2022;35(4) – ABC CARDIOL

Case Report

Primary Cardiac Angiosarcoma Evaluated on PET/CT

Pedro Henrique Rodrigues da Silva et al. Carlos Eduardo Lucena Montenegro Maria Eduarda Duarte de Mello Flamini Mariana Vila Nova de Oliveira Pontual Simone Cristina Soares Brandão

Introduction

Cardiac angiosarcoma is a rare malignant endothelial tumor that is aggressive and has an adverse prognosis.^, It features a high mortality rate because of the tendency for local recurrence and high incidence of systemic metastases. Therefore, its early diagnosis is very important, as is the determination of its local and distant extension, to ensure its proper therapeutic management. The objective of this case report was to show the value of positron emission tomography associated with computed tomography with 18-fluorodeoxyglucose (¹⁸F-FDG PET/CT) in the diagnosis and staging of cardiac angiosarcoma.

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Editorial

DIC-SBC Women’s Group

Samira Saady Morhy et al. Marly Uellendahl

The first meeting of the DIC-SBC Women’s Group was held at the 11^th Conference of the Department of Cardiovascular Imaging (DIC) of the Brazilian Society of Cardiology (Sociedade Brasileira de Cardiologia [SBC], in São Paulo, August 28–31, 2022.

This meeting aimed to organize a work group to encourage and develop greater participation of female DIC members, speakers in scientific activities, guideline authors, and members of the Board of Directors.

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Original Article

Global Longitudinal Strain as Predictor of Chemotherapy-Induced Cardiotoxicity

Monica Samuel Avila et al. Marco Stephan Lofrano Alves Silvia Moreira Ayub-Ferreira Mauro Rogerio de Barros Wanderley Junior … Fatima das Dores Cruz Sara Michelly Gonçalves Brandão Ludhmila Abrahão Hajjar Roberto Kalil Filho Cecilia Beatriz Bittencourt Viana Cruz Maria Cristina Abduch Danilo Bora Moleta Edimar Alcides Bocchi

Abstract

Background

Chemotherapy-induced cardiotoxicity (ChC) is an important complication among patients receiving anthracyclines. Biomarkers and imaging parameters have been studied for their ability to identify patients at risk of developing ChC. Left ventricular global longitudinal strain (LV-GLS) is a sensitive parameter for detecting systolic dysfunction despite the presence of preserved left ventricular ejection fraction (LVEF).

Objective

To evaluate the role of the LV-GLS as a predictor of ChC.

Methods

This was a post-hoc analysis of the Carvedilol for Prevention of Chemotherapy-Related Cardiotoxicity trial, which evaluated the primary prevention of cardiotoxicity with carvedilol during doxorubicin chemotherapy in a population of patients with breast cancer. Cardiotoxicity was defined as a reduction ≥10% in LVEF. LV-GLS was determined before chemotherapy in patients with no prior cardiovascular disease or echocardiogram abnormalities.

Results

Thirty-one patients for whom a complete echocardiography study including measurement of LV-GLS was performed before chemotherapy were included in this analysis. An absolute LV-GLS<16.9% before chemotherapy showed 100% sensitivity and 73% specificity for predicting cardiotoxicity (area under the curve [AUC], 0.85; 95% confidence interval [CI], 0.680–0.959; p<0.001). In this population, LVEF values before chemotherapy did not predict ChC (95% CI, 0.478 to -0.842; p=0.17). The association of low LV-GLS (17 pg/mL) at 2 months after chemotherapy increased the accuracy for detecting early-onset ChC (100% sensitivity, 88% specificity; AUC, 0.94; 95% CI, 0.781–0.995; p<0.0001).

Conclusions

Our data suggest that LV-GLS is a potential predictor of ChC. Larger studies are needed to confirm its clinical relevance in this clinical setting.

