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1.
J Cardiovasc Magn Reson ; 22(1): 49, 2020 06 29.
Artigo em Inglês | MEDLINE | ID: mdl-32600420

RESUMO

BACKGROUND: The right ventricle (RV) often fails when functioning as the systemic ventricle, but the cause is not understood. We tested the hypothesis that myofiber organization is abnormal in the failing systemic right ventricle. METHODS: We used diffusion-weighted cardiovascular magnetic resonance imaging to examine 3 failing hearts explanted from young patients with a systemic RV and one structurally normal heart with postnatally acquired RV hypertrophy for comparison. Diffusion compartment imaging was computed to separate the free diffusive component representing free water from an anisotropic component characterizing the orientation and diffusion characteristics of myofibers. The orientation of each anisotropic compartment was displayed in glyph format and used for qualitative description of myofibers and for construction of tractograms. The helix angle was calculated across the ventricular walls in 5 locations and displayed graphically. Scalar parameters (fractional anisotropy and mean diffusivity) were compared among specimens. RESULTS: The hypertrophied systemic RV has an inner layer, comprising about 2/3 of the wall, composed of hypertrophied trabeculae and an epicardial layer of circumferential myofibers. Myofibers within smaller trabeculae are aligned and organized with parallel fibers while larger, composite bundles show marked disarray, largely between component trabeculae. We observed a narrow range of helix angles in the outer, compact part of the wall consistent with aligned, approximately circumferential fibers. However, there was marked variation of helix angle in the inner, trabecular part of the wall consistent with marked variation in fiber orientation. The apical whorl was disrupted or incomplete and we observed myocardial whorls or vortices at other locations. Fractional anisotropy was lower in abnormal hearts while mean diffusivity was more variable, being higher in 2 but lower in 1 heart, compared to the structurally normal heart. CONCLUSIONS: Myofiber organization is abnormal in the failing systemic RV and might be an important substrate for heart failure and arrhythmia. It is unclear if myofiber disorganization is due to hemodynamic factors, developmental problems, or both.


Assuntos
Imagem de Difusão por Ressonância Magnética , Cardiopatias Congênitas/diagnóstico por imagem , Insuficiência Cardíaca/diagnóstico por imagem , Ventrículos do Coração/diagnóstico por imagem , Miocárdio/patologia , Miofibrilas/patologia , Disfunção Ventricular Direita/diagnóstico por imagem , Função Ventricular Direita , Adolescente , Pré-Escolar , Feminino , Cardiopatias Congênitas/patologia , Cardiopatias Congênitas/fisiopatologia , Cardiopatias Congênitas/cirurgia , Insuficiência Cardíaca/patologia , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/cirurgia , Transplante de Coração , Ventrículos do Coração/patologia , Ventrículos do Coração/fisiopatologia , Ventrículos do Coração/cirurgia , Humanos , Masculino , Valor Preditivo dos Testes , Disfunção Ventricular Direita/patologia , Disfunção Ventricular Direita/fisiopatologia , Disfunção Ventricular Direita/cirurgia , Adulto Jovem
2.
Expert Rev Cardiovasc Ther ; 18(5): 289-308, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32437212

RESUMO

INTRODUCTION: Because end-stage heart failure (HF) often involves both ventricles even if its initial cause was left-sided heart disease, assessment of RV size, geometry and function before, during and after LVAD implantation is of crucial importance. AREAS COVERED: This review discusses the usefulness, benefits, particular challenges and limits of RV assessment in patients with end-stage HF due to primarily impaired LV function who necessitate LVAD support, with or without an additional RV mechanical support. EXPERT OPINION: Although LV unloading often induces reduction of the pulmonary vascular resistance facilitating RV reverse remodeling and functional improvement, drug-refractory RVF after LVAD implantation is not always avoidable. Therefore, patients who need a temporary or long-term biventri-cular mechanical support should already be identified preoperatively or at the latest intraoperatively. Proper assessment of RV function and its adaptability to hemodynamic overloading before LVAD implantation can predict post-implant RVF, thus helping to avoid complications generated by unforeseen RVF in LVAD recipients. Close monitoring of RV size, geometry and function in LVAD recipients with and without additional RV mechanical support is essential for early recognition of imminent RVF in those without RV support and for detection of RV recovery and weaning decision-making in those with a RV support.


