RESUMEN
The case of an asymptomatic patient with prolapsing left atrial myxoma, in whom preoperative coronary angiography revealed a rare coronary artery anatomy in the absence of atherosclerotic obstructive disease, is presented. There was a type IV dual left anterior descending (LAD) artery with intraseptal course of the right aortic sinus-connected (long) LAD artery and an ectopic left circumflex artery originating from the right aortic sinus and having a retroaortic course. The patient underwent successful surgical excision of the mass which was confirmed by histology to be cardiac myxoma. This particular coronary artery anatomy has only been described once, and this is the first reported case of its combination with cardiac myxoma. This report highlights the importance of differentiating between the possible courses of such ectopic coronary arteries. The angiographic signs which enabled differentiation of the intraseptal course of the long LAD artery from the malignant interarterial course with which it is frequently confused are presented.
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Anomalías de los Vasos Coronarios/complicaciones , Anomalías de los Vasos Coronarios/diagnóstico , Vasos Coronarios/diagnóstico por imagen , Neoplasias Cardíacas/complicaciones , Neoplasias Cardíacas/diagnóstico , Mixoma/complicaciones , Mixoma/diagnóstico , Adulto , Angiografía Coronaria , Atrios Cardíacos/diagnóstico por imagen , Humanos , Masculino , UltrasonografíaRESUMEN
Complications of any mechanical prosthesis include thrombus or pannus formation. In our case report we demonstrate that prosthetic aortic valve regurgitation due to pannus formation may be intermittent and non-cyclic in pattern and therefore not obvious at the time of original clinical examination. Under these conditions and as transesophageal echocardiography cannot be repeated promptly, transthoracic 2-D and Doppler echocardiography should be available at any time when symptoms occur and present the method of choice for acute patient evaluation. Thrombolysis seems to be the first treatment of choice in case of thrombus formation and re-do surgery in case of pannus formation.
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Insuficiencia de la Válvula Aórtica/diagnóstico , Insuficiencia de la Válvula Aórtica/etiología , Prótesis Valvulares Cardíacas/efectos adversos , Enfermedad Aguda , Adulto , Insuficiencia de la Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/cirugía , Angiografía Coronaria , Ecocardiografía Transesofágica , Electrocardiografía , Fluoroscopía , Humanos , Masculino , Falla de PrótesisRESUMEN
OBJECTIVE: To compare the prognostic value of regional longitudinal ventricular systolic velocities with that of maximal oxygen consumption (VO(2max)) in patients with dilated cardiomyopathy (DCM). METHODS: VO(2max) derived from cardiopulmonary exercise tests and regional longitudinal ventricular systolic velocities obtained from tissue Doppler imaging were compared in 18 DCM patients with cardiac events (death, cardiac transplantation, hospitalization, group A) and 24 patients without cardiac events (group B). Peak velocities during isovolumic contraction (is) and ejection (ez) were interrogated at the mitral or tricuspid annulus (site 1), at the mid parts of the walls (site 3, at the level of papillary muscle), and at the midpoints (site 2) between sites 1 and 3 of interventricular septum (S), lateral wall of LV (L) and of RV (R) in apical 4 chambers view. RESULTS: R1is, R2is, R2ez, R3is, S1is, S1ez, S2ez, L1is, L1ez and L2ez of group A were significantly lower than those in group B (all P < 0.05). Independent of VO(2max), high sensitivity and specificity were shown for R3ez, S1ez, L1ez, L1is, L2is and L3is in predicting cardiac events of DCM patients. CONCLUSION: LV and RV systolic velocities could independently predict cardiac events in DCM patients.
