Usefulness of Transesophageal Echocardiography in the Evaluation of Celiac Trunk and Superior Mesenteric Artery Involvement in Acute Aortic Dissection.

Mesenteric ischemia is a serious complication of acute aortic dissection (AAD), and its early diagnosis is vital for prognosis and appropriate treatment indication. Arteries affected by this complication are the celiac trunk and superior mesenteric artery, and their evaluation is usually based on computed tomographic angiography. Transesophageal echocardiography is also a useful technique for diagnosing AAD and is essential in monitoring surgical or endovascular treatment when computed tomographic angiography is not available. However, the usefulness of transesophageal echocardiography for evaluating celiac trunk and superior mesenteric artery involvement and mesenteric ischemia mechanisms in AAD is not well established. Real-time information on mesenteric malperfusion is needed at the bedside, in primary care facilities, and in the operating room to achieve prompt diagnosis and better therapeutic management. The aims of this review are to assess the role of TEE to diagnose celiac trunk and superior mesenteric artery involvement in AAD, determine the mechanisms that can cause flow obstruction in patients with mesenteric ischemia, and analyze possible implications in the treatment of this complication.

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.

Miocardiopatía dilatada: ¿cuándo y cómo proceder a la investigación etiológica? / Dilated cardiomyopathy: when and how to proceed to etiological diagnosis?

Resumen: La miocardiopatía dilatada (MCD) es la forma más común de disfunción ventricular con una prevalencia en adultos de alrededor de 1/2.500 individuos. Durante muchos años la forma más descripta de MCD en los registros fue la idiopática. En los últimos diez años, los avances en las imágenes y la genética han permitido identificar formas específicas dentro de este grupo que llamábamos comúnmente idiopático. El estudio de los pacientes con MCD debe seguir los pasos habituales, comenzando con el trabajo clínico, evaluación de antecedentes personales y familiares, examen físico, y análisis profundo de electrocardiograma y ecocardiograma. La identificación de las características clínicas sugestivas de enfermedades específicas debería conducir a un trabajo de diagnóstico de segundo nivel que puede incluir análisis bioquímicos específicos, resonancia cardíaca, estudios anatomopatológicos y genéticos. A continuación repasamos estrategias para la mejor identificación de etiologías específicas.

Summary: Dilated cardiomyopathy is the most common form of ventricular dysfunction with an adult prevalence of about 1 / 2.500 individuals. For many years the most described form of dilated cardiomyopathy in the registries was the idiopathic form. In the last ten years, advances in imaging and genetics have made it possible to identify specific forms within this group that we commonly called idiopathic. The study of patients with dilated cardiomyopathy should follow the usually steps, beginning with clinical work, evaluation of personal and family history, physical examination, and deep electrocardiogram analysis and echocardiography. The identification of clinical features suggestive of specific diseases should lead to a second-level diagnostic work that may include specific biochemical analyzes, cardiac resonance, anatomopathological and genetic studies. Next, we review strategies for the best identification of specific etiologies.

Surgical Treatment of Dysphagia Lusoria Caused by Right-Aortic Arch with Kommerell Diverticulum: Left Heart Bypass without Subclavian Revascularization.

The authors present the case of a 26-year-old patient suffering from dysphagia because of compression by a Kommerell diverticulum in right aortic arch anomaly. Open surgical arch and descending aorta replacement with left heart bypass without left subclavian artery reimplantation was performed.

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.

Miectomía septal ampliada en la miocardiopatía hipertrófica obstructiva, resultados clínicos y evolución ecocardiográfica a mediano plazo / Extended Septal Myectomy in Obstructive Hypertrophic Cardiomyopathy: Mid-term Clinical and Echocardiographic Outcomes

