Reverse Remodeling in Human Heart Failure after Cardiac Resynchronization Therapy Is Associated With Reduced RHO-Kinase Activation.

Background: Reverse remodeling is a clinically relevant endpoint in heart failure with reduced ejection fraction (HFrEF). Rho-kinase (ROCK) signaling cascade activation correlates with cardiac remodeling and left ventricular (LV) systolic dysfunction in HFrEF patients. Cardiac resynchronization therapy (CRT) is effective in HFrEF, especially when there is a left bundle block, as this treatment may stimulate reverse remodeling, thereby improving quality of life and prolonging survival for patients with this severe condition. Here, we evaluate the hypothesis that ROCK activation is reduced after effective CRT in HFrEF. Methods: ROCK activation in circulating leukocytes was evaluated in 28 HFrHF patients, using Western blot (myosin light chain phosphatase subunit 1 phosphorylation, MYPT1p/t), before and three months after initiation of CRT. LV systolic function and remodeling were assessed by echocardiography. Results: Three months after CRT, LV ejection fraction increased an average of 14.5% (p < 0.001) in 13 patients (responders), while no change was observed in 15 patients (non-responders). End-systolic diameter decreased 16% (p < 0.001) in responders, with no change in non-responders. ROCK activation in PBMCs decreased 66% in responders (p < 0.05) but increased 10% in non-responders (NS). LV end-diastolic diameter was also 5.2 mm larger in non-responders vs. responders (p = 0.058). LV ejection fraction, systolic diameter, and ROCK activation levels were similar in both groups at baseline. Conclusion: In HFrEF patients, 3 months of effective CRT induced reverse myocardial remodeling, and ROCK activation was significantly decreased in circulating leukocytes. Thus, decreased ROCK activation in circulating leukocytes may reflect reverse cardiac remodeling in patients with heart failure.

Estenosis mitral con calcificación severa del anillo mitral: reemplazo mitral con prótesis OnX Conform en posición supraanular / Mitral stenosis with severe annular calcification: mitral valve replacement with an OnX Conform prosthesis in a supra annular position

Abstract A 68-year-old man previously subjected to radiotherapy had a prior aortic valve replacement due de radiation induced calcification of the aortic valve. Presently the patient developed severe calcification of the mitral valve ring leading to critical mitral valve stenosis. A supra annular implantation of an On X Conform valve was successfully achieved. The clinical course was uneventful, and the echocardiographic evaluation demonstrated a normal function of the valve. Different alternatives for the surgical management of this complication are discussed.

Rho kinase cascade activation in circulating leukocytes in patients with diabetes mellitus type 2.

BACKGROUND: The intracellular ROCK signaling pathway is an important modulator of blood pressure and of cardiovascular and renal remodeling when Rho-kinase activity is increased. Besides, in preclinical models of diabetes, ROCK activation has also a role in abnormal glucose metabolism as well as in subsequent vascular and myocardial dysfunction. In humans, there are a few data assessing ROCK activation in patients with type 2 diabetes mellitus (T2D) and no studies assessing upstream/downstream components of the ROCK pathway. We assessed here levels of ROCK activation and some of the RhoA/ROCK cascade molecules in peripheral blood mononuclear cells (PBMCs) in T2D patients under current treatment. METHODS: Cross-sectional observational study comparing 28 T2D patients under current antidiabetic treatment with 31 consecutive healthy subjects, matched by age and gender. Circulating levels of malondialdehyde, angiotensin II and inflammatory cytokines IL-6 and IL-8 were determined in all subjects. ROCK activation in PMBCs, upstream and downstream cascade proteins, and levels of the proinflammatory molecules VCAM, ICAM-1 and IL-8 were determined in their PMBCs by Western blot. RESULTS: Compared to healthy controls, ROCK activation in T2D patients measured by 2 direct ROCK targets in PBMCs was increased by 420 and 570% (p < 0001) and it correlated significantly with serum glucose levels. p38 MAPK phosphorylation (downstream from ROCK) and JAK-2 (upstream from ROCK) were significantly higher in the T2D patients by 580% and 220%, respectively. In T2D patients, significantly increased PBMC levels of the proinflammatory molecules VCAM-1, ICAM-1 and IL-8 were observed compared to control subjects (by 180%, 360% and 260%, respectively). Circulating levels of Ang II and MDA were significantly higher in T2D patients by 29 and 63%, respectively. CONCLUSIONS: T2D patients under treatment with glucose-lowering drugs, antihypertensive treatment as well as with statins have significantly increased ROCK activation in their circulating leukocytes along with higher phosphorylation of downstream cascade proteins despite pharmacologic treatment, along with increased plasma angiotensin II and MDA levels. ROCK inhibition might have an additional role in the prevention and treatment of T2D.