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Case Report

Apical Occupation by Endomyocardiofibrosis Associated with Thrombus Diagnosed with Contrast Echocardiography and Resolved with Clinical Treatment

André Timóteo Sapalo et al. Rodolpho Cunha Luis Gustavo Gali Minna Moreira Dias Romano

Abstract

Endomyocardial fibrosis (EMF) is a neglected but prevalent disease in underdeveloped countries. Despite its frequency, it is still considered a rare disease. It is marked by the following findings: architectural distortion, ventricular filling changes, and segmental mobility changes affecting not only diastolic and systolic dynamics but also heart valve function. Apical thrombi can be formed in more advanced disease. In this case report, we revisit EMF and present the challenging case of a 52-year-old woman with New York Heart Association (NYHA) functional classification (FC) IV heart failure. Resting electrocardiography revealed sinus rhythm with left ventricular (LV) overload, high voltage vectors, rectified ST-segment depression, and a negative T-wave in the anterolateral region compatible with the strain pattern. The evaluation of echocardiographic images showed marked left atrial dilation, no ventricular dilatation, and hyper-refringent apical occupation within the LV suggestive of a large sessile thrombus superimposed on the endocardial fibrous layer. Although surgery is the most supported approach in the literature in such situations, this patient was treated with oral anticoagulants (OAC) for 1 month and 24 days. The patient progressed well with an improved NYHA FC. Endocavitary contrast echocardiography performed 2 months after OAC initiation showed regression of the apical thrombus image.

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Original Article

Increased Wasted Myocardial Work as an Indicator of Significant Coronary Lesion

Márcio Mendes Pereira et al. Amanda Castro Barroso Marco Túlio Hercos Juliano Márcio Mesquita Barbosa … Gustavo Travassos Gama Rodrigo de Jesus Louzeiro Melo José Bonifácio Barbosa Carlos Alberto Vieira Gama José Xavier de Melo Filho Auridesio Cutrim de Araujo

Abstract

Introduction

The assessment of global myocardial work indices under baseline conditions may be useful for the clinical stratification of patients with suspected coronary obstruction.

Objective

To correlate the value of global myocardial work indices and the presence of significant obstructive coronary lesions.

Method

Cross-sectional study, with patients referred for elective coronary angiography. An echocardiogram was performed to obtain measurements to calculate the value of myocardial work and evaluated the presence or presence of significant obstructive coronary lesions at coronary angiography.

Results

The sample consisted of 30 patients, with a mean age of 64.2±12.8 years, the majority being male (63.3%), of which 68.4% had significant obstructive coronary lesions. The global myocardial work indices was 1,876mmHg%±253.8 in the group with significant obstructive coronary lesions and 2,054.2mmHg%±417.3 in those without significant lesions (p=0.089). Global constructive myocardial work in patients without significant obstructive coronary lesions was higher (2,329.3mmHg%±462.9) than in those with significant obstructive coronary lesions (2,109.5mmHg%±332.3; p=0.064). Global wasted myocardial work was higher in patients with significant obstructive coronary lesions (103.7mmHg%±47.1 versus 68.3mmHg%±33.8; p=0.038). The cutoff point of 115 mmHg% was the one with the best area under the curve (0.625), with a sensitivity of 83.3%.

Conclusion

The increase in global wasted myocardial work correlated with the presence of significant obstructive coronary lesions in our sample.

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Review Article

Hypertrophic Cardiomyopathy: A Review Using Magnetic Resonance Imaging

Raul Serra Valério et al. Marcio Sommer Bittencourt Marly M. Uellendahl

Abstract

Hypertrophic cardiomyopathy, the most common genetic cardiopathy in the general population, is characterized by asymmetric left ventricular hypertrophy. However, the phenotypic changes in this cardiomyopathy extend beyond ventricular hypertrophy and include changes in the mitral valve apparatus, papillary muscles, and right ventricle. Due to the difficult differential diagnosis among multiple causes of hypertrophy, cardiac magnetic resonance has played a fundamental role in its diagnostic and prognostic evaluation; magnetic cine-resonance in defining the location and extent of hypertrophy; late enhancement, in the detection of areas of myocardial fibrosis; more recent techniques such as T1 mapping that assesses interstitial fibrosis and extracellular volume; and finally tissue tracking in the analysis of myocardial deformation.

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Review Article

My Approach to Contrast Echocardiography

Miguel Osman Dias Aguiar et al. Alessandra Joslin Oliveira Carolina Stangenhaus Wilson Mathias Junior

Introduction

Contrast echocardiography (CE) uses ultrasound enhancing agents (UEA) that, when introduced into the bloodstream and subjected to ultrasound (US), contrast the blood due to the great reflective capacity of microbubbles. It completely opacifies the left ventricle (LV), with better definition of endocardial borders, Doppler signal enhancement, and myocardial perfusion (MP).

