Impacto de la miectomía septal ampliada sobre los cambios ecocardiográficos en la miocardiopatía hipertrófica obstructiva / Impact of Extended Septal Miectomy on Echocardiographic Changes in Hypertophic Obstructivec Cardiomyopathy

RESUMEN Introducción: La miectomía septal ampliada (MSA) ha demostrado ser una estrategia útil para mejorar los síntomas de los pacientes con miocardiopatía hipertrófica obstructiva (MCHO). Objetivos: El objetivo de este trabajo fue analizar el impacto de la MSA en parámetros estructurales y funcionales ecocardiográficos a corto y mediano plazo, en pacientes con MCH y obstrucción dinámica del tracto de salida del ventrículo izquierdo (VI). Material y métodos: Se analizaron los ecocardiogramas en los períodos preoperatorio, postoperatorio inmediato (1 mes post cirugía) y posoperatorio alejado (2 a 3 años) de pacientes sometidos a MSA. Resultados: Se intervinieron 94 pacientes con una edad media de 57,6 ± 13,8 años. Se observó una reducción significativa del máximo espesor septal en el postoperatorio inmediato, que se mantuvo en el posoperatorio alejado, y en el tamaño auricular izquierdo en el postoperatorio inmediato que se profundizó en el alejado (p < 0,001). El gradiente intraventricular en reposo pasó de 49,2 mmHg basal a 6,4 mmHg (p < 0,001) y de allí a 4,6 mmHg (p=0,224) en los períodos inmediato y alejado, y con la maniobra de Valsalva de 93,9 mmHg a 8,7 mmHg (p < 0,001) y de allí a 7,2 mmHg (p=0,226) respectivamente. La función diastólica fue valorada como grado II en el 58,5 % de los pacientes en el preoperatorio, 51,7 % en el postoperatorio inmediato y 29 % en el postoperatorio alejado. En la misma línea se evidenció un cambio en la relación E/e´ y la presión sistólica pulmonar, grado de insuficiencia mitral y dimensiones de la aurícula izquierda. Conclusión: En esta cohorte de pacientes con MCHO, la realización de una MSA se asoció a una mejoría significativa de la función diastólica del VI, reducción de las presiones de llenado y pulmonares y grado de insuficiencia mitral, y remodelado reverso de la aurícula izquierda. Es posible que esta combinación de efectos explique los beneficios clínicos de la intervención.

ABSTRACT Background: Extended septal myectomy (ESM) has proven to be a useful strategy to improve symptoms in patients with hypertrophic obstructive cardiomyopathy (HOCM). Objectives: The aim of this study was to analyze the impact of ESM on short and mid-term structural and functional echocardiographic parameters in patients with HCM and left ventricular (LV) outflow tract dynamic obstruction. Methods: Preoperative, immediate postoperative (1 month after surgery) and late postoperative (2 to 3 years) echocardiograms of patients undergoing ESM were analyzed. Results: A total of 94 patients with mean age of 57.6 ± 13.8 years underwent surgery. A significant reduction was observed in maximum septal thickness in the immediate postoperative period, which was sustained in the late postoperative period, and in atrial size in the immediate postoperative period, which deepened in the late postoperative period (p < 0.001). Intraventricular gradient at rest dropped from 49.2 to 6.4 mmHg (p < 0.001) and then to 4.6 mmHg (p=0.224) in the immediate and late periods and with Valsalva maneuver from 93.9 to 8.7 mmHg (p < 0.001), and then to 7.2 mmHg (p=0.226), respectively. Preoperative diastolic function was assessed as grade II in 58.5% of patients, decreasing to 51.7% in the immediate postoperative period and to 29% in the late postoperative period. In agreement with these results, a change was evidenced in the E/e´ ratio and pulmonary artery systolic pressure, degree of mitral regurgitation and left atrial dimensions. Conclusion: In this cohort of patients with HOCM, ESM was associated with a significant improvement in LV diastolic function, reduction in filling and pulmonary pressures and degree of mitral regurgitation, and left atrial reverse remodeling. It is possible that this combination of effects explains the clinical benefits of the intervention.

Coronary angiotomography in patients with acute coronary syndrome without ST elevation.

