Como eu faço o strain longitudinal do ventrículo direito com softwares automatizados 2D e 3D / My approach to right ventricular longitudinal strain with automated 2D and 3D software

A análise da deformação miocárdica ventricular direita tem surgido como uma ferramenta diagnóstica importante na detecção de disfunção sistólica ventricular direita inicial não detectada pelas técnicas ecocardiográficas convencionais. Além disso, é capaz de trazer informações diagnósticas e prognósticas adicionais aos parâmetros tradicionais de avaliação da função sistólica ventricular direita em diversas patologias. O método ecocardiográfico de escolha para sua avaliação é o strain longitudinal derivado do speckletracking. Ele tem se mostrado mais sensível para pequenas mudanças na função sistólica quando comparado à excursão sistólica do plano do anel tricúspide, estudo da onda s´ ao Doppler tecidual do anel tricúspide e variação da área fracional do ventrículo direito. O avanço da inteligência artificial e a presença de softwares com análise automatizada entram neste cenário visando tornar a aplicabilidade do método mais simples, rápida e com menor variabilidade inter e intraobservador. O objetivo deste artigo de revisão é demonstrar o passo a passo da técnica, desde a otimização e aquisição de imagens até a interpretação dos resultados, com figuras ilustrativas de casos selecionados.(AU)

Right ventricular strain analysis has emerged as an important diagnostic tool in the detection of early right ventricular systolic dysfunction not detected by conventional echocardiography techniques. Furthermore, it is capable of providing additional diagnostic and prognostic information to the traditional parameters for evaluating right ventricular systolic function in various pathologies. The echocardiography method of choice for its assessment is longitudinal strain derived from speckletracking. This method has been shown to be more sensitive for small changes in systolic function when compared to tricuspid annular plane systolic excursion, tissue Doppler imaging of the tricuspid annular s' wave, and right ventricular fractional area change. Advances in artificial intelligence and software with automated analysis have been introduced to this scenario with the aim of making the method simpler and quicker to apply, with lower inter- and intra-observer variability. The objective of this review article is to demonstrate the technique step by step, from image optimization and acquisition to interpretation of results, with illustrative figures of selected cases.(AU)

Chronic Obstructive Pulmonary Disease: The Role of Myocardial Deformation Indices and Right Ventricle Three-Dimensional Echocardiography

Abstract Background: Right ventricular dysfunction is a major complication in chronic obstructive pulmonary disease (COPD) and, despite its prognostic implications, is rarely considered in routine clinical analysis. Objectives: To compare RV function variables with standard and advanced echocardiographic techniques in patients with stable COPD and controls. Methods: Twenty COPD patients classified as GOLD ≥ II (13 men aged 68.4 ± 8.3 years) and 20 matched controls were compared. Myocardial strain/strain rate indices were obtained by tissue Doppler and two-dimensional speckle tracking echocardiography. Right ventricular ejection fraction was obtained with three-dimensional software. Free wall myocardial thickness (FWMT) and tricuspid annular systolic excursion (TAPSE) were also measured. Numerical variables were compared between groups with Student's t-test or the Mann-Whitney test. Associations between categorical variables were determined with Fisher's exact test. P-values < 0.05 were considered statistically significant. Results: All myocardial deformation indices, particularly global longitudinal strain (-17.2 ± 4.4 vs -21.2: ± 4.4 = 0.001) and 3D right ventricular ejection fraction (40.8 ± 9.3% vs 51.1 ± 6.4% p <0.001) were reduced in COPD patients. These patients presented higher right ventricular FWMT and lower TAPSE values than controls. Conclusion: Myocardial deformation indices, either tissue Doppler or speckle tracking echocardiography and 3D right ventricular ejection fraction, are robust markers of right ventricular dysfunction in patients with stable COPD. Assessing global longitudinal strain by speckle tracking echocardiography is a more practical and reproducible method.

Podemos Acreditar no Ecocardiograma de Rotina para Avaliar o Ventrículo Direito e a Insuficiência Pulmonar? Um Estudo Comparativo com Ressonância Magnética Cardíaca / Can we Trust in Routine Echocardiography to Assess the Right Ventricle and Pulmonary Insufficiency? A Comparative Study with Cardiac Magnetic Resonance

