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1.
Circ Res ; 132(10): 1338-1357, 2023 05 12.
Artigo em Inglês | MEDLINE | ID: mdl-37167355

RESUMO

SARS-CoV-2 vaccine-associated myocarditis/myocardial injury should be evaluated in the contexts of COVID-19 infection, other types of viral myocarditis, and other vaccine-associated cardiac disorders. COVID-19 vaccine-associated myocardial injury can be caused by an inflammatory immune cell infiltrate, but other etiologies such as microvascular thrombosis are also possible. The clinical diagnosis is typically based on symptoms and cardiac magnetic resonance imaging. Endomyocardial biopsy is confirmatory for myocarditis, but may not show an inflammatory infiltrate because of rapid resolution or a non-inflammatory etiology. Myocarditis associated with SARS-COVID-19 vaccines occurs primarily with mRNA platform vaccines, which are also the most effective. In persons aged >16 or >12 years the myocarditis estimated crude incidences after the first 2 doses of BNT162b2 and mRNA-1273 are approximately 1.9 and 3.5 per 100 000 individuals, respectively. These rates equate to excess incidences above control populations of approximately 1.2 (BNT162b2) and 1.9 (mRNA-1273) per 100 000 persons, which are lower than the myocarditis rate for smallpox but higher than that for influenza vaccines. In the studies that have included mRNA vaccine and SARS-COVID-19 myocarditis measured by the same methodology, the incidence rate was increased by 3.5-fold over control in COVID-19 compared with 1.5-fold for BNT162b2 and 6.2-fold for mRNA-1273. However, mortality and major morbidity are less and recovery is faster with mRNA vaccine-associated myocarditis compared to COVID-19 infection. The reasons for this include vaccine-associated myocarditis having a higher incidence in young adults and adolescents, typically no involvement of other organs in vaccine-associated myocarditis, and based on comparisons to non-COVID viral myocarditis an inherently more benign clinical course.


Assuntos
Vacinas contra COVID-19 , COVID-19 , Traumatismos Cardíacos , Miocardite , Adolescente , Humanos , Adulto Jovem , Vacina de mRNA-1273 contra 2019-nCoV , Vacina BNT162 , COVID-19/prevenção & controle , Vacinas contra COVID-19/efeitos adversos , Traumatismos Cardíacos/etiologia , Miocardite/epidemiologia , Miocardite/etiologia , SARS-CoV-2 , Vacinação/efeitos adversos
2.
Crit Care ; 28(1): 197, 2024 06 11.
Artigo em Inglês | MEDLINE | ID: mdl-38858766

RESUMO

Though the novel venous excess ultrasound (VExUS) score is increasingly used as a noninvasive means of venous congestion measurement, the inter-rater reliability (IRR), inter-user reproducibility (IUR), and utility of concurrent ECG have not been evaluated. We conducted a multicenter study of the IRR, IUR, and utility of ECG for VExUS interpretation between four attending physicians of diverse specialties, reporting the Kappa statistic (KS) and Intraclass Correlation Coefficient (ICC) for IRR and IUR for scans with and without ECG. Eighty-four paired VExUS exams from 42 patients, 60 of which had a concurrent ECG tracing, were interpreted. They showed substantial IRR, with a KS of 0.71 and ICC of 0.83 for the overall VExUS grade (p < 0.001), and IUR, with a KS 0.63 and ICC of 0.8. There was greater agreement among images with an ECG tracing. These results suggest that ECG-augmented VExUS may be a reliable and reproducible measure interpretable by clinicians with diverse backgrounds.


