Prosthetic valve dysfunction is a significant clinical event. Determining its etiological mechanism and severity can be difficult. The authors present the case of a 50-year-old man, with two ...mechanical valve prostheses in aortic and mitral positions, hospitalized for decompensated heart failure. He had a long history of rheumatic multivalvular disease and had undergone three heart surgeries. On admission, investigation led to a diagnosis of severe dysfunction of both mechanical prostheses with different etiologies and mechanisms: pannus formation in the prosthetic aortic valve and intermittent dysfunction of the mitral prosthesis due to interference of a ruptured chorda tendinea in closure of the disks. The patient was reoperated, leading to significant improvement in functional class.
Abstract A 2-day-old male infant required a conventional VVI pacemaker for congenital atrioventricular block. Three years later, he developed progressive heart failure due to left ventricular (LV) ...dysfunction and mitral regurgitation despite optimized medical treatment, and a cardiac resynchronization therapy (CRT) device was implanted. This is the first Portuguese report of CRT in a pediatric patient. One-year echocardiographic follow-up showed that LV shortening fraction had improved and LV end-diastolic dimension and mitral regurgitation had decreased. New York Heart Association class had improved from III–IV to I at 1-year follow-up.
Um recém-nascido do sexo masculino apresenta bloqueio aurículo-ventricular completo pelo que foi implantado um
pacemaker VVI ao 2.° dia de vida.
Três anos depois o doente desenvolve disfunção ...ventricular esquerda, regurgitação mitral grave e insuficiência cardíaca progressiva apesar da terapêutica médica otimizada. Nesse contexto efetuamos terapêutica de ressincronização (CRT). Este é o primeiro relato português de implantação de CRT em idade pediátrica.
Um ano após a implantação o ecocardiogrma mostra melhoria da fração de ejeção, redução do diâmetro telediastólico do ventrículo esquerdo e redução muito significativa da regurgitação mitral. A classe funcional de
New York Heart Association melhorou de III-IV para I.
A 2-day-old male infant required a conventional VVI pacemaker for congenital atrioventricular block.
Three years later, he developed progressive heart failure due to left ventricular (LV) dysfunction and mitral regurgitation despite optimized medical treatment, and a cardiac resynchronization therapy (CRT) device was implanted. This is the first Portuguese report of CRT in a pediatric patient.
One-year echocardiographic follow-up showed that LV shortening fraction had improved and LV end-diastolic dimension and mitral regurgitation had decreased. New York Heart Association class had improved from III-IV to I at 1-year follow-up.
Introduction: Preoperative fasting was long regarded as an important cause of fluid depletion, leading to hemodynamic instability during surgery should replenishment is not promptly instituted. ...Lately, this traditional point of view has been progressively challenged, and a growing number of authors now propose a more restrictive approach to fluid management, although doubt remains as to the true hemodynamic influence of preoperative fasting. Methods: We designed an observational, analytic, prospective, longitudinal study in which 31 ASA 1 and ASA 2 volunteers underwent an echocardiographic examination both before and after a fasting period of at least 6 hours (h). Data from both static and dynamic preload indices were obtained on both periods, and subsequently compared. Results: Static preload indices exhibited a markedly variable behaviour with fasting. Dynamic indices, however, were far more consistent with one another, all pointing in the same direction, i.e., evidencing no statistically significant change with the fasting period. We also analysed the reliability of dynamic indices to respond to known, intentional preload changes. Aortic velocity time integral (VTI) variation with the passive leg raise manoeuvre was the only variable that proved to be sensitive enough to consistently signal the presence of preload variation. Conclusion: Fasting does not appear to cause a change in preload of conscious volunteers nor does it significantly alter their position in the Frank–Starling curve, even with longer fasting times than usually recommended. Transaortic VTI variation with the passive leg raise manoeuvre is the most robust dynamic index (of those studied) to evaluate preload responsiveness in spontaneously breathing patients. Resumo: Introdução: O jejum no pré-operatório é há muito tempo considerado como uma importante causa de depleção de líquidos, levando à instabilidade hemodinâmica durante a cirurgia, caso a reposição não seja prontamente instituída. Recentemente, esse ponto de vista tradicional vem sendo progressivamente desafiado, e um número crescente de autores agora propõe uma abordagem mais restritiva para o controle de líquidos, embora permaneçam dúvidas quanto à verdadeira influência hemodinâmica do jejum no pré-operatório. Métodos: Estudo observacional, analítico, prospectivo e longitudinal, no qual 31 voluntários ASA I e II foram submetidos a exame ecocardiográfico antes e após um período de