Role Of Echocardiography In The Ventricular Assessment Of The Transplanted Heart Versus Heart Rejection

Background: Heart transplantation is an alternative for individuals with end-stage heart disease. However, episodes of heart rejection (HR) are frequent and increase morbidity and mortality, requiring the use of an accurate non-invasive exam for their diagnosis, since endomyocardial biopsy (EMB) is not a complication-free procedure. Objective: To compare the parameters obtained by use of Doppler echocardiography in a group of transplanted patients with HR (TX1) and another group of transplanted patients without rejection (TX0), having as reference a control group (CG) and observing the behavior of the left ventricular systo-diastolic function expressed as the myocardial performance index (MPI) Methods: Transthoracic echocardiographies were performed from January 2006 to January 2008 to prospectively assess 47 patients divided into three groups: CG (36.2%); TX0 (38.3%); and TX1 (25.5%). The MPI was compared between the groups, and data were analyzed by use of Fisher exact test and nonparametric Kruskal-Wallis test, both with significance level of 5%. Results: The groups did not differ regarding age, weight, height, and body surface. When compared to GC, TX0 and TX1 showed a change in the left ventricular systo-diastolic function, expressed as an increase in MPI, which was greater in TX1 [0.38 (0.29 - 0.44); 0.47 (0.43 - 0.56); 0.58 (0.52 - 0.74), respectively; p < 0.001]. Conclusion: Echocardiography was a very accurate test to detect changes in the systo-diastolic function of the transplanted heart; however, it did not prove to be reliable to replace BEM in the safe diagnosis of HR.99510311039McAlister, F.A., Ezekowitz, J.H., Hooton, N., Vandermeer, B., Spooner, C., Dryden, D.M., Cardiac resynchronization therapy for patients with left ventricular systolic dysfunction: A systematic review (2007) JAMA., 297 (22), pp. 2502-2514Sistema de Informações hospitalares do SUS. Datasus, , http://www.datasus.gov.br, Ministério da Saúde [acesso em 2009 fev 1]. Disponível emMiniati, D.N., Robbins, R.C., Reitz, B.A., Heart and heart-lung transplantation (2001) Heart disease: A textbook of cardiovascular medicine, pp. 615-634. , In: Braunwald E, Zipes DP, Libby P. 6th ed. 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Echocardiography In Cardiac Resynchronization Therapy [o Ecocardiograma Na Terapia De Ressincronização Cardíaca]

Cardiac resynchronization therapy has been an effective option in patients with advanced heart failure. However, 20 to 30% of the patients do not benefit from this therapy. Clinical, electrocardiographic and echocardiographic criteria have been studied in an attempt to select patients who will benefit from a cardiac resynchronization therapy, and the echocardiogram is important both in the selection and in the evaluation and optimization of the therapy. The objective of this review is to describe the main echocardiographic parameters used in the evaluation of the cardiac resynchronization therapy.934409413+433-437+441-445McAlister, F.A., Teo, K.K., Taher, M., Montague, T.J., Humen, D., Cheung, L., Insights into the contemporary epidemiology and outpatient management of congestive heart failure (1999) Am Heart J, 138 (1 PART 1), pp. 87-94Rossi Neto, J.M., A dimensão do problema da insuficiência cardíaca no Brasil e no mundo. (2004) Rev Soc Cardiol Estado de São Paulo, 1, pp. 1-10Sistema de Informações Hospitalares do SUS, , http://www.datasus.gov.br, Ministério da Saúde, Morbidade hospitalar do SUS, Acesso em 2008 nov 10, Disponível emGalvão Filho, S.S., Vasconcelos, J.T.M., Barcelos, C.B., Rabello, A.C., Seleção de pacientes e modos de estimulação cardíaca no tratamento da disfunção ventricular. (2004) Rev Soc Cardiol Estado de São Paulo, 1, pp. 43-54Cazeau, S., Ritter, P., Bakdach, S., Lazarus, A., Limousin, M., Henao, L., Four chamber pacing in dilated cardiomiopathy (1994) Pacing Clin Electrophysiol, 17 (11 PART 2), pp. 1974-1979Aranda, J.M., Woo, G.W., Schofield, R.S., Handberg, E.M., Hill, J.A., Curtis, A.B., Management of heart failure after cardiac resynchronization therapy - integrating advanced heart failure treatment with optimal device function (2005) J Am Coll Cardiol, 46 (12), pp. 2193-2198Epstein, A.E., DiMarco, J.P., Ellenboger, K.A., Estes 3rd, N.A., Freedman, R.A., Gettes, L.S., ACC/AHA/HRS 2008. Guidelines for device-based therapy of cardiac rhythm abnormalities: Executive summary (2008) Heart Rhytm, 5 (6), pp. 