LEFT VENTRICULAR REMODELING WORSENS LEFT VENTRICULAR TORSION IN HEART FAILURE
Roberto M Saraiva1; Sayit Dermikol2; Adisai Buakhamsri2; Zoran B Popovic2; Neil Greenberg2; Deborah A Agler2; James D Thomas2; and Richard Grimm2
1Fundação Oswaldo Cruz, Rio de Janeiro, Brasil; 2Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio.
Background: The development of 2-dimensional speckle tracking imaging (STI) enabled the noninvasive measurement of LV torsion, which is considered a key element for regulating LV systolic mechanics. We sought to address the relationship between LV torsion and LV remodeling in patients with LV systolic dysfunction.
Methods: We retrospectively examined data from 50 consecutive patients with LV systolic dysfunction who performed dyssynchrony studies in our echocardiographic laboratory between July 2008 and April 2009. From those, 28 individuals (62 ± 19 years old) had images suitable for LV torsion analysis. LV torsion was defined as the net-difference of LV rotation (LVrot) between apical and basal short-axis planes obtained from STI analysis and stated in units of degree (°). LV mass was calculated by the area-length method. LV end-diastolic and end-systolic sphericity were calculated as the ratio of the minor axis to the major axis length of the LV. LV volumes and ejection fraction were calculated using Simpson's method.
Results: Most patients were male (71%), had ischemic etiology (54%), and presented with class III or IV symptoms (64%). LV ejection fraction was 36.0 ± 9.6%. Basal LVrot, apical LVrot and LV torsion were −3.7 ± 3.2°, 2.4 ± 4.0°, and 6.1 ± 3.9°, respectively. Basal LVrot was clockwise in 24 patients (86%) and apical LVrot was counterclockwise in 21 patients (75%). LV torsion presented significant negative correlation with LV end-diastolic (r =−0.53; p = 0.004) and end-systolic (r =−0.54; p = 0.003) volumes, LV end-diastolic (r =−0.52; p = 0.005) and end-systolic (r =−0.47; p = 0.01) sphericity indexes, and LV mass index (r =−0.52; p = 0.009) (Figure). The correlation between LV torsion and ejection fraction was marginal (r = 0.32; p = 0.09). LV torsion also correlated negatively with the duration of the QRS of the electrocardiogram (r =−0.41; p = 0.02).
Conclusions: LV torsion has the potential to become an important parameter to assess LV systolic performance and decreases proportionally to LV remodeling with increasing LV volumes and as the LV assumes a more spherical format.
DOPPLER ECHOCARDIOGRAPHIC ASSESSMENT IN PATIENTS WITH CHRONIC SUBCLINICAL RHEUMATIC VALVAR DISEASE: AN INSTRUMENT TO DISCUSS DURATION OF SECONDARY PROPHYLAXIS
Fátima Derlene da Rocha Araújo; Fabiana Arantes Araújo; Lavinia Pimentel Miranda; Kelly Nascimento Brandão; Déborah de Oliveira Lauar Figueiró; Sandra Regina Tolentino Castilho; Zilda Maria Alves Meira
Federal University of Minas Gerais
Introduction: Rheumatic cardiopathy is still an important public health issue in developing countries. Doppler echocardiography has not been included for diagnosis in Jones criteria revision but it is considered an analysis tool to discontinue secondary prophylaxis.
Objectives: To assess echocardiographic changes in rheumatic fever patients with normal cardiovascular exam and to discuss the recommended duration of prophylaxis.
Methods: Seventy-nine 79 patients with diagnosis of rheumatic fever based on Jones criteria were assessed; their cardiovascular examination was normal after at least 5 years of disease progression, regardless of the cardiac alterations in the acute phase (ARF). The criteria for mitral or aortic valvar disease were those applied at international level.
Results: The age of ARF patients ranged from 4 to 15 years (39% males and 61% females). Approximately 32 (41%) exams were classified as normal – in that, 87.5% were normal and 4 (12.5%) presented mild ARF alterations. The remaining 59% of exams presented abnormalities with the following findings: thickening of the anterior mitral leaflet (91%); slight (28%)/mild (91%)/moderate (8.5%) mitral regurgitation; and slight (8.5%)/mild (21%) aortic regurgitation. Enlarged chambers were not observed.
Conclusions: The current recommendation (AHA, 2007) is to continue secondary prophylaxis up to the age of 40 years, even on those that present only echocardiographic alterations. It was observed that such prophylaxis would be maintained in 59% of individuals with normal clinical examination. Only 8.5% presented some echocardiographic abnormality considered significant (moderate mitral lesion or presence of aortic lesion) and just 12.5% of altered exams in the acute phase had echocardiographic resolution. Reassessing duration of prophylaxis is suggested in these cases.
TISSUE DOPPLER EVALUATION IN PULMONARY EMBOLISM: CORRELATION WITH BRAIN NATRIURETIC PEPTIDE AND PROGNOSIS
Ana Clara Tude Rodrigues; Adriana Cordovil; Claudia Monaco; Laise Guimaraes; Andrea Paula Ponchirolli; Wercules Oliveira; Edgar Lira; Marcelo Vieira; Claudio Fischer; Samira Morhy
Hospital Israelita Albert Einstein
While assessment of right ventricular (RV) function with echocardiography is mainly limited to qualitative analysis, tissue Doppler (TD) may be used to evaluate it. Brain natriureticpeptide (BNP) is secreted in response to ventricular strain and seems related to RV dysfunction in pulmonary thromboembolism (PE).
Objective: To evaluate RV performance and prognosis with echocardiography with TD, comparing it to BNP,in patients with PE.
Methods: We evaluated 80 patients (50 male, mean age 54 ± 17 years) with PE diagnosed by chest tomography (76) or scintigraphy (4), with echocardiography and BNP within24 hours of diagnosis. RV function was evaluated qualitatively with bidimensional echocardiography and quantitatively with TD (velocities, strain and tissue tracking) from the tricuspid annulus. Mortality (8 to 24 months after diagnosis) was evaluated regarding clinical and echocardiographic variables. Results: 21 patients (31%) had RV dysfunction. Patients were divided into 2 groups: GI (BNP < 50 pg/ml, n = 54) and GII (BNP ≥ 50 pg/ml, n = 26). GII was older (64 ± 19 years vs 50 ± 13 years), had more RV dysfunction (15 vs 6 pts) and lower TD velocities (S’= 10.3 ± 3.8 vs 13.4 ± 3.8 cm/s and E’= 7.3 ± 3.6 vs 9.1 ± 2.2 cm/s), strain (−23.4 ± 10 vs −17.8 ± 9.5%) and tissue tracking (14 ± 7 vs 18 ± 4 mm) and higher pulmonary pressure (49 ± 11 vs 35 ± 11 mmHg), p < 0.05 for all variables. There was an inverse correlation between S’ and BNP (r =−0.67) and positive for pulmonary pressure (r = 0.69), p < 0.05. Mortality was 13% (6 patients) and related to age, coexisting malignancy and TD E’ velocities.
Conclusion: In patients with PE,TD offers an alternative means of evaluating RV performance; however only E’ velocities may be related to prognosis.
LEFT ATRIAL VOLUME: IS IT REALLY NECESSARY TO MEASURE BOTH 4 AND 2 CHAMBER VIEWS IN TWO-DIMENSIONAL ECHOCARDIOGRAPHY? A COMPARISON WITH THREE-DIMENSIONAL ECHOCARDIOGRAPHY
Normando Gomes Vieira Filho; Orlando Campos Filho; Rudyney E. U. Azevedo; Wercules Oliveira; Manuel A. Gil. Antonio C.C. Carvalho
Escola Paulista de Medicina-UNIFESP
Background: Left atrial volume (LAV) has recently emerged as a new echocardiography prognostic index. Two-dimensional echocardiography (2DE) techniques include average 4 and 2 chambers (4 + 2c) and 4-chambers (4c) apical views. Three-dimensional echocardiography (3DE) is considered a more reliable method to access chamber volumes.
Objectives: To compare LAV assessment by both 2DE techniques with 3DE.
Methods: We studied 89 patients, all in sinus rhythm, mean age 53 years (18 to 89), 51% female, mean ejection fraction 63% (22 to 84%). The 2DE maximum LAV was performed by Simpson's method, getting two measures: 1) Average (4 + 2c) apical views; or 2) Apical 4 chamber view only (4c). These values were compared with maximum 3DE LAV, with full volume method. Student t test and Pearson's correlation test were used, with a significant level of p < 0.05.
Results: The variations of LAV by 3 methods were: 2DE LAV 4 + 2c: 23 to 199 ml; 2DE LAV 4c: 20 to 199 ml; 3DE LAV: 19 to 204 ml, with equivalent mean values (p > 0.05). The correlation between 2DE LAV 4 + 2c and 2DE LAV 4c was r2 = 0.98 (p < 0.05). When compared to 3DE LAV, the correlation with 2D LAV 4 + 2c was r2 = 0.89, and with 2DE LAV 4c was r2 = 0.90.
Conclusion: The LAV estimated by single plane 2DE 4c is similar to LAV estimated from 2DE mean 4 + 2c, and both have a strong correlation with 3DE LAV. The 2DE method using only a 4c apical view can be a valid way to perform a volumetric measure of LAV.
PERCUTANEOUS PROSTHESIS AORTIC IMPLANT: COMPARISON BETWEEN THE MEASURES OF THE AORTA CARRIED OUT BY COMPUTED TOMOGRAPHY AND ECHOCARDIOGRAPHY PRE PROCEDURE
Andrea de Andrade Vilela; Aloyra Guedis Guimarães; Renato Costa Junior; Wesley Rodrigo de Oliveira; David Costa de Souza Le Bihan; Jorge Eduardo Assef; Ibraim Masciarelli Francisco Pinto; Auristela Isabel de Oliveira Ramos; Dimitri Mikaelis Zappi; Amanda Guerra Moraes R. Sousa
Instituto Dante Pazzanese de Cardiologia
Introduction: The percutaneous prosthesis aortic implant for the treatment of severe aortic stenosis is an alternative available and effective for patients with high surgical risk, especially those with advanced age and with multiple comorbidities. The selection of patients fitting for percutaneous prosthesis aortic implant is based on clinical criteria and morphological parameters of aortic complex. These parameters, from measures of angiographic tomography and echocardiography, are essential for the planning of the procedure.
Objective: To compare the measures of the aorta carried out by tomography and echocardiography before percutaneous prosthesis aortic implant.
Method: Studied 11 patients eligible for the percutaneous prosthesis aortic implant and evaluated by tomography and echocardiography, the diameters of the following segments of the aorta: plan of the ring, root, sinus-tubular joint, ascendent aorta and length of Valsalva sinus. Analyzed clinical variables (age, body surface, comorbities, symptoms, physical examination, Euroscore and medications in use) and echocardiographic variables (diameters and volumes of the left chambers, systolic and diastolic function, systolic pressure of pulmonary artery, and anatomical and functional characteristics from the aortic valve.
Results: Only the measure of plan of the ring presented statistically significant difference (p = 0.007) as 25 mm ± 3.9 by tomography and 20 mm ± 3.5 by echocardiography. Age was 82.4 ± 5.81; 64% was female;44% was in functional class III and Euroscore was 12 ± 4. Ejection fraction was 59%± 12; 47% presented moderate pulmonary hypertension; medium systolic gradient aortic valve was 53 mmHg ± 17 and the area of aortic valve was 0,67 cm2 ± 0.17.
Conclusion: The profile of patients selected for percutaneous prosthesis aortic implant is to be in theis eights and nineties with severe aortic stenosis and high surgical risk. The measures of tomography tend to overestimate the diameter of the plan of the ring in 5 mm in relation to the measures of echocardiography.
A HYPERCHOLESTEROLEMIC DIET CAUSE AUGMENT IN THE INFARCT SIZE AND WORST THE HEMODYNAMICS PATTERNS IN RATS SUBJECTS TO AN EXPERIMENTAL MODEL OF MYOCARDIAL ISCHEMIA
PMM Dourado, MBP Landim, A Casella Filho, JM Tsutsui, TFG Galvão, VD Aiello, W Mathias Jr, PL da Luz, ACP Chagas.
Atherosclerosis Unity. Heart Institute (InCor); University of São Paulo Medical School; São Paulo; Brazil
A better comprehension of the hypercholesterolemic diet role in the set of acute myocardial infarct is fundamental
Objective: Evaluation of the role of hypercholesterolemic diet in the determination of the hemodynamics patterns by echocardiography and the infarct size in an acute infarct model in rats.
Methods: Sixty three anesthetized rats were subjected to occlusion of the left anterior descending (LAD) coronary artery and divided in six groups: G1 – just normal diet (ND); G2 – ND and treatment with rosuvastatim for 30 days began after infarct and G3 – ND and 30 days previously to infarct treated with rosuvastatim until 30 days after it; G4 – just hypercholesterolemic diet (HD); G5 – HD and treatment with rosuvastatim for 30 days began after infarct and G6 – HD and 30 days previously to infarct treated with rosuvastatim until 30 days after it. Echocardiography was performed using bidimensional image in the paraesternal long axis. The planimetry of the left ventricle areas in the end of the diastole (LVEDA) and systole (LVESA) were realized before the infarct (pre) and 30 days after the infarct (post) and the% of the infarct was determined by pathology. A p value < 0.05 was considered significant.
Results: see table
Conclusion: The hypercholesterolemic diet augmented the infarct size in the hypercholesterolemic group in comparison with the normocholesterolemic group treated with rosuvastatim and worst the hemodynamics parameters – LVEDA and LVESA.
TRANSCATHETER AORTIC VALVE IMPLANTATION (COREVALVE): SELECTING, MONITORING, AND ECHOCARDIOGRAPHIC FOLLOW-UP
Jairo Alves Pinheiro Junior; Alexandra Alberta dos Santos; Francine K. Araujo; Mercedes Andrade Maldonado; Vera Marcia Gimenes; Adriana Moreira; Jose Eduardo Moraes R. Souza; Adib D. Jatene
Hospital do Coracao – HCOR – IEP
Introduction: Percutaneous implantation of aortic valve (CoreValve) is an emerging alternative for elderly patients with severe aortic stenosis (AoS) to conventional surgical treatment. The procedure offers less morbidity and mortality. Echocardiography is the ideal tool for screening and monitoring procedure.
Method: From October 2009 to February 2010, 04 pacientes (p) elderly with AS were selected and underwent the procedure at the Hospital do Coração – HCor.
Besides the classification of the severity of the echocardiogram provided measures: diameter of the LVOT, annulus diameter, sinotubular junction diameter, diameter and compliance of the sinus of Valsalva and ascending aortic diameter. TEE monitoring during the implant monitoring not only of liberation as well as evaluation of reflux and improvement in ventricular function still in hospital.
Conclusion: Although experience is small no complications and the echocardiogram shows are exuberant from the seletion monitoring this specific group of patients.
ECOCARDIOGRAMA TRIDIMENSIONAL NO DIAGNÓSTICO DE FONTE TROMBOEMBOLICA PULMONAR
Edinaldo Rodrigues Fontes Junior; Flávia Arruda Santos; Giordano Bruno Parente; Djalma Augusto Godoy Santos; Paulo Sérgio Oliveira; Claudia Braga Melo
REALCOR-REAL Hospital Portugues de Pernambuco
Introduction: Authors demonstrate unusual view of thrombus in the right ventricle, diagnosed by tridimensional echocardiogram, resulting in massive pulmonary embolism.
Case Description: A 31 years old, female pacient, ANBMM, with diagnosis of Schistosomiasis performed post-operative routine transthoracic echocardiogram (TTE), which was normal. After 15 days of this TTE, she started with moderate dyspnea.
New TTE showed an increase in right chambers and on the pulmonary artery (PA), and a mass (MVd) in the apex of the right ventricle (RV).
A 3D echocardiogram (3DECHO) was performed and showed: the structural aspect, location, diameter, relations with the ventricle walls and the mobility of the MVd. Transesophageal echocardiogram (TEE) helped in the study. The 3DECHO showed that MVd had a variable echogenicity, was apical and adhered to moderator band, measuring 547 mm of area without relation to the RV walls neither with apex. Magnetic Resonance showed a mass in the RV apex with a delayed capture of gadolinium. A thoracic X-ray revealed the presence of right pulmonary infection and right pulmonary effusion. At the hospital and during preoperative treatment the pacient worsens with dyspnea and hypotension, being required emergency intervention. At surgery, a large thrombus was found in the ApRV, and also occlusion of the right PA and sub-occlusion of the left PA. Postoperatively 3DECO showed a reduction of RC and PA, and there's was no mass in RV.
Comments: This case demonstrates the actual use of the ECO3D on identification and detailing intracardiac structural masses helping the surgeon during the preoperative evaluation.
CLINICAL AND ECHOCARDIOGRAPHIC PARAMETERS ASSOCIATED WITH LOW CHRONOTROPIC INDEX IN NON-ELDERLY PATIENTS
Paulo Fernando Carvalho Secundo; Bruno Fernandes de Oliveira Santos; Francis Lima de Vasconcelos; Nathalie Oliveira de Santana; Débora Consuelo Rocha Silveira; Gustavo Baptista de Almeida Faro; Rívia Siqueira Amorim; Antônio Carlos Sobral Sousa; José Augusto Soares Barreto-Filho; Joselina Luzia Menezes Oliveira
Universidade Federal de Sergipe
Background: Despite all the evidence about increased morbidity and mortality, chronotropic incompetence (CI) still is not a routine and well-defined diagnosis in clinical practice guidelines. Its pathophysiological mechanisms remain unclear, and its clinical importance and prognosis certainly continue to be underestimated in clinical practice.
Objective: To evaluate the clinical and echocardiographic parameters associated with CI in non-elderly patients undergoing exercise echocardiography (EE).
Methods: After exclusion criteria, a total of 1,798 patients who underwent EE between Janeiro 2000 and August 2009 were evaluated, with a mean age of 48.4 ± 7.5 years. Patients with chronotropic index below 0.8 were considered incompetent. Groups were compared regarding clinical features (including classic cardiovascular risk factors) and echocardiographic findings.
Results: The duration of treadmill test was 9.3 ± 2.4 minutes. Chronotropic incompetence was observed in 275 patients (15%) patients. In this group, the mean chronotropic index was 0.7 ± 0.1 vs. 1.0 ± 0.1. Logistic regression identified that dyspnea during EE presents one of the strongest associations with CI [odds ratio (OR) = 4.27, p < 0.0001]. Others parameters included: metabolic equivalents (METs) (OR = 0.70, p = 0.0001), ST segment depression (OR = 0.58, p = 0.0003), previous chest pain (OR = 1.51, p = 0.0111), systolic blood pressure increase (delta SBP) (OR = 0.87, p = 0.0011) and left ventricular (LV) mass index (OR = 1.16, p = 0.0001). Ischemia was not associated with CI.
Conclusion: Dyspnea, previous chest pain and LV mass index are associated with CI in non-elderly patients. METs increase, ST segment depression and delta SBP are associated with normal chronotropic response. New protocols to investigate CI may contribute to early intervention in modifiable cardiovascular risk factors in these patients.
PROGNOSIS OF PATIENTS SUBMITTED TO STRESS ECHOCARDIOGRAPHY
Brivaldo Markman Filho1; Maria Celita Almeida2; Camila Sartechi3; Manuel Markman2; Silvia Marinho Martins3; Clodoval Barros2; Marcia Moreno2; Wilberto Souza2; Maria de Fátima Lôbo2; Sergio Montenegro2
1PROCARDIO – Hospital das Clínicas da UFPE; 2PROCARDIO; 3PROCARDIO – REALCOR
Background: Stress echocardiography (SE) is effective and highly accurate for detection of myocardial ischemia and risk stratification in patients with suspicion of coronary artery disease.
Objective: To evaluate the role of SE to search myocardial ischemia and its ability to predict the composite end point of cardiovascular death, myocardial infarction, unstable angina and myocardial revascularization by percutaneous intervention or surgery.
Methods: Prospective observational study. Patients were submitted to SE with Dipyridamole or Dobutamine between June/2006 to September/2009.
Results: There were 221 patients with mean follow-up of 30 months (3–38 months). The SE was positive for myocardial ischemia in 13% of patients, negative in 84% and inconclusive in 3%. Cardiac events occurred in 18 patients, 16 with a positive SE. The rest of the patients (197) was free of events with negative SE in 184 patients. Event free survival in patients with negative SE was 99% compared with 55% for positive SE (p < 0.001). The univariate analysis showed SE result, basal electrocardiogram, age, Diabetes, LV mass index, past history of percutaneous intervention and surgery of myocardial revascularization (CABG), aspirin use associated with the cardiac events. In multivariate analysis SE result and CABG were independent predictors for cardiac events (p < 0.001).
Conclusion: Positive SE and past history of CABG were the only independent predictors for cardiac events in the study.
LEFT VENTRICULAR DIASTOLIC FUNCTION IN CHAGAS CARDIOMYOPATHY AFTER RENINE-ANGIOTENSINE-ALDOSTERONE SYSTEM INHIBITION
Oliveira, BMR; Botoni, FA; Pinto, AS; Reis, A; Rocha, MOC.
Faculdade de Medicina – Universidade Federal de Minas Gerais
Chronic Chagas cardiomyopathy causes substantial morbidity and mortality in Latin America and its prognosis is dependent on systolic and diastolic left ventriclar (LV) function.
Objective: The objective of this study was to determine the efficacy of renine-angiotensine-aldosterone system (RAAS) inhibitors in improving diastolic dysfunction in chronic Chagas cardiomyopathy, comparing with changes in brain natriuretic peptide (BNP) levels.
Methods: All patients received enalapril (up-titrated to 20 mg BID) and spironolactone (25 mg QD). The end points were changes in LV diastolic function parameters evaluated by transthoracic Doppler echocardiography after RAAS inhibition, and change in BNP levels, used as a surrogate marker of LV filling pressure.
Results: Forty-one patients – 29 (67,4%) males, mean age 48,05 ± 10,42 years – with Chagas cardiomyopathy were studied. Optimization of RAAS inhibition was associated with improvement in LV diastolic function parameters: isovolumic relaxation time (137.47 ± 35,96 ms vs. 151.55 ± 34,55 ms, p = 0.02), increase of inferior wall E’ velocity [6.55 (3,42) cm/s vs. 7.30 (3,51) cm/s, p = 0.03], decrease of inferior E/E’ index [9.23 (3,86) vs. 8.36(5,31), p = 0.065], and increase of antero-lateral wall A’ (5,95 ± 2,12 cm/s vs. 6.78 ± 1,81 cm/s, p = 0.02) and inferior wall A’ velocities (7,49 ± 2,26 cm/s vs. 8,61 ± 2,20 cm/s; p = 0,006). BNP levels decreased significantly [95.90 (295,35) vs 32.55 (138,15); p = 0.026].
Conclusions: In patients with chronic Chagas cardiomyopathy, optimization of treatment with enalapril and spironolactone was associated with significant benefits in LV diastolic function and a decrease of BNP levels.
EVALUATION OF INTER AND INTRAVENTRICULAR DYSSYNCHRONY IN PATIENTS WITH SYSTOLIC HEART FAILURE AND COMPLETE RBBB
Angelo Antunes Salgado; Henrique José Portela Júnior; Ana Catarina Periotto; William Souza; Márcia Bueno Castier
Background: Cardiac resynchronization therapy (CRT) has impact on mortality of patients with heart failure (CHF) associated with left bundle branch block (LBBB). However, contradictory results remain about the importance of CRT in patients with right bundle branch block (RBBB).
Objective: Evaluation by echocardiographic criteria of inter- and intraventricular dyssynchrony, of patients with heart failure and complete RBBB.
Methods: We evaluated 15 patients, 9 (60%) male, 3 (20%) diabetics, 5 (33%) had dyslipidemia, ischemic HF with complete RBBB on ECG (QRS = 163 ± 7 ms) functional class III, mean ejection fraction by Simpson's method was 24.3%, S wave velocity of mitral annular septal of 4.7 cm/s (average), mean ratio of E/E ‘septal 18.14. Variables evaluated: difference between aortic and pulmonary time ejection in evaluation of interventricular dyssynchrony, tissue Doppler analysis of the delay between the basal segments of septum and lateral wall and between the basal segments of inferior and anterior walls in the evaluation of intraventricular dyssynchrony.
Results: The mean difference between aortic and pulmonary ejection time was 39.3 ms, and 5 (33%) had value ≥ 40 ms.The average delay of the basal segments of septum and lateral wall was 84.4 ms, and 7 (47%) had delay ≥ 65 ms and between the basal segments of anterior and inferior walls was 84.3 ms, and 4 (27%) had delay ≥ 65 ms.
Conclusion: In agreement with other clinical studies, RBBB determined smaller mechanical dyssynchrony than in LBBB patients with heart failure, which explains why beneficial effects of CRT are less evident in patients with RBBB.
EXERCISE ECHOCARDIOGRAPHY AS A PREDICTOR OF CARDIAC EVENTS IN PATIENTS WITH LEFT BUNDLE BRANCH BLOCK
Bruno Fernandes de Oliveira Santos; Francis Lima de Vasconcelos; Nathalie Oliveira de Santana; Vanessa Porto de Araújo; Vinício Vieira Leal; Carla Carolina Cardoso Teixeira; Isis Helena Chaplin Andrade; José Augusto Soares Barreto-Filho; Antônio Carlos Sobral Sousa; Joselina Luzia Menezes Oliveira
Universidade Federal de Sergipe
Background: The prognostic value of exercise echocardiography (EE) in patients with left bundle branch block (LBBB) has been investigated. Objective: To evaluate the prognostic value of EE in patients with LBBB.
Methods: Retrospective cohort study, in which 135 patients with LBBB who underwent EE according to Bruce protocol were evaluated. Mean age was 63.5 ± 11.5 years, and 51 patients (38%) were women. Mean follow-up was 45.8 ± 4.7 months. Cox's proportional hazards regression was used, considering as endpoints: death from any cause, acute myocardial infarction (AMI), percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). Hazard ratio (HR) of ischemia in EE was adjusted for age and family history of coronary artery disease.
Results: Exercise echocardiography positive for ischemia was found in 42 (31%) patients. There were 8 deaths, 3 AMI, 2 PCI and 1 CABG during the follow-up. In multivariate analysis, ischemia in EE was an independent predictor of death, acute myocardial infarction, percutaneous coronary intervention or coronary artery bypass grafting in patients with LBBB (HR: 4.1, 95% confidence interval: 1.3 to 13.1, p = 0.018).
