¿Existe correlación metabólica hipoglucémica y el síndrome de Percheron? Reporte de caso

Introducción: El síndrome de Percheron es causa de lesiones isquémicas talamicas bilaterales ocasionando una serie de anomalías clínicas como: alteración del estado de conciencia, oftalmoplejias, y alteraciones de la memoria. Caso clínico: Presentamos el caso de una mujer de 49 años con diabetes mellitus, mal control metabólico, episodios hipoglucémicos e hiperglucemicos repetitivos, quien cursa con sintomatologia inespecífica, se realizan estudios imagenológicos no invasivos documentado lesiones talamica bilaterales. Conclusiones: Los cuadros subagudos e isquémicos parciales que involucran la región paramediana del Talamo bilateral podrían tener alguna relación con episodios hipoglucémicos e hiperglucemicos repetitivos, que pueden llegar a cursar con sintomatología leve e inespecífica, lo cual lo convierte un reto diagnóstico para este síndrome.

Introduction: Percheron syndrome is the cause of bilateral thalamic ischemic lesions, causing a series of clinical abnormalities such as an altered state of consciousness, ophthalmoplegia, and memory alterations. Clinical case: We present the case of 49-year-old woman with diabetes mellitus, poor metabolic control, and repetitive hypoglycemic and hyperglycemic episodes with nonspecific symptoms, non-invasive imaging studies were performed, which documented bilateral thalamic lesions. Conclusions: Subacute and partial ischemic symptoms that involve the paramedian region of the bilateral thalamus could have some relationship with repetitive hypoglycemic and hyperglycemic episodes, and can lead to mild and nonspecific symptoms, which makes it a diagnostic challenge for this syndrome.

Implantación intraabdominal de un injerto renal con dos arterias renales en un receptor pediátrico de bajo peso. Primer caso reportado en el Paraguay / Intra-abdominal implantation of a kidney graft with two renal arteries in a low-weight pediatric recipient. First case reported in Paraguay

El trasplante renal de órganos provenientes de donantes adultos implantados en una cavidad anatómica estrecha en pacientes pediátricos de bajo peso, ofrece importantes desafíos médicos y quirúrgicos a ser considerados. En esta publicación reportamos el primer caso en el Paraguay de un riñón con dos arterias renales injertado a la aorta y vena cava inferior, dentro de la cavidad abdominal de un paciente pediátrico de 12 kilogramos de peso, evaluando las dificultades médicas, anatómicas y quirúrgicas enfrentadas, así como las opciones de tratamiento instituidas para llevar a cabo este procedimiento de manera exitosa

Kidney transplantation of organs from adult donors implanted into a narrow anatomical cavity in underweight pediatric patients offers significant medical and surgical challenges to be considered. In this publication we report the first case in Paraguay of a kidney with two renal arteries, grafted to the aorta and inferior vena cava within the abdominal cavity, on a 12 kilogram pediatric patient, evaluating the medical, anatomical and surgical conditions faced, as well as the treatment options instituted to successfully carry out this procedure

Left Cardiac Remodelling Assessed by Echocardiography Is Associated with Rho-Kinase Activation in Long-Distance Runners.

This single-blind and cross-sectional study evaluated the role of Rho-kinase (ROCK) as a biomarker of the cardiovascular remodelling process assessed by echocardiography in competitive long-distance runners (LDRs) during the training period before a marathon race. Thirty-six healthy male LDRs (37.0 ± 5.3 years; 174.0 ± 7.0 height; BMI: 23.8 ± 2.8; V˙ O2-peak: 56.5 ± 7.3 mL·kg-1·min-1) were separated into two groups according to previous training level: high-training (HT, n = 16) ≥ 100 km·week-1 and low-training (LT, n = 20) ≥ 70 and < 100 km·week-1. Also, twenty-one healthy nonactive subjects were included as a control group (CTR). A transthoracic echocardiography was performed and ROCK activity levels in circulating leukocytes were measured at rest (48 h without exercising) the week before the race. The HT group showed a higher left ventricular mass index (LVMi) and left atrial volume index (LAVi) than other groups (p < 0.05, for both); also, higher levels of ROCK activity were found in LDRs (HT = 6.17 ± 1.41 vs. CTR = 1.64 ± 0.66 (p < 0.01); vs. LT = 2.74 ± 0.84; (p < 0.05)). In LDRs a direct correlation between ROCK activity levels and LVMi (r = 0.83; p < 0.001), and LAVi (r = 0.70; p < 0.001) were found. In conclusion, in male competitive long-distance runners, the load of exercise implicated in marathon training is associated with ROCK activity levels and the left cardiac remodelling process assessed by echocardiography.

Improving the robustness of MOLLI T1 maps with a dedicated motion correction algorithm.