Effect of Early Normotension with Olmesartan on Rho-kinase Activity in Hypertensive Patients.

BACKGROUND: Angiotensin II is a potent activator of the Rho-kinase (ROCK) pathway, through which it exerts some of its adverse vasoconstrictor effects. Clinical evidence on the effects of blocking the angiotensin II receptor 1 on ROCK activity in hypertensive patients is scarce. OBJECTIVE: To demonstrate that ROCK activity in peripheral blood mononuclear cells (PMBCs) in patients with essential hypertension is reduced earlier than previously observed, along with blood pressure (BP) lowering on treatment with olmesartan. METHODS: Prospective pilot open study; 17 hypertensive patients were treated with progressive olmesartan doses starting with 20 mg qd. BP was measured at 3, 6 and 9 weeks after treatment initiation. If treatment failed to normalize BP after 3 weeks, olmesartan dose was increased to 40 mg qd, and if still hypertensive after 6 weeks, 12.5 mg of hydrochlorothiazide qd was added. ROCK activity was measured at baseline and 9 weeks after treatment as myosin phosphatase target subunit 1 phosphorylation (MYPT1-p/T ratio) in PBMC. RESULTS: Mean baseline BP was 162 ± 4.9/101 ± 2.4 mmHg. After 9 weeks of treatment, both systolic and diastolic BP were reduced by 41 and 22 mmHg, respectively (p<0.05). Mean pretreatment MYPT1- p/T ratio in PMBCs was significantly reduced by 80% after 9 weeks with olmesartan (p<0.01). CONCLUSION: Normotension achieved after 9 weeks in 82% of the patients treated with olmesartan was associated with a significant reduction of ROCK activity in PBMC.

Rho-kinase pathway activation and apoptosis in circulating leucocytes in patients with heart failure with reduced ejection fraction.

BACKGROUND: Increased Rho-kinase activity in circulating leucocytes is observed in heart failure with reduced ejection fraction (HFrEF). However, there is little information in HFrEF regarding other Rho-kinase pathway components an on the relationship between Rho-kinase and apoptosis. Here, Rho-kinase activation levels and phosphorylation of major downstream molecules and apoptosis levels were measured for the first time both in HFrEF patients and healthy individuals. METHODS: Cross-sectional study comparing HFrEF patients (n = 20) and healthy controls (n = 19). Rho-kinase activity in circulating leucocytes (peripheral blood mononuclear cells, PBMCs) was determined by myosin light chain phosphatase 1 (MYPT1) and ezrin-radixin-moesin (ERM) phosphorylation. Rho-kinase cascade proteins phosphorylation p38-MAPK, myosin light chain-2, JAK and JNK were also analysed along with apoptosis. RESULTS: MYPT1 and ERM phosphorylation were significantly elevated in HFrEF patients, (3.9- and 4.8-fold higher than in controls, respectively). JAK phosphorylation was significantly increased by 300% over controls. Phosphorylation of downstream molecules p38-MAPK and myosin light chain-2 was significantly higher by 360% and 490%, respectively, while JNK phosphorylation was reduced by 60%. Catecholamine and angiotensin II levels were significantly higher in HFrEF patients, while angiotensin-(1-9) levels were lower. Apoptosis in circulating leucocytes was significantly increased in HFrEF patients by 2.8-fold compared with controls and significantly correlated with Rho-kinase activation. CONCLUSION: Rho-kinase pathway is activated in PMBCs from HFrEF patients despite optimal treatment, and it is closely associated with neurohormonal activation and with apoptosis. ROCK cascade inhibition might induce clinical benefits in HFrEF patients, and its assessment in PMBCs could be useful to evaluate reverse remodelling and disease regression.

