Clinical significance of tissue Doppler imaging in chronic Chagas disease.

INTRODUCTION: Chagas disease (ChD) is one of the main parasitic diseases in Latin-America. Its heart involvement is the most important cause of death. The aim of this study is to evaluate if Doppler Tissue Imaging (DTI) may have a predictive value for later events in subjects with chronic ChD. METHODS: we analyses DTI variables of 543 patients with chronic ChD for the evaluation of predicting factors of events. Major adverse cardiovascular events (MACE) were considered as stroke, heart failure resistant to treatment, sustained ventricular tachycardia, implantable cardioverter-defibrillator, sudden death, and cardiovascular death. The following findings were also included in total evens: heart failure, bradycardia, ventricular arrhythmia, new conduction system abnormalities, and new echocardiographic abnormalities. Multivariate analysis with logistic regression was used in order to assess the Doppler and DTI parameters predicting events. Variables with a P-value ≤ .5 in the univariate analysis were included in the multivariate analysis. RESULTS: In patients with chronic ChD, the analysis of DTI parameters showed that S' wave and E' wave of the lateral wall of the left ventricle were significant predictors of MACE (OR: 0.83; 95% CI: 0.71-0.96; P-value: .015 and OR: 0.80; 95% CI: 0.66-0.98; P-value: .031, respectively). CONCLUSIONS: This study found that patients with chronic ChD who had events showed significantly lower parameters in the DTI. What is more, this study showed that even lower DTI parameters are significant predictors of events.

Mechanical dispersion in Fabry disease assessed with speckle tracking echocardiography.

BACKGROUND: Fabry disease (FD) is a rare X-linked storage disorder caused by deficiency of the lysosomal enzyme α-galactosidase A, and it typically causes multiorgan dysfunction. The main cause of death is heart disease resulting from left ventricular (LV) diastolic dysfunction, LV systolic dysfunction, severe LV hypertrophy (LVH), and sudden death. In several cardiac disorders, LV systolic dysfunction and ventricular arrhythmias are associated with mechanical dispersion (MD). MD has until now not been studied in patients with FD. OBJECTIVE: To investigate the prevalence of MD in patients with FD. METHODS: Complete echocardiographic data and speckle tracking echocardiographic data were collected. MD is an index of inter-segmental discoordination of contraction and is defined as the standard deviation (SD) of the time-to-peak longitudinal negative strain in 17 LV segments with a value >49 milliseconds. Patients with FD were divided into the following 2 groups: group I (patients with FD but no LVH, n = 64) and group II (patients with FD and LVH, n = 25). These groups were compared with a group of healthy subjects (group III, n = 50). Parametric variables were expressed as mean ± SD, and nonparametric variables were expressed as median and inter-quartile range. A P value <.05 was considered significant. RESULTS: A total of 113 patients with FD were included in this study. Of these, 24 (21%) were excluded because of poor imaging quality or presence of comorbidities, and the final study population consisted of 89 patients (mean age of 33.5 ± 14.5 years, 64% female). Group II patients were older than group I patients (46 ± 13 years vs 27 ± 11 years, P < .0001). There was no difference in LV ejection fraction between the 3 groups. There was also no difference in MD between groups I and III (32.4 ms [26-39] vs 32 ms [26-39]). In group II, the MD in 19 patients (76%) was 56 ms (39-80). CONCLUSIONS: To the best of our knowledge, this is the first study to assess the prevalence of MD in patients with FD. MD was observed in 76% of patients with FD and LVH. The use of MD in strain echocardiography may be beneficial in the assessment of patients with FD who develop heart failure.

Comparison of left atrial size and function in hypertrophic cardiomyopathy and in Fabry disease with left ventricular hypertrophy.

