Public insurance program impact on catastrophic health expenditure on acute myocardial infarction

OBJECTIVE

ST-segment elevation myocardial infarction (STEMI) has an important economic burden that poised the urgent need to evaluate its catastrophic medical expense. This study evaluates the first 5 years of the national health initiative called Popular Insurance (PI) at the National Institute of Cardiology in Mexico.

STUDY DESIGN

Retrospective data analysis.

METHODS

STEMI patients with (n=317) and without (n=260) PI were selected. Analysed variables included socio-economical context, management care, cost evaluation and three outcomes (mortality, hospital readmission and therapeutic adherence). Descriptive statistical analyses, Kaplan-Meier survival and Support Vector Machine models were used accordingly.

RESULTS

Treatment costs were higher for PI-covered individuals (P=0.022) and only 1.89% of them remained in debt, in contrast to 16.15% of those without PI. Statistically significant differences were found in relation to days in hospital wards (P<0.001), imaging studies (P<0.001) and surgical materials (P=0.04). Survival analysis (P=0.44) and therapeutic adherence (P=0.38) showed no differences. Hospital readmission was predicted with an 81.97% accuracy. The most important predictive variables included were stent type, number of days at the coronary care unit and hospital wards.

CONCLUSIONS

The PI has proven to be a successful program where no differences were found in terms of health care and survival, whereas it provides timely financial support for families facing catastrophic health challenging events.

Levels of uric acid may predict the future development of pulmonary hypertension in systemic lupus erythematosus: a seven-year follow-up study

OBJECTIVE

The objective of this paper is to assess whether pulmonary hypertension (PH) may be detected at one point in time or longitudinally predicted by serum uric acid (sUA) levels in systemic lupus erythematosus (SLE).

METHODS

We conducted a post-hoc analysis of a long-term followed cohort of Mexican SLE patients. Echocardiography-based definitions of PH by the ESC/ERS/ISHLT and its associations with clinical and laboratory data on enrollment were studied. Especially, the impact that sUA levels at baseline may have on the future development of PH in patients with normal pulmonary artery systolic pressure (PASP) was explored.

RESULTS

Out of the 156 SLE patients originally enrolled in the cohort, 44 met the inclusion criteria for the present study and were grouped as having (n =10) or not having (n = 34) PH. At baseline, sUA levels of 5.83 ± 1.79 and 5.82 ± 1.97 mg/dl (p = ns) were found in patients with and without PH, respectively. No association between PASP and other markers was found. In patients with normal PASP, the presence of sUA ≥ 7 mg/dl at baseline predicted future development of PH (relative risk 8.5, 1.0009 to 72; p = 0.04).

CONCLUSION

In SLE, sUA levels at one point in time are useless to detect PH. However, steady hyperuricemia may predict the future development of PH in patients with normal PASP at baseline.

Two- and three-dimensional echocardiography in primary antiphospholipid syndrome: misdiagnosis as rheumatic valve disease

This is a report of a woman in the fifth decade of life with primary antiphospholipid syndrome and involvement of a heart valve. Diagnosis was reached with echocardiography and serological studies.

Anatomic correlation of left atrial appendage by 3-dimensional echocardiography

The adequate study of the left atrial appendage is an echocardiographic challenge. The purpose of this study was to assess the ability of 3-dimensional echocardiography in reconstructing this potentially complex structure.

The effect of kidney transplant on cardiac function: an echocardiographic perspective

Kidney transplant (KT) resolves many of the cardiac abnormalities associated with chronic kidney failure (CKF). This study analyzed cardiac alterations of kidney failure and their modification with transplant. Thirteen patients in CKF underwent conventional echocardiograms, dobutamine stress echocardiograms, and injection of contrast to examine perfusion before KT and 3 months after transplant. Nine patients had evidence of left ventricular hypertrophy and six had evidence of diastolic dysfunction. Wall thickness, left ventricular mass, and mass index diminished after KT; only two patients continued to manifest hypertrophy. Left ventricular systolic diameters and volumes diminished at 3 months, and diastolic diameters after 4 months. Left ventricular fractional shortening and ejection fraction increased 3 months after transplant. At the end of the study, only two patients continued to show diastolic dysfunction. Dobutamine echocardiograms showed no segmental wall-movement abnormalities. Myocardial perfusion was normal before and after transplant. The results suggest that KT diminishes hypertrophy and improves left ventricular systolic and diastolic function. Echocardiography provides valuable information for detection and follow-up of cardiac abnormalities in patients with kidney disease. Evaluation of segmental wall movement and myocardial perfusion aid in demonstrating that our studied patients with CKF had no indirect signs of coronary artery disease.

Echocardiographic study of patients with congenital heart disease and infective endocarditis

BACKGROUND

Infective endocarditis (IE) occurs with significant frequency in patients with congenital heart disease. The complications leading to increased morbidity and mortality may be detected by echocardiographic examination. This study was undertaken in order to identify echocardiographic findings that influence the outcome of patients with congenital heart disease and IE.

