Resultados a largo plazo de la cirugía de revascularización coronaria según la presencia o no de enfermedad del tronco de la arteria coronaria izquierda / Long-term Outcomes of Coronary Artery Bypass Surgery According to the Presence or Absence of Left Main Coronary Artery Disease

RESUMEN Introducción: La cirugía de revascularización miocárdica (CRM) ha modificado la evolución natural de los pacientes con enfermedad de tronco de la arteria coronaria izquierda (TCI). En nuestro medio es escasa la información relacionada con el seguimiento a mediano y largo plazo de los pacientes intervenidos. Objetivo: Evaluar la implicancia de la enfermedad del TCI en la evolución alejada de los pacientes intervenidos con CRM, y conocer la mortalidad e incidencia de infarto de miocardio (IAM) y/o accidente cerebrovascular (ACV). Resultados: El seguimiento se completó en 438 pacientes (95,6%) con una mediana de 58 meses [Rango intercuartilo (RIC) 35-88 meses]. La sobrevida actuarial fue a 10 años del 91,8% para toda la población, sin diferencias significativas entre el grupo TCI (91,57%) vs. el grupo no TCI (91,86%), HR 1,008, IC95% 0,38-2,65, p=0,98. En el análisis multivariado se encontraron como predictores de mortalidad alejada la fracción de eyección ventricular izquierda preoperatoria (HR 0,95, IC 95% 0,93-0,97, p<0,001), la edad (HR 1,1, IC 95% 1,04-1,13, p< 0,001) y la prioridad no electiva de la cirugía (HR = 3,71; IC 95%: 1,3-10,35; p = 0,01). La sobrevida libre de IAM fue del 96,8% (TCI 94% vs. no TCI 97,4%, p= 0,8) y la libertad de ACV fue del 98% (TCI 97,8% vs. no TCI 98,1%, p= 0,8). Conclusión: En los pacientes sometidos a CRM, la presencia de enfermedad del TCI no incrementó la tasa de eventos duros (muerte, IAM y ACV) en el seguimiento alejado. Los resultados obtenidos en esta serie de pacientes son similares a los publicados en la bibliografía internacional utilizada para desarrollar las guías de revascularización miocárdica.

ABSTRACT Background: Coronary artery bypass grafting (CABG) has modified the natural evolution of patients with left main coronary artery (LMCA) disease. There is little information in our setting regarding the mid- and long-term follow-up of operated patients. Objective: The aim of this study was to evaluate the implication of LMCA disease in the long-term evolution of patients operated on with CABG, and to assess the mortality and incidence of myocardial infarction (AMI) and/or stroke. Results: Follow-up was completed in 438 patients (95.6%) with a median of 58 months [interquartile range (IQR) 35-88 months]. Actuarial survival at 10 years was 91.8% for the entire population, with no significant differences between the LMCA group (91.57%) vs. the non-LMCA group (91.86%), HR 1,008 95% CI 0.38-2.65, p=0.98. In multivariate analysis, preoperative left ventricular ejection fraction (HR = 0.95; 95% CI 0.93-0.97; p < 0.001), age (HR 1.1, 95% CI 1.04-1.13, p<0.001) and non-elective priority of surgery (HR=3.71; 95% CI 1.3-10.35; p=0.01) were independent predictors of long-term mortality. AMI-free survival was 96.8% (LMCA 94% vs. non-LMCA 97.4%, p=0.8) and freedom from stroke was 98% (LMCA 97.8% vs. non-LMCA 98.1 %, p=0.8). Conclusion: In patients undergoing CABG, the presence of LMCA disease did not increase the rate of hard events (death, AMI, and stroke) at the long-term follow-up. The results obtained in this series of patients are similar to those published in the international literature used to develop myocardial revascularization guidelines.

La edad avanzada en forma aislada no constituye una limitación para el reemplazo valvular aórtico quirúrgico / Old Age Alone is not a Limitation for Surgical Aortic Valve Replacement

RESUMEN Introducción: El reemplazo quirúrgico de la válvula aórtica (REEAO) en pacientes con valvulopatía aórtica grave sintomática, es el tratamiento definido como el de referencia. Sin embargo, el implante valvular aórtico transcatéter (TAVI) se posiciona actualmente como una alternativa en pacientes de diferentes riesgos según los scores internacionales. Algunas guías consideran al TAVI como el procedimiento preferible en los pacientes añosos. Objetivos: Conocer el riesgo y resultados de morbimortalidad del REEAO en pacientes adultos clasificados según la edad en mayores de 75 años, o de 75 años o menos. Material y métodos: Estudio retrospectivo sobre 228 pacientes consecutivos intervenidos mediante REEAO entre el 1 de enero de 2011 y el 31 de diciembre de 2020 por valvulopatía aórtica grave sintomática. Del total de pacientes operados, 46 (16%) eran mayores de 75 años (Grupo 1, G1) y 182 pacientes (84%) tenían 75 años o menos (Grupo 2, G2). Se excluyeron pacientes con enfermedad coronaria concomitante, endocarditis bacteriana u otras valvulopatías asociadas. Resultados: Los pacientes del G1 tenían mayor riesgo de morbimortalidad quirúrgica analizado por scores de riesgo validados: ArgenSCORE de 1,55 (RIC 0,99-3,33) vs 1,08 (RIC 0,68-2,23), p = 0,02 y STS score de 2,33 (RIC 1,57-3,23) vs. 0,94 (RIC 0,721,44), p = 0,0001, con respecto al G2; no se encontraron en cambio diferencias significativas en el EuroSCORE II : 2,37 (RIC 1,19-3,61) vs. 1,83 (RIC 1,16-3,04), p = 0,2. La mortalidad registrada global fue del 1,7% (G1: 2,1% vs. G2: 1,6% , p NS); no se observaron accidente cerebrovascular (ACV) ni infarto agudo de miocardio (IAM) perioperatorios. Conclusiones: La escasa presentación de muerte, ACV e IAM sugiere que el tratamiento seleccionado para estos pacientes fue adecuado, con excelentes resultados sin diferencias entre los dos grupos etarios.