BACKGROUND: Fabry disease (FD) and hypertrophic cardiomyopathy (HCM) are two diseases with a different pathophysiology, both cause left ventricular hypertrophy (LVH) and myocardial fibrosis. Although remodeling and systolic dysfunction of the left atrium (LA) are associated with atrial fibrillation and stroke in HCM, changes in the size and function of the LA have not been well studied in FD with LVH. METHODS: The following groups were studied prospectively, and their respective findings compared: 19 patients with non-obstructive HCM (Group I), 20 patients with a diagnosis of Fabry cardiomyopathy (Group II), and 20 normal subjects matched for sex and age (Group III). Left ventricular mass index was measured using Devereux' formula, left atrial volume with Simpson's biplane method and left atrial mechanical function, including strain and strain rate, was measured using the speckle tracking technique. Strain and strain rate of the reservoir were measured during the three phases: reservoir (SR S), passive conduit (SR E) and atrial contraction (SR A). RESULTS: Patients with HCM had a larger left atrial volume than patients with FD (48.16 ± 14.3 mL/m2 vs 38.9 ± 14.9 mL/m2 respectively, P < .001), but in both disorders there was a severe decrease in left atrial function: reservoir strain in the apical four-chamber view: 17.47% in HCM vs 22.5% in FD, P = .24), strain rate in the apical chamber view: SR A: -0.80/seconds in HCM vs -1.04/seconds in FD (P = .88), SR S: 0.69/seconds in HCM vs 0.93 in FD (P = .12), SR E: -0.80 seconds in HCM vs -0.97/seconds in FD (P = .18). CONCLUSIONS: In this echocardiographic study we used speckle tracking to assess left atrial mechanical function and showed that FD is associated to an atrial cardiomyopathy, affecting the three phasic functions of the LA. Although in patients with HCM left atrial volume is larger than in patients with FD, both disorders exhibit severe decrease in left atrial function. These findings should be considered, given the potentially serious complications that can occur with the two diseases.

Bone cement cardiac and pulmonary embolism.

This case describes a complication of bone cement use. A 65-year-old male patient with back spine trauma caused by a fall, underwent a percutaneous vertebroplasty. Five years later, he consulted for palpitations, and the electrocardiogram showed supraventricular arrhythmia. A transthoracic two-dimensional echocardiography showed a hyperechogenic linear structure of 7 cm length, running from the lateral wall of the right ventricle to the right atrium through the tricuspid valve. This foreign body, which was suspicious for bone cement embolism, appeared rigid and was attached at the lateral wall of the right ventricle, with its proximal end free in the right atrium. The tip of the cement embolus was inside the myocardium of the lateral wall of the right ventricle, with risk of cardiac perforation. A fluoroscopy was performed, which confirmed the presence of cement within the right heart, with great mobility in each cardiac cycle. Chest computed tomography (CT) and multidetector CT three-dimensional reconstruction confirmed the presence of cement within the right heart. Chest CT showed two pulmonary embolisms, one in the right upper lobe and one in the left lower pulmonary lobe. This case emphasizes the risk of late clinical manifestations of cardiac and pulmonary embolism of methylmethacrylate after percutaneous vertebroplasty, suggesting that the risk of such embolism might be underestimated. We propose routine chest radiography, two-dimensional echocardiography, and chest CT after every percutaneous vertebroplasty, to detect asymptomatic cardiac and pulmonary embolism and thereby prevent serious delayed cardiopulmonary failures.

Severe mitral regurgitation after radiotherapy.

We present the case of a 69-year-old patient with a history of gynecological neoplasia and a pulmonary metastasis, who in 1996 underwent chemotherapy and mediastinal radiotherapy followed by cancer remission. Ten years later she presented with heart failure and her Doppler echocardiogram showed severe mitral regurgitation with pulmonary hypertension. In 2011, she underwent a mitral valve replacement with a biological prosthesis and the pathology exam revealed valve damage consistent with radiotherapy-induced changes. This unusual mechanism of mitral regurgitation can be demonstrated clearly by echocardiography and should be disseminated among cardiology physicians and in patients who have survived for long periods after radiotherapy, it is important to remember that cardiac complications may indeed occur, and the treating physician is responsible for detecting them.

Cardiovascular adaptive response to training in elite athletes. Comparison between endurance and non-endurance athletes.

INTRODUCTION: The different structural modifications that have been described in the heart of the high-performance athlete depend on factors such as age, gender, type of sport, and the intensity and time dedicated to training. OBJECTIVES: Evaluation of elite athletes through echocardiography for the description of cardiac structure and function, and the comparison between athletes with cardiorespiratory endurance and the rest of the athletes. METHODS: We performed the echocardiographic examination in 224 elite athletes, 96 women and 128 men aged 15 to 38 years (21.7 ± 5.3 years) and they were divided into 2 groups: "Endurance Group" (cardiorespiratory endurance) and "Non-Endurance Group" which included the rest of the sports. Univariate comparison between the two groups was performed by measuring 14 echocardiographic variables. RESULTS: In men, statistically significant higher values were identified in the endurance group for interventricular septum, left ventricular posterior wall, relative wall thickness (RWT), left ventricular mass index and left atrial dimension. In women, the endurance group had significantly lower heart rate values, and significantly higher left ventricular diastolic dimension with normal RWT. CONCLUSIONS: Most of the echocardiographic variables showed higher sample means in the endurance athletes. In the subgroup of men from the Endurance Group, eccentric hypertrophy prevailed with a greater increase in wall thickness, as well as in the diameter of the left atrium, while in women the variables indicated eccentric hypertrophy at the expense of an increase in left ventricle diameter, without increased wall thickness.

