RESUMO
BACKGROUND: Acute cellular rejection (ACR) is a major complication after heart transplantation. Endomyocardial biopsy (EMB) remains the gold standard for its diagnosis, but it has concerning complications. We evaluated the usefulness of speckle tracking echocardiography (STE) and biomarkers for detecting ACR after heart transplantation. METHODS: We prospectively studied 60 transplant patients with normal left and right ventricular systolic function who underwent EMB for surveillance 6 months after transplantation. Sixty age- and sex-matched healthy individuals constituted the control group. Conventional echocardiographic parameters, left ventricular global longitudinal, radial and circumferential strain (LV-GLS, LV-GRS and LV-GCS, respectively), left ventricular systolic twist (LV-twist) and right ventricular free wall longitudinal strain (RV-FWLS) were analyzed just before the procedure. We also measured biomarkers at the same moment. RESULTS: Among the 60 studied patients, 17 (28%) had severe ACR (grade ≥ 2R), and 43 (72%) had no significant ACR (grade 0 - 1R). The absolute values of LV-GLS, LV-twist and RV-FWLS were lower in transplant patients with ACR degree ≥ 2 R than in those without ACR (12.5% ± 2.9% vs 14.8% ± 2.3%, p=0.002; 13.9° ± 4.8° vs 17.1° ± 3.2°, p=0.048; 16.6% ± 2.9% vs 21.4%± 3.2%, p < 0.001; respectively), while no differences were observed between the LV-GRS or LV-GCS. All of these parameters were lower in the transplant group without ACR than in the nontransplant control group, except for the LV-twist. Cardiac troponin I levels were significantly higher in patients with significant ACR than in patients without significant ACR [0.19 ng/mL (0.09-1.31) vs 0.05 ng/mL (0.01-0.18), p=0.007]. The combination of troponin with LV-GLS, RV-FWLS and LV-Twist had an area under curve for the detection of ACR of 0.80 (0.68-0.92), 0.89 (0.81-0.93) and 0.79 (0.66-0.92), respectively. CONCLUSION: Heart transplant patients have altered left ventricular dynamics compared with control individuals. The combination of troponin with strain parameters had higher accuracy for the detection of ACR than the isolated variables and this association might select patients with a higher risk for ACR who will benefit from an EMB procedure in the first year after heart transplantation.
Assuntos
Ecocardiografia/métodos , Rejeição de Enxerto/diagnóstico , Transplante de Coração , Ventrículos do Coração/diagnóstico por imagem , Peptídeo Natriurético Encefálico/sangue , Volume Sistólico/fisiologia , Troponina I/sangue , Doença Aguda , Adulto , Biomarcadores/sangue , Biópsia , Feminino , Seguimentos , Rejeição de Enxerto/metabolismo , Rejeição de Enxerto/fisiopatologia , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Miocárdio/metabolismo , Miocárdio/patologia , Período Pós-Operatório , Prognóstico , Estudos Prospectivos , Reprodutibilidade dos Testes , SístoleRESUMO
BACKGROUND: Cardiac shock-wave therapy (CSWT) has been demonstrated as an option for the treatment of patients with refractory angina (RA), promoting immediate vasodilatory effects and, in the long-term, neoangiogenic effects that would be responsible for reducing the myocardial ischemic load. The aim of this study was to determine the effects of CSWT on myocardial blood flow reserve (MBFR) assessed by quantitative real-time myocardial perfusion echocardiography in patients with RA. METHODS: Fifteen patients (mean age 61.5 ± 12.8 years) with RA who underwent CSWT during nine sessions, over 3 months of treatment, were prospectively studied. A total of 32 myocardial segments with ischemia were treated, while another 31 did not receive therapy because of technical limitations. Myocardial perfusion was evaluated at rest and after dipyridamole stress (0.84 mg/kg) before and 6 months after CSWT, using quantitative real-time myocardial perfusion echocardiography. Clinical effects were evaluated using Canadian Cardiovascular Society grading of angina and the Seattle Angina Questionnaire. RESULTS: The ischemic segments treated with CSWT had increased MBFR (from 1.33 ± 0.22 to 1.74 ± 0.29, P < .001), a benefit that was not observed in untreated ischemic segments (1.51 ± 0.29 vs 1.54 ± 0.28, P = .47). Patients demonstrated increased global MBFR (from 1.78 ± 0.54 to 1.89 ± 0.49, P = .017). Semiquantitative single-photon emission computed tomographic analysis of the treated ischemic segments revealed a score reduction from 2.10 ± 0.87 to 1.68 ± 1.19 (P = .024). There was improvement in Canadian Cardiovascular Society score (from 3.20 ± 0.56 to 1.93 ± 0.70, P < .05) and in Seattle Angina Questionnaire score (from 42.3 ± 12.99 to 71.2 ± 14.29, P < .05). No major cardiovascular events were recorded during follow-up. CONCLUSIONS: CSWT improved MBFR in ischemic segments, as demonstrated by quantitative real-time myocardial perfusion echocardiography. These results suggest that CSWT has the potential to increase myocardial blood flow, with an impact on symptoms and quality of life in patients with RA.