Assuntos
Ultrassonografia , Humanos , Estudos Prospectivos , Reprodutibilidade dos Testes , Feminino , Masculino , Pessoa de Meia-Idade , Ultrassonografia/métodos , Ultrassonografia/normas , Idoso , Hiperemia/diagnóstico por imagem , Adulto , Eletrocardiografia/métodos
3.
Curr Opin Cardiol ; 38(4): 287-296, 2023 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-37115822

RESUMO

PURPOSE OF THE REVIEW: Hypertension accounts for the largest proportion of cardiovascular (CV) mortality worldwide and its prevalence continues to rise. While prominent CV societies have offered strong recommendations on the management of hypertension in adults, the role of noninvasive CV imaging in the evaluation of hypertensive patients remains incompletely defined. RECENT FINDINGS: Noninvasive imaging is a rapidly expanding field with a growing number of sophisticated and readily applicable modalities to assess how cardiac structure and function changes after periods of sustained, elevated blood pressure. Echocardiography remains the initial modality to screen these patients while developments in nuclear, computed tomography and cardiac magnetic resonance complement and expand investigations for alternative diagnoses that may complement or conflict with the diagnosis of left ventricular hypertrophy. SUMMARY: In this review article, we summarize the application of echocardiography, nuclear imaging, cardiac computed tomography, and cardiac magnetic resonance imaging in the evaluation and management of hypertensive heart disease.


Assuntos
Cardiopatias , Hipertensão , Humanos , Coração , Ecocardiografia , Hipertensão/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Imageamento por Ressonância Magnética
4.
Crit Care ; 27(1): 205, 2023 05 26.
Artigo em Inglês | MEDLINE | ID: mdl-37237315

RESUMO

Venous congestion is an under-recognized contributor to mortality in critically ill patients. Unfortunately, venous congestion is difficult to measure, and right heart catheterization (RHC) has been considered the most readily available means for measuring venous filling pressure. Recently, a novel "Venous Excess Ultrasound (VExUS)" score was developed to noninvasively quantify venous congestion using inferior vena cava (IVC) diameter and Doppler flow through the hepatic, portal, and renal veins. A preliminary retrospective study of post-cardiac surgery patients showed promising results, including a high positive-likelihood ratio of high VExUS grade for acute kidney injury. However, studies have not been reported in broader patient populations, and the relationship between VExUS and conventional measures of venous congestion is unknown. To address these gaps, we prospectively assessed the correlation of VExUS with right atrial pressure (RAP), with comparison to inferior vena cava (IVC) diameter. Patients undergoing RHC at Denver Health Medical Center underwent VExUS examination before their procedure. VExUS grades were assigned before RHC, blinding ultrasonographers to RHC outcomes. After controlling for age, sex, and common comorbidities, we observed a significant positive association between RAP and VExUS grade (P < 0.001, R2 = .68). VExUS had a favorable AUC for prediction of a RAP ≥ 12 mmHg (0.99, 95% CI 0.96-1) compared to IVC diameter (0.79, 95% CI 0.65-0.92). These results suggest a strong correlation between VExUS and RAP in a diverse patient population, and support future studies of VExUS as a tool to assess venous congestion and guide management in a spectrum of critical illnesses.


Assuntos
Pressão Atrial , Hiperemia , Humanos , Estudos Retrospectivos , Função do Átrio Direito , Ultrassonografia , Veia Cava Inferior/diagnóstico por imagem
5.
Echocardiography ; 39(7): 1001-1009, 2022 07.
Artigo em Inglês | MEDLINE | ID: mdl-33604936

RESUMO

The pulmonary valve (PV) has historically been ignored by imaging studies. Disorders of the PV encountered in adult cardiac patients are increasingly encountered due to advanced care of patients with congenital heart disease and associated PV diseases. Despite advances in PV imaging, multiple challenges remain when it comes to obtaining high quality PV images. While 2D TTE is the usual initial imaging tool for PV, excellent views of the PV annulus and its one or two leaflets are obtained in less than half of patients. The 3D echocardiography en face view allows all three leaflets to be evaluated concurrently, as well as assessments of the RV outflow tract and main pulmonary artery, which has improved quantitative assessment of PV diseases. Increasing image quality and experience with live/real time 3D TEE amplifies its utility in accurate evaluation and helps guide and monitor successful percutaneous PV interventions. 2D TTE remains the first line diagnostic tool; however, 3D TTE and 3D TEE provide better image quality which increases diagnostic accuracy and guidance to therapy. In this review article, we stress improvement in 3D echocardiography and its role in diagnostic and therapeutic options for PV diseases.


