Is cholecystectomy the treatment of choice for acute acalculous cholecystitis? A systematic review of the literature.

BACKGROUND AND OBJECTIVES: There is currently no consensus with regard to the use of cholecystectomy or percutaneous cholecystostomy as the therapy of choice for acute acalculous cholecystitis. The goal of this study was to review the scientific evidence on the management of these patients according to clinical and radiographic findings. METHODS: A systematic review of the literature from 2000 to 2016 was performed. The databases of PubMed, Índice Médico Español, Cochrane Library and Embase were searched according to the following inclusion criteria: publication language (English or Spanish), adult patients, acalculous etiology and appropriate study design. RESULTS: A total of 1,013 articles were identified and ten articles were selected for review. These included five observational controlled studies and five case series which described the outcome of patients treated with percutaneous cholecystostomy and emergency cholecystectomy. No prospective or randomized studies were identified using the search criteria. The data from the literature and analysis of results suggested that percutaneous cholecystostomy may be a definitive therapy for acute acalculous cholecystitis with no need for subsequent elective cholecystectomy. CONCLUSIONS: Percutaneous cholecystostomy may be the first treatment option for patients with acute acalculous cholecystitis except in cases with a perforation or gallbladder gangrene. Patients at low surgical risk may benefit from cholecystectomy but both treatment options may be effective. Percutaneous cholecystostomy in patients with acute acalculous cholecystitis may be a definitive therapy with no need for a subsequent elective cholecystectomy. However, the overall quality of studies is low and the final recommendations should be considered with caution.

[Clinical and pathological features of gastrointestinal stromal tumors (GIST) in a single institution: A descriptive study and review of the literature]. / Perfil clínico y anatomopatológico de los tumores estromales gastrointestinales de un hospital de área: Estudio descriptivo y revisión de la literatura.

INTRODUCTION: This study was aimed to assess the main clinical, pathological and therapeutic characteristics of a cohort of gastrointestinal stromal tumors (GIST). METHODS: Observational study including 66 patients diagnosed with GIST admitted to our hospital between 2002 and 2015. Parameters related to medical history, clinical manifestations, medical and surgical treatment, histopathology, and morbi-mortality were studied. A review of the literature was included to correlate with the results. RESULTS: The most frequent location of GIST in our patients was the stomach (65.2%), in which the gastric fondo was the predominant region. The most common clinical manifestation was gastrointestinal hemorrhage (45.5%), followed by incidental finding after imaging or invasive procedures (33.3%). 58 patients underwent surgery (90.6%), 15.5% were urgent. A total of 69% of the GISTs had a size between 2 and 10cm. The one-year mortality was 7.9%, all cases related to local or remote extension, or surgical complications. CONCLUSION: There is a large clinical variability among GIST cases. The first choice of treatment is surgery, which is feasible in most cases and should be as conservative as possible. The prognosis varies depending on the size and proliferation index, thus close follow-up should be performed. No tumor marker is clearly associated with a poor prognosis. New molecular biology studies are needed in order to find therapeutic targets.

The use of coffee, chewing-gum and gastrograffin in the management of postoperative ileus: A review of current evidence. / Uso de café, chicle y gastrografín en el manejo del íleo postoperatorio: revisión de la evidencia actual.

Postoperative ileus is one of the main complications in the postoperative period. New measures appeared with the introduction of «fast-track surgery¼ to accelerate recovery: coffee, chewing gum and gastrograffin. We performed a summary of current evidence, reviewing articles from MEDLINE, Cochrane Database of Systematic Reviews, ISI Web of Science, and SCOPUS databases. Employed search terms were «postoperative ileus¼ AND («definition¼ OR «epidemiology¼ OR «risk factors¼ OR «Management¼). We selected 44 articles: 9 systematic reviews 11 narrative reviews, 13 randomized clinical trials, 6 observational studies, and the remaining 5 scientific letters, assumptions, etc. There is little literature about this topic, studies are heterogeneous, with disparity in the results. In addition, they only focus on colorectal and gynecological surgery. New high-quality studies are needed, preferably randomized clinical trials, in order to clarify the usefulness of these measures.

Depression, anxiety, burnout and empathy among Spanish medical students.

