Biopsia endomiocárdica en la práctica actual: Aspectos técnicos, indicaciones y complicaciones / Endomyocardial biopsy in current practice: Technical Aspects, Indications and complications

La biopsia endomiocárdica (BEM) es un procedimiento invasivo y una herramienta diagnóstica, que en el pasado se encontraba principalmente enfocado en el seguimiento del rechazo post trasplante cardíaco. Actualmente, juega un rol importante en el diagnostico de las miocardiopatías no isquémicas. Se realiza frecuentemente por un acceso venoso para acceder al ventrículo derecho. El rendimiento diagnóstico ha mejorado con el avance del análisis anatomo-patológico. El riesgo de complicaciones, cercana al 1%, de este procedimiento en centros con experiencia puede justificarse frente al beneficio potencial de un diagnóstico y pronóstico preciso.

Endomyocardial biopsy (EMB) is an invasive procedure and a diagnostic tool used mainly on the follow-up of post-heart transplant rejection in the past years. Currently, it has an important role in the diagnosis of non-ischemic cardiomyopathies. EMB is frequently performed through a venous access to enter the right ventricle. Diagnostic performance has improved with advances in pathology analysis. Its complications risk, close to 1% in high-volume interventional centers, can be justified considering the potential benefit of an accurate diagnosis and prognosis.

[Endomyocardial biopsy in current practice: Technical Aspects, Indications and complications]. / Biopsia endomiocárdica en la práctica actual: Aspectos técnicos, indicaciones y complicaciones.

Endomyocardial biopsy (EMB) is an invasive procedure and a diagnostic tool used mainly on the follow-up of post-heart transplant rejection in the past years. Currently, it has an important role in the diagnosis of non-ischemic cardiomyopathies. EMB is frequently performed through a venous access to enter the right ventricle. Diagnostic performance has improved with advances in pathology analysis. Its complications risk, close to 1% in high-volume interventional centers, can be justified considering the potential benefit of an accurate diagnosis and prognosis.

Prevalence, risk factors and survival in dogs with myxomatous valve degeneration / [Prevalência, fatores de risco e sobrevivência em cães com degeneração mixomatosa valvar]

The objective of this study was to describe the prevalence, survival time, and risk factors of myxomatous mitral valve disease (MMVD) in dogs by a retrospective observational cohort study design of a Brazilian veterinary center, admitted from 2012 to 2018 (2.585 days). Considering the 105 dog files confirmed as MMVD, the prevalence of the disease was higher in small-breed dogs with ages from 10 to 19 years (30.3%). The survival time of the dogs at B1 stage (1.854 ± 145 days) was higher than the B2 (1.508+209) and C/D (930 ± 209). Higher risks of death (hazard ratio) were detected in the presence of syncope (2.5), pulmonary crackling (2.0), dyspnea (1.9), and higher values of vertebral heart scale (1.7), radiographic left atrium dimension (1.8), the ACVIM staging (1.7), and the duration of QRS complex (1.05). The results achieved demonstrated higher prevalence of MMVD in old small-breed dogs, associated with longer survival time in the B1 stage of the disease, and higher risk of death related to the presence of clinical signs, such as dyspnea, syncope, and pulmonary crackling, beyond some radiographic, echocardiographic, and electrocardiographic variables of heart or atrial enlargement.(AU)

O objetivo deste estudo foi descrever a prevalência, o tempo de sobrevivência e os fatores de risco da doença mixomatosa valvar mitral (DMVM) em cães, por meio de estudo de coorte observacional retrospectivo, os quais foram atendidos em um centro veterinário de 2012 a 2018 (2.585 dias). Considerando os 105 arquivos de cães com confirmação da DMVM, maior prevalência foi observada em raças pequenas com idades entre 10 e 19 anos (30,3%). O tempo de sobrevivência de cães em estágio B1 (1.854+145 dias) foi superior ao B2 (1.508+209) e ao C/D (930+209). Maior risco de morte (hazard ratio) foi observado na presença de síncope (2,5), crepitação pulmonar (2,0), dispneia (1,9), bem como de valores superiores de VHS (1,7), dimensão radiográfica do átrio esquerdo (1,8), estadiamento ACVIM (1,7) e duração do complexo QRS (1,05). Os resultados obtidos demonstraram maior prevalência de DMVM em cães idosos de raças pequenas, associada a maior tempo de sobrevida no estágio B1 da doença e a maior risco de morte relacionado à presença de sinais clínicos como dispneia, síncope e crepitação pulmonar, além de algumas variáveis radiográficas, ecocardiográficas e eletrocardiográficas de cardiomegalia ou aumento atrial esquerdo.(AU)

Cardiac Lesions of Natural and Experimental Infection by Parrot Bornaviruses.

