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The presence of mitral regurgitation (MR) in patients with right ventricular apical pacing can be the result of multiple phenomena. On the one hand, this stimulation causes an asynchronous activation of the left ventricle (LV) and the papillary muscles, leading to a deterioration of the LV ejection fraction and causing an inadequate closure of the valve apparatus. However, there is a wide heterogeneity of ischemic and non-ischemic myocardial conditions that can coexist with mechanical alteration of the LV and the mitral valve leading to or worsening MR in these patients, which can make the etiological determination of valvular regurgitation difficult. Transthoracic echocardiography study allows comprehensive evaluation of mitral valve regurgitation and ventricular function parameters and mechanical asynchrony as a result of artificial pacing. The comprehensive study of these phenomena is relevant in clinical decision-making to define those patients who benefit from cardiac resynchronization therapy to alleviate symptomatic MR.

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The present study provides actual data with regard to the prevalence of myocardial ischemia among patients under contemporary cardiovascular prevention strategies undergoing peripheral vascular interventions. We included a total of 200 consecutive patients who underwent gated single-photon emission computed tomography myocardial perfusion study between January 2012 and January 2014 as preoperative evaluation for peripheral vascular interventions at our institution. The baseline medical treatment comprised aspirin (81%), statins (79%), and ß-blockers (54%). Thirty-two (16%) patients underwent carotid revascularization; 69 (34.5%) patients underwent lower limb revascularization, and 99 patients underwent aortic interventions. Twenty-six (13%) patients showed evidence of myocardial ischemia, with an extensive ischemic burden identified in seven (3.5%) patients. Within the group of patients with peripheral vasculopathy, those with lower limb arteriopathy had a higher prevalence of ischemia. According to the results of the myocardial perfusion study, the cardiology in charge indicated invasive coronary angiography in 11/26 (42%) patients with evidence of myocardial ischemia. Seven of the 11 (64%) patients who had coronary angiography were revascularized. After a mean follow-up of 24 months, no cardiovascular adverse events were detected.

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Introducción: El seudoaneurisma es una complicación ocasional (0,05-0,5%) de los procedimientos intervencionistas cuando se utiliza el acceso femoral. El cierre con inyección local de trombina como alternativa al tratamiento quirúrgico luego de compresión manual fallida cuenta con escasos registros. Objetivo: Evaluar la seguridad y eficacia del cierre del seudoaneurisma femoral iatrogénico mediante la inyección local de trombina guiada por ecografía Doppler. Material y métodos: Entre marzo de 2007 y junio de 2016 se incluyeron 32 pacientes para tratamiento con inyección de trombina. Resultados: La edad media fue de 64,3 ± 10,2 años. La mayoría de los seudoaneurismas estuvieron asociados con la realización de cateterismos coronarios diagnósticos o terapéuticos (59,3%). Siete pacientes habían recibido tratamiento anticoagulante y 21 doble antiagregación plaquetaria. En todos los casos se intentó previamente el cierre por compresión manual. La media del diámetro mayor de los seudoaneurismas fue de 38 mm. Luego del tratamiento, la trombosis inmediata del saco ocurrió en 28 pacientes (87,5%), mientras que 4 pacientes requirieron una segunda inyección, lo que determinó un éxito del 96,8%. En un solo paciente este tratamiento no fue efectivo, con posterior conversión a reparación quirúrgica programada. La dosis media de trombina fue de 450 unidades. Un único paciente presentó complicación trombótica venosa que requirió terapia anticoagulante, con buena evolución clínica. Conclusión: El tratamiento del seudoaneurisma con inyección local de trombina guiada con eco-Doppler fue una alternativa terapéutica segura y eficaz para pacientes con seudoaneurisma femoral refractarios a la compresión manual.