Introducción: Las diferentes modificaciones estructurales que han sido descritas en el corazón del deportista de alto rendimiento dependen de factores como la edad, el género, el tipo de deporte, la intensidad y el tiempo dedicados al entrenamiento. OBJETIVOS: Evaluación de atletas de élite por medio de la ecocardiografía para la descripción de la estructura y la función cardíacas, y la comparación entre deportistas de resistencia cardiorrespiratoria y el resto de los deportistas. Métodos: Realizamos el examen ecocardiográfico en 224 deportistas de elite, 96 mujeres y 128 varones con edades de 15 a 38 años (21.7 ± 5.3 años) y se dividieron en 2 grupos: "Grupo de Resistencia" (resistencia cardiorrespiratoria) y "Grupo de no Resistencia" el cual incluyó al resto de los deportes. Se realizó la comparación univariada de 14 variables ecocardiográficas entre los dos grupos. RESULTADOS: En los hombres se identificaron valores estadísticamente significativos más altos en el grupo de resistencia para septum interventricular, pared posterior, grosor parietal relativo, índice de masa del ventrículo izquierdo y aurícula izquierda. En las mujeres, el grupo de resistencia tuvo valores de frecuencia cardíaca más bajos con diámetro diastólico e índice de masa del ventrículo izquierdo significativamente mayores. CONCLUSIONES: La mayoría de las variables ecocardiográficas mostró valores mayores en los atletas de resistencia. En los hombres del Grupo de Resistencia, predominó la hipertrofia excéntrica con mayor incremento en el grosor parietal y del diámetro de la aurícula izquierda, mientras que en las mujeres las variables indicaron hipertrofia excéntrica a expensas de un aumento del diámetro del ventrículo izquierdo, sin incremento del grosor parietal.

Esophageal carcinoma and transthoracic echocardiography.

We report a rare case of a patient with esophageal carcinoma diagnosed using transthoracic echocardiography. This examination proved to be useful in the identification of a paracardiac mediastinal mass. Images of the esophageal carcinoma, of the stent in the esophagus, and the bubbles inside the stent generated with the ingestion of a carbonated beverage, have not been previously published. Therefore, we believe our findings may be useful to other echocardiographers.

Assessment of coronary flow with transthoracic color Doppler echocardiography in patients with hypertrophic cardiomyopathy.

BACKGROUND: Recent advances in echocardiography have allowed assessment of flow velocity in the epicardial coronary arteries of patients with ischemic heart disease, using transthoracic color Doppler echocardiography (TTDE). However, few data are available regarding coronary blood flow in patients with hypertrophic cardiomyopathy (HCM). OBJECTIVE: To assess the epicardial coronary arteries of patients with HCM. MATERIAL AND METHODS: A group of 25 patients with HCM was assessed prospectively (mean age 57 ± 21 years, 11 male) using TTDE; flow velocities in the epicardial coronary arteries were measured and compared with those obtained in 10 age- and gender-matched controls. Analysis of the diastolic spectral waveform included flow velocity integral (VTI), peak velocity, deceleration time, and deceleration slope measurements, while systolic waveform analysis included peak flow measurement and morphology assessment (positive, absent or negative). An analysis of variance (ANOVA) test was used for multiple comparisons for variables with a normal distribution, and a Kruskal-Wallis test was used for variables with non-Gaussian distribution. RESULTS: Patients with HCM exhibited an increase in diastolic flow velocity with a rapid deceleration slope and a systolic slope which was decreased, absent or reversed, compared to normal subjects. On linear regression analysis there was no correlation with the type of hypertrophy or magnitude of the intraventricular pressure gradient in patients with obstructive HCM. CONCLUSION: In patients with HCM, noninvasive assessment with TTDE revealed abnormal findings in the distal flow of the epicardial coronary arteries, very similar to those seen in the no-reflow phenomenon. These findings were independent of the type of hypertrophy and magnitude of the intraventricular pressure gradient in patients with obstructive HCM.

Two-dimensional speckle tracking echocardiography for early detection of myocardial damage in young patients with Fabry disease.

