2023;36(3) – ABC CARDIOL

ABCIC

ABC Family | ABCIC

Original Article

Diagnostic Accuracy of the Coronary Calcium Score Acquired with Reduced Radiation Dose and Iterative Reconstruction

Daniela Rodrigues Carnaval et al. Adriano Liebl Miguel Morita Fernandes Silva Bruno Marques Sartori … Caio Nogara de Menezes Couto Gabriel Bergonse Garaluz da Silva Ítalo Gabriel Beltrame Vazzoler Vinícius Maksoud Medeiros Rodrigo Julio Cerci

Abstract

Background:

The calcium score is an imaging test used to evaluate cardiovascular risk by detecting coronary artery calcification (CAC). However, exposure to ionizing radiation during computed tomography (CT) has been a concern.

Objective:

The objective of this study was to evaluate radiation dose and the diagnostic quality of the calcium score using reduced tube voltage and iterative image reconstruction.

Methods:

This was a cross-sectional, observational study with patients over 18 years of age. Patients with previous coronary artery disease and patients who declined to participate were excluded. We acquired calcium score twice (120 kV and 100 kV) with different iterative reconstruction techniques. Two professionals interpreted the exams.

Results:

We evaluated 153 patients, and the reduction in radiation dose between acquisitions with 120 kV and 100 kV was 43%. The agreement of the degree of CAC between the different acquisitions was high, ranging from 93.9% to 96.2%. In Bland-Altman analysis, we observed a slight overestimation of the results in the acquisition with 100 kV compared to the acquisition with 120 kV.

Conclusion:

Calcium score acquired at 100 kV using Iterative Model Reconstruction (IMR) iterative reconstruction resulted in a significant reduction in radiation dose. Furthermore, agreement with acquisition at 120 kV was high, indicating that this approach may be a viable alternative to decrease radiation exposure during calcium score testing. However, it is important to underscore the slight overestimation of the results in the acquisition with 100 kV, which must be considered in the clinical interpretation.

Read Full Article

Original Article

Incremental Determinants of The Combined Supine-Prone Protocol for Myocardial Perfusion Scintigraphy

Tiago Oliveira Costa et al. Mário de Seixas Rocha Gilson Feitosa Soares Filho Raphael Abegão de Camargo Cristiano Ricardo Bastos de Macedo

Abstract

Background:

Myocardial perfusion scintigraphy is an important non-invasive method for diagnosing coronary artery disease, but it is not free from artifacts. Performing the combined supine-prone protocol can bring benefits to images with artifacts from the standard protocol in the supine position. The lack of unanimity in the implementation of the combined protocol may be related to the lack of objective data for the prior selection of patients.

Objective:

To evaluate which anthropometric profiles may be associated with a greater benefit in excluding artifacts for the optimized performance of the combined protocol.

Methods:

A cross-sectional and analytical study was carried out with 370 patients at the Nuclear Medicine Group Clinic between April and August 2022. The estimated level of statistical significance was 5%. Statistical analysis using binary logistic regression was used to evaluate the association between anthropometric data and the change in the initial test result after carrying out the combined protocol.

Results:

The combined protocol promoted a 19.7% increase in the normality ratio of the standard protocol. The variables weight, for both genders [OR = 1.02 (95% CI, 1.0002 – 1.04; p = 0.047)], and bust in women [OR = 1.06 (95% CI, 1. 01 – 1.11; p = 0.014)] represented incremental determinants with statistical significance. Weight greater than 76.5kg for both genders (S: 58.5%; E: 61.5%) and bust greater than 100.0 cm in women (S: 73.9%; E: 53.4%) were the best cutoff points in the receiver operating characteristic (ROC) curve.

Conclusion:

The optimized implementation of the combined protocol using the described weight and bust measurement criteria can promote greater efficiency in image acquisition.

