Utilidad de la ecocardiografía de contraste con solución salina agitada en el diagnóstico de la persistencia de vena cava superior izquierda / Usefulness of contrast echocardiography with agitated saline at diagnosis of persistence of the left superior vena cava

Resumen La ecocardiografía contrastada con solución salina agitada es una modalidad de imagen establecida. Este método es usualmente utilizado para el diagnóstico de foramen oval permeable, shunts intracardiacos, anomalías del drenaje venoso y shunts intrapulmonares. En este artículo se revisarán aspectos generales de la ecocardiografía contrastada con solución salina, así como métodos diagnósticos enfocados principalmente a la detección de la persistencia de vena cava superior izquierda y sus variantes.

Abstract Echocardiography contrasted with agitated saline solution is an established imaging modality. This method is usually used for the diagnosis of patent foramen ovale, intracardiac shunts and venous drainage abnormalities. In this article, general aspects of the echocardiography contrasted with saline solution will be reviewed, as well as diagnostic methods focused mainly on the detection of the persistence of the left superior vena cava and its variants.

Acurácia da ecocardiografia com estudo da perfusão miocárdica na avaliação de viabilidade em pacientes com disfunção ventricular esquerda crônica submetidos à revascularização / Real-time perfusion echocardiography accuracy for detecting viability in chronic left ventricular dysfunction undergoing myocardial revascularization

INTRODUÇÃO: A ecocardiografia com perfusão miocárdica em tempo real (EPMTR) é uma técnica que permite a avaliação da perfusão miocárdica e a quantificação do fluxo miocárdico regional. Existem poucos dados na literatura a respeito da acurácia da EPMTR na detecção de viabilidade miocárdica e predição da melhora da qualidade de vida proporcionada pela revascularização miocárdica. MÉTODOS: Vinte e quatro pacientes com doença arterial coronária e disfunção ventricular esquerda crônica foram submetidos à EPMTR e questionário de qualidade de vida antes e após revascularização miocárdica. EPMTR foi realizada com injeção intravenosa contínua de PESDA ou Definity® e energia modulada. Recuperação funcional regional foi considerada padrão de referência (miocárdio hibernante), viabilidade miocárdica foi definida como presença de perfusão homogênea em pelo menos 1 segmento miocárdico no território revascularizado à avaliação qualitativa e a análise do fluxo miocárdico foi realizada nos 17 segmentos do ventrículo esquerdo obtendo-se índices de volume de sangue no miocárdio (A), da velocidade do fluxo () e do fluxo miocárdico absoluto (Ax) na condição de repouso no pré-operatório. Todos territórios revascularizados foram analisáveis. RESULTADOS: Presença de miocárdio hibernante foi observada em 77% dos territórios com viabilidade miocárdica pela EPMTR e em 44% dos territórios sem viabilidade (p=0,03). A presença de viabilidade pela EPMTR qualitativa apresentou sensibilidade, especificidade, valor preditivo positivo (VPP) e valor preditivo negativo (VPN) de 74%, 60%, 77% e 56%, respectivamente. Análise combinada (reserva contrátil e/ou perfusão miocárdica) resultou sensibilidade, especificidade, VPP e VPN de 89%, 40%, 73% e 67%, respectivamente. O valor de Ax 1,76 conferiu sensibilidade de 91,3%, especificidade de 50%, VPP de 75% e VPN de 77,8%, resultando em uma acurácia de 75,7%. O escore de qualidade de vida foi de 36,4 (29,1-43,6) para 18,1 (12,8-23,4; p =0,001)...