Biomarcadores de fibrosis y función ventricular derecha en maratonistas con distinto grado de entrenamiento: estudio en la maratón de Santiago / Fibrosis and right ventricular function biomarkers in marathon runners: a study at the Santiago, Chile marathon

Resumen: Introducción: Atletas altamente entrenados muestran cambios cardíacos estructurales como adaptación a la sobrecarga, producto del ejercicio repetitivo y extenuante. Se han evidenciado elevación de biomarcadores de remodelado y fibrosis miocárdica posterior al ejercicio intenso en atletas. Sin embargo, el comportamiento de estos biomarcadores según el nivel de entrenamiento previo no se ha evaluado. Objetivo: Investigar biomarcadores de fibrosis y función ventricular derecha en maratonistas con distinto nivel de entrenamiento previo. Métodos: Se incluyeron 36 maratonistas hombres, sanos, que completaron 42 km en la maratón de Santiago. Se dividieron según entrenamiento previo en dos grupos, Grupo 1 (G1): ≥100 km/semana y Grupo 2 (G2): <100 km/semana. Se realizó ecocardiografía transtorácica y se evaluaron niveles plasmáticos de galectina-3 y del propéptido amino terminal del procolágeno tipo III (PIIINP) en la semana previa a la carrera e inmediatamente posterior a ésta. Resultados: Posterior a la maratón, la función sistólica del ventrículo derecho disminuyó en el grupo G2 junto con un aumento significativo de los niveles plasmáticos de PIIIPNP (61±16 a 94±24 ng/mL, p=0,01). Estos cambios no se observaron en el grupo G1 (65 ± 11 a 90±29 ng/mL, p=0,10). Los niveles plasmáticos de galectina-3 aumentaron significativamente en ambos grupos posterior al ejercicio (6,8±2,2 a 19,7±4,9 ng/mL, p 0,012 y 6,0±1,1 a 19,4 ± 5,9 ng/mL, p 0,01) en los grupos G1 y G2, respectivamente). Conclusiones: Atletas con menor grado de entrenamiento, presentan posterior a una maratón un significativo aumento de productos de degradación del colágeno (PIIIPNP) asociado a disminución de la función del ventrículo derecho. Los niveles de galectina-3 plasmática aumentan significativamente en ambos grupos post-esfuerzo independiente del entrenamiento previo.

Abstracts: Introduction: Highly trained athletes show structural cardiac changes as adaptation to overload. Rise in remodeling biomarkers and myocardial fibrosis after intense exercise in athletes has been evidenced; however, the behavior of these biomarkers according to pre-competition training level has not been evaluated. Objective: To evaluate fibrosis biomarkers levels and right ventricle function in marathon runners according to their previous training level, in the period prior to a marathon race and immediately after it. Methods: Thirty-six healthy male marathon runners were included. Subjects were grouped according to their previous training level: Group 1 (G1): ≥100 km/week and Group 2 (G2): <100 km/week. Transthoracic echocardiography along with plasmatic levels of galectin-3 and amino terminal propeptide of type III procollagen (PIIINP) were measured one week previous and immediately after the marathon. Results: Post-effort right ventricle systolic function decreased in G2, together with a significant elevation of PIIIPNP (61±16 to 94±24 ng/mL, p=0.01). These changes were not observed in G1 (from 65±11 to 90±29 ng/mL, p=0.10). Plasma galectin-3 increased significantly in both groups immediately post-exercise (6.8±2.2 to 19.7±4.9 ng/mL, p=0.012, and 6.0±1.1 to 19.4±5.9 ng/mL, p=0.01, in G1 and G2. respectively). Conclusion: Less trained athletes evidenced higher post marathon levels of PIIIPNP which is associated with a decreased global right ventricle function. Plasma galectin-3 levels increased significantly after intense exertion regardless of the intensity of previous training.

Insuficiencia aórtica severa aguda, aspectos diagnósticos de la ecocardiografía: a propósito de un caso clínico / Acute severe aortic regurgitacion echocardiography features: clinical case and review

Resumen: La insuficiencia aórtica severa aguda (IASA) constituye una emergencia quirúrgica; sus principales causas son la endocarditis infecciosa y la disección aórtica. Existen tres hallazgos ecocardiográficos distintivos de dicha patología, que ayudan al diagnóstico y manejo que son: el cierre prematuro de la válvula mitral (CPVM), la insuficiencia mitral diastólica (IMD) y la apertura prematura de la válvula aórtica (APVA). Estos elementos reflejan el severo aumento de la presión de fin de diástole del ventrículo izquierdo (PFDVI) y, si bien son específicos, no son únicos de dicha patología. A continuación, se reporta el caso de un paciente con IASA. Hombre de 36 años, sin antecedentes, consulta por estado infeccioso asociado a insuficiencia cardíaca aguda. Ingresa en shock cardiogénico y la ecocardiografía muestra: ventrículo izquierdo severamente dilatado con función sistólica conservada, dilatación leve de la aurícula izquierda y una endocarditis de válvula aórtica trivalvar asociado a insuficiencia severa. Se identifica, además, la presencia de CPVM y de IMD hallazgos que evidenciaban la severidad de la lesión y lo agudo de la presentación. Se realizó un recambio valvular aórtico de urgencia con una prótesis biológica con buena evolución postoperatoria.

