quarta-feira, 31 de agosto de 2011

MitraClip improves outcomes in patients with mitral regurgitation and CRT-resistant HF - by Heart.org

Paris, France - The MitraClip (Abbott) percutaneous mitral-valve repair device may provide new hope for heart-failure patients who have otherwise run out of options [1]. A small study presented here at the European Society of Cardiology (ESC) Congress 2011 looked specifically at the MitraClip in patients too sick for surgery who have failed to respond to cardiac resynchronization therapy (CRT).

According to Dr Angelo Auricchio (Fondazione Cardiocentro Tincino, Lugano, Switzerland), who presented results of the PERMIT CARE study, the study population was "a very compromised group of patients that has not been previously assessed in any randomized controlled trial."

PERMIT CARE was an observational trial of MitraClip in 51 patients at seven centers; all of the patients were considered ineligible for surgery due to comorbidities putting them at high risk of death. In addition to significant functional mitral regurgitation, all of the patients had heart-failure symptoms that had not improved despite at least six months of cardiac resynchronization therapy (CRT), usually with a CRT defibrillator and optimal medical therapy.

The average logistic EuroSCORE of the patients in the study was almost 30. Dr Piotr Ponikowski (Medical University, Wroclaw, Poland), cochair of the session in which Auricchio presented the PERMIT CARE data, remarked that "anyone dealing with heart-failure patients would call these 'no-option' patients."

Prior to treatment with the MitraClip, all of the patients had mitral regurgitation of at least grade 2, but one year after receiving a MitraClip, only 6% had mitral regurgitation of grade 2 or worse. Prior to getting a MitraClip, 92% of the patients had NYHA class 3 or 4 heart failure, compared with just 22% 12 months later. The average left ventricular ejection fraction and ventricular volume also improved significantly 12 months after the procedure.

"The MitraClip technology was developed for primary valve disease, but the majority of patients are in the heart-failure world, where the mitral valve gets regurgitation or is relatively insufficient because the ventricle is dilated," session cochair Dr Frank Rushitzka (University of Zurich, Switzerland) said. "There's a huge opportunity here."

In the study, the 30-day mortality rate was an "acceptable" 4.2%, Auricchio said. During follow-up, there were nine more deaths, including one sudden cardiac death of a patient with an ICD and three noncardiac deaths. Most of the deaths were within six months of treatment and were more frequent in older patients with a previous valve surgery, a much higher logistic EuroSCORE and mean value of N-terminal B-type natriuretic peptide (NT-pro-BNP), longer QRS duration, and a more dilated heart.

Auricchio said that this pattern suggests that there may be a group of patients whose heart failure has become so severe that they cannot benefit from MitraClip therapy. The ideal patient population for this therapy as well as the best timing for MitraClip therapy after a CRT implant will be studied further, he added.

terça-feira, 30 de agosto de 2011

Síndrome de Yamagushi - by Fábio Soares

Cardiomiopatia Hipertrófica Apical é uma variante relativamente rara de HCM. Descrita pela primeira vez no Japão, corresponde de 13% a 25% dos casos de CMH no Japão. No entanto , é visto com muito menos frequência em outras populações.

- Yamaguchi H, Nishiyama S, Nakanishi S, Nishimura S. Electrocardiographic, echocardiographic and ventriculographic characterization of hypertrophic non-obstructive cardiomyopathy. Eur Heart J 1983;4 Suppl F:105–19
Apesar de um prognóstico relativamente bom para CMH apical , as observações de longo prazo têm ocasionalmente incluídos morte súbita cardíaca, arritmias graves, infartos e apical com aneurismas apicais.

domingo, 28 de agosto de 2011

CORP: Colchicine prevents recurrent pericarditis - by the heart

Paris, France -Italian researchers have shown that colchicine, when given in addition to conventional therapy, prevents recurrent episodes of pericarditis [1].

