Caso Clínico da Semana - by Fábio Soares

RN 20 dias, taquipnéia e cianose durante o choro.
ECO: Truncus tipo 1, com estenose grave da valva truncal com insuficiência discreta.

Nota-se fluxo reverso em aorta torácica descendente e aorta abdominal. Qual a causa?

Fluxo VE/Truncus

Fluxo aorta torácica descendente

Fluxo aorta abdominal

Origem do tronco pulmonar

Fluxo reverso em aorta torácica descendente

(interferência devido ao choro do RN)

Speckle Tracking - Congresso Baiano de Cardiologia 2012

Congresso Baiano de Cardiologia - 01 junho de 2012

Tutorial Toshiba com Prof. Dr. André Almeida

Não percam!

Sessão do Departamento de Imagem Cardiovascular / SBC-Ba

Mitral regurgitation: Early hazard, later gains following TAVI - by heart.org

Vancouver, BC and Quebec City, QU - Moderate to severe mitral regurgitation (MR) is relatively common in patients undergoing transcatheter aortic-valve implantation (TAVI) and is associated with a doubling in risk of 30-day death, a new series suggests [1]. Beyond this initial period, however, survival among MR patients is just as good as among patients with no MR, and MR itself is likely to improve over time, authors of a new analysis say.

 

The paper, by Dr Stefan Toggweiler (St Paul's Hospital, Vancouver, BC) and colleagues, is published online April 4, 2012 in the Journal of the American College of Cardiology.

To heartwire, Toggweiler explained that the percentage of patients undergoing TAVI who also have moderate to severe MR has varied across reports, ranging from 25% to 45%. Severe MR was actually an exclusion criterion in the pivotal PARTNER trials, but many patients made it into the trial with a diagnosis of "moderate" MR that was only upgraded after the core lab reviewed the echocardiograms, meaning that even in PARTNER there are subset data on patients with significant MR.

Toggweiler et al tracked outcomes of 478 patients treated over a five-year period at two centers in Canada. (Devices used over this period were the Edwards-Cribier valve [n=56], Edwards Sapien [n=270], and Sapien XT [n=115]). Although the bulk of patients had mild or no MR, 89 had moderate MR, and 43 had severe MR.

At 30 days, mortality among patients with moderate or severe MR was twice as high as among those with mild or less MR (hazard ratio [HR] 2.10, p=0.02); after 30 days and up to two years, however, mortality rates were no different between these groups (HR 0.82, p=0.42).

Of note, among survivors, MR had improved in 55% of subjects, remained the same in another 16%, and had worsened in just 1%. Among those with moderate or severe MR at baseline, 61% of patients experienced some improvement post-TAVI.

"Short-term mortality is a bit higher after TAVI, and in general, these patients are a bit older and have more comorbidities, so certainly immediately postoperative, the risk is a bit higher and they require careful monitoring," Toggweiler summarized. "But again, if they are not treated, they probably don't do well because the combination of MR and aortic stenosis is not well tolerated at all."

To heartwire, he noted that a similar pattern of early hazard post-TAVI, followed by improved outcomes after the 30-day mark, was seen in PARTNER, although the numbers were very low.

Given these findings, he continued, "the advice would be that these patients [who also have moderate to severe MR at the time of their TAVI procedures] need careful monitoring, and we have identified some factors that actually are associated with good outcomes." These include patients with higher mean transaortic gradient at baseline, no atrial fibrillation, no pulmonary hypertension, and functional as opposed to structural MR. "So these [patients] may be candidates for isolated TAVI," Toggweiler said.

Pointing to the fact that MR actually improved in 61% of subjects, Toggweiler noted that there are likely different mechanisms by which patients, if they survive the early postop period, actually do better in the long term.

"What is most likely [happening] is, because the afterload is reduced immediately—because there is no stenosis—there is less pressure gradient between the left ventricle and left atrium, and that leads to reduced MR in the short term. And then some patients have positive remodeling post-TAVI, ejection fraction improves, and that leads to improvement in the long term."

Curiosidade da semana (Agora ficou fácil...) - by Fábio Soares

O que vemos nessa imagem?

Será que ajudaria dizer que o paciente apresenta Hipertensão Arterial Pulmonar grave? E com o eixo curto, já observaram a pegadinha?

Hipertensão Arterial Pulmonar Grave acompanhada de grave hipertrofia do VD e de sua trabécula septomarginalis. À primeira vista, temos a impressão de que o SIV está normal e há um grande tendão móvel no VE, porém o que ocorre é o movimento paradoxal do SIV devido a pressão do VD bastante elevada.

