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Background Current evidence suggests that Brugada syndrome (BrS), far from being a purely electrical condition, is associated with subtle mechanical abnormalities primarily affecting the right ventricle (RV). We aimed to characterize RV function in BrS and investigate the echocardiographic profile of patients with arrhythmic events, with a special focus on parameters of RV dyssynchrony using speckle-tracking echocardiography (STE). Methods An echocardiogram was performed in 71 BrS patients and 25 healthy controls. STE was performed to assess regional and global RV mechanics, including RV outflow tract shortening (RVOTS). RVOT contraction time was considered to calculate the modified RV mechanical dispersion (RVMDm). Arrhythmic events were prospectively evaluated in the BrS cohort. Results Compared to controls, BrS patients showed subtle contractile abnormalities, including impaired RV longitudinal strain, higher RV index of myocardial performance (RIMP) and lower RVOTS. BrS patients also exhibited a greater contraction delay between the lateral and the septal aspect of the RV. After a median follow-up of 7.3 year (IQR 5.2–10.8), 6 patients presented malignant arrhythmic events. RIMP >0.50, RVOTS 42 ms showed high sensitivity for the identification of BrS patients with arrhythmic events during follow-up. Conclusions Subtle RV mechanical abnormalities were present in BrS patients. RIMP and RVOTS, a novel STE-derived parameter, were found to be sensitive markers of arrhythmic events. Adding the RVOT contraction time to the analysis of RVMD may help identify patients at higher risk, reflecting the importance of the RVOT mechanical substrate in the assessment of the arrhythmic risk in BrS.

Cardiac amyloidosis (CA) is produced by amyloid fiber deposition in the myocardium. The most frequent forms are those caused by light chains (AL) and transthyretin (ATTR). Our objective was to describe the diagnosis, treatment and outcomes of CA in a specialized Spanish center.We included all patients diagnosed with CA in Hospital Universitario Puerta de Hierro Majadahonda from May 2008 to September 2018. We analyzed their clinical characteristics, outcomes, and survival.We included 180 patients with CA, of whom 64 (36%) had AL (50% men; mean age, 65±11 years) and 116 had ATTR (72% men; mean age 79±11 years; 18 with hereditary ATTR). The most common presentation was heart failure in both groups (81% in AL and 45% in ATTR, P.01). Other forms of presentation in ATTR patients were atrial arrhythmias (16%), conduction disorders (6%), and incidental finding (6%); 70 patients (40%), had a previous alternative cardiac diagnosis. Diagnosis was noninvasive in 75% of ATTR patients. Diagnostic delay was higher in ATTR (2.8±4.3 vs 0.6±0.7 years, P.001), but mortality was greater in AL patients (48% vs 32%, P=.028). Independent predictors of mortality were AL subtype (HR, 6.16; 95%CI, 1.56-24.30; P=.01), female sex (HR, 2.35; 95%CI, 1.24-4.46; P=.01), and NYHA functional class III-IV (HR, 2.07; 95%CI, 1.11-3.89; P=.02).CA is a clinical challenge, with wide variability in its presentation depending on the subtype, leading to diagnostic delay and high mortality. Improvements are needed in the early diagnosis and treatment of these patients.

Previous studies using conventional echocardiographic measurements have reported subclinical left ventricular (LV) diastolic abnormalities in patients with Marfan syndrome (MFS). Left atrial (LA) strain allows an accurate categorization of LV diastolic dysfunction. We aimed to characterize LV myocardial performance in a cohort of MFS patients using STE-derived measurements (LV and LA strain) along with conventional echocardiographic parameters. We studied 127 adult patients with MFS (no prior cardiac surgery or significant valvular regurgitation) and 38 healthy controls. We performed detailed echocardiograms and selected left atrial reservoir strain (LASr) as a surrogate of impaired relaxation. Additionally, we searched for possible determinants of LASr in patients with MFS, with a special focus on the elastic properties of the aorta. In spite of lower E-wave, septal and lateral e’ velocities and average E/e’ ratio in MFS patients, all participants had normal diastolic function according to current guidelines. MFS patients exhibited reduced LV global longitudinal strain (19.3 ± 2.6 vs 21.6 ± 2.1%, p

