Valva aórtica bivalvular... Você Sabia? - by Fábio Soares

      Valva aórtica bivalvular... Dia desses me deparei com uma dúvida: existe diferença na evolução da disfunção valvar levando-se em conta a orientação espacial da abertura valvar? Quero dizer, com relação a disposição das válvulas: ântero-posterior ou direita-esquerda?

       Vejam esses 2 casos:

"Fusion of the right and left coronary cusps is associated with coarctation of the aorta. Fusion of the right and noncoronary cusps is associated with cuspal pathology."

                                                                        Journal of the American College of Cardiology Vol. 55, No. 25, 2010

A Larger Aortic Annulus Causes Aortic Regurgitation and a Smaller Aortic Annulus Causes Aortic Stenosis in Bicuspid Aortic Valve

A bicuspid aortic valve (BAV) often causes aortic stenosis (AS) or regurgitation (AR). In 54 patients with a BA (48± 16 years), transthoracic and transesophageal echo were performed to measure aortic annulus diameter (AAD), to evaluate the severity of aortic valve disease (AVD) and to calculate the area eccentricity index (AEI) of a BAV defined as a ratio of the larger aortic cusp area to a smaller aortic cusp area. By multiple linear regression analysis, the severity of AR correlated significantly with the AAD (r = 0.38) and AEI (r = 0.35) (P < 0.05) and that of AS correlated significantly with the AAD (r = −0.40) and AEI (r = 0.34) (P < 0.05). Thirty-six patients showed anteroposteriorly (A-P) located BAVs and 18 patients showed right-left (R-L) located BAVs. The AAD was larger in A-P type than in R-L type (15 ± 3 vs 13 ± 2 mm/BSA, P < 0.05) and there was no difference in the age and AEI between the two groups. AR was more severe in A-P type than in R-L type while AS was more severe in R-L type than in A-P type (P< 0.05). Twenty-nine patients showed raphes. The AEI was larger in raphe (+) type than in raphe (–) type (1.83 ± 0.53 vs 1.51 ± 0.47, P < 0.05) and there was no difference in the AAD and severity of AVD between the two groups. In conclusion, a BAV with larger aortic annulus or A-P located will tend to cause AR while a BAV with smaller aortic annulus or R-L located will tend to cause AS. (ECHOCARDIOGRAPHY, Volume 25, March 2008

Reversible Circumflex Coronary Artery Occlusion During Percutaneous Transvenous Mitral Annuloplasty With the Viacor System- JACC

A 68-year-old woman with severe functional mitral regurgitation was referred for a percutaneous transvenous mitral annuloplasty (PTMA) procedure. Multislice computed tomography was performed with 3-dimensional reconstruction and color rendering (A). Three rods were inserted inside the 7-F 3-lumen Viacor PTMA device to produce significant pressure on the posterolateral part of the mitral annulus (C, arrows). As evaluated by transoesophageal echocardiography, mitral regurgitation was acutely reduced (B to D). However, control angiography revealed complete occlusion of the circumflex artery (E to G). Occlusion persisted until removal of the 3 rods (H). The PTMA procedure was aborted, and the patient was continued on medical therapy. The circumflex artery courses between the mitral annulus and coronary sinus in ~25% of cases. Despite computed tomography imaging before the procedure, circumflex artery occlusion could not be anticipated. It is likely that circumflex artery compression will remain an issue with any PTMA device implanted in the cardiac venous system.

Journal of the American College of Cardiology Vol. 59, No. 3, 2012

Caso Clínico da Semana - by Fábio Soares

Pcte masc, 33 anos, sem comorbidades previamente diagnosticadas, cursando há 6 meses com edema de MMII e aumento do volume abdominal. Procurou Clínico geral que solicitou provas de função hepática, sorologia para vírus da Hepatite B e C, USG abdome e EDA. Não foi identificada nenhuma hepatopatia.
Solicitado ecocardiograma que evidenciou:

The effect of breathing manner on inferior vena caval diameter - by Fábio Soares

A veia cava inferior encontra-se sobre influências do peso hepático, da pressão intra-abdominal e do retorno venoso da circulação esplâncnica e MMII. Durante a inspiração não há só uma diminuição da pressão intratorácica, mas um aumento simultâneo da pressão intra-abdominal, pela descida do diafragma!

European Journal of Echocardiography (2011), 12, 120-123

Futuro do Ecocardiografista - by Echotalk

Há algum tempo já notamos e estamos avisando, mas ninguém ouve... A desvalorização do método e sua, em breve, subordinação aos métodos de imagem mais ricos (Tomografia e Ressonância) contribuem para um futuro incerto do Ecocardiografista.

