Circumferential vascular strain rate to estimate vascular load in aortic stenosis: a speckle tracking echocardiography study

Evaluation of vascular mechanics through two-dimensional speckle-tracking (2D-ST) echocardiography is a feasible and accurate approach for assessing vascular stiffening. Degenerative aortic stenosis (AS) is currently considered a systemic vascular disease where rigidity of arterial walls increases. To assess the circumferential ascending aorta strain rate (CAASR) in thoracic aortas of patients with AS, applying 2D-ST technology. 45 patients with indexed aortic valve areas (iAVA) ≤0.85 cm(2)/m(2) were studied. Global CAASR served to assess vascular deformation. Clinical, echocardiographic, and non-invasive hemodynamic data were collected. A follow up (955 days) was also performed. Average age of the cohort was 76. ± 10.3 years, with gender balance. Mean iAVA was 0.43 ± 0.15 cm(2)/m(2). Waveforms adequate for determining CAASR were found in 246 (91 %) of the 270 aortic segments evaluated, for a mean global CAASR of 0.74 ± 0.26 s(-1). Both intra- and inter-observer variability of global CAASR were deemed appropriate. CAASR correlated significantly with age (r = -0.49, p < 0.01), the stiffness index (r = -0.59, p < 0.01), systemic arterial compliance and total vascular resistance. There was a significant positive correlation between CAASR, body surface area (BSA), iAVA, and a negative relationship with valvulo-arterial impedance and E/e' ratio (r = -0.37, p = 0.01). The stiffness index was (β = -0.41, p < 0.01) independently associated with CAASR, in a model adjusted for age, BSA, iAVA and E/e'. Patients with a baseline CAASR ≤0.66 s(-1) had a worse long-term outcome (survival 52.4 vs. 83.3 %, Log Rank p = 0.04). CAASR is a promising echocardiographic tool for studying the vascular loading component of patients with AS.info:eu-repo/semantics/publishedVersio

O Índice de Resistência Microcirculação Para o Estudo Invasivo da Microcirculação Coronária. Descrição e Validação de um Modelo Animal

INTRODUCTION: The index of microcirculatory resistance (IMR) enables/provides quantitative, invasive, and real-time assessment of coronary microcirculation status. AIMS: The primary aim of this study was to validate the assessment of IMR in a large animal model, and the secondary aim was to compare two doses of intracoronary papaverine, 5 and 10 mg, for induction of maximal hyperemia and its evolution over time. METHODS: Measurements of IMR were performed in eight pigs. Mean distal pressure (Pd) and mean transit time (Tmn) were measured at rest and at maximal hyperemia induced with intracoronary papaverine, 5 and 10 mg, and after 2, 5, 8 and 10 minutes. Disruption of the microcirculation was achieved by selective injection of 40-μm microspheres via a microcatheter in the left anterior descending artery. RESULTS: In each animal 14 IMR measurements were made. There were no differences between the two doses of papaverine regarding Pd response and IMR values - 11 ± 4.5 U with 5 mg and 10.6 ± 3 U with 10 mg (p=0.612). The evolution of IMR over time was also similar with the two doses, with significant differences from resting values disappearing after five minutes of intracoronary papaverine administration. IMR increased with disrupted microcirculation in all animals (41 ± 16 U, p=0.001). CONCLUSIONS: IMR provides invasive and real-time assessment of coronary microcirculation. Disruption of the microvascular bed is associated with a significant increase in IMR. A 5-mg dose of intracoronary papaverine is as effective as a 10-mg dose in inducing maximal hyperemia. After five minutes of papaverine administration there is no significant difference from resting hemodynamic status

The Association Between Peri-Hemorrhagic Metabolites and Cerebral Hemodynamics in Comatose Patients With Spontaneous Intracerebral Hemorrhage: An International Multicenter Pilot Study Analysis.