Background: Pseudoaneurysm is a rare complication (0.05-0.5%) after interventional procedures using femoral access. There are few registries of local thrombin injection for pseudoaneurysm closure as an alternative treatment to surgery after failed manual compression. Objective: The aim of this study was to evaluate the safety and efficacy of iatrogenic femoral pseudoaneurysm closure with Doppler ultrasound-guided local thrombin injection. Methods: Thirty-two patients were included for thrombin injection treatment between March 2007 and June 2016. Results: Mean age was 64.3±10.2 years. Most pseudoaneurysms were associated with diagnostic or therapeutic cardiac cath-eterizations (59.3%). Seven patients had received anticoagulant treatment and 21, double antiplatelet therapy. In all cases, prior closure was attempted by manual compression. Mean pseudoaneurysm major diameter was 38 mm. Following treatment, immediate pseudoaneurysm sac thrombosis occurred in 28 patients (87.5%), while 4 patients required a second injection, resulting in 96.8% success rate. Treatment was not effective in only one patient, with subsequent conversion to programmed surgical repair. Mean thrombin dose was 450 units. Only one patient presented with venous thrombosis complication requir-ing anticoagulant therapy, with good clinical outcome. Conclusion: Doppler ultrasound-guided local thrombin injection was a safe and effective therapeutic alternative for pseudoa-neurysm treatment in patients with femoral pseudoaneurysm refractory to manual compression.

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INTRODUCTION: Quantification of mitral regurgitation (MR) by two-dimensional (2D) transthoracic echocardiography (TTE) is based on the analysis of the proximal flow convergence (PFC) and the "vena contracta" (VC). This method assumes geometries and can be misleading. In contrast, three-dimensional (3D) echocardiography directly measures flow volumes and does not assume geometries, which allows for more accurate MR evaluation. AIMS: To report the 3D transesophageal echocardiography (3DTEE) feasibility for MR quantification and evaluate its concordance with 2D echo. METHODS: Twenty-seven consecutive patients undergoing 2D and 3DTEE for presurgical MR evaluation were studied prospectively. MR quantification was performed by classical 2D methods based on PFC. Diameters of the VC in orthogonal planes by 3DTEE were estimated, establishing the VC sphericity index as well as VC area (VCA) by direct planimetry. In case of multiple jets, we calculated the sum of the VCA. RESULTS: MR assessment by 3DTEE was feasible. An adequate concordance between VC measurements by 2D methods (TTE and TEE) was observed; however, there was a poor correlation when compared with 3DTEE. The sphericity index of the VC was: 2.08 (±0. 72), reflecting a noncircular VC. CONCLUSIONS: 3DTEE is a feasible method for the assessment of the MR true morphology, allowing a better quantification of MR without assuming any geometry. This method revealed the presence of multiple jets, potentially improving MR evaluation and leading to changes in medical decision when compared to 2D echo assessment.

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The prevalence of left ventricular noncompacted myocardium (LVNC) is not clearly defined yet. The goal of this study was to prospectively assess the prevalence of LVNC in a population of patients assessed for cardiovascular disease and to analyze the coincidence between observers using the echocardiographic criteria for diagnosis of LVNC. We included patients prospectively during a 1-year period. To analyze the concordance between different observers, we performed a blind analysis of 50 patients between 7 operators to calculate Kappa index for each criteria. The analysis of concordance for final diagnosis of LVNC was free-marginal kappa: 0.94. A total of 10,857 patients underwent echocardiography; 2,931 (27%) were normal. LVNC was found in 26 patients (prevalence = 0.24%), 16 patients were women, mean age of 52.6 years. Patients were divided into 2 groups; group A: ejection fraction (EF) <50% (n = 20) and group B: normal systolic function (n = 6). Among abnormal studies, 294 (2.7%) were dilated cardiomyopathies (DCs) Patients with LVNC and EF <50% comprised 6.8% of DC (20 of 294) and 24% (20 of 75) of patients with idiopathic DC (p <0.0001). Group A patients were older and with less presence of women (both p <0.05). In conclusion, the prevalence of LVNC in a population assessed for cardiovascular diseases is low. In contrast, it is very high in the subgroup of patients with idiopathic DC. The group of patients with LVNC and normal LVEF is younger and with a higher presence of women than those with LVNC and depressed LVEF. Coincidence between operators is very good for the identification of echocardiographic criteria.

