Left ventricular and atrial myocardial strain in heart failure with preserved ejection fraction: the evidence so far and prospects for phenotyping strategy.

BACKGROUND: Heart failure with preserved ejection fraction (HFpEF) represents a significant proportion of heart failure cases. Accurate diagnosis is challenging due to the heterogeneous nature of the disease and limitations in traditional echocardiographic parameters. MAIN BODY: This review appraises the application of Global Longitudinal Strain (GLS) and Left Atrial Strain (LAS) as echocardiographic biomarkers in the diagnosis and phenotyping of HFpEF. Strain imaging, particularly Speckle Tracking Echocardiography, offers a superior assessment of myocardial deformation, providing a more detailed insight into left heart function than traditional metrics. Normal ranges for GLS and LAS are considered, acknowledging the impact of demographic and technical factors on these values. Clinical studies have demonstrated the prognostic value of GLS and LAS in HFpEF, especially in predicting cardiovascular outcomes and distinguishing HFpEF from other causes of dyspnea. Nevertheless, the variability of strain measurements and the potential for false-negative results underline the need for careful clinical interpretation. The HFA-PEFF scoring system's integration of these biomarkers, although systematic, reveals gaps in addressing the full spectrum of HFpEF pathology. The combined use of GLS and LAS has been suggested to define HFpEF phenogroups, which could lead to more personalized treatment plans. CONCLUSION: GLS and LAS have emerged as pivotal tools in the non-invasive diagnosis and stratification of HFpEF, offering a promise for tailored therapeutic strategies. Despite their potential, a structured approach to incorporating these biomarkers into standard diagnostic workflows is essential. Future clinical guidelines should include clear directives for the combined utilization of GLS and LAS, accentuating their role in the multidimensional assessment of HFpEF.

Advanced echocardiography techniques (AETs) to assess left atrial structure and function in individuals with resistant hypertension.

AIMS: Resistant hypertension (RH) is a challenging phenotype within the hypertension (HTN) spectrum, requiring careful assessment and follow-up. Evaluation of left atrial function may be clinically informative, but is usually neglected. Advanced Echocardiography Techniques (AETs), such as Strain Analysis and three-dimensional echocardiography (3D ECHO) may be useful complementary tools to assess atrial function in patients with RH. METHODS AND RESULTS: Ninety-six eligible adult patients were categorized into three groups: resistant hypertensive (RH), controlled hypertensive (CH), and normotensive (N), and underwent AETs to identify morphofunctional changes in the left atrium (LA) across different HTN phenotypes. The LA reservoir strain was significantly lower among RH than in N and CH patients (p < .001). Accordingly, LA conduit strain showed a gradient through the groups: higher among N, followed by CH and RH patients (p = .015). LA contraction strain was higher among CH than in N and RH patients (p = .02). Maximum indexed, pre-A, and minimum atrial volumes obtained by 3D ECHO showed differences between N and the others (p < .001), but not between CH and RH. N patients showed a higher fraction of passive emptying of the LA than the others (p = .02), with no difference between CH and RH. Total emptying of the LA only differed between N and RH patients, while active emptying of the LA showed no difference between the groups (p = .82). CONCLUSION: The left atrium may present early functional changes in response to HTN, which are detectable by AETs. AETs, especially S-LA, allowed to identify markers of atrial myocardial damage in both RH and CH patients.

Myocardial strain pattern progress in patients with Coarctation of the Aorta undergoing aortic stenting.

BACKGROUND AND AIM: Ventricular function evaluation in coarctation of the aorta (CoA) has become more sophisticated and precise with speckle tracking, revealing subclinical changes. However, CoA stenting treatment effects in on myocardial strain are still controversial. This study aimed to estimate the extent to which changes in left ventricular global longitudinal strain (LV GLS) occur in patients with CoA who undergo stenting. METHODS: The study included 21 patients with CoA (median age: 15 years [8-39]) and 21 healthy individuals matched by age and gender. Clinical and echocardiographic evaluations were performed 1 day before, 6 months, and 1 year after stenting. Correlations between LV GLS and arm-leg gradient, isthmus gradient on echocardiogram, age at intervention, left ventricular mass, and ejection fraction were tested. RESULTS: Before treatment, patients with CoA had lower LV GLS than the control group (-18.4% ± 1.96 vs -21.5% ± 1.37; P < .01), showing significant increase to -19.4% ± 2.1 at 6 months and -20.7% ± 2.19 at 1 year, P < .001. Only 28.5% (6 patients) had preserved GLS before treatment, improving to 80.9% (17 patients) in 1 year. The only variable correlated with low LV GLS values before treatment was age at intervention (Spearman's index = -0.571; P = .007). CONCLUSION: Percutaneous therapy showed significant LV GLS improvement 12 months after aortic stenting. Older patients have lower GLS, suggesting that early intervention may have positive effects on preservation of LV systolic function.