BACKGROUND: In patients presenting with acute coronary syndrome (ACS) current clinical practice guidelines recommend coronary angiography for its study. This study aims to describe the role of coronary tomography (CT) in non-ST-segment elevation acute coronary syndromes (NSTE-ACS). RESULTS: Patients over 18 years with a diagnosis of NSTE-ACS who did not meet high-risk criteria and consulted the emergency department of our institution were included. A total of 410 patients were included, in 7% of them, the study was not continued due to an elevated calcium score (>400 AU). 27% had no coronary lesions, 38% had non-obstructive coronary disease (plaques <50%), 27% had plaques over 50%, and 8% were not assessable. Of the total patients, 39% underwent coronary angiography, and 22% required percutaneous angioplasty. CONCLUSIONS: Performing CT in low and moderate-risk NSTE-ACS patients was feasible, avoiding invasive studies in a significant number of patients and providing extensive anatomical information.

Hemodynamically significant prosthesis-patient mismatch can be predicted and is associated with early prosthetic valve dysfunction in aortic bioprosthesis.

OBJECTIVES: To evaluate the accuracy of predicted prosthesis-patient mismatch (PPM) regarding actual PPM measured postoperatively. To assess the association between PPM and prosthetic valve dysfunction. METHODS: Retrospective cohort study including adult patients after aortic valve replacement surgery with a biological prosthesis. Predicted PPM status was determined using mean reference effective orifice area indexed to total body surface (iEOA), without considering reference standard deviations. Postoperative PPM status was determined by measuring iEOA within the first 60 postoperative days. Prosthetic valve dysfunction was defined as thrombosis, pannus, valve degeneration, and/or disruption. RESULTS: 205 patients were enrolled between January 2003 and June 2017: predicted PPM was absent in 52 patients (25.4%), moderate in 137 patients (66.8%), and severe in 16 patients (7.8%). After surgery, the actual postoperative iEOA was measured: 53 (25.9%) did not have PPM, 73 had moderate PPM (35.6%), and 79 had severe PPM (38.5%). Predicted PPM identified the presence of hemodynamically significant actual postoperative PPM (OR = 2.56; 95%CI 1.30-5.05; P = .006), though not its degree of severity. Prosthetic valve dysfunction was more frequent among patients with hemodynamically significant PPM (53.9% vs. 11.3%; P < .001), compared to those without PPM. The association between PPM and prosthetic valve dysfunction was maintained after adjusting for gender, age, and ever-smoking (OR = 9.03; P < .001). The incidence of thrombosis or pannus was also nonsignificantly higher in patients with moderate or severe PPM. CONCLUSIONS: Predicted PPM identifies the presence, possibly not the severity, of actual postoperative PPM. Moderate or severe PPM is associated with prosthetic valve dysfunction. Actual postoperative prosthesis-patient mismatch measured within 60 postoperative days showed a distinctive hemodynamic profile and presented a stronger association with prosthetic valve dysfunction than predicted prosthesis-patient mismatch. A. Echocardiographic follow-up in patients according to the actual postoperative PPM measured within 60 postoperative days. B. Prediction of prosthetic valve dysfunction based on preoperative predicted PPM or on actual postoperative PPM within 60 postoperative days. PPM: prosthesis-patient mismatch. OR: Odds ratio.

Differences in the extent of fibrosis in obstructive and nonobstructive hypertrophic cardiomyopathy.

AIMS: Left ventricular outflow tract (LVOT) obstruction is a key feature of hypertrophic cardiomyopathy (HCM) that identifies patients at increased risk of adverse outcomes. Previous studies have hypothesized that LVOT obstruction enhances myocardial fibrosis and increases left ventricular (LV) filling pressures, producing greater clinical deterioration. However, this hypothesis has not been demonstrated in a clinical cohort comparing obstructive and nonobstructive patients. METHODS: Patients with HCM in whom Doppler echocardiography was performed within 30 days of cardiac MRI were enrolled, using the E/e' ratio to assess LV diastolic function and late gadolinium enhancement to evaluate the extent of fibrosis. Data were assorted according to LVOT obstruction status at rest. RESULTS: The current study enrolled 67 patients who were mostly middle-aged (56.8 ±â€Š13.2 years old) men (75%) with preserved ejection fraction. Obstructive HCM presented a significant association with a high fibrosis extent [odds ratio (OR) 3.33; P = 0.034] which was maintained after adjusting for sex and age (OR 4.37; P = 0.016) but not for maximum LV wall thickness (OR 2.13; P = 0.225). Obstructive HCM was also associated with a clinically significant E/e' ratio more than 14 (OR 7.8; P = 0.001) which decreased slightly after adjusting for age, sex and maximum LV thickness (OR 6.54; P = 0.014). There was a significant association between an E/e' ratio more than 14 and the extent of fibrosis (OR 1.29; P < 0.001) which was maintained after adjusting for age, sex and maximum LV wall thickness (OR 1.36; P = 0.001). CONCLUSION: LVOT obstruction may play a role in the extent of fibrosis in HCM, possibly conditioning greater diastolic dysfunction.

