Introduction: Takayasu's arteritis (TA) is a chronic, idiopathic, inflammatory disease that affects large elastic arteries, including the aorta and its main branches. No consensus exists currently on the superiority of surgery over endovascular repair (angioplasty with or without stenting) for vascular lesions in TA. Case Presentation: A 54-year-old woman with an 11-year history of ankylosing spondylitis (AS) presented with left arm weakness and severe left arm claudication. Duplex ultrasonography of the left upper extremity showed vessel-wall edema of the subclavian, axillary, and brachial arteries. Aortic angiography demonstrated a 70 - 80% stenosis of the left subclavian artery and a long, high-grade stenotic segment of the axillary artery. Intravascular ultrasound (IVUS) of the stenotic subclavian segment showed extensive negative remodeling with minimal plaque formation. The patient responded well to balloon angioplasty on this segment with medical therapy for AS. Conclusions: Our case is the first report of IVUS imaging of subclavian stenosis resulting from Takayasu's arteritis and provides insight into the pathology behind such lesions.

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Introduction: Coronary CT angiography (CCTA) can safely disposition low to intermediate risk chest pain (CP); however, there is conflicting data with respect to cumulative radiation exposure when compared with usual care over short follow-up intervals. Objectives: We report the effective radiation dose from index and downstream testing in low to intermediate risk symptomatic patients evaluated for chest pain in the ED with either CCTA or usual care to define various sources of patient radiation dose and quantify effective dose over a year and a half of follow-up. Patients and Methods: We evaluated radiation exposure from initial and downstream testing in a prospectively collected, matched cohort evaluated for CP in the emergency department (ED) with either CCTA compared with usual care over a median follow-up of 19.6 months. Effective radiation dose was calculated using published conversion factors. Results: Prospective, ECG-triggered acquisition using a 128-slice dual-source multidetector computed tomography (DSCT) scanner was performed in 92.9% of scans with a median effective dose from CCTA of 6.8 mSv (IQR 5.2, 9.1 mSv). CCTA cohort patients were more likely to undergo cardiac testing with exposure to radiation (P < 0.001); however, the median effective dose in patients exposed to radiation from cardiac testing was significantly lower in the CCTA cohort (7.1 mSv vs. 11.8 mSv, P < 0.001). Fewer patients in the CCTA cohort had additional non-cardiac thoracic imaging radiation exposure (40.8%) compared with usual care (92.8%). Total radiation exposure from any source was similar between the CCTA and usual care groups (100% vs 98.4%, P = 0.087), as was median total effective radiation dose (P = 0.105). Upfront CCTA was not associated with higher rates of incidental non-cardiac findings. Conclusions: Initial evaluation of acute chest pain in the ED with CCTA was not associated with an increase in total radiation exposure over a follow-up period of 19 months. CCTA offers a more comprehensive evaluation of multiple thoracic organ systems leading to reduced radiation exposure from non-cardiac thoracic testing and no increase in incidental imaging findings. This may represent an added benefit in this population of patients presenting acutely.

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Introduction: The incidence of mechanical complications related to myocardial infarction has decreased over the last decades, and revascularization certainly plays a major role in this change. However, mortality still remains elevated. This is a case of acute papillary muscle rupture secondary to myocardial infarction leading to cardiogenic shock. Case Presentation: A 71-year-old woman presented to an outside hospital complaining of chest pain and shortness of breath. An electrocardiogram was obtained and revealed depression of the ST segments from leads V1 to V4. Troponin I was elevated at 3.0 ng/mL. She was transferred to our facility for a higher level of care. She was found in cardiogenic shock at arrival. A bedside echocardiogram was ordered, which demonstrated papillary muscle rupture with severe mitral regurgitation. A coronary angiogram followed, which diagnosed severe three-vessel disease. After the insertion of an intra-aortic balloon pump, she was transferred emergently to the surgical suite for mitral valve replacement and revascularization. The operation was uneventful. She was discharged to a rehabilitation center after approximately 1 month of hospital stay. Conclusions: Mortality from papillary muscle rupture remains elevated. Survival largely depends on the early surgical repair or the replacement of the mitral valve.

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Acute myocardial infarction can culminate in sudden cardiac death due to cardiogenic shock and ventricular fibrillation, and also rarely due to cardiac rupture. We present a case of post-infarction myocardial rupture after thrombolytic therapy diagnosed with transthoracic echocardiography and treated with direct closure and coronary artery bypass grafting.

