CARTA CIENTÍFICA
“Tiger stripes” sign in acute coronary syndrome
Signo “manchas de tigre” en síndrome coronario agudo
Jorge A. Cervantes-Nieto1
Daniel A. Rivera-Silverio2
Rodrigo Gopar-Nieto1
Francisco Azar-Manzur3
Maria E. Ruiz-Esparza2
Grecia I.M. Raymundo-Martínez1
*
1Cardiology Fellow in Training. National
Institute of Cardiology Ignacio Chávez, Mexico City, Mexico
2Department of Echocardiography. National
Institute of Cardiology Ignacio Chávez, Mexico City, Mexico
3Department of Teaching. National Institute of
Cardiology Ignacio Chávez, Mexico City, Mexico
Abstract
The incidence of mitral regurgitation in acute myocardial syndromes is variable.
Echocardiographic evaluation is fundamental in making a proper diagnosis of
mechanical complications and to offer timely treatment. We present a case of a
64-year-old male who was admitted to the ER in acute pulmonary edema. The
electrocardiogram showed negative ST-segment deviation from V4-V6, positive
ST-segment deviation in aVR. Multivessel disease with severe mitral
regurgitation was seen in catheterization. A transthoracic echocardiogram
revealed important mitral regurgitation showing the “tiger stripes” sign, seen
in the presence of intracardial oscillating structures, in this case, suspected
papillary muscle rupture. Echocardiographic evaluation is necessary in every
case of myocardial infarction who present with new-onset mitral regurgitation.
Treatment is complex and must be determined with an interdisciplinary group.
A 64-year-old male with no medical background was admitted to the ER after 1 week of
epigastric pain. At his arrival was found in acute pulmonary edema, electrocardiogram
revealed sinus tachycardia, negative ST-segment deviation in V4-V6, and positive
deviation in aVR. He developed cardiogenic shock. Coronary angiography showed
multivessel disease with the left circumflex artery as the culprit artery. A
transthoracic echocardiogram was performed, reporting a left ventricle ejection fraction
of 48%, hypokinesia of inferolateral wall in the basal segment, the mitral valve showed
normal leaflets but with closure limitation conditioning important mitral regurgitation
with suspected rupture of the papillary muscle. On continuous Doppler interrogation of
the mitral regurgitant jet, the spectral signal had a peculiar sound such as goose croak
and a linear fragmentation of the image on the Fourier register resembling “tiger
stripes” suggesting an oscillating intracardiac structure, in this case, posteromedial
papillary muscle rupture (Fig. 1), which was
confirmed with a transesophageal echocardiogram (Fig.
2).
The causes of mitral regurgitation after acute myocardial infarction include ischemic
papillary muscle dysfunction, left ventricular dilatation or true aneurysm, and
papillary muscle or chord rupture1-2. Transesophageal echocardiography is essential for
confirmation. These band-like signals appear to be associated with intracardiac
oscillating structures with the first band (lowest frequency on the Doppler recording)
representing its fundamental frequency. These structures vibrate with a single frequency
with several harmonic overtones. Differential diagnosis of “tiger stripes” includes
valve regurgitation, flail prosthetic valve leaflet, and possibly Lambl’s excrescences
as previously reported1-3.
Ethical disclosures
Protection of human and animal subjects. The authors declare that no
experiments were performed on humans or animals for this study.
Confidentiality of data. The authors declare that no patient data appear
in this article.
Right to privacy and informed consent. The authors declare that no
patient data appear in this article.
References
1. Davogustto G, Fernando RR, Loghin C. Lambl's excrescence,
migrainous headaches, and “tiger stripes“:puzzling findings in one patient. Tex
Heart Inst J. 2015;42:70-2.
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2. Sahu AK, Kapoor A. 'Striped TR signal':an intriguing Doppler
echocardiography artefact or a pathological correlate?Heart Asia.
2016;8:45.
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3. Goyal KK, Mukund DE, Sajeev CG. Tiger stripes sign. J Indian Acad
Echocardiogr Cardiovasc Imaging. 2018;2:139-40.
[ Links ]
Copyright: © 2020 Instituto Nacional de Cardiología Ignacio
Chávez.