Right Ventricular Systolic Function After the Cone Procedure for Ebstein's Anomaly: Comparison Between Echocardiography and Cardiac Magnetic Resonance.

Although the Cone procedure has improved outcomes for patients with Ebstein´s anomaly (EA), neither RV systolic function recovery in long-term follow-up nor the best echocardiographic parameters to assess RV function are well established. Thus, we evaluated RV performance after the Cone procedure comparing two-dimensional (2DEcho) and three-dimensional (3DEcho) echocardiography to cardiac magnetic resonance (CMR). We assessed 27 EA patients after the Cone procedure (53% female, median age of 20 years at the procedure, median post-operative follow-up duration of 8 years). Echocardiography was performed 4 h apart from the CMR. RV global longitudinal strain (GLS), fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE), myocardial performance index and tissue Doppler S' velocity were assessed using 2DEcho, whereas 3DEcho was used to evaluate RV volumes and ejection fraction (RVEF). Echocardiographic variables were compared to CMR-RVEF. All patients were in the NYHA functional class I. Median TAPSE was 15.9 mm, FAC 30.2%, and RV-GLS -15%; median RVEF by 3DEcho was 31.9% and 43% by CMR. Among 2DEcho parameters, RV-GLS and FAC had a substantial correlation with CMR-RVEF (r = - 0.63 and r = 0.55, respectively); from 3DEcho, the indexed RV volumes and RVEF were closely correlated with CMR (RV-EDVi, r = 0.60, RV-ESVi, r = 0.72; and RVEF r = 0.60). RV systolic function is impaired years after the Cone procedure, despite a good clinical status. FAC and RV-GLS are useful 2DEcho tools to assess RV function in these patients; however, 3DEcho measurements appear to provide a better RV assessment.

Impaired Pulmonary Function is an Additional Potential Mechanism for the Reduction of Functional Capacity in Clinically Stable Fontan Patients.

Central factors negatively affect the functional capacity of Fontan patients (FP), but "non-cardiac" factors, such as pulmonary function, may contribute to their exercise intolerance. We studied the pulmonary function in asymptomatic FP and its correlations with their functional capacity. Pulmonary function and cardiopulmonary exercise tests were performed in a prospective study of 27 FP and 27 healthy controls (HC). Cardiovascular magnetic resonance was used to evaluate the Fontan circulation. The mean age at tests, the mean age at surgery, and the median follow-up time of FP were 20(±6), 8(±3), and 11(8-17) years, respectively. Dominant ventricle ejection fraction was within normal range. The mean of peak VO2 expressed in absolute values (L/min), the relative values to body weight (mL/kg/min), and their predicted values were lower in FP compared with HC: 1.69 (±0.56) vs 2.81 (±0.77) L/min; 29.9 (±6.1) vs 41.5 (±9.3) mL/kg/min p < 0.001 and predicted VO2 Peak [71% (±14) vs 100% (±20) p < 0.001]. The absolute and predicted values of the forced vital capacity (FVC), forced expiratory volume in one second (FEV1), inspiratory capacity (IC), total lung capacity (TLC), diffusion capacity of carbon monoxide of the lung (DLCO), maximum inspiratory pressure (MIP), and sniff nasal inspiratory pressure (SNIP) were also significantly lower in the Fontan population compared to HC. An increased risk of restrictive ventilatory pattern was found in patients with postural deviations (OD:10.0, IC:1.02-97.5, p = 0.042). There was a strong correlation between pulmonary function and absolute peak VO2 [FVC (r = 0.86, p < 0.001); FEV1 (r = 0.83, p < 0.001); IC (r = 0.84, p < 0.001); TLC (r = 0.79, p < 0.001); and DLCO (r = 0.72, p < 0.001). The strength of the inspiratory muscles in absolute and predicted values was also reduced in FP [-79(±28) vs -109(±44) cmH2O (p = 0.004) and 67(±26) vs 89(±36) % (p = 0.016)]. Thus, we concluded that the pulmonary function was impaired in clinically stable Fontan patients and the static and dynamic lung volumes were significantly reduced compared with HC. We also demonstrated a strong correlation between absolute Peak VO2 with the FVC, FEV1, TLC, and DLCO measured by complete pulmonary test.

Mechanical Circulatory Assistance in Children: Clinical Outcome.

