Objectives: To further characterize the echocardiographic anatomy of the canine mitral valve in healthy dogs and those affected by myxomatous mitral valve disease (MMVD), and to compare the level of agreement between two methods of assessment of left atrial size in identification of left atrial enlargement in dogs with MMVD. Animals: Sixty dogs with MMVD and 22 normal dogs were prospectively studied with 2-dimensional echocardiography. Methods: The length (AMVL), width (AMVW) and area (AMVA) of the anterior mitral valve leaflet and the diameter of the mitral valve annulus in systole (MVAs) and diastole (MVAd) were measured. Left atrial size was evaluated with the left atrial to aortic root ratio (LA:Ao) and by measuring left atrial volume indexed to body weight (LA Vol/BW). All patients were staged using published ACVIM guidelines and separated into groups B1 and B2/C. Results: Measurements of AMVL, AMVW, AMVA, MVAs and MVAd were all significantly greater in the B2/C group than in the control group. AMVW was significantly greater in group B1 than control. Twelve dogs had left atrial enlargement identified with LA Vol/BW that were considered normal using LA:Ao. Diagnostic disagreement between these two measurements was significant (P = 0.00012). The majority of dogs with diagnostic disagreement had concurrent echocardiographic evidence of more advanced mitral regurgitation. Conclusions: Relative to normal dogs, AMVL, AMVW, AMVA, MVAs and MVAd are greater in patients with advanced MMVD. LA Vol/BW may be superior to LA:Ao for identification of mild left atrial enlargement. / Master of Science

The effect of selected anthropometric indices on the reproducibility of continuous wave (CW) Doppler echocardiographic recordings in exercise were studied in 42 healthy males between 18 and 43 years of age. Each subject was measured and rank ordered in reference to four anthropometric Indices: sum of 3 skinfolds (SK); chest girth-waist girth ratio (CW); biacromial width-chest depth ratio (WD); and peak exercise ventilationâ forced vital capacity ratio (VV). Each subject then performed two maximal bicycle exercise tolerance tests on nonconsecutive days wherein the CW Doppler variables of peak acceleration (pKA), peak velocity (pKV) and stroke velocity integral (SVI) were measured along with heart rate (HR), blood pressure (BP) and respiratory gas analysis data including oxygen consumption (V0₂). Statistical analyses were then conducted to determine if subject groups with high vs. low values on any anthropometric index differentiated with regard to testâ retest reliability between bicycle exercise test trials. Statistical differences were noted between ( the high and a low groups for each index at the .05 alpha level. Pearson's Product Moment correlational analyses revealed that across all subjects the highest test-retest reliability occurred during the moderate intensity of exercise. The average test-retest correlation coefficients for the high and low groups within each index are as follows: SK_H, = .52, SK_L = 62, CW_H = .64, CW_L = .60, WD_H. = 62,WD_L = 58, VV_h. = 61, VV_L = .67. Inspection of test-retest correlations between the high vs. low groups for the anthropometric indicies revealed a trend in the skinfold index. For each dependent measure at all levels of exercise intensity, the low group exhibited higher correlation coefficients than the high group except for pKA at the peak level of exercise. The other three indicies exhibited no such trends. lt was concluded that since The other three indicies exhibited no such trends. lt was concluded that since the overall correlation coefficients (average = .65) were within the ranges of those computed for HR. BP and VO₂; (average = .50) the test-retest reliability with the CW Doppler was acceptable; but only during moderate levels of exercise. It was also determined from the correlation coefficients generated by the skinfold index data that measures obtained on lean individuals may be moree reproducible than measures obtained from obese individuals (See Table 2). / Master of Science

INTRODUÇÃO: A ecocardiografia com perfusão miocárdica em tempo real (EPMTR) é uma técnica que permite a avaliação da perfusão miocárdica e a quantificação do fluxo miocárdico regional. Existem poucos dados na literatura a respeito da acurácia da EPMTR na detecção de viabilidade miocárdica e predição da melhora da qualidade de vida proporcionada pela revascularização miocárdica. MÉTODOS: Vinte e quatro pacientes com doença arterial coronária e disfunção ventricular esquerda crônica foram submetidos à EPMTR e questionário de qualidade de vida antes e após revascularização miocárdica. EPMTR foi realizada com injeção intravenosa contínua de PESDA ou Definity® e energia modulada. Recuperação funcional regional foi considerada padrão de referência (miocárdio hibernante), viabilidade miocárdica foi definida como presença de perfusão homogênea em pelo menos 1 segmento miocárdico no território revascularizado à avaliação qualitativa e a análise do fluxo miocárdico foi realizada nos 17 segmentos do ventrículo esquerdo obtendo-se índices de volume de sangue no miocárdio (A), da velocidade do fluxo () e do fluxo miocárdico absoluto (Ax) na condição de repouso no pré-operatório. Todos territórios revascularizados foram analisáveis. RESULTADOS: Presença de miocárdio hibernante foi observada em 77% dos territórios com viabilidade miocárdica pela EPMTR e em 44% dos territórios sem viabilidade (p=0,03). A presença de viabilidade pela EPMTR qualitativa apresentou sensibilidade, especificidade, valor preditivo positivo (VPP) e valor preditivo negativo (VPN) de 74%, 60%, 77% e 56%, respectivamente. Análise combinada (reserva contrátil e/ou perfusão miocárdica) resultou sensibilidade, especificidade, VPP e VPN de 89%, 40%, 73% e 67%, respectivamente. O valor de Ax 1,76 conferiu sensibilidade de 91,3%, especificidade de 50%, VPP de 75% e VPN de 77,8%, resultando em uma acurácia de 75,7%. O escore de qualidade de vida foi de 36,4 (29,1-43,6) para 18,1 (12,8-23,4; p =0,001) no pós-operatório. Entretanto, não houve correlação estatística com análise de perfusão miocárdica.CONCLUSÃO: Concluímos que a avaliação da perfusão