Background and Objective: Cerebral microdialysis (CMD) enables monitoring brain tissue metabolism and risk factors for secondary brain injury such as an imbalance of consumption, altered utilization, and delivery of oxygen and glucose, frequently present following spontaneous intracerebral hemorrhage (SICH). The aim of this study was to evaluate the relationship between lactate/pyruvate ratio (LPR) with hemodynamic variables [mean arterial blood pressure (MABP), intracranial pressure (ICP), cerebral perfusion pressure (CPP), and cerebrovascular pressure reactivity (PRx)] and metabolic variables (glutamate, glucose, and glycerol), within the cerebral peri-hemorrhagic region, with the hypothesis that there may be an association between these variables, leading to a worsening of outcome in comatose SICH patients. Methods: This is an international multicenter cohort study regarding a retrospective dataset analysis of non-consecutive comatose patients with supratentorial SICH undergoing invasive multimodality neuromonitoring admitted to neurocritical care units pertaining to three different centers. Patients with SICH were included if they had an indication for invasive ICP and CMD monitoring, were &gt;18 years of age, and had a Glasgow Coma Scale (GCS) score of ≤8. Results: Twenty-two patients were included in the analysis. A total monitoring time of 1,558 h was analyzed, with a mean (SD) monitoring time of 70.72 h (66.25) per patient. Moreover, 21 out of the 22 patients (95%) had disturbed cerebrovascular autoregulation during the observation period. When considering a dichotomized LPR for a threshold level of 25 or 40, there was a statistically significant difference in all the measured variables (PRx, glucose, glutamate), but not glycerol. When dichotomized PRx was considered as the dependent variable, only LPR was related to autoregulation. A lower PRx was associated with a higher survival [27.9% (23.1%) vs. 56.0% (31.3%), p = 0.03]. Conclusions: According to our results, disturbed autoregulation in comatose SICH patients is common. It is correlated to deranged metabolites within the peri-hemorrhagic region of the clot and is also associated with poor outcome

Diagnosis and treatment of acute myocarditis in Portugal. Data from the national multicenter registry on myocarditis

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017.Introduction: The diagnosis of acute myocarditis (aMyo) needs a high level of suspicion. Cardiac magnetic resonance (CMR) may contribute to the diagnosis; but endomyocardial biopsy (EMB) is considered the gold standard, although used infrequently worldwide. Short-term course, albeit unpredictable is usually benign and treatment is mainly supportive. Objectives: To assess the usual care attitudes regarding hospitalized patients (pts) with a diagnosis of aMyo in Portugal, report patient's clinical profiles and current therapeutic approaches, and assess the relevance of CMR to eventual changes in management and/or therapeutic decisions. Methods: Prospective nationwide survey of admitted aMyo pts during a 2-year period (25.04.13–15). Electronic CRFs were completed with admission/discharge data, diagnostic tests, treatments and open-ended questions to evaluate physician's opinions and conclusions. Results: 248 pts from 18 centers were included, 98% caucasian, 35±14 (18–84) years old, 83% male. A recent infectious disease was detected in 57.5% (upper respiratory tract in 71.2%) and 23% had been previously treated with antibiotics. On admission, presentation included angina-like thoracic pain (96%), non-CV symptoms- 58.4% (fever-71%, respiratory- 52.8%, GI- 28.1%), heart failure (HF)- 5.4% and cardiogenic shock- 0.8%; abnormal ECG - 82% (mostly ST elevation-78.5%); increased troponin levels in 95%; echo (in 94%pts) showed left ventricular dilatation (LVD) - 5.7%, segmental LV wall abnormalities (segmAbn) - 34%, reduced LV ejection fraction (RLVEF) - 21% and pericardial effusion (PE) - 11.7%. CMR (in 57%pts), didn't change the management in 70% of cases. Coronary angiography (in 40%) revealed significant CAD in 7.4%. EMB was diagnostic in the 2 pts in which was performed (due to severe progressive HF). Multiple viral serologies (in 32.4% pts) were conclusive in only 0.5%. Most pts were treated with NSAIDs, 39% received ACEi or ARB, 36% a beta-blocker (BB) and 8.4% diuretics; 3.4% needed inotropes. Only 1 death occurred (shock). At discharge, an abnormal ECG persisted in 64.4% of pts; echo (in 50.4%) showed LVD in 6%, segmAbn in 24.6%, RLVEF in 14.6% and PE in 10.2%. Most pts (88.2%) were discharged on NSAIDs, 37.6% on ACEi or ARB, 30.36% on BB, and 6.47% on diuretics. Final diagnosis was aMyo in 54.4% (probable/possible in 96.9% and definitive in only 3.1%) and myopericarditis in 45.6%. Diagnostic criteria were “clinical” in 96.4%, supported by lab results in 87.7% and ECG in 68.8%. Echo or CMR contribution in supporting “clinical diagnosis”, was 38.3% and 48.6% respectively. Disease course was in most cases “mild” (87%). Conclusions: Echo and CMR were performed in most pts with aMyo but diagnosis remained mostly “clinical” according to treating physicians. EMB was very rarely performed. Treatment was largely empirical but an “overuse” of CV drugs and NSAIDs was observed.info:eu-repo/semantics/publishedVersio

