A risk score for predicting death in COVID-19 in-hospital infection: A Brazilian single-center study.

BACKGROUND: There is a paucity of information about Brazilian COVID-19 in-hospital mortality probability of death combining risk factors. OBJECTIVE: We aimed to correlate COVID-19 Brazilian in-hospital patients' mortality to demographic aspects, biomarkers, tomographic, echocardiographic findings, and clinical events. METHODS: A prospective study, single tertiary center in Brazil, consecutive patients hospitalized with COVID-19. We analyzed the data from 111 patients from March to August 2020, performed a complete transthoracic echocardiogram, chest thoracic tomographic (CT) studies, collected biomarkers and correlated to in-hospital mortality. RESULTS: Mean age of the patients: 67 ± 17 years old, 65 (58.5%) men, 29 (26%) presented with systemic arterial hypertension, 18 (16%) with diabetes, 11 (9.9%) with chronic obstructive pulmonary disease. There was need for intubation and mechanical ventilation of 48 (43%) patients, death occurred in 21/111 (18.9%) patients. Multiple logistic regression models correlated variables with mortality: age (OR: 1.07; 95% CI 1.02-1.12; p: 0.012; age >74 YO AUC ROC curve: 0.725), intubation need (OR: 23.35; 95% CI 4.39-124.36; p < 0.001), D dimer (OR: 1.39; 95% CI 1.02-1.89; p: 0.036; value >1928.5 ug/L AUC ROC curve: 0.731), C-reactive protein (OR: 1.18; 95% CI 1.05-1.32; p < 0.005; value >29.35 mg/dl AUC ROC curve: 0.836). A risk score was created to predict intrahospital probability of death, by the equation: 3.6 (age >75 YO) + 66 (intubation need) + 28 (C-reactive protein >29) + 2.2 (D dimer >1900). CONCLUSIONS: A novel and original risk score were developed to predict the probability of death in Covid 19 in-hospital patients concerning combined risk factors.

In-hospital COVID-19 infection echocardiographic analysis: a Brazilian, tertiary single-centre experience.

BACKGROUND: Information is lacking concerning in-hospital echocardiography analysis of COVID-19 infection in Brazil. We evaluated echocardiographic parameters to predict a composite endpoint of mortality, pulmonary thromboembolism or acute renal failure. METHODS: A prospective full echocardiographic study of consecutive patients hospitalized with COVID-19, single tertiary centre in Brazil. We correlated echocardiographic findings to biomarkers, clinical information, thoracic tomography, and in-hospital composite endpoint of mortality, pulmonary thromboembolism or renal failure. RESULTS: One hundred eleven patients from March to October 2020, 67 ± 17 years, 65 (58.5%) men, death was observed in 21/111 (18.9%) patients, 48 (43%) required mechanical ventilation, myocardial infarction occurred in 10 (9%), pulmonary thromboembolism in 7 (6.3%) patients, haemodialysis was required for 9 (9.8%). Echocardiography was normal in 51 (46%) patients, 20 (18%) presented with decreased left ventricle ejection, 18 (16.2%) had abnormal left ventricle global longitudinal strain, 35 (31%) had diastolic dysfunction, 6 (5.4%) had an E/e'ratio > 14, 19 (17.1%) presented with right ventricle dilated/dysfunction, 31 (28%) had pericardial effusion. The echocardiographic parameters did not correlate with mortality, biomarkers, clinical events. Tricuspid velocity was related to the composite endpoint of mortality, pulmonary thromboembolism or acute renal failure (p: 00.3; value: 2.65 m/s; AUC ROC curve: 0.739; sensitivity: 73.3; specificity: 66.7; CI: 0.95, inferior: 0.613; superior: 0,866). CONCLUSIONS: Among hospitalized patients with COVID-19, echocardiography was normal in 51(46%) patients, and 20 (18%) patients presented with a decreased left ventricle ejection fraction. Tricuspid velocity was related to the composite endpoint of mortality, pulmonary thromboembolism or acute renal failure.

Spontaneous Tricuspid Valve Chordal Rupture in Idiopathic Pulmonary Hypertension.

Rupture of tricuspid valve is unusual, occurring mainly in the setting of blunt trauma or endomyocardial biopsy. Spontaneous tricuspid valve chordal rupture is particularly rare. We report herein a case of a patient with severe pulmonary hypertension, on the lung transplantation waiting list, who presented with spontaneous chordal rupture, exacerbation of tricuspid insufficiency and worsening of clinical status. Diagnosis and treatment, along with possible mechanisms for this complication, are discussed.

Right ventricular abnormalities in Takotsubo cardiomyopathy.

