Incidental tricuspid valve fibroelastoma associated with patent foramen ovale in a young female: Straightforward diagnosis but controversial management.

Papillary fibroelastoma is an uncommon primary cardiac tumor, predominantly associated with left-sided valvular endocardium. Affectation of tricuspid valve leaflets is rare, and management in asymptomatic patients remains controversial. We present a 30-year-old female referred for evaluation prior to bariatric surgery. A routine echocardiogram revealed a mobile cardiac mass attached to the tricuspid valve. A patent foramen ovale was also present. Tumor was surgically removed. Histology confirmed the definite diagnosis of a papillary fibroelastoma. In our case, the presence of a patent foramen ovale associated with the right-sided fibroelastoma was decisive in the decision for surgery.

Clinical comparison of a handheld cardiac ultrasound device for the assessment of left ventricular function.

PURPOSE: Recently developed handheld ultrasound devices (HHUD) represent a promising method to evaluate the cardiovascular abnormalities at the point of care. However, this technology has not been rigorously evaluated. The aim of this study was to explore the correlation and the agreement between the LVEF (Left Ventricular Ejection Fraction) visually assessed by a moderately experienced sonographer using an HHUD compared to the routine LVEF assessment performed at the Echocardiography Laboratory. METHODS: This was a prospective single center study which enrolled 120 adult inpatients and outpatients referred for a comprehensive Echocardiography (EC). RESULTS: The mean age of the patients was 69.9 ± 12.5 years. There were 47 females (39.2%). The R-squared was r 0.94 (p < 0.0001) and the ICC was 0.93 (IC 95% 0.91-0.95, p ≤ 0.0001). The Bland-Altman plot showed limits of agreement (LOA): Upper LOA 10.61 and Lower LOA - 8.95. The overall agreement on the LVEF assessment when it was stratified as "normal" or "reduced" was 89.1%, with a kappa of 0.77 (p < 0.0001). When the LVEF was classified as "normal", "mildly reduced", "moderately reduced", or "severely reduced," the kappa was 0.77 (p < 0.0001). The kappa between the HHUD EC and the comprehensive EC for the detection of RWMAs in the territories supplied by the LAD, LCX and RCA was 0.85, 0.73 and 0.85, respectively. CONCLUSION: With current HHUD, an averagely experienced operator can accurately bedside visual estimate the LVEF. This may facilitate the incorporation of this technology in daily clinical practice improving the management of patients.

Right ventricular function in patients with pulmonary hypertension; the value of myocardial performance index measured by tissue Doppler imaging.

AIMS: Myocardial performance index (MPI) measured by conventional Doppler is routinely used to assess right ventricular (RV) systolic function in patients with pulmonary hypertension (PH). Our aim was to determine whether MPI measured by Doppler tissue imaging (tMPI) is effective in assessing RV function in these patients. METHODS AND RESULTS: Retrospectively, we have studied 196 patients with chronic PH [pulmonary arterial systolic pressure (PASP) 81 +/- 40 mmHg] and 37 healthy volunteers (PASP of 27 +/- 7 mmHg). According to the exclusion criteria, 172 patients were included in the final study cohort. All patients were evaluated for RV systolic function by different parameters. MPI was measured by both conventional and tissue Doppler imaging. Bland-Altman analysis showed moderate agreement between MPI and tMPI (the mean difference was -0.02, absolute difference = -0.32 to 0.29; 95% intervals of agreement, percentage of average = -46.6 to 40.8%). In 50 consecutive PH patients where additional parameters were calculated, we found a significant correlation between tMPI and RV ejection fraction (r = -0.73, P< 0.0001) and RV fractional area change (r = -0.58, P< 0.0001). No significant inter- and intra-observer variability was identified. CONCLUSION: This study demonstrated a moderate agreement between two methods of measuring MPI. A good correlation of tMPI with RV ejection fraction and RV fractional area change was found indicating that tMPI might be superior to MPI Doppler. tMPI is a parameter unaffected by RV geometry and importantly has the advantage of simultaneously recording the time intervals from the same cardiac cycle.

Angina and Ischemia at 2 Years With Bioresorbable Vascular Scaffolds and Metallic Drug-eluting Stents. ESTROFA Ischemia BVS-mDES Study.

