Patricia Mahía

Impact of contrast-enhanced echocardiography on the diagnostic algorithm of acute aortic dissection

AIMS To determine the usefulness of contrast echocardiography in the diagnosis of aortic dissection (AD) and in the assessment of findings necessary for adequate patient management. METHODS AND RESULTS Conventional and contrast-enhanced transthoracic echocardiography (TTE) and transoesophageal echocardiography (TOE) were performed in 128 consecutive patients with clinically suspected acute AD. Results were validated independently against intraoperative findings in 45 patients and computed tomography information in 83. Sensitivity and specificity of conventional TTE increased after contrast enhancement from 73.7 to 86.8% (P< 0.005) and 71.2 to 90.4% (P < 0.05), respectively. Sensitivity and specificity of enhanced TTE were similar to conventional TOE in ascending aorta (93.3 vs. 95.6% and 97.6 vs. 96.4%, respectively) and in the arch (88.4 vs. 93.0% and 95.3 vs. 98.82%, respectively). Contrast-enhanced TOE permitted the location of non-visualized entry tear in seven cases (10.6%), helped to correctly identify the true lumen in six (9.1%), and diagnosed retrograde dissection in nine (13.6%). CONCLUSION Contrast enhancement substantially improves TTE in the diagnosis of AD and should be considered as the initial imaging modality in the emergency setting. Contrast enhancement also has significant value for obtaining critical morphological and haemokinetic information by TOE useful for adequate patient management.

Coronariografía mediante tomografía computarizada de 16 detectores antes de la cirugía de recambio valvular

INTRODUCTION AND OBJECTIVES Multislice computed tomography is an excellent technique for the detection of significant coronary artery lesions. Our purpose was to assess whether computed tomography could replace routine invasive coronariography before valvular surgery. METHODS We studied 106 consecutive patients (mean age: 67 [10]): 76% aortic valvular disease (62% stenosis, 14% regurgitation), 20% mitral valvular disease (4% stenosis, 16% regurgitation), and 4% mitro-aortic disease. Non-invasive studies were performed by helical computed tomography. Eighty-four percent of patients were in sinus rhythm (40% using beta-blockers, 32% nitrates). Findings from both techniques were analyzed according to a predetermined segmented anatomical model of the coronary artery (a total of 1802 segments). RESULTS The incidence of coronary artery disease in these patients was 30%. Using computed tomography, 96.8% of segments could be evaluated and 3.2% could not. Calcium score ranged from 0 to 7572 (median: 182). In the per patient analysis, computed tomography showed a sensitivity of 95%, specificity 94%, positive predictive value 84%, and negative predictive value 98%. CONCLUSIONS Computed tomography is an excellent technique for ruling out coronary lesions prior to valvular surgery, making an invasive study unnecessary if the quality of the study is good and the result is negative.

Usefulness of real-time three-dimensional transoesophageal echocardiography in the assessment of chronic aortic dissection

AIMS To assess the usefulness of three-dimensional transoesophageal echocardiography (3D-TOE) vs. two-dimensional (2D)-TOE in the evaluation of morphological and dynamic findings of aortic dissection, and compare the results with those obtained by multi-slice computed tomography (CT). METHODS AND RESULTS Twenty-six patients (21 men and 5 women, median age: 67 years, range: 28-74 years) diagnosed of chronic aortic dissection with patent false lumen were studied. A comprehensive 2D-TOE and a real-time 3D-TOE study targeted at assessing dissection variables were performed and compared with CT within 3 months. Both 3D-TOE and 2D-TOE visualized the intimal flap extension and presence of flow in aortic dissection lumina in the same aortic segments. Three-dimensional TOE correctly identified true lumen in all cases, being superior to 2D-TOE in three cases with a spiroidal course of the dissection in descending aorta. Maximum entry tear diameter measured by 3D-TOE showed a better correlation with CT than 2D-TOE (0.96 and 0.87, P< 0.001, respectively). Compared with CT, 2D-TOE underestimated maximum entry tear diameter (-1.75 ± 3.28 mm, P< 0.01) but 3D-TOE did not (-0.20 ± 1.92 mm, P: n.s.). However, entry tear area measured by 3D-TOE and CT showed the best correlation (r: 0.97) and agreement (0.05 ± 0.20 cm(2), P: n.s.). CONCLUSION Three-dimensional TOE provides additional information to 2D-TOE in aortic dissection assessment, particularly in entry tear size quantification. Agreement between entry tear area defined by 3D-TOE and CT was excellent. Three-dimensional TOE permits better morphological and dynamic understanding of aortic dissection when the flap is spiroidal.

