Corazón univentricular sin cirugía de Fontan: el tipo de paliación importa / Univentricular hearts not undergoing Fontan: the type of palliation matters

Introducción y objetivos: La información sobre pacientes con fisiología univentricular (FU) y flujo pulmonar restrictivo no sometidos a cirugía de Fontan es escasa. El objetivo de este estudio es comparar la supervivencia y los eventos cardiovasculares en estos pacientes según el tipo de paliación.MétodosLos datos de pacientes con FU se obtuvieron de las bases de datos de 7 centros con unidades de cardiopatías congénitas del adulto. Se excluyó a los pacientes que completaron la circulación de Fontan o desarrollaron un síndrome de Eisenmenger. Se crearon 3 grupos según la fuente de flujo pulmonar: G1, flujo anterógrado pulmonar restrictivo; G2, shunt cavopulmonar, y G3, shunt aortopulmonar±shunt cavopulmonar. El objetivo principal fue la muerte.ResultadosSe identificó a 120 pacientes. La media de edad en la primera visita fue 32,2 años. El seguimiento medio fue de 7,1 años. Se asignó a 55 pacientes (45,8%) al G1, 30 (25%) al G2 y 35 (29,2%) al G3. Los pacientes del G3 tenían peores función renal, clase funcional y fracción de eyección en la primera visita y mostraron una disminución más marcada de la fracción de eyección durante el seguimiento, especialmente en comparación con el G1. Veinticuatro pacientes (20%) fallecieron, 38 (31,7%) ingresaron por insuficiencia cardiaca y 21 (17,5%) presentaron aleteo/fibrilación auricular durante el seguimiento. Estos eventos fueron más frecuentes en el G3 y al compararlos con los del G1 se encontraron diferencias significativas en muerte (HR=2,9; IC95%, 1,14-7,37; p=0,026) y aleteo/fibrilación auricular (HR=2,9; IC95%, 1,11-7,68; p=0,037).ConclusionesEl tipo de paliación de los pacientes con FU y flujo pulmonar restrictivo no sometidos a cirugía de Fontan identifica distintos perfiles. Los pacientes paliados con derivaciones aortopulmonares presentan un peor pronóstico, con más morbilidad y mortalidad. (AU)

Introduction and objectives: There is scarce information on patients with single ventricle physiology (SVP) and restricted pulmonary flow not undergoing Fontan circulation. This study aimed to compare survival and cardiovascular events in these patients according to the type of palliation.MethodsSVP patient data were obtained from the databases of the adult congenital heart disease units of 7 centers. Patients completing Fontan circulation or developing Eisenmenger syndrome were excluded. Three groups were created according to the source of pulmonary flow: G1 (restrictive pulmonary forward flow), G2 (cavopulmonary shunt), and G3 (aortopulmonary shunts±cavopulmonary shunt). The primary endpoint was death.ResultsWe identified 120 patients. Mean age at the first visit was 32.2 years. Mean follow-up was 7.1 years. Fifty-five patients (45.8%) were assigned to G1, 30 (25%) to G2, and 35 (29.2%) to G3. Patients in G3 had worse renal function, functional class, and ejection fraction at the first visit and a more marked ejection fraction decline during follow-up, especially when compared with G1. Twenty-four patients (20%) died, 38 (31.7%) were admitted for heart failure, and 21 (17.5%) had atrial flutter/fibrillation during follow-up. These events were more frequent in G3 and significant differences were found compared with G1 in terms of death (HR, 2.9; 95%CI, 1.14-7.37; P=.026) and atrial flutter/fibrillation (HR, 2.9; 95%CI, 1.11-7.68; P=.037).ConclusionsThe type of palliation in patients with SVP and restricted pulmonary flow not undergoing Fontan palliation identifies distinct profiles. Patients palliated with aortopulmonary shunts have an overall worse prognosis with higher morbidity and mortality. (AU)

Univentricular hearts not undergoing Fontan: the type of palliation matters.