BACKGROUND: Takotsubo cardiomyopathy, described as transient regional contractile abnormalities limited to the apical and mid-segments of the left ventricle (LV), has also been reported to involve basal and/or mid LV segments (inverted Takotsubo); fewer reports, however, have addressed right ventricular (RV) dysfunction. AIM: To assess the distribution of regional abnormalities and RV involvement in Takotsubo cardiomyopathy and compare it to the literature. METHODS AND RESULTS: We evaluated 23 patients with both classical and inverted presentations (19 female, aged 64 ± 19 years), including 2 recurrences, totaling 25 episodes. Classical Takotsubo was observed in 15 patients, while 10 had the inverted form. LV ejection fraction (EF) was lower for classical compared to inverted presentation (30 ± 7 vs. 45 ± 4%, P < 0.001) with higher troponin values (1.3 ± 1.4 vs. 0.5 ± 0.6, P = 0.034). RV abnormalities were found in 7 patients (28%), mainly with classical presentation (6 patients), presenting with mid and apical RV impairment. One patient with inverted Takotsubo had mid-RV involvement. Patients with RV involvement had lower left ventricular ejection fraction (LVEF) (28 ± 10% vs. 40 ± 10%, P = 0.02), but not when adjusted for presentation type. Overall rate of complications was higher for classical compared to inverted presentation, and not influenced by RV involvement. CONCLUSION: RV contractile abnormalities may follow the same LV regional distribution in Takotsubo cardiomyopathy; the type of presentation rather than the presence of RV dysfunction seems to be responsible for an increased risk of complications and severity of functional impairment.

Exercise echocardiography in cryopreserved aortic homografts: comparison of a prototype stentless, a stented bioprosthesis, and native aortic valves.

BACKGROUND: Aortic valve replacement with a cryopreserved aortic homograft (CH) is an attractive alternative to bioprosthesis implantation. The aim of the study was to compare the hemodynamic performance of CH implanted with aortic root inclusion compared to prototype stentless (SS) bioprosthesis, standard stented (SD) bioprosthesis, and a native aortic valve. METHODS: Hemodynamics and Doppler echocardiographic measurements such as left ventricular ejection fraction, aortic valve orifice area index (AVOAI), mean and maximal transvalvular gradients, were obtained at rest and immediately after exercise in 28 patients after aortic valve replacement with CH (n = 10), SS (n = 9), or SD (n = 9), and in a control group (CG) of 15 normal volunteers. RESULTS: Rest and peak exercise heart rate and workload achieved were not different among the groups. Baseline AVOAI was larger for CH and CG compared to SS and SD groups (P < 0.05). Maximal and mean transvalvular pressure gradients at rest were lower for CH compared to SS and SD groups (P < 0.05), but higher than CG (P < 0,05). CONCLUSION: Implanted aortic CH had better hemodynamic performance than SS and SD bioprosthesis and similar to native normal aortic valves, both at rest and immediately after exercise.

Analysis of left ventricular regional dyssynchrony: comparison between real time 3D echocardiography and tissue Doppler imaging.

BACKGROUND: There is a paucity of information concerning left ventricular (LV) dyssynchrony assessment by real time three-dimensional (3D) echocardiography (RT3DE) versus tissue Doppler imaging (TDI). AIMS: To compare RT3DE and TDI LV dyssynchrony assessment. METHODS: A prospective study of 92 individuals (56 men, age 47 +/- 10 years), 32 with dilated cardiomyopathy (CMP), and 60 healthy individuals. By RT3DE, we measured the LV% dyssynchrony index (DI) of 6, 12, and 16 segments (SDI). By pulsed-wave TDI, we measured the QS electromechanical interval in the basal segments of the mitral valve annulus of the septum, the lateral, anterior and inferior walls, and the TDI% DI. RESULTS: In the normal group, the 3D DI was 1.1 +/- 0.8%, 1.4 +/- 1.3%, 1.8 +/- 1.7%, for 6 segments, 12 segments, and SDI, respectively. The correlation coefficient (Pearson's r) for the TDI DI and SDI was r = 0.2381 (P = 0.0470). In CMP group, the 3D DI was 4.6 +/- 5.4%, 7.9 +/- 7.1%, 11.1 +/- 7.1%, for 6 segments, 12 segments, and SDI, respectively. The correlation coefficient for TDI DI and SDI was r = 0.7838 (P < 0.0001). CONCLUSIONS: We observed a good correlation between RT3DE and tissue Doppler LV dyssynchrony assessment in patients with advanced heart failure.

Relationship of clot burden and echocardiographic severity of right ventricular dysfunction after acute pulmonary embolism.

The impact of pulmonary embolism on right ventricular (RV) performance can be evaluated by echocardiography, however, the relationship between pulmonary vascular involvement and RV burden is controversial. To assess the effect of clot burden on RV performance we studied 85 patients (aged 53 ± 17 years, 39 female) with confirmed PE by multislice computed tomography (CT) and echocardiography within 24 h of diagnosis. A CT score ranging from 1 to 20 points according to the pulmonary arteries involved was used. RV function was evaluated with fractional area change (FAC), with dysfunction present when FAC < 40%. Tissue Doppler RV systolic (s') velocities and myocardial performance index (MPI) were obtained, as well as pulmonary artery pressure (PAP). Mean CT score was 9.4 ± 6.7. Only 31 out of 85 patients (37%) presented with RV dysfunction, with FAC measuring 27.8 ± 7.2% in patients with dysfunction compared to 47.8 ± 4.4 for those with preserved RV function (p < 0.05). RV dysfunction was associated to older age, higher CT scores, increased pulmonary pressures and MPI and decreased s' (p < 0.001). An inverse correlation with CT clot burden was found for FAC (r = -0.57), whereas a direct correlation was seen for PAP (r = 0.51) and MPI (0.32). No correlation was observed for tissue Doppler velocities. In patients with acute PE, the effect of clot burden on RV performance is better expressed FAC than tissue Doppler indexes; the increase in pulmonary pressure is proportional to the magnitude of obstruction.

Right ventricular assessment by tissue-Doppler echocardiography in acute pulmonary embolism.

