Contrast-enhanced magnetic resonance imaging identifies focal regions of intramyocardial fibrosis in patients with severe aortic valve disease: Correlation with quantitative histopathology.

BACKGROUND: Chronic aortic valve disease (AVD) is characterized by progressive accumulation of interstitial myocardial fibrosis (MF). However, assessment of MF accumulation has only been possible through histologic analyses of endomyocardial biopsies. We sought to evaluate contrast-enhanced magnetic resonance imaging (ce-MRI) as a noninvasive method to identify the presence of increased MF in patients with severe AVD. METHODS: Seventy patients scheduled to undergo aortic valve replacement surgery were examined by cine and ce-MRI in a 1.5-T scanner. Cine images were used for the assessment of left ventricular (LV) volumes, mass, and function. Delayed-enhancement images were used to characterize the regions of MF. In addition, histologic analyses of myocardial samples obtained during aortic valve replacement surgery were used for direct quantification of interstitial MF. Ten additional subjects who died of noncardiac causes served as controls for the quantitative histologic analyses. RESULTS: Interstitial MF determined by histopathologic analysis was higher in patients with AVD than in controls (2.7% +/- 2.0% vs 0.6% +/- 0.2%, P = .001). When compared with histopathologic results, ce-MRI demonstrated a sensitivity of 74%, a specificity of 81%, and an accuracy of 76% to identify AVD patients with increased interstitial MF. There was a significant inverse correlation between interstitial MF and LV ejection fraction (r = -0.67, P < .0001). Accordingly, patients with identifiable focal regions of MF by ce-MRI exhibited worse LV systolic function than those without MF (45% +/- 14% vs 65% +/- 14%, P < .0001). CONCLUSIONS: Contrast-enhanced MRI allows for the noninvasive detection of focal regions of MF in patients with severe AVD. Moreover, patients with identifiable MF by ce-MRI exhibited worse LV functional parameters.

Papillary muscle rupture after blunt chest trauma.

We report a case of anterolateral papillary muscle rupture in a 22-year-old man who had blunt chest trauma caused by a car accident. Transesophageal echocardiography revealed severe mitral regurgitation caused by the rupture. He successfully underwent emergency mitral valve replacement and was discharged 9 days after the surgical correction.

[Left atrial myxoma: three-dimensional echocardiographic assessment]. / Mixoma de átrio esquerdo: avaliação ecocardiográfica tridimensional.

The patient was a 70-year-old female with antecedents of diabetes mellitus and hypertension, being followed up in the outpatient care clinic due to chronic anemia after corrective surgery for angiodysplasia of the proximal jejunum, in whom an image suggestive of left atrial myxoma was found on routine transthoracic echocardiography. Then multiplanar transesophageal echocardiography and 3-dimensional echocardiography were performed, showing the latter better anatomical details of the tumor. The patient underwent exeresis of the mass with anatomicopathological confirmation of the tumor. Three-dimensional echocardiography proved to be a technique that can provide additional contributions to the diagnostic investigation of structural heart diseases.

Mixoma de átrio esquerdo: avaliação ecocardiográfica tridimensional

Mulher de 70 anos, com antecedentes de diabetes mellitus e hipertensão arterial sistêmica, em acompanhamento ambulatorial por anemia crônica após cirurgia corretiva de angiodisplasia de jejuno proximal, apresentou imagem de mixoma em átrio esquerdo em exame ecocardiográfico transtorácico de rotina. Foi submetida a investigação ecocardiográfica transesofágica multiplanar e a estudo ecocardiográfico tridimensional. O ecocardiograma tridimensional propiciou melhor detalhamento anatômico da tumoração. A paciente foi submetida a exérese da massa, com confirmação anatomopatológica. O ecocardiograma tridimensional mostrou ser técnica que apresenta contribuição adicional à investigação diagnóstica das cardiopatias estruturais.

Dissecção da aorta associada a lupus eritematoso sistêmico / Aortic dissection associated with systemic lupus erythematosus

Mulher de 33 anos, com história de hipertensão arterial sistêmica (HAS) há 4 anos e diagnóstico de lupus eritematoso sistêmico (LES) há 3 anos, em uso de doses elevadas de corticóides, há 8 meses apresentando infecções respiratórias de repetição e insuficiência cardíaca congestiva. O estudo hemodinâmico confirmou o diagnóstico de insuficiência aórtica (IA o) com dilatação aneurismática do seio posterior de Valsalva, aorta ascendente de calibre normal e artérias coronárias normais. Foi levada à cirurgia onde foi encontrada dissecção da aorta com desabamento das cúspides aórticas levando à IAo, corrigido através de implante de tubo de pericárdio bovino e suspensão da valva aórtica. No pós-operatório (PO) evoluiu com convulsão focal em hemicorpo esquerdo seguido por hemiparesia à esquerda e infecção respiratória, recebendo alta no 25° dia PO com discreta hemiparesia à E e do ponto de vista cardiovascular em classe funcional I (NYHA), em uso de medicação. Enfatizamos a necessidade de se pensar no diagnóstico de dissecção de aorta em pacientes portadores de LES e IAo, principalmente aqueles que tenham história de HAS e uso de corticosteróides por tempo prolongado

A 33 year-old female patient, with a 4-year history of hypertension plus a 3-year history of systemic lupus erythematosus, who had been taking high dosages of corticosteroids, has shown repetitive respiratory infections and congestive heart failure for the past 8 months. Angiocardiography confirmed the diagnosis of aortic insufficiency with aneurismatic dilation of Valsalva's posterior sinus, ascending aorta of normal diameter and normal coronary arteries. Aortic dissection causing aortic insufficiency due to collapse of aortic leaflets was spotted during the surgery and was corrected by a bovine pericardial tube and suspension of aortic valve. The postoperative (PO) period was complicated by leftsided seizures followed by left hemiparesis and respiratory infection. She was discharged on the 25th PO day with mild left hemiparesis and in functional class I (NYHA), using medicines. We emphasize the need to consider the diagnosis of aortic dissection in patients with systemic lupus erithematosus and aortic insufficiency, specially in those who have a history of systemic arterial hypertension and long-term corticosteroid therapy