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Master's Dissertation
DOI
https://doi.org/10.11606/D.17.2020.tde-07092020-100709
Document
Author
Full name
Paula Chiavenato Marçal
E-mail
Institute/School/College
Knowledge Area
Date of Defense
Published
Ribeirão Preto, 2020
Supervisor
Committee
Schmidt, Andre (President)
Almeida Filho, Oswaldo Cesar de
Pazin Filho, Antonio
Title in Portuguese
Ressonância magnética cardíaca na avaliação de pacientes que apresentaram morte súbita cardíaca ou arritmia ventricular instável
Keywords in Portuguese
Arritmia ventricular
Morte súbita cardíaca
Ressonância magnética cardíaca
Taquicardia ventricular instável
Abstract in Portuguese
Morte súbita cardíaca (MSC) é um problema de saúde relevante em países subdesenvolvidos onde recursos diagnósticos e de tratamento avançados são escassos. Ressonância magnética cardíaca (RMC) tem se mostrado cada vez mais importante na identificação do diagnóstico etiológico em sobreviventes de MSC, porém a maioria dos estudos foi realizada em países desenvolvidos. Objetivou-se a avaliação da prevalência das patologias cardiovasculares no grupo estudado, variáveis e preditores de risco comuns aos pacientes, presença e características da fibrose miocárdica, correlação da fibrose miocárdica na RMC com achados eletrocardiográficos e principalmente, avaliar em quais casos o exame contribuiu como método diagnóstico. Foram incluídos pacientes admitidos por MSC abortada ou arritmia ventricular instável no Hospital das Clínicas de Ribeirão Preto - São Paulo, entre 2009 e 2019, que realizaram RMC após o evento. Foram coletados dados demográficos (idade e sexo) e clínicos (medicações, diagnóstico de cardiopatia prévia, local, ritmo cardíaco do evento e critérios eletrocardiográficos de fibrose miocárdica). Foram revisadas as imagens e laudos dos exames (sequências de cine para avaliação das dimensões e função sistólica dos ventrículos, sequências para avaliação de edema e depósito de gordura, além de sequências de realce tardio para identificar presença e padrões de fibrose miocárdica). Foi realizada análise estatística descritiva. Foram incluídos 68 pacientes, porém 4 foram excluídos devido à má qualidade da imagem. Desses 64, 42 (71,9%) eram homens, com idade média de 54,9±15,4 anos, variando entre 16 e 83 anos. A maioria dos eventos foi extra-hospitalar (81,3%) com a taquicardia ventricular instável sendo o ritmo mais identificado (n= 38). Cinquenta e cinco pacientes faziam uso de alguma medicação cardiovascular, sendo os betabloqueadores os mais comuns (37,5%). O eletrocardiograma (ECG) demonstrou áreas eletricamente inativas em 21,9% dos pacientes, com fibrose miocárdica presente na RMC de todos eles. Fração de ejeção do ventrículo direito (FEVD) ≤50% foi encontrada em 32,8% dos casos, com média de 53,2 ± 11,4 %. A média da fração de ejeção do ventrículo esquerdo (FEVE) foi de 44 ± 14%, com 60,9 % dos casos apresentando valores ≤50% e 29,6% com FEVE ≤35%. A disfunção sistólica biventricular esteve presente em 16 casos (25%), considerando-se FE ≤50% para ambos os ventrículos. O realce tardio miocárdico esteve presente em 46 indivíduos (71,9%), com predomínio de padrão transmural na maioria dos casos (43,8%) e dos 39 pacientes com FEVE ≤50%, 33 apresentavam fibrose na RMC. A cardiomiopatia chagásica (CCC) foi a etiologia mais frequente (28,1%), seguida da cardiomiopatia isquêmica. Dos 26 pacientes sem diagnóstico etiológico definido, a RMC foi capaz de promover elucidação em 15 deles (57%). Desta maneira, em concordância com estudos internacionais anteriores, esse estudo demonstrou que a incorporação da RMC na prática cardiológica permitiu avaliar a presença de substrato arritmogênico e importante elucidação diagnóstica nessa população, tendo impacto no manejo clínico adequado das cardiopatias.
Title in English
Cardiac magnetic resonance as diagnostic tool in patients recovered from sudden cardiac arrest or unstable ventricular arrhythmia
Keywords in English
Cardiac magnetic resonance
Sudden cardiac death
Unstable ventricular tachycardia
Ventricular arrhythmia
Abstract in English
Sudden cardiac death (SCD) is a relevant health problem in underdeveloped countries where advanced diagnostic and treatment resources are scarce. Cardiac magnetic resonance (CMR) has consistently proved to be valuable in providing etiological diagnosis in survivors of SCD, but most studies occurred in developed countries where device use is widely available. The objective was to assess the prevalence of cardiovascular pathologies in the studied group, possible variables and risk predictors common to patients, presence and characteristics of myocardial fibrosis, correlation of myocardial fibrosis with electrocardiographic findings, and mainly, to evaluate in which cases the CMR contributed as a diagnostic method. Patients admitted due to aborted SCD or unstable ventricular arrhythmia at the Clinics Hospital of Ribeirão Preto - University of São Paulo, between 2009 and 2019, that performed a CMR after the event were included. Demographic (age and gender) and clinical data (medications, previous cardiac diagnosis, its location, cardiac rhythm and electrocardiographic criteria for myocardial fibrosis) were collected. The images and reports of the exams were reviewed (cine sequences to evaluate the dimensions and systolic function of the ventricles, sequences for assessing edema and fat deposition, as well as delayed enhancement sequences to identify the presence and patterns of myocardial fibrosis). Sixtyeight patients were included but 4 were excluded due to poor imaging quality. From those 64, 42 were men, 54.9 ±15.4 (16-83) years-old. Most events were out of hospital (81.3%) and in 22 cases no arrest rhytm was described. Unstable VT was the most identifiable rhytm (38 patients), followed by ventricular fibrillation (2 cases) and torsades de pointes in one case. 55 patients were taking cardiovascular medications such as beta blockers in 37.5% and ACE inhibitors in 35.9%. The electrocardiogram presented eletcrically inactive areas em 21.9% of them and fibrosis was identified by CMR in all cases. Right ventricular ejection fraction (RVEF) ≤50% was seen in 32.8% and its mean value was 53 ± 11%.Mean left ventricular ejection fraction (LVEF) was 44 ± 14% with 60.9 % with values ≤50%, and only 29.6% had it ≤35%. Biventricular dysfunction (defined as both ejection fractions below 50%) occurred in 16 patients. Late enhancement was noted in 46(71.9%) patients with a transmural pattern inmost cases (43.8%), and 39 patients with LVEF ≤50%, 33 had fibrosis on CMR. Chronic Chagas Cardiomyopathy (CCC) was the most common etiological diagnosis (28.1%) followed by ischemic cardiomyopathy (17.2%). Of the 26 patients without a defined etiological diagnosis, CMR was able to elucidate 15 of them (57%). Thus, in agreement with previous international studies, this study demonstrated that the incorporation of CMR in cardiological practice allowed the assessment of the presence of an arrhythmogenic substrate and presented important diagnostic clarification in this population, impacting the adequate clinical management cardiomyopathies.
 
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Publishing Date
2020-10-20
 
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