The aim of the study is to quantify ventricular interactions by comparing tissue and spectral systolic echocardiographic parameters to allow the early identification of ventricular dysfunction. Clinical, paraclinical, electrocardiographic and echocardiographic evaluations were performed. Right ventricular hypertrophy was diagnosed in the M mode subcostal echocardiographic section. RV hypertrophy was defined by a right ventricular free wall thickness of ] 5 mm in diastole. We assessed the following RV and LV tissue and spectral systolic indices: apical systolic excursion of the lateral mitral ring (MAPSE), apical systolic excursion of the lateral tricuspid ring (TAPSE), left (Svs) and right (Svd) ventricular tissue systolic velocities, and RV and LV ejection times. We calculated the following to assess systolic ventricular interdependence: MAPSE/TAPSE, the normal value of which was considered as 0.66 � 0.14, and Svs/Svd, the normal value of which was considered as 0.76 � 0.21. The study group was compared to a control group with the same clinical features but without ventricular hypertrophy. Twenty-one patients were included in the study: 13 men (62%) and eight women (38%) with a mean age of 56 � 3.8 years. We compared the values between the study group and control group, with the following results: TAPSE = 20.4 � 0.9 vs. 24.1 � 0.76 and MAPSE/TAPSE = 0.74 � 0.06 vs. 0.75 � 0.04. MAPSE was comparable between the groups. Svs was comparable between the groups (0.09 � 0.01 vs. 0.12 � 0.02), whereas Svd was different between the groups (0.11 � 0.03 vs 0.16 � 0.03). Svs/Svd was 0.81 � 0.05 in the study group and 0.75 � 0.08 in the control group. LV ejection time was comparable between the two groups (299.8 � 23.6 ms vs. 303.3 � 28 ms), whereas, RV ejection time differed between the groups (275 � 17 ms vs. 245.5 � 28.5). Changes in TAPSE and MAPSE/TAPSE, in addition to Svd and Svs/Svd, are related to right ventricular dysfunction and suggest pathological changes in the interdependence mechanism of the ventricles in patients with RV hypertrophy. In addition, RV free wall thickness was strongly correlated with ventricular interdependence parameters, with the exception of MAPSE. Assessing these parameters and proportions in clinical practice will facilitate the early detection and appropriate treatment of right ventricular dysfunction.

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Purpose of the study: echocardiographic evaluation of the form of degenerative aortic stenosis (DAS) with preserved ejection fraction (EF) and low transvalvular gradient, in order to formulate the indication of valvular prosthesis as early as possible; retrospective observational study that includes patients admitted or sent for ambulatory evaluation by other medical services. The echocardiographic parameters used: systolic and diastolic indices, tissue and spectral, mitral and tricuspid veins, aortic orifice area, maximal aortic systolic velocity, maximal and medium aortic transvalvular gradient, myocardial mass index, volume of left atrium, left ventricular (LV) thickness. 42 patients with severe DAS and preserved EF, average age 71.7�3.85 years. Two groups were isolated: A - with increased gradient (22 patients) and B - with low gradient (20 patients). The gender distribution was comparable: women representing 33% in group A versus 30% in group B. The average age of women in both groups was higher than that of the men: in group A: 72�8 years in the case of women vs. 67�6 years in the case of men and in group B 72�3.5 years in women vs. 68�6 years in men. Apical displacement of the mitral ring: 14�2mm in lot A vs. 11�2mm in lot B. Myocardial mass index: 120 � 9g/m2 in lot A vs. 126 � 12g/m2 in lot B. Left ventricular filling ratio E/e�: 8�2 in lot A vs. 13�2 in lot B; maximum aortic systolic velocity: 4.3�0.9m/s in lot A vs. 3.1�0.8m/s in lot B; maximum gradient: 73.9�10mmHg in lot A vs. 37�12mmHg in lot B; aortic orifice area: 0.80�10.5 in lot A vs. 0.79�0.07 in lot B. Statistical analysis shows the Pearson correlation index r with the highest values of 95% at the significance threshold between the aortic orifice area and the valve opening (r=0.87), the ratio E/e� (r=-0.85) and diastolic thickness of the posterior wall of the aortic left ventricle (r = 0.78). Aortic stenosis with preserved ejection fraction and low gradient was more common in men. The filling ratio E/e� was increased (13 � 2) in group B, suggesting the increase of filling pressures of LV in patients with DAS and low transvalvular gradient. Tissue spectral systolic and longitudinal velocities were lower in group B, suggesting the onset of systolic LV dysfunction. The aortic valve opening and the E/e� ratio showed the highest correlation coefficient with the area of the aortic orifice in both groups. The myocardial mass index and the thickness of the walls of the LV cavity are similar in the two groups, suggesting that the reduction of the LV cavity through hypertrophy may not explain, at least in totality, the form of DAS with low gradient and preserved ejection fraction.

