Anatomical and Clinical Factors Associated With Valvulopathy and Aortopathy in Mexican Patients With Bicuspid Aortic Valves.

The bicuspid aortic valve (BAV) is associated with significant aortic valve dysfunction. We aimed to study Mexican patients with BAV to assess phenotypic expressions of BAV, and associations of valvulopathy and aortopathy and their predictors. A cross-sectional, retrospective study was designed. The patients were divided according to (1) normally or minimally dysfunctional BAV, (2) predominant aortic regurgitation (AR), and (3) predominant aortic stenosis (AS). A total of 189 patients were included with a high prevalence of males (68%). The overall median age was 42 (23 to 52) years. The distribution of fused BAV phenotypes was right-left fusion (77%), right noncoronary fusion (17%) and left noncoronary fusion (6%). AS-predominant group was the oldest with a high prevalence of hypertension, type 2 diabetes mellitus (T2DM), and raphe. In multivariable analysis T2DM (odds ratio [OR] 10.5 [95% confidence interval (CI) 2.1 to 52], p <0.01) and presence of raphe (OR 2.58 [95% CI 1.02 to 6.52], p = 0.04) were independently associated with AS. The AR-predominant group was composed mostly of males with significantly fewer cardiovascular risk factors. Male gender (OR 2.84 [95%CI 121 to 6.68], p = 0.01) and aortic dilatation (OR 3.58 [95% CI 1.73 to 7.39], p <0.01) were associated with AR-predominance in multivariable analysis. Aortic dilatation was associated with age (OR 1.03 [95% CI 1.008 to 1.05], p <0.01) and AR (OR 4.31 [95% CI 2.05 to 9.06], p <0.01). Independent factors associated with the root phenotype were male gender (OR 12.4 [95% CI 1.6 to 95], p <0.01) and AR (OR 5.25 [95% CI 2.18 to 12.6], p <0.01).In conclusion, in a mestizo population, the distribution of BAV-fused phenotypes was similar to European and North American populations, the presence of raphe and T2DM were independently associated with AS-predominance, and male gender and aortic dilatation were independently associated with AR-predominance.

[Management of heart failure with His bundle pacing in right bundle branch block: case report]. / Manejo de la insuficiencia cardiaca con estimulación hisiana en bloqueo de rama derecha: reporte de caso.

La terapia de resincronización cardiaca mediante estimulación hisiana ha demostrado ser efectiva en pacientes con bloqueo de rama izquierda del haz de His e insuficiencia cardiaca. Paciente masculino, con 47 años de edad, con insuficiencia cardiaca, fracción de expulsión del 17% y miocardio dilatada idiopática, electrocardiograma en ritmo sinusal, bloqueo auriculoventricular de 1.er grado, intervalo PR 400 ms, bloqueo completo de rama derecha del haz de His, bloqueo del fascículo anterior de la rama izquierda del haz de His, duración del QRS 200 ms. Se decidió realizar estimulación selectiva del haz de His. La resincronización cardiaca biventricular convencional en pacientes con presencia de bloqueo completo de la rama derecha del haz de His no está indicada debido a la pobre respuesta al tratamiento. La estimulación hisiana permite reclutar la rama bloqueada y reestablecer la conducción a través de ella, de tal forma que, en ausencia de necrosis, se logre sincronía biventricular. En el caso presentado el reclutamiento de la rama derecha mediante estimulación hisiana se reflejó en el restablecimiento de la sincronía biventricular, medida por rastreo de marcas (speckle tracking) e incremento significativo de la fracción de expulsión del ventrículo izquierdo del 17 al 36.6%, con un incremento absoluto del 19.6%.Cardiac resynchronization therapy has proven to be an effective therapy in patients with left bundle branch block and heart failure. Male, 47 years old, heart failure with a left ventricle ejection fraction of 17%, idiopathic heart failure. ECG with sinus rhythm, 1st degree AV block, PR 400 ms, complete right bundle branch block, anterior hemi-fascicle of the left bundle of His, and QRS duration 200 ms. We decided to perform a selective His bundle pacing. In patients with right bundle branch block the biventricular cardiac resynchronization is not indicated due to low treatment response. His bundle pacing allows recruiting the blocked branch and restoring conduction throughout it, therefore, in the absence of necrosis the biventricular synchrony is achieved. We presented a case of His bundle pacing with recruitment of the right bundle branch, which reestablish biventricular synchrony measured by speckle tracking, and with a significant increase of the left ventricle ejection fraction from 17 to 36.6%, with an absolute increase of 19.6%.

