Morphological Assessment and Possible Clinical Implications of the Left Ventricle Papillary Muscles. Study in a Colombian Population Sample

SUMMARY: Papillary muscles in the left ventricle present multiple anatomic expressions that are relevant for medical fields focusing on the understanding of clinical events involving these structures. Here, the aim was to perform a morphological characterization of the left ventricle papillary muscles in a sample of Colombian population. In the study were included eighty-two hearts from male individuals who underwent autopsy at the Institute of Legal Medicine and Forensic Sciences in Bucaramanga, Colombia. In each heart was carefully performed a longitudinal incision on the obtuse margin to visualize the papillary muscles. Data set was registered, and analysis of the continuous and categorical variables was carried out. Single anterior papillary muscle was observed in 74 samples (90.2 %) whereas this represented only 48 specimens (58.5 %) for the posterior papillary muscle (p = 0.3). Mean length and breadth of the anterior muscle were 29.9 ± 4.94 and 11.74 ± 2.75 mm, and those for the posterior muscle were 27.42 ± 7.08 and 10.83 ± 4.08 mm. Truncated apical shape was the most frequent type observed on the papillary muscles, anterior 41 (50 %) and posterior 37 (45.1 %), followed by flat-topped in the anterior 25 (30.5 %) and bifurcated in posterior muscle 14 (17.1 %). A mean of 9.04 ± 2.75 chordae raised from the anterior and 7.50 ± 3.3 from posterior papillary muscle. In our study we observed a higher incidence of single papillary muscles and slightly larger dimensions than information reported in the literature. The anatomic diversity of the papillary muscles should be considered for the correct image interpretation, valve implantation and performance evaluation on myocardial ischemic events.

Los músculos papilares del ventrículo izquierdo presentan múltiples expresiones anatómicas que son relevantes para las áreas médicas que se centran en la comprensión de los eventos clínicos que involucran estas estructuras. El objetivo fue realizar una caracterización morfológica de los músculos papilares del ventrículo izquierdo en una muestra de población colombiana. En el estudio se incluyeron ochenta y dos corazones de individuos masculinos a los que se les realizó autopsia en el Instituto de Medicina Legal y Ciencias Forenses de Bucaramanga, Colombia. En cada corazón se realizó cuidadosamente una incisión longitudinal en el margen obtuso para visualizar los músculos papilares. Se registró el conjunto de datos y se realizó el análisis de las variables continuas y categóricas. Se observó un solo músculo papilar anterior en 74 muestras (90,2 %), mientras que este rasgo se presentó en 48 muestras (58,5 %) para el músculo papilar posterior (p = 0,3). La longitud y anchura media del músculo anterior fueron 29,9 ± 4,94 y 11,74 ± 2,75 mm, y las del músculo posterior fueron 27,42 ± 7,08 y 10,83 ± 4,08 mm. La forma apical truncada fue el tipo más frecuente observado en los músculos papilares, anterior 41 (50 %) y posterior 37 (45,1 %), seguido de la forma plana en los 25 anteriores (30,5 %) y bifurcada en el músculo posterior 14 (17,1 %). Una media de 9,04 ± 2,75 cuerdas elevadas desde el músculo papilar anterior y 7,50 ± 3,3 desde posterior. En nuestro estudio observamos una mayor incidencia de músculos papilares únicos y dimensiones ligeramente mayores que la información reportada en la literatura. La diversidad anatómica de los músculos papilares debe ser considerada para la correcta interpretación de imágenes, implantación valvular y evaluación del desempeño en eventos isquémicos miocárdicos.

Cardiac Corpuscles: A "New" Morphofunctional Entity? / Corpúsculos Cardíacos: ¿Una "Nueva" Entidad Morfofuncional?

SUMMARY: The existence of "transitional muscular structures" between subendocardial branches (Purkinje fibers) and ventricular working muscle fibers (WF) was first described by the German anatomist, Kurt Goerttler, in 1964. He designated them as "subendocardial nucleus organs." He supposed such fibers functioned as mechanoreceptors, controlling of the intensity of contraction of the ventricular musculature. Brazilian anatomist Ferraz de Carvalho described similar structures in 1993. A thorough literature search failed to identify any other research articles confirming or denying their existence. The objective of this work was to find such structures in subendocardial ventricular walls in human hearts. We collected fifteen formalin-preserved hearts from the Anatomy Department of São Paulo University and sectioned the apical portions on the right and left ventricles according to method used by Goerttler. We utilized conventional histology (light microscopy- LM), scanning electron microscopy (SEM), and a new preservation method called micro- plastination (MP). At the anterior wall of the right ventricle in the subendocardial region between the interventricular septum and moderator band, we found several bundles of fusiform and helicoidal fibers of similar histology to the WF. The bundles measured between 400 and 1150 µm in length and were separated from adjacent muscular fibers by thin collagen fiber, thus acting as a "pseudo capsule." Some structures seemed to be linked to PF and were appeared to be lymphatic and blood vessels and nerves. We called those structures "cardiac corpuscles" (CC). The observation of the previously "unknown" CC in this initial study confirmed the previous descriptions and its discovery may contribute to new perspectives in the study of cardiac muscle structure and function.

