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Introducción: En la estenosis aórtica (EAo) con bajo flujo/bajo gradiente paradójico (BFBGP), el eco transtorácico 2D (ETT2D) podría subestimar el cálculo de flujo porque asume el tracto de salida del ventrículo izquierdo (TSVI) con una morfología circular. El eco transesofágico 3D (ETE3D) es metodológicamente mejor que el 2D para medir el TSVI. Objetivos: Evaluar el volumen eyectivo indexado (VEi) del ventrículo izquierdo por ETT2D y ETE3D en pacientes con corazón normal (GN) y con EAo grave (GEAo) y determinar cuántos pacientes con BFBGP por ETT2D se consideran también con BFBGP por ETE3D. Material y métodos: Se evaluaron 35 pacientes con ETT2D y ETE3D: GN = 17 pacientes y GEAo = 18 pacientes. Se estimó en ambos grupos el área del TSVI en protosístole por ETT2D (TSVI2Dprot) y por planimetría ETE3D (TSVI3Dprot) y como promedio sistólico (TSVI3Dprom). Multiplicando cada área del TSVI por su integral de flujo, se obtuvieron los VEi (VEi ETT2D prot, VEi ETE3D prot y VEi ETE3D prom) tanto del GN como del GEAo. En el GEAo se determinó BFBGP según criterio actual. Resultados: GN: área TSVI ETT2D prot vs. ETE3D prot p < 0,05. GEAo: área TSVI ETT2D prot vs. ETE3D prot p < 0,001 y vs. ETE3D prom p < 0,023; VEi ETT2D prot vs. VEi ETE3D prot p < 0,002 y vs. VEi ETE3D prom p < 0,038. En el GN, el VEi en el límite inferior de lo normal por ETT2D, ETE3D prot y ETE3D prom fue < 34, < 38,9 y < 35,9 ml/m², respectivamente. Tres pacientes del GEAo fueron BFBGP por ETT2D, pero ninguno por ETE3D. Conclusiones: Los pacientes con BFBGP por ETT2D podrían ser reclasificados por el ETE3D. Este hallazgo se relaciona con las limitaciones del eco 2D para el cálculo del área del TSVI.
Background: In paradoxical low-flow, low gradient (LF-LG) aortic stenosis, 2D-transthoracic echocardiography (2D-TTE) may underestimate flow because it assumes a circular left ventricular outflow tract (LVOT) shape. Three-dimensional trans-esophageal echocardiography (3D-TEE) is a better method to measure LVOT area. Objectives: The aim of this study was to evaluate left ventricular stroke volume index (SVi) by 2D-TTE and 3D-TEE in patients with normal heart (NG) and with severe aortic stenosis (ASG) and to determine how many patients are categorized as paradoxical LF-LG by 2D-TTE and 3D-TEE. Methods: Thirty-five patients were evaluated by 2D-TEE and 3D-TEE: NG=17 patients and ASG=18 patients. Left ventricular outflow tract area was estimated during early systole (ES) by 2D-TTE (ES2DLVOT Ar) and by 3D-TEE (ES3DLVOT Ar) planimetry, and as systolic average (Avg 3DLVOT Ar). Each LVOT area was multiplied by its corresponding flow integral to obtain SVi (ES2D-TTE SVi, ES3D-TEE SVi and Avg 3D-TEE SVi) in NG and ASG. Paradoxical LF-LG was determined in ASG following standard criterion. Results: NG: ES2DLVOT Ar vs. ES3DLVOT Ar p<0.05; ASG: ES2DLVOT Ar vs. ES3DLVOT Ar p<0.001 and vs. Avg 3DL-VOT Ar p<0.023; ES2D-TTE SVi vs. ES3D-TEE SVi p<0.002 and vs. Avg 3D-TEE SVi p<0.038. In the NG, the lower limit of normal SVi for 2D-TTE, ES3D-TEE and Avg 3D-TEE was <34, <38.9 and <35.9 ml/m², respectively. Three patients with severe aortic stenosis were categorized as paradoxical LF-LG by 2D-TTE, but none by 3D-TEE. Conclusions: Patients with paradoxical LF-LG by 2D-TTE could be recategorized by 3D-TEE. This finding is related with the limitations of 2D-echocardiography for estimating LVOT area.
