Position Statement on the Use of Myocardial Strain in Cardiology Routines by the Brazilian Society of Cardiology's Department Of Cardiovascular Imaging - 2023. / Posicionamento do Departamento de Imagem Cardiovascular da Sociedade Brasileira de Cardiologia sobre o Uso do Strain Miocárdico na Rotina do Cardiologista ­ 2023.

Central Illustration : Position Statement on the Use of Myocardial Strain in Cardiology Routines by the Brazilian Society of Cardiology's Department Of Cardiovascular Imaging - 2023 Proposal for including strain in the integrated diastolic function assessment algorithm, adapted from Nagueh et al.67 Am: mitral A-wave duration; Ap: reverse pulmonary A-wave duration; DD: diastolic dysfunction; LA: left atrium; LASr: LA strain reserve; LVGLS: left ventricular global longitudinal strain; TI: tricuspid insufficiency. Confirm concentric remodeling with LVGLS. In LVEF, mitral E wave deceleration time < 160 ms and pulmonary S-wave < D-wave are also parameters of increased filling pressure. This algorithm does not apply to patients with atrial fibrillation (AF), mitral annulus calcification, > mild mitral valve disease, left bundle branch block, paced rhythm, prosthetic valves, or severe primary pulmonary hypertension.

Figura Central : Posicionamento do Departamento de Imagem Cardiovascular da Sociedade Brasileira de Cardiologia sobre o Uso do Strain Miocárdico na Rotina do Cardiologista ­ 2023 Proposta de inclusão do strain no algoritmo integrado de avaliação da função diastólica, adaptado e traduzido de Nagueh et al. 67 AE: átrio esquerdo; Ap: duração da onda A reversa pulmonar; Am: duração da onda A mitral; DD: disfunção diastólica; FEVEr: fração de ejeção do ventrículo esquerdo reduzida; IT: insuficiência tricúspide; SAEr: strain do AE de reservatório; SLGVE: strain longitudinal global do ventrículo esquerdo. Se remodelamento concêntrico, confirmar com SLGVE. Na presença de FEVEr, tempo de desaceleração da onda E mitral (TDE) < 160 ms e onda S < D pulmonar também são parâmetros de pressão de enchimento aumentada. Esse algoritmo não se aplica a pacientes com fibrilação atrial (FA), calcificação do anel mitral ou valvopatia mitral maior que discreta, bloqueio de ramo esquerdo (BRE), ritmo de marca-passo, próteses valvares ou hipertensão pulmonar (HP) primária grave.

Reduction in Hospitalization and Increase in Mortality Due to Cardiovascular Diseases during the COVID-19 Pandemic in Brazil. / Redução na Hospitalização e Aumento na Mortalidade por Doenças Cardiovasculares durante a Pandemia da COVID-19 no Brasil.

BACKGROUND: In the COVID-19 pandemic, the increase in the incidence of cardiovascular diseases (CVD) and mortality from them has been recognized worldwide. In Brazil, the impact of COVID-19 on CVD must be evaluated. OBJECTIVES: To assess the impact of the current pandemic on the numbers of hospital admissions (HA), in-hospital deaths (ID), and in-hospital fatality (IF) from CVD by use of national epidemiological data from the Brazilian Unified Public Health System. METHODS: Time-series observational study using comparative analysis of the HA, ID, and IF due to CVD recorded from January to May 2020, having as reference the values registered in the same period from 2016 to 2019 and the values projected by linear regression methods for 2020. The statistical significance level applied was 0.05. RESULTS: Compared to the same period in 2019, there was a 15% decrease in the HA rate and a 9% decrease in the total ID due to CVD between March and May 2020, followed by a 9% increase in the IF rate due to CVD, especially among patients aged 20-59 years. The HA and IF rates registered in 2020 differed significantly from the projected trend for 2020 (p = 0.0005 and 0.0318, respectively). CONCLUSIONS: During the first months of the pandemic, there were a decline in HA and an increase in IF due to CVD in Brazil. These data might have resulted from the inadequate planning of the CVD management during the pandemic. Thus, immediate actions are required to change this scenario. (Arq Bras Cardiol. 2021; [online].ahead print, PP.0-0).