Assuntos
Ecocardiografia Tridimensional , Doenças das Valvas Cardíacas , Valva Pulmonar , Adulto , Ecocardiografia Tridimensional/métodos , Ecocardiografia Transesofagiana/métodos , Humanos , Valva Pulmonar/diagnóstico por imagem
6.
Echocardiography ; 39(7): 975-984, 2022 07.
Artigo em Inglês | MEDLINE | ID: mdl-33095471

RESUMO

The growth of transcatheter structural heart disease interventions has created a subspecialty of interventional imagers who focus on preprocedural planning and the periprocedural guidance of these complex cases. In particular interventional imagers who focus on periprocedural guidance have developed a specific expertise in interventional transesophageal echocardiography (iTEE). This nascent field has challenges in training, reimbursement, and occupational hazards which are unique to this field. This review encompasses the evolution of iTEE, current challenges, and future opportunities.


Assuntos
Ecocardiografia Tridimensional , Insuficiência da Valva Mitral , Ecocardiografia , Ecocardiografia Transesofagiana , Humanos
7.
Echocardiography ; 39(1): 89-100, 2022 01.
Artigo em Inglês | MEDLINE | ID: mdl-34913188

RESUMO

Transesophageal echocardiography (TEE) has experienced tremendous increase in interest and demand alongside the rapid growth of transcatheter structural cardiac interventions. TEE instruction prolongs the procedure, increasing the risk of probe malfunction from overheating and patient complications from prolonged sedation. Echocardiographic simulation programs have been developed to hone the procedural skills of novice operators in a time-unrestricted, low-pressure environment before they perform TEEs on real patients. Simulators likely benefit training in interventional TEE for the same reasons. We searched PubMed, basic Google, and Google Scholar for currently marketed TEE simulators, including foreign as well as US companies. We queried the vendors regarding features of the simulators that pertain to effective instructional design for diagnostic TEE. We also queried regarding the simulators' applicability to training in interventional TEE. The vendors' responses are reported here. In addition, we discuss the specific training needs for structural heart interventions, for which echocardiographic simulation could be a powerful educational tool. Lastly, we discuss the role of simulation for formative and summative assessment, and the advances required to improve training in complex procedures within the field of interventional echocardiography.


Assuntos
Ecocardiografia Transesofagiana , Tecnologia , Simulação por Computador , Ecocardiografia Transesofagiana/métodos , Humanos
8.
Echocardiography ; 39(7): 1011-1027, 2022 07.
Artigo em Inglês | MEDLINE | ID: mdl-35088455

RESUMO

We describe the role of three-dimensional echocardiography in the assessment of the aortic valve and the aorta. The manuscript is heavily illustrated with figures and movie clips.


Assuntos
Estenose da Valva Aórtica , Ecocardiografia Tridimensional , Aorta/diagnóstico por imagem , Valva Aórtica/diagnóstico por imagem , Ecocardiografia Tridimensional/métodos , Humanos
9.
Nature ; 510(7504): 273-7, 2014 Jun 12.
Artigo em Inglês | MEDLINE | ID: mdl-24776797

RESUMO

Pluripotent stem cells provide a potential solution to current epidemic rates of heart failure by providing human cardiomyocytes to support heart regeneration. Studies of human embryonic-stem-cell-derived cardiomyocytes (hESC-CMs) in small-animal models have shown favourable effects of this treatment. However, it remains unknown whether clinical-scale hESC-CM transplantation is feasible, safe or can provide sufficient myocardial regeneration. Here we show that hESC-CMs can be produced at a clinical scale (more than one billion cells per batch) and cryopreserved with good viability. Using a non-human primate model of myocardial ischaemia followed by reperfusion, we show that cryopreservation and intra-myocardial delivery of one billion hESC-CMs generates extensive remuscularization of the infarcted heart. The hESC-CMs showed progressive but incomplete maturation over a 3-month period. Grafts were perfused by host vasculature, and electromechanical junctions between graft and host myocytes were present within 2 weeks of engraftment. Importantly, grafts showed regular calcium transients that were synchronized to the host electrocardiogram, indicating electromechanical coupling. In contrast to small-animal models, non-fatal ventricular arrhythmias were observed in hESC-CM-engrafted primates. Thus, hESC-CMs can remuscularize substantial amounts of the infarcted monkey heart. Comparable remuscularization of a human heart should be possible, but potential arrhythmic complications need to be overcome.