Read Full Article

Case Report

Initial Experience of Intracardiac Echocardiography-Guided Left Atrial Appendage Occlusion: Report of Six Cases

Fabricio Sarmento Vassallo et al. Henrique Teixeira Giestas Serpa Betina Reseck Walker Vinícius Fraga Mauro … Carlos Volponi Lovatto Eduardo Serpa Lucas Corsino dos Santos Hermes Carloni Aloyr Simões Edevaldo da Silva Gracielly Barros Renato Giestas Serpa

Introduction

In recent decades, the incidence of atrial fibrillation (AF) has increased exponentially worldwide.^, This comorbidity is directly related to cardioembolic events, and oral anticoagulation is considered the gold standard treatment for its prevention. Although oral anticoagulation is effective in preventing ischemic stroke, warfarin is contraindicated in 14% to 44% of patients at risk for cardioembolic stroke; nevertheless, even in eligible patients, only 54% are anticoagulated. Currently, direct-acting oral anticoagulants (DOAC) are preferable as preventive therapy for ischemic stroke; however, the discontinuation rates of these drugs reported in clinical trials, mainly due to intolerance or side effects, vary from 23% to 35%. In patients with a history of hemorrhagic stroke, uncontrolled non-intracranial bleeding, and end-stage chronic kidney disease or dialysis, the use of DOAC is relatively or absolutely contraindicated.

In cases of non-valvular AF, when the aforementioned contraindications to DOAC use are present, left atrial appendage occlusion (LAAO) has shown to be effective as a therapeutic alternative. This procedure has been guided and performed using transesophageal echocardiography, which is considered the gold standard. However, services that have incorporated intracardiac echocardiography as an auxiliary tool during catheter ablation for the treatment of AF went on to use this method as a safe and effective alternative to transesophageal echocardiography in LAAO procedures.^–

[…]

Read Full Article

Editorial

Decoding the Diagnostic Dilemmas of Heart Failure with Preserved Ejection Fraction: Applying the Universal Definition for Enhanced Diagnosis Standardization

Renato A. Hortegal

Implementing the Universal Definition of HF for HFpEF Diagnosis

The clinical diagnosis of HFpEF is straightforward when a patient presents with typical symptoms and signs of left and/or right congestive HF with LVEF ≥50%, along with echocardiography abnormalities and elevated NP.

However, patients with HFpEF may not display this classical HF presentation. Indeed, a significant proportion of patients (∼50%) will only display symptoms during exertion, without current or previous evidence of fluid overload on clinical examination or prior hospitalization for decompensated HF (). This exercise-induced left atrial hypertension phenotype makes diagnosis challenging in clinical practice, with the Framingham criteria showing limited sensitivity.^,

[…]

Read Full Article

Case Report

Uhl's Anomaly: Case Report and Differential Diagnosis in an Adult

Isaura Elaine Goncalves Moreira Rocha et al. Paulo Henrique Benevides Siqueira Beatriz Gonçalves Rocha Bruno Farias Oliveira … George Elias Luna Martins Simone Cristina Soares Brandão

Introduction

Uhl’s anomaly (UA) is a disorder exclusive to the right ventricle (RV) characterized by the absence of total or partial myocardium, in such a way that the ventricular wall is comprised of the overlapping of the endocardium and the epicardium, with no fatty tissue, or inflammatory or infiltrative process. The muscles of the atria, the interventricular septum and the left ventricle (LV) are not involved in the process.^,

The clinical manifestations are due to right ventricular failure (RVF). Forms with partial involvement may be mildly symptomatic and remain undiagnosed for long periods, and may be confused with other more frequent pathologies that affect the right heart in adult life.^,

[…]

Read Full Article

Case Report

Cardiac Lipoma as an Incidental Finding in Cardiovascular Imaging Exam

Fábio P. Taniguchi et al. Marcelo G. Silas Patrícia M. Oliveira

Introduction

The advent of cardiac imaging has ushered in an era where incidental findings can be detected using less invasive methods, even in asymptomatic patients. The clinical presentation of cardiac masses, characterized by their varying growth rates and diverse locations within the heart, poses a formidable challenge to cardiologists. Therefore, paramount importance lies in reducing the clinical burden and costs, considering the potential of cardiac imaging to optimize the clinical pathway. The most common cardiac masses in the right atrium include thrombi, vegetations, and neoplasia. Approximately 75% of primary tumors are benign, with myxomas comprising 50% of benign cases. Other benign tumors that usually may arise in the right atrium are rhabdomyomas, fibromas, fibroelastomas, and lipomas. Cardiac lipomas are rare, accounting for 2.9% to 8% of all benign cardiac tumors. They rank third in frequency after myxomas and papillary fibroelastomas. The literature suggests that 25% of cardiac lipomas are intramyocardial; 25% are extracavitary of epicardial origin, and 50% are intracavitary of subendocardial origin. Lipomas are well-encapsulated and homogeneous masses composed of mature fat. Although the etiology of cardiac lipomas is unknown, they can originate from any of the three cardiac tissues: subendocardial (the most common), pericardial, or myocardial.

