A Sonotrombólise Promove Melhora dos Índices de Motilidade e Perfusão do Ventrículo Esquerdo após o Infarto Agudo do Miocárdio / Sonothrombolysis Promotes Improvement in Left Ventricular Wall Motion and Perfusion Scores after Acute Myocardial Infarction

Resumo Fundamento Demonstrou-se recentemente que a aplicação de ultrassom de alta energia com microbolhas, técnica conhecida como sonotrombólise, causa a dissolução de trombos intravasculares e aumenta a taxa de recanalização angiográfica no infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAM-CSST). Objetivo Avaliar o efeito da sonotrombólise nos índices de motilidade e perfusão miocárdicas em pacientes com IAM-CSST, utilizando a ecocardiografia com perfusão miocárdica em tempo real (EPMTR). Método Uma centena de pacientes com IAM-CSST foram randomizados em dois grupos: Terapia (50 pacientes tratados com sonotrombólise e angioplastia coronária primária) e Controle (50 pacientes tratados com angioplastia coronária primária). Os pacientes realizaram EPMTR para analisar a fração de ejeção do ventrículo esquerdo (FEVE), o índice de escore de motilidade segmentar (IEMS) e o número de segmentos com defeito de perfusão miocárdica, 72 horas após o IAM-CSST e com 6 meses de acompanhamento. Foi considerado significativo p < 0,05. Resultados Pacientes tratados com sonotrombólise apresentaram FEVE mais alta que o grupo Controle em 72 horas (50 ± 10% vs. 44 ± 10%; p = 0,006), e essa melhora foi mantida em seis meses (53 ± 10% vs. 48 ± 12%; p = 0,008). O IEMS foi similar nos grupos Terapia e Controle em 72 horas (1,62 ± 0,39 vs. 1,75 ± 0,40; p = 0,09), mas tornou-se menor no grupo Terapia em 6 meses (1,46 ± 0,36 vs. 1,64 ± 0,44; p = 0,02). O número de segmentos com defeito de perfusão não foi diferente entre os grupos em 72 horas (5,92 ± 3,47 vs. 6,94 ± 3,39; p = 0,15), mas ficou menor no grupo Terapia em 6 meses (4,64 ± 3,31 vs. 6,57 ± 4,29; p = 0,01). Conclusão A sonotrombólise em pacientes com IAM-CSST resulta na melhora dos índices de motilidade e perfusão ventricular ao longo do tempo.

Abstract Background It has recently been demonstrated that the application of high-energy ultrasound and microbubbles, in a technique known as sonothrombolysis, dissolves intravascular thrombi and increases the angiographic recanalization rate in patients with ST-segment-elevation myocardial infarction (STEMI). Objective To evaluate the effects of sonothrombolysis on left ventricular wall motion and myocardial perfusion in patients with STEMI, using real-time myocardial perfusion echocardiography (RTMPE). Methods One hundred patients with STEMI were randomized into the following 2 groups: therapy (50 patients treated with sonothrombolysis and primary coronary angioplasty) and control (50 patients treated with primary coronary angioplasty). The patients underwent RTMPE for analysis of left ventricular ejection fraction (LVEF), wall motion score index (WMSI), and number of segments with myocardial perfusion defects 72 hours after STEMI and at 6 months of follow-up. P < 0.05 was considered statistically significant. Results Patients treated with sonothrombolysis had higher LVEF than the control group at 72 hours (50% ± 10% versus 44% ± 10%; p = 0.006), and this difference was maintained at 6 months of follow-up (53% ± 10% versus 48% ± 12%; p = 0.008). The WMSI was similar in the therapy and control groups at 72 hours (1.62 ± 0.39 versus 1.75 ± 0.40; p = 0.09), but it was lower in the therapy group at 6 months (1.46 ± 0.36 versus 1.64 ± 0.44; p = 0.02). The number of segments with perfusion defects on RTMPE was similar in therapy and control group at 72 hours (5.92 ± 3.47 versus 6.94 ± 3.39; p = 0.15), but it was lower in the therapy group at 6 months (4.64 ± 3.31 versus 6.57 ± 4.29; p = 0.01). Conclusion Sonothrombolysis in patients with STEMI resulted in improved wall motion and ventricular perfusion scores over time.

