Queridos Residentes, Cuidaos: una Guía Para Sobrevivir a la Psicología Clínica / Dear Trainees, Take Care of Yourselves: A Guide to Surviving Clinical Psychology

La residencia en psicología clínica es un proceso que pondrá al límite la capacidad de adaptación de los residentes,especialmente si no gozan de la supervisión y el soporte institucional adecuados. Conscientes de esta situación, estetrabajo pretende normalizar la complejidad que supone formarse como psicólogo clínico en España, poniendo unénfasis especial en los primeros pasos como residente en el Sistema Nacional de Salud y en los desafíos personalesque ello implica. Asimismo, persigue incrementar la sensibilidad sobre la necesidad de medidas que permitan a losresidentes sobrevivir a la psicología clínica. Por ende, se discute el estado del arte sobre el concepto de autocuidadodentro del campo de la psicología clínica y la psicoterapia desde la perspectiva de que especialistas mejor formadospodrán mejorar el Sistema Nacional de Salud y la atención a la salud mental de los más vulnerables.(AU)

The training system in clinical psychology in Spain is a process that will test the adaptability of trainees to thelimit, especially if they do not have adequate supervision and institutional support. Aware of this issue, this paperaims to normalize the complexity of training as a clinical psychologist in Spain, placing special emphasis on thefirst steps as a trainee in the National Health System and on the personal challenges involved. Moreover, it seeksto increase sensitivity and awareness about the importance of establishing measures that enable trainees to surviveclinical psychology. Therefore, the state of the art on the topic of self-care within the field of clinical psychologyand psychotherapy is discussed from the perspective that better trained specialists will improve the National HealthSystem and mental health care for the most vulnerable people.(AU)

Spanish validation of the Detachment and Compartmentalization Inventory (DCI) in a community and clinical sample. A new instrument for measuring dissociation.

INTRODUCTION: Dissociative symptoms are a type of phenomenon which is present in a wide variety of psychopathological disorders. It is therefore necessary to develop scales that measure this type of experience for therapy and research. Starting out from the bipartite model of dissociation, this study intended to adapt and validate the Detachment and Compartmentalization Inventory (DCI) in Spanish. MATERIAL AND METHODS: For this, 308 participants (268 from the community population and 40 with psychiatric pathology) completed the DCI, the Dissociative Experiences Scale (DES-II), the Somatoform Dissociation Questionnaire (SDQ20) and the Mindfulness Attention Awareness Scale (MAAS). RESULTS: The results showed that the Spanish version has a two-factor structure similar to the original version and was invariant across participants. The reliability of DCI scores was adequate and acquired evidence of validity related to other instruments. CONCLUSIONS: It is concluded that the DCI is a valid scale for detecting detachment and compartmentalization dissociative experiences, both in the clinic and research.

Childhood and adolescent trauma and dissociation: The mediating role of rumination, intrusive thoughts and negative affect.

Dissociation is a complex phenomenon which is present in a wide variety of psychiatric disorders and also in the general population. The objective of this study was to examine the relationship between childhood and adolescent traumas and development of dissociative phenomena in a nonclinical population, emphasizing the potentially mediating role of rumination, intrusive thoughts and negative affect in a population with no psychiatric pathology in adulthood. The sample was comprised of 337 participants from the general population (58.8% women) with a mean age of 33.10 years (SD: 14.08). They completed the Juvenile Victimization Questionnaire (JVQ), the Ruminative Response Scale (RRS), the White Bear Suppression Scale (WBSI), the Dissociative Experience Scale, 2d ver. Rev. (DES-II) and the Depression, Anxiety and Stress Scale (DASS-21). The results supported the starting hypotheses showing a positive correlation between childhood and adolescent trauma and dissociation, and between childhood and adolescent trauma and rumination, intrusive thoughts and negative affect, and mediation of these variables between childhood and adolescent trauma and dissociative states. The relationship between trauma in early ages and dissociation in adulthood is complex. Although the design used in this study was cross-sectional, the results are compatible with the starting hypothesis that rumination, intrusive thoughts and negative affect mediate this relationship.

Dissociation as a Mediator of Traumatic Childhood Experiences and Ideas of Reference.

Ideas of reference (IR) - self-attributions about what happens in the social environment are a frequent phenomenon present in a wide variety of people with mental health disorders as well as in the nonclinical population. The purpose of this study was to find out the relationship between traumatic childhood experiences, IR and dissociative states in the nonclinical population, emphasizing the potential mediating role of dissociation between traumatic experiences and IR. The sample was comprised of 337 participants from the general population (58.8% women) with a mean age of 33.20 years (SD = 14.08). They filled in the Juvenile Victimization Questionnaire (JVQ), the Dissociative Experiences Scale-II (DES-II) and the Referential thinking Scale (REF). The results supported the original hypotheses and showed that the participants with higher frequency of IR reported more childhood traumatic (χ2 (2) = 64.33, p < .001, f = .39, 1- ß = .99) and dissociative experiences (χ2 (2) = 50,414, p < .001, f = .38, 1- ß = .99), and that dissociative states (ß = .12, p < .05; 95%CI [.07, .19]; c´ = .26, p < .001), specifically absorption (ß = .09, p < .05; 95% CI [.03, .15]; c´ = .26, p < .001), mediated between traumatic childhood experiences and referential thinking. It was concluded that the relationship between traumatic experiences and IR is complex and may be mediated by variables such as dissociation.

