Extended septal myectomy versus alcohol septal ablation: clinical results at a national referral centre.

OBJECTIVES: Extended septal myectomy and alcohol septal ablation are 2 invasive treatments for hypertrophic obstructive cardiomyopathy. Our goal was to compare which of these techniques achieved a higher reduction in gradients, improvement in New York Heart Association (NYHA) functional class and reduction in medical treatment. METHODS: It is a single-centre observational and retrospective analysis. We used multivariable regression analyses to assess the association of ablation/myectomy with different outcomes. The odds ratio or coefficient along with the 95% confidence interval was estimated according to the group and adjusted for the corresponding preprocedural variables and EuroSCORE II. RESULTS: A total of 78 patients underwent septal myectomy, and 25 patients underwent alcohol septal ablation. Basal and Valsalva gradients after myectomy were reduced to a higher degree in comparison to ablation: 21.0 mmHg [P < 0.001, 95% confidence interval -30.7; -11.3], and 34.3 mmHg (P < 0.001, -49.1; -19.5) respectively. Those patients who received a myectomy had a lower probability of having moderate mitral regurgitation (odds ratio = 0.18, P = 0.054). Patients after septal myectomy were more likely to be NYHA functional class I (80.4%), whereas patients after ablation were more likely to be NYHA functional class III (48%). Both groups continued with beta-blocker therapy, but disopyramide could be discontinued after the myectomy in more cases (20%-36% vs 59%-1.3%; P < 0.001), and there was a tendency to discontinue calcium channel blockers (48%-16% vs 15.4-3.8%; P = 0.054). CONCLUSIONS: After adjustment using preprocedural gradients and EuroSCORE II, myectomy achieves greater reduction in left ventricular outflow tract gradients compared to septal ablation.

Left atrial strain in the assessment of diastolic function: providing new insights into primary myocardial dysfunction in Marfan syndrome.

Previous studies using conventional echocardiographic measurements have reported subclinical left ventricular (LV) diastolic abnormalities in patients with Marfan syndrome (MFS). Left atrial (LA) strain allows an accurate categorization of LV diastolic dysfunction. We aimed to characterize LV myocardial performance in a cohort of MFS patients using STE-derived measurements (LV and LA strain) along with conventional echocardiographic parameters. We studied 127 adult patients with MFS (no prior cardiac surgery or significant valvular regurgitation) and 38 healthy controls. We performed detailed echocardiograms and selected left atrial reservoir strain (LASr) as a surrogate of impaired relaxation. Additionally, we searched for possible determinants of LASr in patients with MFS, with a special focus on the elastic properties of the aorta. In spite of lower E-wave, septal and lateral e' velocities and average E/e' ratio in MFS patients, all participants had normal diastolic function according to current guidelines. MFS patients exhibited reduced LV global longitudinal strain (19.3 ± 2.6 vs 21.6 ± 2.1%, p < 0.001) and reduced LASr (32.9 ± 8.5 vs 43.3 ± 7.8%, p < 0.001) compared to controls. In the MFS cohort, we found weak significant (p < 0.05) correlations between LASr and certain parameters: E/A ratio (R = 0.258), E wave (R = 0.226), aortic distensibility (R = 0.222), stiffness index (R = - 0.216), LV ejection fraction (R = 0.214), lateral e' (R = 0.210), LV end-systolic volume index (R = - 0.210), LV global longitudinal strain (R = 0.201), septal e' (R = 0.185). After multivariate analysis, only LV end-systolic volume index and E/A ratio maintained a weak independent association with LASr (R = - 0.220; p = 0.017 and R = 0.199; p = 0.046, respectively). In conclusion, LASr is reduced in patients with MFS, which may represent an early stage of LV diastolic dysfunction. LASr is not determined by the elastic properties of the aorta, suggesting that impaired myocardial relaxation is a primary condition in MFS.

Right ventricular function and dyssynchrony in Brugada syndrome: Highlighting the importance of the mechanical substrate in the right ventricular outflow tract.

