Jorge A. Lax

Estimation of the Ejection Fraction in Patients with Myocardial Infarction Obtained from the Combined Index of Systolic and Diastolic Left Ventricular Function: A New Method

UNLABELLED The index of myocardial performance combining systolic and diastolic time intervals (Index) is a useful method, already explained in past studies, that offers new values that have not been widely known among clinical cardiologists. The aim of this study is to obtain from this Index a measurement of the ejection fraction (EF), which is a very well-known value. The study involved 97 patients with myocardial infarction, 55 of whom were studied retrospectively (group A, aged 46-62 years, 50 men) to obtain and test the formula EF = 60 - (34 x Index). The second group (group B, aged 47-63 years, 40 men) included 42 patients who were evaluated prospectively. The EF obtained was compared with that reached through the use of radionuclide angiography (EF-RNA). The Index was obtained through the use of the formula (a - b)/b, where a is the interval between cessation and onset of the mitral inflow, and b is the ejection time. In group A the EF obtained by the Index (EF-Index) was 37.5% +/-.8%, and the EF-RNA was 37.7% +/- 11% (r = 0.76). In group B the EF-Index was 41.6% +/- 7%, and the EF-RNA was 41.2% +/- 10% (r = 0. 75). CONCLUSION Through the new formula described here it is possible to obtain a reliable measurement of the EF in patients with myocardial infarction, a well-known and extremely useful value, especially for those patients with poor acoustic windows.

Two-dimensional speckle tracking echocardiography for the assessment of atrial function

Echocardiography is the most common diagnostic method for assessing atrial function but the technique has some limitations. Traditionally, assessment of left atrial function has been performed by measuring volumes with 2D echocardiography. Additionally, it can be assessed with transmitral Doppler and pulmonary vein Doppler. Recently, an alternative method has been incorporated, namely, measurement of myocardial deformation with color tissue Doppler-derived strain. However, this method has several limitations, such as suboptimal reproducibility, angle-dependence, signal artifacts and the fact that it only measures regional strain and does not obtain information about the curved portion of the atrial roof. To overcome these limitations in the quantification of atrial function, the use of speckle tracking echocardiography (STE) strain has been proposed. This technique is not derived from Doppler but rather from 2D echocardiography; it is angle-independent and allows one to measure global as well as regional atrial strain. In this editorial, we describe the physical and pathophysiological concepts of STE and underline the clinical usefulness of this new technique.

Intermittent acute aortic regurgitation of a mechanical bileaflet aortic valve prosthesis: diagnosis and clinical implications

Intermittent aortic regurgitation (AR) is an unusual complication after a mechanical prosthetic replacement. We describe a rare case of intermittent dysfunction of a bileaflet mechanical aortic prosthetic valve in a 41-year-old man with a 21 mm Tri-technologies prosthetic valve implanted 4 years before. Transthoracic echocardiography (TTE) before discharge was normal and prosthesis-patient mismatch was ruled out. He was admitted to our hospital because of mild dyspnoea at effort. TTE revealed acute and severe intermittent AR. The patient underwent surgery, during which abnormal proliferation of subvalvular pannus overgrowth on the inflow aspect of the prosthesis was found impeding the normal closure of one of the discs of the prosthesis. The pannus formation was resected, the Tri-technologies prosthetic valve was prophylactic explanted and a 23 mm St Jude Medical bileaflet mechanical prosthesis valve was implanted. We describe the role of TTE and the limitation of the cinefluoroscopy in the diagnosis of Tri-technologies prosthetic dysfunction.

Two-dimensional speckle tracking echocardiography for early detection of myocardial damage in young patients with Fabry disease.

Fabry disease (FD) is characterized by left ventricular hypertrophy (LVH). Conventional echocardiography is not sensitive enough to perform the preclinical diagnosis To assess whether longitudinal myocardial strain of the left ventricle (LV), using speckle tracking, is useful to detect early myocardial involvement in FD. Forty‐four patients with FD who were diagnosed with genetic testing were prospectively included and were compared to a sex‐matched control group. They were divided into three groups: 22 with LVH (Group I), 22 without LVH (Group II), and 22 healthy volunteers (Group III). LV longitudinal strain was measured from the apical views. An ANOVA test was used for multiple comparisons for variables with a normal distribution, and a Kruskal–Wallis test was used for variables with non‐Gaussian distribution. Longitudinal LV strain was different in the three groups: it was ≥−15% in at least one segment in all Group I patients, in 50% of patients of Group II and in no patient of Group III. Seventy percent of the segments with abnormal strain in Group II were located in the basal regions (32/46). These findings show that the presence of at least one strain value ≥−15% demonstrates subclinical myocardial dysfunction in patients with preclinical FD. Longitudinal myocardial LV strain measured with speckle tracking is a useful tool to detect early myocardial involvement in young patients with FD. This information allows the detection and treatment of myocardial dysfunction at an early stage, which is of high clinical importance.