Assuntos
Insuficiência Cardíaca/cirurgia , Coração Auxiliar , Disfunção Ventricular Direita/cirurgia , Insuficiência Cardíaca/fisiopatologia , Ventrículos do Coração/fisiopatologia , Hemodinâmica , Humanos
3.
Arq Bras Cardiol ; 114(4): 638-644, 2020 04.
Artigo em Inglês, Português | MEDLINE | ID: mdl-32074202

RESUMO

BACKGROUND: The practice of screening for complications has provided high survival rates among heart transplantation (HTx) recipients. OBJECTIVES: Our aim was to assess whether changes in left ventricular (LV) and right ventricular (RV) global longitudinal strain (GLS) are associated with cellular rejection. METHODS: Patients who underwent HTx in a single center (2015 - 2016; n = 19) were included in this retrospective analysis. A total of 170 biopsies and corresponding echocardiograms were evaluated. Comparisons were made among biopsy/echocardiogram pairs with no or mild (0R/1R) evidence of cellular rejection (n = 130 and n = 25, respectively) and those with moderate (2R) rejection episodes (n=15). P-values < 0.05 were considered statistically significant Results: Most patients were women (58%) with 48 ± 12.4 years of age. Compared with echocardiograms from patients with 0R/1R rejection, those of patients with 2R biopsies showed greater LV posterior wall thickness, E/e' ratio, and E/A ratio compared to the other group. LV systolic function did not differ between groups. On the other hand, RV systolic function was more reduced in the 2R group than in the other group, when evaluated by TAPSE, S wave, and RV fractional area change (all p < 0.05). Furthermore, RV GLS (-23.0 ± 4.4% in the 0R/1R group vs. -20.6 ± 4.9% in the 2R group, p = 0.038) was more reduced in the 2R group than in the 0R/1R group. CONCLUSION: In HTx recipients, moderate acute cellular rejection is associated with RV systolic dysfunction as evaluated by RV strain, as well as by conventional echocardiographic parameters. Several echocardiographic parameters may be used to screen for cellular rejection.


Assuntos
Transplante de Coração , Disfunção Ventricular Direita , Adulto , Ecocardiografia , Feminino , Rejeição de Enxerto , Ventrículos do Coração , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Disfunção Ventricular Esquerda , Disfunção Ventricular Direita/cirurgia , Função Ventricular Direita
5.
Eur J Cardiothorac Surg ; 56(5): 904-910, 2019 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-31323661

RESUMO

OBJECTIVES: Right ventricular pressure overload, which can result in restrictive right ventricular physiology, predicts slow recovery after biventricular repair of congenital heart defects. The goal of the study was to assess how extubation in the operating room influences the postoperative course in these patients. METHODS: Between January 2013 and June 2017, a total of 65 children [median age 0.96 (0.13-9.47) years; median weight 8 (3.05-25.8) kg] with right ventricular pressure overload underwent an intracardiac correction. The most common malformations were tetralogy of Fallot (n = 34) and double outlet right ventricle with pulmonary stenosis (n = 11). The patients were divided into 2 groups: the first (n = 36) comprised late extubated (LE) and the second (n = 29), early extubated (EE) children, immediately after chest closure in the operating room. Preoperative, perioperative and postoperative records were analysed retrospectively. RESULTS: Children who had EE had a lower heart rate (EE 124.2 vs LE 133.6 bpm; P = 0.03), higher arterial blood pressure (systolic: EE 87.9 ± 9.35 vs LE 81.4 ± 12.0 mmHg; P = 0.029; diastolic: EE 51.1 ± 6.5 vs LE 45.9 ± 6.64 mmHg; P = 0.003), lower central venous pressure (EE 8.6 ± 1.89 mmHg vs LE 9.9 ± 2.42 mmHg; P = 0.03), fewer pleural effusions in the first 6 postoperative days (EE 1.38 ml/kg/day vs LE 5.98 ml/kg/day; P = 0.009), shorter time of dopamine support ≥3 µg/kg (EE 7.29 ± 12.26 h vs LE 34.78 ± 38.05 h, P < 0.001), shorter stays in the intensive care unit (EE 2.7 ± 2.67 vs LE 5.0 ± 4.77 days, P = 0.001) and hospital (EE 11.8 ± 4.79 vs LE 15.5 ± 7.8 days; P = 0.022). CONCLUSIONS: Extubation in the operating room of children with right ventricular pressure overload undergoing biventricular correction is feasible and safe and has a beneficial effect on the postoperative course.


