True morphology of mitral regurgitant flow assessed by three-dimensional transesophageal echocardiography.

INTRODUCTION: Quantification of mitral regurgitation (MR) by two-dimensional (2D) transthoracic echocardiography (TTE) is based on the analysis of the proximal flow convergence (PFC) and the "vena contracta" (VC). This method assumes geometries and can be misleading. In contrast, three-dimensional (3D) echocardiography directly measures flow volumes and does not assume geometries, which allows for more accurate MR evaluation. AIMS: To report the 3D transesophageal echocardiography (3DTEE) feasibility for MR quantification and evaluate its concordance with 2D echo. METHODS: Twenty-seven consecutive patients undergoing 2D and 3DTEE for presurgical MR evaluation were studied prospectively. MR quantification was performed by classical 2D methods based on PFC. Diameters of the VC in orthogonal planes by 3DTEE were estimated, establishing the VC sphericity index as well as VC area (VCA) by direct planimetry. In case of multiple jets, we calculated the sum of the VCA. RESULTS: MR assessment by 3DTEE was feasible. An adequate concordance between VC measurements by 2D methods (TTE and TEE) was observed; however, there was a poor correlation when compared with 3DTEE. The sphericity index of the VC was: 2.08 (±0. 72), reflecting a noncircular VC. CONCLUSIONS: 3DTEE is a feasible method for the assessment of the MR true morphology, allowing a better quantification of MR without assuming any geometry. This method revealed the presence of multiple jets, potentially improving MR evaluation and leading to changes in medical decision when compared to 2D echo assessment.

Eco 3D transesofágico en la estenosis aórtica con bajo flujo/bajo gradiente paradójico / 3D-Transesophageal Echocardiography in Paradoxical Low-Flow, Low-Gradient Aortic Stenosis

Introducción: En la estenosis aórtica (EAo) con bajo flujo/bajo gradiente paradójico (BFBGP), el eco transtorácico 2D (ETT2D) podría subestimar el cálculo de flujo porque asume el tracto de salida del ventrículo izquierdo (TSVI) con una morfología circular. El eco transesofágico 3D (ETE3D) es metodológicamente mejor que el 2D para medir el TSVI. Objetivos: Evaluar el volumen eyectivo indexado (VEi) del ventrículo izquierdo por ETT2D y ETE3D en pacientes con corazón normal (GN) y con EAo grave (GEAo) y determinar cuántos pacientes con BFBGP por ETT2D se consideran también con BFBGP por ETE3D. Material y métodos: Se evaluaron 35 pacientes con ETT2D y ETE3D: GN = 17 pacientes y GEAo = 18 pacientes. Se estimó en ambos grupos el área del TSVI en protosístole por ETT2D (TSVI2Dprot) y por planimetría ETE3D (TSVI3Dprot) y como promedio sistólico (TSVI3Dprom). Multiplicando cada área del TSVI por su integral de flujo, se obtuvieron los VEi (VEi ETT2D prot, VEi ETE3D prot y VEi ETE3D prom) tanto del GN como del GEAo. En el GEAo se determinó BFBGP según criterio actual. Resultados: GN: área TSVI ETT2D prot vs. ETE3D prot p < 0,05. GEAo: área TSVI ETT2D prot vs. ETE3D prot p < 0,001 y vs. ETE3D prom p < 0,023; VEi ETT2D prot vs. VEi ETE3D prot p < 0,002 y vs. VEi ETE3D prom p < 0,038. En el GN, el VEi en el límite inferior de lo normal por ETT2D, ETE3D prot y ETE3D prom fue < 34, < 38,9 y < 35,9 ml/m², respectivamente. Tres pacientes del GEAo fueron BFBGP por ETT2D, pero ninguno por ETE3D. Conclusiones: Los pacientes con BFBGP por ETT2D podrían ser reclasificados por el ETE3D. Este hallazgo se relaciona con las limitaciones del eco 2D para el cálculo del área del TSVI.

