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Introduction: Paravalvular leak (PVL) is a common serious complication associated with prosthetic valve implantation. Objective: The aim of this study was to report our single-center experience in a retrospective review and to analyze possible predictors of success. Methods: We performed 33 percutaneous PVL closures in 26 patients (54% female, mean age 65±13 years). All mitral prostheses were studied previously with 3D transesophageal echocardiography (TEE), and aortic prostheses with 2D/3D TEE. 3D TEE and fluoroscopy were used for the assessment, planning, and guidance of the interventions. Twelve patients also underwent computed tomography angiography for better characterization of anatomic details. Results: Eighteen patients (69.2%) were admitted due to heart failure (New York Heart Association [NYHA] III or IV, seven (26.9%) because of heart failure and hemolysis, and one (3.8%) due to hemolysis only. Regarding the leaks, 46.2% were in aortic and 53.8% in mitral prostheses, 88.5% in mechanical and 7.7% in biological prostheses, and 3.8% in transcatheter aortic valve implants. All the aortic patients had severe aortic regurgitation. Furthermore, all mitral patients but one had moderate to severe or severe mitral regurgitation. Closure was successful in 17 patients (65.4%), partially successful in four (15.4%) and unsuccessful in five (19.2%). After the procedure, 69% were in NYHA I-II. Hemolysis worsened in three patients despite successful closure; all required further valvular surgery and two died. Regarding angiographic and echocardiographic procedural success, we analyzed age, gender, type of prosthesis (mechanical or biological), location (aortic or mitral), clinical data, maximum leak diameter, anatomic regurgitant orifice, leak location (anterior, posterior, inferior and lateral for mitral leaks and left, right and non-coronary sinus for aortic leaks), and number of devices (plugs) used for closure. No parameters presented a significant relationship with success excepting previous hemolysis. There was a relationship between clinical improvement and reduction of PVL (p=0.0001). In follow-up, cardiac-related events (new hospital admissions, cardiac valvular surgery, need for transfusion) were more frequent in patients with partially successful or unsuccessful closure (p=0.012). There was a relationship between cardiac-related events and death (p=0.029). Conclusion: Percutaneous PVL closure has emerged as an alternative treatment for PVL. Predictors of procedural success are difficult to establish. Survival is related to reduction of regurgitation and improvement in NYHA functional class. Resumo: Introdução: Os leaks perivalvulares são uma complicação potencialmente grave após cirurgia protésica, com uma taxa de mortalidade ainda importante, sobretudo em doentes submetidos a reoperações sucessivas. Objetivo: Avaliar retrospetivamente a nossa experiência e resultados e encontrar possíveis fatores preditores de sucesso. Métodos: Revimos 33 procedimentos consecutivos de encerramento de leak perivalvular efetuados em 26 doentes (dts) (54% dos dts eram de sexo feminino, idade média 65 ± 13 anos). Todos os casos de leaks em posição mitral foram previamente estudados com ecocardiograma transesofágico 3 D (ETE), os leaks em posição aórtica foram avaliados por ETE 2D e nalguns casos 3D. Utilizaram-se a ecocardiografia transesofágica (2D/3D) e a fluoroscopia para a avaliação, planeamento, orientação e libertação dos dispositivos de encerramento; 12 dts efetuaram previamente angioTAC para melhor caracterização e definição anatómica do leak. Resultados: Clinicamente 18 dts tinham queixas de insuficiência cardíaca (New York Heart Association [NYHA] III/IV (69,2%), 7 dts tinham insuficiência cardíaca e hemólise (26,9%) e um doente apenas emólise (3,8%); 46,2% dos leaks eram aórticos e 53,8% mitrais, a maioria, 88,5%, em próteses mecânicas, 7,7% em próteses biológicas e 3,8% (um dt) em prótese percutânea aórtica (VAP). Todos os dts de leak aórtico tinham insuficiência cardíaca por regurgitação grave, os dts com leak mitral tinham insuficiência cardíaca, alguns, hemólise e um tinha apenas hemólise. O grau de regurgitação mitral era moderado a grave ou grave, com excepção do doente só com hemólise.O encerramento foi considerado de sucesso em 17 dts (65,4%), sucesso parcial em 4 (15,4%) e insucesso em 5 (19,2%). Após o procedimento, 69% melhoraram, com melhoria das queixas de ICC (NYHA I-II), 3 dts tiveram um agravamento da hemólise apesar do encerramento ser considerado de sucesso, tendo necessitado de cirurgia, complicada em dois casos (morte).Na tentativa de encontrar fatores preditores de sucesso de encerramento do leak, analisámos dados clínicos (idade, sexo, tipo e localização da prótese, manifestações clinicas), dados ecocardiográficos (diâmetro máximo do leak, área do orifício anatómico, localização do leak, classificando-o em anterior, posterior, inferior e lateral para as próteses mitrais e para as próteses aórticas de acordo com o seio coronário adjacente em esquerdo, direito e não coronário) e ainda o número de dispositivos de encerramento utilizados (plugs). Nenhum dos parâmetros avaliados teve correlação com o sucesso do encerramento, com excepção para a hemólise. Verificou-se relação entre melhoria clínica e redução do leak (p = 0,0001). Os dts com sucesso parcial/insucesso tiveram mais eventos cardíacos (p = 0,012), a ocorrência de mais eventos cardíacos (internamento hospitalar, nova cirurgia cardíaca, transfusões) se relacionou com pior prognóstico e morte (p = 0,029). Conclusão: O encerramento percutâneo de leaks protésicos pode ser uma opção ao tratamento convencional cirúrgico. Os fatores preditores de sucesso do encerramento são difíceis de estabelecer. A sobrevida destes dts relacionou-se com redução da regurgitação e melhoria clínica (NYHA).

Background According to the 2016 ESC/ERS Guidelines on Pulmonary Hypertension (PH), the right atrial area (RAA) and the presence ofa pericardial effusion (PE) are the two main echocardiographic prognostic markers in PH patients (pts). Aim To assess the predictive ability of these two parameters. Methods Pts with PH were prospectively studied and several clinical/demographic/echocardiographic were retrieved as well as data from six-minute walk test (6MWT) and brain natriuretic peptide (BNP). All-cause mortality was analyzed by PE, RAA and other echocardiographic parameters for positive (PPV) and negative predictive value (NPV) to detect if the current guideline recommended cut-offs can precisely stratify risk in this setting. A survival analysis was performed to evaluate risk stratification (RS) provided by several different cut-offs. Results A total of 51 PH pts (mean age 54±46 years, 33.3% male, baseline BNP of 342.4±439.9pg/mL, mean 6MWT distance of 360.3±109.2 meters and baseline pulmonary artery systolic pressure of 78±26mmHg), of which 64.7% had Group I PH (GI) and 35.3% presented chronic thromboembolic pulmonary hypertension. There were no significant differences between these two groups, however pts in GI were significantly younger (p=0.001), achieved a lower 6MWT distance (p=0.038) and had worse values of right ventricular strain (p=0.040). 27 pts (52.9%) died during a mean follow-up of 52 months, with no differences between groups (p=0.756). The presence of a PE had a low NPV and PPV for the primary endpoint (45.0% and 45.5%, respectively), as well as the guideline recommended cut-offs for RAA (18cm2: NPV- 50.0% and PPV– 55.2%; 26cm2: NPV- 51.3% and PPV– 66.7%). A Pulsed Doppler Tei index (TIp) cut-off of 0.40 had a higher NPV (70.8%) and PPV (74.1%). By Kaplan-Meieran alysis, neither the presence of PE (log rank p=0.508) nor the recommended RAA cut-offs provided accurate risk discrimination (log rank p>0.05 for all). Pts below a TIp cut-off of 0.40 presented a significantly lower survival during follow-up (log rank p=0.002) Conclusion The currently recommended echocardiographic prognostic markers cannot precisely discriminate risk in PH pts. Markers of Right Ventricular Dysfunction may improve RS in this population. Funding Acknowledgement Type of funding sources: None.

Introduction The left atrial appendage occlusion (LAAO) procedure is a therapeutic option for stroke prevention in patients with atrial fibrillation (AF) which have contraindication to oral anticoagulants or still develop embolic events despite therapeutic anticoagulation. Transesophageal echocardiography (TEE) has been the gold standard to guide this procedure, with the intracardiac echocardiography (ICE) emerging as an alternative because of the advantage of reducing the general anesthesia burden compared to TEE. Objectives This study aims to compare the safety, procedure-related parameters and outcomes between TEE-guided LAAO and ICE-guided LAAO. Methods In a tertiary center, patients who underwent TEE-guided LAAO and ICE-guided LAAO were compared retrospectively regarding technical success, procedure-related events, procedure-related parameters (fluoroscopy time, dose of radiation and contrast volume), 45 days-transthoracic echocardiography (TTE) and 1-year outcomes (mortality, stroke and major bleeding). Results 88 patients underwent LAAO between 2009 and 2020 (n=43 with TEE, n=45 with ICE). Baseline characteristics were similar. Success was achieved in 95.3% (n=41) and 95.6% (n=43) of the patients in the TEE and ICE groups, respectively (OR 0.95, p=0.96). Procedure-related complications (major vascular complications, perforation, device embolization) didn't show significant differences (14.0% vs 8.9%, OR 1.66, p=0.46) in the TEE and ICE groups, respectively. Fluoroscopy time was inferior in the TEE group (29.1±13.6 vs 44.1±17.4 minutes, p=0.001), while radiation dose (2761±1555 vs 3397±2118 mGy, p=0.113) and contrast volume (220.3±104.1 vs 204.0±100.9mL, p=0.469) showed no significant differences. 45 days-TTE showed no significant differences between the TEE and ICE groups regarding peri-device leaks (14.0% vs 24.4%, p=0.212), device thrombus (2.3% vs 0%, p=0.990) and iatrogenic atrial septal defects, all mild (4.7% vs 13.3%, p=0.174). 1-year outcomes showed no significant differences regarding stroke (9.3% vs 4.4%, p=0.186), major bleeding (9.3% vs 2.2%, p=0.78) and all-cause mortality (9.3% vs 11.1%, p=0.38) between the TEE and ICE groups, respectively. Conclusions ICE-guided LAAO is associated with similar results, procedure-related events, procedure related-parameters (fluoroscopy time being the only exception) and 1-year outcomes, compared with TEE-guided LAAO. Funding Acknowledgement Type of funding sources: None.