Resumo Fundamento A ressonância magnética cardíaca (RMC) é o método de escolha para avaliar as dimensões e a função do ventrículo direito (VD), e a insuficiência pulmonar (IP). Objetivos Avaliar a acurácia da ecocardiografia bidimensional (ECO 2D) em estimar a função e as dimensões do VD e o grau de IP, e comparar os resultados obtidos pela ECO 2D com os da RMC. Métodos Comparamos os relatórios de ECO e RMC de pacientes cuja indicação para RMC havia sido para avaliar VD e IP. Um valor de p < 0,05 foi considerado estatisticamente significativo. Resultados Incluímos 51 pacientes com cardiopatia congênita com idade mediana de 9,3 anos (7-13,3 anos). Observou-se uma baixa concordância entre ECO 2D e RMC quanto à classificação da dimensão (Kappa 0,19; IC 95% 0,05 a 0,33, p 0,004) e da função do VD (Kappa 0,16; IC 95% -0,01 a +0,34; p 0,034). O tamanho do VD foi subestimado pela ECO 2D em 43% dos casos, e a função do VD foi superestimada pela ECO 2D em 29% dos casos. O grau de concordância entre os métodos quanto à classificação da IP não foi significativo (Kappa 0,014; IC 95% -0,03 a +0,06; p 0,27). Houve uma tendência de a ECO 2D superestimar o grau da IP. Conclusões A ECO 2D mostrou baixa concordância com a RMC quanto às dimensões e função do VD, e grau de IP. Em geral, a ECO subestimou as dimensões do VD e superestimou a função do VD e o grau de IP quando comparada à RMC.

Abstract Background Cardiac magnetic resonance (CMR) is the method of choice for assessing right ventricular (RV) dimensions and function, and pulmonary insufficiency (PI). Objectives To assess the accuracy of two-dimensional echocardiography (2D ECHO) in estimating RV function and dimensions, and the degree of PI, and compare the 2D ECHO and CMR findings. Methods We compared ECHO and CMR reports of patients whose indication for CMR had been to assess RV and PI. A p-value < 0.05 was considered statistically significant. Results We included 51 congenital heart disease patients, with a median age of 9.3 years (7-13.3 years). There was poor agreement between 2D ECHO and CMR for classification of the RV dimension (Kappa 0.19; 95% CI 0.05 to 0.33, p 0.004) and function (Kappa 0.16; 95% CI -0.01 to +0.34; p 0.034). The RV was undersized by 2D ECHO in 43% of the cases, and RV function was overestimated by ECHO in 29% of the cases. The degree of agreement between the methods in the classification of PI was not significant (Kappa 0.014; 95% CI -0.03 to +0.06, p 0.27). 2D ECHO tended to overestimate the degree of PI. Conclusions The 2D ECHO showed a low agreement with CMR regarding the RV dimensions and function, and degree of PI. In general, ECHO underestimated the dimensions of the RV and overestimated the function of the RV and the degree of PI as compared with CMR.

Achados ao ecocardiograma transtorácico em pacientes hospitalizados com COVID- 19: resultados do registro brasileiro de ecocardiografia durante a pandemia de COVID-19 (ECOVID) / Transthoracic echocardiography findings of hospitalized patients with COVID-19: results from the brazilian echocardiography registry during the COVID-19 Pandemic (ECOVID)

Fundamento: A ecocardiografia transtorácica (ETT) pode desempenhar um papel crucial na avaliação das manifestações cardíacas da COVID-19. Objetivo: Nosso objetivo foi relatar a prevalência das principais anormalidades ecocardiográficas em pacientes hospitalizados com COVID-19. Métodos: Realizou-se estudo observacional multicêntrico prospectivo com pacientes com COVID-19 submetidos a ETT durante a internação. Pacientes com insuficiência cardíaca prévia, doença arterial coronariana ou fibrilação atrial foram classificados como portadores de doença cardiovascular (DCV) prévia. Foram coletados dados clínicos e ecocardiográficos da estrutura e da função cardíaca. Resultados: Avaliamos 310 pacientes com COVID-19, com 62±16 anos de idade, 61% homens, 53% com hipertensão arterial, 33% com diabetes e 23% com DCV prévia. No total, 65% dos pacientes necessitaram de suporte em unidade de terapia intensiva. As alterações ecocardiográficas mais prevalentes foram hipertrofia do ventrículo esquerdo (VE) (29%), hipertensão pulmonar (25%), disfunção sistólida do VE (16,5%), disfunção sistólica do ventrículo direito (VD) (15,9%), disfunção diastólica do VE grau II/III (11%) e alteração da contratilidade regional do VE (11%). Derrame pericárdico foi incomum (7%). Hipertrofia do VE (25 vs. 45%, p=0,001), disfunção sistólica do VE (11 vs. 36%, p<0,001), alterações da contratilidade regional (6 vs. 29%, p<0,001), disfunção diastólica do VE grau II/III (9 vs. 19%, p=0,03) e hipertensão pulmonar (22 vs. 36%, p=0,019) foram menos comuns nos pacientes sem do que com DCV prévia. A disfunção sistólica do VD mostrou-se semelhante em pacientes sem e com DCV prévia (13 vs. 25%, p=0,07). Conclusões: Entre os pacientes hospitalizados com COVID-19, os achados ecocardiográficos anormais foram comuns, porém menos encontrados naqueles sem DCV. A disfunção sistólica do VD pareceu afetar de forma semelhante pacientes com e sem DCV prévia. (AU)

