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International audience; BACKGROUND: Availability of normative reference values for cardiac chamber dimensions, volumes, mass, and function is a prerequisite for the accurate application of echocardiography for both clinical and research purposes. However, due to the lack of consistency in current echocardiographic 'reference values', their use for clinical decision-making remains questionable. AIMS: The aim of the 'Normal Reference Ranges for Echocardiography Study (NORRE Study)' is to obtain a set of 'normal values' for cardiac chamber geometry and function in a large cohort of healthy Caucasian individuals aged over a wide range of ages (25-75 years) using both conventional and advanced echocardiographic techniques. METHODS: The NORRE Study is a large prospective, observational multicentre study in which transthoracic echocardiographic studies will be acquired in 22 laboratories accredited by the European Association of Cardiovascular Imaging and in one laboratory in the USA accredited by ICAEL. The final sample size has been estimated in 1100 normal subjects in whom M-mode, 2D, and 3D imaging, colour Doppler, pulsed-wave Doppler, pulsed-wave tissue Doppler, and colour tissue Doppler imaging data will be obtained. All studies will be sent to a central echocardiographic core laboratory for quantitative analysis. Multiple studies will be performed for reproducibility analysis. CONCLUSION: After completion of the NORRE Study, uniform reference limits according to age, gender, and anthropometric parameters will be available to standardize the quantitative interpretation of echocardiography.

