Como eu faço a avaliação pós-intervenções tricúspides: dicas e truques / My approach to assessment after tricuspid interventions: tips and tricks

A regurgitação tricúspide (RT) importante está associada à alta morbidade e mortalidade. Como o tratamento cirúrgico da RT isolada tem sido associado à alta mortalidade, as intervenções transcateter na valva tricúspide (VT) têm sido utilizadas para o seu tratamento, com risco relativamente mais baixo. Há um atraso na intervenção da RT e provavelmente está relacionado a uma compreensão limitada da anatomia da VT e do ventrículo direito, além da subestimação da gravidade da RT. Nesse cenário, faz-se necessário o conhecimento anatômico abrangente da VT, a fisiopatologia envolvida no mecanismo de regurgitação, assim como a sua graduação mais precisa. A VT tem peculiaridades anatômica, histológica e espacial que fazem a sua avalição ser mais complexa, quando comparado à valva mitral, sendo necessário o conhecimento e treinamento nas diversas técnicas ecocardiográficas que serão utilizadas frequentemente em combinação para uma avaliação precisa. Esta revisão descreverá a anatomia da VT, o papel do ecocardiograma no diagnóstico, graduação e fisiopatologia envolvida na RT, as principais opções atuais de tratamento transcateter da RT e a avaliação do resultado após intervenção transcateter por meio de múltiplas modalidades ecocardiográficas.(AU)

Severe tricuspid regurgitation (TR) is associated with high morbidity and mortality. Given that surgical treatment of TR alone has been associated with high mortality, transcatheter interventions in the tricuspid valve (TV) have been used for its treatment, with relatively lower risk. There is a delay in intervention for TR, and this is probably related to a limited understanding of the anatomy of the TV and the right ventricle, in addition to an underestimation of the severity of TR. In this scenario, it is necessary to have comprehensive anatomical knowledge of the TV, the pathophysiology involved in the mechanism of regurgitation, and more accurate grading. The TV has anatomical, histological, and spatial peculiarities that make its assessment more complex when compared to the mitral valve, requiring knowledge and training in the various echocardiographic techniques that will often be used in combination for accurate assessment. This review will describe the anatomy of the TV, the role of echocardiography in the diagnosis, grading, and pathophysiology involved in TR; the main transcatheter treatment options currently available for TR; and the assessment of outcomes after transcatheter intervention by means of multiple echocardiographic modalities.(AU)

Pericardial Effusion and Cardiac Tamponade: Etiology and Evolution in the Contemporary Era

Abstract Background: Pericardial effusion is a relatively common finding and can progress to cardiac tamponade; etiological diagnosis is important for guiding treatment decisions. With advances in medicine and improvement in the social context, the most frequent etiological causes have changed. Objectives: To evaluate the clinical and laboratory characteristics, etiology, and clinical course of patients with pericardial effusion and cardiac tamponade. Materials and methods: Patients with pericardial effusion classified as small (< 10 mm), moderate (between 10-20 mm), or severe (> 20 mm) were included. Data from the clinical history, physical examination, laboratory tests, and complementary tests were evaluated in patients with pericardial effusion and cardiac tamponade. The significance level was set at 5%. Results: A total of 254 patients with a mean age of 53.09 ± 17.9 years were evaluated, 51.2% of whom were female. A total of 40.4% had significant pericardial effusion (> 20 mm). Pericardial tamponade occurred in 44.1% of patients. Among pericardial effusion patients without tamponade, the most frequent etiologies were: idiopathic (44.4%) and postsurgical (17.6%), while among those with tamponade, the most frequent etiologies were postsurgical (21.4%) and postprocedural (19.6%). The mean follow-up time was 2.2 years. Mortality was 42% and 23.2 in those with and without tamponade, respectively (p=0.001). Conclusions: There is an etiological difference between pericardial effusion patients with and without cardiac tamponade. An idiopathic etiology is more common among those without tamponade, while postinterventional/postsurgical is more common among those with tamponade. The tamponade group had a higher mortality rate.