miocárdica pela EPMTR apresenta boa acurácia para detecção de miocárdio hibernante em pacientes com DAC crônica e DVE. A presença de miocárdio viável pela EPMTR não foi capaz de prever a melhora da qualidade de vida após a cirurgia de revascularização miocárdica / BACKGROUND: Real-time perfusion echocardiography (RTPE) is an emerging modality for assessing myocardial perfusion and allows noninvasive quantification of regional myocardial blood flow. Little is known about the accuracy of the RTPE for the assessment of myocardial viability and the possibility of prediction of quality of life improvement after myocardial revascularization. METHODS: Twenty four patients with coronary artery disease and ventricular dysfunction underwent RTPE and answered Minnesota Quality of Life Questionnaire before and repeated after myocardial bypass coronary surgery. RTPE was performed using continuous PESDA or Definity intravenous infusion with power modulation image. Regional function recovery after surgical procedure was considered the standard reference (hibernating myocardial). Qualitatively, viability was defined as presence of homogeneous opacification in at least one myocardial segment in a rest revascularized territory, according coronary distribution. For myocardial blood flow evaluation, the left ventricle was divided into 17 segments, and indexes of myocardial blood volume (A), blood flow velocity (), and myocardial blood flow (Ax) were obtained for each myocardial segment at rest condition. All revascularized territories were analyzed. RESULTS: Hibernating myocardial was observed in 77% of RTPE viable territories and in 44% in non-viable ones (p=0.03). Sensitivity, specificity, predictive positive and negative values of qualitative RTPE viability detecting were 74%, 60%, 77% and 56%, respectively. A combined analysis (contractile reserve and/or myocardial perfusion) provided sensitivity, specificity, predictive positive and negative values of 89%, 40%, 73% e 67%, respectively. The sensitivity, specificity, predictive positive and negative values of Ax1.76 for recovery of function were 91%, 50%, 75% and 78%, respectively, with an accuracy of 76%. Quality of life score improved from 36.4 (29.1-43.6) to 18.1 (12.8-23.4; p =0.001). However, there was no statistical correlation with RTPE. CONCLUSION: In conclusion, RTPE provides good accuracy of detecting hibernating myocardial in patients with coronary artery disease and ventricular dysfunction. Nevertheless, it couldnt predict the quality of life improvement after myocardial revascularization

Background：Aortic stenosis (AS) is the commonest valve disease in the West. Aortic valve replacement (AVR) remains the only available management for AS and results in improved symptoms and recovery of ventricular functions. In addition, it is well known that AVR results in disruption of LV function mainly in the form of reversal of septal motion as well as depression of right ventricular (RV) systolic function. The aim of this thesis was to study, in detail, the early and mid-term response of ventricular function to AVR procedures (surgical and TAVI) as well as post operative patients’ exercise capacity. Methods：We studied LV and RV function by Doppler echocardiography and speckle tracking echocardiography (STE) in the following 4 groups; (1) 30 severe AS patients (age 62±11 years, 19 male) with normal LV ejection fraction (EF) who underwent AVR, (2) 20 severe AS patients (age 79±6 years, 14 male) who underwent TAVI, (3) 30 healthy controls (age 63±11 years, 16 male), (4) 21 healthy controls (age 57±9 years, 14 male) who underwent exercise echocardiography. Results: After one week of TAVI, the septal radial motion and RV tricuspid annulus peak systolic excursion (TAPSE) were not different from before, while surgical AVR had significantly reversed septal radial motion and TAPSE dropped by 70% compared to before. The extent of the reversed septal motion correlated with that of TAPSE (r=0.78, p<0.001) in the patients as a whole after AVR and TAVI (Study I). Compared with controls, the LV twist function was increased in AS patients before and normalized after 6 months of surgical AVR. In controls, the LV twist correlated with LV fractional shortening (r=0.81, p<0.001), a relationship which became weak in patients before (r=0.52, p<0.01) and after AVR (r=0.34, p=ns) (Study II). After 6 months of surgical AVR, the reversed septal radial motion was still significantly lower than before. The septal peak displacement also decreased and its time became prolonged. In contrast, the LV lateral wall peak displacement increased and the time to peak displacement was early. The accentuated lateral wall peak displacement correlated with the septal peak displacement time delay (r=0.60, p<0.001) and septal-lateral time delay (r=0.64, p<0.001) (Study III). In 21 surgical AVR patients who performed exercise echocardiography, the LV function was normal at rest but different from controls with exercise. At peak exercise, oxygen consumption (pVO2) was lower in patients than controls. Although patients could achieve cardiac output (CO) and heart rate (HR) similar to controls at peak exercise, the LV systolic and early diastolic myocardial velocities and strain rate as well as their delta changes were significantly lower than controls. pVO2 correlated with peak exercise LV myocardial function in the patients group only, and the systolic global longitudinal strain rate (GLSRs) at peak exercise was the only independent predictor of pVO2 in multivariate regression analysis (p=0.03) (Study IV). Conclusion: Surgical AVR is an effective treatment for AS patients, but results in reversed septal radial motion and reduced TAPSE. The newly developed TAVI procedure maintains RV function which results in preservation of septal radial motion. In AS, the LV twist function is exaggerated, normalizes after AVR but loses its relationship with basal LV function. While the reversed septal motion results in decreased and delayed septal longitudinal displacement which is compensated for by the accentuated lateral wall displacement and the time early. These patients remain suffering from limited exercise capacity years after AVR.