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Introducción: En la estenosis aórtica (EAo) con bajo flujo/bajo gradiente paradójico (BFBGP), el eco transtorácico 2D (ETT2D) podría subestimar el cálculo de flujo porque asume el tracto de salida del ventrículo izquierdo (TSVI) con una morfología circular. El eco transesofágico 3D (ETE3D) es metodológicamente mejor que el 2D para medir el TSVI. Objetivos: Evaluar el volumen eyectivo indexado (VEi) del ventrículo izquierdo por ETT2D y ETE3D en pacientes con corazón normal (GN) y con EAo grave (GEAo) y determinar cuántos pacientes con BFBGP por ETT2D se consideran también con BFBGP por ETE3D. Material y métodos: Se evaluaron 35 pacientes con ETT2D y ETE3D: GN = 17 pacientes y GEAo = 18 pacientes. Se estimó en ambos grupos el área del TSVI en protosístole por ETT2D (TSVI2Dprot) y por planimetría ETE3D (TSVI3Dprot) y como promedio sistólico (TSVI3Dprom). Multiplicando cada área del TSVI por su integral de flujo, se obtuvieron los VEi (VEi ETT2D prot, VEi ETE3D prot y VEi ETE3D prom) tanto del GN como del GEAo. En el GEAo se determinó BFBGP según criterio actual. Resultados: GN: área TSVI ETT2D prot vs. ETE3D prot p < 0,05. GEAo: área TSVI ETT2D prot vs. ETE3D prot p < 0,001 y vs. ETE3D prom p < 0,023; VEi ETT2D prot vs. VEi ETE3D prot p < 0,002 y vs. VEi ETE3D prom p < 0,038. En el GN, el VEi en el límite inferior de lo normal por ETT2D, ETE3D prot y ETE3D prom fue < 34, < 38,9 y < 35,9 ml/m², respectivamente. Tres pacientes del GEAo fueron BFBGP por ETT2D, pero ninguno por ETE3D. Conclusiones: Los pacientes con BFBGP por ETT2D podrían ser reclasificados por el ETE3D. Este hallazgo se relaciona con las limitaciones del eco 2D para el cálculo del área del TSVI.

Background: In paradoxical low-flow, low gradient (LF-LG) aortic stenosis, 2D-transthoracic echocardiography (2D-TTE) may underestimate flow because it assumes a circular left ventricular outflow tract (LVOT) shape. Three-dimensional trans-esophageal echocardiography (3D-TEE) is a better method to measure LVOT area. Objectives: The aim of this study was to evaluate left ventricular stroke volume index (SVi) by 2D-TTE and 3D-TEE in patients with normal heart (NG) and with severe aortic stenosis (ASG) and to determine how many patients are categorized as paradoxical LF-LG by 2D-TTE and 3D-TEE. Methods: Thirty-five patients were evaluated by 2D-TEE and 3D-TEE: NG=17 patients and ASG=18 patients. Left ventricular outflow tract area was estimated during early systole (ES) by 2D-TTE (ES2DLVOT Ar) and by 3D-TEE (ES3DLVOT Ar) planimetry, and as systolic average (Avg 3DLVOT Ar). Each LVOT area was multiplied by its corresponding flow integral to obtain SVi (ES2D-TTE SVi, ES3D-TEE SVi and Avg 3D-TEE SVi) in NG and ASG. Paradoxical LF-LG was determined in ASG following standard criterion. Results: NG: ES2DLVOT Ar vs. ES3DLVOT Ar p<0.05; ASG: ES2DLVOT Ar vs. ES3DLVOT Ar p<0.001 and vs. Avg 3DL-VOT Ar p<0.023; ES2D-TTE SVi vs. ES3D-TEE SVi p<0.002 and vs. Avg 3D-TEE SVi p<0.038. In the NG, the lower limit of normal SVi for 2D-TTE, ES3D-TEE and Avg 3D-TEE was <34, <38.9 and <35.9 ml/m², respectively. Three patients with severe aortic stenosis were categorized as paradoxical LF-LG by 2D-TTE, but none by 3D-TEE. Conclusions: Patients with paradoxical LF-LG by 2D-TTE could be recategorized by 3D-TEE. This finding is related with the limitations of 2D-echocardiography for estimating LVOT area.