Asunto(s)
Cardiomiopatía Dilatada/diagnóstico , Consumo de Oxígeno , Adulto , Anciano , Cardiomiopatía Dilatada/diagnóstico por imagen , Cardiomiopatía Dilatada/metabolismo , Ecocardiografía Doppler , Prueba de Esfuerzo , Femenino , Estudios de Seguimiento , Ventrículos Cardíacos/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Sístole , Función Ventricular Izquierda , Función Ventricular DerechaRESUMEN
OBJECTIVE: To measure the distance between the mitral leaflet coaptation point and the mitral annulus (CPMA) and assess the relation of this index to structural and functional characteristics of the failing left ventricle. DESIGN: Echocardiographic indices and CPMA were measured at baseline and again during dobutamine infusion and leg lifting. Left ventricular diastolic and systolic dimensions, left ventricular ejection fraction (LVEF) by Simpson's rule, mitral annulus dimension, and E point septal separation were correlated with CPMA. SETTING: Tertiary referral centre. PATIENTS: The total study population of 129 patients included 94 with LVEF < 35% and 35 with LVEF 35%-45%; 76 had coronary artery disease and 53 had dilated cardiomyopathy. INTERVENTIONS: A dobutamine infusion was given in 18 patients and preload increase by leg lifting in 28. MAIN OUTCOME MEASURES: Correlations between CPMA and contractility indices at baseline and during interventions. RESULTS: CPMA was correlated with left ventricular diastolic dimension (r = 0.52), left ventricular systolic dimension (r = 0.53), LVEF (r = -0.44), fractional shortening (r = -0.42), E point septal separation (r = 0.48), and mitral annulus dimension (r = 0.44) (all p < 0.001). Dobutamine decreased CPMA from (mean (SD)) 12.04 (3.64) mm to 8.92 (2.56) mm and increased LVEF from 27 (6.2)% at baseline to 33.4 (6.9)% at 10 microg/kg/min (both p < 0.001). These changes were strongly related (r = 0.68, p < 0.007). After leg lifting, CPMA decreased from 13 (4) mm at baseline to 10 (3) mm (p < 0.001), and LVEF increased from 32 (11)% at baseline to 39 (11)% (p < 0.001). Fractional shortening and left ventricular diastolic dimension also increased (p < 0.001) and mitral annulus dimension and E point septal separation decreased (p < 0.002), but left ventricular systolic dimension did not change. CONCLUSIONS: The mechanism displacing the mitral coaptation point towards the left ventricular apex is multifactorial. The correlations between CPMA difference (before versus after interventions) and ejection fraction difference (before versus after interventions) shows that this index depends mainly on left ventricular function.
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Gasto Cardíaco Bajo/fisiopatología , Cardiomiopatía Dilatada/patología , Enfermedad Coronaria/patología , Insuficiencia de la Válvula Mitral/patología , Prolapso de la Válvula Mitral/patología , Adulto , Anciano , Anciano de 80 o más Años , Velocidad del Flujo Sanguíneo , Cardiomiopatía Dilatada/diagnóstico por imagen , Cardiomiopatía Dilatada/fisiopatología , Cardiotónicos , Enfermedad Coronaria/diagnóstico por imagen , Enfermedad Coronaria/fisiopatología , Dobutamina , Ecocardiografía Doppler , Ejercicio Físico/fisiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/fisiopatología , Prolapso de la Válvula Mitral/diagnóstico por imagen , Prolapso de la Válvula Mitral/fisiopatología , Estudios Prospectivos , Volumen Sistólico/fisiología , Disfunción Ventricular Izquierda/fisiopatologíaRESUMEN
AIMS: The study sought to investigate the relationship of myocardial viability detected by dobutamine stress echocardiography to changes of QT dispersion and to the presence of arrhythmias during dobutamine infusion in patients with old myocardial infarction. We also examined whether patency of the infarct-related artery is associated with the presence of myocardial viability and QT dispersion. BACKGROUND: QT dispersion and myocardial variability have been associated with the presence of arrhythmias during late post infarction but not during dobutamine stress. Restoration of anterograde coronary flow has beneficial effects on ventricular systolic function and repolarization, suggesting that the extent of viable myocardium may determine ventricular repolarization. METHODS: Seventy five patients with previous myocardial infarction were studied in a low dose (up to 20 microg(-1) x kg(-1) x min(-1)) dobutamine stress echocardiography study. ECGs were obtained at rest and peak stress for measurement of QT intervals. The presence of ventricular arrhythmias (Lown grade >lb) during stress was noted. A reduction in the total wall motion score of the left ventricle at peak stress confirmed the presence of myocardial viability. RESULTS: Dobutamine infusion increased QT dispersion in all patients (P<0.01). Patients with myocardial viability had a lower resting QT dispersion (P<0.05) and a greater increase in QT dispersion% (P<0.01) than patients without. The combination of a resting QT dispersion <65 ms or an increase in QT dispersion >30% predicted viability with a sensitivity of 67%, a specificity of 96%, and an accuracy of 78%. A patent infarct-related artery, as well as ventricular arrhythmias, were more commonly observed in patients with evidence of viable myocardium (P<0.05). Patients with arrhythmias had a higher QT dispersion than patients without (P<0.05). CONCLUSION: The combination of a resting QT dispersion +/-65 ms or an increase in QT dispersion >30% predicts the presence of viable myocardium and thus, may represent a simple index for the assessment of viability in everyday clinical practice. Myocardial viability is related to a patent coronary artery and to a high incidence of arrhythmias accompanied by a greater increase in QT dispersion at peak dobutamine infusion.
