Coexisting bicuspid aortic and pulmonary valves diagnosed by 3D transthoracic echocardiography.

Coexisting bicuspid aortic and pulmonary valves is an extremely rare condition, and there have been few published cases. Diagnosis of bicuspid aortic valve is straightforward with 2D echocardiography; however, analysis of the morphology of the pulmonary valve is challenging. In this study, we report on a case of a 32-year-old man with bicuspid aortic and pulmonary valves diagnosed by 2D and 3D transthoracic echocardiography. The enlarged pulmonary artery without any obvious etiology led us to suspect a pulmonary valve anomaly; thus, we comprehensively evaluated it with 2D and 3D echocardiography, which confirmed the diagnosis of bicuspid pulmonary valve.

Myocardial Rupture in Acute Myocardial Infarction: Mechanistic Explanation Based on the Ventricular Myocardial Band Hypothesis.

BACKGROUND: Torrent-Guasp explains the structure of the ventricular myocardium by means of a helical muscular band. Our primary purpose was to demonstrate the utility of echocardiography in human and porcine hearts in identifying the segments of the myocardial band. The second purpose was to evaluate the relation of the topographic distribution of the myocardial band with some post-myocardial infarction ruptures. METHODS: Five porcine and one human heart without cardiopathy were dissected and the ventricular myocardial segments were color-coded for illustration and reconstruction purposes. These segments were then correlated to the conventional echocardiographic images. Afterwards in three cases with post-myocardial infarction rupture, a correlation of the topographic location of the rupture with the distribution of the ventricular band was made. RESULTS: The human ventricular band does not show any differences from the porcine band, which confirms the similarities of the four segments; these segments could be identified by echocardiography. In three cases with myocardial rupture, a correlation of the intra-myocardial dissection with the distribution of the ventricular band was observed. CONCLUSIONS: Echocardiography is helpful in identifying the myocardial band segments as well as the correlation with the topographic distribution of some myocardial post-infarction ruptures.

Evaluación postquirúrgica por ecocardiografía del paciente sometido a cambio valvular aórtico: ¿Se aplican las recomendaciones de las guías? / Echocardiographic evaluation of patients after aortic valve replacement: Do we follow the guidelines?

Objetivo: Determinar la metodología de evaluación ecocardiográfica empleada en el Instituto Nacional de Cardiología (hospital de tercer nivel) en pacientes operados de cambio valvular aórtico. Método: Se incluyeron a todos los pacientes consecutivos mayores de 18 años con estenosis aórtica que fueron llevados a cirugía de cambio valvular aórtico en el Instituto Nacional de Cardiología "Ignacio Chávez", durante el periodo de enero del 2011 a junio del 2012. Se determinó la fecha de cirugía, tipo de prótesis y el número y fecha de ecocardiogramas realizados después del evento quirúrgico. Resultados: Se encontró que en el 81% de los pacientes el primer ecocardiograma postquirúrgico se realizó durante su internamiento. Esta primera evaluación fue realizada dentro de las primeras 24 a 48 horas a 42 pacientes (51.8%); entre los 3 y los 7 días a 27 pacientes (33.3%); entre los 8 y los 14 días a 7 pacientes (8.6%) y posterior a los 14 días a 5 pacientes (6.1%). A 19 pacientes no se les realizó ecocardiograma. Conclusiones: En el Instituto Nacional de Cardiología "Ignacio Chávez", se realiza una evaluación y seguimiento ecocardiográfico de los pacientes operados de cambio valvular aórtico distinto a las recomendaciones internacionales.

Objective: To determine the methodology for the echocardiographic evaluation of patients with aortic valve replacement at the Instituto Nacional de Cardiología. Method: We included all consecutive patients, 18 years old or more with aortic valve replacement secondary to aortic stenosis at the Instituto Nacional de Cardiología "Ignacio Chávez", between January 2011 and June 2012. We described the date of the surgery, type of prosthetic valve and the number and date of the echocardiograms after the valve replacement. Results: Between January 2011 and June 2012, 100 patients underwent aortic valve replacement. In 81% the first echocardiogram was made during hospitalization. The first evaluation was made within the first 24-48 hours in 42 patients (51.8%), between the 3rd and 7th day in 27 patients (33.3%), between the 8th and the 14th day in 7 patients (8.6%) and after 14 days in 5 patients (6.1%). No echocardiogram was made in 19 patients. Conclusions: At the Instituto Nacional de Cardiología "Ignacio Chávez" we made an echocardiographic evaluation and follow up different from the international recommendations for patients with valve replacement.

