Diagnostic Imaging – ABC CARDIOL

IJCS

Original Article

Echocardiogram in Critically ill Patients with COVID-19: ECOVID Study

Bruno Ferraz de Oliveira Gomes et al. Armando Luis Cantisano Iliana Regina Ribeiro Menezes Anny de Sousa Azevedo … Thiago Moreira Bastos da Silva Valdilene Lima Silva Giovanni Possamai Dutra Suzanna Andressa Morais de Paula Barbara Ferreira da Silva Mendes Plinio Resende do Carmo Junior Basilio de Bragança Pereira Joao Luiz Fernandes Petriz Glaucia Maria Moraes de Oliveira

Abstract

Background

Literature is scarce on echocardiographic characteristics of COVID-19 patients admitted to the intensive care unit (ICU).

Objectives

To describe echocardiographic characteristics of ICU COVID-19 patients and associate them with clinical signals/symptoms, laboratory findings and outcomes.

Methods

Patients with RT-PCR-confirmed COVID-19, admitted to the ICU, who underwent echocardiography were included. Clinical characteristics associated with an abnormal echocardiogram (systolic ventricular dysfunction of any degree — left and/or right ventricle — and/or high filling pressures and/or moderate to severe pericardial effusion) were analyzed. Groups were compared using the Student’s t-test, chi-square, and logistic regression. A p < 0.05 was considered statistically significant.

Results

A total of 140 patients met inclusion criteria, and 74 (52.9%) had an abnormal echocardiogram. A low number of left and right ventricular systolic dysfunction was observed, and 35% of the population had a normal diastolic function. In the univariate analysis, characteristics associated with abnormal echocardiogram were age, chronic kidney disease, elevated troponin, previous heart failure, and simplified acute physiology score 3 (SAPS 3). In the regression model, troponin and SAPS3 score were independent markers of abnormal echocardiogram. An abnormal echocardiogram was associated with a higher prevalence of in-hospital death (RR 2.10; 95% CI 1.04-4.24) and orotracheal intubation (RR 2.3; 95% CI 1.14-4.78).

Conclusions

COVID-19 has little effect on ventricular function, but it is common to find increased filling pressures. Elevated serum troponin level and SAPS3 score were the independent markers of an abnormal echocardiogram. In addition, the prevalence of in-hospital death and need for mechanical ventilation were higher in patients with abnormal echocardiogram.

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Case Report

First-degree Atrioventricular Block as an Early Marker of Advanced Disease of the Conduction System in a Patient with Hereditary Val142Ile Cardiac Amyloidosis

Nágela S. V. Nunes et al. Evandro Tinoco Mesquita Claudio Tinoco Mesquita Paulo Roberto Benchimol-Barbosa

Introduction

Cardiac amyloidosis (CA) is a type of restrictive cardiomyopathy secondary to amyloid infiltration in the heart. The most common clinical forms are immunoglobulin light chain amyloidosis (AL) and amyloidosis resulting from amyloid deposits secondary to the destabilization of the protein tetramer transthyretin (ATTR), which is divided into two types: the hereditary form (ATTRm) and the wild type (ATTRwt).

Cardiac impulse conduction disorders and atrial arrhythmias are more frequent in ATTR than in the AL form, and this seems to reflect the longer survival of patients affected by ATTR, given that the AL form manifests with high mortality up to 6 months from diagnosis, because conduction system disease appears to be a later manifestation.

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Case Report

Cardiac Magnetic Resonance and Positron Emission Tomography in the Diagnosis and Follow-Up of Acute Rheumatic Fever – Case Report

David Salazar et al. Cristhian Espinoza Romero Mariana Pezzute Lopes Carlos Eduardo de Barros Branco … José Soares Junior Antonio de Santis Roney Orismar Sampaio Flávio Tarasoutchi

Introduction

Rheumatic fever (RF) is a prevalent condition in developing countries, accounting for a cardiac mortality of rate 7.9% in Brazil (DATASUS). Cases of rheumatic fever are often underdiagnosed and recognized only after permanent valve damage due to previous carditis. Secondary prevention of RF aims to limit the development and/or progression of valvular lesions and their complications. However, even on therapy with benzathine penicillin every 21 days, patients may experience recurrence of acute RF, making diagnosis a greater challenge. The development of new diagnostic methods can contribute to the early detection of rheumatic carditis (RC) considering that 90% of cases are subclinical. In addition, not only the usual gallium-67 scintigraphy, but also, tests such as cardiac nuclear magnetic resonance imaging (MRI) and positron emission tomography (PET-CT) may have the potential to be diagnostic tools in acute rheumatic carditis. However, more studies are needed to validate these methods.^,

