Resumo Fundamento Demonstrou-se recentemente que a aplicação de ultrassom de alta energia com microbolhas, técnica conhecida como sonotrombólise, causa a dissolução de trombos intravasculares e ...aumenta a taxa de recanalização angiográfica no infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAM-CSST). Objetivo Avaliar o efeito da sonotrombólise nos índices de motilidade e perfusão miocárdicas em pacientes com IAM-CSST, utilizando a ecocardiografia com perfusão miocárdica em tempo real (EPMTR). Método Uma centena de pacientes com IAM-CSST foram randomizados em dois grupos: Terapia (50 pacientes tratados com sonotrombólise e angioplastia coronária primária) e Controle (50 pacientes tratados com angioplastia coronária primária). Os pacientes realizaram EPMTR para analisar a fração de ejeção do ventrículo esquerdo (FEVE), o índice de escore de motilidade segmentar (IEMS) e o número de segmentos com defeito de perfusão miocárdica, 72 horas após o IAM-CSST e com 6 meses de acompanhamento. Foi considerado significativo p < 0,05. Resultados Pacientes tratados com sonotrombólise apresentaram FEVE mais alta que o grupo Controle em 72 horas (50 ± 10% vs. 44 ± 10%; p = 0,006), e essa melhora foi mantida em seis meses (53 ± 10% vs. 48 ± 12%; p = 0,008). O IEMS foi similar nos grupos Terapia e Controle em 72 horas (1,62 ± 0,39 vs. 1,75 ± 0,40; p = 0,09), mas tornou-se menor no grupo Terapia em 6 meses (1,46 ± 0,36 vs. 1,64 ± 0,44; p = 0,02). O número de segmentos com defeito de perfusão não foi diferente entre os grupos em 72 horas (5,92 ± 3,47 vs. 6,94 ± 3,39; p = 0,15), mas ficou menor no grupo Terapia em 6 meses (4,64 ± 3,31 vs. 6,57 ± 4,29; p = 0,01). Conclusão A sonotrombólise em pacientes com IAM-CSST resulta na melhora dos índices de motilidade e perfusão ventricular ao longo do tempo.
Contrast-enhanced ultrasound imaging is a radiation-free diagnostic tool that uses biocompatible ultrasound contrast agents (UCAs) to improve image clarity. UCAs, which do not contain dye, often ...salvage “technically difficult” ultrasound scans, increasing the accuracy and reliability of a front-line ultrasound diagnosis, reducing unnecessary downstream testing, lowering overall health care costs, changing therapy, and improving patient care. Two UCAs currently are approved and regulated by the US Food and Drug Administration. They have favorable safety profiles and risk/benefit ratios in adult and pediatric populations, including compromised patients with severe cardiovascular diseases. Nevertheless, these UCAs are contraindicated in patients with known or suspected right-to-left, bidirectional, or transient right-to-left cardiac shunts. These patients, who constitute 10% to 35% of the general population, typically receive no UCAs when they undergo echocardiography. If their echocardiographic images are suboptimal, they may receive inappropriate diagnosis and treatment, or they may be referred for additional diagnostic testing, including radiation-based procedures that increase their lifetime risk for cancer or procedures that use contrast agents containing dye, which may increase the risk for kidney damage. An exhaustive review of current peer-reviewed research demonstrated no scientific basis for the UCA contraindication in patients with known or suspected cardiac shunts. Initial safety concerns were based on limited rodent data and speculation related to macroaggregated albumin microspheres, a radioactive nuclear imaging agent with different physical and chemical properties and no relation to UCAs. Radioactive macroaggregated albumin is not contraindicated in adult or pediatric patients with cardiac shunts and is routinely used in these populations. In conclusion, the International Contrast Ultrasound Society Board recommends removal of the contraindication to further the public interest in safe, reliable, radiation-free diagnostic imaging options for patients with known or suspected cardiac shunts and to reduce their need for unnecessary downstream testing.
Cardiovascular Sonothrombolysis Porter, Thomas R.; Mathias, Wilson
Current cardiology reports,
08/2019, Letnik:
21, Številka:
8
Journal Article
Recenzirano
Purpose of Review
This review will provide recent pre-clinical and initial clinical trials exploring the efficacy of sonothrombolysis as an adjunct to current emergent therapies in acute coronary ...syndromes.
