Utilidad de la RM cardíaca en el pronóstico y seguimiento de la cardiopatía isquémica / Usefulness of cardiac MRI in the prognosis and follow-up of ischemic heart disease

La resonancia magnética cardíaca (cardiorresonancia magnética –CRM–) es una importante herramienta que permite evaluar en pacientes con enfermedad cardiovascular no solo el infarto y las alteraciones en la perfusión miocárdica, sino también otros fenómenos como la obstrucción microvascular y la isquemia. Los principales factores pronósticos en la CRM son la disfunción ventricular, la necrosis en las secuencias de realce tardío y la isquemia en las secuencias de estrés. En el infarto agudo de miocardio, la CRM puede evaluar la zona periinfarto y cuantificar el tamaño del infarto. Además, la capacidad de la CRM para detectar y evaluar la obstrucción microvascular la convierte en una herramienta fundamental para establecer el pronóstico de la cardiopatía isquémica. En los pacientes con cardiopatía isquémica crónica, la CRM puede detectar isquemia inducible con estrés farmacológico y diagnosticar infartos que pueden pasar desapercibidos con otras técnicas (AU)

Cardiac magnetic resonance imaging (MRI) is an important tool that makes it possible to evaluate patients with cardiovascular disease; in addition to infarction and alterations in myocardial perfusion, cardiac MRI is useful for evaluating other phenomena such as microvascular obstruction and ischemia. The main prognostic factors in cardiac MRI are ventricular dysfunction, necrosis in late enhancement sequences, and ischemia in stress sequences. In acute myocardial infarction, cardiac MRI can evaluate the peri-infarct zone and quantify the size of the infarct. Furthermore, cardiac MRI's ability to detect and evaluate microvascular obstruction makes it a fundamental tool for establishing the prognosis of ischemic heart disease. In patients with chronic ischemic heart disease, cardiac MRI can detect ischemia induced by pharmacological stress and can diagnose infarcts that can be missed on other techniques (AU)

Usefulness of cardiac MRI in the prognosis and follow-up of ischemic heart disease.

Cardiac magnetic resonance imaging (MRI) is an important tool that makes it possible to evaluate patients with cardiovascular disease; in addition to infarction and alterations in myocardial perfusion, cardiac MRI is useful for evaluating other phenomena such as microvascular obstruction and ischemia. The main prognostic factors in cardiac MRI are ventricular dysfunction, necrosis in late enhancement sequences, and ischemia in stress sequences. In acute myocardial infarction, cardiac MRI can evaluate the peri-infarct zone and quantify the size of the infarct. Furthermore, cardiac MRI's ability to detect and evaluate microvascular obstruction makes it a fundamental tool for establishing the prognosis of ischemic heart disease. In patients with chronic ischemic heart disease, cardiac MRI can detect ischemia induced by pharmacological stress and can diagnose infarcts that can be missed on other techniques.

Utilidad del calcio arterial coronario para detectar enfermedad arterial coronaria significativa en sujetos asintomáticos / Usefulness of coronary artery calcium for detecting significant coronary artery disease in asymptomatic individuals