[Aortic valve calcification evaluated by echocardiography associated with baseline conduction abnormalities as a predictor for pacemaker placement after aortic valve replacement]. / La extension de la calcificación aórtica evaluada mediante ecocardiografia asociada a trastornos de la conducción como predictors de marcapasos dedinitivos en el postoperatorio de cambio valvular aórtico.

INTRODUCTION: Aortic valve replacement in patients with severe aortic stenosis may be complicated by complete atrioventricular block (CAVB), requiring a permanent pacemaker (PPM) implantation. Predicting this complication could help to plan the surgical. OBJECTIVE: Determine whether electrocardiography and echocardiography are useful methods for predicting the need for PPM. MATERIAL AND METHODS: A retrospective, observational and transversal study was performed. An echocardiography based semi-quantitative classification was implemented to graduate the extent of calcification of the aortic valve. RESULTS: We included 95 patients; 10 of them required PPM implantation (10.52%). In the pre-surgical basal electrocardiogram we observed that 90% of patients that required PPM had conduction abnormalities as opposed to only 24.7% in the other group, p = 0.001. A 1st and 2nd degree AV block (AVB 1 and 2) was identified in 8 patients that subsequently needed PPM (80%) vs. 5 patients (5.9%), in the group that did not required it, p = 0.001.OR 41.7, IC 95% 6.5-68. We found a grade 3 calcification extent in 80% of patients who required PPM implant compared with only 17.6% of patients in the other group, p = 0.04, OR 4.8, IC 95% 0.76-29. The AVB 1 and 2 were the single predictor in multivariate analysis but the calcification 3 + AVB 1 and 2, increased sensibility. CONCLUISON: In patients with aortic stenosis in whom aortic valve replacement was performed, identifying AVB 1 and 2 on the basal electrocardiogram is a useful tool in order to identify requirement of PPM. The grade 3 of calcification extent increased the sensibility of this prediction.

Left ventricular longitudinal strain measured by speckle tracking as a predictor of the decrease in left ventricular deformation in children with congenital stenosis of the aorta or coarctation of the aorta.

Children born with a left ventricular outflow tract obstruction (LVOTO) can present with symptoms of left ventricular (LV) failure while ejection fraction (EF) is normal. A more sensitive parameter of systolic function might be obtained with speckle tracking echocardiography, which describes ventricular longitudinal deformation in strain values. It is presumed that despite a normal or only slight decrease in ejection fraction, patients with a LVOTO demonstrate aberrations in the longitudinal deformation of the left ventricle. In addition, it is expected that after a successful intervention, longitudinal deformation returns to normal values. Standard trans-thoracic echocardiography was performed on 33 consecutive patients with a LVOTO, either an isolated aortic coarctation (AoCo) or an isolated aortic stenosis (AoSt). Before intervention a significant decrease in strain values was observed compared with the control group (N = 40), with an additional decrease in strain values in the first week after intervention (N = 16). Strain values recovered after a mean follow-up period of 42 wk (N = 9), though normal values were never reached. In addition, patients with an AoCo had a smaller decrease in strain values compared with patients with AoSt. All strain values were measured with a concomitant ejection fraction between normal limits. It is concluded that patients with a congenital LVOTO have decreased ventricular systolic function measured as strain values, whereas their ejection fraction is within the normal range. Therefore, as ejection fraction may not be an accurate measure, speckle tracking-based strain may be significant in the identification of subtle changes in longitudinal deformation and may create opportunities for patients to benefit from early treatment for heart failure.

Intramyocardial dissecting hematoma and postinfarction cardiac rupture.

Potentially fatal cardiac rupture is a complication of myocardial infarction (MI), which can appear in the first hours of the acute event and during the course of the first week. The intramyocardial dissecting hematoma might appear as a component of the rupture during the evolution process. The description of the myocardium as a helical muscular band facilitates the explanation of the fiber dissection. With echocardiography, it is possible to diagnose intramyocardial dissecting hematomas (IDH), determine its location, progression, potential complications, and in some cases its reabsorption. It is necessary to search for neocavitations in the infarcted myocardium and identify the intramyocardial edge that surrounds the defect, as well as the flow inside the myocardial dissection, the pathway of the dissection, and its communication with ventricular cavities, and also to look for the complete or partial reabsorption of the cavitary image. The greater the myocardial dissection is, the worse the prognosis. If the dissecting hematoma is confined to the apical segments, it is more likely to reabsorb spontaneously. Tissue characterization with magnetic resonance during an acute myocardial infarction allows identification of reperfusion injuries with altered microcirculation and intramyocardial hemorrhage (IMH). It is necessary to search for IMH in reperfused patients with ventricular arrhythmias, stunned myocardium, and no reflow. These patients may develop an increased stiffness in the infarcted wall and a major likelihood to develop a parietal rupture. Everything seems to indicate that we are facing the same physiopathological process which can be characterized by 2 complementary imaging methods, echocardiography and magnetic resonance.