Background: Transthoracic echocardiography (TTE) may play a crucial role in the evaluation of cardiac manifestations of coronavirus disease 2019 (COVID-19). Objective: We aimed to report the prevalence of the main echocardiographic abnormalities of hospitalized COVID-19 patients. Methods: We performed a prospective multicenter observational study in patients with COVID-19 who underwent TTE during hospitalization. Patients with pre-existing heart failure, coronary artery disease, or atrial fibrillation were categorized as having previous cardiovascular disease (CVD). Clinical and echocardiographic data about cardiac structure and function were collected. Results: We evaluated 310 patients with COVID-19 (mean age, 62±16 years; 61% men; 53% with arterial hypertension; 33% with diabetes; and 23% with previous CVD). Overall, 65% of the patients required intensive care unit support. The most prevalent echocardiographic abnormalities were LV hypertrophy (29%), pulmonary hypertension (25%), left ventricular (LV) systolic dysfunction (16.5%), right ventricular (RV) systolic dysfunction (15.9%), grade II/III LV diastolic dysfunction (11%), and LV regional wall motion abnormality (11%). Pericardial effusion was uncommon (7% of cases). LV hypertrophy (25% vs. 45%, p=0.001), LV systolic dysfunction (11% vs. 36%, p<0.001), regional wall motion abnormalities (6% vs. 29%, p<0.001), grade II/III LV diastolic dysfunction (9% vs. 19%, p=0.03), and pulmonary hypertension (22% vs. 36%, p=0.019) were less common in patients without previous CVD. RV systolic dysfunction occurred at similar frequencies in patients with versus without previous CVD (13% vs. 25%, p=0.07). Conclusions: Among patients hospitalized with COVID-19, abnormal echocardiographic findings were common, but less so among those without previous CVD. RV systolic dysfunction appeared to affect similar proportions of patients with versus without previous CVD. (AU)

Caracterización de la fisiología restrictiva del ventrículo derecho mediante flujo 4D / 4-D flow characterization of right ventricular restrictive physiology

Abstract: Right ventricular restrictive physiology (RVRP) occurs in diverse clinical scenarios, most frequently after repair of Tetralogy of Fallot (TOF). Cardiac magnetic resonance (CMR) can comprehensively evaluate RVRP using 4D flow along with anatomical and fibrosis characterization. Also, RVRP is associated with less pulmonary regurgitation and fewer right ventricle enlargement; its long term protective role is debated. RVRP is a challenging and relevant diagnosis, which hallmark is the presence of antegrade pulmonary arterial Flow in late diastole throughout the respiratory cycle. Also, other hemodynamic findings could aid such us flow in; caval veins, suprahepatic, coronary sinus and tricuspid valve. Obtaining all these flow curves is virtually impossible by echocardiography. CMR with 4DF is a unique and powerful technique enabling this comprehensive hemodynamic evaluation as depicted in this case.

Trombo serpiginoso em átrio direito: apresentação atípica de tromboembolismo pulmonar. Relato de caso / Serpiginous thrombus in right atrium: atypical presentation of pulmonary thromboembolism. Case report

O tromboembolismo pulmonar é um grave problema de saúde pública devido ao subdiagnóstico e às elevadas morbidade e mortalidade. Quando a embolia pulmonar é maciça com repercussão hemodinâmica importante e a terapia adequada não ocorre nas primeiras horas, a mortalidade é superior a 85%. Na suspeita clínica de tromboembolismo pulmonar, a avaliação ecocardiográfica pode ter papel fundamental na avaliação da mobilidade e da estrutura do ventrículo direito, presença de hipertensão pulmonar e documentação da presença de trombo. A detecção ecocardiográfica de trombo móvel nas câmaras cardíacas direitas permite identificar um grupo de pacientes de alto risco, com mortalidade muito elevada, quando comparada ao tromboembolismo pulmonar em geral. Além da terapia clínica clássica, com heparinas e trombolíticos, as terapêuticas endovascular e cirúrgica devem ser consideradas e podem contribuir para o prognóstico desses pacientes. Relata-se um caso de uma paciente de 33 anos de idade admitida em uma unidade de emergência da no 8o dia de pós-operatório de apendicectomia, com queixas de dor torácica e dispneia de início súbito. Ecocardiograma transtorácico evidenciou presença de trombo serpiginoso solto em átrio direito, que ocluía intermitentemente a valva tricúspide durante o ciclo cardíaco. Diante das características ecocardiográficas atípicas do trombo e da significativa chance de embolização maciça, optou-se por intervenção cirúrgica de emergência.

