Actualización en válvula aórtica bicúspide y complicaciones asociadas

Bicuspid aortic valve (BAV) is the most common congenital heart disease affecting 1-2% of the population. It affects more frequently males than females with a ratio of 3:1. Despite the fact that it has been historically considered a relatively benign disease, 35% of individuals with BAV will develop complications throughout life such as valve dysfunction, aortic aneurysm or aortic dissection. In spite of the relevance of this disease many aspects are not still clarified. The aim of this article is to show an updated version of the basic aspects of this pathology with emphasis on the latest developments related to the diagnosis, evolution and associated complications from a cardiac imaging viewpoint.La válvula aórtica bicúspide (VAB) es la cardiopatía congénita más frecuente y afecta a un 1-2% de la población. Afecta de forma más habitual a varones que a mujeres, con una relación 3:1. A pesar de haberse considerado históricamente una patología de carácter relativamente benigno, un 35% de los individuos con VAB desarrollará a lo largo de la vida complicaciones derivadas como disfunción valvular, endocarditis, aneurisma aórtico o disección aórtica. A pesar de la relevancia de esta patología quedan aún muchos aspectos por dilucidar. El objetivo de este artículo es mostrar una revisión actualizada de los aspectos básicos de esta patología haciendo hincapié en las últimas novedades relacionadas con su diagnóstico, evolución y complicaciones asociadas desde el punto de vista de la imagen cardíaca

Comparación de los resultados a largo plazo de cirugía y valvuloplastia percutánea para el tratamiento de la estenosis pulmonar aislada

Se compararon en una población de 211 pacientes con estenosis pulmonar reparada el tratamiento quirúrgico y percutáneo, las complicaciones y reintervenciones a largo plazo y predictores de las mismas. Los pacientes del grupo quirúrgico se intervinieron de forma más precoz, presentaban una anatomía más compleja, más síntomas y peor perfil hemodinámico. El tiempo medio de seguimiento global fue de 22 ± 10,21 años y no se observaron diferencias significativas en cuanto a la necesidad de reintervención. La aparición de complicaciones no difirió entre los dos grupos. Una mayor edad en el momento de la cirugía, defectos congénitos asociados y síntomas prequirúrgicos fueron factores de riesgo para padecer complicaciones mayores. Por lo tanto, a pesar de que la evolución a largo plazo es globalmente buena, la aparición de complicaciones y la necesidad de reintervención a lo largo del seguimiento no es despreciable y sigue reportándose a pesar de la introducción de la valvuloplastia percutánea como tratamiento de primera línea.Es van comparar en una població de 211 pacients amb estenosi pulmonar reparada el tractament quirúrgic i percutani, les complicacions i reintervencions a llarg termini i predictors d'aquestes. Els pacients del grup quirúrgic es van reintervenir de forma més precoç, presentaven una anatomia més complexa, més símptomes i pitjor perfil hemodinàmic. El temps mig de seguiment global va ser de 22 ± 10,21 anys i no es van observar diferències significatives pel que fa a la la necesitat de reintervenció. L'aparició de complicacions no va diferir entre els dos grups. Més edat en el moment de la cirurgia, presentar defectes congènits associats i símptomes prequirúrgics van ser factors de risc per patir complicacions majors. Per tant, tot i que l'evolució a llarg termini és globalment bona, l'aparició de complicacions i la necesitat de reintervenció al llarg del seguiment no és despreciable i segueix reportant-se malgrat la introducció de la valvuloplàstia percutània com a tractament de primera linia

Organización escolar. Importancia de la relación familia-escuela. Validación CPPRFE / School organization. Importance of the family-school relationship CPPRFE validation