Evaluación ecocardiográfica de la sincronía ventricular: implicaciones en la selección de pacientes y en los resultados del tratamiento / Echocardiographic assessment of ventriculara synchrony: implications to patient selection and treatment outcome

Heart failure is one of the most prevalent diseases in industrialized countries. Up to 30% of the patients with advanced heart failure present disturbances in intra-ventricular conduction, and this produce asynchrony of ventricular contractility, leading to further deterioration in heart function. Cardiac resynchronization (TRC) is an increasingly important therapeutic option for a subgroup of patients with heart failure. Several methods have been show to be useful in study the mechanical asynchrony. However, there are discrepancies between the results of the different methods. The echocardiography provides the best parameters in predicting a good response.

2D and 3D echocardiography of a left ventricular diverticulum.

A real time transthoracic 3D study of a left ventricular diverticulum established through a narrow orifice located between the aortic and mitral valves is presented. Diverticular morphology was reconstructed and its volumes were calculated by this technique for the first time in the literature.

Subepicardial aneurysm: echocardiographic evaluation and evolution.

Subepicardial aneurysms (SEA) are an infrequent and serious form of subacute cardiac rupture complicating myocardial infarction. An early diagnosis and surgical repair may be life saving. SEA comprise an abrupt interruption of the myocardium, with a narrow neck and thin wall containing only the epicardium. It may progress to fatal cardiorrhexis. We describe the echocardiographic evolution of this type of cardiac rupture and the contribution of contrast-enhanced echocardiography. A possible pathophysiological mechanism is proposed.

[Echocardiographic assessment of ventricular synchrony. Implications to patient selection and treatment outcome]. / Evaluación ecocardiográfica de la sincronía ventricular. Implicaciones en la selección de pacientes y en los resultados del tratamiento.

Heart failure is one of the most prevalent diseases in industrialized countries. Up to 30% of the patients with advanced heart failure present disturbances in intra-ventricular conduction, and this produce asynchrony of ventricular contractility, leading to further deterioration in heart function. Cardiac resynchronization (TRC) is an increasingly important therapeutic option for a subgroup of patients with heart failure. Several methods have been show to be useful in study the mechanical asynchrony. However, there are discrepancies between the results of the different methods. The echocardiography provides the best parameters in predicting a good response.

Dissecting intramyocardial hematoma: clinical presentation, pathophysiology, outcomes and delineation by echocardiography.

BACKGROUND: In large necropsy studies dissecting intramyocardial hematoma (DIH) with serpiginous tracts across the myocardial fibers has been reported in both the septum and the left ventricle free wall. METHODS: We studied 15 patients admitted to the hospital with acute myocardial infarction (AMI) in which DIH was demonstrated by either transthoracic and/or transesophageal and confirmed intraoperatively or by necropsy. RESULTS: In nine patients the hemorrhagic dissection was predominantly in the septum and in the remaining it was in the free wall of the left ventricle (LV). Myocardial infarction involved the left ventricular inferior wall in two, and the anterior wall in 13 patients. The overall mortality was 47%, and in the group with septal hematoma it reached to 78%. Echocardiography disclosed the various acoustic densities of the evolving intramyocardial hematoma, its extension through the hemorrhagic dissection, its spontaneous reabsorption, as well as its communication with the ventricular cavities. CONCLUSIONS: Echocardiography is the method of choice for the noninvasive diagnosis of patients with suspected myocardial rupture and intramyocardial dissection postmyocardial infarction.

[Cardiac myxomas and the Carney complex]. / Mixomas cardiacos y complejo de Carney.

The study involved 63 patients with an echocardiographic, surgical and histopathologic diagnosis of cardiac myxoma who were seen over a period of 20 years. Tumor recurrence or relapse was documented in five of these patients (7.9%), 3 of whom had a confirmed diagnosis of Carney complex, while one other patient had a probable diagnosis. Genetic studies demonstrated abnormalities in the PRKAR1A gene on chromosome 17 in 2 patients and their immediate family. In 11 of the 58 patients who did not experience relapse of the myxoma, genetic studies failed to show any abnormality. In conclusion, the possible presence of the Carney complex should be investigated in patients with multiple myxomas or with a cardiac myxoma whose location is atypical.

A deletion in the PRKAR1A gene is associated with Carney complex.

