Thesis (M.S.)--University of Michigan, 2006. / eContent provider-neutral record in process. Description based on print version record. Includes bibliographical references (leaves 66-80).

Diss. (sammanfattning) Umeå : Umeå universitet, 2010.

A angiotomografia de múltiplos detectores (TC) é um exame útil no diagnóstico de doença arterial coronariana (DAC). Recentemente, a TC foi associada à perfusão miocárdica com estresse (PTC) para detectar DAC. O objetivo é comparar a perfusão miocárdica da TC, após estresse com dipiridamol, com a cintilografia miocárdica (SPECT) na detecção de estenose coronariana significativa (>70%), usando o cateterismo (CATE) como método de referência. Trinta e seis pacientes (62±8,0 anos, 20 homens) com suspeita de DAC e com SPECT positivo em menos de 2 meses foram submetidos a um protocolo de TC para avaliação da PTC e angiografia pela tomografia computadorizada (ATC). TC foi realizada em um equipamento de 64 detectores (Aquillion 64, Toshiba), com uma primeira aquisição com os seguintes parâmetros:100mA,120Kv, 32x1mm colimação e 60ml de contraste a 3ml/s, após estresse com dipiridamol (0,56mg/Kg/4min), seguida de uma aquisição de repouso/ATC após aminofilina e metoprolol (270-400mA, 120Kv,64x0,5mm e 80 ml de contraste a 5ml/s). Observadores cegos e independentes, sem conhecimento prévio dos dados clínicos ou dos exames, realizaram análise visual e quantitativa da perfusão e angiotomografia, além de análise angiográfica quantitativa (QCA) para avaliação do CATE. Todos os pacientes completaram o protocolo sem efeitos adversos com dose de radiação média de 14,7 ± 3,0 mSv e exames interpretáveis. PTC foi positiva em 27 de 36 pacientes (75%). Dos nove casos (25%) com discordâncias (PTC negativa e SPECT positivo), 6 pacientes tinham ATC ou CATE normal e 2 tinham estenose coronariana menor que 50%. Um apresentava stent pérvio e o outro um ramo diagonal com redução luminal de 50%.O terceiro paciente apresentava uma oclusão do ramo ventricular posterior da artéria coronária direita com circulação colateral detectado pela ATC e confirmado pelo CATE. A comparação entre a PTC e o SPECT em uma análise por paciente mostrou boa concordância (Kappa =0,53;p<0,001). Em 26 pacientes com CATE, como referência, os valores diagnósticos foram sensibilidade, especificidade, valor preditivo positivo, valor preditivo negativo e acurácia para a PTC 88,0; 79,3; 66,7; 93,3; 82,1% e para o SPECT 68,8; 76,1; 66,7; 77,8 e 73,1%, respectivamente. A perfusão miocárdica de repouso e estresse após dipiridamol na avaliação de doença aterosclerótica coronariana, associada à angiografia pela tomografia é factível e os resultados foram similares ao do SPECT. A combinação da informação anatômica e perfusional permite identificar os casos positivos do SPECT, sem estenose coronariana significativa. / Multidetector computed tomography is a useful method for the diagnosis of coronary artery disease. Recently, myocardial stress CT perfusion (CTP) was shown to detect myocardial ischemia. Our main objective was to evaluate the feasibility of dipyridamole stress CTP and compare to SPECT perfusion to detect significant coronary stenosis using conventional angiography (CCA) (stenosis >70%) as reference method. Thirty-six patients (62.0±8.0 years old, 20 males) with suspected CAD and < 2 months prior positive SPECT underwent a customized multidetector-row computed tomography (MDCT) protocol with rest/stress myocardial perfusion evaluation and CTA. MDCT was performed in a 64 scanner (Aquillion 64, Toshiba) with stress perfusion after 0.56mg/kg/4min of dipyridamole (100mA, 120 kV, collimation-32 x 1 mm and 60 ml of iodinated contrast) followed by aminophyline and metoprolol infusion prior to a second rest perfusion/CTA acquisition (270-400mA, 120 kV, collimation-64 x 0,5 mm and 80 ml of iodinated contrast). Independent blinded observers with no knowledge of clinical data or other exams performed visual and quantitative analysis of CTP, CTA, SPECT and quantitative coronary angiography (QCA) analysis, that was performed on CCA. All 36 patients completed the CT protocol with no adverse events, mean radiation dose of 14.7 ± 3.0 mSv and with interpretable scans. CTP was positive in 27 of 36 patients (75%). From the 9 (25%) disagreements with normal CTP and positive SPECT, 6 patients had normal CCA or CTA and 2 had no coronary stenosis > 70 %. One had patent stents and the other had a diagonal branch with mild luminal reduction at CCA. The remaining patient had an occluded right posterior lateral branch with collateral flow detect by CTA and confirmed by CCA. Good agreement was demonstrated between CTP and SPECT on a per-patient analysis (kappa 0.53). In 26 patients using CCA as reference, sensitivity, specificity, positive predictive value, negative predictive values and accuracy for CTP were 88.0, 79.3, 66.7, 93.3%, 82,1% and for SPECT 68.8, 76.1, 66.7, 77.8% and 73,1% respectively. Rest and dipyridamole-stress computed tomography myocardial perfusion is feasible and results are similar to SPECT scintigraphy. The combined anatomical information provided by computed tomography coronary angiography may allow identification of false-positives on perfusion scans.