RESUMO: A presença de Hipertensão Pulmonar e de Cor Pulmonale é um factor de mau prognóstico no contexto da Doença Pulmonar Crónica Obstrutiva.A Ecocardiografia modo M. bidimensional e Doppler é um método não invasivo que permite avaliar as alterações morfológicas e funcionais do coração direito e estimar a Pressão Sistólica na Artéria Pulmonar.No entanto, condicionantes vários como a hiperinsuflação pulmonar, as alterações da parede torácica e a obesidade frequentemente presentes em doentes com patologia respiratória crónica, podem impedir a obtenção de exame com boa qualidade téscnica.O objectivo deste trabalbo é avaliar a exeqwoilidade deste método nos doentes com Doença Pulmonar Crónica Obstrutiva e correlacionar os dados obtidos por Ecocardiografia com os aspectos clinicos sugestivos de falência cardíaca direita.Foram estudados 35 doentes, 29 do sexo masculino e 6 do sexo feminino, com idade média de 66,2 anos, com Doença Pulmonar Crónica Obstrutiva seguidos na Consults de Oxigenioterapia de Longa Duração do Serviço de Pneumologia do Hospital de Santa Maria.Cada doente realizou um Ecocardiograma modo M, bidimensional e Doppler para determinação da espessura da parede livre do ventrículo direito (VD), do diâmetro da cavidade ventricular direita e da Pressão Sistólica na Artéria Pulmonar (PAPs) utilizando as vias paraesternal esquerda, apical e subcostal.Em 80% dos doentes estudados obtiveram-se registos satisfatórios que permitiram determinar a espessura da parede livre do VD, avaliar o diâmetro desta cavidade e estimar a PAPs.Foram registados critérios de Hipertrofia Ventricular Direita em 75% dos registos validados (espessura média da parede livre do VD - 7,1±1,3 mm) e critérios de dilatação ventricular direita em 25% dos casos.Em 60% destes doentes conseguiu-se estimar a PAPs a partir do fluxo de Insuficiência Tricúspide. O valor médio da PAPs foi de 60±21,6 mmHg, registando-se critérios de Hipertensão Pulmonar (HTP) em 77% dos casos estimados.Nos doentes em que não foi possível quantificar a PAPs procedeu-se à avaliação do fluxo da câmara de saida do VD. Destes, 66% apresentavam critérios sugestivos de HTP.Dos doentes com critérios ecocardiográficos sugestivos de Hipertrofia ventricular direita 50% apresentavam história clínica de um ou mais episódios prévios de falêncla cardíaca direita.Dos doentes com critérios ecocardiográficos de dilataçãio do VD 83% apresentavam história clínica de um ou mais episódios prévios de falência cardíaca direita.Os dados preliminares parecem assim sugerir que a Ecocardiografia é um método não invasivo útil na avaliaçãio dos doentes com Doença Pulmonar Crónica Obstrutiva permitindo o diagnóstico precoce de Cor Pulmonale e a quantificação da PAPs. ABSTRACT: NON INVASIVE DIAGNOSIS OF PULMONARY HYPERTENSION AND COR PULMONALE IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASEPulmonary hypertension and cor pulmonale are indicators of poor prognosis in patients with Chronic Obstructive Pulmonary Disease (COPD).M-mode, bidimensional and Doppler echocardiography is a non invasive technique usefull in the assessment of the morphological and functional characteristics of the right heart and usefull in the evaluation of the systolic pulmonary artery pressure (sPAP).Yet, some characteristics often present in these patients such as pulmonary emphysema, obesity and deformities of the thoracic wall make difficult the obtention of adequate recordings.The aim of this study was to analyse the feasibility of this method in patients with COPD and to compare its sensitivity to clinical methods in the assessment of Pulmonary Hipertension and Cor Pulmonale in these patients.Thirty-five patients with COPD under long therm Oxigeniotherapy were studied by M-mode, bidimensional and Doppler Echocardiography using left paraesternal, apical and subcostal views, in order to assess the thickness of the free right ventricula wall, the dimension of the right ventricle and the Pulmonary systolic pressure.Adequate recordings were obtained in 80% of the patients.75% of the patients bad echocardiographic: criteria of right ventricular hypertrophy (thickness of the right ventricular wall - 7,1±1,3 mm) and 25% bad echocardiograpbic criteria of right ventricular dilatation.In 60% of the patients it was possible to estimate the sPAP through the measurement of the peak velocity of the tricuspid regurgitant jet.The mean value of the sPAP was 60Ã21,6 mmHg. Ecbocardiographic criteria of pulmonary hypertension were recorded in 77% of the patients.When it was not possible to estimate de sPAP we recorded the pulmonic ejection flow. Using this approach 77% of the cases studied had echocardiographic criteria of Pulmonary Hypertension.50% of the patients with echocardiographic criteria of right ventricular hypertrophy had clinical evidence of right heart failure while 83% of the patients with echocardiograpbic criteria of right ventricular dilatation had clinical evidence of right heart failure.The preliminary data sugest that echocardiography is usefull as a non invasive method in the evaluation of patients with COPD allowing the early diagnosis of Cor Pulmonale and the quantification of the sPAP. Palavras-chave: Ecocardiografia, hipertensão pulmonar, cor pulmonale, doença pulmonar crónica obstrutiva, Key-words: Echocardiography, Pulmonary Hypertension, Cor Pulmonale, Chronic Obstructive Pulmonary Disease

