Função Sistólica não é Fração de Ejeção!! Qual o melhor método?

Abaixo alguns artigos que merecem ser lidos na íntegra por todos Ecocardiografistas.

Um número, é isso o que muitos olham a receber um laudo de ecocardiograma a Fração de Ejeção... Bom, não vamos entrar nesta discussão, neste momento. Mas qual o melhor método? E a análise da contratilidade segmentar? Isso vai dar muito pano para manga...

A Study of the 16-Segment Regional Wall Motion Scoring Index and Biplane Simpson’s Rule for the Calculation of Left Ventricular Ejection Fraction: A Comparison with Cardiac Magnetic Resonance Imaging

Rae F. Duncan, M.B.Ch.B., B.Sc., M.Sc., M.R.C.P.,∗† Ben K. Dundon, M.B.B.S., F.R.A.C.P.,∗ Adam J. Nelson, B.Sc., M.B.B.S.,∗ James Pemberton, M.B.B.S., M.D., M.R.C.P.,† Kerry Williams, Dip. Appl. Sci.,∗ Matthew I. Worthley, M.B.B.S., Ph.D., F.R.A.C.P.,∗ Azfar Zaman, M.B.Ch.B., B.Sc., M.D., F.R.C.P.,† Honey Thomas, M.B.B.S., M.D., M.R.C.P.,† and Stephen G. Worthley, M.B.B.S., Ph.D., F.R.A.C.P.∗

∗Cardiovascular Research Centre, Royal Adelaide Hospital and University of Adelaide, Adelaide, South
Australia, Australia; and †Cardiology, The Freeman Hospital and Institute of Cellular Medicine, Newcastle
University, Newcastle-upon-Tyne, UK
 

Aims: Accurate calculation of left ventricular ejection fraction (LVEF) is important for diagnostic, prognostic and therapeutic reasons. Cardiac magnetic resonance (CMR) is the reference standard for LVEF calculation, followed by real time three-dimensional echocardiography (RT3DE). Limited availability of CMR and RT3DE leaves Simpson’s rule as the two-dimensional echocardiography (2DE) standard by which LVEF is calculated. We investigated the accuracy of the 16-Segment Regional Wall Motion Score Index (RWMSI) as an alternative method for calculating LVEF by 2DE and compared this to Simpson’s rule and CMR.

Methods and Results: The 2D echocardiograms of 110 patients were studied (LVEF range: 7–74%); 57 of these underwent CMR. A RWMS was applied, based on the consensus opinion of two experienced cardiologists, to each of 16 American Heart Association myocardial segments (RWMSI: hyperkinesis = 3; normal regional contraction = 2; mild hypokinesis = 1.25; severe hypokinesis = 0.75; akinesis = 0; dyskinesis = –1). LVEF was calculated by: LVEF(%) = (16segRWMS)/16×30. LVEF was calculated by Simpson’s rule and CMR using standard methods. Results were correlated against CMR. Intertechnique agreement was examined. A P value of<0.05 was considered significant. RWMSI-LVEF correlated strongly with Biplane Simpson’s rule (P< 0.001, r = 0.915). RWMSI-LVEF had a strong correlation to CMR (P < 0.001, r = 0.916); Simpson’s rule-LVEF had a moderate correlation to CMR (P<0.001, r = 0.647). In patients with LV dysfunction (EF < 55%), on linear regression analysis, RWMSILVEF had a better correlation with CMR than Simpson’s rule. Further more Simpson’s rule overestimated LVEF compared to CMR (mean difference: –6.12 ± 16.44, P = 0.002) whereas RWMSI did not (mean difference: 2.58 ± 14.80, P = NS).