Myocardial tissue T1 constitutes a reliable indicator of several heart diseases related to extracellular changes (e.g. edema, fibrosis) as well as fat, iron and amyloid content. Magnetic resonance (MR) T1-mapping is typically achieved by pixel-wise exponential fitting of a series of inversion or saturation recovery measurements. Good anatomical alignment between these measurements is essential for accurate T1 estimation. Motion correction is recommended to improve alignment. However, in the case of inversion recovery sequences, this correction is compromised by the intrinsic contrast variation between frames. A model-based, non-rigid motion correction method for MOLLI series was implemented and validated on a large database of cardiac clinical cases (n = 186). The method relies on a dedicated similarity metric that accounts for the intensity changes caused by T1 magnetization relaxation. The results were compared to uncorrected series and to the standard motion correction included in the scanner. To automate the quantitative analysis of results, a custom data alignment metric was defined. Qualitative evaluation was performed on a subset of cases to confirm the validity of the new metric. Motion correction caused noticeable (i.e. > 5%) performance degradation in 12% of cases with the standard method, compared to 0.3% with the new dedicated method. The average alignment quality was 85% ± 9% with the default correction and 90% ± 7% with the new method. The results of the qualitative evaluation were found to correlate with the quantitative metric. In conclusion, a dedicated motion correction method for T1 mapping MOLLI series has been evaluated on a large database of clinical cardiac MR cases, confirming its increased robustness with respect to the standard method implemented in the scanner.

Anomalía coronaria sospechada por el signo "RAC" en resonancia magnética cardíaca / Anomalous coronary artery suspected by cardiac magnetic resonance "RAC" sign

Abstract A 63 year-old-male was admitted with a non-ST-segment elevation acute coronary syndrome. Due to poor acoustic windows ventricular function could not be evaluated by echocardiography. Magnetic resonance (CMR) revealed normal biventricular size and function without fibro- sis and portraying a rare finding consisting of a tubular structure originated in the aortic root following a retro aortic course between the aorta and left atrium, traversing through the atrioventricular groove. These characteristics raised the suspicion of an anomalous coronary artery origin. Coronary angiography confirmed the presence of two coronary arteries, the right coronary artery (RCA) and the left circumflex artery (LCx) originating from the right coronary sinus via two separate ostia. The LCx followed a retro aortic course proximally be- fore irrigating the left ventricular lateral wall. From the left coronary sinus, the left anterior descending artery followed its normal course with a thin diagonal vessel that presented an acute plaque. Due to these low-risk findings, medical management was chosen.

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.

Caracterización de la fisiología restrictiva del ventrículo derecho mediante flujo 4D / 4-D flow characterization of right ventricular restrictive physiology

Abstract: Right ventricular restrictive physiology (RVRP) occurs in diverse clinical scenarios, most frequently after repair of Tetralogy of Fallot (TOF). Cardiac magnetic resonance (CMR) can comprehensively evaluate RVRP using 4D flow along with anatomical and fibrosis characterization. Also, RVRP is associated with less pulmonary regurgitation and fewer right ventricle enlargement; its long term protective role is debated. RVRP is a challenging and relevant diagnosis, which hallmark is the presence of antegrade pulmonary arterial Flow in late diastole throughout the respiratory cycle. Also, other hemodynamic findings could aid such us flow in; caval veins, suprahepatic, coronary sinus and tricuspid valve. Obtaining all these flow curves is virtually impossible by echocardiography. CMR with 4DF is a unique and powerful technique enabling this comprehensive hemodynamic evaluation as depicted in this case.

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.

Entrenamiento físico de alta intensidad en maratonistas produce mayor remodelado cardíaco y reduce respuesta de estrés oxidativo / High-intensity training in marathon runners increases cardiac remodeling and diminishes oxidative stress response

Resumen: Introducción: El ejercicio físico reduce la mortalidad cardiovascular y genera remodelado cardíaco. Altas cargas de entrenamiento pueden generar remodelado cardíaco adverso. Biomarcadores (BMC) de inflamación Interleukina 6 (IL-6) y de estrés oxidativo Malondialdehído (MDA), potencialmente pueden caracterizar la respuesta al esfuerzo. Objetivo: Evaluar actividad de IL-6 y MDA en respuesta a una maratón en atletas con distinto nivel de entrenamiento y remodelado cardíaco asociado. Sujetos y Métodos: Estudio prospectivo, simple ciego, incluyó 16 atletas que completaron la maratón de Santiago (42 k), separados según entrenamiento previo, grupo 1 (G1, n: 8): Alto ≥ 100 km/semana y grupo 2 (G2, n: 8): Bajo <100 km/semana). Se obtuvo pre y post maratón: niveles de IL-6, MDA y ecocardiografía Doppler transtorácica (ETT); cuantificando cámaras cardíacas izquierdas, derechas y deformación del ventrículo izquierdo (strain longitudinal). Se utilizaron las pruebas de Mann-Whitney, Wilcoxon y Kruskal-Wallis. Resultados: Edad G1: 38.13±7.18 años vs G2: 40.38±6.63 años (NS). Tiempo maratón G1: 185.75±14.87 min vs G2: 219.75±24.92 min (p<0.01). Masa del ventrículo izquierdo G1: 91±21 g/m2 vs G2: 73±12 g/m2 (p<0.01). Volumen aurícula izquierda G1: 39.4±12.6 ml/m2 vs 30.6±4.6 ml/m2 (p<0.01). FEVI G1: 55.8±3.3% vs G2: 58.6±6.7% (NS). MDA G1: PRE 0.17±0.13 uM/L, POST 0.67±0.59 uM/L, G2: PRE 0.29±0.24 uM/L, POST 1.01±1.15 uM/L (p<0.01). IL-6 G1: PRE 2.50±1.35 pg/ml, POST 93.91±27.23 pg/ml vs G2: PRE 4.65±5.89 pg/ml, POST 97.83±30.72 pg/ml (NS). Conclusión: El ejercicio físico aumenta los BMC de inflamación y estés oxidativo (IL-6, MDA). Un entrenamiento físico de alta intensidad disminuye la respuesta de estrés oxidativo y se asocia a un mayor remodelado cardíaco.