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Introducción El cálculo del volumen regurgitante en la insuficiencia mitral por eco transtorácico 2D (ETT2D) es poco confiable y está relacionado con una medición inadecuada del anillo mitral (AM). El eco transesofágico 3D (ETE3D) posee mejores herramientas de medición del AM. Objetivos Comparar el área del AM y la diferencia de volumen del tracto de entrada y del tracto de salida del ventrículo izquierdo (TSVI y TEVI) por ETT2D y ETE3D en corazones normales. Evaluar en qué nivel del aparato mitral se encuentra el orificio mitral efectivo. Material y métodos Se incluyeron 13 pacientes consecutivos y prospectivos, de 42 (29-47) años, 7 de sexo femenino, con indicación de eco transesofágico (9 por búsqueda de fuente embolígena y 4 por síndrome febril), que tenían un ETT2D normal y se encontraban con ritmo sinusal y normotensos en el momento del estudio. Se les realizó simultáneamente ETT2D y ETE3D. El área del TSVI y del AM se midió por ETT2D y ETE3D. Se estimó por ETE3D el área de la válvula mitral (VM) distal al AM. El volumen de cada tracto se calculó como el producto del área por la integral velocidad-tiempo (VTI) del flujo. Se estableció una hipotética área mitral efectiva (AME) como el cociente entre el volumen del TSVI (ETE3D) y la VTI del TEVI. Resultados Correlación (rs), concordancia e IC 95% entre área del AM por ETT2D vs. ETE3D: 0,506, 1,97 (-0,40 a 4,34), AME vs. ETE3D 0,549, 2,41 (-4,03 a -0,79) y AME vs. VM a 10.5 mm (8-12) del AM: 0,982, 0,079 (-0,26 a 0,42). La diferencia de volumen (ml) entre ambos tractos fue: ETT2D 12,8 (7,5-19), ETE3D 32,8 (25,9-48) y ETE3D (desde VM distal al AM) 1,8 (1,25-3,6). Conclusiones Cuanto mejor medimos el anillo mitral, más lejos estamos del orificio mitral efectivo. El área mitral a 1 cm del punto más alto del anillo mitral es la que más se acerca al orificio mitral efectivo.(AU)

Introduction Two-dimensional transthoracic echocardiography (2DTTE) is not a reliable method for estimating regurgitatant volume in mitral insufficiency due to inadequate measurement of the mitral annulus (MA). Three-dimensional transesophageal echocardiography (3DTEE) offers better tools for measuring the MA. Objectives The aim of this study was to compare the MA area and the difference in mitral inflow (MI) volume and left ventricular out-flow tract (LVOT) volume determined by 2DTTE and 3DTEE in normal hearts, and to evaluate at what level of the mitral valve apparatus the mitral effective orifice is actually located. Methods A total of 13 consecutive and prospective patients with indication of transesophageal echocardiography (9 to rule out cardioembolic source and 4 due to febrile syndrome) were included in the study. Their mean age was 42 (29-47) years and 7 were women. All the patients had normal 2DTTE, were in sinus rhythm and had normal blood pressure at the moment of the study. 2DTTE and 3DTEE were simultaneously performed. LVOT area and MA area were calculated by 2DTTE and 3DTEE. Mitral valve (MV) area distal to the MA was estimated by 3DTEE. Mitral inflow and LVOT volume were calculated as the product between the area and flow velocity time integral (VTI). The effective mitral valve area (EMVA) was hypothetically estimated by dividing the LVOT (3DTEE) volume by MI VTI. Results Correlation (rs), concordance and 95% CI between MA area by 2DTTE vs. 3DTEE: 0.506, 1.97 (-0.40 to 4.34), EMVA vs. 3DTEE: 0.549, 2.41 (-4.03 to -0.79) and EMVA vs. MV at 11 mm (8-12) of the MA: 0.982, 0.079 (-0.26 to 0.42). The difference between MI volume and LVOT volume (ml) was: 2DTTE: 12.8 (7.5-19), 3DTEE: 32.8 (25.9-48) and 3DTEE (from the MV distal to the MA) 1.8 (1.25-3.6). Conclusions The better the technique for measuring the mitral annulus, the farther we are from the mitral effective orifice. The mitral valve area measured at one centimeter of the highest point of the mitral annulus is the best approximation to the effective mitral orifice.(AU)