ABSTRACT Background: Surgical aortic valve replacement (SAVR) is the reference treatment in patients with symptomatic severe aortic valve disease. However, according to international scores, transcatheter aortic valve implantation (TAVI) is currently an alternative in different risk patients, and some guidelines consider TAVI as a preferable procedure in elderly patients. Objectives: The aim of this study was to assess SAVR morbidity and mortality risk and results in adult patients, classified according to age as >75 years or ≤75 years. Methods: A retrospective study was performed on 228 consecutive patients undergoing SAVR between January 1, 2011 and December 31, 2020 for symptomatic severe aortic valve disease. Among the total number of patients operated on, 46 (16%) were >75 years (Group 1, G1) and 182 (84%) were ≤75 years (Group 2, G2). Patients with concomitant coronary heart disease, bacterial endocarditis or other associated valve diseases were excluded from the analysis. Results: Group 1 patients had greater risk of surgical morbidity and mortality analyzed by validated risk scores: ArgenSCORE 1.55 (IQR 0.99-3.33) vs 1.08 (IQR 0.68-2.23), p = 0.02 and STS score 2.33 (IQR 1.57-3.23) vs. 0.94 (IQR 0.72-1.44), p = 0.0001, with respect to G2, while no significant differences were found for EuroSCORE II: 2.37 (IQR 1.19-3.61) vs. 1.83 (IQR 1.163.04), p = 0.2. Overall mortality was 1.7% (G1: 2.1% vs. G2: 1.6%, p=NS), with no perioperative stroke or acute myocardial infarction (AMI). Conclusions: The low number of deaths, stroke and AMI observed suggests that the selected treatment for these patients was adequate, with excellent results and without significant differences between these two age groups.

Estimación del riesgo en cirugía cardíaca en el "mundo real": ArgenSCORE ajustado al centro / Cardiovascular Surgery Risk Assessment in the "Real World": ArgenSCORE Adjusted by Center

RESUMEN Introducción: El ArgenSCORE tiene una versión original (I) desarrollada en 1999 sobre una población con mortalidad del 8% y una versión II (recalibración del modelo en 2007) sobre una población con una mortalidad del 4%. Evaluamos en el registro CONAREC XVI la hipótesis de que el ArgenSCORE II podría estimar mejor el riesgo de mortalidad intrahospitalaria en los centros con baja mortalidad; en cambio, el ArgenSCORE I estimaría mejor la mortalidad en los centros con alta mortalidad. Material y métodos: Se analizaron 2548 pacientes de 44 centros del registro prospectivo y multicéntrico en cirugía cardíaca, CONAREC XVI. En cada centro se evaluó la mortalidad media observada (MO) y se calculó la mortalidad estimada media (ME) aplicando ambas versiones del ArgenSCORE. Se calculó la relación MO/ME de cada centro para los dos modelos y se evaluó si había diferencias significativas mediante el test Z. Resultados: La mortalidad intrahospitalaria del registro fue del 7,69%. El 75% de los centros (33/44) presentaban una mortalidad mayor del 6%. En centros con mortalidad menor del 6%, al aplicar el ArgenSCORE II, la relación MO/ME mostró valores cercanos a 1 y sin diferencias significativas. En centros con mortalidad mayor del 6%, el ArgenSCORE II subestima significativamente el riesgo. En cambio, cuando se aplica en estos centros el ArgenSCORE I, la relación MO/ME es cercana a 1 (sin diferencias significativas). Conclusiones: En centros con mortalidad menor del 6%, es recomendable utilizar el ArgenSCORE II-recalibrado; en centros con mortalidad mayor del 6%, tiene mejor desempeño el ArgenSCORE I-original.

ABSTRACT Background: The ArgenSCORE I was developed in 1999 on a population with 8% mortality. The ArgenSCORE II emerged after recalibrating the original model in 2007 on a validation population with 4% mortality. Using the CONAREC XVI registry, we evaluated the hypothesis that the ArgenSCORE II could better predict the risk of in-hospital mortality in centers with low mortality, whereas the ArgenSCORE I could better predict mortality in centers with high mortality. Methods: A total of 2548 patients from 44 centers of the prospective and multicenter cardiac surgery CONAREC XVI registry, were analyzed. Mean observed mortality (OM) and mean expected mortality (EM) were estimated applying both versions of the ArgenSCORE. The OM/EM ratio was calculated in each center for both models and the Z test was used to evaluate significant differences. Results: In-hospital mortality was 7.69% for the entire registry. In 75% of the centers (33/44) mortality was >6%. In centers with mortality <6%, the OM/EM ratio was close to 1 after applying the ArgenSCORE II, without significant differences. In centers with mortality >6%, the ArgenSCORE II significantly underestimated the risk. On the contrary, when the ArgenSCORE I was applied in these centers, the OM/EM ratio was close to 1, without significant differences. Conclusions: The recalibrated ArgenSCORE II is recommended in centers with mortality <6%, while in those with mortality >6% the original ArgenSCORE I has better performance.

Implicancia de la enfermedad del tronco de coronaria izquierda en los resultados de la cirugía de revascularización miocárdica / Implication of Left Main Coronary Artery Disease on Coronary Artery Bypass Graft Surgery Results

RESUMEN Introducción: La cirugía de revascularización miocárdica (CRM) ha sido el abordaje indicado para el tratamiento de la lesión del tronco de la coronaria izquierda (TCI), siendo la angioplastia coronaria (ATC) un tratamiento alternativo en un grupo muy seleccionado de pacientes. Sin embargo, los criterios de no inferioridad de los resultados de la ATC en términos de mortalidad e infarto de miocardio (IAM) en el seguimiento a mediano plazo es tema de discusión actual. Objetivo: Evaluar las características clínicas, funcionales y angiográficas de los pacientes sometidos a CRM con y sin TCI, y las implicancias de morbimortalidad halladas. Material y métodos: Se sometió a 458 pacientes consecutivos a CRM; 187 (40.82%) presentaban TCI. El grupo con TCI tenía un perfil de riesgo mayor: ArgenScore: 2.78 (1.55-5.9) vs 2.78 (1.95-7) p=0.03, STS score: 0.85 (0.55-1.8) vs 0.77 (0.5-1.17) p=0.01 y EuroSCORE II: 2.2 (1.35-3.97) vs 1.75 (1.08-2.9) p=0.04 respecto al grupo sin TCI. Resultados: A pesar del mayor riesgo esperado no hubo diferencias estadísticamente significativas en mortalidad 3.2% vs 1.1%, IAM 2.6% vs 1.1% y ACV 1% vs 0.3% en los dos grupos. En el análisis multivariado el TCI no fue predictor de morbimortalidad (HR = 2.1; IC 95% 0.70-6.23; p = 0.18) e identifico positivamente a la fracción de eyección preoperatoria (HR = 0.96; IC 95%: 0.93-0.99; p = 0.040) y la cirugía no programada (HR = 3.44; IC 95%: 1.60-7.41; p = 0.002). Conclusiones: en nuestra experiencia los pacientes intervenidos con CRM el TCI no es predictor de muerte, IAM y/o ACV.