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Case Report

Kounis Syndrome: Case Report in Goiânia/BR

Marília Pereira et al. Gabriela Lima Vieitas Anna Ilona Hunkar Freitas Karoly Gyula Olivas Hunkar

Abstract

22-year-old male patient with no heart disease, who was given an ambulatory medication with analgesics due to an acute renal crisis. After the drug administration, the patient presented dyspnea, cyanosis, and hemoptysis. There was suspicion of anaphylactic shock, which was treated, but there was no improvement in the clinical condition. The patient was referred to the Intensive Care Unit, where tests were performed showing elevated cardiac enzymes and Immunoglobulin E and Computed Tomography of Thoracic revealed alveolar hemorrhage. He developed clinical worsening and died after sepsis. The final diagnosis was of kounis syndrome due to the hypersensitivity reaction to the analgesics introduced in the patient, generating an acute coronary syndrome (ACS). The purpose of this case report was to highlight a syndrome that is little reported because it is not part of the differential diagnosis routines of ACS, but it generates important complications.

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Review Article

Nuclear Medicine Methods for Assessment of Chronic Chagas Heart Disease

Marcus Vinicius Simões et al. Denise Mayumi Tanaka José Antonio Marin-Neto

Abstract

Several different imaging methods can be used to evaluate patients with Chagas heart disease (CHD) for diagnostic and prognostic purposes, including plain chest radiography; echocardiography; myocardial perfusion scintigraphy, for detection of ischemia and fibrosis; radionuclide gated-angiography, for evaluation of biventricular function; ¹²³I-MIBG labeling of sympathetic myocardial innervation; MRI, for detection and quantitation of myocardial fibrosis; and coronary angiography. This study aims to review the contributions of these nuclear medicine methods to understanding of the pathophysiology of chronic Chagas cardiomyopathy (CCC). Careful analysis and integration of findings provided by these imaging methods in patients with CCC at different stages has contributed significantly to improving understanding of several peculiarities of the disease. Clinical and experimental studies in animal models show that perfusion abnormalities detected in association with dysfunctional but viable myocardium are a common finding in CCC patients and correspond to areas of cardiac sympathetic denervation, as assessed by ¹²³I-MIBG imaging. Furthermore, recent reports have demonstrated a close relationship between coronary microvascular disturbances and myocardial inflammation. Thus, ongoing research, mainly focused on refinements of ¹⁸F-FDF -PET techniques and further exploration of nuclear methods, such as SPECT, have the potential to contribute to detection and monitoring of early subclinical myocardial damage thereby enabling evaluation of therapeutic strategies targeting inflammation and microvascular ischemia that could result in better prognostic stratification of patients with CHD.

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Editorial

After a STEMI, is Less Sugar more Protective to Myocardium?

Rafael Willain Lopes et al. Alexandre Hohl

The infarct size reduction in acute myocardial infarction (AMI) has been studied for more than 50 years. Animal experiments were conducted in the 1970s, followed by the first clinical studies to reduce infarct size (IS), with fibrinolytic agents or with mechanical coronary angioplasty (PTCA). The clinical experience of coronary reperfusion indicated that left ventricle function was not normalized in 30% of the patients, and despite unblocking the epicardial vessel, demonstrated hemodynamically, there was no equivalent in myocardial perfusion. New concepts emerged such as reperfusion injury, microvascular dysfunction, “no-reflow” phenomenon, and stunned and hibernating myocardium, which became the focus of basic research and clinical investigation. To improve characterization, different technologies were used, such as contrast echocardiography, isotopic studies, including positron emission tomography, and magnetic resonance.

Cardioprotection (CP) aims to reduce IS and improve clinical outcomes. The translation of CP from preclinical and promising proof-of-concept studies to clinical benefit (CB) for patients has been quite unsatisfactory. Almost all these studies that did not translate into CB had infarct size reduction as the primary endpoint and used protocols selected to achieve IS reduction.

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Review Article

The Role of 18F-FDG PET/CT in Cardiac Sarcoidosis

Christiane Wiefels et al. Olabimpe Lamai Riina Kandolin David Birnie … Eugene Leung Claudio Tinoco Mesquita Rob Beanlands

Introduction

Systemic sarcoidosis (SS) was first described more than a century ago by the Norwegian dermatologist Caesar Boeck. He correlated skin nodules with epithelioid cells with large nuclei and giant cells as “multiple benign sarcoid of the skin”, for their resemblance with sarcoma. Today, the cause of the disease remains unknown, but evidence points toward immunological response to an unidentified antigenic trigger in individuals with genetic susceptibility. The estimation of the prevalence of SS in the population varies in the literature also depending on the type of study: epidemiologic, autopsy or imaging.