Pulmonary thromboembolism is a serious public health problem due to misdiagnosis and high morbidity and mortality. When pulmonary embolism is massive with important hemodynamic repercussion, and the appropriate therapy does not take place in the early hours, mortality is higher than 85%. If there is clinical suspicion of pulmonary thromboembolism, an echocardiographic evaluation may have a key role in the evaluation of mobility and structure of the right ventricle, presence of pulmonary hypertension, and documentation of the presence of thrombus. Echocardiographic detection of mobile thrombus in right cardiac chambers allows the identification of a group of high-risk patients with very high mortality when compared to pulmonary thromboembolism in general . In addition to the classical clinical therapy with heparins and thrombolytics, endovascular and surgical therapy should be considered and may contribute to these patients' prognosis. A case is reported of a 33-year-old female patient admitted to an Emergency Unit at 8th postoperative day (POD) of appendectomy, with complaints of chest pain and dyspnea of sudden onset. Transthoracic echocardiography showed the presence of a floating serpiginous thrombus in the right atrium, which intermittently occluded the tricuspid valve during the cardiac cycle. Due to the atypical echocardiographic features of the thrombus, and significant chance of massive embolization, an emergency surgery was chosen.

Echocardiographic Correlation between Right Ventricular Function and Left Atrial Volume / Correlação Ecocardiográfica entre Função Ventricular Direita e Volume Atrial Esquerdo

Abstract Background: Few reports exist on the relationship of the left ventricular diastolic dysfunction (LVDD) with its most important features including enlargement of the left atrium and left ventricular hypertrophy (LVH), and with the right ventricular (RV) function. Objective: To determine the correlation between the left atrial size and the RV function and dimensions in patients with and without LVDD and LVH. Methods: Fifty patients were included, 25 (40% men) of them with LVDD, aged 67.1 ± 10.6 years (study group) and 25 without LVDD (52% men) aged 49.9 ± 16.3 years (control group). Patients underwent transthoracic echocardiography with evaluation of the left atrial size and volume (LAV), LVDD, LVH, and RV function and dimensions. P-values < 0.05 were considered statistically significant. Results: LAV > 34 mL/m2 and left atrial size > 40 mm were associated with lower absolute values of tricuspid annular plane systolic excursion (TAPSE) and RV lateral S' (p ≤ 0.001, Pearson's correlation coefficient -0.4 and -0.38, respectively) in the study group. Patients in the study group showed higher incidence of LVH (p = 0.02) and greater left atrial diameter (p = 0.03) compared with the control group. In addition, greater left atrial diameter (p = 0.02) and LAV (p = 0.01) values were found in patients with LVDD grade II compared with LVDD grade I. Conclusions: The present study determined, for the first time, the correlation of left atrial enlargement with progressive RV dysfunction in patients with LVDD.

Resumo Fundamentos: A relação entre a disfunção diastólica do ventrículo esquerdo (DDVE), seus achados mais importantes, como aumento do átrio esquerdo e hipertrofia ventricular esquerda (HVE), e a função do ventrículo direito (VD) tem pouca documentação na literatura científica. Objetivo: Avaliar a correlação entre o tamanho atrial esquerdo em indivíduos com e sem DDVE e HVE e função e dimensões do VD. Métodos: Foram selecionados 50 pacientes, sendo 25 com DDVE (grupo de estudo [GE]; 67,1 ± 10,6 anos; 40% homens) e 25 sem DDVE (grupo-controle [GC]; 49,9 ± 16,3 anos; 52% homens). Os pacientes foram submetidos a ecocardiografia transtorácica com avalição do tamanho e volume atrial esquerdo (VAE), DDVE, HVE, dimensões e função do VD. Valores de p < 0,05 indicaram significância estatística. Resultados: VAE > 34 ml/m2 e tamanho atrial esquerdo > 40 mm apresentaram menores valores absolutos de excursão sistólica do plano do anel tricúspide (TAPSE) e S' lateral do VD (p ≤ 0,001, coeficiente de correlação de Pearson de -0,4 e -0,38, respectivamente) no GE. O GE apresentou maior incidência de HVE e maior diâmetro atrial esquerdo quando comparado ao GC (p = 0,02 e p = 0,03, respectivamente). O GE apresentou maior diâmetro e VAE nos indivíduos com DDVE grau II quando comparados aos indivíduos com DDVE grau I (p = 0,02 e p = 0,01, respectivamente). Conclusões: O presente estudo permitiu correlacionar de maneira inédita o aumento atrial esquerdo com diminuição progressiva da função ventricular direita em pacientes com disfunção diastólica de VE.

Echocardiographic assessment of right ventricular function by two-dimensional strain in patients with left-sided valvular heart disease: comparison whit three-dimendional echocardiography / Avaliação ecocardiográfica da função ventricular direita por strain bidimensional em pacientes com valvopatia à esquerda: comparação com ecocardiografia tridimensional