RESUMEN: Introducción: La miectomía septal ampliada constituye el tratamiento de elección para pacientes con miocardiopatía hipertrófica obstructiva sintomática, refractarios al tratamiento farmacológico. Objetivos: Evaluar los resultados posoperatorios, el cambio en los síntomas y la evolución ecocardiográfica de una población sometida a miectomía septal ampliada por miocardiopatía hipertrófica obstructiva sintomática. Material y métodos: Desde noviembre de 2011 a octubre de 2017, se intervino un total de 28 pacientes. Se analizaron la evolución posoperatoria, clínica y ecocardiográfica al alta y al seguimiento. Resultados: Edad promedio 53,3 ± 13,4 años. La mortalidad perioperatoria (< 30 días) fue del 0%. Un paciente falleció a los 90 días (3,5%). No se produjeron comunicaciones interventriculares, daño de la válvula aórtica ni se reemplazó la válvula mitral en ningún paciente. El 91% de ellos se encontraban con disnea en CF III-IV en el preoperatorio, los restantes tenían angina o síncope. En el seguimiento, el 92,8% estaban asintomáticos, 1 paciente en CF III y otro en CF II. El gradiente preoperatorio basal promedio fue de 53,5 mmHg y con valsalva 86,4 mmHg; los gradientes basal y con valsalva posoperatorios fueron 9,4 mmHg y 13,5 mmHg (p < 0,01). Al seguimiento, los gradientes en reposo y con valsalva fueron aún más bajos, 8,3 mmHg y 10,7 mmHg, respectivamente (p: NS). Nueve pacientes (32%) presentaban insuficiencia mitral moderada a grave previa por movimiento anterior sistólico o patología intrínseca mitral. Se detectó solo un paciente con insuficiencia mitral moderada asintomática en el seguimiento (3,5%). La mediana de seguimiento fue de 400 días, Pc 25-75 de 695 días (mínimo de 30 días y el máximo de 1868 días). Conclusión: Con la miectomía septal ampliada se obtiene una mejoría hemodinámica y clínica de los pacientes sintomáticos, con bajo número de complicaciones posoperatorias. Esto tiene como resultado una mejor calidad de vida.

E/e' ratio and left atrial area are predictors of atrial fibrillation in patients with hypertrophic cardiomyopathy.

INTRODUCTION: Atrial fibrillation (AF) occurs in about 20%-25% of patients with hypertrophic cardiomyopathy and is associated with increased risk of cardioembolism and heart failure impacting on patients' morbidity and mortality. The aim of this study was to identify echocardiographic predictors of AF in a cohort of patients with hypertrophic cardiomyopathy (HCM). METHODS: Patients were recruited from 2 centers: Buenos Aires Cardiovascular Institute and the Hospital Vall d'Hebron of Barcelona which were analyzed together. Retrospective study using electronic charts. RESULTS: A total of 321 patients with HCM and no documented history of AF were included. Median follow-up was 3 years. Mean age was 54 ± 16 years. Obstructive HCM was present in 41% of the patients, and 94.2% had preserved systolic function. Thirty-eight patients developed AF during the follow-up period (11.8%). Univariate analysis showed that age, maximum myocardial thickness, atrial area, an E/e' ratio ≥ 17, and systolic pulmonary pressure estimated by echocardiography were associated with new-onset AF. Multivariate analysis showed that E/e' ≥ 17 ratio {HR 3.27 ([1.10-9.27] P = .033)} and atrial area {HR 1.06 ([1.01-1.13] P = .037)} remained predictors of AF. CONCLUSIONS: An E/e' ratio ≥ 17, as an expression of left ventricular filling pressures with impact on the left atrium, and left atrial area ≥28 cm2 are strong predictors of AF in patients with HCM.

Shone's syndrome: Insights from three-dimensional echocardiography.

Shone's syndrome is a rare congenital anomaly defined as the presence of at least two of the following heart obstructions: a mitral supravalvular ring, a "parachute" mitral valve stenosis, subaortic stenosis, and aortic coarctation. A 58-year-old man presented with a mitral ring and a "parachute" mitral valve on two-dimensional transthoracic echocardiography, raising suspicion of Shone's syndrome. Three-dimensional transesophageal echocardiography revealed a subannular mitral ring inserted directly on the mitral leaflets, thus acting as a "valvar ring." This distinction can have therapeutic implications as a "valvar" mitral ring could require valve repair or replacement, instead of simple resection.

Three-dimensional echocardiography for predicting postoperative ventricular volumes after surgical ventricular reconstruction of left ventricular aneurysm: A case-based presentation.

Three-dimensional transthoracic echocardiography (3DTTE) may have a role in predicting final left ventricular volumes and clinical response after the surgical ventricular reconstruction (SVR) of left ventricular aneurysms and pseudoaneurysms. Left ventricle final volumes can be calculated through "virtual aneurysmectomy." We present a patient with a huge ventricular dilation combined with myocardial dissection, localized wall rupture, and aneurysm of the left ventricular apex after acute myocardial infarction in which accurate predictions from 3DTTE suggest potential clinical value.