Objetivos: Confirmar el valor de la puntuación o score del calcio arterial coronario (CAC) como indicador de enfermedad arterial coronaria (EAC) significativa en población española asintomática, mediante coronariografía no invasiva por tomografía computarizada multidetector (TCMD). Métodos: Estudio retrospectivo de 232 individuos asintomáticos, remitidos para un chequeo de salud cardiovascular que incluyó CAC y TCMD. Resultados: La edad media de los sujetos estudiados fue de 54,6 años (DE: 12,8; 73,3% varones). El valor medio del CAC fue de 117,8 (DE: 277). Los individuos con hipertensión arterial, diabetes mellitus, tabaquismo y con ≥3 factores de riesgo mostraron un CAC significativamente mayor. Un 16,4% de los sujetos se encontraban en el percentil poblacional ≥75 de CAC. La TCMD identificó a 148 individuos (63,8%) con EAC, siendo las lesiones coronarias no significativas en 116 individuos (50%) y significativas (estenosis>50%) en 32 (13,8%). Los sujetos con diabetes, tabaquismo y ≥3 factores de riesgo vascular mostraron una mayor prevalencia de estenosis significativa. Los individuos con estenosis>50% presentaron valores de CAC superiores (352,5 vs. 1; p<0,0001) y los de percentil ≥75 presentaron un alto porcentaje de lesiones (57,9 vs. 5,2%; p<0,0001). Como variables predictoras de EAC significativa destacaron el CAC >300 (OR=10,9; IC95%: 3,35-35,8; p=0,0001), ocupar un percentil ≥75 (OR=5,65; IC95%: 1,78-17,93; p=0,03) y la agrupación de ≥3 factores de riesgo vascular (OR=4,19; IC95%: 1,44-12,14; p=0,008). Conclusión: La cuantificación del CAC es un método eficaz para determinar la extensión y magnitud de la EAC y delimitar la capacidad predictiva de los factores de riesgo tradicionales (AU)

Objectives: To confirm the value of the coronary artery calcium (CAC) score as an indicator of significant coronary artery disease (CAD) in the asymptomatic Spanish population, using noninvasive coronary angiography by multidetector computed tomography (MDCT). Methods: This was a retrospective study of 232 asymptomatic individuals, referred for a cardiovascular health checkup that included CAC and MDCT. Results: Participants’ mean age was 54.6 years (SD±12.8); 73.3% of them were men. The mean CAC value was 117.8 (SD±277). The individuals with arterial hypertension, diabetes mellitus, smoking and 3 or more risk factors had significantly greater CAC scores. Some 16.4% of the participants were in the ≥75 percentile population for CAC. The MDCT identified 148 individuals (63.8%) with CAD; the coronary lesions were not significant in 116 individuals (50%) and were significant (>50% stenosis) in 32 (13.8%). The participants with diabetes, smoking and ≥3 risk vascular factors had a greater prevalence of significant stenosis. The individuals with >50% stenosis had higher CAC values (352.5 vs. 1; P<.0001), and those in the ≥75 percentile had a high percentage of significant lesions (57.9% vs. 5.2%; P<.0001). The predictors of significant CAD were a CAC score >300 (OR=10.9; 95% CI 3.35-35.8; P=.0001), belonging to the ≥75 percentile (OR=5.65; 95% CI 1.78-17.93; P=.03) and having 3 or more vascular risk factors (OR=4.19; 95% CI 1.44-12.14; P=.008). Conclusion: CAC quantification is an effective method for determining the extent and magnitude of CAD and delimiting the predictive capacity of traditional risk factor (AU)

Usefulness of coronary artery calcium for detecting significant coronary artery disease in asymptomatic individuals.

OBJECTIVES: To confirm the value of the coronary artery calcium (CAC) score as an indicator of significant coronary artery disease (CAD) in the asymptomatic Spanish population, using noninvasive coronary angiography by multidetector computed tomography (MDCT). METHODS: This was a retrospective study of 232 asymptomatic individuals, referred for a cardiovascular health checkup that included CAC and MDCT. RESULTS: Participants' mean age was 54.6 years (SD ± 12.8); 73.3% of them were men. The mean CAC value was 117.8 (SD ± 277). The individuals with arterial hypertension, diabetes mellitus, smoking and 3 or more risk factors had significantly greater CAC scores. Some 16.4% of the participants were in the ≥75 percentile population for CAC. The MDCT identified 148 individuals (63.8%) with CAD; the coronary lesions were not significant in 116 individuals (50%) and were significant (>50% stenosis) in 32 (13.8%). The participants with diabetes, smoking and ≥3 risk vascular factors had a greater prevalence of significant stenosis. The individuals with >50% stenosis had higher CAC values (352.5 vs. 1; P<.0001), and those in the ≥75 percentile had a high percentage of significant lesions (57.9% vs. 5.2%; P<.0001). The predictors of significant CAD were a CAC score >300 (OR=10.9; 95% CI 3.35-35.8; P=.0001), belonging to the ≥75 percentile (OR=5.65; 95% CI 1.78-17.93; P=.03) and having 3 or more vascular risk factors (OR=4.19; 95% CI 1.44-12.14; P=.008). CONCLUSION: CAC quantification is an effective method for determining the extent and magnitude of CAD and delimiting the predictive capacity of traditional risk factors.

