Cardiology Institute of Rio Grande Do Sul

Rio Grande, Brazil

Cardiology Institute of Rio Grande Do Sul

Rio Grande, Brazil
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Miglioranza M.H.,Cardiology Institute of Rio Grande do Sul | Picano E.,National Research Council Italy | Badano L.P.,University of Padua | Sant'Anna R.,Cardiology Institute of Rio Grande do Sul | And 7 more authors.
International Journal of Cardiology | Year: 2017

Background Pulmonary congestion is the main cause of hospital admission among heart failure (HF) patients. Lung ultrasound (LUS) assessment of B-lines has been recently proposed as a reliable and easy tool for evaluating pulmonary congestion. Objective To determine the prognostic value of LUS in predicting adverse events in HF outpatients. Methods Single-center prospective cohort of 97 moderate-to-severe systolic HF patients (53 ± 13 years; 61% males) consecutively enrolled between November 2011 and October 2012. LUS evaluation was performed during the regular outpatient visit to evaluate the presence of pulmonary congestion, determined by B-lines number. Patients were followed up for 4 months to assess admission due to acute pulmonary edema. Results During follow-up period (106 ± 12 days), 21 hospitalizations for acute pulmonary edema occurred. At Cox regression analysis, B-lines number ≥ 30 (HR 8.62; 95%CI: 1.8–40.1; p = 0.006) identified a group at high risk for acute pulmonary edema admission at 120 days, and was the strongest predictor of events compared to other established clinical, laboratory and instrumental findings. No acute pulmonary edema occurred in patients without significant pulmonary congestion at LUS (number of B-lines < 15). Conclusion In a HF outpatient setting, B-line assessment by LUS identifies patients more likely to be admitted for decompensated HF in the following 4 months. This simple evaluation could allow prompt therapy optimization in those patients who, although asymptomatic, carry a significant degree of extravascular lung water. Condensed abstract Pulmonary congestion is the main cause of hospital admissions among heart failure patients. Lung ultrasound can be used as a reliable and easy way to evaluate pulmonary congestion through assessment of B-lines. In a cohort of heart failure outpatients, a B-lines cutoff ≥ 30 (HR 8.62; 95%CI: 1.8–40.1) identified patients most likely to develop acute pulmonary edema at 120-days. © 2017 Elsevier B.V.


Blume C.A.,Cardiology Institute of Rio Grande do Sul | Boni C.C.,Cardiology Institute of Rio Grande do Sul | Casagrande D.S.,Federal University of Rio Grande do Sul | Casagrande D.S.,Grande Rio University | And 4 more authors.
Obesity Surgery | Year: 2012

Background Bariatric surgery is considered the most effective treatment for obesity class II and III. However, postoperative side effects may occur, such as nutritional deficiencies resulting from reduced gastric capacity and alterations in nutrient absorption along the gastrointestinal tract. Methods A total of 170 patients (136 women and 34 men) submitted to Roux-en-Y gastric bypass (RYGB) between 2000 and 2005 were retrospectively assessed. Anthropometric and laboratory data were evaluated and the use of vitamin and mineral supplements, before and 1, 6, 12, 24, and 36 months following surgery, was assessed, as well. Results Mean excess weight loss at 24 and 36 months was 81.5±19.2 and 78.5±20.8 %, respectively. Anemia was present in 6.5 % of subjects prior to the surgery and increased to 33.5 % at 36 months. The levels of total cholesterol, low-density lipoprotein cholesterol, triglycerides, and glycemia were reduced, while high-density lipoprotein cholesterol was increased. Albumin and vitamin B12 levels showed no significant differences at the end of the study compared to the preoperative evaluation. Folic acid levels increased significantly during the follow-up. Almost 6 % of the patients had used standard vitamin and mineral supplements in the preoperative period and 72.4, 85.3, 74.7, 77.1, and 72.4 % at 1, 6, 12, 24, and 36 months following RYGB, respectively. Conclusions Bariatric surgery is an effective treatment for long-term weight loss. However, nutritional deficiency is one of its side effects and should be properly diagnosed and handled, aimed at improving the patient's quality of life and preventing severe complications. © Springer Science + Business Media, LLC 2012.