Supradesnivelamento do Segmento ST localizado como apresentação atípica de perimiocardite aguda / Located ST-Segment Elevation as atypical presentation of acute perimiocarditis

Relatamos o caso de um paciente jovem admitido no pronto-socorro com quadro de dor precordial. O eletrocardiograma de admissão identificou supradesnivelamento do segmento ST localizado em parede lateral associado à imagem em "espelho", com enzimas cardíacas altamente elevadas, o que sugere diagnóstico de síndrome coronariana com supradesnivelamento de ST. O ecocardiograma evidenciou derrame pericárdico com fração de ejeção preservada e ausência de alterações segmentares, sugerindo, assim, pericardite aguda, com comprometimento do miocárdio. Desta forma, foi realizada ressonância magnética cardíaca, que evidenciou presença de realce tardio não isquêmico, confirmando o diagnóstico de perimiocardite. Trata-se de situação pouco frequente na prática clínica e que merece maior compreensão e atenção por parte dos médicos que trabalham em prontos-socorros

Taponamiento cardíaco como forma de presentación de metástasis pericárdica / Cardiac tamponade as a form of presentation of pericardial metastasis

Se realizó un estudio descriptivo, retrospectivo y longitudinal con el objetivo de caracterizar aspectos de interés en 13 pacientes con taponamiento cardíaco egresados de la unidad de cuidados intensivos del Hospital "Dr. Agostinho Neto" de Guantánamo durante el período 2010­2016. Este padecimiento puede ser la forma de presentación de metástasis pericárdica de diferentes neoplasias Se estudiaron las siguientes variables: edad, sexo, estado al egreso, estudios complementarios realizados, diagnósticos y tratamiento aplicado. La edad de los pacientes fue de 66.5 ± 10.1 años; predominó el sexo masculino y todos egresaron fallecidos. Se realizaron estudios de hemoquímica, ecocardiograma transtorácico, pericardiocentésis, estudio de líquido pericárdico (citoquímico, citológico y bacteriológico) y radiografía de tórax. Las causas más comunes fueron la neoplasia del pulmón y de mama. El taponamiento cardiaco se expresa como una forma de presentación de derrames pericárdicos malignos, por lo que se debe tener en cuenta esta apreciación ante un paciente críticamente enfermo por derrame pericárdico de gran cuantía(AU)

Introduction: Cardiac tamponade may be the form of presentation of pericardial metastases of different neoplasms. Objective: to characterize aspects of interest in patients with cardiac tamponade from the intensive care unit of the Hospital "Dr. Agostinho Neto de Guantánamo during the period 2010-2016. Material and method: A descriptive, retrospective and longitudinal study was carried out. The following variables were studied: age, sex, state at discharge, complementary studies performed, semiodiagnostics and applied treatment. Results: the age of the patients was 66.5 ± 10.1 years; The majority were men (61.5%) and died (61.5%). All patients underwent haemochemistry, transthoracic echocardiography, pericardiocentesis, pericardial fluid (cytochemical, cytological and bacteriological) and chest X-rays. The most common causes were lung neoplasia (30.7%) and breast cancer (23.1%). Conclusions: cardiac tamponade is expressed as a form of presentation of malignant pericardial effusions, and this should be taken into account in a critically ill patient due to large pericardial effusion(AU)

Pericardite aguda e crônica / Acute and chronic pericarditis

A pericardite é a forma mais comum das doenças do pericárdio e pode se apresentar nas formas aguda e crônica. Frequentemente é idiopática e de evolução benigna. Quando não, as causas mais comuns são tuberculose, neoplasias malignas e doenças autoimunes. O diagnóstico clínico requer a presença de dor precordial típica, atrito pericárdico, elevação difusa do segmento ST e derrame pericárdico. Os exames laboratoriais incluem: ECG, ecocardiograma, RX do tórax e marcadores de inflamação e necrose miocárdica Procedimentos adicionais e internação devem ser considerados para o pacientes de maior risco. Os marcadores de risco são febre >38ºC, evolução subaguda, derrame pericárdico volumoso ou tamponamento cardíaco e ausência de resposta ao tratamento com anti-inflamatórios. O tratamento da pericardite deve ser focar a causa específica, quando identificável. Genericamente, usa-se aspirina ou anti-inflamatórios não hormonais para os casos de etiologia viral ou idiopáticos. A colchicina pode ser útil como droga adicional nos casos recorrentes. A pericardiocentese está indicada nos pacientes com tamponamento cardíaco, quando há chance elevada de tuberculose, pericardite purulenta ou neoplasia. A pericardiectomia fica reservada para os casos de pericardite constrictiva crônica.

