Domingos Hatem

Estudo do encurtamento global do átrio esquerdo em fetos de mães diabéticas

OBJECTIVE: To test the hypothesis that left atrial shortening fraction is lower in fetuses of diabetic mothers than in fetuses of mothers with no systemic disease. METHODS: Forty-two fetuses of mothers with previous diabetes or gestational diabetes and 39 healthy fetuses of mothers with no systemic disease (controls) underwent echocardiographic examination. Their gestational ages ranged from 25 weeks to term. The left atrial shortening fraction was obtained with the following formula: (left atrial maximum diameter - left atrial minimum diameter)/left atrial maximum diameter. Data were compared using the Student t test, with an alpha level of 0.05. RESULTS: Mean left atrial shortening fractions in fetuses of diabetic mothers and in those in the control group were 0.39±0.15 and 0.51±0.11, respectively. This difference was significant with P < 0.001. CONCLUSION: Left atrial dynamics, with a reduction in global left atrial shortening, is increased in fetuses of diabetic mothers. We speculate that this parameter may be useful in assessing fetal left ventricular diastolic function.

Short- and long- term results of percutaneous balloon valvuloplasty in pulmonary valve stenosis

OBJECTIVE To assess the long-term results of percutaneous balloon valvuloplasty at a single institution. METHODS This study comprised 189 patients with pulmonary valve stenosis undergoing percutaneous balloon valvuloplasty from 1984 to 1996, whose mean age was 7.97+/-9.25 years. The procedure was classified as successful when the RV-PA gradient was reduced to levels < 36 mmHg; restenosis was indicated by RV-PA gradients > 36 mmHg after an effective procedure. RESULTS After the procedure, the peak-to-peak transvalvular gradient decreased from 70.12+/-30.06 to 25.11 +/-20.23 mmHg (P<0.001). Immediate success was obtained in 148 (78.72%) patients. A later reduction in the gradient to values < 36 mmHg was obtained in 24 other patients previously categorized as unsuccessful. Therefore, percutaneous balloon valvuloplasty was considered effective in 172 (91.01%) patients. Effectiveness increased to 93.53% (159/170) in the cases of typical morphology. Follow-up ranged from 4.39+/-3 years to 13.01 years. Restenosis was observed in 24 (13.95%) patients. Pulmonary regurgitation was detected in 95.1% of the patients, being more intense than mild in 29.5% of the patients. The probability of maintaining an appropriate result, at any time point, with no restenosis was 92.29% in 2 years, 87.38% in 5 years, 82.46% in 8 years, and 64.48% in 10 years. CONCLUSION Percutaneous balloon valvuloplasty was effective and safe for the treatment of pulmonary valve stenosis with excellent short- and long-term results.OBJETIVO: Determinar os resultados em longo prazo da valvoplastia percutânea por balao em uma instituicao isolada. METODOS: Estudados 189 pacientes com estenose valvar pulmonar submetidos a valvoplastia percutânea por balao, entre 1984-1996, com idade media de 7,97±9,25 anos, classificando-se como bem sucedida, a reducao do gradiente VD-AP em niveis 36mmHg apos procedimento eficaz. RESULTADOS: Apos o termino do procedimento, o gradiente pico a pico transvalvar reduziu-se de 70,12±30,06 para 25,11±20,23 mmHg (p<0,001). Obtiveram sucesso imediato 148 (78,72%) pacientes. Houve reducao posterior do gradiente para valores < 36mmHg em outros 24 pacientes categorizados sem sucesso no grupo. Assim a valvoplastia percutânea por balao foi considerada efetiva em 172 (91,01%) pacientes. A efetividade aumentou para 93,53% (159/170) nos casos de morfologia tipica. O tempo de seguimento foi de 4,39±3anos ate o periodo maximo de 13,01 anos. Observou-se reestenose em 24 (13,95%). A presenca de regurgitacao pulmonar foi detectada em 95,1% dos pacientes, sendo que em 29,5% com grau maior do que leve. A probabilidade de se manter um resultado adequado, ate qualquer ponto no tempo, sem a ocorrencia de reestenose, foi de 92,29% em 2 anos, de 87,38 % em 5 anos, de 82,46% em 8 anos e de 64,48% em 10 anos. CONCLUSAO: A valvoplastia percutânea por balao foi efetiva e segura no tratamento da estenose valvar pulmonar com excelentes resultados imediatos e a longo prazo.

