Como eu faço a avaliação pós-intervenções tricúspides: dicas e truques / My approach to assessment after tricuspid interventions: tips and tricks

A regurgitação tricúspide (RT) importante está associada à alta morbidade e mortalidade. Como o tratamento cirúrgico da RT isolada tem sido associado à alta mortalidade, as intervenções transcateter na valva tricúspide (VT) têm sido utilizadas para o seu tratamento, com risco relativamente mais baixo. Há um atraso na intervenção da RT e provavelmente está relacionado a uma compreensão limitada da anatomia da VT e do ventrículo direito, além da subestimação da gravidade da RT. Nesse cenário, faz-se necessário o conhecimento anatômico abrangente da VT, a fisiopatologia envolvida no mecanismo de regurgitação, assim como a sua graduação mais precisa. A VT tem peculiaridades anatômica, histológica e espacial que fazem a sua avalição ser mais complexa, quando comparado à valva mitral, sendo necessário o conhecimento e treinamento nas diversas técnicas ecocardiográficas que serão utilizadas frequentemente em combinação para uma avaliação precisa. Esta revisão descreverá a anatomia da VT, o papel do ecocardiograma no diagnóstico, graduação e fisiopatologia envolvida na RT, as principais opções atuais de tratamento transcateter da RT e a avaliação do resultado após intervenção transcateter por meio de múltiplas modalidades ecocardiográficas.(AU)

Severe tricuspid regurgitation (TR) is associated with high morbidity and mortality. Given that surgical treatment of TR alone has been associated with high mortality, transcatheter interventions in the tricuspid valve (TV) have been used for its treatment, with relatively lower risk. There is a delay in intervention for TR, and this is probably related to a limited understanding of the anatomy of the TV and the right ventricle, in addition to an underestimation of the severity of TR. In this scenario, it is necessary to have comprehensive anatomical knowledge of the TV, the pathophysiology involved in the mechanism of regurgitation, and more accurate grading. The TV has anatomical, histological, and spatial peculiarities that make its assessment more complex when compared to the mitral valve, requiring knowledge and training in the various echocardiographic techniques that will often be used in combination for accurate assessment. This review will describe the anatomy of the TV, the role of echocardiography in the diagnosis, grading, and pathophysiology involved in TR; the main transcatheter treatment options currently available for TR; and the assessment of outcomes after transcatheter intervention by means of multiple echocardiographic modalities.(AU)

Quantification of mitral regurgitation after transcatheter edge-to-edge repair: Comparison of echocardiography and patient-specific in silico models.

BACKGROUND: Doppler echocardiographic (echo) assessment of residual mitral regurgitation (MR) after transcatheter edge-to-edge repair (TEER) is challenging and often subjective. This study aimed to evaluate the accuracy and feasibility of standardized quantitative echo methods for assessment of MR severity after MitraClip repair by comparing measurements against a reference MR severity obtained from patient-specific in silico models. METHODS: Post-procedure hemodynamics were simulated under five different MitraClip configurations in previously validated patient-specific in silico models for the treatment of functional MR. The residual regurgitant volume was calculated as in clinical practice using four quantitative virtual echo methods: pulsed Doppler, volumetric, proximal isovelocity surface area (PISA) and vena contracta area (VCA). Multiple permutations were performed for each method. Virtual echo MR results were evaluated against reference MR values directly extracted from the 5 patient-specific in silico models. RESULTS: The echo methods with the greatest accuracy were the three-dimensional (3D) volumetric method (r = 0.957, bias -0.8 ± 1.2 ml, p = 0.01), the 3D VCA method wherein velocity time integrals were evaluated for each jet assessed (r = 0.919, bias -1.5 ± 1.7 ml, p = 0.03), and the 3D PISA method integrating surface areas throughout systole (r = 0.98, bias -2.0 ± 0.9 ml, p = 0.003). The pulsed Doppler and 2D volumetric methods had technical limitations that may result in a high underestimation or overestimation of the MR severity after TEER. In the case of multiple regurgitant jets, a more accurate MR assessment was obtained when all significant jets were evaluated. CONCLUSIONS: Clinically, the 3D volumetric, 3D VCA and 3D PISA methods gave the most accurate MR quantification after TEER. Three-dimensional echo technologies harbor the potential of becoming the non-invasive imaging tool of choice for MR quantification after complex transcatheter mitral interventions.

