All Roads Lead to Rome: Diverse Etiologies of Tricuspid Regurgitation Create a Predictable Constellation of Right Ventricular Shape Changes.

Introduction: Myriad disorders cause right ventricular (RV) dilation and lead to tricuspid regurgitation (TR). Because the thin-walled, flexible RV is mechanically coupled to the pulmonary circulation and the left ventricular septum, it distorts with any disturbance in the cardiopulmonary system. TR, therefore, can result from pulmonary hypertension, left heart failure, or intrinsic RV dysfunction; but once it occurs, TR initiates a cycle of worsening RV volume overload, potentially progressing to right heart failure. Characteristic three-dimensional RV shape-changes from this process, and changes particular to individual TR causes, have not been defined in detail. Methods: Cardiac MRI was obtained in 6 healthy volunteers, 41 patients with ≥ moderate TR, and 31 control patients with cardiac disease without TR. The mean shape of each group was constructed using a three-dimensional statistical shape model via the particle-based shape modeling approach. Changes in shape were examined across pulmonary hypertension and congestive heart failure subgroups using principal component analysis (PCA). A logistic regression approach based on these PCA modes identified patients with TR using RV shape alone. Results: Mean RV shape in patients with TR exhibited free wall bulging, narrowing of the base, and blunting of the RV apex compared to controls (p < 0.05). Using four primary PCA modes, a logistic regression algorithm identified patients with TR correctly with 82% recall and 87% precision. In patients with pulmonary hypertension without TR, RV shape was narrower and more streamlined than in healthy volunteers. However, in RVs with TR and pulmonary hypertension, overall RV shape continued to demonstrate the free wall bulging characteristic of TR. In the subgroup of patients with congestive heart failure without TR, this intermediate state of RV muscular hypertrophy was not present. Conclusion: The multiple causes of TR examined in this study changed RV shape in similar ways. Logistic regression classification based on these shape changes reliably identified patients with TR regardless of etiology. Furthermore, pulmonary hypertension without TR had unique shape features, described here as the "well compensated" RV. These results suggest shape modeling as a promising tool for defining severity of RV disease and risk of decompensation, particularly in patients with pulmonary hypertension.

Transient recovery of epicardial and torso ST-segment ischemic signals during cardiac stress tests: A possible physiological mechanism.

BACKGROUND: Acute myocardial ischemia has several characteristic ECG findings, including clinically detectable ST-segment deviations. However, the sensitivity and specificity of diagnosis based on ST-segment changes are low. Furthermore, ST-segment deviations have been shown to be transient and spontaneously recover without any indication the ischemic event has subsided. OBJECTIVE: Assess the transient recovery of ST-segment deviations on remote recording electrodes during a partial occlusion cardiac stress test and compare them to intramyocardial ST-segment deviations. METHODS: We used a previously validated porcine experimental model of acute myocardial ischemia with controllable ischemic load and simultaneous electrical measurements within the heart wall, on the epicardial surface, and on the torso surface. Simulated cardiac stress tests were induced by occluding a coronary artery while simultaneously pacing rapidly or infusing dobutamine to stimulate cardiac function. Postexperimental imaging created anatomical models for data visualization and quantification. Markers of ischemia were identified as deviations in the potentials measured at 40% of the ST-segment. Intramural cardiac conduction speed was also determined using the inverse gradient method. We assessed changes in intramyocardial ischemic volume proportion, conduction speed, clinical presence of ischemia on remote recording arrays, and regional changes to intramyocardial ischemia. We defined the peak deviation response time as the time interval after onset of ischemia at which maximum ST-segment deviation was achieved, and ST-recovery time was the interval when ST deviation returned to below thresholded of ST elevation. RESULTS: In both epicardial and torso recordings, the peak ST-segment deviation response time was 4.9±1.1 min and the ST-recovery time was approximately 7.9±2.5 min, both well before the termination of the ischemic stress. At peak response time, conduction speed was reduced by 50% and returned to near baseline at ST-recovery. The overall ischemic volume proportion initially increased, on average, to 37% at peak response time; however, it recovered to only 30% at the ST-recovery time. By contrast, the subepicardial region of the myocardial wall showed 40% ischemic volume at peak response time and recovered much more strongly to 25% as epicardial ST-segment deviations returned to baseline. CONCLUSION: Our data show that remote ischemic signal recovery correlates with a recovery of the subepicardial myocardium, whereas subendocardial ischemic development persists.

Pharmacological and simulated exercise cardiac stress tests produce different ischemic signatures in high-resolution experimental mapping studies.

