Pericardial hematoma mimicking pericardial abscess.

A 26-year-old man, with human immunodeficiency virus infection, on hemodialysis, was hospitalized due to infective endocarditis. A mechanical prosthetic mitral valve was implanted. During postoperative period, he maintained signs suggestive of infection. The transthoracic echocardiograms (TTE) revealed a pericardial effusion. One week later was visible a circumscribed collection compatible with a pericardial abscess. He was refused for cardiac surgery; however, inflammatory parameters elevation persisted. The TTE showed a periprosthetic mitral leak, and cardiac surgery was performed. The pericardial drainage revealed a hematoma. This case highlights the difficulty on echocardiographic differential diagnosis between a pericardial hematoma and pericardial abscess in clinical practice.

Clinical applications of exercise stress echocardiography in the treadmill with upright evaluation during and after exercise.

Exercise stress echocardiography is the most frequently used stress test in our laboratory. Exercise echocardiography is used mainly in the study of patients with coronary artery disease. However, the technique is increasingly being used to study other diseases. In our centre, we use an original methodology, published by us in 2000, in which we evaluate heart function during exercise in the treadmill. After the exercise, patients are maintained in orthostatic position when appropriate or lying down in left lateral decubitus for further evaluation. Since this method seems to increase the quality and the quantity of information obtained in so many clinical arenas, we now present a detailed review of this methodology and its applications.

Glossopharyngeal neuralgia with cardioinhibitory syncope: Is a permanent pacemaker required?

Glossopharyngeal neuralgia is a rare facial pain syndrome, which in more rare cases can be associated with syncope. We present the outcome of a case report that combines this rare association that received medical therapy with anti-epileptic medication and permanent dual chamber pacemaker implantation. In this case, syncope episodes were associated with both vasodepressor and cardioinhibitory reflex syncope types. The patient found relief from syncope, hypotension, and pain after initiation of anti-epileptic therapy. Although a dual chamber pacemaker was implanted, the pacemaker interrogation revealed no requirement for pacing at one-year follow-up. As far as we know, this is the first case that reports pacemaker interrogation during follow-up and, taking into account the absence of pacemaker activation at one-year follow-up, the device was not needed to prevent bradycardia and syncope episodes. This case report supports the current guidelines for pacing in neurocardiogenic syncope, by demonstrating a lack of requirement for pacing in the event of both cardioinhibitory and vasodepressor responses.

[Dyspnea in aortic stenosis: appearances can be deceptive]. / Dispneia na estenose aórtica: nem tudo o que parece é.

Valvular aortic stenosis is the most common valvular disorder in Europe. Although recommended, stress exams are still underused in its evaluation. We report the case of a 60-year-old man who, following a routine electrocardiogram with abnormal ventricular repolarization, underwent stress testing, which was positive for myocardial ischemia, and an echocardiogram that revealed moderate aortic stenosis. Cardiac catheterization showed no angiographic coronary lesions and an intraventricular gradient of 45 mmHg. In view of the latter, stress echocardiography was performed, which documented an increase in the intraventricular gradient from 30 mmHg to 131 mmHg. Repeat stress echocardiography under treatment with bisoprolol showed an increase in test duration and a maximum intraventricular gradient at peak exercise of 36 mmHg. Stress exams may have an important role in the diagnostic and therapeutic management of patients with aortic stenosis.

The importance of transesophageal echocardiography evaluation in a patient with acute limb ischaemia.

This a case of a patient with acute limb ischaemia in whom thorough transesophageal echocardiography (TEE) evaluation depicted a patent foramen ovale and allowed for the detection of a large thrombus arising from an atherosclerotic calcified plaque in the thoracic aorta. We aim to illustrate the importance of performing TEE when systemic emboli are suspected and to not neglect thoracic aorta evaluation when a potential intracardiac cause has been detected.

Exercise stress echocardiography: Where are we now?

