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RESUMEN Introducción: El T1 mapping es una técnica que permite mejorar la caracterización tisular por resonancia magnética cardíaca (RMC), y posee creciente evidencia a su favor como herramienta de diagnóstico precoz y estratificación. Presentamos los resultados de la cuantificación del T1 nativo miocárdico en individuos sanos, estudiados en un campo de 3.0 T, a fin de proveer valores de referencia para el medio local. Material y métodos: Se incluyeron 124 individuos consecutivos derivados a nuestro centro para realización de RMC, cuyos estudios resultaron normales. Se midió el T1 mapping en un eje corto medioventricular. Se analizaron los resultados según edad y sexo. Se incluyeron también 27 pacientes con diagnóstico de miocardiopatía hipertrófica, 11 con diagnóstico de miocardiopatía dilatada y 8 con amiloidosis cardíaca. Resultados: Se analizaron 124 estudios. La media global de T1 mapping fue de 1220,7 ± 21,2 mseg. Redondeando a valores enteros, se consideró 1178-1263 mseg como "rango de normalidad" (p5-p95). Se observó un tiempo T1 ligeramente superior en mujeres. No hubo diferencias con respecto a la edad. Se observó una excelente reproducibilidad, evaluada por el coeficiente de correlación intraclase (0,97) y el método de Bland-Altman. Los valores de T1 mapping fueron significativamente superiores en los grupos de individuos portadores de miocardiopatía. Conclusiones: Reportamos valores normales de T1 mapping nativo en una población adulta local. Los mismos son levemente mayores en mujeres, diferencia que no impresiona relevante desde el punto de vista clínico. Al comparar con individuos portadores de miocardiopatía hipertrófica, dilatada o con amiloidosis cardíaca, se obtuvo una muy buena discriminación. La variabilidad interobservador fue muy baja.
ABSTRACT Background: T1mapping is a technique that improves tissue characterization by cardiovascular magnetic resonance (CMR), and there is growing evidence favoring its use as a tool for early diagnosis and stratification. We present the results of native myocardial T1 quantification in a 3.0 T field in healthy individuals, in order to provide local reference values. Methods: A total of 124 consecutive adults with normal studies, referred to our center for CMR, were included in the study. T1 relaxation time was measured in a midventricular short axis slice, analyzing age and sex dependance. For comparison, 27 patients with hypertrophic cardiomyopathy, 11 with dilated cardiomyopathy and 8 with cardiac amyloidosis were also included. Results: Mean global T1mapping of the 124 studies analyzed was 1220.7 ±21.2 msec, and rounding to unity, 1178-1263 msec (p5-p95) was considered as "normal range". A slightly longer T1 time was observed in women and no differences were found with respect to age. Excellent reproducibility was obtained, evaluated by intraclass correlation coefficient (0.97) and BlandAltman plot. T1 mapping values were significantly higher in both groups of individuals with cardiomyopathy. Conclusions: We report normal values of native T1 mapping in a local healthy adult population. Times were slightly higher in women, a difference that was not considered clinically relevant. When comparing with individuals with hypertrophic or dilated cardiomyopathy, a very good discrimination was obtained between the 3 populations. The interobserver variability was very low.
