Ricardo Ronderos

Morphologic pattern of late gadolinium enhancement in Takotsubo cardiomyopathy detected by early cardiovascular magnetic resonance

Takotsubo cardiomyopathy (TTC) presents clinically as an acute coronary syndrome. It is characterized by transient left ventricular wall dyskinesis‐akinesis, without significant epicardial coronary lesions. Late gadolinium enhancement (LGE) sequences on cardiac magnetic resonance (CMR) allow to clarify the pathophysiology in patients with chest pain, elevated troponin, and normal epicardial coronary arteries; in patients with TTC, previous studies have shown absence of LGE.

Reverse atrial electrical remodeling: A systematic review

Atrial remodeling is a term introduced in 1995 to describe alterations in atrial structure or function. Atrial electrical remodeling is characterized by a reduction of refractory period and action potential duration, dispersion in refractoriness, and a reduction in conduction velocity of impulse propagation. Numerous animal and human studies have demonstrated that atrial electrical remodeling impairs normal atrial conduction and provides an environment for ectopic and re-entrant activity, thus creating a substrate for the initiation or maintenance of atrial fibrillation. Interestingly, atrial electrical remodeling has been shown to be reversible. In this systematic review, we examine the occurrence of reverse atrial electrical remodeling in various clinical settings.

Diagnostic role of new Doppler index in assessment of renal artery stenosis

BackgroundRenal artery stenosis (RAS) is one of the main causes of secondary systemic arterial hypertension. Several non-invasive diagnostic methods for RAS have been used in hypertensive patients, such as color Doppler ultrasound (US). The aim of this study was to assess the sensitivity and specificity of a new renal Doppler US direct-method parameter: the renal-renal ratio (RRR), and compare with the sensitivity and specificity of direct-method conventional parameters: renal peak systolic velocity (RPSV) and renal aortic ratio (RAR), for the diagnosis of severe RAS.MethodsOur study group included 34 patients with severe arterial hypertension (21 males and 13 females), mean age 54 (± 8.92) years old consecutively evaluated by renal color Doppler ultrasound (US) for significant RAS diagnosis. All of them underwent digital subtraction arteriography (DSA). RAS was significant if a diameter reduction > 50% was found. The parameters measured were: RPSV, RAR and RRR. The RRR was defined as the ratio between RPSV at the proximal or mid segment of the renal artery and RPSV measured at the distal segment of the renal artery. The sensitivity and specificity cutoff for the new RRR was calculated and compared with the sensitivity and specificity of RPSV and RAR.ResultsThe accuracy of the direct method parameters for significant RAS were: RPSV >200 cm/s with 97% sensitivity, 72% specificity, 81% positive predictive value and 95% negative predictive value; RAR >3 with 77% sensitivity, 90% specificity, 90% positive predictive value and 76% negative predictive value. The optimal sensitivity and specificity cutoff for the new RRR was >2.7 with 97% sensitivity (p < 0.004) and 96% specificity (p < 0.02), with 97% positive predictive value and 97% negative predictive value.ConclusionThe new RRR has improved specificity compared with the direct method conventional parameters (RPSV >200cm/s and RAR >3). Both RRR and RPSV show better sensitivity than RAR for the RAS diagnosis.

Prognostic utility of ischemic response in functional imaging tests (SPECT or stress echocardiography) in low-risk unstable angina patients

BACKGROUND The aim of this study is to determine the ability of ischemic response in imaging stress tests (single-photon emission computed tomography [SPECT] or stress echocardiography [SE]) to predict events in low-risk unstable angina patients. METHODS Three hundred and fifty-nine patients with unstable angina (< 24 h), asymptomatic at admission, without ST-segment elevation or depression, normal troponins, and undergoing SPECT (n = 188) or SE (n = 171) during hospitalization (median = 1 day) were included. A positive imaging test (IMAGING+) was defined as the presence of reversible perfusion defects or wall motion abnormalities in at least 2 contiguous segments. Multivariate models were constructed using these results and clinical variables to predict events at 6 months. RESULTS Ninety-nine (27%) patients had IMAGING+, 72/188 (38%) in SPECT and 27/17 (16%) in SE (p < 0.0001). Events occurred in 84 (23%) patients: 4 had myocardial infarction, 47 new hospitalizations due to angina and 33 coronary artery revascularizations. Independent predictors of coronary artery disease were: IMAGING+ (OR: 6.4, 95% CI: 3.4-11.8, p < 0.0001), history of coronary artery disease (OR: 2.5, 95% CI: 1.2-5.2, p < 0.02) and TIMI risk (OR: 1.5, 95% CI: 1.1-2.2, p < 0.03). CONCLUSIONS In low-risk unstable angina patients, an ischemic response in functional stress tests (SPECT or SE) was associated with adverse events and severe coronary artery disease.

Predictores ecocardiográficos de capacidad de ejercicio en pacientes con insuficiencia cardiaca sistólica. Valor de la insuficiencia mitral

INTRODUCTION AND OBJECTIVES Patients with heart failure and similar left ventricular systolic dysfunction have differing exercise capacity. The aim of this study was to identify echocardiographic predictors of exercise capacity in patients with heart failure and systolic dysfunction. METHODS We included 150 patients with class II (70%) or III (30%) heart failure with left ventricular ejection fraction below 40%. Six-minute walking test and cardiac color Doppler-echo, including tissue Doppler of mitral and tricuspid rings, were performed. Moderate and severe mitral regurgitation were considered as significant. Two groups were divided according to the median walking distance (290 m): Group 1, <290 m and Group 2, ≥290 m. RESULTS Mitral regurgitation was detected in 112 patients (75%), which was significant in 40 (27%). Group 1 showed more significant mitral regurgitation (35 vs 18%), increased left atrium area (27±1 vs 24±1cm(2)), mitral E amplitude (88±5 vs 72±3cm/s) and systolic pulmonary pressure (37±1 vs 32±1mmHg, all P<.05). By logistic regression analysis, only the presence of significant mitral regurgitation was independently associated with less walked distance (odds ratio: 3.44 95% confidence interval 1.02-11.66, P<.05). By multiple linear regression, the only independent predictor of walked distance was left atrium area (r=0.25, beta coefficient: -6.52±2, P<.01). CONCLUSIONS In patients with class II-III heart failure and left ventricular systolic dysfunction, the main echocardiographic predictors of exercise capacity are related to the presence of significant mitral regurgitation.