Evaluación del ventrículo izquierdo por ecocardiografia tridimensional. Comparación con la Cardio-RM / Evaluation of the left ventricle with three-dimensional echocardiography: comparison with cardiac magnetic resonance

Objetivo. La implantación de la ecocardiografia tridimensional (E3D) en el ámbito clínico está experimentando importantes avances. Sin embargo, la calidad de imagen depende de la ventana acústica, y puede ser difícil la identificación de los bordes endocárdicos. El objetivo de este estudio fue comparar la E3D en la determinación de los volúmenes y la fracción de eyección del ventrículo izquierdo en pacientes no seleccionados, usando la resonancia magnética cardiaca (RMC) como patrón de referencia. Material y métodos. A 47 pacientes no seleccionados sometidos a un estudio de RMC, se les practicó también una E3D mediante la técnica de adquisición en tiempo real y análisis con detección semiautomática de los bordes. Resultados. Se excluyeron 4 pacientes (8,5%) por tener una ventana acústica extremadamente deficiente. En el resto (43 pacientes), incluyendo aquellos con una ventana subóptima, se obtuvo una correlación aceptable entre la E3D y la RMC: volumen telediastólico: 0,71; volumen telesistólico: 0,77; fracción de eyección: 0,74. Aunque hubo una infraestimación sistemática del volumen telediastólico, no se observaron diferencias significativas en la determinación de la fracción de eyección. Al excluir los 11 pacientes con ventana subóptima, se observó una infraestimación sistemática de los volúmenes telediastólico y telesistólico, lo que dio lugar paradójicamente a una mejoría de los coeficientes de correlación (0,79, 0,92, 0,84), resultando más exacta la fracción de eyección. Conclusiones. En comparación con la RMC, la E3D infraestima sistemáticamente los volúmenes ventriculares, pero permite la determinación adecuada de la fracción de eyección ventricular izquierda independientemente de la ventana acústica (AU)

Objective. Three-dimensional echocardiography (3DE) is becoming increasingly common in clinical environments. However, the quality of the images depends on the acoustic window, and it can be difficult to identify the endocardial borders. The objective of this study was to evaluate the performance of 3DE in determining the volumes and left ventricular ejection fraction in unselected patients against the gold standard, cardiac magnetic resonance (CMR). Material and methods. In 47 unselected patients who underwent CMR, we performed 3DE using a real-time acquisition technique and semiautomatic border detection. Results. We excluded 4 patients (8.5%) because they had an extremely deficient acoustic window. In the remaining 43 patients, including those with a suboptimal acoustic window, we obtained the following correlations between 3DE and CMR: end-diastolic volume, 0.71; end-systolic volume, 0.77; ejection fraction, 0.74. Although the end-diastolic volume was systematically underestimated, no significant differences were observed in the ejection fraction. When the 11 patients with suboptimal acoustic windows were excluded, we observed a systematic underestimation of the end-diastolic and end-systolic volumes, which paradoxically gave rise to improved correlation coefficients (0.79, 0.92, and 0.84, respectively) and a more accurate ejection fraction. Conclusions. Compared to CMR, 3DE systematically underestimates the ventricular volumes but enables adequate determination of the left ventricular ejection fraction regardless of the quality of the acoustic window (AU)

