Como eu faço avaliação ecocardiográfica de pericardite constritiva / My approach to echocardiographic assessment for constrictive pericarditis

A pericardite constritiva (PC) é uma condição na qual a cicatrização e perda de elasticidade do pericárdio resultam em enchimento ventricular prejudicado, disfunção diastólica e insuficiência cardíaca direita. O diagnóstico dessa patologia é desafiador, sendo frequente a necessidade de técnicas de imagem multimodal, dentre as quais a ecocardiografia representa a modalidade de imagem inicial para a avaliação diagnóstica, além de permitir a diferenciação da PC da cardiomiopatia restritiva (CMR) e outras condições que mimetizam constrição. (AU)

Constrictive pericarditis (CP) is a condition in which scarring and loss of elasticity of the pericardium result in impaired ventricular filling, diastolic dysfunction, and right heart failure. The diagnosis of this pathology is challenging, with frequent need for multimodal imaging techniques, among which echocardiography represents the initial imaging modality for the diagnostic evaluation, in addition to allowing the differentiation of CP from restrictive cardiomyopathy (RCM) and other conditions that mimic constriction. (AU)

Epicardial Fat Tissue Thickness and Omentin in Patients with Atrial Fibrillation

Abstract Background: Although electrical and structural remodeling has been recognized to be important in the pathophysiology of atrial fibrillation, the mechanisms underlying remodeling process are unknown. There has been increasing interest in the involvement of inflammatory molecules and adipokines released from the epicardial fat tissue in the pathophysiology of atrial fibrillation. Objectives: In our study, we aimed to investigate the relationship of atrial fibrillation with increased epicardial adipose tissue, inflammatory molecules released from this tissue and omentin. Methods: Thirty-six patients who were followed up with a diagnosis of permanent AF at the cardiology outpatient clinic 33 individuals without atrial fibrillation (controls) were included in the study. Epicardial adipose tissue thickness of patients was measured by echocardiography. Serum omentin, IL 6, IL 1 beta, TNF alpha and CRP levels were measured. Man-Whitney U test was performed for comparisons and significance was established at 5% (p<0.05). Results: Epicardial adipose tissue thickness was significantly greater in the patient group (6mm [4-5.5]) than controls (4mm [3-5.5]) (p <0.001). No significant difference was found in the concentrations of omentin or inflammatory molecules between the groups. Conclusion: No relationship was found between atrial fibrillation and serum levels or omentin or inflammatory markers. A relationship between epicardial adipose tissue thickness measured by echocardiography and atrial fibrillation was determined.

Deep learning segmentation and quantification method for assessing epicardial adipose tissue in CT calcium score scans.

Epicardial adipose tissue volume (EAT) has been linked to coronary artery disease and the risk of major adverse cardiac events. As manual quantification of EAT is time-consuming, requires specialized training, and is prone to human error, we developed a deep learning method (DeepFat) for the automatic assessment of EAT on non-contrast low-dose CT calcium score images. Our DeepFat intuitively segmented the tissue enclosed by the pericardial sac on axial slices, using two preprocessing steps. First, we applied a HU-attention-window with a window/level 350/40-HU to draw attention to the sac and reduce numerical errors. Second, we applied a novel look ahead slab-of-slices with bisection ("bisect") in which we split the heart into halves and sequenced the lower half from bottom-to-middle and the upper half from top-to-middle, thereby presenting an always increasing curvature of the sac to the network. EAT volume was obtained by thresholding voxels within the sac in the fat window (- 190/- 30-HU). Compared to manual segmentation, our algorithm gave excellent results with volume Dice = 88.52% ± 3.3, slice Dice = 87.70% ± 7.5, EAT error = 0.5% ± 8.1, and R = 98.52% (p < 0.001). HU-attention-window and bisect improved Dice volume scores by 0.49% and 3.2% absolute, respectively. Variability between analysts was comparable to variability with DeepFat. Results compared favorably to those of previous publications.

Epicardial course of the musculature related to the great cardiac vein: Anatomical considerations and clinical implications for mitral isthmus block after vein of Marshall ethanol infusion.