E/e` ratio is superior to speckle tracking for detecting elevated left ventricular end-diastolic pressure in patients with coronary artery disease and preserved ejection fraction.

BACKGROUND: A weak correlation has been reported between left ventricular filling pressures and the traditional echocardiographic tools for the evaluation of diastolic function in patients with coronary artery disease (CAD) and preserved left ventricular ejection fraction (LVEF). On the other hand, studies that compared invasive measurements with speckle tracking echocardiography have shown promising results, but they were not exclusively targeted on this specific population. METHODS AND RESULTS: Immediately before the left heart catheterization, a comprehensive two-dimensional Doppler echocardiography and speckle tracking analysis was prospectively performed in outpatients referred for coronary angiography. Left ventricular end-diastolic pressure (LVEDP) was measured before any contrast exposure. Eighty-one patients with coronary artery disease were studied, and the group with high LVEDP (n = 40) showed increased left atrial volume index (22 ± 6 mL/m2 vs 26 ± 8.26 mL/m2 , P = 0.04), E-wave velocity (65 ± 15 cm/s vs 78 ± 20 cm/s, P = 0.02), E/e` (average) ratio (8.14 ± 2.0 vs 11.54 ± 2.7, P = 0.03), and E/global circumferential strain rate E peak ratio (E/GCSRE ) (39 cm vs 46 cm, P < 0.01). There was a positive correlation between LVEDP and E/e` (ρ = 0.56; P = 0.03), and between LVEDP and E/GCSRE ratio (ρ = 0.43; P < 0.01). The area under the receiver operating characteristics (ROC) curve was 0.83 and 0.73, respectively (P < 0.05). E/e` and E/GCSRE were both independent predictors of elevated LVEDP (P < 0.05), with a higher C-statistic for the model including E/e` (0.89 vs 0.85). CONCLUSION: The E/e` ratio was able to identify elevated LVEDP in CAD patients with preserved LVEF with more accuracy than the E/GCSRE ratio.

Mid-Term Outcomes after Percutaneous Closure of the Secundum Atrial Septal Defect with the Figulla-Occlutech Device.

OBJECTIVES: To evaluate the mid-term outcomes after percutaneous closure of the secundum atrial septal defects (ASD) using the Figulla-Occlutech device (FOD). BACKGROUND: Transcatheter closure has become the method of choice for most patients with ASD. Although the FOD may have some advantageous characteristics there is a paucity of data on later outcomes after the use of this relatively new device. METHODS: Observational, single arm study including 200 non-consecutive patients who underwent ASD closure between 04/09 and 07/15 in 2 centers. Device performance, deployment technique, and immediate and mid-term outcomes were assessed. RESULTS: Median age and weight were 24 years (4-72) and 58 kg (15-92), respectively. Single defects were observed in 171 patients (median size of 19 mm). The remainder had multiple or multifenestrated defects. Implantation of FOD (median size of 24 mm) was successful in all (99%), but 2 patients (1 with deficient postero-inferior rim; 1 with a large ASD for the size of the child). Embolization with device retrieval occurred in 2 (1%). Median follow-up of 36 months was obtained in 172 patients. Serial echocardiographic assessment showed complete closure in all but 2 patients, in whom an additional small non-significant posterior defect was purposely left untouched. There have been no episodes of late arrhythmias, device embolization, cardiac erosion, endocarditis, thromboembolism, wire fracture, or death. CONCLUSIONS: Transcatheter closure of ASDs in older children, adolescents, and adults using the FOD was highly successful in a wide range of anatomical scenarios with high closure rates and no complications in mid-term follow-up.

Early improvement in left atrial remodeling and function after mitral valve repair or replacement in organic symptomatic mitral regurgitation assessed by three-dimensional echocardiography.

BACKGROUND: Left atrial (LA) dilation is associated with worse prognosis in various clinical situations including chronic mitral regurgitation (MR). Real time three-dimensional echocardiography (3DE) has allowed a better assessment of LA volumes and function. Little is known about LA size and function in early postoperative period in symptomatic patients with chronic organic MR. We aimed to investigate these aspects. METHODS: By means of 3DE, 43 patients with symptomatic chronic organic MR were prospectively studied before and 30 days after surgery (repair or bioprosthetic valve replacement). Twenty subjects were studied as controls. Maximum (Vol-max), minimum, and preatrial contraction LA volumes were measured and total, passive, and active LA emptying fractions were calculated. RESULTS: Before surgery patients had higher LA volumes (P < 0.001) but smaller LA emptying fractions than controls (P < 0.01). After surgery there was a reduction in all 3 LA volumes and an increase in active atrial emptying fraction (AAEF). Multivariate analysis showed that independent predictors of early postoperative Vol-max reduction were preoperative diastolic blood pressure (coefficient = -0.004; P = 0.02), lateral mitral annular early diastolic velocity (e') (coefficient = 0.023; P = 0.008), and the mean transmitral diastolic gradient increment (coefficient = -0.035; P < 0.001). Furthermore, e' was also independently associated with AAEF increase (odds ratio = 1.66, P = 0.027). CONCLUSION: Early LA reverse remodeling and functional improvement occur after successful surgery of symptomatic organic MR regardless of surgical technique. Diastolic blood pressure and transmitral mean gradient augmentation are variables negatively related to Vol-max reduction. Besides, e' is positively correlated with both Vol-max reduction and AAEF increase.