Pulsatilidade venosa pulmonar em fetos de mães diabéticas: estudo doppler-ecocardiográfico pré-natal

OBJECTIVE To verify the hypothesis that the pulmonary vein pulsatility index is higher in fetuses of diabetic mothers than it is in normal fetuses of nondiabetic mothers. METHODS Twenty-four fetuses of mothers with either gestational or previous diabetes (cases), and 25 normal fetuses of mothers without systemic disease (control) were examined. Fetuses were examined through prenatal Doppler and color flow mapping. The pulmonary vein pulsatility index was obtained by placing the pulsed Doppler sample volume over the right superior pulmonary vein and applying the formula (systolic velocity - presystolic velocity)/mean velocity. RESULTS The mean gestational age of the study fetuses was 30.3 2.7 weeks, and gestational age of the controls was 29 3.3 weeks, with no significant difference in gestational age between groups (p=0.14). Fetuses of diabetic mothers had a mean pulmonary vein pulsatility index of 1.6 1, and those of the control group had an index of 0.86 0.27. CONCLUSION Fetuses of diabetic mothers had pulmonary vein pulsatility indexes (parameter easily obtained through Doppler echocardiography that may be related to fetal diastolic function) higher than those in fetuses of mothers with normal glycemia.

Fluxo no ducto venoso e hipertrofia miocárdica em fetos de mães diabéticas

OBJECTIVE To test the hypothesis that the pulsatility index of ductus venosus (PIDV) is greater in the fetuses of diabetic mothers (FDM) with myocardial hypertrophy (MH) than in the FDM with no MH and in the control fetuses of nondiabetic mothers (FNDM). Comparing the results with mitral and tricuspid diastolic peak flows. METHODS The cross-sectional study included fetuses with gestational ages ranging from 20 weeks to term, divided into the following 3 groups: 56 FDM with MH (group I), 36 FDM with no MH (group II), and 53 FNDM (group III, control). The Doppler echocardiogram assessed the PIDV through the ratio (systolic velocity - presystolic velocity)/mean velocity. The mitral and tricuspid E and A waves were also assessed. RESULTS The mean PIDV in groups I, II, and III were 1.13 +/- 0.64, 0.84 +/- 0.38, and 0.61 +/- 0.17, respectively. Using ANOVA and the Tukey test, a statistically significant difference was found in the 3 groups (P = 0.015 between groups I and II; P < 0.001 between groups I and III; and P = 0.017 between groups II and III). The mean mitral E wave was significantly greater in group I (0.39 +/- 0.12 m/s) than in groups II (0.32 +/- 0.08 m/s) (P = 0.024) and III (0.32 +/- 0.08 m/s) (P = 0.023). The mean tricuspid E wave was also greater in group I (0.43 +/- 0.1 m/s) than in group III (0.35 +/- 0.10 m/s) (P = 0.031). CONCLUSION The PIDV is significantly greater in FDM with MH than in FDM with no MH and in FNDM. Because the PIDV may represent modifications in ventricular compliance, this index may be a more sensitive parameter for assessing fetal diastolic function.

Dynamics of the Pulmonary Venous Flow in the Fetus and Its Association With Vascular Diameter