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BACKGROUND: Heart failure is a common complication of diabetes characterized by an elevation in left ventricular filling pressures (LVF) that often develops in the absence of clinical symptoms. Diastolic dysfunction in the setting of low total testosterone (LTT) occurs through changes in the regulation of peripheral hemodynamics. LTT is highly prevalent among individuals with type 2 diabetes. The aim of this study was to compare LVF in male diabetic patients with no structural heart disease and normal serum testosterone levels vs. those with LTT. METHODS: Type 2 diabetic patients were assessed using tissue Doppler imaging to evaluate LVF and other conventional parameters of diastolic function. The E/e' ratio was used to estimate LVF through the ratio of peak passive trans-mitral left ventricular inflow velocity to the peak passive inflow velocity at the lateral mitral annulus. Patients were assigned to one of two groups based upon their total testosterone levels. Group A consisted of low (< 3.5 ng/mL) testosterone levels and group B consisted of normal (> 3.5 ng/mL) testosterone levels. RESULTS: A total of 148 male patients were included: group A--47 (32%) patients; group B--101 (68%) patients, respectively. Mean age was 58 ± 5.8 years and mean time of diabetes evolution was 7 ± 3.1 years. There were no significant differences between the groups regarding age, duration of diabetes evolution, hypertension, weight, heart rate, body mass index, and echocardiographic parameters. The E/e' ratio for group A was 8.05 ± 1.9 vs. 6.1 ± 1.7 for group B (p < 0.0001). The E/A ratio was 0.94 ± 0.10 vs. 1.19 ± 0.12 (p = 0.01), deceleration time 242 ± 7.4 ms vs. 205 ± 9 ms (p = 0.026) and systolic pulmonary artery pressure 27 ± ± 2.2 mm Hg vs. 22 ± 1.7 mm Hg (p = 0.11). CONCLUSIONS: Patients with type 2 diabetes and LTT have a higher E/e' ratio demonstrating a pre-clinical increase in LVF when compared to similar patients with normal testosterone levels. This finding is independent of time of diabetes evolution, hypertension and other echocardiographic parameters.
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Diabetes Mellitus Tipo 2/complicações , Hipogonadismo/complicações , Testosterona/deficiência , Disfunção Ventricular Esquerda/etiologia , Função Ventricular Esquerda , Pressão Ventricular , Biomarcadores/sangue , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/fisiopatologia , Ecocardiografia Doppler , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/fisiopatologia , Humanos , Hipogonadismo/sangue , Hipogonadismo/diagnóstico , Hipogonadismo/fisiopatologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Fatores de Risco , Testosterona/sangue , Disfunção Ventricular Esquerda/sangue , Disfunção Ventricular Esquerda/diagnóstico , Disfunção Ventricular Esquerda/fisiopatologiaRESUMO
BACKGROUND: Low total T is associated with an increased risk of atherosclerotic complications. However, the magnitude of this association in middle-aged patients with type 2 diabetes (T2D) has not been determined. MATERIALS AND METHODS: This cross-sectional study evaluated atherosclerotic disease markers in T2D patients with normal and low plasma total T. A total of 115 male patients, aged younger than 70 years, without a history of cardiovascular events, and with normal [≥ 3.5 ng/mL (≥ 12.1 nmol/L), n = 79] or low [< 3.5 ng/mL (≤ 12.1 nmol/L), n = 36] total T underwent the measurement of highly sensitive C-reactive protein, carotid artery carotid intima-media thickness (IMT), and atherosclerotic plaque by high-resolution B-mode ultrasound and to asses endothelial function by brachial artery flow-mediated dilation. RESULTS: Carotid IMT was negatively correlated with total T concentration (r = -0.39, P < .0001). Compared with subjects with normal T, a higher proportion of patients with low total T had carotid IMT of 0.1 cm or greater [80% vs 39%, odds ratio (OR) 6.41; 95% CI 2.5-16.4, P < .0001], atherosclerotic plaques (68.5% vs 44.8%, OR 2.60, 95% CI 1.12-6.03, P < .0001); endothelial dysfunction (80.5% vs 42.3%, OR 5.77, 95% CI 2.77-14.77, P < .003), and higher highly sensitive C-reactive protein levels (2.74 ± 5.82 vs 0.89 ± 0.88 mg/L, P < .0001). Similar results were found when free T was considered. Multiple logistic regression analyses adjusted for age, diabetes mellitus duration, hemoglobin A1c, lipids, treatment effect, and body mass index reported that a low total T level was independently associated with greater IMT [OR 8.43 (95% CI 2.5-25.8)] and endothelial dysfunction [OR 5.21 (95% CI 1.73-15.66)] but not with the presence of atherosclerotic plaques (OR 1.77, 95% CI 0.66-4.74). CONCLUSIONS: Low T is associated with more advanced atherosclerotic disease markers in middle-aged patients with T2D.