BACKGROUND: In countries where organ donation is scarce, mortality in the pediatric heart transplant waiting list is high, and ventricular assist devices (VADs) are therapeutic alternatives in these situations. Berlin Heart EXCOR is currently 1 of the few VADs specific for children. METHODS: This retrospective study includes pediatric patients who underwent Berlin Heart EXCOR placement in a Brazilian hospital between 2012 and 2021. Clinical and laboratory data at the time of VAD implantation and the occurrence of complications and outcomes (success as a bridge to transplant or death) were analyzed. RESULTS: Eight patients, from 8 months to 15 years, were included: 6 with cardiomyopathy and 2 with congenital heart disease. Six were on Intermacs 1 and 2 on Intermacs 2. The most common complications observed were stroke and right ventricular dysfunction. Six were transplanted, and 2 died. Those submitted to transplant had a higher mean weight than those who died, with no statistically significant difference. The underlying disease had no impact on the outcome. The group undergoing transplant had lower brain natriuretic peptide and lactate values, but no laboratory variable showed a statistically significant difference in the outcome. CONCLUSION: A VAD is an invasive treatment with potentially serious adverse effects and is still poorly available in Brazil. However, as a bridge to transplant, it is a useful treatment for children in progressive clinical decline. In this study, we did not observe any clinical or laboratory factor at the time of VAD implantation that implied better outcomes.

SARS-CoV-2 among inmates aged over 60 during a COVID-19 outbreak in a penitentiary complex in Brazil: Positive health outcomes despite high prevalence.

OBJECTIVES: To assess SARS-CoV-2 prevalence and health outcomes among inmates over 60 years during a COVID-19 outbreak in a major penitentiary complex in the Federal District, Brazil. METHODS: A mass test campaign was performed on May 13, 2020, using antibody-detection rapid tests for asymptomatic inmates and reverse transcriptase-polymerase chain reaction testing for those who were symptomatic. Those with negative results were retested on June 16. Inmates were interviewed to characterise background health conditions and the presence of symptoms. RESULTS: A total of 159 inmates were evaluated. In the first mass testing, 79.9% (127/159) of inmates had been infected, of whom 53.5% (68/127) reported symptoms. In the second testing round, 17 new cases were identified, increasing the total to 90.6% (144/159) of inmates with a positive result. Comorbidities were present in 67.3% of inmates; 2 hospitalisations and no COVID-related deaths were recorded. CONCLUSION: More than 90% of inmates aged >60 years were infected with SARS-CoV-2 during the outbreak. Periodic health monitoring, active case finding and early care for symptomatic patients contributed to positive post-infection outcomes. Such measures must be considered essential for the surveillance of COVID-19 in environments with limited capacity to promote social distance, such as penitentiary institutions.

Perinatal outcome of fetal atrioventricular block: one-hundred-sixteen cases from a single institution.

BACKGROUND: Fetal atrioventricular (AV) block is an uncommon lesion with significant mortality. Because of the rarity of this disorder, the natural course, extensive evaluation of untreated fetuses, and late follow-up remain unclear. METHODS AND RESULTS: Of the 116 consecutive cases of fetal AV block studied from 1988 to 2006, only 1 was terminated, and 75% were live births. Fifty-nine cases of AV block were associated with major structural heart disease, mainly left atrial isomerism (n=40), with only 26% of neonatal survivors. Of the 57 fetuses with normal cardiac anatomy, 41 (72%) were positive for maternal antinuclear antibodies, and 32 of these seropositive mothers did not receive any treatment. This untreated group had live-birth and 1-year infant survival rates of 93% and 90% [corrected], respectively. Five fetuses from seronegative mothers showed regression to sinus rhythm during pregnancy. The presence of major structural heart disease, hydrops, an atrial rate 90% of our untreated patients with isolated forms of AV block raises concerns about any decision to intervene with immunosuppressive agents.

Analysis of left ventricular regional dyssynchrony: comparison between real time 3D echocardiography and tissue Doppler imaging.