BACKGROUND: Current evidence suggests that Brugada syndrome (BrS), far from being a purely electrical condition, is associated with subtle mechanical abnormalities primarily affecting the right ventricle (RV). We aimed to characterize RV function in BrS and investigate the echocardiographic profile of patients with arrhythmic events, with a special focus on parameters of RV dyssynchrony using speckle-tracking echocardiography (STE). METHODS: An echocardiogram was performed in 71 BrS patients and 25 healthy controls. STE was performed to assess regional and global RV mechanics, including RV outflow tract shortening (RVOTS). RVOT contraction time was considered to calculate the modified RV mechanical dispersion (RVMDm). Arrhythmic events were prospectively evaluated in the BrS cohort. RESULTS: Compared to controls, BrS patients showed subtle contractile abnormalities, including impaired RV longitudinal strain, higher RV index of myocardial performance (RIMP) and lower RVOTS. BrS patients also exhibited a greater contraction delay between the lateral and the septal aspect of the RV. After a median follow-up of 7.3 year (IQR 5.2-10.8), 6 patients presented malignant arrhythmic events. RIMP >0.50, RVOTS <16.2% and RVMDm > 42 ms showed high sensitivity for the identification of BrS patients with arrhythmic events during follow-up. CONCLUSIONS: Subtle RV mechanical abnormalities were present in BrS patients. RIMP and RVOTS, a novel STE-derived parameter, were found to be sensitive markers of arrhythmic events. Adding the RVOT contraction time to the analysis of RVMD may help identify patients at higher risk, reflecting the importance of the RVOT mechanical substrate in the assessment of the arrhythmic risk in BrS.

Clinical profile and outcome of cardiac amyloidosis in a Spanish referral center.

INTRODUCTION AND OBJECTIVES: Cardiac amyloidosis (CA) is produced by amyloid fiber deposition in the myocardium. The most frequent forms are those caused by light chains (AL) and transthyretin (ATTR). Our objective was to describe the diagnosis, treatment and outcomes of CA in a specialized Spanish center. METHODS: We included all patients diagnosed with CA in Hospital Universitario Puerta de Hierro Majadahonda from May 2008 to September 2018. We analyzed their clinical characteristics, outcomes, and survival. RESULTS: We included 180 patients with CA, of whom 64 (36%) had AL (50% men; mean age, 65±11 years) and 116 had ATTR (72% men; mean age 79±11 years; 18 with hereditary ATTR). The most common presentation was heart failure in both groups (81% in AL and 45% in ATTR, P <.01). Other forms of presentation in ATTR patients were atrial arrhythmias (16%), conduction disorders (6%), and incidental finding (6%); 70 patients (40%), had a previous alternative cardiac diagnosis. Diagnosis was noninvasive in 75% of ATTR patients. Diagnostic delay was higher in ATTR (2.8±4.3 vs 0.6±0.7 years, P <.001), but mortality was greater in AL patients (48% vs 32%, P=.028). Independent predictors of mortality were AL subtype (HR, 6.16; 95%CI, 1.56-24.30; P=.01), female sex (HR, 2.35; 95%CI, 1.24-4.46; P=.01), and NYHA functional class III-IV (HR, 2.07; 95%CI, 1.11-3.89; P=.02). CONCLUSIONS: CA is a clinical challenge, with wide variability in its presentation depending on the subtype, leading to diagnostic delay and high mortality. Improvements are needed in the early diagnosis and treatment of these patients.

Usefulness of Two-Dimensional Strain Parameters to Diagnose Acute Rejection after Heart Transplantation.

