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Background: Various human cardiovascular pathophysiological conditions associate aberrant expression of microRNAs (miRNAs) and circulating miRNAs are emerging as promising biomarkers. In mice, myocardial miR-21 overexpression is related to cardiac fibrosis elicited by pressure overload. This study was designed to determine the role of myocardial and plasmatic miR-21 in the maladaptive remodeling of the extracellular matrix induced by pressure overload in aortic stenosis (AS) patients and the clinical value of miR-21 as a biomarker for pathological myocardial fibrosis., Methods: In left ventricular biopsies from 75 AS patients and 32 surgical controls, we quantified the myocardial transcript levels of miR-21, miR-21-targets and ECM- and TGF-β-signaling-related elements. miR-21 plasma levels were determined in 25 healthy volunteers and in AS patients. In situ hybridization of miR-21 was performed in myocardial sections., Results: The myocardial and plasma levels of miR-21 were significantly higher in the AS patients compared with the controls and correlated directly with the echocardiographic mean transvalvular gradients. miR-21 overexpression was confined to interstitial cells and absent in cardiomyocytes. Using bootstrap validated multiple linear regression, the variance in myocardial collagen expression was predicted by myocardial miR-21 (70% of collagen variance) or plasma miR-21 (52% of collagen variance), together with the miR-21 targets RECK and PDCD4, and effectors of TGF-ß signaling., Conclusions: Our results support the role of miR-21 as a regulator of the fibrotic process that occurs in response to pressure overload in AS patients and underscore the value of circulating miR-21 as a biomarker for myocardial fibrosis., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Background: Myocardial microRNA-133a (miR-133a) is directly related to reverse remodeling after pressure overload release in aortic stenosis patients. Herein, we assessed the significance of plasma miR-133a as an accessible biomarker with prognostic value in predicting the reversibility potential of LV hypertrophy after aortic valve replacement (AVR) in these patients., Methods and Results: The expressions of miR-133a and its targets were measured in LV biopsies from 74 aortic stenosis patients. Circulating miR-133a was measured in peripheral and coronary sinus blood. LV mass reduction was determined echocardiographically. Myocardial and plasma levels of miR-133a correlated directly (r=0.46, P<0.001) supporting the myocardium as a relevant source of plasma miR-133a. Accordingly, a significant gradient of miR-133a was found between coronary and systemic venous blood. The preoperative plasma level of miR-133a was higher in the patients who normalized LV mass 1 year after AVR than in those exhibiting residual hypertrophy. Logistic regression analysis identified plasma miR-133a as a positive predictor of the hypertrophy reversibility after surgery. The discrimination of the model yielded an area under the receiver operator characteristic curve of 0.89 (P<0.001). Multiple linear regression analysis revealed plasma miR-133a and its myocardial target Wolf-Hirschhorn syndrome candidate 2/Negative elongation factor A as opposite predictors of the LV mass loss (g) after AVR., Conclusions: Preoperative plasma levels of miR-133a reflect their myocardial expression and predict the regression potential of LV hypertrophy after AVR. The value of this bedside information for the surgical timing, particularly in asymptomatic aortic stenosis patients, deserves confirmation in further clinical studies.

Background: Left ventricular (LV) reverse remodelling after valve replacement in aortic stenosis (AS) has been classically linked to the hydraulic performance of the replacement device, but myocardial status at the time of surgery has received little attention., Objective: To establish predictors of LV mass (LVM) regression 1 year after valve replacement in a surgical cohort of patients with AS based on preoperative clinical and echocardiographic parameters and the myocardial gene expression profile at surgery., Methods: Transcript levels of remodelling-related proteins and regulators were determined in LV intraoperative biopsies from 46 patients with AS by RT-PCR. Using multiple linear regression analysis, an equation was developed (adjusted R²=0.73; p<0.0001) that included positive [preoperative LVM, microRNA-133a, serum response factor (SRF, which is known to be a transactivator of miR-133) and age] and negative [body mass index (BMI), Wolf-Hirschhorn syndrome candidate-2 (WHSC2, which is a target for repression by miR-133a), β-myosin heavy chain, myosin light chain-2, diabetes mellitus, and male gender] independent predictors of LVM reduction., Results: Aortic valve area gain or the reduction in transvalvular gradient maintained no significant relationships with the dependent variable. Logistic regression analysis identified microRNA-133a as a significant positive predictor of LVM normalisation, whereas β-myosin heavy chain and BMI constituted negative predictors., Conclusions: Hypertrophy regression 1 year after pressure overload release is related to the preoperative myocardial expression of remodelling-related genes, in conjunction with the patient's clinical background. In this scenario, miR-133 emerges as a key element of the reverse remodelling process. Postoperative improvement of valve haemodynamics does not predict the degree of hypertrophy regression or LVM normalisation. These results led us to reconsider the current reverse remodelling paradigm and (1) to include criteria of hypertrophy reversibility in the decision algorithm used to decide timing for the operation; and (2) to modify other prevailing factors (overweight, diabetes, etc) known to maintain LV hypertrophy.

