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BackgroundTrans-thoracic echocardiography (TTE) is a commonly performed non-invasive investigation for the assessment of ventricular function and cardiac morphology. The British Society of Echocardiography have established guidance outlining twelve clinical indications in which echocardiography may provide incremental value to patient management (BSE Guidance).AimsThe aim of this study was to audit TTE requests received by the Cardiology Department and compare them against BSE Guidance. Our overall aim is to promote appropriate resource utilisation.MethodsWe retrospectively collected all TTE requests received by the Cardiology Department over a four week period from August 2019 to September 2019. We examined the clinical indications for ordering a TTE and used BSE Guidance to classify the indications as appropriate, inappropriate, or unclear.ResultsThirty-two requests for TTE were received over the study period. The median patient age was 74 years [range 32–93 years]. Just over half of the patients 17/32 (52%) were male. The most common indications for TTE were to evaluate valvular pathology 11/32 (34%); either initial assessment 5/32 (16%) or surveillance of known valvular disease 6/32 (18%). The second most common indication was to assess cardiomyopathy 8/32 (25%), followed by evaluation of arrhythmias, palpitations or syncope 4/32 (13%). When compared with BSE Guidance, 18 (56%) requests were appropriate and 11 (34%) were inappropriate. Three (9%) requests were deemed unclear due to the lack of information contained in the request.ConclusionAn almost equal number of females and males were referred for TTE. The median age reflects the older cohort of patients at our hospital. Valvular pathology; either for diagnostic assessment or repeat evaluation was the most common indication for echocardiography, More than one-third of TTE requests received were not clinically indicated and combined with unclear requests, this amounted to more than 40% of requests. We would recommend implementation of BSE Guidance at our hospital to provide guidance for physicians making requests and ensure appropriate utilisation of limited resources for clinically indicated echocardiograms.

Aortic dissection is a catastrophic vascular emergency with a high mortality rate if not diagnosed and managed in a timely manner. The classic presentation of thoracic aortic dissection includes the sudden onset of severe chest pain radiating to the back. Still, it may also present with atypical symptoms and signs of end-organ vascular compromise. We present a case of a 57-year-old female with a medical history of hypertension with poor medication adherence, major depressive disorder, chronic low back pain, and cocaine use disorder, who initially presented to the ED with worsening chronic low back pain, which was attributed to a musculoskeletal origin. She received analgesics, which improved the pain. Approximately 7 hours after presentation, the following morning, the patient developed acute-onset chest pain, prompting repeat evaluation, including an electrocardiogram and cardiac biomarkers, which revealed T-wave inversion in the lateral leads and elevated troponin levels. Based on these findings, the non-ST elevation myocardial infarction (NSTEMI) protocol was initiated. While the back pain and chest pain improved, her kidney function continued to rapidly deteriorate from the time of admission, prompting the team to perform a sonogram and subsequently an abdominal CT, which revealed a heterogeneous, hyperechoic right kidney with loss of corticomedullary distinction and possible aortic pathology. A CT angiogram of the chest, abdomen, and pelvis confirmed a type A aortic dissection extending from the aortic root to the iliac bifurcation. The dissection caused significant narrowing at the origin of the left common carotid artery and partial infarction of the right kidney due to involvement of the renal artery. The patient was transferred to a tertiary hospital for surgical intervention and remained hemodynamically stable; however, she opted against surgical intervention and left against medical advice despite extensive counseling. Clinicians should maintain a high index of suspicion for aortic dissection in patients with unexplained back pain, particularly when there are signs of multiorgan ischemia.

A 64-year-old woman with a past medical history of diverticulosis and duodenal ulcer presented with classical features of ST-elevation myocardial infarction (STEMI), including cardiac sounding chest pain, ST-elevations on electrocardiography (ECG), and elevated cardiac biomarkers. She was an ex-smoker and had a family history of heart disease, but did not report other significant cardiovascular risk factors such as hypertension, diabetes, or hyperlipidemia. Notably, she also described experiencing a recent period of emotional stress due to her friend being diagnosed with cancer. The case was initially considered a routine presentation of STEMI. However, on the day of admission (day 0), a coronary angiogram was performed, which revealed unobstructed coronary arteries. The left ventricular angiogram demonstrated mid-ventricular ballooning with a normal apex. Subsequent imaging included an echocardiogram on day 1, which showed a normal left ventricular size but impaired systolic function with ejection fraction (EF) of approximately 45% and regional wall motion abnormalities. A cardiac magnetic resonance imaging (MRI) scan performed on day 5 showed normal cardiac size and function with hypokinesia in the mid- to apical anteroseptal and anterior wall regions and a normal apex, along with mild edema, patchy diffuse late gadolinium enhancement, and elevated T1 values. These imaging features were consistent with atypical Takotsubo cardiomyopathy (TTC) or regional myocarditis. The improvement in EF from 45% to 63% over a few days, along with the absence of viral prodrome and pericardial effusion, indicates reversible ventricular dysfunction, further supporting the diagnosis of TTC. She showed significant improvement during her hospital stay, with left ventricular function returning to normal. She was started on a beta-blocker, and we advised her general practitioner (GP) to prescribe ramipril once her blood pressure improves. She was followed up at her local hospital and has returned to her usual daily activities. This case underscores the importance of considering stress-induced cardiomyopathy in differential diagnosis when patients present as acute coronary syndrome but have normal coronary arteries. While typical TTC is characterized by apical ballooning, atypical variants such as basal hypokinesia, mid-ventricular hypokinesia, and isolated right ventricular involvement can occur, often presenting with variable echocardiographic findings. In this patient, regional wall motion abnormalities were seen without typical apical involvement. Although B-type natriuretic peptide (BNP) was not measured in this case, a relatively high BNP-to-troponin ratio is seen in TTC due to marked ventricular wall stress. If this had been measured in our patient, it might have facilitated a quicker diagnosis and steered the management strategy away from ischemic etiologies. This will be considered in future similar cases to support earlier diagnosis and management.