Aneurisma de aorta ascendente: ¿cuál es el riesgo de reemplazar la raíz? / Ascending Aorta Aneurysm: What is the Risk of Replacing the Aortic Root?

RESUMEN Introducción: El riesgo-beneficio del reemplazo de los senos de Valsalva con el consiguiente reimplante coronario frente a la alternativa de mantenerlos, cuando hay dilataciones moderadas de la raíz, es un tópico que se debe definir. Objetivo: Analizar la morbimortalidad posoperatoria y a largo plazo en pacientes sometidos a reemplazo de la raíz aórtica comparados con aquellos en los que se han respetado los senos de Valsalva. Material y métodos: Entre 2002 y 2016, a 426 pacientes se les realizó reemplazo de aorta ascendente. Tras excluir de esa población las cirugías de urgencia, las aortopatías genéticas (excepto bicúspide), las reoperaciones y las cirugías del arco, se conformó una población de 259 pacientes. En 99 de ellos (38,2%) se reemplazó la aorta ascendente conservando la raíz; estos pacientes fueron comparados con los 160 (61,8%) pacientes restantes, en quienes se reemplazaron los senos de Valsalva. Resultados: El grupo en el que se preservó la raíz fue más añoso, con más mujeres, con un Euroscore mayor, con mayor incidencia de válvula bicúspide y enfermedad coronaria. El tiempo de circulación extracorpórea fue mayor en el grupo en el que se reemplazó la raíz. La mortalidad hospitalaria no fue diferente (1% para la conservación de raíz vs. 3,1% para el reemplazo de los senos de Valsalva (p = 0,272). En el análisis multivariado, el tiempo de circulación extracorpórea fue predictor de mortalidad posoperatoria. La sobrevida a 8 años no mostró diferencias significativas entre grupos. En el seguimiento, ningún paciente requirió reoperación debido a complicaciones de la aorta. En el análisis multivariado, la edad y la presencia de enfermedad valvular mitral fueron predictores de mortalidad alejada. Conclusión: El reemplazo de la aorta ascendente, ya sea reemplazando la raíz o respetando los senos de Valsalva, es una cirugía segura, con baja morbimortalidad hospitalaria. A largo plazo, la preservación de los senos de Valsalva no se asocia con más eventos ni con mayor mortalidad.

ABSTRACT Background: In mildly dilated aortic root, the cost-benefit of replacing of the sinuses of Valsalva with reimplantation of the coronary arteries or preserving them is still a matter of debate. Objective: The goal of this study was to analyze the postoperative and long-term morbidity and mortality of patients undergo-ing aortic root replacement versus aortic root surgery with sinuses of Valsalva preservation. Methods: Between 2002 and 2016, 426 patients underwent replacement of the ascending aorta. After excluding patients under-going urgent procedures, genetic aortic diseases (except for bicuspid aortic valve), reoperations and surgery of the aortic arch, the cohort was made up of 259 patients. In 99 of them (38.2%) the ascending aorta was replaced, preserving the aortic root; these patients were compared with the remaining 160 (61.8%) patients who underwent replacement of the sinuses of Valsalva. Results: Patients undergoing preservation of the aortic root were older, had higher percentage of female sex, higher EuroSCORE and with greater incidence of bicuspid aortic valve and coronary artery disease. Cardiopulmonary bypass time was longer in the group undergoing aortic root replacement. There were no significant differences in in-hospital mortality between both groups (1% in the group with preservation of the aortic root vs. 3.1% for replacement of the sinuses of Valsalva, p=0.272). Multivariate analysis showed that cardiopulmonary bypass was a predictor of in-hospital mortality. Survival at 8 years was similar in both groups. There were no new operations due to complications in the aorta during follow-up. At multivariate analysis, age and mitral valve disease were identified as predictors of long-term mortality. Conclusion: Replacement of the ascending aorta, either replacing the aortic root or preserving the sinuses of Valsalva, is a safe procedure, with low in-hospital mortality. Preservation of the sinuses of Valsalva is not associated with greater rate of events or mortality at the long-term.

