Mid- to long-term clinical and echocardiographic outcomes after transcatheter aortic valve replacement with a new-generation, self-expandable system.

OBJECTIVES: The aim of the study was to evaluate mid- to late clinical and echocardiographic outcomes after transcatheter aortic valve replacement (TAVR) with Acurate neo™ (Boston Scientific, Boston, MA). BACKGROUND: TAVR is an established treatment for aortic stenosis (AS). Few data exist on mid- to long-term outcomes and durability after new-generation valves. METHODS: All consecutive patients (n = 104) who underwent Acurate neo™ implantation from 2012 to 2018 were included. Follow-up was systematically performed at 1, 6, 12, and 24 months and yearly thereafter. Outcomes were reported according to VARC-2, and structural valve deterioration (SVD) or bioprosthetic valve failure defined accordingly to new definitions. RESULTS: Mean age was 82 ± 5.4 years, 56.7% were female and the Society of Thoracic Surgeons score for mortality was 5.9 ± 4%. Patients were followed for a median of 3 years (1,092 days; IQR 1.5-4 years), and the maximum follow-up was 7 years. All-cause mortality values at 1 and 5 years were 8.5% and 40.5%, respectively. No relevant changes in mean gradient and orifice area occurred (7.9 ± 3.8 mmHg and 1.9 ± 0.3 cm2 at 1 year; 6.6 ± 2.1 mmHg and 1.8 ± 0.3 cm2 at 5 years), and there was a significant rate of paravalvular leaks resolution at 1, 2, and 3 years (p = .004; p < .001; p < .001, respectively). None of the patients had leaflet thrombosis or endocarditis. One patient developed SVD at 84 months. CONCLUSIONS: Acurate neo™ was associated with sustained echocardiographic results. Reassuring mid- to long-term outcomes was observed in this cohort of elderly patients with severe AS.

Evaluation of late atrial enhancement by cardiac magnetic resonance imaging in patients with obstructive sleep apnea.

INTRODUCTION: Atrial fibrillation (AF) is a growing public health problem especially due to its association with thromboembolic phenomena. Among its risk factors, obstructive sleep apnea (OSA) has increased in incidence and is often under diagnosed. OSA increases the risk of AF by mechanisms not fully known, but it may lead to remodeling and structural alteration of the atria. Cardiac magnetic resonance (CMR), in addition to assessing heart morphology, allows the identification of areas of fibrosis, including the atrium, by the late gadolinium enhancement technique (LGE) and could identify cases of OSA with potential atrial instability. OBJECTIVE: To evaluate the relationship of LGE atrial by CMR in patients with atrial fibrillation with OSA. METHODS: We selected 81 patients who were divided into four groups: Group 1: 20 OSA patients without AF, Group 2: 20 OSA and AF patients, Group 3: 21 patients with only atrial fibrillation without OSA and Group 4: 20 healthy patients without associated comorbidities. All underwent CMR for morphofunctional evaluation and LGE research. RESULTS: The average age was 57.1+-10.59 years. Clinical variables such as hypertension (p = 0.24) and Diabetes Mellitus (p = 0.20) were not predictors of AF in OSA patients. Of the 40 cases with OSA, 18, 45% had severe obstructive disorder, and in this group AF was more prevalent. The mean left ventricular ejection fraction was 62.9% (+-7.46) and it did not differ between groups (p = 0.2). Patients with concomitant OSA and AF had significantly larger left atria (p < 0.001). Cases of OSA with AF showed significantly more atrial LGE (95% vs. 30%, p < 0.001), being an independent predictor in multivariate analysis (P < 0,001). CONCLUSION: Atrial LGE is independently associated with the presence of AF in patients with OSA. These elements may help to identify cases of higher risk for developing AF in OSA patients in clinical practice.

Angiotomography in the diagnosis of coronary aneurysm secondary to Kawasaki disease

