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Background: It is still very controversial whether the characteristics of pain in the acute myocardial infarction could be related to the culprit coronary artery. There are no data about associations of pain with the ST-segment elevation myocardial infarction (STEMI) and left ventricular (LV) fibrotic segments. Methods: Data from 328 participants who had STEMI and were included in the B and T Types of Lymphocytes Evaluation in Acute Myocardial Infarction (BATTLE-AMI) study were analyzed. The culprit artery was identified by coronary angiography and the injured myocardial segments by cardiac magnetic resonance. The statistical significance was established by P value < 0.05. Results: A total of 223 patients (68%) were selected. Association was not observed between chest pain and the culprit artery (P = 0.237), as well as between pain irradiation and the culprit artery (P = 0.473). No significant difference was observed in the pain localization in relation to the segments in the short axis basal, mid, apical, and long axis, except for the mid inferior segment. The data were not considered clinically relevant because this association was observed in only one of 17 segments after multiple comparisons. Conclusions: In patients with STEMI, no associations were observed between the location or irradiation of acute chest pain and/or adjacent areas and the culprit artery, or between pain and segmental myocardial fibrosis in the LV.
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Resumen Introducción: En los pacientes con DCPT, la disfunción ventricular es inevitable, y más temprana en VU derechos. La deformación miocárdica por STE y RMC-FT parece promisoria. Objetivo: Analizar la función ventricular mediante STE y RMC-FT en pacientes con DCPT, en comparación con RMC convencional según la morfología del VU y la posible implicación en su diagnóstico temprano. Método: Se recogieron medidas del strain longitudinal y circunferencial por STE y RMC-FT, volúmenes ventriculares y FE por RMC en 64 pacientes con DCPT. Resultados: La morfología ventricular no se relacionó con disfunción por RMC. Los VU derechos tuvieron valores por STE y RMC-FT disminuidos respecto de los VU izquierdos, con FE similares. Existe correlación entre STE y RMC-FT, no equivalentes, con buena factibilidad y reproducibilidad. Conclusiones: La RMC-FT y el STE son técnicas útiles en el diagnóstico temprano y la vigilancia de la función ventricular en VU derechos con FE preservada.
Abstract Introduction: In patients with TCPC, the development of ventricular dysfunction is inevitable and is more precocious in SRVs. Myocardial deformation by STE and CMR-FT is promising. Objective: To analize ventricular function in patients with TCPC using STE and CMR-FT compared with conventional cMRI, depending on SV morphology, to determine their role in early diagnosis of ventricular dysfunction. Method: Sixty-four patients with TCPC were included. Longitudinal and circumferential strain by STE and CMR-FT and ventricular volume and EF were obtained. Results: Dysfunction analyzed by cMRI showed no association with ventricular morphology. SRVs had lower values in STE and CMR-FT compared with SLVs, with similar EF. While not equivalent, correlation was observed between the STE and the CMR-FT values, demonstrating good feasibility and reproducibility. Conclusion: The strain data in CMR-FT and STE could be useful for diagnosis and monitoring of ventricular function and as markers of early SRV dysfunction with preserved EF.
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Atherosclerosis is defined as an inflammatory disease. Low-grade inflammation is present in all phases of the cardiovascular continuum, since the establishment of cardiovascular risk factors and ischemic heart disease until cardiovascular events, such as myocardial infarction, heart failure and death. Not all inflammatory pathways are linked to cardiovascular outcomes, and thus, not all anti-inflammatory approaches decrease cardiovascular events. The most common cause of ventricular remodeling and heart failure is ischemic heart disease. Biomarkers such as high-sensitivity C-reactive protein can identify individuals at risk of major cardiovascular complications, but this biomarker has no causal effect on cardiovascular disease. On the other hand, interleukin 6 appears to be causally associated with cardiovascular disease. CANTOS was the first proof of concept study showing that anti-inflammatory therapy reduces major cardiovascular outcomes. Based on many anti-inflammatory trials, only therapies acting on the NLRP3 inflammasome, or interleukin 1beta, showed benefits on cardiovascular disease. Ventricular remodeling, particularly after myocardial infarction seems also influenced by the intensity of inflammatory responses, suggesting that anti-inflammatory therapies may reduce the residual cardiovascular risk. Inflammasome (NLRP3) activation, subtypes of lymphocytes, interleukin 6, and some inflammatory biomarkers, are associated with larger infarct size and impaired ventricular function after myocardial infarction. Cardiovascular risk factors commonly present in patients with myocardial infarction, and advanced age are associated with higher inflammatory activity.
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Resumo Fundamento: Há dados limitados sobre o valor prognóstico da ressonância magnética cardíaca (RMC) em estresse em pacientes idosos. Objetivo: Determinar o valor prognóstico da RMC em estresse com adenosina em idosos com doença arterial coronariana (DAC) conhecida ou suspeita. Métodos: Entre 2010 e 2015, pacientes consecutivos com 65 anos ou mais encaminhados para RMC em estresse com adenosina foram acompanhados para a ocorrência de eventos cardíacos graves (morte cardíaca e infarto do miocárdio não-fatal) e eventos cardiovasculares adversos maiores (ECAM) que também incluíram hospitalização por insuficiência cardíaca e acidente vascular cerebral isquêmico. As análises univariadas e multivariadas foram realizadas para determinar o valor prognóstico da isquemia miocárdica, com valor de p <0,05 considerado estatisticamente significante. Resultados: Após um período médio de seguimento de 50,4 meses em 324 pacientes (48% do sexo masculino, 73±7 anos), ocorreram 21 eventos cardíacos graves e 52 ECAM. Pacientes com isquemia miocárdica (n=99) apresentaram taxas significantemente maiores de eventos cardíacos graves (HR 5,25 [IC 95% 2,11-13,04], p<0,001) e ECAM (HR 3,01 [IC 95% 1,75-5,20], p<0,001) do que aqueles sem isquemia. A análise multivariada determinou a isquemia como preditor independente de eventos cardíacos graves (HR 3,14 [IC 95% 1,22-8,07], p=0,02) e ECAM (HR 1,91 [IC 95% 1,02-3,59], p=0,04). A isquemia forneceu um valor prognóstico incremental sobre fatores clínicos e fração de ejeção do ventrículo esquerdo para predizer eventos cardíacos graves e ECAM (p<0,01 para ambos). Nenhum evento adverso grave ocorreu durante ou imediatamente após os exames de RMC. Conclusão: A RMC em estresse com adenosina é segura e demonstra valor prognóstico em idosos com DAC conhecida ou suspeita.