Funding Acknowledgements Type of funding sources: None. Introduction Percutaneous mitral valve repair has shown to prevent and even reverse adverse LV remodelling in most patients with moderate to severe mitral regurgitation (MR). This effect is, however, highly variable and may differ according to the MR etiology. Objectives The aim of the present study is to evaluate cardiac remodelling patterns and clinical outcomes after MitraClip implantation (MI) in ischemic and non-ischemic patients (P). Methods A standardized registry was prospectively performed between 2013 and 2019 for all P who underwent MitraClip insertion in a single terciary care centre. Transthoracic echocardiographic information was assessed at baseline and 1, 6, 12 and 18 months after MI. Student’s t-test was used to assess the procedure’s effect on several variables. Clinical outcomes were compared with the use of Fisher’s exact test or the chi-square test, as appropriate. Results 46 P, 61% male, mean age 65 ± 14 years. 39% had ischemic MR. Dyslipidemia was more frequent in ischemic P (52% versus 93%, p= 0.002) as well as history of smoking (32% versus 67%, p= 0.022). Atrial fibrillation was significantly associated with non-ischemic etiology (75% versus 44%, p= 0.036). MI success rate was 87% (proper placement and reduction in MR to grade 2 or less), with an average of 1.5 clips. Considering the 37 P that completed 18 months of follow-up (FU), the echocardiographic parameters at baseline were: left ventricular ejection fraction (LVEF) 36 ± 12%, LV end-diastolic dimeter (LVEDD) 68.2 ± 10.2mm, LV end-systolic diameter (LVESD) 52.2 ± 13.5mm and left atrial diameter (LAD) 53.1 ± 6.7mm; there were no significant differences between groups. After MI, a compelling difference in LVEDD was noticeable early in the first month, with significant lower dimensions in non-ischemic P (66.6 ± 11.4 versus 72.8 ± 5.4, p= 0.039). Sustained differences in LVEDD were consistent at 6, 12 and 18 months (62.4 ± 12.3 versus 73.5 ± 7.4, p= 0.025). There was also a reduction in LVESD that became apparent in the sixth month (45.5 ± 15.1 versus 55.3 ± 9.8mm, p= 0.047) and that was sustained after 18 months from MI (45.4 ± 11.7 versus 58.3± 8.9, p= 0.012). No significant differences in LVEF or LAD were noticed over time. Regarding clinical outcomes at 18 months, overall mortality (M) was 24% (9P) and 51% (19P) died or were hospitalized due to heart failure (MH). No difference was found between groups: M (p= 0.119), MH (p= 0.091). Conclusion This study reports better LV reshape effects after MI in P with non-ischemic etiology, with sustained improvement over time. However, no differences regarding mortality or hospitalization due to HF were apparent at the 18-month FU. Larger long-term studies are required to evaluate these results. Abstract Figure. LV remodelling pattern

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart defect. Survival into adulthood is currently expected following surgical repair, leading to a growing population of adults with repaired TOF. In this literature review, we aim to summarize the current state of knowledge on the quality of life of adults with repaired TOF.A search was conducted on PubMed and results were reviewed for articles published between January of 2010 and June of 2020. Search terms included “Tetralogy of Fallot”, “repaired”, “adults” and “quality of life”.For the subjective health status evaluation, most published studies used Short-Form-36. Most studies agree that physical complex status is poorer for adult patients with repaired TOF than for controls. Mental complex status was also lower. Patients reported similar satisfaction with their lives and levels of social participation. Most patients had a college or university degree. Higher education, male gender and having a partner were positively associated with being employed. Studies found no difference in the proportion of patients that are married or living with a partner, compared to control groups. Patients operated for TOF have a lower reproduction rate compared with the background population.A consistent finding of these studies is abnormal physical parameters compared to psychosocial issues. The diverse needs of adults with repaired TOF require a multidisciplinary care, that takes into consideration all aspects that affect their quality of life.Despite abnormal physical functional status, it is reassuring that most adult patients with TOF lead independent and productive lives. Resumo: Tetralogia de Fallot (TOF) é a cardiopatia congénita cianótica mais comum. A sobrevivência até à idade adulta após correção cirúrgica é expectável, levando ao aumento da população de adultos com TOF corrigida. Nesta revisão da literatura, pretendemos sumarizar a evidência relativamente à qualidade de vida (QoL) destes doentes.Procedemos a uma pesquisa na Pub-Med de artigos publicados entre janeiro de 2010 e junho de 2020, utilizando os termos “Tetralogy of Fallot”, “repaired”, “adults” e “quality of life”.Para avaliação subjetiva do estado de saúde a maioria dos estudos usou o questionário Short-Form-36. A maioria concluiu que os complexos físico e mental são inferiores nos adultos com TOF corrigida, quando comparados aos grupos de controlo. No entanto, a maioria dos doentes refere níveis de satisfação com as suas vidas e de participação social semelhantes. A maioria concluiu o ensino secundário ou universitário. Um nível de educação superior, género masculino e ter um companheiro foram positivamente associados a estar empregado. Os estudos não encontram diferença na proporção de doentes casados ou a viver maritalmente. Esta população apresenta taxa de reprodução inferior à população de controlo.Um achado consistente entre os estudos é a inferioridade dos parâmetros físicos, comparativamente ao desempenho psicossocial. As necessidades diversas dos adultos com TOF corrigida requerem uma abordagem multidisciplinar, que tenha em consideração todos os aspetos que podem influenciar a qualidade de vida destes doentes.Apesar das limitações físicas, é encorajador perceber que a maioria dos adultos com TOF corrigida conquista vidas independentes e produtivas.

Copyright © 2021, The Author(s), under exclusive licence to Springer Nature B.V. part of Springer Nature, Late gadolinium enhancement on cardiac magnetic resonance adds prognostic information in patients with hypertrophic cardiomyopathy. Whether Myocardial work, a new parameter on transthoracic echocardiographic, can be associated with significant fibrosis in hypertrophic cardiomyopathy patients is unknown. In a single-centre prospective evaluation of hypertrophic cardiomyopathy patients in whom transthoracic echocardiographic and cardiac magnetic resonance were performed, Myocardial work and related indices were calculated from global longitudinal strain and from estimated left ventricular pressure curves. The extent of late gadolinium enhancement was quantitatively assessed. Late gadolinium enhancement ≥ 15% was chosen to define significant fibrosis. Logistic regression analysis was used to find the variables associated with late gadolinium enhancement ≥ 15% and cut-off values were determined. Among the forty-six patients analysed mean age was 56 ± 15 years, 28 (61%) were male patients and the mean left ventricular ejection fraction by transthoracic echocardiographic was 67 ± 8%. Global constructive work and global work index were significantly related to late gadolinium enhancement ≥ 15%, while global longitudinal strain nearly reached statistical significance. A cut-off ≤ 1550 mmHg% of global constructive work was associated with significant fibrosis with a sensitivity of 91% and a specificity of 84%, while the best cut-off for global longitudinal strain (> - 15%) had a sensitivity of 67% and a specificity of 76%. In our study cohort, global constructive work was associated with significant left ventricular myocardial fibrosis in cardiac magnetic resonance, suggesting its utility in patients who may not be able to have a cardiac magnetic resonance study.

Funding Acknowledgements Type of funding sources: None. Background Right atrial (RA) strain is as a promising technique for assessment of RA function and several studies have suggested it is a powerful prognostic marker in pulmonary hypertension (PH) patients (pts). Our aim was to assess the prognostic power of RA strain in Pulmonary Arterial Hypertension (PAH) and Chronic Thromboembolic Pulmonary Hypertension (CTEPH) pts. Methods Pts with PH were prospectively studied and several clinical/demographic/echocardiographic were retrieved as well as data from six-minute walk test (6MWT) and brain natriuretic peptide (BNP). Correlation between RA strain and other variables was tested with Pearson"s correlation analysis. Regression and survival analysis were performed to assess the combined endpoint of all-cause mortality or hospitalization in the first follow-up year (MH1). Results A total of 51 PH pts (mean age 54 ± 46 years, 33.3% male, baseline BNP of 342.4 ± 439.9pg/mL and baseline pulmonary artery systolic pressure – PASP - of 78 ± 26mmHg), of which 64.7% had PAH and 35.3% presented CTEPH. 19 ots (37.3%) met the primary endpoint. The mean RA strain was -21.9 ± -4.9%, with no significant difference between groups (-23.4% vs -17.8%, p = 0.150), however male pts had a significantly lower RA strain (-15.9% vs -25.1%, p = 0.014). There was a statistically significant (p < 0.05) correlation between RA strain and age (r = -0.287), indexed RA area (r = -0.539), index RA volume (r = -0.522) and right ventricular strain (r = -0.453). There was no correlation between RA strain and BNP value (p = 0.150), 6MWT distance (p = 0.145) or PASP (p = 0.072). RA strain was a predictor of MH1 (OR = 0.94, 95% CI: 0.894-0.998, p = 0.048). Pts who met the primary endpoint had a significantly worse RA strain (-17.0 vs -24.6%, p = 0.032). Those with a RA strain worse than -19% presented a significantly lower survival free of events during the first follow-up year (log rank p = 0.022). Conclusion RA strain is a powerful predictor of adverse events in a PH population and should be systematically assessed in order to improve risk stratification. Abstract Figure.

Funding Acknowledgements Type of funding sources: None. Objective To analyze the relationship between coronary microvascular dysfunction (MCD) and left ventricular (LV) myocardial deformation in hypertrophic cardiomyopathy (HCM). Methods Prospectively inclusion of HCM patients (P). MCD was assessed by CMR, during regadenoson-induced hyperemia. For perfusion assessment, the myocardium was divided into 32 subsegments (16 AHA segments subdivided into an endocardial and epicardial layer). Ischemic burden was calculated as the number of involved subsegments, assigning 3% of myocardium to each subsegment. Epicardial coronary artery disease was excluded by computed tomography or invasive coronary angiography. LV myocardial deformation was evaluated by 2D and 3D speckle-tracking echocardiography (STE), including global longitudinal strain (GLS), peak systolic dispersion (PDS), global circumferential strain (GCS), global radial strain (GRS), area strain, twist and torsion. Results 31 P enrolled (51%male,age57.8 ± 15.5years). Asymmetric septal hypertrophy was seen in 55%, apical in 29%, concentric in 16%,maximal wall thickness (MWT) of 20.5 ± 4.9mm; 26% with LVOT obstruction; LV ejection fraction 67.9 ± 7.9%. In 2DSTE analysis, P with more ischemia (>20%of LV) presented more severe impaired GLS and greater PDS, comparing with patients with ≤20% of ischemia. Similarly, 3DSTE imaging showed worse LV performance in P with greater ischemic burden, expressed by significant difference in GLS, GRS and area strain. GCS also trended to be worse in the presence of >20% of ischemia. The stronger correlation was found between 2D GLS and ischemic burden (Pearson correlation factor 0.545; p = 0.002). Conclusion In HCM, the severity of ischemia secondary to MCD was associated with impairment in LV myocardial deformation evaluated by 2D and 3D STE. Table 1. Echocardiography Ischemic burden (% of LV) 2D parameters ≤ 20% (n = 15) > 20% (n = 16) p-value GLS (%) -15.6 ± 2.7 -12.1 ± 4.7 0.016 PSD (ms) 73.2 ± 25.6 102.1 ± 57.6 0.150 3D parameters GLS (%) -10.3 ± 4.5 -7.3 ± 3.0 0.010 GCS (%) -12.6 ± 3.0 -10.1 ± 4.5 0.079 GRS (%) 30.8 ± 8.5 22.8 ± 11.4 0.035 Area strain(%) -20.8 ± 4.9 -15.8 ± 6.3 0.020 Twist (deg) 6.0 ± 4.8 4.1 ± 4.0 0.175 Torsion (deg/cm) 1.2 ± 0.9 0.8 ± 0.7 0.232