CASE REPORT: A 13yo patient, with a history of Kawasaki disease at the age of 2yo, diagnosed at the time with coronary artery aneurysm, treated with immunoglobulin and continued dual antiplatelet. Without follow-up, remained asymptomatic until January 2024, when has began to develop sporadic episodes of short-term chest pain, without well-identified triggering factors. He underwent Cardiac Computed Tomography Angiography (CCTA) demonstrating partially thrombosed aneurysm and calcified walls in the middle segment of the Right Coronary Artery (RCA), measuring 23 mm length and diameters of 12 x 10.5mm, with slight luminal reduction (Figure 1); There was also evidence of an aneurysm at the origin of the Circumflex Artery (ACx) with diameters of 7 x 6 mm without signs of a thrombus (Figure 2). After the test results, antithrombotic therapy and outpatient follow-up care was estabilished. In subsequent evaluations, the patient reported absent of new episodes of chest pain. DISCUSSION: An aneurism of coronary artery is an uncomun lesion, wich is defined as a 50% or greater increase in coronary artery diameter compared with an adjacent arterial segment. The number of complications related to coronary aneurysm are many, and includes embolic phenomenon, thrombosis, spasm, arteriovenous fistulization, and rupture. Kawasaki desease is a granulomatous inflammatory vasculitis wich can affect different anatomic regions of the heart, including the coronary arteries in 20-40% of the cases leading to stenosis or aneurysms. To date, there is no consensus on the most assertive method for diagnosing Kawasaki disease when transthoracic echocardiography is limitated. However, CCTA has been shown to be highly specific and sensitive for the accurate detection of coronary artery aneurysms. It can be considered a better and safer strategy, since it doesn't expose this population, pediatric in most cases, to the risk of possible procedural and vascular complications associated with invasive coronary angiography; and it has been also shownd to be superior to transthoracic echocardiogram. CONCLUSION: Based on the results demonstrated by imaging exams illustrated in the case described, we can highlight that CCTA can be considered a superior diagnostic instrument. As it is a non-invasive method, it offers a better safety profile for the diagnosis and long-term follow-up of patients with coronary artery aneurysm, to quickly guide appropriate management in order to avoid complications.

Ressonância magnética cardíaca no diagnóstico da endomiocardiofibrose / Cardiac magnetic resonance imaging in the diagnosis of endomyocardial fibrosis

APRESENTAÇÃO DO CASO: Paciente do sexo feminino, 38 anos, hipertensa, procurou atendimento com queixa de dispneia de início recente. Relata diagnóstico de fibrilação atrial e trombo em ventrículo esquerdo, com início de anticoagulação oral. Na internação foi realizada ressonância magnética cardíaca (RMC) que evidenciou preenchimento da cavidade do ventrículo esquerdo com tecido fibrótico na porção apical e dos segmentos inferior e inferolateral médios, causando obliteração apical e realce tardio subendocárdico na porção apical ("morfologia em V"). Além disso, observou-se aumento do átrio esquerdo, fração de ejeção ventricular esquerda preservada e insuficiência mitral. Os achados foram sugestivos de endomiocardiofibrose. Foi introduzido tratamento medicamentoso para insuficiência cardíaca, além da manutenção de terapia anticoagulante. DISCUSSÃO: A endomiocardiofibrose (EMC) é uma forma de cardiomiopatia restritiva de etiologia desconhecida, caracterizada por fibrose endocárdica dos ápices e vias de entrada de um ou ambos os ventrículos, levando à obliteração da cavidade ventricular e regurgitação das valvas atrioventriculares. É predominante nas regiões tropicais e subtropicais, afetando a população mais jovem. Fatores dietéticos, ambientais e infecciosos também podem estar associados, levando a um processo inflamatório e hipereosinofílico. A característica marcante da doença consiste no depósito de colágeno e proliferação de fibroblastos, levando a obliteração fibrótica do ventrículo e consequentemente à cardiomiopatia restritiva. As imagens de RMC são capazes de fornecer os volumes cardíacos e a função sistólica ventricular, além de distinguir a EMF de outras cardiomiopatias restritivas pela presença de fibrose subendocárdica e obliteração apical, podendo também demonstrar o padrão típico de realce tardio e a presença de trombo no ápice do ventrículo. O realce tardio estende-se da região subvalvar até o ápice dos ventrículos, onde é mais proeminente. Possui uma aparência de 3 camadas (sinal do duplo V), com uma camada interna sem perfusão devido à presença de trombo, uma camada intermediária refletindo o tecido fibrótico e uma camada externa de miocárdio quase normal. CONCLUSÃO: A EMF é uma doença com etiopatogenia não totalmente compreendida que consiste em uma das causas de cardimiopatia restritiva. A RMC é um exame de extrema importância para o diagnóstico de EMF, capaz de fornecer informações sobre a morfologia ventricular e caracterização tecidual.

