Juan Lacalzada-Almeida

Interatrial block and atrial remodeling assessed using speckle tracking echocardiography

BackgroundTo evaluate the possibility of left atrial (LA) remodeling using speckle tracking echocardiography (STE) in patients with interatrial block (IAB).MethodsWe performed a cross-sectional study with three groups of patients: 56 without IAB, 21 with partial IAB (pIAB), and 22 with advanced IAB (aIAB). Transthoracic echocardiographic (TTE) STE was performed and clinical and echocardiographic findings were analyzed.ResultsTTE showed higher LA volume/body surface area in the patients with IAB. With STE, the absolute value of strain rate during atrial booster pump function (SRa) and early reservoir period (SRs) decreased in the pIAB group and even more in the aIAB group, compared to the group without IAB. The independent variables were the echocardiographic measures of LA size and function. After adjusting for confounders, both multiple linear regression and multivariate multinomial regression showed good correlation with dependent variables: longer P-wave duration on electrocardiography and with the type of IAB, respectively. SRa (p < 0.001), SRs (p < 0.001), and maximal peak LA longitudinal strain in the reservoir period (p = 0.009) were independently associated with P-wave duration. SRa was also associated with the presence of pIAB (OR = 11.5; 95% confidence interval (CI): 2.7–49.0; p = 0.001) and aIAB, (OR = 98.2; 95% CI: 16–120.4; p < 0.001) and SRs was associated with pIAB (OR: 0.03; CI: 0.003–0.29; p = 0.003) and with aIAB (OR: 0.008; CI: 0.001–0.12; p = 0.004).ConclusionsIAB correlates directly with structural remodeling and a decrease in the absolute value of LA SRa and SRs determined using STE.

Speckle-Tracking Echocardiography and Advanced Interatrial Block

Juan Lacalzada-Almeida,* Javier Garcı́a-Niebla, and Antonio Bayés-de Luna a Sección de Imagen Cardiaca, Servicio de Cardiologı́a, Complejo Hospitalario Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain Centro de Salud Valle del Golfo, Servicios Sanitarios del Área de Salud de El Hierro, Frontera-El Hierro, Santa Cruz de Tenerife, Spain c Institut Català de Ciències Cardiovasculars, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain

Valve Calcification in Aortic Stenosis: Etiology and Diagnostic Imaging Techniques

Aortic stenosis is the most common valvulopathy in the Western world. Its prevalence has increased significantly in recent years due to population aging; hence, up to 8% of westerners above the age of 84 now have severe aortic stenosis (Lindroos et al., 1993). This causes increased morbidity and mortality and therein lies the importance of adequate diagnosis and stratification of the degree of severity which allows planning the best therapeutic option in each case. Long understood as a passive age-related degenerative process, it is now considered a rather more complex entity involving mechanisms and factors similar to those of atherosclerosis (Stewart et al., 1997). In this review, we summarize the pathophysiological mechanisms underlying the onset and progression of the disease and analyze the current role of cardiac imaging techniques for diagnosis.

Congenital multiple coronary arteriovenous fistulas

Coronary arteriovenous fistulas are congenital or acquired abnormalities characterized by abnormal communication between the coronary circulation and cardiac chambers or other vessels. Frequently, patients are asymptomatic and their diagnosis can be carried out incidentally by echocardiography. Knowing the echocardiographic findings characteristic of this malformation will prevent the diagnosis from going unnoticed.

Bayes Syndrome and Imaging Techniques.

BACKGROUND Interatrial block (IAB) is due to disruption in the Bachmann region (BR). According to whether interatrial electrical conduction is delayed or completely blocked through the BR, it can be classified as IAB of first, second or third degree. On the surface electrocardiogram, a P wave ≥ 120 ms (partial IAB) is observed or associated to the prolongation of the P wave with a biphasic (positive / negative) morphology in the inferior leads (advanced IAB). Bayes syndrome is defined as an advanced IAB associated with atrial arrhythmia, more specifically atrial fibrillation. Objective and Conclusion: The purpose of this review is to describe the latest evidence about an entity considered an anatomical and electrical substrate with its own name, which may be a predictor of supraventricular arrhythmia and cardioembolic cerebrovascular accidents, as well as the role of new imaging techniques, such as echocardiographic strain and cardiac magnetic resonance imaging, in characterizing atrial alterations associated with this syndrome and generally in the study of anatomy and atrial function.

