RESUMEN
Valvular heart disease is a growing public health problem, with an increasing prevalence due to an ageing population. Despite advances, the medical management of symptomatic valvular heart diseases remains suboptimal, necessitating surgical correction. The challenge remains in identifying an asymptomatic or mildly symptomatic patient who will benefit from timely surgery before irreversible changes in cardiac function have occurred. The potential risks of surgery versus watchful expectancy require careful decision-making. This review is a focused update on the existing guidelines and identifies the knowledge gaps and avenues of future research in the management of patients with valvular heart diseases.
RESUMEN
Randomised trials involving large number of patients have demonstrated the benefits of cardiac resynchronisation therapy (CRT) in patients with heart failure who have failed optimal medical treatment. Echocardiography plays an important role in defining dyssynchrony which is key to optimal patient selection. The electrocardiographic criteria for patient selection is supplemented by the finding of dyssynchrony on Doppler myocardial imaging, and echocardiography with Doppler myocardial imaging may eventually replace the electrocardiographic criteria for selection of patients who derive benefit from CRT.
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Estimulación Cardíaca Artificial/métodos , Insuficiencia Cardíaca/terapia , Arritmias Cardíacas/etiología , Arritmias Cardíacas/terapia , Procedimientos Quirúrgicos Cardíacos/métodos , Respiración de Cheyne-Stokes/etiología , Humanos , Insuficiencia de la Válvula Mitral/etiología , Insuficiencia de la Válvula Mitral/terapia , Ensayos Clínicos Controlados Aleatorios como Asunto , Apnea Central del Sueño/etiología , Disfunción Ventricular Izquierda/terapiaAsunto(s)
Enfermedad Coronaria/terapia , Recolección de Datos/estadística & datos numéricos , Infarto del Miocardio/terapia , Evaluación de Procesos y Resultados en Atención de Salud/estadística & datos numéricos , Sociedades Médicas , Causas de Muerte , Ensayos Clínicos como Asunto/estadística & datos numéricos , Enfermedad Coronaria/mortalidad , Estudios de Evaluación como Asunto , Humanos , Infarto del Miocardio/mortalidad , Ajuste de Riesgo , Tasa de Supervivencia , Estados UnidosRESUMEN
PURPOSE: To determine the incidence of thromboembolic complications after cardioversion in patients with atrial flutter. SUBJECTS AND METHODS: We reviewed 615 electrical cardioversions performed electively in 493 patients with atrial flutter. Embolic complications were evaluated during the 30 days after cardioversion. Follow-up data were obtained by follow-up visits and by contacting the treating physician. RESULTS: Anticoagulants had been administered in 415 cardioversions (67%). Cardioversion was successful in 570 procedures (93%). Three embolic events (in 3 patients) occurred in the 30 days after 550 successful cardioversions with completed follow-up (0.6% of successful procedures; 95% confidence interval, 0.1% to 1.6%). Two of the 3 patients had not been anticoagulated, whereas the third patient had subtherapeutic oral anticoagulation. No embolic event occurred in procedures performed with adequate anticoagulation. The incidence of embolism in patients regardless of subtherapeutic anticoagulation was 1% (3 of 303 successful cardioversions). CONCLUSIONS: We observed a low (0.6%) incidence of postcardioversion thromboembolic complications in patients with atrial flutter. Embolic events did not occur in patients with adequate anticoagulation.