Medical Education studies suggest that medical students experience mental distress in a proportion higher than in the rest of the population In the present study, we aimed to conduct a nationwide analysis of the prevalence of mental health problems among medical students. The study was carried out in 2020 in all 43 medical schools in Spain, and analyzes the prevalence of depression, anxiety, empathy and burnout among medical students (n = 5216). To measure these variables we used the Beck Depression Inventory Test for assessing depression, the Maslach Burnout Inventory Survey for Students was used for burnout, the State-Trait Anxiety Inventory (STAI) was used to assess anxiety state and trait and the Jefferson Empathy Scale 12 to obtain empathy scores. In relation to depression, the data indicate an overall prevalence of 41%, with 23.4% of participants having moderate to severe levels, and 10% experiencing suicidal ideation. Burnout prevalence was 37%, significantly higher among 6th year than among 1st year students. Anxiety levels were consistent with those reported previously among medical students (25%), and were higher than in the general population for both trait and state anxiety. The prevalence of trait anxiety was higher among women. Empathy scores were at the top end of the scale, with the highest-scoring group (>130) containing a greater percentage of women. Similarly to those published previously for other countries, these results provide a clear picture of the mental disorders affecting Spanish medical students. Medicine is an extremely demanding degree and it is important that universities and medical schools view this study as an opportunity to ensure conditions that help minimize mental health problems among their students. Some of the factors underlying these problems can be prevented by, among other things, creating an environment in which mental health is openly discussed and guidance is provided. Other factors need to be treated medically, and medical schools and universities should therefore provide support to students in need through the medical services available within their institutions.

Feasibility and validation of the targeted axillary dissection technique in the axillary staging of breast cancer after neoadjuvant therapy: Definitive results.

AIM: to study the feasibility and value of "Targeted Axillary Dissection" (TAD) in cN1 breast cancer (BC) patients undergoing neoadjuvant chemotherapy (NACT), in order to avoid unnecessary axillary lymph node dissection (ALND). MATERIALS AND METHODS: Design: Prospective observational study. INCLUSION CRITERIA: Patients with histologically confirmed cN1 staging BC and treated with NACT between January 2016 and August 2019 who accomplished clinical response. METHOD: Fine-Needle Aspiration (FNA) positive axillary nodes were marked with a metallic clip prior to neoadjuvant treatment. All patients were summited to TAD and ALND. Analysis of data: We performed [1]: a feasibility analysis of clinical, radiological and pathological variables, as well as difficulties and complications of the TAD [2]; a diagnostic test study of the sentinel lymph node biopsy (SLNB), clipped lymph node biopsy (BCLIP) and their combination (TAD), using ALND as the Gold Standard. RESULTS: 60 patients were included. 43 patients (71.7%) had a complete clinical lymph node response to NACT. Neither limitations nor complications in clip placement were found. Intraoperative location of the clipped node was problematic in 7 cases (11.7%). The pathological complete response rate (pCR) was 30.5% (18 patients) and ypN0 staging rate was 38.3% (23 patients). Sensitivity values of each technique were: SLNB: 80.9% (95%CI: 61.8-100); BCLIP: 80.8% (95%CI: 63.7-97.8); TAD: 92.6% (95%CI: 80.9-100) with negative predictive values of: SLNB: 84.6% (95%CI: 68.8-100); BCLIP: 81.0% (95%CI: 63.7-97.8); TAD: 91.3% (95%CI: 77.6-100). CONCLUSION: TAD is feasible and valid to rule out axillary metastatic involvement in cN1 breast cancer patients who respond to NACT.

Development of a predictive score of axillary lymph node dissection based on targeted axillary dissection in patients with breast cancer diagnosis, affected lymph nodes, and neoadjuvant treatment.

