Echocardiographic features of pre- and postcapillary pulmonary hypertension with a focus on the right ventricle in dogs / Características ecocardiográficas da hipertensão pulmonar pré e pós-capilar em cães com foco no ventrículo direito

Pulmonary hypertension (PH) in dogs is a syndrome that can occur secondary to several causes, including left heart disease (postcapillary) and chronic respiratory disease (precapillary). This study evaluates morphological and functional consequences in the right ventricle (RV) of dogs with pre- and postcapillary PH through echocardiography, and also considers the severity of PH (mild, moderate or severe). Echocardiography was performed on 66 dogs of various breeds and weights (age >3 years old) which were assigned to three groups: postcapillary PH, which included mitral valve disease/endocardiosis, precapillary PH, which included chronic respiratory diseases (bronchitis, collapse of the trachea and primary lung cancer or metastasis), and finally, a healthy group of controls. The parameters for RV morphology were RV1, RV2, and RV3 for systole and diastole. The following measurements were used to assess RV systolic function: tricuspid annular plane systolic excursion (TAPSE), TAPSE:Ao (aorta), maximum velocity of the tricuspid systolic wave obtained by tissue Doppler (S'), S':Ao, right ventricle end-diastolic area (RVEDA); RVEDA:BSA (body surface area); flow velocity integral (FVI) and FVI:Ao. The variables were assessed using ANOVA. The results showed that RV3d, RV1s, S':Ao, S', and FVI were able to distinguish cases of pre- and postcapillary PH in this study. Remodeling of the RV of dogs with PH was observed, which can be influenced by the pre- or postcapillary origin of the PH, with dilation in dogs with postcapillary PH and severe PH. The results for RV systolic function were similar, with FVI and FVI:Ao showing that RV ejection function is reduced in dogs with postcapillary PH and with severe PH.(AU)

A hipertensão pulmonar (HP) em cães é uma síndrome que pode ocorrer secundária às diversas causas, dentre elas, a doença cardíaca esquerda (pós-capilar) e a doença respiratória crônica (pré-capilar). Essa é uma condição importante que motivou os objetivos do estudo: avaliar ecocardiograficamente as consequências morfológicas e funcionais no ventrículo direito (VD) dos cães acometidos com HP pré- e pós-capilar, considerando também o estágio de severidade da HP (leve, moderada ou severa). A ecocardiografia foi realizada em 66 cães de diversas raças e pesos, com pelo menos quatro anos de idade, que compuseram um grupo com doença valvar mitral, ou endocardiose, outro com doença respiratória crônica (bronquite, colapso de traqueia e neoplasia pulmonar primária ou metástase), e por último, um grupo saudável. Os parâmetros para a morfologia do VD foram RV1, RV2 e RV3 na sístole e na diástole. Para a avaliação da função sistólica do VD foram mensurados: excursão sistólica do plano anular tricúspide (TAPSE), TAPSE:Ao (aorta), velocidade máxima da onda sistólica da tricúspide obtida pelo doppler tecidual (S'), S':Ao, área do ventrículo direito no final da diástole (RVEDA); RVEDA:BSA (body superficie area); integral tempo velocidade (FVI) e FVI:Ao. As variáveis foram avaliadas por meio da ANOVA. Os resultados mostraram que RV3d, RV1s, S':Ao, S' e FVI foram capazes de distinguir casos de HP pré e pós-capilar neste estudo. Observou-se que há remodelamento do VD de cães com HP e este pode ser influenciado pela origem pré ou pós-capilar da HP, encontrando-se dilatado em cães com HP pós capilar e com HP severa. Os resultados para a função sistólica do VD foram similares, uma vez que o FVI e FVI:Ao mostraram que a capacidade de ejeção do VD está reduzida nos cães com HP pós-capilar e com HP severa.(AU)

Comparison of 2D versus M-mode echocardiography for assessing fetal myocardial wall thickness.

