Descending aortic mechanics and atrial fibrillation: a two-dimensional speckle tracking transesophageal echocardiography study.

Vascular mechanics assessed with two-dimensional speckle tracking echocardiography (2D-STE) could be used as a new imaging surrogate of vascular stiffening. The CHA2DS2-VASc score is considered accurate as an estimate of stroke risk in non-valvular AF, although many potential stroke risk factors have not been included in this scoring method. The purpose of this research is to study the feasibility of evaluating vascular mechanics at the descending aorta in non-valvular AF patients using transesophageal 2D-STE and to analyze the association between descending aortic mechanics and stroke. We prospectively recruited a group of 44 patients referred for a transesophageal echocardiogram (TEE) in the context of cardioversion for non-valvular AF. A short-axis view of the descending aorta, one to two centimeters after the aortic arch was selected for the vascular mechanics assessment with the 2D-STE methodology. The vascular mechanics parameters analyzed were circumferential aortic strain (CAS) and early circumferential aortic strain rate (CASR). A clinical assessment was performed with focus on the past stroke history and the CHA2DS2-VASc score. The mean age of our cohort was 65 ± 13 years and 75% were men; AF was known for 2.8 ± 2.5 years and it was considered paroxystic in 41% of cases. Waveforms adequate for measuring 2D-STE were present in 85% of the 264 descending aortic wall segments. The mean CAS was 3.5 ± 1.2% and the mean CASR was 0.7 ± 0.3 s-1. The inter- and intra-observer variability for aortic mechanics was considered adequate. The median CHA2DS2VASc score was 2 (2-3). As the score increased we noted that both the CAS (r = -0.38, P = 0.01) and the CASR (r = -0.42, P < 0.01) decreased. Over 16% of the AF patients had a past history of stroke. These patients had lower values of both descending aortic strain [2.2 (1.8-2.6) vs. 3.9 (3.3-4.9)%, P < 0.01] and strain rate [0.4 (0.3-0.4) vs. 0.7 (0.6-1.1) s-1, P < 0.01]. CAS remained independently associated with a past history of stroke after adjustment for the CHA2DS2VASc score. Our data showed that non-valvular AF patients with a past history of stroke had lower values of aortic mechanics assessed with transesophageal 2D-STE.

Possible refinement of clinical thromboembolism assessment in patients with atrial fibrillation using echocardiographic parameters.

AIM: Some transoesophageal echocardiogram (TEE) findings are associated with an increased risk of stroke in patients with atrial fibrillation (AF). This study was designed to evaluate and compare the accuracy of CHADS(2) and CHA(2)DS(2)-VASc in the prediction of these findings and test the additive value of transthoracic echocardiogram (TTE)-derived parameters as a possible refinement for these classifications. METHODS AND RESULTS: Cross-sectional study of 405 consecutive patients who underwent TTE and TEE evaluation during AF. Stroke risk assessment was performed using the CHADS(2) and CHA(2)DS(2)-VASc scores, alone and alongside with the addition of two TTE-derived parameters (left atrium area and left ventricle global systolic function). Comparisons regarding the presence of left atrial appendage thrombi (LAA T), dense spontaneous echo contrast (SEC), and left atrial appendage (LAA) low flow velocities (LFV) were performed using receiver operating characteristic curves. In low-risk patients, as assessed through the CHA(2)DS(2)-VASc score and CHADS(2) and CHA(2)DS(2)-VASc scores plus echo parameters, no high-risk features were found on TEE. In subjects classified as low risk using CHADS(2), this figure rose to 10%. No significant differences were found between CHADS(2) and CHA(2)DS(2)-VASc in the prediction of LAA T, dense SEC, and LAA LFV. The addition of TTE-derived parameters to the previous clinical-risk scores resulted in improved prediction of the TEE endpoints. CONCLUSION: These findings suggest that the use of TTE-derived parameters may be a valuable way of refining the available clinical risk schemes for the detection of surrogate markers of stroke. Follow-up studies using clinical endpoints will be necessary to confirm this hypothesis.