Impacto da pandemia de Covid-19 na realização de exames diagnósticos cardiológicos no Brasil: uma análise do SUS e da medicina suplementar / Impact of the Covid-19 pandemic on the performance of cardiological diagnostic exams in Brazil: an analysis of the SUS and supplementary medicine

RESUMO: Introdução/Justificativa: A pandemia de COVID-19 provocou redirecionamento massivo dos recursos do sistema de saúde brasileiro no atendimento aos pacientes, que aliado às medidas de isolamento social tiveram impacto sobre o diagnóstico e tratamento das doenças cardiovasculares. Até o momento não há dados precisos sobre o impacto desses eventos sobre a realização de exames diagnósticos cardiológicos nos primeiros 2 anos da pandemia. OBJETIVO: avaliar o número de exames diagnósticos cardiológicos no SUS e na medicina suplementar nos anos de 2019 a 2021 no Brasil. MÉTODO: coletamos dados referentes aos exames de teste ergométrico, ecocardiograma (repouso e estresse; transtorácico e transesofágico), cintilografia (perfusão de estresse e repouso), cineangiocoronariografia, tomografia computadorizada e ressonância magnética cardíaca realizados nos anos de 2019, 2020 e 2021 no SUS e na medicina suplementar. Os dados foram agrupados por ano, método diagnóstico, sistema (público ou privado) e região do Brasil e os resultados foram comparados. RESULTADOS: no ano de 2019, foram realizados 10,5 milhões de exames diagnósticos cardiológicos (SUS+suplementar); em 2020 houve queda para 8,2 milhões; já em 2021 houve recuperação parcial, com 10,3 milhões de exames realizados. As tendências diferiram conforme o sistema: enquanto no SUS observou-se queda de 24,5% em 2020 e queda de 5,2% em 2021 (referentes a 2019), na saúde suplementar encontramos queda de 20,7% em 2020 e queda de 0,2% em 2021 (referentes a 2019). A avaliação por método diagnóstico também mostrou comportamento heterogêneo: teste ergométrico, cintilografia miocárdica e cateterismo apresentaram queda em 2020 e recuperação apenas parcial em 2021 em relação aos nùmeros de 2019; já o ecocardiograma mostrou queda em 2019 com crescimento em 2021 acima dos números de 2019; por fim, tomografia computadorizada e ressonância magnética cardíacas apresentaram aumento contínuo ao longo de 2020 e 2021 em relação a 2019. Por fim, a análise por região também mostrou comportamento heterogêneo: regiões Nordeste e Sudeste apresentaram queda em 2020 com recuperação parcial em 2021; já as regiões Norte, Centro- Oeste e Sul apresentaram queda em 2020 seguida de aumento em 2021 acima do número de exames realizados em 2019. CONCLUSÃO: a pandemia de COVID-19 provocou impacto significativo na realização de exames diagnósticos cardiológicos no Brasil, com impacto heterogêneo conforme o método, região e sistema de saúde analisado.

Impacto da pandemia de Covid-19 nos exames cardiológicos no Brasil: uma análise do SUS e da medicina suplementar / Impact of the Covid-19 pandemic on cardiological exams in Brazil: an analysis of the SUS and supplementary medicine

INTRODUÇÃO: a pandemia de COVID-19 ocasionou grande impacto no sistema de saúde brasileiro. Além da sobrecarga de pacientes infectados pelo virus, o risco de contaminação obrigou múltiplos serviços de saúde a interromper ou reduzir drasticamente a oferta de exames diagnósticos em cardiologia. O objetivo desse estudo foi avaliar o impacto da pandemia sobre a realização de exames cardiológicos no Sistema Único de Saúde (SUS) e na saúde suplementar. MÉTODOS: coletamos dados referentes aos exames de teste ergométrico, ecocardiograma (repouso e estresse; transtorácico e transesofágico), cintilografia (perfusão de estresse e repouso; avaliação de necrose; viabilidade), cineangiocoronariografia e ressonância magnética cardíaca realizados nos anos de 2019 e 2020 no SUS e no sistema suplementar (mesmos métodos acrescidos de tomografia para escore de cálcio e angiotomografia coronariana) em pacientes internados e ambulatoriais. Os dados foram coletados online a partir do DATASUS e da plataforma da Agência Nacional de Saúde (ANS) e os anos de 2019 e 2020 foram comparados. RESULTADOS: No ano de 2019, foram realizados no Brasil 10.647.379 exames diagnósticos cardiológicos no SUS e no sistema suplementar no Brasil; já no ano 2020, foram apenas 8.315.215 - redução de 2.332.164 exames ou queda de 21,9% em relação ao ano anterior. No SUS, a redução no número de exames foi de 781.529 (24,4%) no comparativo entre os dois anos; já na saúde suplementar, a queda foi de 1.550.635 exames (20,8%). Na análise nacional por método diagnóstico, observamos comportamento heterogêneo ao longo do biênio 2019/2020: teste ergométrico apresentou queda relativa de 28,1%, ecocardiograma 19%, cintilografia miocárdica 26,7% e cineangiocoronariografia 16,5%; já a ressonância magnética cardíaca apresentou aumento de 5% no período. Tendências heterogêneas também foram observadas na comparação entre os exames realizados no SUS e na saúde suplementar ao longo do período de análise. Dados de tomografia cardíaca (disponíveis somente na saúde suplementar) mostraram aumento de 36,7 mil exames em 2019 para 47,1 mil exames em 202 (aumento de 28,4%). CONCLUSÕES: a pandemia de COVID-19 ocasionou alteração importante na estratégia de investigação diagnóstica entre pacientes cardiológicos no Brasil no ano de 2020, com redução significativa no número de exames no SUS e na saúde suplementar e impacto heterogêneo conforme a modalidade diagnóstica. Esses resultados podem contribuir para o planejamento de ações no âmbito público e privado voltadas para a melhoria na investigação cardiológica nos próximos anos.