Commercially available second-generation UEA are composed of high molecular weight gases surrounded by an outer shell of albumin, phospholipid, or polymer. These inert structures aggregate and remain within the intravascular space, presenting kinetics similar to those of red blood cells but at less than half their size (1.0–4.5 µm), which allows them to pass the pulmonary capillary barrier and reach the left chambers. They are predominantly excreted through the lungs, have a high metabolism (half-life, 10–12 min), do not deposit in the tissues, and, unlike iodinated contrast agents, present no known risk factors of nephrotoxicity.^,

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Editorial

Difficulty Introducing Contrast Echocardiography in Daily Clinical Practice in South America: A Matter of Economy?

Ricardo Ronderos

Contrast echocardiography has shown invaluable utility in the clinical setting during the last 20 years. Most studies have demonstrated its successful application in different clinical scenarios. Ultrasound contrast agents (UCA) have evolved incredibly since their first-generation iterations at the end of the last century. From weak and short-term duration agents like Levovist™ to the development of fluorocarbons with simple storage requirements like Definity™ and Sonovue™, significant improvements have been achieved and the logistics in echocardiography labs became easier. Nevertheless, their clinical application did not increase as expected, especially in South America.

To analyze this fact, we must consider the probability of a new diagnostic technique becoming a regular and widespread diagnostic tool. A new diagnostic technique should be superior to its predecessors and available in different clinical scenarios; feature simple instrumentation, simple interpretation, well-defined normal patterns; be attractive and comprehensive in terms of image quality; and be cost-effective to ensure acceptance by health system financiers.^, ()

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Case Report

Percutaneous Closure of Multiple Atrial Septal Defects with Hemodynamic Repercussions: Report of Two Cases in First-Degree Related Adult Patients

Débora Freire Ribeiro Rocha et al. Henrique Lima Guimarães Maurício Prudente Lopes João Batista Masson Silva Giulliano Gardenghi

Introduction

Atrial septal defects (ASD) account for 7–10% of congenital heart anomalies.^, ASD are classified as three anatomical types: ostium secundum (OS) (70% of cases), ostium primum (15–20% of cases), and sinus venosus (5–10% of cases) defects. OS involves the fossa ovalis region and results from poor embryological development of septum secundum or excessive absorption of septum primum resulting in the lack of a septum in the fossa ovalis.

Affected patients are usually asymptomatic. Exercise intolerance in the form of dyspnea or fatigue is the most common initial presentation. Echocardiography is a fundamental tool in the diagnosis and management of patients with ASD. Transthoracic echocardiography (TTE) identifies ASD type and size, shunt direction, and the presence of anomalous sinus venous drainage. Three-dimensional transesophageal echocardiography (3DTEE) details the morphology and anatomical relationships of the atrial septum, providing fundamental information for choosing treatment.^,

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Review Article

My Approach to Assess Diastolic Function in the Presence of Atrial Fibrillation?

Antonio Amador Calvilho Júnior et al. João Moron Saes Braga Jorge Eduardo Assef Andrea de Andrade Vilela

Introduction

Atrial fibrillation (AF) is a prevalent arrhythmia that can occur alone or in combination with other clinical conditions. Its onset interferes both in common diagnostic algorithms and in their respective protocol procedures. In diastolic function assessments by echocardiography, it drastically changes the analysis sequence. This relationship becomes even more complex because diastolic dysfunction is onc cause of non-valvular AF.

A group of conditions called “special populations” or “situations” in diastology also modify study algorithms, especially but not exclusively sinus tachycardia, hypertrophic cardiomyopathy, restrictive cardiomyopathy, non-cardiac pulmonary hypertension, mitral stenosis, mitral regurgitation, greater than mild mitral annulus calcification, heart transplantation, and constrictive pericarditis.^–

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Review Article

My Approach to the Echocardiographic Assessment of a Pediatric Patient with Cancer

Claudia Cosentino Gallafrio et al. Ricardo H. Pignatelli

What is the importance of cardiovascular assessments in pediatric patients with cancer?

