2020;33(4) – ABC CARDIOL

Case Report

Inverted Takotsubo Versus Acute Myocarditis: the Importance of Cardiac Resonance for Differential Diagnosis

Carina Massariol Belinassi et al. Stella de Souza Carneiro Débora Pereira Galvêas Negri Davi Muzi Rios … Murilo Jardim de Carvalho José Augusto Murad

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Case Report

Left Atrial Myxoma Involving Multisystemic Manifestations in an Eldery Female Patient

Vanessa de Assis Reis et al. Bruno Oliveira Isabella Marcelo Loula Novais de Paula Ana Terra Fonseca Barreto

Abstract

Atrial myxomas may progress asymptomatically or present systemic manifestations. Echocardiography is an effective complementary exam to diagnose such pathology. Cardiac surgery represents the definitive treatment; particularly when performed early, it can avoid tumor growth–related complications. This article reports the case of an elderly high-risk cardiovascular patient admitted with acute ST elevation myocardial infarction in a cardiac unit progressing with cardiogenic shock, which contributed to the low suspicion of cardiac tumor as the initial diagnosis.

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Statement

Position Statement on Indications for Echocardiography in Fetal and Pediatric Cardiology and Congenital Heart Disease of the Adult – 2020

Samira Saady Morhy et al. Silvio Henrique Barberato Alessandro Cavalcanti Lianza Andressa Mussi Soares … Gabriela Nunes Leal Ivan Romero Rivera Marcia Ferreira Alves Barberato Vitor Guerra Zilma Verçosa de Sá Ribeiro Ricardo Pignatelli Carlos Eduardo Rochitte Marcelo Luiz Campos Vieira

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Case Report

Non-Hodgkin’s Lymphoma with Heart Disease as a Rare Cause of Acute Heart Failure: A Case Report

Edielle de Sant’Anna Melo et al. Fernanda Sayuri Oshiro Patrícia Maquinêz Veloso Andréia Sevestrin Terêncio … Gilberto Szarf Maria Eduarda Menezes de Siqueira

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Original Article

Value of Cardiac Magnetic Resonance in the Diagnosis and Prognosis of Patients with Acute Myocardial Infarction with Nonobstructive Coronary Artery Disease (MINOCA)

Márcio Vinícius Lins de Barros et al. Carlos Eduardo Ornelas Maria Helena Albernaz Siqueira Rochelle Coppo Militão … Marcus de Almeida Melo Júnior Sérgio Marcos Ferreira Costa Welber Azevedo Rabello Henrique Patrus Mundim Pena

Abstract

Background

Myocardial infarction is one of the major causes of morbidity and mortality worldwide and 13.2% of patients with acute coronary syndrome have normal or unobstructed coronary arteries, called MINOCA (Myocardial Infarction with Non-Obstructive Coronary Artery). Cardiac magnetic resonance (CMR) is the gold standard for investigating the etiology of acute coronary syndrome. Although MINOCA has a more benign evolution than myocardial infarction due to coronary obstruction, its prognostic factors are not completely elucidated.

Objective

To evaluate prognosis, predictive factors and describe the incidence of major adverse cardiovascular events in patients with MINOCA.

Methods

Prospective cohort through data collection of patients admitted to the emergency department of a tertiary hospital, diagnosed with MINOCA from 2012 to 2019. The mean follow-up was 45 months, the outcomes considered were: death, rehospitalization due to cardiac causes, recurrence of chest pain, myocardial revascularization (MACE).

Results

Of the 179 patients, 52% were male, with a mean standard deviation age of 57.3 ± 15.5 years. A MACE rate of 17.9% was observed during a mean follow-up of 45 ± 21 months. Mortality at the end of follow-up was 3.8%. In the multivariate analysis using the Cox regression model, patients with normal CMR was shown to be a predictor of good prognosis (HR 0.09; 95% CI 0.01 – 0.88; p = 0.04). The Kaplan-Meier curve showed a significant difference (Log Rank x2 = 9.83 p = 0.02) in the prediction of free MACE.

