A randomized clinical trial to evaluate the efficacy and safety of rivaroxaban in patients with bioprosthetic mitral valve and atrial fibrillation or flutter: Rationale and design of the RIVER trial.

The efficacy and safety of rivaroxaban in patients with bioprosthetic mitral valves and atrial fibrillation or flutter remain uncertain. DESIGN: RIVER was an academic-led, multicenter, open-label, randomized, non-inferiority trial with blinded outcome adjudication that enrolled 1005 patients from 49 sites in Brazil. Patients with a bioprosthetic mitral valve and atrial fibrillation or flutter were randomly assigned (1:1) to rivaroxaban 20 mg once daily (15 mg in those with creatinine clearance <50 mL/min) or dose-adjusted warfarin (target international normalized ratio 2.0-30.); the follow-up period was 12 months. The primary outcome was a composite of all-cause mortality, stroke, transient ischemic attack, major bleeding, valve thrombosis, systemic embolism, or hospitalization for heart failure. Secondary outcomes included individual components of the primary composite outcome, bleeding events, and venous thromboembolism. SUMMARY: RIVER represents the largest trial specifically designed to assess the efficacy and safety of a direct oral anticoagulant in patients with bioprosthetic mitral valves and atrial fibrillation or flutter. The results of this trial can inform clinical practice and international guidelines.

Training Program for Cardiology Residents to Perform Focused Cardiac Ultrasound Examination with Portable Device.

INTRODUCTION: Training requirements for general cardiologists without echocardiographic expertise to perform focused cardiac ultrasound (FCU) with portable devices have not yet been defined. The objective of this study was to evaluate a training program to instruct cardiology residents to perform FCU with a hand-carried device (HCD) in different clinical settings. METHODS: Twelve cardiology residents were subjected to a 50-question test, 4 lectures on basic echocardiography and imaging interpretation, the supervised interpretation of 50 echocardiograms and performance of 30 exams using HCD. After this period, they repeated the written test and were administered a practical test comprising 30 exams each (360 patients) in different clinical settings. They reported on 15 parameters and a final diagnosis; their findings were compared to the HCD exam of a specialist in echocardiography. RESULTS: The proportion of correct answers on the theoretical test was higher after training (86%) than before (51%; P = 0.001). The agreement was substantial among the 15 parameters analyzed (kappa ranging from 0.615 to 0.891; P < 0.001). The percentage of correct interpretation was lower for abnormal (75%) than normal (95%) items, for valve abnormalities (85%) compared to other items (92%) and for graded scale (87%) than for dichotomous (95%) items (P < 0.0001, for all). For the final diagnoses, the kappa value was higher than 0.941 (P < 0.001; 95% CI [0.914, 0.955]). CONCLUSION: The training proposed enabled residents to perform FCU with HCD, and their findings were in good agreement with those of a cardiologist specialized in echocardiography.

Preoperative left ventricular ejection fraction and left atrium reverse remodeling after mitral regurgitation surgery.

BACKGROUND: Left atrium enlargement has been associated with cardiac events in patients with mitral regurgitation (MR). Left atrium reverse remodeling (LARR) occur after surgical correction of MR, but the preoperative predictors of this phenomenon are not well known. It is therefore important to identify preoperative predictors for postoperative LARR. METHODS: We enrolled 62 patients with chronic severe MR (prolapse or flail leaflet) who underwent successful mitral valve surgery (repair or replacement); all with pre- and postoperative echocardiography. LARR was defined as a reduction in left atrium volume index (LAVI) of ≥ 25%. Stepwise multiple regression analysis was used to identify independent predictors of LARR. RESULTS: LARR occurred in 46 patients (74.2%), with the mean LAVI decreasing from 85.5 mL/m2 to 49.7 mL/m2 (p <0.001). These patients had a smaller preoperative left ventricular systolic volume (p =0.022) and a higher left ventricular ejection fraction (LVEF) (p =0.034). LVEF was identified as the only preoperative variable significantly associated with LARR (odds ratio, 1.086; 95% confidence interval, 1.002-1.178). A LVEF cutoff value of 63.5% identified patients with LARR of ≥ 25% with a sensitivity of 71.7% and a specificity of 56.3%. CONCLUSIONS: LARR occurs frequently after mitral valve surgery and is associated with preoperative LVEF higher than 63.5%.