Asunto(s)
Aleteo Atrial/terapia , Cardioversión Eléctrica/efectos adversos , Tromboembolia/etiología , Tromboembolia/fisiopatología , Administración Oral , Anciano , Anciano de 80 o más Años , Anticoagulantes/administración & dosificación , Anticoagulantes/uso terapéutico , Aleteo Atrial/diagnóstico por imagen , Aleteo Atrial/fisiopatología , Femenino , Estudios de Seguimiento , Heparina/uso terapéutico , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Estudios Retrospectivos , Factores de Riesgo , Tromboembolia/diagnóstico por imagen , UltrasonografíaRESUMEN
OBJECTIVES: The aim of this study was to examine the association between atherosclerosis risk factors, aortic atherosclerosis and aortic valve abnormalities in the general population. BACKGROUND: Clinical and experimental studies suggest that aortic valve sclerosis (AVS) is a manifestation of the atherosclerotic process. METHODS: Three hundred eighty-one subjects, a sample of the Olmsted County (Minnesota) population, were examined by transthoracic and transesophageal echocardiography. The presence of AVS (thickened valve leaflets), elevated transaortic flow velocities and aortic regurgitation (AR) was determined. The associations between atherosclerosis risk factors, aortic atherosclerosis (imaged by transesophageal echocardiography) and aortic valve abnormalities were examined. RESULTS: Age, male gender, body mass index (odds ratio [OR]: 1.07 per kg/m(2); 95% confidence interval [CI]: 1.02 to 1.12), antihypertensive treatment (OR: 1.93; CI: 1.12 to 3.32) and plasma homocysteine levels (OR: 1.89 per twofold increase; CI: 0.99 to 3.61) were independently associated with an increased risk of AVS. Age, body mass index and pulse pressure (OR: 1.21 per 10 mm Hg; CI: 1.00 to 1.46) were associated with elevated (upper quintile) transaortic velocities, whereas only age was independently associated with AR. Sinotubular junction sclerosis (p = 0.001) and atherosclerosis of the ascending aorta (p = 0.03) were independently associated with AVS and elevated transaortic velocities, respectively. CONCLUSIONS: Atherosclerosis risk factors and proximal aortic atherosclerosis are independently associated with aortic valve abnormalities in the general population. These observations suggest that AVS is an atherosclerosis-like process involving the aortic valve.
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Enfermedades de la Aorta/patología , Válvula Aórtica/patología , Arteriosclerosis/patología , Cardiomiopatías/patología , Factores de Edad , Anciano , Anciano de 80 o más Años , Enfermedades de la Aorta/epidemiología , Arteriosclerosis/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores de RiesgoAsunto(s)
Isquemia Encefálica/diagnóstico por imagen , Ecocardiografía Transesofágica , Defectos del Tabique Interatrial/diagnóstico por imagen , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/etiología , Estudios de Casos y Controles , Femenino , Defectos del Tabique Interatrial/etiología , Humanos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Estudios Prospectivos , Factores de RiesgoRESUMEN
OBJECTIVE: To assess thromboembolic complications in cardioversions in patients with atrial fibrillation or flutter and a previous embolic event. PATIENTS AND METHODS: The study population consisted of 104 patients with previous embolic events who underwent 128 electrical cardioversions for termination of atrial fibrillation or flutter. The primary outcome measure was successful cardioversion. RESULTS: Anticoagulants were administered in 118 procedures (92%). Cardioversion was successful in 108 (84%) of the 128 procedures. Only 1 embolic event occurred within 30 days after cardioversion (incidence, 0.9% of successful procedures; 95 % confidence interval, 0.02%-5.3%). The single embolic event was a transient neurologic deficit occurring 22 days after cardioversion in a patient with previous atrial fibrillation. This patient had a sub-therapeutic level of anticoagulation. Transesophageal echocardiography revealed no spontaneous echo contrast or thrombi before the procedure. No thromboembolism was noted in patients who had therapeutic anticoagulation or in those with failed cardioversion. CONCLUSION: Patients with previous embolism are not at additional risk of thromboembolic complications after cardioversion if anticoagulation is adequate.