jejum de no mínimo 6 horas. Os dados dos índices de pré-carga tanto estáticos quanto dinâmicos foram obtidos em ambos os períodos e, subsequentemente, comparados. Resultados: Os índices estáticos de pré-carga mostraram um comportamento acentuadamente variável com o jejum. Os índices dinâmicos, entretanto, foram bem mais consistentes entre si, todos apontando na mesma direção; isto é, não evidenciando nenhuma alteração estatisticamente significativa com o período de jejum. Analisamos também a confiabilidade dos índices dinâmicos para responder a alterações pré-carga intencionais conhecidas. A variação da integral de velocidade-tempo (VTI) aórtica com a manobra de elevação passiva dos membros inferiores foi a única variável que mostrou sensibilidade suficiente para sinalizar de forma consistente a presença de variação na pré-carga. Conclusão: O jejum não pareceu causar uma alteração na pré-carga de voluntários conscientes nem alterou substancialmente a sua posição na curva de Frank-Starling, mesmo com tempos de jejum mais prolongados que o normalmente recomendado. A variação do VTI transaórtico com a manobra de elevação passiva dos membros inferiores foi o índice dinâmico mais robusto (dos estudados) para avaliar a capacidade de resposta a variações da pré-carga em pacientes respirando espontaneamente. Keywords: Fasting, Echocardiography, Fluid therapy, Hemodynamics, Palavras-chave: Jejum, Ecocardiografia, Fluidoterapia, Hemodinâmica
We describe the case of a 76-year-old man with a history of ischemic heart disease and functional mitral regurgitation who over the previous six months had experienced worsening of functional class ...(NYHA III/IV) under optimal medical therapy, without ischemic symptoms and with negative ischemic tests. Mitral valve annuloplasty was considered. As the patient presented left bundle branch block on the surface ECG, cardiac resynchronization therapy (CRT) was also considered. There was, however, severe biventricular dysfunction and moderate to severe pulmonary hypertension, which are considered predictors of non-response to CRT. On echocardiographic evaluation of mechanical dyssynchrony by two-dimensional strain (2DS), spectral Doppler and color tissue Doppler imaging (TDI)/tissue synchronization imaging (TSI), we observed absence of atrioventricular dyssynchrony and presence of interventricular dyssynchrony, with inconclusive intraventricular longitudinal dyssynchrony, but with marked intraventricular radial dyssynchrony. The latter, immediately observed on the two-dimensional image, and termed multiphasic septal motion or septal flash, was characterized and quantified with 2DS. In our experience, the presence of such septal motion, for which the substrate is predominantly radial dyssynchrony, is a predictor of CRT response. Weighing the risks and benefits of mitral valve annuloplasty without associated revascularization versus CRT, we opted for the latter. Marked improvement in clinical and echocardiographic parameters was observed, compatible with the current criteria for "responder". The improvement began one month after implantation and continued throughout two-year follow-up. In this case, detailed echocardiographic study of mechanical synchrony enabled the most appropriate and effective therapeutic strategy to be chosen.
Descreve-se o caso clínico de um doente de 76 anos, com antecedentes de cardiopatia isquémica e regurgitação mitral grave funcional, que nos últimos 6 meses se encontrava em classe funcional NYHA ...III/IV, sob terapêutica médica optimizada, na ausência de sintomas isquémicos e com testes de isquémia negativos. Foi considerada a hipótese de cirúrgica de anuloplastia mitral de redução, mas como o doente apresentava no ECG de superfície padrão de bloqueio completo do ramo esquerdo (BCRE), optou-se por terapêutica de ressincronização (CRT), apesar de existir disfunção biventricular grave e hipertensão pulmonar (HTP) moderada a grave, factores considerados predictores de não-resposta a CRT. Na avaliação ecocardiográfica de dessincronia mecânica por
strain bidimensional (2DS), Doppler espectral e Doppler tecidular cor sincronizado para a sístolo (TDI/TSI) verificou-se a ausência de dessincronia aurículo-ventricular, a presença de dessincronia interventricular, sendo a análise da dessincronia intraventricular longitudinal ambígua, mas com evidente dessincronia intraventricular radial. Esta última era desde logo evidente na apreciação visual da imagem bidimensional e modo M, podendo ser descrita como movimento septal multifásico, ou
septal flash, tendo sido caracterizada e quantificada por 2DS. Na nossa experiência, a presença deste movimento septal que tem como substrato dessincronia intraventricular de predomínio radial, parece ser um marcador de resposta a CRT, pelo que, ponderados os riscos/benefícios da terapêutica cirúrgica mitral sem revascularização associada,
versus CRT, optou-se por esta última, tendo sido observado comportamento de resposta clínica e ecocardiográfica compatível com a actual designação de «respondedor», registada ao primeiro mês e mantida no seguimento de dois anos. Neste caso o estudo ecocardiográfico detalhado do sincronismo mecânico, permitiu a escolha da estratégia terapêutica mais adequada e eficaz.