La existencia de "estructuras musculares de transición" entre los ramos subendocárdicos (fibras de Purkinje) y las fibras musculares ventriculares activas(FMV) fue descrita por primera vez por el anatomista alemán Kurt Goerttler en 1964, quien las denominó "órganos del núcleo subendocárdico". Supuso que tales fibras funcionaban como mecanoreceptores, controlando la intensidad de la contracción de la musculatura ventricular. El anatomista brasileño Ferraz de Carvalho describió estructuras similares en 1993. Una búsqueda bibliográfica exhaustiva no logró identificar ningún otro artículo de investigación que confirmara o negara su existencia. El objetivo de este trabajo fue encontrar dichas estructuras en las paredes ventriculares subendocárdicas de corazones humanos. Recolectamos 15 corazones conservados en formalina del Departamento de Anatomía de la Universidad de São Paulo y seccionamos las porciones apicales de los ventrículos derecho e izquierdo según el método utilizado por Goerttler. Utilizamos histología convencional (microscopía de luz-LM), microscopía electrónica de barrido (SEM) y un nuevo método de conservación llamado microplastinación (MP). En la pared anterior del ventrículo derecho en la región subendocárdica entre el tabique interventricular y la banda moderadora, encontramos varios haces de fibras fusiformes y helicoidales de histología similar a la FMV. Los haces medían entre 400 y 1150 µm de longitud y estaban separados de las fibras musculares adyacentes por una fina fibra de colágeno, actuando así como una "pseudocápsula". Algunas estructuras parecían estar vinculadas a la fibras de purkinje y parecían ser vasos linfáticos, sanguíneos y nerviosos. Llamamos a esas estructuras "corpúsculos cardíacos" (CC). La observación del CC previamente "desconocido" en este estudio inicial confirmó las descripciones anteriores y su descubrimiento puede contribuir a nuevas perspectivas en el estudio de la estructura y función del músculo cardíaco.

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)

Right ventricular anatomical and functional parameters in healthy Mexican term newborns / Parámetros anatómicos y funcionales del ventrículo derecho en recién nacidos Mexicanos sanos

Abstract Objective: Right ventricle (RV) function plays an important role during fetal and neonatal transitional circulation. Despite the published echocardiography guidelines in children including neonates, there is scare evidence on RV assessment using echocardiography in Mexican neonates. This study was aimed at assessing RV function and anatomical measures in healthy term newborns and defines normal values in this cohort of patients. Methods: A prospective study involving healthy term newborns in a single center were enrolled in the study to assess RV, all patients were recruited within 24-72 h after birth. The right ventricular assessment was performed as per American Society of Echocardiography's guidelines. Results: Seventy healthy term newborns with a median gestational age of 38 (38.5 ± 2.7) weeks had RV function assessment and anatomical structures measures with a predefined ten echocardiographic parameters protocol. The mean values for: tricuspid valve diameter was 13 mm ± 1.8, basal diameter of the RV 16.7 mm ± 2, RV length 27.8 mm ± 2.2, mid cavity diameter 14.3 mm ± 1.7, RV-anteroinferior basal diameter 21.5 mm ± 2.5, tricuspid regurgitation gradient 13.3 mmHg ± 5.9, tricuspid annular plane systolic excursion 8.7 mm, right ventricular fractional area change (RVFAC) 4 chamber (%) 40.6 ± 7.5, tricuspid E/A 0.7 ± 0.5, myocardial velocities (cm/s) E´ 8 ± 2.7, A´ 9.6 ± 2.4, S´ 6.9 ± 1.2, myocardial performance index 0.5 ± 0.1, RVFAC 3 chamber (%) 37.8 ± 15.8, and pulmonary acceleration time mean value 58.8 ± 14.9. Flattening of interventricular septum was seen in 13% infants. Conclusions: This study describes echocardiographic parameters for anatomical structures and assessment of RV function in healthy term newborns during transitional circulation. We reported novel anatomical measures of the RV; this information can provide normal reference range values and be referenced while assessing RV function in normal and sick newborns during transitional circulation.

Resumen Objetivo: Realizar una valoración ecocardiográfica de parámetros anatómicos y funcionales del ventrículo derecho (VD) en recién nacidos de término (RNT) sanos durante el periodo transicional. Método: Estudio prospectivo en RNT sanos de la Unidad de Cuidados Intensivos Neonatales del Hospital Español. Todos los pacientes fueron estudiados en las primeras 24-72 horas de vida, con base en las guías de la American Society of Echocardiography. Resultados: Se estudiaron 70 RNT sanos con una media de edad gestacional de 38 semanas de gestación (38.5 ± 2.7); en estos pacientes se obtuvieron 10 parámetros ecocardiográficos. El valor medio obtenido para la válvula tricúspide fue de 13 ± 1.8 mm, diámetro basal del VD 16.7 ± 2 mm, longitud 27.8 ± 2.2 mm, cavidad media del VD 14.3 ± 1.7 mm, diámetro basal anteroinferior 21.5 ± 2.5 mm, gradiente de insuficiencia tricuspídea 13.3 ± 5.9 mmHg, tricuspid annular plane systolic excursion (TAPSE) 8.7 mm, Fracción de acortamiento del VD (FAVD) 4 cámaras (%) 40.6 ± 7.5, E/A tricuspídeo 0.7 ± 0.5, velocidades miocárdicas (cm/s) E´ 8 ± 2.7, A´ 9.6 ± 2.4, S´ 6.9 ± 1.2, índice de rendimiento miocárdico 0.5 ± 0.1, FAVD 3 cámaras (%) 37.8 ± 15.8, tiempo de aceleración pulmonar 58.8 ± 14.9. Conclusiones: Este estudio describe parámetros anatómicos y funcionales del VD en RNT sanos durante el periodo de transición. Se reportan valores de normalidad que pueden servir como referencia.

