Student survey after ten years of continuous blended teaching of echocardiography.

OBJECTIVE: To analyse the impact of 10 years of blended echocardiography teaching. METHODS AND RESULTS: A questionnaire was emailed to all medical doctors who graduated from the blended learning diploma in echocardiography developed by the University of Chile and taught by a team from Chile and Spain. One hundred and forty of the 210 students who graduated from the program between 2011 and 2020 completed the questionnaire: 53.57% were anaesthesiologists, and 26.42% were intensivists. More than 85% of respondents indicated that the online teaching met their expectations, and 70.2% indicated that the hands-on practice fulfilled the stated objectives. In a retrospective analysis using self-reported data, graduates reported that their use of transthoracic and transoesophageal echocardiography has increased from 24.29% to 40.71% and from 13.57% to 27.86%, repectively, after the programme compared to before the programme. They used echocardiography mainly in the perioperative period (56.7%) and during intensive care (32.3%), while only 11% of respondents used it in emergency care units. Nearly all (92.4%) respondents reported that the skills learned was very useful in their professional practice. CONCLUSIONS: Ten years after its launch, the blended learning diploma in echocardiography was well rated by graduate specialists, and is associated with a significant increase in the use of echocardiography in the perioperative period and during intensive care. The main challenges are to establish a longer period of practice and achieve greater implantation in emergency medicine.

Serum osteoprotegerin in prevalent hemodialysis patients: associations with mortality, atherosclerosis and cardiac function.

BACKGROUND: To assess whether serum osteoprotegerin (OPG) and/or fetuin-A predict mortality and cardiovascular (CV) morbidity and mortality in hemodialysis patients. METHODS: Multicenter, observational, prospective study that included 220 hemodialysis patients followed up for up to 6 years. Serum OPG and fetuin-A levels were measured at baseline and their possible association with clinical characteristics, CV risk biomarkers, carotid ultrasonographic findings, as well as their association with overall and CV mortality and CV events were assessed. RESULTS: During a mean follow-up of 3.22 ± 1.91 years, there were 74 deaths (33.6%) and 86 new cardiovascular events. In the Kaplan-Meier survival analysis, the highest tertile of OPG levels was associated with higher overall mortality (p = 0.005), as well as a higher, although non-significant, incidence of CV events and CV mortality. In contrast, fetuin-A levels did not predict any of these events. OPG levels were directly associated with age, the Charlson comorbidity index (CCI), prevalent cardiovascular disease, carotid intima-media thickness, adiponectin, troponin-I and brain natriuretic peptide (BNP). OPG showed a negative correlation with left ventricular ejection fraction (LVEF) and phosphate levels. In the multivariate Cox proportional hazard analysis, all-cause mortality was associated with the highest tertile of OPG (HR:1.957, p = 0.018), age (HR:1.031, p = 0.036), smoking history (HR:2.122, p = 0.005), the CCI (HR:1.254, p = 0.004), troponin-I (HR:3.894, p = 0.042), IL-18 (HR:1.061, p < 0.001) and albumin levels (HR:0.886, p < 0.001). In the bootstrapping Cox regression analysis, the best cut-off value of OPG associated with mortality was 17.69 pmol/L (95%CI: 5.1-18.02). CONCLUSIONS: OPG, but not fetuin-A levels, are independently associated with overall mortality, as well as clinical and subclinical atherosclerosis and cardiac function, in prevalent hemodialysis patients.

A rare cause of severe mitral stenosis and reversible pulmonary hypertension.

Myxoma is a rare cause of severe mitral stenosis. We describe a challenging case of severe mitral stenosis and reversible pulmonary hypertension produced by a giant left atrial myxoma. The greatest risk is a diagnostic delay due to focus on discarding a pulmonary etiology of dyspnea. Physical examination and early echocardiographic assessment are the keys to avoid overlooking this uncommon pathology.

Characterizing the spectrum of right ventricular remodelling in response to chronic training.