Background: Assessment of 2D/3D left ventricular ejection fraction (LVEF) and 2D global longitudinal strain (GLS) is the gold standard for diagnosing cancer therapeutics-related cardiac dysfunction (CTRCD). Although 3D speckle-tracking echocardiography (STE) has several advantages, it is not used in this setting. Methods: 105 breast cancer patients who underwent serial echocardiographic assessment during anthracycline therapy were included. STE was used to estimate 2D GLS, 3D GLS, 3D global circumferential strain (GCS), 3D global radial strain (GRS), and 3D global area strain (GAS). CTRCD was defined as an absolute decrease in 2D/3D LVEF > 10% to a value < 54% or a relative decrease in 2D GLS > 15%. Results: 24 patients developed CTRCD. There was a significant worsening of all 3D strain parameters during chemotherapy. 3D strain regional analysis showed impaired contractility in the anterior, inferior, and septal walls. Variations of 3D GRS and 3D GCS were associated with a higher incidence of CTRCD and the variation of 3D GRS was an independent predictor of CTRCD. Variations of 3D GCS and 3D GRS had a good discrimination for predicting CTRCD, with optimal cutoff values of - 34.2% for 3D GCS and - 34.4% for 3D GRS. These variations were observed 45 and 23 days before the diagnosis of CTRCD, respectively. Conclusion: Variations of 3D strain parameters were predictive of and preceded CTRCD, and thus have added value over currently recommended 2D/3D LVEF and 2D GLS. Routine application of this technique should be considered to offer targeted monitoring and timely initiation of cardioprotective treatment. info:eu-repo/semantics/publishedVersion

Introduction: Transposition of the great arteries (TGA) is a rare form of congenital heart disease in which most patients reach adulthood. Right ventricular dysfunction is the most severe residual complication in long-term follow-up, both in patients treated by atrial switch and in those with congenitally corrected TGA. New echocardiographic tools such as longitudinal strain by two-dimensional (2D) speckle tracking may improve assessment of ventricular function in these patients. Methods and Results: We performed a retrospective analysis of echocardiograms in adult patients with TGA (26 patients with dextro-TGA – 15 treated by atrial switch and six by arterial switch – and five with congenitally corrected TGA) and in a control group of 14 healthy individuals. Right ventricular strain was significantly worse (p

Introduction and Aim: Infective endocarditis (IE) is associated with high morbidity and mortality. It is important to determine which factors increase the risk of poor outcome in order to enable early detection and aggressive treatment, including surgery. The aim of our study was to identify factors predicting complications and in-hospital mortality in patients with IE and to analyze conditions predisposing to surgery and its outcome. Methods: We performed a retrospective study including patients with IE who underwent transesophageal echocardiography in a tertiary hospital center (2006-2014). Results: A total of 233 patients were analyzed (69.1% male; mean age 63.4±15.2 years; mean follow-up 28.4±30.7 months). The complication rate was 56.6% and in-hospital mortality was 16.3%. Independent predictors of mortality were chronic obstructive pulmonary disease (OR 4.89; CI 1.36-17.63; p=0.015), clinical course complicated by cerebral embolism (OR 9.38; CI 3.26-26.96; p

Introduction and Objectives: Left ventricular reverse remodeling (LVRR) is strongly related to the long-term prognosis of patients undergoing cardiac resynchronization therapy (CRT). The aim of this study was to assess the long-term clinical outcome of patients without LVRR at six months after CRT implantation and to determine the prognostic impact of clinical response in this population. Methods: We analyzed 178 consecutive patients who underwent successful CRT device implantation (age 64±11 years; 69% male; 89% in New York Heart Association [NYHA] functional class III; 35% with ischemic cardiomyopathy). Clinical status and echocardiographic parameters were determined before and six months after CRT implantation. We identified those without criteria for LVRR (≥10% increase in left ventricular ejection fraction with ≥15% reduction in left ventricular end-systolic diameter compared to baseline). Clinical responders were defined by a sustained improvement of at least one NYHA functional class. Results: At six-month assessment after CRT, 109 (61%) patients showed LVRR. During a mean follow-up of 56±21 months, 47 (26%) patients died, with higher mortality in the group without LVRR (36% vs. 20%, p=0.023). Clinical response was greater in patients with LVRR (88% vs. 55%, p

PURPOSE: Aortic valve area (AVA) is usually estimated by the continuity equation (CE) in which the left ventricular outflow tract (LVOT) area is calculated assuming a circular shape. This study aimed to compare measurements of LVOT area using standard 2D transthoracic echocardiography (2DTTE), 3D transesophageal echocardiography (3DTEE), and multidetector computed tomography (MDCT) and assess their relative impact on AVA estimated by the CE. METHODS AND RESULTS: We prospectively enrolled 60 patients with severe aortic stenosis (AS) referred for transcatheter aortic valve replacement (TAVR) who systematically underwent 2DTTE, 3DTEE, and MDCT. Mean LVOT areas obtained by 2DTTE (3.28±0.66 cm2 ) and 3DTEE (3.95±0.90 cm2 ) were significantly underestimated when compared to the mean MDCT LVOT area (4.31±0.99 cm2 ). LVOT was rather elliptical than round, with a mean eccentricity index of 1.47 (ratio of maximum to minimum LVOT diameters) assessed by MDCT. Mean TTE AVA estimated by the CE was 0.62±0.20 cm2 . Substitution of 2DTTE LVOT area by 3DTEE LVOT area in the CE resulted in AVA of 0.74±0.24 cm2 , while using MDCT LVOT area held an AVA of 0.80±0.24 cm2 . MDCT-derived AVA was similar to MDCT planimetric AVA and allowed 24% of patients to be reclassified from severe to moderate AS. CONCLUSIONS: 2DTTE and 3DTEE underestimate LVOT area when compared to MDCT with significant impact on AVA estimation. Assessment through MDCT fusion AVA may be of incremental value in patients with discrepant severity criteria for AS. info:eu-repo/semantics/publishedVersion

Introduction: Cardiac resynchronization therapy (CRT) has modified the prognosis of chronic heart failure (HF) with left ventricular systolic dysfunction. However, 30% of patients do not have a favorable response. The big question is how to determine predictors of response. Aims: To identify baseline characteristics that might influence echocardiographic response to CRT. Methods and Results: We performed a prospective single-center hospital-based cohort study of consecutive HF patients selected to CRT (NYHA class II-IV, left ventricular ejection fraction (LVEF)

Aims Myocardial work is a new transthoracic echocardiogram (TTE) parameter that enhances the information provided through left ventricular (LV) global longitudinal strain (GLS). Nothing is known about the impact of sacubitril/valsartan (LCZ696) therapy on myocardial work parameters. The aim of this study was to evaluate the effects of LCZ696 on LV myocardial work in heart failure patients. Methods Prospective evaluation of chronic heart failure patients with LV ejection fraction of 40% or less despite optimized standard of care therapy, in which LCZ696 therapy was started and no other heart failure treatment was expected to change. TTE study was performed before and 6 months after LCZ696 therapy. A semiautomated analysis of LV GLS was made and myocardial work estimated using custom software of the GE Vivid E95 ultrasound system. Results Of the 42 patients, 35 (83.3%) completed the 6 months, follow-up, since 2 (4.8%) patients died and 5 (11.9%) discontinued treatment due to adverse events. Mean age was 58.6 ± 11.1 years. TTE data showed a significant reduction in LV dimensions and atrial volumes, as well as an improvement in LV ejection fraction (29.3 vs. 35.2%, P = 0.001) and GLS (-7.0 vs. -8.9%, P = 0.001). Myocardial work had a significant increase in global constructive work (720.2 vs. 900.6 mmHg%, P = 0.016) and global work efficiency (78.6 vs. 86.6%, P = 0.027), with a nonsignificant decrease in global wasted work (150.2 vs. 136.8 mmHg%, P = 0.441) at 6 months. Conclusion LCZ696 therapy was associated with signs of reverse remodelling by usual TTE parameters and LV myocardial work at 6 months, including an increase in global constructive work and work efficiency.

Background Coronary microvascular dysfunction has been described as an important pathophysiologic feature in hypertrophic cardiomyopathy (HCM). Objective To analyse the impact of coronary microcirculatory dysfunction on left ventricular (LV) deformation parameters obtained by 4D echocardiography in HCM. Methods HCM patients (P) prospectively underwent dedicated transthoracic echocardiogram for microcirculation study. The evaluation of coronary flow velocity reserve (CFVR) was performed in apical three chambers view for the left anterior descending (LAD) artery and in an apical two chambers view for the posterior descending (PD) artery. Diastolic coronary flow velocity (CFV) was measured at basal conditions and during hyperaemia, induced with adenosine perfusion (0.14 mg/kg/min intravenously, during 2 minutes). Absolute CFVR was calculated as the ratio of hyperaemic to basal peak diastolic flow velocities. By 4D TTE (GE E95 equipment) LV global longitudinal strain (GLS), global circumferential stain, global radial strain, area strain, twist and torsion were analysed. Results 23 P were enrolled (57% male, mean age 57.9 ± 13.7 years). Asymmetric septal hypertrophy was verified in 70% of patients, with maximal wall thickness of 21.6 ± 4.3mm. Obstructive HCM was documented in 35% of patients. CFV was successfully measured in the LAD in all patients, but only in 70% of patients in the PD due to technical issues related to poor acoustic window and anatomical constraints. 78% of P (n = 18) presented CFVR At baseline conditions, 4D GLS < -8% was associated with lower LAD flow (34.3 ± 8.3 vs 42.7 ± 9.7cm/s; p = 0.037), trend to lower PD flow (35.3 ± 17.8 vs 49.9 ±18.4 cm/s; p = 0.066). 4D GLS < -8% P presented higher CFVR PD (2.0 ± 0.8 vs 1.1 ± 0.2; p = 0.009), with no significant difference in CFVR LAD. Global circumferential stain 4deg presented higher CFV PD at baseline (49.6 ± 16.5 vs 33,8 ± 12.9 cm/s; p = 0.039) and during hyperemia (68.0 ± 12.2 vs 52.9 ± 12.1cm/s; p = 0.032). Conclusion HCM P with greater impairment in LV deformation parameters by 4D echocardiography presented increased basal diastolic CFV, which can be explained by increased coronary vascular resistance and a higher oxygen demand at baseline conditions. Worse LV performance was also associated with decreased CFVR, mainly in PD.

