Juarez Ortiz

National alert campaign about increased cholesterol: determination of cholesterol levels in 81,262 Brazilians

OBJECTIVE To determine the levels of total cholesterol in a significant sample of the Brazilian population. METHODS Blood cholesterol was determined in 81.262 individuals > 18 years old (51% male, 44.7 +/- 15.7 years), using Accutrend equipment, in the cities São Paulo, Campinas, Campos do Jordão, São José dos Campos, Santos, Santo André , Ribeirão Preto, Porto Alegre, Rio de Janeiro, Belo Horizonte, Curitiba, Brasília, Salvador and documented in the presence of other risk factors (RF) for coronary artery disease (CAD) (systemic hypertension, CAD in the family, smoking, and diabetes). Participants were classified according to sex, age, and the presence or absence of RF, respectively, as 0 RF, 1 RF and > 2 RF. The percentage of individuals with cholesterol > 200 mg/dL and > 240 mg/dL was evaluated. RESULTS The prevalence of individuals with 0, 1, and > 2 risk factors was 30% (n = 24,589), 36% (n =29,324), and 34% (n = 27,349) respectively, (P=0.657), and the mean total cholesterol of the population was 199.0 +/- 35.0 mg/dL. Cholesterol levels above 200 and 240 mg/dL were found, respectively, in 40% (n = 32,515) and 13% (10.942) of individuals. The greater the number of risk factors the higher the levels of cholesterol (P<0.0001) and the greater the proportion of individuals with cholesterol > 200 mg/dL (P=0.032). No difference existed in the proportion of individuals with cholesterol > 240 mg/dL (P=0.11). CONCLUSION A great percentage of individuals with cholesterol levels above those recommended to prevent coronary artery disease was found.

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.

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.

Disfunção erétil: um marcador para alterações da perfusão miocárdica?

OBJECTIVE To study the correlation between erectile dysfunction (ED) and myocardial perfusion impairment in men with suspected or diagnosed coronary artery disease (CAD). METHODS In this prospective study a self-administered IIEF-5 questionnaire was answered by 287 patients that underwent myocardial perfusion imaging under both resting and stress condition with technetium-99m sestamibi, through gated SPECT nuclear scintigraphy technique, before and after physical or pharmacological stress. RESULTS Some degree of erectile dysfunction (group ED+) was found in 137 (47.8%) patients and in these, age was significantly higher (60.60+/-9.84 vs 50.67+/-9.94 - p<0.001)) than in those without erectile dysfunction (group ED-). In the ED+ group, it was observed a higher prevalence of hypertension, diabetes, myocardial infarction (MI) and percutaneous coronary angioplasty (PCTA). Regardless of the age factor, ED+ patients also presented higher occurrence of myocardial perfusion impairment (necrosis and/or ischemia) and left ventricular systolic wall motion and thickening abnormalities. CONCLUSION Patients with ED have higher estimated probability of presenting segmental myocardial perfusion and functional contraction impairment and, therefore, CAD, independent of the aging factor. The authors conclude that ED may be considered not only a marker for CAD but also a condition related to the occurrence of major coronary events such as MI and PCTA.

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.

Left ventricular pseudoaneurysm due to penetrating injury of the chest: an echocardiographic diagnosis.

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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)