Background: The purpose of this study was to evaluate the change in renal function and its determinants after replacement of calcineurin inhibitors with a proliferation signal inhibitor (sirolimus or everolimus) in long-term heart transplant recipients., Methods: We studied 49 consecutive patients in whom a switch to a proliferation signal inhibitor was carried out 9 ± 4 years after transplantation. Evolutive glomerular filtration rate was assessed at a mean of 28 months after conversion by the simplified MDRD equation., Results: Pre-conversion glomerular filtration rate (40 ± 22 ml/min/1.73 m(2)) remained stable at 1 year after conversion (41 ± 22 ml/min/1.73 m(2)), but decreased significantly by the end of follow-up (35 ± 22 ml/min/1.73 m(2); p = 0.008 and p = 0.002 vs pre-conversion and 1-year values, respectively). In a multivariate model, including age, time from transplantation to conversion, pre-conversion glomerular filtration rate, presence of diabetes and use of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB) therapy, the rate of decline in renal function was related only to the presence of diabetes (p = 0.017) and inversely related to the use of ACEI/ARB therapy (p = 0.003). There were no significant differences with respect to age, time between transplantation and replacement and baseline glomerular filtration rate., Conclusion: In long-term heart transplant recipients, late substitution of a calcineurin inhibitor for a proliferation signal inhibitor does not preclude a decrease in renal function in the long-term setting. We identified the presence of diabetes as the main clinical predictor of renal function deterioration. In contrast, we found that the use of ACEI/ARB therapy could exert a protective effect., (Copyright © 2011 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Objective: To compare early and late outcome of patients with prosthetic valve endocarditis treated medically versus surgically and to determine predictors of in-hospital death. We retrospectively reviewed patient's clinical records, including laboratory findings, surgery, and pathologic files, in an acute-care, 1200-bed teaching hospital., Methods: One hundred thirty-three episodes of definite prosthetic valve endocarditis as defined by the Duke University diagnostic criteria occurred in 122 patients from January 1986 to December 2005. Logistic regression model was used to identify prognostic factors of in-hospital mortality. Long-term follow-up was made to assess late prognosis., Results: Bioprostheses were involved in 52% of cases and mechanical valves in 48%. The aortic valve was affected in 45% of patients. Staphylococcus epidermidis was isolated in 23% of cases, Streptococcus spp in 21%, S aureus in 13%, and Enterococcus in 8%. Cultures were negative in 18% of cases. Twenty-six patients were treated medically and 107 with combined antibiotics and valve replacement. The operative mortality was 6.5% and the in-hospital mortality, 29%. Presence of an abscess at echocardiography, urgent surgical treatment, heart failure, thrombocytopenia, and renal failure were significant predictors of in-hospital death. Kaplan-Meier survival at 12 months was 42% in patients treated medically and 71% in those treated surgically (P = .0007). Freedom from endocarditis was 91% at the end of follow-up., Conclusions: Prosthetic valve endocarditis is a serious condition with high mortality. Patients with perivalvular abscess had a worse prognosis, and combined surgical and medical treatment could be the preferred approach to improve outcome., (Copyright 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Introduction and Objectives: To investigate changes in the clinical characteristics, etiology and prognosis of prosthetic valve endocarditis at a tertiary-care hospital., Methods: Retrospective cohort study of all patients diagnosed with prosthetic valve endocarditis using modified Duke criteria between 1986 and 2005. The analysis covered two time periods: January 1986 to December 1995 (P1) and January 1996 to December 2005 (P2)., Results: In total, 133 episodes of endocarditis occurred in 122 patients. Of these, 73 (54.9%) were diagnosed in P1 and 60 (45.1%) in P2, with incidences of 2.19% and 2.18%, respectively. The patients' mean age (SD) was 52.6+/-16.6 years in P1 and 66.2+/-11.5 years in P2 (P=.0001). Clinical characteristics were similar in the two study periods. The increase in Enterococcus infection was remarkable (12.5% in P2 vs. 4.9% in P1; relative risk [RR]=2.5; 95% confidence interval [CI], 0.7-9.6), as was the decrease in viridans group Streptococcus infection (12.5% in P2 vs. 31.1% in P1; RR=0.4; 95% CI, 0.2-0.9). Some 90.4% of patients (63/73) underwent surgery in P1, while 68.3% (41/60) underwent surgery in P2. The difference was significant (RR=0.8; 95% CI, 0.6-0.9). The in-hospital mortality rate was 28.8% in P1 and 30% in P2 (RR=1; 95% CI, 0.6-1.7)., Conclusions: Changes in the epidemiology and microbiological etiology of prosthetic valve endocarditis were observed over the 20-year study period. Diagnostic and therapeutic approaches also changed, but mortality remained high.