INTRODUCTION AND OBJECTIVES: There is scarce information on patients with single ventricle physiology (SVP) and restricted pulmonary flow not undergoing Fontan circulation. This study aimed to compare survival and cardiovascular events in these patients according to the type of palliation. METHODS: SVP patient data were obtained from the databases of the adult congenital heart disease units of 7 centers. Patients completing Fontan circulation or developing Eisenmenger syndrome were excluded. Three groups were created according to the source of pulmonary flow: G1 (restrictive pulmonary forward flow), G2 (cavopulmonary shunt), and G3 (aortopulmonary shunts±cavopulmonary shunt). The primary endpoint was death. RESULTS: We identified 120 patients. Mean age at the first visit was 32.2 years. Mean follow-up was 7.1 years. Fifty-five patients (45.8%) were assigned to G1, 30 (25%) to G2, and 35 (29.2%) to G3. Patients in G3 had worse renal function, functional class, and ejection fraction at the first visit and a more marked ejection fraction decline during follow-up, especially when compared with G1. Twenty-four patients (20%) died, 38 (31.7%) were admitted for heart failure, and 21 (17.5%) had atrial flutter/fibrillation during follow-up. These events were more frequent in G3 and significant differences were found compared with G1 in terms of death (HR, 2.9; 95%CI, 1.14-7.37; P=.026) and atrial flutter/fibrillation (HR, 2.9; 95%CI, 1.11-7.68; P=.037). CONCLUSIONS: The type of palliation in patients with SVP and restricted pulmonary flow not undergoing Fontan palliation identifies distinct profiles. Patients palliated with aortopulmonary shunts have an overall worse prognosis with higher morbidity and mortality.

Percutaneous or mini-invasive surgical radiofrequency re-ablation of atrial fibrillation: Impact on atrial function and echocardiographic predictors of short and long-term success.

Objectives: The aim of this study was to compare percutaneous catheter ablation vs. minimally invasive surgical ablation, evaluating the impact of repeated ablation on atrial function, and evaluating predictors of atrial fibrillation (AF) recurrence. Background: When AF ablation fails, re-ablations are required in up to 40% of patients to treat recurrent arrhythmia; surgical ablation is more effective than catheter ablation. Methods: Thirty-two patients with failed prior catheter ablation and referred for a second ablation (18 catheter and 14 surgical) were included in a descriptive observational study. Left atrial volumes, strain, and strain rate were measured with 2D speckle tracking echocardiography at baseline and 6 months after the procedures to assess left atrial functions. Patients received up to 1 year of clinical and Holter follow-up. Results: At the 12-month follow-up, catheter ablation was effective in 56% and surgical ablation in 72% of patients (OR 2 (CI 0.45-8.84), p 0.36). Left atrial booster function was similar in all patients, but left atrial reservoir function was more impaired in those patients who underwent surgical ablation. Left atrial booster function was predictive of arrhythmia recurrence after both catheter and surgical ablation: late diastolic strain rate (LASRa) cut-off ≤ -0.89 s-1 (sensitivity 88%, specificity 70%, AUC 0.82) and ≤ -0.85 s-1 (sensitivity 60%, specificity 100%, AUC 0.82), respectively. Conclusion: Surgical ablation has a more negative impact on LA reservoir function despite being slightly more effective in arrhythmia suppression. LA booster function is not significantly impaired by either procedure. LA booster function predicts arrhythmia elimination after a re-ablation (catheter or surgical).

Long-term Outcomes of Adults With Single Ventricle Physiology Not Undergoing Fontan Repair: A Multicentre Experience.

BACKGROUND: To describe long-term survival and cardiovascular events in adult patients with single ventricle physiology (SVP) without Fontan palliation, focusing on predictors of mortality and comparing groups according to their cardiovascular physiology. METHODS: Multicentre observational and retrospective study including adult patients with SVP without Fontan palliation since their first adult clinic visit. The cohort was subdivided into 3 groups: Eisenmenger, restricted pulmonary flow, and aortopulmonary shunt. Death was considered as the main end point. Other clinical outcomes occurring during follow-up were considered as secondary end points. RESULTS: A total of 146 patients, mean age 32.5 ± 11.1 years, were analysed. Over a mean follow-up of 7.3 ± 4.1 years, 33 patients (22.6%) died. Survival was 86% and 74% at 5 and 10 years, respectively. Right ventricular morphology was not associated with higher mortality. Four variables at baseline were related to a higher mortality: at least moderate atrioventricular valve regurgitation, platelet count < 150 × 103/mm3, GFR < 60 mL/min/1.73 m2, and QRS > 120 ms). A total of 34.2% of patients were admitted to the hospital due to heart failure, and 7.5% received a heart transplant. Other cardiovascular outcomes were also frequent: atrial arrhythmias in 19.2%, stroke in 15.1%, and pacemaker/implantable cardioverter-defibrillator in 6.2%/2.7%. CONCLUSIONS: Adult patients with SVP who had not undergone Fontan exhibit a high mortality rate and frequent major cardiovascular events. At least moderate atrioventricular valve regurgitation, thrombocytopenia, renal dysfunction, and QRS duration > 120 ms at baseline visit allow identification of a cohort of patients at higher risk of mortality.