Assuntos
Angina Pectoris/terapia , Circulação Coronária/fisiologia , Vasos Coronários/diagnóstico por imagem , Tratamento por Ondas de Choque Extracorpóreas/métodos , Ondas de Choque de Alta Energia/uso terapêutico , Angina Pectoris/diagnóstico , Angina Pectoris/fisiopatologia , Vasos Coronários/fisiopatologia , Ecocardiografia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Tomografia Computadorizada de Emissão de Fóton Único , Resultado do TratamentoRESUMO
BACKGROUND: Preclinical studies have demonstrated that high mechanical index (MI) impulses from a diagnostic ultrasound transducer during an intravenous microbubble infusion (sonothrombolysis) can restore epicardial and microvascular flow in acute ST-segment elevation myocardial infarction (STEMI). OBJECTIVES: This study tested the clinical effectiveness of sonothrombolysis in patients with STEMI. METHODS: Patients with their first STEMI were prospectively randomized to either diagnostic ultrasound-guided high MI impulses during an intravenous Definity (Lantheus Medical Imaging, North Billerica, Massachusetts) infusion before, and following, emergent percutaneous coronary intervention (PCI), or to a control group that received PCI only (n = 50 in each group). A reference first STEMI group (n = 203) who arrived outside the randomization window was also analyzed. Angiographic recanalization before PCI, ST-segment resolution, infarct size by magnetic resonance imaging, and systolic function (LVEF) at 6 months were compared. RESULTS: ST-segment resolution occurred in 16 (32%) high MI PCI versus 2 (4%) PCI-only patients before PCI, and angiographic recanalization was 48% in high MI/PCI versus 20% in PCI only and 21% in the reference group (p < 0.001). Infarct size was reduced (29 ± 22 g high MI/PCI vs. 40 ± 20 g PCI only; p = 0.026). LVEF was not different between groups before treatment (44 ± 11% vs. 43 ± 10%), but increased immediately after PCI in the high MI/PCI group (p = 0.03), and remained higher at 6 months (p = 0.015). Need for implantable defibrillator (LVEF ≤30%) was reduced in the high MI/PCI group (5% vs. 18% PCI only; p = 0.045). CONCLUSIONS: Sonothrombolysis added to PCI improves recanalization rates and reduces infarct size, resulting in sustained improvements in systolic function after STEMI. (Therapeutic Use of Ultrasound in Acute Coronary Artery Disease; NCT02410330).
Assuntos
Intervenção Coronária Percutânea/métodos , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Terapia Trombolítica/métodos , Ultrassonografia de Intervenção/métodos , Idoso , Terapia Combinada , Angiografia Coronária , Eletrocardiografia , Feminino , Fluorocarbonos/administração & dosagem , Humanos , Imageamento por Ressonância Magnética , Masculino , Microbolhas , Pessoa de Meia-Idade , Estudos Prospectivos , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico por imagem , Método Simples-Cego , Resultado do TratamentoRESUMO
BACKGROUND: Cardiac shockwave therapy (CSWT) is a new potential option for the treatment of patients with chronic coronary disease and refractory angina (RA). We aimed to study the effects of CSWT on left ventricular myocardial perfusion and mechanics in patients with RA. METHOD: We prospectively studied 19 patients who underwent CSWT. Left ventricular mechanics were evaluated by speckle tracking echocardiography (STE), and myocardial perfusion by single-photon emission computed tomography, using stress/rest-Technetium-99 m Sestamibi, for determination of summed stress score (SSS). Canadian Cardiac Society (CCS), New York Heart Association (NYHA), and quality of life by Seattle Angina Questionnaire (SAQ) were assessed at baseline and 6 months after therapy. RESULTS: CSWT therapy was applied without major side effects. At baseline, 18 patients (94.7%) had CCS class III or IV, and after CSWT there was reduction to 3 (15.8%), P = .0001, associated with improvement in SAQ (38.5%; P < .001). Thirteen (68.4%) had class NYHA III or IV before treatment, with significant reduction to 7 (36.8%); P = .014. No change was observed in the global SSS from baseline to 6-month follow-up (15.33 ± 8.60 vs 16.60 ± 8.06; P = .157). However, there was a significant reduction in the average SSS of the treated ischemic segments (2.1 ± 0.87 pre vs 1.6 ± 1.19 post CSWT; P = .024). Global longitudinal strain by STE remained unaltered (-13.03 ± 8.96 pre vs -15.88 ± 3.43 6-month post CSWT; P = .256). CONCLUSION: CSWT is a safe procedure for the treatment of patients with RA that results in better quality of life, improvement in myocardial perfusion of the treated segments with preservation of left ventricular mechanics.