Simplified single plane echocardiography is comparable to conventional biplane two-dimensional echocardiography in the evaluation of left atrial volume: a study validated by three-dimensional echocardiography in 143 individuals.

The left atrial volume index (LAVI) is a biomarker of diastolic dysfunction and a predictor of cardiovascular events. Three-dimensional echocardiography (3DE) is highly accurate for LAVI measurements but is not widely available. Furthermore, biplane two-dimensional echocardiography (B2DE) may occasionally not be feasible due to a suboptimal two-chamber apical view. Simplified single plane two-dimensional echocardiography (S2DE) could overcome these limitations. We aimed to compare the reliability of S2DE with other validated echocardiographic methods in the measurement of the LAVI. We examined 143 individuals (54 ± 13 years old; 112 with heart disease and 31 healthy volunteers; all with sinus rhythm, with a wide range of LAVI). The results for all the individuals were compared with B2DE-derived LAVIs and validated using 3DE. The LAVIs, as determined using S2DE (32.7 ± 13.1 mL/m(2)), B2DE (31.9 ± 12.7 mL/m(2)), and 3DE (33.1 ± 13.4 mL/m(2)), were not significantly different from each other (P = 0.85). The S2DE-derived LAVIs correlated significantly with those obtained using both B2DE (r = 0.98; P < 0.001) and 3DE (r = 0.93; P < 0.001). The mean difference between the S2DE and B2DE measurements was <1.0 mL/m(2). Using the American Society of Echocardiography criteria for grading LAVI enlargement (normal, mild, moderate, severe), we observed an excellent agreement between the S2DE- and B2DE-derived classifications (κ = 0.89; P < 0.001). S2DE is a simple, rapid, and reliable method for LAVI measurement that may expand the use of this important biomarker in routine echocardiographic practice.

Echocardiographic parameters and brain natriuretic peptide in patients after surgical repair of tetralogy of Fallot.

BACKGROUND: Although the residual lesions after surgical correction of tetralogy of Fallot (TOF) can be evaluated by Doppler echocardiography (DE), the relation of DE parameters with the proBNP level, a potential biomarker of right ventricle overload, is not well known. The objective of this study was to evaluate the DE parameters and their relation to proBNP levels. METHODS: proBNP plasma level and Doppler echocardiography parameters were obtained on the same day in 49 patients later after repair of TOF (mean age of 14.7 years, 51% female, mean PO time of 9.5 years). The DE parameters studied were the dimensions of the right atrium (RA) and ventricle (RV), RV diastolic and systolic function, and residual pulmonary lesions. The relation between them and proBNP levels were analyzed and the cutoff values of DE parameters for elevated proBNP determined. RESULTS: proBNP was elevated in 53% and correlated with RV diastolic diameter (r = 0.41; P = 0.003), RA longitudinal (r = 0.52; P = 0.0001) and transversal (r = 0.47; P = 0.001) diameters, pressure half time of pulmonary regurgitation (PR) velocity (PHT) (r =-0.42; P = 0.005), and the PR index (r =-0.60; P < 0.001). By multivariate analysis, the PR index (r =-597; P = 0,001; CI: -913.2 to -280.8) and RA longitudinal (r = 7.74; P < 0,001; CI 4.18 to 11.31) were independent predictors of elevated proBNP. PHT lower than 64 msec (0.76) and PRi lower than 0.65 (0.81) had the best accuracy for elevated proBNP. CONCLUSION: proBNP may be increased in patients after surgical repair of TOF, correlated with the size of right cardiac chambers and the severity of PR.

Doppler echocardiographic predictors of mortality in female rats after myocardial infarction.

BACKGROUND: Doppler echocardiogram is useful for the evaluation of anatomical and functional changes in late myocardial infarction (MI) in rats. However, no studies have evaluated the prognostic value of echocardiographic parameters 1 week after MI. METHODS AND RESULTS: Doppler echocardiogram was performed in 84 female Wistar rats 1 week after MI to determine infarction size, left chambers dimensions, fractional area change (FAC) of the left ventricle (LV), mitral inflow and tissue Doppler, myocardial performance index (MPI), and signs of pulmonary hypertension. The 365-day follow-up showed 53.6% mortality rate. Nonsurvivors showed larger (P < .05) MI size and cavity dimensions, poorer diastolic and systolic function, and higher frequency of pulmonary hypertension. Parameters at early stage of MI associated with higher mortality risk by Cox multivariate regression model were FAC or=0.60 (RR 3.49, 95% CI, 1.80-6.76), LV systolic area >or=0.26 cm(2) (RR 4.38, 95% CI, 1.88-10.21), E/E' ratio >or=20.3 (RR 2.12, 95% CI, 1.15-4.34), and E/A ratio associated with FAC (RR 2.99, 95% CI, 1.44-6.18). CONCLUSION: Some diastolic and systolic Doppler echocardiographic parameters in rats may be able to predict late mortality risk after MI.

