[Effect of exercise on systolic left ventricular outflow velocity in healthy adults]. / Efecto del ejercicio sobre las velocidades de flujo sistólico ventricular izquierdo en adultos sanos.

The occurrence of exercise-induced dynamic obstruction of the left ventricular outflow tract in patients without cardiomyopathy has recently been reported. However, it is not known if this phenomenon is a normal response to exercise in healthy adults. We studied 23 healthy adults using exercise Doppler echocardiography. We measured the left ventricular outflow velocity at rest and after maximum tolerated exercise. After a mean exercise duration of 12 min 45 s (2 min 32 s), the heart rate was 97.61 (6.71)% of the theoretical maximum. Left ventricular outflow velocity increased from 1.07 (0.18) m/s (range: 0.77-1.44 m/s) to 1.58 (0.35) m/s (range: 1.09-2.4 m/s). In healthy adults, exercise increased the left ventricular outflow velocity by 50%, though in no subject was it greater than 2.5 m/s. This observation appears to rule out the possibility that a high intraventricular pressure gradient is a normal response to exercise in healthy adults.

[Morphologic study of the pulmonary veins by magnetic resonance angiography]. / Estudio morfológico de las venas pulmonares por angiorresonancia magnética.

Accurate knowledge of the anatomy of the pulmonary veins is important in clinical electrophysiology. In order to evaluate the usefulness of magnetic resonance angiography for this purpose, we studied 17 unselected patients. All the pulmonary veins were visualized in each individual. The diameters of the ostia ranged between 9 mm and 22 mm. The cross-section of the ostium was elliptical in 35% of cases. In 14 patients (82%), the 4 veins each had independent drainage. In 2 patients (12%), there was an additional intermediate right vein and, in 1 patient (6%), both left veins had a common ostium. In 74% of patients, the right pulmonary veins had a short common trunk with early branching. This pattern was seen in only 10% of left veins. Magnetic resonance angiography using a contrast medium is an excellent technique for studying the anatomy of the pulmonary veins and for identifying variants. The resulting information is potentially useful for electrophysiologists.

[Systolic ventricular dysfunction, a new marker of coronary artery disease in patients with aortic stenosis without previous myocardial infarction]. / Disfunción ventricular sistólica, un nuevo marcador de enfermedad coronaria en pacientes con estenosis aórtica sin infarto de miocardio previo.

Identification of clinical factors associated with coronary artery disease could obviate the need for coronary angiography in selected patients with severe aortic stenosis. We studied 315 patients (68 [8] years) with severe aortic stenosis without previous infarction who underwent coronary angiography. In the univariate analysis, age (P = .001), dyslipidemia (P = .003), angina (P = .018), aortic gradient (P = .001) and reduced ejection fraction (P = .006) were predictors of coronary artery disease. After multivariate analysis, age (OR = 1.079, P = .01), ejection fraction < 40% (OR = 2.685, P = .02), angina (OR = 2.518, P = .04) and dyslipidemia (OR = 2.34, P = .008) were the factors independently associated with coronary artery disease. Left ventricular dysfunction correlated independently with the presence of coronary artery disease.

Should we treat patients with moderately severe stenosis of the left main coronary artery and negative FFR results?

BACKGROUND: The prognostic importance of significant left main coronary artery disease is unequivocal. However, moderate lesions of the left main coronary artery (LMCA) are sometimes found in patients presenting significant stenosis in other coronary arteries or equivocal symptoms. The ability of myocardial fractional flow reserve (FFR) to predict coronary events could be useful in the decision-making process in these patients. The present study was designed to investigate the occurrence of cardiac events in patients with coronary syndromes and LMCA stenosis of moderate severity in whom FFR failed to show an haemodynamic significant repercussion of the LMCA. METHODS AND RESULTS: We studied 27 consecutive patients (mean age 62.7 +/- 10.5 years) with moderate stenoses (30-50%) of the LMCA. In seven patients who presented significantly reduced FFR (< 0.75) at the LMCA level (Group A), coronary revascularization of this vessel was performed. In 20 patients with negative FFR (greater than or equal to 0.75) at the LMCA level (Group B), the LMCA stenosis was not revascularized, being the revascularization procedures (if any) limited to other arteries with significant obstructions. During a mean follow-up period of 26.2 +/- 12.1 months, clinical events occurred in 3 patients in the whole group. One patient with positive FFR died during coronary bypass surgery. Two group B patients were surgically revascularized 4 months and 4 years after the initial coronariography. CONCLUSIONS: Patients with coronary lesions of moderate severity on the LMCA and negative FFR may constitute a subgroup of good prognosis in the follow-up. Our findings suggest that negative FFR is a potentially useful indicator of the likelihood of cardiac events, and thus represents a useful aid in clinical decision-making in the hemodynamics laboratory.

