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Resumo Fundamento A ecocardiografia é essencial para avaliação do coração transplantado. No entanto, os valores de normalidade no transplante cardíaco (TC) não estão claramente definidos. Objetivos: Comparar parâmetros ecocardiográficos convencionais e pela técnica de Speckle Tracking entre pacientes transplantados cardíacos sem rejeição e uma população de indivíduos saudáveis. Métodos Foram estudados prospectivamente pacientes adultos, com menos de 1 ano de TC, que realizaram biópsia endomiocárdica de vigilância seguido de ecocardiograma transtorácico (ETT). Medidas convencionais de ETT acrescidas da avaliação de mecânica cardíaca por meio do Strain pelo Speckle Tracking foram realizadas e comparadas com um grupo de voluntários saudáveis. A significância estatística adotada para o estudo foi de 5%. Resultados Avaliou-se 36 pacientes transplantados sem rejeição, os quais foram comparados com 30 indivíduos saudáveis. Observou-se redução nos valores de Strain Global Longitudinal de Ventrículo Esquerdo em valor absoluto (11,99% transplantados, 20,60% controle, p<0,0001), Strain de parede livre de Ventrículo Direito (transplantados 16,67%, controle 25,50%, p<0,0001) e dos índices de trabalho miocárdico (p<0,0001), maior tamanho do átrio esquerdo (38,17 ml/m2 transplantados, controle 18,98 ml/m2, p<0,0001), maior índice de massa e espessura relativa das paredes (p<0,0001) e a presença da Doença de Chagas como principal etiologia para o transplante. Conclusão Os transplantados cardíacos estáveis e sem rejeição apresentaram diferenças com relação aos parâmetros ecocardiográficos comparados com indivíduos saudáveis. Estes achados indicam que medidas ecocardiográficas convencionais e de mecânica cardíaca são alteradas em transplantados mesmo na ausência de rejeição e podem ser relevantes para o contexto clínico e acompanhamento dos pacientes.

Abstract Background Echocardiography is essential for the assessment of patients with heart transplants. However, normal values in such individuals are not clearly defined. Objectives To compare conventional echocardiographic and speckle tracking variables between patients with unrejected heart transplants and healthy individuals. Methods : A prospective study was conducted with adult patients having undergone heart transplantation at least one year earlier and submitted to endomyocardial biopsy followed by transthoracic echocardiogram (TTE). Conventional TTE measures and mechanical heart strain assessments using speckle tracking were performed and the results were compared to those of a group of healthy volunteers. Statistical significance was set at 5% (p < 0.05). Results Thirty-six transplant patients without rejection were analyzed and compared to 30 healthy individuals. Chagas disease was the main reason for transplantation. Lower left ventricular global longitudinal strain expressed in absolute values was found (11.99% in transplant patients vs. 20.60% in controls; p <0.0001), right ventricular free wall longitudinal strain (16.67% in transplant patients vs. 25.50% in controls; p <0.0001) and myocardial work indices (p < 0.0001) as well as a larger size of the left atrium (38.17 ml/m2 in transplant patients vs. 18.98 ml/m2 in controls; p <0.0001) and greater mass and relative wall thickness (p <0.0001). Conclusion Stable patients having undergone heart transplants without rejection have differences concerning echocardiographic variables compared to healthy individuals. These findings indicate that conventional echocardiographic measures and heart mechanics are altered in transplant patients even in the absence of rejection. Such findings are relevant to the clinical context and follow-up of the patient.

