RESUMO
BACKGROUND: The ratio of tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) is a validated index of right ventricular-pulmonary arterial (RV-PA) coupling with prognostic value. We determined the predictive value of TAPSE/PASP ratio and adverse clinical outcomes in hospitalized patients with COVID-19. METHODS: Two hundred and twenty-nine consecutive hospitalized racially/ethnically diverse adults (≥18 years of age) admitted with COVID-19 between March and June 2020 with clinically indicated transthoracic echocardiograms (TTE) that included adequate tricuspid regurgitation (TR) velocities for calculation of PASP were studied. The exposure of interest was impaired RV-PA coupling as assessed by TAPSE/PASP ratio. The primary outcome was in-hospital mortality. Secondary endpoints comprised of ICU admission, incident acute respiratory distress syndrome (ARDS), and systolic heart failure. RESULTS: One hundred and seventy-six patients had both technically adequate TAPSE measurements and measurable TR velocities for analysis. After adjustment for age, sex, BMI, race/ethnicity, diabetes mellitus, and smoking status, log(TAPSE/PASP) had a significantly inverse association with ICU admission (p = 0.015) and death (p = 0.038). ROC analysis showed the optimal cutoff for TAPSE/PASP for death was 0.51 mm mmHg-1 (AUC = 0.68). Unsupervised machine learning identified two groups of echocardiographic function. Of all echocardiographic measures included, TAPSE/PASP ratio was the most significant in predicting in-hospital mortality, further supporting its significance in this cohort. CONCLUSION: Impaired RV-PA coupling, assessed noninvasively via the TAPSE/PASP ratio, was predictive of need for ICU level care and in-hospital mortality in hospitalized patients with COVID-19 suggesting utility of TAPSE/PASP in identification of poor clinical outcomes in this population both by traditional statistical and unsupervised machine learning based methods.
Assuntos
COVID-19 , Disfunção Ventricular Direita , Adulto , Humanos , Ecocardiografia Doppler , Prognóstico , Estudos Prospectivos , Aprendizado de Máquina não Supervisionado , Função Ventricular DireitaRESUMO
BACKGROUND: Patients with obstructive hypertrophic cardiomyopathy have increased symptomatic burden. Mavacamten was recently approved for treatment of obstructive hypertrophic cardiomyopathy based on 2 randomized controlled trials. However, its use under real-world conditions and in diverse populations is under-studied. METHODS AND RESULTS: This was a prospective observational cohort study of patients seen at the Johns Hopkins HCM center and prescribed mavacamten for obstructive hypertrophic cardiomyopathy between July 7, 2022 and January 6, 2024. Patients were followed longitudinally, with serial echocardiography and clinical evaluation as mandated by the risk evaluation and mitigation strategy program. Sixty-six patients received mavacamten (mean age 59 years, 47% male, 29% non-White [Black, Hispanic/Latino, Asian, Native Hawaiian or Pacific Islander], 47% obese). Before treatment, all patients had New York Heart Association class II (51.5%) or III (48.5%) heart failure symptoms. Initial maximum peak left ventricular outflow tract gradient was 107±46 mm Hg. Median treatment duration was 9 months. For patients on mavacamten after ≥6 months (n=43), symptoms improved by ≥1 New York Heart Association class in 72% of patients, and peak left ventricular outflow tract gradient decreased by 80±46 mm Hg, eliminating hemodynamically significant left ventricular outflow tract obstruction in 79.1% of patients. Mavacamten was temporarily discontinued in 3 patients due to left ventricular ejection fraction decrease <50%. There were no medication-related adverse events. Effectiveness and safety were similar between White and non-White patients, but symptomatic relief was attenuated in patients with body-mass index ≥35 kg/m2. CONCLUSIONS: Mavacamten was effective and safe when used under real-world conditions in a racially diverse population of symptomatic patients with obstructive hypertrophic cardiomyopathy. Patients with comorbid obesity were less likely to experience symptomatic improvement while on mavacamten.