Conclusion: RWMSI-LVEF correlates strongly with CMR with good intertechnique agreement. In centers where CMR and RT3DE are not readily available, the use by experienced individuals, of the RWMSI for calculating LVEF may be a more simple, accurate, and reliable alternative to Simpson’s rule. (Echocardiography 2011;28:597-604)

Reliability of Visual Assessment of Global and Segmental Left Ventricular Function: A Multicenter Study by the Israeli Echocardiography Research Group

David S. Blondheim, MD, Ronen Beeri, MD, Micha S. Feinberg, MD, Mordehay Vaturi, MD, Sarah Shimoni, MD, Wolfgang Fehske, MD, Alik Sagie, MD, David Rosenmann, MD, Peter Lysyansky, PhD, Lisa Deutsch, PhD, Marina Leitman, MD, Rafael Kuperstein, MD, Ilan Hay, MD, Dan Gilon, MD, Zvi Friedman, PhD, Yoram Agmon, MD, Yossi Tsadok, BSc, and Noah Liel-Cohen, MD, Hadera, Jerusalem, Tel Aviv, Petah Tikva, Rehovot, Haifa, Zerifin, and Beer Sheva, Israel; Cologne, Germany

Background: The purpose of this multicenter study was to determine the reliability of visual assessments of segmental wall motion (WM) abnormalities and global left ventricular function among highly experienced echocardiographers using contemporary echocardiographic technology in patients with a variety of cardiac conditions.

Methods: The reliability of visual determinations of left ventricular WM and global function was calculated from assessmentsmade by 12 experienced echocardiographers on 105 echocardiograms recorded using contemporary echocardiographic equipment. Ten studies were reread independently to determine intraobserver reliability.

Results: Interobserver reliability for visual differentiation between normal, hypokinetic, and akinetic segments

had an intraclass correlation coefficient of 0.70. The intraclass correlation coefficient for dichotomizing segments into normal versus other abnormal was 0.63, for hypokinetic versus other scores was 0.26, and for akinetic versus other scores was 0.58. Similar results were found for intraobserver reliability. Interobserver

reliability for WM score index was 0.84 and for left ventricular ejection fraction was 0.78. Similar values

were obtained for the intraobserver reliability of WM score index and ejection fraction. Compared to angiographic data, the accuracy of segmental WM assessments was 85%, and correct determination of the culprit artery was achieved in 59% of patients with myocardial infarctions.

Conclusion: Among experienced readers using contemporary echocardiographic equipment, interobserver and intraobserver reliability was reasonable for the visual quantification of normal and akinetic segments but poor for hypokinetic segments. Reliability was good for the visual assessment of global left ventricular function by WM score index and ejection fraction. (J Am Soc Echocardiogr 2010;23:258-64.)

Trombos aderidos ao cateter venoso central - by Fábio Soares

Solicitado Doppler de Carótidas e Vertebrais para paciente idosa admitida com síndrome neurológica aguda. Aterosclrose discreta do bulbo esquerdo. de achado adicional...

E aí? Retira?Mantém? Anticoagula? Observa?

(Obs: esse cateter foi passado em veia subclávia esquerda e migrou para a jugular)

Resposta do Caso Clínico - IM grave pós-valvotomia percutânea

   O mecanismo da insuficiência valva mitral pós valvotomia é um dos critérios mais importantes a ser levado em conta para o manejo desta comlicação. O desenvolvimento de IM não necessariamente implica em falha do procedimento ou mesmo pior porgnóstico. A história natural destes pacientes é bastante variável, e uma parcela significativa destes pode tolerar essa condição sem necessariamente seguir para troca valvar.

   O ecocardiograma tem papel fundamental nesta decisão através da análise do mecanismo da IM e aspectos hemodinâmicos, tais como o gradiente médio imediatamente após a valvotomia, que apresenta importante informação prognóstica nestes pacientes.

Recomendo a leitura deste artigo.