Background: Patients residing or starting symptomatology for AMI in non-metropolitan areas face numerous obstacles in accessing health care. These may be less likely to receive evidence-based therapies and experience worse outcomes, little is known about indicators of quality of care, particularly in non-metropolitan regions in Sergipe. Aims: To compare the speed of access to the hospital with angioplasty, use of reperfusion therapies and 30-day mortality among patients with STEMI who started the symptoms in the non-metropolitan region with those who started in the metropolitan region of Sergipe state. Method: Data from the VICTIM Study (VIa Crucis for the Treatment of Myocardial Infarction) were used from December 2014 to October 2017. The sampling was done for convenience using Pearson's χ2 test and Student's T-test for analysis of the data, a significance level of 5% was adopted. Results: 878 patients participated in the study, of which 382 patients started the symptoms in the metropolitan region and 496 in the non-metropolitan region. Males were predominant in both groups. Patients from the non-metropolitan region presented higher age (63 ± 13 years vs. 60 ± 12, p = 0.001) and higher mean GRACE score (146 vs.140 p <0.001). In addition, they traveled more distances (104 ± 58km vs. 16 ± 49km, p <0.001), went through more than 1 institution (96% vs. 73%, p <0.001) and had a longer delay acess to hospital with angioplasty (11h [7-26] vs. 7h [3-17], p< 0,001) and consequently lower percentage received primary angioplasty (45% vs. 59%, p <0.001). Higher mortality of 30 days (14% vs. 8%, p 0.004) was evidenced in the population of this region when compared to patients in the metropolitan region. In addition, in the full multivariate model, the odds ratio for 30-day mortality for the non-metropolitan group was also higher (OR 1.84, 95% CI, 1.12 to 3.04, p = 0.016). Conclusion: We observed disparities in access, use of reperfusion therapies and 30-day mortality rates among patients who started the symptoms in the non-metropolitan region when compared to those of the metropolitan in Sergipe. These findings may help in the better design of the care line for patients with STEMI, especially regarding the logistics of access to reperfusion therapies in Sergipe. / Introdução: O IAMCSST requer tratamento imediato para preservar o músculo e reduzir mortalidade. Pacientes que iniciam sintomatologia para IAM em regiões não metropolitanas podem ser menos propensos a receber terapias baseadas em evidências e, portanto experimentar piores resultados. Contudo, há escassez de estudos sobre os indicadores de qualidade assistencial particularmente nesta população no Brasil. Objetivo: Comparar a celeridade do acesso ao hospital com disponibilidade para intervenção coronariana percutânea (ICP), uso das terapias de reperfusão e mortalidade em 30 dias entre os pacientes com IAMCSST que iniciaram os sintomas na região não metropolitana com aqueles que iniciaram na região metropolitana do estado de Sergipe. Método: Utilizou-se dados do Estudo VICTIM (VIa Crucis para Tratamento do Infarto do Miocárdio), realizado no período de dezembro de 2014 a setembro de 2017. A amostragem foi feita por conveniência, utilizando teste χ2 de Pearson e T-Student para análise dos dados, foi adotado nível de significância de 5%. Resultados: Participaram do estudo 878 voluntários, dos quais 382 pacientes iniciaram os