Abstract: Background: Exercise reduces cardiovascular mortality and generates cardiac remodeling. High training loads can induce adverse cardiac remodeling, and its associated cardiac remodeling. Therefore, interleukin 6 (IL 6) and malondialdehyde (MDA), biomarkers of inflammatory response and oxidative stress respectively, may have a role in stratifying this risk. Objective: To assess the activity of IL-6 and MDA in response to a marathon race in athletes with different previous training status. Subjects And Methods: Prospective, single-blind study involving 16 male athletes that finished the Santiago Marathon (42 k), allocated into two groups according to their previous training: Group 1 (G1, n: 8) with high training (≥ 100 km/weekly) and Group 2 (G2, n: 8) with low training (< 100 km/weekly). Before and after the race serum levels of IL-6, MDA and transthoracic Doppler echocardiography for cardiac chamber quantification and left ventricle deformation (longitudinal strain) were measured. Mann-Whitney, Wilcoxon, and Kruskal-Wallis tests were used to assess statistical significance. Results: Age G1: 38.13±7.18 years-old vs G2: 40.38±6.63 years-old (NS). Marathon finishing time G1: 185.75±14.87 min vs G2: 219.75±24.92 min (p<0.01). Left ventricle mass G1: 91±21 g/m2 vs G2: 73±12 g/m2 (p<0.01). Left atrium volume G1: 39.4±12.6 ml/m2 vs 30.6±4.6 ml/m2 (p<0.01). LVEF G1: 55.8±3.3% vs G2: 58.6±6.7% (NS). MDA G1: PRE 0.17±0.13 uM/L, POST 0.67±0.59 uM/L, G2: PRE 0.29±0.24 uM/L, POST 1.01±1.15 uM/L (p<0.01). IL-6 G1: PRE 2.50±1.35 pg/ml, POST 93.91±27.23 vs G2: PRE 4.65±5.89 pg/ml, POST 97.83±30.72 pg/ml (NS). Conclusion: Physical exercise generates a rise in biomarkers (IL-6, MDA). Athletes with high-intensity training level have a diminished oxidative stress response post effort and greater cardiac remodeling.

Increased active phase atrial contraction is related to marathon runner performance.

PURPOSE: Left atrial (LA) contraction is essential for left ventricular (LV) filling during exertion. We sought to evaluate the relationship of LA contraction and exercise capacity in trained athletes. METHODS: Sixteen male marathon runners were recruited and allocated into two groups according to their previous training status (≥ or < 100 km peer week). All subjects underwent a baseline cardiopulmonary test to evaluate maximal aerobic capacity and a transthoracic echocardiography previous and immediate post-marathon. LA contractile function evaluation was accomplished by measuring the negative deformation of the post P wave strain curve (LASa). LASa change was defined as LASa pre-marathon minus LASa immediate post-marathon. RESULTS: Mean age was 39 ± 6 years. LA volume index (39 ± 13 vs. 31 ± 5 mL/m2, p = 0.04), LV mass index (91 ± 21 vs. 73 ± 12 g/m2, p = 0.04), VO2 max (59 ± 3 vs. 50 ± 8 mL/kg/min, p = 0.036) were higher in more intensive trained group and marathon time was lower (185 ± 14 vs. 219 ± 24 min, p = 0.017). An increase in LASa after immediate post-marathon was observed in both groups, which was significantly greater in the highly trained group (18.9 ± 5.8 vs. 6.3 ± 3.5%, p < 0.003). Maximum VO2 measured previous to the marathon was inversely related to marathon time and directly correlated to LASa change (rho = 0.744, p = 0.001, rho = 0.546, p = 0.028, respectively). CONCLUSIONS: Athletes with more intensive training load have larger LV mass and LA size. An increase in LA contraction was seen post-marathon, which was significantly greater in the highly trained group. This increase in the LA contraction was related to the maximum VO2 measured previous to the marathon and to performance in a highly demanding test.

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.

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.