Wilson Mathias Junior

Evaluation of Segmentary Contractility in Chagas' Disease by Using the Integral of the Myocardial Velocity Gradient (Myocardial Strain) Obtained Through Tissue Doppler Echocardiography

OBJECTIVEnTo quantify the percentage of contractility of different myocardial segments in patients with Chagas disease by measuring myocardial strain and to assess the differences in the radial and longitudinal ventricular contractile function in the undetermined and dilated forms of chronic chagasic cardiomyopathy as compared with those in a group of healthy individuals.nnnMETHODSnThe study comprised 39 individuals [20 (51.3%) of the male sex] divided into the following 4 groups: 1) Nl: 17 (43.6%) healthy individuals; 2) Und: 7 (17.9%) patients with the undetermined form of Chagas disease; 3) C1: 7 (17.9%) patients with the chronic form of Chagas disease with ejection fraction < 50%; and 4) C2: 8 (20.5%) patients with the chronic form of Chagas disease with ejection fraction > 50%. After performing baseline echocardiography, Doppler tissue images were recorded to measure myocardial strain in different segments on longitudinal and transversal parasternal, and apical 2- and 4-chamber views.nnnRESULTS AND CONCLUSIONnThe percentage of contractility in the different myocardial segments, both the radial and longitudinal components, is greater in healthy individuals than in patients with the chronic form of Chagas disease, and in those with the undetermined form of the disease as compared with that of chronic chagasic patients with EF < 50%. Left ventricular radial contractility is greater than left ventricular longitudinal contractility in all groups (Nl, Und, and Chronic). The data presented allow us to propose a progressive character of myocardial impairment in patients with Chagas disease.

Coronary spasm induced by dobutamine-atropine stress echocardiography

This is the report on a 45-year-old female, with a history of systemic arterial hypertension and cigarette smoking, submitted to dobutamine-atropine stress echocardiography for the investigation of coronary artery disease. At stress peak, the patient reported sudden, highly intense precordial pain. The 12-lead electrocardiogram showed ST segment elevation in DII, DIII, aVF, V5 and V6, and depression in DI, aVL, V2 and V3. Echocardiographic imaging monitoring showed dyskinesia of inferior septum and akinesia of inferior wall. The test was interrupted immediately. The patient was medicated and improved her precordial pain condition as well as wall motion abnormalities. Coronary angiography showed irregular coronary lesions with <50% luminal diameter obstruction. It is a case of coronary spasm induced by alpha-adrenergic stimulation during dobutamine-atropine stress echocardiography.

Papel da ecodopplercardiografia na avaliação da hipertensão arterial pulmonar

A precise evaluation of pulmonary pressure is of fundamental importance for the diagnosis and management of patients with hypertension of the pulmonary artery (PH). Dopper echodopplercardiography is a low cost, non-invasive method in widespread use for anatomical and functional assessment of the right cardiac chambers and estimation of pulmonary pressures, demonstrating a good correlation with the hemodynamic data obtained by cardiac catheterization. Although the most adequate and widely used technique for determination of pulmonary pressure is measurement of the gradient between right ventricle and right atrium through tricuspid regurgitation, it can also be performed by analysis of pulmonary regurgitation or systolic pulmonary flow. Transesophageal echocardiography is a very useful procedure when acoustic window is limited by transthoracic approach and allows for high quality imaging of cardiac structures and detection of some disorders related to PH. The role of echocardiography is already established in the literature for the diagnosis of PH, as well as for therapeutic and prognostic evaluation. In patients with pulmonary thromboembolism, detection of right ventricular dysfunction by echocardiography is an important input for adoption of thrombolytic therapy. Furthermore, this method is already customary in monitoring the therapeutic response in patients with primary in the assessment of chronic obstructive pulmonary disease and in the follow up of patients submitted to pulmonary transplantation.