Introducción y objetivos La amiloidosis cardiaca (AC) se produce por depósito de fibras de amiloide en el miocardio. Las formas más frecuentes son la amiloidosis por cadenas ligeras (AL) y por transtiretina (ATTR). Nuestro objetivo es describir la experiencia en el diagnóstico, tratamiento y pronóstico en un centro especializado español. Métodos Se incluyeron todos los pacientes diagnosticados de AC en el XXXX1 desde mayo de 2008 a septiembre de 2018 y se analizaron sus características clínicas, evolución y supervivencia. Resultados Se incluyeron 180 pacientes con AC, de los cuales, 64 (36%) eran AL (50% varones;65±11 años) y 116 ATTR (72% varones;79±11 años, 19 con ATTR hereditaria). La forma de presentación más frecuente fue la insuficiencia cardiaca en ambos grupos (81% AL y 45% ATTR;p

Se presenta una mujer de 78 años portadora de doble prótesis mecánica aórtica y mitral en la que, en el contexto de un accidente isquémico transitorio, se descubre una disfunción de la prótesis mitral. Dicha disfunción consistía en falta de apertura de uno de sus discos por la presencia de un trombo intraprotésico. El diagnóstico definitivo lo proporcionó la intervención quirúrgica después de un estudio exhaustivo. Se presentan las distintas técnicas de imagen que se emplearon para el estudio etiológico previo a la cirugía, y que incluyen ecocardiografía transtorácica y transesofágica, escopia con fluoroscopia y cardio-TC.

Varón de 42 años con antecedentes de coartación de aorta intervenida en la adolescencia que se presentó con insuficiencia cardíaca progresiva, requiriendo finalmente trasplante cardíaco. El diagnóstico mediante las técnicas de imagen, y confirmado por la anatomía patológica, fue de miocardiopatía restrictiva debida a fibroelastosis endocárdica con calcificaciones extensas. Se presentan los principales hallazgos de las técnicas de imagen en este paciente y se discuten las características clínicas más relevantes de esta rara enfermedad.

Learning objectives Hypertrophic cardiomyopathy (HCM) is the most common genetic cardiovascular disease, affecting 1 in 500 individuals in the general population. In 60% of cases, HCM presents an autosomal-dominant trait due to mutations in genes encoding cardiac sarcomeric proteins, and the remaining aetiologies include a variety of clinical entities such as glycogen and lysosomal storage disorders, mitochondrial diseases or cardiac amyloidosis (CA), among others.1 In all cases, a systematised echocardiographic approach is essential to establish the diagnosis of HCM and to decide on specific therapeutic strategies. Moreover, echocardiography plays a key role in the evaluation and guidance of the different options to tackle obstructive HCM (HOCM). Indeed, recent improvements in survival and quality of life in HCM might be attributed to several factors, including the development of reliable imaging techniques. On top of this, echocardiography provides valuable information for the management of HCM regarding other aspects beyond left ventricular outflow tract obstruction (LVOTO). This includes sudden cardiac death (SCD) prediction, thromboembolic risk stratification and family screening. In this article, we review and focus on the current role of echocardiography in the diagnosis and management of HCM. ### Role of echocardiography in the diagnosis and evaluation of HCM A systematic echocardiographic approach is essential to establish the diagnosis of HCM and should include the following features (summarised in figure 1). Figure 1 Echocardiographic assessment of hypertrophic cardiomyopathy (HCM): key points. LVOTO, left ventricular outflow tract obstruction; SAM, systolic anterior motion; WT, wall thickness. ### Left ventricular hypertrophy evaluation In individuals with suspected …

