Clinical Application of Exercise Stress Echocardiography in an Outpatient Pediatric Population.

Background: Exercise stress echocardiography (ESE) is commonly employed in adults, but its applicability in pediatric populations remains to be clarified. Methods: A total of 309 consecutive children (C), with a mean age of 14.1 ± 2.6 years (range 6-17 years), underwent treadmill ESE starting in 2002. They were divided into two groups: Group I comprised 258 children, including 237 with symptoms related to exercise (such as chest pain, fatigue, lipothymia/syncope, or one aborted sudden death), 15 with electrocardiogram (ECG) abnormalities, and 6 with a positive ECG stress test showing ST changes. Group II consisted of 10 asymptomatic children whose parents requested routine screening, 11 with symptoms unrelated to exercise, 12 with a family history of sudden death, and 17 with known pathologies (including 10 with hypertrophic cardiomyopathy, 2 with aortic coarctation, and the remainder with various conditions, such as Cortriatriatum sinister, pulmonary stenosis, subaortic stenosis, bicuspid aortic valve, left ventricular hypertrophy related to arterial hypertension, and aortic switch operation). Regional wall motion abnormalities (RWMAs) and transvalvular or intraventricular (IVG) gradients were assessed using 2D and continuous-wave Doppler, respectively, in all cases. Results: The success rate was 100% (309/309). Stress-induced RWMAs were observed in two children. A significant IVG (>30 mmHg) was detected in 101 out of the 258 children (39%) in Group I, who presented with exercise-related symptoms, ECG abnormalities, or positive stress ECG. In Group I, the odds ratio (OR) of ESE reproducing the symptoms in children with IVG compared to those without IVG was 8.22 (95% CI: 4.84-13.99, p < 0.001). Conclusions: Treadmill ESE is both feasible and safe for pediatric populations. RWMAs demonstrated limited utility in our cohort of children, while IVG induced by exercise was frequently observed in symptomatic children.

The Importance of Left Ventricular Outflow Tract and Mid-Ventricular Gradients in Stress Echocardiography: A Narrative Review.

This review aims to serve as a guide for clinical practice and to appraise the current knowledge on exercise stress echocardiography in the evaluation of intraventricular obstruction in HCM, in patients with cardiac syndrome X, in athletes with symptoms related to exercise, and in patients with normal left ventricular systolic function and exercise-related unexplained tiredness. The appearance of intraventricular obstruction while exercising is considered rare, and it usually occurs in patients with hypertrophy of the left ventricle. The occurrence of intraventricular obstruction when exercising has been evidenced in patients with hypertrophic cardiomyopathy, athletes, patients with cardiac syndrome X, patients with syncope or dizziness related to exercise, and patients with dyspnea and preserved ejection fraction. The clinical significance of this observation and the exercise modality that is most likely to trigger intraventricular obstruction remains unknown. Supine exercise and lying supine after exercise are less technically demanding, but they are also less physiologically demanding than upright exercise. Importantly, in everyday life, human beings generally do not become supine after exercise, as takes place in post-exercise treadmill stress echocardiograms in most echocardiography labs. The presence of induced intraventricular obstruction might be considered when patients have exercise-related symptoms that are not understood, and to assess prognosis in hypertrophic cardiomyopathy.

Exercise-Induced Intraventricular Gradients As a Potential Cause of Sudden Cardiac Death.

A 16-year-old boy reported an episode of dizziness related to intense training six months before an episode of aborted sudden death. The screening required for competitive sports practice was normal. There were no personal or familial antecedents of sudden death or heart disease. After winning a triathlon competition, he experienced a cardiac arrest episode. He received defibrillation with the return of spontaneous circulation. A medical evaluation that included electrocardiogram (ECG) and echocardiogram had normal results. A complete study including cardiac MRI, coronary CT angiography, a genetic study for heart disease, the flecainide test, and a stress echocardiogram with ergometrine was done, and all results were normal. During a Holter ECG and exercise stress echo, isolated premature ventricular complexes were detected. During the effort treadmill stress echocardiogram, the athlete developed a significant intraventricular obstruction with an end-systolic peak, without systolic anterior movement of the mitral valve, which disappeared in the first minute of the recovery. We highlight the possible cause-effect relation between the events.

Spring water quality monitoring using multiple bioindicators from multiple collection sites.

