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Objective To assess the relationship between functional mitral regurgitation (MR) after a non-ST segment elevation acute coronary syndrome (NSTSEACS) and long-term prognosis, ventricular remodelling and further development of atrial fibrillation (AF), since functional MR is common after myocardial infarction. Design and setting Prospective cohort study conducted in a tertiary referral centre. Patients We prospectively studied 237 patients consecutively discharged in New York Heart Association class I–II (74% men; mean age 66.1 years) after a first NSTSEACS. All underwent an ECG the first week after admission and were echocardiographically and clinically followed-up (median 6.95 years). Results MR was detected in 95 cases (40.1%) and became an independent risk factor for the development of heart failure (HF) and major adverse cardiovascular events (MACE) (per MR degree, HR HF 1.71, 95% CI 1.138 to 2.588, p=0.01; HR MACE 1.49, 95% CI 1.158 to 1.921, p=0.002). Left ventricular diastolic (grade I 12.7±40.7; grade II 26.8±12.4; grade III 46.3±50.9 mL, p=0.01) and systolic (grade I 10.4±37.3; grade II 10.12±12.7; grade III 36.8±46.0 mL, p=0.02) mean volumes were higher after follow-up in patients with MR, in proportion to the initial degree of MR. In the rhythm analysis (126 patients; previously excluding those with any history of AF) during follow-up, 11.4% of patients with degree I MR, 14.3% with degree II MR and 75% with degree III MR developed AF, while only 5.1% of those with degree 0 developed AF, p Conclusions MR is common after an NSTSEACS. The presence and greater degree of MR confers a worse long-term prognosis after a first NSTSEACS. This can in part be explained by increased negative ventricular remodelling and increased occurrence of AF.

Transcatheter aortic valve implantation (TAVI) techniques have been presenting good procedural success and favorable clinical outcomes. However, optimal management of aortic valve disease in elderly patients depends on quality of life (QoL) improvement. In this study we aimed to evaluate changes in QoL in patients referred for TAVI.Prospective analysis of 74 consecutive patients (34 male), aged 81.6 ± 8 years with symptomatic severe aortic valve stenosis (AS) ineligible for conventional aortic valve replacement, referred to TAVI in one tertiary center. For the assessment of QoL, the Minnesota Living with Heart Failure Questionnaire (MLHFQ) was used before the procedure and at 6.5 months. The mortality was 9.5% at 30 days and 20.2% at 6.5 months follow-up. Fifty three (71.6%) patients completed MLHFQ at baseline and at follow-up. All patients showed good hemodynamic results and no signs of prosthesis dysfunction were observed on transthoracic echocardiography. The New York Heart Association (NYHA) class (2.9 ± 0.4 to 1.4 ± 0.7; p0.001), and the MLHFQ scores [overall (37.0 ± 14.7 vs. 14.4 ± 10.1; p0.001), physical dimension (23.2 ± 9.5 vs. 8.6 ± 5.9; p0.001) and emotional dimension (5.4 ± 4.2 vs. 2.6 ± 3.0; p0.001)] were significantly improved 6.5 months after TAVI. Patients with peripheral vascular disease (PVD) had an inferior improvement in QoL caused by a lower enhancement in physical dimension MLHFQ score (mean difference: -17.0 ± 10.2 vs. -10.1 ± 11.5; p=0.036).TAVI significantly improves symptoms and QoL in patients with severe AS and high surgical risk. Patients with PVD might be expected to have a less impressive improvement in QoL after TAVI.

