José Rodrigues Parga

Partial left ventriculectomy with mitral valve preservation in the treatment of patients with dilated cardiomyopathy.

OBJECTIVE This study reports initial results of partial left ventriculectomy performed with preservation of the mitral valve in the treatment of 27 patients with idiopathic dilated cardiomyopathy. METHODS Patients were in New York Heart Association class III or IV. Partial ventriculectomy was performed as an isolated procedure in four patients and associated with mitral annuloplasty in 23 patients. There were four hospital deaths (14.8%) and the remaining patients were followed for 11.2 +/- 6 months. RESULTS Decrease of left ventricular diastolic diameter (81.8 +/- 8.7 to 68.5 +/- 7.6 mm, p < 0.001) and improvement of left ventricular wall shortening (12% +/- 3.1% to 18.1% +/- 3.9%, p < 0.001) were demonstrated by echocardiography after the operation. Left ventricular radioisotopic angiography showed reduction of diastolic volume (495 +/- 124 ml to 352 +/- 108 ml, p < 0.001) and increase of ejection fraction (17.7% +/- 4.6% to 23.7% +/- 8.8%, p < 0.001). Right-sided heart catheterization demonstrated improvement of stroke index (24.3 +/- 7.7 ml/m2 to 28.3 +/- 7.6 ml/m2, p < 0.01) and decrease of pulmonary wedge pressure (23.2 +/- 8.8 mm Hg to 17 +/- 7 mm Hg, p < 0.01). Similar results were documented at 6 and 12 months of follow-up. Functional class improved from 3.6 +/- 0.5 to 1.4 +/- 0.6 (p < 0.001). However, seven patients died at midterm follow-up because of heart failure progression or arrhythmia-related events, and survival rate was 59.2% +/- 9.4% from 6 to 24 months of follow-up. CONCLUSIONS Partial left ventriculectomy performed with preservation of the mitral valve improves left ventricular function and congestive heart failure in patients with dilated cardiomyopathy. Nevertheless, the high incidences of heart failure progression and arrhythmia-related deaths observed after this procedure preclude its wide clinical application.

Relation between visceral fat and coronary artery disease evaluated by multidetector computed tomography

Visceral abdominal fat has been associated to cardiovascular risk factors and coronary artery disease (CAD). Computed tomography (CT) coronary angiography is an emerging technology allowing detection of both obstructive and nonobstructive CAD adding information to clinical risk stratification. The aim of this study was to evaluate the association between CAD and adiposity measurements assessed clinically and by CT. We prospectively evaluated 125 consecutive subjects (57% men, age 56.0+/-12 years) referred to perform CT angiography. Clinical and laboratory variables were determined and CT angiography and abdominal CT were performed in a 64-slice scanner. CAD was defined as any plaque calcified or not detected by CT angiography. Visceral and subcutaneous adiposity areas were determined at different intervertebral levels. CT angiography detected CAD in 70 (56%) subjects, and no association was found with usual anthropometric adiposity measurements (waist and hip circumferences and body mass index). Otherwise, CT visceral fat areas (VFA) were significantly related to CAD. VFA T12-L1 values > or =145cm(2) had an odds ratio of 2.85 (95% CI 1.30-6.26) and VFA L4-L5 > or =150cm(2) had a 2.87-fold (95% CI 1.31-6.30) CAD risk. The multivariate analysis determined age and VFA T12-L1 as the only independent variables associated to CAD. Visceral fat assessed by CT is an independent marker of CAD determined by CT angiography.

Late Gadolinium Enhancement Magnetic Resonance Imaging in the Diagnosis and Prognosis of Endomyocardial Fibrosis Patients

Background— Endocardial fibrous tissue (FT) deposition is a hallmark of endomyocardial fibrosis (EMF). Echocardiography is a first-line and the standard technique for the diagnosis of this disease. Although late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) allows FT characterization, its role in the diagnosis and prognosis of EMF has not been investigated. Methods and Results— Thirty-six patients (29 women; age, 54±12 years) with EMF diagnosis after clinical evaluation and comprehensive 2-dimensional Doppler echocardiography underwent cine-CMR for assessing ventricular volumes, ejection fraction and mass, and LGE-CMR for FT characterization and quantification. Indexed FT volume (FT/body surface area) was calculated after planimetry of the 8 to 12 slices obtained in the short-axis view at end-diastole (mL/m2). Surgical resection of FT was performed in 16 patients. In all patients, areas of LGE were confined to the endocardium, frequently as a continuous streak from the inflow tract extending to the apex, where it was usually most prominent. There was a relation between increased FT/body surface area and worse New York Heart Association functional class and with increased probability of surgery (P<0.05). The histopathologic examination of resected FT showed typical features of EMF with extensive endocardial fibrous thickening, proliferation of small vessels, and scarce inflammatory infiltrate. In multivariate analysis, the patients with FT/body surface area >19 mL/m2 had an increased mortality rate, with a relative risk of 10.8. Conclusions— Our study provides evidence that LGE-CMR is useful in the diagnosis and prognosis of EMF through quantification of the typical pattern of FT deposition.

