Mariano Falconi

Prospective Validation of the Prognostic Usefulness of Brain Natriuretic Peptide in Asymptomatic Patients With Chronic Severe Mitral Regurgitation

OBJECTIVES The purpose of the study was to determine the independent and additive prognostic value of brain natriuretic peptide (BNP) in patients with severe asymptomatic mitral regurgitation and normal left ventricular function. BACKGROUND Early surgery could be advisable in selected patients with chronic severe mitral regurgitation, but there are no criteria to identify candidates who could benefit from this strategy. Assessment of BNP has not been studied in asymptomatic patients with severe mitral regurgitation; hence, its prognostic value remains unclear. METHODS We prospectively evaluated 269 consecutive patients with severe asymptomatic organic mitral regurgitation and left ventricular ejection fraction above 60%. The first 167 consecutive patients served as the derivation cohort, and the following 102 patients served as a validation cohort. The combined end point was the occurrence of either symptoms of congestive heart failure, left ventricular dysfunction, or death at follow-up. RESULTS The end point was reached in 35 (21%) patients of the derivation set and in 21 (20.6%) patients of the validation cohort. The receiver-operating characteristics curve yielded an optimal cutoff point of 105 pg/ml of BNP that was able to discriminate patients at higher risk in both cohorts (76% vs. 5.4% and 66% vs. 4.0%, respectively). In both sets, BNP was the strongest independent predictor by multivariate analysis. CONCLUSIONS Among patients with severe asymptomatic organic mitral regurgitation, BNP > or =105 pg/ml discriminates a subgroup of patients at higher risk. Because of its incremental prognostic value, BNP assessment should be considered in clinical routine workup for risk stratification.

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.

Different Clinical Features of Aortic Intramural Hematoma Versus Dissection Involving the Descending Thoracic Aorta

Objective: The objective of this study is to test the hypothesis that the absence of flow communication in aortic intramural hematoma (IMH) involving the descending aorta may have a different clinical course compared with aortic dissection (AD). Methods: We prospectively evaluated clinical and echocardiographic data in AD (76 patients) and IMH (27 patients) of the descending thoracic aorta. Results: Patients did not differ with regard to age, gender, or clinical presentation. IMH and AD had the same predictors of complications at follow‐up: aortic diameter (>5 cm) at diagnosis and persistent back pain. Surgical treatment was more frequently selected in AD (39% vs. 22%, P < 0.01) and AD patients who underwent surgical treatment had higher mortality than those with IMH (36% vs. 17%, P < 0.01). There was no difference in mortality with medical treatment (14% in AD vs. 19% in IMH, P = 0.7). During follow‐up, of 23 patients with IMH, 11 (47%) showed complete resolution or regression, 6 (26%) increased the diameter of the descending aorta, and typical AD developed in 3 patients (13%). No changes occurred in 14% of the group. Three‐year survival rate did not show significant differences between both groups (82 ± 6% in IMH vs. 75 ± 7% in AD, P = 0.37). Conclusion: IMH of the descending thoracic aorta has a relatively frequent rate of complications at follow‐up, including dissection and aneurysm formation. Medical treatment with very frequent imaging and timed elective surgery in cases with complications allows a better patient management.

Written Consent to Use the Drug in Children: The Problem of Off-Label Drugs

Cardiac arrhythmias in pediatric patients have different mechanisms and frequencies compared to adult patients. There are many physiological differences between children and adults that may affect the pharmacodynamic and pharmacokinetic of the antiarrhythmic drugs in pediatric population. Children, and specially breast feeding children, cannot be considered low weighted adults to select antiarrhythmic drug doses. Although radiofrequency ablation has experienced great technological advances, it is performed in selected pediatric patients. Therefore, the main therapeutic strategy is the use of antiarrhythmic drugs in children. The medical management of arrhythmias in pediatric patients is challenging and complex. There are few clinical guidelines. There is scarce and incomplete information about the efficacy and safety of antiarrhythmic drugs in pediatric population. Most of the doses and drug administration intervals are extrapolated from adult population and applied to children. Antiarrhythmic drug doses have been extensively studied in adult population. However, in pediatric population, there are very few clinical trials and the safety of these drugs is not well known. In general, dose regimens are based on small uncontrolled studies, extrapolation of drug doses from studies performed in the adult population or physician experience. As a consequence, there is a need for further studies to assess the most effective antiarrhythmic drug regimens in children reducing the risk of side effects. Evidence suggests that medical research in pediatric population is necessary and morally valuable. But investigators involved must take care of moral and ethical values, including the respect for the child-subject and his parents or legal representatives, and this respect compels them to consider the patient and family in the decision making process. The participation request and the informed consent must be obtained according to the competitions the patient exhibits, trying to anticipate information about benefits and possible damages derived from the investigation in an understandable language for him. In our opinion the pharmacologic clinical investigation of antiarrhythmic treatments in pediatrics is necessary. More clinical studies must be carried out under rigorous scientific rules that contemplate the particular ethical dilemmas this population faces.