AIM: To determine predictive factors of axillary lymph node dissection (ALND) results in breast cancer (BC) patients undergoing neoadjuvant chemotherapy (NACT), and subsequent staging using Targeted Axillary Dissection (TAD). MATERIAL AND METHOD: Case-control study between January 2016 and August 2019. Patients with BC, cN1 staging, marked with a metallic clip prior to NACT, and subsequently staged with TAD and ALND were included. They were divided into 2 groups: ALND patients with or without metastatic involvement (group 1 and group 2, respectively). We carried out a univariate analysis comparing clinical, radiological, surgical and pathological variables, and a logistic regression, (dependent variable: positive result of ALND; independent variables: number of suspicious lymph nodes in diagnostic ultrasound, positive hormone receptors, HER2 positive, complete clinical-radiological response to NACT, positive TAD, and biopsy of ≤2 nodes in TAD). A score for prediction of a metastatic ALND was proposed, with an internal validation study. RESULTS: 60 patients were included: Group 1: 33 (55.0%); Group 2: 27 (45.0%). Tumor size (Odds Ratio (OR) = 1.67; 95%CI 1.02-2.74), number of suspected nodes in ultrasound (OR = 2.20; 95%CI 1.01-4, 77), HER2 positive (OR 0.04; 95%CI 0.003-0.54), clinical-radiological response to NACT (OR = 0.07; 95%CI 0.01-0.75), and positive TAD (OR 15.48; 95%CI 1.68-142.78) were independent predictors of a positive result in ALND. We developed a "positive ALND predictive score", with good calibration (Hosmer-Lemeshow test: p = 0.65), and discrimination (AUC = 0.93; 95% CI 0, 87-0.99), with highest Youden index (0.7) at cut-off point of 17% risk of positive ALND (sensitivity = 100%; specificity = 70%). CONCLUSION: Tumor size, number of suspected nodes, positive HER2, response to NACT, and metastatic TAD are independent predictors of ALND. The predictive score for positive ALND would be a good indicator to safely omit ALND.

Ultrasound staging in breast cancer: A decision-making oriented approach to axillary metastatic burden prediction.

PURPOSE: The possibility of avoiding axillary lymphadenectomy (AL) in patients with breast cancer (BC) after positive sentinel lymph node biopsy (SLNB) and low metastatic burden (< ó = 2 positive lymph nodes) has put into question the role of axillary ultrasound due to the risk of overtreatment after positive axillary lymph node biopsy with low metastatic burden. Our aim was to identify clinical and ultrasound features to detect low and high metastatic burden. METHODS: A retrospective study of 405 BC patients with primary surgical treatment with axillary ultrasound examination and subsequent AL after positive fine needle aspiration (FNA) or SLNB. The low and high tumor burdens after AL were correlated with clinical and ultrasound variables: lymph node morphology (UN1 to UN5), number of suspicious lymph nodes, and Berg level. RESULTS: Positive FNA, lymph node morphology UN4 (focal thickening with displacement of the fatty hilum) or UN5 (complete replacement of the fatty hilum) and >2 suspicious lymph nodes were significantly associated with "high metastatic burden". Lymph node morphology UN2 and UN3, even after FNA+, lymph node morphology UN4 after FNA-, and suspicious lymph nodes at Berg level I were low metastatic burden criteria. Lymph node morphology UN5, lymph node morphology UN4 after FNA+, two nodes or more with UN4/UN5 morphology, and suspicious lymph nodes at Berg levels II and III with FNA+ were associated with high metastatic burden. CONCLUSIONS: Axillary lymph node ultrasound data for patients with early BC allows predicting the axillary metastatic burden, guiding the optimal clinical management of the axilla.

The problem of axillary staging in breast cancer after neoadjuvant chemotherapy. Role of targeted axillary dissection and types of lymph node markers. / El problema de la estadificación axilar en el cáncer de mama tras quimioterapia neoadyuvante. Papel de la disección axilar dirigida y tipos de marcadores ganglionares.

Targeted axillary dissection (TAD) consists of a new axillary staging technique that combines sentinel lymph node biopsy (SLNB) and clipped lymph node biopsy (CLNB) in the same surgery, in order to re-stage patients with breast cancer and positive axillary lymph nodes undergoing neoadjuvant chemotherapy (NAQT). Prior to the NAQT, the affected lymph node is punctured and a solid marker is left inside echo-guided, in order to biopsy it in the subsequent surgery. There are numerous types of markers: metallic (steel, titanium or polyglycolic acid clips), radioiodine or ferromagnetic seeds, which differ in the method of location (wire, gamma-detection or magnetic probe). The aim of this study is to perform a systematic review about the current status of the TAD, as well as to explain the different techniques and types of axillary marking, based on the current available evidence.