OBJECTIVE: M-mode and 2D have been proposed for evaluating fetal myocardial thickness. However, studies comparing the performance of both modalities are lacking. We aimed to compare 2D versus M-mode reproducibility for assessing myocardial wall thicknesses. METHODS: A prospective study including 45 healthy fetuses from low-risk pregnancies evaluated between 18 and 41 weeks of gestation. Left and right ventricular free-wall and septal myocardial thicknesses were measured at end-diastole (ED) and end-systole (ES) in transverse 4-chamber view using 2D and M-mode. Intra- and interobserver reproducibility was evaluated by the concordance correlation coefficient (CCC). Both techniques were compared by t-test of the CCC. RESULTS: 2D and M-mode demonstrated excellent and similar intraobserver repeatability, with the best concordance in ES septal thickness (M-mode CCC 0.956 versus 2D-mode CCC 0.914). Interobserver reproducibility demonstrated also a high concordance, optimal in ES left ventricular free wall (M-mode 0.925 versus 2 D 0.855). Comparison of both techniques demonstrated a high concordance in all measurements, except for ED septal thickness with better reproducibility using M-mode (CCC 0.954 versus 0.847, p = .017). CONCLUSIONS: 2D and M-mode can be used in a reproducible manner for measuring fetal myocardial thickness, with a slightly better performance of M-mode for assessing ED septal wall thickness.

Frontal QRS-T angle and World Health Organization classification for body mass index.

BACKGROUND: The frontal QRS-T angle, defined as the absolute value of the difference between QRS axis and T-wave axis on 12­lead electrocardiogram (ECG), is the difference in orientation between ventricular depolarization and repolarization. We tested the hypothesis that QRS-T angle is affected by obesity. METHODS: A total of 177 patients undergoing both ECG and echocardiography within one month were recruited from outpatient clinic. Using the World Health Organization (WHO) classification of body mass index (BMI), the patients were classified into the four groups: underweight (<18.5 kg/m2, n = 25), normal weight (18.5-24.9 kg/m2, n = 79), overweight (25-29.9 kg/m2, n = 38) and obese (≥30 kg/m2, n = 35). RESULTS: Obese patients were significantly younger than those in other groups. As for echocardiographic variables, left ventricular internal dimension and left ventricular mass (LVM) increased with increased WHO classification of BMI. QRS axis and T-wave axis decreased with increased WHO classification of BMI, whereas QRS-T angle increased. Multivariate linear regression analysis showed that BMI (ß = 0.23, p = 0.01) and LVM (ß = 0.19, p = 0.046) were independent determinants of QRS-T angle. CONCLUSIONS: Our results suggest that BMI is an independent determinant of QRS-T angle.

Power of resting echocardiographic measurements to classify pulmonary hypertension patients according to European society of cardiology exercise testing risk stratification cut-offs.

BACKGROUND: Right ventricular function is the major determinant of morbidity and mortality in pulmonary arterial hypertension (PAH). The ESC risk assessment strategy for PAH is based on clinical status, exercise testing, NTproBNP, imaging and haemodynamics but does not include right ventricular function. Our aims were to test the power of resting echocardiographic measurements to classify PAH patients according to ESC exercise testing risk stratification cut-offs and to determine if the classification power of echocardiographic parameters varied in chronic thrombo-embolic pulmonary hypertension (CTEPH). METHODS: We prospectively and consecutively recruited 46 PAH patients and 42 CTEPH patients referred for cardio-pulmonary exercise testing and comprehensive transthoracic echocardiography. Exercise testing parameters analyzed were peak oxygen consumption, percentage of predicted maximal oxygen consumption and the slope of ventilation against carbon dioxide production. Receiver operator characteristic curves were used to determine the optimal diagnostic cut-off values of echocardiographic parameters for classifying the patients in intermediate or high risk category according to exercise testing. RESULTS: Measurements of right ventricular systolic function were the best for classifying in PAH (area under the curve 0.815 to 0.935). Measurements of right ventricular pressure overload (0.810 to 0.909) were optimal for classifying according to exercise testing in CTEPH. Measurements of left ventricular function were of no use in either group. CONCLUSIONS: Measurements of right ventricular systolic function can classify according to exercise testing risk stratification cut-offs in PAH. However, this is not the case in CTEPH where pressure overload, rather than right ventricular function seems to be linked to exercise performance.

