BackgroundEchocardiography provides important information on the cardiac evaluation of patients with heart failure. The identification of echocardiographic parameters in severe Chagas heart disease would help implement treatment and assess prognosis. ObjectiveTo correlate echocardiographic parameters with the endpoint cardiovascular mortality in patients with ejection fraction < 35%. MethodsStudy with retrospective analysis of pre-specified echocardiographic parameters prospectively collected from 60 patients included in the Multicenter Randomized Trial of Cell Therapy in Patients with Heart Diseases (Estudo Multicêntrico Randomizado de Terapia Celular em Cardiopatias) - Chagas heart disease arm. The following parameters were collected: left ventricular systolic and diastolic diameters and volumes; ejection fraction; left atrial diameter; left atrial volume; indexed left atrial volume; systolic pulmonary artery pressure; integral of the aortic flow velocity; myocardial performance index; rate of increase of left ventricular pressure; isovolumic relaxation time; E, A, Em, Am and Sm wave velocities; E wave deceleration time; E/A and E/Em ratios; and mitral regurgitation. ResultsIn the mean 24.18-month follow-up, 27 patients died. The mean ejection fraction was 26.6 ± 5.34%. In the multivariate analysis, the parameters ejection fraction (HR = 1.114; p = 0.3704), indexed left atrial volume (HR = 1.033; p < 0.0001) and E/Em ratio (HR = 0.95; p = 0.1261) were excluded. The indexed left atrial volume was an independent predictor in relation to the endpoint, and values > 70.71 mL/m2 were associated with a significant increase in mortality (log rank p < 0.0001). ConclusionThe indexed left atrial volume was the only independent predictor of mortality in this population of Chagasic patients with severe systolic dysfunction.
A 23-year-old male patient presented with fever, weight loss, anorexia, and night sweats for 6 months, followed by progressive exertional dyspnea and cough. Transthoracic and transesophageal echocardiograms were performed, revealing a cavity (28 × 35 mm; area = 7.5 cm 2 ) ( Fig. 1A-C) related to the posterior leaflet of the mitral valve, suggestive of a subvalvular pseudoaneurysm associated with severe mitral regurgitation and pulmonary hypertension. A transthoracic real time, three-dimensional echo (RT3D Echo) provided a better imaging and detailed anatomic information about this finding ( Fig. 2A-C) (movie clip 1). Systolic flow communication between the left ventricle and the pseudoaneurysm was shown by a color Doppler examination. A cardiac magnetic resonance imaging was performed, which confirmed the findings of the echocardiographic examination (movie clip 2). The patient was discharged from the hospital, and after 6 months of antituberculosis treatment, he was referred for mitral valve repair. A resection of the pseudoaneurysm and a posterior annuloplasty were performed ( Fig. 3A and 3B). The patient's symptoms had improved, and he was discharged from the hospital 20 days after the surgery. Subvalvular mitral pseudoaneurysms are unusual findings, related mostly to mitral valve repair. Echocardiography plays a fundamental role in the diagnosis of these cases. Transthoracic bidimensional echocardiography and Doppler echocardiography are very useful tools for identifying the pseudoaneurysm, locating it and demonstrating the blood flow turbulence within the cardiac chambers. 1 In this case, the three-dimensional echocardiogram more precisely identified the pseudoaneurysm and the orifice that was allowing communication between the left ventricle and this structure. In addition, the RT3D Echo allowed a detailed anatomic evaluation of the pseudoaneurysm and its relationship to the mitral valve and the subvalvular apparatus to be made, facilitating better surgical planning. This case report addresses the role of RT3D Echo in the diagnosis of this rare clinical situation. This noninvasive, portable and fast diagnostic method provides complementary information to two-dimensional echocardiography and can be as accurate as cardiac magnetic resonance imaging in the diagnosis of mitral subvalvular pseudoaneurysm. 2-4 References 1. Du Toit HJ, Von Oppell UO, Hewitson J, et al: Left ventricular sub-valvular mitral pseudopseudoaneurysms. Interact Cardiovasc Thorac Surg 2003;2:547-551. 2. Liang D, Paloma A, Kuppahally SS, et al: Multiplanar visualization in 3D transthoracic echocardiography for precise delineation of mitral valve pathology. Echocardiography 2008;25:84-87. 3. Chen CC, Hsiung MC, Wei J, et al: Mitral annular subvalvular left ventricular aneurysm. Echocardiography 2005;22:434-437. 4. Han J, He Y, Li Z, et al: Pseudoaneurysm of the mitralaortic intervalvular fibrosa in a patient after radio frequency catheter ablation of atrial fibrillation. J Ultrasound Med 2009;28:249-251. 473
Background Cancer chemotherapy using anthracyclines is associated with cardiotoxicity (CTX), and left ventricular ejection fraction (LVEF) analysis is not sensitive to early cardiotoxic changes. Left ventricular global longitudinal strain (LV GLS) monitoring helps screen subclinical CTX; however, the intervals at which it should be performed remain unclear. We aimed to evaluate the incidence of CTX in women with breast cancer and the associated factors and compare two echocardiographic monitoring strategies using two cutoff points for LV GLS variation. Methods Patients with breast cancer prescribed doxorubicin underwent serial LVEF and LV GLS assessments using two-dimensional echocardiography every 3 weeks for 6 months. Results We included 43 women; none developed a clinical CTX. Considering a relative reduction of LV GLS > 15%, subclinical CTX was present in 12 (27.9%) and six (14%) patients at 3-week and 3-month intervals, respectively (P = 0.28). Additionally, considering a reduction of > 12%, subclinical CTX was present in 17 (39.5%) and 10 (23.3%) patients (P = 0.16), respectively. There were no significant differences in either reference value at 3-week (P = 0.19) and 3-month intervals (P = 0.41). Age ≥ 60 years (P = 0.018) and hypertension (HTN) (P = 0.022) were associated with subclinical CTX in the univariate analysis. Conclusions There was no difference in the incidence of subclinical CTX between the two cutoff points and no benefit in performing echocardiography every 3 weeks compared with quarterly monitoring. Advanced age and HTN were associated with the development of subclinical CTX.
Purpose This study aims to define which of the right ventricular myocardial deformation indices best correlates with the classic echocardiographic measurements and indices of right ventricular (RV) dysfunction in patients with stable chronic obstructive pulmonary disease (COPD). Patients and Methods Ninety-one patients with stable COPD underwent clinical evaluation, spirometry, a 6-minute walk test, and echocardiographic examination. Patients were divided into two groups: “with RV dysfunction” (≥1 classic parameter) and “without RV dysfunction”. We used speckle tracking to estimate myocardial deformation. For all analyses, results were considered significant if p < 0.05. Results The mean age across all participants was 65 ± 9 years, with 53% (48/91) being male. Patients in the group with RV dysfunction were able to walk shorter distances and had higher estimated right ventricular systolic pressure (RVSP) and mean pulmonary arterial pressure (mPAP). The RV free wall longitudinal strain (RVFWLS) was the only deformation indices that showed a significant correlation with all classic measurements and indices in the diagnosis of RV dysfunction (Wald test, 10.24; p < 0.01; odds ratio, 1.61). In the ROC curve analysis, the absolute value <20% was the lowest cut-off point of this index for detection of RV dysfunction (AUC = 0.93, S: 95.8%, and E: 88%). Conclusion In COPD patients, RVFWLS is the myocardial deformation index that best correlates with classic echocardiographic parameters for the diagnosis of RV dysfunction using <20% as a cut-off point.
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