Randomized clinical trial on prevention of radial occlusion after transradial access using Nitroglycerin: PATENS trial

OBJECTIVES: The aim of this study was to evaluate whether administration of nitroglycerin at the beginning or end of a transradial approach (TRA) procedure would preserve radial patency. BACKGROUND: The TRA is becoming the preferred vascular access route in coronary interventions. Radial artery occlusion (RAO) is the most frequent complication. Routine vasodilator treatment aims to reduce spasm and possibly prevent RAO. METHODS: The authors designed a prospective, multicenter, randomized, double-blind, 2-by-2 factorial, placebo-controlled trial encompassing patients undergoing the TRA. Patients were randomized to either 500 µg nitroglycerin or placebo; each arm was also subrandomized to early (upon sheath insertion) or late (right before sheath removal) nitroglycerin administration to evaluate the superiority of nitroglycerin in the prevention of RAO with 24 hours on Doppler ultrasound. RESULTS: A total of 2,040 patients were enrolled. RAO occurred in 49 patients (2.4%). Fifteen of these patients (30.6%) showed reestablishment of flow at 30 days. Nitroglycerin, compared with placebo, did not reduce the risk for RAO at either of the 2 time points (early, 2.5% vs 2.3% [P = 0.66]; late, 2.3% vs 2.5% [P = 0.66]). By multivariable analysis, the presence of spasm (OR: 3.53; 95% CI: 1.87-6.65; P < 0.001) and access achieved with more than 1 puncture attempt (OR: 2.58; 95% CI: 1.43-4.66; P = 0.002) were independent predictors of RAO. Conclusions: The routine use of nitroglycerin was not associated with a reduction in the rate of RAO, regardless of the time of administration (at the beginning or end of the TRA procedure).

Aneurisma verdadeiro isolado de artéria femoral profunda associado a doença arterial periférica: relato de caso / True isolated deep femoral artery aneurysm associated with peripheral artery disease: case report

Resumo Os aneurismas verdadeiros de artéria femoral profunda são extremamente raros, representando cerca de 0,5% do total dos aneurismas periféricos. Neste relato, descrevemos um paciente de 79 anos de idade, sexo masculino, com histórico de abordagem cirúrgica prévia convencional devido a aneurisma de aorta abdominal, que deu entrada no Serviço de Cirurgia Vascular do Hospital das Clínicas com quadro de claudicação intermitente de membros inferiores. Foi realizado eco-Doppler colorido arterial do membro inferior direito, que revelou doença arterial periférica femoro-poplítea e infrapatelar. A angiotomografia computadorizada identificou oclusão aortoilíaca e do enxerto bifurcado desde o segmento infrarrenal da aorta, além de aneurisma de artéria femoral profunda de 3,7 x 3,5 cm de diâmetro com 7 cm de extensão. Procedeu-se com a ressecção do aneurisma e revascularização da artéria femoral profunda por interposição de prótese de Dacron® e reimplante de artéria femoral superficial na prótese. Portanto, nos casos de aneurisma de artéria femoral profunda concomitante a doença arterial periférica, deve-se atentar para revascularização e perfusão adequada do membro inferior.

Abstract True deep femoral artery aneurysms are extremely rare, accounting for about 0.5% of all peripheral aneurysms. In this report, we describe a 79-year-old male patient with a history of prior abdominal aortic aneurysm surgery via a conventional approach who was admitted to the vascular surgery service at the Hospital das Clínicas with intermittent claudication of the lower limbs. Arterial color-Doppler ultrasonography of the right lower limb was performed, revealing peripheral arterial disease of the femoral--popliteal and infrapatellar segments. Computed tomography angiography identified aortoiliac and bifurcated graft occlusion from the infrarenal segment of the aorta, in addition to a deep femoral artery aneurysm with diameters of 3.7 cm x 3.5 cm and length of 7 cm. Resection of the aneurysm was followed by revascularization of the deep femoral artery by interposition of a Dacron® graft and reimplantation of the superficial femoral artery into the graft. In cases of deep femoral artery aneurysms with concomitant peripheral arterial disease, it is important to ensure revascularization and adequate perfusion of the lower limb.

Análise Comparativa do Padrão de Fluxo de Artérias Coronárias das Hipertrofias Miocárdicas Secundárias e por Mutação Sarcomérica / Comparative Analysis of the Coronary Arteries Flow Pattern in Secondary Myocardial Hypertrophies and by Sarcomeric Mutation