Background: In paradoxical low-flow, low gradient (LF-LG) aortic stenosis, 2D-transthoracic echocardiography (2D-TTE) may underestimate flow because it assumes a circular left ventricular outflow tract (LVOT) shape. Three-dimensional trans-esophageal echocardiography (3D-TEE) is a better method to measure LVOT area. Objectives: The aim of this study was to evaluate left ventricular stroke volume index (SVi) by 2D-TTE and 3D-TEE in patients with normal heart (NG) and with severe aortic stenosis (ASG) and to determine how many patients are categorized as paradoxical LF-LG by 2D-TTE and 3D-TEE. Methods: Thirty-five patients were evaluated by 2D-TEE and 3D-TEE: NG=17 patients and ASG=18 patients. Left ventricular outflow tract area was estimated during early systole (ES) by 2D-TTE (ES2DLVOT Ar) and by 3D-TEE (ES3DLVOT Ar) planimetry, and as systolic average (Avg 3DLVOT Ar). Each LVOT area was multiplied by its corresponding flow integral to obtain SVi (ES2D-TTE SVi, ES3D-TEE SVi and Avg 3D-TEE SVi) in NG and ASG. Paradoxical LF-LG was determined in ASG following standard criterion. Results: NG: ES2DLVOT Ar vs. ES3DLVOT Ar p<0.05; ASG: ES2DLVOT Ar vs. ES3DLVOT Ar p<0.001 and vs. Avg 3DL-VOT Ar p<0.023; ES2D-TTE SVi vs. ES3D-TEE SVi p<0.002 and vs. Avg 3D-TEE SVi p<0.038. In the NG, the lower limit of normal SVi for 2D-TTE, ES3D-TEE and Avg 3D-TEE was <34, <38.9 and <35.9 ml/m², respectively. Three patients with severe aortic stenosis were categorized as paradoxical LF-LG by 2D-TTE, but none by 3D-TEE. Conclusions: Patients with paradoxical LF-LG by 2D-TTE could be recategorized by 3D-TEE. This finding is related with the limitations of 2D-echocardiography for estimating LVOT area.

Left ventricular filling pressure in male patients with type 2 diabetes and normal versus low total testosterone levels.

BACKGROUND: Heart failure is a common complication of diabetes characterized by an elevation in left ventricular filling pressures (LVF) that often develops in the absence of clinical symptoms. Diastolic dysfunction in the setting of low total testosterone (LTT) occurs through changes in the regulation of peripheral hemodynamics. LTT is highly prevalent among individuals with type 2 diabetes. The aim of this study was to compare LVF in male diabetic patients with no structural heart disease and normal serum testosterone levels vs. those with LTT. METHODS: Type 2 diabetic patients were assessed using tissue Doppler imaging to evaluate LVF and other conventional parameters of diastolic function. The E/e' ratio was used to estimate LVF through the ratio of peak passive trans-mitral left ventricular inflow velocity to the peak passive inflow velocity at the lateral mitral annulus. Patients were assigned to one of two groups based upon their total testosterone levels. Group A consisted of low (< 3.5 ng/mL) testosterone levels and group B consisted of normal (> 3.5 ng/mL) testosterone levels. RESULTS: A total of 148 male patients were included: group A--47 (32%) patients; group B--101 (68%) patients, respectively. Mean age was 58 ± 5.8 years and mean time of diabetes evolution was 7 ± 3.1 years. There were no significant differences between the groups regarding age, duration of diabetes evolution, hypertension, weight, heart rate, body mass index, and echocardiographic parameters. The E/e' ratio for group A was 8.05 ± 1.9 vs. 6.1 ± 1.7 for group B (p < 0.0001). The E/A ratio was 0.94 ± 0.10 vs. 1.19 ± 0.12 (p = 0.01), deceleration time 242 ± 7.4 ms vs. 205 ± 9 ms (p = 0.026) and systolic pulmonary artery pressure 27 ± ± 2.2 mm Hg vs. 22 ± 1.7 mm Hg (p = 0.11). CONCLUSIONS: Patients with type 2 diabetes and LTT have a higher E/e' ratio demonstrating a pre-clinical increase in LVF when compared to similar patients with normal testosterone levels. This finding is independent of time of diabetes evolution, hypertension and other echocardiographic parameters.