Non-invasive isthmus identification of complex arrhythmias in congenital heart disease.

Sustained re-entrant tachyarrhythmias treatment has become pivotal in the grown-up congenital heart patients clinical management. Cardiac LGE-MRI tissue characterization integrated with high definition electroanatomic map could allow fast recognition and effective treatment of substrate of tachyarrhythmias. Cardiac LGE-MRI areas were suggestive of post-surgical changes both in atrium and ventricle. High-density electro-anatomical map localized areas of slow conduction identifying conducting isthmuses of re-entrant arrhythmias.

Combined Heart and Liver Transplantation for Uhl's Anomaly: A Case Report.

BACKGROUND: Uhl's anomaly is an extremely rare congenital heart defect characterized by absence of the right ventricle myocardium and preserved left ventricular myocardium. Although the disease has a poor prognosis and is generally fatal in the perinatal period, some patients may reach adulthood. METHODS: We describe a case of Uhl's anomaly complicated with heart failure and decompensated cardiac cirrhosis in a 42-year-old man treated by combined heart-liver transplant. RESULTS: The patient underwent heart transplant using the bicaval technique followed by subsequent liver transplant with the piggyback technique without venovenous bypass. Total ischemia time was 108 minutes for the heart and 360 and 25 minutes of cold and warm ischemia, respectively, for the liver. No intraoperative complications occurred. The patient was discharged without severe complications on postoperative day 22. Pathologic examination of the organs reported advanced cirrhosis of the liver and severe dilated myocardiopathy of right ventricle with absence of myocardium and a normal left ventricle. Twenty-seven months after the transplant the patient has been free from hospital admissions, with normal function of both transplanted organs. CONCLUSIONS: We report the first successful combined heart-liver transplant for Uhl's anomaly indication in an adult patient. Despite of the insufficient knowledge of natural history of this exceptional disease, we successfully apply the management principles of other end-stage right heart disorders complicated with liver failure.

Automated Pattern Recognition in Whole-Cardiac Cycle Echocardiographic Data: Capturing Functional Phenotypes with Machine Learning.

BACKGROUND: Echocardiography provides complex data on cardiac function that can be integrated into patterns of dysfunction related to the severity of cardiac disease. The aim of this study was to demonstrate the feasibility of applying machine learning (ML) to automate the integration of echocardiographic data from the whole cardiac cycle and to automatically recognize patterns in velocity profiles and deformation curves, allowing the identification of functional phenotypes. METHODS: Echocardiography was performed in 189 clinically managed patients with hypertension and 97 healthy individuals without hypertension. Speckle-tracking analysis of the left ventricle and atrium was performed, and deformation curves were extracted. Aortic and mitral blood pool pulsed-wave Doppler and mitral annular tissue pulsed-wave Doppler velocity profiles were obtained. These whole-cardiac cycle deformation and velocity curves were used as ML input. Unsupervised ML was used to create a representation of patients with hypertension in a virtual space in which patients are positioned on the basis of the similarity of their integrated whole-cardiac cycle echocardiography data. Regression methods were used to explore patterns of echocardiographic traces within this virtual ML-derived space, while clustering was used to define phenogroups. RESULTS: The algorithm captured different patterns in tissue and blood-pool velocity and deformation profiles and integrated the findings, yielding phenotypes related to normal cardiac function and others to advanced remodeling associated with pressure overload in hypertension. The addition of individuals without hypertension into the ML-derived space confirmed the interpretation of normal and remodeled phenotypes. CONCLUSIONS: ML-based pattern recognition is feasible from echocardiographic data obtained during the whole cardiac cycle. Automated algorithms can consistently capture patterns in velocity and deformation data and, on the basis of these patterns, group patients into interpretable, clinically comprehensive phenogroups that describe structural and functional remodeling. Automated pattern recognition may potentially aid interpretation of imaging data and diagnostic accuracy.

