Wercules Oliveira

Impact of continuous positive airway pressure treatment on left atrial volume and function in patients with obstructive sleep apnoea assessed by real-time three-dimensional echocardiography

Background: Obstructive sleep apnoea (OSA) has been reported as a predictor of left ventricle (LV) diastolic dysfunction and left atrium (LA) remodelling. The aim of this study is to evaluate the impact of OSA treatment with a continuous positive airway pressure device (CPAP) on the LA volume and function, as well as on the LV diastolic function. Methods: In total, 56 OSA patients were studied. All patients underwent real-time three-dimensional (RT3DE) and two-dimensional echocardiogram with tissue Doppler evaluation in order to estimate LA volumes, function and LV diastolic performance. A total of 30 patients with an apnoea-hypopnoea index greater than 20 were randomly selected to receive sham CPAP (n = 15) or effective CPAP (n = 15) for 24 weeks. They underwent echo examination on three different occasions: at baseline, after 12 weeks and 24 weeks of CPAP or sham CPAP. Results: In the effective CPAP group we observed the following changes from the baseline to the 24-week echo evaluation: (a) a reduction in the E/E′ ratio (10.3 (1.9) to 7.9 (1.3), p = 0.03); (b) an increase in the LA passive emptying fraction (28.8% (11.9%) to 46.8% (9.3%), p = 0.01); and (c) a reduction in the LA active emptying fraction (42.7% (11.5%) to 25.7 (15.7), p<0.01). In the sham group, there were no changes from the baseline to the 24-week echo. We found a positive correlation between 24 week/baseline LA active emptying volume and 24 week/baseline E/E′ ratios (r = 0.40, p<0.05) and a negative correlation between 24 week/baseline LA passive emptying volume and 24 week/baseline E/E′ ratios (r = −0.53, p<0.05). No significant changes were found on LA total emptying fraction. Conclusion: CPAP improved LV diastolic function and LA passive emptying, but not LA structural variables in OSA patients. Trial registration number: NCT00768807.

Cysteine A Potential Biomarker for Obstructive Sleep Apnea

OBJECTIVE Obstructive sleep apnea (OSA) is a risk factor for a number of cardiovascular conditions. Although homocysteine (Hcy) and cysteine (Cys) are regarded as cardiovascular risk factors, few studies have analyzed Hcy and Cys plasma concentrations in patients with OSA. The aim of this study was to evaluate the role of Hcy and Cys in OSA in comparison with subjects without OSA and to determine the possible influence of obesity on these variables. METHODS Patients who submitted to polysomnography studies were recruited to engage in an 8-h fasting period for blood sample withdrawal, physical examination, ECG, and echocardiogram. A subgroup of lean patients with OSA (BMI < 25 kg/m(2)) were analyzed to rule out the influence of obesity. Fifteen patients were randomly assigned to participate in a continuous positive airway pressure (CPAP) protocol to assess the influence of OSA treatment on the obtained measurements. RESULTS A total of 75 patients and 75 control subjects matched for age and sex were analyzed. The Cys plasma levels were higher in patients with OSA compared with control subjects (490.16 ± 67.00 μmol/L vs 439.81 ± 76.12 μmol/L, respectively, P < .01); however, the Hcy plasma levels did not differ between groups. Cys plasma levels were also higher in the OSA lean subgroup when compared with lean control subjects (484.21 ± 71.99 μmol/L vs 412.01 ± 70.73 μmol/L, respectively, P = .009). There was a significant decrease of Cys plasma levels after 6 months of CPAP effective therapy. CONCLUSION Cys is a potential biomarker of OSA in obese and nonobese patients and is reduced after effective OSA treatment.

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)

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.