Doppler-derived myocardial performance index in patients with impaired left ventricular relaxation and preserved systolic function.

BACKGROUND: The Doppler-derived myocardial performance index (MPI) has been used in the evaluation of left ventricular (LV) function in several diseases. In patients with isolated diastolic dysfunction, the diagnostic utility of this index remains unclear. The aim of this study was to determine the diagnostic utility of MPI in patients with systemic hypertension, impaired LV relaxation, and normal ejection fraction. METHODS: Thirty hypertensive patients with impaired LV relaxation were compared to 30 control subjects. MPI and its components, isovolumetric relaxation time (IRT), isovolumetric contraction time (ICT), and the ejection time (ET), were measured from LV outflow and mitral inflow Doppler velocity profiles. RESULTS: MPI was higher in patients than in control subjects (0.45 +/- 0.13 vs 0.37 +/- 0.07 P < 0.0029). The increase in MPI was due to the prolongation of IRT without significant change of ICT and ET. MPI cutoff value of > or =0.40 identified impaired LV relaxation with a sensitivity of 63% and specificity of 70% while an IRT >94 ms had a sensitivity of 67% and specificity of 80%. Multivariate analysis identified relative wall thickness, mitral early filling wave velocity (E), and systolic myocardial velocity (Sm) as independent predictors of MPI in patients with hypertension. CONCLUSIONS: MPI was increase in patients with hypertension, diastolic dysfunction, and normal ejection fraction but was not superior to IRT to detect impaired LV relaxation.

Prognostic value of real-time three-dimensional echocardiography compared to two-dimensional echocardiography in patients with systolic heart failure.

Heart failure (HF) is associated with morbidity and mortality. Real-time three-dimensional echocardiography (RT3DE) may offer additional prognostic data in patients with HF. The study aimed to evaluate the prognostic value of real-time three-dimensional echocardiography (RT3DE). This is a prospective study that included 89 patients with HF and left ventricular ejection fraction (LVEF) < 0.50 who were followed for 48 months. Left atrium and ventricular volumes and functions were evaluated by RT3DE. TDI and two-dimensional echocardiography parameters were also obtained. The endpoint was a composite of death, heart transplantation and hospitalization for acute decompensated HF. The mean age was 55 ± 11 years, and the LVEF was 0.32 ± 0.10. The composite endpoint occurred in 49 patients (18 deaths, 30 hospitalizations, one heart transplant). Patients with outcomes had greater left atrial volume (40 ± 16 vs. 32 ± 12 mL/m2; p < 0.01) and right ventricle diameter (41 ± 9 vs. 37 ± 8 mm, p = 0.01), worse total emptying fraction of the left atrium (36 ± 13% vs. 41 ± 11%; p = 0.03), LVEF (0.30 ± 0.09 vs. 0.34 ± 0.11; p = 0.02), right ventricle fractional area change (34.8 ± 12.1% vs. 39.2 ± 11.3%; p = 0.04), and greater E/e' ratio (19 ± 9 vs. 16 ± 8; p = 0.04) and systolic pulmonary artery pressure (SPAP) (50 ± 15 vs. 36 ± 11 mmHg; p < 0.01). In multivariate analysis, LVEF (OR 4.6; CI 95% 1.2-17.6; p < 0.01) and SPAP (OR 12.5; CI 95% 1.8-86.9; p < 0.01) were independent predictors of patient outcomes. LVEF and the SPAP were independent predictors of outcomes in patients with HF.

Growth hormone replacement improves thyroxine biological effects: implications for management of central hypothyroidism.