Abstracts: Severe acute aortic regurgitation (SAAR) constitutes a surgical emergency. Its main causes are infective endocarditis and aortic dissection. Three echocardiographic hallmarks aid in its diagnosis and management, namely: premature opening of the aortic valve (POAV), premature mitral valve closure (PMVC) and diastolic mitral regurgitation (DMR), findings that reflect the great increase in left ventricular end-diastolic pressure. Also, these findings are distinctive but not unique to SAAR. We report a 36-year-old male, without past medical history that refers three weeks of malaise, fever and heart failure. At the emergency department, the patient evolved to cardiogenic shock being admitted to the coronary unit. A transthoracic and transesophageal echocardiography revealed a severely dilated left ventricle with normal systolic function, a mild left atrium enlargement and endocarditis of a trileaflet aortic valve with severe regurgitation. Furthermore, PMVC and DMR were identified, findings that portrayed the severe and acute presentation of the disease. A surgical aortic valve replacement was performed uneventfully, and the patient discharged in good conditions.

"Gigantic" biatrial myxoma with right heart functional impairment.

Cardiac myxomas are frequently located in the left or right atria, with multiple locations being rare. We report a 59-year-old healthy female with 5 months of cough and exertional dyspnea. A transthoracic echocardiography (TTE) exhibits a 9 × 5 cm nonpedunculated tumor arising from the interatrial septum (IAS) and inhabiting both atria, but was unable to depict the relation with the IAS. Transesophageal echocardiography exposes a single tumor crossing the IAS through an ostium secundum atrial septal defect (ASD) causing right heart functional impairment. Uneventful cardiac surgery allowed complete resection of the lesion and ASD closure. Pathology reported a myxoma.

Endocarditis infecciosa asociada a catéter de hemodiálisis: hallazgos clínicos y ecocardiográficos / Infective endocarditis associated with hemodialysis catheters: clinical and ehocardiographic findings

Resumen: Hallazgos clínicos y ecocardiográficos en pacientes con endocarditis infecciosa (E.I.) asociada a catéter de hemodiálisis (CHD) fueron comparados con sujetos controles con E.I. "habitual". Pacientes y métodos: Del total de registros ecocardiográficos de una Clínica privada de Antofagasta entre 2009 y 2014, 4 pacientes presentaban E.I. asociada CHD (E.I.-CHD) y 16 otro tipo de E.I. (controles). Se compararon ambos grupos clínicamente y en las distintas modalidades de ecografía, para evaluar el aporte de cada una de ellas en el diagnóstico, manejo y comprensión del mecanismo de producción de la E.I. Resultados: El periodo del inicio de los síntomas hasta la hospitalización y el comprendido entre ésta hasta el fallecimiento fue variable, con tendencia a fallecimiento más precoz en el grupo E.I.-CHD (promedio 14,6 vs 20,6 días en el grupo control). La edad en E.I.-CHD fue mayor (65 versus 62.2 años), con mayor incidencia de las 3 comorbilidades más frecuentes: hipertensión arterial (100% versus 56,25%), diabetes mellitus (75% versus 50%) e insuficiencia cardíaca (75% versus 31,25%). La mortalidad fue 18.75% en el grupo control y 75% en la E.I.-CHD. En los pacientes con E.I.-CHD se aisló: Cándida (50%), Bacilos gram negativo (Stenotrophomonas maltophilia) (25%) y SAMR (25%) mientras que en el grupo control fueron aislados Enterococcus faecalis (25%), Streptococcus viridans (12.5%), Streptococcus spp (6.25%), Staphylococcus aureus (6.25%), Streptococcus grupo C (6.25%), Abiotrophia defectiva (6.25%) y Streptococcus pneumoniae (6.25). En 31.25% de los casos los hemocultivos fue-ron negativos. La localización más frecuente de las vegetaciones en los pacientes con E.I.-CHD correspondió a la pared de AD, sitio de impacto del jet del CHD, en un 100%, seguida por CHD 50%, tricúspide 25% y aórtica 25%. En los controles las localizaciones fueron 75% en válvula aórtica y 25% en válvula mitral. En el grupo de E.I.-CHD, la mitad presentó disfunción sistólica e insuficiencia valvular, mientras que en el grupo control fue predominante la insuficiencia valvular (62,5%) seguida por la perforación de velo (25%). Conclusión: En las E.I.-CHD se aislaron gérmenes asociados a un peor pronóstico (hongos o bacterias atípicas), con altísima mortalidad. La localización principal de las vegetaciones fue en la pared de la aurícula derecha (AD), alrededor de la desembocadura de la vena cava inferior (VCI), sitio de impacto del jet del CHD, y en el tercio distal del catéter. Clinical and echocardiographic findings in patients with infective endocarditis (I.E.) associated to the presence of hemodialysis catheters (HDC) were compared to those in subjects with other types of I.E.