3D Echo pilot study of geometric Left Ventricular changes after acute myocardial infarction

Background Left ventricular remodeling (LVR) after AMI characterizes a factor of poor prognosis. There is little information in the literature on the LVR analyzed with three-dimensional echocardiography (3D ECHO). Objective To analyze, with 3D ECHO, the geometric and volumetric modifications of the left ventricle (VE) six months after AMI in patients subjected to percutaneous primary treatment. Methods Prospective study with 3D ECHO of 21 subjects (16 men, 56 ± 12 years-old), affected by AMI with ST segment elevation. The morphological and functional analysis (LV) with 3D ECHO (volumes, LVEF, 3D sphericity index) was carried out up to seven days and six months after the AMI. The LVR was considered for increase > 15% of the end diastolic volume of the LV (LVEDV) six months after the AMI, compared to the LVEDV up to seven days from the event. Results Eight (38%) patients have presented LVR. Echocardiographic measurements (n = 21 patients): I- up to seven days after the AMI: 1- LVEDV: 92.3 ± 22.3 mL; 2- LVEF: 0.51 ± 0.01; 3- sphericity index: 0.38 ± 0.05; II- after six months: 1- LVEDV: 107.3 ± 26.8 mL; 2- LVEF: 0.59 ± 0.01; 3- sphericity index: 0.31 ± 0.05. Correlation coefficient (r) between the sphericity index up to seven days after the AMI and the LVEDV at six months (n = 8) after the AMI: r: 0.74, p = 0.0007; (r) between the sphericity index six months after the AMI and the LVEDV at six months after the AMI: r: 0.85, p < 0.0001. Conclusion In this series, LVR has been observed in 38% of the patients six months after the AMI. The three-dimensional sphericity index has been associated to the occurrence of LVR.

Cardiovascular profile in patients with obstructive sleep apnea

BACKGROUND Obstructive Sleep Apnea (OSA) is a risk factor for several cardiovascular conditions including increased cardiovascular mortality. It is therefore essential to know the major cardiovascular effects of sleep-disordered breathing during a clinical evaluation. OBJECTIVE To analyze the cardiovascular characteristics of patients with OSA. METHODS Patients underwent baseline polysomnography and were consecutively selected from the database of the Sleep Institute between March 2007 and March 2009. All patients were instructed to attend the clinic for blood collection, physical examination, 12-lead electrocardiogram, spirometry, cardiopulmonary exercise testing on a treadmill and transthoracic echocardiography. The study was approved by the Research Ethics Committee and recorded at http://clinicaltrials.gov/ under number: NCT00768625. RESULTS We analyzed 261 patients and 108 controls. The main characteristics of patients with OSA were: obesity, hypertension, low plasma levels of high density lipoprotein (HDL) and increased left atrial diameter compared with controls (3.75 ± 0.42; 3.61 ± 0.41, p = 0.001), respectively. These associated characteristics correspond to a 16.6 increase in the likelihood of OSA regardless of reporting any symptoms of this disorder, such as sleepiness or snoring. CONCLUSION In the sample studied, the mostly found cardiovascular profile of patients with OSA was: obesity, hypertension, low plasma levels of HDL and left atrial diameter increased.FUNDAMENTO: Apneia Obstrutiva do Sono (AOS) e um fator de risco para varias condicoes cardiovasculares incluindo aumento na mortalidade cardiovascular. Sendo assim, e essencial o conhecimento das principais repercussoes cardiovasculares dos disturbios respiratorios do sono durante uma avaliacao clinica. OBJETIVO: Analisar as caracteristicas cardiovasculares de pacientes com AOS. METODOS: Pacientes submetidos a polissonografia basal foram consecutivamente selecionados do banco de dados do Instituto do Sono entre marco de 2007 e marco de 2009. Todos os pacientes foram orientados a comparecer ao ambulatorio para coleta de sangue, exame fisico, eletrocardiograma de 12 derivacoes, espirometria, teste cardiopulmonar em esteira ergometrica e ecocardiograma transtoracico. O estudo foi aprovado pelo comite de etica e pesquisa e registrado no site http://clinicaltrials.gov/ sob o numero: NCT00768625. RESULTADOS: Foram analisados 261 pacientes e 108 controles. As principais caracteristicas dos pacientes com AOS foram: obesidade, hipertensao, baixos niveis plasmaticos de lipoproteinas de alta densidade (HDL) e aumento no diâmetro do atrio esquerdo quando comparados com controles (3,75 ± 0,42; 3,61 ± 0,41, p = 0,001), respectivamente. Essas caracteristicas associadas correspondem a um acrescimo de 16,6 vezes na probabilidade de ocorrencia de AOS independentemente do relato de algum sintoma dessa desordem, como sonolencia ou ronco. CONCLUSAO: Na amostra avaliada, o perfil cardiovascular dos pacientes com AOS mais encontrado foi: obesidade, hipertensao arterial, baixos niveis plasmaticos de HDL e atrio esquerdo com diâmetro aumentado.

