Claudio Henrique Fischer

Implante transapical de endoprótese valvada balão-expansível em posição aórtica sem circulação extracorpórea

OBJECTIVE The aortic valve replacement is a routine procedure, and involves replacement of the native valve/prosthesis. In most of the patients who undergo such procedure the risk is acceptable, but in some cases, such risk can justify contraindication. The minimally invasive transcatheter aortic valve implantation without cardiopulmonary bypass (CPB) has been shown to be viable, with lower morbidity and mortality. The aim of this study was to develop a catheter-mounted aortic bioprosthesis for implantation without CPB. METHODS After developing in animals, three patients with high EuroSCORE underwent implantation. Case 1: patients with bioprosthesis dysfunction; Case 2: severe aortic stenosis; Case 3: dysfunction of aortic bioprosthesis. After minithoracotomy and under echocardiographic and fluoroscopic control, a balloon catheter was placed on aortic position and inflated. After, a second balloon with valved endoprosthesis was positioned and released under high ventricular rate. Echocardiographic and angiographic controls were performed and the patients were referred to ICU. RESULTS In the first case, implantation without CPB was possible with appropriate results. The patient evolved with improvement of ventricular function. After, this patient developed bronchopneumonia, tracheoesophageal fistula and died due to mediastinitis. Autopsy confirmed proper valve positioning and leaflets preservation. The second case showed the device migration after inflation of the balloon, with the need for urgent median sternotomy, CPB and conventional valve replacement. This patient evolved well and was discharged from the ICU on the 14th postoperative day without complications. This patient developed respiratory infection, septic shock and died on the 60th postoperative day. The patient from the third case underwent successful implantation. CONCLUSION The off-pump transapical implantation of catheter-mounted bioprosthesis was shown to be a feasible procedure. Technical details and learning curve require further discussion.Objective: The aortic valve replacement is a routine procedure, and involves replacement of the native valve/ prosthesis. In most of the patients who undergo such

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)

Echocardiography for hemodynamic evaluation in the intensive care unit.

The use of echocardiography in the intensive care unit for patients in shock allows the accurate measurement of several hemodynamic variables in a noninvasive way. By using echocardiography as a hemodynamic monitoring tool, the clinician can evaluate several aspects of shock states, such as cardiac output and fluid responsiveness, myocardial contractility, intracavitary pressures, and biventricular interactions. However, to date, there have been few guidelines suggesting an objective hemodynamic-based examination in the intensive care unit, and most intensivists are usually not familiar with this tool. In this review, we describe some of the most important hemodynamic parameters that can be obtained at the bedside with transthoracic echocardiography.

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.

Role of contrast-enhanced transesophageal echocardiography for detection of and scoring intrapulmonary vascular dilatation.

Background: Intrapulmonary vascular dilatations (IVD) are microvascular pulmonary changes mediated by nitric oxide that cause right‐to‐left shunt and hypoxemia. Contrast‐enhanced transthoracic echocardiography (cTTE) is the gold standard diagnostic test for IVD. Objective: To evaluate contrast‐enhanced transesophageal echocardiography (cTEE) in the diagnosis and grading of IVD. Methods: A study group (SG) of 63 cirrhotic patients were compared to 20 shunt‐free control subjects (CG). Both groups underwent cTEE and cTTE using intravenous injections of agitated saline solution for contrast tests. Patients with patent foramen ovale, when detected, were excluded. Late appearance of microbubbles in the left atrium was diagnostic of pulmonary shunt (positive contrast test) and was graded as trivial, mild, moderate or severe by cTEE. Contrast tests were negative in 7 patients (35%) and trivial in the remaining 13 (65%) in CG, so only contrast grades ≥ mild were considered to be positive IVD tests in the SG. Gasometric change was expressed as the alveolar‐arterial oxygen tension difference (A‐aO2D) and was considered abnormally high at values >20 mmHg. Results: SG: positive IVD tests were present in 23 patients (36%) by cTTE and 47 (75%) by cTEE (P < 0.001). These patients showed A‐aO2D values significantly higher than those with negative IVD tests (P < 0.02) and were directly proportional to the contrast grade. cTEE allowed the diagnosis of IVD in three additional patients with high A‐aO2D that were not detected by cTTE. Conclusion: cTEE enabled diagnosis of IVD in a greater number of patients with gasometric changes compared to cTTE. The contrast effect grade by cTEE seems to be proportional to IVD magnitude. (Echocardiography 2010;27:1233‐1237)

Comparison between respiratory changes in the inferior vena cava diameter and pulse pressure variation to predict fluid responsiveness in postoperative patients

PURPOSE The objective of our study was to assess the reliability of the distensibility index of the inferior vena cava (dIVC) as a predictor of fluid responsiveness in postoperative, mechanically ventilated patients and compare its accuracy with that of the pulse pressure variation (PPV) measurement. MATERIALS AND METHODS We included postoperative mechanically ventilated and sedated patients who underwent volume expansion with 500mL of crystalloids over 15minutes. A response to fluid infusion was defined as a 15% increase in the left ventricular outflow tract velocity time integral according to transthoracic echocardiography. The inferior vena cava diameters were recorded by a subcostal view using the M-mode and the PPV by automatic calculation. The receiver operating characteristic (ROC) curves were generated for the baseline dIVC and PPV. RESULTS Twenty patients were included. The area under the ROC curve for dIVC was 0.84 (95% confidence interval, 0.63-1.0), and the best cutoff value was 16% (sensitivity, 67%; specificity, 100%). The area under the ROC curve for PPV was 0.92 (95% confidence interval, 0.76-1.0), and the best cutoff was 12.4% (sensitivity, 89%; specificity, 100%). A noninferiority test showed that dIVC cannot replace PPV to predict fluid responsiveness (P=.28). CONCLUSION The individual PPV discriminative properties for predicting fluid responsiveness in postoperative patients seemed superior to those of dIVC.