Lymphoplasmacytic inflammation associated with bornavirus N protein occurs in the epicardial ganglia, myocardium and endocardium of birds diagnosed with proventricular dilatation disease (PDD). These pathological findings suggest that sudden death in psittacine birds might stem from cardiac compromise due to parrot bornavirus (PaBV) infection. Therefore, we investigated cardiac lesions in cases of PDD, searching databases from 1988 to 2019, and reviewed three experimental studies of PaBV infection. Fifty cases of PDD in birds infected naturally with PaBV and 27 cases of PDD in birds infected experimentally with PaBV (all having descriptions of inflammatory cardiac lesions) were reviewed. For each case, five regions of the heart were evaluated by light microscopy and immunohistochemistry (IHC). These regions were the epicardial ganglia/nerves, the endocardium, the myocardium, the Purkinje fibres and the great vessels. Sudden death was documented in 17/50 naturally infected cases, while 23/50 had digestive signs, and only 12/50 had neurological signs. Grossly, only five naturally-infected and five experimentally-infected cases had cardiomegaly or hydropericardium. Epicardial ganglioneuritis was the most consistent microscopical finding in natural (46/50) and experimental cases (26/27), followed by myocarditis (34/50) for naturally-infected and endocarditis for experimentally-infected birds (6/27). PaBV-2 antigen was detected most frequently by IHC in the epicardial ganglia (54/77) compared with the other tissues. This retrospective study demonstrates the presence of PaBV protein and inflammation in the heart of birds infected with PaBV and suggests a link between PaBV and cardiac disease and sudden death in psittacine birds.

Sequential measurement of Trypanosoma cruzi parasitic load in endomyocardial biopsies for early detection and follow-up of Chagas disease reactivation after heart transplantation.

BACKGROUND: Reactivation of Chagas disease after heart transplantation is characterized by proliferation and dissemination of Trypanosoma cruzi parasites to several organs. Reactivation affecting the allograft can simulate acute cellular rejection, from which it should be distinguished through the analysis of endomyocardial biopsies (EMB). METHODS: We evaluated retrospectively 100 EMB collected in the first year of follow-up from 13 heart-transplanted, chagasic patients who presented reactivation and were successfully treated. Additionally, 37 EMB from 8 patients who did not present reactivation constituted the control group. We reviewed histopathology and performed a real-time PCR-based assay in order to evaluate the T cruzi parasitic load of each EMB. RESULTS: The parasitic load of the EMB at the time of reactivation ranged from 22.80 to 190 000/106 cells (median: 1555). In 6 patients, none of the EMB obtained prior to reactivation amplified T cruzi DNA. On the other hand, 10 EMB from 7 patients, obtained 9-105 days before reactivation (median: 26 days), showed parasitic load ranging from 8.25 to 625/106 cells (median: 167.55). In all patients, the parasitic load increased at the time of reactivation, usually sharply. After initiation of treatment, all patients showed negative PCR or a dramatic reduction of the parasitic load in the following EMB. None of the EMB from the control group amplified T cruzi DNA. CONCLUSIONS: Sequential measurement of T cruzi parasitic load in EMB is useful for monitoring Chagas disease reactivation after heart transplantation. Its increase suggests imminent reactivation and its decrease after treatment indicates favorable evolution for cure of the episode of reactivation.

Excess weight in children and adolescents is associated with altered subendocardial blood supply among girls but not boys.

Subendocardial viability ratio (SEVR) is a reliable index of myocardial supply-workload balance. This study sought to investigate whether overweight/obese children and adolescents have altered SEVR and to identify which are the associated factors. This cross-sectional study involved 789 individuals. Central haemodynamic was measured by radial applanation tonometry. Diastolic time was shorter (496 ± 122 vs 537 ± 140 ms, P = .014) and diastolic pressure-time index was lower (2681 ± 412 vs 2814 ± 423 mm Hg seconds, P = .024) in overweight/obese compared with eutrophic girls. SEVR was lower in girls than in boys (1.34 ± 0.39 vs 1.48 ± 0.41, P = .018) but only among overweight/obese. SEVR may be affected by small variations in the temporal determinants of cardiac cycle.

Trigeminismo supraventricular em um cão com doença mixomatosa da valva mitral / Supraventricular trigeminy in a dog with myxomatous mitral valve disease

Supraventricular trigeminy is an uncommon cardiac impulse formation disturbance. Detecting and treating cardiac arrhythmias is an important therapeutic goal in cardiology. The aim of this note is to report an occurrence of supraventricular trigeminy in a dog with myxomatous mitral valve disease (MMVD). A 15-year-old intact male mongrel dog weighing 13kg and with a history of heart murmur, cough, dyspnea, and ascites was referred for cardiac evaluation. Echocardiographic findings were consistent with a diagnosis of myxomatous mitral and tricuspid valves disease with a severe hemodynamic compromise. Electrocardiography (ECG) revealed a sinus arrhythmia with isolated supraventricular premature complexes, supraventricular couplets, and periods of supraventricular trigeminy. Previous retrospective and prospective studies that evaluated cardiac arrhythmias in dogs have not reported supraventricular trigeminy. The present report showed that supraventricular trigeminy may occur in dogs with MMVD with severe hemodynamic compromise, probably related to atrial enlargement. In addition, this case reinforces the importance of performing ECG in dogs with MMVD, since it complements the echocardiogram and enables a better therapeutic approach.(AU)