Exercise stress echocardiography (ESE) is a widely used diagnostic test in cardiology departments. ESE is mainly used to study patients with coronary artery disease; however, it has increasingly been used in other clinical scenarios including valve pathology, congenital heart disease, hypertrophic and dilated cardiomyopathies, athlete evaluations, diastolic function evaluation, and pulmonary circulation study. In our laboratories, we use an established methodology in which cardiac function is evaluated while exercising on a treadmill. After completing the exercise regimen, patients remain in a standing position or lie down on the left lateral decubitus, depending on the clinical questions to be answered for further evaluation. This method increases the quality and quantity of information obtained. Here, we present the various methods of exercise stress echocardiography and our experience in many clinical arenas in detail. We also present alternatives to ESE that may be used and their advantages and disadvantages. We review recent advances in ESE and future directions for this established method in the study of cardiac patients and underline the advantage of using a diagnostic tool that is radiation-free.

Neurological Complications in Patients with Infective Endocarditis: Insights from a Tertiary Centre. / Complicações Neurológicas em Pacientes com Endocardite Infecciosa: Perspectivas de um Centro Terciário.

BACKGROUND: Neurological complications are common in patients with infective endocarditis (IE). Recent data suggest that neurologic events are a major determinant of prognosis, and that surgery is critical in improving the outcome. OBJECTIVE: To characterize patients with IE and neurological complications and to determine predictors of embolization to the central nervous system (CNS) and mortality. METHODS: Retrospective analysis of patients admitted to a tertiary center with the diagnosis of IE from 2006 to 2016. Statistical significance was defined by a p-value < 0.05. RESULTS: We identified 148 episodes of IE, 20% of which had evidence of CNS embolization. In patients with CNS embolization, 76% presented with ischemic stroke. During follow-up, 35% were submitted to surgery and both in-hospital and one-year mortality were 39%. These patients had longer hospitalizations, but there were no significant differences regarding mortality in patients with and without CNS embolization. The independent predictors of neurological complications were diabetes (p=0.005) and the absence of fever at presentation (p=0.049). Surgery was associated with lower mortality (0 vs. 58%; p=0.003), while patients with septic shock had a poorer prognosis (75 vs. 25%; p=0.014). In multivariate Cox regression, human immunodeficiency virus (HIV) infection was the only independent predictor of in-hospital and 1-year mortality (p=0.011 in both). CONCLUSIONS: In this population, embolization to the CNS was common, more often presented as ischemic stroke, and was associated with longer hospitalization, although without significant differences in mortality. In patients with CNS embolization, those submitted to surgery had a good clinical evolution, while patients with septic shock and HIV infection had a worse outcome. These results should be interpreted with caution, taking into consideration that patients with more severe complications or more fragile were probably less often considered for surgery, resulting in selection bias.

FUNDAMENTO: Complicações neurológicas são comuns em pacientes com endocardite infecciosa (EI). Dados recentes sugerem que os eventos neurológicos são os principais determinantes do prognóstico e que a cirurgia é crítica para melhorar o resultado. OBJETIVO: Caracterizar pacientes com EI e complicações neurológicas e determinar preditores de embolização para o sistema nervoso central (SNC) e mortalidade. MÉTODOS: Análise retrospectiva de pacientes internados em centro terciário com diagnóstico de EI no período de 2006 a 2016. Significância estatística foi definida por um valor de p <0,05. RESULTADOS: Identificamos 148 episódios de EI, 20% dos quais tinham evidências de embolização do SNC. Em pacientes com embolização do SNC, 76% apresentaram acidente vascular cerebral isquêmico. Durante o seguimento, 35% foram submetidos à cirurgia e a mortalidade hospitalar e em um ano foi de 39%. Esses pacientes tiveram hospitalizações mais longas, mas não houve diferenças significativas em relação à mortalidade em pacientes com e sem embolização do SNC. Os preditores independentes de complicações neurológicas foram diabetes (p = 0,005) e ausência de febre na apresentação (p = 0,049). A cirurgia foi associada a menor mortalidade (0 vs. 58%; p = 0,003), enquanto os pacientes com choque séptico tiveram pior prognóstico (75 vs. 25%; p = 0,014). Na regressão multivariada de Cox, a infecção pelo vírus da imunodeficiência humana (HIV) foi o único preditor independente de mortalidade hospitalar e de 1 ano (p = 0,011 em ambos). CONCLUSÕES: Nessa população, a embolização para o SNC foi comum, mais frequentemente apresentada como acidente vascular cerebral isquêmico, e esteve associada a maior tempo de internação, embora sem diferenças significativas na mortalidade. Nos pacientes com embolização do SNC, os submetidos à cirurgia tiveram boa evolução clínica, enquanto os pacientes com choque séptico e infecção pelo HIV tiveram pior evolução. Esses resultados devem ser interpretados com cautela, levando em consideração que os pacientes com complicações mais graves ou mais frágeis foram provavelmente menos considerados para a cirurgia, resultando em viés de seleção.