Asunto(s)
Fibrilación Atrial/terapia , Aleteo Atrial/terapia , Cardioversión Eléctrica/efectos adversos , Cardioversión Eléctrica/métodos , Tromboembolia/diagnóstico , Anciano , Anticoagulantes/administración & dosificación , Fibrilación Atrial/complicaciones , Fibrilación Atrial/diagnóstico por imagen , Fibrilación Atrial/mortalidad , Aleteo Atrial/complicaciones , Aleteo Atrial/diagnóstico por imagen , Aleteo Atrial/mortalidad , Intervalos de Confianza , Ecocardiografía Transesofágica , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Recurrencia , Medición de Riesgo , Sensibilidad y Especificidad , Tasa de Supervivencia , Tromboembolia/complicaciones , Tromboembolia/epidemiología , Resultado del TratamientoRESUMEN
Erectile dysfunction (ED) occurs in varying degrees in an estimated 20 to 30 million American men and is associated with adverse effects on quality of life; particularly personal well-being, family and social interrelationships. Research into ED has focused primarily on the physiologic mechanisms of corpus cavernosum smooth muscle relaxation, and penile erection as the end result of smooth muscle relaxation. These processes are mediated by cholinergic, nonadrenergic, noncholinergic (NANC, e.g., nitric oxide), vasoactive intestinal peptide (VIP), and potentially calcitonin gene-related peptide (CGRP) containing nerves. Release of nitric oxide following sexual stimulation from non-adrenergic, non cholinergic nerves and vascular endothelium activates guanylyl cyclase and induces intracellular cGMP synthesis. In turn, cGMP results in lowering intracellular concentrations, inhibits contractility of the penile smooth muscle, and induces an erectile response. Phosphodiesterase type 5 (PDE 5) is the predominant enzyme responsible for cGMP hydrolysis in trabecular smooth muscle. Activation of PDE 5 terminates NO-induced, cGMP-mediated smooth muscle relaxation, and subsequent penile flaccidity. Sildenafil citrate is a potent PDE type 5 reversible and selective inhibitor which blocks cGMP hydrolysis effectively. FDA approval of sildenafil citrate as the first oral agent for ED in males has resulted in significant interest. We discuss the clinical and pharmacologic properties of sildenafil citrate as well as the urologic and cardiac implications.
Asunto(s)
Inhibidores de Fosfodiesterasa/farmacología , Piperazinas/farmacología , 3',5'-GMP Cíclico Fosfodiesterasas , Fenómenos Fisiológicos Cardiovasculares/efectos de los fármacos , Fosfodiesterasas de Nucleótidos Cíclicos Tipo 5 , Disfunción Eréctil/tratamiento farmacológico , Humanos , Masculino , Inhibidores de Fosfodiesterasa/uso terapéutico , Hidrolasas Diéster Fosfóricas , Piperazinas/uso terapéutico , Purinas , Citrato de Sildenafil , SulfonasRESUMEN
OBJECTIVE: To examine the association between atrial fibrillation (AF) and aortic atherosclerosis in the general population. SUBJECTS AND METHODS: Transesophageal echocardiography was performed in 581 subjects, a random sample of the adult Olmsted County, Minnesota, population (45 years of age or older) participating in the Stroke Prevention: Assessment of Risk in a Community (SPARC) study. The frequency of aortic atherosclerosis was determined in 42 subjects with AF and compared with that in 539 subjects without AF (non-AF group). RESULTS: Subjects with AF were significantly older than non-AF subjects (mean +/- SD age, 82+/-10 vs 66+/-13 years, respectively; P<.001) and more commonly had hypertension (28 [66.7%] vs 288 [53.4%], respectively; P=.10). The 2 groups were similar in sex and frequency of diabetes mellitus, hyperlipidemia, or smoking history (P>.10). The odds of aortic atherosclerosis (of any degree) were 2.87 times greater (95% confidence interval [CI], 1.41-5.83; P=.004) and the odds of complex atherosclerosis (protruding atheroma >4 mm thick, mobile debris, or plaque ulceration) were 2.71 times greater (CI, 1.13-6.53; P=.03) in the AF group than in the non-AF group. Age was a significant predictor of aortic atherosclerosis (P<.001). After adjusting for age, the odds of atherosclerosis and complex atherosclerosis were not significantly different between the 2 groups (P=.13 and P=.75, respectively). CONCLUSIONS: In the general population, AF is associated with aortic atherosclerosis, including complex atherosclerosis. This association is related to age since both AF and aortic atherosclerosis are more frequent in the elderly population.
Asunto(s)
Enfermedades de la Aorta/complicaciones , Arteriosclerosis/complicaciones , Fibrilación Atrial/complicaciones , Adulto , Distribución por Edad , Anciano , Enfermedades de la Aorta/diagnóstico por imagen , Arteriosclerosis/diagnóstico por imagen , Arterias Carótidas/diagnóstico por imagen , Ecocardiografía , Ecocardiografía Transesofágica , Femenino , Humanos , Hipertensión/complicaciones , Masculino , Persona de Mediana Edad , Distribución Aleatoria , Factores de Riesgo , Distribución por SexoRESUMEN
Extrinsic compression of the left main coronary artery is a rare cause of coronary ischemia. We describe a 35-year-old Asian woman with complete asymptomatic occlusion of the left main coronary artery by a large aortic pseudoaneurysm. She underwent repair of the pseudoaneurysm and coronary artery bypass grafting at the Mayo Clinic in Rochester, Minn. The differential diagnosis is discussed. Based on this patient's age and associated vascular lesions, we conclude that Takayasu arteritis was the most likely cause of her condition.