Conclusion: Exercise echocardiography positive for ischemia predicts death, acute myocardial infarction, percutaneous coronary intervention or coronary artery bypass grafting in patients with left bundle branch block.
SUBCLINICAL RIGHT VENTRICULAR DYSFUNCTION IN OBESITY
Márcia M Barbosa; Alline Maria Rezende Beleigoli; Antonio Luiz P Ribeiro; Maria de Fátima Haueisen Sander Diniz; Maria Carmo P Nunes
Federal University of Minas Gerais; Ecocenter, Socor Hospital – Belo Horizonte, Brazil
The effect of excess weight on left ventricular (LV) morphology and function has been documented, but much less is known about the effects of obesity on right ventricular (RV) characteristics. We used conventional echocardiographic, tissue Doppler imaging (TDI), and strain indexes to determine whether RV dysfunction was associated with obesity.
Methods: Standard and tissue Doppler echocardiography was performed in obese subjects with a body mass index [BMI] of 40 kg/m2 or higher who had never been submitted to bariatric surgery. Twenty healthy individuals were used as a control group. Tissue Doppler was used to measure RV systolic (Sm) and diastolic (Em) velocities and strain indexes.
Results: The study population consisted of 92 obese subjects (mean BMI of 53 kg/m2). Mean age was 43 ± 11 years, and 74 were women. No patient had LV dysfunction (mean LVEF of 66%). Among the obese patients, 78% had hypertension, 35% diabetes, 78% metabolic syndrome, and 3% coronary artery disease. Only 3.4% were in atrial fibrillation and 1.3 had moderate or severe mitral regurgitation.Obese subjects had reduced RV function compared with controls, evidenced by reduced peak strain (strain: −26.9 ± 6.3% vs −31.4 ± 6.5%, p = 0.007) and diastolic velocity (Em: 14.1 ± 3.8 cm/s vs 16.1 ± 2.6 cm/s, p = 0.028).
Conclusion: In a group of severely obese subjects without clinically overt heart diseases, incipient and subclinical RV dysfunction was detected by the detection of a lower RV longitudinal strain and lower RV E’ by TDI in comparison with healthy individuals. This may have clinical impact in terms of suggesting that these obese patients be followed in order to detect early RV failure.
UTILITY OF A COMBINATION OF STANDARD DEﬂECTABLE ABLATION CATHETER AND INTRACARDIAC ECHO TOAVOID ESOPHAGUS INJURY DURING LEFT ATRIAL ABLATION
Simone Santos; Benhur Henz; Fábio Giuseppin; Anderson Oliveira; André Zanatta; Ayrton Peres; Henrique Maia; Clarissa Novakoski; José R. Barreto; André B. D’Ávila; Luiz Leite
Centro de Estudos de ArritmiaCardiaca, Brasilia, Brazil
Esophageal injury has been reported even when luminal esophageal temperature (LET) monitoring is used, probably because of the limitations of the current methods for LET monitoring. To reduce this complication an ideal method for LET monitoring is strongly desirable.
Methods: To evaluate the utility of ICE to guide LET monitoring, we prospectively studied 45 pts underwent AF ablation. Ablation was performed with 3.5 mm thermocool catheter. Energy was stopped if LET rose >2OC. ICE was used to visualize the esophagus position and a deﬂectable catheter (eso-cath) used for LET LET monitoring. If the esophagus was close to the ablation site by ICE image, eso-cath was aproximated to the ablation area. Esophagogastroscopy was performed 1 day after ablation.
Results: 45 pts were included. By our LET monitoring method, in 100% there was at least one site with rises of LET. According to the ICE, in 19(43.2%) pts esophagus was close to left-sided veins, in 4(9.1%) right-sided veins and in 21(47.7%) close to both. In 41 (93%) patients there was accordance of thevisualization of the esophagus by ICE and ﬂuoroscopy. When the esophagus was close to the left veins, theeso-cath position was located in the left side in 93% of the cases without any deﬂection. In only 2 cases it had to be deﬂected to the left side. On the other hand, there was discordance with ICE visualization in 23 out of 25 pts with esophagus related to the right-sided veins, requiring more deﬂection of eso-cath to detect LET rises (p < 0.001, 92% vs. 7% compared with left side). After eso-cathdeﬂection, ablation resulted in LET rises and required power off in theses cases. However, in 12 (27.3%) pts we were able to observe dislodgement of the esophagus toward the left atrium by ICE visualizationand the eso-cath had to be repositioned. With this method there was no acute lesion visualized byesophagogastroscopy performed after ablation.
Conclusions: Intracardiac echocardiogram is a reliable method to guide LET monitoring. This method might reduce the risks of esophagus damage during AF ablation.
PHARMACOLOGICAL STRESS ECHOCARDIOGRAPHY – PATIENT PROFILE
Brivaldo Markman Filho1; Maria Celita Almeida2; Camila Sartechi3; Manuel Markman2; Silvia Marinho Martins3; Marcia Moreno2; Clodoval Barros2; Maria Ignez Labanca2
1PROCARDIO – Hospital das Clínicas da UFPE; 2PROCARDIO; 3PROCARDIO – REALCOR
Introduction: Pharmacological stress echocardiography has been a good diagnostic option on the evaluation of myocardial ischemia due to its efficacy and cost effectiveness compared with other non invasive diagnostic tests.
Objective: To evaluate the patient profile of stress echocardiography in a private cardiology service in Recife – Pernambuco, Brazil.
Methods: Observational study. Patients were submitted to stress echocardiography between January/2003 to November/2008.
Results: There were 575 patients with mean age of 60 years (23–90), 60% were women. Its important to note the high number of elderly women (45%), hypertensive (72%) and hypercholesterolemic (62%). Amongst the men, 22% had previous myocardial infarction, 22% had a previous revascularization procedure (PTCA or CABG), 25% diabetic and tobacco use was present in 22%. Atypical chest pain was present in 56% of the patients, angina in 10%, and 30% were asymptomatic with 34% of these patients showed a positive treadmill test (EKG changes or anginal pain). The basal EKG was normal in 73% of the patients. In respect of the pharmacological stressor used, dobutamine was used in 27% and Dipyridamole in 73%. The stress echocardiography was negative in 85%, positive in 12% and inconclusive in 3% of the cases. The medications used by patients were betablockers (39%), Calcium blockers (20%), nitrates (13%), ACE inhibitors (35%), Aspirin (35%) and statins (35%).
Conclusion: In this study female gender, atypical chest pain and previous history of hypertension and hypercholesterolemia were more prevalent.
LEFT ATRIUM REMODELING AND EJECTION FRACTION INCREASING AFTER PERCUTANEOUS BALLON MITRAL VALVE VALVULOPLASTY IN PATIENTS WITH MITRAL VALVE STENOSIS: BIDIMENSIONAL AND THREE-DIMENSIONAL ECHOCARDIOGRAPHIC STUDY
Marcelo L. C. Vieira; Murilo C. da Silva; Camila R. Wagner; Flavio Tarasoutchi; Luis J Kajita; Luis F Cardoso; Guilherme Spina; Nelson Samesina; Carlos A Pastore; Max Grinberg; Wilson Mathias Jr.
Heart Institute (InCor), São Paulo University Medical School, São Paulo, Brazil
Background: bad prognosis relative to left atrium (LA) increase and to LA dysfunction was demonstrated in patients presenting mitral valve stenosis.
Objective: to analyse by 2D and 3D transthoracic echocardiography the immediate effects of percutaneous balloon valvuloplasty (PBV) in patients presenting mitral valve stenosis (MVS).
Methods: a prospective study of 24 symptomatic patients (22 females, 39 ± 12 years) presenting MVS who were submitted to PBV. Two and 3D echocardiographic studies were performed pre PBV. Parameters analysed: 1-mitral valve area (MVA)(planimetry 2D, PHT, 3D, invasive measurement); 2- LA end diastolic volumes (EDVLA) and LA end systolic volume (ESVLA) (2D,3D); 3- LA ejection fraction (LAEF) (2D,3D); 4- Mitral valve gradient (maximum,medium); 5- Pulmonary artery pressure (PAP). Statistical analysis: Pearson's correlation coefficient, 95% CI, p < 0.05, T test, linear regression equation, Bland and Altman test.
Results: Pre PBV: 1- MVA (Plan): 1.14 ± 0.25 cm2;2- MVA (PHT): 1.07 ± 0.21 cm2;3- LAEF 2D: 31 ± 10%; 4- MV Gradient Max/Med: 20 ± 7/9 ± 5 mmHg;5- LAEF 3D: 28 ± 10%; 6- EDVLA 2D/3D: 95,6 ± 36,2 l/87,4 ± 33,1 mL; 7-PAP: 38,2 ± 9,6 mmHg. Post PBV: 1- MVA (Plan): *1.81 ± 0.39 cm2; 2- MVA (PHT): *1.72 ± 0.34 cm2;3- FEAE 2D: *40 ± 8%; 4- MV Gradient Max/Med: *13 ± 5/*5 ± 2 mmHg; 5- LAEF 3D: * 40 + 9%; 6- VDFAE 2D/3D: *84.4 ± 30. l/*75.7 ± 22.1 mL; 7-PAP: *32.4 ± 6.3 mmHg, mean ± SD,*p < 0.05.
Conclusion: In this series, it was observed LA reverse remodelling and LAEF improvement (2D and 3D Echocardiography) in symptomatic patients presenting mitral valve stenosis shortly after percutaneous balloon valvuloplasty.
RIGHT VENTRICLE DYSFUNCTION IS RELATED TO FUNCTIONAL CAPACITY REDUCTION IN SPONTANEOUSLY HYPERTENSIVE RATS AFTER SINOARTIC DENERVATION
Raquel de Assis Sirvente; Bruno Rodrigues; Leandro Ezequiel de Souza; Raquel Nitrosi de La Fuente; Cristiano Mostarda; Jose Luiz Barros Pena; Afonso H Matsumoto; Maria Claudia Irigoyen; Charles Mady; Vera Maria Cury Salemi
Introduction: During the development of hypertension, sympathetic hyperactivity commonly seems to be related to the left ventricular dysfunction and baro and chemo reflexes impairment. However, right ventricle (RV) function has not been evaluated specially regarding the association of hypertension and baroreflex dysfunction. In this issue, the aim of this study was to evaluate the role of chemo and baroreflex dysfunction induced by sinoaortic denervation (SAD) on RV performance of spontaneously hypertensive rats (SHR), as well as the impact of this alteration on functional capacity.
Materials and Methods: The animals were divided into 2 randomized groups (n = 8, each group): SHR and SHR+SAD. SAD was induced in 2 month-old SHR rats. After 10 weeks of SAD induction the animals underwent maximal exercise test (MET) on a treadmill and RV function was assessed noninvasively by echocardiography and by RV catheterization.
Results: SAD+SHR group displayed reduction of maximum running speed (0.8 ± 0.06 Km/h) on MET in comparison with SHR group (1.5 ± 0.1 Km/h). The values of acceleration time right ventricular outflow (ATRV) and RV fractional area change (RVFA), assessed by echocardiography, were reduced in SAD+SHR group when compared to SHR group (26.7 ± 0.5 vs. 31.9 ± 0.3 ms; 33 ± 2 vs. 41 ± 2%, respectively). RV end diastolic pressure (RVEDP) was increased in SAD+SHR group as compared to SHR group (8 ± 0.3 vs. 6 ± 0.3 mmHg). Additionally, positive correlations were observed between MET speed and ATRV (r = 0.75; p = 0.0003) and RVFA (r = 0.78; p = 0.0006). Furthermore, negative correlation was obtained between RVEDP and MET speed (r =−0.8; p = 0.0004).
Conclusions: These data suggest that the reflex dysfunction induced by SAD in SHR may lead to an additional impairment on RV function, as demonstrated by a reduction of ATRV and RVFA, as well as an increase of RVEDP. Furthermore, the RV dysfunction indexes were correlated with functional capacity reduction, indicating the importance of autonomic control on the time course of the disease.
APICAL TORSION CORRECTED FOR LONGITUDINAL AXIS OF THE LEFT VENTRICLE
Del Castillo JM*, Nissen WN**, Herszkowicz N*, Cortese MDS**, Boschilia T**, Capuano RL**, Kusano T**, Polido JCC**, Martini Jr PFV**, Lorenzi VL**.
*Faculty of Medicine of the ABC, Santo Andre, Brazil; ** Bandeirantes Hospital, Sao Paulo, Brazil
Left ventricular torsion results from helical myocardial contraction and meets important role in systolic and diastolic function (ventricular filling). This method shows good sensitivity to detect regional and global dysfunctions. Torsion results by the difference on basal and apical LV rotations, obtained by two-dimensional strain. Their values are expressed in degrees and degrees/sec. The normalization to the longitudinal axis of the LV (in degrees/cm) seems to better separate the changes of apical torsion.
Objective: The aim of this work is to study apical torsion in normal subjects and patients with various degrees of left ventricular dysfunction, normalizing these values to the longitudinal axis of the LV.
Material: We studied 30 healthy subjects (mean age 42.1 years, 18 males) and 35 patients with various degrees of cardiomyopathies (mean age 39.5 years, 19 males).
Methods: In all patients and controls was performed conventional echocardiogram. Basal and apical rotation was determined with two-dimensional strain. Apical torsion is the algebraic difference between basal and apical rotations and expressed in degrees. The time of torsion was expressed in degrees/seg. Torsion normalized by longitudinal LV axis was expressed in degrees/cm. Longitudinal dimension of the LV is the mean value of the LV longitudinal diameter between systole and diastole. The data was compared with Student's t-test and the significance was p < 0.05.
Results: Basal rotation was similar in patients and control group (-1.9 ± 0.6° vs −2 ± 0.8°). Apical rotation was lower in patients with cardiomyopathies (4.4 ± 1.8° vs. 3.3 ± 1.6°). Apical torsion was lower in patients with cardiomyopathies (6.7 ± 1.4° vs. 5.5 ± 1.7°). Torsion normalized to longitudinal axis of the LV was lower in patients with cardiomyopathies (0.7 ± 0.03°/cm vs. 0.5 ± 0.03°/cm).
Conclusion: Apical torsion is decreased in patients with cardiomyopathies. Normalization for the longitudinal dimension of the LV seems to increase statistical differences, improving the sensitivity of the method.
ECHOCARDIOGRAPHIC FINDINGS AFTER ENZYME REPLACEMENT THERAPY FOR MUCOPOLYSACCHARIDOSIS TYPE I: INITIAL RESULTS
Leal, GN; Paula, AC; Leone C; Kim CA.
Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo
Objective: To report the echocardiographic findings in children with Mucopolysaccharidosis type I, who received recombinant human alfa-L-iduronidase.
Method: Echocardiographic data from 3 male patients aged 2.1, 2.7 and 10.1 years at the initiation of therapy were revised. They received alfa-L-iduronidase 0.58 mg/kg weekly and a control examination was obtained after 2.3 ± 0.5 years.
Comparison were made using Student's t test, with p ≤ 0.05 considered significant.
Results: Before treatment, all patients had mitral valve thickening and regurgitation was noted in two. Aortic thickening was present in two, accompanied by regurgitation in only one. Pulmonary hypertension was diagnosed in two. There was no left ventricle systolic dysfunction but mild diastolic dysfunction was detected in two. The Z-score of the left ventricle diastolic diameter was −0.06 ± 0.49, of the interventricular septum +3.44 ± 0.32 and of the posterior wall +3.63 ± 1.25.
After treatment, there was mitral thickening and regurgitation in all three. Aortic valvar thickening was universal, with regurgitation in two of them. Nevertheless, there was no patient with pulmonary hypertension and mild diastolic dysfunction was present in only one. Significant reduction in septal (+1.70 ± 0.46) and posterior wall (+1.00 ± 0.72) Z-score was detected (p = 0.05 and p = 0.02, respectively). The average left ventricle diastolic diameter was unchanged (Z-score =+0.23 ± 0.25; p = 0.3).
Conclusion: Enzyme replacement can reduce ventricular hypertrophy and improve diastolic feeling pattern, besides lowering pulmonary pressure. Unfortunately, the valve pathology doesn't seem to be altered in a short period of observation.
EARLY FETAL ECHOCARDIOGRAPHY FOR FETUSES AT RISK OF CONGENITAL HEART DISEASE
Karina Reis De Melo Lopes; Annabelle Azancot
Hôpital Robert Debré
Objectives: Study the accuracy of early fetal echocardiography for fetuses at risk of congenital heart disease.
Methods: Fetuses referred for nuchal translucency (NT > 3 mm) or for congenital heart disease (CHD) history were examined for the first time before the 18th gestational week (w), and re-examined after 18w for control at least once.
Results: One hundred forty eight fetuses were examined. Gestational age ranged from 12.2 to 17.6 weeks (mean 15 ± 1,5w). One hundred twelve fetuses were referred for NT and 36 for CHD history.
The exam was inconclusive in 14 (mean 14 +−1.6 w) of the 148 cases. There were 16 cases of congenital heart disease, 15 in the NT group and 1 in the group of CHD history (hypoplastic left heart syndrome). The exam was normal in 118 cases.
Among the cases with diagnosis of congenital heart disease, 5 were conotruncal malformations, 3 single ventricles, 4 atrioventricular septal defects, 1 left ventricular fibroelastosis and 2 aortic atresia
Two cases presented a peculiar evolution: normal examination at 17w and aortic hypoplasia with small left ventricle at 26w and 28.6w respectively.
The sensitivity of early fetal echocardiography was 73%, the specificity 98%, the positive predictive value was 85% and negative predictive value 97%.
Conclusion: Fetal echocardiography can detect complex congenital heart disease early in pregnancy, but care must be taken with congenital heart diseases that may evolve later in gestation. A control exam in the second trimester is recommended.
THE DOPPLER ECHOCARDIOGRAPHY AS AN IMPORTANT TOOL IN DIAGNOSING AND MONITORING PATENT DUCTUS ARTERIOSUS IN NEONATAL UNIT CARE
Carolina Andrade Bragança Capuruço; Cleonica de Carvalho Coelho Mota
Objective: A common complication for premature neonates is patent ductus arteriosus (PDA). And delayed closure of PDA may results in worse outcome. Prospective study (1 January 2002–31 December 2006) included newborns <37 weeks’ assisted at Hospital das Clínicas Neonatal Care of the Federal University of Minas Gerais. The objective was evaluate the association of PDA and echocardiography findings with mmorbidity and mortality following the various treatment options.
Study Design: Doppler echocardiography was performed in all newborns ≤28 weeks’ gestation or ≤1000 g birth weight within 48–96 h after birth and further in case of clinical suspicion of PDA. The data collected was analyzed with the, Chi-square, Fisher Exact and Mann-Whitney tests.
Results: Among 2626 newborn infants, 190 (7,2%) developed a hemodynamically significant patent ductus. The spontaneous closure occurred in 28 (14,7%) neonates, and 25 (13,2%) died. 43 (22,6%) follow conservative treatment, 50 (26,3%) were submitted to a surgical treatment, 83 (43,7%) received indomethacin and 14 (7,3%) required ductal ligation and medical treatment.
The birth weight, gestational age and mean internal diameter PDA, were significantly different in neonates with spontaneous closure of PDA. The rates of major complications and treatment failure with indomethacin were higher in those with greater diameter of PDA and mean values of the other Doppler echocardiography parameters studied.
Conclusion: The ductus arteriosus frequently is associated with morbidity in preterm neonates. The early eechocardiography is the gold standard exam for diagnosing a PDA and it should very important to guide therapeutical decision and improve outcome for the risk population.
VALVULAR HEART DISEASES IN CHILDREN AND ADOLESCENTS WITH NO HISTORY OF ACUTE RHEUMATIC FEVER: THE IMPORTANCE OF DOPPLER
Fátima Derlene da Rocha Araújo; Fabiana Arantes Araújo; Lavínia Pimentel Miranda; Zilda Maria Alves Meira
Federal University of Minas Gerais
Objectives: Rheumatic fever (RF) is the main cause of acquired cardiopathy in children and young adults in Brazil. The diagnosis is based on Jones criteria of 2 major manifestations or 1 major and 2 minor plus evidence of preceding streptococcal infection; isolated presence of chorea or prolonged carditis. The importance of Doppler echocardiography is discussed in cases with no definition of the acute phase (ARF).
Methods: A total of 283 patients diagnosed as RF were evaluated as to clinical history and Jones criteria. Forty-one patients with suspected diagnosis based on pediatric visit findings were selected. After at least 5 years of diagnosis, they were reassessed clinically and by echocardiography to rule out other etiologies. Valvular morphology was considered abnormal in cases of thickness greater than 3 mm for anterior mitral leaflet, decreased mobility of the posterior leaflet (M-mode and/or two-dimensional) and pathological mitral and/or aortic regurgitation, if regurgitant jet by color flow extended over 1 cm away from the leaflets and was seen in two planes, high-velocity Doppler sign, filling over 50% of systole or diastole.
Results: Age at diagnosis varied from 4 to 15 years (51% female/49% male). RF was ruled out in only one subject diagnosed as Marfan syndrome. Four individuals had associated diseases – drepanocytosis (3) and Down syndrome (1), which present valvar alterations. However, the image was compatible with rheumatic involvement. Secondary prophylaxis was continued in 40 patients.
Conclusion: Detailed Doppler echocardiography is important in cases with no acute RF and secondary prophylaxis may influence the course of the disease.
KAWASAKI DISEASE – IMPORTANCE OF CLINICAL SUSPICION AND EARLY DIAGNOSIS
Andressa Mussi Soares; Paulo José Ferreira Soares; Herval Ribeiro Soares Filho; Renata B Pacífico; Patrícia L Mota; Susi L Aranha; Marlus M Thompson; Marcelo R Crespo; José Coimbra Rezende Neto; Magnus S Machado
Hospital Evangélico – Cachoeiro de Itapemirim – ES
Introduction: The mistaken or late diagnosis of the Kawasaki disease (KD) may lead to often irreversible coronary and cardiac alterations with hemodynamic consequences. Objective: To demonstrate cases of diagnosed KD with different clinical features, highlighting its prevalence in a certain region.
Patients and Methods: From February/2003 to March/2009, 13 children with mean age = 30.3 ± 17.8 months and mean weight = 14.4 ± 6.8 Kg met the criteria for KD. All of them resided in the south of the state of Espírito Santo, Brazil, and nine of them lived in the surroundings of the city of Castelo. Blood tests, thorax X-radiograph, electrocardiography, and echocardiography were accomplished.
Results: The clinical manifestation of the newborn (NB) was atypical compared to the other patients. NB presented with high-pitched cry, paleness, and sudoresis, as well as elevated serum troponin and CKMB; the electrocardiogram revealed signs of ischemia. All the patients (pts) exhibited altered inflammatory activity tests and discreet cardiomegaly, as revealed by the thorax X-ray. The echocardiogram of only two pts did not present any coronary alterations, two pts presented coronary aneurysms, and the left anterior descending (LAD) could not be visualized in the NB. Coronariography of the NB demonstrated ectasy of the right coronary and of the left coronary main trunk, as well as 80% obstruction of the LAD. Twelve pts received human immunoglobulin and all pts were administered ASA. The clinical conditions of the pts improved, as well as the coronary lesions. All the pts are being currently followed up.
Conclusion: The early diagnosis of the KD is extremely important due to the potential risk of coronary burden and improved prognosis upon adequate treatment. Therefore, KD should always be investigated when suspected.
PULMONARY HOMOGRAFT POSITION VS FUNCTION IN THE LATE FOLLOW-UP OF RIGHT VENTRICULAR OUTFLOW TRACT RECONSTRUCTION. A TOMOGRAPHIC AND ECHOCARDIOGRAPHIC STUDY
Roberta Paes Santos; Pedra, SRFF; Moreira, VM; Camilotti, L; Jesus, CA; Santana, MV; Chaccur, P; Barretto, RB; Assef, JE; Sousa, AGMR.
Instituto Dante Pazzanese
Although pulmonary homograft (PH) implantation has emerged as an interesting alternative for right ventricular outflow tract (RVOT) reconstruction, late follow-up results have been disapointing due to restenosis and insufficiency. Echocardiography (Echo) is an useful tool to evaluate homograft dysfunction and its impact on right ventricular (RV) function, diastolic diameter, and wall thickness after surgery. However, computer tomography (CT) seems to be better to define 3-D PH position, angulation in the RVOT and degree of calcification. This study aims to verify whether there is any correlation between the position of the PH in the RVOT and its function in the late follow-up.
Patients and methods: 14 patients (pts) (mean age = 15.0 ± 8.4 years) who had RVTO reconstruction using a PH underwent echocardiographic and tomographic evaluation of the RVOT 15.0 ± 8.4 months after surgery. PH degree of stenosis and/or insuficiency were assessed by Echo, and its axial alignment (using three vessel view), angulation and calcification were assessed by CT. All parameters were classified as mild, moderate or severe and were considered clinically significant when greater than mild.
Results: Significant insufficiency was seen in 3 pts (21%) and stenosis in 6 pts (42%), with a median gradient of 23 mmHg. Axial malalignment of the PH was observed in 4 pts (28%), significant calcification in 6 pts (42%) and severe angulation in 3 pts (21%). Subvalvar and supravalvar stenosis were present in 3 (21%) and 1 pts (7%), respectively. The only factor related to significant stenosis was anteroposterior angulation of the PH (p = 0,003).
Conclusion: In this small cohort of pts, PH dysfunction was mainly due to stenosis related to the anteroposterior angulation of the graft. CT was considered to be an excellent tool to evaluate the late post-operative results of PH implantation, especially when associated with standard echocardiography.
ECHOCARDIOGRAPHIC PARAMETERS AND BRAIN NATRIURETIC PEPTIDE IN PATIENTS AFTER SURGICAL REPAIR OF TETRALOGY OF FALLOT
Tatani SB; Andriolo A; Carvalho AC; Campos O; Moises VA
Unifesp – EPM and Fleury SA
Background: Although the residual lesions after surgical correction of tetralogy of Fallot (TOF) can be evaluated by Doppler echocardiography (DE), the relation of DE parameters with the proBNP level, a potential biomarker of right ventricle overload, is not well known. The objective this study was to evaluate the DE parameters and their relation to proBNP levels.
Methods: proBNP plasma level and Doppler echocardiography parameters were obtained in the same day in 49 patients later after repair of TOF (mean age of 14.7 years, 51% female, mean PO time of 9.5 years). The DE parameters studied were the dimensions of the right atrium (RA) and ventricle (RV), RV diastolic and systolic function and residual pulmonary lesions. The relation between them and proBNP levels were analyzed and the cutoff values of DE parameters for elevated proBNP determined.