Simplified Single Plane Echocardiography Is Comparable to Conventional Biplane Two‐Dimensional Echocardiography in the Evaluation of Left Atrial Volume: A Study Validated by Three‐Dimensional Echocardiography in 143 Individuals

The left atrial volume index (LAVI) is a biomarker of diastolic dysfunction and a predictor of cardiovascular events. Three‐dimensional echocardiography (3DE) is highly accurate for LAVI measurements but is not widely available. Furthermore, biplane two‐dimensional echocardiography (B2DE) may occasionally not be feasible due to a suboptimal two‐chamber apical view. Simplified single plane two‐dimensional echocardiography (S2DE) could overcome these limitations. We aimed to compare the reliability of S2DE with other validated echocardiographic methods in the measurement of the LAVI. We examined 143 individuals (54 ± 13 years old; 112 with heart disease and 31 healthy volunteers; all with sinus rhythm, with a wide range of LAVI). The results for all the individuals were compared with B2DE‐derived LAVIs and validated using 3DE. The LAVIs, as determined using S2DE (32.7 ± 13.1 mL/m2), B2DE (31.9 ± 12.7 mL/m2), and 3DE (33.1 ± 13.4 mL/m2), were not significantly different from each other (P = 0.85). The S2DE‐derived LAVIs correlated significantly with those obtained using both B2DE (r = 0.98; P < 0.001) and 3DE (r = 0.93; P < 0.001). The mean difference between the S2DE and B2DE measurements was <1.0 mL/m2. Using the American Society of Echocardiography criteria for grading LAVI enlargement (normal, mild, moderate, severe), we observed an excellent agreement between the S2DE‐ and B2DE‐derived classifications (κ = 0.89; P < 0.001). S2DE is a simple, rapid, and reliable method for LAVI measurement that may expand the use of this important biomarker in routine echocardiographic practice.