Left atrial strain as a predictor of left ventricular filling pressures in coronary artery disease with preserved ejection fraction: a comprehensive study with left ventricular end-diastolic and pre-atrial contraction pressures.

Assessing left ventricular (LV) filling pressure (LVFP) is challenging in patients with coronary artery disease (CAD) and preserved LV ejection fraction (LVEF). We aimed to correlate left atrial strain (LAS) with two invasive complementary parameters of LVFP and compared its accuracy to other echocardiographic data to predict high LVFP. This cross-sectional, single-center study enrolled 81 outpatients with LVEF > 50% and significant CAD from a database. Near-simultaneous echocardiography and invasive measurements of both LV end-diastolic pressure (LVEDP) and LV pre-atrial contraction (pre-A) pressure were performed in each patient, based on the definition of LVEDP > 16 mmHg and LV pre-A > 12 mmHg as high LVFP. A moderate to strong correlation was observed between LAS reservoir (LASr), contractile strain, and LVEDP (r: 0.67 and 0.62, respectively; p < 0.001); the same was true for LV pre-A (r: 0.65 and 0.63, respectively; p < 0.001). LASr displayed good diagnostic performance to identify elevated LVFP, which was higher when compared to traditional parameters. Median value of LASr was higher for an isolated increase of LVEDP than for simultaneously high LV pre-A. The cutoff found to predict high LVFP was lower for LV pre-A than that one for LVEDP. In the current study, LASr did not provide an additional contribution to the 2016 diastolic function algorithm. LAS is a valuable tool for predicting LVFP in patients with CAD and preserved LVEF. The choice of LVEDP or LV pre-A as the representative marker of LVFP leads to different cutoffs to predict high pressures. The best strategy for adding this tool to a multiparametric algorithm requires further investigation.

Mechanical dispersion is a superior echocardiographic feature to predict exercise capacity in preclinical and overt heart failure with preserved ejection fraction.

BACKGROUND: Heart Failure with Preserved Ejection Fraction (HFpEF) is a syndrome characterized by different degrees of exercise intolerance, which leads to poor quality of life and prognosis. Recently, the European score (HFA-PEFF) was proposed to standardize the diagnosis of HFpEF. Even though Global Longitudinal Strain (GLS) is a component of HFA-PEFF, the role of other strain parameters, such as Mechanical Dispersion (MD), has yet to be studied. In this study, we aimed to compare MD and other features from the HFA-PEFF according to their association with exercise capacity in an outpatient population of subjects at risk or suspected HFpEF. METHODS: This is a single-center cross-sectional study performed in an outpatient population of 144 subjects with a median age of 57 years, 58% females, referred to the Echocardiography and Cardiopulmonary Exercise Test to investigate HFpEF. RESULTS: MD had a higher correlation to Peak VO2 (r=-0.43) when compared to GLS (r=-0.26), MD presented a significant correlation to Ventilatory Anaerobic Threshold (VAT) (r=-0.20; p = 0.04), while GLS showed no correlation (r=-0.14; p = 0.15). Neither MD nor GLS showed a correlation with the time to recover VO2 after exercise (T1/2). In Receiver Operator Characteristic (ROC) analysis, MD presented superior performance to GLS to predict Peak VO2 (AUC: 0.77 vs. 0.62), VAT (AUC: 0.61 vs. 0.57), and T1/2 (AUC: 0.64 vs. 0.57). Adding MD to HFA-PEFF improved the model performance (AUC from 0.77 to 0.81). CONCLUSION: MD presented a higher association with Peak VO2 when compared to GLS and most features from the HFA-PEFF. Adding MD to the HFA-PEFF improved the model performance.

Afterload increase challenge unmasks systolic abnormalities in heart failure with preserved ejection fraction.

