Cardiac involvement in acromegaly: specific myocardiopathy or consequence of systemic hypertension?

To evaluate the relative contributions of past or present GH hypersecretion and of hypertension to the cardiac abnormalities present in acromegaly, we have studied the serum GH and insulin-like growth factor I concentrations, systolic and diastolic blood pressures, and morphological and functional cardiac indexes as measured by echocardiography-Doppler, in 39 patients with active or cured acromegaly, 16 hypertensive controls, and 17 normotensive controls. Hypertension was present in 42.8% of patients with active acromegaly and in 28.0% of patients in which acromegaly was cured. Hypertension was independently related to an increase in indexes of cardiac morphology (left ventricular mass, left ventricular posterior wall thickness, interventricular septum thickness, relative wall thickness with respect to the diastolic diameter of the left ventricle, and left atrial end-systolic diameter), systolic function (stroke volume, fractional shortening, and end-systolic stress), and diastolic function (isovolumic relaxation time and maximal late diastolic flow velocity) and to a reduction in the early to late maximal diastolic flow velocity ratio. Acromegaly was related to an increase in left ventricular mass, stroke volume, cardiac output, and isovolumic relaxation time, which were independent from the presence of hypertension. End-systolic stress was reduced by acromegaly. In the five patients in which active acromegaly was successfully treated, left ventricular mass and left ventricular posterior wall thickness were reduced 1 yr later. In conclusion, the asymptomatic morphological and functional cardiac abnormalities present in acromegalic patients are independently related to acromegaly and hypertension, pointing to the existence to a specific acromegalic myocardiopathy that might be aggravated by the coexistence of hypertension.

[Doppler echocardiography in hypertrophic myocardiopathy]. / Ecocardiografía-Doppler en la miocardiopatía hipertrófica.

Hypertrophic cardiomiopathy is a peculiar process with different anatomical and functional abnormalities which are present in different degrees in each case. Echocardiography and Doppler techniques have contributed definitively to the knowledge of this process and these procedures are choices for establishing the diagnosis of hypertrophic cardiomyopathy and to evaluate the clinical and morphological diversity of this process consisting of a spectrum of abnormalities with a variable presence in each case. Disproportionate septal hypertrophy is the most frecuent finding but the hypertrophy can involve other segments and different patterns can be present; concentric hypertrophy, apical, involving right ventricle, inverted asymetric, etc. Anterior mitral valve motion can be produced by the interrelation between anatomic factors of the valve, geometry of the outflow tract and physical forces produced by flow changes. Doppler echocardiography allows us to evaluate subaortic obstruction, to define its site, to demonstrate and measure the degree of mitral regurgitation and to carry out intraoperative studies. In hypertrophy cardiomyopathy the pattern of delayed relaxation is the most frequent but patients with severe obstruction and mitral regurgitation can pseudonormalize this pattern and even show restrictive patterns.

[Psoriatic arthritis associated with severe aortic insufficiency and complete auriculoventricular blockage]. / Artritis psoriásica asociada a insuficiencia aórtica severa y bloqueo auriculoventricular completo.

We report on a case of long lasting psoriatic arthritis HLA B27 positive, complicated by the presence of severe aortic regurgitation and complete atrioventricular block, which required valve replacement and a permanent pacemaker. Valvular tissue histopathological analysis showed changes similar to those found in other seronegative spondyloarthritis.

[Prognostic significance of silent ischemia in the exercise test in patients with coronary disease]. / Significado pronóstico de la isquemia silente durante la prueba de esfuerzo en pacientes con enfermedad coronaria.

To evaluate the prognostic significance of silent ischemia during exercise testing, 152 consecutive patients (143 males, 9 females) with a mean SD of 55 +/- 7 years (age range 32-73) who underwent exercise testing and coronary arteriography within 3 months were studied. All patients had the following characteristics: 1) a positive electrocardiographic exercise test response; 2) significant coronary artery disease on the arteriography; 3) uninterrupted clinical follow-up for a minimum of 6 months. The 152 patients were divided in 2 groups: group I: 56 patients (37%) with ischemic ST-segment depression during exercise testing without angina (silent ischemia); group II: 96 patients (63%) with ischemic ST-segment depression and angina (symptomatic ischemia). Patients in group I and group II showed similar time to ST-segment depression (3.6 +/- 1.5 min vs 3.2 +/- 1.4 min; p = NS), maximal ST-segment depression and peak heart rate-systolic pressure product (21,151 +/- 7,124 vs 20,456 +/- 6,024; p = NS). Exercise duration was longer in group I than in group II (5.6 +/- 2.1 min vs 4.8 +/- 1.5 min; p less than 0.001). The extent of coronary artery disease defined by the number of significant narrowed coronary vessels, left ventricular end diastolic pressure and ejection fraction were similar in the 2 groups. Sixty six patients who underwent coronary bypass surgery were not included in the analysis. The remaining 86 patients (40 in group I and 46 in group II) were medically treated. The mean follow-up period was 43,5 +/- 25 months (range 6-101).2+ myocardial ischemia during exercise testing.