La hora de la evaluación ambulatoria / The time of ambulatory assessment

La evaluación ambulatoria aglutina un conjunto de métodos que permiten evaluar mediante dispositivos móviles, y en múltiples momentos temporales, el comportamiento de las personas en su entorno natural y contexto diario. Permite una evaluación más precisa, dinámica, contextual e ideográfica que los métodos clásicos, abriendo nuevos horizontes con claras implicaciones para el diagnóstico y la intervención psicológica. El objetivo de este trabajo es realizar una introducción a la evaluación ambulatoria. En primer lugar, se realiza una delimitación conceptual y se comentan las cuestiones que viene a solucionar y sus posibles beneficios. En segundo lugar, se exponen aspectos relacionados con la metodología, abordando los diseños, los tipos de datos y un protocolo general de evaluación. En tercer lugar, se comentan algunas de las principales limitaciones, y se exponen las aplicaciones más relevantes. Finalmente, se comentan algunas recomendaciones para la aplicación de este tipo de metodología, y se analizan los retos y perspectivas futuras.(AU)

Ambulatory assessment brings together a set of methods that make it possible to evaluate, through mobile devices, and at multiple moments in time, the behavior of people in their natural environment and daily context. It allows a more precise, dynamic, contextual, and ideographic evaluation than the classical approaches, opening new horizons with clear implications for psychological intervention. The main goal of this paper is to provide an introduction to ambulatory assessment. First, a conceptual delimitation is made and the issues to be solved are discussed, as well as their possible benefits. Second, aspects related to the methodology are exposed, addressing the designs, data types, and a general evaluation protocol. Third, some of the main limitations are discussed, and the most relevant applications are presented. Finally, some recommendations for the application of this type of methodology are discussed, and some challenges and future perspectives are analyzed.(AU)

[Different phenotypes of mitral regurgitation in patients with right apical ventricular pacing: an echocardiographic approach in a heterogeneity of clinical scenarios]. / Distintos fenotipos de insuficiencia mitral en pacientes con estimulación apical del ventrículo derecho: un abordaje ecocardiográfico en una heterogeneidad de escenarios clínicos.

The presence of mitral regurgitation (MR) in patients with right ventricular apical pacing can be the result of multiple phenomena. On the one hand, this stimulation causes an asynchronous activation of the left ventricle (LV) and the papillary muscles, leading to a deterioration of the LV ejection fraction and causing an inadequate closure of the valve apparatus. However, there is a wide heterogeneity of ischemic and non-ischemic myocardial conditions that can coexist with mechanical alteration of the LV and the mitral valve leading to or worsening MR in these patients, which can make the etiological determination of valvular regurgitation difficult. Transthoracic echocardiography study allows comprehensive evaluation of mitral valve regurgitation and ventricular function parameters and mechanical asynchrony as a result of artificial pacing. The comprehensive study of these phenomena is relevant in clinical decision-making to define those patients who benefit from cardiac resynchronization therapy to alleviate symptomatic MR.

Actual impact of screening for myocardial ischemia with single-photon emission tomography among patients undergoing peripheral vascular interventions.

The present study provides actual data with regard to the prevalence of myocardial ischemia among patients under contemporary cardiovascular prevention strategies undergoing peripheral vascular interventions. We included a total of 200 consecutive patients who underwent gated single-photon emission computed tomography myocardial perfusion study between January 2012 and January 2014 as preoperative evaluation for peripheral vascular interventions at our institution. The baseline medical treatment comprised aspirin (81%), statins (79%), and ß-blockers (54%). Thirty-two (16%) patients underwent carotid revascularization; 69 (34.5%) patients underwent lower limb revascularization, and 99 patients underwent aortic interventions. Twenty-six (13%) patients showed evidence of myocardial ischemia, with an extensive ischemic burden identified in seven (3.5%) patients. Within the group of patients with peripheral vasculopathy, those with lower limb arteriopathy had a higher prevalence of ischemia. According to the results of the myocardial perfusion study, the cardiology in charge indicated invasive coronary angiography in 11/26 (42%) patients with evidence of myocardial ischemia. Seven of the 11 (64%) patients who had coronary angiography were revascularized. After a mean follow-up of 24 months, no cardiovascular adverse events were detected.

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.

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.

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.

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.

¿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)

Estenosis de la aorta abdominal sintomática: una rara complicación de la disección crónica de la aorta torácica descendente / Symptomatic stenosis of abdominal aorta: a rare complication of chronic dissection of the thoracic descending aorta

Se presenta el caso de un varón de 54 años que sufrió una disección aórtica torácica tipo B, inicialmente sin complicaciones. Con el tiempo se observó un aumento de la presión arterial asociado con deterioro de la función renal, claudicación de miembros inferiores y aparición de soplo abdominal. Diversos estudios evidenciaron compresión de la luz verdadera en la aorta abdominal por una falsa luz dilatada, proximal al origen de las renales. Con el implante de un stent aórtico desaparecieron el soplo abdominal, la claudicación y se normalizaron la presión arterial y la función renal.