2024;37(2) – ABC CARDIOL

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Review Article

What do Cardiologists Expect Regarding Echocardiogram in Aortopathies

Gustavo de Azevedo Martinhago et al. Alan Rodrigues Andrade Vinicius Machado Correia Fabio Fernandes … Jose Augusto Duncan Santiago Ricardo Ribeiro Dias Vagner Madrini Junior

Abstract

The echocardiogram is an available and essential imaging tool for the evaluation of thoracic aortic diseases. This examination plays a significant role in the identification and diagnosis, as well as the follow-up of chronic cases. Its availability, portability, cost-effectiveness, and the absence of exposure to radiation or contrast make it an important tool for monitoring patients with known aortopathy, who usually require serial examinations for follow-up. Although it is inferior in the total and detailed characterization of the aorta in all its sections compared to aortic angiotomography or angioresonance, the echocardiogram allows for functional assessment of the aortic valve and valve apparatus. In acute aortopathies, it also enables the evaluation of complications and can be performed on hemodynamically unstable patients. This article will discuss the theoretical and practical aspects of the applicability of the echocardiogram in the context of aortopathies.

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Review Article

My Approach to Perform Echocardiographic Assessment during Cardiopulmonary Arrest

Fátima Elizabeth Fonseca de Oliveira Negri et al. Alexandre Jorge de Andrade Negri Alexandre Jorge de Andrade Negri Júnior Taciana Assis Bezerra Negri

Abstract

Cardiopulmonary arrest (CPA) is one of the most common events encountered by health care professionals. Attempts to reverse it by performing cardiopulmonary resuscitation (CPR) maneuvers still have very low success rates. Pulseless electrical activity (PEA) and asystole are associated with the worst outcomes. Major CPR guidelines emphasize the importance of identifying potentially treatable causes of CPA. Point-of-care ultrasound (PoCUS), when performed in a systematic, orderly fashion (i.e., without delaying or interfering with other CPR maneuvers), may be important in this change in outcome because it is a diagnostic and prognostic tool used in a scenario where the physical examination is not always conclusive. In this context, the main applications of PoCUS include diagnosis of CPA, differential diagnosis between PEA and pseudo-PEA, and etiologic diagnosis. Several protocols have been developed to optimize the performance of cardiac PoCUS simultaneously with each central pulse check. Pulmonary, abdominal and vascular PoCUS should be performed during resuscitation maneuvers, as they do not interfere with these maneuvers. In addition, PoCUS should preferably be performed by a trained physician who is not actively involved in the resuscitation maneuvers so that the dynamics of CPR are maintained. PoCUS contributes to the diagnosis, prognosis, and therapeutic care of patients suffering from CPA, especially in cases of PEA and asystole; however, there is still no robust evidence that the use of PoCUS reduces mortality among these patients.

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Review Article

My Approach to Evaluation of Cardiac Masses Using FDG PET/CT

Simone Cristina Soares Brandão et al. João Marcelo Duarte Ribeiro Sobrinho Emanuel Davi Lima de Matos Leão Lara Cristiane Terra Ferreira Carreira Adriana Soares Xavier de Brito

Abstract

Cardiac masses represent solid formations of various origins, with accurate diagnosis being crucial, particularly for those of a malignant nature, which are typically associated with a worse prognosis. Given this diversity, a comprehensive approach often involves the integration of multiple imaging modalities. Conventional cardiovascular imaging techniques such as transthoracic echocardiography, magnetic resonance imaging (MRI), and cardiac tomography offer insights into anatomical features and hemodynamic implications associated with these masses. However, due to its limitations, greater precision in the etiological investigation of these masses can be achieved by combining Nuclear Medicine with complementary methods, notably positron emission tomography combined with computed tomography using fluorodeoxyglucose-Fluorine-18 (FDG PET/CT). This approach aids in effectively assessing cardiac masses’ metabolic activity, particularly when distinguishing between benign and malignant masses, guiding optimal biopsy site selection, and facilitating comprehensive staging. The Standardized Uptake Value (SUVmax) serves as a quantitative measure of FDG uptake by the mass, with elevated SUVmax values indicating malignancy. Clinical and conventional imaging data should complement the interpretation of FDG PET/CT findings for a more conclusive diagnosis. Thus, a multimodal strategy, particularly incorporating FDG PET/CT, enables a more precise differentiation between benign and malignant cardiac masses, ultimately optimizing patient management.