El presente trabajo expone una visión que, continuando la línea de aproximación de Alonso (2020), pretende ofrecer un punto de partida acerca de la importancia de la organización e intervención en un aspecto tan relevante —en lo que a educación general se refiere— como es la colaboración del centro educativo y las familias. Para ello, se presenta una aproximación epistemológica basada en autores relevantes en la materias, así como una revisión de las leyes vinculantes más relevantes. Este proceso de revisión exhaustiva dio como resultado la duda —no resuelta en artículos de investigación presentados en los últimos años— acerca de si los docentes —parte fundamental del citado proceso de colaboración— son conscientes o no de la importancia de esta relación. Es por ello que se procedió a la confección y validación de un cuestionario (CPPRFE) que, sin lugar a duda, servirá como base para futuras investigaciones

Diagnostic value of quantitative parameters for myocardial perfusion assessment in patients with suspected coronary artery disease by single- and dual-energy computed tomography myocardial perfusion imaging

To compare performance of visual and quantitative analyses for detecting myocardial ischaemia from single- and dual-energy computed tomography (CT) in patients with suspected coronary artery disease (CAD). Eighty-four patients with suspected CAD were scheduled for dual-energy cardiac CT at rest (CTA) and pharmacological stress (CTP). Myocardial CT perfusion was analysed visually and using three parameters: mean attenuation density (MA), transmural perfusion ratio (TPR) and myocardial perfusion reserve index (MPRI), on both single-energy CT and CT-based iodine images. Significant CAD was defined in AHA-segments by concomitant myocardial hypoperfusion identified visually or quantitatively (parameter < threshold) and coronary stenosis detected by CTA. Single-photon emission CT and invasive coronary angiography were used as reference. Perfusion-parameter cut-off values were calculated in a randomly-selected subgroup of 30 patients. The best-performing thresholds for TPR, MPRI and MA were 0.96, 23 and 0.5 for single-energy CT and 0.97, 47 and 0.3 for iodine imaging. For both CT-imaging modalities, TPR yielded the highest area under receiver operating characteristic curve (AUC) (0.99 and 0.97 for single-energy CT and iodine imaging, respectively, in vessel-based analysis) compared to visual analysis, MA and MPRI. Visual interpretation on iodine imaging resulted in higher AUC compared to that on single-energy CT in per-vessel (AUC: 0.93 vs 0.86, respectively) and per-patient (0.94 vs 0.93) analyses. Transmural perfusion ratio on both CT-imaging modalities is the best-performing parameter for detecting myocardial ischaemia compared to visual method and other perfusion parameters. Visual analysis on CT-based iodine imaging outperforms that on single-energy CT

The current role of echocardiography in acute aortic syndrome

Acute aortic syndrome (AAS) comprises a range of interrelated conditions caused by disruption of the medial layer of the aortic wall, including aortic dissection, intramural haematoma and penetrating aortic ulcer. Since mortality from AAS is high, a prompt and accurate diagnosis using imaging techniques is paramount. Both transthoracic (TTE) and transoesophageal echocardiography (TEE) are useful in the diagnosis of AAS. TTE should be the first imaging technique to evaluate patients with thoracic pain in the emergency room. Should AAS be suspected, contrast administration is recommended when images are not definitive. TEE allows high-quality images in thoracic aorta. The main drawback of this technique is that it is semi-invasive and the presence of a blind area that limits visualisation of the distal ascending aorta near. TEE identifies the location and size of the entry tear, secondary communications, true lumen compression and the dynamic flow pattern of false lumen. Although computed tomography (CT) is the most used imaging technique in the diagnosis of AAS, echocardiography offers complementary information relevant for its management. The best imaging strategy for appropriately diagnosing and assessing AAS is to combine CT, mainly ECG-gated contrast-enhanced CT, and TTE. Currently, TEE tends to be carried out in the operating theatre immediately before surgical or endovascular therapy and in monitoring their results. The aims of this review are to establish the current role of echocardiography in the diagnosis and management of AAS based on its advantages and limitations

Decreased rotational flow and circumferential wall shear stress as early markers of descending aorta dilation in Marfan syndrome : a 4D flow CMR study