Low rate of cardiovascular events in patients with acute myocarditis diagnosed by cardiovascular magnetic resonance

BACKGROUND Myocarditis is a relatively common inflammatory disease that affects the myocardium. Infectious disease accounts for most of the cases either because of a direct viral infection or post-viral immune-mediated reaction. Cardiovascular magnetic resonance (CMR) has become an established non-invasive diagnosis tool for acute myocarditis. A recent large single centre study with patients with biopsy-proven viral myocarditis undergoing CMR scans found a high rate of mortality. The aim of this study was to assess the rate of clinical events in our population of patients with diagnosed myocarditis by CMR scan. METHODS Patients who consulted to the emergency department with diagnosis of myocarditis by CMR were retrospectively included in the study from January 2008 to May 2012. A CMR protocol was used in all patients, and were followed up to assess the rate of the composite endpoint of all-cause death, congestive heart failure, sudden cardiac death, hospitalization for cardiac cause, recurrent myocarditis or need of radiofrequency ablation or implantable cardiac defibrillator (ICD). A descriptive statistical analysis was performed. RESULTS Thirty-two patients with myocarditis were included in the study. The mean age was 42.6±21.2 years and 81.2% were male. In a mean follow up of 30.4±17.8 months, the rate of the composite endpoint of all-cause death, congestive heart failure, sudden cardiac death, hospitalization for cardiac cause, recurrent myocarditis or need of radiofrequency ablation or ICD was 15.6% (n=5). Two patients had heart failure (one of them underwent heart transplant), one patient needed ICD because of ventricular tachycardia and two other patients were re-hospitalized, for recurrent chest pain and for recurrent myocarditis respectively. CONCLUSIONS In our series of acute myocarditis diagnosed by CMR we found a low rate of cardiovascular events without mortality. These findings might oppose data from recently published myocarditis trials.

Síndrome de ortodeoxia-platipnea y embolia luego de endocarditis derecha complicada: consecuencias del Foramen Oval Permeable

Se presenta el caso clinico de una mujer de 63 anos de edad con Endocarditis de la Valvula Tricuspide que de-sarrollo tromboembolismo pulmonar y un sindrome de platipnea-ortodeoxia, explicado por la presencia de un formen oval permeable. La paciente se recupero satis-factoriamente despues de un reemplazo de la valvula tricuspide.

Valor diagnóstico de la resonancia magnética cardíaca en pacientes con arritmia ventricular frecuente y ecocardiograma Doppler normal

