Anorexia nervosa (AN) is an eating disorder that most frequently afflicts females in adolescence. In these subjects, cardiovascular complications are the main cause of morbidity and mortality. Aim of this review is to analyze the hemodynamic, pro-arrhythmic and structural changes occurring during all phases of this illness, including re-feeding. A systematic literature search was performed on studies in the MEDLINE database, from its inception until September 2017, with PUBMED interface focusing on AN and cardiovascular disease. This review demonstrated that the most common cardiac abnormalities in AN are bradycardia and QT interval prolongation, which may occasionally degenerate into ventricular arrhythmias such as Torsades des Pointes or ventricular fibrillation. As these arrhythmias may be the substrate of sudden cardiac death (SCD), they require cardiac monitoring in hospital. In addition, reduced cardiac mass, with smaller volumes and decreased cardiac output, may be found. Furthermore, mitral prolapse and a mild pericardial effusion may occur, the latter due to protein deficiency and low levels of thyroid hormone. In anorectic patients, some cases of hypercholesterolemia may be present; however, conclusive evidence that AN is an atherogenic condition is still lacking, although a few cases of myocardial infarction have been reported. Finally, refeeding syndrome (RFS), which occurs during the first days of refeeding, may engender a critically increased risk of acute, life-threatening cardiac complications.

We present the case of a 69-year-old patient with a history of gynecological neoplasia and a pulmonary metastasis, who in 1996 underwent chemotherapy and mediastinal radiotherapy followed by cancer remission. Ten years later she presented with heart failure and her Doppler echocardiogram showed severe mitral regurgitation with pulmonary hypertension. In 2011, she underwent a mitral valve replacement with a biological prosthesis and the pathology exam revealed valve damage consistent with radiotherapy-induced changes. This unusual mechanism of mitral regurgitation can be demonstrated clearly by echocardiography and should be disseminated among cardiology physicians and in patients who have survived for long periods after radiotherapy, it is important to remember that cardiac complications may indeed occur, and the treating physician is responsible for detecting them.

A 46-year-old woman presented with progressive dyspnea. Physical examination revealed a blood pressure of 140/60 mmHg, a heart rate of 80 bpm and respiration of 16 breaths/min. Heart sounds were regular and distant. No murmurs or rubs were noted. Jugular venous pressure was normal. Lungs were clear, abdomen soft and no peripheral edema was found. The electrocardiogram and the chest X-ray film were normal. Two-dimensional transthoracic echocardiography revealed a large left atrial (LA) mass (31 9 40 9 45 mm), above the mitral valve, and seemingly attached to the posterior wall of the left atrium with a wide pedicle (Fig. 1a, b; Video 1 and 2). Moderate mitral stenosis due to the diastolic obstruction by the tumor and mild mitral regurgitation was observed (Video 3). Mean transmitral gradient was 12 mmHg and mitral valve area was 1.4 cm 2 . Transesophageal echocardiography did not add any additional information. A diagnosis of atrial myxoma was made. The patient underwent surgical removal of the mass. At the time of surgery, the tumor had a smooth surface and a rubbery consistency (Fig. 1c). It was found attached in the LA floor without involvement of either the pulmonary veins or the mitral valve. The tumor was shaved off the atrium. The surgeon decided not to resect the tumor en bloc due to the risk of bleeding in the reconstruction of the floor of the LA. Serial sectioning showed areas of focal necrosis. Histopathologic and immunophenotypic features revealed a primary cardiac benign myopericytoma (Fig. 1d). The patient underwent FDG PET/CT imaging of the chest, abdomen and pelvis, and extracardiac metastases were ruled out. The patient did well and was ultimately discharged home. A follow-up echocardiogram at 24 months disclosed no abnormalities.

Pannus formation is a rare complication and occurs almost exclusively in mechanical prosthetic valves. It consists of fibrous tissue that covers the surface of the prosthesis either concentrically or eccentrically, resulting in valve dysfunction. The pathophysiology seems to be associated to a chronic inflammatory process that explains the late and insidious clinical presentation. This diagnosis should be considered in patients with high transvalvular gradients on transthoracic echo, and workup should be completed with fluoroscopy and transesophageal echocardiography. Treatment is always surgical and recurrence is rare. We present a case of pannus formation in a prosthetic aortic valve and a review of the literature regarding this disorder.

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