BACKGROUND: Assessment of the right ventricular (RV) function by echocardiography in patients with pulmonary thromboembolism (PTE) is complex and frequently qualitative. Tissue Doppler has been used for the semiquantitative assessment of this chamber, although with some limitations. OBJECTIVE: To evaluate RV function in PTE using tissue-Doppler echocardiography, in addition to atrial natriuretic peptide (BNP). METHODS: Patients with PTE were studied using tissue-Doppler echocardiography and BNP up to 24 hours after diagnosis; myocardial velocities (s'), strain, strain rate and RV myocardial performance index were obtained. RV dysfunction was diagnosed by chamber hypokinesia, abnormal septal motion and a RV/LV ratio >1. According to their BNP levels, the patients were divided into Group I, BNP < 50 pg/mL and Group II, BNP > 50 pg/mL. RESULTS: Of 118 patients, 100 (60 men, age = 55 ± 17 years) were analyzed; RV dysfunction was observed in 28%, more frequently in group II (19 vs. 9 patients, p < 0.001). Patients in group II were older (64 ± 19 vs. 50 ± 15 years), and had lower s' velocity (10.5 ± 3.5 vs. 13.2 ± 3.1 cm/s), and higher pulmonary pressure (48 ± 11 vs. 35 ± 11 mmHg), p < 0.001. The cut-off point of s' for RV dysfunction was 10.8 cm/s (specificity = 85%, sensitivity = 54%), with moderate correlation between BNP and s' wave (r = -0.39). CONCLUSION: In PTE, RV dysfunction on echocardiography is accompanied by BNP elevation; although tissue-Doppler imaging adequately confirms the presence of RV dysfunction, it has a limited sensitivity for this diagnosis.

3D Echo pilot study of geometric left ventricular changes after acute myocardial infarction.

BACKGROUND: Left ventricular remodeling (LVR) after AMI characterizes a factor of poor prognosis. There is little information in the literature on the LVR analyzed with three-dimensional echocardiography (3D ECHO). OBJECTIVE: To analyze, with 3D ECHO, the geometric and volumetric modifications of the left ventricle (VE) six months after AMI in patients subjected to percutaneous primary treatment. METHODS: Prospective study with 3D ECHO of 21 subjects (16 men, 56 ± 12 years-old), affected by AMI with ST segment elevation. The morphological and functional analysis (LV) with 3D ECHO (volumes, LVEF, 3D sphericity index) was carried out up to seven days and six months after the AMI. The LVR was considered for increase > 15% of the end diastolic volume of the LV (LVEDV) six months after the AMI, compared to the LVEDV up to seven days from the event. RESULTS: Eight (38%) patients have presented LVR. Echocardiographic measurements (n = 21 patients): I- up to seven days after the AMI: 1- LVEDV: 92.3 ± 22.3 mL; 2- LVEF: 0.51 ± 0.01; 3- sphericity index: 0.38 ± 0.05; II- after six months: 1- LVEDV: 107.3 ± 26.8 mL; 2- LVEF: 0.59 ± 0.01; 3- sphericity index: 0.31 ± 0.05. Correlation coefficient (r) between the sphericity index up to seven days after the AMI and the LVEDV at six months (n = 8) after the AMI: r: 0.74, p = 0.0007; (r) between the sphericity index six months after the AMI and the LVEDV at six months after the AMI: r: 0.85, p < 0.0001. CONCLUSION: In this series, LVR has been observed in 38% of the patients six months after the AMI. The three-dimensional sphericity index has been associated to the occurrence of LVR.

Assessing prognosis of pulmonary embolism using tissue-Doppler echocardiography and brain natriuretic peptide.

OBJECTIVE: To assess prognosis of pulmonary thromboembolism using tissue Doppler echocardiography and brain natriuretic peptide. METHODS: Patients aged over 18 years were evaluated within 24 hours of confirmed diagnosis (chest tomography/pulmonary scintigraphy) of pulmonary embolism using two-dimensional echocardiography and tissue Doppler for right ventricular systolic (s') velocities, strain, tissue tracking and myocardial performance index. Plasma brain natriuretic peptide was also obtained within 24 hour. The influence of echocardiographic and clinical variables on mortality was examined (up to 12 months) using Cox regression analysis. RESULTS: Out of 118 patients, 100 patients were included in the study (60 males, aged 55±17 years). Right ventricular dysfunction was observed in 28% using two-dimensional echocardiography. Tissue Doppler right ventricular variables (s' velocities, tissue tracking and strain) were decreased only for patients with right ventricular dysfunction, whereas myocardial performance index and systolic pulmonary artery pressure were increased. Mean brain natriuretic peptide value was 66±111pg/mL, also increased in patients with right ventricular dysfunction (136±146pg/mL). Mortality was 11% and related to age, malignancy and brain natriuretic peptide levels. The only echocardiographic variables capable of predicting events by univariate analysis were pulmonary pressure and right ventricular s' velocity. However, multivariate analysis showed only malignancy to predict mortality in this group. CONCLUSION: Lower tissue Doppler systolic velocities and elevated brain natriuretic peptide levels are associated with poorer prognosis in patients with pulmonary thromboembolism; but only malignancy emerged as an independent predictor of mortality.

Caseous calcification of the mitral annulus: case report.