INTRODUCTION AND OBJECTIVES: Bioresorbable vascular scaffolds (BVS) have the potential to restore vasomotion but the clinical implications are unknown. We sought to evaluate angina and ischemia in the long-term in patients treated with BVS and metallic drug-eluting stents (mDES). METHODS: Multicenter study including patients with 24 ± 6 months of uneventful follow-up, in which stress echocardiography was performed and functional status was assessed by the Seattle Angina Questionnaire (SAQ). The primary endpoint was a positive result in stress echocardiography. RESULTS: The study included 102 patients treated with BVS and 106 with mDES. There were no differences in the patients' baseline characteristics. Recurrent angina was found in 18 patients (17.6%) in the BVS group vs 25 (23.5%) in the mDES group (P = .37), but SAQ results were significantly better in the BVS group (angina frequency 96.0 ± 8.0 vs 89.2 ± 29.7; P = .02). Stress echocardiography was positive in 11/92 (11.9%) of BVS patients vs 9/96 (9.4%) of mDES patients in the (P = .71) and angina was induced in 2/102 (1.9%) vs 7/106 (6.6%) (P = .18), respectively, but exercise performance was better in the BVS group even in those with positive tests (exercise duration 9.0 ± 2.0minutes vs 7.7 ± 1.8minutes; P = .02). A propensity score matching analysis yielded similar results. CONCLUSIONS: The primary endpoint was similar in both groups. In addition, recurrent angina was similar in patients with BVS and mDES. The better functional status, assessed by means of SAQ and exercise performance, detected in patients receiving BVS should be confirmed in further studies.

Evolution of subclinical myocardial dysfunction detected by two-dimensional and three-dimensional speckle tracking in asymptomatic type 1 diabetic patients: a long­term follow-up study.

BACKGROUND: We sought to assess the long-term evolution of left ventricular (LV) function using two-dimensional (2D) and three-dimensional (3D) speckle tracking echocardiography (STE) for the detection of preclinical diabetic cardiomyopathy, in asymptomatic type 1 diabetic patients, over a 6-year follow-up. DESIGN AND METHODS: Sixty-six asymptomatic type 1 diabetic patients with no cardiovascular risk factors were compared to 26 matched healthy controls. Conventional, 2D and 3D-STE were performed at baseline. A subgroup of 14 patients underwent a 6-year follow-up evaluation. RESULTS: At baseline, diabetic patients had similar LV ejection fraction (60 vs 61%; P = NS), but impaired longitudinal function, as assessed by 2D-global longitudinal strain (GLS) (-18.9 ± 2 vs -20.5 ± 2; P = 0.0002) and 3D-GLS (-17.5 ± 2 vs -19 ± 2; P = 0.003). At follow-up, diabetic patients had worsened longitudinal function compared to baseline (2D-GLS: -18.4 ± 1 vs -19.2 ± 1; P = 0.03). Global circumferential (GCS) and radial (GRS) strains were unchanged at baseline and during follow-up. Metabolic status did not correlate with GLS, whereas GCS and GRS showed a good correlation, suggestive of a compensatory increase of circumferential and radial functions in advanced stages of the disease - long-term diabetes (GCS: -26 ± 3 vs -23.3 ± 3; P = 0.008) and in the presence of microvascular complications (GRS: 38.8 ± 9 vs 34.3 ± 8; P = 0.04). CONCLUSIONS: Subclinical myocardial dysfunction can be detected by 2D and 3D-STE in type 1 diabetic patients, independently of any other cardiovascular risk factors. Diabetic cardiomyopathy progression was suggested by a mild decrease in longitudinal function at the follow-up, but did not extend to a clinical expression of the disease, as no death or over heart failure was reported.

Coronary angiography with flat panel digital detectors significantly increases the sensitivity for calcium detection in relation to conventional fluoroscopy: comparison of both systems with intravascular ultrasound.

OBJECTIVE: To compare the sensitivity and specificity for coronary calcium detection of two fluoroscopic systems: 1) conventional system based on image intensifier chains (CONV); and 2) flat panel digital detector (FPDD) system, using intravascular ultrasound (IVUS) as the gold standard. BACKGROUND: Coronary calcification represents advanced atherosclerotic disease and has implications during coronary interventions. Angiography has been reported to have low sensitivity for calcium detection compared with IVUS. METHODS: Lesion calcification was assessed by two different fluoroscopic systems (FPDD and CONV), and by IVUS. RESULTS: In two consecutive periods, a total of 200 consecutive patients were included, 100 in each group. Clinical characteristics were similar, without significant differences between groups. In the CONV group, IVUS detected calcium in 77% of cases, and angiography in 32%. Sensitivity was 41.6% and specificity 91.3%. In the FPDD group, IVUS reported calcification in 79% of patients, and angiography in 57%. Sensitivity was 72% (p < 0.0001 for comparison with CONV) and specificity was 90.4%. CONCLUSION: The new fluoroscopic systems, based on FPDD, considerably increase the sensitivity for calcium detection without detrimental effect on specificity.