Assuntos
Cardiomiopatia Hipertrófica , Humanos , Masculino , Cardiomiopatia Hipertrófica/tratamento farmacológico , Cardiomiopatia Hipertrófica/fisiopatologia , Cardiomiopatia Hipertrófica/etnologia , Pessoa de Meia-Idade , Feminino , Estudos Prospectivos , Resultado do Tratamento , Idoso , Benzilaminas/uso terapêutico , Uracila/análogos & derivados , Uracila/uso terapêutico , Uracila/efeitos adversos , Pirimidinonas/uso terapêutico , Pirimidinonas/efeitos adversos , Função Ventricular Esquerda/efeitos dos fármacos , Fatores de Tempo , EcocardiografiaRESUMO
BACKGROUND: Pressure overload resulting from aortic stenosis causes maladaptive ventricular and vascular remodeling that can lead to pulmonary hypertension, heart failure symptoms, and adverse outcomes. Retarding or reversing this maladaptive remodeling and its unfavorable hemodynamic consequences has the potential to improve morbidity and mortality. Preclinical models of pressure overload have shown that phosphodiesterase type 5 inhibition is beneficial; however, the use of phosphodiesterase type 5 inhibitors in patients with aortic stenosis is controversial because of concerns about vasodilation and hypotension. METHODS AND RESULTS: We evaluated the safety and hemodynamic response of 20 subjects with severe symptomatic aortic stenosis (mean aortic valve area, 0.7 ± 0.2 cm(2); ejection fraction, 60 ± 14%) who received a single oral dose of sildenafil (40 or 80 mg). Compared with baseline, after 60 minutes, sildenafil reduced systemic (-12%; P<0.001) and pulmonary (-29%; P=0.002) vascular resistance, mean pulmonary artery (-25%; P<0.001) and wedge (-17%; P<0.001) pressures, and increased systemic (13%; P<0.001) and pulmonary (45%; P<0.001) vascular compliance and stroke volume index (8%; P=0.01). These changes were not dose dependent. Sildenafil caused a modest decrease in mean systemic arterial pressure (-11%; P<0.001) but was well tolerated with no episodes of symptomatic hypotension. CONCLUSIONS: This study shows for the first time that a single dose of a phosphodiesterase type 5 inhibitor is safe and well tolerated in patients with severe aortic stenosis and is associated with improvements in pulmonary and systemic hemodynamics resulting in biventricular unloading. These findings support the need for longer-term studies to evaluate the role of phosphodiesterase type 5 inhibition as adjunctive medical therapy in patients with aortic stenosis.
Assuntos
Estenose da Valva Aórtica/tratamento farmacológico , Estenose da Valva Aórtica/fisiopatologia , Nucleotídeo Cíclico Fosfodiesterase do Tipo 5/metabolismo , Inibidores da Fosfodiesterase 5/administração & dosagem , Piperazinas/administração & dosagem , Circulação Pulmonar/efeitos dos fármacos , Sulfonas/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/diagnóstico por imagem , Pressão Sanguínea/efeitos dos fármacos , Complacência (Medida de Distensibilidade)/efeitos dos fármacos , Feminino , Humanos , Masculino , Inibidores da Fosfodiesterase 5/efeitos adversos , Piperazinas/efeitos adversos , Purinas/administração & dosagem , Purinas/efeitos adversos , Índice de Gravidade de Doença , Citrato de Sildenafila , Volume Sistólico/efeitos dos fármacos , Sulfonas/efeitos adversos , Resultado do Tratamento , Ultrassonografia , Resistência Vascular/efeitos dos fármacos , Função Ventricular Esquerda/efeitos dos fármacos , Função Ventricular Direita/efeitos dos fármacosRESUMO
