Valvulopatía mitral y tricuspídea: diagnóstico y tratamiento. Posicionamiento conjunto de la Sección de Valvulopatías y las Asociaciones de Imagen, Cardiología Clínica y Cardiología Intervencionista de la SEC / Mitral and tricuspid valve disease: diagnosis and management. Consensus document of the Section on Valvular Heart Disease and the Cardiovascular Imaging, Clinical Cardiology, and Interventional Cardiology Associations of the Spanish Society of Cardiology

El diagnóstico y el tratamiento de la valvulopatía mitral y tricuspídea han sufrido unos cambios extraordinarios en los últimos años. La irrupción de las intervenciones percutáneas y la generalización de las nuevas técnicas de imagen han modificado las recomendaciones para el diagnóstico y el tratamiento de estas afecciones. La ingente cantidad de publicaciones y estudios en este campo obliga a una continua actualización de nuestros protocolos. La publicación de la guía de la Sociedad Europea de Cardiología de 2021 sobre el tratamiento de las valvulopatías no cubre algunos aspectos novedosos de estos tratamientos y, además, el número de intervenciones realizadas en los países de nuestro entorno es muy variable, lo que exige una adecuación de las recomendaciones al contexto local. Además, es indispensable un resumen de toda esta información para que se pueda generalizar su uso. Por estos motivos, se considera necesario el posicionamiento común de la Asociación de Cardiología Intervencionista, la Asociación de Imagen Cardiaca, la Asociación de Cardiología Clínica y la Sección de Valvulopatías y Patología Aórtica de la Sociedad Española de Cardiología para el diagnóstico y el tratamiento de la valvulopatía mitral y tricuspídea (AU)

The diagnosis and management of mitral and tricuspid valve disease have undergone major changes in the last few years. The expansion of transcatheter interventions and widespread use of new imaging techniques have altered the recommendations for the diagnosis and treatment of these diseases. Because of the exponential growth in the number of publications and clinical trials in this field, there is a strong need for continuous updating of local protocols. The recently published 2021 European Society of Cardiology guidelines for the management of valvular heart disease did not include some of the new data on these new therapies and, moreover, the number of mitral and tricuspid interventions varies widely across Europe. Therefore, all this information must be summarized to facilitate its use in each specific country. Consequently, we present the consensus document of the Section on Valvular Disease, Cardiovascular Imaging, Clinical Cardiology, and Interventional Cardiology Associations of the Spanish Society of Cardiology for the diagnosis and management of mitral and tricuspid valve disease (AU)

International experts' practice in the antibiotic therapy of infective endocarditis is not following the guidelines.

OBJECTIVE: The management of infective endocarditis (IE) may differ from international guidelines, even in reference centres. This is probably because most recommendations are not based on hard evidence, so the consensus obtained for the guidelines does not represent actual practices. For this reason, we aimed to evaluate this question in the particular field of antibiotic therapy. METHODS: Thirteen international centres specialized in the management of IE were selected, according to their reputation, clinical results, original research publications and quotations. They were asked to detail their actual practice in terms of IE antibiotic treatment in various bacteriological and clinical situations. They were also asked to declare their IE-related in-hospital mortality for the year 2015. RESULTS: The global compliance with guidelines concerning antibiotic therapy was 58%, revealing the differences between theoretical 'consensus', local recommendations and actual practice. Some conflicts of interest were also probably expressed. The adherence to guidelines was 100% when the protocol was simple, and decreased with the seriousness of the situation (Staphylococus spp. 54%-62%) or in blood-culture-negative endocarditis (0%-15%) that requires adaptation to clinical and epidemiological data. CONCLUSION: Worldwide experts in IE management, although the majority of them were involved and co-signed the guidelines, do not follow international consensus guidelines on the particular point of the use of antibiotics.

Endocarditis infecciosa detectada mediante PET-TC con 18F-FDG en un paciente con bacteriemia por gram positivo de origen desconocido / Infective endocarditis detected by 18F-FDG PET-CT in a patient with gram-positive bacteraemia of unknown origin

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Diagnosis of infection in a patient with implantable device with 18F-FDG PET-CT / Diagnóstico de infección en un paciente con dispositivo implantable con 18F-FDG PET-TC

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Acute aortic syndrome: a new look at an old conundrum.

The term acute aortic syndrome (AAS), coined several years ago, is now widely recognised. In the light of new findings in aortic pathology and in an era when modern imaging techniques are widely available and interventional management of AAS is increasing, some morphological and diagnostic aspects of acute aortic pathology have been examined and the syndrome updated. This article provides a new, comprehensive overview of the pathology, diagnosis, evolution and management of patients with AAS. As acute aortic disease is the most common fatal condition in patients with chest pain, prompt recognition and treatment is of paramount importance.

