Alteraciones cardíacas subclínicas detectadas por ecocardiografía en escolares Mexicanos con sobrepeso y obesidad / Subclinical cardiac alterations detected by echocardiography in Mexican schoolchildren with overweight and obesity

Resumen Objetivo: El propósito de este estudio fue evaluar los cambios tempranos en la función miocárdica en niños con sobrepeso y obesidad, sin hipertensión arterial. Métodos: Estudio transversal en el que se incluyeron 150 participantes de ambos sexos entre 6 y 15 años. Se realizaron evaluaciones antropométricas, bioquímicas y de función ventricular mediante métodos ecocardiográficos convencionales y análisis de deformación miocárdica con ecocardiografía bidimensional speckle tracking. La comparación global entre los grupos de estudio (niños con peso normal, sobrepeso y obesidad) se llevó a cabo con la prueba de análisis de varianza (ANOVA) de una vía y análisis post hoc con corrección de Bonferroni para las comparaciones múltiples, y se consideró a los niños con peso normal como grupo de referencia. Resultados: La muestra final fue de 142 participantes, 50 (35%) con peso normal, 39 (28%) con sobrepeso y 53 (37%) con obesidad. El diámetro diastólico del ventrículo izquierdo (VI) y el septum interventricular, y el diámetro de la aurícula izquierda (AI) y la masa del VI fueron significativamente más altos en el grupo con obesidad en comparación con el grupo con peso normal. No se observaron diferencias significativas en los indicadores convencionales de la función sistólica y diastólica ventricular izquierda. Se observaron diferencias significativas en la deformación miocárdica regional entre los tres grupos. La media de deformación miocárdica longitudinal global fue más baja en los pacientes con obesidad (−20.9% vs. −23.5%; p menor 0.05) en comparación con los niños con peso normal. Conclusiones: La obesidad infantil se asoció a alteraciones en la deformación miocárdica, incluso en presencia de fracción de expulsión normal. La evaluación de la deformación miocárdica es relevante en los pacientes pediátricos con obesidad.

Abstract Objective: The purpose of this study was to evaluate early changes in myocardial function in overweight and obese children without hypertension. Methods: Cross-sectional study involving 150 participants of both sexes between 6 and 15 years old. Anthropometric and biochemical evaluations were performed. Ventricular function was assessed by conventional echocardiographic methods and myocardial deformation analysis by two-dimensional speckle tracking echocardiography. One-way analysis of variance was employed for the global comparison of study variables between groups (children with normal weight, overweight and obesity), and post hoc analysis with Bonferroni correction was used for multiple comparison, considering normal-weight children as the reference category. Results: Overall, 142 participants were included, 50 (35%) with normal weight, 39 (28%) overweight and 53 (37%) obesity. Diastolic diameter of the left ventricular (LV) and interventricular septum, diameter of the left atrium and LV mass were significantly higher in children with obesity compared to those with normal weight. No significant differences in the conventional indicators of LV systolic and diastolic function were found between groups. Significant differences in the regional myocardial deformation between the three groups were observed. Mean global longitudinal myocardial deformation was smaller in patients with obesity (−20.9% vs. −23.5%, p less 0.05) compared to children with normal weight. Conclusions: The childhood obesity was associated with altered myocardial deformation, even in the presence of normal ejection fraction. Myocardial deformation evaluation is relevant in the assessment of pediatric patients with obesity.