[Treatment of lesions with a high risk of stenosis. Comparative study in 300 patients of rapamycin- and Paclitaxel-eluting polymer-based stents, and bare metal stents]. / Tratamiento de lesiones con alto riesgo de reestenosis. Estudio comparativo en 300 pacientes del stent liberador de rapamicina, el stent con polímero liberador de paclitaxel y el stent convencional.

INTRODUCTION AND OBJECTIVES: Rapamycin- and taxol-eluting stents have been shown to reduce restenosis, but there are no large-scale studies of their usefulness in lesions with a high risk of restenosis, or of the relative merits of the two devices. This prospective study compared their safety and efficacy in lesions with a high risk of restenosis. PATIENTS AND METHOD: We included consecutive patients with lesions to treat that met at least one of the following criteria: a) in-stent restenosis; b) diffuse (>20 mm) restenosis; c) small vessel (< or =2.5 mm) restenosis; or d) total occlusion. Patients received different devices along three consecutive study periods: bare metal (conventional) stents, sirolimus-eluting (rapamycin) stents and paclitaxel-eluting (taxol) stents. RESULTS: One hundred patients in each group were included, for a total of 300 patients. In the sirolimus group, after 8.5+/-2 months of follow-up, there were 2 late thromboses (2%) and only 1 patient (1%) required target lesion revascularization. In the paclitaxel group 2 patients (2%) had in-hospital stent thrombosis (1 acute, 1 subacute), and after 9+/-2.5 months of follow-up only 1 patient (1%) needed target lesion revascularization. In the conventional group, after 8+/-2 months of follow-up, there was 1 subacute thrombosis (1%) and 15 patients (15%) had clinical restenosis requiring target lesion revascularization. Event-free survival curves were significantly better with drug-eluting stents (P<.01 vs conventional stents). CONCLUSION: Rapamycin- and taxol-eluting stents were safe for lesions with a high risk of restenosis. These stents were associated with a lower rate of target lesion revascularization during follow-up compared to bare metal stents.

Validation of the isovolumetric relaxation time for the estimation of pulmonary systolic arterial blood pressure in chronic pulmonary hypertension.

AIMS: Transthoracic echocardiography is a useful technique for non-invasive detection of pulmonary arterial systolic pressure (PASP). Isovolumic relaxation time (IVRT) measured by Doppler tissue imaging (DTI) is a sensitive measurement of changes in pulmonary vasculature. Our aim was to validate IVRT in the echocardiographic assessment of pulmonary hypertension (PH) patients. METHODS AND RESULTS: We studied 196 PH patients (67% women, mean age 51.8 ± 16.6 years, mean PASP: 81 ± 24 mmHg) and 37 consecutive age- and sex-matched controls (58% women, mean age 44.7 ± 16.4 years, mean PASP 27.7 ± 5.5 mmHg). The estimation of PASP was derived from tricuspid regurgitation velocity according to the Bernoulli equation. The measurement of IVRT was calculated using pulsed tissue Doppler. In the PH group and in the healthy volunteers group (P < 0.0001), the average IVRT was 113.4 ± 28.5 ms [95% confidence interval (CI): 109-117] and 41 ± 12.5 ms (95% CI: 37-45), respectively. We found a strong correlation between IVRT and systolic pulmonary pressure in the PH group (r = 0.52, P < 0.0001) and a cut-off of 75 ms showed a sensitivity and specificity of 94% and 97%, respectively, for the prediction of elevated PASP. CONCLUSION: The determination of IVRT by DTI is a simple and reproducible method that correlates well with PASP. It is, therefore, a parameter to consider in the echocardiographic assessment of patients with PH, and may be particularly important when the tricuspid Doppler signal is poor.

The inextricable link between atherosclerosis and prototypical inflammatory diseases rheumatoid arthritis and systemic lupus erythematosus.

The increased burden of cardiovascular disease in patients with rheumatoid arthritis and systemic lupus erythematosus has recently become the focus of intense investigation. Proatherogenic risk factors and dysregulated inflammation are the main culprits, leading to enhanced atherosclerosis in subgroups of patients with inflammatory diseases. Common molecular pathways shared by atherosclerosis and inflammatory disease may be involved. In this review we map the key determinants of the increased incidence of cardiovascular disease in patients with inflammatory diseases at each step of the atherogenesis.

[Current surgical treatment of calcified aortic stenosis]. / Tratamiento quirúrgico actual de la estenosis aórtica calcificada.