METHODS

Twenty-five patients with an average age of 28 years were selected and divided into two groups according to evolution. Group I included patients who survived the infectious process, while Group II included patients who died during hospitalization or after release.

RESULTS

Aortic valve disease was the most frequent anomaly. The clinical finding of most relevance for evolution during hospitalization was heart failure. Acute kidney failure and multiple organ failure from sepsis were the most common complications in patients who died. Echocardiograms established the diagnosis in all cases. Transesophageal studies revealed all periaortic abscesses.

CONCLUSIONS

Echocardiography makes it possible to identify and evaluate complications associated with elevated morbidity and mortality in patients with congenital heart disease and IE.

Evaluation of the response to pharmacological stress in chronic aortic regurgitation

We evaluated the hemodynamic response of patients with chronic aortic regurgitation and decreased ejection fraction (EF), mean value +/- SD (37 +/- 9), to dobutamine stress echocardiography (DSE). Eleven patients were studied with DSE. Nine patients were in New York Heart Association (NYHA) Class II and two in NYHA Class III. Ten patients received medical treatment in the only other periodic evaluation. With DSE in nine patients, a significant decrease in left ventricular end-diastolic and end-systolic diameters (LVEDD and LVESD) as well as LV end-diastolic and end-systolic volumes (LVEDV and LVESV) was documented in comparison to resting values. EF and fractional shortening (FS) improved significantly with DSE. Systolic wall stress (SWS) and pulmonary arterial systolic pressure (PASP) did not change. Average follow-up was 6.7 months. Three patients underwent valve replacement with mechanical prostheses. Two of them are in NYHA Class I and the other died of LV failure 3 days after surgery. One patient deteriorated beyond surgical treatment and was in NYHA Class II. The other seven patients remain in NYHA Class II and await valve replacement. In patients with chronic aortic regurgitation and depressed EF, the variables relevant to myocardial reserve appear to be EF, FS, LVEDD, LVESD, LVEDV, and LVESV.

Two- and three-dimensional echocardiographic unroofed coronary sinus

We present the 2-dimensional findings and 3-dimensional reconstruction of images from an 18-year-old patient with unroofed coronary sinus, persistent left superior vena cava, a common atrium with levoisomerism, ventricular septal defect, and double-outlet right ventricle. The left superior vena cava showed continuity with the floor of the coronary sinus. Diagnosis of the constellation of anomalies established by transesophageal reconstruction clarified the continuity of the coronary sinus with left superior vena cava and atrial wall.

Cor triatriatum dexter: transesophageal echocardiographic diagnosis and 3-dimensional reconstruction

Cor triatriatum dexter is an unusual cardiac abnormality with division between the sinus and primitive atrial portions of the right atrium. Three-dimensional echocardiography is a novel technique that defines this entity.

Two- and three-dimensional transesophageal echocardiographic diagnosis of intramyocardial dissecting hematoma after myocardial infarction

The echocardiographic findings of an intramyocardial dissecting hematoma that formed after an extensive acute myocardial infarction of the anterior wall of a 42-year- old man are described. Serial transesophageal studies were used to construct 3-dimensional images that clarified the participation of various myocardial layers that surrounded the dissecting hematoma. The patient was successfully treated with intra-aortic balloon counterpulsation and subsequently coronary artery bypass grafting. Intramyocardial dissecting hematoma is a rare complication of acute infarction; differential diagnosis must be made with pseudoaneurysm by establishing integrity of epicardium and with intracavitary thrombosis by identifying the endomyocardial layer surrounding the neoformation and associated wall movement.

[Utility of echo enhancers in the study of pulmonary circulation time]

Pulmonary circulation time (PCT) varies under different clinical conditions. To evaluate the PCT, the persistence of contrast in both ventricles and the digital arterial saturation of oxygen with peripheral intravenous injection of microbubbles, were examined 14 patients. Groups: I normals, II left ventricular hypertrophy (EF > 50%), III with mitral stenosis and IV in congestive heart failure. In seven patients, isosorbide S/L was administered after the first injection. The transpulmonary transit in beats was 7.3 in normals, and larger in the others. The persistence of echo contrast in right chambers was 31 beats in group I, and larger in the other groups. In left chambers it was 20.6 beats in group I, and larger in others. There were no alterations with regards to peripheral arterial saturation of oxygen. AII patients with isosorbide presented shorter PCT and persistence of contrast in right chambers.

CONCLUSIONS

There are differences in PCT among normals, patients with mitral stenosis and those with congestive heart failure. Prolonged persistence contrast in right chambers indicates abnormally slow transpulmonary transit. Patients with congestive heart failure and ventricular damage, have longer persistence of echo contrast. PCT studied with contrast is an easy means of evaluating some aspects of pulmonary circulation.