Assuntos
Angina Pectoris/terapia , Ecocardiografia/métodos , Tratamento por Ondas de Choque Extracorpóreas/métodos , Coração/fisiologia , Disfunção Ventricular Esquerda/terapia , Angina Pectoris/complicações , Angina Pectoris/fisiopatologia , Feminino , Coração/diagnóstico por imagem , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Compostos Radiofarmacêuticos , Tecnécio Tc 99m Sestamibi , Tomografia Computadorizada de Emissão de Fóton Único , Resultado do Tratamento , Disfunção Ventricular Esquerda/complicações , Disfunção Ventricular Esquerda/fisiopatologiaRESUMO
Cell therapy repair strategies using adult mesenchymal stromal cells have shown promising evidence to prevent cardiac deterioration in rodents even in the absence of robust differentiation of the cells into cardiomyocytes. We tested whether increasing doses of porcine adipose-tissue derived mesenchymal stem cells (pASCs) increase cardiac tissue perfusion in pigs post-myocardial infarction (MI) receiving angiotensin-converting-enzyme inhibitor (ACE inhibitors) and Beta-blockers similarly to patients. Female pigs were subjected to MI induction by sponge permanent occlusion of left circumflex coronary artery (LCx) generating approximately 10% of injured LV area with minimum hemodynamic impact. We assessed tissue perfusion by real time myocardial perfusion echocardiography (RTMPE) using commercial microbubbles before and following pASCs treatment. Four weeks after the occlusion of the left circumflex artery, we transplanted placebo or pASCs (1, 2 and 4x106 cells/Kg BW) into the myocardium. The highest dose of pASCs increased myocardial vessel number and blood flow in the border (56% and 3.7-fold, respectively) and in the remote area (54% and 3.9-fold, respectively) while the non-perfused scar area decreased (up to 38%). We also found an increase of immature collagen fibers, although the increase in total tissue collagen and types I and III was similar in all groups. Our results provide evidence that pASCs-induced stimulation of tissue perfusion and accumulation of immature collagen fibers attenuates adverse remodeling post-MI beyond the normal beneficial effects associated with ACE inhibition and beta-blockade.
Assuntos
Tecido Adiposo/citologia , Transplante de Células-Tronco Mesenquimais , Infarto do Miocárdio/patologia , Infarto do Miocárdio/terapia , Remodelação Ventricular , Animais , Circulação Coronária/efeitos dos fármacos , Enalaprilato/farmacologia , Feminino , Hemodinâmica/efeitos dos fármacos , Metoprolol/farmacologia , Infarto do Miocárdio/fisiopatologia , Suínos , Transplante Homólogo , Remodelação Ventricular/efeitos dos fármacosRESUMO
OBJECTIVE: We sought to determine the prognostic value of qualitative and quantitative analysis obtained by real-time myocardial perfusion echocardiography (RTMPE) in patients with known or suspected coronary artery disease (CAD). BACKGROUND: Quantification of myocardial blood flow reserve (MBFR) in patients with CAD using RTMPE has been demonstrated to further improve accuracy over the analysis of wall motion (WM) and qualitative analysis of myocardial perfusion (QMP). METHODS: From March 2003 to December 2008, we prospectively studied 168 patients with normal left ventricular function (LVF) who underwent dobutamine stress RTMPE. The replenishment velocity reserve (ß) and MBFR were derived from RTMPE. Acute coronary events were: cardiac death, myocardial infarction and unstable angina with need for urgent coronary revascularization. RESULTS: During a median follow-up of 34 months (5 days to 6.9 years), 17 acute coronary events occurred. Abnormal ß reserve in ≥2 coronary territories was the only independent predictor of events hazard ratio (HR) = 21, 95% CI = 4.5-99; p<0.001). Both, abnormal ß reserve and MBFR added significant incremental value in predicting events over qualitative analysis of WM and MP (χ2 = 6.6 and χ2 = 24.6, respectively; p = 0.001 and χ2 = 6.6 and χ2 = 15.5, respectively; p = 0.012, respectively). When coronary angiographic data was added to the multivariate analysis model, ß reserve remained the only predictor of events with HR of 21.0 (95% CI = 4.5-99); p<0.001. CONCLUSION: Quantitative dobutamine stress RTMPE provides incremental prognostic information over clinical variables, qualitative analysis of WM and MP, and coronary angiography in predicting acute coronary events.
Assuntos
Doença da Artéria Coronariana/diagnóstico por imagem , Ecocardiografia sob Estresse/métodos , Infarto do Miocárdio/diagnóstico por imagem , Prognóstico , Idoso , Meios de Contraste/administração & dosagem , Doença da Artéria Coronariana/fisiopatologia , Dobutamina/administração & dosagem , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/fisiopatologia , Imagem de Perfusão do Miocárdio/métodos , Valor Preditivo dos Testes , Função Ventricular Esquerda/fisiologiaRESUMO
BACKGROUND: Diagnosis of cardiac masses is still challenging by echocardiography and distinguishing tumors from thrombi has important therapeutical implications. We sought to determine the diagnostic value of real-time perfusion echocardiography (RTPE) for cardiac masses characterization. METHODS: We prospectively studied 86 patients, 23 with malignant tumors (MT), 26 with benign tumors (BT), 33 with thrombi and 6 with pseudotumors who underwent RTPE. Mass perfusion was analyzed qualitatively and blood flow volume (A), blood flow velocity (ß), and microvascular blood flow (A x ß) were determined by quantitative RTPE. RESULTS: Logistic regression models showed that the probability of having a tumor increased by 15.8 times with a peripheral qualitative perfusion pattern, and 34.5 times with a central perfusion pattern, in comparison with the absence of perfusion. Using quantitative RTPE analysis, thrombi group had parameters of blood flow lower than tumor group. A values for thrombi, MT, and BT were 0.1 dB (0.01-0.22), 2.78 dB (1-7) and 2.58 dB (1.44-5), respectively; p < 0.05, while A x ß values were 0.0 dB/s(-1) (0.01-0.14), 2.00 dB/s(-1) (1-6), and 1.18 dB/s(-1) (0.52-3), respectively; p < 0.05. At peak dipyridamole stress, MT had greater microvascular blood volume than BT [A = 4.18 dB (2.14-7.93) versus A = 2.04 dB (1.09-3.55); p < 0.05], but no difference in blood flow [Axß = 2.46 dB/s(-1) (1.42-4.59) versus Axß = 1.55 dB/s [1] (0.51-4.08); p = NS]. An A value >3.28 dB at peak dipyridamole stress predicted MT (AUC = 0.75) and conferred 5.8-times higher chance of being MT rather than BT. CONCLUSION: RTPE demonstrated that cardiac tumors have greater microvascular blood volume and regional blood flow when compared with thrombi. Dipyridamole stress was useful in differentiating MT from BT.