Fabry disease (FD) is characterized by left ventricular hypertrophy (LVH). Conventional echocardiography is not sensitive enough to perform the preclinical diagnosis To assess whether longitudinal myocardial strain of the left ventricle (LV), using speckle tracking, is useful to detect early myocardial involvement in FD. Forty-four patients with FD who were diagnosed with genetic testing were prospectively included and were compared to a sex-matched control group. They were divided into three groups: 22 with LVH (Group I), 22 without LVH (Group II), and 22 healthy volunteers (Group III). LV longitudinal strain was measured from the apical views. An ANOVA test was used for multiple comparisons for variables with a normal distribution, and a Kruskal-Wallis test was used for variables with non-Gaussian distribution. Longitudinal LV strain was different in the three groups: it was ≥-15% in at least one segment in all Group I patients, in 50% of patients of Group II and in no patient of Group III. Seventy percent of the segments with abnormal strain in Group II were located in the basal regions (32/46). These findings show that the presence of at least one strain value ≥-15% demonstrates subclinical myocardial dysfunction in patients with preclinical FD. Longitudinal myocardial LV strain measured with speckle tracking is a useful tool to detect early myocardial involvement in young patients with FD. This information allows the detection and treatment of myocardial dysfunction at an early stage, which is of high clinical importance.

[Primary pericardial synovial sarcoma]. / Sarcoma sinovial primario de pericardio.

Primary pericardial synovial sarcoma is an extraordinarily very rare tumor with a poor prognosis, and little is known about its therapeutic management. We describe the case of a 51-year-old woman patient who underwent incomplete surgical resection, chemotherapy, and radiotherapy. To the best of our knowledge, no primary pericardial synovial sarcoma has been described which, after surgery, remains asymptomatic for 5 years, and until a control CT scan detects cardiac metastases that compromised the lumen of the right cavities and with chemotherapy, echocardiography demonstrated complete resolution of cardiac metastases.

El sarcoma sinovial primario del pericardio es un tumor muy raro y de mal pronóstico y se sabe poco en cuanto al manejo terapéutico. Presentamos el caso de una paciente de 51 años a quien se le realizó resección quirúrgica incompleta, quimioterapia y radioterapia. Hasta donde sabemos, este es el primer caso de un sarcoma sinovial primario de pericardio que luego de operado se mantuvo asintomático durante 5 años hasta que en una TAC de control se le detectaron metástasis cardiacas que comprometían las cavidades derechas y con quimioterapia, la ecocardiografía demostró la resolución completa de las mismas.

Myocardial perfusion SPECT in the diagnosis of apical hypertrophic cardiomyopathy.

BACKGROUND: Apical hypertrophy cardiomyopathy (ACM) is a rare condition characterized by asymmetric myocardial hypertrophy of the apex of the left ventricle. When two-dimensional echocardiography is limited by a poor acoustic window, patients are often referred for MRI. Our hypothesis is that a cheaper and more widely available diagnostic modality like myocardial perfusion single photon emission computed tomography (SPECT) may be helpful in the diagnosis of ACM. OBJECTIVE: The purpose of this prospective study was to define the characteristics of rest and stress SPECT studies in patients with known ACM, and whether SPECT may be helpful in the diagnosis of ACM. METHODS: Adult patients with ACM were enrolled in the study. Diagnosis was made with 2-D echo. A rest and exercise or dipyridamole stress SPECT study was performed in all patients with Tc-99m sestamibi. RESULTS: We enrolled 20 patients (mean age 60 +/- 16 years), 9 were female, with ACM. SPECT at rest revealed in 15 patients (75%) an increased apical tracer uptake, a spade-like deformity of the left ventricular chamber, and the "Solar Polar" map pattern consistent with ACM. The sensitivity, specificity, positive predictive value, and negative predictive value of SPECT for detecting ACM were 75%, 100%, 100%, and 80%, respectively. CONCLUSION: Three-fourths of adult patients with ACM showed, on myocardial perfusion SPECT, characteristic findings which were not seen in age-matched control subjects, such as a significant increased apical tracer uptake, a spade-like deformity of the left ventricle, and the "Solar Polar" map. Nuclear physicians should be aware of these SPECT findings because many ACM patients may first end up in the nuclear labs due to their markedly abnormal ECG for exclusion of obstructive coronary artery disease.

Impaired myocardial function in hypertrophic cardiomyopathy.

