Marcelo Luiz Campos Vieira

Recommendations for the imaging assessment of prosthetic heart valves: a report from the European Association of Cardiovascular Imaging endorsed by the Chinese Society of Echocardiography, the Inter-American Society of Echocardiography, and the Brazilian Department of Cardiovascular Imaging †

Prosthetic heart valve (PHV) dysfunction is rare but potentially life-threatening. Although often challenging, establishing the exact cause of PHV dysfunction is essential to determine the appropriate treatment strategy. In clinical practice, a comprehensive approach that integrates several parameters of valve morphology and function assessed with 2D/3D transthoracic and transoesophageal echocardiography is a key to appropriately detect and quantitate PHV dysfunction. Cinefluoroscopy, multidetector computed tomography, cardiac magnetic resonance imaging, and to a lesser extent, nuclear imaging are complementary tools for the diagnosis and management of PHV complications. The present document provides recommendations for the use of multimodality imaging in the assessment of PHVs.

Quantification of Right Ventricular Volumes and Function by Real Time Three‐Dimensional Echocardiographic Longitudinal Axial Plane Method: Validation in the Clinical Setting

Background: Measurement of right ventricular (RV) volumes and right ventricular ejection fraction (RVEF) by three‐dimensional echocardiographic (3DE) short‐axis disc summation method has been validated in multiple studies. However, in some patients, short‐axis images are of insufficient quality for accurate tracing of the RV endocardial border. This study examined the accuracy of long‐axis analysis in multiple planes (longitudinal axial plane method) for assessment of RV volumes and RVEF. Methods: 3DE images were analyzed in 40 subjects with a broad range of RV function. RV end‐diastolic (RVEDV) and end‐systolic volumes (RVESV) and RVEF were calculated by both short‐axis disc summation method and longitudinal axial plane method. Results: Excellent correlation was obtained between the two methods for RVEDV, RVESV, and RVEF (r = 0.99, 0.99, 0.94, respectively; P < 0.0001 for all comparisons). Conclusion: 3DE longitudinal‐axis analysis is a promising technique for the evaluation of RV function, and may provide an alternative method of assessment in patients with suboptimal short‐axis images.

Effects of growth hormone replacement therapy on metabolic and cardiac parameters, in adult patients with childhood-onset growth hormone deficiency

OBJECTIVE We evaluated metabolic and cardiac parameter changes with GH-therapy. DESIGN Sixteen adults with childhood-onset hypopituitarism receiving pituitary hormone replacement, except GH-replacement, were assessed at baseline and after 6 and 12 months of GH-replacement. Sixteen healthy adults matched for sex, age, weight, height, body mass index, and body surface area served as the control group to compare cardiac function in both groups. RESULTS All patients had GH-deficiency. After 12 months, serum insulin-like growth factor-1 levels normalized. Basal glucose or insulin levels had no alterations. The low/high density lipoprotein-cholesterol ratio decreased (3.18+/-1.32 x 2.17+/-0.8, p<0.001). Percent lean body mass increased (69.9+/-5.5 x 78.4+/-8.1%), and percent fat body mass decreased (30.1+/-5.5 x 21.6+/-8.1%) (both, p<0.001). Before treatment, patients had decreased left ventricular (LV) echocardiographic morphologic indexes, which were corrected (initial versus 12 months): interventricular septal thickness (0.68+/-0.06 x 0.78+/-0.06 cm), LV posterior wall thickness (0.69+/-0.07 x 0.78+/-0.05 cm), and LV mass index (58.9+/-11.0 x 71.1+/-9.4 g/m(2)) (all, p<0.001). Exercise capacity improved, as assessed by oxygen consumption (7.84+/-1.44 x 9.67+/-1.74 METS, p<0.001). CONCLUSIONS GH-replacement seems to reduce cardiovascular risks in adults with childhood-onset GH-deficiency.