Introduction Papillary fibroelastomas are rare benign primary cardiac tumors that more frequently involve cardiac valves. They are frequently incidentally discovered by echocardiography but may also cause symptoms. Purpose The aim of this study was to characterize several features of histologically confirmed fibroelastomas. Methods Retrospective analysis of patients with echocardiographic suspicion of fibroelastoma between 2009 and 2019 in a single tertiary center. Echocardiography was compared with histology, and echocardiographic, surgical and pathological information about confirmed fibroelastomas was collected. Results 37 patients (P) (54.1% men) with an echocardiographic suspicion and/or histologically confirmed fibroelastoma were included, with a mean age of 58 +- 3 years (min 22, max 82). Echocardiographic report was analyzed in 34P (91.9%), with 32P (94.1%) reporting a likely fibroelastoma and 2P (5.9%) reporting a non-specified mass. 21P (56.8%) had surgery, with 12P (57.1%) having a surgical suspicion of a fibroelastoma, 2P (9.5%) of a mixoma, 1P (4.8%) of a non-specified mass and 6P (28.6%) with undefined suspicion. Of the 21P who had surgery, 66.7% (14P) had a histologically confirmed fibroelastoma, 1P (4.8%) had a mixoma, and 6P (28.6%) had other diagnoses. From the 14P with histologically confirmed fibroelastoma 64.3% had this suspicion by echocardiography and 35.7% had an echocardiogram reporting a non-specified. There was a global concordance between echocardiography and histology in 52.9%. The mean age of confirmed fibroelastoma P was 54 +-5years, and 50% were men. 7P (50%) were asymptomatic, 2 (14.3%) had a stroke, 2 (14.3%) had syncope, 1 (7.1%) had fatigue, 1 (7.1%) had palpitations and 1P had consciousness alteration. In echocardiography most P (71.4%) had only one mass but 1P had 4 different masses. The tumors had a longer axis between 6 and 25mm, with the majority (57.1%) measuring more than 10mm. 12P (85.7%) had valvular fibroelastomas, 50% of these in the aortic valve (3 in non-coronary cusp, 1 in right coronary cusp and 2 non-specified) and 50% in the mitral valve (all in sub-valvular apparatus, involving anterior leaflet, tendinous chord or papillary muscle). 1P had a left ventricular fibroelastoma (apical) and 1P had four masses in the left atrium. Macroscopically 4 lesions had a gelatinous consistency, 2 of them were membranous, 2 were elastic, 2 were friable, 1 was villainous and in 3 of them consistency was not described. The majority (57%) was white, 14% was translucent and in the rest the color was not specified. There was no described recurrence after surgery and there were no deaths registered. Conclusion In this population there was a reasonable concordance between echocardiography and histology, but in some cases the diagnosis was undefined or wrong. 50% of the patients were asymptomatic and the majority had valvular fibroelastomas, but a few had a different location.

Aims: Cardiotoxicity is a possible complication of cancer treatment, particularly with anthracyclines and anti-HER2 drugs. Systolic dysfunction has already been described. Diastolic dysfunction and left atrial function are less studied. We sought to analyze the impact of cardiotoxic treatments on left ventricular diastolic function and left atrial (LA) function. Methods and results: Retrospective study of 100 patients (all women, with a mean age of 54 ± 12 years) with three exams in the span of 1 year during treatment for breast cancer. Patients with previous cancer treatment, coronary artery disease, significant valvular disease, and atrial arrhythmias were excluded. Diastolic dysfunction was classified according to international guidelines and left atrial strain was analyzed by two-dimensional speckle tracking. In our sample, 74% received anthracyclines, 83% anti-HER2, and 76% radiation treatment. In the follow-up, 20% developed new or worsening diastolic dysfunction. Age was the only independent predictor (OR 1.93, 95% CI 1.04-3.58, P = .037). In left atrial function, only the contractile function was significantly reduced in 20.8% of the patients and age was also the only independent predictor, but with a protective effect (OR 0.51, 95% CI 0.28-0.91, P = .023). Conclusions: During breast cancer treatment, 20% of the patients develop new or worsening diastolic dysfunction, being age the main determinant, suggesting higher impact of chemotherapy in older patients. Contractile left atrial function is also compromised but, in this case, age seems to be protective. Our results support a stricter surveillance in older patients together to eventually adjust chemotherapy regimens. info:eu-repo/semantics/publishedVersion

Introduction: In obstructive hypertrophic cardiomyopathy (HCM), alcohol septal ablation (ASA) can lead to gradient reduction and symptom improvement. We aimed to assess the efficacy and safety of ASA in a long-term outcome study. Methods: We analyzed patients who underwent ASA over a seven-year period in a tertiary center. The primary echocardiographic endpoint was >50% reduction in left ventricular outflow tract (LVOT) gradient within a year of the procedure. The primary clinical endpoints were improvement in functional capacity and a combined endpoint of cardiac death and rehospitalization for cardiac cause. The follow-up period was 4.17±2.13 years. Results: A total of 80 patients, mean age 63.9±12.3 years, 30.0% male, were analyzed. Baseline LVOT gradient was 96.3±34.6 mmHg and interventricular septal thickness was 21.6±3.1 mm. Minor complications were observed in 6.3% and major complications in 2.5%, and 8.8% received a permanent pacemaker.The primary echocardiographic endpoint was achieved by 85.7%. At three-month follow-up, LVOT gradient was 25.8±26.0 mmHg in the successful procedure group, compared to 69.2±35.6 mmHg in the other patients (p=0.001). At six months, LVOT gradient was 27.1±27.4 vs. 58.2±16.6 mmHg (p=0.024). Among 74 patients in NYHA class III/IV before the procedure, 57 (77%) improved to NHYA class I/II. The combined primary clinical endpoint (cardiac death and rehospitalization for cardiac cause) was observed in 27.5% (n=22). In the unsuccessful group, the combined endpoint was observed in 54.5%, compared to only 22.7% in the successful group. Only two patients died of cardiac causes. Conclusion: ASA is a safe procedure with a high success rate. Patients who achieved significant reductions in LVOT gradient suffered less cardiac death and rehospitalization for cardiac cause. Resumo: Introdução: Na miocardiopatia hipertrófica obstrutiva (MCHO), ablação septal alcoólica (ASA) pode levar a redução do gradiente e melhoria sintomática. O objetivo foi avaliar a eficácia e segurança da ASA no desfecho a longo prazo. Métodos: Análise de doentes submetidos a ASA, durante sete anos, num centro terciário. Endpoint primário ecocardiográfico: redução >50% do gradiente na câmara de saída do ventrículo esquerdo (CSVE) durante o primeiro ano após o procedimento. Endpoints primários clínicos: a) melhoria da capacidade funcional; b) endpoint combinado: morte de causa cardíaca+hospitalização de causa cardíaca. Tempo de seguimento 4,17±2,13 anos. Resultados: Oitenta doentes, idade média de 63,9±12,3 anos, 30,0% homens. De base, o gradiente na CSVE era 96,3±34,6 mmHg, espessura do septo interventricular 21,6±3,1 mm. Complicações minor foram verificadas em 6,3%, complicações major em 2,5% e 8,8% receberam um pacemaker definitivo. O endpoint primário ecocardiográfico foi atingido em 85,7%. Aos três meses, o gradiente na CSVE foi de 25,8±26,0 mmHg no grupo com sucesso no procedimento contrastando com 69,2±35,6 mmHg nos restantes doentes (p=0,001). Aos seis meses, os gradientes na CSVE foram 27,1±27,4 versus 58,2±16,6 mmHg (p=0,024).De entre os 74 doentes em classe NYHA III/IV antes do procedimento, 57 (77%) melhoraram para classe NYHA I/II. O endpoint primário combinado (morte de causa cardíaca+hospitalização de causa cardíaca) verificou-se em 27,5% (n=22). No grupo sem sucesso, o endpoint primário composto verificou-se em 54,5%, contrastando com apenas 22,7% no grupo com sucesso. Apenas dois doentes apresentaram morte de causa cardíaca. Conclusão: A ASA é um procedimento seguro com elevada taxa de sucesso. Doentes que atingiram redução significativa do gradiente na CSVE apresentam menor morte de causa cardíaca e hospitalização de causa cardíaca. Keywords: Obstructive hypertrophic cardiomyopathy, Alcohol septal ablation, Left ventricular outflow tract gradient, Palavras chave: Miocardiopatia hipertrófica obstrutiva, Ablação septal alcoólica, Gradiente na câmara de saída do ventrículo esquerdo

Sacubitril/Valsartan (LCZ696) reduced sudden cardiac death in the PARADIGM-HF trial. However, the mechanism by which LCZ696 reduces ventricular arrhythmias remains unclear. The aim of this study was to compare electrocardiographic (ECG) parameters and mechanical dispersion index, assessed by left ventricular (LV) global longitudinal strain (GLS), before and after LCZ696 therapy. We prospectively evaluated chronic Heart Failure (HF) patients with LV ejection fraction &le, 40%, despite optimal medical and device therapy, in which LCZ696 therapy was started, while no additional HF treatment was expected to change. ECG and transthoracic echocardiographic data were gathered in the week before starting LCZ696 and at six months of therapy. A semiautomated analysis of LV GLS was performed and mechanical dispersion index was defined as the standard deviation from 16 time intervals corresponding to each LV segment. Of the 42 patients, 35 completed the six month follow-up, since two patients died and five discontinued treatment for adverse events. QTc interval (451.9 vs. 426.0 ms, p &lt, 0.001), QRS duration (125.1 vs. 120.8 ms, p = 0.033) and mechanical dispersion index (88.4 vs. 78.1 ms, p = 0.036) were significantly reduced at six months. LCZ696 therapy is associated with a reduction in QTc interval, QRS duration and mechanical dispersion index as assessed by LV GLS.