Optimización en la técnica de medida de la presión arterial pulmonar por ecocardiografía Doppler con el uso de contraste en pacientes con enfermedad pulmonar obstructiva crónica / Improvement in the measurement technique of pulmonary artery pressure by Doppler echocardiography with contrast in chronic obstructive pulmonary disease

Objetivo Evaluar el beneficio del contraste en la ecocardiografía para medir la presión de arteria pulmonar sistólica (PAPs). Diseño Estándar de referencia (ecocardiografía) comparada con contraste. Ambito Gabinete de ecocardiografia. Pacientes Ambulatorio con enfermedad pulmonar obstructiva crónica (EPOC). Intervención La señal de la regurgitación tricuspidea (RT) por Doppler fue evaluada antes y después de administrar contraste intravenoso (Levovist(R)). Se definió una escala de 4 patrones de señal de RT: 0=ausencia de regurgitación; 1=señal protosistólica que no permite la medida de la velocidad pico; 2=señal de intensidad no homogénea pero que permite la medida de la velocidad pico y 3=señal uniforme y pansistólica. El valor de la PAPs fue estimado añadiendo 10mmHg al gradiente transtricuspideo. Resultados La PAPs fue calculada solo en 20 (49%) pacientes antes del contraste. Diecisiete pacientes fueron clasificados en el patrón 2 y 3 en el patrón 3 de la señal de la RT. Tras la administración de contraste 41 (95%) pacientes mostraron señal de RT. Dos fueron clasificados en el patrón 1, 11 con el patrón 2 y 28 con el 3. En los 20 pacientes en los que la PAPs fue estimada antes del contraste se observó aumento de su valor, 44±10mmHg vs. 56±15mmHg (p<0,01). Conclusión El uso de un agente de contraste intravenoso en la ecocardiografía Doppler aumenta el número de pacientes EPOC en los que la PAPs puede ser estimada de manera no invasiva y podría evitar una infraestimación del valor de la PAPs (AU)

Objective To evaluate the benefit of contrast echocardiography in the assessment of systolic pulmonary artery pressure (PAPs). Design Compare standard reference (Doppler-echocardiography) with contrast. Location Echocardiography department. Patients Ambulatory chronic obstructive patient disease (COPD). Intervention Continuous wave Doppler spectral signal of tricuspid regurgitation (TR) was evaluated before and after intravenous injection of a galactose-based intravenous echo-enhancing agent. A four patterns scale classified the quality of the TR signal: 0=absent regurgitation; 1=protosystolic signal not allowing the recognition of peak velocity; 2=non-homogenous signal intensity, albeit allowing the measurement of maximal velocity; and 3=uniform pansystolic velocity signal. PAPs was estimated adding 10mmHg to the transtricuspid gradient, calculated from the TR peak velocity. Results PAPs was only calculated reliably in 20 (49%) patients before the administration of contrast. Seventeen patients were classified as pattern 2, and three as pattern 3 on the scale of the TR quality signal. After contrast 41 (95%) patients showed a reliable TR signal. Two were classified as pattern 1, 11 as pattern 2 and 28 as pattern 3 on the scale of the TR quality signal. In the 20 patients in whom PAPs was estimated before contrast, a significant increase in PAPs values occurred after contrast, 44±10mmHg vs. 56±15mmHg (p<0.01). ConclusionThe use of an echocardiography contrast agent increases the number of COPD patients in whom PAPs can be estimated non-invasively and may avoid underestimation of the PAP value (AU)

[Evaluation of the left ventricle with three-dimensional echocardiography: comparison with cardiac magnetic resonance]. / Evaluación del ventrículo izquierdo por ecocardiografia tridimensional. Comparación con la Cardio-RM.