Fundamento: O fluxo coronariano com predomínio diastólico aumenta duas a cinco vezes na hiperemia, mediada por vasodilatação (reserva de fluxo coronariano), podendo, na hipertrofia, ocorrer isquemia relativa. Na hipertrofia secundária, o fluxo em repouso torna-se isquêmico pelo aumento da demanda. Na cardiomiopatia hipertrófica com fibrose perivascular, há funcionalização de vasos colaterais, para aumentar a irrigação dos segmentos hipertrofiados. Objetivo: Determinar o padrão do fluxo coronariano em pacientes com hipertrofia secundária e cardiomiopatia hipertrófica, avaliando a reserva de fluxo coronariano. Métodos: Avaliamos o fluxo coronariano em 34 pacientes com hipertrofia secundária, em 24 com cardiomiopatia hipertrófica e em 16 controles. A artéria descendente anterior foi detectada com Doppler transtorácico com calibração adequada do equipamento. Nos grupos controle e com hipertrofia secundária, foi calculada a reserva de fluxo coronariano com dipiridamol (0,84 mg/kg) endovenoso. O mesmo procedimento foi realizado em seis pacientes do grupo com cardiomiopatia hipertrófica, nos quais também foi avaliado o fluxo das colaterais da região hipertrófica. Os dados foram comparados por variância com significância de 5%. Resultados: Na hipertrofia secundária, houve aumento do índice de massa e, na cardiomiopatia hipertrófica, predominou o aumento da espessura relativa. A fração de ejeção e a disfunção diastólica foram maiores no grupo com cardiomiopatia hipertrófica. A reserva de fluxo coronariano foi menor no grupo com cardiomiopatia hipertrófica, sendo detectado, também, fluxo de colaterais com redução da reserva de fluxo coronariano. Conclusão: A análise da circulação coronariana com Doppler transtorácico é possível em indivíduos normais e hipertróficos. Pacientes com hipertrofia secundária e cardiomiopatia hipertrófica apresentam diminuição da reserva de fluxo coronariano, e aqueles com cardiomiopatia hipertrófica mostram fluxo de vasos colaterais dilatados observados na região hipertrófica, com diminuição da reserva de fluxo coronariano.(AU)

Background: Coronary flow with a diastolic predominance increases two to five times in hyperemia, mediated by vasodilation (coronary flow reserve, CFR) and, in hypertrophy, relative ischemia may occur. In secondary hypertrophy (LVH), the flow, normal at rest, becomes ischemic due to increased demand. In hypertrophic cardiomyopathy (HCM) with perivascular fibrosis, collateral vessels appear to increase the irrigation of hypertrophied segments. Objective: To determine the coronary flow pattern in patients with secondary hypertrophy and hypertrophic cardiomyopathy, evaluating the coronary flow reserve. Methods: Coronary flow was evaluated in 34 patients with secondary hypertrophy, 24 with hypertrophic cardiomyopathy and in 16 controls. The anterior descending artery was detected with transthoracic Doppler with adequate equipment calibration. In the hypertrophic cardiomyopathy group, the flow of collaterals from the hypertrophic region was evaluated. In the control and secondary hypertrophy groups and in six patients in the hypertrophic cardiomyopathy group, the intravenous dipyridamole (0.84 mg) coronary flow reserve was calculated. The data were compared by variance with a significance of 5%Results: In secondary hypertrophy there was an increase in mass index and blood pressure, and in hypertrophic cardiomyopathy an increase in relative thickness predominated. Ejection fraction and diastolic dysfunction were higher in the hypertrophic cardiomyopathy group. The coronary flow reserve was lower in the hypertrophic cardiomyopathy group, and flow of collaterals was also detected, with a reduction in the coronary flow reserve. Conclusion: the analysis of coronary circulation with transthoracic Doppler is possible in normal and hypertrophic individuals. Patients with secondary hypertrophy and hypertrophic cardiomyopathy have a decrease in the coronary flow reserve, and patients with hypertrophic cardiomyopathy show a hyper flow of dilated collateral vessels observed in the hypertrophic region, with a decrease in the coronary flow reserve.(AU)

Uso do doppler colorido das carótidas no diagnóstico de um paciente com fístula carotideocavernosa direta / Use of color doppler of carotids in the diagnosis of a patient with direct carotid-cavernous fistula

Adulto jovem de 18 anos que evoluiu após traumatismo craniencefálico leve com fístula carotídea direta. Apresentou zumbido e exoftalmia, ambos de característica pulsátil e à esquerda. Foi submetido a estudo com Doppler das carótidas, que mostrou elevadas velocidades do fluxo sanguíneo e índices de resistência reduzidos nas artérias carótidas comum e interna esquerdas, compatíveis com fístula carotídea direta. A angiotomografia computadorizada cerebral confirmou a fístula carotídea. Foi encaminhado para tratamento endovascular por embolização, com sucesso. O Doppler de carótidas pode ter papel importante no diagnóstico das fístulas carotídeas diretas e acompanhamento de pacientes submetidos à terapêutica endovascular.(AU)

Tissue Doppler Imaging and strain rate of the left atrial lateral wall: age related variations and comparison with parameters of diastolic function.