Cardiac computed tomography (CT) documents the presence of coronary artery disease, regardless of the degree of stenosis. The prognostic value of non-obstructive coronary artery disease documented by cardiac CT has recently been validated. However, there are still no clear guidelines on the management of such patients, particularly concerning initiation of more aggressive pharmacological measures for primary prevention. The approach to these patients remains controversial, especially in cases in which there is a discrepancy between cardiovascular risk and the atherosclerotic burden as documented by cardiac CT.The authors describe the case of a patient with a discrepancy between the extent of documented coronary atherosclerosis and that estimated according to pretest probability and cardiovascular risk scores. As this individual had more severe coronary atherosclerosis than expected (calcium score above the 90th percentile and non-obstructive coronary artery disease on cardiac CT) but was a competitive athlete and otherwise asymptomatic and without risk factors or cardiovascular history, with a very low estimated cardiovascular risk, it was difficult to decide on the risks and benefits of pharmacological primary prevention. Resumo: A tomografia computorizada cardíaca (angioTC cardíaca) permite documentar a presença de doença coronária, independentemente do seu grau de estenose. Recentemente, foi validado o valor prognóstico da doença coronária não obstrutiva documentada por angioTC cardíaca. No entanto, não existem ainda recomendações claras acerca da abordagem destes doentes, nomeadamente sobre o início de medidas farmacológicas mais agressivas em prevenção primária. A abordagem destes doentes permanece controversa, sobretudo nos casos em que existe uma discrepância entre o risco cardiovascular e a carga aterosclerótica objetivada na angioTC.Os autores descrevem o caso de um doente com discrepância entre a extensão da aterosclerose coronária objetivada e a sua estimativa de acordo com os scores de probabilidade pré-teste e de eventos cardiovasculares. Tratando-se de um indivíduo com documentação de aterosclerose coronária acima do esperado - score de cálcio superior ao percentil 90 e doença coronária não obstrutiva na angioTC cardíaca, mas por outro lado, assintomático e sem fatores de risco nem antecedentes cardiovasculares, com uma estimativa de risco cardiovascular muito baixa e atleta de competição, torna-se difícil decidir acerca do risco/benefício de medidas farmacológicas de prevenção primária. Keywords: Cardiac computed tomography, Non-obstructive coronary artery disease, Physical exercise, Palavras-chave: Tomografia computorizada cardíaca, Doença coronária não obstrutiva, Exercício físico

Echocardiographic imaging is ideally suited for the evaluation of cardiac mechanics because of its intrinsically dynamic nature. Because for decades, echocardiography has been the only imaging modality that allows dynamic imaging of the heart, it is only natural that new, increasingly automated techniques for sophisticated analysis of cardiac mechanics have been driven by researchers and manufacturers of ultrasound imaging equipment. Several such techniques have emerged over the past decades to address the issue of reader's experience and intermeasurement variability in interpretation. Some were widely embraced by echocardiographers around the world and became part of the clinical routine, whereas others remained limited to research and exploration of new clinical applications. Two such techniques have dominated the research arena of echocardiography: (1) Dopplerbased tissue velocity measurements, frequently referred to as tissue Doppler or myocardial Doppler, and (2) speckle tracking on the basis of displacement measurements. Both types of measurements lend themselves to the derivation of multiple parameters of myocardial function. The goal of this document is to focus on the currently available techniques that allow quantitative assessment of myocardial function via image-based analysis of local myocardial dynamics, including Doppler tissue imaging and speckle-tracking echocardiography, as well as integrated backscatter analysis. This document describes the current and potential clinical applications of these techniques and their strengths and weaknesses, briefly surveys a selection of the relevant published literature while highlighting normal and abnormal findings in the context of different cardiovascular pathologies, and summarizes the unresolved issues, future research priorities, and recommended indications for clinical use. Copyright 2011 by the American Society of Echocardiography.

The application of a translational medicine approach to the study of diseases enables personalized clinical diagnosis and prognosis.

Thromboembolism is a major cause of death in cancer patients. The association between paraneoplastic hypercoagulability of oncological patients and long-term central venous catheters (CVC) may result in CVC associated thrombosis. Patent Foramen Ovale (PFO), especially when associated with atrial septal aneurysm (ASA) is a risk factor for paradoxical embolism. We report a case of paradoxical embolism with stroke in an oncological patient with a huge CVC thrombus playing "ping-pong" with an hypermobile ASA with a PFO. We review the management of hypercoagulability in oncologic patients and discuss the potential role of routine transthoracic echocardiography before the implantation of long term central venous catheters to identify predisposing conditions to paradoxical embolism and select patients for anticoagulant therapy.