Recent Findings
The initial clinical trials examining the efficacy of short pulse duration diagnostic ultrasound (DUS) high mechanical index impulses in patients with ST segment elevation myocardial infarction (STEMI) have demonstrated that there is improved patency of the infarct vessel, and improved microvascular flow following percutaneous coronary intervention. Subsequent randomized prospective trials have confirmed that in patients with acute STEMI receiving an intravenous microbubble infusion, diagnostic high mechanical index impulses applied in the apical windows pre- and post-percutaneous coronary intervention have reduced myocardial infarction size, as assessed by magnetic resonance imaging at 72 h following presentation, and have been associated with better left ventricular systolic function at 6 month follow-up.
Summary
Sonothrombolysis has potential for improving early epicardial coronary artery patency and reduce left ventricular remodeling when added to current interventional strategies in STEMI.
Background
Cardiac shockwave therapy (CSWT) is a new potential option for the treatment of patients with chronic coronary disease and refractory angina (RA). We aimed to study the effects of CSWT on ...left ventricular myocardial perfusion and mechanics in patients with RA.
Method
We prospectively studied 19 patients who underwent CSWT. Left ventricular mechanics were evaluated by speckle tracking echocardiography (STE), and myocardial perfusion by single‐photon emission computed tomography, using stress/rest–Technetium‐99 m Sestamibi, for determination of summed stress score (SSS). Canadian Cardiac Society (CCS), New York Heart Association (NYHA), and quality of life by Seattle Angina Questionnaire (SAQ) were assessed at baseline and 6 months after therapy.
Results
CSWT therapy was applied without major side effects. At baseline, 18 patients (94.7%) had CCS class III or IV, and after CSWT there was reduction to 3 (15.8%), P = .0001, associated with improvement in SAQ (38.5%; P < .001). Thirteen (68.4%) had class NYHA III or IV before treatment, with significant reduction to 7 (36.8%); P = .014. No change was observed in the global SSS from baseline to 6‐month follow‐up (15.33 ± 8.60 vs 16.60 ± 8.06; P = .157). However, there was a significant reduction in the average SSS of the treated ischemic segments (2.1 ± 0.87 pre vs 1.6 ± 1.19 post CSWT; P = .024). Global longitudinal strain by STE remained unaltered (‐13.03 ± 8.96 pre vs ‐15.88 ± 3.43 6‐month post CSWT; P = .256).
Conclusion
CSWT is a safe procedure for the treatment of patients with RA that results in better quality of life, improvement in myocardial perfusion of the treated segments with preservation of left ventricular mechanics.
The diagnostic ultrasound-guided high mechanical index impulses during an intravenous microbubble infusion (sonothrombolysis) improve myocardial perfusion in acute ST segment elevation myocardial ...infarction, but its effect on left ventricular diastolic dysfunction (DD), left atrial (LA) mechanics and remodeling is unknown. We assessed the effect of sonothrombolysis on DD grade and LA mechanics.
One hundred patients (59 ± 10 years; 34% women) were randomized to receive either high mechanical index impulses plus percutaneous coronary intervention (PCI) (therapy group) or PCI only (control group) (n = 50 in each group). Diastolic dysfunction grade and LA mechanics were assessed immediately before and after PCI and at 48 to 72 hours, 1 month, and 6 months of follow-up. Diastolic dysfunction grades were classified as grades I, II, and III. The LA mechanics was obtained by two-dimensional speckle-tracking echocardiography-derived global longitudinal strain (GLS).
As follow-up time progressed, increased DD grade was observed more frequently in the control group than in the therapy group at 1 month and 6 months of follow-up (all P < .05). The LA-GLS values were incrementally higher in the therapy group when compared with the control group at 48 to 72 hours, 24.0% ± 7.3% in the therapy group versus 19.6% ± 7.2% in the control group, P = .005; at 1 month, 25.3% ± 6.3% in the therapy group versus 21.5% ± 8.3% in the control group, P = .020; and at 6 months, 26.2% ± 8.7% in the therapy group versus 21.6% ± 8.5% in the control group, P = .015. The therapy group was less likely to experience LA remodeling (odds ratio, 2.91 1.10-7.73; P = .03). LA-GLS was the sole predictor of LA remodeling (odds ratio, 0.79 0.67-0.94; P = .006).
