Liliane Kopel

Automatic measurement of carotid diameter and wall thickness in ultrasound images

Carotid vessel ultrasound imaging is a reliable noninvasive technique to measure the arterial morphology. Lumen Diameter (LD), intima-media thickness (IMT) of the far wall, and plaque presence can be reliably determined using B-mode ultrasound. In order to measure the carotid IMT as well as any other more complex quantitative indices of vessel morphology, it is necessary to identify lumen-intima and media-adventitia borders in the ultrasound images. In this paper we describe an automatic approach to measure LD and IMT based on an active contour technique improved by a multiresolution analysis. The measurements of LD and IMT were compared to manual tracing of the vessels border in terms of coefficients of variability (CV) and correlation (R). The results have shown that the method is a reliable and reproducible way of assessing the LD and far wall IMT in the carotid artery.

Assessment of carotid diameter and wall thickness in ultrasound images using active contours improved by a multiresolution technique

Carotid vessel ultrasound imaging is a reliable non-invasive technique to measure the arterial morphology. Vessel diameter, intima-media thickness (IMT) of the far wall and plaque presence can be reliably determined using B-mode ultrasound. In this paper we describe a semi-automatic approach to measure artery diameter and IMT based on an active contour technique improved by a multiresolution analysis. The operator selects a region-of-interest (ROI) in a series of carotid images obtained from B-mode ultrasound. This set of images is convolved with the corresponding partial derivatives of the Gaussian filter. The filter response is used to compute a 2D gradient magnitude image in order to refine the vessels boundaries. Using an active contour technique the vessels border is determined automatically. The near wall media-adventitia (NWMA), far wall media-adventitia (FWMA) and far wall lumen-intima (FWLI) borders are obtained by a least-square fitting of the active contours result. The distance between NWMA and FWLI (vessel diameter) and between FWLI and FWMA (far wall intima-media thickness) are obtained for all images and the mean value is computed during systole and diastole. The proposed method is a reliable and reproducible way of assessing the vessel diameter and far wall intima-media thickness of the carotid artery.

Emergência de infecção por Trichosporon Asahii em pacientes portadores de insuficiência cardíaca em unidade de terapia intensiva cardiológica: relato de caso e revisão da literatura

BACKGROUND AND OBJECTIVES: Infection with the non-Candida yeast species Trichosporon have been recognized with increasing frequency over the last two decades. Invasive disease due to trichosporonosis has been reported from neutropenic patients with cancer and the mortality is high. Recently, others groups of patients have become susceptible to this rare fungi. We report the emerging of infection with pathogenic Trichosporon asahii in severely ill heart failure patients in a tertiary cardiological intensive care unit (CICU). We describe our data, and report a fatal case of disseminated trichosporonosis in a patient with heart failure. We also review literature pertaining to T. asahii infections. CASE REPORT: An 85 year-old woman with a history of hypertension, heart failure (ejection fraction (EJ): 30%) and pulmonary embolism was admitted to a medical cardiological ICU after cardiac arrest (ventricular fibrillation) resuscitated during a routine consultation. There were no neurological sequelae and the echocardiogram revels no changes, neither the cardiac biomarkers. Ventricular fibrillation was considered secondary to heart failure. The patient had extubation failure and difficult weaning needing long term mechanical ventilation even after tracheostomy. Her hospital course was complicated by acute renal failure and recurrent respiratory, urinary and systemic bacterial infections, which responded to broad-spectrum antibiotics. After a temporary improvement she developed urinary infection and subsequent septic shock. Cultures of urine and blood specimens grew T. asahii. Treatment with liposome amphotericin B (5 mg/kg/day) was started. Despite receiving vancomycin and imipenem, the clinical condition of the patient deteriorates. Blood taken for culture on the seventh day of amphotericin B therapy were negative but urine specimen still grew T. asahii. On the eighteenth day of antifungal therapy, the patient died with multiorgan failure. CONCLUSIONS: The increasing of severely ill patients, and the use of broad spectrum antibiotics, has predisposed the emerging of invasive infections by rare and new opportunistic fungal pathogens. Severe infection related to T. asahii, until recently restricted to neutropenic patients with cancer, has been frequently identified in heart failure patients with advanced age. The mortality is high. These data highlights the importance of considering this group of patients as a risk group for T. asahii infection.