Introduccion La arritmia ventricular frecuente puede ser una alteracion electrica primaria o estar asociada con una cardiopatia. El impacto pronostico y terapeutico depende de la presencia de cardiopatia estructural. El ecocardiograma Doppler transtoracico ha sido el estudio complementario mas importante para evaluar la presencia de alteraciones estructurales cardiacas. Objetivos Determinar la capacidad de la resonancia magnetica cardiaca para detectar alteraciones estructurales a nivel cardiaco en pacientes con ecocardiograma Doppler normal y conocer la incidencia de eventos cardiovasculares adversos en el seguimiento. Material y metodos Se incluyeron 66 pacientes consecutivos con arritmia ventricular frecuente definida como > 5.000 extrasistoles ventriculares en un registro Holter de 24 horas, taquicardia ventricular o muerte subita resucitada con ecocardiograma Doppler normal. A todos los pacientes se les realizo una resonancia magnetica cardiaca con protocolo para evaluar miocardiopatias. Resultados El 57% de los pacientes presentaron alguna alteracion estructural; las patologias diagnosticadas mas prevalentes fueron la secuela de miocarditis, el miocardio no compactado y la secuela de infarto subendocardico. En el seguimiento medio de 24 ± 22 meses, la incidencia de eventos cardiovasculares adversos fue del 6,06%. El numero de extrasistoles ventriculares fue mayor en los pacientes con resonancia anormal. Conclusiones Este trabajo demuestra que en pacientes con arritmia ventricular frecuente con ecocardiograma Doppler normal la realizacion de una resonancia magnetica cardiaca con gadolinio permite detectar en mas de la mitad de los casos alguna alteracion estructural. Los pacientes con arritmia ventricular frecuente en el Holter, Doppler normal y alteraciones leves en la resonancia presentan riesgo bajo de eventos cardiovasculares.(AU) Introduction Frequent ventricular arrhythmia can be a primary electrical disturbance or may be associated to cardiomyopathy. The prognostic and therapeutic impact depends on the presence of structural heart disease. Transthoracic Doppler echocardiography has been the most important complementary study to evaluate the presence of cardiac structural abnormalities. Objectives The aims of this study were to determine the ability of cardiac magnetic resonance imaging to detect structural heart disease in patients with normal Doppler echocardiography and to assess the incidence of adverse cardiovascular events during follow-up. Methods The study included 66 consecutive patients with frequent ventricular arrhythmia defined as > 5000 ventricular extrasystoles in a 24-hour Holter monitoring, ventricular tachycardia or resuscitated cardiac respiratory arrest with normal Doppler echocardiogram. All patients underwent cardiac magnetic resonance imaging to assess cardiomyopathies. Results Fifty-seven percent of patients had structural heart disease. The most prevalent diagnosed pathologies were myocarditis sequelae, non-compacted myocardium and subendocardial infarction scar. At mean follow-up of 24 ± 22 months, the incidence of adverse cardiovascular events was 6.06%. The number of ventricular extrasystoles was higher in patients with abnormal cardiac magnetic resonance. Conclusions This work demonstrates that in patients with frequent ventricular arrhythmia and normal Doppler echocardiogram, gadolinium cardiac magnetic resonance imaging can detect structural heart disease in more than half of the cases. Patients with frequent ventricular arrhythmia during Holter monitoring, normal Doppler and mild alterations in the magnetic resonance present low risk of cardiovascular events.(AU)

Precisión diagnóstica del espesor íntima-media carotídeo para la detección de aterosclerosis coronaria. Utilidad en la práctica clínica

Introduccion El espesor intima-media carotideo (EIMC) es un marcador independiente de riesgo cardiovascular. El puntaje de calcio coronario (PCC) es un predictor superior al EIMC, pero de costo elevado y en nuestro pais pocos pacientes pueden acceder a su medicion. Objetivos 1) Evaluar la precision diagnostica del EIMC para la deteccion de un PCC > 0. 2) Determinar el punto de corte optimo del EIMC para discriminar entre la presencia o la ausencia de calcio coronario. Material y metodos Estudio descriptivo transversal de muestras consecutivas obtenidas en los consultorios de prevencion cardiovascular. Se midio el EIMC medio y maximo mediante un eco-Doppler carotideo. Se efectuo una tomografia computarizada de 64 pistas para la evaluacion del PCC. Se determino la precision diagnostica del EIMC para la deteccion de un PCC > 0 mediante un analisis ROC. Resultados Se incluyeron 202 sujetos consecutivos que participan de un programa de prevencion primaria. Caracteristicas de la poblacion (media } desviacion estandar): edad 57 } 13 anos, sexo femenino: 49%, tabaquismo: 13%, estatinas: 37%, diabetes mellitus: 13%, puntaje de Framingham en no diabeticos: 9% } 7%, EIMC medio: 0,953 } 0,342 mm, EIMC maximo: 1,383 } 0,679 mm, prevalencia de placa aterosclerotica carotidea: 37% y de PCC > 0: 62%. Las correlaciones entre el EIMC medio y maximo y el PCC fueron moderadas (r = 0,56 y r = 0,55, respectivamente). El area bajo la curva ROC del EIMC maximo fue de 0,822 (IC 95% 0,763-0,880) y la del EIMC medio fue de 0,829 (IC 95% 0,771-0,888). El punto de corte optimo del EIMC maximo para discriminar entre PCC > 0 o PCC = 0 fue de . 1,01 mm y la sensibilidad, la especificidad, el valor predictivo positivo (VPP) y el valor predictivo negativo (VPN) fueron del 78%, 75%, 83% y 67%, respectivamente. El punto de corte optimo del EIMC medio para discriminar entre PCC > 0 o PCC = 0 fue . 0,82 mm y la sensibilidad, la especificidad, el VPP y el VPN fueron del 77%, 78%, 85% y 67%, respectivamente. Conclusiones En esta poblacion predominantemente de riesgo bajo, la precision diagnostica del EIMC para detectar PCC > 0 fue moderada. Una ecografia Doppler carotidea gnormal no excluyo la presencia de aterosclerosis subclinica coronaria. Estos resultados podrian mejorar la seleccion de pacientes que requieran la medicion del PCC para estratificar el riesgo cardiovascular.