Acute aortic syndrome: a new look at an old conundrum.

The term acute aortic syndrome (AAS), coined several years ago, is now widely recognised. In the light of new findings in aortic pathology and in an era when modern imaging techniques are widely available and interventional management of AAS is increasing, some morphological and diagnostic aspects of acute aortic pathology have been examined and the syndrome updated. This article provides a new, comprehensive overview of the pathology, diagnosis, evolution and management of patients with AAS. As acute aortic disease is the most common fatal condition in patients with chest pain, prompt recognition and treatment is of paramount importance.

International experts' practice in the antibiotic therapy of infective endocarditis is not following the guidelines.

OBJECTIVE: The management of infective endocarditis (IE) may differ from international guidelines, even in reference centres. This is probably because most recommendations are not based on hard evidence, so the consensus obtained for the guidelines does not represent actual practices. For this reason, we aimed to evaluate this question in the particular field of antibiotic therapy. METHODS: Thirteen international centres specialized in the management of IE were selected, according to their reputation, clinical results, original research publications and quotations. They were asked to detail their actual practice in terms of IE antibiotic treatment in various bacteriological and clinical situations. They were also asked to declare their IE-related in-hospital mortality for the year 2015. RESULTS: The global compliance with guidelines concerning antibiotic therapy was 58%, revealing the differences between theoretical 'consensus', local recommendations and actual practice. Some conflicts of interest were also probably expressed. The adherence to guidelines was 100% when the protocol was simple, and decreased with the seriousness of the situation (Staphylococus spp. 54%-62%) or in blood-culture-negative endocarditis (0%-15%) that requires adaptation to clinical and epidemiological data. CONCLUSION: Worldwide experts in IE management, although the majority of them were involved and co-signed the guidelines, do not follow international consensus guidelines on the particular point of the use of antibiotics.

Transesophageal echocardiography in right-sided endocarditis.

OBJECTIVES: Our aim was to determine the diagnostic value of transesophageal echocardiography in right-sided endocarditis. BACKGROUND: Recent studies have demonstrated that transesophageal echocardiography is superior to transthoracic echocardiography in the detection of vegetations associated with left-sided endocarditis. Its diagnostic value in right-sided endocarditis has not been established. METHODS: Transthoracic and transesophageal echocardiography were prospectively performed in 48 patients who met specific criteria for the suspicion of right-sided endocarditis. All were intravenous drug abusers. RESULTS: Vegetations were found in 22 of 48 patients by both transthoracic and transesophageal echocardiography. The vegetations were more precisely characterized by transesophageal echocardiography in 14 (63%) of 22 patients. In the remaining 26 patients, no vegetations were found by either transthoracic or transesophageal echocardiography. No statistically significant differences were found between the two techniques in the assessment of tricuspid regurgitation, which was detected in 21 (44%) of 48 patients. CONCLUSIONS: We conclude that transesophageal echocardiography does not improve the diagnostic accuracy of transthoracic echocardiography in the detection of vegetations associated with right-sided endocarditis in intravenous drug abusers. Transesophageal echocardiography may not be indicated as a routine procedure in patients suspected of having right-sided endocarditis.

Penetrating atherosclerotic aortic ulcer: documentation by transesophageal echocardiography.

OBJECTIVES: This study sought to describe the ability of transesophageal echocardiography (TEE) to document the presence of penetrating atherosclerotic aortic ulcers and their complications. BACKGROUND: TEE has greatly enhanced our ability to assess patients with suspected aortic disease. However, the utility of this technique in the diagnosis of penetrating atherosclerotic aortic ulcers is still undefined. METHODS: TEE was performed prospectively in 194 patients to evaluate aortic disease. Twelve patients with the diagnosis of aortic ulcers or their complications were specifically studied. The diagnosis was confirmed by pathologic studies in six patients and by an additional diagnostic technique (angiography, computed tomography or magnetic resonance imaging) in the other six. All 12 patients were hypertensive and presented with chest or back pain; the mean age was 65 years (range 56 to 79). The initial working diagnosis was acute aortic dissection in nine patients. Aortic ulcers were located in the descending thoracic aorta in eight patients, the aortic arch in two and the ascending aorta in two. RESULTS: TEE could detect aortic ulcers or their complications in 10 patients but failed to detect these lesions in the remaining 2 (1 with aortic ulcers in the distal ascending aorta and 1 with aortic ulcers in the aortic arch). In four patients, aortic ulcers were detected as a calcified focal outpouching of the aortic wall and were associated with concomitant aneurysmal dilation of the aorta in two patients and with a small localized intramural hematoma in one. TEE visualized a partially thrombosed pseudoaneurysm complicating an aortic ulcer in the descending thoracic aorta of two patients. Four patients had an aortic ulcer complicated by a "limited aortic dissection" in the descending aorta that could be detected by TEE. Five patients underwent operation, two because of aneurysmal dilation of the aorta and three because of aortic dissection; two patients died of aortic rupture; the remaining five did well (11-month follow-up) without operation. CONCLUSIONS: Aortic ulcers should be included in the differential diagnosis of chest or back pain, especially in elderly hypertensive patients. These ulcers and their complications may be recognized by TEE.