[Dynamic left ventricular outflow tract obstruction induced by exercise]. / Obstrucción dinámica intraventricular izquierda inducida por esfuerzo.

INTRODUCTION AND OBJECTIVES: Dynamic left intraventricular outflow tract obstruction occurs occasionally in patients without hypertrophic cardiomyopathy. We hypothesized that dynamic intraventricular obstruction might occur during effort in patients with angina or dyspnea without evident disease. The objective of this prospective study was to investigate: a) whether it appears with effort; b) its incidence, magnitude and determining factors, and c) its clinical course. PATIENTS AND METHOD: We performed baseline and stress Doppler echocardiography in 211 patients with angina, dyspnea or both with exercise. Patients with previous myocardial infarction, valvular heart disease, ventricular dysfunction or ventricular hypertrophy without hypertension were excluded. Dynamic intraventricular obstruction was defined as intracavitary flow velocity > or =2.5 m/s. RESULTS: 134 patients (59 women) were included: mean age was 58 (9) years; history of hypertension was present in 69.7%, dyslipidemia in 35.8% and diabetes in 24.6%. Dynamic intraventricular obstruction appeared in 18 patients (13.4%), with gradients ranging between 25 and 53 mmHg (mean 32.19 [6.6]). Demographic variables, cardiovascular risk factors and exercise performed were similar in group A (with obstruction) and group B (without obstruction). No patient in group A had evidence of ischemia. Five patients in this group had symptoms during exercise; the gradients were greater in these patients (42.65 [10.5] vs 28.15 [2.37] mmHg; P<.0001) than in the remaining group A patients. Left ventricular outflow tract size was found to be the only independent predictive factor in the multivariate analysis. After 369.9 (133.5) days of follow-up, no cardiac events were recorded. CONCLUSIONS: Our study suggests that some patients with angina or dyspnea without evidence of ischemia may develop dynamic left ventricular outflow tract obstruction induced by effort.

Short- and long-term outcomes of surgery for severe tricuspid regurgitation.

INTRODUCTION AND OBJECTIVES: There is little data available for Spain on the outcomes of surgical treatment for severe tricuspid regurgitation. The aim of this study was to analyze clinical and echocardiographic outcomes in a series of patients who received surgical treatment for severe tricuspid regurgitation and to compare outcomes according to the operative approach to valve repair or replacement. METHODS: Retrospective study in 119 consecutive patients with severe tricuspid regurgitation undergoing valve surgery between April 1996 and February 2010. RESULTS: A total of 61 ringless and 23 ring annuloplasties were performed and 11 bioprostheses and 24 mechanical prostheses were implanted. Perioperative mortality was 18.5% and was associated with age and cardiopulmonary bypass time. During clinical follow-up (median, 41 [interquartile range, 24-89] months), 2 reoperations were required in the ring annuloplasty and mechanical prosthesis groups; prosthetic thrombosis was diagnosed in 4 patients in the latter group. Total mortality after follow-up was 29.9% and was associated with age>70 years and extracorporeal circulation time. The emergence of new severe tricuspid regurgitation was associated with age and ringless annuloplasty (P=.04). CONCLUSIONS: Ringless repair was significantly associated with recurrence of severe tricuspid regurgitation. The use of mechanical prostheses was associated with a high rate of thrombosis. No significant differences in perioperative or total mortality were found between the different methods used for repair or valve replacement.

Taquicardia con QRS ancho tras instilación de atropina tópica oftálmica como primera manifestación de enfermedad de Steinert / Wide QRS complex tachycardia after atropine eye drop instillation as the first manifestation of steinert disease

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Síndrome de tortuosidad arterial: un diagnóstico tardío e inesperado y la descripción de una nueva mutación probablemente patogénica / Arterial tortuosity syndrome: a late and unexpected diagnosis and description of a novel likely pathogenic mutation

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Cirugía de la regurgitación tricuspídea grave: resultados a corto y largo plazo / Short- and long-term outcomes of surgery for severe tricuspid regurgitation