Efectos de la actividad locomotriz voluntaria gestacional sobre la morfología cardiaca en crías murinas / Effects of gestational voluntary locomotor activity on cardiac morphology in murine offspring

RESUMEN: El objetivo del presente estudio es analizar los efectos de la actividad locomotriz voluntaria gestacional, como un tipo de entrenamiento físico, sobre la morfología de la bomba cardíaca de la cría, en modelo murino de la cepa CF-1. 12 hembras gestantes fueron divididas aleatoriamente en un grupo control y un grupo que realizó actividad locomotriz voluntaria, accediendo a una rueda de actividad durante los primero 12 días de gestación. Se evaluó la morfología cardiaca mediante cortes transversales, midiendo espesor y área de las paredes del ventrículo derecho, ventrículo izquierdo y septum, tanto en valores absolutos como en valores relativos a la masa corporal del individuo. Se observó que la masa corporal de las crías control (GC) fue significativamente mayor que las del grupo cuyas hembras accedieron a la rueda de actividad (GE) (p<0.01). Solo hubo diferencias en los valores absolutos de espesores y áreas miocárdicas de ventrículo derecho, entre el grupo GE y GC (p<0.05), pero al evaluar los espesores y áreas relativos a la masa corporal se observó que las crías del grupo GE presentaron espesores y áreas significativamente mayores que las que grupo GC (p<0.01). En conclusión, la actividad física gestacional altera el desarrollo morfológico de la bomba cardíaca en ratones CF-1, aumentando significativamente el espesor y área de las paredes miocárdicas en relación a la masa corporal total de la cría.

SUMMARY: The objective of the present study is to analyze the effects of gestational voluntary locomotor activity, as a type of physical training, on the morphology of the offspring´s heart pump, in a murine model of the CF-1 strain. Twelve (12) pregnant females were randomly divided in a control group and a group performing voluntary locomotor activity, by accessing an activity wheel during the first 12 days of gestation. Cardiac morphology was evaluated using cross sections, measuring thickness and area of the walls of the right ventricle, left ventricle, and septum, both in absolute values and values relative to the individual's body mass. It was observed that the body mass of the control pups (CG) was significantly higher than those of the group whose females accessed the activity wheel (GE) (p <0.01). Differences were observed only in absolute values of thickness and myocardial areas of the right ventricle, between the GE and GC group (p <0.05). However, when evaluating the thickness and areas relative to body mass, it was observed that the offspring of the GE group presented thicknesses and areas significantly larger than those in the GC group (p <0.01). In conclusion, gestational physical activity alters the morphological development of the heart pump in CF-1 mice, significantly increasing the thickness and area of the myocardial walls in relation to offspring total body mass.

Anatomia macroscópica interna e avaliação elétrica do coração de Bradypus variegatus / Internal macroscopic anatomy and electrical evaluation of the Bradypus variegatus heart

The Bradypus variegatus species presents peculiar anatomophysiological properties and many aspects of its organic systems still need to be clarified, especially regarding the cardiovascular system, given its participation in vital activities. Disorderly anthropic action has had drastic consequences in sloth populations and the need to treat sick and injured animals is increasingly common. To this end, the importance of knowing its characteristics is emphasized. Therefore, this study proposed to describe the internal macroscopic structures of the sloth's heart, as well as to measure the ventricular walls and indicate the electrical activity of the organ. For the dissections, 15 Bradypus variegatus cadavers were used (1 young female, 9 adults females and 5 adult males) belonging to the Área de Anatomia of the Departamento de Morfologia e Fisiologia Animal (DMFA), Universidade Federal Rural de Pernambuco (UFRPE), Recide, PE, Brazil. After they were fixed and preserved, the specimens received a midsagittal incision in the chest, followed by soft tissue folding and removal of ribs to access the heart. The organ was derived from the cavity and sectioned sagittal medially to identify its internal anatomy. Ventricular walls and interventricular septum were measured with a steel caliper (150 mm / 0.02 mm). An electrocardiogram was performed to determine the electrical profile on 5 healthy B. variegatus sloths, living under semi-livestock conditions at the Recife Zoo, PE, Brazil. The electrodes were taken from the regions, scapular and glutes of the animals that were called hugging a keeper during the procedure, carried out in the Zoo itself, using a portable device. Based on the data obtained, sloths have cardiac chambers separated by septa, however between atria and ventricles, in both antimeres, there are atrioventricular ostia, where valves are found, consisting of 3 valves on the right and 2 on the left. The atria are practically smooth inside and have their cavity enlarged by the atria, the right being larger than the left, these having a greater amount of pectineal muscles in relation to the atria. The ventricles have trabeculae and papillary muscles, 3 on the right and 2 on the left. These muscles hold the tendinous chords that connect the valves. The existence of trabeculae marginal septum was not evidenced. The thickness of the wall of the left ventricle, as well as that of the interventricular septum, proved to be greater than the thickness of the wall of the right ventricle, regardless of the age or sex of the animals. Based on the electrocardiographic recordings, the sloths presented sinus rhythm, with a heart rate between 67 and 100 bpm. The electrical axis ranged from -60º to -90º. The P wave is smoother than the QRS complex. While the S-T segment was classified as isoelectric. The T wave was shown to be + and predominantly > or = at 25% of the S wave, which characterized an rS type QRS deflection in both females and males. The general characteristics of the cardiac chambers in sloths are similar to those observe in other domestic and wild mammals. However, the presence of pectineal muscles associated with the atria and auricles differs from that observed in mammals such as the paca and raccoon and in birds such as the ostrich, which have trabecular structures in these cavities. The number of valves in sloths is equal to the anteater. However, it has a marginal trabeculae septum, not seen in Bradypus variegatus. According to the electrocardiographic findings, the rhythm was sinus, but much lower than that observed in the capuchin monkey, which also maintains arboreal habits.(AU)