[Safety and efficiency of Echogen. Transthoracic echocardiography study]

This study was performed to determine the safety and efficacy of intravenous dodecafluoropentane emulsion (Echo Gen), to determine the efficacy and duration of contrast agent in left cavities by transthoracic echocardiography and to evaluate the clinical impact of Echogen. Fifteen patients were studied, by transthoracic echocardiography. Duration of contrast intensity of left ventricular cavity opacification and endocardial border definition were studied. The adverse effects were assessed immediately, 24 hours and 7 days after Echogen. Both the vital signs and electrocardiogram did not show any significant changes. Minimal changes in hepatic function in one patient and in renal function in other one were observed. The mean duration of left ventricular opacification was 4 minutes 47 seconds and full or intermediate opacification was more frequently observed after Echogen. Endocardial border delineation was poor in one patient, intermediate in five and excellent in nine. In 86.7% the diagnostic information obtained was sufficiently and allowed other studies.

CONCLUSIONS

This study demonstrates that Echogen is effective for Left ventricular cavity opacification, endocardial border definition and assessment of left ventricular volume and ejection fraction 2) The obtained information with the use of Echogen allowed other studies. 3) The intravenous administration of Echogen is safe in doses of 0.05 ml/Kg.

[Echocardiography advances in infarction of the right ventricle]

This review describes echocardiographic findings in patients with inferior myocardial infarction and right ventricular extension. Transthoracic echocardiography has limitations to explore some wall segments of the right ventricle, especially the apical ones, as well as in the evaluation of the right atrial wall motion; further more, this technique offers poor information because this kind of patient frequently has a deficient thoracic acoustic window. Transesophageal echocardiography is the best non-invasive technique because it allows to evaluate all the right chamber segments; when complemented with the administration of dobutamine, it helps to identify viable myocardial tissue.

Nonobstructive asymmetrical septal hypertrophy and ostium secundum-type atrial septal defect

We report a 36-year-old woman with hypertrophic cardiomyopathy with asymmetric septal hypertrophy without outflow tract obstruction associated with an ostium secundum-type atrial septal defect with significant hemodynamic repercussion. Diagnosis was established with transesophageal echocardiography. This is the second case of this rare association reported in the literature and the first evaluated by transesophageal echocardiography.

Transesophageal echocardiographic diagnosis of thrombus in accessory lobes of the left atrial appendage

Fifty-four percent of left atrial appendages have two lobes. The number ranges from one to four lobes. We describe three patients with accessory lobes of the left atrial appendage studied with multiplanar transesophageal echocardiography (TEE). In one patient there was evidence of thrombi in the accessory lobe.

[Usefulness of transesophageal echocardiography in the diagnosis of aortic intramural hematoma]

Aortic intramural hematoma or atypical aortic dissection is an aortic dissection without intimal tear nor flow communication and it may be the first step of a typical dissection. We describe five cases, in which transesophageal echocardiography detected intramural hematoma of the aorta. Transesophageal echocardiography is a safe, accurate and specific method that allows bedside diagnosis as well as follow-up of patients with hematoma of the aorta.

Recurrent myxoma implanted in the left atrial appendage

We present the case of a young woman who developed myxomas in multiple cardiac chambers for the third time. One of the tumors was found in the left atrial appendage with the use of transesophageal echocardiography, indicating that this technique is the method of choice for the follow-up of multiple myxomas.

Left atrial thrombosis after percutaneous mitral valvuloplasty: resolution with conservative management

We report the detection of a thrombus 72 hours after mitral valvuloplasty through the use of the technique of Inoue. Images obtained by transesophageal echocardiography revealed its localization on the interatrial septum at the level of the transseptal puncture. Although the patient subsequently underwent surgery for the placement of a prosthetic valve in mitral position due to failure of the valvuloplasty, the thrombus resolved with conservative management.

[Valvulopathy in primary antiphospholipid syndrome. Prospective echocardiography study]

Echocardiographic studies have demonstrated a high prevalence of valvular disease in patients with primary antiphospholipid syndrome (PAPS). However, there are no studies assessing changes over time in valvular abnormalities. We conducted a study to determine whether there are changes over time in valvular lesions as detected by serial transesophageal echocardiography (TEE). Twelve patients with a first TEE had a second evaluation after a mean period of 13.5 months. There were 10 women and two men with a mean age of 38 years. Two patients had normal TEE on both initial and follow-up studies. Ten patients (83%) had valvular abnormalities, predominantly of the mitral and aortic valves in both studies. Abnormalities consisted of thickening, nodules, regurgitation, regurgitation and stenosis, and calcification. The type and frequency of lesions changed over time. As an example, one mitral valve nodule disappeared on follow up but three new aortic nodules developed even though all patients were receiving anticoagulant therapy. Two patients with mitral and aortic nodules presented cerebral ischemia. Mitral valvuloplasty was performed in one case. These results show that valvular abnormalities in patients with PAPS resolve, appear, or persist irrespective of anticoagulant therapy. Regurgitation is often mild or moderate, but stenosis may appear.