Assuntos
Ecocardiografia/métodos , Neoplasias Cardíacas/diagnóstico por imagem , Interpretação de Imagem Assistida por Computador/métodos , Imagem de Perfusão do Miocárdio/métodos , Neovascularização Patológica/diagnóstico por imagem , Trombose/diagnóstico por imagem , Velocidade do Fluxo Sanguíneo , Sistemas Computacionais , Diagnóstico Diferencial , Feminino , Neoplasias Cardíacas/complicações , Neoplasias Cardíacas/fisiopatologia , Humanos , Aumento da Imagem/métodos , Masculino , Pessoa de Meia-Idade , Neovascularização Patológica/etiologia , Neovascularização Patológica/fisiopatologia , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , Trombose/fisiopatologiaRESUMO
BACKGROUND: Left ventricular (LV) dysfunction is the major reason for poor outcomes in patients with congenital complete atrioventricular block (CCAVB) and pacemaker. Long-term pacing has been associated with LV mechanical dyssynchrony. However, the relationship of dyssynchrony and LV dysfunction is not clear. OBJECTIVE: We sought to evaluate the prevalence of LV dyssynchrony by real time three-dimensional echocardiography (RT3DE) in patients with CCAVB and its association with LV dysfunction. In addition, we evaluated the agreement between RT3DE and tissue Doppler imaging (TDI) for detecting LV dyssynchrony. METHOD: We studied 50 patients [median age 20 years old (5 months to 62 years), 68% women] with CCAVB and pacemaker who underwent complete two-dimensional echocardiography and RT3DE. LV dyssynchrony was considered if the systolic dyssynchrony index (SDI) was ≥ 5%. Intraventricular mechanical delay was defined by TDI when differences in electromechanical activation between LV walls were > 65 msec. RESULTS: LV systolic dysfunction was present in 16 patients (32%) by two-dimensional and in 20 patients (40%) by RT3DE. There was a good correlation between LV ejection fraction by two-dimensional and RT3DE (r = 0.75; P < 0.001). Fourteen (28%) patients had intraventricular dyssynchrony by TDI, while 12 (24%) had intraventricular dyssynchrony by RT3DE. There was a good agreement between LV dyssynchrony by TDI and RT3DE (Kappa = 0.735; P < 0.001). There was a negative correlation between LV ejection fraction and SDI obtained by RT3DE (r = -0.58; P < 0.001) CONCLUSIONS: In patients with CCAVB and long-term pacing, LV dyssynchrony occurred in one-third of patients and was related to LV dysfunction. There was a good correlation between dyssynchrony obtained by RT3DE and TDI.
Assuntos
Bloqueio Atrioventricular/diagnóstico por imagem , Bloqueio Atrioventricular/terapia , Estimulação Cardíaca Artificial , Ecocardiografia Tridimensional , Bloqueio Cardíaco/congênito , Disfunção Ventricular Esquerda/diagnóstico por imagem , Adolescente , Adulto , Bloqueio Atrioventricular/complicações , Criança , Pré-Escolar , Comorbidade , Feminino , Bloqueio Cardíaco/complicações , Bloqueio Cardíaco/diagnóstico por imagem , Bloqueio Cardíaco/terapia , Ventrículos do Coração/diagnóstico por imagem , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Prevalência , Disfunção Ventricular Esquerda/complicações , Adulto JovemRESUMO
OBJECTIVE: Polycystic ovary syndrome (PCOS) is associated with increased risk for cardiovascular disease. We sought to evaluate the effects of insulin resistance (IR) on myocardial microcirculation and peripheral artery function in patients with PCOS. METHODS: We studied 55 women (28 with PCOS without IR, 18 with PCOS and IR and 11 normal controls) who underwent laboratorial analysis, high-resolution vascular ultrasound and real time myocardial contrast echocardiography (RTMCE). Intima-media thickness (IMT) and brachial artery flow-mediated dilation (FMD) were evaluated by vascular ultrasound. The replenishment velocity (ß), plateau of acoustic intensity (A) and myocardial blood flow reserve (MBFR) were determined by quantitative dipyridamole stress RTMCE. RESULTS: ß reserve in group PCOS + IR was lower than control (2.34 ± 0.55 vs. 3.60 ± 0.6; P < 0.001) and than PCOS without IR (2.34 ± 0.55 vs. 3.17 ± 0.65; P < 0.001). MBFR in patients with PCOS without IR did not differ from those of control (4.59 ± 1.59 vs. 5.30 ± 1.64; P = 0.22) or from patients with PCOS + IR (4.59 ± 1.59 vs. 3.70 ± 1.47; P = 0.07). When comparing with control group, patients with PCOS + IR had lower MBFR (5.30 ± 1.64 vs. 3.70 ± 1.47; P = 0.01). No significant differences were found between control, PCOS without IR and PCOS + IR for FMD (0.18 ± 0.05, 0.15 ± 0.04 and 0.13 ± 0.07; P =NS) or IMT (0.48 ± 0.05, 0.47 ± 0.05 and 0.49 ± 0.07; P = NS). CONCLUSION: Women with PCOS and IR had depressed ß and MBFR as demonstrated by quantitative RTMCE, but no alteration in endothelial dysfunction or IMT. PCOS without IR showed isolated depression in ß reserve, probably an earlier marker of myocardial flow abnormality.
