Browsing by Author "Castro, G"
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- Aortic Valve Disease and Vascular Mechanics: Two-Dimensional Speckle Tracking Echocardiographic AnalysisPublication . Leite, L; Teixeira, R; Oliveira-Santos, M; Barbosa, A; Martins, R; Castro, G; Gonçalves, L; Pego, MPURPOSE: Degenerative aortic valve disease (AVD) is a complex disorder that goes beyond valve itself, also undermining aortic wall. We aimed to assess the ascending aortic mechanics with two-dimensional speckle tracking echocardiography (2DSTE) in patients with aortic regurgitation (AR) and hypothesized a relationship with degree of AR. Aortic mechanics were then compared with those of similarly studied healthy controls and patients with aortic stenosis (AS); finally, we aimed to assess the prognostic significance of vascular mechanics in AVD. METHODS: Overall, 73 patients with moderate-to-severe AR and 22 healthy subjects were enrolled, alongside a previously examined cohort (N = 45) with moderate-to-severe AS. Global circumferential ascending aortic strain (CAAS) and strain rate (CAASR) served as indices of aortic deformation; corrected CAAS was calculated as CAAS/pulse pressure (PP). Median clinical follow-up was 438 days. RESULTS: In patients with severe (vs. moderate) AR, CAASR (1.53 ± 0.29/sec vs. 1.90 ± 0.62/sec, P < 0.05) and corrected CAAS (0.14 ± 0.06%/mmHg vs. 0.19 ± 0.08%/mmHg, P < 0.05) were significantly lower, whereas CAAS did not differ significantly. Measurers of aortic mechanics (CAAS, corrected CAAS, CAASR) differed significantly (all P < 0.01) in patients with AS and AR and in healthy subjects, with lower values seen in patients with AS. In follow-up, survival rate of AVD patients with baseline CAASR >0.88/sec was significantly higher (log rank, 97.4% vs. 73.0%; P = 0.03). CONCLUSIONS: Quantitative measures of aortic mechanics were lower for AS patients, suggesting a more significant derangement of aortic elastic properties. In the context of AVD, vascular mechanics assessment proved useful in gauging clinical prognosis.
- Complexo de Carney a propósito de um caso clínicoPublication . Teixeira, R; Lourenço, C; Coelho, L; Vieira, H; Ramos, D; Castro, G; Monteiro, P; Donato, P; Ferreira, MJ; Providência, LA
- Controvérsias na Anticoagulação Oral: Continuar ou Interromper os Anticoagulantes Orais durante a Intervenção Estomatológica?Publication . António, N; Castro, G; Ramos, D; Machado, A; Gonçalves, L; Macedo, T; Providência, LAThe management of patients taking long-term oral anticoagulants who require dental surgery is still highly controversial. The risk of bleeding associated with dental treatment under oral anticoagulants must be weighed against the risk of thromboembolism associated with suspension of antithrombotic therapy. Mortality and morbidity associated with thromboembolic events are higher than those associated with hemorrhagic events after minor oral surgery procedures. Evidence-based information does not support oral anticoagulant suspension before minor oral surgery. The authors propose a management protocol for chronically anticoagulated patients who require a dental procedure, to reduce both thromboembolic risk and the risk of bleeding.
- Exercise echocardiography for the assessment of pulmonary hypertension in systemic sclerosis: a systematic reviewPublication . Baptista, R; Serra, S; Martins, R; Teixeira, R; Castro, G; Salvador, MJ; Pereira da Silva, JA; Santos, L; Monteiro, P; Pêgo, MBACKGROUND: Pulmonary arterial hypertension (PAH) complicates the course of systemic sclerosis (SSc) and is associated with poor prognosis. The elevation of systolic pulmonary arterial pressure (sPAP) during exercise in patients with SSc with normal resting haemodynamics may anticipate the development of PAH. Exercise echocardiography (ExEcho) has been proposed as a useful technique to identify exercise-induced increases in sPAP, but it is unclear how to clinically interpret these findings. In this systematic review, we summarize the available evidence on the role of exercise echocardiography to estimate exercise-induced elevations in pulmonary and left heart filling pressures in patients with systemic sclerosis. METHODS: We conducted a systematic review of the literature using MEDLINE, Cochrane Library and Web of Knowledge, using the vocabulary terms: ('systemic sclerosis' OR 'scleroderma') AND ('exercise echocardiography') AND ('pulmonary hypertension'). Studies including patients with SSc without a prior diagnosis of PAH, and subjected to exercise echocardiography were included. All searches were limited to English and were augmented by review of bibliographic references from the included studies. The quality of evidence was assessed by the Effective Public Health Practice Project system. RESULTS: We identified 15 studies enrolling 1242 patients, who were mostly middle-aged and female. Several exercise methods were used (cycloergometer, treadmill and Master's two step), with different protocols and positions (supine, semi-supine, upright); definition of a positive test also varied widely. Resting estimated sPAP levels varied from 18 to 35 mm Hg, all in the normal range. The weighted means for estimated sPAP were 22.2 ± 2.9 mmHg at rest and 43.0 ± 4.3 mmHg on exercise; more than half of the studies reported mean exercise sPAP ≥40 mmHg. The assessment of left ventricular diastolic function on peak exercise was reported in a minority of studies; however, when assessed, surrogate variables of left ventricular (LV) diastolic dysfunction were associated with higher sPAP on exercise. CONCLUSIONS: We found very high heterogeneity in the methods, the protocols and the estimated sPAP response to exercise. LV diastolic dysfunction was common and was associated with greater elevation of sPAP on exercise.