An asymptomatic 40-year-old man with no conventional risk factors for coronary artery disease had a positive treadmill stress test based on ECG criteria. Coronary CT angiography showed a small plaque in the left anterior descending artery and dobutamine-atropine stress echocardiography was negative for myocardial ischemia but showed a significant outflow gradient (100 mmHg) during pharmacological stress.

Background- Left ventricular outflow tract obstruction is an independent predictor of adverse outcome in hypertrophic cardiomyopathy (HCM). The classical quantification of intraventricular obstruction is performed in resting conditions in supine position, but this assessment does not reflect what happens in HCM patients (pts) in their daily activities, neither during effort nor during orthostatic recovery. Aim- To assess intraventricular gradients with echocardiography during treadmill exercise and in the recovery period in upright position, in HCM pts. Methods- We studied 17 HCM pts (9 males, mean age 53 ± 16 years, 11 with obstructive HCM). Each pt had 2 echocardiographic evaluations at rest (left lateral decubitus (LLD) and orthostatic position). The pts then underwent a treadmill exercise test and intraventricular gradients were measured at peak exercise and during recovery in orthostatic position. Results- 3 pts with non-obstructive HCM at rest developed intraventricular gradients during exercise. 1 pt developed this gradient only during orthostatic recovery. The mean intraventricular gradient in LLD was 49 ± 24 mmHg; in orthostatic position was 62 ± 29 mmHg (p < 0.001 versus in LLD); at peak exercise was 83 ± 35 mmHg (p < 0.001 versus supine rest); during recovery it was 96 ± 35 mmHg (p < 0.001 versus peak exercise) Conclusion- In HCM pts the intraventricular gradient increases in orthostatic position, increases significantly during treadmill exercise and continues increasing in the recovery period in orthostatic position. This type of evaluation can help us to better understand the physiopathology, the symptoms and the efficacy of different therapeutic modalities in this disease and should be routinely used in the assessment of HCM pts.

Objective:Our groups has previously demonstrated that aortic arch mechanics with 2D-speckle tracking (2D-ST) echocardiography was a feasible methodology. We have proved that hypertensive patients had lower values of vascular mechanics when compared to an age-matched control group. We have also demon

Smoking is a major and reversible risk factor for coronary artery disease. The present work aims to define the risk factors, angiographic and clinical characteristics and evolution of acute coronary syndromes in smokers.We studied 521 consecutive patients with acute coronary syndrome admitted to the intensive care unit who underwent catheterization. We assessed the population in terms of risk factors, pathology (unstable angina or acute myocardial infarction), coronary morphology, left ventricular function, the need for intervention, evolution and complications over a one-year period. The characteristics of smokers were then compared with those of non-smokers.Of the 521 patients with acute coronary syndrome (391 men), 182 (35 %) were smokers. The smokers were younger than the non-smokers (56.3+/-9.5 versus 66.4 +/- 7.8; p0.001), were more frequently male (91 versus 66%; p0.001), and presented more risk factors (43% with 3 or more risk factors versus 17% in non-smokers; p0.001), more obesity (11 versus 5%; p0.01), and less diabetes (19 versus 37%; p0.001). Smokers presented greater prevalence of acute myocardial infarction (57 versus 40%; p0.001) and less unstable angina. Coronary morphology was not significantly different in smokers compared to non- smokers and left ventricular function after the aculte coronary syndrome was similar in both groups. Smokers less frequently underwent surgery during hospitalization (22% versus 35%; p0.01) but needed angioplasty as often as non-smokers (48% versus 16%; NS). Smokers presented more frequent complications (angina, heart failure, re-infarction or CABG) than non-smokers (26% versus 17%; p0.01), during the first year of follow-up. One-year mortality was similar in both groups. The results were not significantly different when adjusted for gender.On average, acute coronary syndrome occurred 10 years earlier in smokers than in non-smokers. The former generally presented more risk factors, lower prevalence of diabetes and higher of obesity, more myocardial infarctions and less unstable angina. After the acute coronary syndrome, at one year, smokers presented more complications than non-smokers but had similar mortality.