Pericarditis is the most common form of pericardial diseases and most of the cases are idiopathic and and follow a benign course. Major nonidiopathic etiologies include tuberculosis, neoplasia and autoimmune diseases.The clinical diagnosis is confirmed when the following criteria are present: typical chest pain, pericardial friction rub, widespread ST-segment elevation, and pericardial effusion. Tests for pericarditis include ECG, echocardiogram, chest radiography and inflammation markers. High-risk patients need tests for etiology search and hospitalization. High-risk patients present fever >38oC, a subacute course, large pericardial effusion or cardiac tamponade and/or failure of antiinflammatory drugs.Treatment should target the specific etiology, if known. Generically, aspirin or a non-steroid anti-inflammatory drug is used for treatment of viral and idiopathic pericarditis. Colchicine is recommended as adjunct therapy for recurrent events. Pericardiocentesis is indicated for cardiac tamponade, high suspicion of tuberculosis, purulent pericarditis or neoplasia. Pericardiectomy is recommended for persistent constriction.

Tumores do pericárdio / Pericardial tumors

O acometimento neoplásico do pericárdio deve ser sempre suspeitado em pacientes com neoplasia, uma vez que os sinais e sintomas são inespecíficos, assim como os achados em exames gerais. O acometimento neoplásico pericárdico é comumente metatástico e se manifesta com sinais de restrição. O diagnóstico que pode ser realizado com maior precisão pela biopsia pericárdica citológica, em particular com auxílio de pericardioscopia, e tem importância, já que a pericardite neoplásica pode impor maior gravidade a estes pacientes. O tratamento direcionado para a doença de base e as possibilidades terapêuticas locais pericárdicas permitem que uma grande porcentagem de pacientes fique livre da recorrência da doença.

Neoplastic involvement of the pericardium should always be suspected in patients with cancer, since the signs and symptoms are nonspecific, as well as the findings in general examinations. Neoplastic pericardial involvement is often metastatic and it manifests with signs of restriction. The diagnosis can be more accurately performed with pericardial biopsy and cytology, in particular with the aid of pericardioscopy, which is quite important because neoplastic pericarditis may impose more severe risk in these patients. Treatment directed to the underlying disease and therapeutic possibilities of pericardial neoplasms allow a large percentage...

Pericarditis tuberculosa: informe de caso / Pericardial tuberculosis: case report

Introducción. La pericarditis tuberculosa es una manifestación infrecuente de tuberculosis en nuestro país. Se asocia con una morbilidad y mortalidad significativa y frecuentemente está asociada como causa de pericarditis constrictiva. Resulta de la extensión al pericardio de lesiones tuberculosas de pulmón, pleura, o adenitis mediastinales. Los medios diagnósticos más importantes son la radiografía de tórax, el electrocardiograma y el ecocardiograma, confirmándose el diagnostico por aspiración del liquido pericárdico o la realización debiopsia. Caso clínico. Se presenta caso de un paciente masculino de 54 años, ex –fumador, sin antecedentes patológicos importantes, quien se presentó con disnea y tos seca y datos de insuficiencia cardíaca congestiva progresivas de 2 meses de evolución. Desarrolló derrame pericárdico, del cual se drenó 2000cc de líquido hemorrágico. Posteriormente desarrolló derrame pleural derecho. La biopsia mostró pericarditis fibrinosa crónica granulomatosa. Discusión. El diagnostico oportuno y el tratamiento con antifímicos y esteroides mejoraron el cuadro clínico y el pronóstico de vida, como está escrito en la literatura...

Derrame pericárdico associado a abscesso prostático em paciente diabético / Pericardial efusion in a diabetic patient with prostatic abscess

Pericardite purulenta é doença rara e potencialmente fatal. O diagnóstico e tratamento são difíceis. Antibioticoterapia e drenagem do pericárdio são essenciais para o tratamento de pericardite purulenta. Descrevemos caso não usual de paciente diabético com pericardite purulenta e abscesso prostático com boa evolução após tratamento adequado.

Pericardial effusion in childhood nephrotic syndrome.

