Del soplo inocente a la hipertensión arterial pulmonar / From an innocent heart murmur to pulmonary arterial hypertension

Resumen Introducción: La detección de cardiopatías congénitas en la etapa neonatal a partir de un soplo cardiaco o cianosis no es efectiva. Las cardiopatías congénitas críticas, como el tronco arterioso común (TAC), causan la mayoría de las muertes neonatales por malformaciones congénitas. El tamizaje por oximetría de pulso en los recién nacidos detecta hasta el 70% de estas cardiopatías. El TAC presenta una alta mortalidad en el primer año de vida. Caso clínico: Se presenta el caso de un paciente de sexo femenino de 4 años de edad con soplo cardiaco, palpitaciones, disnea y cianosis perioral, con diagnóstico al nacimiento de soplo inocente. Se detectó TAC mediante una ecocardiografía. Las resistencias vasculares pulmonares fueron evaluadas por medio de cateterismo cardiaco derecho, con hallazgo de hipertensión arterial pulmonar y vasorreactividad pulmonar. Se realizó corrección quirúrgica. A la fecha, la hipertensión arterial pulmonar continúa presente, por lo que se implementó Bosentan® (Actelion, USA) como tratamiento a largo plazo. Conclusiones: En recién nacidos, el tamizaje por oximetría de pulso después de las 24 horas de vida es un método efectivo para el diagnóstico oportuno de cardiopatías congénitas críticas antes de los signos de colapso cardiovascular. Por ello, resulta una herramienta diagnóstica fundamental para reducir la morbimortalidad. Aunque la corrección quirúrgica de cardiopatías congénitas con hipertensión arterial pulmonar es factible en algunos pacientes, su manejo subsecuente es complejo e impacta de manera adversa en la calidad de vida.

Abstract Background: The detection of congenital heart disease in newborns, based on a heart murmur or cyanosis is not effective. Critical congenital heart diseases, such as truncus arteriosus (TA), cause most of neonatal deaths due to congenital malformations. The screening for pulse oximetry in newborns detects up to 70% of these heart diseases. TA presents high mortality in the first year of life. Case report: A 4-year-old female patient with a heart murmur, palpitations, dyspnea, and perioral cyanosis was diagnosed with an innocent heart murmur at birth. TA was detected by echocardiography. Pulmonary vascular resistances were evaluated through right cardiac catheterization, and pulmonary arterial hypertension and pulmonary vasoreactivity were diagnosed as well. Surgical correction was performed. Currently, pulmonary arterial hypertension persists, for which Bosentan® (Actelion, USA) has been implemented as a long-term treatment. Conclusions: In newborns, the pulse oximetry screening after 24 hours of life is an effective method for suitable diagnosis of critical congenital heart disease before the signs of cardiovascular collapse. Therefore, it has become an essential diagnostic tool to reduce morbidity and mortality. Although the surgical correction of congenital heart disease with pulmonary arterial hypertension is feasible in some patients, its subsequent management is complex and has an adverse impact on the quality of life.

Consultorio de orientaciòn de cardilogía: epidemiología y perfil de la población / Cardiology guidance clinic: Epidemiology and profile of the population