ABSTRACT Background: Coronary artery bypass graft surgery (CABG) has been the indicated approach for the treatment of left main coronary artery disease (LMCA), with percutaneous coronary intervention (PCI) as an alternative treatment in a highly selected group of patients. However, the non-inferiority criteria of PCI outcomes in terms of mortality and acute myocardial infarction (AMI) in the mid-term follow-up are currently subject of debate. Objective: The aim of this study was to evaluate the clinical, functional and angiographic characteristics of patients undergoing CABG with and without LMCA disease, and the implications of morbidity and mortality encountered. Methods: A total of 458 consecutive patients underwent CABG; 187 (40.82%) presented LMCA disease. This group had a higher risk profile compared with the group without LMCA disease: ArgenSCORE: 2.78 (1.55-5.9) vs. 2.78 (1.95-7); p=0.03, STS score: 0.85 (0.55-1.8) vs. 0.77 (0.5-1.17); p=0.01 and EuroSCORE II: 2.2 (1.35-3.97) vs. 1.75 (1.08-2.9); p=0.04. Results: Despite the higher expected risk, there were no statistically significant differences in mortality (3.2% vs. 1.1%), AMI (2.6% vs. 1.1%) and stroke (1% vs. 0.3%) in the two groups. In the multivariate analysis, LMCA disease was not a predictor of morbidity and mortality (HR=2.1; 95% CI 0.70-6.23; p=0.18) and positively identified the preoperative ejection fraction (HR=0.96; 95% CI 0.93-0.99; p=0.040) and non-programmed surgery (HR=3.44; 95% CI 1.60-7.41; p=0.002). Conclusions: In our experience, LMCA disease in patients undergoing CABG is not a predictor of death, AMI and/or stroke.

Loss of dystrophin is associated with increased myocardial stiffness in a model of left ventricular hypertrophy.

Transition from compensated to decompensated left ventricular hypertrophy (LVH) is accompanied by functional and structural changes. Here, the aim was to evaluate dystrophin expression in murine models and human subjects with LVH by transverse aortic constriction (TAC) and aortic stenosis (AS), respectively. We determined whether doxycycline (Doxy) prevented dystrophin expression and myocardial stiffness in mice. Additionally, ventricular function recovery was evaluated in patients 1 year after surgery. Mice were subjected to TAC and monitored for 3 weeks. A second group received Doxy treatment after TAC. Patients with AS were stratified by normal left ventricular end-diastolic wall stress (LVEDWS) and high LVEDWS, and groups were compared. In mice, LVH decreased inotropism and increased myocardial stiffness associated with a dystrophin breakdown and a decreased mitochondrial O2 uptake (MitoMVO2). These alterations were attenuated by Doxy. Patients with high LVEDWS showed similar results to those observed in mice. A correlation between dystrophin and myocardial stiffness was observed in both mice and humans. Systolic function at 1 year post-surgery was only recovered in the normal-LVEDWS group. In summary, mice and humans present diastolic dysfunction associated with dystrophin degradation. The recovery of ventricular function was observed only in patients with normal LVEDWS and without dystrophin degradation. In mice, Doxy improved MitoMVO2. Based on our results it is concluded that the LVH with high LVEDWS is associated to a degradation of dystrophin and increase of myocardial stiffness. At least in a murine model these alterations were attenuated after the administration of a matrix metalloprotease inhibitor.

Severe aortic stenosis with preserved ejection fraction and evidence of impairment in structure, myocardial strain and ventricular function: A new contribution to clinical decision making.

BACKGROUND: Left ventricular ejection fraction (LVEF) is among the parameters that are usually employed to define surgical timing of severe aortic stenosis (AS). Our hypothesis states that even when their LVEF is preserved, patients with severe symptomatic AS have impaired myocardial structure and function, and such impairment is related to the deleterious progression of left ventricular hypertrophy (LVH) from the compensated to the decompensated stage, as shown by the changes in diastolic function and the increase in left ventricular end-diastolic pressure (LVEDP). METHODS AND RESULTS: A total of 26 patients with severe AS and LVEF > 50% referred for aortic valve replacement underwent catheterization, echocardiography and an intraoperative biopsy. Patients with severe symptomatic AS were classified as: group 1 (G1; compensated LVH, LVEDP < 15 mm Hg without coronary artery disease [CAD], n = 7), group 2a (G2a, decompensated LVH, without CAD, n = 7), and group 2b (G2b, decompensated LVH with CAD, n = 12). Differences were seen in the following: myocyte area [µm2]: G1: 328 ± 66, G2a: 376 ± 22, G2b: 385 ± 13, p < 0.01; collagen volume [%]: G1: 4.77 ± 1.27, G2a: 8.40 ± 1.27, G2b: 11.05 ± 3.08, p < 0.01; LVEDP normalized by diastolic diameter [mm Hg/mm]: G1: 0.27 ± 0.01, G2a: 0.39 ± 0.06, G2b: 0.44 ± 0.11, p < 0.02; +dP/dtmax/LVEDP [mm Hg/s/mm Hg]: G1: 176 ± 45, G2a: 89.6 ± 20, G2b: 113.1 ± 41, p < 0.01; two-dimensional peak systolic longitudinal strain [%]: G1: ­17.7 ± 4.75, G2a: ­13.4 ± 3.04, G2b: ­13.5 ± 3.13, p < 0.05. CONCLUSIONS: Patients with severe symptomatic AS and preserved ejection fraction who develop decompensated LVH characterized by increased LVEDP, exhibit an abnormal myocardial structure and diastolic and systolic impairment.