Análisis de las características de la válvula mitral en ecocardiograma tridimensional / Three-Dimensional Echocardiographic Analysis of Mitral Valve Characteristics

Introducción El ecocardiograma transesofágico en tres dimensiones (ETE 3D) es una herramienta especialmente útil en el estudio de la patología de la válvula mitral. En la bibliografía existe poca información, ninguna de nuestro país, acerca de los valores normales a partir de los cuales se pueda definir la enfermedad. Objetivo Definir los valores normales de las medidas del anillo y de las valvas de la válvula mitral a través del estudio de una población sin cardiopatía utilizando el ETE 3D. Material y métodos Se incluyeron prospectivamente 26 pacientes sin patología cardiovascular que fueron estudiados con ETE en dos y tres dimensiones. Con el mejor volumen 3D adquirido se construyó un modelo tridimensional de la válvula mitral del que se obtuvieron las medidas de las valvas y del anillo (indexadas por superficie corporal). Los datos se presentan como mediana con rango intercuartil. Resultados La edad fue de 64,5 años (39,1-69,7), el 46% eran hombres. Las medidas del anillo mitral fueron: diámetro intercomisural 18,7 mm (16,5-19,9), diámetro anteroposterior 16,4 mm (15,1-17,8), altura 4,4 mm (3,6-5,4), circunferencia en un plano 55,1 mm (52,2-60), circunferencia en 3D 57,8 mm (55,5-64,1), área en un plano 433,9 mm² (405,3-489) y área en 3D 457,8 mm² (431,2-515,8). Las medidas de las valvas fueron: longitud de la valva anterior 13,4 mm (12,4-14), área de la valva anterior 328,6 mm² (297-359,8), longitud de la valva posterior 7,8 mm (7,1-8,3) y área de la valva posterior 242 mm² (214,3-265,5). Se evaluó la reproducibilidad de las mediciones del anillo mitral en 3D y se observó muy buena concordancia tanto intraobservador como interobservador. Conclusiones Los resultados muestran los valores de referencia de las valvas y del anillo de la válvula mitral en una población sin cardiopatía estudiada con ETE 3D. Sientan las bases para futuros estudios que, asociando mediciones similares en todo el rango de gravedad de la patología mitral, permitan definir prospectivamente la sensibilidad y la especificidad del estudio para enfermedad mitral.

Introduction Three-dimensional transesophageal echocardiography (3D TEE) is a useful tool, particularly for the evaluation of mitral valve disease. There are few reports in the literature, none of our country, about the normal values in order to define the disease. Objective The aim of this study was to define the normal values of the mitral valve annulus and leaflets in a population without heart disease using 3D TEE. Methods Twenty-six patients without heart disease were prospectively included and underwent two-dimensional and 3D TEE. The best 3D volume acquired was used to construct a three dimensional model of the mitral valve to measure the mitral valve leaflets and annulus (indexed for body surface area). Data are presented as median with interquartile range. Results Age was 64.5 years (39.1-69.7) and 46% were men. Mitral annulus measurements were: intercommissural diameter 18.7 mm (16.5-19.9), anteroposterior diameter 16.4 mm (15.1-17.8), height 4.4 mm (3.6-5.4), circumference in projection plane 55.1 mm (52.2-60), 3D circumference 57.8 mm (55.5-64.1), area in projection plane 433.9 mm² (405.3-489) and 3D area 457.8 mm² (431.2-515.8). The leaflets measurements were: anterior leaflet length 13.4 mm (12.4-14), anterior leaflet area 328.6 mm² (297-359.8), posterior leaflet length 7.8 mm (7.1-8.3) and posterior leaflet area 242 mm² (214.3-265.5). The reproducibility of mitral annulus measurements in 3D was evaluated and showed good intraobserver and interobserver agreement. Conclusions Results show reference values of the mitral valve leaflets and annulus estimated by 3D TEE in a population without heart disease. These data lay the foundations for future studies which, by associating similar measurements across all the ranges of severity of mitral valve disease, may prospectively define the sensitivity and specificity of the method for mitral valve assessment.

