Aníbal Arias

Prospective Validation of the Prognostic Usefulness of Brain Natriuretic Peptide in Asymptomatic Patients With Chronic Severe Mitral Regurgitation

OBJECTIVES The purpose of the study was to determine the independent and additive prognostic value of brain natriuretic peptide (BNP) in patients with severe asymptomatic mitral regurgitation and normal left ventricular function. BACKGROUND Early surgery could be advisable in selected patients with chronic severe mitral regurgitation, but there are no criteria to identify candidates who could benefit from this strategy. Assessment of BNP has not been studied in asymptomatic patients with severe mitral regurgitation; hence, its prognostic value remains unclear. METHODS We prospectively evaluated 269 consecutive patients with severe asymptomatic organic mitral regurgitation and left ventricular ejection fraction above 60%. The first 167 consecutive patients served as the derivation cohort, and the following 102 patients served as a validation cohort. The combined end point was the occurrence of either symptoms of congestive heart failure, left ventricular dysfunction, or death at follow-up. RESULTS The end point was reached in 35 (21%) patients of the derivation set and in 21 (20.6%) patients of the validation cohort. The receiver-operating characteristics curve yielded an optimal cutoff point of 105 pg/ml of BNP that was able to discriminate patients at higher risk in both cohorts (76% vs. 5.4% and 66% vs. 4.0%, respectively). In both sets, BNP was the strongest independent predictor by multivariate analysis. CONCLUSIONS Among patients with severe asymptomatic organic mitral regurgitation, BNP > or =105 pg/ml discriminates a subgroup of patients at higher risk. Because of its incremental prognostic value, BNP assessment should be considered in clinical routine workup for risk stratification.

Dobutamine-Precipitated Takotsubo Cardiomyopathy Mimicking Acute Myocardial Infarction A Multimodality Image Approach

A 77-year-old woman was referred for a dobutamine stress test. She had a prior history of hypertension. Basal ECG was normal (Figure 1A). At 40 μg · kg−1 · min−1 she developed typical chest pain with ST-segment elevation in DI, DII, and the anterior leads with ventricular bigeminy (Figure 1B and 1C). The echocardiogram showed apical and mid-wall myocardial segment akinesis with basal hyperkinesis and left outflow tract gradient obstruction of 60 mm Hg. The …

Prognostic Value of Left Atrial Volume in Asymptomatic Organic Mitral Regurgitation

BACKGROUND Basal left atrial volume (LAV) indexed to body surface area (LAVI) predicts adverse events in patients with organic mitral regurgitation, but information is lacking regarding change in left atrial volume during follow-up. METHODS One hundred forty-four asymptomatic patients (mean age, 71 ± 12 years; 66% women; mean ejection fraction, 66 ± 4.8%) with moderate to severe mitral regurgitation were prospectively included, with a median follow-up period of 2.76 years (interquartile range, 1.86-3.48 years). RESULTS Fifty-four patients (37.50%) reached the combined end point of dyspnea and/or systolic dysfunction. Both basal and change in LAV were independently associated with the combined end point on multivariate analysis: for basal LAVI ≥ 55 mL/m(2), odds ratio, 2.26 (95% confidence interval, 1.04-4.88; P = .038), and for change in LAV ≥ 14 mL, odds ratio, 7.32 (95% confidence interval, 3.25-16.48; P < .001), adjusted for effective regurgitant orifice area and deceleration time. Combined event-free survival at 1, 2, and 3 years was significantly less in patients with basal LAVI ≥ 55 mL/m(2) (75%, 58%, and 43%) than in those with basal LAVI < 55 mL/m(2) (95%, 89%, and 77%) (log-rank test = 15.38, P = .0001). The incidence of the combined end point was highest (88%) in patients with basal LAVI ≥ 55 mL/m(2) and change in LAV ≥ 14 mL. CONCLUSIONS Measurement of basal LAV and its increase during follow-up predict an adverse course in patients with moderate and severe asymptomatic mitral regurgitation. Hence, its assessment could be incorporated into the currently used algorithm for risk stratification and decision making in this group of patients.