BACKGROUND: Acute cellular rejection (ACR) is still a relevant complication after orthotopic heart transplantation. The diagnosis of ACR is based on endomyocardial biopsy (EMB). Recent advances in two-dimensional strain imaging may allow early noninvasive detection of ACR. The objective of this study was to analyze the usefulness of conventional and new echocardiographic parameters to exclude ACR after orthotopic heart transplantation. METHODS: Thirty-four consecutive adult heart transplant recipients admitted to a single center between January 2010 and December 2012 for orthotopic heart transplantation were prospectively included. A total of 235 pairs of EMB and echocardiographic examination were performed. A median of seven studies per patient (interquartile range, six to eight studies per patient) were performed during the first year of follow-up. Classic echocardiographic parameters; speckle-tracking-derived left ventricular (LV) longitudinal, radial, and circumferential strain; and global and free wall right ventricular (RV) longitudinal strain were analyzed. RESULTS: ACR was detected in 26.4% of EMB samples (n = 62); 5.1% (n = 12) required specific treatment (ACR degree ≥ 2R). Lower absolute values of global LV longitudinal strain and free wall RV longitudinal strain were present in patients with ACR degree ≥ 2R compared with those without ACR (13.7 ± 2.7% vs 17.8 ± 3.4% and 16.6 ± 3.6% vs 23.3 ± 5.2%, respectively). An average LV longitudinal strain < 15.5% had 85.7% sensitivity, 81.4% specificity, 98.8% negative predictive value, 25.0% positive predictive value, and 81.7% accuracy for the presence of ACR degree ≥ 2R. Free wall RV longitudinal strain < 17% had 85.7% sensitivity, 91.1% specificity, 98.8% negative predictive value, 42.9% positive predictive value, and 90.7% accuracy for ACR degree ≥ 2R. Both variables were normal in 106 echocardiograms (57.6%); none of these patients presented with ACR degree ≥ 2R. CONCLUSIONS: The combination of two new echocardiographic measures, global LV and RV free wall longitudinal strain, may be able to identify a group of heart transplant patients who are unlikely to have ACR. If these findings are confirmed independently, it may be possible to use LV and RV strain measures as reliable tools to exclude ACR and to reduce the burden of repeated EMB.

Resonancia magnética para la detección no invasiva de la enfermedad microcirculatoria asociada a la vasculopatía de alotrasplante: validación de la determinación intracoronaria / Magnetic resonance for noninvasive detection of microcirculatory disease associated with allograft vasculopathy: intracoronary measurement validation

Introducción y objetivos. La vasculopatía del aloinjerto cardiaco afecta tanto al compartimento coronario epicárdico como al de la microcirculación. Se ha propuesto el uso de las técnicas de imagen de perfusión de la resonancia magnética como instrumento útil para la evaluación de la microcirculación, principalmente fuera del contexto del trasplante de corazón. La pendiente de velocidad del flujo-presión diastólica hiperémica instantánea, que es un índice de la fisiología intracoronaria, ha mostrado mejor correlación con el remodelado microcirculatorio en la vasculopatía del aloinjerto cardiaco que la de otros índices como la reserva de velocidad del flujo coronario. Con objeto de investigar el potencial de las técnicas de imagen de perfusión de resonancia magnética para detectar la presencia de remodelado microcirculatorio en la vasculopatía de aloinjerto cardiaco, se ha comparado los datos de perfusión de resonancia magnética con los índices fisiológicos intracoronarios invasivos, para estudiar la microcirculación en una población de pacientes con trasplante de corazón que presentaban una enfermedad macrovascular no obstructiva demostrada por la ecografía intravascular. Métodos. Se estudió a 8 pacientes con trasplante de corazón (media de edad, 61 ± 12 años; el 100% varones) que presentaban una vasculopatía del aloinjerto epicárdica definida por ecografía intravascular, estenosis coronarias no significativas y una resonancia magnética de estrés con dobutamina con evaluación visual del movimiento de la pared/perfusión negativa. Se determinaron los datos de perfusión de resonancia magnética cuantitativa en estrés y en reposo para establecer el índice de reserva de perfusión miocárdica, de manera no invasiva, y se determinaron cuatro índices fisiológicos intracoronarios evaluados de manera invasiva. Resultados. Los datos posprocesados mostraron una media del índice de reserva de perfusión miocárdica de 1,22 ± 0,27, mientras que la reserva de flujo fraccional, la reserva de velocidad del flujo coronario, la resistencia microvascular hiperémica y la pendiente de velocidad del flujo-presión diastólica hiperémica instantánea fueron de 0,98 ± 0,02, 2,34 ± 0,55, 2,00 ± 0,69 y 0,91 ± 0,65 cm/s/mmHg respectivamente. El índice de reserva de perfusión miocárdica presentó una correlación intensa tan solo con la pendiente de velocidad del flujo-presión diastólica hiperémica instantánea (r = 0,75; p = 0,033). Conclusiones. El índice de reserva de perfusión miocárdica obtenido a partir de la resonancia magnética de estrés con dobutamina completa resulta una técnica fiable para la detección no invasiva de la enfermedad coronaria microcirculatoria asociada a la vasculopatía de aloinjerto cardiaco (AU)