CONTEXT: The biological significance of GH-induced changes in serum TH concentrations is unknown. It has been suggested that serum free T(4) (FT(4)) should be targeted at the high-normal range during GH replacement. OBJECTIVE: Our objective was to evaluate the effects of GH replacement on T(4) biological effects. HYPOTHESIS: If GH modulates thyroxine biological effects, serum FT(4) should be targeted accordingly. DESIGN AND SETTING: We conducted observational (study 1) and interventional (studies 2 and 3)/outpatient studies. PATIENTS: Thirty-two GH-deficient patients (13 off GH; 22 on l-T(4)) participated in the study. INTERVENTIONS: In study 2, levothyroxine was administered to increase FT(4) (>1.0 ng/dl). In study 3, GH was administered or withdrawn. MAIN OUTCOME MEASURES: We measured FT(4), total T(3) (TT(3)), myocardial isovolumic contraction time (ICT), and resting energy expenditure (REE). RESULTS: In study 1, off-GH and on-GH groups had similar FT(4), but off GH showed lower TT(3) (P < 0.01) and REE (P = 0.02), higher ICT (P < 0.05) than on-GH and controls. On GH, ICT and REE correlated only with TT(3) (r = -0.48; r = 0.58; P < 0.05). Off GH, ICT correlated only with FT(4) (P < 0.01). In study 2, off GH, levothyroxine intervention increased FT(4) (P = 0.005) and TT(3) (P = 0.012), decreased ICT (P = 0.006), and increased REE (P = 0.013); ICT and FT(4) changes correlated (r = -0.72; P = 0.06). On GH, levothyroxine increased FT(4) (P = 0.0002), TT(3) (P = 0.014), and REE (P = 0.10) and decreased ICT (P = 0.049); REE and TT(3) changes correlated (r = 0.60; P = 0.05). In study 3, GH decreased FT(4), increased TT(3), decreased ICT, and increased REE (P < 0.05). REE correlated (P < 0.05) with IGF-I (r = 0.57) and TT(3) (r = 0.64). ICT correlated only with TT(3) (r = -0.46). CONCLUSIONS: GH replacement improves the biological effects of T(4). Serum FT(4) should be targeted at the high-normal range in GH-deficient patients only off GH replacement.

Immediate functional effects of left ventricular reduction: a Doppler echocardiographic study in the rat.

BACKGROUND: Immediate functional effects of left ventricle reduction (LVR) are not yet fully defined. Those effects have been studied in the experimental model of myocardial infarction scar plication (MISP) in the rat. METHODS AND RESULTS: A Doppler echocardiogram was performed immediately before and after MISP in 20 rats with infarction of the left ventricle (LV) larger than 40%. LV diastolic volume reduction (475 +/- 114 versus 185 +/- 65 muL) was accompanied by heart rate decrease (230 +/- 25 versus 166 +/- 27 beats/min) and increase of ejection fraction (37 +/- 7 versus 67 +/- 12%), fractional shortening (18 +/- 3 versus 46 +/- 8%) and posterior wall shortening velocity (1.50 +/- 0.62 versus 2.01 +/- 0.46 cm/s). LV diastolic volume/stroke volume slope was steeper after LVR, suggesting enhancement of the Frank-Starling mechanism. Restrictive pattern of left atrial emptying was alleviated after LVR (E wave: 101 +/- 15 versus 66 +/- 14 cm/s; E/A ratio: 6.8 +/- 2.9 versus 5.0 +/- 2.2; E wave deceleration time: 36 +/- 6 versus 51 +/- 10 msec) even though left atrial diameter (0.69 +/- 0.07 versus 0.66 +/- 0.06 cm) and A wave (18.0 +/- 9.4 versus 15.8 +/- 7.8 cm/s) did not vary. Additionally, a pulmonary flow profile suggesting pulmonary hypertension was observed in 12 of 17 animals before, and in only 3 after, LVR. CONCLUSION: LVR favors cardiac function not only by reducing afterload. The present data are in consonance with previous suggestions that the Frank-Starling mechanism is enhanced after MISP and, in addition to LV ejection function improvement, the unprecedented facilitation of left atrial emptying after LVR was particularly noteworthy. Even though LVR restricts ventricular distensibility, atrial emptying can be facilitated, probably on account of LV ejection improvement.

Hyperglycemia and nocturnal systolic blood pressure are associated with left ventricular hypertrophy and diastolic dysfunction in hypertensive diabetic patients.