Arterial distensibility as a possible compensatory mechanism in chronic aortic regurgitation

OBJECTIVE: To evaluate elastic properties of conduit arteries in asymptomatic patients who have severe chronic aortic regurgitation. METHODS: Twelve healthy volunteers aged 30±1 years (control group) and 14 asymptomatic patients with severe aortic regurgitation aged 29±2 years and left ventricular ejection fraction of 0.61±0.02 (radioisotope ventriculography) were studied. High-resolution ultrasonography was performed to measure the systolic and diastolic diameters of the common carotid artery. Simultaneous measurement of blood pressure enabled the calculation of arterial compliance and distensibility. RESULTS: No differences were observed between patients with aortic regurgitation and the control group concerning age, sex, body surface, and mean blood pressure. Pulse pressure was significantly higher in the aortic regurgitation group compared with that in the control group (78±3 versus 48±1mmHg, P<0.01). Arterial compliance and distensibility were significantly greater in the aortic regurgitation group compared with that in the control group (11.0±0.8 versus 8.1±0.7 10-10 N-1 m4, P=0.01 e and 39.3±2.6 versus 31.1±2.0 10-6 N-1 m2, P=0.02, respectively). CONCLUSION: Patients with chronic aortic regurgitation have increased arterial distensibility. Greater vascular compliance, to lessen the impact of systolic volume ejected into conduit arteries, represents a compensatory mechanism in left ventricular and arterial system coupling.

Cardiac tamponade in hereditary hemorrhagic telangiectasia

Hereditary hemorrhagic telangiectasia, also known as Osler-Weber-Rendu disease, is an inherited autosomal dominant disorder characterized by widespread vascular malformations that may rupture spontaneously(1). Epistaxis and telangiectases of the skin and mucosal surfaces are the most frequent clinical manifestations. Involvement of the gut, lungs, and liver have been reported. We report a patient with hereditary hemorrhagic telangiectasia who developed a large pericardial effusion with cardiac tamponade, and provide data demonstrating vascular involvement of the pericardium.

Therapeutic hypothermia after sudden cardiac arrest: Endothelial function evaluation

Therapeutic hypothermia (TH) is now part of the treatment trategy for patients successfully resuscitated after cardiac arrest nce it was demonstrated to improve neurologic outcome and ncrease survival rates.1 TH is associated with several cardiovasular effects. There is a decrease in heart rate and cardiac index and n increase in mean blood pressure and systemic vascular resisance. A variety of arrhythmias may be induced by hypothermia. owever, it is unknown whether vascular reactivity is impaired uring TH after cardiac arrest. We describe an evaluation of endothelium function in a case f an out-of-hospital survivor of cardiac arrest submitted to TH. uring hypothermia and after rewarming brachial flow-dependent asodilation was evaluated. The patient was a 39-year-old male atient victim of ventricular fibrillation who had been resuscitated t home after 20 min and remained comatose after the resumption f spontaneous circulation (ROSC). At hospital admission, Glasgow oma Scale was 8. Cardiovascular risk stratification was performed. lectrocardiography showed sinus rhythm with diffuse repolarzation abnormalities. Angiographic study revealed no coronary bstructive lesions and moderate diffuse left ventricular dysfuncion. Patient was admitted to the ICU and general management of ost-cardiac arrest care was initiated, including TH for 24 h. After ecovery, electrophysiological testing was performed and revealed entricular fibrillation triggered by the use of propafenone. An mplantable cardioverter-defibrillator was indicated. Patient was ischarged from the hospital without neurological sequelae. Using noninvasive approach, with high-resolution ultrasound, we meaured brachial artery diameter and brachial artery blood flow elocity at rest and during reactive hyperemia (RH) after a 5in occlusion of the brachial artery with a blood pressure cuff2,3 Fig. 1) in two moments: first at temperature of 32.6 ◦C, after the ooling period, and second at 37.1 ◦C, after rewarming. After the timuli of RH, the % increases in brachial diameter, peak blood ow and mean blood flow during hypothermia were 20.8 ± 2.3%, 41.3 ± 14.9% and 416.7 ± 14.3%, respectively. After rewarming, hese changes expressed as % were: 8.9 ± 3.5%, 84.5 ± 14.2% and 28.6 ± 18.9%, respectively. Flow-dependent vasodilation, that is econdary to endothelial NO release during RH, was maintained uring TH suggesting an intact endothelial function. ROSC after prolonged whole-body ischemia and subsequent eperfusion that happens after successful cardiopulmonary resusitation is a complex pathological process. The post-cardiac rrest syndrome is a multiple disorder process that causes brain njury, myocardial dysfunction and systemic ischemia/reperfusion esponse, including coagulation disorders, adrenal dysfunction, assive inflammation and microcirculatory impairment.4 The icrocirculatory function is abnormal in post-resuscitation period 4

Avaliação nutricional do cardiopata crítico em terapia de substituição renal: dificuldade diagnóstica