Introduction and objectives. Cardiac allograft vasculopathy affects both epicardial and microcirculatory coronary compartments. Magnetic resonance perfusion imaging has been proposed as a useful tool to assess microcirculation mostly outside the heart transplantation setting. Instantaneous hyperemic diastolic flow velocity-pressure slope, an intracoronary physiology index, has demonstrated a better correlation with microcirculatory remodelling in cardiac allograft vasculopathy than other indices such as coronary flow velocity reserve. To investigate the potential of magnetic resonance perfusion imaging to detect the presence of microcirculatory remodeling in cardiac allograft vasculopathy, we compared magnetic resonance perfusion data with invasive intracoronary physiological indices to study microcirculation in a population of heart transplantation recipients with macrovascular nonobstructive disease demonstrated with intravascular ultrasound. Methods. We studied 8 heart transplantation recipients (mean age, 61 [12] years, 100% male) with epicardial allograft vasculopathy defined by intravascular ultrasound, nonsignificant coronary stenoses and negative visually-assessed wall-motion/perfusion dobutamine stress magnetic resonance. Quantitative stress and rest magnetic resonance perfusion data to build myocardial perfusion reserve index, noninvasively, and 4 invasive intracoronary physiological indices were determined. Results. Postprocessed data showed a mean (standard deviation) myocardial perfusion reserve index of 1.22 (0.27), while fractional flow reserve, coronary flow velocity reserve, hyperemic microvascular resistance and instantaneous hyperemic diastolic flow velocity-pressure slope were 0.98 (0.02), cm/s/mmHg, 2.34 (0.55) cm/s/mmHg, 2.00 (0.69) cm/s/mmHg and 0.91 (0.65) cm/s/mmHg, respectively. The myocardial perfusion reserve index correlated strongly only with the instantaneous hyperemic diastolic flow velocity-pressure slope (r = 0.75; P = .033). Conclusions. Myocardial perfusion reserve index derived from a comprehensive dobutamine stress magnetic resonance appears to be a reliable technique for noninvasive detection of microcirculatory coronary disease associated with cardiac allograft vasculopathy (AU)

Magnetic Resonance for Noninvasive Detection of Microcirculatory Disease Associated With Allograft Vasculopathy: Intracoronary Measurement Validation.