Recomendo uma lida neste breve tópico postado por Prof. Dr. José Roberto em seu blog

http://echotalk.blogspot.com/2012/02/esta-na-hora-de-procurar-outro-ramo-de.html?spref=fb

Measurement of Ventricular Torsion by Two-Dimensional Ultrasound Speckle Tracking Imaging - JACC

Aproveitando a recomendação de leitura do Prof. Dr. José Roberto, do blog Echotalk, e aproveitando o gancho do post anterior.

icoidais, devido à torção ventricular

Só lembrando:

As partes são o todo - by Fábio Soares

(se não quiser ver o vídeo inteiro - o qual vale bastante a pena - vá direto ao 5o minuto)

Em 1980, Francisco Torrent-Guasp demonstrou pela primeira vez, dissecando um coração bovino, que o músculo cardíaco é formado por um feixe muscular único, enrolado em si mesmo e ancorado nas suas extremidades nos anéis pulmonar e aórtico, sofrendo reflexão ao nível do septo interaventricular.

Portanto, é vedado ao médico pensar em ventrículos direito e esquerdo como músculos separados, como câmaras independentes, bem como imaginar que funções diastólica e sistólica são propriedades distintas. Na verdade, estamos lidando com um único feixe de músculo, distribuído em bandas  que apresentam despolarizações sucessivas e harmônicas. Qualquer comprometimento na estrutura muscular determina algum grau de disfunção, quer sistólica ou diastólica... A limitação de um método diagnóstico, não significa ausência de "doença". O desenvolvimento de novas técnicas vem refinando o diagnóstico e acompanhamento de várias patologias (Cardiomiopatia Chagásica na sua forma indeterminada, Amiloidose, Cardiomiopatia Hipertrófica, Verificação de viabilidade miocárdica, etc)

Right Ventricular Myocardial Systolic and Diastolic Dysfunction in Heart Failure with Normal Left Ventricular Ejection Fraction

Daniel A. Morris, MD, Mudather Gailani, MD, Amalia Vaz Perez, MD, Florian Blaschke, MD, Rainer Dietz, MD, Wilhelm Haverkamp, MD, and Cemil € Ozcelik, MD, Berlin, Germany

Objective:

We hypothesized that in patients with heart failure with normal left ventricular (LV) ejection fraction (HFNEF), the same fibrotic processes that affect the subendocardial layer of the LV could also alter the subendocardial fibers of the right ventricle (RV). Consequently, these alterations and to a lesser extent chronically elevated pulmonary arterial pressures would lead to both systolic and diastolic subendocardial dysfunction of the RV (i.e., impaired RV longitudinal systolic and diastolic function) in patients with HFNEF.\

Methods:

Patients with HFNEF and a control group consisting of asymptomatic patients with LV diastolic dysfunction (asymptomatic LVDD) matched by age, gender, and LV ejection fraction were studied by twodimensional speckle-tracking echocardiography.

Results:

A total of 565 patients were included (201 with HFNEF and 364 with asymptomatic LVDD). RV longitudinal diastolic (RV global longitudinal early-diastolic strain rate [RV-SRe]) and systolic (RV global longitudinal systolic strain [RV-Strain]) function were significantly more impaired in patients with HFNEF than in patients with asymptomatic LVDD (HFNEF: RV-Strain   14.41%  +/- 3.80% and RV-SRe 0.86 +/- 0.33 s 1; asymptomatic LVDD: RV-Strain 16.90% +/- 4.28% and RV-SRe 1.02 +/- 0.34 s 1; all P < .0001). On multiple regression analysis, LV global longitudinal systolic strain was the most important independent predictor of RV longitudinal systolic and diastolic function, in contrast with pulmonary arterial systolic pressure, which was weakly related to these functions. Furthermore, in patients with HFNEF the subendocardial function of both the LV and RV were significantly impaired in similar proportions. In that regard, in patients with HFNEF the prevalences of RV longitudinal systolic and diastolic dysfunction were 75% and 48%, whereas the rates of LV longitudinal systolic and diastolic dysfunction were 80% and 60%, respectively. In addition, patients with both systolic and diastolic longitudinal dysfunction of the RV presented worse New York Heart Association functional class.

 

Conclusion:

In patients with HFNEF, RV subendocardial systolic and diastolic dysfunction are common and possibly associated with the same fibrotic processes that affect the subendocardial layer of the LV and to a lesser extent with RV pressure overload. Furthermore, our findings suggest that RV longitudinal systolic and diastolic dysfunction could contribute to the symptomatology of patients with HFNEF. (J Am Soc Echocardiogr 2011;24:886-97.)

PHT e análise de Prótese Mitral - by Fábio Soares

É comum vermos nos laudos dos ecocardiogramas, a estimativa da área efetiva de uma prótese mitral utilizando o "Pressure Half Time". Mas será que isto é o ideal? Vejamos o que diz a literatura

Pressure Half-Time.