sintomas na região metropolitana e 496 na região não metropolitana. O sexo masculino foi predominante em ambos os grupos. Os pacientes da região não metropolitana apresentam maior idade (63±13anos vs. 60 ± 12, p=0,001) e maior média de GRACE score (146 vs.140 p<0,001). Além disso, percorreram maiores distâncias (104± 58km vs. 16±49km, p < 0,001), passaram por mais de 1 instituição (96% vs. 73%, p< 0,001), apresentam maior atraso até o hospital com ICP (11h [7-26] vs. 7h [3-17], p< 0,001) e, portanto, realizaram menos ICP primária (45% vs. 59%, p<0,001). Constatou-se ainda que, aqueles da região não metropolitana comparativamente a metropolitana apresentaram maior mortalidade em 30 dias (14% vs. 8%, p. 0,004) e, no modelo multivariado completo, mais chance de morte aos 30 dias (OR 1,84, IC 95%, 1,12 a 3,04, p = 0,016). Conclusão: Observou-se disparidades no acesso, no uso das terapias de reperfusão e nas taxas de mortalidade de 30 dias entre pacientes que iniciaram os sintomas na região não metropolitana quando comparados com os da metropolitana em Sergipe. Esses achados podem auxiliar no melhor delineamento da linha de cuidado aos pacientes com IAMCSST, principalmente no que tange à logística de acesso às terapias de reperfusão em Sergipe. / Aracaju, SE

INTRODUÇÃO: A deformação miocárdica e a rotação ventricular têm sido amplamente empregadas na avaliação segmentar e global da função cardíaca no contexto clínico das diversas patologias cardiológicas. São escassos os estudos científicos reportados na literatura que analisaram o impacto do treinamento físico sobre o parâmetros de avaliação da dinâmica de contração do ventrículo esquerdo em coronariopatas inseridos em programas de reabilitação cardíaca. OBJETIVO: O presente estudo analisou a influência do treinamento aeróbico na capacidade física e nos parâmetros de avaliação do remodelamento ventricular e da mecânica de contração do ventrículo esquerdo em pacientes com infarto do miocárdio. MATERIAIS E MÉTODOS: Foram prospectivamente investigados 30 pacientes, 55,1 ± 8,9 anos, acometidos por infarto do miocárdio de parede anterior, aleatorizados em três grupos: grupo treinamento intervalado (GTI) (n=10), grupo treinamento moderado (GTM) (n=10) e grupo controle (GC) (n=10). Antes e após as 12 semanas de seguimento clínico, os pacientes realizaram avaliação cardiológica, eletrocardiograma, teste cardiopulmonar de exercício e ressonância magnética cardíaca. Os grupos treinados realizaram treinamento aeróbico supervisionado, em esteira ergométrica, aplicando-se duas intensidades distintas. A análise estatística foi realizada por meio de modelo linear de efeitos mistos (aleatórios e fixos). RESULTADOS: Observou-se diferença estatisticamente significante no consumo de oxigênio (VO2) pico do GTI (21,9±5,6, p=0.01) e do GTM (21,6±4,5, p=0.02) comparativamente ao GC (17,1±4,6 ml/kg/min) e, também, diferença estatisticamente significante na ventilação-minuto (VM) do GTI (72,2±21,9, p=0.001) e do GTM (68,6±15,5, p=0.004) comparativamente ao GC (48,4±15,9 L/min) na avaliação intergrupos, após o período de seguimento clínico. Não houve mudança estatisticamente significante dos volumes cavitários, da massa e da fração de ejeção do ventrículo esquerdo nos três grupos, tanto na análise intragrupo quanto na intergrupos, após o seguimento clínico. Observou-se aumento estatisticamente significante do strain radial basal (STRAD_B) somente no GC de 