2025;38(3) – ABC CARDIOL

ABCIC

ABC Family | ABCIC

Review Article

Tricuspid Valve: Anatomical Basis and Patient Selection Criteria for Transcatheter Structural Interventions

Alexandre Costa Souza et al. Halsted Alarcão Gomes Pereira da Silva Alex dos Santos Felix

Abstract

Tricuspid regurgitation has been recognized as a relevant clinical entity, with a direct impact on morbidity and mortality. Recent advances in multimodal cardiovascular imaging have promoted more detailed anatomical and functional assessment of the tricuspid apparatus, guiding the indication and planning of transcatheter interventions. To provide a review of the anatomical basis of the tricuspid valve and discuss echocardiographic and clinical criteria for selecting candidates for transcatheter therapies. This narrative review of the anatomical variability of the tricuspid valve and its subvalvular apparatus incorporates recent recommendations from echocardiography societies and clinical evidence. Special emphasis has been given to three-dimensional echocardiography, transesophageal echocardiography, and computed tomography for morphological and functional characterization of tricuspid regurgitation. Contemporary evidence has demonstrated that up to 45% of patients present with non-classical morphologies (quadricuspid or pentacuspid valves), which impact the viability and outcomes of edge-to-edge repair. The integration of three-dimensional echocardiography enhances accuracy in grading regurgitation severity, enables precise measurement of the vena contracta area, and assists in device selection. Clinical factors including right ventricular function, pulmonary artery systolic pressure, and the presence of intracardiac devices also influence patient selection. Appropriate selection of candidates for transcatheter tricuspid valve therapies requires a systematic approach with integrated application of imaging methods and clinical parameters. Detailed echocardiographic characterization of leaflet morphology, coaptation gap, and annulus geometry is crucial for planning the procedure, selecting the device, and predicting outcomes.

Read Full Article

Editorial

Left Atrium Reservoir Strain and Cardiovascular Hemodynamics: the Hidden Truths Reveal Far More Than What is Readily Apparent

Renato A. Hortegal et al. David Le Bihan Rodrigo Barretto Wilson Mathias Jr

Over the past 15 years, Speckle-tracking Echocardiography has evolved into a robust technique for assessing both global and regional myocardial function. Among its expanding applications, Left Atrial (LA) strain, particularly in the reservoir phase, has emerged as a clinically relevant parameter. A reduced Left Atrial Strain reservoir (LASr) has been independently associated with elevated Left Ventricular (LV) filling pressures, recurrence of atrial fibrillation, heart failure hospitalizations, and overall cardiovascular mortality.^, Reflecting this growing body of evidence, LASr has been formally incorporated into clinical practice in the recently published “Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography and for Heart Failure With Preserved Ejection Fraction Diagnosis: An Update From the American Society of Echocardiography.”

Despite this, the complexity of LA mechanics has largely followed an oversimplified approach: it is often treated as a surrogate marker of filling pressures, evaluated in isolation and interpreted using fixed cut-off values, without integrating the hemodynamic and mechanical context in which the atrium operates. While such an approach has facilitated its clinical adoption, it may obscure important physiological nuances and lead to misinterpretation in complex scenarios.

[…]

Read Full Article

Original Article

Safety of dobutamine stress echocardiography using a modified protocol in a large unselected population

José Sebastião de Abreu et al. Tereza Cristina Pinheiro Diógenes Marília Esther Benevides Abreu Isadora Sucupira Machado Chagas … Sarah Gomes Diógenes Ana Gardenia Liberato Ponte Farias Marcia Maria Carneiro

Abstract

Background

Dobutamine stress echocardiography (DSE) using the conventional protocol (CP-DSE) may lead to important adverse effects.

Objective

This study was aimed at assessing the safety of DSE using a modified protocol (MP-DSE).

Methods

Data were collected from our institutional database to compare MP-DSE with the CP-DSE. In the CP-DSE, atropine could be administered during the fourth stage or its extension. In the MP-DSE, atropine was initiated at the beginning of the third stage, and there was no stage extension. Upon completion of DSE or for arrhythmia control, metoprolol was administered in the CP-DSE and esmolol in the MP-DSE. In cases of typical angina, nitroglycerin was administered at the examiner’s discretion in the CP-DSE, whereas its use was predetermined in the MP-DSE. A p-value < 0.05 was considered statistically significant.