The significance and spectrum of reduced right ventricular (RV) deformation, reported in endurance athletes, is unclear. To comprehensively analyze the cardiac performance at rest of athletes, especially focusing on integrating RV size and deformation to unravel the underlying triggers of this ventricular remodelling. Hundred professional male athletes and 50 sedentary healthy males of similar age were prospectively studied. Conventional echocardiographic parameters of all four chambers were obtained, as well as 2D echo-derived strain (2DSE) in the left (LV) and in the RV free wall with separate additional analysis of the RV basal and apical segments. Left and right-sided dimensions were larger in athletes than in controls, but with a disproportionate RA enlargement. RV global strain was lower in sportsmen (-26.8 ± 2.8% vs -28.5 ± 3.4%, p < 0.001) due to a decrease in the basal segment (-22.8 ± 3.5% vs -25.8 ± 4.0%, p < 0.001) resulting in a marked gradient of deformation from the RV inlet towards the apex. By integrating size, deformation and stroke volume, we observed that the LV working conditions were similar in all sportsmen while a wider variability existed in the RV. Cardiac remodelling in athletes is more pronounced in the right heart cavities with specific regional differences within the right ventricle, but with a wide variability among individuals. The large inter-individual differences, as well as its acute and chronic relevance warrant further investigation.

Minimally Invasive Transradial Percutaneous Closure of Aortic Paravalvular Leaks: Following the Steps of Percutaneous Coronary Intervention.

Two patients with severe aortic paravalvular leaks (PVLs) in a mechanical prosthesis were percutaneously treated. Procedures were performed with mild sedation, angiographic guidance, and a 6-French right radial artery approach with good final results. Percutaneous PVL treatment is routinely performed with general anaesthesia, transesophageal echocardiographic guidance, and femoral access. Although another case of radial aortic PVL closure has been previously reported, it was performed with an 8-French radial sheath, transesophageal echocardiographic guidance, and general anaesthesia. According to our initial experience, aortic PVLs could be treated in a minimally invasive way. Larger studies should be conducted to confirm these observations.

Utilidad del ecocardiograma en la revisión preparticipativa de deportistas de competición / Usefulness of Echocardiography in Preparticipation Screening of Competitive Athletes

Introducción y objetivos A pesar del establecido valor diagnóstico del electrocardiograma en la revisión preparticipativa de sujetos deportistas, algunas alteraciones estructurales cardiacas podrían pasar inadvertidas, en especial en fases precoces de la enfermedad. El objetivo de este estudio es valorar la prevalencia de alteraciones estructurales cardiacas mediante el uso sistemático de la ecocardiografía en la revisión preparticipativa de deportistas de competición. Métodos Se estudió a los deportistas incluidos en un programa de competición o profesionales. Se realizó a todos los deportistas una revisión que incluyó historia familiar y personal, examen físico, electrocardiograma, prueba de esfuerzo y ecocardiograma Doppler. Resultados Se incluyó a 2.688 deportistas (el 67% varones; media de edad, 21 ± 10 años). La mayoría de los estudios ecocardiográficos (92,5%) fueron estrictamente normales y solo 203 (7,5%) tenían alteraciones; la más frecuente de ellas fue la hipertrofia ventricular izquierda, en 50 deportistas (1,8%). En 4 casos (0,14%) se indicó el cese de la práctica deportiva: 2 por miocardiopatía hipertrófica (el electrocardiograma mostraba alteraciones pero no cumplía criterios diagnósticos), 1 pectus excavatum con compresión del ventrículo derecho y 1 estenosis valvular pulmonar significativa; el resto de las alteraciones no implicaron el cese de la práctica deportiva y solo requirieron seguimiento periódico. Conclusiones: Algunas alteraciones estructurales cardiacas, aunque poco frecuentes, pueden pasar inadvertidas al examen físico y en el electrocardiograma; en cambio, son fácilmente reconocibles con un ecocardiograma. Estas observaciones indican introducir el ecocardiograma al menos en la primera valoración preparticipativa de deportistas de competición para mejorar la eficacia de los programas de prevención de la muerte súbita del deportista (AU)