FUNDAMENTO: Na pandemia pela COVID-19, o aumento da ocorrência e da mortalidade por doenças cardiovasculares (DCV) vem sendo reconhecido no mundo. No Brasil, é essencial que o impacto da COVID-19 na DCV seja analisado. OBJETIVOS: Avaliar o impacto desta pandemia nos números de internações hospitalares (IH), óbitos hospitalares (OH) e letalidade intra-hospitalar (LH) por DCV a partir de dados epidemiológicos do Sistema Único de Saúde (SUS). MÉTODOS: Estudo observacional de séries temporais por meio da análise comparativa das taxas de IH, OH e LH por DCV registrados entre janeiro e maio de 2020, usando como referência os valores obtidos no mesmo período entre 2016 e 2019 e os valores projetados por métodos de regressão linear para o ano de 2020. O nível significância estatística utilizado foi de 0,05. RESULTADOS: Em comparação com o mesmo período de 2019, houve um decréscimo de 15% na taxa de IH e de 9% no total de OH por DCV entre março e maio de 2020, acompanhado de um aumento de 9% na taxa de LH por esse grupo de doenças, sobretudo entre pacientes com idade de 20-59 anos. As taxas de IH e LH registradas em 2020 diferiram significativamente da tendência projetada para o corrente ano (p=0,0005 e 0,0318, respectivamente). CONCLUSÕES: Durante os primeiros meses da pandemia, observou-se um declínio na IH associado a um aumento da LH por DCV no Brasil. Esses dados possivelmente são consequência do planejamento inadequado no manejo das DCV durante a pandemia, sendo necessária a implementação de ações imediatas para modificar esse cenário. (Arq Bras Cardiol. 2021; [online].ahead print, PP.0-0).

Repercussions of the COVID-19 Pandemic on the Care Practices of a Tertiary Hospital. / Repercussões da Pandemia de COVID-19 na Prática Assistencial de um Hospital Terciário.

BACKGROUND: We still do not have information regarding the impact of the COVID-19 pandemic on medical care activity in Brazil. OBJECTIVE: To describe the repercussions of the COVID-19 pandemic on the care routine of a tertiary hospital, which is a regional reference in cardiology and oncology. METHODS: Cross-sectional cohort study. We conducted a survey of medical visits from March 23, 2020 (when local commerce was closed) to April 23, 2020 (P20), in comparison with the same period in 2019 (P19). RESULTS: We found decreases in the number of cardiology consultations, exercise tests, Holter, ambulatory blood pressure monitoring, electrocardiogram, and echocardiogram (90%, 84%, 94%, 92%, 94%, and 81%, respectively). In relation to cardiac surgery and cardiac catheterization, there were 48% and 60% decreases, respectively. There was an increase in the number of percutaneous transluminal coronary angioplasties (33%) and definitive pacemaker implantations (29%). There were 97 admissions to the ICU during P19, in contrast with 78 during P20, a 20% decrease. Visits to the cardiac emergency room (45%) and admissions to the cardiology ward (36%) also decreased. The decrease in oncology consultations was 30%. Chemotherapy sessions decreased from 1,944 to 1,066 (45%), and radiotherapy sessions decreased by 19%. CONCLUSION: COVID-19 has led to a considerable decrease in the number of consultations in outpatient clinics for cardiology, oncology, and other specialties. There was a concerning decrease in the number of cardiac surgeries, chemotherapy sessions, and radiotherapy sessions during the initial weeks of the pandemic. The number of people seeking care in the cardiac emergency room and the number of admissions to the cardiology ward and ICU also decreased, generating concern regarding the evolution and prognosis of these patients with pathologies other than COVID-19 during this pandemic time. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0).

FUNDAMENTO: Ainda não temos informações acerca do impacto da pandemia da COVID-19 sobre a atividade médica assistencial no Brasil. OBJETIVO: Descrever as repercussões da pandemia da COVID-19 na rotina de atendimentos em um hospital terciário, referência regional em cardiologia e oncologia. MÉTODOS: Estudo de corte transversal. Foi realizado levantamento dos atendimentos no período de 23/03/2020 (fechamento do comércio local) até 23/04/2020 (P20) e comparado com o mesmo período em 2019 (P19).Resultados: Detectamos redução no número de consultas cardiológicas, teste ergométrico, Holter, monitorização ambulatorial da pressão arterial, eletrocardiograma e ecocardiograma (90%, 84%, 94%, 92%, 94% e 81%, respectivamente). Em relação à cirurgia cardíaca e cateterismo cardíaco, houve redução de 48% e 60%, respectivamente. Aumento no número de angioplastia transluminal coronária (33%) e de implante de marca-passo definitivo (29%). Houve 97 internamentos na UTI em P19, contra 78 em P20, redução de 20%. Diminuição dos atendimentos no pronto-socorro cardiológico (45%) e nos internamentos na enfermaria de cardiologia (36%). Houve diminuição nas consultas oncológicas de 30%. Sessões de quimioterapia reduziram de 1.944 para 1.066 (45%). Sessões de radioterapia diminuíram 19%. CONCLUSÃO: A COVID-19 provocou redução considerável no número de consultas nos ambulatórios de cardiologia, oncologia e demais especialidades. Houve uma preocupante diminuição no número de cirurgias cardíacas e nas sessões de quimioterapia e radioterapia nas semanas iniciais da pandemia. A procura por atendimento no pronto-socorro cardiológico, assim como as internações na UTI e enfermaria cardiológicas, também reduziram, gerando preocupação acerca da evolução e prognóstico destes pacientes portadores de outras patologias, que não a COVID-19, nestes tempos de pandemia. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0).