Results

Of 17,811 tests performed, 9,121 were conducted using the MP-DSE. During DSE, myocardial oxygen consumption, represented by the rate-pressure product, was significantly higher in the MP-DSE group (22,530 ± 4,575 vs 23,037 ± 4,072 bpm.mmHg; p < 0.001). Hypertensive peak (1% vs 0.4%; p = 0.0001) and nonsustained ventricular tachycardia (0.6% vs 0.1%; p = 0.0001) were more frequent in the CP-DSE, while supraventricular tachyarrhythmia (2.1% vs 3.78%; p = 0.0001) and atrial fibrillation (0.8% vs 1.3%; p = 0.003) were more common in the MP-DSE. These arrhythmias resolved spontaneously or with medication. In the CP-DSE, two patients had ventricular fibrillation and one, acute coronary syndrome.

Conclusion

In our study, the modified protocol for DSE proved to be a safe option, with no severe adverse effects observed, despite the presence of an elevated rate-pressure product.

Read Full Article

Editorial

Transesophageal Echocardiogram Always Before TAVI?

Jairo Alves Pinheiro et al. João Lucas Pinheiro Lucas Velloso Dutra Luciano Holanda Renata de Sá Cassar

Cardiovascular imaging is crucial in the selection and planning of interventions for structural heart disease.

Transcatheter aortic valve implantation (TAVI) has transformed the management of severe aortic stenosis (AS) in high-risk surgical populations and is currently being expanded to intermediate- and low-risk populations.

[…]

Read Full Article

Case Report

Challenges and Implications of Uncorrected Atrioventricular Septal Defect in Adults: A Complex Case Report

Saulo Rodrigo Cunha et al. Rafael Felipe Minotto Fernanda Pandolfo Fernando Colares Barros … Pedro Tregnago Barcellos Ana Carolina Martins Mazzuca Eduardo Gatti Pianca

Case report

Male patient, 18 years old, admitted to a tertiary care hospital presenting with fever, cough, and dyspnea for the past seven days. According to the patient’s mother, he sought medical attention on the second day of symptoms at an urgent care clinic, where he was prescribed ibuprofen and azithromycin to take at home. Due to lack of improvement, he sought hospital care.

Medical history includes congenital heart disease, specifically a surgically uncorrected AVSD, as he had lost follow-up at the reference hospital since childhood. On physical exam, he appeared in fair condition, with a productive cough, rapid breathing, and cyanosis around the lips and extremities. Hemodynamically stable, with blood pressure of 125 × 86 mmHg, heart rate of 105 bpm in atrial fibrillation rhythm, and oxygen saturation of 69% on room air.

[…]

Read Full Article

Case Report

Long-term Follow-Up of a Patient with FLNC Gene Mutation-Related Cardiomyopathy: A Case Report

Isabela Bispo Santos da Silva Costa et al. Bruno Soares da Silva Rangel Antonio Tito Paladino Filho Bruno Normande Colombo … Thamara Carvalho Morais Ludhmila Abrahão Hajjar

Introduction

Heart Failure (HF) is estimated to affect approximately 26 million people worldwide.^, In Brazil, prevalence is high, with about 2 million diagnosed patients and an incidence of roughly 240,000 new cases every year. Between 2011 and 2021, more than 2.5 million HF-related hospitalizations were recorded in the Brazilian Unified Health System (SUS), underscoring the relevance of the disease in the national context. These figures highlight the need for early diagnostic strategies and etiological definition for the appropriate management of these patients. Establishing an etiological diagnosis is often challenging but essential to provide disease-specific treatments and improve prognosis. Diagnosis encompasses multimodality cardiac imaging, with Cardiac Magnetic Resonance imaging (CMR) being a useful tool for evaluating non-ischemic cardiomyopathy phenotypes and establishing an etiological diagnosis.