Is the number of rib fractures a risk factor for delayed complications? A case-control study.

AIM: To analyse factors that may predict the appearance of rib fracture complications during the first days of evolution and determine whether the number of fractures is related to these complications. METHOD: Retrospective case-control study of patients admitted with a diagnosis of rib fractures between 2010 and 2014. Two groups were established depending on the appearance or not of pleuropulmonary complications in the first 72 h, and the following were compared: age, sex, Charlson comorbidity index (CCI), number and uni- or bilateral involvement, mechanism of trauma, days of hospital stay, haemoglobin on discharge minus haemoglobin on admission, pleuropulmonary complications during admission (pneumothorax, haemothorax or pulmonary contusion) and placement of pleural drainage. RESULTS: One hundred and forty-one cases of rib fractures were admitted in the period mentioned. There were no differences in the patients' baseline characteristics (age, sex and Charlson Comorbidity Index) between the two groups. Differences were found in the number of fractures (2.98 ± 1.19 in the group without complications vs 3.55 ± 1.33 in the group with complications, p = 0.05) and in the drop in the level of haemoglobin (0.52 ± 0.91 mg/dl vs 1.22 ± 1.29 mg/dl, p = 0.01). The length of hospital stay varied considerably in each group (5.35 ± 4.05 days vs 7.86 ± 6.96 days), but without statistical significance (p = 0.11). CONCLUSIONS: The number of fractured ribs that best predicted the appearance of complications (delayed pleuropulmonary complications and greater bleeding) was 3 or more.

Validation of the targeted axillary dissection technique in the axillary staging of breast cancer after neoadjuvant therapy: Preliminary results.

AIM: To study the feasibility and validity of ultrasound-guided pre-chemotherapy marking of metastatic axillary lymph nodes followed by targeted axillary dissection (TAD), in breast cancer patients undergoing neoadjuvant chemotherapy (NACT). MATERIAL AND METHOD: Prospective diagnostic test study conducted between January 2016 and March 2018. Patients with breast cancer and indication for NACT, cN1 or cN2 axillary staging, were included. A clip was placed in the affected lymph node prior to NACT. A sentinel lymph-node biopsy (SLNB) and a clipped lymph-node biopsy (BCLIP) were conducted, followed by axillary lymph node dissection (ALND). Location rate (LR) and negative predictive value (NPV) were evaluated, taking SLNB, BCLIP and their combination (TAD) as evaluated tests and metastatic involvement in the ALND specimen as the gold standard. RESULTS: Twenty-three patients were included in the study. Sentinel lymph node could only be detected in 19 cases (LR = 80.61%), whereas BCLIP was successful in 22 (LR = 95.65%). The sentinel lymph node coincided with the marked lymph node in 14 patients (60.9%). We found a NPV for the SLNB of 0.85 (95%CI: 0.61-1.0), whereas for TAD it was 1.00 (95%CI: 0.74-1.0). CONCLUSION: TAD is a feasible test for axillary restaging after NACT, with a higher success rate than SLNB.

Genetic Factors Associated with Postoperative Nausea and Vomiting: a Systematic Review.

BACKGROUND: In previous studies, there seems to be a relationship between different genetic polymorphisms and postoperative nausea and vomiting (PONV). We perform a systematic review of the current literature about the relationship between genetic polymorphisms and the presence of PONV. METHODS: Two bibliographic searches were carried out in three databases (PubMed, Web of Science, and Scopus) of studies, preferably prospective, about PONV following abdominal surgery. It was completed with a backward citation searching. A total of 73 articles were found of which 6 were selected after their critical lecture using CASPe network criteria. Relative frequency and relative risk were taken in each study according to the polymorphism. RESULTS: Studies about 5-HT3B gene receptor polymorphisms, ABCB1 transporter, and dopamine D2 receptor showed a significant association with the presence of PONV (p = 0.02, 0.01, and 0.034 respectively). In relation to cytochrome P-450 2D6 (CYP2D6) polymorphisms, two of the three analysed articles showed a significant association with postoperative vomiting (p = 0.007). CONCLUSION: Genetic polymorphisms could play an important role in PONV. The AAG deletion in both alleles of the 5-HT3B receptor gene, the Taq IA polymorphism of the dopamine D2 receptor, and the presence of three or more functional alleles of CYP2D6 seem to be related with a higher incidence of PONV, especially in the first 24 h after surgery. The 2677TT and 3435TT genotypes of the ABCB1 transporter could reduce the PONV due to their association with a greater effectiveness of ondansetron. However, new quality studies are needed to consider this relationship.