Introduction and objectives Despite the established diagnostic value of the electrocardiogram in preparticipation screening of athletes, some cardiac structural changes can be missed, particularly in early disease stages. The aim of this study was to evaluate the prevalence of cardiac structural changes via the systematic use of echocardiography in preparticipation screening of competitive athletes. Methods Professional athletes or participants in a competitive athletic program underwent a screening that included family and personal medical history, physical examination, electrocardiography, exercise testing, and Doppler echocardiography. Results A total of 2688 athletes (67% men; mean age [standard deviation], 21 [10] years) were included. Most of the echocardiographic evaluations (92.5%) were normal and only 203 (7.5%) showed changes; the most frequent change was left ventricular hypertrophy, seen in 50 athletes (1.8%). Cessation of athletic activity was indicated in 4 athletes (0.14%): 2 for hypertrophic cardiomyopathy (electrocardiography had shown changes that did not meet diagnostic criteria), 1 pectus excavatum with compression of the right ventricle, and 1 significant pulmonary valve stenosis; the rest of the changes did not entail cessation of athletic activity and only indicated periodic monitoring. Conclusions Although rare, some cardiac structural changes can be missed on physical examination and electrocardiography; in contrast, they are easily recognized with echocardiography. These findings suggest the use of echocardiography in at least the first preparticipation screening of competitive athletes to improve the effectiveness of programs aimed at preventing sudden death in athletes (AU)

Usefulness of echocardiography in preparticipation screening of competitive athletes.

INTRODUCTION AND OBJECTIVES: Despite the established diagnostic value of the electrocardiogram in preparticipation screening of athletes, some cardiac structural changes can be missed, particularly in early disease stages. The aim of this study was to evaluate the prevalence of cardiac structural changes via the systematic use of echocardiography in preparticipation screening of competitive athletes. METHODS: Professional athletes or participants in a competitive athletic program underwent a screening that included family and personal medical history, physical examination, electrocardiography, exercise testing, and Doppler echocardiography. RESULTS: A total of 2688 athletes (67% men; mean age [standard deviation], 21 [10] years) were included. Most of the echocardiographic evaluations (92.5%) were normal and only 203 (7.5%) showed changes; the most frequent change was left ventricular hypertrophy, seen in 50 athletes (1.8%). Cessation of athletic activity was indicated in 4 athletes (0.14%): 2 for hypertrophic cardiomyopathy (electrocardiography had shown changes that did not meet diagnostic criteria), 1 pectus excavatum with compression of the right ventricle, and 1 significant pulmonary valve stenosis; the rest of the changes did not entail cessation of athletic activity and only indicated periodic monitoring. CONCLUSIONS: Although rare, some cardiac structural changes can be missed on physical examination and electrocardiography; in contrast, they are easily recognized with echocardiography. These findings suggest the use of echocardiography in at least the first preparticipation screening of competitive athletes to improve the effectiveness of programs aimed at preventing sudden death in athletes.

Risk factors for pericardial effusion in native valve infective endocarditis and its influence on outcome.

Data on the incidence, associated factors, and prognosis of pericardial effusion (PE) in patients with infective endocarditis (IE) are scarce. Patients with native valve IE were prospectively followed in our center from 1990 to 2007. A logistic regression analysis was performed to identify independent variables associated with PE and mortality. We included 479 episodes of IE from 459 patients (70% men, mean age 51 years). Small-to-moderate PE was observed in 109 episodes (23%) and large-to-very large PE was observed in 9 episodes (2%). Patients with small-to-moderate PE had a greater prevalence of intravenous drug use (38% vs 23%) and more frequent right-sided IE than patients without PE (33% vs 17%). Patients with large-to-very large PE had a higher rate of systemic emboli (22% vs 18%) and periannular abscess (22% vs 6%) than patients without PE. Renal failure was associated with a higher risk of PE (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.3 to 3.3); age was associated with a lower risk of PE (OR 0.98, 95% CI 0.97 to 0.99). One-year mortality of patients with IE with large-to-very large PE was higher than that of patients with small-to-moderate and absence of PE (56%, 18%, and 24%, respectively, p = 0.033). Large-to-very large PE increases the 1-year mortality of IE (OR 3.0, 95% CI 1.2 to 7.9). In conclusion, renal failure and younger age are associated with a higher risk of PE. Large-to-very large PE was associated with an increase in 1-year mortality.

Nocturnal, every-other-day, online haemodiafiltration: an effective therapeutic alternative.

