Estado nutricional, obesidad y eventos en pacientes con fibrilación auricular / Nutrition status, obesity and outcomes in patients with atrial fibrillation

Introducción y objetivos Se ha descrito un efecto protector paradójico de la obesidad en pacientes con fibrilación auricular (FA) cuya mecanismo no está claro. El objetivo de este estudio fue determinar el impacto del estado nutricional y el índice de masa corporal (IMC) en el pronóstico de los pacientes con FA. Métodos Se realizó un estudio de cohortes retrospectivo de pacientes con FA entre 2014 y 2017 de una única área sanitaria en España. La escala CONUT se utilizó para evaluar el estado nutricional. La asociación del IMC y escala CONUT con la mortalidad se analizó por regresión de Cox. La asociación con eventos embólicos y hemorrágicos se evaluó mediante análisis de riesgos competitivos. Resultados Entre los 14.849 pacientes, se observó sobrepeso y obesidad en 42,6% y 46,0%, respectivamente, mientras que malnutrición en 34,3%. Durante un seguimiento medio de 4,4 años, 3.335 pacientes murieron, 984 pacientes sufrieron un evento embólico y 1.317 una hemorragia. El IMC se asoció inversamente con la mortalidad, embolias y hemorragias en el análisis univariado; sin embargo, esta asociación se perdió después del ajuste por edad, sexo, comorbilidades y escala CONUT (HR para el combinado de eventos 0,98; IC95%, 0,95-1,01; p=0,719). Por el contrario, la escala CONUT si se asoció con la mortalidad, la embolia y la hemorragia (HR = 1,15; IC95%, 1,14-1,17; p<0,001). Conclusiones El IMC no fue un predictor independiente de eventos en pacientes con FA, a diferencia del estado nutricional, que mostró una fuerte asociación con la mortalidad, la embolia y la hemorragia (AU)

Introduction and objectives A paradoxical protective effect of obesity has been previously reported in patients with atrial fibrillation (AF). The aim of this study was to determine the impact of nutritional status and body mass index (BMI) on the prognosis of AF patients. Methods We conducted a retrospective population-based cohort study of patients with AF from 2014 to 2017 from a single health area in Spain. The CONUT score was used to assess nutritional status. Cox regression models were used to estimate the association of BMI and CONUT score with mortality. The association with embolism and bleeding was assessed by a competing risk analysis. Results Among 14 849 AF patients, overweight and obesity were observed in 42.6% and 46.0%, respectively, while malnutrition was observed in 34.3%. During a mean follow-up of 4.4 years, 3335 patients died, 984 patients had a stroke or systemic embolism, and 1317 had a major bleeding event. On univariate analysis, BMI was inversely associated with mortality, embolism, and bleeding; however, this association was lost after adjustment by age, sex, comorbidities, and CONUT score (HR for composite endpoint, 0.98; 95%CI, 0.95-1.01; P=.719). Neither obesity nor overweight were predictors of mortality, embolism, and bleeding events. In contrast, nutritional status—assessed by the CONUT score—was associated with mortality, embolism and bleeding after multivariate analysis (HR for composite endpoint, 1.15; 95%CI, 1.14-1.17; P<.001). Conclusion BMI was not an independent predictor of events in patients with AF in contrast to nutritional status, which showed a strong association with mortality, embolism, and bleeding (AU)

Aplicabilidad de los criterios de alto riesgo hemorrágico del Academic Research Consortium al síndrome coronario agudo sometido a intervención coronaria percutánea / Applicability of the Academic Research Consortium for High Bleeding Risk in acute coronary syndrome undergoing percutaneous coronary intervention