An Automated System for Categorizing Transthoracic Echocardiography Indications According to the Echocardiography Appropriate Use Criteria.

The Echocardiography Appropriate Use Criteria (EAUC) are a set of indications for transthoracic echocardiography (TTE) developed to guide physician decision making around ordering of TTE. In this study, an automated rule-based method for processing "indications" listed within TTE reports and classification into one of the major EAUC categories was developed and validated against a clinician-annotated reference standard. The system performed at a comparable level to trained physicians allowing for the automated classification of more than 30,000 TTE indications from a public database in less than ten minutes. The most common indication for TTE was Valvular assessment closely followed by General. Hypertension/Heart Failure/Cardiomyopathy, Acute, and Cardiac Structure assessment each contributed more than ten percent within this patient population. These results suggest potential for automated approaches for tracking appropriate use of TTE, as well as guide the development of systems for prospectively identifying when TTE use is recommended.

Pediatric Echocardiography by Work Relative Value Units: Is Study Complexity Adequately Captured?

BACKGROUND: Present resource-based relative value unit (RVU) assignment for echocardiography is based on Current Procedural Terminology (CPT) codes, which do not incorporate complexity of diagnosis, time spent for image acquisition, or interpretation of echocardiograms. The objective of this study was to determine whether CPT-based RVU assignment accurately reflects physician effort in performing and interpreting pediatric echocardiographic examinations. METHODS: Cardiac complexity category (CCC) and physician time for study interpretation of 123 echocardiograms (June to September 2013) were prospectively assigned. Categories included (1) focused effusion/function evaluation, (2) normal anatomy/focused preterm infant studies, (3) acquired heart disease, (4) congenital heart disease excluding single ventricles, (5) single ventricles including heterotaxy syndrome, and (6) hearts on mechanical support. Subsequently, a random sample of echocardiograms (March to August 2013) were retrospectively analyzed, and each study was assigned a CCC and an extrapolated median interpretation time (MIT) on the basis of prospective data collection. Assigned work RVUs based on CPT codes were recorded. Comparisons were made between CCC and time for study interpretation, work RVUs, number of images acquired, and total scan time. RESULTS: A total of 933 echocardiograms were analyzed: 198 (21%), 174 (19%), 98 (11%), 359 (35%), 84 (9%), and 20 (2%) studies in CCCs 1 to 6, respectively. Total scan time, MIT, number of images, and work RVUs were different among CCCs (P < .0001). However, among the more complex studies (CCCs 2-5), work RVUs were similar, while number of images obtained and MIT were different (P < .001). Correlation analysis showed no association between work RVUs and CCC, total scan, or number of images per study. Compared with older patients, work RVUs of studies in children <2 years of age were lower, while all other markers of study complexity were higher (P < .05). CONCLUSIONS: Current CPT-based assignment of work RVUs does not discriminate study complexity and physician effort. The results of this study highlight the need for a refined system that accurately assesses physician effort in pediatric echocardiography.

Appropriateness use criteria for transthoracic echocardiography: relationship with radiology benefit managers preauthorization determination and comparison of the new (2010) criteria to the original (2007) criteria.