The Prognostic Value of Exercise Echocardiography After Percutaneous Coronary Intervention.

BACKGROUND: Exercise echocardiography (EE) is a valuable noninvasive method for diagnostic and prognostic assessment of ischemic cardiac disease. The prognostic value of a negative EE test is well known overall, but its role in patients who undergo percutaneous coronary intervention remains poorly validated. The aim of this study was to ascertain the prognostic value of treadmill EE and to determine predictors of cardiac events in this population, with an emphasis on nonpositive (negative or inconclusive) test results. METHODS: A retrospective single-center study was performed. It included 516 patients (83% man; mean age, 62 ± 9 years) previously subjected to percutaneous coronary intervention who underwent treadmill EE between 2008 and 2017. Demographic, clinical, echocardiographic, and angiographic data were collected. The occurrence of cardiac events (cardiac death, acute coronary syndrome, or coronary revascularization) during follow-up was investigated. A multivariate Cox regression analysis was used to evaluate predictors of cardiac events. The Kaplan-Meier method was used to evaluate event-free survival rates. RESULTS: The results of EE were negative for myocardial ischemia in 245 patients (47.5%), inconclusive in 144 (27.9%), and positive in 127 (24.6%). During a mean follow-up period of 40 ± 34 months, cardiac events occurred in 152 patients (29.5%). The positive and negative predictive values of EE were 81.6% and 85.3%, respectively. The sensitivity of the exercise test was 73.9%, with specificity of 90.1%. Predictors of cardiac events were typical angina (hazard ratio [HR], 1.95; 95% CI, 1.16-3.27; P = .011), a positive ischemic response detected by electrocardiographic monitoring during EE (HR, 2.01; 95% CI, 1.21-3.34; P = .007), and the test result (inconclusive result: HR, 1.06; 95% CI, 0.51-2.19; P = .878; positive result: HR, 4.35; 95% CI, 2.42-7.80; P < .001). Patients with inconclusive (log-rank P = .038) and positive (log-rank P < .001) results had significantly more cardiac events during follow-up than those with negative EE test results. Focusing on those patients with nonpositive results, cardiac event-free survival rates at 1, 3, and 5 years were 96.6 ± 0.9%, 88.3 ± 1.9%, and 79.5 ± 2.6%, respectively. In this subpopulation, an inconclusive test result (HR, 1.67; 95% CI, 1.03-2.70; P = .039), more extensive coronary artery disease (two vessels: HR, 1.37; 95% CI, 0.75-2.30; P = .304; three vessels: HR, 2.59; 95% CI, 1.38-4.87; P = .003), and arterial hypertension (HR, 2.07; 95% CI, 1.10-3.91; P = .025) were significantly associated with the occurrence of cardiac events. CONCLUSION: Patients with known coronary disease with negative results on EE are at low risk for hard events. Patients with inconclusive results are at higher risk for cardiac events than those with negative results. The detection of patients with low-risk results on EE should decrease the number of unnecessary repeat invasive coronary angiographic examinations.

[Value of exercise echocardiography in aortic recoarctation--case report]. / Utilidade da ecocardiografia de esforço na recoarctação da aorta--caso clínico.

In this article the authors present a case study of a young man with coarctation of the aorta that underwent surgical correction at 4 months old, for whom the exercise echocardiogram was important in determining the functional importance of recoarctation and the decision of the timing for re-intervention, demonstrating the importance of this technique to discriminate the functional significance of this pathology.

Risk Factors for In-Hospital Mortality in Infective Endocarditis.