Background: Right ventricular (RV) dysfunction is a well-known predictor of mortality in patients with valvular heart disease (VHD). The assessment of RV function is often difficult due to complex geometry and hemodynamic factors. Objective: We aim to analyze RV function in patients with severe mitral and/or aortic valve disease using two-dimensional strain (2DS) imaging and conventional echocardiographic parameters, comparing it with right ventricular ejection fraction (RVEF) measured by three-dimensional echocardiography (3DE). Methods: Fifty-three patients with severe mitral and/or aortic VHD underwent complete transthoracic echocardiogram in the preoperative setting for cardiac surgery, including conventional echocardiographic parameters of RV function and speckle-tracking derived 2DS indices: RV global longitudinal strain (RVGS) and RV free wall longitudinal strain (RVFWS). Conventional echocardiographic and 2DS parameters were compared with real-time 3DE RVEF using Spearman correlation test. For comparison between two groups of patients based on the presence of RV dysfunction (normal RVEF ≥ 44% - A, abnormal RVEF < 44% - B), we used nonparametric Mann-Whitney U test. ROC (receiver operating characteristic) curve analysis was used to assess the clinical utility of all RV function variables in defining RV dysfunction. P values <0,05 were considered statistically significant.Results: We found a significant correlation between all parameters and RVEF (p<0.05), with best results for RV fractional area change (FAC), RVGS, and RVFWS. Dividing the population into two-groups based on RVEF, we found 14 patients with RV dysfunction (27.4%), and significant differences between the groups for all RV function variables. For detection of RV dysfunction defined by 3DE, ROC curve analysis showed the best area under the curve (AUC) for RVGS (0.872), RVFWS (0.851) and FAC (0.932). Conclusions: We observed significant correlation between RVGS, RVFWS and RVEF, with good accuracy in detecting RV dysfunction, comparable to FAC and better than other conventional parameters of RV function assessment. The evaluation of RV myocardial deformation with 2DS may have additional diagnostic and prognostic value in patients with severe left-sided VHD

Right Ventricular Functional Improvement after Pulmonary Rehabilitation Program in Patients with COPD Determined by Speckle Tracking Echocardiography / Melhora da Função Ventricular Direita após Programa de Reabilitação Pulmonar em Pacientes com DPOC Avaliada por Ecocardiografia Speckle Tracking

Abstract Background: Although right ventricular (RV) dysfunction in pulmonary diseases has been associated with increased morbidity, tools for RV dysfunction identification are not well defined. Objective: The aim of this study was to evaluate the magnitude of RV dysfunction by means of speckle tracking echocardiography (STE) in patients with chronic obstructive pulmonary disease (COPD) and to investigate whether STE could be used as an index of RV improvement after a pulmonary rehabilitation (PR) program. Methods: Forty-six patients with COPD undergoing PR program and 32 age-sex matched healthy subjects were enrolled. RV function was evaluated at admission and after PR program by conventional two-dimensional echocardiography (2DE) and STE. In addition, exercise tolerance of subjects was evaluated using the six-minute walk test (6MWT). Results: COPD patients had worse RV function according to STE and 2DE as well. STE was more sensitive than conventional 2DE in determining RV improvement after PR program - RV global longitudinal strain (LS): 20.4 ± 2.4% vs. 21.9 ± 2.9% p < 0.001 and RV free wall LS: 18.1 ± 3.4% vs. 22.9 ± 3.7%, p < 0.001). RV free wall LS was directly related to distance walked at baseline 6MWT (r = 0.58, p < 0.001) and to the change in the 6MWT distance (6MWTD ∆) (r = 0.41, p = 0.04). Conclusions: We conclude that STE might be as effective as 2DE for evaluation of global and regional RV functions. STE may become an important tool for assessment and follow-up of COPD patients undergoing PR program to determine the relationship between RV function and exercise tolerance.

Resumo Fundamento: Embora a disfunção do ventrículo direito (VD) nas doenças pulmonares tenha sido associada ao aumento da morbidade, as ferramentas para a identificação da disfunção do VD não estão bem definidas. Objetivo: O objetivo deste estudo foi avaliar a disfunção do VD por ecocardiografia speckle tracking (STE) em pacientes com doença pulmonar obstrutiva crônica (DPOC), e se a STE pode ser usada como indicador de melhora da função ventricular direita após um programa de reabilitação pulmonar (RP). Métodos: Quarenta e seis pacientes com DPOC submetidos ao programa de RP e 32 controles sadios pareados por sexo e idade foram incluídos no estudo. A função do VD foi avaliada na admissão e após o programa de RP por ecocardiografia bidimensional convencional e por STE. Além disso, a tolerância ao exercício foi avaliada pelo teste de caminhada de seis minutos (TC6M). Resultados: Pacientes com DPOC apresentaram pior função do VD segundo STE e ecocardiografia bidimensional convencional. Em comparação ao método convencional, a STE mostrou maior sensibilidade em determinar melhora da função ventricular direita após o programa de RP - strain longitudinal (SL) global do VD: 20,4 ± 2,4% vs. 21,9 ± 2,9% p < 0,001; SL da parede livre do VD: 18,1 ± 3,4% vs. 22,9 ± 3,7%, p < 0,001. O SL da parede livre do VD relacionou-se diretamente com a distância percorrida no TC6M basal (r = 0,58, p < 0,001) e com a variação no TC6M ∆ (TC6M) (r = 0,41, p = 0,04). Conclusões: Concluímos que a STE pode ser tão eficaz como a ecocardiografia bidimensional convencional na avaliação das funções globais e regionais do VD. Ainda, a STE pode se tornar uma importante ferramenta de avaliação e acompanhamento de pacientes com DPOC submetidos à RP para determinar a relação entre função ventricular direita e tolerância ao exercício.