BACKGROUND: Provocative maneuvers have the potential to overcome the low sensitivity of resting echocardiography and biomarkers in the detection of heart failure with preserved ejection fraction (HFpEF). We investigate the mechanical response of the left ventricle to an afterload challenge in patients with preclinical and early-stage HFpEF (es-HFpEF). METHODS: Three groups of patients (non-HFpEF - n = 42, pre-HFpEF - n = 43, and es-HFpEF - n = 39) underwent echocardiography at rest and during an afterload challenge induced by handgrip maneuver combined with pneumatic constriction of limbs. RESULTS: Patients in the non-HF group displayed a median ΔLPSS = -4% (IQR: -10%, +2%), LPSS rest<16% in 3/42(7%) and LPSS stress<16% in 6/43(14%). Subjects in the pre-HFpEF group displayed median ΔLPSS = -3% (IQR: -10%, +5%) LPSS rest<16% in 13/43(30%) and LPSS stress<16% in 19/43 (44%). 11/43 (25%) subjects in this group increased at least one absolute point in LPSS during stress. Patients in es-HFpEF group displayed a median ΔLPSS = -10% (IQR: -18%, -1%), LPSS rest<16% in 15/39(38%) and LPSS stress<16% in 25/39(64%). Changes in LPSS (ΔLPSS) were significantly greater in es-HFpEF than pre-HFpEF (p = 0.022). In multivariate analysis, this group effect was maintained after adjustment of the LPSS for systolic blood pressure, use of ß-blockers, LV mass, RWT, age, and sex. CONCLUSION: Our data suggest that patients with HFpEF have a marked decrease in peak strain during acute pressure overload. Longitudinal studies are needed to test and compare the clinical impact of each pattern in early and long-term follow-ups.

Position Statement on the Use of Myocardial Strain in Cardiology Routines by the Brazilian Society of Cardiology's Department Of Cardiovascular Imaging - 2023. / Posicionamento do Departamento de Imagem Cardiovascular da Sociedade Brasileira de Cardiologia sobre o Uso do Strain Miocárdico na Rotina do Cardiologista ­ 2023.

Central Illustration : Position Statement on the Use of Myocardial Strain in Cardiology Routines by the Brazilian Society of Cardiology's Department Of Cardiovascular Imaging - 2023 Proposal for including strain in the integrated diastolic function assessment algorithm, adapted from Nagueh et al.67 Am: mitral A-wave duration; Ap: reverse pulmonary A-wave duration; DD: diastolic dysfunction; LA: left atrium; LASr: LA strain reserve; LVGLS: left ventricular global longitudinal strain; TI: tricuspid insufficiency. Confirm concentric remodeling with LVGLS. In LVEF, mitral E wave deceleration time < 160 ms and pulmonary S-wave < D-wave are also parameters of increased filling pressure. This algorithm does not apply to patients with atrial fibrillation (AF), mitral annulus calcification, > mild mitral valve disease, left bundle branch block, paced rhythm, prosthetic valves, or severe primary pulmonary hypertension.

Figura Central : Posicionamento do Departamento de Imagem Cardiovascular da Sociedade Brasileira de Cardiologia sobre o Uso do Strain Miocárdico na Rotina do Cardiologista ­ 2023 Proposta de inclusão do strain no algoritmo integrado de avaliação da função diastólica, adaptado e traduzido de Nagueh et al. 67 AE: átrio esquerdo; Ap: duração da onda A reversa pulmonar; Am: duração da onda A mitral; DD: disfunção diastólica; FEVEr: fração de ejeção do ventrículo esquerdo reduzida; IT: insuficiência tricúspide; SAEr: strain do AE de reservatório; SLGVE: strain longitudinal global do ventrículo esquerdo. Se remodelamento concêntrico, confirmar com SLGVE. Na presença de FEVEr, tempo de desaceleração da onda E mitral (TDE) < 160 ms e onda S < D pulmonar também são parâmetros de pressão de enchimento aumentada. Esse algoritmo não se aplica a pacientes com fibrilação atrial (FA), calcificação do anel mitral ou valvopatia mitral maior que discreta, bloqueio de ramo esquerdo (BRE), ritmo de marca-passo, próteses valvares ou hipertensão pulmonar (HP) primária grave.

Association between left atrial strain and left ventricular diastolic function in patients with acute coronary syndrome.

BACKGROUND: Left ventricular diastolic function is an important prognostic marker in acute coronary syndrome. However, classification of the dysfunction grade using isolated echocardiographic parameters remains difficult. Therefore, it is necessary to combine multiple data in diagnostic algorithms. The purpose of this study was to evaluate the capacity of left atrial strain (LAS) components to classify left ventricular diastolic dysfunction (DD) grade. METHODS: Cross-sectional study with 109 consecutive patients admitted to the emergency room with acute coronary syndrome. Patients were referred for echocardiographic evaluation within 72 h. Mean values of LAS, corresponding to three phases of atrial function (reservoir, conduit and contraction), were obtained by speckle-tracking echocardiography. Patients were divided according to the diastolic dysfunction grade for later association with the LAS. RESULTS: The three LAS components showed moderate correlation with most diastolic variables (left atrial volume index, E/e' ratio and e' wave). In addition, there was related reduction of the LAS, which was inversely proportional to the DD grade (p < 0.05). LAS was effective for the identification of patients with DD grade III [area under the curve (AUC) for the reservoir = 0.99; conduit AUC = 0.89; contraction AUC = 0.99) and also those with DD grade II or III (reservoir AUC = 0.94; conduit AUC = 0.92; contraction AUC = 0.80]. CONCLUSIONS: LAS alone presented excellent capacity to classify DD in patients with acute coronary syndrome and may represent an additional tool for this purpose.