Deformación sistólica longitudinal del ventrículo izquierdo en pacientes pediátricos con antecedente de enfermedad de Kawasaki / Left ventricular longitudinal systolic strain in children with history of Kawasaki disease

Resumen Objetivo La enfermedad de Kawasaki (EK) es una vasculitis sistémica cuya complicación más grave es la formación de lesiones coronarias, las cuales pueden llevar a infarto del miocardio y muerte súbita. El estudio ecocardiográfico es parte del seguimiento obligado de los pacientes con EK. La deformación sistólica longitudinal (DSL) medida mediante speckle tracking es una herramienta precisa para evaluar la función de la fibra miocárdica (longitudinal) del ventrículo izquierdo. No se ha establecido la utilidad en la práctica clínica de la DSL en niños con antecedente de EK. El objetivo de este estudio fue analizar si la presencia de lesiones coronarias condiciona alteraciones en la DSL segmentaria y su correspondencia con el territorio coronario en donde se encuentra la lesión. Método Serie de casos. Se realizó un estudio ecocardiográfico completo y la evaluación de la DSL a niños con antecedente de EK al menos 6 meses después de la fase aguda. Resultados Se estudiaron 9 pacientes. La mediana de edad fue de 6 años (mínimo 2 y máximo 17). El 56% era de sexo masculino. El 77% presentó aneurismas coronarios. La DSL resultó alterada en el 56% de la muestra estudiada. Dentro de los pacientes que presentaron una DSL anormal, todos mostraron aneurismas coronarios y lesiones estenóticas u oclusivas demostradas mediante cateterismo de arterias coronarias, además de alteraciones de la perfusión miocárdica en estudio de Medicina Nuclear. Conclusiones En la muestra estudiada, los pacientes en quienes se encontró una DSL anormal, resultaron tener lesiones coronarias que condicionaban isquemia o infarto.

Abstract Objective Kawasaki disease (KD) is a systemic vasculitis that affects young children. Coronary artery aneurisms, ectasia and stenosis are its main complications and may lead to ischemic heart disease or sudden death. Echocardiography evaluation it's mandatory in all patients with history of KD. Left ventricular longitudinal systolic strain (LVLSS) measured by speckle tracking it's an accurate tool to evaluate global and segmental left ventricle mechanics. Clinical utility of LVLSS in children with KD hasn't been established. The goal of this study was to analyse if the presence of coronary lesions alters segmental LVLSS and if there is a relationship with the affected coronary territory. Method Case series. A complete transthoracic echocardiography with LVLSS was performed in children with history of KD with at least 6 months after the acute phase. Results Nine patients where studied, with a median age of 6 years (minimum 2 and maximum 17). A percentage of 56 were male, and 77% had coronary aneurisms. An abnormal LVLSS was found in 56% of the population studied. All of the patients that had an abnormal LVLSS had coronary aneurisms with stenosis or complete occlusion confirmed by invasive coronary angiography and abnormal Nuclear Medicine perfusion scans. Conclusions On the population studied, all patients with an abnormal LVLSS had obstructive coronary lesions and ischemic heart disease.

Evaluación postquirúrgica por ecocardiografía del paciente sometido a cambio valvular aórtico: ¿Se aplican las recomendaciones de las guías? / Echocardiographic evaluation of patients after aortic valve replacement: Do we follow the guidelines?

Objetivo: Determinar la metodología de evaluación ecocardiográfica empleada en el Instituto Nacional de Cardiología (hospital de tercer nivel) en pacientes operados de cambio valvular aórtico. Método: Se incluyeron a todos los pacientes consecutivos mayores de 18 años con estenosis aórtica que fueron llevados a cirugía de cambio valvular aórtico en el Instituto Nacional de Cardiología "Ignacio Chávez", durante el periodo de enero del 2011 a junio del 2012. Se determinó la fecha de cirugía, tipo de prótesis y el número y fecha de ecocardiogramas realizados después del evento quirúrgico. Resultados: Se encontró que en el 81% de los pacientes el primer ecocardiograma postquirúrgico se realizó durante su internamiento. Esta primera evaluación fue realizada dentro de las primeras 24 a 48 horas a 42 pacientes (51.8%); entre los 3 y los 7 días a 27 pacientes (33.3%); entre los 8 y los 14 días a 7 pacientes (8.6%) y posterior a los 14 días a 5 pacientes (6.1%). A 19 pacientes no se les realizó ecocardiograma. Conclusiones: En el Instituto Nacional de Cardiología "Ignacio Chávez", se realiza una evaluación y seguimiento ecocardiográfico de los pacientes operados de cambio valvular aórtico distinto a las recomendaciones internacionales.