Background: TGF-beta1 is involved in cardiac remodeling through an auto/paracrine mechanism. The contribution of TGF-beta1 from plasmatic source to pressure overload myocardial remodeling has not been analyzed. We investigated, in patients with valvular aortic stenosis (AS), and in mice subjected to transverse aortic arch constriction (TAC), whether plasma TGF-beta1 relates with myocardial remodeling, reflected by LV transcriptional adaptations of genes linked to myocardial hypertrophy and fibrosis, and by heart morphology and function., Methodology/principal Findings: The subjects of the study were: 39 patients operated of AS; 27 healthy volunteers; 12 mice subjected to TAC; and 6 mice sham-operated. Myocardial samples were subjected to quantitative PCR. Plasma TGF-beta1 was determined by ELISA. Under pressure overload, TGF-beta1 plasma levels were significantly increased both in AS patients and TAC mice. In AS patients, plasma TGF-beta1 correlated directly with aortic transvalvular gradients and LV mass surrogate variables, both preoperatively and 1 year after surgery. Plasma TGF-beta1 correlated positively with the myocardial expression of genes encoding extracellular matrix (collagens I and III, fibronectin) and sarcomeric (myosin light chain-2, beta-myosin heavy chain) remodelling targets of TGF-beta1, in TAC mice and in AS patients., Conclusions/significance: A circulating TGF-beta1-mediated mechanism is involved, in both mice and humans, in the excessive deposition of ECM elements and hypertrophic growth of cardiomyocytes under pressure overload. The possible value of plasma TGF-beta1 as a marker reflecting preoperative myocardial remodeling status in AS patients deserves further analysis in larger patient cohorts.

Pulmonary venous vascular complications after lung transplantation are rare and a major cause of morbidity and mortality unless diagnosed and treated early. The epidemiological, diagnostic, and management characteristics of 33 patients (two of them in our hospital) with post-transplant pulmonary vein obstruction published in the literature were reviewed. We consider of utmost importance to differentiate stenosis from thrombosis as the cause of the obstruction. The angiography, considered the gold standard for diagnosis, was replaced by transesophageal echocardiography (TEE) in 79% of the cases, but no echocardiographic diagnostic criteria were defined. A diameter of the pulmonary veins, with 2D/color TEE, <0.5 cm, peak systolic flow velocity (PSFV) >1 m/s, pulmonary vein-left atrial pressure gradient (PVLAG) >/=10-12 mmHg, non-permeable flow through the stenosis and the presence of thrombus at that level, must lead us to suspect this complication. Higher mortality rates were found in unilateral procedures and in women. We consider that TEE must be carried out as part of the intraoperative routine or within the first 24 h of the post-operative period.

Gender influence on left ventricular (LV) remodeling associated to aortic valve stenosis (AS) has been long recognized, but underlying myocardial gene expression patterns have not been explored. We studied whether sex differences in echocardiographic LV anatomy and function in AS patients are associated with specific changes in myocardial mRNA expression of remodeling proteins. AS (n=39) and control (n=23)patients were assessed echocardiographically, and LV myocardial mRNA levels were quantified by PCR. AS patients exhibit increased wall thicknesses and LV mass index (LVMI), but only men show chamber dilation.Collagens and fibronectin mRNA levels increased correlatively to transforming growth factor-beta1 (TGF-beta1). In AS women, collagen I upregulation was proportionally higher than other extracellular matrix (ECM)components. No changes in matrix metalloproteinase-2 and tissue inhibitor of metalloproteinase-2 were detected. Gene expressions of sarcomeric proteins (beta-myosin heavy chain and myosin light chain-2) and TGF-beta1 were directly correlated with each other. Myosin light chain-2 mRNA levels increased proportionally to the transvalvular gradient, but women did so in a greater extent than men for a given gradient. In women, the hypertrophic growth response, reflected by LVMI, was proportional to the expression of genes encoding sarcomeric proteins and TGF-beta1. In men, chamber dilation and deterioration of LVEF was proportional to collagens, fibronectin, and TGF-beta1 gene expression levels. We evidenced gender biased gene expression patterns of the intracellular TGF-beta pathways involving the Smad branch, but not the TAK-1 branch, that could contribute to the remodeling differences observed in AS men and women. Based on these findings, a gender specific therapeutic approach of pressure overload LV hypertrophy could be justified.

