Cardiac and peripheral autonomic control in restrictive cardiomyopathy.

AIMS: Autonomic dysfunction determines the advance of dilated cardiomyopathy (DCM) and is related to poor outcomes. However, this autonomic imbalance is unknown in patients with restrictive cardiomyopathy (RCM) even though they have similar symptoms and poor quality of life as DCM patients have. The aim of this study was to evaluate if autonomic and neurovascular controls were altered in RCM patients. METHODS AND RESULTS: Fifteen RCM patients, 10 DCM patients, and 10 healthy subjects were evaluated. Heart rate and blood pressure (BP) were recorded. Peripheral sympathetic activity [muscle sympathetic nerve activity (MSNA)] by microneurography and cardiac sympathetic activity by power spectrum analysis of heart rate variability. Spontaneous baroreflex sensitivity (BRS) was evaluated by the sequence method and forearm blood flow by venous occlusion plethysmography. Both cardiomyopathy groups had higher MSNA frequency (P < 0.001) and MSNA incidence (P < 0.001), higher cardiac sympathovagal balance (P < 0.02), reduced BRS for increase (P = 0.002) and for decrease in BP (P = 0.002), and lower forearm blood flow (P < 0.001) compared with healthy subjects. We found an inverse correlation between BRS for increase and decrease in BP and peripheral sympathetic activity (r = -0.609, P = 0.001 and r = -0.648, P < 0.001, respectively) and between BRS for increase and decrease in BP and cardiac sympathetic activity (r = -0.503, P = 0.03 and r = -0.487, P = 0.04, respectively). CONCLUSIONS: The RCM patients had cardiac and peripheral autonomic dysfunctions associated with peripheral vasoconstriction. Nonetheless, the presence of normal ejection fraction underestimates the evolution of the disease and makes clinical treatment difficult. These alterations could lead to a similar cardiovascular risk as that observed in DCM patients.

Left atrium reverse remodeling in patients with mitral valve stenosis after percutaneous valvuloplasty: a 2- and 3-dimensional echocardiographic study.

INTRODUCTION AND OBJECTIVES: The left atrium is clinically relevant in patients with mitral valve stenosis. The objective of this study was to analyze the effects of percutaneous balloon valvuloplasty on left atrium volumes and the left atrium emptying fraction in symptomatic mitral valve stenosis patients using 2-dimensional and real-time 3 -dimensional transthoracic echocardiography. METHODS: We carried out a prospective study of 28 consecutive symptomatic mitral valve stenosis patients, aged 22-72 (39 [11.5]) years, 24/28 (85.6%) women, who underwent to percutaneous balloon valvuloplasty between March 2009 and May 2011. Patients underwent 2- and 3-dimensional transthoracic and transesophageal echocardiography (atrial fibrillation) and invasive mitral valve area measurement. Echocardiographic analysis was performed before, 72 h after and 12 months after percutaneous balloon valvuloplasty. The following parameters were analyzed: a) mitral valve area (2-dimensional planimetry, pressure half-time, 3-dimensional echocardiography, invasive hemodynamic measurement); b) indexed left atrium maximum and indexed minimum volumes, and c) left atrium emptying fraction. RESULTS: The 3-dimensional parameters of the mitral valve stenosis patients before and 72 h and 12 months after percutaneous balloon valvuloplasty were as follows: a) mitral valve area: 0.9 (0.1) cm(2); 1.8 (0.2) cm(2) (P<.001); 1.7 (0.2) cm(2) (P<.001); b) left atrium maximum volumes: 49.9 (12) mL/m(2); 42 (11.4) mL/m(2) (P<.001); 40.3 (10.2) mL/m(2) (P<.001), and c) left atrium emptying fraction: 30.1 (9.4%); 40.6 (7.4%) (P<.001); 44.1 (8%) (P<.001), respectively. CONCLUSIONS: In symptomatic mitral valve stenosis patients who underwent percutaneous balloon valvuloplasty analysis by 2- and 3-dimensional echocardiography, improvements in left atrium reverse remodeling and left atrium emptying fraction were observed 72 h and 12 months after the procedure.

Avaliação ecocardiográfica da sincronia cardíaca: há a necessidade de hierarquização dos métodos? / Echocardiographic evaluation of cardiac dysynchrony: is it mecessary to hierachize the methods?

A detecção e quantificação da dissincronia cardíaca têm papel central na indicação da terapia de ressincronização. O ecocardiograma é o método mais utilizado para esse fim, porém nenhum parâmetro ecocardiografico, até o momento, mostrou superioridade em relação aos demais. Esse artigo visa a enfatizar as vantagens e limitações associadas a cada método, além de propor uma abordagem sequencial na avaliação da sincronia cardíaca.

Cardiac resynchronization therapy evaluated by myocardial scintigraphy with 99mTc-MIBI: changes in left ventricular uptake, dyssynchrony, and function.