The conventional echocardiographic assessment of myocardial function in patients with obstructive hypertrophic cardiomyopathy (HOCM) is complex, because of the load dependency of this method. Tissue Doppler imaging (TDI) may improve this evaluation.To compare regional myocardial function with TDI, between patients with hypertrophic obstructive cardiomyopathy (HOCM) and with non-obstructive forms of the disease (NOHCM).26 patients with HOCM and 23 with NOHCM were studied with pulsed TDI. We studied longitudinal (8 left ventricular segments, apical views) and radial regional function (2 segments, short axis view), and analyzed velocities, time intervals, velocity-time integrals and heterogeneity and asynchrony indices and the meridional (basal-medial segments) velocity gradient in each wall. Data were compared within each group and between groups.Compared to NOHCM, HOCM patients showed: systolic functions: a) longitudinal: similar velocities, time intervals and integrals; b) radial: higher meridional gradient, lower velocity-time integrals. Diastolic function: a) longitudinal: lower a, higher e and e/a tendency; lower e meridional gradient, higher percentage of septal and anterior wall segments with e/aor = 1; b) radial: lower a velocities and integrals, shorter diagnostic time.This study shows that in HOCM patients, the presence of obstruction and its associated load conditions have a different impact on systolic and diastolic regional myocardial function, in long and short axis, assessed with TDI. So, in HOCM patients: 1-Long axis regional systolic function is similar to the non-obstructive forms, suggesting relative load independence. 2-Long and short axis regional diastolic function is, in specific segments and parameters, different from the non-obstructive forms. These data should be taken into account in the assessment of regional myocardial function with TDI in HOCM.

The distinction between hypertrophic cardiomyopathy (HCM) and the athlete's (AT) heart is an important clinical problem, and the analysis of regional myocardial function with Doppler tissue imaging may be useful in the differential diagnosis.Our aim was to compare regional function assessed by Doppler tissue imaging in rowers and in a group of patients with HCM.In 24 patients with nonobstructive HCM and in 20 competitive rowers with similar age, blood pressure, and heart rate, we analyzed with pulsed Doppler tissue imaging left ventricular (LV) regional function (velocities, time intervals, heterogeneity and asynchrony indices, and meridional gradient) in the longitudinal (8 segments, apical views) and in the radial (2 segments, short-axis view) axis.Compared with AT, patients with HCM showed: (1). systolic function; (a). longitudinal: lower velocities and meridional gradient; longer precontraction period (PCP); and higher PCP/LV contraction time; (b). radial: lower velocities and gradient; longer PCP; and higher PCP/LV contraction time; (2.diastolic function; (a). logitudinal: lower e (early diastolic), a (late diastolic), and e/a velocities; and longer prerelaxation time and time to peak e. The percentage of segments with e/a1 was 25% in the HCM group and 0% in the AT heart group; (b). radial: lower e velocity and gradient; lower e/a gradient; and longer medial prerelaxation and basal time to peak e. Most of these differences also occurred in the nonhypertrophied inferior wall of patients with HCM.There are significant differences between regional LV function of competitive rowers and patients with HCM. These differences (1). occur in systole and diastole; (2). affect velocities and time intervals; (3). are more striking in the long axis, but are also seen in the short axis, and (4). also occur in nonhypertrophied segments, suggesting the usefulness of the technique in the differential diagnosis between the 2 situations, namely in individuals that fall in Maron's "grey zone."

