Eulo Lupi-Herrera

Acute right ventricular infarction: clinical spectrum, results of reperfusion therapy and short-term prognosis

BackgroundThe role of thrombolytic therapy (TT) and percutaneous coronary interventions (PCIs) in subgroups of patients with right ventricular infarction (RVI) has not been evaluated. Methods and ResultsWe risk-stratified 302 patients with RVI into three subsets upon admission. Class A (n =197) comprised patients without right ventricular (RV) failure, Class B (n =69) with RV failure and Class C (n =36) with cardiogenic shock. All eligible patients in Class A or B received either PCI or TT. Patients in Class C eligible for reperfusion were treated with PCI. All patients were evaluated for in-hospital major adverse cardiac events and short-term mortality. There was a statistically significant difference in in-hospital mortality among the classes. Classes B and C were the strongest indicators of in-hospital mortality. By multivariate analysis TT or PCI did not reduce mortality in Classes A and B, but a clinically favorable trend in mortality reduction was documented: both methods decreased RV dysfunction in Class B (from 97% to 61% with TT and to 28% with PCI;P u2009<u20090.001) and PCI reduced the risk of mortality in Class C (89.5% compared with 58%;P u2009<u20090.05). ConclusionsClassification into types A, B or C allows the prediction of mortality. The use of TT or PCI suggests a clinical favorable trend in the reduction of mortality in Class A, either is beneficial in Class B for decreasing morbidity and PCI appears to be the most appropriate procedure for Class C since it reduced mortality.

Clinical-Echocardiographic Correlation of Myocardial Infarction with Extension to Right Chambers.

In order to determine the transesophageal echocardiographic characteristics in patients with acute myocardial infarction of right ventricle and establish the relationship between these findings, the clinical condition, and their prognostic value, 38 patients consecutively admitted to the Instituto Nacional de Cardiología with a diagnosis of acute left ventricular myocardial infarction with extension to right ventricle and/or atrium were retrospectively studied. Of the left ventricular infarctions, 37 were posteroinferior and one anterior. Significant elevations of CPK and DHL were found in 35. In 30 patients (78%) electrocardiographic evidence of extension of infarction to the right ventricle was found, and in 3, evidence of right atrial infarction. Twenty‐one patients presented clinical data compatible with right ventricular infarction. In 19, cardiac rhythm and atrioventricular conduction disturbances were documented. Coronary angiograms practiced on 34 patients demonstrated single‐vessel (right coronary) disease in 12, affection of two vessels in 14, and lesions in three or more in 6. Coronary arteries presented no significant lesions in two cases. With TEE, alterations of right ventricular segmental mobility were demonstrated in all patients, and in 6, alterations of right atrial mobility as well. As respects the ventricular wall movement index, 68.5% had total scores (RV + LV) of 7lt;5. The other 31.5% had scores ≤ 5. In 26%, the right ventricular wall movement index was ≤ 4. The RVDD/LVDD ratio was 1 or less in 30 patients (78%) and > 1 in only 8 (22%). The conclusions from these findings are that: (1) TEE is an excellent diagnostic means of identifying right ventricular and/or atrial infarction; and (2) a relationship exists between the magnitude of right ventricular damage and a wall movement index of 5 or more or an RV/LV diastolic diameter ratio > 1:postinfarction hemodynamic deterioration is significantly greater and the incidence of intrahospitalary complications higher.

Multiplane Transesophageal Echocardiography with Dobutamine in Patients with Biventricular Inferior Myocardial Infarction

The purpose of this study was to evaluate the alterations of ventricular wall movement in patients with acute posteroinferior myocardial infarction with extension to right cavities with multiplane transesophageal echocardiography (TEE), as well as the utility of dobutamine with this technique to analyze myocardial viability. Nine men with a mean age of 51 years fulfilled the inclusion criteria. Myocardial TEE was performed in all the men 72 hours after the acute event with long‐ and short‐axis transgastric images of both ventricles under basal conditions and with dobutamine infusions of 5 and 10 μg/kg per minute. Results were compared with myocardial perfusion findings obtained with Tc‐99m Sestamibi SPECT. Left ventricular myocardial viability was demonstrated in 28 of 45 altered segments with dobutamine stress myocardial TEE and Tc‐99m Sestamibi SPECT. Right ventricular myocardial viability was identified in 27 of 30 altered segments with dobutamine stress myocardial TEE in transgastric short and long axes, and with Tc‐99m Sestamibi SPECT in 23 of 25 segments only in short‐axis images. Multiplane TEE provided excellent image resolution and better definition of endocardial and epicardial borders, which facilitated detailed evaluation of ventricular segmental wall movement. Infusion of low doses of dobutamine made it possible to identify viable tissue in both ventricles, and results were comparable to those of nuclear medicine.