BACKGROUND: The best regional anesthesia plan with the best clinical results for Carotid endarterectomy (CEA) has not been defined yet. METHODS: Prospective multicentric observational study of two non-randomized matched cohorts including patients undergoing elective unilateral CEA (N.=100) between January-October 2021. Main outcomes were cerebral oximetry measurements, verbal numeric pain score assessment, peripheral nerve blockades and in-hospital stay. The main objective is to compare results achieved after carotid endarterectomy (CEA) performed under loco-regional blockade (LRB) versus general anesthesia (GA), in terms of intraoperative hemodynamic and neurologic variability. Patients undergoing LRB were performed under ultrasound (US) guidance and mild sedation. RESULTS: The LRB and GA groups showed no differences in comorbidities and risk factors. However, there was a significant difference in the intraoperative hemodynamic behavior due to the amount of vasoactive drugs used (0% vs. 16% for phenylephrine, P=0.006). The results showed neurological stability through the cerebral oximetry measurements during the procedure except for the left hemisphere de-clamp values, which were higher in the GA group (68.7±9.9 vs. 72.7±8.8; P=0.035). There were also significant differences in the verbal pain scale scores assessed 6 hours and 12 hours after the procedure; better pain control was evidenced in the LRB group (0[0-1] vs. 1[0-3], P=0.01; 1[0.5-2] vs. 0[0-2], P=0.01). An increased transient hypoglossal and laryngeal nerves blockade was observed in the LRB group (30% vs. 4%; P<0.001). The in-hospital length of stay was longer in the GA group (77.2±36.3 hours vs. 129.1±41.1 hours; P<0.001). CONCLUSIONS: Although the use of intermediate-deep cervical plexus blockade for CEA confers similar neurologic stability as GA does, there is a difference on the hemodynamic behaviour due to the differences in vasoactive drug consumption. Loco-regional techniques provide a better postoperative pain control and shorten in-hospital length of stay.
Assuntos
Anestesia por Condução , Endarterectomia das Carótidas , Humanos , Endarterectomia das Carótidas/efeitos adversos , Endarterectomia das Carótidas/métodos , Circulação Cerebrovascular , Resultado do Tratamento , Oximetria , Anestesia por Condução/métodos , Anestesia Geral/efeitos adversos , Ultrassonografia de Intervenção/métodos , Dor/etiologiaRESUMO
OBJECTIVE: the aim of this study was to assess the results of mechanochemical endovenous ablation either in the primary or recurrent saphenous vein insufficiency, including only patients with veno-venous shunt type III. METHODS: retrospective analysis of a prospective study of patients with symptomatic chronic venous insufficiency who underwent ClariVein® technique. A total of 134 saphenous veins were included between August 2017 and August 2018. Follow-up was performed by Duplex ultrasound at 1, 6 and 12 months. Primary endpoints were technical and anatomical success. Secondary endpoints were the need for further treatment of varicose collateral veins by sclerotherapy, outcomes regarding recurrent insufficiency and clinical success. RESULTS: A total of 111 great saphenous veins and 23 small saphenous veins were treated with a technical success of 95.6%. The overall anatomical success rates at 1, 6 and 12 month were 96.2%, 88.8% and 84.4%, respectively, without differences between primary and recurrent insufficiency. Deferred sclerotherapy over varicose collaterals was carried out in 28% of the patients with anatomical success. Clinical improvement was achieved in 87.3%. CONCLUSIONS: MOCA technique has proven to be an effective technique, although additional treatment over varicose collaterals could be necessary in up to one-third. Atrophy of the saphenous vein and the lack of persistent varicose collateral veins during follow-up seem to be indicators of successful therapy.