PURPOSE: (99m)Tc-MIBI gated myocardial scintigraphy (GMS) evaluates myocyte integrity and perfusion, left ventricular (LV) dyssynchrony and function. Cardiac resynchronization therapy (CRT) may improve the clinical symptoms of heart failure (HF), but its benefits for LV function are less pronounced. We assessed whether changes in myocardial (99m)Tc-MIBI uptake after CRT are related to improvement in clinical symptoms, LV synchrony and performance, and whether GMS adds information for patient selection for CRT. METHODS: A group of 30 patients with severe HF were prospectively studied before and 3 months after CRT. Variables analysed were HF functional class, QRS duration, LV ejection fraction (LVEF) by echocardiography, myocardial (99m)Tc-MIBI uptake, LV end-diastolic volume (EDV) and end-systolic volume (ESV), phase analysis LV dyssynchrony indices, and regional motion by GMS. After CRT, patients were divided into two groups according to improvement in LVEF: group 1 (12 patients) with increase in LVEF of 5 or more points, and group 2 (18 patients) without a significant increase. RESULTS: After CRT, both groups showed a significant improvement in HF functional class, reduced QRS width and increased septal wall (99m)Tc-MIBI uptake. Only group 1 showed favourable changes in EDV, ESV, LV dyssynchrony indices, and regional motion. Before CRT, EDV, and ESV were lower in group 1 than in group 2. Anterior and inferior wall (99m)Tc-MIBI uptakes were higher in group 1 than in group 2 (p<0.05). EDV was the only independent predictor of an increase in LVEF (p=0.01). The optimal EDV cut-off point was 315 ml (sensitivity 89%, specificity 94%). CONCLUSION: The evaluation of EDV by GMS added information on patient selection for CRT. After CRT, LVEF increase occurred in hearts less dilated and with more normal (99m)Tc-MIBI uptake.

Standard values for real-time transthoracic three-dimensional echocardiographic dyssynchrony indexes in a normal population.

BACKGROUND: There is a paucity of information describing the real-time 3-dimensional echocardiography (RT3DE) and dyssynchrony indexes (DIs) of a normal population. We evaluate the RT3DE DIs in a population with normal electrocardiograms and 2- and 3-dimensional echocardiographic analyses. This information is relevant for cardiac resynchronization therapy. METHODS: We evaluated 131 healthy volunteers (73 were male, aged 46 +/- 14 years) who were referred for routine echocardiography; who presented normal cardiac structure on electrocardiography, 2-dimensional echocardiography, and RT3DE; and who had no history of cardiac diseases. We analyzed 3-dimensional left ventricular ejection fraction, left ventricle end-diastolic volume, left ventricle end-systolic volume, and left ventricular systolic DI% (6-, 12-, and 16-segment models). RT3DE data were analyzed by quantifying the statistical distribution (mean, median, standard deviation [SD], relative SD, coefficient of skewness, coefficient of kurtosis, Kolmogorov-Smirnov test, D'Agostino-Pearson test, percentiles, and 95% confidence interval). RESULTS: Left ventricular ejection fraction ranged from 50% to 80% (66.1% +/- 7.1%); left ventricle end-diastolic volume ranged from 39.8 to 145 mL (79.1 +/- 24.9 mL); left ventricle end-systolic volume ranged from 12.9 to 66 mL (27 +/- 12.1 mL); 6-segment DI% ranged from 0.20% to 3.80% (1.21% +/- 0.66%), median: 1.06, relative SD: 0.5482, coefficient of skewness: 1.2620 (P < .0001), coefficient of Kurtosis: 1.9956 (P = .0039); percentile 2.5%: 0.2900, percentile 97.5%: 2.8300; 12-segment DI% ranged from 0.22% to 4.01% (1.29% +/- 0.71%), median: 1.14, relative SD: 0.95, coefficient of skewness: 1.1089 (P < .0001), coefficient of Kurtosis: 1.6372 (P = .0100), percentile 2.5%: 0.2850, percentile 97.5%: 3.0700; and 16-segment DI% ranged from 0.29% to 4.88% (1.59 +/- 0.99), median: 1.39, relative SD: 0.56, coefficient of skewness: 1.0792 (P < .0001), coefficient of Kurtosis: 0.9248 (P = .07), percentile 2.5%: 0.3750, percentile 97.5%: 3.750. CONCLUSION: This study allows for the quantification of RT3DE DIs in normal subjects, providing a comparison for patients with heart failure who may be candidates for cardiac resynchronization therapy.

Anomalous origin of the left coronary artery from the pulmonary artery: report of an adult case.

We report the clinical findings, pathophysiology, diagnostic characteristics, and surgical repair of anomalous origin of the left coronary artery from the pulmonary artery in a 26-year-old female patient with a clinical diagnosis of coronary heart disease.

Anomalous origin of the left coronary artery from the pulmonary artery: report of an adult case / Origem anômala da artéria coronária esquerda no tronco pulmonar. Relato de um caso em adulto

We report the clinical findings, pathophysiology, diagnostic characteristics, and surgical repair of anomalous origin of the left coronary artery from the pulmonary artery in a 26-year-old female patient with a clinical diagnosis of coronary heart disease