BACKGROUND: The aim of this study was to determine if hypertensive type 2 diabetic patients, when compared to patients with essential hypertension have an increased left ventricular mass index (LVMI) and a worse diastolic function, and if this fact would be related to 24-h pressoric levels changes. METHODS: Ninety-one hypertensive patients with type 2 diabetes mellitus (DM) (group-1 [G1]), 59 essential hypertensive patients (group-2 [G2]) and 26 healthy controls (group-3 [G3]) were submitted to 24-h Ambulatory Blood Pressure Monitoring (ABPM) and echocardiography (ECHO) with Doppler. We calculated an average of fasting blood glucose (AFBG) values of G1 from the previous 4.2 years and a glycemic control index (GCI) (percentual of FBG above 200 mg/dl). RESULTS: G1 and G2 did not differ on average of diurnal systolic and diastolic BP. However, G1 presented worse diastolic function and a higher average of nocturnal systolic BP (NSBP) and LVMI (NSBP = 132 +/- 18 vs 124 +/- 14 mmHg; P < 0.05 and LVMI = 103 +/- 27 vs 89 +/- 17 g/m2; P < 0.05, respectively). In G1, LVMI correlated with NSBP (r = 0.37; P < 0.001) and GCI (r = 0.29; P < 0.05) while NSBP correlated with GCI (r = 0.27; P < 0.05) and AFBG (r = 0.30; P < 0.01). When G1 was divided in tertiles according to NSBP, the subgroup with NSBP> or =140 mmHg showed a higher risk of LVH. Diabetics with NSBP> or =140 mmHg and AFBG>165 mg/dl showed an additional risk of LVH (P < 0.05; odds ratio = 11). In multivariate regression, both GCI and NSBP were independent predictors of LVMI in G1. CONCLUSION: This study suggests that hyperglycemia and higher NSBP levels should be responsible for an increased prevalence of LVH in hypertensive patients with Type 2 DM.

Myocardial dysfunction in mitochondrial diabetes treated with Coenzyme Q10.

Maternally-inherited diabetes and deafness (MIDD) has been related to an A to G transition in the mitochondrial tRNA Leu (UUR) gene at the base pair 3243. Although some previous articles have reported that this mutation may be a cause of cardiomyopathy in diabetes, the degree of cardiac involvement and a specific treatment has not been established. Here, we reported a case of a patient with MIDD who developed congestive heart failure and the therapeutic usefulness of Coenzyme Q10 (CoQ10). In our patient, after the introduction of Coenzyme Q10 150 mg/day, there was a gradual improvement on left ventricular function evaluated by echocardiography. The fractional shortening (FS) and ejection fraction (EF) increased from 26 to 34% and from 49 to 64%, respectively. No side effects were noted. Three months after CoQ10 discontinuation, the parameters of systolic function evaluated by echocardiography decreased, suggesting that CoQ10 had a beneficial effect. Identification of diabetes and cardiomyopathy due to mitochondrial gene mutation may have therapeutic implications and Coenzyme Q10 is a possible adjunctive treatment in such patients.

Cardiovascular effects of successful renal transplantation: a 1-year sequential study of left ventricular morphology and function, and 24-hour blood pressure profile.

BACKGROUND: Cardiovascular disease is the leading cause of death in renal transplant recipients. The purpose of this study was to determine the effects of a successful renal transplantation on left ventricular morphology and function and on the 24-hr blood pressure profile. METHODS: Twenty-four patients with end-stage renal disease were prospectively studied by ambulatory blood pressure monitoring and echocardiography before and at 3, 6, and 12 months after renal transplantation. Patients were also analyzed according to their renal function after transplantation. RESULTS: We observed a significant drop in the mean values of daytime and nocturnal systolic blood pressure and in the 24-hr systolic pressure load at 12 months after transplantation. The most frequent echocardiographic finding was left ventricular hypertrophy (LVH), for which the incidence decreased from 75% before transplantation to 52.1% at 12 months after transplantation (P = 0.125). There was a significant decrease in left ventricular dilatation, and systolic dysfunction normalized in all patients after 12 months. The variables that best independently predicted the decrease in LVH were serum creatinine levels and the 24-hr systolic pressure load as registered by ambulatory blood pressure monitoring at 12 months after transplantation. We observed significant decreases in left ventricular mass and left ventricular mass index in the group of patients who had adequate renal function, as compared with no changes in patients who did not. CONCLUSIONS: Correction of the uremic state by renal transplantation leads to complete resolution of systolic dysfunction, regression of LVH, and improvement of left ventricular dilatation. In fact the reduction of LVH was dependent on adequate renal function and on a decrease in the systolic pressure levels.