Pediatric oncology has greatly progressed in recent decades due to the development of more effective treatment protocols; in fact, 5-year disease-free survival rates now exceed 80%. However, despite improved survival rates, the cardiovascular risks arising from these therapies are 5- to 6-fold greater in long-term surviving oncology patients than the general pediatric population.^, Thus, cardiovascular events, such as myocardial infarction, heart failure, and stroke, are the major cause of non-cancer death in these patients.

Cardiotoxicity is defined as any structural or functional damage incurred by the heart and circulation during or after cancer treatment. These changes may be caused by chemotherapeutic agents, radiotherapy, or even the disease itself (). Cardiotoxicity may present as symptomatic or asymptomatic heart failure, pericardial changes, arrhythmias, thromboembolic events, arterial hypertension, or valve and coronary diseases^, and can be classified by time of onset as follows:

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Editorial

How to Perform a Diagnostic and Prognostic Analysis of Hypertrophic Cardiomyopathy in 2022: Should we Divide to Improve Treatment?

Alexandra Toste et al. Nuno Cardim

Hypertrophic cardiomyopathy (HCM), the most common genetic heart disease, has an estimated prevalence in the general population of 1:500–1:200. The diagnosis is based on the presence of left ventricular hypertrophy (LVH) that is not fully explained by loading conditions, and HCM occurs in the absence of other cardiac, systemic, or metabolic disease or in the context of a multiorgan syndrome associated with LVH.

Despite being considered a genetic disease, the initial diagnosis of HCM does not require genetic testing. The diagnostic power of current genetic panels is modest, just 46%; therefore, failure to detect a mutation does not exclude the diagnosis. Current guidelines recommend genetic testing, especially when the possibility of cascading familial genetic screening is anticipated or in cases in which the clinical presentation suggests a specific non-sarcomeric etiology potentially treatable with specific therapy, such as Anderson-Fabry disease, Danon disease, or familial amyloidosis.

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Systematic Review

Myocardial Work: a Systematic Review of Novel Echocardiography Method and Clinical Applications

Sidhi Laksono et al. Hillary Kusharsamita Mefri Yanni Astri Astuti

Abstract

Background:

Myocardial work (MW) is a novel imaging modality that has emerged as a potential left ventricular (LV) function assessment in various clinical settings. MW calculates speckle-tracking echocardiography strain curves with an estimated LV pressure curve by non-invasively utilizing standard brachial blood pressure curves.

Objective:

This study aimed to provide a summary of current knowledge of non-invasive MW and its clinical applications, including in heart failure, coronary artery disease, cardiomyopathy, and hypertension. In addition, the limitations, and recommendations of MW in clinical practice are discussed.

Methods:

We searched the PubMed database using the following keywords: (myocardial constructive work) OR (wasted septal work) OR (global myocardial work) OR (myocardial work) OR (myocardial constructive work) OR (novel echocardiography). We further subjected 12 studies to full-text review and included them in this systematic review.

Results:

While MW indices, particularly global work index and global constructed work, have shown good correlations with ejection fraction (EF) and strain parameters, the opportunity of offering incremental information that is unaffected by loading conditions has made MW application particularly useful in a variety of clinical settings.

Conclusion:

Compared to EF and global longitudinal strain, MW is a promising test with higher sensitivity and accuracy for identifying individuals with cardiovascular disease. Clinicians should also evaluate symptoms and electrocardiographic findings until extensive multicenter studies validating this strategy are performed to establish the incremental value of MW in daily echocardiographic assessments.

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Review Article

The Role of Cardiac Magnetic Resonance in patients with Amyloidosis and Aortic Stenosis

Pedro Macedo Esmeraldo Barbosa et al. Tiago Augusto Magalhães

Abstract

Cardiac magnetic resonance imaging (CMR) plays an important role in the diagnosis and prognosis of various heart diseases. The incidence of cardiac amyloidosis and aortic stenosis has been increasing in recent years, especially with the aging population, and their possible coexistence has created frequent diagnostic challenges in clinical practice. CMR assumes an important value in this context due to its unique capacity for multiparametric assessment evaluations that include anatomical, functional, and histopathological aspects. The present review aimed to increase our knowledge of the diagnosis and prognosis of amyloidosis in the presence of aortic stenosis and highlighted the importance of CMR in this scenario.

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