Manejo de la insuficiencia cardiaca con estimulación hisiana en bloqueo de rama derecha: reporte de caso / Management of heart failure with His bundle pacing in right bundle branch block: case report

Resumen La terapia de resincronización cardiaca mediante estimulación hisiana ha demostrado ser efectiva en pacientes con bloqueo de rama izquierda del haz de His e insuficiencia cardiaca. Paciente masculino, con 47 años de edad, con insuficiencia cardiaca, fracción de expulsión del 17% y miocardio dilatada idiopática, electrocardiograma en ritmo sinusal, bloqueo auriculoventricular de 1.er grado, intervalo PR 400 ms, bloqueo completo de rama derecha del haz de His, bloqueo del fascículo anterior de la rama izquierda del haz de His, duración del QRS 200 ms. Se decidió realizar estimulación selectiva del haz de His. La resincronización cardiaca biventricular convencional en pacientes con presencia de bloqueo completo de la rama derecha del haz de His no está indicada debido a la pobre respuesta al tratamiento. La estimulación hisiana permite reclutar la rama bloqueada y reestablecer la conducción a través de ella, de tal forma que, en ausencia de necrosis, se logre sincronía biventricular. En el caso presentado el reclutamiento de la rama derecha mediante estimulación hisiana se reflejó en el restablecimiento de la sincronía biventricular, medida por rastreo de marcas (speckle tracking) e incremento significativo de la fracción de expulsión del ventrículo izquierdo del 17 al 36.6%, con un incremento absoluto del 19.6%.

Abstract Cardiac resynchronization therapy has proven to be an effective therapy in patients with left bundle branch block and heart failure. Male, 47 years old, heart failure with a left ventricle ejection fraction of 17%, idiopathic heart failure. ECG with sinus rhythm, 1st degree AV block, PR 400 ms, complete right bundle branch block, anterior hemi-fascicle of the left bundle of His, and QRS duration 200 ms. We decided to perform a selective His bundle pacing. In patients with right bundle branch block the biventricular cardiac resynchronization is not indicated due to low treatment response. His bundle pacing allows recruiting the blocked branch and restoring conduction throughout it, therefore, in the absence of necrosis the biventricular synchrony is achieved. We presented a case of His bundle pacing with recruitment of the right bundle branch, which reestablish biventricular synchrony measured by speckle tracking, and with a significant increase of the left ventricle ejection fraction from 17 to 36.6%, with an absolute increase of 19.6%.

[Amplatzer® Vascular Plug III, for closing residual mitral paravalvular leak: three-dimensional transesophageal echocardiography image]. / Amplatzer® Vascular Plug III, para cierre de fuga paravalvular mitral residual: imagen de ecocardiograma transesofágico tridimensional.

Paravalvular leak is a significant complication after surgical valve replacement. Traditionally, redo surgery has been considered the treatment of choice, but is associated with high morbidity and mortality as well as increase risk of developing new leaks. Percutaneous treatment of paravalvular leak appears as an attractive alternative. Such treatment has been made possible by the current ability to integrate multiple imaging modalities that have helped to define the anatomy of the defect and planning and guiding the percutaneous closure procedure, thus resulting in better outcomes. The Amplatzer® Vascular Plug III (St. Jude Medical) is the first device specifically designed for percutaneous closure of paravalvular leak with promising results. We present the three-dimensional transesophageal echocardiographic images of a successful outcome of percutaneous closure of a residual mitral paravalvular leak with an Amplatzer® Vascular Plug III device (St. Jude Medical), after an initial procedure of percutaneous closure with an Amplatzer® duct occluder (St. Jude Medical).

Amplatzer® Vascular Plug III, para cierre de fuga paravalvular mitral residual: imagen de ecocardiograma transesofágico tridimensional / Amplatzer® Vascular Plug III, for closing residual mitral paravalvular leak: three-dimensional transesophageal echocardiography image

La fuga paravalvular es una complicación relevante después del cambio valvular quirúrgico. Tradicionalmente la cirugía ha sido considerada el tratamiento de elección, sin embargo, conlleva una elevada morbimortalidad, así como un incremento en el riesgo de desarrollar fuga paravalvular recurrente. El tratamiento percutáneo de la fuga paravalvular se presenta como una atractiva alternativa. Dicho tratamiento ha sido posible por la capacidad actual de integrar múltiples modalidades de imagen que han ayudado a definir la anatomía del defecto y a planificar y guiar el procedimiento de cierre percutáneo, resultando en mejores desenlaces. El Amplatzer® Vascular Plug III (St. Jude Medical) es el primer dispositivo específicamente diseñado para el cierre percutáneo de la fuga paravalvular con resultados prometedores. Presentamos la imagen ecocardiográfica transesofágica tridimensional del resultado exitoso de cierre percutáneo de una fuga paravalvular mitral residual con un dispositivo Amplatzer® Vascular Plug III (St. Jude Medical), después de un procedimiento inicial de cierre percutáneo con un dispositivo Amplatzer® Duct Occluder (St. Jude Medical).

Paravalvular leak is a significant complication after surgical valve replacement. Traditionally, redo surgery has been considered the treatment of choice, but is associated with high morbidity and mortality as well as increase risk of developing new leaks. Percutaneous treatment of paravalvular leak appears as an attractive alternative. Such treatment has been made possible by the current ability to integrate multiple imaging modalities that have helped to define the anatomy of the defect and planning and guiding the percutaneous closure procedure, thus resulting in better outcomes. The Amplatzer® Vascular Plug III (St. Jude Medical) is the first device specifically designed for percutaneous closure of paravalvular leak with promising results. We present the three-dimensional transesophageal echocardiographic images of a successful outcome of percutaneous closure of a residual mitral paravalvular leak with an Amplatzer® Vascular Plug III device (St. Jude Medical), after an initial procedure of percutaneous closure with an Amplatzer® duct occluder (St. Jude Medical).