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Aneurisma Falso/complicaciones , Aneurisma de la Aorta/complicaciones , Enfermedad Coronaria/etiología , Arteritis de Takayasu/complicaciones , Adulto , Aneurisma Falso/diagnóstico , Aneurisma Falso/cirugía , Aneurisma de la Aorta/diagnóstico , Aneurisma de la Aorta/cirugía , Puente de Arteria Coronaria , Enfermedad Coronaria/cirugía , Femenino , HumanosRESUMEN
BACKGROUND: Sildenafil citrate (Viagra) is indicated for the treatment of erectile dysfunction. Large and sudden decreases in systemic blood pressure were reported in a substantial number of patients taking sildenafil citrate combined with nitroglycerin. We studied the effect of sildenafil citrate on the relationship between changes in systemic blood pressure and coronary blood flow. METHODS AND RESULTS: Healthy male beagles were used to assess systemic blood pressure, pulmonary arterial pressure, and flow in the left circumflex artery (in which a critical stenosis was established) and left anterior descending coronary artery. After measurement of the hemodynamic variables, 2 mg/kg sildenafil citrate was administered via a nasogastric tube. Hemodynamic changes were monitored for 1 hour. Subsequently, the acute effect of nitrate combined with sildenafil citrate was studied by the bolus injection of 0.2 mg isosorbide dinitrate before and after sildenafil citrate. Systemic blood and pulmonary arterial pressures and circumflex flow did not change during this study; however, left anterior descending coronary arterial flow increased from 16.0+/-5.8 to 24.6+/-8.7 mL/min 1 hour after administration of sildenafil citrate. The prolongation of systemic blood pressure decrease and the circumflex flow decrement induced by isosorbide dinitrate after sildenafil citrate were significantly larger and longer than those before sildenafil citrate. CONCLUSIONS: Sildenafil citrate had the effect of vasodilation in a normal coronary artery; however, a combined effect with nitrate resulted in large and protracted decreases in systemic blood pressure and coronary blood flow in vessels with critical stenosis.
Asunto(s)
Presión Sanguínea/efectos de los fármacos , Circulación Coronaria/efectos de los fármacos , Corazón/efectos de los fármacos , Dinitrato de Isosorbide/administración & dosificación , Piperazinas/administración & dosificación , Administración Oral , Animales , Velocidad del Flujo Sanguíneo/efectos de los fármacos , Gasto Cardíaco/efectos de los fármacos , Puente de Arteria Coronaria , Enfermedad Coronaria/tratamiento farmacológico , Vasos Coronarios/efectos de los fármacos , Vasos Coronarios/cirugía , Perros , Sinergismo Farmacológico , Frecuencia Cardíaca/efectos de los fármacos , Inyecciones , Masculino , Inhibidores de Fosfodiesterasa/farmacología , Piperazinas/sangre , Arteria Pulmonar/efectos de los fármacos , Arteria Pulmonar/fisiología , Purinas , Citrato de Sildenafil , Volumen Sistólico/efectos de los fármacos , Sulfonas , Vasodilatadores/farmacologíaRESUMEN
The effect of volume reduction on various diastolic Doppler parameters of left ventricular filling was assessed in 13 patients before and after hemodialysis. Volume reduction decreased early diastolic mitral annular velocities to a lesser extent than early diastolic mitral inflow velocities.