Relación entre el strain rate y la estructura miocárdica en la estenosis aórtica grave / Relationship between Strain Rate and Myocardial Structure in Severe Aortic Stenosis

Introducción: En la estenosis aórtica sintomática grave (EASG), la alteración del strain global longitudinal sistólico (SGLS) tendría correlación con las modificaciones de la histoarquitectura y podría identificar compromiso contráctil temprano en pacientes con fracción de eyección conservada (FEyC). Objetivo: Analizar el SGLS, el volumen de colágeno (VC), el área miocitaria (ArMi) y el compromiso contráctil en pacientes con EASG y FEyC. Material y métodos: Se incorporaron 26 pacientes con EASG y FEyC (edad 67 ± 11 años, 53% hombres). Se realizaron un estudio hemodinámico preoperatorio y una biopsia endomiocárdica intraoperatoria para determinar el VC y el ArMi. Se identificaron tres grupos de pacientes: G1, hipertrofia ventricular izquierda (HVI) compensada sin enfermedad coronaria (n = 8); G2, HVI descompensada sin enfermedad coronaria (n = 7) y G3, HVI descompensada con enfermedad coronaria (n = 11). El SGLS se normalizó por volumen sistólico, estrés meridional de fin de sístole (δ) y diámetro de fin de diástole (DFD). Resultados: G1, G2 y G3, sin diferencias en volumen sistólico, δ y DFD y con diferencias en VC (%) (G1: 4,7 ± 1,2; G2: 8,4 ± 1,2; G3: 11,0 ± 3,0; p < 0,01), ArMi (mm²) (G1: 328,7 ± 66,2; G2: 376,7 ± 21,9; G3: 385,0 ± 13,0; p = 0,01), PFDVI (mm Hg) (G1: 13,1 ± 1,5; G2: 19,0 ± 3,8; G3: 23,6 ± 5,8; p < 0,01), +dP/dt máx (mm Hg/seg / PFDVI, mm Hg) (G1: 176,4 ± 45,5; G2: 89,6 ± 20,1; G3: 113,1 ± 43,7; p < 0,01), SGLS (%) (G1: -17,9 ± 4,2; G2: -13,5 ± 2,5; G3: -13,6 ± 3; p = 0,021). El SGLS se correlacionó con VC y PFDVI y hubo tendencia con un índice de contractilidad (+dP/dt máx mm Hg/seg / PFDVI, mm Hg). Conclusiones: Las alteraciones del SGLS en pacientes con EASG y FEyC son expresión de alteraciones estructurales del miocardio relacionadas con incremento del VC, asociado con un aumento de la PFDVI y con probable falla miocárdica contráctil.

Background: In severe symptomatic aortic stenosis (SSAS) altered global longitudinal systolic strain (GLSS) would correlate with changes in myocardial histological architecture and could identify early contractile involvement in patients with preserved ejection fraction (PEF). Objective: The aim of this study was to analyze GLSS, collagen volume (CV), myocyte area (MyAr) and contractile involvement in patients with SSAS and PEF. Methods: Twenty six patients with SSAS and PEF (67±11 years old, 53% male) were included in the study. A preoperative hemodynamic study and an intraoperative endomyocardial biopsy were performed to determine CV and MyAr. Three groups of patients were identified: G1: compensated left ventricular hypertrophy (LVH) without coronary disease (n=8); G2: decompensated LVH without coronary disease (n=7) and G3: decompensated LVH with coronary disease (n=11). GLSS was normalized by stroke volume, meridional end-systolic wall stress (δ) and end-diastolic diameter (EDD). Results: No significant differences in stroke volume, δ and EDD were observed between groups G1, G2 and G3. Differences between groups were observed in: CV (%) (G1: 4.7 ± 1.2, G2: 8.4 ± 1.2, G3: 11.0 ± 3.0; p < 0.01), MyAr (mm²) (G1: 328.7 ± 66.2, G2: 376.7 ± 21.9, G3: 385.0 ± 13.0; p = 0.01), LVEDP (mm Hg) (G1: 13.1 ± 1.5, G2: 19.0 ± 3.8, G3: 23.6 ± 5.8; p < 0.01), +dP/dt max (mm Hg/sec / LVEDP, mm Hg) (G1: 176.4 ± 45.5, G2: 89.6 ± 20.1, G3: 113.1 ± 43.7; p < 0.01), and GLSS (%) (G1: -17.9 ± 4.2, G2: -13.5 ± 2.5, G3: -13.6 ± 3; p = 0.021). GLSS correlated with CV and LVEDP and it evidenced a trend to correlate with a contractility index (+dP/dt max mm Hg/s / LVEDP, mm Hg). Conclusions: Altered GLSS in patients with SSAS and PEF expresses myocardial structural changes related to increase in C V, which is associated with enhanced LVEDP and probable myocardial contractile failure.

Obstructive membrane at the base of the left atrial appendage, a multi-imaging approach.

The left atrial appendage (LAA) is a small muscular extension that grows from the anterolateral wall of the left atrium, in the proximity of the left pulmonary veins. The presence of a membrane in the LAA is a rare clinical entity whose origin is not known. Its clinical implication in the genesis of atrial arrhythmias and thromboembolic risk remains unknown. We report a case of an obstructive membrane located at the base of the LAA, found incidentally in a young patient who was initially undergoing a transesophageal echocardiogram prior to an invasive treatment for atrial fibrillation.

Integración de marcadores humorales, ecocardiograma Doppler convencional y strain bidimensional sistólico en la detección de toxicidad miocárdica secundaria a la quimioterapia / Serum Markers, Conventional Doppler Echocardiography and Two-dimensional Systolic Strain in the Diagnosis of Chemotherapy-Induced Myocardial Toxicity

Introducción La disfunción ventricular izquierda es una complicación grave del tratamiento antineoplásico, con impacto desfavorable en la evolución clínica futura. El diagnóstico precoz de cardiotoxici-dad en pacientes que reciben quimioterapia podría ser de utilidad para definir una estrategia de prevención del deterioro de la función ventricular. Objetivo Analizar la utilidad de marcadores humorales [troponina T (TnT), BNP y NT-proBNP] y del strain bidimensional sistólico longitudinal (SBL) y radial (SBR) para la detección de disfunción ventricular sistólica en pacientes tratados con quimioterapia cardiotóxica. Material y métodos Se incluyeron forma prospectiva 36 pacientes, edad promedio (± DE) de 47 ± 16 años (42% hombres), con enfermedad neoplásica con masa miocárdica normal y fracción de eyección = 55% tratados con agentes antineoplásicos. Se efectuaron dosajes de marcadores humorales y ecocardiograma basales y al 2°, 3°, 4° y 6° mes posterior al inicio del tratamiento oncológico. Se consideró punto final (PF) a los 6 meses a la caída de la fracción de eyección según consenso internacional. Resultados Alcanzaron el PF 7 pacientes (19,4%). Se observaron los siguientes predictores relacionados con el PF: NT-proBNP 4° mes [PF positivo (G1) 152 ± 42 pg/ml vs. PF negativo (G2) 61 ± 38 pg/ml; p < 0,001], BNP 4° mes (G1 41 ± 12 pg/ml vs. G2 26 ± 11 pg/ml; p < 0,01), SBL 3er mes (G1 -16,3 ± 2,4% vs. G2 -19,6 ± 2,02%; p < 0,01) y 4° mes (G1 -15,9 ± 1,77% vs. G2 -19,9 ± 2,2%; p < 0,001) y SBR 4° mes (G1 46,4 ± 2,4% vs. G2 52 ± 3,4%; p < 0,001). Conclusiones El dosaje de péptidos natriuréticos y la medición del strain bidimensional sistólico longitudinal y radial fueron de utilidad para predecir disfunción sistólica ventricular de grado leve en pacientes tratados con quimioterapia.