Long-Term Prognostic Value of Myocardial Fibrosis in Patients With Chagas Cardiomyopathy.

BACKGROUND: Myocardial fibrosis (MF) according to cardiac magnetic resonance (CMR) is a frequent finding in Chagas cardiomyopathy and has been associated with risk factors of poor outcome. OBJECTIVES: The goal of this study was to determine the prognostic value of MF in predicting combined hard events or all-cause mortality. METHODS: Patients with Chagas cardiomyopathy who had a previous CMR evaluation were included, and clinical follow-up was retrospectively obtained. The primary outcome was a combination of all-cause mortality, heart transplantation, antitachycardia pacing or appropriate shock from an implantable cardioverter-defibrillator, and aborted sudden cardiac death; the secondary outcome was all-cause mortality. RESULTS: A total of 130 patients were included; mean age was 53.6 ± 11.5 years, and 53.9% were female. The majority of patients reported no symptoms of heart failure or arrhythmia, but electrocardiographic and echocardiographic abnormalities were common. On CMR, left ventricular dilatation and dysfunction were frequent, and MF was found in 76.1%, with a mean mass of 15.2 ± 16.5 g. Over a median follow-up of 5.05 years, 58 (44.6%) patients reached the combined endpoint, and 45 (34.6%) patients died. MF was associated with the primary outcome as a continuous variable (adjusted hazard ratio: 1.031; 95% CI: 1.013 to 1.049; p = 0.001) and as a categorical variable (MF ≥12.3 g) (adjusted hazard ratio: 2.107; 95% CI: 1.111 to 3.994; p = 0.022), independently from the Rassi risk score. MF expressed as a continuous variable was also associated with all-cause mortality (adjusted hazard ratio: 1.028; 95% CI: 1.005 to 1.051; p = 0.017) independently from the Rassi risk score. CONCLUSIONS: MF is an independent predictor of adverse outcome in Chagas cardiomyopathy. Our data may support the use of CMR in better risk-stratifying this population and possibly guiding therapy.

Electrocardiography scar quantification correlates with scar size of hypertrophic cardiomyopathy seen by multidetector computed tomography.

BACKGROUND: Hypertrophic cardiomyopathy (HCM), a genetically transmitted disease, is the most common genetic cardiovascular disease. Current strategies to stratify risk are expensive and concentrated in wealthy centers. Twelve-lead electrocardiography (ECG) is inexpensive, universally available, and can be readily used for Selvester QRS scoring, which estimates scar size. This study aimed to establish the relation between ECG scar quantification and myocardial fibrosis (extent of myocardial delayed enhancement) in multidetector computed tomography (MDCT). HYPOTHESIS: There is a significant association between ECG scar quantification and the extent of myocardial delayed enhancement in MDCT. METHODS: Seventy-five patients with HCM underwent a routine clinical evaluation and echocardiography, 12-lead ECG, and MDCT study. Patients with and without an implantable cardioverter-defibrillator were included. RESULTS: The estimated Selvester QRS score of myocardial fibrosis was correlated significantly (R = 0.70; P < 0.01) with the quantified MDCT fibrosis. Compared with MDCT, the QRS score had 84.8% sensitivity and 88.8% specificity. Myocardial fibrosis was present in 88% of these patients with HCM (fibrotic mass, 9.87 ±10.8 g) comprising 5.66% ±6.16% of the total myocardial mass seen on the MDCT images. The Selvester QRS score reliably predicted the fibrotic mass in 76% of patients, which estimated 8.44% ±7.39% of the total myocardial mass. CONCLUSIONS: The Selvester QRS score provides reliable quantification of myocardial fibrosis and was well correlated with MDCT in patients with HCM.