Effects of pneumoperitoneum and Trendelenburg position on intracranial pressure assessed using different non-invasive methods

$\textbf{Background:}$ The laparoscopic approach is becoming increasingly frequent for many different surgical procedures. However, the combination of pneumoperitoneum and Trendelenburg positioning associated with this approach may increase the patient's risk for elevated intracranial pressure (ICP). Given that the gold standard for the measurement of ICP is invasive, little is known about the effect of these common procedures on ICP. $\textbf{Methods:}$ We prospectively studied 40 patients without any history of cerebral disease who were undergoing laparoscopic procedures. Three different methods were used for non-invasive estimation of ICP: ultrasonography of the optic nerve sheath diameter (ONSD); transcranial Doppler-based (TCD) pulsatility index (ICP$_{\text{PI}}$); and a method based on the diastolic component of the TCD cerebral blood flow velocity (ICP$_{\text{FVd}}$). The ONSD and TCD were measured immediately after induction of general anaesthesia, after pneumoperitoneum insufflation, after Trendelenburg positioning, and again at the end of the procedure. $\textbf{Results:}$ The ONSD, ICP$_{\text{FVd}}$, and ICP$_{\text{PI}}$ increased significantly after the combination of pneumoperitoneum insufflation and Trendelenburg positioning. The ICP$_{\text{FVd}}$ showed an area under the curve of 0.80 [95% confidence interval (CI) 0.70-0.90] to distinguish the stage associated with the application of pneumoperitoneum and Trendelenburg position; ONSD and ICP$_{\text{PI}}$ showed an area under the curve of 0.75 (95% CI 0.65-0.86) and 0.70 (95% CI 0.58-0.81), respectively. $\textbf{Conclusions:}$ The concomitance of pneumoperitoneum and the Trendelenburg position can increase ICP as estimated with non-invasive methods. In high-risk patients undergoing laparoscopic procedures, non-invasive ICP monitoring through a combination of ONSD ultrasonography and TCD-derived ICP$_{\text{FVd}}$ could be a valid option to assess the risk of increased ICP.Cambridge Commonwealth European and International Trust Scholarship (D.C.); Woolf Fisher Trust Scholarship (J.D.); Gates Cambridge Trust Scholarship (X.L.); CNPQ Scholarship (Research Project 203792/2014-9 to B.C.); NIHR Brain Injury Healthcare Technology Co-operative, Cambridge (M.C. and D.C.)

The multi-modality cardiac imaging approach to the Athlete's heart: an expert consensus of the European Association of Cardiovascular Imaging.

The term 'athlete's heart' refers to a clinical picture characterized by a slow heart rate and enlargement of the heart. A multi-modality imaging approach to the athlete's heart aims to differentiate physiological changes due to intensive training in the athlete's heart from serious cardiac diseases with similar morphological features. Imaging assessment of the athlete's heart should begin with a thorough echocardiographic examination.Left ventricular (LV) wall thickness by echocardiography can contribute to the distinction between athlete's LV hypertrophy and hypertrophic cardiomyopathy (HCM). LV end-diastolic diameter becomes larger (>55 mm) than the normal limits only in end-stage HCM patients when the LV ejection fraction is <50%. Patients with HCM also show early impairment of LV diastolic function, whereas athletes have normal diastolic function.When echocardiography cannot provide a clear differential diagnosis, cardiac magnetic resonance (CMR) imaging should be performed.With CMR, accurate morphological and functional assessment can be made. Tissue characterization by late gadolinium enhancement may show a distinctive, non-ischaemic pattern in HCM and a variety of other myocardial conditions such as idiopathic dilated cardiomyopathy or myocarditis. The work-up of athletes with suspected coronary artery disease should start with an exercise ECG. In athletes with inconclusive exercise ECG results, exercise stress echocardiography should be considered. Nuclear cardiology techniques, coronary cardiac tomography (CCT) and/or CMR may be performed in selected cases. Owing to radiation exposure and the young age of most athletes, the use of CCT and nuclear cardiology techniques should be restricted to athletes with unclear stress echocardiography or CMR