Background Left ventricular dysfunction is a serious complication of antineoplastic treatment with unfavorable impact in future clinical outcome. Early diagnosis of cardiotoxicity in patients receiving chemotherapy might be useful to define a strategy for the prevention of ventricular function impairment. Objective The aim of this study was to analyze the usefulness of serum markers [troponin T (TnT), BNP and NT-proBNP] and two-dimensional longitudinal (LS) and radial (RS) strain to detect ventricular systolic dysfunction in patients treated with cardiotoxic chemotherapy. Methods Thirty six patients [average age (±SD) 47±16 years, 42% men], with neoplastic disease with normal myocardial mass and left ventricular ejection fraction (LVEF) =55% receiving chemotherapy treatment, were prospectively included. Assessment of serum markers and echocardiography were performed before chemotherapy and at 2, 3, 4 and 6 months after onset of cancer treatment. The 6-month cardiotoxicity endpoint (EP) was defined as reduced LVEF according to international consensus. Results Seven patients reached the EP (19.4%). Endpoint predictors were: NT-proBNP at 4 months (positive EP (G1): 152 ±42 pg/ml vs. negative EP (G2) 61±38 pg/ml; p <0.001), BNP at 4 months (G1 41±12 pg/ml vs. G2 26±11 pg/ml; p <0.01), two-dimensional LS at 3 months (G1 -16.3±2.4% vs. G2 19.6±2.02%; p <0.01) and 4 months (G1 -15.9±1.77% vs. G2 19.9±2.2%; p <0.001), and two-dimensional RS at 4 months (G1 46.4±2.4% vs. G2 52±3.4%; p <0.001). Conclusions Natriuretic peptides and two-dimensional LS and RS were useful to predict mild ventricular systolic dysfunction in chemotherapy-treated patients.

Sodium intake is associated with parasympathetic tone and metabolic parameters in mild hypertension.

BACKGROUND: Although the impairment of parasympathetic cardiac control was described in hypertensives submitted to a high salt diet, the impact of this autonomic abnormality on metabolic and inflammation markers in patients with mild hypertension has not been explored. METHODS: Four hundred and ninety mild essential hypertensive patients (144 ± 9/94 ± 9 mm Hg, 49.5 ± 13.9 years, 67.9 % male) were studied. Dietary sodium intake was estimated by measuring 24-h urinary sodium excretion (UNa), and the patients were classified according to UNa levels as follows: low (<50 mEq/l), medium (50-99 mEq/l), and high UNa (≥100 mEq/l). Parasympathetic tone was evaluated by assessing heart rate recovery (HRR) after an exercise stress test. HRR, plasma lipids, glucose metabolism, and inflammatory biomarkers were compared across UNa groups. RESULTS: HRR and high-density lipoprotein (HDL)-cholesterol were progressively lower, and insulin (INS), homeostasis model assessment of insulin resistance (HOMAir), ultrasensitive-C-reactive protein (usCRP) were progressively higher across increasing UNa groups. In the low and medium UNa groups, HDL-cholesterol was higher and CRP was lower than that in high UNa (P < 0.01 and P < 0.05, respectively) (Dunnett post-hoc test). In the low UNa group, triglycerides (TGs), INS, and HOMAir were lower than that in high UNa (P < 0.05). Multiple linear regression analysis showed that UNa, HOMAir, and heart rate (HR) were negatively associated with HRR (P < 0.0001, P < 0.0001, and P = 0.001, respectively). CONCLUSIONS: In the essential hypertensive patients studied high sodium intake is associated with parasympathetic inhibition, lipid disturbances, and inflammation. Studies designed to assess causality between sodium intake and metabolic and autonomic status are needed to evaluate the relevance of controlling sodium intake, especially in hypertensive patients.

Local and systemic cellular immunity in early renal artery atherosclerosis.

BACKGROUND AND OBJECTIVES: Modern imaging techniques have increased the incidental detection of renal atherosclerotic disease (RAD). Because immune activation may hasten RAD progression, identifying cellular immune markers might provide clues to clinical activity. In this study, cellular immune markers were assessed in early RAD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Immune cell markers in peripheral blood of two groups of hypertensive patients with normal carotid and coronary arteries were evaluated: 28 patients had incidental RAD and 22 patients had normal renal arteries; 21 renal arteries obtained at necropsy from individuals with history of hypertension and tissue evidence of RAD were examined and matched with 21 individuals with normal renal arteries. Cell subpopulations were measured by flow cytometry in peripheral blood and direct cell count, respectively, using T and dendritic cells monoclonal antibodies. RESULTS: Peripheral blood of RAD patients showed increased numbers of cells expressing CD3, CD4, CD83, and CD86. CD4 to CD8 ratio was 8.3 ± 1.4 (RAD) to 3.4 ± 0.9 (normal; P<0.001). No differences were found in CD25, CD8, and S100 among groups. Postmortem samples from RAD showed increased CD3+, CD4+, CD86+, and S100+ cells, whereas CD25+ and CD8+ were unmodified between groups. CD4+ to CD8+ ratio was higher in the RAD(PM) group. CONCLUSIONS: These results are consistent with an increased expression of immune cell markers in early RAD. Additional studies will explore if they may potentially turn into treatment targets to prevent disease progression.