Abstract Background: There is limited data on the prognostic value of stress cardiac magnetic resonance (CMR) in older adults. Objective: To determine the prognostic value of adenosine stress CMR in older individuals with known or suspected coronary artery disease (CAD). Methods: Between 2010 and 2015, consecutive patients aged 65 years or older referred for adenosine stress CMR were followed for the occurrence of severe cardiac events (cardiac death and nonfatal myocardial infarction) and major adverse cardiovascular events (MACE) that also included hospitalization for heart failure and ischemic stroke. Univariate and multivariate analyses were performed to determine the prognostic value of myocardial ischemia, with p-value <0.05 considered statistically significant. Results: After a mean follow-up period of 50.4 months in 324 patients (48% male, 73±7 years), 21 severe cardiac events and 52 MACE occurred. Patients with myocardial ischemia (n=99) had significantly higher rates of severe cardiac events (HR 5.25 [95% CI 2.11-13.04], p<0.001) and MACE (HR 3.01 [95% CI 1.75-5.20], p<0.001) than those without ischemia. Multivariable analysis determined ischemia as an independent predictor of severe cardiac events (HR 3.14 [95% CI 1.22-8.07], p=0.02) and MACE (HR 1.91 [95%CI 1.02-3.59], p=0.04). Ischemia provided an incremental prognostic value over clinical factors and left ventricular ejection fraction for predicting severe cardiac events and MACE (p<0.01 for both). No severe adverse events occurred during or immediately after CMR examinations. Conclusion: Adenosine stress CMR is safe and has prognostic value in older adults with known or suspected CAD.
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Primary cardiac sarcomas are very aggressive, being a challenge to cardio-oncology specialty. Surgical planning and innovative techniques have enhanced the possibility of resection. We have described a case of recurrent primary left atrium angiosarcoma, successfully resected with a modified partial autotransplantation technique, planned using a 3-dimensional model created from computed tomography. (Level of Difficulty: Intermediate.).
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OBJECTIVE: We sought to evaluate contractile function in single-ventricle patients before and after imposition of Fontan physiology. METHODS: Single right ventricle (SRV; n = 38) and single left ventricle (SLV; n = 11) patients underwent cardiac magnetic resonance imaging pre and post Fontan operation. Global radial strain (GRS), global circumferential strain (GCS), and global longitudinal strain were measured along with ejection fraction (EF) and atrioventricular valve regurgitation (AVVR). RESULTS: Age at cardiac magnetic resonance imaging before the Fontan operation was 3.1 ± 1.3 years and after the Fontan procedure was 5.8 ± 2.7 years. There were no significant EF differences between SRV and SLV patients before and after the Fontan procedure, and EF did not deteriorate significantly after the Fontan operation. GRS was significantly lower for SRV patients than for SLV patients before (24.3% vs 32.1%; P = .048) and after (21.8% vs 29.7%; P = .045) the Fontan procedure. GRS and GCS of the SRV patients deteriorated significantly after the Fontan operation (GRS, P = .01; GCS, P = .009). Strains showed positive correlations before and after the Fontan operation with positive correlations among each strain. Within all patients, strains correlated positively with EF. Strains and EF negatively correlated with AVVR (GRS P = .03, r = -0.22; GCS P = .03, r = -0.23; EF P < .001, r = -0.37). CONCLUSIONS: Strains were lower for SRV than for SLV patients before and after the Fontan operation and deteriorated after the Fontan operation. Our study suggests that strain measures might detect ventricular deterioration earlier than EF. Because strains before and after the Fontan operation were positively correlated, and negatively correlated with AVVR, the early institution of myocardial protective therapy including AVVR management, especially for SRV patients, might have benefit.
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Técnica de Fontan , Coração Univentricular/fisiopatologia , Coração Univentricular/cirurgia , Função Ventricular , Fenômenos Biomecânicos , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Estudos Retrospectivos , Volume SistólicoRESUMO
Resumen La enfermedad de Chagas es un problema de salud pública en Latinoamérica, donde afecta a aproximadamente a 6 millones de personas. En Costa Rica se ha descrito la enfermedad desde 1941, con varios reportes de casos confirmados agudos y crónicos. La miocardiopatía chagásica afecta al 30% de los individuos con infección crónica y es la manifestación más grave de la enfermedad, con una morbimortalidad mayor que otras miocardiopatías. La resonancia magnética cardíaca, debido a su capacidad de caracterización tisular permite identificar con alta correlación histopatológica la presencia de fibrosis, edema e inflamación en la miocardiopatía chagásica. Esto ha permitido una mejor comprensión de la compleja fisiopatología de la enfermedad y además permite el diagnóstico diferencial con otras patologías simuladoras como lo es la cardiopatía isquémica. En la MCh la presencia de fibrosis miocárdica predice de manera independiente eventos adversos mayores tales como taquicardia ventricular sostenida y muerte cardiovascular. Debido a lo anterior la resonancia magnética cardíaca es una robusta herramienta capaz de mejorar el diagnóstico, la estratificación de riesgo y el pronóstico de estos pacientes, con miras a mejores y oportunas intervenciones terapéuticas.