BACKGROUND: Tissue Doppler imaging (TDI) parameters of peak myocardial velocities (S', E', and A') has been employed to assess the regional left ventricular myocardial function. The global function index (GFI) derived from TDI has been recently employed to distinguish the different etiologies of left ventricular hypertrophy. OBJECTIVE: To analyze whether the GFI or individual TDI parameters of peak myocardial velocities (S', E', and A') allows detecting different degrees of regional myocardial dysfunction in the most frequent forms of hypertrophic cardiomyopathy (HCM). METHODS: GFI = (E/E')/S' (where E is the peak transmitral flow velocity, E' is the early diastolic myocardial velocity, and S' is the peak systolic myocardial velocity) and TDI peak myocardial velocities was measured in the septal and lateral mitral annulus in 101 patients with HCM (mean age 47.5 +/- 14 years, 58 women) and in age-matched group of 30 healthy controls (mean age 46 +/- 6 years, 16 women). RESULTS: Forty-five patients had nonobstructive asymmetric septal HCM, 20 patients had a subaortic gradient >or= 30 mm Hg, 21 p. had apical HCM, and 15 p. had other forms of HCM (midventricular, symmetric, and biventricular). All patients with HCM exhibited a decrease in early diastolic (E') and systolic (S') myocardial velocities, both in the lateral and septal-mitral annulus border, but more pronounced in septal-mitral annulus. Septal GFI was higher in HCM patients than in healthy subjects (1.8 (1.1-2.5) and (0.57 (0.31-0.92), respectively, P < 0.001), but no differences were seen when different forms of HCM were compared. CONCLUSIONS: In a selected population of patients with HCM and a preserved left ventricular(LV) systolic function, GFI and individual TDI parameters of peak velocity (S', E', and A') and E/E' ratio were similar in different forms of HCM, indicating that in all patients with HCM there is regional systolic and diastolic myocardial dysfunction, regardless of the location of hypertrophy.

Retrieval of a leaflet escaped in a Tri-technologies bileaflet mechanical prosthetic valve.

The escape of the prosthetic heart valve disc is one of the causes of prosthetic dysfunction that requires emergency surgery. The removal of the embolized disc should be carried out because of the risk of a progressive extrusion on the aortic wall. Several imaging techniques can be used for the detection of the missing disc localization. In this report we describe a 32-year-old man who underwent mitral valve replacement with a Tri-technologies bileaflet valve three years ago, and was admitted in cardiogenic shock. Transesophageal echocardiography showed acute-onset massive mitral regurgitation. The patient underwent emergency replacement of the prosthetic valve. Only one of the two leaflets remained in the removed prosthetic valve. The missing leaflet could not be found within the cardiac cavity. The abdominal fluoroscopic study and plain radiography were unable to detect the escaped leaflet. The abdominal computed tomography scan and the ultrasound showed the escaped leaflet in the terminal portion of the aortic bifurcation. To retrieve the embolized disc laparotomy and aortotomy were performed three months later. The escaped leaflet shows a fracture of one of the pivot systems caused by structural failure. This kind of failure mode is usually the result of high stress concentration.

Valve replacement with bileaflet HP-Biplus mechanical prostheses versus standard prostheses: long-term results.

BACKGROUND AND AIM OF THE STUDY: At present, no reports are available regarding the hemodynamic assessment and survival of patients undergoing valve replacement with HP-Biplus prostheses. Hence, the present study was designed to acquire this information. The aim was to assess: (i) any potential hemodynamic differences between the HP-Biplus prosthesis and the 'standard' bileaflet mechanical valves (SJM, ATS, Sorin Bicarbon and CarboMedics); and (ii) the incidence of postoperative complications and long-term mortality. METHODS: The data from 242 patients (139 males, 103 females; mean age 58.4 +/- 14.0 years) who survived mitral or aortic valve surgery with mechanical bileaflet standard prostheses (SJM, ATS, Sorin Bicarbon or CarboMedics), between January 1985 and December 2005, were analyzed retrospectively. Evaluations were conducted consecutively with Doppler echocardiography, and compared with 35 patients (20 males, 15 females; mean age 52.2 +/- 12.8 years) who received an HP-Biplus prosthesis and underwent surgery between January 2000 and December 2005. RESULTS: At seven years after surgery, actuarial survival was 40% for the HP-Biplus prosthesis and 84% for the 'standard' prostheses (p < 0.0001). The HP-Biplus prostheses had a higher rate of reoperations for aortic valves (15.2% versus 1.7%; p < 0.003, OR 10.2), a higher rate of prosthesis dysfunction (62.9% versus 7.8%; p < 0.00001, OR 25), and a higher rate of total events (72% versus 21.8%; p < 0.0001, OR 11). CONCLUSION: The present study was the first to compare long-term results of the HP-Biplus prostheses with those obtained with 'standard' mechanical prostheses. Valve replacement with standard prostheses was shown to carry low morbidity and mortality (21.8%), whereas the HP-Biplus prosthesis showed high morbidity and mortality (92%). The data acquired may be very important when selecting prostheses with better hemodynamic characteristics, and show that the HP-Biplus prosthesis, in the authors' opinion, is not suitable for clinical use.

Left and right atrial function after percutaneous mitral valvuloplasty in mitral stenosis and sinus rhythm.