We present a rare case of probable caseous calcification of the mitral. This pathology is more frequently detected in asymptomatic women older than 70 years. To recognize this image is important because echocardiography is the easiest way to elucidate this diagnosis, and more importantly because this structure could be easily misdiagnosed as tumors, thrombus and vegetations, which are much more common. Normally, it has a benign evolution, and the correct diagnosis is crucial to avoid unnecessary surgical interventions.

Avaliação dos Parâmetros de Deformação Miocárdica pelo Ecocardiograma Tridimensional e Speckle Tracking em Atletas Competitivos / Evaluation of Strain Parameters by Three Dimensional Speckle Tracking Echocardiography in Competitive Athletes

Introdução: A ecocardiografia é fundamental na distinção entre adaptações fisiológicas promovidas pela atividade física e alterações patológicas. O ecocardiograma tridimensional com speckle tracking (3DSTeco) poderia mostrar-se acurado para a detecção de alterações subclínicas da função cardíaca. Objetivos: Determinar o efeito do exercício nos parâmetros da deformação miocárdica em atletas, por meio do 3DSTeco. Método: Realizado ecocardiograma convencional, ecocardiograma tridimensional (3Deco) e 3DSTeco em boxeadores de elite, para análise dos volumes do ventrículo esquerdo (VE), índice de massa indexada à superfície corpórea (IMISC), fração de ejeção (FE), strain global longitudinal (GLS), strain global circunferencial (GCS), strain global radial (GRS), twist, torção e área tracking. Estes dados foram comparados com medidas efetuadas em indivíduos controle não treinados. Resultados: Analisados 16 atletas e 14 controles, com idade (23 ± 4 vs 21 ± 4 anos; p = NS) e sexo (14 vs 12 homens) similares. A FE do VE foi normal e semelhante nos 2 grupos. O IMISC foi maior nos atletas (83 ± 21 vs 65 ± 15 g/m²; p < 0,05), assim como o GRS (24,7 ± 5.2 vs 16.3 ± 7.2; p = 0.007). Não houve diferença significativa para os demais parâmetros como GCS (-26 ± 2 vs -28 ± 6), GLS (-16 ± 2 vs -17 ± 3), twist (3.1 ± 1.3 vs 3.7 ± 1.9), torção (2.0 ± 0.8 vs 1.4 ± 0.4) e área tracking (37 ± 4 vs 41 ± 6). Conclusão: Atletas e indivíduos não treinados apresentam parâmetros de deformação miocárdica comparáveis pelo 3DSTeco, contudo, um incremento do GRS foi observado apenas nos atletas. O 3DSTeco poderia auxiliar na detecção precoce de alterações cardíacas subclínicas em atletas

Introduction: Echocardiography is fundamental in the distinction between physiological adaptations promoted by physical activity and pathological abnormalities. Three-dimensional speckle tracking echocardiography (3D-STE) could prove accurate in detecting subclinical abnormalities in cardiac function. Objectives: To determine the effect of exercise on the parameters of myocardial strain in athletes through 3D STE. Method: Elite boxers underwent conventional three-dimensional echocardiography (3D-echo) and 3D-STE to analyze left ventricular (LV) volumes, left ventricular mass indexed to body surface area (LVMIBSA), ejection fraction (EF), longitudinal global strain (LGS), circumferential global strain (CGS), radial global strain (RGS), twist, torsion and tracking area. These data were compared with measurements performed on untrained control individuals. Results: The analyses included 16 athletes and 14 controls with similar age (23 ± 4 vs. 21 ± 4 years; p = NS) and gender (14 vs. 12 males). LVEF was normal and similar in the 2 groups. LVMIBSA was higher in the athletes (83 ± 21 vs. 65 ± 15 g/m², p < 0.05), as well as RGS (24.7 ± 5.2 vs. 16.3 ± 7.2; p = 0.007). There was no significant difference for the other parameters, such as CGS (-26 ± 2 vs. -28 ± 6), LGS (-16 ± 2 vs. -17 ± 3), twist (3.1 ± 1.3 vs. 3.7 ± 1.9), torsion (2.0 ± 0.8 vs. 1.4 ± 0.4) and tracking area (37 ± 4 vs. 41 ± 6). Conclusion: Athletes and untrained individuals have comparable myocardial strain parameters on 3D-STE. However, an increase in RGS was observed only in the athletes. 3D-STE could help in the early detection of subclinical cardiac issues in athletes

Influência do posicionamento do paciente sobre a qualidade das imagens ecocardiográficas em exames realizados no leito / Influence of patient’s positioning on the quality of bedside echocardiography images