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RESUMEN Introducción: Se ha descrito que la infección por COVID-19 se asocia a complicaciones cardiovasculares en pacientes hospitalizados en 7-28%de los casos, con diagnóstico basado en elevación de biomarcadores. La afección cardiaca subclínica post COVID-19 en pacientes ambulatorios representa una preocupación creciente, así como las secuelas cardiovasculares a mediano y largo plazo. El objetivo del presente trabajo fue determinar la utilidad de la detección de compromiso cardiovascular en pacientes post COVID-19 ambulatorios, y su asociación con síntomas y factores de riesgo. Material y métodos: Se incluyeron 668 pacientes de manera prospectiva, >18 años entre septiembre de 2020 y marzo de 2021. Debían tener polimerasa de transcriptasa inversa (PCR) positiva en una muestra del tracto respiratorio positiva para COVID-19, y se les realizó evaluación con examen físico, electrocardiograma (ECG) y eco Doppler cardíaco. A quienes presentaban síntomas de riesgo o anomalías en el ECG o el eco Doppler, se les solicitó resonancia cardíaca (RMC) con contraste endovenoso. Resultados: La edad media fue de 42,9 ± 14,9 años; el 56,9% fueron mujeres. El 12,9% eran hipertensos, el 4,3% diabéticos y el 6,9% obesos. El 57,6% no tenía factores de riesgo cardiovascular y solo el 4,2% contaba con antecedentes cardiovasculares. El 73,2% presentó enfermedad leve, un 16,3% requirió internación y el 1,05% asistencia ventilatoria mecánica. Solo 5 pacientes tuvieron diagnóstico por RMC de miocarditis, y tanto el derrame pericárdico como la presencia de trastornos de la repolarización se asociaron significativamente con la misma (p <0,0001). Conclusiones: La presencia de alteraciones en el ECG o el eco Doppler cardíaco en nuestra cohorte fue infrecuente. Se diagnosticaron 5 casos de miocarditis viral con clínica compatible y confirmación por RMC.
ABSTRACT Introduction: COVID-19 infection has been associated with cardiovascular complications in 7-28% of hospitalized patients, with the diagnosis based on biomarkers elevation. Subclinical cardiac involvement in outpatients recovered from COVID-19 represents a growing concern, as well as mid- or long-term cardiovascular effects. Objective: The aim of the present study was to determine the usefulness of detecting cardiovascular involvement in outpatients recovered from COVID-19, and its association with symptoms and risk factors. Methods: Between September 2020 and March 2021, 668 patients >18 years were prospectively included. All the patients had to have COVID-19 confirmed diagnosis by a positive reverse transcription-polymerase chain reaction (RT-PCR) test in a respiratory tract sample COVID-19. They were evaluated with physical examination, electrocardiogram (ECG) and Doppler echocardiography. Patients with symptoms suggestive of risk or abnormal findings on ECG or echocardiogram underwent cardiac magnetic resonance imaging (CMRI) with gadolinium-based contrast agent. Results: Mean age was 42.9 ± 14.9 years and 56.9% were women; 12.9% were hypertensive, 4.3% were diabetic and 6.9% obese. Overall, 57.6% had no cardiovascular risk factors and only 4.2% had a history of cardiovascular disease. The disease was mild in 73.2%; 16.3% required hospitalization and 1.05% needed mechanical ventilation. Only 5 patients had myocarditis diagnosed by CMRI, and both pericardial effusion and abnormal repolarization were significantly associated with myocarditis (p < 0.0001). Conclusions: Abnormal ECG or echocardiographic findings were uncommon in our cohort. The diagnosis of viral myocarditis was made in 5 cases with clinical signs and symptoms, and was confirmed by CMRI.
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RESUMEN Introducción: La pandemia de COVID-19 sigue causando mortalidad y morbilidad significativas en todo el mundo. La afectación cardiovascular se asocia con malos resultados clínicos a corto y mediano plazo. La resonancia magnética cardíaca (RMC) es un método muy útil para detectar y caracterizar alteraciones del miocardio, por lo que se ha utilizado para identificar las diferentes complicaciones post COVID-19. El objetivo de este estudio fue evaluar la presencia, el tipo y el pronóstico a 6 meses de los hallazgos de RMC en una cohorte no seleccionada de pacientes derivados a nuestro centro. Material y métodos: Estudio observacional de cohorte, prospectivo, unicéntrico. Se incluyeron pacientes consecutivos derivados para realización de RMC. Se clasificó a los pacientes en cinco grupos: RMC normal (grupo A), fibrosis inespecífica (grupo B), inflamación miocárdica aislada (grupo C), miocarditis (grupo D) y fibrosis isquémica (grupo E). Se realizó seguimiento a 6 meses. Resultados: Se incluyeron 298 pacientes, 51% mujeres. La RMC se realizó una mediana de 68 días posterior al alta epidemiológica. El 64,5% fue clasificado como grupo A, el 21,8% como grupo B, el 10,4% como grupo C. De estos, en 6 pacientes se repitió la RMC, que evidenció normalización de la alteración basal. Seis pacientes presentaron diagnóstico de miocarditis (2%, grupo D), y cuatro (1,3%), de infarto de miocardio (grupo E). Dos pacientes del grupo E fueron revascularizados en el seguimiento, el resto de la cohorte no presentó eventos. Conclusiones: La mayoría de los pacientes (86%) no presentaron hallazgos patológicos en la RMC. Dada la magnitud de la pandemia, no creemos recomendable el tamizaje de complicaciones cardíacas post COVID-19 con RMC en la población general, sino que debería reservarse para aquellos individuos con sospecha de injuria miocárdica.