Objective: To determine the methodology for the echocardiographic evaluation of patients with aortic valve replacement at the Instituto Nacional de Cardiología. Method: We included all consecutive patients, 18 years old or more with aortic valve replacement secondary to aortic stenosis at the Instituto Nacional de Cardiología "Ignacio Chávez", between January 2011 and June 2012. We described the date of the surgery, type of prosthetic valve and the number and date of the echocardiograms after the valve replacement. Results: Between January 2011 and June 2012, 100 patients underwent aortic valve replacement. In 81% the first echocardiogram was made during hospitalization. The first evaluation was made within the first 24-48 hours in 42 patients (51.8%), between the 3rd and 7th day in 27 patients (33.3%), between the 8th and the 14th day in 7 patients (8.6%) and after 14 days in 5 patients (6.1%). No echocardiogram was made in 19 patients. Conclusions: At the Instituto Nacional de Cardiología "Ignacio Chávez" we made an echocardiographic evaluation and follow up different from the international recommendations for patients with valve replacement.

Evaluación ecocardiográfica de la sincronía ventricular: implicaciones en la selección de pacientes y en los resultados del tratamiento / Echocardiographic assessment of ventriculara synchrony: implications to patient selection and treatment outcome

Heart failure is one of the most prevalent diseases in industrialized countries. Up to 30% of the patients with advanced heart failure present disturbances in intra-ventricular conduction, and this produce asynchrony of ventricular contractility, leading to further deterioration in heart function. Cardiac resynchronization (TRC) is an increasingly important therapeutic option for a subgroup of patients with heart failure. Several methods have been show to be useful in study the mechanical asynchrony. However, there are discrepancies between the results of the different methods. The echocardiography provides the best parameters in predicting a good response.

Tetralogía de Fallot con conexión anómala total de venas pulmonares a seno coronario: reporte de un caso con esta rara asociación / Tetralogy of fallot and total anomalous pulmonary venous drainage to coronary sinus: case report

We report the case of an infant 3 months old with a rare association, tetralogy of Fallot with total anomalous pulmonary veins connection the diagnosis was made by echocardiography and a successful complete reparation was achieved.

Espectro anatómico entre el defecto de la tabicación atrioventricular completo y parcial. Evaluación con ecocardiografía bi y tridimensional / Anatomic spectrum between complete and partial atrioventricular septal defect. Two and three-dimensional echocardiography approach

INTRODUCTION: It has been postulated that there is a morphogenetic relation between the atrioventricular septal defect (AVSD) type A of Rastelli and the type of two separated orifices, this so called partial forms, existent between both types a spectrum of anatomical forms in which interchordal spaces determinate the ventricular septal defects (VSD) size to forms in which the VSD is closed by fusion of the left septal valves to the crest of ventricular septum. METHODS: We present five patients which illustrates the variability of the atrioventricular defect by means of two dimensional and three-dimensional echocardiography. In each case was made a transesophagic echocardiogram using three-dimensional reconstruction with an Echo-Scan system (4.0 TomTec Gmb version, Munich, Germany). RESULTS: It was observed the following spectrum of atrioventricular defect: one patient had a complete closure of the VSD by the insertion of the left septal valves to the interventricular septal crest. One patient has a partially closed VSD. The last 3 patients had a large VSD with a large shunt and high pulmonary pressure. In those patients in whom the VSD was completely or partially closed, the hemodynamic behavior depended of the interatrial shunt and the regurgitation of the atrioventricular valve. They didn't present pulmonary hypertension, what allowed them to be less symptomatic. CONCLUSIONS: The three-dimensional echocardiographic study of the spectrum of AVSD type A of Rastelli, defines accurately the valve components and septal structures, so we can understand the transition between complete and partial forms. This difference determines the clinical evolution of the patients.

