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.

[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.

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.

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.

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.

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.

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.

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.

[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.

Risk factors, echocardiographic patterns, and outcomes in patients with acute ventricular septal rupture during myocardial infarction.

Ventricular septal rupture (VSR), which can complicate an acute myocardial infarction (MI), carries a high mortality rate. Because precordial and transesophageal echocardiography can identify the type of rupture and assess right ventricular (RV) function at the patient's bedside, we examined the prognostic significance of echocardiographic patterns in postinfarct VSR by postulating that complex rupture and RV involvement carry a worse prognosis. Seventeen patients (10 men; mean age 66 years) who had confirmed postinfarct VSR underwent precordial and transesophageal echocardiography followed by coronary angiography. Serial 12-lead and right precordial leads were also available. Type of septal rupture was classified as simple or complex based on autopsy-proved echocardiographic criteria. Three patients had inferior wall MI and 14 had anterior wall MI. ST-segment elevation persisted >72 hours in all 3 patients who had inferior wall MI and in 12 who had anterior wall MI. Segmental wall motion abnormalities helped in detecting the left ventricular entry site, and use of unconventional views superimposed with color flow Doppler provided the RV exit site. RV function was better appreciated with transesophageal echocardiography. Two patients who had inferior wall MI and 7 who had anterior wall MI had complex ruptures. All 3 patients who had inferior wall MI and 7 who had anterior wall MI had electrocardiographic and echocardiographic evidence of RV involvement. Mortality rate was higher in patients who had complex rupture (78% vs 38%, p <0.001) and in those who had RV extension (71% vs 29%, p <0.001). In conclusion, persistent ST elevation is a common finding in patients who have postinfarct VSR. Complex VSR and RV involvement are significant determinants of clinical outcome.

[Unruptured sinus of Valsalva aneurysm. Bi and three-dimensional echocardiography approach]. / Valoración ecocardiográfica bi y tridimensional de aneurisma no roto del seno de Valsalva.

Aneurysm of the sinus of Valsalva is a rare anomaly that can be congenital or acquire. The most common among the acquire is aortic endocarditis. At the present time echocardiography has be come the election diagnostic method. We present two pediatric patients with unrupture aneurysm of the sinus of Valsalva and cardiac failure secondary to a acute aortic insufficiency manifestations. Transthoracic and transesophageal bidimensional images were compared, in one of them also three-dimensional image. Assessing the quality of images, localization and anatomical morphology of aneurysm, obstruction or compression and presence of associated defects. The usefulness of the three dimensional echocardiography assessment for these congenital malformations is demonstrated.

[Recurrent myxoma. Bi and three-dimensional echocardiography approach]. / Mixoma recidivante. Diagnóstico ecocardiográfico bi y tridimensional.

The case of a 16-years old female patient with left atrial myxoma and cerebral embolism is reported. She was subjected to surgical excision of the mass. At 40 months of follow-up she initiates with dyspnea and an aortic murmur is detected. The transthoracic and transesophageal echocardiographic analysis revealed the presence of three tumors: in the left atrium, left and right ventricle. The myxoma of the left ventricle obstructs the aortic valve. We discuss the usefulness of bi-and three-dimensional echocardiography as initial diagnostic method.

[Echocardiographic diagnosis of obstructive intermittent dysfunction of a mitral disc prosthetic valve]. / Diagnóstico ecocardiográfico de disfinción por obstrucción intermitente de prótesis de disco mitral.

Echocardiographic findings in six patients with obstructive intermittent dysfunction of mechanical disc prosthetic mitral valve (OIPD) are described. All with a clinical picture of gradual installation and progressive dyspnea of several weeks of evolution. TTE with Bd recordings were performed in all of them with "oriented" M mode from apical 4/C view. The findings were compared with a control group of 14 patients with normal prosthetic valves. In the group of OIDP, all patients displayed a variable delay in the opening of the prosthetic disc, registered as a "protodiastolic step" in M mode. In three patients, the dysfunction was due to a thrombus. In two, due to pannus. Three were operated. One with thrombolysis. In two, the treatment consisted of heparin and increased oral anticoagulation. None die during the acute handling of the intermittent dysfunction. Two patients died: one seven months later due to cardiac failure and the other a year later due to prosthetic rethrombosis. In patients with mechanical prosthetic valve in mitral valve position and progressive dyspnea, the presence of a variable delay in the opening of the prosthesis is diagnostic of OIDP and requires urgent handling with thrombolysis or surgery.