ABSTRACT Background: COVID-19 continues to cause significant mortality and morbidity worldwide. Cardiac involvement is associated with long-term and medium-term negative clinical outcomes. Cardiac magnetic resonance imaging (CMRI) is a useful technique to detect and characterize myocardial disorders, so it has been used to identify different post-COVID-19 complications. Objective: This study was aimed to evaluate the presence, the type, and the 6-month prognosis of the CMRI findings in an unselected cohort of patients referred to our site. Methods: Single-center, prospective, observational cohort study. We included consecutive patients referred to our site for a CMRI. They were classified into five groups: normal CMRI (Group A), nonspecific myocardial fibrosis (Group B), isolated myocardial inflammation (Group C), myocarditis (Group D) and ischemic myocardial fibrosis (Group E). A 6-month followup was performed. Results: We enrolled 298 patients, 51% women. CMRI was performed at a median of 68 days following epidemiological discharge. Patients were assigned to the groups as follows: 64.5% to Group A, 21.8% to Group B, and 10.4% to Group C. CMRI was repeated in six patients, and it showed that altered basal levels returned to normal. Six patients in Group D (2%) were diagnosed with myocarditis, and four in Group E (1.3%) suffered from myocardial infarction. Two patients in Group E underwent a revascularization procedure during their follow-up. The remaining cohort did not suffer from any event. Conclusion: No pathological findings were found on most patients' CMRI (86%). Given the scale of the pandemic, we do not consider advisable to assess post-COVID-19 cardiac complications in general population by means of CMRI. In contrast, CMRI should be performed on those patients suspected of myocardial injury.
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RESUMEN Introducción: Algunos autores sugieren que la dilatación aórtica forma parte del corazón de atleta. Las guías recientes proponen indexar los diámetros aórticos por superficie corporal (SC). En deportistas esta variable puede aumentar solo a expensas de la masa muscular y la indexación podría subestimar las dimensiones. El objetivo del estudio fue comparar los diámetros aórticos en jugadores de rugby de elite vs controles, evaluando distintas formas de cuantificación. Material y métodos: Se cuantificó mediante ecocardiografía el diámetro aórtico máximo (AoMax) y el diámetro máximo indexado a SC (AoSC). Se calculó en forma adicional el peso ideal esperado para cada individuo y se estableció el diámetro aórtico indexado por SC esperada (AoSCe). Se definió como dilatación un AoMax mayor que 40 mm o un AoSC/AoSCe mayor que 21 mm/m². Resultados: El AoMax fue mayor en deportistas (34,9 ± 2,6 vs 32,4 ± 2,9 mm; p < 0,01). Los atletas tuvieron una SC significativamente mayor y, en este contexto, presentaron menor AoSC (15,6 ± 1,2 vs 16,2 ± 1,6 mm/m2; p = 0,02). Al realizar el cálculo del peso ideal y comparar el AoSCe, no se observaron diferencias (16,6 ± 1,3 vs 16,3 ± 1,3 mm/m2; p = 0,2). El porcentaje de pacientes con AoMax mayor que 40 mm fue similar en controles y deportistas (2,3% y 1,7%; p = NS). Ningún paciente presentó diámetros indexados en rango patológico. Conclusiones: Los deportistas presentan mayores diámetros aórticos en términos absolutos, en contexto de una mayor SC. Debido al desarrollo muscular, la indexación por SC podría subestimar las dimensiones. El cálculo del AoSCe podría ser un parámetro útil. Las dimensiones aórticas en rango patológico deben ser consideradas anormales.
