Cecilia Corros

3D color-Doppler echocardiography and chronic aortic regurgitation: A novel approach for severity assessment

BACKGROUND 3D echocardiography provides a complete evaluation of the aortic valve and adjacent structures and it improves the assessment of this cardiac region. Three-dimensional color-Doppler echocardiography (3DCDE) evaluation might improve the measurements of the functional regurgitant orifice in patients with Chronic Aortic Regurgitation (CAR). OBJECTIVES Our aim was to compare the accuracy of current echo-Doppler methods and 3DCDE for the assessment of CAR severity. The reference method used in this work was the CAR severity determined by means of cardiac magnetic resonance (CMR) METHODS: Thirty-two consecutive patients with an established diagnosis of CAR recruited in our institution comprised our study group. CAR severity was determined by conventional Echo-Doppler methods and by 3DCDE and their results were compared with those obtained by means of CMR. RESULTS Mean age was 63.0 ± 13.5 years. Twenty-two patients (68.8%) were men. Compared with the traditional echo-Doppler methods, 3DCDE evaluation had the best linear association with CMR results (3D vena contracta cross sectional area method: r = 0.88; r square = 0.77; p < 0.001. 3D vena contracta cross sectional area/left ventricular outflow tract cross sectional area method: r = 0.87; r square = 0.75; p < 0.001). The ROC analysis showed an excellent area under curve for detection of severe CAR (3D vena contracta cross sectional area method = 0.97; 3D vena contracta cross sectional area/left ventricular outflow tract cross sectional area method = 0.98). Inter- and intra-observer variability for the 3DCDE evaluation was good (ICC = 0.89 and ICC = 0.91 for inter and intra observer variability respectively). CONCLUSIONS 3DCDE is an accurate and highly reproducible diagnostic tool for estimating CAR severity. Compared with the traditional echo-Doppler methods, 3DCDE has the best agreement with the CMR determined CAR severity. Thus, 3DCDE is a diagnostic method that may improve the therapeutic management of patients with CAR.

Relocation of minimal luminal diameter after bare metal and drug-eluting stent implantation: Incidence and impact on angiographic late loss

Late loss (LL) has been a fundamental angiographic end‐point in drug‐eluting stents (DES) clinical trials. However, calculation of LL may be affected by a mismatch between post‐procedure (PO) and follow‐up (FU) sites of the minimal lumen diameter (MLD). Our aims were to investigate the incidence and methodological implications of the relocation of MLD after bare metal (BMS), sirolimus‐eluting (SES), and paclitaxel‐eluting (PES) stent implantation. Data from DIABETES I and II trials, which involved diabetic patients treated with BMS, SES, and PES, were analyzed. Angiographic data with matched projections between PO and 9‐month angiographic FU were included. In‐stent, in‐lesion, and in‐segment analyses included conventional and customized sub‐segmental (5‐mm/subsegment) methodology. MLD relocation was considered when the sites of MLD shifted a distance ≫ the intrinsic variability of the method. Conventional LL, site matched LL, maximal LL (MaxLL), and average LL (AvgLL) were calculated. Relationships between various LL and 1‐year target lesion revascularization (TLR) were investigated. Post MLD was located distally, outside the stent, in ≥65% of the analyses. At FU, MLD relocation occurred in 70.5% (BMS), 40% (SES), and 35% (PES). MLD shifted ≥11 mm on average, mainly towards the stented segment. MLD relocation still occurred in 42.8% (BMS), 33.7% (SES), and 36.4% (PES), when analysis was restricted to in‐stent segment. Among LL measurements, MaxLL showed the best association with TLR rates. Relocation of the MLD is a frequent phenomenon after both BMS and DES, and should be taken into account when calculating LL. Comprehensive LL analyses, including MaxLL and AvgLL, provides a better appraisal of the biological and clinical effectiveness of DES.

Usefulness of cardiac magnetic resonance imaging in left ventricular non‐compaction cardiomyopathy