The aim of this study was to examine the water quality of the Extrema River spring in a Brazilian Cerrado area. Three collection sites (P1 - P3) were sampled in the dry and rainy seasons, which are close to industries from different sectors. In the physicochemical analysis, a decrease in dissolved oxygen levels (<5 mg/L) and pH (< 6) at P3 was detected. An increase in heterotrophic bacteria count was recorded at all sites (> 500 colonies/ml). In ecotoxicological analyses, P2 and P3 exhibited toxicity using Vibrio fischeri (> 20%). In evaluating toxicity, the reduction in seed germination was significant utilizing Lactuca sativa at all locations and with Allium cepa only at P2; rootlet length was decreased at P3 on L. sativa and at all sites with A. cepa. In contrast, loss of membrane integrity and mitochondrial function of meristems was adversely affected at all locations using both L. sativa and A. cepa assays. Principal components analysis (PCA) approach indicated that seasonality apparently did not markedly interfere with the obtained data, but it is important to include more collection locations to be evaluated with multiple bioindicators in the spring region. Our data indicate the urgent need for more rigorous programs to monitor the discharge of effluents into water springs.

Intraventricular gradients-When we have to "exercise" our minds: A case report.

Increased intraventricular pressure gradients due to dynamic left ventricular outflow tract obstruction during exercise have long been known to cause different symptoms. Exercise stress echocardiography is fundamental in the diagnostic approach of symptoms presenting during exercise. We hypothesize on the possible pathophysiological mechanisms responsible for our patient's syncopal episodes.

Fish biomarker responses reflect landscape anthropic disturbance in savanna streams.

Disturbance in the landscape surrounding streams can interfere with water quality and cause harm to aquatic organisms. In this study, we evaluate the influence of land use on the genetic and biochemical biomarkers of fish in streams of Brazilian savanna (Cerrado). We also evaluated whether biomarker responses are seasonally consistent. For this purpose, individuals of the Neotropical tetra fish Astyanax lacustris were exposed in cages for 96 h, in 13 streams draining agroecosystems with different degrees of disturbance during the dry and wet seasons. After exposure, blood, liver, and gills were collected for multibiomarker analyses (micronuclei, erythrocytic nuclear abnormalities, lipid peroxidation, antioxidant enzymes, and biotransformation enzyme). The results showed that the gradient of anthropic disturbance was positively associated with genotoxic damage (erythrocytic nuclear abnormalities) and negatively associated with antioxidant and biotransformation enzymes of the liver in both seasons. No association of the gradient of anthropic disturbance with the frequency of micronuclei and for most gill enzymes was found for both seasons. Landscape disturbance was also negatively associated with water quality in the wet season. These results indicate that changes in land use interfere with the genetic and biochemical processes of organisms. Thus, the multibiomarker approach may represent an effective strategy for assessing and monitoring terrestrial landscape disturbance.

What can the Allium cepa test say about pesticide safety? A review.

The increasing use of pesticides has caused global concerns about the toxic effects and adverse consequences of pesticides on humans and the environment. Among the ways to understand the impact of pesticides, the Allium cepa bioassay stands out. This test is suitable to evaluate different toxic, cytotoxic, genotoxic, and mutagenic outcomes. In this context, the present review aimed to summarize the history of using the A. cepa bioassay to investigate pesticide damages. Data on the experimental conditions were also discussed. The reviewed studies showed the toxicity profile of 113 active ingredients primarily tested in the laboratory, using water for exposure. The most used biomarkers were the mitotic index, chromosomal aberrations, and nuclear abnormalities. All active ingredients caused some toxicity levels in A. cepa, showing the efficiency and sensibility of this bioindicator and the adverse effect of pesticides on humans and the environment. Furthermore, it was evident that pesticides have great potential to damage the mitotic spindle and DNA because almost all active ingredients tested induced chromosomal aberrations and nuclear abnormalities. The current review showed that the A. cepa bioassay is an effective and appropriate model to evaluate pesticide toxicity, and it might indicate research gaps and recommendations for further studies.

Exercise stress echocardiography: Where are we now?