The rate of blood flow across the mitral valve is dominated by the mitral orifice area in the presence of moderate or severe stenosis. However, when the mitral stenosis is only mild or there is a normally functioning valve, the rate of flow also depends on atrial and ventricular compliance, ventricular relaxation, and the pressure difference at the start of diastole. Thus, a large rise in pressure half-time on serial studies or a markedly prolonged single measurement (>200 ms) may be a clue to the presence of prosthetic valve obstruction, because the pressure half-time seldom exceeds 130ms across a normally functioning mitral valve prosthesis. However, minor changes in pressure half-time occur as a result of nonprosthetic factors, including loading conditions, drugs, or aortic insufficiency. Pressure half-time should not be obtained in tachycardic rhythms or first-degree atrioventricular block when E and A velocities are merged or the diastolic filling period is short.

Calculation of EOA from pressure half-time, as traditionally applied in native mitral stenosis, is not valid in prosthetic valves, because of its dependence on LV and LA compliance and initial LA pressure. Therefore, EOA calculation by the continuity equation is preferable to that measured by pressure half-time in mitral prostheses. In bileaflet valves, the smaller central orifice has a higher velocity thant he larger outside orifices, which may lead to underestimation of EOA by the continuity equation. Thus, the accuracy of EOA by the continuity equation may be better for bioprosthetic valves and single tilting disc mechanical valves. EOA is derived as stroke volume through the prosthesis divided by the VTI of the mitral jet velocity:

Fernandes V, Olmos L, Nagueh SF, Quinones MA, Zoghbi WA. Peak early diastolic velocity rather than pressure half-time is the best index of mechanical prosthetic mitral valve function. Am J Cardiol 2002;89:704-10.

Malouf JF, Ballo M, Connolly HM, et al. Doppler echocardiography of 119 normal-functioning St Jude Medical mitral valve prostheses: a comprehensive assessment including time-velocity integral ratio and prosthesis performance index. J Am Soc Echocardiogr 2005;18: 252-6.

Dumesnil JG, Honos GN, Lemieux M, Beauchemin J. Validation and applications of mitral prosthetic valvular areas calculated by Doppler echocardiography. Am J Cardiol 1990;65:1443-8

Bitar JN, Lechin ME, Salazar G, ZoghbiWA. Doppler echocardiographic assessment with the continuity equation of St. Jude Medical mechanical prostheses in the mitral valve position. Am J Cardiol 1995;76:287-93

Correção de CIA em adultos - by Fábio Soares

Benefit of atrial septal defect closure in adults: impact of ageEur Heart J (2011) 32 (5): 553-560
.
Methods and results Functional status, the presence of arrhythmias, right ventricular (RV) remodelling, and pulmonary artery pressure (PAP) were studied in 236 consecutive patients undergoing transcatheter ASD closure [164 females, mean age of 49 ± 18 years, 78 younger than 40 years (Group A), 84 between 40 and 60 years (Group B) and 74 older than 60 years (Group C)]. Defect size [median 22 mm (inter-quartile range, 19, 26 mm)] and shunt ratio [Qp:Qs 2.2 (1.7, 2.9)] did not differ among age groups. Older patients had, however, more advanced symptoms and both, PAP (r = 0.65, P < 0.0001) and RV size (r = 0.28, P < 0.0001), were significantly related to age. Post-interventionally, RV size decreased from 41 ± 7, 43 ± 7, and 45 ± 6 mm to 32 ± 5, 34 ± 5, and 37 ± 5 mm for Groups A, B, and C, respectively (P < 0.0001), and PAP decreased from 31 ± 7, 37 ± 10, and 53 ± 17 mmHg to 26 ± 5, 30 ± 6, and 43 ± 14 mmHg (P < 0.0001), respectively.

.
Conclusions At any age, ASD closure is followed by symptomatic improvement and regression of PAP and RV size. However, the best outcome is achieved in patients with less functional impairment and less elevated PAP. Considering the continuous increase in symptoms, RV remodelling, and PAP with age, ASD closure must be recommended irrespective of symptoms early after diagnosis even in adults of advanced age.

Aortic stenosis grading system misses rare, high-risk group - by the heart.org

    Não é de hoje que falamos em Paradoxal Low Flow/Low Gradient Aortic Stenosis (FEVE preervada). Mas parece que este assunto fica marginal nas discussões, mesmo entre os ecocardiografistas! A utilização exclusiva do gradiente para graduação da estenose aórtica é falha, e não deve ser a única variável analisada.