Estudio de la función ventricular y su correlación con la morfometría en pacientes con estenosis aórtica grave sintomática / Relationship of Ventricular Function and Morphometry in Patients with Symptomatic Aortic Stenosis / Relationship of Ventricular Function and Morphometry in Patients with Symptomatic Severe Aortic Stenosis

Introducción En la estenosis aórtica, el mecanismo de adaptación miocárdica a la sobrecarga de presión es la hipertrofia ventricular. Diferentes trabajos han planteado la correlación entre estructura y función en la sobrecarga de presión por estenosis aórtica y su posible asociación con la evolución de la patología ventricular. Sin embargo, son escasos los trabajos en los que se evalúan estas variables en corazones con hipertrofia ventricular compensada (sin incremento significativo del estrés parietal) y con fracción de eyección conservada. Objetivos Evaluar la función ventricular sistólica y diastólica en pacientes con estenosis aórtica grave sintomática con fracción de eyección conservada y correlacionarla con el volumen de colágeno y el área miocitaria. Material y métodos Se estudiaron 12 pacientes, edad 65 ± 13 años, sexo masculino 58%, con estenosis aórtica grave sintomática y 6 pacientes sin patología valvular. En todos se realizaron Doppler tisular y cateterismo cardíaco; asimismo, se efectuaron biopsias intraoperatorias para determinar el volumen de colágeno y el área miocitaria (µm²). Resultados La media ± error estándar del volumen de colágeno fue del 6,1% ± 0,7%, la del área miocitaria fue de 388,4 ± 15,8 µm² y la mediana del strain tisular del septum basal fue del 14% (IIC 6,9-19). Se observó una correlación significativa entre el strain tisular del septum y el volumen de colágeno (coeficiente de correlación de -0,79; p = 0,03). No se observó correlación entre el strain tisular del septum y el área miocitaria (R² = 0,15; p = 0,8). La +dP/dt máx normalizada por presión de fin de diástole del ventrículo izquierdo obtenida en estudio hemodinámico se correlacionó en forma negativa con el área miocitaria (R -0,94; p = 0,005). La constante de caída de la presión (tau) se incrementó el 55% ± 3,5% (p < 0,05) y se correlacionó positivamente con el área miocitaria (R = 0,81; p = 0,04). Conclusión El presente trabajo demuestra que en los pacientes con estenosis aórtica grave sintomática y fracción de eyección conservada existen alteraciones de la función sistólica y diastólica que se correlacionan con cambios estructurales del ventrículo izquierdo, representados por un incremento del volumen de colágeno intersticial y del área miocitaria.

Background Ventricular hypertrophy is an adaptive mechanism of the myocardium to pressure overload in aortic stenosis. Different studies have postulated a correlation between structure and function in pressure overload due to aortic stenosis and the possible association with the development of pathological ventricular growth. However, there are a few studies evaluat-ing these variables in hearts with compensated ventricular hypertrophy (without a significant increase in wall stress) and preserved ejection fraction. Objectives To evaluate systolic and diastolic ventricular function in patients with symptomatic severe aortic stenosis with preserved ejection fraction and its correlation with collagen volume fraction and myocyte cross-sectional area. Material and Methods A total of 12 patients with symptomatic severe aortic stenosis were evaluated and compared with 6 patients without valvular heart disease; mean age was 65±13 years and 58% were men. All patients underwent tissue Doppler imaging and cardiac catheterization. Endomyocardial biopsies were obtained to determine collagen volume fraction and myocyte cross-sectional area (µm²). Results Mean collagen volume was 6.1±0.7%; mean myocyte cross-sectional area was 388.4±15.8 µm² and median strain in the basal septum was 14% (IIC 6.9-19). There was a significant correlation between septal strain measured by tissue Doppler imaging and collagen volume fraction (correlation coefficient -0.79; p = 0.03). We found no correlation between septal strain and myocyte cross-sectional area (R² = 0.15; p = 0.8). The max positive dP/dt normalized for left ventricular end-diastolic pressure obtained during cardiac catheterization had a negative correlation with the myocyte cross-sectional area (R -0.94; p = 0.005).The time constant of pressure decay (tau) increased by 55%±3,5% (p <0,05) and had a positive correlation with the myocyte cross-sectional area (R = 0.81; p = 0.04). Conclusion This study demonstrates the presence of anomalies in diastolic and systolic function in patients with symptomatic severe aortic stenosis and preserved ejection fraction that correlate with structural changes in the left ventricle, represented by increased interstitial collagen volume fraction and myocyte cross-sectional area.

Estimulación paraseptal permanente: Indicaciones y seguimiento / Permanent Para-Hisian Pacing: Indications and Follow-Up

Introducción Se ha demostrado que la estimulación definitiva en el ápex del ventrículo derecho provoca disincronía ventricular izquierda y eventualmente deterioro contráctil y ello ha llevado a la búsqueda de otros sitios alternativos de estimulación. Las indicaciones y los resultados de la estimulación septal, así como las dificultades técnicas del implante, se encuentran actualmente en estudio. Objetivos Analizar la indicación, la factibilidad y el seguimiento en un grupo de pacientes con estimulación septal parahisiana. Material y métodos Se evaluaron 22 pacientes con edades entre 27 y 68 años, con complejo QRS angosto sin trastorno de conducción intraventricular, con indicación de marcapasos. Se utilizaron catéteres comunes para la aurícula con fijación activa y catéteres con vaina deflectable para la estimulación septal. Durante el implante y el seguimiento se midieron los umbrales y la amplitud de la onda R. Resultados Los umbrales durante el implante fueron menores de 2 voltios/0,50 mseg y la onda R mayor de 5 m V. El tiempo de implante promedio de los catéteres convencionales fue de 30 ± 10 min y el de los catéteres especiales, de 15 ± 5 min. El seguimiento promedio fue de 24 meses. Los umbrales crónicos fueron de 2,5 ± 1,5 voltios con una amplitud de onda R media de 5 ± 2 voltios. Hubo un desplazamiento durante el seguimiento. Conclusiones La estimulación septal parahisiana presentó un índice bajo de complicaciones. El uso de catéteres y vainas especiales redujo el tiempo de implante. La ubicación parahisiana se caracterizó por umbrales más altos y amplitud de la onda R menor que en la comunicada durante estimulación convencional. La estimulación septal parahisiana sería una alternativa válida para evitar la disincronía producida por la estimulación del ventrículo derecho en pacientes sin trastornos de la conducción intraventricular.