ABSTRACT Background: Some authors suggest that aortic dilatation is part of the athlete's heart. The recent guidelines recommend indexing aortic diameters by body surface area (BSA). This variable can be greater in athletes due to increased muscle mass, and indexing for this parameter might underestimate the measurements. Objective: The aim of this study was to compare aortic dimensions between elite rugby athletes and controls, evaluating different methods of quantification. Methods: Maximum aortic diameter (MAD) and maximum diameter indexed by BSA (MAD-BSA) were quantified by echocardiography. The expected ideal weight was calculated for each individual and MAD was indexed by the expected body surface area (eBSA). Aortic dilatation was defined as MAD >40 mm or MAD-BSA to MAD-eBSA ratio >21 mm/m2. Results: Maximum aortic diameter was greater in athletes (34.9±2.6 mm vs.32.4±2.9 mm; p <0.01). Body surface area was significantly increased in athletes and, in this setting, MAD-BSA was lower (15.6±1.2 mm/m2 vs. 16.2±1.6 mm/m2; p=0.02). After estimating the ideal weight, MAD-eBSA was not significantly different in both populations (16.3±1.3 mm/m2 vs. 16.6±1.3 mm/m2; p=0.2) The percentage of patients with MAD >40 mm was similar in controls and athletes (2.3% vs. 1.7%, respectively; p=NS). None of the patients presented indexed diameters above the normal ranges. Conclusions: Elite rugby players present larger maximum aortic diameters in absolute values in the context of greater BSA. Due to increased muscle mass, indexing by BSA could underestimate the measurements. The MAD-eBSA ratio could be a useful parameter. Aortic diameters above reference values should be considered abnormal.
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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.
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Takotsubo cardiomyopathy (TC) is a disease that can be misinterpreted as a more serious acute coronary syndrome. Its clinical characteristics resemble those of a myocardial infarct, while its imaging characteristics are critical on correctly characterizing and diagnosing the disease. From angiography, where coronary anatomy is evaluated, to cardiac magnetic resonance (CMR), where morphology and tissue characterization is assessed, the array of imaging options is quite extent. In particular, CMR has achieved great improvements (stronger magnetic fields, better coils, etc.) in the last decade which in turn has made this imaging technology more attractive in the evaluation and diagnosis of TC. With its superior soft tissue resolution and dynamic imaging capabilities, CMR is currently, perhaps, the most useful imaging technique in TC as apical ballooning or medio-basal wall motion abnormalities (WMA), presence of wall edema and late gadolinium enhancement (LGE) characteristics are critical in the diagnosis and characterization of this pathology. In this review, CMRs role in TC will be evaluated in light of the current available evidence in medical literature, while also revising the clinical and physiopathologic characteristics of TC.
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Introducción La arritmia ventricular frecuente puede ser una alteración eléctrica primaria o estar asociada con una cardiopatía. El impacto pronóstico y terapéutico depende de la presencia de cardiopatía estructural. El ecocardiograma Doppler transtorácico ha sido el estudio complementario más importante para evaluar la presencia de alteraciones estructurales cardíacas. Objetivos Determinar la capacidad de la resonancia magnética cardíaca para detectar alteraciones estructurales a nivel cardíaco en pacientes con ecocardiograma Doppler normal y conocer la incidencia de eventos cardiovasculares adversos en el seguimiento. Material y métodos Se incluyeron 66 pacientes consecutivos con arritmia ventricular frecuente definida como > 5.000 extrasístoles ventriculares en un registro Holter de 24 horas, taquicardia ventricular o muerte súbita resucitada con ecocardiograma Doppler normal. A todos los pacientes se les realizó una resonancia magnética cardíaca con protocolo para evaluar miocardiopatías. Resultados El 57% de los pacientes presentaron alguna alteración estructural; las patologías diagnosticadas más prevalentes fueron la secuela de miocarditis, el miocardio no compactado y la secuela de infarto subendocárdico. En el seguimiento medio de 24 ± 22 meses, la incidencia de eventos cardiovasculares adversos fue del 6,06%. El número de extrasístoles 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 realización de una resonancia magnética cardíaca con gadolinio permite detectar en más de la mitad de los casos alguna alteración estructural. Los pacientes con arritmia ventricular frecuente en el Holter, Doppler normal y alteraciones leves en la resonancia presentan riesgo bajo de eventos cardiovasculares.