BACKGROUND: Longer and more frequent dialysis sessions have demonstrated excellent survival and clinical advantages, while online haemodiafiltration (OL-HDF) provides the most efficient form of dialysis treatment. The aim of this study was to evaluate the beneficial effects of a longer (nocturnal) and more frequent (every-other-day) dialysis schedule with OL-HDF at the same or the highest convective volume. METHODS: This prospective, in-centre crossover study was carried out in 26 patients, 18 males and 8 females, 49.2±14 years old, on 4-5 h thrice-weekly post-dilution OL-HDF, switched to nocturnal every-other-day OL-HDF. Patient inclusion criteria consisted of stable patients with good vascular access and with good prospects for improved occupational, psychological and social rehabilitation. Patients were randomly assigned into two groups: Group A received the same convective volume as previously for 6 months followed by a higher convective volume for a further 6 months, while Group B received the same schedule in reverse order. RESULTS: Nocturnal every-other-day OL-HDF was well tolerated and 56% of patients who were working during the baseline period continued to work throughout the study with practically no absenteeism. The convective volume was 26.7±2 L at baseline, 27.5±2 with the unchanged volume and 42.9±4 L with the higher volume. eKt/V increased from 1.75±0.4 to 3.37±0.9. Bicarbonate, blood urea nitrogen (BUN) and creatinine values decreased, while phosphate levels fell markedly with a 90% reduction in phosphate binders. Blood pressure and left ventricular hypertrophy (LVH) improved and the use of anti-hypertensive drugs decreased. In both groups, BUN, creatinine and ß2-microglobulin reduction ratios improved. Different removal patterns were observed for myoglobin, prolactin and α1-acid glycoprotein. CONCLUSIONS: Nocturnal every-other-day OL-HDF could be an excellent therapeutic alternative since good tolerance and occupational rehabilitation, marked improvement in dialysis dose, nutritional status, LVH, phosphate and hypertension control and a substantial reduction in drug requirements were observed. In this crossover study, different removal patterns of large solutes were identified.

Remodelado auricular adverso en atletas de alto rendimiento: Estudio de deformación auricular con speckle tracking 2D / Adverse left atrial remodeling in highly trained athletes: an echocardiography study using 2D speckle tracking

Background: Highly trained athletes are at increased risk of atrial fibrillation (AF) and flutter. Atrial dilatation and dysfunction might be the underlying substrate for the increased risk. The aim of the present study was to relate atrial size and deformation in a selected group of highly trained athletes and patients with paroxysmal atrial fibrillation (PAF). Methods: 20 professional male hand-ball players, 18 patients with PAF and 20 healthy age-matched, non-sportive males were compared. All subjects underwent a transthoracic echocardiogram with evaluation of left atrial (LA) dimensions. Left atrial strain (LASa) and strain rate (LASRa) derived from speckle tracking were used to evaluate LA deformation post atrial contraction. Results: LA volumes were significantly larger in athletes and PAF patients compared to controls (36 + 1.7 ml/m2; 36 ± 2.3 ml/m2 and 24 + 1 ml/m2, respectively, p < 0.01;). LASa and LASRa during active atrial contraction were decreased in PAF patients compared to athletes and controls (-10.6 ± 0.2 %; -12.2 ± 0.4 % and -14.5 ± 0.5 %, p < 0.01 for LASa and -1.2 ± 0.08 sec-1; -1.5 ± 0.12 sec-1; -1.7 ± 0.13 sec-1, p= 0.04 for LASRa respectively). Athletes with LA volume > 40 ml/m2 (n=7) showed reduced LASa compared to athletes with LA volume < 40 mL/m2 (-10.3 ± 0.4% versus -13.0 ± 0.5%, p < 0.01). PAF patients had LASa values similar to those of subjects with normal LA volume. Conclusion: Athletes with increased LA volume exhibit lower strain parameters compared to subjects with PAF. It is postulated that measurement of LA strain may be used to predict development of AF in highly trained athletes.