Bohmer A.E.,Federal University of Rio Grande do Sul | Souza D.G.,Federal University of Rio Grande do Sul | Hansel G.,Federal University of Rio Grande do Sul | Brum L.M.B.P.,Cardiology Institute of Rio Grande do Sul | And 2 more authors.
Chemico-Biological Interactions | Year: 2010

Cyclosporine (CsA) is an immunosuppressive agent frequently used in the clinic for prevention of allograft rejection and for the treatment of autoimmune diseases. Despite its desired action on the immune system, CsA treatment may present serious adverse effects, which are masked by the concomitant use of other drugs. The search for effective immunosuppression protocols which does not affect the quality of life of patients is driving research to investigate the CsA involvement in vascular diseases, frequent in patients under immunosuppression. Thus, 45 non-transplanted Wistar rats were treated for 8 weeks with vehicle or 5 or 15. mg/kg CsA (n=15/group) by gavage administration to evaluate the specific influence of cyclosporine on the levels of risk factors (metabolic and inflammatory) of vascular disease and its mechanism of action. Therefore, serum insulin levels, glucose tolerance test, serum lipids profile, total homocysteine and fibrinogen levels were assessed. The biochemical alterations reported here suggest the development of a framework straight to diabetes. Glucose homeostasis was affected as indicated by decreased insulin levels and altered glucose tolerance test in CsA 15. mg/kg group compared to other groups. Serum insulin and total homocysteine levels presented a significant negative correlation (R=- 0.76, P<0.0001). Fibrinogen and serum lipids profiles were significantly increased in CsA 15. mg/kg group compared to other groups and correlated positively with total homocysteine levels. Considering the well-established correlation among insulin resistance, lipid and total homocysteine levels, hypercoagulability and atherosclerosis, we can assume that this protocol of long-term CsA treatment in non-transplanted rats alter biochemical parameters related to cardiovascular and cerebrovascular risk, mainly in CsA 15. mg/kg group. Insulin and tHcy serum levels appear to be central in this process. © 2010 Elsevier Ireland Ltd.


PubMed | Fatebenefratelli Hospital, Hospital San Jose, Elisabeth Hospital, National Research Council Italy and 22 more.
Type: Journal Article | Journal: Cardiovascular ultrasound | Year: 2017

Stress echocardiography (SE) has an established role in evidence-based guidelines, but recently its breadth and variety of applications have extended well beyond coronary artery disease (CAD). We lack a prospective research study of SE applications, in and beyond CAD, also considering a variety of signs in addition to regional wall motion abnormalities.In a prospective, multicenter, international, observational study design, > 100 certified high-volume SE labs (initially from Italy, Brazil, Hungary, and Serbia) will be networked with an organized system of clinical, laboratory and imaging data collection at the time of physical or pharmacological SE, with structured follow-up information. The study is endorsed by the Italian Society of Cardiovascular Echography and organized in 10 subprojects focusing on: contractile reserve for prediction of cardiac resynchronization or medical therapy response; stress B-lines in heart failure; hypertrophic cardiomyopathy; heart failure with preserved ejection fraction; mitral regurgitation after either transcatheter or surgical aortic valve replacement; outdoor SE in extreme physiology; right ventricular contractile reserve in repaired Tetralogy of Fallot; suspected or initial pulmonary arterial hypertension; coronary flow velocity, left ventricular elastance reserve and B-lines in known or suspected CAD; identification of subclinical familial disease in genotype-positive, phenotype- negative healthy relatives of inherited disease (such as hypertrophic cardiomyopathy).We expect to recruit about 10,000 patients over a 5-year period (2016-2020), with sample sizes ranging from 5,000 for coronary flow velocity/ left ventricular elastance/ B-lines in CAD to around 250 for hypertrophic cardiomyopathy or repaired Tetralogy of Fallot. This data-base will allow to investigate technical questions such as feasibility and reproducibility of various SE parameters and to assess their prognostic value in different clinical scenarios.The study will create the cultural, informatic and scientific infrastructure connecting high-volume, accredited SE labs, sharing common criteria of indication, execution, reporting and image storage of SE to obtain original safety, feasibility, and outcome data in evidence-poor diagnostic fields, also outside the established core application of SE in CAD based on regional wall motion abnormalities. The study will standardize procedures, validate emerging signs, and integrate the new information with established knowledge, helping to build a next-generation SE lab without inner walls.