Introducción y objetivos. En nuestro medio hay pocos datos sobre los resultados del tratamiento quirúrgico de la insuficiencia tricuspídea grave. Nuestro objetivo es analizar los resultados clínicos y ecocardiográficos de nuestra población con insuficiencia tricuspídea grave sometida a cirugía comparándolos según el tipo de reparación o de sustitución valvular. Métodos. Realizamos un estudio retrospectivo incluyendo a 119 pacientes consecutivos con insuficiencia tricuspídea grave sometidos a cirugía de dicha válvula entre abril de 1996 y febrero de 2010. Resultados. Se realizaron 61 anuloplastias sin anillo y 23 con anillo, y se implantaron 11 prótesis biológicas y 24 mecánicas. La mortalidad perioperatoria fue del 18,5%, y se asociaron a ella la edad y el tiempo de circulación extracorpórea. Durante el seguimiento clínico (mediana, 41 [intervalo intercuartílico, 24-89] meses), el grupo anuloplastia con anillo precisó dos reoperaciones, al igual que el grupo de prótesis mecánica, en el que se diagnosticó trombosis protésica a 4 pacientes. La mortalidad total tras seguimiento fue del 29,9%, y se asociaron a ella la edad > 70 años y el tiempo de circulación extracorpórea. La aparición de nueva insuficiencia tricuspídea grave se asoció a la edad y la anuloplastia sin anillo (p = 0,04). Conclusiones. La reparación sin anillo se asoció significativamente con recurrencia de insuficiencia tricuspídea grave. El implante de prótesis mecánica se asoció a una elevada tasa de trombosis en el seguimiento. No se encontraron diferencias significativas en la mortalidad perioperatoria o total según el tipo de reparación o sustitución valvular (AU)

Introduction and objectives: There is little data available for Spain on the outcomes of surgical treatment for severe tricuspid regurgitation. The aim of this study was to analyze clinical and echocardiographic outcomes in a series of patients who received surgical treatment for severe tricuspid regurgitation and to compare outcomes according to the operative approach to valve repair or replacement. Methods: Retrospective study in 119 consecutive patients with severe tricuspid regurgitation undergoing valve surgery between April 1996 and February 2010. Results: A total of 61 ringless and 23 ring annuloplasties were performed and 11 bioprostheses and 24 mechanical prostheses were implanted. Perioperative mortality was 18.5% and was associated with age and cardiopulmonary bypass time. During clinical follow-up (median, 41 [interquartile range, 24-89] months), 2 reoperations were required in the ring annuloplasty and mechanical prosthesis groups; prosthetic thrombosis was diagnosed in 4 patients in the latter group. Total mortality after follow-up was 29.9% and was associated with age>70 years and extracorporeal circulation time. The emergence of new severe tricuspid regurgitation was associated with age and ringless annuloplasty (P=.04). Conclusions: Ringless repair was significantly associated with recurrence of severe tricuspid regurgitation. The use of mechanical prostheses was associated with a high rate of thrombosis. No significant differences in perioperative or total mortality were found between the different methods used for repair or valve replacement (AU)

Rotura de aneurisma del seno de Valsalva izquierdo a cavidad pericárdica / Rupture of a left sinus of Valsalva aneurysm into the pericardial cavity

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Efecto del ejercicio sobre las velocidades de flujo sistólico ventricular izquierdo en adultos sanos / Effect of exercise on systolic left ventricular outflow velocity in healthy adults

Recientemente se ha descrito la aparición de obstrucción dinámica intraventricular izquierda inducida por esfuerzo y caracterizada por aparición de gradientes intraventriculares en pacientes sin miocardiopatía hipertrófica. Se desconoce si este hallazgo podría aparecer en sujetos sanos como respuesta normal al ejercicio. Se estudió a 23 sujetos sanos mediante ecocardiografía-Doppler de esfuerzo. Basalmente y tras el esfuerzo máximo tolerado, medimos las velocidades del flujo de salida ventricular izquierdo. Tras un ejercicio de 12 min 45 s ± 2 min 32 s alcanzaron frecuencias cardíacas del 97,61 ± 6,71% respecto a la máxima teórica. Las velocidades del flujo aumentaron de 1,07 ± 0,18 m/s (rango, 0,77-1,44 m/s) hasta 1,58 ± 0,35 m/s (rango, 1,09-2,4 m/s). Concluimos que el ejercicio máximo tolerado por sujetos sanos aumentó hasta un 50% las velocidades de flujo de salida ventricular y en ningún caso se alcanzaron los 2,5 m/s. Esto parece descartar que los gradientes intraventriculares elevados sean una respuesta normal al ejercicio en sujetos sanos