Acute cellular rejection (ACR) is still a relevant complication after orthotopic heart transplantation. The diagnosis of ACR is based on endomyocardial biopsy (EMB). Recent advances in two-dimensional strain imaging may allow early noninvasive detection of ACR. The objective of this study was to analyze the usefulness of conventional and new echocardiographic parameters to exclude ACR after orthotopic heart transplantation.Thirty-four consecutive adult heart transplant recipients admitted to a single center between January 2010 and December 2012 for orthotopic heart transplantation were prospectively included. A total of 235 pairs of EMB and echocardiographic examination were performed. A median of seven studies per patient (interquartile range, six to eight studies per patient) were performed during the first year of follow-up. Classic echocardiographic parameters; speckle-tracking-derived left ventricular (LV) longitudinal, radial, and circumferential strain; and global and free wall right ventricular (RV) longitudinal strain were analyzed.ACR was detected in 26.4% of EMB samples (n = 62); 5.1% (n = 12) required specific treatment (ACR degree ≥ 2R). Lower absolute values of global LV longitudinal strain and free wall RV longitudinal strain were present in patients with ACR degree ≥ 2R compared with those without ACR (13.7 ± 2.7% vs 17.8 ± 3.4% and 16.6 ± 3.6% vs 23.3 ± 5.2%, respectively). An average LV longitudinal strain15.5% had 85.7% sensitivity, 81.4% specificity, 98.8% negative predictive value, 25.0% positive predictive value, and 81.7% accuracy for the presence of ACR degree ≥ 2R. Free wall RV longitudinal strain17% had 85.7% sensitivity, 91.1% specificity, 98.8% negative predictive value, 42.9% positive predictive value, and 90.7% accuracy for ACR degree ≥ 2R. Both variables were normal in 106 echocardiograms (57.6%); none of these patients presented with ACR degree ≥ 2R.The combination of two new echocardiographic measures, global LV and RV free wall longitudinal strain, may be able to identify a group of heart transplant patients who are unlikely to have ACR. If these findings are confirmed independently, it may be possible to use LV and RV strain measures as reliable tools to exclude ACR and to reduce the burden of repeated EMB.

Resumen Introduccion y objetivos La vasculopatia del aloinjerto cardiaco afecta tanto al compartimento coronario epicardico como al de la microcirculacion. Se ha propuesto el uso de las tecnicas de imagen de perfusion de la resonancia magnetica como instrumento util para la evaluacion de la microcirculacion, principalmente fuera del contexto del trasplante de corazon. La pendiente de velocidad del flujo-presion diastolica hiperemica instantanea, que es un indice de la fisiologia intracoronaria, ha mostrado mejor correlacion con el remodelado microcirculatorio en la vasculopatia del aloinjerto cardiaco que la de otros indices como la reserva de velocidad del flujo coronario. Con objeto de investigar el potencial de las tecnicas de imagen de perfusion de resonancia magnetica para detectar la presencia de remodelado microcirculatorio en la vasculopatia de aloinjerto cardiaco, se ha comparado los datos de perfusion de resonancia magnetica con los indices fisiologicos intracoronarios invasivos, para estudiar la microcirculacion en una poblacion de pacientes con trasplante de corazon que presentaban una enfermedad macrovascular no obstructiva demostrada por la ecografia intravascular. Metodos Se estudio a 8 pacientes con trasplante de corazon (media de edad, 61 ± 12 anos; el 100% varones) que presentaban una vasculopatia del aloinjerto epicardica definida por ecografia intravascular, estenosis coronarias no significativas y una resonancia magnetica de estres con dobutamina con evaluacion visual del movimiento de la pared/perfusion negativa. Se determinaron los datos de perfusion de resonancia magnetica cuantitativa en estres y en reposo para establecer el indice de reserva de perfusion miocardica, de manera no invasiva, y se determinaron cuatro indices fisiologicos intracoronarios evaluados de manera invasiva. Resultados Los datos posprocesados mostraron una media del indice de reserva de perfusion miocardica de 1,22 ± 0,27, mientras que la reserva de flujo fraccional, la reserva de velocidad del flujo coronario, la resistencia microvascular hiperemica y la pendiente de velocidad del flujo-presion diastolica hiperemica instantanea fueron de 0,98 ± 0,02, 2,34 ± 0,55, 2,00 ± 0,69 y 0,91 ± 0,65 cm/s/mmHg respectivamente. El indice de reserva de perfusion miocardica presento una correlacion intensa tan solo con la pendiente de velocidad del flujo-presion diastolica hiperemica instantanea (r = 0,75; p = 0,033). Conclusiones El indice de reserva de perfusion miocardica obtenido a partir de la resonancia magnetica de estres con dobutamina completa resulta una tecnica fiable para la deteccion no invasiva de la enfermedad coronaria microcirculatoria asociada a la vasculopatia de aloinjerto cardiaco.