934-955Leclercq, C., Faris, O., Tunin, R., Johnson, J., Kato, R., Evans, F., Systolic improvement and mechanical resynchronization does not require electrical synchrony in the dilated failing heart with left bundle-branch block (2002) Circulation, 106 (14), pp. 1760-1763Abraham, W.T., Fisher, W.G., Smith, A.L., Delurgio, D.B., Leon, A.R., Loh, E., MIRACLE Study Group Multicenter InSync Randomized Clinical Evaluation. Cardiac resynchronization in chronic heart failure (2002) N Engl J Med, 346 (24), pp. 1845-1853Mullens, W., Tang, W.H., Grimm, R.A., Using echocardiography in cardiac resynchronization therapy (2007) Am Heart J, 154 (6), pp. 1011-1020Cazeau, S., Gras, D., Lazarus, A., Ritter, P., Mugica, J., Multisite stimulation for correction of cardiac asynchrony (2000) Heart, 84 (6), pp. 579-581Rodrigues, A.C.T., Tsutsui, J.M., Mathias Jr, W., Avaliação de dissincronia cardíaca pelo ecocardiograma: Estratégias para um resultado adequado. (2006) Rev Bras Ecocardiogr, 19 (3), pp. 46-51Auricchio, A., Stellbrink, C., Block, M., Sack, S., Vogt, J., Bakker, P., Effect of pacing chamber and atrioventricular delay on acute systolic function of paced patients with congetive heart failure: The pacing therapies for congestive heart failure study group. The Guidant congestive heart failure research group (1999) Circulation, 99 (23), pp. 2993-3001Gorcsan, J., Abraham, T., Agler, D.A., Bax, J.J., Derumeaux, G., Grimm, R.A., Echocardiography for cardiac resynchronization therapy: Recommendations for performance and reporting - a report from the American Society of Echocardiography Dyssynchrony writing Group Endorsed by the Heart Rhytm Society (2008) J Am Soc Echocardiogr, 21 (3), pp. 191-213Agler, D.A., Adams, D.B., Waggoner, A.D., Cardiac resynchronization therapy and the emerging role of echocardiography (Part 2): The comprehensive examination (2007) J Am Soc Echocardiogr, 20 (1), pp. 76-90Bax, J.J., Ansalone, G., Breithardt, O., Derumeaux, G., Leclercq, C., Schalij, M.J., Echocardiographic evaluation of cardiac resynchronization therapy: Ready for routine clinical use? A critical appraisal (2004) J Am Coll Cardiol, 44 (1), pp. 1-9Bordachar, P., Lafitte, S., Reuter, S., Sanders, P., Jais, P., Haissaguerre, M., Echocardiographic parameters of ventricular dyssynchrony validation in patients with heart failure using sequential biventricular pacing (2004) J Am Coll Cardiol, 44 (11), pp. 2157-2165Penicka, M., Bartunck, J., De Bruync, B., Vanderheyden, M., Goethals, M., De Zutter, M., Improvement of left ventricular function after cardiac resynchronization therapy is predicted by tissue Doppler imaging echocardiography (2004) Circulation, 109 (8), pp. 978-983Yu, C.M., Fung, J.W., Zhang, Q., Chan, C.K., Chan, Y.S., Lin, H., Tissue Doppler imaging is superior to strain rate imaging and postsystolic shortening on the prediction of reverse remodeling in both ischemic and nonischemic heart failure after cardiac resynchronization therapy (2004) Circulation, 110 (1), pp. 66-73Bax, J.J., Bleeker, G.B., Marwick, T.H., Molhoek, S.G., Boersma, E., Steendijk, P., Left ventricular dyssynchrony predicts response and prognosis after cardiac resynchronization therapy (2004) J Am Coll Cardiol, 44 (9), pp. 1834-1840Pitzalis, M.V., Iacoviello, M., Romito, R., Massari, F., Rizzon, B., Luzzi, G., Cardiac resynchronization therapy tailored by echocardiographic evaluation of ventricular asynchrony (2002) J Am Coll Cardiol, 40 (9), pp. 1615-1622Waggoner, A.D., Agler, D.A., Adams, D.B., Cardiac resynchronization therapy and the emerging role of echocardiography (part 1): Indications and results from current studies (2007) J Am Soc Echocardiogr, 20 (1), pp. 70-75Pitzalis, M.V., Iacoviello, M., Romito, R., Guida, P., De Tommasi, E., Luzzi, G., Ventricular asynchrony predicts a better outcome in patients with chronic heart failure receiving cardiac resynchronization therapy (2005) J Am Coll Cardiol, 45 (1), pp. 65-69Parro Jr, A., Paulitsch, F.S., Cherubin, M.C., Miola, L., Armstron, S.F., Sierra, M.A.C., Emprego da ecocardiografia convencional na avaliação de pacientes com miocardiopatia dilatada, candidatos à terapia de ressincronização. (2006) Reblampa, 19 (1), pp. 34-44Bleeker, G.B., Schalij, M.J., Molhoek, S.G., Verwey, H.F., Holman, E.R., Boersma, E., Relationship between QRS duration and left ventricular dyssynchrony in patients with end-stage heart failure (2004) J Cardiovasc Electrophysiol, 15 (5), pp. 544-549Yu, C.M., Fung, W.H., Lin, H., Zhang, Q., Sanderson, J.E., Lau, C.P., Predictors of left ventricular reverse remodeling after cardiac