Epipericardial fat necrosis (EFN) is an uncommon self-limiting benign condition that can present with substantial chest pain. The first case was reported by Jackson et al 1 in 1957 and since then only a few cases were reported. However, new imaging modalities have increased its diagnosis.Epipericardial fat necrosis should be suspected in a patient with severe precordial pain after life-threatening/ major differential diagnosis such as acute coronary syndrome, pulmonary embolism, acute pericarditis, or pneumonia have been ruled out. | C A S E REP ORTWe present a case of an otherwise healthy 42-year-old man who presented to the emergency department with severe nonradiating left-sided pleuritic chest pain for the previous 4 days, only partially relieved by analgesics. Patient denied other symptoms or history of previous infection. Physical examination was unremarkable; chest radiograph (CXR), electrocardiogram (ECG), and routine laboratory testing (including D-dimer and troponin) were unrevealing. Contrast-enhanced thorax CT showed an increased radiolucency and nodularity of anterior pericardial fat with nodular appearance consistent with EFN (Figure 1, panel A-B). The transthoracic echocardiogram showed normal dimensions of cardiac chambers and no wall motion abnormalities, without other significant findings. A cardiac magnetic resonance imaging (MRI) was then performed to better characterize this lesion. MRI confirmed a small nodular lesion (10 x 17 mm) with regular contours, externally to the pericardium, in relation to the apex of the right ventricle and the anterior thoracic wall. There was hypersignal on T1-and T2-weighted images with loss of signal in fat saturation sequences and no first-pass or late gadolinium enhancement. The mass was delimited from the remaining pericardiac fat by a regular halo that presented hypersignal in T2, late enhancement and did not saturate on fat saturation sequences (Figure 2, panel A-B).Combined anti-inflammatory therapy (with colchicine and nonsteroidal anti-inflamatory drugs (NSAID)) was started with favorable evolution. Since the symptoms did not recur, biopsy of the lesion was dismissed.At 3-and 6-month follow-up, the patient remained symptom-free. A follow-up CT was performed and showed a slight densification of the anterior mediastinum's fat in lesser degree than in the previous exam (Figure 3, panel A-B). AbstractEpipericardial fat necrosis (EFN) is an uncommon self-limiting benign condition that can present with substantial chest pain. We present a case of an otherwise healthy 42-year-old man who presented with severe chest pain in the emergency department. Initial cardiopulmonary workup was unrevealing. Contrast-enhanced thorax CT demonstrated an increased radiolucency and nodularity of anterior pericardial fat consistent with epipericardial fat necrosis. The transthoracic echocardiogram was normal, and cardiac magnetic resonance imaging confirmed the lesion. Combined anti-inflammatory therapy was started with favorable evolution. K E Y W O R D Schest pain, CT, epiper...
A 23-year-old man presented with cough and progressive shortness of breath. Echocardiogram showed a biscupid aortic valve with a large vegetation causing severe regurgitation. Blood cultures were positive for Neisseria gonorrhoeae sensitive to cefotaxime and penicillin. Despite direct antibiotherapy, the patient required cardiac surgery with aortic valve replacement.
Funding Acknowledgements Type of funding sources: None. Introduction The HCM Risk-SCD estimates the risk of sudden cardiac death at 5 years in patients (pts) with hypertrophic cardiomyopathy (HCM). According to ESC Guidelines, in pts with a 5-year risk of SCD <4%, an implantable cardioverter defibrillator (ICD) is generally not indicated, in pts with a risk of 4 to less than 6%, an ICD may be considered and in pts with a 5-year risk ≥6%, an ICD should be considered. The association between the degree of LVH and sudden cardiac death (SCD) has been based on measurements of maximum LVWT by echocardiography which is part of HCM Risk-SCD score. However, cardiac magnetic resonance (CMR) has shown a superior resolution in characterization of cardiac structures, with additional role in SCD risk stratification. Whether measurements of LVWT by echocardiography and CMR are interchangeable has been brought to question. Purpose We sought to evaluate the incidence of discrepant measurements of maximal LVWT between echocardiography and CMR and determine its implication in HCM Risk-SCD score and ICD indication. Methods Unicentric, retrospective analysis of pts submitted to CMR who had HCM as definitive diagnosis, between 1/2013 and 9/2019. CMR and echocardiographic measures were compared, as well as HCM Risk-SCD score calculated with these values (maximum LVWT was the only variable that differed between measures). Subsequently, pts were divided in three groups according to HCM Risk-SCD score: pts with a 5-year risk of SCD <4% (G1), risk of 4 to less than 6% (G2) and risk ≥6% (G3). Results Out of the 781 CMR studies evaluated, 59 pts were found to have HCM (7.6%) with mean age of 62 ± 11 years and female predominance (50.8%). 12 pts had obstructive phenotype (20.3%). Mean LVWT was 20.0 ± 4.6mm when measured by CMR and 18.8 ± 4.6mm by echo; when comparing the measures by echo with CMR, there was a positive correlation between them (p < 0.001; r 0.719). Mean HCM Risk-SCD was 2.80 ± 1.51% when measured by CMR and 2.69 ± 1.53% by echo; there was a positive correlation between these measures too (p < 0.001; r 0.963). Maximum LV thickness evaluated by CMR showed a positive correlation (p = 0.006, r 0.384) with the HCM risk-score assessed by CMR. Only 1 pt changed risk group with CMR measurement of maximum LVWT (from G1 to G2). Conclusion: In this cohort, there was a positive, linear relationship between maximum LVWT and HCM Risk-SCD score measured by CMR and echocardiogram. Only 1 pt changed risk stratification group (5-year risk of SCD <4% to 4 to less than 6%). Although CMR measurements, when interpreted correctly, are more precise compared with echocardiography, in this cohort there was no impact on the patient"s future clinical orientation regarding ICD implantation.
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