INTRODUÇÃO: A ecocardiografia com perfusão miocárdica em tempo real (EPMTR) é uma técnica que permite a avaliação da perfusão miocárdica e a quantificação do fluxo miocárdico regional. Existem poucos dados na literatura a respeito da acurácia da EPMTR na detecção de viabilidade miocárdica e predição da melhora da qualidade de vida proporcionada pela revascularização miocárdica. MÉTODOS: Vinte e quatro pacientes com doença arterial coronária e disfunção ventricular esquerda crônica foram submetidos à EPMTR e questionário de qualidade de vida antes e após revascularização miocárdica. EPMTR foi realizada com injeção intravenosa contínua de PESDA ou Definity® e energia modulada. Recuperação funcional regional foi considerada padrão de referência (miocárdio hibernante), viabilidade miocárdica foi definida como presença de perfusão homogênea em pelo menos 1 segmento miocárdico no território revascularizado à avaliação qualitativa e a análise do fluxo miocárdico foi realizada nos 17 segmentos do ventrículo esquerdo obtendo-se índices de volume de sangue no miocárdio (A), da velocidade do fluxo () e do fluxo miocárdico absoluto (Ax) na condição de repouso no pré-operatório. Todos territórios revascularizados foram analisáveis. RESULTADOS: Presença de miocárdio hibernante foi observada em 77% dos territórios com viabilidade miocárdica pela EPMTR e em 44% dos territórios sem viabilidade (p=0,03). A presença de viabilidade pela EPMTR qualitativa apresentou sensibilidade, especificidade, valor preditivo positivo (VPP) e valor preditivo negativo (VPN) de 74%, 60%, 77% e 56%, respectivamente. Análise combinada (reserva contrátil e/ou perfusão miocárdica) resultou sensibilidade, especificidade, VPP e VPN de 89%, 40%, 73% e 67%, respectivamente. O valor de Ax 1,76 conferiu sensibilidade de 91,3%, especificidade de 50%, VPP de 75% e VPN de 77,8%, resultando em uma acurácia de 75,7%. O escore de qualidade de vida foi de 36,4 (29,1-43,6) para 18,1 (12,8-23,4; p =0,001) no pós-operatório. Entretanto, não houve correlação estatística com análise de perfusão miocárdica.CONCLUSÃO: Concluímos que a avaliação da perfusão miocárdica pela EPMTR apresenta boa acurácia para detecção de miocárdio hibernante em pacientes com DAC crônica e DVE. A presença de miocárdio viável pela EPMTR não foi capaz de prever a melhora da qualidade de vida após a cirurgia de revascularização miocárdica / BACKGROUND: Real-time perfusion echocardiography (RTPE) is an emerging modality for assessing myocardial perfusion and allows noninvasive quantification of regional myocardial blood flow. Little is known about the accuracy of the RTPE for the assessment of myocardial viability and the possibility of prediction of quality of life improvement after myocardial revascularization. METHODS: Twenty four patients with coronary artery disease and ventricular dysfunction underwent RTPE and answered Minnesota Quality of Life Questionnaire before and repeated after myocardial bypass coronary surgery. RTPE was performed using continuous PESDA or Definity intravenous infusion with power modulation image. Regional function recovery after surgical procedure was considered the standard reference (hibernating myocardial). Qualitatively, viability was defined as presence of homogeneous opacification in at least one myocardial segment in a rest revascularized territory, according coronary distribution. For myocardial blood flow evaluation, the left ventricle was divided into 17 segments, and indexes of myocardial blood volume (A), blood flow velocity (), and myocardial blood flow (Ax) were obtained for each myocardial segment at rest condition. All revascularized territories were analyzed. RESULTS: Hibernating myocardial was observed in 77% of RTPE viable territories and in 44% in non-viable ones (p=0.03). Sensitivity, specificity, predictive positive and negative values of qualitative RTPE viability detecting were 74%, 60%, 77% and 56%, respectively. A combined analysis (contractile reserve and/or myocardial perfusion) provided sensitivity, specificity, predictive positive and negative values of 89%, 40%, 73% e 67%, respectively. The sensitivity, specificity, predictive positive and negative values of Ax1.76 for recovery of function were 91%, 50%, 75% and 78%, respectively, with an accuracy of 76%. Quality of life score improved from 36.4 (29.1-43.6) to 18.1 (12.8-23.4; p =0.001). However, there was no statistical correlation with RTPE. CONCLUSION: In conclusion, RTPE provides good accuracy of detecting hibernating myocardial in patients with coronary artery disease and ventricular dysfunction. Nevertheless, it couldnt predict the quality of life improvement after myocardial revascularization