This book provides undergraduate and postgraduate students with an accessible and comprehensive overview of the fascinating area of cardiac electrophysiology. Based on lectures presented to intercalating BSc medical students, it has been designed with the undergraduate in mind, but offers enough scope to be worthwhile at the postgraduate level.

Membranous interventricular septal aneurysm (MVSA) is a rare congenital cardiac anomaly, typically associated with interventricular septal defects. Isolated MVSAs are even more uncommon and often discovered incidentally. While generally asymptomatic, MVSAs carry the potential for significant complications, warranting thorough evaluation and follow-up. We present the case of a 30-year-old physician with no personal or family history of cardiovascular disease, who was referred to our department following the incidental discovery of a cardiac abnormality during a transthoracic echocardiography workshop. The patient was asymptomatic, with a normal physical examination and electrocardiogram. Echocardiography revealed a 21 × 19 mm membranous interventricular septal aneurysm protruding into the right heart chambers, with no evidence of interventricular shunting, right ventricular outflow obstruction, aortic regurgitation, or vegetation. A 24-hour Holter ECG showed no arrhythmias. A conservative management strategy was adopted after a multidisciplinary discussion. The patient was informed of the potential risks, advised to avoid strenuous isometric activities, and scheduled for echocardiographic follow-up every six months during the first year, then annually. At 12-month follow-up, the patient remained asymptomatic with stable findings. This case emphasizes the importance of recognizing and evaluating isolated MVSAs, even in asymptomatic individuals, due to their potential for serious complications.

Takotsubo cardiomyopathy associated with alcohol withdrawal is rare in Japan, and its management in such cases using percutaneous left ventricular assist devices (Impella; Abiomed, Japan) is not common. This report describes the treatment of a patient with cardiogenic shock resulting from alcohol withdrawal-induced Takotsubo cardiomyopathy using Impella support. A female patient in her 60s with a history of alcohol dependence presented to the emergency room with fever and convulsions. Upon arrival, she developed status epilepticus requiring intubation and mechanical ventilation. Subsequently, her blood pressure decreased, leading to shock. On day two of hospitalization, laboratory tests revealed elevated creatine kinase and troponin I levels, and an electrocardiogram demonstrated ST elevation. Transthoracic echocardiography demonstrated a reduced left ventricular ejection fraction of approximately 30-40%. Coronary angiography revealed no significant stenoses. Left ventricular angiography indicated akinesis in the mid-ventricle, with hyperkinesis at the base and apex. Based on the Mayo Clinic criteria, the patient was diagnosed with mid-ventricular Takotsubo cardiomyopathy. Myocardial biopsy ruled out myocarditis. Furthermore, CT revealed no obvious adrenal tumor, and pheochromocytoma was also ruled out. No evidence of alternative causes such as emotional stressors, severe infection, or exogenous catecholamine administration was found; thus, alcohol withdrawal was identified as the likely underlying trigger. The hemodynamic data showed a left ventricular pressure of 99/10 mmHg, an aortic pressure of 79/58 mmHg, with a significant intraventricular pressure gradient, and an elevated left ventricular end-diastolic pressure (LVEDP) of 33 mmHg. Right heart catheterization performed simultaneously revealed a pulmonary artery pressure of 46/31/37 mmHg, a pulmonary capillary wedge pressure of 32/30/29 mmHg, a cardiac output (CO) of 3.16 L/minute, and a cardiac index of 2.16 L/minute/m². The patient was in cardiogenic shock and required mechanical circulatory support. Given the presence of an elevated intraventricular pressure gradient and LVEDP, we judged that the Impella device would provide adequate circulatory support while unloading the left ventricle to reduce LVEDP and wall stress without exacerbating the left ventricular outflow tract gradient. An Impella CP was inserted and initiated at a support level of P8. Concurrently, antiepileptic therapy was administered for status epilepticus. On hospital day three, the LVEDP decreased while CO and cardiac power output (CPO) improved, indicating effective left ventricular support. While targeting a mean arterial pressure >65 mmHg, CPO >0.6 W, pulmonary artery pulsatility index >0.9, and lactate <2.0 mmol/L as reference parameters, the support level was gradually reduced. On hospital day five, CO recovered to 5.0 L/minute, and the Impella support level was successfully weaned to P3, allowing for device removal. The patient was discharged from the intensive care unit on hospital day 12. This case suggests that Impella support may provide appropriate hemodynamic stabilization in Takotsubo cardiomyopathy complicated by cardiogenic shock. However, as this is a single case report, further accumulation of similar cases is warranted in the future.