Conclusion

Normal CMR was an independent predictor of good prognosis in this sample and could be useful in the risk stratification of patients with MINOCA.

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Editorial

Left Atrium: Novel Insights and Future Directions

Cristiane de Carvalho Singulane et al. Karima Addetia Roberto Miguel Lang

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Original Article

Echocardiography and Analysis of Subclinical Cardiovascular Diseases in Indigenous People Living in Different Degrees of Urbanization: Project of Atherosclerosis Among Indigenous Populations (Pai)

Pedro Vinícius Amorim de Medeiros Patriota et al. Ana Marice T. Ladeia Juracy Marques Ricardo Khoury … Aldina Barral Alvaro A. Cruz Luis Claudio L. Correia Manoel Barral-Netto Joao A. C. Lima Anderson C. Armstrong

Abstract

Background

The urbanization process impacts the burden of cardiovascular disease (CVD). Indigenous populations can undergo a devastating epidemiological transition.

Objective

The present study aimed to describe the Project of Atherosclerosis among Indigenous Populations (PAI) study protocol for assessing echocardiographic images and subclinical CVD in indigenous populations according to the degree of urbanization and report its preliminary results.

Methods

The PAI is a cross-sectional study that includes volunteers aged 30–70 years among Brazilian indigenous groups exposed to low and advanced stages of urbanization (Fulni-ô and Truká, respectively) and an urban control group. Individuals with known CVD or who were on hemodialysis were excluded. The pilot study began in Fulni-ô territory in September 2016. The participants underwent clinical and laboratory evaluations, electrocardiography, carotid artery ultrasound, and a comprehensive echocardiography protocol including global longitudinal strain (GLS) assessed by speckle tracking. The preliminary results are described by participant sex in univariate analysis.

Results

The pilot study evaluated the protocol used in 55 Fulni-ô individuals (mean age, 48.7 ± 12.0 years; 80% women). Traditional risk factors such as hypertension, diabetes, and dyslipidemia were found in 40%, 36%, and 54% of participants, respectively, without significant statistical differences between the sexes. Tobacco use was extremely prevalent, reported in 91% of participants. Most echocardiographic parameters were within the normal range; however, mean GLS was 17.3 ± 3.4% (p = 0.73 between sexes).

Conclusion

We described the PAI study protocol for assessing subclinical CVD and risk factors in indigenous populations by urbanization stage. Its preliminary results suggest a high prevalence of these factors in the indigenous population exposed to a lower degree of urbanization.

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Editorial

My Approach to Assessing Right Ventricular Strain

Marcela Momesso et al. Cintia Galhardo Tressino Rodrigo Bellio de Mattos Barretto David Le Bihan

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Original Article

Longitudinal Strain and Ischemic Stroke in the Absence of Known Heart Disease

Jeova Cordeiro de Morais Junior et al. Nayane Carolina Pertile Salvioni Dannyl Roosevelt de Vasconcelos Lima Crissvânia Firmino Confessor … Alexsandro Paulo Costa Galdino Junior Lara Sodré Cardoso Antônio Marconi Leandro da Silva Joao Lima Anderson da Costa Armstrong Luis Claudio Lemos Correia

Abstract

Background

Stroke is prevalent worldwide, and early recognition of subclinical cardiovascular (CV) disease could predict a first ischemic stroke (IS) episode. Speckle-tracking echocardiography (STE) allows the detection of early subclinical myocardial dysfunction.

Aim

To examine the association between myocardial deformation, evaluated by STE, and first episode of IS in a sample of otherwise healthy patients.

Methods

We included individuals between 40–80 years old, with a first incidence of IS, with no known CV disease, matched to healthy controls by sex, age, and hypertension at a 1:2 ratio. STE was used to assess LV global longitudinal strain (GLS), and traditional echocardiography was performed. Univariate and multivariable analyses were performed to assess the relationship among stroke, CV risk factors, and echocardiography-derived parameters.

