José Luis Vega

Right Ventricular Asynergy During Dobutamine-Atropine Echocardiography

OBJECTIVES We sought to analyze right ventricular contractility during dobutamine infusion in patients with right coronary artery disease and to elucidate whether the development of right ventricular asynergy aids in characterizing a right coronary artery stenosis. BACKGROUND Clinical investigations are emphasizing the importance of right ventricular function in patients with coronary artery disease. Thus, prognosis of patients with inferior myocardial infarction is influenced by right ventricular function. This study describes the echocardiographic and electrocardiographic findings during dobutamine-atropine echocardiography in patients with right coronary artery disease. METHODS We studied 31 patients with isolated right coronary artery disease and no previous myocardial infarction. Six patients with poor acoustic window were excluded (feasibility 80%). The remaining 25 patients underwent dobutamine-atropine echocardiography. A right coronary artery stenosis located before the origin of the right ventricular branches was considered proximal; otherwise, it was considered distal. RESULTS Right ventricular asynergy during dobutamine-atropine testing developed in 17 patients (sensitivity 68%); 14 had proximal and 3 had distal right coronary artery disease. The following segments were involved: inferior (n = 17), lateral (n = 5) and outflow tract (n = 1). No patient showed anterior asynergy. All 17 patients had left ventricular asynergy as well. Ischemia-free time was 10.7 +/- 6.2 (mean +/- SD) min for the right ventricle and 8.9 +/- 5.2 min for the left ventricle (p < 0.05). Ischemic ST changes were recorded in 15 patients (in standard leads in 14 and in right precordial leads in 8). All patients with right precordial changes showed ST elevation and had right ventricular asynergy (sensitivity and specificity for right ventricular asynergy 47% and 100%, respectively). A control group of 25 patients with no right coronary artery disease (5 with no disease, 15 with left anterior descending and 5 with left circumflex coronary artery disease) underwent dobutamine echocardiography. Right ventricular asynergy developed in two patients with left anterior descending artery stenosis (specificity 92%); in both, the anterior wall was affected. CONCLUSIONS Echocardiography during dobutamine infusion is a reliable technique for assessing right ventricular dysfunction in patients with right coronary artery disease. Right ventricular contractility can be assessed during dobutamine echocardiography in selected patients.

Valor pronóstico de la ecocardiografía con dobutamina después de un infarto agudo de miocardio no complicado

Introduccion y objetivos. Despues de un infarto es importante detectar a los pacientes con riesgo de eventos adversos. Nuestro objetivo fue valorar la utilidad pronostica de la ecocardiografia con dobutamina tras un infarto no complicado. Metodo. Se realizo ecocardiografia con dobutamina a 125 pacientes (edad media 65 ± 11 anos, el 82% varones) en los primeros diez dias despues de un infarto no complicado. Se consideraron las siguientes respuestas del miocardio: a) negativo; b) mejoria mantenida de la contractilidad; c) mejoria inicial con empeoramiento posterior, y d) empeoramiento de la contractilidad en la zona del infarto o a distancia. Resultados. Con un seguimiento de 7,4 ± 4,6 meses hubo 47 eventos: 3 muertes no cardiacas, 6 muertes cardiacas, 5 infartos, 21 anginas, 2 insuficiencias cardiacas y 10 revascularizaciones. El analisis mediante la prueba de regresion de Cox demostro que el empeoramiento fue el mejor predictor (p Conclusiones. La mejoria mantenida de la contractilidad en la zona del infarto no es predictor de eventos. El empeoramiento de la contractilidad en la zona del infarto o a distancia durante la ecocardiografia con dobutamina en los primeros 10 dias tras un infarto no complicado predice la aparicion de eventos. Por tanto, esta prueba podria emplearse en la estratificacion de riesgo postinfarto.

Edema agudo de pulmón con coronarias normales: identificación del mecanismo con ecocardiografía con ergonovina

Coronary spasm is a constriction of the epicardial coronary arteries that produces myocardial ischemia. It is considered the main mechanism of the dynamic coronary artery stenosis. The standard method for diagnosing coronary spasm is the ergonovine test during diagnostic coronary angiography. Another test currently used is stress echocardiography with intravenous ergonovine injection. We present the case of a patient with angina, acute pulmonary edema and normal angiographic coronary arteries in which stress echocardiography with ergonovine demonstrated transient severe mitral regurgitation.