Specifically, the study, Colchicine for Recurrent Pericarditis (CORP), looked at the use of the drug during a first recurrence of pericarditis, said Dr Massimo Imazio (Maria Vittoria Hospital, Turin, Italy), who presented the findings during a late-breaking clinical-trial session at the European Society of Cardiology (ESC) 2011 Congress today. The results also are published online in the Annals of Internal Medicine.

"Colchicine appears to be a safe, low-cost drug for rapid symptom relief, improved remission rates at one week, and reduced recurrence after an initial episode of recurrent pericarditis," he commented.

Discussant of the study, Dr Andre Keren (Hadassah Hebrew University Hospital, Jerusalem, Israel), noted that "recurrence is a troublesome and frequent complication of acute pericarditis" and that both CORP and an earlier single center study, CORE, show that low-dose colchicine is effective in preventing recurrences of the disease. "The time has come where colchicine should be more freely used," Keren urged.
Colchicine halves rate of pericarditis recurrence

Around a third of patients who develop pericarditis will suffer recurrences, Imazio said, noting that CORP is the first multicenter, double-blind randomized trial of colchicine in the secondary prevention of pericarditis and confirms the findings of the earlier CORE study.
The time has come where colchicine should be more freely used. In the trial, 120 patients with a first recurrence of pericarditis were randomized to either placebo or low-dose colchicine (1 mg twice daily for 24 hours then 0. 5 mg twice daily for six months for those weighing over 70 kg) in addition to conventional treatment—aspirin 800 to 1000 mg or ibuprofen 600 mg orally every eight hours for seven to 10 days as a first choice or prednisone 0.2 to 0.5 mg/kg/day for four weeks as second choice.

The primary end point was recurrence rate at 18 months. Secondary end points included symptom persistence at 72 hours, remission rate at one month, number of recurrences, time to subsequent recurrence, disease-related hospitalization, cardiac tamponade, and constrictive pericarditis.
Colchicine halved the rate of recurrence—24% of those taking colchicine had recurrence compared with 55% of those on placebo (relative risk reduction 56%; p<0.001), and there were also significant reductions in a number of secondary end points among those taking colchicine compared with placebo.
This translates to a number needed to treat (NNT) of only three patients to prevent one recurrence, Imazio said.
The drug was safe in the doses used, he added, with no difference in adverse events between the colchicine and placebo groups.  The results support the use of low-dose colchicine as a first-line adjuvant to standard care in recurrent pericarditis, he said, calling the results "impressive."
He noted, however, that the CORP findings are specific for the population tested—adult patients with a first recurrence of pericarditis, excluding those with bacterial or neoplastic pericarditis and others who may have contraindications to colchicine use—and therefore may not be generalizable to other settings or patient populations, such as children. Also, he noted that use of colchicine for pericarditis is an off-label indication.
Last year at the ESC meeting, Imazio reported that colchicine prevented the development of postpericardiotomy syndrome (PPS) after heart surgery.

quarta-feira, 24 de agosto de 2011

Valva Pulmonar Bivalvular - by Fábio Soares

- Embora a valva pulmonar seja trivalvuar, pode ocorrer de maneira bivalvular associada a outras cardiopatias congênitas.

- Cerca de 7% dos casos de estenose pulmonar valvar são associadas a valva pulmonar bivalvular 

Este caso é referente a paciente, sexo feminino 17 anos, submetida a correção de CIA tipo ostium secundum e comissurotomia valvar pulmonar (EPV grave - gradiente pré-peratório 50 mmHg).

Segue link com imagens de RM cardíaca de caso semelhante

LV diastolic dysfunction, even in healthy people, linked to heart failure - by Theheat.org

Rochester, MN - Signs of left ventricular diastolic dysfunction that may eventually lead to heart failure can be detected even in healthy patients, new data from the Olmsted County Heart Function Study show [1].