Abstracts: Methods: Between 2009 and 2014 an echocardiographic diagnosis of I.E. was established in 4 subjects with a hemodialysis catheter in place and 16 patients had a common variety of I.E. (controls). Clinical and echocardiographic findings, including echocardiographic modalities were compared between groups. Results: Time from onset of symptoms and time to patient death were shorter in I.E.-HDC patients compared to controls (mean 14.6 vs 20.6 days, respectively. I.E. -HDC patients tended to be older (65.0 vs 62.2 years old). The incidence of main comorbidities was higher in I.E.-HDC: hypertension (100% vs 56.2%), diabetes (75 vs 59%) and heart failure (75% vs 31.2%), respectively. Mortality was much higher in I.E-HDC (74% vs 18%). Infective agents also differed between groups: I.E.-HDC was associate to C albicans (50%), Gram negative rods (Stenotrophomonas maltophilia) (25%) y SAMR (25%). In contrast, the agents involved in controls were E faecalis (25%), S viridans (12.5%), S. group C (6.25%), S aureus (6,25%), group C Streptococcus (6.25%), Abiotrophic defectiva (6.25%) and S pneumoniae (6.25%). Overall, blood cultures were negative in 31.2% patients. Among patients with I.E.-HDC vegetations were most commonly found at the right atrial wall (100%), on the catheter (50%), at the tricuspid valve (25%) and at the aortic valve (25%). In non I.E.-HDC, vegetations were located at the aortic valve (75%) and the mitral valve (25%). Half the patients with I.E.- HDC patients presented ventricular dysfunction and valvular regurgitation while control patients had predominantly valvular insufficiency (62.5%) or leaflet perforation (25%). Conclusion: Mortality in I.E.-HDC patients was very high, associated to the presence of aggressive microbial or fungal agents. Vegetations were most commonly located at the right atrial wall, around de junction with the inferior vena cava and on the catheter itself.

Aporte de la ecocardiografía tridimensional en el diagnóstico y manejo de la endocarditis infecciosa: experiencia clínica / Added value of three-dimensional echocardiography in the diagnosis and management of infective endocarditis: clinical experience

Resumen: El diagnóstico ecocardiográfico (eco) de la endocarditis infecciosa ha tenido una evolución vertiginosa, destacando el desarrollo de la ecocardiografía transesofágica (ETE), la imagen armónica y la ecocardiografía tridimensional (Eco 3D), tecnologías que han incrementado su capacidad diagnóstica. Presentamos una serie de endocarditis donde el Eco 3D tuvo un rol importante. CASO 1: Hombre de 18 años, antecedente remoto de artritis séptica y deterioro de capacidad funcional asociado a soplo de insuficiencia mitral. La ecocardiografía transtorácica (ETT) objetivó leve dilatación ventricular izquierda e insuficiencia mitral severa, el Eco 3D identificó una perforación circular en el velo anterior mitral, logrando la reparación valvular con un parche de pericardio. CASO 2. Hombre de 29 años, con absceso dental reciente, se presenta en shock séptico, el ETT y ETE mostraron una válvula aórtica bicúspide (VAB) con insuficiencia severa y un absceso del velo anterior mitral. El Eco 3D identificó una perforación del velo no rafial, se realizó un doble recambio valvular. CASO 3: Hombre de 61 años, con antecedente previo de endocarditis y VAB. Consulta por estado infeccioso. El ETT y ETE informaron insuficiencia aórtica moderada asociado a insuficiencia mitral severa, el eco 3D identificó prolapso del segmento P3 de la válvula mitral, ayudando a programar su reparación. CASO 4. Mujer de 78 años, con diagnóstico de endocarditis mitral protésica, el Eco 3D objetivó un absceso periprotésico posterior de 16 mm, siendo referida a cirugía. El Eco 3D aporta información complementaria en diversos escenarios de la endocarditis, tales como: perforaciones valvulares, compromiso perianular, endocarditis protésica, optimizando su manejo.