Treatment of patients with aortic atherosclerotic disease with paclitaxel-associated lipid nanoparticles.

OBJECTIVE: The toxicity of anti-cancer chemotherapeutic agents can be reduced by associating these compounds, such as the anti-proliferative agent paclitaxel, with a cholesterol-rich nanoemulsion (LDE) that mimics the lipid composition of low-density lipoprotein (LDL). When injected into circulation, the LDE concentrates the carried drugs in neoplastic tissues and atherosclerotic lesions. In rabbits, atherosclerotic lesion size was reduced by 65% following LDE-paclitaxel treatment. The current study aimed to test the effectiveness of LDE-paclitaxel on inpatients with aortic atherosclerosis. METHODS: This study tested a 175 mg/m2 body surface area dose of LDE-paclitaxel (intravenous administration, 3/3 weeks for 6 cycles) in patients with aortic atherosclerosis who were aged between 69 and 86 yrs. A control group of 9 untreated patients with aortic atherosclerosis (72-83 yrs) was also observed. RESULTS: The LDE-paclitaxel treatment elicited no important clinical or laboratory toxicities. Images were acquired via multiple detector computer tomography angiography (64-slice scanner) before treatment and at 1-2 months after treatment. The images showed that the mean plaque volume in the aortic artery wall was reduced in 4 of the 8 patients, while in 3 patients it remained unchanged and in one patient it increased. In the control group, images were acquired twice with an interval of 6-8 months. None of the patients in this group exhibited a reduction in plaque volume; in contrast, the plaque volume increased in three patients and remained stable in four patients. During the study period, one death unrelated to the treatment occurred in the LDE-paclitaxel group and one death occurred in the control group. CONCLUSION: Treatment with LDE-paclitaxel was tolerated by patients with cardiovascular disease and showed the potential to reduce atherosclerotic lesion size.

Membrana subvalvar aórtica em adulto, diagnóstico por angiotomografia: relato de caso / Aortic subvalvular membrane in an adult, diagnosed by CT angiography: case report

INTRODUÇÃO: A angiotomografia computadorizada (AngioTC) tem mostrado seu papel de impacto no diagnóstico de cardiopatias congênitas (CC), por ser de ótima acurácia e não invasiva. A Estenose Aórtica Subvalvar (EAoS), uma CC, rara, que pode ser causa de obstrução à via de saída do ventrículo esquerdo (VSVE). CASO CLÍNICO: Homem,79 anos, hipertenso, com quadro de angina CCS III e síncope. Ao exame físico: sopro sistólico em foco aórtico +3/+6, irradiado para fúrcula esternal. Ecocardiograma transtorácico (ECOTT): Fração de ejeção 69%, valva aórtica trivalvular(VAo), espessadas e calcificadas, refluxo discreto, área valvar de 1,0cm2, gradiente sistólico médio 49mmHg. Devido à estenose aórtica (EAo) estágio D1, de risco intermediário, foi indicado o implante transcateter da válvula aórtica (TAVI) (IIaA). Submetido à angioTC de aorta para programação do procedimento, evidenciando uma VAo trivalvular, fusão de seus folhetos e com calcificação importante (2743 Agatston), com extensão para a VSVE, causando redução da abertura valvar, e imagem de membrana subaórtica (MSAo). Sendo assim, o procedimento de TAVI foi contraindicado e paciente foi encaminhado para cirurgia corretiva da VAo. DISCUSSÃO: A EAo e EAoS são patologias que podem condicionar gradientes hemodinâmicos na VSVE. A EAoS é responsável por 1% de todas CC, sendo 15 a 20% de todos os defeitos fixos de obstrução à VSVE e até 65% tem associação com outras malformações, como a coarctação de aorta. Devido à presença da MSAo, esta pode estar aderida ao septo interventricular ou contornar VSVE, causando disfunção importante da valva aórtica (VAo). O ECOTT é o exame de escolha para diagnosticar EAoS, porém nos casos inconclusivos, a angioTC surge como um importante método de imagem adjuvante. A excelente resolução espacial da angioTC permite avaliação funcional e anatômica, sobretudo nos casos nos quais a membrana é muito fina e muito próxima do plano valvar, podendo assim dificultar a avaliação ao ECOTT. Estudo de grande coorte (Talwar e cols) associou miectomia septal com menos recorrências e com excelente sobrevida. Como tratamento paliativo, pode ser realizada valvoplastia percutânea com balão. (Figura 1) CONCLUSÃO: A estenose subaórtica permanece um diagnóstico raro e clinicamente desafiador na população adulta. Muitas vezes, uma combinação de modalidades de imagem é necessária para o diagnóstico diferencial de obstrução do fluxo na VSVE. A angioTC cardíaca é um método de alta resolução espacial, com papel relevante no diagnóstico das cardiopatias congênitas, impactando nas decisões terapêuticas.