Estimation of Prevalence of the Left Ventricular Noncompaction Among Adults.

The prevalence of left ventricular noncompacted myocardium (LVNC) is not clearly defined yet. The goal of this study was to prospectively assess the prevalence of LVNC in a population of patients assessed for cardiovascular disease and to analyze the coincidence between observers using the echocardiographic criteria for diagnosis of LVNC. We included patients prospectively during a 1-year period. To analyze the concordance between different observers, we performed a blind analysis of 50 patients between 7 operators to calculate Kappa index for each criteria. The analysis of concordance for final diagnosis of LVNC was free-marginal kappa: 0.94. A total of 10,857 patients underwent echocardiography; 2,931 (27%) were normal. LVNC was found in 26 patients (prevalence = 0.24%), 16 patients were women, mean age of 52.6 years. Patients were divided into 2 groups; group A: ejection fraction (EF) <50% (n = 20) and group B: normal systolic function (n = 6). Among abnormal studies, 294 (2.7%) were dilated cardiomyopathies (DCs) Patients with LVNC and EF <50% comprised 6.8% of DC (20 of 294) and 24% (20 of 75) of patients with idiopathic DC (p <0.0001). Group A patients were older and with less presence of women (both p <0.05). In conclusion, the prevalence of LVNC in a population assessed for cardiovascular diseases is low. In contrast, it is very high in the subgroup of patients with idiopathic DC. The group of patients with LVNC and normal LVEF is younger and with a higher presence of women than those with LVNC and depressed LVEF. Coincidence between operators is very good for the identification of echocardiographic criteria.

Evolución a largo plazo de pacientes con miocardiopatía hipertrófica / Long-term Outcome of Patients with Hypertrophic Cardiomyopathy

Introducción: La miocardiopatía hipertrófica es una enfermedad compleja que se ha asociado durante años con tasas altas de morbimortalidad. Sin embargo, mucha de la información que tenemos en relación con su evolución proviene de centros en los que se incluyeron pacientes seleccionados, principalmente de riesgo alto. Objetivo: Evaluar los eventos en el seguimiento de pacientes con miocardiopatía hipertrófica en nuestro medio. Material y métodos: Se evaluó una cohorte retrospectiva de pacientes con diagnóstico de miocardiopatía hipertrófica. Se analizó la evolución de la clase funcional junto con la ocurrencia de eventos clínicos. Se recabaron datos del ecocardiograma y de la resonancia magnética cardíaca. Resultados: Se incluyeron 259 pacientes, con una mediana de seguimiento de 3,5 años (2-10). La edad promedio fue de 56 ± 16,8 años y el 38,2% de los pacientes tenían formas obstructivas de la enfermedad. Al inicio del seguimiento, el 67% se encontraban en clase funcional I. En la evolución, la mortalidad global fue del 1,6%, con el 1,1% de muerte súbita o choque apropiado de desfibrilador y el 6,6% de los pacientes presentaron fibrilación auricular. La tasa de internación por insuficiencia cardíaca resultó del 5,8% y en el 14,3% de los pacientes empeoró la clase funcional. Se realizaron 22 procedimientos de ablación septal y 15 miectomías, con mejoría significativa de la sintomatología. Conclusiones: El trabajo muestra que en el seguimiento de esta cohorte de pacientes con miocardiopatía hipertrófica la tasa de morbimortalidad fue baja; el principal evento adverso fue el empeoramiento de la clase funcional, seguido por el desarrollo de fibrilación auricular y la insuficiencia cardíaca, con una tasa baja de muerte súbita.

Utility of Real Time 3D Echocardiography for the Assessment of Left Ventricular Mass in Patients with Hypertrophic Cardiomyopathy: Comparison with Cardiac Magnetic Resonance.

INTRODUCTION AND OBJECTIVES: Patients with hypertrophic cardiomyopathy (HCM) have irregular ventricular shapes with small and sometimes obliterated cavities at end-systole that affect the quantification of left ventricular mass (LVM) by conventional methods, such as M-mode or two-dimensional echocardiography. The goal of this study was to validate the use of real time three-dimensional echocardiography (RT3DE) to quantify LVM using cardiac magnetic resonance imaging (CMR) as a reference, in a large population of patients with different types of HCM. METHODS: Forty-eight consecutive patients with HCM had a complete transthoracic examination and CMR performed within 7 days. LVM was calculated by M-mode and RT3DE and compared to CMR that served as gold standard. RESULTS: Left ventricular mass calculated by RT3DE was 195 ± 41 g and 187 ± 49 g by CMR. The correlation between the two methods was moderate, with a Lin index of 0.63 and good linear correlation (r = 0.63, P < 0.0001). The correlation was high when RT3DE was of high or adequate image quality. The correlation between LVM by M-mode and CMR was poor. CONCLUSION: Three-dimensional echocardiography is an accurate method for the quantification of LVM in patients with different subtypes of HCM that is in better agreement with CMR reference values than M-mode measurements.