Fundamento: O ecocardiograma é particularmente importante para a avaliação de pacientes instáveis hemodinamicamente. Apesar de sua realização à beira do leito eliminar o risco resultante do transporte, a obtenção de imagens pode ficar prejudicada; o posicionamento adequado poderia contribuir para uma melhor qualidade de imagem e consequentemente análise do exame. Objetivo: Avaliar se o posicionamento do paciente pela enfermagem poderia influenciar a qualidade das imagens ecocardiográficas obtidas no leito. Métodos: Foram estudados de maneira consecutiva os pacientes com solicitação de exame no leito. Durante a realização de ecocardiograma transtorácico foram adquiridos vídeos dos planos para esternal longitudinal (PEL) e apical 4-câmaras(Apical-4C) e a imagem estática do fluxo aórtico (FAo) em decúbito lateral esquerdo (DLE) e em decúbito dorsal (DD). As imagens digitalizadas foram analisadas cegamente por dois observadores em relação ao tipo de decúbito utilizado. A qualidade das imagens foi graduada como 1:boa/ótima; 2:inadequada/ruim; e comparadas com o teste de Kappa e correlação de Pearson. Resultados: Foram estudados 68 pacientes, com idade de 69 ± 24 anos, sendo 37 do sexo masculino e superfície corpórea 1,85 ± 0,09 m2. Em relação aos cortes, as imagens em DLE apresentam melhor qualidade (p < 0,001) quando comparadas ao DD tanto para os vídeos Apical-4C (Kappa 0,19) e PEL (Kappa 0,25) e FAo (Kappa 0,13); a concordância entre os avaliadores para a qualidade das imagens foi de 95%. Conclusão: O posicionamento adequado do paciente no leito em decúbito lateral esquerdo contribui significativamente para a aquisição de imagens de melhor qualidade.

Background: Echocardiography is particularly important for assessing hemodynamically unstable patients. Despite being carried out at the bedside to eliminate the risk resulting from patient’s transportation, the imaging maybe impaired. Proper patient’s positioning could contribute to enhancing both the image quality and analysis of the exam. Objective: To evaluate whether patient’s positioning by nurses could influence the quality of the echocardiographic images obtained at the bedside. Methods: Patients whose examinations were requested to be carried out at the bedside were studied in a consecutive manner. During transthoracic echocardiography, videos of the parasternal longitudinal view (PLV) and 4-chamber apical view (Apical-4C) were obtained, as well as the still image of the aortic flow (FAo), in the left lateral decubitus (LLD) and supine decubitus (SD). The scanned images were blindly analyzed by two observers comparing the type of decubitus used. The image quality was rated as 1: good/excellent quality; 2: inadequate/poor, and then submitted to Kappa agreement test and Pearson correlation. Results: 68 patients were studied, aged 69 ± 24 years, 37 males and body surface 1.85 ± 0.09 m2. When the distinct views were compared, LLD images showed better quality (p < 0.001) when compared to SD for both the Apical-4C videos (Kappa 0.19) and PLV (Kappa 0.25) and FAo (Kappa 0.13); interobserver agreement of the quality of the images was 95%. Conclusion: Patient’s proper positioning in bed in left lateral decubitus contributes significantly to the acquisition of better quality images.

[Chronic left ventricular pseudoaneurism of undetermined etiology]. / Pseudoaneurisma crônico do ventrículo esquerdo de etiologia indeterminada.

Pseudoaneurysms occur as a rare complication of the myocardial infarction, of which hemorrhagic process is contained by adherences of the visceral or parietal pericardium - or of both - preventing the development of cardiac tamponade. We report the case of a 55-year-old patient, with a chronic left ventricular pseudoaneurysm of undetermined etiology, who was submitted to a conservative treatment.

Relation between three-dimensional and two-dimensional echocardiography and biochemical analysis in patients with ST-segment elevation myocardial infarction percutaneously treated.

OBJECTIVE: The prognosis of patients with acute myocardial infarction depends on multiple features that can demonstrate myocardial injury degree (such as serum markers of cardiac necrosis), and also on adaptive mechanisms relative to the acute event. The aim of the study was to assess the relation between biochemical and echocardiographic findings from three-dimensional echocardiographic (3D Echo) analysis and echocardiographic two-dimensional (2D Echo) left ventricular ejection fraction in patients with ST-segment elevation acute myocardial infarction, submitted to primary percutaneous treatment. METHODS: A prospective study with 2D Echo and 3D Echo of 23 patients (17 males, mean age of 57 ± 13 years) with ST-segment elevation acute myocardial infarction, primarily percutaneously treated (stent). Serum cardiac markers (creatine kinase MB, Troponin I and Myoglobin) and serum brain natriuretic peptide were compared to echocardiographic parameters (volumes, left ventricular ejection fraction and ventricular dyssynchrony index). The statistical analysis was performed using Pearson's correlation coefficient, 95% CI, p < 0.05, linear regression equation and Bland & Altman test. RESULTS: Pearson's correlation coefficient (r)relative to 3D left ventricular ejection fraction: 1- brain natriuretic peptide: r: - 0.7427, p < 0.0001; 2- creatine kinase MB: r: - 0.660, p = 0.001. Left ventricular ejection fraction 2D (r) : 1- brain natriuretic peptide: r: - 0.5478, p = 0.001; 2- creatine kinase MB: r: - 0.4800, p < 0.0277. Other associations were not significant. CONCLUSIONS: In this series, it was observed better correlation in regard to serum creatine kinase MB, brain natriuretic peptide and 3D Echo left ventricular ejection fraction, when compared to 2D Echo left ventricular ejection fraction.

Safety of transesophageal echocardiography in adults: study in a multidisciplinary hospital.