The importance of echocardiography in the diagnosis and treatment of ostium secundum-type atrial septal defect.

Ostium secundum-type atrial septal defect (osASD) is one of the most common congenital heart defects. Treatment of these defects was revolutionized by the introduction of percutaneous closure. Echocardiography has a major role in the evaluation and treatment of this disease. The authors review the role of this imaging technique in diagnosis and in treatment decisions, as well as its advantages in monitoring and follow-up of percutaneous closure. In this context, we present our center's experience with different types of echocardiography, namely transthoracic, transesophageal and intracardiac, in closure of osASD.

Pulmonary hypertension in patients with ostium secundum atrial septal defect--is it related to echocardiographic complexity?

INTRODUCTION: Atrial septal defect (ASD) is one of the most common congenital heart defects. Patients may reach adulthood before being diagnosed and sometimes develop pulmonary hypertension (PH). According to the latest Euro Heart Survey on Congenital Heart Disease, 24.77% of ASD patients develop PH. The reasons for this evolution in only some patients are still unknown. OBJECTIVES: To assess the prevalence of PH in patients with ostium secundum ASD (osASD) in our district and to determine whether the echocardiographic morphology of the defect can be an indicator of evolution to PH. METHODS: The study included 181 consecutive patients, mean age 43.1+/-18.4 years, 65.2% women, with a diagnosis of osASD, referred for transthoracic and transesophageal evaluation in our center from January 2000 to September 2008. We assessed right atrial (RA) and ventricular (RV) dimensions, measured the rims and size of the ASD and determined pulmonary artery systolic pressure (PASP) (RV/RA gradient plus a value corresponding to the degree of inferior vena cava collapse). The type of shunt at the atrial level was assessed with intravenous injection of agitated saline. Statistical analysis was performed using SPSS 15.0. RESULTS: Seventy-seven patients (42.5%) had moderate to severe enlargement of the right heart chambers and 48 (26.5%) had pulmonary hypertension, defined as PASP of over 40 mmHg (equivalent to mean pulmonary artery pressure of 25-30 mmHg). Patients with PH were older (52.8+/-16.9 vs. 39.0+/-17.6 years; p<0.001) and had larger defects (19.7+/-9.6 mm vs. 13.1+/-7.1 mm; p<0.001). The proportion of women was similar in both groups (64.6% in patients with PH vs. 68.75% in those without; p=NS). Most patients with PH had ASDs with more complex shapes on echocardiography. However, some patients with simpler and smaller defects, such as central ASD with a diameter of <5 mm, also developed PH. The prevalence of PH in patients with closed ASDs was much lower: 20.3% vs. 43.75%; p<0.002. CONCLUSIONS: According to these data, development of PH in patients with ASD is frequent and seems to be related to the diameter of the defect. However, patients with smaller and simpler defects may also develop PH. This seems to occur at older ages and not to be gender-dependent. Early ASD closure appears to prevent this.

Valvoplastia mitral percutânea complicada com tamponamento cardíaco em paciente gestante / Percutaneous mitral valvuloplasty complicated by cardiac tamponade in a pregnant patient

A ocorrência de Hemopericárdio com Tamponamento Cardíaco é uma complicação da Valvoplastia Mitral Percutânea por balão (VMB), que apesar de pouco freqüente, pode ter graves conseqüências materno-fetais. Este artigo descreve o caso de um tamponamento cardíaco após VMB em uma mulher de 28 anos, com estenose mitral reumática severa na 20ª semana de gravidez.

The occurrence of hemopericardium with cardiac tamponade is a complication of percutaneous balloon mitral valvuloplasty (BMV) which, although uncommon, may have severe maternal and fetal consequences. This article describes a case of cardiac tamponade following BMV in a 28-year-old woman with severe rheumatic mitral stenosis in the 20th week of gestation.

Aquarium sign in sepsis.