Right ventricular asynergy during dobutamine-atropine echocardiography.

OBJECTIVES: We sought to analyze right ventricular contractility during dobutamine infusion in patients with right coronary artery disease and to elucidate whether the development of right ventricular asynergy aids in characterizing a right coronary artery stenosis. BACKGROUND: Clinical investigations are emphasizing the importance of right ventricular function in patients with coronary artery disease. Thus, prognosis of patients with inferior myocardial infarction is influenced by right ventricular function. This study describes the echocardiographic and electrocardiographic findings during dobutamine-atropine echocardiography in patients with right coronary artery disease. METHODS: We studied 31 patients with isolated right coronary artery disease and no previous myocardial infarction. Six patients with poor acoustic window were excluded (feasibility 80%). The remaining 25 patients underwent dobutamine-atropine echocardiography. A right coronary artery stenosis located before the origin of the right ventricular branches was considered proximal; otherwise, it was considered distal. RESULTS: Right ventricular asynergy during dobutamine-atropine testing developed in 17 patients (sensitivity 68%); 14 had proximal and 3 had distal right coronary artery disease. The following segments were involved: inferior (n = 17), lateral (n = 5) and outflow tract (n = 1). No patient showed anterior asynergy. All 17 patients had left ventricular asynergy as well. Ischemia-free time was 10.7 +/- 6.2 (mean +/- SD) min for the right ventricle and 8.9 +/- 5.2 min for the left ventricle (p < 0.05). Ischemic ST changes were recorded in 15 patients (in standard leads in 14 and in right precordial leads in 8). All patients with right precordial changes showed ST elevation and had right ventricular asynergy (sensitivity and specificity for right ventricular asynergy 47% and 100%, respectively). A control group of 25 patients with no right coronary artery disease (5 with no disease, 15 with left anterior descending and 5 with left circumflex coronary artery disease) underwent dobutamine echocardiography. Right ventricular asynergy developed in two patients with left anterior descending artery stenosis (specificity 92%); in both, the anterior wall was affected. CONCLUSIONS: Echocardiography during dobutamine infusion is a reliable technique for assessing right ventricular dysfunction in patients with right coronary artery disease. Right ventricular contractility can be assessed during dobutamine echocardiography in selected patients.

Eustachian valve endocarditis: Is it worth searching for?

BACKGROUND: Only a few cases of eustachian valve endocarditis have been reported. Whether the eustachian valve is an uncommon site for a vegetation to be attached or whether the disease is missed because a systematic approach to this valve is not routinely performed in the search for vegetations is not known. METHODS: Every patient suspected of having endocarditis undergoes a specific approach, which includes a systematic study of the eustachian valve. In 10 patients with large valves but without signs and symptoms of endocarditis, we identified 2 specific findings: width <3 mm and a regular oscillating movement. A blinded evaluation in the 10 control subjects and 30 patients with right-sided endocarditis, including the 5 with eustachian valve endocarditis, showed an agreement of 97% (39/40). RESULTS: Five of 152 patients with right-sided endocarditis were found to have eustachian valve vegetations (3.3%). Patients were young (age range 22-34 years) and all had predisposing factors (3 intravenous drug abusers, 2 central venous lines), fever, and septic pulmonary embolism. Staphylococcus aureus was cultured in all cases. Tricuspid involvement was found in 4 patients, and only 1 patient had isolated eustachian valve endocarditis. All patients did well with culture-guided antibiotics. CONCLUSIONS: Our results suggest that eustachian valve endocarditis may be more frequent than is believed. Thus a systematic interrogation of the eustachian valve should be included in the echocardiographic examination of a patient suspected of having endocarditis.

