Carlos Eduardo Suaide Silva

One-year mortality prognosis in heart failure: a neural network approach based on echocardiographic data.

OBJECTIVES This study sought to assess the usefulness and accuracy of artificial neural networks in the prognosis of 1-year mortality in patients with heart failure. BACKGROUND Artificial neural networks is a computational technique used to represent and process information by means of networks of interconnected processing elements, similar to neurons. They have found applications in medical decision support systems, particularly in prognosis. METHODS Clinical and Doppler-derived echocardiographic data from 95 consecutive patients with diffuse impairment of myocardial contractility were studied. After 1 year, data regarding survival or death were obtained and produced the prognostic variable. The data base was divided randomly into a training data set (47 cases, 8 deaths) and a testing data set (48 cases, 7 deaths). Results of artificial neural network classification were compared with those from linear discriminant analysis, clinical judgment and conventional heuristically based programs. RESULTS The study group included 57 male (47 survivors) and 38 female patients (33 survivors). Linear discriminant analysis was not efficient for separating survivors from nonsurvivors because the accuracy at the ideal cutoff value was only 67.4%, with a sensitivity of 67.5%, positive predictive value of 27.8% and negative predictive value of 91.5%. In contrast, all artificial neural networks were able to predict outcome with an accuracy of 90%, specificity of 93% and sensitivity of 71.4%, for the best artificial neural network. Both clinical judgment and automatic heuristic methods were also inferior in performance. CONCLUSIONS The artificial neural network method has proved to be reliable for implementing quantitative prognosis of mortality in patients with heart failure. Additional studies with larger numbers of patients are required to better assess the usefulness of artificial neural networks.

Prognosis in Dilated Myocardial Disease: Influence of Diastolic Dysfunction and Anatomical Changes

A prospective study has been conducted, in patients with dilated myocardial disease, in order to examine the relation between echocardiographic variables and mortality rate. Patients were divided into two major groups: (1) group A—designed to evaluate the influence of the ventricular filling pattern in the mortality rate. It included 95 patients, followed‐up for a period ranging from 1–23 months (mean = 12.6 months), divided into three subgroups: AF (atrial filling predominant pattern, n = 22); N (normal or “normalized” filling pattern, n = 40), and RF (rapid filling predominant pattern, n = 33); and (2) group B—designed to correlate echocardiographic variables to the 1‐year mortality rate. It included 52 patients divided into two subgroups: survivors (n = 40) and nonsurvivors (n = 12). In group A, a progressive decrease in survival rate was noted on comparing subgroups N to AF to RF. At the 14 months follow‐up a survival rate of 89% was noted in N, 75% in AF, and 50% in RF. Univariate analysis in group B showed high 1‐year mortality rate associated with mitral flow deceleration time ≤ 140 msec (50%, P = 0.003), left ventricular diastolic diameter/thickness ratio ≥ 3.4 (35.3%, P = 0.002), and left atrial index ≥ 25 mm/m2 (40.7%, P = 0.001). The highest mortality rate (61.5%, P = 0.0004) was observed in patients with increased left atrial index and decreased deceleration time. Thus, diastolic dysfunction and anatomical changes, as evaluated by echocardiography, are confident parameters to estimate the prognosis in dilated myocardial disease.

Avaliação ecocardiográfica da terapia de ressincronização cardíaca

. Cardiac resynchronization therapy (CRT) was introduced in the beginning of the 1990’s and rapidly developed until its approval in 2001 by the FDA (Food and Drugs Administration) 4 . In the American Heart Association guidelines, CRT has been considered to be IIA evidence level 5 . Those guidelines were based on 2 large trials: the MUSTIC 6 and the MIRACLE 7 . In both, the inclusion criteria were similar: a) significant heart failure despite appropriate therapy; b) low ejection fraction; and c) broad QRS with left bundle-branch block pattern (duration>120 ms). Both studies have confirmed that CRT significantly improves symptoms, tolerance to exercise, and quality of life. Nevertheless, 20% to 30% of the patients do not improve with CRT 8 , emphasizing the need for new criteria of patients’ selection.