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Diástole/fisiología , Válvula Mitral/fisiología , Diálisis Renal , Velocidad del Flujo Sanguíneo/fisiología , Ecocardiografía Doppler , Femenino , Humanos , Masculino , Persona de Mediana Edad , Distribución Aleatoria , Función Ventricular Izquierda/fisiologíaRESUMEN
BACKGROUND AND PURPOSE: There is little population-based information on cerebrovascular events and survival among valvular heart disease patients. We used the Kaplan-Meier product-limit method and the Cox proportional hazards model to determine rates and predictors of cerebrovascular events and death among valve disease patients. METHODS: This population-based historical cohort study in Olmsted County, Minnesota, reviewed residents with a first echocardiographic diagnosis of mitral stenosis (n=19), mitral regurgitation (n=528), aortic stenosis (n=140), and aortic regurgitation (n=106) between 1985 and 1992. RESULTS: During 2694 person-years of follow-up, 98 patients developed cerebrovascular events and 356 died. Compared with expected numbers, these observations are significantly elevated, with standardized morbidity ratio of 3.2 (95% CI, 2.6 to 3.8) and 2. 5 (95% CI, 2.2 to 2.7), respectively. Independent predictors of cerebrovascular events were age, atrial fibrillation, and severe aortic stenosis. The risk ratio of severe aortic stenosis was 3.5 (95% CI, 1.4 to 8.6), with atrial fibrillation conferring greater risk at younger age. Predictors of death were age, sex, cerebrovascular events, ischemic heart disease, and congestive heart failure, the greatest risk being among those with both congestive heart failure and cerebrovascular events (risk ratio=8.8; 95% CI, 5. 8 to 13.4). Valve disease type and severity were not independent determinants of death. CONCLUSIONS: The risk of cerebrovascular events and death among patients with valve disease remains high. Age, atrial fibrillation, and severe aortic stenosis are independent predictors of cerebrovascular events, and age, sex, cerebrovascular events, congestive heart failure, and ischemic heart disease are independent predictors of death in these patients.
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Trastornos Cerebrovasculares/diagnóstico , Trastornos Cerebrovasculares/mortalidad , Enfermedades de las Válvulas Cardíacas/diagnóstico , Adolescente , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Trastornos Cerebrovasculares/epidemiología , Estudios de Cohortes , Ecocardiografía/estadística & datos numéricos , Femenino , Estudios de Seguimiento , Cardiopatías/diagnóstico , Cardiopatías/epidemiología , Enfermedades de las Válvulas Cardíacas/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Minnesota/epidemiología , Probabilidad , Modelos de Riesgos Proporcionales , Factores de Riesgo , Análisis de SupervivenciaRESUMEN
BACKGROUND: Atherosclerosis of the thoracic aorta is associated with stroke. The association between hypertension, a major risk factor for stroke, and aortic atherosclerosis has not been determined in the general population. METHODS AND RESULTS: Transesophageal echocardiography was performed in 581 subjects, a random sample of the Olmsted County (Minnesota) population aged >/=45 years participating in the Stroke Prevention: Assessment of Risk in a Community (SPARC) study. Blood pressure was assessed by multiple office measurements and 24-hour ambulatory blood pressure monitoring. The association between blood pressure variables and aortic atherosclerosis was evaluated by multiple logistic regression, adjusting for other associated variables. Among subjects with atherosclerosis, blood pressure variables associated with complex aortic atherosclerosis (protruding plaques >/=4 mm thick, mobile debris, or ulceration) were determined. Age and smoking history were independently associated with aortic atherosclerosis of any degree (P:=0.001) and with complex atherosclerosis (P:=0.002), whereas sex, diabetes mellitus, and body mass index were not. Multiple systolic and pulse pressure variables (office and ambulatory), but none of the diastolic blood pressure variables, were associated with atherosclerosis and complex atherosclerosis, adjusting for age and smoking. Among subjects with atherosclerosis, the odds of complex atherosclerosis increased as ambulatory out-of-bed systolic blood pressure increased (odds ratio 1.43 per 10 mm Hg increase, 95% CI 1. 10 to 1.87) and with hypertension treatment, adjusting for age and smoking history. CONCLUSIONS: High blood pressure is independently associated with aortic atherosclerosis. Among subjects with atherosclerosis, high blood pressure is associated with complex atherosclerosis.