Currently, aortic stenosis is the main indication for cardiac surgery in western countries. With the aim of describing the clinical and surgical characteristics and the short-term outcome of current surgical treatment, we carried out a retrospective study of 238 patients (mean age 71 years, 43% female) who underwent surgery during 2002-2003. Of these, 73% had a EuroSCORE >6. Surgical procedures included isolated aortic valve replacement in 61%, ascending aorta surgery in 14%, coronary artery by-pass grafting in 21%, and mitral surgery in 4%. The in-hospital mortality rate in the 30 days after surgery was 7.1%. Multivariate analysis, adjusted for age, sex and left ventricular ejection fraction, showed that only concomitant coronary artery by-pass grafting was significantly associated with in-hospital mortality (odds ratio=4; P=.019). Factors associated with mortality at 18 months were: previous neurological disease (hazard ratio [HR]=3.25; P=.017), prosthesis diameter <21 mm (HR=2.86; P=.018), and coronary artery by-pass grafting (HR=2.35; P=.05).

[Management of syncope in the emergency department without hospital admission: usefulness of an arrhythmia unit coordinated protocol]. / Manejo del síncope en el servicio de urgencias sin ingreso hospitalario: utilidad de un protocolo coordinado con la unidad de arritmias.

INTRODUCTION AND OBJECTIVES: The main aim of this study was to demonstrate that a protocol for managing syncope in the emergency department that is based on the early detection of heart disease enables patients to be diagnosed quickly and with few admissions, without there being a negative impact on prognosis. METHODS: The study was performed prospectively in 199 consecutive patients (54% male; mean age, 67 [17] years) who presented with syncope at the emergency department of our hospital during a 17-month period. A two-step diagnostic algorithm was developed in which patients initially underwent clinical and electro-cardiographic assessment, and thereafter were submitted to a diagnostic protocol that involved carrying out a sequence of diagnostic tests in the emergency room to avoid hospital admission. RESULTS: A presumptive diagnosis was established in 120 (60%) patients during the initial assessment. After completion of the diagnostic protocol, 78% of patients were given a clear diagnosis within a mean stay of 19 [15] h in the emergency department. Some 10% of patients were admitted. Three patients died during a mean follow-up period of 237 days. CONCLUSIONS: Implementation of a protocol for managing syncope in the emergency department that was based on screening patients according to the presence of heart disease enabled a large percentage to receive a diagnosis. Moreover, the majority of patients could be discharged rapidly from the emergency department without there being any negative impact on medium-term prognosis.

[Prospective use of an intravascular ultrasound-derived minimum lumen area cut-off value in the assessment of intermediate left main coronary artery lesions]. / Aplicación prospectiva de un valor de corte de área luminal mínima por ecografía intravascular en la evaluación de lesiones intermedias del tronco.

BACKGROUND AND OBJECTIVES: Angiographic assessment of the severity of intermediate lesions in the left main coronary artery (LMCA) is subject to significant limitations. Intravascular ultrasound (IVUS) can provide accurate measurement, but there is no agreement on the minimum lumen cross-sectional area (MLA) that indicates significant disease. The aim of this study was to determine the long-term safety of applying a cut-off value of 6 mm2 for the MLA in the LMCA. METHODS: The study included patients with intermediate lesions (i.e., 25-50%) in unprotected LMCAs, with no previous evidence of associated ischemia. An IVUS examination was carried out and revascularization was indicated when the MLA was < or =6 mm2. RESULTS: In total, 79 patients were recruited between 2000-2005. In 31 (39%), the MLA was < or =6 mm2, and they underwent LMCA revascularization; in the remaining 48 (61%), the MLA was >6 mm2, and patients either underwent angioplasty for other lesions (n=37) or continued medical treatment (n=11). In a follow-up period of 40 [17] months, four patients (8.3%) died from heart disease, all of whom had an MLA between 9-10 mm2 in the baseline study. Revascularization of the LMCA was necessary in only two patients (4.2%), both of whom had elective surgery more than 2 years after the initial study. CONCLUSIONS: Intravascular ultrasound assessment of intermediate LMCA lesions using an MLA cut-off value of 6 mm2 appears safe over the long term provided the clinical and angiographic criteria applied to patient selection are similar to those used in this study.

Sirolimus in de novo heart transplant recipients with severe renal impairment.

Two patients with end-stage heart failure and advanced renal dysfunction (under chronic dialysis therapy) underwent heart transplantation. In order to avoid further renal impairment, a calcineurine inhibitor-free immunosuppression regimen based on the sirolimus was used. Although temporary perioperative support with hemofiltration and dialysis was needed, both patients eventually regained a reasonable renal function with no episodes of clinical rejection and normal cardiac function at 13 and 11 months, respectively, after transplantation. Sirolimus-based immunosuppression might be an interesting alternative to calcineurine inhibitors in the management of patients with significant renal impairment.