Myocardial infarction scar plication in the rat: cardiac mechanics in an animal model for surgical procedures.

BACKGROUND: The immediate effects of surgical reduction of left ventricle cavity on cardiac mechanics have not been well defined. METHODS: Cardiac mechanics were analyzed before and after myocardial infarction scar plication in 11 isolated infarcted rat hearts. RESULTS: Despite a decrease in myocardial stiffness, an increase in chamber stiffness was noted after myocardial infarction scar plication. Systolic function was favored in more than one way. For the same diastolic pressures, maximal developed pressures were higher after myocardial infarction scar plication, and the slope of the systolic pressure-volume relationship was steeper afterwards as compared with before; this means that Frank-Starling recruitment is accentuated in smaller cavities. In addition, the developed net forces needed to generate these pressures were clearly lower afterward than before, indicating reduced ventricular afterload. CONCLUSIONS: The study results show that diastolic function is harmed and systolic function is favored by myocardial infarction scar plication. We suggest that preoperative evaluation of the degree of diastolic dysfunction and impairment of the Frank-Starling mechanism may help to identify patients who may have a poor postoperative outcome due to diastolic or systolic dysfunction.

Diagnosis of subclinical central hypothyroidism in patients with hypothalamic-pituitary disease by Doppler echocardiography.

OBJECTIVE: The diagnosis of subclinical central hypothyroidism in hypothalamic-pituitary patients cannot be established by serum markers of thyroid hormone action. Myocardial function by echocardiography has been shown to reflect thyroid hormone action in primary thyroid dysfunction. We evaluated the performance of echocardiography in diagnosing subclinical central hypothyroidism. DESIGN: Cross-sectional and before and after. METHODS: Echocardiography and serum thyroid hormones were assessed in overt primary (n=20) and central (n=10) hypothyroidism, subclinical primary hypothyroidism (n=10), hypothalamic-pituitary disease with normal free thyroxine (FT(4); n=25), and controls (n=28). Receiver operating characteristic (ROC) curves were generated using overt hypothyroidism patients and selected cut-off values were applied to detect both primary and central subclinical hypothyroidism. After levothyroxine (l-T(4)) intervention, patients were echocardiographically reevaluated at predefined targets: normal thyrotropin (TSH) in primary hypothyroidism, normal FT(4) in overt central hypothyroidism, and higher than pretreatment FT(4) in echo-defined subclinical central hypothyroidism. RESULTS: Parameters with highest areas under the ROC curves (area under the curve (AUC) ≥0.94) were as follows: isovolumic contraction time (ICT), ICT/ejection time (ET), and myocardial performance index. Highest diagnostic accuracy (93%) was obtained when at least one parameter was increased (positive and negative predictive values: 93%). Hypothyroidism was echocardiographically diagnosed in eight of ten patients with subclinical primary hypothyroidism and in 14 of 25 patients (56%) with hypothalamic-pituitary disease and normal serum FT(4). Echocardiographic abnormalities improved significantly after l-T(4) and correlated (0.05

Left atrial dysfunction in chagas cardiomyopathy is more severe than in idiopathic dilated cardiomyopathy: a study with real-time three-dimensional echocardiography.