Análisis de las características de la válvula mitral en ecocardiograma tridimensional / Three-Dimensional Echocardiographic Analysis of Mitral Valve Characteristics

Introducción El ecocardiograma transesofágico en tres dimensiones (ETE 3D) es una herramienta especialmente útil en el estudio de la patología de la válvula mitral. En la bibliografía existe poca información, ninguna de nuestro país, acerca de los valores normales a partir de los cuales se pueda definir la enfermedad. Objetivo Definir los valores normales de las medidas del anillo y de las valvas de la válvula mitral a través del estudio de una población sin cardiopatía utilizando el ETE 3D. Material y métodos Se incluyeron prospectivamente 26 pacientes sin patología cardiovascular que fueron estudiados con ETE en dos y tres dimensiones. Con el mejor volumen 3D adquirido se construyó un modelo tridimensional de la válvula mitral del que se obtuvieron las medidas de las valvas y del anillo (indexadas por superficie corporal). Los datos se presentan como mediana con rango intercuartil. Resultados La edad fue de 64,5 años (39,1-69,7), el 46% eran hombres. Las medidas del anillo mitral fueron: diámetro intercomisural 18,7 mm (16,5-19,9), diámetro anteroposterior 16,4 mm (15,1-17,8), altura 4,4 mm (3,6-5,4), circunferencia en un plano 55,1 mm (52,2-60), circunferencia en 3D 57,8 mm (55,5-64,1), área en un plano 433,9 mm² (405,3-489) y área en 3D 457,8 mm² (431,2-515,8). Las medidas de las valvas fueron: longitud de la valva anterior 13,4 mm (12,4-14), área de la valva anterior 328,6 mm² (297-359,8), longitud de la valva posterior 7,8 mm (7,1-8,3) y área de la valva posterior 242 mm² (214,3-265,5). Se evaluó la reproducibilidad de las mediciones del anillo mitral en 3D y se observó muy buena concordancia tanto intraobservador como interobservador. Conclusiones Los resultados muestran los valores de referencia de las valvas y del anillo de la válvula mitral en una población sin cardiopatía estudiada con ETE 3D. Sientan las bases para futuros estudios que, asociando mediciones similares en todo el rango de gravedad de la patología mitral, permitan definir prospectivamente la sensibilidad y la especificidad del estudio para enfermedad mitral.(AU)

Introduction Three-dimensional transesophageal echocardiography (3D TEE) is a useful tool, particularly for the evaluation of mitral valve disease. There are few reports in the literature, none of our country, about the normal values in order to define the disease. Objective The aim of this study was to define the normal values of the mitral valve annulus and leaflets in a population without heart disease using 3D TEE. Methods Twenty-six patients without heart disease were prospectively included and underwent two-dimensional and 3D TEE. The best 3D volume acquired was used to construct a three dimensional model of the mitral valve to measure the mitral valve leaflets and annulus (indexed for body surface area). Data are presented as median with interquartile range. Results Age was 64.5 years (39.1-69.7) and 46% were men. Mitral annulus measurements were: intercommissural diameter 18.7 mm (16.5-19.9), anteroposterior diameter 16.4 mm (15.1-17.8), height 4.4 mm (3.6-5.4), circumference in projection plane 55.1 mm (52.2-60), 3D circumference 57.8 mm (55.5-64.1), area in projection plane 433.9 mm² (405.3-489) and 3D area 457.8 mm² (431.2-515.8). The leaflets measurements were: anterior leaflet length 13.4 mm (12.4-14), anterior leaflet area 328.6 mm² (297-359.8), posterior leaflet length 7.8 mm (7.1-8.3) and posterior leaflet area 242 mm² (214.3-265.5). The reproducibility of mitral annulus measurements in 3D was evaluated and showed good intraobserver and interobserver agreement. Conclusions Results show reference values of the mitral valve leaflets and annulus estimated by 3D TEE in a population without heart disease. These data lay the foundations for future studies which, by associating similar measurements across all the ranges of severity of mitral valve disease, may prospectively define the sensitivity and specificity of the method for mitral valve assessment.(AU)