OBJECTIVE: Test the hypothesis that exercise and pharmacological cardiac stressors create different electrical ischemic signatures. INTRODUCTION: Current clinical stress tests for detecting ischemia lack sensitivity and specificity. One unexplored source of the poor detection is whether pharmacological stimulation and regulated exercise produce identical cardiac stress. METHODS: We used a porcine model of acute myocardial ischemia in which animals were instrumented with transmural plunge-needle electrodes, an epicardial sock array, and torso arrays to simultaneously measure cardiac electrical signals within the heart wall, the epicardial surface, and the torso surface, respectively. Ischemic stress via simulated exercise and pharmacological stimulation were created with rapid electrical pacing and dobutamine infusion, respectively, and mimicked clinical stress tests of five 3-minute stages. Perfusion to the myocardium was regulated by a hydraulic occluder around the left anterior descending coronary artery. Ischemia was measured as deflections to the ST-segment on ECGs and electrograms. RESULTS: Across eight experiments with 30 (14 simulated exercise and 16 dobutamine) ischemic interventions, the spatial correlations between exercise and pharmacological stress diverged at stage three or four during interventions (p<0.05). We found more detectable ST-segment changes on the epicardial surface during simulated exercise than with dobutamine (p<0.05). The intramyocardial ischemia formed during simulated exercise had larger ST40 potential gradient magnitudes (p<0.05). CONCLUSION: We found significant differences on the epicardium between cardiac stress types using our experimental model, which became more pronounced at the end stages of each test. A possible mechanism for these differences was the larger ST40 potential gradient magnitudes within the myocardium during exercise. The presence of microvascular dysfunction during exercise and its absence during dobutamine stress may explain these differences.

Right Ventricular Shape Distortion in Tricuspid Regurgitation.

Tricuspid regurgitation (TR) is a failure in right-sided AV valve function which, if left untreated, leads to marked cardiac shape changes and heart failure. However, the specific right ventricular shape changes resulting from TR are unknown. The goal of this study is to characterize the RV shape changes of patients with severe TR. RVs were segmented from CINE MRI images. Using particle-based shape modeling (PSM), a dense set of homologous landmarks were placed with geometric consistency on the endocardial surface of each RV, via an entropy-based optimization of the information content of the shape model. Principal component analysis (PCA) identified the significant modes of shape variation across the population. These modes were used to create a patient-prediction model. 32 patients and 6 healthy controls were studied. The mean RV shape of TR patients demonstrated increased sphericity relative to controls, with the three most dominant modes of variation showing significant widening of the short axis of the heart, narrowing of the base at the RV outflow tract (RVOT), and blunting of the RV apex. By PCA, shape changes based on the first three modes of variation correctly identified patient vs. control hearts 86.5% of the time. The shape variation may further illuminate the mechanics of TR-induced RV failure and recovery, providing potential targets for therapies including novel devices and surgical interventions.

Análisis y predicción de la incidencia de tuberculosis pulmonar con baciloscopia positiva en Cienfuegos / Analysis and Prediction of the Incidence of Smear-positive Pulmonary Tuberculosis in Cienfuegos

Fundamento: la eliminación de la tuberculosis como problema de salud pública precisa el perfeccionamiento de las acciones preventivas sobre los casos de tuberculosis pulmonar con baciloscopia positiva.Objetivo: analizar la incidencia de tuberculosis pulmonar con baciloscopia positiva en el municipio Cienfuegos durante 1995-2013 y establecer pronóstico para el cuatrienio 2014- 2017.Métodos: estudio descriptivo retrospectivo que incluyó 133 casos de pacientes con baciloscopia positiva notificados. Se analizó: edad, sexo, área de salud, resultado de la baciloscopia, demora y lugar de diagnóstico. La predicción fue realizada con el modelo suavizado exponencial de Brown.Resultados: la baciloscopia positiva presentó una tendencia decreciente, representó el 56,1 % del total de casos de tuberculosis pulmonar. Predominaron los enfermos masculinos y el grupo de edades de 60 años y más. El 84,2 % de los casos presentó codificaciones altas en los exámenes microscópicos de esputo realizados. Menos del 52 % de los diagnósticos fueron realizados en la atención primaria de salud y solo el 50 % se enmarcó dentro del tiempo establecido por el programa como indicador operacional. Se predice que ocurrirá un discreto descenso de casos nuevos de pacientes con baciloscopia positiva en los próximos cuatro años. Conclusiones: eliminar la tuberculosis como problema sanitario es posible a mediano plazo en Cienfuegos; sin embargo el incumplimiento persistente de los indicadores que evalúan las acciones preventivas realizadas en los casos con baciloscopia positiva es y será un obstáculo serio para reducir la morbilidad y transmisibilidad de la enfermedad en la localidad.