Abstract Chagas disease is a public health problem in Latin America, where it affects approximately 6 million people. In Costa Rica the disease has been described since 1941, with several reports of acute and chronic confirmed cases. Chagas cardiomyopathy affects 30% of individuals with chronic infection and is the most serious manifestation of the disease, with a higher morbidity and mortality than other cardiomyopathies. Cardiac magnetic resonance, due to its capacity for tissue characterization, identifies the presence of fibrosis, aedema and inflammation in Chagas cardiomyopathy with high histopathological correlation. This has allowed a better understanding of the complex pathophysiology of the disease and also allows differential diagnosis with other pathologies that can simulate, such as ischemic heart disease. In Chagas cardiomyopathy, the presence of myocardial fibrosis independently predicts major adverse events such as sustained ventricular tachycardia and cardiovascular death. Due to the above, cardiac magnetic resonance is a robust tool capable of improving the diagnosis, risk stratification and prognosis of these patients, with a view to better and timely therapeutic interventions.
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Humanos , Espectroscopia de Ressonância Magnética/uso terapêutico , Cardiomiopatia Chagásica/diagnóstico por imagem , Doença de Chagas/terapiaRESUMO
Los innegables progresos en la supervivencia de los pacientes con cardiopatía congénita en los últimos años fue acompañado de los avances en todas las áreas concurrentes a la cirugía cardiovascular, incluyendo la recuperación y los métodos diagnósticos que permiten una mejor comprensión de la patología cardíaca congénita o adquirida. La velocidad con que se desarrollan estas herramientas en el arsenal médico, exige una mejor comprensión a la hora de definir la estrategia diagnóstica para cada paciente en particular. Tradicionalmente, las imágenes diagnósticas de las cardiopatías congénitas eran dominio de la ecocardiografía y el cateterismo. En los últimos 10 años, la Resonancia y la Tomografía Computada fueron ganando terreno. La principal ventaja de la Resonancia es que no utiliza Rayos X para obtener las imágenes, diferencia de la angiografía por cateterismo y la tomografía axial computada. La resonancia magnética cardíaca se ha convertido en una herramienta importante para evaluar la enfermedad cardíaca congénita y también la adquirida en niños y adultos. La variedad y complejidad de la patología y sus posibilidades quirúrgicas hace indispensable la presencia del cardiólogo infantil durante la adquisición de las imágenes y su post procesamiento. En esta sección se presentarán algunas de las herramientas o secuencias que utiliza la Resonancia Magnética Cardíaca y su utilización práctica en el diagnóstico de las cardiopatías más frecuentes (AU)
The undeniable progress in survival of patients with congenital heart defects in recent years has been accompanied by advances in all areas related to cardiovascular surgery, including recovery and diagnostic methods that allow for a better understanding of congenital or acquired heart disease. The speed with which these tools are developed in the medical arsenal requires a better understanding when defining the diagnostic strategy for each individual patient. Traditionally, diagnostic images of choice for congenital heart disease were echocardiography and catheterization. Over the last 10 years, MRI. and CT scan have become more important. The main advantage of MRI is that it does not use X-rays to obtain the images, unlike catheterization and computed tomography angiogram. Cardiac MRI has become an important tool for assessing congenital and acquired heart disease in children and adults. The variety and complexity of the disease and its surgical possibilities warrant the presence of the child cardiologist during imaging acquisition and processing. This section will present some of the MRI tools and sequences and their practical use in the diagnosis of the most common heart diseases (AU)
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Humanos , Recém-Nascido , Lactente , Pré-Escolar , Criança , Adolescente , Imageamento por Ressonância Magnética/instrumentação , Imageamento por Ressonância Magnética/tendências , Cardiopatias Congênitas/diagnóstico por imagem , Cardiomiopatias/diagnóstico por imagem , Técnicas de Diagnóstico CardiovascularRESUMO
BACKGROUND: Cardiac magnetic resonance (CMR) imaging has gained importance in pulmonary hypertension (PH) and studies have demonstrated its use as a surrogate marker and in following treatment of these patients. The pathophysiology of PH differs between pulmonary arterial hypertension (PAH, group 1) and chronic thromboembolic PH (CTEPH, group 4). OBJECTIVES: The present study tested the hypothesis that PAH and CTEPH display different characteristics on CMR imaging. METHODS: 46 patients were evaluated for pulmonary vascular disease in the French National Reference Center for PH (23 PAH and 23 CTEPH matched for age and gender). All patients had the right heart catheterization (RHC) and CMR imaging performed within 48h. CMR imaging was performed on a 1.5 T scanner. RESULTS: PAH and CTEPH had similar body surface area and similar invasive hemodynamics, including mean pulmonary arterial pressure, cardiac index, pulmonary vascular resistance and right atrial pressure. PAH and CTEPH had similar CMR data. Right ventricular (RV) morphology and function and pulmonary artery (PA) data were also similar. CONCLUSION: Age- and sex-matched PAH and CTEPH patients displayed similar values of the CMR indices of RV and PA morphology and function, suggesting that the RV-PA responses are similar in both groups, mostly related to the overall increase in after load.