Análise Ecocardiográfica das Câmaras Direitas segundo Sexo e Superfície Corporal / Echocardiographic Assessment of Right Chambers by Gender and Body Surface Area

Introdução: A avaliação sistemática das dimensões e da função das câmaras direitas, de acordo com sexo, idade, superfície corporal e índice de massa corporal, não é uniformemente realizada. Objetivo: Avaliar, ao ecocardiograma transtorácico, as dimensões e a função das câmaras direitas de acordo com o sexo, superfície corporal e índice de massa corporal em uma população ambulatorial. Métodos: Estudo observacional, transversal. Foram selecionados 81 pacientes, 60,4 ± 13,5 anos, de ambos os sexos (57 mulheres, 70%). Foram avaliados: diâmetro proximal do ventrículo direito, basal do ventrículo direito, médio e longitudinal; área do átrio direito e volume do átrio direito; espessura da parede livre do ventrículo direito; excursão sistólica do anel valvar tricúspide; e Doppler tecidual do anel tricúspide, onda S'. Resultados: O sexo feminino apresentou menores diâmetros em relação ao sexo masculino (teste t de Student) de diâmetro proximal do ventrículo direito (20,6 mm ± 2,4 vs. 22,7 mm ± 2,2; p = 0,001), basal do ventrículo direito (34,4 mm ± 3,5 vs. 38,2 mm ± 4,8; p < 0,001), diâmetro médio do ventrículo direito (27 mm ± 3,3 vs. 32,4 mm ± 4,9; p < 0,001), área do átrio direito (13,7 cm² ± 2,7 vs. 16,6 cm² ± 3,9; p = 0,002) e volume do átrio direito (37 mL ± 10,6 vs. 50,7 mL ± 15,6 ; p = 0,002). O índice de massa corporal e a superfície corporal se correlacionaram positivamente com o diâmetro proximal do ventrículo direito (coeficiente de correlação - CC 0,24; p = 0,03), diâmetro basal do ventrículo direito (CC 0,22; p = 0,04), diâmetro médio do ventrículo direito (CC 0,23; p = 0,04), diâmetro longitudinal do ventrículo direito (CC 0,28; p = 0,01), área do átrio direito (CC 0,40; p = 0,001) e volume do átrio direito (CC 0,24; p = 0,0006). Conclusão: As médias dos diâmetros ventriculares, área e volume atriais direitos foram menores no sexo feminino. Foi encontrada correlação positiva destes parâmetros com o índice de massa corporal e a superfície corporal. Os valores da excursão sistólica do anel valvar tricúspide e S' não foram influenciados por sexo, índice de massa corporal e superfície corporal.

Introduction: Assessment of right chambers dimensions and function according to gender, age, body surface area and body mass index is not uniformly performed. Objective: To evaluate, by transthoracic echocardiography dimensions and function of right chambers, according to gender, body surface area and body mass index in an outpatient population. Method: Cross-sectional study. Eighty-one patients were selected, 60.4 ± 13.5 years (57 women, 70%). Parameters assessed were the following: proximal, basal, medium and longitudinal, right ventricle diameter; right atrium area and right atrium volume; right ventricle wall thickness; tricuspid annular plane systolic excursion; and tricuspid annulus tissue Doppler and S' wave. Results: Female sex presented lower diameters (Student's t-test) of proximal right ventricle diameter (20.6 mm ± 2.4 vs. 22.7 mm ± 2.2; p = 0.001), basal right ventricle diameter (34,4 mm ± 3,5 vs. 38,2 mm ± 4,8; p <0.001), medium right ventricle diameter (27 mm ± 3.3 vs. 32.4 mm ± 4.9; p <0.001), right atrium area (13.7 cm² ± 2.7 vs. 16.6 cm² ± 3.9; p = 0.002) and right atrium volume (37 mL ± 10.6 vs.

Avaliação do ventrículo esquerdo em pacientes com DPOC e hipoxemia noturna / Evaluation of the left ventricle in patients with COPD and nocturnal hypoxemia

RESUMO Objetivo Verificar a associação entre massa e espessura do ventrículo esquerdo (VE) e presença de hipoxemia noturna significativa em pacientes portadores de DPOC com hipoxemia diurna leve. Métodos Estudo transversal realizado em pacientes ambulatoriais, clinicamente estáveis, portadores de DPOC e hipoxemia leve (saturação de oxigênio ≥ 90 a ≤ 94%, identificados por oximetria não invasiva) em um centro clínico especializado no atendimento de doenças respiratórias em Goiânia (GO). Todos foram submetidos a avaliação clínica, espirometria, polissonografia, ecocardiografia, gasometria arterial, teste de caminhada de 6 minutos e radiografia de tórax. Resultados Foram avaliados 64 pacientes com DPOC e hipoxemia noturna. Pacientes com hipoxemia noturna significativa apresentaram parâmetros ecocardiográficos associados a mais quantidade de musculatura do VE quando comparados a pacientes com hipoxemia noturna leve. A relação entre volume/massa do VE foi significativamente menor no grupo com hipoxemia noturna significativa (0,64 ± 0,13 versus 0,72 ± 0,12; p = 0,04) e a espessura diastólica do septo interventricular e a espessura diastólica da parede posterior do VE foram significativamente maiores nesse grupo (9,7 ± 0,92 versus 9,1 ± 0,90; p = 0,03) (9,7 ± 1,0 versus 8,9 ± 1,0; p = 0,01). O tempo de sono REM com saturação abaixo de 85% prediz significativamente a espessura do septo (ajuste para índice de massa corporal [IMC], idade e pressão arterial média; r2 = 0,20; p = 0,046). Conclusão Em indivíduos portadores de DPOC e hipoxemia noturna significativa, foi observada associação entre hipoxemia severa no sono REM e parâmetros ecocardiográficos que indicam aumento da massa do VE. Tal fato sugere que esse subgrupo de indivíduos pode se beneficiar de uma avaliação ecocardiográfica do VE.