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Enfermedades de la Aorta/complicaciones , Arteriosclerosis/complicaciones , Hipertensión/complicaciones , Distribución por Edad , Anciano , Anciano de 80 o más Años , Aorta Torácica , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores de RiesgoRESUMEN
The objectives of this study were to establish reference values and define the determinants of left atrial appendage (LAA) flow velocities in the general population. LAA flow velocities (contraction and filling velocities) were assessed by transesophageal echocardiography in 310 subjects aged > or = 45 years, sampled from the population-based Stroke Prevention: Assessment of Risk in a Community study. All subjects were in sinus rhythm, with preserved left ventricular systolic function (ejection fraction > or = 50%), and without valvular disease. Values of LAA contraction and filling velocities were established for various age groups in the population. Age was negatively associated with LAA contraction and filling velocities, which decreased by 4.1 cm/s (p < 0.001) and 2.0 cm/s (p < 0.01) for every 10 years of age, respectively. Contraction velocities were 5 cm/s higher in men than in women (p < 0.05). After adjusting for age and sex, heart rate was independently associated with LAA contraction velocities (p < 0.001; nonlinear association). Body surface area, left atrial size, left ventricular mass index, and a history of previous cardiac disease or hypertension showed no significant association with LAA flow velocities (p > 0.05). Furthermore, detailed analysis of 24-hour ambulatory blood pressure data (available in 253 subjects) showed no association between various blood pressure parameters (systolic and diastolic blood pressure, out-of-bed and in-bed measurements) and LAA flow velocities (all p > 0.05). In summary, the present study establishes the reference values for LAA flow velocities in a large sample of the general population. LAA flow velocities progressively decline with age in subjects with preserved left ventricular systolic function.
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Función Ventricular Izquierda/fisiología , Factores de Edad , Anciano , Velocidad del Flujo Sanguíneo/fisiología , Ecocardiografía , Ecocardiografía Transesofágica , Frecuencia Cardíaca/fisiología , Humanos , Persona de Mediana Edad , Contracción Miocárdica/fisiología , Valores de Referencia , Factores SexualesRESUMEN
This study evaluates the coronary flow reserve (CFR) in hypertensive patients with and without left ventricular (LV) hypertrophy. CFR was assessed by transesophageal Doppler echocardiography in 15 normal subjects (group I), 21 hypertensive patients without LV hypertrophy (group II), and 27 hypertensive patients with LV hypertrophy (group III). All hypertensive patients were complaining of typical anginal pain and had normal coronary angiograms. The sample volume was placed at the bifurcation of the left main and left anterior descending coronary arteries. Coronary blood flow velocities were evaluated at rest, 2 minutes after dipyridamole infusion, and 2 minutes after intravenous aminophylline. The ratios of dipyridamole to rest peak diastolic and systolic velocities were considered as indexes of CFR. Peak diastolic velocity ratio was significantly lower in group III than in groups I and II (1.6 +/- 0.2, 2.7 +/- 0.4, and 2.1 +/- 0.2, respectively; p <0.05), and it was significantly lower in group II than I (p <0.05). The peak systolic velocity ratio was significantly lower in group III than in groups I and II (1.7 +/- 0.3, 2.8 +/- 0.3, and 2.1 +/- 0.2, respectively; p <0.05), and it was significantly lower in group II than I (p <0.05). The peak diastolic velocity ratio was inversely related to systolic blood pressure, diastolic blood pressure, and LV mass index (r = -0.48, -0. 51, and -0.37 respectively) in hypertensive patients. It is concluded that CFR is significantly impaired in hypertensive patients, especially those with LV hypertrophy, compared with healthy subjects. The degree of impairment of CFR is related to LV mass index.
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Circulación Coronaria/fisiología , Enfermedad Coronaria/diagnóstico por imagen , Dipiridamol , Ecocardiografía Doppler , Ecocardiografía Transesofágica , Hipertensión/diagnóstico por imagen , Vasodilatadores , Angina de Pecho/diagnóstico por imagen , Angina de Pecho/fisiopatología , Velocidad del Flujo Sanguíneo/fisiología , Enfermedad Coronaria/fisiopatología , Diástole/fisiología , Femenino , Humanos , Hipertensión/fisiopatología , Hipertrofia Ventricular Izquierda/diagnóstico por imagen , Hipertrofia Ventricular Izquierda/fisiopatología , Infusiones Intravenosas , Masculino , Persona de Mediana Edad , Sístole/fisiologíaAsunto(s)
Sistema de Conducción Cardíaco/fisiopatología , Infarto del Miocardio/fisiopatología , Función Ventricular Izquierda , Angioplastia Coronaria con Balón , Cardiotónicos , Puente de Arteria Coronaria , Dobutamina , Prueba de Esfuerzo , Humanos , Infarto del Miocardio/diagnóstico por imagen , Infarto del Miocardio/cirugía , Infarto del Miocardio/terapia , Valor Predictivo de las Pruebas , UltrasonografíaRESUMEN
The left atrial (LA) appendage is a common source of cardiac thrombus formation associated with systemic embolism. Transesophageal echocardiography allows a detailed evaluation of the structure and function of the appendage by two-dimensional imaging and Doppler interrogation of appendage flow. Specific flow patterns, reflecting appendage function, have been characterized for normal sinus rhythm and various abnormal cardiac rhythms. Appendage dysfunction has been associated with LA appendage spontaneous echocardiographic contrast, thrombus formation and thromboembolism. These associations have been studied extensively in patients with atrial fibrillation or atrial flutter, in patients undergoing cardioversion of atrial arrhythmias and in patients with mitral valve disease. The present review summarizes the literature on the echocardiographic assessment of LA appendage structure, function and dysfunction, which has become an integral part of the routine clinical transesophageal echocardiographic examination.