Results: proBNP was elevated in 53% and correlated with RV diastolic diameter (r = 0.41; p = 0.003), RA longitudinal (r = 0.52; p = 0.0001) and transversal (r = 0.47; p = 0.001) diameters, pressure half time of pulmonary regurgitation (PR) velocity (PHT) (r =−0.42; p = 0.005) and the PR index (r =−0.60; p < 0.001). By multivariate analysis the PR index (r =−597; p = 0,001; CI: −913.19 to −280.81) and RA longitudinal (r = 7.74; p < 0,001; CI 4.18 to 11.31) were independent predictors of elevated proBNP. PHT lower than 64 ms (0.76) and PRi lower than 0.65 (0.81) had the best accuracy for elevated proBNP.
Conclusion: proBNP may be increased in patients after surgical repair of TOF, correlated with the size of right cardiac chambers and the severity of PR.
FETAL ECHOCARDIOGRAPHY IN LOW-RISK POPULATION
Marcia F. A. Barberato; Cristiane N. Binotto; Mary Julianne M. Cavalcanti; Silvio H. Barberato; Nelson I. Miyague
Unidade de Saúde Mãe Curitibana, Curitiba, Paraná, Brazil
Background: Doppler echocardiography is an essential tool for the accurate diagnosis of congenital heart disease (CHD) in fetal life
Objective: We report our experience with a large series of echocardiographic assesment of antenatal cardiac alterations (including CHD) in a primary public health center.
Methods: This was a cross-sectional observational study conducted between December 2006 and January 2010. Fetal Doppler echocardiograms were performed in low-risk second and third trimester pregnancies, using a sequential segmentar analysis of the heart (four chamber, ventricular outflow tract, arterial duct, and aortic arch).
Results: 7515 fetuses with gestational age 26 ± 4,5 weeks (range 15 to 40) and maternal age 26 ± 7 years (range 12 to 45) were examined. Routine screening was the indication in 65.5% of the exams, contrasting with only 0.8% of suspected CHD after a routine obstetric ultrasound. About 91% of the exams were normal. Among the abnormalities, we observed CHD in 1.7%; arrhythmias in 1.1%; “golf ball” in 4.4% and tricuspid valvar regurgitation in 1.3% of the fetuses. The most prevalent fetal structural defects were ventricular septal defect (0.8%), atrioventricular defect (0.3%) and hypoplastic left heart syndrome (0.1%).
Conclusions: Antenatal cardiac abnormalities were common in this low-risk population. Remarkably, only half of the CHD cases were suspected after undergone a conventional obstetric ultrasound, which highlights the importance of achieving fetal echocardiography in all pregancies.
LEFT VENTRICULAR NONCOMPACTION IN NEWBORN – CASE REPORT
Benício de Oliveira Romão; José Maria Gonçalves Fernandes; Ivan Romero Rivera; Maria Alayde Mendonça da Silva
Universidade Federal de Alagoas
Introduction: Left ventricular noncompaction cardiomyopathy has increasingly been reported in the medical literature, however is rarely related in neonatal patients. We present a female newborn with failure to thrive and poor feeding, who was referred by pediatrician to the echocardiography laboratory for evaluation of heart disease. On physical examination she was slightly dyspneic, acyanotic, not pale and with wheezing and fine rales on auscultation of the chest. Cardiac examination revealed regular tachycardia, third heart sound present and no murmurs. Echocardiogram showed a dilated left ventricle with diminished systolic function; multiple, prominent apical and lateral trabeculations; deep intertrabecular recesses in continuity with ventricular cavity enhanced by color Doppler echocardiography and a ratio of noncompacted to compacted layers of the myocardium > 2.
Comments: Although first described in 1932 in a newborn with aortic atresia, noncompacted ventricular myocardium is a rare myocardial disease mainly in the isolated form, with few cases reported in the literature.
EPICARDIAL FAT DEPOSIT IS CORRELATED TO CAROTID INTIMA MEDIA THICKNESS AND OCCURRENCE OF CAROTID PLAQUE
Carlos Alberto da Silva Magliano1; Cesar Augusto Nascimento2; Roberto Magalhães Saraiva3
1Total Care; Labs-Cardiolab; INC; 2Instituto Nacional de Cardiologia, 3Fundação Oswaldo Cruz; Total Care
Objective: Epicardial fat is one of the visceral fat deposits and its value as a cardiovascular risk factor is under investigation. Therefore, we sought to evaluate the correlation between the thickness of the epicardial fat and carotid intima media thickness and carotid atherosclerosis.
Methods: One hundred and twelve consecutive patients (53 male; 52 ± 18 years old) were evaluated using Vivid 3 or 7 ultrasound machines (GE Medical Systems). The maximum carotid intima media thickness at the distal portion of the common carotid, the degree of stenosis caused by carotid plaque, and the end-systolic thickness of the epicardial fat were evaluated. The epicardial fat was measured in front of the right ventricular free wall at the long-axis view above the aortic annulus.
Results: Among studied patients, 40 (36%) presented carotid plaque, 12 (11%) presented diabetes mellitus, 13 (12%) had coronary artery disease, and 56 (50%) had hypertension. The carotid intima media thickness averaged 8.6±2.6 mm and the epicardial fat thickness averaged 5.0±2.3 mm. The epicardial fat thickness correlated significantly to the carotid intima media thickness (r = 0.56, p < 0.0001). The epicardial fat thickness was also significantly larger in patients with carotid plaque than without carotid plaque (6.7±1.8 mm, n = 40 vs. 4.1±2.1 mm, n = 72, p < 0.0001).
Conclusion: The epicardial fat thickness correlated to the carotid intima media thickness and to the occurrence of carotid plaque. New studies are needed to evaluate the potential value of the epicardial fat as a new surrogate for cardiovascular risk prediction.
ARTERIAL AND VENOUS MAPPING FOR MAKING ARTERIOVENOSAS FISTULAS: 3-YEAR EXPERIMENT
Antonio Carlos dos Santos Nogueira1; Marcia Lopes Mathias2; Sandra Pereira Leite2; Salomon Israel Do Amaral1; Paulo Cesar Studart1; Luciano H. J. Belém1; Arnaldo Rabischoffsky1; Fernanda Belloni dos Santos Nogueira1; Andrea Moreira Candido2; Rafael Di Iulio R. Correa1
1Hospital Pró-Cardiaco; 2DASA-RJ
Background: Hemodialysis is without any doubt the best therapeutic option for many patients in the end stage of their renal insufficiency; accordingly, they need suitable access (arteriovenous fistulas (AVFs)) for treatment. When badly made or badly “planned” these accesses may show high rates of failure within the 1st year (up to 40%),
Objective: To evaluate the importance of the Eco Color Doppler in “planning” AVFs, seeking to identify most suitable veins for anastomosis, in a three-year experiment.
Methodology: Eighty-five (85) members of 62 patients (38 H) were studied, aged between 25 and 77, in the period from January 2007 to January 2010. Vivid7 apparatus made by GE UltraSound, with a 7/10 mhz linear transducer were used, and an application for vascular ultra-sound with pulsed and color Doppler.
In our examination protocol, we evaluated the arteries of that member (diameters, speed and morphology of flow), as well as the patency and functionality of the palmar arch. We also examined the venous network (superficial, deep and central) and outflow of that member.
Results: An alteration was noted (such as anatomical variation, diameter abnormality, onset of atherosclerosis, arterial occlusion or venous thrombosis, which could compromise the working of the FAV in 63 members of 49 patients.
Making native FAV was counter-indicated for 18 members.
Conclusion: Over the three-year evaluation, the ECD proved to be an important mapping tool for planning and making AVFs.
THREE-YEAR EXPERIMENT USING THE ECO COLOR DOPPLER TO EVALUATE ARTERIOVENOUS FISTULAS
Antonio Carlos Dos Santos Nogueira1; Sandra Pereira Leite2; Marcia Lopes Mathias2; Salomon Israel Do Amaral1; Arnaldo Rabischoffsky1; Luciano H. J. Belém1;Paulo Cesar Studart1; Fernanda Belloni dos Santos Nogueira1; Andrea Moreira Candido2; Flavia Candolo P. Barbosa1
1Hospital Pró-Cardiaco; 2DASA-RJ
Background: Patients suffering from terminal renal insufficiency mostly have arteriovenous fistulas (AVFs) as access for carrying out hemodialysis. These AVFs may show both correctable problems as well as failure within the 1st year after they are made.
Objective: Retrospective analysis of a 3-year experiment evaluating AVFs with the Eco Color Doppler (ECD).
Methodology: From January 2007 to January 2010, we studied 96 AVFs, in 94 patients, (53 H), aged from 24 to 65 years old. Vivid7 apparatus made by GE UltraSound was used, and a 7/10 MHz linear transducer was used and an application for vascular ultra-sound with pulsed and color Doppler.
In our examination, we evaluated the inflow artery(ies) and the distal to fistula arterial segment, the anastomosis (arterial and venous in the case of a graft), the outflow vein, as well as deep and central outflow veins of that member.
Results: We identified 108 abnormalities in 67 AVFs (69.7%); of these, 67 patients, 41 (61.1%), shows difficulty in carrying out hemodialysis; 9 patients of this group plus 1 were successfully submitted to some kind of intervention.
Conclusion: Over the 3 years, the ECD proved to be capable not only of identifying AVF abnormalities, but also of collaborating in the choice of the most suitable intervention to be adopted.
CAROTID ARTERY INTIMAL-MEDIA THICKNESS AND CORONARY ARTERY DISEASE: IMPORTANCE OF THE MEASUREMENT AFTER 2008 ASE CONSENSUS
Simone Santos1; Jaqueline Kuymjian1; Cynthia Nonato1; Wladimir Magalhães; Geniberto Campos1; Augusto Martins1; José R. Barreto2; Daniel Vasconcelos2; Luiz Leite2
1Clínica Biocardios – DF; 2Hospital Brasília – DF
Introduction: Carotid artery intimal-media thickness (IMT) is a non invasive and reproducible technique to evaluate cardiovascular risk. On February 2008, the American Society of Echocardiography” (ASE) endorsed by “Society for Vascular Medicine” proposed a standardization for IMT measurement. The aim of this study was to evaluate this IMT measurement as predictor of positive stress echocardiography (SE).
Method: We studied 101 pts (66.6±10.6 yo, 58.4% male) referred to a tertiary vascular laboratory, who underwent SE. IMT was measured as proposed by ASE according to age, sex, race, and classified by percentile, using a IE33 equipment (Philips).
Results: The total of 101 pts were included in two groups according to IMT percentile: G1 = percentile 25 or 50 (54 pts, 53.5%), and G2 = percentile 75 (47 pts, 46.5%). IMT, SE and clinical data were respectively for G1 e G2: male 28(52%) x 31 (66%) (p = ns), age 62.5 ± 10.4 × 71.5 ± 8.7 (p < 0.0001), HBP 38 (70%)x43 (91%) (p = 0.011), obesity 19 (35%) x 15 (32%) (p = ns), DM 13(24%) x 13 (28%) (p = ns), dislipidemia 28(51%) x 29(62%) (p = ns), statin users 30 (55.6%) x 30 (63.8%) (p = ns), medium IMT 0.71 ± 0.12 × 0.89 ± 0.18 (p < 0.0001), maximal IMT 1.03 ± 0.46 × 1.63 ± 0.52 (p < 0.0001), EF = 67.1 ± 5.1 × 62.7 ± 8.9 (p = 0.002), preWMSI = 1.02 ± 0.11 × 1.14 ± 0.22 (p < 0.0001), postWMSE = 1.03 ± 0.13 × 1.22 ± 0.25 (p < 0.0001), SE+ 5 (9,3%) x 28 (60%) (p < 0.0001). Percentile 75 IMT had 65,1% sensibility, 90,7% specificity, 84,8% PPV, 76,5% NPV, 79,4% accuracy. Multivariate analysis showed age, EF and percentile 75 as independent predictors of myocardial ischemia on stress echocardiography.
Conclusion: IMT, measured as ASE standardization consensus, has a good accuracy for identifying patients with functional relevant coronary disease, and is an independent predictor of myocardial ischemia on stress echocardiography.
ERGOTISM: RARE CAUSE OF INTERMITTENT CLAUDICATION (CASE REPORT)
Felipe Souto Barros, MD; João Luiz Sandri, MD; Cristiano Negri Modenesi, MD; Fanilda Souto Barros, MD; Daniela Souto Barros, MD; Rafael Paiva, MD
From Angiolab, Vascular Laboratory, Vitória, Espirito Santo, Brazil
Introduction: Ergotism, an intoxication caused by ergot alkaloids, is a rare complication of treatments with drugs that contain ergot derivatives. The most frequent symptom is lower extremity ischemia, whereas digestive and neurological symptoms are less frequent.
Case Report: A 42-year-old white woman was admitted with bilateral claudication, cold and pale lower extremities, abdominal pain, nausea and tachycardia. Distal pulses were absent bilaterally. Her medical history was only remarkable for the ingestion of a migraine medicine containing ergotamine tartrate (Ormigrein). She underwent color Doppler ultrasound (CDU), which revealed bilateral patency of the whole aortoiliac/femoral segment, but markedly smaller artery diameters when compared to veins. Flow was monophasic and damped.
After the drug was discontinued and treatment with a vasodilator (cilostazol) was initiated, CDU was repeated and showed normal arterial flow and diameter.
Comments: This case draws attention to a rare cause of arterial ischemia caused by drugs containing ergot derivatives and largely used in migraine treatment. Diagnoses are made according to clinical history, physical examination, and, currently, CDU findings, a diagnostic method that has replaced arteriography because it is noninvasive and highly accurate.
Keywords: ergotism, color Doppler ultrasound, ischemia
DOES QUANTIFICATION OF MYOCARDIAL BLOOD FLOW BY CONTRAST ECHOCARDIOGRAPHY ADD SIGNIFICANT VALUE FOR PREDICTING EVENTS OVER VISUAL ANALYSIS OF MYOCARDIAL PERFUSION?
Angele Alves Mattoso; Jeane M. Tsutsui; Ingrid Kowatsch; Victoria Y. de La Cruz; Wilson Mathias, Jr.
Instituto do Coração (INCOR) – HCFMUSP
Background: Assessment of myocardial perfusion (MP) by visual analysis using nuclear scintigraphy and real-time myocardial contrast echocardiography (RTMCE) has been demonstrated useful for predicting cardiovascular events. The value of determining myocardial blood flow reserve (MBFR) by quantitative RTMCE is not clear. The aim of this study was to evaluate the prognostic value of MBFR obtained by high-dose dobutamine stress RTMCE.
Methods: 84 patients with mean age 57 ± 9 years, normal resting ejection fraction (>55%) were studied by high-dose dobutamine-atropine stress echocardiography with analysis of wall motion (WM), MP and MBFR using RTMCE. MBFR was determined by quantitative RTMCE using Q-Lab software through analysis of microbubble-replenishment velocity and myocardial blood volume at baseline and peak stress. The incremental prognostic value of quantitative RTMCE over clinical risk factors and qualitative perfusion data was examined using a stepwise log-rank test.
Results: A total of 23 patients (27%) had cardiovascular events occurred in a median follow-up period of 42 month (1 death, 2 nonfatal myocardial infarctions, 9 unstable angina, 9 coronary artery bypass surgery and 2 percutaneous coronary intervention). Abnormal qualitative MP and MBFR < 2.74 were independently predictors of events. The rate of events was significantly higher in patients with MBFR < 2.74 in ≥2 territories (p < 0.001), but no difference was observed between patients with abnormal MBFR in 1 or ≥2 territories (p = 0.058). MBFR added incremental prognostic value over wall motion data and qualitative analysis of MP (Chi-square increased from 7.79 to 11.94; p = 0.003).
Conclusion: Determination of MBFR during dobutamine stress RTMCE is an independent predictor of cardiovascular events. Quantification of myocardial blood flow adds significant prognostic information over clinical and qualitative analysis of MP.
PREVALENCE AND PROGNOSTIC VALUE OF PULMONARY HYPERTENSION IN PATIENTS WITH ACUTE DECOMPENSATED HEART FAILURE: AN ECOCARDIOGRAPHIC STUDY
Pedro Pimenta de Mello Spineti; Marcelo Iorio Garcia; Marcella de Agostini Iso; Ana Luiza Ferreira Sales; Eliza de Almeida Gripp; Anna Luiza Rennó Marinho; Cláudia Cozendey Parada; Debora Angélica Lopes Reis; Luis Augusto Feijó; Sérgio Salles Xavier
Federal University of Rio de Janeiro
Backgrounds: Pulmonary arterial hypertension (PAH) is a common condition in patients with acute decompensated heart failure (ADHF). Its prevalence and prognostic value are little known.
Objectives: To analyze the prevalence and prognostic value (in-hospital mortality (HM) and post-discharge mortality (PDM)) of PAH in patients admitted to a university hospital for ADHF.
Methods: retrospective and observational study of 316 consecutive admissions for ADHF in which at least one echocardiogram was performed from 01/01/2006 to 06/30/2009. PAH was defined as a systolic pulmonary artery pressure (SPAP) > 35 mmHg (estimated on echocardiogram) and classified as mild (SPAP: 35–44 mmHg), moderated (45–59 mmHg) and severe (≥60 mmHg). On univariate analysis (UA) the association between SPAP and HM was tested trough Mann-Whitnney test. To evaluate PDM, Kaplan-Meyer curves, stratified according to the presence of PAH, were built and compared by log-rank test. On multivariate analysis (MA) we used logistic regression to evaluate HM and Cox proportional model for PDM.
Results: SPAP estimates were obtained from 213 echocardiograms (67%). The prevalence of PAH was 76%(absent: 24%, mild: 24%; moderate: 35% and severe: 17%). HM was 10%(22 deaths) and PDM was 45%(83 deaths). The mean follow up was 17 ± 13 months. In UA SPAP was associated with higher HM (p = 0.011) and higher PDM (p = 0.018). Survival estimates in 1 year were 54% versus 85%, depending on the presence or absence of SPAP, respectively. In MA, SPAP prognostic value was kept independently from other predictors of HM (p = 0.033) and PDM (p = 0.003).
Conclusion: PAH is frequent in ADHF and is an independent predictor of higher in-hospital and post-discharge mortality.
PROGNOSTIC VALUE OF ADENOSINE STRESS ECHOCARDIOGRAPHY ASSOCIATED WITH MYOCARDIAL PERFUSION IN REAL TIME IN PATIENTS WITH SUSPECTED CORONARY ARTERIAL DISEASE – PRELIMINARY RESULTS
Angele Azevedo Alves Mattoso; Jeane M. Tsutsui; Ingrid Kowatsch; Victoria Y. de La Cruz; Wilson M. Jr
Instituto do Coração (INCOR) – HCFMUSP
Introduction: Real-time myocardial contrast echocardiography (RTMCE) has been demonstrated to improve the accuracy for detecting coronary artery disease (CAD).
Objective: To evaluate the prognostic value of qualitative (QP) and quantitative myocardial perfusion analysis and their additional value over wall motion (WM) analysis during adenosine stress RTMCE in patients with suspected CAD.
Methods: We studied 104 patients (mean age 58 ± 9 years, 48% men) who underwent adenosine (140 mcg/Kg/min, for 6 minutes) stress RTMCE with low-mechanical index pulse sequence schemes following intravenous infusion of contrast agent. The replenishment velocity reserve (β) and an index of myocardial flow reserve (Axβ) were derived from quantitative RTMCE using Q-Lab software. The best cutoff values of β and Axβ reserves to predict total events were determined using ROC curves. Events were defined as cardiac death, myocardial infarction, unstable angina and coronary revascularization.
Results: During the median follow-up time of 36 months, 28 events occurred (4 myocardial infarction, 1 cardiac death, 9 unstable angina, 2 percutaneous revascularizations and 12 surgical revascularizations). Using univariate analysis, predictors of events were anormal QP (p = 0.009), β reserve (p < 0.001) and Axβ reserve (p < 0.001). Using multivariate analysis, independent predictors of events were anormal QP (RR = 3.267, p = 0.01), β reserve (RR = 12.667, p = 0.023) and Axβ reserve (RR = 4.846, p = 0.028). There was incremental value of the WM+QP analysis (Chi-square increased from 4.021 to 7.016, p = 0.008) and WM+QP+β reserve (Chi-square increased from 7.016 to 28.205, p < 0.01) and WM+QP+ Axβ reserve (Chi-square increased from 7.016 to 13.704, p = 0.001). Higher proportion of events occurred among patients with β and Axβ abnormal reserves in ≥02 coronary territories versus 01 coronary territory (53.8%x25% and 48.6%x31.6%, respectively).
Conclusion: Adenosine stress RTMCE provides additional and independent prognostic information in patients with CAD. Quantitative analysis of myocardial perfusion may identify a subgroup with worst prognosis (β and Axβ abnormal reserve in ≥ 02 coronary territories).
NEW EQUATION FOR THE PREDICTION OF RESPONSE AFTER CARDIAC RESYNCHRONIZATION THERAPY: THREE-DIMENSIONAL ECHOCARDIOGRAPHY APPRECIATION
Viviane T. Hotta; Marcelo L. C. Vieira; Martino Martinelli Filho; Daniela do C. Rassi; Silvana A.D. Nishioka; Charles Mady; Wilson Mathias Jr
Background: The selection of patients to cardiac resynchronization therapy (CRT) still requires a definite method that provides information regarding the response to this treatment. After the PROSPECT trial results, echocardiography was undervalued in the evaluation of patients pre-CRT. The aim of this study was to determine the role of integrated data from conventional echocardiography (2DEcho), real time three-dimensional echocardiography (RT3DE) for prediction of LV reverse remodeling (LVRR) post-CRT.
Methods: Twenty-four consecutive patients with heart failure, sinus rhythm, QRS ≥ 150 ms,functional class III or IV (NYHA) despite optimal medical treatment and left ventricular ejection fraction (LVEF) ≤ 0.35, underwent CRT. All patients were submitted to clinical and echocardiographic evaluation [2D Echo, RT3DE with systolic dyssynchrony index (SDI) analysis and TDI] pre- and six months post-CRT. Patients were included in the responder group if there was clinical improvement (by at least 1 level of the NYHA functional class) and a reduction of≥15% of LVSV. Responders and non-responders were compared with respect to baseline characteristics, electrocardiographic patterns,and echocardiographic measurements (anatomical and morphological variables, and LV dyssynchrony indexes were evaluated by TDI and RT3DE). A univariate analysis of clinical, electrocardiographic,and echocardiographic baseline characteristics was performed to construct a logistic regression model.
Results: Nine of twenty-four (38%) patients presented with LVRR six months post-CRT. The best predictors of LVRR post-CRT were cardiac dyssynchrony indexes evaluated by TDI (twelve segments) and SDI. After construction of receiver operating characteristic curves, an equation considering LVDD (2DEcho), LVEF, and SDI (RT3DE) data was established to predict LVRR post-CRT as follows: LVRR =−0.4LVDD (mm) + 0.5LVEF (%) + 1.1SDI (%), with responders presenting values > 0.
Conclusions: In this preliminary study,an equation is proposed for prediction of LVRR after CRT by including data from 2DEcho (LVDD) and 3DEcho (LVEF and SDI). Although larger trials are needed to validate these findings, this equation can be of value to candidates for CRT in the clinical setting.
ANALYSIS OF THE LEFT ATRIAL FUNCTION THROUGH TRIDIMENSIONAL ECOCARDIOGRAPHY IN PATIENTS WITH SEVERE CHRONIC MITRAL REGURGITATION BEFORE AND AFTER SURGICAL CORRECTION
David Costa de Souza Le Bihan1; Rodrigo Bellio Mattos Barretto1; Dorival Dellatogna1; Leonardo Mello Guimarães de Toledo1; Carina Amorim Pouillard Carneiro1; Tais Araújo de Jesus1; Zilda M. Meneghelo1; Orlando Campos Filho2; Jorge Eduardo Assef1; Amanda Guerra de Moraes Rego Sousa1
1Instituto Dante Pazzanese de Cardiologia; 2UNIFESP
Introduction: The enlargement of the left atrium (LA) assessed by echocardiography is one of the worst prognostic indexes in several conditions, and it has been related with diastolic dysfunction, atrial fibrillation and stroke. Echocardiography can also measure the left atrial emptying fractions: active left atrial emptying fraction (ALAEF) dependent on atrial contraction; passive left atrial emptying fraction (PLAEF) and total left atrial emptying fraction (TLAEF). There are few studies on LA function, assessed through its volume and emptying fractions, in patients with chronic mitral regurgitation (MR).
Objectives: 1) To assess the performance of the left atrial emptying fractions through tridimensional echocardiography (3D ECHO) within a group of patients with MR before and after surgery. 2) To correlate the findings with the type of surgery performed (valve replacement or valve repair).
Methods: Sixteen patients with MR (all in sinus rhythm) were prospectively studied before surgery and a month after surgery. LA volumes were measured by 3D ECHO at three different phases: maximal volume (MV) at the systolic peak; minimal volume (min V) at the end of the diastole; volume before (or in the ascending phase) of the P wave of the electrocardiogram (PV). ALAEF was then defined as: PV – minV/PV. TLAEF was obtained through: MV-minV/MV. PLAEF was calculated through: MV-PV/MV.
Results: Eight patients underwent valve replacement, and eight patients underwent valve repair. Patients that presented post-operative left ventricular ejection fraction below 0.6 also presented larger left ventricular end-systolic diameter and smaller TLAEF (37% VS. 45%, p = 0.02) preoperatively. Post-operatively, TLAEF was significantly more reduced in the group submitted to the replacement when compared to the group submitted to the repair (12% VS. 4%, p = 0.03). However, there was no difference in terms of the ALAEF when comparing the two groups (1.3% VS. 4%, p = 0.2).
Conclusions: Patients with lower TLAEF before surgery presented a left ventricular ejection fraction below 0.6 after surgery. The type of surgery did not interfere in the effectiveness of the post-operative atrial contraction.
ACCURACY OF CORONARY CALCIUM SCORE TO DETECT SIGNIFICANT CORONARY STENOSIS IN PATIENTS WITH ACUTE CORONARY SYNDROME – A CORE64 SUBSTUDY
Leonardo Sara; Alexandre Volney Villa; Adriano Carneiro; Leonardo Fiaschi Zancaner; Ilan Gottlieb; Tiago Augusto Magalhães; Valeria de Melo Moreira; Antonio Mansur; Jose Carlos Nicolau; Carlos Eduardo Rochitte
Instituto do Coração, INCOR, FMUSP
Objectives: We investigated the prevalence of significant coronary obstruction and coronary calcification in patients presenting with suspected acute coronary syndrome (ACS) in a multicenter trial.