BACKGROUND: Mitral isthmus gaps have been ascribed to an epicardial musculature anatomically related to the great cardiac vein (GCV) and the vein of Marshall (VOM). Their lumen offers an access for radiofrequency application or ethanol infusion, respectively. OBJECTIVE: The purpose of this study was to evaluate the frequency of mitral isthmus gaps accessible via the GCV lumen, to assess their location around the GCV circumference, and to propose an efficient ablation strategy when present. METHODS: One hundred consecutive patients underwent VOM ethanol infusion (step 1) and endocardial linear ablation from the mitral annulus to the left inferior pulmonary vein (step 2). In cases of mitral isthmus gap, endovascular ablation of the GCV anchored wall facing the left atrium was systematically performed (step 3), while the opposite GCV free wall was targeted in case of block failure only (step 4). RESULTS: After VOM ethanol infusion and endocardial ablation, mitral isthmus block occurred in 51 patients (51%). Pacing maneuvers and activation sequences demonstrated an epicardial gap via the VOM in 2 patients (2%) and via the GCV in 47 patients (47%). In the latter case, block was achieved at the GCV anchored wall in 42 patients (89%) and the GCV free wall in 5 patients (11%). Global success rate of mitral isthmus block was 98%. No tamponade occurred. CONCLUSION: With the advent of VOM ethanol infusion, residual mitral isthmus gaps are mostly eliminated within the first centimeter of the GCV. Thorough mapping of the entire circumference of the GCV wall can help identify these epicardial gaps.

Hemopericardium in the acute clinical setting: Are we ready for a tailored management approach on the basis of MDCT findings?

The clinical spectrum of pericardial effusions varies from innocuous serous fluid to life-threatening hemopericardium. A misdiagnosis may be made by similar clinical presentation of acute chest pain/hypotension. Echocardiography is the first-line test for diagnosis of pericardial effusion and its etiology, but sometimes there are different drawbacks to the correct cardiovascular ultrasound diagnosis. Radiologists are reporting an increasing amount of thoracic Multidetector CT examinations at the emergency department. Multidetector CT has now become an established and complementary method for cardiac imaging, and diseases of the pericardium can now be quickly identified with increasing certainty. The aim of this review is to discuss the hemopericardium key Multidetector CT features in acute clinical setting which indicate the need to proceed with predominantly medical or surgical treatment, however, being able to identify forms of bleeding pericardial effusion for which only "a watch and wait strategy" and/or deferred treatment is indicated. In the emergency care setting, radiologists must be aware of different findings of hemopericardium in order to address a tailored and timely management approach.

Anatomy of the Pericardial Space.

The pericardial cavity and its boundaries are formed by the reflections of the visceral and parietal pericardial layers. This space is an integral access point for epicardial interventions. As the pericardial layers reflect over the great vessels and the heart, they form sinuses and recesses, which restrict catheter movement. The epicardial vasculature is also important when performing nearby catheter ablation. The phrenic nerve and esophagus are other important structures to appreciate so as to avoid collateral injury. In addition, the Larrey space, or left sternocostal triangle, is a key avascular window through which pericardial access can be safely achieved.

Percutaneous Epicardial Ablation of Atrial Fibrillation.

The observations afforded by epicardial mapping have not only increased the appreciation of distinct epicardial structures in the left atrium but also underscore the need to address the substrate transmurally. Although epicardial access and ablation have attendant risks, comparative studies with hybrid surgical approaches are lacking. In the search to find unifying mechanisms of atrial fibrillation, a conceptual shift that emphasizes the substrate in 3 dimensions, with the epicardium distinct from the endocardium, holds promise for future investigation and evolving therapeutic tools.

Pericardial adipose tissue is an independent risk factor of coronary artery disease and is associated with risk factors of coronary artery disease.

