Biomedical subjects
Publications and source records attributed to Carlos Cotrim.
The authors report a case of a 42-year-old male, with the incidental finding of a fistula from the aortic root (sinus of Valsalva) to the right ventricle in the diagnostic work-up of atypical chest pain. The images and results of the exams are presented and the therapeutic options are discussed after the final diagnosis.
UNLABELLED: The development of intraventricular gradients during dobutamine stress echocardiography has been widely reported and this finding is commonly associated with symptoms during stress testing. In a previous study, we investigated the incidence of intraventricular gradients during dobutamine stress echocardiography in 46 patients and concluded that they occur frequently (43%). In another study we looked for the same phenomenon in 50 other consecutive patients during exercise stress echocardiography and only found a small gradient in one patient (2%). The purpose of the present study was to look for the development of intraventricular gradients during exercise echocardiography, in patients in whom this phenomenon occurred during dobutamine stress echocardiography. We studied 10 patients who developed a significant intraventricular gradient in a negative or inconclusive dobutamine stress echocardiography study. Five of the patients were male, mean age was 63 +/- 15.9 years (34-79). Three patients had previously undergone coronary angioplasty. The presence of intraventricular gradients was evaluated in all patients by color, pulsed and continuous wave Doppler echocardiography during dobutamine and exercise stress testing. An intraventricular gradient was considered significant when the intraventricular flow velocity increased by more than 1 m/s at the end of systole. The mean intraventricular gradient developed during dobutamine stress echocardiography was 101.7 +/- 68 mmHg (47-270). Only one of these patients developed a small intraventricular gradient during exercise stress echocardiography. CONCLUSION: In a small population of patients who developed significant intraventricular gradients during dobutamine stress echocardiography, this finding was not reproduced with exercise echocardiography.
The high prevalence of coronary artery disease in western countries has led to the development of non-invasive methods for the detection of myocardial ischemia, notably stress echocardiography (SE). We began our experience in SE in January 1999, 2326 consecutive SE studies being performed up to December 3rd 2001. The mode of stress used was: exercise in 1146 patients (pts); dobutamine in 1117 pts; dipyridamole in 35 pts; permanent pacing in 28 pts; hyperventilation in 4 pts. Eight (0.3%) significant complications occurred during these exams in this period. During exercise stress echocardiography three significant complications occurred: one case of cardiac rupture, one case of sustained ventricular tachycardia and one case of fixed 2nd degree atrioventricular block. In dobutamine stress echocardiography, five significant complications were documented: one case of non-sustained ventricular tachycardia, two cases of sustained ventricular tachycardia and two cases of 2nd degree atrioventricular block. Stress echocardiography is a feasible and safe method for the non-invasive detection of myocardial ischemia, but significant complications may occur and the staff must be prepared to perform immediate cardiopulmonary resuscitation.
The authors report the case of a 49-year-old female with a history of rheumatic valvular heart disease who underwent valve surgery in 1997, with implantation of St. Jude prosthetic valves in aortic and mitral position. She was asymptomatic until the end of July 2001, when she was admitted to Garcia de Orta Hospital emergency unit because of heart failure, fever and suspicion of endocarditis. Cardiologic evaluation was requested and the transthoracic (TTE) and transesophageal (TEE) echocardiograms revealed vegetations on the prosthetic mitral valve. Blood cultures were negative. She started empiric antibiotic therapy and the clinical course stabilized in the first week. After ten days of medical therapy her symptoms became worse and TTE and TEE were repeated. TTE showed significant left ventricular-aortic gradient, suggesting aortic valve obstruction. Decreased left ventricular function was now present with hypokinesia in the anterior descending coronary artery territory. In the TEE, a large thrombotic process on the mitral prosthesis valve was seen, with a prosthesis disk blocked. There were similar findings in the aortic valve. Cardiac fluoroscopic images were obtained at the mitral and aortic position confirming the TEE report. The coronary angiogram was normal. Promptly transferred to a cardiac surgery center, the patient underwent aortic and mitral prosthetic valve replacement. The intraoperative findings were compatible with those from echocardiography and cardiac fluoroscopy.