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Intramural haematoma (IMH) forms part of the acute aortic syndrome presenting physiopathologic and evolutive patterns different from those of aortic dissection. The aim of this study was to determine the mortality and predictive factors of IMH in the first 3 months of evolution.Sixty-eight consecutive patients diagnosed of IMH (12 type A, 56 type B) were prospectively studied. Ten patients (eight type A, two type B) were surgically treated for clinical or haemodynamic evolution. Mortality rate was 19% (six type A and seven type B): five surgically treated (three type A, two type B) and eight medically treated (three type A, five type B). No relationship was observed between clinical variables and evolution. Maximum aortic diameter was greater in the group of patients who died (65.5+/-14.4 mm vs 46.0+/-7.6 mm; P0.0001). Mortality rate in patients with aortic diameter50 mm was 50% (P0.0001). Significant periaortic bleeding was mortality-related (47%; P0.005). Multivariate analysis showed only a significant relationship between mortality and maximum aortic diameter50 mm (OR=11.33; P0.005) and ascending aorta involvement (OR=11.18; P0.05).Intramural haematoma mortality in the first 3 months of evolution is high (19%). Maximum aortic diameter50 mm and ascending aorta involvement are predictive of early mortality.

Although different Doppler methods have been validated for aortic regurgitation quantification, the benefit of combining information from different methods has not been defined.Our study included 2 phases. In the initial phase (60 patients), Doppler parameters (jet width, short-axis jet area, apical jet area, regurgitant fraction from pulmonary and mitral flow, and deceleration slope) were correlated with angiography; range values for each severity grade were defined and intraobserver and interobserver and intermachine variability were studied. In the validation phase (158 patients), defined value ranges were prospectively tested and a strategy based on considering as the definitive severity grade that in which the two best methods agreed was tested.Jet width had the best correlation with angiography (r = 0.91), and its ratio with the left ventricular outflow diameter did not improve the correlation (r = 0.85) and decreased reproducibility. Apical jet area and regurgitant fraction from pulmonary flow permitted acceptable quantification (r = 0.87 and 0.86, respectively) but with worse reproducibility. The other methods were not assessable in 20% to 30% of studies. Concordance with angiography decreased in jet width when the jet was eccentric (90% vs 77%, P.01), in apical jet area when mitral valve disease was present (84% vs 65%, P.02), and in short-axis jet area and regurgitant fraction from pulmonary flow with concomitant aortic stenosis (77% vs 44%, P.002 and 77% vs 53%, P.02, respectively). Agreement with angiography was very high (94 [95%] of 99) when severity grade coincided in both jet width and apical jet area. In 59 cases without concordance, regurgitant fraction from pulmonary flow was used as a third method. Overall, this strategy permitted concordance with angiography in 146 patients (92%).Jet width is the best predictor in aortic regurgitation quantification by Doppler echocardiography. However, better results were obtained when a strategy based on concordance between jet width and another Doppler method was established, particularly when the jet was eccentric.

One hundred one patients with asymptomatic chronic severe aortic regurgitation and normal ejection fraction were monitored for up to 10 years (mean 55.4 +/- 33.5 months). Predefined surgical indications were the development of cardiac symptoms or the documentation of impaired basal left ventricular function. During the follow-up period there were no cardiac deaths; 14 patients needed surgery, 8 because of development of symptoms and 6 because of left ventricular impairment. The risk of surgery was 12% at 5 years and 24% at 10 years. Baseline end-systolic diameter50 mm and radionuclide ejection fraction60% were independent predictors or either cardiac symptoms or left ventricular dysfunction. In patients needing surgery, a pattern of progressive left ventricular dilatation was demonstrated. There were no deaths during surgery, and echocardiographic and radionuclide parameters normalized in the first year of follow-up. Our data confirm that the prognosis of severe aortic regurgitation in patients with no symptoms is good and that the occurrence of asymptomatic left ventricular dysfunction is an uncommon event. Surgery can be safely postponed until the appearance of cardiac symptoms or the documentation of left ventricular dysfunction at rest.

Background— Aortic intramural hematoma (IMH) evolves very dynamically in the short-term to regression, dissection, or aortic rupture. The aim of the present study was to assess the long-term clinical and morphological evolution of medically treated IMH. Methods and Results— Fifty of 68 consecutive patients with aortic IMH monitored clinically and by imaging techniques at 3, 6, and 12 months and annually thereafter were prospectively studied. Mean follow-up was 45±31 months. In the first 6 months, total IMH regression was observed in 14 and progression to aortic dissection in 18 patients; in 14 of these, the dissection was localized, and 12 later developed pseudoaneurysm. At the end of follow-up, the IMH had regressed completely without dilatation in 17 patients (34%), progressed to classical dissection in 6 (12%), evolved to fusiform aneurysm in 11 (22%), evolved to saccular aneurysm in 4 (8%), and evolved to pseudoaneurysm in 12 (24%). Evolution to dissection was related to echolucency ( P P Conclusions— The most frequent long-term evolution of IMH is to aortic aneurysm or pseudoaneurysm. Complete regression without changes in aorta size is observed in one third of cases, and progression to classical dissection is less common. A normal aortic diameter in the acute phase is the best predictor of IMH regression without complications, and absence of echolucent areas and atherosclerotic ulcerated plaque are associated with evolution to aortic aneurysm.

