Carlos Cotrim

Evaluation of left ventricular outflow tract gradient during treadmill exercise and in recovery period in orthostatic position, in patients with hypertrophic cardiomyopathy

Background-Left ventricular outflow tract obstruction is an independent predictor of adverse outcome in hypertrophic cardiomyopathy (HCM). The classical quantification of intraventricular obstruction is performed in resting conditions in supine position, but this assessment does not reflect what happens in HCM patients (pts) in their daily activities, neither during effort nor during orthostatic recovery.Aim-To assess intraventricular gradients with echocardiography during treadmill exercise and in the recovery period in upright position, in HCM pts.Methods-We studied 17 HCM pts (9 males, mean age 53 ± 16 years, 11 with obstructive HCM). Each pt had 2 echocardiographic evaluations at rest (left lateral decubitus (LLD) and orthostatic position). The pts then underwent a treadmill exercise test and intraventricular gradients were measured at peak exercise and during recovery in orthostatic position.Results-3 pts with non-obstructive HCM at rest developed intraventricular gradients during exercise. 1 pt developed this gradient only during orthostatic recovery. The mean intraventricular gradient in LLD was 49 ± 24 mmHg; in orthostatic position was 62 ± 29 mmHg (p < 0.001 versus in LLD); at peak exercise was 83 ± 35 mmHg (p < 0.001 versus supine rest); during recovery it was 96 ± 35 mmHg (p < 0.001 versus peak exercise)Conclusion-In HCM pts the intraventricular gradient increases in orthostatic position, increases significantly during treadmill exercise and continues increasing in the recovery period in orthostatic position. This type of evaluation can help us to better understand the physiopathology, the symptoms and the efficacy of different therapeutic modalities in this disease and should be routinely used in the assessment of HCM pts.

Native valve endocarditis due to Pichia ohmeri

Abstract.Candida species can cause clinical manifestations in various organs of the cardiovascular system, i.e., the pericardium, myocardium, and endocardium, with endocarditis being the best-known clinical entity. Endocarditis is seen primarily in intravenous drug users and in individuals with damaged native valves, especially in congenital heart disease or rheumatic valvular diseases, and in prosthetic heart valves. The authors present a case of Pichia ohmeri endocarditis in an intravenous drug user, with an unusual presentation form. This is a case of a 42-year-old man, an intravenous heroin user, who was admitted to our Vascular Surgery Department because of fever and acute serious ischemia of the left inferior limb. He presented with fever (39°C), a pale and cold left limb, absence of the left popliteal pulse, and a pansystolic murmur at the cardiac apex. The transthoracic echocardiogram showed a large vegetation on the anterior leaflet of the mitral valve and severe mitral regurgitation with good left ventricular systolic function. Empirical antibiotic therapy was started. Six days after admission, embolectomy was performed with partial clinical recovery. Three blood cultures and the embolus showed a teleomorphic form of Candida guilliermondii – Pichia ohmeri. Therapy with intravenous liposomal amphotericin B, fluocitosin, imipenem, and aztreonam was started. Two weeks later, his clinical condition deteriorated with acute heart failure refractory to medical therapy, mandating mechanical ventilation and high-dose vasopressor and inotropic amine support. He underwent urgent mitral valve replacement with a biologic prosthetic valve. Rapid stabilization of the cardiac status occurred, but ischemic limb lesions required further vascular interventions.

Stress-Induced Intraventricular Gradients in Symptomatic Athletes During Upright Exercise Continuous Wave Doppler Echocardiography

The development of significant intraventricular gradients (IVGs) during exercise has been described anecdotally in athletes. However, the prevalence and clinical effect of this observation are unclear. In addition, the most appropriate exercise technique (upright vs semisupine) for eliciting IVGs also remains unknown. The present study had 2 main aims: (1) to identify the prevalence of exercise IVGs in athletes whose preparticipation cardiovascular screening result for sports practice, according to the European Society of Cardiology guidelines, was positive; and (2) to evaluate the influence of performing exercise echocardiography, as described, on the detection of IVGs. We enrolled 139 consecutive athletes (135 amateurs and 4 professionals, mean age 22 ± 9.9 years; 30 women) who underwent treadmill exercise echocardiography. In each athlete, the IVG was evaluated by continuous wave Doppler during 5 conditions: left lateral decubitus at rest; upright at rest; upright at peak treadmill exercise; upright in the recovery phase; and left lateral decubitus in the recovery phase. All patients had normokinetic regional wall motion at rest and during exercise. According to the detection of IVG during treadmill echocardiography (IVG was considered significant if >30 mm Hg at rest or >50 mm Hg during/after exercise), 2 groups were identified: a group (n = 52), with significant IVG and a group (n = 87) without significant IVG. The IVG was greater in the upright position, both at rest (only 2 athletes from group with IVG) and after exercise (52 athletes, all from group with IVG). The IVG was lower in the recovery phase in the left lateral decubitus position (55 ± 15 mm Hg in 30 athletes, all from group with IVG) than in the upright position in the recovery phase (95 ± 35 mm Hg in 52 athletes, all from group with IVG) and at peak exercise (66 ± 24 mm Hg in 41 athletes from group with IVG). We observed systolic anterior movement of the mitral valve in 33 of the 52 athletes in the group with IVG and in none of the athletes in the group without IVG. In conclusion, in athletes, exercise-induced symptoms and/or ischemia-like electrocardiographic signs are often associated with significant IVG, developing in the absence of wall motion abnormalities. IVG was more evident during post-treadmill upright imaging.