Study of the Myocardial Contraction and Relaxation Velocities through Doppler Tissue Imaging Echocardiography: A New Alternative in the Assessment of the Segmental Ventricular Function

OBJECTIVE Doppler tissue imaging (DTI) enables the study of the velocity of contraction and relaxation of myocardial segments. We established standards for the peak velocity of the different myocardial segments of the left ventricle in systole and diastole, and correlated them with the electrocardiogram. METHODS We studied 35 healthy individuals (27 were male) with ages ranging from 12 to 59 years (32.9 plus minus 10.6). Systolic and diastolic peak velocities were assessed by Doppler tissue imaging in 12 segments of the left ventricle, establishing their mean values and the temporal correlation with the cardiac cycle. RESULTS The means (and standard deviation) of the peak velocities in the basal, medial, and apical regions (of the septal, anterior, lateral, and posterior left ventricle walls) were respectively, in cm/s, 7.35(1.64), 5.26(1.88), and 3.33(1.58) in systole and 10.56(2.34), 7.92(2.37), and 3.98(1.64) in diastole. The mean time in which systolic peak velocity was recorded was 131.59ms (+/- 19.12ms), and diastolic was 459.18ms (+/- 18.13ms) based on the peak of the R wave of the electrocardiogram. CONCLUSION In healthy individuals, maximum left ventricle segment velocities decreased from the bases to the ventricular apex, with certain proportionality between contraction and relaxation (P<0.05). The use of Doppler tissue imaging may be very helpful in detecting early alterations in ventricular contraction and relaxation.

Double outlet right ventricle with anterior and left-sided aorta and subpulmonary ventricular septal defect

Double outlet right ventricle (DORV) is a heterogeneous group of abnormal ventriculoarterial connections where, by definition, both great arteries (pulmonary artery and aorta) arise primarily from the morphologically right ventricle. This condition affects 1-1.5% of the patients with congenital heart diseases, with a frequency of 1 in each 10,000 live births. We report the case of an 18-day-old infant with DORV and extremely rare anatomical features, such as anterior and left-sided aorta and subpulmonary ventricular septal defect (VSD). In addition to the anatomic features, the role of the echocardiogram for guiding the diagnosis and the surgical therapy of this congenital heart disease are discussed.

Effective dose of sedation in transesophageal echocardiography: relation to age, body surface area and left ventricle function

BACKGROUND Sedation with midazolam and meperidine is widely used in transesophageal echocardiography. However, no mean dose is established for each individual case. OBJECTIVE To correlate the mean midazolam and meperidine doses for proper sedation for transesophageal echocardiography with age range, body surface area, and left ventricular ejection fraction. METHODS Retrospective study comprising 1,841 patients undergoing sedation based on the Ramsay scale, with a solution containing midazolam 1.5 mg (1.5 ml), meperidine 1 mg (1 ml) and distilled water (7.5 ml). Four age groups were analyzed: G1: < 24 years; G2: 25 to 44 years; G3: 45 to 64 years; and G4: > 65 years. Body surface area was calculated using the formula {[(height x 100)0.725] x (weight(0.425)) x 0.0071}. As regards the left ventricular ejection fraction, two groups were studied: GA: < 55%; and GB: > 55%. The statistical analysis was carried out using the Kruskal-Wallis test for the correlation with age and left ventricular ejection fraction, and simple linear correlation for body surface area. RESULTS As regards age, the mean doses of sedation required were significantly lower in G3 and G4 (p<0.01). The analysis of left ventricular ejection fraction showed that this was significantly lower in GA (p<0.01). The linear correlation coefficient between dose of sedation and body surface area was 0.09 (null). CONCLUSION The mean dose of sedatives required was lower in older individuals and in those with left ventricular systolic dysfunction. No correlation with body surface area was found.FUNDAMENTO: A sedacao com midazolam e meperidina e amplamente utilizada em ecocardiografia transesofagica, entretanto, nao existe dose media estabelecida para cada caso. OBJETIVO: Correlacionar as doses medias de midazolam e meperidina para sedacao adequada em ecocardiografia transesofagica com faixa etaria, area de superficie corporea e fracao de ejecao do ventriculo esquerdo. METODOS: Estudo retrospectivo envolvendo 1.841 pacientes submetidos a sedacao baseada na escala de Ramsay, com solucao contendo midazolam 1,5 mg (1,5 ml), meperidina 1 mg (1 ml) e agua destilada (7,5 ml). Analisamos quatro grupos etarios: G1: 65 anos. Obtivemos a area de superficie corporea pela formula: {[(altura x 100)0,725] x (peso0,425) x 0,0071}. Com relacao a fracao de ejecao do ventriculo esquerdo, estudamos dois grupos: GA: 55%. Na analise estatistica utilizamos o teste de Kruskal-Wallis para correlacao com idade e fracao de ejecao do ventriculo esquerdo, e correlacao linear simples para area de superficie corporea. RESULTADOS: No estudo da idade, as doses medias de sedacao necessarias foram significativamente menores no G3 e G4 (p < 0,01). Na analise da fracao de ejecao do ventriculo esquerdo, esta foi significativamente menor no GA (p < 0,01). O coeficiente de correlacao linear entre dose de sedacao e area de superficie corporea foi 0,09 (nulo). CONCLUSAO: Houve menor dose media necessaria de sedativos nos individuos com maior idade e em portadores de disfuncao sistolica do ventriculo esquerdo, e nao houve correlacao com area de superficie corporea.Métodos: Estudio retrospectivo involucrando 1.841 pacientes sometidos a sedación basada en la escala de Ramsay, con solución conteniendo midazolam 1,5 mg (1,5 ml), meperidina 1 mg (1 ml) y agua destilada (7,5 ml). Analizamos cuatro grupos etarios: G1: ≤ 24 años; G2: 25 a 44 años; G3: 45 a 64 años; y G4: ≥ 65 años. Obtuvimos el área de superficie corporal mediante la fórmula: {[(altura x 100)0,725] x (peso0,425) x 0,0071}. Con relación a la fracción de eyección del ventrículo izquierdo, estudiamos dos grupos: GA: < 55%; y GB: ≥ 55%. En el análisis estadístico utilizamos el test de Kruskal-Wallis para correlación con edad y fracción de eyección del ventrículo izquierdo, y correlación lineal simple para área de superficie corporal.