Tratamiento del seudoaneurisma femoral mediante la inyección local de trombina / Femoral Pseudoaneurysm Treatment by Local Thrombin Injection

Introducción: El seudoaneurisma es una complicación ocasional (0,05-0,5%) de los procedimientos intervencionistas cuando se utiliza el acceso femoral. El cierre con inyección local de trombina como alternativa al tratamiento quirúrgico luego de compresión manual fallida cuenta con escasos registros. Objetivo: Evaluar la seguridad y eficacia del cierre del seudoaneurisma femoral iatrogénico mediante la inyección local de trombina guiada por ecografía Doppler. Material y métodos: Entre marzo de 2007 y junio de 2016 se incluyeron 32 pacientes para tratamiento con inyección de trombina. Resultados: La edad media fue de 64,3 ± 10,2 años. La mayoría de los seudoaneurismas estuvieron asociados con la realización de cateterismos coronarios diagnósticos o terapéuticos (59,3%). Siete pacientes habían recibido tratamiento anticoagulante y 21 doble antiagregación plaquetaria. En todos los casos se intentó previamente el cierre por compresión manual. La media del diámetro mayor de los seudoaneurismas fue de 38 mm. Luego del tratamiento, la trombosis inmediata del saco ocurrió en 28 pacientes (87,5%), mientras que 4 pacientes requirieron una segunda inyección, lo que determinó un éxito del 96,8%. En un solo paciente este tratamiento no fue efectivo, con posterior conversión a reparación quirúrgica programada. La dosis media de trombina fue de 450 unidades. Un único paciente presentó complicación trombótica venosa que requirió terapia anticoagulante, con buena evolución clínica. Conclusión: El tratamiento del seudoaneurisma con inyección local de trombina guiada con eco-Doppler fue una alternativa terapéutica segura y eficaz para pacientes con seudoaneurisma femoral refractarios a la compresión manual.

Background: Pseudoaneurysm is a rare complication (0.05-0.5%) after interventional procedures using femoral access. There are few registries of local thrombin injection for pseudoaneurysm closure as an alternative treatment to surgery after failed manual compression. Objective: The aim of this study was to evaluate the safety and efficacy of iatrogenic femoral pseudoaneurysm closure with Doppler ultrasound-guided local thrombin injection. Methods: Thirty-two patients were included for thrombin injection treatment between March 2007 and June 2016. Results: Mean age was 64.3±10.2 years. Most pseudoaneurysms were associated with diagnostic or therapeutic cardiac cath-eterizations (59.3%). Seven patients had received anticoagulant treatment and 21, double antiplatelet therapy. In all cases, prior closure was attempted by manual compression. Mean pseudoaneurysm major diameter was 38 mm. Following treatment, immediate pseudoaneurysm sac thrombosis occurred in 28 patients (87.5%), while 4 patients required a second injection, resulting in 96.8% success rate. Treatment was not effective in only one patient, with subsequent conversion to programmed surgical repair. Mean thrombin dose was 450 units. Only one patient presented with venous thrombosis complication requir-ing anticoagulant therapy, with good clinical outcome. Conclusion: Doppler ultrasound-guided local thrombin injection was a safe and effective therapeutic alternative for pseudoa-neurysm treatment in patients with femoral pseudoaneurysm refractory to manual compression.

Clinical Implications of Focal Intimal Disruption in Patients With Type B Intramural Hematoma.

BACKGROUND: Focal intimal disruption (FID) has been described in >20% of type B intramural hematomas (IMH), with unclear prognosis and management. OBJECTIVES: This study aimed to evaluate the short- and long-term evolution of medically treated patients with type B IMH with and without FID. METHODS: There were 107 consecutive patients with acute type B IMH were included prospectively in a multicenter protocol of clinical and imaging follow-up. FID was defined as an intimal disruption with contrast material-filled outpouching from the aorta lumen with a communicating orifice of >3 mm. RESULTS: There were 43 patients (40%) who developed an FID with larger basal maximum aortic diameter and hematoma thickness. Patients with acute FID had a higher risk of aorta-related events than those without FID (hazard ratio: 24.43; 95% confidence interval: 7.65 to 78.04; p < 0.001). Of the 94 discharged patients, 33 (35%) developed an FID within the first 6 months of follow-up: 19 evolved with mild (<1 mm/year), 8 with moderate (1 to 2 mm/year), and 6 with severe (>2 mm/year) aortic enlargement. Chronic FID was not associated with aorta-related events (hazard ratio: 0.98; 95% confidence interval: 0.22 to 4.34; p = 0.987). CONCLUSIONS: The development of FID in the acute phase of type B IMH has a poor prognosis owing to the high risk of aortic rupture. In the chronic phase, most FIDs evolve with slow aortic dilation and without complications. Although acute FIDs should be treated early and invasively, lesions developing in the subacute-chronic phase can be managed with medical treatment and close imaging surveillance.

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.

Prognostic utility of ischemic response in functional imaging tests (SPECT or stress echocardiography) in low-risk unstable angina patients.