Miglioranza M.H.,University of Padua | Miglioranza M.H.,Cardiology Institute of Rio Grande Do sul | Mihil S.,University of Padua | Mihil S.,Carol Davila University of Medicine and Pharmacy | And 4 more authors.
Journal of the American Society of Echocardiography | Year: 2015

Background: Tricuspid annular (TA) size and function play important roles in planning the need for associated TA annuloplasty in patients undergoing cardiac surgery for left-sided heart valve diseases. However, TA diameter normative values and the extent of TA dynamic changes during cardiac cycle remain to be established. Methods: This was a prospective, cross-sectional study of 219 healthy volunteers (mean age, 43 ± 15 years; 57% women), using conventional two-dimensional transthoracic echocardiographic (2DE) imaging to assess the variability of TA diameter measurement in relation to 2DE view and timing during cardiac cycle. TA diameter was obtained from apical right ventricular (RV)-focused four-chamber, parasternal long-axis RV inflow, and parasternal short-axis at aortic plane 2DE views at five time points during the cardiac cycle. Right atrial and RV volumes were measured using three-dimensional echocardiography. Results: TA diameters differed significantly among the three 2DE views and changed significantly during the cardiac cycle in all views. Moreover, mean fractional shortening of TA diameter was 24 ± 6% in the four-chamber view, 20 ± 7% in the parasternal long-axis RV inflow view, and 29 ± 11% in the parasternal short-axis at aortic plane view. One multivariate linear regression analysis, age, gender, and right atrial and RV volumes were independently correlated with TA diameters and accounted for 55% of the variance of midsystolic TA diameter in the four-chamber view. Conclusions: This study provides references values for TA diameters and dynamics using 2DE imaging. Age, gender, and right chamber sizes, as well as the 2DE view and time during the cardiac cycle, significantly influenced TA diameters in healthy individuals. These data may help better identify TA dilatation using 2DE imaging for surgical planning. © 2015 American Society of Echocardiography.


Muraru D.,University of Padua | Cucchini U.,University of Padua | Mihaila S.,University of Padua | Mihaila S.,Carol Davila University of Medicine and Pharmacy | And 9 more authors.
Journal of the American Society of Echocardiography | Year: 2014

Background Despite growing interest in applying three-dimensional (3D) speckle-tracking echocardiography (STE) to measure left ventricular (LV) myocardial deformation in various diseases, normative values for 3D speckle-tracking echocardiographic parameters and the effects of demographic, hemodynamic, and technical factors on these values are unknown. Methods In 265 healthy volunteers (age range, 18-76; 57% women), longitudinal strain (3DLε), circumferential strain (3DCε), radial strain (3DRε), and area strain (3DAε) were measured by using vendor-specific (Vsp) 3D speckle-tracking echocardiographic equipment. LV strain was also measured by using Vsp two-dimensional (2D) and vendor-independent 3D speckle-tracking echocardiographic software packages, for comparison. Results Reference values (lower limit of normality) for Vsp 3D STE were -17% to -21% (-15%) for 3DLε, -17% to -20% (-14%) for 3DCε, -31% to -36% (-26%) for 3DAε, and 47% to 59% (38%) for 3DRε. Three-dimensional longitudinal strain decreased, whereas 3DCε increased, with aging (P <.003), with different trends in men and women. Men had lower 3DLε, 3DRε, 3DAε, and 2D longitudinal strain than women (P <.02). LV 3D strain parameters were also influenced by LV volumes and mass, image quality, and temporal resolution (P <.02). Reference values obtained by Vsp 2D STE were -20% to -23% (-18%) for 2D longitudinal strain, -20% to -24% (-17%) for 2D circumferential strain, and 39% to 54% (28%) for 2D radial strain (P <.001 vs Vsp 3D STE). Significantly different 3DCε and 3DRε values were obtained with vendor-independent versus Vsp 3D STE (P <.001). Conclusions In healthy subjects, reference values of LV 3D strain parameters were significantly influenced by demographic, cardiac, and technical factors. Limits of normality of LV strain by Vsp 3D STE should not be used interchangeably with Vsp 2D STE or with Vin 3D STE software. © 2014 by the American Society of Echocardiography.