Introducción: Las cardiopatías congénitas (CC) son las anomalías congénitas más frecuentes. Representan el 0,8-1,2% de todos los defectos del nacimiento y tienen una prevalencia de alrededor de 5,8 por cada 1000 personas. El Servicio de Cardiología del Hospital Garrahan es un centro de referencia nacional y de países limítrofes donde se realizan 18000 consultas anuales. Los pacientes que concurren por primera vez se atienden en el consultorio de orientación. Objetivo: Describir la epidemiologia y perfil de los pacientes que asisten diariamente al consultorio de orientación de cardiología infantil en un hospital pediátrico de tercer nivel de Buenos Aires. Métodos: Entre septiembre de 2017 y febrero de 2018 se recolectaron los datos de 1000 pacientes atendidos en forma consecutiva en el consultorio de orientación de cardiología. A la totalidad de los pacientes se les realizó anamnesis, examen físico cardiovascular, electrocardiograma, y en los casos en los que se consideró necesario, saturometría, radiografía de tórax y/o ecocardiograma. Las variables a considerar fueron edad, procedencia, presencia o ausencia de cardiopatías congénitas o adquiridas, soplo, cianosis, insuficiencia cardíaca, estado nutricional, síndromes genéticos asociados, métodos diagnósticos e indicaciones terapéuticas implementadas. Se subdividió la población en cinco grupos: Grupo A (pacientes con cardiopatía congénita), Grupo B (cardiopatías operadas), Grupo C (miocardiopatías), Grupo D (arritmias), Grupo E (corazón sano). Resultados: La edad mediana fue 4.86 años (0.03 a 18.9 años). El 64% de los pacientes procedían de la provincia de Buenos Aires. Los motivos de consulta fueron: interconsultas internas 29.5%, derivación por cardiopatía 27.2%, soplo 17.6%, síncope 7%, segunda opinión 5.1%, arritmias 4.8%, precordialgia 3.1%, palpitaciones 2.6%, episodio paroxístico 1.4%, cardiomegalia 0.7%, disnea 0.5%, mal progreso de peso 0.3%. El 10.6% tenían un síndrome genético. Grupo A: 252 pacientes con una edad mediana de 1.9 años. Las cardiopatías acianóticas con hiperflujo pulmonar fueron las más frecuentes (66.66%, 168/252). Grupo B: 51 pacientes, 23.52%(12/51) fueron Fallot reparados en otra institución. Grupo C: 22 pacientes, siendo la miocardiopatía hipertrófica la más frecuente. Grupo D: 47 pacientes, la preexcitación ventricular fue el hallazgo más frecuente (34,04%, 16/47). Grupo E: 628 pacientes, 45.70% (287/628) derivados por pediatras del área ambulatoria, principalmente para valoración de pacientes con enfermedades sistémicas o síndromes genéticos. Conclusión: Los motivos de derivación al consultorio de orientación de cardiología fueron muy diversos. La mayoría de los pacientes provenían de provincia de Buenos Aires. Solamente el 37.2% presentó algún problema cardiológico de base. El 91% de los pacientes que consultaron por soplo, no tuvieron cardiopatía. El grupo correspondiente a los pacientes con cardiopatías no operadas (grupo A) fue el de menor edad (mediana de 1.9 años) y las cardiopatías simples no cianóticas con hiperflujo pulmonar representaron el 66.66% de las cardiopatías. La implementación del ecocardiograma portátil en el consultorio de orientación permitió confirmar el diagnóstico y definir la conducta terapéutica en el 29.4% de los pacientes durante la primer consulta (AU)

Introduction: Congenital heart defects (CHD) are the most common congenital abnormalities. They account for 0.8-1.2% of all birth defects and have a prevalence of around 5.8 per 1000 people. The Department of Cardiology of Garrahan Hospital is a national and bordering-country reference center, receiving 18000 consultations annually. Patients seen for the first time are assessed at the cardiology guidance clinic. Objective: To describe the epidemiology and profile of patients who seen daily at the child cardiology guidance clinic of a third-level pediatric hospital in Buenos Aires. Methods: Between September 2017 and February 2018, data from 1000 patients consecutively seen at the cardiology guidance clinic were collected. All patients underwent anamnesis, cardiovascular physical examination, electrocardiogram and, if considered necessary, pulse oximetry, chest x-ray, and/or echocardiogram. The variables considered were age, place of origin, presence or absence of congenital or acquired heart disease, murmur, cyanosis, heart failure, nutritional status, associated genetic syndromes, diagnostic methods, and treatment. The population was divided into five groups: Group A (patients with congenital heart defects), Group B (operated cardiopathies), Group C (myocardiopathies), Group D (arrhythmias), Group E (healthy heart). Results: Median age was 4.86 years (0.03 to 18.9 years). Overall, 64% of patients came from the province of Buenos Aires. The reasons for consultation were: internal consultations 29.5%, cardiac shunt 27.2%, murmur 17.6%, syncope 7%, second opinion 5.1%, arrhythmias 4.8%, precordialgia 3.1%, palpitations 2.6%, paroxysmal episode 1.4%, cardiomegaly 0.7%, dyspnea 0.5%, 0.3% poor weight gain. A genetic syndrome was identified in 10.6%. Group A: 252 patients with a median age of 1.9 years. Acyanotic congenital heart defect with pulmonary hyperflow was the most common (66.66%, 168/252). Group B: 51 patients, 23.52% (12/51) had tetralogy of Fallot repaired at another institution. Group C: 22 patients, in whom hypertrophic cardiomyopathy was the most common. Group D: 47 patients, in whom ventricular preexcitation was the most common finding (34.04%, 16/47). Group E: 628 patients, 45.70% (287/628) referred by pediatricians from the outpatient clinics, mainly for the assessment of systemic diseases or genetic syndromes. Conclusion: The reasons for referral to the cardiology guidance clinic were varied. Most of the patients came from the province of Buenos Aires. Only 37.2% had an underlying heart disease. Of the patients who consulted because of a murmur, 91% did not suffer from heart disease. The group of patients with congenital heart disease who had not undergone surgery (group A) was the youngest (median 1.9 years) and simple non-cyanotic heart disease with pulmonary hyperflow accounted for 66.66% of heart diseases. The implementation of the portable echocardiography in the guidance clinic confirmed the diagnosis and defined the management in 29.4% of patients during the first consultation (AU)