Medição automática de valva mitral a partir de ecocardiograma utilizando processamento digital de imagens / Automatic measurement of the mitral valve based on echocardiography using digital image processing

Fundamento: A avaliação da área valvar mitral por meio da reconstrução multiplano na ecocardiografia tridimensional é restrita a softwares específicos e à experiência dos ecocardiografistas. Eles precisam selecionar manualmente o frame do vídeo que contenha a área de abertura máxima da valva mitral, dimensão fundamental para a identificação de estenose mitral. Objetivo: Automatizar o processo de determinação da área de abertura máxima da valva mitral, por meio da aplicação de Processamento Digital de Imagens (PDI) em exames de ecocardiograma, desenvolvendo um algoritmo aberto com leitura de vídeo no formato avi. Método: Este estudo piloto observacional transversal foi realizado com vinte e cinco exames diferentes de ecocardiograma, sendo quinze com abertura normal e dez com estenose mitral reumática. Todos os exames foram realizados e disponibilizados por dois especialistas, com autorização do Comitê de Ética em Pesquisa, que utilizaram dois modelos de aparelhos ecocardiográficos: Vivid E95 (GE Healthcare) e Epiq 7 (Philips), com sondas multiplanares transesofágicas. Todos os vídeos em formato avi foram submetidos ao PDI através da técnica de segmentação de imagens. Resultados: As medidas obtidas manualmente por ecocardiografistas experientes e os valores calculados pelo sistema desenvolvido foram comparados utilizando o diagrama de Bland-Altman. Observou-se maior concordância entre valores no intervalo de 0,4 a 2,7 cm². Conclusão: Foi possível determinar automaticamente a área de máxima abertura das valvas mitrais, tanto para os casos advindos da GE quanto da Philips, utilizando apenas um vídeo como dado de entrada. O algoritmo demonstrou economizar tempo nas medições quando comparado com a mensuração habitual. (AU)

Background: The evaluation of mitral valve area through multiplanar reconstruction in 3-dimensional echocardiography is restricted to specific software and to the experience of echocardiographers. They need to manually select the video frame that contains the maximum mitral valve opening area, as this dimension is fundamental to identification of mitral stenosis. Objective: To automate the process of determining the maximum mitral valve opening area, through the application of digital image processing (DIP) in echocardiography tests, developing an open algorithm with video reading in avi format. Method: This cross-sectional observational pilot study was conducted with 25 different echocardiography exams, 15 with normal aperture and 10 with rheumatic mitral stenosis. With the authorization of the Research Ethics Committee, all exams were performed and made available by 2 specialists who used 2 models of echocardiographic devices: Vivid E95 (GE Healthcare) and Epiq 7 (Philips), with multiplanar transesophageal probes. All videos in avi format were submitted to DIP using the image segmentation technique. Results: The measurements obtained manually by experienced echocardiographers and the values calculated by the developed system were compared using a Bland-Altman diagram. There was greater agreement between values in the range from 0.4 to 2.7 cm². Conclusion: It was possible to automatically determine the maximum mitral valve opening area, for cases from both GE and Philips, using only 1 video as input data. The algorithm has been demonstrated to save time on measurements when compared to the usual method. (AU)

Is paclitaxel less cardiotoxic in the treatment of breast cancer before or after doxorubicin? / Qual estratégia terapêutica é menos cardiotóxica no tratamento do câncer de mama: uso de paclitaxel antes ou depois da doxorrubicina?