Coronary artery aneurysm is defined as a coronary dilation that exceeds the diameter of adjacent segments or the diameter of the patient's largest normal coronary vessel by 1.5×. It is an uncommon disease that has been diagnosed with increasing frequency since the widespread appearance of coronary angiography. The published incidence varies from 1.5% to 5%, suggesting male dominance and a predilection for the right coronary artery. Although several causes have been described, atherosclerosis accounts for ≥50% of coronary aneurysms in adults. Reported complications include thrombosis and distal embolization, rupture, and vasospasm, causing ischemia, heart failure, or arrhythmias. The natural history and prognosis remain unknown, as definitive data are scarce. Controversies persist regarding the use of medical management (antithrombotic therapy) or interventional/surgical procedures. Only some case reports or small case series are available about this condition. The Coronary Artery Aneurysm Registry (CAAR; http://www.ClinicalTrials.gov NCT02563626) is a multicenter international ambispective registry that aims to provide insights on anatomic, epidemiologic, and clinical aspects of this substantially unknown entity. In addition, the registry will assess management strategies (conservative, interventional, or surgical) and their short‐ and long‐term results in a large cohort of patients. Clinical Trial registration: ClinicalTrials.gov. Unique identifier: NCT02563626.

Resumen Introduccion y objetivos El sindrome de tako-tsubo induce un grado variable de disfuncion ventricular izquierda transitoria. Nuestro objetivo es determinar su pronostico a corto y largo plazo y valorar la incidencia de insuficiencia cardiaca en este ambito, los factores de riesgo relacionados con su desarrollo y su influencia en la evolucion posterior en nuestro medio. Metodos Se recogieron prospectivamente las caracteristicas clinicas y los eventos durante el ingreso hospitalario y durante el seguimiento de 100 pacientes con sindrome de tako-tsubo. Se llevo a cabo un analisis estratificado en relacion con el desarrollo de insuficiencia cardiaca (Killip ≥ II) durante el ingreso indice. Resultados El 89% eran mujeres (media de edad, 68 anos); 70 pacientes cursaban sin insuficiencia cardiaca; 15 estaban en Killip II; 5; en Killip III, y 10, en Killip IV. Los factores de riesgo cardiovascular —diabetes incluida— eran frecuentes, pero mas en el grupo con insuficiencia cardiaca. La fraccion de eyeccion del ventriculo izquierdo era inferior en aquellos con insuficiencia cardiaca al ingreso (el 51 frente al 42%; p Conclusiones En el sindrome de tako-tsubo, la insuficiencia cardiaca es frecuente; se observa sobre todo en pacientes con mas comorbilidades y peores clases funcionales previas y se asocia a mas eventos adversos, tanto durante el ingreso como en el seguimiento a largo plazo. El pronostico a largo plazo es generalmente bueno.

Introduccion y objetivos La relacion entre los puentes miocardicos y el dolor toracico todavia no esta bien definida. El objetivo de nuestro estudio es evaluar la relacion entre los puentes miocardicos detectados mediante tomografia computarizada multidetectores y los sintomas de una poblacion de pacientes evaluados por dolor toracico. Metodos Se incluyo a 393 pacientes consecutivos sin enfermedad coronaria previa, estudiados por dolor toracico y remitidos para tomografia computarizada multidetectores entre enero de 2007 y diciembre de 2010. Se les realizo una coronariografia no invasiva mediante tomografia computarizada multidetectores. Se definio puente miocardico como una parte de una arteria coronaria completamente rodeada por el miocardio en las imagenes axiales y las reconstrucciones multiplanares. Resultados La media de edad fue 64,6±12,4 anos; el 44,8% de los pacientes eran varones. La tomografia computarizada multidetectores mostro 86 puentes miocardicos en 82 de los 393 pacientes (20,9%). La descendente anterior izquierda fue la arteria coronaria afectada con mayor frecuencia (87,2%). La prevalencia de puente miocardico fue significativamente superior entre los pacientes sin estenosis coronaria aterosclerotica significativa segun la tomografia computarizada multidetectores (el 24,9 frente al 15,0%; p=0,02). Los pacientes con puente miocardico eran mas jovenes (60,3±13,8 frente a 65,8±11,9 anos; p < 0,001), tenian menor prevalencia de hiperlipemia (el 29,3 frente al 41,8%; p=0,03) y mayor prevalencia de miocardiopatia (el 6,1 frente al 1,6%; p=0,02) que los pacientes sin puente miocardico observado en la tomografia computarizada multidetectores. Conclusiones La tomografia computarizada multidetectores es una herramienta facil y fiable para diagnosticar los puentes miocardicos in vivo. Los resultados del presente estudio indican que los puentes miocardicos son la causa del dolor toracico en un subgrupo de pacientes mas jovenes, con menor prevalencia de hiperlipemia y mayor prevalencia de miocardiopatia que los pacientes en que se observa ateroesclerosis coronaria significativa en la tomografia computarizada multidetectores