ABSTRACT Objective To verify association between left ventricular (LV) mass and thickness and the presence of significant nocturnal hypoxemia in patients with COPD with mild diurnal hypoxemia. Methods A cross-sectional study carried out in clinically stable outpatients with COPD and mild hypoxemia (oxygen saturation ≥90 to ≤94%, identified by noninvasive oximetry) in a clinic specialized in the treatment of respiratory diseases in Goiânia-GO. All patients were submitted to clinical evaluation, spirometry, polysomnography, echocardiography, arterial blood gas analysis, 6-minute walk test and chest X-ray. Results Patients with significant nocturnal hypoxemia had echocardiographic parameters associated with increase of LV musculature when compared to patients with mild nocturnal hypoxemia. The LV volume/mass ratio was significantly lower in the group with significant nocturnal hypoxemia (ratio 0.64 ± 0.13 versus 0.72 ± 0.12, p = 0.04), the thickness diastolic diameter of the interventricular septum and the diastolic thickness of the LV posterior wall were significantly higher in this group (9.7 ± 0.92 versus 9.1 ± 0.90 p = 0.03), (9.7 ± 1.0 versus 8.9 ± 1.0, p = 0.01. The time in REM sleep with saturation below 85% significantly predicted septum thickness (adjustment for BMI, age and mean blood pressure, r2 = 0.20; p = 0.046). Conclusion We observed association between severe REM sleep hypoxemia and echocardiographic parameters indicating increased LV mass in individuals with COPD and significant nocturnal hypoxemia. This suggests that this subgroup of individuals may benefit from an echocardiographic evaluation of the left ventricle.

Análisis del Ventrículo derecho / Analysis of the right ventricle

Resumen El ventrículo derecho, históricamente, ha sido en gran medida olvidado e y la gran mayoría de las técnicas diagnósticas,los abordajes terapéuticos y las investigaciones clínicas están dirigidas al ventrículo izquierdo. Con una anatomía y fisiologíamuy diferente a su contraparte izquierda, el ventrículo derecho dispone de limitadas opciones terapéuticas cuando éste falla, lo cual empeora enormemente el pronóstico del paciente. La presente revisión pretende hacer un análisis de la anatomía, fisiología, fisiopatología, estudios de imagen y tratamiento de la falla ventricular derecha con el fin de retomar su importancia en la cardiología actual.

Abstract The right ventricle has been, historically, largely forgotten and the vast majority of diagnostic techniques, therapeutic approaches and clinical research are directed to the left ventricle. With a very different anatomy and physiology from its left counterpart, the right ventricle has limited therapeutic options when it fails, which greatly worsens the patient's prognosis. The present review intends to analyze the anatomy, physiology, physiopathology, imaging studies and treatment of right ventricular failure in order to resume its importance in current cardiology.

The artery of Mouchet: blood supply of the septomarginal trabecula in 50 human hearts

SUMMARY The septomarginal trabecula is a muscular structure which transmits the right branch of the atrioventricular bundle. It is usually supplied by a branch from the second anterior septal artery. Anastomoses between the right and left coronary arteries may happen on the septomarginal trabecula. They are of great significance in order to prevent ischemia during a myocardial infarction. Surgeries such as Konno's and Ross' procedures implies in knowledge of these vessels anatomy. The coronary arteries of 50 human hearts were injected with latex and subsequentely dissected with the purpose of identifying the arterial branch that supplied the septomarginal trabecula. The trabecular branch arose from the second anterior septal artery in 38% of cases, and the branch arose from the first anterior septal artery in 26%. One of the hearts had its septomarginal trabecula supplied by the conus arteriosus arteryliterature. Anastomoses between the right and left coronary arteries were found inside the septomarginal trabecula. The right branch of the atrioventricular bundle is subject to a great number of clinical conditions and is often manipulated during surgery, thus, the study of the septal branches of the coronary arteries and the trabecular branch is essential.

RESUMO A trabécula septomarginal é uma estrutura muscular que transmite o ramo direito do feixe atrioventricular. É usualmente suprida por um ramo da segunda artéria septal anterior. Anastomoses entre as artérias coronárias direita e esquerda podem ocorrer na trabécula. São de grande significância especialmente na prevenção de isquemia durante um infarto do miocárdio. Procedimentos cirúrgicos como o de Konno's e Ross implicam conhecimento anatômico desses vasos. As artérias coronárias de 50 corações humanos foram injetadas com látex e dissecadas com o propósito de identificar o ramo arterial que supria a trabécula septomarginal. Em somente 38% dos casos o ramo foi proveniente da segunda artéria septal anterior, enquanto que em 26% dos casos a artéria se originou da primeira septal anterior. Um dos corações teve a trabécula septomarginal suprida por um ramo originário da artéria do cone arterioso. Além disso, foram encontradas anastomoses entre as artérias coronárias no interior da trabécula septomarginal. Em suma, o ramo direito do feixe atrioventricular está sujeito a inúmeras condições clínicas e é alvo de manuseio em cirurgias, logo, o estudo dos ramos septais das artérias coronárias, em especial o ramo trabecular é essencial.

