Gustavo Avegliano

Long-Term Follow-Up of Aortic Intramural Hematoma Predictors of Outcome

Background—Aortic intramural hematoma (IMH) evolves very dynamically in the short-term to regression, dissection, or aortic rupture. The aim of the present study was to assess the long-term clinical and morphological evolution of medically treated IMH. Methods and Results—Fifty of 68 consecutive patients with aortic IMH monitored clinically and by imaging techniques at 3, 6, and 12 months and annually thereafter were prospectively studied. Mean follow-up was 45±31 months. In the first 6 months, total IMH regression was observed in 14 and progression to aortic dissection in 18 patients; in 14 of these, the dissection was localized, and 12 later developed pseudoaneurysm. At the end of follow-up, the IMH had regressed completely without dilatation in 17 patients (34%), progressed to classical dissection in 6 (12%), evolved to fusiform aneurysm in 11 (22%), evolved to saccular aneurysm in 4 (8%), and evolved to pseudoaneurysm in 12 (24%). Evolution to dissection was related to echolucency (P <0.02) and to longitudinal extension of IMH (P <0.01). Multivariate analysis showed an independent association between regression and smaller maximum aortic diameter and between aneurysm formation and atherosclerotic ulcerated plaque and absence of echolucent areas in IMH. Conclusions—The most frequent long-term evolution of IMH is to aortic aneurysm or pseudoaneurysm. Complete regression without changes in aorta size is observed in one third of cases, and progression to classical dissection is less common. A normal aortic diameter in the acute phase is the best predictor of IMH regression without complications, and absence of echolucent areas and atherosclerotic ulcerated plaque are associated with evolution to aortic aneurysm.

Impact of contrast-enhanced echocardiography on the diagnostic algorithm of acute aortic dissection

AIMS To determine the usefulness of contrast echocardiography in the diagnosis of aortic dissection (AD) and in the assessment of findings necessary for adequate patient management. METHODS AND RESULTS Conventional and contrast-enhanced transthoracic echocardiography (TTE) and transoesophageal echocardiography (TOE) were performed in 128 consecutive patients with clinically suspected acute AD. Results were validated independently against intraoperative findings in 45 patients and computed tomography information in 83. Sensitivity and specificity of conventional TTE increased after contrast enhancement from 73.7 to 86.8% (P< 0.005) and 71.2 to 90.4% (P < 0.05), respectively. Sensitivity and specificity of enhanced TTE were similar to conventional TOE in ascending aorta (93.3 vs. 95.6% and 97.6 vs. 96.4%, respectively) and in the arch (88.4 vs. 93.0% and 95.3 vs. 98.82%, respectively). Contrast-enhanced TOE permitted the location of non-visualized entry tear in seven cases (10.6%), helped to correctly identify the true lumen in six (9.1%), and diagnosed retrograde dissection in nine (13.6%). CONCLUSION Contrast enhancement substantially improves TTE in the diagnosis of AD and should be considered as the initial imaging modality in the emergency setting. Contrast enhancement also has significant value for obtaining critical morphological and haemokinetic information by TOE useful for adequate patient management.

Morphologic pattern of late gadolinium enhancement in Takotsubo cardiomyopathy detected by early cardiovascular magnetic resonance

Takotsubo cardiomyopathy (TTC) presents clinically as an acute coronary syndrome. It is characterized by transient left ventricular wall dyskinesis‐akinesis, without significant epicardial coronary lesions. Late gadolinium enhancement (LGE) sequences on cardiac magnetic resonance (CMR) allow to clarify the pathophysiology in patients with chest pain, elevated troponin, and normal epicardial coronary arteries; in patients with TTC, previous studies have shown absence of LGE.

Diagnóstico y cuantificación del foramen oval permeable. ¿Cuál es la técnica de referencia? Estudio simultáneo con Doppler transcraneal, ecocardiografía transtorácica y transesofágica

INTRODUCTION AND OBJECTIVES Patent foramen ovale (PFO) is the most common cause of cryptogenic stroke in patients younger than 55. Transesophageal echocardiography (TEE) has been accepted as the reference diagnostic technique. The purpose of this study was to compare the accuracy of transthoracic echocardiography (TTE), TEE and transcranial Doppler (TCD) in the diagnosis and quantification of patent foramen ovale. METHODS We studied 134 patients prospectively. Simultaneous TTE with TCD and TEE with TCD were performed, using agitated saline solution to detect right to left shunt. RESULTS In 93 patients diagnosed with PFO, the shunt was visualized at baseline by TCD in 69% of cases, by TTE in 74% and by TEE in 58%. The Valsalva maneuver produced a similar improvement in shunt diagnosis with all 3 techniques (26%-28%). TTE and TCD showed higher sensitivity (100% vs 97%; non significant difference) than TEE in the diagnosis of PFO (86%; P<.001). TCD performed during TEE did not diagnose 12 (13%) shunts previously diagnosed during TTE. Similarly, TEE underestimated shunt severity. CONCLUSIONS TTE enables adequate diagnosis and quantification of PFO. TEE is less sensitive and tends to underestimate the severity of the shunt.