Mutations of the PRKAR1A gene are an important cause of Carney complex (CC). The PRKAR1A gene encodes the type 1A regulatory subunit of cAMP-dependent protein kinase A. We have identified one mutation of PRKAR1A (553delG) in three members of the same family affected by CC. This mutation was not identified in six unaffected family members, 12 patients with sporadic cardiac myxoma and 100 non-related healthy individuals. The novel mutation (553delG) is predicted to produce a frameshift leading to a premature stop codon. RNA analysis in the index patient showed normal size transcripts in RT-PCR amplicons of several exons, but an overall tendency to lower amounts of transcripts in relation to GAPDH controls. In Western blot analyses only full-length protein was present without any evidence of truncated product. These data suggest that the mutant allele might be a null allele due to degradation of the mutant mRNA via nonsense-mediated decay.

Three-dimensional transesophageal echocardiography of the atrial septal defects.

Transesophageal echocardiography has advantages over transthoracic technique in defining morphology of atrial structures. Even though real time three-dimensional echocardiographic imaging is a reality, the off-line reconstruction technique usually allows to obtain higher spatial resolution images. The purpose of this study was to explore the accuracy of off-line three-dimensional transesophageal echocardiography in a spectrum of atrial septal defects by comparing them with representative anatomic specimens.

Ecocardiografía: aportaciones en la evaluación del daño valvular: nuevas perspectivas / Echocardiography in valvular heart disease: new perspectives

Echocardiography occupies an excellent place in the field of valvular heart disease study. Its presence is being increased in the catheterism and surgery rooms as well as in the intensive cares units. The ultrasound machines development has improved its technology and echocardiographic diagnoses has a greater repercussion in clinical decisions every time. The greater challenge than appears to us is to be able to have prepared enough professionals that know the tool, the physiopathology, the therapeutics modalities, and who can apply and take advantage of the new technological developments for a better cardiological practice.

[Acute right atrial and ventricular infarction]. / Infarto agudo de aurícula y ventrículo derechos.

Acute coronary syndromes involving the right side of the heart are associated with increased mortality, a complex clinical course, and lengthy hospitalization, as well as with frequent mechanical and electrical complications. It is important that the signs and symptoms associated with the spread of ischemic disease to the right heart chambers are recognized so that the patient can be given appropriate treatment, which can improve short-term and long-term prognosis. The purpose of this review was to summarize key aspects of the diagnosis, prognosis and treatment of this condition.

[Echocardiography in valvular heart disease. New perspectives]. / Ecocardiografía: aportaciones en la evaluación del daño valvular: nuevas perspectivas.

Echocardiography occupies an excellent place in the field of valvular heart disease study. Its presence is being increased in the catheterism and surgery rooms as well as in the intensive cares units. The ultrasound machines development has improved its technology and echocardiographic diagnoses has a greater repercussion in clinical decisions every time. The greater challenge than appears to us is to be able to have prepared enough professionals that know the tool, the physiopathology, the therapeutics modalities, and who can apply and take advantage of the new technological developments for a better cardiological practice.

Long-term follow-up of intramyocardial dissecting hematomas complicating acute myocardial infarction.

Intramyocardial dissecting hematoma is a form of subacute cardiac rupture complicating acute myocardial infarction. Initially contained within the myocardial wall, the hematoma may expand, rupture into adjacent structures, or spontaneously resolve. However, long-term follow-up is unknown because clinical and serial imaging data are lacking. The purpose of this study was to characterize the early and late myocardial wall changes after transmural myocardial infarction using serial ultrasound examinations of the infarct-related segments. Clinical, electrocardiographic, and echocardiographic features of 8 patients (7 men, mean age 59 years) who presented with acute myocardial infarction and echocardiographically documented intramyocardial dissecting hematoma were analyzed. All patients had precordial echocardiography and 6 underwent transesophageal echocardiography. Differentiating hematoma from trabeculations, thrombus, or pseudoaneurysm was done with contrast and color flow Doppler. Seven patients presented with S-T elevation in V1 to V4, and in 3 the elevation extended to V5, V6, I, and aVL. One patient presented with S-T elevation in II, III, aVF, V3R, and V4R. The most striking feature was persistent S-T elevation of more than 72 hours in all patients. Hematoma consisted of a cysticlike, echolucent cavity variable in size, adjacent to severely hypokinetic or dyskinetic infarct-related segments. Hematoma acoustic characteristics depended on time of evolution. Two patients underwent elective revascularization and the rest were medically treated. Two patients died and 6 were alive at the mean follow-up of 12 months. In conclusion, persistent S-T elevation is an important clue in suggesting intramyocardial dissecting hematoma, which is confirmed by its unique ultrasound appearance. Serial echocardiography is useful in determining its evolving nature, and may guide outcome.