BACKGROUND: There is a paucity of information concerning left ventricular (LV) dyssynchrony assessment by real time three-dimensional (3D) echocardiography (RT3DE) versus tissue Doppler imaging (TDI). AIMS: To compare RT3DE and TDI LV dyssynchrony assessment. METHODS: A prospective study of 92 individuals (56 men, age 47 +/- 10 years), 32 with dilated cardiomyopathy (CMP), and 60 healthy individuals. By RT3DE, we measured the LV% dyssynchrony index (DI) of 6, 12, and 16 segments (SDI). By pulsed-wave TDI, we measured the QS electromechanical interval in the basal segments of the mitral valve annulus of the septum, the lateral, anterior and inferior walls, and the TDI% DI. RESULTS: In the normal group, the 3D DI was 1.1 +/- 0.8%, 1.4 +/- 1.3%, 1.8 +/- 1.7%, for 6 segments, 12 segments, and SDI, respectively. The correlation coefficient (Pearson's r) for the TDI DI and SDI was r = 0.2381 (P = 0.0470). In CMP group, the 3D DI was 4.6 +/- 5.4%, 7.9 +/- 7.1%, 11.1 +/- 7.1%, for 6 segments, 12 segments, and SDI, respectively. The correlation coefficient for TDI DI and SDI was r = 0.7838 (P < 0.0001). CONCLUSIONS: We observed a good correlation between RT3DE and tissue Doppler LV dyssynchrony assessment in patients with advanced heart failure.

Breast cancer: Is grief a risk factor?

Cancer is characterized by the disordered growth of cells that have high capacity of invasion to the tissues and organs. One of the types of tumour that has national incidence and high mortality is breast cancer. Studies show that in addition to hereditary factors, lifestyle and environmental factors, there are factors related to emotional distress (mourning), which interfere with the development of breast cancer. Thus, it is necessary to investigate if the experience of mourning can trigger the appearance of the tumour. For this, an integrative review was performed to verify the existence of the relationship between mourning and development of breast cancer, which presented contradictory results. Methodological errors and lack of access to important information, such as alcohol and tobacco use, were pointed out as the main causes of the contradiction found. A possible mechanism involving cortisol release has been proposed, but more research is needed to make it clear whether the association between mourning and breast cancer really exists, and by what path.

[The role of echocardiography as an isolated method for indicating surgery in patients with congenital heart disease]. / O papel do ecocardiograma como método isolado na indicação cirúrgica de pacientes portadores de cardiopatia congênita.

OBJECTIVE: To determine the diagnostic accuracy of echocardiography for indicating surgery without catheterization in patients with congenital heart disease through a prospective analysis and comparison of the echocardiographic diagnosis with the intraoperative findings, or invasive study, or both. METHODS: From February 2000 to January 2001, 493 patients with congenital heart diseases indicated for surgery were followed up. They underwent echocardiography with color-flow mapping for a therapeutic decision. The results were compared with the findings of surgery or catheterization, or both, when the latter were performed for diagnostic reasons. RESULTS: Of the patients studied, 94.3% (465 cases) underwent congenital heart disease correction based only on echocardiographic findings, without a diagnostic catheterization. The invasive study was performed for diagnostic reasons in 28 (5.6%) patients, the surgical treatment was performed in more than 95% of the patients, and therapeutic catheterization was performed in 3.6%. The echocardiographic findings were confirmed in 464 (94.1%) patients, which showed the high accuracy of the method. False-positive findings occurred in 8 (1.6%) patients, and false-negative findings in 39 (7.9%). According to surgeons, no diagnostic error led to complications or adversely affected the surgical results. CONCLUSION: Echocardiography proved to be a sensitive and safe method for indicating surgery, making catheterization, often, unnecessary. The invasive study was restricted to diagnostic or therapeutic uses.

Clinical and echocardiographic characteristics associated with the evolution of the ductus arteriosus in the neonate with birth weight lower than 1,500g.