Cardiac Sarcoidosis Evaluated by Delayed-Enhanced Magnetic Resonance Imaging

A 56-year-old woman with a history of chronic coughing and occasional wheezing was referred to the gastroenterology clinic with jaundice and weight loss of recent onset. Clinical evaluation showed evidence of chronic liver disease. Chest computed tomography showed an interstitial bilateral lung infiltrate and diaphragmatic lymphadenopathy. A liver biopsy was performed, revealing a noncaseating granulomatous hepatitis (Figure 1). Thorough investigation of granulomatous diseases was performed and the final diagnosis was sarcoidosis. A resting ECG showed premature atrial and ventricular beats and conduction disturbances (right bundle branch block and left anterior fascicular block). The patient was then referred to the Heart Institute (InCor) for cardiac evaluation. Figure 1. Liver biopsy showing numerous small and …

Evolutional aspects of children and adolescents with surgically corrected aortic coarctation: clinical, echocardiographic, and magnetic resonance image analysis of 113 patients

OBJECTIVE The goals of this study were to determine the prevalence of hypertension and recoarctation in operated children and teenagers and to integrate clinical and imaging technique data. METHODS One hundred thirteen infants and children (ages 14 years or less) were retrospectively divided into 3 groups according to the age at operation and the surgical technique: 79 underwent resection with end-to-end anastomosis; 14 had patch enlargement; 13 had subclavian flap aortoplasty; and 7 had other techniques performed. The mean age at operation was 3.95 +/- 4.17 years and the mean follow-up period was 4.62 +/- 4.90 years. Each patient was clinically examined and Doppler echocardiography was performed in 112 patients. Sixty-six patients underwent magnetic resonance imaging. Diameters of aortic arch were measured at 4 levels; the ratios between each one and descendent aorta diameters were calculated. Qualitative variables and associations were studied by Fisher exact test or chi-squared test. Comparisons of measurements in different groups were performed using variance analysis, with tests of selective contrasts (nonparametric tests). The level of statistical significance was <.05. RESULTS The prevalence of hypertension and recoarctation was 38% and 14%, respectively. No statistical difference was found among the age groups. In 65 patients who underwent magnetic resonance imaging, the transverse aortic arch was hypoplastic in 31 (47%) patients; 41 (63%) had stenosis at the site of anastomosis (ratio < 0.9). CONCLUSION Hypoplasia of transverse aortic arch was highly prevalent. These data suggest that hypoplastic aortic arch should be corrected concomitantly with coarctation.

Contrast-enhanced magnetic resonance imaging identifies focal regions of intramyocardial fibrosis in patients with severe aortic valve disease: Correlation with quantitative histopathology.

BACKGROUND Chronic aortic valve disease (AVD) is characterized by progressive accumulation of interstitial myocardial fibrosis (MF). However, assessment of MF accumulation has only been possible through histologic analyses of endomyocardial biopsies. We sought to evaluate contrast-enhanced magnetic resonance imaging (ce-MRI) as a noninvasive method to identify the presence of increased MF in patients with severe AVD. METHODS Seventy patients scheduled to undergo aortic valve replacement surgery were examined by cine and ce-MRI in a 1.5-T scanner. Cine images were used for the assessment of left ventricular (LV) volumes, mass, and function. Delayed-enhancement images were used to characterize the regions of MF. In addition, histologic analyses of myocardial samples obtained during aortic valve replacement surgery were used for direct quantification of interstitial MF. Ten additional subjects who died of noncardiac causes served as controls for the quantitative histologic analyses. RESULTS Interstitial MF determined by histopathologic analysis was higher in patients with AVD than in controls (2.7% +/- 2.0% vs 0.6% +/- 0.2%, P = .001). When compared with histopathologic results, ce-MRI demonstrated a sensitivity of 74%, a specificity of 81%, and an accuracy of 76% to identify AVD patients with increased interstitial MF. There was a significant inverse correlation between interstitial MF and LV ejection fraction (r = -0.67, P < .0001). Accordingly, patients with identifiable focal regions of MF by ce-MRI exhibited worse LV systolic function than those without MF (45% +/- 14% vs 65% +/- 14%, P < .0001). CONCLUSIONS Contrast-enhanced MRI allows for the noninvasive detection of focal regions of MF in patients with severe AVD. Moreover, patients with identifiable MF by ce-MRI exhibited worse LV functional parameters.