Perfil neuro-hormonal de pacientes reumáticos com insuficiência aórtica crônica importante

BACKGROUND Neurohormones are involved in the physiopathology of heart failure, but little is known about its behavior in significant chronic aortic regurgitation (AR). We aimed at analyzing the behavior of these mediators in AF. OBJECTIVE We aimed at analyzing the behavior of these mediators in AF. METHODS We analyzed 89 patients with AF, whose mean age was 33.6+/-11.5 years and of whom 84.6% were males, 60% asymptomatic, all with rheumatic etiology. After the clinical and echocardiographic assessment, plasma measurements of tumor necrosis factor (TNF), soluble TNF receptor types I and II (sTNFRI e sTNFRII), interleukin-6 (IL-6), its soluble receptor (sIL6R), endothelin-1 and B-type natriuretic peptide (BNP) were carried out; 12 healthy individuals were used as controls. RESULTS The mean values of the left ventricle diastolic diameter (LVDD) were 71.9+/-8.3mm, whereas the mean values of the LV systolic diameter (LVSD) were 50.4+/-9.3mm. The neurohormonal levels were elevated in patients with AF (TNF 92.65+/-110.24 pg/mL vs. 1.67+/-1.21 pg/ml in controls, p<0.001), (IL-6 7.17+/-7.78 pg/ml vs. 0.81+/-0.38 pg/mL in controls, p=0.0001) and TNFRI (894.75+/-348.87 pg/mL vs. 521.42+/-395.13 pg/ml, p=0.007). Except for the BNP levels, symptomatic and asymptomatic patients presented a similar neurohormonal profile. There was a correlation between TNFRII and LVDD (r=-0.329, p=0.038) and LVSD (r=-0.352, p=0.027). BNP levels were significantly higher in symptomatic patients and only in the latter it was possible to establish a correlation between BNP and ventricular diameters. CONCLUSION Patients with significant chronic AF present high neurohormonal levels, with no correlation with the symptomatic status. The TNFRII and BNP levels could be correlated with ventricular diameters, but only the latter could be correlated with symptoms.FUNDAMENTO: Os neuro-hormonios estao envolvidos na fisiopatologia da insuficiencia cardiaca, mas pouco se sabe sobre seu comportamento na insuficiencia aortica cronica importante (IAo). OBJETIVO: Analisar o comportamento desses mediadores na IAo. METODOS: Analisamos 89 pacientes com IAo, com media etaria de 33,6±11,5 anos, 84,6% do sexo masculino, 60% assintomaticos, todos de etiologia reumatica. Apos avaliacao clinica e ecocardiografica, realizaram-se dosagens plasmaticas de fator de necrose tumoral (TNF), seus antagonistas receptores soluveis tipos I e II (sTNFRI e sTNFRII), interleucina-6 (IL-6), seu receptor soluvel, endotelina-1 e peptideo natriuretico tipo B (BNP). Doze individuos saudaveis serviram como controle. RESULTADOS: O valor medio de diâmetro diastolico (DD) do ventriculo esquerdo (VE) foi de 71,9±8,3 mm, e o do diâmetro sistolico (DS) do VE, de 50,4±9,3 mm. Os niveis de neuro-hormonios estavam elevados nos pacientes com IAo: TNF 92,65±110,24 pg/ml vs. 1,67±1,21 pg/ml nos controles, p<0,001; IL-6 7,17±7,78 pg/ml vs. 0,81±0,38 pg/ml nos controles, p = 0,0001; e TNFRI 894,75±348,87 pg/ml vs. 521,42±395,13 pg/ml, p = 0,007. Com excecao dos niveis de BNP, os pacientes sintomaticos e assintomaticos apresentaram perfil neuro-hormonal semelhante. Houve correlacao entre TNFRII e diâmetro diastolico do ventriculo esquerdo (DDVE) (r = -0,329, p = 0,038) e diâmetro sistolico do ventriculo esquerdo (DSVE) (r = -0,352, p = 0,027). Os niveis de BNP estavam significativamente mais altos em pacientes sintomaticos, e apenas nestes foi possivel correlacao entre BNP e diâmetros ventriculares. CONCLUSAO: Pacientes com insuficiencia aortica cronica importante apresentam altos niveis neuro-hormonios, sem correlacao com o status sintomatico. Os niveis de TNFRII e BNP puderam ser correlacionados com diâmetros ventriculares, mas apenas este ultimo com sintomas.

Analysis of left ventricular regional dyssynchrony: comparison between real time 3D echocardiography and tissue Doppler imaging.