Background: This study describes our experience with proliferation signal inhibitors in de novo heart transplant recipients with significant renal impairment. To circumvent further nephrotoxicity, calcineurin inhibitors were avoided in the peri-operative period., Methods: Immunosuppression in 20 patients was with a proliferation signal inhibitor (sirolimus, 14; everolimus, 6), an anti-mitotic drug, and corticosteroids from the time of transplantation. Induction was used in 9 patients (45%). All patients had preoperative significant renal dysfunction (mean glomerular filtration rate <30 ml/min/1.73 m(2)), and 4 patients required dialysis., Results: Post-operatively, the glomerular filtration rate significantly increased (>65 ml/min/1.73 m(2) at Month 1, remaining stable thereafter). No patients required dialysis after the first month of transplantation. Mean follow-up was 500 days. Rejection episodes occurred in 11 patients (55%), and 4 patients died (2 of rejection, although 1 death occurred 48 days after conversion to conventional treatment with tacrolimus). Half of the patients were eventually converted to conventional calcineurin-inhibitor therapy because of proliferation signal inhibitor adverse events., Conclusion: Although this immunosuppressive approach was associated with a somewhat high rate of rejection and frequent side effects, it represents an attractive alternative in the complicated peri-operative setting of patients with significant renal impairment. This approach could serve as a temporary bridge to a conventional treatment.

Pulmonary toxicity (PT) is emerging as a frequent and serious complication of sirolimus, a proliferation signal inhibitor (PSI) used in solid-organ transplantation. Everolimus is a more recently developed PSI with molecular structure very similar to that of sirolimus. Surprisingly, although experience with everolimus is increasing and becoming substantial, there remains very little information about everolimus-related PT. Herein we report 2 heart transplant recipients who developed a non-infectious pulmonary syndrome after everolimus treatment was started. Transbronchial pulmonary biopsy specimens showed typical interstitial pneumonitis, and everolimus discontinuation resulted in rapid clinical and radiological improvement. Although PT seems to be more common after sirolimus exposure, everolimus is by no means spared from this potentially lethal complication and should always be suspected in the relevant clinical setting.

Introduction and Objectives: It is vital that obstruction of the left main coronary artery (LMCA) is diagnosed early. We investigated the value of ST-segment and QRS-complex vector analysis in identifying LMCA obstruction in acute coronary syndrome., Methods: The study involved 57 consecutive patients with electrocardiographic features suggestive of LMCA obstruction. Both ST-segment and QRS-complex parameter vectors were analyzed., Results: Coronary angiography showed that the obstructed vessel was the LMCA in 20 patients, the left circumflex artery in 19, the right coronary artery in 10, and the left anterior descending artery in three. Five patients had three-vessel disease. An ST vector that was directed between -90 degrees and 180 degrees in the frontal plane was observed in 100% of patients with an LMCA obstruction (P< .001). The specificity of this observation was 78%. An ST vector directed anteriorly or parallel to the horizontal plane was present in 95% of patients (19/20) with an LMCA obstruction (P< .001; specificity 92%). A QRS vector with a left shift é-30 degrees was observed in 75% (15/20) with LMCA disease (P< .001; specificity 95%). An ST vector directed between -90 degrees and 180 degrees and anteriorly had a sensitivity of 95% and specificity of 100% for LMCA obstruction. An ST vector directed between -90 degrees and 180 degrees combined with a left QRS vector shift > or =-30 degrees had a sensitivity of 75% and a specificity of 100% for LMCA obstruction. A simple algorithm combining these observation was able to predict LMCA obstruction in 100% of patients., Conclusions: In acute coronary syndrome, ST-segment and QRS-complex vector analysis can predict the presence of LMCA obstruction.

Background: The existence of a diabetic cardiomyopathy has been recently supported by epidemiological studies. Increased oxidative stress and myocardial fibrosis has been hypothesized as etiopathogenic mechanisms. We sought to demonstrate the existence of incipient myocardial dysfunction in type 2 diabetes and its relation with markers of oxidative stress and myocardial fibrosis., Methods: We studied by echocardiography 25 uncomplicated type 2 diabetic patients and 12 sex- and age-matched control subjects. Stress-corrected endocardial and midwall shortening and systolic and early diastolic velocity of the lateral mitral annulus (Doppler tissue) were used as parameters of myocardial function. Serum levels of glutathione peroxidase and procollagen type I carboxy-terminal peptide were used as markers of oxidative stress and myocardial fibrosis, respectively., Results: Diabetics had significant lower values of corrected endocardial shortening than control subjects (P = 0.029). Both systolic and early diastolic mitral annulus velocities were significantly reduced in diabetics as compared to control subjects (P = 0.008 and P = 0.003, respectively). In diabetic patients, corrected endocardial (r = -0.56) and midwall shortening (r = -0.38) correlated with procollagen type I carboxy-terminal peptide, whereas systolic and early diastolic velocities of the mitral annulus correlated with glutathione peroxidase (both r = 0.44)., Conclusions: In a highly selected group of uncomplicated type 2 diabetic patients, we found evidence of systolic and diastolic myocardial dysfunction, especially with the use of pulsed Doppler tissue imaging. The correlations between parameters of myocardial function and glutathione peroxidase and procollagen type I carboxy-terminal peptide support a mechanistic role for the increased oxidative stress and myocardial fibrosis in the myocardial dysfunction of type 2 diabetes.