BACKGROUND: Real-time perfusion echocardiography (RTPE) is an emerging modality for assessing myocardial perfusion and allows noninvasive quantification of regional myocardial blood flow. Little is known about the accuracy of the RTPE for the assessment of myocardial viability and the possibility of prediction of quality of life improvement after myocardial revascularization. METHODS: Twenty four patients with coronary artery disease and ventricular dysfunction underwent RTPE and answered Minnesota Quality of Life Questionnaire before and repeated after myocardial bypass coronary surgery. RTPE was performed using continuous PESDA or Definity intravenous infusion with power modulation image. Regional function recovery after surgical procedure was considered the standard reference (hibernating myocardial). Qualitatively, viability was defined as presence of homogeneous opacification in at least one myocardial segment in a rest revascularized territory, according coronary distribution. For myocardial blood flow evaluation, the left ventricle was divided into 17 segments, and indexes of myocardial blood volume (A), blood flow velocity (), and myocardial blood flow (Ax) were obtained for each myocardial segment at rest condition. All revascularized territories were analyzed. RESULTS: Hibernating myocardial was observed in 77% of RTPE viable territories and in 44% in non-viable ones (p=0.03). Sensitivity, specificity, predictive positive and negative values of qualitative RTPE viability detecting were 74%, 60%, 77% and 56%, respectively. A combined analysis (contractile reserve and/or myocardial perfusion) provided sensitivity, specificity, predictive positive and negative values of 89%, 40%, 73% e 67%, respectively. The sensitivity, specificity, predictive positive and negative values of Ax1.76 for recovery of function were 91%, 50%, 75% and 78%, respectively, with an accuracy of 76%. Quality of life score improved from 36.4 (29.1-43.6)...

Estado actual de la ecocardiografía de contraste en la perfusión miocárdica / Contrast echocardiography in myocardial perfusion today

Avances en la ingeniería ultrasónica han llevado a la creación de micropartículas "inteligentes" con capacidad de atravesar en cantidad suficiente la barrera pulmonar transcapilar para permitir la obtención de imágenes de corazón izquierdo, lo que ha hecho posible la evaluación de la perfusión miocárdica. Si bien la Food and Drug Administration de los Estados Unidos ha aprobado varios agentes de contraste para empleo en opacificación ventricular y visualización de bordes endocárdicos en sujetos que tienen estudios subóptimos, no ha aprobado hasta el momento ningún agente de contraste para uso en perfusión miocárdica. En la actualidad existen dos estudios multicéntricos a gran escala que fueron diseñados exclusivamente para perfusión miocárdica en comparación con medicina nuclear y coronariografía. Nuestro laboratorio ha tenido la oportunidad de participar activamente en ambos estudios. Esta revisión incluye el diseño, criterios de interpretación y resultados preliminares de CARDIOsphere. Además, presentamos criterios de interpretación del estudio con la burbuja AI-700 que se encuentra actualmente en fase III de investigación clínica. La ecocardiografía de contraste para perfusión miocárdica enfrenta varios retos que deberá resolver antes de que se establezca como una alternativa eficiente. Una limitante común es la aplicabilidad de este método en sujetos con mala ventana acústica, la creación de artefactos intrínsecos al sistema como son la atenuación distal y lateral, la inevitable curva de aprendizaje, y el establecimiento de criterios en la cuantificación de los defectos.

Advances in ultrasonic engineering have made possible the development of "intelligent" micro-particles with the capacity of passing through the pulmonary circulation in sufficient amount to acquire images of the left heart, making possible the evaluation of myocardial perfusión. Although the Food and Drug Administration of the United States has approved several contrast agents for use in ventricular opacification and visualization of endocardial borders in subjects that have sub-optimal studies, at this time, it has not approved any agent of contrast for use in myocardial perfusión. Currently, there are two multicenter studies on a great scale that were exclusively designed for myocardial perfusión in comparison with nuclear medicine and angiography. Our laboratory has had the opportunity to actively participate in both trials. This revision includes the design, interpretation criteria, and preliminary results of CARDIOsphere. As well, we are presenting the interpretation criteria of the AI-700 bubble, which is currently in phase III of clinical investigation. Myocardial perfusión assessment with contrast echocardiography faces several challenges that need to be addressed before it becomes established as an efficient alternative. A common limitation is the viability of this method in subjects with bad acoustic window, the creation of intrinsic artifacts to the system, as distal and lateral attenuation; the unavoidable learning curve, and the settlement of defect quantification criteria. (Arch Cardiol Mex 2005; 75: 197-209).