Assuntos
Artéria Braquial/fisiopatologia , Doença da Artéria Coronariana/fisiopatologia , Circulação Coronária , Resistência à Insulina , Síndrome do Ovário Policístico/fisiopatologia , Adulto , Velocidade do Fluxo Sanguíneo , Artéria Braquial/diagnóstico por imagem , Doença da Artéria Coronariana/diagnóstico por imagem , Feminino , Humanos , Síndrome do Ovário Policístico/diagnóstico por imagem , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , UltrassonografiaRESUMO
BACKGROUND: Quantification of myocardial blood flow reserve in patients with coronary artery disease using real-time myocardial perfusion echocardiography (RTMPE) has been demonstrated to further improve accuracy over the analysis of wall motion and qualitative analysis of myocardial perfusion. The aim of this study was to determine the prognostic value of qualitative and quantitative analyses obtained by RTMPE in patients with known or suspected coronary artery disease. METHODS: From March 2003 to December 2008, 227 consecutive patients with normal left ventricular function who underwent RTMPE were prospectively studied. Replenishment velocity reserve (ß) and myocardial blood flow reserve were derived from RTMPE. Primary outcomes were cardiac death, myocardial infarction and unstable angina with need for urgent coronary revascularization, and secondary outcomes were coronary bypass graft surgery or angioplasty. RESULTS: During a median follow-up period of 32 months (range, 5 days to 6.9 years), 19 major events (two deaths, six myocardial infarctions, and 11 episodes of unstable angina) and 46 total events occurred. Wall motion (hazard ratio [HR], 2.8; 95% confidence interval [CI], 1.4-5.6; P = .003) and qualitative myocardial perfusion analysis (HR, 4.3; 95% CI, 2.1-8.5; P < .001) were predictors of total events but not primary events. Abnormal myocardial blood flow reserve and abnormal ß reserve were predictors of total events (HR, 8.1; 95% CI, 3-21; P < .001; and HR, 16.5; 95% CI, 5.5-49; P < .001) and primary events (HR, 3.8; 95% CI, 1-15; P = .048; and HR, 8.7; 95% CI, 1.8-40; P = .005). On multivariate analysis, only abnormal ß reserve was an independent predictor of total (HR, 10.6; 95% CI, 2.5-43; P = .001) and primary (HR, 10.5; 95% CI, 1.5-6; P = .015) events. Abnormal ß reserve added incremental value in predicting primary events (χ(2) = 2.0-13.2; P = .014). CONCLUSIONS: Quantitative adenosine stress RTMPE added independent and additional prognostic information over wall motion and qualitative myocardial perfusion analysis in patients with known or suspected coronary artery disease and normal left ventricular function.
Assuntos
Doença das Coronárias/diagnóstico por imagem , Ecocardiografia sob Estresse , Adenosina , Ecocardiografia sob Estresse/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , VasodilatadoresRESUMO
BACKGROUND: Coronary and microvascular blood flow reserve have been established as important predictors of prognosis in patients with cardiovascular disease. The aim of this study was to assess the value of coronary flow velocity reserve (CFVR) and real-time myocardial perfusion echocardiography (RTMPE) for predicting events in patients with nonischemic dilated cardiomyopathy. METHODS: One hundred ninety-five patients (mean age 54 ± 12 years; 66% men) with dilated cardiomyopathy (left ventricular ejection fraction < 35% and no obstructive coronary disease on invasive angiography or multidetector computed tomography) who underwent dipyridamole stress (0.84 mg/kg over 10 min) RTMPE were prospectively studied. CFVR was calculated as the ratio of hyperemic to baseline peak diastolic velocities in the distal left anterior coronary artery. The replenishment velocity (ß), plateau of acoustic intensity (A(N)), and myocardial blood flow reserve were obtained from RTMPE. RESULTS: Mean CFVR was 2.07 ± 0.52, mean A(N) reserve was 1.05 ± 0.09, mean ß reserve was 2.05 ± 0.39, and mean myocardial blood flow reserve (A(N) × ß) was 2.15 ± 0.48. During a median follow-up period of 29 months, 45 patients had events (43 deaths and two urgent transplantations). Independent predictors of events were left atrial diameter (relative risk, 1.16; 95% confidence interval, 1.08-1.26; P < .001) and ß reserve ≤ 2.0 (relative risk, 3.22; 95% confidence interval, 1.18-8.79; P < .001). After adjustment for ß reserve, CFVR and myocardial blood flow reserve no longer had predictive value. Left atrial diameter added prognostic value over clinical factors and left ventricular ejection fraction (χ2 = 36.8-58.5, P < .001). Beta reserve added additional power to the model (χ2 = 70.2, P < .001). CONCLUSIONS: Increased left atrial diameter and depressed ß reserve were independent predictors of cardiac death and transplantation in patients with nonischemic dilated cardiomyopathy. Beta reserve by RTMPE provided incremental predictive value beyond that provided by current known prognostic clinical and echocardiographic factors.
