Subcostal right ventricular free wall strain in patients with pulmonary hypertension / Strain subcostal de la pared libre del ventriculo derecho en pacientes con hipertensión pulmonar

Abstract Right ventricular longitudinal strain (RVLS) is frequently used as a measure of right ventricular systolic function. Abnormal RV strain is associated with poor prognosis in patients with pulmonary hyper tension (PH); however, the measure is not always easy to obtain in patients with poor apical acoustic windows. Objective: This study aims to analyze the RVLS and determine if there is a difference when measured from the apical and subcostal views. Methods: In this cross-sectional study, we analyzed 22 adult outpatients (≥ 18 years old), 81% female, mean age 49.9 ± 17.3 years, with a diagnosis of PH using right heart catheterization, followed from January 2016 to January 2020. Results: RVLS measured in the RV free wall from the apical views was -15% (-19% to -10%) and subcostal views -14.5% (-18% to -11%) were highly correlated (Person's r = 0.969, p < 0.0001). Segment by segment analysis did not show significant differences either: basal four-chamber vs. sub costal view was -16.5% (-21% to -11%) vs. -15.5% (-20% to -11%), p = 0.99, mid four-chamber view vs. subcotal view was -16.5% (-21% to -12%) vs. -16.5% (-20% to -11%), p = 0.87, apical four-chamber view vs. subcostal view was -12% (-18% to -8%) vs. -13.5% (-19% to -10%), p = 0.93. Conclusion: Subcostal RVLS free wall is a feasible and accurate alternative to conventional RVLS free wall from the apical view in patients with pulmonary hypertension and could be useful in patients with poor acoustic apical four-chamber windows.

Resumen El strain longitudinal del ventrículo derecho (SLVD) permite medir la función sistólica del ventrículo derecho (VD). La disminución del strain (deformación) del VD se asocia con mal pronóstico en pacientes con hipertensión pulmonar (HP), pero no siempre es fácil de obtener en pacientes con mala ventana acústica apical. Objetivo: Este estudio tiene como objetivo analizar el SLVD y determinar si las vistas apical y subcostal son comparables. Métodos: En este estudio transversal, se incluyeron 22 pacientes adultos ambulatorios (≥18 años), 81% mujeres, edad promedio 49.9 ± 17.3 años, con diagnóstico de HP mediante cateterismo cardíaco derecho, seguidos desde enero de 2016 hasta enero de 2020. Se midió la deformación de la pared libre del ventrículo derecho desde las vistas de cuatro cámaras apical y cuatro cámaras subcostal. Resultados: El SLVD medido en la pared libre del VD desde la vista apical fue -15% (-19% a -10%) vs. -14.5% (-18% a -11%) cuando se midió desde la vista subcostal (p = 0,99). El análisis segmento por s egmento tampoco mostró diferencias significativas: el segmento basal apical vs. subcostal fue -16.5% (-21% a -11%) vs. -15.5% (-20% a -11%), p = 0.99, el segmento medio apical vs. la vista subcotal fue -16.5% (-21% a -12%) vs. a -16.5% (-20% a -11%), p = 0.87, el segmento apical vs. la vista subcostal fue -12% (-18% a -8%) frente a -13.5% (-19% a -10%), p = 0.93. Conclusión: En pacientes con HP, el SLVD obtenido en la pared libre subcostal es una alternativa útil en los casos con ventana acústica apical subóptima.

Subcostal right ventricular free wall strain in patients with pulmonary hypertension.