Transesophageal echocardiographic monitoring of percutaneous mitral balloon valvulotomy.

This study was designed to evaluate the usefulness of performing transesophageal echocardiography (TEE) during percutaneous mitral balloon valvulotomy (PMBV). TEE was performed in 35 consecutive patients with symptomatic severe mitral stenosis during PMBV (group A). Another group of 27 patients with mitral stenosis who underwent PMBV without TEE was used for comparison (group B). TEE was most helpful in guiding transseptal puncture, aiding in proper positioning of the balloon during the dilatation procedure and enabling early detection of complications. The results show that PMBV when aided by TEE has a tendency to decrease the frequency of significant mitral regurgitation without compromising the final mitral valve area. TEE decreased the x-ray exposure time and was well-tolerated. Thus, TEE provides information that makes this interventional catheterization procedure safer and easier to perform.

Clinical, anatomic, and echocardiographic characteristics of aneurysms of the mitral valve.

This study describes the clinical, anatomic, echocardiographic, and Doppler features of 13 patients with mitral valve aneurysms. Eleven patients had definitive criteria for infective endocarditis. Transesophageal echocardiography was superior to conventional echocardiography in detecting and assessing aneurysms. Patients with heart failure required surgery. Echocardiographic detection of this lesion should not be, by itself, an immediate surgical indication.

Supravalvular aortic stenosis in aortic dissection.

Supravalvular aortic stenosis is a rare complication of aortic dissection. We report on echocardiographic and magnetic resonance observations in 2 cases of aortic dissection with false lumen thrombosis of the ascending aorta and severe narrowing of the true lumen.

Clinical course, microbiologic profile, and diagnosis of periannular complications in prosthetic valve endocarditis.

Whether periannular extension of prosthetic valve endocarditis (abscesses, pseudoaneurysms, fistulas) is related to the etiologic agent, the clinical course and the prognosis is still unknown. Likewise, transesophageal echocardiographic accuracy in detecting periannular complications in prosthetic recipients remains unsettled. We retrospectively analyzed data from 87 patients with anatomically proven prosthetic valve endocarditis who underwent a transesophageal echocardiographic examination. Periannular complications (30 abscesses, 18 pseudoaneurysms, 8 fistulas; 8 with >1) were found in 46 patients; results were compared with the remaining 41 without complications. Transesophageal echocardiography correctly identified 27 abscesses (90%) and all pseudoaneurysms and fistulas. One diagnosis of pseudoaneurysm by echocardiography was not found at surgery. No statistical differences were found regarding age, sex, type of prosthesis (mechanical vs biologic), and etiologic agent. Periannular complications were more frequent in aortic location (70% vs 20% in mitral position; p <0.001) and in early (within 6 months after surgery) endocarditis (63% vs 38% in late endocarditis; p = 0.04). The same percentage of patients from both groups underwent surgery (98% with and 90% without complications). At discharge, 62% and 67% of patients were alive, respectively. Thus, periannular complications in prosthetic valve endocarditis are more frequent in aortic location and within 6 months after surgery. Neither the type of prosthesis nor the etiologic agent are related to the presence of periannular complications. Short-term prognosis in patients who underwent surgery is not affected by the presence of periannular complications.

Dipyridamole and dobutamine-atropine stress echocardiography in the diagnosis of coronary artery disease. Comparison with exercise stress test, analysis of agreement, and impact of antianginal treatment.