Early Assessment of Right Ventricular Function in Systemic Lupus Erythematosus Patients using Strain and Strain Rate Imaging / Avaliação Precoce da Função Ventricular Direita em Pacientes com Lúpus Eritematoso Sistêmico pelo Strain e Strain Rate

Abstract Background: Right ventricular function is a crucial factor of the prognosis of systemic lupus erythematosus (SLE). Objectives: To evaluate the right ventricular function in SLE patients with different degrees of pulmonary hypertension (PH) by strain and strain rate imaging. Methods: A total of 102 SLE patients and 30 healthy volunteers were studied between October 2015 and May 2016. Patients were divided into three groups according to pulmonary artery systolic pressure (PASP) estimated by echocardiography: group control (A); PASP ≤ 30 mmHg (group B, n = 37); PASP 30-50 mmHg (mild PH; group C, n = 34); and PASP ≥ 50 mmHg (moderate-to-severe PH; group D, n = 31). Longitudinal peak systolic strain (ε) and strain rate (SR), including systolic strain rate (SRs), early diastolic strain rate (SRe) and late diastolic strain rate (SRa) were measured in the basal, middle and apical segments of the right ventricular free wall in participants by two-dimensional speckle tracking echocardiography (2D-STE) from the apical four-chamber view. A p < 0.05 was set for statistical significance. Results: The parameters of ε, SRs, SRe, and SRa were significantly decreased in groups C and D compared with groups A and B. The ε of each segments was significantly lower in group D than in group C, while there were no differences in SRs, SRe and SRa between groups C and D. Conclusions: Strain and strain rate imaging could early detect the right ventricular dysfunction in SLE patients with PH, and provide important value for clinical therapy and prognosis of these patients. (Arq Bras Cardiol. 2018; [online].ahead print, PP.0-0)

Resumo Fundamento: A função ventricular direita é fator crucial do prognóstico do lúpus eritematoso sistêmico (LES). Objetivos: Avaliar a função ventricular direita em pacientes com LES e diferentes graus de hipertensão pulmonar (HP) por avaliação do strain e do strain rate. Métodos: Um total de 102 pacientes com LES e 30 voluntários sadios foram estudados entre outubro de 2015 e maio de 2016. Os pacientes foram divididos em três grupos de acordo com a pressão sistólica da artéria pulmonar (PSAP) estimada por ecocardiografia: grupo controle (A); PSAP ≤ 30 mmHg (grupo B, n = 37); PSAP 30-50 mmHg (HP leve; grupo C, n = 34); e PSAP ≥ 50 mmHg (HP moderada a grave; grupo D, n = 31). Foram medidos, nos segmentos basal, medial e apical da parede livre do ventrículo direito, o pico sistólico longitudinal (ε) e o strain rate (SR), incluindo o SR sistólico (SRs), o SR diastólico precoce (SRp) e o SR diastólico tardio (SRt) pela técnica de ecocardiografia bidimensional com rastreamento de "pontos" (two-dimensional speckle tracking echocardiography, 2D-STE) pela visualização apical de quatro câmaras. Um p < 0,05 foi adotado como estatisticamente significativo. Resultados: Os parâmetros ε, SRs, SRp e SRt foram significativamente menores nos grupos C e D em comparação aos grupos A e B. O ε de cada segmento foi significativamente menor no grupo D que no grupo C, ao passo que não houve diferença no SRs, SRp ou SRt entre os grupos C e D. Conclusões: O strain e o SR obtidos por 2D-STE puderam detectar precocemente disfunção ventricular direita em pacientes com LES e HP, contribuindo para o tratamento clínico e prognóstico desses pacientes. (Arq Bras Cardiol. 2018; [online].ahead print, PP.0-0)

Resonancia magnética cardíaca en el seguimiento alejado de pacientes con tetralogía de Fallot / Cardiac Magnetic Resonance in long term follow-up of Tetralogy of Fallot