Hernia de Morgagni en la edad adulta / Morgagni's hernia in adulthood

Introducción: La hernia de Morgagni es una anomalía congénita rara, responsable del 3 por ciento de las hernias diafragmáticas, que provoca opacidades radiológicas paracardíaca y retroesternal que suelen confundirse con otras afecciones. Objetivo: Notificar el caso de un paciente adulto diagnosticado con hernia de Morgagni en el Hospital General Docente Dr. Antonio Luaces Iraolade Ciego de Ávila. Caso clínico: Se presenta el caso de un varón de 28 años de edad con antecedentes de contusión torácica severa, que presentó dolor abdominal, dispepsias, dolor recurrente en región baja posterior del hemitórax derecho, falta de aire ligera y tos seca. Con la aplicación de un correcto método clínico se excluyeron otros posibles diagnósticos planteados previamente y se concluyó con estudios imagenológicos como una hernia de Morgagni. Se realizó tratamiento quirúrgico mediante laparotomía convencional. La evolución fue favorable, sin complicaciones posoperatorias y con egreso hospitalario precoz. Conclusiones: Se notificó el caso de un paciente diagnosticado con hernia de Morgagni que constituyó un tipo raro de hernia en adultos, cuyo diagnóstico se debe tener en cuenta en pacientes con manifestaciones clínicas digestivas o respiratorias, que presentan radiopacidad paracardíaca en la radiografía de tórax. Es necesario realizar tratamiento quirúrgico oportuno para prevenir posibles complicaciones(AU)

Introduction: Morgagni's hernia is a rare congenital anomaly, responsible for 3percent of diaphragmatic hernias, which causes paracardiac and retrosternal radiological opacities that are often confused with other conditions. Objective: To report the case of an adult patient diagnosed with Morgagni's hernia at Dr. Antonio Luaces Iraola General Teaching Hospital from Ciego de Avila. Clinical casereport: We report the case of a 28-year-old man with history of severe chest contusion, who showed abdominal pain, dyspepsia, recurrent pain in the lower posterior region of the right hemithorax, slight shortness of breath, and dry cough. With the use of the correct clinical method, other possible diagnoses were excluded from what was previously raised. Imaging studies concluded to be a Morgagni hernia. Surgical treatment was performed by conventional laparotomy. The evolution was favorable, without postoperative complications and with early hospital discharge. Conclusions: The case of a patient diagnosed with Morgagni's hernia was reported. It constituted a rare type of hernia in adults. Its diagnosis should be taken into account in patients with digestive or respiratory clinical manifestations, showing paracardiac radiopacity on chest X-ray. Timely surgical treatment is necessary to prevent possible complications(AU)

Página web para el estudio del modelo celular de la coagulación en la carrera de medicina y residencia de especialidades clínicas / Website For The Study Of The Cellular Model Of Coagulation In Medicine Major And The Residency Of Clinical Specialties

Introducción: El modelo de la coagulación ha experimentado cambios para alcanzar un consenso con relación a los trastornos hemorrágicos que se aprecian en la práctica médica. El modelo celular de la coagulación es el más aceptado con el que se cuenta dentro de esta área del conocimiento, sin embargo, es poco conocido e integrado en los planes de estudio en Cuba. Objetivo: Confeccionar una página web que integre los elementos actuales acerca del modelo celular de la coagulación. Materiales y métodos: Se realizó un estudio de tipo innovación tecnológica entre los meses de enero de 2017 y enero de 2018 en Ciego de Ávila. Se desarrolló en tres etapas: confección, validación por expertos y comprobación de efectividad por usuarios. Para el diseño se empleó el software Drupal, y el lenguaje HTML. Para la comprobación se contó con dos grupos de expertos que valorara desde el punto de vista de pertinencia educativa e informática. Se comprobó la efectividad mediante un posprueba aplicada a 106 estudiantes de medicina y 16 residentes. Resultados: Se obtuvieron valoraciones de adecuado y muy adecuado por consenso de expertos, siendo la originalidad (7,13 ± 1,24) y la pertinencia (7,20 ± 1,74) los aspectos mejor valorados. Más del 90 % de los usuarios valoraron igualmente la página web como muy satisfactorias según los contenidos tratados y la originalidad. Durante la posprueba el 84,91 por ciento de los estudiantes y 66,67 por ciento de los residentes se suscriben a la calificación de excelente. Conclusiones: Se confeccionó una página con la capacidad de integrar los elementos actuales acerca del modelo celular de la coagulación(AU)