Ecocardiograma: da Solicitação do Exame pelo Pediatra à Realização pelo Cardiologista Pediátrico / Echocardiography: The Examination Request by the Pediatriciant Achieving the Pediatric Cardiologist

Fundamento: O ecocardiograma é uma ferramenta diagnóstica utilizada para avaliar anomalias cardíacas e esclarecer dúvidas quanto ao caráter benigno de certos achados do exame clínico cardiovascular. Objetivos: Identificar os principais motivos da solicitação do ecocardiograma pelo pediatra e avaliar o grau de ansiedade dos familiares gerado por essa conduta. Métodos: Foram incluídos pacientes com idade inferior a 18 anos, sem diagnóstico prévio de cardiopatia e encaminhados para o primeiro exame de ecocardiograma. Os familiares responsáveis pelos pacientes responderam a um questionário para avaliar o grau de ansiedade deles desde o pedido até a realização do ecocardiograma, com pontuação entre 0 e 19. Os dados foram analisados através de porcentagens, desvio padrão e teste T de Student. Resultados: Estudados 30 pacientes com idade média de 4,45 anos. O motivo de encaminhamento mais prevalente foi sopro cardíaco (23 casos), dos quais 70% não tiveram a hipótese de cardiopatia congênita confirmada após o ecocardiograma. A pontuação média no questionário de ansiedade foi 11 ± 6, sendo relacionado significativamente à presença de cardiopatia, com média de 13,0 ± 5,3 vs. 9,3 ± 5,2 no grupo sem a hipótese da mesma (p = 0,007). Conclusão: O achado de sopro foi o principal motivo para solicitação de ecocardiograma pelo pediatra. A confirmação de cardiopatia foi maior nos menores de 1 ano e com achado de sopro. Apesar do grau de ansiedade ter sido maior no grupo dos pacientes que tiveram o diagnóstico de cardiopatia congênita, este não foi desprezível nos familiares no grupo dos pacientes sem cardiopatia

Background: Echocardiography is a diagnostic tool used to evaluate cardiac anomalies and clarify doubts about the benign nature of certain findings of cardiovascular clinical examination. Objectives: To identify the main reasons for the request of echocardiography by pediatrician and evaluate the degree of anxiety of the family generated by this conduct. Methods: We included patients younger than 18 years without previous diagnosis of heart disease and referred for the first echocardiogram. Family members responsible for the patients answered a questionnaire to assess the degree of their anxiety from order to the performance of the echocardiogram, with scores between 0 and 19. Data were analyzed using percentages, standard deviation and Student's t test. Results: Studied 30 patients with a mean age of 4.45 years. The most prevalent reason for referral was heart murmur (23 cases), of which 70% patients had no congenital heart disease hypothesis confirmed, after echocardiography. The average score on the anxiety questionnaire was 11 ± 6 significantly associated with the presence of heart disease, with a mean of 13.0 ± 5.3 vs. 9.3 ± 5.2 in the group without the possibility of it (p = 0.007). Conclusion: The murmurs findings was the main reason for echocardiography request by the pediatrician. Confirmation of heart disease was higher in children under 1 year and with murmurs findings. Despite the anxiety level was higher in the group of patients who were diagnosed with congenital heart disease, this was not negligible in the family in the group of patients without heart disease

Características clínicas de los pacientes con soplos atendidos en una consulta de cardiopediatría / Clinical characteristics of patients with murmurs cared in a pediatric cardiology consultation