Ecocardiografía: aportaciones en la evaluación del daño valvular: nuevas perspectivas / Echocardiography in valvular heart disease: new perspectives

Echocardiography occupies an excellent place in the field of valvular heart disease study. Its presence is being increased in the catheterism and surgery rooms as well as in the intensive cares units. The ultrasound machines development has improved its technology and echocardiographic diagnoses has a greater repercussion in clinical decisions every time. The greater challenge than appears to us is to be able to have prepared enough professionals that know the tool, the physiopathology, the therapeutics modalities, and who can apply and take advantage of the new technological developments for a better cardiological practice.

Hipertensión arterial pulmonar en niños con síndrome de Down y cardiopatía congénita. Es realmente más severa? / Pulmonary hypertension in children with Down's syndrome and congenital heart disease. Is it really more severe?

OBJECTIVE: To compare the hemodynamic state, the severity and reversibility of pulmonary arterial hypertension (PAH) in patients with Down's syndrome and congenital heart disease (CHD) with respect to those without chromosomal pathologies. MATERIAL AND METHODS: 30 patients with congenital heart disease and left to right shunt were studied, corroborated by echocardiography; 16 patients had Down's syndrome and CHD and the control group was constituted by 14 patients without chromosomal abnormalities and with CHD. The age was R = 4.7 +/- 5.8 years for the Down's syndrome group and x = 5.3 +/- 4.5 years for the control group. All patients were subjected to a complete hemodynamic study, as well as to structural analysis by pulmonary wedge angiography (PWA), tested with oxygen administration. RESULTS: The most frequent diagnosis was ventricular septal defect for the control group and common atrioventricular canal for the Down's group. The systolic and mean pulmonary pressure depicted very similar values in both groups, with an average of 84.87 +/- 13.16 mm Hg for the Down's group and 84.21 +/- 22.05 for the control group. After oxygen administration, a tendency of increased Qp/Qs was found with a drop in pulmonary resistance in both groups, but being more important in the control group. During PWA assessment no quantitative differences were observed in PAH between both groups nor after the angiography with oxygen administration. CONCLUSIONS: Although patients with Down's syndrome present CHD with greater predisposition to develop irreversible pulmonary arterial hypertension like common atrioventricular canal, the hemodynamic behavior of pulmonary hypertension and during the challenge with oxygen was similar in both groups.

Válvula aórtica cuadricúspide (VAC) en transposición de grandes arterias: Reporte de un caso diagnosticado por ecocardiografia bidimensional / Quadricuspid aortic valve in a patient with D- transposition of the great arteries

En este reporte presentamos el caso de un paciente con discordancia ventrículo arterial (d-TGA) en quien se diagnosticó por ecocardiografia bidimensional la presencia de válvula aórtica cuadricúspide, con el propósito de ampliar las lesiones asociadas a d-TGA y manifestar la preocupación de la repercusión clínica de anomalías en el número de velos valvulares en la evolución de este tipo de pacientes.

In this report we present the case of a patient with ventricular-arterial discordance in which a QAV was diagnosed by bidimensional echocardiogram with the purpose of expanding the anatomical spectrum of the anomalies associated with d-TGA and to manifest the clinical awareness of the consequence that the QAV has on the evolution of the patients that undergo to anatomic correction.

Mixoma recidivante: Diagnóstico ecocardiográfico bi y tridimensional / Recurrent myxoma: Bi and three-Dimensional echocardiography approach

Se presenta el caso clínico y ecocardiográfico de una paciente en edad pediátrica con mixomas recidivantes, que se manifiesta a los 16 años con embolismo cerebral. Se detecta mixoma auricular izquierdo y se realiza resección quirúrgica y electrocoagulación. A los 40 meses de seguimiento inicia con disnea de grandes esfuerzos, auscultándose soplo expulsivo aórtico. El ecocardiograma bidimensional muestra la presencia de 3 masas tumorales: en aurícula y ventrículo izquierdo y en ventrículo derecho. El mixoma de ventrículo izquierdo obstruía casi en su totalidad la válvula aórtica. Se discuten la utilidad de la ecocardiografía bi y tridimensional como método diagnóstico inicial.