    Recentemente, acompanhei paciente com estenose aórtica grave, com hipertrofia concêntrica grave, com AVA estimada em 0,6cm2 por equação da continuidade, apresentando gradiente de pico VE/Ao 53mmHg e médio de 33mmHg. Como a paciente apresentava inúmeras comorbidades (DPOC, IRC não dialítica, coronariopatia estáve;), foi encaimnhada para implante percutâneo de prótese aórtica. Foi solicitado por médico assistente CATE, e aproveitou-se para medir os gradientes VE/AO. Como o gradiente foi de 27mmHg (pico/pico), foi considerado como estenose moderada e contra-indicado o procedimento!!! Esta paciente,em um intervalo de 3 meses, deu entrada 7 vezes na unidade de emergência com edema agudo de pulmão!!! Repeti 5 vezes este mesmo exame. Conversado com equipe de Hemodinâmica e médico assistente e finalmente concordado com procedimento!

Liege, Belgium - Some asymptomatic patients previously thought to have only moderate aortic stenosis actually have a poor prognosis, a study of a new aortic stenosis classification system has found [1].

"We need to classify the aortic stenosis not only according to the valve area and the gradient, but also according to the flow," Dr Patrizio Lancellotti (University of Liege, Belgium) told heartwire.

Lancellotti and colleagues evaluated 150 asymptomatic aortic stenosis patients using normal exercise test results with transthoracic echocardiography and B-type natriuretic peptide tests. The patients were categorized into four groups based on left-ventricular flow and aortic valve pressure gradient levels. The cutoff for low vs normal flow was 35 mL/m², and the cutoff for low vs high gradient was 40 mm Hg.

Lancellotti explained to heartwire that under existing guidelines an aortic valve with low flow and a low gradient would be considered to have only a moderate stenosis, but the study shows that patients with low flow and a low gradient had an even worse prognosis than those in the more obvious low-flow/high-gradient group [2].

In an accompanying editorial, Drs Frank Flachskampf and Mohammad Kavianipour (Uppsala University, Sweden) explain that the study by Lancellotti et al "re-emphasizes the utility of close follow-up (six- to 12-month intervals) and liberal use of exercise to confirm lack of symptoms" and "calls for a more complete evaluation of aortic stenosis severity than just the peak and mean gradient, and ejection fraction" [3].

Not merely "moderate" stenosis

In the study, two-year cardiac event-free survival was 83% for patients with normal flow and a low gradient, 44% for patients with normal flow and a high gradient, 30% for patients with low flow and a high gradient, and 27% for patients with a low flow and a low gradient (p<0.0001). Multivariable analysis showed that low flow/low gradient patients were 5.26-times more likely to have an event than patients with normal flow and a high gradient (p=0.046).

Low-flow/low-gradient patients are rare—only 7% of this study population—but "this is really important," Lancellotti said. "We cannot miss this diagnosis, because if we do, when we have the patients in front of us, we will face the problem of saying that 'ok, this is not important . . . This is a moderate stenosis.'" Earlier studies show that these patients are less frequently referred to surgery than patients with normal flow and a high gradient, he said. But "it's really important to recognize this entity, and we cannot deny surgery to these asymptomatic patients. We cannot deny close follow-up because their prognosis is totally impaired," Lancellotti said.

The low-flow/low-gradient patients in this study also had preserved left-ventricular ejection fraction and an aortic valve area <1 cm². These so-called "paradoxical" low-flow aortic stenosis patients also tend to have more pronounced LV concentric remodeling, a smaller left-ventricular cavity, increased global left-ventricular afterload, intrinsic myocardial dysfunction, and a "dismal prognosis," the authors note. This cluster of findings suggests that these patients are most likely at an advanced stage of disease, they say.

However, the patients with normal flow and a low gradient had significantly lower B-type natriuretic peptide (BNP) levels than those with low flow and a high gradient or those with low flow and a low gradient. "This observation emphasizes that risk scores might fail to predict the actual risk on an individual basis," Lancellotti et al note. This finding might be linked to "exhausted BNP production", higher BNP clearance, or diminished BNP release secondary to reduced left-ventricular wall stress.

Identifying at-risk patients

Lancellotti said that his group's next step is to find a way to use exercise echo data to identify the subset of patients with low flow who are at increased risk of CV events over the short term. Echo "could perhaps predict, in a more appropriate way, the outcomes, compared to BNP, longitudinal function, and left-ventricular area."

Flachskampf and Kavianipour add that "if confirmed, [low-flow/low-gradient] patients should perhaps be further evaluated with regard to LV longitudinal function and BNP. Clear guidance as to which cutoffs might prompt valve replacement is missing so far, but studies like the present report help in making informed individual decisions."