Methods: Patients included in the CORE64 study were categorized as suspected ACS or non-ACS based on clinical data. 64-Row Multidetector Computed Tomography Angiography (Aquilion 64, Toshiba Medical Systems Corp.–Ottawara, Japan) was performed before scheduled invasive coronary angiography. An initial calcium score (CS) scan was done with prospective acquisition (4×3.0 mm slice collimation, 120 kV, 300 mA) and quantified using Agatston score.
Results: From 291 patients with CS <600, 80 (27%) were categorized as suspected ACS. The mean Agatston CS was 120 ± 159 (median 91, 75th percentile 180) in suspected ACS and 148 ± 166 (median 80, 75th percentile 286) in non-ACS group. From the 80 suspected ACS patients, 16 (20%) had no coronary calcification, from which 6 (8%) had coronary stenosis ≥50%. In non-ACS group, 8 patients (4%) had CS = 0 and significant coronary stenosis. Considering patients with zero or low CS (0 to 9), 12 (15%) in suspected ACS and 11 (5%) in non-ACS group had significant coronary stenosis (p = 0.014).
Conclusion: In our suspected ACS patient group, the absence or minimal coronary artery calcification could not exclude the presence of significant coronary stenosis. These findings suggest that in this higher-risk group of patients, a low CS might underestimate the overall plaque burden.
LEFT VENTRICULAR SPHERICITY AS AN EARLY INDICATOR OF DECOMPENSATED HYPERTROPHY IN EXPERIMENTAL AORTA REGURGITATION
Meliza Goi Roscani; Bertha Furlan Polegato; Ana Paula Mena Lousada; Suzana E. Tanni; Marcos F. Minicucci; Paula S. Azevedo; Mario B. Bruno; Silmeia Garcia Zanati; Luiz Shiguero Matsubara; Beatriz Bojikian Matsubara
Faculdade de Medicina de Botucatu – UNESP
Purpose: Increased left ventricular (LV) diastolic diameter (DD) has been used as a marker for surgical replacement of insufficient aortic valve. However, this enlargement may occur after irreversible damage of myocardium. The aim of this study was to evaluate in vivo temporal changes of the heart and how this is associated with LV function.
Methods: Male Wistar rats (BW: 250 g) underwent surgical procedure (anesthesia: ketamine-50 mg/kg plus xylazine-1 mg/kg) for inducing acute aorta regurgitation (AR group, n = 23) or sham operation (SH group, n = 12). Transthoracic echocardiograms were performed at 1, 4, 8 and 16 weeks after procedure. Anatomic variables were: LVDD, LV sphericity index (SI), normalized left atrium area (LAA) and LV relative wall thickness (RWT) and functional index was LV fractional shortening (FS). Statistical analyses used GEE model (General Estimative Equation, STATA 10.0) or repeated measures ANOVA (p < 0.05).
Results: There were interactions between time and AR for increasing LVDD (p < 0.001), LAA (p = 0.0011) and SI (p < 0.001), and for decreasing RWT (p = 0.002) and FS (p < 0.001). Compared to week 1, the increased SI at week 4 (0.72 ± 0.09 vs. 0.65 ± 0.64; p < 0.001) preceded the LVDD enlargement (9.0 ± 1.3 mm vs. 7.6 ± 0.63 mm; p < 0.05) and LAA increasing (1.56 ± 0.32 vs. 1.45 ± 0.20; p < 0.05) observed at week 8 and RWT decreasing observed at week 16 (0.175 ± 0.044 vs. 0.20 ± .025; p = 0.003). There was an interaction between time and SI for reducing FS (p < 0.001). LV systolic dysfunction was detected at week 8 and preceded LAA enlargement at week 16. This suggested increased LV diastolic pressure and it was coincident with the decreased RWT indicating LV dilation.
Conclusion: Left ventricular spherical geometry in aorta regurgitation is an early sign of decompensated hypertrophy, preceding systolic and diastolic LV dysfunction.
3-DIMENSIONAL SPECKLE TRACKING: A NEW TECHNOLOGY TO OBTAIN SYSTOLIC STRAIN. STUDY IN HEALTHY VOLUNTEERS
Luiz D.Cortez; José L. Andrade; Orlando Campos; Ana L. Arruda; Jairo Pinheiro; Luciana Vulcanis; Tiago S. Shiratsuchi; Roberto Kalil-Filho
Hospital Sírio Libanês
Objective: To describe peak systolic regional measurements of radial (Rs), longitudinal (Ls) and circumferential (Cs) strain obtained by 3-Dimensional Speckle Tracking (3DT) in a group of normal adults with global preserved left ventricular (LV) function.
Methods: Rs, Ls and Cs were measured by 3DT using commercially available ultrasound equipment (Artida™, Toshiba Medical Systems, Japan) in 50 consecutive healthy volunteers (mean age 32 ± 9 years; mean LV ejection fraction: 64 ± 7%). We used a model of 16 myocardial segments, considering basal (B), mid (M) and apical (A) regions of LV.
Results: We excluded 3 studies because of poor image definition. In the remaining 47, Rs measurements varied from 33,8% to 65,8%, Ls from 14,2% to 25,1% and Cs from 28,1% to 40,6%. The table shows mean values ± 1SD of each segment.
Conclusions: Different values of regional peak systolic Rs, Ls and Cs derived from 3DT are observed in normal individuals. Further studies with a larger number of participants with this new technology are necessary to establish reference values for the normal population.
|Basal anterior||64,2 ± 27,0||21,0 ± 6,6|| 28,8 ± 11,7|
|B. anteroseptum||57,6 ± 24,5||14,8 ± 6,1|| 31,1 ± 11,0|
|B. anterolateral||63,8 ± 24,9||24,2 ± 7,6|| 31,4 ± 12,3|
|B. inferior||47,9 ± 15,6||22,3 ± 9,0|| 36,4 ± 10,1|
|B. inferoseptum||51,9 ± 19,3||16,9 ± 6,1||31,7 ± 9,1|
|B. inferolateral||58,5 ± 9,6 ||24,7 ± 9,6||39,8 ± 9,9|
|Mid anterior||51,2 ± 18,7||18,2 ± 6,7||30,8 ± 9,8|
|M. anteroseptum||48,4 ± 17,3||16,4 ± 7,1||29,1 ± 8,0|
|M. anterolateral||48,5 ± 14,5||18,8 ± 7,0|| 33,8 ± 10,0|
|M. inferior||42,3 ± 11,6||16,3 ± 6,4||34,6 ± 8,3|
|M. inferoseptum||45,0 ± 13,7||17,1 ± 6,0||31,6 ± 9,3|
|M. inferolateral||44,0 ± 12,1||15,9 ± 7,1||36,5 ± 8,9|
|Apical anterior||37,1 ± 12,2||15,2 ± 6,6|| 30,8 ± 10,7|
|A. septal||38,7 ± 12,3||19,8 ± 6,2||31,4 ± 9,2|
|A. inferior||34,7 ± 12,4||22,6 ± 6,3||33,6 ± 8,7|
|A. lateral||36,1 ± 13,0||18,9 ± 6,9||34,3 ± 9,9|
LEFT ATRIAL DYSFUNCTION EVALUATED WITH TRIDIMENSIONAL ECHOCARDIOGRAPHY (3D) IMAGE IN PATIENTS WITH CHAGAS’DISEASE WITH NORMAL EJECTION FRACTION (EF) AND HEALTHY VOLUNTEERS
Cesar A.S. Nascimento1; Ademir B. Cunha1; Barbara Ruivo1; Gabriel Camargo1; Rodrigo Lustosa1; Luciano Belém1; Roberto M. Saraiva1,2.
1Instituto Nacional de Cardiologia; 2Fiocruz
Objectives: The measurements Left Atrium (LA) using Tridimensional echocardiography (3D) image, may emerge as an important component in the evaluation of a number of diseases. We did it patients with Chagas’disease with Normal Ejection Fraction (EF) and healthy volunteers.
Methodology: We prospectively examined images from seventh (n = 17) patients with Chagas’disease and seventh (n = 17) healthy volunteers after undergoing thorough medical histories and physical examinations, EKG and Sorology. Studies were performed using phased-array ultrasound systems (Vivid 7; GE Medical Systems, Milwaukee, WI) equipped with 3S phased-array transducers. Cardiac dimensions were measured in accordance with the recommendations of the American Society of Echocardiography. The values for 2D echocardiographic parameters were obtained after averaging 3 consecutive cycles.
M-mode echocardiography was used to measure LA diameter and LVend-diastolic and end-systolic diameters. LVand LA volumes were determined using the modified Simpson's rule with images obtained from apical 4-chamber and 2-chamber views. Pulsed-wave Doppler was obtained in the apical 4-chamber view. From transmitral recordings, the peak early (E) and late (A) diastolic filling velocities, E/A ratio, E-wave deceleration time, E-wave velocity-time integral (VTIE), A-wave VTI (VTIA), and LA filling fraction (VTIA/[VTIE + VTIA]) were obtained. From pulmonary vein velocities obtained at the right upper pulmonary vein, the following measurements were taken: peak S-wave inflow velocity during ventricular systole, peak D-wave inflow velocity during the early phase of ventricular diastole and the corresponding S/D ratio, peak reversed atrial wave (Ar) velocity during LA contraction, S-wave VTI, D-wave VTI, and Arwave VTI. Doppler tissue imaging of the mitral annular level was obtained at the septal and lateral positions. The diastolic myocardial velocities are averages of the values obtained at septal and lateral positions. The following indexes of LA function were calculated Maximum LA volume (ml), Minimum LA volume (ml). Precontraction LA volume _ minimum LA volume. Passive LA stroke volume was calculated as maximum LA volume _ precontraction LA volume. The total LA emptying fraction (%) was calculated as (total LA stroke volume/maximum LA volume) _ 100. The active LA emptying fraction was calculated as (active LA stroke volume/precontraction LA volume) _ 100. The passive LA (%) with good quality images, enough depth to include the whole left atrium and acquired with high frame rates were used for analysis with Tomtec software and EchoPAC; GE Medical Systems.
Results: The patients with Chagas’disease was slighly older (59 ± 14 vs. 47 ± 13 anos, p < 0,05), but they presented the same ejection fraction (EF) and mitral flow transmitral recordings, the peak early (E) and late (A) diastolic filling velocities, E/A ratio, E-wave deceleration time, than the control group. (tabela I)
The TVI early (E’) was small in Chagas’disease (9 ± 2 vs.11 ± 3 cm/s, p < 0,05) and the ratio E/E’ higher (9,2 ± 2,3* vs. 7,4 ± 1,8, p < 0,05) than healthy volunteers.
The minimum LA volume was higher in Chagas’disease (21,5 ± 6,4 vs. 15,5 ± 6,9 ml, p < 0,05) than healthy volunteers.
And Total LA filling fraction (52 ± 11 vs. 65 ± 10%, p < 0,05) and active (24 ± 10 vs. 39 ± 10%, p < 0,05) was small in Chagas’disease than the controls. The A’ values was small in Chagas’disease than in controls (7,4 ± 2,6 vs. 9,7 ± 2,3 cm/s, p < 0,05).
Conclusion: The patients with Chagas’disease with normal Ejection Fraction had a contraction of Left Atrial Dysfunction compare with healthy volunteers and to be recognized like prognostic marker it should be confirmed with another studies.
|Age (ys)||47 ± 13||59 ± 14*|
|LA diameter (cm)||3.6 ± 0.5||3.8 ± 0.4|
|LV end-diastolic diameter (cm)||4.7 ± 0.4||5.3 ± 0.5*|
|LV end-systolic diameter (cm)||2.8 ± 0.4||3.3 ± 0.7*|
|LV end-diastolic volume (ml)||100 ± 28||105 ± 26|
|LV end-systolic volume (ml)||29 ± 10||34 ± 14|
|LV ejection fraction (%)||71 ± 6||68 ± 8|
|E (cm/s)||78.8 ± 14.7||78.9 ± 20.3|
|A (cm/s)||64.8 ± 13.3||70.0 ± 16.9|
|E/A ratio||1.3 ± 0.5||1.2 ± 0.4|
|E-wave deceleration time (ms)||193 ± 37||196 ± 60|
|E’ average (cm/s)||11 ± 3||9 ± 2*|
|E/E’ ratio average||7.4 ± 1.8||9.2 ± 2.3*|
|A’ lateral (cm/s)||9.7 ± 2.3||7.4 ± 2.6*|
|Ar (cm/s)||32 ± 9||28 ± 4†|
|S/D ratio||1.3 ± 0.4||1.2 ± 0.4|
|LV mass (g)||139 ± 39||122 ± 68|
|Maximum LA volume (ml)||43.5 ± 10.0||46.0 ± 11.7|
|Minimum LA volume (ml)||15.5 ± 6.9||21.5 ± 6.4*|
|Pre-A LA volume (ml)||25.1 ± 8.7||28.5 ± 8.0|
|Total LA emptying fraction (%)||65 ± 10||52 ± 11*|
|Active LA emptying fraction (%)||39 ± 10||24 ± 10*|
|Passive LA emptying fraction (%)||43 ± 12||39 ± 12|
THE ROLE OF THREE-DIMENSIONAL ECHOCARDIOGRAPHY AND TISSUE DOPPLER IMAGING IN THE EVALUATION OF CARDIAC DYSSYNCHRONY PRE AND POST CARDIAC RESYNCHRONIZATION THERAPY: COMPARISON BETWEEN THE TWO METHODS
Viviane T. Hotta; Marcelo L. C. Vieira; Daniela do C. Rassi; Silvana A.D. Nishioka; Martino Martinelli Filho; Charles Mady; Wilson Mathias Jr
Background: The identification of cardiac dyssynchrony plays a fundamental role in the selection of patients treated with cardiac resynchronization therapy (CRT). Tissue Doppler Imaging (TDI) has been the most utilized echocardiographic technique for the evaluation of cardiac dyssynchrony, but numerous recent reports have shown the superiority of real time three-dimensional echocardiography (RT3DE) for this purpose. The aim of this study was to compare the evaluation of cardiac dyssynchrony by these two techniques in the setting of heart failure patients treated with CRT.
Methods: Twenty-four consecutive patients with heart failure,sinus rhythm,QRS ≥ 150 ms, functional class III or IV (NYHA) despite optimal medical treatment and left ventricular ejection fraction (LVEF) ≤ 0.35, underwent CRT. All patients were submitted to clinical and echocardiographic evaluation[2D Echo,RT3DE with systolic dyssynchrony index (SDI) analysis and TDI]pre-, three and six months post-CRT. The TDI analysis was performed with the evaluation of four (TDI4S), six (TDI6S) and twelve (TDI12S) myocardial segments. Comparisons between the cardiac dyssynchrony evaluated by RT3DE and TDI were performed with Pearson's correlation analysis.
Results: Twenty-four consecutive patients were evaluated three and six months post-CRT. At the baseline, there was no strong correlation between TDI4S and SDI (r = 0.08), TDI6S and SDI (r = 0.08), and TDI12S and SDI (r = 0.25). Three months post-CRT, there was moderate correlation between TDI4S and SDI (r = 0.61), TDI6S and SDI (r = 0.52). Six months post-CRT, there was no strong correlation between TDI4S and SDI (r = 0.06), TDI6S and SDI (r = 0.06) and TDI12S and SDI (r = 0.10).
Conclusions: In this study, there was no strong correlation observed between TDI and RT3DE in the evaluation of cardiac dyssynchrony pre- and post-CRT.
STRESS ECHO ASSESSMENT IN AN EXPERIMENTAL MODEL OF ADJUSTABLE PULMONARY ARTERY BANDING
Gustavo Antonio Guimarães Favaro; Renato Assad; Maria C. Abduch; Gustavo Justo; Guilherme Gomes; Jose Lazaro Andrade; Jose E. Krieger; Noedir A. G. Stolf
Objectives: Retraining of the left ventricle (LV) has been used in patients with transposition of the great arteries (TGA) beyond the neonatal period, and in congenitally corrected TGA or after Senning or Mustard operation with right ventricle (RV) failure. This study was designed to assess ventricular function in two protocols of pulmonary artery banding (PAB).
Methods: Nineteen young goats were divided into three groups: Sham (n = 7; loose PAB, no systolic pressure overload), Continuous (n = 6; systolic overload maintained for 96 hours) and Intermittent (n = 6; 4 periods of 12-hour systolic overload, alternated with a resting period of 12 hours). Echocardiographic and hemodynamic evaluations were performed every day. Myocardial performance index and ejection fraction were evaluate at rest and during dobutamine stress. The animals were then killed for myocardial water content and weight evaluation.
Results: Intermittent group was submitted to a significant smaller systolic overload area, measured by RV to PA pressure gradient over time, as compared to Continuous group (p < 0.05). However, both groups had increased RV and septal masses, as compared to Sham (p < 0.0002). There was a major increase in the RV wall thickness of the Intermittent group (+64.8%± 23.37%), when compared to continuous group (+43.9%± 19.26%; p = 0.015). A significant increase in RV diastolic volume was observed in the Continuous Group after 96 hours (p = 0.015). RV dysfunction was observed in both study groups after starting systolic overload (zero and 24-hour moments, p < 0.002), with full recovery of RV function at the end of protocol (p < 0.001). Myocardial performance index was significantly better for the Intermittent group at the end of protocol, under resting and dobutamine infusion, when compared to Continuous group (p < 0.012).
Conclusions: Both systolic overload protocols have promoted rapid RV hypertrophy. However, RV function of the Intermittent group was better preserved than continuous group, at the end of the protocol, both at rest and under dobutamine infusion. This study suggests that a more efficient hypertrophy to prepare the left ventricle can be achieved with intermittent systolic overload.
QUANTITATIVE ASSESSMENT OF ATRIAL FUNCTION USING STRAIN IMAGING IN CHAGAS AND IDIOPATHIC DILATED CARDIOMYOPATHY
Maria do Carmo P Nunes; Fernando A Botoni; Manoel Otávio C Rocha; Mariana Campos Palma; Rafaela Drumond Araújo; Paula Athayde Braga Machado; Márcia M Barbosa
Postgraduate Course of Tropical Medicine and Statistical Department, Federal University of Minas Gerais; Ecocenter, Socor Hospital – Belo Horizonte, Brazil
Background: In the setting of Chagas cardiomyopathy, severe myocardial inflammation and fibrosis can involve the atrial myocardium. However, quantitative assessment of atrial function has been difficult. This study aimed to assess left and right atrial function by strain and strain rate (SR) imaging in dilated cardiomyopathy and also to compare these parameters of atrial function among patients with Chagas and idiopathic cardiomyopathy.
Methods: Seventy-one patients with dilated cardiomyopathy and 20 healthy controls were evaluated by standard echocardiogram study and by Doppler myocardial imaging (strain and strain rate of right and left atrium) from 3 apical views and analyzed off-line. Peak strain and peak SR, early diastolic SR, and late diastolic SR were measured at septal and inferior segment of the left atrium and at lateral segment of the right atrium.
Results: Thirty-six patients with Chagas cardiomyopathy (22 males; mean age, 42 ± 11 years) and 35 with idiopathic cardiomyopathy (20 males; mean age, 44 ± 10 years) were enrolled. Atrial myocardial deformation indices of both RA and LA were similar between Chagas and idiopathic patients (strain: −31.1 ± 10.3% vs −29.8 ± 13.1%, p = 0.743; strain rate: −1.36 ± 0.6 s−1 vs −1.45 ± 0.8 s−1, p = 0.649). However, these indices were significantly compromised in cardiomyopathy patients when compared with controls (strain: −30.4 ± 11.8% vs −52.2 ± 20.8%, p < 0.001; strain rate: −1.4 ± 0.7 s−1 vs −2.2 ± 0.7 s−1, p < 0.001), indicating atrial dysfunction.
Conclusion: This study demonstrated that atrial myocardial deformation properties are abnormal in patients with Chagas cardiomyopathy, similar to patients with idiopathic cardiomyopathy.
LONGITUDINAL STRAIN AND VELOCITY BY TISSUE DOPPLER IN PATIENTS WITH PRESERVED LEFT VENTRICULAR SYSTOLIC FUNCTION: EFFECT OF QRS WIDTH
Adelino Parro Junior; João Batista Masson Silva; Luciana Freitas Wenzel; Vanessa Calil de Almeida; Glaucia dos Santos; Marta Lancia Carramona Cherubini; Luciano Miola
Instituto de Moléstias Cardiovasculares
Objective: Some variables derived from tissue color Doppler (TCD) have been proposed for the identification of intraventricular dyssynchrony (IVD) in patients (pcs) with congestive heart failure (CHF). The aim of this study was to evaluate IVD by using velocity (V) and longitudinal strain (LS) in pcs with preserved left ventricular systolic function (nlLVF) and without CHF, and the effect of the width of the QRS in these parameters.
Methods: Twenty nine pcs were included (50,5 ± 1,1 years; 18 men), 19 of whom with QRS < 120 ms (G-I) and 10 with QRS > 120 ms (G-II). The standard deviation of the time interval between the Q wave of ECG and the maximum tissue velocity (SD-12-V), and between Q wave and the peak of the LS (SD-12-LS) of the mid and basal LV segments, from the 3 apical views, was measured
Results: The groups differed in age (G-I = 44,7 ± 16,6 vs G-II = 61,7 ± 12,1 years, p < 0,01), LV ejection fraction (GI = 69, 9 ± 5,6 vs G-II = 63,4 ± 9,4%, p = 0,02) and diastolic blood pressure (G-I = 84,6 ± 8,7 vs G-II = 77,8 ± 6 7 mmHg, p = 0,04). The DP-12-V in G-I and G-II was 46,9 ± 22,3 and 49,5 ± 13,9 ms (p = ns), respectively, and the DP-12-LS was 48,7 ± 11,9 ms in G-I and 63,0 ± 15,3 ms in G-II (p = 0.009).
Conclusion: In pcs with nlLVF the mean value of DP-12-V was high in both groups when compared with the values from the literature for pcs with CHF, with no statistically significant difference between G-I and G-II, while the DP-12-LS was significantly higher in G-II.
ANOMALOUS MITRAL ARCADE WITH TRICUSPID SUBVALVULAR DYSPLASIA – REPORT OF A RARE CASE, DOCUMENTED WITH 3D IMAGES
Alex dos Santos Félix1; Cesar Nascimento2; Marcela Cedenilla2; Luis Henrique Weitzel2; Luisa Maria Alves1; Luciano Herman Belem2; Clara Weksler2
1Instituto Nacional de Cardiologia – DASA/RJ; 2Instituto Nacional de Cardiologia
Summary: Anomalous Mitral Arcade is a rare congenital malformation, with just a few cases reported to date in the medical literature. We found only 3 cases described in adults, none of these cases associated with tricuspid anomaly.
We report a case of a 20-year-old woman, with a vague diagnosis of cardiopathy since infancy, without adequate medical follow-up ever since.
She had a long-lasting history of moderate dyspnea that evolved progressively in the last 3 years, after her pregnancy, to severe dyspnea (mild efforts), orthopnea, paroxysmal nocturnal dyspnea and lower extremities edema.
Examination showed a physically hypodeveloped patient. Ictus cordis was left deviated and there was a palpable S3. Cardiac rhythm was regular, and a pansystolic mitral murmur (3+/6+) with posterior irradiation and a systolic tricuspid murmur (2+/6+) were notable on auscultation.
The Echocardiogram (transthoracic, 3D and transesophageal), showed enlargement of the four cardiac cavities, and biventricular systolic dysfunction, with moderate to severe left ventricular dysfunction.
The mitral valve was anomalous (dysplastic), with thickened and degenerated leaflets, hypodevelopment of the anterior leaflet and the subvalvular apparatus, mainly the chordae tendineae related to the posterior mitral leaflet, almost directly attaching the malformed papillary muscles to the free edge of the posterior mitral leaflet.
The papillary muscles were anomalous, with a “bridge” of fibrous tissue connecting them, like an arch, with a network of poorly differentiated chordae extending between the anterior mitral leaflet and the “bridge”, creating the aspect of a “Mitral Arcade” .
Resulting severe mitral regurgitation was seen at color Doppler study, caused by the prolapse and non-coaptation of the leaflets, with no valvular stenosis. Severe pulmonary hypertension was associated.
In this particular case we could observe tricuspid valve dysplasia, with a kind of fibromuscular “crest” below the valve, projecting from the lateral basal wall towards the septum, with coarse trabeculae, where attaches thin and anomalous chordae, resulting in non-coaptation of leaflets and moderate valvular regurgitation.
She was candidate to cardiac transplant, but significant socioeconomical and psicological issues switched the surgical choice to mitral and tricuspid valve repair, achieving good echocardiographic and clinical results, being discharged from hospital with improved functional class.
Keywords: Anomalous Mitral Valve Arcade, Mitral Dysplasia, congenital heart disease
SPONTANEOUS MICROBUBBLES IN PATIENTS WITH HEART VALVE PROSTHESIS: CLINICAL RELEVANCE OF CAVITATION PHENOMENON
Alex dos Santos Félix1; Rodolfo P. Lustosa2; Gabriel Cordeiro Camargo2; Luisa Maria Alves1; Sergio Salles Xavier3
1Instituto Nacional de Cardiologia – DASA/RJ; 2Instituto Nacional de Cardiologia; 3HUCFF – UFRJ
Summary: The consequence of gas microemboli, microbubbles, is underrecognized and usually overlooked in daily practice. It may originate in extracorporeal lines (cardiopulmonary by-pass and dialysis machines), but may be endogenous, in cases of mechanical heart valves, phenomenon called cavitation.
With the advance of sonographic techniques, detection of microbubbles in the blood stream and into the cardiac chambers has enhanced, but evidences of the clinical implications and interference in prosthesis durability are still lacking, and there are few cientific data regarding this subject.
This was a retrospective transversal study. Eighty nine patients with heart valve prosthesis were enrolled (51 woman, 38 men with a mean age of 47,9 ± 14,5 years). Among these patients 52 (58%) with mechanical mitral prosthesis (MM), 16 (18%) mechanical aortic (MA), 10 (12%) mechanical mitro-aortic (MMA), 9 (10%) biological mitral (BM) and 2 (2%) biological aortic (BMA).
All patients were submitted to a complete echocardiographic exam and a transcranial Doppler (TCD), with a brief anamnesis directed to neurological symptoms attributable to central nervous system emboli.
Continuous variables are expressed as mean ± SD. Dichotomous variables were compared by using chi-square analysis. A value of p < 0,05 was considered statistically significant.