Distribution of myocardial work in arterial hypertension: insights from non-invasive left ventricular pressure-strain relations.

A index of non-invasive myocardial work (MWI) can account for pressure during the assessment of cardiac function, potentially separating the influence of loading conditions from the influence of the underlying tissue remodelling. The aim is to assess LV function accounted for loading and explore hypertensive MWI distribution by comparing healthy individuals to hypertensive patients without and with localized basal septal hypertrophy (BSH). An echocardiogram was performed in 170 hypertensive patients and 20 healthy individuals. BSH was defined by a basal-to-mid septal wall thickness ratio ≥ 1.4. LV speckle-tracking was performed, and the MWI calculated globally and regionally for the apical, mid and basal regions. An apex-to-base gradient, seen in regional strain values, was preserved in the distribution of myocardial work, with the apical region compensating for the impairment of the basal segments. This functional redistribution was further pronounced in patients with localized BSH. In these patients, segmental MWI analysis revealed underlying impairment of regional work unrelated to acute loading conditions. Non-invasive MWI analysis offers the possibility to compare LV function regardless of blood pressure at the time of observation. Changes in MWI distribution can be seen in hypertension unrelated to the load-dependency of strain. Accentuated functional changes affirm the role of BSH as an echocardiographic marker in hypertension.

Caracterización de la fisiología restrictiva del ventrículo derecho mediante flujo 4D / 4-D flow characterization of right ventricular restrictive physiology

Abstract: Right ventricular restrictive physiology (RVRP) occurs in diverse clinical scenarios, most frequently after repair of Tetralogy of Fallot (TOF). Cardiac magnetic resonance (CMR) can comprehensively evaluate RVRP using 4D flow along with anatomical and fibrosis characterization. Also, RVRP is associated with less pulmonary regurgitation and fewer right ventricle enlargement; its long term protective role is debated. RVRP is a challenging and relevant diagnosis, which hallmark is the presence of antegrade pulmonary arterial Flow in late diastole throughout the respiratory cycle. Also, other hemodynamic findings could aid such us flow in; caval veins, suprahepatic, coronary sinus and tricuspid valve. Obtaining all these flow curves is virtually impossible by echocardiography. CMR with 4DF is a unique and powerful technique enabling this comprehensive hemodynamic evaluation as depicted in this case.

Aortic root remodelling in competitive athletes.

BACKGROUND: Controversy remains about the cut-off limits for detecting aortic dilatation in athletes, particularly in large-sized individuals. The allometric scaling model has been used to obtain size-independent measurements in cardiovascular structures in the general population. AIM: The purpose of this study was to validate the use of allometric scaling in the measurement of the aortic root for competitive athletes and to offer reference values. METHODS: This was a cross-sectional study that analyses the dimensions of aortic root found in the echocardiogram performed as part of pre-participation sports screening in competitive athletes between 2012-2015. Beta exponents were calculated for height and body surface area in the whole cohort. In order to establish whether a common exponent could be used in both genders the following model was assessed y = axb*exp(c*sex). If a common exponent could not be applied then sex-specific beta exponents were calculated. RESULTS: Two thousand and eighty-three athletes (64% men) were included, from a broad spectrum of 44 different sports disciplines, including basketball, volleyball and handball. The mean age was 18.2 ± 5.1 years (range 12-35 years) and all athletes were Caucasian, with a training load of 12.5 ± 5.4 h per week. Indexed aortic root dimension showed a correlation with ratiometric scaling by body surface area (r: -0.419) and generated size independence values with a very light correlation with height (r: -0.084); and with the allometric scaling by body surface area (r: -0.063) and height (r: -0.070). The absolute value of aortic root was higher in men than in women (p < 0.001). These differences were maintained with allometric scaling. CONCLUSION: Size-independent aortic root dimension values are provided using allometric scaling by body surface area and height in a large cohort of competitive athletes. Aortic root values were larger in men than in women, both in absolute values and after allometric scaling. The use of these indexed aortic reference ranges can be useful for the early detection of aortic pathologies.

Prevalence, features and predictive factors of liver nodules in Fontan surgery patients: The VALDIG Fonliver prospective cohort.