57,4±16,6 para 84,1±30,9%, p=0.009, na análise intragrupo. Observou-se diferença estatisticamente significante no STRAD_B do GTI (58,6±18,8, p=0.01) e do GTM (60,4±25,5, p=0.01) comparativamente ao GC (84,1±30,9%) na avaliação intergrupos, após o período de seguimento clínico. CONCLUSÃO: O treinamento aeróbico propiciou a manutenção do status da capacidade funcional, e não determinou remodelamento ventricular adverso, nos grupos treinados comparativamente ao GC. O comportamento distinto do strain radial basal, entre os grupos treinados e o GC, possivelmente reflete uma adaptação do miocárdio pósinfarto relacionada ao treinamento aeróbico. / INTRODUCTION: The myocardial deformation and the ventricular rotation have been widely used in the evaluation of the segment and overall cardiac function in the clinical setting of the various cardiac pathologies. There are few scientific studies reported in the literature that it analyzed the impact of the physical training on the assessment parameters of the left ventricular contraction dynamics in the coronary patients inserted in cardiac rehabilitation programs. OBJECTIVE: This study examined the influence of the aerobic training in the physical fitness and in the evaluation parameters of the ventricular remodeling and of the left ventricular contraction mechanics in patients with myocardial infarction. MATERIALS AND METHODS: Thirty patients were prospectively investigated, 55.1 ± 8.9 years, affected by myocardial anterior wall infarction, randomized into three groups: interval training group (GTI) (n = 10), moderate training group (GTM) (n = 10) and control group (GC) (n = 10). Before and after 12 weeks of the follow-up, the patients underwent cardiac assessment, ECG, cardiopulmonary exercise test and cardiac magnetic resonance imaging. The trained groups performed the aerobic training supervised in treadmill, applying two different intensities. The statistical analysis was performed using a linear mixed effects model (random and fixed). RESULTS: There was a statistically significant difference in the oxygen uptake (VO2) peak of the GTI (21.9 ± 5.6, p = 0.01) and of the GTM (21.6 ± 4.5, p = 0.02) compared to the GC (17.1 ± 4.6 ml / kg / min), and an also statistically significant difference in the minute ventilation (VM) of the GTI (72.2 ± 21.9, p = 0.001) and of the GTM (68.6 ± 15.5, p = 0.004) compared to the GC (48.4 ± 15.9 L / min) in the intergroup assessment, after the follow-up period. There was no significant change in chamber volumes, mass and left ventricular ejection fraction in the three groups, both in the intragroup and intergroup analysis, after the follow-up. There was a statistically significant increase of the basal radial strain (STRAD_B) only in the GC 57.4 ± 16.6 to 84.1 ± 30.9%, p = 0.009, in the intragroup analysis. There was a statistically significant difference of the STRAD_B in the GTI (58.6 ± 18.8, p = 0.01) and in the GTM (60.4 ± 25.5, p = 0.01) compared to the GC (84.1 ± 30.9 %) in the intergroup evaluation, after the follow-up period. CONCLUSION: The aerobic training provided a maintenance of the status of the physical fitness, and it has not determined an adverse ventricular remodeling, in the trained groups compared to the GC. The different behavior of the basal radial strain between the trained groups and the GC possibly reflects a post-myocardial infarction adaptation related to the aerobic training.