None of the biological prosthesis presented cavitation, being detected in 83% (43) of the MM group, 75%(12) of the MA group, and in 100%(10) of the MMA group. The DTC showed gas microemboli in 20% (13) of the patients with microbubbles detectable on echocardiogram, among these 16% (7) of the MM group, 14% (2) of the MA group and 67% (4) of the MMA group (p < 0,005).
There was no significant correlation between rhythm (sinusal or atrial fibrillation) and cavitation (p = 0,587), neither between left ventricle dysfunction and cavitation (p = 0,349).
We found significant correlation between cavitation and absence of prosthetic dysfunction (p = 0,014).
In our casuistic there was no patients with history of neurologic ischemic events (stroke or TIA). Symptoms of headache and migraine didn't show any correlation with detection of cerebral gas microemboli (p = 0,12), diverging from previous studies findings.
Keywords: Microbubbles, cavitation, mechanical valve prosthesis, gas microemboli.
DIASTOLIC FUNCTION EVALUATION IN STRESS ECHOCARDIOGRAPHY
Ana Camarozano; Luis Henrique Weitzel; Marcelo Holanda; Elizabeth Simões; Cesar Nascimento; Luciano Belem
National Cardiology Institute – Rio de Janeiro – RJ – Brazil
Background: The diastolic function of left ventricle has been studied for many years, and its study under dinamic conditions is growing more recently. The left ventricle filling pressure can be estimated by mitral flow (E-wave) and tissue Doppler (E’-wave) and a high E/E’ relation indicates high left ventricle end-diastolic pressure.
Objective: To assess the factibility and the parameters of left ventricle diastolic function evaluation in patients with preserved and depressed systolic function at stress echocardiography.
Methods: Forty-four patients submitted to dobutamine stress echocardiography to investigate coronary disease were analyzed. We measured E-wave, E’-wave and E/E’ relation at rest and stress in all patients. They were divided in two groups: (A) with E/E’ relation ≤ 10 and (B) with E/E’ relation > 10 at rest. Both groups were analyzed accordingly left ventricle systolic function (divided in those with ejection fraction above or below 45%) and the presence of myocardial ischemia at stress echocardiography.
Results: The male gender was predominant and the average age was 57 years-old. Most of them had more than 2 risk factors for coronary disease or previous angina or myocardial infarction. There was no statistical significant difference between E/E’ relations at rest and stress echocardiography in (A) and there was a reduction in (B) (p < 0,05). The E-wave was different at rest and stress echocardiography in patients with preserved or depressed systolic function (p < 0,01) but E/E’ relation wasn't different in both kind of patients. There was an increase in E’-wave from rest to stress in patients with preserved (p < 0,05) or depressed (p < 0,001) left ventricular systolic function. The E/E’ relation wasn't different in patients with or without ischemic stress echocardiography.
Conclusion: Our results demonstrate that the diastolic function evaluation in stress echocardiography is easy and factible and our preliminary data suggest that there are hemodynamic changes in diastolic function capable to be analyzed non-invasively by stress echocardiography.
STRESS-INDUCED TRANSIENT LEFT VENTRICULAR DYSFUNCTION (INVERSE TAKOTSUBO) AFTER ABDOMINAL SURGERY
Ana Clara Tude Rodrigues; Adriana Cordovil; Claudia Monaco; Laise Guimaraes; Andrea Paula Ponchirolli; Wercules Oliveira; Edgar Lira; Claudio H Fischer; Marcelo Vieira; Samira Morhy
Hospital Israelita Albert Einstein
Classically, stress induced transient left ventricular (LV) dysfunction (Takotsubo) affects mid and apical left ventricular (LV) segments, sparing basal segments, and is more frequent in elderly women following intense physical or emotional stress. Recently, cases affecting basal and mid segments of the LV, sparing the apex have been reported (inverse Takotsubo). We report herein a case in which reversible akinesia was observed only at mid LV segments.
Case Report: A 54 year old female patient with a metastatic breast disease came to the Emergency Room with severe abdominal pain, malaise and hypotension. Abdominal ultra-sonography displayed pneumoperitoneum, and a perfurative peritonitis was diagnosed. The patient underwent urgent laparotomy and hemicolectomy. Post-operatively she developed persistent dispnea and tachycardia (120 bpm). Chest X-Ray was consistent with pulmonary congestion, however, ECG and cardiac enzymes were normal. Echocardiography showed normal cardiac cavities, akinesia all of mid LV segments and hipercontractility of the remaining segments, with a reduced ejection fraction (45%), and mild diastolic dysfunction. Due to clinical findings and regional contractility pattern, not characteristic of coronary heart disease, a clinical hypothesis of Takotsubo was made, and decided for conservative treatment without coronary angiography. The patient improved clinically, with echocardiography after 4 days showing normalization of contractile abnormalities and ejection fraction (70%).
Conclusion: This report confirms others suggesting a new form of Takotsubo, with similar clinical presentation and a distinct echocardiographic pattern. This could help elucidate pathophysiology of the disease, since its mechanism is still unclear.
CLINICAL AND DOPPLER ULTRASOUND FEATURES IN HYPERTENSIVE PATIENTS WITH RENAL ARTERIES STENOSIS AND/OR OCCLUSION
Petisco ACGP, Barbosa, JE; Saleh, MH, Barretto RBM, Garcia, VB; Jesus, CA, Carvalho, CMP, Braga, JCMS, Assef JE, Sousa, AGMR
Instituto Dante Pazzanese de Cardiologia
The main cause of Secondary Hypertension is the significant renal artery (RA) stenosis (> 60%) and can be diagnosed by Doppler ultrasound (DU), using direct (peak systolic velocity of the RA and the RA/Aorta ratio velocities) and indirect parameters (renal segmental branches flow analysis).
Objective: To analyze the clinical and DU features in hypertensive patients (p) with RA stenosis and/or occlusion.
Methods: Between 2008 and 2009, 610p realized DU of the RA in our institution, 70p (11.5%) had RA stenosis and/or occlusion, 28p (40%) were men, with mean age of 64 ± 14 years, divided in 5 groups (G): GI: one RA with stenosis > 60% and without significant contralateral obstruction, GII: bilateral RA stenosis > 60%; GIII: one RA occlusion and without significant contralateral obstruction, GIV: one RA stenosis > 60% and contralateral RA occlusion and GV: bilateral RA occlusion. These patients were evaluated for clinical aspects.
Results: There were no significant differences in age, sex, BMI, diabetes, smoking, coronary artery disease, dyslipidemia, stroke, peripheral vascular disease, number of anti hypertensive drugs and serum creatinine, between the G. The most common etiology of RA disease was atherosclerosis (86%). The DU direct parameters identified RA stenosis > 60%. Between indirect parameters, the acceleration time> 70 ms identified the occlusions, however, shown good specificity (94%) but low sensitivity (48%) for diagnosis of RA stenosis > 60%. The longitudinal kidney diameter <9 cm was related to the ipsilateral RA occlusion.
Conclusions: Clinical variables are similar, once diagnosed a significant disease of the RA. Atherosclerosis remains the most common cause of this affection. A DU diagnosis of RA stenosis > 60% should not be based on indirect parameters alone.
IDIOPATHIC RIGHT ATRIAL ANEURYSM – CASE REPORT AND REVIEW OF THE LITERATURE
Ana Claudia Soares Teixeira; Tatiana Franco Hirakawa; Marcus Vinicius Freitas Moreira; Cesar A. M. Cattani; Gustavo S. Fernandes; Cintia Acosta Melo; Amilton Silva Junior; Marcelo Patricio; Henry Abensur
Hospital Beneficencia Portuguesa e Med Imagem, São Paulo – Brasil
Right atrial aneurysm is a rare abnormality. It can be detected at any time between fetal and adult life. Due to its rare occurrence, right atrial aneurysm may easily be confused with other, more common anomalies to right atrial enlargement, such as Ebstein's anomaly. Right atrial aneurysms may be asymptomatic, however, some patients develop arrhythmias or intracavitary thrombi. The optimal therapeutic approach for right atrial aneutysm is controversial. We report the case of an asymptomatic man who was diagnosed with giant right atrial aneurysm and underwent successful surgical treatment
THE ACTION OF THE DIAGNOSTIC ULTRASOUND IN THE SYSTEMIC INFLAMMATORY RESPONSE
Ana Camarozano; Fatima Cyrino; Kelly Camarozano; Daniel Botino; Eliete Bouskela
Universidade Estadual do Rio de Janeiro – Microcirculation Lab
Purpuse: There has been much debate on the adhesion of microspheres to the leukocytes in inflammatory tissue, however, little is known about their behavior in the capillaries. Evaluation of the circulatory effects of this agent may explain its effect on the myocardium.
Aim: To evaluate the microvascular and hemodynamic behavior of the microspheres in the following sub-groups: ischemia-reperfusion, type-2 diabetes, diabetes with ischemia and sepsis.
Método: An experimental study of the micro-circulation in 65 male hamsters’ cheek pouches was done. The animals were divided into groups according to induction of disease: GC = control; GIR = ischemia/reperfusion; GD = diabetes; GDI = diabetes with ischemia; and GS = sepsis.
We analyzed arterial blood pressure (BP), heart rate (HR), blood flow (BF) and reology, according to mean leukocyte response of three capillaries at each time point (AL = adhered leukocytes, RL = rolling leukocytes), and DV = vein diameter, at baseline, after 60 minutes intervention and the post to pre delta (Δ). During the procedure we administered: Definity (D), a lipid coated microsphere containing perfluoropropane gas, or a placebo (P). Mann-Whitney test was used for comparisons, with significance level set at 5%.
|Δ LEUKO ADHERED||yes|| 7.17||0,29|
|Δ LEUKO ROLLING||yes|| 9.2||0,31|
|Δ VEIN DIAMETER||yes|| 1.1||0,51|
|no|| 3.0|| |
Results: The diabetic hamsters presented greater weight while the septic animals showed a worsening of general condition with higher mortality. The number of AL and RL was higher in the pre and post in GDI (mainly RL) and GS (mainly AL) compared to GC and GIR (p < 0,05). There was no difference in VD, AL, RL, and Δ with or without microspheres in the different groups. There was also no difference in BP and HR before and after Definity (NS) and BF was subjectively worse in GS. The mortality was significantly higher in GS.
Conclusion: The inflammatory response seemed to be higher in GDI and GS, independent of microsphere-Definity usage. Reology and hemodynamics showed no alteration with this agent. These findings may be important to establish the safety level when using contrast for ultrasound.
APPLICABILITY OF HYPNOSIS IN TRANSESOPHAGEAL ECHOCARDIOGRAPHY
Anderson Souza de Lima; Carlos Antonio da Mota Silveira; Eugenio Soares de Albuquerque; Vandete Maria Larangeiras; Maria da Piedade Costa Reis; Clodoval de Barros Pereira Junior; Michel Moura Fernandes; Suela Delmondes de Farias; Frank Land Lima de Carvalho; Fabio Soares Petrucci
Objective: To compare the effectiveness of hypnosis outside the midazolam and control (without sedation), when used as a sedative before the transesophageal echocardiography (TEE).
Methodology: A prospective study of 60 patients who underwent TEE in “Pronto-socorro Cardiológico de Pernambuco” between February/2009 and December/2009, after approval by the Ethics in Research. Patients were assigned into one of three groups: sedation with midazolam intravenous, sedation with hypnosis or without sedation. All three groups received lidocaine spray in the throat. The allocation group hypnosis required that the patient was classified as sensitive during test susceptibility. After examination, patients and physicians operators answered a questionnaire. Statistical analysis was performed by the program Bioestat 5.0 using initially the Kruskal-Wallis test and Dunn a posteriori.
Results: The group of hypnotic sedation significant difference against the control group on the lower level of memory of the procedure (H = 20.87, df = 2; p < 0.01) and less discomfort (H = 7.65, df = 2, p < 0.05) by the patient. The hypnosis group had a greater degree of ease for the doctor performing the examination front groups of sedation with midazolam and control group (H = 12.34, df = 2, p < 0.01). There was no significant difference between groups regarding the degree of pain or nausea.
Conclusion: As a preparation technique on TEE, hypnosis was shown to be superior when which applied in relation to traditional techniques when analyzed the degree of remembrance or discomfort by the patient and especially the degree of ease in execution of the procedure by the doctor.
TAKAYASU'S ARTERITIS DIAGNOSED IN AN OLIGOASYMPTOMATIC FEMALE TEENAGER
Andressa Mussi Soares; Paulo José Ferreira Soares; Maria Fernanda A A Fernandes; Rogério A Pedra de Abreu; Fabiana G Piovezan Coelho; Marcelo R Crespo; Magnus S Machado; José Coimbra de Rezende Neto; Saulo Ayub Fernandes; Marlus M Thopmson
Hospital Evangélico – Cachoeiro de Itapemirim – ES
Introduction: Takayasu's arteritis (TA) is an idiopathic inflammatory chronic arteritis affecting the great arteries, involving mainly the aortal and the proximal portion of the major branches. The onset of disease usually occurs after the second or third decade of life, because of late diagnosis. Objective: To highlight the importance of physical examination even in oligoasymptomatic patients.
Case Report: An eighteen-year-old female teenager weighing 44 Kg, with a family history of sudden death (sister), complaining of atypical chest pain, cephalea, and occasional abdominal pain. Physical examination detected bilateral lack of radial, brachial, and axilar pulses; carotide, femoral, tibial, and pedious pulses were normal. Blood pressure (BP) was lower in the upper limbs compared with the lower limbs, with a difference of around 40 mmHg. The remaining cardiac examination was unremarkable. Thorax X-ray, ECG, echocardiogram, Holter, and abdominal and renal ultrasonic scan were normal, as well as Doppler of the carotid arteries. Doppler of the axilar, brachial, radial, and ulnar arteries revealed significantly reduced or absent flows bilaterally. Angiography detected total bilateral obstruction of the origin of the subclavial arteries; renal arteriography and coronariography were normal. Inflammatory activity and renal function tests were unremarkable. Patient presented non-reactive PPD and negative VDRL, ANF, and HIV. Final results from hepatitis serological tests are being awaited, in order to start immunosuppression and corticoid therapy.
Conclusion: The Takayasu's arteritis is a systemic vasculopathy that may progress to ischemia of the related organs. Its late diagnosis can cause disease progression with more severe sequelae.
ECHOCARDIOGRAPHIC DIAGNOSIS OF ANOMALOUS ORIGIN OF THE RIGHT PULMONARY ARTERY FROM THE ASCENDING AORTA IN NEWBORN WITH DI GEORGE SYNDROME
Andressa Mussi Soares; Claudia B Feitosa; Maura Moulin; Lygia R Bernardo; Paulo José F Soares; Marcelo R Crespo; Magnus S Machado; José Coimbra Rezende Neto; Marlus M Thompson; Luiz Daniel F Torres
Hospital Evangélico – Cachoeiro de Itapemirim – ES
Introduction: The anomalous origin of the right pulmonary artery from the ascending aorta is a rare congenital heart disease, also referred to as hemitruncus. Its diagnosis is feasible provided that adequate morphological characterization is accomplished.
Case Report: Term NB weighing 2.3 Kg at birth progressed with tachydyspnea, paleness, and tachycardia during the first week. Physical examination revealed hyperphonetic second sound and systo-diastolic murmur in the left infraclavicular region. Thorax X-ray evidenced left lung congestion and significant cardiomegaly, whereas ECG showed right atrial overload and right bundle branch block. Echocardiogram detected atrial septal defect (ASD), patent ductus arteriosus, and right pulmonary artery arising from the left portion of the ascending aorta. The NB progressed with heart failure unresponsive to drug therapeutics, so surgical correction was accomplished 16 days after birth. The right pulmonary artery was reimplanted into the pulmonary main trunk and the patent ductus arteriosus was ligated. There was significant reduction in the cardiac size on the first postoperative day along with hemodynamic stabilization. However, the NB presented with hypocalcemia unresponsive to medical management and cardiorespiratory arrest, and died.
Conclusion: Adequate and detailed sequential segmental approach was crucial to the correct morphological diagnosis and therapeutic conduct in this NB. Although the Di George syndrome is more commonly associated with Common Arterial Trunk, in this case it was present together with the anomalous origin of the right pulmonary artery, despite the fact that these two cardiac disorders bear no embryological relation.
DIASTOLIC FUNCTION IN INDIVIDUALS WITH THE METABOLIC SYNDROME: INTERMEDIATE PATTERN BETWEEN HEALTHY CONTROLS AND PATIENTS WITH DIABETES
Ângela B. S. Santos; Maurício Junges; Adriana Macari; Bruno Schneider de Araujo; Beatriz G.S. Seligman; Murilo Foppa; Nadine Clausell
Hospital de Clínicas de Porto Alegre and Federal University of Rio Grande do Sul
Introduction: Diastolic dysfunction is frequent in diabetic (Diab) patients and is associated with heart failure development. Diabetes related hemodynamic and neurohumoral factors are also present in the metabolic syndrome (MetS), suggesting the presence of common cardiometabolic mechanisms.
Objectives: To compare echocardiographic parameters of diastolic function among healthy controls (CTR), Metabolic Syndrome (MetS) and diabetes (Diab) patients.
Methods: We compared 75 MetS patients (65.3% men; 43.2 + 7.8 y), with 30 CTR (63.3% men; 40.9 ± 6.5 y) and 17 Diab (52.9% men, 54.3 ± 7.3 y). Patients were submitted to clinical, laboratory and echocardiographic evaluation. Diastolic function was measured using diastolic transmitral flow and mitral tissue Doppler velocities (mean of septum and lateral walls) obtained following recommendations of the Brazilian and American Echocardiographic Societies.
Results: Despite age group matching, Diab patients were older. MetS had blood pressure levels, inflammatory activity (us-CRP) and insulin resistance (HOMA) intermediate between CTR and Diab, although they were more obese. Diastolic function showed a progressive dysfunction pattern among groups, evaluated by A wave (CTR = 53.1 ± 8.9 cm/s; MetS = 63.4 ± 14 cm/s; Diab = 81.4 ± 16 cm/s), E/A relation (CTR = 1.4 ± 0.3; MetS = 1.3 ± 0.4; Diab = 0.9 ± 0.2), and increased mean left atrial pressure measured by E/E’ relation (CTR = 5.3 ± 1.0; MetS = 6.3 ± 1.3; Diab = 7.2 ± 1.8). These relationships maintained statistical significance after adjustment for age, except for E/A relation.
Conclusions: Regardless echocardiographic measurements were distributed in normal range values, young adults with MetS showed an intermediate diastolic function pattern between healthy adults and diabetic patients, suggesting an early installation of inappropriate cardiovascular adaptive mechanisms in this group.
Support: FIPE/HCPA and CNPq
EARLY REGRESSION OF DIASTOLIC FUNCTION PARAMETERS IN PATIENTS WITH METABOLIC SYNDROME SUBMITTED TO A LIFESTYLE MODIFICATION PROGRAM
Ângela B. S. Santos; Maurício Junges; Adriana Macari; Bruno Schneider de Araujo; Beatriz G. S. Seligman; Murilo Foppa; Nadine Clausell
Hospital de Clínicas de Porto Alegre and Federal University of Rio Grande do Sul
Introduction: Metabolic Syndrome (MetS) is a sum of risk factors related to cardiovascular disease and diabetes. Interventions on MetS could reduce its large impact on deaths and disabilities.
Objective: To evaluate the effects of a lifestyle modification program on echocardiographic parameters of diastolic function in patients with MetS.
Methods: Analysis of the 75 patients randomized into a clinical trial to 3 different strategies combining diet counseling and physical activity that included: 1) low fat diet or 2) low carb and high protein diet; plus 1) general exercise recommendation, or 2) monitored walking, or 3) supervised high intensity fitness. Patients were submitted to clinical and laboratorial evaluation, flow-mediated dilation, and echocardiography at baseline (BL) and after 12 weeks. Differences in time were compared using paired t test.
Results: At 12 weeks, 64% of patients did not meet MetS criteria any longer, regardless of allocated group strategy. There were significant reductions in parameters as: BMI, waist to hip ratio, blood pressure, heart rate, inflammatory response, HOMA IR, and FMD. There were no changes in left ventricular and atrial dimensions. Diastolic pattern showed A wave increase (BL: 63.5 ± 14 cm/s; 12 Wks: 60.2 ± 12 cm/s; p < 0.05) with mean left atrial pressure reduction, estimated by E/E’ relation (BL: 6.23 ± 1.3; 12 Wks 5.98 ± 1.3; p < 0.05).
Conclusions: Pragmatic lifestyle interventions are capable of improving MetS in 12 weeks. Early diastolic function parameters reflect these metabolic changes.
Support FIPE-HCPA and CNPq
CARDIAC INVOLVEMENT IN A PATIENT WITH H1N1 AND RESPIRATORY FAILURE
Annie Suphia Fagundes; Ana Clara Tude Rodrigues; Ana Lucia Arruda; Edna Pitombeira; Andrea Ogawa; Tatiana Rocha Souza; Elizabeth Osawa; Meive Furtado; Giovanni G Cerri; Jose L Andrade
Ecocardiografia – INRAD – HC- FMUSP
A new pandemy of an influenza vírus (H1N1) has recently been recognized, resulting in an increasing number of respiratory complications and mortality. We report herein a case of H1N1 virus with respiratory insufficiency, associated left ventricular dysfunction and cardiovascular failure
Case Report: A 28 year old male came to the Emergency Room with cough, dyspnea, daily fever and headache for 10 days. At physical examination the patient had 40°C temperature, taquipnea (20 excursions/min), and heart beat was 120 bpm; blood pressure was inaudible, and there were rales at pulmonary basis. Laboratory exams showed leucopenia (4014 leucocytes/mm3), creatinine = 1.1 mg/dl, Urea = 44 mg/dl, K+= 3.6 mEq/l. Arterial gases showed pH = 7.43, pO2 = 37 mmHg, pCO2 = 36 mmHg, HCO3 = 23 mm/l, SatO2 = 72%. Arterial lactate was 23 mg/dl. Chest X-ray displayed a left interstitial infiltrate, and detection of H1N1 was positive. Blood pressure was initially controlled with intravenous fluid and treatment with oseltamivir started. The patient developed renal failure (creatinine = 6.4 mg/dl, K = 7,0 mEq/l) and hypotension; vasoactive drugs were administered, and transthoracic echocardiography performed, showing mild left ventricular dilatation, global hypokinesia and left ventricular (LV) dysfunction (ejection fraction = 48%) and mild mitral regurgitation. The patient improved, and after 9 days a new echocardiography showed normalization of LV function (EF = 0.55%) and disappearance of mitral regurgitation.
Conclusion: Though H1N1 virus is mainly characterized by mild disease, it might be associated to respiratory failure; this is the first documented case of cardiac involvement in a patient with H1N1 and cardiovascular instability. Knowing the prevalence of such involvement would be important to better treat the disease.
REFERENCE VALUES FOR EPICARDIAL FAT DIAMETER MEASURED BY ECHOCARDIOGRAPHY IN A NORMAL POPULATION
Carlos Alberto da Silva Magliano1; Cesar Augusto Nascimento2; Roberto Magalhães Saraiva3
1Total Care; Labs-Cardiolab; INC; 2Instituto Nacional de Cardiologia, 3Fundação Oswaldo Cruz; Total Care
Objectives: Epicardial fat is one of the deposits of visceral fat which is considered a risk factor for cardiovascular diseases. However, reference values for epicardial fat measurement are scarce and we sought to measure its diameter in a normal population.
Methods: Forty asymptomatic individuals without any known diseases with normal transthoracic echocardiogram and ultrasound carotid examination were evaluated using Vivid 3 or 7 (GE Medical Systems) machines. The end-systolic diameter of the epicardial fat was measured in front of the right ventricular free wall in the long-axis view above the aortic annulus.
Results: The subjects (50% male) were 40 ± 16 years old, ranging from 18 to 76 years old. The epicardial fat thickness averaged 3.5±1.7 mm with no significant difference between men or women. Among subjects with ≤ 30 years old, the thickness of the epicardial fat was 2.7±0.8 mm (n = 15), among subjects aging from 31 to 49 years old, it measured 3.1±1.3 mm (n = 15), and in subjects aging ≥ 50 years old, it measured 4.8±2.3 mm (n = 13). There was a significant difference among these groups (p = 0.003 by ANOVA). The thickness of the epicardial fat correlated positively to age (r = 0.62, p < 0.0001).
Conclusion: The thickness of the epicardial fat in this normal population averaged 3.5 mm. The epicardial fat thickness correlated positively with age. New studies are still necessary to better define the normal upper-limits of this new potential surrogate for measurement of visceral fat and cardiovascular risk.
THYMOMA CYSTIC WITH TYPICAL APPEARANCE OF PERICARDIAL CYST ON ECHOCARDIOGRAM
Creso Benedito da Conceição Oliveira1; Mauricio de Toledo Abreu1; Dorival Julio Della Togna2; Mirella de Paiva Dias3; Rodrigo Bellio de Mattos Barretto4; Jairo Alves Pinheiro Jr3; Mercedes Maldonado Andrade4; Alexandra Alberta dos Santos3; Luciana Farto V de Sousa3; Vera Marcia Lopes Gimenes4
1HCOR e Abreu Cardiologia; 2Abreu Cardiologia e IDPC; 3HCOR; 4HCOR e IDPC
Thymoma is a tumor of epithelial cells of the thymus. Even being the most common cancer in anterior mediastinum (20–30%), it is still extremely rare (0.15 per 100,000). It grows slowly and was slightly more common in men between 40 and 60 years. Most patients with thymoma (two thirds) are symptomatic, with cough, breathlessness or thoracic pain
Case Report: Patient, male, white, 26 years, was seen in March 2005 admitted to emergency room with signs and symptons of common flue. Has Chest radiography showed a mass at right hemithorax. paracardiac. The patient was previously asymptomatic, with normal physical examination and electrocardiograms. Transthoracic echocardiogram showed probable pericardial cyst, with diameter of 7 cm, near the right atrium. This diagnosis was confirmed by 3D echocardiogram. Patient underwent MRI that in addition to right cystic formation paracardiac, showed thickening in the lateral wall of the same. These findings were confirmed with CT, with diagnosis of cystic teratoma. Patient was operated in 2008 and pathological examination and immunohistochemistry was consistent with type B2 thymoma, stage 2 Masaoka.
Commentaries: The differential diagnosis of pericardial cyst and mediastinal tumors such as thymoma, teratoma, etc., can be very difficult, even using various imaging methods,because of similarities between them and unspecific clinical presentation.