"The septomarginal trabecula (also known as moderator band) is a muscular band of heart tissue found in the right ventricle. It is well-marked in sheep and some other animals, and frequently extends from the base of the anterior papillary muscle to the ventricular septum.

This septomarginal trabecula is important because it carries part of the right bundle branch of the AV bundle of the conduction system of the heart to the anterior papillary muscle. This shortcut across the chamber of the ventricle seems to facilitate conduction time, allowing coordinated contraction of the anterior papillary muscle."

Resposta do caso clínico - by Fábio Soares

Nota-se grande trombo ocupando o ápice do ventrículo esquerdo (área acinética), bastante móvel e com características recentes (várias fases). Este paciente permaneceu internado em ajuste de medidas para disfubnção ventricular, uso de dupla agregação plaquetária e anticoagulação plena com Heparina de baixo peso molecular.

Após 1 semana,repito o ecocardiograma deste paciente:

Caso clinico da semana - by Fábio Soares

Paciente masculino, 73 anos, HAS, DLP, admitido na unidade de emergência com IAM com supra ST de parede anterior com início há >24h, porém com recorrência de dor. CATE evidenciando lesão de DA 90% em 1/3 proximal com fluxo TIMI 2. Realizado PTCA de DA com stent convensional. Ecocardiograma realizado 12 horas apos o procedimento evidencia:

O Teste ergométrico pede passagem - by DERC

Para todos os cardiologistas e interessados em Ergometria, segue um artigo da Revista do DERC sobre a polêmica do Segmento ST com ascensão lenta: Isquêmico em quem?

http://departamentos.cardiol.br/sbc-derc/revista/2012/18-1/pdf/Rev18-1a-polemica.pdf

PARTNER A: Even mild paravalvular leaks linked with higher mortality at two years - by the Heart

Chicago, IL (updated) - Paravalvular leaks—a phenomenon virtually unheard of in the surgical valve replacement era—have truly been propelled into the limelight today, with the presentation of two-year results from the PARTNER A transcatheter aortic-valve intervention (TAVI) trial [1]. At two years, rates of death from any cause were not statistically different between transcatheter aortic-valve replacement (TAVR) and surgical valve replacement, but paravalvular regurgitation was more common after TAVR than surgery. And strikingly, even mild paravalvular regurgitation was associated with increased late mortality.

Dr Susheel Kodali (Columbia University, New York, NY) presented the two-year results here at the American College of Cardiology (ACC) 2012 Scientific Sessions; they were published online simultaneously in the New England Journal of Medicine. One-year results from the trial debuted at last year's ACC meeting, as reported at the time by heartwire.

"TAVR should be considered an alternative to surgery with similar mortality and clinical benefits," Kodali said this morning. "Periprocedural stroke concerns after TAVR have diminished with longer follow-up, and TAVR valve hemodynamics have remained stable, although periprocedural [aortic regurgitation] (even mild) has emerged as a predictor of late mortality."

Co-principal investigator, Dr Craig Smith (Columbia University), commenting on the two-year results for heartwire, acknowledged: "The paravalvular-leak findings were a surprise. Of the concerns dogging TAVR, paravalvular leak was the one for which two answers were given: one, it will become less frequent with time, experience, and modifications in design; and, two, it doesn't appear to matter anyway. For stroke and vascular complications, [the second explanation] clearly never applied.  We're back to number one alone for paravalvular leak, which shouldn't surprise us."

Kodali called the lack of difference in mortality and stroke the "most important" news from the two-year results but acknowledged that the finding that mild regurgitation is linked with mortality is "clearly interesting" and new. "What we've identified is a potential target in terms of improving on this procedure," he told heartwire. The procedure will continue to evolve, he pointed out, and a wider range of valve sizes, better recognition of patient characteristics, better imaging techniques will all help reduce the incidence of aortic regurgitation, he said. "This is a new procedure, being performed by inexperienced operators, going up against a decades-old therapy in the hands of the best surgeons," Kodali added. He believes the paravalvular findings "are not going to dampen enthusiasm for TAVI. If anything, this will motivate us to improve on these procedures and these devices."