Perfil clínico y pronóstico de los pacientes con endocarditis y seudoaneurismas perianulares

Introduccion y objetivos El proposito de este estudio ha sido conocer el curso clinico y el pronostico de los pacientes con endocarditis que desarrollan un seudoaneurisma. Metodos Se describen las caracteristicas clinicas y evolutivas de un grupo de 18 pacientes (11 varones, edad media 55 ± 4 anos) con endocarditis infecciosa, en quienes la ecografia transesofagica diagnostico la presencia de seudoaneurisma. Resultados Catorce seudoaneurismas se localizaron en posicion aortica (6 sobre valvula nativa y 8 sobre protesis), tres en posicion mitral (tres protesis) y uno en posicion tricuspidea. En 6 casos aparecio bloqueo auriculoventricular que no existia al ingreso, y en todos ellos el seudoaneurisma estaba en posicion aortica. Los microorganismos mas frecuentemente aislados fueron los estafilococos (n = 5) y estreptococos (n = 5). Se encontraron abscesos en 5 pacientes. La presencia de seudoaneurisma no fue considerada per se como criterio de cirugia. De los 11 pacientes operados, 5 fallecieron tras la cirugia (45%), uno presento reinfeccion y otros 5 estan asintomaticos. Los restantes 7 pacientes recibieron exclusivamente tratamiento medico: fallecieron dos (28%), uno presento reinfeccion y cuatro estan asintomaticos. En el grupo de tratamiento conservador que estan asintomaticos (n = 4), el tamano del seudoaneurisma no se modifico despues de 24 meses de seguimiento (diametro mayor 21 ± 5 frente a 22 ± 5 mm en el seguimiento; p = NS). Conclusiones La presencia de seudoaneurisma identifica a un subgrupo de pacientes con endocarditis que tienen una alta mortalidad. Los seudoaneurismas son mas frecuentes en posicion aortica y alrededor de material protesico. El tratamiento medico puede considerarse una alternativa a la cirugia cuando no existan otras indicaciones quirurgicas. Finalmente, el tamano del seudoaneurisma en el grupo de pacientes tratados de forma conservadora permanece estable a lo largo del tiempo.

Post-Traumatic Ventricular Septal Defect: From Clinical Suspicion to Treatment

Ventricular septal defect (VSD) following closed thoracic trauma is an unusual complication,1,2 that generally has a delayed diagnosis. We present the case of an 18-year-old male who suffered severe thoracic trauma with bilateral pleural effusion, lacerations of abdominal viscera and bone fractures following a road traffic accident. He was intubated for hypovolaemic shock and had multiple transfusions, required splenectomy, repair of liver lacerations and surgical re-exploration due to haemorrhage. Upon admission, no heart murmurs were detected, the electrocardiogram revealed sinus tachycardia with Q-waves in II, III, and aVF and the maximum troponin-T was 2.33 ng/mL. The initial creatine kinase (CK) (1017 U/L; CK-MB, 79 U/L) increased to a maximum of 2510 U/L (CK-MB, 65 U/L) 24 hours later. The transthoracic echocardiogram (TTE) revealed a contusion of the interventricular septum (IVS), slightly thickened from the middle third to the apex and a reduction in movement, a slightly dilated right ventricle, and a pulmonary artery pressure of 50 mm Hg. At 24 hours, a proto-mesosystolic murmur was heard at the left sternal border and haemodynamic instability, tachycardia, and the need for vasoactive drugs persisted. High oxygen saturation in the pulmonary artery (PA) led to the suspicion of a VSD, which was confirmed by TTE. Severe dilation of the right ventricle was seen with mild systolic dysfunction, the appearance of an apical pseudoaneurysm and a large irregular longitudinal VSD in the mid-distal portion of the IVS (Figure 1). He underwent urgent intervention, the mid-inferior apical septum had a linear VSD with irregular borders measuring 435 cm, which was closed with a Dacron patch (Figure 2). No other lesions were found except for the contusion of the apex of the heart. Subsequent progress was satisfactory. Only 5% of closed thoracic traumas are complicated with a VSD. Asymptomatic myocardial contusion with an increase in cardiac enzymes is more common.1,2 Two mechanisms cause rupture of the IVS: the increase in intrathoracic pressure that compresses the heart and the myocardial contusion, with direct cellular damage or a change in coronary blood-flow and a secondary myocardial infarction.1,3 Both mechanisms complement each other in our patient, in whom ischaemia was seen at admission and the apical myocardial contusion was seen during surgery. VSD following closed trauma usually affects the muscular septum,1,4,5 is located in the apex and is linear; occasionally there can be several.3,4 The diagnosis is usually delayed (between 12 h and 12 days)1,3,5 (in this case, it evolved in 2 phases: initially, from the myocardial contusion seen on the echocardiogram, and delayed, at 24 hours, due LETTERS TO THE EDITOR