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Aims To determine the prevalence of mitral regurgitation (MR) in a large cohort of consecutive patients undergoing clinically indicated echocardiography and to examine the distribution of primary and secondary MR Methods and results All patients undergoing an echocardiographic study in 19 European centres within a 3-month period were prospectively included. MR assessment was performed as recommended by the European Association of Cardiovascular Imaging (EACVI). MR was classified according to mechanism as primary or secondary and aetiologies were reported. A total of 63 463 consecutive echocardiographic studies were reviewed. Any degree of MR was described in 15 501 patients. Concomitant valve disease of at least moderate grade was present in 28.5% of patients, being tricuspid regurgitation the most prevalent. In the subgroup of moderate and severe MR (n = 3309), 55% of patients had primary MR and 30% secondary MR. Both mechanisms were described in 14% of the studies. According to Carpentier's classification, 26.7% of MR were classified as I, 19.9% of MR as II, 22.4% of MR as IIIa, and 31.1% of MR as IIIb Conclusion To date, this is the largest echocardiography-based study to analyse the prevalence and aetiology distribution of MR in Europe. The burden of secondary MR was higher than previously described, representing 30% of patients with significant MR. In our environment, degenerative disease is the most common aetiology of primary MR (60%), whereas ischaemic is the most common aetiology of secondary MR (51%). Up to 70% of patients with severe primary MR may have a Class I indication for surgery. However, the optimal therapeutic approach for secondary MR remains uncertain.

Although mitral regurgitation (MR) is a well-recognized prognosis factor, its true prevalence is probably underestimated and its etiology and mechanisms have not been sufficiently explored. The study aim was to evaluate the burden of MR, focusing attention on its frequency, severity, etiology, mechanism, and other associated conditions.Between February and June 2015, a total of 39,855 consecutive echocardiographic studies was performed at nine tertiary hospitals, and were prospectively included in the study. MR severity was graded into four groups, ranging from none or trace to severe MR, in accordance with the recommendations of the European Association of Cardiovascular Imaging. Patients with moderate to severe MR were selected for the analysis.MR was detected in 22.6% of cases. MR severity was mild in 82.5% of patients (n = 7,376), moderate in 11.7% (n = 1,048), and severe in 5.8% (n = 521). Concomitant valvular heart disease was present in 3,544 patients (39.7%), with tricuspid regurgitation the most frequently encountered (21.6%). Among moderate and severe MR, primary MR was more frequent than secondary MR (58.8% versus 23.5%), with degenerative valve disease being the most common cause of primary MR (49.2%). A third group composed of mixed forms of MR was described in 17.8% of cases.MR is a common finding on echocardiography, and is frequently associated with other valvular heart disease. Most MRs are of degenerative origin. The primary and secondary forms of MR differ significantly in their clinical presentation with regard to gender, age, and ventricular function. There appears to be a gap for a 'mixed' group, though further studies are needed to confirm this suggestion.

Resumen Introduccion y objetivos La regurgitacion mitral sintomatica tiene un pronostico desfavorable sin tratamiento quirurgico. Sin embargo, segun el registro europeo de enfermedad cardiaca valvular, no se intervino al 49% de los pacientes en esa situacion. El tratamiento percutaneo de la regurgitacion mitral con MitraClip® se ha demostrado seguro y eficaz anadido al tratamiento medico en este perfil de pacientes. El objetivo de este trabajo es describir la experiencia inicial con MitraClip® en Espana. Metodos Estudio observacional retrospectivo que incluye a todos los pacientes tratados desde noviembre 2011 hasta julio 2013 por los cuatro hospitales espanoles con mayor numero de implantes. Resultados Se trato a 62 pacientes (el 77,4% varones), principalmente con regurgitacion mitral funcional restrictiva (85,4%), de gravedad grado III (37%) o IV (63%), fraccion de eyeccion media del 36 ± 14% y clase funcional de la New York Heart Association III (37%) o IV (63%). En el 98% de los pacientes, se implanto con exito el dispositivo. Al ano, el 81,2% tenia regurgitacion mitral ≤ 2 y el 90,9% en clase funcional de la New York Heart Association ≤ II . Hubo un solo caso de mortalidad periprocedimiento (sepsis 20 dias despues del implante) y otros 3 fallecimientos en el seguimiento (media, 9,1 meses). Fue necesario implantar un nuevo dispositivo por dehiscencia parcial del previo a 2 pacientes y se sometio a trasplante cardiaco a otros 2. Conclusiones El tratamiento con MitraClip® en Espana se ha dirigido principalmente a pacientes con insuficiencia mitral funcional, disfuncion ventricular sistolica significativa y elevado riesgo quirurgico, y se perfila como una opcion segura de tratamiento con capacidad de reducir la regurgitacion mitral y mejorar la capacidad funcional.