Background Evolution of left and right ventricular (LV and RV) function after heart transplantation (HT) has not been well described. Our objective was to evaluate the evolution of echocardiographic parameters of both ventricles along the first 2 years after HT. Methods We followed 31 HT recipients with serial echocardiograms for up to 2 years. Echocardiograms with AR ≥2R were excluded. We analyzed LV global longitudinal strain (LV GLS) by speckle tracking in 12 segments in four- and two-chamber views and RV global longitudinal strain (RV GLS) in four-chamber view. Control group included 25 healthy volunteers. Results Even though LVEF was preserved, LV GLS was reduced early post-HT (−17.7 ± 3.0 in HT vs. −20.7 ± 2.8 in controls, P = 0.02), improving progressively until its complete normalization 2 years after HT (−20.0 ± 3.7 vs. −20.7 ± 2.8, P = 0.60). TAPSE was impaired in the early post-HT period and increased progressively (11.9 ± 2.9 mm at baseline vs. 19.0 ± 3.6 mm at 2 years, P < 0.001). RV GLS rose during follow-up as well (−17.4 ± 3.5 at baseline vs. −22.6 ± 3.3 at 2 years, P = 0.001), reaching normal values 1 year after HT. Conclusion In this series of HT recipients with uneventful postoperative course, LV and RV GLS values were significantly reduced early after HT and improved progressively until their complete normalization two and 1 year after HT, respectively. This is the first study to show a full recovery of LV and RV deformation parameters and offers “normal” strain values that, if confirmed in larger studies, could be useful for monitoring the evolution of HT recipients.

ObjetivosLa reparación valvular (RV) es el tratamiento quirúrgico ideal de la insuficiencia mitral (IM). Evaluamos los resultados de la RV en pacientes con IM crónica intervenidos en nuestro centro en los últimos 8 años.MétodosEntre enero de 1997 y mayo de 2004, 70 pacientes con IM crónica fueron sometidos a RV. El 16% tenía una fracción de eyección ventricular izquierda (FEVI) ≤39%. La etiología de la IM fue degenerativa en 36 casos, isquémica en 11, miocardiopatía hipertrófica en 10, miocardiopatía dilatada en cinco, endocarditis en cuatro y reumática en cuatro. Las plastias más frecuentes fueron: resección cuadrangular de velo posterior y anillo (n=25), Alfieri (n=18), anillo (n=14) y plicatura del velo anterior (n=10).ResultadosEl seguimiento medio fue de 38±22 meses. Los grados de IM y disnea mejoraron significativamente tras la RV. La FEVI se preservó tras la cirugía, el diámetro telediastólico del ventrículo izquierdo disminuyó y el telesistólico lo hizo sólo en el grupo con FEVI deprimida. La mortalidad hospitalaria fue del 2,8 y 9% en el grupo con disfunción ventricular. La supervivencia global y libre de reoperación fue del 95,7±2,4% y 94,6±3,1% a los 3 años, respectivamente.ConclusionesLa RV produce una adecuada corrección de la IM, con una morbimortalidad y una tasa de reoperación bajas, previene la disfunción sistólica posquirúrgica y revierte el remodelado ventricular. En pacientes con disfunción sistólica preoperatoria se puede realizar de forma segura y puede constituir una alternativa al trasplante en casos seleccionados.ObjectivesValve repair (VR) is the ideal surgical therapy for mitral regurgitation (MR). We evaluate the surgical results in patients with chronic MR that underwent VR at our center during the past 8 years.MethodsBetween January 1997 and May 2004, 70 patients with chronic MR underwent VR. 16% had a left ventricular ejection fraction (LVEF) δ39%. The etiology of MR was degenerative in 36 cases, ischemic in 11, hypertrophic cardiomyopathy in 10, dilated cardiomyopathy in 5, endocarditis in 4, and rheumatic in 4. Most frequently performed valvuloplasties were: posterior leaflet quadrangular resection plus annuloplasty (n=25), Alfieri repair (n=18), annuloplasty (n=14), and anterior leaflet plication (n=10).ResultsMean follow-up was 38±22 months. After VR, the degree of MR and dyspnea significantly improved, LVEF was preserved, left ventricle end-diastolic diameter decreased and endsystolic diameter was reduced only in low LVEF group. Overall hospital mortality was 2.8 and 9% in low LVEF group. Overall survival and reoperation- free survival were 95.7±2.4% and 94.6±3.1% at 3 years, respectively.ConclusionsVR leads to an adequate correction of MR with a low morbidity, mortality and reoperation rate; it prevents postoperative systolic dysfunction and ventricular remodeling. In patients with preoperative ventricular impairment VR can be safely performed and should be considered an alternative to transplantation in selected cases.