Fundamento: La auscultación de un soplo cardíaco durante el examen físico de un niño es frecuente, por lo que constituye el principal motivo de interconsulta en cardiología pediátrica. Objetivo: Identificar las características clínicas de los pacientes con soplos atendidos en una consulta de cardiopediatría. Metodología: Se estudiaron 118 niños durante el periodo de septiembre 2011 a diciembre 2012. Las variables utilizadas fueron edad, sexo, antecedentes patológicos familiares, síntomas asociados, localización del soplo, intensidad, complementarios (telecardiograma, electrocardiograma y ecocardiograma doppler). Resultados: Predominó el grupo de cero días a cinco años, y el sexo masculino. El dolor precordial, las palpitaciones y la disnea constituyeron los síntomas más frecuentes asociados al soplo. En 94 niños el soplo se ubicó en la región mesocárdica y en 106 fueron grado II. Conclusiones: La auscultación de un soplo cardíaco durante el examen físico de un niño es un hecho frecuente, por lo que constituye motivo de interconsulta periódicamente en la cardiología pediátrica.

Background: auscultation of a heart murmur during a physical examination of a child is common, which is the main interclinical reason in pediatric cardiology. Objective: To identify clinical characteristics of patients with murmurs cared in a pediatric cardiology consultation. Methodology: 118 children were studied from September 2011 to December 2012. The variables used were age, gender, family medical history, associated symptoms, location of the murmur, intensity, complementary exams (telecardiogram, electrocardiogram and echocardiogram doppler). Results: The group of 0 days to five years and male sex predominated. Chest pain, palpitations and dyspnea were the most common symptoms associated with the murmur. In 94 children the murmur was located in the mesocardiac region and 106 were grade II. Conclusions: Auscultation of a heart murmur during a physical examination of a child is frequent, that is why it is a periodically interclinical reason in pediatric cardiology consultation.

Variações eletrocardiográficas em pacientes portador de cardiopatia hipertrófica em uso de CDI / Eletrocardiographic changes in patients with hypertrophic cardiomyopathy using ICD

A cardiomiopatia hipertrófica (CMH) é uma forma relativamente comum e complexa de doença cardíaca genética, sendo considerada a maior causa de morte súbita (MS) cardíaca em pessoas jovens, incluindo atletas, respondendo por 36% dos casos em jovens atletas nos Estados Unidos (EUA). O implante decardioversor-desfibrilador (CDI) tem demonstrado alta eficácia na prevenção desse evento. Para avaliação diagnóstica da CMH, o eletrocardiograma (ECG)representa ferramenta bastante útil, pois se encontra alterado em 75% a 95% dos casos clínicos. Após o implante do CDI, como demonstrado no caso relatado, são observadas variações no ECG que podem explicar a mudança benéfica na fisiopatologia obstrutiva da CMH.

Hypertrophic cardiomyopathy (HCM) is a relatively common and complex genetic heart disease, rated as main cause of sudden cardiac death (SCD) in young people, including athletes, accounting for 36% of these cases in young athletes in the United States(USA). IDC implants have proved highly effective for preventing such events. For diagnostic evaluations of CMH, the electrocardiogram (ECG) is a very useful tool, being altered in 75% to 95% of clinical cases. After an ICD implant, as demonstrated in this case report, variations in the ECG are noted that could explain the beneficial alteration in the pathophysiology of obstructive HCM.

Efficiency, sensitivity and specificity of automated auscultation diagnosis device for detection and discrimination of cardiac murmurs in children

Intelligent electronic stethoscopes and computer-aided auscultation systems have highlighted a new era in cardiac auscultation in children. Several collaborative multidisciplinary researches in this field are performed by physicians and computer specialists. Recently, a novel medical software device, Automated Auscultation Diagnosis Device [AADD], has been reported with intelligent diagnosing ability to differentiate cardiac murmur from breath sounds in children with normal and abnormal hearts due to congenital heart disease. The aim of this study is to determine efficiency, sensitivity and specificity of the diagnoses made by this AADD in children with and without cardiac disease. We performed a cross-sectional study to determine efficiency, sensitivity and specificity of diagnoses made by AADD. Our patient population was two groups of children with and without cardiac disease [563 patients and 50 normal]. SPSS version 16 was used to calculate sensitivity, specificity and efficiency and descriptive analysis. Using cardiac sound recording in four conventional cardiac areas of auscultation [including aortic, pulmonary, tricuspid and mitral], AADD proved to have a >/= 90% sensitivity, specificity and efficiency for making the correct diagnosis in children with heart disease and 100% diagnostic accuracy in children with normal hearts either with or without innocent murmurs. Considering the high sensitivity, specificity and efficiency of AADD for making the correct diagnosis, application of this software is recommended for family physicians to enhance proper and timely patients' referral to pediatric cardiologists in order to provide better diagnostic facilities for pediatric patients who live in deprived and underserved rural areas with lack access to pediatric cardiologists

A relative value method for measuring and evaluating neonatal cardiac reserve.