Diseases of the descending aorta have emerged as a clinical issue in Marfan syndrome following improvements in proximal aorta surgical treatment and the consequent increase in life expectancy. Although a role for hemodynamic alterations in the etiology of descending aorta disease in Marfan patients has been suggested, whether flow characteristics may be useful as early markers remains to be determined. Seventy-five Marfan patients and 48 healthy subjects were prospectively enrolled. In- and through-plane vortexes were computed by 4D flow cardiovascular magnetic resonance (CMR) in the thoracic aorta through the quantification of in-plane rotational flow and systolic flow reversal ratio, respectively. Regional pulse wave velocity and axial and circumferential wall shear stress maps were also computed. In-plane rotational flow and circumferential wall shear stress were reduced in Marfan patients in the distal ascending aorta and in proximal descending aorta, even in the 20 patients free of aortic dilation. Multivariate analysis showed reduced in-plane rotational flow to be independently related to descending aorta pulse wave velocity. Conversely, systolic flow reversal ratio and axial wall shear stress were altered in unselected Marfan patients but not in the subgroup without dilation. In multivariate regression analysis proximal descending aorta axial (p = 0.014) and circumferential (p = 0.034) wall shear stress were independently related to local diameter. Reduced rotational flow is present in the aorta of Marfan patients even in the absence of dilation, is related to aortic stiffness and drives abnormal circumferential wall shear stress. Axial and circumferential wall shear stress are independently related to proximal descending aorta dilation beyond clinical factors. In-plane rotational flow and circumferential wall shear stress may be considered as an early marker of descending aorta dilation in Marfan patients. The online version of this article (10.1186/s12968-019-0572-1) contains supplementary material, which is available to authorized users

Oral Presentation No. 121. Aortic stiffness descriptors by cardiac magnetic resonance are correlated with mechanical testing of ex-vivo aortic aneurysms specimens

Background Aortic stiffness independently predicts mayor adverse cardiovascular events and mortality in the general population. Cardiovascular magnetic resonance (CMR) permits the assessment of a number of parameters theoretically linked to aortic stiffness, such as distensibility (AD), pulse wave velocity (PWV) and proximal aorta longitudinal strain. However, no previous study validates these parameters as descriptors of aortic wall stiffness against ex-vivo mechanical testing. Materials and methods Ascending aorta (AAo) specimens were collected from 20 patients undergoing AAo replacement for aneurysms. Patients underwent a CMR protocol in the days leading to the surgery, including 4D flow CMR. Two 15×5 mm specimens (one oriented in the circumferential and the other in the longitudinal aortic direction) were extracted during surgery, and later tested controlling for extension force. Elongation was measured by laser video extensometer and the tangent of the stress-strain curve at diastolic pressure was extracted. AAo PWV and the Eh product (E being Young modulus and h wall thickness) were measured from 4D flow CMR while AD and AAo longitudinal were quantified from cine images. Results and conclusions Marked correlations were found between circumferential elastic modulus and AAo AD (R = −0.502), PWV(R = 0.652) and Eh (R = 0.602). Similarly, strong correlation was identified between AAo longitudinal strain and longitudinal elastic modulus(R = −0.513). In conclusion, PWV and the Eh product are positively related to aortic wall stiffness while aortic distensibility and strain show negative relationships. Thus, these biomarkers are a reliable expression of aortic wall stiffness

Aortic flow patterns and wall shear stress maps by 4D-flow cardiovascular magnetic resonance in the assessment of aortic dilatation in bicuspid aortic valve disease