Badano L.P.,University of Padua | Miglioranza M.H.,Cardiology Institute of Rio Grande do Sul | MihAilA S.,Carol Davila University of Medicine and Pharmacy | Peluso D.,University of Padua | And 6 more authors.
Circulation: Cardiovascular Imaging | Year: 2016

Background - Our study sought to (1) identify reference values for left atrial (LA) volumes and phasic function indices by 3-dimensional echocardiography (3DE) and compare them with those measured by 2-dimensional echocardiography (2DE) and (2) analyze their relationship with age, sex, body size, and left ventricular function. Accuracy and reproducibility of 3DE and 2DE have been also tested to evaluate the robustness of our data. Methods and Results - We obtained maximal, minimal, and preA LA volumes by 3DE and 2DE in 276 healthy volunteers (18-79 years; 57% women). Limits of normality for LA volumes and total LA emptying fraction were larger with 3DE than with 2DE (maximal LA volume: 43 versus 35 mL/m2; preA LA volume: 31 versus 25 mL/m2; minimal LA volume: 18 versus 14 mL/m2; 53 versus 48%, respectively; P<0.001). 3DE LA volumes indexed by body surface area were similar in men and women and increased with age. On multivariable analysis, age, weight, and left ventricular systolic and diastolic function indices resulted as correlates of LA 3DE indices. LA volumes were tightly correlated with cardiac magnetic resonance measurements, yet more underestimated by 2DE versus 3DE (bias±SD: -17±16 versus -7±15 mL, respectively). Among all LA parameters, maximal LA volume and total emptying fraction were the most reproducible, including at test-retest and at expert versus trainee comparisons. Conclusions - This study provides reference values for LA 3DE volumes and function from a relatively large cohort of healthy subjects with a wide age range. Our data may help clinicians to identify LA remodeling and dysfunction.


Mihaila S.,University of Padua | Mihaila S.,Carol Davila University of Medicine and Pharmacy | Muraru D.,University of Padua | Piasentini E.,University of Padua | And 7 more authors.
Journal of the American Society of Echocardiography | Year: 2014

Background Quantitative assessment of the mitral annulus provides information regarding the pathophysiology of mitral regurgitation and aids in the planning of reparative surgery. Three-dimensional (3D) transthoracic echocardiographic data sets acquired with current scanners have enough spatial and temporal resolution to allow the quantitative analysis of the mitral annulus. Accordingly, the authors performed (1) a validation study to assess the agreement of quantitative analysis of the mitral annulus performed on 3D transthoracic echocardiography (TTE) and 3D transesophageal echocardiography (TEE) and (2) a normative study to obtain the reference values of 3D transthoracic echocardiographic parameters for mitral annular (MA) geometry and dynamics. Methods Mitral valve data sets were obtained by 3D TEE and 3D TTE in 30 consecutive patients with clinically indicated TEE (validation study) and 3D TTE in 224 healthy volunteers (aged 18-76 years) (normative study). Results In the validation study, MA measurements obtained by 3D TTE were similar to those obtained by 3D TEE (P = NS). In the normative study, MA analysis by 3D TTE was feasible (94.5%) and reproducible (intraclass correlation coefficient = 0.78-0.97). MA diameters, area, and circumference were correlated with body surface area (r > 0.50 for all) but not with age. Men had larger MA areas than women (4.9 ± 1.0 vs 4.5 ± 0.7 cm2/m2, P =.004). During systole, MA area decreased by 29 ± 5%. This decrease was related mainly to anteroposterior diameter shortening (20 ± 7%). Conclusions MA quantitative analysis by 3D TTE was accurate compared with 3D TEE in unselected patients with mitral valve disease. In healthy subjects, it was highly feasible and reproducible. The availability of reference values for MA geometry and dynamics may foster the implementation of MA quantitative analysis by 3D TTE in clinical settings. © 2014 by the American Society of Echocardiography.