[…]

Read Full Article

Review Article

Role of Transthoracic Echocardiography in Percutaneous Closure of Ventricular Septal Defect

João Batista Masson Silva et al. Cloves Geraldino da Silva Junior

Abstract

Ventricular septal defect (VSD) is the most common congenital heart defect, and its management has evolved with percutaneous closure, a minimally invasive alternative to surgery. In this context, echocardiography has established itself as the primary imaging tool, crucial in all phases of the procedure. Transthoracic echocardiography (TTE) is essential for diagnosis, anatomical classification (perimembranous, muscular, inlet and outlet), initial hemodynamic assessment, and long-term follow-up. Indication for closure is based on such criteria as the left ventricular (LV) volume overload, with Qp:Qs ≥ 1.5:1. For detailed planning and intraprocedural guidance, transesophageal echocardiography (TEE), especially with three-dimensional (3D) reconstruction, is the gold standard. 3D TEE offers an accurate measurement of defect diameters, a border analysis for safe device anchorage, and an assessment of the relationship with adjacent structures, such as the aortic and tricuspid valves. The success of the intervention, both in congenital VSDs and in the rare and complex post-infarction VSDs, depends directly on the quality of the echocardiographic evaluation. The multimodal approach, which integrates TTE and TEE, ensures appropriate patient selection and safe procedure management, optimizing outcomes and expanding the realms of percutaneous VSD treatment.

Read Full Article

Review Article

My approach to optimize my equipment for the use of ultrasound contrast agents

Marcio S. M. Lima

Abstract

Contrast echocardiography, based on ultrasound contrast agents composed of microbubbles, has been increasingly incorporated into echocardiography labs. It involves the infusion of compounds that enhance the visualization of various cardiac and vascular structures. The multiple adjustments required are usually included in pre-configured packages (presets) installed by manufacturers on the equipment. However, it is possible – and sometimes necessary – to make modifications to optimize image generation and, guided by the objective of the echocardiographic study, to achieve the full potential this technique can offer.

Read Full Article

Review Article

Convolutional Neural Network Applications In Cardiac Imaging

Luiz Henrique Cartaxo Fernandes et al. José Lucas Formiga Dantas Marilia Graziela Vieira de Macena Lima Glaudir Donato Marcelo Dantas Tavares de Melo

Abstract

Neural networks are computer models that mimic the workings of the human brain, learning from large volumes of data to perform increasingly complex tasks. This is done by means of interconnected artificial neurons that propagate information from raw layers to refined layers, sometimes of a weighted nature, weaving in the classification or identification of non-linear patterns. The Convolutional Neural Network (CNN) is a specialized deep learning architecture designed to extract and analyze spatial patterns within images, enabling applications in diagnostic decision-making and longitudinal clinical monitoring. Its use in Computed Tomography and Magnetic Resonance Imaging through cardiac image segmentation makes it possible to quickly and efficiently define cardiac structures, playing an important role in the reconstruction of three-dimensional images and in supporting preoperative procedures. In addition, compared to other forms of conventional analysis, it guarantees objective interpretations and superior image quality, based on the removal of artifacts from the studied segment. Echocardiograms have shown good results in identifying pathologies such as pulmonary hypertension, amyloidosis, hypertrophic cardiomyopathy and congenital diseases, and studies on the automation of these exams have shown an opening for what could be a dissemination framework in more remote areas where manual operators are not available. Consequently, CNN-based approaches have the potential to streamline cardiovascular imaging workflows, minimize inter-observer variability, and expand diagnostic capabilities to underserved and remote regions with limited access to specialized care.

Read Full Article

Research Letter

3D Printing of a Heart With Amyloidosis

Mariana de Paula Cruz et al. Davi Shunji Yahiro Daniel Gama das Neves Renato Pereira Barbosa … Alexandre Todorovic Fabro Pedro Manoel Marques Garibaldi Marcus Simões Claudio Tinoco Mesquita

Abstract

Cardiac Amyloidosis is a restrictive cardiomyopathy caused by the accumulation of amyloid protein in the heart. The advances in non-invasive diagnosis have been increasing its identification among patients with Heart Failure (HF), being previously considered to be a rare condition. Currently, it represents around 13% of the cases of Heart Failure with preserved Ejection Fraction (HFpEF). We report the case of a 72-year-old male patient who presented to the clinic reporting dyspnea and fatigue in low-effort activities. Laboratory exams were conducted, revealing increased cardiac markers, along with evidence of ventricular hypertrophy in electrocardiographic analysis. Cardiac imaging, serum free light chain (AL) assay, and endomyocardial biopsy indicated the diagnosis of AL amyloidosis. A three-dimensional model was constructed using magnetic resonance imaging (MRI) data. This model is intended to increase the awareness around amyloidosis as a possible differential diagnosis of HF, while also promoting patients’ and families’ education, demonstrating the typical structural abnormalities of the disease.