Die chirurgische Mitralklappenrekonstruktion (MKR) ist der konservativen Therapie bei signifikanter Mitralklappeninsuffizienz (MI) überlegen. Bisher fehlen sensitive präoperative Parameter zur Detektion latenter linksventrikulärer Funktionsstörungen. Aufgrund der pathophysiologisch bedingten Nachlastreduktion und Vorlaststeigerung bei MI bergen die konventionell verwendeten Ejektionsindices, Ejektionsfraktion (EF) und Fractional Area Change (FAC), die Gefahr der Überschätzung der effektiven Pumpfunktion des linken Ventrikels (LV). Der dopplersonographisch erhobene Tei Index gilt als ein Marker globaler myokardialer Funktion. Ziel der vorliegenden Studie war es, mit dem Tei Index (bzw. dem Myokardialen Performance Index, MPI) einen sensitiveren präoperativen Parameter zur Prädiktion der postoperativen linksventrikulären Funktion zu finden. Hierzu wurden im Rahmen einer prospektiven klinischen Studie 130 Patienten mit signifikanter MI am Herzzentrum Leipzig entsprechend den ASE/SCA Leitlinien vor und nach kardiopulmonaler Bypass-Operation mittels transösophagealer echokardiographischer (TEE) Bildgebung untersucht. Die Quantifizierung der MI erfolgte durch Messung der Vena contracta (VC). Die FAC wurde in der transgastrischen midpapillären kurzen Achse und die EF im midösophagealen Zwei- sowie Vier-Kammer-Blick erfasst. Die Zeitintervalle zur Berechnung des Tei Index wurden im tiefen transgastrischen und midösophagealen Vier-Kammer-Blick erfasst. Eine statistische Korrelation zwischen präoperativen Tei Index und postoperativer EF und FAC konnte zur Validierung unserer Hypothese nicht detektiert werden. Folgend kann der Tei Index nicht als Prädiktor der effektiven linksventrikulären Funktion vor MKR gewertet werden.

Introdução: Disfunção diastólica (DD) e diminuição da reserva contrátil do ventrículo esquerdo aumentam o risco cardiovascular de pacientes com hipertensão arterial sistêmica. As estatinas, pelos seus benefícios sobre a fibrose miocárdica, podem melhorar a função diastólica ou reserva contrátil de forma mais eficaz que inibidores da enzima de conversão da angiotensina (I-ECA) nesses pacientes. Objetivos: Investigar o efeito aditivo da estatina ao I-ECA na função diastólica e reserva contrátil de hipertensos com níveis de colesterol limítrofe. Métodos: Pacientes hipertensos com DD e LDL-colesterol < 160mg/dl submeteram-se a uma fase experimental para atingir pressão arterial sistólica (PAS) < 135mmHg e pressão arterial diastólica (PAD) < 85mmHg com enalapril ou enalapril e hidroclorotiazida. Quatro semanas após atingir o objetivo terapêutico, 55 pacientes foram aleatorizados para receber 80mg de sinvastatina (n = 27) ou placebo (n = 28) por um período de 20 semanas. Ecocardiograma de repouso e de estresse com dobutamina foram realizados antes e após o tratamento. O volume máximo do átrio esquerdo (VAE) foi medido pelo método biplanar de Simpson. Foram obtidas as velocidades de Doppler convencional e tecidual (DT) na diástole precoce (E, e) e diástole tardia (A, a) em repouso e durante estresse. As velocidades de DT foram a média dos 4 anéis mitrais basais. A reserva contrátil e a reserva diastólica do VE foram calculadas. A PA foi aferida mensalmente em consultório e o perfil lipídico foi dosado a cada 2 meses. Resultados: Após 20 semanas, a sinvastatina reduziu significativamente a PAS (-4±2mmHg; p=0,02), os níveis de colesterol total (-47±6 para estatina versus 6,2±5mg/dl para placebo; p<0,0001), LDL-colesterol (-41±5 para estatina versus 9,6±4mg/dl para placebo; p<0,0001) e triglicérides (-22,8±11,1 para estatina versus 15,3±8,3mg/dl para placebo; p<0,01). A razão E/A aumentou significativamente no grupo estatina (1,00±0,05 para 1,18±0,06 para estatina versus 1,06±0,05 para 1,06±0,04 para placebo; p=0,03), ao mesmo tempo em que o VAE reduziu significativamente neste grupo quando comparado ao placebo (24,5±0,9 para 21,1±0,8ml/m² para estatina versus 23,5±1,0 para 23,2±1,1ml/m² para placebo; p=0,048). A velocidade de e aumentou marginalmente no grupo estatina (9,6±0,6 para 10,2±0,5cm/s; p=0,05), mas sem diferença entre os grupos. A reserva contrátil aumentou significativamente em ambos os grupos (0,53±0,03 para 0,66± 0,05, p=0,009 para placebo versus 0,58±0,05 para 0,70±0,05, p=0,02 para estatina). Não houve correlação entre razão E/A, VAE e mudanças na pressão arterial ou níveis de colesterol. Houve uma moderada correlação positiva entre pressão arterial e LDL-colesterol (r=0,54; p=0,004). Conclusões: 1) A adição da sinvastatina ao enalapril melhora parâmetros de função diastólica em pacientes hipertensos com níveis de colesterol limítrofe, sendo este efeito independente da redução da pressão arterial ou do colesterol. 