Manuel Adán Gil

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.

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.

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)

Coronary Spasm during the Dobutamine Stress Echocardiography

The drug most widely used in pharmacological stress is dobutamine. Its sympathomimetic, inotropic and positive chronotropic action increases myocardial oxygen consumption and may trigger ischemia in patients with significant obstruction of coronary arteries. This agent is well tolerated and has a short half-life (2 to 3 minutes). Therefore, its effect can be stopped relatively quickly and safely. Betablockers such as metoprolol are often used at the end of the test to reverse the effects of dobutamine.

An Insignificant Flow That Intrigues Echocardiographers. Echocardiographic Pattern in 15 Cases of Coronary-Pulmonary Fistula and Literature Review

An Insignificant Flow That Intrigues Echocardiographers. Echocardiographic Pattern in 15 Cases of Coronary-Pulmonary Fistula and Literature Review Carlos Eduardo Suaide Silva,1 Vera Demarchi Aiello,2 Renata Rejane Linhares,1 Luciana Braz Peixoto,1 Mariane Daltrini Trandafilov Pimentel,3 Lucas Bercht,1 Fernanda Storti,1 Manuel Adán Gil,1 Claudia Gianini Monaco1 Diagnósticos da América SA (DASA-SP);1 Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo;2 OMNI-CCNI Medicina Diagnóstica,3 São Paulo, SP – Brazil

Comparison of Block-Matching and Optical Flow in Strain Echocardiography Analysis

Introdução: Diferentes tecnologias têm sido utilizadas para avaliar a função sistólica do ventrículo esquerdo. De particular interesse, está a ecocardiografia com strain bidimensional (2DSTE). Dois métodos diferentes têm sido usados para quantificar a deformação miocárdica (strain miocárdico) pela 2DSTE: block matching e optical flow. Ambos estão presentes em ecocardiógrafos comercialmente disponíveis. Entretanto, não há consenso a respeito se as medidas do strain longitudinal por estes métodos são sobreponíveis.

Pharmacological Stress Echocardiography in Patients with Anomalous Origin of Left Coronary Artery in Pulmonary Trunk

Pharmacological Stress Echocardiography in Patients with Anomalous Origin of Left Coronary Artery in Pulmonary Trunk Denise Bibiana Masselli1, Manuel Adan Gil1, Claudia Gianini Monaco1, Roberta Longo Machado1, Alfredo Jose Borges da Cunha1, Carlos Eduardo Suaide Silva1,2, Roberto Augusto Vasques Junior1, Felipe Silva Yared1, Guilherme Silva Yared1, Thaiene Martins Miranda2 OMNI-CCNI Medicina Diagnostica de Sao Paulo1; Diagnosticos da America de Sao Paulo (DASA)2, Sao Paulo, SP Brazil

Measures of Endocardial and Epicardial Longitudinal Strain by the Technique of Xstrain®: Are there Differences between their Values?

Material e métodos: Foram avaliados 32 pacientes hígidos com idade média de 31,6 ± 9,8 anos, sendo 18 masculinos (56%). Utilizamos o ecocardiógrafo modelo MyLab60® da Esaote (Firenze, Itália) com sonda multifrequencial (1,5 MHz a 2,6 MHz), e programa de computador para realização das novas técnicas ecocardiográficas (MyLab Desk, v 8.0, Esaote). Mediu-se o strain nas camadas endocárdica e epicárdica aos cortes apicais de 2, 3 e 4 câmaras.

Restrictive Cor Triatriatum in Asymptomatic Adult Patient

Cor Triatriatum (CT), inicialmente descrito em 1868, e uma malformacao congenita resultante da falha na reabsorcao da veia pulmonar comum durante a formacao embrionaria do coracao. Esse erro genetico representa 0,1% das cardiopatias congenitas, com incidencia de obito infantil em 75% das criancas sintomaticas nao tratadas. Na forma classica, caracteriza-se pela presenca de uma membrana fibromuscular no atrio esquerdo, dividindo essa estrutura em duas câmaras: uma proximal, dita acessoria, que recebe as veias pulmonares, e uma distal, correspondendo o verdadeiro atrio esquerdo, onde se encontra o orificio do apendice atrial e a valva mitral1-5. A gravidade e a idade com que manifestam os sintomas da doenca sao determinadas, essencialmente, pelo numero e tamanho das fenestracoes. Doentes com fenestracoes de diâmetro superior a 1 cm sao habitualmente assintomaticos6,7. Os doentes com fenestracoes pequenas desenvolvem, geralmente, sintomas decorrentes da hipertensao pulmonar (dispneia de esforco, ortopneia, hemoptise etc.) com fisiologia semelhante a da estenose valvar mitral. O cor triatriatum esta, frequentemente, associado a outras anomalias congenitas como comunicacao interatrial, persistencia de veia cava superior esquerda, anomalias do retorno venoso pulmonar, comunicacao interventricular ou mesmo cardiopatias mais complexas como tetralogia de Fallot8.

Echocardiographic identification of the oblique vein of the left atrium: its relationship to the persistent left superior caval vein

Thus far, little has been written concerning echocardiographic identification of the oblique vein of the left atrium, or Marshalls vein. There is much discussion, nonetheless, on the potential significance of the vein, or its ligamentous remnant, as an arrhythmic substrate. We describe here four patients in whom transthoracic echocardiography revealed a venous structure protruding within the cavity of the left atrium. We discuss the possibility that these structures represent Marshalls vein, albeit probably as part of a persistent left superior caval vein.