We present a case report of an 80-year-old frail woman with hemolytic anemia and cardiac failure secondary to mitral severe paravalvular regurgitation. Her clinical history was significant for mitral valve replacement that was complicated with a paravalvular leak two months after surgery. The leak was closed percutaneously with an Amplatzer Vascular Plug III single device. A year later she is readmitted with heart failure and the transesophageal echocardiogram revealed a severe paravalvular leak beside the Vascular Plug III device that seemed to be dislodged and rocking. During a new attempt of percutaneous leak closure, while trying to lasso the old device, it embolized to the iliac bifurcation. The old device could be removed from the right femoral artery and the leak could be closed with two new Vascular Plug III devices deployed simultaneously. To our knowledge this is the first reported case of a late embolization of a Vascular Plug III device. © 2013 Wiley Periodicals, Inc.

Aims: To evaluate how often patients with moderate-to-severe or severe mitral regurgitation (MR) meet the anatomical criteria for MitraClip implant and to examine the role of transthoracic echocardiography (TTE) for this task. Methods and Results: From February to June 2015, all patients undergoing a TTE in nine Spanish hospitals were prospectively included. Patients with moderate-to-severe and severe mitral regurgitation were selected for analysis. Anatomical eligibility criteria for MitraClip were defined according to the EVEREST trial. A total of 39 855 consecutive TTE were reviewed, and 1403 patients with moderate-to-severe and severe MR were finally included. Primary MR was found in 779 patients (56%). Only in 74 patients (16%), all anatomical criteria for MitraClip could be assessed by TTE. Of these, 56% of patients had optimal valve morphology. Secondary MR was described in 361 patients (26%), and at least 249 of these (69%) had a high surgical risk. All five criteria for MitraClip were adequately assessed by TTE in 299 patients (83%). Of them, 118 patients (39%) had optimal valve morphology. Conclusions: A considerable proportion of patients have optimal mitral valve morphology for MitraClip. Moreover, TTE was particularly useful in determining whether or not the anatomical criteria for MitraClip implant were met in the majority of patients with secondary MR but in only a minority of those with primary MR.

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Mitral regurgitation is the most prevalent valvular heart disease in the United States and the second most prevalent in Europe. Patients with severe mitral regurgitation have a poor prognosis with medical therapy once they become symptomatic or develop signs of significant cardiac dysfunction. However, as many as half of these patients are inoperable because of advanced age, ventricular dysfunction, or other comorbidities. Studies have shown that surgery increases survival in patients with organic mitral regurgitation due to valve prolapse but has no clinical benefit in those with functional mitral regurgitation. In this scenario, percutaneous repair for mitral regurgitation in native valves provides alternative management of valvular heart disease in patients at high surgical risk. Percutaneous repair for mitral regurgitation is a growing field that relies heavily on imaging techniques to diagnose functional anatomy and guide repair procedures.

Paciente varon de 46 anos con antecedentes de hipercolesterolemia y obesidad, que fue admitido en el servicio de urgencias del hospital con diagnostico de sindrome coronario agudo con elevacion del segmento ST en V1 y V2. Se realizo coronariografia invasiva emergente, que mostro lesion del 30% tanto en el origen de la arteria descendente anterior y como en el origen de la arteria descendente posterior. Ante dicho resultado, se decidio completar el estudio con cardiorresonancia magnetica, que mostro alteracion de la contractilidad segmentaria a nivel de camara de salida del ventriculo derecho (figura 1, flecha en panel superior), que coincidia con una zona de captacion de contraste tardia compatible con necrosis (figura 1, flechas en el panel inferior). Un posterior estudio por angiografia coronaria no invasiva por tomografia computarizada con multidetectores confirmo las lesiones objetivadas en el cateterismo y mostro, ademas, una rama conal de distribucion en el area infartada con oclusion trombotica en su origen (figuras 2A y B, flechas). Tal lesion habia pasado inadvertida en el cateterismo, pero en una de las proyecciones reanalizadas se visualizaba el munon correspondiente al origen de dicha rama conal ocluida (figura 2C, flecha). El caso ilustra la alta sensibilidad de la cardiorresonancia magnetica en la deteccion de areas de necrosis de cualquier localizacion, asi como la utilidad de combinar la tomografia computarizada con multidetectores para un analisis integral de la enfermedad arterial coronaria. Contraste tardio Sistole Diastole