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BACKGROUND: Critical care management heavily relies on accurate cardiac output (CO) measurement. Echocardiography has been a mainstay in non-invasive cardiac monitoring; however, its comparability to invasive methods warrants further exploration. Recent studies have suggested the potential of carotid Doppler measurements as a promising approach to estimate CO. Despite this potential, the literature presents mixed outcomes regarding its reliability and accuracy. This study aims to evaluate the correlation and concordance between carotid Doppler ultrasonography and invasive hemodynamic monitoring in estimating CO in critically ill patients. Furthermore, it assesses the concordance and correlation between echocardiography CO and the standard invasive CO measurements. METHODS: This concordance study involved critically ill adults requiring invasive CO measurement. Patients with arrhythmias, severe valvulopathy, pregnancy, and poor acoustic window were excluded. Statistical analyses comprised univariate analysis, Wilcoxon signed-rank test, Spearman correlation, and intraclass correlation coefficient. Ethical approval was granted by the institution's ethics committee. RESULTS: A total of 49 critically ill patients were included, predominantly male (63.27%), with a median age of 57 years. Diagnoses included subarachnoid hemorrhage (53.06%) and heart failure (8.16%). Mean cardiac index was 3.36 ± 0.81 L/min/m2 and mean cardiac output was 5.98 ± 1.47 L/min. Spearman correlation coefficient between echocardiography and invasive CO measurements was 0.58 (p-value = p < 0.001), with an ICC of 0.59 for CO and 0.52 for cardiac index. Carotid measurements displayed no significant correlation with invasive CO. CONCLUSION: There is a moderate correlation and concordance between echocardiography and invasive CO measurements. There is no significant correlation between carotid variables and invasive CO, underscoring the necessity for cautious interpretation and application, particularly in patients with distinctive cerebral blood flow dynamics.

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Background: Tuberous sclerosis complex is a genetic neurocutaneous autosomal dominant syndrome, characterized by the development of multiple benign tumors (hamartomas) affecting various systems. Heart-benign tumors that result from the complex are called cardiac rhabdomyomas. Unlike hamartomas that occur in other organs, cardiac rhabdomyomas are most prevalent in infants and very young children with tuberous sclerosis complex. We present a case of a young adult with tuberous sclerosis who had an unusually late diagnosis of cardiac rhabdomyomas. Case report: A 22-year-old male patient of Afro-descendant, diagnosed with tuberous sclerosis complex in childhood, presented with refractory epilepsy and was treated only with lacosamide. The patient came to medical consultation due to a recent history of episodic, persistent chest pain in the sternal region, associated with physical effort. Echocardiography revealed a non-dilated left ventricle, with several rounded masses of high echogenicity without pedicles at the apical level, the largest measuring 14 × 11 mm, consistent with cardiac rhabdomyomas. Conclusion: Cardiac rhabdomyomas rarely develop in adulthood for individuals with tuberous sclerosis. These late-onset cases can exhibit various symptoms, from simple to complex presentations. Regular clinical checkups are essential for adults with tuberous sclerosis complex.

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A 49-year-old female patient, asymptomatic, presented to the cardiology office for a right atrial mass, identified incidentally in a non-electrocardiogram (ECG)-gated contrast-enhanced computed tomography, performed for follow-up of pulmonary tuberculosis. Echocardiography, surprisingly, showed an anechogenic ovoid mass in the right atrium measuring 40 × 40 mm2, implanted in the interatrial septum without affecting the tricuspid valve. ECG-gated computed tomography angiography (CTA), confirmed the dimensions of the mass, which presented homogeneous content, calcified areas, and a 12-mm pedicle implanted near the ostium of the coronary sinus. Additionally, contrast uptake and infiltration of adjacent structures were ruled out. In the surgical field, an encapsulated mass with blood content was found, which pathology reported as a hematic endocardial cyst (HEC). These are rare cardiac masses, constituting 1.5% of all primary cardiac tumors. It is usually an incidental finding, and its clinical presentation will depend on its dimensions and the intracardiac hemodynamic impact. A highlighting feature is its anechogenic content on ultrasound, however, multimodality imaging allows for making diagnostic assumptions, discerning between primary cardiac tumors, and provides morphological and hemodynamic information useful for therapeutic decision making. The age of the patient, the large size of the HEC, and its location in the interatrial septum make up a completely atypical presentation of this rare disease, which motivated this report.