Assuntos
Células-Tronco Embrionárias/citologia , Coração , Infarto do Miocárdio/patologia , Infarto do Miocárdio/terapia , Miócitos Cardíacos/citologia , Regeneração , Animais , Arritmias Cardíacas/fisiopatologia , Cálcio/metabolismo , Sobrevivência Celular , Vasos Coronários/fisiologia , Criopreservação , Modelos Animais de Doenças , Eletrocardiografia , Humanos , Macaca nemestrina , Masculino , Camundongos , Medicina Regenerativa/métodos
10.
Echocardiography ; 37(5): 769-780, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32338402

RESUMO

Increased catheter-based interventions in congenital and structural heart disease require imaging modalities to be oriented in the same visual perspective. The use of echocardiography-fluoroscopy fusion (EFF) imaging has been developed for better characterization of complex anatomy and to facilitate key steps in interventional procedures. This review will detail the technology behind EFF, the differences between the two ultrasound fusion systems, and essential features of EFF imaging in congenital and structural heart disease interventions.


Assuntos
Cardiopatias Congênitas , Radiografia Intervencionista , Cateterismo Cardíaco , Ecocardiografia , Fluoroscopia , Cardiopatias Congênitas/diagnóstico por imagem , Humanos , Imagem Multimodal , Ultrassonografia de Intervenção
11.
Echocardiography ; 36(5): 930-937, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-31002189

RESUMO

BACKGROUND: The present study designed to evaluate feasibility of transesophageal echocardiographic (TEE) imaging of the pulmonary valve (PV) at the transaortic upper esophageal (TAUE) window. We hypothesized that patients with larger aorta would be more likely to have visualization of the PV from this TAUE window. METHODS: 2D TEE images of the PV were prospectively acquired by one operator at the TAUE window looking through the aortic arch. Patients were divided into four groups based on image quality of PV (group 1, not visualized; group 2, barely visualized; group 3, sufficient visualization; group 4, excellent visualization). Clinical, echocardiographic, and radiologic parameters were collected. RESULTS: A total of 212 consecutive patients (54 ± 14 years, 63.7% male) were enrolled. Group distribution was as follows: group 1, n = 60 (28.3%); group 2 n = 39 (18.4%); group 3, n = 27 (12.7%); group 4, n = 86 (40.6%). There were no differences between groups' baseline clinical characteristics. There was a weak although statistically negative correlation between PV image quality and aortic arch dimension (r = -0.17 P = 0.01). There was a stronger positive correlation between PV thickness (r = 0.38 P < 0.001) and PV image quality. Retrospective subgroup analysis of 76 patients with recent chest CT showed similar, but not significant trends as by TEE. CONCLUSION: The use of 2D TEE TAUE results in diagnostic image quality of the PV in the majority of patients and outstanding image quality in a subset of patients. PV image quality is negatively affected by increasing aorta diameter and positively affected by PV thickness.


Assuntos
Ecocardiografia Transesofagiana/métodos , Valva Pulmonar/diagnóstico por imagem , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos Retrospectivos
12.
Echocardiography ; 36(4): 732-741, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30801804