Right ventricular longitudinal strain (RVLS) is frequently used as a measure of right ventricular systolic function. Abnormal RV strain is associated with poor prognosis in patients with pulmonary hypertension (PH); however, the measure is not always easy to obtain in patients with poor apical acoustic windows. OBJECTIVE: This study aims to analyze the RVLS and determine if there is a difference when measured from the apical and subcostal views. METHODS: In this cross-sectional study, we analyzed 22 adult outpatients (= 18 years old), 81% female, mean age 49.9 ± 17.3 years, with a diagnosis of PH using right heart catheterization, followed from January 2016 to January 2020. RESULTS: RVLS measured in the RV free wall from the apical views was -15% (-19% to -10%) and subcostal views -14.5% (-18% to -11%) were highly correlated (Person's r = 0.969, p < 0.0001). Segment by segment analysis did not show significant differences either: basal four-chamber vs. subcostal view was -16.5% (-21% to -11%) vs. -15.5% (-20% to -11%), p = 0.99, mid four-chamber view vs. subcotal view was -16.5% (-21% to -12%) vs. -16.5% (-20% to -11%), p = 0.87, apical four-chamber view vs. subcostal view was -12% (-18% to -8%) vs. -13.5% (-19% to -10%), p = 0.93. CONCLUSION: Subcostal RVLS free wall is a feasible and accurate alternative to conventional RVLS free wall from the apical view in patients with pulmonary hypertension and could be useful in patients with poor acoustic apical four-chamber windows.

El strain longitudinal del ventrículo derecho (SLVD) permite medir la función sistólica del ventrículo derecho (VD). La disminución del strain (deformación) del VD se asocia con mal pronóstico en pacientes con hipertensión pulmonar (HP), pero no siempre es fácil de obtener en pacientes con mala ventana acústica apical. Objetivo: Este estudio tiene como objetivo analizar el SLVD y determinar si las vistas apical y subcostal son comparables. Métodos: En este estudio transversal, se incluyeron 22 pacientes adultos ambulatorios (=18 años), 81% mujeres, edad promedio 49.9 ± 17.3 años, con diagnóstico de HP mediante cateterismo cardíaco derecho, seguidos desde enero de 2016 hasta enero de 2020. Se midió la deformación de la pared libre del ventrículo derecho desde las vistas de cuatro cámaras apical y cuatro cámaras subcostal. Resultados: El SLVD medido en la pared libre del VD desde la vista apical fue -15% (-19% a -10%) vs. -14.5% (-18% a -11%) cuando se midió desde la vista subcostal (p = 0,99). El análisis segmento por s egmento tampoco mostró diferencias significativas: el segmento basal apical vs. subcostal fue -16.5% (-21% a -11%) vs. -15.5% (-20% a -11%), p = 0.99, el segmento medio apical vs. la vista subcotal fue -16.5% (-21% a -12%) vs. a -16.5% (-20% a -11%), p = 0.87, el segmento apical vs. la vista subcostal fue -12% (-18% a -8%) frente a -13.5% (-19% a -10%), p = 0.93. Conclusión: En pacientes con HP, el SLVD obtenido en la pared libre subcostal es una alternativa útil en los casos con ventana acústica apical subóptima.

Case report: Stepwise transition from subcutaneous treprostinil to epoprostenol in high-risk pulmonary arterial hypertension.

BACKGROUND: Idiopathic pulmonary arterial hypertension is associated with high morbidity and mortality. In recent years, the use of targeted therapies has led to an improvement in prognosis. Prostacyclin analogues treprostinil and epoprostenol require continuous subcutaneous or intravenous infusion and are generally administered in a stepwise approach. However, there are no clear recommendations for transition in high-risk patients requiring high doses of prostacyclin analogues. CASE SUMMARY: In this report, we describe the case of a 20-year-old woman under combined treatment with sildenafil, macitentan, and treprostinil who required transition from subcutaneous treprostinil therapy to intravenous epoprostenol due to erratic drug absorption and functional class progression. The transition was performed over 48 h in a stepwise approach reducing treprostinil dose 4 ng/kg/min every 3 h while increasing epoprostenol infusion 2 ng/kg/min until achieving a maintenance dose of 32 ng/kg/min. There were no side effects requiring changes in the infusion rate. DISCUSSION: Patients with advanced pulmonary arterial hypertension may necessitate switching from subcutaneous treprostinil to epoprostenol. Although many protocols have been used to date, there are no guidelines to direct this process safely. This 48-h scheme based on the pharmacokinetic properties of each drug was successful and well-tolerated.