Introducción y objetivos: La reciente propuesta del Academic Research Consortium for High Bleeding Risk (ARC-HBR), por consenso, no considera el síndrome coronario agudo (SCA) un criterio de hemorragia per se a pesar de tratarse de una situación de alto riesgo hemorrágico (ARH). En este artículo, se investiga la aplicabilidad de la clasificación y los criterios del ARC-HBR a los pacientes con SCA. Métodos: Se clasificó retrospectivamente a los pacientes con SCA sometidos a implante de stent coronario entre 2012 y 2018 en un hospital terciario como ARH si cumplían al menos 1 criterio mayor o 2 o más criterios menores del ARC-HBR. El objetivo primario fue la incidencia acumulada a 1 año de hemorragias de grado Bleeding Academic Research Consortium (BARC) 3-5. Resultados: De los 4.412 pacientes incluidos, el 29,5% estaba en ARH. La incidencia de hemorragias fue mayor en el grupo con ARH que en el de no ARH (el 9,4 frente al 1,3%; p < 0,01). Las tasas de hemorragias hospitalarias periprocedimiento y tras el alta también fueron mayores en el grupo con ARH (el 4,3 frente al 0,5% y el 5,3 frente al 0,9% respectivamente; p < 0,01). El riesgo hemorrágico se incrementó gradualmente a medida que aumentaban los criterios ARC-HBR: el 1,8, el 5,0, el 9,4, el 16,8, el 25,2 y el 25,9% con, respectivamente: solo 1 criterio menor, 2 o más criterios solo menores, 1 criterio mayor (solo o sumado a 1 criterio menor), 1 criterio mayor con 2 o más criterios menores, 2 o más criterios mayores (solos o sumados a 1 criterio menor) y 2 o más criterios mayores con 2 o más criterios menores. De los 20 criterios del ARC-HBR, 16 (80%) cumplieron los cortes predefinidos del riesgo hemorrágico BARC 3-5. Conclusiones: Este estudio respalda la aplicación de la clasificación y los criterios del ARC-HBR en el contexto del SCA. La clasificación ARC-HBR proporciona una estimación precisa del riesgo de hemorragia mayor y parece adecuada para la identificación y el tratamiento de los pacientes con ARH (AU)

Introduction and objectives: The recent Academic Research Consortium for High Bleeding Risk (ARC-HBR) proposal did not consider acute coronary syndrome (ACS), by consensus, a bleeding criterion per se despite being a high bleeding risk (HBR) scenario. We investigated the applicability of the ARC-HBR classification and criteria in ACS patients. Methods: Patients with ACS undergoing coronary stenting between 2012 and 2018 at a tertiary hospital were retrospectively classified as being at HBR if they met ≥ 1 major or ≥ 2 minor ARC-HBR criteria. The primary endpoint was the 1-year cumulative incidence of Bleeding Academic Research Consortium (BARC) 3 or 5 bleeding.Results: Among 4412 patients, 29.5% were at HBR. The incidence of bleeding was higher in the HBR group than in the non-HBR group (9.4% vs 1.3%; P < .01). The rates of in-hospital periprocedural and postdischarge bleeding were also higher in the HBR group (4.3% vs 0.5% and 5.3% vs 0.9%, respectively; P < .01). Bleeding risk gradually increased with increasing ARC-HBR criteria: 1.8%, 5.0%, 9.4%, 16.8%, 25.2%, and 25.9% for 1 isolated minor criterion, ≥ 2 isolated minor criteria, 1 major criterion (isolated or plus 1 minor criterion), 1 major plus ≥ 2 minor criteria, ≥ 2 major criteria (isolated or plus 1 minor criterion), and ≥ 2 major plus ≥ 2 minor criteria, respectively. Sixteen (80%) out of 20 ARC-HBR criteria satisfied the ARC-HBR predefined cutoffs for BARC 3 or 5 bleeding risk. Conclusions: This study supports the use of the ARC-HBR classification and criteria in the ACS setting. The ARC-HBR classification provides an accurate major bleeding risk estimate and it seems suitable for the identification and management of patients at HBR (AU)

Balance entre el efecto de los eventos embólicos frente a los hemorrágicos en la mortalidad de los pacientes ancianos con fibrilación auricular / Trade-off between the effects of embolic versus bleeding events on mortality in elderly patients with atrial fibrillation

Introducción y objetivos: La toma de decisiones clínicas sobre la anticoagulación de pacientes ancianos con fibrilación auricular (FA) requiere que se considere no solo la incidencia de eventos embólicos y hemorrágicos, sino también el riesgo de muerte tras esos efectos adversos. Nuestro objetivo es analizar el balance con respecto a la mortalidad entre los eventos embólicos y hemorrágicos en pacientes ancianos con FA. Métodos: Se analizó a todos los pacientes de 75 o más años de un área de salud española diagnosticados de FA entre 2014 y 2017 (n=9.365). El riesgo de muerte se estimó utilizando modelos de Cox que incluyeron los episodios embólicos y hemorrágicos como variables dependientes del tiempo. Resultados: Durante una mediana de seguimiento de 4,0 años, los eventos se asociaron con mayor mortalidad, tanto los embólicos (HR=2,39; IC95%, 2,12-2,69) como los hemorrágicos (HR=1,79; IC95%, 1,64-1,96). El riesgo de muerte fue un 33% mayor después de una embolia que después de una hemorragia (rRR=1,33; IC95%, 1,15-1,55), aunque con accidente isquémico transitorio el riesgo fue menor que con hemorragia (rRR=0,79; IC95%, 0,63-0,99). La mortalidad tras una hemorragia intracraneal fue similar que tras una embolia mayor (RR=1,00; IC95%, 0,75-1,29). Conclusiones: En los pacientes de edad avanzada con FA, los eventos embólicos parecen estar asociados con una mayor mortalidad que las hemorragias extracraneales, salvo los accidentes isquémicos transitorios. Con hemorragia intracraneal, el riesgo de muerte es similar al de una embolia mayor (AU)