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Aterosclerose/sangue , Biomarcadores/sangue , Diabetes Mellitus Tipo 2/sangue , Testosterona/deficiência , Glicemia/metabolismo , Espessura Intima-Media Carotídea , Estudos Transversais , Endotélio Vascular/fisiopatologia , Humanos , Lipídeos/sangue , Masculino , Pessoa de Meia-Idade , Testosterona/sangueRESUMO
Introducción El cálculo del volumen regurgitante en la insuficiencia mitral por eco transtorácico 2D (ETT2D) es poco confiable y está relacionado con una medición inadecuada del anillo mitral (AM). El eco transesofágico 3D (ETE3D) posee mejores herramientas de medición del AM. Objetivos Comparar el área del AM y la diferencia de volumen del tracto de entrada y del tracto de salida del ventrículo izquierdo (TSVI y TEVI) por ETT2D y ETE3D en corazones normales. Evaluar en qué nivel del aparato mitral se encuentra el orificio mitral efectivo. Material y métodos Se incluyeron 13 pacientes consecutivos y prospectivos, de 42 (29-47) años, 7 de sexo femenino, con indicación de eco transesofágico (9 por búsqueda de fuente embolígena y 4 por síndrome febril), que tenían un ETT2D normal y se encontraban con ritmo sinusal y normotensos en el momento del estudio. Se les realizó simultáneamente ETT2D y ETE3D. El área del TSVI y del AM se midió por ETT2D y ETE3D. Se estimó por ETE3D el área de la válvula mitral (VM) distal al AM. El volumen de cada tracto se calculó como el producto del área por la integral velocidad-tiempo (VTI) del flujo. Se estableció una hipotética área mitral efectiva (AME) como el cociente entre el volumen del TSVI (ETE3D) y la VTI del TEVI. Resultados Correlación (rs), concordancia e IC 95% entre área del AM por ETT2D vs. ETE3D: 0,506, 1,97 (-0,40 a 4,34), AME vs. ETE3D 0,549, 2,41 (-4,03 a -0,79) y AME vs. VM a 10.5 mm (8-12) del AM: 0,982, 0,079 (-0,26 a 0,42). La diferencia de volumen (ml) entre ambos tractos fue: ETT2D 12,8 (7,5-19), ETE3D 32,8 (25,9-48) y ETE3D (desde VM distal al AM) 1,8 (1,25-3,6). Conclusiones Cuanto mejor medimos el anillo mitral, más lejos estamos del orificio mitral efectivo. El área mitral a 1 cm del punto más alto del anillo mitral es la que más se acerca al orificio mitral efectivo.
Introduction Two-dimensional transthoracic echocardiography (2DTTE) is not a reliable method for estimating regurgitatant volume in mitral insufficiency due to inadequate measurement of the mitral annulus (MA). Three-dimensional transesophageal echocardiography (3DTEE) offers better tools for measuring the MA. Objectives The aim of this study was to compare the MA area and the difference in mitral inflow (MI) volume and left ventricular out-flow tract (LVOT) volume determined by 2DTTE and 3DTEE in normal hearts, and to evaluate at what level of the mitral valve apparatus the mitral effective orifice is actually located. Methods A total of 13 consecutive and prospective patients with indication of transesophageal echocardiography (9 to rule out cardioembolic source and 4 due to febrile syndrome) were included in the study. Their mean age was 42 (29-47) years and 7 were women. All the patients had normal 2DTTE, were in sinus rhythm and had normal blood pressure at the moment of the study. 2DTTE and 3DTEE were simultaneously performed. LVOT area and MA area were calculated by 2DTTE and 3DTEE. Mitral valve (MV) area distal to the MA was estimated by 3DTEE. Mitral inflow and LVOT volume were calculated as the product between the area and flow velocity time integral (VTI). The effective mitral valve area (EMVA) was hypothetically estimated by dividing the LVOT (3DTEE) volume by MI VTI. Results Correlation (rs), concordance and 95% CI between MA area by 2DTTE vs. 3DTEE: 0.506, 1.97 (-0.40 to 4.34), EMVA vs. 3DTEE: 0.549, 2.41 (-4.03 to -0.79) and EMVA vs. MV at 11 mm (8-12) of the MA: 0.982, 0.079 (-0.26 to 0.42). The difference between MI volume and LVOT volume (ml) was: 2DTTE: 12.8 (7.5-19), 3DTEE: 32.8 (25.9-48) and 3DTEE (from the MV distal to the MA) 1.8 (1.25-3.6). Conclusions The better the technique for measuring the mitral annulus, the farther we are from the mitral effective orifice. The mitral valve area measured at one centimeter of the highest point of the mitral annulus is the best approximation to the effective mitral orifice.