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Ventrículos do Coração/diagnóstico por imagem , Imageamento por Ressonância Magnética/métodos , Hipertensão Arterial Pulmonar/diagnóstico por imagem , Embolia Pulmonar/diagnóstico por imagem , Adulto , Idoso , Cateterismo Cardíaco/métodos , Doença Crônica , Feminino , França/epidemiologia , Átrios do Coração/fisiopatologia , Ventrículos do Coração/fisiopatologia , Hemodinâmica , Humanos , Hipertensão Pulmonar/fisiopatologia , Pulmão/irrigação sanguínea , Pulmão/patologia , Pulmão/fisiopatologia , Masculino , Pessoa de Meia-Idade , Hipertensão Arterial Pulmonar/fisiopatologia , Artéria Pulmonar/patologia , Artéria Pulmonar/fisiopatologia , Embolia Pulmonar/fisiopatologia , Pressão Propulsora Pulmonar/fisiologia , Doenças Vasculares/fisiopatologia , Resistência Vascular , Função Ventricular Direita/fisiologiaRESUMO
BACKGROUND: Early reperfusion of the occluded coronary artery during acute myocardial infarction is considered crucial for reduction of infarcted mass and recovery of ventricular function. Effective microcirculation and the balance between protective and harmful lymphocytes may have roles in reperfusion injury and may affect final ventricular remodeling. METHODS/DESIGN: BATTLE-AMI is an open-label, randomized trial comparing the effects of four therapeutic strategies (rosuvastatin/ticagrelor, rosuvastatin/clopidogrel, simvastatin plus ezetimibe/ticagrelor, or simvastatin plus ezetimibe/clopidogrel) on infarcted mass and left ventricular ejection fraction (LVEF) (blinded endpoints) in patients with ST-segment elevation myocardial infarction submitted to fibrinolytic therapy before coronary angiogram (pharmacoinvasive strategy). All patients (n = 300, 75 per arm) will be followed up for six months. The effects of treatment on subsets of B and T lymphocytes will be determined by flow-cytometry/ELISPOT and will be correlated with the infarcted mass, LVEF, and microcirculation perfusion obtained by cardiac magnetic resonance imaging. The primary hypothesis is that the combined rosuvastatin/ticagrelor therapy will be superior to other therapies (particularly for the comparison with simvastatin plus ezetimibe/clopidogrel) for the achievement of better LVEF at 30 days (primary endpoint) and smaller infarcted mass (secondary endpoint) at 30 days and six months. The trial will also evaluate the improvement in the immune/inflammatory responses mediated by B and T lymphocytes. Omics field (metabolomics and proteomics) will help to understand these responses by molecular events. DISCUSSION: BATTLE-AMI is aimed to (1) evaluate the role of subsets of lymphocytes on microcirculation improvement and (2) show how the choice of statin/antiplatelet therapy may affect cardiac remodeling after acute myocardial infarction with ST elevation. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02428374 . Registered on 28 September 2014.
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Anti-Inflamatórios/administração & dosagem , Linfócitos B/efeitos dos fármacos , Inibidores de Hidroximetilglutaril-CoA Redutases/administração & dosagem , Mediadores da Inflamação/sangue , Inibidores da Agregação Plaquetária/administração & dosagem , Infarto do Miocárdio com Supradesnível do Segmento ST/tratamento farmacológico , Linfócitos T/efeitos dos fármacos , Terapia Trombolítica , Adenosina/administração & dosagem , Adenosina/análogos & derivados , Anti-Inflamatórios/efeitos adversos , Linfócitos B/imunologia , Linfócitos B/metabolismo , Biomarcadores/sangue , Brasil , Protocolos Clínicos , Clopidogrel , Angiografia Coronária , Quimioterapia Combinada , ELISPOT , Ezetimiba/administração & dosagem , Feminino , Citometria de Fluxo , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/efeitos adversos , Imageamento por Ressonância Magnética , Masculino , Metabolômica , Inibidores da Agregação Plaquetária/efeitos adversos , Proteômica , Projetos de Pesquisa , Rosuvastatina Cálcica/administração & dosagem , Infarto do Miocárdio com Supradesnível do Segmento ST/sangue , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico por imagem , Infarto do Miocárdio com Supradesnível do Segmento ST/imunologia , Sinvastatina/administração & dosagem , Volume Sistólico/efeitos dos fármacos , Linfócitos T/imunologia , Linfócitos T/metabolismo , Terapia Trombolítica/efeitos adversos , Ticagrelor , Ticlopidina/administração & dosagem , Ticlopidina/análogos & derivados , Fatores de Tempo , Resultado do Tratamento , Função Ventricular Esquerda/efeitos dos fármacos , Remodelação Ventricular/efeitos dos fármacosRESUMO
OBJECTIVES: This study aimed to evaluate the amount and pattern of cardiac biomarker release after elective percutaneous coronary intervention (PCI) in patients without evidence of a new myocardial infarction (MI) after the procedure as assessed by cardiac magnetic resonance (CMR) with late gadolinium enhancement (LGE). BACKGROUND: The release of myocardial necrosis biomarkers after PCI frequently occurs. However, the correlation between biomarker release and the diagnosis of procedure-related MI type 4a has been controversial. METHODS: Patients with normal baseline cardiac biomarkers who were referred for elective PCI were prospectively included. CMR with LGE was performed in all of the patients before and after the intervention. Measurements of troponin I (TnI) and creatine kinase MB fraction (CK-MB) were systematically performed before and after the procedure. Patients with a new LGE on the post-procedure CMR were excluded. RESULTS: Of the 56 patients with no evidence of a procedure-related MI as assessed by CMR after the PCI, 48 (85.1%) exhibited an elevation of TnI above the 99th percentile. In 32 patients (57.1%), the peak was greater than five times this limit. Additionally, 17 patients (30.4%) had a CK-MB peak above the 99th percentile limit, but this peak was greater than five times the 99th percentile in only two patients (3.6%). The median peak release of TnI was 0.290 (0.061-1.09) ng/mL, which was 7.25-fold higher than the 99th percentile. CONCLUSIONS: In contrast to CK-MB, an abnormal release of TnI often occurs after an elective PCI procedure, despite the absence of a new LGE on CMR.