OBJECTIVE: To identify clinical and echocardiographic parameters associated with the evolution of the ductus arteriosus in neonates with birth weight lower than 1,500g. METHODS: Retrospective study of 119 neonates in which clinical parameters (Prenatal: maternal age, risk of infection and chorioamnionitis, use of corticosteroid, mode of delivery and gestational age. Perinatal: weight, Apgar score, gender and birth weight/gestational age classification; Postnatal: use of surfactant, sepsis, fluid intake, heart murmur, heart rate, precordial movement and pulses, use of diuretics, oxygenation index, desaturation/apnea, ventilatory support, food intolerance, chest radiography, renal function, hemodynamic instability, and metabolic changes) and echocardiographic parameters (ductus arteriosus diameter, ductus arteriosus/weight ratio, left atrium/ aorta ratio, left ventricular diastolic diameter, and transductal flow direction, pattern and velocity) were analyzed. The clinical and echocardiographic parameters analyzed were considered statistically significant when p<0.05. RESULTS: In the 119 neonates, the incidence of patent ductus arteriosus was 61.3%; 56 received treatment (46 pharmacological and 10 surgical treatment), 11 had spontaneous closure, 4 died, and 2 were discharged with patent ductus arteriosus. A higher incidence of chorioamnionitis, use of surfactant, lower weight and gestational age, sepsis, heart murmur, ventilatory support and worse oxygenation indices were observed in the neonates receiving treatment. The group with spontaneous closure had a smaller ductus arteriosus diameter, lower ductus arteriosus/weight ratio, and higher transductal flow velocity. CONCLUSION: Based on clinical and echocardiographic parameters, the neonates with spontaneous closure of the ductus arteriosus could be differentiated from those who required treatment.

Breast cancer: Is grief a risk factor?

SUMMARY Cancer is characterized by the disordered growth of cells that have high capacity of invasion to the tissues and organs. One of the types of tumour that has national incidence and high mortality is breast cancer. Studies show that in addition to hereditary factors, lifestyle and environmental factors, there are factors related to emotional distress (mourning), which interfere with the development of breast cancer. Thus, it is necessary to investigate if the experience of mourning can trigger the appearance of the tumour. For this, an integrative review was performed to verify the existence of the relationship between mourning and development of breast cancer, which presented contradictory results. Methodological errors and lack of access to important information, such as alcohol and tobacco use, were pointed out as the main causes of the contradiction found. A possible mechanism involving cortisol release has been proposed, but more research is needed to make it clear whether the association between mourning and breast cancer really exists, and by what path.

RESUMO: O câncer é caracterizado pelo crescimento desordenado das células que possuem alta capacidade de invasão aos tecidos e órgãos. Um dos tipos de tumour que possui incidência nacional e alta mortalidade é o câncer de mama. Estudos mostram que, além dos fatores hereditários, ambientais e dos hábitos de vida, existem fatores relacionados a um trauma emocional (luto) que interferem no desenvolvimento do câncer de mama. Dessa forma, é necessário investigar se a vivência do luto pode desencadear o aparecimento do tumour. Para isso, realizou-se uma revisão integrativa para verificar a existência da relação entre o luto e o desenvolvimento do câncer de mama, que apresentou resultados contraditórios. Os erros metodológicos e a falta de acesso a informações importantes, como uso de álcool e fumo, foram apontadas como as principais causas da contradição encontrada. Um possível mecanismo envolvendo liberação de cortisol tem sido proposto, mas são necessárias mais investigações para que fique claro se a associação entre luto e câncer de mama realmente existe, e por qual mecanismo ocorre.

Cone reconstruction in Ebstein's anomaly repair: early and long-term results.

BACKGROUND: The main Ebstein anomaly (EA) repairs are based on the monocusp reconstruction of the tricuspid valve and are limited by the frequent need for replacement or the high recurrence of valve regurgitation. OBJECTIVE: To evaluate the feasibility and effects of anatomical repair of Ebstein's anomaly using the cone reconstruction technique on patients' clinical evaluation, tricuspid valve function and right ventricular morphology. METHODS: We compared the clinical, echocardiographic and radiological data of 52 consecutive patients, with a mean age of 18.5 ± 13.8 years, submitted to the cone reconstruction technique, obtained in the preoperative, early postoperative (EPO) and long-term (LPO) periods. RESULTS: There were two in-hospital deaths (3.8%) and two more during the follow-up. Mean functional class of pre-operative heart failure improved from 2.2 to 1.2 after 57 months of mean follow up of 97% of patients (p <0.001). The mean degree of preoperative tricuspid regurgitation decreased from 3.6 to 1.6 in the EPO (p <0.001), remaining at 1.9 in LPO period (p> 0.05). The indexed RV functional area increased from 8.53 ± 7.02 cm²/m² preoperatively to 21.01 ± 6.87 cm²/m² in the EPO (p <0.001) and remained unchanged at 20.28 ± 5.26 cm²/m² in LPO period (p> 0.05). The mean cardiothoracic ratio was decreased from 0.66 ± 0.09 to 0.54 ± 0.06 (p <0.001) in the long term. CONCLUSION: The cone technique showed low in-hospital mortality, resulting in an effective and long-lasting repair of tricuspid regurgitation, restoring the functional area of the right ventricle and allowing reverse remodeling of the heart and clinical improvement in most patients in the long term.