Background—The usual positioning of the Doppler sample volume to assess fetal pulmonary vein flow is in the distal portion of the vein, where the vessel diameter is maximal. This study was performed to test the association of the pulmonary vein pulsatility index (PVPI) with the vessel diameter. Methods and Results—Twenty-three normal fetuses (mean gestational age, 28.6±5.3 weeks) were studied by Doppler echocardiography. Pulmonary right upper vein flow was assessed adjacent to the venoatrial junction (“distal” position) and in the middle of the vein (“proximal” position). The vessel diameter was measured by 2D echocardiography with power Doppler, and the PVPI was obtained by the ratio (maximal velocity [systolic or diastolic peak]−minimal velocity [presystolic peak])/mean velocity. The statistical analysis used t test and exponential correlation studies. Mean distal diameter was 0.33±0.10 cm (0.11 to 0.57 cm), and mean proximal diameter was 0.16±0.08 cm (0.11 to 0.25 cm) (P <0.0001). Mean distal PVPI was 0.84±0.21 (0.59 to 1.38), and mean proximal PVPI was 2.09±0.59 (1.23 to 3.11) (P <0.0001). Exponential inverse correlation between pulmonary vein diameter and pulsatility index was highly significant (P <0.0001), with a determination coefficient of 0.439. Conclusions—In the normal fetus, the pulmonary venous flow pulsatility decreases from the lung to the heart, and this parameter is inversely correlated to the diameter of the pulmonary vein, which increases from its proximal to its distal portion. This study emphasizes the importance of the correct positioning of the Doppler sample volume, adjacent to the venoatrial junction, to assess pulmonary venous flow dynamics.

Results of the surgical treatment of chronic atrial fibrillation

OBJECTIVE Report clinical experience in surgical treatment of atrial fibrillation (AF) by Cox-maze procedure. METHODS 61 patients underwent surgical treatment for AF. Two had primary AF and 59 AF secondary to heart disease (2 atrial septal defects, 57 mitral). Ages ranged from 20 to 74 years (mean = 49). There were 44 females (72%). The surgical technique employed was Cox 3 without cryoablation. The patients were follow-up in specific at patient clinics and underwent periodical ECG, exercise tests, echocardiogram and Holter monitoring. RESULTS In-hospital mortality was 4.9% and late mortality 1.6%. A temporary pacemaker was used in 28 (46%) and a definitive in 7 patients (11.4%). On hospital discharge, AF remained in 17%; 63.9% had sinus rhythm, 6.9% atrial rhythm, 1.7% junctional rhythm, and 10.3% had pacemaker rhythm. In the last evaluation, AF was present in 19.5%; (70.5% sinus rhythm, 4% atrial rhythm, 2% atrial tachycardia, and 4% pacemaker rhythm). There was no report of thromboembolic episodes. Chronotropic response was considered adequate in 19%, intermediate in 29%, and inadequate in 42%. In Holter monitoring, the mean heart rate was 82 +/- 8 bpm, with a minimum of 57 +/- 7 bpm and maximum of 126 +/- 23 bpm, with supraventricular extrasystoles in 2.3 +/- 5.5% of the total heartbeats and ventricular extrasystoles in 0.8 +/- 0.5%. In the echocardiogram, the A wave was present in the left atrium in 87.5%. CONCLUSION Maze procedure is effective and has acceptable surgical risk. Atrial or sinus rhythms remain stable with a small but remarkable frequency of atrial and ventricular arrhythmias. Left atrial contraction is present, although attenuated, as well as the chronotropic response to exercise.

Variações de parâmetros da função diastólica do ventrículo esquerdo de acordo com a idade através da ecocardiografia com Doppler tissular

OBJETIVO: Determinar a correlacao entre as velocidades diastolicas do Doppler tissular com a idade em amostra de adultos saudaveis, e correlacionar a idade com as velocidades do fluxo transmitral e de veias pulmonares. METODOS: Estudados, atraves da ecocardiografia, 51 individuos saudaveis, com idades entre 21 e 69 anos e registradas as velocidades miocardicas diastolicas ao Doppler tissular e determinadas as velocidades dos fluxos transmitral e venoso pulmonar. RESULTADOS: As velocidades miocardicas diastolicas iniciais septal basal e lateral basal apresentaram correlacao inversa com a idade, com r = - 0,40 (p = 0,004) e r = - 0,60 (p = 0,0001) respectivamente. As velocidades atriogenicas do Doppler tissular foram diretamente correlacionadas com a idade, sendo no segmento septal basal r = 0,56 (p = 0,0001) e no segmento lateral basal r = 0,50 (p = 0,0001). As velocidades do fluxo transmitral e do fluxo venoso pulmonar tambem mostraram correlacao com a idade. CONCLUSAO: Existe correlacao entre a idade e as velocidades miocardicas diastolicas do Doppler tissular e com as velocidades do fluxo transmitral e fluxo venoso pulmonar, demonstrando em individuos saudaveis uma variacao de parâmetros da funcao diastolica do ventriculo esquerdo com a evolucao natural da idade.