INTRODUCTION AND OBJECTIVES: Cardiac allograft vasculopathy affects both epicardial and microcirculatory coronary compartments. Magnetic resonance perfusion imaging has been proposed as a useful tool to assess microcirculation mostly outside the heart transplantation setting. Instantaneous hyperemic diastolic flow velocity-pressure slope, an intracoronary physiology index, has demonstrated a better correlation with microcirculatory remodelling in cardiac allograft vasculopathy than other indices such as coronary flow velocity reserve. To investigate the potential of magnetic resonance perfusion imaging to detect the presence of microcirculatory remodeling in cardiac allograft vasculopathy, we compared magnetic resonance perfusion data with invasive intracoronary physiological indices to study microcirculation in a population of heart transplantation recipients with macrovascular nonobstructive disease demonstrated with intravascular ultrasound. METHODS: We studied 8 heart transplantation recipients (mean age, 61 [12] years, 100% male) with epicardial allograft vasculopathy defined by intravascular ultrasound, nonsignificant coronary stenoses and negative visually-assessed wall-motion/perfusion dobutamine stress magnetic resonance. Quantitative stress and rest magnetic resonance perfusion data to build myocardial perfusion reserve index, noninvasively, and 4 invasive intracoronary physiological indices were determined. RESULTS: Postprocessed data showed a mean (standard deviation) myocardial perfusion reserve index of 1.22 (0.27), while fractional flow reserve, coronary flow velocity reserve, hyperemic microvascular resistance and instantaneous hyperemic diastolic flow velocity-pressure slope were 0.98 (0.02), cm/s/mmHg, 2.34 (0.55) cm/s/mmHg, 2.00 (0.69) cm/s/mmHg and 0.91 (0.65) cm/s/mmHg, respectively. The myocardial perfusion reserve index correlated strongly only with the instantaneous hyperemic diastolic flow velocity-pressure slope (r=0.75; P=.033). CONCLUSIONS: Myocardial perfusion reserve index derived from a comprehensive dobutamine stress magnetic resonance appears to be a reliable technique for noninvasive detection of microcirculatory coronary disease associated with cardiac allograft vasculopathy.

Erysipelas and acute myocarditis: an unusual combination.

Myocarditis is a rare disease with variable clinical presentation and diverse electrocardiographic and echocardiographic features. Viral infection is the most common cause, but myocarditis can also be caused by bacterial infection. The most frequently involved bacterial agent is group A Streptococcus, which is also an etiologic agent of erysipelas. We present the case of a man aged 46 years with left-leg erysipelas who developed myocarditis. Cardiac magnetic resonance played an essential role in diagnosis. This case is, to our knowledge, the first description of an association between erysipelas and myocarditis.

Theoretical study of interactions of BSA protein in a NaCl aqueous solution.

Bovine Serum Albumine (BSA) aqueous solutions in the presence of NaCl are investigated for different protein concentrations and low to intermediate ionic strengths. Protein interactions are modeled via a charge-screened colloidal model, in which the range of the potential is determined by the Debye-Hückel constant. We use Monte Carlo computer simulations to calculate the structure factor, and assume an oblate ellipsoidal form factor for BSA. The theoretical scattered intensities are found in good agreement with the experimental small angle X-ray scattering intensities available in the literature. The performance of well-known integral equation closures to the Ornstein-Zernike equation, namely the mean spherical approximation, the Percus-Yevick, and the hypernetted chain equations, is also assessed with respect to computer simulation.

Implicaciones pronósticas de la morfología asimétrica en la implantación de prótesis aórticas transcatéter: a propósito de un caso / Prognostic implications of asymmetric morphology in transcatheter aortic valve implantation: a case report

No disponible

Predicción del rendimiento académico en alumnos de ESO y Bachillerato mediante el Inventario Clínico para Adolescentes de Millon (escala MACI) / Prediction of academic achievement in obligatory compulsory education and baccalaureate students through the Millon Adolescent Clinical Inventory

El aumento creciente de la conflictividad en las aulas, los problemas de comportamiento entre alumnos y profesores y la aparición progresiva y creciente de trastornos de personalidad, unido a un rendimiento académico cada vez menor en algunos grupos de alumnos, al que se unen aspectos familiares disfuncionales y cuestiones sociales e interpersonales en los jóvenes cada vez más heterogéneas ha hecho plantearnos desde una perspectiva psicopatológica y clínica (dada la insuficiencia explicativa de las variables únicamente organizativas y pedagógicas de los centros de enseñanza), un estudio preferentemente correlacional multivariante (diseño “ex post facto”), con técnicas de regresión logística binaria, que intente encontrar relaciones iniciales entre variables de personalidad y educativas (rendimiento) que ayuden a clarificar dichos problemas y que puedan servir, de forma complementaria, para el diseño y puesta en práctica de programas de salud mental en la escuela, su derivación a los servicios correspondientes de la red sanitaria o la puesta en práctica de medidas psicopedagógicas más idóneas. Alrededor de 380 alumnos de un instituto público de educación secundaria (ESO -12 a 16 años- y Bachillerato -16 a 19 años-), formaron parte de esta investigación, a los que se les administró la escala MACI (entre otras), así como medidas de rendimiento escolar

