Edgar Bezerra Lira Filho

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)

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.

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.

Segurança da ecocardiografia transesofágica em adultos: estudo em um hospital multidisciplinar

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.

Evaluation of Strain Parameters by Three Dimensional Speckle Tracking Echocardiography in Competitive Athletes

Method: Elite boxers underwent conventional three-dimensional echocardiography (3D-echo) and 3D-STE to analyze left ventricular (LV) volumes, left ventricular mass indexed to body surface area (LVMIBSA), ejection fraction (EF), longitudinal global strain (LGS), circumferential global strain (CGS), radial global strain (RGS), twist, torsion and tracking area. These data were compared with measurements performed on untrained control individuals.

Tissue Doppler Imaging Limitations for Evaluating the Diastolic Function in Elderly People

Results: The group consisted of 56 subjects (70.1 ± 6.6 years), 23 (41.1%) in the GC and 33 (58.9%) in the HAS. Except for LV hypertrophy, more frequent in the HAS group compared to HG (34.4% versus 4.8% respectively; p=0.017), all structural echocardiographic findings were similar. Tissue Doppler analysis revealed no differences between the groups (septal e’: 8.0 ± 1.5 vs. 7.2 ± 1.9 cm/s; p=0.083 and lateral e’: 9.8 ± 2.2 versus 8.7 ± 2.0 cm/s; p=0.074, respectively, for GC and HAS). A longer E‑wave deceleration time was observed for HAS group (253 ± 62 versus 208 ± 36 ms in GC; p=0.003). Conclusion: In the analysis of diastolic function in elderly, tissue Doppler imaging was not able to discriminate hypertensive individuals, with the greatest potential for the occurrence of diastolic dysfunction, to the non‑hypertensive individuals.The E‑wave deceleration time proved to be a valuable parameter in this population. (Arq Bras Cardiol: Imagem cardiovasc. 2014;27(3):184‑190)

Relation between three-dimensional and two-dimensional echocardiography and biochemical analysis in patients with ST-segment elevation myocardial infarction percutaneously treated.

OBJECTIVE The prognosis of patients with acute myocardial infarction depends on multiple features that can demonstrate myocardial injury degree (such as serum markers of cardiac necrosis), and also on adaptive mechanisms relative to the acute event. The aim of the study was to assess the relation between biochemical and echocardiographic findings from three-dimensional echocardiographic (3D Echo) analysis and echocardiographic two-dimensional (2D Echo) left ventricular ejection fraction in patients with ST-segment elevation acute myocardial infarction, submitted to primary percutaneous treatment. METHODS A prospective study with 2D Echo and 3D Echo of 23 patients (17 males, mean age of 57 ± 13 years) with ST-segment elevation acute myocardial infarction, primarily percutaneously treated (stent). Serum cardiac markers (creatine kinase MB, Troponin I and Myoglobin) and serum brain natriuretic peptide were compared to echocardiographic parameters (volumes, left ventricular ejection fraction and ventricular dyssynchrony index). The statistical analysis was performed using Pearsons correlation coefficient, 95% CI, p < 0.05, linear regression equation and Bland & Altman test. RESULTS Pearsons correlation coefficient (r)relative to 3D left ventricular ejection fraction: 1- brain natriuretic peptide: r: - 0.7427, p < 0.0001; 2- creatine kinase MB: r: - 0.660, p = 0.001. Left ventricular ejection fraction 2D (r) : 1- brain natriuretic peptide: r: - 0.5478, p = 0.001; 2- creatine kinase MB: r: - 0.4800, p < 0.0277. Other associations were not significant. CONCLUSIONS In this series, it was observed better correlation in regard to serum creatine kinase MB, brain natriuretic peptide and 3D Echo left ventricular ejection fraction, when compared to 2D Echo left ventricular ejection fraction.

Seguridad de la ecocardiografía transesofágica en adultos: estudio en un hospital multidisciplinario

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.

Left atrial appendage: real-time three-dimensional transthoracic echocardiographic image

1-4 . This fact becomes especially relevant when anatomical observation translates into prognostic clinical implications, such as in the identification of images of thrombi in the left atrium or left atrial appendage. In most clinical situations, the investigation of intra-atrial images of thrombi with the use of two-dimensional transthoracic echocardiography does not allow anatomical information reliable enough for a diagnostic definition. Use of multiplane bidimensional transesophagic echocardiography enabled additional diagnostic information for discrimination of intra-atrial masses caused by the use of transducers with a greater ultrasound emission frequency, at a greater proximity to the structure of interest, providing images with a better quality of structural definition. Nevertheless, this semi-invasive echocardiographic modality does not yet allow structural from all anatomic planes of observation (a primary limitation for structural identification based on frontal and transversal cardiac planes, with observation point in atrioventricular, pulmonary, and aortic valve rings). Real-time three-dimensional transthoracic echocardiography is an advancement in anatomical analysis because it allows a rotation of heart structures based on three primary planes of structural definition (infero-superior plane, mid-lateral plane, and depth or elevation plane), as well as a structural composition based on the analysis of composite planes or diagonal planes. Image acquisition is made in real-time, and the final image may be obtained by the projection of interest to the clinician or surgeon. In the case shown, we observe the two-dimensional transthoracic echocardiographic analysis of the left atrial appendage (Figure 1), and the real-time three-dimensional transthoracic image of the left atrial appendage from different observation planes (Figures 2A, 2B and 2C), as from the frontal plane (en face). Currently, transesophagic echocardiography is still the most appropriate echocardiographic technique for visualization of the left atrial appendage and investigation of intracavitary thrombi, as it shows evidence based on analyses with a large number of patients. Further studies are needed for a definition of the diagnostic and prognostic impact of the anatomical findings obtained by the use of real-time threedimensional transthoracic echocardiography.1-4 . This fact becomes especially relevant when anatomical observation translates into prognostic clinical implications, such as in the identification of images of thrombi in the left atrium or left atrial appendage. In most clinical situations, the investigation of intra-atrial images of thrombi with the use of two-dimensional transthoracic echocardiography does not allow anatomical information reliable enough for a diagnostic definition. Use of multiplane bidimensional transesophagic echocardiography enabled additional diagnostic information for discrimination of intra-atrial masses caused by the use of transducers with a greater ultrasound emission frequency, at a greater proximity to the structure of interest, providing images with a better quality of structural definition. Nevertheless, this semi-invasive echocardiographic modality does not yet allow structural from all anatomic planes of observation (a primary limitation for structural identification based on frontal and transversal cardiac planes, with observation point in atrioventricular, pulmonary, and aortic valve rings). Real-time three-dimensional transthoracic echocardiography is an advancement in anatomical analysis because it allows a rotation of heart structures based on three primary planes of structural definition (infero-superior plane, mid-lateral plane, and depth or elevation plane), as well as a structural composition based on the analysis of composite planes or diagonal planes. Image acquisition is made in real-time, and the final image may be obtained by the projection of interest to the clinician or surgeon. In the case shown, we observe the two-dimensional transthoracic echocardiographic analysis of the left atrial appendage (Figure 1), and the real-time three-dimensional transthoracic image of the left atrial appendage from different observation planes (Figures 2A, 2B and 2C), as from the frontal plane (en face). Currently, transesophagic echocardiography is still the most appropriate echocardiographic technique for visualization of the left atrial appendage and investigation of intracavitary thrombi, as it shows evidence based on analyses with a large number of patients. Further studies are needed for a definition of the diagnostic and prognostic impact of the anatomical findings obtained by the use of real-time threedimensional transthoracic echocardiography.