DIASTOLIC DYSFUNCTION IN PREGNANT WOMEN WITH CHRONIC HYPERTENSION
Cristina Maria Marcolan Quitete, Wolney de Andrade Martins, Evandro Tinoco Mesquita
Universidade Federal Fluminense, Niteroi (RJ), Clinica Endocor, Teresopolis (RJ) e Centro Universitario Serra dos Orgaos, Teresopolis (RJ)
Objectives: Evaluate the diastolic function in chronic hypertensive pregnant women.
Methods: Nineteen chronic hypertensive pregnant women (CH) were submitted to an echodopplercardiography in their third trimester and compared to 19 normotensive pregnant women (PRE). The left atrium volume (LAV) was evaluated by the average of three measurements by Simpson and was indexed to body surface, just like the E-wave velocity (E), the A-wave velocity (A) and the E/A relation of mitral flux. 5% significance levels were adopted.
Results: The average age for the CH and PRE groups were 29.8 ± 6.7 and 24.6 ± 5.9. The LAV was 33.4 ± 9.4 mL in the CH group and 29.4 ± 6.2 in the PRE (p = 0.13). When the subgroup of 13 hypertensive pregnant women with hypertension for more than a year prior to the pregnancy was evaluated, a significant difference in the LAV = 35.4 ± 8.8 mL was observed in comparison to the PRE group (p = 0.04). There were no significant differences on A and E mitral flow waves between both groups. The subgroup of hypertensive pregnant women with evolution of more than a year presented the average values of A 0.65 ± 0.19 m/s in comparison to 0.52 ± 0.10 m/s on the PRE group (p = 0.04).
Conclusion: The diastolic function evaluated by the left atrium volume and by the A-wave velocity was altered in chronic hypertensive pregnant women with hypertension evolution for more than a year compared to normotensive pregnant women.
ANATOMICALLY CORRECTED MALPOSITION OF THE GREAT ARTERIES (ACMGA): A CASE REPORT
Déborah de Oliveira Lauar Figueiró1; Kelly Nascimento Brandão1; Sandra Regina Tolentino Castilho1; Fátima Derlene da Rocha Araújo1; Roberto Max Lopes2; Zilda Maria Alves Meira1
1Universidade Federal de Minas Gerais; 2Hospital Biocor
Background: We present a case of a 4 months old girl diagnosed as anatomically corrected malposition of the great arteries by echocardiography and cardiac catheterization. Anatomically corrected malposition is a rare form of conotruncal malformation in wich the great arterial trunks arise from their morfologically appropriate ventricles, but are abnormally related one to the other, with the aorta arising in an anterior position. The case report is justified by the rarity of the diagnose.
Case Presentation: J.C.S.P.O., 4 months old, female, weighing 11 pounds, admitted to the emergency with tachypnea and dyspnea. Physical examination revealed tachypnea, with oxygen saturation of 95%, fixed, loud and widely split second heart sound with accentuated pulmonary component, systolic regurgitative murmur grade IV/VI and hepatomegaly. Chest radiography showed marked cardiomegaly and increased pulmonary vascular markings.
Echo Doppler: large ventricular septal defect, aorta arising from the morphologically left ventricle in a left sided and anterior position relative to the pulmonary trunk (anatomically corrected malposition of the great arteries).
Medical therapy was instituted with diuretics with symptoms improvement and the child underwent a cardiac catheterization that confirmed the diagnosis and was subsequently referred for a surgical repair of the ventricular septal defect.
Discussion: A literature review by Anderson (2005) about anatomically corrected malposition of the great arteries has confirmed 72 cases reported with concordant ventriculo-arterial connections. The majority (92%) had usual atrial arrangement.
A carefull approach to ventricular identification is mandatory for the correct diagnosis, confirming the concordant ventriculo-arterial connection and the abnormal spatial relationship between the great arteries. It is established that anatomically corrected malposition can occur with a subaortic conus, as well as with a bilateral conus and ventricular septal defects, and this associations must be described as well.
ECHOCARDIOGRAM IN THE INVESTIGATION AND ATTENDANCE OF THE FEBRILE NEUTROPENIC PATIENT WITH DIAGNOSIS OF CARDIAC ASPERGILLOSIS
André Luiz Cândido S. Drumond Nobre1; Douglas Lourenço Dias1; Bárbara Athayde Linhares Martins Vrandecic1; Andrea Wandalsen A. Almeida2; Anderson Martins Pereira2
1Biocor Instituto – Cardiology; 2Biocor Instituto – Hematology
Introduction: Aspergillus endocarditis typically happens in patients severely immunodepressed and it is usually fatal for being an infection of difficult diagnosis and treatment. It is told a 18 year-old patient's clinical history, bearer of medular aplasy that, in the investigation for febrile neutropenia, she had in the echocardiographic discoveries orientation for her diagnosis and therapeutics.
Description of the Case: Patient of 18 years, masculine, bearer of medular aplasy, already submitted to protocol of immunosuppressive therapy, awaiting marrow transplant. He began with prostration and intermittent fever, with a month of evolution, without improvement with antibioticoterapy. Laboratory exams presented hemoglobin of 9 g.dL-1 and trombocytopenia - 6.000 platelets.mm-3. Investigation was negative for infectious focus, except the echocardiogram (mainly in the transesophageal modality) that revealed a intra-left atrial mass of great dimensions with high risk of systemic embolization. It was submitted to the surgery for ressection of the atrial mass, being the material submitted to anatomic pathology test that revealed infected thrombus by Aspergillus sp (fungal endocarditis). Serial echocardiograms accomplished in the 4th and 7th postoperative day revealed fast recurrence of the intra-atrial mass. Patient developed with clinical worsening, breathing inadequacy, cardiorespiratory arrest and death.
Comments: Species of Aspergillus frequently form great intracardiac fungal masses. The echocardiogram is a safety diagnostic tool to identify such masses that, being of fungal aetiology, they have the immediate surgical treatment already indicated due to inefficacy of the clinical treatment and the risk of embolization. In that way, in the investigation of infectious focus in immunosuppressed patients, everybody should to attempt for the clinical presentation of Aspergillosis.
Keywords: endocarditis, cardiac aspergillosis, echocardiogram
RIGHT VENTRICULAR CARDIOMYOPATHY IN A 7 MONTH OLD DOWN SYNDROME INFANT: A CASE REPORT
Fátima Derlene da Rocha Araújo; Kelly Nascimento Brandão; Fabiana Arantes Brandão; Zilda Maria Alves Meira
Universidade Federal de Minas Gerais
Background: Trisomy 21 (Down's Syndrome) is associated with an increased risk of structural congenital heart disease and pulmonary hypertension. However, pulmonary hypertension resulting in right ventricular cardiomyopathy and mural thrombus formation is distinctly uncommon on this age group.
Case Presentation: P.S., a 7 months old patient with Down syndrome, male, weighing 8,8 pounds, was attendeden-US in the emergency room in a great respiratory distress. There was a previous history of poor controlled bronchospasm unresponsive to corticosteroid and bronchodilators.
Physical Examination: The child was active, reactive, ruddy and hydrated. Presented an oxygen saturation of 89%, severe dyspnea with diffuse inspiratory wheezing, thachycardia, grade II/VI systolic ejection murmur, loud second heart sound and hepatomegaly.
Chest Radiography: Grossly enlarged heart.
Electrocardiogram: Sinus rhythm, right atrial and ventricular hypertrophy.
Echo Doppler: Two-dimensional echocardiography showed enlargement of the right atrium and right ventricle, presence of large thrombi adherent to the right ventricular wall. Impaired right ventricular function, 6 mm atrial septal defect, pulmonary artery preassure of 60 mmHg.
Medical therapy was instituted whith diuretics, vasodilators and anticoagulants, with great improvement and thrombi resolution after a month. The child underwent an otorhinological and fibronasolaryngoscopy that showed no anomalies and was referred to a cardiac catheterization.
Discussion: Routine echocardiography avaliation is mandatory in neonatal period in Down Syndrome pacients. Clinical and echocardiography follow up are necessary because of the possibility of developing valve disease and cardiomyopathies by the raising of pulmonary artery pression.
ARTERIOSUS IN EXTREMELY PREMATURE INFANTS AND INDICATORS OF POOR RESPONSE TO CLINICAL TREATMENT
ARAUJO FDR*; LAZARONI PSO**; CAMPOS FAO**; MIRABEAU IR**; BRANDÃO KN*; CAPANEMA FD***; MEIRA ZMA***
*Odilon Behrens Municipal Hospital (HMOB) – Belo Horizonte, Minas Gerais State, Brazil; **Human Ecology and Health Faculty (FASEH) – Vespasiano, Minas Gerais State, Brazil; *** Minas Gerais Federal University (UFMG) – Belo Horizonte, Minas Gerais State, Brazil
Introduction: The ductus arteriosus (DA) is a vital structure for fetus, but its persistence can cause damage to various organs of extremely low birth weight infants. It is argued about the most effective approach and which parameter must be used to quantify it.
Objective: To assess prevalence of DA in extremely premature infants with echocardiography, correlate clinical findings and evaluate indicators of non-response to clinical treatment.
Methods: From January/2005 to December/2009, 204 preterm infants with gestational age (GA) less than or equal to 30 weeks and/or birth weight (BW) less than or equal to 1000 g were subjected to clinical examination and echocardiogram from the third to fifth day of life. Semiological and echocardiographic findings (DA diameter, shunt magnitude, AO/AE proportion and square DA diameter by birth weight index) were evaluated. It was formulated the groups: 1 = absence of DA (107 cases), 2 = spontaneous closure (17), 3 = response to pharmacological closure (27) and 4 = surgical closure (53), which was subdivided by indication: A = failure of drug treatment (22), B = direct surgery due to gravity (2) and C = contraindication to the use of drug (29).
Results: Determined prevalence was 44.6%, with GA ranging from 24 to 34 weeks, BW 500 to 1550 g, DA diameter 0.9 to 3.8 mm (mean 2.1 mm). Preterm infants referred for surgical treatment of groups A and B were analyzed according to clinical and echocardiographic findings, and someone with GA less than 26 weeks, BW less than 600 g, beyond DA greater than or equal to 2.2 mm and an index greater than 9 mm/Kg to echoDoppler showed statistical significances related with poor response to clinical treatment.
Conclusions: Echocardiography is an important instrument in the assessment of DA persistence and hemodynamic effects in extremely premature infants and should be included as a routine in all neonatal care units.
ECHODOPPLERCARDIOGRAPHIC STUDY IN SYDENHAM'S CHOREA
Fátima Derlene da Rocha Araújo; Fabiana Arantes Araújo; Cleonice C. C. Mota; Zilda Maria Alves Meira
Universidade Federal de Minas Gerais
Objective: To evaluate the echocardiographic evolution of valvular lesions in patients with Sydenham's chorea (SC) and compare the type of manifestation of chorea with its gravity and other manifestations of rheumatic fever (RF).
Methods: We evaluated 82 patients who had SC as the initial manifestation of RF and an echocardiographic study at diagnosis, and after at least 5 years of illness. They were divided into groups according to the severity of SC (Mild, moderate, severe), the type (active, resolved, persistent) and according to the Jones criteria (SC “pure” (38), SC + carditis (30), SC + polyarthritis (6), SC + carditis + polyarthritis (8)). After the division, they were compared with the following groups: carditis “pure” (8), carditis + polyarthritis (34), polyarthritis “pure” (23), according to the severity of valve lesions and its evolution.
Results: In the group SC “pure” we found mild mitral insufficiency (MI) (11), moderate MI (3), mild aortic insufficiency (AOI) (6) and moderate AOI (1), all tests were normal, kept normal during the chronic phase and there was no serious injury. When analyzed SC associated with carditis, the findings were: mild MI (12), moderate MI (13), severe MI (5), mild AOI (10), moderate AOI (3) and severe AOI (1).
Conclusions: Subclinical carditis was more common in the group with “pure” SC than in those with “pure” polyarthritis. The severity of valvulopathy manifestations were related to the presence of clinical carditis, alone or associated with polyarthritis, at the diagnosis. The association SC + carditis were related to a better progress of lesions when compared to carditis + polyarthritis. The severity of lesions was not related to the type, or grade, or with recurrence of SC.
CARCINOID SYNDROME AFFECTING LEFT HEART
Fernando S. Botelho, Daniella S. Bastos; Flávio Ricardo L. Vieira; Maria Luiza Meurer Alves; Paulo Golebiovski; Roberto Osório Ferreira
Hospital dos Servidores do Estado
Introduction: Carcinoid tumors are rare neuroendocrine neoplasms most commonly originated from the gastrointestinal tract that produce vasoactive substances like serotonine and prostaglandin. Carcinoid syndrome occurs when there is metastasis to the liver, where those substances are inactivated. Characteristic clinical features are flushing, diarrhea, bronchoconstriction and cardiac abnormalities (70% of cases)
Case Report: We describe a case of a 46-year-old female patient with previous atypical carcinoid tumor in the lung, with a history of left pneumectomy, who was admitted with abdominal cramps and flushing symptoms. Abdominal CT scan detected multiple liver metastasis. Echocardiography showed enlarged right ventricle with paradoxical septal motion, tricuspid and mitral valves diffusely thickened with severe regurgitation on both.
Comments: Cardiac manifestation in carcinoid syndrome is common and confers a worse prognosis. Echocardiography is the method of choice for assessment, since it detects pathognomonic valvular lesions. Left valves are affected in 15% of cases, because of normal inactivation of serotonine in the lungs. It happens when there is patent oval foramen with right-left shunt, high level of vasoactive substances or bronchial tumor, like in this case.
ANALYSIS OF SAFETY IN THE BALOON ATRIAL SEPTOSTOMY GUIDED BY ECHOCARDIOGRAPHY
Flavia Gurgel; Renata Mattos Silva; Fabio Bergman; Erika Porto; Paulo Martins Soares; Paula Vargas; Rosanea Rodrigues; Yeti Caboudy Sztajnbok; Claudia Fernanda Fonseca; Luiz Carlos Simoes
Instituto Nacional de Cardiologia
Background: The balloon atrial septostomy (BAS), described by Rashkind W (JAMA1966), is important in the management of newborn (NB) with congenital heart disease (CHD), considered a safe initial palliation. Most often it is driven echocardiography Doppler (ECD) at the bedside.
Objective: To analyze the techniques (fluoroscopy or ECD) BAS in a tertiary center pediatric cardiology and the justifications for the procedure guided by fluoroscopy.
Methodology: Retrospective case series of BAS in the NB January/2006 to January/2010. The justification of the study were analyzed under fluoroscopy and complications comparing the two methods.
Results: We reviewed 62 BAS in infants, and 55% TGA + IVS, 4.8% TGA + DSV and pulmonary stenosis (PS), 8% TGA + DSV, 3.2% TGA + DSV and coarctation of the aorta (CoAo), 9.6% Hipoplastic left heart syndrome; PA IVS 13%, 1.6% Double-outlet right ventricle (DORV) with pulmonary artery banding,1.6% DORV with mitral atresia,3.2% Ebstein + PS.In 8 infants (12.9%) BAS under fluoroscopy was necessary and in 5 (8%) if used both methods. Difficulties in crossing the septum by ECD (8 NB) complications requiring vision radioscopic (1 NB), or X-ray study concurrent interventional procedure (4NB) were the justifications for the displacement of the newborn to the catheterization laboratory. There were 2 (3.2%) complications larger, related to BAS with ECD.
Conclusion: BAS with ECD is safe, reduces radiation exposure by giving more speed the procedure. BAS in restrictive septal with small left atriummay need the support option radioscopic, bringing greater security and efficiency.
RELATION BETWEEN ECHOCARDIOGRAPHIC VARIABLES AND FUNCTIONAL CLASS IN PATIENTS WITH NON-ISCHEMIC DILATED CARDIOMYOPATHY. AN REAL-TIME THREE-DIMENSIONAL AND TISSUE DOPPLER IMAGING STUDY
Frederico José Neves Mancuso; Orlando Campos Filho; Dirceu Rodrigues de Almeida; Valdir Ambrósio Moisés; Eduardo Segalla de Mello; Wercules A. Oliveira; Jose Alexandre Silveira; Dalva Poyares; Sergio Tufik; Antonio Carlos de Camargo Carvalho
Universidade Federal de São Paulo – UNIFESP/EPM
Introduction: NYHA functional class (FC) is the most used parameter for evaluation and following patients with heart failure, with correlation with prognosis and quality of life. Real-time three-dimensional echocardiography (RT3DE) and tissue Doppler imaging (TDI) are new echocardiography techniques that allows a better structural and functional evaluation of the heart.
Methods: Ninety patients with non-ischemic dilated cardiomyopathy and left ventricular ejection fraction ≤ 0,50, with sinus rhythm and optimized treatment for heart failure were included. The FC was determined by investigator blind to the echocardiography. With RT3DE and Doppler we analyzed: maximum left atrial volume indexed for body surface area (MLAVi), left ventricular diastolic and systolic volumes and ejection fraction, right ventricle area change fraction, S wave velocity of the right ventricle by TDI, E wave mitral inflow velocity, e' wave mitral by TDI, E/' ratio, intraventricular delay by TDI, dissynchrony index by RT3DE, mitral regurgitation vena contracta (VC) and pulmonary artery systolic pressure. The correlation between FC and the above variables were analyzed by Pearson coefficient. A multiple regression analysis was performed including FC as a dependent variable and the variables correlated as predictive variables.
Results: The mean age, FC, left ventricular ejection fraction and QRS duration were, respectively: 52 ± 11 years old; 2.1 ± 0.5; 32 ± 9% e 141 ± 3 ms. In univariated analysis, the variables correlated to FC were: MLAVi (r: 0.22; p = 0.05), left ventricle ejection fraction (r: −0.25; p = 0.01), e' wave (r: −0.29; p < 0.01), E/e' ratio (r: 0.39; p < 0.01), intraventricular delay by TDI (r: 0.27; p = 0.01) and VC (r: 0.21; p < 0.05). In multivariated analysis, the E/e' ratio (p = 0.02) and intraventricular delay by TDI (p = 0.05) were independent predictable of the FC.
Conclusion: In patients with non-ischemic dilated cardiomyopathy, the FC is independently correlated with end-diastolic pressure of the left ventricle (E/e' ratio) and intraventricular delay by TDI.
LEFT ATRIAL ACTIVE FUNCTION DETERMINANTS IN PATIENTS WITH NON-ISCHEMIC DILATED CARDIOMYOPATHY. A REAL-TIME THREE-DIMENSIONAL ECHOCARDIOGRAPHY AND TISSUE DOPPLER STUDY
Frederico José Neves Mancuso; Orlando Campos Filho; Dirceu Rodrigues de Almeida; Valdir Ambrósio Moisés; Eduardo Segalla de Mello; Wercules A. Oliveira; Dalva Poyares; Sergio Tufik; Antonio Carlos de Camargo Carvalho
Universidade Federal de São Paulo – UNIFESP/EPM
Introduction: The left atrial (LA) active function is related to symptoms in patients with heart failure. We aimed to analyze which parameters are its determinants in patients with non-ischemic dilated cardiomyopathy (DCMP) and left ventricular (LV) systolic dysfunction.
Methods: We included 90 patients with DCMP, LV ejection fraction ≤ 0,50, sinus rhythm and optimized medical treatment for heart failure. With real-time three-dimensional echocardiography (RT3DE) we measure the LA maximum (LAVM), minimum (LAVm) and before P-wave of EKG (LAVP) volumes and calculated the active LA emptying fraction (ALAEF): (LAVP-LAVm)/LAVP. With RT3DE, Doppler and tissue Doppler imaging we analyzed the following variables: LAVM indexed for body surface area, end-diastolic LV volume and ejection fraction, E/e' ratio, mitral regurgitation vena contracta (VC), intraventricular delay by tissue Doppler and systolic and diastolic blood pressure. With Pearson coefficient we determined the variables related to ALAEF. A multiple regression analysis was performed including ALAEF as a dependent variable and the variables correlated as predictive variables.
Results: The mean age, functional class, LV ejection fraction and ALAEF were: 52 ± 11 years old; 2.1 ± 0.5; 0.32 ± 0.09; 0.28 ± 0.11. In univariated analysis, the variables related to ALAEF were: LAVM indexed (r =−0.54; p < 0.01), end-diastolic LV volume (r: −0.18; p < 0.01), E/e' ration (r: −0.38; p < 0.01) and VC (r: −0.26; p = 0.01). In multivariated analysis, LAVM indexed (p < 0.01) and E/e' ration (p = 0.02) were independent predictors of ALAEF.
Conclusion: ALAEF is independently determined by LAVM indexed and LV end-diastolic pressure (E/e' ratio).
LEFT VENTRICULAR SYSTO-DIASTOLIC FUNCTION IS MILDLY IMPAIRED IN OBESE ADOLESCENTS
Gustavo Alberto Frazatto Naccarato; Priscila L. Sanches; Fernando Sales; Lian Tock Ana Dâmaso; Marco Tulio de Mello; Sergio Tufik; Orlando Campos Filho
Universidade Federal de São Paulo
Objective: Obesity impinges a burden to the cardiovascular system. Our aim was to evaluate left ventricular (LV) systolic and diastolic function in obese adolescents.
Methods: 46 healthy obese adolescents (OA; 16,3 ± 1,3 y.o, 101,1 ± 13,5 kg) and 24 normal lean adolescents (16,9 ± 1,5 y.o, 61,3 ± 13 kg) as a control group (CG) were evaluated. At Doppler echocardiography, we measured E and A wave from diastolic mitral inflow; and systolic (S’) as well diastolic E’ and A’ waves from tissue Doppler velocity of the mitral annulus of lateral (lat), septal (sep), inferior (inf) and posterior (post) walls of the LV. Values from OA and CG were compared by Student T test, at a level of significance of p < 0.05.
Results: Both groups had normal blood pressure and LV ejection fraction. The OA had larger A waves (0,46 ± 0,1 m/s) than CG (0,38 ± 0,07 m/s; p < 0.05). Despite no differences in mean E waves between the groups, the E/A ratio was significantly smaller in OA (2,0 ± 0,57) than in CG (2,54 ± 0,82; p < 0,05). At tissue Doppler analysis, OA group had smaller annular E’ waves (E'lat: 16,5 ± 2,9 cm/s) and larger A’ waves (A'lat: 7,6 ± 1,8 cm/s) than CG (E'lat: 19,0 ± 2,2 cm/s; p < 0,05; A'lat: 6 ± 1,4 cm/s; p < 0,05) at all analyzed LV walls. The systolic annular velocities of OA were significantly reduced in all LV walls when compared to CG (S’lat: 10,7 ± 1,8 cm/s vs 11,9 ± 1,7 cm/s; p < 0,05).
Conclusion: Aparently normal obese adolescents present some degree of subclinical LV systolic and diastolic disfunction
EVALUATION OF SYSTOLIC FUNCTION OF LEFT VENTRICLE WITH TISSUE DOPPLER IN MAMA CANCER PATIENTS DURING CHEMOTHERAPEUTIC TREATMENT
Imara Correia de Queiroz Barbosa1; Ana Cláudia Andrade Lucena1; Alex Barbosa1; Bruno Robalinho Cavalcante Barbosa1; Alexandre Magno da Nóbrega Marinho2; Eveline Barros Calado3; Renata Loureiro Santos4
1Cardiodiagnóstico LTDA; 2Universidade Federal de Campina Grande; 3Universidade de Pernambuco – PROCAPE; 4Fundação Assistencial da Paraíba
Introduction: The left ventricle ejection fraction (EF) is commonly utilized for analysis of left ventricular systolic function. Studies have demonstrated correlation between EF and systolic maximum velocity in tissue Doppler (S' wave). Our goal is to evaluate the amplitude reduction of S' wave in the tissue Doppler analysis of mitral anulus velocities and modifications in the EF estimated by Teicholz method in mama cancer patients submitted to chemotherapy with adriamicin, doxorrubicin and hercetapin.
Methods: Women with mama cancer diagnosis were prospectively evaluated from January of 2009 to July of 2009. Patients with limited echocardiographic acustic window or EF inferior to 55% were excluded. Each patient was submitted to a pre-treatment echocardiogram exam and two more after chemotherapy with a three month interval of time. The S'waves were measured in both medial and lateral mitral anulus positions.
Results: Seven patients were enrolled with a medium age of 47,43y (DP ± 6,5). During the follow up period of time there were no important variations in the measure of EF = 2,156 (1,15–6,92) p > 0,05, S'wave of lateral mitral anulus position = 1,478 (1,2–6,1) p > 0,05 or S'wave of medial mitral anulus position = 1,0 (1,09–5,4) p > 0,05.
Conclusion: Our study sugests that chemotherapeutic drugs in usual doses are safe and do not signifcantly affect FE and S'wave. Larger studies are necessary to validate these findings.
DYNAMIC CHANGES IN MICROCIRCULATORY BLOOD FLOW AT DOBUTAMINE STRESS MYOCARDIAL CONTRAST ECHOCARDIOGRAPHY
Wilson Mathias Jr; Ingrid Kowatsch; Ally Nader Roquetti Saroute; Altamiro Filho Ferraz Osório; João Cesar Nunes Sbano; Jeane Mike Tsutsui
Instituto do Coração (INCOR) – HCFMUSP
Objectives: We sought to determine variations in myocardial blood flow (MBF) that occur during dobutamine-atropine stress echocardiography (DASE) using quantitative real-time myocardial contrast echocardiography (RTMCE).
Background: Although DASE has been widely used for evaluating patients with coronary artery disease (CAD), dynamic changes that occur at microcirculatory level have not been demonstrated in humans.
Methods: We studied 45 patients who underwent coronary angiography and RTMCE. Replenishment velocity (β) and MBF reserves were obtained at baseline, intermediate stage, peak and at recovery phase after rapid injection of metoprolol.
Results:β and MBF reserve was lower in patients with than without CAD at intermediate (1.65 versus 2.10;p = 0.001 and 2.44 versus 3.23;p = 0.004) and peak (1.63 versus 3.00;p < 0.001 and 2.14 versus 3.98;p < 0.001). In patients without CAD β and MBF reserves increased from intermediate to peak stress and decreased post metoprolol, while in those without CAD reserves did not change significantly. The best parameter for detecting CAD in all stages was β reserve. Optimal cutoff values of β reserve at intermediate, peak and post-metoprolol were 1.78, 2.09 and 1.70, with areas under the curves of 0.80 (95%CI 0.67–0.94), 0,89 (95%CI 0.79–0.99) and 0.69 (95%CI 0.53–0.85). Sensitivity, specificity and accuracy for detecting CAD at intermediate stage were 68% (95%CI 48–89), 85% (95%CI 71–98) and 78% (95% CI 66–90), at peak stress 79% (95%CI 61–97), 96% (95%CI 89–100) and 89% (95% CI 80–98), and post-metoprolol 74% (95%CI 54–93), 65% (95%CI 47–84) and 69% (95% CI 55–82), respectively.