BACKGROUND & AIMS: Fontan surgery is used to treat a variety of congenital heart malformations, and may lead to advanced chronic liver disease in the long-term. This study examines the prevalence, characteristics and predictors of liver nodules in patients following Fontan surgery. METHODS: This was a prospective, cross-sectional, observational study conducted at 8 European centres. Consecutive patients who had undergone Fontan surgery underwent blood tests, abdominal ultrasonography (US), transient elastography (Fibroscan®), echocardiography, haemodynamic assessments, and abdominal MRI/CT scan. The primary outcome measure was liver nodules detected in the MRI/CT scan. Predictors of liver nodules were identified by multivariate logistic regression. RESULTS: One hundred and fifty-two patients were enrolled (mean age 27.3 years). The mean time elapsed from surgery to inclusion was 18.3 years. Liver nodule prevalences were 29.6% (95% CI 23-37%) on US and 47.7% (95% CI 39-56%) on MRI/CT. Nodules were usually hyperechoic (76.5%), round-shaped (>80%), hyperenhancing in the arterial phase (92%) and located in the liver periphery (75%). The sensitivity and specificity of US were 50% (95% CI 38-62%) and 85.3% (95% CI 75-92%), respectively. Inter-imaging test agreement was low (adjusted kappa: 0.34). In the multivariate analysis, time since surgery >10 years was the single independent predictor of liver nodules (odds ratio 4.18; p = 0.040). Hepatocellular carcinoma was histologically diagnosed in 2 of the 8 patients with hypervascular liver nodules displaying washout. CONCLUSION: While liver nodules are frequent in Fontan patients, they may go unnoticed in US. Liver nodules are usually hyperechoic, hypervascular and predominantly peripheral. This population is at risk of hepatocellular carcinoma, the diagnosis of which requires confirmatory biopsy. LAY SUMMARY: Fontan surgery is the standard of care for many patients with univentricular congenital cardiopathies. Recent advances have improved the survival of Fontan patients, and nowadays most of them reach adulthood. In this setting, Fontan-associated liver disease (FALD) is increasingly recognised, and has become a significant prognostic factor. Liver nodules are considered a component of FALD yet their prevalence, imaging features and predictors have hardly been evaluated. In this study, we observed that liver nodules are frequent, typically hyperechoic, hypervascular and predominantly peripheral in patients with FALD. This population is at risk of hepatocellular carcinoma, the diagnosis of which must be confirmed by biopsy.

Female Athlete With a Double-Chambered Right Ventricle.

A 35-year-old female athlete presented with recent episodes of pre-syncope on exertion while exercising. An isolated double-chambered right ventricle was diagnosed by transthoracic echocardiography and cardiac magnetic resonance. This defect typically presents during infancy and/or early childhood, is rarely reported in adults, and is usually associated with other congenital defects. (Level of Difficulty: Advanced.).

Improvement of Reverse Remodeling Using Electrocardiogram Fusion-Optimized Intervals in Cardiac Resynchronization Therapy: A Randomized Study.

OBJECTIVES: The aim of this study was to compare patient response to cardiac resynchronization therapy (CRT) using fusion-optimized atrioventricular (AV) and interventricular (VV) intervals versus nominal settings. BACKGROUND: The additional benefit obtained by AV- and VV-interval optimization in patients undergoing CRT remains controversial. Previous studies show short-term benefit in hemodynamic parameters; however, midterm randomized comparison between electrocardiogram optimization and nominal parameters is lacking. METHODS: A group of 180 consecutive patients with left bundle branch block treated with CRT were randomized to fusion-optimized intervals (FOI) or nominal settings. In the FOI group, AV and VV intervals were optimized according to the narrowest QRS, using fusion with intrinsic conduction. Clinical response was defined as an increase >10% in the 6-min walk test or an increment of 1 step in New York Heart Association functional class. The left ventricular (LV) remodeling was defined as >15% decrease in left ventricular end-systolic volume (LVESV) at 12-month follow-up. Additionally, patients with LVESV reduction >30% relative to baseline were considered super-responders; by contrast, negative responders had increased LVESV relative to baseline. RESULTS: Participant characteristics included a mean age of 65 ± 10 years, 68% male, 37% with ischemic cardiomyopathy, LV ejection fraction 26 ± 7%, and QRS 180 ± 22 ms. Baseline QRS was shortened significantly more by FOI, compared with nominal settings (-56.55 ± 17.65 ms vs. -37.81 ± 22.07 ms, respectively; p = 0.025). At 12 months, LV reverse remodeling was achieved in a larger proportion of the FOI group (74% vs. 53% [odds ratio: 2.02 (95% confidence interval: 1.08 to 3.76)], respectively; p = 0.026). No significant differences were observed in clinical response (61% vs. 53% [odds ratio: 1.43 (95% confidence interval: 0.79 to 2.59)], respectively; p = 0.24). CONCLUSIONS: Device optimization based on FOI achieves greater LV remodeling, compared with nominal settings. (ECG Optimization of CRT: Evaluation of Mid-Term Response [BEST]; NCT01439529).