BACKGROUND: Infective endocarditis (IE) is associated with severe complications and high mortality. The assessment of mortality rates and predictors for fatal events is important to identify modifiable factors related to the pattern of treatment, in order to improve outcomes. OBJECTIVES: We sought to evaluate clinical outcomes of patients with IE and to determine predictors of in-hospital mortality. METHODS: Retrospective single-center study including patients with IE admitted during a 10-year period (2006-2015). Data on comorbidities, clinical presentation, microbiology and clinical outcomes during hospitalization were evaluated. Risk factors of in-hospital death were analyzed. A p-value < 0.05 was considered significant. RESULTS: A total of 134 cases were included (73% males, mean age of 61 ± 16 years-old). Half of them had previous valvular heart disease. Healthcare-associated IE and negative blood-cultures occurred in 22% and prosthetic IE in 25%. The aortic valve was the one most often affected by infection. Staphylococcus aureus was the most commonly isolated microorganism. Forty-four (32.8%) patients underwent cardiac surgery. The in-hospital mortality rate was 31.3% (42 patients). The identified risk factors for in-hospital mortality were Staphylococcus aureus etiology (OR 6.47; 95% CI: 1.07-39.01; p = 0.042), negative blood-cultures (OR 9.14; 95% CI: 1.42-58.77; p = 0.02), evidence of valve obstruction in echocardiography (OR 8.57; 95% CI: 1.11-66.25; p = 0.039), clinical evolution with heart failure (OR 4.98; 95%CI: 1.31-18.92; p = 0.018) or septic shock (OR 20.26; 95% CI: 4.04-101.74; p < 0.001). Cardiac surgery was a protective factor of mortality (OR 0.14; 95% CI 0.03-0.65; p = 0.012). CONCLUSION: The risk factors for in-hospital mortality were clinical (heart failure, septic shock), evidence of valve obstruction in echocardiography, Staphylococcus aureus etiology or negative blood cultures. Invasive treatment by surgery significantly decreased the mortality risk.

Clinical and Echocardiographic Characterization of False-Positive Results from Stress Echocardiography.

BACKGROUND: Stress echocardiography has a 72%-85% sensitivity and an 80%-95% specificity. In this study, we characterized patients who received a false-positive stress echocardiogram result. METHODS: A total of 5,256 patients underwent a stress echocardiogram (induced by exercise, dobutamine, or dipyridamole) between 2009 to 2018, and 405 patients (7.7%) received a positive result. Among the positive patients, 300 underwent coronary angiography within 12 months, and these patients were included in this study (mean age = 64.9 ± 9.4 years, 230 men [76.7%]). Coronary artery disease was diagnosed by stenosis ≥50% in any epicardial coronary artery. Clinical and echocardiographic variables were compared between patients with true- and false-positive stress echocardiogram results. RESULTS: Seventy-two patients (24%) had a false-positive stress echocardiogram, with similar rates across stressor types (p = 0.574). Patients with false positives were less frequently men (63.9% vs. 80.7%, p = 0.003), had lower diabetes mellitus prevalence (15.3% vs. 45.6%, p = 0.001), were similar to true positive patients with regard to body-mass index, arterial hypertension prevalence, hyperlipidemia and smoking, and had lower pre-test probability of coronary artery disease (23% vs. 32%, p = 0.016). The wall motion score index (WMSI) was higher in the true-positive stress group, and wall motion abnormalities were more frequent in the apical segments (70.5% vs. 56.7%, p = 0.034). In a multivariable predictive model, men (odds ratio [OR] = 2.994), diabetes (OR = 5.440), and peak WMSI (OR = 10.690) were associated with a true-positive result. CONCLUSIONS: Twenty-four percent of our study population received a false-positive stress echocardiogram result, with similar rates across stressor types. Patients with true-positive stress echocardiogram results are more likely to be men, diabetic, and have a high peak WMSI.

The role of echocardiography in assessing parachute mitral valve.

Treadmill exercise echocardiography with Doppler evaluation during effort has been used for several years in our department. The usefulness of this methodology in the management of patients with coronary heart disease is recognized but it is being increasingly used in patients with valvular heart disease. We report the case of a 44-year-old man with parachute mitral valve, in which transesophageal echocardiography characterized the pathology and exercise stress echocardiography was important for accurate functional assessment and clinical decisions.

Echocardiography during treadmill exercise testing in a patient with mitral stenosis.

Treadmill exercise echocardiography with Doppler during effort has been used for several years in our department. This form of echocardiography is used mainly in evaluation of patients with coronary heart disease and it is being increasingly used in valvular heart disease. We report the case of a 49-year-old woman with moderate mitral stenosis, in which stress echocardiography was important in making correct clinical decisions.