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Editorial

One-Dimensional Echocardiography: Still Needed or Already Outdated?

Fernando Antonio de Portugal Morcerf

There is a widespread lack of knowledge about one-dimensional echocardiography (M-mode) by the current generation of echocardiographers. Has two-dimensional echocardiography (B-mode) and Doppler made M-mode outdated? M-mode provides information that cannot be obtained by using B-mode or even Doppler—be it spectral, color, or tissue Doppler—for two reasons:

Now let us consider some conditions that can only be detected by M-mode and not by B-mode or Doppler, which can aid in the diagnosis via B-mode or in the understanding of pathologies.

[…]

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Review Article

Assessment of Myocardial Ischemia with the Integrated Use of Multimodality Imaging

Thiago Nunes Pereira Leite et al. Luís Henrique Wolff Gowdak

Abstract

Myocardial ischemia, which is characterized by reduced oxygen supply to the myocardium, is a common manifestation of coronary artery disease (CAD), one of the leading causes of morbidity and mortality worldwide. Early and accurate detection of myocardial ischemia is essential for risk stratification, treatment planning, and improved clinical outcomes. In recent years, advances in cardiac imaging modalities have provided a more comprehensive assessment of myocardial ischemia. This article reviews recent advances in the assessment and detection of myocardial ischemia with a focus on the integrated use of multimodality imaging. The article discusses the main techniques available, their advantages and limitations, and their role in current clinical practice, in addition to future perspectives in this area. Cardiac imaging modalities for assessment of myocardial ischemia include exercise electrocardiography, stress echocardiography, single-photon emission computed tomography, positron emission tomography, cardiac magnetic resonance imaging, and coronary computed tomography angiography. When selected imaging tests, it is necessary to consider the pre-test probability (PTP) of CAD and patients’ clinical characteristics. Non-invasive functional modalities are preferable for patients with intermediate probability of CAD. The integration of these modalities can improve sensitivity, specificity, and diagnostic accuracy, offering a more complete assessment of the patient’s cardiovascular condition and allowing for more personalized therapeutic planning.

In conclusion, the multimodal approach to myocardial ischemia assessment improves early detection, risk stratification, and therapeutic planning. The combination of several imaging modalities allows a holistic view of the cardiovascular condition, improving diagnostic accuracy and clinical outcomes in patients with suspected or established diagnosis of CAD.

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Review Article

Cardiac Tumors: Recognition Is Essential!

Eliza de Almeida Gripp et al. Bruna Zanforlin Jácome Anna Esther Araujo e Silva Fernanda Baptista Ribeiro Dias … Bruna Barbosa Chagas de Almeida Arnaldo Rabischoffsky

Abstract

Although cardiac tumors are rare and often found accidentally, they can be associated with constitutional, cardiac, or embolic symptoms and, thus, must always be considered in diagnostic hypotheses. Three-dimensional Doppler echocardiography and contrast enhancement are additional diagnostic resources and can help determine the most appropriate surgical approach, when necessary.

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Review Article

My Approach to Atrial Strain by Cardiac Magnetic Resonanc

Isabela Bispo Santos da Silva Costa et al. Rafael Almeida Fonseca Carlos Eduardo Rochitte

Abstract

Assessment of left atrial strain (LAS) using cardiac magnetic resonance (CMR) is gaining interest in cardiology as a novel parameter, as it quantifies the left atrium’s (LA) deformation throughout the cardiac cycle. Traditionally, LA function was inferred from left ventricular ejection fraction and LA volume. However, recent studies emphasize the prognostic significance of directly analyzing atrial function, particularly in atrial fibrillation (AF), heart failure, and arterial hypertension. CMR provides a thorough evaluation of cardiac anatomy and function, enabling precise and reproducible measurement of atrial tissue deformation.