The aim of this report is to present a case of an asymptomatic right atrial lipoma and to discuss the etiology, natural history, and optimal management strategies for right atrial lipomas.

[…]

Read Full Article

Review Article

What do Cardiologists Expect from Imaging For Ischemic Heart Disease in Women

Maria Cristina Costa de Almeida et al. Claudia Maria Vilas Freire Larissa Espíndola Neto Gláucia Maria Moraes de Oliveira

Abstract

Ischemic heart disease (IHD) is an important cause of morbidity and mortality in women and men. This paper emphasizes the differences of IHD in women, focusing on the diagnostic investigation in its stable phase.

The higher prevalence of atypical symptoms, anatomical differences, and adverse psychosocial aspects, in addition to the association of specific risk factors regarding obstetrical history, requires an accurate clinical assessment and a targeted diagnostic investigation that consider the limitations, as well as the positive and negative predictive values of the methods. Because of breast exposure, tests involving radiation should be reconsidered in selected cases.

It is worth emphasizing that non-cardiological tests often performed in women, such as mammography, provide an opportunity to assess CVR at early ages or even in patients with few traditional risk factors.

Complementary tests for microcirculation assessment should be used in cases of proven ischemia in the absence of obstructive coronary artery disease, which is known to be more frequent in women.

Read Full Article

Editorial

Women in the DIC: What Motivates Us?

Samira Saady Morhy

During the period from November 2022 to March 2023, a survey was made available on the website of the Department of Cardiovascular Imaging (DIC) of the Brazilian Society of Cardiology (SBC), aimed at female members of the DIC-SBC, with the objective of better understanding the challenges faced by women during their training and professional exercise.

We obtained 131 responses, and the results are displayed in to .

[…]

Read Full Article

Editorial

Role of Strain Echocardiography in the Evaluation of Patients with Chagas Disease

Vinicius Tostes Carvalho et al. Luís Henrique Coelho Pinto Maria Carmo Pereira Nunes

Chagas disease continues to be a significant public health challenge, affecting approximately six million people worldwide. With increasing globalization, Trypanosoma cruzi has already been detected in regions that were not previously considered endemic for the transmission vector, thus becoming one of the main neglected parasites. Although a percentage of infected individuals remain asymptomatic in the chronic indeterminate form of the disease, it is estimated that 2% to 3% of all patients annually progress to the cardiac form. Chagas heart disease was the most severe manifestation of Chagas disease, clinically appearing with heart failure, ventricular and supraventricular arrhythmias, conduction disorders, and embolic events.

The echocardiogram is an important propaedeutic method in the evaluation of patients with Chagas disease, especially in the presence of Chagas heart disease. In general, the echocardiogram investigates parameters related to the analysis of segmental contractility and global systolic function, which is essential for the treatment and prognosis of the disease. However, even well-established variables in the literature, such as ejection fraction, face challenges in simulating all the pathological aspects of Chagas disease.

[…]

Read Full Article

Case Report

Cardiac Metastasis and Krukenberg Tumor: A Case Report

Jessyca Gonçalves Cruz et al. Ana Gardenia Liberato Ponte Farias João David Leitão de Lucena Christiane Bezerra Rocha Liberato … Ana Carolina Brito de Alcantara Mauricio Costa Lima

Introduction

Primary cardiac tumors are rare, affecting between 0.0017% and 0.28% of the population. Secondary or metastatic tumors, on the other hand, are 40 to 100 times more frequent than primary tumors. The primary sites that most often metastasize to the heart are the lungs, breast, malignant melanoma, and hematological tumors. Cardiac metastasis secondary to ovarian tumors is infrequent and, in the cases described, mainly affects the pericardium, with no intracavitary lesions described. Metastatic neoplasms can reach the heart by these routes: hematogenous, direct extension, lymphatic vessels, and through the pulmonary veins and vena cava.^,

The term “Krukenberg tumor” is used clinically to designate a metastatic carcinoma of mucin-secreting signet ring cells in the dense fibroblastic stroma of the ovary.^, It mainly affects premenopausal women, at a mean age of diagnosis of 45 years, with 70% of cases in the stomach as the most common primary site, followed by the colon, appendix, and breast.^, A history of carcinoma prior to the diagnosis of Krukenberg is obtained in only 20% of cases, and the primary site is often unknown. The mortality rate is high, and survival is 14 months on average after diagnosis.^,

[…]

Read Full Article

Case Report

Prosthetic Aortic Valve Endocarditis With Extensive Para-Aortic Abscess: The Relevance of Multimodal Imaging