OBJECTIVE: Pericardial adipose tissue volume (PATV) is related to the mechanism of coronary artery disease (CAD), but its association with CAD risk factors is not clear. This study aimed to investigate the relationships between PATV and its associated factors. METHODS: A total of 682 inpatients were consecutively enrolled in this study. Patients were divided into the high PATV group (PATV ≥174.5 cm3; n = 506) and low PATV group (PATV < 174.5 cm3; n = 176). Multiple linear regression analysis was conducted to evaluate the related factors of PATV. Multivariable logistic regression was used to analyze the risk factors of CAD. RESULTS: Left ventricular fat volume, right ventricular fat volume, body mass index, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol were significant and independent risk factors of enlargement of PATV. Increased PATV was identified as an independent risk factor of CAD, and increased pulse pressure was also independently and positively correlated with CAD. CONCLUSIONS: PATV is significantly correlated with the classic risk factors of CAD. Pulse pressure is also correlated with PATV. PATV is an independent risk factor of CAD, and pericardial adipose tissue may alternatively be used in non-invasive diagnostic examination of CAD.

Histological study on the heart ventricle of Egyptian bovines (Bos aegyptiacus).

Background: The heart ventricles have thicker walls than atrium as they pump blood through blood vessels into all body organs. Aim: This study aimed to describe the histological changes of the heart ventricles in Egyptian bovine (Bos aegyptiacus) with special reference to Purkinje fibers. Methods: A total of 10 male Egyptian bovines of 1-10 years old were divided into three groups according to age; immature, mature, and adult animals. Results: The histological sections from all examined animals' groups revealed three different layers of the wall of both right and left ventricles; endocardium, myocardium, and epicardium. The endocardium was lined with endothelium and filled with fibrous connective tissue. The endocardium of adult bovine was the thickest. Purkinje fibers appeared of pale cytoplasm with few myofibrils. They were present in the deep layer of the endocardium and in the myocardium. The size of Purkinje fibers and the amount of their myofibrils appeared to be increased with advanced age. Bundles of cardiac muscles were the main constituent of the myocardium. The myocardial bundles were separated by fine connective tissue in immature animals that showed an increased amount in the adult animals. The hypereosinophilic cardiac muscle cells were observed in the ventricles of both mature and adult animals suggesting hypercontraction during rigor mortis. An external layer of the ventricles was the epicardium which consisted of connective tissue and covered with mesothelium. Conclusion: Overall, this study revealed histological changes in the wall of the ventricle and Purkinje fibers of Egyptian bovines (B. aegyptiacus) in relation to age. Additionally, the hypereosinophilia of the cardiac muscle cells was recorded in the ventricles of mature and adult bovines.

Anatomic Considerations for Epicardial and Endocardial Left Atrial Appendage Closure.

Left atrial appendage closure is an increasingly used means of achieving thromboprophylaxis in atrial fibrillation, particularly in patients with contraindications to anticoagulation. Left atrial appendage anatomy is highly variable, and preprocedural imaging is critical to choosing the correct device and approach for left atrial appendage closure. This article reviews the common endocardial and epicardial closure systems, including anatomic considerations, advantages and disadvantages, as well as complications to be avoided.

Epicardial fat thickness is increased and associated with disease severity in hidradenitis suppurativa.

Previous studies showed an association between various dermatological diseases and epicardial fat thickness (EFT). However, EFT, which has been accepted as a cardiometabolic risk factor in recent years, has not been studied in the context of hidradenitis suppurativa (HS). Therefore, we aimed to determine whether EFT is increased in HS patients, and whether EFT is associated with disease severity. Forty adult patients with HS and 100 age- and sex-matched controls were included. Patients with diabetes mellitus, cardiovascular diseases, chronic renal or hepatic diseases, or other inflammatory conditions were excluded. The EFT was measured by transthoracic echocardiography. Disease severity was assessed by Hurley stage, and stage III patients have been described as having severe disease. High-sensitivity C-reactive protein (hs-CRP) and EFT were significantly higher in HS patients compared to controls. There were positive correlations between EFT and the duration of the disease, hs-CRP, and Hurley stage. The EFT was proportionally increased in HS patients with increasing disease severity; the largest EFT was found in Hurley stage 3 patients (7.34 ± 2.30 mm), followed by Hurley stage 2 patients (6.12 ± 1.82 mm), and Hurley stage 1 patients (4.83 ± 0.98 mm). Multivariate analysis showed that male gender, hs-CRP, body mass index, and EFT ≥ 5.9 mm were independent predictors of severe disease. The EFT is increased in HS, and it is an independent predictor of disease severity in adult patients with HS.