2) A PAS reduz com a sinvastatina, sendo esta redução correlacionada à redução do LDL-colesterol. 3) A reserva contrátil melhora com o tratamento com enalapril independente do uso da sinvastatina / Background: Diastolic dysfunction (DD) and decreased contractile reserve associated with hypertension are a surrogate for increased cardiovascular risk. Statins have experimental benefits on myocardial fibrosis, and could improve diastolic function or contractile reserve to a greater extend than ACE-inhibitors in hypertension. Objectives: Test in a double-blinded, placebo-controlled randomized study the effects of simvastatin added to enalapril treatment on DD and contractile reserve in hypertensive patients with average cholesterol levels. Methods: Hypertensive patients with DD and LDL-cholesterol < 160mg/dl underwent a run-in phase to achieve a systolic blood pressure (SBP) < 135mmHg and diastolic blood pressure (DBP) < 85mmHg with enalapril. Hydrochlorothiazide was added when need to achieve SBP or DBP control. Four weeks after reaching the optimum anti-hypertensive regimen, 55 patients were randomized to receive 80mg simvastatin (n = 27) or placebo (n = 28) for a period of 20 weeks. Transthoracic echocardiograms at rest and with dobutamine stress were performed before and after treatment. Left atrial volume (LAV) was measured by biplane modified Simpsons rule. Conventional mitral Doppler velocities were obtained at early diastole (E), late diastole (A) and E/A ratio was calculated, also Tissue Doppler velocities from mitral annulus (average from 4 basal walls) were measured at early diastole (e), late diastole (a) and systole (s); both at rest and during stress. The contractile and diastolic reserves were calculated at low dose of dobutamine stress. Blood pressure was measured monthly and lipid profile was analyzed every two months. Results: After 20 weeks, statin group showed a significant decrease in SBP (-4±2mmHg; p=0.02), total cholesterol (-47±6 for statin and 6.2±5mg/dl for placebo; p<0,0001), LDL-cholesterol (-41±5 for statin and 9.6±4mg/dl for placebo; p<0,0001) and tryglicerides levels (-22.8±11 for statin and 15.3±8mg/dl for placebo; p<0,01). E/A ratio increased significantly in statin group (1±0.05 to 1.18±0.06 for statin and 1,06±0,05 to 1,06±0,04 for placebo; p=0.03) at the same time that left atrial volume decreased (24.5±0.9 to 21.1±0.8ml/m² for statin and 23.5±1.0 to 23.2±1.1ml/m² for placebo; p=0.048). Moreover, e velocity had a trend to increase in statin (9.6±0.6 to 10.2±0.5cm/s; p=0.05) but there was no difference from placebo. Contractile reserve increased equally in both groups at lower dose of dobutamine (0.53±0.03 to 0.66±0.05, p=0.009 for placebo; 0.58±0.05 to 0.70±0.05, p=0.02 for statin). There was no correlation between E/A ratio, LAV and changes in blood pressure or cholesterol levels. There was a positive moderate correlation of blood pressure and LDL-cholesterol changes (r=0.54; p=0.004). Conclusions: 1) Simvastatin added to enalapril treatment in hypertensive patients with average cholesterol levels improves parameters of diastolic function independent of blood pressure or cholesterol changes. 2) Simvastatin decrease in SBP is correlated with LDL-cholesterol decrease. 3) Contractile reserve improves with hypertensive treatment irrespective to treatment with simvastatin

INTRODUÇÃO: A artrite idiopática juvenil (AIJ) pode acometer o sistema cardiovascular em até 45% dos pacientes, principalmente nas formas mais graves. A insuficiência cardíaca congestiva ocorre em 3,9% dos adultos com artrite reumatoide (AR), havendo relatos em literatura da piora da função cardíaca em pacientes com AR em uso de terapia anti-TNF. Entretanto, não há dados em literatura sobre a segurança cardiovascular desta terapia em crianças. OBJETIVOS: Avaliação global da função cardíaca em pacientes com AIJ sob terapia anti-TNF. MÉTODOS: 25 pacientes com AIJ de curso poliarticular ativo e 22 indivíduos saudáveis foram submetidos a avaliação clínica e ecocardiográfica com Doppler convencional e tecidual e mensuração dos níveis dos biomarcadores cardíacos [própeptídeo natriurético