Catecholamine-Induced Myocarditis in Pheochromocytoma

A 25-year-old man arrived at the emergency room of his community hospital complaining of abdominal pain, headaches, and palpitations that had appeared suddenly while he was playing soccer. He had no history of hypertension. An abdominal ultrasound revealed a tumor located in the right adrenal gland. He was subsequently transferred to our hospital for further evaluation. On admission, he presented acute pulmonary edema with severe hypertension (blood pressure, 220/120 mm Hg). He was admitted to the coronary care unit. Intravenous vasodilators and loop diuretics were administered, with rapid recovery of clinical status. ECG showed sinus rhythm, a heart rate of 80 bpm, and T-wave inversion in the DI, DII, and AVL leads. Transthoracic echocardiography revealed left …

New-Onset Liver Failure: Pitfalls of an Unusual Diagnosis

Introduction: Heart failure is the second most common cause of ascites after cirrhosis. There are cardiac and noncardiac etiologies of ascites, and the multimodality imaging approach is a rich tool to redefine the final diagnosis. Case Presentation: We present a case-series where 3 patients were referred to our hospital for further hepatology assessment due to severe abdominal ascites and liver failure. Constrictive pericarditis was diagnosed in all of them. Nowadays, constrictive pericarditis is a well-known disease, but sometimes its clinical presentation may delay the treatment and worsen the prognosis. Our 3 cases had similar clinical scenarios and hemodynamic patterns when undergoing right-heart catheterization, but they had different anatomical pericardium-compromise, requiring different surgical strategies. Conclusions: Nowadays, multimodality imaging, especially cardiac magnetic resonance imaging and cardiac computed tomography, allows us to study a wide spectrum of the same disease in terms of anatomical compromise and cardiac physiology in order to stratify different prognosis and treatment options. We describe 3 unusual clinical cases where the initial differential diagnosis denoted noncardiac etiologies. The level of serum NT-proBNP proved pivotal to the redefinition of the clinical scenario and differentiation between the cardiac and noncardiac etiologies of new-onset ascites. A multidisciplinary approach in this setting between internists, hepatologists, and cardiologists was helpful to establish the final diagnosis in all the patients.

Hypertrophic Cardiomyopathy, All Phenotypes in one

Hypertrophic cardiomyopathy (HCM) is an intrinsic myocardial disorder characterized by cardiac hypertrophy (wall thickness ≥ 15 mm), that is not explained by conditions of pressure overload (eg, hypertension, severe aortic stenosis).1 HCM is the most common genetic primary cardiomyopathy, with a prevalence estimated to be about one in 500 adults in the general population.2 More than 450 mutations have been identified in the 20 genes that cause different phenotypes. In most cases, HCM is associated with sarcomere protein gene mutations, and exhibits multiple phenotypic expressions. We present a case that combines all phenotypes.3

Takotsubo Cardiomyopathy with Extracorporeal Membrane Oxygenation (ECMO) Requirement after Atrial Myxoma Surgery

Mailing Address: Fernando Garagoli Peron, 4190. Postal Code: C1183AEG, Almagro, Ciudad Autónoma de Buenos Aires – Argentina. E-mail: fernando.garagoli@hospitalitaliano.org.ar Takotsubo Cardiomyopathy with Extracorporeal Membrane Oxygenation (ECMO) Requirement after Atrial Myxoma Surgery Fernando Garagoli, Aníbal Arias, Vadim Kotowicz, Arturo Cagide, César Belziti Hospital Italiano de Buenos Aires, Caba – Argentina

Síndrome de ortodeoxia-platipnea y embolia luego de endocarditis derecha complicada: consecuencias del Foramen Oval Permeable

Se presenta el caso clinico de una mujer de 63 anos de edad con Endocarditis de la Valvula Tricuspide que de-sarrollo tromboembolismo pulmonar y un sindrome de platipnea-ortodeoxia, explicado por la presencia de un formen oval permeable. La paciente se recupero satis-factoriamente despues de un reemplazo de la valvula tricuspide.