BACKGROUND: TEE is a semi-invasive tool broadly used and its utilization associated to sedatives drugs might to affect the procedure safety. OBJECTIVE: to analyze aspects of TEE safety associated to the use of Midazolan (MZ) and Flumazenil (FL) and the influence of the clinical variables on the event rate. METHOD: prospective study with 137 patients that underwent TEE with MZ associated to moderate sedation. We analyzed the following events: complications related with the topical anesthesia, with MZ use and with the procedure. Uni- and multivariate analyses were used to test the influence of the clinical variables: age, sex, stroke, myocardiopathy (MP), duration of the test, mitral regurgitation (MR) and the MZ dose. RESULTS: All patients (65+/-16 yrs; 58% males) finished the examination. The mean doses of MZ and FL were 4.3+/-1.9 mg and 0.28+/-0.2 mg, respectively. The duration of the examination and the mean ejection fraction (EF) were 16.4+/-6.1 minutes and 60+/-9%, respectively. Mild hypoxia (SO2<90%) was the most common event (11 patients); 3 patients (2%) presented transient hypoxia due to upper airway obstruction by probe introduction and 8 (5.8%) due to hypoxia caused by MZ use. Transient hypotension (SAP<90mmHg) occurred in 1 patient (0.7%). The multivariate analysis showed that severe MR, MP (EF<45%) and high doses of MZ (>5mg) were associated with events (p<0.001). The EF was 40%, in the group with MP and 44% in the group with severe MR and it can be a factor associated with clinical events in the last group. CONCLUSION: TEE with sedation presents a low rate of events. There were no severe events and there was no need to interrupt the examinations.

Análise da função diastólica e função atrial em ciclistas de alto desempenho por meio da ecocardiografia tridimensional / Analysis of diastolic function and atrial function in high performance cyclists through three-dimensional echocardiography

Objetivos: Avaliar a função diastólica e a função atrial esquerda por meio do estudo com Doppler e ecocardiograma tridimensional em ciclistas de alto desempenho; comparar as variáveis estudadas a controles não esportistas. Métodos: Foram estudados 18 ciclistas profissionais (homens, idade 29, 5±4, 3 anos) e 18 indivíduos controles não esportistas (homens, idade 28, 8±5, 8 anos). Todos os indivíduos foram submetidos a ecocardiograma bidimensional e tridimensional com medidas de variáveis de função diastólica e de esvaziamento atrial como volume atrial esquerdo máximo, mínimo e antes de sua contração. Com base nestes volumes fundamentais foram calculadas a função de esvaziamento ativo, passivo e total, bem como a força de contração atrial. Resultados: Os indivíduos de ambos grupos apresentaram variáveis antropométricas semelhantes. Foi observado no grupo ciclista em relação aos controles: menor velocidade da onda A’ (5,9cm/s ± 2,2 versus 7,6 ± 2,3cm/s, com P=0,03), menor força de contração atrial (4,7 ±1,4Kdyn Vs. 6,2 ± 2,1Kdyn, com P= 0,02) e maior fração de esvaziamento passivo (43,8 ± 12,8% versus 34,8 ± 10,4% com P=0,03). Foi observada correlação linear entre a velocidade da onda A’ e a força de contração atrial no grupo dos ciclistas (r=0,80, P<0,05), entre a força de contração atrial e a fração de esvaziamento passivo (r=-0,88, P<0,05) e entre a força de contração atrial e o volume atrial antes de sua contração (r=0,65, P<0,05). Conclusão: O grupo ciclistas apresentou aumento do componente passivo em detrimento de uma redução do componente ativo no esvaziamento atrial total, o que mostrou estar correlacionado à atividade diastólica supernormal nesse grupo.

Objectives: To assess left ventricular diastolic and atrial function by means of Doppler and three-dimensional echocardiography of high-performance cyclists; To compare the variables studied for non-athlete controls. Methods: The study included 18 professional cyclists (men, age 29, 5±4, 3 years) and 18 non-athlete control individuals (men, age 28, 8±5, 8 years). All individuals underwent two-dimensional and three-dimensional echocardiography including measures of diastolic function variables and atrial emptying, such as maximum, minimum and before contraction left atrial volume. Based on these fundamental volumes, active, passive and total emptying function, and atrial contraction strength were calculated. Results: The individuals of both groups had similar anthropometric variables. The following was observed in the cyclist group as for the controls: lower A’ wave velocity (5.9 cm/s ± 2.2 versus 7.6 ± 2.3 cm/s, with P = 0.03), smaller atrial contraction force (4.7 ± 1,4Kdyn vs. 6.2 ± 2.1Kdyn, P = 0.02) and greater passive emptying fraction (43.8% ± 12.8 versus 34.8 ± 10.4% with P = 0.03). A linear correlation was found between A’ wave velocity and atrial contraction force in the cyclists group (r = 0.65, P <0.05), between atrial contraction force and passive emptying fraction (r = 0.80, P <0.05) and between atrial contraction and volume before contraction (r = 0.65, P < 0.05). Conclusion: The cyclists group showed an increase in the passive component to the detriment of a reduction in the active component in total atrial emptying, which was showed to be correlated with supernormal diastolic activity in this group.