O trigeminismo supraventricular é um distúrbio incomum de formação do impulso elétrico cardíaco. Detectar e tratar arritmias cardíacas são um importante objetivo terapêutico em cardiologia. O objetivo desta nota é relatar a ocorrência de trigeminismo supraventricular em um cão com doença mixomatosa da valva mitral (DMVM). Um cão sem raça definida, macho, inteiro, 15 anos de idade e 13kg foi levado para avaliação cardíaca com um histórico de sopro cardíaco, tosse, dispneia e ascite. Os achados ecocardiográficos foram compatíveis com doença mixomatosa de valvas mitral e tricúspide com comprometimento hemodinâmico severo. A eletrocardiografia (ECG) revelou arritmia sinusal com presença de complexos supraventriculares prematuros isolados, aos pares e períodos de trigeminismo supraventricular. O trigeminismo supraventricular não é relatado em estudos retrospectivos e prospectivos que avaliaram arritmias cardíacas em um grande número de cães. O presente relato evidencia que o trigeminismo supraventricular pode ocorrer em cães com DMVM e comprometimento hemodinâmico severo, provavelmente relacionado à dilatação atrial. Ainda, reforça a importância da realização do ECG em cães com DMVM, complementando as informações ecocardiográficas e possibilitando uma melhor abordagem terapêutica.(AU)

Trigeminismo supraventricular em um cão com doença mixomatosa da valva mitral / Supraventricular trigeminy in a dog with myxomatous mitral valve disease

Supraventricular trigeminy is an uncommon cardiac impulse formation disturbance. Detecting and treating cardiac arrhythmias is an important therapeutic goal in cardiology. The aim of this note is to report an occurrence of supraventricular trigeminy in a dog with myxomatous mitral valve disease (MMVD). A 15-year-old intact male mongrel dog weighing 13kg and with a history of heart murmur, cough, dyspnea, and ascites was referred for cardiac evaluation. Echocardiographic findings were consistent with a diagnosis of myxomatous mitral and tricuspid valves disease with a severe hemodynamic compromise. Electrocardiography (ECG) revealed a sinus arrhythmia with isolated supraventricular premature complexes, supraventricular couplets, and periods of supraventricular trigeminy. Previous retrospective and prospective studies that evaluated cardiac arrhythmias in dogs have not reported supraventricular trigeminy. The present report showed that supraventricular trigeminy may occur in dogs with MMVD with severe hemodynamic compromise, probably related to atrial enlargement. In addition, this case reinforces the importance of performing ECG in dogs with MMVD, since it complements the echocardiogram and enables a better therapeutic approach.

O trigeminismo supraventricular é um distúrbio incomum de formação do impulso elétrico cardíaco. Detectar e tratar arritmias cardíacas são um importante objetivo terapêutico em cardiologia. O objetivo desta nota é relatar a ocorrência de trigeminismo supraventricular em um cão com doença mixomatosa da valva mitral (DMVM). Um cão sem raça definida, macho, inteiro, 15 anos de idade e 13kg foi levado para avaliação cardíaca com um histórico de sopro cardíaco, tosse, dispneia e ascite. Os achados ecocardiográficos foram compatíveis com doença mixomatosa de valvas mitral e tricúspide com comprometimento hemodinâmico severo. A eletrocardiografia (ECG) revelou arritmia sinusal com presença de complexos supraventriculares prematuros isolados, aos pares e períodos de trigeminismo supraventricular. O trigeminismo supraventricular não é relatado em estudos retrospectivos e prospectivos que avaliaram arritmias cardíacas em um grande número de cães. O presente relato evidencia que o trigeminismo supraventricular pode ocorrer em cães com DMVM e comprometimento hemodinâmico severo, provavelmente relacionado à dilatação atrial. Ainda, reforça a importância da realização do ECG em cães com DMVM, complementando as informações ecocardiográficas e possibilitando uma melhor abordagem terapêutica.

Diastolic function is impaired in dogs with myxomatous mitral valve disease / Disfunção diastólica em cães com doença mixomatosa da valva mitral

Myxomatous mitral valve disease (MMVD) is the most common cardiac disease in dogs, and the echocardiogram is required to investigate the degree of remodeling and the intensity of cardiac dysfunction. Therefore, the aim of this study was to assess diastolic function in dogs with MMVD in different stages, and to compare them with healthy animals. This study enrolled 12 mature dogs with MMVD, which were subdivided in two groups: stage B2 (n=7) and stage C (n=5). Also, 9 healthy adult dogs were recruited to serve as controls. Several echocardiographic data were obtained for the assessment of diastolic function, as well as some parameters intended to evaluate the cardiac structure and systolic function, which were used to search for correlations with the diastolic parameters. Concerning diastolic function, a significant difference was found to exist between groups for the peak velocity of left ventricular slow filling, the isovolumic relaxation time, and the mitral annular velocities at early and late diastole. These findings are associated with the structural and hemodynamic changes ascribed to the progression of MMVD and the intensification of congestive heart failure. The indices calculated from the peak velocity of left ventricular rapid filling and the mitral annular velocities obtained at early and late diastole also differed between healthy and diseased dogs. Because some of these indices aresurrogates for left ventricular filling pressure and the congestive status of the patient, the results of this study are supportive of the relationship between the progression of MMVD and diastolic impairment, besides the eccentric structural remodeling attributable to this cardiac disease.