Background: The combination of doxorubicin (DOX) with paclitaxel (PTX) effectively treats breast cancer (BC). However, DOX-associated cardiotoxicity (CTX) is aggravated by the use of PTX. Consensus is lacking about which drug sequence involves the most CTX. Objectives: To evaluate whether DOX followed by PXT or the reverse sequence has the greatest cardiotoxic potential in the treatment of BC. Methods: Prospective study of women with primary BC who received four cycles of DOX and 12 infusions of PTX. Participants were divided into Group 1 (G1; PXT before DOX) and Group 2 (G2; DOX before PXT) at the discretion of the oncologist. CTX was defined as an absolute reduction in left ventricular ejection fraction (LVEF) > 10% to a value <53%. Patients underwentclinical evaluations and echocardiography before treatment (Phase 1) and one year after treatment (Phase 2). Results: Sixty-nine women were evaluated: 19 in G1 and 50 in G2. The groups had similar clinical characteristics. The doses of radiation, DOX, and PTX used were similar. Eight (11.6%) patients developed CTX: two (10.5%) in G1 and six (12.0%) in G2 (p=0.62). The mean LVEF was similar between groups in Phase 1 (G1=65.1±3.5%; G2=65.2±3.9%; p=0.96), with a significant reduction noted after one year in both groups: G1=61.4±8.1% (p=0.021) and G2=60.8±7.6% (p<0,001). Although lower, mean LVEF remained similar between groups after Phase 2 (p=0.79). Conclusions: In women with BC who underwent chemotherapy, the incidence of CTX at the end of the first year of treatment was similar regardless of whether DOX was used before or after PTX. (AU)

Redução na Hospitalização e Aumento na Mortalidade por Doenças Cardiovasculares durante a Pandemia da COVID-19 no Brasil / Reduction in Hospitalization and Increase in Mortality Due to Cardiovascular Diseases during the COVID-19 Pandemic in Brazil

Resumo Fundamento Na pandemia pela COVID-19, o aumento da ocorrência e da mortalidade por doenças cardiovasculares (DCV) vem sendo reconhecido no mundo. No Brasil, é essencial que o impacto da COVID-19 na DCV seja analisado. Objetivos Avaliar o impacto desta pandemia nos números de internações hospitalares (IH), óbitos hospitalares (OH) e letalidade intra-hospitalar (LH) por DCV a partir de dados epidemiológicos do Sistema Único de Saúde (SUS). Métodos Estudo observacional de séries temporais por meio da análise comparativa das taxas de IH, OH e LH por DCV registrados entre janeiro e maio de 2020, usando como referência os valores obtidos no mesmo período entre 2016 e 2019 e os valores projetados por métodos de regressão linear para o ano de 2020. O nível significância estatística utilizado foi de 0,05. Resultados Em comparação com o mesmo período de 2019, houve um decréscimo de 15% na taxa de IH e de 9% no total de OH por DCV entre março e maio de 2020, acompanhado de um aumento de 9% na taxa de LH por esse grupo de doenças, sobretudo entre pacientes com idade de 20-59 anos. As taxas de IH e LH registradas em 2020 diferiram significativamente da tendência projetada para o corrente ano (p=0,0005 e 0,0318, respectivamente). Conclusões Durante os primeiros meses da pandemia, observou-se um declínio na IH associado a um aumento da LH por DCV no Brasil. Esses dados possivelmente são consequência do planejamento inadequado no manejo das DCV durante a pandemia, sendo necessária a implementação de ações imediatas para modificar esse cenário. (Arq Bras Cardiol. 2021; [online].ahead print, PP.0-0)

Abstract Background In the COVID-19 pandemic, the increase in the incidence of cardiovascular diseases (CVD) and mortality from them has been recognized worldwide. In Brazil, the impact of COVID-19 on CVD must be evaluated. Objectives To assess the impact of the current pandemic on the numbers of hospital admissions (HA), in-hospital deaths (ID), and in-hospital fatality (IF) from CVD by use of national epidemiological data from the Brazilian Unified Public Health System. Methods Time-series observational study using comparative analysis of the HA, ID, and IF due to CVD recorded from January to May 2020, having as reference the values registered in the same period from 2016 to 2019 and the values projected by linear regression methods for 2020. The statistical significance level applied was 0.05. Results Compared to the same period in 2019, there was a 15% decrease in the HA rate and a 9% decrease in the total ID due to CVD between March and May 2020, followed by a 9% increase in the IF rate due to CVD, especially among patients aged 20-59 years. The HA and IF rates registered in 2020 differed significantly from the projected trend for 2020 (p = 0.0005 and 0.0318, respectively). Conclusions During the first months of the pandemic, there were a decline in HA and an increase in IF due to CVD in Brazil. These data might have resulted from the inadequate planning of the CVD management during the pandemic. Thus, immediate actions are required to change this scenario. (Arq Bras Cardiol. 2021; [online].ahead print, PP.0-0)

Subclinical ventricular dysfunction detected by speckle tracking two years after use of anthracycline.