Surgical treatment of pulmonary venous tunnel stenosis [corrected] after modified Senning procedure.

A 13-year-old male was admitted to undergoing correction of a pulmonary venous baffle stenosis (PVBS) after a modified Senning procedure was performed by the age of five months. Recurrent Pulmonary congestion and pneumonia episodes were followed by echocardiography and cardiac catheterization that confirmed PVBS. Previous catheter balloon angioplasty was attempted, and a surgical revision was done under cardiopulmonary bypass. The bovine pericardial patch used for augmentation of the right atrium, retracted and calcified producing PVBS. Stenotic area was excised and enlargement was done with polytetrafluoroethylene membrane. Intraoperative transesophageal echocardiogram showed relief of stenosis.

Relation between three-dimensional and two-dimensional echocardiography and biochemical analysis in patients with ST-segment elevation myocardial infarction percutaneously treated.

OBJECTIVE: The prognosis of patients with acute myocardial infarction depends on multiple features that can demonstrate myocardial injury degree (such as serum markers of cardiac necrosis), and also on adaptive mechanisms relative to the acute event. The aim of the study was to assess the relation between biochemical and echocardiographic findings from three-dimensional echocardiographic (3D Echo) analysis and echocardiographic two-dimensional (2D Echo) left ventricular ejection fraction in patients with ST-segment elevation acute myocardial infarction, submitted to primary percutaneous treatment. METHODS: A prospective study with 2D Echo and 3D Echo of 23 patients (17 males, mean age of 57 ± 13 years) with ST-segment elevation acute myocardial infarction, primarily percutaneously treated (stent). Serum cardiac markers (creatine kinase MB, Troponin I and Myoglobin) and serum brain natriuretic peptide were compared to echocardiographic parameters (volumes, left ventricular ejection fraction and ventricular dyssynchrony index). The statistical analysis was performed using Pearson's correlation coefficient, 95% CI, p < 0.05, linear regression equation and Bland & Altman test. RESULTS: Pearson's correlation coefficient (r)relative to 3D left ventricular ejection fraction: 1- brain natriuretic peptide: r: - 0.7427, p < 0.0001; 2- creatine kinase MB: r: - 0.660, p = 0.001. Left ventricular ejection fraction 2D (r) : 1- brain natriuretic peptide: r: - 0.5478, p = 0.001; 2- creatine kinase MB: r: - 0.4800, p < 0.0277. Other associations were not significant. CONCLUSIONS: In this series, it was observed better correlation in regard to serum creatine kinase MB, brain natriuretic peptide and 3D Echo left ventricular ejection fraction, when compared to 2D Echo left ventricular ejection fraction.

Safety of transesophageal echocardiography in adults: study in a multidisciplinary hospital.

BACKGROUND: TEE is a semi-invasive tool broadly used and its utilization associated to sedatives drugs might to affect the procedure safety. OBJECTIVE: to analyze aspects of TEE safety associated to the use of Midazolan (MZ) and Flumazenil (FL) and the influence of the clinical variables on the event rate. METHOD: prospective study with 137 patients that underwent TEE with MZ associated to moderate sedation. We analyzed the following events: complications related with the topical anesthesia, with MZ use and with the procedure. Uni- and multivariate analyses were used to test the influence of the clinical variables: age, sex, stroke, myocardiopathy (MP), duration of the test, mitral regurgitation (MR) and the MZ dose. RESULTS: All patients (65+/-16 yrs; 58% males) finished the examination. The mean doses of MZ and FL were 4.3+/-1.9 mg and 0.28+/-0.2 mg, respectively. The duration of the examination and the mean ejection fraction (EF) were 16.4+/-6.1 minutes and 60+/-9%, respectively. Mild hypoxia (SO2<90%) was the most common event (11 patients); 3 patients (2%) presented transient hypoxia due to upper airway obstruction by probe introduction and 8 (5.8%) due to hypoxia caused by MZ use. Transient hypotension (SAP<90mmHg) occurred in 1 patient (0.7%). The multivariate analysis showed that severe MR, MP (EF<45%) and high doses of MZ (>5mg) were associated with events (p<0.001). The EF was 40%, in the group with MP and 44% in the group with severe MR and it can be a factor associated with clinical events in the last group. CONCLUSION: TEE with sedation presents a low rate of events. There were no severe events and there was no need to interrupt the examinations.