RESUMO

BACKGROUND: The effects of edge-to-edge percutaneous mitral valve repair on the shape and size of the mitral annulus and its relation to mitral regurgitation (MR) have not been well characterized. We evaluated acute changes in mitral annular shape and dimensions, and their effect on MR severity, in patients with functional and degenerative MR following MitraClip® . METHODS: Patients that underwent MitraClip® between January 2013 and May 2016 at our institution were retrospectively reviewed. EXCLUSIONS: inadequate images, prior mitral valve repair, and rapid atrial fibrillation. Intra-procedure TEE 3D images acquired prior to and after implantation of MitraClip® were analyzed using software to model the mitral valve apparatus. RESULTS: Of seventy-eight patients that underwent MitraClip® procedure, 60 were eligible. Mean age was 78.3 ± 11 years. Severe MR (4+) was present in 37 patients, moderately/severe MR (3+) in 23. All patients achieved MR reduction to ≤2. 3D annular circumference, bicommissural diameter, and anteroposterior diameter had a significant size reduction after MitraClip® . None of the mitral annular measures had significantly different mean change between the large and small MR change groups at the 0.05 significance level. CONCLUSIONS: In patients with functional or degenerative MR, the MitraClip® significantly affect mitral annular dimensions; however, these changes do not correlate with the immediate MR reduction.


Assuntos
Ecocardiografia Tridimensional/métodos , Ecocardiografia Transesofagiana/métodos , Implante de Prótese de Valva Cardíaca , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/diagnóstico por imagem , Valva Mitral/fisiopatologia , Insuficiência da Valva Mitral/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Resultado do Tratamento
14.
Ann Emerg Med ; 67(4): 469-476.e1, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26363571

RESUMO

STUDY OBJECTIVE: Survivors of sudden cardiac arrest may be exposed to iodinated contrast from invasive coronary angiography or contrast-enhanced computed tomography, although the effects on incident acute kidney injury are unknown. The study objective was to determine whether contrast administration within the first 24 hours was associated with acute kidney injury in survivors of sudden cardiac arrest. METHODS: This cohort study, derived from a prospective clinical trial, included patients with sudden cardiac arrest who survived for 48 hours, had no history of end-stage renal disease, and had at least 2 serum creatinine measurements during hospitalization. The contrast group included patients with exposure to iodinated contrast within 24 hours of sudden cardiac arrest. Incident acute kidney injury and first-time dialysis were compared between contrast and no contrast groups and then controlled for known acute kidney injury risk factors. RESULTS: Of the 199 survivors of sudden cardiac arrest, 94 received iodinated contrast. Mean baseline serum creatinine level was 1.3 mg/dL (95% confidence interval [CI] 1.4 to 1.5 mg/dL) for the contrast group and 1.6 mg/dL (95% CI 1.4 to 1.7 mg/dL) for the no contrast group. Incident acute kidney injury was lower in the contrast group (12.8%) than the no contrast group (17.1%; difference 4.4%; 95% CI -9.2% to 17.5%). Contrast administration was not associated with significant increases in incident acute kidney injury within quartiles of baseline serum creatinine level or after controlling for age, sex, race, congestive heart failure, diabetes, and admission serum creatinine level by regression analysis. Older age was independently associated with acute kidney injury. CONCLUSION: Despite elevated baseline serum creatinine level in most survivors of sudden cardiac arrest, iodinated contrast administration was not associated with incident acute kidney injury even when other acute kidney injury risk factors were controlled for. Thus, although acute kidney injury is not uncommon among survivors of sudden cardiac arrest, early (<24 hours) contrast administration from imaging procedures did not confer an increased risk for acute kidney injury.


Assuntos
Injúria Renal Aguda/induzido quimicamente , Meios de Contraste/efeitos adversos , Parada Cardíaca/diagnóstico por imagem , Injúria Renal Aguda/terapia , Idoso , Biomarcadores/sangue , Angiografia Coronária , Creatinina/sangue , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Diálise Renal , Fatores de Risco , Tomografia Computadorizada por Raios X
15.
Echocardiography ; 31(8): E250-3, 2014 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-25039665

RESUMO

Gerbode defect and sinus of Valsalva aneurysm fistula are congenital and acquired forms of intracardiac shunt. The increasing prevalence of invasive, recurrent cardiovascular procedures cause tissue damage and has led to more iatrogenic and acquired cases of predominantly congenital shunt over time. We report 2 cases of acquired intracardiac fistula precisely defined by Real time three-dimensional transesophageal echocardiography (3DTEE). The first case is a 70-year-old male with Gerbode defect after second aortic valve replacement surgery due to prosthetic valve endocarditis and the other case is a 41-year-old male with sinus of Valsalva aneurysm fistula between aorta and right atrium post subclinical infective endocarditis. Advanced cardiac imaging techniques such as cardiac computerized tomography, MRI and Real time three-dimensional (3D) echocardiography help to precisely detect intracardiac fistula and provide detailed anatomic and physiologic information. The relatively low cost, lack of radiation exposure, portability and guiding characteristic make real time 3DTEE an imaging technique with arguably the most advantages. Surgical repair is the usual treatment for intracardiac shunt, and percutaneous catheter-based closure is a less invasive alternative.