BACKGROUND: Heart failure is a severe complication associated with doxorubicin (DOX) use. Strain, assessed by two-dimensional speckle tracking (2D-STE), has been shown to be useful in identifying subclinical ventricular dysfunction. OBJECTIVES: a) To investigate the role of strain in the identification of subclinical ventricular dysfunction in patients who used DOX; b) to investigate determinants of strain response in these patients. METHODS: Cross-sectional study with 81 participants: 40 patients who used DOX ± 2 years before the study and 41 controls. All participants had left ventricular ejection fraction (LVEF) ≥ 55%. Total dose of DOX was 396 mg (242 mg/ms2). The systolic function of the LV was evaluated by LVEF (Simpson), as well as by longitudinal (εLL), circumferential (εCC), and radial (εRR) strains. Multivariate linear regression (MLR) analysis was performed using εLL (model 1) and εCC (model 2) as dependent variables. RESULTS: Systolic and diastolic blood pressure values were higher in the control group (p < 0.05). εLL was lower in the DOX group (-12.4 ± 2.6%) versus controls (-13.4 ± 1.7%; p = 0.044). The same occurred with εCC: -12.1 ± 2.7% (DOX) versus -16.7 ± 3.6% (controls; p < 0.001). The S' wave was shorter in the DOX group (p = 0.035). On MLR, DOX was an independent predictor of reduced εCC (B = -4.429, p < 0.001). DOX (B = -1.289, p = 0.012) and age (B = -0.057, p = 0.029) were independent markers of reduced εLL. CONCLUSION: a) εLL, εCC and the S' wave are reduced in patients who used DOX ± 2 years prior to the study despite normal LVEF, suggesting the presence of subclinical ventricular dysfunction; b) DOX was an independent predictor of reduced εCC; c) prior use of DOX and age were independent markers of reduced εLL.

Repercussões da Pandemia de COVID-19 na Prática Assistencial de um Hospital Terciário / Repercussions of the COVID-19 Pandemic on the Care Practices of a Tertiary Hospital

Resumo Fundamento Ainda não temos informações acerca do impacto da pandemia da COVID-19 sobre a atividade médica assistencial no Brasil. Objetivo Descrever as repercussões da pandemia da COVID-19 na rotina de atendimentos em um hospital terciário, referência regional em cardiologia e oncologia. Métodos Estudo de corte transversal. Foi realizado levantamento dos atendimentos no período de 23/03/2020 (fechamento do comércio local) até 23/04/2020 (P20) e comparado com o mesmo período em 2019 (P19).Resultados: Detectamos redução no número de consultas cardiológicas, teste ergométrico, Holter, monitorização ambulatorial da pressão arterial, eletrocardiograma e ecocardiograma (90%, 84%, 94%, 92%, 94% e 81%, respectivamente). Em relação à cirurgia cardíaca e cateterismo cardíaco, houve redução de 48% e 60%, respectivamente. Aumento no número de angioplastia transluminal coronária (33%) e de implante de marca-passo definitivo (29%). Houve 97 internamentos na UTI em P19, contra 78 em P20, redução de 20%. Diminuição dos atendimentos no pronto-socorro cardiológico (45%) e nos internamentos na enfermaria de cardiologia (36%). Houve diminuição nas consultas oncológicas de 30%. Sessões de quimioterapia reduziram de 1.944 para 1.066 (45%). Sessões de radioterapia diminuíram 19%. Conclusão A COVID-19 provocou redução considerável no número de consultas nos ambulatórios de cardiologia, oncologia e demais especialidades. Houve uma preocupante diminuição no número de cirurgias cardíacas e nas sessões de quimioterapia e radioterapia nas semanas iniciais da pandemia. A procura por atendimento no pronto-socorro cardiológico, assim como as internações na UTI e enfermaria cardiológicas, também reduziram, gerando preocupação acerca da evolução e prognóstico destes pacientes portadores de outras patologias, que não a COVID-19, nestes tempos de pandemia. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