OBJECTIVE: Three-dimensional echocardiography (3DE) is becoming increasingly common in clinical environments. However, the quality of the images depends on the acoustic window, and it can be difficult to identify the endocardial borders. The objective of this study was to evaluate the performance of 3DE in determining the volumes and left ventricular ejection fraction in unselected patients against the gold standard, cardiac magnetic resonance (CMR). MATERIAL AND METHODS: In 47 unselected patients who underwent CMR, we performed 3DE using a real-time acquisition technique and semiautomatic border detection. RESULTS: We excluded 4 patients (8.5%) because they had an extremely deficient acoustic window. In the remaining 43 patients, including those with a suboptimal acoustic window, we obtained the following correlations between 3DE and CMR: end-diastolic volume, 0.71; end-systolic volume, 0.77; ejection fraction, 0.74. Although the end-diastolic volume was systematically underestimated, no significant differences were observed in the ejection fraction. When the 11 patients with suboptimal acoustic windows were excluded, we observed a systematic underestimation of the end-diastolic and end-systolic volumes, which paradoxically gave rise to improved correlation coefficients (0.79, 0.92, and 0.84, respectively) and a more accurate ejection fraction. CONCLUSIONS: Compared to CMR, 3DE systematically underestimates the ventricular volumes but enables adequate determination of the left ventricular ejection fraction regardless of the quality of the acoustic window.

[Improvement in the measurement technique of pulmonary artery pressure by Doppler echocardiography with contrast in chronic obstructive pulmonary disease]. / Optimización en la técnica de medida de la presión arterial pulmonar por ecocardiografía Doppler con el uso de contraste en pacientes con enfermedad pulmonar obstructiva crónica.

OBJECTIVE: To evaluate the benefit of contrast echocardiography in the assessment of systolic pulmonary artery pressure (PAPs). DESIGN: Compare standard reference (Doppler-echocardiography) with contrast. LOCATION: Echocardiography department. PATIENTS: Ambulatory chronic obstructive patient disease (COPD). INTERVENTION: Continuous wave Doppler spectral signal of tricuspid regurgitation (TR) was evaluated before and after intravenous injection of a galactose-based intravenous echo-enhancing agent. A four patterns scale classified the quality of the TR signal: 0=absent regurgitation; 1=protosystolic signal not allowing the recognition of peak velocity; 2=non-homogenous signal intensity, albeit allowing the measurement of maximal velocity; and 3=uniform pansystolic velocity signal. PAPs was estimated adding 10 mm Hg to the transtricuspid gradient, calculated from the TR peak velocity. RESULTS: PAPs was only calculated reliably in 20 (49%) patients before the administration of contrast. Seventeen patients were classified as pattern 2, and three as pattern 3 on the scale of the TR quality signal. After contrast 41 (95%) patients showed a reliable TR signal. Two were classified as pattern 1, 11 as pattern 2 and 28 as pattern 3 on the scale of the TR quality signal. In the 20 patients in whom PAPs was estimated before contrast, a significant increase in PAPs values occurred after contrast, 44±10 mm Hg vs. 56±15 mm Hg (p<0.01). CONCLUSION: The use of an echocardiography contrast agent increases the number of COPD patients in whom PAPs can be estimated non-invasively and may avoid underestimation of the PAP value.

An unusual case of bioprosthetic mitral valve thrombosis.

Bioprosthetic valve thrombosis and related embolism are considered extremely unlikely, thus allowing most patients to avoid long-term anticoagulation. There is, however, limited experience in the diagnosis and treatment of such a condition. We present the case of a patient with a porcine mitral bioprosthesis who presented with acute thrombosis with unusual echocardiographic features. A favorable outcome was observed after conventional anticoagulant treatment.

Myocardial cell damage in human hypertension.

