[Aortico-left ventricular tunnel. Presentation of 2 new cases. Usefulness of non-invasive study]. / Túnel aorta-ventrículo izquierdo. Presentación de dos nuevos casos. Utilidad del estudio no invasivo.

In the last years the anatomic characteristics of the left aorto-ventricular tunnel and the clinical aspects of this uncommon malformation have been well described. Its evolution usually fatal without surgical procedure is in great contrast with the slight symptoms encountered by us in two new cases. This particular finding joined to the specific aspects found in the noninvasive color Doppler study, have lead us to present two new cases of left aorto-ventricular tunnel successfully operated.

[Absent pulmonary valve syndrome with ductal origin of the left pulmonary artery. Diagnosis only by 2-D echo doppler color flow mapping]. / Síndrome de agenesia valvular pulmonar con emergencia ductal de arteria pulmonar izquierda. Papel de la ecocardiografía Doppler color.

A two-month old infant is described with the rare combination of absent pulmonary valve syndrome, ventricular septal defect, pulmonar "anular" stenosis and ductal origin of the left pulmonary artery. The diagnosis that was confirmed in the operating room was made by 2-D echocardiographic Doppler color flow mapping study without the support of cardiac catheterization.

[Aortico-left ventricular tunnel associated with pulmonary valve stenosis]. / Túnel aorta-ventrículo izquierdo asociado con estenosis valvular pulmonar.

Aortico-left ventricular tunnel is an unusual cardiac anomaly. The main clinical feature is early, severe aortic regurgitation, and surgical management is mandatory. Exceptionally this defect is associated with pulmonary valve stenosis. A case of a newborn with aortico-left ventricular tunnel plus pulmonary valve stenosis is reported. Initially she underwent percutaneous pulmonary valvuloplasty during diagnostic cardiac catheterization and with surgical closure of the tunnel later.

[Redundancy of the interatrial septum without associated congenital cardiopathy. Its prenatal echocardiographic diagnosis and follow-up]. / Redundancia del septo interatrial sin cardiopatía congénita asociada. Diagnóstico ecocardiográfico prenatal y seguimiento.

INTRODUCTION AND OBJECTIVE: Aneurysm of the atrial septum at the level of the foramen ovale is reported commonly at the routine fetal echocardiographic examination. Cases with entire involvement of the atrial septum have been exceptionally reported. We described the data concerning the prenatal detection of a total redundancy of the atrial septum in 6 cases without congenital heart disease. METHODS: The gestational age was between 28 and 38 weeks, and none of the fetuses had evidence of heart defect. A routine fetal echocardiography was made in all the cases. Rhythm disturbances were studied by M mode. During the first three months of life, a cardiologic control was made in all the cases. RESULTS: The large displacement of the atrial septum towards the left atrium was clearly visualized in four-chambers view; by using Pulsed Doppler and Color flow mapping, the pulmonary venous return and mitral orifice flow were not impaired. Premature atrial beats were found in two fetuses and no hemodynamic disfunction was observed in all entire study group. Postnatal echocardiographic control was normal in all patients. The atrial septum becomes completely rectified with normal patency of the foramen ovale membrane in the newborn studies. The supraventricular extrasystoles were confirmed in the neonatal period. In both, the arrhythmia disappeared in a few days after delivery without treatment. CONCLUSIONS: Despite the benign follow-up in our cases, the unexpected presence of an extremely redundant atrial septum, leads to a close prenatal attention particularly in the presence of rhythm disturbance. The pathologic substrate of this anomaly might be an intrinsic alteration of the myocardial structure of the septum like seems demonstrated in the aneurysm circumscribed to area of the fossa ovalis [correction of fosa ovale]. The increase in the left atrial pressure after birth will produce a normal 2-D echo patterns in the newborn period.

[The ghost intraventricular obstruction. Its detection in the right ventricle by Doppler color]. / Obstrucción intraventricular fantasma. Su detección con Doppler color en ventrículo derecho.