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Meios de Contraste/administração & dosagem , Creatina Quinase Forma MB/sangue , Compostos Heterocíclicos/administração & dosagem , Imageamento por Ressonância Magnética , Infarto do Miocárdio/sangue , Infarto do Miocárdio/diagnóstico por imagem , Miocárdio/metabolismo , Compostos Organometálicos/administração & dosagem , Intervenção Coronária Percutânea/efeitos adversos , Troponina I/sangue , Idoso , Biomarcadores/sangue , Angiografia Coronária , Eletrocardiografia , Feminino , Fibrose , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Miocárdio/patologia , Necrose , Intervenção Coronária Percutânea/instrumentação , Valor Preditivo dos Testes , Estudos Prospectivos , Reprodutibilidade dos Testes , Fatores de Risco , Stents , Resultado do Tratamento , Regulação para CimaRESUMO
A 58-year-old male with a history of a soft tissue sarcoma in remission presented with a 2 weeks history of progressive dyspnea. Transthoracic echocardiography showed right ventricular dilation; right ventricular systolic pressure (RVSP) of 110 mm Hg, and a lobulated mass in the right ventricular outflow tract (RVOT) causing obstruction. Microbubble contrast was administered showing perfusion within the mass, which suggested malignancy. A CT pulmonary angiogram (CTPA) confirmed the presence of the mass in the RVOT without evidence of pulmonary embolism. This case demonstrates the importance of the multimodality imaging approach for the differential diagnosis of masses in the RVOT.
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Angiografia por Tomografia Computadorizada/métodos , Ecocardiografia/métodos , Neoplasias Cardíacas/complicações , Neoplasias Cardíacas/diagnóstico por imagem , Obstrução do Fluxo Ventricular Externo/diagnóstico por imagem , Obstrução do Fluxo Ventricular Externo/etiologia , Meios de Contraste , Diagnóstico Diferencial , Ventrículos do Coração/diagnóstico por imagem , Humanos , Aumento da Imagem/métodos , Masculino , Microbolhas , Pessoa de Meia-IdadeRESUMO
The usefulness of echocardiography and the new noninvasive cardiac techniques in assessing heart failure is analyzed. The usefulness of non-invasive CT coronary angiography, as well as the growing applications of magnetic resonance imaging (MRI) in the study of ischemic heart disease, cardiomyopathy and arrhythmogenic right ventricular dysplasia is considered. For this puspose, some clinical cases are used. The combined use of these techniques, especially in patients in whom the etiology of heart failure is ischemic heart disease or cardiomyopathy is emphasized.
Se analiza la utilidad de la ecocardiografía y nuevas técnicas de dianóstico cardiológico no invasivo en la valoración de la insuficiencia cardiaca. Se valora la utilidad de la coronariografía no invasiva por tomografía computarizada, así como las crecientes aplicaciones de la resonancia magnética en el estudio de la cardiopatía isquémica, miocardiopatías y displasia arritmogénica del ventrículo derecho. Para este propósito, se utilizan algunos casos clínicos. Se enfatiza la importancia del uso combinado de estas técnicas, especialmente en los pacientes con insuficiencia cardiaca cuya etiología sea la cardiopatía isquémica o alguna miocardiopatía.
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Angiografia por Tomografia Computadorizada/métodos , Angiografia Coronária/métodos , Insuficiência Cardíaca/diagnóstico por imagem , Displasia Arritmogênica Ventricular Direita/diagnóstico por imagem , Cardiomiopatias/diagnóstico por imagem , Humanos , Imageamento por Ressonância Magnética/métodos , Isquemia Miocárdica/diagnóstico por imagemRESUMO
BACKGROUND: The incidence of arrhythmias may be increased in acromegaly, but the pathophysiologic mechanisms involved are still unclear, and it has never been correlated with structural heart changes analyzed by the gold-standard method cardiac magnetic resonance (CMR). AIM: Evaluate the frequency of arrhythmias in drug-naïve acromegaly patients at baseline and after 1 year of somatostatin analogs (SA) treatment and to correlate the occurrence of arrhythmias with the presence of structural heart changes. PATIENTS AND METHODS: Consecutive drug-naïve acromegaly patients were recruited. The occurrence of arrhythmias and structural heart changes were studied through 24-h Holter and CMR, respectively, at baseline and after 1-year SA treatment. RESULTS: Thirty-six patients were studied at baseline and 28 were re-evaluated after 1 year of SA treatment. There were 13 females and median age was 48 years (20-73 years). Nine patients (32 %) were controlled after treatment. No sustained arrhythmias were reported in the 24-h Holter. No arrhythmia-related symptoms were observed. Only two patients presented left ventricular hypertrophy and three patients presented fibrosis at baseline. There was no correlation of the left ventricular mass with the number of episodes of arrhythmias and they were not more prevalent in the patients presenting cardiac fibrosis. CONCLUSION: We found no sustained arrhythmias and a lack of arrhythmia-related symptoms at baseline and after 1 year of SA treatment in a contemporary cohort of acromegaly patients that also present a low frequency of structural heart changes, indicating that these patients may have a lower frequency of heart disease than previously reported.