Assuntos
Extubação , Ventrículos do Coração , Disfunção Ventricular Direita , Pressão Ventricular/fisiologia , Extubação/efeitos adversos , Extubação/métodos , Extubação/mortalidade , Extubação/estatística & dados numéricos , Pressão Sanguínea/fisiologia , Criança , Pré-Escolar , Feminino , Cardiopatias Congênitas/fisiopatologia , Cardiopatias Congênitas/cirurgia , Frequência Cardíaca/fisiologia , Ventrículos do Coração/fisiopatologia , Ventrículos do Coração/cirurgia , Humanos , Lactente , Masculino , Disfunção Ventricular Direita/fisiopatologia , Disfunção Ventricular Direita/cirurgia
7.
Curr Cardiol Rep ; 21(8): 82, 2019 07 05.
Artigo em Inglês | MEDLINE | ID: mdl-31278558

RESUMO

PURPOSE OF REVIEW: Right ventricular (RV) failure in patients with pulmonary arterial hypertension (PAH) and left ventricular assist device (LVAD) is associated with increased hospitalizations, worsening functional class, and poor survival. Accurate RV function assessment is essential in diagnosing RV failure, guiding therapies, and determining prognosis. Noninvasive imaging techniques provide fast and reliable quantification of RV morphology and function. RECENT FINDINGS: We review echocardiography, nuclear medicine, and cardiac magnetic resonance imaging (MRI) uses for RV function assessment in patients with PAH and LVAD. We identify current knowledge gaps in utilizing noninvasive tests to assess RV function. Echocardiography is most widely used to quantify RV function in patients with PAH and LVAD, followed by cardiac MRI for RV morphology and function measurement in PAH patients. The first-pass radionuclide angiography with radiolabeled RBC is the gold standard for calculating RV function. Gated blood pool SPECT can be an alternative as it separates the cardiac chambers well and provides accurate assessment of the RV function with high reproducibility, which is particularly useful for monitoring treatment. More research is needed to compare and validate these modalities in evaluating RV function.


Assuntos
Angiografia/métodos , Ecocardiografia/métodos , Coração Auxiliar , Imagem por Ressonância Magnética/métodos , Hipertensão Arterial Pulmonar/cirurgia , Disfunção Ventricular Direita/diagnóstico por imagem , Função Ventricular Direita/fisiologia , Ventrículos do Coração/fisiopatologia , Humanos , Imagem Cinética por Ressonância Magnética , Hipertensão Arterial Pulmonar/complicações , Hipertensão Arterial Pulmonar/fisiopatologia , Reprodutibilidade dos Testes , Disfunção Ventricular Direita/fisiopatologia , Disfunção Ventricular Direita/cirurgia
8.
J Cardiol ; 74(3): 217-222, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31230902

RESUMO

BACKGROUND: Percutaneous pulmonary valve implantation (PPVI) numbers are rising but are still minor compared to surgery due to several contraindications. We sought to analyze the impact of PPVI compared to standard surgery in an unselected cohort with dysfunctional right ventricular outflow tract (RVOT). Reasons for PPVI failure and possible contraindications were explored. METHODS: Between 2010 and 2015 all consecutive patients who underwent surgery or intervention for a dysfunctional RVOT were investigated. RESULTS: A total of 382 cases was identified - 246 patients underwent successful valve insertion: 166 surgeries (166/246=67.4%) with 55/166 homografts (33.1%), 106 Contegra® grafts (63.8%), 5 Hancock valves (3.0%). Overall, 70/246 patients presented a priori with an enlarged RVOT>28mm (28.5%) not appropriate for PPVI and 14/246 (5.7%) had additional defects necessitating surgery. Some 31/246 patients had surgery for initial repair of congenital defects or were too small (<20kg) for PPVI (12.6%). 80 underwent successful PPVI (32.5% of 246 valves implanted) [51 Edwards Sapien® valves (63.7%), 29 Melody valves (36.3%)]. The RVOT was too large for PPVI in 22/246 patients (8.9%). A total 20/246 patients (8.1%) showed coronary compression after balloon interrogation. In 4/246 patients PPVI was not possible due to technical issues (1.4%). CONCLUSION: PPVI could be performed successfully in 80/382 patients (20.9%). An enlarged RVOT, small patient size, and coronary compression were the major obstacles for interventional management. Future developments for larger RVOTs and smaller body weight may expand the indication for PPVI.


Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Implante de Prótese de Valva Cardíaca/efeitos adversos , Próteses Valvulares Cardíacas/efeitos adversos , Insuficiência da Valva Pulmonar/cirurgia , Valva Pulmonar/cirurgia , Adolescente , Criança , Estudos de Coortes , Contraindicações , Feminino , Implante de Prótese de Valva Cardíaca/métodos , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Insuficiência da Valva Pulmonar/complicações , Insuficiência da Valva Pulmonar/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Disfunção Ventricular Direita/complicações , Disfunção Ventricular Direita/cirurgia
9.
J Cardiothorac Surg ; 14(1): 110, 2019 Jun 15.
Artigo em Inglês | MEDLINE | ID: mdl-31202281

RESUMO

BACKGROUND: Constrictive Pericarditis(CP) can be viewed as a constellation of syndromes resulting from compression of the heart, etiologies, course and types are well discussed in other reports. However, localized CP as a cause of right heart failure is rare, and presentation with interposed fluid under-pressure is extremely odd. CASE REPORT: A case of C.X. Z, male aged 39 years old, who presented to our department with sudden onset of symptoms of subacute right heart failure due localized CP. In January, 2018 C.X.Z presented to the county hospital with complaints of 10-day history of transient mild bilateral pedal edema. He was managed on diuretic therapy and symptoms resolved completely. 10 months later, he suddenly presented to the local facility with symptoms of subacute right heart failure. 7 days after on-set of symptoms, his condition shifted from NYHA I to III-IV. Although wake-up chest radiography appeared normal, standard medical therapy yielded no positives results. He was referred to our hospital, upon which after echocardiography and computed tomography investigations, aforementioned diagnosis was made. We performed off-pump partial pericardiectomy with no complications. After operation, he received analgesics and diuretics for pain and edema(ascites) respectively. He was discharged 7-days after operation on analgesics only, with no symptoms of right heart failure. CONCLUSION: Localized constrictive pericarditis as a cause of subacute right heart failure (RHF) has never been reported elsewhere, and presentation with interposed fluid is extremely odd. Progressive symptoms of Acute RHF in the absence of typical radiologic clue 'egg-shell' should heighten suspicion index of CP.


Assuntos
Insuficiência Cardíaca/diagnóstico , Pericardite Constritiva/diagnóstico , Disfunção Ventricular Direita/diagnóstico , Adulto , Diagnóstico Diferencial , Ecocardiografia , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/cirurgia , Humanos , Masculino , Pericardiectomia , Pericardite Constritiva/complicações , Pericardite Constritiva/diagnóstico por imagem , Pericardite Constritiva/cirurgia , Síndrome , Tomografia Computadorizada por Raios X , Disfunção Ventricular Direita/complicações , Disfunção Ventricular Direita/diagnóstico por imagem , Disfunção Ventricular Direita/cirurgia
10.
JACC Cardiovasc Interv ; 12(16): 1594-1603, 2019 08 26.
Artigo em Inglês | MEDLINE | ID: mdl-31202951

RESUMO

OBJECTIVES: The aim of this study was to report long-term outcomes after percutaneous pulmonary valve implantation (PPVI). BACKGROUND: Excellent short- and mid-term results after PPVI for right ventricular outflow tract (RVOT) dysfunction have been reported. Data on long-term results after PPVI are scarce. METHODS: All 226 patients treated with PPVI at a single institution were prospectively enrolled in a database and included in the study. Follow-up information regarding outcomes was collected. Risk-factor analysis for death and reinterventions was performed. RESULTS: Follow-up data (up to 11 years) were available in 96% of the patients. At the end of the study period, 219 patients (92.8%) still lived with the initially implanted valve. Seven patients died, 2 of them from procedure-related complications. Seventeen patients (7.2%) needed valve replacement surgically (n = 11) or percutaneously (n = 6) for infectious endocarditis (n = 10) or valve degeneration (n = 7). In the remaining patients, the valves retained excellent function, and right ventricular dimensions and exercise capacity improved. A post-interventional RVOT gradient >15 mm Hg was a risk factor for death (hazard ratio: 7.57; 95% confidence interval: 1.26 to 45.38; p = 0.027) and for valve failure (hazard ratio: 3.76; 95% confidence interval: 1.43 to 9.93; p = 0.007). The best outcome was achieved with RVOT pre-stenting and a post-interventional gradient <15 mm Hg, resulting in an estimated event-free survival rate of 88% at 10 years. CONCLUSIONS: Patients after PPVI have excellent long-term outcomes. Right ventricular volumes, function, and exercise capacity improve significantly. A residual RVOT gradient <15 mm Hg was associated with the best outcome.