Imaging techniques in chagas' disease.

etiology and considering the risk factors, singlephoton emission CT (SPECT) was performed. The results were clinically and electrically negative for ischemia, and showed a fixed inferior defect (Figure, A). A noninvasive approach with CT and CMRI was used to investigate the perfusion defect. Coronary disease was ruled out (Figure, B) and fibrosis was detected in the affected territory (Figures, C and D). These tests enabled a suspected diagnosis of Chagas disease to be established, which was confirmed by positive serology for Trypanosoma cruzi. This case illustrates the usefulness of noninvasive imaging techniques in cardiac involvement by Chagas disease and provides a new diagnostic and prognostic approach to consider in the clinical management of this condition.

Impact of Calcium Score on Agreement Between Multidetector Computed Tomography and Invasive Coronary Angiography

INTRODUCTION AND OBJECTIVES Multidetector computed tomography (MDCT) has been demonstrated as a feasible alternative to invasive coronary angiography (ICA). However, contradictory results have been reported regarding the effect of coronary artery calcium score (CS) on the diagnostic accuracy of MDCT. Our aim was to assess the agreement of MDCT and ICA and to evaluate the influence of CS on this agreement. METHODS We enrolled 266 consecutive patients who underwent evaluation with 64-slice MDCT and ICA. Standard CS software tools were used to calculate the Agatston score. Stenosis was qualitatively classified as mild, moderate, or severe by 1 blinded observer and the results were compared with those of ICA, which was used as the gold standard. RESULTS The mean age of the patients was 65.4 ± 11.2 years, and 188 patients (70.3%) were men. A total of 484 segments with coronary stenosis ≥ mild were qualitatively evaluated and quantified with MDCT. Noninvasive measurements were concordant with ICA in 402 stenoses (83.05%; Kappa, 0.684), with no significant differences between vessels and with no statistically significant influence of CS on this agreement (OR, 0.93; 95%CI, 0.76-1.09; P = .21). Multidetector computed tomography had high sensitivity, specificity, positive predictive value, and negative predictive value on a per-segment, per-vessel, and per-patient basis. CONCLUSIONS Non-ICA using MDCT showed good agreement with ICA in the qualitative quantification coronary stenosis and CS had no significant impact on this agreement.

Comments on the ESC guidelines on the management of valvular heart disease (version 2012). A report of the Task Force of the Clinical Practice Guidelines Committee of the Spanish Society of Cardiology.

A task force was formed consisting of experts from different fields. Members of the task force were proposed by the SEC Clinical Cardiology, Cardiac Catheterization, and Cardiac Imaging sections and by the SECTCV (Spanish Society of Thoracic and Cardiovascular Surgery). The Task Force was coordinated by 2 representatives of the CGPC. The guidelines were divided into blocks and sent to members of the Task Force, who analyzed the most novel and important aspects in terms of clinical practice. They also gave their opinion on the methodology used, possible areas of conflict, and limitations with regard to other guidelines. In addition, they were asked to describe the implications for actual practice in the Spanish setting. The information received was used to produce a first draft of the document, which the original committee evaluated before referring it to a second group of 11 reviewers also proposed by sections of the SEC and the SECTCV. All authors and reviewers were asked to disclose any conflicts of interest, details of which are provided at the end of the article.

Three-dimensional Tricuspid Area. A New Criterion to Improve Patient Selection for Annuloplasty in Tricuspid Regurgitation

INTRODUCTION AND OBJECTIVES Late functional tricuspid regurgitation after rheumatic left-sided valve surgery is an important predictor of poor prognosis. This study investigated the usefulness and accuracy of 3-dimensional transthoracic echocardiography tricuspid area compared with conventional 2-dimensional diameter (2DD) for assessing significant tricuspid annulus dilatation, providing cutoff values that could be used in clinical practice to improve patient selection for surgery. METHODS We prospectively included 109 patients with rheumatic heart disease in the absence of previous valve replacement. Tricuspid regurgitation was divided into 3 groups: mild, moderate, and severe. Optimal 3-dimensional area (3DA) and 2DD cutoff points for identification of significant tricuspid annulus dilatation were obtained and compared with current guideline thresholds. Predictive factors for 3DA dilatation were also assessed. RESULTS Optimal cutoff points for both absolute and adjusted to body surface area (BSA) tricuspid annulus dilatation were identified (3DA: 10.4 cm2, 6.5 cm2/m2; 2DD: 35 mm, 21 mm/m2); 3DA/BSA had the best diagnostic performance (AUC=0.83). Three-dimensional transthoracic echocardiography tricuspid area helped to reclassify surgical indication in 14% of patients with mild tricuspid regurgitation (95%CI, 1%-15%; P=.03) and 37% with moderate tricuspid regurgitation (95%CI, 22%-37%; P<.0001), whereas 3DA/BSA changed surgery criteria in cases of mild tricuspid regurgitation (17%; 95%CI, 3%-17%; P=.01) compared with 2DD/BSA. On multivariable analysis, right and left atrial volumes and basal right ventricle diameter were independently correlated with 3DA. CONCLUSIONS The current 40 mm threshold underestimates tricuspid annulus dilatation. Although 21 mm/m2 seems to be a reasonable criterion, the combination with 3DA assessment improves patient selection for surgery.