Resumo: Introdução e objetivos: A avaliação seriada da fração de ejeção ventricular esquerda (FEVE) é o padrão de referência na vigilância da cardiotoxicidade induzida por quimioterapia (CIT). A avaliação da deformação longitudinal com técnicas de speckle tracking permite uma avaliação mais detalhada da contractilidade miocárdica. O objetivo deste estudo foi avaliar a relação entre a deformação longitudinal global (GLS) e regional e a incidência de CIT. Métodos: Foram incluídos 158 pacientes num estudo prospetivo observacional de doentes com neoplasia da mama submetidos a quimioterapia com antraciclinas, com ou sem terapêutica adjuvante com trastuzumab. Foi efetuada uma monitorização ecocardiográfica seriada de parâmetros de função sistólica e diastólica, incluindo a avaliação da deformação miocárdica longitudinal bidimensional. A incidência de CIT foi definida como uma diminuição da FEVE para valor

Objective: To determine whether right ventricular and/or atrial speckle tracking strain is associated with previous arrhythmic events in patients with repaired tetralogy of Fallot. Methods and Results: We studied right ventricular and atrial strain in 100 consecutive patients with repaired tetralogy of Fallot referred for routine echocardiographic evaluation. Patients were divided into two groups, one with previous documentation of arrhythmias (n=26) and one without arrhythmias, in a median follow-up of 22 years. Patients with arrhythmias were older (p

Resumo: Introdução: A insuficiência valvular mitral (IM) é a valvulopatia mais comum e começa agora a ser alvo de abordagens percutâneas. O dispositivo MitraClip é virtualmente o único dispositivo com uma experiência considerável, ultrapassando atualmente as 20 000 implantações. Objetivo: Descrever a experiência inicial da terapêutica percutânea da IM com o dispositivo MitraClip. Métodos: Descrevem‐se os primeiros seis casos de MitraClip realizados nesta instituição (idade 58,5 ± 13,1 anos), com IM 4 + de etiologia funcional e insuficiência cardíaca classe III ou IV (n = 3) da New York Heart Association (NYHA), sem indicação cirúrgica ou recusados para cirurgia, com um follow‐up médio 290 ± 145 dias avaliado clinicamente pela sobrevivência, classe funcional, teste da marcha dos seis minutos, estudo ecocardiográfico e determinação do proBNP. Resultados: O sucesso do procedimento (IM ≤ 2 +) foi de 100%, com um tempo de procedimento de 115,8 ± 23,7 mins, sem intercorrências intra‐hospitalares, alta entre o 4.° e 8.° dia e uma melhoria consistente no teste da marcha dos seis minutos (329,8 ± 98,42 versus 385,3 ± 106,95 m) e da classe funcional (três dos pacientes com melhoria de duas classes funcionais NYHA). Na totalidade do follow‐up (290 ± 145 dias) constatam‐se dois óbitos, em dois dos quatro pacientes que tinham sido considerados para transplantação cardíaca. Conclusões: O procedimento de implantação do dispositivo MitraClip é seguro, com uma alta taxa de sucesso imediato nos pacientes com IM funcional. A médio prazo o benefício clínico parece esbater‐se ou anular‐se nos pacientes com insuficiência cardíaca mais terminal, nomeadamente nos pacientes a aguardar ou recusados para transplante. Abstract: Introduction: Mitral regurgitation (MR) is the most common valvular disease and has recently become the target of a number of percutaneous approaches. The MitraClip is virtually the only device for which there is considerable experience, with more than 20 000 procedures performed worldwide. Objective: To describe our initial experience of the percutaneous treatment of MR with the MitraClip device. Methods: We describe the first six MitraClip cases performed in this institution (mean age 58.5±13.1 years), with functional MR grade 4+ and New York Heart Association (NYHA) heart failure class III or IV (n=3), with a mean follow‐up of 290±145 days. Results: Procedural success (MR ≤2+) was 100%. Total procedure time was 115.8±23.7 min, with no in‐hospital adverse events and discharge between the fourth and eighth day, and consistent improvement in the six‐minute walk test (329.8±98.42 vs. 385.33±106.95 m) and in NYHA class (three patients improved by two NYHA classes). During follow‐up there were two deaths, in two of the four patients who had been initially considered for heart transplantation. Conclusion: In patients with functional MR the MitraClip procedure is safe, with both a high implantation and immediate in‐hospital success rate. A longer follow‐up suggests that the clinical benefit decreases or disappears completely in patients with more advanced heart disease, namely those denied transplantation or on the heart transplant waiting list. Palavras‐chave: MitraClip, Insuficiência mitral, Reparação percutânea da válvula mitral, Insuficiência mitral funcional, Keywords: MitraClip, Mitral regurgitation, Percutaneous mitral valve repair, Functional mitral regurgitation

BACKGROUND: The use of impedance cardiography (ICG) may play a role in the assessment of cardiac effects of hypertension (HT), especially its hemodynamic features. Hypertensive heart disease involves structural changes and alterations in left ventricular geometry that end up causing systolic and/or diastolic dysfunction. The IMPEDDANS study aims to assess the usefulness of ICG for the screening of left ventricular diastolic dysfunction (LVDD) in patients with HT. METHODS: Patients with HT were assessed by echocardiography and ICG. Receiver-operating characteristic curve and the area under the curve were used to assess the discriminative ability of the parameters obtained by ICG to identify LVDD, as diagnosed by echocardiography. RESULTS: ICG derived pre-ejection period (PEP), left ventricle ejection time (LVET), systolic time ratio (STR) and D wave were associated (p

PURPOSE: Renal dysfunction is often associated with chronic heart failure, leading to increased morbi-mortality. However, data regarding these patients after cardiac resynchronization therapy (CRT) is sparse. We sought to evaluate response and long-term mortality in patients with heart failure and renal dysfunction and assess renal improvement after CRT. METHODS: We analyzed 178 consecutive patients who underwent successful CRT device implantation (age 64 ± 11 years; 69% male; 92% in New York Heart Association (NYHA) functional class ≥ III; 34% with ischemic cardiomyopathy). Echocardiographic response was defined as ≥ 15% reduction in left ventricular end-systolic diameter and clinical response as a sustained improvement of at least one NYHA functional class. Renal dysfunction was defined as an estimated glomerular filtration rate (eGFR) below 60 mL/min/1.73 m2. RESULTS: Renal dysfunction was present in 34.7%. Renal dysfunction was not an independent predictor of echocardiographic response (OR 1.109, 95% CI 0.713-1.725, p 0.646) nor clinical response (OR 1.003; 95% CI 0.997-1.010; p 0.324). During follow-up (mean 55.2 ± 32 months), patients with eGFR < 60mL/min/1.73 m2 had higher overall mortality (HR 4.902, 95% CI 1.118-21.482, p 0.035). However, clinical response in patients with renal dysfunction was independently associated with better long-term survival (HR 0.236, 95% CI 0.073-0.767, p 0.016). Renal function was significantly improved in patients who respond to CRT (ΔeGFR + 5.5 mL/min/1.73 m2 at baseline vs. follow-up, p 0.049), while this was not evident in nonresponders. Improvements in eGFR of at least 10 mL/min/1.73 m2 were associated with improved survival in renal dysfunction patients (log-rank p 0.036). CONCLUSION: Renal dysfunction was associated with higher long-term mortality in CRT patients, though, it did not influence echocardiographic nor functional response. Despite worse overall prognosis, renal dysfunction patients who are responders showed long-term survival benefit and improvement in renal function following CRT. info:eu-repo/semantics/publishedVersion

Introduction: The benefits of cardiac resynchronization therapy (CRT) documented in heart failure (HF) may be influenced by atrial fibrillation (AF). We aimed to compare CRT response in patients in AF and in sinus rhythm (SR). Methods: We prospectively studied 101 HF patients treated by CRT. Rates of clinical, echocardiographic and functional response, baseline NYHA class and variation, left ventricular ejection fraction, volumes and mass, atrial volumes, cardiopulmonary exercise test (CPET) duration (CPET dur), peak oxygen consumption (VO2max) and ventilatory efficiency (VE/VCO2 slope) were compared between AF and SR patients, before and at three and six months after implantation of a CRT device. Results: All patients achieved ≥95% biventricular pacing, and 5.7% underwent atrioventricular junction ablation. Patients were divided into AF (n=35) and SR (n=66) groups; AF patients were older, with larger atrial volumes and lower CPET dur and VO2max before CRT. The percentages of clinical and echocardiographic responders were similar in the two groups, but there were more functional responders in the AF group (71% vs. 39% in SR patients; p=0.012). In SR patients, left atrial volume and left ventricular mass were significantly reduced (p=0.015 and p=0.021, respectively), whereas in AF patients, CPET dur (p=0.003) and VO2max (p=0.001; 0.083 age-adjusted) showed larger increases. Conclusion: Clinical and echocardiographic response rates were similar in SR and AF patients, with a better functional response in AF. Improvement in left ventricular function and volumes occurred in both groups, but left ventricular mass reduction and left atrial reverse remodeling were seen exclusively in SR patients (ClinicalTrials.gov identifier: NCT02413151; FCT code: PTDC/DES/120249/2010). Resumo: Introdução: Os benefícios da terapêutica de ressincronização cardíaca (TRC), documentados na insuficiência cardíaca (IC), poderão ser influenciados pela fibrilhação auricular (FA). Pretendemos avaliar comparativamente efeitos TRC em doentes em FA e em ritmo sinusal (RS). Métodos: Foram estudados prospetivamente 101 doentes submetidos a TRC. Percentagens de respondedores clínicos, ecocardiográficos e funcionais, valores basais e variação de classe NYHA, fração de ejeção, volumes e massa ventriculares esquerdos, volumes auriculares, duração da prova de esforço cardiorrespiratória (PECR dur), consumo pico de oxigénio (VO2p) e eficiência ventilatória de esforço (VE/VCO2) foram comparados entre grupos FA e RS, pré-implantação TRC e nos seis meses após implantação. Resultados: Os doentes tiveram percentagens de pacing biventricular ≥95%, com 5,7% de ablação auriculoventricular juncional. Definimos grupo FA (n=35) e grupo RS (n=66), tendo os doentes com FA idade superior, maiores volumes auriculares, menores PECR dur e VO2p pré-CRT. Percentagens de respondedores clínicos e ecocardiográficos foram idênticas nos dois grupos, mas de respondedores funcionais foram superiores nos doentes FA (71 versus 39% no grupo RS; p=0,012). Nos doentes RS verificou-se a redução significativa do volume auricular esquerdo e da massa ventricular esquerda (p=0,015 e p=0,021, respetivamente) e nos doentes com FA maior aumento da PECR dur (p=0,003) e VO2p (p=0,001; p=0,083 ajustado para idade). Conclusão: As respostas clínica e ecocardiográfica à TRC foram semelhantes nos doentes FA e RS, com resposta funcional superior em FA. A melhoria de função e dimensões ventriculares esquerdas foi idêntica nos dois grupos, contudo redução de massa ventricular esquerda e remodelagem inversa auricular esquerda foram exclusivas de doentes RS (ClinicalTrials.gov Identifier: NCT02413151; FCT code: PTDC/DES/120249/2010). Keywords: Heart failure, Cardiac resynchronization, Atrial fibrillation, Responder, Palavras-chave: Insuficiência cardíaca, Ressincronização cardíaca, Fibrilhação auricular, Respondedor

BackgroundBicuspid aortic valve is the most common CHD. Its association with early valvular dysfunction, endocarditis, thoracic aorta dilatation, and aortic dissection is well established.ObjectiveThe aim of this study was to assess the incidence and predictors of cardiac events in adults with bicuspid aortic valve.MethodsWe carried out a retrospective analysis of cardiac outcomes in ambulatory adults with bicuspid aortic valve followed-up in a tertiary hospital centre. Outcomes were defined as follows: interventional – intervention on the aortic valve or thoracic aorta; medical – death, aortic dissection, aortic valve endocarditis, congestive heart failure, arrhythmias, or ischaemic heart disease requiring hospital admission; and a composite end point of both. Kaplan–Meier curves were generated to determine event rates, and predictors of cardiac events were determined by multivariate analysis.ResultsA total of 227 patients were followed-up over 13±9 years; 29% of patients developed severe aortic valve dysfunction and 12.3% reached ascending thoracic aorta dimensions above 45 mm. At least one cardiac outcome occurred in 38.8% of patients, with an incidence rate at 20 years of follow-up of 47±4%; 33% of patients were submitted to an aortic valve or thoracic aorta intervention. Survival 20 years after diagnosis was 94±2%. Independent predictors of the composite end point were baseline moderate–severe aortic valve dysfunction (hazard ratio, 3.19; 95% confidence interval, 1.35–7.54; pConclusionsIn this study of bicuspid aortic valve, the long-term survival was excellent but with occurrence of frequent cardiovascular events. Baseline aortic valve calcification and dysfunction were the only independent predictors of events.