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The advent of ultra-minimally invasive endoscopic spine surgery, characterized by significantly reduced surgery times, minimal blood loss, and minimal tissue trauma, has precipitated a paradigm shift in the preoperative management of patients with cardiac disease undergoing elective spine procedures. This perspective article explores how these advancements have influenced the requirements for preoperative cardiac workups and the protocols surrounding the cessation of anticoagulation and antiplatelet therapies. Traditionally, extensive cardiac evaluations and the need to stop anticoagulation and antiplatelet agents have posed challenges, increasing the risk of cardiac events and delaying surgical interventions. However, the reduced invasiveness of endoscopic spine surgery presents a safer profile for patients with cardiac comorbidities, potentially minimizing the necessity for rigorous cardiac clearance and allowing for more flexible anticoagulation management. This perspective article synthesizes current research and clinical practices to provide a comprehensive overview of these evolving protocols. It also discusses the implications of these changes for patient safety, surgical outcomes, and overall healthcare efficiency. Finally, the article suggests directions for future research, emphasizing the need for updated guidelines that reflect the reduced perioperative risk associated with these innovative surgical techniques. This discussion is pivotal for primary care physicians, surgeons, cardiologists, and the broader medical community in optimizing care for this high-risk patient population.

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OBJECTIVES: Arrhythmogenic cardiomyopathy (ACM) is a complex cardiac disorder associated with ventricular arrhythmias. Understanding the relationship between mechanical uncoupling and cardiac structural changes in ACM patients is crucial for improved risk stratification and management. METHODS: In this study, we enrolled 25 ACM patients (median age 34 years, 72% men) based on the 2019 Modified Task Force and Padua criteria. Patients were categorized by the presence or absence of clinically relevant ventricular tachycardia (crVT), necessitating emergency interventions. Right ventricular-arterial coupling (VAC) was assessed using echocardiography. Low-rank regression splines were employed to model left ventricular ejection fraction (LVEF) and right ventricular ejection fraction (RVEF) in relation to VAC. RESULTS: Positive associations were observed between VAC and LVEF (ρ = 0.472, p = 0.023), RVEF (ρ = 0.522, p = 0.038), and right ventricular (RV) indexed stroke volume (ρ = 0.79, p < 0.001). Patients with crVT exhibited correlations with RV shortening, reduced RVEF (39.6 vs. 32.2%, p = 0.025), increased left ventricular (LV) mass (38.99 vs. 45.55, p = 0.045), and LV end-diastolic volume (LVEDV) (56.99 vs. 68.15 mL/m2, p = 0.045). Positive associations for VAC were noted with LVEDV (p = 0.039) and LV mass (p = 0.039), while negative correlations were observed with RVEF by CMR (p = 0.023) and RV shortening by echocardiography (p = 0.026). CONCLUSIONS: Our findings underscore the significance of right VAC in ACM, demonstrating correlations with RV and LVEF, RV stroke volume, and clinically relevant arrhythmias. Insights into RVEF, LV mass, and end-diastolic volume provide valuable contributions to the understanding of ACM pathophysiology and may inform risk assessment strategies.

OBJETIVOS: La miocardiopatía arritmogénica (MCA) es un trastorno cardíaco complejo asociado con arritmias ventriculares (AV). Comprender la relación entre el desacoplamiento mecánico y los cambios estructurales cardíacos en pacientes con MCA es crucial para una estratificación de riesgos y una gestión mejorada. MÉTODOS: En este estudio, reclutamos a 25 pacientes con MCA (edad media 34 años, 72% hombres) basándonos en los criterios del Task Force 2019 y los criterios de Padua. Los pacientes se clasificaron según la presencia o ausencia de taquicardia ventricular clínicamente relevante (crVT), que requería intervenciones de emergencia. Se evaluó el acoplamiento ventricular derecho-arterial (VAC) mediante ecocardiografía. Se utilizaron low-rank regression splines para modelar la fracción de eyección del ventrículo izquierdo (FEVI) y la fracción de eyección del ventrículo derecho (FEVD) en relación con el VAC. RESULTADOS: Se observaron asociaciones positivas entre el VAC y la FEVI (ρ = 0.472, p = 0.023), la FEVD (ρ = 0.522, p = 0.038) y el volumen de eyección indexado del ventrículo derecho (ρ = 0.79, p < 0.001). Los pacientes con crVT mostraron correlaciones con acortamiento del ventrículo derecho, disminución de la FEVD (39.6 vs. 32.2%, p = 0.025), aumento de la masa ventricular izquierda (38.99 vs. 45.55, p = 0.045) y volumen diastólico final del ventrículo izquierdo (VDVI) (56.99 vs. 68.15 mL/m2, p = 0.045). Se observaron asociaciones positivas para el VAC con el VDVI (p = 0.039) y la masa ventricular izquierda (p = 0.039), mientras que se observaron correlaciones negativas con la FEVD por RMC (p = 0.023) y el acortamiento del ventrículo derecho por ecocardiografía (p = 0.026). CONCLUSIONES: Nuestros hallazgos subrayan la importancia del VAC derecho en la MCA, demostrando correlaciones con la FEVD y FEVI, el volumen de eyección del ventrículo derecho y arritmias clínicamente relevantes. Las percepciones sobre la FEVD, la masa ventricular izquierda y el volumen diastólico final proporcionan contribuciones valiosas para comprender la fisiopatología de la MCA y pueden informar estrategias de evaluación de riesgos.