BACKGROUND AND AIM OF THE STUDY: Percutaneous mitral valvuloplasty (PMV) is an effective method for treating patients with severe mitral stenosis. The study aim was to compare left and right atrial appendage functions before and after PMV. METHODS: Twenty-five patients (23 women, two men; mean age 38 +/- 9 years; range: 21-57 years) with severe mitral stenosis and sinus rhythm who underwent PMV were included in the study. Transesophageal echocardiography (TEE) was performed before and at six months after PMV, to evaluate the intensity of spontaneous echo contrast (SEC), left atrial appendage (LAA) dimensions and function, and right atrial appendage (RAA) function. RESULTS: After PMV, the SEC (at TEE) was decreased in all patients, while increases were observed in the contraction and relaxation velocity flows of the LAA (pre-PMV 18 +/- 5 cm/s; post-PMV 24 +/- 9 cm/s; p < 0.001 and pre-PMV 25.5 +/- 10.2 cm/s; post-PMV 32.9 +/- 12.6 cm/s; p < 0.006, respectively). The tissue myocardial velocities were also increased in the LAA (pre-PMV 6.92 +/- 3.77 cm/s; post-PMV 11.16 +/- 6.61 cm/s; p < 0.002) and RAA (pre-PMV 16.2 +/- 3.7 cm/s; post-PMV 19.1 +/- 4.1 cm/s; p < 0.001). CONCLUSION: In patients with mitral stenosis and sinus rhythm, improvements were noted in the left atrial, LAA and RAA systolic functions after PMV. This suggests that the relief of mitral stenosis may not only confer hemodynamic benefits to improve symptoms but also have a favorable influence on future thromboembolic complications. Thus, an early intervention might benefit patients with sinus rhythm by preventing the development of atrial fibrillation and systemic and pulmonary embolism.

Absence of myocardial dysfunction during cold pressor stress echocardiography in patients with endothelial dysfunction.

BACKGROUND: Several methods are available for the assessment of coronary endothelial function, but there are no reports to date regarding the usefulness of cold pressor stress echocardiography (CPSE). OBJECTIVE: To assess regional systolic and diastolic left ventricular function using CPSE in patients with endothelial dysfunction. METHODS: We studied 24 patients, of whom 10 were men, aged 27 to 68 years, who had coronary risk factors and a normal exercise MP-SPECT test. They were compared with 10 normal subjects (6 men), aged 21 to 44 years. All patients underwent a CPSE. RESULTS: The cold pressor-MP-SPECT revealed myocardial ischemia in 10 patients (Group I) and was normal in 14 patients (Group II). All normal subjects (Group III) had normal cold pressor-MP-SPECT. The cold pressor test caused a significant increase in systolic BP in the three groups (baseline 117 +/- 17 mmHg vs. postcold test 137 +/- 16 mmHg, P < 0.05), without changes in heart rate, PR interval, or the corrected QT interval. During the CPSE, no patient developed WMA in 2D echo or changes in regional systolic or diastolic LV function in the pulsed Doppler tissue imaging. CONCLUSIONS: In patients with endothelial dysfunction and no known coronary artery disease, the ischemic response to the cold pressor-MP-SPECT is not accompanied by WMA or changes in regional systolic or diastolic LV function during CPSE. Such negative findings indicate that the amount of ischemia that occurs secondarily to endothelial dysfunction does not involve sufficient myocardial mass to cause contractile dysfunction.

Sarcoma sinovial primario de pericardio / Primary pericardial synovial sarcoma

Resumen El sarcoma sinovial primario del pericardio es un tumor muy raro y de mal pronóstico y se sabe poco en cuanto al manejo terapéutico. Presentamos el caso de una paciente de 51 años a quien se le realizó resección quirúrgica incompleta, quimioterapia y radioterapia. Hasta donde sabemos, este es el primer caso de un sarcoma sinovial primario de pericardio que luego de operado se mantuvo asintomático durante 5 años hasta que en una TAC de control se le detectaron metástasis cardiacas que comprometían las cavidades derechas y con quimioterapia, la ecocardiografía demostró la reso lución completa de las mismas.

Abstract Primary pericardial synovial sarcoma is an extraor dinarily very rare tumor with a poor prognosis, and little is known about its therapeutic management. We describe the case of a 51-year-old woman patient who underwent incomplete surgical resection, chemotherapy, and radiotherapy. To the best of our knowledge, no pri mary pericardial synovial sarcoma has been described which, after surgery, remains asymptomatic for 5 years, and until a control CT scan detects cardiac metastases that compromised the lumen of the right cavities and with chemotherapy, echocardiography demonstrated complete resolution of cardiac metastases.