Aims Data regarding the effects of TAVI on LV after are scarce and conflicting results have been reported immediately after aortic valvuloplasty. This study aimed to determine the acute haemodynamic effects of transcatheter aortic valve implantation (TAVI) in left ventricle (LV) diastolic performance, immediately after aortic valvuloplasty and prosthesis deployment. Methods and results Sixty-one patients with severe aortic valve stenosis, and preserved LV systolic function submitted to successful TAVI, were included. All procedures were guided through transoesophageal echocardiography, and parameters of diastolic function were evaluated before and minutes after TAVI. The mean age was 83.5 ± 6 years and mean log EuroSCORE was 18.2 ± 9.4. Before the procedure, all patients presented LV diastolic dysfunction. Immediately after TAVI, fewer patients presented a restrictive pattern [27 (44.3%), before the procedure, vs. 20 (34.4%), after TAVI ( P = 0.047)], and an increase in E wave deceleration time (211.2 ± 75.5 vs. 252.7 ± 102.3 cm/s, P = 0.001), in E wave velocity (109.5 ± 41.2 vs. 120.3 ± 43.6 cm/s, P = 0.025), and in isovolumetric relaxation time (83 ± 36.5 vs. 97.1 ± 36.0 ms, P = 0.013) was observed. On multivariate analysis of covariance (ANCOVA), adjusting to LV systolic function, heart rate, blood pressure, and haematocrit values, the results remained significant. Patients referred to percutaneous approach had invasive haemodynamic data collected, showing a decrease in LV end-diastolic pressure after valve implantation [18.8 ± 5.7 vs. 14.7 ± 4.7, mean difference −4.1 (95% CI: −5.9; −2.9)]. Patients with a restrictive pattern immediately after TAVI presented a smaller decrease in LV end diastolic pressure (−3.3 ± 4.7) than those with diastolic dysfunction grade I or II (−9.5 ± 4.7; P = 0.017). Conclusion This is the first study describing LV diastolic performance during TAVI. Our results show improvement in diastolic function parameters in patients with preserved LV systolic function, immediately after successful TAVI.

Aims Cardiac involvement, including progressive cardiomyopathy, is common in Fabry disease and is a leading cause of premature mortality. We sought to determine if tissue Doppler imaging (TDI) could identify Fabry disease patients at risk for the development of cardiomyopathy and if enzyme replacement therapy (ERT) with agalsidase alfa might slow or prevent the progression of cardiac involvement. Methods and results Fabry disease patients were enrolled in this prospective, observational study. Echocardiography was performed at baseline and periodically throughout the study. A single investigator, blinded to both the type of assessment (baseline or follow-up) and enzyme replacement status of the patient, evaluated all echocardiograms. Seventy-six patients (26 male, 50 females) were enrolled in the study. Twenty men and 13 women were treated with agalsidase alfa during the study. At baseline, increasing interventricular septum thickness was significantly associated with decreasing TDI velocities. Twenty-nine patients >18 years old (23 females) had no evidence of cardiac involvement at baseline (normal LVM and normal TDI velocities). In this cohort, 80% (16 of 20) of patients not on ERT progressed to demonstrating an abnormal TDI velocity during follow-up, whereas only 33% (3 of 9) of patients on ERT progressed to TDI abnormalities ( P = 0.031). Conclusion In Fabry disease, reduced TDI velocity seems to be the initial sign of cardiac involvement that occurs before the development of cardiac hypertrophy. ERT with agalsidase alfa delays the onset of cardiac involvement and should be considered at an earlier stage of the disease, even in the absence of left ventricular hypertrophy.

