Corações “Fora do Prazo”: Dois Casos de Amiloidose AL

A amiloidose cardíaca é considerada uma doença rara e classicamente descrita como de mau prognóstico, com sobrevivência média de seis meses, desde a instalação da sintomatologia de insuficiência cardíaca. Quando há suspeita  de amiloidose cardíaca está indicado o estudo etiológico, para caracterização do tipo de proteína implicada, bem como a avaliação do atingimento de outros órgãos. Neste artigo, os autores relatam dois casos, diagnosticados e tratados no Hospital CUF Descobertas (HCD) - em colaboração com o Instituto Português de Oncologia de Lisboa (IPOL) e o National Amyloidosis Centre (NAC), Londres- de insuficiência cardíaca por amiloidose AL associada a gamapatia monoclonal.Atualmente os doentes mantêm seguimento no HCD e apresentam-se clinicamente bem. Recebido: 02/05/2017 - Aceite: 18/08/2017

Do patients with intraventricular gradients during dobutamine stress echocardiography have intraventricular gradients with exercise testing?

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.

Fistula from the aortic sinus of Valsalva to the right ventricle--case report

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.

Complications in stress 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.

Pseudo-aneurysm of the aortic root in a patient with mechanical aortic prosthesis

The authors describe a case of an ex-intravenous drug user, who received mechanical valve prostheses in the aortic and mitral position for Staphylococcus aureus endocarditis and developed a pseudo-aneurysm of the aortic root with major peri-valvular regurgitation one year after surgery. The images of the transesophageal echocardiogram are presented.

Exercise induced ventricular gradient in a young patient with a positive treadmill test and normal coronary arteries

Exercise induced intraventricular gradients have been reported during exercise stress echocardiogram in a few cases. We describe a clinical case of a 23-year old-male with a positive treadmill exercise test and normal coronary angiogram given an exercise stress echocardiogram who developed a significant intraventricular gradient. We discuss the possible physiopathologic explanation for this event.