Long-Term Outcomes of Significant Mitral Regurgitation After Percutaneous Mitral Valvuloplasty

Mi-Jeong Kim, MD; Jae-Kwan Song, MD; Jong-Min Song, MD; Duk-Hyun Kang, MD;

Young-Hak Kim, MD; Cheol Whan Lee, MD; Myeong-Ki Hong, MD; Jae-Joong Kim, MD;

Seong-Wook Park, MD; Seung-Jung Park, MD

Background—Mild commissural mitral regurgitation (MR) is associated with significantly higher restenosis-free survival after percutaneous mitral valvuloplasty (PMV), which suggests that different mechanisms of significant MR after PMV may have different clinical courses. We therefore analyzed long-term prognostic factors of significant MR after PMV.

Methods and Results—Echocardiographic and clinical follow-up data on 380 patients were analyzed (286 women, mean age 44 11 years) who underwent PMV with the Inoue balloon technique between 1995 and 2000. Significant MR developed in 47 patients (12.4%). The survival rate at 8 years was 96 3% and 98 10% in patients with and without significant MR, respectively (P 0.084). The most frequent mechanism was commissural MR, or MR that originated at the site of successful commissurotomy, which occurred in 27 of 47 patients (57%), whereas noncommissural MR occurred in 20 (43%) patients, 12 (26%) with subvalvular damage resulting in chordae rupture and flail motion and 8 (17%) with leaflet laceration. The 8-year event-free survival rate was significantly lower in patients with significant MR than in those without (47 8% versus 83 3%, P 0.001) and was significantly higher in patients with commissural versus noncommissural MR (63 11% versus 29 11%, P 0.001). Of the 47 patients with significant MR, who were followed up for 74 29 months, 19 patients (40%) underwent mitral valve replacement, and 28 patients (60%) received medical treatment only. Patients with commissural MR had a significantly lower rate of mitral valve replacement than patients with noncommissural MR (15% versus 70%, P 0.001). Multivariate analysis showed that atrial fibrillation (odds ratio, 7.4; 95% CI, 1.1 to 56.4; P 0.038), mean mitral gradient immediately after PMV (odds ratio, 1.5; 95% CI, 1.1 to 2.0; P 0.009), and the mechanism of MR (odds ratio, 16.7; 95% CI, 2.3 to 122.2; P 0.005) were independent factors associated with mitral valve replacement.

Conclusions—Clinical outcome of patients with significant MR after PMV varied according to MR mechanism and the adequacy of hemodynamic improvement, which is easily assessed by echocardiography immediately after PMV. (Circulation. 2006;114:2815-2822.)

Vejamos alguns gráficos que ilustram alguns pontos importantes referentes a esta complicação:

Média da área valvar em pctes com IM e sem IM após valvotomia percutânea

Sobrevida livre de eventos em pacientes com IM significativa ou não 

 Agora, observe quando é levado em conta a causa da IM, a sobrevida livre de eventos daqueles pacientes que desenvolvem IM comissural se aproxima daqueles pacientes que não apresentaram IM significativa. Isto pode sugerir que o contínuo processo de fibrose e calcificação da valva pode levar a "cura" desta IM...

Resumindo, nem tudo que reluz é OURO!!!

Complicação pós valvotomia por balão - by Fábio Soares

Paciente feminina, portadora de estenose mitral grave (área valvar pré-procedimento 0,9cm2), sintomática, encaminhada a Valvotomia Percutânea por Balão. Após o procedimento realizado Ecocardiograma de controle, que evidenciou:

O que fazer? Toda insuficiência mitral grave pós valvotomia percutânea deve ser encaminhada a cirurgia cardíaca para troca ou plastia?

Acho que o pessoal da Cintilografia não vai gostar... - from the heart

Providence, RI - Test result reports sent from nuclear cardiology labs to requesting physicians frequently omit important information, including basics like the report date or clear quantification of the myocardial defect [1].

A retrospective study of 1301 US nuclear cardiology labs applying for accreditation by the Intersocietal Commission for the Accreditation of Nuclear Medicine Laboratories (ICANL) found that 57% were noncompliant with at least one of 18 required reporting elements and site characteristics of ICANL standards in 2008. The results of the study, led by Dr Peter Tilkemeier (Miriam Hospital, Providence, RI), appear in the Journal of Nuclear Cardiology.