Introduction and objectives: Clinical decision-making on anticoagulation in elderly patients with atrial fibrillation (AF) requires clinicians to consider not only the incidence of embolic and bleeding events, but also the risk of death following these adverse events. We aimed to analyze the trade-off between embolic and bleeding events with respect to mortality in elderly patients with AF. Methods: The study cohort comprised all patients aged ≥ 75 years from a Spanish health area diagnosed with AF between 2014 and 2017 (n=9365). The risk of death was investigated using Cox proportional hazards models, including embolic and bleeding events as time-dependent binary indicators. Results: During a median follow-up of 4.0 years, both embolic and bleeding events were associated with a higher risk of death (adjusted HR, 2.39; 95%CI, 2.12-2.69; and adjusted HR, 1.79; 95%CI, 1.64-1.96, respectively). The relative risk of death was 33% higher following an embolism than following a bleeding event (rRR, 1.33; 95%CI, 1.15-1.55), although for transient ischemic attack the risk was lower than for bleeding (rRR, 0.79; 95%CI, 0.63-0.99). The risk of death associated with intracranial hemorrhage was similar to that of major embolisms (RR, 1.00; 95%CI, 0.75-1.29). Conclusions: In elderly AF patients, embolic events appeared to be associated with a higher risk of mortality than extracranial bleeding, except for transient ischemic attacks, which have a better prognosis. For ICH, the mortality risk was similar to that of major embolism (AU)

A versatile wearable sEMG recording system for long-term epileptic seizure monitoring.

Surface electromyography (sEMG) can be used to detect motor epileptic seizures non-invasively. For clinical use, a compact-size, user-friendly, safe and accurate sEMG measurement system can be worn by epileptic patients to detect and characterize a seizure. Such devices must be small, wireless, power-efficient minimally invasive and robust to avoid movement artefacts, friction, and slipping of the electrode, which can compromise data integrity and/or generate false positives or false negatives. This paper presents a highly versatile device that can be worn in different locations on the body to capture sEMG signals in a freely moving user without movement artefact. The system can be safely worn on the body for several hours to capture sEMG from wet Ag/AgCl electrodes, while sEMG data is wirelessly transmitted to a host computer within a range of 20 m. We demonstrate the versatility of our sensor by recording sEMG from five different body locations in a freely moving volunteer. Then, simulated seizure data was captured while the device was placed on the extensor carpi ulnaris. We show that sEMG bursts were successfully recorded to characterize the seizure afterward. The presented sensor prototype is small (5 cm x 3.5 cm x 1 cm), lightweight (46 g), and has an autonomy of 12 hrs from a small 110-mAh battery.

Anti-inflammatory effects of diet and caloric restriction in metabolic syndrome.

BACKGROUND: Weight loss in patients with metabolic syndrome has positive effects on cardiovascular and type 2 diabetes risks, but its effects on peripheral cytokines and lipid profiles in patients are still unclear. AIM: To determine the effects of diet-induced weight loss on metabolic parameters, lipids and cytokine profiles. METHODS: Eighteen adult males with metabolic syndrome (defined according to IDF 2009) and Body Mass Index (BMI) between 25 and 35 kg/m2 were subjected to a balanced hypocaloric diet for 6 months to reach at least a 5% body weight loss. RESULTS: After weight loss, a significant improvement in BMI, waist circumference, insulin, fasting blood glucose and HOMA-IR (homeostasis model assessment of insulin resistance) was observed. The analysis of LDL (low-density lipoprotein cholesterol) and HDL (high-density lipoprotein cholesterol) lipoproteins showed a change in their composition with a massive transfer of triacylglycerols from HDL to LDL. This was associated with a significant reduction in peripheral pro-inflammatory cytokines such as IL-6, TNF-α, IL-8 and MIP-1ß, leading to an overall decreased inflammatory score. An interesting positive correlation was also observed among peripheral cytokines levels after diet and peripheral levels of CETP (cholesteryl ester transfer protein), an enzyme with a key role in lipid change. CONCLUSION: Weight loss through caloric restriction is associated with an improvement in peripheral lipid and cytokine profiles that may play a major role in improving cardiovascular risk.