Assuntos
Cardiomiopatia Dilatada/diagnóstico por imagem , Cardiomiopatia Dilatada/fisiopatologia , Circulação Coronária/fisiologia , Análise de Variância , Velocidade do Fluxo Sanguíneo/fisiologia , Cardiomiopatia Dilatada/mortalidade , Cardiomiopatia Dilatada/cirurgia , Distribuição de Qui-Quadrado , Angiografia Coronária , Teste de Esforço , Feminino , Transplante de Coração/estatística & dados numéricos , Humanos , Masculino , Microcirculação/fisiologia , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Modelos de Riscos Proporcionais , Estudos Prospectivos , Tomografia Computadorizada por Raios X , UltrassonografiaRESUMO
BACKGROUND: Hypercholesterolemia induces early microcirculatory functional and structural alterations that are reversible by cholesterol reduction. Real time myocardial contrast echocardiography (RTMCE) and vascular ultrasound evaluate the effects of hyperlipidemia on peripheral and central blood flow reserve. This study investigated the effects of lipid-lowering therapy on coronary and peripheral artery circulation in patients with familial hypercholesterolemia (FH). METHODS: RTMCE and vascular ultrasound were performed in 10 healthy volunteers (validation group) at baseline and after 12-week clinical observation, and in 16 age- and sex-matched FH patients without obstructive coronary artery disease (CAD) by computed tomography angiography at baseline and after 12-week atorvastatin treatment. Indexes of relative myocardial blood flow (MBF) were obtained at rest and during adenosine infusion. RESULTS: In validation group, there was no significant difference between flow-mediated dilation (FMD) at baseline and after 12 weeks (0.15 ± 0.02 vs. 0.14 ± 0.03; P = 0.39). Similarly, no differences were observed in MBF reserve at baseline and after 12 weeks (3.31 ± 0.63 vs. 3.48 ± 0.89; P = 0.89). FMD was blunted in FH patients, at baseline, as compared with validation group (0.08 ± 0.04 vs. 0.15 ± 0.02; P < 0.001) and became similar to that group (0.13 ± 0.05 vs. 0.14 ± 0.03; P = 0.07) after treatment. MBF reserve was blunted at baseline in FH patients in comparison with the validation group (2.78 ± 0.71 vs. 3.31 ± 0.63; P = 0.003). After treatment, MBF reserve values were no longer different (3.43 ± 0.66 and 3.48 ± 0.89; P = 0.84, respectively, for FH and validation groups). CONCLUSION: Patients with FH and no obstructive CAD have blunted MBF reserve and lower FMD values as compared with healthy volunteers. Both FMD and MBF reserve were normalized after atorvastatin treatment.
Assuntos
Circulação Coronária/efeitos dos fármacos , Ácidos Heptanoicos/uso terapêutico , Hiperlipoproteinemia Tipo II/tratamento farmacológico , Hiperlipoproteinemia Tipo II/fisiopatologia , Pirróis/uso terapêutico , Adulto , Anticolesterolemiantes/uso terapêutico , Atorvastatina , Velocidade do Fluxo Sanguíneo/efeitos dos fármacos , Doença da Artéria Coronariana/etiologia , Doença da Artéria Coronariana/fisiopatologia , Doença da Artéria Coronariana/prevenção & controle , Feminino , Humanos , Hiperlipoproteinemia Tipo II/complicações , Masculino , Imagem de Perfusão do Miocárdio , Resultado do TratamentoRESUMO
INTRODUCTION: This case report illustrates a rare case of teratoma of the mediastinum which was continuous to the pericardium and caused extrinsic compression to the right atrium. CASE PRESENTATION: A 22-year-old Caucasian man with no complaints or comorbid conditions presented to our hospital with obliteration of the right cardiophrenic sinus by a mass. A non-invasive investigation demonstrated a tumoral mass which was continuous to the pericardium and caused extrinsic compression to the right atrium. The clinical suspicion was a pericardial or bronchogenic cyst. Surgical and anatomopathologic findings led to the diagnosis of a mature cystic teratoma with atrophic thymic tissue at the external teratoma surface. CONCLUSION: We present an original report of a mature teratoma causing obliteration of the right cardiophrenic sinus with extrinsic heart compression. The diagnosis of this tumor is very difficult through non-invasive investigation.