Ecocardiografia transesofágico intraoperatório na avaliação de gradientes residuais após correção cirúrgica das obstruções das vias de saída ventriculares direita e esquerda / Intraoperative transesophageal echocardiography in the evaluation of residual gradients after surgical correction of right and left ventricular outflow tract obstructions

Fundamento: O Ecocardiograma Transesofágico (ETE) intraoperatório tem sido muito utilizado durante as correções das cardiopatias congênitas; entretanto, em obstruções de vias de saída dos ventrículos, as informações são limitadas. Objetivo: Avaliar a confiabilidade do ETE em detectar gradientes residuais em pacientes com obstruções de vias de saída dos ventrículos. Pacientes e Método: Os gradientes sistólicos após circulação extracorpórea ao ETE de 127 pacientes (idade média de 7 anos), sendo 79 com obstrução direita e 48 com obstrução esquerda, foram comparados ao Ecocardiograma Transtorácico (ETT) após cirurgia. Gradientes maiores que 40 mmHg foram considerados de significância hemodinâmica.Resultados: Nas obstruções esquerdas o ETE mostrou gradientes médios maiores que o ETT (30 mmHg vs 24mmHg; p = 0,014). Os gradientes ao ETE foram menores que 40 mmHg em 75% dos pacientes e houve concordância com o ETT em 97%. Nos demais, o gradiente ao ETE foi maior que 40 mmHg e houve concordância com o ETT em 33%. Nas obstruções direitas o ETE mostrou gradientes médios semelhantes ao ETT (28 mmHg vs 25 mmHg; p = 0,21). Os gradientes ao ETE foram menores que 40 mmHg em 88% dos pacientes e houve concordância com o ETT em 91,5%. Nos demais, o gradiente ao ETE foi maior que 40 mmHg e houve concordância com o ETT em 60%. Conclusão: O ETE mostrou-se útil na detecção de gradientes residuais nas vias de saída dos ventrículos nos pacientes estudados. Entretanto, em gradientes maiores que 40 mmHg, o ETE sugere maior severidade das obstruções, particularmente no lado esquerdo.

Background: Despite the large use of intraoperative Transesophageal Echocardiography (TEE) in congenital heart surgery, limited information is available regarding ventricular outflow tract obstruction. Objective: The aim of this study was to assess the reliability of the post-bypass TEE to detect residual gradients in patients with ventricular outflow obstruction. Patients and Methods: Post-bypass TEE peak systolic gradients of 127 patients (mean age of 7 years), being 79 with right ventricular outflow tract obstruction and 48 with left ventricular outflow tract obstruction, were compared with the postoperative TTE. Postoperative lesions were considered of hemodynamic significance when peak systolic gradient was higher than 40 mmHg. Results: In patients with left ventricular outflow tract obstruction TEE showed mean peak systolic gradients higher than TTE (30 mmHg versus 24 mmHg; p= 0,014). In 75%, TEE gradients were lower than 40 mmHg and agreed with TTE in 97%. In the remaining patients, TEE gradients were higher than 40 mmHg and agree with TTE in 33%. In patients with right ventricular outflow tract obstruction TEE mean gradients agreed with TTE (28 mmHg versus 25 mmHg; p= 0.21). In 88%, TEE gradients were lower than 40 mmHg and agreed with TTE in 91.5%. In the remaining patients, TEE gradients were higher than 40 mmHg and agreed with TTE in 60%.Conclusion: TEE showed to be a reliable technique to detect residual ventricular outflow tract obstructions in the majority of patients. However, when considered gradients higher than 40 mmHg, TEE suggested a greater severity of obstructions, particularly on the left side.