When and why was the phrenicoabdominal branch of the left phrenic nerve placed into the esophageal hiatus in German textbooks of anatomy? An anatomical study on 400 specimens reevaluating its course through the diaphragm.

BACKGROUND: The phrenicoabdominal branch of the left phrenic nerve passes between muscle fiber bundles within the costal part of the diaphragm near the pericardium. In most German textbooks of anatomy, however, its passage is described to be found in the esophageal hiatus. The aim of this study was to reevaluate its topography relative to the diaphragm in a multicentric study and to identify the initiation of this description. METHODS: In this multicentric study, the most dorsomedial branch of the left phrenic nerve was identified as the phrenicoabdominal branch in 400 embalmed anatomic specimens of Caucasian origin. The distance between its passage and the apex of the pericardium, the left border of the esophageal hiatus, and the inner aspect of the left sixth rib was measured on the cranial aspect of the diaphragm. Textbooks on human anatomy published in German language between 1700 and 2018 were reviewed for their description of the passage of the left phrenicoabdominal branch through the diaphragm. RESULTS: The first statement on the passage of the left phrenicoabdominal branch through the esophageal hiatus was given in 1791 by Sömmering. Since then, in German textbooks of anatomy, a duality in the description of the passage of the left phrenicoabdominal branch persists. In none of the individuals examined in this study, the left phrenicoabdominal branch passed through the esophageal hiatus. In 99.5% of all cases, it pierced the costal part of the diaphragm dorsal to or at the same level as the apex of the pericardium. The mean distances (standard deviations) were 3.4 (±1.5) cm to the apex of the pericardium, 5.8 (±2.2) cm to the esophageal hiatus, and 5.5 (±1.6) cm to the inner aspect of the left sixth rib. CONCLUSION: The findings on the position of the left phrenicoabdominal branch relative to the diaphragm help to improve topographical knowledge and prevent inadvertent nerve injury during surgical interventions on or near the diaphragm. Further to this, these results may form a substantial basis to adopt the correct description of the passage of the left phrenicoabdominal branch to anatomical textbook knowledge.

Epicardial adipose tissue volume and annexin A2/fetuin-A signalling are linked to coronary calcification in advanced coronary artery disease: Computed tomography and proteomic biomarkers from the EPICHEART study.

BACKGROUND & AIMS: The role of epicardial adipose tissue (EAT) in the pathophysiology of late stage-coronary artery disease (CAD) has not been investigated. We explored the association of EAT volume and its proteome with advanced coronary atherosclerosis. METHODS: The EPICHEART Study prospectively enrolled 574 severe aortic stenosis patients referred to cardiac surgery. Before surgery, EAT volume was quantified by computed tomography (CT). During surgery, epicardial, mediastinal (MAT) and subcutaneous (SAT) adipose tissue samples were collected to explore fat phenotype by analyzing the proteomic profile using SWATH-mass spectrometry; pericardial fluid and peripheral venous blood were also collected. CAD presence was defined as coronary artery stenosis ≥50% in invasive angiography and by CT-derived Agatston coronary calcium score (CCS). RESULTS: EAT volume adjusted for body fat was associated with higher CCS, but not with the presence of coronary stenosis. In comparison with mediastinal and subcutaneous fat depots, EAT exhibited a pro-calcifying proteomic profile in patients with CAD characterized by upregulation of annexin-A2 and downregulation of fetuin-A; annexin-A2 protein levels in EAT samples were also positively correlated with CCS. We confirmed that the annexin-A2 gene was overexpressed in EAT samples of CAD patients and positively correlated with CCS. Fetuin-A gene was not detected in EAT samples, but systemic fetuin-A was higher in CAD than in non-CAD patients, suggesting that fetuin-A was locally downregulated. CONCLUSIONS: In an elderly cohort of stable patients, CCS was associated with EAT volume and annexin-A2/fetuin-A signaling, suggesting that EAT might orchestrate pro-calcifying conditions in the late phases of CAD.