We report the case of a 44-year-old man with dilated cardiomyocardiopathy, pulmonary hypertension and high pulmonary resistance who underwent orthotopic heart transplant. Following transplantation severe hypoxia was observed after weaning of cardiopulmonary bypass secondary to a patent foramen oval in the donor heart. This situation does not usually lead to problems in the donor, however taking into account the special hemodynamic conditions of the transplanted patient, with high pressure in the right side, an opening occurred producing a significant right-left shunt causing severe receptor hypoxia. Successful closure of the patent foramen oval was performed.

This article presents the program for training in cardiology. The document was elaborated by the National Committee of the Specialty of Cardiology, from the Ministry of Health and Ministry of Education, and describes the theoretical and practical aspects of training in cardiology prevailing at present in Spain.

We present a case of a 57-year-old man with a giant-cell myocarditis that made its debut as a sustained ventricular polymorphic tachycardia interpreted in the context of old apical myocardium infarct, with a posterior evolution towards refractory heart failure, which finally needed urgent cardiac transplantation. We explain the characteristics of this unusual myocarditis, which has a poor prognosis, and also the results of the laboratory techniques that led to an equivocal diagnosis in this patient.

Objective: The objective of this study is to analyze the value of the electrocardiogram in the identification of the coronary artery responsible for acute inferior myocardial infarction., Material and Methods: One hundred consecutive patients with acute inferior myocardial infarction were studied, 67 with a lesion in the right coronary artery and 33 in the circumflex artery. The ST segment changes in the inferior, lateral, precordial and right-chest leads were analyzed, as well as the arithmetic sum of the ST segment in the inferior and V2 leads (II + V2, III + V-2 and aVF + V2). We also developed a diagnostic process based on a stepwise approach of three electrocardiographic criteria: a) elevation of the ST segment in DI; b) arithmetic sum of the ST magnitude in DIII + V2 < 0; c) depression of the ST segment in V4R., Results: This study shows that the most useful parameters to predict (with a specificity of 100%) the lesioned coronary artery in acute inferior myocardial infarction are: a) the arithmetic sum of the ST segment: aVF + V2 > 0, for the right coronary artery; b) the arithmetic sum of the ST segment: III + V2 < 0, for the circumflex artery; c) the arithmetic sum of the ST segment: aVF + V2 > 1 mm, for the proximal right coronary artery., Conclusions: The incorporation of these three criteria in an algorithm diagnostic system allows us to locate the coronary artery responsible for acute myocardial infarction with 100% sensitivity and specificity.

A case of a 64-year-old man is described, who was diagnosed as having a false aneurysm of the left ventricle, or pseudoaneurysm, a year following an inferior wall myocardial infarction. The echocardiogram demonstrated the presence of two ways of entry which communicated the inferior wall of the left ventricle to the false aneurysm. The patient was taken to surgery, where the diagnosis was confirmed. Aspects related to the diagnosis, treatment and prognosis of this case are discussed.

The aim of this prospective study was to determine the etiologic factors leading to stroke in a group of young adults. We studied 95 patients aged 50 years or under who were admitted with the diagnosis of stroke over a 2-year period. These patients underwent complete clinical and laboratory assessment for stroke. The etiology was established in 73 (76.8%) out of 95 cases. Arterial hypertension, embolism and atherosclerosis were found to be the most frequent causes in patients with ischemic stroke, whereas hypertension and aneurysm rupture were the most prevailing etiologies in patients with hemorrhagic stroke. Miscellaneous causes represented one fourth of all cases of the series. Coagulation abnormalities occurred in some patients, but in these cases there were also other well established causes. Paradoxical embolism was not observed. This study corroborates the importance of thorough diagnostic evaluation to establish an accurate diagnosis.