Registro OBELISCO-SAC. OBsErvaciones de cLinicas, Instituciones y Servicios de Cardio-Oncología SAC / OBELISCO-SAC Registry. OBsErvations from cLinics, InstitutionS and Cardio-Oncology services SAC

RESUMEN Introducción: La cardio-oncología (CO) es una nueva disciplina, que genera nuevas áreas de trabajo en las instituciones. Desconocemos cuántos equipos de CO existen en nuestro país, su estructura y el manejo de los pacientes. Objetivos: Nuestro objetivo primario es reportar cuántos centros de CO existen en nuestro país, y de ellos cuántos trabajan de acuerdo con las recomendaciones de guías y consensos. Secundariamente, definir la especialidad y formación de los médicos integrantes, si se realiza evaluación de riesgo previo al inicio del tratamiento oncológico, cómo se evalúa la función ventricular y cómo se utilizan los biomarcadores. Material y métodos: Registro nacional, multicéntrico, transversal, descriptivo, y prospectivo que incluyó 51 instituciones generales, de oncología y/o de cardiología que referían poseer grupos de trabajo o servicios de CO. Resultados: De los 51 centros, pertenecen al ámbito público el 47,1% y al privado el 52,9%. El 49% se halla en la Ciudad Autónoma de Buenos Aires, el 17,6% en la Provincia de Buenos Aires y el resto en otros lugares del país. Sobre 47 centros, el 48,9% considera funcionar de acuerdo con las recomendaciones de Guías Internacionales y el Consenso de la Sociedad Argentina de Cardiología. El 27,7% de los centros realiza siempre estratificación de riesgo cardio-oncológico o cardiovascular antes de iniciar el tratamiento. Un 35,3% de los centros deriva siempre a cardiología a los pacientes que iniciarán un tratamiento potencialmente cardiotóxico, un 47,1% ocasionalmente. El 43,1% de los centros realiza ecocardiografía basal en todos los pacientes, el 56,9% solo en algunos. Durante el seguimiento el ecocardiograma se indica de acuerdo con el esquema utilizado en el 64,7% y en el resto según su evolución. Todos los centros evalúan la fracción de eyección ventricular izquierda mediante ecocardiografía, en el 68,1% bidimensional. El 63,8% utiliza el análisis de la deformación longitudinal sistólica global. El 47,1% deriva algunos pacientes a resonancia cardíaca y el 35,3% a tomografía cardíaca. Solo el 7,8% utiliza biomarcadores. El 5,9% indica siempre prevención primaria con antagonistas neurohormonales. El dexrazoxano es utilizado en el 5,9%, la antraciclina liposomal en el 74,5%. Frente a la aparición de cardiotoxicidad, el 76,5% inicia tratamiento cardioprotector. El 41% suspende la quimioterapia, el 47% la modifica. Conclusiones: este es el primer registro nacional de CO. Brinda información y un panorama actual del estado de esta subespecialidad en nuestro país. Casi la mitad de los centros consideró funcionar de acuerdo con Guías y Consensos. Solo un tercio de los pacientes que van a iniciar tratamiento oncológico potencialmente cardiotóxico son derivados a CO. El método más utilizado en nuestro país para evaluar la función ventricular es el ecocardiograma bidimensional, los biomarcadores son poco utilizados.

ABSTRACT Background: Cardio-oncology (CO) is a new discipline that generates new work areas within the institutions. We ignore how many CO teams exist in our country, their structure and how patients are managed. Objectives: Our primary objective is to report how many CO centers exist in our country, and how many of them work according to the recommendations of guidelines and consensus statements. We also want to define the specialty and specific training of the physicians involved, determine if they perform risk assessment before cancer treatment, establish the method used to assess ventricular function and how biomarkers are used. Methods: The OBELISCO registry is a national, multicenter, cross-sectional, descriptive and prospective registry including 51 general hospitals, cancer centers and institutions specialized in cardiology with CO work groups or services. Results: Of the 51 centers, 47.1% were public hospitals and 52.9% were private centers. Most centers were in the Autonomous City of Buenos Aires (49%) and in the Province of Buenos Aires and the rest were distributed throughout the country. Of 47 centers, 48.9% considered that their institution had CO services complying with the recommendations of international guidelines and of the consensus statement of the Argentine Society of Cardiology. Global cardio-oncological or cardiovascular risk assessment is always performed in 27.7% of the centers before starting treatment. Patients who will start potentially cardiotoxic treatment are always referred to cardiology in 35.3% of the centers and are sometimes referred to cardiology in 47.1%. Baseline echocardiography is performed in all the patients before starting treatment in 43.1% of the centers and only in some patients in 56.9%. During follow-up, echocardiography is indicated according to the treatment schedule used in 64.7% and according to the patients' outcome in the rest of the centers. All the centers evaluate left ventricular ejection fraction with echocardiography, and 68.1% use twodimensional echocardiography. Global longitudinal systolic strain is used in 63.8% of the centers. Only 47.1% order cardiac magnetic resonance imaging in some patients, and 35.3% indicate cardiac computed tomography scan. Biomarkers are used in only 7.8% of the centers. Primary prevention with neurohormonal antagonist drugs is always indicated in 5.9% of the centers. Dexrazoxane is used in only 5.9% and liposomal anthracycline in 74.5% If cardiotoxicity develops, 76.5% indicate cardioprotection, 41% discontinue chemotheraphy and 47% modify cancer treatment. Conclusions: This is the first national CO registry. It provides information and a current outlook of the status of this subspecialty in our country. Almost 50% of the centers considered to be functioning in line with guidelines and consensus statements. Only one third of the patients who will initiate cancer treatment with potentially cardiotoxic drugs are referred to CO. Two-dimensional echocardiography is the method most used in our country to evaluate ventricular function; biomarkers are scarcely used.