Introduction: The coagulation model has undergone changes to reach a consensus regarding the bleeding disorders that are seen in medical practice. The cellular model of coagulation is the most accepted that is available within this area of knowledge; however, it is little known and integrated into the curricula in Cuba. Objective: Create a web page that integrates the current elements about the cellular model of coagulation. Materials and methods: A technological innovation study was carried out between January 2017 and January 2018 in Ciego de Ávila province. It was developed in three stages: preparation, validation by experts and verification of effectiveness by users. For the design was used Drupal software, and HTML language. For the verification, there were two groups of experts to assess from the point of view of educational and computer relevance. Effectiveness was tested by a post-test applied to 106 medical students and 16 residents. Results: Adequate and very adequate assessments were obtained by consensus of experts, with originality (7.13 ± 1.24) and relevance (7.20 ± 1.74) being the best valued aspects. More than 90 percent of users also rated the website as very satisfactory according to the contents treated and originality. During the post-test, 84.91 percent of students and 66.67 percent of residents confirmed the excellent rating. Conclusions: A web page was made with the ability to integrate the current elements about the cellular model of coagulation(AU)

Página web para el estudio del modelo celular de la coagulación en la carrera de medicina y residencia de especialidades clínicas / Website For The Study Of The Cellular Model Of Coagulation In Medicine Major And The Residency Of Clinical Specialties

Introducción: El modelo de la coagulación ha experimentado cambios para alcanzar un consenso con relación a los trastornos hemorrágicos que se aprecian en la práctica médica. El modelo celular de la coagulación es el más aceptado con el que se cuenta dentro de esta área del conocimiento, sin embargo, es poco conocido e integrado en los planes de estudio en Cuba. Objetivo: Confeccionar una página web que integre los elementos actuales acerca del modelo celular de la coagulación. Materiales y métodos: Se realizó un estudio de tipo innovación tecnológica entre los meses de enero de 2017 y enero de 2018 en Ciego de Ávila. Se desarrolló en tres etapas: confección, validación por expertos y comprobación de efectividad por usuarios. Para el diseño se empleó el software Drupal, y el lenguaje HTML. Para la comprobación se contó con dos grupos de expertos que valorara desde el punto de vista de pertinencia educativa e informática. Se comprobó la efectividad mediante un posprueba aplicada a 106 estudiantes de medicina y 16 residentes. Resultados: Se obtuvieron valoraciones de adecuado y muy adecuado por consenso de expertos, siendo la originalidad (7,13 ± 1,24) y la pertinencia (7,20 ± 1,74) los aspectos mejor valorados. Más del 90 por ciento de los usuarios valoraron igualmente la página web como muy satisfactorias según los contenidos tratados y la originalidad. Durante la posprueba el 84,91 por ciento de los estudiantes y 66,67 por ciento de los residentes se suscriben a la calificación de excelente. Conclusiones: Se confeccionó una página con la capacidad de integrar los elementos actuales acerca del modelo celular de la coagulación(AU)

Introduction: The coagulation model has undergone changes to reach a consensus regarding the bleeding disorders that are seen in medical practice. The cellular model of coagulation is the most accepted that is available within this area of knowledge; however, it is little known and integrated into the curricula in Cuba. Objective: Create a web page that integrates the current elements about the cellular model of coagulation. Materials and methods: A technological innovation study was carried out between January 2017 and January 2018 in Ciego de Ávila province. It was developed in three stages: preparation, validation by experts and verification of effectiveness by users. For the design was used Drupal software, and HTML language. For the verification, there were two groups of experts to assess from the point of view of educational and computer relevance. Effectiveness was tested by a post-test applied to 106 medical students and 16 residents. Results: Adequate and very adequate assessments were obtained by consensus of experts, with originality (7.13 ± 1.24) and relevance (7.20 ± 1.74) being the best valued aspects. More than 90 percent of users also rated the website as very satisfactory according to the contents treated and originality. During the post-test, 84.91 percent of students and 66.67 percent of residents confirmed the excellent rating. Conclusions: A web page was made with the ability to integrate the current elements about the cellular model of coagulation(AU)

High prevalence of subclinical atherosclerosis in Brazilian postmenopausal women with low and intermediate risk by Framingham score.