Spontaneous Regression of Cardiac Tumors

The authors report a case of an asymptomatic 3‐day‐old baby with multiple biventricular tumors detected 2 years ago by echocardiography. In spite of the major anatomical anomaly, no functional abnormality was found. There was no outflow tract obstruction and, therefore, an expectant and noninterventional approach was recommended. Serial echocardiographic follow‐up revealed spontaneous and progressive regression of the tumors. Today the child remains asymptomatic and only three small masses persist.

Double Lumen Aortic Arch or Persistence of Fifth Aortic Arch?– Report of a Case with No Associated Cardiac Defects and Literature Review

Different vascular abnormalities have been reported under the denomination of “persistence of the fifth aortic arch.” Detailed studies on experimental embryology raised the discussion about the existence of the fifth aortic arch as an embryological structure, both in humans and mammals. In 1969 the Van Praaghs described the occurrence of double left aortic arch, denominating such anomaly as persistence of the fifth arch. We describe here a female patient showing the presence of an anomalous vessel in parallel with the aortic arch. The finding was occasional, during a preoperative evaluation for cholecystectomy. (Echocardiography 2011;28:E143‐E145)

An Insignificant Flow That Intrigues Echocardiographers. Echocardiographic Pattern in 15 Cases of Coronary-Pulmonary Fistula and Literature Review

An Insignificant Flow That Intrigues Echocardiographers. Echocardiographic Pattern in 15 Cases of Coronary-Pulmonary Fistula and Literature Review Carlos Eduardo Suaide Silva,1 Vera Demarchi Aiello,2 Renata Rejane Linhares,1 Luciana Braz Peixoto,1 Mariane Daltrini Trandafilov Pimentel,3 Lucas Bercht,1 Fernanda Storti,1 Manuel Adán Gil,1 Claudia Gianini Monaco1 Diagnósticos da América SA (DASA-SP);1 Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo;2 OMNI-CCNI Medicina Diagnóstica,3 São Paulo, SP – Brazil

Comparison of Block-Matching and Optical Flow in Strain Echocardiography Analysis

Introdução: Diferentes tecnologias têm sido utilizadas para avaliar a função sistólica do ventrículo esquerdo. De particular interesse, está a ecocardiografia com strain bidimensional (2DSTE). Dois métodos diferentes têm sido usados para quantificar a deformação miocárdica (strain miocárdico) pela 2DSTE: block matching e optical flow. Ambos estão presentes em ecocardiógrafos comercialmente disponíveis. Entretanto, não há consenso a respeito se as medidas do strain longitudinal por estes métodos são sobreponíveis.