Mid- to long-term clinical and echocardiographic outcomes after transcatheter aortic valve replacement with a newgeneration, self-expandable system / Desfechos clínicos e ecocardiográficos de médio a longo prazo após a substituição da válvula aórtica transcateter com uma nova geração, sistema auto-expansível

Abstract Objectives: The aim of the study was to evaluate mid- to late clinical and echocardiographic outcomes after transcatheter aortic valve replacement (TAVR) with A curate neo™ (Boston Scientific, Boston, MA). Background: TAVR is an established treatment for aortic stenosis (AS). Few data exist on mid- to long-term outcomes and durability after new-generation valves. Methods: All consecutive patients (n = 104) who underwent A curate neo™ implantation from 2012 to 2018 were included. Follow-up was systematically performed at 1, 6, 12, and 24 months and yearly thereafter. Outcomes were reported according to VARC-2, and structural valve deterioration (SVD) or bioprosthetic valve failure defined accordingly to new definitions. Results: Mean age was 82 ± 5.4 years, 56.7% were female and the Society of Thoracic Surgeons score for mortality was 5.9 ± 4%. Patients were followed for a median of 3 years (1,092 days; IQR 1.5­4 years), and the maximum follow-up was 7 years. All-cause mortality values at 1 and 5 years were 8.5% and 40.5%, respectively. No relevant changes in mean gradient and orifice area occurred (7.9 ± 3.8 mmHg and 1.9 ± 0.3 cm2 at 1 year; 6.6 ± 2.1 mmHg and 1.8 ± 0.3 cm2 at 5 years), and there was a significant rate of paravalvular leaks resolution at 1, 2, and 3 years (p = .004; p < .001; p < .001, respectively). None of the patients had leaflet thrombosis or endocarditis. One patient developed SVD at 84 months. Conclusions: A curate neo™ was associated with sustained echocardiographic results. Reassuring mid- to long-term outcomes was observed in this cohort of elderly patients with severe AS.

A ressonância magnética na avaliação atrial do coração de atleta / Magnetic resonance imaging in atrial assessment of athlete's heart

FUNDAMENTO: A avaliação dos átrios de atletas e esportistas através da ressonância magnética foi pouco realizada até o presente momento, o que implica na necessidade do reconhecimento de padrões de normalidade dessas câmaras cardíacas para essa população. OBJETIVOS: realizar a avaliação morfofuncional biatrial em atletas e esportistas de endurance e compará-las com indivíduos sedentários e hígidos da mesma faixa etária e gênero; MÉTODOS: Estudo observacional e retrospectivo realizado no Instituto Dante Pazzanese de Cardiologia. Foram analisadas ressonâncias magnéticas de 25 atletas e esportistas, do gênero masculino, com idade entre 30 e 60 anos e comparadas com as de 10 sedentários, de mesmo gênero e faixa etária. Para ambos os átrios foram avaliados volumes diastólicos final (VDF) e sistólico final (VSF) e fração de ejeção, além da espessura de septo interatrial (SIA) e diâmetro anteroposterior do átrio esquerdo (AE). RESULTADOS: Apresentaram diferença estatística: VDF de átrio direito (AD) de 105,56 mL ±24,86 para atletas e 69,90 mL ±8,9 para sedentários... (AU)

Long-Term Prognostic Value of Myocardial Fibrosis in Patients With Chagas Cardiomyopathy