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.

Real-time three-dimensional echocardiographic left ventricular systolic assessment: side-by-side comparison with 64-slice multi-detector cardiac computed tomography

AIMS To investigate by real-time 3D echocardiography (RT3DE) and cardiac computed tomography (CCT) the analysis of left ventricle ejection fraction (LVEF) and volumes. METHODS AND RESULTS A total of 67 patients (37 males, 55 +/- 11 years) were studied prospectively by RT3DE and by 64-slice CCT. RT3DE data: LVEF ranged from 30 to 78.6% (63.1 +/- 7.33); left ventricular end-diastolic volume (LVEDV) from 44.1 to 210 (104.9 +/- 29.7) mL; left ventricular end-systolic volume (LVESV) from 11.4 to 149 ( 38.9 +/- 19.3) mL. CCT data: LVEF ranged from 28 to 86% (66 +/- 8.4); LVEDV from 51 to 212 (110.3 +/- 31.2) mL; LVESV from 7 to 152 (38.2 +/- 19.2) mL. Correlations relative to RT3DE and CCT were: LVEF (r: 0.79, P < 0.0001); LVEDV (r: 0.82, P < 0.0001); and LVESV (r: 0.91, P < 0.0001). CONCLUSION It was observed adequate correlation between RT3DE and CCT ventricular systolic function and geometry assessment.

Simplified Single Plane Echocardiography Is Comparable to Conventional Biplane Two‐Dimensional Echocardiography in the Evaluation of Left Atrial Volume: A Study Validated by Three‐Dimensional Echocardiography in 143 Individuals

The left atrial volume index (LAVI) is a biomarker of diastolic dysfunction and a predictor of cardiovascular events. Three‐dimensional echocardiography (3DE) is highly accurate for LAVI measurements but is not widely available. Furthermore, biplane two‐dimensional echocardiography (B2DE) may occasionally not be feasible due to a suboptimal two‐chamber apical view. Simplified single plane two‐dimensional echocardiography (S2DE) could overcome these limitations. We aimed to compare the reliability of S2DE with other validated echocardiographic methods in the measurement of the LAVI. We examined 143 individuals (54 ± 13 years old; 112 with heart disease and 31 healthy volunteers; all with sinus rhythm, with a wide range of LAVI). The results for all the individuals were compared with B2DE‐derived LAVIs and validated using 3DE. The LAVIs, as determined using S2DE (32.7 ± 13.1 mL/m2), B2DE (31.9 ± 12.7 mL/m2), and 3DE (33.1 ± 13.4 mL/m2), were not significantly different from each other (P = 0.85). The S2DE‐derived LAVIs correlated significantly with those obtained using both B2DE (r = 0.98; P < 0.001) and 3DE (r = 0.93; P < 0.001). The mean difference between the S2DE and B2DE measurements was <1.0 mL/m2. Using the American Society of Echocardiography criteria for grading LAVI enlargement (normal, mild, moderate, severe), we observed an excellent agreement between the S2DE‐ and B2DE‐derived classifications (κ = 0.89; P < 0.001). S2DE is a simple, rapid, and reliable method for LAVI measurement that may expand the use of this important biomarker in routine echocardiographic practice.

Cirurgia robótica em Cardiologia: um procedimento seguro e efetivo

OBJECTIVE: To evaluate the short and medium-term outcomes of patients undergoing robotic-assisted minimally invasive cardiac surgery. METHODS: From March 2010 to March 2013, 21 patients underwent robotic-assisted cardiac surgery. The procedures performed were: mitral valve repair, mitral valve replacement, surgical correction of atrial fibrillation, surgical correction of atrial septal defect, intracardiac tumor resection, totally endoscopic coronary artery bypass surgery and pericardiectomy. RESULTS: The mean age was 48.39±18.05 years. The mean cardiopulmonary bypass time was 151.7±99.97 minutes, and the mean aortic cross-clamp time was 109.94±81.34 minutes. The mean duration of intubation was 7.52±15.2 hours, and 16 (76.2%) patients were extubated in the operating room immediately after the procedure. The mean length of intensive care unit stay was 1.67±1.46 days. There were no conversions to sternotomy. There was no in-hospital death or deaths during the medium-term follow-up. Patients mean follow up time was 684±346 days, ranging from 28 to 1096 days. CONCLUSION: Robotic-assisted cardiac surgery proved to be feasible, safe and effective and can be applied in the correction of various intra and extracardiac pathologies.ABSTRACT Objective: To evaluate the short and medium-term outcomes of patients undergoing robotic-assisted minimally invasive cardiac surgery. Methods: From March 2010 to March 2013, 21 patients underwent robotic-assisted cardiac surgery. The procedures performed were: mitral valve repair, mitral valve replacement, surgical correction of atrial fibrillation, surgical correction of atrial septal defect, intracardiac tumor resection, totally endoscopic coronary artery bypass surgery and pericardiectomy. Results: The mean age was 48.39±18.05 years. The mean cardiopulmonary bypass time was 151.7±99.97 minutes, and the mean aortic cross-clamp time was 109.94±81.34 minutes. The mean duration of intubation was 7.52±15.2 hours, and 16 (76.2%) patients were extubated in the operating room immediately after the procedure. The mean length of intensive care unit stay was 1.67±1.46 days. There were no conversions to sternotomy. There was no in-hospital death or deaths during the medium-term follow-up. Patients mean follow up time was 684±346 days, ranging from 28 to 1096 days. Conclusion: Robotic-assisted cardiac surgery proved to be feasible, safe and effective and can be applied in the correction of various intra and extracardiac pathologies.