BACKGROUND: Nephrotic syndrome (NS) is one of the most common renal diseases in children, which is defined as idiopathic NS and secondary NS. Current data on adult showed that pericardial effusion was related only to SLE, but not to non-SLE nephrotic patients. Until now there were no studies about children. OBJECTIVE: To compare the frequency and clinical manifestations of pericardial effusion in childhood NS with SLE and non-SLE patients. MATERIAL AND METHOD: Consecutive cases of NS at Queen Sirikit National Institute of Child Health (QSNICH) from June 2004 to May 2005 were prospectively studied. Information concerning the following: gender, age, clinical manifestations, laboratory investigation and echocardiogram in each patient were obtained. RESULTS: A total of 37 cases were included, 13 with SLE and 24 with idiopathic cause. Pericardial effusion was found without any symptoms and signs of pericardial disease in both groups; 9 cases (69.2%) of SLE and 2 cases (8.3%) of non-SLE patients. Statistically significant differences were demonstrated between two groups (p = 0.001). CONCLUSION: Pericardial effusion in childhood NS was more frequent in SLE than non-SLE nephrotic patients statistically significant. This result was different from previous study in adult which revealed no pericardial effusion in non-SLE group.

Pseudo-aneurysm of left ventricle presenting as non-resolving chronic pericardial effusion.

Left ventricular pseudo-aneurysm is a variation of left ventricular free wall rupture, in which collection of blood occurs in pericardial sac, through ventricular wall defect. In pseudo-aneurysm, blood from defect does not fill the entire pericardial sac. Instead, because of adhesions between ventricular wall and the sac, escaping blood is isolated to a localised area between wall and pericardium. Here a case of ventricular pseudo-aneurysm of late onset which behaved as non-resolving pericardial effusion is presented.

Primary hypothyroidism with pericardial tamponade.

We report a rare case of pericardial effusion and tamponade in a 10-yr-old child with undiagnosed primary hypothyroidism, who presented to us with delayed milestones, anasarca for 7 mth and respiratory distress for 20 days. The child recovered with ultrasound guided pericardial tap and thyroxine replacement therapy.

Pathology of Toxoplasma myocarditis in acquired immunodeficiency syndrome.

Involvement of the myocardium by Toxoplasma gondii is seen in patients of acquired immunodeficiency syndrome (AIDS), mostly in association with toxoplasma encephalitis. Only few patients die as a direct result of cardiac dysfunction. Clinico-pathological findings of three cases of toxoplasma myocarditis are reported, one of which presented and died due to massive pericardial effusion. All cases showed diffuse myocarditis with parasites on histopathological examination. Incidence of toxoplasma myocarditis in patients dying with AIDS was 8.3% (3 out of 36 cases).

Resolución de la pericarditis tuberculosa en pacientes HIV / Solution in pericardial tuberculous effusions in HIV patients

Antecedentes: Entre las manifestaciones cardíacas de los pacientes con SIDA, el derrame pericárdico constituye una de las entidades que pone en peligro la vida. El reconocimiento temprano del mismo, como de su etiología y su pronta evacuación aseguran un pronóstico favorable. Objetivo: Demostrar que la cirugía torácica videoasistida (VATS) es ideal para el diagnóstico y tratamiento de los derrames pericárdicos tuberculosos en pacientes con SIDA. Lugar de aplicación: Hospital público. Diseño: Estudio retrospectivo. Población: Se operaron 4 pacientes con SIDA y pericarditis tuberculosa concomitante. Método: Los pacientes con derrames pericárdico, por clínica y ecografía, y SIDA asociado fueron tratados quirúrgicamente, mediante VATS. El líquido obtenido así como el pericardio resecado fueron procesados en el laboratorio. Resultados: 4 pacientes presentaron pericarditis tuberculosa, 2 demostrados con biopsia y 2 con PCR. La cirugía de inicio en todos fue la VATS. La morbilidad fue nula y sólo hubo un caso de mortalidad, no relacionado con el procedimiento quirúrgico. El promedio de internación fue de 9 días. Ninguno presentó recidiva del derrame. Conclusiones: La VATS es el procedimiento de elección ante la presencia de ésta patología, ya que con buenos resultados asegura el diagnóstico etiológico, y al mismo tiempo brinda el tratamiento que menos recidiva ocasiona

Pericarditis tuberculosa: una forma inusual de presentación de esta infección / Tuberculous pericarditis: an anusual clinical presentation of this infection

Se presenta el caso de un hombre de 68 años, con antecedentes de probable tuberculosis pleural en 1952. Ingresa por cuadro de derrame pericárdico que evoluciona rápidamente a un taponamiento cardiaco. Se realiza drenaje pericárdico resultando un líquido cetrino con adenosin deaminasa de 212 U/L. Se obtiene un Koch directo de esputo que resulta positivo. Se inicia terapia antituberculosa y prednisona. Su evolución clínica es satisfactoria. Se presenta una discusión de esta entidad