A degeneração mixomatosa da valva mitral (DMVM) é a cardiopatia de maior prevalência em cães e a ecocardiografia é necessária para avaliar o grau de remodelamento e a intensidade da disfunção cardíaca. Assim, o escopo desta pesquisa foi avaliar a função diastólica em cães com DMVM em diferentes estágios, comparando-os com cães saudáveis. Foram arrolados 12 cães adultos portadores de DMVM, os quais foram subdivididos em dois grupos: estágio B2 (n=7) e estágio C (n=5). Além disso, foi constituído um grupo controle com 9 cães adultos clinicamente saudáveis. Foram obtidos parâmetros ecocardiográficos para avaliação da função diastólica, assim como algumas variáveis para avaliação estrutural do coração e da função sistólica, as quais foram empregadas para investigar correlações com os parâmetros diastólicos. No tocante à função diastólica, houve diferença significativa entre grupos na avaliação da velocidade máxima do enchimento ventricular esquerdo lento, do tempo de relaxamento isovolumétrico e das velocidades anulares da mitral em início e final da diástole. Tais resultados refletem modificações estruturais e hemodinâmicas que acompanham a progressão da enfermidade mitral e a intensificação da insuficiência cardíaca congestiva. Os índices calculados a partir das relações entre a velocidade máxima do enchimento ventricular esquerdo rápido e as velocidades anulares da mitral, bem como entre asvelocidades anulares da mitral obtidas no início e final da diástole, também foram diferentes entre cães saudáveis eenfermos. Como alguns desses parâmetros refletem a pressão de enchimento do ventrículo esquerdo e o estado congestivo do paciente, os resultados desta pesquisa apontam para a relação existente entre a progressão da DMVM e o prejuízo diastólico, além do remodelamento estrutural excêntrico que acompanha essa enfermidade.

Diastolic function is impaired in dogs with myxomatous mitral valve disease / Disfunção diastólica em cães com doença mixomatosa da valva mitral

Myxomatous mitral valve disease (MMVD) is the most common cardiac disease in dogs, and the echocardiogram is required to investigate the degree of remodeling and the intensity of cardiac dysfunction. Therefore, the aim of this study was to assess diastolic function in dogs with MMVD in different stages, and to compare them with healthy animals. This study enrolled 12 mature dogs with MMVD, which were subdivided in two groups: stage B2 (n=7) and stage C (n=5). Also, 9 healthy adult dogs were recruited to serve as controls. Several echocardiographic data were obtained for the assessment of diastolic function, as well as some parameters intended to evaluate the cardiac structure and systolic function, which were used to search for correlations with the diastolic parameters. Concerning diastolic function, a significant difference was found to exist between groups for the peak velocity of left ventricular slow filling, the isovolumic relaxation time, and the mitral annular velocities at early and late diastole. These findings are associated with the structural and hemodynamic changes ascribed to the progression of MMVD and the intensification of congestive heart failure. The indices calculated from the peak velocity of left ventricular rapid filling and the mitral annular velocities obtained at early and late diastole also differed between healthy and diseased dogs. Because some of these indices aresurrogates for left ventricular filling pressure and the congestive status of the patient, the results of this study are supportive of the relationship between the progression of MMVD and diastolic impairment, besides the eccentric structural remodeling attributable to this cardiac disease.(AU)

A degeneração mixomatosa da valva mitral (DMVM) é a cardiopatia de maior prevalência em cães e a ecocardiografia é necessária para avaliar o grau de remodelamento e a intensidade da disfunção cardíaca. Assim, o escopo desta pesquisa foi avaliar a função diastólica em cães com DMVM em diferentes estágios, comparando-os com cães saudáveis. Foram arrolados 12 cães adultos portadores de DMVM, os quais foram subdivididos em dois grupos: estágio B2 (n=7) e estágio C (n=5). Além disso, foi constituído um grupo controle com 9 cães adultos clinicamente saudáveis. Foram obtidos parâmetros ecocardiográficos para avaliação da função diastólica, assim como algumas variáveis para avaliação estrutural do coração e da função sistólica, as quais foram empregadas para investigar correlações com os parâmetros diastólicos. No tocante à função diastólica, houve diferença significativa entre grupos na avaliação da velocidade máxima do enchimento ventricular esquerdo lento, do tempo de relaxamento isovolumétrico e das velocidades anulares da mitral em início e final da diástole. Tais resultados refletem modificações estruturais e hemodinâmicas que acompanham a progressão da enfermidade mitral e a intensificação da insuficiência cardíaca congestiva. Os índices calculados a partir das relações entre a velocidade máxima do enchimento ventricular esquerdo rápido e as velocidades anulares da mitral, bem como entre asvelocidades anulares da mitral obtidas no início e final da diástole, também foram diferentes entre cães saudáveis eenfermos. Como alguns desses parâmetros refletem a pressão de enchimento do ventrículo esquerdo e o estado congestivo do paciente, os resultados desta pesquisa apontam para a relação existente entre a progressão da DMVM e o prejuízo diastólico, além do remodelamento estrutural excêntrico que acompanha essa enfermidade.(AU)