INTRODUCTION: The Color Doppler echocardiography is a method of choice to detect the regional acceleration of flow in the left ventricle. The color study confirm it also in the right ventricle of infants with diseases other than hypertrophic cardiomyopathy. MATERIAL: We centered our attention in this finding observed in 16 infants with a mean age of 2.5 months (3 of whom were neonates) with several congenital heart malformations: 9 immediately after surgical ventricular septal defect closure (A-V canal type in 6, and isolated in 3); 2 with pulmonary atresia+intact septum+reconstruction of right ventricular-pulmonary artery connection; 2 with severe aortic stenosis; 1 with a double outlet right ventricle+pulmonary band; 1 with Jatene operation; finally 1 after balloon pulmonary valvuloplasty. RESULTS: The phenomenon consisted in a late Doppler systolic signal in the right ventricular apex whose velocity ranged between 1.5 and 2.9 m/s. The jet was directed towards the tricuspid orifice, with a normal pulmonary flow. The turbulence was easily viewed in the apical four chambers and subcostal sagittal plane of the right ventricle, the spectral signal showed a morphology with left side concavity. An erroneous diagnosis of apical ventricular septal defect was suggested in 2 cases in whom the left ventricular angiogram performed before treatment excluded the lesion. CONCLUSION: The dynamic nature of the jet suggest that an asynchronous order of myocardial contraction in hypertrophic right ventricule play a role in its genesis. With the increasing use of Doppler color technique, this finding can be observed with greater frequency in neonates and infants with operated or unoperated heart diseases and right ventricular hypertrophy. Apical ventricular septal defect will be included in the differential diagnosis.

[Balloon pulmonary valvuloplasty in the neonatal period. The clinical and echocardiographic effects]. / Valvuloplastia pulmonar con balón en el período neonatal. Efectos clínicos y ecocardiográficos.

AIM: To analyze the efficacy of balloon pulmonary valvuloplasty (BPV) as the elective treatment for neonatal critical pulmonary valvar stenosis (PVS). MATERIALS AND METHODS: The results of clinical and echocardiographic features before and after the BPV were reviewed in 29 neonates (18+/-12 days of life). Different hemodynamic and 2-D color Doppler echocardiographic were evaluated. The BPV result was classified as favourable if no other balloon or surgical therapy was required to normalise pulmonary flow and achieve a sustained right ventricle-pulmonary artery (RV-PA) Doppler gradient below 40 mmHg. It was considered unfavourable if the neonate died, needed surgery or redilation and/or the RV-PA Doppler gradient was > or =40 mm Hg. The study developed in three phases: pre BPV immediate post BPV until the hospital discharge (14+/-11 days), and in the mid-term follow-up of between 8 and 96 months (51+/-31 months). RESULTS: Mortality was not registered with BPV. The RV/left ventricular systolic pressure decreased from 1.4+/-0.3 to 0.8+/-0.3 (p<0.01) as a consequence of the dilation, and the the systemic oxygen saturation increased from 85 +/-12 to 92+/-6% (p<0.01). The RV-PA Doppler gradient diminished from 86+/-18 to 28+/-16 mm Hg immediately after BPV (p<0.01) and was registered at 13+/-6 mm Hg in the follow-up (n = 24). The RV-PA junction Z value grew from -1.25+/-0.9 before valvuloplasty to -0.51 +/-0.7 at the final echocardiogram (p<0.01). No changes in the tricuspid diameter were detected between both periods of time. Five neonates obtained unsatisfactory results: 4 in the immediate post BPV (systemic-pulmonary artery shunt 2, transannular patch 2), and 1 in the mid-term follow-up (valvectomy + transannular patch). The actuarial curve reflects that 82,7% of the patients were free form reinterventions at 8 years. CONCLUSIONS: BPV is safe and effective to relief PVS in the neonate. The balloon promotes advantageous changes in both, pulmonary annulus and the right ventricle. In addition, the RV-PA Doppler gradient observations in the follow-up, support the expectation that the BPV is a "curative" therapy.

[Pulmonary arterial bnading hemodinamic and clinical evaluation in 23 cases (author's transl)]. / Valoración de los resultados de cerclaje de la arteria pulmonar en 23 casos estudiados por cateterismo.

This is a study of 23 cases with pulmonary plethora and cardiac failure. A "banding" of pulmonary artery was performed, to diminish the pulmonary bloodflow in order to avoid the development of pulmonary hypertensive changes and to improve the heart failure. The mean age of the cases operated upon was 16,9 months. The complications post-banding were: stenosis of the pulmonary outflow tract and necrosis or calcification of the pulmonary artery wall. There was a direct relationship between these complications and the time of persistence of the "banding". The pulmonary artery pressure, distal to the "banding", was reduced as much as 2/3 of the previous pressure in all patients below 6 months and in 63,64% of those patients above 1 year old. A patent ductus arteriosus, complicating the ventricular septal defectis closed prior to perform the "banding" in order to see its role in the pulmonary hyperkinetic hypertension. This is carried out only if pulmonary hypertension remains unaffected.

[Value of two-dimensional Doppler color echocardiography in mitral-ventricular-aortic obstructive disease in the newborn]. / Valor de la ecocardiografía bidimensional Doppler color en la patología obstructiva mitroventriculoaórtica del neonato.