We have read with great interest the paper published recently in your journal by Habib et al. about isolated left ventricular non-compaction in adults. As the authors say, the genetic and clinical features, prognosis and characterization of this fascinating entity remain incompletely understood and the subject of interesting debate in the scientific community. As stated by the authors, difficulties commence with the diagnostic criteria, as different timings of measurement, at systole or diastole, have been proposed. In addition even for experts, making a final diagnosis can be difficult; and echocardiography laboratories have contributed to the great increase in noncompaction cardiomyopathy diagnosis or over diagnosis. Certainly, although both 3D and contrast echocardiography can improve the assessment of this cardiomyopathy, we must not forget that cardiac magnetic resonance imaging (MRI) can also play an important role in its diagnosis. The spatial resolution of this technique, its ability for evaluating cardiac function and what is more, the tissue characterization by the late-gadolinium hyperenhancement sequence makes it an excellent tool for the diagnosis of cardiomyopathies, especially in the case of non-compaction in which differential diagnosis from other entities such as hypertrophic cardiomyopathy, can sometimes be difficult. Late gadolinium enhancement is a surrogate of myocardial fibrosis, Nucifora et al. recently published a report in this journal demonstrating correlation of fibrosis with clinical severity and ventricular dysfunction in patients with non-compaction disease. Thus, fibrosis represents a marker of poor prognosis that could be used as a stratification tool in these patients, similar to that proposed for hypertrophic cardiomyopathy. Many questions remain about left ventricular non-compaction disease, but cardiac MRI can provide some of the answers: a more precise diagnosis based on a better endomyocardial definition and tissue characterization that can help to determine patient prognosis.

Estudio de la deformación miocárdica: predictor de disfunción ventricular a medio plazo tras cirugía en pacientes con insuficiencia mitral crónica

Introduccion y objetivos. El desarrollo de disfuncion ventricular izquierda tras la sustitucion valvular mitral es un problema frecuente en pacientes con insuficiencia mitral grave cronica. El analisis de la deformacion miocardica permite estimar con precision la contractilidad miocardica. Nuestro objetivo fue comparar el valor predictivo de strain (S) y strain rate (SR) preoperatorios obtenidos por speckle-tracking y Doppler tisular (DTI) para predecir la disminucion de la fraccion de eyeccion del ventriculo izquierdo (FEVI) a medio plazo tras la cirugia. Metodos. Treinta y ocho pacientes consecutivos con insuficiencia mitral grave cronica programados para sustitucion valvular mitral fueron incluidos prospectivamente. Se analizo el S y el SR longitudinal del septo interventricular en el periodo preoperatorio mediante speckle-tracking y DTI. La FEVI preoperatoria y postoperatoria se obtuvo por ecocardiografia tridimensional. Los estudios ecocardiograficos se realizaron dentro de las 48 h previas a la cirugia y 6 meses despues de la cirugia. Resultados. La media de edad de los pacientes era 59,9 ± 11,3 anos; 10 pacientes (29,4%) eran varones. Tanto el speckle-tracking como el DTI resultaron predictores de disminucion de la FEVI > 10% a 6 meses. Sin embargo, el valor predictivo del speckle-tracking fue superior al del DTI. El S longitudinal del septo interventricular basal mediante speckle-tracking fue el parametro con mayor poder predictivo, con un area bajo la curva de 0,85 y un punto de corte optimo de -0,11. Conclusiones. El speckle-tracking permite predecir la disminucion de la FEVI a medio plazo tras la sustitucion valvular mitral. Ademas, el speckle-tracking es mas preciso que el DTI para este fin.

Evaluación de los cambios dinámicos de las placas coronarias y sus consecuencias clínicas en pacientes con diabetes mellitus tipo 2: un estudio de ecografía intracoronaria seriada

INTRODUCTION AND OBJECTIVES One of the aims of secondary prevention is to achieve plaque stabilization. This study sought to investigate the clinical consequences and predictive factors of the change in the type of plaque (CTP) as assessed by serial intracoronary ultrasound in type II diabetic patients with known coronary artery disease. METHODS 237 segments (45 patients) from the DIABETES I, II, and III trials were included. Intracoronary ultrasound from motorized pullbacks (0.5mm/s) after index procedure and at 9-month angiographic follow-up was performed in the same coronary segment. Nontreated mild lesions (angiographic stenosis <25%) with ≥0.5mm plaque thickening and ≥5mm of length assessed by intracoronary ultrasound were included. As different types of plaques may be encountered throughout a given coronary lesion, each study lesion was divided into 3 segments for serial quantitative and qualitative analyses. Statistical adjustment by multiple lesion segments per patient (generalized estimating equations method) was performed. A CTP was defined as any qualitative change in plaque type at follow-up. At 1-year follow-up, major adverse cardiac events - death, myocardial infarction and target vessel revascularization) - were recorded. RESULTS A CTP was observed in 48 lesions (20.2%) and occurred more frequently (52.1%) in mixed plaques. Independent predictors of CTP were glycated hemoglobin levels (odds ratio [OR] 1.2; 95% confidence interval [CI] 1.01-1.5; P=.04); glycoprotein IIb-IIIa inhibitors (OR 0.3; 95% CI 0.1-0.7; P=.004) and statin administration (OR 0.3; 95% CI 0.1-0.8; P=.02). At 1-year follow-up CTP was associated with an increase in major adverse cardiac events rate (CTP 20.8% vs non-CTP 13.8%, P=.008; hazard ratio=1.9, 95% CI 1.3-1.9, P=.01). CONCLUSIONS Qualitative changes in mild stenosis documented by intracoronary ultrasound in type II diabetics are associated with suboptimal secondary prevention and may have clinical consequences. Full English text available from: www.revespcardiol.org.