N-terminal (NT-proBNP) e troponina T] no tempo basal (BL - préterapia anti-TNF). Os pacientes com AIJ foram avaliados a cada 3 meses por um período de 24 meses. RESULTADOS: Pacientes com AIJ e controles foram equivalentes em relação a idade (p=0,898) e gênero feminino (p=0,38). No BL, o tempo de relaxamento isovolumétrico (p=0,03), a velocidade da onda e\' no septo (p=0,014) e da onda S\' septal (p=0,03) foram significantemente reduzidos em pacientes com AIJ comparados a controles. As frequências dos níveis elevados de NT-proBNP e troponina T foram similares nesses dois grupos (p=0,297 e p=0,756), permanecendo dentro da normalidade durante toda a avaliação prospectiva, exceto por um paciente com elevação discreta da troponina T. Durante a terapêutica anti-TNF, nenhum dos 21 pacientes apresentou falência cardíaca, alteração da fração de ejeção e de outros parâmetros do Doppler. Só um paciente apresentou hipertensão pulmonar discreta. Avaliação adicional demonstrou que os pacientes com AIJ que apresentaram níveis elevados de NT-proBNP no BL tinham mais articulações ativas (p=0,025), VHS mais elevado (p=0,034) e maiores pontuações do JADAS-27 (p=0,014). CONCLUSÃO: Há segurança cardiovascular a longo prazo em pacientes com AIJ submetidos a terapia anti-TNF. Níveis elevados de NT-proBNP foi associado com atividade inflamatória na AIJ, reforçando uma interpretação mais cuidadosa deste biomarcador em pacientes com doença ativa / INTRODUCTION: Juvenile idiopathic arthritis (JIA) may cause heart damage in up to 45% of patients. Congestive cardiac failure may occur in 3,9% of adults with rheumatoid arthritis. It is described in literature, that some patients may presente with heart failure due to anti- TNF therapy. There is no data regarding cardiovascular safety in JIA patients. OBJECTIVE: To perform global assessment of long-term cardiac function in juvenile idiopathic arthritis (JIA) patients under TNF blockage therapy. METHODS: 25 polyarticular-course JIA patients pre-anti-TNF and 22 healthy controls underwent conventional/tissue Doppler echocardiography and cardiac biomarkers measurements [N-terminal pro-brain natriuretic peptide (NT-pro-BNP) and troponin T] at baseline (BL). Twenty-one JIA patients completed six evaluations during two consecutive years. Clinical/laboratorial evaluations were assessed before and during TNF blockage therapy. RESULTS: JIA patients and controls were comparable regarding current age (p=0.898) and female gender (p=0.38). At BL isovolumetric relaxation time of left ventricle (p=0.03), ventricular septum velocity (VS), E\' wave (p=0.014) and VS S wave (p=0.03) were significantly reduced in JIA patients compared to controls. Frequencies of elevated NT-pro-BNP and troponin T levels were similar in JIA and controls (p=0.297 and p=0.756) and levels remained within normal range throughout the study, except for one patient with mild troponin T elevation. During TNF blockage therapy, none of the 21 participants had heart failure, ejection fraction or other parameters alterations in conventional and tissue Doppler. Only one had mild pulmonary hypertension. Further analysis revealed that JIA patients with elevated levels of NT-pro-BNP at BL had significantly more active joints (p=0.025), higher ESR (p=0.034) and higher JADAS-27 (p=0.014). CONCLUSIONS: Long-term TNF blockage safety was demonstrated in JIA patients in spite of the observed subclinical diastolic involvement. Elevated cardiac biomarker in these patients was associated with inflammatory parameters reinforcing the need for a careful interpretation of this finding in patients with active disease

INTRODUÇÃO: A ecocardiografia tridimensional em tempo real (E3DTR) vem provando sua acurácia para quantificar os volumes do ventrículo esquerdo (VE), fração de ejeção (FEVE) e massa em pacientes com cardiomiopatia. Na cardiomiopatia hipertrófica (CMH), onde a morfologia ventricular pode estar muito alterada, a análise das estruturas cardíacas é fundamental para indicação da terapêutica ideal. A ressonância magnética cardiovascular (RMC) é um método superior na análise segmentar do VE em comparação a ecocardiografia bidimensional (E2D), mas com alta complexidade e existente em poucos centros diagnósticos, com contraindicações e limitações para a sua realização. MÉTODOS: Estudo transversal, comparativo, duplo cego, em 20 portadores de CMH, com E2D, E3DTR e RMC realizados com intervalo máximo de 06 meses e armazenados em formato digital. A espessura das paredes, volumes, função