Compression of the right coronary artery by an aortic pseudoaneurysm after infective endocarditis: an unusual case of myocardial ischemia

A 61-year-old male with a prosthetic St Jude aortic valve size 24 presented with heart failure symptoms and minimal-effort angina. Eleven months earlier, the patient had undergone cardiac surgery because of an aortic root dilatation and bicuspid aortic valve with severe regurgitation secondary to infectious endocarditis by Coxiela burnetii and coronary artery disease in the left circumflex coronary artery. Then, a prosthesis valve and a saphenous bypass graft to the left circumflex coronary artery were placed. The patient was admitted to the Cardiology Department of Hospital Universitario de Canarias, Tenerife, Spain and a transthoracic echocardiography was performed that showed severe paraprosthetic aortic regurgitation and an aortic pseudoaneurysm. The 64-slice multidetector computed tomography confirmed the pseudoaneurysm, originating from the right sinus of Valsalva, with a compression of the native right coronary artery and a normal saphenous bypass graft. On the basis of these findings, we performed surgical treatment with a favorable postoperative evolution. In our case, results from complementary cardiac imaging techniques were crucial for patient management. The multidetector computed tomography allowed for a confident diagnosis of an unusual mechanism of coronary ischemia.

Radiotherapy-induced Recurrent Syncope

Cardiac toxicity secondary to radiotherapy has an incidence of 10% to 30%. This complication usually develops 5 to 10 years after the administration of the therapy and has been related both to the location of the radiation in the thoracic region and to the dose used (generally over 40 Gy). Radiotherapy-induced cardiac toxicity can lead to ischemic heart disease, different degrees of valve involvement, hypertensive heart disease, ventricular dysfunction, or changes in the intrinsic conduction system. The major causal mechanism is the fibrosis developed by the patients, which can first be detected up to 20 to 25 years after therapy was received. We present the case of a 44-year-old man with no cardiovascular risk factors, who had undergone radiotherapy and chemotherapy 20 years earlier to treat Hodgkin’s lymphoma. He attended the emergency department after experiencing 2 episodes of exertional syncope. The initial electrocardiogram revealed complete right bundle branch block, a previously diagnosed condition (Figure 1) for which the patient had undergone cardiac evaluation a few years earlier, including transthoracic echocardiography which revealed left ventricular hypertrophy. During the first 24 hours of electrocardiographic monitoring, there were no changes in heart rhythm or arrhythmic events of interest. The transthoracic electrocardiogram revealed severe mitral and aortic valve calcification, with mild aortic stenosis and moderate regurgitation. We also observed a small subvalvular aortic calcification near the anterior mitral leaflet, which did not produce an important resting gradient (videos 1-3 of the supplementary material). As the syncope had occurred more than once and had been induced on both occasions by mild exertion, and given the risk associated with the patient’s occupation (truck driver), an in-depth study was carried out. The responses to carotid sinus massage and tilt table test were negative. The electrophysiological study revealed an AH interval of 108 ms, an HV interval of 65 ms, and a supra-Hisian Wenckebach period of 410 ms, all within normal limits, whereas the responses to atropine and procainamide were negative. As there was a dynamic obstruction in the left ventricular outflow tract related to the subaortic calcification, exercise echocardiography was performed in an attempt to reproduce the symptoms. In the third minute of the test, the patient developed atrioventricular dissociation with a 12-second pause (Figure 2), followed by a syncopal episode, with subsequent spontaneous recovery. The next day, he underwent implantation of a permanent dual-chamber pacemaker. The long-term survival associated with Hodgkin’s lymphoma due to the good response generally achieved with radiotherapy and chemotherapy, and the high radiation doses administered in the thoracic region 20 years earlier, were important factors in the development of cardiac toxicity over the long-term. We have no information on the chemotherapy regimen received by our patient, as it was administered at another center. The progressive myocardial fibrosis generated by the radiotherapy leads to cardiac manifestations; among these, involvement of the conduction system is one of the least frequent, compared with cardiac valve involvement, ischemic heart disease, or left ventricular systolic dysfunction, which are the most common reasons for patients with this profile to seek medical attention. The follow-up of asymptomatic patients has not been clearly established, but symptoms such as angina or dyspnea should point to radiotherapy as a possible cause in those who have undergone this treatment in the past. Our patient had been evaluated 5 years prior to hospital admission due to the presence of asymptomatic right bundle branch block. This block is an incidental finding resulting from conduction system involvement and is generally more common