Limitações do Doppler tecidual na avaliação da função diastólica em idosos / Tissue doppler imaging limitations for evaluating the diastolic function in elderly people / Limitaciones del doppler tisular en la evaluación de la función diastólica en añosos

Fundamento: O Doppler tecidual é uma técnica que complementa a análise da função diastólica do ventrículo esquerdo. No entanto, alguns fatores podem influenciar suas medidas, entre estes a idade, cuja contribuição não está adequadamente esclarecida.Objetivo: Comparar o comportamento dos índices de função diastólica derivados do Doppler tecidual em indivíduos idosos hipertensos e não hipertensos.Métodos: Indivíduos com idade acima de 60 anos foram divididos em um grupo controle (GC), sem comorbidades cardiovasculares, e um grupo de hipertensos (HAS). Foram avaliadas as funções sistólica e diastólica (Doppler convencional e tecidual) do ventrículo esquerdo e obtidos os volumes do átrio esquerdo e massa ventricular. Resultados: Foram analisados 56 indivíduos (idade de 70,1 ± 6,6 anos), sendo 23 (41,1%) do GC e 33 (58,9%) do HAS. Os achados ecocardiográficos estruturais foram semelhantes entre os grupos, exceto para hipertrofia ventricular esquerda, mais frequente no HAS (34,4% versus 4,8%; p=0,017). A análise do Doppler tecidual não revelou diferenças entre os grupos (e’ septal: 8,0 ± 1,5 versus 7,2 ± 1,9cm/s; p=0,08 e e’ lateral: 9,8 ± 2,2 versus 8,7 ± 2,0cm/s; p=0,07, respectivamente para o GC e HAS). No HAS observou-se tempo de desaceleração da onda E (TD) mais prolongado (253 ± 62 versus 208 ± 36 ms no GC; p=0,003). Conclusão: Na análise da função diastólica em idosos, o Doppler tecidual não foi capaz de discriminar de forma acurada, indivíduos hipertensos, com maior potencial para a ocorrência de disfunção diastólica, de indivíduos não hipertensos. O TD revelou-se um parâmetro a ser valorizado nesta população.

Background: Tissue Doppler imaging is a technique that complements the analysis of left ventricular (LV) diastolic function. Some factors may influence these parameters, however the true influence of age on Tissue Doppler velocities remains unclear. Objective: To compare the indices of diastolic function derived from tissue Doppler imaging in hypertensive and non-hypertensive elderly individuals. Methods: Subjects aged over 60 years, divided into two groups were studied: a control group (GC) without cardiovascular comorbidities and a hypertensive group (HAS). Left ventricular systolic and diastolic function (conventional and tissue Doppler) was assessed, and measurements of left atrial volumes and LV mass were obtained. Results: The group consisted of 56 subjects (70.1 ± 6.6 years), 23 (41.1%) in the GC and 33 (58.9%) in the HAS. Except for LV hypertrophy, more frequent in the HAS group compared to HG (34.4% versus 4.8% respectively; p=0.017), all structural echocardiographic findings were similar. Tissue Doppler analysis revealed no differences between the groups (septal e’: 8.0 ± 1.5 vs. 7.2 ± 1.9 cm/s; p=0.083 and lateral e’: 9.8 ± 2.2 versus 8.7 ± 2.0 cm/s; p=0.074, respectively, for GC and HAS). A longer E-wave deceleration time was observed for HAS group (253 ± 62 versus 208 ± 36 ms in GC; p=0.003).Conclusion: In the analysis of diastolic function in elderly, tissue Doppler imaging was not able to discriminate hypertensive individuals, with the greatest potential for the occurrence of diastolic dysfunction, to the non-hypertensive individuals.The E-wave deceleration time proved to be a valuable parameter in this population.

Fundamento: El Doppler tisular es una técnica que complementa el análisis de la función diastólica del ventrículo izquierdo. Mientras tanto, algunos factores pueden influenciar sus medidas, entre estos la edad, cuya contribución no está adecuadamente aclarada. Objetivo: Comparar el comportamiento de los índices de función diastólica derivados del Doppler tisular en individuos añosos hipertensos y no hipertensos. Métodos: Individuos con edad encima de 60 años fueron divididos en un grupo control (GC), sin comorbilidades cardiovasculares, y un grupo de hipertensos (HAS). Fueron evaluadas las funciones sistólica y diastólica (Doppler convencional y tisular) del ventrículo izquierdo y obtenidos los volúmenes del atrio izquierdo y de la masa ventricular. Resultados: Fueron analizados 56 individuos (edad de 70,1 ± 6,6 años), siendo 23 (41,1%) del GC y 33 (58,9%) del HAS. Los hallazgos ecocardiográficos estructurales fueron semejantes entre los grupos, excepto para hipertrofia ventricular izquierda, más frecuente en el HAS (34,4% versus 4,8%; p = 0,017). El análisis del Doppler tisular no reveló diferencias entre los grupos (e' septal: 8,0 ± 1,5 versus 7,2 ± 1,9 cm/s; p = 0,08 y e' lateral: 9,8 ± 2,2 versus 8,7 ± 2,0 cm/s; p = 0,07, respectivamente para el GC y HAS). En la HAS, se observó tiempo de desaceleración de la onda E (TD) más prolongado (253 ± 62 versus 208 ± 36 ms en el GC; p = 0,003). Conclusión: En el análisis de la función diastólica en añosos, el Doppler tisular no fue capaz de discriminar, de forma precisa, individuos hipertensos, con mayor potencial para la ocurrencia de disfunción diastólica, de individuos no hipertensos. El TD se reveló un parámetro a ser valorizado en esta población. (Arq Bras Cardiol: Imagem cardiovasc. 2014;27(3):184-190)

Ventricular dyssynchrony index: comparison with two-dimensional and three-dimensional ejection fraction.