Unsupervised Clustering of HRV Features Reveals Preictal Changes in Human Epilepsy.

Over a third of patients suffering from epilepsy continue to live with recurrent disabling seizures and would greatly benefit from personalized seizure forecasting. While electroencephalography (EEG) remains most popular for studying subject-specific epileptic precursors, dysfunctions of the autonomous nervous system, notably cardiac activity measured in heart rate variability (HRV), have also been associated with epileptic seizures. This work proposes an unsupervised clustering technique which aims to automatically identify preictal HRV changes in 9 patients who underwent simultaneous electrocardiography (ECG) and intracranial EEG presurgical monitoring at the University of Montreal Hospital Center. A 2-class k-means clustering combined with a quantitative preictal HRV change detection technique were adopted in a subject- and seizure-specific manner. Results indicate inter and intra-patient variability in preictal HRV changes (between 3.5 and 6.5 min before seizure onset) and a statistically significant negative correlation between the time of change in HRV state and the duration of seizures (p<0.05). The presented findings show promise for new avenues of research regarding multimodal seizure prediction and unsupervised preictal time assessment.Clinical Relevance- This study proposed an unsupervised technique for quantitatively identifying preictal HRV changes which can be eventually used to implement an ECG-based seizure forecasting algorithm.

Cardiopatía isquémica crónica en el anciano / Chronic ischaemic heart disease in the elderly

Este artículo pretende tener en cuenta las peculiaridades y características específicas de los pacientes ancianos con cardiopatía isquémica crónica desde una perspectiva multidisciplinar, con la participación de la Sociedad Española de Cardiología (secciones de Cardiología Geriátrica y Cardiopatía Isquémica/Cuidados Agudos Cardiovasculares), la Sociedad Española de Medicina Interna, la Sociedad Española de Médicos de Atención Primaria y la Sociedad Española de Geriatría y Gerontología. En este documento de consenso se detalla cómo el abordaje de estos enfermos de edad avanzada exige una valoración integral de la comorbilidad, la fragilidad, el estado funcional, la polifarmacia y las interacciones medicamentosas. Concluimos que en la mayoría de los pacientes el tratamiento médico es la mejor opción y que, a la hora de programarlo, se deben tener en cuenta los factores anteriores y las alteraciones biológicas asociadas al envejecimiento (AU)

It is the aim of this manuscript to take into account the peculiarities and specific characteristics of elderly patients with chronic ischaemic heart disease from a multidisciplinary perspective, with the participation of the Spanish Society of Cardiology (sections of Geriatric Cardiology and Ischaemic Heart Disease/Acute Cardiovascular Care), the Spanish Society of Internal Medicine, the Spanish Society of Primary Care Physicians and the Spanish Society of Geriatrics and Gerontology. This consensus document shows that in order to adequately address these elderly patients a comprehensive assessment is needed, which includes comorbidity, frailty, functional status, polypharmacy and drug interactions. We conclude that in most patients medical treatment is the best option and that this treatment must take into account the above factors and the biological changes associated with aging (AU)

[Chronic ischaemic heart disease in the elderly]. / Cardiopatía isquémica crónica en el anciano.

It is the aim of this manuscript to take into account the peculiarities and specific characteristics of elderly patients with chronic ischaemic heart disease from a multidisciplinary perspective, with the participation of the Spanish Society of Cardiology (sections of Geriatric Cardiology and Ischaemic Heart Disease/Acute Cardiovascular Care), the Spanish Society of Internal Medicine, the Spanish Society of Primary Care Physicians and the Spanish Society of Geriatrics and Gerontology. This consensus document shows that in order to adequately address these elderly patients a comprehensive assessment is needed, which includes comorbidity, frailty, functional status, polypharmacy and drug interactions. We conclude that in most patients medical treatment is the best option and that this treatment must take into account the above factors and the biological changes associated with aging.

Mehran contrast nephropathy risk score: Is it still useful 10 years later?