BACKGROUND: In response to growth in cardiac imaging, medical societies have published appropriateness use criteria (AUC) and payers have introduced preauthorization mandates, largely through radiology benefits managers (RBM). The correlation of algorithms used to determine preauthorization with the AUC is unknown. In addition, studies applying the 2007 AUC for transthoracic echocardiography revealed that many echocardiograms could not be classified. We sought to examine the impact of the revised 2010 AUC on appropriateness ratings of transthoracic echocardiograms previously classified by the 2007 AUC and the relationship of preauthorization determination to AUC rating. METHODS: We reclassified indications for transthoracic echocardiography as appropriate, inappropriate, uncertain, or unclassifiable using the 2010 AUC in the same 625 patients previously reported using 2007 AUC. We also evaluated the relationship between preauthorization status by 2 RBM precertification algorithms and appropriateness rating by 2007 AUC. RESULTS: The appropriateness classification of 148 (24%) transthoracic echocardiograms was changed by the updated AUC (P < .001). The number of unclassifiable echocardiograms was markedly reduced from 99 (16%) to 8 (1%), and more echocardiograms were classified as inappropriate (95 [15%] vs 45 [7%]) or uncertain (43 [7%] vs 0 [0%]). Limited correlation between the 2007 AUC rating and RBM preauthorization determinations was noted, with only moderate agreement with RBM no. 1 (90%, κ = 0.480, P < .001) and poor agreement with RBM no. 2 (72%, κ = 0.177, P < .001). CONCLUSION: The updated AUC (2010) provide enhanced clinical value compared with 2007 AUC. There is limited agreement between RBM preauthorization determination and 2007 AUC rating.

Valvoplastia mitral pela técnica de inoue: registro do hospital das clínicas da faculdade de medicina de Ribeirão Preto da universidade de São Paulo / Mitral valvuloplasty with the Inoue ballon technique: registry of patients treated at hospital das clínicas, Ribeirão Preto medical school

Introdução: Apesar da alta prevalência de estenose mitral no Brasil, nota-se impressionante subnotificação dos procedimentos de tratamento percutâneo dessa afecção na literatura nacional. Este artigo tem como objetivo relatar os resultados e a evolução dos pacientes com estenose mitral reumática, tratados pela técnica de Inoue. Métodos: Foram analisados parâmetros clínicos, ecocardiográficos e relacionados ao procedimento de pacientes tratados no período de 1997 a 2009 e acompanhados por pelo menos um mês. Resultados: Foram avaliados 102 pacientes, a maioria do sexo feminino (89,2%), com média de idade de 38,1 + 11,1 anos, dos quais 80,4% estavam em classe funcional II-III. A área valvar média pela ecocardiografia (ECO) era de 1,01 + 0,19 cm2 e pelo cateterismo (CAT), de 0,87 + 0,2 cm2. O escore de Wilkins & Block estava entre 5 e 8 em cerca de 90% dos pacientes e 88,2% estavam em ritmo sinusal. O procedimento alcançou sucesso em 76,5% dos casos, com aumento da área valvar mitral média de 1,9 + 0,5 cm2 pelo ECO (P < 0,001) e de 2 + 0,5 cm2 pelo CAT (P < 0,001). O gradiente médio átrio esquerdo-ventrículo esquerdo reduziu- se de 16,6 mmHg para 4,2 mmHg (P < 0,001). O débito cardíaco aumentou de 3,75 l/min para 4,67 l/min (P < 0,001), sendo um preditor de sucesso para o procedimento. Em 79,4% dos pacientes obteve-se a evolução de um ano, em que 87,6% dos pacientes estavam em classe funcional I e apenas 2 pacientes necessitaram tratamento cirúrgico. Durante o seguimento de cinco anos não foi observado nenhum caso de acidente vascular cerebral ou óbito de causa cardíaca. Conclusões: A valvoplastia mitral por técnica de Inoue para o tratamento da estenose mitral reumática é técnica eficaz a médio prazo, e com baixa taxa de complicações.