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Arritmias Cardíacas/diagnóstico , Cardiotónicos , Dobutamina , Ventrículos Cardíacos/efectos de los fármacos , Infarto del Miocardio/fisiopatología , Cardiotónicos/farmacología , Estudios de Cohortes , Dobutamina/farmacología , Ecocardiografía/métodos , Electrocardiografía , Prueba de Esfuerzo , Femenino , Sistema de Conducción Cardíaco/efectos de los fármacos , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios ProspectivosRESUMEN
Little is known about the association of echocardiographic estimates of right ventricular (RV) function with survival, in relation to hemodynamic and exercise-derived predictors of outcome in congestive heart failure. We prospectively studied 40 patients (age 55+/-10 years, in New York Heart Association functional class III [70%] and IV [30%]), with left ventricular (LV) ejection fraction <30%. At enrollment, all patients underwent echocardiographic evaluation of LV dimensions and function. RV shortening was measured as the difference of the end-diastolic distance - the end-systolic distance between the tricuspid annulus and the RV apex. Thirty-five patients (88%) were able to perform a maximal symptom-limited exercise test. Peak oxygen consumption (peak VO2) and percent peak age- and gender-adjusted predicted oxygen consumption (%peak VO2) were calculated. Of 40 patients, 10 died during a mean follow-up period of 14+/-10 months. On univariate analysis, nonsurvivors had lower RV shortening (p=0.0001), higher pulmonary artery wedge pressure (p=0.009), higher pulmonary vascular resistance (p=0.02), and lower mean aortic pressure (p=0.05). Cox proportional-hazards model revealed that the only independent associate of survival was RV shortening (p=0.0005), with a trend toward significance for mean aortic pressure (p=0.08). The best cutoff point of RV shortening identified by the receiver-operating curve was 1.25 cm. This value had a sensitivity of 90%, specificity of 80%, and overall predictive accuracy of 83% to distinguish survivors from nonsurvivors. In patients with advanced heart failure, preserved RV function as indicated by an echocardiographically derived RV shortening > 1.25 cm is a strong predictor of survival.
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Insuficiencia Cardíaca/diagnóstico por imagen , Ventrículos Cardíacos/diagnóstico por imagen , Cateterismo Cardíaco , Gasto Cardíaco , Ecocardiografía , Prueba de Esfuerzo , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/fisiopatología , Ventrículos Cardíacos/metabolismo , Ventrículos Cardíacos/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Contracción Miocárdica , Consumo de Oxígeno , Pronóstico , Arteria Pulmonar/diagnóstico por imagen , Arteria Pulmonar/fisiopatología , Presión Esfenoidal Pulmonar , Tasa de Supervivencia , Resistencia VascularRESUMEN
Coronary atherosclerosis, during its initial stages of development, may result in abnormal endothelium-dependent vasomotor responses. The relation between the degree of vasoreactivity and the amount of atheromatous plaque load has not been decisively determined. The aim of the present study was to investigate the effects of segmental plaque burden on endothelium-dependent and independent coronary stimulation. We studied 37 individual coronary segments along the course of coronary arteries that had angiographically either nonvisible or nonobstructive atheromatous lesions. Endothelium-dependent and independent stimulation of each segment from 10 patients with known significant coronary artery disease was examined with intracoronary administrations of normal saline, acetylcholine 10(-6) M and 10(-5) M, and nitroglycerin, respectively, using quantitative coronary angiography. Simultaneous vasomotor effects on the microcirculation were evaluated by a Doppler guidewire (Flowire). Subsequently, intracoronary ultrasound was used at each segment for detailed morphometric and composition analysis. By quantitative coronary angiography, when compared with normal saline, acetylcholine produced a reduction in minimal lumen diameter of 15.2 +/- 25.6%, and nitroglycerin produced an increase of 18.0 +/- 22.5%. The degree of vasoconstriction induced by acetylcholine correlated inversely (r = 0.51, p = 0.001) to the amount of segmental maximal plaque thickness. No relation between the response to nitroglycerin and the parameters obtained by intracoronary ultrasound was documented. Fibrous coronary plaques showed less vasomotor changes than plaques with mixed echogenicity, probably due to a significantly larger plaque burden. Acetylcholine produced overall a differential vasomotor response in the epicardial segments (vasoconstriction) compared with the microcirculation (vasodilation). These results indicate that in early atheromatous coronary lesions, the degree of endothelium-dependent vasoconstrictive response is inversely related to the amount of segmental plaque burden.