OBJECTIVES: The goal of this study was to investigate the presence of myocardial cell damage in patients with systemic hypertension and its relationship with left ventricular hypertrophy (LVH). BACKGROUND: Although initially compensatory, LVH adversely affects myocellular integrity and contributes to congestive heart failure in hypertensive patients. Noninvasive detection of myocardial damage can be of value. METHODS: We performed imaging studies with 111In-labeled monoclonal antimyosin antibodies to identify myocardial damage in 39 patients with systemic hypertension and variable degrees of LVH. Three groups were considered: 16 asymptomatic patients with normal echocardiographic left ventricular mass (LVM) (group I); 14 asymptomatic patients with LVH (group II) and 9 patients with symptomatic hypertensive heart disease and advanced LVH (group III). The severity of myocardial damage was represented as heart-to-lung (target-to-background) antibody uptake ratio (normal: <1.55). RESULTS: Mean LVM index was 105+/-14 g/m2 in group I, 124+/-24 in group II and 174+/-29 in group III. Heart-to-lung ratios of antimyosin uptake were: 1.45+/-0.14 in group I, 4 of the 16 (25%) patients showing an abnormal scan; 1.50+/-0.07 in group II with abnormal scans in 2 of the 14 (16%) patients and 1.77+/-0.16 (p < 0.001) in group III, all 9 patients presenting with abnormal antimyosin scans. On multivariate regression analysis LVM index was the main variable that independently correlated with the degree of myocardial uptake of antimyosin (r = 0.815; p = 0.001). CONCLUSIONS: This study provides the first in vivo evidence of myocyte damage in patients with hypertension. The severity of myocardial damage can be related to the magnitude of LVH.

[Heart angiosarcoma: heart magnetic resonance diagnosis]. / Angiosarcoma cardíaco: diagnóstico por resonancia magnética cardíaca.

The case of a young male with a primary cardiac angiosarcoma of the right atrium is reported. The patient presented with a relapsing cardiac tamponade due to hemopericardium, the diagnosis being made by magnetic resonance. The resection of the tumor did not prevent an adverse outcome, as the patient died due to metastatic dissemination.

Usefulness of the I/D angiotensin-converting enzyme genotype for detecting the risk of left ventricular hypertrophy in pharmacologically treated hypertensive men.

The insertion/deletion polymorphism (I/D) of the angiotensin-converting enzyme (ACE) gene has been associated in some studies with a higher prevalence of left ventricular hypertrophy (LVH), but few of them were performed on pharmacologically treated hypertensive patients. The present study was undertaken to determine whether ACE genotype determination could help in the identification of pharmacologically treated hypertensive patients at a higher risk of LVH. Ninety-six consecutive men with essential hypertension were selected for the study. Left ventricular mass (LVM) was assessed by echocardiography and indexed by body surface area and 82 patients were considered suitable for the study. Three groups of patients were defined on the basis of their I/D ACE genotype: DD (n = 39), ID (n = 33) and II (n = 10). There were no statistically significant differences between the three groups regarding to the severity of hypertension at diagnosis, degree of control of blood pressure or type of antihypertensive drug therapy used. No statistically significant differences were found between the three groups regarding to LVM index (total 124 +/- 31, DD 121 +/- 29, ID 127 +/- 35 and II 122 +/- 18 g/m2), relative wall thickness (total 0.5 +/- 0. 2, DD 0.5 +/- 0.3, ID 0.48 +/- 0.07 and II 0.47 +/- 0.04) or prevalence of LVH (total 34%, DD 31%, ID 39% and II 30% by Cornell criteria and total 39%, DD 33%, ID 45% and II 40% by Framingham criteria). Furthermore, the I and D allele frequency distribution was similar in the whole group of patients, in patients with LVH, and in a control group of healthy volunteers. Our data do not support that the I/D ACE genotype determination helps in identifying treated hypertensive patients at higher risk of LVH. Journal of Human Hypertension (2000) 14, 327-331

[Emergency valvular replacement in infective endocarditis: hospital and long term clinical course. Analysis of 45 patients]. / Sustitución valvular urgente en la endocarditis infecciosa: evolución hospitalaria y a largo plazo. Análisis de 45 pacientes.