OBJECTIVE: Evaluate the nutritional status of patients with cardiac disease and concomitant renal dysfunction requiring renal replacement therapy. METHODS: Patients with cardiac disease and renal failure receiving renal replacement therapy, admitted to an intensive care unit, were submitted to nutritional evaluation, by use of anthropometric measurements and laboratory data. RESULTS: We studied 43 patients, mean age 64±15 years, 26 were men. The mean left ventricular ejection fraction was 0.36±0.16. Analysis of anthropometric measurements, based on body mass index disclosed that, 18 patients were normal, 6 were underweight and 19 were overweight or obese. Based on measurement of triceps skinfold thickness, 16 patients were considered normal and 27 had some degree of depletion. Measurements of midarm circumference and midarm muscular circumference showed 41 patients with some degree of depletion. Laboratory data revealed 28 patients with depletion based on albumin levels and 27 with depletion based on lymphocyte count. CONCLUSIONS: Malnutrition is common in critically ill patients with cardiac disease and renal failure receiving renal replacement therapy. Nutritional assessment based on body mass index did not prove to be a good index for diagnosis of nutritional disorders. The nutritional evaluation must be complemented in order to identify malnutrition and introduce early nutritional support.

Aortic Counterpulsation Therapy in Patients with Advanced Heart Failure: Analysis of the TBRIDGE Registry

Background The use of aortic counterpulsation therapy in advanced heart failure is controversial. Objectives To evaluate the hemodynamic and metabolic effects of intra-aortic balloon pump (IABP) and its impact on 30-day mortality in patients with heart failure. Methods Historical prospective, unicentric study to evaluate all patients treated with IABP betwen August/2008 and July/2013, included in an institutional registry named TBRIDGE (The Brazilian Registry of Intra-aortic balloon pump in Decompensated heart failure - Global Evaluation). We analyzed changes in oxygen central venous saturation (ScvO2), arterial lactate, and use of vasoactive drugs at 48 hours after IABP insertion. The 30-day mortality was estimated by the Kaplan-Meier method and diferences in subgroups were evaluated by the Log-rank test. Results A total of 223 patients (mean age 49 ± 14 years) were included. Mean left ventricle ejection fraction was 24 ± 10%, and 30% of patients had Chagas disease. Compared with pre-IABP insertion, we observed an increase in ScvO2 (50.5% vs. 65.5%, p < 0.001) and use of nitroprusside (33.6% vs. 47.5%, p < 0.001), and a decrease in lactate levels (31.4 vs. 16.7 mg/dL, p < 0.001) and use of vasopressors (36.3% vs. 25.6%, p = 0.003) after IABP insertion. Thirty-day survival was 69%, with lower mortality in Chagas disease patients compared without the disease (p = 0.008). Conclusion After 48 hours of use, IABP promoted changes in the use of vasoactive drugs, improved tissue perfusion. Chagas etiology was associated with lower 30-day mortality. Aortic counterpulsation therapy is an effective method of circulatory support for patients waiting for heart transplantation.

Ressonância nuclear magnética no diagnóstico de pseudoaneurisma de ventrículo esquerdo. Antigo problema, nova opção

We describe the case of a 61 year-old female patient admitted to the hospital with acute lateral myocardial infarction, in pulmonary edema, who evolved to cardiogenic shock in the first hours. Transesophageal echodoppler-cardiogram and nuclear magnetic resonance imaging showed the diagnosis of a left ventricular pseudoaneurysm. Surgical repair was successfully undertaken.

Cerebral blood flow changes during intermittent acute hypoxia in patients with heart failure

Objective Heart failure (HF) is associated with intermittent hypoxia, and the effects of this hypoxia on the cardiovascular system are not well understood. This study was performed to compare the effects of acute hypoxia (10% oxygen) between patients with and without HF. Methods Fourteen patients with chronic HF and 17 matched control subjects were enrolled. Carotid artery changes were examined during the first period of hypoxia, and brachial artery changes were examined during the second period of hypoxia. Data were collected at baseline and after 2 and 4 minutes of hypoxia. Norepinephrine, epinephrine, dopamine, and renin were measured at baseline and after 4 minutes hypoxia. Results The carotid blood flow, carotid systolic diameter, and carotid diastolic diameter increased and the carotid resistance decreased in patients with HF. Hypoxia did not change the carotid compliance, distensibility, brachial artery blood flow and diameter, or concentrations of sympathomimetic amines in patients with HF, but hypoxia increased the norepinephrine level in the control group. Hypoxia increased minute ventilation and decreased the oxygen saturation and end-tidal carbon dioxide concentration in both groups. Conclusion Hypoxia-induced changes in the carotid artery suggest an intensification of compensatory mechanisms for preservation of cerebral blood flow in patients with HF.