L’analyse de la fonction systolique en échocardiographie représente un challenge majeur depuis une vingtaine d’années dans le but d’améliorer la détection et la quantification des anomalies de la contraction myocardique. L’analyse des déformations myocardiques consiste à étudier le pourcentage d’étirement ou de raccourcissement myocardiques au cours du cycle cardiaque. Après le grand pas en avant dans ce domaine, consécutif à l’avènement du Doppler tissulaire il y a un quinzaine d’années, ces 4 dernières années ont vu naître une nouvelle technique d’analyse bidimensionnelle des déformations, porteuse de grands espoirs car s’affranchissant de la limitation liée à l’angle d’incidence Doppler et basée sur le suivi des marqueurs acoustiques de la paroi myocardique : le « speckle tracking echocardiography » ou « 2D strain ». Cette thèse rapporte tout d’abord une série de travaux orientés sur la validation de ce nouvel outil. Nous avons ensuite appliqué expérimentalement cette technique pour évaluer sa capacité à détecter l’ischémie myocardique lors d’un examen de stress sous dobutamine en comparaison à l’analyse de perfusion myocardique en échographie de contraste. Enfin, nous exposons plusieurs expériences cliniques qui témoignent de quelques applications potentielles de cette technique dans la prise en charge des patients porteurs de cardiopathies diverses : myocardiopathie hypertrophique, fibrillation auriculaire paroxystique et recherche de viabilité sous faibles doses de dobutamine chez les patients porteurs d’une cardiopathie ischémique. / For 20 years, analysis of systolic myocardial function by echocardiography is a major challenge to improve the detection and the quantification of myocardial contractility abnormalities. The principle of myocardial deformation analysis consists in evaluating the percentage of myocardial thickening or shortening during the cardiac cycle. After a big step forward with the advent of tissue Doppler imaging for 15 years, the 4 last years have seen the apparition of a new technique of bidimensional analysis, without angle dependency, based on the tracking of the acoustic markers of the myocardial wall, and called « speckle tracking echocardiography » or « 2D strain ». This thesis reports serial studies oriented on the validation of this new tool and on the experimental application of this technique in the detection of myocardial ischemia during pharmacological dobutamine stress echocardiography, in comparison with myocardial perfusion analysis by contrast echocardiography. Finally, we report some clinical experiences using the speckle tracking echocardiography which attest of some clinical potential applications of this technique in the management of the patients with different cardiomyopathies: hypertrophic cardiomyopathy, lone paroxysmal atrial fibrillation, and analysis of myocardial regional deformation during low doses dobutamine infusion to investigate viability in patients with ischemic cardiomyopathy.

Introdução: A história natural da insuficiência mitral associa-se a décadas de remodelação ventricular esquerda com fibrose intersticial. A fronteira entre o processo adaptativo e a miocardiopatia dilatada demanda avaliação clínico-histológica. Atualmente, sabe-se que o melhor método empregado para quantificar as alterações decorrentes do remodelamento que acomete o ventrículo esquerdo é a biópsia miocárdica, que analisa a doença, somente após a cirurgia ou no post mortem. O presente estudo visa avaliar a fibrose miocárdica associada à insuficiência mitral crônica, através de estudo pela Ressonância Magnética, de maneira não invasiva, precoce e rápida. Objetivos: Avaliar a capacidade e a aplicabilidade da ressonância magnética cardíaca de detectar a fibrose miocárdica na insuficiência mitral crônica importante, tendo como referência a biópsia miocárdica. Métodos: Foram selecionados 52 pacientes portadores de IM crônica pura ou associada a estenose mitral leve, com PVM e DR, e com indicação cirúrgica. Todos os pacientes foram reavaliados pelo EcoDopplercardiograma e realizaram ressonância magnética cardíaca para avaliação da função ventricular, volumes e índice de massa ventricular esquerda, através da cine-ressonância e pela técnica do realce tardio miocárdico, com injeção de 0,2 mmol/kg de contraste gadolínio para a detecção de FM, sendo submetidos a cirurgia de plástica ou troca de válvula mitral com bióspsias miocárdicas, retiradas de locais padrão, na parede lateral do ventrículo esquerdo. Todas foram coradas pela técnica do hematoxilinaeosina, e as positivas para FM, confirmadas pelo corante picrossirius, que cora colágeno, e quantificadas pelo aparelho do quantimet. Resultados: Os pacientes foram divididos em quatro grupos, conforme a RM e a biópsia. A RM diagnosticou FM em 18 pacientes, concordantes com a BM (RMC/BM +). A RM foi negativa para FM em 33 pacientes, sendo 28 concordantes com a BM (RMC/BM -). Observou-se discordância de RM com a BM, em 7 casos falsos negativos (RMC-/BM +). A sensibilidade da RMC à fibrose foi de 72%, especificidade de 100%, e acurácia de 86,3%. Nos grupos distintos estudados, a sensibilidade, especificidade e acurácia foram de 64,7%, 100% e 