Introducción: Atletas de alto rendimiento tienen un riesgo aumentado de desarrollar fibrilacion auricular (FA) y flutter. La dilatación y disfunción auricular podrían ser el sustrato subyacente para este incremento en el riesgo. El objetivo fue analizar y relacionar el tamaño y deformación auricular en un grupo seleccionado de atletas y en pacientes con FA paroxística. Métodos: Se incluyeron 20 jugadores de balón-mano profesionales y 20 controles sedentarios, pareados por edad y sexo, junto a 18 pacientes con FA paroxística. En todos los sujetos se realizó un estudio ecocardiográfico bidimensional con evaluación de las dimensiones y de la deformación (post contracción auricular) por strain (Sa) y strain rate (SRa) de la aurícula izquierda (AI). Resultados: El volumen AI fue significativamente mayor en atletas y pacientes con FA respecto de los controles (36 + 1,7 ml/m2; 36 ± 2,3 ml/m2 y 24 + 1 ml/m2, p < 0,01; respectivamente). El SaAI y SRaAI durante la contracción auricular estaban disminuidos en los pacientes con FA paroxística respecto de atletas y controles (-10,6 ± 0,2 %; -12,2 ± 0,4 % y -14,5 ± 0,5 %, p < 0,01 para SaAI y -1,2 ± 0,08 sec-1; -1,5 ± 0,12 sec-1; -1,7 ± 0,13 sec-1, p= 0,04 para SRaAI, respectivamente). Los atletas con un volumen AI > 40 ml/m2 (n=7) mostraron valores reducidos de SaAI comparados con atletas con un volumen AI < 40 mL/m2 (-10,3 ± 0,4% versus -13,0 ± 0,5%, p < 0,01) y éstos fueron similares a los pacientes con FA (-10,3 ± 0,4% versus -10,6 ± 0,2%, p= 0,6). Conclusiones: Una proporción de atletas con dilatación AI presentan evidencia de disfunción contráctil de la AI, caracterizado por valores de strain disminuidos que son similares a los de pacientes con FA paroxística. Esto podría corresponder a un sustrato para el desarrollo posterior de arritmias auriculares en estos atletas.

Chagas cardiomyopathy: the potential of diastolic dysfunction and brain natriuretic peptide in the early identification of cardiac damage.

INTRODUCTION: Chagas disease remains a major cause of mortality in several countries of Latin America and has become a potential public health problem in non-endemic countries as a result of migration flows. Cardiac involvement represents the main cause of mortality, but its diagnosis is still based on nonspecific criteria with poor sensitivity. Early identification of patients with cardiac involvement is desirable, since early treatment may improve prognosis. This study aimed to assess the role of diastolic dysfunction, abnormal myocardial strain and elevated brain natriuretic peptide (BNP) in the early identification of cardiac involvement in Chagas disease. METHODOLOGY/PRINCIPAL FINDINGS: Fifty-four patients divided into 3 groups--group 1 (undetermined form: positive serology without ECG or 2D-echocardiographic abnormalities; N = 32), group 2 (typical ECG abnormalities of Chagas disease but normal 2D-echocardiography; N = 14), and group 3 (regional wall motion abnormalities, left ventricular [LV] end-diastolic diameter >55 mm or LV ejection fraction <50% on echocardiography; N = 8)--and 44 control subjects were studied. Patients with significant non-cardiac diseases, other heart diseases and previous treatment with benznidazol were excluded. The median age was 37 (20-58) years; 40% were men. BNP levels, longitudinal and radial myocardial strain and LV diastolic dysfunction increased progressively from group 1 to 3 (p for trend <0.01). Abnormal BNP levels (>37 pg/ml) were noted in 0%, 13%, 29% and 63% in controls and groups 1 to 3, respectively. Half of patients in the undetermined form had impaired relaxation patterns, whereas half of patients with ECG abnormalities suggestive of Chagas cardiomyopathy had normal diastolic function. In group 1, BNP levels were statistically higher in patients with diastolic dysfunction as compared to those with normal diastolic function (27 ± 26 vs. 11 ± 8 pg/ml, p = 0.03). CONCLUSION/SIGNIFICANCE: In conclusion, the combination of diastolic function and BNP measurement adds important information that could help to better stratify patients with Chagas disease.

Relation of plasma brain natriuretic peptide levels on admission for ST-elevation myocardial infarction to left ventricular end-diastolic volume six months later measured by both echocardiography and cardiac magnetic resonance.