Severe dynamic obstruction of the left ventricular outflow tract induced by dobutamine

We present the case of a 63-year-old man who developed a subaortic gradient of 182 mmHg during an echocardiographic pharmacological stress study with dobutamine.

Echocardiographic, catheterization, and nuclear medicine findings of an aneurysm of the muscular interventricular septum associated with aneurysm of the interatrial septum

The unusual case of a young woman with an aneurysm of the muscular interventricular septum associated with an aneurysm of the interatrial septum and a muscular interventricular septal defect is presented. The echocardiographic, electrocardiographic, catheterization, and nuclear medicine findings are described.

Echocardiographic evaluation of patients with primary antiphospholipid syndrome

BACKGROUND

A third to half of the patients with primary antiphospholipid syndrome have valve disease.

METHODS AND RESULTS

The echocardiographic characteristics of primary antiphospholipid syndrome were analyzed, and the utility of treatment with anticoagulants and/or antiplatelet agents (acetylsalicylic acid) is examined with the use of transesophageal echocardiography in the evaluation of valvular lesions after 1 year of therapy. Twenty-nine patients, 22 women and 7 men with average age of 35.4 years, were studied. Transesophageal echocardiography was performed on all patients before beginning anticoagulant and/or antiplatelet treatment. Valve lesions were found in 22 (75.9%) patients. Of these, other cardiac abnormalities were found in 3 cases, myocardial infarction in 2, and atrial septal defect in 1. In 7 (24.1%) cases, no valvular abnormality was detected, although in 1 of these, alterations in left ventricular segmental wall movement secondary to myocardial infarction were found. One year after initiation of anticoagulant and/or antiplatelet therapy, it was possible to perform transesophageal echocardiograms on 13 patients. No modification of valve lesions was found in 6 (46.2%) cases; new lesions had appeared in the remaining 7 (53.8%) as well as left ventricular apical akinesis in 1 case.

CONCLUSIONS

These results indicate that the predominant heart lesion in primary antiphospholipid syndrome is valvular; anticoagulant and/or antiplatelet treatment does not diminish the noninfective valve lesions, and on occasion this entity may be associated with myocardial infarction despite angiographically normal coronary arteries.

Infectious endocarditis in pacemaker endocardial leads: report of three cases

Three cases of endocarditis affecting endocardial leads of permanent pacemakers are presented with a review of the literature. Vegetations were identified using transesophageal echocardiography. Infection of pacemaker leads is far less common than infection at the site of the pulse generator with greater morbidity and mortality and generally requiring surgical removal of both electrodes and power source. The most frequent infective agents are stahylococcus varieties.

Tetralogy of Fallot with absent pulmonary valve and total anomalous pulmonary venous connection

It has been shown that congenital absence of the pulmonary valve rarely occurs by itself but tends to be associated with other heart defects, especially tetralogy of Fallot. Other malformations and other complex cardiac malformations also have been described in patients with absent pulmonary valve. In this report we describe the findings of a patient with this combination of cardiac defects who survived spontaneously to adulthood.

Myocardial contrast and transesophageal echocardiographic study of the left coronary artery from the main pulmonary artery

A case of a 26-year-old woman with thoracic pain and anomalous origin of the left coronary artery from the main pulmonary artery is described. The diagnosis was by coronary angiography and complemented with Doppler and transesophageal myocardial contrast.

[Effect of acute myocardial ischemia on pulmonary venous flow pattern. Experimental study with transesophageal echocardiography]

Pulmonary venous flow (PVF) has been analyzed by Doppler echocardiography in various cardiopathies, but up to now no studies of its behavior in acute myocardial ischemia have been reported. The purpose of this study is to describe the changes observed in the normal pattern of PVF with myocardial ischemia in an experimental model. Thoracotomy and pericardiectomy with exposure of the heart were performed on 19 mongrel dogs, weighing between 18 and 25 kg anesthetized with intravenous sodium pentobarbital. Pulmonary venous and mitral flows were analyzed by transesophageal echocardiography with pulsed Doppler and simultaneous recording of intracavitary pressures in left atrium (LA) and left ventricle (LV) before and after 30 minutes of partial occlusion of the middle portion of the anterior descending coronary artery distal to the first diagonal branch. The variables examined included maximal velocities and time-velocity integrals of antegrade systolic(s) and diastolic (D) PVF, mitral rapid filling flow (E) and left ventricular isovolumic relaxation time (LVIRT). The pressures directly measured were mean left atrial pressure (MLAP), systolic and diastolic pressures of the LV. Results included a decrease in peak velocities and time-velocity integrals of PVF (S and D) with myocardial ischemia, S velocity from 70.1 +/- 14.8 to 49.5 +/- 13.8 cm/sec (p < 0.001) and D from 41.4 +/- 16.5 to 29.5 +/- 11.4 cm/sec (p = 0.001), with an increase in LVIRT from 65.8 +/- 8.6 to 76.0 +/- 12.6 msec (p < 0.006) and elevation of the mean pressure of the LA from 4.3 +/- 1.0 to 6.4 +/- 1.5 mmHg (p < 0.001). This findings suggest that acute myocardial ischemia alters the normal pattern of PVF, producing a significant decrease in peak velocities and time-velocity integrals of antegrade systolic and diastolic flows as well as an increase in LVIRT and MLAP, which taken together may reflect altered diastolic function of the LV.