The most common mistake, made by 26.4% of labs, was not listing the date of the report. "The date of the report sounds like a very minor thing, but the date of the report is the means of tracking the time it takes from when the patient walks out the door until when the study is read by a physician and then proofread by a physician, which is very important," said Mary Beth Farrell, study coauthor and Director of Accreditation at the Intersocietal Accreditation Commission.

Almost 20% of the labs did not always include the myocardial defect size, severity, type, and location in the report using standardized terminology.

"The most important part of the test is to communicate the results to the person who is caring for the patient," Farrell told heartwire. Educating nuclear cardiology imaging lab personnel about the importance of clear communication with physicians requesting tests is one of "the primary goals for the American Society of Nuclear Cardiology," Farrell said.

The compliance process, itself, appears to be one of the best education tools. The study found that labs were more likely to comply with ICANL reporting standards the more times they had been through the accreditation process. Also, laboratories in states that did not require accreditation for reimbursement had greater noncompliance compared with laboratories in states with that requirement, the study found.

"The data demonstrate that the ICANL accreditation process works," Tilkemeier and colleagues argue. "By setting standards of policies and procedures, based on guideline documents developed by the professional societies, ICANL is an instrument driving the improvement process. . . . Accreditation is a learning process for the laboratories." The study found that labs usually went through two accreditation application cycles before reaching full compliance. The authors speculate it took this long because "changing long-standing processes requires time and multiple interventions that include motivation, belief in the change, and accountability."

In an accompanying editorial [2], Dr Frans Wackers (Yale University, New Haven, CT) observes: "One may feel that accreditation is just one more burden imposed on physicians and laboratories in an already (over) regulated medical practice environment, [but the study by Tilkemeier et al shows] the process of accreditation, ie, submitting data on all aspects of a laboratory and receiving feedback from reviewers, appears to have educational value."

Clarity counts

"The report, being an instrument of communication, must be evaluated for its effectiveness. Nuclear cardiology is not that esoteric that it cannot be described in plain English," Wackers argues. "If the wording of a report does not convey a clear message that is informative to the referring physician, communication has failed, as well as the purpose of performing the test in the first place."

"Curiously, some people who speak perfectly normal and understandable English in normal life may use very strange, indirect and convoluted language when creating a nuclear cardiology report," Wackers observes. "One of the reasons for unclear and cautious language may be the hesitation to commit unequivocally to either normal or abnormal interpretation. Not infrequently an interpreter has to make a choice between artifact and true perfusion abnormality. The interpreter, being the expert, should not share his/her ambiguity with the referring clinician, but bite the bullet and commit him/herself one way or the other in clear language."

Patterns of noncompliance

The study also assigned importance scores for each reporting element required by the ICANL standards. The most important elements are succinct impression, defect quantification, wall motion findings, indication, timeliness, and nomenclature or standardization. Moderately important elements include physician's signature, description of procedure, date of report, nonradioactive dose and route of administration, and exact dose of the radiopharmaceutical.

The study found that labs in western US states were more likely to miss the most important report elements than labs in other regions and mobile labs had higher rates of missed report elements than multispecialty facilities, private practices, or hospitals. Hospitals generally had the best rates of compliance weighted by severity, "but you can't outright say that hospitals were [always] better than private centers," Farrell stressed. The number of tests the lab performed and number of interpreting physicians working at the lab did not affect the distribution of severity of noncompliant elements.

Even prior to this study, many cardiologists were pushing for improvement in the quality of reporting from nuclear cardiology labs, Farrell said. "We expected as much and now we have the data to say specifically, what parts of the country we should spend more time on and we know the specific elements [of reports] that are most frequently missed."