Speckle Tracking Imaging in Patients with Pulmonary Hypertension.

BACKGROUND: Right ventricular (RV) systolic dysfunction is a strong predictor of mortality in pulmonary hypertension (PH). The goal of this study was to investigate whether right atrium (RA) and RV myocardial strain related to PH using speckle tracking echocardiography provide a superior estimation of RV systolic function than 2-dimensional (2D)-echo. METHODS: This cross-sectional study analyzed 22 patients with a diagnosis of PH stratified by right heart catheterization, and they were compared to a control group of 22 age- and sex-matched healthy subjects. RESULTS: Global longitudinal peak systolic strain measured in the RV free wall from the apical 4 chamber view was -15% vs. -14.5% when measured from the subcostal view (p = 0.99). Mean longitudinal strain during reservoir phase, and longitudinal strain rate during atrial reservoir and passive conduit function was significantly impaired measured in the right atrial free wall in patients with PH. CONCLUSIONS: This study showed impaired LV contractility in patients with PH assessed by speckle tracking strain. RV free wall longitudinal strain does not correlate with any of the measurements of RV systolic function obtained by 2D echocardiography. A major strength of RV longitudinal strain is its ability to assess the RV function without the limitations of 2D parameters. The subcostal RV strain is a feasible and accurate alternative to conventional RV strain from the apical view in patients with poor acoustic apical 4-chamber windows. The RA strain and strain rates values may be a valuable additive to assess right-sided heart function.

Evaluación de la miocardiopatía no compactada con resonancia magnética cardíaca en pacientes con función sistólica del ventrículo izquierdo conservada y disminuida / Evaluation of non-compaction cardiomyopathy with cardiac magnetic resonance imaging in patients with preserved and decreased left ventricular systolic function

Objective: Non-compaction cardiomyopathy (NCC) is a genetic disorder characterized by the presence of an extensive trabecular layer of myocardium with intertrabecular recesses in communication with the ventricular cavity. The objective of this study is to evaluate the clinical and morphological characteristics of patients with NCC with and without systolic dysfunction assessed by cardiac magnetic resonance (CMR) imaging, as well as to discuss the value and limitations of echocardiography and CMR imaging in its diagnosis. Twenty patients diagnosed with NCC were retrospectively included. Studies were performed on a 1.5 Tesla resonator. The end-diastolic volume (LVEDV) and end-systolic volumen (LVESV), end-diastolic diameter (LVEDD) and end-systolic diameter (LVESD), left ventricular ejection fraction (LVEF), cardiac mass and LV trabeculations were determined. A 17-segment myocardium segmentation model was applied. Student s T test was used to compare variables between groups. Significance level was set at p <0.05. Correlation between 2 continuous variables was calculated using the linear regression model. The statistical software package used for data analysis was StatsDirect (Version 2.6.5,. Altrincham, UK. Results: The average thickness of NC myocardial segments and normal myocardium was 13.1 +/- 3.3 mm and 3.6 +/- 0.6 mm, respectively. The average number of myocardial segments with NC was 8.2 +/- 1.2. The more affected segments were the apex of the heart and the lateral segments at the apical and mid-ventricular level. LVEDD, LVEDV, global LV mass, compacted and trabeculated, were significantly increased in the group of patients with ventricular dysfunction. LVEF had a negative linear correlation with trabecular myocardal mass (MM)/ m2 (R = 0.67, p = 0.001), LVEDV /m2 (R = 0.77, p <0.001) and LVEDD/m2 (R = 0.7, p <0.001). Similarly, a negative linear correlation between LVTM/m² and LVEDV/m² (R = 0.76, p < 0.001) was observed. Conclusion: In our population...