Clinical and echocardiographic aspects of double-outlet left atrium.

Double outlet left atrium is a very rare complex atrial malformation. We present 3 cases of double outlet left atrium with 2 atrioventricular valves diagnosed by transthoracic and transesophageal echocardiography.

Three-dimensional echocardiography in congenital malformations of the mitral valve.

Three-dimensional echocardiography has proved to be valuable in congenital heart disease by enhancing the evaluation of morphologic abnormalities and increasing the understanding of complex relationships. This study was undertaken to determine how 3-dimensional echocardiography could be best used to study some of the congenital malformations of the mitral valve such as mitral arcade, double orifice mitral valve, accessory mitral tissue, cleft mitral valve, and unicuspid mitral valve. Five patients were studied. Three-dimensional echocardiography was found to be helpful in defining spatial location and extent of deformities.

The impact of right atrial ischemia on inferior myocardial infarction with extension to right ventricle: transesophageal echocardiographic examination.

BACKGROUND: The role of the right atrium in adaptation to the hemodynamic changes produced by extension of myocardial infarction (MI) of the left ventricular inferior wall to the right ventricle is fundamental. HYPOTHESIS: The aim of this study was analyze a group of patients with MI with extension of right chambers, and particularly right atrial alterations, by transesophageal echocardiography and to correlate it with clinical and angiographic variables. METHODS: Thirty patients with right ventricular (RV) MI involving obstruction of the right coronary artery without stenosis of the left coronary artery were included; 18 underwent early reperfusion. Transesophageal echocardiography was performed on all within 5 days of coronary angiography. Follow-up was continued from hospitalization to the present. RESULTS: When patients with right atrial ischemia were compared with those with normal right atrium, the RV wall movement score was significantly greater in the group with right atrial ischemia, severe RV dilatation was more frequent, and association with proximal occlusion of the artery responsible for the MI, as well as absence of right atrial branches and poor collateral circulation, were significant. Hospitalization was more prolonged in this group, and there was a higher incidence of arrhythmias, complete atrioventricular block, and mortality. CONCLUSIONS: Right atrial ischemia associated with RV infarction leads to a higher incidence of complications and higher mortality. Transesophageal echocardiography is a safe, reproducible technique that provides detailed anatomic information about right chambers and aids in the determination of prognosis and therapeutic decisions.

Echocardiographic Diagnosis of Biventricular Thrombi in a Cocaine-Induced Myocardial Infarction.

We present the case of a patient with a biventricular myocardial infarction induced by cocaine and a large left and a smaller right ventricular apical thrombus. Serial multiplane transesophageal echocardiography was used to document the morphological course of the thrombi during anticoagulation therapy over a period of 6 weeks.

Transesophageal Echocardiographic Evidence for Acute Right Atrial Dysfunction.

We describe the clinical course and echocardiographic findings of a 64-year-old man who was hospitalized with an infarction of the inferior myocardial wall of 5 days' evolution and extension to the right ventricle. Transesophageal echocardiography showed biventricular inferior dyssynergia and akinesis of the right atrial wall. One thrombus was visible in the right atrial appendage, and another crossed the foramen ovale and reached the mitral valve. After the patient received anticoagulant agents, transesophageal studies showed the disappearance of atrial thrombi, as well as recuperation of right atrial movement and active participation of atrial contraction in right ventricular filling. The findings of these serial echocardiograms support the existence of ischemic right atrial stunning manifested by wall akinesis that favored slow atrial flow and the formation of thrombi.