[Transthoracic and transesophageal echocardiographic study in aortic valve replacement with pulmonary valve autograft]

Eleven patients who underwent pulmonary valve autograft to aortic position with placement of bovine pericardial prosthesis in pulmonary position were studied with echocardiography. Transthoracic echocardiography, was performed on all patients before surgery. Transesophageal echocardiograms were practiced during the surgical procedure. The latter technique aided in immediate postoperative evaluation. Transthoracic and transesophageal echocardiography provide a practical and valuable means of investigating the pre, trans and postoperative conditions of patients undergoing Ross surgery.

[Corrected transposition of the great arteries in patients over 65]

Three cases with corrected transposition of the great arteries in patients older than 65 years are described. Two had atrial situs solitus and one atrial situs inversus. One had pulmonary valvular stenosis with valvular calcification and a small ventricular septal defect in association with ischemic heart disease. This patient died due to cardiac failure at the age of 80 years. The second case was associated with ventricular septal defect, atrial septal defect and pulmonary hypertension. The third patient presented with mild tricuspid regurgitation. Although this congenital heart malformation is theoretically compatible with normal life, few patients have long survival because of associated congenital defects or the subsequent development of tricuspid regurgitation or atrioventricular block.

[Diagnosis of thoracic aorta dissection using transesophageal echocardiography]

During a 36 month period there were 20 patients in our hospital with aortic dissection suspected clinically. All of them were examined with transesophageal echocardiography (TEE); 17 were examined with transthoracic echocardiography (TTE); six with computed tomography (CT) and seven with aortography. Twelve patients required surgery: eight with proximal aortic dissection (Type-A), two with distal dissection (Type-B) and two with aortic aneurysm without dissection. With the goal of investigating the utility of TEE for the diagnosis of aortic dissection in our hospital, we compared this and other available methods to the surgery findings. The sensitivity to TEE was 100% and the specificity 92%, with test accuracy at 92%. The sensitivity of the other tests was low: 66% with TTE; 50% with TAC; 57%, with aortography. The specificity was 90% with TTE, and higher with CT and aortography (100%). The ultrasound tests reveal additional information about complications like aortic regurgitation. Transesophageal echocardiography is the best test to examine patients with aortic dissection in our hospital. Computed tomography, aortography and magnetic resonance imaging have indication only to answer specific doubts.

[The usefulness of transesophageal echocardiography in the diagnosis of intracardiac and extracardiac tumors]

We studied 18 patients with suspected intrathoracic mass from january 1990 to august 1993. In all patients electrocardiogram, X-ray, transthoracic and transesophageal echocardiography were performed. Accordingly, the patients were divided into two groups: I) 8 patients with intracardiac myxoma, and II) 10 patients with no myxomatous tumor. The histopathologic identification of the intracardiac or extracardiac tumor was corroborated in all patients of group I and in only 8 patients of group II. In group I the mean age was 39 years and the female sex was more frequently (75%); with transthoracic and transesophageal approaches the myxoma was found in right atrium in four patients, in left atrium in three, and in the last patient the four chambers were occupied. In group II the mean age was 36 years, and the male sex was predominant (60%). In three patients cardiac tumors were detected by echocardiography, two of them were found in the right cavities (leiomyoma and leiomyosarcoma), in the rest the histologic lineage of the left atrial tumors was not possible to recognize. In the other seven patients with mediastinal tumor the heart was not infiltrated. On the basis of the obtained results we conclude that transthoracic echocardiography permits the identification of the intracardiac tumor; in these patients transesophageal studies give us an additional valuable information about the valves, the site of tumoral implantation and the wall infiltration. Transesophageal approach provides more information about its potential cardiac compression.

[The usefulness of transesophageal echocardiography during percutaneous balloon mitral valvulotomy]

The purpose of this study is to report the experience at Instituto de Cardiología de México with transesophageal echocardiography during percutaneous mitral valvulotomy and to compare its utility with transthoracic echocardiography. Sixteen patients with isolated or predominant mitral stenosis were examined and underwent percutaneous mitral valvulotomy with a single balloon catheter (Inoue [correction of Ionue] technique). Transthoracic echocardiography was done in all cases previous to the procedure. The procedure orientation was done with transesophageal in thirteen patients and with. Transthoracic echocardiography in the other three. The results were successful in all cases. Transesophageal echocardiography was more useful in the initial evaluation in patients with poor transthoracic windows, in those with clinical and/or transthoracic evidence of atrial thrombosis, as well as in procedure orientation, spontaneous contrast detection, mitral regurgitation and atrial septal defect evaluation after the procedure. Transesophageal echocardiography is superior to transthoracic technique in procedure orientation, early evaluation of results and potential complications. However, its practical utility is limited and its routine use is not recommended.

