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.

Right Ventricular Systolic Function After the Cone Procedure for Ebstein's Anomaly: Comparison Between Echocardiography and Cardiac Magnetic Resonance.

Although the Cone procedure has improved outcomes for patients with Ebstein´s anomaly (EA), neither RV systolic function recovery in long-term follow-up nor the best echocardiographic parameters to assess RV function are well established. Thus, we evaluated RV performance after the Cone procedure comparing two-dimensional (2DEcho) and three-dimensional (3DEcho) echocardiography to cardiac magnetic resonance (CMR). We assessed 27 EA patients after the Cone procedure (53% female, median age of 20 years at the procedure, median post-operative follow-up duration of 8 years). Echocardiography was performed 4 h apart from the CMR. RV global longitudinal strain (GLS), fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE), myocardial performance index and tissue Doppler S' velocity were assessed using 2DEcho, whereas 3DEcho was used to evaluate RV volumes and ejection fraction (RVEF). Echocardiographic variables were compared to CMR-RVEF. All patients were in the NYHA functional class I. Median TAPSE was 15.9 mm, FAC 30.2%, and RV-GLS -15%; median RVEF by 3DEcho was 31.9% and 43% by CMR. Among 2DEcho parameters, RV-GLS and FAC had a substantial correlation with CMR-RVEF (r = - 0.63 and r = 0.55, respectively); from 3DEcho, the indexed RV volumes and RVEF were closely correlated with CMR (RV-EDVi, r = 0.60, RV-ESVi, r = 0.72; and RVEF r = 0.60). RV systolic function is impaired years after the Cone procedure, despite a good clinical status. FAC and RV-GLS are useful 2DEcho tools to assess RV function in these patients; however, 3DEcho measurements appear to provide a better RV assessment.

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.

Left Atrial Volume Determinants in Patients with Non-Ischemic Dilated Cardiomyopathy / Determinantes do Volume do Átrio Esquerdo em Pacientes com Cardiomiopatia Dilatada Não Isquêmica

Left atrial volume (LAV) is a predictor of prognosis in patients with heart failure.

O Volume do Átrio Esquerdo (VAE) é preditor prognóstico em pacientes com insuficiência cardíaca.

Left Atrial Volume Determinants in Patients with Non-Ischemic Dilated Cardiomyopathy.

BACKGROUND: Left atrial volume (LAV) is a predictor of prognosis in patients with heart failure. OBJECTIVE: We aimed to evaluate the determinants of LAV in patients with dilated cardiomyopathy (DCM). METHODS: Ninety patients with DCM and left ventricular (LV) ejection fraction ≤ 0.50 were included. LAV was measured with real-time three-dimensional echocardiography (eco3D). The variables evaluated were heart rate, systolic blood pressure, LV end-diastolic volume and end-systolic volume and ejection fraction (eco3D), mitral inflow E wave, tissue Doppler e' wave, E/e' ratio, intraventricular dyssynchrony, 3D dyssynchrony index and mitral regurgitation vena contracta. Pearson's coefficient was used to identify the correlation of the LAV with the assessed variables. A multiple linear regression model was developed that included LAV as the dependent variable and the variables correlated with it as the predictive variables. RESULTS: Mean age was 52 ± 11 years-old, LV ejection fraction: 31.5 ± 8.0% (16-50%) and LAV: 39.2±15.7 ml/m2. The variables that correlated with the LAV were LV end-diastolic volume (r = 0.38; p < 0.01), LV end-systolic volume (r = 0.43; p < 0.001), LV ejection fraction (r = -0.36; p < 0.01), E wave (r = 0.50; p < 0.01), E/e' ratio (r = 0.51; p < 0.01) and mitral regurgitation (r = 0.53; p < 0.01). A multivariate analysis identified the E/e' ratio (p = 0.02) and mitral regurgitation (p = 0.02) as the only independent variables associated with LAV increase. CONCLUSION: The LAV is independently determined by LV filling pressures (E/e' ratio) and mitral regurgitation in DCM.