Utility of Real Time 3D Echocardiography for the Assessment of Left Ventricular Mass in Patients with Hypertrophic Cardiomyopathy: Comparison with Cardiac Magnetic Resonance.

Patients with hypertrophic cardiomyopathy (HCM) have irregular ventricular shapes with small and sometimes obliterated cavities at end‐systole that affect the quantification of left ventricular mass (LVM) by conventional methods, such as M‐mode or two‐dimensional echocardiography. The goal of this study was to validate the use of real time three‐dimensional echocardiography (RT3DE) to quantify LVM using cardiac magnetic resonance imaging (CMR) as a reference, in a large population of patients with different types of HCM.

Shone's syndrome: Insights from three-dimensional echocardiography

Shones syndrome is a rare congenital anomaly defined as the presence of at least two of the following heart obstructions: a mitral supravalvular ring, a “parachute” mitral valve stenosis, subaortic stenosis, and aortic coarctation. A 58‐year‐old man presented with a mitral ring and a “parachute” mitral valve on two‐dimensional transthoracic echocardiography, raising suspicion of Shones syndrome. Three‐dimensional transesophageal echocardiography revealed a subannular mitral ring inserted directly on the mitral leaflets, thus acting as a “valvar ring.” This distinction can have therapeutic implications as a “valvar” mitral ring could require valve repair or replacement, instead of simple resection.

Influence of dynamic obstruction and hypertrophy location on diastolic function in hypertrophic cardiomyopathy.

Background Hypertrophic cardiomyopathy (HCM) is a disease with marked genetic and phenotypic heterogeneity. It is well known that obstructive septal forms of this disease entail worse clinical outcome compared with nonobstructive septal and apical forms. The objective of this study was to analyze the differences in left ventricular diastolic function in different subgroups of HCMs and to assess the influence of the location of myocardial hypertrophy and the presence of dynamic obstruction on impairment of diastolic function and its correlation with the clinical status. Methods We studied 86 patients with HCM; 27 with the obstructive asymmetric septal type (OAS), 37 with the nonobstructive asymmetric septal type (NOAS) and 22 with apical hypertrophic cardiomyopathy (ApHCM). Patients underwent conventional and tissue Doppler echocardiography and were assessed applying the latest recommendations regarding diastolic dysfunction. Cardiac magnetic resonance was used to study the various morphologic subtypes and quantify left ventricular mass (LVM). Results The early diastolic annular velocity (e′) was significantly lower in OAS with a median of 5 cm/s compared with NOAS with 7 cm/s and ApHCM with 7.5 cm/s (P = 0.0002), and the E/e′ ratio was 8.5 in ApHCM, 10 in NOAS and 14 in OAS (P = 0.0001); no significant differences were found in LVM or maximal wall thickness. Conclusion In HCM, the location of left ventricular hypertrophy and the presence of dynamic obstruction affect the degree of diastolic dysfunction; impairment is greater in patients with the OAS type, and markedly less in patients with apical involvement.

Exaggerated inflammatory response following sirolimus-eluting stent fracture

A 46-year-oldmanwith a history of recurrent right coronary artery (RCA) in-stent restenosiswas admitted because of stable angina. Three months earlier, a 3.0×33-mm Cypher stent (Cordis Corp., Warren, New Jersey) was implanted, with optimal angiographic results. On admission, a roundedmyocardialmasswas found (Fig. 1A) encircling a fractured stent (Fig. 1B, D). Coronary angiogram revealed in-stent restenosis and confirmed stent fracture (Fig. 1E–F). We proceeded with cardiac surgery in order to further clarify the nature of the mass and by-pass the RCA. Microscopic sample evaluation of the excised mass demonstrated dense fibrosis coupled with mononuclear cell infiltration, while there were no neoplastic cells (Fig. 1C). Following an uneventful surgical recovery, the patient was discharged home at postoperative day 4. Drug-eluting stent fracture can lead to complications such as restenosis [1], thrombosis [2,3], aneurismal formation [4] and even perforation with catastrophic consequences. In the current case, the presence of increased vessel rigidity (i.e. long overlapping stented segments and the use of stent with closed-cell design) and angulation may have caused stent fracture [5,6]. In addition, animal and human data indicate that chronic coronary vessel exposure to either paclitaxel or sirolimus-eluting stent is associated with a whole host of local detrimental effects such as inflammation, endothelial dysfunction and inappropriate vessel remodeling. It is conceivable that the development of severe drug-eluting stent fracture created an ideal scenario for an amplify vessel exposure to all drug-eluting stent components and hence, provoke an exaggerated inflammatory response. To the best of

E/eʹ ratio and left atrial area are predictors of atrial fibrillation in patients with hypertrophic cardiomyopathy

Atrial fibrillation (AF) occurs in about 20%–25% of patients with hypertrophic cardiomyopathy and is associated with increased risk of cardioembolism and heart failure impacting on patients’ morbidity and mortality. The aim of this study was to identify echocardiographic predictors of AF in a cohort of patients with hypertrophic cardiomyopathy (HCM).