This study "documents that, with the passage of time, there is a tendency for diastolic dysfunction in middle-aged and older people to worsen. That occurs not only in people who have risk factors for heart failure . . . but also in people who have no evidence for any sort of underlying cardiovascular disease," study coauthor Dr Richard Rodeheffer (Mayo Clinic, Rochester, MN) told heartwire. "It supports the general idea that the aging process just all by itself is probably associated with some deterioration of diastolic function of the left ventricle, and then if you add onto that problems like hypertension, cardiovascular disease, diabetes, and obesity, the probability of developing heart failure with preserved ejection fraction goes up quite substantially as people get older."

The National Institutes of Health-sponsored study, led by Dr Garvan Kane (Mayo Clinic), examined 2042 patients 45 years or older with echocardiography and clinical examination between 1997 and 2000 and graded their diastolic left ventricular function, from normal to severely dysfunctional, by validated Doppler techniques. The researchers reexamined study participants four years later, and they were then followed through 2010 for ascertainment of new-onset heart failure. A total of 1402 of the 1960 surviving patients came in for the second evaluation.

Between the first exam and the four-year follow-up exam, the prevalence of diastolic dysfunction in the study group increased from 23.8% to 39.2% (p<0.001). Nearly a quarter of study participants' diastolic function grade worsened during this period, while it improved in about 9% and stayed the same in just over two-thirds of the participants.

Worsened diastolic dysfunction was associated with age 65 years or older (odds ratio 2.85), and after a mean of 6.3 years of additional follow-up, 12.2% of patients whose LV diastolic dysfunction was moderate to severe developed heart failure. By contrast, during the follow-up period, only 2.6% of people with normal diastolic dysfunction showed heart failure, and 7.8% of participants with mild diastolic dysfunction developed heart failure (p<.001). The study also showed that diastolic dysfunction was associated with incident heart failure after adjustment for age, hypertension, diabetes, and coronary artery disease (hazard ratio 1.81).
"We have known for some time that hypertension and cardiovascular disease and diabetes all predispose one to the development of heart failure with preserved ejection fraction, and it's been presumed that part of the reason that those risk factors contributed to the development of heart failure with preserved ejection fraction had something to do with diastolic dysfunction, but nobody had ever really made measurements to show that that was the case," Rodeheffer said.

This study adds a longitudinal "change-within-individual" dimension to a previous analysis of the Olmsted study that provided cross-sectional estimates of left ventricular dysfunction prevalence in the community and described the relationship between ventricular dysfunction and clinical status, Kane and colleagues explain."This age-related progression of diastolic dysfunction in the population contributes to the pathophysiologic substrate from which overt heart failure emerges, [but] the biological pathways leading to heart failure with preserved LVEF are manifold, and understanding its pathophysiology remains a work in progress," Kane et al explain. Contributing factors may include changes in the myocardial relaxation and elastic recoil, ventricular load and diastolic stiffness, external constraint, or abnormal systolic function; the loss of peripheral vascular elasticity with age may affect ventricular load and stiffness.

1.Kane G, Karon B, Mahoney D, et al. Progression of left-ventricular diastolic dysfunction and risk of heart failure. JAMA 2011; 306:856-863.

sábado, 20 de agosto de 2011

Internal carotid IMT slightly improves risk classification - by theheart.org

Boston, MA - Cardiovascular risk assessment can be modestly improved with ultrasound measurement of the intima-media thickness (IMT) of the internal carotid artery wall, a new study from the Framingham Offspring Study cohort shows [1].

Recent American College of Cardiology (ACC)/American Heart Association (AHA) guidelines on cardiovascular risk assessment in asymptomatic patients give carotid IMT—the distance between the lumen-intima interface to the media-adventitia interface—a level 2a recommendation, the same level as the ankle-brachial index and coronary artery calcium scoring, emphasizing that patients with a common carotid-artery IMT above the 75th percentile should be categorized as high risk.

However, "in primary prevention, the incremental predictive value of the IMT of either the common carotid artery or the internal carotid artery, over and above the value of traditional cardiovascular risk factors, is questionable," Dr Joseph Polak (Tufts Medical Center, Boston, MA) and colleagues write in the July 21, 2011 issue of the New England Journal of Medicine.