BACKGROUND; Myocardial fibrosis (MF) according to cardiac magnetic resonance (CMR) is a frequent finding in Chagas cardiomyopathy and has been associated with risk factors of poor outcome. OBJECTIVES The goal of this study was to determine the prognostic value of MF in predicting combined hard events orall-cause mortality. METHODS: Patients with Chagas cardiomyopathy who had a previous CMR evaluation were included, and clinical follow-up was retrospectively obtained. The primary outcome was a combination of all-cause mortality, heart transplantation, antitachycardia pacing or appropriate shock from an implantable cardioverter-defibrillator, and aborted sudden cardiac death; the secondary outcome was all-cause mortality. RESULTSA: total of 130 patients were included; mean age was 53.6 11.5 years, and 53.9% were female. The majority of patients reported no symptoms of heart failure or arrhythmia, but electrocardiographic and echocardiographic abnormalities were common. On CMR, left ventricular dilatation and dysfunction were frequent, and MF was found in76.1%, with a mean mass of 15.2 16.5 g. Over a median follow-up of 5.05 years, 58 (44.6%) patients reached the combined endpoint, and 45 (34.6%) patients died. MF was associated with the primary outcome as a continuous variable (adjusted hazard ratio: 1.031; 95% CI: 1.013 to 1.049; p»0.001) and as a categorical variable (MF$12.3 g) (adjusted hazard ratio: 2.107; 95% CI: 1.111 to 3.994; p»0.022), independently from the Rassi risk score. MF expressed as a continuous variable was also associated with all-cause mortality (adjusted hazard ratio: 1.028; 95% CI: 1.005 to 1.051; p»0.017) independently from the Rassi risk score. CONCLUSIONS: MF is an independent predictor of adverse outcome in Chagas cardiomyopathy. Our data may support the use of CMR in better risk-stratifying this population and possibly guiding therapy.

Electrocardiography scar quantification correlates with scar size of hypertrophic cardiomyopathy seen by multidetector computed tomography

BACKGROUND: Hypertrophic cardiomyopathy (HCM), a genetically transmitted disease, is the most common genetic cardiovascular disease. Current strategies to stratify risk are expensive and concentrated in wealthy centers. Twelve-lead electrocardiography (ECG) is inexpensive, universally available, and can be readily used for Selvester QRS scoring, which estimates scar size. This study aimed to establish the relation between ECG scar quantification and myocardial fibrosis (extent of myocardial delayed enhancement) in multidetector computed tomography (MDCT). HYPOTHESIS: There is a significant association between ECG scar quantification and the extent of myocardial delayed enhancement in MDCT. METHODS: Seventy-five patients with HCM underwent a routine clinical evaluation and echocardiography, 12-lead ECG, and MDCT study. Patients with and without an implantable cardioverter-defibrillator were included. RESULTS: The estimated Selvester QRS score of myocardial fibrosis was correlated significantly (R = 0.70; P < 0.01) with the quantified MDCT fibrosis. Compared with MDCT, the QRS score had 84.8% sensitivity and 88.8% specificity. Myocardial fibrosis was present in 88% of these patients with HCM (fibrotic mass, 9.87 10.8 g) comprising 5.66% 6.16% of the total myocardial mass seen on the MDCT images. The Selvester QRS score reliably predicted the fibrotic mass in 76% of patients, which estimated 8.44% 7.39% of the total myocardial mass. CONCLUSIONS: The Selvester QRS score provides reliable quantification of myocardial fibrosis and was well correlated with MDCT in patients with HCM.

Myocardial fibrosis detected by cardiac CT predicts ventricular fibrillation/ventricular tachycardia events in patients with hypertrophic cardiomyopathy.

BACKGROUND: Myocardial fibrosis (MF) occurs in up to 80% of subjects with asymptomatic or mildly symptomatic hypertrophic cardiomyopathy (HCM) and can constitute an arrhythmogenic substrate for re-entrant, life-threatening ventricular arrhythmias in predisposed persons. OBJECTIVE: The aim was to investigate whether MF detected by delayed enhancement cardiac CT is predictive of ventricular tachycardia (VT) and fibrillation (VF) that require appropriate therapy by an implantable cardioverter defibrillator (ICD) in patients with HCM. METHODS: Twenty-six patients with HCM with previously (for at least 1 year) implanted ICD underwent MF evaluation by cardiac CT. MF was quantified by myocardial delayed enhanced cardiac CT. Data on ICD firing were recorded every 3 months after ICD implantation. Risk factors for sudden cardiac death in patients with HCM were evaluated in all patients. RESULTS: MF was present in 25 of 26 patients (96%) with mean fibrosis mass of 20.5 ± 15.8 g. Patients with appropriate ICD shocks for VF/VT had significantly greater MF mass than patients without (29.10 ± 19.13 g vs 13.57 ± 8.31 g; P = .01). For a MF mass of at least 18 g, sensitivity and specificity for appropriate ICD firing were 73% (95% CI, 49%-88%) and 71% (95% CI, 56%-81%), respectively. Kaplan-Meier curves indicated a significantly greater VF/VT event rate in patients with MF mass ≥18 g than in patients with MF <18 g (P = .02). In the Cox regression analysis, the amount of MF was independently associated with VF/VT in ICD-stored electrograms. CONCLUSION: The mass of MF detected by cardiac CT in patients with HCM at high risk of sudden death was associated with appropriate ICD firings.