Diastolic function study with conventional and pulsed tissue Doppler echocardiography imaging in acromegalic patients.

Acromegaly is associated with myocardial hypertrophy and it can progress to diastolic and systolic dysfunction. Purpose: To evaluate diastolic function in acromegalic patients through conventional echocardiography (CD) and tissue Doppler imaging (TDI). Methods: Seventeen acromegalic patients were submitted to CD and TDI, and early (E) and atriogenic (A) transmitral flow were evaluated in mitral, septal, and tricuspid regions. Results: In comparison with controls the means of conventional (1.06), septal (1.01), and tricuspid (0.98) E/A ratio were significantly lower in acromegalic patients. E/A ratio <1.0 was demonstrated in 41% and 49% of acromegalics by DC and TDI, respectively, with no statistical difference among the two methods. An inverse linear correlation was shown between mitral E/A ratio and acromegalic age (r =−0.7). Conclusion: In this study, DC and TDI were equally effective in demonstrating diastolic dysfunction, a common finding in acromegalic patients. (ECHOCARDIOGRAPHY, Volume 26, July 2009)

Isolamento das veias pulmonares em pacientes com fibrilação atrial permanente secundária a valvopatia mitral

OBJECTIVE To assess the efficacy of surgical isolation of the pulmonary veins for re-establishing sinus rhythm in patients with atrial fibrillation secondary to mitral valve disease. METHODS Thirty-three (67% were women) patients with permanent atrial fibrillation and indication for surgical correction of the mitral valve underwent surgical isolation of the pulmonary veins. Their mean age was 56.3+/-10 years, preoperative NYHA functional class was 3.2+/-0.6, left atrial size was 5.5+/-0.9 cm, and ejection fraction was 61.3+/-13%. The surgical technique consisted of a circumferential incision surrounding the 4 pulmonary veins, excision of the left atrial appendage, and a perpendicular incision originating in the inferior margin of the circumferential incision isolating the pulmonary veins down to the mitral valve. Early arrhythmias were aggressively treated with cardioversion. RESULTS The mean follow-up was 23.9+/-17 months, and 3 patients died in the postoperative period. Ten patients required electrical cardioversion in the postoperative period; 87% had sinus rhythm in the last medical visit, and 33% were using amiodarone. CONCLUSION Isolation of the pulmonary veins associated with mitral valve surgery is an effective and safe technique for maintaining sinus rhythm in patients with permanent atrial fibrillation.

Correlação e concordância entre medidas ecocardiográficas obtidas durante o exame no ecocardiógrafo com medidas de imagens digitalizadas: estudo transversal

OBJECTIVE: To evaluate the correlation and concordance between the measurements of echocardiographic analysis of cardiac dimensions obtained through the Echo off-line applicative (software for obtaining digitized image measurements in a dedicated workstation) available to public domain, and those obtained through the conventional method. METHOD: Transversal contemporary study, of 56 randomized patients whose images were obtained during examina-tions. The measurements of the M mode and 2D, were done in the ventricles, left atrium, and aorta by the Echo off-line program. These measurements were compared to those obtained by another professional, through Pearsons correlation test (r), alpha = 0.05 and by concordance analysis (Bland and Altman). RESULT: The measurements carried out by the Echo off-line system showed r that varied from 0.85 to 0.98. The analysis of concordance showed that for most measu-rements, the mean difference between the methods was approximately zero. The variation of absolute values did not show, in average, a clinical significance. The Echo off-line applicative allows a reduction of approximately 30% in the time spent to obtain the measurements. CONCLUSION: This study demonstrated the accuracy of the Echo off-line program to measure cardiac dimensions in a dedicated workstation, showing that it can be routinely used in echocardiography labs.