Background: Despite the high prevalence of mitral stenosis in Brazil, there is a significant underreporting of percutaneous procedures in the treatment of this disease in the national literature. This study is aimed at reporting the results and course of patients with rheumatic mitral stenosistreated with the Inoue balloon. Methods: Clinical, echocardiographicand procedure-related parameters of patients treated from 1997 to 2009 who were followed-up for at least a month were evaluated. Results: One hundred and two patients were evaluated, most of them females (89.2%), with mean age of 38.1 + 11.1 years, 80.4% were in functional class II-III. Mean mitral valve area obtained by echocardiography (ECHO) was 1.01 + 0.19 cm² and 0.87 + 0.2 cm² byhemodynamic measurements (HEMO). Wilkins & Block score ranged from 5 to 8 in about 90% of the patients and 88.2% of them were in sinus rhythm. The procedure was successful in 76.5% patients with mean mitral valve area increasing to 1.9 + 0.5 cm² as measured by ECHO (P < 0.001) and to2 + 0.5 cm² as calculated by HEMO (P < 0.001). Mean left atrial-left ventricular gradient was reduced from 16.6 mmHgto 4.2 mmHg (P < 0.001). Cardiac output increased from 3.75 L/min to 4.67 L/min (P < 0.001) and this change was a predictor of success. Of 79.4% patients who were followedup for 1 year, 87.6% were in functional class I and only 2 cases required surgical treatment. During the 5-year follow-up there were no cases of stroke or death due to cardiac causes. Conclusions: Mitral valvuloplasty with the Inoue balloon is effective for the treatment of rheumatic mitral stenosis in the medium term and has a low complication rate.

[Comparison of 3 hand-carried ultrasound devices with comprehensive echocardiographic devices in elderly cardiac inpatient examinations].

In order to test the clinical capacity of hand-carried ultrasound (HCU) devices in elderly inpatients with heart disease, chamber sizes of heart structure, ventricular wall thickness and motion abnormality (WMA), mitral valve and tricuspid regurgitation evaluated by HCU devices in 401 elderly inpatients with heart disease were compared with those evaluated by comprehensive echocardiography (CE) devices. As a result, there was no significant difference in measurements of cardiac chamber dimensions or left ventricular ejection fraction between the two techniques. The HCU's WMA detection rate relative to the CE was 92.15%. Their conformable rates for detection of mitral and tricuspid regurgitation was 93% and 91.4% respectively. Therefore, we conclude that HCU is one of the practical modalities for diagnosis and monitoring in elderly inpatients with heart disease.

Tissue harmonic imaging for standard left ventricular measurements: fundamentally flawed?

Tissue harmonic imaging (THI) is a B mode imaging technique that improves echocardiographic image quality by reducing superficial artefact. The modality increases image signal-to-noise ratio at the expense of reduced axial resolution. While the qualitative improvements of harmonic echocardiographic imaging are widely accepted, the degree to which this is translated into improved quantitative measurements and whether THI-derived measurements result in systematic bias continue to be areas of uncertainty. This review examines differences between THI and fundamental imaging-derived measurements from a theoretical, tissue phantom and clinical perspective.

Pitfalls of echocardiographic measurement in tissue harmonic imaging: in vitro and in vivo study.

BACKGROUND: Tissue harmonic imaging (THI) is a useful method for endocardial border detection by transthoracic echocardiography, especially in technically difficult patients, even though accuracy of this method in the echocardiographic measurement is unclear. The purpose of this study is to evaluate the accuracy of echocardiographic measurement by THI in vivo and in vitro. METHODS: In vitro, we measured wall thickness, dimension, and volume of the excised hearts by THI. In 11 patients, we assessed the comparative accuracy of THI and fundamental imaging (FI) in determination of left ventricular (LV) wall thickness, dimension, volume, and ejection fraction. RESULTS: In vitro, thickness measurements by THI overestimated true length, and both volume and dimension measurements by THI underestimated true values. In vivo, LV ejection fraction measurements obtained by THI exhibited excellent correlation and agreement with those obtained by FI. However, LV wall thickness determined by THI was significantly larger than that determined by FI, and the dimensions and volume of LV measured by THI were significantly smaller than those measured by FI. CONCLUSION: Although THI is an excellent imaging technique for determination of LV ejection fraction, echocardiographic measurement by THI underestimates LV dimensions and volume, and overestimates LV wall thickness.