La reparacion valvular es el tratamiento quirurgico ideal de la insuficiencia mitral. En este trabajo presentamos los resultados de la reparacion valvular en pacientes con insuficiencia mitral cronica operados en nuestro centro durante los ultimos 8 anos. Analizamos el grado de correccion de la insuficiencia, el beneficio funcional, la morbimortalidad hospitalaria, la evolucion posquirurgica de la funcion ventricular y la supervivencia global y libre de reoperacion a medio plazo.

Valve repair is the best surgical treatment for mitral regurgitation. In the present article we describe the results of mitral valve repair in patients with chronic mitral regurgitation treated at our center during the last eight years. The degree of correction of valve insufficiency, functional benefit, in-hospital morbidity and mortality, postoperative outcome of ventricular function, and middle-term overall and reoperation-free survival are analyzed.

La terapia de resincronizacion cardiaca produce mejoria sintomatica y hemodinamica en pacientes con insuficiencia cardiaca avanzada y asincronia ventricular. Los resultados de diferentes estudios han demostrado de forma consistente que la resincronizacion produce mejoria significativa de la calidad de vida, capacidad de ejercicio y de la funcion cardiaca, objetivandose una reduccion significativa de la mortalidad total y del numero de hospitalizaciones en pacientes tratados con insuficiencia cardiaca avanzada, en clase funcional de la New York Heart Association (NYHA) III o IV a pesar de tratamiento medico optimo y de un complejo QRS ancho. Claramente, el tratamiento de la insuficiencia cardiaca requiere, en el momento actual, una colaboracion multidisciplinaria entre los clinicos especialistas en insuficiencia cardiaca, electrofisiologos y cirujanos. Sin embargo, hasta el 30% de los pacientes puede no beneficiarse de esta terapia. Se estan investigando nuevos marcadores de asincronia, como la determinacion de asincronia guiada por ecocardiografia, en un intento de mejorar la identificacion de los respondedores. Actualmente se esta investigando el beneficio de la terapia de resincronizacion en otros grupos de pacientes que potencialmente se podrian beneficiar de ella, como aquellos en fibrilacion auricular (aproximadamente el 20-30% de los pacientes con insuficiencia cardiaca severa), asincronia secundaria a estimulacion convencional derecha, o en clase II de la NYHA. En pacientes con insuficiencia cardiaca avanzada y complejo QRS ancho que permanecen sintomaticos a pesar de recibir tratamiento medico optimo, la terapia de resincronizacion ha demostrado una reduccion de la morbimortalidad. Por tanto, actualmente deberia considerarse de forma sistematica en estos pacientes.

Introduccion y objetivos Un 5% de los pacientes con miocardiopatia hipertrofica obstructiva (MHO) tienen sintomas pertinaces al tratamiento medico y son candidatos a una terapia invasiva. El objetivo de este trabajo fue analizar nuestros resultados en la cirugia de la MHO durante los ultimos 10 anos. Pacientes y metodo Entre julio de 1993 y enero de 2004 hemos intervenido a 26 pacientes con MHO pertinaz a tratamiento farmacologico. El procedimiento realizado fue una miectomia septal extendida, que se asocio a plicatura del velo anterior mitral (PVA) en 19 (73%) casos y a reemplazo valvular mitral en 5 (19%). Se analizaron la evolucion posquirurgica del grado de disnea, el gradiente en el tracto de salida del ventriculo izquierdo (GTSVI), la insuficiencia mitral (IM) y el movimiento sistolico anterior (SAM). Resultados El seguimiento medio fue de 63 ± 37 meses. Tras la cirugia se produjo una reduccion significativa del GTSVI (de 96,5 a 19,5 mmHg; p Conclusiones La cirugia en pacientes con MHO produce una gran mejoria clinica con una baja morbimortalidad. Al tratar simultaneamente los componentes miocardico y valvular de la enfermedad, permite no solo reducir el GTSVI, sino corregir la IM y suprimir el SAM.