Cardiac remodeling indicators in adolescent athletes / Indicadores de remodelagem cardíaca em atletas adolescentes

Summary Objective: The idea that different sports and physical training type results in different cardiac adaptations has been widely accepted. However, this remodelling process among different sport modalities is still not fully understood. Thus, the current study aims to investigate the heart morphology variation associated with a set of different modalities characterized by distinct models of preparation and different methods and demands of training and completion. Method: The sample comprises 42 basketball players, 73 roller hockey players, 28 judo athletes and 21 swimmers. Anthropometry was assessed by a single and experienced anthropometrist and the same technician performed the echocardiographic exams. Analysis of variance was used to study age, body size and echocardiograph parameters as well as different sport athlete's comparison. Results: Basketball players are taller (F=23.448; p<0.001; ES-r=0.553), heavier (F=6.702; p<0.001; ES-r=0.334) and have a greater body surface area (F=11.896; p<0.001; ES-r=0.427). Basketball and hockey players have larger left auricle diameters compared with judo athletes (F=3.865; p=0.011; ES-r=0.316). Interventricular end-diastolic septal thickness (F=7.287; p<0.001; ES-r=0.347) and left ventricular posterior wall thickness (F=8.038; p<0.001; ES-r=0.362) of the judokas are smaller compared to the mean values of other sports participants. In addition, relative left parietal ventricular wall thickness is lower among swimmers compared with judokas (F=4.127; p=0.008; ES-r=0.268). Conclusion: The major contributors to changes in heart morphology are for the most part associated with sport-specific training and competition and the specific dynamics and adaptive mechanisms imposed by each sport.

Resumo Objetivo: Os efeitos decorrentes da prática de diferentes modalidades desportivas resultam em padrões divergentes de adaptação cardíaca. A presente pesquisa procura estudar a variação da morfologia do coração associada a um conjunto de modalidades desportivas distintas quanto à natureza do esforço e aos modelos de preparação, incluindo metodologias de treino e sistemas de competição. Método: Foram estudados 42 basquetebolistas, 73 hoquistas, 28 judocas e 21 nadadores. A antropometria foi avaliada por um único e experiente antropometrista e os exames ecocardiográficos foram realizados pelo mesmo operador. Recorreu-se à análise da variância para estudar a variação associada a idade, medidas de tamanho corporal e parâmetros ecocardiográficos, bem como para a comparação entre os atletas de diferentes modalidades desportivas. Resultados: Os basquetebolistas são os atletas mais altos (F=23,448; p<0,001; ES-r=0,553), mais pesados (F=6,702; p<0,001; ES-r=0,334), com maior superfície corporal (F=11,896; p<0,001; ES-r=0,427) e, com os hoquistas, apresentam um diâmetro da aurícula esquerda superior ao dos judocas (F=3,865; p=0,011; ES-r=0,316). A espessura telediastólica do septo interventricular (F=7,287; p<0,001; ES-r=0,347) e da parede posterior do ventrículo esquerdo (F=8,038; p<0,001; ES-r=0,362) dos judocas é inferior à dos outros atletas, mesmo quando controlado para o tamanho corporal. Os nadadores apresentam uma espessura parietal relativa do ventrículo esquerdo superior à dos judocas (F=4,127; p=0,008; ES-r=0,268). Conclusão: As diferentes fontes de variação da morfologia cardíaca prendem-se com as dinâmicas do processo de treino, competição e correspondentemente com os mecanismos adaptativos, sobrepondo-se ao processo de formação desportiva a longo prazo.

Evaluation of coronary dominance in pigs; a comparative study with findings in human hearts / Avaliação da dominância coronária em suínos. Estudo comparativo com os achados em corações humanos

Coronary dominance in swine has been poorly evaluated. The frequencies of each type of dominance have been described, but few details have been given as to the different expressions of each one. The aim of this study was to characterize coronary dominance in commercial breed swine. One hundred and fifty eight pig hearts were evaluated. The coronary arteries (CA) were infused with synthetic resin (Palatal 85% and Styrene15%) through the ostia after channeling. The coronary artery that gives origin to the posterior interventricular artery (PIA), and the site of termination of both the circumflex arteries (CXA), and left retroventricular branch (LRVB) were determined in order to establish the coronary dominance pattern. Right coronary dominance was found in 105 hearts (66.5%), and a balanced circulation in 53 specimens (33.5%). No dominance was observed for the left coronary artery in the hearts studied. The CXA ended on the posterior aspect of the left ventricle in 101 samples (64%) and on the crux cordis in 55 specimens (34.8%). In two specimens (1.3%) it ended as a left marginal artery. In all cases the PIA was a branch of the RCA, and was long in 105 hearts (66%), 55% of which corresponded to males and 45% to females, but this difference was not statistically significant (p=0.77). The AIA ended on the apex in 126 specimens (80%), 71 of which (56%) corresponded to males and 55 (44%) to females (p=0.74)...