Total anomalous pulmonary venous connection in adults. Long-term follow-up

Between 1961 and 1989, 19 patients with total anomalous pulmonary venous connection underwent surgical correction. Ages ranged from 18 to 38 years (mean 26.2 +/- 6.5 years). The anatomic variants included 10 patients with total anomalous pulmonary venous connection to the vertical vein, 6 patients with total anomalous pulmonary venous connection to the coronary sinus, and 2 with total anomalous pulmonary venous connection directly to the right atrium. The last patient had mixed connection to the coronary sinus and left vertical vein. Two patients died, one because of left atrial rupture and another of low cardiac output. Long-term follow-up after surgical repair ranged from 2 to 24 years (mean 7 +/- 6.2 standard deviation). Preoperative disability, assessed according to New York Heart Association criteria, showed 12 patients in functional class II and seven in class III. After treatment, 16 patients were in class I and one in class II (p less than 0.001). Echocardiographic evaluation of six patients revealed in all a normal left ventricular ejection fraction; the diastolic function was also normal except in one patient. The postoperative evaluation of the pulmonary arterial systolic pressure performed by both Doppler echocardiography and right cardiac catheterization in 14 patients showed a significant reduction of the mean pulmonary arterial systolic pressure from 51.1 +/- 3.4 to 37.4 +/- 14.4 mm Hg (p less than 0.01). The remaining three patients evaluated in the follow-up period only by clinical examination are in New York Heart Association functional class I. The anatomic characteristics of our patients were responsible for the long-term outcome without correction. Surgical treatment of older patients can be performed with satisfactory results and excellent long-term survival.

[Dynamic intracavitary echoes studied by transthoracic and transesophageal echocardiography]

One hundred consecutive echocardiograms performed on adults using transthoracic and transesophageal (TEE) transducers were analyzed in order to determine the prevalence of spontaneous contrast (SC) and the factors associated with it. Indications for study included complex congenital cardiopathy, evaluation of valve lesions or prosthetic valves, dissecting aortic aneurysm, cardiac masses and evaluation of ventricular function. SC was observed only with TEE and appeared in 25% of cases, most frequently in left atrium. Factors associated with contrast included mitral valve disease and replacement, ventricular dysfunction, left atrial dilatation and atrial fibrillation. An important relationship existed between SC and presence of thrombi. Atrioventricular valvular regurgitation was not associated with SC. Results are compared with those of previous series.

[Transesophageal echocardiography in the study of intracardiac thrombosis, tumors and vegetations]

Of 200 consecutive patients, studied with transesophageal echocardiography the findings were analyzed with respect to the presence of thrombi, tumors or vegetations. Thrombus formation was detected in 18 patients; their location and associated pathology are described. Tumors were present in 9 cases and in 10 patients endocarditis in native or prosthetic valves. The information obtained by transesophageal echocardiography was compared with transthoracic echocardiographic data. Transoesophageal echocardiography was demonstrated to be more sensitive, especially in the detection of intracavitary masses in the posterior structures of the heart.

[Doppler color transesophageal echocardiography. Report of the first 110 studies carried out at the Ignacio Chávez National Institute of Cardiology]

Transesophageal echocardiography allows views of the posterior structures of the heart. This approach provides additional and complementary information to the transthoracic study, it is also an alternative in those patients with technical limitations for optimal precordial imaging. This study analysis the first 110 cases studied with transesophageal echocardiography in the National Institute of Cardiology Ignacio Chávez. They correspond to patients with valvular heart disease, prosthesis, acute and chronic ischemic heart disease, dissecting aortic aneurysm, cardiomyopathies, thrombus, tumors and masses. As well as paediatric and adult with complex congenital heart disease. The advantages of the transesophageal technique compared with the precordial approach are described.

[Transesophageal echocardiography. General principles and applications]

A new echocardiographic technique is described, which allows cardiovascular ultrasonic exploration by means of a transducer mounted on the distal tip of a gastroscope. The transducer is moved along the esophagus and from time to time into the stomach, which permits real-time visualization of the different cardiac segments and the great arteries. This technique is of special utility in the exploration of posterior structures as are the left atrium and its appendage, the pulmonary veins, etc. The most important views in the transverse plane are described, as well as the technical aspects, the limitations and the possible complications.