- Exercise-induced pulmonary hypertension in scleroderma patients: a common finding but with elusive pathophysiologyPublication . Baptista, R; Serra, S; Martins, R; Salvador, MJ; Castro, G; Gomes, M; Santos, L; Monteiro, P; Pereira da Silva, JA; Pêgo, MBACKGROUND: The etiology of exercise-induced pulmonary hypertension (exPH) in systemic sclerosis (SSc) remains a complex task, as both left ventricle (LV) diastolic dysfunction and pulmonary vascular disease can contribute to its development. We determined the incidence of exPH in SSc and examined the association between pulmonary artery systolic pressure (PASP) and tissue Doppler-derived indexes of pulmonary capillary wedge pressure (PCWP). METHODS: Thirty-eight patients with SSc were studied, using a cycloergometer protocol; 10 were excluded due to resting PH or absence of tricuspid regurgitation (TR); TR and mitral E-wave velocities, LV outflow tract time-velocity integral and LV septal E'-wave were measured before and in peak exercise to calculate cardiac output (CO), PCWP and pulmonary vascular resistance (PVR). RESULTS: Mean age of diagnosis was 57.9 ± 8.9 years. At a mean workload of 64 ± 29 Watts, 48% of patients increased PASP ≥ 50 mmHg. PCWP, assessed by the E/e' ratio, did not change significantly during exercise (10.2 ± 3.1-10.0 ± 5.1; P = NS). Only 3 patients had elevations of the E/e' ratio ≥ 13 during exercise; 2 of them had an exercise PASP ≥ 50 mmHg, yielding a proportion of exPH due to elevated LV filling pressures of 2/11 (18%). Patients with exPH had lower DLCO and had more frequently the diffuse SSc. CONCLUSION: The elevation of PASP during exercise in most patients of this cohort seems to be related to a reduced pulmonary vascular reserve, and not to an increase in PCWP. Further studies are warranted to determine the therapeutic, as well as prognostic implications of these findings.
- Going beyond classic echo in aortic stenosis: left atrial mechanics, a new marker of severityPublication . Marques-Alves, P; Marinho, AV; Teixeira, R; Baptista, R; Castro, G; Martins, R; Gonçalves, LBACKGROUND: There is limited information regarding left atrial (LA) mechanics in aortic valve stenosis (AS). We assessed LA mechanics in AS through speckle-tracking echocardiography (STE) according to severity and prognosis. METHODS: We included 102 patients diagnosed with severe AS (sAS) and 80 patients with moderate AS (mAS), all with preserved ejection fraction and no coronary artery disease. LA mechanics and left ventricular global longitudinal strain (LV-GLS) were assessed by STE. The cohort was followed-up for a median of 30 (IQR 12.6-50) months, and outcomes were determined (combined outcome of HF, death, and aortic valve replacement). RESULTS: In our sample set, values of LV-GLS (- 18.5% vs - 17.1, p = 0.025), E/e' ratio (15.8 vs 18.4, p = 0.03), and global LA mechanics (LA ɛsys, 23% vs 13.8%, p < 0.001) were worse for sAS compared to those for mAS. However, LA ɛsys (AUC 0.85, 95% CI 0.78-0.90, p < 0.001), ɛe (AUC 0.83, 95% CI 0.75-0.88, p < 0.001), and ɛa (AUC 0.80, 95% CI 0.70-0.84, p < 0.001) were the best discriminators of sAS, with sensitivities higher than 85%. LA ɛsys showed a stronger correlation with both aortic valve area (r2 = 0.6, p < 0.001) and mean LV/aortic gradient (r2 = 0.55, p < 0.001) than LV-GLS (r2 = 0.3 and r2 = 0.25, p = 0.01). Either LV-GLS or LA ɛsys, but not the E/e' ratio, TAPSE, or RV/RA gradient, were a significant predictors of the combined outcome. CONCLUSIONS: LA global strain was the best discriminator of severity, surpassing E/e' ratio and LV-GLS, and a significant predictor of prognosis in AS.