sistólica e massa ventricular esquerda foram analisados pelos métodos ecocardiográficos e pela RMC, assim como o movimento anterior sistólico da valva mitral, o índice geométrico do VE e o índice sistólico de dissincronia do VE. ANÁLISE ESTATÍSTICA: Análise estatística pelo coeficiente de concordância de Lin, correlação linear de Pearson e modelo de Bland-Altman. RESULTADOS: Foi obtida exeqüibilidade elevada acima de 94%, dependente do parâmetro avaliado. Concordância satisfatória e forte correlação linear evidenciada para a análise segmentar (Rc>0.84 e r>0.85; p<0.0001) observada para os métodos ecocardiográficos comparados à RMC, com concordância excelente entre os métodos ecocardiográficos (Rc=0,92 e r=0,92, p<0,0001). Concordância satisfatória e forte correlação linear para a fração de ejeção do VE (Rc=0.83 e r=0.93; p<0.0001) pela E3DTR comparada à RMC. Concordância excelente e forte correlação linear para o VDFVE e VSFVE pela E3DTR comparada à RMC e pela E2D comparada à E3DTR (Rc>0.90 and r>0.95; p<0.0001), assim como para a massa do VE, para os métodos E3DTR e RMC (Rc=0.96 e r=0.97; p<0.0001). Evidenciada maior exeqüibilidade da análise do MAS pela E3DTR. O índice geométrico do VE foi >0,15mmxm²xml-1 para todos os métodos. Observada correlação negativa entre o índice de dissincronia do VE e o percentual de fibrose miocárdica, sem significância estatística. CONCLUSÕES: A E3DTR é precisa e superior à E2D na avaliação da distribuição da hipertrofia miocárdica, quantificação dos volumes, função e massa ventricular esquerda em pacientes com CMH quando comparada à RMC, e parece ser superior na análise do MAS, pela melhor visão espacial da valva mitral.Todas as medidas do índice geométrico do ventrículo esquerdo estavam acima de 0,15mmxm²xml-1, compatível com CMH. Não foi identificada correlação entre o índice sistólico de dissincronia ventricular esquerda e a fibrose miocárdica. / INTRODUCTION: Real-time three-dimensional echocardiography (RT3D) has been demonstrated an accurate technique for the quantification of left ventricular (LV) volumes, ejection fraction (LVEF), and mass. In patients with hypertrophic cardiomyopathy (HCM), in which alterations of ventricular morphology are common, cardiac structural analysis is of utmost importance for guiding adequate therapy. Although magnetic resonance imaging (MRI) seems to have better definition for segmental analysis than two-dimensional echocardiography, (2D-E), it is considered a complex test with low availability and some limitations for use. METHODS: Comparative and double-blinded study in 20 patients with HCM. All patients underwent 2DE, RT3D and MRI within maximal interval of 6 months. Parameters analyzed by echocardiography and MRI included: wall thickness, LV volumes, systolic function, LV mass, systolic anterior motion of mitral valve, LV geometric index and LV dyssynchrony index. Statistical analysis was performed by Lin agreement coefficient, Pearson linear correlation and Bland-Altman model. RESULTS: Feasibility for measurements by MRI and echocardiography was 94%. There was good agreement and linear correlation between segmental analysis by echocardiography and MRI (Rc>0.84 and r>0.85; p<0.0001) and excellent correlation between 2DE and RT3DE (Rc=0.92 and r=0.92; p<0.0001). We also observed good agreement and linear correlation between RT3DE and MRI for ejection fraction (Rc=0.83 and r=0.93; p<0.0001) and excellent agreement and linear correlation between RT3DE and MRI for LV end diastolic volume and LV end systolic volume determinations (Rc>0.90 and r>0.95; p<0.0001) and mass (Rc=0.96 and r=0.97; p<0.0001). The feasibility for systolic anterior motion of mitral valve was higher by RT3DE (91%) than 2DE (64%). LV geometric index was >0.15 mmxm²xml-1 for all techniques. There was no correlation between LV dyssynchrony index and the percentage of myocardial fibrosis. CONCLUSIONS: RT3D is an accurate technique with superior performance than 2DE for the evaluation of myocardial hypertrophy localization, LV volume and functional determination as well as for LV mass assessment in patients with HCM in comparison with MRI. In addition, it seems to be superior for the analysis of systolic anterior motion due to its better spatial view of mitral valve. All measurements of LV geometric index were above the value of 0.15 mmxm²xml-1, and such findings are compatible with HCM. No correlation between LV dyssynchrony index by RT3D and the percentage of myocardial fibrosis determined by MRI was identified.