PARTNER A: Deaths, strokes at two years

Between years one and two in the PARTNER A cohort, 32 more patients died in the TAVR group and 25 in the surgery group, with no statistical differences in deaths from any cause or from cardiovascular causes. For strokes, the end point that drove much of the conversation after one-year results were reported, an additional eight strokes occurred, four in each group. Two transient ischemic attacks (TIAs) occurred in year 2 among TAVI-treated patients as compared with just one in the surgery group, yielding an overall neurological event rate that was higher in the TAVR group than in the surgery group, reaching borderline statistical significance. For strokes alone, however, no significant differences were seen between groups at two years. By year 2, 19 patients treated surgically received a new pacemaker, compared with 23 in the TAVR group, a statistically insignificant difference.

Mortality was higher in the transapically treated patients than in the transfemorally treated patients, but Kodali stressed to a morning press conference that the trial was not powered to compare these groups, and the transapical group included the "learning-curve experience." And Dr Robert Guyton (Emory School of Medicine, Atlanta, GA), a surgeon and trial investigator, pointed out that in patients in the continued-access program (CAP) registry, which now includes over 800 patients treated via a transapical approach, mortality rates have come down. "As experienced developed, mortality actually ended up being numerically lower than in the transfemoral arm . . . and stroke rate was dramatically reduced, to less than 3%, which is one of the lowest stroke rates reported" in transcatheter trials.

Paravalvular regurgitation in the spotlight

The finding from PARTNER A year 2 that is raising eyebrows here today is the paravalvular-regurgitation data. Moderate to severe paravalvular regurgitation has already been identified as a predictor of mortality among TAVR-treated patients, but as Leon said in an interview with heartwire, this is the first time mild regurgitation has been linked with a higher death rate, and within a prospective, multicenter, randomized clinical trial, with independent core-lab echocardiographic review. "The effect of aortic regurgitation on mortality was proportional to the severity of the regurgitation, but even mild aortic regurgitation was associated with increased rate of late deaths," Kodali et al write.

Aortic regurgitation	None/trace	Mild	Moderate/severe	P (log rank)
1-y mortality (%)	14.5	29.2	29.5	<0.001
2-y mortality (%)	24.8	39.2	41.1	<0.001

Commenting on the paravalvular-regurgitation data, Dr Robert Bonow (Northwestern University, Chicago, IL) pointed out that moderate to severe paravalvular regurgitation has emerged as an important, possibly even the most important predictor of mortality in TAVI-treated patients. In patients who undergo surgical valvular replacement, the rate of moderate to severe aortic regurgitation is typically less than 1%. "Here you have 40% of TAVR-treated patients with mild aortic regurgitation, and another 10% with moderate to severe aortic regurgitation, so 50% of patients have mild regurgitation or greater—that's a potential Achilles heel."

Speaking with heartwire, senior author on the study, Dr Martin Leon (Columbia University), agreed but, like Kodali, sees a silver lining: "This is an important observation, but I would put it in perspective. If you look at overall mortality between surgery and TAVR, the rates are identical, and in no subgroup is overall mortality different," Leon told heartwire. "We're thinking paravalvular leak can be treated or prevented, and there's clear evidence that there was valve undersizing in PARTNER that we think can be corrected using postdilatation if done selectively and carefully. If you can reduce the incidence of paravalvular leak down to 'none or trace,' you could potentially reduce mortality by half."

And looking at mortality among patients with no paravalvular regurgitation vs patients with mild to severe paravalvular regurgitation, mortality rates were halved, he noted. "This suggests that this should become a very aggressive target, and new technology, improved procedure characteristics, and better sizing of the devices—those all may be important in reducing mortality as compared with surgery," Leon said.

Room to expand

Dr Craig Smith

Bonow and Smith tended to agree with Leon and Kodali, with Smith, a surgeon, predicting that "the frequency of paravalvular leak will decrease with experience and will not be a major impediment. Design may also play a role but is a more complicated and theoretical discussion."

Bonow, likewise, said that interventionalists he's spoken with are now doing everything they can to make sure they "fix" a paravalvular leak when they see moderate to severe regurgitation, by reexpanding the device or even using a valve-in-valve procedure. But to date, he says, operators haven't been overly concerned about mild regurgitation—that should likely change.

Already, speculation is mounting as to whether the paravalvular data might be one reason the FDA has not yet announced a date for its advisory committee to review the PARTNER A data, where the sponsor is seeking to extend the indication for TAVR to patients who are also eligible for surgery.

"In a regulatory environment sensitized by lead fractures, failing steel hip prostheses, and other postapproval embarrassments, this is sure to be noticed and will probably slow approval in young, low-risk populations until long term success is better understood," Smith speculated.

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