The main objective of this study was to investigate the relation between brain natriuretic peptide (BNP) levels within the first 96 hours after ST-segment elevation acute myocardial infarction (STEMI) and the development of left ventricular (LV) dilatation at 6-month follow-up. Eighty-two patients with first STEMIs, reperfused within 12 hours of symptom onset, were prospectively included. Plasma BNP was determined on admission and at 1- and 6-month follow-up. Clinically significant LV dilatation, defined as a >20% increase in LV end-diastolic volume at 6-month follow-up, was assessed using echocardiography and cardiac magnetic resonance. Thirty-two percent of patients developed clinically significant LV dilatation. BNP values on admission and at follow-up were significantly higher in patients who developed clinically significant LV dilatation at 6 months (182 +/- 117 vs 106 +/- 91 pmol/ml). After adjusting for age, infarct size, E-wave deceleration time, and the LV ejection fraction, BNP on admission was an independent predictor of LV dilatation, whether assessed by echocardiography (B = 0.075, p = 0.04) or cardiac magnetic resonance (B = 0.085, p = 0.04). In conclusion, high BNP levels on admission and at follow-up predict LV dilatation after STEMI. The early determination of plasma BNP upon admission for STEMI could be helpful in identifying patients at higher risk for LV dilatation, in whom aggressive management is warranted.

Long-term effect of cardiac resynchronization therapy on functional mitral valve regurgitation.

Cardiac resynchronization therapy (CRT) has been shown to reduce functional mitral regurgitation (MR). The aims of this study were to analyze the underlying mechanisms leading to this reduction and to identify the best candidates with functional MR for this therapy. Changes in mitral geometry, left ventricular (LV) remodeling, and LV synchrony were studied in patients who underwent CRT acutely and at 6- and 12-month follow-up. Of 151 patients (mean age 69 +/- 9 years, 82% men) who underwent CRT, 57 (38%) had nontrivial MR (regurgitant orifice area > or =10 mm(2)). The median reduction of MR with CRT was 18% acutely and 38% at 12-month follow-up. CRT induced an acute improvement in LV systolic function (LV dP/dt from 508 +/- 143 to 700 +/- 249 mm Hg, p <0.05) and a reduction in dyssynchrony (interventricular delay from 51 +/- 31 to 29 +/- 27 ms, p <0.05). At 12-month follow-up, additional reverse global and local LV remodeling (LV end-systolic volume from 183 +/- 77 to 151 +/- 50 ml, tenting area from 3.36 +/- 0.98 to 2.78 +/- 0.75 cm, p <0.05 for both) and a reduction in LV dyssynchrony (septal-lateral delay from 90 +/- 63 to 53 +/- 42 ms, p <0.05) were found. Significant reductions in MR were found in 28 patients (49%) and similarly observed in either ischemic MR or functional MR of other causes. Baseline mitral tenting area was the strongest predictor of significant MR reduction with CRT. In conclusion, CRT induced acute and sustained reductions in functional MR in almost 50% of patients by initially improving LV systolic function and dyssynchrony; long-term reverse LV remodeling contributed to this sustained effect. Patients with larger mitral valve tenting areas are less amenable to benefit from CRT.

[Influence of cardiopathy etiology on responses to cardiac resynchronization therapy]. / Influencia de la cardiopatía subyacente en la respuesta a la terapia de resincronización cardiaca.

INTRODUCTION AND OBJECTIVES: Little is known about how responses to cardiac resynchronization therapy (CRT) are affected by the nature of the underlying cardiopathy. The aim of this study was to investigate how cardiopathy etiology influences the effect of CRT on reverse left ventricular remodeling. METHODS: The study included 106 patients with left ventricular systolic dysfunction and left bundle branch block (LBBB) who were receiving CRT. Clinical and echocardiographic investigations were performed at baseline before implantation and at 6 and 12 month follow-up to determine left ventricular diameter, volume and systolic function, and to quantify mitral regurgitation. RESULTS: During follow-up, it was observed that CRT reduced left ventricular volume and diameter, increased left ventricular ejection fraction (LVEF), and reduced mitral regurgitation severity irrespective of the etiology of the cardiopathy. In patients with ischemic dilated cardiomyopathy, LVEF increased by 34% and end-diastolic and end-systolic volumes decreased by 4% and 12%, respectively; in those with idiopathic dilated cardiomyopathy, LVEF increased by 38% and end-diastolic and end-systolic volumes decreased by 13% and 19%, respectively (P=NS for ischemic vs. non-ischemic disease). Nor were differences observed between the groups in clinical outcome: 74% of the ischemic group responded compared with 62% of the non-ischemic group (P=NS). CONCLUSIONS: At 12-month follow-up, patients with left ventricular systolic dysfunction and LBBB treated by CRT showed clinical improvements and demonstrated reverse ventricular remodeling, irrespective of the etiology of their cardiopathy.