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)

Simplified single plane echocardiography is comparable to conventional biplane two-dimensional echocardiography in the evaluation of left atrial volume: a study validated by three-dimensional echocardiography in 143 individuals.

The left atrial volume index (LAVI) is a biomarker of diastolic dysfunction and a predictor of cardiovascular events. Three-dimensional echocardiography (3DE) is highly accurate for LAVI measurements but is not widely available. Furthermore, biplane two-dimensional echocardiography (B2DE) may occasionally not be feasible due to a suboptimal two-chamber apical view. Simplified single plane two-dimensional echocardiography (S2DE) could overcome these limitations. We aimed to compare the reliability of S2DE with other validated echocardiographic methods in the measurement of the LAVI. We examined 143 individuals (54 ± 13 years old; 112 with heart disease and 31 healthy volunteers; all with sinus rhythm, with a wide range of LAVI). The results for all the individuals were compared with B2DE-derived LAVIs and validated using 3DE. The LAVIs, as determined using S2DE (32.7 ± 13.1 mL/m(2)), B2DE (31.9 ± 12.7 mL/m(2)), and 3DE (33.1 ± 13.4 mL/m(2)), were not significantly different from each other (P = 0.85). The S2DE-derived LAVIs correlated significantly with those obtained using both B2DE (r = 0.98; P < 0.001) and 3DE (r = 0.93; P < 0.001). The mean difference between the S2DE and B2DE measurements was <1.0 mL/m(2). Using the American Society of Echocardiography criteria for grading LAVI enlargement (normal, mild, moderate, severe), we observed an excellent agreement between the S2DE- and B2DE-derived classifications (κ = 0.89; P < 0.001). S2DE is a simple, rapid, and reliable method for LAVI measurement that may expand the use of this important biomarker in routine echocardiographic practice.

Os critérios para classificação da insuficiência mitral não foram adequados na cardiomiopatia dilatada / Criteria for mitral regurgitation classification were inadequate for dilated cardiomyopathy

FUNDAMENTO: A insuficiência mitral (IM) é frequente nos pacientes com cardiomiopatia dilatada. Não se sabe se os critérios para classificação da IM são adequados para pacientes com cardiomiopatia dilatada OBJETIVO: Avaliar a concordância entre os quatro métodos ecocardiográficos mais utilizados para classificação da IM. MÉTODOS: Noventa pacientes com cardiomiopatia dilatada foram incluídos. A IM foi classificada por quatro métodos ecocardiográficos: área do jato regurgitante (AJ), vena contracta (VC), área do orifício regurgitante (AOR) e volume regurgitante (VR). A IM foi classificada em leve, moderada ou importante segundo os critérios da American Society of Echocardiography e também foi dividida em tercis conforme os valores absolutos. O teste de Kappa foi utilizado para avaliar a concordância entre os métodos. O coeficiente de Pearson foi utilizado para avaliar a correlação entre os valores absolutos por cada método. RESULTADOS: A classificação da IM, de acordo com cada método, foi a seguinte: AJ: 26 leve, 44 moderada, 20 importante; VC: 12 leve, 72 moderada, 6 importante; AOR: 70 leve, 15 moderada, 5 importante; VR: 70 leve, 16 moderada, 4 importante. A concordância entre os métodos foi ruim (kappa = 0,11; p < 0,001), porém foi observada uma forte correlação entre os valores absolutos de cada método (0,70 a 0,95; p < 0,01). A concordância foi melhor com a divisão dos valores em tercis (kappa = 0,44; p < 0,01). CONCLUSÃO: Os critérios para classificação da IM não são adequados para os pacientes com cardiomiopatia dilatada. É necessário estabelecer novos valores de corte para classificar a IM nestes pacientes.