Sincronia e função ventricular esquerda em pacientes pediátricos portadores de marca-passo definitivo / Left ventricular synchrony and function in pediatric patients with definitive pacemakers

FUNDAMENTO: A estimulação crônica do ventrículo direito (EVD) induz um padrão de contração dessincronizado, produzindo assincronia interventricular e intraventricular. Muitos estudos têm mostrado a relação entre EVD e a forma e função ventricular esquerda (VE) comprometida. OBJETIVO: O objetivo deste estudo foi avaliar a sincronia e a função do VE em pacientes pediátricos que receberam EVD em comparação com aqueles que receberam estimulação do VE (EVE). MÉTODOS: As funções sistólica e diastólica e a sincronia do VE foram avaliadas em 80 pacientes pediátricos com bloqueio atrioventricular total não cirúrgico ou pós-cirúrgico, com estimulação a partir do endocárdio do ventrículo direito (VD) (n = 40) ou do epicárdio do VE (n = 40). Foram analisados dados ecocardiográficos obtidos antes da implantação do marca-passo, imediatamente após a implantação, e no final de um acompanhamento médio de 6,8 anos. RESULTADOS: A função diastólica do VE não se alterou em nenhum dos pacientes durante o acompanhamento. A função sistólica ventricular esquerda foi preservada nos pacientes que receberam EVE. No entanto, a fração de encurtamento e a fração de ejeção diminuíram de medianas de 41% ± 2,6% e 70% ± 6,9% antes da implantação para 32% ± 4,2% e 64% ± 2,5% (p < 0,0001 e p < 0,0001), respectivamente, no acompanhamento final. O atraso mecânico interventricular foi significativamente maior com a EVD (66 ± 13 ms) do que com a EVE (20 ± 8 ms). Da mesma forma, nos dois grupos houve uma diferença significativa entre os seguintes parâmetros: atraso mecânico do VE (EVD: 69 ± 6 ms, EVE: 30 ± 11 ms, p < 0,0001); atraso septo-lateral (RVP: 75 ± 19 ms, LVP: 42 ± 10 ms, p < 0,0001) e atraso septo-posterior (EVD: 127 ± 33 ms, EVE: 58 ± 17 ms, p < 0,0001). CONCLUSÃO: Quando comparado ao endocárdio do VD, o epicárdio do VE é um local ideal para a estimulação para preservar a sincronia e a função cardíaca.

BACKGROUND: Chronic right ventricular pacing (RVP) induces a dyssynchronous contraction pattern,producing interventricular and intraventricular asynchrony. Many studies have shown the relationship of RVP with impaired left ventricular (LV) form and function. OBJECTIVE: The aim of this study was to evaluate LV synchrony and function in pediatric patients receiving RVP in comparison with those receiving LV pacing (LVP). METHODS:LV systolic and diastolic function and synchrony were evaluated in 80 pediatric patients with either nonsurgical or postsurgical complete atrioventricular block, with pacing from either the RV endocardium (n = 40) or the LV epicardium (n = 40). Echocardiographic data obtained before pacemaker implantation, immediately after it, and at the end of a mean follow-up of 6.8 years were analyzed. RESULTS: LV diastolic function did not change in any patient during follow-up. LV systolic function was preserved in patients with LVP. However, in children with RVP the shortening fraction and ejection fraction decreased from medians of 41% ± 2.6% and 70% ± 6.9% before implantation to 32% ± 4.2% and 64% ± 2.5% (p < 0.0001 and p < 0.0001), respectively, at final follow-up. Interventricular mechanical delay was significantly larger with RVP (66 ± 13 ms) than with LVP (20 ± 8 ms). Similarly, the following parameters were significantly different in the two groups: LV mechanical delay (RVP: 69 ± 6 ms, LVP: 30 ± 11 ms, p < 0.0001); septal to lateral wall motion delay (RVP: 75 ± 19 ms, LVP: 42 ± 10 ms, p < 0.0001); and, septal to posterior wall motion delay (RVP: 127 ± 33 ms, LVP: 58 ± 17 ms, p < 0.0001). CONCLUSION: Compared with RV endocardium, LV epicardium is an optimal site for pacing to preserve cardiac synchrony and function.