A 91-year-old man appeared in our lab with fever for a transthoracic echocardiography assessment. Highly unusual echo images were found, with a size and movement resembling 'bubbles in an aquarium' in every cardiac chamber, both left and right. The patient died 8 days later, due to a methicillin-resistant Staphylococcus aureus sepsis. These are highly unusual images that should not be confused with microbubbles from contrast agents or radiofrequency ablation, and were previously reported once in association with atrioesophageal fistula.

Echocardiographic assessment of secundum-type atrial septal defects in the adult: role in treatment decisions.

The purpose of this study is to evaluate morphologic patterns of ostium secundum-type atrial septal defects (osASD) in the adult, analyzing their role in treatment decisions. The population was composed of 155 adults (age 43.3 +/- 18.9 years) consecutively diagnosed with osASD in our center, and confirmed by transthoracic and transesophageal echocardiography, between January 2000 and December 2007. Of these, 83 (53.5%) underwent successful percutaneous closure. Surgical closure was used in 31 patients (20.0%). The remaining 42 patients (27.1%) received conservative medical treatment. The mean diameter of the defects was 15.8 +/- 8.5 mm. The prevalence of mitral valve prolapse and severe pulmonary hypertension was also assessed. Based on the criteria in the literature, we detected 14 different morphologic patterns of osASD. There was a central defect in 45/155; 40/155 had a short rim and 20/155 two short rims, 24/155 were multifenestrated and 15/155 PFO-like, and 12/155 had three or more short rims. The different morphologic patterns in each treatment arm, as well as the criteria leading to their inclusion in each, are described. While percutaneously closed defects had a simpler morphology, those that were surgically closed were normally larger and had a more complex shape (with two or more deficient rims or multifenestrated, and thus not suitable for percutaneous closure).

Percutaneous mitral valvuloplasty complicated by cardiac tamponade in a pregnant patient.

The occurrence of hemopericardium with cardiac tamponade is a complication of percutaneous balloon mitral valvuloplasty (BMV) which, although uncommon, may have severe maternal and fetal consequences. This article describes a case of cardiac tamponade following BMV in a 28-year-old woman with severe rheumatic mitral stenosis in the 20th week of gestation.

Coarctaçäo da aorta: a propósito de um caso clínico de difícil diagnóstico / Aortic coarctation: apropos of a clinical case with difficult diagnosis

É descrito um caso clínico, referente a uma criança com 4 anos de idade do sexo masculino, com coarctaçäo da aorta associada a comunicaçäo interventricular de difícil diagnóstico: foi feita uma pequena revisäo teórica da literatura, realçando os métodos de diagnóstico e o momento da intervençäo cirúrgica; atualmente, a maior parte dos autores tem recomendado que a intervençäo seja antes dos 5 anos de idade e que se evitem, na medida do possível, as recoarctaçöes pós-operatórias

Infarto do miocárdio de localizaçäo anterior: valor prognóstico do índice de Gaasch / Myocardial infarction of anterior localization: prognostic value of the Gaasch index

Trinta doentes (28 do sexo masculino), com idade média 55 + ou - 12 anos, com seguimento de 13 a 25 meses (média 20 meses), acometidos de infarto do miocárdio de localizaçäo anterior, anteriormente estudados, foram submetidos a novos ecocardiograma e a reavaliaçäo clínica. Quatro doentes (13,3%) morreram de causa cardíaca (grupo A). Os sobreviventes (83,3%) formaram o grupo B e o foram divididos em sintomáticos (28%-grupo I) e assintomáticos (72%-grupo II). Compararam-se as variáveis ecocardiográficas dos grupos A e B, tendo havido diferenças significativas no que respeita ao índice de Gaasch (IG). A comparaçäo entre os grupos I e II, revelou diferenças estatisticamente significativas em relaçäo ao diâmetro diastólico, à distância E-septo e ao IG. Conclui-se que o IG forneceu a única diferença estatisticamente significativa entre os grupos A e B (p < 0,02), sendo 3,2 um valor discriminativo entre os grupos A e B os grupos I e II (p < 0,001), constituindo uma variável ecocardiográfica com valor prognóstico nos doentes com infarto do miocárdio de localizaçäo anterior, apesar do seguimento ter sido só de 20 meses