The occurrence of exercise-induced dynamic obstruction of the left ventricular outflow tract in patients without cardiomyopathy has recently been reported. However, it is not known if this phenomenon is a normal response to exercise in healthy adults. We studied 23 healthy adults using exercise Doppler echocardiography. We measured the left ventricular outflow velocity at rest and after maximum tolerated exercise. After a mean exercise duration of 12 min 45 s (2 min 32 s), the heart rate was 97.61 (6.71)% of the theoretical maximum. Left ventricular outflow velocity increased from 1.07 (0.18) m/s (range: 0.77-1.44 m/s) to 1.58 (0.35) m/s (range: 1.09-2.4 m/s). In healthy adults, exercise increased the left ventricular outflow velocity by 50%, though in no subject was it greater than 2.5 m/s. This observation appears to rule out the possibility that a high intraventricular pressure gradient is a normal response to exercise in healthy adults

Estudio morfológico de las venas pulmonares por angiorresonancia magnética / Morphologic study of the pulmonary veins by magnetic resonance angiography

El desarrollo de la electrofisiología clínica ha potenciado el interés por el conocimiento de la anatomía de las venas pulmonares. Con el objetivo de valorar la utilidad de la angiografía por resonancia magnética para este fin se estudió a 17 pacientes no seleccionados, en los que se visualizó la totalidad de las venas en cada paciente. El diámetro máximo de los ostium osciló entre 9 y 22 mm y su morfología era oval en el 35% de casos. En 14 casos (82%) se observó una desembocadura independiente de las 4 venas. En 2 (12%) había una vena media derecha independiente y 1 (6%) presentaba un ostium común para las venas izquierdas. Las venas derechas mostraron ramificación precoz en un 74% de los casos, frente a un 10% de las izquierdas. La angiorresonancia magnética con contraste permite estudiar, de manera adecuada, la morfología de las venas pulmonares y sus variantes anatómicas, información potencialmente útil para el electrofisiólogo

Accurate knowledge of the anatomy of the pulmonary veins is important in clinical electrophysiology. In order to evaluate the usefulness of magnetic resonance angiography for this purpose, we studied 17 unselected patients. All the pulmonary veins were visualized in each individual. The diameters of the ostia ranged between 9 mm and 22 mm. The cross-section of the ostium was elliptical in 35% of cases. In 14 patients (82%), the 4 veins each had independent drainage. In 2 patients (12%), there was an additional intermediate right vein and, in 1 patient (6%), both left veins had a common ostium. In 74% of patients, the right pulmonary veins had a short common trunk with early branching. This pattern was seen in only 10% of left veins. Magnetic resonance angiography using a contrast medium is an excellent technique for studying the anatomy of the pulmonary veins and for identifying variants. The resulting information is potentially useful for electrophysiologists

Disfunción ventricular sistólica, un nuevo marcador de enfermedad coronaria en pacientes con estenosis aórtica sin infarto de miocardio previo / Systolic ventricular dysfunction, a new marker of coronary artery disease in patients with aortic stenosis without previous myocardial infarction

La determinación de factores clínicos predictivos de la presencia de enfermedad coronaria podría obviar la necesidad de realizar una coronariografía en pacientes seleccionados con estenosis aórtica severa. Se estudió a315 pacientes (68 ± 8 años) sin infarto previo con estenosis aórtica severa a los que se realizó coronariografía. En el análisis univariable, resultaron significativas la edad (p = 0,001), la dislipemia (p = 0,003), la angina (p =0,018), el gradiente aórtico (p = 0,001) y la fracción deeyección (FE) reducida (p = 0,006). En el análisis multivariable las variables asociadas de forma independiente ala lesión coronaria fueron la edad (odds ratio [OR] =1,079, p = 0,01), la FE < 40% (OR = 2,685, p = 0,02), la angina (OR = 2,518, p = 0,04) y la dislipemia (OR = 2,34,p = 0,008).La disfunción ventricular se correlaciona de forma independiente con la presencia de lesiones coronarias