Resumen Fundamento y objetivo La enfermedad de Fabry (EF) es una enfermedad hereditaria con manifestaciones clinicas multisistemicas. El diagnostico suele ser tardio, por lo que la afectacion organica puede ser irreversible. La deteccion precoz de la enfermedad, en especial la afectacion cardiaca, es crucial para que los pacientes puedan beneficiarse del tratamiento de reemplazo enzimatico. El objetivo de este estudio fue valorar si la resonancia magnetica con secuencia de realce tardio con gadolinio puede ser util para la deteccion precoz de la afectacion cardiaca. Pacientes y metodos Se estudio a 20 pacientes (9 varones) con diagnostico de EF a quienes se les realizo ecografia, Doppler tisular (DTI) y resonancia magnetica. Se considero hipertrofia un grosor del septo y la pared posterior mayor o igual a 12 mm. El DTI fue alterado con una velocidad de las ondas sistolicas, las ondas diastolicas tempranas o las ondas diastolicas tardias del anillo septal y lateral menor de 8 cm/s. Se realizo la resonancia magnetica con secuencias de realce tardio con gadolinio. Resultados Los pacientes incluidos se dividieron en 3 grupos segun los resultados obtenidos: 1) DTI normal, sin hipertrofia del ventriculo izquierdo (HVI) 2) DTI alterado, sin HVI 3) DTI alterado e HVI La resonancia detecto realce tardio en un paciente (DTI alterado e HVI). Conclusiones El DTI es la unica herramienta de diagnostico precoz de afectacion cardiaca en la EF. La resonancia magnetica podria ser de gran valor para la estratificacion diagnostica.

We read with interest the article by Abu-Assi et al. on the impact of left coronary dominance on prognosis in the context of ST-segment elevation myocardial infarction and, in addition to wishing to congratulate the authors for the contribution it represents, as well as on their elegant statistical analysis, we consider it appropriate to put forward certain considerations. Although the available data are limited, it is reasonable to think that the occlusion of a coronary artery could have a stronger impact in a patient with 2 major vessels (left dominance) than in a patient with 3. This is the point that the above-mentioned article makes in the conclusions, which can undoubtedly have a simple practical application. Nevertheless, it might be interesting to know whether the prognostic influence of the dominance pattern is maintained specifically in the group of patients with involvement of the anterior descending artery (anterior myocardial infarctions) and, if so, to examine whether its importance is greater or lesser than when the myocardial infarction affects the territory of the circumflex artery (the segments in question when

Background— Aortic dissection type A is a disease with high mortality. Iatrogenic aortic dissection after interventional procedures is infrequent, and prognostic data are scarce. Our objective was to analyze its incidence, patient profile, and long-term prognosis. Methods and Results— Between 2000 and 2014, we retrospectively analyzed 74 patients with dissection of the ascending aorta. Clinical and procedural data were reviewed, and later, we performed a prospective clinical follow-up by telephone or in the office. The incidence of aortic dissection was 0.06%. Our patients, predominantly male (67.6%), had a mean age of 66.9±10.8 years. With multiple cardiovascular risk factors, the main reason for cardiac catheterization was an acute coronary syndrome (n=54). The complication was detected acutely in all, trying to engage the right coronary artery in 47 and the left main artery in 30 and after other maneuvers in 2, mostly complex therapeutic procedures (78.4%). A coronary artery was involved in 45 patients (60.8%). Thirty-five patients underwent an angioplasty and stent implantation; 3 had cardiac surgery; and 36 were managed conservatively. Two patients died of cardiogenic shock after the dissection. After a median follow-up of 51.2 months (range, 16.4–104.8 months), none of the remaining patients developed complications as a result of the dissection, progression, ischemia, pain, or dissection recurrence. Conclusions— Iatrogenic catheter dissection of the aorta is a rare complication that carries an excellent short- and long-term prognosis with the adoption of a conservative approach. When a coronary artery is involved as an entry point, it usually can be safely sealed with a stent with good long-term outcomes.