The case of a 16-years old female patient with left atrial myxoma and cerebral embolism is reported. She was subjected to surgical excision of the mass. At 40 months of follow-up she initiates with dyspnea and an aortic murmur is detected. The transthoracic and transesophageal echocardiographic analysis revealed the presence of three tumors: in the left atrium, left and right ventricle. The myxoma of the left ventricle obstructs the aortic valve. We discuss the usefulness of bi-and three-dimensional echocardiography as initial diagnostic method.

Valoración ecocardiográfica bi y tridimensional de aneurisma no roto del seno de Valsalva / Unruptured sinus of Valsalva aneurysm. Bi and three-dimensional echocardiography approach

Los aneurismas de los senos de Valsalva son malformaciones raras que pueden ser congénitas o adquiridas. La causa más común de los adquiridos es la endocarditis aórtica. Actualmente la ecocardiografía se ha convertido en el método diagnóstico de elección. Se presentan dos pacientes en edad pediátrica con aneurismas del seno de Valsalva no roto y manifestaciones de falla cardíaca secundaria a insuficiencia aórtica aguda. Se compararon las imágenes ecocardiográficas bidimensionales transtorácicas y transesofágicas y en uno de ellos tridimensionales, analizando la calidad de la imagen, localización y detalles anatómicos del aneurisma, obstrucción o compresión de estructuras adyacentes y la presencia de otros defectos asociados. Se demuestra la utilidad de la valoración ecocardiográfica tridimensional en el abordaje diagnóstico de estas lesiones.

Aneurysm of the sinus of Valsalva is a rare anomaly that can be congenital or acquire. The most common among the acquire is aortic endocarditis. At the present time echocardiography has be come the election diagnostic method. We present two pediatric patients with unrupture aneurysm of the sinus of Valsalva and cardiac failure secondary to a acute aortic insufficiency manifestations. Transthoracic and transesophageal bidimensional images were compared, in one of them also three-dimensional image. Assessing the quality of images, localization and anatomical morphology of aneurysm, obstruction or compression and presence of associated defects. The usefulness of the three dimensional echocardiography assessment for these congenital malformations is demonstrated. (Arch Cardiol Mex 2005; 75: 148-153).

Anillo vascular por doble arco aórtico simétrico. Reporte de un caso / Double symmetrical aortic arch. Case report

Describimos un paciente de 6 meses de edad con doble arco aórtico simétrico y sintomatología obstructiva traqueal y esofágica, tratado quirúrgicamente. Se realizó una correlación entre las imágenes diagnósticas obtenidas con esofagograma, ecococardiografía y angiografía con un espécimen anatómico, dando énfasis a la utilidad del ecocardiograma como estudio inicial.

We report a six-month-old patient with a double symmetrical aortic arch with tracheal and esophageal obstructive symptoms, who was treated surgically. The diagnostic images consisting of esophagogram, echocardiography and angiography were correlated with an anatomical specimen; the usefulness of the echocardiogram as an initial test is emphasized. (Arch Cardiol Mex 2005; 75: 178-181).

Tratamiento de conducto arterioso permeable: Comparación de costos del cierre quirúrgico y transcateterismo en una institución pública / Treatment of patent ductus arteriosus: Comparison of costs between surgical and trans-catheter closures in a public institution