Objetivos: La miocardiopatía no compactada (MNC) es un desorden genético caracterizado por la presencia de una extensa capa de miocardio trabeculado con recesos intertrabeculares comunicados con la cavidad ventricular. El objetivo del trabajo es evaluar las características clínicas y morfológicas de los pacientes con MNC con y sin disfunción sistólica evaluados por resonancia magnética cardíaca (RMC), y poner en discusión los alcances y las limitaciones de la ecocardiografía y la RMC en su diagnóstico. Material y métodos: Se incluyeron en forma retrospectiva 20 pacientes con diagnóstico de MNC. Los estudios se realizaron en un resonador de 1.5 Tesla. Se determinaron: volumen de fin de diástole (VFDVI) y sístole, diámetro de fin de diástole (DFDVI) y sístole, fracción de eyección (FEVI), masa cardíaca y trabeculaciones del VI. La distribución del miocardio NC se llevó a cabo con el modelo de 17 segmentos miocárdicos. Se empleó el test de Student para comparar las variables entre ambos grupos. El nivel de significancia fue establecido en p < 0,05. La correlación entre 2 variables continuas se calculó usando el modelo de regresión lineal. Los análisis se realizaron utilizando el software de estadística StatsDirect (versión 2.6.5, Altrincham, UK). Resultados: El espesor medio del miocardio NC y el miocardio normal fue 13.1 +/- 3.3 mm y 3.6 +/- 0.6 mm respectivamente. El número medio de segmentos con miocardio NC fue 8.2 +/- 1.2, siendo los más afectados el ápex y los segmentos laterales a nivel apical y medioventricular. El DFDVI, el VFDVI, la masa global, compactada y trabeculada del VI estuvieron incrementados en forma significativa en el grupo de pacientes con disfunción ventricular. La FEVI tuvo una correlación lineal negativa con masa de miocardio trabeculado del VI (MTVI)/m2 (R = 0.67, p = 0.001), el VFDVI/m2 (R = 0.77, p < 0.001) y el DFDVI/m2 (R = 0.7, p < 0.001). Asimismo, hubo una correlación lineal negativa entre la MTVI/m2 y el VFDVI/m2...

Evaluación de la miocardiopatía no compactada con resonancia magnética cardíaca en pacientes con función sistólica del ventrículo izquierdo conservada y disminuida / Cardiac Magnetic Resonance Imaging for Evaluation of Non-Compaction Cardiomyopathy in Patients with or without Left Ventricular Systolic Dysfunction

Introducción La miocardiopatía no compactada (MNC) es un trastorno genético que se caracteriza por la presencia de una extensa capa de miocardio trabeculado con recesos intertrabeculares comunicados con la cavidad ventricular. Si bien su prevalencia es mayor en poblaciones sintomáticas con disfunción ventricular, las nuevas modalidades diagnósticas incrementaron su detección en pacientes asintomáticos con función sistólica conservada. No obstante, la patología permanece subdiagnosticada debido al bajo índice de sospecha sumado al uso de clasificaciones ecocardiográficas con criterios diagnósticos dispares. Se establecieron dos criterios diagnósticos de resonancia magnética cardíaca (RMC) que reconocen correctamente esta entidad. Objetivo Evaluar las características clínicas y morfológicas de los pacientes con MNC con disfunción sistólica y sin ella evaluados por resonancia magnética cardíaca (RMC). Material y métodos Se incluyeron en forma retrospectiva 20 pacientes con diagnóstico de MNC. Se determinaron: volumen de fin de diástole (VFDVI) y de sístole, diámetro de fin de diástole (DFDVI) y de sístole, fracción de eyección (FEVI), masa cardíaca y trabeculaciones del ventrículo izquierdo (VI). La distribución del miocardio NC se llevó a cabo con el modelo de 17 segmentos miocárdicos. Resultados El espesor medio del miocardio NC y el miocardio C fue de 13,1 ± 3,3 mm y de 3,6 ± 0,6 mm, respectivamente. El DFDVI, el VFDVI, la masa global, compactada y trabeculada del VI estuvieron incrementados en forma significativa en el grupo de pacientes con disfunción ventricular. Hubo una correlación positiva y una relación lineal entre el DFDVI y la MTVI (g/m2): r = 0,76; r² = 0,59; p < 0,001. Conclusiones Hallamos dos formas de presentación de la patología, una sutil con función sistólica conservada y otra asociada con disfunción ventricular que se comporta como la miocardiopatía dilatada.