BACKGROUND: To define the evolution of patients with infective endocarditis who require urgent valve replacement in our environment. PATIENTS AND METHODS: We followed 45 consecutive cases of infective endocarditis that require valve replacement during their hospitalization. 32 patients had native valve infective endocarditis, 7 early prosthesis valve endocarditis and 6 late prosthesis valve endocarditis. Patients were followed for a long-term period, clinical and echocardiographycally. RESULTS: In 39 cases valve replacement was performed before ending antibiotic therapy. The main indications for surgery were refractory heart failure (24 patients) and shock (11 patients). The mortality rate was 24%: 19% in native valve infective endocarditis, 43% in early prosthetic valve endocarditis and 33% in late prosthesis valve endocarditis. The first cause of death was septic shock (46%). We followed 31 over 34 survivors for a mean time 65 (DS 49) months. We found two relapses and six deaths (1 sudden death, 2 endocarditis) and 72% of patients presented class I NYHA. We detected 17% prosthetic leaks (34% in the prosthetic valve endocarditis group). CONCLUSIONS: The need of urgent valve replacement in the context of infective endocarditis is associated with a high mortality rate, and should be considered a serious condition. Long term prognosis is, however, acceptable, although 17% of patients had prosthesis leak, specially those with prosthetic valve endocarditis.

[Guidelines of the Spanish Society of Cardiology on magnetic resonance]. / Guías de práctica clínica de la Sociedad Española de Cardiología en resonancia magnética.

A wide perspective of the cardiac applications of magnetic resonance is presented in this report, including technical aspects of the practice, recommendations on the appropriate training of medical personnel for the practice of examination and also, an extensively commented review of the accepted clinical indications for the practice of a cardiac magnetic resonance imaging study at present.

[Patency study of internal mammary artery grafts: the usefulness of echo-enhancers for identifying the flow signal by color Doppler echocardiography]. / Estudio de la permeabilidad de los injertos de arteria mamaria interna: utilidad de los ecopotenciadores para identificar la señal de flujo mediante ecocardiografía-Doppler color.

OBJECTIVES: a) To study the capacity of the technique of high-frequency color Doppler to detect flow signal of left internal mammary artery grafts; b) to assess the usefulness of an echo-enhancer agent to facilitate the detection of the signal, and c) to evaluate the patency of the graft according to its pulsed Doppler velocity profile pattern. METHODS: 39 consecutive patients were studied. A Hewlett-Packard 5500 echocardiograph was used, with a high-frequency probe (S12) applied at the high left parasternal border. When a graft signal was not elicited after a predetermined 5-minute check period, an intravenous dose of 4 g of Levovist (Schering España) at 400 mg/ml was administrated. According to previous studies, a pulsed Doppler flow profile with a predominantly diastolic pattern was considered a normal graft patency, while a systolic one was deemed as abnormal. RESULTS: Graft flow was identified by color Doppler in 33/39 patients (85%). The additional use of an echo-enhancer in 6 patients with no detected signal increased this proportion to 38/39 (97%). Normal flow patterns were seen in 34/38 (89%). Among the four patients with abnormal pattern, 1 case of early myocardial infarction was observed, while angiographic studies showed distal occlusion of the graft in 1 or the presence of competitive flow in 2 patients. CONCLUSIONS: The high-frequency color Doppler technique allows the detection of a flow signal from internal mammary artery grafts in most patients. The administration of an echo-enhancer agent is useful in those with non detectable signals. An abnormal pulsed Doppler velocity pattern indicates graft malfunction.

[Acute myocardial infarct studied by magnetic resonance with gadolinium-DTPA contrast compared to echocardiography]. / Estudio del infarto agudo de miocardio mediante resonancia magnética de contraste con gadolinio-DTPA en comparación con la ecocardiografía.