Platypnea–orthodeoxia syndrome: additive value of three-dimensional echocardiography

A 76-year-old man was admitted to the hospital after 3 weeks of dyspnea that worsened upon standing and improved when lying down. He had no murmurs or jugular venous distention and heart sounds were normal. Neither chest X-ray nor chest computed tomography revealed any apparent pulmonary disease that could cause his dyspnea. A two-dimensional transthoracic echocardiogram revealed normal left and right ventricular function and a thin and hypermobile inter-atrial septum. Subsequently, transoesophageal echocardiography was performed, revealing the presence of a highly mobile inter-atrial septal aneurysm with 2 cm bowing into the left atrium, and large patent foramen ovale (PFO) that was only evident in the upright position, with a maximal separation of 5 mm (Fig. 1a, see supplementary data online, video 1). Color Doppler imaging demonstrated a massive right-to-left shunt, proceeding directly from the inferior vena cava into the left atrium across the PFO in the upright position (Fig. 1b, see supplementary data online, video 2). Live 3D echocardiography was performed, which provided better evaluation of the size and shape of the PFO and mobility of the atrial septal aneurysm (Fig. 1c, d, see supplementary data online, videos 3 and 4), including direct en face visualization from the left atrium (Fig. 1e, f, see supplementary data online, videos 5 and 6). The PFO was large and had a hemielliptic rather than a circular shape, with diameters of 5 9 21 mm obtained using a 3D multiplanar review mode. The patient was given the diagnosis of platypnea–orthodeoxia syndrome. Platypnea–orthodeoxia is an uncommon syndrome characterized by the onset or worsening of dyspnea and deoxygenation in the upright position that improves or disappears in recumbency [1]. There has been described three pathological mechanisms: intracardiac shunting, intrapulmonary shunting, or ventilation–perfusion mismatch [2, 3]. When this syndrome is due to an intracardiac mechanism, there must coexist two conditions: an anatomical element in the form of an inter-atrial commu-

Giant and thrombosed left ventricular aneurysm.

Left ventricular aneurysms are a frequent complication of acute extensive myocardial infarction and are most commonly located at the ventricular apex. A timely diagnosis is vital due to the serious complications that can occur, including heart failure, thromboembolism, or tachyarrhythmias. We report the case of a 78-year-old male with history of previous anterior myocardial infarction and currently under evaluation by chronic heart failure. Transthoracic echocardiogram revealed a huge thrombosed and calcified anteroapical left ventricular aneurysm. Coronary angiography demonstrated that the left anterior descending artery was chronically occluded, and revealed a big and spherical mass with calcified borders in the left hemithorax. Left ventriculogram confirmed that this spherical mass was a giant calcified left ventricular aneurysm, causing very severe left ventricular systolic dysfunction. The patient underwent cardioverter-defibrillator implantation for primary prevention.

Long-term Evolution of Type B Dissection and Endovascular Therapy Indications

The long-term evolution of type B aortic dissection has relatively high mortality or need for surgery, which approach 50% in 5 years. Some clinical predictive such as age, chronic obstructive pulmonary disease, hypertension and Marfan Syndrome factors have been associated with a high risk of complications. However, information obtained by imaging techniques has significant prognostic value. In addition to maximum aorta diameter, the combination of large entry tear size and true lumen compression or partial false lumen thrombosis is the best predictor of mortality and aortic dilatation. In these cases endovascular therapy should be considered in subacute phase. Treatment efficacy is greater in this phase than in chronic phase when the aorta is severely dilated and the intima is less elastic. Indications for stent grafting or surgery in the chronic phase are based on the size and growth of the dissecting aneurysm. Careful blood pressure control and annual follow-up by imaging techniques are necessary to prevent the aortic rupture, and elective endovascular therapy should be considered if aortic diameter exceeds 60 mm or increases significantly (> 5 mm/y).