Read Full Article

Original Article

Overview of Professional Practice in Computed Tomography and Cardiac Magnetic Resonance Imaging in Brazil

Isabela Bispo Santos da Silva Costa et al. Jorge Andion Torreão Juliano de Lara Fernandes Henrique Trad … Gabriela Liberato Roberto Sasdelli Neto Silvio Henrique Barberato Ibraim Masciarelli Pinto Tiago Senra

Abstract

Background:

Non-invasive imaging for cardiovascular disease diagnosis has grown in volume and relevance in recent years, and it is important for early detection of cardiovascular diseases. There is a lack of data from Brazil on the availability of methods such as computed tomography (CT) and cardiac magnetic resonance imaging (CMR).

Objective:

This study assessed the regional distribution of professional practice and the exams performed, correlating these factors with population data and the number of active professionals.

Methods:

A nationwide survey was conducted by means of an online questionnaire applied to professionals who perform CT and CMR, compared with demographic data and the number of scans performed within Brazilian public and private healthcare systems.

Results:

A total of 219 professionals filled out the questionnaire, 139 (63.8%) male, 161 (73.9%) cardiologists, and 46 (21.1%) radiologists. Regarding regional distribution, the Southeast had 125 professionals (57.3%), the Northeast 35 (16.1%), the South 30 (13.8%), the Central-West 22 (10.1%), and the North 6 (2.8%). The profile of these professionals in Brazilian regions was similar, with no statistical differences observed regarding the proportion of men (p = 0.2451), cardiologists (p = 0.1325), radiologists (p = 0.4564), or training time > 2 years (p = 0.8519). The Southeast had the highest absolute number of exams, and the North had the lowest.

Conclusion:

The data revealed structural disparities in access to cardiovascular imaging throughout Brazil, in terms of both number of professionals and number of exams performed. The regional discrepancies observed in this study reflect distinct demographic and economic circumstances in Brazilian regions.

Read Full Article

Review Article

My Approach to Three-Dimensional Echocardiography in Mitral Stenosis: How and When?

Alexandre Costa Souza et al. Marcus Vinicius Silva Freire de Carvalho Marco André Moraes Sales

Abstract

Three-dimensional echocardiography has become an essential tool in the assessment of mitral stenosis, allowing detailed anatomical analyses and reliable measurements, even in complex anatomies or extensive calcification. Based on daily clinical experience in an imaging laboratory, this article offers a practical guide for image acquisition and optimization, multiplanar reconstruction, and three-dimensional planimetry, focusing on technical adjustments, the use of tools such as rotation and cropping, and strategies for integrating the method into the routine workflow of cardiovascular imaging centers.

Read Full Article

Case Report

Lutembacher Syndrome Associated With Pulmonary Hypertension: The Importance of Early Diagnosis for Enabling Surgical Treatment

Ana Luiza Caldeira Lopes et al. Maria Estefânia Bosco Otto Bianca Corrêa Rocha de Mello Michelle Bruna da Silva Sena Wagner Luis Gali

Introduction

Lutembacher syndrome (LS) is defined by the simultaneous presence of an atrial septal defect (ASD) and mitral stenosis (MS). Although it is a rare condition, its clinical significance lies in the considerable hemodynamic impact and the potential for early progression to irreversible pulmonary hypertension (PH).

The exact prevalence of LS remains unknown. However, for estimation purposes, MS is considered the most frequent manifestation of rheumatic fever (RF) in young women, and the prevalence of RF in developing countries ranges from 5 to 10 cases per 1,000 children. Furthermore, the incidence of congenital ASD in patients with MS is estimated at 0.6% to 0.7%.

[…]

Read Full Article

Editorial

Between the Physiological and the Pathological Spectra: When the Athlete's Heart Demands More Than Admiration

Antonio Amador Calvilho Júnior et al. Julia Galetto Nisgoski Maria Eduarda da Silva Pires Joao Nádson Granja Nunes Beatriz Moraes dos Santos Branco

The increasing participation in high-intensity sports has expanded the role of cardiology in athlete screening and monitoring. Although Sudden Cardiac Death (SCD) is rare, it has a deep impact on society as a whole. Echocardiography is central in this setting, serving as the primary imaging modality to distinguish physiological remodeling in the athlete’s heart from structural cardiomyopathies.

