Adriana Cordovil

Exeqüibilidade, segurança e acurácia do ecocardiograma sob estresse com dobutamina/ atropina para detecção de doença arterial coronariana em candidatos a transplante renal

OBJECTIVE To evaluate the feasibility, safety and accuracy of dobutamine/atropine stress echocardiography (DASE) for the detection of coronary artery disease (CAD) in renal transplant candidates. METHODS Patients candidates to renal transplant were submitted consecutively to DASE and coronary angiography. The adopted angiographic criteria for CAD were an obstructive lesion of > or = 50% and > or = 70%. RESULTS 148 patients underwent the DASE and the coronary angiography. Mean age was 52 +/- 9 years, 69% of the patients were males; 27% had diabetic nephropathy and 73% had LVH; 63% were asymptomatic; 36% and 22% presented coronary obstructions > or = 50% and 70%, respectively. The DASE performance was 91% and major complication rate was 2.7%. The sensibility, specificity and accuracy for the diagnosis of coronary obstruction > 50% were 53% (CI:45-61), 87% (CI:81-93), and 75% (CI:63-83) respectively. For coronary obstruction > or = 70% these values were, respectively, 71% (CI:64-92), 85% (CI:79-91) and 81% (CI:75-87). The sensibility to detect univessel and multivessel disease was 41% (CI:19-63) and 78% (CI:64-92), respectively. CONCLUSION The DASE was practical and safe; however, it presented a poor result for the detection of CAD regarding obstructions > or = 50%. It can be a useful screening for the detection of CAD in candidates with obstructions > or = 70% and multivessel disease.

Analysis of left ventricular regional dyssynchrony: comparison between real time 3D echocardiography and tissue Doppler imaging.

Background: There is a paucity of information concerning left ventricular (LV) dyssynchrony assessment by real time three‐dimensional (3D) echocardiography (RT3DE) versus tissue Doppler imaging (TDI). Aims: To compare RT3DE and TDI LV dyssynchrony assessment. Methods: A prospective study of 92 individuals (56 men, age 47 ± 10 years), 32 with dilated cardiomyopathy (CMP), and 60 healthy individuals. By RT3DE, we measured the LV% dyssynchrony index (DI) of 6, 12, and 16 segments (SDI). By pulsed‐wave TDI, we measured the QS electromechanical interval in the basal segments of the mitral valve annulus of the septum, the lateral, anterior and inferior walls, and the TDI% DI. Results: In the normal group, the 3D DI was 1.1 ± 0.8%, 1.4 ± 1.3%, 1.8 ± 1.7%, for 6 segments, 12 segments, and SDI, respectively. The correlation coefficient (Pearsons r) for the TDI DI and SDI was r = 0.2381 (P = 0.0470). In CMP group, the 3D DI was 4.6 ± 5.4%, 7.9 ± 7.1%, 11.1 ± 7.1%, for 6 segments, 12 segments, and SDI, respectively. The correlation coefficient for TDI DI and SDI was r = 0.7838 (P < 0.0001). Conclusions: We observed a good correlation between RT3DE and tissue Doppler LV dyssynchrony assessment in patients with advanced heart failure. (ECHOCARDIOGRAPHY, Volume 26, July 2009)

Right Ventricular Abnormalities in Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy, described as transient regional contractile abnormalities limited to the apical and mid‐segments of the left ventricle (LV), has also been reported to involve basal and/or mid LV segments (inverted Takotsubo); fewer reports, however, have addressed right ventricular (RV) dysfunction.

3D Echo pilot study of geometric Left Ventricular changes after acute myocardial infarction

Background Left ventricular remodeling (LVR) after AMI characterizes a factor of poor prognosis. There is little information in the literature on the LVR analyzed with three-dimensional echocardiography (3D ECHO). Objective To analyze, with 3D ECHO, the geometric and volumetric modifications of the left ventricle (VE) six months after AMI in patients subjected to percutaneous primary treatment. Methods Prospective study with 3D ECHO of 21 subjects (16 men, 56 ± 12 years-old), affected by AMI with ST segment elevation. The morphological and functional analysis (LV) with 3D ECHO (volumes, LVEF, 3D sphericity index) was carried out up to seven days and six months after the AMI. The LVR was considered for increase > 15% of the end diastolic volume of the LV (LVEDV) six months after the AMI, compared to the LVEDV up to seven days from the event. Results Eight (38%) patients have presented LVR. Echocardiographic measurements (n = 21 patients): I- up to seven days after the AMI: 1- LVEDV: 92.3 ± 22.3 mL; 2- LVEF: 0.51 ± 0.01; 3- sphericity index: 0.38 ± 0.05; II- after six months: 1- LVEDV: 107.3 ± 26.8 mL; 2- LVEF: 0.59 ± 0.01; 3- sphericity index: 0.31 ± 0.05. Correlation coefficient (r) between the sphericity index up to seven days after the AMI and the LVEDV at six months (n = 8) after the AMI: r: 0.74, p = 0.0007; (r) between the sphericity index six months after the AMI and the LVEDV at six months after the AMI: r: 0.85, p < 0.0001. Conclusion In this series, LVR has been observed in 38% of the patients six months after the AMI. The three-dimensional sphericity index has been associated to the occurrence of LVR.