STUDY OBJECTIVES: To compare the usefulness of dipyridamole echocardiography, dobutamine-atropine echocardiography, and exercise stress testing in the diagnosis of coronary artery disease and to analyze the agreement among the tests. DESIGN: Performance of these three tests in random order on a consecutive cohort of patients. SETTING: A tertiary care and university center. PATIENTS: One hundred two consecutive patients with chest pain and no history of coronary artery disease. INTERVENTIONS: Dipyridamole echocardiography, dobutamine-atropine echocardiography, exercise stress testing, and coronary angiography. MEASUREMENTS AND RESULTS: Dobutamine-atropine test was positive in 49 (77%) of 63 patients with coronary artery disease, dipyridamole test in 49 (77%), and exercise stress test in 44 (68%; p = NS). Both echocardiographic tests showed an overall specificity (dipyridamole, 97%; dobutamine, 95%) higher than exercise stress test (79%; p < 0.05). Sensitivity of dipyridamole testing decreased from 93 to 61% (p = 0.002) if patients were receiving antianginal treatment but sensitivity of dobutamine-atropine testing was not affected (77% in patients receiving and not receiving treatment). When results were considered as positive-negative, agreement between dipyridamole and dobutamine-atropine echocardiography was 85% (kappa = 0.70). With regards to regional analysis, concordance was good (93% for segments, kappa = 0.76; and 95% for coronary arteries, kappa = 0.92). Major complications were more frequent during dobutamine-atropine (n = 7) than during dipyridamole infusion (n = 2) (p = 0.06). CONCLUSIONS: Dobutamine-atropine and dipyridamole echocardiography have a similar sensitivity and a higher specificity than that obtained by exercise ECG for the diagnosis of coronary artery disease. Similar information is obtained with dipyridamole and dobutamine-atropine echocardiography. It is our thought that pharmacologic stress echocardiography should be used as a first-step test to rule out coronary artery disease in patients not capable of exercising.

Selection of the optimal stress test for the diagnosis of coronary artery disease.

OBJECTIVE: To compare the value and limitations of exercise testing, dipyridamole echocardiography, dobutamine-atropine echocardiography, and MIBI-SPECT (technetium-99m methoxyisobutyl nitrile single photon emission computed tomography) during dobutamine infusion in the diagnosis of coronary artery disease. DESIGN: The performance of these four tests was assessed in random order on a consecutive cohort of patients. The presence or absence of coronary artery disease was confirmed by coronary angiography. SETTING: Two tertiary care and university centres. PATIENTS: 102 consecutive patients with chest pain and no previous history of coronary artery disease. Ten patients with left bundle branch block were excluded for further analysis of exercise testing and scintigraphy results. RESULTS: MIBI-SPECT was the most sensitive (87%) but the least specific test (70%). Exercise stress testing had a sensitivity of 66%, which increased to 80% when patients with inconclusive results were excluded. Dipyridamole and dobutamine echocardiography had similar sensitivity (81%, 78%) and specificity (94%, 88%). All four tests had similar accuracy and positive and negative predictive values. Agreement between the echocardiographic techniques was excellent (detection of coronary artery disease 87%, kappa = 0.72; regional analysis 93%, kappa = 0.72; diagnosis of the "culprit" vessel 95%, kappa = 0.92), and it was good between echocardiographic techniques and MIBI-SPECT (diagnosis of the culprit vessel 90%, kappa = 0.84 with dobutamine and 92%, kappa = 0.85 with dipyridamole). CONCLUSIONS: Exercise stress testing has a sensitivity comparable to other tests in patients capable of exercising and with no basal electrical abnormalities. The greatest sensitivity is offered by MIBI-SPECT and the greatest specificity is obtained with stress echocardiography. Redundant information is obtained with dipyridamole echocardiography, dobutamine echocardiography, and MIBI-SPECT.

Atherosclerotic aortic rupture: documentation by transesophageal echocardiography.

We report a case of a 77-year-old woman who had a rupture of the descending thoracic aorta as a complication of an atherosclerotic aortic plaque. Transesophageal echocardiography enabled the diagnosis of aortic rupture and was very useful in the patient's surgical management.

Aortic intramural hematoma during coronary angioplasty: insights into the pathogenesis of intramedial hemorrhage.

We report a case of a 74-year-old woman who had an aortic intramural hematoma as a complication of percutaneous coronary angioplasty. Transesophageal echocardiography enabled the diagnosis of aortic intramural hematoma and was very useful in the patient's management and follow-up.

Primary mycotic aneurysm of the ascending aorta diagnosed by transesophageal echocardiography.

Primary mycotic aneurysms are rare, and they can be difficult to diagnose before rupture. Early diagnosis is the cornerstone to effective management. Preoperative diagnosis has traditionally involved angiography and computed tomography. We report a case of Staphylococcus aureus aortitis with an aortic wall abscess and posterior pseudoaneurysm formation involving the ascending aorta in which transesophageal echocardiography was fundamental in diagnosis and patient management.