Prognostic value of left atrial volume in asymptomatic organic mitral regurgitation.

BACKGROUND: Basal left atrial volume (LAV) indexed to body surface area (LAVI) predicts adverse events in patients with organic mitral regurgitation, but information is lacking regarding change in left atrial volume during follow-up. METHODS: One hundred forty-four asymptomatic patients (mean age, 71 ± 12 years; 66% women; mean ejection fraction, 66 ± 4.8%) with moderate to severe mitral regurgitation were prospectively included, with a median follow-up period of 2.76 years (interquartile range, 1.86-3.48 years). RESULTS: Fifty-four patients (37.50%) reached the combined end point of dyspnea and/or systolic dysfunction. Both basal and change in LAV were independently associated with the combined end point on multivariate analysis: for basal LAVI ≥ 55 mL/m(2), odds ratio, 2.26 (95% confidence interval, 1.04-4.88; P = .038), and for change in LAV ≥ 14 mL, odds ratio, 7.32 (95% confidence interval, 3.25-16.48; P < .001), adjusted for effective regurgitant orifice area and deceleration time. Combined event-free survival at 1, 2, and 3 years was significantly less in patients with basal LAVI ≥ 55 mL/m(2) (75%, 58%, and 43%) than in those with basal LAVI < 55 mL/m(2) (95%, 89%, and 77%) (log-rank test = 15.38, P = .0001). The incidence of the combined end point was highest (88%) in patients with basal LAVI ≥ 55 mL/m(2) and change in LAV ≥ 14 mL. CONCLUSIONS: Measurement of basal LAV and its increase during follow-up predict an adverse course in patients with moderate and severe asymptomatic mitral regurgitation. Hence, its assessment could be incorporated into the currently used algorithm for risk stratification and decision making in this group of patients.

Registro argentino de ecocardiograma transesofágico / Argentine Registry of Transesophageal Echocardiography

RESUMEN Introducción: No disponemos de datos nacionales que informen la realidad del uso de ecocardiograma transesofágico en nuestro país. Objetivos: El objetivo principal fue evaluar la tasa de complicaciones del ecocardiograma transesofágico en centros de nuestro país. Objetivos secundarios: Relevar características de los laboratorios, nivel de formación de los operadores, tasa de uso de sedación y anestesia, identificar los principales motivos de solicitud y analizar la pertinencia de las indicaciones y el aporte del método al manejo clínico del paciente. Método: Registro prospectivo, multicéntrico, de todos los ecocardiogramas transesofágicos realizados en 46 centros de Argentina entre noviembre de 2016 y septiembre de 2018. Resultados: Fueron analizados 2562 ecocardiogramas transesofágicos, la edad media fue de 61,4 (±16) años; el 61% de los pacientes era de sexo masculino. La duración media resultó de 14,5 min (±11). Los estudios ambulatorios constituyeron el 50,5%. La tasa de uso de sedación fue del 28,7% y el 8,4% se realizó bajo anestesia. Indicaciones más frecuentes: endocarditis: 22,7%, fuente embolígena: 21,5%, valvulopatía: 20,3% y fibrilación auricular/aleteo auricular: 17,2%. Se registraron complicaciones menores en 30 casos (1,17%) y complicaciones respiratorias o cardiovasculares, en 25 estudios (0,98%). Se registró 1 caso de lesión de mucosa gástrica (0,039%) sin perforación. Se reportaron hallazgos clínicamente significativos en 1296 estudios (50,6%); agregó información adicional al ecocardiograma transtorácico en 1600 (62,5%) y se describieron hallazgos no sospechados en 282 (11%), mientras que el 82,7% de los estudios tuvieron una indicación apropiada. Conclusiones: Este es el primer registro multicéntrico sobre ecocardiograma transesofágico en nuestro país. Entre los resultados obtenidos, se destacan una alta tasa de indicación apropiada, un considerable rédito diagnóstico y la baja tasa de complicaciones.