Abstracts: The echocardiographic diagnosis of infective endocarditis has evolved in a vertiginous manner. Among its main hallmarks are; the development of transesophageal echocardiography (TEE), harmonics imaging and three-dimensional echocardiography (3D Echo), thereby enhancing its diagnosis capability. The following endocarditis cases revealed the usefulness of 3D Echo. CASE 1. 18 year-old male, past history of septic arthritis, refers decline in functional capacity associated with a mitral regurgitation murmur. Transthoracic echocardiography (TTE) pictured a mildly dilated left ventricle and severe mitral regurgitation. 3D Echo identified a circular perforation of the anterior mitral leaflet; successful mitral valve repair was accomplished. CASE 2. 29 year-old male, with recent dental abscess, presents in septic shock. TTE and TEE portrayed a bicuspid aortic valve (BAV) with severe regurgitation along with an abscess of the anterior mitral valve leaflet. 3D Echo showed a perforation of the nonfused aortic leaflet; double valve replacement was uneventfully performed. CASE 3. 61 year-old male, with remote history of endocarditis and BAV, evaluated with TTE and TEE due to sepsis, depicting moderate aortic regurgitation and P3 prolapse with rupture chordae and severe mitral regurgitation. Based on the 3D Echo data the mitral valve was repaired and the aortic valve replaced. CASE 4. 78 year-old woman with prosthetic mitral valve endocarditis, 3D Echo allowed complete visualization of a 16 mm diameter posterior abscess, being referred to surgery. Thus, 3D Echo has added value in several endocarditis scenarios such as; leaflet perforations, periannular involvement, prosthetic valve endocarditis, improving its management.

Hipertrofia ventricular izquierda con patrón de strain característico / Left ventricular hypertrophy with a characteristic strain pattern

Abstracts: A 68 year-old male, with no past medical history, presented progressive shortness of breath on exertion and leg edema during the previous year. Trans-thoracic echocardiography depicted; severe left ventricular hypertrophy with mild systolic dysfunction (LVEF 50% biplane Simpson's method), severe diastolic dysfunction and moderate left atrial enlargement. Left ventricular myocardial deformation imaging by two-dimensional speckle-tracking was paramount for elucidating the differential diagnosis.

Big thrombus "sitting" in an atrial septal aneurysm.

A 79 year-old-man presented three episodes of upper gastrointestinal bleeding and weight loss. Endoscopy revealed bleeding and extrinsic compression at the pyloric region. Computed tomography scan showed a pancreatic tumor, peritoneal carcinomatosis, vascular infiltration, and incidentally found a partially calcified hypodense lesion of 35 mm in the left atrium, suggesting a myxoma or a thrombus. Echocardiography revealed moderate left atrium enlargement, dilated left atrial appendage with spontaneous echo contrast, moderate dilatation and dysfunction of the left ventricle, ejection fraction was 39%, and an atrial septal aneurysm in which a piriform, mass of 35×33×25 mm, was "sitting," suggesting an organized thrombus.

Implante percutáneo de válvula aórtica con apoyo de circulación extracorpórea en paciente con insuficiencia aórtica severa / Trans catheter aortic valve implantation with extra corporeal circulation support in a patient with severe aortic insufficiency

An 84-year man with prior coronary artery bypass surgery and endovascular repair of an abdominal aortic aneurysm developed congestive heart failu-re. He had calcific aortic valve disease with severe regurgitation. A #29 Edwards-Sapien aortic valve via trans-apical approach was implanted with the patient connected to extra corporeal circulation. The patient recovered successfully and remained in functional class II 8 months after hospital dis-charge.