BACKGROUND: Nowadays, contrast-induced nephropathy (CIN) is the third cause of acquired acute renal impairment in hospital. CIN is related to increased in-hospital morbidity, mortality, costs of medical care, and long admissions. Because of this, we hypothesized it would be useful to determine the risk of CIN with scores such as the Mehran score. The aim of this study was to validate the Mehran score in a contemporary cohort of Spanish patients with acute coronary syndrome (ACS). METHODS: We assessed the calibration and discriminatory capacity of Mehran score to predict CIN in a cohort of 1520 patients with a definitive diagnosis of ACS and who underwent coronary angiography between March 2008 and June 2012. We excluded patients on chronic dialysis and those without data of contrast volume. The calibration of the model was assessed with the Hosmer-Lemeshow goodness-of-fit test and discriminatory capacity was assessed by C-statistic, which is equivalent to the area under the receiver-operating characteristic curve. RESULTS: From the total group, 118 patients (7.8%) developed CIN. They were older, with higher rates of diabetes (DM) and hypertension and worse renal function and anemia (p<0.001). The odds ratios for different score components in Mehran's population versus our study were similar except for DM, hypotension, and intra-aortic balloon pump (1.6%, 2.68%, 2.55% vs 0.9%, 1.89%, and 2.86%, respectively). Calibration and discriminatory capacity of Mehran score were excellent with a Hosmer-Lemeshow p=0.7, C-statistic value >0.8. CONCLUSIONS: Mehran risk score has been validated in our study as a good score for predicting CIN in patients with ACS who underwent coronary angiography. According to this, we support its use in patients hospitalized for ACS in order to identify the ones at risk, and to optimize CIN prophylactic therapy prior to and after catheterization.

Acid sphingomyelinase determines melanoma progression and metastatic behaviour via the microphtalmia-associated transcription factor signalling pathway.

Melanoma is a rapidly growing and highly metastatic cancer with high mortality rates, for which a resolutive treatment is lacking. Identification of novel therapeutic strategies and biomarkers of tumour stage is thus of particular relevance. We report here on a novel biomarker and possible candidate therapeutic target, the sphingolipid metabolising enzyme acid sphingomyelinase (A-SMase). A-SMase expression correlates inversely with tumour stage in human melanoma biopsies. Studies in a mouse model of melanoma and on cell lines derived from mouse and human melanomas demonstrated that A-SMase levels of expression actually determine the malignant phenotype of melanoma cells in terms of pigmentation, tumour progression, invasiveness and metastatic ability. The action of A-SMase is mediated by the activation of the extracellular signal-regulated kinase, the subsequent proteasomal degradation of the Microphtalmia-associated transcription factor (Mitf) and inhibition of cyclin-dependent kinase 2, Bcl-2 and c-Met, downstream targets of Mitf involved in tumour cell proliferation, survival and metastatisation.

Comparison of the reliability and validity of four contemporary risk stratification schemes to predict thromboembolism in non-anticoagulated patients with atrial fibrillation.

BACKGROUND: The risk of thromboembolic (TE) complications in atrial fibrillation (AF) patients is not homogeneous. Risk schemes can help target anticoagulant therapy for patients at highest risk of TE complications. OBJECTIVES: To test the predictive ability of 4 risk schemes: The Framingham, the 8th ACCP, the ACC/AHA/ESC 2006, and the CHA2DS2-VASc. METHODS: 186 patients with non-valvular AF and off anticoagulant therapy were included. All subjects who experienced a stroke, transient ischemic attack, or peripheral embolism were identified. Each schema was divided into low, intermediate, and high-risk categories. Discrimination was assessed via the c-statistic. RESULTS: We identified 10 TE events that occurred during 668 person-years off anticoagulation therapy. All risk schemes had fair discriminating ability (c-statistic ranged from 0.59 [for CHA2DS2-VASc] to 0.73 [for Framingham]). The proportion of patients assigned to individual risk categories varied widely across schemes. CHA2DS2-VASc categorized the fewest patients into low and intermediate-risk categories, whereas the Framingham schema assigned the highest patients into low-risk strata. There were no TE events in the low and intermediate-risk categories using CHA2DS2-VASc, whereas the most schemes assigned patients into intermediate-risk category had a event rate ranging from 2.5 (ACC/AHA/ESC and 8th ACCP schemes) to 6% (Framingham). The negative predictive value of TE events was of 100% for the no high-risk patients using CHA2DS2-VASc. CONCLUSIONS: Compared to ACC/AHA/ESC, 8th ACCP, and Framingham, CHA2DS2-VASc risk stratification schema may be better in discriminating between patients at a low and intermediate risk of TE complications.