Influencia de la cardiopatía subyacente en la respuesta a la terapia de resincronización cardiaca / Influence of cardiopathy etiology on responses to cardiac resynchronization therapy

Introducción y objetivos. La influencia del tipo de cardiopatía en la respuesta a la terapia de resincronización cardiaca (TRC) es poco conocida. El objetivo de este estudio fue analizar el efecto de la TRC en el remodelado, en función de la etiología de la cardiopatía subyacente. Métodos. Se incluyó a 106 pacientes con disfunción sistólica del ventrículo izquierdo (VI) y bloqueo de rama izquierda del haz de His (BRIHH) tratados con TRC. Se les realizó una evaluación clínica y ecocardiográfica para estudiar los diámetros, los volúmenes y la función sistólica del VI y cuantificar la insuficiencia mitral, antes del implante y a los 6 y los 12 meses de seguimiento. Resultados. La TRC indujo en el seguimiento una reducción de los volúmenes y diámetros ventriculares, aumentó la fracción de eyección (FE) y se redujo la insuficiencia mitral independientemente de la etiología de la cardiopatía: los pacientes isquémicos (MCD-CI) incrementaron la FE del VI (FEVI) un 34% y los volúmenes telediastólico y telesistólico se redujeron en el 4 y el 12% frente a un incremento de la FE del 38% y una reducción de volúmenes del 13 y el 19% en los pacientes con miocardiopatía dilatada idiopática (MCD) (sin diferencia significativa entre MCD-CI y MCD). Tampoco se encontraron diferencias en el número de respondedores clínicos: el 74% en los pacientes con MCD-CI y el 62% de los portadores de una MCD (sin diferencia significativa). Conclusiones. A los 12 meses de seguimiento, los pacientes con disfunción sistólica del VI y BRIHH tratados con TRC presentaron mejoría clínica y un remodelado ventricular inverso independientemente de la etiología de su cardiopatía (AU)

Introduction and objectives. Little is known about how responses to cardiac resynchronization therapy (CRT) are affected by the nature of the underlying cardiopathy. The aim of this study was to investigate how cardiopathy etiology influences the effect of CRT on reverse left ventricular remodeling. Methods. The study included 106 patients with left ventricular systolic dysfunction and left bundle branch block (LBBB) who were receiving CRT. Clinical and echocardiographic investigations were performed at baseline before implantation and at 6 and 12 month follow-up to determine left ventricular diameter, volume and systolic function, and to quantify mitral regurgitation. Results. During follow-up, it was observed that CRT reduced left ventricular volume and diameter, increased left ventricular ejection fraction (LVEF), and reduced mitral regurgitation severity irrespective of the etiology of the cardiopathy. In patients with ischemic dilated cardiomyopathy, LVEF increased by 34% and end-diastolic and end-systolic volumes decreased by 4% and 12%, respectively; in those with idiopathic dilated cardiomyopathy, LVEF increased by 38% and end-diastolic and end-systolic volumes decreased by 13% and 19%, respectively (P=NS for ischemic vs. non-ischemic disease). Nor were differences observed between the groups in clinical outcome: 74% of the ischemic group responded compared with 62% of the non-ischemic group (P=NS). Conclusions. At 12-month follow-up, patients with left ventricular systolic dysfunction and LBBB treated by CRT showed clinical improvements and demonstrated reverse ventricular remodeling, irrespective of the etiology of their cardiopathy (AU)

Optimizing the programation of cardiac resynchronization therapy devices in patients with heart failure and left bundle branch block.