Anatomically correct assessment of the orientation of the cardiomyocytes using diffusion tensor imaging.

Diffusion tensor imaging has been used for assessing the orientation of cardiac myocytes for decades. Striking methodological differences exist between studies when quantifying these orientations. This limits the comparability between studies, and impedes collaboration and the drawing of appropriate physiological conclusions. We have sought to elucidate these differences, permitting us to propose a standardised "tool set" that might better establish consensus in future studies. We fixed hearts from seven 25 kg pigs in formalin, and scanned them using diffusion tensor imaging. Using various angle definitions as found in literature, we assessed the orientations of cardiomyocytes, comparing them in terms of helical and intrusion angles, along with the orientation of their aggregations. The difference between assessment of the helical angle with and without relation to the epicardial curvature was 25.2° (SD: 7.9) at the base, 5.8° (1.9) at the equatorial level, and 28.0° (7.0) at the apex, ANOVA P = 0.001. In comparable fashion, the intrusion angle differed by 25.9° (12.9), 7.6° (0.98) and 17.5° (4.7), P = 0.01, and the angle of the aggregates (E3-angle) differed by 25.0° (13.5) at the base, 9.4° (1.7) at the equator, and 23.1° (6.2) apically, P = 0.003. When assessing 14 definitions used in literature to calculate the orientation of aggregates, only 4 rendered identical results. The findings show that any attempt to use projection of eigenvectors introduces considerable bias. The epicardial curvature of the ventricular cone needs to be taken into account when seeking to provide accurate quantification of the orientation of the aggregated cardiomyocytes, especially in the apical and basal regions. This means that projection of eigenvectors should be avoided prior to quantifying myocyte orientation, especially when assessing radial orientation. Based on our results, we suggest appropriate methods for valid assessment of myocyte orientation using diffusion tensor imaging.

The relationship of circulating fibroblast growth factor 21 levels with pericardial fat: The Multi-Ethnic Study of Atherosclerosis.

Previous small studies have reported an association between circulating fibroblast growth factor 21 (FGF21) levels and pericardial fat volume in post-menopausal women and high cardiovascular disease (CVD) risk patients. In this study, we investigated the relationship of FGF21 levels with pericardial fat volume in participants free of clinical CVD at baseline. We analysed data from 5765 men and women from the Multi-Ethnic Study of Atherosclerosis (MESA) with both pericardial fat volume and plasma FGF21 levels measured at baseline. 4746 participants had pericardial fat volume measured in at least one follow-up exam. After adjusting for confounding factors, ln-transformed FGF21 levels were positively associated with pericardial fat volume at baseline (ß = 0.055, p < 0.001). When assessing change in pericardial fat volume over a mean duration of 3.0 years using a linear mixed-effects model, higher baseline FGF21 levels were associated with higher pericardial fat volume at baseline (2.381 cm3 larger in pericardial fat volume per one SD increase in ln-transformed FGF21 levels), but less pericardial fat accumulation over time (0.191 cm3/year lower per one SD increase in ln-transformed FGF21 levels). Cross-sectionally, higher plasma FGF21 levels were significantly associated with higher pericardial fat volume, independent of traditional CVD risk factors and inflammatory markers. However, higher FGF21 levels tended to be associated with less pericardial fat accumulation over time. Nevertheless, such change in pericardial fat volume is very modest and could be due to measurement error. Further studies are needed to elucidate the longitudinal relationship of baseline FGF21 levels with pericardial fat accumulation.

Statins Reduce Epicardial Adipose Tissue Attenuation Independent of Lipid Lowering: A Potential Pleiotropic Effect.