Bernardo Boccalon et al. André Barcellos Amon Thiago Ferreira Serafini Álvaro Schmidt Albrecht … Murilo Foppa Angela Barreto Santiago Santos

Introduction

Infectious endocarditis (IE) is defined as the infection of the endocardium or prosthetic material in the heart, whose pathogenesis is bacterial adherence to the vulnerable endocardium or implanted prosthetic material during a bacteremia. Its clinical presentation is highly variable, depending on the micro-organism that causes it, underlying heart conditions and preexisting comorbidities. The annual estimated incidence of IE is up to 10/100,000 in western countries, and mortality of up to 30% in 30 days.

[…]

Read Full Article

Editorial

ABCDE Protocol in Stress Echocardiography

José Luis de Castro e Silva Pretto et al. Clarissa Borguezan Daros

A for Asynergy

This is based on the presumable myocardial contractility alteration induced by stress in the presence of flow-limiting coronary stenosis. The substrate supply-demand imbalance leads to a reduction in myocardial radial thickening, a parameter sometimes limited by its semi-quantitative and subjective nature. Operator dependency can be minimized (but not eliminated) by specialized training and the adoption of conservative reading measures, as well as the accreditation and quality control of advanced echocardiography laboratories.

The regional motility assessment indicates that the higher the number of affected segments (universally defined), the worse the prognosis. This parameter is viewed as stenosis centered and has its value limited outside the epicardial coronary disease context.

[…]

Read Full Article

Case Report

Evaluation of Coronary Flow Reserve by Myocardial Scintigraphy in Left Ventricular Hypertrophy

Renata Christian Martins Felix et al. Felipe Hermely Villela Pedras Odorico de Souza Lima Neto Leonardo Medeiros Vitório

Introduction

The microvascular integrity of the myocardial bed can be assessed by coronary flow reserve (CFR), which is a calculation of the ratio between the absolute coronary blood flow under vasodilator stress and under resting conditions. This measurement is capable of estimating vasomotor dysfunction, and it reflects the hemodynamic effect of focal, diffuse, or small-vessel coronary disease.

Currently, it is possible to measure CFR invasively using the techniques of thermodilution or intracoronary Doppler and through non-invasive methods, such as echocardiography, magnetic resonance imaging, computed tomography, or nuclear medicine.

[…]

Read Full Article

Editorial

Is Echocardiographic Assessment of Strain Essential In Daily Routine?

Carlos Eduardo Suaide Silva

The assessment of myocardial fiber deformation (myocardial strain) during the cardiac cycle is a direct measurement of muscle function, which can be obtained by conventional imaging tests such as echocardiography and magnetic resonance.

Strain measurement can identify abnormalities in global and regional myocardial function, in addition to making the differential diagnosis of some cardiomyopathies. Furthermore, it is an earlier marker of ventricular dysfunction than ejection fraction and may predict adverse cardiovascular events.

[…]

Read Full Article

Case Report

Incidental Finding of Arrhythmogenic Right Ventricular Cardiomyopathy in a 72-Year-Old Man Admitted With Acute Coronary Syndrome

Rafael Modesto Fernandes et al. Luciana Cunha Weber Vitor Queiroz de Castro Souza Mariana Baptista Guedes … Diogo Freitas Cardoso de Azevedo Marcia Maria Nova Rabelo

Introduction

Arrhythmogenic right ventricular cardiomyopathy (ARVC) – also known as arrhythmogenic right ventricular (RV) dysplasia – is a genetic disorder characterized by progressive loss of RV cardiomyocytes, which are replaced with fibrofatty tissue. This replacement may delay intraventricular conduction and contribute to ventricular arrhythmias through a fibrosis-related macro-reentry mechanism. Thus, ARVC is one of the main causes of arrhythmic cardiac arrest in young people and athletes.

Although initially designated as dysplasia, ARVC is not a congenital defect in the myocardium development. It is caused by mutations in the genes that encode desmosomal proteins, which are responsible for cell-to-cell adhesion. This discovery led to the disease being recognized as cardiomyopathy and included in the classification of cardiomyopathies by the American Heart Association.^,

[…]

Read Full Article

Case Report

8F-FDG PET/CT in Diagnosis, Therapeutic Evaluation and Definition of Management in Cardiac Sarcoidosis: Learn From This Case Report

Simone Cristina Soares Brandão et al. Matheus de Araújo Lucena Christiane Wiefels Pedro Rodrigues da Silva … Claudio Tinoco Mesquita Maria Fernanda Rezende Fabio Mastrocola

Introduction

Sarcoidosis is a non-caseating granulomatous inflammatory disease of unknown etiology. The presentation can range from an asymptomatic condition with nonspecific findings on chest radiography to organ failure. Any part of the body can be affected, but the most common sites are the mediastinal lymph nodes and the lungs, followed by the skin and ocular structures such as the uvea. Other systems, such as the nervous, endocrine, gastrointestinal, urinary, musculoskeletal, and cardiovascular systems, can also be affected.