[The utility of color Doppler in dissecting aortic aneurysm]

We inform about the utility of Color-Doppler to identify dissection in aortic aneurysm. We studied five patients, fourth with dissection and one without dissection. All of them were in the fourth decade of life, except the patient without dissection, who developed symptoms at the age of 62. Two-dimensional echocardiography displayed the alterations of the aorta, such as dilatation of the walls, the presence or absence of dissection and in the cases with dissection the extension of it (three patients had DeBakey Type I, one DeBakey Type III an other DeBakey Type II). In all patients with dissection the Doppler study determined the presence or absence of flow through the false channel, in particular in the second and fifth patient and with Color-Doppler we observed that the flow was bidirectional. Also the degree of aortic incompetence could be quantified. It is concluded that with two-dimentional echocardiography it is possible to identify the anatomical features of aortic aneurysm and that Doppler study gives additional hemodynamic information which has importance in therapy and prognosis.

[Thrombosis of the left auricle. Diagnostic usefulness of two-dimensional echocardiography]

The purpose of this study is to determine the sensitivity and specificity of two dimensional echocardiography in the diagnosis of thrombosis of the left atrial appendage. Sixty patients with mitral rheumatic heart disease were examined prospectively 24 to 72 hours prior to cardiac surgery. Two images were used to identify thrombosis in the appendage: parasternal short axis at the level of the aortic valve with a lateral and superior inclination of the transducer and a modified apical five chamber view with counter clockwise rotation of the transducer between the apical long axis and the five chamber view. Diagnosis was corroborated during surgery and by histopathological analysis. In all cases the presence and predominance of mitral lesion (stenosis or regurgitation) were established by clinical history, electrocardiogram, chest roentgenogram and two dimensional echocardiogram. In 58 patients the lesions were also confirmed by cardiac catheterization. Of the 60 patients (46 females and 14 males between 16 and 61 years of age), eleven cases (18.3%) of left atrial thrombosis were detected, of which seven had formed in the left atrial appendage. All were confirmed during surgical intervention and pathological analysis. One thrombus in the left atrial appendage not diagnosed by echocardiography was found during surgery (Sensitivity:90.9%). In this case pathology studies demonstrated recently formed thrombi. In all cases in which two dimensional echocardiography did not show signs suggesting thrombosis, surgery confirmed that atrial thrombosis did not exist (Specificity: 100%). This study demonstrates the utility of two dimensional echocardiography in the diagnosis of thrombosis of the left atrial appendage, thus making it possible to schedule corrective surgery and the use of anticoagulants.

[Echocardiographic and Doppler study of pulmonary atresia with an intact interventricular septum]

Pulmonary atresia with intact ventricular septum represents a congenital cardiac lesion for which the prognosis depends on the patency of the ductus arteriosus. Nine children with pulmonary atresia and intact ventricular septum underwent echocardiographic studies before cardiac catheterization trying to visualize the anatomy of the outflow tract of the right ventricle, the dimension of the ventricular cavity, the characteristics of the tricuspid valve and finally the size and integrity of the interventricular septum. Using Doppler ultrasound it was possible to evaluate the function of the tricuspid valve and the patency of the ductus arteriosus. The results obtained were correlated with the angiographic and anatomic studies. We concluded that noninvasive assessment of this malformation permits an excellent correlation with the angiographic and anatomic studies.

[Usefulness of 2-dimensional echocardiography in detecting intraventricular thrombi in patients with acute myocardial infarction]

The purpose of this study is to determine the importance of two-dimensional echocardiography performed soon after admission to the coronary care unit to provide useful information concerning wall-motion abnormalities, and to detect and characterize left ventricular thrombi. A major goal is to identify a subgroup of patients with acute myocardial infarction who are at risk for systemic embolization; in this subgroup the benefits of anticoagulation treatment would theoretically outweigh the associated risks. We studied 7 consecutive male patients, age range from 32 to 60 years, with acute myocardial infarction. Five patients had antero-septal infarction, 1 anterolateral and another had anterior wall infarction. We performed two-dimensional echocardiography within the first week after admission. All patients had severe apical-wall-motion abnormalities (akinesis or dyskinesis) and left ventricular thrombi. All patients received anticoagulation therapy. Two-dimensional echocardiography, performed one month after the first study, showed that the thrombi had decreased in size in 6 patients and could not be visualized in 1 patient. The noninvasive nature of echocardiography allows serial evaluations of patients with known left ventricular thrombi and permits assessment of the effect of therapy.

[Diagnosis of constrictive pericarditis and restrictive cardiomyopathy by pulsed Doppler echocardiography]

Characteristics of flow through atrioventricular valves were analyzed by pulsed Doppler echocardiography (PDE) in 7 patients with either constrictive pericarditis or restrictive cardiomyopathy and 10 controls to determine the value of this technique in their differentiation. All patients were admitted with systemic venous congestion and underwent right and left heart catheterization. PDE variables considered included peak flow velocity (PV), acceleration time, peak velocity of the atrial component (PVA), PVA/PV quotient, duration of early diastolic fillings, deceleration of early diastolic filling, duration of diastolic flow and mean temporal velocity. Ventricular filling differed between patients and controls in that the former group was characterized by higher PV's, lower PVA's, higher deceleration and lower PVA/PV quotient. When we compared both patient groups we found a significant tendency toward higher PV's, faster deceleration and lower PVA/PV quotient in constrictive pericarditis.