Cardiovascular diseases are the leading cause of mortality among women in several countries. Early detection of subclinical atherosclerosis (SA) could enable the adoption of preventive measures to avoid cardiovascular events. This study aimed to determine the prevalence of SA in Brazilian asymptomatic postmenopausal women in Framingham Risk Score (FRS) low and intermediate groups. Computed tomography (CT) and ultrasound (US) scans were performed in 138 asymptomatic postmenopausal women (56.1 ± 4.9 years of age) to survey for coronary artery and aortic calcification (CT scan) and assess carotid intima-media thickness (CIMT) and identify carotid plaques (US). The mean FRS was 2.64 ± 2.13 %. The prevalence of increased CIMT, carotid plaques, increased CIMT and/or plaques, coronary artery calcification (CAC) >0 and aortic calcification (AC) were, respectively, 45.7, 37.7, 62.3, 23.9 and 45.7 %. Normal imaging tests were found in 22.4 %. SA, defined as at least one abnormal imaging test, was associated with age, FRS, waist-to-rip ratio, systolic and diastolic blood pressure, HDL-c and ApoA1 levels, and ApoA1/ApoB ratio. In logistic regression, SA was associated with higher age (OR 1.108, 95 % CI 1.010-1.215, p = 0.029) and lower ApoA1 levels (OR 0.979, 95 % CI 0.960-0.998, p = 0.029). SA was prevalent in Brazilian postmenopausal women with low and intermediate risk groups (FRS) and was associated with higher age and lower levels of ApoA1. Carotid atherosclerosis was the most common presentation of SA in this group.

Síndrome de Marfán / Marfan syndrome

El síndrome de Marfán constituye una enfermedad infrecuente de herencia autosómica dominante, con una incidencia de 2-3 casos por cada 10,000 personas. Es caracterizada por manifestaciones musculo-esqueléticas, cardiovasculares oftalmológicas y pulmonares. Se presentan dos pacientes con lazos familiares, diagnosticados en consulta especializada, con alteraciones somatoesqueléticas características, paladar ojival, signos odontológicos y complicaciones valvulares cardiacas. Se revisa la literatura actualizada y se indican pautas terapéuticas preventivas y de rehabilitación. Es una entidad clínica rara, de pronóstico incierto. Su diagnóstico oportuno prevé la detección de complicaciones que pueden ser invalidantes, a la vez que debe instaurarse un tratamiento precoz que incluya medidas de rehabilitación y posibilite una mejor calidad de vida del paciente para alcanzar una expectativa de vida satisfactoria(AU)

Marfan syndrome is a rare disease of autosomal dominant inheritance, with an incidence of 2-3 cases per 10,000 people. It is characterized by musculoskeletal, cardiovascular, ophthalmological and pulmonary manifestations. We report two patients with family ties, diagnosed in a specialized consultation, with characteristic somatoeskeletal alterations, high palate, dental signs and cardiac valve complications. The updated literature was reviewed and preventive and rehabilitative therapeutic guidelines were indicated. It is a rare clinical entity with uncertain prognosis. Its timely diagnosis foresees the detection of complications that can be invalidating, at the same time that an early treatment must be established that includes rehabilitation measures and allows better quality of life for the patient to achieve satisfactory life expectancy(AU)

Serial assessment of arterial structure and function in patients with coarctation of the aorta undergoing stenting.

Stenting for CoA has become an acceptable treatment modality in the last 20 years. However little is known about arterial changes after this procedure. To assess arterial structure and function including peripheral reactivity and stiffness and intima-media thickness (IMT) pre and post stenting for coarctation of the aorta (CoA). Twenty-one patients [median age: 15 years (8-39)] were studied at baseline, 1 day, 6 months and 1 year after stenting. Twenty-one healthy subjects (1:1 matched) were used as controls. Left ventricular (LV) mass, ejection fraction, flow-mediated dilation (FMD) and nitrate-mediated dilation (NMD) of left brachial artery, common carotid (CC) and right subclavian artery (RSCA) IMT and pulse wave velocity (PWV) were assessed by echocardiography and vascular ultrasound. CoA patients had higher LV indexed mass (p < 0.0001), impaired FMD (p < 0.0001) and NMD (p < 0.0001), increased PWV (p < 0.0001), carotid and RSCA IMT (both p < 0.0001). All procedures were successful and resulted in significant gradient reduction (p < 0.001). One year after stenting there was improvement in LV function (p = 0.034) and although there was significant reduction of LV mass (103.29 ± 24.77 vs. 74.39 ± 22.07 g/m(2), p < 0.0001) values did not normalize. There was no significant change in FMD, NMD, PWV and CC or RSCA IMT. In patients with CoA, arterial reactivity is impaired and LV mass, arterial stiffness and thickness are increased. Although stenting is successful to relieve the obstruction resulting in better LV function and mass reduction, arterial structure and function remains abnormal after 1 year of follow-up.

Estimation of right ventricular mass by two-dimensional echocardiography.

