Intra-procedural imaging of the left atrial appendage: Implications for closure with the AmplatzerTM cardiac plug / Evaluación de la orejuela izquierda durante el cierre percutáneo con el dispositivo AmplatzerTM cardiac plug

Objectives: To evaluate intra-procedural imaging with transesophageal echocardiography and angiography during left atrial appendage occlusion using the Amplatzer™ Cardiac Plug with regard to sizing and final device shape. Methods: Left atrial appendage ostium dimensions and diameter at a depth of 10 mm from the ostium were measured by transesophageal echocardiography (0-180°) and angiography (RAO 30° - Cranial 20°) in consecutive patients undergoing left atrial appendage occlusion using the ACP with an oversizing strategy of 10-20% relative to the baseline measurements. After delivery, ACP dimensions were measured and device shape was assessed. Results: Twenty-seven consecutive patients underwent successful uncomplicated left atrial appendage closure with Amplatzer™ Cardiac Plug. We found a significant difference between the largest and smallest left atrial appendage diameter measured with transesophageal echocardiography (22.3 ± 4.2 vs. 18.1 ± 4.1 mm, p <0.001). By the end of the procedure (by angiography), ACP had an optimal shape in 17 patients (63%), a strawberry-like shape in 7 patients (26%), and a square-like shape in 3 patients (11%). ACP was oversized on average by 1.5±2.7 and 3.3±2.3mm compared to transesophageal echocardiography and angiography, respectively. The final shape of the device was not significantly associated with the degree of oversizing. Conclusions: We found a considerable variability in the assessment of the left atrial appendage, using transesophageal echocardiography and angiography. The degree of Amplatzer™ Cardiac Plug expansion within the left atrial appendage and the final shape of the device were not associated with the degree of oversizing.

Objetivos: Evaluar las dimensiones de la orejuela izquierda antes del cierre percutáneo y la correlación de sus dimensiones finales y la forma del dispositivo Amplatzer™ cardiac plug con ecocardiografia transesofágica y angiografia. Métodos: Se midieron las dimensiones de la orejuela izquierda a una distancia de 10 mm a partir del ostium con ecocardiografia transesofágica (0 a 180°) y angiografia (RAO 30° Craneal 20°). Se utilizó una estrategia para sobre dimensionar el tamano del dispositivo del 10 al 20% con respecto a las mediciones iniciales. Se evaluaron las dimensiones y la forma final del dispositivo. Resultados: Se realizó el procedimiento en 27 pacientes. Se encontró una diferencia significativa entre el diámetro mayor y menor de orejuela izquierda medido por ecocardiografia transesofágica (22.3±4.2 vs 18.1 ±4.1 mm, p< 0.001). Una vez liberado el dispositivo, se encontró que en 17 pacientes (63%) adoptó una forma óptima, de "fresa" en 7 (26%) y cuadrada en 3 (11%). El tamaño del dispositivo seleccionado se sobre dimensionó en promedio 1.5 ± 2.7mm con la ecocardiografia transesofágica y 3.3 ± 2.3 mm con la angiografia. La forma final del dispositivo no se asoció de manera significativa con el grado de sobre dimensionamiento del mismo. Conclusiones: Existe variabilidad considerable en la evaluación de la orejuela izquierda entre la ecocardiografia transesofágica y la angiografia. No se encontró asociación entre el grado de expansión del dispositivo dentro de la orejuela izquierda ni de su forma final con el grado de sobre dimensionamiento del mismo.

Multiplanar transesophageal echocardiography for the evaluation and percutaneous management of ostium secundum atrial septal defects in the adult / Ecocardiografía transesofágica multiplanar para la evaluación y el tratamiento percutáneo de la comunicación interauricular tipo ostium secundum en el adulto

The purpose of this paper is to review the usefulness of multiplanar transesophageal echocardiography before, during and after percutaneous transcatheter closure of secundum atrial septal defects. Transesophageal echocardiography imaging techniques, including their role in patient selection, procedural guidance and immediate assessment of technical success and complications are described and discussed in this review. Percutaneous transcatheter closure is indicated for ostium secundum atrial septal defects of less than 40 mm in maximal diameter. The defect must have a favorable anatomy, with adequate rims of at least 5 mm to anchor the prosthesis. Transesophageal echocardiography plays a critical role before the procedure in identifying potential candidates for percutaneous closure and to exclude those with unfavorable anatomy or associated lesions, which could not be addressed percutaneously. Transesophageal echocardiography is also important during the procedure to guide the deployment of the device. After device deployment, the echocardiographer must assess the device (integrity, position and stability), residual shunt, atrio-ventricular valve regurgitation, obstruction to systemic or venous return and pericardial effusion, in order to determine procedural success and diagnose immediate complications.