BACKGROUND: Strain Rate Imaging (SRI) is one of the most used techniques to study left atrial (LA) and diastolic function. Its availability in low-income countries is diminished since it requires additional expensive software, among other limitations. In contrast, Tissue Doppler Imaging (TDI) is widely available and easy to use. We hypothesize TDI could detect changes in LA and diastolic function associated with age similarly to SRI. The aim of this study is to evaluate the effects of age on LA and diastolic function assessed by LA lateral wall TDI online by spectral pulse, and to compare them with age-related variations of LA SRI and other parameters of diastolic function in a population of healthy adults. MATERIALS AND METHODS: Ninety-one healthy adults were prospectively evaluated. In apical four - chamber view the LA lateral wall was divided in three portions. Peak velocities of basal and mid portions were measured with TDI online by spectral pulse and with SRI by speckle tracking. A first positive wave (S'la and SRS) and two negative waves (E'la and SRE, and A'la and SRA respectively) were obtained. E'la/A'la ratio and SRE/SRA ratio were analyzed. The distribution of the variables by age subgroups was described and analyzed. Correlation analyses were performed. RESULTS: The median age was 42 years old and 54.9% were female. E'la/A'la showed a negative good correlation with age. E'la/A'la and SRE/SRA ratios changed from > 1 to < 1 in the age group of 41-50 years old, while this occurred in the group of 51-60 years old for the E/A ratio. Lateral and septal mitral annulus E´ showed decrease with age and prolongation of E-wave deceleration time was observed in the age group over 61 years old. CONCLUSION: Normal values​​ according to age group of TDI of the LA lateral wall were obtained. Age-related changes in LA and diastolic function could be detected as early with TDI as with SRI. Future studies are required to explore if this method could be used to address in part LA or diastolic function in other populations with established cardiovascular disease or at risk of presenting it, which could be useful in low-income settings, where SRI is not available.

Right ventricular free wall strain predicts functional capacity in patients with repaired Tetralogy of Fallot.

To investigate the role of right ventricular free wall strain (RVFWSL) to predict low functional capacity in repaired tetralogy of Fallot (rTOF). We prospectively enrolled 33 patients with rTOF with moderate to severe PR who underwent rest and peak exercise echocardiography on a semisupine cycloergometer. Conventional function and strain imaging parameters of both ventricles were measured. Patients performing < 7 METS were defined to have low functional capacity. Logistic regression was used to identify parameters associated with low functional capacity. Eleven patients (33.3%) had low functional capacity. These patients were shorter (height 155 ± 7 vs 163 ± 9 cm, p = 0.023), more frequently female (27.3 vs 72.7%, p = 0.024) and had history of Blalock-Taussig shunt (45.5 vs 9.1%, p = 0.027). On multivariate analysis RVFWSL was the only predictor of low functional capacity OR 1.39 (CI 95%, 1.06-1.83., p = 0.018) per % change. A RVFWSL < 17% (absolute value) had an AUC of 0.785, sensitivity of 81.8% and specificity of 77.3% to predict low functional capacity. Right ventricular free wall strain is an independent predictor of low functional capacity in repaired tetralogy of Fallot with moderate to severe PR. A value < 17% might be useful in deciding when to perform pulmonary valve replacement, when functional capacity cannot be objectively measured.

Carditis in Acute Rheumatic Fever in a High-Income and Moderate-Risk Country.

OBJECTIVE: To describe clinical presentation, electrocardiographic, and echocardiographic characteristics of carditis at the time of diagnosis of acute rheumatic fever (ARF) over a 13-year period. STUDY DESIGN: A single-center retrospective chart analysis was conducted involving all consecutive patients diagnosed with ARF between 2003 and 2015. Patient age, sex, clinical characteristics, recent medical history for group A streptococcal pharyngotonsillitis and antibiotic treatment, and laboratory, echocardiographic, and electrocardiographic findings were recorded. RESULTS: Of 98 patients (62 boys, mean age 8.81 ± 3.04 years), 59 (60.2%) reported a positive history of pharyngotonsillitis; 48 (49%) had received antibiotic (mean duration of treatment of 5.9 ± 3.1 days), and, among these, 28 (58.3%) had carditis. Carditis was the second most frequent finding, subclinical in 27% of patients. Mitral regurgitation was present in 49 of 56 patients (87.5%) and aortic regurgitation in 36/56 (64.3%) no stenosis was documented. CONCLUSIONS: ARF is still present in high-income countries and can develop despite primary prophylaxis, especially when given for a short course. Our findings highlight the need for 10 days of antistreptococcal treatment to prevent ARF. Echocardiography is important because 27% of cases with carditis were subclinical.