Assuntos
Procedimentos Endovasculares , Varizes , Insuficiência Venosa , Humanos , Estudos Prospectivos , Estudos Retrospectivos , Veia Safena/diagnóstico por imagem , Veia Safena/cirurgia , Soluções Esclerosantes/uso terapêutico , Escleroterapia , Fatores de Tempo , Resultado do Tratamento , Varizes/diagnóstico por imagem , Varizes/cirurgia , Insuficiência Venosa/diagnóstico por imagem , Insuficiência Venosa/cirurgiaRESUMO
Common causes of heart failure are associated with derangements in myocardial fuel utilization. Evidence is emerging that metabolic abnormalities may contribute to the development and progression of myocardial disease. The peroxisome proliferator-activated receptor (PPAR) family of nuclear receptor transcription factors has been shown to regulate cardiac fuel metabolism at the gene expression level. The three PPAR family members (alpha, beta/delta and gamma) are uniquely suited to serve as transducers of developmental, physiological, and dietary cues that influence cardiac fatty acid and glucose metabolism. This review describes murine PPAR loss- and gain-of-function models that have shed light on the roles of these receptors in regulating myocardial metabolic pathways and have defined key links to disease states including the hypertensive and diabetic heart.
Assuntos
Metabolismo Energético , Ácidos Graxos/metabolismo , Regulação da Expressão Gênica , Glucose/metabolismo , Insuficiência Cardíaca/metabolismo , Miocárdio/metabolismo , Receptores Ativados por Proliferador de Peroxissomo/metabolismo , Animais , Diabetes Mellitus/genética , Diabetes Mellitus/metabolismo , Metabolismo Energético/genética , Ácidos Graxos/genética , Regulação da Expressão Gênica/genética , Glucose/genética , Insuficiência Cardíaca/genética , Humanos , Hipertensão/genética , Hipertensão/metabolismo , Camundongos , Receptores Ativados por Proliferador de Peroxissomo/genéticaRESUMO
â¢UAV is a rare congenital anomaly that leads to severe symptomatic stenosis.â¢Echocardiography plays a critical role in the evaluation of aortic stenosis.â¢Correctly distinguishing between UAV and BAV is relevant in determining intervention.
RESUMO
Echocardiography is the foundation for diagnostic cardiac testing, allowing for direct identification and management of various conditions. Point-of-care ultrasound (POCUS) has emerged as an invaluable tool for bedside diagnosis and management. The objective of this review is to address the current use and clinical applicability of POCUS to identify, triage, and manage a wide spectrum of cardiac conditions. POCUS can change diagnosis and management decisions of various cardiovascular conditions in a range of settings. In the outpatient setting, it is used to risk stratify and diagnose a variety of medical conditions. In the emergency department (ED) and critical care settings, it is used to guide triage and critical care interventions. Furthermore, the skills needed to perform POCUS can be taught to noncardiologists in a way that is retained and allows identification of normal and grossly abnormal cardiac findings. Various curricula have been developed that teach residents and advanced learners how to appropriately employ point-of-care ultrasound. In conclusion, POCUS can be a useful adjunct to the physical exam, particularly in critical care applications.
Assuntos
Doenças Cardiovasculares/diagnóstico por imagem , Ecocardiografia/métodos , Sistemas Automatizados de Assistência Junto ao Leito , Humanos , Medição de Risco , TriagemRESUMO
In urban populations, worsening renal function (WRF) is well established in patients hospitalized with acute decompensated heart failure with preserved ejection fraction (HFpEF). However, the mechanisms for development of WRF in the setting of acute HF in HFpEF are unclear. In the present study, we sought to characterize conventional echocardiographic measures of right ventricular (RV) chamber size and function to determine whether RV dysfunction and/or adverse RV remodeling is related to WRF in patients with HFpEF. Our study included 104 adult patients with HFpEF (EF ≥ 55%) with technically adequate 2-dimensional echocardiograms performed during their hospitalization for acute decompensated HF to determine echocardiographic predictors of WRF, defined as a serum creatinine (Cr) increase of ≥ 0.3 mg/dl within 72 hours of hospitalization. Thirty-eight of the 104 patients (36%) developed WRF (mean Cr increase = 0.9 ± 0.1 mg/dl) during the hospitalization (mean age ± SD of 64 ± 12 years, 27 women [71%], 29 black [76%]). There were no significant differences in LV medial E/e' ratio and RV systolic pressure by WRF status or in linear dimensions of RV and right atrial size. RV fractional area change, a measure of RV function, however, was significantly decreased in HFpEF patients with WRF compared with the no WRF group (p = 0.003), whereas RV free wall thickness (p = 0.001) was increased. In conclusion, linear and volumetric measures of dimensions of right atrial and RV chamber size did not distinguish HFpEF patients with and without WRF. However, in HFpEF patients with WRF during acute HF hospitalization, there was a significant decrease in RV function and a significant increase in RV free wall thickness compared with matched patients with no WRF. These findings suggest that adverse RV remodeling and RV dysfunction occur in HFpEF patients with WRF.