Clinical and Functional Outcome of Percutaneous alcohol septal ablation in Obstructive Hypertrophic Cardiomyopathy / Resultados clínicos y funcionales de la ablación septal percutánea con alcohol en la miocardiopatía hipertrófica obstructiva

background: Percutaneous septal ablation is a therapeutic option for patients with obstructive hypertrophic cardiomyopathy refrac-tory to optimal medical therapy. However, results of initial persistence and long-term safety are still controversial. Objectives: The aim of this study was to report percutaneous alcohol septal ablation technique, clinical and functional outcome, cardiovascular events and its impact on long-term follow-up. Methods: A total of 23 patients were included in the study. Functional class (FC), left ventricular outflow tract gradient before and after the procedure and long-term cardiovascular events were evaluated. results: Median follow-up was 52 months (IR 33-72). All patients were in FC III or IV prior to the procedure, under maximum tolerated medical therapy. The procedure was successful in 91% of cases, with 85% of patients currently in FC I and 15% in FC II. Baseline left ventricular outflow tract gradient decreased from 75 mmHg (95% CI 51-89) to 25 mmHg (95% CI 10-37) (p <0.003) and with Valsalva maneuver from 118 mmHg (95% CI 88-152) to 38 mmHg (95% CI 16-69) (p <0.0002), persisting in the long-term follow-up. During hospitalization, two patients presented with complete atrioventricular block requiring permanent pacemaker implantation. No cardiovascular deaths occurred during follow up. Conclusions: Alcohol septal ablation is a promising option for the treatment of a selected population with hypertrophic obstructive cardiomyopathy, generating sustained clinical and functional improvement with low incidence of events in the long-term follow up.

Lateral left ventricular wall rupture following acute myocardial infarction: pathophysiological interpretation by multimodality imaging approach.

Lateral left ventricular wall rupture (LVWR) is a rare complication following acute myocardial infarction (AMI) less than 1%. After cardiogenic shock, LVWR constitutes the most common cause of in-hospital death in AMI patients. Around 40% of all LVWR occurred during the first 24 hours and 85% within the first week. In the present case, 76 hours following the intervention, LVWR was observed likely due to a small infarction at the lateral left ventricular wall possibly due to the marginal lesion. Our patient refused surgery and was followed clinically. Eighteen months later, real time three-dimensional echocardiography showed a pseudoaneurysm.

Papillary muscle rupture associated to essential thrombocytosis.

Essential thrombocytosis (ET) falls under the umbrella of myeloproliferative disorders, which also includes chronic myelogenous leukemia, polycythemia vera, and myelofibrosis with myeloid metaplasia. Essential thrombocytosis results from a clonal proliferation of megakaryocites within the bone marrow, leading to an absolute elevation of platelets that can cause both hemorrhagic and thrombotic complications.

Predictores ecocardiográficos de capacidad de ejercicio en pacientes con insuficiencia cardiaca sistólica. Valor de la insuficiencia mitral / Echocardiographic predictors of exercise capacity in patients with heart failure and systolic dysfunction: role of mitral regurgitation

