Luiz Francisco Rodrigues de Ávila

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.

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).

Extensive Xanthomas and Severe Subclinical Atherosclerosis in Homozygous Familial Hypercholesterolemia

![Figure][1] An asymptomatic 20-year-old man presented with a history of high plasma cholesterol levels and gigantic tendinous xanthomas over the extensor tendons of his metacarpophalangeal joints and patellas (A to C) . Laboratory tests showed total cholesterol of 785 mg/dl, low-density

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.

I Diretriz de Ressonância e Tomografia Cardiovascular da Sociedade Brasileira de Cardiologia Sumário Executivo

Cesar Augusto Mastrofrancisco Cattani, Dany Jasinowodolinsk, Fabiano Lucchesi, Fabio Berezowsky Rocha, Fatima Cristina Pedroti, Gilberto Szarf, Guilherme Urpia Monte, Iugiro Roberto Kuroki , Joalbo Andrade, Jose Rodrigues Parga Filho, Luis Claudio Correia, Luiz Francisco Avila, Marcelo Hadlich, Marcelo Zapparoli, Marcia Barbosa, Marcia Lima Mugnaini, Maria Helena Albernaz Siqueira, Marly Maria Uellendhal, Miguel Abraao Rosario Neto, Paulo R. Schwarzman, Raul Dias dos Santos Filho, Ricardo Loureiro, Roberto Kalil Filho, Robson de Macedo Vieira

Ressonância magnética vs cintilografia com pirofosfato marcado com tecnécio-99m para a detecção de necrose miocárdica perioperatória

BACKGROUND: Perioperative myocardial infarction (POMI) is a complication of coronary artery bypass grafting (CABG) with a potential prognostic impact. Technetium-99m pyrophosphate myocardial scintigraphy (MS) is used in the diagnosis of POMI; however it shows a limited sensitivity for subendocardial lesions. Cardiovascular magnetic resonance imaging (CMRI), in turn, has a high accuracy in the detection of myocardial necrosis. OBJECTIVE: To compare CMRI and MS for the detection of POMI after CABG. METHODS: A total of 24 patients with chronic coronary artery disease were studied using the delayed contrast enhanced CMRI and MS before and after CABG by analyzing the development of areas of perioperative myocardial necrosis (POMI). Biochemical markers of myocardial injury (CKMB and troponin I) were also determined before and after surgery. RESULTS: Nineteen patients completed the study. Of these, 6 (32%) presented POMI on CMRI and 4 (21%) on MS (p = NS). Of the 323 left ventricular segments assessed, 17 (5.3%) showed perioperative necrosis on CMRI and 7 (2.2%) on MS (p = 0.013). Moderate agreement was observed between the methods (kappa = 0.46). There was disagreement regarding the diagnosis of POMI in 4 (21%) cases, most of them with small areas of perioperative necrosis on CMRI which were not visualized on MS. In all cases with POMI on CMRI, significant CKMB and troponin I elevations were observed. CONCLUSION: Moderate diagnostic agreement was observed between the methods for the detection of POMI, but CMRI enabled visualization of small areas of perioperative myocardial necrosis which were not identified on MS and were associated with elevation of biochemical markers of myocardial injury.

Late enhancement and myocardial perfusion in hypertrophic cardiomyopathy (comparison betw een groups)

BACKGROUND The magnetic resonance imaging (MRI) is an effective method to study hypertrophic cardiomyopathy (HCM). OBJECTIVE To evaluate, using MRI, the parameters of systolic function, perfusion and myocardial viability in patients with HCM, comparing the groups with and without obstruction of the left ventricular outflow tract. METHODS Twenty-one patients with a diagnosis of HCM underwent the assessment of myocardial function, viability and perfusion under stress and at rest through MRI. RESULTS The ventricular segments most severely impaired by hypertrophy were those of the septal region. The obstructive group presented segmental myocardial thickening distribution similar to the non-obstructive group, but with higher means than the first group. The mean ejection fraction of the patients in the obstructive group was higher than in the non-obstructive group, whereas the means of the end systolic and diastolic volumes were lower in the obstructive group. There was a positive correlation between the ventricular segmental thickening and the late enhancement segmental mass. The stress induction resulted in an increase in the number of segments with perfusion alterations and this alteration was more evident in the obstructive group. CONCLUSION The thickest ventricular segments are the septal ones. The hypertrophic regions are associated to a greater extension of late enhancement. There was a positive correlation between the areas of ventricular hypertrophy and altered myocardial perfusion and these findings were more evident in the obstructive group.FUNDAMENTO: La resonancia magnetica es un metodo eficaz para estudio de la cardiomiopatia hipertrofica. OBJETIVO: Evaluar, por la resonancia magnetica, los parametros de funcion sistolica, perfusion y viabilidad miocardica en pacientes portadores de cardiomiopatia hipertrofica, comparando los grupos con y sin obstruccion en la via de salida del ventriculo izquierdo. METODO: Veinte y un pacientes con diagnostico de cardiomiopatia hipertrofica realizaron estudios de funcion, viabilidad y perfusion miocardica en las fases de estres y de reposo por la resonancia magnetica. RESULTADOS: Los segmentos ventriculares mas comprometidos por la hipertrofia fueron los de la region septal. El grupo obstructivo presento distribucion segmental de espesor miocardico semejante al no obstructivo, pero con mayores promedios que el primer grupo. El promedio de la fraccion de eyeccion de los pacientes del grupo obstructivo fue mayor que el grupo no obstructivo, mientras que los promedios de los volumenes sistolico y diastolico finales se hallaron menores en el grupo obstructivo. Hubo correlacion positiva entre el espesor de los segmentos del ventriculo y la masa segmental del realce tardio. La induccion de estres determino aumento del numero de segmentos con alteracion de perfusion, y esa alteracion fue mas evidente en el grupo obstructivo. CONCLUSION: Los segmentos ventriculares con mayor espesor son los septales. Las regiones hipertroficas estan asociadas a la mayor extension de realce tardio. Hubo correlacion positiva entre las areas de hipertrofia ventricular y perfusion miocardica alterada, y estos hallazgos fueron mas evidentes en el grupo obstructivo.