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.

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.

Three-dimensional transesophageal echocardiographic evaluation of aortic plaque after cerebrovascular event.

INTRODUCTION AND OBJECTIVES: Transesophageal echocardiography (TEE) is crucial in order to assess aortic anatomy after stroke. Although routinely used to assess cardiovascular anatomy and function, three-dimensional echocardiography (3D TEE) is less used for aortic evaluation. We thus sought to assess prospectively whether additional information on aortic plaque morphology could be obtained with 3D TEE after an ischemic stroke. METHODS: Patients within one week of a stroke (confirmed by brain computed tomography/magnetic resonance) underwent TEE and 3D findings were compared with two-dimensional (2D) (aorta plaque number, dimensions, area and the presence of debris and ulcerations). Patients were followed for two years for death or a new stroke. RESULTS: We assessed 78 patients, 43 (55%) male, aged 62±14 years old, 92% in sinus rhythm. Aortic atheroma was found mainly in the descending aorta (50%); plaque thickness was similar for 2D TEE (0.29±0.03 cm) and 3D TEE (0.29±0.04 cm), whereas plaque area was slightly increased for 3D measurements (0.24±0.02 cm2 versus 0.37±0.03 cm2 respectively, p<0.05), with a strong correlation found both for aortic plaque thickness (r=0.91) and area (r=0.80) measurements. While aortic debris were equally seen with both techniques, 3D TEE defines the presence of ulcerations (six ulcerations unseen with 2D TEE better, p=0.03). There were 11 events (six deaths and five new strokes) during follow-up, unrelated to plaque characteristics. CONCLUSION: To evaluate aortic plaque morphology, 3D TEE is superior to 2D TEE due to improved detection of ulcerated aortic plaque; this might provide additional information in patients after ischemic stroke.

Ventricular arrhythmia in incident kidney transplant recipients: prevalence and associated factors.

Cardiovascular mortality in kidney transplant recipients has shown to be substantially elevated particularly in the first year of transplantation. Complex ventricular arrhythmia (VA) has been pointed as one of the etiologies of sudden death. The aim of this study was to evaluate the prevalence of VA and to investigate the factors associated with their occurrence in incident kidney transplant recipients. A total of 100 incident kidney transplant recipients were included in the study (39.7 ± 10.1 years, 55% male, 43.6 ± 10.1 days of transplantation, 66% living donors). All the patients underwent 24 h electrocardiogram, echocardiogram and multi-slice computed tomography. Thirty percent of the patients had VA. Left ventricular hypertrophy was observed in 57% of the patients while heart failure was found in 5%. Coronary artery calcification (CAC) was observed in 26 patients, from which 31% had severe calcification. The group of patients with VA was predominantly male, had been on dialysis therapy for a longer time and had more coronary calcification. In the multiple logistic regression analysis, male gender and CAC score were independently associated with the presence of VA. In conclusion, kidney transplant recipients exhibited a high prevalence of VA and the factors associated with its occurrence were the male gender and the presence of CAC.

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.

Importance of adequately performed Valsalva maneuver to detect patent foramen ovale during transesophageal echocardiography.

BACKGROUND: Transesophageal echocardiography (TEE) plays an important role in evaluating cardioembolic sources of emboli. The identification of a patent foramen ovale (PFO) is reportedly improved with TEE compared with transthoracic echocardiography (TTE), but the Valsalva maneuver during TEE may be difficult or suboptimal. The aim of this study was to assess the efficacy of the Valsalva maneuver for PFO diagnosis using TEE compared with TTE by evaluating patients with ischemic stroke referred for echocardiography. METHODS: Only patients able to perform the Valsalva maneuver during TTE were included; efficacy was defined by a 20 cm/sec decrease in transmitral E velocity. A PFO was judged present when microbubbles of agitated intravenous saline were seen in the left chambers within three cycles after right atrial opacification. RESULTS: Of 108 patients (mean age, 55 ± 15 years; 61 men), 48 (44%) were judged to have PFOs by TEE and/or TTE. In 36 patients (33% of the total, 75% of those with PFOs), microbubbles were observed both by TEE and TTE, in seven patients only during TTE, and in five patients only during TEE. In patients able to satisfactorily perform the Valsalva maneuver during TEE, 22 PFOs were found, and two shunts (9%) were missed, whereas in patients unable to perform this maneuver, 26 PFOs were observed, with five shunts missed (19%) (P < .05). When a PFO was missed by TTE, either the echocardiographic window was suboptimal or the shunt was small. CONCLUSIONS: An adequate Valsalva maneuver is crucial for diagnosis of PFO; most patients with stroke may be screened using TTE with contrast and the Valsalva maneuver, with TEE indicated in case of suboptimal transthoracic images.

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.