A 78-year-old woman with a history of coronary artery bypass grafting underwent transapical transcatheter aortic valve replacement with a Sapien XT (Edwards, Irvine, California) prosthesis that was complicated by an apical left ventricular pseudoaneurysm (LVPA). Unsuccessful attempts at closure

Introduction and objectives Symptomatic mitral regurgitation has an unfavorable prognosis unless treated by surgery. However, the European registry of valvular heart disease reports that 49% of patients with this condition do not undergo surgery. Percutaneous treatment of mitral regurgitation with MitraClip ® has been proved a safe, efficient adjunct to medical treatment in patients with this profile. The objective of the present study is to describe initial experience of MitraClip ® therapy in Spain. Methods Retrospective observational study including all patients treated between November 2011 and July 2013 at the 4 Spanish hospitals recording the highest numbers of implantations. Results A total of 62 patients (77.4% men) were treated, mainly for restrictive functional mitral regurgitation (85.4%) of grade III (37%) or grade IV (63%), mean (standard deviation) ejection fraction 36% (14%), and New York Heart Association functional class III (37%) or IV (63%). Device implantation was successful in 98% of the patients. At 1 year, 81.2% had mitral regurgitation ≤ 2 and 90.9% were in New York Heart Association functional class ≤ II. One periprocedural death occurred (sepsis at 20 days post-implantation) and another 3 patients died during follow-up (mean, 9.1 months). Two patients needed a second implantation due to partial dehiscence of the first device and 2 others underwent heart transplantation. Conclusions In Spain, MitraClip ® therapy has principally been aimed at patients with functional mitral regurgitation, significant systolic ventricular dysfunction, and high surgical risk. It is considered a safe alternative treatment, which can reduce mitral regurgitation and improve functional capacity.

Time-resolved, 3-dimensional phase-contrast magnetic resonance imaging (3D+t PCMRI) is employed to obtain complete spatial and temporal coverage of the vessels blood combined with spatially registered 3-directional pulsatile blood flow velocities[1][2]. Recent studies have reported that Wall Shear Stress (WSS) quantification from PCMRI are able to use the WSS as biomarkers for different aortas pathologies [3]. Figure [1] shows the pathline visualization of blood flow during one cardiac cycle in the heart of a healthy patient at peak early LV filling, diastasis, peak atrial contraction, and peak systole.

Presentamos un caso excepcional de tratamiento con cuatro dispositivos MitraClip en un paciente varon de 72 anos afecto de una miocardiopatia isquemica. Se presento en 1985 con un infarto anterior no revascularizado. En 2004 sufrio 2 episodios coronarios agudos, y una coronariografia mostro oclusion de la arteria descendente anterior. El estudio isotopico mostro ligera isquemia anterolateral, con necrosis apical e inferior, para lo que se decidio un manejo conservador. Durante el seguimiento presento remodelado ventricular negativo, reduccion importante de la fraccion de eyeccion y una insuficiencia mitral secundaria importante. Tras la terapia de resincronizacion mejoro su capacidad funcional, aunque transitoriamente, por lo que se le remitio para la valoracion de MitraClip. Partiendo de una valvula mitral con area de 5 cm, gradiente medio basal de 2 mmHg y regurgitacion de grado III-IV (figuras A-C), tras el implante de cuatro clips (figura D) quedo sin regurgitacion (figura E) y con un gradiente medio final de 4 mmHg sin incremento de las presiones de llenado en la auricula izquierda (el patron Doppler de las venas pulmonares paso de una inversion de la onda sistolica de llenado auricular antes del procedimiento a su normalizacion). Las figuras B y C muestran la apertura valvular mitral antes del procedimiento en ecocardiografia transesofagica tridimensional (figura B) y en un modelo esquematico (figura C). Tras el implante de los cuatro MitraClips, observamos la union de la zona central con la apertura de los 2 orificios laterales caracteristicos de este procedimiento, con representacion en la ecocardiografia transesofagica tridimensional (figura F) y en el modelo esquematico (figura G).