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BACKGROUND: MAZE IV surgery is effective in restoring sinus rhythm (SR) and atrial contraction (AC) in patients with nonrheumatic persistent atrial fibrillation (AF). However, there is less information on its effectiveness to restore AC in patients with rheumatic disease. AIMS: To assess the effectiveness of the MAZE IV surgery in restoring AC in patients with rheumatic disease and long persistent AF. METHODS: Prospective, consecutive study in patients who underwent cardiovascular surgery and had long persistent AF in whom MAZE IV surgery was performed. The presence of AC was assessed by lateral mitral annulus tissue Doppler. RESULTS: A total of 75 patients were included. Mean age 60 years (±11.7); 27 men (36%). AF duration was 63 months (±34.1). Primary indication for surgery: rheumatic mitral stenosis 67 patients and mitral insufficiency eight patients. Mean left ventricular ejection fraction (LVEF) was 51.8% (±12.1) and mean left atrial area was 37 cm(2) (±10.3). After a mean follow-up of 28 months (±9.3), 69 patients remained alive and 59 were in SR. AC was detected in 37.3% (Group A) and absent in 62.7% (Group B). The mean difference between groups was the high prevalence of AF longer than 5 years in group B (P = 0.000001). There were no differences related to left atrial size, LVEF, and age. CONCLUSIONS: In patients with rheumatic disease, the absence of correlation between SR recovery and AC recovery post MAZE IV surgery is significant. A history of long persistent AF lasting more than 5 years was a strong predictor for the absence of AC.
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Fibrilação Atrial/cirurgia , Procedimentos Cirúrgicos Cardíacos/métodos , Átrios do Coração/cirurgia , Contração Miocárdica/fisiologia , Cardiopatia Reumática/complicações , Cardiopatia Reumática/cirurgia , Idoso , Fibrilação Atrial/etiologia , Feminino , Átrios do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Estenose da Valva Mitral/cirurgia , Estudos Prospectivos , Cardiopatia Reumática/fisiopatologia , Resultado do TratamentoRESUMO
Introducción La cirugía de MAZE III izquierdo demostró una efectividad elevada en la restauración a ritmo sinusal. Sin embargo, la efectividad en la restauración de la sístole auricular en poblaciones con cardiopatía estructural y el predominio de enfermedad reumática resultan áreas de incertidumbre. Objetivo Evaluar la efectividad de la cirugía de MAZE en la restauración de la sístole auricular en pacientes con cardiopatía estructural. Material y métodos Estudio prospectivo, consecutivo de 27 pacientes portadores de fibrilación auricular crónica persistente con indicación de cirugía cardiovascular y en los que se realizó la técnica de MAZE como tratamiento de la arritmia. La presencia de sístole auricular se evaluó mediante Doppler tisular del anillo mitral lateral. Resultados En una población caracterizada por predominancia de cardiopatía reumática (41%) y tiempo prolongado de evolución de la arritmia (61 meses promedio), al final del seguimiento el 87% se encontraba en ritmo sinusal en el 80% de los casos con actividad mecánica. El antecedente de cardiopatía reumática, una duración de la arritmia mayor de 5,5 años, el sexo femenino y el reemplazo de válvula mitral fueron variables estadísticamente significativas en cuanto a la ausencia de sístole auricular. No tuvieron significación la edad, la fracción de eyección del ventrículo izquierdo y el tamaño de la aurícula izquierda. Conclusiones En esta población es significativa la falta de correspondencia entre ritmo sinusal y sístole auricular. El Doppler tisular es un método útil para identificar a aquellos pacientes sin contracción auricular. El impacto clínico de este hallazgo está vinculado con la decisión en la continuidad del tratamiento anticoagulante.
Introduction Left MAZE III surgery has proven a high level of effectiveness in restoring the sinus rhythm. However, the effectiveness in restoring the atrial systole in individuals with structural cardiopathy and the prevalence of rheumatic disease are still uncertain areas. Objective To assess the effectiveness of the MAZE surgery in restoring the atrial systole in patients with structural cardiopathy. Material and Methods Prospective, consecutive study in 27 patients with persistent or chronic atrial fibrillation and recommendation for cardiovascular surgery, who underwent the MAZE technique for treating the arrhythmia. The presence of atrial systole was assessed by lateral mitral annular tisular Doppler. Results In a population characterized by rheumatic cardiopathy predominance (41%) and long arrhythmia evolution (61 months on average), 87% individuals had sinus rhythm and 80% of them had mechanical activity at the end of the follow- up. A history of rheumatic cardiopathy, an arrhythmia lasting more than 5.5 years, the fact of being female, and the mitral valve replacement were statistically significant variables, considering the absence of atrial systole. Factors like age, left ventricle ejection fraction, and left atrial size were not significant. Conclusions In this population, the absence of correlation between the sinus rhythm and the atrial systole is significant. The tisular Doppler is a useful method to identify those patients with no atrial contraction. The clinical impact of this finding is related to the decision on continuing the anticoagulant therapy.