Myocardial infarction has a higher incidence in men. However, in women, although less frequent, it has a worse prognosis.With the present work we aim to define the clinical and angiographical characteristics and evolution of myocardial infarction in women compared with men.We studied 235 sequential inpatients with acute myocardial infarction in the Intensive Care Unit who underwent post-infarction catheterization. We then compared female with male patients in terms of risk factors, location and type of infarction, coronary morphology and post-infarction complications.About 22% of the patients hospitalized following myocardial infarction were female. The women were older than the men (65.9 +/- 11.2 vs. 60.3 +/- 11.9; p0.01), and had a higher prevalence of high blood pressure (71% vs. 54%, p0.05) and a lower prevalence of smoking (19% vs. 50%, p0.001). Post-infarction angina was more frequent in women (50% vs. 23%, p0.001). Neither Q-wave versus non-Q wave myocardial infarction nor its location were significantly different between the sexes. In terms of coronary morphology, myocardial infarction without significant lesions was more frequent in women (10% vs. 3%, p0.05) and there were no significant.

Hypertrophic cardiomyopathy is classically defined as a diastolic disease with normal systolic function. Long axis left ventricular function is an important and sensitive determinant of global ventricular function but its assessment is often difficult and complex. Tissue Doppler imaging of the mitral annulus allows the study of long axis left ventricular function.47 patients with non-obstructive hypertrophic cardiomyopathy and 45 healthy volunteers, matched by age and sex, were studied with pulsed tissue Doppler imaging of the 4 sides of the mitral annulus (septal, lateral, inferior, anterior) in 4 and 2 chamber views. In each wave (systolic-s, rapid filling-e, atrial contraction-a) we analyzed velocities, time intervals and velocity-time integrals, as well as heterogeneity and asynchrony. Data were compared among the different sides in each group, between groups and with conventional Doppler data.In contrast to normal subjects, hypertrophic cardiomyopathy patients showed: 1--Systolic function: lower velocities, longer systolic time intervals (isovolumic relaxation time, time to peak s, ejection time), higher systolic asynchrony (time to peak s, ejection time, systolic time) and lower s/shortening fraction ratio. These changes occurred despite normal indices of global systolic function. 2--Diastolic function: lower velocities (much lower rapid filling velocity, lower atrial contraction velocity, lower septal e/a), higher e/a heterogeneity index, longer protodiastolic times (isovolumic relaxation time and time to peak e), higher diastolic asynchrony (time to peak e) and lower e wave integral. Hypertrophic cardiomyopathy patients also showed higher average number of annular sides with e/a1 per patient and higher percentage of e/a1, mainly on the septal side.This study shows that: 1--Tissue Doppler imaging allows the detailed analysis of long axis left ventricular function in hypertrophic cardiomyopathy patients. 2--Long axis systolic function is abnormal in this disease, even in the presence of normal indices of global systolic function. 3--Long axis diastolic function is deeply disturbed in hypertrophic cardiomyopathy, at ventricular and atrial levels. 4--Long axis dysfunction occurs in annular sides contiguous to hypertrophied and non-hypertrophied walls, highlighting the role of other factors in its pathophysiology.

The different diagnosis between hypertrophic cardiomyopathy and athlete's heart has important clinical implications. The assessment of long axis left ventricular function with tissue Doppler imaging in hypertrophic cardiomyopathy (showing systolic and diastolic dysfunction with heterogeneity and asynchrony), may be useful in the differentiation of these situations.To study, with tissue Doppler imaging, long axis left ventricular function in a population of athletes (rowers) and to compare it with a population of non-obstructive hypertrophic cardiomyopathy patients.In 24 patients with non-obstructive hypertrophic cardiomyopathy and in 20 competitive rowers with similar age, blood pressure and heart rate, we analyzed mitral annulus motion with pulsed tissue Doppler imaging in the 4 sides of the annulus (septal, lateral, inferior, anterior), in apical views. In each wave (systolic, rapid filling and atrial contraction) we measured velocities, time intervals and velocity-time integrals, and calculated heterogeneity and asynchrony indices. Data were compared between the groups, between the different sides in each group ("parallel analysis") and with conventional indices of global function.Hypertrophic cardiomyopathy patients showed: systolic function: lower velocities and integrals, shorter ejection time and shorter systolic time. These abnormalities occurred even in annular sites contiguous to walls without hypertrophy. DIASTOLIC FUNCTION: Much lower rapid filling velocities and integrals, lower atrial contraction velocities and integrals, lower e/a, longer isovolumic relaxation time and time to peak rapid filling wave. These abnormalities occurred even in annular sites adjacent to walls without hypertrophy. In the athletes group, the e/a ratio was never1, in any annular site. In hypertrophic cardiomyopathy patients this ratio was1 in 27% of the sites.1--Systolic and diastolic long axis left ventricular function is different in hypertrophic cardiomyopathy and in athletes, in all mitral annulus sides. 2--The presence of these abnormalities in annular sites contiguous to walls without hypertrophy suggests that this technique may be useful in the differential diagnosis between these groups, particularly in the "gray zone" of Maron.