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Acromegalia/complicações , Arritmias Cardíacas/etiologia , Somatostatina/uso terapêutico , Acromegalia/tratamento farmacológico , Acromegalia/patologia , Adulto , Idoso , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/epidemiologia , Brasil/epidemiologia , Eletrocardiografia Ambulatorial , Feminino , Fibrose , Ventrículos do Coração/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Somatostatina/análogos & derivados , Adulto JovemRESUMO
Left ventricle non-compaction cardiomyopathy is currently considered as a well-defined individual entity. However, it includes a broad spectrum of clinical, radiological and pathophysiological findings. In this review we describe 3 different scenarios of this entity: an isolated case with severe left ventricle dysfunction, an "associated" case in a patient with previous atrial septum defect and pulmonary stenosis and finally, as a finding in a patient with a transient cerebrovascular ischemic attack. In the 2 last cases, both asymptomatic, morphological criteria of left ventricle non-compaction were found but, ventricular function was normal and cardiac-MRI showed no late gadolinium hyperenhancement. Periodical follow-up and familial screening were recommended. Natural history and prognosis factors of this disease are still not well known. Further and longer series of patients with this diagnosis are needed to completely define radiological criteria, clinical presentation and evolution.
La miocardiopatía no compactada está considerada actualmente como una entidad independiente y bien definida. Sin embargo, presenta un espectro amplio de hallazgos clínicos, radiológicos y fisiopatológicos. En la presente revisión describimos 3 escenarios clínicos diferentes de dicha entidad: un caso con disfunción ventricular severa, un caso como entidad «asociada¼ a una cardiopatía congènita en un pacientes con un defecto del septo interauricular previo y estenosis pulmonar, y finalmente, como un hallazgo casual en un paciente con un accidente cerebrovascular transitorio. En estos 2 últimos casos se encontraron criterios morfológicos de miocardiopatía no compactada con función ventricular normal y sin presencia de realce tardío de gadolinio en el estudio de cardio-RM. En todos ellos se recomendó estudio familiar. La historia natural y el pronóstico de esta anatomía patológica no son todavía del todo conocidos. Series mayores y seguimiento más largos son necesarios para definir completamente los criterios radiológicos, la presentación clínica y la evolución de esta fascinante entidad.
Assuntos
Adulto , Feminino , Humanos , Masculino , Adulto Jovem , Técnicas de Imagem Cardíaca , Miocárdio Ventricular não Compactado Isolado/diagnóstico , Imageamento por Ressonância MagnéticaRESUMO
Introducción: La Tetralogía de Fallot reparada (TOFr) a largo plazo evoluciona frecuentemente con insuficiencia pulmonar (IP). La resonancia magnética cardíaca (RMC) juega un rol fundamental en la indicación de recambio valvular pulmonar destinada a evitar las complicaciones de la IP. Objetivo: El objetivo de este trabajo es buscar qué índice(s) ecocardiográfico(s) permite(n) identificar a los pacientes con TOFr que tienen VD dilatado y fracción de eyección (FE) disminuida en la RMC. Método: En 20 pacientes (9 mujeres, 8-25 años, promedio 15,8 años) con TOFr se realizó ecocardiograma (ECO) y RMC en el Hospital Sótero del Río. Por ECO se obtuvieron mediciones de excursión sistólica máxima anular tricuspídea (TAPSE), onda s tisular, aceleración miocárdica isovolumétrica (IVA), y grado de IP (leve, moderado o severo). Por RMC se midieron la FE, volumen fin de diástole (VFD) del VD y fracción de regurgitación de la arteria pulmonar (FR). Se realizó un análisis estadístico multivariado. Resultados: No se obtuvo ninguna correlación entre algún parámetro de ECO versus VFD o FE del VD. Sin embargo, se encontró un modelo basado en el TAP-SE e IP que en nuestros pacientes pudo predecir el VDF del VD con un r2 = 0.6. (VDF-VD = 8.60*TAPSE + 36.19*IP - 77.213). Al comparar la IP con la FR se encontró que la ecografía puede distinguir correctamente aquellos casos que tienen IP leve de severa (p<0.001), o moderada de severa (p=0.004), pero no puede diferenciar con significancia estadística aquellos casos de IP leve de moderada (p=0.272). Conclusión: En este estudio preliminar se encontró un modelo estadístico basado en el TAPSE e IP que podría ser útil en la selección de pacientes que son derivados para estudio con RMC. La estimación del grado de IP medida por ECO es un parámetro fácil de obtener, sin embargo no siempre es informado en forma categórica (leve, moderado o severo). Si bien este estudio se debe validar en un mayor número de pacientes, éste nos indica la...