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Nowadays, understanding the anatomy of the tricuspid valve is crucial. The bicuspid tricuspid valve is a rare anatomical variation of this valve. We present highly illustrative images with 3D echo that allow a more realistic analysis of the forgotten valve.

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Objetive: Percutaneous occlusion of patent ductus arteriosus (PDA) has classically been performed entirely by fluoroscopy, however in recent years, transthoracic echocardiography (TE) has been used as an aid to fluoroscopy or entirely by echocardiography, which avoids access of femoral artery, use of contrast and decrease in time and dose of radiation exposure. The objective of this study was to evaluate the success rate with the use of TE in percutaneous PDA closure. Material and method: Descriptive, comparative, retrospective study between patients in whom PDA closure was performed with fluoroscopy plus angiography (group 1) and fluoroscopy plus ET (group 2), between January 2018 and December 2022. The data were obtained from the clinical history electronic and procedure report. Results: One hundred eight patients were analyzed, fluoroscopy group (n: 57) and TE (n: 51). The success rate in PDA occlusion using TE was 100% and 98% for the fluoroscopy group, with no statistically significant difference The average age of group 2 was 2.9 years, while the average age of group 1 was 5 years (p=0.001), the average fluoroscopy time in group 1 was 16.9 min and 4.71 min in group 2 (p < 0.001); the fluoroscopy dose in group 1 was 68.98 mGy and 5.17 mGy in group 2 (p<0.001). Krichenko, but without significant difference in both groups. Conclusions: The success rate of percutaneous PDA closure using echocardiography and fluoroscopy is appropiate, with a success rate similar to the classic technique. In addition, it makes it possible to reduce the dose and time of fluoroscopy, avoid the use of contrast, and access the femoral artery.

Objetivo: La oclusión percutánea del ductus arterioso persistente (DAP) clásicamente se ha realizado por fluoroscopía y angiografía; sin embargo, en los últimos años se está utilizando la ecocardiografía transtorácica (ETT) como ayuda a la fluoroscopía o íntegramente por ETT, lo que evita el acceso de arteria femoral, uso de contraste y disminución de tiempo y dosis exposición a la radiación. El objetivo del estudio fue evaluar la tasa de éxito con la utilización de la ETT en el cierre percutáneo del DAP. Materiales y métodos: Estudio descriptivo de tipo comparativo, retrospectivo, entre pacientes en quienes se realizó el cierre del DAP con fluoroscopía más angiografía (grupo 1) y fluoroscopía más ETT (grupo 2), entre enero 2018 y diciembre 2022. Los datos fueron obtenidos de la historia clínica electrónica y del informe del procedimiento. Resultados: Se analizaron 108 pacientes, de los cuales 57 pertenecen al grupo de fluoroscopía más angiografía y 51 al grupo de fluoroscopía más ETT. La tasa de éxito en la oclusión del DAP utilizando fluoroscopía más ETT fue del 100% y 98% para el grupo de fluoroscopía más angiografía, sin diferencia estadísticamente significativa. La edad promedio del grupo 2 fue de 2,9 años, mientras que la edad promedio del grupo 1 fue 5 años (p< 0,001), el tiempo promedio de fluoroscopía en el grupo 1 fue de 16,9 min y 4,7 min en el grupo 2 (p < 0,001); la dosis de fluoroscopía en el grupo 1 fue de 68,98 mGy y 5,17 mGy en el grupo 2 (p< 0,001). Se encontró que el tipo de DAP predominante fue el tipo A de Krichenko, pero sin diferencia significativa en ambos grupos. Conclusión: La tasa de éxito del cierre percutáneo del DAP con el uso de la ecocardiografía y fluoroscopia es adecuada, con un nivel de éxito similar a la técnica clásica, esto permite, además, disminuir la dosis y tiempo de fluoroscopia, evitar el uso de contraste y el acceso de la arteria femoral.