ABSTRACT Background: There is currently no data regarding the utilization of transesophageal echocardiography in Argentina. Objective: The main purpose of this study was to evaluate the complication rate of transesophageal echocardiography in our country Other objectives were to identify the characteristics of the laboratories, the operators' training level, the rate of sedation and/or anesthesia and the main reasons for itis request, and to analyze the suitability of the indications and the contribution of the method to the clinical management of patientis. Methods: A prospective, multicenter registry was conducted of all the transesophageal echocardiographies performed in 46 centers in Argentina between November 2016 and September 2018. Resultis: A total of 2,562 transesophageal echocardiograms were analyzed. Patientis' mean age was 61.4 (±16) years and 61% were men. Mean study duration was 14.5 minutes (±11). Ambulatory echocardiograms constituted 50.5% of cases. The rate of sedation was 28.7% and 8.4% were performed under anesthesia. The most frequent indications were: endocarditis 22.7%, embolic source 21.5%, heart valve disease 20.3% and atrial fibrillation/atrial flutter 17.2%. Minor complications were regis-tered in 30 cases (1.17%) and respiratory or cardiovascular complications in 25 studies (0.98%). There was 1 case of gastric mucosal lesion (0.039%) without perforation. Clinically significant findings were reported in 1,296 studies (50.6%), additional information to transthoracic echocardiography was provided in 1,600 cases (62.5%), unsuspected findings were described in 282 studies (11%), and 82.7% of the studies had an adequate indication. Conclusions: This is the first multicenter registry on transesophageal echocardiography in our country. The resultis highlight a high rate of adequate indication, a considerable diagnostic yield and low complication rate.

Síndrome de ortodeoxia-platipnea y embolia luego de endocarditis derecha complicada: consecuencias del Foramen Oval Permeable / Platypnea-Orthodeoxia syndrome and embolism after complicated right side endocarditis

Se presenta el caso clínico de una mujer de 63 años de edad con Endocarditis de la Válvula Tricúspide que desarrolló tromboembolismo pulmonar y un síndrome de platipnea-ortodeoxia explicado por la presencia de un formen oval permeable. La paciente se recuperó satisfactoriamente después de un reemplazo de la válvula tricúspide.

The case of 63 year old woman with Endocarditis at the Tricuspid Valve, pulmonary and paradoxical embolism with platypnea-orthodeoxia syndrome is presented. The patient recovered after surgical replacement of the tricuspid valve.

Síndrome de platipnea-ortodesoxia: ¿una causa oculta de disnea? / Platypnea-orthodeoxia Syndromea: ¿ Hidden Cause of Dyspnea? / Platypnea-orthodeoxia Syndrome: a Hidden Cause ofDyspnea?

El foramen oval permeable (FOP) es un defecto del septum interauricular que puede coexistir con aneurisma de éste y se asocia con pasaje de flujo de izquierda a derecha. Su presencia se ha vinculado con accidente cerebrovascular (ACV) embólico y con el síndrome de platipneaortodesoxia. En esta presentación se describe el caso de una paciente con síndrome de platipnea-ortodesoxia que representó un verdadero desafío diagnóstico, ya que ingresó a nuestra institución por neumonía y luego incidentalmente se diagnosticó una tromboembolia de pulmón (TEP). Dada la tórpida evolución y al evidenciarse disnea con desaturación que se acentuaba al sentarse, se realizó un ecocardiograma transesofágico (ETE) que mostró un FOP con aneurisma del septum interauricular y pasaje marcado de burbujas de derecha a izquierda en forma espontánea (en decúbito dorsal). Luego de completar tratamiento antibiótico, se procedió al cierre percutáneo del FOP con la colocación de un Amplatzer.

A patent foramen ovale (PFO) is an atrial septal defect with or without atrial septal aneurysm, associated with left-to-right shunt.It is also related with embolic stroke and platypnea-orthodeoxia syndrome.This report describes the case of a patient with platypnea-orthodeoxia syndrome, which represented a diagnostic challenge because she was admitted due to pneumonia but then was incidentally diagnosed with pulmonary thromboembolism (PTE). Given the unfavorable progression of her condition, and worsening of dyspnea with hypoxemia upon sitting, a transesophageal echocardiography (TEE) was performed, revealing a PFO with atrial septal aneurysm and marked right-to-left bubble passage occurring spontaneously (in dorsal recumbent position). After completion of antibiotic treatment, percutaneous closure of patent foramen ovale was performed with an Amplatzer device.