Presentamos un caso de hipoperfusion miocardica detectada excepcionalmente por tomografia computarizada secundaria a una diseccion aortica aguda con afectacion coronaria. Se trataba de un paciente varon de 55 anos con el unico antecedente de hipertension arterial. Consulto a urgencias de nuestro centro por dolor centrotoracico y abdominal intenso, con signos de mala perfusion periferica y asimetria de pulsos. El ECG presentaba un ritmo sinusal con supradesnivel del ST en I, aVL, V1 y V2 y cambios especulares en II, III y aVF. Ante la sospecha de un sindrome aortico agudo con afectacion coronaria, se realizo una tomografia computarizada toracoabdominal con adquisicion prospectiva, sincronizada con el ECG, que mostro la presencia de una diseccion aortica tipo I de DeBakey (figura A). La puerta de entrada se situaba a nivel del tronco braquiocefalico, con afectacion retrograda hasta la raiz aortica y diseccion del ostium del tronco coronario izquierdo (TCI), sin afectar a la arteria coronaria derecha (figura B, asterisco). Las arterias coronarias no presentaban lesiones ateroscleroticas estenoticas. La luz verdadera del TCI mostraba trombosis secundaria a compresion extrinseca desde la luz falsa (figura B, flecha), hallazgos confirmados quirurgicamente. El miocardio ventricular izquierdo mostraba amplia hipodensidad en los segmentos dependientes del TCI (figuras C y D, flechas); el infarto se confirmo analiticamente, con extensa acinesia anterolateral en el ecocardiograma. El paciente fue intervenido de sustitucion de aorta ascendente y arco aortico (elephant trunk) con resuspension de comisuras de la valvula aortica. El curso posquirurgico tuvo un desenlace fatal por insuficiencia cardiaca y sepsis refractarias al tratamiento. Figura.

Computational simulations of the heart are a powerful tool for a comprehensive understanding of cardiac function and its intrinsic relationship with its muscular architecture. Cardiac biomechanical models require a vector field representing the orientation of cardiac fibers. A wrong orientation of the fibers can lead to a non-realistic simulation of the heart functionality. In this paper we explore the impact of the fiber information on the simulated biomechanics of cardiac muscular anatomy. We have used the John Hopkins database to perform a biomechanical simulation using both a synthetic benchmark fiber distribution and the data obtained experimentally from DTI. Results illustrate how differences in fiber orientation affect heart deformation along cardiac cycle.

We present a case report of an 80-year-old frail woman with hemolytic anemia and cardiac failure secondary to mitral severe paravalvular regurgitation. Her clinical history was significant for mitral valve replacement that was complicated with a paravalvular leak two months after surgery. The leak was closed percutaneously with an Amplatzer Vascular Plug III single device. A year later she is readmitted with heart failure and the transesophageal echocardiogram revealed a severe paravalvular leak beside the Vascular Plug III device that seemed to be dislodged and rocking. During a new attempt of percutaneous leak closure, while trying to lasso the old device, it embolized to the iliac bifurcation. The old device could be removed from the right femoral artery and the leak could be closed with two new Vascular Plug III devices deployed simultaneously. To our knowledge this is the first reported case of a late embolization of a Vascular Plug III device.