Background Non-compaction cardiomyopathy (NCC) is a genetic disorder characterized by deep trabeculations in the ventricular wall, which define recesses communicating with the main ventricular chamber. The prevalence of NCC is greater in symptomatic populations with left ventricular dysfunction; yet, it may also be detected in asymptomatic patients with normal left ventricular function using novel diagnostic tools. However, this condition is under-diagnosed due to a low index of clinical suspicion and to the use of echocardiography classifications based on different diagnostic criteria. The use of cardiac magnetic resonance imaging (CMRI) has established two diagnostic criteria that clearly recognize this disease. Objective To evaluate the clinical and morphological characteristics of patients with NCC with and without systolic dysfunction undergoing cardiac magnetic resonance imaging (CMRI). Material and Methods A total of 20 patients with NCC were retrospectively included. The following parameters were determined: left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV); left ventricular end-diastolic diameter (LVEDD); left ventricular end-systolic diameter (LVESD); cardiac mass and left ventricular trabeculations. The distribution of NC myocardium was evaluated according to the model of 17 myocardial segments. Results Mean myocardial thickness was 13.1±3.3 mm and 3.6±0.6 mm in NC versus normal myocardium, respectively. Patients with left ventricular dysfunction presented increased LVEDD, LVEDV, total cardiac mass, and LV non-compaction and trabeculations. We found a positive correlation and a linear relationship between LVEDD and TLVM (g/m2): r=0.76; r²=0.59; p<0.001. Conclusions We found that NCC can present either as a subtle condition with normal systolic function or as a dilated cardiomyopathy associated with ventricular dysfunction.

Aleteo auricular postrasplante cardíaco tratado exitosamente mediante ablación por catéter / Atrial Flutter Following Cardiac Transplantation Successfully Treated with Catheter Ablation

El desarrollo de arritmias supraventriculares es un hallazgo frecuente en el seguimiento de pacientes sometidos a trasplante cardíaco. La ablación por radiofrecuencia del aleteo auricular ha demostrado que es el tratamiento de elección en pacientes con cardiopatía subyacente y sin ella, en tanto que son escasas las comunicaciones en la bibliografía acerca de su eficacia postrasplante cardíaco. En esta presentación se describe el caso de un paciente de 26 años con antecedente de trasplante cardíaco que presentó aleteo auricular en la evolución. En el estudio electrofisiológico se observó un aleteo auricular típico antihorario dependiente del istmo en la aurícula derecha del donante. La aurícula derecha del receptor se encontraba disociada, en ritmo sinusal. Durante la aplicación de radiofrecuencia en el istmo a la altura de la línea de sutura auriculoauricular derecha se observó la interrupción del aleteo. Ambas aurículas derechas quedaron en ritmo sinusal, disociadas por bloqueo bidireccional a nivel de la anastomosis.

Supraventricular arrhythmias are frequently found during follow-up of patients undergoing cardiac transplantation. Radiofrequency catheter ablation of atrial flutter has proved to be the treatment of choice in patients with and without underlying heart disease; however, there are few reports of the efficacy of this technique after cardiac transplantation. We describe the case of a 26-year old male patient who developed atrial flutter during the follow-up of cardiac transplantation. The electrophysiology study revealed the presence of a typical, counterclockwise atrial flutter in the isthmus of the donor's right atrium. The recipient right atrium was in sinus rhythm with dissociation of electrical activity. While delivering radiofrequency energy at the level of the right atrio-atrial suture line of the isthmus the atrial flutter was interrupted. Both right atria remained in sinus rhythm, dissociated by bidirectional block at the level of the anastomosis.