Sonothrombolysis is associated with better DD grade and LA mechanics, reducing LA remodeling.
Exercise plays a positive role in the course of the ischemic heart disease, enhancing functional capacity and preventing ventricular remodeling.
To investigate the impact of exercise on left ...ventricular (LV) contraction mechanics after an uncomplicated acute myocardial infarction (AMI).
A total of 53 patients was included, 27 of whom were randomized to a supervised training program (TRAINING group), and 26 to a CONTROL group, who received usual recommendations on physical exercise after AMI. All patients underwent cardiopulmonary stress testing and a speckle tracking echocardiography to measure several parameters of LV contraction mechanics at one month and five months after AMI. A p value < 0.05 was considered statistically significant for the comparisons of the variables.
No significant difference were found in the analysis of LV longitudinal, radial and circumferential strain parameters between groups after the training period. After the training program, analysis of torsional mechanics demonstrated a reduction in the LV basal rotation in the TRAINING group in comparison to the CONTROL group (5.9±2.3 vs. 7.5±2.9o; p=0.03), and in the basal rotational velocity (53.6±18.4 vs.68.8±22.1 º/s; p=0.01), twist velocity (127.4±32.2 vs. 149.9±35.9 º/s; p=0.02) and torsion (2.4±0.4 vs. 2.8±0.8 º/cm; p=0.02).
Physical activity did not cause a significant improvement in LV longitudinal, radial and circumferential deformation parameters. However, the exercise had a significant impact on the LV torsional mechanics, consisting of a reduction in basal rotation, twist velocity, torsion and torsional velocity which can be interpreted as a ventricular "torsion reserve" in this population.
Purpose
To report lung parenchymal findings on high-resolution computed tomography (HRCT) in a population of asymptomatic, never-smoker urban dwellers aged 65 years and older.
Materials and Methods
...After institutional approval, asymptomatic older patients from the Geriatrics Outpatient Clinic aged 65 years and older (older group) and healthy volunteers aged 30–50 years (younger group) were invited to participate in the study. Asymptomatic, never-smoker subjects considered free of relevant disease after spirometry and echocardiography underwent chest HRCT. Three researchers reviewed every scan, noting the absence/presence and distribution of pre-specified parenchymal findings. Statistical comparisons between groups were performed using appropriate tests with the aid of software.
Results
Forty-seven older and 24 younger subjects were included in this analysis. A higher proportion of women and a longer history of urban dwelling were present in the older group. Parenchymal findings were more prevalent in the older group (78.7 vs. 25 % in the younger group;
p
< 0.001). Parenchymal bands (59.6 vs. 25 %;
p
= 0.007), ground-glass opacities (25.5 vs. 0 %;
p
= 0.006), and septal lines (21.3 vs. 0 %;
p
= 0.013) were more prevalent in the elderly. When only subjects aged 75 years and older were considered as the older group, micronodules, reticular opacities, cysts, and bronchiectases (19.1 vs. 0 % for all comparisons;
p
= 0.04) were also more frequently found among the elderly.
Conclusion
Parenchymal bands, ground-glass opacities, septal lines, bronchiectasis, micronodules, reticular opacities, and lung cysts were more prevalent among the elderly.
Although autonomic dysfunction has been shown to be associated with liver cirrhosis, the prevalence and prognostic implications are unclear. Abnormal heart rate variability (HRV), a measure of ...autonomic function, has not been well investigated in cirrhosis.
To evaluate the prevalence of high-risk HRV parameters in a cohort of cirrhotic patients and their association with cardiac dysfunction and mortality.
Prospective observational study conducted in the Federal University of São Paulo.
A cohort of 120 patients, comprising 17 healthy controls and 103 cirrhotic outpatients, was evaluated and followed for 10 months. HRV analysis was based on 24-hour Holter monitoring and defined using time-domain and frequency-domain parameters.
