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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.

Introduction. 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. Patients and method. 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. Results. 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, P

Full English text available at: www.revespcardiol.org A 40-year-old woman without heart disease suffered two embolic episodes in both legs due to a thrombus of the aortic valve. Transesophageal echocardiography performed after the first episode was considered normal, but a second study performed after the second embolism demonstrated a thrombus in the non-coronary leaflet that failed to resolve with the intravenous administration of heparin for two weeks. Surgical excision of the mass revealed a thrombus on an otherwise healthy aortic valve. The case is interesting because it is an exceptional cause of systemic embolism and the patient did not present a prothrombotic status in coagulation studies. The 3 years of follow-up was uneventful.

Introduccion y objetivos El objetivo del presente estudiofue analizar el valor pronostico y la evolucion delecocardiograma-Doppler en una poblacion hospitalariaadulta con miocardiopatia hipertrofica (MH). Metodos Se estudiaron 119 pacientes consecutivosdiagnosticados de MH (52 ± 12 anos, 60 mujeres) duranteun seguimiento medio de 9,7 ± 6,7 anos. La evolucionecocardiografica se analizo en los 104 pacientes (67 conobstruccion dinamica) en quienes se disponia al menosde 2 ecocardiogramas con un intervalo de 3,7 ± 3 anos(uno a 7 anos) entre ambas exploraciones. Resultados Durante el seguimiento 7 pacientes fallecierony 31 presentaron complicaciones severas (siete fallecimientos,15, sincope, cuatro, angina grado IV, tres,disnea grado IV y dos, infarto). La presencia de insuficienciamitral (p = 0,001) y un gradiente dinamico superior a50 mmHg (p = 0,02) fueron predictores de mortalidad, yun indice de auricula izquierda superior a 25 mm/m2 (p =0,028), de complicaciones severas. En un 15% de los pacientescon MH no obstructiva en el primer registro estapaso a ser obstructiva en el ultimo registro. Tambien seobservo un incremento del numero de pacientes con insuficienciamitral (el 80 frente al 66%; p = 0,01) y en su severidad(p = 0,038) durante el seguimiento. Conclusiones La presencia de insuficiencia mitral, degradiente dinamico superior a 50 mmHg, y un indice deauricula izquierda superior a 25 mm/m2 son variablesde mal pronostico en los pacientes adultos con MH. Duranteel seguimiento se observa la evolucion a formasobstructivas en un 15% de las MH no obstructivas y unatendencia a la progresion de la insuficiencia mitral.

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.

Introduccion y objetivos El proposito de este estudio ha sido comparar los diferentes tipos morfologicos de miocardiopatia hipertrofica observados mediante tomogammagrafia miocardica de perfusion con los del ecocardiograma. Material y metodos En 76 de 119 pacientes (64%) con miocardiopatia hipertrofica, el ecocardiograma permitio una aceptable visualizacion de todos los segmentos del ventriculo izquierdo en la proyeccion paraesternal transversal y la asignacion de los pacientes a alguno de los 6 tipos morfologicos clasicos: tipo I (hipertrofia septal anterior), tipo II (hipertrofia septal anterior y septal posterior), tipo III (hipertrofia septal y anterolateral), tipo IV (hipertrofia septal posterior y/o anterolateral), tipo V (hipertrofia concentrica) y tipo VI (hipertrofia apical). Sin conocimiento de los datos ecocardiograficos, dos observadores experimentados intentaron asignar con las imagenes del eje corto de la tomogammagrafia miocardica de perfusion en reposo con 9 9 mTc-tetrofosmina a alguno de estos tipos. Resultados La concordancia global entre las dos tecnicas fue del 75%. El tipo III fue el mas frecuente, tanto en el ecocardiograma (76%) como en la tomografia miocardica de perfusion (74%), aunque tambien fue el que origino la mayoria de discrepancias. Con la tomogammagrafia miocardica de perfusion se observo en 4 pacientes una hipertrofia localizada en la region septal e inferior que no correspondia a ninguno de los 6 tipos de la clasificacion ecocardiografica clasica y que por ecocardiograma habia sido clasificada como tipo III en 3 casos y en 1 como tipo V. Conclusiones Se observo concordancia entre el ecocardiograma y la tomogammagrafia miocardica de perfusion en la clasificacion morfologica de la mayoria (75%) de los pacientes con miocardiopatia hipertrofica, aunque se hallaron discrepancias con respecto al ecocardiograma, sobre todo en el tipo III.