Acute aortic syndrome: a new look at an old conundrum.

The term acute aortic syndrome (AAS), coined several years ago, is now widely recognised. In the light of new findings in aortic pathology and in an era when modern imaging techniques are widely available and interventional management of AAS is increasing, some morphological and diagnostic aspects of acute aortic pathology have been examined and the syndrome updated. This article provides a new, comprehensive overview of the pathology, diagnosis, evolution and management of patients with AAS. As acute aortic disease is the most common fatal condition in patients with chest pain, prompt recognition and treatment is of paramount importance.

Taquicardia ventricular en paciente joven / Ventricular tachycardia in a young patient

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Aspectos morfológicos de la disección aórtica / Morphological aspects of aortic dissections

Introducción. La disección aórtica clásica forma parte del síndrome aórtico agudo. En esta revisión se exponen los aspectos anatómicos más relevantes de los pacientes con disección aórtica clásica. Desarrollo. Esta enfermedad se caracteriza desde el punto de vista morfológico por tres hechos importantes: la presencia de una puerta de entrada, una aorta con luz doble y un colgajo intimomedial que separa las dos luces. En muchos pacientes también se puede observar una puerta de reentrada y algunos puntos de comunicación entre las dos luces. Ponemos énfasis en el trayecto habitual que sigue la progresión del hematoma disecante y sus posibilidades evolutivas. Se señalan las marcas diacríticas que distinguen las luces verdadera y falsa y se enumeran la mayoría de las complicaciones que pueden tener lugar en estos pacientes, sobre todo, la rotura de la pared externa de la luz falsa, la regurgitación aórtica que acompaña a algunos pacientes con disección tipo A y la afectación de las ramas aórticas. Conclusión. El conocimiento de los distintos aspectos morfológicos y evolutivos de la disección aórtica ayuda a comprender y valorar mejor los resultados de la utilización de las técnicas no invasivas en estos pacientes, lo cual va a suponer una mejora tanto en el diagnóstico como en el tratamiento

Introduction. Classical aortic dissection is included as a part of acute aortic syndrome. In this review we describe the most significant anatomical aspects of patients with classical aortic dissection. Development. From the morphological point of view this disease is characterised by three important facts, namely, the presence of a port of entry, an aorta with double lumen and an intimal-medial flap that separates the two lumina. A port of re-entry and a number of points communicating the two lumina can also be observed in many patients. We focus on the trajectory usually followed by the progression of dissecting haematomas and the possible ways they can develop. The diacritic marks that distinguish true and false lumina are specified, and most of the complications that can occur in these patients are also listed, the most important being rupture of the external wall of the false lumen, the aortic regurgitation suffered by some patients with type A dissection, and involvement of the aortic branches. Conclusions. A more comprehensive knowledge of the different morphological and developmental aspects of aortic dissections can help to better understand and appraise the results of using non-invasive techniques in these patients, which will lead to improvements in both their diagnosis and their treatment

Biphasic response to dobutamine predicts improvement of left ventricular dysfunction after revascularization: correlation with positron emission and rest-redistribution 201Tl tomographies.

BACKGROUND: Dobutamine echocardiography (DSE), positron emission tomography (PET) and 201Tl-single photon emission computed tomography (SPECT) have been used to identify myocardial viability. There are few reports, however, that compare high doses DSE with myocardial metabolic and perfusion imaging techniques in the same patient population. The aim of this study was to determine the correlation between high doses DSE, metabolic PET and 201Tl-SPECT imaging to predict the recovery of function after revascularization in patients with severe left ventricular (LV) dysfunction. METHODS: Twenty-five patients underwent DSE (up to 40 microg/kg/min), rest and 4-hour redistribution 201Tl SPECT, rest 13N-ammonia and 18fluoro-deoxy-glucose PET imaging and coronary angiography 7-10 days before surgical revascularization. A follow-up 2D-echocardiography was performed 6 weeks after surgery. RESULTS: Of the 109 successfully revascularized segments with severe dysfunction, 62 (57%) improved. LV ejection fraction increased from 30 +/- 10% to 42 +/- 13 at follow-up (p < 0.05). 201Tl SPECT, PET and the presence of contractile reserve determined by DSE had a similar sensitivity (77-87%) to predict recovery of function, but specificity was higher for the PET mismatch pattern and biphasic DSE (85-89%) than for any of the 201Tl viability patterns (19-64%). The highest positive predictive values were obtained by biphasic DSE and PET mismatch pattern (78-79%) compared to all other criteria (54-67%). In a multivariate model, which included evidence of viability by all imaging modalities, biphasic response was the best predictor of regional recovery of function (Odds ratio, OR: 9.9, 95% confidence intervals, 95% CI: 3.5-27.8). CONCLUSIONS: Although DSE and PET had overall comparable results, the presence of contractile reserve by the biphasic response to dobutamine was a best predictor for the improvement of LV contractile function in this group of patients.

