Luciano Lucas

Prognostic Value of Left Atrial Volume in Asymptomatic Organic Mitral Regurgitation

BACKGROUND Basal left atrial volume (LAV) indexed to body surface area (LAVI) predicts adverse events in patients with organic mitral regurgitation, but information is lacking regarding change in left atrial volume during follow-up. METHODS One hundred forty-four asymptomatic patients (mean age, 71 ± 12 years; 66% women; mean ejection fraction, 66 ± 4.8%) with moderate to severe mitral regurgitation were prospectively included, with a median follow-up period of 2.76 years (interquartile range, 1.86-3.48 years). RESULTS Fifty-four patients (37.50%) reached the combined end point of dyspnea and/or systolic dysfunction. Both basal and change in LAV were independently associated with the combined end point on multivariate analysis: for basal LAVI ≥ 55 mL/m(2), odds ratio, 2.26 (95% confidence interval, 1.04-4.88; P = .038), and for change in LAV ≥ 14 mL, odds ratio, 7.32 (95% confidence interval, 3.25-16.48; P < .001), adjusted for effective regurgitant orifice area and deceleration time. Combined event-free survival at 1, 2, and 3 years was significantly less in patients with basal LAVI ≥ 55 mL/m(2) (75%, 58%, and 43%) than in those with basal LAVI < 55 mL/m(2) (95%, 89%, and 77%) (log-rank test = 15.38, P = .0001). The incidence of the combined end point was highest (88%) in patients with basal LAVI ≥ 55 mL/m(2) and change in LAV ≥ 14 mL. CONCLUSIONS Measurement of basal LAV and its increase during follow-up predict an adverse course in patients with moderate and severe asymptomatic mitral regurgitation. Hence, its assessment could be incorporated into the currently used algorithm for risk stratification and decision making in this group of patients.

Cardiac Lymphoma: A Rare Cause of Acute Heart Failure with Restrictive Physiology

DOI: 10.5935/abc.20180015 A 74-year-old woman with a history of membranous glomerulonephritis and a recent diagnosis of mediastinal adenopathy was admitted to the emergency department with acute heart failure. She complained of progressive dyspnea and weakness in the last week. Physical examination revealed hypotension, tachypnea, jugular vein distention, and desaturation. The most relevant laboratory findings were: anemia, lymphocytopenia, lactic acidosis, and increased lactate dehydrogenase. An electrocardiogram showed rapid atrial fibrillation and low-voltage QRS complexes. An echocardiogram revealed severe pericardial effusion and diffuse heterogeneous thickening of the ventricular and atrial walls. The patient required mechanical ventilation and inotropic support. Therapeutic pericardiocentesis was performed without clinical improvement. Cardiovascular magnetic resonance imaging (CMR) showed septal bounce (compatible with restrictive physiology) and a heterogeneous isointense mass surrounding the ventricular and atrial walls with late gadolinium enhancement of the myocardium and hypoenhancement of the tumor (Figure 1), compatible with primary cardiac lymphoma. A diagnosis of large B-cell lymphoma was confirmed by flow cytometry of the pericardial fluid. The patient died before starting chemotherapic treatment. Secondary involvement of the myocardium in patients with systemic lymphoma is relatively frequent (around 30% in disseminated non-Hodgkin lymphoma) whereas primary cardiac lymphoma is rare (1-2%). We present a case of acute heart failure with restrictive physiology secondary to cardiac lymphoma. In our experience, CMR was key to the final diagnosis.

Prosthetic heart valve thrombosis treated with slow infusion fibrinolytic therapy in patient with acute isquemic stroke

La trombosis de válvula protésica mecánica es una seria complicación, dada su alta tasa de mortalidad, que oscila entre el 80-90%. Su incidencia varía de acuerdo a las diferentes series, encontrándose entre el 0.3% y el 1.3% por año1. Los factores de riesgo más importantes para el desarrollo de la misma son: la posición mitral de la prótesis y una anticoagulación en subrango terapéutico2. Este cuadro puede manifestarse clínicamente como disfunción valvular protésica (que ocasiona insuficiencia cardiaca o arritmias) o embolias sistémicas. El ecocardiograma transesofágico (ETE) es el método de referencia para el diagnóstico de disfunción protésica3. Las opciones terapéuticas son: la anticoagulación, la trombectomía quirúrgica y la trombólisis sistémica4. En líneas generales, las guías de valvulopatías, tanto europeas como americanas, recomiendan la cirugía de urgencia cuando el paciente se encuentra descompensado hemodinámicamente, con disnea de reposo, o cuando el trombo es móvil y tiene un tamaño mayor a 10 mm. Por el contrario, la terapia fibrinolítica se reserva para los pacientes estables hemodinámicamente con disnea de esfuerzo o cuando la cirugía de urgencia no está disponible, o el paciente es de alto riesgo quirúrgico5--7. Por último, es importante resaltar que las características anatómicas de la válvula halladas en el procedimiento de reemplazo valvular podrán condicionar el abordaje terapéutico posterior. Sin embargo, la estrategia terapéutica en pacientes que cursan con un accidente cerebrovascular isquémico secundario a trombosis valvular mecánica protésica es controversial. Informe de caso