This study was conducted to investigate the clinical impact of cardiac resynchronization device optimization. A series of 100 consecutive patients received cardiac resynchronization therapy. In the first 49 patients, an empirical atrioventricular delay of 120 ms was set, with simultaneous biventricular stimulation (interventricular [VV] interval=0 ms). In the next 51 patients, systematic atrioventricular optimization was performed. VV optimization was also performed, selecting 1 VV delay: right or left ventricular preactivation (+30 or -30 ms) or simultaneous (VV interval=0 ms), according to the best synchrony obtained by tissue Doppler-derived wall displacement. At follow-up, patients who were alive without cardiac transplantation and showed improvement of >or=10% in the distance walked in the 6-minute walking test were considered responders. There were no differences between the 2 groups at baseline. Left ventricular ejection fraction improved in the 2 groups, but left ventricular cardiac output improved only in the optimized group. At 6 months, patients with optimized devices walked slightly further in the 6-minute walking test (497+/-167 vs 393+/-123 m, p<0.01), with no differences in New York Heart Association functional class or quality of life compared with nonoptimized patients. Overall, the number of nonresponders were similar in the 2 groups (27% vs 23%, p=NS). In conclusion, the echocardiographic optimization of cardiac resynchronization devices provided a slight incremental clinical benefit at midterm follow-up. Simple and rapid methods to routinely optimize the devices are warranted.

Usefulness of ventricular dyssynchrony measured using M-mode echocardiography to predict response to resynchronization therapy.

There are discordant data about the utility of septal-to-posterior wall motion delay (SPWMD) assessed using M-mode echocardiography to predict an improvement with cardiac resynchronization therapy (CRT). Baseline SPWMD was measured using M-mode in a parasternal short-axis view in a series of 67 patients undergoing CRT and followed up after 6 months. Heart failure was caused by coronary artery disease in 27 patients. Clinical responders were patients who were alive, had not undergone heart transplantation, and also increased the distance walked in 6 minutes by >10%. Baseline SPWMDs were mean 155 +/- 113 ms and median 135. Thirty-four patients (51%) had an SPWMD >130 ms. At 6-month follow-up, there were 17 nonresponders. At baseline, there were no significant differences between patients with SPWMD >130 or <130 ms in age, drug therapy, permanent atrial fibrillation, New York Heart Association functional class, underlying cause of cardiomyopathy, QRS duration, left ventricular (LV) ejection fraction, LV dimensions, or neurohormonal activation (norepinephrine and atrial and brain natriuretic peptide). At 6-month follow-up, baseline SPWMD was not associated with clinical response, New York Heart Association functional class, distance walked in 6 minutes, LV reverse remodeling, or neurohormonal activation. SPWMD >130 ms was also not a predictor. In conclusion, SPWMD is not a good predictor of response to CRT.

Is there an anatomical substrate for idiopathic paroxysmal atrial fibrillation? A case-control echocardiographic study.

AIM: Idiopathic paroxysmal atrial fibrillation (AF) occurs in patients with apparently normal heart. Its mechanisms may be complex and are poorly understood. The aim of the study was to evaluate whether patients with idiopathic AF have any structural abnormality that may explain the occurrence of AF. METHODS AND RESULTS: A case-control study was undertaken including 60 consecutive patients (mean age 48 +/- 12 years; 75% men) with idiopathic AF admitted to the emergency department. Sixty sex- and age-matched healthy volunteers made up the control group. An echocardiogram was performed in all patients and volunteers to assess the left atrial (LA) and ventricular (LV) dimensions and valvular function. LV diastolic function was also evaluated by analysis of the LV inflow and pulmonary vein flow velocity patterns and tissue Doppler imaging of the mitral annulus. All AF patients showed normal echocardiographic studies with similar LV dimensions, ejection fraction, and diastolic function when compared with normal controls. However, patients with AF had larger LA dimensions (27 +/- 3 vs. 24 +/- 3 mm/m(2)), LA area (10 +/- 2 vs. 8 +/- 2 mm(2)/m(2)), and LA volume (27 +/- 9 vs. 19 +/- 6 mL/m(2)) (P < 0.05 for all). Among patients with AF, there were no differences in LA size between patients with a first episode or recurrent paroxysmal episodes. CONCLUSION: Patients with idiopathic AF showed larger left atria when compared with controls, there being no differences between patients with a first episode or a recurrence. This suggests the presence of an enhanced substrate to develop idiopathic lone AF.

A rare association of pheochromocytoma and thoracic paraganglioma: utility of 2D contrast enhanced echocardiography.

Pheochromocytomas with concomitant paragangliomas are very rare, particularly when the latter is located close to cardiac structures. We report a pheochromocytoma with an associated paraganglioma located adjacent to the left atrium as demonstrated by echocardiography.