Eustachian valve endocarditis: Is it worth searching for?

BACKGROUND: Only a few cases of eustachian valve endocarditis have been reported. Whether the eustachian valve is an uncommon site for a vegetation to be attached or whether the disease is missed because a systematic approach to this valve is not routinely performed in the search for vegetations is not known. METHODS: Every patient suspected of having endocarditis undergoes a specific approach, which includes a systematic study of the eustachian valve. In 10 patients with large valves but without signs and symptoms of endocarditis, we identified 2 specific findings: width <3 mm and a regular oscillating movement. A blinded evaluation in the 10 control subjects and 30 patients with right-sided endocarditis, including the 5 with eustachian valve endocarditis, showed an agreement of 97% (39/40). RESULTS: Five of 152 patients with right-sided endocarditis were found to have eustachian valve vegetations (3.3%). Patients were young (age range 22-34 years) and all had predisposing factors (3 intravenous drug abusers, 2 central venous lines), fever, and septic pulmonary embolism. Staphylococcus aureus was cultured in all cases. Tricuspid involvement was found in 4 patients, and only 1 patient had isolated eustachian valve endocarditis. All patients did well with culture-guided antibiotics. CONCLUSIONS: Our results suggest that eustachian valve endocarditis may be more frequent than is believed. Thus a systematic interrogation of the eustachian valve should be included in the echocardiographic examination of a patient suspected of having endocarditis.

[Thallium-201 scintigraphy and dobutamine echocardiography in the assessment of myocardial viability]. / Gammagrafía con talio-201 y ecocardiografía con dobutamina en la valoración de viabilidad miocárdica.

BACKGROUND: The possibility of differentiating viable from non-viable tissue among patients with severe coronary artery disease and severe left ventricular impairment entails relevant clinical and therapeutic implications since it may influence the indication of patient revascularization. To evaluate the presence of myocardial viability two techniques are available in the clinical setting: echocardiography with intravenous infusion of dobutamine and scintigraphy with myocardial perfusion with thalliem-201 by means of single-photon emission tomography. OBJECTIVE: To compare prospectively the value of these techniques for detecting viable myocardium. MATERIAL AND METHODS: Thirty-five patients with severe coronary disease and severe left ventricular dysfunction were included in the study. All patients underwent an echocardiogram using incremental doses of dobutamine, from 5 up to 40 micrograms/kg/min in three-minute periods. For thallium-201 scintigraphy the rest redistribution protocol with delayed images at 4 hours was used. The criteria for detecting viability were: a) for thallium-201, the presence of redistribution in delayed images and normal uptake at rest, and b) for dobutamine echocardiography, a sustained improvement in regional motion, biphasic response, and worsening. RESULTS: By considering the segmental improvement post-revascularization as "gold standard" of viability, the statistically significant variables in a logistic regression model and, therefore, predictors of segmental functional recovery were the biphasic response and the sustained response for dobutamine echocardiography and normal uptake at rest and redistribution in the delayed images for thallium-201. Taken together, the result was significant for the biphasic response of dobutamine echocardiography. CONCLUSIONS: The biphasic response with dobutamine echocardiography is the echocardiographic pattern that best predicts the functional recovery of the ischemic myocardium. A normal uptake and redistribution at four hours is the only scintigraphic pattern that can predict functional improvement. Of both patterns, the biphasic response is the best predictor of the functional recovery of the dysfunctional myocardium.

[Isolated ventricular diverticulum in asymptomatic male]. / Divertículo ventricular aislado en varón asintomático.

Ventricular diverticulum are small outpouchings, in the cardiac wall, which are mostly described as a part of malformation syndromes. This finding is infrequent in asymptomatic patients with no pathology in the thoraco abdominal line. The case we present shows a diverticulum in the cardiac apex in a male patient with no cardiological clinic manifestations and with an abnormal electrocardiogram. At present, magnetic resonance is the best diagnostic test, for this kind of malformation, and is also the most reliable in the follow-up of these patients.

Atherosclerotic aortic rupture: documentation by transesophageal echocardiography.

We report a case of a 77-year-old woman who had a rupture of the descending thoracic aorta as a complication of an atherosclerotic aortic plaque. Transesophageal echocardiography enabled the diagnosis of aortic rupture and was very useful in the patient's surgical management.