Background: Pulmonary insufficiency (PI) frequently appears long-term after repair of Tetralogy of Fallot (TOFr). Cardiac magnetic resonance (CMR) plays a fundamental role in the indication of pulmonary valve replacement, in order to avoid complications of PI. However, CMR is a scarce and expensive resource in our reality, which is why its indication must be optimized. Aim: The objective of this work is to find echocar-diographic indices to identify patients with TOFr with dilated RV and reduced ejection fraction (EF). Method: Images from echocardiograms (ECHO) and CMR in 20 patients (9 women, 8-25 years of age, average 15,8 years old) with TOFr were retrospectively reviewed. From ECHO images we obtained measurements for tricuspid annular plane systolic excursion (TAPSE), tissular s wave, isovolumetric acceleration (IVA), and severity of PI (mild, moderate, or severe). From CMR images, we measured EF, end diastolic volume (EDV) of the RV, and regurgitant fraction (RF) of the pulmonary artery. We performed a multivariate statistical analysis to explore the relation between ECHO parameters and CMR findings. Results: No correlation was found between individual ECHO parameters and EDV or RV EF. However, we did find a model based on the TAPSE and PI that was able to predict the EDV of the RV with an r2 = 0.6. (FDV-RV = 8.60*TAPSE + 36.19*PI - 77.213). After comparing the PI with RF, we found that that echocar-diography could correctly distinguish cases with mild PI from those with severe PI (p<0.001), or moderate from severe (p=0.004), but not mild from moderate PI. Conclusion: In this preliminary study, we found a statistical model based on the TAPSE and PI which could be useful in the selection of patients with TOFr that are referred to CMR. While this study needs to be validated on a greater number of patients, it indicates the relevance of some echocardiographic parameters, which should always be included in the evaluation of patients with TOFr.
Assuntos
Humanos , Masculino , Feminino , Criança , Adolescente , Adulto Jovem , Tomografia Computadorizada por Emissão de Fóton Único de Sincronização Cardíaca , Ecocardiografia/métodos , Tetralogia de Fallot/diagnósticoRESUMO
A cardiomiopatia periparto (CMPP) é uma das causas comuns de cardiomiopatia secundária de etiologia desconhecida. Caracteriza-se pela presenþa de insuficiÛncia cardíaca congestiva (ICC) materna, no último mÛs de gestaþÒo ou até cinco meses pós-parto, com disfunþÒo ventricular sistólica esquerda, na ausÛncia de outras causas de insuficiÛncia cardíaca e em mulheres previamente saudáveis. A terapÛutica médica consiste no bloqueio neuro-hormonal, suporte inotrópico, reduþÒo da pré e pós-carga cardíaca e anticoagulaþÒo. O transplante cardíaco está reservado aos casos graves e refratários O terapÛutica medicamentosa. O prognóstico é variável: aproximadamente 50-60% das pacientes recuperam completamente a funþÒo cardíaca, na maioria das vezes dentro dos primeiros seis meses. Relata-se um caso de mulher negra, 37 anos, multípara, pré-natal sem intercorrÛncias, sem comorbidades prévias ou uso de drogas, que desenvolveu um quadro de ICC, de instalaþÒo súbita, com disfunþÒo ventricular comprovada ao ecocardiograma 15 dias após parto normal. Houve suspeiþÒo clínica de miocárdio nÒo-compactado (MNC) que levou a dúvida quanto ao diagnóstico de CMPP, posto ser esta um diagnóstico de exclusÒo. A presenþa de MNC foi afastada pela ressonÔncia nuclear magnética cardíaca.(AU)
La miocardiopatía periparto (MCPP) es una causa frecuente de miocardiopatía secundaria de etiología desconocida. Se caracteriza por la presencia de insuficiencia cardíaca congestiva (ICC) en la madre en el último mes del embarazo o hasta cinco meses después del parto, con disfunción sistólica del ventrículo izquierdo en ausencia de otras causas de insuficiencia cardíaca en mujeres previamente sanas. El tratamiento médico consiste en el bloqueo neurohormonal, soporte inotrópico, la reducción de la pre y post-carga cardíaca y anticoagulación. El trasplante cardíaco está reservado para casos graves y refractarios al tratamiento farmacológico. El pronóstico es variable: aproximadamente el 50-60% de las pacientes recuperan completamente la función cardíaca, en la mayoría de los casos en los primeros seis meses. Se presenta el caso clínico de una mujer de raza negra de 37 años, multípara, prenatal sin complicaciones, sin comorbilidades previas o uso de drogas, que desarrollo ICC, de aparición súbita, con disfunción ventricular demostrada en el ecocardiograma 15 días después de un parto normal. No había sospecha clínica de miocardiopatía no compactada (MNC) que dio lugar a duda sobre el diagnóstico de MCPP, ya que éste es un diagnóstico de exclusión. La presencia de MNC fue descartada por resonancia magnética nuclear cardíaca.(AU)
Peripartum cardiomyopathy (PPCM) is a common cause of secondary cardiomyopathy of unknown etiology. It is characterized by the presence of congestive heart failure (CHF) in the mother in the last month of pregnancy or until five months after birth with left ventricular systolic dysfunction in the absence of other causes of heart failure in previously healthy women. Medical treatment consists of neurohormonal blockade, inotropic support, reduced pre-and post-cardiac load and anticoagulation. Heart transplantation is reserved for severe cases refractory to medical therapy. The prognosis is variable: approximately 50-60% of patients recover full cardiac function, in most cases in the first six months. We report the case of a black woman of 37 years, multiparous, prenatal without complications, comorbidities or previous drug use that developed CHF, sudden onset, demonstrated ventricular dysfunction on echocardiography 15 days after childbirth normal. There was no clinical suspicion of non-compaction cardiomyopathy (NCC) which gave rise to doubt about the diagnosis of PPCM, since this is a diagnosis of exclusion. The presence of NCC was ruled out by cardiac magnetic resonance imaging.(AU)
RESUMO
A cardiomiopatia periparto (CMPP) é uma das causas comuns de cardiomiopatia secundária de etiologia desconhecida. Caracteriza-se pela presença de insuficiência cardíaca congestiva (ICC) materna, no último mês de gestação ou até cinco meses pós-parto, com disfunção ventricular sistólica esquerda, na ausência de outras causas de insuficiência cardíaca e em mulheres previamente saudáveis. A terapêutica médica consiste no bloqueio neuro-hormonal, suporte inotrópico, redução da pré e pós-carga cardíaca e anticoagulação. O transplante cardíaco está reservado aos casos graves e refratários à terapêutica medicamentosa. O prognóstico é variável: aproximadamente 50-60% das pacientes recuperam completamente a função cardíaca, na maioria das vezes dentro dos primeiros seis meses. Relata-se um caso de mulher negra, 37 anos, multípara, pré-natal sem intercorrências, sem comorbidades prévias ou uso de drogas, que desenvolveu um quadro de ICC, de instalação súbita, com disfunção ventricular comprovada ao ecocardiograma 15 dias após parto normal. Houve suspeição clínica de miocárdio não-compactado (MNC) que levou a dúvida quanto ao diagnóstico de CMPP, posto ser esta um diagnóstico de exclusão. A presença de MNC foi afastada pela ressonância nuclear magnética cardíaca.