resynchronization therapy for heart failure secondary to idiopathic dilated a ischemic cardiomyopathy (2003) Am J Cardiol, 91 (6), pp. 684-688Yu, C.M., Zhang, Q., Fung, J.W., Chan, H.C., Chan, Y.S., Yip, G.W., A novel tool to assess systolic asynchrony and identify responders of cardiac resynchronization therapy by tissue synchronization imaging (2005) J Am Coll Cardiol, 45 (1), pp. 677-684Bax, J.J., Molhoek, S.G., van Erven LVoogd, P.J., Somer, S., Boersma, E., Usefulness of myocardial tissue Doppler echocardiography to evaluate left ventricular dyssynchrony before and after biventricular pacing in patients with idiopathic dilated cardiomyopathy (2003) Am J Cardiol, 91 (1), pp. 94-97Gorcsan, J., Kanzaki, H., Bazaz, R., Dohi, K., Schwartzman, D., Usefulness of echocardiographic tissue synchronization imaging to predict acute response to cardiac resynchronization therapy (2004) Am J Cardiol, 93 (9), pp. 1178-1181Yu, C.M., Lin, H., Zhang, Q., Sanderson, J.E., High prevalence of left ventricular systolic and diastolic asynchrony in patients with congestive heart failure and normal QRS duration (2003) Heart, 89 (1), pp. 54-60Silva, C.E.S., Barreto, A.C.P., Avaliação ecocardiográfica da terapia de ressincronização cardíaca. (2005) Arq Bras Cardiol, 84 (6), pp. 50-57Pan, C., Hoffmann, R., Kühl, H., Severin, E., Franke, A., Hanrath, P., Tissue tracking allows rapid and accurate visual evaluation of left ventricular function (2001) Eur J Echocardiogr, 2 (3), pp. 197-202Vieira, M.L.C., Morhy, S.S., Maddukuri, P., Phang, R., Fischer, C., Lira, F.E., O ecocardiograma na terapia de ressincronização. (2005) Einstein, 3 (1), pp. 41-45Roelondt, J.R., Yao, J., Kasprzak, J.D., Three-dimensional echocardiography (1998) Curr Opin Cardiol, 13 (6), pp. 386-396Vieira, M.L.C., Cury, A.F., Naccarato, G., Oliveira, W.A., Monaco, C.G., Cordovil, A., Índice de dissincronia ventricular: Comparação com a fração de ejeção bidimensional e tridimensional. (2008) Arq Bras Cardiol, 91 (3), pp. 142-147Ansalone, G., Giannantoni, P., Ricci, R., Trambaiolo, P., Fedele, F., Santini, M., Doppler myocardial imaging to evaluate the effectiveness of pacing sites in patients receiving biventricular pacing (2002) J Am Coll Cardiol, 39 (3), pp. 489-499Kindermann, M., Frolhig, G., Doerr, T., Schieffer, H., Optimizing the AV delay in DDD pacemaker patients with high degree AV block: Mitral valve Doppler versus impedance cardiography (1997) Pacing Clin Electrophysiol, 20 (10 PART 1), pp. 2453-2462Suffoletto MS, Dohi K, Cannesson M, Saba S, Gorcsan J 3rd. Novel speckletracking radial strain from routine black-and-white echocardiographic images to quantify dyssynchrony and predict response to cardiac resynchronization therapy. Circulation. 2006113 (17): 960-

Echocardiographic Assessment Of Cardiac Resynchronization Therapy: Two-year Follow-up Period [evaluación Ecocardiográfica De La Terapia De Resincronización Cardiaca: Dos Años De Seguimiento]

Background: The cardiac resynchronization therapy (CRT) is an effective option for patients with advanced heart failure (HF). Clinical, electrocardiographic and echocardiographic criteria have been studied in an attempt to find the patients that will benefit from the CRT, considering that the echocardiogram is the method that is used both in the selection and in the assessment of such therapy. Objective: The objective of this work is to analyze the use of echocardiogram to assess the CRT, in a ten-day follow-up period and after two years of evolution. Method: The assessment considered 20 patients subjected to CRT, for a period of two years, 80% of which were male. The Minnesota Living with Heart Failure Questionnaire (MLWHF) was filled out. Patients underwent a six-minute walking test. Then, the two-dimensional echo-Doppler-cardiogram was performed. The initial assessment was repeated ten days after and two year after the implantation of the biventricular pacemaker. Results: In two years, 5 patients (25%) died; 4 had cardiomyopathy caused by the Chagas's disease. There was no statistically significant change in the ejection fraction between the pre-operation period and the following ten days, but there was a significant change between the pre-operation period and two years after that, and the ten-day period and two years after that. In the ten-day follow-up period, there was the worsening of the intraventricular dyssynchrony, as evaluated by the tissue Doppler method, and the "living with heart failure" score was higher in the group of deaths. 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