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BACKGROUND: The relation between left ventricular filing velocities determined by Doppler echocardiography and autonomic nervous system function assessed by heart rate variability (HRV) is unclear. The aim of this study was to evaluate the influence of the autonomic nervous system assessed by the time and frequency domain indices of HRV in the Doppler indices of left ventricular diastolic filling velocities in patients without heart disease. METHODS: We studied 451 healthy individuals (255 female [56.4%]) with normal blood pressure, electrocardiogram, chest x-ray, and treadmill electrocardiographic exercise stress test results, with a mean age of 43+/-12 (range 15-82) years, who underwent transthoracic Doppler echocardiography and 24-hour electrocardiographic ambulatory monitoring. We studied indices of HRV on time (standard deviation [SD] of all normal sinus RR intervals during 24 hours, SD of averaged normal sinus RR intervals for all 5-minute segments, mean of the SD of all normal sinus RR intervals for all 5-minute segments, root-mean-square of the successive normal sinus RR interval difference, and percentage of successive normal sinus RR intervals>50 ms) and frequency (low frequency, high frequency, very low frequency, low frequency/high frequency ratio) domains relative to peak flow velocity during rapid passive filling phase (E), atrial contraction (A), E/A ratio, E-wave deceleration time, and isovolumic relaxation time. Statistical analysis was performed with Pearson correlation and logistic regression. RESULTS: Peak flow velocity during rapid passive filling phase (E) and atrial contraction (A), E/A ratio, and deceleration time of early mitral inflow did not demonstrate a significant correlation with indices of HRV in time and frequency domain. We found that the E/A ratio was<1 in 45 individuals (10%). Individuals with an E/A ratio<1 had lower indices of HRV in frequency domain (except low frequency/high frequency) and lower indices of the mean of the SD of all normal sinus RR intervals for all 5-minute segments, root-mean-square of the successive normal sinus RR interval difference, and percentage of successive normal sinus RR intervals>50 ms in time domain. Logistic regression demonstrated that an E/A ratio<1 was associated with lower HF. CONCLUSION: Individuals with no evidence of heart disease and an E/A ratio<1 demonstrated a significant decrease in indexes of HRV associated with parasympathetic modulation.
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Sistema Nervoso Autônomo/fisiologia , Velocidade do Fluxo Sanguíneo/fisiologia , Ecocardiografia Doppler em Cores/métodos , Átrios do Coração/inervação , Frequência Cardíaca/fisiologia , Ventrículos do Coração/inervação , Valva Mitral/diagnóstico por imagem , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Eletrocardiografia Ambulatorial/métodos , Feminino , Seguimentos , Átrios do Coração/diagnóstico por imagem , Cardiopatias , Ventrículos do Coração/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/fisiologia , Prognóstico , Valores de Referência , Adulto JovemRESUMO
BACKGROUND: : Several factors have been implicated in the high-mortality rate of posttraumatic pneumonectomy. In this study, we evaluated the hemodynamic and echocardiographic changes induced by pneumonectomy and fluid resuscitation after hemorrhagic shock. METHODS: : Fourteen dogs were bled to a target mean arterial pressure of 40 mmHg. The animals were assigned to two groups: control (no fluid resuscitation) and lactated Ringer's (3 x shed blood volume). The left pulmonary hilum was cross clamped, and the animals were observed for 60 minutes. Systemic hemodynamics was evaluated using Swan-Ganz, arterial catheter, and ultrasonic flow probe. Systemic O2-derived variables were calculated. Ejection fraction was determined by two-dimensional echocardiography. RESULTS: : Fluid resuscitation improved the mean arterial pressure and systemic oxygen delivery. After pneumonectomy, no significant increase in right ventricular pressure was observed in the LR group. No signs of major ventricular dilation or changes in arterial oxygenation were observed. CONCLUSION: : Our data suggest that pneumonectomy is not associated with early pulmonary hypertension; gentle fluid resuscitation improves cardiovascular performance and is not associated with an increase in right ventricular pressure.
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Hidratação , Pneumonectomia , Choque Hemorrágico/fisiopatologia , Choque Hemorrágico/terapia , Animais , Pressão Sanguínea , Cães , Soluções Isotônicas , Masculino , Consumo de Oxigênio , Circulação Pulmonar , Lactato de Ringer , Choque Hemorrágico/diagnóstico por imagem , Volume Sistólico , Ultrassonografia , Pressão VentricularRESUMO
Although a new protocol of dobutamine stress echocardiography with the early injection of atropine (EA-DSE) has been demonstrated to be useful in reducing adverse effects and increasing the number of effective tests and to have similar accuracy for detecting coronary artery disease (CAD) compared with conventional protocols, no data exist regarding its ability to predict long-term events. The aim of this study was to determine the prognostic value of EA-DSE and the effects of the long-term use of beta blockers on it. A retrospective evaluation of 844 patients who underwent EA-DSE for known or suspected CAD was performed; 309 (37%) were receiving beta blockers. During a median follow-up period of 24 months, 102 events (12%) occurred. On univariate analysis, predictors of events were the ejection fraction (p <0.001), male gender (p <0.001), previous myocardial infarction (p <0.001), angiotensin-converting enzyme inhibitor therapy (p = 0.021), calcium channel blocker therapy (p = 0.034), and abnormal results on EA-DSE (p <0.001). On multivariate analysis, the independent predictors of events were male gender (relative risk [RR] 1.78, 95% confidence interval [CI] 1.13 to 2.81, p = 0.013) and abnormal results on EA-DSE (RR 4.45, 95% CI 2.84 to 7.01, p <0.0001). Normal results on EA-DSE with beta blockers were associated with a nonsignificant higher incidence of events than normal results on EA-DSE without beta blockers (RR 1.29, 95% CI 0.58 to 2.87, p = 0.54). Abnormal results on EA-DSE with beta blockers had an RR of 4.97 (95% CI 2.79 to 8.87, p <0.001) compared with normal results, while abnormal results on EA-DSE without beta blockers had an RR of 5.96 (95% CI 3.41 to 10.44, p <0.001) for events, with no difference between groups (p = 0.36). In conclusion, the detection of fixed or inducible wall motion abnormalities during EA-DSE was an independent predictor of long-term events in patients with known or suspected CAD. The prognostic value of EA-DSE was not affected by the long-term use of beta blockers.