Assuntos
Cateterismo Cardíaco , Implante de Prótese de Valva Cardíaca , Estenose da Valva Pulmonar/cirurgia , Valva Pulmonar/cirurgia , Disfunção Ventricular Direita/cirurgia , Função Ventricular Direita , Pressão Ventricular , Adolescente , Adulto , Idoso , Valvuloplastia com Balão , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/instrumentação , Cateterismo Cardíaco/mortalidade , Criança , Pré-Escolar , Bases de Dados Factuais , Remoção de Dispositivo , Feminino , Próteses Valvulares Cardíacas , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/instrumentação , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Intervalo Livre de Progressão , Estudos Prospectivos , Falha de Prótese , Valva Pulmonar/diagnóstico por imagem , Valva Pulmonar/fisiopatologia , Estenose da Valva Pulmonar/diagnóstico por imagem , Estenose da Valva Pulmonar/mortalidade , Estenose da Valva Pulmonar/fisiopatologia , Fatores de Risco , Fatores de Tempo , Disfunção Ventricular Direita/diagnóstico por imagem , Disfunção Ventricular Direita/mortalidade , Disfunção Ventricular Direita/fisiopatologia , Adulto Jovem
11.
Am J Physiol Heart Circ Physiol ; 316(5): H1005-H1013, 2019 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-30822119

RESUMO

Right ventricular failure (RVF) is a common cause of death in patients suffering from pulmonary arterial hypertension (PAH). The current treatment for PAH only moderately improves symptoms, and RVF ultimately occurs. Therefore, it is necessary to develop new treatment strategies to protect against right ventricle (RV) maladaptation despite PAH progression. In this study, we hypothesize that local mesenchymal stem cell (MSC) delivery via a novel bioscaffold can improve RV function despite persistent PAH. To test our hypothesis, we induced PAH in adult rats with SU5416 and chronic hypoxia exposure; treated with rat MSCs delivered by intravenous injection, intramyocardial injection, or epicardial placement of a bioscaffold; and then examined treatment effectiveness by in vivo pressure-volume measurement, echocardiography, histology, and immunohistochemistry. Our results showed that compared with other treatment groups, only the MSC-seeded bioscaffold group resulted in RV functional improvement, including restored stroke volume, cardiac output, and improved stroke work. Diastolic function indicated by end-diastolic pressure-volume relationship was improved by the local MSC treatments or bioscaffold alone. Cardiomyocyte hypertrophy and RV fibrosis were both reduced, and von Willebrand factor expression was restored by the MSC-seeded bioscaffold treatment. Overall, our study suggests a potential new regenerative therapy to rescue the pressure-overload failing RV with persistent pulmonary vascular disease, which may improve quality of life and/or survival of PAH patients. NEW & NOTEWORTHY We explored the effects of mesenchymal stem cell-seeded bioscaffold on right ventricles (RVs) of rats with established pulmonary arterial hypertension (PAH). Some beneficial effects were observed despite persistent PAH, suggesting that this may be a new therapy for RV to improve quality of life and/or survival of PAH patients.


Assuntos
Pressão Arterial , Hipertrofia Ventricular Direita/cirurgia , Transplante de Células-Tronco Mesenquimais/métodos , Hipertensão Arterial Pulmonar/cirurgia , Artéria Pulmonar/fisiopatologia , Tecidos Suporte , Disfunção Ventricular Direita/cirurgia , Função Ventricular Direita , Animais , Células Cultivadas , Modelos Animais de Doenças , Fibrose , Hipertrofia Ventricular Direita/etiologia , Hipertrofia Ventricular Direita/metabolismo , Hipertrofia Ventricular Direita/fisiopatologia , Hipóxia/complicações , Indóis , Masculino , Contração Miocárdica , Miocárdio/metabolismo , Miocárdio/patologia , Hipertensão Arterial Pulmonar/etiologia , Hipertensão Arterial Pulmonar/metabolismo , Hipertensão Arterial Pulmonar/fisiopatologia , Pirróis , Ratos Sprague-Dawley , Recuperação de Função Fisiológica , Regeneração , Disfunção Ventricular Direita/etiologia , Disfunção Ventricular Direita/metabolismo , Disfunção Ventricular Direita/fisiopatologia , Remodelação Ventricular , Fator de von Willebrand/metabolismo
12.
Ann Thorac Surg ; 108(3): e153-e155, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-30853593

RESUMO

A 58-year-old woman had medically refractory heart failure due to idiopathic dilated cardiomyopathy. She underwent tricuspid repair and left ventricular assist device implantation for inotropic-dependent heart failure. Because of severe right ventricular dysfunction, she experienced progressive bradycardia and ventricular asystole with electrocardiographic and echocardiographic standstill. Despite the lack of native cardiac activity, she maintained end-organ perfusion with inotropic support until she underwent successful transplantation. This report highlights a case of mechanical circulatory support with an isolated left ventricular assist device implantation even in the absence of native right ventricular function.


