Echocardiography, Transesophageal/methods

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Fibroelastoma, an Incidentaloma Disease? – Image Cases of Fibroelastomas as Incidental Findings in Four Patients, Four Different Valves

Joana Lima Lopes et al. Antonio Freitas João Bicho Augusto

Abstract

Fibroelastomas are the second most common benign cardiac tumor. They are small avascular structures with a mean size of 9mm, ranging up to 70mm, usually attached to the heart valves’ surface (aortic and mitral are the most affected, followed by tricuspid and pulmonary valves). Their etiology is unclear, but the hypothesis of coalescence of microthrombus at the coaptation margins of valves is the most widely accepted theory. On echocardiography, they are pedicled, mobile, with a filamentous surface, and usually have a speckled appearance with echolucencies and a stippled pattern near the edges. Clinically, they may be associated with embolic phenomena; however, in most cases, the diagnosis is incidental. We present a series of four clinical cases with an incidental diagnosis of fibroelastomas across the four cardiac valves as assessed by transthoracic echocardiography (; ).

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Editorial

Intracardiac Echocardiography Must Be Used in All Patients Who Underwent AF Ablation?

Cristiano F. Pisani et al. Mauricio Scanavacca

Atrial fibrillation ablation has become a widely used technique in treating patients with atrial fibrillation in the last 20 years due to better knowledge of its pathophysiological mechanisms, evolution in techniques for isolating pulmonary veins, and reduction of complications associated with the procedure. During this period, there have been large investments in new technologies by the industry, mainly in the improvement of images such as electroanatomical mapping systems, development of new catheters and new energies to produce more effective and lasting lesions and also with the use of intracardiac echocardiography (ICE) to add safety in the performance of the procedure to the allow instant visualization of heart structures and their relationships with catheters and sheaths.^,

The ICE is an invasive imaging technique that uses a specialized catheter to deliver ultrasound images from a probe that is located inside the heart. It presents an excellent image definition capable of recognizing in detail the location of the oval fossa and the ostia of the pulmonary veins. Allows monitoring the proper positioning and contact of the catheter tip with the structures of interest during RF application, as well as monitoring the formation of thrombi or microbubbles and alterations in tissue refraction that precede the formation of the so-called “Steam-pops”. Another advantage of the ICE is that it is operated in the field by the electrophysiologist himself, without the need for an echocardiographer.

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IJCS

Original Article

Is Age Associated with Complications of Atrial Fibrillation Catheter Ablation?

Carlos Volponi Lovatto et al. Vinicius Louback Baldon Júlia Henriques Fabrício Vassallo … Eduardo Serpa Aloyr Simões Hermes Carloni Christiano Lemos Cunha Dalbian Gasparini Roberto Barbosa Osmar Araujo Calil Renato Giestas Serpa Luiz Fernando Machado Barbosa

Abstract

Background

Atrial fibrillation (AF) is the most frequent arrhythmia, and its prevalence increases with age. The management of AF in the elderly is challenging, as it is normally associated with comorbidities and frailty. AF catheter ablation (CA) is a safe and superior alternative to antiarrhythmic drugs (AADs) for the maintenance of sinus rhythm.

Objectives

To evaluate the rate of complications associated with CA for AF across different age groups.

Methods

A retrospective analysis of 219 patients who underwent CA for AF between 2016 and 2020 were divided into 3 age groups: less than 60 years, 60 to 70 years, and > 70 years. All the included patients underwent radiofrequency ablation using an electroanatomic mapping system. Categorical variables were evaluated with chi-square and Fisher’s test, and continuous variables were evaluated by Kruskal-Wallis and post-hoc Tamhane’s T2. P values less than 0.05 were considered significant.

Results

We found an overall total complication rate of 4.6%. The total complication rate was 3.3% in patients 70 years (p = 0.742). No deaths occurred.

Conclusion

There was no significant difference in the AF CA-related complications when comparing the patients by age group.

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Peek-A-Boo What are You? The Diagnostic Challenge of a Cardiac Mass

Mariana Tinoco et al. Filipa Castro Sérgio Leite Francisco Sousa António Lourenço

A 49-year-old female was found to have an incidental right atrial mass on a routine transthoracic echocardiography (TTE) ( ). She reported no previous significant medical history, besides a mammoplasty in 2017 complicated with implant rupture in 2019. She did not take any medication, was fit and well, and showed full exercise tolerance. There were no risk factors for venous thromboembolism, and she had no significant family medical history. The patient is a former smoker of 12 pack-years. She had 2 previous pregnancies with no miscarriages. The physical examination was unremarkable.

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Research Letter

Coxiella Burnetii Endocarditis: Can Positron Emission Tomography be an Alternative to Diagnosis?

Marjorie Hayashida Mizuta et al. Cristhian Espinoza Romero Santiago Castro Vintimilla Tatiana de Carvalho Andreucci Torres Leal … Paulo Rogério Soares Alexandre de Matos Soeiro

Introduction

Coxiella burnetii infective endocarditis (IE) represents a rarely reported zoonosis in Brazil. It is estimated that Coxiella burnetii is responsible for up to 5% of all IE cases worldwide. The disease affects mostly valvulopathy patients and immunocompromised subjects.

Different from the classical acute and sub-acute endocarditis, the clinical picture is frustrating, and, because this is an obligate intracellular microorganism, hemocultures (HMC) are predominantly negative, which makes the clinical suspicion more difficult.