Prevention of sudden death in adolescent athletes: Incremental diagnostic value and cost-effectiveness of diagnostic tests.

Introduction Pre-participation screening in athletes attempts to reduce the incidence of sudden death during sports by identifying susceptible individuals. The objective of this study was to evaluate the diagnostic capacity of the different pre-participation screening points in adolescent athletes and the cost effectiveness of the programme. Methods Athletes were studied between 12-18 years old. Pre-participation screening included the American Heart Association questionnaire, electrocardiogram, echocardiogram, and stress test. The cost of test was established by the Catalan public health system. Results Of 1650 athletes included, 57% were men and mean age was 15.09 ± 1.82 years. Positive findings were identified as follows: in American Heart Association questionnaire 5.09% of subjects, in electrocardiogram 3.78%, in echocardiogram 4.96%, and in exercise test 1.75%. Six athletes (0.36%) were disqualified from participation and 10 (0.60%) were referred for interventional treatment. Diagnostic capacity was assessed by the area under the curve for detection of diseases that motivated disqualification for sport practice (American Heart Association questionnaire, 0.55; electrocardiogram, 0.72; echocardiogram, 0.88; stress test, 0.57). The cost for each athlete disqualified from the sport for a disease causing sudden death was €45,578. Conclusion The electrocardiogram and echocardiogram were the most useful studies to detect athletes susceptible to sudden death, and the stress test best diagnosed arrhythmias with specific treatment. In our country, pre-participatory screening was cost effective to detect athletes who might experience sudden death in sports.

Gender influence on the adaptation of atrial performance to training.

BACKGROUND: High-intensity training has been associated with atrial remodelling and arrhythmias in men. Our purpose was to analyse atrial performance in female endurance athletes, compared to male athletes and controls. METHODS: This was a cross-sectional study. We included four groups: female athletes, females controls, male athletes and male controls. Left (LA) and right atrial (RA) volumes and function were assessed using 2D and speckle-tracking echocardiography to determine peak atrial strain-rate at atrial (SRa) and ventricular contraction (SRs), as surrogates of atrial contractile and reservoir function, respectively. ANOVA and Bonferroni's statistical tests were used to compare variables among groups. RESULTS: We included 82 subjects, 39 women (19 endurance athletes, 20 controls) and 43 men (22 endurance athletes, 21 controls). Mean age was similar between groups (36.6 ± 5.6 years). Athletes had larger bi-atrial volumes, compared to controls (women, LA 27.1 vs. 15.8 ml/m2, p < 0.001; RA 22.31 vs. 14.2 ml/m2, p = 0.009; men, LA: 25.0 vs. 18.5 ml/m2, p = 0.003; RA 30.8 vs. 21.9 ml/m2, p < 0.001) and lower strain-rate (women, LASRa -1.60 vs. -2.18 s-1, p < 0.001; RASRa -1.89 vs. -2.38 s-1, p = 0.009; men, LASRa -1.21 vs. -1.44 s-1, p = 1; RASRa -1.44 vs. -1.60 s-1, p = 1). However, RA indexed size was lower and bi-atrial deformation greater in female athletes, compared to male athletes. CONCLUSIONS: The atria of both male and female athletes shows specific remodelling, compared to sedentary subjects, with larger size and less deformation at rest, particularly for the RA. Despite a similar extent of remodelling, the pattern in women had greater bi-atrial myocardial deformation and smaller RA size.