Safety of transesophageal echocardiography in adults: study in a multidisciplinary hospital

BACKGROUND: TEE is a semi-invasive tool broadly used and its utilization associated to sedatives drugs might to affect the procedure safety. OBJECTIVE: to analyze aspects of TEE safety associated to the use of Midazolan (MZ) and Flumazenil (FL) and the influence of the clinical variables on the event rate. METHOD: prospective study with 137 patients that underwent TEE with MZ associated to moderate sedation. We analyzed the following events: complications related with the topical anesthesia, with MZ use and with the procedure. Uni- and multivariate analyses were used to test the influence of the clinical variables: age, sex, stroke, myocardiopathy (MP), duration of the test, mitral regurgitation (MR) and the MZ dose. RESULTS: All patients (65±16 yrs; 58% males) finished the examination. The mean doses of MZ and FL were 4.3±1.9 mg and 0.28±0.2 mg, respectively. The duration of the examination and the mean ejection fraction (EF) were 16.4±6.1 minutes and 60±9%, respectively. Mild hypoxia (SO2 5mg) were associated with events (p<0.001). The EF was 40%, in the group with MP and 44% in the group with severe MR and it can be a factor associated with clinical events in the last group. CONCLUSION: TEE with sedation presents a low rate of events. There were no severe events and there was no need to interrupt the examinations.BACKGROUND TEE is a semi-invasive tool broadly used and its utilization associated to sedatives drugs might to affect the procedure safety. OBJECTIVE to analyze aspects of TEE safety associated to the use of Midazolan (MZ) and Flumazenil (FL) and the influence of the clinical variables on the event rate. METHOD prospective study with 137 patients that underwent TEE with MZ associated to moderate sedation. We analyzed the following events: complications related with the topical anesthesia, with MZ use and with the procedure. Uni- and multivariate analyses were used to test the influence of the clinical variables: age, sex, stroke, myocardiopathy (MP), duration of the test, mitral regurgitation (MR) and the MZ dose. RESULTS All patients (65+/-16 yrs; 58% males) finished the examination. The mean doses of MZ and FL were 4.3+/-1.9 mg and 0.28+/-0.2 mg, respectively. The duration of the examination and the mean ejection fraction (EF) were 16.4+/-6.1 minutes and 60+/-9%, respectively. Mild hypoxia (SO2<90%) was the most common event (11 patients); 3 patients (2%) presented transient hypoxia due to upper airway obstruction by probe introduction and 8 (5.8%) due to hypoxia caused by MZ use. Transient hypotension (SAP<90mmHg) occurred in 1 patient (0.7%). The multivariate analysis showed that severe MR, MP (EF<45%) and high doses of MZ (>5mg) were associated with events (p<0.001). The EF was 40%, in the group with MP and 44% in the group with severe MR and it can be a factor associated with clinical events in the last group. CONCLUSION TEE with sedation presents a low rate of events. There were no severe events and there was no need to interrupt the examinations.

A elevação da pressão arterial sistólica durante o teste ergométrico após transplante cardíaco: correlação com o quadro clínico e a função ventricular avaliada pela ecocardiografia sob estresse com dobutamina

OBJECTIVE: Patients who underwent heart transplantation (HTX) experience a reduction in the elevation that is usual in systolic blood pressure during exercise testing. Of unknown origin, this phenomenon varies in frequency and intensity. The aim of this study was to analyze the relationship between systolic blood pressure increase (delta SBP) and clinical aspects, as well as variables measured during exercise testing (ET) and dobutamine stress echocardiography (DSE) in patients in the late post-transplantation course. METHODS: Forty-five men, mean age 49.04 ± 10.19, underwent clinical assessment, ET and DSE 40.91 ± 27.46 months after heart transplantation. Left ventricular wall motion score index and ejection fraction were assessed. Delta SBP < 35mmHg during ET was considered abnormal (SBC,1995). RESULTS: No significant correlation was found between delta SBP and post-transplantation time, graft ischemic time, history of rejection, diltiazem dosage, oxygen uptake, ejection fraction, and wall motion score index (WMSI). Delta SBP was normal in 17 patients (Group I) and abnormal in 28 (Group II). Patients of both groups did not differ significantly in regard to clinical features and ET and DSE results. CONCLUSION: Unlike other populations, no correlation was found between delta SBP during exercise testing and clinical condition or left ventricular function in heart transplant patients. Pathophysiological factors associated with delta SBP reduction during exercise testing remain unknown.