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.

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.

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

Prevalência de sintomas e lesões osteoarticulares em ecocardiografistas / Prevalence of symptoms and osteoarticular lesions on Brazilian echocardiographers

Síntomas y lesiones articulares y neuromusculares (SLANM) pueden ocurrir por esfuerzo repetitivo, con elevada prevalencia en técnicos en ecocardiografía. La prevalencia de los SLANM diagnosticados aun es desconocida en ecocardiografistas brasileños. Objetivo:Evaluar la prevalencia de SLANM en cardiólogos brasileños relacionada al trabajo como ecocardiografistas. Métodos: Médicos asociados al Departamento de Imagen Cardiovascular fueron invitados a responder preguntas relacionadas al perfil antropométrico, de trabajo como ecocardiografista, y SLANM. La comparación entre los participantes con (grupo 1) y sin SLANM (grupo 2) fue hecha con el test t no pareado para variables continuas y con Chi-cuadrado para categóricas. Fueron considerados significativos valores de p <0,05. Resultados: De junio de 2014 a junio de 2015, 474 respondieron el cuestionario; de esos, 311 fueron válidos; 248 (80%) fueron del grupo1 (45 ± 9,2 años; 48% mujeres) y 63 (20%), del grupo 2 (43 ± 9,8 años; 29% mujeres). En el grupo 1, el tiempo medio de aparición de los SLANM fue de 6,8 ± 5,3 años a partir del entrenamiento como ecocardiografista; 144(58%) procuraron atención; 126 (88%) requirieron tratamiento; 51 (35%) necesitaron apartamiento temporal; y 5(4%), de cirugía. Los SLANM fueron más frecuentes en los hombros y en los profesionales con más de 10 años de trabajo como ecocardiografista (65%); en el grupo 2 había menos mujeres (p = 0,009). No hubo diferencia entre los grupos en relación a las medidas antropométricas, miembro superior utilizado para el examen (p = 0,25), número de exámenes por semana(p = 0,49), o práctica de actividades físicas(p = 0,91).Conclusión:La prevalencia de SLANM en ecocardiografistas brasileños parece ser elevada. Las mujeres y los profesionales con más de 10 años de ecocardiografía parecen más susceptible.

Introduction: Joint and neuromuscular injuries and symptoms (JNIS) may occur due to repetitive strain, with high prevalence in echocardiography technicians. The prevalence of diagnosed JNIS remains unknown in Brazilian echocardiographers. Objective: Evaluate the prevalence of JNIS in Brazilian cardiologists related to their work as echocardiographers. Methods: Physicians from the Department of Cardiovascular Imaging were asked to answer a questionnaire about their anthropometric profile, their work as echocardiographers, and JNIS. Participants with JNIS (group 1) and without JNIS (group 2) were analyzed as follows: a comparison of continuous variables was made by the unpaired t-test, and a comparison of categorical variables was made by a chi-square test. P values were considered significant if <0.05. Results: From June 2014 to June 2015, 474 answered the questionnaire; of these, 311 were valid; 248 (80%) were in group 1 (45 ± 9.2 years; 48%women) and 63 (20%) in group 2 (43 ± 9.8 years; 29% women). In group 1, the mean time to the onset of JNIS was 6.8 ± 5.3 years as from the start of echocardiography training; 144 (58%) sought care; 126 (88%) required treatment; 51 (35%) required temporary leave; and 5 (4%) underwentsurgery. JNIS were more common on shoulders and in professionals with more than 10 years working as echocardiographers (65%); group 2 had fewer women (p = 0.009). There was no difference between groups in relation to anthropometric measurements; test criteria: upper limb used for the exam(p = 0.25), number of exams per week (p = 0.49), or physical activity (p = 0.91). Conclusion: The prevalence of JNIS in Brazilian echocardiographers seems to be high. Women and professionals with over 10-years’ experience in echocardiography seem more susceptible.

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.

Impacto do fentanil associado ao midazolam na sedação para ecocardiograma transesofágico / Impact of fentanyl associated with midazolam in sedation for transesophageal echocardiography / Impacto del Fentanil Asociado al Midazolam en la Sedación para Ecocardiograma Transesofágico