A dominância coronária em suínos tem sido pouco avaliada. Descreveram-se as frequências de cada um dos tipos, mas não detalharam as diferentes expressões de cada um deles. O objetivo deste estudo foi caracterizar a dominância coronária em suínos de raças comerciais. Avaliaram-se 158 corações de suínos. As artérias coronárias (AC) foram infundidas através da canalização dos seus ostium com resina sintética (Palatal 85% e Estireno15%). Para estabelecer o tipo de dominância coronária, determinou-se de qual coronária desprendia-se a artéria interventricular posterior (AIP) e o lugar de finalização das artérias circunflexa (ACX) e do ramo retro ventricular esquerdo (RRVI). Encontrou-se dominância coronária direita em 105 corações (66%) e circulação balanceada em 53 exemplares (34%). Não foi observada a dominância coronária esquerda nos corações estudados. O calibre proximal e médio da ACD nos casos de dominância coronária direita foi de 3,84 ± 0,80 mm. Por outro lado, encontrou-se que este mesmo calibre nos corações com dominância coronária balanceada foi de 3,97 + 0,79 mm. (p=0,88). A ACX finalizou-se na face posterior do ventrículo esquerdo em 101 amostras (64%) e na crux cordis em 55 exemplares (34,8%). A AIP emergiu em todos os casos da ACD sendo comprida em 105 corações (66%) dos quais 55% correspondia a machos e 45% a fêmeas, sem que esta diferença fosse estatisticamente significativa (p=0,77). A AIA finalizou-se no ápice em 126 exemplares (80%), dos quais 71 (56%) corresponderam a machos e 55 (44%) a fêmeas (p=0,74)...

Nova contribuição ao estudo do remodelamento ventricular e dos anéis valvares na cardiomiopatia dilatada: avaliação anátomo-histopatológica / New contribution to the study of ventricular remodeling and valve rings in dilated cardiomyopathy: anatomical and histological evaluation

Introdução: A cardiomiopatia dilatada idiopática (CMDId) é causadora de grande impacto, porém aspectos de sua fisiopatologia são desconhecidos. Objetivo: Avaliar aspectos anatomo-histológicos de corações com CMDId comparando-os a corações normais, com medidas perimetrais dos anéis atrioventriculares direito (AVD) e esquerdo (AVE) e dos ventrículos direito (VD) e esquerdo (VE) e a porcentagem de fibras colágenas e elásticas dos anéis. Métodos: Foram avaliados 13 corações de cadáveres portadores de CMDId e 13 corações normais, que foram dissecados mantendo-se os anéis atrioventriculares e a massa ventricular, com laminação em segmentos correspondentes a 20%, 50% e 80% da distância entre o sulco atrioventricular e o ápice ventricular. Os cortes foram submetidos à digitalização fotográfica, sendo comparadas as medidas. Os anéis foram dissecados, medidos e enviados ao laboratório de anatomia patológica, sendo realizadas colorações por meio de hematoxilina-eosina, picrossírius e resorcina fuccina oxidada. Resultados: Com relação aos ventrículos, no grupo CMDId ocorre dilatação nos segmentos apical, equatorial e basal. A medida do AVD foi maior no grupo CMDId, não havendo diferença no AVE entre os grupos. Com relação ao percentual de fibras colágenas, há diminuição no grupo CMDId em relação ao grupo normal. Com relação às fibras elásticas, não houve diferença entre os grupos. Conclusão: Ocorre alteração da geometria ventricular com dilatação no grupo CMDId. Na CMDId observou-se aumento no perímetro do AVD. Não se observou aumento do perímetro do AVE. Houve diminuição percentual na área total de colágeno tanto no AVD quanto no AVE em corações com CMDId. .

Introduction: Idiopathic dilated cardiomyopathy causes great impact but many aspects of its pathophysiology remain unknown. Objective: To evaluate anatomical and histological aspects of hearts with idiopathic dilated cardiomyopathy and compare them to a control group, evaluating the behavior of the perimeters of the atrioventricular rings and ventricles and to compare the percentage of collagen and elastic fibers of the atrioventricular rings. Methods: Thirteen hearts with cardiomyopathy and 13 normal hearts were analysed. They were dissected keeping the ventricular mass and atrioventricular rings, with lamination of segments 20%, 50% and 80% of the distance between the atrioventricular groove and the ventricular apex. The sections were subjected to photo scanning, with measurement of perimeters. The atrioventricular rings were dissected and measured digitally to evaluate their perimeters, later being sent to the pathology laboratory, and stained by hematoxylin-eosin, picrosirius and oxidized resorcin fuccin. Results: Regarding to ventricles, dilation occurs in all segments in the pathological group, and the right atrioventricular ring measurement was higher in idiopathic dilated cardiomyopathy group, with no difference in the left side. With respect to collagen, both sides had lower percentage of fibers in the pathological group. With respect to the elastic fibers, there was no difference between the groups. Conclusion: There is a change in ventricular geometry in cardiomyopathy group. The left atrioventricular ring does not dilate, in spite of the fact that in both ventricles there is lowering of collagen. .

Athlete’s Heart with a Systemic Right Ventricle.

Objective: High load of regularly vigorous exercise leads to multiple physiological adaptations. The major cardiovascular effects are hypertrophy and dilation, predominantly of the left ventricle, and bradycardia. However, there are no reports on an athlete’s heart in a systemic right ventricle. Subject: We report on a 23 year old male endurance athlete (177cm, 69kg) with a systemic subaortic right ventricle after atrial redirection (Senning procedure) for simple transposition of the great arteries in infancy. Albeit medical doctors had imposed activity restriction to him, he has lead an active lifestyle from early childhood on, intensifying his sport activities over the years especially in cycling and running to a training volume of about 10 hours per week in winter and about 15 hours per week in summer. In 2009 he performed 1:50h on the half marathon distance. In 2013 he finished his first Marathon in 4:34h. Results: Cardiopulmonary exercise testing revealed a maximum oxygen uptake of 52.3ml/min/kg and a peak work load of 353 Watt, corresponding to 5.1Watt per kilogram body mass. Cardiovascular Magnetic Resonance showed a cardiac index of 2.9ml/min/m², a tricuspid regurgitation fraction of 4%, and a systemic right ventricle enddiastolic volume of 109ml/m² with an ejection fraction of 53%. Conclusions: With regular exercise training a systemic right ventricle can become very efficient comparable to healthy amateur athletes.