Early detection of left ventricular diastolic dysfunction in Chagas' disease.

BACKGROUND: Chagas' disease may cause left ventricular diastolic dysfunction and its early detection in asymptomatic patients would allow to stratify the risk and to optimize medical treatment. The aim of this study is to investigate if transmitral Doppler flow can detect early abnormalities of the diastolic left ventricular function in patients during the indeterminate phase of Chagas' disease, in which the electrocardiogram (ECG), chest x-ray and 2-D echocardiogram (2D-echo) are normal. METHODS: a group of 54 patients with Chagas' disease was studied and compared to a control group of 27 subjects of similar age. All were assessed with an ECG, chest X-ray, 2-D echo, and transmitral Doppler flow. RESULTS: both groups had similar values in the 2D-echo. In patients with Chagas' disease, the transmitral Doppler showed a higher peak A velocity (control group: 0.44 m/sec, Chagas group: 0.55 m/sec, p = 0.001), a lower E/A ratio (control group: 1.45, Chagas group: 1.22, p < 0.05), and a lengthening of the deceleration time of early diastolic filling (control: 138.7 +/- 26.8 msec, Chagas group: 167.9 +/- 34.6 msec, p = 001), thus revealing an early disorder of the diastolic left ventricular function in patients with Chagas' disease. CONCLUSION: in patients with Chagas' disease who are in the indeterminate phase, transmitral Doppler flow allowed to identify early abnormalities of the left ventricular diastolic function, which provide useful clinical information for prognostic stratification and treatment.

[Usefulness of pulsed Doppler tissue imaging in the early detection of diastolic myocardial abnormalities in first-degree relatives of patients with familial hypertrophic cardiomyopathy]. / Utilidad del Doppler pulsado tisular en la detección precoz de anormalidades diastólicas en familiares de primer grado de pacientes con miocardiopatía hipertrófica familiar.

INTRODUCTION AND OBJECTIVES: Doppler tissue imaging (DTI) enables regional myocardial function to be assessed irrespective of preload. Our aim was to determine the usefulness of DTI in healthy relatives of patients with familial hypertrophic cardiomyopathy. PATIENTS AND METHOD: We studied 47 first-degree relatives of patients with familial hypertrophic cardiomyopathy (group GI) and 47 normal subjects (group GII). Echocardiographic studies, including DTI, were performed in both groups. DTI was used to measure myocardial velocities during systole (S'), early diastole (E') and atrial contraction (A') at the mitral annulus, septum, and tricuspid annulus. Isovolumic relaxation and contraction times were corrected for heart rate. With DTI assessment of regional diastolic myocardial function and use of the E'/A' ratio, normal (i.e., E'/A'>1) and abnormal (i.e., E'/A'<1) diastolic function could be distinguished. RESULTS: There were no abnormalities in regional diastolic function in group GII (right E'/A' 1.78 (0.58), septum E'/A' 2.03 (0.53), and left E'/A' 2.55 (0.80). However, in group GI, two subgroup could be distinguished using E'/A' ratio values: group GIa comprised 37 first-degree relatives with normal diastolic function (right E'/A' 1.8 (0.44), septum E'/A' 2.07 (0.41), and left E/A 2.35 (0.6) who did not differ significantly from control subjects, and group GIb comprised 10 first-degree relatives with abnormal right diastolic function (right E'/A' 0.70 (0.28), P<.001) but with less significant differences at the septum (1.57 (0.49), P<.01) and mitral annulus (1.85 (0.53), P<.01). CONCLUSIONS: In 10 of 47 (21.3%) first-degree relatives of patients with familial hypertrophic cardiomyopathy, DTI enabled the detection of ventricular diastolic abnormalities, which were more evident in the right ventricle. They could be a preclinical manifestation of disease.