Polak and colleagues measured the mean and maximum IMT of the internal carotid artery in 2965 participants in the Framingham Offspring Study cohort. During a mean follow-up of 7.2 years, 296 participants had a cardiovascular event.

Traditional Framingham risk factors predicted these events with a C statistic of 0.748. For a one standard-deviation increase in maximum IMT of the internal carotid artery, the hazard ratio was 1.21, with a modest but statistically significant increase in the C statistic of 0.009. Reclassification of patients' cardiovascular risk was aided by adding the IMT of the internal carotid artery to the Framingham score; the net reclassification index—a statistical measure of how much a new factor improves the accuracy of a risk-prediction model—increased 7.6% (p<0.001).
However, the adjusted hazard ratio for cardiovascular disease associated with a one standard-deviation increase in common carotid artery mean IMT was 1.13 and the associated change in the C statistic of 0.003 was nonsignificant. The IMT of the common carotid artery did not improve reclassification; the net reclassification index did not change (0%, p=0.99).
In patients in whom carotid plaque was detected in the internal carotid artery, the net reclassification index was 7.3% (p=0.01), with an increase in the C statistic of 0.014. The presence of plaque in the internal carotid artery can either be measured as part of the continuous IMT or assumed to be there if the thickness exceeds 1.5 mm, Polak and colleagues explain

1. Polak J, Pencina M, Pencina K, et al. Carotid-wall intima-media thickness and cardiovascular events. N Engl J Med 2011; 365:213-221

quinta-feira, 18 de agosto de 2011

Resposta do Caso Clínico da Semana - by Fábio Soares

Ao realizar este exame, a paciente ainda encontrava-se na unidade de emergência e não possuia médico assistente. Contactado o médico da emergência e o serviço de ressonância para encaminharmos a paciente e caracterizar a massa como trombo ou êmbolo tumoral.

Abaixo clips da RNM cardíaca

O laudo da RNM foi compatível com embolia tumoral(visto a massa apresentar citoplasma)
A paciente se recusou a submeter-se a cirurgia cardiaca e solicitou alta hospitalar.

terça-feira, 16 de agosto de 2011

Continuando o Caso Clínico da Semana - by Fábio Soares

Evolução do caso clínico anterior :

A paciente encontrava-se no apartamento em uso de anticoagulação plena, quando desenvolveu Insuficiência Respiratória Aguda grave com necessidade de intubação orotraqueal. Ao exame físico, havia sibilância expiratória difusa e redução importante do murmúrio vesicular. Repetido ecocardiograma que mantinha as mesmas características. Acrescento algumas imagens do Eco transesofágico realizado. (de muito difícil realização).

sábado, 13 de agosto de 2011

quarta-feira, 10 de agosto de 2011

Sinal de El-Sherif - from Medscape

A 54-year-old man with history of previous myocardial infarction (MI) is seen by his cardiologist for follow-up. He has been complaining of occasional palpitations, which were discovered on Holter monitor to be runs of nonsustained ventricular tachycardia (VT).

Focusing on the precordial leads, which of the following cardiac structural abnormalities are suggested by the ECG to exist in this patient?

This patient, who has had a previous MI, is at risk for several post-MI complications, including dysrhythmias, congestive heart failure, mitral regurgitation, and ventricular wall rupture. Another such complication is ventricular aneurysm, which has developed in this patient. The QRS complexes are noted to be prolonged at 140 msec. In addition, the El-Sherif sign, which is an rSr' complex in the anterior precordial leads, is present in V4. This complex represents the depolarization current of the ventricle traveling around the aneurysm. Medical management includes arrhythmia management, the use of angiotensin-converting enzyme inhibitors, and monitoring for aneurysmal thrombus. If the left ventricular (LV) ejection fraction is below 35%, a prophylactic internal cardiac defibrillator should also be considered.