CoreValve Prosthesis Causes Anterior Mitral Leaflet Perforation Resulting in Severe Mitral Regurgitation

Percutaneous transcatheter aortic valve replacement (TAVR) has become an alternative to surgical therapy for patients with severe aortic stenosis and high operative risk, but it is associated with specific complications. We report the case of a 72-year-old man who underwent the procedure without complications; however, 45 days after the procedure, he was admitted to the hospital with symptoms of heart failure secondary to severe mitral regurgitation. Necropsy findings showed prosthesis malposition and perforation of the anterior mitral leaflet caused by the contact of the stent of the CoreValve prosthesis (Medtronic, Minneapolis, MN). We discuss TAVR complications, specifically regarding low positioning of the prosthetic valve.

Impaired Myocardial Function in Hypertrophic Cardiomyopathy

Background: Tissue Doppler imaging (TDI) parameters of peak myocardial velocities (S′, E′, and A′) has been employed to assess the regional left ventricular myocardial function. The global function index (GFI) derived from TDI has been recently employed to distinguish the different etiologies of left ventricular hypertrophy. Objective: To analyze whether the GFI or individual TDI parameters of peak myocardial velocities (S′, E′, and A′) allows detecting different degrees of regional myocardial dysfunction in the most frequent forms of hypertrophic cardiomyopathy (HCM). Methods: GFI = (E/E′)/S′ (where E is the peak transmitral flow velocity, E′ is the early diastolic myocardial velocity, and S′ is the peak systolic myocardial velocity) and TDI peak myocardial velocities was measured in the septal and lateral mitral annulus in 101 patients with HCM (mean age 47.5 ± 14 years, 58 women) and in age‐matched group of 30 healthy controls (mean age 46 ± 6 years, 16 women). Results: Forty‐five patients had nonobstructive asymmetric septal HCM, 20 patients had a subaortic gradient ≥ 30 mm Hg, 21 p. had apical HCM, and 15 p. had other forms of HCM (midventricular, symmetric, and biventricular). All patients with HCM exhibited a decrease in early diastolic (E′) and systolic (S′) myocardial velocities, both in the lateral and septal‐mitral annulus border, but more pronounced in septal‐mitral annulus. Septal GFI was higher in HCM patients than in healthy subjects (1.8 (1.1–2.5) and (0.57 (0.31–0.92), respectively, P < 0.001), but no differences were seen when different forms of HCM were compared. Conclusions: In a selected population of patients with HCM and a preserved left ventricular(LV) systolic function, GFI and individual TDI parameters of peak velocity (S′, E′, and A′) and E/E′ ratio were similar in different forms of HCM, indicating that in all patients with HCM there is regional systolic and diastolic myocardial dysfunction, regardless of the location of hypertrophy. (ECHOCARDIOGRAPHY, Volume 26, July 2009)

Papillary fibroelastoma: clinical and echocardiographic features and initial approach in 54 cases.

Papillary fibroelastoma (PFE) is a benign cardiac tumor that is currently detected more often due to the technological improvements in echocardiography.

Bone cement cardiac and pulmonary embolism

This case describes a complication of bone cement use. A 65‐year‐old male patient with back spine trauma caused by a fall, underwent a percutaneous vertebroplasty. Five years later, he consulted for palpitations, and the electrocardiogram showed supraventricular arrhythmia. A transthoracic two‐dimensional echocardiography showed a hyperechogenic linear structure of 7 cm length, running from the lateral wall of the right ventricle to the right atrium through the tricuspid valve. This foreign body, which was suspicious for bone cement embolism, appeared rigid and was attached at the lateral wall of the right ventricle, with its proximal end free in the right atrium. The tip of the cement embolus was inside the myocardium of the lateral wall of the right ventricle, with risk of cardiac perforation. A fluoroscopy was performed, which confirmed the presence of cement within the right heart, with great mobility in each cardiac cycle. Chest computed tomography (CT) and multidetector CT three‐dimensional reconstruction confirmed the presence of cement within the right heart. Chest CT showed two pulmonary embolisms, one in the right upper lobe and one in the left lower pulmonary lobe. This case emphasizes the risk of late clinical manifestations of cardiac and pulmonary embolism of methylmethacrylate after percutaneous vertebroplasty, suggesting that the risk of such embolism might be underestimated. We propose routine chest radiography, two‐dimensional echocardiography, and chest CT after every percutaneous vertebroplasty, to detect asymptomatic cardiac and pulmonary embolism and thereby prevent serious delayed cardiopulmonary failures.

Assessment of Coronary Flow with Transthoracic Color Doppler Echocardiography in Patients with Hypertrophic Cardiomyopathy

Recent advances in echocardiography have allowed assessment of flow velocity in the epicardial coronary arteries of patients with ischemic heart disease, using transthoracic color Doppler echocardiography (TTDE). However, few data are available regarding coronary blood flow in patients with hypertrophic cardiomyopathy (HCM).

Comparison of left atrial size and function in hypertrophic cardiomyopathy and in Fabry disease with left ventricular hypertrophy

Fabry disease (FD) and hypertrophic cardiomyopathy (HCM) are two diseases with a different pathophysiology, both cause left ventricular hypertrophy (LVH) and myocardial fibrosis. Although remodeling and systolic dysfunction of the left atrium (LA) are associated with atrial fibrillation and stroke in HCM, changes in the size and function of the LA have not been well studied in FD with LVH.