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Case Report

Dural Arteriovenous Fistula: A Rare Finding Identified by Vascular Ultrasonography

Halsted Alarcão Gomes Pereira da Silva et al. Fanilda Souto Barros João Luiz Sandri Simone Nascimento dos Santos

Introduction

Intracranial dural arteriovenous fistulas (AVFs) are abnormal arteriovenous communications located in the intracranial dura mater. The main supply arteries are generally the meningeal branches of the external carotid artery, internal carotid artery, and vertebral artery. Digital subtraction cerebral angiography continues to be the standard method for diagnosing dural AVFs.^,

Vascular ultrasound (VUS) is highly accurate in the diagnosis of diseases that involve extracranial vessels, and the objective of this case report is to demonstrate that, by analyzing the flow in these arteries, it is possible to consider intracranial lesions that are not accessible on conventional Doppler.

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Case Report

Patent Foramen Ovale: An Unusual Cause of Refractory Hypoxemia

Inês Miranda et al. Christopher Strong Pedro Póvoa

Case Report

We report the case of a 70-year-old woman with a history of cryptogenic ischemic stroke for which she underwent intravenous fibrinolysis with no neurological sequelae. She had no known history of pulmonary or heart disease.

Approximately 1.5 years later, she presented to the Emergency Department (ED) with a one-week history of cough, fatigue, and shortness of breath. She denied fever, chest pain, orthopnea, or paroxysmal nocturnal dyspnea.

[…]

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Review Article

My Approach to Assessment of Mitral Paraprosthetic Leak

Abstract

Mitral paraprosthetic leak is a common, often asymptomatic condition. When presented with clinical manifestations such as heart failure and/or hemolysis, interventional treatment is indicated. The transcatheter approach has become increasingly popular, requiring careful planning using imaging methods, particularly echocardiography. Echocardiography is crucial for assessing the severity, location, size, shape, and number of leaks. Once these variables are determined, the treatment approach is planned, typically using the transseptal route. The optimal puncture site depends on various factors, with precise puncture location being paramount. Intraoperative echocardiographic evaluation is essential for procedure success, guiding device positioning and adjustments while also identifying any potential complications.

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Case Report

Stent Implantation in the Right Ventricular Outflow Tract to Pulmonary Artery in a Child with Pentalogy of Cantrell: Case Report

Jonathan Guimarães Lombardi et al. Paulo Correia Calamita Laura Moreira Tannus Mayra Rosana Palmeira Barreto … Luiza Emylce Pelá Rosado Giulliano Gardenghi

Introduction

Pentalogy of Cantrell is a syndrome that was first described in 1958. It is characterized by 5 main malformations: defect in the lower sternum, defect in the anterior pericardium, defect in the upper abdomen, deficiency of the anterior diaphragm, and heart defects. The syndrome is rare, with an incidence of 1 in 65,000 live births. It is characterized by midline defects resulting from defective development of the septum transversum. Other congenital heart lesions associated with pentalogy of Cantrell may include atrial septal defect, pulmonary valve stenosis, tetralogy of Fallot, dextrocardia, anomalous pulmonary venous connection, tricuspid atresia, and truncus arteriosus. Children with pentalogy of Cantrell constitute a population with high morbidity and mortality. In this case report, we demonstrate a hemodynamic procedure performed in a patient with this rare congenital anomaly.

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Review Article

My Approach to 3-Dimensional Left Ventricular Strain

Rafael Bonafim Piveta et al. Miguel Osman Dias Aguiar Liria Lima Maria da Silva Marcelo Luiz Campos Vieira

Abstract

The role of strain analysis using 2-dimensional speckle tracking (2DST) has been well documented, and it represents an important complementary tool in the assessment of cardiac mechanics, adding value in the identification of incipient and subclinical myocardial injury in different clinical scenarios. A significant advance related to echocardiography was the development of 3-dimensional speckle tracking (3DST), which has the potential to overcome many limitations intrinsic to 2-dimensional technology, offering additional parameters of myocardial deformation (such as area strain) and a more comprehensive quantification of the geometry and function of the left ventricular myocardium, based on a single image acquisition. Among its main limitations, the low temporal and spatial resolution stands out, in addition to the dependence on high-quality images and a well-trained operator. Although it is a relatively recent technique that is still under development, several experimental studies and some clinical investigations have already demonstrated the reproducibility and potential applicability of 3DST. The objective of this article is to add information about adequate analysis of 3-dimensional left ventricular strain and explore its main points of vulnerability, discussing important variables to increase the accuracy and reproducibility of this technology.