Endomyocardial Biopsy Guided by Echocardiography

In the recent year, transcatheter endomyocardial biopsy is a procedure relatively simple that has been increasingly utilized in cardiomyopathy diagnosis. It is estimated that over 50,000 biopsies are performed annually in the United States in general to control rejection episodes after heart transplantation. Endomyocardial biopsy plays important role in the diagnosis and treatment of adult and pediatric cardiovascular disease due to many specific myocardial disorders the etiology is seldom discovery by noninvasive testing. The indication this procedure may be especially challenging for many nonspecialists because the method is invasive and always must weigh the risks and benefits. The percutaneous transvenous endomyocardial biopsy has become the procedure safe and more convenient for rejection control after heart transplantation, histopathological diagnosis of cardiomyopathies or tumors1,2,3. The endomyocardial biopsy technique is safe in experienced hands however the method may lead to several complications, the most serious them is the right ventricle perforation with cardiac tamponade4,5. Heart biopsy already experimented investigation with different methods such as: open thoracotomy6; partial extrapleural thoracotomy with resection of a rib to facilitate the exposition7; percutaneous introduction of Vim-Silverman and Menghini needle8,9,10; introduction of a modified Ross transseptal needle through the superior vena cava or carotid artery11; and the use of cutting blades introduced through a catheter for endomyocardial biopsy12. Unfortunately, the heart biopsy history was marked by severe complications, which included pericardial tamponade, cardiac perforation, pneumothorax and hemothorax, and eventually death. Since 1980, the technique has become routinely used. Weinberg et al., in 1958, reported their experience with five patients who were undergone pericardial and myocardial biopsy13. The procedure was performed percutaneously under local anesthesia and the thorax was opened by resection of the fourth cartilage on the left. This invasive method did not gain ample acceptance due to high risk. The cardiac biopsy with needle through a limited thoracotomy was associated with pulmonary injuries, cardiac tamponade, coronary vessels laceration, arrhythmia, and sometimes with death. Despite these risks, direct needle biopsy was carried out in some centers.

Intramural hematoma of the ascending aorta

It is reported the case of a 71 year old male patient admitted to the emergency service pale and with systemic arterial hypertension and thoracic pain. In the diagnostic investigation, there was no evidence of compatible with acute myocardial ischemia. The thorax x-ray showed important enlargement of the mediastinum. In the echocardiogram the ascending aorta measured 47 mm, at the level of the pulmonary artery. One day after the echo, submitted to exam of magnetic resonance (RNM), the ascending aorta had a diameter of 62 mm, without false lumen flow or intimal flap, but showing intramural hematoma envolving the ascending aorta and the proximal portion of the aorta. It was submitted to the surgical correction, being accomplished by resection of the ascending aorta and part of the aortic arch (hemiarch), with preservation of the aortic valve with suspension of the comissures. The patient had uneventful recovery, being discharged in the 9th postoperative day. We emphasized the similarity of the clinical presentation of the intramural hematoma of the aorta with that of aortic dissection, the importance of establishing correct diagnosis and the best treatment.

Revascularização do miocárdio minimamente invasiva

There is a tendency in all fields of surgery to move towards less invasive surgical techniques in recent years. The end point of this study was to analyse the possibility of myocardial revascularization through a minimum left thoracotomy approach. From September 1995 till March 1996 we operated on 19 patients that had isolated lesion of interventricular anterior artery (IAA) and/or diagonal. The anastomoses were made by a left minor thoracotomy, opening the pleura at the 4o intercostal space. Through this incision we dissected the thoracic internal artery with ligation of only few branches. The anastomoses were performed without extracorporeal circulation, with a simple interruption of coronary blood flow. At the second postoperative day we studied the patients with angiography and transthoracic echo-Doppler, to verify patency and flow. All patients had uneventful recovery without major complications. Angiography was made in 16 out of 19 and showed patency in 13. The 3 patients with graft occlusion were reoperated on without complications. The presented technique did not involve ligation of the intercostal branches, however these branches were not demonstrated by angiography. Transthoracic Doppler showed good relationship with angiographic findings. The initial results with this technique suggest that we can have another option of minimum invasive myocardial revascularization for selected patients.

Low-Flow Low-Gradient and Low-Ejection Fraction Aortic Stenosis and Projected Aortic Valve Area Calculation: So Important but so Complicated. Let us Just Keep it Simple!