BACKGROUND: Mitral regurgitation (MR) is common in patients with dilated cardiomyopathy (DCM). It is unknown whether the criteria for MR classification are inadequate for patients with DCM. OBJECTIVE: We aimed to evaluate the agreement among the four most common echocardiographic methods for MR classification. METHODS: Ninety patients with DCM were included. Functional MR was classified using four echocardiographic methods: color flow jet area (JA), vena contracta (VC), effective regurgitant orifice area (ERO) and regurgitant volume (RV). MR was classified as mild, moderate or important according to the American Society of Echocardiography criteria and by dividing the values into terciles. The Kappa test was used to evaluate whether the methods agreed, and the Pearson correlation coefficient was used to evaluate the correlation between the absolute values of each method. RESULTS: MR classification according to each method was as follows: JA: 26 mild, 44 moderate, 20 important; VC: 12 mild, 72 moderate, 6 important; ERO: 70 mild, 15 moderate, 5 important; RV: 70 mild, 16 moderate, 4 important. The agreement was poor among methods (kappa=0.11; p<0.001). It was observed a strong correlation between the absolute values of each method, ranging from 0.70 to 0.95 (p<0.01) and the agreement was higher when values were divided into terciles (kappa = 0.44; p < 0.01) CONCLUSION: The use of conventional echocardiographic criteria for MR classification seems inadequate in patients with DCM. It is necessary to establish new cutoff values for MR classification in these patients.

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.

Criteria for mitral regurgitation classification were inadequate for dilated cardiomyopathy.

BACKGROUND: Mitral regurgitation (MR) is common in patients with dilated cardiomyopathy (DCM). It is unknown whether the criteria for MR classification are inadequate for patients with DCM. OBJECTIVE: We aimed to evaluate the agreement among the four most common echocardiographic methods for MR classification. METHODS: Ninety patients with DCM were included. Functional MR was classified using four echocardiographic methods: color flow jet area (JA), vena contracta (VC), effective regurgitant orifice area (ERO) and regurgitant volume (RV). MR was classified as mild, moderate or important according to the American Society of Echocardiography criteria and by dividing the values into terciles. The Kappa test was used to evaluate whether the methods agreed, and the Pearson correlation coefficient was used to evaluate the correlation between the absolute values of each method. RESULTS: MR classification according to each method was as follows: JA: 26 mild, 44 moderate, 20 important; VC: 12 mild, 72 moderate, 6 important; ERO: 70 mild, 15 moderate, 5 important; RV: 70 mild, 16 moderate, 4 important. The agreement was poor among methods (kappa=0.11; p<0.001). It was observed a strong correlation between the absolute values of each method, ranging from 0.70 to 0.95 (p<0.01) and the agreement was higher when values were divided into terciles (kappa = 0.44; p < 0.01) CONCLUSION: The use of conventional echocardiographic criteria for MR classification seems inadequate in patients with DCM. It is necessary to establish new cutoff values for MR classification in these patients.

Avaliação prognóstica do tromboembolismo pulmonar por ecocardiograma com Doppler tecidual e peptídeo atrial natriurético tipo B / Assessing prognosis of pulmonary embolism using tissue-Doppler echocardiography and brain natriuretic peptide