Left ventricular synchrony and function in pediatric patients with definitive pacemakers.

BACKGROUND: Chronic right ventricular pacing (RVP) induces a dyssynchronous contraction pattern,producing interventricular and intraventricular asynchrony. Many studies have shown the relationship of RVP with impaired left ventricular (LV) form and function. OBJECTIVE: The aim of this study was to evaluate LV synchrony and function in pediatric patients receiving RVP in comparison with those receiving LV pacing (LVP). METHODS: LV systolic and diastolic function and synchrony were evaluated in 80 pediatric patients with either nonsurgical or postsurgical complete atrioventricular block, with pacing from either the RV endocardium (n = 40) or the LV epicardium (n = 40). Echocardiographic data obtained before pacemaker implantation, immediately after it, and at the end of a mean follow-up of 6.8 years were analyzed. RESULTS: LV diastolic function did not change in any patient during follow-up. LV systolic function was preserved in patients with LVP. However, in children with RVP the shortening fraction and ejection fraction decreased from medians of 41% ± 2.6% and 70% ± 6.9% before implantation to 32% ± 4.2% and 64% ± 2.5% (p < 0.0001 and p < 0.0001), respectively, at final follow-up. Interventricular mechanical delay was significantly larger with RVP (66 ± 13 ms) than with LVP (20 ± 8 ms). Similarly, the following parameters were significantly different in the two groups: LV mechanical delay (RVP: 69 ± 6 ms, LVP: 30 ± 11 ms, p < 0.0001); septal to lateral wall motion delay (RVP: 75 ± 19 ms, LVP: 42 ± 10 ms, p < 0.0001); and, septal to posterior wall motion delay (RVP: 127 ± 33 ms, LVP: 58 ± 17 ms, p < 0.0001). CONCLUSION: Compared with RV endocardium, LV epicardium is an optimal site for pacing to preserve cardiac synchrony and function.

Eosinophilic endocarditis and Strongyloides stercoralis.

A 40-year-old woman from El Salvador presented with 3 months of abdominal pain and diarrhea followed by 2 weeks of atypical chest pain and exertional dyspnea and was diagnosed with eosinophilic endocarditis secondary to Strongyloides stercoralis infection. Transthoracic echocardiogram revealed apical masses in the left and right ventricles and a thickened posterior mitral valve leaflet and cardiac magnetic resonance imaging confirmed the presence of a left ventricular apical mass with diffuse subendocardial delayed enhancement consistent with endocardial fibrosis. In conclusion, eosinophilic endocarditis is a rare cause of restrictive cardiomyopathy characterized by endomyocardial fibrosis and apical thrombosis and fibrosis with frequent involvement of the posterior mitral valve leaflet.

A novel noninvasive method to detect rejection after heart transplantation

Prompt and accurate detection of rejection prior to pathological changes after organ transplantation is vital for monitoring rejections. Although biopsy remains the current gold standard for rejection diagnosis, it is an invasive method and cannot be repeated daily. Thus, noninvasive monitoring methods are needed. In this study, by introducing an IL-2 neutralizing monoclonal antibody (IL-2 N-mAb) and immunosuppressants into the culture with the presence of specific stimulators and activated lymphocytes, an activated lymphocyte-specific assay (ALSA) system was established to detect the specific activated lymphocytes. This assay demonstrated that the suppression in the ALSA test was closely related to the existence of specific activated lymphocytes. The ALSA test was applied to 47 heart graft recipients and the proliferation of activated lymphocytes from all rejection recipients proven by endomyocardial biopsies was found to be inhibited by spleen cells from the corresponding donors, suggesting that this suppression could reflect the existence of activated lymphocytes against donor antigens, and thus the rejection of a heart graft. The sensitivity of the ALSA test in these 47 heart graft recipients was 100%; however, the specificity was only 37.5%. It was also demonstrated that IL-2 N-mAb was indispensible, and the proper culture time courses and concentrations of stimulators were essential for the ALSA test. This preliminary study with 47 grafts revealed that the ALSA test was a promising noninvasive tool, which could be used in vitro to assist with the diagnosis of rejection post-heart transplantation.

A novel noninvasive method to detect rejection after heart transplantation.

Prompt and accurate detection of rejection prior to pathological changes after organ transplantation is vital for monitoring rejections. Although biopsy remains the current gold standard for rejection diagnosis, it is an invasive method and cannot be repeated daily. Thus, noninvasive monitoring methods are needed. In this study, by introducing an IL-2 neutralizing monoclonal antibody (IL-2 N-mAb) and immunosuppressants into the culture with the presence of specific stimulators and activated lymphocytes, an activated lymphocyte-specific assay (ALSA) system was established to detect the specific activated lymphocytes. This assay demonstrated that the suppression in the ALSA test was closely related to the existence of specific activated lymphocytes. The ALSA test was applied to 47 heart graft recipients and the proliferation of activated lymphocytes from all rejection recipients proven by endomyocardial biopsies was found to be inhibited by spleen cells from the corresponding donors, suggesting that this suppression could reflect the existence of activated lymphocytes against donor antigens, and thus the rejection of a heart graft. The sensitivity of the ALSA test in these 47 heart graft recipients was 100%; however, the specificity was only 37.5%. It was also demonstrated that IL-2 N-mAb was indispensible, and the proper culture time courses and concentrations of stimulators were essential for the ALSA test. This preliminary study with 47 grafts revealed that the ALSA test was a promising noninvasive tool, which could be used in vitro to assist with the diagnosis of rejection post-heart transplantation.