¿Dónde está el orificio mitral efectivo?: Divergencia entre el volumen del tracto de salida y el tracto de entrada del ventrículo izquierdo por ecocardiografía / Where is the Effective Mitral Orifice?: Echocardiographic Divergence Between Mitral Inflow Volume and Left ventricular Outflow Tract Volume

Introducción El cálculo del volumen regurgitante en la insuficiencia mitral por eco transtorácico 2D (ETT2D) es poco confiable y está relacionado con una medición inadecuada del anillo mitral (AM). El eco transesofágico 3D (ETE3D) posee mejores herramientas de medición del AM. Objetivos Comparar el área del AM y la diferencia de volumen del tracto de entrada y del tracto de salida del ventrículo izquierdo (TSVI y TEVI) por ETT2D y ETE3D en corazones normales. Evaluar en qué nivel del aparato mitral se encuentra el orificio mitral efectivo. Material y métodos Se incluyeron 13 pacientes consecutivos y prospectivos, de 42 (29-47) años, 7 de sexo femenino, con indicación de eco transesofágico (9 por búsqueda de fuente embolígena y 4 por síndrome febril), que tenían un ETT2D normal y se encontraban con ritmo sinusal y normotensos en el momento del estudio. Se les realizó simultáneamente ETT2D y ETE3D. El área del TSVI y del AM se midió por ETT2D y ETE3D. Se estimó por ETE3D el área de la válvula mitral (VM) distal al AM. El volumen de cada tracto se calculó como el producto del área por la integral velocidad-tiempo (VTI) del flujo. Se estableció una hipotética área mitral efectiva (AME) como el cociente entre el volumen del TSVI (ETE3D) y la VTI del TEVI. Resultados Correlación (rs), concordancia e IC 95% entre área del AM por ETT2D vs. ETE3D: 0,506, 1,97 (-0,40 a 4,34), AME vs. ETE3D 0,549, 2,41 (-4,03 a -0,79) y AME vs. VM a 10.5 mm (8-12) del AM: 0,982, 0,079 (-0,26 a 0,42). La diferencia de volumen (ml) entre ambos tractos fue: ETT2D 12,8 (7,5-19), ETE3D 32,8 (25,9-48) y ETE3D (desde VM distal al AM) 1,8 (1,25-3,6). Conclusiones Cuanto mejor medimos el anillo mitral, más lejos estamos del orificio mitral efectivo. El área mitral a 1 cm del punto más alto del anillo mitral es la que más se acerca al orificio mitral efectivo.