The HRV parameters were statistically lower in cirrhotic patients than in healthy subjects. High-risk HRV parameters were prevalent, such that 64% had at least one high-risk parameter. Time-domain parameters correlated with Child scores (P < 0.0001). In regression models, HRV parameters were independent predictors of diastolic dysfunction and mortality. During 10 months of follow-up, there were 11 deaths, all of patients with at least one high-risk HRV parameter. Kaplan-Meier analysis estimated low survival rates among patients with standard deviation of normal-to-normal RR intervals (SDNN) < 100.
Reduced HRV is prevalent in liver cirrhosis and is related to cardiac dysfunction, severity of liver disease and mortality. Abnormal high-risk HRV parameters are prevalent among cirrhotic patients and are also predictors of mortality. Our findings highlight the need for a more careful cardiac evaluation of cirrhotic patients.
Aims
Individuals with resistant arterial hypertension are particularly at risk of developing target organ damage and cardiovascular events. The advanced echocardiography technique called myocardial ...work (MW), through the analysis of the left ventricular pressure‐strain loop, is among the possibilities for evaluating these individuals. Our study was designed to describe the behavior of MW indices in individuals with resistant arterial hypertension (RH), controlled hypertension (CH), and normal arterial pressure (N).
Methods and Results
Seventy‐one patients underwent Ambulatory Blood Pressure Monitoring (ABPM) and were characterized into three groups after a medical consult: RH (subjects with hypertension on four or more antihypertensive medications despite having controlled blood pressure); CH (subjects with hypertension on up to two antihypertensive medications); and N (individuals with normal ABPM; not using any medications). Echocardiographic analysis was performed using the Vivid E95 ultrasound system and blood pressure was measured at the time of the examination and subsequently used to determine myocardial work indices. RH demonstrated lower global work efficiency (GWE, mean = .95%; p = .005) and higher global wasted work (GWW, mean = 114 mm Hg%; p = .011) compared to other groups. Left ventricular mass measured by three‐dimensional echocardiography, systolic wall stress, relative wall thickness and peak systolic dispersion were inversely correlated to GWE. No difference was observed between CH and N groups regarding MW indices. On multivariate analysis, only systolic wall stress remained as an independent predictor of GWE, when controlled by 3D mass index, relative wall thickness, peak systolic dispersion, and the hypertension group.
Conclusion
Individuals with resistant hypertension have lower global work efficiency and higher global wasted work, compared to individuals with controlled hypertension and without arterial hypertension.
Background
Left ventricular (LV) dysfunction is the major reason for poor outcomes in patients with congenital complete atrioventricular block (CCAVB) and pacemaker. Long‐term pacing has been ...associated with LV mechanical dyssynchrony. However, the relationship of dyssynchrony and LV dysfunction is not clear.
Objective
We sought to evaluate the prevalence of LV dyssynchrony by real time three‐dimensional echocardiography (RT3DE) in patients with CCAVB and its association with LV dysfunction. In addition, we evaluated the agreement between RT3DE and tissue Doppler imaging (TDI) for detecting LV dyssynchrony.
Method
We studied 50 patients median age 20 years old (5 months to 62 years), 68% women with CCAVB and pacemaker who underwent complete two‐dimensional echocardiography and RT3DE. LV dyssynchrony was considered if the systolic dyssynchrony index (SDI) was ≥5%. Intraventricular mechanical delay was defined by TDI when differences in electromechanical activation between LV walls were >65 msec.
Results
LV systolic dysfunction was present in 16 patients (32%) by two‐dimensional and in 20 patients (40%) by RT3DE. There was a good correlation between LV ejection fraction by two‐dimensional and RT3DE (r = 0.75; P < 0.001). Fourteen (28%) patients had intraventricular dyssynchrony by TDI, while 12 (24%) had intraventricular dyssynchrony by RT3DE. There was a good agreement between LV dyssynchrony by TDI and RT3DE (Kappa=0.735; P < 0.001). There was a negative correlation between LV ejection fraction and SDI obtained by RT3DE (r = −0.58; P < 0.001)
Conclusions
In patients with CCAVB and long‐term pacing, LV dyssynchrony occurred in one‐third of patients and was related to LV dysfunction. There was a good correlation between dyssynchrony obtained by RT3DE and TDI.
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