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Introducción El cálculo del volumen regurgitante en la insuficiencia mitral por eco transtorácico 2D (ETT2D) es poco confiable y está relacionado con una medición inadecuada del anillo mitral (AM). El eco transesofágico 3D (ETE3D) posee mejores herramientas de medición del AM. Objetivos Comparar el área del AM y la diferencia de volumen del tracto de entrada y del tracto de salida del ventrículo izquierdo (TSVI y TEVI) por ETT2D y ETE3D en corazones normales. Evaluar en qué nivel del aparato mitral se encuentra el orificio mitral efectivo. Material y métodos Se incluyeron 13 pacientes consecutivos y prospectivos, de 42 (29-47) años, 7 de sexo femenino, con indicación de eco transesofágico (9 por búsqueda de fuente embolígena y 4 por síndrome febril), que tenían un ETT2D normal y se encontraban con ritmo sinusal y normotensos en el momento del estudio. Se les realizó simultáneamente ETT2D y ETE3D. El área del TSVI y del AM se midió por ETT2D y ETE3D. Se estimó por ETE3D el área de la válvula mitral (VM) distal al AM. El volumen de cada tracto se calculó como el producto del área por la integral velocidad-tiempo (VTI) del flujo. Se estableció una hipotética área mitral efectiva (AME) como el cociente entre el volumen del TSVI (ETE3D) y la VTI del TEVI. Resultados Correlación (rs), concordancia e IC 95% entre área del AM por ETT2D vs. ETE3D: 0,506, 1,97 (-0,40 a 4,34), AME vs. ETE3D 0,549, 2,41 (-4,03 a -0,79) y AME vs. VM a 10.5 mm (8-12) del AM: 0,982, 0,079 (-0,26 a 0,42). La diferencia de volumen (ml) entre ambos tractos fue: ETT2D 12,8 (7,5-19), ETE3D 32,8 (25,9-48) y ETE3D (desde VM distal al AM) 1,8 (1,25-3,6). Conclusiones Cuanto mejor medimos el anillo mitral, más lejos estamos del orificio mitral efectivo. El área mitral a 1 cm del punto más alto del anillo mitral es la que más se acerca al orificio mitral efectivo.

Introduction Two-dimensional transthoracic echocardiography (2DTTE) is not a reliable method for estimating regurgitatant volume in mitral insufficiency due to inadequate measurement of the mitral annulus (MA). Three-dimensional transesophageal echocardiography (3DTEE) offers better tools for measuring the MA. Objectives The aim of this study was to compare the MA area and the difference in mitral inflow (MI) volume and left ventricular out-flow tract (LVOT) volume determined by 2DTTE and 3DTEE in normal hearts, and to evaluate at what level of the mitral valve apparatus the mitral effective orifice is actually located. Methods A total of 13 consecutive and prospective patients with indication of transesophageal echocardiography (9 to rule out cardioembolic source and 4 due to febrile syndrome) were included in the study. Their mean age was 42 (29-47) years and 7 were women. All the patients had normal 2DTTE, were in sinus rhythm and had normal blood pressure at the moment of the study. 2DTTE and 3DTEE were simultaneously performed. LVOT area and MA area were calculated by 2DTTE and 3DTEE. Mitral valve (MV) area distal to the MA was estimated by 3DTEE. Mitral inflow and LVOT volume were calculated as the product between the area and flow velocity time integral (VTI). The effective mitral valve area (EMVA) was hypothetically estimated by dividing the LVOT (3DTEE) volume by MI VTI. Results Correlation (rs), concordance and 95% CI between MA area by 2DTTE vs. 3DTEE: 0.506, 1.97 (-0.40 to 4.34), EMVA vs. 3DTEE: 0.549, 2.41 (-4.03 to -0.79) and EMVA vs. MV at 11 mm (8-12) of the MA: 0.982, 0.079 (-0.26 to 0.42). The difference between MI volume and LVOT volume (ml) was: 2DTTE: 12.8 (7.5-19), 3DTEE: 32.8 (25.9-48) and 3DTEE (from the MV distal to the MA) 1.8 (1.25-3.6). Conclusions The better the technique for measuring the mitral annulus, the farther we are from the mitral effective orifice. The mitral valve area measured at one centimeter of the highest point of the mitral annulus is the best approximation to the effective mitral orifice.

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Se presenta el caso de un varón de 54 años que sufrió una disección aórtica torácica tipo B, inicialmente sin complicaciones. Con el tiempo se observó un aumento de la presión arterial asociado con deterioro de la función renal, claudicación de miembros inferiores y aparición de soplo abdominal. Diversos estudios evidenciaron compresión de la luz verdadera en la aorta abdominal por una falsa luz dilatada, proximal al origen de las renales. Con el implante de un stent aórtico desaparecieron el soplo abdominal, la claudicación y se normalizaron la presión arterial y la función renal.

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