BACKGROUND: This report describes two original echocardiographic approaches to measure right ventricular (RV) mass (RVM). METHODS: In the bullet formula (5/24 pi D1 D2 L), where D1 and D2 are short axes and L the log axis, the RVM is obtained by subtracting the cavity volume from the RV total volume and subsequently multiplying the difference by myocardium density. The second method uses 3 endocardium segments measured at: (1) short axis plane of the aortic valve and left atrium (b1); (2) short axis plane at the midpoint between the tricuspid valve annulus and the apex (b2); and (3) 4-chamber view (h). Those segment lengths are applying in the formula A = [(b1 + b2)/2] x h. The result is multiplied by the wall thickness and by myocardium density. RESULTS: Both formulas were primarily tested in 30 mongrel dogs and have shown good correlation with the true mass ( r = 0.869 with the segments formula and r = 0.819 with the bullet formula). The same method was used in 20 human patients before heart transplant with similar results ( r = 0.810 with the segments formula and r = 0.836 with the bullet formula). CONCLUSIONS: The RVM can be satisfactorily estimated by 2-dimensional echocardiography. The linear regression between the calculated mass (using the smoothest and thinner myocardium thickness) and the actual mass may provide the correction factor for the RVM calculation. Two echocardiographic methods were used to measure right ventricular mass. One of them used a bullet formula variant (5/24 pi D1 D2 L). The second method used 3 endocardium segments measured in 3 2-dimensional echocardiographic planes (short axis of aortic valve and left ventricle, and 4-chamber view), and applied in the formula A = [(b1 + b2)/2] x h. Both formulas have shown good correlation with the true mass in 30 mongrel dogs ( r = 0.869 with the segments formula and r = 0.819 with the bullet formula) and in 20 human patients before heart transplant ( r = 0.810 and r = 0.836, respectively).

Altered left ventricular twist is associated with clinical severity in adults and adolescents with homozygous sickle cell anemia.

BACKGROUND: Sickle cell anemia (SCA) is associated with cardiac abnormalities and premature death. The aims of this study were to identify early markers of cardiac dysfunction through ventricular strain and ventricular twist and determine the relationships between these measures and other markers of cardiovascular risk. METHODS: Forty patients with SCA (mean age, 23.5 ± 9.3 years; 24 male patients) and 40 age- and sex-matched healthy individuals were compared. All subjects participated in structured interviews, and blood samples were collected. Standard echocardiography with subsequent offline evaluations using left ventricular (LV) and right ventricular systolic strain and rotational analyses of the left ventricle using two-dimensional speckle-tracking echocardiography were performed. RESULTS: There were no differences in LV ejection fraction, global LV strain (longitudinal, circumferential, and radial), and global right ventricular longitudinal strain between patients and controls; however, LV twist was significantly lower in the patient group (mean, 7.4 ± 1.2° vs 10.7 ± 1.8°; P < .0001). Several variables were strongly related to LV twist, including the clinical severity index (ρ = -0.97, Z score = -6.05, P < .0001), E/e' ratio (r = 0.78, P < .0001), LV end-diastolic volume index (r = 0.81, P < .0001), and pulmonary artery systolic pressure (r = 0.72, P < .0001). CONCLUSIONS: LV twist is altered in patients with SCA. There were strong correlations between left ventricular twist and clinical severity index, E/e' ratio, LV end-diastolic volume index, and pulmonary artery systolic pressure. These data suggest that decreased LV twist may indicate a subgroup of patients with SCA at greater cardiac risk.

Síndrome de Barré-Lieou en un anciano / Barre-Lieou syndrome in an elderly

Se describe el caso clínico de un anciano de 85 años de edad a quien se le diagnosticó síndrome de Barré-Lieou en el Hospital Provincial General Docente Dr. Antonio Luaces Iraola de Ciego de Ávila, por lo cual fue atendido en consultas multidisciplinarias. Mediante la radiografía contrastada del esófago se observó compresión extrínseca de su tercio distal por grandes osteofitos cervicales anteriores, así como estrechamiento anterior y posterior desde la cuarta hasta la séptima vértebras cervicales; asimismo, las imágenes de la resonancia magnética de cráneo y columna cervical permitieron comprobar la presencia de complejos disco-osteofitos de vértebras cervicales con edema óseo, de carácter compresivo. Se comenta sobre el tratamiento empleado y se ofrecen las sugerencias terapéuticas de los expertos en el tema.

The case report of a 85 years elderly to whom the Barré-Lieou syndrome was diagnosed in Dr. Antonio Luaces Iraola Teaching General Provincial Hospital in Ciego de Ávila is described, reason why he was assisted in multidisciplinary visits. By means of the contrasted x-ray of the esophagus, extrinsic compression of his distal third was observed caused by huge anterior cervical osteophytes, as well as early and posterior narrowing of the fourth to the seventh cervical vertebrae; also, the magnetic resonance images of skull and cervical spine allowed to check the presence of disk-osteophytes complexes of cervical vertebrae, with bony edema, of compressive character. It is commented on the used treatment and the therapeutic indications of experts in the topic are offered.