El costo del tratamiento transcateterismo del conducto arterioso permeable en comparación con el quirúrgico es un asunto controvertido en nuestro medio. El propósito de este estudio fue estimar y comparar los costos directos relacionados con ambos procedimientos. Método: Se incluyeron 57 pacientes tratados con intervencionismo y 26 con cirugía. Se obtuvo información sobre las características sociodemográficas, el número y tipo de exámenes de laboratorio y de gabinete, el tipo y duración de anestesia, la duración del procedimiento y la estancia hospitalaria y de terapia intensiva. Se construyó una matriz que integró los costos del sistema institucional de costos unitarios vigente. Resultados: Ambos grupos compartían características sociodemográficas. El diámetro del conducto fue mayor en el grupo quirúrgico (p<0.05). Tanto la estancia hospitalaria como el número de complicaciones post intervención fueron menores en los pacientes tratados con intervencionismo (p<0.05). El tratamiento con dispositivo Amplatzer® es más costoso que el tratamiento quirúrgico y ambos más costosos que el oclusor tipo resorte. En el tratamiento quirúrgico el 86.5% de los costos totales lo consumen la estancia hospitalaria, con el Amplatzer® este rubro fue del 36%, sin embargo el dispositivo representa el 40% del costo total. Conclusiones: No obstante el costo del tratamiento con dispositivo Amplatzer® es mayor que el quirúrgico, el cierre con oclusor representa ventajas con relación a menor estancia hospitalaria, consumo de recursos y número de complicaciones, lo que permite la optimización de los recursos hospitalarios.

The costs of transcatheter closure of patent ductus arteriosus in relation to the surgical closure still a controvertial issue in our hospitals. The aim of the study was compared the costs of both treatments. Methods: We included 57 patients treated with transcatheter occlusion and 26 underwent surgery. Information about laboratory tests, average in hospital days of stay, anesthesia type and duration, operating and hemodinamic room costs, was gather. A database containing the costs from the institution unitary costs system in force was designed. Results: sociodemographyc characteristics were similar in both groups. Ductus size was larger in patients treated with surgery (p<0.05). In hospital stay, as well as, the number of complications after the procedure were less in the patients treated with transcatheter occlusion (p<0.05). The closure with Amplatzer® device was more expensive than the surgical one, and both were more expensive than coil. With surgical treatment, 86.5% of the costs are due to in hospital stay, with the Amplatzer® this issues represented a 36%, however, the cost of the devices by itself represents a 40% of the total treatment cost. Conclusions: Even though total charges of Amplatzer® devices are more expensive than surgery, transcatheter occlusion represents advantages in relation to less in hospital stay, resources used and number of complications, which allows hospital resources optimization.

Ecocardiografía intracardíaca (EIC) en sala de operaciones como método de apoyo en la evaluación de resultados quirúrgicos inmediatos en cardiopatías congénitas / Intracardiac Echocardiography (ICE) in the Operating Room as a Support Measure in the Evaluation of Immediate Surgical Results in Congenital Cardiopathies

La utilización de ecocardiografía intracardíaca es una alternativa reciente en el control de procedimientos en la sala de hemodinámica. Presentamos el resultado de un estudio piloto, en 10 pacientes sometidos a corrección total de su cardiopatía, en quienes la valoración inmediata de los resultados quirúrgicos se realizó en base a la aplicación de ecocardiografía intracardíaca (EIC) en sala de operaciones. En todos los pacientes fue posible obtener imágenes adecuadas con EIC, sólo se presentó un caso falso negativo, postoperado de corrección de conexión anómala de venas pulmonares, en el que no se identificó obstrucción de venas pulmonares derechas. Concluimos que EIC es una alternativa en la evaluación de resultados quirúrgicos inmediatos.

The utilization of intracardiac echocardiography (ICE) is a recent alternative in the control of procedures in the Cath Lab. In this paper we presents the results of a pilot study, in 10 patients submitted to total correction of its congenital heart disease, in who the analysis of the surgical results was done in base to the application of intracardiac echocardiography in operations room. In all the patients it was possible to obtain adequate images with ICE, there was a case false negative, a Total anomalous return Pulmonary Veins, in whom there not indentified a obstruction in right pulmonary veins flow. We conclude that ICE is a good alternative in the evaluation of surgical results.