Coronary calcium score as predictor of stenosis and events in pretransplant renal chronic failure

BACKGROUND Coronary artery disease (CAD) is the major cause of death among chronic renal failure (CRF) patients. Traditional, non-invasive exams to detect CAD and to predict events have shown insufficient results in this group. CT Scan evaluation of Coronary Calcium Score (CCS) has proven to be of prognostic value for the population reporting no renal condition. OBJECTIVE To investigate CCS accuracy in detecting obstructive CAD and in predicting cardiovascular events in candidates to renal transplant as compared to quantitative invasive coronary angiography (ICA). METHODS Ninety-seven (97) CRF patients aged > or =35 were evaluated. Obstructive CAD was considered as > or =50% or > or =70% stenosis on ICA. Descriptive data, concordance, diagnostic tests, Kaplan-Meier, and multivariate analysis were used. RESULTS Agatston mean score was 580.6 +/- 1,102.2. Minimum and maximum values were 0 and 7,994, with median at 176. Only 14 patients had zero calcium score. No differences were reported in regard to ethnicity. Highest regional calcium was associated to the highest probability of coronary stenosis in the same segment. Agatston calcium score showed high accuracy for the diagnosis of > or =50% and > or =70% stenosis, with area under ROC curve (AUC) of 0.75 and 0.70, respectively. At the threshold of 400, calcium score identified a subgroup with a higher rate of cardiovascular events at an average follow-up time of 29+/-11.0 months. CONCLUSION CCS proved to have good diagnostic and prognostic performance for cardiovascular events evaluation in CRF patients.FUNDAMENTO: A doenca arterial coronariana (DAC) e a principal causa de obito em pacientes com insuficiencia renal cronica (IRC). Os exames nao invasivos tradicionais para deteccao de DAC e predicao de eventos tem apresentado resultados insuficientes nesse grupo. A avaliacao do escore de calcio coronariano (ECC) por tomografia computadorizada tem comprovado valor prognostico na populacao sem doenca renal. OBJETIVO: Avaliar a acuracia do ECC para detectar DAC obstrutiva e prever eventos cardiovasculares em candidatos a transplante renal comparada a angiografia coronariana invasiva (ACI) quantitativa. METODOS: Foram avaliados 97 pacientes com IRC e idade > 35anos. Foi considerada DAC obstrutiva a presenca de estenose >50% ou >70% pela ACI. Dados descritivos, concordância, testes diagnosticos, Kaplan-Meier e analise multivariada foram utilizados. RESULTADOS: O escore de Agatston medio foi de 580,6 ± 1.102,2; os valores minimos e maximos foram 0 e 7.994, e mediana de 176. Apenas 14 pacientes tinham escore de calcio de zero. Nao houve diferencas entre as etnias e a maior presenca de calcio regional associou-se a maior probabilidade de estenose coronaria no mesmo segmento. O escore de calcio de Agatston apresentou boa acuracia para o diagnostico de estenose, >50% e >70% com area sob a curva ROC de 0,75 e 0,70, respectivamente. No limiar de 400, o escore de calcio identificou o subgrupo com maior taxa de eventos cardiovasculares em tempo medio de seguimento de 29,1±11,0 meses. CONCLUSAO: O ECC na avaliacao de DAC apresentou boa performance diagnostica e prognostica para eventos cardiovasculares em pacientes com insuficiencia renal cronica (IRC).

Cardiovascular Magnetic Resonance In Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is the most frequent genetic cardiac disease that causes sudden death in young people, with an incidence of 1:500 adults. The routinely used criteria for worst prognosis have limited sensitivity and specificity. Thus, the estimated risk of evolving to dilated cardiomyopathy or sudden death is somewhat inaccurate, leading to management uncertainty of HCM patients. Therefore, an accurate noninvasive method for the diagnosis of HCM with prognostic value is of great importance. In the last years, Cardiovascular Magnetic Resonance (CMR) emerged not only as a diagnostic tool, but also as a study with prognostic values, by characterizing myocardial fibrosis with great accuracy in HCM patients. Additionally, CMR identifies the types of hypertrophy, analyses the ventricular function, estimates the intraventricular gradient and allows the determination of differential diagnosis. Moreover, CMR can uniquely access myocardial fibrosis in HCM.