Tricuspid valve injury after heart transplantation due to endomyocardial biopsy: an analysis of 3550 biopsies.

INTRODUCTION: Tricuspid regurgitation (TR) is the most commonly valvular dysfunction found after heart transplantation (HTx). It may be related to endomyocardial biopsy (EMB) performed for allograft rejection surveillance. OBJECTIVE: This investigation evaluated the presence of tricuspid valve tissue fragments obtained during routine EMB performed after HTx and its possible effect on short-term and long-term hemodynamic status. METHOD: This single-center review included prospectively collected and retrospectively analyzed data. From 1985 to 2010, 417 patients underwent 3550 EMB after HTx. All myocardial specimens were reviewed to identify the presence of tricuspid valve tissue by 2 observers initially and in doubtful cases by a third observer. The echocardiographic and hemodynamic parameters were only considered for valvular functional damage analysis in cases of tricuspid tissue inadvertently removed during EMB. RESULTS: The 417 HTx patients to 3550 EMB, including 17,550 myocardial specimens. Tricuspid valve tissue was observed in 12 (2.9%) patients corresponding to 0.07% of the removed fragments. The echocardiographic and hemodynamic parameters of these patients before versus after the biopsy showed increased TR in 2 cases (2/12; 16.7%) quantified as moderate without progression in the long term. Only the right atrial pressure showed a significant increase (P = .0420) after tricuspid injury; however, the worsening of the functional class was not significant enough in any of the subjects. Thus, surgical intervention was not required. CONCLUSIONS: Histological evidence of chordal tissue in EMB specimens is a real-world problem of relatively low frequency. Traumatic tricuspid valve injury due to EMB rarely leads to severe valvular regurgitation; only a minority of patients develop significant clinical symptoms. Hemodynamic and echocardiographic alterations are also less often observed in most patients.

Comparative analysis of the complications of 5347 endomyocardial biopsies applied to patients after heart transplantation and with cardiomyopathies: a single-center study.

INTRODUCTION: Endomyocardial biopsy (EMB) plays an important role in allograft surveillance to screen an acute rejection episode after heart transplantation (HT), to diagnose an unknown cause of cardiomyopathies (CMP) or to reveal a cardiac tumor. However, the procedure is not risk free. OBJECTIVE: The main objective of this research was to describe our experience with EMB during the last 33 years comparing surgical risk between HT versus no-HT patients. METHOD: We analyzed retrospectively the data of 5347 EMBs performed from 1978 to 2011 (33 years). For surveillance of acute rejection episodes after HT we performed 3564 (66.7%), whereas 1777 (33.2%) for CMP diagnosis, and 6 (1.0%) for cardiac tumor identification. RESULTS: The main complications due to EMB were divided into 2 groups to facilitate analysis: major complications associated with potential death risk, and minor complications. The variables that showed a significant difference in the HT group were as follows: tricuspid injury (.0490) and coronary fistula (.0000). Among the no-HT cohort they were insufficient fragment (.0000), major complications (.0000) and total complications (.0000). CONCLUSIONS: EMB can be accomplished with a low risk of complications and high effectiveness to diagnose CMP and rejection after HT. However, the risk is great among patients with CMP due to their anatomic characteristics. Children also constitute a risk group for EMB due to their small size in addition to the heart disease. The risk of injury to the tricuspid valve was higher among the HT group.

Ecocardiografia por Doppler tecidual no diagnóstico de rejeição após transplante cardíaco / Tissue doppler echocardiography in the diagnosis of heart transplantation rejection / Ecocardiografía con Doppler tisular en el diagnóstico de rechazo después de transplante cardíaco