A 58-year-old man presented to our hospital with effort angina. Ten months prior, he was treated with a Bioresorbable vascular scaffold (BVS). During the current admission, an image angiographically compatible with in-BVS restenosis at the circumflex ostium with a radiolucent image in the ostial left anterior descending artery was shown. BVS failure is very infrequent and this is one of the first cases of BVS restenosis described. Thus, data on the best management option are scarce. We treated it like a drug-eluting stent restenosis, performing first an intracoronary optical coherence tomography scan in order to identify the left descending radiolucent image and to prepare the best treatment strategy.

A novel variant-specific surface protein (VSP) from Giardia was identified using the monoclonal antibody 9B10, raised against purified cyst walls. VSP9B10B is preferentially induced during encystation and expressed simultaneously with other VSPs on the surface of encysting trophozoites. These results support the hypothesis that encystation and antigenic variation are processes that are mechanistically related.

A 62-year-old woman was admitted with chest pain of two hours’ duration, ECG changes in the precordial leads and left ventricular ejection fraction of 30% on the echocardiogram. Emergent catheterization demonstrated severe flow disturbance in the left coronary artery. An intra-aortic balloon pump and a drug-eluting stent were implanted. However, the flow disturbance persisted. Optical coherence tomography followed by intravascular ultrasound provided crucial data on the mechanism and helped to optimize treatment in this critical patient. Resumo: Uma mulher de 62 anos foi internada devido a dor torácica com duas horas de duração, associada a alterações eletrocardiográficas nas derivações precordiais e FEVE: 30% determinada por ecocardiografia. Um cateterismo emergente revelou alterações graves no fluxo da coronária esquerda. Foram implantados um balão intra-aórtico e um stent revestido. Contudo, o fluxo continuou com alterações. A tomografia de coerência ótica e a ultrassonografia intravascular proporcionaram os dados únicos acerca do mecanismo envolvido e contribuíram para otimizar o tratamento numa doente crítica. Keywords: Acute coronary syndrome, Coronary dissection, Optical coherence tomography, Three-dimensional optical coherence tomography, Intravascular ultrasound, Palavras-chave: Síndrome coronária aguda, Disseção coronária, Tomografia de coerência ótica, Tomografia de coerência ótica 3-D, Ultrassonografia intravascular

After very rapid advances in the development of the technique and devices, transcatheter aortic valve implantation (named TAVI or TAVR), is today a reality that is here to stay. It has become the minimally-invasive treatment option for high-risk and non-surgical patients with severe symptomatic aortic stenosis. Requiring the participation of a multidisciplinary team for its implementation, cardiac imaging plays an important role. From pre-assessment to determine the suitability of the patient, the access site, the type of device, to the guidance during the procedure, and ultimately the long term monitoring of the patient. Correct selection of the patient and device, correct placement of the stent-valve and early detection of complications are of paramount importance for procedural success and for patient outcome. Each technique has advantages and disadvantages, being the cardiologist who will determine the best approach according to the type of patient and the expertise of the center in each one of them. This article summarizes the last contributions of the most common used imaging techniques, in each step of the procedure.