El propósito de esta revisión es analizar la utilidad de la ecocardiografía transesofágica multiplanar antes, durante y después del cierre percutáneo de la comunicación interauricular tipo ostium secundum. Las consideraciones técnicas de imagen durante la ecocardiografía transesofágica multiplanar, su utilidad en la evaluación de los pacientes, la guía peri-procedimiento, la evaluación del éxito técnico y las complicaciones son descritas y discutidas en esta revisión. El cierre percutáneo está indicado en la comunicación interauricular tipo ostium secundum con diámetro máximo de 40 mm. El defecto debe tener una anatomía favorable con bordes de al menos 5 mm. La ecocardiografía transesofágica multiplanar tiene un papel determinante antes del procedimiento para identificar a candidatos potenciales para el cierre percutáneo y para excluir aquéllos con anatomía no favorable o lesiones asociadas que no pueden ser manejados vía percutánea. La ecocardiografía transesofágica multiplanar es importante durante el procedimiento para guiar la liberación del dispositivo. Después de la liberación del dispositivo el ecocardiografista debe evaluar la posición y estabilidad del dispositivo, la presencia de corto-circuito residual, la regurgitación de las válvulas A-V, el retorno venoso sistémico y pulmonar, y el pericardio, a fin de determinar el éxito del procedimiento y descartar complicaciones asociadas.

Evaluación de la función y sincronía de la contracción ventricular en pacientes con enfermedad de Chagas en estadio de latencia / Evaluation of the function and ventricular synchrony in patients with latency stage of Chagas' disease

OBJECTIVE: To compare the left ventricular function and the ventricular synchrony in patients with Chagas disease in latency stage respect to a control group. METHODS: We analyze a prospective, comparative, transversal and non randomized study of the left ventricular function (LVF) and the ventricular contraction synchronicity (VCS) in 36 subjects with positive serology for Chagas disease (18 males and 18 females), with mean of 15 +/- 5-years-old. The findings were compared with respect to 23 control volunteers (11 males and 12 females) with mean of 28 +/- 5-years-old. LVF and VCS were evaluated using equilibrium radionuclide angiography images (ERNA). The comparison of both Chagas and control populations was carried out by t Student test for independent samples, considering a statistically significant value of p < 0.05. RESULTS: The parameters of the ventricular function and the ventricular synchronicity in subjects with positive serology for Chagas disease were not statistically different with respect to the parameters of the control group. However, although they have a homogeneous contraction, the mean time of contraction for the right and the left ventricle is statistically smaller with respect to the control group. CONCLUSIONS: In clinically incipient stages of Chagas disease we do not found abnormalities in the ventricular function and the ventricular synchronicity. It's necessary to consider the follow up of the studied populations using indices for the identification of abnormalities of the autonomic nervous system.

Comparación de metoprolol versus clonazepam como tratamiento de primera intención en pacientes con síncope neurocardiogénico / Comparison of metoprolol vs clonazepam as a first treatment choice among patients with neurocardiogenic syncope

Objetivo: Comparar la eficacia de metoprolol versus clonazepam como tratamiento de primera intención en pacientes con síncope neurocardiogénico. Material y métodos: Se llevó a cabo estudio prospectivo, longitudinal y aleatorizado en el que se evaluó el efecto del metoprolol (50 mg dos veces al día) versus clonazepam (0.5 mg una vez al día) sobre la sintomatología asociada a los tres meses y la recurrencia de síncope a 12 meses. La distribución de los datos fue normal, el análisis estadístico se realizó por métodos paramétricos considerándose significancia estadística una p≤0.05. Resultados: De 54 pacientes, 32 fueron tratados con metoprolol y 22 con clonazepam. No hubo diferencias en las características basales entre ambos grupos. El número de síntomas por paciente se redujo en el grupo de metoprolol de 5.2±2.5 a 1.9±2.1 (p<0.001), y en el grupo de clonazepam de 5.5±2.5 a 1.5±2.2 (p<0.001). La recurrencia de síncope a los 12 meses fue de 10% en el primer grupo y de 5% en el grupo de clonazepam, sin diferencia estadísticamente significativa. Conclusiones: El tratamiento con metoprolol o clonazepam disminuye en forma significativa los síntomas de distonía neurovegetativa asociados y la recurrencia de síncope es similar con ambos tratamientos.

OBJECTIVE: We compared the effects of a metoprolol and clonazepam in patients with neurocardiogenic syncope. METHODS: We compared the effects of a metoprolol and clonazepam in a prospective, randomised trial in 54 patients. Patients were randomly assigned to metoprolol (starting dose 50 mg bid) or clonazepam (starting dose 0.5 mg qd). We assessed a primary combined endpoint of syncope and pre-syncope on a follow-up of 12 months. RESULTS: The primary combined endpoint of syncope and presyncope occurred in the metoprolol group in 3, 4, and 10% of patients at 3, 6, and 12 months respectively. In the clonazepam group it was no recurrence in the first 6 months, and 5% recurrence at 12 months follow-up (nonsignificant differences between groups). Clinical symptoms commonly associated with neurally mediated syncope were decreased similarly in both treatment groups, in the metoprolol group from 5.2+/-2.5 to 1.9+/-2.1 (p < 0.001) and in the clonazepam group from 5.5+/-2.5 to 1.5+/-2.2 (p<0.001). CONCLUSIONS: Pharmacological treatment of neurocardiogenic syncope with metoprolol or clonazepam resulted in similar prevention of syncope and presyncope. Both treatments decreased clinical symptoms but complete symptomatic resolution was rarely observed.