Prolonged and intense exercise induces adaptive phenotypic and physiological changes that enhance myocardial performance. These adaptations, known as “athlete’s heart,” are extensively studied because they need to be differentiated from potentially fatal cardiovascular diseases.^– The Athlete’s Heart shares phenotypic characteristics with several pathological conditions, such as Hypertrophic Cardiomyopathy (HCM), Dilated Cardiomyopathy (DCM), and Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC). Cardiologists need to be aware of these overlaps to correctly diagnose and prevent serious outcomes, especially in young, apparently healthy individuals, who may not experience symptoms until they engage in intense exercise. Equally important is the ability to identify normal adaptive cardiac remodeling, thereby enabling precise screening and appropriate guidance for elite athletes.

[…]

Read Full Article

Review Article

Assessment of Acute Chest Pain in the Emergency Department: How Point-of-Care Ultrasound Can Assist the Cardiologist

Alexandre de Matos Soeiro et al. Lucas Lentini Herling de Oliveira Rômulo Fonseca de Moraes Tatiana de Carvalho Andreucci Torres Leal

Abstract

The use of point-of-care ultrasound (POCUS) in emergency settings is now well established as part of the initial assessment of critically ill patients. In cases of acute chest pain, POCUS plays a significant role in differential diagnosis, helping to reduce diagnostic errors and, most importantly, preventing the discharge of patients with potentially life-threatening conditions. In this context, the main diagnostic considerations include acute coronary syndrome (ACS), pericarditis, pulmonary thromboembolism (PTE), and acute aortic syndromes (AAS). POCUS has proven effective in all of these scenarios and can be widely applied with proper training, both by novice physicians and experienced echocardiographers. This article aims to discuss the key ways in which POCUS can specifically aid in the differential diagnosis of chest pain.

Read Full Article

Case Report

Turmoil of Symptoms: The Devastating Impact of Cardiac Lymphoma – Multiple Clinical Manifestations and the Lethal Causes of Cardiac Involvement

Gustavo Carvalho et al. Maria Fernanda Miranda Carvalho Tiago Magalhães Alexandre Manoel Varela … Kamila Fernanda Staszko Mariana Rie Hayashida

Abstract

Primary cardiac lymphoma (PCL) is a rare and highly lethal neoplasm, whose nonspecific clinical presentation makes early diagnosis difficult. This article reports the case of an elderly patient, previously healthy, who experienced dizziness and syncope for four months before the discovery of a large tumor mass in the heart. Imaging exams, such as echocardiography and magnetic resonance imaging, were crucial for tumor identification, and the biopsy confirmed it to be a B-cell lymphoma with high replication. However, given the severity of the condition and the family’s refusal to proceed with treatment, the patient progressed to sudden death two weeks after diagnosis. Primary cardiac tumors (PCTs) are underdiagnosed, with varied symptoms that may include vascular obstructions, arrhythmias, and heart failure. PCLs account for only 1% to 2% of primary cardiac masses and are more common in elderly men. The diagnosis is challenging due to the absence of specific signs, making imaging exams and biopsies essential for disease confirmation. This case illustrates the complexity of managing PCLs, whose rapid progression limits therapeutic options. The lack of specific symptoms and silent progression highlight the importance of early diagnosis. The high mortality rate reinforces the need for greater medical attention to this condition, which frequently leads to fatal outcomes before an effective intervention can be implemented.

Read Full Article

Case Report

Late Discovery of Left Ventricular Pseudoaneurysm: A Rare Clinical Case

Angélica Pedreira da Silva et al. Gilson Soares Feitosa Gabriel de Castro Vaz Leal Rilson Fraga Moitinho Jorge Andion Torreão

Abstract

Left ventricular (LV) pseudoaneurysm is a rare complication of acute myocardial infarction (AMI). We report the case of a 67-year-old male patient seen in 2024. Following an AMI in 2019, the patient was diagnosed with a LV pseudoaneurysm after complaining of dyspnea and undergoing imaging tests including echocardiogram and magnetic resonance imaging. The patient underwent aneurysmectomy and revascularization surgery, progressing satisfactorily during the postoperative period.

Read Full Article