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Original Article

Percutaneous Transseptal Bioprosthetic Implantation in Failed Prosthetic Surgical Mitral Valve – Brazilian Multicenter Experience

Pedro Felipe Gomes Nicz et al. Pedro Henrique M. Craveiro de Melo Pedro Henrique Ferro de Brito Eliane Nogueira Lima … Ricardo Cavalcante e Silva Maurício Lopes Prudente Fernando Henrique Fernandes Maurilio Onofre Deininger Marcelo Antônio Cartaxo Queiroga Lopes Fúlvio Soares Petrucci Fernando Roquette Reis Filho Marcos Antonio Marino Rodrigo de Castro Bernardes Eduardo Pessoa de Melo Marco Antonio Praça Oliveira José Armando Mangione Fernanda Marinho Mangione Carlos Henrique Eiras Falcão Estêvão Carvalho de Campos Martins Walter Lunardi Fernando Bacal Flávio Tarasoutchi Fábio Sândoli de Brito Jr

Abstract

Background

Percutaneous intervention in patients with bioprosthetic mitral valve dysfunction is an alternative to conventional surgical treatment.

Objectives

To report the first Brazilian experience with transseptal transcatheter bioprosthetic mitral valve-in-valve implantation (transseptal-TMVIV).

Methods

Patients with surgical bioprosthetic dysfunction submitted to transseptal-TMVIV in 12 Brazilian hospitals were included. The significance level adopted was p<0.05.

Results

From June/2016 to February/2019, 17 patients underwent transseptal-TMVIV. Their median age was 77 years (IQR,70-82) and median Society of Thoracic Surgeons predicted risk of mortality (STS-PROM) score was 8.7% (IQR,7.2-17.8). All patients had limiting symptoms of heart failure (FC≥III) and 5 (29.4%) had undergone more than one previous thoracotomy. Transseptal-TMVIV was successful in all patients. Echocardiographic assessment showed a significant reduction in mean mitral valve gradient (pre-intervention, 12±3.8 mmHg; post-intervention, 5.3±2.6 mmHg; p<0.001), in addition to an increase in mitral valve area (pre-intervention, 1.06±0.59 cm²; post-intervention, 2.18±0.36 cm²; p<0.001) sustained for 30 days. There was a significant and immediate reduction in the pulmonary artery systolic pressure, with an additional reduction in 30 days (pre-intervention, 68.9±16.4 mmHg; post-intervention, 57.7±16.5 mmHg; 30 days, 50.9±18.7 mmHg; p<0.001). During follow-up (median, 162 days; IQR, 102-411), significant clinical improvement (FC≤II) was observed in 87.5% of the patients. One patient (5.9%) had left ventricular outflow tract (LVOT) obstruction and died right after the procedure, and another died at 161 days of follow-up.

Conclusion

The first Brazilian experience with transseptal-TMVIV shows the safety and effectivity of the new technique. The LVOT obstruction is a potentially fatal complication, reinforcing the importance of patients’ selection and of procedural planning. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

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Editorial

Transesophageal Echocardiogram with Contrast in Pulmonary Intravascular Dilation in Hepatosplenic Schistosomiasis

Sandra Nívea dos Reis Saraiva Falcão

The Hepatopulmonary syndrome (HPS) is defined as a defect in arterial oxygenation induced by intrapulmonary vascular dilation (IPVD) associated with liver disease. The vascular component includes diffuse or localized capillary dilation and, less commonly, pulmonary arteriovenous malformations.

A sensitive approach for the early detection of altered arterial oxygenation is the calculation of the alveolar-arterial oxygen pressure difference (PA-aO₂). This difference can be elevated before arterial oxygen pressure becomes abnormal. At sea level, PA-aO₂ ≥ 15 mmHg is considered abnormal (it changes to 20 mmHg in individuals over 64 years).

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Original Article

Value of Contrast Transesophageal Echocardiography in the Detection of Intrapulmonary Vascular Dilatations in Hepatosplenic Schistosomiasis

Aparecida de Gouvea et al. Claudio Henrique Fischer Jaquelina Sonoe Ota Arakaki Frederico José Mancuso … Paulo Brant Valdir Ambrósio Moisés Orlando Campos Filho

Abstract

Background:

Hepatopulmonary syndrome (HPS), found in cirrhotic patients, has been little studied in hepatosplenic schistosomiasis (HSS) and includes the occurrence of intrapulmonary vascular dilatations (IPVD). Contrast transesophageal echocardiography (cTEE) with microbubbles is more sensitive than contrast transthoracic echocardiography (cTTE) with microbubbles in the detection of IPVD in cirrhosis.

Objective:

To assess the performance of the cTEE, compared with that of cTTE, in detecting IPVD for the diagnosis of HPS in patients with HSS.

Methods:

cTEE and cTTE for investigation of IPVD and laboratory tests were performed in 22 patients with HSS. Agitated saline solution was injected in peripheral vein during the cTEE and cTTE procedures. Late appearance of the microbubbles in the left chambers indicated the presence of IPVD. Results of the two methods were compared by the Student’s t-test and the chi-square test (p < 0.05).

Results:

cTEE was performed in all patients without complications. Three patients were excluded due to the presence of patent foramen ovale (PFO). The presence of IPVD was confirmed in 13 (68%) of 19 patients according to the cTEE and in only six (32%, p < 0.01) according to the cTTE. No significant differences in clinical or laboratory data were found between the groups with and without IPVD, including the alveolar-arterial gradient. The diagnosis of HPS (presence of IPVD with changes in the arterial blood gas analysis) was made in five patients by the cTEE and in only one by the cTTE (p = 0.09).

Conclusion:

In HSS patients, cTEE was safe and superior to cTTE in detecting IPVD and allowed the exclusion of PFO.

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