Cardiac motion estimation by joint alignment of tagged MRI sequences.

Image registration has been proposed as an automatic method for recovering cardiac displacement fields from tagged Magnetic Resonance Imaging (tMRI) sequences. Initially performed as a set of pairwise registrations, these techniques have evolved to the use of 3D+t deformation models, requiring metrics of joint image alignment (JA). However, only linear combinations of cost functions defined with respect to the first frame have been used. In this paper, we have applied k-Nearest Neighbors Graphs (kNNG) estimators of the α-entropy (H(α)) to measure the joint similarity between frames, and to combine the information provided by different cardiac views in an unified metric. Experiments performed on six subjects showed a significantly higher accuracy (p<0.05) with respect to a standard pairwise alignment (PA) approach in terms of mean positional error and variance with respect to manually placed landmarks. The developed method was used to study strains in patients with myocardial infarction, showing a consistency between strain, infarction location, and coronary occlusion. This paper also presents an interesting clinical application of graph-based metric estimators, showing their value for solving practical problems found in medical imaging.

Characterizing Myocardial Deformation in Patients With Left Ventricular Hypertrophy of Different Etiologies Using the Strain Distribution Obtained by Magnetic Resonance Imaging

Introduccion y objetivos. Se ha senalado que, en la miocardiopatia hipertrofica (MCH), la desorganizacion de las fibras regionales da lugar a segmentos en los que la deformacion es nula o esta gravemente reducida, y que estos segmentos tienen una distribucion no uniforme en el ventriculo izquierdo (VI). Esto contrasta con lo observado en otros tipos de hipertrofia como en el corazon de atleta o la hipertrofia ventricular izquierda hipertensiva (HVI-HT), en los que puede haber una deformacion cardiaca anormal, pero nunca tan reducida como para que se observe ausencia de deformacion. Asi pues, proponemos el empleo de la distribucion de los valores de strain para estudiar la deformacion en la MCH. Metodos. Con el empleo de resonancia magnetica marcada (tagged), reconstruimos la deformacion sistolica del VI de 12 sujetos de control, 10 atletas, 12 pacientes con MCH y 10 pacientes con HVI-HT. La deformacion se cuantifico con un algoritmo de registro no rigido y determinando los valores de strain sistolico maximo radial y circunferencial en 16 segmentos del VI. Resultados. Los pacientes con MCH presentaron unos valores medios de strain significativamente inferiores a los de los demas grupos. Sin embargo, aunque la deformacion observada en los individuos sanos y en los pacientes con HVI-HT se concentraba alrededor del valor medio, en la MCH coexistian segmentos con contraccion normal y segmentos con una deformacion nula o significativamente reducida, con lo que se producia una mayor heterogeneidad de los valores de strain. Se observaron tambien algunos segmentos sin deformacion incluso en ausencia de fibrosis o hipertrofia. Conclusiones. La distribucion de strain caracteriza los patrones especificos de deformacion miocardica en pacientes con diferentes etiologias de la HVI. Los pacientes con MCH presentaron un valor medio de strain significativamente inferior, asi como una mayor heterogeneidad de strain (en comparacion con los controles, los atletas y los pacientes con HVI-HT), y tenian regiones sin deformacion.INTRODUCTION AND OBJECTIVES In hypertrophic cardiomyopathy (HCM), it has been suggested that regional fiber disarray produces segments that exhibit no or severely reduced deformation, and that these segments are distributed nonuniformly within the left ventricle (LV). This contrasts with observations in other types of hypertrophy, such as in athletes heart or hypertensive left ventricular hypertrophy (HLVH), in which abnormal cardiac deformation may exist but the reduction is not so severe that some segments exhibit no deformation. Our aim was to use the strain distribution to study deformation in HCM. METHODS We used tagged magnetic resonance imaging to reconstruct LV systolic deformation in 12 controls, 10 athletes, 12 patients with HCM, and 10 patients with HLVH. Deformation was quantified using a fast nonrigid registration algorithm and peak radial and circumferential systolic strain values were determined in 16 LV segments. RESULTS Patients with HCM had significantly lower average strain values than individuals in other groups. However, while the deformation observed in healthy subjects and HLVH patients clustered around the mean, in HCM patients, segments with normal contraction coexisted with segments exhibiting no or significantly reduced deformation, which resulted in a greater heterogeneity of strain values. Moreover, some nondeforming segments were observed even when fibrosis and hypertrophy were absent. CONCLUSIONS The strain distribution characterized specific patterns of myocardial deformation in patients with LVH due to different etiologies. Patients with HCM had significantly lower mean strain values and a greater heterogeneity in strain values than controls, athletes and HLVH patients. In addition, they had nondeforming regions.