Introduction and Objectives: Regurgitant jet area is to date the most widely accepted color Doppler parameter for quantitation of atrium-ventricular regurgitations. In experimental studies, it has been demonstrated that color regurgitant jet area is greatly influenced by technical settings. The present study was aimed to analyze the effect of gain setting, pulse repetition frequency and echocardiographic plane on color jet area in patients with tricuspid regurgitation., Methods: We studied 64 patients with nontrivial (more than 1 cm2), rheumatic tricuspid regurgitation. Examinations were performed in apical four-chamber and right ventricle inflow-tract views, at two gain settings (subsaturation gain and 1/3 reduced gain) and at two pulse repetition frequencies (3.1 and 3.8 kHz). Therefore, every regurgitant jet was study under 8 different technical conditions. The remaining technical settings were held unchanged included throughout the studies. The traced area induced central varianced and aliased signals, as well as the immediately contiguous nonturbulent velocities that were moving in the same direction as the jet. Measurements were taken from 5 and 3 representative cycles in patients with atrial fibrillation and sinus rythm, respectively., Results: Globally, reduction in gain setting produced a color area decrease by 50%. This reduction was of greater extent for small jets (less than 5 cm2, 45 +/- 17%) with respect to larger jets (more than 5 cm2, 61 +/- 30%, p = 0.0009). Results were similar for both apical four-chamber and right ventricle inflow views and for the two pulse repetition frequencies. At a given color gain level and echocardiographic view, pulse repetition frequency at 3.1 kHz produced greater color areas (by 3-11%) than frequency at 3.8 kHz, but the difference was not significant. Overall, color jet area was significantly greater in right ventricle inflow view than in apical four-chamber view, but substantial individual variability was observed. Difference between both views was greater than 40% in 28% of patients, with the largest color area in right ventricle inflow view in most, especially in those patients with eccentric jets., Conclusions: Gain setting and echocardiographic view greatly affect regurgitant jet area by color Doppler in patients with tricuspid regurgitation. Therefore, standardization of technical settings is mandatory in order to avoid diagnostic pitfalls.

The correlation between data obtained by Doppler color flow imaging and angiographic severity has been investigated in mitral and aortic regurgitation. However, similar studies have not been performed for tricuspid regurgitation (TR). This study was performed to establish the correlation between measurements of regurgitant jet area by Doppler color flow imaging and the angiographic severity of TR. Fifty-four patients with rheumatic heart disease who underwent right ventriculography and transthoracic Doppler color flow imaging were studied. The regurgitant jet area was measured as the largest clearly definable flow disturbance in apical four-chamber and right ventricle inflow views, and expressed in both views as the absolute jet area or as the ratio of maximal jet area to right atrial area. Correlation of all Doppler color flow measurements with angiographic grades of TR were comparable, absolute jet area in apical four-chamber view being closest at r = 0.80. A regurgitant jet area in apical four-chamber view < 5 cm2 predicted minimal or mild TR by angiography with a sensitivity of 78% and a specificity of 100%, whereas a regurgitant jet area > 10 cm2 predicted severe TR with a sensitivity of 92% and a specificity of 91%. Values between 5 and 10 cm2 predicted moderate TR with a sensitivity of 89% and a specificity of 89%. Sensitivity and specificity were not improved with use of the ratio of jet area to right atrial area or with use of right ventricle inflow view. Thus, Doppler color flow jet measurements correlate closely with angiographic results in the evaluation of TR.(ABSTRACT TRUNCATED AT 250 WORDS)

A case of lipomatous hypertrophy of the interatrial septum in a patient with a history of repeated pulmonary embolism is presented. Thickening of the interatrial septum mimicking the presence of a right atrial mass was evidenced by transthoracic and transesophageal echocardiography. Lipomatous hypertrophy was suspected. The diagnostic was confirmed by echo guided (transesophageal) percutaneous transvenous biopsy. To our knowledge, there is no relationship between lipomatous hypertrophy and pulmonary embolism and in this case, it could be associated with smoking habit and oral contraceptives.

Introduction and Objectives: To assess the anti-ischemic efficacy of nitroglycerin patches (10 mg/day), we studied, by means of serial exercise testing (Bruce protocol), 10 patients with stable effort angina in a randomized, placebo-controlled, cross-over, double-blind essay., Methods: Patients were exercised 1, 4, 12 and 24 hours after a single patch, and 4 and 12 hours after a 48 hours therapy course. Chronic therapy was assessed after both continuous and intermittent (intermission of 12 hours) patch application., Results: After single patch, time to angina and time to 1 mm ST depression were significantly increased with respect to placebo at 1-hour test (83 +/- 27 s and 119 +/- 39 s, respectively), 4-hour test (100 +/- 34 s and 87 +/- 29 s, respectively) and 12-hour test (46 +/- 15 s and 64 +/- 20 s, respectively). No effect was demonstrated at 24-hour test. After continuous treatment no differences with respect to placebo were found at any test. After intermittent treatment time to angina was prolonged (75 +/- 23 s) only at 4-hour test, and time to 1 mm ST depression at 4-hour test (61 +/- 19 s) and 12-hour test (41 +/- 14 s)., Conclusions: Nitroglycerin patches improve parameters of exercise ischemia for a 12 hours period. Tolerance is developed very early and provokes absolute lack of efficacy. Tolerance can be avoided with intermittent patch application. No treatment schedule shows 24 hours efficacy.