Factores asociados a bajo gradiente en estenosis aórtica severa con fracción de eyección preservada / Factors associated with low gradient in severe aortic valve stenosis with preserved ejection fraction

Introducción: La estenosis aórtica es frecuente en países desarrollados, cuando es severa (EAS) y sintomática se recomienda reemplazo valvular. Su diagnóstico ecocardiográfico se realiza con cualquiera de; área valvular aórtica (AVA) <1.0 cm², gradiente medio (GM) >40 mmHg, velocidad máxima >4 m/s. Habitualmente existe concordancia entre estos criterios, pero diversas razones generan discordancia hasta en un 40%, principalmente entre área y gradiente (DAG), causando incertidumbre diagnóstica en presencia de fracción de eyección preservada del ventrículo izquierdo (FEp) (FEVI >50%). Objetivos: Caracterizar pacientes con EAS en la red UC. Establecer prevalencia y factores asociados a DAG en pacientes con EAS y FEp. Métodos: Estudio de corte transversal, incluyó todos los pacientes con AVA<1.0 cm2 durante 17.5 años en la red UC. Se registraron variables biodemográficas y eco-cardiográficas. Los pacientes con EAS y FEp se subdivi-dieron en 2 grupos según GM, bajo (<40 mmHg) y alto (>40mmHg), se utilizó t-student y Chi cuadrado. Resultados: 1281 pacientes cumplieron criterio de AVA<1.0 cm2. Edad 71.8±13 años, mujeres 51.4%, hombres el 48.6%. FEVI 68.71 ± 14.62%, FEp 89,2%, Características grupo GM Bajo: Edad 81.66 ± 6.56 años, Mujeres 56.3%, fibrilación auricular (FA) 14.1%. Grupo GM Alto. 68.08 ± 13.21 años, mujeres 47.6%, FA 8%. Presencia de DAG 42.5%. Factores asociados a bajo gradiente con FEp fueron: edad avanzada (>70 años), mujer y fibrilación auricular. Conclusiones: La EAS en nuestro medio se observa en personas mayores con FEp. La presencia de DAG es frecuente y el principal factor asociado en presencia de FEp es la FA.

Introduction: Aortic stenosis (AS) is the most prevalent valvular heart disease in developed countries. Symptomatic severe AS requires surgical intervention, and its echocardiographic criteria encompass: Aortic valve area (AVA) < 1.0 cm2, aortic mean gradient (MG) > 40 mmHg, peak aortic jet velocity > 4 m/s. Usually there is agreement among these criteria, but several reasons can cause up to 40% discordant results, mainly between AVA an MG, casting doubt about severity in the setting of preserved left ventricular ejection fraction (pLVEF). Objectives: Characterize patients with severe AS. Assess prevalence and factors related to AG discordance (AGD) in patients with pLVEF. Methods: Cross-sectional study, that included all patients with an AVA <1.0 cm2 during the last 17.5 years in UC health network. Bio-demographic and echocardiographic variables were registered. Patients with severe AS and pLVEF where allocated in 2 subgroups according to the MG as low (<40 mmHg) and high (>40 mmHg), 2 sides t-student and chi-squared test were performed. Results: 1281 patients fulfill criteria of AVA<1.0 cm2. Age 71.8±13 years, women 51.4%, male 48.6%, LVEF 68.71 ± 14.62%. pLVEF 89.2%. Low MG group: Age 81.66 ± 6.56 y, women 56.3%, atrial fibrillation (AF) 14.1%. High MG group: Age 68.08 ± 13.21 y, women 47.6%, AF 8%. AGD prevalence was 42.5%. Factors related to low MG with pLVEF were; advance age (>70 y), women and AF. Conclusions: Severe AS occurs mainly in advance age patients with pLVEF. AGD is frequent and the foremost related factor is AF.

Insuficiencia aórtica sistólica: un fenómeno singular / Systolic aortic regurgitation: a remarkable event