Introduction and objectives Cardiac allograft vasculopathy affects both epicardial and microcirculatory coronary compartments. Magnetic resonance perfusion imaging has been proposed as a useful tool to assess microcirculation mostly outside the heart transplantation setting. Instantaneous hyperemic diastolic flow velocity-pressure slope, an intracoronary physiology index, has demonstrated a better correlation with microcirculatory remodelling in cardiac allograft vasculopathy than other indices such as coronary flow velocity reserve. To investigate the potential of magnetic resonance perfusion imaging to detect the presence of microcirculatory remodeling in cardiac allograft vasculopathy, we compared magnetic resonance perfusion data with invasive intracoronary physiological indices to study microcirculation in a population of heart transplantation recipients with macrovascular nonobstructive disease demonstrated with intravascular ultrasound. Methods We studied 8 heart transplantation recipients (mean age, 61 [12] years, 100% male) with epicardial allograft vasculopathy defined by intravascular ultrasound, nonsignificant coronary stenoses and negative visually-assessed wall-motion/perfusion dobutamine stress magnetic resonance. Quantitative stress and rest magnetic resonance perfusion data to build myocardial perfusion reserve index, noninvasively, and 4 invasive intracoronary physiological indices were determined. Results Postprocessed data showed a mean (standard deviation) myocardial perfusion reserve index of 1.22 (0.27), while fractional flow reserve, coronary flow velocity reserve, hyperemic microvascular resistance and instantaneous hyperemic diastolic flow velocity-pressure slope were 0.98 (0.02), cm/s/mmHg, 2.34 (0.55) cm/s/mmHg, 2.00 (0.69) cm/s/mmHg and 0.91 (0.65) cm/s/mmHg, respectively. The myocardial perfusion reserve index correlated strongly only with the instantaneous hyperemic diastolic flow velocity-pressure slope ( r = 0.75; P = .033). Conclusions Myocardial perfusion reserve index derived from a comprehensive dobutamine stress magnetic resonance appears to be a reliable technique for noninvasive detection of microcirculatory coronary disease associated with cardiac allograft vasculopathy.

Introduccion y objetivos Recientemente se ha desarrollado la tecnica de MAZE como un procedimiento quirurgico efectivo para el tratamiento de la fibrilacion auricular refractaria al tratamiento medico. Este estudio trata de describir los riesgos y beneficios de realizar la tecnica de MAZE en aquellos enfermos con fibrilacion auricular que van a ser intervenidos de otra lesion cardiaca organica Material y metodos Desde noviembre de 1993, hemos realizado 10 intervenciones con la tecnica de MAZE, para el tratamiento de fibrilacion auricular refractaria. La indicacion para realizar la tecnica se establecio en 5 pacientes por existir un antecedente de embolismo sistemico bajo tratamiento anticoagulante, en dos casos por existir una contraindicacion absoluta para la anticoagulacion y en 5 casos por refractariedad al tratamiento antiarritmico. Dos pacientes presentaban mas de una indicacion. En todos los casos se realizo una cirugia acompanante, 5 reemplazos valvulares mitrales, una plastia mitral, otra tricuspide y tres cierres de comunicacion interauricular tipo ostium secundum. Resultados Inmediatamente tras la cirugia el ritmo auricular en 9 casos y de fibrilacion auricular en uno. Cuatro enfermos precisaron estimulacion auricular transitoria durante el postoperatorio. Una enferma requirio un marcapasos definitivo por bradicardia sinusal sintomatica. Durante los primeros 3 meses, 4 enfermos tuvieron episodios paroxisticos de fibrilacion o flutter auricular. De los diez pacientes uno fallecio subitamente un mes despues de la cirugia. Siete enfermos han completado el seguimiento a dos anos manteniendose en ritmo sinusal estable, con buena respuesta cronotropica y en grado funcional I, sin precisar ninguno de ellos tratamiento antiarritmico. Todos ellos tienen evidencia ecocardiografica de actividad mecanica en ambas auriculas, habiendose reducido el tamano de la auricula izquierda desde 5,3 ± 0,7 a 4,5 ± 0,7 cm (p Conclusiones La tecnica de MAZE es una buena alternativa en enfermos seleccionados con fibrilacion auricular refractaria a tratamiento medico o con antecedentes de embolismo sistemico. Sin embargo, no esta exenta de problemas que complican el manejo postoperatorio.

Cardiac Magnetic Resonance (CMR) imaging has recently become a very useful tool in the diagnosis of myocarditis. We describe a patient in whom acute myocarditis was presented as an acute myocardial infarction and had an atypical course with rapid normalization of ECG abnormalities. In this case CMR imaging was essential to confirm the diagnosis of myocarditis.