Some previous data showed prevalence as high as 100-330 cases per 100,000 inhabitants.^, Environmental factors have been attributed to those differences, including sex, age and ethnicity, showing a predisposition for environmental and genetic factors. The reported incidence is similar across sex in North American population but greater in females in Scandinavian and Japanese populations,^, but more likely to be chronic and fatal in black Americans. The disease usually develops before the age of 50 years, with a peak incidence at 20 to 39 years old,^, and is very uncommon under the age or 15 or older than 70. Symptomatic cardiac sarcoidosis (CS) has been reported in 2-5% of the patients with the systemic form.^– However, with the advance of new cardiac imaging techniques, cases of asymptomatic (clinically silent) cardiac involvement have been diagnosed. The disease has been reported in at least 20% of the autopsies and imaging report in the United States to as much as 50% in Japan.^,

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Case Report

Isolated Non-Compacted Myocardium: Should We Consider the Presence of Extrasystoles as the Initial Manifestation?

Erivelton Alessandro do Nascimento et al. Raphaella Nagib Carvalho Santos Fernanda Fraga Tolomelli Dutra Maria Gabriela Inocente Vitório

Abstract

Ventricular non-compaction occurs due to failure in myocardial morphogenesis during the fetal period. Patients can have heart failure, as well as systemic complications due to thromboembolism and cardiac arrhythmias. Early diagnosis is essential. We present the case of an asymptomatic 49-year-old woman who initially manifested ventricular extrasystoles and heart failure with reduced ejection fraction and a myocardial noncompaction diagnosis.

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Original Article

Evaluation of Galectin-3 and Myocardial Fibrosis in Patients with Hypertrophic Cardiomyopathy

Murillo de Oliveira Antunes et al. Edmundo Arteaga-Fernández Fabio Fernandes Carla David Soffiatti … Paula de Cássia Buck Ester Cerdeira Sabino Carlos Henrique Valente Moreira Charles Mady

Abstract

Background:

Galectin-3 is the designation given to the protein that binds to ß-galactosides, expressed by activated macrophages and described as a cardiac fibrosis mediator. In hypertrophic cardiomyopathy (HCM), myocardial fibrosis is an independent predictor of adverse outcome; however, the association between Galectin-3 and myocardial fibrosis has not been studied in this cardiopathy.

Objective:

To evaluate the association of Galectin-3 and the presence of myocardial fibrosis in a patient with hypertrophic cardiomyopathy.

Methods:

Galectin-3 was measured in automated equipment using the Elisa technique in 100 participants divided into two groups: 50 patients with hypertrophic cardiomyopathy and 50 healthy control subjects. All patients with hypertrophic cardiomyopathy underwent magnetic nuclear resonance with the late enhancement technique to investigate myocardial fibrosis. For the statistical analysis, p values < 0.05 were considered statistically significant.

Results:

Galectin-3 levels were low and did not show significant differences between patients with hypertrophic cardiomyopathy and the control group, 10.3 ± 3.1 ng/dL and 11.3 ± 2.6 ng/dL (p = 0.12) respectively. Myocardial fibrosis was a common finding and was identified in 84% (42/50) of patients with HCM, but no differences were observed between Galectin-3 levels when comparing patients with and without fibrosis, 10.3 ± 2.4 ng/dL and 10.1 ± 2.1 ng/dL (p = 0.59).

Conclusion:

The results did not show an association between Galectin-3 and myocardial fibrosis in patients with hypertrophic cardiomyopathy, suggesting that non-inflammatory mechanisms of myocardial fibrosis formation and cardiac remodeling are involved in this cardiopathy.

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Viewpoint

Remoras and Spontaneous Echocardiographic Contrast

Charles André

Abstract

The term “Remora” (hindrance) – re (again)/mora (delay) -originally designated a family of fishes – the suckerfishes. In ancient Greece and Rome and up to the early 19^th century, these fishes were believed to slow down ships by attaching to them. Medicine adopted the term “remora” to describe fluid/blood stasis. Intracardiac blood stasis, or remora, especially in the left atrial appendage, is associated with thrombogenesis and responsible for cardioembolic phenomena. The slow and swirling movement of blood causes the appearance of spontaneous echocardiographic contrast (SEC). I briefly narrate the Naval Battle of Actium, whose result was mythically attributed to the remora fishes, and make a short review of remoras. I also describe Laennec’s discussion about intracardiac blood stasis and give a short account of SEC, its original descriptions and importance.

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