Análisis de la utilidad de ecocardiografía de contraste y medicina nuclear en afección cardiovascular de origen autoinmune / Analysis of the usefulness of contrast echocardiography and nuclear medicine in cardiovascular affection due to autoimmune diseases

Actualmente, 1 de cada 3 hombres y 1 de cada 10 mujeres desarrolla un evento cardiovascular ateroesclerótico mayor antes de los 60 años, por lo que la enfermedad arterial coronaria continúa siendo un problema de salud pública. Existe una asociación significativa entre enfermedades autoinmunes tales como lupus eritematoso sistémico, artritis reumatoide y ateroesclerosis coronaria prematura o acelerada. Los objetivos del estudio fueron: a) Valorar la perfusión miocárdica en pacientes con enfermedades reumatológicas, mediante ecocardiografia de contraste (EC) y establecer su utilidad comparando con los resultados obtenidos por medicina nuclear como método de referencia (MN). b) Evaluar la prevalencia de alteraciones en la perfusión miocárdica subclínica en enfermedades autoinmunes y establecer una estrategia para evaluar los cambios cardiovasculares en este padecimiento. Se estudiaron mediante EC en reposo y en el pico máximo del estrés y MN a 37 pacientes pertenecientes a la Consulta externa del Departamento de Reumatología para valorar la perfusión miocárdica del ventrículo izquierdo. La prevalencia de alteraciones en la perfusión miocárdica en síndrome antifosfolípido primario (SAFP), lupus eritematoso y artritis reumatoide por EC y MN, cuando estos métodos se analizaron en forma independiente o juntos fue del 27%. El valor predictivo positivo de ambas pruebas fue del 80%, la sensibilidad del 80% y la especificidad del 93%. En los pacientes con SAFP se encontró que cuando se realizan ambas pruebas diagnósticas la MN alcanza una sensibilidad del 100% si el EC es positivo y una especificidad del 100% cuando el EC negativo. Podemos concluir que es importante determinar la existencia de enfermedad coronaria subclínica en los pacientes con enfermedades inmunológicas mediante estudios no invasivos (Sestamibi SPECT y/o ecocardiografía de contraste) que permiten valorar la perfusión miocárdica.

A significant correlation between autoimmune diseases such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) and premature or accelerated coronary atherosclerosis was found. The objectives of the study were: a) evaluate myocardial perfusion in patients with rheumatic diseases by means of contrast echocardiography (CE) and to establish its usefulness as compared to the results obtained by nuclear medicine (NM) (reference method), b) evaluate the prevalence of alterations in subclinical myocardial perfusion in autoimmune diseases and to establish a strategy to evaluate the cardiovascular changes in this disease. Myocardial perfusion in 37 outpatients of the rheumatology department was evaluated by CE at rest and with pharmacological stress (dobutamine) and NM. The prevalence of alterations in the myocardial perfusion in autoimmune diseases by CE and NM, when these methods were analyzed independently or when both methods were used was 27%. The positive predictive value (PPV) and negative predictive value (NPV) of both tests was 80% and 93%, respectively, the sensitivity was 80% and the specificity was 93%. The prevalence of alterations of perfusion in the primary antiphospholipid syndrome (PAPS) was of 30%. In this patients it was found that when both diagnostic tests are performed, NM reaches a sensitivity of 100% if the CE is positive and an specificity of 100% when the CE is negative. We can conclude that it is important to determine the presence of subclinic coronary artery disease in patients with autoimmune disease by noninvasive studies such as Sestamibi SPECT and/or CE for assessment of myocardial perfusion in order to plan an adequate treatment and follow-up.