Echocardiographic assessment of right ventricular contractile reserve in patients with pulmonary hypertension

INTRODUCTION AND AIM Right ventricular function is a major determinant of prognosis in pulmonary hypertension. The aim of this study was to assess and compare right ventricular contractile reserve in healthy subjects (controls) and in subjects with pulmonary hypertension (cases). METHODS In this prospective study of seven cases and seven controls undergoing treadmill stress echocardiography, right ventricular S-wave velocity, tricuspid annular plane systolic excursion (TAPSE), right ventricular fractional area change (RVFAC) and stroke volume index were assessed at rest and with exercise. The increase in each parameter between rest and exercise for cases and controls was analyzed and the magnitude of change in each parameter with exercise between cases and controls was compared. RESULTS A significant increase in S-wave velocity was observed in cases (rest: 9.4 ± 3.1; exercise: 13.7 ± 4.8 cm/s [p < 0.05]). In controls there was a statistically significant increase in S-wave velocity (12.9 ± 2.3 to 23.0 ± 7.2 cm/s [p < 0.005]), TAPSE (25.7 ± 2.4 to 31.0 ± 3.5 mm [p < 0.05]) and RVFAC (53.8 ± 14.7% to 64.4 ± 9.9% [p < 0.005]). The magnitude of change in S-wave velocity (cases: 4.3 ± 3.3; controls: 10.1 ± 5.5 cm/s [p < 0.05]), TAPSE (cases: 0.6 ± 2.5; controls: 5.3 ± 3.8 mm [p < 0.05]) and RVFAC (cases: -0.4 ± 11.8; controls: 10.6 ± 5.9% [p < 0.05]) was significantly different between cases and controls. CONCLUSIONS S-wave velocity, TAPSE and RVFAC increased significantly with exercise in controls. S-wave velocity was the only parameter that showed a significant increase in cases, although the magnitude of this increase was significantly less than in controls.

The usefulness of contrast during exercise echocardiography for the assessment of systolic pulmonary pressure

BackgroundThe systolic pulmonary artery pressure (PAPs) can be accurately estimated, non-invasively, using continuous-wave Doppler (CWD) ultrasound measurement of the peak velocity of a tricuspid regurgitant (TR) jet.However, it is often difficult to obtain adequate tricuspid regurgitation signals for measurement of PAPs, what could lead to its underestimation. Therefore, utilization of air-blood-saline contrast has been implemented for the improvement of Doppler signal in several clinical contexts.It is now recommended in the evaluation of patients with pulmonary hypertension. Physical activity is severely restricted in patients with PAH, being exertional dypnea the most typical symptom. Exercise stress echo-Doppler imaging allows assessment of the response to exercise. It is an excellent screening test for patients with suspected PAH. Our purpose was to evaluate the value and accuracy of agitated saline with blood contrast echocardiography, in the improvement of the Doppler signal, to quantify PAPs during treadmill exercise-echocardiography.PurposeTo evaluate the value of contrast echocardiography, using agitated saline with blood, in the improvement of the Doppler signal used to quantify the pulmonary artery systolic pressure during exercise.MethodsFrom a total of 41 patients (pts), we studied 38 pts (93%), 35 women, aged 54 ± 12 years-old. 27 with the diagnosis of systemic sclerosis, 10 with history of pulmonary embolism and one patient with a suspected idiopathic PAH, who were referred to the Unity of Heart Failure and Pulmonary Hypertension for screening of PAH. According to the Unity protocol, a transthoracic echocardiogram was made, in left decubitus (LD), with evaluation of right ventricle-right atria gradient (RV/RAg). A peripheral venous access was obtained, with a 3-way stopcock and the patients were placed in orthostatism (O), with a new evaluation of RV/RAg. Exercise echocardiography (EE) was begun, with evaluation of RV/RAg at peak exercise (P) and afterwards agitated saline (8 cc with 1 cc of air and 1 cc of blood) was injected, followed by a new evaluation of RV/RAg (PC) and then the interruption of the EE. Pulmonary Hypertension was diagnosed when RV/RAg at the end of the exercise was superior to 40 mmHg.ResultsThe quality of Doppler signal was deteriorated in 5 pts, maintained in 6 pts and improved in 26 pts, with the use of contrast. In one patient, an interventricular septal defect was diagnosed. In 6 pts, a Doppler signal was only obtained with the use of contrast. In 15 pts, a RV/RAg superior to 40 mmHg was only obtained with the use of contrast. Of these, 9 have already been submitted to right heart cathetherism, that confirmed the diagnosis of pulmonary hypertension in 5 of them (56%). RV/RAg (P) was 44 ± 11 mmHg and RV/RAg (PC) was 54 ± 11 mmHg, p < 0,001.Conclusion1. The method is applicable in a large number of patients. 2. RV/RA gradients obtained at peak exercise are higher with the use of contrast, and the clinical meaning of this difference should be evaluated in a larger number of pts submitted to right heart cathetherism. The high number of false positives should lead to a higher diagnostic threshold. 3. This method seems to have relevant clinical value in the diagnosis of pulmonary arterial hypertension.