Contraindicaciones cardiológicas para la práctica deportiva / Cardiological contraindications in sports

La muerte súbita en el deporte está causada en la mayoría de ocasiones por enfermedades cardiacas. El objetivo del cribado pre-participativo es poder identificar a los individuos que requieran un tratamiento específico para continuar el deporte o el cese de la práctica deportiva. La evidencia científica actual se basa en recomendaciones de expertos que en algunos casos son controvertidas y en ocasiones poco prácticas. Esta revisión tiene como objetivo dar un enfoque actualizado y pragmático de las recomendaciones en los deportistas con cardiopatía

In most cases, sudden death in sports is caused by heart disease. The aim of preparticipation screening is to identify individuals who require specific treatment to continue the sport or stop practicing it. Current scientific evidence is based on expert recommendations that in some cases are controversial and sometimes impractical. This review aims to present an updated and pragmatic approach to the recommendations in athletes with heart disease

Characterizing the spectrum of right ventricular remodelling in response to chronic training.

The significance and spectrum of reduced right ventricular (RV) deformation, reported in endurance athletes, is unclear. To comprehensively analyze the cardiac performance at rest of athletes, especially focusing on integrating RV size and deformation to unravel the underlying triggers of this ventricular remodelling. Hundred professional male athletes and 50 sedentary healthy males of similar age were prospectively studied. Conventional echocardiographic parameters of all four chambers were obtained, as well as 2D echo-derived strain (2DSE) in the left (LV) and in the RV free wall with separate additional analysis of the RV basal and apical segments. Left and right-sided dimensions were larger in athletes than in controls, but with a disproportionate RA enlargement. RV global strain was lower in sportsmen (-26.8 ± 2.8% vs -28.5 ± 3.4%, p < 0.001) due to a decrease in the basal segment (-22.8 ± 3.5% vs -25.8 ± 4.0%, p < 0.001) resulting in a marked gradient of deformation from the RV inlet towards the apex. By integrating size, deformation and stroke volume, we observed that the LV working conditions were similar in all sportsmen while a wider variability existed in the RV. Cardiac remodelling in athletes is more pronounced in the right heart cavities with specific regional differences within the right ventricle, but with a wide variability among individuals. The large inter-individual differences, as well as its acute and chronic relevance warrant further investigation.

Prognostic Value of Left Atrial Strain in Outpatients with De Novo Heart Failure.

BACKGROUND: Left atrial (LA) dysfunction has been related to symptom onset in patients with heart failure (HF). However, the potential prognostic role of LA function has been scarcely studied in outpatients with new-onset HF symptoms. METHODS: Consecutive outpatients with suspected HF onset evaluated at a one-stop clinic were screened. HF diagnosis was performed according to current guidelines. LA function was analyzed in patients in sinus rhythm by speckle-tracking echocardiography, determining LA peak strain rate after atrial contraction (LASRa) as a surrogate of atrial contractile function. Yearly prospective follow-up was conducted to report cardiovascular hospital admission or death. Patients without HF in sinus rhythm were followed as a control group. Survival curves were estimated using the Kaplan-Meier method. RESULTS: One hundred fifty-four outpatients were included (mean age, 74 ± 10 years; 67% women) with a median follow-up duration of 44.4 months (interquartile range, 31-58 months). Final diagnosis was 29.9% non-HF and 70.1% HF. More than two in five patients with HF (44.4%) had AF (n = 48), and 55.6% (n = 60) were in sinus rhythm. The latter were divided according to LASRa tertile: highest, -1.93 ± 0.39 sec-1; middle, -1.08 ± 0.21 sec-1; and lowest, -0.47 ± 0.18 sec-1. At the end of follow-up, patients with atrial fibrillation had a low event-free survival rate (56.3%), similar to those in the lower LASRa tertile (55.0%). The non-HF group had the best prognosis, and the higher and middle LASRa tertiles had intermediate prognoses (event-free survival, 85%, 75%, and 70%, respectively). CONCLUSIONS: The study of contractile LA function in outpatients with new-onset HF provides prognostic stratification. The early identification of patients at higher risk on the basis of their atrial function would allow focusing on them independently of their final diagnoses.