Exercise stress echocardiography (ESE) is a widely used diagnostic test in cardiology departments. ESE is mainly used to study patients with coronary artery disease; however, it has increasingly been used in other clinical scenarios including valve pathology, congenital heart disease, hypertrophic and dilated cardiomyopathies, athlete evaluations, diastolic function evaluation, and pulmonary circulation study. In our laboratories, we use an established methodology in which cardiac function is evaluated while exercising on a treadmill. After completing the exercise regimen, patients remain in a standing position or lie down on the left lateral decubitus, depending on the clinical questions to be answered for further evaluation. This method increases the quality and quantity of information obtained. Here, we present the various methods of exercise stress echocardiography and our experience in many clinical arenas in detail. We also present alternatives to ESE that may be used and their advantages and disadvantages. We review recent advances in ESE and future directions for this established method in the study of cardiac patients and underline the advantage of using a diagnostic tool that is radiation-free.

Children's Understanding of Informed Assents in Research Studies.

The assent procedure reflects an effort to enable the minor to understand, to the degree they are capable of, what their participation in the decision making process would involve. AIMS: To evaluate the minors' ability to understand the information provided to them when obtaining assent and to evaluate the opinion of the parents regarding the importance of asking the child's assent. METHODS: The sample included a total of 52 minors aged between 10 and 17 years who underwent exercise echocardiogram. The Quality of Informed Consent is divided into two parts: Part A was used to measure objective understanding and part B to measure subjective understanding. RESULTS: The results show that the minors have a high capacity to understand the information given to them when asking for assent. A positive relationship was found between the two parts of the questionnaire. No statistically significant relationship was found between age and sex and part A and part B or between both age groups (<14 years old and ≥14 years old) and the measure. In the case of the parents, 96.6% of parents consider assent as an advantage for the child's acceptance of health care. The opinion of the parents is not related to the age, sex or level of schooling. CONCLUSION: Minors showed a substantial level of understanding regarding the information provided to them. The parents considered the implementation of assent fundamental to the child's acceptance of health care.

Prognostic Value of Reduced Heart Rate Reserve during Exercise in Hypertrophic Cardiomyopathy.

BACKGROUND: Sympathetic dysfunction can be evaluated by heart rate reserve (HRR) with exercise test. OBJECTIVES: To determine the value of HRR in predicting outcome of patients with hypertrophic cardiomyopathy (HCM). METHODS: We enrolled 917 HCM patients (age = 49 ± 15 years, 516 men) assessed with exercise stress echocardiography (ESE) in 11 centres. ESE modality was semi-supine bicycle in 51 patients (6%), upright bicycle in 476 (52%), and treadmill in 390 (42%). During ESE, we assessed left ventricular outflow tract obstruction (LVOTO), stress-induced new regional wall motion abnormalities (RWMA), and HRR (peak/rest heart rate, HR). By selection, all patients completed the follow-up. Mortality was the predetermined outcome measure Results: During ESE, RWMA occurred in 22 patients (2.4%) and LVOTO (≥50 mmHg) in 281 (30.4%). HRR was 1.90 ± 0.40 (lowest quartile ≤ 1.61, highest quartile > 2.13). Higher resting heart rate (odds ratio 1.027, 95% CI: 1.018-1.036, p < 0.001), older age (odds ratio 1.021, 95% CI: 1.009-1.033, p < 0.001), lower exercise tolerance (mets, odds ratio 0.761, 95% CI: 0.708-0.817, p < 0.001) and resting LVOTO (odds ratio 1.504, 95% CI: 1.043-2.170, p = 0.029) predicted a reduced HRR. During a median follow-up of 89 months (interquartile range: 36-145 months), 90 all-cause deaths occurred. At multivariable analysis, lowest quartile HRR (Hazard ratio 2.354, 95% CI 1.116-4.968 p = 0.025) and RWMA (Hazard ratio 3.279, 95% CI 1.441-7.461 p = 0.004) independently predicted death, in addition to age (Hazard ratio 1.064, 95% CI 1.043-1.085 p < 0.001) and maximal wall thickness (Hazard ratio 1.081, 95% CI 1.037-1.128, p < 0.001). CONCLUSIONS: A blunted HRR during ESE predicts survival independently of RWMA in HCM patients.

The Prognostic Value of Exercise Echocardiography After Percutaneous Coronary Intervention.