Background: There is a paucity of information concerning left ventricular (LV) dyssynchrony assessment by real time three‐dimensional (3D) echocardiography (RT3DE) versus tissue Doppler imaging (TDI). Aims: To compare RT3DE and TDI LV dyssynchrony assessment. Methods: A prospective study of 92 individuals (56 men, age 47 ± 10 years), 32 with dilated cardiomyopathy (CMP), and 60 healthy individuals. By RT3DE, we measured the LV% dyssynchrony index (DI) of 6, 12, and 16 segments (SDI). By pulsed‐wave TDI, we measured the QS electromechanical interval in the basal segments of the mitral valve annulus of the septum, the lateral, anterior and inferior walls, and the TDI% DI. Results: In the normal group, the 3D DI was 1.1 ± 0.8%, 1.4 ± 1.3%, 1.8 ± 1.7%, for 6 segments, 12 segments, and SDI, respectively. The correlation coefficient (Pearsons r) for the TDI DI and SDI was r = 0.2381 (P = 0.0470). In CMP group, the 3D DI was 4.6 ± 5.4%, 7.9 ± 7.1%, 11.1 ± 7.1%, for 6 segments, 12 segments, and SDI, respectively. The correlation coefficient for TDI DI and SDI was r = 0.7838 (P < 0.0001). Conclusions: We observed a good correlation between RT3DE and tissue Doppler LV dyssynchrony assessment in patients with advanced heart failure. (ECHOCARDIOGRAPHY, Volume 26, July 2009)

Echocardiography for hemodynamic evaluation in the intensive care unit.

The use of echocardiography in the intensive care unit for patients in shock allows the accurate measurement of several hemodynamic variables in a noninvasive way. By using echocardiography as a hemodynamic monitoring tool, the clinician can evaluate several aspects of shock states, such as cardiac output and fluid responsiveness, myocardial contractility, intracavitary pressures, and biventricular interactions. However, to date, there have been few guidelines suggesting an objective hemodynamic-based examination in the intensive care unit, and most intensivists are usually not familiar with this tool. In this review, we describe some of the most important hemodynamic parameters that can be obtained at the bedside with transthoracic echocardiography.

Cardiac Mechanics Evaluated by Speckle Tracking Echocardiography

Natural myocardial markers, or speckles, originated from constructive and destructive interference of ultrasound in the tissues may provide early diagnosis of myocardial changes and be used in the prediction of some cardiac events. Due to its relatively temporal stability, speckles can be tracked by dedicated software along the cardiac cycle, enabling the analysis of the systolic and diastolic function. They are identified by either conventional 2D grey scale and by 3D echo, conferring independence of the insonation angle, thus allowing assessment of cardiac mechanics in the three spatial planes: longitudinal, circumferential, and radial. The purposes of the present paper are: to discuss the role and the meaning of cardiac strain obtained by speckle tracking during the evaluation of cardiac physiology and to discuss clinical applications of this novel echocardiographic technology.

Right Ventricular Abnormalities in Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy, described as transient regional contractile abnormalities limited to the apical and mid‐segments of the left ventricle (LV), has also been reported to involve basal and/or mid LV segments (inverted Takotsubo); fewer reports, however, have addressed right ventricular (RV) dysfunction.

Left cardiac sympathetic denervation for treatment of symptomatic systolic heart failure patients: a pilot study

To evaluate the feasibility, safety, and potential beneficial effects of left cardiac sympathetic denervation (LCSD) in systolic heart failure (HF) patients.

Resultados imediatos e tardios da valvoplastia mitral percutânea em pacientes com estenose mitral

BACKGROUND The analysis of immediate and long-term results of mitral valvoplasty by balloon catheter (MVRBC) are still lacking in literature, mainly in the national context. OBJECTIVE To assess the immediate and late results of patients submitted to mitral valve repair by balloon catheter. METHOD A total of 330 consecutive patients were followed-up by 47 +/- 36 months (up to 126 months). Univariate and multivariate analyses assessed the factors associated with the success of the procedure, restenosis and late events (death or necessity of new intervention on mitral valve). Kaplan-Meier method estimated survival without events. RESULTS The procedure was successful in 305 cases (92.4%). The mitral valve anatomy was the main predictor for immediate success for the procedure. During the procedure, restenosis occurred in 77 (23.3%) patients and was associated with smaller mitral valve area and with larger calcification before the process. In a mean period of 38 +/- 26-month follow-up, 67 events occurred. The probability of survival without events was of 95% in one year, 75% in five years and 61% in ten years. The predictors of survival without events were: age, echocardiography score and immediate result of the procedure. CONCLUSION Mitral valve repair by balloon catheter is an effective procedure, as 60% patients did not present events after the follow-up. The anatomical condition of the mitral valve and the patients age were the best predictors of survival without events, and should be taken into account when selecting patients for the mentioned procedure.