Cardiac magnetic resonance imaging (Cardiac MRI) has become a gold standard diagnostic technique for the assessment of cardiac mechanics, allowing the non-invasive calculation of left ventricular long axis longitudinal shortening (LVLS) and absolute myocardial torsion (AMT) between basal and apical left ventricular slices, a movement directly related to the helicoidal anatomic disposition of the myocardial fibers. The aim of this study is to determine AMT and LVLS behaviour and normal values from a group of healthy subjects. A group of 21 healthy volunteers (15 males) (age: 23-55 y.o., mean: 30.7 +/- A 7.5) were prospectively included in an observational study by Cardiac MRI. Left ventricular rotation (degrees) was calculated by custom-made software (Harmonic Phase Flow) in consecutive LV short axis planes tagged cine-MRI sequences. AMT was determined from the difference between basal and apical planes LV rotations. LVLS (%) was determined from the LV longitudinal and horizontal axis cine-MRI images. All the 21 cases studied were interpretable, although in three cases the value of the LV apical rotation could not be determined. The mean rotation of the basal and apical planes at end-systole were -3.71A degrees A A +/- A 0.84A degrees and 6.73A degrees A A +/- A 1.69A degrees (n:18) respectively, resulting in a LV mean AMT of 10.48A degrees A A +/- A 1.63A degrees (n:18). End-systolic mean LVLS was 19.07 +/- A 2.71%. Cardiac MRI allows for the calculation of AMT and LVLS, fundamental functional components of the ventricular twist mechanics conditioned, in turn, by the anatomical helical layout of the myocardial fibers. These values provide complementary information about systolic ventricular function in relation to the traditional parameters used in daily practice.

Myocardium deformation and displacement analysis by echocardiography has proven useful to evaluate the synchrony of myocardial mechanics. The aim of our study was to evaluate the mean standard deviation of time to longitudinal peak displacement in 16 cardiac segments by 3D echo wall motion Speckle Tracking analysis. We studied 15 patients with ventricular dyssynchrony-defined by a QRS > 120 ms in the ECG. We obtained the differences between time peaks of endocardial longitudinal displacement for 16 segments of the heart by 3D echo Speckle Tracking. We compared the temporal dispersion of these peaks with results obtained in a control group of 13 healthy individuals without dyssynchrony. The results showed a significant difference (p < 0,001) between the dispersion of standard deviation in the 13 patients in the control group (34 ms +/- A 19) and the 15 patients in the dyssynchrony group (117 ms +/- A 57). We describe a new parameter obtained by 3D echo wall motion Speckle Tracking analysis for the detection of dyssynchrony. It can be useful to identify dyssynchrony of left ventricular myocardial mechanics, to indicate the resynchronization therapy, to optimize the parameters of the device and to achieve a less operator-dependent evaluation.

Un varon de 84 anos sin antecedentes patologicos de interes previos, consulto por un infarto inferoposterior de mas de 24 h de evolucion. Se le practico una coronariografia, que mostro una oclusion de la rama posterolateral, con trombo organizado, que no se pudo revascularizar, y quedo con un flujo TIMI I. El paciente se mantuvo asintomatico y estable, hasta que 4 dias mas tarde sufrio un nuevo dolor opresivo asociado a hipotension; en la ecocardiografia se observaba una comunicacion interventricular (CIV) septoinferomedial (figura A). Se desestimo la opcion quirurgica por un EuroSCORE de mortalidad > 20% y, con vistas a la reparacion transcateter, se realizo una tomografia computarizada (TC) cardiaca. Mostro una CIV de 22 mm con un septum desflecado hacia el ventriculo derecho (figura B). Con estos hallazgos, se decidio cerrar la CIV realizando un asa venovenosa femoroyugular (femoral derecha-transeptal-auricula izquierdaventriculo izquierdo-ventriculo derecho-auricula derecha-vena yugular) que permitiera liberar primero el disco en el ventriculo derecho y atraer todo el tejido desflecado alineando el septum. Mediante esta tecnica se implanto con exito un dispositivo para oclusion de CIV tras infarto Amplatzer de 24 mm (figuras C y D). El paciente evoluciono satisfactoriamente y en el seguimiento a los 16 meses seguia vivo, en clase funcional II y con un QP/QS residual de 1,8. Este caso demuestra la gran utilidad de la TC para perfilar el septo interventricular y determinar el tamano del defecto, los bordes y la anfractuosidad de las CIV tras infarto aportando informacion esencial para las estrategias de cierre transcateter.

A 70-year-old male diagnosed with idiopathic pulmonary artery dilatation at 23. The patient was asymptomatic until the age of 68, when he started with exertional dyspnoea and was found to have a chronic pulmonary artery dissection with …