World Heart Federation Cholesterol Roadmap: The Portuguese case

Atherosclerotic cardiovascular disease (ASCVD) remains the major cause of premature death and disability; effective cardiovascular (CV) risk prevention is fundamental. The World Heart Federation (WHF) Cholesterol Roadmap provides a framework for national policy development and aims to achieve ASCVD prevention. At the invitation of the WHF, a group of experts from the Portuguese Society of Cardiology (SPC), addressed the cholesterol burden at nationally and discussed possible strategies to include in a Portuguese cholesterol roadmap. The literature review showed that the cholesterol burden in Portugal is high and especially uncontrolled in those with the highest CV risk. An infographic scorecard was built to include in the WHF collection, for a clear idea about CV risk and cholesterol burden in Portugal, which would also be useful for health policy advocacy. The expert discussion and preventive strategies proposal followed the five pillars of the WHF document: awareness improvement; population-based approaches for CV risk and cholesterol; risk assessment/population screening; system-level approaches; surveillance of cholesterol and ASCVD outcomes. These strategies were debated by all the expert participants, with the goal of creating a national cholesterol roadmap to be used for advocacy and as a guide for CV prevention. Several key recommendations were outlined: include all stakeholders in a multidisciplinary national program; create a structured activities plan to increase awareness in the population; improve the quality of continuous CV health education; increase the interaction between different health professionals and non-health professionals; increment the referral of patients to cardiac rehabilitation; screen cholesterol levels in the general population, especially high-risk groups; promote patient self-care, engage with patients' associations; use specific social networks to spread information widely; create a national database of cholesterol levels with systematic registry of CV events; redefine strategies based on the evaluation of results; create and involve more patients' associations - invert the pyramid order. In conclusion, ASCVD and the cholesterol burden remain a strong global issue in Portugal, requiring the involvement of multiple stakeholders in prevention. The Portuguese cholesterol roadmap can provide some solutions to help urgently mitigate the problem. Population-based approaches to improve awareness and CV risk assessment and surveillance of cholesterol and ASCVD outcomes are key factors in this change. A call to action is clearly needed to fight hypercholesterolemia and ASCVD burden.info:eu-repo/semantics/publishedVersio

3D echocardiographic reference ranges for normal left ventricular volumes and strain: Results fromthe EACVI NORRE study

Aim To obtain the normal ranges for 3D echocardiography (3DE) measurement of left ventricular (LV) volumes, function, and strain from a large group of healthy volunteers. Methods and results A total of 440 (mean age: 45613 years) out of the 734 healthy subjects enrolled at 22 collaborating institutions of the Normal Reference Ranges for Echocardiography (NORRE) study had good-quality 3DE data sets that have been analysed with a vendor-independent software package allowing homogeneous measurements regardless of the echocardiographic machine used to acquire the data sets. Upper limits of LV end-diastolic and end-systolic volumes were larger in men (97 and 42 mL/m2) than in women (82 and 35 mL/m2; P<0.0001). Conversely, lower limits of LV ejection fraction were higher in women than in men (51% vs. 50%; P<0.01). Similarly, all strain components were higher in women than in men. Lower range was -18.6% in men and -19.5% in women for 3D longitudinal strain, -27.0% and -27.6% for 3D circumferential strain, -33.2% and -34.4% for 3D tangential strain and 38.8% and 40.7% for 3D radial strain, respectively. LV volumes decreased with age in both genders (P<0.0001), whereas LV ejection fraction increased with age only in men. Among 3DE LV strain components, the only one, which did not change with age was longitudinal strain. Conclusion The NORRE study provides applicable 3D echocardiographic reference ranges for LV function assessment. Our data highlight the importance of age- and gender-specific reference values for both LV volumes and strain. All rights reserved