Background It has been demonstrated that permanent right ventricular apical pacing produces left ventricular dyssynchrony and decreases contractile function. For this reason other sites of stimulation have been explored. The indications, outcomes and technical difficulties of para-hisian pacing are currently under investigation. Objectives To analyze the indications, feasibility and follow-up in a group of patients undergoing para-hisian pacing. Material and Methods A total of 22 patients between 27 and 68 years with indication of permanent pacing, narrow QRS complexes and preserved intraventricular conduction were evaluated. Activefixation atrial leads and ventricular leads with a deflectable sheath for parahisian stimulation were used. Pacing thresholds and R-wave amplitude were measured during implantation and follow-up. Results During implantation, pacing thresholds were <2 V/0.50 ms and R-wave amplitude was >5 m V. The average duration of placement of conventional leads and special leads were 30±10 min and 15±5 min, respectively. Mean follow-up was 24 months. Chronic thresholds were 2.5±1.5 Volts, and mean R-wave amplitude was 5±2 Volts. One lead displacement was reported during follow-up. Conclusions Para-hisian pacing presented a low rate of complications. The use of special leads and sheaths reduced the implantation time. Compared to conventional pacing, para-hisian pacing presented higher thresholds and lower R-wave amplitude. Para-hisian pacing would be a valid option to avoid ventricular dyssynchrony related to right ventricular pacing in patients with preserved intraventricular conduction.

Clinical value of the tissue Doppler s wave to characterize left ventricular hypertrophy as defined by echocardiography.

UNLABELLED: Left ventricular hypertrophy (LVH) may be a physiological finding and may also be associated with different disease entities and hence, with different outcomes. Regional myocardial function can be assessed with color Doppler tissue imaging, specifically by the waveform of the isovolumic contraction (IC) period and the regional systolic wave ("s"). METHODS AND RESULTS: We studied five groups (G): healthy, sedentary young volunteers (G1, n:10); healthy sedentary adult volunteers (G2, n:8); and subjects with LVH (left ventricular mass index >125 g/m(2)) including: high performance athletes (G3, n:21), subjects with hypertension (G4, n:21), subjects with hypertrophic cardiomyopathy (HCM) (G5, n:18). We measured peak "s" wave velocity (cm/sec) at the basal and mid septum, the IC/s ratio, and basal to mid-septal velocity difference (BMVD) of the "s" wave. Regional "s" wave values (cm/sec) were G1 = 5.6 +/- 1; G2 = 5.4 +/- 0.8; G3 = 5.7 +/- 0.6; G4 = 5.3 +/- 1.1; G5 = 4.2 +/- 1.1 (P < 0.0001). The IC/s ratio was G1 = 0.28 +/- 0.18; G2 = 0.39 +/- 0.21; G3 = 0.23 +/- 0.10; G4 = 0.42 +/- 0.15; G5 = 0.64 +/- 0.15 (P < 0.0001). The BMVD (cm/sec) was G1 = 2 +/- 0.51; G2 = 1.71 +/- 0.29; G3 = 1.78 +/- 0.44; G4 = 1.26 +/- 0.96; G5 = 0.45 +/- 0.4 (P < 0.0001). IC/s < 0.38 discriminated physiological from pathological forms of hypertrophy (sensitivity 90%; specificity 88%). Peak "s" wave velocity discriminated HCM from other causes of hypertrophy, with a cutoff value of 4.46 cm/sec (sensitivity 72%; specificity 90%). BMVD <0.98 cm/sec detected HCM with 89% sensitivity and 86% specificity. CONCLUSIONS: Peak "s" wave velocity and two indices: IC/s and BMDV are novel parameters that may allow to discriminate physiological from pathological forms of hypertrophy as well as different subtypes of hypertrophy.

Valor clínico de la utilización del strain rate sistólico en el estudio de distintas formas de hipertrofia ventricular izquierda / Clinical Value of Systolic Strain Rate Utilization in the Assessment of Different Types of Left Ventricle Hypertrophy

Introducción La hipertrofia del ventrículo izquierdo (HVI) incluye diferentes etiologías, estados evolutivos y pronóstico. El strain rate sistólico (SRS) o estudio de la deformación miocárdica permite analizar la función sistólica regional al evaluar la velocidad de acortamiento miocárdico en función del tiempo, con independencia del movimiento traslativo del corazón o del tironeamiento de estructuras vecinas. Objetivo Determinar la utilidad del strain rate sistólico para diferenciar formas de hipertrofia del ventrículo izquierdo. Material y métodos La población del estudio estuvo conformada por cuatro grupos: Grupo 1: (G1, n = 10): voluntarios sanos sedentarios; grupo 2 (G2, n = 21): atletas de alto rendimiento con aumento del índice de masa del ventrículo izquierdo (IMVI) > 125 g/m²; grupo 3 (G3, n = 15): pacientes hipertensos según VII JNC con IMVI > 125 g/m² y grupo 4 (G4, n = 12): pacientes con miocardiopatía hipertrófica (MCH), septum > 15 mm y/o relación septum/pared posterior > 1,5:1, sin causa que lo justifique. Resultados En los grupos con IMVI incrementado no hubo diferencia en la fracción de acortamiento mesoparietal (p = 0,3) o el IMVI (p = 0,6). SRS 01 seg (G1) 0,75 1/s, (G2) 0,87 1/s, (G3) 0,57 1/s, (G4) 0,29 1/s (p < 0,001). SRS 02 seg (G1) 0,67 1/s, (G2) 0,52 1/s, (G3) 0,49 1/s (G4) 0,18 1/s (p < 0,001). SRS 03 seg (G1) 0,57 1/s, (G2) 0,38 1/s, (G3) 0,25 1/s (G4) 0,11 1/s (p < 0,002). EL SRS permitió diferenciar MCH en deportistas durante toda la sístole. Conclusión El acortamiento sistólico regional determinado por SRS está disminuido en la MCH. La utilización de esta técnica permite diferenciar formas de hipertrofia patológica de la hipertrofia fisiológica.