BACKGROUND: Although there is anatomopathologic evidence of atrial involvement in Chagas cardiomyopathy (CCM), the impact in left atrial (LA) function is unknown. The aim of this study was to evaluate LA function in patients with CCM with real-time three-dimensional echocardiography (RT3DE) and to compare it with patients with idiopathic dilated cardiomyopathy (DCM). METHODS: A total of 30 patients with CCM, 30 patients with DCM, and 20 normal subjects used as the control group were studied. With the use of RT3DE, we measured LA maximum (maxLAV), minimum, and pre-atrial contraction volumes and calculated total and active LA emptying fractions. RESULTS: Left ventricular ejection fraction and mitral regurgitation were similar in both groups. MaxLAV/m(2) was larger in the CCM group than in the DCM group (76.9 ± 21.9 mL vs. 59.1 ± 26.0 mL; P < .01), and both were significantly larger than in the control group (P < .01). Total LA emptying fraction was lower in the CCM group than in the DCM group (0.30 ± 0.10 vs. 0.40 ± 0.12; P < .01), and both were lower than in the control group (P = .01). Active LA emptying fraction was also lower in the CCM group than in the DCM group (0.22 ± 0.09 vs. 0.28 ± 0.11; P < .01), and both were lower than in the control group (P = .01). The E/e' ratio was higher in the CCM group than in the DCM group (21 ± 10 vs. 15 ± 6; P < .01), and both were greater than in the control group (P < .01). In a multiple regression model, the E/e' ratio was the only independent predictor of a worsening active LA emptying fraction. CONCLUSION: LA function is more compromised in patients with CCM than in patients with DCM. This finding indicates a more diffuse and severe myocardial impairment in Chagas disease that is probably related to increased left ventricular filling pressures and atrial myopathy.

Influência dos critérios de indexação da massa do ventrículo esquerdo no diagnóstico de hipertrofia ao ecocardiograma em crianças com insuficiência renal crônica / Influence of left ventricular mass indexation criteria in the diagnosis of left ventricular hypertrophy by echocardiogram: study in children with chronic renal disease

Fundamento: O diagnóstico ecocardiográfico de hipertrofia ventricular esquerda (HVE) em crianças baseia-se no cálculo damassa do ventrículo esquerdo (VE) indexada. Entretanto, o critério de indexação ainda não é consenso.Objetivo: Comparar diferentes critérios usados no diagnóstico de HVE à ecocardiografia em crianças.Método: Foram incluídas crianças com doença renal crônica (DRC) em diálise (grupo DI) ou em tratamento conservador (grupoTC). Foram obtidas as medidas e calculada a massa do VE conforme recomendado. Os critérios de HVE utilizados foram: 1)massa (g) – HVE conforme gênero e área da superfície corporal (ASC); 2) massa (g) indexada à ASC (g/m2) – HVE conforme gênero e ASC; 3) massa em gramas indexada à altura (m) à potência de 2,7 (g/m2,7) – diagnóstico de HVE conforme nomograma de idade, gênero e altura; 4) escore z http://parameterz.blogspot.com/2008/09/lv-mass-z-scores – HVE se > 2 desvios-padrão).As proporções de HVE foram comparadas por teste do X2; significante se p < 0,05.Resultados: Sessenta crianças com DRC foram incluídas; 34 no grupo DI (17 meninos; mediana da idade = 109 meses) e 26no grupo TC (15 meninos; mediana da idade = 80 meses). Conforme o critério, no grupo total, as proporções de HVE foram, respectivamente, 31/60, 33/60, 41/60 e 31/60 (p = 0,049), menor pelo critério 2 em relação ao 3 (p = 0,026); no grupo DI foram23/34; 23/34; 31/34 e 29/34 (p = 0,006), maior com o critério 3 em relação aos critérios 1 (p = 0,033) e 2 (p = 0,004) e com ocritério 4 em relação ao 2 (p = 0,029); no grupo TC foram 8/26; 10/26; 10/26 e 2/26 (p = 0,038), menor pelo critério 4 em relaçãoaos critérios 2 (p = 0,038) e 3 (p = 0,009).

Background: the echocardiographic diagnosis of left ventricular hypertrophy (LVH) in children is based on the indexed left ventricle mass calculation.However, the indexation criterion is still not defined.Objective: to compare different criteria used for the diagnosis of LVH by echocardiography in children.Method: The study included children with chronic renal disease (CRD) in dialysis (DI) or in conservative treatment (CT). Measures for left ventriclemass calculation were obtained as recommended. The criteria used for LVH were: 1) mass (g) – LVH according to gender and body surface area(BSA, m2) – based on large study of normal Brazilian children; 2) mass indexed to body surface area (g/m2) – LVH according to gender and bodysurface area (BSA, m2) – based on large study of normal Brazilian children; 3) g/altura2,7 but diagnosis of LVH by a nomogram of age, gender andheight; 4) z score (http://parameterz.blogspot.com/2008/09/lv-mass-z-scores) – LVH if > 2 standard-deviation. The proportion of LVH among thegroups were compared by X2; significant if p < 0.05.Results: 60 children with CKD were included; 34 in DI (17 boys; median of age= 109 months) and 26 in CT (15 boys; median of age= 80 months).According to each criteria, in the hole group, the proportions of LVH were, respectively, 31/60, 33/60, 41/60 e 31/60 (p=0.049), lower for criterion2 compared to 3 (p=0.026); in DI group were 23/34; 23/34; 31/34 e 29/34 (p=0.006), higher with criterion 3 compared to criteria 1 (p=0.033)and 2 (p=0.004), and with 4 compared to 2 (p=0.029); in TC group were 8/26; 10/26; 10/26 e 2/26 (p=0.038), lower for criterion 4 comparedto criteria 2 (p=0.038) and 3 (p=0.009). Conclusion: in children with CKD the proportion of LVH by echocardiography was different according to the criterion used. (Arq Bras Cardiol:Imagem cardiovasc. 2016;29(2):42-46).