BACKGROUND: The aim of this study is to determine the ability of ischemic response in imaging stress tests (single-photon emission computed tomography [SPECT] or stress echocardiography [SE]) to predict events in low-risk unstable angina patients. METHODS: Three hundred and fifty-nine patients with unstable angina (< 24 h), asymptomatic at admission, without ST-segment elevation or depression, normal troponins, and undergoing SPECT (n = 188) or SE (n = 171) during hospitalization (median = 1 day) were included. A positive imaging test (IMAGING+) was defined as the presence of reversible perfusion defects or wall motion abnormalities in at least 2 contiguous segments. Multivariate models were constructed using these results and clinical variables to predict events at 6 months. RESULTS: Ninety-nine (27%) patients had IMAGING+, 72/188 (38%) in SPECT and 27/17 (16%) in SE (p < 0.0001). Events occurred in 84 (23%) patients: 4 had myocardial infarction, 47 new hospitalizations due to angina and 33 coronary artery revascularizations. Independent predictors of coronary artery disease were: IMAGING+ (OR: 6.4, 95% CI: 3.4-11.8, p < 0.0001), history of coronary artery disease (OR: 2.5, 95% CI: 1.2-5.2, p < 0.02) and TIMI risk (OR: 1.5, 95% CI: 1.1-2.2, p < 0.03). CONCLUSIONS: In low-risk unstable angina patients, an ischemic response in functional stress tests (SPECT or SE) was associated with adverse events and severe coronary artery disease.

Cardiac manifestations other than valvulopathy in antiphospholipid syndrome: long-time echocardiography follow-up study.

AIM: Non-valvular cardiac disease in the antiphospholipid syndrome (APS) has been scanty studied. We wanted to assess the prevalence and evolution of left myocardial disease, pulmonary hypertension and intracardiac thrombi in a cohort of APS patients. METHOD: A total of 53 patients with APS, either primary (n = 34, 64%) or associated to lupus (n = 19, 36%) and 20 controls were included. Initial transthoracic echocardiography assessment was performed in patients at diagnosis, with echocardiography controls performed along mean follow-up of 12 years. Prevalence of myocardial disease in APS cohort was assessed taking into account primary risk factors (hemodynamically significant valvular disease, systemic hypertension, diabetes, alcoholism, myocardial infarction or myocarditis), the same as for pulmonary hypertension (severe left ventricular dysfunction or chronic lung disease). RESULTS: Left myocardial disease had a prevalence of 3.8% (2/53 patients), not different from controls (P = 0.12). Both patients had diastolic dysfunction grade I that maintained stability throughout echocardiographic follow-up period. Pulmonary hypertension had a prevalence of 11.3% (6/53 patients), not different from controls (P = 0.12); all cases were related to pulmonary embolism. Patients diagnosed with pulmonary hypertension in baseline maintained stable pressures throughout follow-up in the absence of new thrombosis. Intracardiac thrombi had a prevalence of 1.8% (1/53 patients), not different from controls (P = 0.4), without changes along echocardiographic follow-up. CONCLUSION: Pulmonary hypertension is the most prevalent non-valvular cardiac manifestation in APS, with an evolution associated with thromboembolic disease, while left myocardial disease and intracardiac thrombi would be rare manifestations in APS.

Traumatic rupture of the tricuspid valve and multi-modality imaging.

INTRODUCTION: Motor vehicle accident (MVA) account for most cases of traumatic rupture of the tricuspid valve. Valve rupture during an MVA is generated by an abrupt deceleration coupled with an increase in right-side cardiac pressures (Valsalva maneuver and thorax compression). CASE: A 39-year-old asymptomatic man was referred for an echocardiogram due to the presence of a systolic murmur. He had no prior significant medical history, except for a remote MVA 3 years ago. Real-time 3D echocardiography (RT3DE) showed a tear in the body of the anterior leaflet and not at the cord, as was suggested by two-dimensional transthoracic echocardiography (2D-TTE). Based on these findings, the mechanism was considered anterior leaflet rupture of the tricuspid valve, secondary to chest blunt trauma. The anterior leaflet was repaired using two polytetrafluoroethylene sutures, and tricuspid annuloplasty with an Edwards ring was performed. CONCLUSIONS: Multimodality imaging helps to determine timing of surgery in asymptomatic traumatic tricuspid rupture. The combination of echocardiography and magnetic resonance imaging provide information of volumetric data and contractility of the right ventricle (RV) during follow-up. RT3DE gives information relevant to the morphological and functional characterization of the valve, allowing the planning of appropriate surgical procedure.

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.