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

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

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

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

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

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

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

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

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

Síndrome de Yamagushi - by Fábio Soares

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

- Yamaguchi H, Nishiyama S, Nakanishi S, Nishimura S. Electrocardiographic, echocardiographic and ventriculographic characterization of hypertrophic non-obstructive cardiomyopathy. Eur Heart J 1983;4 Suppl F:105–19

Apesar de um prognóstico relativamente bom para CMH apical , as observações de longo prazo têm ocasionalmente incluídos morte súbita cardíaca, arritmias graves, infartos e apical com aneurismas apicais.

CORP: Colchicine prevents recurrent pericarditis - by the heart

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

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

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

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

Colchicine halves rate of pericarditis recurrence

Around a third of patients who develop pericarditis will suffer recurrences, Imazio said, noting that CORP is the first multicenter, double-blind randomized trial of colchicine in the secondary prevention of pericarditis and confirms the findings of the earlier CORE study.

The time has come where colchicine should be more freely used. In the trial, 120 patients with a first recurrence of pericarditis were randomized to either placebo or low-dose colchicine (1 mg twice daily for 24 hours then 0. 5 mg twice daily for six months for those weighing over 70 kg) in addition to conventional treatment—aspirin 800 to 1000 mg or ibuprofen 600 mg orally every eight hours for seven to 10 days as a first choice or prednisone 0.2 to 0.5 mg/kg/day for four weeks as second choice.

The primary end point was recurrence rate at 18 months. Secondary end points included symptom persistence at 72 hours, remission rate at one month, number of recurrences, time to subsequent recurrence, disease-related hospitalization, cardiac tamponade, and constrictive pericarditis.

Colchicine halved the rate of recurrence—24% of those taking colchicine had recurrence compared with 55% of those on placebo (relative risk reduction 56%; p<0.001), and there were also significant reductions in a number of secondary end points among those taking colchicine compared with placebo.

This translates to a number needed to treat (NNT) of only three patients to prevent one recurrence, Imazio said.

The drug was safe in the doses used, he added, with no difference in adverse events between the colchicine and placebo groups.  The results support the use of low-dose colchicine as a first-line adjuvant to standard care in recurrent pericarditis, he said, calling the results "impressive."

He noted, however, that the CORP findings are specific for the population tested—adult patients with a first recurrence of pericarditis, excluding those with bacterial or neoplastic pericarditis and others who may have contraindications to colchicine use—and therefore may not be generalizable to other settings or patient populations, such as children. Also, he noted that use of colchicine for pericarditis is an off-label indication.

Last year at the ESC meeting, Imazio reported that colchicine prevented the development of postpericardiotomy syndrome (PPS) after heart surgery.

Valva Pulmonar Bivalvular - by Fábio Soares

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

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

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

Segue link com imagens de RM cardíaca de caso semelhante

Caso JACC

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

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

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

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

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

Worsened diastolic dysfunction was associated with age 65 years or older (odds ratio 2.85), and after a mean of 6.3 years of additional follow-up, 12.2% of patients whose LV diastolic dysfunction was moderate to severe developed heart failure. By contrast, during the follow-up period, only 2.6% of people with normal diastolic dysfunction showed heart failure, and 7.8% of participants with mild diastolic dysfunction developed heart failure (p<.001). The study also showed that diastolic dysfunction was associated with incident heart failure after adjustment for age, hypertension, diabetes, and coronary artery disease (hazard ratio 1.81).

"We have known for some time that hypertension and cardiovascular disease and diabetes all predispose one to the development of heart failure with preserved ejection fraction, and it's been presumed that part of the reason that those risk factors contributed to the development of heart failure with preserved ejection fraction had something to do with diastolic dysfunction, but nobody had ever really made measurements to show that that was the case," Rodeheffer said.

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

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

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

Espessamento do Complexo Médio-Intimal

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

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

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

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

Traditional Framingham risk factors predicted these events with a C statistic of 0.748. For a one standard-deviation increase in maximum IMT of the internal carotid artery, the hazard ratio was 1.21, with a modest but statistically significant increase in the C statistic of 0.009. Reclassification of patients' cardiovascular risk was aided by adding the IMT of the internal carotid artery to the Framingham score; the net reclassification index—a statistical measure of how much a new factor improves the accuracy of a risk-prediction model—increased 7.6% (p<0.001).

However, the adjusted hazard ratio for cardiovascular disease associated with a one standard-deviation increase in common carotid artery mean IMT was 1.13 and the associated change in the C statistic of 0.003 was nonsignificant. The IMT of the common carotid artery did not improve reclassification; the net reclassification index did not change (0%, p=0.99).

In patients in whom carotid plaque was detected in the internal carotid artery, the net reclassification index was 7.3% (p=0.01), with an increase in the C statistic of 0.014. The presence of plaque in the internal carotid artery can either be measured as part of the continuous IMT or assumed to be there if the thickness exceeds 1.5 mm, Polak and colleagues explain

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

Resposta do Caso Clínico da Semana - by Fábio Soares

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

Abaixo clips da RNM cardíaca

O laudo da RNM foi compatível com embolia tumoral(visto a massa apresentar citoplasma)

A paciente se recusou a submeter-se a cirurgia cardiaca e solicitou alta hospitalar.

Continuando o Caso Clínico da Semana - by Fábio Soares

Evolução do caso clínico anterior :

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

Homenagem ao Dia dos Pais

Sinal de El-Sherif - from Medscape

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


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

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

Answer: Ventricular Aneurysm



Estenose Aórtica - by Fábio Soares

European Heart Journal (2011) 32, 888–896

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

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

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

Caso Clínico da Semana - by Fábio Soares

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

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

A complacência ventricular (idosos, HAS grave, EAo grave), taquicardia, insuficiência aórtica (maior que leve), valvotomia percutânea ou cirúrgia e valvoplastia cirúrgica influenciam diretamente a medida da área valvar por PHT. Mesmo em próteses valvares este método apresenta limitações.

 - Chambers J, Jackson G, Jewitt D. Limitations of Doppler ultrasound in the assessment of the function of prosthetic mitral valves. Heart 1990;63:189–94.

- A inadequação do PHT provavelmente é devido ao fato de que este método é mais dependente de outras variáveis que a própria área valvar (assim como ocorre com as próteses valvares, é provável que o mesmo se aplique às valvas submetidas a plastia)

 - Chambers J, McLoughlin N, Rapson A, Jackson G. Effect of changes in heart rate on pressure half-time in normally functioning mitral valve prostheses. Br Heart J 1988;60:502–6.

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

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

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

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.