The case for utilizing more strict quantitative Doppler echocardiographic criterions for diagnosis of subclinical rheumatic carditis.

AIM: Our aim was to perform a comparative, quantitative and qualitative, analysis of valvar echocardiographic findings in patients with acute rheumatic fever, with or without clinical manifestations of carditis, as compared to healthy controls. METHODS AND RESULTS: We analyzed cross-sectional Doppler echocardiographic images of 31 patients with acute rheumatic fever diagnosed according to the Jones criterions as modified in 1992. Of 31 patients, 22 presented with clinical carditis, while 9 had subclinical carditis. The patients, and a control group of 20 healthy individuals, underwent cardiac examination and echocardiographic assessment, assessing quantitative and qualitative findings of mitral and aortic valvar abnormalities. The leaflets of the mitral valve were statistically thicker in those with clinical and subclinical carditis when compared to controls (p less than 0.001). We observed a greater frequency of mitral variance, convergence of mitral flow, and aortic regurgitation for those with clinical and subclinical carditis when compared to controls (p less than 0.001, p less than 0.001 and p equal to 0.003, respectively). Patients with clinical and subclinical carditis had more quantitative and qualitative changes in the parameters than did the controls. CONCLUSION: Echocardiography is a sensitive method to detect valvar abnormalities in patients with acute rheumatic fever and carditis. Additionally, by using regular standardized criterions, abnormalities that lead to a diagnosis of subclinical carditis are found in those patients with acute rheumatic fever in the apparent absence of cardiac involvement.

Cardioprotective effect of dexrazoxane during treatment with doxorubicin: a study using low-dose dobutamine stress echocardiography.

AIM: To assess the late cardioprotective effect of dexrazoxane associated with doxorubicin during treatment of osteosarcoma by means of low-dose dobutamine stress echocardiography (LDDSE) in non-relapsed asymptomatic children and teenagers. PATIENTS AND METHODS: The study population included 58 patients with osteosarcoma divided in three groups, with equivalent age range, gender proportion and body surface area. Group I (21 patients, 14 males, 15 +/- 4 years) was analyzed before chemotherapy and considered the control group; Group II (19 patients, 11 males, 19.7 +/- 4 years) was treated with 348.4 +/- 18 mg/m2 of doxorubicin only and Group III (18 patients, 14 male, 16.8 +/- 5 years) treated with 396.5 +/- 55 mg/m2 of doxorubicin with dexrazoxane in the ratio 10:1. The patients were submitted to LDDSE (maximal dose 5 microg/kg/min). No major side effects were observed. Heart rate, blood pressure, left ventricular diameters, end systolic wall stress (ESWS), and other diastolic and systolic function indexes were assessed at rest conditions and during LDDSE and compared between the three groups. RESULTS: Group III received a doxorubicin dose significantly greater than Group II (P = 0.001). During LDDSE there were no significant changes in the diastolic function indexes in any of the groups, but there was a significant increase of systolic indexes and a decrease of ESWS in Group III compared to group II. There was no significant difference of any systolic functional parameters between Group I and III. Considering the ejection fraction (EF) at rest or at LDDSE, 13 patients (69.4%) in Group II and 5 patients (27.7%) in Group III were considered to have systolic dysfunction. (P = 0.02). CONCLUSION: Myocardial response to LDDSE in patients treated with doxorubicin and dexrazoxane was similar to patients without chemotherapy and better than those treated with doxorubicin only, suggesting less cardiotoxicity.