82,4%, respectivamente, na PVM, e de 97,5%, 100% e 92,9%, respectivamente, na DR. O índice Kappa foi de 0,724 (p<0,001) para o grupo total; 0,665 (p<0,001) para PVM e 0,857(p<0,001) na DR. VDF, VSF e IMVE tiveram correlação positiva e significativa com a porcentagem de fibrose, sendo que, quanto maiores esses valores, maior a porcentagem de fibrose. Conclusão: RMC teve boa concordância com a BM, em relação aos achados de FM / Introduction: The natural history of mitral insufficiency (MI) is associated to decades of left ventricular remodelation with intersticial fibrosis. The frontier between adaptative process and dilatade miocardiopaty needs clinic and histologic evaluation. Now a days , we know that the best method to quantify the alterations of remodelation in left ventricule is myocardial biopsies which analyses the illness only after surgery or post morten. This actual study aims to evaluate myocardial fibrosis associated with cronic MI, through the study with magnetic resonance (MR), in a not invasive, early and quickly way. Objectives: Evaluate capacity and applicability of the magnetic resonance in detection of myocardial fibrosis in chronic important mitral insufficiency in reference with myocardial biopsis. Methods: It was selected 52 patients with pure chronic MI or associated with mild mitral stenosis, with cirurgical indication. All of the patients were reevaluated by EcoDopplercardiogram and it was done cardiac MR to evaluate ventricular function, volumes and left ventricular mass rate through MR cine and myocardial late realce techinique with 0,2 mmol/Kg with gadoline contrast and myocardial fibrosis (MF) detection and being undergone plastic or mitral valvular changes surgery with myocardial biopsis (MB) were taken from the left ventricular lateral wall. All of them were colored with hematoxilin eosine and the positives were confirmated with picrossirius and quantified with quantimet device. Results: Patients were divided in four groups according to MR and biopsies. MR diagnosticated MF in 18 patients agreed with MB (MR / MB +). MR was negative for MF in 33 patients where 28 agreed with MB (MR / MB -). We observated discordance with MR and MB in 7 cases false negatives (MR- /MB+). The sensibility of MR to fibrosis was 72%, specificity was 100% and acurace was 86,3%. In the distinct groups studied, we see sensibility, specifity and acure were 64,7%, 100 % and 82,4% respectivity in PVM and 97,5%, 100% and 92,9% respectivity in reumathic disease. The Kappa indice is 0,714 (p<0,001) for the total group; 0,665 (p<0,001) for PMV and 0,857 (p<0,001) in RD. There is a positive correlation and significative between fibroses percentage with VDF, VSF, IMVE of the MR. So the higher the values, higher the fibrosis percentage. Conclusion: MR had a good concordance with MB in relation to found the MF in IMC

Coronary artery disease remains the leading cause of death in the United States with over 1 million acute coronary events predicted to take place in 2019 alone. Heart failure, a common and deadly sequela of myocardial infarction (MI), is attributed to adverse ventricular remodeling driven by cardiomyocyte death, inflammation, and mechanical factors. Despite strong evidence suggesting the importance of myocardial mechanics in driving cardiac remodeling, many <i>in vivo</i> MI studies still rely on 2D analyses to estimate global left ventricular (LV) function and approximate strain using a linear definition. These metrics, while valuable in evaluating the overall impact of ischemic injury on cardiac health, do not capture regional differences in myocardial contractility. The objective of this work is therefore to expand upon existing ultrasound studies by enabling regional analysis of 3D myocardial strain. By integrating our recently developed four-dimensional ultrasound (4DUS) imaging technique with a direct deformation estimation algorithm for 3D strain, we identified unique remodeling patterns and regional strain differences between two murine models of MI with different infarct severities. By constructing 3D strain maps of the remodeling LVs, we were able to capture strain heterogeneity and characterize a sigmoidal strain profile at infarct border zones. Finally, we demonstrated that the maximum principal component of the 3D Green-Lagrange strain tensor correlates with LV remodeling severity and is predictive of final infarct size. Taken together, the presented work provides a novel and thorough approach to quantify regional 3D strain, an important component when assessing post-MI remodeling.

Osteopontin, also called cytokine Eta-1, is a multifunctional protein containing Arg-Gly-Asp-Ser (RODS) cell-binding sequence. It interacts with αvβ1, αvβ3 and αvβ5 integrins and CD44 receptors. OPN is suggested to play a role during inflammation via the recruitment and retention of macrophages and T-cells to inflamed sites. OPN regulates the production of inflammatory cytokines and nitric oxide in macrophages. In this review, we will discuss diverse roles of OPN related to cardiovascular diseases, including atherosclerosis, valvular stenosis, hypertrophy, myocardial infarction and heart failure.

No description available.