Objective: To determine the clinical implications of the development of a perivalvular abscess in the course of an infective endocarditis and evaluate the utility of two-dimensional echocardiography in the diagnosis of this complication., Design: Retrospective clinical review. Investigator-blinded comparative echographic case-control study., Setting: Tertiary referral center., Patients: Forty patients with infective endocarditis and a histologically proved diagnosis of perivalvular abscess., Intervention: Two-dimensional echocardiograms corresponding to 36 of these 40 patients were blindly compared with two-dimensional echocardiograms of 20 randomly chosen patients with infective endocarditis in whom myocardial abscesses had not been demonstrated during surgery., Measurements and Main Results: During surgery or at autopsy, 40 patients had a total of 41 definite perivalvular abscesses. Native valve endocarditis was present in 27 patients, and prosthetic valve endocarditis was present in 13 patients. Abscesses were more frequent in aortic-valve endocarditis (57.5 percent) than in infections of other valves, and the infecting organism was more often Staphylococcus (42.5 percent of cases). The hospital mortality rate was 90 percent in the 10 patients who did not receive surgical treatment, as compared with 26.6 percent in the 30 operated-on patient (p < 0.001). Sensitivity and specificity for the detection of abscesses associated with endocarditis were 80.5 percent and 85 percent, respectively, for transthoracic two-dimensional echocardiography., Conclusions: Our data indicate that transthoracic echocardiography remains an accurate method for the diagnosis of abscesses associated with endocarditis, even in the presence of a prosthetic valve, and it could help to indicate early surgery in these patients.

We report the case of a man 67-years-old with right-to-left shunt through a patent foramen ovale in absence of pulmonary hypertension. The contrast and transesophageal echocardiography showed significant right-to-left shunt and provided insight about the mechanisms that cause it. The aortic root was enlarged compressing the right atrium. Surgical repair was performed, the foramen ovale was closed and right atrial enlargement with a patch was carried out. Disappearance of the shunt was confirmed by means of transesophageal echocardiography in surgical-room.

Background: To evaluate the clinic characteristics and therapeutic aspects of endocarditis by Streptococcus pneumoniae sensitive and resistant to penicillin., Methods: Twelve cases of pneumococcal endocarditis evaluated in 4 Spanish hospitals over the last 10 years were studied, analyzing their clinical characteristics and the existence of resistance to penicillin. The features were compared with a series of 98 cases found in a review of the literature., Results: All the patients were males, most being alcoholics. The course of the disease was acute (2 weeks) in all the cases and evolved with great aggressivity: cardiac failure (9 patients), myocardial abscess (7 patients), multiple arterial embolisms (5 patients), septic arthritis (4 patients). Three patients had simultaneous pneumococcal meningitis but only one had pneumonia. The valve most affected was the aortic (9 cases). Three cases were due to strains of Streptococcus pneumoniae with moderate resistance to penicillin (CMI 0.5-1 micrograms/ml). Global mortality was 42%. All the patients receiving inadequate antibiotic treatment died. Vancomycin and cefotaxime appear to be effective in the treatment of cases produced by strains of pneumococcus with intermediate sensitivity to penicillin. There were no apparent differences in mortality between the cases of endocarditis by pneumococcus sensitive or moderately resistant to penicillin., Conclusions: Pneumococcal endocarditis continues to condition a high mortality similar to that produced in previously made series. The classic relation with meningitis and pneumonia is infrequent today. The appearance of strains resistant to penicillin may increase the incidence of this infection and further worsen prognosis.

In order to determine the value of the analysis of the hepatic vein flow pattern in the gradation of aortic regurgitation, two-dimensional and Doppler studies were carried out in 13 healthy individuals (control group) and 36 patients with aortic regurgitation (study group), in a prospective fashion. By 2-D and Doppler Echocardiography, aortic regurgitation was graded as mild in 5 patients, moderate in 13 and severe in the remaining. In 25 patients of the study group, hemodynamic and angiographic studies were available. Moderate or severe pulmonary hypertension was detected in 11 patients. Peak and integral velocities of the systolic, diastolic and "A" waves were measured on pulsed Doppler hepatic veins flow tracings. Both peak and integral hepatic vein diastolic flow velocities in postexpiratory apnea were significant lower in patients with severe aortic regurgitation with respect to the remaining study group patients and control group patients. Sensitivity and specificity for the detection of severe aortic regurgitation were 100 and 67% respectively. An postexpiratory increase in the retrograde "A" wave was observed in 11 patients with severe and 6 with moderate aortic regurgitation. Sensitivity and specificity for the detection of severe aortic regurgitation were 58 and 67% respectively. In this study, characteristic pulsed Doppler hepatic vein flow patterns are defined for patients with aortic regurgitation. Sensitivity and specificity of the findings allows the identification of severe AR. This results could have diagnostic and therapeutic implications.