Exercise-induced intra-ventricular gradients as a frequent potential cause of myocardial ischemia in cardiac syndrome X patients

BackgroundThe development of intra-ventricular gradients (IVG) during dobutamine or exercise stress is not infrequent, and can be associated to symptoms during stress.The purpose of this study was to assess the occurrence of IVG during exercise stress echocardiography in cardiac syndrome X patients.MethodsWe prospectively evaluated 91 patients (pts) mean aged 51 ± 12 years (age ranged 20 to 75 years old), 44 of whom were women. All pts had angina, positive exercise ECG treadmill testing, normal rest echocardiogram and no coronary artery disease on coronary angiogram (cardiac X syndrome). After complete Doppler echocardiographic evaluation with determination of left ventricular outflow tract index (LVOTi), relative left ventricular wall thickness (RLVWT) and left ventricular end-diastolic volume index (LVDVi), all patients underwent stress echocardiography with two-dimensional and Doppler echographic evaluation during and after treadmill exercise.ResultsFor analysis purpose patients were divided in 2 groups, according to the development of IVG. Doppler evidence of IVG was found in 33 (36%) of the patients (Group A), with mean age 47 ± 14 years old (age ranged 20 to 72 years) and with a mean end-systolic peak gradient of 86 ± 34 mmHg (ranging from 30 to 165 mmHg). The IVG development was accompanied by SAM of the mitral valve in 23 pts. Three of these pts experienced symptomatic hypotension. Ten were women (30% pts). 58 pts in group B, 34 of whom were women (59%) (p = 0,01 vs group A), mean aged 53,5 ± 10,9 years old (age ranged 34 to 75 years) (p = 0,03 vs group A), did not develop IVG. LVOTi was 10,29 ± 0,9 mm/m2 in group A and 11,4 ± 1 mm/m2 in group B (p < 0,000); RLVWT was 0,36 ± 0,068 in group A and 0,33 ± 0,046 in group B (p < 0,01); LVDVi was 44,8 ± 10 ml/m2 in group A and 56 ± 11,6 ml/m2 in group B (p = 0,000).Conclusion1. A significant number of patients with cardiac X syndrome developed IVG during upright exercise in treadmill. These pts (group A) are mainly males and younger than those who did not develop IVG.2. The development of IVG and mitral valve SAM on exertion seems to be associated with ST segment downsloping during stress testing in patients without epicardial coronary disease.3. The development of IVG and mitral valve SAM seems to be associated with lower LVOTi, lower LVDVi and higher RLVWT.

Need for a standardized protocol for stress echocardiography in provoking subaortic and valvular gradient in various cardiac conditions

Abstract(Semi) supine exercise testing has an established role in the evaluation of patients with valvular heart disease and can help clinical decision making. Stress echocardiography has the advantages of its wide availability, low cost, and versatility for the assessment of disease severity. However, exercise-induced changes in valve hemodynamics, left ventricular outflow obstruction and pulmonary artery pressure depended on load variation. Changing position from supine to upright rapidly decreases load conditions for the ventricles. Therefore several cardiac centers have proposed exercise stress echocardiography in the upright position with gradient monitoring sometimes also in post-exercise recovery. Doppler measurement of subaortic gradient has been a very helpful and informative examination in several heart diseases (especially in hypertrophic cardiomyopathy, valve heart diseases, prosthesis dysfunction).

Prognostic role of stress echocardiography in hypertrophic cardiomyopathy: The International Stress Echo Registry.