Dynamic intraventricular gradients (DIG) after valve replacement in severe aortic stenosis have been reported, although the incidence of DIG and clinical signs are still poorly understood.Aim. To evaluate the incidence of DIG)and determine risk factors and associated morbimortality.One hundred nine consecutive patients with severe aortic valve stenosis undergoing valve replacement were studied prospectively by echocardiography to detect the postoperative appearance of DIG, defined as a maximum flow velocity/= 2.5 m/s.Sixteen patients (14.9%) developed postoperative DIG. Significant differences between the patients with or without DIG were found for ventricular diameter (left end-diastolic ventricular diameter (LEDVD) 43.2 vs. 47.7 mm, respectively, p0.001; left end-systolic ventricular diameter (LESVD) 21 vs. 29 mm, p0.001); left ventricular mass index (165 vs. 193 g/m(2), p0.05); mean aortic valve gradient (68 vs. 59 mmHg, p0.01),; ejection fraction (73 vs. 61%, p0.001). No significant differences were found with respect to ventricular wall thicknesses (septal 16.3 vs. 15.7; posterior 14.37 vs. 14.62), the presence of aortic insufficiency, or other postoperative factors (anemia, inotropic agents, etc.).DIG after aortic valve replacement to treat severe stenosis is not unusual (15%). DIG is usually found at a midventricular location, close to the septum. In patients with postoperative DIG the most common associated factors were small LEDVD, high ejection fractions and ratios of intraventricular septal to posterior wall ratios, high valve gradients and small left ventricular masses. Preoperative echocardiography can identify patients with a higher risk of developing DIG after aortic valve replacement.

A case of recurrent left atrial free-floating thrombus in a patient with mitral prosthesis and multiple emboli is described. Transthoracic echocardiography failed to show the first ball thrombus, whereas transesophageal echocardiography proved highly useful both in diagnosis and in indicating the left atrial appendage as the source of the thrombi.

Objectives.We attempted to ascertain whether cardiac index can be directly estimated from Doppler mean velocity.Background.Although diverse Doppler echocardiographic methods have been described for cardiac output quantification, they are not widely used in clinical practice. Cross-sectional area measurement has been identified as the main source of error in flow volume quantification.Methods.A three-phase study by Doppler echocardiography was conducted in 306 patients. In phase I, the normal mean velocity ratio of the left and right ventricular outflow tracts was established in 170 normal subjects. In phase II, cardiac index, calculated as the product of aortic annular area index by mean velocity (conventional method), and mean velocity determined in the left ventricular outflow tract and ascending aorta by pulsed and continuous wave Doppler, respectively, were correlated with thermodilution cardiac index in 66 patients. In phase III, the accuracy of the regression equations obtained was prospectively assessed in an additional 70 patients.Results.The normal left/right ventricular outflow tract mean velocity ratio by pulsed wave Doppler was 1.1 ± 0.1. Cardiac index (CI) calculated by the conventional method and thermodilution (TD) showed acceptable correlation (r = 0.90, CITD= 1.20 CIPWD+ 357; r = 0.86, CITD= 0.90 CICWD+ 262) for pulsed (PWD) and continuous wave (CWD) Doppler, respectively, but with systematic underestimation (−28 ± 13%, p < 0.01) by pulsed wave Doppler. Mean velocity (MV) showed excellent correlation with the thermodilution cardiac index (r = 0.97, CITD= 172 MVPWD−172; r = 0.93, CITD= 129 MVCWD−255). When these regression equations were prospectively applied, better agreement with the thermodilution cardiac index was obtained by pulsed wave Doppler directly from mean velocity (SD 240 ml/min per m2) than when aortic annular area was considered in the calculation (SD 428 ml/min per m2). Similar results were obtained by continuous wave Doppler (SD 433 vs. 599 ml/min per m2) but with less accuracy.Conclusions.Left ventricular outflow tract mean velocity determined by pulsed wave Doppler permits easy, accurate cardiac index quantification in the absence of left ventricular outflow abnormalities. The simplicity of this method enhances its clinical applicability in noninvasive monitoring of cardiac index.