Altres ajuts: This study has been funded by , La Marató de TV3 (project number 20151330). Guala A. has received funding from the European Union Seventh Framework Programme FP7/People under grant agreement n° 267128.In patients with bicuspid valve (BAV), ascending aorta (AAo) dilatation may be caused by altered flow patterns and wall shear stress (WSS). These differences may explain different aortic dilatation morphotypes. Using 4D-flow cardiovascular magnetic resonance (CMR), we aimed to analyze differences in flow patterns and regional axial and circumferential WSS maps between BAV phenotypes and their correlation with ascending aorta dilatation morphotype. One hundred and one BAV patients (aortic diameter ≤ 45 mm, no severe valvular disease) and 20 healthy subjects were studied by 4D-flow CMR. Peak velocity, flow jet angle, flow displacement, in-plane rotational flow (IRF) and systolic flow reversal ratio (SFRR) were assessed at different levels of the AAo. Peak-systolic axial and circumferential regional WSS maps were also estimated. Unadjusted and multivariable adjusted linear regression analyses were used to identify independent correlates of aortic root or ascending dilatation. Age, sex, valve morphotype, body surface area, flow derived variables and WSS components were included in the multivariable models. The AAo was non-dilated in 24 BAV patients and dilated in 77 (root morphotype in 11 and ascending in 66). BAV phenotype was right-left (RL-) in 78 patients and right-non-coronary (RN-) in 23. Both BAV phenotypes presented different outflow jet direction and velocity profiles that matched the location of maximum systolic axial WSS. RL-BAV velocity profiles and maximum axial WSS were homogeneously distributed right-anteriorly, however, RN-BAV showed higher variable profiles with a main proximal-posterior distribution shifting anteriorly at mid-distal AAo. Compared to controls, BAV patients presented similar WSS magnitude at proximal, mid and distal AAo (p = 0.764, 0.516 and 0.053, respectively) but lower axial and higher circumferential WSS components (p < 0.001 for both, at all aortic levels). Among BAV patients, RN-BAV presented higher IRF at all levels (p = 0.024 proximal, 0.046 mid and 0.002 distal AAo) and higher circumferential WSS at mid and distal AAo (p = 0.038 and 0.046, respectively) than RL-BAV. However, axial WSS was higher in RL-BAV compared to RN-BAV at proximal and mid AAo (p = 0.046, 0.019, respectively). Displacement and axial WSS were independently associated with the root-morphotype, and circumferential WSS and SFRR with the ascending-morphotype. Different BAV-phenotypes present different flow patterns with an anterior distribution in RL-BAV, whereas, RN-BAV patients present a predominant posterior outflow jet at the sinotubular junction that shifts to anterior or right anterior in mid and distal AAo. Thus, RL-BAV patients present a higher axial WSS at the aortic root while RN-BAV present a higher circumferential WSS in mid and distal AAo. These results may explain different AAo dilatation morphotypes in the BAV population. The online version of this article (10.1186/s12968-018-0451-1) contains supplementary material, which is available to authorized users

Multicentric Atrial Strain COmparison between Two Different Modalities: MASCOT HIT Study

Two methods are currently available for left atrial (LA) strain measurement by speckle tracking echocardiography, with two different reference timings for starting the analysis: QRS (QRS-LASr) and P wave (P-LASr). The aim of MASCOT HIT study was to define which of the two was more reproducible, more feasible, and less time consuming. In 26 expert centers, LA strain was analyzed by two different echocardiographers (young vs senior) in a blinded fashion. The study population included: healthy subjects, patients with arterial hypertension or aortic stenosis (LA pressure overload, group 2) and patients with mitral regurgitation or heart failure (LA volume–pressure overload, group 3). Difference between the inter-correlation coefficient (ICC) by the two echocardiographers using the two techniques, feasibility and analysis time of both methods were analyzed. A total of 938 subjects were included: 309 controls, 333 patients in group 2, and 296 patients in group 3. The ICC was comparable between QRS-LASr (0.93) and P-LASr (0.90). The young echocardiographers calculated QRS-LASr in 90% of cases, the expert ones in 95%. The feasibility of P-LASr was 85% by young echocardiographers and 88% by senior ones. QRS-LASr young median time was 110 s (interquartile range, IR, 78-149) vs senior 110 s (IR 78-155); for P-LASr, 120 s (IR 80-165) and 120 s (IR 90-161), respectively. LA strain was feasible in the majority of patients with similar reproducibility for both methods. QRS complex guaranteed a slightly higher feasibility and a lower time wasting compared to the use of P wave as the reference