BACKGROUND: Exercise echocardiography (EE) is a valuable noninvasive method for diagnostic and prognostic assessment of ischemic cardiac disease. The prognostic value of a negative EE test is well known overall, but its role in patients who undergo percutaneous coronary intervention remains poorly validated. The aim of this study was to ascertain the prognostic value of treadmill EE and to determine predictors of cardiac events in this population, with an emphasis on nonpositive (negative or inconclusive) test results. METHODS: A retrospective single-center study was performed. It included 516 patients (83% man; mean age, 62 ± 9 years) previously subjected to percutaneous coronary intervention who underwent treadmill EE between 2008 and 2017. Demographic, clinical, echocardiographic, and angiographic data were collected. The occurrence of cardiac events (cardiac death, acute coronary syndrome, or coronary revascularization) during follow-up was investigated. A multivariate Cox regression analysis was used to evaluate predictors of cardiac events. The Kaplan-Meier method was used to evaluate event-free survival rates. RESULTS: The results of EE were negative for myocardial ischemia in 245 patients (47.5%), inconclusive in 144 (27.9%), and positive in 127 (24.6%). During a mean follow-up period of 40 ± 34 months, cardiac events occurred in 152 patients (29.5%). The positive and negative predictive values of EE were 81.6% and 85.3%, respectively. The sensitivity of the exercise test was 73.9%, with specificity of 90.1%. Predictors of cardiac events were typical angina (hazard ratio [HR], 1.95; 95% CI, 1.16-3.27; P = .011), a positive ischemic response detected by electrocardiographic monitoring during EE (HR, 2.01; 95% CI, 1.21-3.34; P = .007), and the test result (inconclusive result: HR, 1.06; 95% CI, 0.51-2.19; P = .878; positive result: HR, 4.35; 95% CI, 2.42-7.80; P < .001). Patients with inconclusive (log-rank P = .038) and positive (log-rank P < .001) results had significantly more cardiac events during follow-up than those with negative EE test results. Focusing on those patients with nonpositive results, cardiac event-free survival rates at 1, 3, and 5 years were 96.6 ± 0.9%, 88.3 ± 1.9%, and 79.5 ± 2.6%, respectively. In this subpopulation, an inconclusive test result (HR, 1.67; 95% CI, 1.03-2.70; P = .039), more extensive coronary artery disease (two vessels: HR, 1.37; 95% CI, 0.75-2.30; P = .304; three vessels: HR, 2.59; 95% CI, 1.38-4.87; P = .003), and arterial hypertension (HR, 2.07; 95% CI, 1.10-3.91; P = .025) were significantly associated with the occurrence of cardiac events. CONCLUSION: Patients with known coronary disease with negative results on EE are at low risk for hard events. Patients with inconclusive results are at higher risk for cardiac events than those with negative results. The detection of patients with low-risk results on EE should decrease the number of unnecessary repeat invasive coronary angiographic examinations.

Genotoxic effect of heavy metals on Astyanax lacustris in an urban stream.

Uncontrolled urbanization growth contributes to the pollution of aquatic environments. Heavy metals released by domestic and industrial effluents can negatively affect aquatic organisms. This study aimed to evaluate the effect of environmental pollutants, such as metals, on fish DNA damage, in stretches of an urban stream. Specimens of the Neotropical fish, Astyanax lacustris, were exposed in situ for 96 h along the Antas stream, a Brazilian aquatic system deteriorated by anthropogenic factors. Water and sediment samples were collected simultaneously for physicochemical and heavy metal analyses. The comet assay was performed as a biomarker of genotoxicity. Fish located downstream had a higher frequency of DNA damage than in the reference site. We found concentrations of Cr and Ni above acceptable levels in sediment samples. Generally, Ba, Mn, Mg, Zn, Cr, and Ni were the elements most associated with genotoxic damage. Water and sediment of the Antas stream showed genotoxic potential in A. lacustris according to the urbanization gradient, demonstrating the importance to prevent the release of environmental pollutants, especially heavy metals in urban areas.

Tricuspid Prosthesis Malfunction Unmasked By Exercise Stress Echocardiography.

Exercise echocardiography is used mainly in the study of patients with coronary artery disease, however the technique is increasingly used in the study of other pathologies. We present the first case of use of exercise stress echocardiography for clinical decision in one patient with biological prostheses in tricuspid position. The clinical exam, the echocardiogram, the cardiac MRI, the NT proBNP were normal and the patient has been considered to have no indication for surgery. The patient was only presented and accepted for surgery after the results of exercise stress echocardiography.

A pregnant woman with a mechanical prosthetic valve.