Introduction Two-dimensional transthoracic echocardiography (2DTTE) is not a reliable method for estimating regurgitatant volume in mitral insufficiency due to inadequate measurement of the mitral annulus (MA). Three-dimensional transesophageal echocardiography (3DTEE) offers better tools for measuring the MA. Objectives The aim of this study was to compare the MA area and the difference in mitral inflow (MI) volume and left ventricular out-flow tract (LVOT) volume determined by 2DTTE and 3DTEE in normal hearts, and to evaluate at what level of the mitral valve apparatus the mitral effective orifice is actually located. Methods A total of 13 consecutive and prospective patients with indication of transesophageal echocardiography (9 to rule out cardioembolic source and 4 due to febrile syndrome) were included in the study. Their mean age was 42 (29-47) years and 7 were women. All the patients had normal 2DTTE, were in sinus rhythm and had normal blood pressure at the moment of the study. 2DTTE and 3DTEE were simultaneously performed. LVOT area and MA area were calculated by 2DTTE and 3DTEE. Mitral valve (MV) area distal to the MA was estimated by 3DTEE. Mitral inflow and LVOT volume were calculated as the product between the area and flow velocity time integral (VTI). The effective mitral valve area (EMVA) was hypothetically estimated by dividing the LVOT (3DTEE) volume by MI VTI. Results Correlation (rs), concordance and 95% CI between MA area by 2DTTE vs. 3DTEE: 0.506, 1.97 (-0.40 to 4.34), EMVA vs. 3DTEE: 0.549, 2.41 (-4.03 to -0.79) and EMVA vs. MV at 11 mm (8-12) of the MA: 0.982, 0.079 (-0.26 to 0.42). The difference between MI volume and LVOT volume (ml) was: 2DTTE: 12.8 (7.5-19), 3DTEE: 32.8 (25.9-48) and 3DTEE (from the MV distal to the MA) 1.8 (1.25-3.6). Conclusions The better the technique for measuring the mitral annulus, the farther we are from the mitral effective orifice. The mitral valve area measured at one centimeter of the highest point of the mitral annulus is the best approximation to the effective mitral orifice.

¿Dónde está el orificio mitral efectivo?: Divergencia entre el volumen del tracto de salida y el tracto de entrada del ventrículo izquierdo por ecocardiografía / Where is the Effective Mitral Orifice?: Echocardiographic Divergence Between Mitral Inflow Volume and Left ventricular Outflow Tract Volume

Introducción El cálculo del volumen regurgitante en la insuficiencia mitral por eco transtorácico 2D (ETT2D) es poco confiable y está relacionado con una medición inadecuada del anillo mitral (AM). El eco transesofágico 3D (ETE3D) posee mejores herramientas de medición del AM. Objetivos Comparar el área del AM y la diferencia de volumen del tracto de entrada y del tracto de salida del ventrículo izquierdo (TSVI y TEVI) por ETT2D y ETE3D en corazones normales. Evaluar en qué nivel del aparato mitral se encuentra el orificio mitral efectivo. Material y métodos Se incluyeron 13 pacientes consecutivos y prospectivos, de 42 (29-47) años, 7 de sexo femenino, con indicación de eco transesofágico (9 por búsqueda de fuente embolígena y 4 por síndrome febril), que tenían un ETT2D normal y se encontraban con ritmo sinusal y normotensos en el momento del estudio. Se les realizó simultáneamente ETT2D y ETE3D. El área del TSVI y del AM se midió por ETT2D y ETE3D. Se estimó por ETE3D el área de la válvula mitral (VM) distal al AM. El volumen de cada tracto se calculó como el producto del área por la integral velocidad-tiempo (VTI) del flujo. Se estableció una hipotética área mitral efectiva (AME) como el cociente entre el volumen del TSVI (ETE3D) y la VTI del TEVI. Resultados Correlación (rs), concordancia e IC 95% entre área del AM por ETT2D vs. ETE3D: 0,506, 1,97 (-0,40 a 4,34), AME vs. ETE3D 0,549, 2,41 (-4,03 a -0,79) y AME vs. VM a 10.5 mm (8-12) del AM: 0,982, 0,079 (-0,26 a 0,42). La diferencia de volumen (ml) entre ambos tractos fue: ETT2D 12,8 (7,5-19), ETE3D 32,8 (25,9-48) y ETE3D (desde VM distal al AM) 1,8 (1,25-3,6). Conclusiones Cuanto mejor medimos el anillo mitral, más lejos estamos del orificio mitral efectivo. El área mitral a 1 cm del punto más alto del anillo mitral es la que más se acerca al orificio mitral efectivo.(AU)