Conclusion: RTMCE allows for quantification of dynamic changes in microcirculatory blood flow at each stage of DASE. β reserve presented the best diagnostic accuracy for detecting CAD in all stages.
EVALUATING DIFFERENT ECHOCARDIOGRAPHIC CRITERIA IN THE PROCESS OF DIAGNOSING INTRAVENTRICULAR DYSSYNCHRONY UNDER LBBB. RELEVANCE OF STRAIN DOPPLER AND TWO-DIMENSIONAL STRAIN
José Carlos Araujo Haertel12; Marcelo Haertel Miglioranza1; Maristela Winkler 12; Paulo Affonso Salgado Filho12; Ana Rosa Vaccari 12; João Regis Lessa12; Nara A. Pomar12; Luiz Alberto Borba2; Rogério N. Kersten12; Eduardo Menti1
1Instituto de Cardiologia do RS; 2PREVENCOR – HMD
Objectives: Investigate the reliability and the accuracy of the results provided by different echocardiographic approaches in the diagnose of intraventricular (IV) dyssynchrony under LBBB.
Methods: Cross-sectional study involving patients with ischemic or non-ischemic heart failure evaluated according to clinical, electrocardiographic and echocardiographic criteria: tissue M-mode (septal flash), radial Strain2D and dyssynchrony index with tissue Doppler (TVI)/Strain Doppler.
Results: A sample consisting of 20 patients, including 10 females were used in this study. The average age of the patients was 70.5 ± 11.3 years old, 25% presenting ischemic HF, 70% NYHA≥3, all with LBBB with QRS > 120 ms and ejection fraction 33.25 ± 6.6%. Tissue M-mode showed a difference in the peaks septal-posterior wall equal to 305.05 ± 84.3 ms; radial Strain2D difference obtained between systolic Strain peak septal postero-lateral of 347.15 ± 76.27 ms; dyssynchrony index on TVI of 42.45 ± 19.56 ms; dyssynchrony index on Strain Doppler of 147.96 ± 38.25 ms. In a TVI evaluation, 8 patients (40%) did not show any alteration in the dyssynchrony index. The other echocardiographic methodology, however, yielded abnormal indices for the entire sample. When subjected to the TVI technique, 12 patients (60%) showed a later activation on the septal region, as opposed to the Strain approach, in which the totality of the patients showed a later activation on postero-lateral walls.
Conclusion: This study has shown that echocardiographic Strain technics yielded more accurated results than the TVI method in the diagnosis of IV dyssynchrony. This fact was due to the Strain capability of better discriminating active vs. passive myocardial motion. In addition to that, the Strain method proved to be capable of better accuracy to determine isovolumetric septal contraction and the latter contraction myocardial segment. As the role of echocardiography in the cardiac resynchronization therapy is being reevaluated, the findings in this study raises a question regarding the best approach to be implemented in dyssynchrony diagnoses (probably Strain). Another question refers to whether the pre-ejection phase should be included in the TVI analysis. (consider LBBB initial premature contraction).
RIGHT ATRIAL MOBILE THROMBI MIMICKING THE APPEARANCE OF A TUMOR
Júlia Medeiros Fernandes; Isabella Morais Martins; Márcio Vinícius Lins de Barros, Daniel Mendes Pinto, Rodolfo Guillermo Vigil Verástegui Rocha, Maria Carmo Pereira Nunes.
Hospital Mater Dei, Division of Cardiology and Cardiovascular Surgery and Federal University of Minas Gerais – School of Medicine – Department of Internal Medicine, Belo Horizonte, MG, Brazil.
Background: Floating right heart thrombi can embolize leading to severe pulmonary embolism. In general, floating right heart thrombi are in transit from the legs to the pulmonary arteries. We present a case report of right atrial thrombi in a patient with deep venous thrombosis complicated with massive pulmonary embolism.
Case Reporter: A 62-year-old male was admitted to hospital with dyspnea and palpitations. An electrocardiogram indicated atrial fibrillation (AF) with heart rate of 140 bpm. A transesophageal echocardiogram (TEE) was performed before electric cardioversion. A large, unexpected mass was identified in the right atrium. In addition, a dilated right ventricle with difuse hypokinesia and pulmonary hypertension was observed. Multidetector computed tomographic evidenced a massive bilateral pulmonary thromboembolism. After that, venous duplex scan of the lower limbs confirmed the presence of thrombus in the left poplitean and femoral veins. Anticoagulation using low molecular weight heparin was started. Patient remained stable during hospitalization and was discharged on treatment with warfarin.
Conclusion: Right heart's thromboembolism is results of embolized deep venous thromboses that is temporarily lodged in the right atrium or ventricle and are often referred to as “emboli in transit.” The majority of right heart's thrombi are located in the right atrium. Our patient presented an AF with a high ventricular response, probably due to a pulmonary embolism event. Intending to electric cardioversion the arrhythmia, the right atrium thrombus was seen during the TEE. Therefore, the echocardiographic visualization of the right atrial thrombus permitted to change the treatment strategy, with anticoagulation instead of electrical cardioversion of the AF.
PRENATAL DIAGNOSIS OF ABSENT PULMONARY VALVE WITH MEMBRANOUS TRICUSPID ATRESIA AND INTACT VENTRICULAR SEPTUM
Karina Reis de Melo Lopes1; Annabelle Azancot2; Annelise Delazoide2
1IMIP; 2Hôpital Robert Debré
Introduction: Absent pulmonary valve associated with tricuspid atresia and intact ventricular septum is a rare malformation. We present the echocardiographic, anatomic and histological findings of a case diagnosed prenatally.
Case Report: We examined, at 32.6 weeks of gestation (w), a fetus referred because a routine ultrasound examination suspected a cardiac malformation. The fetal Doppler echocardiography revealed a small and hyperechogenic right ventricle with an asymmetric hypertrophic cardiomyopathy causing subaortic stenosis. There was membranous tricuspid atresia, and an absent pulmonary valve with retrograde filling of the right ventricle. Pregnancy was terminated at 37w. The pathological examination confirmed the findings typical of the syndrome: abnormal tricuspid valve (membranous atresia/stenosis), atrial septal defect, abnormalities of the interventricular septum (asymmetric hypertrophy), right ventricular dysplasia, absent pulmonary valve and patent ductus arteriosus.
Comments: This rare syndrome has an unknown etiology. The morphogenetic mechanism is different from usual tricuspid atresia. Initially it was proposed that a persistent large right venous valve, interfering with right ventricular inflow, was responsible for the findings, however, such valve was only found in a few cases. In all cases, the right ventricular myocardium was very abnormal, suggesting that it was responsible, at least in part, for the tricuspid atresia and absent pulmonary valve. Surgical interventions to create a systemic to pulmonary shunt are described as the only option for treatment but the mortality is very high.
Prenatal diagnosis is important for adequate counseling due to the severe prognosis.
A LARGE ATRIAL MYXOMA CAUSING MITRAL OBSTRUCTION AND SEVERE PULMONARY HYPERTENSION
Laura Gomide Moura, M.D.1; Luisa Campos C. Brant, M.D.2; Felipe Batista L. Barbosa, M.D.2; Fábio Torres Rabelo, M.D.2; Renato Bráulio, M.D.2; Maria Carmo P. Nunes, M.D., P.H.D.2
1Department of Internal Medicine and 2Division of Cardiology and Cardiovascular Surgery, Federal University of Minas Gerais, University Hospital, Belo Horizonte, MG, Brazil
Atrial myxoma is a benign heart tumor that occurs predominantly in the left atrium. Depending on size and location, it may cause mitral valve obstruction and pulmonary hypertension. We report a case of a large left atrial myxoma simulating severe mitral stenosis.
The patient was a previously hypertensive 55-year-old woman who presented dyspnea (class III NYHA) and atypical thoracic pain. Her physical examination suggested significant pulmonary arterial hypertension. Radiography showed mainly an enlargement of pulmonary artery, eletrocardiography a right ventricular hypertrophy with strain pattern in anteroseptal leads.
Transthoracic echocardiography detected a left atrium mass attached to the septum, prolapsing into the ventricle during diastole, obstructing the mitral valve (mean pressure gradient of 12 mmHg). Apical 4-chamber view denoted enlargement and disfunction of right cavities. Doppler indicated mitral and tricuspid regurgitation.
Cardiac catheterization and coronary angiography revealed a filling defect in the atrium and systolic pressure of main pulmonary artery of 90 mmHg (echocardiography had estimated 116). After resection the control echocardiographic measurement was only 39 mmHg, the mitral valve had mild insufficiency, no tricuspid regurgitation, right ventricle showed improvement of its function.
Histopathology confirmed a myxoma of 7 × 5 × 3.5 cm. The patient soon reported relief of the dyspnea, beeing discharged with a functional class I.
Left atrium myxomas may cause severe pulmonary hypertension and right ventricular failure, mimicking mitral stenosis. These complications can be accurately diagnosed by echocardiography and have great potential for reversibility. This case describes the highest pulmonary hypertension reported in literature secondary to a left atrium myxoma.
Keywords: Atrial myxoma, mitral obstruction, pulmonary hypertension, right heart failure
DIASTOLIC DYSFUNCTION AND LEFT ATRIUM VOLUME
Lilia M. Mameri El Aouar1,2; Diana Meyerfreund2; Leonard Hermann Roelke2; Yara Brasil2; Roberto S Cunha, Sergio Lamego Rodrigues2; Nabib Amin El Aouar1; José Geraldo Mill1
1MEDCENTER PRAIA DA COSTA-ES
Background: Increased left atrial volume indexed to body surface area (LAVi) has been associated with left ventricular (LV) diastolic dysfunction (DD) and described as an independent predictor of cardiovascular events.
Objectives: We examined the association between diastolic function and LAVi.
Methods: A cross-sectional study performed from January to December 2009 in 880 subjects, 20 to 80 years old, submitted to transtoracic echocardiogram (clinically-indicated or for routine check-up) at Medcenter- Praia da Costa. Eighty individuals were excluded from analysis because of non-sinus rhythm, valvular heart disease, pacemaker implantation or without optimal echocardiographic window. LA volume was measured using the Simpson's method. The LV diastolic function grade was defined according to the guidelines of the American Society of Echocardiography (2009).
Results: Final sample of 800 subjects, 55% women, mean age 53 ± 13 years, 43% hypertensive, 7.5% smokers, 7.5% diabetic, 25% obese and 42% with LV hypertrophy. The prevalence of DD was 29%. The LAVi increased with worsening DD: 24 ± 6 ml/m2 (normal), 25 ± 7 ml/m2 (grade I DD), 29 ± 8 ml/m2 (grade II DD) and 50 ± 9 ml/m2 (grade III to IV DD) p < 0,001. In bivariate analyses age, left ventricular mass index, E/E’ ratio and DD grade were positively associated, whereas ejection fraction (EF) and E’ were inversely associated with LAVi (p < 0,001).
Conclusions: These data suggest that DD contributes to LA remodeling and LAVi express the severity of diastolic dysfunction being associated with greater prevalence of cardiovascular risk factors.
Area: Echo-Adult – Function VE-ICC/New Techniques.
Type: Poster presentation
Keywords: Diastolic Dysfunction, volume of the left atrium
Acknowledgements: Department of Physiology -UFES
Intraoperative Transesophageal Echocardiography on Ross Procedure
Salgado, Marcello; Orlanti, Arthur; Oliveira, Andrey; Gomes, Mara Salgado Filho, Marcelo Fonseca M.D.*; Siciliano Junior, Arthur Orlanti M.D.*; Oliveira, Andrey Jose M.D.**; Gomes, Mara Lucia Neves dos Santos Mosqueira M.D.***.
*Anesthesiology; **Congenital Cardiac Surgery; ***Echocardiography Lab, Instituto Nacional de Cardiologia, Rio de Janeiro, Brazil.
We report the case of a Ross procedure in a 15 years old boy who presented severe congenital aortic regurgitation. The surgery was monitored by TEE. After weaning from bypass, TEE showed competent pulmonary homograft and RV moderate/important dysfunction. Intravenous milrinone was administered in order to improve RV function. Patient exhibited satisfactory response to drug therapy, leaving the operating room in good hemodynamic conditions, was discharged from ICU in the 4th postoperative day and from hospital in two weeks. In this case report, we discuss Ross procedure increasing indication treating aortic valve regurgitation in children and young adults and how valuable is the contribution of intraoperative transesophageal echocardiography as an important tool guiding surgeons and anesthesiologists evaluating surgical results and monitoring bypass weaning.
MEASURE OF THE PULMONARY VASCULAR RESISTANCE BY ECHOCARDIOGRAPHY
Marcelo Felipe Kozak; Ana Carolina Leiroz Ferreira Botelho Maisano Kozak
Faculdade de Medicina de São José do Rio Preto
Introduction: Pulmonary hypertension with elevated pulmonary vascular resistance (PVR) is common in patients with congenital heart diseases. Diagnosing this situation based just on clinical judgment is difficult, but having this information is very important for the patient's management. Cardiac catheterization is the gold-standard exam to confirm it. Less invasive exams, as the echocardiogram (ECHO), are desirable in the pediatric population. Abbas and cols., JACC 2003;41(6):1021–1027, proposed a formula obtained by Doppler echocardiography to calculate the PVR.
Objective: To verify the applicability of this formula in newborns with persistent pulmonary hypertension (PPH), an in vivo model of elevated PVR.
Method: It were measured the peak tricuspid regurgitant velocity and the right ventricular outflow tract time-velocity integral by Doppler echocardiography in five consecutive newborns with PPH. These data were used in the formula proposed by Abbas and cols.
Results: In all patients, the PVR was higher than 4 Wood units, characterizing elevated PVR.
Conclusion: The formula proposed by Abbas and cols. may be used in newborns with PPH. Its application in other situations must be tested.
EVALUATION OF EPICARDIAL ADIPOSE TISSUE BY ECHOCARDIOGRAM: A NEW MARKER OF CENTRAL OBESITY AND METABOLIC SYNDROME IN PATIENTS WITH TYPE 1 DIABETES
Marcio Antonio Epifanio2; Claudio Domenico Sahione Schettino2; Jose Carlos Moreira Santos2; Denise Prado Momesso1; Isabela Bussade1; Rosane F. Kupfer1; Luis Augusto Tavares Russian3
1Department of Diabetes, Diabetes and Endocrinology State Institute, IEDE, Rio de Janeiro, Brazil; 2Gaveacor, Clínica São Vicente, Rio de Janeiro, Brazil; 3CCBR Brasil- Center for Basic and Clinical Research, Rio de Janeiro, Brazil
Objectives: Epicardial adipose tissue (EAT) assessed by echocardiogram has been correlated with the presence and severity of coronary artery disease. This study evaluated the association of epicardial adipose tissue with body fat composition and clinical criteria of metabolic syndrome (MS) in patients with type 1 Diabetes mellitus (DM).
Methods: Forty-five type 1 DM women with no previous history of cardiovascular disease were evaluated (mean age 36 ± 9 years; mean diabetes duration 18 ± 9 years, mean body mass index 24.6 ± 4.4 kg/m2). Metabolic Syndrome was defined using the World Health Organization criteria. Body fat composition and EAT were analyzed by dual-energy-x-ray absorptiometry and echocardiogram, respectively.
Results: Twenty patients (45%) had MS. There was an increase in android (central) fat deposition in patients with MS (41.9 ± 2.0 vs 33.7 ± 1.8%, p = 0.004). Total body fat and gynoid (peripheral) fat distribution were similar between the groups. Mean EAT was higher in patients with MS than in patients without MS (6.15 ± 0.34 vs 4.96 ± 0.25 mm; p = 0.006). Epicardial adipose tissue was positively correlated with android (central) fat distribution (r = 0.44; p = 0.002) and with total body fat (r = 0.43; p = 0,002); however no correlation was found with gynoid (peripheral) fat distribution (r = 0.27; p = 0.07).
Conclusion: There was a high incidence of MS in type 1 DM related to increased central adiposity, despite the absence of obesity. Metabolic syndrome and central obesity were associated with increased EAT. The measurement of epicardial adipose tissue by echocardiogram can therefore be used clinically as a marker of risk of metabolic syndrome and visceral obesity, allowing early and feasible assessment of cardio- metabolic risk in patients with DM.
Keywords: type 1 diabetes; epicardial adipose tissue; metabolic syndrome; body fat composition.
EFFECT OF PACING-INDUCED VENTRICULAR DYSSYNCHRONY ON RIGHT VENTRICULAR FUNCTION
Maria Carmo P Nunes; Cláudia Drumond G Abreu; Manoel Otávio C Rocha; Antônio Luiz P Ribeiro; Marcia M Barbosa
Postgraduate Course of Tropical Medicine, Federal University of Minas Gerais; Ecocenter, Socor Hospital – Belo Horizonte, Brazil
Background: Asynchronous electrical activation induced by right ventricular (RV) pacing can cause several abnormalities in left ventricular (LV) function. However, the effect of ventricular pacing on RV function has not been well established. We evaluated RV function in patients undergoing long-term RV pacing.
Methods: An echocardiogram was performed in 85 patients after pacemaker implantation (mean interval = 90 months). Twenty- four healthy controls were also included. Conventional echocardiography and tissue Doppler imaging (TDI) were used to analyze RV function. Strain imaging measurements included peak systolic strain and strain rate at the basal RV free wall. LV function and ventricular dyssynchrony by TDI were assessed. Intra- and interobserver variabilities of TDI parameters were tested on 15 randomly selected cases.
Results: All patients were in NYHA functional class I or II and no patient had significant LV dysfunction. Percentage of ventricular pacing was 96 ± 4%. RV apical induced electromechanical dyssynchrony manifested by lengthening of the QRS duration (140 ms), increased interventricular delay (41.7 ± 19 ms), and intraventricular dyssynchrony with septal-to-lateral delay ≥ 65 ms. All echocardiographic indexes of RV function were similar between patients and controls (strain: −22.8 ± 5.8% vs −22.1 ± 5.6%, p = 0.630; strain rate: −1.47 ± 0.91 s−1 vs −1.42 ± 0.39 s−1, p = 0.702), indicating preserved RV function. Intra- and interobserver variability for RV strain was 3.1% and 5.3%, and strain rate was 1.3% and 2.1%, respectively.
Conclusions: In patients with standard pacing indications, RV apical pacing did not seem to affect RV systolic function, despite induction of electromechanical dyssynchrony.
LOW-DOSE DOBUTAMINE STRESS ECHOCARDIOGRAPHY (LDDSE) TO ASSESS MYOCARDIAL RESERVE IN PATIENTS WITH CONGENITAL AORTIC STENOSIS
Maria Elisa Martini Albrecht; Pedra, S; Barretto, R; Chiaradia, M; Pereira, P; Vilela, A; Gimenes. V; Santana, MV; Assef, J; Sousa, AGMR
The ideal timing for surgery to correct aortic insufficiency (AI) in children and adolescents is not well established. It is well known that patients may stay asymptomatic for many years, being at risk for irreversible left ventricular dysfunction in the long term. Studies have demonstrated that exercise echocardiography in the evaluation of myocardial reserve is a predictor of LV deterioration. This study aims to demonstrate the utility of LDDSE in patients with congenital aortic stenosis.
Patients and Methods: 24 patients (pts) with severe AI (mean age = 16 ± 7,7 years) underwent an echo study where systolic functional parameters were measured at rest and after 10 minutes of continuous infusion of 5 mcg/kg/min. Parameters evaluated were: M-mode shortening and ejection fractions, Vcfc, systolic blood pressure and LVOTO flow velocity. Normal myocardial reserve was considered when at least 3 independent parameters increased in 5% when compared to its rest value.
Results: Ten pts had previous surgery for VSD closure and aortic leaflet prolapse; 7, isolated congenital AI; 4 had any type of aortic valve procedure in the past and 3 had other interventions. Three patients were on functional class (FC) III (12,5%), with the remaining being on FC I and II. Only 2 pts had EF < 60% (LV dysfunction). After the examination, 8 patients were referred to surgery because of bad response to LDDSE in 5 and FC III in the other 3 pts.
Conclusion: LDDSE may be an interesting test in the follow-up of patients with severe aortic insufficiency. It may help in the decision for aortic valve surgery timing.
CARDIOGENIC SHOCK IN A PATIENT WITH TAKOTSUBO CARDIOMYOPATHY
Ali Kassen Omais1; Miriam Marchese1; Júlio César de Oliveira2; Fábio Ridolfi Figueiredo3; José Alfredo Sejópoles3; Alberto Najar3; Sidney Munhoz Júnior3; Carlos José Alves4; Gilberto Paulo Pereira Franco4; Ronaldo Marcelo Taques4
1Hospital Geral Universitário; 2Atrium – Centro de Cardiologia de Mato Grosso; 3LACIC – Laboratório de Hemodinâmica; 4GCMI – Grupo Cuiabano de Medicina Intensiva
Introduction: Takotsubo Syndrome, also called stress-induced cardiomyopathy, apical balooning syndrome and broken heart syndrome. Takotsubo cardiomyopathy is a rare cause of acute left ventricular aneurysm, reversible, without coronary artery obstruction. Symptoms maybe similar to those from acute myocardial infarction. We reported a case of cardiogenic shock in Takotsubo syndrome with good evolution.
Case Report: FLZ, 67 years old, female with hypertension. Started with typical chest pain, diaphoresis, dyspnea after 20 hours of a emotional stress visiting a son with cocaine dependence.
Vital Signs: Blood pressure- 70/40 mmHg, Respiratory rate:26/minute; pulse 102 bpm
Regular heart rhythm, S3, 2/6 grade systolic ejection murmur in mitral area
Fine crackles in the base of the thorax.
Admitted to the intensive care and treated with dobutamine and noradenaline, captopril and carvedilol.
The patiente revealed important improvement after one week of the admission.
Cardiac Enzymes: Troponin: 1.8 ng/ml 1st day; 1.7 ng/ml 2nd Day; 1.5 ng/ml 5th day
MB-CK: 22 u/ml 1st Day; 36 u/ml 2nd day; 18 u/ml 5th day
Sinus rhythm, ST segment elevation in leads DII, DIII and aVF and anterior wall.
Echocardiogram: important dysfunction of the left ventricle (Ejection fraction 36% by Simpson) with medium to apical ballooning of all left ventricular walls.
Echocardiogram showed near complete resolution of the wall motion abnormalities after one week of the initial symptoms (Ejection Fraction 74%)
Coronary angiogram was normal with ballooning aspect of the left ventricle.
Discussion: Acute left ventricular aneurysm in Takotsubo Syndrome, without coronary artery obstruction, is caused by emotional and physical stress, explained by excess catecolamines, coronary spasm, microvascular dysfuntion. Much more common in women than men, 61–76 years old. The left venytricular dysfunction is reverted in aproximatelly 18 days. Takotsubo syndrome can present with chest pain, arryhthmias, pulmonary congestion and cardiogenic schock.
Keyword: Takotsubo, myocardiopathy, cardiogenic shock
SUPERIOR VENA CAVA SYNDROME CAUSED BY METASTATIC MELANOMA IN THE RIGHT ATRIUM
Ali Kassen Omais1; Júlio César de Oliveira2; Marcelo Bumlai1; Ronaldo Peixoto de Mello1; Miriam Marchese1; Haitham Ahmad1; Mônica Trevisan1; Bruno Baranhuk1; Valdiro José Cardolos Júnior3; Valdiney Vieira de Carvalho3
1Hospital Geral Universitário – UNIC; 2Universidade Federal de Mato Grosso; 3ATRIUM – Centro de Cardiologia de Mato Grosso
Cardiac tumors may be symptomatic or found incidentally during clinical evaluation, echocardiography, magnetic resonance imaging or computed tomography. Metastatic involvement of the heart secondary to malignant neoplasias is relatively common. Melanoma has a great propensity to metastasize to the heart, pericardium and intracardiac masses. We reported a case of a patiente with previous cutaneous melanoma with intracardiac metastases and superior vena cava syndrome.
Case Report: MBC, 29 years old, male, reported voice alteration, sufocamento, swelling face sensation, dilated vases in the anterior chest compatible with superor vena cava syndrome since the resection of a previous cutaneous melanoma 8 days before hospital admission.
The blood pressure was 120/80 mmHg, pulse regular of 98 bpm and respiratory rate of 20/minute.
Transthoracic echocardiogram- a right atrium occupied by a fixed mass measuring 4,79 × 3,78 cm, without tricuspid obstruction.
Transesophagic echocardiogram showed a mass extendind from the superior vena cava and filling the right atrium cavity measuring 4,6 × 4,9 cm.
Computed Tomography- a large filling defect in the right atrium.
After 2 months of chemotherapy patient died secondary to septic schock.
AGE AND HEART RATE ARE THE MAIN CORRELATES OF EPICARDIAL FAT THICKNESS IN PATIENTS WITH THE METABOLIC SYNDROME
Murilo Foppa; Mauricio Junges; Angela B S Santos; Adriana Macari; Bruno Schneider de Araújo; Beatriz G S Seligman; Bruce B Duncan
Hospital de Clinicas de Porto Alegre and Federal University of Rio Grande do Sul
Epicardial fat is a visceral fat depot measurable by echocardiography. However, its main biological determinants and its distribution in different populations are still unknown.
Objectives: To identify variables independently associated with epicardial fat thickness in patients with the metabolic syndrome (MetS).
Methods: We measured epicardial fat and additional demographic (gender, age, height, BMI, waist-hip ratio), clinical (systolic and diastolic blood pressure, resting heart rate, hypertension, smoking), and laboratory (glucose, insulin, OGTT, Triglycerides, us-CRP) variables in 53 patients with MetS (age 43+-8 y; BMI 34.4+-2.9 Kg/m2; SBP = 129+-12 mmHg; HR = 86+-11 bpm) Epicardial fat was defined as the layer between the right ventricle epicardial surface and the parietal epicardium in longitudinal and short axis paraesternal windows, both in systole and diastole. Associations were evaluated utilizing a multivariable linear regression model.
Results: Among investigated variables, age and resting heart rate were independently associated with epicardial fat thickness, measured in systole (age: Beta = 0.55; t = 4.7; p < 0.001 and HR: Beta = 0.26; t = 2.2; p = 0.03) and in diastole (age: Beta = 0.59; t = 5.1; p < 0.001 and HR: Beta = 0.23; t = 2.1; p = 0.04).