Angiotomografia coronária no consultório: quando solicitar / Utility of coronary computed tomography angiography in outpatients

A angiotomografia coronária (CTA) é um método diagnóstico não-invasivo com elevada acurácia na detecção da doença arterial coronária (DAC). Pacientes com DAC não-obstrutiva ou obstrutiva identificadas pela CTA apresentam prognóstico progressivamente pior que os pacientes com CTA normal. A investigação de angina em pacientes de risco baixo e intermediário utilizando CTA como primeiro exame resultou em taxa de mortalidade similar à investigação com métodos funcionais. No entanto, estudos recentes mostraram que pacientes com investigação e tratamento baseados na CTA podem apresentar menor taxa de infarto miocárdico fatal e não-fatal quando comparados aos pacientes investigados e tratados conforme resultados de métodos diagnósticos que avaliam isquemia miocárdica. No contexto do paciente ambulatorial, diretrizes brasileiras e internacionais propõe a CTA como primeiro exame na investigação de DAC, no paciente com avaliação funcional prévia, na avaliação pré-operatória, na diferenciação entre cardiopatias isquêmicas e não isquêmicas e na avaliação de origem anômala de artéria coronária

Coronary computed tomography angiography (CCTA) is a non invasive diagnostic test with high accuracy in the detection of coronary artery disease (CAD). Non obstructive or obstructive CAD detected by CCTA portends increasingly worse prognosis than a normal CCTA. The evaluation of low- and moderate-risk patients with stable angina using CCTA as a first test resulted in similar rates of death when compared to functional tests. However, recent studies have shown that patients evaluated by and treated according to CCTA results may develop lower rates of fatal and non fatal myocardial infarction when compared to patients submitted to and treated according to functional tests. In the context of outpatients, Brazilian and international guidelines propose CCTA as the first diagnostic test in the evaluation of CAD, in patients with previous functional tests, in the preoperative diagnostic workup, in the differentiation between ischemic and non ischemic cardiomyopathy and in the evaluation of anomalous coronary artery origin

Percutaneous coronary intervention in late presentation acute myocardial infarction without viability. effects on left ventricular remodelling and contractility ­ rationale and design

INTRODUCTION: The potential benefits attributable to late reperfusion fall under the "open artery hypothesis", in which the stunned peri-infarction zone after revascularization restores blood supply, improving its contractility. A study showed that late coronary recanalization after myocardial infarction (MI), irrespective of the viability status, improved left ventricular ejection fraction (LVEF) and myocardial contractility mainly in the segments adjacent and distant to the infarction. Purpose: To evaluate whether late recanalization in patients with STEMI without viability by Cardiovascular Magnetic Resonance (CMR) can reduce the reverse remodeling. Viable cases will be kept in the registry. METHODS: This is a prospective randomized controlled trial, with at least 6 months follow-up. Patients with STEMI not reperfused between 24 hours and 28 days with IRA with lesion greater than 50% with segmental dysfunction and absence of viability on CMR are eligible for inclusion. Patients with previous MI, cardiomyopathy or clinical instability are excluded. Participants randomly assigned (1:1) to PCI and Optimal Medical Treatment (OMT) or only OMT. Expected outcome is the change on reverse remodeling of the end systolic volume at 6 months likewise the improvement in segmental contractility at 6 months. The sample size of 35 patients in each group provides 80% power with a two-sided significance level of 0.05. Descriptive statistics and statistical inferential methods are employed to measure changes between the groups. The trial has local ethical review board approval. RESULTS: 28 patients have been already enrolled. CONCLUSION: This trial will provide insights into the potential benefits of opening the IRA in segments without viability, improving contractility of surrounding myocardium.