La insuficiencia aórtica consiste en el reflujo diastólico de sangre desde la aorta hacia el ventrículo izquierdo, sus mecanismos son múltiples y su magnitud queda determinada por: el área del orificio regurgitante, el gradiente diastólico entre la aorta y el ventrículo izquierdo y la duración de la diástole. En contraposición a esto la insuficiencia aórtica sistólica (IAS) es un fenómeno inusual, con escasos reportes y con una fisiopatología particular. Reportamos tres casos clínicos que ilustran los mecanismos de la IAS. CASO 1: Hombre 54 años, consulta por palpitaciones y disnea, la ecocardiografía transtorácica (ETT) objetiva hipertrofia ventricular izquierda leve con buena función y una valvulopatía aórtica degenerativa con insuficiencia leve, durante el examen se registran ex-trasístoles ventriculares aislados asociado a IAS. CASO 2: Hombre de 61 años con diagnóstico de miocardiopatía dilatada no isquémica en estadio D. Su ETT basal evidencia severa dilatación y disfunción ventricular izquierda (FEVI 19%, DTD 90 mm), insuficiencia mitral funcional severa e insuficiencia aórtica leve. Por dependencia a infusión de inótropos se implanta en Marzo del 2016 un dispositivo de asistencia ventricular izquierda HeartWa-re, en control ambulatorio el dispositivo funcionaba normalmente y el ETT objetiva una significativa disminución de los diámetros del ventrículo izquierdo (DTD 70 mm) una válvula aórtica con apertura intermitente asociado a una IAS en rango leve a moderado. CASO 3: Mujer de 82 años con insuficiencia cardíaca y severa disfunción y dilatación ventricular izquierda, se hospitaliza por infección respiratoria, un ETT muestra insuficiencia mitral funcional severa asociado a IAS moderada.

Aortic regurgitation is a diastolic event in which blood from the aorta regurgitates back to the left ventricle, with several possible mechanisms. Its magnitude is determined by: the regurgitant orifice area, the diastolic gradient between the aorta and the left ventricle and the duration of diastole. In contrast, systolic aortic regurgitation (SAR) is an unusual phenomenon with few cases reported in the literature and with a particular pathophysiology. We report three cases of SAR that illustrate its mechanisms. CASE 1: 54 years-old hypertensive male, refers dyspnea associated with irregular heartbeatsTrans-thoracic echocardiography (TTE) revealed a mild left ventricular hypertrophy with normal function along with a degenerative aortic valve that presented mild regurgitation, isolated premature ventricular contractions were frequently observed associated with mild SAR. CASE 2. 61 years-old diabetic male, with a long history of stage D dilated non ischemic cardiom-yopathy. His last TTE was remarkable for a severe left ventricular dilatation and dysfunction (LVEF 19%, EDD 90 mm), severe functional mitral regurgitation, mild aortic regurgitation and pulmonary hypertension (SPAP 60 mmHg) along with right ventricular dysfunction. Because of inotrope infusion dependency a left ventricular assist device (LVAD) Heartware was implanted. At six months outpatient control, LVAD presented normal function parameters and TTE showed significant reduction in left ventricle diameters (EDD 70 mm) along with mild to moderate SAR. CASE 3: 82 year-old female, longstanding heart failure with severe LV dilatation and dysfunction (LVEF 15%), admitted for a respiratory infection, TTE showed moderate SAR along with functional severe mitral regurgitation.

Síncope secundario a mixoma gigante del anillo mitral: reporte de un caso / Large mitral annulus myxoma presenting with syncope: report of one case

We report a 23-year-old woman, with three recent exertional syncopes. Transthoracic (TTE) and transesophageal (TEE) echocardiography found a large heterogeneous mass (38 x 35 mm) arising from the posterior mitral annulus, protruding in systole through the left ventricular outflow tract (LVOT). Heart MRI confirmed the echocardiography findings, suggesting a cardiac myxoma. Cardiac surgery accomplished the complete resection of the lesion, confirming a mass arising from the posterior mitral annulus and preserving mitral anatomy and function. Pathology was positive for a myxoma. Uneventful evolution allowed the discharge of the patient at the fifth postoperative day. Control TTE discarded any complication.

[Large mitral annulus myxoma presenting with syncope: Report of one case]. / Síncope secundario a mixoma gigante del anillo mitral: Reporte de un caso.

We report a 23-year-old woman, with three recent exertional syncopes. Transthoracic (TTE) and transesophageal (TEE) echocardiography found a large heterogeneous mass (38 x 35 mm) arising from the posterior mitral annulus, protruding in systole through the left ventricular outflow tract (LVOT). Heart MRI confirmed the echocardiography findings, suggesting a cardiac myxoma. Cardiac surgery accomplished the complete resection of the lesion, confirming a mass arising from the posterior mitral annulus and preserving mitral anatomy and function. Pathology was positive for a myxoma. Uneventful evolution allowed the discharge of the patient at the fifth postoperative day. Control TTE discarded any complication.