Recomendo a todos uma olhadinha neste trabalho:

Paradoxical Low-Flow, Low-Gradient Severe Aortic Stenosis Despite Preserved Ejection Fraction Is Associated With Higher Afterload and Reduced Survival

Zeineb Hachicha, MD; Jean G. Dumesnil, MD; Peter Bogaty, MD; Philippe Pibarot, DVM, PhD

Background: Recent studies and current clinical observations suggest that some patients with severe aortic stenosis on the  basis of aortic valve area may paradoxically have a relatively low gradient despite the presence of a preserved left ventricular (LV) ejection fraction. The objective of the present study was to document the prevalence, potential mechanisms, and clinical relevance of this phenomenon.

Methods and Results: We retrospectively studied the clinical and Doppler echocardiographic data of 512 consecutive patients with severe aortic stenosis (indexed aortic valve area 0.6 cm2 m 2) and preserved LV ejection fraction 50%). Of these patients, 331 (65%) had normal LV flow output defined as a stroke volume index 35 mL m2, and 181 (35%) had paradoxically low-flow output defined as stroke volume index 35 mL m 2. When compared with normal flow patients, low-flow patients had a higher prevalence of female gender (P 0.05), a lower transvalvular gradient (32+/- 17 versus 40 +/- 15 mm Hg; P 0.001), a lower LV diastolic volume index (52+/- 12 versus 59+/- 13 mL m 2; P 0.001), lower LV ejection fraction (62 +/- 8% versus 68,+/- 7%; P 0.001), a higher level of LV global afterload reflected by a higher valvulo-arterial impedance (5.3 +/- 1.3 versus 4.1 0.7 mm Hg · mL 1 · m 2; P 0.001) and a lower overall 3-year survival (76% versus 86%;

P0.006). Only age (hazard ratio, 1.04; 95% CI, 1.01 to 1.08; P0.025), valvulo-arterial impedance 5.5 mm Hg · mL 1 · m 2 (hazard ratio, 2.6; 95% CI, 1.2 to 5.7; P0.017), and medical treatment (hazard ratio, 3.3; 95% CI, 1.8 to 6.7;  P0.0003) were independently associated with increased mortality.

Conclusion: Patients with severe aortic stenosis may have low transvalvular flow and low gradients despite normal LV ejection fraction. A comprehensive evaluation shows that this pattern is in fact consistent with a more advanced stage of the disease and has a poorer prognosis. Such findings are clinically relevant because this condition may often be misdiagnosed, which leads to a neglect and/or an underestimation of symptoms and an inappropriate delay of aortic valve replacement surgery.

(Circulation. 2007;115:2856-2864.)

Reiniciando os trabalhos em 2012

Feliz Ano Novo a todos!
Reiniciando os trabalhos em 2012, começo com um texto bastante interessante sobre Claude Monet, mais uma vez do belíssimo site Arte Médica.

 Arte Médica - Claude Monet

Feliz Natal e Ano Novo a todos... Em especial ao meu 2011

Caso Clínico da Semana - by Fábio Soares

Paciente masculino, 32 anos, assintomático com relato de sopro cardíaco de longa data (não sabe precisar). Negou trauma torácico, passado de endocardite, cirurgia cardíaca prévia.

Tamponamento Cardíaco e Pericardiocentese

Surgery ups survival in infective endocarditis with HF of any severity: International study - theheart.org

Chicago, IL - Around the world, surgery decreased in-hospital mortality by one-fourth and one-year mortality by more than half compared with medical therapy in patients with infective endocarditis and heart failure, new research has found [1]. The cohort study, which included over 4000 patients, probably represents the largest number of people with infective endocarditis ever prospectively followed as a group, the authors say.

Yet, according to an analysis from the International Collaboration on Endocarditis-Prospective Cohort Study, valve-replacement surgery is performed in less than two-thirds of such endocarditis cases with heart failure, note the authors, led by Dr Todd Kiefer (Duke University Medical Center, Durham, NC) in the November 23/30, 2011 issue of the Journal of the American Medical Association.

Other independent predictors of in-hospital and one-year mortality included older age, diabetes, and a history of stroke; infection with Staphylococcus aureus or fungi also raised both mortality risks, while other types of infection did not. Of note, heart-failure severity was also a mortality predictor, but surgery conferred a significant benefit whether NYHA status was 3-4 or 1-2.

According to Dr Andrew Wang (Duke University Medical Center), that was one of the trial's surprises: "The benefit of surgery on longer-term outcome, even in patients who had relatively mild heart failure." Heart failure, he told heartwire, "is one of the strongest indications for surgery in this disease. And although the rate of surgery was really higher in this group than in any other endocarditis [with HF] study—most showed the rate of surgery somewhere between 40% and 50%, and the rate here was 62%—I think seeing the benefit across the whole spectrum of heart failure makes you wonder why it isn't higher and what can we do to make that rate higher."