Recurrence of cardiac myxoma is a rare condition, observed in about 3% of patients in sporadic cases, although it is more frequent in familial ones.Several mechanisms have been proposed to explain such recurrence, and the importance of increased vascularization as a facilitating feature is the subject of debate.The authors report the case of a non-familial right atrial myxoma, unusual for both its histopathology and recurrence. Resumo: A recorrência de mixomas cardíacos é rara, acontecendo em cerca de 3% dos doentes com mixomas esporádicos, embora seja mais frequente nos casos familiares.Vários mecanismos foram propostos para explicar as recorrências e a importância da vascularização aumentada como fenómeno facilitador é controversa.Os autores descrevem o caso de um mixoma esporádico do coração direito, peculiar pelas suas características histológicas e recorrência. Keywords: Right atrial myxoma, Recurrent cardiac myxoma, Palavras-chave: Mixoma do coração direito, Mixoma recorrente

Acromegaly is a rare disease, mostly caused by a growth hormone (GH)-secreting benign pituitary tumor, with an increased production of GH and insulin-like growth factor 1 (IGF-1). Cardiovascular complications are common and are associated with cardiomyocyte apoptosis and concentric cardiac hypertrophy. Suppression of GH and IGF-1 appears to improve cardiac function only in the short term, with little or no decrease in left ventricular mass or improvement in cardiac function after prolonged treatment. Alcohol septal ablation (ASA) has emerged as a minimally invasive alternative to septal myectomy, with significant improvement in symptoms, gradients and left ventricular remodeling. In this report, we describe the case of a 73-year-old woman with acromegaly due to a pituitary adenoma diagnosed and treated surgically at the age of 38 but with recurrence and reoperation at the age of 50. She was referred to our cardiology department due to a three-month history of progressively worsening exercise-induced dyspnea and orthopnea under optimal medical therapy. Echocardiography and magnetic resonance imaging revealed severe basal hypertrophy of the interventricular septum (19 mm), dynamic left ventricular outflow tract obstruction with a gradient of 70 mmHg at rest and 120 mmHg with Valsalva maneuver, and systolic anterior movement (SAM). Genetic testing excluded the most frequent forms of familial hypertrophic cardiomyopathy. ASA was performed with injection of 2 cc of alcohol in the first septal branch of the left coronary artery, without complications. At one-year reassessment, significant clinical and echocardiographic improvement was noted, with disappearance of SAM. To our knowledge, there have been no previously reported cases of ASA in hypertrophic cardiomyopathy due to acromegaly. We report a case of successful ASA in acromegalic cardiomyopathy. Resumo: A acromegalia é uma doença rara, causada essencialmente por um tumor benigno da glândula pituitária secretor de hormona de crescimento (HC), provocando uma produção excessiva de HC e de fator de crescimento semelhante à insulina tipo 1 (IGF-1). As complicações cardiovasculares são comuns e têm sido associadas à apoptose de cardiomiócitos e à hipertrofia cardíaca concêntrica. A supressão de HC e de IGF-1 parece melhorar a função cardíaca apenas a curto prazo, com pouco ou nenhum efeito na redução da massa ventricular esquerda ou na melhoria da função cardíaca a longo prazo. A ablação septal alcoólica (ASA) surgiu como uma alternativa minimamente invasiva à miectomia septal com melhoria significativa a nível de sintomas, gradientes e remodelagem ventricular esquerda. Neste caso clínico, descrevemos as imagens de uma mulher de 73 anos de idade, com acromegalia devido a um adenoma da glândula pituitária diagnosticado, e submetida a cirurgia aos 38 anos, mas com recorrência e reoperação aos 50 anos. A doente foi referenciada ao nosso departamento de cardiologia por um quadro com três meses de evolução de dispneia de esforço e ortopneia com agravamento progressivo sob terapêutica médica otimizada. O ecocardiograma e ressonância magnética cardíaca revelaram uma hipertrofia grave da porção basal do septo interventricular (19 mm), com um gradiente obstrutivo dinâmico da câmara de saída do ventrículo esquerdo de 70 mmHg em repouso e de 120 mmHg com a manobra de Valsalva e com movimento sistólico anterior (SAM) da válvula mitral. A avaliação genética excluiu as formas mais frequentes de cardiomiopatia hipertrófica (CMH) familiar. A ASA foi realizada com 2 cc de injeção de álcool na primeira artéria coronária septal, sem complicações. Na reavaliação do primeiro ano, houve uma melhora clínica e ecocardiográfica significativa com o desaparecimento de SAM. Tanto quanto é do nosso conhecimento, não existe na literatura a descrição de casos de ASA em doentes com CMH por acromegalia. Relatamos aqui o caso de uma ASA bem-sucedida numa cardiomiopatia acromegálica. Keywords: Hypertrophic cardiomyopathy, Acromegaly, Alcohol septal ablation, Palavras-chave: Cardiomiopatia hipertrófica, Acromegalia, Ablação septal alcoólica

Introduction: Baroreflex function is an independent marker of prognosis in heart failure (HF). However, little is known about its relation to response to cardiac resynchronization therapy (CRT). The aim of this study is to assess arterial baroreflex function in HF patients who are candidates for CRT. Methods: The study population consisted of 25 patients with indication for CRT, aged 65±10 years, NYHA functional class ≥III in 52%, QRS width 159±15 ms, left ventricular ejection fraction (LVEF) 29±5%, left ventricular end-systolic volume (LVESV) 150±48 ml, B-type natriuretic peptide (BNP) 357±270 pg/ml, and peak oxygen consumption (peak VO2) 18.4±5.0 ml/kg/min. An orthostatic tilt test was performed to assess the baroreflex effectiveness index (BEI) by the sequence method. This group was compared with 15 age-matched healthy individuals. Results: HF patients showed a significantly depressed BEI during tilt (31±12% vs. 49±18%, p=0.001). A lower BEI was associated with higher BNP (p=0.038), lower peak VO2 (p=0.048), and higher LVESV (p=0.031). By applying a cut-off value of 25% for BEI, two clusters of patients were identified: lower risk cluster (BEI >25%) QRS 153 ms, LVESV 129 ml, BNP 146 pg/ml, peak VO2 19.0 ml/kg/min; and higher risk cluster (IEB ≤25%) QRS 167 ms, LVESV 189 ml, BNP 590 pg/ml, peak VO2 16.2 ml/kg/min. Conclusions: Candidates for CRT show depressed arterial baroreflex function. Lower BEI was observed in high-risk HF patients. Baroreflex function correlated closely with other clinical HF parameters. Therefore, BEI may improve risk stratification in HF patients undergoing CRT. Resumo: Introdução: O barorreflexo arterial é comprovadamente um marcador independente de prognóstico na IC. Contudo, pouco se sabe sobre a relação entre a função do barorreflexo e a resposta à TRC. Assim, o objetivo deste estudo é avaliar a função barorreflexa em doentes com IC candidatos a TRC. Métodos: A população deste estudo prospetivo consistiu em 25 doentes com 65±10 anos, classe NYHA ≥III em 52%, QRS 159±15 ms, fração de ejeção do ventrículo esquerdo (FEVE) 29±5%, volume telessistólico do ventrículo esquerdo (VTSVE) 150±48 mL, péptido natriurético tipo-B (BNP) 357±270 pg/ml, consumo máximo de oxigénio (VO2 max) 18,4±5,0 ml/kg/min. Foi implementado um teste de ortostatismo passivo para avaliar o índice de eficácia do barorreflexo (IEB), através do método sequencial. O grupo controlo foi constituído por 15 indivíduos saudáveis emparelhados para a idade. Resultados: Os doentes com IC apresentaram um IEB significativamente reduzido durante o tilt (31±12% versus 49±18%, p=0,001). Um IEB diminuído associou-se a um BNP elevado (p=0,038), a um VO2 diminuído (p=0,048) e a um VTSVE aumentado (p=0,031). Aplicando um cut-off 25% para o IEB, foram identificados dois clusters de doentes: cluster de risco menor risco (IEB>25%) QRS 153 ms, VTSVE 129 mL, BNP 146 pg/mL, VO2 max 19,0 mL/kg/min; cluster de maior risco (IEB≤25%) QRS 167 ms, VTSVE 189 mL, BNP 590 pg/mL, VO2 max 16,2 mL/kg/min. Conclusões: Doentes candidatos a TRC apresentam barorreflexo deprimido. O BEI diminuído foi observado nos doentes de maior risco. O barorreflexo correlacionou-se bem com outros parâmetros de gravidade de IC. Desta forma, o BEI pode contribuir para a estratificação de risco dos doentes com IC submetidos a TRC. Keywords: Heart failure, Cardiac resynchronization therapy, Arterial baroreflex, Palavras-chave: Insuficiência cardíaca, Ressincronização cardíaca, Reflexo barorrecetor arterial

ObjectiveThe role of right ventricular longitudinal strain for assessing patients with repaired tetralogy of Fallot is not fully understood. In this study, we aimed to evaluate its relation with other structural and functional parameters in these patients.MethodsPatients followed-up in a grown-up CHD unit, assessed by transthoracic echocardiography, cardiac MRI, and treadmill exercise testing, were retrospectively evaluated. Right ventricular size and function and pulmonary regurgitation severity were assessed by echocardiography and MRI. Right ventricular longitudinal strain was evaluated in the four-chamber view using the standard semiautomatic method.ResultsIn total, 42 patients were included (61% male, 32±8 years). The mean right ventricular longitudinal strain was −16.2±3.7%, and the right ventricular ejection fraction, measured by MRI, was 42.9±7.2%. Longitudinal strain showed linear correlation with tricuspid annular systolic excursion (r=−0.40) and right ventricular ejection fraction (r=−0.45) (all pConclusionsRight ventricular longitudinal strain is a powerful method for evaluating patients with tetralogy of Fallot. It correlated with echocardiographic right ventricular function parameters and was independently associated with right ventricular ejection fraction derived by MRI.