BACKGROUND: Left ventricular (LV) electromechanical coupling (synchrony) is important in the analysis of the systolic performance, especially for the indication of cardiac resynchronization therapy in patients with advanced CHF. OBJECTIVE: To compare LV synchrony as analyzed by real-time three-dimensional (3D) echocardiography (ECHO) with LVEF measurements as obtained with 2D and 3D ECHO. METHODS: Prospective study of 92 individuals (56 men, 47 +/- 10 years of age), of which 60 had normal heart structure (ECHO) and ECG (N group), and 32 had dilated cardiomyopathy (DCM group). Using 3D ECHO, LVEF, volumes and dyssynchrony index (%DI) for 16 LV segments were measured. Using 2D ECHO, LVEF (Simpson's method), and LV systolic and diastolic volumes were measured. STATISTICAL ANALYSIS: Pearson's correlation coefficient, 95% CI, linear regression model, Bland & Altman analysis, p<0.05. RESULTS: %DI ranged from 0.2900 to 28.1000 (5.2014+/-6.3281), 3D LVEF ranged from 0.17 to 0.81 (0.52+/-0.17); and 2D LVEF ranged from 0.3 to 0.69 (0.49+/-0.11). The correlation between DI and 3D LVEF was (r): -0.7432, p<0.0001, CI: -0.8227 to -0.6350, the linear relation between DI (x) and 3D LVEF (y) was y = 19.8124 + (-27.9578) x, p<0.0001. The correlation between DI and 2D LVEF was (r): -0.7012, p<0.0001, CI: -0.7923 to -0.5797. CONCLUSION: In this case series, a good negative correlation was observed between LV electromechanical three-dimensional systolic coupling and LVEF as measured by echocardiography (3D and 2D).

Avaliação do ventrículo direito pelo ecocardiograma com doppler tecidual na embolia pulmonar aguda / Right ventricular assessment by tissue-Doppler echocardiography in acute pulmonary embolism

FUNDAMENTO: A avaliação da função Ventricular Direita (VD) pelo ecocardiograma em pacientes com Tromboembolismo Pulmonar (TEP) é complexa, frequentemente qualitativa; o Doppler tecidual tem sido utilizado para avaliação semiquantitativa dessa câmara, com algumas limitações. OBJETIVO: Avaliar a função do VD no TEP pelo ecocardiograma com Doppler tecidual, complementando com o peptídeo atrial natriurético (BNP). MÉTODOS: Foram estudados pacientes com TEP pelo ecocardiograma com Doppler tecidual e BNP até 24 horas do diagnóstico, obtendo-se as velocidades miocárdicas (s'), strain, strain rate e índice de performance miocárdica do VD; disfunção do VD foi iagnosticada por hipocinesia da câmara, movimento anormal septal e relação VD/VE >1. De acordo com o BNP os pacientes foram divididos em Grupo I, BNP < 50 pg/mL e Grupo II, BNP > 50 pg/mL. RESULTADOS: De 118 pacientes, 100 (60 homens, idade = 55 ± 17 anos) foram analisados; observou-se disfunção do VD em 28%, mais frequentemente no grupo II (19 vs. 9 pacientes, p < 0,001). O grupo II era mais idoso (64 ± 19 vs. 50 ± 15 anos), apresentava menor velocidade de s' (10,5 ± 3,5 vs. 13,2 ± 3,1 cm/s) e maior pressão pulmonar (48 ± 11 vs. 35 ± 11 mmHg), p < 0,001 para todos. O ponto de corte de s' para disfunção do VD foi de 10,8 cm/s (especificidade = 85%, sensibilidade = 54%), com moderada correlação entre o BNP e a onda s'(r = -0,39). CONCLUSÃO: No TEP, a disfunção do VD pelo ecocardiograma se acompanha de elevação do BNP; apesar confirmar adequadamente a presença de disfunção do VD, o Doppler tecidual apresenta sensibilidade limitada para este diagnóstico.

BACKGROUND: Assessment of the right ventricular (RV) function by echocardiography in patients with pulmonary thromboembolism (PTE) is complex and frequently qualitative. Tissue Doppler has been used for the semiquantitative assessment of this chamber, although with some limitations. OBJECTIVE: To evaluate RV function in PTE using tissue-Doppler echocardiography, in addition to atrial natriuretic peptide (BNP). METHODS: Patients with PTE were studied using tissue-Doppler echocardiography and BNP up to 24 hours after diagnosis; myocardial velocities (s'), strain, strain rate and RV myocardial performance index were obtained. RV dysfunction was diagnosed by chamber hypokinesia, abnormal septal motion and a RV/LV ratio >1. According to their BNP levels, the patients were divided into Group I, BNP < 50 pg/mL and Group II, BNP > 50 pg/mL. RESULTS: Of 118 patients, 100 (60 men, age = 55 ± 17 years) were analyzed; RV dysfunction was observed in 28%, more frequently in group II (19 vs. 9 patients, p < 0.001). Patients in group II were older (64 ± 19 vs. 50 ± 15 years), and had lower s' velocity (10.5 ± 3.5 vs. 13.2 ± 3.1 cm/s), and higher pulmonary pressure (48 ± 11 vs. 35 ± 11 mmHg), p < 0.001. The cut-off point of s' for RV dysfunction was 10.8 cm/s (specificity = 85%, sensitivity = 54%), with moderate correlation between BNP and s' wave (r = -0.39). CONCLUSION: In PTE, RV dysfunction on echocardiography is accompanied by BNP elevation; although tissue-Doppler imaging adequately confirms the presence of RV dysfunction, it has a limited sensitivity for this diagnosis.