Background High epicardial adipose tissue (EAT) attenuation (Hounsfield units [ HUs] ) on computed tomography is considered a marker of inflammation and is associated with an increased risk of cardiovascular events. Statins reduce the volume of EAT , but it is unknown whether they affect EAT HUs . Methods and Results We reviewed the chest computed tomographic scans of 420 postmenopausal women randomized to either 80 mg of atorvastatin or 40 mg of pravastatin daily and rescanned after 1 year to measure change in coronary artery calcium score. EAT HUs were measured near the proximal right coronary artery and remote from any area of coronary artery calcium. Computed tomographic images were also queried for subcutaneous adipose tissue (SubQ) attenuation ( HUs ) change over time. The mean patients' age was 65±6 years. The baseline EAT HU value was higher than the SubQ HU value (-89.4±24.0 HU versus -123.3±30.4 HU ; P<0.001). The EAT HU value decreased significantly in the entire cohort (-5.4±29.7 HU [-6% change]; P<0.001), but equally in the patients given atorvastatin and pravastatin (-6.35+31 HU and -4.55+28 HU ; P=0.55). EAT HU change was not associated with change in total cholesterol, low-density lipoprotein cholesterol, coronary artery calcium, and EAT volume (all P=not significant). Change in high-density lipoprotein cholesterol was marginally associated with EAT HU change ( P=0.07). Statin treatment did not induce a change in SubQ HUs . Conclusions Statins induced a decrease in EAT HUs over time, independent of intensity of low-density lipoprotein cholesterol lowering. The positive effect on EAT and the neutral effect on SubQ suggest that statins induced a decrease in metabolic activity in EAT by reduction in cellularity, vascularity, or inflammation. The clinical significance of the observed change in EAT HUs remains to be demonstrated.

Association between epicardial fat thickness and cognitive function in elderly. A preliminary study.

BACKGROUND: Recent studies suggested that the visceral fat could exert a predictive role in the pathogenesis of dementia. The aims of the present study were to evaluate: i) possible differences between groups with different epicardial adipose tissue (EAT) thickness on the included variables; ii) the possible predictive role of the EAT levels on cognitive functioning. METHODS: 65 community-dwelling subjects were enrolled and divided into two groups: EAT < 7 mm (n = 36); EAT > 7 mm (n = 29). The metabolic profile was assessed through the evaluation of the biochemical parameters whereas the EAT thickness was measured through the transthoracic echocardiography. The Mini Mental State Examination (MMSE) was also administered. RESULTS: The two EAT groups reported several significant differences, included on the MMSE scores. The multiple linear regression analysis showed that the EAT thickness levels and the hypertension had a predictive effect on the MMSE scores. CONCLUSIONS: These preliminary findings support the association between EAT thickness levels and cognitive impairment.

Epicardial fat thickness is significantly increased and related to LDL cholesterol level in patients with familial hypercholesterolemia.

PURPOSE: Increased epicardial fat thickness (EFT) is accepted as a risk factfcardiovascular diseases in some studies. There are conflicting results about the relation between plasma low-density lipoprotein cholesterol (LDL-C) level and EFT. As well, the relation between EFT and familial hypercholesterolemia is not clearly documented in the literature. Our aim was to investigate EFT in familial hypercholesterolemia patients and to determine which parameters were related to EFT increase. METHODS: A total of 150 subjects enrolled in our study. Subjects were separated into two groups: 75 hypercholesterolemia patients (16 men, mean age 52.8 ± 7.4 years) and 75 familial hypercholesterolemia patients (26 men, mean age 50.7 ± 9.2 years). Medical history assessments and complete physical examinations were done. Routine laboratory tests and echocardiographic measurements were performed. RESULTS: Coronary artery disease frequency was significantly higher in the familial hypercholesterolemia group (p < 0.001). This group had significantly higher TC and LDL-C levels than the hypercholesterolemia group (p < 0.05 for all). EFT values were higher in the familial hypercholesterolemia group, and were significantly different than in the other group (p < 0.001). LDL-C was found to be independently related to EFT in the linear regression analysis. CONCLUSIONS: Epicardial fat thickness increased in the familial hypercholesterolemia patients. In addition, LDL-C levels were significantly crelated with increased EFT.

The transverse and oblique sinuses of the pericardium: Anatomic and echocardiographic insights.

A number of masses and pseudomasses may be encountered during the echocardiographic examination of the transverse and oblique sinuses with significant clinical implications. This review discusses the clinically relevant anatomy of the pericardial sinuses emphasizing diagnostic pitfalls that may be encountered during their echocardiographic examination.