INTRODUCTION AND OBJECTIVES: Gadolinium-DTPA used as a contrast agent in magnetic resonance imaging allows the detection and quantification of the necrotic area in acute myocardial infarction. The aim of the present study is to assess the value of this method for the diagnosis of myocardial infarction in comparison with clinical and echocardiographic data. METHODS: Contrast magnetic resonance imaging and echocardiographic studies were performed on 16 patients during the first week after admission for acute myocardial infarction. Necrotic and total myocardial mass were calculated from magnetic resonance images and this was compared to the extension of the myocardial infarction assessed by electrocardiography and the peak level of total creatinine-phosphokinase serum enzyme. The number and localization of myocardial segments showing contrast uptake was related to segments with contractile abnormalities at the echocardiographic exam. RESULTS: The mean value of the mass of myocardial necrosis calculated from the total area of gadolinium-DTPA uptake in each patient was 25 g (range: 2-67 g), corresponding to 17% of the total myocardial mass (range: 1-45%). This value correlated with the peak serum level of total creatinine-phosphokinase enzyme (r = 0.714; p < 0.003) and with the number of Q waves present at the electrocardiogram (r = 0.69; p < 0.005). A very good agreement between the location of the myocardial infarction by ECG, echocardiography and magnetic resonance was evidenced, and a satisfactory correlation existed between myocardial segments with gadolinium-DTPA uptake and akinetic echocardiographic segments (kappa = 0.65). CONCLUSIONS: The detection and quantitation of the necrotic area in the acute myocardial infarction with gadolinium-DTPA contrast magnetic resonance shows a good correlation with clinical and echocardiographic data.

[Evaluation of the patency of left internal mammary artery graft by transcutaneous Doppler flow velocity analysis]. / Evaluación de la permeabilidad de los injertos de arteria mamaria interna izquierda mediante análisis de la velocidad del flujo por técnica Doppler transcutánea.

OBJECTIVE: To analyze the features of Doppler flow velocity curve of left internal mammary artery by-pass grafts in relation with their permeability as assessed by selective angiography. METHODS: Twenty-five consecutive patients with a left mammary artery graft were studied by angiography and transcutaneous Doppler technique. From the Doppler tracings, peak velocity and time-velocity integral of the systolic and diastolic components were determined. Patency of the graft and the characteristics of the distal native coronary artery were evaluated at angiography. RESULTS: Doppler flow signal was obtained in 23 (92%) of 25 analyzed patients. The graft was angiographically patent in 17 (68%) of 25 patients; in 15 (88%) of them the Doppler flow velocity signal was mainly diastolic and in only 2 (12%) it was predominantly systolic. In 8 (32%) of the 25 patients the graft was angiographically occluded, 6 (75%) of these patients showing a predominantly systolic Doppler signal, while the remaining 2 (25%) patients were those in whom the signal could not be elicited. Sensitivity and specificity of a predominantly diastolic Doppler flow pattern for the presence of graft patency was 88% and 100% respectively, with a predictive positive value of 100% and a negative one of 80%. CONCLUSIONS: Doppler flow velocity pattern of internal mammary artery by-pass grafts is related with patency of the graft, the presence of a predominantly diastolic curve being highly indicative of a patent graft.

[A double fistulous communication between the aortic root and both left cardiac chambers. Its diagnosis by multiplanar transesophageal echocardiography]. / Doble trayecto fistuloso entre la raíz aórtica y ambas cavidades cardíacas izquierdas. Diagnóstico mediante ecocardiografía transesofágica multiplanar.

The case of a patient with mitral and aortic mechanical valve prostheses is presented who developed early postoperative infective endocarditis and, subsequently, a fistulous communication between the posterior aortic sinus and both the left atrium and the left ventricle. A diastolic murmur of apparent aortic prosthesis regurgitation was heard, although an abnormal aortic valve function could not be demonstrated in the transthoracic echocardiographic study. Instead, the presence of a systolic high velocity flow by continuous wave Doppler suggested prosthetic mitral leakage. The clinical presentation of progressive congestive heart failure and pulmonary hypertension by Doppler prompted a further study by means of transesophageal echocardiography with multiplanar probe showing the above mentioned double fistulous communication. The diagnosis was later confirmed by angiography and also at surgery.