Objective. To devise some indicators for measuring and evaluating the neonatal cardiac reserve by using phonocardiogram test (PCGT). Methods. Two hundred and thirty one (231) full term and one hundred and fifty four (154) preterm infants participated in this study. The amplitude ratio of the first heart sound to the second heart sound (S1/S2), the ratio of diastolic to systolic duration (D/S) and the cardiac contractility change trend after stimulation (CCCTS) of the neonates were measured, calculated and analyzed. Results. The S1/S2, D/S and CCCTS of full preterm infants were higher than that of preterm infants. The differences of D/S and CCCTS between them were significant (P<0.05). According to the full term neonatal cardiac reserve data, a normal reference range of full term neonatal cardiac reserve was primarily known. Conclusions. The indicators S1/S2, D/S and CCCTS may be beneficial for evaluating the neonatal cardiac reserve. We can screen out neonates with reduced cardiac reserve by using the phonocardiogram test.

Significance of heart murmur in diagnosis of congenital heart disease in newborn babies

This study was conducted to determine the clinical and echocardiographic evaluation of neonate with heart murmur and contribution of neonatal examination especially presence or absence of cardiac murmur in the detection of congenital heart disease [CHD]. The study was carried out in neonatology unit in althawra teaching Hospital-albaida Libya during the-period from January 2009 to January 2010. Neonates having heart murmur or when there were some clues to doubt CHD like cyanosis, respiratory distress, heart failure and echocardiography were done for all. CHD were classified according to the structural defect with the echocardiographic findings. Total 722 neonates were admitted during one year period. Heart murmurs were found in 81 cases. Out of 8 leases 34 [41.9%] had CHD confirmed by echocardiography. Another 9 neonates were found to have CHD without murmur after echocardiography. In total 43 [5.9%] neonates had CHD. Infant with CHD may present with or without murmur. Clinical examination with Careful auscultation is mandatory in the initial evaluation of neonates to identify CHD. The infant having suggestive features for CHD with or without murmur should undergone echocardiography, so that appropriate management and early intervention can be done

Analysis and diagnosis of heart sounds

Auscultation [the interpretation by a physician of heart sounds] is a fundamental component in cardiac diagnosis. It is, however, a difficult skill to acquire. In this paper, we present study for a system Intended to aid in heart sound analysis and diagnosis based on detection of different events [main and additional sounds, murmurs and clicks] present in the cardiac cycle with resolution at the level of sampling period in time and in frequency at the level of FFT points used and for each event set of parameters in time and frequency domains have been extracted for normal and abnormal cases without using ECG signal as reference. These parameters could be easily used by the doctor for analyzing the extracted parameters for normal, mitralstenosis, and s2 split sounds have been extracted from recorded sounds

Cardiopatia congênita no recém-nascido: da solicitação do pediatra à avaliação do cardiologista / Congenital heart diseases in the newborn: from the pediatrician's request to the cardiologist's evaluation