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Antagonistas Adrenérgicos beta/uso terapêutico , Atropina/administração & dosagem , Doença das Coronárias/diagnóstico por imagem , Doença das Coronárias/tratamento farmacológico , Ecocardiografia sob Estresse , Feminino , Humanos , Injeções , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Fatores de TempoRESUMO
Introdução: A pressão sistólica da artéria pulmonar (PSAP), aferida com ecocardiografia Doppler (ED), é estimada pelo refluxo tricúspide, o qual nem sempre está presente. Por causa disso, outros métodos podem ser utilizados. Objetivo: Determinar o valor dos demais métodos pela ED para o diagnóstico de hipertensão pulmonar(HP). Métodos: Foram incluídos pacientes encaminhados para estudo ecodopplercardiográfico, nos quais foi possível determinar a pressão pulmonar pelos métodos de refluxo tricúspide, refluxo pulmonar (pressão média; gradiente de pressão inicial - PMPIP; pressão diatólica, gradiente diastólico fical - PSPIP), e tempo de aceleração de fluxo na via de saída do ventrículo direito (PMPTAC). Foram analisados: sensibilidade, especificidade, valores preditivos positivo (VPP) e negativo(VPN), acurácia e concordância pelo teste Kappa, além de correlação, sendo a determinação da pressão pulmonar pelo método do refluxo tricúspide considerado padrão ouro. Resultados: Foram incluídos 28 pacientes, com média etária de 55 anos. A PSAP foi 40 +- 15,5 mmHg a PMPIP foi 17 +- 10,2 mmHg;a PDPIP foi 12,7 +- 7 mmHg;a PMPTAC foi 23 +- 13,9 mmHg. Os índices de correlação (r) com a PSAP da PMPIP, PDPIP e PMPTAC foram 0,73; 0,77 e 0,79, respectivamente. A sensibilidade foi de 73 por cento, 66 por cento e 78 por cento; a especificidade 100 por cento; o VPP 100 por cento, e 88 por cento;VPN 85 por cento, 82 por cento, 82 por cento; a acurácia 89 por cento, 87 por cento e 84 por cento; a concordância (Kappa) 0,77, 071 e 0,61, respectivamente. Conclusão: Com relação ao método do refluxo tricúspide, os outros métodos para avaliação da pressão pulmonar demonstraram boa correlação, moderada sensibilidade, alta especificidade e alta acurácia para o diagnóstico de HP e podem ser usados na prática clínica.
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Humanos , Adulto , Pessoa de Meia-Idade , Hipertensão Pulmonar/diagnóstico , Hipertensão Pulmonar/terapia , Ecocardiografia Doppler/métodos , Ecocardiografia Doppler , Artéria PulmonarRESUMO
UNLABELLED: Real time three-dimensional echocardiography (RT3DE) has been demonstrated to be an accurate technique to quantify left ventricular (LV) volumes and function in different patient populations. We sought to determine the value of RT3DE for evaluating patients with hypertrophic cardiomyopathy (HCM), in comparison with cardiac magnetic resonance imaging (MRI). METHODS: We studied 20 consecutive patients with HCM who underwent two-dimensional echocardiography (2DE), RT3DE, and MRI. Parameters analyzed by echocardiography and MRI included: wall thickness, LV volumes, ejection fraction (LVEF), mass, geometric index, and dyssynchrony index. Statistical analysis was performed by Lin agreement coefficient, Pearson linear correlation and Bland-Altman model. RESULTS: There was excellent agreement between 2DE and RT3DE (Rc = 0.92), 2DE and MRI (Rc = 0.85), and RT3DE and MRI (Rc = 0.90) for linear measurements. Agreement indexes for LV end-diastolic and end-systolic volumes were Rc = 0.91 and Rc = 0.91 between 2DE and RT3DE, Rc = 0.94 and Rc = 0.95 between RT3DE and MRI, and Rc = 0.89 and Rc = 0.88 between 2DE and MRI, respectively. Satisfactory agreement was observed between 2DE and RT3DE (Rc = 0.75), RT3DE and MRI (Rc = 0.83), and 2DE and MRI (Rc = 0.73) for determining LVEF, with a mild underestimation of LVEF by 2DE, and smaller variability between RT3DE and MRI. Regarding LV mass, excellent agreement was observed between RT3DE and MRI (Rc = 0.96), with bias of-6.3 g (limits of concordance = 42.22 to-54.73 g). CONCLUSION: In patients with HCM, RT3DE demonstrated superior performance than 2DE for the evaluation of myocardial hypertrophy, LV volumes, LVEF, and LV mass.