The study included 4075 patients with confirmed native- or prosthetic-valve infective endocarditis and known HF status enrolled at 61 centers in 28 countries from 2000 through 2006. Of those patients, 1359 (33.4%) had heart failure, two-thirds of whom had NYHA functional status 3 or 4.

Although usual-care options varied at the study sites, all had access to cardiac surgery, Wang noted. Not surprisingly, in-hospital mortality in infective endocarditis rose significantly with the presence of heart failure, with an odds ratio (OR) of 2.80 (95% CI 2.38-3.29) vs no heart failure. However, surgery during that hospitalization cut the risk by a third, with an OR of 0.66 (95% CI 0.56-0.77) vs medical therapy alone. Both risk reductions were significant at p<0.001. The effect was much more pronounced in NYHA 3-4 patients, but remained significant in those who were less symptomatic.

In-hospital mortality with surgery vs no surgery during index hospitalization, by NYHA class (total rate 29.7%)

Heart failure severity	Surgery (%)	No surgery (%)	p
NYHA class 1-2	7.9	15.0	0.03
NYHA class 3-4	23.4	54.5	< 0.001
All heart failure	20.6	44.8	< 0.001

Across the entire cohort, mortality at one year was 29.1% in those who underwent surgery vs 58.4% in those who received medical therapy alone (p<0.001), according to the group. In an analysis adjusted for surgery propensity, significant predictors of death within a year included increased age, diabetes, infection by S aureus or fungi (but not infection by Viridans group streptococcus or Streptococcus bovis), NYHA class 3-4 heart failure, stroke, and paravalvular complications.

Hazard ratio (HR) for one-year mortality by selected subgroups across entire cohort

Subgroup	HR (95% CI)
Surgery, yes vs no	0.44 (0.34-0.56)
NYHA class 3-4, yes vs no	3.03 (2.45-3.80)
Diabetes, yes vs no	1.34 (1.14-1.57)
Age vs <45 y (y)
46-60	1.44 (1.13-1.84)
61-70	1.62 (1.26-2.09)
> 70	2.40 (1.92-3.02)

Some of the variability in outcomes across the broadly international trial had to do with differences in criteria for selecting patients for surgery. The report notes other factors beyond heart failure that seemed to raise the likelihood, "including severity of heart failure, younger age, paravalvular complication, and transfer from another hospital." They suggest, among other things, "that surgery was performed in patients with the most serious complications of infective endocarditis . . . who had acceptable operative risk."

Also, according to Wang, "one of the next big questions is, if a patient has a reason for surgery, when is the best time for it?" He pointed to the recently reported but small EASE study, covered by heartwire, that showed a significant reduction in clinically significant embolic events with surgery performed within 48 hours.

Still, "the true decision-making as to why a patient has surgery, why at a certain time in the course of a long disease, and why some who have reasons for surgery don't have surgery, still need further investigation, and that's the objective of the next iteration of this collaboration."

My name is TEP!! - by Fábio Soares

Dia 09 de novembro de 2011, às 1:30h da manhã, o dia começaria cedo...Sobreaviso acionado!

Caso 1: Pcte masc, 58 anos, em 1PO de prostatectomia radical por neoplasia maligna. Encaminhado a UTI por hipotensão sintomática, posterior evolução para choque e 10 PCRs. Solicitado Eco a beira do leito:

Ok, amanhece e a rotina corre normalmente até a tarde, quando...

Caso 2: Paciente feminina, 78 anos em 4PO de histerectomia e anexectomia por neoplasia maligna de endométrio. Cursando com dispnéia e hipoxemia em unidade aberta.

Pergunta: O que fazer nestes 2 casos?
Trombólise (2 cirurgias de grandeporte recentíssima)?
Heparinização plena apenas?
Trombólise in situ (via hemodinämica)?
Nada a fazer?

PARTNER B - by theheart.org

San Francisco, CA - Two-year outcomes in the PARTNER B trial, testing transcatheter aortic-valve replacement (TAVR) using the Sapien device (Edwards Lifesciences) against best medical care, show that survival curves are continuing to separate and the number needed to treat to save one life dropped from five at one year to four patients at two.

"Two-year data continue to support the role of TAVR as the standard of care for symptomatic patients with aortic stenosis who are not surgical candidates," said Dr Raj R Makkar (Cedars-Sinai Medical Center, Los Angeles, CA), who presented the results here at TCT 2011.

The FDA approved the Sapien valve for the US market last week, based on PARTNER B results.

By two years, 67.6% of patients in the medical group had died, compared with 43.3% in the TAVR group, a difference of 24.3%, Makkar noted. In a landmark analysis looking only at deaths between the one- and two-year mark, 35% of patients randomized to medical management who survived one year were dead within two, whereas half that amount, just 18% of the TAVR group, died in this period.