Role of Dobutamine-Atropine Stress Echocardiography in Prognostic Evaluation of 300 Women

Background: Dobutamine‐atropine stress echocardiography (DASE) is a safe and accurate method to diagnose coronary artery disease (CAD), and can identify individuals at high risk for cardiac events such as myocardial infarction and cardiac‐related death. The literature is limited regarding the prognostic value of DASE in women. Objective: The objective was to determine the prognostic value of DASE in 300 women with known or suspected CAD. Results: The 300 women underwent DASE and were followed up for 65 months (mean: 27 months). Ninety‐five women had positive tests and 205 had negative tests. We demonstrated that women with negative tests had a 94% hard‐event‐free survival rate at follow‐up (myocardial infarction and death), and in those with positive tests the event‐free survival rate was 27% (P = 0.0003). The difference between women with positive and negative tests was also significant when minor events and total events were considered. Women with positive tests had 16.7 times more chance of having events than women with negative tests. Furthermore, women with positive tests but without cardiac events at follow‐up (mean of peak WMSI – rest WMSI = 0.24 ± 0.16) had less ischemic myocardium than women with positive tests and cardiac events at follow‐up (mean of peak WMSI – rest WMSI = 0.34 ± 0.26)(P < 0.04). Conclusion: Dobutamine‐atropine stress echocardiography has good prognostic value for cardiac events in women. Women with negative tests have low probability for follow‐up infarction or death. Women with positive tests and higher severity of induced ischemia have the highest incidence of cardiac events. (ECHOCARDIOGRAPHY, Volume 21, February 2004)

Calcificação caseosa do anel mitral: relato de caso

ABSTRACT We present a rare case of probable caseous calcification of the mitral. This pathology is more frequently detected in asymptomatic women older than 70 years. To recognize this image is important because echocardiography is the easiest way to elucidate this diagnosis, and more importantly because this structure could be easily misdiagnosed as tumors, thrombus and vegetations, which are much more common. Normally, it has a benign evolution, and the correct diagnosis is crucial to avoid unnecessary surgical interventions.

Relação entre a análise bioquímica e ecocardiográfica tridimensional e bidimensional em pacientes com infarto do miocárdio com supradesnivelamento do segmento ST tratados por via percutânea

Objetivo: O prognostico dos pacientes portadores de infarto agudo do miocardico depende de multiplos aspectos que espelhem o grau de agressao ao miocardio (como marcadores enzimaticos de necrose miocardica), assim como dos mecanismos de adaptacao ao evento agudo. O objetivo do estudo foi verificar a associacao entre os achados bioquimicos e ecocardiograficos derivados da analise ecocardiografica transtoracica tridimensional (ECO 3D) com a fracao de ejecao do ventriculo esquerdo (ECO 2D) em pacientes acometidos por infarto agudo do miocardio com supradesnivelamento do segmento ST, que tenham sido submetidos a tratamento primario percutâneo. Metodos: Estudo prospectivo com Eco 3D e 2D de 23 individuos (17 homens, 57 ± 13 anos), acometidos por infarto agudo do miocardio com elevacao do segmento ST, primariamente tratados com implante de stent coronariano. Foi feita a dosagem serica de creatina cinase fracao MB, Troponina I, Mioglobina e peptideo atrial natriuretico e comparada com os parâmetros ecocardiograficos (volumes, fracao de ejecao do ventriculo esquerdo e indice de dissincronia ventricular). A analise estatistica foi feita com a determinacao do coeficiente de correlacao (Pearson), IC = 95%, p < 0,05, com teste de regressao linear e teste de Bland & Altman. Resultados: Coeficiente de correlacao (r) entre fracao de ejecao do ventriculo esquerdo 3D: 1- peptideo atrial natriuretico: r: - 0,7427, p < 0,0001; 2- creatina cinase fracao MB: r: -0,660, p = 0,001. fracao de ejecao do ventriculo esquerdo 2D (r) : 1- peptideo atrial natriuretico: r: - 0,5478, p = 0,001; 2- creatina cinase fracao MB: r: -0,4800, p < 0,0277. As demais associacoes entre os parâmetros ecocardiograficos e as dosagens sericas nao foram significativas. Conclusoes: Nesta serie, foi observada correlacao melhor entre a dosagem serica de peptideo atrial natriuretico, de creatina cinase fracao MB e a fracao de ejecao do ventriculo esquerdo aferida por Eco 3D do que a correlacao com a fracao de ejecao do ventriculo esquerdo aferida por Eco 2D.

Chronic left ventricular pseudoaneurism of undetermined etiology

Pseudoaneurysms occur as a rare complication of the myocardial infarction, of which hemorrhagic process is contained by adherences of the visceral or parietal pericardium - or of both - preventing the development of cardiac tamponade. We report the case of a 55-year-old patient, with a chronic left ventricular pseudoaneurysm of undetermined etiology, who was submitted to a conservative treatment.Os pseudoaneurismas ocorrem como rara complicacao do infarto do miocardio, apos rotura miocardica, cujo processo hemorragico e contido por aderencias do pericardio visceral, parietal - ou de ambos -, impedindo o desenvolvimento de tamponamento cardiaco. Relatamos o caso de um paciente de 55 anos, com pseudoaneurisma cronico do ventriculo esquerdo de etiologia indefinida, de longa evolucao, que foi submetido a tratamento conservador.