Abnormal carotid IMT results change physician, but not patient, behaviors - from theheart.org

Madison, WI - Abnormal findings on an office-based carotid ultrasound test results in physicians changing their use of aspirin and cholesterol-lowering medications, including setting more aggressive lipid and blood-pressure targets [1]. Patients, on the other hand, failed to make changes to their diet or increase physical activity levels, and in some instances, even failed to quit smoking, despite an increased awareness of their cardiovascular-disease risk.

"This isn't a randomized clinical trial, and obviously that's a weakness," senior investigator Dr James Stein (University of Wisconsin School of Medicine, Madison) told heartwire. "But the most interesting finding in this study is that the results of the carotid ultrasound didn't really affect the patients. We know that when doctors see abnormalities on a calcium scan or carotid ultrasound, they are very inclined to do things, like prescribe aspirin and have more aggressive targets for cholesterol and blood pressure. We also know that patients say they're going to do all kinds of things, but after one month in this trial those intentions were already extinguished."

The results of the study are published in the July 2011 issue of the Journal of the American Society of Echocardiography.

Increased carotid intima-media thickness (IMT) and the presence of carotid plaque are independent predictors of future cardiovascular-disease events, and carotid ultrasound screening has been recommended as a tool to help risk prediction, particularly in intermediate-risk patients, such as those with a 6% to 20% risk of MI or coronary heart disease over 10 years. The devices have also become more widespread in clinical practice—some of today's inexpensive carotid ultrasound systems are handheld—and are being used by nonsonographer physicians to identify increased carotid IMT and carotid plaque.

Community-based practices

In the present study, led by Dr Heather Johnson (University of Wisconsin School of Medicine, Madison), the researchers identified 355 subjects who underwent carotid ultrasound screening at five nonacademic community practices in the US. Patients were >40 years of age and had at least one cardiovascular disease risk factor. Of these subjects, 75% had an abnormal result on the carotid ultrasound, defined as carotid IMT >75th percentile or the presence of carotid plaque.

For the physicians, an abnormal finding on the ultrasound resulted in a change in the LDL-cholesterol target for the patient. In one-third of the patients with abnormal results, the physicians decreased the LDL-cholesterol target from 130 mg/dL to 100 mg/dL and decreased the LDL-cholesterol goal from 100 mg/dL to 70 mg/dL in another 21% of patients. Similarly, for those with an abnormal result, the doctors altered systolic blood-pressure goals from 140 mm Hg to 130 mm Hg. Physicians were also more likely to prescribe aspirin in patients with an abnormal ultrasound result. Overall, 26% of patients were started on aspirin, while 10% had increases in the baseline aspirin dose.

LDL-cholesterol and systolic blood pressure targets were not changed in patients with normal carotid ultrasound results, while just three subjects with a normal ultrasound were prescribed aspirin.

For the patients, the presence of an abnormal carotid ultrasound predicted intentions to change health-related behaviors. For example, these patients stated they would attempt to achieve their exercise goals and to change their diet to lower LDL-cholesterol levels, such as decreasing saturated-fat intake. In the small group of smokers, they also stated an intention to quit smoking. At 30 days, however, just 34% of patients increased their exercise frequency and just 37% lost weight. The presence of an abnormal ultrasound result did not predict the increase in exercise frequency or weight loss.

"The very act of screening people heightens their attention to health-related behaviors," said Stein. "It makes perfect sense to doctors that if you show somebody a picture and you scare them they'll be motivated to change their behavior. But really, motivation is on the doctor's side. There is ample evidence now showing that a one-time intervention really doesn't last very long, and this study showed that, too."

Stein told heartwire that physicians need to be humble and realize that patient psychology is more complicated than efforts to scare them into change. He said that patients appear to change their behavior, such as losing weight or eating healthily, only if they feel these changes are possible for them. Regardless of the risk, patients tend to simply avoid their physician or ignore their advice, if they feel the changes are impossible.