INTRODUCCIÓN: La tetralogía de Fallot (TF) es la cardiopatía congénita cianótica más frecuente. La insuficiencia pulmonar (IP) y dilatación del ventrículo derecho (VD) son las complicaciones más frecuentes a largo plazo. La resonancia magnética cardiaca (RMC) es el "gold standard" para la evaluación del VD. OBJETIVO: Analizar la información obtenida de las RMC en el seguimiento de pacientes con TF. PACIENTES Y MÉTODO: Se incluyeron RMC realizadas entre 2007 y 2012 a pacientes con TF, reparados con parche transanular (PTA) o ampliación infundibular (AInf) y sin recambio valvular pulmonar (RVP). La fracción de regurgitación pulmonar (FRP), el volumen y función ventricular fueron evaluados. RESULTADOS: Se realizaron 122 RMC a 114 pacientes. Edad promedio al examen 15,4 ± 7,4 años. 53,3% presentó IP severa (> 40%). La media del volumen de fin de diástole del VD (VFDVD) fue 157,3 ± 38,6 ml/m2, fin de sístole (VFSVD) de 85,3 ± 27 ml/m2 y fracción de eyección (FEVD) 46,4 ± 7,1%. 48,4% presentaba un VFDVD mayor de 150 ml/m2 y el 32,8% mayor a 170 ml/ m2. El PTA se relacionó con mayores volúmenes de VD que la AInf. VFDVD mayor a 170 ml/m2 mostraron peor FEVD (FEVD 47,9 ± 7% vs 43,2 ± 6,4%, p < 0,01). DISCUSIÓN: Casi la mitad mostró una significativa dilatación del VD demostrando que la indicación de RMC es tardía en el seguimiento. El PTA se asoció con mayores VFDVD y VFSVD pero no a peor FEVD.

INTRODUCCIÓN: Tetralogy of Fallot (TOF) is the most frequent cyanotic congenital heart disease. Pulmonary regurgitation (PR) and right ventricle (RV) enlargement and dysfunction are the most common long-term complications. Cardiac magnetic resonance (CMR) is the gold standard for RV evaluation. OBJECTIVE: To analyze CMR results in the follow-up of TOF patients. PATIENTS AND METHOD: All CMR performed between 2007 and 2012 in TOF patients with transannular patch (TAP) repair or infundibular widening, and without pulmonary valve replacement (PVR) were included. Pulmonary regurgitant fraction (PRF), ventricular end-diastolic (EDV) and end-systolic volume (ESV), and ejection fraction (EF) were examined. RESULTS: 122 CMR were performed in 114 patients. Average age at CMR was 15.4±7.4 years. 53.3% of them presented severe PR (> 40%). RVEDV was 157.3 ± 38.6 ml/m2, RVESV was 85.3 ± 27 ml/m2 and RVEF was 46.4 ± 7.1%. RVEDV was > 150 ml/ m2 in 48.4% and > 170 ml/m2 in 32.8% of patients. Patients with TAP showed larger RV volumes compared with those with infundibular widening. RVEDV > 170 ml/m2 showed worse RVEF that those with lower RVEDV (47.9 ± 7% vs 43.2 ± 6.4%, p < 0.01). CONCLUSION: Almost half of the pa tients showed significant RV enlargement, demonstrating that the indication of CMR is late in their follow-up. TAP was associated with higher RVEDV and RVESV, but no worse RVEF.

Evaluación ecocardiográfica de pacientes pediátricos post-trasplante cardiaco en Chile: Aplicación inicial de un protocolo funcional con Strain longitudinal global / Echocardiographic evaluation after pediatric heart transplant in Chile: initial application of a functional protocol with global longitudinal strain

Resumen: Introducción: La evaluación ecocardiográfica de pacientes post-trasplante cardiaco pediátrico es una herramienta útil. Sin embargo, aún es necesario definir un protocolo óptimo de seguimiento. Obje tivo: Caracterizar los resultados de la aplicación de un protocolo de evaluación ecocardiográfica fun cional en pacientes en control post-trasplante cardiaco pediátrico ortotópico. Pacientes y Método: Posterior al trasplante cardiaco pediátrico se realizó una ecocardiografía con un protocolo funcional que incluyó strain longitudinal global. Se evaluaron además los datos de la biopsia endomiocárdica y del estudio hemodinámico contemporáneos. Resultados: De un total de 9 pacientes sólo 1 presentó disfunción sistólica de ventrículo izquierdo según parámetros clásicos, pero casi la totalidad presentó un strain longitudinal global alterado. No se observaron episodios de rechazo moderado o severo en estos pacientes. Todos los pacientes presentaban disfunción sistólica ventricular derecha. No se ob servó correlación entre estos parámetros y la presión de arteria pulmonar. Conclusiones: Se observó disfunción sistólica biventricular subclínica en la mayoría de los pacientes de esta serie. No hubo aso ciación con episodios de rechazo o con hipertensión pulmonar, lo que podría estar en relación con la ausencia de episodios de rechazo moderado o severo en la biopsia contemporánea y con el reducido tamaño muestral. Sólo el seguimiento a largo plazo de estos pacientes permitirá definir la relevancia clínica de los hallazgos descritos.