Double pseudoaneurysm, recurrent subvalvular aortic membrane and small left ventricular outflow tract in the same patient: who dares?

Patients with pseudoaneurysm in the left ventricular outflow tract (LVOT) commonly present vague and nonspecific symptoms making the diagnosis difficult. We present the case of a 37-year-old patient with two subvalvular pseudoaneurysms in whom a combined resection surgery, enlargement of the LVOT, aortic valve replacement (AVR) and aortic root replacement were performed using the technique of Cabrol.

Infective endocarditis and caseous calcification of the mitral annulus: The odd couple

Caseous calcification of the mitral annulus is an infrequent echocardiographic finding. The differential diagnosis includes other entities like tumors, abscess or thrombus. Both cardiac CT and cardiac MRI may be useful for its definitive diagnosis.

Atrial septal dissection and left-to-right shunt after mitral valve replacement: assessment with real-time three-dimensional transoesophageal echocardiography

A 68-year-old woman with a history of rheumatic heart disease was referred to our Institution with heart failure symptoms. In 1991, she had undergone aortic valve replacement due to aortic stenosis. A two-dimensional transthoracic echocardiogram (2D-TTE) revealed severe mitral regurgitation (SMR) and stenosis, severe tricuspid regurgitation, pulmonary hypertension, giant left atrium (LA) and non-dilated LV with normal left …

The importance of echocardiography in transcatheter aortic valve implantation: TAVI: a multimodality approach.

recently publishedin your journal about the importance of echocar-diography in transcatheter aortic valve implanta-tion (TAVI). We completely agree with theauthors regarding the major role of echocardiog-raphy in the selection of patients, prior to proce-dure, during the procedure, and also in thefollow-up. However, we think that in the era ofmultimodality imaging different techniques mustbe take into account, to provide a comprehen-sive assessment before and post TAVI. In thisaspect, multidetector computed tomography(MCT) plays an important role in patient screen-ing before TAVI, provides detailed anatomicassessment of the aortic root and valve annulus,assesses the suitability of iliofemoral access, anddetermines appropriate coaxial angles to opti-mize the valve implantation procedure.

Heart involvement in systemic sclerosis: present but not evident

A 42 year old woman, with a previous diagnosis of systemic sclerosis (SSc) with Raynaud‘s phenomenon and skin involvement, came into the Emergency Department complaining of dyspnea and palpitations. Previous echocardiogram practised several months ago was normal. Pulmonary pressure and pulmonary function tests were also normal. ANAs were positive while RNP and anti Scl 70 antibodies were negative. Physical exam revealed severe skin sclerosis with sclerodactilia. Tachycardia without murmurs and a normal jugular venous pressure. No crackles or rales over lungs. No peripheral oedema. ECG showed an atrial flutter, previously unknown while thorax radiography and contrast enhanced spiral CT ruled out pulmonary disease or thromboembolism. Cardioversion of atrial flutter was practised after transoesophageal echocardiogram which exluded thrombus in left atrium, with good clinical evolution. Cardiac-MRI was carried out with a 1.5 T MRI scanner. It revealed a diffuse, anular and non-coronary distribution myocardial late gadolinium hyperenhancement, without hypertrophy or contraction abnormalities. (Figure 1: Short axis and two chamber view. SSFP sequence and late gadolinium hyperenhancement sequence, note the anular enhancement). Myocardial fibrosis in SSc has been reported in 50–80% of necropsy series. It can manifest as biventricular cardiac failure, both atrial and ventricular arrhytmias, like in our case, and even with sudden death. The diagnosis of myocardial fibrosis is difficult by non-invasive methods. Several studies have analyzed the late myocardial fibrosis by MRI. Usually it has a linear pattern limited to the midwall layer with invariable sparing of the subendocardium and epicardium [1, 2]. Patients with abnormal Holter studies and those with long duration of Raynaud‘s phenomenon