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Aortic stenosis is associated with aortic plaques in up to 85% of cases because they share risk factors and pathogenic pathways. Intrinsically, complex aortic plaques carry a high risk of stroke, which has also been demonstrated in the context of aortic stenosis, especially in patients who underwent percutaneous or surgical replacement. Transesophageal echocardiography (TEE) is the imaging test of choice to detect plaques in the thoracic aorta and classify them as complex plaques. Furthermore, the 3D modality allows us to better specify its dimensions and anatomical characteristics, such as added thrombi or the presence of ulcers inside. This review aims to evaluate the use of TEE to detect complex aortic plaques in patients with an indication for percutaneous or surgical aortic valve replacement. To highlight the association between aortic stenosis and complex aortic plaques, we attached to the review some TEE studies from our experience.

La estenosis aórtica se asocia con placas aórticas hasta en un 85% de los casos, porque comparten factores de riesgo y vías patogénicas. Intrínsecamente, las placas aórticas complejas conllevan un alto riesgo de accidente cerebrovascular, lo que también se ha demostrado en el contexto de estenosis aórtica, especialmente en pacientes sometidos a reemplazo percutáneo o quirúrgico. La ecocardiografía transesofágica (ETE) es la prueba de imagen de elección para detectar placas en la aorta torácica y clasificarlas como placas complejas. Además, la modalidad 3D nos permite precisar mejor sus dimensiones y características anatómicas como trombos añadidos o la presencia de úlceras en su interior. Esta revisión tiene como objetivo evaluar el uso de ETE para detectar placas aórticas complejas en pacientes con indicación de reemplazo valvular aórtico percutáneo o quirúrgico. Para resaltar la asociación de estenosis aórtica y placas aórticas complejas adjuntamos a la revisión algunos estudios de ETE de nuestra experiencia.

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OBJECTIVES: To investigate the incidence of intravalvular leak after aortic valve replacement with the Inspiris Resilia valve. DESIGN: This study was a retrospective chart review. SETTING: This study used data from a single tertiary care academic center. PARTICIPANTS: A total of 81 patient charts and echo images were reviewed. INTERVENTIONS: All patients underwent an aortic valve replacement using the Inspiris Resilia valve. Pediatric patients and patients receiving an aortic valve conduit were excluded. MEASUREMENTS AND MAIN RESULTS: Transesophageal echocardiography (TEE) images were reviewed independently by 2 echocardiographers for the incidence and severity of intravalvular leak after Inspiris Resilia valve placement. Outpatient follow-up imaging was then compared to intraoperative findings. Valve size and mean gradients were documented as well. Of the 81 TEEs that were reviewed, 56 (69.1%) were found to have a strut leak at the time of implantation. Among these 56 cases, 30 were classified as trace regurgitation, 21 as mild regurgitation, and 5 as moderate regurgitation. Only 1 case necessitated a return to cardiopulmonary bypass owing to persistent intravalvular leak. Follow-up transthoracic echocardiography reports were available for 50 of the patients with no persistent leaks. CONCLUSIONS: This pattern of intravalvular leak is unique to the Inspiris Resilia valve and is commonly found in the intraoperative period. While many hypotheses exist for the origin of this leak, the exact mechanism is unclear. Given the high frequency of this postprocedure finding, it is essential that intraoperative echocardiographers be able to distinguish this clinically insignificant leak based on its origin, severity, and direction and to provide appropriate recommendations to our surgical colleagues.