Evaluation of left ventricular outflow tract gradient during treadmill exercise and in recovery period in orthostatic position, in patients with hypertrophic cardiomyopathy.

BACKGROUND: Left ventricular outflow tract obstruction is an independent predictor of adverse outcome in hypertrophic cardiomyopathy (HCM). The classical quantification of intraventricular obstruction is performed in resting conditions in supine position, but this assessment does not reflect what happens in HCM patients (pts) in their daily activities, neither during effort nor during orthostatic recovery. AIM: To assess intraventricular gradients with echocardiography during treadmill exercise and in the recovery period in upright position, in HCM pts. METHODS: We studied 17 HCM pts (9 males, mean age 53 +/- 16 years, 11 with obstructive HCM). Each pt had 2 echocardiographic evaluations at rest (left lateral decubitus (LLD) and orthostatic position). The pts then underwent a treadmill exercise test and intraventricular gradients were measured at peak exercise and during recovery in orthostatic position. RESULTS: 3 pts with non-obstructive HCM at rest developed intraventricular gradients during exercise. 1 pt developed this gradient only during orthostatic recovery. The mean intraventricular gradient in LLD was 49 +/- 24 mmHg; in orthostatic position was 62 +/- 29 mmHg (p < 0.001 versus in LLD); at peak exercise was 83 +/- 35 mmHg (p < 0.001 versus supine rest); during recovery it was 96 +/- 35 mmHg (p < 0.001 versus peak exercise) CONCLUSION: In HCM pts the intraventricular gradient increases in orthostatic position, increases significantly during treadmill exercise and continues increasing in the recovery period in orthostatic position. This type of evaluation can help us to better understand the physiopathology, the symptoms and the efficacy of different therapeutic modalities in this disease and should be routinely used in the assessment of HCM pts.

Early flow propagation velocity for assessment of diastolic function in myocardial infarction treated with acute reperfusion.

INTRODUCTION: Acute myocardial infarction (MI) causes left ventricular (LV) diastolic dysfunction, which influences prognosis and clinical evolution. Early flow propagation velocity (FPV), evaluated by color M-mode Doppler, has been demonstrated to be a diastolic function parameter with excellent correlation with relaxation constant tau, and is relatively independent of pre- and afterload. OBJECTIVE: The aim of this study was to evaluate left ventricular relaxation in MI patients treated with acute reperfusion therapy. METHODS: Patients with ST-elevation MI treated with reperfusion therapy were evaluated by echocardiagraphy in the first 48 hours and after one week. The parameters studied were: early peak filling velocity (E), late peak filling velocity (A), E/A ratio, E-wave deceleration time (EDT), isovolumic relaxation time (IVRT) and FPV. The values obtained at the first and second evaluation were compared; we evaluated the relation between pain-to-reperfusion time (PRT; < or =3 hours vs. >3 hours) and the presence of single-vessel or multivessel disease with the parameters previously mentioned. RESULTS: 40 patients were studied and 19 included, 15 (80%) male, mean age 57+/-14 The most prevalent risk factors were: hypertension (11 patients - 58%), smoking (14 - 74%), diabetes (6 - 30%), and dyslipidemia (12 - 63%). MI location was anterior in six patients (31%) and inferior in 13 (69%). Five patients (26%) underwent fibrinolysis and 14 (74%) direct percutaneous coronary intervention. Mean pain-to-reperfusion time was 3.7+/-2.8 hours. Four patients (21%) had single-vessel disease and 14 (74%) had multivessel disease. Near significance was found for the difference in the E/A ratio between the two evaluations and a significant difference in the FPV. A significant correlation was also found between PRT and E/A ratio at the two evaluations (p=0.003, p=0.05), and between PRT and IVRT after one week (p=0.011). E/A ratio, IVRT and FPV were normal at the two evaluations in patients who had undergone earlier reperfusion therapy. No significance was found between the number of diseased vessels and the parameters of diastolic function assessed. DISCUSSION AND CONCLUSIONS: In the early phase of M1 treated with acute reperfusion, a delayed relaxation pattern was observed, which evolved to a normal pattern by the second evaluation, as statistically confirmed by FPV. Earlier reperfusion therapy preserves diastolic function. FPV is a sensitive and independent parameter for assessment of diastolic function in MI patients treated with acute reperfusion therapy.