The differential diagnosis between hypertrophic cardiomyopathy and hypertensive heart disease has clinical, therapeutic and prognostic implications, but is not always easy with conventional echocardiography. Tissue Doppler imaging of the mitral annulus allows the detailed study of long axis left ventricular function in hypertrophic cardiomyopathy and may be useful in the differential diagnosis.23 patients with non-obstructive hypertrophic cardiomyopathy and 25 hypertensive patients with concentric left ventricular hypertrophy with similar age, body surface and heart rate were studied with pulsed tissue Doppler imaging of the 4 sides of the mitral annulus (septal, lateral, inferior, anterior) in 4 and 2 chamber views. In each wave (systolic-s, rapid filling-e, atrial contraction-a) we analyzed velocities, time intervals and velocity-time integrals, as well as heterogeneity and asynchrony. Data were compared among the different sides in each group, between groups and with conventional Doppler data.In contrast to hypertensive patients, hypertrophic cardiomyopathy patients showed: 1--Systolic function: lower "s" wave velocities and integrals, higher systolic heterogeneity, longer isovolumic relaxation time and higher PEP/LVET (pre ejection period/left ventricular ejection time). 2--Diastolic function: lower "e" and "a" wave, higher "a" and "e/a" heterogeneity index, higher percentage of annular sides with e/aor = l, longer isovolumic relaxation time and time to peak e, and higher diastolic asynchrony. Some of these abnormalities occurred in annular sides adjacent to non-hypertrophied walls.This study shows that: 1--Long axis systolic and diastolic left ventricular function are significantly different between hypertrophic cardiomyopathy patients and hypertensive patients with concentric left ventricular hypertrophy. 2--These functional differences occur in the velocity domain (with heterogeneity), in the time domain (with asynchrony) and also in velocity time integrals. 3--Long axis systolic and diastolic dysfunction occur in annular sides contiguous to hypertrophied and non-hypertrophied walls, enhancing the role of tissue Doppler imaging in the differential diagnosis between these diseases.

Several case-control studies agree that elevated homocysteinemia (HC) is a risk factor for cardiovascular disease, particularly for acute myocardial infarction (AMI). However, this agreement does not extend to prospective studies--some of which confirm and others (MRFIT and Karelia) reject this relation. After an AMI there are significant changes in biochemical and laboratory parameters, including a decrease in cholesterolemia, which takes several months to return to baseline levels. The evolution of HC after AMI is still unknown. In this work we set out to evaluate the evolution of homocysteinemia values after acute myocardial infarction. We evaluated fasting homocysteinemia in 34 sequential patients after admission to the Intensive Care Unit and after confirmation of acute myocardial infarction (26 male; mean age 63.8 +/- 13.9 years) in the first 36 hours, between the 3rd and 6th day, and one month after AMI. Simultaneously, we studied traditional risk factors and performed routine laboratory tests. The mean values found for HC were 13.85 +/- 5.46 mol/l in the first 36 hours after AMI, 16.16 +/- 6.63 mol/l between the 3rd and the 6th day, and 16.27 +/- 7.27 mol/l one month after myocardial infarction. The difference between the first and the second, and between the first and the third measurements, was significant (p0.05). The HC values found 3-6 days and one month after myocardial infarction were similar (p = 0.88). A highly significant correlation was found between HC values assessed in the first and second (correlation coefficient [CC] = 0.62) and in the second and third measurements (CC = 0.57), both with p = 0.001. We can conclude that HC levels increase significantly 36 hours after an acute myocardial infarction, an increase of around 20%, which is maintained until at least one month after the infarction. In these circumstances the difference in the vascular risk of HC found between case-control and prospective studies may be explained, at least partially, by the HC increase after AMI.