Retrograde atrial kick in acute aortic regurgitation. Study of mitral and pulmonary venous flow velocities by transthoracic and transesophageal echocardiography.

BACKGROUND AND HYPOTHESIS: The purpose of this study was the comprehensive evaluation of the changes in pulmonary venous and mitral flow velocities of patients with acute and chronic severe aortic regurgitation. Transmitral flow velocities obtained with pulsed-wave Doppler echocardiography have been used to provide information on left ventricular (LV) filling and diastolic function. Pulmonary venous flow tracings are an important adjunct to LV inflow pattern in assessing LV diastolic function. METHODS: Fourteen patients with severe aortic regurgitation (8 chronic and 6 acute) and in sinus rhythm were examined by transthoracic and transesophageal pulsed Doppler echocardiography. Mitral and pulmonary flow velocities were recorded and compared. All patients had ejection fractions > 40%. RESULTS: Early mitral flow peak velocity was higher in patients with acute regurgitation (p < 0.001). The mitral A wave was absent in five patients with acute regurgitation. In contrast, a prominent reverse atrial pulmonary systolic wave AR was demonstrated in these patients. Peak diastolic velocity of the pulmonary venous flow was greater in patients with acute aortic regurgitation (0.76 +/- 0.13) than in patients with chronic aortic regurgitation (0.40 +/- 0.09) (p < 0.001). Peak systolic velocity did not differ significantly between the two groups. The systolic fraction of pulmonary venous flow in patients with acute aortic regurgitation was lower (0.43 +/- 0.05) than that of patients with chronic regurgitation (0.63 +/- 0.1) (p < 0.01). All patients with acute aortic regurgitation had an S/D ratio < 1, while those with chronic regurgitation had an S/D > 1 (p < 0.001) and an E/A < 1. CONCLUSION: Patients with severe acute aortic regurgitation showed a retrograde atrial kick (absence of transmitral A wave with prominent pulmonary AR wave). These patients had an S/D ratio < 1 (restrictive Doppler pattern). Patients with chronic aortic regurgitation exhibited a Doppler pattern of abnormal LV relaxation (E/A < 1, S/D > 1).

[Aortic intramural hematoma and penetrating aortic ulcer]. / Hematoma intramural aórtico y úlcera penetrante aórtica.

Two poor-defined acute aortic syndromes (intramural aortic hematoma and penetrating aortic ulcer) that must be distinguished from the classic dissection are reviewed in this article. Based on the literature and our own experience we describe the clinical characteristics, diagnostic aspects and treatment.

[Echocardiography and aortic dissection]. / Ecocardiografía y disección aórtica.

Echocardiography is the technique most used in the diagnosis of aortic dissection. In this article the echocardiographic signs of aortic dissection are described. The following issues regarding the usefulness of echocardiography in aortic dissection are reviewed as well: detection of entry site, distinction between false and true lumen, assessment of aortic regurgitation, ventricular function, aortic branches involvement, pericardial effusion and follow-up.

[Aortic dissection: clinical evaluation, comparison of diagnostic techniques and treatment election]. / Disección de aorta: evaluación clínica, comparación de las técnicas diagnósticas y elección del tratamiento.

Aortic dissection is a life-threatening disease with a high mortality in the first hours. The diagnosis must be established as promptly as possible and a high index of suspicion is needed. Then, a thorough evaluation of the patient is necessary for an adequate clinical decision making. In this article, the definition, classification, predisposing factors, clinical signs and symptoms, diagnostic methods and treatment are reviewed.

[Isolated ventricular diverticulum in asymptomatic male]. / Divertículo ventricular aislado en varón asintomático.

Ventricular diverticulum are small outpouchings, in the cardiac wall, which are mostly described as a part of malformation syndromes. This finding is infrequent in asymptomatic patients with no pathology in the thoraco abdominal line. The case we present shows a diverticulum in the cardiac apex in a male patient with no cardiological clinic manifestations and with an abnormal electrocardiogram. At present, magnetic resonance is the best diagnostic test, for this kind of malformation, and is also the most reliable in the follow-up of these patients.