Identification of clinical factors associated with coronaryartery disease could obviate the need for coronary angiography in selected patients with severe aortic stenosis.We studied 315 patients (68 [8] years) with severe aortic stenosis without previous infarction who underwent coronary angiography. In the univariate analysis, age(P=.001), dyslipidemia (P=.003), angina (P=.018), aortic gradient (P=.001) and reduced ejection fraction (P=.006)were predictors of coronary artery disease. After multivariate analysis, age (OR = 1.079, P=.01), ejection fraction< 40% (OR = 2.685, P=.02), angina (OR = 2.518, P=.04) and dyslipidemia (OR = 2.34, P=.008) were the factors independently associated with coronary artery disease. Left ventricular dysfunction correlated independently with the presence of coronary artery disease

Obstrucción dinámica intraventricular izquierda inducida por esfuerzo / Dynamic Left Ventricular Outflow Tract Obstruction Induced by Exercise

Introducción y objetivos. La obstrucción dinámica intraventricular izquierda puede aparecer ocasionalmente en pacientes sin miocardiopatía hipertrófica. Planteamos si podría aparecer inducida por esfuerzo en pacientes con angina o disnea de esfuerzo sin causa aparente. El objetivo de este estudio prospectivo es conocer: a) si aparece con esfuerzo; b) su incidencia, magnitud y factores determinantes, y c) evolución de los pacientes que la presentan. Pacientes y método. Realizamos ecocardiograma Doppler basal y postesfuerzo en 211 pacientes con angina o disnea de esfuerzo. Excluimos a los que tenían infarto previo, valvulopatía, disfunción ventricular o hipertrofia ventricular sin hipertensión. Definimos obstrucción dinámica intraventricular como flujo intraventricular con velocidad ≥ 2,5 m/s. Resultados. Se incluyó a 134 pacientes (59 mujeres), con una edad de 58 ± 9 años; el 69,7% tenía antecedentes de hipertensión, el 35%, dislipemia y el 24,6%, diabetes. Apareció obstrucción intraventricular en 18 (13,4%) pacientes, con un gradiente entre 25 y 53 mmHg (media, 32,19 ± 6,6). Las variables demográficas, los factores de riesgo y el ejercicio realizado fueron similares en el grupo A (con obstrucción) y B (sin obstrucción). En el grupo A, ningún paciente tuvo evidencia de isquemia y los 5 que presentaron síntomas durante el esfuerzo tuvieron mayores gradientes (42,65 ± 10,5 frente a 28,15 ± 2,37 mmHg; p < 0,0001) que el resto del grupo A. El análisis multivariante identificó el diámetro del tracto de salida como único factor predictor independiente. Tras un seguimiento de 369,9 ± 133,5 días, no se registraron eventos. Conclusiones. Nuestros datos sugieren que algunos pacientes con angina o disnea de esfuerzo sin evidencia de isquemia pueden tener obstrucción dinámica ventricular izquierda inducida por esfuerzo (AU)

Introduction and objectives. Dynamic left intraventricular outflow tract obstruction occurs occasionally in patients without hypertrophic cardiomyopathy. We hypothesized that dynamic intraventricular obstruction might occur during effort in patients with angina or dyspnea without evident disease. The objective of this prospective study was to investigate: a) whether it appears with effort; b) its incidence, magnitude and determining factors, and c) its clinical course. Patients and method. We performed baseline and stress Doppler echocardiography in 211 patients with angina, dyspnea or both with exercise. Patients with previous myocardial infarction, valvular heart disease, ventricular dysfunction or ventricular hypertrophy without hypertension were excluded. Dynamic intraventricular obstruction was defined as intracavitary flow velocity ≥2.5 m/s. Results. 134 patients (59 women) were included: mean age was 58 (9) years; history of hypertension was present in 69.7%, dyslipidemia in 35.8% and diabetes in 24.6%. Dynamic intraventricular obstruction appeared in 18 patients (13.4%), with gradients ranging between 25 and 53 mmHg (mean 32.19 [6.6]). Demographic variables, cardiovascular risk factors and exercise performed were similar in group A (with obstruction) and group B (without obstruction). No patient in group A had evidence of ischemia. Five patients in this group had symptoms during exercise; the gradients were greater in these patients (42.65 [10.5] vs 28.15 [2.37] mmHg; P<.0001) than in the remaining group A patients. Left ventricular outflow tract size was found to be the only independent predictive factor in the multivariate analysis. After 369.9 (133.5) days of follow-up, no cardiac events were recorded. Conclusions. Our study suggests that some patients with angina or dyspnea without evidence of ischemia may develop dynamic left ventricular outflow tract obstruction induced by effort (AU)