Introduction: Left ventricular reverse remodeling (LVRR), defined as reduction of end-diastolic and end-systolic dimensions and improvement of ejection fraction, is associated with the prognostic implications of cardiac resynchronization therapy (CRT). The time course of LVRR remains poorly characterized. Nevertheless, it has been suggested that it occurs ≤6 months after CRT. Objective: To characterize the long-term echocardiographic and clinical evolution of patients with LVRR occurring >6 months after CRT and to identify predictors of a delayed LVRR response. Methods: A total of 127 consecutive patients after successful CRT implantation were divided into three groups according to LVRR response: Group A, 19 patients (15%) with LVRR after >6 months (late LVRR); Group B, 58 patients (46%) with LVRR before 6 months (early LVRR); and Group C, 50 patients (39%) without LVRR during follow-up (no LVRR). Results: The late LVRR group was older, more often had ischemic etiology and fewer patients were in NYHA class ≤II. Overall, group A presented LVRR between group B and C. This was also the case with the percentage of clinical response (68.4% vs. 94.8% vs. 38.3%, respectively, p6 meses após TRC, e identificar preditores de uma resposta de RIVE tardia. Métodos: Cento e vinte e sete P consecutivos, após implantação bem-sucedida de TRC, foram divididos em três grupos, de acordo com a resposta de RIVE: grupo A, 19P (15%) com RIVE após seis meses (RIVE tardia); grupo B, 58P (46%) com RIVE antes dos seis meses (RIVE precoce) e grupo C, 50P (39%) sem RIVE durante o follow-up (sem RIVE). Resultados: O grupo da RIVE tardia era mais velho, tinha mais etiologia isquémica e menos P em classe NYHA≥III. Globalmente, o grupo A apresentou um grau de RIVE entre os grupos B e C. O mesmo ocorreu em relação ao grau da resposta clínica (68,4 versus 94,8 versus 38,3%, respetivamente, p

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Introduction: Mitral regurgitation (MR) is the most common valvular disease and has recently been the target of a number of percutaneous approaches. The MitraClip is virtually the only device for which there is considerable experience, with more than 20 000 procedures performed worldwide. Objective: To describe our initial experience of the percutaneous treatment of MR with the MitraClip device. Methods: We describe the first six MitraClip cases performed in this institution (mean age 58.5±13.1 years), with functional MR grade 4+ and New York Heart Association (NYHA) heart failure class III or IV (n=3), with a mean follow-up of 290±145 days. Results: Procedural success (MR ≤2+) was 100%. Total procedure time was 115.8±23.7 min, with no in-hospital adverse events and discharge between the fourth and eighth day, and consistent improvement in the six-minute walk test (329.8±98.42 vs. 385.33±106.95 m) and in NYHA class (three patients improved by two NYHA classes). During follow-up there were two deaths, in two of the four patients who had been initially considered for heart transplantation. Conclusion: In patients with functional MR the MitraClip procedure is safe, with both a high implantation and immediate in-hospital success rate. A longer follow-up suggests that the clinical benefit decreases or disappears completely in patients with more advanced heart disease, namely those denied transplantation or on the heart transplant waiting list. Resumo: Introdução: A insuficiência valvular mitral (IM) é a valvulopatia mais comum e começa agora a ser alvo de abordagens percutâneas. O dispositivo MitraClip é virtualmente o único dispositivo com uma experiência considerável, ultrapassando atualmente as 20 000 implantações. Objetivo: Descrever a experiência inicial da terapêutica percutânea da IM com o dispositivo MitraClip. Métodos: Descrevem-se os primeiros seis casos de MitraClip realizados nesta instituição (idade 58,5 ± 13,1 anos), com IM 4+ de etiologia funcional e insuficiência cardíaca classe III ou IV (n = 3) da New York Heart Association (NYHA), sem indicação cirúrgica ou recusados para cirurgia, com um follow-up médio 290 ± 145 dias avaliado clinicamente pela sobrevivência, classe funcional, teste da marcha dos seis minutos, estudo ecocardiográfico e determinação do proBNP. Resultados: O sucesso do procedimento (IM ≤2 +) foi de 100%, com um tempo de procedimento de 115,8 ± 23,7 mins, sem intercorrências intra-hospitalares, alta entre o 4.° e 8.° dia e uma melhoria consistente no teste da marcha dos seis minutos (329,8 ± 98,42 versus 385,3 ± 106,95 m) e da classe funcional (três dos pacientes com melhoria de duas classes funcionais NYHA). Na totalidade do follow-up (290 ± 145 dias) constatam-se dois óbitos, em dois dos quatro pacientes que tinham sido considerados para transplantação cardíaca. Conclusões: O procedimento de implantação do dispositivo MitraClip é seguro, com uma alta taxa de sucesso imediato nos pacientes com IM funcional. A médio prazo o benefício clínico parece esbater-se ou anular-se nos pacientes com insuficiência cardíaca mais terminal, nomeadamente nos pacientes a aguardar ou recusados para transplante. Keywords: MitraClip, Mitral regurgitation, Percutaneous mitral valve repair, Functional mitral regurgitation, Transcatheter mitral repair, Palavras-chave: MitraClip, Insuficiência mitral, Reparação percutânea da válvula mitral, Insuficiência mitral funcional

Mário M Oliveira, Luisa M Branco, Ana Galrinho, Nogueira da Silva, Pedro S Cunha, Bruno Valente, Joana Feliciano, Ricardo Pimenta, Ana Sofia Delgado, Rui Cruz Ferreira Santa Marta Hospital, Lisbon, Portugal Background: Inappropriate settings of atrioventricular (AV) and ventriculo-ventricular (VV) intervals can be one of the factors impacting response to cardiac resynchronization therapy (CRT). Optimal concordance of AV and VV intervals between echocardiographic-based assessment and a device-based automatic programming with a hemodynamic sensor was investigated, together with left ventricle (LV) reverse remodeling after 6 months of regular automatic device-based optimization.Methods: We evaluated blindly 30 systematic echocardiographic examinations during 6 months in 17 patients (12 men, 64±10 years, in sinus rhythm and New York Heart Association class III; 76% with non-ischemic dilated cardiomyopathy, LV ejection fraction [LVEF] 40%). A statistically significant increase in LVEF was observed between baseline and 6 months post implant (P

We report the case of a 59-year-old patient, with a history of severe chest trauma with rib fractures at the age of 20 and recent onset of fatigue and palpitations, who was diagnosed with atrial tachycardia, which was converted pharmacologically. Cor triatriatum or Ebstein's anomaly were suspected on initial imaging studies (transthoracic echocardiography and MRI).Due to recurrence of arrhythmia, he subsequently underwent repeat echocardiographic evaluation, which established a diagnosis of right atrial aneurysm. The arrhythmia was converted electrically. The patient has remained asymptomatic during 18 months of follow-up, without arrhythmia recurrence, medicated with carvedilol (after an initial period with amiodarone) and warfarin. Resumo: Relata-se o caso de um paciente de 59 anos de idade, com história de traumatismo torácico grave com fractura de vários arcos costais aos 20 anos, com início recente de cansaço e palpitações, a quem foi detectada taquicardia auricular, convertida farmacologicamente. Os estudos imagiológicos (ecocardiografia transtorácica e RMN) realizados inicialmente levantaram a hipótese de se tratar de cor triatriatum ou anomalia de Ebstein.Posteriormente por recorrência da arritmia, foi efectuada nova avaliação ecocardiografica transtorácica que estabeleceu o diagnóstico de aneurisma da aurícula direita. A arritmia foi convertida electricamente. Durante o seguimento de 18 meses o paciente encontra-se assintomático, sem recorrência de arritmias, medicado com carvedilol (após período sob amiodarona) e varfarina. Keywords: Aneurysm, Right atrium, Chest trauma, Echocardiography, Cardiac magnetic resonance, Palavras-chave: Aneurisma, Aurícula direita, Traumatismo torácico, Ecocardiografia, Ressonância magnética cardíaca

Resumo: Os benefícios demonstrados com a terapêutica de ressincronização cardíaca (TRC) na redução da mortalidade e hospitalização por ICC, melhoria da classe funcional e obtenção de remodelagem inversa em doentes selecionados com insuficiência cardíaca (ICC), têm contribuído para a crescente utilização destes dispositivos na prática clínica.No entanto, permanece controverso o impacto da TRC como fator causador de arritmias ventriculares complexas. Apresentamos o caso duma doente com cardiopatia valvular operada, disfunção sistólica grave e ICC classe III da NYHA, com terapêutica médica otimizada, sem documentação prévia de arritmias ventriculares significativas. Após implantação do sistema de TRC com cardioversor‐desfibrilhador, desenvolveu quadro de tempestade arrítmica com múltiplos episódios de taquicardia ventricular monomórfica (TV) e necessidade de 12 choques, mantendo padrão de bigeminismo ventricular reprodutível e indução de salvas de TV pelo pacing biventricular. Dada a inacessibilidade a outra veia tributária do seio coronário foi decidido implantar elétrodo epicárdico em localização diferente (de veia póstero‐lateral para posição lateral‐mediana), sem registo de recorrência de arritmias num follow‐up de seis meses. Este caso sugere que a TRC pode contribuir para um efeito pró‐arrítmico com consequências clínicas potencialmente graves. Abstract: The demonstrated benefits of cardiac resynchronization therapy (CRT) in reducing mortality and hospitalizations for heart failure, improving NYHA functional class and inducing reverse remodeling have led to its increasing use in clinical practice. However, its potential contribution to complex ventricular arrhythmias is controversial.We present the case of a female patient with valvular heart failure and severe systolic dysfunction, in NYHA class III and under optimal medical therapy, without previous documented ventricular arrhythmias. After implantation of a CRT defibrillator, she suffered an arrhythmic storm with multiple episodes of monomorphic ventricular tachycardia (VT), requiring 12 shocks. Subsequently, a pattern of ventricular bigeminy was observed, as well as reproducible VT runs induced by biventricular pacing.Since no other vein of the coronary sinus system was accessible, it was decided to implant an epicardial lead to stimulate the left ventricle, positioned in the left ventricular mid‐lateral wall. No arrhythmias were detected in the following six months.This case highlights the possible proarrhythmic effect of biventricular pacing with a left ventricular lead positioned in the coronary sinus venous system. Palavras‐chave: Ressincronização cardíaca, Pacing epicárdico, Heterogeneidade da repolarização, Keywords: Cardiac resynchronization, Epicardial pacing, Repolarization heterogeneity

Objective: To evaluate the usefulness of pulsed Doppler (PD) mitral flow E wave deceleration time (EDcT) to detect and quantify changes of pulmonary capillary wedge pressure (PCWP) in patients (pt) with dilated chronic heart failure (CHF) submitted to tailored therapy. Methods: In 14 pt with dilated cardiomyopathy (DCM) (59.4 ± 10.0 years, 11 males, sinus rhythm), admitted to the ICU because of worsening CHF, serial simultaneous hemodynamic and echocardiographic studies were performed (3–5/pt; overall 49 evaluations). PD mitral flow register was used to measure EDcT and correlated with PCWP at each study. Results: PCWP ranged from 36 to 3 mmHg (17.6 ± 8.8) and EDcT from 271 to 52 ms (104.9 ± 42.4). The correlation between EDcT and PCWP was −0.65 (PCWP = 31.7–0.134EDcT). Using this equation to calculate PCWP, individual absolute values difference (identity error — IE) was 5.6 ± 3.5 mmHg (0.4–14.6). In 29 cases (59.2%) IE was > 5 mmHg, defined as major error. Considering EDcT percent change (Δ%EDcT) and PCWP variation (ΔPCWP) in serial evaluations, we found a correlation of −0.87 (ΔPCWP = −2.83–0.19 Δ%EDcT). Using this equation, the IE was 2.3 ± 1.6 mmHg (0–5.2) and there were only two (6%) major errors (P < 0.0001). Conclusions: In pt with DCM and advanced CHF, EDcT shows a reasonable correlation with PCWP, but when it is used to calculate PCWP the IE to hemodynamic values is often large. However, our results with EDcT percent change in serial evaluations using a first simultaneous invasive determination, suggest that this technique is reliable for monitoring PCWP and can be particularly useful for pt submitted to tailored therapy.