Assuntos
Cardiotônicos/uso terapêutico , Insuficiência Cardíaca/cirurgia , Transplante de Coração/métodos , Coração Auxiliar , Implantação de Prótese/efeitos adversos , Disfunção Ventricular Direita/diagnóstico por imagem , Cardiomiopatia Dilatada/complicações , Cardiomiopatia Dilatada/diagnóstico por imagem , Cardiomiopatia Dilatada/tratamento farmacológico , Progressão da Doença , Ecocardiografia/métodos , Eletrocardiografia/métodos , Feminino , Sobrevivência de Enxerto , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/etiologia , Humanos , Pessoa de Meia-Idade , Prognóstico , Implantação de Prótese/métodos , Medição de Risco , Falha de Tratamento , Resultado do Tratamento , Disfunção Ventricular Direita/cirurgia
13.
J Med Case Rep ; 13(1): 30, 2019 Feb 05.
Artigo em Inglês | MEDLINE | ID: mdl-30722790

RESUMO

BACKGROUND: Pulmonary regurgitation is a common complication after tetralogy of Fallot repair, resulting in right ventricular dysfunction, arrhythmia, and sudden death. However, the indications and optimal timing for pulmonary valve replacement are not fully known. We describe a case in which a four-dimensional imaging tool was useful in the decision to re-operate, thus resulting in decreased energy loss and improved right ventricular function after the re-operation for tetralogy of Fallot. CASE PRESENTATION: A 54-year-old Japanese woman visited our hospital due to palpitations and wide QRS tachycardia with persistent tiredness for several months. She underwent repair of tetralogy of Fallot when she was 2-years old. An electrocardiogram showed prolonged QRS duration (199 msec) with a complete right bundle branch block and an echocardiograph demonstrated that her right ventricle was highly enlarged and had poor contraction, and severe pulmonary valve regurgitation with one leaflet flail. Four-dimensional flow magnetic resonance imaging demonstrated that regurgitant volumes and regurgitant fractions of pulmonary regurgitation were calculated as 63.12 ml and 54.0%, respectively. Right ventricular end-diastolic/end-systolic volume index was 169.54/99.76 mL/m2, and the cardiac index was 1.78 L/minute per m2. Flow energy loss was 2.93 mW, which is estimated to be three times higher than normal controls. An electrophysiological study showed an intact anterior internodal pathway and a slow pathway just through the outside of the right atriotomy line scar, which is supposed to cause a re-entry circuit. We decided to perform a pulmonary valve replacement and a right maze procedure. A 27 mm bioprosthetic valve was implanted in the native pulmonary annulus with a supra-annular position. Concomitantly, the right maze procedure was performed. A four-dimensional flow magnetic resonance imaging done 3 months later showed that right ventricular end-diastolic/end-systolic volume index had significantly reduced to 85.24/55.41 mL/m2 and the cardiac index had increased from 1.78 to 2.58 L/minute per m2. Energy loss had greatly improved from 2.93 to 1.48 mW. CONCLUSIONS: A four-dimensional imaging tool was useful in the decision to re-operate, thus resulting in decreased energy loss and improved right ventricular function after the re-operation for tetralogy of Fallot.


Assuntos
Implante de Prótese de Valva Cardíaca/métodos , Imagem por Ressonância Magnética/instrumentação , Insuficiência da Valva Pulmonar/cirurgia , Tetralogia de Fallot/cirurgia , Disfunção Ventricular Direita/cirurgia , Eletrocardiografia , Feminino , Humanos , Pessoa de Meia-Idade , Valva Pulmonar , Insuficiência da Valva Pulmonar/fisiopatologia , Reoperação , Volume Sistólico , Tetralogia de Fallot/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Disfunção Ventricular Direita/etiologia , Disfunção Ventricular Direita/fisiopatologia
14.
Eur Heart J Cardiovasc Imaging ; 20(4): 373-382, 2019 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-30715281

RESUMO

Mechanical circulatory support with continuous-flow left ventricular assist devices (LVADs) has emerged as a viable treatment modality for patients with advanced heart failure. LVAD support results in unique haemodynamic and echocardiographic alterations that must be understood to provide optimal care for these patients. In this review, we propose essential echocardiographic and haemodynamic elements for the assessment of optimal LVAD function based on the literature and the use of simulation software. A key element of LVAD physiology remains the interaction between an unloaded left ventricle and a loaded right ventricle. The echocardiographic assessment and treatment of the pathophysiology of the right-sided part of the heart remains critical to maintaining optimal LVAD support.