OBJETIVO: Analisar a importância dos sintomas, como motivo de interconsulta com o cardiologista pediátrico, no diagnóstico de cardiopatias congênitas (CC) em recém-nascidos (RN). MÉTODOS: Estudo prospectivo de RN vivos encaminhados para avaliação cardiológica, com realização de eletrocardiografia, radiografia de tórax e ecocardiografia. Solicitação de interconsulta mediante preenchimento de ficha de múltipla escolha, constando os sintomas e sinais sugestivos de CC. Persistência do canal arterial (PCA) sem repercussão clínica e/ou hemodinâmica não foi considerada cardiopatia. RESULTADOS: Entre 1999 e 2002, foram estudados 358 dentre 3.716 RN, demonstrando 49 casos de CC e 128 de PCA. A prevalência de CC foi de 13,2:1.000 RN. O principal motivo para interconsulta com o cardiologista foi sopro em 256 (72 por cento) dos RN, dentre os quais 39 (15 por cento) eram portadores de CC e 91 por cento dos 128 casos, de PCA. Em 14 (4 por cento) dos RN, o motivo de interconsulta foi cianose, dentre os quais 8 (57 por cento) eram portadores de CC. Insuficiência cardíaca foi o motivo de interconsulta em 37 (10 por cento) dos RN, dentre os quais 17 (46 por cento) eram portadores de CC. Arritmia, malformações congênitas associadas ou cromossomopatias foram os motivos de interconsulta em 14 por cento dos casos. CONCLUSÃO: O principal motivo da interconsulta foi ausculta de sopro. Apesar de cianose e insuficiência cardíaca serem pouco freqüentes como motivo de interconsulta, sua presença indicou alta probabilidade de diagnóstico de cardiopatia. A triagem pediátrica tem papel importante para o diagnóstico.

OBJECTIVE: To analyze the importance of symptoms as a reason for referral to pediatric cardiologists in the diagnosis of congenital heart diseases (CHD) in the newborn (NB). METHODS: Prospective study on live NB referred for cardiac evaluation, with performance of electrocardiogram, chest radiography and echocardiography. Cardiology consultation was requested by means of a multiple-choice form including signs and symptoms suggestive of CHD. Patent ductus arteriosus (PDA) without clinical and/or hemodynamic consequences was not considered a heart disease. RESULTS: From 1999 to 2002, 358 out of 3716 NB were studied, and 49 cases of CHD and 128 of PDA were found. The prevalence of CHD was 13.2:1000 NB. The main reason for referral to the cardiologist was heart murmur in 256 (72 percent) NB, of which 39 (15 percent) had CHD, and in 91 percent of the 128 cases of PDA. In 14 (4 percent) NB, the reason for referral was cyanosis, and eight of these patients (57 percent) had a CHD. Heart failure was the reason for referral in 37 (10 percent) NB, of whom 17 (46 percent) had CHD. Arrhythmia, associated congenital malformations, or chromosome disorders were the reasons for referral in 14 percent of the cases. CONCLUSION: The main reason for referral was detection of a heart murmur on cardiac auscultation. Although cyanosis and heart failure were uncommon reasons for referral, their presence indicated a high probability of the diagnosis of heart disease. Pediatric screening plays a key role in this diagnosis.

Investigação de sopro em pacientes pediátricos / Inquiry of blow in pediatrics patients

Sopro cardíaco pediátrico é um diagnóstico de grande freqüência nos ambulatórios. O pediatra deve estar apto a distinguir um sopro inocente de um sopro patológico baseado em uma anamnese e exame físico sistematizados sem a necessidade de exames complementares. Também deve estar ciente dos sinais de alerta que indicam cardiopatias e encaminhar estes pacientes ao especialista.

Diagnostico soplo cardiaco + PB (estenosis pulmunar) + neumonía + Dx II grado / I diagnose heart blow + PB (estenosis pulmunar) + pneumonia + Dx II degree

El presente trabajo fue realizado a un niño de 5 años de edad ingresado en pediatria en el Hospital Pedro Altamirano (La Trinidad), con el diagnóstico de soplo cardíaco probable estenosis pulmonar mas neumonía mas desnutrición de segundo grado. En este estudio se logro identificar los factores que están afectando la salud del niño siendo los mas principales: el nivel de educación de los padres; el nivel económico; el bajo nivel cultural y social, la mala higiene en el hogar, así como brindar educación y orientación a la madre para el cuidado de su hijo, se logró aplicar planes de enfermería de acuerdo a las necesidades del paciente, también se logro adquirir la experiencia de realizar un proceso de enfermería con un pacientito de pediatría donde se tuvo que aplicar conocimientos habilidades y principios científicos.

Los soplos cardiacos izquierdos: controversia entre los aspectos clínicos y los ecocardiograficos / The left blowings cardiac: controversy between the clinical aspects and the ecocardiograficos

Se pretende con la presente revisión recordar al cuerpo médico la importancia de los invaluables y en ocasiones injustamente olvidados elementos clínicos, en los cuales debe fundamentarse el diagnóstico de estas patologías,sin olvidar obviamente el desarrollo de la tecnología de punta (ecocardiografia) detrás de la cual, siempre debe existir un médico diagnosticando a un paciente...