Meive Furtado

Importance of adequately performed Valsalva maneuver to detect patent foramen ovale during transesophageal echocardiography.

BACKGROUND Transesophageal echocardiography (TEE) plays an important role in evaluating cardioembolic sources of emboli. The identification of a patent foramen ovale (PFO) is reportedly improved with TEE compared with transthoracic echocardiography (TTE), but the Valsalva maneuver during TEE may be difficult or suboptimal. The aim of this study was to assess the efficacy of the Valsalva maneuver for PFO diagnosis using TEE compared with TTE by evaluating patients with ischemic stroke referred for echocardiography. METHODS Only patients able to perform the Valsalva maneuver during TTE were included; efficacy was defined by a 20 cm/sec decrease in transmitral E velocity. A PFO was judged present when microbubbles of agitated intravenous saline were seen in the left chambers within three cycles after right atrial opacification. RESULTS Of 108 patients (mean age, 55 ± 15 years; 61 men), 48 (44%) were judged to have PFOs by TEE and/or TTE. In 36 patients (33% of the total, 75% of those with PFOs), microbubbles were observed both by TEE and TTE, in seven patients only during TTE, and in five patients only during TEE. In patients able to satisfactorily perform the Valsalva maneuver during TEE, 22 PFOs were found, and two shunts (9%) were missed, whereas in patients unable to perform this maneuver, 26 PFOs were observed, with five shunts missed (19%) (P < .05). When a PFO was missed by TTE, either the echocardiographic window was suboptimal or the shunt was small. CONCLUSIONS An adequate Valsalva maneuver is crucial for diagnosis of PFO; most patients with stroke may be screened using TTE with contrast and the Valsalva maneuver, with TEE indicated in case of suboptimal transthoracic images.

Serum B-type natriuretic peptide in the initial workup of patients with new onset ascites: A diagnostic accuracy study

Heart failure (HF) is, after cirrhosis, the second‐most common cause of ascites. Serum B‐type natriuretic peptide (BNP) plays an important role in the diagnosis of HF. Therefore, we hypothesized that BNP would be useful in the differential diagnosis of ascites. Consecutive patients with new onset ascites were prospectively enrolled in this cross‐sectional study. All patients had measurements of serum‐ascites albumin gradient (SAAG), total protein concentration in ascitic fluid, serum, and ascites BNP. We enrolled 218 consecutive patients with ascites resulting from HF (n = 44), cirrhosis (n = 162), peritoneal disease (n = 10), and constrictive pericarditis (n = 2). Compared to SAAG and/or total protein concentration in ascites, the test that best discriminated HF‐related ascites from other causes of ascites was serum BNP. A cutoff of >364 pg/mL (sensitivity 98%, specificity 99%, and diagnostic accuracy 99%) had the highest positive likelihood ratio (168.1); that is, it was the best to rule in HF‐related ascites. Conversely, a cutoff ≤182 pg/mL had the lowest negative likelihood ratio (0.0) and was the best to rule out HF‐related ascites. These findings were confirmed in a 60‐patient validation cohort. Conclusions: Serum BNP is more accurate than ascites analyses in the diagnosis of HF‐related ascites. The workup of patients with new onset ascites could be streamlined by obtaining serum BNP as an initial test and could forego the need for diagnostic paracentesis, particularly in cases where the cause of ascites is uncertain and/or could be the result of HF. (Hepatology 2014;59:1043–1051)

Left Ventricular Dilation and Pulmonary Vasodilatation after Surgical Shunt for Treatment of Pre-Sinusoidal Portal Hypertension.

Objective The aim of this study was to prospectively investigate the long-term cardiovascular and pulmonary hemodynamic effects of surgical shunt for treatment of portal hypertension (PH) due to Schistosomiasis mansoni. Location The University of São Paulo Medical School, Brazil; Public Practice. Methods Hemodynamic evaluation was performed with transesophageal Doppler and contrast-enhanced echocardiography (ECHO) on twenty-eight participants with schistosomal portal hypertension. Participants were divided into two groups according to the surgical procedure used to treat their schistosomal portal hypertension within the last two years: group 1—distal splenorenal shunt (DSRS, n = 13) and group 2—esophagogastric devascularization and splenectomy (EGDS, n = 15). Results The cardiac output (5.08 ± 0.91 L/min) and systolic volume (60.1 ± 5.6 ml) were increased (p = 0.001) in the DSRS group. DSRS participants had a significant increase (p < 0.0001) in their left ventricular end-systolic and end-diastolic diameters as well as in their left ventricular end-diastolic and end-systolic volumes (p < 0.001) compared with the preoperative period. No statistically significant difference was found in the patients who underwent EGDS. ECHO revealed intrapulmonary vasodilatation (IPV) in 18 participants (64%), 9 DSRS and 9 EGDS (p > 0.05). Conclusions The late increase in the cardiac output, stroke volume and left ventricular diameters demonstrated left ventricular dilatation after a distal splenorenal shunt. ECHO revealed a greater prevalence for IPV in patients with schistosomiasis than has previously been described in patients with PH from liver cirrhosis.

Endophthalmitis as a first manifestation of right-sided endocarditis in a patient with patent foramen ovale

Endogenous endophthalmitis is a rare complication of endocarditis, rendering poor visual prognosis. We report a case of a 66-year-old female with renal failure who presented with fever, ocular pain, and purulent eye discharge. After a diagnosis of endogenous endophthalmitis, she was treated with antibiotics and enucleation of the eye. Due to persistent fever and positive blood cultures, a transesophageal echocardiography was undertaken, disclosing a large mural vegetation in the right atrium, catheter-associated vegetations, and a patent foramen ovale. Endocarditis is an uncommon source of endogenous endophthalmitis, and has rarely been associated to right-sided endocarditis and paradoxical septic embolization.

Erratum to: Pre and Post Operative 3D Echocardiographic Appearance of Isolated Cleft of the Anterior Mitral Valve Leaflet

A 15-year-old boy with progressive fatigue presented with failure to thrive, pan systolic murmur at the apex, left ventricular overload shown on the electrocardiogram (ECG), and cardiac enlargement shown on the X-ray. Twodimensional echocardiography (2DE) showed a cleft of the anterior mitral valve leaflet with severe regurgitation (Fig. 1), whereas RT3DE showed a much more clear definition of the mitral anatomy and the extension of the isolated cleft at the free edges of the leaflet (Fig. 3a and Movie clip 1). The boy underwent surgical treatment with simple interrupted suture of the cleft. The postoperative 2DE showed bright points on the anterior leaflet corresponding to the suture stitches of the cleft with trivial residual regurgitation (Fig. 2). The RT3DE disclosed a better view of the entire suture line and the closure of the cleft (Fig. 3b and Movie clip 2). The boy’s postoperative course was uneventful. Discussion

Impact of Fentanyl Associated with Midazolam in Sedation for Transesophageal Echocardiography

Introducao: O ecocardiograma transesofagico e atualmente uma das principais ferramentas no diagnostico de diversas alteracoes cardiacas. Para uma maior seguranca e conforto na sua realizacao, o exame tem sido realizado sob sedacao consciente moderada, sendo os benzodiazepinicos os agentes de escolha. Nessa classe de medicamentos, o midazolam e o mais utilizado, todavia nao esta isento de possiveis complicacoes relacionadas ao seu uso, como hipoxia, hipotensao, entre outras. Sabemos que grau de sedacao e dose-dependente, portanto, quanto menor a dose utilizada, sera menor o risco de complicacoes do procedimento.