A similar separation of curves was seen for cardiovascular mortality and repeat hospitalizations. In fact, said Makkar, "there was half the number of repeat hospitalizations in the TAVR group as in the standard-therapy group, despite the fact that there were many more patients alive in the TAVR group at one year." The difference in median days alive out of hospital between the two groups added up to a full year.

Two-year outcomes: PARTNER B

End point	Standard therapy (%)	TAVR (%)	Absolute difference	Log rank p
All-cause mortalitya	67.6	43.3	24.3	< 0.0001
Cardiovascular mortalityb	62.4	31.0	31.4	< 0.0001
Repeat hospitalizations	72.5	35	37.5	< 0.0001

a. Intention-to-treat analysis; crossover patients followed

b. Intention-to-treat analysis; crossover patients censured

A low number of cerebrovascular events continued to accrue in the TAVR arm, but not the standard-therapy arm, after the one-year mark. By two years, the "all-strokes" rate was twice as high in the TAVR group, at 11.2%, compared with 5.5% in the standard group.

Showing slides that used 30 days as the cut point—to separate periprocedural stroke from other stroke causes—Makkar showed that four hemorrhagic strokes and five ischemic strokes occurred between 30 days and two years in the TAVR group, compared with one hemorrhagic stroke and four ischemic strokes in the standard group.

"Beyond 30 days, the reason for strokes is multifactorial," he said, including things like medication use and falls.

Of note, an analysis looking at patients with mild or no paravalvular leaks and moderate or severe leaks found no mortality difference at two years.

Commenting on the study during a morning press conference, Dr Michael Mack observed, "This is absolutely a dramatic result that bolsters the one-year results. An extremely positive trial. You don't have to do anything more than look at the lines of survival between TAVR and control: there was a dramatic difference, with a 20% absolute improvement at one year, and the question is how long is the improvement going to be sustained? And the answer from this is two years . . . and hopefully longer than that."

First-of-kind HCM diagnosis, treatment recommendations published - by theheart.org

Dallas, TX and Washington, DC - "It still has the reputation of something that's hard to treat, and what we've done here, not only in the guidelines, but in the research leading up to the guidelines, is to try to change that perception," said Dr Barry J Maron (Minneapolis Heart Institute, MN), referring to a landmark set of society-sponsored recommendations for the diagnosis and management of patients with hypertrophic cardiomyopathy (HCM) [1].

Medicine's perception of the disorder, "the most common cause of sudden death in young people," Maron told heartwire, has evolved from something a bit mysterious with a generally poor outcome to "a complex but highly treatable genetic heart disease. The guidelines are an accurate recognition of not only the change in our perception of the disease and its treatment, but also of what hypertrophic cardiomyopathy is today."

Treatment follows several, sometimes overlapping, pathways that address the heightened sudden-death risk and development and progression of heart failure; atrial fibrillation is another possible manifestation that can be directly addressed.

In particular, "the defibrillator, translated to patients with hypertrophic cardiomyopathy, has altered the clinical course of the disease for many patients and is in fact the only treatment available in HCM that is proven to prolong life," Maron said.

"The idea that you can effectively prevent sudden death in this disease is a major innovation for the patient population. These are young, otherwise-healthy people, generally, who—if they are high risk—can now have the expectation that it's possible to prevent sudden cardiac death and achieve normal longevity."

The new recommendations are published online today in Circulation and copublished in the Journal of the American College of Cardiology and the Journal of Thoracic and Cardiovascular Surgery, with Maron and Dr Bernard Gersh (Mayo Clinic, Rochester, MN) as the first two authors and noted as cochairs of the writing committee.

With the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) as its marquis sponsoring organizations, the document, it says, was developed in collaboration with the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.

The writing committee acknowledged that their recommendations (aimed mainly at cardiologists, Maron noted) are rooted primarily in expert consensus (level of evidence C) given a "lack of high levels of evidence regarding HCM provided by clinical trials." But that in itself may represent something of an achievement, given the broad subspecialty spectrum of the organizations that signed off on the recommendations and their sometimes-contrasting takes on diagnostic and therapeutic approaches.

Septal reduction therapy: Two strategies

For example, the document's class I position on invasive correction of left ventricular outflow tract (LVOT) obstruction, a hallmark of HCM, says "septal-reduction therapy should be performed only by experienced operators in the context of a comprehensive HCM clinical program and only for the treatment of eligible patients with severe drug-refractory symptoms and LVOT obstruction."

But how septal reduction is carried out has sometimes been a touchy issue, one on which different subspecialties—and their representing organizations, to some extent—have historically had different takes. Although the guidelines favor a long tried-and-true surgical approach as first line and define a catheter-based technique as second tier, in clinical practice the latter is performed more broadly than that.

