients with SMR than males. The lower survival in males with SMR might be due to a larger proportion of atrial SMR in females, fewer patients with ischemic SMR, and lower ejection fractions in males with non-ischemic SMR. The current focus on rapid heart failure medication optimization may improve the prognosis of the most vulnerable group; future studies can be directed to see whether this will be the case.
Despite increased awareness of its clinical consequences, personalized risk stratification in patients with moderate aortic stenosis (AS) remains ambiguous. We studied predictors of progression and clinical outcomes in moderate AS to improve risk stratification and add to the existing literature.
Data collected through the Tempus Next care pathway intelligence platform at our tertiary referral center were retrospectively analyzed. The reports of echocardiograms performed from October 2017 to January 2020 were screened for descriptive or quantitative evidence of moderate AS. Follow-up extended until January 2022. Clinical data were extracted following manual chart review. Socioeconomic variables were collected based on zip-code–aggregated United States census data. The endpoints were progression from moderate to severe valvular AS, all-cause mortality, all-cause hospitalization, and heart failure (HF) hospitalization. The final multivariable model was selected using a variable selection algorithm inspired by greedy causal discovery algorithms.
A total of 34 450 echocardiograms (N = 25 204 patients) were screened during the inclusion period; 367 patients met inclusion criteria and were included in the final analysis. Progression to severe AS was noted in 172 patients (median time to progression 16 months). The final predictive models after variable selection exhibited modest predictive power: progression to severe AS, AUC = 0.68; all-cause mortality, 0.797; all-cause hospitalization, 0.629; heart failure hospitalization, 0.744. Variables predictive for the endpoints included comorbidities, echocardiographic variables, and demographics.
Our findings support further work and exploration of a paradigm shift in the assessment and management of AS, moving beyond traditional measures to a multiparametric model incorporating a broader spectrum of clinical, echocardiographic, and socioeconomic variables.
Echocardiographic quantification of myocardial deformation is a valuable tool to assess left ventricular systolic function in children at risk for systolic dysfunction. Since clinical utility is dependent on accurate and reproducible data, pediatric echo labs should establish a process to ensure high quality strain performance and interpretation. We describe our institutional experience of a successful strain implementation pathway.
Starting in 2016, various plan-do-study-act cycles were implemented, including a comprehensive echocardiography function protocol, knowledge and skill-based education, updated equipment and software to optimize acquisition, reporting, and billing for global longitudinal strain (GLS). We reviewed a sample of echocardiograms annually from 2019 to 2023 on children at risk for chemotherapy related cardiotoxicity (CTRCD). We calculated the percentage of echocardiograms that performed and reported GLS, reviewing for accuracy.
From 2019 to 2023, 685 echocardiograms were reviewed. GLS reporting increased from 39% in 2019 to 76% in 2023 and accuracy improved from 57% to 72% (p < 0.001). Reasons for inaccurate GLS included poor 2D image quality (24%), endocardial border tracing errors despite good image quality (45%) or both (21%). In almost half the studies where GLS was measurable but not reported [99/214; 46%], GLS had not been performed on the echo cart. Reporting of GLS improved from 27% in 2019 to 66% in 2023 with on-cart automation and easier post-processing; and other interventions, including iterative education.
Implementation of administrative, technological, and educational interventions helps to establish a pathway of consistent, high-quality performance and accurate reporting of GLS in pediatric echocardiography labs.
Takotsubo syndrome (TS) is an acute and reversible form of myocardial dysfunction characterized by distinctive left ventricular (LV) wall motion abnormalities that typically extend beyond the distribution of a single epicardial coronary artery. Cardiovascular magnetic resonance (CMR) has emerged as a key non-invasive imaging modality for the evaluation of TS, offering a comprehensive assessment of myocardial function and tissue characterization. Among CMR techniques, late gadolinium enhancement (LGE) is a cornerstone for the diagnosis and risk stratification of various cardiopathies, primarily identifying areas of myocardial fibrosis or expansion of the interstitial space. In TS, the typical CMR profile includes myocardial edema in the absence of corresponding LGE, a finding often used to support the diagnosis. However, emerging evidence has reported the presence of LGE in a subset of TS patients, raising questions about its prevalence, underlying mechanisms, and clinical significance. This narrative review aims to explore current evidence on LGE in TS, examining its pathophysiological basis, diagnostic value, and potential prognostic implications.
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