In non-obstructive hypertrophic cardiomyopathy, tissue Doppler imaging of the mitral annulus shows severe systolic and diastolic dysfunction, with marked heterogeneity and asynchrony. In obstructive forms, the complexity of pathophysiological interactions makes conventional echocardiographic functional assessment extremely difficult and complex.To study longitudinal left ventricular function with tissue Doppler imaging in the obstructive forms of hypertrophic cardiomyopathy.Twenty-six patients with hypertrophic obstructive cardiomyopathy and 23 patients with the non-obstructive form of the disease, matched by age, were studied with pulsed tissue Doppler imaging of the 4 sides of the mitral annulus (septal, lateral, inferior, anterior) in 4 and 2 chamber views. In each wave (systolic-s, rapid filling-e, atrial contraction-a) we analyzed velocities, time intervals and velocity-time integrals, as well as heterogeneity and asynchrony indexes. Data were compared between the different sides in each group, between groups and with conventional Doppler data.In contrast to the non-obstructive forms, patients with intraventricular obstruction showed: Systolic function: similar velocities and integrals, the relations between the different sides of the annulus usually being preserved; longer isovolumic contraction time, time to peak s and PEP/LVET. Diastolic function: similar rapid filling and e/a velocities and integrals, lower atrial contraction velocity and integral, similar number of sides with e/a higher than or equal to 1 on the lateral and inferior side of the annulus; similar diastolic time intervals, except diastolic time.This study shows that the presence of dynamic intraventricular obstruction and the loading conditions of obstructive forms of hypertrophic cardiomyopathy do not significantly influence most annular tissue Doppler imaging parameters, showing the relative load independence of the technique. So, in obstructive hypertrophic cardiomyopathy patients: 1--Longitudinal systolic function (velocities) is similar to the non-obstructive forms--longitudinal systolic dysfunction. 2--Longitudinal diastolic function (velocities and time intervals) is similar to the non-obstructive forms--longitudinal diastolic dysfunction. 3--Left atrial dysfunction is more severe than in non-obstructive forms. 4--The inferior and lateral sides of the annulus should be those selected in order to identify pseudonormalization of the transmitral flow.

Use of both magnetic resonance imaging (MRI) and pacing devices has undergone remarkable growth in recent years, and it is estimated that the majority of patients with pacemakers will need an MRI during their lifetime. These investigations will generally be denied due to the potentially dangerous interactions between cardiac devices and the magnetic fields and radio frequency energy used in MRI. Despite the increasing reports of uneventful scanning in selected patients with conventional pacemakers under close surveillance, MRI is still contraindicated in those circumstances and cannot be considered a routine procedure. These limitations prompted a series of modifications in generator and lead engineering, designed to minimize interactions that could compromise device function and patient safety. The resulting MRI-conditional pacemakers were first introduced in 2008 and the clinical experience gathered so far supports their safety in the MRI environment if certain conditions are fulfilled. With this technology, new questions and controversies arise regarding patient selection, clinical impact, and cost-effectiveness. In this review, we discuss the potential risks of MRI in patients with electronic cardiac devices and present updated information regarding the features of MRI-conditional pacemakers and the clinical experience with currently available models. Finally, we provide some guidance on how to scan patients who have these devices and discuss future directions in the field.