Objetivo El proposito del presente estudio fuedeterminar la utilidad pronostica en la deteccion deenfermedad multivaso de la ecocardiografia de esfuerzopracticada antes del alta hospitalaria de uninfarto agudo de miocardio no complicado. Pacientes y metodos Se han estudiado 65 pacientesconsecutivos afectados de un primer episodiode infarto agudo de miocardio no complicado, confuncion ventricular normal o ligeramente deprimida(FE > 40%). Se practico una prueba de esfuerzosubmaxima (60% VO2max) a los 7-10 dias del infartorealizando un ecocardiograma antes e inmediatamentepostesfuerzo. El seguimiento fue de 15 ± 8meses presentando 15 pacientes angina y 9 revascularizacion.Un paciente fallecio. Resultados La aparicion de isquemia en el electrocardiogramatuvo una baja sensibilidad y valorpredictivo negativo respecto a la presencia decomplicaciones durante la evolucion (44 y 73%, respectivamente),pero su especificidad y su valor predictivopositivo fueron altos (97 y 92%, respectivamente).Por el contrario, la deteccion de isquemiaen el ecocardiograma presento mucha mejor sensibilidady valor predictivo negativo (72 y 83%, respectivamente),con una ligera disminucion de la especificidady del valor predictivo positivo (87 y78%, respectivamente). Tanto la evidencia de isquemiaa distancia como el incremento del indicede contractilidad segmentaria global superior a0,25 durante el esfuerzo tuvieron una alta significacionpronostica (p Conclusiones La ecocardiografia de esfuerzo esde gran utilidad en la estratificacion pronostica delos pacientes antes del alta hospitalaria despuesde un infarto de miocardio no complicado. La respuestaisquemica, a nivel submaximo de esfuerzo,valorada por ecocardiografia, fue mucho mas sensibleque la electrocardiografica en la prediccionde nuevos episodios coronarios y enfermedad multivaso.

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.

The authors report the cases of two patients, with no risk factors for thromboembolism, in whom a mobile thrombus of the thoracic aorta was diagnosed by transesophageal echocardiography, after an episode of systemic embolism. The outcomes of the two cases were very different. In one patient the thrombus was no longer present after anticoagulant treatment with no recurrent embolic event. The other patient had a new embolic event and the thrombus persisted while having anticoagulant therapy. This patient underwent surgery, and the thrombus was removed. These cases illustrate the value of transesophageal echocardiography in the detection of embolic source.

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.

A 40-year-old woman without heart disease suffered two embolic episodes in both legs due to a thrombus of the aortic valve. Transesophageal echocardiography performed after the first episode was considered normal, but a second study performed after the second embolism demonstrated a thrombus in the non-coronary leaflet that failed to resolve with the intravenous administration of heparin for two weeks. Surgical excision of the mass revealed a thrombus on an otherwise healthy aortic valve. The case is interesting because it is an exceptional cause of systemic embolism and the patient did not present a prothrombotic status in coagulation studies. The 3 years of follow-up was uneventful.

In recent years, technological advances in echocardiography have led to improvements in the diagnosis of acute aortic disease. With transesophageal echocardiography (TEE) and, particularly, bi- and multiplane probes, the physiopathologic understanding of these diseases has widened. Thus, new entities such as penetrating ulcer and intramural hematoma have been described and differentiated from classical aortic dissection.

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.

La ecocardiografia transesofagica es una tecnicade gran utilidad en el estudio de la patologia de laaorta toracica, en particular la diseccion aortica yel hematoma intramural de aorta. Presentamos uncaso de hematoma intramural de aorta originadocomo complicacion de la angioplastia con balon deuna recoartacion aortica. Se ilustra la importanciade la ecocardiografia transesofagica en el diagnosticoy seguimiento de posibles complicaciones despuesde este procedimiento.

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.