[A simplified method of continuous-wave Doppler noninvasive assessment of ventricular relaxation in mitral insufficiency]. / Método simplificado para el análisis no invasivo de la relajación ventricular mediante Doppler continuo en la insufficiencia mitral.

INTRODUCTION AND OBJECTIVES: The minimum value of dP/dT is a parameter of diastolic function that can be estimated noninvasively by analyzing the profile of velocity of the mitral regurgitant jet, recorded by continuous-wave Doppler. This estimation requires a complex analysis of the curves that impedes its practical use. Our objective was to validate a simplified method to estimate noninvasively the value of dP/dTmin when mitral regurgitation exists. We calculated the pendient of the profile of velocity of the curve of mitral regurgitation during its deceleration, between 3 and 1.5 m/s, an interval that defines a difference in pressure using the formula delta p = (4v2(1) - 4v2(2)). We divided this interval by the time needed by the jet to decelerate from 3 to 1.5 m/s, obtaining the rate of pressure decay, in mmHg/s. METHODS: We provoked mitral regurgitation in five pigs and registered dP/dT and the curve velocity of mitral regurgitation simultaneously, by micromanometer-tipped catheter and continuous-wave Doppler, respectively. The rate of pressure decay was calculated on the mitral regurgitation curve. RESULTS: We obtained 29 simultaneous registers. The coefficient for the correlationship between dP/dT and the rate of pressure decay was with an r value of 0.62 (p < 0.0001). The rate of pressure decay underestimated systematically the value of dP/dT. Intra and interobserver variability of TDP was 9 and 11%, respectively. CONCLUSIONS: This study validates a simplified method to estimate dP/dT noninvasively, with acceptable correlation with invasive measurements and adequate reproducibility.

[Study of active myocardial damage in children with suspected myocarditis using antimyosin monoclonal antibodies (AMMoAb-111In)]. / Estudio evolutivo del daño miocárdica activo en niños con sospecha de miocarditis mediante anticuerpos monoclonales antimiosina (AbMoAM-111In).

BACKGROUND: The study with monoclonal antimyosin antibody-111In has proved to be useful in the detection of the myocardial damage present in different processes. There is active myocardial damage and specific antimyosin uptake in myocarditis, as both experimental and clinical trials have shown. In experimental models the evolution of myocardial damage has been studied, where a parallelism between the histological changes of the myocardial damage and the evolution on the antimyosin uptake has been found. In clinical myocarditis it is difficult to do an histological follow up of the inflammatory process, and therefore the evolution of myocardial damage present in myocarditis is unknown. The antimyosin antibody images allow a non-invasive study of this evolution. OBJECTIVES: a) to study with monoclonal antimyosin antibody-111In, the myocardial damage present regarding the disease evolution in children with suspected clinical diagnosis of myocarditis; b) to evaluate the evolution of the active myocardial damage reflected on the changes on the monoclonal antimyosin antibody-111In uptake. METHODS: A study with monoclonal antimyosin antibody-111In was carried out on 43 children, 16 males and 27 females with a median age of 39 months (SD 48 m; range: 2-167) with suspected diagnosis of acute myocarditis defined as the presence of congestive cardiac failure or severe ventricular arrhythmia with less than 12 months of evolution. The image evaluation was done visually and through the heart to lung ratio. Twenty of these patients were also followed up with antimyosin antibody scan for a period of 19 +/- 9 months, and 3.8 +/- 1.7 studies were performed on them in this time. RESULTS: The prevalence of positive myocardial uptake was 83.72%. There is a negative correlation (r = -0.352; p < 0.02) between the evolution time of the process and the heart to lung ratio: patients studied before two months, have a higher heart to lung ratio and greater prevalence of positive studies than those studied later (heart to lung ratio 2.09 vs 1.74; p = 0.013; 90% vs 69.2%). Of the patients followed up with antimyosin antibody scans, 6 showed a clinical relapse which increased their heart to lung ratio. The other 14 showed an progressive decrease of the heart to lung ratio reaching normality in 14 +/- 6 months. CONCLUSIONS: a) the uptake intensity of monoclonal antimyosin antibody-111In, as a reflection of the myocardial damage, depends on the disease evolution time, as in the first two months is when the major damage happens; b) the uptake intensity slowly decreases, tending to normality around the 14th month, although this evolution may be altered by the appearance of relapses.

[Hypertrophic obstructive myocardiopathy complicated by severe mitral insufficiency secondary to rupture of the chordae tendineae]. / Miocardiopatía hipertrófica obstructiva complicada con insuficiencia mitral severa secundaria a rotura de cuerdas tendinosas.