Introduction Two-dimensional transthoracic echocardiography (2DTTE) is not a reliable method for estimating regurgitatant volume in mitral insufficiency due to inadequate measurement of the mitral annulus (MA). Three-dimensional transesophageal echocardiography (3DTEE) offers better tools for measuring the MA. Objectives The aim of this study was to compare the MA area and the difference in mitral inflow (MI) volume and left ventricular out-flow tract (LVOT) volume determined by 2DTTE and 3DTEE in normal hearts, and to evaluate at what level of the mitral valve apparatus the mitral effective orifice is actually located. Methods A total of 13 consecutive and prospective patients with indication of transesophageal echocardiography (9 to rule out cardioembolic source and 4 due to febrile syndrome) were included in the study. Their mean age was 42 (29-47) years and 7 were women. All the patients had normal 2DTTE, were in sinus rhythm and had normal blood pressure at the moment of the study. 2DTTE and 3DTEE were simultaneously performed. LVOT area and MA area were calculated by 2DTTE and 3DTEE. Mitral valve (MV) area distal to the MA was estimated by 3DTEE. Mitral inflow and LVOT volume were calculated as the product between the area and flow velocity time integral (VTI). The effective mitral valve area (EMVA) was hypothetically estimated by dividing the LVOT (3DTEE) volume by MI VTI. Results Correlation (rs), concordance and 95% CI between MA area by 2DTTE vs. 3DTEE: 0.506, 1.97 (-0.40 to 4.34), EMVA vs. 3DTEE: 0.549, 2.41 (-4.03 to -0.79) and EMVA vs. MV at 11 mm (8-12) of the MA: 0.982, 0.079 (-0.26 to 0.42). The difference between MI volume and LVOT volume (ml) was: 2DTTE: 12.8 (7.5-19), 3DTEE: 32.8 (25.9-48) and 3DTEE (from the MV distal to the MA) 1.8 (1.25-3.6). Conclusions The better the technique for measuring the mitral annulus, the farther we are from the mitral effective orifice. The mitral valve area measured at one centimeter of the highest point of the mitral annulus is the best approximation to the effective mitral orifice.(AU)

Comportamiento de la presión pulmonar y función del ventrículo derecho intraesfuerzo / Pulmonary Artery Pressure and Right Ventricular Function during Exercise

Introducción El comportamiento fisiológico de la presión pulmonar durante el ejercicio continúa sin establecerse con precisión. La literatura es discordante con respecto a los valores considerados patológicos de presión pulmonar intraesfuerzo (PPI) en ausencia de valvulopatía mitral e incluso, las últimas guías no recomiendan utilizar la presión pulmonar media ≥ 30 mmHg con el esfuerzo para definir hipertensión pulmonar. Es escasa la información disponible en relación a la respuesta hemodinámica y funcional del ventrículo derecho (VD) con el esfuerzo y tampoco sobre el hecho de si podría discriminar entre una respuesta fisiológica o patológica de la presión pulmonar. Objetivo Determinar el comportamiento de la PPI y comparar los parámetros ecocardiográficos de función sistólica y diastólica del VD en relación a sus niveles. Material y Métodos Se incluyeron 94 pacientes sin cardiopatías significativas, con adecuada factibilidad para estimar presión pulmonar sistólica (PPS) basal y en máxima carga durate el eco-estrés en ejercicio. De acuerdo al valor de presión pulmonar con el ejercicio, la población fue estratificada en dos grupos: a) PI < 50 mmHg / Hg (56) y b) PI ≥ 50 mm. (38) Se compararon las variables de función sistólica (onda S del Doppler tisular) y diastólica (Doppler pulsado en tracto de entrada y Doppler tisular de pared lateral) del VD. Resultados El 40% de la población analizada alcanzó una PPI ≥ 50 mm/Hg y se relacionó con mayor edad, sexo femenino y valores elevados de PPS basal. Los parámetros de función diastólica del VD no demostraron diferencias significativas. El grupo conPPI ≥ 50 mmHg presentó un menor incremento de la onda S del Doppler tisular como expresión de una disminución de la respuesta compensadora contráctil del VD. Conclusiones Un porcentaje elevado de la población estudiada desarrolló una PPI ≥ 50 mmHg. En relación al VD, no se observaron diferencias significativas en las variables de función diastólica y el grupo con PPI ≥ 50 mmHg presentó una menor respuesta sistólica compensadora con las cargas, como expresión de disfunción sub-clínica.