Syncope caused by severe hypotension and intraventricular gradient during dobutamine stress echocardiography.

Dobutamine stress echocardiography is widely used for the evaluation of coronary artery disease. This form of stress echocardiography is safe but not without complications. We report a case of hypotension and syncope during dobutamine stress echocardiography in which a severe intraventricular gradient of over 200 mmHg and systolic anterior movement of the mitral valve were observed.

Consensus document on transthoracic echocardiography in Portugal. / Documento de Consenso e Recomendações para a realização de Ecocardiografia Transtorácica em Portugal.

Echocardiography is the most widely used imaging technique in modern cardiological clinical practice, since it is readily available, portable and safe, and provides a comprehensive morphological and functional assessment at low cost compared to other imaging modalities. Recent technological advances have introduced new echocardiographic techniques and widened the clinical applications of echocardiography. However, these developments have also led to an increase in information, rendering interpretation of the data provided by the exam more complex; this may result in assessment errors by less experienced operators. Standardization of procedures and training in echocardiography is therefore essential to ensure quality and safety for patients. The present document aims to contribute to this end, recommending quality requirements for operators and echocardiography laboratories in Portugal.

Evaluation of systolic and systo-diastolic function: the Tei index in acute myocardial infarction treated with acute reperfusion therapy--early and late evaluation.

INTRODUCTION: Evaluation of systolic and diastolic function by non-invasive methods in the acute phase of myocardial infarction (MI) is of great importance for risk stratification and prognosis. Ejection fraction (EF), as determined by echocardiography using the Simpson method, is the main parameter for assessing left ventricular (LV) function. The Tei index (TI), a Doppler-derived index that reflects systolic and diastolic function in MI, has an excellent correlation with prognosis. OBJECTIVE: The purpose of this study was to evaluate systolic and systo-diastolic function in the acute and late phase of ST-elevation MI treated with acute reperfusion therapy. METHODS: Patients with ST-elevation MI who underwent acute reperfusion therapy were evaluated by echocardiography in the first 48 hours and after one week. The parameters studied were: EF, wall motion score index (WMSI), and TI. The values obtained at the first and second evaluation were compared and correlated with pain to reperfusion time (PRT) (<3 vs. > or =3 hours), presence of single or multivessel disease, ejection fraction, total CK (<1500 or > or =1500 UI/l), and MI location (anterior vs. other). RESULTS: 40 patients were studied and 19 were included, of whom 15 (80%) were male, mean age 57 +/- 14 years. Risk factors included hypertension (11 patients, 58%), smoking (14, 74%), diabetes (6, 30%), and dyslipidemia (12, 63%). MI location was anterior in 6 patients (32%) and inferior in 13 (68%). Five patients (26%) underwent fibrinolysis and 14 (74%) direct percutaneous coronary intervention. Mean pain to reperfusion time was 3.7 +/- 2.8 hours. Four patients (21%) had single vessel disease and 14 (74%) multivessel disease. Significant differences were found: (a) in mean EF and WMSI between the two evaluations (p < 0.0001 and p = 0.002 respectively); (b) between PRT and EF (p = 0.001) and WMSI (p = 0.020) at 48 hours; (c) between PRT and EF (p = 0.01) and TI (p = 0.033), and MI location and EF (p = 0.005) after one week. DISCUSSION AND CONCLUSIONS: Early systolic function and LV remodeling one week after MI were accurately evaluated by EF and WMSI. Early reperfusion therapy positively influences early and late systolic and systo-diastolic function.

Cardiac resynchronization therapy: Femoral approach.

We describe the case of a 62-year-old female patient with bilateral subclavian vein occlusion, in whom a cardiac resynchronization system was implanted via a femoral vein.

Suspected dysfunction of a Starr-Edwards aortic prosthesis implanted 33 years ago: the role of exercise stress echocardiography. Case report.

The authors present a case report of suspected dysfunction of a Starr-Edwards mechanical aortic prosthesis implanted in 1972. Its characteristic longevity, but also its disadvantageous hemodynamic profile, are discussed. Treadmill exercise echocardiography, whose role has yet to be clarified in the study of valve prosthesis, was used in the evaluation of the patient.