Answer: Ventricular Aneurysm

segunda-feira, 8 de agosto de 2011

Estenose Aórtica - by Fábio Soares

European Heart Journal (2011) 32, 888–896

Aims : The haemorrhage in the plaque (intraplaque haemorrhage) plays a critical role in the progression of atherosclerosis. The purpose of this study is to clarify whether the haemorrhage in the aortic valve leaflet (intraleaflet haemorrhage) accelerates the progression of aortic valve stenosis (AS).

Methods and results : We examined specimens of aortic valve leaflets obtained from 36 patients who had undergone aortic valve replacement for degenerative AS and in whom echocardiographic data were available just before the operation and at least 180 days before the last study. The stenotic valves were examined by immunohistochemistry to detect intraleaflet haemorrhage with antibody against glycophorin A, an erythrocyte-specific protein. The progression of AS was assessed by annualized change in the aortic valve area (DAVA: cm2/year). The patients were divided into two groups, namely the rapid progression group (DAVA ≥ 0.1 cm2/year) and the slow progression group (DAVA , 0.1 cm2/year), according to the reported average progression rate of AS. Intraleaflet haemorrhage was observed in 78 % of the specimens. Intraleaflet haemorrhage was associated with neovascularization and macrophage infiltration. The areas of intraleaflet haemorrhage and macrophage infiltration were greater in the rapid progression group than in the slow progression group. Multivariate analysis has shown that the area of intraleaflet haemorrhage was the sole independent factor that positively correlated with DAVA.

Conclusions: Intraleaflet haemorrhage was frequently observed in the valve leaflets of degenerative AS and associated with a rapid progression of AS.

sábado, 6 de agosto de 2011

Caso Clínico da Semana - by Fábio Soares

Pcte feminina, 81 anos, HAS, em investigaçãoambulatorial de tumoração em região cervical esquerda. Havia realizado biópsia excisional há 5 dias, ainda sem resultado. Procurou a unidade de emergência devido a dispnéia progressiva há 4 dias, com piora nas últimas 24 horas. Reaizou ecocardiograma que evidenciou:

quarta-feira, 3 de agosto de 2011

PHT serve para estimar a área valvar após reparo cirúrgico? - by Fábio Soares

A complacência ventricular (idosos, HAS grave, EAo grave), taquicardia, insuficiência aórtica (maior que leve), valvotomia percutânea ou cirúrgia e valvoplastia cirúrgica influenciam diretamente a medida da área valvar por PHT. Mesmo em próteses valvares este método apresenta limitações.
 - Chambers J, Jackson G, Jewitt D. Limitations of Doppler ultrasound in the assessment of the function of prosthetic mitral valves. Heart 1990;63:189–94.

- A inadequação do PHT provavelmente é devido ao fato de que este método é mais dependente de outras variáveis que a própria área valvar (assim como ocorre com as próteses valvares, é provável que o mesmo se aplique às valvas submetidas a plastia)
 - Chambers J, McLoughlin N, Rapson A, Jackson G. Effect of changes in heart rate on pressure half-time in normally functioning mitral valve prostheses. Br Heart J 1988;60:502–6.

Aims Pressure half-time is an inaccurate measure of mitral valve area in many clinical situations. The utility of the pressure half-time method to calculate mitral valve area after mitral valve repair is not well defined.

Methods and results Forty-two patients with a repaired mitral valve were identified. Mitral valve area was calculated by both the pressure half-time method and the continuity equation. The two mitral valve areas were then directly compared and also correlated with mean gradient. The two mitral valve areas were significantly different from one another with a mean of 1.81+0.53 cm2 by continuity equation and 2.65+0.69 cm2 by pressure half-time. The continuity equation correlated well with mean gradient (r ¼ 20.63), whereas the correlation for pressure half-time was weak (r ¼ 20.08).

Conclusion A non-linear, inverse correlation was found between mitral valve area by the continuity equation and mean gradient. No correlation was found between the pressure half-time method for mitral valve area and mean gradient. The continuity equation likely provides a better estimate of mitral valve area in repaired mitral valves.