Assuntos
Ecocardiografia , Insuficiência Cardíaca/fisiopatologia , Ventrículos do Coração/fisiopatologia , Coração Auxiliar , Disfunção Ventricular Esquerda/fisiopatologia , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/cirurgia , Insuficiência Cardíaca/terapia , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/cirurgia , Coração Auxiliar/efeitos adversos , Hemodinâmica , Humanos , Disfunção Ventricular Esquerda/diagnóstico por imagem , Disfunção Ventricular Esquerda/cirurgia , Disfunção Ventricular Esquerda/terapia , Disfunção Ventricular Direita/diagnóstico por imagem , Disfunção Ventricular Direita/fisiopatologia , Disfunção Ventricular Direita/cirurgia , Disfunção Ventricular Direita/terapia , Função Ventricular/fisiologia
16.
J Cardiothorac Vasc Anesth ; 33(3): 651-660, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30683595

RESUMO

OBJECTIVE: To report the authors' 12 years of experience with intratracheal milrinone administration and to assess the efficacy and limitations of intratracheal milrinone bolus administration for the treatment of unexpected acute right ventricular (RV) failure in patients undergoing cardiac surgery. DESIGN: Retrospective analysis. SETTING: Single-center university hospital. PARTICIPANTS: One hundred seventy-six patients (4.6%) undergoing on-pump cardiac surgery. INTERVENTIONS: Endotracheal tube administration of milrinone (5-mg bolus) after unexpected acute RV failure during separation from cardiopulmonary bypass (CPB) weaning. RV failure was defined as the simultaneous presence of all of the following criteria: (1) hemodynamic instability or difficult separation from CPB with associated elevated central venous pressure or abnormal RV pressure waveform, (2) >20% reduction of RV fractional area change from baseline evaluated by transesophageal echocardiography, and (3) anatomical visualization of impaired or absent RV wall motion by direct intraoperative visual inspection. MEASUREMENTS AND MAIN RESULTS: Intratracheal milrinone administration was found to improve RV failure in 109 patients (61.9%) whereas RV failure persisted in 67 patients (38.1%). Using a multiple logistic regression model, severely decreased left ventricular ejection fraction (<35% v >50%) (adjusted odds ratio [OR] 3.72; 95% confidence interval [CI] 1.2-11.3; p = 0.012), longer CPB time (adjusted OR 1.014; CI 1.01-1.02; p = 0.001) and elevated postoperative fluid balance (adjusted OR 1.39; CI 1.1-1.8; p = 0.02) were found to be significant predictors of persistent RV failure. CONCLUSION: Intratracheal instillation of milrinone was associated with clinical improvement of RV failure occurring during separation from CPB in almost two-thirds of patients. Factors limiting its therapeutic efficacy include severe left ventricular dysfunction, increased fluid balance, and long CPB time.


Assuntos
Ponte Cardiopulmonar/tendências , Cardiotônicos/administração & dosagem , Intubação Intratraqueal/tendências , Milrinona/administração & dosagem , Disfunção Ventricular Direita/tratamento farmacológico , Disfunção Ventricular Direita/cirurgia , Doença Aguda , Idoso , Ecocardiografia Transesofagiana/tendências , Feminino , Insuficiência Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Disfunção Ventricular Direita/diagnóstico por imagem
17.
Eur Heart J Cardiovasc Imaging ; 20(8): 925-931, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-30629127