Abstract Background We still do not have information regarding the impact of the COVID-19 pandemic on medical care activity in Brazil. Objective To describe the repercussions of the COVID-19 pandemic on the care routine of a tertiary hospital, which is a regional reference in cardiology and oncology. Methods Cross-sectional cohort study. We conducted a survey of medical visits from March 23, 2020 (when local commerce was closed) to April 23, 2020 (P20), in comparison with the same period in 2019 (P19). Results We found decreases in the number of cardiology consultations, exercise tests, Holter, ambulatory blood pressure monitoring, electrocardiogram, and echocardiogram (90%, 84%, 94%, 92%, 94%, and 81%, respectively). In relation to cardiac surgery and cardiac catheterization, there were 48% and 60% decreases, respectively. There was an increase in the number of percutaneous transluminal coronary angioplasties (33%) and definitive pacemaker implantations (29%). There were 97 admissions to the ICU during P19, in contrast with 78 during P20, a 20% decrease. Visits to the cardiac emergency room (45%) and admissions to the cardiology ward (36%) also decreased. The decrease in oncology consultations was 30%. Chemotherapy sessions decreased from 1,944 to 1,066 (45%), and radiotherapy sessions decreased by 19%. Conclusion COVID-19 has led to a considerable decrease in the number of consultations in outpatient clinics for cardiology, oncology, and other specialties. There was a concerning decrease in the number of cardiac surgeries, chemotherapy sessions, and radiotherapy sessions during the initial weeks of the pandemic. The number of people seeking care in the cardiac emergency room and the number of admissions to the cardiology ward and ICU also decreased, generating concern regarding the evolution and prognosis of these patients with pathologies other than COVID-19 during this pandemic time. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

Metabolic syndrome, strain, and reduced myocardial function: multi-ethnic study of atherosclerosis.

BACKGROUND: Subclinical cardiovascular disease is prevalent in patients with Metabolic Syndrome (MetSyn). Left ventricular (LV) circumferential strain (εCC) and longitudinal strain (εLL), assessed by Speckle Tracking Echocardiography (STE), are indices of systolic function: shortening is indicated by negative strain, and thus, the more negative the strain, the better the LV systolic function. They have been used to demonstrate subclinical ventricular dysfunction in several clinical disorders. OBJECTIVE: We hypothesized that MetSyn is associated with impaired myocardial function, as assessed by STE. METHODS: We analyzed Multi-Ethnic Study of Atherosclerosis (MESA) participants who underwent STE and were evaluated for all MetSyn components. RESULTS: Among the 133 participants included [women: 63%; age: 65 ± 9 years (mean ± SD)], the prevalence of MetSyn was 31% (41/133). Individuals with MetSyn had lower εCC and lower εLL than those without MetSyn (-16.3% ± 3.5% vs. -18.4% ± 3.7%, p < 0.01; and -12.1% ± 2.5% vs. -13.9% ± 2.3%, p < 0.01, respectively). The LV ejection fraction (LVEF) was similar in both groups (p = 0.09). In multivariate analysis, MetSyn was associated with less circumferential myocardial shortening as indicated by less negative εCC (B = 2.1%, 95%CI:0.6 3.5, p < 0.01) even after adjusting for age, ethnicity, LV mass, and LVEF). Likewise, presence of MetSyn (B = 1.3%, 95%CI:0.3 2.2, p < 0.01) and LV mass (B = 0.02%, 95% CI: 0.01-0.03, p = 0.02) were significantly associated with less longitudinal myocardial shortening as indicated by less negative εLL after adjustment for ethnicity, LVEF, and creatinine. CONCLUSION: Left ventricular εCC and εLL, markers of subclinical cardiovascular disease, are impaired in asymptomatic individuals with MetSyn and no history of myocardial infarction, heart failure, and/or LVEF < 50%.

Pacemaker electrode misplaced in the left ventricle.

This study reports the case of an anomalous implantation of VVI pacemaker electrode in the left ventricle (LV) diagnosed during routine evaluation, two years after implantation. The patient is a 65-year-old woman with Chagas disease. Electrocardiogram (ECG) revealed a pattern of right branch block. Profile chest X-ray showed electrode with posterior curvature path. In transthoracic echocardiography, the diagnosis revealed that the catheter penetrated the right atrium, crossed the atrial septum, descended through the left atrium and mitral valve orifice and deployed on the LV wall. The following related aspects are addressed: potential deployment routes, clinical, radiological, electrocardiographic and echocardiographic pictures, complications and treatment options.