Introducción y objetivos. Pacientes con insuficiencia cardiaca y similar disfunción sistólica del ventrículo izquierdo tienen diferente capacidad de ejercicio. El objetivo de este estudio es detectar predictores ecocardiográficos de capacidad de ejercicio en pacientes con insuficiencia cardiaca y disfunción sistólica. Métodos. Se incluyó a 150 pacientes con insuficiencia cardiaca en clase II (70%) o III (30%) con fracción de eyección ventricular izquierda < 40%. Se efectuó prueba de los 6 minutos de marcha y eco-Doppler color cardiaca, incluyendo Doppler tisular de los anillos mitral y tricuspídeo. Se consideró insuficiencia mitral significativa los grados moderado y severo. Se dividió a los pacientes en dos grupos según la mediana de caminata (290 m): el grupo 1 caminó <290 m y el grupo 2, >=290 m. Resultados. Se detectó insuficiencia mitral en 112 pacientes (75%), que fue significativa en 40 (27%). El grupo 1 evidenció más insuficiencia mitral significativa (el 35 frente al 18%), área auricular izquierda (27±1 frente a 24±1cm2), amplitud de E mitral (88±5 frente a 72±3cm/s) y presión sistólica pulmonar (37±1 frente a 32±1 mmHg; todos p<0,05). En el análisis multivariable de regresión logística, sólo la presencia de insuficiencia mitral significativa se asoció en forma independiente a menor distancia caminada (odds ratio=3,44; intervalo de confianza del 95%, 1,02-11,66; p<0,05). En el análisis de regresión lineal múltiple, el único predictor independiente de la distancia caminada fue el área auricular izquierda (r=0,25; Beta=–6,52±2; p<0,01). Conclusiones. En pacientes con insuficiencia cardiaca en clase II-III y disfunción sistólica ventricular izquierda, los principales predictores ecocardiográficos de capacidad de ejercicio se relacionan con la presencia de insuficiencia mitral significativa (AU)

Introduction and objectives. Patients with heart failure and similar left ventricular systolic dysfunction have differing exercise capacity. The aim of this study was to identify echocardiographic predictors of exercise capacity in patients with heart failure and systolic dysfunction. Methods. We included 150 patients with class II (70%) or III (30%) heart failure with left ventricular ejection fraction below 40%. Six-minute walking test and cardiac color Doppler-echo, including tissue Doppler of mitral and tricuspid rings, were performed. Moderate and severe mitral regurgitation were considered as significant. Two groups were divided according to the median walking distance (290 m): Group 1, < 290 m and Group 2, >=290 m. Results. Mitral regurgitation was detected in 112 patients (75%), which was significant in 40 (27%). Group 1 showed more significant mitral regurgitation (35 vs 18%), increased left atrium area (27±1 vs 24±1cm2), mitral E amplitude (88±5 vs 72±3cm/s) and systolic pulmonary pressure (37±1 vs 32±1mmHg, all P<.05). By logistic regression analysis, only the presence of significant mitral regurgitation was independently associated with less walked distance (odds ratio: 3.44 95% confidence interval 1.02-11.66, P<.05). By multiple linear regression, the only independent predictor of walked distance was left atrium area (r=0.25, beta coefficient: −6.52±2, P<.01). Conclusions. In patients with class II-III heart failure and left ventricular systolic dysfunction, the main echocardiographic predictors of exercise capacity are related to the presence of significant mitral regurgitation (AU)

[Echocardiographic predictors of exercise capacity in patients with heart failure and systolic dysfunction: role of mitral regurgitation]. / Predictores ecocardiográficos de capacidad de ejercicio en pacientes con insuficiencia cardiaca sistólica. Valor de la insuficiencia mitral.

INTRODUCTION AND OBJECTIVES: Patients with heart failure and similar left ventricular systolic dysfunction have differing exercise capacity. The aim of this study was to identify echocardiographic predictors of exercise capacity in patients with heart failure and systolic dysfunction. METHODS: We included 150 patients with class II (70%) or III (30%) heart failure with left ventricular ejection fraction below 40%. Six-minute walking test and cardiac color Doppler-echo, including tissue Doppler of mitral and tricuspid rings, were performed. Moderate and severe mitral regurgitation were considered as significant. Two groups were divided according to the median walking distance (290 m): Group 1, <290 m and Group 2, ≥290 m. RESULTS: Mitral regurgitation was detected in 112 patients (75%), which was significant in 40 (27%). Group 1 showed more significant mitral regurgitation (35 vs 18%), increased left atrium area (27±1 vs 24±1cm(2)), mitral E amplitude (88±5 vs 72±3cm/s) and systolic pulmonary pressure (37±1 vs 32±1mmHg, all P<.05). By logistic regression analysis, only the presence of significant mitral regurgitation was independently associated with less walked distance (odds ratio: 3.44 95% confidence interval 1.02-11.66, P<.05). By multiple linear regression, the only independent predictor of walked distance was left atrium area (r=0.25, beta coefficient: -6.52±2, P<.01). CONCLUSIONS: In patients with class II-III heart failure and left ventricular systolic dysfunction, the main echocardiographic predictors of exercise capacity are related to the presence of significant mitral regurgitation.