Transesophageal Echocardiographic Study of Right Atrial Myocardial Infarction and Myocardial Viability

In order to determine the effects of dobutamine on right atrial wall movement, two groups were studied using transesophageal echocardiography. Group A included six patients without ischemic heart disease. Group B included six patients with infarction of the inferior wall of both ventricles and abnormal wall movement of the right atrium. In group A, an increase in the amplitude of right atrial movement was observed with dobutamine at doses of 5 and 10 μ/kg per minute. In group B, infusion of dobutamine did not modify wall akinesis in three patients with right atrial infarction; in the remaining three, alterations of segmental atrial movement were evident, and their responses to dobutamine were related to the patency of right atrial coronary branches. The following conclusions were reached: (1) dobutamine has a positive inotropic effect on atrial myocardium; (2) right atrial ischemia appears in the echocardiogram as altered segmental or global wall movement; (3) dobutamine can be used in the evaluation of atrial myocardial viability.

Primary reperfusion in acute right ventricular infarction: An observational study

AIMnTo investigate the impact of primary reperfusion therapy (RT) on early and late mortality in acute right ventricular infarction (RVI).nnnMETHODSnRVI patients (n = 679) were prospectively classified as without right ventricular failure (RVF) (class A, n = 425, 64%), with RVF (class B, n = 158, 24%) or with cardiogenic shock (CS) (class C, n = 96, 12%). Of the 679 patients, 148 (21.7%) were considered to be eligible for thrombolytic therapy (TT) and 351 (51.6%) for primary percutaneous coronary intervention (PPCI). TIMI 3-flow by TT was achieved for A, B and C RVI class in 65%, 64% and 0%, respectively and with PPCI in 93%, 91% and 87%, respectively.nnnRESULTSnFor class A without RT, the mortality rate was 7.9%, with TT was reduced to 4.4% (P < 0.01) and with PPCI to 3.2% (P < 0.01). Considering TT vs PPCI, PPCI was superior (P < 0.05). For class B without RT the mortality was 27%, decreased to 13% with TT (P < 0.01) and to 8.3% with PPCI (P < 0.01). In a TT and PPCI comparison, PPCI was superior (P < 0.01). For class C without RT the in-hospital mortality was 80%, with TT was 100% and with PPCI, the rate decreased to 44% (P < 0.01). At 8 years, the mortality rate without RT for class A was 32%, for class B was 48% and for class C was 85%. When PPCI was successful, the long-term mortality was lower than previously reported for the 3 RVI classes (A: 21%, B: 38%, C: 70%; P < 0.001).nnnCONCLUSIONnPPCI is superior to TT and reduces short/long-term mortality for all RVI categories. RVI CS patients should be encouraged to undergo PPCI at a specialized center.

Left atrial cardiac myxoma. Two unusual cases studied by 3D echocardiography.

We describe two patients with cardiac tumors in the left atrium, which by their association and histopathological lineage, are extremely rare. The clinical, echocardiographic and pathological findings were analysed. The first case was asymptomatic, but in the control studies of colon adenocarcinoma, an intracardiac mass was found by chest computed tomography (CT). A transesophageal 3D (TEE 3D) echocardiogram revealed a left atrial mass attached to the interatrial septum. The mass was surgically removed and histopathologic findings showed myxoma. The second had history of chronic intermittent diarrhea. A thoraco-abdominal CT showed a left atrial mass. The TEE 3D echocardiography reported an intracardiac mass attached to the roof of the left atrium. The mass was surgically removed and the histopathogical findings showed a myxoma, with dystrophic ossification and extramedullary hematopoiesis. TEE 3D echocardiography provides an acceptable morphological characterisation of intracardiac masses, with good correlation with surgery.

Ventricular Septal Defect in Adults: Analysis of Survival with and Without Interventional Procedures. The Relevant Role of Echocardiography

Background: Ventricular septal defects (VSDs) are one of the most common congenital heart defects, although many close spontaneously by adulthood. nThe main aim of this investigation was a) to investigate by echo the best cut-off value of pulmonary artery systolic pressure (PASP) in relation to VSD size, for defining the surgical or interventional treatment (SIT), b) to compare medical versus SIT results and c) to analyze morbidity and mortality of adults with VSDs. nMaterial: 193 patients aged ≥16 years with VSDs were studied. All had a complete clinical examination, electrocardiogram, chest x-ray and transthoracic echocardiography. Fifty three (27.5%) patients underwent cardiac catheterization. nResults: Seventy (36.3%) were asymptomatic, 119 (61.7%) had cardiomegaly, and 124 (64.2%) pulmonary artery hypertension (PAH). The PASP in small defined VSDs was 38 ± 19, and in large it was 69 ± 34 mmHg. Twenty one (11%) developed Eisenmenger syndrome (ES). The best cut-off point for PASP was 65 mmHg. The coefficient of correlation between VSD size and degree of PASP was 0.64 (p ≤0.000). Forty-five patients had surgical and 10 interventional VSD closure. The patients who underwent SIT had better survival than those who received medical treatment (P <0.000). There were 32 (16.6%) cardiac deaths. nConclusions: VSD in adulthood is symptomatic in the majority of cases. The best cut-off point for PASP was 65 mmHg for defining SIT. There were 32 (16.6%) deaths during the follow-up period. Patients with ES had a poor prognosis. Patients who underwent SIT had better survival than those who received medical treatment.