Autonomic dysfunction is common in liver cirrhosis and is associated with cardiac dysfunction and mortality: prospective observational study

ABSTRACT BACKGROUND: Although autonomic dysfunction has been shown to be associated with liver cirrhosis, the prevalence and prognostic implications are unclear. Abnormal heart rate variability (HRV), a measure of autonomic function, has not been well investigated in cirrhosis. OBJECTIVE: To evaluate the prevalence of high-risk HRV parameters in a cohort of cirrhotic patients and their association with cardiac dysfunction and mortality. DESIGN AND SETTING: Prospective observational study conducted in the Federal University of São Paulo. METHOD: A cohort of 120 patients, comprising 17 healthy controls and 103 cirrhotic outpatients, was evaluated and followed for 10 months. HRV analysis was based on 24-hour Holter monitoring and defined using time-domain and frequency-domain parameters. RESULTS: The HRV parameters were statistically lower in cirrhotic patients than in healthy subjects. High-risk HRV parameters were prevalent, such that 64% had at least one high-risk parameter. Time-domain parameters correlated with Child scores (P < 0.0001). In regression models, HRV parameters were independent predictors of diastolic dysfunction and mortality. During 10 months of follow-up, there were 11 deaths, all of patients with at least one high-risk HRV parameter. Kaplan-Meier analysis estimated low survival rates among patients with standard deviation of normal-to-normal RR intervals (SDNN) < 100. CONCLUSION: Reduced HRV is prevalent in liver cirrhosis and is related to cardiac dysfunction, severity of liver disease and mortality. Abnormal high-risk HRV parameters are prevalent among cirrhotic patients and are also predictors of mortality. Our findings highlight the need for a more careful cardiac evaluation of cirrhotic patients.

Ultrassom e microbolhas na recanalização de artérias coronarianasno infarto agudo do miocárdio / Ultrasound and microbubbles for coronary artery recanalization in acute myocardial infarction

Fundamento: Microbolhas intravenosas (MB) e ultrassom (US) têm sido utilizados para recanalizar vasos epicárdicos em modelos animais de infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAM-SST). Nenhum estudo prévio demonstrando o valor dessa técnica foi realizado em humanos. Objetivo: Estudo piloto realizado com o objetivo de avaliar a eficácia da utilização de MB e US (sonotrombólise) sobre as taxas iniciais de recanalização de artérias coronarianas em pacientes com IAM-SST. Método: Estudamos 24 pacientes (18 homens, média etária de 58 ± 9 anos) que deram entrada no serviço de emergência com IAM-SST. Pacientes foram randomizados em um dos três grupos: MB + US especificamente desenvolvido para este protocolo, com duração de pulso 4-20 useg e índice mecânico (IM) >1.0 (n = 7), MB + US com impulsos repetitivos de alto IM (1.0), com duração de pulso < 2 useg (n = 8), ou grupo controle (n = 9) que recebeu MB + US apenas paraanalisar a perfusão dentro da área de risco. As MB utilizadas no estudo consistiam em solução de Definity 3%. Todos os pacientes foram submetidos a intervenção coronariana percutânea (ICP). Resultados: As médias dos tempos porta-balão foram 76 ± 35 minutos no grupo MB + US 4-20 useg, 70 ± 20 minutos no grupo MB + US impulsos repetitivos e 81 ± 13 minutos no grupo controle (p = NS). Recanalização angiográfica antes da angioplastia foi observada em 75% dos pacientes tratados com MB + US impulsos repetitivos, em 43% nogrupo tratado com MB + US 4-20 useg e em 11% do grupo controle (p = < 0,05). Conclusão: Utilização de MB e US com impulsos repetitivos pode ser um método para recanalização precoce de artérias epicárdicas em pacientes com IAM-SST.

Background: Intravenous microbubbles (MB) and transthoracic ultrasound (US) have been utilized to recanalize epicardial vessels in animalmodels of ST segment elevation myocardial infarction (STEMI). The feasibility of such an ultrasound-guided approach in humans with STEMIhave not been studied. Objective: Pilot study with the aim to evaluate the efficacy of MB plus US on coronary artery recanalization rate in patients with STEMI. Methods: Twenty-four patients (18 men, mean age 58 ± 9 years) admitted to the emergency room with STEMI were randomized into 3 groups. Patients either received MB plus custom designed high mechanical index (MI) impulses at 4-20 usec pulse duration (n = 7), MB plus diagnostichigh MI (MI = 1.0) with multiple impulses < 2 usec pulse duration (n = 8) or MB plus limited diagnostic high MI impulses (< 5) just to analyzemyocardial perfusion, control group (n = 9). MB utilized in the study consisted of a solution of Definity 3%. All randomized groups underwent emergent PCI.Results: The mean door-to-balloon time were 76 ± 35 minutes in group US 4-20 usec, 70 ± 20 minutes in group US multiple impulses and 81 ± 13 minutes in control group (p = NS). Angiographic recanalization before PCI was observed in 75% of patients treated with US multiple impulses, in 43% for US 4-20 usec and 11% in control (p = <0.05).Conclusion: Utilization of MB and diagnostic US with multiple impulses may be a method of achieving early recanalization in acute STEMI.