Abstract: Introduction: The echocardiographic evaluation of patients after heart transplantation is a useful tool. However, it is still necessary to define an optimal follow-up protocol. Objective: To describe the results of the application of a functional echocardiographic protocol in patients being followed after pediatric heart transplantation. Patients and Method: Alls patients being followed at our institution after pediatric heart transplantation underwent an echocardiographic examination with a functional protocol that included global longitudinal strain. Contemporaneous endomyocardial biopsy results and hemodynamic data were recorded. Results: 9 patients were evaluated with our echocardiographic functional protocol. Of these patients, only 1 showed systolic left ventricular dysfunction according to classic parameters. However, almost all patients had an abnormal global longitudinal strain. Right ventricular systolic dysfunction was observed in all patients. No epidodes of moderate to severe rejectiom were recorded. No correlation was observed between these parameters and pulmonary artery pressure. Conclusions: Subclinical biventricular systolic dysfunction was observed in the majority of the patients in this study. No association with rejection episodes or pulmonary hypertension was observed, which may be related to the absence of moderate or severe rejection episodes during the study period, and to the small sample size. Long term follow-up of these patients may better define the clinical relevance of our findings.

Analysis of dyssynchrony and ventricular function in right univentricular stimulation at different positions

Abstract Introduction: Chronic stimulation of the right ventricle with pacemaker is associated with ventricular dyssynchrony and loss of contractility, even in subjects without previous dysfunction. In these patients, there is a debate of which pacing site is less associated with loss of ventricular function. Objective: To compare pacemaker-induced dyssynchrony among different pacing sites in right ventricular stimulation. Methods: Cross-sectional study of outpatients with right ventricle stimulation higher than 80% and preserved left ventricular ejection fraction. Pacing lead position (apical, medial septum or free wall) was assessed through chest X-rays. Every patient underwent echocardiogram to evaluate for dyssynchrony according to CARE-HF criteria: aortic pre-ejection time, interventricular delay and septum/posterior wall delay on M mode. Results: Forty patients were included. Fifty-two percent had apical electrode position, 42% mid septum and 6% free wall. Mean QRS time 148.97±15.52 milliseconds. A weak correlation between the mean QRS width and pre-aortic ejection time (r=0.32; P=0.04) was found. No difference in QRS width among the positions could be noted. Intraventricular delay was lower in apical patients against mid septal (34.4±17.2 vs. 54.3±19.1 P<0.05) - no difference with those electrode on the free wall. No difference was noted in the pre-aortic ejection time (P=0.9). Conclusion: Apical pacing showed a lower interventricular conduction delay when compared to medial septum site. Our findings suggest that apical pacing dyssynchrony is not ubiquitous, as previously thought, and that it should remain an option for lead placement.

Pulmonary embolism in cancer patients.

Aims and Objectives: Pulmonary embolism (PE) is rare in the Indian population and is under-reported in patients with malignancy. We studied the clinical profile and outcome of patients with PE and cancer in the Indian population. Materials and Methods: Data of cancer patients with PE, admitted in a tertiary cancer centre, was analyzed. The prevalence of PE was calculated as the number of patients with PE per 10,000 hospital admissions. The demographic data, details of cancer, co-morbidities, details of PE, and treatment given for PE and their outcomes were recorded and analyzed. Results: There were 56,425 hospital admissions in the study period. The prevalence of PE was 6.4 per 10,000 hospital admissions .Thirty-six cancer patients were diagnosed to have PE. In females, gynecological malignancies (36.84%) and in males gastrointestinal, head and neck cancers, and hematological malignancies were the most common sites (17.7% each). PE was associated with DVT in 41.7%. Dyspnea was the most common presenting symptom. Five patients (13.88%) were asymptomatic and were incidentally detected to have PE . The most common echocardiographic finding was right ventricular dysfunction (55.55%). Mortality among the treated patients was 22% (7 / 31) and in untreated patients it was 80% (4 / 5). The factors that had an impact on a three-month survival were, the presence of massive PE (P = 0.019) and the presence of RV dysfunction at presentation (P = 0.005). Conclusion: The prevalence of PE and mortality due to PE is high in cancer patients. Risk stratification for venous thromboembolism (VTE) should be done in all cancer patients and thromboprophylaxis should be optimally used.

Prenatal Diagnosis of Pallister-Killian Syndrome Associated with Pulmonary Stenosis and Right Ventricular Dilatation / 대한진단검사의학회지

Pallister-Killian syndrome (PKS) is a rare disorder characterized cytogenetically by tetrasomy 12p for isochromosome of the short arm of chromosome 12. PKS is diagnosed by prenatal genetic analysis through chorionic villous sampling, genetic amniocentesis, and cordocentesis, or by chromosomal analysis of skin fibroblasts, but is not usually detected by chromosomal analysis of peripheral blood cells. Herein, we report a case of a gravida at 23 weeks gestation with pulmonary stenosis and right ventricular dilation of the heart which were detected by sonography. Fluorescence in situ hybridization and a multicolor banding technique were performed to verify the diagnosis as 47,XX, +mar.ish i(12)(p10)(TEL++)[16]/46,XX[4], and an autopsy confirmed the cardiac anomalies detected on antenatal sonography.