Assuntos
Ecocardiografia Tridimensional/métodos , Endocardite/complicações , Endocardite/diagnóstico por imagem , Implante de Prótese de Valva Cardíaca/efeitos adversos , Fístula Vascular/diagnóstico por imagem , Fístula Vascular/cirurgia , Idoso , Endocardite/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Fístula Vascular/etiologia
16.
Chest ; 165(3): 590-600, 2024 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-37813180

RESUMO

BACKGROUND: Venous excess ultrasound (VExUS) is a novel ultrasound technique previously reported as a noninvasive measure of venous congestion and predictor of cardiorenal acute kidney injury. RESEARCH QUESTION: Are there associations between VExUS grade and cardiac pressures measured by right heart catheterization (RHC) and cardiac biomarkers and clinical outcomes in patients undergoing RHC? STUDY DESIGN AND METHODS: We conducted a prospective cohort study at the Denver Health Medical Center from December 20, 2022, to March 25, 2023. All patients undergoing RHC underwent a blinded VExUS assessment prior to their procedure. Multivariable regressions were conducted to assess relationships between VExUS grade and cardiac pressures, biomarkers, and changes in weight among patients with heart failure, a proxy for diuretic success. Receiver operating characteristic curve and area under the curve (AUC) were derived for VExUS, inferior vena cava (IVC) diameter, and IVC collapsibility index (ICI) to predict right atrial pressure (RAP) > 10 and < 7 mm Hg. RESULTS: Among 81 patients, 45 of whom were inpatients, after adjusting for age, sex, and Charlson Comorbidity Index, there were significant relationships between VexUS grade of 2 (ß = 4.8; 95% CI, 2.6-7.1; P < .01) and 3 (ß = 11; 95% CI, 8.9-14; P < .01) and RAP, VExUS grade of 2 (ß = 6.8; 95% CI, 0.16-13; P = .045) and 3 (ß = 15; 95% CI, 7.3-22; P < .01) and mean pulmonary artery pressure, and VExUS grade of 2 (ß = 7.0; 95% CI, 3.9-10; P < .01) and 3 (ß = 13; 95% CI, 9.5-17; P < .01) and pulmonary capillary wedge pressure. AUC values for VExUS, IVC diameter, and ICI as predictors of RAP > 10 mm Hg were 0.9 (95% CI, 0.83-0.97), 0.77 (95% CI, 0.68-0.88), and 0.65 (95% CI, 0.52-0.78), respectively. AUC values for VExUS, IVC diameter, and ICI as predictors of RAP < 7 mm Hg were 0.79 (95% CI, 0.70-0.87), 0.74 (95% CI, 0.64-0.84), and 0.62 (95% CI, 0.49-0.76), respectively. In a subset of 23 patients with heart failure undergoing diuresis, there was a significant association between VExUS grade 3 and change in weight between time of RHC and discharge (P = .025). INTERPRETATION: Although more research is required, VExUS has the potential to increase diagnostic and therapeutic capabilities of physicians at the bedside and increase our understanding of the underappreciated problem of venous congestion.