"The guidelines say that for patients with progressive heart failure refractory to drug treatment who are severely symptomatic, the preferred and gold-standard treatment for most of those patients is surgical septal myectomy," Maron said, adding that the percutaneous strategy, alcohol septal ablation, is an effective alternative in selected patients.

"When surgery is contraindicated or the risk is considered unacceptable because of serious comorbidities or advanced age," the guidelines state, "alcohol septal ablation, when performed in experienced centers, can be beneficial in eligible adult patients with HCM."

Gene testing most powerful for relatives

Genetic testing, another issue that has evolved over the years and been crystallized in the new guidelines, should be reserved for HCM patients and their families and only in some circumstances; it isn't specific enough for broad population screening.

The guidelines, Maron said, point out that tests for known HCM-related gene variants can't usefully predict outcomes "but have proved to be most powerful in family screening and early detection of relatives without left ventricular hypertrophy."

In class I recommendations, the guidelines state that "screening (clinical, with or without genetic testing) is recommended in first-degree relatives of patients with HCM" and that "genetic testing for HCM and other genetic causes of unexplained cardiac hypertrophy is recommended in patients with an atypical clinical presentation of HCM or when another genetic condition is suspected to be the cause" (level of evidence B for both).

Otherwise, a class IIa recommendation states, genetic testing of the HCM patient is "reasonable . . . to facilitate the identification of first-degree family members at risk for developing HCM" (level of evidence B).

Exercising caution

The guidelines document is much further reaching, however, covering risk-stratification techniques; the roles and relative value of different imaging modalities, including transthoracic echocardiography (TTE), angiography, and cardiac magnetic resonance (CMR); drug therapy, with beta blockade a cornerstone and positive inotropic agents generally persona non grata; and recommendations on engaging in sports and other physical activities.

Almost any sport at an advanced competitive level should be off-limits for patients with HCM, according to the document, but it makes room for engagement in light competitive sports such as golf and in a range of recreational sports, including cycling, "modest hiking," lap swimming, doubles tennis, and bowling.

But "patients with HCM should avoid recreational sports in which participation is intense and simulates competitive organized athletics." Sports that entail "burst exertion" are less suitable than those with more consistent exertion, such as lap swimming or cycling.

"General recommendations for recreational exercise in patients with HCM should be tailored to the individual's desires and abilities," the document states.

Onda L - by Fábio Soares

E alguém ainda lembra da onda L?

- A diástase compreende o período da diástole entre as fases de enchimento precoce e tardia, sendo muitas vezes assumida como quiescente. Em alguns casos, um  gradiente transmitral positivo está presente durante a diástase, freqüentemente observadas durante a análise do Doppler mitral como onda"L". Graficamente, corresponde a uma curva positiva ocorrendo entre as ondas E e A,  determinando um padrão trifásico ("fluxo da médio diástole" - FMD).

- A diástole é um processo complexo e incompletamente compreendida  envolvendo elementos ativos e passivos. Didaticamente é dividida em fases: relaxamento isovolumétrico, enchimento ventricular esquerdo precoce,  diástase e enchimento ventricular esquerdo tardio (devido à contração atrial esquerda). Seguindo a fase de enchimento inicial, as pressões do AE e VE se equilibram, e praticamente cessa o fluxo mitral. Em alguns indivíduos jovens normais, o relaxamento ativo do VE é determinado por um recoil pronunciado  (untwist) que cria uma "avenida" para a sucção do VE levando ao início de enchimento do VE. Este fenômeno , determina uma rápida queda dapressão do AE e aumeto da pressão do VE, com uma inversão transitória do gradiente AE/VE. Quando o átrio recebe o fluxo dasveias pulmonares, ocorre reestabelecimento do gradiente AE/VE e o fluxo mitral é reacelerado na médio-diástole.

- Na presença de alguma patologia miocárdica, essa aspiração vigorosa deixaria de ocorrer e não seria suficiente para ocorrência deste fluxo na médio-diástole, e portanto da onda L. Uma hipótese seria que o retardo acentuado do relaxamento ativo do VE pode promover o FMD, diminuindo a pressão diastólica do VE durante a diástase. Mas a maioria dos trabalhos, relaciona o FMD com as pressões de enchimento do VE elevadas e sobrecarga volumétrica, determinando mais um efeito "push" (aumento da rigidez atrial) que um efeito "pull"(sucção do VE).

Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography

Journal of the American Society of Echocardiography February 2009

Middiastolic flow is an important signal to recognize. Low velocities can occur in normal subjects, but when increased (20 cm/s), they often represent markedly delayed LV relaxation and elevated filling pressures.

Ha JW, Oh JK, Redfield MM, Ujino K, Seward JB, Tajik AJ. Triphasic mitral inflow velocity with middiastolic filling: clinical implications and associated echocardiographic findings. J Am Soc Echocardiogr 2004;17: 428-31.