Perfil cardiovascular em pacientes com apneia obstrutiva do sono

BACKGROUND Obstructive Sleep Apnea (OSA) is a risk factor for several cardiovascular conditions including increased cardiovascular mortality. It is therefore essential to know the major cardiovascular effects of sleep-disordered breathing during a clinical evaluation. OBJECTIVE To analyze the cardiovascular characteristics of patients with OSA. METHODS Patients underwent baseline polysomnography and were consecutively selected from the database of the Sleep Institute between March 2007 and March 2009. All patients were instructed to attend the clinic for blood collection, physical examination, 12-lead electrocardiogram, spirometry, cardiopulmonary exercise testing on a treadmill and transthoracic echocardiography. The study was approved by the Research Ethics Committee and recorded at http://clinicaltrials.gov/ under number: NCT00768625. RESULTS We analyzed 261 patients and 108 controls. The main characteristics of patients with OSA were: obesity, hypertension, low plasma levels of high density lipoprotein (HDL) and increased left atrial diameter compared with controls (3.75 ± 0.42; 3.61 ± 0.41, p = 0.001), respectively. These associated characteristics correspond to a 16.6 increase in the likelihood of OSA regardless of reporting any symptoms of this disorder, such as sleepiness or snoring. CONCLUSION In the sample studied, the mostly found cardiovascular profile of patients with OSA was: obesity, hypertension, low plasma levels of HDL and left atrial diameter increased.FUNDAMENTO: Apneia Obstrutiva do Sono (AOS) e um fator de risco para varias condicoes cardiovasculares incluindo aumento na mortalidade cardiovascular. Sendo assim, e essencial o conhecimento das principais repercussoes cardiovasculares dos disturbios respiratorios do sono durante uma avaliacao clinica. OBJETIVO: Analisar as caracteristicas cardiovasculares de pacientes com AOS. METODOS: Pacientes submetidos a polissonografia basal foram consecutivamente selecionados do banco de dados do Instituto do Sono entre marco de 2007 e marco de 2009. Todos os pacientes foram orientados a comparecer ao ambulatorio para coleta de sangue, exame fisico, eletrocardiograma de 12 derivacoes, espirometria, teste cardiopulmonar em esteira ergometrica e ecocardiograma transtoracico. O estudo foi aprovado pelo comite de etica e pesquisa e registrado no site http://clinicaltrials.gov/ sob o numero: NCT00768625. RESULTADOS: Foram analisados 261 pacientes e 108 controles. As principais caracteristicas dos pacientes com AOS foram: obesidade, hipertensao, baixos niveis plasmaticos de lipoproteinas de alta densidade (HDL) e aumento no diâmetro do atrio esquerdo quando comparados com controles (3,75 ± 0,42; 3,61 ± 0,41, p = 0,001), respectivamente. Essas caracteristicas associadas correspondem a um acrescimo de 16,6 vezes na probabilidade de ocorrencia de AOS independentemente do relato de algum sintoma dessa desordem, como sonolencia ou ronco. CONCLUSAO: Na amostra avaliada, o perfil cardiovascular dos pacientes com AOS mais encontrado foi: obesidade, hipertensao arterial, baixos niveis plasmaticos de HDL e atrio esquerdo com diâmetro aumentado.

Left Atrial Volume Determinants in Patients with Non-Ischemic Dilated Cardiomyopathy

Background Left atrial volume (LAV) is a predictor of prognosis in patients with heart failure. Objective We aimed to evaluate the determinants of LAV in patients with dilated cardiomyopathy (DCM). Methods Ninety patients with DCM and left ventricular (LV) ejection fraction ≤ 0.50 were included. LAV was measured with real-time three-dimensional echocardiography (eco3D). The variables evaluated were heart rate, systolic blood pressure, LV end-diastolic volume and end-systolic volume and ejection fraction (eco3D), mitral inflow E wave, tissue Doppler e´ wave, E/e´ ratio, intraventricular dyssynchrony, 3D dyssynchrony index and mitral regurgitation vena contracta. Pearson´s coefficient was used to identify the correlation of the LAV with the assessed variables. A multiple linear regression model was developed that included LAV as the dependent variable and the variables correlated with it as the predictive variables. Results Mean age was 52 ± 11 years-old, LV ejection fraction: 31.5 ± 8.0% (16-50%) and LAV: 39.2±15.7 ml/m2. The variables that correlated with the LAV were LV end-diastolic volume (r = 0.38; p < 0.01), LV end-systolic volume (r = 0.43; p < 0.001), LV ejection fraction (r = -0.36; p < 0.01), E wave (r = 0.50; p < 0.01), E/e´ ratio (r = 0.51; p < 0.01) and mitral regurgitation (r = 0.53; p < 0.01). A multivariate analysis identified the E/e´ ratio (p = 0.02) and mitral regurgitation (p = 0.02) as the only independent variables associated with LAV increase. Conclusion The LAV is independently determined by LV filling pressures (E/e´ ratio) and mitral regurgitation in DCM.

Calcificação caseosa do anel mitral: relato de caso

ABSTRACT We present a rare case of probable caseous calcification of the mitral. This pathology is more frequently detected in asymptomatic women older than 70 years. To recognize this image is important because echocardiography is the easiest way to elucidate this diagnosis, and more importantly because this structure could be easily misdiagnosed as tumors, thrombus and vegetations, which are much more common. Normally, it has a benign evolution, and the correct diagnosis is crucial to avoid unnecessary surgical interventions.