Background: the elimination of tuberculosis as a public health problem requires improvement of preventive actions focusing on smear-positive pulmonary tuberculosis patients. Objectives: to analyze the incidence of smear-positive pulmonary tuberculosis in the municipality of Cienfuegos during 1995-2013 and to establish the prediction for the four-year period from 2014 through 2017. Methods: a retrospective descriptive study involving 133 notified smear-positive patients was conducted. The variables analyzed were: age, sex, health area, smear result, diagnostic delay and setting where diagnosis was established. The prediction was performed using the Brown’s exponential smoothing method. Results: positive smears showed a decreasing trend, accounting for 56.1% of all cases of pulmonary tuberculosis. Male patients and the group aged 60 years and over predominated. Eighty four point two percent of the patients had high grading in the sputum examinations performed. Less than 52% of the diagnoses were established in the primary health care and only 50% was reached within the time set by the program as an operational indicator. A discrete decline in new smear-positive cases in the next four years is predicted. Conclusions: the elimination of tuberculosis as a health problem can be achieved in the medium term in Cienfuegos; however the persistent failure to comply with the indicators evaluating preventive actions for smear-positive cases is and will be a serious obstacle to reducing morbidity and transmissibility of the disease in this municipality. .

Análisis y predicción de la incidencia de tuberculosis pulmonar con baciloscopia positiva en Cienfuegos / Analysis and prediction of the incidence ofsSmear-positive pulmonary tuberculosis in Cienfuegos

Fundamento: la eliminación de la tuberculosis como problema de salud pública precisa el perfeccionamiento de las acciones preventivas sobre los casos de tuberculosis pulmonar con baciloscopia positiva. Objetivo: analizar la incidencia de tuberculosis pulmonar con baciloscopia positiva en el municipio Cienfuegos durante 1995-2013 y establecer pronóstico para el cuatrienio 2014- 2017. Métodos: estudio descriptivo retrospectivo que incluyó 133 casos de pacientes con baciloscopia positiva notificados. Se analizó: edad, sexo, área de salud, resultado de la baciloscopia, demora y lugar de diagnóstico. La predicción fue realizada con el modelo suavizado exponencial de Brown. Resultados: la baciloscopia positiva presentó una tendencia decreciente, representó el 56,1 por ciento del total de casos de tuberculosis pulmonar. Predominaron los enfermos masculinos y el grupo de edades de 60 años y más. El 84,2 por ciento de los casos presentó codificaciones altas en los exámenes microscópicos de esputo realizados. Menos del 52 por ciento de los diagnósticos fueron realizados en la atención primaria de salud y solo el 50 por ciento se enmarcó dentro del tiempo establecido por el programa como indicador operacional. Se predice que ocurrirá un discreto descenso de casos nuevos de pacientes con baciloscopia positiva en los próximos cuatro años.Conclusiones: eliminar la tuberculosis como problema sanitario es posible a mediano plazo en Cienfuegos; sin embargo el incumplimiento persistente de los indicadores que evalúan las acciones preventivas realizadas en los casos con baciloscopia positiva es y será un obstáculo serio para reducir la morbilidad y transmisibilidad de la enfermedad en la localidad(AU)

Background: the elimination of tuberculosis as a public health problem requires improvement of preventive actions focusing on smear-positive pulmonary tuberculosis patients. Objectives: to analyze the incidence of smear-positive pulmonary tuberculosis in the municipality of Cienfuegos during 1995-2013 and to establish the prediction for the four-year period from 2014 through 2017. Methods: a retrospective descriptive study involving 133 notified smear-positive patients was conducted. The variables analyzed were: age, sex, health area, smear result, diagnostic delay and setting where diagnosis was established. The prediction was performed using the Brown's exponential smoothing method.Results: positive smears showed a decreasing trend, accounting for 56.1 percent of all cases of pulmonary tuberculosis. Male patients and the group aged 60 years and over predominated. Eighty four point two percent of the patients had high grading in the sputum examinations performed. Less than 52 percent of the diagnoses were established in the primary health care and only 50 percent was reached within the time set by the program as an operational indicator. A discrete decline in new smear-positive cases in the next four years is predicted. Conclusions: the elimination of tuberculosis as a health problem can be achieved in the medium term in Cienfuegos; however the persistent failure to comply with the indicators evaluating preventive actions for smear-positive cases is and will be a serious obstacle to reducing morbidity and transmissibility of the disease in this municipality(AU)

Atresia esofágica y fístula traqueoesofágica: nuestra experiencia / Esophageal atresia and tracheosophageal fistula: our experience

Se realiza una introducción y se enfatiza en la necesidad del diagnóstico y tratamiento precoz de esta anomalia, para disminuir la morbimortalidad. Se realiza un estudio retrospectivo del total de pacientes diagnosticados e intervenidos quirúrgicamente durante el período 1969-1983 en el Hospital Pediátrico Docente "Eliseo (Noel) Caamaño" de Matanzas

Atresia esofágica y fístula traqueoesofágica: nuestra experiencia / Esophageal atresia and tracheosophageal fistula: our experience

Se realiza una introducción y se enfatiza en la necesidad del diagnóstico y tratamiento precoz de esta anomalia, para disminuir la morbimortalidad. Se realiza un estudio retrospectivo del total de pacientes diagnosticados e intervenidos quirúrgicamente durante el período 1969-1983 en el Hospital Pediátrico Docente "Eliseo (Noel) Caamaño" de Matanzas (AU)