Takotsubo cardiomyopathy (TK) includes a transient left ventricular dysfunction without obstructive coronary disease, sometimes after stressful situations with elevated cathecolamines. Since catecholamines activate platelets we aimed to study the platelet influence in a TK setting. We included 32 patients with a TK diagnosis, 13 with an acute coronary syndrome (ACS) and 18 healthy volunteers. Once consent informed was obtained, blood samples were extracted and processed (at admission and after 3 months follow-up). Clinical, ecg, echocardiographic and angiographic features were thoroughly recorded.Previous treatment before admission was similar between groups. No differences were observed in clinical features or any of the acute markers studied regarding platelet reactivity between TK compared to ACS. After follow-up, aggregation levels and platelet reactivity showed differences, mainly due to the antithrombotic therapy prescribed at discharge, but similar to volunteers. Circulating epinephrine during the acute phase was significantly higher in TK (p < 0.001). Patients with higher levels of epinephrine had elevated platelet activation and aggregation after 3 months. No differences were observed in Takotsubo acute platelet aggregation compared to patients with ACS, in spite of higher blood levels of adrenaline. Takotsubo patients had elevated platelet aggregation and activation compared with ACS patients at 3 months follow-up because they were less frequently on chronic clopidogrel and ASA. However, they had similar platelet aggregation and activation levels to healthy volunteers despite treatment with low-dose ASA. Takotsubo patients who had higher levels of adrenaline in the acute phase displayed increased platelet reactivity during follow-up.

Background Left atrium (LA) size assessment is clinically relevant, but the accuracy of two-dimensional echocardiographic (2D-echo) methods is limited. Three-dimensional (3D) echocardiography is an excellent alternative but is far from being used in daily clinical practice. Three-dimensional-wall motion tracking (3D-WMT) allows us to obtain volumes in a very simple and rapid manner. The aims of this study were to evaluate the accuracy of 3D-WMT technology to assess LA volume using cardiac magnetic resonance (CMR) as a reference method, to evaluate its reproducibility, and to determine its added clinical value to classify the LA enlargement severity. Methods and results Seventy consecutive patients referred for a CMR study were prospectively enrolled. They underwent LA volume assessment by means of 2D-echo, 3D-WMT, and CMR. Inter-methods agreement was assessed. The mean age was 56 ± 18 years and 42 patients (60%) were males. Average maximal LA volume obtained by 2D-echo, 3D-WMT, and CMR were 63.33 ± 26.82, 79.80 ± 29.0, and 79.80 ± 28.99 mL, respectively. Univariate linear regression analysis showed a good correlation between 3D-WMT and CMR ( r = 0.83; P < 0.001). The agreement analysis showed a similar result (ICC = 0.83; 95% CI = 0.74–0.89; P < 0.001). Furthermore, the LA enlargement degree was better evaluated with 3D-WMT than with 2D-echo. Conclusion This study validates LA volume measurements obtained using the new and fast 3D-WMT technology, compared with CMR. This method is fast, accurate, and reproducible, and it allows a better classification of left LA enlargement severity compared with 2D-echo.

Background The two-dimensional (2D) proximal isovelocity surface area (PISA) method has some technical limitations, mainly the geometric assumptions of PISA shape required to calculate effective regurgitant orifice area (EROA). Recently developed single-beat, real-time three-dimensional (3D) color Doppler imaging allows direct measurement of PISA without geometric assumptions. The aim of this study was to validate this novel method in patients with chronic mitral regurgitation (MR). Methods Thirty-three patients were included, 25 (75.7%) with degenerative MR and eight (24.2%) with functional MR. EROA and regurgitant volume were assessed using transthoracic 2D and 3D PISA methods. The quantitative Doppler method and 3D transesophageal echocardiographic planimetry of EROA were used as reference methods. Results Both EROA and regurgitant volume assessed using the 3D PISA method had better correlations with the reference methods than conventional 2D PISA. A consistent significant underestimation of EROA and regurgitant volume using 2D PISA was observed, particularly in the assessment of eccentric jets. On the basis of 3D transesophageal echocardiographic planimetry of EROA, 14 patients had severe MR (EROA ≥ 0.4 cm 2 ). Of these 14 patients, 42.8% (6 of 14) were underestimated as having nonsevere MR (EROA ≤ 0.4 cm 2 ) by the 2D PISA method. In contrast, the 3D PISA method had 92.9% (13 of 14) agreement with 3D transesophageal planimetry in classifying severe MR. Good intraobserver and interobserver agreement for 3D PISA measurements was observed, with intraclass correlation coefficients of 0.96 and 0.92, respectively. Conclusions Direct measurement of PISA without geometric assumptions using single-beat, real-time 3D color Doppler echocardiography is feasible in the clinical setting. MR quantification using this methodology is more accurate than the conventional 2D PISA method.