Cardiac sarcoidosis is a disease that is still under-researched in cardiology. It is related to cardiomyopathy conditions that can be confused with hypertrophic, infiltrative, or even ischemic cardiomyopathy, and it courses with ventricular arrhythmias and conduction disorders with possible progression to heart failure and/or sudden death. It is worth emphasizing that cardiac sarcoidosis is responsible for up to 35% of cases of complete atrioventricular block (CAVB) in patients under 60 years of age. These patients benefit from the implantation of a pacemaker and implantable cardioverter defibrillator (ICD). Immunosuppressive therapy is indicated to control the inflammatory process.

[…]

Read Full Article

Review Article

Echocardiographic Characteristics of PRKAG2 Syndrome: An Integrative Review

José Luiz Barros Pena et al. Igor de Souza Neto Alice Pinheiro Barbosa Dinamar Amador dos Santos Neto

Abstract

PRKAG2 syndrome is a rare, early-onset, autosomal dominant, inherited lysosomal glycogen storage disease that develops with ventricular preexcitation syndrome, supraventricular arrhythmias, and cardiac hypertrophy. The disease is caused by mutations in the gene encoding the adenosine monophosphate-activated protein kinase (AMPK) protein, leading to glycogen accumulation in cardiomyocytes. Echocardiography is a noninvasive, widely available, and highly effective technique for identifying and quantifying left ventricular hypertrophy (LVH). Therefore, this review focuses mainly on echocardiographic patterns, describing the main alterations in patients with PRKAG2 syndrome. O objective of this paper is to conduct an integrative review of the echocardiographic features presented by patients with PRKAG2 syndrome. We conducted an integrative review of echocardiographic features in PRKAG2 syndrome by searching PubMed, SciELO, IBECS, and LILACS electronic databases using the following keywords: “PRKAG2 syndrome” and “PRKAG2.” The predominant echocardiographic finding in patients with PRKAG2 syndrome was cardiac chamber hypertrophy, particularly affecting the left ventricle. In addition, other findings included abnormal ejection fraction, changes in strain patterns, and heart valve abnormalities. Cardiac chamber hypertrophy was demonstrated in most studies, with a predominance of LVH. Reduced ejection fraction was also described, both in the left and right ventricles. Other features reported included atrial enlargement, cardiac dyskinesia, and valve dysfunction. However, the findings varied widely, highlighting the phenotypic variability of this syndrome.

Read Full Article

Review Article

My Approach to Myocardial Work: Why and for Whom?

Rodolfo de Paula Lustosa et al. Arnaldo Rabischoffsky Eliza de Almeida Gripp

Abstract

The emergence of a new noninvasive tool known as myocardial work (MW) for assessing ventricular function, which is independent of load conditions, has been fundamental in advancing current imaging methods, such as myocardial strain. Strain is considered a sensitive technique in the detection of subclinical dysfunction, even though it is still dependent on load conditions, making it impossible to differentiate contractile alteration from interference caused by increased afterload alone. This new technology incorporated into myocardial strain will increase the sensitivity of the method.

Read Full Article

Case Report

Giant Right Coronary Artery Aneurysm with Arteriovenous Fistula

Maria Eduarda Menezes de Siqueira et al. Mayra Isabel Dias Ana Claudia Vincezi Raudan Uski Luciano Figueiredo de Aguiar Filho

Introduction

Coronary artery aneurysm (CAA) is defined as a dilation that exceeds the normal diameter of the adjacent artery or the diameter of the patient’s largest coronary artery by 1.5 times. Some authors consider a giant coronary aneurysm when the diameter is > 20 mm, whereas the American Heart Association defines giant aneurysms as those > 8 mm. Giant CAA is a rare pathology with an approximate incidence of 0.02%. We report a case of giant right coronary artery aneurysm with fistula to the coronary sinus, appearing as a giant “mass”.

[…]

Read Full Article