Imaging techniques for diagnosis of infective endocarditis.

With the ability to structurally characterize cardiac manifestations, echocardiography is used for the diagnosis and management of infective endocarditis. In establishing the diagnosis according to the Duke criteria, the findings of endocardial involvement (vegetation, abscess, prosthetic valve dehiscence) or new valvular regurgitation represent "major" diagnostic criteria. As echocardiography cannot reliably differentiate noninfective from infective lesions, however, proper diagnosis lies in correlating echocardiography with clinical findings. The more invasive transesophageal approach provides substantially greater image resolution; this approach should be considered first in the evaluation of patients with higher prior probabilities of endocarditis and those with potential endocardial complications.

Ecografía tridimensional en uroginecología / Dimensional ultrasound in urogynecology

La ecografía 3D permite observar, en tres planos y sistema volumétrico, el suelo pélvico, la uretra, el rabdoesfínter y el cuello vesical. Los estudios existentes muestran una excelente correlación entre los hallazgos 3D de esta nueva tecnología y los estudios de presiones.La ecografía 3D se convertirá, con toda probabilidad, en una nueva y excelente ayuda para el estudio de la disfunción pélvica y la incontinencia urinaria (AU)

Distribution and categorization of echocardiographic measurements in relation to reference limits: the Framingham Heart Study: formulation of a height- and sex-specific classification and its prospective validation.

BACKGROUND: Despite widespread categorization of echocardiographic measurements, there are no standardized guidelines for partitioning values exceeding reference limits. METHODS AND RESULTS: We used regression analyses to develop sex- and height-specific reference limits for cardiac M-mode measurements (left ventricular [LV] mass, LV wall thickness, and LV and left atrial dimensions) in a healthy reference sample (n=1099) from the Framingham Heart Study. We then examined the distribution of measurements in a broad sample (n=4957) and classified the measurements according to increasing deviation from the height- and sex-specific reference limits and the 95th, 98th, and 99th percentile values for the broad sample (categories 0 through 4, respectively). To validate the categorization scheme, we used multivariable proportional-hazards regression to assess the relations of LV mass and LV wall thickness categories to risk of cardiovascular events and the relations of left atrial size to risk of atrial fibrillation. During a mean follow-up period of 7.7 years, 587 subjects developed new cardiovascular disease events, and 166 subjects developed new-onset atrial fibrillation. After adjustment for known risk factors, there was a 1.2- and 1.3-fold risk of cardiovascular disease events per category of LV wall thickness and LV mass, respectively, and a 1.6-fold risk of atrial fibrillation per category of left atrial size. CONCLUSIONS: Using a large community-based study sample, we propose a classification scheme that provides a standardized and validated framework for partitioning echocardiographic measurements. If adopted, the categorization scheme should promote uniformity in describing measurements among echocardiographic laboratories and enhance the comprehensibility of measurements to clinicians.

Endocarditis infecciosa: estado actual / Infective endocarditis: present state

La endocarditis infecciosa es la infección de las estructuras endocárdicas, incluyendo las válvulas cardíacas y el endocardio mural. Es una enfermedad en constante evolución siendo su incidencia y característica afectadas por muchos factores. Se han producido diversos cambios en cuanto a la epidemiología, manifestaciones clínicas y espectro microbiológico. En este artículo, revisamos la literatura recientemente publicada sobre endocarditis infecciosa, básicamente en sus aspectos generales, manifestaciones clínicas, hallazgos de laboratorio, microorganismos causuales incluyendo patógenos inusuales, imágenes, diagnóstico diferencial junto a tratamiento médico y quirúrgico. Presentamos las técnicas actuales de diagnóstico para endocarditis infecciosa considerando los avances en ecocardiografía y cultivos microbiológicos. De igual forma, mostramos las nuevas guías de tratamiento de la endocarditis infecciosa, así como una sección de prevención, pronóstico y complicaciones de esta infección