- One-shot diagnostic and prognostic assessment in intermediate- to high-risk acute pulmonary embolism: The role of multidetector computed tomographyPublication . Baptista, R; Santiago, I; Jorge, E; Teixeira, R; Mendes, P; Curvo-Semedo, L; Castro, G; Monteiro, P; Caseiro-Alves, F; Providência, LAINTRODUCTION: Contrast-enhanced multidetector computed tomography (MDCT) is useful for the diagnosis of pulmonary embolism (PE). However, current guidelines do not support its use for risk assessment in acute PE patients. OBJECTIVES: We compared the prognostic impact of MDCT-derived indices regarding medium-term mortality in a population of intermediate- to high-risk PE patients, mostly treated by thrombolysis. METHODS: Thirty-nine consecutive patients admitted to an intensive care unit with acute PE were studied. All patients had a pulmonary MDCT on admission to the emergency room as part of the diagnostic algorithm. We assessed the following MDCT variables: right ventricular/left ventricular diameter (RV/LV) ratio, arterial obstruction index, pulmonary artery-to-aorta diameter ratio and azygos vein diameter. A 33-month follow-up was performed. RESULTS: Mean age was 59.1±19.6 years, with 80% of patients receiving thrombolysis. Follow-up all-cause mortality was 12.8%. Of the MDCT-derived variables, only the RV/LV ratio had significant predictive value, being higher in patients who suffered the endpoint (1.6±0.5 vs. 1.9±0.4, p=0.046). Patients with an RV/LV ratio ≥1.8 had 11-fold higher medium-term all-cause mortality (3.8% vs. 38.8%, p<0.001). Regarding this endpoint, the c-statistic was 0.78 (95% CI, 0.60-0.96) for RV/LV ratio and calibration was good (goodness-of-fit p=0.594). No other radiological index was predictive of mortality. CONCLUSIONS: MDCT gives the possibility, in a single imaging procedure, of diagnosing and assessing the prognosis of patients with intermediate- to high-risk PE. Although further studies are needed, the simple-to-calculate RV/LV ratio has good discrimination and calibration for predicting poorer outcomes in patients with acute PE.
- Pulmonary hypertension in Portugal: first data from a nationwide registryPublication . Baptista, A; Meireles, J; Agapito, A; Castro, G; Silva, AM; Shiang, T; Gonçalves, F; Robalo-Martins, S; Nunes-Diogo, A; Reis, AINTRODUCTION: Pulmonary arterial hypertension (PAH) is a rare disease that must be managed in specialized centers; therefore, the availability of epidemiological national data is critical. METHODS: We conducted a prospective, observational, and multicenter registry with a joint collaboration from five centers from Portugal and included adult incident patients with PAH or chronic thromboembolic pulmonary hypertension (CTEPH). RESULTS: Of the 79 patients enrolled in this study, 46 (58.2%) were classified as PAH and 33 patients (41.8%) as CTEPH. PAH patients had a mean age of 43.4 ± 16.4 years. Idiopathic PAH was the most common etiology (37%). At presentation, PAH patients had elevated right atrial pressure (RAP) (7.7 ± 5.9 mmHg) and mean pulmonary vascular resistance (11.4 ± 6.5 Wood units), with a low cardiac index (2.7 ± 1.1 L·min(-1)·m(-2)); no patient was under selective pulmonary vasodilators; however, at follow-up, most patients were on single (50%), double (28%), or triple (9%) combination vasodilator therapy. One-year survival was 93.5%, similar to CTEPH patients (93.9%), that were older (60.0 ± 12.5 years) and had higher RAP (11.0 ± 5.2 mmHg, P = 0.015). CONCLUSIONS: We describe for the first time nationwide data on the diagnosis, management, and prognosis of PAH and CTEPH patients in Portugal. Clinical presentation and outcomes are comparable with those reported on other national registries.
- Pulmonary veno-occlusive disease: a case reportPublication . Teixeira, R; Castro, G; Carvalho, L; Marinho da Silva, A; Monteiro, P; Ferreira, MJ; Providência, LAThe authors present the case of a 22-year-old female patient, white, referred to the cardiovascular outpatient clinic in November 2006 for pulmonary arterial hypertension. Complementary diagnostic exams revealed elevated pulmonary arterial pressure, normal capillary wedge pressure and a reduced cardiac index on invasive hemodynamic study. A high-resolution pulmonary CT scan identified a diffuse ground-glass opacity with a centrilobular pattern, and a marked decrease in CO diffusion on respiratory function assessment. An open lung biopsy was accordingly performed in January 2007, which was compatible with pulmonary arterial hypertension with associated venous lesions: pulmonary veno-occlusive disease. Therapy was begun with oxygen support, warfarin and bosentan (62.5 mg twice a day) Monthly follow-up was maintained, but her clinical and functional status progressively worsened and one year after the diagnosis the patient was admitted to our heart failure clinic for acute right heart failure. She was stabilized with inotropic therapy and diuretics and was subsequently referred to an international pulmonary transplantation center. The authors highlight the diagnostic challenge of this entity and its poor response to medical therapy and dismal prognosis.