Results

A total of 29 cases and 62 controls were included. The mean age of the patients was 60 ± 12 y/o, and 54% were males. Smoking was more prevalent in cases compared to controls (34% vs. 9%; p = 0.001), and there were no significant differences in the other examined risk factors. Cases had less myocardial deformation compared to controls (GLS: -16.7% ± 3.4% vs. -19.2 ± 2.8%; p < 0.001), and there was no significant difference regarding traditional echocardiography parameters. After adjusting for smoking and hyperlipidemia, GLS maintained an independent association with stroke (OR = 1.3; 95% CI, 1.1–1.6; p = 0.005). The area under the ROC curve for stroke significantly increased after adding GLS to smoking (0.65 to 0.78, p = 0.009).

Conclusion

GLS has a consistent and independent association with a first IS episode in middle-aged adults with generally normal hearts. Therefore, GLS may be a useful risk marker in this population.

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Case Report

Giant Coronary Fistula Between Circumflex Artery and Coronary Sinus: Initial Diagnosis by Echocardiography

Israel Nilton de Almeida Feitosa et al. Maria Rafaela Viana de Sá Jonas Silva Andrade Ana Raquel Avelino Diniz Gonzaga

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Case Report

A Young Patient with Chest Pain: Going Beyond the Obvious

Sebastian Gallo Bernal et al. Azucena Martínez Juan F Vasquez-Rodriguez Nicolás Isaza … Daniel Isaza Camilo A Calixto Claudia Jaimes

Abstract

Background

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is diagnostically and therapeutically challenging for clinicians, as a large spectrum of causes may result in this clinical condition, multiple entities can mimic it, and there are relatively few evidence-based recommendations for its assessment.

Discussion

Accurate diagnosis of the underlying etiology of MINOCA requires a systematic and dynamic evaluation of the clinical history and work-up of each patient, as well as the use of additional diagnostic tools that allow more in-depth characterization of the cardiac anatomy and coronary function, such as cardiac magnetic resonance imaging, coronary vascular imaging (intravascular ultrasound, optical coherence tomography), and coronary functional assessments. The prognosis of MINOCA highly depends on its underlying cause, and therefore, an accurate diagnosis of its etiology is necessary.

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Original Article

Semiautomatic Quantification of Left Ventricular Ejection Fraction and Volumes by Two-Dimensional Echocardiography: Comparison with Automatic Three-Dimensional Echocardiography

Rafael Borsoi et al. Miguel Morita Fernandes da Silva Silvio Henrique Barberato

Abstract

Background

Left ventricular ejection fraction is one of the most used echocardiographic parameters in clinical practice. Its estimation by two-dimensional manual method (Simpson method) has limited reproducibility and accuracy, and semi-automatic methods have been proposed. It becomes necessary to compare the semi-automatic two-dimensional method with more accurate methods of assessing left ventricular ejection fraction, such as measurement by automatic three-dimensional echocardiography.

Objective

To compare the left ventricular ejection fraction, and left ventricular end-diastolic and end-systolic volumes estimates by the semi-automatic two-dimensional method with those obtained using the automatic three-dimensional method.

Method

Observational cross-sectional study, including patients in sinus rhythm, left ventricular ejection fraction > 50% and without significant structural heart disease, submitted to transthoracic echocardiography. Student’s t test, Pearson’s coefficient and Bland-Altman analysis were used in the statistical analysis.

Results

Forty patients were included, 53% women, 35% with arterial hypertension, 25% with dyslipidemia, 10% diabetic, 10% smokers and 13% with previous angioplasty. The mean values of left ventricular ejection fraction by three-dimensional and two-dimensional were 62.1 ± 5.8% and 61.7 ± 5.9% (p = 0.50), respectively. There was a strong correlation between left ventricular ejection fraction determined by two-dimensional and three-dimensional (r = 0.75; p <0.001), as well as with left ventricular end-diastolic (r = 0.75; p <0.001) and end-systolic (r = 0.76; p < 0.001). There was good agreement between two-dimensional and three-dimensional left ventricular ejection fraction (mean difference: -0.39; 95% confidence interval -1.7-0.9).