La función de la aurícula izquierda está alterada en algunos pacientes con ictus criptogénico: potenciales implicaciones en su evaluación y tratamiento / Left atrial function is impaired in some patients with stroke of undetermined etiology: potential implications for evaluation and therapy

Introducción y objetivos: El 30% de los casos de ictus sigue siendo de etiología desconocida (criptogénicos). En un 20-28% de los pacientes con ictus inicialmente clasificados como criptogénicos, se detecta posteriormente fibrilación auricular paroxística. El objetivo de este estudio es analizar la función auricular izquierda de pacientes con ictus isquémico para identificar patrones asociados a la etiología cardioembólica y determinar si se puede observar tales patrones en individuos clasificados inicialmente como ictus criptogénicos. Métodos: Se incluyó una cohorte de pacientes hospitalizados por ictus isquémico remitidos a ecocardiografía transtorácica. Los neurólogos al cargo determinaron la etiología del ictus según la clasificación TOAST. Se evaluó la función contráctil de la aurícula izquierda utilizando ecocardiografía bidimensional para determinar su fracción de eyección, y mediante técnicas de deformación miocárdica (speckle tracking o rastreo de marcas) se determinó la onda a del strain rate (tasa de deformación). Se comparó la función de la aurícula izquierda entre los subgrupos etiológicos del ictus así como con un grupo de control de individuos sanos. Resultados: Se incluyó a 97 pacientes (de 67 ± 15 años) con ictus isquémico (el 16,5% aterotrombóticos, el 15,5% lacunares, el 11,3% cardioembólicos, el 5,1% de otra etiología determinada y el 51,1% criptogénicos) y 10 voluntarios sanos (de 63 ± 7 años). Se observó una disminución significativa de la fracción de eyección de la aurícula izquierda solo en los pacientes con ictus cardioembólico y criptogénico respecto al grupo de control (31,5 ± 17,2%, 40,2 ± 17,1% y 59,1 ± 8,4% respectivamente; p = 0,004). El strain-rate de la aurícula izquierda fue significativamente inferior en los pacientes con ictus cardioembólicos, criptogénicos o aterotrombóticos en comparación con el grupo control (-0,86 ± 0,49, -1,31 ± 0,56, -1,5 ± 0,47 y -2,37 ± 1,18 respectivamente; p < 0,001). Conclusiones: Los pacientes con ictus criptogénico que presentan una función auricular izquierda (fracción de eyección y strain) similar a la de los pacientes con ictus cardioembólico podrían estar clasificados de forma incorrecta, por lo que en ellos sería útil una monitorización electrocardiográfica prolongada. El análisis de la función auricular izquierda (fracción de eyección y strain) podría ser útil para identificar a los pacientes con ictus cardioembólico inicialmente mal clasificados como criptogénicos (AU)

Introduction and objectives: Stroke etiology remains undetermined in up to 30% of cases. Paroxysmal atrial fibrillation is found in 20% to 28% of patients with stroke initially classified as being of undetermined etiology. The aim of our study was to analyze left atrial function in ischemic stroke patients to identify patterns associated with cardioembolic etiology and to determine whether the patterns identified can be found in individuals initially classified as having a stroke of undetermined etiology. Methods: We studied a cohort of in-hospital ischemic stroke patients referred for transthoracic echocardiography. Treating neurologists determined stroke etiology based on the TOAST classification. Left atrial contractile function was assessed using 2-dimensional echocardiography to determine their ejection fraction and speckle tracking to measure left atrial strain rate: a-wave. Left atrial function was compared between stroke etiology subgroups and healthy controls. Results: Ninety-seven patients (aged 67 ± 15 years) with ischemic stroke (16.5% large-artery atherosclerosis, 15.5% small-vessel occlusion, 11.3% cardioembolic, 5.1% other determined etiology, 51.1% undetermined etiology) and 10 healthy volunteers (aged 63 ± 7 years) were included. Left atrial ejection fraction was significantly decreased only in patients with stroke of cardioembolic and undetermined etiology compared with the control group (31.5 ± 17.2%, 40.2 ± 17.1%, and 59.1 ± 8.4%, respectively; P = .004). The left atrial strain rate was significantly lower in patients with stroke caused by cardioembolic or undetermined etiology, or large-artery atherosclerosis compared with controls (−0.86 ± 0.49, −1.31 ± 0.56, −1.5 ± 0.47, −2.37 ± 1.18, respectively; P < .001). Conclusions: Patients with stroke of undetermined etiology with left atrial function (ejection fraction and strain) similar to that of cardioembolic stroke patients may be misclassified and could potentially benefit from prolonged electrocardiography monitoring. Left atrial function analysis (ejection fraction and strain) might help to identify potential cardioembolic sources in patients with stroke of undetermined etiology (AU)