Tako-tsubo syndrome produces a variable degree of transient left ventricular dysfunction. Our objective was to determine the short- and long-term prognosis of this syndrome, the incidence of and risk factors for the development of heart failure, and the influence on heart failure on the long-term outcome in our patient population.We prospectively recorded the clinical features and events during the hospital stay and follow-up of 100 patients with tako-tsubo syndrome. The risk factors for heart failure during hospital stay, considered as Killip class≥II, were assessed.Most of the patients were women (89%), with a mean age of 68 years. The distribution according to Killip class was: Killip I, 70 patients; Killip II, 15; Killip III, 5; and Killip IV, 10. Cardiovascular risk factors, including diabetes, were common in the overall group, but were more so in the heart failure cohort. The left ventricular ejection fraction was lower in the heart failure group (51% vs 42%; P.01). There were no differences in preadmission medications or biomarkers of necrosis. Over a median follow-up of 1380 days, the incidence of events reported during the hospital stay and long-term follow-up, both for death and the combined endpoints, was higher in the heart failure cohort.Although the prognosis in tako-tsubo syndrome is usually good, heart failure occurs quite frequently, mainly in patients with a greater number of comorbidities and poorer previous functional class. Moreover, heart failure is associated with a higher number of early and late adverse events. The overall long-term prognosis is good. Full English text available from:www.revespcardiol.org.

A B S T R A C T Introduction and objectives: The relationship between myocardial bridging and symptoms is still unclear. The purpose of our study was to assess the relationship between myocardial bridging detected by multidetector computed tomography and symptoms in a patient population with chest pain syndrome. Methods: The study enrolled 393 consecutive patients without previous coronary artery disease studied for chest pain and referred to multidetector computed tomography between January 2007 and December 2010. Noninvasive coronary angiography was performed using multidetector computed tomography. Myocardial bridging was defined as part of a coronary artery completely surrounded by myocardium on axial and multiplanar reformatted images. Results: Mean age was 64.6 (12.4) years and 44.8% were male. Multidetector computed tomography detected 86 myocardial bridging images in 82 of the 393 patients (20.9%). Left anterior descending was the most frequent coronary artery involved (87.2%). The prevalence of myocardial bridging was significantly higher in patients without significant atherosclerotic coronary stenosis on multidetector computed tomography (24.9% vs 15.0%; P=.02). Patients with myocardial bridging were younger (60.3 (13.8) vs 65.8 (11.9); P

Paravalvular aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) is common, but the evaluation of its severity by two-dimensional (2D) transthoracic echocardiography (TTE) presents several constrains. The aim of this study was to assess the usefulness of a new methodology, using three-dimensional (3D) TTE, for better assessment of paravalvular AR after TAVI.Two-dimensional and 3D TTE was performed in 72 patients, 5 months after TAVI, using the X5-1 PureWave microbeamforming xMATRIX probe. The position and severity of the paravalvular AR jets were described using 2D and 3D TTE, and a model was designed for paravalvular AR systematic location description. Vena contracta width was measured using 2D transthoracic echocardiographic views, and the planimetry of the vena contracta was assessed after the perfect alignment plane was obtained using the multiplanar 3D transthoracic echocardiographic reconstruction tool. AR volume was calculated as the difference between 3D TTE-derived total left ventricular stroke volume and right ventricular stroke volume estimated using 2D TTE. Diagnostic efficiency for moderate AR was assessed using receiver operating characteristic curve analysis.Forty-three patients (57.4%) presented with AR; 10 (13.3%) had central AR, and 33 (44.0%) had paravalvular AR jets. Vena contracta widths were similar between patients with moderate and mild AR (2.1 ± 0.53 vs 1.9 ± 0.16 mm, P = .16), but vena contracta planimetry was larger in patients with moderate AR than in those with mild AR (0.30 ± 0.12 vs 0.09 ± 0.07 cm(2), P = .001). Vena contracta planimetry on 3D TTE was better correlated with AR volume than vena contracta width on 2D TTE (Kendall's τ = 0.82 [P.001] vs 0.66 [P.001]). The areas under the receiver operating characteristic curves were 0.96 for vena contracta planimetry and 0.35 for vena contracta width.This study proposes an alternative methodology for paravalvular AR assessment after TAVI. Using vena contracta planimetry on 3D TTE, an accurate methodology for paravalvular AR jet evaluation and moderate AR classification is described.