Caracterización de la deformación miocárdica en pacientes con hipertrofia ventricular izquierda de diferente etiología mediante el uso de distribuciones de strain obtenidas de imágenes de resonancia magnética

Introduccion y objetivos. Se ha senalado que, en la miocardiopatia hipertrofica (MCH), la desorganizacion de las fibras regionales da lugar a segmentos en los que la deformacion es nula o esta gravemente reducida, y que estos segmentos tienen una distribucion no uniforme en el ventriculo izquierdo (VI). Esto contrasta con lo observado en otros tipos de hipertrofia como en el corazon de atleta o la hipertrofia ventricular izquierda hipertensiva (HVI-HT), en los que puede haber una deformacion cardiaca anormal, pero nunca tan reducida como para que se observe ausencia de deformacion. Asi pues, proponemos el empleo de la distribucion de los valores de strain para estudiar la deformacion en la MCH. Metodos. Con el empleo de resonancia magnetica marcada (tagged), reconstruimos la deformacion sistolica del VI de 12 sujetos de control, 10 atletas, 12 pacientes con MCH y 10 pacientes con HVI-HT. La deformacion se cuantifico con un algoritmo de registro no rigido y determinando los valores de strain sistolico maximo radial y circunferencial en 16 segmentos del VI. Resultados. Los pacientes con MCH presentaron unos valores medios de strain significativamente inferiores a los de los demas grupos. Sin embargo, aunque la deformacion observada en los individuos sanos y en los pacientes con HVI-HT se concentraba alrededor del valor medio, en la MCH coexistian segmentos con contraccion normal y segmentos con una deformacion nula o significativamente reducida, con lo que se producia una mayor heterogeneidad de los valores de strain. Se observaron tambien algunos segmentos sin deformacion incluso en ausencia de fibrosis o hipertrofia. Conclusiones. La distribucion de strain caracteriza los patrones especificos de deformacion miocardica en pacientes con diferentes etiologias de la HVI. Los pacientes con MCH presentaron un valor medio de strain significativamente inferior, asi como una mayor heterogeneidad de strain (en comparacion con los controles, los atletas y los pacientes con HVI-HT), y tenian regiones sin deformacion.

Prognostic utility of ischemic response in functional imaging tests (SPECT or stress echocardiography) in low-risk unstable angina patients

BACKGROUND The aim of this study is to determine the ability of ischemic response in imaging stress tests (single-photon emission computed tomography [SPECT] or stress echocardiography [SE]) to predict events in low-risk unstable angina patients. METHODS Three hundred and fifty-nine patients with unstable angina (< 24 h), asymptomatic at admission, without ST-segment elevation or depression, normal troponins, and undergoing SPECT (n = 188) or SE (n = 171) during hospitalization (median = 1 day) were included. A positive imaging test (IMAGING+) was defined as the presence of reversible perfusion defects or wall motion abnormalities in at least 2 contiguous segments. Multivariate models were constructed using these results and clinical variables to predict events at 6 months. RESULTS Ninety-nine (27%) patients had IMAGING+, 72/188 (38%) in SPECT and 27/17 (16%) in SE (p < 0.0001). Events occurred in 84 (23%) patients: 4 had myocardial infarction, 47 new hospitalizations due to angina and 33 coronary artery revascularizations. Independent predictors of coronary artery disease were: IMAGING+ (OR: 6.4, 95% CI: 3.4-11.8, p < 0.0001), history of coronary artery disease (OR: 2.5, 95% CI: 1.2-5.2, p < 0.02) and TIMI risk (OR: 1.5, 95% CI: 1.1-2.2, p < 0.03). CONCLUSIONS In low-risk unstable angina patients, an ischemic response in functional stress tests (SPECT or SE) was associated with adverse events and severe coronary artery disease.

Endocarditis trombótica no bacteriana sobre válvula aórtica en mujer joven

Full English text available at: www.revespcardiol.org A 40-year-old woman without heart disease suffered two embolic episodes in both legs due to a thrombus of the aortic valve. Transesophageal echocardiography performed after the first episode was considered normal, but a second study performed after the second embolism demonstrated a thrombus in the non-coronary leaflet that failed to resolve with the intravenous administration of heparin for two weeks. Surgical excision of the mass revealed a thrombus on an otherwise healthy aortic valve. The case is interesting because it is an exceptional cause of systemic embolism and the patient did not present a prothrombotic status in coagulation studies. The 3 years of follow-up was uneventful.

Left-ventricular epi- and endocardium extraction from 3D ultrasound images using an automatically constructed 3D ASM

In this paper, we propose an automatic method for constructing an active shape model (ASM) to segment the complete cardiac left ventricle in 3D ultrasound (3DUS) images, which avoids costly manual landmarking. The automatic construction of the ASM has already been addressed in the literature; however, the direct application of these methods to 3DUS is hampered by a high level of noise and artefacts. Therefore, we propose to construct the ASM by fusing the multidetector computed tomography data, to learn the shape, with the artificially generated 3DUS, in order to learn the neighbourhood of the boundaries. Our artificial images were generated by two approaches: a faster one that does not take into account the geometry of the transducer, and a more comprehensive one, implemented in Field II toolbox. The segmentation accuracy of our ASM was evaluated on 20 patients with left-ventricular asynchrony, demonstrating plausibility of the approach.