INTRODUÇÃO: Pouco se sabe sobre parâmetros ultrassonográficos transvaginais possíveis de serem avaliados durante a gestação além do comprimento do colo uterino. A escassa literatura sugere que o volume calculado através da ultrassonografia tridimensional, a quantificação de sinal power Doppler em todo o órgão e o Doppler das artérias uterinas possam sofrer alterações de acordo com o comprimento cervical, e até mesmo anteceder seu encurtamento no processo que leva ao parto. OBJETIVOS: agregar novos parâmetros bi e tridimensionais ultrassonográficos à avaliação do colo uterino em gestações únicas. MÉTODO: Estudo transversal desenvolvido com dados de 2014 a janeiro de 2018 do projeto PROPE, no qual foi realizada ultrassonografia transvaginal em pacientes entre 20 e 23 semanas e 6 dias de gestação. Foram compilados e submetidos à análise secundária os dados de 162 gestantes com comprimento do colo uterino >= 25 mm (grupo Controle), 68 gestantes com comprimento do colo >= 15 mm e < 25 mm (grupo Colo Curto) e 18 gestantes com comprimento do colo < 15 mm (grupo Colo Muito Curto). Foram analisadas as características demográficas e antecedentes obstétricos das gestantes, e foram comparados entre os grupos os parâmetros cervicais de comprimento, volume e vascularização, além do Doppler de artérias uterinas bilateralmente. RESULTADOS: O comprimento médio (± DP) dos colos uterinos de cada grupo foi 35,28 ± 5,12 mm para o grupo Controle, 20,51 ± 2,47 mm para o grupo Colo Curto, e 10,72 ± 2,51 mm para o grupo Colo Muito Curto. Houve diferença entre os grupos quanto à idade materna, cor (etnia) e idade gestacional de inclusão. Quanto aos antecedentes obstétricos, houve associação somente entre a presença de colo curto na gestação atual e pelo menos um parto prematuro anterior em gestantes não nulíparas (p = 0,021). Em relação aos parâmetros ultrassonográficos, verificou-se correlação linear positiva moderada entre volume e comprimento do colo (coeficiente de Pearson=0.587, valor p < 0.0001). Os grupos Controle, Colo Curto e Colo Muito Curto foram estatisticamente diferentes em relação às médias (± DP) de volume (46,38 ± 13,60 cm vs. 32,15 ± 13,14 cm vs. 22,08 ± 11,10 cm, respectivamente)(p <= 0,001), e em relação às médias (± DP) de índice de fluxo (IF) (39,81 ± 6,42 cm vs. 38,73 ± 4,99 cm vs. 36,02 ± 5,34 cm, respectivamente) (p = 0,027), em que a diferença estatística ocorre entre os grupos Controle e Colo Muito Curto. Porém, na presença da informação do volume, após regressão linear, a associação entre os grupos e IF deixa de ser significativa. Também não houve relação entre os grupos estudados e o Doppler de artérias uterinas. CONCLUSÃO: Existe correlação linear positiva entre o volume e o comprimento do colo uterino. Na ausência de informações sobre o volume, comprimento cervical e índices de vascularização não se correlacionam. O comprimento cervical também não está relacionado a alterações no Doppler de artérias uterinas. Apesar das limitações de uma amostra pequena e escassez de dados comparativos na literatura, este estudo foi realizado com uma amostra homogênea da população e abre caminho para maiores pesquisas sobre o assunto / INTRODUCTION: Little is known about transvaginal ultrasound parameters other than cervical length that can be assessed during gestation. The literature suggests that changes in volume on three-dimensional ultrasound, quantification of power Doppler signal in the entire organ, and Doppler sonography of uterine arteries may be related to cervical length, and even precede its shortening during spontaneous delivery. OBJECTIVES: To include new two- and three-dimensional ultrasonographic parameters for evaluation of the uterine cervix in single pregnancies. METHODS: A crosssectional study of data from Project PROPE on transvaginal ultrasonography performed in patients between 20 and 23 weeks and 6 days of gestation from May 2014 to January 2018 was conducted. Secondary analysis of data from 162 pregnant women with uterine cervical length >= 25 mm (Control group), 68 pregnant women with cervical length >= 15 mm and < 25 mm (Short Cervix group), and 18 pregnant women with cervical length < 15 mm (Very Short Cervix group) was performed. The demographic characteristics and obstetric history of the pregnant women were analyzed, and the cervical length, volume, and vascularization were compared between the groups. In addition, Doppler velocimetry of the uterine arteries was performed bilaterally. RESULTS: The mean cervical length (± SD) was 35.28 ± 5.12 mm for the Control group, 20.51 ± 2.47 mm for the Short Cervix group, and 10.72 ± 2, 51 mm for the Very Short Cervix group. The groups differed in maternal age, ethnicity, and gestational age. When analyzing the obstetric history of only non-nulliparous patients we observed a significant association between the presence of a short cervix in the current pregnancy and at least one previous preterm birth (p = 0.021). With regard to the ultrasonographic parameters, we observed a moderate positive linear correlation between the volume and length of the cervix (Pearson coefficient = 0.587, p < 0.0001). The Control, Short Cervix, and Very Short Cervix groups showed differences in the mean (± SD) volume (46.38 ± 13.60 cm vs. 32.15 ± 13.14 cm vs. 22.08 ± 11.10 cm, respectively) (p <= 0.001) and mean (± SD) flow index (FI) parameter of cervical vascularization (39.81 ± 6.42 cm vs. 38.73 ± 4.99 cm vs. 36.02 ± 5.34 cm, respectively) (p = 0.027), and the difference between the Control and Very Short Cervix groups was statistically significant. However, after linear regression, in the presence of volume information, we found no association between the groups and FI. CONCLUSION: Cervical length and volume are positively correlated. When information about the volume is not provided, there\'s no association between cervical length and vascularization. Uterine artery Doppler is not related to cervical length. Despite the limitations of a small sample size and less comparative data in the literature, this study was performed with a homogeneous sample population and paves the way toward further research on the subject