BACKGROUND Stress echo (SE) may have a role in the outcome in patients with hypertrophic cardiomyopathy (HCM). OBJECTIVES The aim was to assess the prognostic value of SE in a retrospective multicenter study in HCM. METHODS We enrolled 706 HCM patients. The employed stress was exercise (n=608) and/or vasodilator (n=146, dipyridamole in 98 and adenosine in 48). We defined SE positivity according to clinical/hemodynamic criteria including: symptoms (all stress modalities), exercise-induced hypotension (failure to increase or fall >20mmHg, exercise) and exercise-induced left ventricular outflow tract obstruction (left ventricular outflow tract obstruction >50mmHg); and ischemic criteria, such as new wall motion abnormalities (new wall motion abnormality) and/or reduction of coronary flow reserve velocity (CFVR≤2.0) on left anterior descending coronary artery with vasodilator stress assessed in 116 patients. All patients completed the clinical follow-up. RESULTS Positive SE showed more frequently CFVR reduction, exercise-induced hypotension, left ventricular outflow tract obstruction, and symptoms (38, 23, 20 and 15% respectively), but new wall motion abnormality only in 6%. During a median follow-up of 49months 180 events were observed, including 40 deaths. Clinical/hemodynamic criteria did not predict outcome (X2 0.599, p=0.598), whereas ischemia-related SE criteria (X2: 111.120, p<0.0001) was significantly related to outcome. Similarly, mortality was predicted with SE ischemic-criteria (X2 16.645, p<0.0001). CONCLUSIONS SE has an important prognostic significance in HCM patients, with ischemia-related end-points showing greater predictive accuracy than hemodynamic endpoints. New wall motion abnormalities and impairment of CFVR should be specifically included in SE protocols for HCM.

Controlled pericardiocentesis in patients with cardiac tamponade complicating aortic dissection: Experience of a centre without cardiothoracic surgery

Background: Cardiac tamponade has been reported in 18.7% of patients with acute type A aortic dissection and its presence is associated with worse outcomes. Emergency aortic repair together with intra-operative pericardial drainage is the recommended treatment approach. However, controversy surrounds how to manage patients with haemopericardium and cardiac tamponade who cannot survive until surgery. Purpose: To describe a case series of patients with critical cardiac tamponade complicating aortic dissection admitted to a hospital without cardiothoracic surgery, and in whom preoperative controlled pericardial drainage was performed. Methods and results: Single centre retrospective study: during a nine-year period, 21 patients with Stanford type A aortic dissection were admitted at our centre; six of them (28.6%) presented clinical and echocardiographic signs of cardiac tamponade (four males; mean age 58±17 years). In this subgroup, controlled pericardiocentesis was safely performed with no major immediate complications and it was effective in five patients, improving haemodynamic instability and allowing transfer to the operating room. Conclusions: Preoperative controlled pericardiocentesis can be lifesaving when managing patients with critical cardiac tamponade (pulseless electrical activity or refractory hypotension) complicating acute type A aortic dissection, namely when cardiac surgery is not immediately available.

Efficacy of beta-blocker therapy in symptomatic athletes with exercise-induced intra-ventricular gradients

BackgroundUpright exercise stress echocardiography (SE) induces significant intraventricular gradient (IVG) and systolic anterior motion (SAM) in a large proportion of symptomatic athletes, who may therefore benefit from a negative inotropic therapy.The purpose of the present study was to assess the effect of chronic oral β blocker therapy on the occurrence of exercise-induced IVG and mitral valve SAM, in symptomatic athletes.MethodsWe enrolled 35 symptomatic athletes (age = 23 ± 11 years) with IVG (>30 mmHg) during SE off therapy. All repeated SE on chronic oral beta-blocker therapy (atenolol up to 50 mg, bisoprolol up to 10 mg, or metoprolol up to 100 mg daily according to physician-driven choice).ResultsOn therapy, there was during SE a reduction in IVG (35 off vs 17 on beta blocker, p < 0.01), decrease of IVG (102 ± 34 mmHg off vs 69 ± 24 mmHg on beta blocker, p < 0.01), peak heart rate (178 ± 15 bpm off vs 157 ± 9 bpm on beta blocker), SAM (24 off vs 9 on beta blocker, p < 0.001), symptoms during SE (17 off vs 2 on beta blocker p < 0.001), ST segment depression (13 off vs 2 on beta blocker, p < 0.001).ConclusionsIn athletes with positive screening on medical evaluation for sports practice and IVG on exertion, treatment with oral beta blockers improved symptoms in the large majority of patients. Symptomatic benefit was mirrored by objective evidence of improvement of echocardiographic signs of obstruction (IVG and SAM) and reduction of ischemia-like electrocardiographic changes.