Conclusion

Left ventricular ejection fraction estimated by the two-dimensional semi-automatic method showed good agreement with the automatic three-dimensional method. The findings suggest the two-dimensional semi-automatic method as a reliable alternative for assessing volumes and left ventricular ejection fraction.

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Editorial

My Approach to Left Ventricular Strain Assessment

Cintia Galhardo Tressino et al. Renato de Aguiar Hortegal Marcela Momesso Rodrigo Bellio de Mattos Barretto David Le Bihan

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Original Article

Analysis of the Safety and Feasibility of Dobutamine Stress Echocardiography in Ten Thousand and Six Tests of a General Population

José Sebastião de Abreu et al. Tereza Cristina Diógenes Pinheiro Marília Esther Benevides de Abreu Ana Gardenia Liberato Ponte Farias Marcia Maria Carneiro

Abstract

Background

Adverse effects and inconclusive results may occur on dobutamine stress echocardiography.

Objective

To assess the safety and feasibility of dobutamine stress echocardiography in a large general population.

Methods

A total of 10,006 dobutamine stress echocardiographies were performed between July 1996 and September 2007. Dobutamine was administered in four stages (10, 20, 30, and 40 μcg·kg^-1·min^-1) to research myocardial ischemia starting with 5 μcg·kg^-1·min^-1 to analyze myocardial viability. Atropine was started according to the protocols used in the period. Clinical, hemodynamic, and adverse effect data associated with dobutamine stress echocardiography findings were verified.

Results

Typical angina (8.9%), hypertensive peak (1.7%), isolated ventricular ectopias (31%), supraventricular tachyarrhythmia (1.89%), atrial fibrillation (0.76%), and non-sustained ventricular tachycardia (0.6%) occurred during dobutamine stress echocardiography. The adverse effects occurred more frequently in patients with positive dobutamine stress echocardiography findings for ischemia than in those with negative findings. Paradoxical sinus deceleration (0.16%) did not occur in cases of positive dobutamine stress echocardiography findings. Three severe complications occurred in cases that tested positive for ischemia on dobutamine stress echocardiography: two (0.02%) of ventricular fibrillation and one of acute coronary syndrome (0.01%). There were no cases of sustained ventricular tachycardia, cardiac rupture, asystole, or death. Compared to those with complete tests, patients with inconclusive results used less atropine (81.5% versus 49.9%, p < 0.001) and more beta-blockers (4.7% versus 19%, p < 0.001) and more commonly presented with a hypertensive peak (1.1% versus 14.2%, p = 0.0001) or non-sustained ventricular tachycardia (0.5% versus 2.2%, p < 0.001).

Conclusion

When properly performed, dobutamine stress echocardiography is safe and has high feasibility.

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Image

Association among Subaortic Membrane, Interventricular Membranous Septal Aneurysm, and Septal Defect

Israel Nilton de Almeida Feitosa

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Editorial

My approach to assess Kawasaki disease by echocardiogram

Andressa Mussi Soares

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Case Report

Giant Left Atrial Myxoma and Mitral Valve Obstruction: a Case Report

Lucas F. Cardoso et al. Elinthon T. Veronese Carlos Manuel de Almeida Brandão Pablo Maria Alberto Pomerantzeff … Carlos E. Rochitte Fabio B. Jatene

Abstract

Myxomas are rare entities that represent the majority of benign cardiac tumors in adults. Their clinical presentation may vary by dimension and location, and they can occur in asymptomatic individuals as an incidental finding of cardiac mass from imaging exams. This article reports the case of a female patient with no known comorbidities who was admitted to the emergency department with acute heart failure. Transthoracic echocardiography revealed a mass in left atrium corresponding to a giant myxoma partially occluding the mitral valve, which required urgent surgical intervention.

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