OBJETIVO: Avaliar o prognóstico do tromboembolismo pulmonar usando o ecocardiograma com Doppler tecidual e o peptídeo atrial natriurético. MÉTODOS: Pacientes com idade acima de 18 anos foram avaliados pelo ecocardiograma bidimensional e Doppler tecidual para medidas das velocidades miocárdicas (s'), strain e índice de performance miocárdica do ventrículo direito até 24 horas da confirmação diagnóstica do tromboembolismo pulmonar (tomografia/ cintilografia), sendo também o peptídeo atrial natriurético obtido até 24 horas. A influência das variáveis na mortalidade até 1 ano foi testada pela regressão de Cox. RESULTADOS: Dos 118 pacientes estudados, 100 foram incluídos, sendo 60 homens, com idade de 55±17 anos. Pelo ecocardiograma bidimensional, 28% dos pacientes apresentavam disfunção do ventrículo direito. As medidas da onda s', strain e deslocamento estiveram diminuídas para tais pacientes, que apresentavam, ainda, índice de performance miocárdica e pressão sistólica pulmonar aumentados. O peptídeo atrial natriurético médio foi de 66±111pg/mL, sendo 136±146pg/mL para pacientes com disfunção do ventrículo direito. A mortalidade foi 11% e pela análise univariada, relacionada à idade, neoplasia e peptídeo atrial natriurético. Entre as variáveis ecocardiográficas, somente a onda s' do Doppler tecidual e a pressão pulmonar associaram-se à maior mortalidade. Pela análise multivariada, entretanto, a presença de neoplasia foi o único preditor de óbito. CONCLUSÃO: Velocidades miocárdicas diminuídas e peptídeo atrial natriurético elevado estão associados a pior prognóstico em pacientes com tromboembolismo pulmonar, mas, nessa população, somente a presença de neoplasia foi capaz de predizer a mortalidade de maneira independente.

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.

Calcificação caseosa do anel mitral: relato de caso / Caseous calcification of the mitral annulus: case report

Relatamos um caso raro de provável calcificação caseosa do anel mitral. Essa patologia é mais frequentemente encontrada em mulheres assintomáticas e com idade acima de 70 anos. O reconhecimento dessa imagem é importante, primeiramente devido à ecocardiografia ser a forma mais fácil para elucidação diagnóstica e também por ela ser comumente confundida com outras massas, como tumores, trombos e vegetações, entidades mais comuns. Habitualmente, apresenta evolução benigna e seu correto diagnóstico é fundamental para evitar intervenções cirúrgicas desnecessárias.

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.

Estudo piloto com Eco 3D das modificações geométricas do VE após infarto do miocárdio / 3D Echo pilot study of geometric Left Ventricular changes after acute myocardial infarction

FUNDAMENTO: Remodelamento ventricular esquerdo (RVE) após IAM caracteriza fator de mau prognóstico. Há pouca informação na literatura sobre o RVE analisado com ecocardiografia tridimensional (ECO 3D) OBJETIVO: Analisar com ECO 3D as modificações geométricas e volumétricas do ventrículo esquerdo (VE) seis meses após IAM em pacientes submetidos a tratamento primário percutâneo. MÉTODOS: Estudo prospectivo com ECO 3D de 21 indivíduos (16 homens, 56 ± 12 anos), acometidos por IAM com elevação do segmento ST. Foi feita a análise morfofuncional (VE) com ECO 3D (volumes, FEVE, índice de esfericidade 3D) até sete dias e seis meses após o IAM. RVE foi considerado para aumento > 15% do volume diastólico final do VE (VDFVE) após seis meses do IAM, comparado ao VDFVE até sete dias do evento. RESULTADOS: Oito (38%) pacientes apresentaram RVE. Medidas ecocardiográficas (n = 21 pacientes): I- até sete dias do IAM: 1- VDFVE: 92,3 ± 22,3 mL; 2- FEVE: 0,51 ± 0,01; 3- índice de esfericidade: 0,38 ± 0,05; II- após seis meses: 1- VDFVE: 107,3 ± 26,8 mL; 2- FEVE: 0,59 ± 0,01; 3- índice de esfericidade: 0,31 ± 0,05. Coeficiente de correlação (r) entre índice de esfericidade até sete dias do IAM e VDFVE aos seis meses (n = 8) após o IAM: r: 0,74, p = 0,0007; (r) entre índice de esfericidade após seis meses do IAM e VDFVE aos seis meses do IAM: r: 0,85, p < 0,0001. CONCLUSÃO: Nesta série, foi observado RVE em 38% dos pacientes seis meses após IAM. O índice de esfericidade tridimensional foi associado à ocorrência de RVE.

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.

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.