"The only thing that seems to work is case management, where you have repeated encounters with the healthcare system," said Stein. "Patients get feedback on their progress, you help them solve problems, and you work with them through setbacks. These are the only things that have been shown to work in terms of changing patient behaviors. We need a systems-based approach to make sure that patients are coming in for screening and rescreening, to make sure they are complying with their medication and have more encounters with the healthcare system. And it doesn't have to be doctors—it could be nurses, exercise physiologists, or dieticians. People who can really give them the guidance

Resposta do Caso Clínico - Efeito Bernheim - by Fábio Soares

O caso anterior trata-se de uma Cardiomiopatia Hipertrófica Obstrutiva (SAM). Chama a atenção o padrão do fluxo de via de saída do ventrículo DIREITO, Apesar de não apresentar gradiente significativo, nota-se um padrão de fluxo em ADAGA, tal qual o da via de saída do ventrículo esquerdo.

Existe, de há muito, a descrição de pacientes com congestão venosa sistêmica, hepatomegalia e insuficiência ventricular direita em pacientes com estenose aórtica e ventrículos hipertróficos. A hipertrofia septal projetando-se para o VD, pode levar a levando a dificuldade de enchimento do VD bem como levar a uma obstrução dinâmica da via de saída do mesmo. Este é o efeito Bernheim.

Os casos inicialmente foram descritos relacionados a estenose aórtica, porém foram observados casos semelhantes em CMH, IAM septal, etc.

Curiosidade... - by Fábio Soares

Alguém arrisca um palpite?

New Guideline - Doença arterial carotídea e vertebral

From http://www.theheart.org/

The American College of Cardiology, American Heart Association, and Society for Cardiovascular Angiography and Interventions, in conjunction with a range of other medical societies, released new guidelines on the use of stenting and surgery in the management of patients with extracranial carotid and vertebral artery disease [1].

Of note are new recommendations for management of carotid disease, where carotid stenting is now seen as an alternative to carotid endarterectomy for symptomatic patients at average or low risk of complications, with stenosis greater than 70% on duplex ultrasonography.

Dr Thomas G Brott (Mayo Clinic Jacksonville, FL) was cochair of the writing committee for the new guidelines and also principal investigator of the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST).

The results of CREST suggest that in addition to carotid surgery and medical therapy, "we now have a third option, carotid stenting," he said. "Both surgery and stenting have been shown to be safe, and so far, in CREST, both have been shown to be durable."

The new guidelines are concordant with recently released guidelines on primary and secondary stroke prevention, as well as a recommendation last week by the Food and Drug Administration Circulatory System Devices Panel, Brott said, which voted 7 to 3 in favor of an expanded indication for the RX Acculink Carotid Stent System (Abbott, Abbott Park, IL), stating the benefits of carotid stenting in patients at standard risk for adverse events from endarterectomy outweigh the risks. Currently, the system is approved only for those at high surgical risk.

The role of stenting vs surgery has been controversial, given results of previous randomized comparisons such as the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) trial and the International Carotid Stenting Study (ICSS) that had suggested surgery to be the safer option.

"I would say in other situations where we have three choices for treatment of a particular condition, physician groups and patients don't always agree on the options for a particular patient, and that's likely to occur with carotid disease as well," Brott said in an interview.

The guidelines suggest it maybe "reasonable" to choose surgery over stenting in older patients, particularly those with anatomy unfavorable for stenting, and likewise reasonable to choose stenting over surgery when neck anatomy is not suitable for surgery.

The document is published online January 31, 2011 in Circulation, Stroke, and the Journal of the American College of Cardiology.

Routine screening not recommended

The new recommendations deal with diagnostic testing, medical and surgical therapies, and risk-factor modification in patients with extracranial carotid and vertebral artery disease.