Utilidad de la resonancia magnética cardíaca en la valoración de los pacientes con dolor torácico, troponinas elevadas y ausencia de obstrucción arterial coronaria / Cardiac Magnetic Resonance Imaging in Patients with Chest Pain, High Troponin Levels and Absence of Coronary Artery Obstruction

El infarto de miocardio con coronarias angiográficamente normales tiene una prevalencia de aproximadamente el 7-10%. Muchas veces, el diagnóstico etiológico es dificultoso, y tiene importancia tanto en la clínica como en el pronóstico. El objetivo de nuestro estudio fue mostrar una serie consecutiva de pacientes con diagnóstico inicial de síndrome coronario agudo con elevación de troponina y ausencia de obstrucción arterial coronaria; en los cuales, la RM cardíaca (RMC) orientó al diagnóstico etiológico mediante la caracterización de la lesión miocárdica. Desde enero de 2005 hasta diciembre de 2009 ingresaron 720 pacientes consecutivos, con diagnóstico inicial de síndrome coronario agudo y troponinas positivas, de los cuales, 64 no presentaron lesiones coronarias angiográficamente significativas. A estos pacientes, luego del cateterismo (dentro de las 72 ± 24 hs) se les practicó RMC, realizándose secuencias de cine (b-SSFP) en eje corto, con 2, 3 y 4 cámaras para valorar la motilidad segmentaria, en secuencias potenciadas en T2 e imágenes de realce tardío del miocardio (RTM) con secuencia "inversión-recuperación". De estos pacientes, 39 fueron diagnosticados de miocarditis; 12 con infartos, 8 con síndrome de Takotsubo, 2 con miocardiopatía hipertrófica apical y solo 3 casos quedaron sin diagnóstico. Estos hallazgos ponen de manifiesto la gran utilidad de la RMC en el escenario clínico de síndromes de dolor precordial, ECG no definitivos y troponinas elevadas con arterias angiográficamente normales. La presencia de RTM y su patrón de distribución permiten definir el diagnóstico etiológico y orientar a la interpretación del proceso fisiopatológico.

The prevalence of myocardial infarction with angiographically normal coronary arteries is approximately 7-10%. The etiological diagnosis is sometimes difficult and is important in terms of clinical practice and prognosis. The goal of our study was to show a series of consecutive patients with an initial diagnosis of acute coronary syndrome with high troponin levels and absence of coronary artery obstruction in which cardiac magnetic resonance imaging (CMRI) gave a description of the myocardial lesion, orientating towards the etiological diagnosis. From January 2005 to December 2009, 720 consecutive patients with an initial diagnosis of acute coronary syndrome and elevated troponins were included; 64 of these patients did not present angiographically significant coronary artery stenosis. Within 72 ± 24 h after coronary angiography, these patients underwent CMRI using b-SSFP sequences for cine imaging in short-axis, 2-, 3- and 4- chamber views for the evaluation of segmental wall motion, with T2-weighted and delayed enhancement (DE) images of the myocardium with an "inversion-recovery" sequence. The following diagnoses were made: myocarditis (39 patients); myocardial infarction (12 patients); Tako-Tsubo syndrome (8 patients); apical hypertrophic cardiomyopathy (2 patients); 3 patients remained without diagnosis. These findings demonstrate the usefulness of CMRI in the clinical scenario of patients with chest pain, inconclusive ECG findings and high troponin levels with angiographically normal coronary arteries. The presence and distribution pattern of DE make it possible to define the etiological diagnosis and interpret the physiopathological process.

Morphologic pattern of late gadolinium enhancement in Takotsubo cardiomyopathy detected by early cardiovascular magnetic resonance.

BACKGROUND: Takotsubo cardiomyopathy (TTC) presents clinically as an acute coronary syndrome. It is characterized by transient left ventricular wall dyskinesis-akinesis, without significant epicardial coronary lesions. Late gadolinium enhancement (LGE) sequences on cardiac magnetic resonance (CMR) allow to clarify the pathophysiology in patients with chest pain, elevated troponin, and normal epicardial coronary arteries; in patients with TTC, previous studies have shown absence of LGE. HYPOTHESIS: Early CMR in Takotsubo patients could show a morphological pattern of LGE improving clinical diagnosis. METHODS: Between January 2005 and January 2007, 8 consecutive patients with TTC criteria underwent CMR within the first 3 days of admission. Cine, T2-weighted, and LGE images were acquired. Patient follow-up included clinical exam and imaging techniques: echocardiogram on days 3, 7, 30, and 60, and CMR at 3 months. RESULTS: Six patients had experienced a previous stressful situation. No significant lesions were found on coronary angiography, and wall motion improvement was noted at 15 (7-30) days. Median EFs at admission and recovery were 46.5% and 65%, respectively. Dyskinesis was midapical in 6 cases, apical in 1 case, and mid-ventricular in 1 case. Late gadolinium enhancement showed mild hyperenhancement in areas of abnormal wall motion, whereas normal segments had no contrast enhancement. On follow-up CMR, wall motion was normal without late enhancement. CONCLUSIONS: Early CMR in TTC demonstrates a special morphological pattern of late gadolinium uptake that might correspond to localized inflammation and edema in the affected area, suggesting diffuse microcirculation damage rather than epicardial vessel involvement.