We describe the case of a 76-year-old man with a history of ischemic heart disease and functional mitral regurgitation who over the previous six months had experienced worsening of functional class (NYHA III/IV) under optimal medical therapy, without ischemic symptoms and with negative ischemic tests. Mitral valve annuloplasty was considered. As the patient presented left bundle branch block on the surface ECG, cardiac resynchronization therapy (CRT) was also considered. There was, however, severe biventricular dysfunction and moderate to severe pulmonary hypertension, which are considered predictors of non-response to CRT. On echocardiographic evaluation of mechanical dyssynchrony by two-dimensional strain (2DS), spectral Doppler and color tissue Doppler imaging (TDI)/tissue synchronization imaging (TSI), we observed absence of atrioventricular dyssynchrony and presence of interventricular dyssynchrony, with inconclusive intraventricular longitudinal dyssynchrony, but with marked intraventricular radial dyssynchrony.
The latter, immediately observed on the two-dimensional image, and termed multiphasic septal motion or septal flash, was characterized and quantified with 2DS. In our experience, the presence of such septal motion, for which the substrate is predominantly radial dyssynchrony, is a predictor of CRT response. Weighing the risks and benefits of mitral valve annuloplasty without associated revascularization versu
s CRT, we opted for the latter. Marked improvement in clinical and echocardiographic parameters was observed, compatible with the current criteria for “responder”. The improvement began one month after implantation and continued throughout two-year follow-up. In this case, detailed echocardiographic study of mechanical synchrony enabled the most appropriate and effective therapeutic strategy to be chosen.
This report describes a case of a 62 year-old man admitted for recurrent myocardial infarction and normal coronary arteries, caused by coronary embolism from aortic papillary fibroelastoma. Other ...conditions causing acute coronary syndrome and normal coronary arteries are discussed. A careful evaluation by transthoracic and transesophageal echocardiography is required in this clinical setting. Surgical excision of the tumor is safe and curative.
Infective endocarditis continues to be associated with high mortality, despite the medical and surgical therapeutic options available. Surgical intervention is indicated in cases of heart failure or ...uncontrolled infection and sometimes for the prevention of embolic phenomena. The authors present the case of a 56-year-old male patient, with fibro-calcific mitral-aortic valve disease, splenectomized and with recently relapsed Hodgkin's lymphoma, who was admitted with infective endocarditis due to Streptococcus dysgalactiae. On the thirtieth day of directed antibiotic therapy, the mitral vegetation showed a significant increase in size and mobility. Surgery was considered at this point. However, given the patient's clinical stability and laboratory results, it was decided to adopt a conservative approach and to extend antibiotic therapy. The vegetation had regressed considerably seven days later. Given this atypical vegetation behavior, with slower than usual regression for the causative agent, the authors suggest that antibiotic therapy should be extended in patients with some degree of immunosuppression.
Abstract Infective endocarditis continues to be associated with high mortality, despite the medical and surgical therapeutic options available. Surgical intervention is indicated in cases of heart ...failure or uncontrolled infection and sometimes for the prevention of embolic phenomena. The authors present the case of a 56-year-old male patient, with fibro-calcific mitral–aortic valve disease, splenectomized and with recently relapsed Hodgkin's lymphoma, who was admitted with infective endocarditis due to Streptococcus dysgalactiae . On the thirtieth day of directed antibiotic therapy, the mitral vegetation showed a significant increase in size and mobility. Surgery was considered at this point. However, given the patient's clinical stability and laboratory results, it was decided to adopt a conservative approach and to extend antibiotic therapy. The vegetation had regressed considerably seven days later. Given this atypical vegetation behavior, with slower than usual regression for the causative agent, the authors suggest that antibiotic therapy should be extended in patients with some degree of immunosuppression.
A 2-day-old male infant required a conventional VVI pacemaker for congenital atrioventricular block. Three years later, he developed progressive heart failure due to left ventricular (LV) dysfunction ...and mitral regurgitation despite optimized medical treatment, and a cardiac resynchronization therapy (CRT) device was implanted. This is the first Portuguese report of CRT in a pediatric patient. One-year echocardiographic follow-up showed that LV shortening fraction had improved and LV end-diastolic dimension and mitral regurgitation had decreased. New York Heart Association class had improved from III-IV to I at 1-year follow-up.
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