Primary tumours of the heart are uncommon entities, cardiac myxomas being the most frequent. However, mitral valve myxomas are exceptionally rare. In the last 12 years, there have been 25 myxomas diagnosed at our institution, with only two of them originating from the mitral valve. Both patients were female, the first, 25, and the second, 72 years old. The younger patient was very symptomatic with a large mass, 4 cm long, which involved both leaflets causing significant obstruction to the left ventricular inflow. The second one had a smaller mass located at the atrial side of the posterior leaflet that only produced some flow divergence. Neither of them had constitutional nor embolic symptoms. Both patients were submitted to emergent surgical resection that in the first case involved the mitral valve and replacement with mechanical prosthesis. The macroscopic appearance of these tumours suggested a malignant aetiology which may represent somewhat different features of the myxomas when originating from the cardiac valves. Both patients are well reflecting the good prognosis of this illness after resection, although the younger patient was re-operated because of prosthetic valve obstruction and suspicion of recurrence that was not confirmed. Because of the illustrative images and different presentations, we found it interesting to report and discuss them together.

A case is reported of a male patient with rheumatic mitral valve disease and open mitral valve commissurotomy, performed 13 years before, who had fever and multiple septic embolic events. Serial blood cultures were positive for Pseudomonas aeruginosa . Transthoracic and transesophageal echocardiography demonstrated the presence of an irregular, round, very mobile mass inserted in the fossa ovalis region of the interatrial septum. After resolution of the infectious process, surgery was performed. The structure previously described corresponded to an elongated suture material covered by fibrin. It had been secondarily infected and it was the cause of the entire process. (J Am Soc Echocardiogr 1997;10:371-4.)

Background: Increased left atrial (LA) size is a prognostic marker of mortality in the general population. LA size varies considerably in patients with dilated cardiomyopathy (DCM), but its clinical significance has not been widely studied. Objective: To evaluate the long-term prognostic value of LA volume (LAV) in patients with DCM. Methods: We prospectively studied patients admitted between January and December 2004 with a diagnosis of DCM, in sinus rhythm. Complete echocardiographic study at rest and after pharmacological stress was performed in all patients.The composite endpoint of mechanical ventricular assistance (MVA), heart transplantation or death during follow-up was assessed by univariate and multivariate analysis using a Cox regression model. Results: The study population consisted of 35 patients (68.6% male, mean age 52.0) with DCM, 82.9% of non-ischemic etiology. Ejection fraction (EF) at rest was 31.1±9.4%.During follow-up, eight patients died, one was placed on MVA and one underwent transplantation. Univariate Cox analysis showed various potential echocardiographic markers of prognosis in our population, including LA size in M-mode (HR 1.12, CI: 0.99–1.26, p=0.067), LAV (HR 1.03, CI: 1.00–1.07, p=0.046), LAV adjusted for body surface area (HR 1.03, CI: 0.99–1.26, p=0.049), E/A ratio (HR 0.99; CI: 0.99–1.81; p=0.060); E/A >2 (HR 7.00, CI: 1.48–32.43, p=0.014) and mitral E/E’ ratio (HR 1.04, CI: 1.00–1.09, p=0.074).The only variable that remained in the multivariate model was LAV, with a cut-off value of 63 ml (HR 7.7, CI: 0.97–60.61, p=0.05). Conclusions: LAV was the only echocardiographic determinant of MVA, heart transplantation or death in our population with DCM. The echocardiographic parameters commonly used for risk stratification such as EF, left ventricular end-diastolic diameter and contractile reserve did not show prognostic significance in our study. Resumo: Introdução: O aumento da aurícula esquerda (AE) é um marcador de mortalidade na população geral. Os doentes com miocardiopatia dilatada (MCD) têm um amplo espetro de tamanhos de AE, mas a importância clínica desta observação tem sido pouco estudada. Objectivo: Avaliar a importância prognóstica a longo prazo do volume da AE (VAE) em doentes com MCD. Métodos: Estudo prospetivo de doentes admitidos durante o ano de 2004 com o diagnóstico de MCD, em ritmo sinusal. Foi realizado estudo ecocardiográfico completo em repouso e após stress farmacológico. O endpoint composto considerou a assistência ventricular mecânica (AVM), a transplantação cardíaca ou a morte. Resultados: Foram incluídos 35 doentes (68,6% sexo masculino, idade média 52,0), 82,9% etiologia não isquémica. Fração ejeção em repouso 31,1 ± 9,4%.Durante o seguimento, oito doentes morreram, um foi colocado em AVM e um foi transplantado. A análise de Cox univariável revelou potenciais marcadores ecocardiográficos de prognóstico na amostra tais como a dimensão da AE em modo M (HR-1,12; IC: 0,99-1,26; p = 0,067); VAE (HR-1,02; IC: 1,00-1,04; p = 0,046); VAE ajustado à superfície corporal (HR-1,03; IC: 1,00-1,07; p = 0,049); E/A (HR-0,99; IC: 0,99-1,81; p = 0,060); E/A > 2 (HR-7,00; IC:1,48-32,43; p = 0,014) e E/E’ mitral (HR-1,04; IC: 1,00-1,09; p = 0,074). Na análise multivariável a única variável que permaneceu no modelo foi o VAE com o ponto de corte de 63 ml (HR-7,7, IC: 0,97-60,61, p = 0,05). Conclusão: Nesta amostra, o VAE foi o único parâmetro ecocardiográfico determinante de AVM, transplantação cardíaca ou morte. Os parâmetros ecocardiográficos habitualmente utilizados para estratificação de risco, tais como a fração ejeção do ventrículo esquerdo, a dimensão do ventrículo esquerdo e a reserva contrátil não tiveram valor prognóstico na nossa amostra. Keywords: Left atrial volume, Dilated cardiomyopathy, Echocardiographic prognostic value, Palavras-chave: Volume aurícula esquerda, Cardiomiopatia dilatada, Valor prognóstico ecocardiográfico

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Reportamos o caso de um doente de 31 anos, sexo masculino, fumador, com internamento previo em Servico de Medicina por pancreatite necro-hemorragica alitiasica. Reinternado um mes apos alta por queixas de cansaco facil para pequenos esforcos, dispneia de esforco, ortopneia, astenia, suores nocturnos e emagrecimento (6 kg num mes 10 % do peso total). Foi transferido para o nosso servico com diagnostico de derrame pericardico com tamponamento cardiaco e pancreatite necro-hemorragica alitiasica. A chegada ao SU o doente apresentava-se taquipneico (FR-22cpm) com TA-96/60 mmHg, FC-120 bpm, ingurgitamento jugular total a 30o e hepatoesplenomegalia. AC-S1 e S2 com intensidade diminuida, AP-MV presente bilateralmente contudo diminuido na base direita, ECG em ritmo sinusal com frequencia de 125 bpm, ma progressao da onda R nas derivacoes precordiais. O ecocardiograma transtoracico realizado no hospital de origem revelou volumoso derrame pericardico, massa de 12x16 mm aderente ao tecto da auricula direita (AD) e colapso diastolico do ventriculo direito (VD) mantendo funcao biventricular preservada (fi g. 1). A TAC toraco-abdominal evidenciou area hipodensa com cerca de 3 cm de maior diâmetro sugestiva de pancreatite com componente necrotico envolvendo a cauda do pâncreas, IMAGENS EM CARDIOLOGIA

Ventricular septal dissection may rarely result from infective endocarditis, myocardial infarction or sinus of Valsalva aneurysm progression. A rare case that developed in a 66-year-old female after mitral valve replacement for severe mitral regurgitation with cordal rupture is presented and discussed. It resulted from a coronary artery fistula, from a septal branch, to a 6 cm wide saccular cystic cavity within the interventricular septum, which was detected by transthoracic echocardiography some months after surgery. Coronary arteries were anatomically normal. Coronary angiography was helpful to clarify the origin of the fistula. Later on the patient developed heart failure and atrial fibrillation, but she refused any further intervention. She has been followed up for more than 7 years and is presently stable on medical therapy. A review of the peculiar aspects of the case is done and the most relevant aspects and images are presented and discussed.

This case report discusses an unusual presentation of ST-segment elevation myocardial infarction (STEMI) with normal coronary arteries and severe mechanical complications successfully treated with surgery. An 82-year-old man presented STEMI with angiographically normal coronary arteries and no major echocardiographic alterations at discharge. At the first month follow-up, he complained of fatigue and dyspnea, and contrast echocardiography complemented by cardiac magnetic resonance imaging revealed a large left ventricular apical aneurysm with a thrombus communicating by two jets of a turbulent flow to an aneurysmatic formation of the right ventricular apex. The patient underwent a Dor procedure, which was successful.Ventricular septal defects and ventricular aneurysms are rare but devastating complications of STEMI, with almost all patients presenting multivessel coronary artery disease. Interestingly in this case, the angiographic pattern was normal. Resumo: O presente caso clínico discute a apresentação incomum de um enfarte agudo do miocárdio com supradesnivelamento de ST (EAMCST) com complicações mecânicas graves e artérias coronárias normais tratado cirurgicamente com sucesso. Um homem de 82 anos sofreu um EAMCST com artérias coronárias angiograficamente normais e sem alterações ecocardiográficas de relevo aquando da alta. Na consulta do primeiro mês pós enfarte, por queixas de cansaço e dispneia, realizou um ecocardiograma complementado por uma ressonância magnética cardíaca que revelaram um grande aneurisma apical do ventrículo esquerdo, com trombo, comunicando através de dois jatos de fluxo turbulento com uma formação aneurismática do ápice do ventrículo direito. O paciente foi submetido a um procedimento de Dor com sucesso.A rutura do septo interventricular e os aneurismas ventriculares permanecem eventos raros mas devastadores com a quase maioria dos pacientes apresentado doença coronária multivaso. Curiosamente neste caso, o padrão angiográfico era normal. Keywords: Ventricular septal defect, Ventricular aneurysm, Myocardial infarction, Normal coronary arteries, Palavras-chave: Rutura interventricular, Aneurisma ventricular, Enfarte do miocárdio, Artérias coronárias normais