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Editorial

Transesophageal Echocardiography in Aortic Valve Stenosis: A Pre-Intervention “Toll”?

Antonio de Santis et al. Francisco Monteiro de Almeida Magalhães

Aortic stenosis (AS) has become one of the most relevant valve diseases in cardiology care due to its increasing prevalence, resulting from the positive relationship between the preeminently degenerative etiology and global population aging. In Brazil, we highlight an epidemiological scenario characterized by an etiopathogenic coexistence: rheumatic fever and bicuspid valve disease in younger patients and calcific (degenerative) etiology in elderly patients. Regarding the natural history, AS leads to elevated cardiovascular morbidity and mortality in its symptomatic phase, with unfavorable prognosis when it is not diagnosed correctly and without timely intervention.^–

Echocardiography is still a fundamental tool for diagnosis, allowing both evaluation of etiological characteristics and grading of AS severity using parameters such as aortic valve area, transvalvular pressure gradient, and peak aortic jet velocity. However, there are still questions related to the best window for acquiring echocardiographic data. Is the transesophageal window a necessary “toll” for all patients with AS for whom intervention is planned? In general, transesophageal echocardiography (TEE) has the potential to provide superior image quality to transthoracic echocardiography (TTE) in the evaluation of posterior cardiac structures close to the esophagus, for example, the mitral valve. In this case, the greater distance between these structures and the echocardiographic transducer might make evaluation through the transthoracic window difficult. However, the anterior anatomical topography of the aortic valve allows adequate analysis by TTE in most patients, thus avoiding exposure to sedation and possible complications of the transesophageal modality. Data from the literature have shown that TTE and TEE are comparable, mainly in the anatomical and etiological characterization of AS, with compatible results in estimating the valve area.^– Nonetheless, there is evidence that the determination of the hemodynamic severity of AS, expressed by the transvalvular pressure gradient and aortic jet velocity, may be underestimated in TEE. Variations in blood volume and preload, conditioned by the fasting and sedation required for the exam, could justify these particularities in transesophageal evaluation.

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Original Article

Use of a 3D Printer in the Prototyping of an Anatomical Model of the Human Heart with Morphophysiological Alterations

Kaio Gomes de Freitas et al. Ana Laura Barros Lana Vinícius Lana Ferreira Melissa Araújo Ulhôa Quintão

Abstract

Background:

Three-dimensional (3D) printing has a wide range of applications, including medicine and medical education. It presents itself as an alternative to traditional teaching-learning methods of human morphophysiology.

Objectives:

To report the initial experience in prototyping a 3D-printed anatomical model of the human heart with valvular heart disease, as well as its potential use in the active teaching-learning process in human morphophysiology.

Methods:

This is an experimental, descriptive study developed in three distinct stages: 1) Selection of the morphofunctional structure for manufacturing the 3D part; 2) design and adaptation of the object in 3D computer-aided design (CAD) software; and 3) printing and application of the prototype. Models extracted from the Thingiverse website, simulating cardiac structures, were used.

Results:

A cardiac prototype was 3D-printed to illustrate morphophysiological changes, including aortic stenosis and mitral insufficiency, modeled on the aortic and mitral valves, respectively.

Conclusion:

The valve diseases represented in the prototype accurately reflect the pathological changes used as the basis for the study, providing a detailed and precise view of the anatomy, which shows significant potential for enhancing the teaching-learning approaches in morphophysiology and medical pathology.