Infarto do miocárdio: alterações morfológicas e breve abordagem da influência do exercício físico / Myocardial infarction: Morphological changes and brief approach to the influence of exercise

As doenças cardiovasculares representam a principal causa de mortalidade e incapacidade no Brasil e no mundo. O infarto agudo do miocárdio (IAM) é uma das afecções coronarianas mais comuns, e reflete a morte dos cardiomiócitos causada por um desequilíbrio entre a oferta e demanda de nutrientes ao tecido, consequente à obstrução do fluxo coronariano,podendo ser transitório ou permanente. Com base nessas informações, foi realizada revisão da literatura em bancos de bases bibliográficas e acervos de livros, objetivando um estudo das alterações morfológicas do IAM e as variações morfológicas que favorecem o acometimento dessa doença. Observa-se que há vários trabalhos relacionados ao assunto, porém poucos estão relacionados às alterações morfofuncionais do sistema cardiovascular. São encontrados estudos que relatam a melhora da função cardíaca, remodelamento cardíaco e redução das placas de ateroma.

Cardiovascular diseases are the leading cause of mortality and disability in Brazil and worldwide, with acute myocardial infarction (AMI) being one of the most common coronary diseases. This reflects cardiac myocyte death caused by an imbalance between the supply and demand of nutrients to the tissue caused by obstruction of the coronary flow, which may be atransient or permanent condition. Based on this information, a review of the literature was conducted in bibliographical databases and book collections,providing input for a study of morphological changes in AMI and morphological variations that may lead to the appearance of this pathology. There a reseveral works on this subject, although few explore morpho-functional alterations to the cardiovascular system. Some studies reported improved cardiac function and remodeling, together with a decrease in atherosclerotic plaque, among patients undergoing cardiac rehabilitation.

Morphologic expression of the left coronary artery in pigs. An approach in relation to human heart / Expressão morfológica da artéria coronária esquerda em porcos. Abordagem em relação ao coração humano

Introduction: In spite of its importance as an experimental model, the information on the left coronary artery in pigs is sparse. Objective: To determine the morphologic features of the left coronary artery in pigs. Methods: We evaluated 158 pig hearts. The left coronary artery was perfused with synthetic resin after their ostia had been catheterized. Diameters and courses of the vascular beds were measured with an electronic caliper (Mitutoyo(r)). Results: The diameter of left coronary artery was 6.98 ± 1.56 mm and its length was 3.51±0.99 mm. It was found to end up by bifurcating itself into the anterior interventricular artery and the circumflex artery in 79% of the cases, and by trifurcating in 21% of the cases, with the presence of the diagonal artery. The anterior interventricular artery ended up at the apex in 79.7% of the cases, and the circumflex artery at the posterior aspect of the left ventricle in 64% of the case, this artery never reached the posterior interventricular sulcus. An anastomosis between the terminal branches of the anterior interventricular artery and the posterior interventricular artery was found in 7.6% of the specimens. The antero-superior branch of the anterior interventricular artery occurred in 89.9% of the hearts. A left marginal branch was observed in 87.9% of the cases with a diameter of 2.25±0.55 mm. Conclusion: Compared with humans, pigs have shorter left coronary artery trunks and branches; even the circumflex artery never reaches the posterior interventricular sulcus. Our findings are useful for the design of experimental hemodynamic and procedural models. .

Introdução: Apesar de sua importância como modelo experimental, a informação sobre a artéria coronária esquerda em suínos é escassa. Objetivo: Determinar as características morfológicas da artéria coronária esquerda em suínos. Métodos: Foram avaliados 158 corações de porcos. A artéria coronária esquerda foram perfundidos com resina sintética após a sua óstios foram cateterizados. Diâmetros e cursos dos leitos vasculares foram medidos com um paquímetro eletrônico (Mitutoyo(r)). Resultados: O diâmetro da artéria coronária esquerda foi 6,98±1,56 mm e seu comprimento era de 3,51±0,99 mm. Verificou-se que acabam bifurcando-se no interior da artéria descendente anterior e da artéria circunflexa em 79 % dos casos, e dividindo-se em três em 21% dos casos, com a presença da artéria diagonal. A artéria interventricular anterior acabou no ápice em 79,7% dos casos, sendo a artéria marginal na face posterior do ventrículo esquerdo em 64% dos casos, esta artéria nunca chegou ao sulco interventricular posterior. Uma anastomose entre os ramos terminais da artéria interventricular anterior e artéria interventricular posterior foi encontrado em 7,6% das amostras. O ramo ântero-superior da artéria interventricular anterior ocorreu em 89,9% dos corações. Um ramo marginal esquerda foi observado em 87,9% dos casos, com diâmetro de 2,25±0,55 mm. Conclusão: Em comparação com os seres humanos, os porcos têm troncos das artérias coronárias esquerdas mais curtos e ramos; até a artéria circunflexa nunca atinge o sulco interventricular posterior. Nossos resultados são úteis para a concepção de hemodinâmica experimental e modelos processuais. .