Asunto(s)
Apéndice Atrial/diagnóstico por imagen , Ecocardiografía Doppler , Ecocardiografía Transesofágica , Apéndice Atrial/fisiopatología , Fibrilación Atrial/complicaciones , Fibrilación Atrial/diagnóstico por imagen , Aleteo Atrial/complicaciones , Aleteo Atrial/diagnóstico por imagen , Función Atrial , Velocidad del Flujo Sanguíneo , Cardiopatías/diagnóstico por imagen , Cardiopatías/etiología , Frecuencia Cardíaca , Humanos , Valor Predictivo de las Pruebas , Trombosis/diagnóstico por imagen , Trombosis/etiologíaRESUMEN
Noncompaction of the ventricular myocardium is a rare congenital cardiomyopathy resulting from an arrest in normal endomyocardial embryogenesis. The characteristic echocardiographic findings consist of multiple, prominent myocardial trabeculations and deep intertrabecular recesses communicating with the left ventricular cavity. The disease uniformly affects the left ventricle, with or without concomitant right ventricular involvement, and results in systolic and diastolic ventricular dysfunction and clinical heart failure. Noncompaction was initially described in children. However, recent studies have characterized this disease in the adult population, in whom this process may be more prevalent than currently appreciated. We describe an illustrative case of isolated noncompaction of the ventricular myocardium in a 57-year-old woman with the typical clinical and echocardiographic features of the disease. The literature on the topic is reviewed.
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Cardiopatías Congénitas/diagnóstico por imagen , Diagnóstico Diferencial , Ecocardiografía Doppler en Color , Ecocardiografía Transesofágica , Femenino , Corazón/embriología , Cardiopatías Congénitas/embriología , Cardiopatías Congénitas/patología , Ventrículos Cardíacos/patología , Humanos , Persona de Mediana Edad , Miocardio/patologíaRESUMEN
OBJECTIVES: This study was performed to determine the accuracy and outcome implications of mitral regurgitant lesions assessed by echocardiography. BACKGROUND: In patients with mitral regurgitation (MR), valve repair is a major incentive to early surgery and is decided on the basis of the anatomic mitral lesions. These lesions can be observed easily with transesophageal echocardiography (TEE), but the accuracy and implications for outcome and clinical decision-making of these observations are unknown. METHODS: In 248 consecutive patients operated on for MR, the anatomic lesions diagnosed with TEE were compared with those observed by the surgeon and those seen on 216 transthoracic echocardiographic (TTE) studies, and their relationship to postoperative outcome was determined. RESULTS: Compared with surgical diagnosis, the accuracy of TEE was high: 99% for cause and mechanism, presence of vegetations and prolapsed or flail segment, and 88% for ruptured chordae. Diagnostic accuracy was higher for TEE than TTE for all end points (p < 0.001), but the difference was of low magnitude (<10%) except for mediocre TTE imaging or flail leaflets (both p < 0.001). The type of mitral lesions identified by TEE (floppy valve, restricted motion, functional lesion) were determinants of valve repairability and postoperative outcome (operative mortality and long-term survival; all p < 0.001) independent of age, gender, ejection fraction and presence of coronary artery disease. CONCLUSIONS: Transesophageal echocardiography provides a highly accurate anatomic assessment of all types of MR lesions and has incremental diagnostic value if TTE is inconclusive. The functional anatomy of MR defined by TEE is strongly and independently predictive of valve repairability and postoperative outcome. Therefore, the mitral lesions assessed by echocardiography represent essential information for clinical decision making, particularly for the indication of early surgery for MR.