RESUMO

AIMS: To investigate the utility of novel deep learning (DL) algorithms in recognizing transposition of the great arteries (TGA) after atrial switch procedure or congenitally corrected TGA (ccTGA) based on routine transthoracic echocardiograms. In addition, the ability of DL algorithms for delineation and segmentation of the systemic ventricle was evaluated. METHODS AND RESULTS: In total, 132 patients (92 TGA and atrial switch and 40 with ccTGA; 60% male, age 38.3 ± 12.1 years) and 67 normal controls (57% male, age 48.5 ± 17.9 years) with routine transthoracic examinations were included. Convolutional neural networks were trained to classify patients by underlying diagnosis and a U-Net design was used to automatically segment the systemic ventricle. Convolutional networks were build based on over 100 000 frames of an apical four-chamber or parasternal short-axis view to detect underlying diagnoses. The DL algorithm had an overall accuracy of 98.0% in detecting the correct diagnosis. The U-Net architecture model correctly identified the systemic ventricle in all individuals and achieved a high performance in segmenting the systemic right or left ventricle (Dice metric between 0.79 and 0.88 depending on diagnosis) when compared with human experts. CONCLUSION: Our study demonstrates the potential of machine learning algorithms, trained on routine echocardiographic datasets to detect underlying diagnosis in complex congenital heart disease. Automated delineation of the ventricular area was also feasible. These methods may in future allow for the longitudinal, objective, and automated assessment of ventricular function.


Assuntos
Ecocardiografia , Aprendizado de Máquina , Transposição dos Grandes Vasos/diagnóstico por imagem , Disfunção Ventricular Direita/diagnóstico por imagem , Adulto , Transposição das Grandes Artérias , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Sensibilidade e Especificidade , Transposição dos Grandes Vasos/fisiopatologia , Transposição dos Grandes Vasos/cirurgia , Disfunção Ventricular Direita/fisiopatologia , Disfunção Ventricular Direita/cirurgia
18.
Echocardiography ; 36(1): 150-163, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30592784

RESUMO

The usefulness of two-dimensional transthoracic echocardiography (2DTTE) in the assessment of right heart compression and dysfunction produced by pectus excavatum chest wall deformity has been well described in the literature by several investigators. However, there is a paucity of reports describing incremental value of live/real time three-dimensional transthoracic echocardiography (3DTTE) over the two-dimensional technique in the evaluation of right heart function in these patients. We present a severe case of pectus excavatum chest wall deformity in a young male, in whom 3DTTE provided incremental value over standard 2DTTE in assessing compression of the right heart before surgery and marked improvement in right heart function parameters following surgical repair. In addition, an updated summary of salient features of this deformity, including 2D and 3DTTE findings as well as right heart echocardiographic parameters by both 2D and 3DTTE in normal/healthy subjects summarized from the literature have been provided in a tabular form for comparison.


Assuntos
Ecocardiografia Tridimensional/métodos , Tórax em Funil/complicações , Disfunção Ventricular Direita/etiologia , Adulto , Ecocardiografia/métodos , Tórax em Funil/cirurgia , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Disfunção Ventricular Direita/cirurgia , Adulto Jovem
19.
J Cardiothorac Vasc Anesth ; 33(4): 1105-1121, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30197170

RESUMO

Left ventricular assist device (LVAD) therapy has greatly improved outcomes in patients with end-stage heart failure. However, development of right ventricular failure (RVF) in LVAD recipients is associated with increased long- and short-term morbidity and mortality. The incidence of RVF after LVAD placement is difficult to assess due to the lack of a common definition. Risk-score models attempting to identify patients at risk for RVF prior to the placement of LVADs had equivocal outcomes. With the exception of cardiac magnetic resonance, right ventricle (RV) imaging lacks accuracy. Echocardiographic evaluation is expanded to 3D technology and deformation imaging in an attempt to get further insight into the functional reserve of the RV in states of abnormal RV function. Beyond commonly use agents, pharmacological treatment for RVF and post-bypass vasoplegia in LVAD patients include the off-label use of methylene blue and/or hydroxycobalamin. Communication among the perioperative team may be beneficial for early initiation of temporary right-sided mechanical support in order to avoid RVF-related complications. As long-term RVADs are unavailable, currently approved treatment of prolonged RVF is limited to heart transplantation or the placement of a total artificial heart as bridge-to-transplant. Strategies to improve outcome in this patient population should include better risk stratification for RVF prior to LVAD placement as well as frank discussions about LVAD candidacy in patients ineligible for transplantation. The development of durable right-sided mechanical support would improve the scope of care of LVAD patients developing persistent RVF.


Assuntos
Insuficiência Cardíaca/cirurgia , Ventrículos do Coração/cirurgia , Coração Auxiliar/tendências , Disfunção Ventricular Direita/cirurgia , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/etiologia , Ventrículos do Coração/diagnóstico por imagem , Coração Auxiliar/efeitos adversos , Humanos , Disfunção Ventricular Direita/diagnóstico por imagem , Disfunção Ventricular Direita/etiologia
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