Introduction Left ventricular hypertrophy (LVH) includes different etiologies, evolution status and prognosis. Systolic strain rate (SSR) or myocardial deformation assessment allows analyzing the regional systolic function by assessing myocardial shortening velocity throughout time, independently of the translation movement of the heart or pulling of neighboring structures. Objective To determine if the systolic strain rate is a useful resource to differentiate types of left ventricle hypertrophy. Material and methods Study population included four groups: Group 1 (G1, n=10): healthy sedentary volunteers; Group 2 (G2, n=21): highperformance athletes with left ventricle mass index increase (LVMI) >125 g/m²; Group 3 (G3, n=15): hypertensive patients according to VII JNC with LVMI >125 g/m² and Group 4 (G4, n=12): patients with hypertrophic cardiomyopathy (HCM), septum >15 mm and/or posterior septum/wall relation >1,5:1, without any cause. Results There were no differences between groups with increased LVMI in mesoparietal shortening fraction (p=0.3) or LVMI (p=0.6). SRS 01 sec (G1) 0.75 1/s. (G2) 0.87 1/s; (G3) 0.57 1/s; (G4) 0.29 1/s (p<0.001). SRS 02 sec (G1) 0.7 1/s, (G2) 0.52 1/s, (G3) 0.49 1/s (G4) 0.18 1/s (p<0.001). SRS 03 sec (G1) 0.57 1/s, (G2) 0.38 1/s, (G3) 0.25 1/s (G4) 0.11 1/s (p<0,002). SSR allows differentiating HCM in athletes during the systole. Conclusion Regional systolic shortening assessed by SSR is decreased in HCM. The use of this technique allows differentiating types of pathological hypertrophy from physiological hypertrophy.

Valor clínico del análisis de la fase sistólica de la contracción ventricular con Doppler tisular en la discriminación de hipertrofia fisiológica de formas patológicas / Clinical value of tissue Doppler analysis of systolic phase contraction in the discrimination of physiological and pathological ventricular hypertrophy

Introducción: La hipertrofia del ventrículo izquierdo (HVI) incluye diferentes etiologías, estados evolutivos y pronóstico. El Doppler tisular (DT) pulsado permite estudiar aspectos de la función miocárdica mediante el análisis de la velocidad regional. Objetivo: Determinar la utilidad del análisis de las ondas del período isovolúmico (IVCa) y de la onda sistólica regional (s del DT pulsado para diferenciar formas de hipertrofia ventricular izquierda. Material y métodos: Se conformaron cinco grupos de estudio: voluntarios sanos sedentarios jóvenes (G1, n = 10), adultos sanos (G2, n = 8) y los portadores de HVI (índice de masa ventricular izquierda [IMVI] >125 g/m²) incluyeron atletas de alto rendimiento (G3, n = 10), hipertensos diagnosticados según el JNC VII (G4, n = 10) y miocardiopatía hipertrófica (MCH) (G5, n = 8). Se analizaron la velocidad máxima de la onda s en cm/seg del septum basal y medio, la relación IVCa/s y la diferencia de velocidad de la onda s del septum basal y medio (DVMB). Resultados: Edad (años): G1 33 ± 8, G2 53 ± 5, G3 32 ± 10, G4 51 ± 14, G5 51 ± 12, IMVI (g/m 2 ): G1, 90,5, G2 95, G3 138, G4 178, G5 161; p = 0,003. No se observaron diferencias entre grupos en la fracción de acortamiento mesoparietal (FAM) (p = 0,3) ni en el estrés de fin de sístole (EFS) (p = 0,1). La s regional fue: G1 5,62 ± 1,41, G2 5,41 ± 0,85, G3 5,57 ± 0,71, G4 4,86 ± 0,63, G5 3,99 ± 1,02 (p = 0,002), la relación IVCa/s fue: G1 0,28 ± 0,17, G2 0,38 ± 0,21, G3 0,20 ± 0,12, G4 0,45 ± 0,14, G5 0,77 ± 0,28 (p = 0,001) y la DVMB fue: G1 1,99 ± 0,5, G2 1,71 ± 0,3, G3 1,72 ± 0,5, G4 1,42 ± 0,4, G5 0,56 ± 0,3 (p = 0,001). La relación IVCa/s < 0,38 discrimina hipertrofia fisiológica de patológica con una sensibilidad del 90 por ciento y una especificidad del 88 por ciento. La DVMB < 0,98 identificó MCH con una sensibilidad del 100 por ciento y una especificidad del 95 por ciento. En un análisis de regresión logística, la onda s fue el único predictor de MCH ...

La caracterización y el Doppler tisular mejoran el diagnóstico diferencial de la hipertrofia ventricular entre atletas e hipertensos / Tissue characterization and tissue Doppler to discriminate between athletes and hypertensive patients

El presente trabajo se realizó con el propósito de determinar: 1) la capacidad del Doppler tisular (DT) y de la caracterización tisular (CT) mediante el uso del backscatter integrado en el análisis de las propiedades acústicas del miocardio para discriminar distintos tipos de hipertrofia ventricular izquierda, 2) la utilidad del análisis de la función sistólica regional analizando la onda "s" en eje longitudinal para discriminar alteración de la función sistólica en diferentes tipos de hipertrofia. Material y métodos: se incorporaron 32 pacientes asignados a grupo 1 (G1): 13 pacientes hipertensos, grupo 2 (G"): 11 atletas, ambos grupos con masa ventricular > 124 gm/m² y grupo 3 (G3): 8 voluntarios. Se evaluó función ventricular sistólica por ecocardiograma, función regional con DT y CT mediante el uso del backscatter estático (BI) y su variación en el ciclo cardíaco (VCBI) expresado en decibeles (dB). Resultados: Fracción de acortamiento (FAC por ciento): G1: 36,46 ± 4; G2: 33,9 ± 3; G3: 35,1 ± 4,8, p = NS. Fracción de acortamiento mesoparietal (FAM por ciento): G1: 26,9 ± 3,5 G2: 27,5 ± 4; G3: 25 ± 3, p = NS. Velocidad de onda "s" en DT: G1: 4,8 ± 0,9; G2: 5,6 ± 0,8; p = 0,04; VCBI dB: G1: 5,3 ± 2,5; G2: 7,6 ± 2,1; G3:7,4 ± 2,7; p = 0,048; BI dB G1: 41 ± 6,G2: 29 ± 6, G3: 31 ± 7,3, p: 0,001. G1 y G2 presentaron índices ecocardiográficos eyectivos de función conservados. El DT mostró disminución de la velocidad de onda "s" en el G1 respecto del G2. El G2 mostró un incremento de la VCBI con el incremento de la masa, lo cual sugiere un comportamiento "supranormal" para este grupo. p = diferencias entre grupo G1 y G2. Conclusiones: El DT y la CT diferenciaron dos tipos de hipertrofia, hipertensos versus atletas, no detectados por ecocardiografía convencional. Estos cambios serían la manifestación ecocardiográfica de modificaciones en la función (depresión de la función sistólica) y en la estructura (posible incremento del componente de fibrosis) observadas en la hipertrofia patológica en comparación con la fisiológica.