Coronary computed tomography angiography-adapted Leaman score as a tool to noninvasively quantify total coronary atherosclerotic burden

To describe a coronary computed tomography angiography (CCTA)-adapted Leaman score (CT-LeSc) as a tool to quantify total coronary atherosclerotic burden with information regarding localization, type of plaque and degree of stenosis and to identify clinical predictors of a high coronary atherosclerotic burden as assessed by the CT-LeSc. Single center prospective registry including a total of 772 consecutive patients undergoing CCTA (Dual-source CT) from April 2011 to March 2012. For the purpose of this study, 581 stable patients referred for suspected coronary artery disease (CAD) without previous myocardial infarction or revascularization procedures were included. Pre-test CAD probability was determined using both the Diamond-Forrester extended CAD consortium method (DF-CAD consortium model) and the Morise score. Cardiovascular risk was assessed with the HeartScore. The cut-off for the 3rd tercile (CT-LeSc ≥8.3) was used to define a population with a high coronary atherosclerotic burden. The median CT-LeSc in this population (n = 581, 8,136 coronary segments evaluated; mean age 57.6 ± 11.1; 55.8 % males; 14.6 % with diabetes) was 2.2 (IQR 0-6.8). In patients with CAD (n = 341), the median CT-LeSc was 5.8 (IQR 3.2-9.6). Among patients with nonobstructive CAD, most were classified in the lowest terciles (T1, 43.0 %; T2, 36.1 %), but 20.9 % were in the highest tercile (T3). The majority of the patients with obstructive CAD were classified in T3 (78.2 %), but 21.8 % had a CT-LeSc in lower terciles (T1 or T2). The independent predictors of a high CT-LeSc were: Male sex (OR 1.73; 95 % CI 1.04-2.90) diabetes (OR 2.91; 95 % CI 1.61-5.23), hypertension (OR 2.54; 95 % CI 1.40-4.63), Morise score ≥16 (OR 1.97; 95 % CI 1.06-3.67) and HeartScore ≥5 (OR 2.42; 95 % CI 1.41-4.14). We described a cardiac CT adapted Leaman score as a tool to quantify total (obstructive and nonobstructive) coronary atherosclerotic burden, reflecting the comprehensive information about localization, degree of stenosis and type of plaque provided by CCTA. Male sex, hypertension, diabetes, a HeartScore ≥5 % and a Morise score ≥16 were associated with a high coronary atherosclerotic burden, as assessed by the CT-LeSc. About one fifth of the patients with nonobstructive CAD had a CT-LeSc in the highest tercile, and this could potentially lead to a reclass

Prevalence and predictors of coronary artery disease in patients with a calcium score of zero

The absence of coronary calcification is associated with an excellent prognosis. However, a calcium score of zero does not exclude the presence of coronary artery disease (CAD) or the possibility of future cardiovascular events. Our aim was to study the prevalence and predictors of coronary artery disease in patients with a calcium score of zero. Prospective registry consisted of 3,012 consecutive patients that underwent cardiac CT (dual source CT). Stable patients referred for evaluation of possible CAD that had a calcium score of zero (n = 864) were selected for this analysis. The variables that were statistically significant were included in a multivariable logistic regression model. From 864 patients with a calcium score of zero, 107 (12.4 %) had coronary plaques on the contrast CT (10.8 %, n = 93 with nonobstructive CAD and 1.6 %, n = 14 with obstructive CAD). By logistic regression analysis, the independent predictors of CAD in this population were age >55 years [odds ratio (OR) 1.63 (1.05-2.52)], hypertension [OR 1.64 (1.05-2.56)] and dyslipidemia [OR 1.54 (1.00-2.36)]. In the presence of these 3 variables, the probability of having coronary plaques was 21 %. The absence of coronary artery calcification does not exclude the presence of coron