FUNDAMENTO: A biópsia endomiocárdica (BEM) é o método padrão-ouro para o diagnóstico de rejeição celular (RC) após transplante cardíaco (TC). OBJETIVO: Testar a hipótese de que o exame de imagem por Doppler tecidual (IDT) pode detectar RC > 3A e agregar informação diagnóstica, comparado ao Doppler convencional. MÉTODOS: Cinquenta e quatro pacientes com TC foram submetidos à BEM e estudo ecocardiográfico através de IDT em até 24 horas. Comparamos os pacientes com TC e RC > 3A com pacientes com TC e RC < 3A, com um grupo controle normal (13 pacientes). Foram medidas através da IDT, as velocidades sistólica (S), diastólica precoce (e'), diastólica tardia (a') relação das velocidades e'/a' no anel ventricular esquerdo, nos segmentos basal e médio das paredes septal (SEP), lateral (LAT), inferior (INF) e no anel ventricular direito. RESULTADOS: Os pacientes com TC mostraram RC > 3A em 39/129 (30,2 por cento) das BEM. O melhor preditor isolado para o diagnóstico de RC foi a a'LAT, com sensibilidade de 76,3 por cento, especificidade de 73,8 por cento (p = 0,001). Na análise multivariada, a a'LAT (p = 0,001), a'SEP (p = 0,002), relação e'/a' LAT (p = 0,006), relação e'Mitral/ e'LAT (p = 0,014), SINF (p = 0,009) foram preditores de RC > 3A. Obtivemos um escore com sensibilidade de 88,2 por cento, acurácia de 79,6 por cento, e valor preditivo negativo de 92,9 por cento para diagnosticar RC > 3A. O Doppler convencional (fluxo mitral e pulmonar venoso) não foi relevante para predizer a RC > 3A. CONCLUSÃO: O estudo de IDT agregou informação diagnóstica para predizer RC > 3A quando comparado ao Doppler convencional. O modelo baseado em IDT pode ser tornar um método em potencial para detectar RC > 3A após TC.

BACKGROUND: Endomyocardial biopsy (EMB) is the gold standard method for the diagnosis of cellular rejection (CR) after heart transplantation (HT). OBJECTIVE: To test the hypothesis that tissue Doppler imaging (TDI) could detect CR > 3A and add diagnostic information compared to conventional Doppler. METHODS: Fifty-four HT patients underwent 129 EMB and a TDI echocardiographic study within 24 hours. We compared HT patients with CR > 3A versus HT patients with CR < 3A, with a normal matched control group (13 patients). We measured TDI systolic (S), early diastolic (e'), late diastolic (a') velocities and e'/a' ratio in the left ventricular annulus, basal and medium (mid) segments of the septal (SEP), lateral (LAT), inferior (INF), anterior (ANT) walls; and in the right ventricular annulus. RESULTS: HT patients showed CR > 3A in 39/129 (30.2 percent) EMB. The best isolated predictor for CR diagnosis was a'LAT, with a sensitivity of 76.3 percent, specificity of 73.8 percent (p = 0.001). In the multivariate analysis, a'LAT (p = 0.001), a'SEP (p = 0.002), e'/a' LAT ratio (p = 0.006), e'Mitral/ e'LAT ratio (p = 0.014), SINF (p = 0.009) predicted CR > 3A. We obtained a score with a sensitivity of 88.2 percent, accuracy of 79.6 percent and negative predictive value of 92.9 percent to diagnose CR > 3A. Conventional Doppler (mitral and pulmonary venous flow) was not relevant to predict CR > 3A. CONCLUSION: TDI added diagnostic information to predict CR > 3A compared to conventional Doppler. A TDI-based model could become a potential method to detect CR > 3A after Heart Transplantation.

FUNDAMENTO: La biopsia endomiocárdica (BEM) es el método gold standard para el diagnóstico de rechazo celular (RC) después de transplante cardíaco (TC). OBJETIVO: Testear la hipótesis de que el examen de imagen con Doppler tisular (IDT) puede detectar RC > 3A y agregar información diagnóstica, comparado al Doppler convencional. MÉTODOS: Cincuenta y cuatro pacientes con TC fueron sometidos a BEM y estudio ecocardiográfico a través de IDT en hasta 24 horas. Comparamos los pacientes con TC y RC > 3A con pacientes con TC y RC < 3A, con un grupo control normal (13 pacientes). Fueron medidas a través de la IDT, las velocidades sistólica (S), diastólica precoz (e`), diastólica tardía (a') relación de las velocidades e'/a' en el anillo ventricular izquierdo, en los segmentos basal y medio de las paredes septal (SEP), lateral (LAT), inferior (INF) y en el anillo ventricular derecho. RESULTADOS: Los pacientes con TC mostraron RC > 3A en 39/129 (30,2 por ciento) de las BEM. El mejor predictor aislado para el diagnóstico de RC fue la a'LAT, con sensibilidad de 76,3 por ciento, especificidad de 73,8 por ciento (p = 0,001). En el análisis multivariado, la a'LAT (p = 0,001), a'SEP (p = 0,002), relación e'/a' LAT (p = 0,006), relación e'Mitral/e'LAT (p = 0,014), SINF (p = 0,009) fueron predictores de RC > 3A. Obtuvimos un escore con sensibilidad de 88,2 por ciento, precisión de 79,6 por ciento, y valor predictivo negativo de 92.9 por ciento para diagnosticar RC > 3A . El Doppler convencional (flujo mitral y pulmonar venoso) no fue relevante para predecir la RC > 3A. CONCLUSIÓN: El estudio de IDT agregó información diagnóstica para predecir RC > 3A cuando fue comparado al Doppler convencional. El modelo basado en IDT puede volverse un método en potencial para detectar RC > 3A después de TC.