The progressive increase of the conflicting in the classrooms, the behavior problems among students and teachers and the increasing appearance of personality disorders, added to a bigger academic failure in some groups of adolescents joined to social and familiar dysfunctions have done posed us, from a clinical and psychopatological perspective, a research basically correlational multivariable with binary logistic regression techniques, intending to found initial relationships between personality and educational (achievement) variables. About 380 students of Compulsory Secondary Education (ESO – 12 to 16, and Baccalaureate –16 to 19 years) were administered the Millon Adolescents Clinical Inventory (and other materials) as well as academic performance measures

Cardiac magnetic resonance imaging in the diagnosis of myocarditis mimicking myocardial infarction.

Cardiac Magnetic Resonance (CMR) imaging has recently become a very useful tool in the diagnosis of myocarditis. We describe a patient in whom acute myocarditis was presented as an acute myocardial infarction and had an atypical course with rapid normalization of ECG abnormalities. In this case CMR imaging was essential to confirm the diagnosis of myocarditis.

[Valve repair for chronic mitral regurgitation]. / Reparación valvular en la insuficiencia mitral crónica.

Valve repair is the best surgical treatment for mitral regurgitation. In the present article we describe the results of mitral valve repair in patients with chronic mitral regurgitation treated at our center during the last eight years. The degree of correction of valve insufficiency, functional benefit, in-hospital morbidity and mortality, postoperative outcome of ventricular function, and middle-term overall and reoperation-free survival are analyzed.

Reparación valvular en la insuficiencia mitral crónica / Valve repair for chronic mitral regurgitation

La reparación valvular es el tratamiento quirúrgico ideal de la insuficiencia mitral. En este trabajo presentamos los resultados de la reparación valvular en pacientes con insuficiencia mitral crónica operados en nuestro centro durante los últimos 8 años. Analizamos el grado de corrección de la insuficiencia, el beneficio funcional, la morbimortalidad hospitalaria, la evolución posquirúrgica de la función ventricular y la supervivencia global y libre de reoperación a medio plazo

Valve repair is the best surgical treatment for mitral regurgitation. In the present article we describe the results of mitral valve repair in patients with chronic mitral regurgitation treated at our center during the last eight years. The degree of correction of valve insufficiency, functional benefit, in-hospital morbidity and mortality, postoperative outcome of ventricular function, and middle-term overall and reoperation-free survival are analyzed

Predictors of lack of response to resynchronization therapy.

About 30% of patients treated with cardiac resynchronization therapy (CRT) do not respond to treatment. The aim of this study was to identify clinical predictors of lack of improvement in patients receiving CRT. From 197 consecutive patients scheduled to receive CRT, 143 fulfilled the inclusion criteria. Mean age was 68 +/- 7 years and 79% were men. Heart failure was due to ischemic heart disease in 49 patients (34%). Mean QRS duration was 165 +/- 26 ms, and left ventricular ejection fraction was 27 +/- 7%. Nonresponder patients were defined as those who died of heart failure, underwent heart transplantation, or did not increase the distance walked in 6 minutes >10%. At 6-month follow-up, there were 28 nonresponders (20%). Among nonresponders, 2 patients received a heart transplantation and 9 patients died of heart failure. In logistic regression analysis, independent predictors of lack of response to CRT were ischemic heart disease (odds ratio [OR] 2.9, 95% confidence interval [CI] 1.2 to 7; p = 0.023), severe mitral regurgitation (OR 3.5, 95% CI 1.3 to 9; p = 0.014), and left ventricular end-diastolic diameter > or =75 mm (OR 3.1, 95% CI 1.1 to 8; p = 0.026). Patients with these 3 predictors had a probability response of 27%.