Fabry disease is a hereditary disorder. Clinical manifestations are multisystemic. The majority of the patients remain undiagnosed until late in life, when alterations could be irreversible. Early detection of cardiac symptoms is of major interest in Fabry's disease (FD) in order to gain access to enzyme replacement therapy. Echo-Doppler tissular imaging (TDI) has been used as a cardiologic early marker in FD.This study is intended to determine whether the cardiac magnetic resonance is as useful tool as TDI for the early detection of cardiac affectation in FD.Echocardiography, tissue Doppler and Cardio magnetic resonance was performed in 20 patients with confirmed Fabry Disease. Left ventricular hypertrophy was defined as septum and left ventricular posterior wall thickness ≥12 mm. An abnormal TDI velocity was defined as (Sa), (Ea) and/or (Aa) velocities8 cm/s at either the septal or lateral corner. Late phase gadolinium-enhanced images sequences were obtained using magnetic resonance.Twenty patients included in the study were divided into three groups: 1. Those without left ventricular hypertrophy nor tissue Doppler impairment 2. Those without left ventricular hypertrophy and tissue Doppler impairment 3. Those with left ventricular hypertrophy and Tissue Doppler impairment. Late gadolinium enhancement was found in only one patient, who has already altered DTI and LVH.Tissue Doppler imaging (TDI) is the only diagnostic tool able to provide early detection of cardiac affectation in patients with FD. Magnetic resonance provides information of the disease severity in patients with LVH, but can not be used as an early marker of cardiac disease in patients with FD. However MRI could be of great value for diagnostic stratification.

Transient apical dyskinesia syndromes present features similar to acute coronary syndromes, but with normal coronary arteries and rapid complete resolution of wall motion alterations. We report the case of a 73-year-old woman who was admitted to hospital because of typical chest pain at rest after her brother's death. She had had a pacemaker implanted in 2001. Troponin levels were elevated and apical hypokinesia was shown by ventriculography and echocardiography, with normal coronary arteries. Evolving ECG alterations were observed in spite of the continued pacing rhythm. All these alterations were fully resolved after discharge. This case shows that, even in the presence of a pacemaker, evolving ECG alterations can be observed in Takotsubo syndrome. Resumo: As síndromes de discinesia apicais transitórias apresentam características semelhantes às síndromes coronárias agudas, embora com artérias coronárias normais e resolução completa rápida das alterações da contractilidade segmentar. Apresentamos o caso de uma mulher de 73 anos que recorreu ao hospital em virtude de dor torácica na sequência da morte do irmão. Tinha pacemaker implantado desde 2001. Verificou-se elevação da troponina e foi detetada hipocinesia apical através de ecocardiograma, com coronárias normais. São reveladas alterações evolutivas no ECG, apesar do ritmo de pace continuado. Todas estas alterações foram totalmente resolvidas, após a alta hospitalar. Este caso mostra que, mesmo na presença de um pacemaker, as alterações evolutivas no ECG podem ser observadas na síndrome de Takosubo. Keywords: Apical ballooning syndrome, Takotsubo cardiomyopathy, Pacing, Electrocardiogram, Palavras chave: Síndrome de balonização apical com balão, Miocardiopatia Takotsubo, Pacing, Electrocardiograma