Dinámica del tracto de salida del ventrículo izquierdo durante el ciclo cardíaco evaluada con ecocardiografía tridimensional / Assessment of Left ventricular outflow tract dynamics during the cardiac cycle by three-dimensional echocardiography

Introducción El tracto de salida del ventrículo izquierdo (TSVI) suele estar implicado con relativa frecuencia en alteraciones anatómicas y anatomofuncionales, que son objeto de estudios. Sin embargo, su dinámica normal también es importante, en particular en procedimientos que involucran su área, y los nuevos métodos de imágenes tridimensionales permiten evaluarla. Objetivo Evaluar la dinámica del TSVI durante el ciclo cardíaco por ecocardiografía tridimensional transesofágica (eco 3D TE). Material y métodos Se incluyeron en forma prospectiva 42 pacientes derivados para ecocardiografía transesofágica. Los estudios se realizaron con sonda transesofágica tridimensional, con adquisiciones de volumen completo integradas por 4 latidos gatillados para análisis off-line. El ciclo cardíaco se dividió en protosístole (S1), mesosístole (S2) y telesístole (S3) y en protodiástole (D1), mesodiástole (D2) y telediástole (D3). El área del TSVI se estimó por planimetría del eje corto por cortes ortogonales al eje mayor del TSVI en cada fase. Resultados La edad media fue de 67 ± 10 años; el 63% eran hombres. El área del TSVI (cm2) en las diferentes fases del ciclo cardíaco fue: S1: 4,44 ± 1,02; S2: 4,15 ± 0,91; S3: 3,9 ± 0,89; D1: 3,76 ± 0,98; D2: 3,89 ± 1,04; D3: 4,34 ± 1,11. El área máxima se observó en S1, correspondiendo a la aposición de cierre de la valva anterior mitral (VaM) y escasa excursión del septum interventricular (SIV) hacia el TSVI; el área mínima se observó en D1 coincidiendo con cierta persistencia del SIV en el TSVI y la apertura máxima de la VaM ocupando parte del TSVI. La modificación total del área fue del 15% ± 11% (p < 0,0001), cambiando además de forma parcialmente elíptica o circular (sístole) a marcadamente elíptica o semilunar (diástole). Conclusión El TSVI presenta una variación en su área y su forma durante el ciclo cardíaco, con dependencia fundamentalmente del movimiento del SIV (en sístole) y de la apertura mitral (en diástole).

Assessment of Left Ventricular Outflow Tract Dynamics During the Cardiac cycle by Three-Dimensional Echocardiography Background Anatomical and anatomo-functional disorders of the left ventricular outflow tract (LVOT) are subject of numerous studies. However, LVOT normal dynamic behavior, especially in procedures involving this area is also relevant, and may be evaluated with new three-dimensional imaging methods. Objective The aim of this study was to assess LVOT dynamics during the cardiac cycle with three-dimensional transesophageal echocardiography (TEE). Methods Forty two patients referred for transesophageal echocardiography (TEE) were prospectively included. All TEE studies were performed with a three-dimensional transesophageal probe. For complete volume images, 4 gated beats were acquired for off-line analysis. The cardiac cycle was divided in proto-systole (S1), mid-systole (S2) and tele-systole (S3) and proto-diastole (D1), mid-diastole (D2) and tele-diastole (D3). The LVOT area was measured by planimetry of the short axis, through orthogonal sections to the long axis of the LVOT in each phase. Results Mean age was 67 ± 10 years, and 63% of the patients were male. The LVOT area (cm2) in the different phases of the cardiac cycle was: S1: 4.44 ± 1.02; S2: 4.15 ± 0.91; S3: 3.9 ± 0.89; D1: 3.76 ± 0.98; D2: 3.89 ± 1.04; D3: 4.34 ± 1.11. Maximum area was observed in S1, corresponding to the closed position of the anterior leaflet of the mitral valve (AL) and reduced motion of the interventricular septum (IVS) towards LVOT; minimum area was obtained in D1 consistent with a certain persistence of IVS in the LVOT and maximal AL opening occupying part of the LVOT. Total area reduction was 15 ± 11% (p<0.0001), changing the LVOT from a partially elliptical or circular shape (systole) to a markedly elliptical or semilunar one (diastole). Conclusion The LVOT changes its area and shape during the cardiac cycle, depending basically on the movement of the IVS (during systole) and mitral valve opening (during diastole).