Background The physiological behavior of pulmonary artery pressure during exercise has not been precisely established yet. There is lack of agreement in the published literature about the abnormal values of pulmonary artery pressure (PAP) during exercise in the absence of mitral valve disease. Indeed, the last guidelines do not recommend using mean pulmonary artery pressure value ≥ 30 mmHg during exercise to define pulmonary hypertension. There is scarce information about the hemodynamic and functional response of the right ventricle (RV) during exercise and if it is useful to discriminate between a physiological or abnormal response of the pulmonary artery pressure. Objectives To determine the behavior of PAP during exercise and to compare the echocardiographic parameters of systolic and diastolic RV function in relation to PAP levels. Material and Methods A total of 94 patients without significant heart disease were included. Systolic pulmonary artery pressure (SPAP) at rest and maximum exercise during dobutamine stress echocardiography was adequately measured in all patients. The population was divided into two groups according to the value of pulmonary artery pressure during exercise: a) PAP <50 mmHg (56) b) PAP ≥50 mmHg (38). We also compared the variables of RV systolic function (S-wave measured by tissue Doppler imaging) and diastolic function (using pulsed Doppler echocardiography in the inlet tract and tissue Doppler echocardiography in the lateral wall). Results During exercise, 40% of the analyzed population reached a PAP ≥50 mm mmHg This value was associated with greater age, female gender and elevated values of SPAP at rest. The parameters of RV diastolic function did not present significant differences. The group with PAP ≥ 50 mmHg during exercise presented a less increase in the S-wave measured by tissue Doppler imaging as an expression of a compensatory reduced RV contractile performance. Conclusions A high percentage of the population developed PAP ≥50 mmHg during exercise. The variables of RV diastolic function did not show significant differences and the group with PAP ≥50 mmHg during exercise presented compensatory reduced RV contractile performance as an expression of subclinical dysfunction.

Thickening of the pulmonary artery wall in acute intramural hematoma of the ascending aorta.

BACKGROUND: The occurrence of pulmonary artery obstruction in the course of acute aortic dissection is an unusual complication. The mechanism implicated is the rupture of the outer layer of the aorta and the subsequent hemorrhage into the adventitia of the pulmonary artery that causes its wall thickening and, at times, produces extrinsic obstruction of the vessel. There are no reports of this complication in acute intramural hematoma. CASE PRESENTATION: An 87-year-old woman was admitted to the hospital in shock after having had severe chest pain followed by syncope. An urgent transesophageal echocardiogram revealed the presence of acute intramural hematoma, no evidence of aortic dissection, severe pericardial effusion with cardiac tamponade, and periaortic hematoma that involved the pulmonary artery generating circumferential wall thickening of its trunk and right branch with no evidence of flow obstruction. Urgent surgery was performed but the patient died in the operating room. The post mortem examination, in the operating room, confirmed that there was an extensive hematoma around the aorta and beneath the adventitial layer of the pulmonary artery, with no evidence of flow obstruction. CONCLUSION: This is the first time that this rare complication is reported in the scenario of acute intramural hematoma and with the transesophageal echocardiogram as the diagnostic tool.