Some of their other recommendations include:

•The guidelines advocate duplex ultrasonography, performed by a qualified technologist in a certified laboratory, as the initial diagnostic test for suspected carotid stenosis. However, the writing group recommends against routine screening of asymptomatic patients without clinical symptoms or risk factors for atherosclerosis.

•In patients with extracranial carotid disease not undergoing revascularization, the guidelines recommend antiplatelet therapy with aspirin, 75 to 325 mg daily, for patients with obstructive or nonobstructive atherosclerosis in extracranial carotid and/or vertebral arteries for prevention of MI and other cardiovascular events. The benefit of treatment to prevent stroke in asymptomatic patients hasn't been established, they note.

•For those with extracranial carotid or vertebral atherosclerosis with a history of ischemic stroke or transient ischemic attack (TIA), antiplatelet therapy with aspirin alone (75 to 325 mg daily), clopidogrel alone (75 mg daily), or the combination of aspirin plus extended-release dipyridamole (25 and 200 mg twice daily, respectively) is recommended and preferred over the combination of aspirin with clopidogrel.

•Carotid duplex ultrasound screening before CABG is reasonable in patients over 65 and those with left main coronary stenosis, a history of stroke or TIA, or carotid bruit. Revascularization with surgery or stenting with embolic protection is reasonable for those who have experienced ipsilateral ischemic symptoms, but for asymptomatic patients, the safety and efficacy of carotid revascularization before or during CABG is "not well established."

"Vast opportunities" for research

Although the authors note that their recommendations are "whenever possible, evidence-based," review of the literature has shown that great gaps in knowledge remain.

"As evident from the number of recommendations in this document that are based on consensus in a void of definitive evidence, there are vast opportunities for research," they write.

Among these is the lack of evidence to support the benefit of carotid surgery in women, a clear need for more information on the "imperfect correlation" between the severity of carotid stenosis and ischemic events, and better methods to improve diagnostic accuracy of stenosis.

"CREST answered some questions about the relative value of [carotid artery stenting] and [carotid endarterectomy] but raised others," they write. "The reported event rates were generally low with either method of revascularization among symptomatic patients, but there was an important difference related to patient age that requires explanation.

"The most pressing question is how either technique of revascularization compares with intensive contemporary medical therapy, particularly among asymptomatic patients, and a direct comparative trial should include a sufficiently broad range of patients to permit meaningful analysis of subgroups based on age, sex, ethnicity, and risk status," the authors write.

"Huge gaps" in knowledge about vertebral arterial disease will be more difficult to solve because of its relative infrequency compared with carotid stenosis, they add. "This requires well-designed registries that capture data about prevalence, pathophysiology, natural history, and prognosis."

1.Brott TG, Halperin JL, Abbara S, et al. JASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: Executive summary. Circulation 2011: DOI:10.1161/CIR.0b013e31820d8d78. Available at: http://circ.ahajournals.org. Stroke 2011;DOI:10.1161/STR.0b013e3182112d08. Available at: http://stroke.ahajournals.org. J Am Coll Cardiol 2011; DOI:10.1016/j.jacc.2010.11.006. http://content.onlinejacc.org.

Resposta do Caso Clínico da Semana - by Fábio Soares

Pcte feminina, 59 anos, com diagnóstico de neoplasia maligna do trato genitourinário. Comparece para realizar Ecocardiograma de controle após quimioterapia.

--> Houve fratura do Portocath quando da sua retirada. Paciente foi encaminhada ao serviço de hemodinâmica tendo sido o cateter "laçado" e retirado por via femural sem intercorrêcnias.

(Imagem ilustrativa)

Caso Clínico da Semana - novas incidências a pedido...

Linfoma mediastinal com compressão extrínseca da via de saída do VD e envolvimento da aorta e artéria pulmonar (vide corte transvresal supraesternal). Administrado QT e corticóide, sendo que após 1 semana, houve redução significativa da massa e melhora do gradiente da via de saída do VD.

corte supraesternal transverso

Caso Clínico da Semana - by Fábio Soares