Over the last years, the bidimensional echocardiography has assumed an increasingly impact in the management of heart disease in neonates. With the addition of Doppler technique and color flow mapping this non invasive method provide the most accurate definition of cardiac anatomy and physiology. It is particularly true in newborns with left inflow or outflow obstruction disease such as: pulmonary vein stenosis, divided left atrium, mitral and aortic stenosis or atresia, subvalvular narrowing, and hypoplastic left ventricle and aortic tract. The combination of these two methods contribute to recognize a specific left cardiac abnormalities and allow us to evaluate the therapeutical success in the follow up period.

Contribution of Doppler atrioventricular flow waves to ventricular filling in the human fetus.

The normal fetal flow velocity profile across the atrioventricular valves is characterized by an early peak (E), which is related to preload and to active ventricular muscle relaxation, and a higher late peak (A), which is caused by the atrial contraction and also influenced by ventricular compliance. The purpose of this study was to determine how these two elements of ventricular filling change during gestation in both ventricles. A total of 485 normal fetuses from 17 weeks to term were examined by Doppler echocardiography. We measured E and A peak velocities and E/A ratio for both mitral and tricuspid valves. Simple regression analysis was applied to assess possible correlation between Doppler variables and gestational age. Moreover, E and A peak velocities were compared using paired Student's t-test. With the advance of gestation a significant linear increase in the E wave and E/A ratio was found for both mitral and tricuspid valves. The A wave shows little change throughout pregnancy. We found significantly higher Doppler velocities for the tricuspid valve than for the mitral valve. The relationship between the E/A ratios for the two valves and gestational age diverge slightly, with higher values for the mitral E/A ratio. This study shows that the A wave velocity remains constant throughout gestation, suggesting little or no change in ventricular compliance. The E wave is mainly responsible for the change in E/A ratio for both atrioventricular valves during gestation. These findings suggest progressive enhancement of relaxation and elastic recoil, an increase in preload, or both, throughout gestation, rather than a change in myocardial compliance as an explanation for the observed increase in the E/A ratio.

[Heart growth in the normal human fetus. A two-dimensional echocardiographic study]. / Crecimiento cardíaco en el feto humano normal. Estudio mediante ecocardiografía bidimensional.

INTRODUCTION: Fetal cardiac growth was studied by two-dimensional echocardiography. The size of various cardiac structures were compared with gestational age. Normal values for each measurement were determined, with special attention being paid to the differences between the right and left chambers. PATIENTS AND METHODS: Ninety human fetuses with a gestational ages between 17 and 39 weeks were studied. Any structural abnormality was excluded at prenatal and postnatal examination. Aortic, pulmonary artery, tricuspid and mitral valve annulus diameters were measured with classical echocardiographic views. These variables were compared between them and plotted against gestational age. The correlations were determined by Student's T-test and regression analysis using 95% confidence limits. RESULTS: A good correlation (r > 0,7) between all the measurements and gestational age was obtained. In absolute values, tricuspid and pulmonary artery valve diameters were significantly greater (p < 0,01) than mitral and aortic valve diameters, respectively. Nevertheless, the diastolic diameter of the left ventricle (LV) was slightly greater than the diastolic diameter of the right ventricle (RV). Separating the data of the second trimester from of those of the third, the initial dominance of LV (RV/LV ratio = 0,93) tends to disappear and a slight dominance of RV (RV/LV ratio = 1,03) was observed at term. CONCLUSION: This study establishes normal values based on two-dimensional echocardiographic cardiac measurements throughout gestational stages. The data obtained will be very useful for the prenatal diagnosis and perinatal management of certain cardiopathies like the hypoplastic left heart syndrome. The relative dominance of RV in utero was also demonstrated. The different morphology of both ventricular outflow tracts and their volume changes throughout gestation, secondary to placental resistance variation, could justify the changes in the RV/LV ratio during the intrauterine period.

Temas de ecocardiográfía: IV. Diagnóstico ecocardiográfico de aneurisma coronario en enfermedad de Kawasaki; presentación de dos casos / Echocardiography: IV. Echocardiographic diagnosis of coronary aneurism in Kawasaki diseases; report of 2 cases

Se presentan dos casos de síndrome mucocutáneo (enfermedad de Kawasaki), con afectación aneurismática del origen de la coronaria izquierda, diagnosticado mediante ecocoardiografía bidimensional. La fiabilidad del estudio ecocardiográfico, en nuestros casos, frente a la mortalidad de la angiografía, en el estadio agudo de la enfermedad, nos inclina a considerar el estudio ecocardiográfico como un método diagnóstico idóneo en esta patología