Conclusions: In a sample of MetS patients, age and resting heart rate were independently associated with epicardial fat, suggesting that non-metabolic demographic factors may have an important role in its composition. However, the homogenous demographic characteristics of this sample limit the simultaneous evaluation of the other metabolic factors, suggesting the necessity of evaluation of these associations in population-based samples.
Support: HCPA/FIPE and CNPq
EPICARDIAL FAT IS ASSOCIATED WITH LEFT VENTRICULAR MASS AND DIASTOLIC FUNCTION IN INDIVIDUALS WITH THE METABOLIC SYNDROME
Murilo Foppa; Mauricio Junges; Angela B S Santos; Adriana Macari; Bruno Schneider de Araújo; Beatriz G S Seligman; Bruce B Duncan
Hospital de Clinicas de Porto Alegre and Federal University of Rio Grande do Sul
Echocardiography has been used to identify subclinical cardiovascular abnormalities such as left ventricular hypertrophy and diastolic dysfunction. Epicardial fat measurement is one of new proposed techniques to refine patient stratification.
Objective: To evaluate the association between epicardial fat and other echocardiographic measurements in patients with the metabolic syndrome (MetS).
Methods: We measured epicardial fat thickness in 53 patients with MetS. Epicardial fat was defined as the layer between the right ventricle epicardial surface and the parietal epicardium in longitudinal and short axis paraesternal windows, both in systole and diastole. The thickness of this fat was compared in a bivariate form with left atrium and ventricle dimensions, left ventricular mass (LVM), relative wall thickness (RWT), transmitral Doppler flow, mitral tissue Doppler velocities, obtained following recommendations of the Brazilian and American Echocardiographic Societies. Associations with functional capacity and flow-mediated vasodilation were also evaluated. We considered significant associations as those with p < 0.01.
Results: Among investigated variables, epicardial fat in systole was associated with septal thickness (r = 0.38), posterior wall thickness (r = 0.34), RWT (r = 0.32), LVM (r = 0.28), mitral tissue E wave (r =−0.42) and E:Em relation (r = 0.34). Epicardial fat in diastole was associated with septal thickness (r = 0.47), posterior wall thickness (r = 0.49), RWT (r = 0.49), LVM (r = 0.30), midwall fractional shortening (r =−0.41), E wave deceleration time (r =−0.31) and E:Em relation (r = 0.31).
Conclusions: Epicardial fat is associated with left ventricular mass and diastolic function, but not with functional capacity and endothelial dysfunction. Our data suggest that significant cardiac depots of visceral fat may coexist with other common subclinical echocardiographic abnormalities.
Support: HCPA/FIPE and CNPq
EPICARDIAL FAT IS INCREASED IN PATIENTS WITH DIABETES AND WITH THE METABOLIC SYNDROME
Murilo Foppa; Mauricio Junges; Angela B S Santos; Adriana Macari; Bruno Schneider de Araújo; Beatriz G S Seligman; Bruce B Duncan
Hospital de Clinicas de Porto Alegre and Federal University of Rio Grande do Sul
Epicardial fat is a visceral fat depot measurable by echocardiography. Its measurement could allow additional inference about the metabolic state of patients.
Objective: To compare epicardial fat thickness among patients with Diabetes (Diab), Metabolic Syndrome (MetS) and healthy controls (CTR).
Methods: We compared 53 individuals with MetS, 17 with Diab and 30 CTR, matched for gender and age group. All participants were submitted to transthoracic echocardiography, clinical and laboratory evaluation. Epicardial fat was defined as the hypoechoic layer between the right ventricle epicardial surface and the parietal epicardium. We used the mean of three consecutive beats both from longitudinal and short axis paraesternal windows. Groups were compared using ANOVA, with Duncan post-hoc analysis between groups.
Results: Epicardial fat thickness in Diab (54 +−7 y; BMI = 30.7 +−4.4 Kg/m2), MetS (43 +−8 y; BMI = 34.7 +−2.8 Kg/m2) and CTR (41 +−6 y; BMI = 25 +−2.6 Kg/m2) were respectively, in systole (Diab = 5.1 +−1.5 mm; MetS = 4.0 +−1.3 mm; CTR 3.5 +−1.2 mm) and diastole (Diab = 2.5 +−1.3 mm; MetS = 1.4 +−1.0 mm; CTR 0.4+−0.4 mm). Among groups, epicardial fat in systole was statistically significantly greater in Diab than in other groups (p < 0.05). In diastole, epicardial fat means were different among all three groups (p < 0.05).
Conclusion: In this sample, we observed a progressive increase in epicardial fat thickness according to the degree of metabolic disturbance. Epicardial fat measurement may become a new tool to help risk stratification in patients with disturbances of glucose metabolism.
Support: HCPA/FIPE and CNPq
AORTO-RIGHT ATRIAL FISTULA CAUSED BY CORONARY SINUS RUPTURE
Nila Maria Orrico Costa12; Ricardo Eloy Pereira1; Amancio Valois3; Sidnei Nardeli1; Carlos Roberto Matos1
1Hospital Santa Izabel; 2Hospital São Rafael (SSA/BA); 3Cardioprev
Introduction: Aorto-right cavities fistula is a rare anomaly generally occurring after cirurgic manipulation (valve replacement), as endocarditis complication or sinus coronary aneurism. The incidence on the first case is 0,15%. We report case of a young lady previously healthy that presented an aorto-right atrial fistula caused by coronary sinus rupture without previous valve pathology, endocarditis-associated or sinus coronary aneurism.
Case Report: A 25-year-old lady was referred to us complaining about progressive dyspnea for one year and legs edema for five months. She was previously healthy, with no thoracic trauma history, infection disease, cardiopathy or previous surgery intervention. Physical examination revealed blood pressure of 130/40/0 mmhg, heart rate of 80 beats/min with collapsing pulse, signs of elevated jugular venous pressure. She had a grade 3/6 continuous systolic and diastolic murmur at the left medium and up sterna edge, hepatomegaly and leg edema ++/4+. ECK showed right ventricular overload. Chest X-ray showed cardiac enlargement with cardiothoracic index = 0,7. Transthoracic and transesophageal echocardiogram: right cavities enlarged, right coronary sinus with no aneurism from where a great fistula emerged and drained towards tricuspid valve. There was tricuspid annulus dilatation with severe tricuspid regurgitation, and a small pericardic effusion. There was no damage of right coronary ostium.
She was submitted to cardiac surgery with fistula closed, fibrotic cone reduction around tricuspid valve and tricuspid valve repair. The pos operative course was uneventful and echocardiogram showed no residual shunt and a competent tricuspid valve.
Comment: Transesophageal echocardiogram was an excellent noninvasive method to establish the diagnosis in this case. Inspite of the aorto-right atrial fistula be a rare anomaly, it was the apparently spontaneous occurrence that called our
LOW-DOSE DOBUTAMINE STRESS ECHOCARDIOGRAPHY ASSOCIATED TO EARLY ATROPINE DOSE AND ISOMETRIC EXERCISE (HAND GRIP) – A CASE REPORT OF A NEW PROTOCOL EXPERIENCE
Arraes, Wilson Alves; Cardoso, Ronald Lobato; Damas, Estela Mara Peres; Barbato, Alfonso; Osella, Oscar Francisco Sanchez
CLINECO – Centro Clínico e Ecocardiográfico de Brasília; ISO – Instituto Sanchez Osella de Cardiologia – Brasília – DF
Background: The dobutamine stress echocardiography (DSE) complications derive from the patient's clinical condition and are directly related to the dosage, which depends on the chronotropic response.
Objectives: Report our experience of using low-dose DSE associated to early atropine dose and isometric exercise.
Methods: 151 patients (pat) with no contractility alterations neither meaningful valve diseases at baseline were recruited and divided into two groups: 75 female pat (FemGr), age 59(+−14) and 77 male pat (MaleGr), age 54(+−13). After standard exam, dobutamine infusion was initiated at 5 mcg/kg/minute, been increased to 10, 15 and 20 mcg/kg/minute at three-minute time intervals. Isometric continuous exercise (hand grip) was associated to the test by the time the 10 mcg/kg/minute dosage was reached and an IV atropine 0,25 mg bolus was repeated after each dosage increase.
Results: Respectively in both groups, FemGr/MaleGr, 47/50 pat were considered normal; 0/1 ineffective; 10/7 ischemic out of segmental alterations; 4/10 ischemic out of EKG changes and no segmental alterations; 4/8 interrupted by hyper-active arterial pressure; 3/1 interrupted by arrhythmia; 7/2 interrupted by meaningful intraventricular gradient. The dosages of dobutamine were respectively 5 mcg/kg/minute in 5/1 pat; 10 mcg in 45/38; 15 mcg in 24/38; 20 mcg in 2/4. Among all patients, the dobutamine dosage was 5 mcg/kg/minute in 6 pat (3,9%); 10 mcg in 83 pat (55%); 15 mcg in 62 pat (34%) and 20 mcg in 6 pat (3,9%). There were no complications.
Conclusions: The association of an isometric exercise to the atropine dose in the DSE allowed us to reach the exam's goal with significant decrease in the dobutamine dosage, shortening the exam's duration without complications.
ROSUVASTATIM REDUCED THE LEVELS OF METALLOPROTEINASE 2 IN RATS SUBJECTED A HYPERCHOLESTEROLEMIC DIET IN AN EXPERIMENTAL MODEL OF MYOCARDIAL INFARCT
PMM Dourado; MBP Landim; A Casella Filho; JM Tsutsui; TFG Galvão; VD Aiello; W Mathias Jr; PL da Luz; ACP Chagas.
Atherosclerosis Unity. Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
Objective: Evaluation of the role of interleucin-6 (IL-6), metalloproteinase 2 (MMP-2), tumor necrosis factor (TNF-alpha) and asymmetric dimethylarginine (ADMA) in hypercholesterolemic rats and its correlation with the infarct size in an acute infarct model in rats.
Methods: Sixty three anesthetized rats were subjected to occlusion of the left anterior descending (LAD) coronary artery and divided in six groups: G1 – just normal diet (ND); G2 – ND and treatment with rosuvastatim for 30 days began after infarct and G3 – ND and 30 days previously to infarct treated with rosuvastatim until 30 days after it; G4 – just hypercholesterolemic diet (HD); G5 – HD and treatment with rosuvastatim for 30 days began after infarct and G6 – HD and 30 days previously to infarct treated with rosuvastatim until 30 days after it. The biochemical analysis was evaluated by ELISA and% of the infarct was determined by pathology. A p value < 0.05 was considered significant.
Results: See table
Conclusion: The use of rosuvastatim in a hypercholesterolemic group reduced the levels of MMP-2, but did not reduce the levels of TNF-alpha, IL-6 and ADMA. There was no correlation between the MMP-2 reductions with infarct size.
CORRELATION OF ECHOCARDIOGRAPHIC FINDINGS WITH CARDIOPULMONARY EXERCISE TESTING IN HEART TRANSPLANT CANDIDATES
Rodrigo Bellio de Mattos Barretto; RA Rezende; RSL Teixeira; MA Finger; AS Ferraz; JM Rossi; LS Piegas; JE Assef; AGMR Sousa
Instituto Dante Pazzanese de Cardiologia
Introduction: Cardiopulmonary exercise testing and echocardiography are essential tools in the assessment of patients considered for cardiac transplantation. Echocardiography is able to assess cardiac shape, global and regional cardiac function, as well as examine the temporality of mechanical phenomena, such as synchronism. There are few studies comparing these echocardiographic findings with results of cardiopulmonary exercise testing in heart transplant candidates. The aim of this study is to identify echocardiographic variables associated with a worse functional capacity by cardiopulmonary exercise testing in these patients.
Methods: The study population was patients who were candidates for heart transplantation in sinus rhythm. They underwent echocardiography and cardiopulmonary exercise testing with an interval of 90 days. We evaluate the slope VE/VCO2 in cardiopulmonary exercise testing conventional measures of echocardiography and other more specific as sphericity, overall longitudinal strain, torsion of left ventricular, dimensions and function of the left atrium through its ejection fraction and longitudinal strain as well as ventricular and atrial syncronism and ventricular fibrillation by tissue Doppler. The latter was evaluated by dispersion and standard deviation of the regional displacement of the left atrium during atrial contraction.
Results: There were 21 patients, 5 women, aged 54 ± 10 years, 76.0% with class III/IV. The most prevalent past history were hypertension (52.0%) and coronary artery disease (43%). The VE/VCO2 did not related to any measure of conventional echocardiography, sphericity, torsion, left atrial or ventricular strain. There were an association of E/VCO2-slope eiyth measurement of left atrial dyssynchrony (dispersion – R2= 0.31, p = 0.009, standard deviation – R2= 0.26, p = 0.02).
Conclusion: This study shows that the synchronism of left atrium is associated with worse functional capacity, which can help identify a subgroup of patients with high risk that are candidates for heart transplantation.
THE TRUE VALUE RATIO E/A <1 IN DIAGNOSIS OF LEFT VENTRICULAR DIASTOLIC DYSFUNCTION (LVDD)
Ronaldo Campos Rodrigues; Evandro Tinoco Mesquita; Sandra Marina Ribeiro de Miranda; Cláudio Tinoco Mesquita.
Universidade Federal Fluminense – Niterói – Brasil
Instituto de Pós Graduação Médica do RJ – Rio de Janeiro – Brasil
Introduction: Diastolic function can be assessed by both invasive and noninvasive. Since the measures include reduction in blood pressure during isovolumetric relaxation, ventricular stiffness and end-diastolic pressure. The E/A ratio is an index that reflects the contribution of rapid filling and atrial contraction for ventricular filling. But the method has limitations, because the parameters of diastolic filling are influenced by several factors among which includes age and loading conditions. The LV diastolic dysfunction type 1 (abnormal relaxation) shows a pattern of mitral flow, obtained by pulsed Doppler, type E/A <1, associated with deceleration time of E wave periods. Obtaining the propagation velocity of mitral flow by Color M-mode, allows us to differentiate patients with normal LV diastolic function from those with diastolic dysfunction, but does not allow us to differentiate the types of diastolic dysfunction among themselves. Unfortunately it is still frequent in clinical practice, the diagnosis of abnormal relaxation LV only by identifying the E/A ratio <1, the analysis of mitral flow with pulsed Doppler.
Objectives: To assess the true value of E/A ratio <1 in the diagnosis of left ventricular diastolic dysfunction (LVDD)
Material and Methods: We evaluated 31 pts, age: 65 ± 13th, 9 H (29%) and 22 M (71%). All had E/A ratio <1 (0.73 ± 0.20). The TD average was 252 ± 55 mseg and VPF valve was 46 ± 13.6 cm/sec. The cutoff for the TD was 230 msec and the valve was 45 cm/seg VPF. Of the 31 pts, 14 (48%) had normal mitral VPF (> = 45 cm/seg) and 13 pts (41.9%) had normal TD (< = 230 mseg). Of total pts, 12 (39%) had both the VPF as normal and TD would be misclassified in Group LV diastolic dysfunction in type 1 (Amendment of LV relaxation) where the diagnostic criteria used were only the E/A <1.
Conclusion: In this population, the characterization of DD type Change of LV relaxation, only the detection of the standard E/A <1, alone, enabled the correct diagnosis of the entity in question in just over half of patients (61%). Important to report that the results obtained, the classification of patients in Group 1, Diastolic Dysfunction, based only on E/A ratio <1 is unsatisfactory.
THE DOPPLER AN ASSESSMENT OF LEFT VENTRICULAR DIASTOLIC FUNCTION
Ronaldo Campos Rodrigues; Evandro Tinoco Mesquita; Sandra Marina Ribeiro de Miranda; Cláudio Tinoco Mesquita
Universidade Federal Fluminense – Niterói – Brasil
Instituto de Pós Graduação Médica do RJ – Rio de Janeiro – Brasil
Introduction: The presence of diastolic abnormalities in absence of symptoms (DD) is common in older, hypertensive, diabetic and suffering from metabolic syndrome. In recent years, has demonstrated its prognostic value in different clinical conditions for the occurrence of cardiovascular events. About 50 to 60% of CHF patients have heart failure with normal ejection fraction. The prevalence of HFNEF has grown progressively in the order of 1% per year in modern communities, and mortality remains high and unchanged, despite treatment, in recent decades. Survival is similar to patients with ICFER. The echocardiographic study has advanced in recent years in the assessment of LV diastolic function (FDVE), creating over the years, several echocardiographic techniques, with great accuracy in the evaluation of FDVE. They are: 1) transmitral diastolic flow (FDTM) with pulsed Doppler (PW), and 2) Study Doppler pulmonary vein (PV), 3) tissue Doppler (TD) in the mitral annulus, both in its septal portion, as in its lateral portion; 4) The propagation velocity of mitral flow by color M-mode (VPFM) and 5) the variations imposed by the Valsalva maneuver (VM) in Mitral Flow.
Objectives: To identify the best method associated with the study of FM, which has the highest diagnostic equivalence, with the result obtained by analyzing the FDVE, using the five echocardiographic methods for assessing FDVE.
Material and Methods: Cross-sectional study, which evaluated the FDVE in 62 pacts, age > 20 years, of both sexes who were referred to perform a routine U.S.. In all of the pacts was the analysis of LV diastolic function using the 05 methods listed.
Results: There were 62 pacts with mean age 48 ± 18.7 to, 28 H (45%) and 34 M (55%). The pacts were grouped into four groups according to the result obtained by the combined analysis of 05 echocardiographic methods for assessing FDVE: Group 1 – Twenty-three (23) pacts with FDVE normal. Group 2 – Thirty-one (31) pacts with the pattern of change in LV relaxation. Group 3 – Five (5) pacts with pseudo-normal pattern. Group 4 – Three (7) pacts. with a restrictive pattern of diastolic dysfunction. Success rates for each method or combination of methods used in relation to the result reached by the joint analysis of five methods (benchmark proposed), were obtained by calculating the contingency coefficients (CC). The analysis using the study of FM with DP associated with the measurement of the VPF achieved the best among all evaluated CC (CC = 0.86). The association study of FM with the analysis of Doppler Tissue generated a CC of 0.84
Conclusions: In this population of patients, performed with Doppler transmitral pulsed Doppler, associated with mitral propagation velocity in M-Mode Color Flow Mitral presented the best diagnostic equivalence in relation to assessment of FDVE through combined analysis of 05 methods. The study of FM associated with the TD of the mitral annulus was the 2nd best combination of methods used for assessing FDVE.
THE EXERCISE TOLERANCE IS LIMITED BY THE DIASTOLIC DYSFUNCTION IN PATIENTS WITH SYSTOLIC HEART FAILURE
Márjory Fernanda Bussoni; Gabriel Negretti Guirado, Luiz Shiguero Matsubara; Meliza Goi Roscani; Bertha Furlan Polegato; Silméia Garcia Zanati; Beatriz Bojikian Matsubara
Botucatu Medical School – UNESP
Background: Patients with systolic heart failure (SHF) have low tolerance to exercise which is not associated with the left ventricular ejection fraction (EF). The role of diastolic dysfunction in this limitation is not defined.
Objectives: To evaluate the association between physical capacity and indices of diastolic function in patients with compensated SHF and to analyze the association between systolic and diastolic dysfunction.
Methods: This was a prospective study including 28 consecutive patients of both genders, with a history of previous hospitalization for SHF. Physical examination, conventional transthoracic echocardiogram and a 6-minute walk test (6MWT) were performed in a sequence. The indicators of systolic function were EF (biplane Simpson) and annular mitral systolic velocity (Sm, tissue Doppler image). The indices of diastolic function were transmitral flow velocities (E and A, Doppler), annular diastolic velocities (Em and Am, tissue Doppler image) and the E/Em ratio (normal value < 8). The associations between the 6MWT and systolic or diastolic function indices were assessed by linear regression analyses. Significance level was taken at p < 0.05.
Results: There was a direct association between 6MWT and E/Em (R = 0.45, p = 0.016) but not between 6MWT and EF (R = 0.17, p = 0.386). EF and E/Em were inversely correlated (R = 0.58, p = 0.001) and a direct association was found between Sm and Em (R = 0.50, p = 0.006).
Conclusions: Patients with SHF have limited tolerance to exertion associated with LV diastolic dysfunction, but not with systolic performance, although the systolic and diastolic dysfunctions are directly correlated.
IMPORTANCE OF ADEQUATELY PERFORMED VALSALVA MANOUVER FOR DETECTION OF PATENT FORAMEN OVALE
Thais Flores Carvalho; Ana Clara Tude Rodrigues; Ana Lucia Arruda; Aime Carbone; Tatiana Rocha Souza; Edna Pitombeira; Elizabeth Osawa; Giovanni G Cerri; Jose L Andrade
Ecocardiografia – INRAD – HC- FMUSP
Background: Transesophageal echocardiography (TEE) is routinely used to assess source of emboli after cerebrovascular accidents (CVA). To adequately evaluate the presence of patent foramen ovale (PFO) however, an effective Valsalva manouver is desirable
Aim: To evaluate the efecctiveness of Valsalva manouver during TEE, comparing it with transthoracic echocardiography (TTE) in pacients with CVA.
Methods: We evaluated 47 patients with CVA referred for TEE, 26 male, aged 60 ± 9 years old. Valsalva manouver was explained during TTE and agitated saline used to assess PFO. The amount of microbubbles in left chambers were semi-quantitatively assessed. Conscious sedation with midazolam was used fot TEE.
Results: Midazolam dose was 3.2 ± 1.6 mg. Valsalva manouver was adequately performed during TTE, however only 47%(22) patients performed it during TEE, which was complemented with abdominal compression and/or cough. 18(38%) out of 47 patients had PFO by one of the examinations; in 14 (30%), both examinations confirmed PFO. In 3 patienst PFO was only detected by TTE, while in 1 it could only be detected by TEE. The 3 patients in whom FOP was not detected by TEE could not perform Valsalva and had 5, 3 and 3 mg midazolam. Microbubbles were detected with similar intensity for both examinations in 10 patients, better seen in 2 patients in TEE and more intense during TTE in 2.
Conclusion: Though established for diagnosis of PFO, TEE might eventually not be sensitive enough to detect it in patients in whom Valsalva is not effective. It might be important to associate agitated saline and Valsalva manouver by TTE.
DOPPLER ECHOCARDIOGRAPHY IMPORTANCE ON DIAGNOSIS OF UNSUSPECTED CARDIAC ABNORMALITIES IN CHILDREN AND ADOLESCENTS
Sandra Regina Tolentino Castilho; Thiago Augusto Gonçalves Nogueira Vilela; Tiago Spizzirri Pereira; Letícia Drumond Alberto; Juliana Sofia Esteves Fantini; Alan Alvarez Conde; Juliana Cristina Leite; Henrique Fonseca Assis Tonelli; Zilda Maria Alves Meira
Faculdade Medicina – Hospital das Clínicas – UFMG
Objective: Determine the occurrence of cardiac abnormalities not suspected on clinical examination and initial cardiac workup: exams electrocardiographic (ECG) and chest radiology (chest X-ray).
Methodology: Children and adolescents referred for performance of Doppler echocardiography in a University Hospital underwent clinical cardiovascular examination and had their ECG and chest X-ray analyzed when available, prior to completion of Doppler echocardiography. Presumptive diagnoses were made before and after the performance of Doppler echocardiography.
Results: We included 291 patients, 43.9% females and 56.1% male. The Doppler echocardiography confirmed 85.0% of clinical hypotheses obtained from the cardiovascular examination, complemented by analysis of ECG and chest X-ray. In 42 patients (15.0%), the echocardiographic examination changed the clinical diagnosis. In one infant was diagnosed IVC by clinical (ECG and chest X-ray were not available), but it was tetralogy of Fallot. Heart disease unsuspected clinically, without hemodynamic repercussions, and diagnosed by echocardiogram included CIA, EPV, PDA, VSD and AS. In an infant were visualized tumors in the RV and a pre-school showed dilatation of the left coronary artery, both with normal clinical evaluation. In 5.7% of patients the murmur was not considered innocent, but Doppler echocardiography was normal. The main physiological findings on echocardiography, in descending order, were: tricuspid, pulmonary and mitral valves regurgitation. Among those tested, 58.5% were normal.
Conclusion: High rate of normal dopplerechocardiographic exams indicates the need to enhance the clinical examination and initial cardiac propaedeutic. The Doppler echocardiography proved important in the definition of suspected or not cardiac abnormalities.
THE TRANSTHORACIC ECHOCARDIOGRAM (TTE) DEFINING DIAGNOSIS AND SAVING LIVES IN DISEASES OF THE AORTIC, EVEN IN DISTANT CITIES. REPORT OF TWO CASES IN THE ITAPEVA-SP- BRAZIL
V. Glauser1,2; V C. Veiga1; A C S. Teixeira1; H. Abensur1; J M. Souza1; D. Cacciacarro Filho2
1Hospital Beneficência Portuguesa of São Paulo, São Paulo, Brazil, 2Santa Casa de Misericórdia of Itapeva, Itapeva- SP, Brazil
Introduction: The dissections of thoracic aortic at high mortality. The tests of choice for study of the thoracic aortic are: transesophagic echocardiography (TEE), computed tomography and magnetic resonance angiography. But in cities far from major medical centers, there is not always the availability of these resources, thus transthoracic echocardiography (TTE) is the only alternative available. We report two cases of aortic disease diagnosed by TTE in the Itapeva – SP – Brazil in 2009.
Case 1: BG, 26 years old, complaining of atypical chest pain, where the TTE was employed by the cardiologist who entered telephone contact with the echocardiography service of the Hospital Beneficência Portuguesa (HBP), reporting ‘supposed image of the membrane above the aortic valve’ and afterdescribing the biotype of the patient (tall and hands arachnodactyly), made up (by call) the possibility of treating Marphan Syndrome, with possible dissection of the ascending aortic. The patient was referred to the HBP, and the TEE was in intimal flap in the ascending aortic, confirmed the diagnosis. Corrective surgery was performed successfully.
Case 2: MSD, 45 years old, complained of chest pain. To TTE: intimal flap that started after the aortic arch, with the image of pericardial effusion and hemothorax, formulated the hypothesis of dissection with aortic rupture, was transferred to HBP, performed TEE showed that the breaking point with effused of blood pleural cavity and pericardial. In this case, was decided to endovascular correction with an endoprosthesis implant. The performed was successfully.
Comment: The ETT its can be an alternative, can be use in cities distant medical centers, screening serious cases of aortic disease center for medical reference, saving lives.