Assuntos
Insuficiência Cardíaca , Hiperemia , Humanos , Estudos Prospectivos , Hiperemia/diagnóstico por imagem , Ultrassonografia , Veia Cava Inferior/diagnóstico por imagem , Insuficiência Cardíaca/diagnóstico por imagem , Biomarcadores
17.
Res Sq ; 2024 Apr 08.
Artigo em Inglês | MEDLINE | ID: mdl-38659788

RESUMO

Background: The evaluation of volume status is essential to clinical decision-making, yet multiple studies have shown that physical exam does not reliably estimate a patient's intravascular volume. Venous excess ultrasound score (VExUS) is an emerging volume assessment tool that utilizes inferior vena cava (IVC) diameter and pulse-wave Doppler waveforms of the portal, hepatic and renal veins to evaluate venous congestion. A point-of-care ultrasound exam initially developed by Beaubein-Souligny et al., VExUS represents a reproducible, non-invasive and accurate means of assessing intravascular congestion. VExUS has recently been validated against RHC-the gold-standard of hemodynamic evaluation for volume assessment. While VExUS scores were shown to correlate with elevated cardiac filling pressures (i.e., right atrial pressure (RAP) and pulmonary capillary wedge pressure (PCWP)) at a static point in time, the ability of VExUS to capture dynamic changes in volume status has yet to be elucidated. We hypothesized that paired VExUS examinations performed before and after hemodialysis (HD) would reflect changes in venous congestion in a diverse patient population. Methods: Inpatients with end-stage renal disease undergoing intermittent HD were evaluated with transabdominal VExUS and lung ultrasonography before and following HD. Paired t-tests were conducted to assess differences between pre-HD and post-HD VExUS scores, B-line scores and dyspnea scores. Results: Fifty-six patients were screened for inclusion in this study. Ten were excluded due to insufficient image quality or incomplete exams, and forty-six patients (ninety-two paired ultrasound exams) were included in the final analysis. Paired t-test analysis of pre-HD and post-HD VExUS scores revealed a mean VExUS grade change of 0.82 (p<0.001) on a VExUS scale ranging from 0 to 4. The mean difference in B-line score following HD was 0.8 (p=0.001). There was no statistically significant difference in subjective dyspnea score (p=0.41). Conclusions: Large-volume fluid removal with HD was represented by changes in VExUS score, highlighting the utility of the VExUS exam to capture dynamic shifts in intravascular volume status. Future studies should evaluate change in VExUS grade with intravenous fluid or diuretic administration, with the ultimate goal of evaluating the capacity of a standardized bedside ultrasound protocol to guide inpatient volume optimization.

18.
J Clin Lipidol ; 18(3): e308-e319, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38565461

RESUMO

Since the 2019 National Lipid Association (NLA) Scientific Statement on Use of Lipoprotein(a) in Clinical Practice was issued, accumulating epidemiological data have clarified the relationship between lipoprotein(a) [Lp(a)] level and cardiovascular disease risk and risk reduction. Therefore, the NLA developed this focused update to guide clinicians in applying this emerging evidence in clinical practice. We now have sufficient evidence to support the recommendation to measure Lp(a) levels at least once in every adult for risk stratification. Individuals with Lp(a) levels <75 nmol/L (30 mg/dL) are considered low risk, individuals with Lp(a) levels ≥125 nmol/L (50 mg/dL) are considered high risk, and individuals with Lp(a) levels between 75 and 125 nmol/L (30-50 mg/dL) are at intermediate risk. Cascade screening of first-degree relatives of patients with elevated Lp(a) can identify additional individuals at risk who require intervention. Patients with elevated Lp(a) should receive early, more-intensive risk factor management, including lifestyle modification and lipid-lowering drug therapy in high-risk individuals, primarily to reduce low-density lipoprotein cholesterol (LDL-C) levels. The U.S. Food and Drug Administration approved an indication for lipoprotein apheresis (which reduces both Lp(a) and LDL-C) in high-risk patients with familial hypercholesterolemia and documented coronary or peripheral artery disease whose Lp(a) level remains ≥60 mg/dL [∼150 nmol/L)] and LDL-C ≥ 100 mg/dL on maximally tolerated lipid-lowering therapy. Although Lp(a) is an established independent causal risk factor for cardiovascular disease, and despite the high prevalence of Lp(a) elevation (∼1 of 5 individuals), measurement rates are low, warranting improved screening strategies for cardiovascular disease prevention.