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Review Article

My Approach to Evaluate Systemic Venous Congestion: VExUS Protocol

Angelo Antunes Salgado et al. Marcos Paulo Lacerda Bernardo Fernando Melo Netto

Abstract

The use of non-invasive tools for analyzing systemic venous congestion in critically ill patients in the intensive care unit has been gaining increasing popularity for diagnosis, estimating the severity of congestion, and providing prognostic estimates. Patients with systemic congestion are more likely to develop renal dysfunction compared to those without congestion. In this review, the authors demonstrate how to perform systemic congestion analysis, its potential limitations, and its practical and objective applicability.

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Case Report

A Rare Case of Pulmonary Sarcoidosis With Extracranial Carotid System Involvement

Fanilda Souto Barros et al. Halsted Alarcão Gomes Pereira da Silva Daniela Souto Barros Simone Nascimento dos Santos

Introduction

Sarcoidosis is a disease of unknown etiology, whose pathogenesis appears to involve genetic, immunologic, infectious, and environmental factors. It was first described in 1889 by Ernest Besnier and is also called Besnier-Boeck-Schaumann disease.^,

In sarcoidosis, a noninfectious inflammatory process leads to the formation of granulomas, which predominantly affect the lungs and intrathoracic lymph nodes in approximately 90% to 95% of cases. Close to 30% of patients with sarcoidosis present with extrapulmonary involvement, which may be the primary manifestation of the disease or occur in isolation.^–

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Case Report

Takotsubo Syndrome in a Critical COVID-19 Patient: Electrocardiographic and Echocardiographic Evolution

Cuitláhuac Arroyo-Rodríguez et al. Alejandra Hernández-Parra

Background

By resembling a Japanese traditional octopus trap, i.e. a takotsubo, Hikaru Sato described the first case of “Takotsubo cardiomyopathy” in a patient without coronary stenosis and end-systolic left ventricular apical ballooning on a cardiac left ventriculography.Takotsubo syndrome (TTS) is a clinical syndrome characterized by an acute and transient left ventricular systolic dysfunction related to an emotional or physical stressful event. COVID-19 is a recognized trigger for TTS, with the possible explanations being the enormous emotional stress caused by the pandemic and the entire spectrum of myocardial damage associated with SARS-COV-2.

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Case Report

Giant Left Atrium due to Probable Rheumatic Disease and Atrial Functional Mitral Insufficiency

Israel Nilton de Almeida Feitosa et al. Isaac Newton Guimarães Andrade

Introduction

Giant left atrium is a rare condition, and most cases described in the literature are associated with rheumatic disease. However, some clinical descriptions suggest a nonrheumatic etiology for this condition, in which characteristic findings of rheumatic disease are not identified or anatomopathological findings do not suggest a specific etiology.

Atrial fibrillation is present in almost all cases and contributes to the maintenance of left atrial remodeling and persistent changes in structure and function.

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Case Report

Post-infarction Left Ventricular Pseudoaneurysm Treated with Percutaneous Transcatheter Occlusion: A Case Report

Isabela Galizzi Fae et al. Carolina Kuchenbecker Soares Ricardo Wang Gustavo Brandão de Oliveira … Maria Carmo Pereira Nunes Glaucia Cristina da Silva Rochelle Coppo Militão Rausch Luiz Ricardo de Ataide Castro Anderson Ferreira Leite

Abstract

Left ventricular pseudoaneurysm (LVPSA) is a rare complication after myocardial infarction (MI) with a significant risk of rupture if untreated. Given the elevated surgical risk in this context, alternative treatments are emerging. This case describes a percutaneous closure of an LVPSA after extensive MI with delayed revascularization.

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Case Report

Idiopathic Mitral and Aortic Subvalvular Aneurysm in a Young Patient

João Pedro Laydner et al. Ana Paula Siciliano Rafael Castro da Silva Alex dos Santos Felix Maximiliano Freire Dutra

Abstract

Left ventricular aneurysms are primarily caused by coronary artery disease. Among them, there are also less common types, such as those located in the subvalvular regions of idiopathic origin. This article describes the case of a patient with a history of aortic subvalvular and Sinus of Valsalva aneurysm repairs who developed a new mitral subvalvular aneurysm.

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