A case of suddenly increasing dyspnea in a patient with hypertrophic obstructive cardiomyopathy is reported. Transesophageal echocardiography showed severe mitral regurgitation secondary to ruptured chordae tendineae. Mitral valve replacement was done, correcting both mitral regurgitation and subaortic gradient. Utility of transesophageal echocardiography in diagnosis and therapeutic options are discussed.

[Penetrating trauma by foreign body in the left heart ventricle]. / Traumatismo penetrante con cuerpo extraño en el ventrículo izquierdo.

We present the case of a patient who suffered a cardiac penetrating trauma due to a 6-cm long steel splinter. He was self-admitted to the emergency room and was asymptomatic. Cardiac trauma was diagnosed by the presence of a foreign body in his chest X-ray. Transthoracic and transesophageal echocardiography showed pericardial effusion and a dense foreign body that crossed the left ventricle from upside down and forward to back. The patient underwent cardiac surgery under extracorporal circulation. A shooting wound was seen on the left ventricular free wall. Transesophageal echocardiography was performed during surgery in order to define the position of the foreign body and to discard lesions due to multidirectional injury. Lesions were repaired and the patient was discharged with no complications. This case report illustrates the possibility of survival after cardiac penetrating trauma, and the role of echocardiography in the diagnosis and surgical repair of this type of trauma.

[Yield of transthoracic echocardiography with high frequency transducer in the study of the anterior descending coronary artery]. / Rendimiento de la ecocardiografía transtorácica con sonda de alta frecuencia en el estudio de la descendente anterior.

INTRODUCTION AND OBJECTIVES: This study was performed to evaluate the feasibility and utility of a transthoracic high frequency transducer to detect and measure the left anterior descending coronary artery flow in patients with lesions in this artery or anterior myocardial infarction. MATERIALS AND METHODS: We studied 11 subjects with lesions greater than 75% and another 10 with anterior myocardial infarction. We compared the results with a control group of 18 subjects. An ATL HDI 5000 ultrasound unit with a 5-8 MHz transducer was used to identify the left anterior descending in the anterior interventricular sulcus from an apical four chamber window. We considered that left anterior descending was detected when a diastolic predominant flow pattern was obtained with pulse Doppler. RESULTS: Left anterior descending was detected in 37/39 of cases (94.4%). Patients with coronary lesions showed a decrease in the limit of significance in the diastolic/systolic peak velocity ratios: 2.5 (SD 0.7) vs 1.8 (SD 0.3) with a p = 0.024. Patients with anterior myocardial infarction obtained lower diastolic/systolic peak velocity ratios than controls: 2.5 (SD 0.7) vs 1.4 (SD 0.3) with a p = 0.001. CONCLUSIONS: Left anterior descending coronary artery flow can be assessed by transthoracic high frequency echocardiography in greater than 90% of the cases. Patients with coronary lesions and those with anterior myocardial infarction have a decreased diastolic/systolic peak velocity ratio.

[Rupture of the intraventricular septum and free wall of the left ventricle secondary to non-penetrating thoracic injury. Doppler echocardiography diagnosis]. / Rotura de septo interventricular y pared libre de ventrículo izquierdo secundaria a traumatismo torácico no penetrante. Diagnóstico por ecocardiografía Doppler.

The heart is often injured in the setting of blunt chest trauma with a broad spectrum of cardiac lesions. We present a twenty-nine years old man with interventricular septal and rupture and left ventricular free wall rupture following chest trauma. Doppler echocardiography was essential in the diagnostic and therapeutic procedure. We concluded that Doppler-echocardiography must be performed in all patients with suspicion of cardiac affectation after blunt chest trauma.

[Traumatic rupture of the aorta presenting as aortic coarctation syndrome]. / Rotura traumática de aorta manifestada como síndrome de coartacion aortica.

Aortic rupture is a frequent cause of death in chest trauma. The coincidence with other associated severe lesions and the absence of clear cardiographic signs may induce to an important delay in the diagnosis. We report a case in which the late apparition of arterial hypertension expressed as an acute aortic coarctation syndrome pointed out the diagnosis. We review the pathogenic mechanisms of arterial hypertension in traumatic aortic rupture and the utility of different diagnostic procedures.

Severe pulmonary arterial hypertension due to toxic oil syndrome: a new cause of plexogenic arteriopathy.

Ten patients with severe pulmonary hypertension due to Toxic Oil Syndrome (TOS) (3 men, 7 women; mean age 27.9 +/- 11.23 yrs.) are presented. The pulmonary vessels were examined with a micromorphometric technique. All patients had intimal fibrosis of the arteries and veins. Seven also had a thrombus in different stages. All arteries were shown to have medial hypertrophy. Plexiform lexions were found in eight cases. It is concluded that TOS can produce severe pulmonary hypertension histologically undistinguishable from the primary form. TOS can be added to the list of diseases causing plexogenic arteriopathy.