Myocarditis is a rare disease with variable clinical presentation and diverse electrocardiographic and echocardiographic features. Viral infection is the most common cause, but myocarditis can also be caused by bacterial infection. The most frequently involved bacterial agent is group A Streptococcus, which is also an etiologic agent of erysipelas. We present the case of a man aged 46 years with left-leg erysipelas who developed myocarditis. Cardiac magnetic resonance played an essential role in diagnosis. This case is, to our knowledge, the first description of an association between erysipelas and myocarditis.

About 30% of patients treated with cardiac resynchronization therapy (CRT) do not respond to treatment. The aim of this study was to identify clinical predictors of lack of improvement in patients receiving CRT. From 197 consecutive patients scheduled to receive CRT, 143 fulfilled the inclusion criteria. Mean age was 68 +/- 7 years and 79% were men. Heart failure was due to ischemic heart disease in 49 patients (34%). Mean QRS duration was 165 +/- 26 ms, and left ventricular ejection fraction was 27 +/- 7%. Nonresponder patients were defined as those who died of heart failure, underwent heart transplantation, or did not increase the distance walked in 6 minutes >10%. At 6-month follow-up, there were 28 nonresponders (20%). Among nonresponders, 2 patients received a heart transplantation and 9 patients died of heart failure. In logistic regression analysis, independent predictors of lack of response to CRT were ischemic heart disease (odds ratio [OR] 2.9, 95% confidence interval [CI] 1.2 to 7; p = 0.023), severe mitral regurgitation (OR 3.5, 95% CI 1.3 to 9; p = 0.014), and left ventricular end-diastolic diameter > or =75 mm (OR 3.1, 95% CI 1.1 to 8; p = 0.026). Patients with these 3 predictors had a probability response of 27%.

Transesophageal echocardiography is a semi-invasive diagnostic technique with a very low incidence of significant complications. Only two deaths related to the procedure have been reported in the literature. We present the case of a 46-year-old man with a right atrial mass, presumably a cardiac myxoma. During attempts at esophageal intubation for a transesophageal echocardiography procedure, the mass fragmented and dislodged, causing massive pulmonary embolism and death. We believe that to avoid this potential complication, great care must be taken in the evaluation of patients with a right intracardiac mass by means of transesophageal echocardiography.

A 65-year-old cardiac transplant recipient suffered rupture of the mitral valve apparatus during endomyocardial biopsy of the left ventricle. Severe mitral regurgitation resulted, and because of heart failure with progressive clinical deterioration the patient was finally subjected to mitral valve replacement. He had a favorable postoperative course and is now asymptomatic.

With the aim of assessing the effectiveness and safety of lovastatin in patients with hypercholesterolemia after heart transplantation, as well as the potential differences in the lipid-lowering effect of lovastatin between patients with or without pretransplant coronary artery disease (CAD), we studied 63 heart transplant patients who had serum total cholesterol250 mg/dl in spite of dietary therapy. Mean age of subjects was 47 +/- 2 years. Triple-drug immunosuppressive therapy consisted of cyclosporine, azathioprine, and steroids. Thirty-nine patients (62%) had pretransplant CAD and 24 (38%) did not. Pretreatment serum lipid levels were: total cholesterol, 302 +/- 32 mg/dl; low-density lipoprotein (LDL) cholesterol, 201 +/- 35 mg/dl; high-density lipoprotein (HDL) cholesterol, 60 +/- 19 mg/dl; triglycerides, 205 +/- 86 mg/dl; and total/HDL cholesterol ratio, 5.4 +/- 1.6. Patients received 10 to 40 mg/day of lovastatin (mean dose 17 +/- 6) for 13 +/- 4 months. There were no serious adverse events. At 3 months, lovastatin decreased total cholesterol by 15% (p0.001), LDL cholesterol by 21% (p0.001), triglycerides by 17% (p0.05), and total/HDL cholesterol ratio by 17% (p0.001), and increased HDL cholesterol by 3% (NS). Although lovastatin was effective in both patients with pretransplant CAD and non-CAD, analysis of its effect in each subgroup (CAD and non-CAD) revealed that its lipid-lowering effect was higher for non-CAD patients (-20% vs -12% for total cholesterol, and -27% vs -17% for LDL cholesterol, both p0.01).(ABSTRACT TRUNCATED AT 250 WORDS)