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.
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Introducción Existen controversias sobre las variaciones temporales en los niveles lipídicos luego de un síndrome coronario agudo (SCA). En nuestro país, la información sobre las características del perfil lipídico basal y la variabilidad de sus componentes luego de un SCA es limitada y no incluye la medición directa de C-LDL ni de apolipoproteínas. Objetivos 1) Analizar las variaciones en los niveles de lipoproteínas y apolipoproteínas en un grupo de pacientes internados por SCA y 2) describir el perfil lipídico basal y compararlo con el de una población saludable. Material y métodos Se midieron los niveles plasmáticos de colesterol total (CT), triglicéridos, C-LDL, C-HDL, ApoB y ApoA al ingreso, a las 18 h y a las 42 h en pacientes internados por SCA. Ningún paciente recibía fármacos hipolipemiantes ni fue tratado con ellos durante las primeras 48 h de la internación. Resultados Se incluyeron 31 pacientes (edad media 61 años, 87% hombres, IAM con onda Q 51%, IAM no Q 19% y angina inestable 30%). Las concentraciones de CT, C-noHDL y C-LDL se redujeron significativamente durante la internación (media ± desviación estándar de la admisión, 18 h y 42 h, valor de p): CT (218 ± 53, 206 ± 40 y 194 ± 41; p = 0,005), C-noHDL (180± 54, 169,8 ± 40 y 157,6 ± 39; p = 0,01), C-LDL (136 ± 30, 134 ± 33 y 127 ± 37; p = 0,01). Los niveles de ApoB y de C-HDL no variaron en forma significativa. El nivel basal de ApoA correspondió al percentil 5 de una población saludable y se observó un descenso precoz y significativo durante la internación (115 ± 21, 108 ± 18 y 106 ± 3; p = 0,01). Conclusiones La admisión es el momento más adecuado para evaluar el perfil lipídico basal del paciente con SCA. Los niveles de ApoB se mantuvieron estables y podrían utilizarse como alternativa para seleccionar la estrategia terapéutica. El transporte reverso del colesterol estaba afectado en más del 50% de la población.
Background Controversy exists regarding the temporal changes in lipid levels after an acute coronary syndrome (ACS). In our country, there is limited information about the basal characteristics of the lipid profile and the variability of its components after an ACS, and it does not include direct measuring of LDL-C or apolipoproteins. Objectives 1) To analyze the changes in lipoprotein and apolipoprotein levels in a group of patients hospitalized with ACS, and 2) to describe the basal lipid profile and compare it with that of a healthy population. Material and Methods Plasma levels of total cholesterol (TC), LDL-C, HDL-C, ApoB and ApoA were measured at admission, 18 hours and 42 hours in patients hospitalized with ACS. None of the participants were taking lipid-lowering drugs or received them within 48 hours after hospitalization. Results A total of 31 patients were included (mean age 61 years, 87% were men, 51% with Q-wave AMI, 19% with non Q- wave AMI and 30% with unstable angina). Plasma levels of TC, non HDL-C and LDL-C presented a significant reduction during hospitalization (mean ± standard deviation at admission, 18 hours and 42 hours, p value): TC (218±53, 206±40 and 194±41; p=0,005), non HDL-C (180±54, 169.8±40 and 157.6±39; p=0,01), LDL-C (136±30, 134±33 and 127±37; p=0.01). ApoB and HDL-C levels did not change in a significant fashion. Baseline ApoA levels corresponded to the 5th percentile of a healthy population and there was an early and significant reduction during hospitalization (115±21, 108±18 and 106±3; p=0,01). Conclusions In patients with ACS basal lipid profile should be evaluated at the moment of hospitalization. ApoB levels remained stable and might be used to select the therapeutic strategy. Reverse cholesterol transport was affected in more than 50% of the population.