Aportaciones de las técnicas de imagen cardíaca en la valoración del paciente de alto riesgo cardiovascular / Contributions of cardiac imaging techniques in the assessment of hight cardiovascular risk patients

La aterosclerosis es una enfermedad común y grave, sus complicaciones trombóticas causan la mayoría de las enfermedades mortales y discapacitantes. En el 30-50% de la población general, su primera manifestación clínica es el infarto de miocardio, que a menudo es fatal. Resulta inaceptable que con el arsenal terapéutico disponible actualmente, en la prevención primaria, el infarto de miocardio y la muerte súbita permanezcan con demasiada frecuencia como primeras manifestaciones de la aterosclerosis coronaria. Por lo tanto, la detección temprana de esta enfermedad puede proporcionar una gran oportunidad para prevenir muchos eventos cardiovasculares. Actualmente, disponemos de varias modalidades no invasivas de imagen que tienen el potencial para medir y monitorizar la aterosclerosis subclínica. Revisaremos en este capítulo las aportaciones en este sentido de la ecocardiografía, la tomografía por emisión de positrones, la tomografía computarizada para la detección de calcio coronario, la resonancia magnética y la ecografía carotidea (AU)

Atherosclerosis is a common and dangerous disease, its thrombotic complications cause the majority of fatal and disabling diseases. In 30-50% of the general population, its first manifestation is myocardial infarction, which is often fatal. In the contemporary era of aggressive management of cardiovascular risk factors, it is unacceptable that myocardial infarction and sudden death remain highly common as first manifestation of coronary atherosclerosis. Therefore, early detection of this disease, may provide an important opportunity to prevent many cardiovascular events. Currently we have several non-invasive imaging modalities that have the potential to measure and monitor subclinical athero–sclerosis. In the present article, the contributions of stress echocardiography, positron emission tomography, electron beam computed tomography, magnetic resonance coronary angiography and carotid ultrasonography, are reviewed (AU)

Evaluating daily nursing use and needs in the intensive care unit: a method to assess the rate and appropriateness of ICU resource use.

BACKGROUND: We designed a tool to measure the rate and appropriateness of intensive care unit (ICU) nursing coverage as a proxy for the use of resources. METHODS: We tested the tool in 32 Italian ICUs during a cross-sectional study (4 days/week, October 2001 and April 2002). The level of care was classified as high or low. The appropriate patient-to-nurse ratio for both levels (2/1 and 3/1 in this ICU mix) was defined. The provided and theoretical nurse assistance was computed, the difference between the two quantifying the ICU use of personnel: a positive difference means over-utilization, a negative one under-utilization. We calculated the maximum number of high-level and low-level care days available for ICU and the relative utilization rates. These two rates quantify the appropriateness of resource use in relation to the planned use. RESULTS: Analysing 5783 treatment-days, the tool identified units using almost all available resources (five), overcrowded (14: too small units) or empty (16: too big). Units were overcrowded on account of the high-level of care required (five: utilization rate >100%) or reallocated too much of their residual high-care nursing capacity to low-level care (six). In empty units both utilization rates were lower than expected. CONCLUSIONS: The method quantifies the rate and appropriateness of resource usage and suggests the best management in units with fixed human resources or a fixed number of beds.

Posterior myocardial infarction complicated by rupture of the posteromedial papillary muscle.

A 61-year-old man was admitted with acute posterior myocardial infarction and, on physical examination, was shown to have a mitral regurgitation (MR) murmur. Transthoracic echocardiography (TTE) showed severe hypokinesis of the posterior wall and severe MR by color flow. Right heart catheterization with a balloon-tipped catheter revealed a pulmonary artery wedge pressure of 30 mmHg. No 'step-up' was seen in blood samples from the right atrium and right ventricle. On angiography, a subtotal occlusion of the mid circumflex artery was found which was angioplastied and stented. As the patient's clinical condition did not improve, he underwent transesophageal echocardiography (TEE) for further evaluation. This showed complete rupture of the posteromedial papillary muscle. The patient underwent urgent surgery with successful mitral valve replacement. The postoperative course was uncomplicated, and clinical improvement seen. This case report underscores the value of TEE in accurate preoperative diagnosis of papillary muscle rupture by providing preoperative anatomic details of the mitral valve apparatus and surrounding structures.

Assessment of valvular heart disease. Why echocardiography is an essential component.

Assessment of patients with valvular heart disease has undergone many changes in the past few decades with the introduction of noninvasive techniques such as echocardiography. Along with the history, physical examination, electrocardiogram, and chest films, echocardiography is an important component of the assessment, providing essential information for diagnosis and follow-up.