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Enfermedad de la Arteria Coronaria/fisiopatología , Vasos Coronarios/fisiopatología , Vasoconstricción , Vasodilatación , Acetilcolina/farmacología , Anciano , Angina de Pecho/etiología , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/patología , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/patología , Endotelio Vascular/efectos de los fármacos , Humanos , Masculino , Persona de Mediana Edad , Nitroglicerina/farmacología , Ultrasonografía Intervencional , Vasoconstricción/efectos de los fármacos , Vasodilatación/efectos de los fármacosRESUMEN
The aim of this study was to investigate the influence of mitral regurgitation (MR) on left atrial (LA) thrombus formation and spontaneous echocardiographic contrast in patients with rheumatic mitral valve disease. LA thrombus and spontaneous contrast are considered risk factors for embolic complications. The presence of MR has been related to a low incidence of embolization; however, its effect on thrombus formation and spontaneous contrast has not been clarified. We studied by transesophageal echocardiography 55 patients with rheumatic mitral valve disease, who were receiving anticoagulant treatment. Atrial thrombus was detected in 13 patients who had a lower incidence of significant MR (p < 0.03), a smaller regurgitant jet (p < 0.02), and a higher incidence of atrial fibrillation (p < 0.05) than the rest of the group. Spontaneous contrast was detected in 34 patients with larger atria (p < 0.006), smaller regurgitant jets (p < 0.05), a smaller mitral valve area (p < 0.008), and a higher incidence of atrial fibrillation (p < 0.002) than the rest of the group. Patients without significant MR are at high risk for LA thrombus formation and subsequent embolization and represent a subgroup in whom careful anticoagulation is needed. Conversely, the presence of significant MR correlates with a lower incidence of spontaneous contrast, thrombi, and embolization.
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Atrios Cardíacos/diagnóstico por imagen , Cardiopatías/etiología , Insuficiencia de la Válvula Mitral/complicaciones , Cardiopatía Reumática/complicaciones , Trombosis/etiología , Adulto , Anciano , Ecocardiografía Transesofágica , Femenino , Cardiopatías/diagnóstico por imagen , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Estenosis de la Válvula Mitral/complicaciones , Estenosis de la Válvula Mitral/diagnóstico por imagen , Estudios Prospectivos , Cardiopatía Reumática/diagnóstico por imagen , Factores de Riesgo , Trombosis/diagnóstico por imagenRESUMEN
Severe tricuspid regurgitation developed in a 51-year-old woman with rheumatic heart disease and a previous replacement of the mitral valve 8 years after a De Vega anuloplasty. At transthoracic echocardiography, rupture of the anuloplasty material was suspected, which was definitely confirmed at transesophageal echocardiography. She underwent operation solely by echocardiographic diagnosis, which was completely confirmed at operation.
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Ecocardiografía Transesofágica , Ecocardiografía , Complicaciones Posoperatorias/diagnóstico por imagen , Dehiscencia de la Herida Operatoria/diagnóstico por imagen , Insuficiencia de la Válvula Tricúspide/cirugía , Femenino , Hemodinámica/fisiología , Humanos , Persona de Mediana Edad , Complicaciones Posoperatorias/cirugía , Reoperación , Rotura Espontánea , Dehiscencia de la Herida Operatoria/cirugía , Técnicas de Sutura , Válvula Tricúspide/diagnóstico por imagen , Válvula Tricúspide/cirugía , Insuficiencia de la Válvula Tricúspide/diagnóstico por imagenRESUMEN
Neurohormonal factors may account for the fact that patients with similar severity and duration of hypertension develop different degrees of left ventricular hypertrophy (LVH). The purpose of this work was to compare the pressor hormone profiles of hypertensive subjects off medication during exercise testing. Nineteen patients, stratified according to echocardiographically diagnosed absence (Group I n = 6) or presence (Group II n = 13) of LVH, underwent testing on the treadmill according to the Bruce protocol. Both groups were comparable in age, severity and duration of hypertension and reached similar double product at peak exercise. Measurements of plasma renin activity (PRA), plasma catecholamines and vasopressin (AVP) at baseline, peak exercise and post exercise revealed significant differences between groups: Group I had suppressed PRA levels throughout and had significantly higher baseline AVP levels, which increased further at peak effort. Group II had significantly higher baseline PRA levels, which tended to increase further at peak effort, and had suppressed AVP levels throughout. There was a significant negative correlation between percent increments in AVP and increments in double product. Norepinephrine increased significantly with effort in both groups, but the levels attained were higher in Group I. In view of the known negative inotropic action of AVP and the trophic effect of angiotensin, we speculate that lower baseline AVP and higher PRA, together with inability of AVP to increase with effort, may be causally related to development of LVH.