Assuntos
Taxa de Filtração Glomerular/fisiologia , Insuficiência Cardíaca/fisiopatologia , Ventrículos do Coração/fisiopatologia , Insuficiência Renal/etiologia , Volume Sistólico/fisiologia , Disfunção Ventricular Direita/fisiopatologia , Função Ventricular Direita/fisiologia , Progressão da Doença , Ecocardiografia Doppler , Feminino , Seguimentos , Insuficiência Cardíaca/complicações , Ventrículos do Coração/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Insuficiência Renal/fisiopatologia , Estudos Retrospectivos , Disfunção Ventricular Direita/diagnóstico , Disfunção Ventricular Direita/etiologia , Remodelação VentricularAssuntos
Competência Clínica , Infecções por Coronavirus/epidemiologia , Currículo , Ecocardiografia , Educação de Pós-Graduação em Medicina/organização & administração , Pandemias/estatística & dados numéricos , Pneumonia Viral/epidemiologia , COVID-19 , Técnicas de Imagem Cardíaca/métodos , Doenças Cardiovasculares/diagnóstico por imagem , Infecções por Coronavirus/prevenção & controle , Feminino , Humanos , Controle de Infecções/métodos , Masculino , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Estados UnidosRESUMO
BACKGROUND: The diabetic heart exhibits increased left ventricular (LV) mass and reduced ventricular function. However, this relationship has not been studied in patients with aortic stenosis (AS), a disease process that causes LV hypertrophy and dysfunction through a distinct mechanism of pressure overload. The aim of this study was to determine how diabetes mellitus (DM) affects LV remodeling and function in patients with severe AS. METHODS AND RESULTS: Echocardiography was performed on 114 patients with severe AS (mean aortic valve area [AVA], 0.6 cm(2)) and included measures of LV remodeling and function. Multivariable linear regression models investigated the independent effect of DM on these aspects of LV structure and function. Compared to patients without diabetes (n=60), those with diabetes (n=54) had increased LV mass and LV end-systolic and end-diastolic dimensions, and decreased LV ejection fraction (EF) and longitudinal systolic strain (all P<0.01). In multivariable analyses adjusting for age, sex, systolic blood pressure, AVA, body surface area, and coronary disease, DM was an independent predictor of increased LV mass (ß=26 g, P=0.01), LV end-systolic dimension (ß=0.5 cm, P=0.008), and LV end-diastolic dimension (ß=0.3 cm, P=0.025). After also adjusting for LV mass, DM was associated with reduced longitudinal systolic strain (ß=1.9%, P=0.023) and a trend toward reduced EF (ß=-5%, P=0.09). Among patients with diabetes, insulin use (as a marker of disease severity) was associated with larger LV end-systolic dimension and worse LV function. LV mass was a strong predictor of reduced EF and systolic strain (both P<0.001). CONCLUSIONS: DM has an additive adverse effect on hypertrophic remodeling (increased LV mass and larger cavity dimensions) and is associated with reduced systolic function in patients with AS beyond known factors of pressure overload.