Assuntos
Doenças Cardiovasculares , Lipoproteína(a) , Humanos , Lipoproteína(a)/sangue , Doenças Cardiovasculares/prevenção & controle , Doenças Cardiovasculares/sangue , Fatores de Risco , Hipolipemiantes/uso terapêutico
19.
J Am Soc Echocardiogr ; 37(1): 2-63, 2024 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-38182282

RESUMO

In patients with significant cardiac valvular disease, intervention with either valve repair or valve replacement may be inevitable. Although valve repair is frequently performed, especially for mitral and tricuspid regurgitation, valve replacement remains common, particularly in adults. Diagnostic methods are often needed to assess the function of the prosthesis. Echocardiography is the first-line method for noninvasive evaluation of prosthetic valve function. The transthoracic approach is complemented with two-dimensional and three-dimensional transesophageal echocardiography for further refinement of valve morphology and function when needed. More recently, advances in computed tomography and cardiac magnetic resonance have enhanced their roles in evaluating valvular heart disease. This document offers a review of the echocardiographic techniques used and provides recommendations and general guidelines for evaluation of prosthetic valve function on the basis of the scientific literature and consensus of a panel of experts. This guideline discusses the role of advanced imaging with transesophageal echocardiography, cardiac computed tomography, and cardiac magnetic resonance in evaluating prosthetic valve structure, function, and regurgitation. It replaces the 2009 American Society of Echocardiography guideline on prosthetic valves and complements the 2019 guideline on the evaluation of valvular regurgitation after percutaneous valve repair or replacement.


Assuntos
Doenças das Valvas Cardíacas , Coração , Adulto , Humanos , Imageamento por Ressonância Magnética , Ecocardiografia , Próteses e Implantes , Doenças das Valvas Cardíacas/diagnóstico , Doenças das Valvas Cardíacas/cirurgia , Espectroscopia de Ressonância Magnética
20.
Am J Cardiol ; 213: 99-105, 2024 Feb 15.
Artigo em Inglês | MEDLINE | ID: mdl-38110022

RESUMO

The association, if any, between the effective regurgitant orifice area (EROA) to left ventricular end-diastolic volume (LVEDV) ratio and 1-year mortality is controversial in patients who undergo mitral transcatheter edge-to-edge repair (m-TEER) with the MitraClip system (Abbott Vascular, Santa Clara, CA). This study's objective was to determine the association between EROA/LVEDV and 1-year mortality in patients who undergo m-TEER with MitraClip. In patients with severe secondary (functional) mitral regurgitation (MR), we analyzed registry data from 11 centers using generalized linear models with the generalized estimating equations approach. We studied 525 patients with secondary MR who underwent m-TEER. Most patients were male (63%) and were New York Heart Association class III (61%) or IV (21%). Mitral regurgitation was caused by ischemic cardiomyopathy in 51% of patients. EROA/LVEDV values varied widely, with median = 0.19 mm2/ml, interquartile range [0.12,0.28] mm2/ml, and 187 patients (36%) had values <0.15 mm2/ml. Postprocedural mitral regurgitation severity was substantially alleviated, being 1+ or less in 74%, 2+ in 20%, 3+ in 4%, and 4+ in 2%; 1-year mortality was 22%. After adjustment for confounders, the logarithmic transformation (Ln) of EROA/LVEDV was associated with 1-year mortality (odds ratio 0.600, 95% confidence interval 0.386 to 0.933, p = 0.023). A higher Society of Thoracic Surgeons risk score was also associated with increased mortality. In conclusion, lower values of Ln(EROA/LVEDV) were associated with increased 1-year mortality in this multicenter registry. The slope of the association is steep at low values but gradually flattens as Ln(EROA/LVEDV) increases.


Assuntos
Implante de Prótese de Valva Cardíaca , Insuficiência da Valva Mitral , Humanos , Masculino , Feminino , Insuficiência da Valva Mitral/epidemiologia , Insuficiência da Valva Mitral/cirurgia , Valva Mitral/cirurgia , Resultado do Tratamento , Sistema de Registros , América do Norte
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