La miocardiopatía periparto (MCPP) es una causa frecuente de miocardiopatía secundaria de etiología desconocida. Se caracteriza por la presencia de insuficiencia cardíaca congestiva (ICC) en la madre en el último mes del embarazo o hasta cinco meses después del parto, con disfunción sistólica del ventrículo izquierdo en ausencia de otras causas de insuficiencia cardíaca en mujeres previamente sanas. El tratamiento médico consiste en el bloqueo neurohormonal, soporte inotrópico, la reducción de la pre y post-carga cardíaca y anticoagulación. El trasplante cardíaco está reservado para casos graves y refractarios al tratamiento farmacológico. El pronóstico es variable: aproximadamente el 50-60% de las pacientes recuperan completamente la función cardíaca, en la mayoría de los casos en los primeros seis meses. Se presenta el caso clínico de una mujer de raza negra de 37 años, multípara, prenatal sin complicaciones, sin comorbilidades previas o uso de drogas, que desarrollo ICC, de aparición súbita, con disfunción ventricular demostrada en el ecocardiograma 15 días después de un parto normal. No había sospecha clínica de miocardiopatía no compactada (MNC) que dio lugar a duda sobre el diagnóstico de MCPP, ya que éste es un diagnóstico de exclusión. La presencia de MNC fue descartada por resonancia magnética nuclear cardíaca.
Peripartum cardiomyopathy (PPCM) is a common cause of secondary cardiomyopathy of unknown etiology. It is characterized by the presence of congestive heart failure (CHF) in the mother in the last month of pregnancy or until five months after birth with left ventricular systolic dysfunction in the absence of other causes of heart failure in previously healthy women. Medical treatment consists of neurohormonal blockade, inotropic support, reduced pre-and post-cardiac load and anticoagulation. Heart transplantation is reserved for severe cases refractory to medical therapy. The prognosis is variable: approximately 50-60% of patients recover full cardiac function, in most cases in the first six months. We report the case of a black woman of 37 years, multiparous, prenatal without complications, comorbidities or previous drug use that developed CHF, sudden onset, demonstrated ventricular dysfunction on echocardiography 15 days after childbirth normal. There was no clinical suspicion of non-compaction cardiomyopathy (NCC) which gave rise to doubt about the diagnosis of PPCM, since this is a diagnosis of exclusion. The presence of NCC was ruled out by cardiac magnetic resonance imaging.
RESUMO
El ventrículo izquierdo no compacto (VINC) o "esponjoso", es una cardiomiopatía recientemente descrita y reconocida con implicaciones pronósticas importantes. Se caracteriza por la presencia de un miocardio ancho con nichos intertrabeculares profundos sobre el lado endocavitario, llevando a hipertrabeculación. Aunque la etiología es desconocida, se ha descrito una importante agregación familiar y una superposición de esta patología con otras cardiopatías de carácter genético como la cardiomiopatía dilatada (CMD) y la cardiomiopatía hipertrófica (CMH). Desde el punto de vista clínico se presenta como un síndrome de falla cardiaca, aunque puede debutar con muerte súbita, arritmias o embolismo sistémico. En la actualidad la herramienta diagnóstica de mayor utilidad es la ecocardiografía, por sus menores costos, reproducibilidad y disponibilidad en forma extensa en los servicios médicos. Sin embargo, se ha demostrado una mayor certeza diagnóstica con la resonancia magnética cardiaca (RMC). El tratamiento de estos pacientes no difiere del recomendado para pacientes con síndrome de falla cardiaca de otras etiologías. (Acta Med Colomb 2011; 36: 187-195).
Left ventricular noncompaction (LVNC), or "spongy" cardiomyopathy, is a recently described and recognized finding with important prognostic implications. It is characterized by the presence of ventricular trabeculations and deep intertrabecular recesses on the endocavitary side, leading to hypertrabeculation. Although the etiology is unknown, a significant family aggregation of this disease as well as overlap with other genetic cardiomyopathies such as dilated cardiomyopathy and hypertrophic cardiomyopathy have been described. From the clinical point of view, LVNC often presents as heart failure, but may present with sudden death, arrhythmias and systemic embolism. At the present time the most useful diagnostic tool is transthoracic echocardiography because of its lower cost, reproducibility and availability, though cardiac magnetic resonance (CMR) imaging has shown greater diagnostic accuracy. Treatment of these patients is no different than that recommended for patients with heart failure syndromes of other etiologies. (Acta Med Colomb 2011; 36: 187-195).