Background and aim. Coronary artery disease (CAD) is one of the most important causes of death worldwide. ST-elevation myocardial infarction (STEMI) is an acute form of presentation in patients with CAD. Percutaneous coronary intervention (PCI) is the treatment of choice in STEMI patients. Generally, a stent is placed after the culprit lesion is dilated in order to ensure the patency of the coronary artery. In-stent restenosis (ISR) is a possible chronic complication in this setting. The following study is one of the few of its kind, since it investigates ISR in a cohort of Romanian patients who underwent PCI in the setting of STEMI. Our current descriptive study aims at highlighting the characteristics of these patients and identifying potential risk factors in this specific population, which could be validated by a further larger study. Methods. We studied 68 patients from “Dr. Carol Davila” Central Military Emergency University Hospital in Bucharest, Romania, who presented with STEMI in 2016. The mean time for angiographic reevaluation was 111 days. Results. 94% (64) of the patients underwent primary PCI, while in 6% (4) of the cases thrombolysis was initially attempted before PCI. The most prevalent risk factors that we identified were: arterial hypertension (61%), dyslipidemia (60%) and smoking or history of smoking (47%). The anterior myocardial infarction was the most prevalent (49%). Only 6% of the patients had a documented history of CAD, while on the other hand chronic occlusions were observed in most patients (85%). Of note is that only 11% of the patients reported recurrent angina before the angiographic reevaluation. Conclusion. Common cardiovascular risk factors are also involved in ISR. Their poor management in the case of Romanian patients with STEMI increases the risk of ISR. The lack of symptoms in patients with ISR constitutes a warning sign for clinicians and shows that ISR is a complication which can be easily omitted. Therefore, its incidence is probably underestimated.

Objective: This case underlines the importance of thoroughly investigating alternative causes for hypertension in patients with atypical presentations, regardless of their age and risk factors. Design and method: Clinical case. Results: We present the case of a 68 year old woman without known cardiovascular diseases who came to the ER complaining of headaches, palpitations and chest pain of two hours duration. Upon admission, her blood pressure was 300/150 mmHg - overlapping values in all limbs with no asymmetric pulse. Heart rate was 140 bpm, rhythmic and without heart murmurs, abdomen without murmurs or palpable masses. Her ECG showed diffuse ST segment depression and high sensitivity troponin level at 0 h was 258 ng/L. Cardiac echo showed no wall motion abnormalities and no hypertrophy of the left ventricle. Her BP was acutely controlled with ACEi and iv nitroglycerin. Two hours after admission her BP returned to normal and remained within normal range without medication. Her ECG showed normal sinus rhythm with no other pathological findings. Coronary angiography was performed the next day and showed no atherosclerotic lesions. At this stage, her diagnosis was type 2 MI caused by severely elevated BP. Blood and urine tests revealed high levels of serum catecholamines and urinary normetanephrines - over 4000 micrograms/24 h. Abdominal ultrasound found a mass near her right kidney. Abdominal CT confirmed the presence of a nodular 5 × 3 cm mass in the right adrenal gland, compatible with a pheochromocytoma. She was submitted to laparoscopic adrenalectomy with normalization of her BP after the surgery. During follow-up, the patient presented with persistently normal blood pressure and normal ECG aspect without any chronic medication. Conclusions: Pheochromocytoma is a rare neuroendocrine tumour originating in the adrenal gland medulla. Sustained or paroxysmal arterial hypertension is sometimes associated with the classic triad: episodic headaches, profuse sweating and tachycardia. A timely diagnosis and an effective therapeutic strategy are important, as this is a potentially fatal disease with a very good prognosis if discovered and treated early. It should be excluded in patients with high paroxysmal BP, especially if under 20 or over 50 years old.