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Arginina Vasopresina/sangre , Cardiomegalia/etiología , Catecolaminas/sangre , Hipertensión/sangre , Renina/sangre , Estrés Fisiológico/complicaciones , Adulto , Cardiomegalia/sangre , Prueba de Esfuerzo , Femenino , Humanos , Hipertensión/complicaciones , Masculino , Persona de Mediana Edad , Esfuerzo Físico , DescansoRESUMEN
Doppler echocardiography was used to assess diastolic function in 40 patients with hypertrophic cardiomyopathy and to relate it to the patients' symptoms, anaerobic threshold and maximal oxygen consumption during cardiopulmonary exercise testing. The patients had a smaller early (E wave) (p less than 0.01), higher late (A wave) (p less than 0.05) mitral diastolic flow velocity, larger A/E ratio (p less than 0.01), longer isovolumetric relaxation time and E wave duration (p less than 0.001) and slower deceleration rate of the E wave (p less than 0.001) than 40 age- and gender-matched normal subjects. In the patients with hypertrophic cardiomyopathy, maximal oxygen consumption and anaerobic threshold were, respectively, 26.3 +/- 9.2 and 21.1 +/- 6.1 ml/kg per min compared with 47 (range 39 to 68) (p less than 0.01) and 41 (range 27 to 58) ml/kg per min (p less than 0.01) in normal subjects. There was no relation between Doppler indexes and symptoms but symptomatic patients had lower maximal oxygen consumption and anaerobic threshold compared with asymptomatic patients (21.4 +/- 7 vs. 30.7 +/- 10, p less than 0.001 and 18.6 +/- 4.7 vs. 23.1 +/- 5.7, respectively, p less than 0.001). In conclusion, Doppler echocardiography can identify abnormalities of left ventricular filling in patients with hypertrophic cardiomyopathy. However, these indexes measured at rest do not correspond to the patient's professed symptomatic status or exercise capacity measured objectively. Conversely, cardiopulmonary exercise testing reveals a depressed maximal oxygen consumption and anaerobic threshold even in the least symptomatic patients.
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Cardiomiopatía Hipertrófica/fisiopatología , Diástole/fisiología , Ejercicio Físico/fisiología , Adolescente , Adulto , Anciano , Velocidad del Flujo Sanguíneo , Cardiomiopatía Hipertrófica/diagnóstico por imagen , Ecocardiografía Doppler , Prueba de Esfuerzo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Consumo de Oxígeno , PresiónRESUMEN
The clinical outcome of 52 consecutive patients with hypertrophic cardiomyopathy who developed paroxysmal (less than 1 week) or established (greater than or equal to 1 week) atrial fibrillation between 1960 and 1985 was examined retrospectively and compared with that of a matched group of patients with hypertrophic cardiomyopathy and sinus rhythm. Follow-up study until death or the present ranged from 6 months to 24 years (median 11 years) from diagnosis and from 6 months to 22 years (median 7 years) from the onset of atrial fibrillation. Atrial fibrillation was present in 6 patients at the time of diagnosis, whereas it developed subsequently in 46. The acute onset of arrhythmia was associated with a change in symptoms in 41 (89%) of the 46. After initial treatment of acute atrial fibrillation, sinus rhythm was restored in 29 (63%) of the 46 patients; 43 (93%) of the 46 returned to their original symptom class. Stepwise logistic regression revealed that shorter duration of arrhythmia and amiodarone therapy were the most powerful predictors of return to sinus rhythm. Sinus rhythm was maintained during a median follow-up period of 5.5 years in 22 of the 29 patients in whom it was restored after initial therapy. During follow-up study, 25 of the 52 patients were treated with conventional therapy alone and 7 with amiodarone alone. Amiodarone therapy was associated with maintenance of sinus rhythm, fewer alterations in drug therapy, fewer embolic episodes and fewer attempted direct current cardioversions (during a shorter follow-up period).(ABSTRACT TRUNCATED AT 250 WORDS)