DOI: 10.5935/abc.20180030 Low-flow low-gradient aortic stenosis with low ejection fraction is still one of the main challenges not only for echocardiography but to cardiology itself. It is the very late stage of aortic stenosis that portends very poor prognosis with medical treatment, in addition to a very high operative mortality.1 In subjects with that condition, dobutamine stress echocardiography is of paramount importance to stratify aortic stenosis status (real aortic stenosis vs pseudo aortic stenosis) and to predict surgical mortality by the evaluation of the left ventricular contractile reserve status.1-3

Global Longitudinal Strain or Left Ventricular Twist and Torsion? Which Correlates Best with Ejection Fraction?

Background Estimative of left ventricular ejection fraction (LVEF) is a major indication for echocardiography. Speckle tracking echocardiography (STE) allows analysis of LV contraction mechanics which includes global longitudinal strain (GLS) and twist/torsion, both the most widely used. Direct comparison of correlations between these novel parameters and LVEF has never been done before. Objective This study aims to check which one has the highest correlation with LVEF. Methods Patients with normal LVEF (> 0,55) and systolic dysfunction (LVEF <0,55) were prospectively enrolled, and underwent echocardiogram with STE analysis. Correlation of variables was performed by linear regression analysis. In addition, correlation among levels of LV systolic impairment was also tested. Results A total of 131 patients were included (mean age, 46 ± 14y; 43%, men). LVEF and GLS showed a strong correlation (r = 0.95; r2 = 0.89; p < 0.001), more evident in groups with LV systolic dysfunction than those with preserved LVEF. Good correlation was also found with global longitudinal strain rate (r = 0.85; r2 = 0.73; p < 0.001). Comparing to GLS, correlation of LVEF and torsional mechanics was weaker: twist (r = 0.78; r2 = 0.60; p < 0.001); torsion (r = 0.75; r2 = 0.56; p < 0.001). Conclusion GLS of the left ventricle have highly strong positive correlation with the classical parameter of ejection fraction, especially in cases with LV systolic impairment. Longitudinal strain rate also demonstrated a good correlation. GLS increments analysis of LV systolic function. On the other hand, although being a cornerstone of LV mechanics, twist and torsion have a weaker correlation with LV ejection, comparing to GLS.

Cardiomiopatia de takotsubo como causa de disfunção ventricular transitória

This is the report of a 74-year-old female patient with a history of systemic hypertension and peripheral vascular disease who presented acute coronary syndrome symptoms. Coronary angiography showed coronary arteries with no significant obstructions. Ventriculography and echocardiography showed akinesia in mid and apical segments; and hyperkinesia of left ventricle basal segments. Two weeks after the onset of symptoms, a new echocardiogram demonstrated normal global and regional systolic function. The uncommon, reversible pattern for systolic dysfunction and segmental compromising that gives left ventricle a Takotsubo-like shape is known today as stress cardiomyopathy.

Three-dimensional transesophageal echocardiographic imaging of mitral valve bioprosthesis leaflets perforation due to infective endocarditis

Echocardiography, three-dimensional; echocardiography, transesophageal; heart valve prosthesis; endocarditis. Echogardiographic aspects have been added to the criteria used to investigate the diagnosis of infective endocarditis1. However, under some circumstances, the two-dimensional echocardiographic technique, whether transthoracic or transesophageal, fails to provide sufficient diagnostic information. We report the case of a 43-year old patient with a biological prosthesis in the mitral position, who presented an episode of infective endocarditis with positive blood cultures for Staphylococcus aureus. The patient underwent two-dimensional transthoracic and transesophageal echocardiographic investigation and later to three-dimensional transesophageal reconstruction. The perforation of the leaflets of the bioprosthesis was evidenced only after the three-dimensional echocardiographic analysis was carried out (Figure 1). The patient underwent bioprosthesis replacement, and discharged from hospital seven weeks after the surgery. Three-dimensional echocardiography adds diagnostic information as it allows the study of the heart from multiplane structural observation2,3.