Introdução: O ecocardiograma transesofágico é atualmente uma das principais ferramentas no diagnóstico de diversas alterações cardíacas. Para uma maior segurança e conforto na sua realização, o exame tem sido realizado sob sedação consciente moderada, sendo os benzodiazepínicos os agentes de escolha. Nessa classe de medicamentos, o midazolam é o mais utilizado, todavia não está isento de possíveis complicações relacionadas ao seu uso, como hipóxia, hipotensão, entre outras. Sabemos que grau de sedação é dose-dependente, portanto, quanto menor a dose utilizada, será menor o risco de complicações do procedimento.Objetivo: Verificar o impacto do uso do fentanil na administração endovenosa de midazolam, no intuito de avaliar eficiência de protocolo de sedação de pacientes submetidos a ecocardiograma transesofágico, utilizando ambos os medicamentos. Metodologia: : Estudamos 201 pacientes (idade média de 51,5 anos, 115 homens) submetidos a ecocardiograma transesofágico, com sedação por via endovenosa divididos em dois grupos: Grupo A (n = 89), seguindo protocolo definido com uso de fentanil associado ao midazolam; e Grupo B (n = 112), sem o emprego de fentanil. Comparou-se então a dosagem de midazolam administrada em ambos os grupos. Monitorização adequada dos sinais vitais foi realizada durante todo o procedimento. Resultados: A dose média de midazolam utilizada foide 2,6 ± 1,4 mg no Grupo A e de 4,0 ± 2,7 mg no Grupo B (p < 0,01). A dose de fentanil empregada foi de 66,2 ± 24,8 mcg. Não houve diferença significativa entre idade (p = 0,08) e gênero (p > 0,1) nos grupos estudados. Conclusão: O uso de fentanil na sedação para realização de ecocardiograma transesofágico associado à administração de midazolam permite a administração de uma dose menor desse benzodiazepínico.

Introduction: Transesophageal echocardiography is currently one of the main tools in the diagnosis of various cardiac abnormalities. For greater safety and comfort, the test has been performed under moderate conscious sedation and benzodiazepines were the agents of choice. In this class of drugs, midazolam is the most commonly used, however it is not free of potential complications related to its use, such as hypoxia, hypotension, among others. We know that sedation level is dose-dependent. Therefore, the lower the dose, the lower the risk of complications from the procedure.Objective: To check the impact of fentanyl in the intravenous administration of midazolam in order to assess the sedation protocol efficiency on patients undergoing transesophageal echocardiography using both drugs.Methodology: We have studied 201 patients (mean age 51.5 years, 115 men) who underwent transesophageal echocardiography with intravenous sedation divided into two groups: Group A (n = 89), following the protocol with fentanyl associated with midazolam; and Group B (n = 112) without the use of fentanyl. The dose of midazolam administered in both groups was then compared. Proper monitoring of vital signs was performed throughout the procedure.Results: The mean dose of midazolam used was 2.6 ± 1.4 mg in Group A and 4.0 ± 2.7 mg in Group B (p < 0.01). The dose of fentanyl used was 66.2 ± 24.8 mcg. There was no significant difference between age (p = 0.08) and gender (p > 0.1) in the groups studied. Conclusion: The use of fentanyl in sedation for transesophageal echocardiography associated with administration of midazolam allows the administration of a lower dose of this benzodiazepine.

Introducción: El ecocardiograma transesofágico es actualmente una de las principales herramientas en el diagnóstico de diversas alteraciones cardíacas. Para una mayor seguridad y confort en su realización, el examen ha sido realizado bajo sedación conciente moderada, siendo los benzodiazepínicos los agentes de elección. En esa clase de medicamentos, el midazolam es el más utilizado, sin embargo no está exento de posibles complicaciones relacionadas a su uso, como hipoxia, hipotensión, entre otras. Sabemos que grado de sedación es dosis-dependiente, por lo tanto, cuanto menor es la dosis utilizada, será menor el riesgo de complicaciones del procedimiento.Objetivo: Verificar el impacto del uso del fentanil en la administración endovenosa de midazolam, con el propósito de evaluar eficiencia de protocolo de sedación de pacientes sometidos a ecocardiograma transesofágico, utilizando ambos medicamentos.Metodología: Estudiamos 201 pacientes (edad media de 51,5 anos, 115 hombres) sometidos a ecocardiograma transesofágico, con sedación por vía endovenosa divididos en dos grupos: Grupo A (n = 89), siguiendo protocolo definido con uso de fentanil asociado al midazolam; y Grupo B (n = 112), sin el empleo de fentanil. Se comparó entonces el dosaje de midazolam administrada en ambos grupos. Monitoreo adecuado de los signos vitales fue realizada durante todo el procedimiento. Resultados: La dosis media de midazolam utilizada fue de 2,6 ± 1,4 mg en el Grupo A y de 4,0 ± 2,7 mg en el Grupo B (p < 0,01). La dosis de fentanil empleada fue de 66,2 ± 24,8 mcg. No hubo diferencia significativa entre edad (p = 0,08) y género (p > 0,1) en los grupos estudiados. Conclusión: El uso de fentanil en la sedación para realización de ecocardiograma transesofágico asociado a la administración de midazolam permite la administración de una dosis menor de ese benzodiazepínico

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.

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.