Pulmonary arterial hypertension: noninvasive detection with phase-contrast MR imaging.

PURPOSE: To retrospectively identify pulmonary arterial (PA) flow parameters measured with phase-contrast magnetic resonance (MR) imaging that allow noninvasive diagnosis of chronic PA hypertension (PAH). MATERIALS AND METHODS: The study was HIPAA compliant and was approved by the institutional review board; a waiver of informed consent was obtained. Fifty-nine patients (49 female patients; mean age, 46 years; range, 16-85 years) known to have or suspected of having PAH underwent breath-hold phase-contrast MR imaging and right-sided heart catheterization (RHC). The presence of PAH (mean pulmonary artery pressure [mPAP], >25 mm Hg) was confirmed in 42 patients. Parameters, including PA areas, PA strain, average velocity, peak velocity, acceleration time, and ejection time, were measured in each patient by investigators blinded to RHC results. These measurements were correlated with mPAP, systolic pulmonary artery pressure (sPAP), and pulmonary vascular resistance index (PVRI). The diagnostic ability of phase-contrast MR imaging to depict PAH was quantified. Statistical tests included Spearman rho coefficients, receiver operating characteristic curve analysis, and Bland-Altman plots. RESULTS: Results showed average velocity to have the best correlation with mPAP, sPAP, and PVRI (r = -0.73, -0.76, and -0.86, respectively; P < .001). Average velocity (cutoff value = 11.7 cm/sec) revealed PAH with a sensitivity of 92.9% (39 of 42) and a specificity of 82.4% (14 of 17). Sensitivity and specificity for the minimum PA area (cutoff value = 6.6 cm(2)) were 92.9% (39 of 42) and 88.2% (15 of 17), respectively. CONCLUSION: The average blood velocity throughout the cardiac cycle is strongly correlated with pulmonary pressures and resistance.

The importance of end-systole for optimal reconstruction protocol of coronary angiography with 16-slice multidetector computed tomography.

OBJECTIVES: Multidetector-row computed tomography coronary images are usually analyzed in mid-diastole (MD). Because of slow coronary motion also in end-systole (ES), we evaluated the impact on image quality of including ES images and defined an efficient reconstruction protocol. MATERIAL AND METHODS: In 50 coronary multidetector-row computed tomography studies, 9 reconstructions (at 10% increments of the RR interval) were graded for image quality. Multiple combinations of reconstructions were compared. RESULTS: MD (60-70% of the RR interval) offered the best image quality. In 44% patients, the best reconstruction for >or=1 coronary was found in ES (20-30%). Their heart rate was higher (68.2+/-9.9 bpm vs. 59.2+/-8.8 bpm, P=0.0014). Combining ES and MD consistently offered superior image quality and less nonevaluable vessels than even larger numbers of diastolic reconstructions alone. A combination of 2-3 reconstructions was most efficient. Adding more reconstructions did not significantly improve results. CONCLUSIONS: Combining ES and MD reconstructions reduces nonevaluable coronary arteries, particularly with higher heart rates. A protocol including 2-3 reconstructions is the most efficient.

Assessment of myocardial ischemia and viability using cardiac magnetic resonance.

Cardiac magnetic resonance (CMR) is a burgeoning area of noninvasive cardiac imaging. Today, its clinical utility spans from the qualitative and quantitative assessment of cardiac function and morphology to the challenging task of determining the severity and reversibility of coronary heart disease. Advances in magnet and coil design, pulse sequence, and contrast media have contributed greatly, helping CMR become the multipurpose tool of today's cardiac imaging. This article reviews and explores some of the most exciting clinical applications of CMR in the assessment of coronary artery disease.