[Diagnosis by two-dimensional and Doppler echocardiography of coronary aneurysm in a Mexican boy with Kawasaki disease]

The mucocutaneous lymph node syndrome or Kawasaki's disease, is a clinical entity consisting of high fever, mucocutaneous involvement and cervical lymphadenopathy that affects infants and young children. Although syndrome is predominantly found in Japan, it has become increasingly recognized in other countries. This disease appears to be benign and self-limited in most instances. However, extensive cardiac involvement may cause sudden death due to myocardial infarction from occlusive coronary artery disease, rupture of a coronary aneurysm or conduction abnormalities. As a result, it has become important to establish a noninvasive diagnostic method for assessing cardiac involvement in this disease. The purpose of this study is to describe the echocardiographic recognition of a left coronary artery aneurysm in a 3 years old mexican boy with Kawasaki's disease.

[Echocardiographic diagnosis of pulmonary valve calcification]

Calcification of the pulmonary valve is a uncommon condition. Non invasive diagnostic methods such as M-mode and two dimensional echocardiography have facilitated the identification of vegetations and calcifications on the pulmonary valve. Very few cases of isolated calcification on the pulmonary valve have been reported; a previous lesion of the valve almost always exists. The purpose of this communication is to report two cases with calcification of pulmonary valves without underlying pathology and to highlight the great utility of echocardiography in diagnosis and follow-up of such cases.

[Usefulness of M-mode echocardiography, two-dimensional and Doppler, in the study of pericardial diseases]

The objective of this communication is to determine utility of echocardiography M mode, two-dimensional and Doppler, in the diagnosis and follow-up of patients with pericardial disease. This procedure was used initially to the diagnosis of pericardial effusion, actually it has a lot of new applications. It's noninvasive and low cost, and would give us important information about our patients.

[Left ventricular hypertrophy simulating an intracavitary tumor. Echocardiographic diagnosis]

We report a case of a 14 month old infant with severe stenosis of the pulmonary valve in whom the angiographic image suggested the presence of a right ventricular (RV) tumor mass. The patient was admitted because of clinical manifestations of heart failure. Right heart catheterization demonstrated a transvalvular pulmonary gradient and filling defects in the infundibulum compatible with an intracavitary mass. Two dimensional and Doppler echocardiography confirmed pulmonary stenosis and showed that the mass corresponded to hypertrophy of the anterior RV wall. The combination of two dimensional and Doppler echocardiography are the indicated techniques in differential diagnosis of RV tumor masses and RV hypertrophy secondary to severe pulmonary valve stenosis.

[Malposition of the great arteries. Is this term a valid one?]

We present four cases of a congenital heart malformation classically known as malposition of the great arteries. This term means there are concordant ventriculo-arterial connections with abnormal spatial relations of the aortic and the pulmonary arteries, in which the former is anterior relative to the latter, and either to the right or to the left, according to the position of the corresponding ventricle. This anomaly can be found in any type of atrial situs, notwithstanding the type or mode of atrioventricular connection, as in the cases we studied. If we consider that this anomaly depends on the associated lesions in order to produce physiological heart alterations, we think that the term of malposition of the great arteries is not valid, since in the anatomic diagnosis of congenital heart disease it is important to consider the connections between atria, ventricles and arteries, the spatial relations between them being of second importance.

[Quantification of pulmonary arterial hypertension by phonocardiography and M-mode echocardiography in children with congenital cardiopathies]

We studied 20 children with congenital heart disease using Echo-Phonocardiographic techniques to determine the presence and magnitude of pulmonary arterial hypertension. The results were compared with those obtained by catheterization. There was a significant correlation between the pulmonary arterial systolic pressure (PSP) estimated from the right ventricular isovolumetric relaxation period and the PSP from the catheterization (r = 0.92). The ratio preejection period /right ventricular ejection time (PEP/RVET) identified the patients (PEP/RVET greater than or equal to 0.30) with a PSP mean value = 64.5 mmHg (p less than 0.01). The presence of a systolic notch on the pulmonary valve echogram distinguished the group with a PSP mean value = 60 mmHg (p less than 0.005). There was a poor correlation between the depth of the "a" wave and the E-F slope of the pulmonary valve echogram and the catheterization PSP (r = -0.50 and r = -0.40, respectively). The interval PR from the electrocardiogram minus the distance AC from the tricuspid valve echogram had a poor correlation with the right ventricular end diastolic pressure (r = 0.57). We conclude that there are some Echo-Phonocardiographic signs which are very useful in the diagnosis and measurement of pulmonary arterial hypertension in children with congenital heart disease.