Non-invasive assessment of right ventricular function in the late follow-up of the Senning procedure

Deteriorating ventricular function is a major concern after the Senning operation. A Doppler-derived non-geometric measurement, the so-called myocardial performance index, has been described for use in adults and children. We aimed to assess the utility of this index as a method for quantification of right ventricular function in patients in the late follow-up of the Senning procedure, and to correlate the right ventricular ejection fraction and the first derivative of right ventricular pressure as derived using echocardiography with the ejection fraction determined using magnetic resonance imaging. We studied 44 patients within a mean postoperative period of 15.3 years. We calculated the right ventricular myocardial performance index by pulsed wave Doppler interrogation of tricuspid inflow and aortic outflow, the ejection fraction by Simpsons rule, and the first derivative of right ventricular pressure by continuous wave Doppler from tricuspid regurgitation. Mean values of right ventricular myocardial performance index, ejection fraction, and the first derivative of right ventricular pressure were 0.50, 39 percent and 1,398 millimetres of mercury per second, respectively. A cut-off value of 0.47 for the right ventricle myocardial performance index was determined, with a sensitivity of 75 percent and a specificity of 62.5 percent. We found no correlation between ejection fraction and the first derivative of right ventricular pressure as estimated by echocardiography and the ejection fraction as shown by magnetic resonance imaging (r2 equal to 0.29 and 0.04 respectively). We concluded, first, that patients with preserved right ventricular function had values for the right ventricular myocardial performance index lower than 0.47, and second, that ejection fraction and the first derivative of right ventricular pressure as determined echocardiographically did not correlate with values derived using magnetic resonance imaging.

Partial left ventriculectomy in severe idiopathic dilated cardiomyopathy: Assessment of short-term results and their impact on late survival by magnetic resonance imaging

We evaluated short‐term effects of partial ventriculectomy on left ventricular (LV) parameters and its impact on late survival by magnetic resonance imaging (MRI). Twenty patients and 10 normal volunteers were studied, and LV volumes (EDV, ESV), ejection fraction (EF), short‐ and long‐axis dimensions (SA, LA), wall thickness (Wth), shape (LA/SA), geometry (Wth/SA), a geometry index (Phi), and wall‐motion score index (WMSI) were evaluated pre‐ and postoperatively. Also, we compared results and survival of patients with preoperative EF ≤17% vs. EF >17%. Short‐term results showed significant changes (P < 0.001) in: EF (17.3 ± 7.3% vs. 30.4 ± 9.5%), EDV (391.9 ± 118 vs. 272.7 ± 90 mL); ESV (308.2 ± 102.8 vs. 190.3 ± 68.4 mL); SA (80.5 ± 10.4 vs. 71.7 ± 7.8 mm); LA/SA (1.13 ± 0.1 vs. 1.34 ± 0.1); Wth (8.35 ± 0.99 vs. 9.75 ± 1.41 mm); Wth/SA (0.10 ± 0.01 vs. 0.14 ± 0.02), diastolic( 0.80 ± 0.16 vs. 0.58 ± 0.13) and systolic (0.78 ± 0.18 vs. 0.55 ± 0.12) Phi; and WMSI (−2 vs. −1) (P = 0.032). The EF division showed differences in: LA/SA (1.26 ± 0.10 vs. 1.49 ± 0.12) (P < 0.001); Wth/SA (0.13 ± 0.02 vs. 0.15 ± 0.02) (P = 0.023); diastolic (0.65 ± 0.11 vs. 0.48 ± 0.11) and systolic (0.63 ± 0.09 vs. 0.46 ± 0.09) Phi (P < 0.001); and WMSI (−2 vs. −1) (P = 0.033). Finally, correlation between pre/postoperative EF showed for EF < 17%, r = 0.32 and for EF >17%, r = 0.83, which had different late survival. Our study showed significant changes on LV parameters after ventriculectomy. Patients with EF >17% showed better EF correlation between pre/postoperative values and higher survival rate. J. Magn. Reson. Imaging 2001;13:781–786.