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Background: Limited data are available about feasibility and clinical value of left atrium (LA) quantitative evaluation obtained from real time 3D (RT-3D) echocardiography in critically ills. Objectives: Aims of this study were: 1) to evaluate feasibility of RT-3D echocardiography for LA evaluation in an acute care setting and in a population including a majority of critically ills; 2) to evaluate correlation between two-dimensional (2D) and RT-3D echocardiographic LA quantitative evaluation; 3) to assess clinical consistency and prognostic value of LA measurements obtained from RT-3D images in subjects without CV diseases and in patients with AF and CHF, evaluated in the acute phase of the disease. Patients and Methods: In 382 subjects admitted in the emergency department (ED), we evaluated maximal (Volmax) and minimal (Volmin) LA volumes and LA emptying fraction (LA-EF), from RT-3D images, with a semiautomated border detection program. A follow-up was performed in order to evaluate all-cause mortality and new hospital admission for cardiovascular events. Results: The correlation between measures obtained from 2D and 3D was good (LA Volmax: r = 0.896, P < 0.001; Volmin: r = 0.906, P < 0,001; LA EF: r = 0.749, P < 0.001). Among 77 normal subjects, people aged ≥ 65 years demonstrated comparable LA dimensions with younger subjects (LA Volmax: 25 ± 11 vs 20 ± 7 mL/m², Volmin: 11 ± 7 vs 8 ± 5 mL/m²). Subjects with normal left ventricular ejection fraction showed LA Volmax significantly lower than patients with LV systolic dysfunction or congestive heart failure (23 ± 11 vs 29 ± 10 vs 33 ± 12 mL/m², P < 0.05). Patients in atrial fibrillation showed a significantly dilated LA compared with subjects in sinus rhytm (24 ± 11 vs 37 ± 22 mL/m², P < 0.05). LA dimensions were significantly higher in non-survivors (LA Volmax: 33 ± 9 vs 25 ± 9 mL/m²), in patients with a new hospital admission for cardiovascular disease (LA Volmax: 34 ± 13 vs 23 ± 10 mL/m²) or with a new AF episode (LA Volmax: 40 ± 12 vs 24 ± 11 mL/m², all P < 0.005). Conclusions: RT-3D evaluation of LA volumes and function is feasible in a non selected series of critically ills. LA dilation was associated with a worse outcome in terms of morbidity and mortality.

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Background: Understanding the relation between ventricular-arterial coupling (VAC) and myocardial mechanical parameters could offer an adjunctive perspective on left ventricular function. Objectives: Our aim was to study the relation between VAC and the parameters of myocardial mechanics using three-dimensional speckle-tracking echocardiography (3DSTE). Patients and Methods: We studied 68 normal participants (mean age, 35 ± 12.2 y; 36 [53%] males). VAC was measured by the ratio of arterial elastance (Ea) to ventricular elastance (Ees). The peak systolic value of longitudinal strain (LS), circumferential strain (CS), radial strain, three-dimensional global strain (3DGS), apical rotation, torsion, and twist and their time to peak were calculated. Results: Almost all deformation indices were higher in the women than in the men. LS (r = -0.41, P < 0.01), twist (r = 0.26, P < 0.03), rotation (r = 0.41, P < 0.01), and 3DGS (r = - 0.39, P < 0.01) were associated with age. Although significant associations were found between VAC and Ea or Ees in the men and women, no relation was found between Ea and Ees in both sexes (r = 0.07 in men and r = 0.08 in women). Indeed, VAC had a stronger association with Ea than with Ees (r = 0.708 vs. r = -0.537). Ees and VAC were related to torsion (r = 0.30 vs. r = -0.37; both P < 0.05); and Ea, Ees, and VAC were also associated with CS (r = 0.64, r = -0.45, and r = 0.79; all P < 0.05) and 3DGS (r = -0.55, r = 0.38, and r = -0.64; all P < 0.01). Conclusions: Amongst all myocardial mechanical parameters, VAC was related to CS and 3DGS as well as torsion.

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Introduction: In patients with acute heart failure, pleural fluid localized in an inter-pleural fissure produces a mass on chest X-ray, which mimics a tumor. Case Presentation: Such masses have been designated as vanishing tumors of the lung. It is extremely rare that a vanishing tumor occurs in the apex of the lung. Conclusions: This is the first case report of a vanishing tumor in the right pulmonary apex.

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