A 24-year-old woman who was 11 weeks pregnant and had a mechanical mitral valve presented at the emergency department with ischemic stroke. Although treatment with aspirin and unfractionated heparin was initially successful, subsequent management was almost impossible, as she eventually suffered a right hemispheric stroke, requiring percutaneous intervention and an emergency cesarian; prosthetic valve thrombosis with hemodynamic instability; and multiple bleeding complications. This case demonstrates how difficult it can be to select the appropriate treatment strategy for prosthetic valve thrombosis.

Aggregatibacter aphrophilus aortic valve infective endocarditis / Endocarditis infecciosa en válvula aórtica por Aggregatibacter aphrophilus

Nowadays, infective endocarditis remains a major cause of morbidity and mortality worldwide and there are concerns related to the increased number of infections associated with virulent agents and medical procedures. We present a case of a homeless man with unknown medical history, admitted for lumbar pain who became confused, hypotensive and tachy cardic, evolving to severe sepsis. His initial investigation was also suggestive of acute myocardial infarction but the transthoracic echocardiogram revealed massive aortic valve vegetation with perivalvular abscess leading to severe aortic regurgitation. The patient died with the final diagnosis of infective endocarditis. Later on the blood cultures was identified Aggregatibacter aphrophilus, an HACEK group agent. This case confirms that, albeit the general favorable outcomes, there are cases of serious infections, especially if the diagnosis and treatment were late.

Hoy día, la endocarditis infecciosa continúa siendo una causa importante de mor-bimortalidad en todo el mundo y es preocupante el aumento del número de infecciones asociadas con agentes virulentos y procedimientos médicos. Presentamos el caso de un indigente con antecedentes médicos desconocidos, ingresado por dolor lumbar, que comenzó a sentirse confuso, hipotenso y taquicárdico. Poco después de su ingreso su estado evolucionó a septicemia grave. Los resultados de las pruebas iniciales también eran indicativos de infarto agudo de miocardio, pero el ecocardiograma transtorácico reveló una vegetación masiva en la válvula aórtica con absceso perivalvular condicionando regurgitación aórtica grave. El paciente murió, con el diagnóstico definitivo de endocarditis infecciosa. Más tarde, en los hemocultivos se identificó Aggregatibacter aphrophilus, un microorganismo del grupo HACEK. Este caso confirma que, a pesar de los resultados favorables en general, hay casos de infecciones graves, sobre todo si el diagnóstico y el tratamiento fueron tardíos.

Prognostic role of stress echocardiography in hypertrophic cardiomyopathy: The International Stress Echo Registry.

BACKGROUND: Stress echo (SE) may have a role in the outcome in patients with hypertrophic cardiomyopathy (HCM). OBJECTIVES: The aim was to assess the prognostic value of SE in a retrospective multicenter study in HCM. METHODS: We enrolled 706 HCM patients. The employed stress was exercise (n=608) and/or vasodilator (n=146, dipyridamole in 98 and adenosine in 48). We defined SE positivity according to clinical/hemodynamic criteria including: symptoms (all stress modalities), exercise-induced hypotension (failure to increase or fall >20mmHg, exercise) and exercise-induced left ventricular outflow tract obstruction (left ventricular outflow tract obstruction >50mmHg); and ischemic criteria, such as new wall motion abnormalities (new wall motion abnormality) and/or reduction of coronary flow reserve velocity (CFVR≤2.0) on left anterior descending coronary artery with vasodilator stress assessed in 116 patients. All patients completed the clinical follow-up. RESULTS: Positive SE showed more frequently CFVR reduction, exercise-induced hypotension, left ventricular outflow tract obstruction, and symptoms (38, 23, 20 and 15% respectively), but new wall motion abnormality only in 6%. During a median follow-up of 49months 180 events were observed, including 40 deaths. Clinical/hemodynamic criteria did not predict outcome (X2 0.599, p=0.598), whereas ischemia-related SE criteria (X2: 111.120, p<0.0001) was significantly related to outcome. Similarly, mortality was predicted with SE ischemic-criteria (X2 16.645, p<0.0001). CONCLUSIONS: SE has an important prognostic significance in HCM patients, with ischemia-related end-points showing greater predictive accuracy than hemodynamic endpoints. New wall motion abnormalities and impairment of CFVR should be specifically included in SE protocols for HCM.