Blood flow pattern recording of hepatic veins using pulsed Doppler technique is a valid method for the assessment of hemodynamic changes in right atrium. We describe a patient with severe aortic regurgitation secondary to acute infective endocarditis who underwent surgical repair. Before surgery and during the postoperative period, several evolutive studies (including conventional echo and hepatic veins pulsed Doppler recordings) were performed. The different central blood flow patterns were correlated with changing hemodynamic conditions during follow-up of the patient. These central flow velocities reflect changes in right atrial pressure contours, and are easily obtained non-invasively with pulsed wave Doppler ultrasound of the hepatic veins. They could be an useful method for assessing right heart filling dynamics, reporting characteristic patterns in other cardiac disease states.

Mycotic aneurysm of the septal leaflet of the mitral valve is an infrequent complication associated with aortic infective endocarditis. The most probable mechanisms implicated on its formation are two: the lesion induced by regurgitant jet striking on septal mitral leaflet and the direct spreading of infection through the fibrosa inter-valvular. We describe the preoperative diagnosis of mycotic aneurysms of the septal mitral leaflet by two-dimensional echocardiography and color flow mapping in 2 patients. Surgical management will depend on the anatomic characteristics of the aneurysm and its hemodynamic repercussion. Careful echocardiographic search for mycotic mitral aneurysms should be performed in cases of aortic valve endocarditis, in view of its important prognostic implications.

We have performed a retrospective analysis of the clinical, echocardiographic, surgical and necropsy data in 40 patients affected by infective endocarditis complicated by paravalvular abscess. The abscess developed on prosthetic valve in 13 cases, and on native valve in 27. Aortic valve was the most affected (85%). The clinical course was considered to be acute in 52% of the patients. Fever persisted despite of adequate antibiotic therapy in 57%. In 90%, overt heart failure were present. Staphylococcus were the most frequent causative microorganism (S. aureus, 22.5%; S. epidermidis, 20%). Bundle branch or atrioventricular block were detected in 18 patients (sensibility, 45%; specificity, 88%). Bidimensional echocardiography, along with Doppler techniques when necessary, detected an abscess in 81% of patients (sensibility, 80%; specificity, 84%). Thirty patients were operated. Eight of them (26%) died, two intraoperatively. Ten patients were not operated and nine died (90%). The difference was significant (p less than 0.001). Only age and surgical treatment were related to early survival. Over the follow-up of the operated patients, five presented prosthetic dehiscence, but only two required a new operation 3 months after the first intervention, and none died. In conclusion, the detection of a paravalvular abscess complicating an infective endocarditis is an indication for surgical treatment. Both surgical mortality and postoperative prosthetic dehiscence are acceptable. Bidimensional echocardiography is the most reliable tool for the diagnosis of this complication.

Double-orifice mitral valve is an uncommon congenital heart defect. The isolated occurrence of this anomaly is exceptional and, more often, is encountered in association with other congenital cardiac abnormalities. Principal among these are the partial and complete forms of the atrioventricular canal. In this paper, we present two cases of double-orifice mitral valve. Our first case is associated with subaortic stenosis and coarctation of aorta. The second case is an isolated one resembling a severe mitral stenosis. As we know, the diagnosis of this rare anomaly by color-Doppler technique has not been previously reported. We believe this technique provides definite anatomical and functional information about double-orifice mitral valve.

A case of Listeria monocytogenes valvular endocarditis is reported. This patient required mitral and aortic valve replacement by Björk-Shiley mechanical prostheses. Patient clinical condition was progressively deteriorated, affecting the left ventricular function, increasing the size of vegetations and the presence of aortic annular abscess. This case represents the 48th reported in the literature and the third in our country. We here comment about the clinical aspects and the treatment of this infrequent entity.

Eleven patients with endocarditis of a natural valve due to coagulase-negative staphylococci are reported. Nine had some underlying heart disease. The course was subacute in seven and acute (two weeks or less) in the remaining four. All patients developed complications: heart failure in nine, arterial emboli in eight, atrioventricular conduction disorders in four, development of paravalvular and/or myocardial abscesses in four, and perforation or rupture of valve leaflets in four. Eight patients were cured, seven of them requiring surgical treatment. Three of the isolated coagulase-negative staphylococci strains were methicillin-resistant; two of them caused community-acquired endocarditis. Natural valve endocarditis due to coagulase-negative staphylococci usually has a subacute course with a tendency to develop severe complications. This makes surgical therapy necessary in a sizeable number of patients.