Estratificación de riesgo en la insuficiencia mitral grave asintomática: ¿cómo se podría identificar a los pacientes con evolución adversa? / Risk Stratification in Severe and Asymptomatic Mitral Valve Insufficiency: How Could Patients with Adverse Outcomes Be Identified?

Objetivo Evaluar un puntaje que incorpore variables clínicas, ecocardiográficas y de ejercicio que identifiquen peor evolución en pacientes con insuficiencia mitral grave de causa orgánica asintomáticos. Material y métodos Se evaluaron 375 pacientes asintomáticos con insuficiencia mitral grave de causa orgánica (61 ± 10 años, 63% hombres, fracción de eyección del ventrículo izquierdo [FEVI] 67% ± 5%). Se elaboró un puntaje basado en la presencia de fibrilación auricular, diámetro de fin de sístole ≥ 40 mm, orificio regurgitante efectivo > 55 mm², volumen auricular izquierdo > 120 cm³, edad > 60 años, tiempo de ejercicio < 7 minutos. El rango del puntaje fue de 0-6,5. El punto final primario fue desarrollo de síntomas y/o disfunción ventricular (caída de la FEVI > 5% o FEVI < 60%). Los puntos secundarios fueron síntomas aislados, disfunción ventricular aislada, muerte cardíaca y cirugía valvular. Resultados Durante un seguimiento promedio de 10 ± 3,5 años, 145 pacientes (39%) presentaron el punto final primario; 157 (42%) presentaron síntomas, 99 (26%) disfunción ventricular, 10 (2,6%) fallecieron (7 de causa cardíaca) y se operaron 207 pacientes (55%). El punto final primario con puntaje < 2 fue del 2,3%, con puntaje 2-3 fue del 26% y con puntaje > 3 fue del 78%. La tasa de eventos primarios con puntaje < 2, 2-3 y > 3 fue del 2,3% ± 0,1%, 28% ± 4% y 73% ± 9%, respectivamente. El área bajo la curva operador-receptor fue de 0,87. Conclusión En pacientes asintomáticos con insuficiencia mitral grave, la utilización de un puntaje que considere variables clínicas, ecocardiográficas y de ejercicio permite identificar subgrupos de mayor riesgo a largo plazo.

Objective To assess the usefulness of a score which might identify adverse outcomes in asymptomatic patients with severe organic mitral valve insufficiency using clinical, echocardiographic and exercise variables. Material and Methods We assessed 375 asymptomatic patients with severe organic mitral valve insufficiency (61±10 years, left ventricular ejection fraction [LVEF] 67%±5%). The score performed included the presence of atrial fibrillation, end-diastolic diameter ≥ 40 mm, effective regurgitant orifice 55 mm², left atrium volume >120 cm³, age >60, and exercise time <7 minutes. The score ranged from 0 to 6.5. The primary endpoint was the development of symptoms and/or left ventricular dysfunction, defined as a decrease in LVEF >5% or LVEF <60%. The secondary endpoints included isolated symptoms, isolated left ventricular dysfunction, cardiac death and valvular surgery. Results During a mean follow-up of 10±3.5 years, 145 patients (39%) presented the primary endpoint; 157 (42%) had symptoms, 99 (26%) ventricular dysfunction, 10 patients (2.6%) died (7 of cardiovascular causes) and 207 patients underwent surgery (55%). The incidence of the primary endpoint with a score <2, between 2-3 and >3 was 2.3%, 26% and 78%, respectively. Primary event rate with a score <2, 2-3 and >3 was 2.3%±0.1%, 28%±4% and 73%±9%, respectively. The area under the ROC curve was 0.87. Conclusion In asymptomatic patients with severe mitral valve insufficiency, a score using clinical, echocardiographic and exercise variables is useful to identify subgroups of patients at greater long-term risk.