Miglioranza M.H.,Cardiology Institute of Rio Grande Do sul | Gargani L.,National Research Council Italy | Sant'Anna R.T.,Cardiology Institute of Rio Grande Do sul | Rover M.M.,Cardiology Institute of Rio Grande Do sul | And 10 more authors.
JACC: Cardiovascular Imaging | Year: 2013

Objectives The aim of this study was to define the performance of lung ultrasound (LUS) compared with clinical assessment, natriuretic peptides, and echocardiography, to evaluate decompensation in patients with systolic heart failure (HF) in an outpatient clinic. Background Evaluation of pulmonary congestion in chronic HF is challenging. LUS has been recently proposed as a reliable tool for the semiquantification of extravascular lung water through assessment of B-lines. Methods This was a cohort study of patients with moderate to severe systolic HF. Receiver-operating characteristic (ROC) analyses were performed to compare LUS with a previously validated clinical congestion score (CCS), amino-terminal portion of B-type natriuretic peptide (NT-proBNP), E/e′ ratio, chest x-ray, and 6-min walk test. Results Ninety-seven patients were enrolled. Decompensation was present in 57.7% of patients when estimated by CCS, 68% by LUS, 53.6% by NT-proBNP, and 65.3% by E/e′ ≥15. The number of B-lines was correlated to NT-proBNP (r = 0.72; p < 0.0001), E/e′ (r = 0.68; p < 0.0001), and CCS (r = 0.43; p < 0.0001). In ROC analyses, considering as reference for decompensation a combined method (E/e′ ≥15 and/or NT-proBNP >1,000 pg/ml), LUS yielded a C-statistic of 0.89 (95% confidence interval: 0.82 to 0.96), providing the best accuracy with a cutoff ≥15 B-lines (sensitivity 85%, specificity 83%). A systematic approach using CCS, E/e′, NT-proBNP, chest x-ray, and 6-min walk test in different combinations as reference for decompensation also corroborated this cutoff and found a similar accuracy for LUS. Conclusions In an HF outpatient clinic, B-lines were significantly correlated with more established parameters of decompensation. A B-line ≥15 cutoff could be considered for a quick and reliable assessment of decompensation in outpatients with HF. © 2013 By The American College of Cardiology Foundation.


Miglioranza M.H.,Cardiology Institute of Rio Grande Do sul | Becker D.,Ramon y Cajal Hospital | Jimenez-Nacher J.-J.,Ramon y Cajal Hospital | Moya J.L.,Ramon y Cajal Hospital | And 2 more authors.
Echocardiography | Year: 2013

Tricuspid regurgitation (TR) produced by endocavitary leads (EL) from permanent pacemakers and implantable cardiac defibrillators is a well-known complication of this procedure. The EL may damage or interfere with tricuspid valve function causing mechanical interference of the valve leaflets leading to incomplete valve closure. It is important to recognize this mechanical complication because it could be corrected by repositioning the lead. In this case report we demonstrate how three-dimensional transthoracic echocardiography permits to obtaining an en face view, which allows simultaneous visualization of the 3 moving leaflets during the cardiac cycle, their attachment to the tricuspid annulus and the pattern of leaflet coaptation. Thus, we propose three-dimensional transthoracic echocardiography as the tool of choice to evaluate TR related to EL, to evaluate the necessity of repositioning the lead if severe regurgitation or tricuspid valve malfunction are demonstrated. Mini-Abstract Tricuspid regurgitation (TR) produced by endocavitary leads (EL) is a well-known complication of this procedure. The EL may damage or interfere with tricuspid valve function causing mechanical interference of the valve leaflets leading to incomplete valve closure. It is important to recognize this mechanical complication because it could be corrected by repositioning the lead. In this case report we demonstrate how three-dimensional transthoracic echocardiography permits obtaining an en face view, which allows simultaneous visualization of the 3 moving leaflets during the cardiac cycle, their attachment to the tricuspid annulus and the pattern of leaflet coaptation. © 2013, Wiley Periodicals, Inc.

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