Current Cardiology Reviews - Volume 7, Issue 3, 2011

Echocardiography is a valuable diagnostic tool allowing visualization of heart chambers for a complete anatomical and functional evaluation. In the past years there was a clear trend toward its use in other than cardiology areas, like intensive care and anesthesiology. In the Intensive Care its use is now widely accepted, as the concepts on hemodynamic monitoring evolved. This evolution is related to the criticism on pulmonary artery catheter use and its relation with both morbidity and mortality. The use of invasive diagnostic tools is therefore to be avoided but alternatives should also be available. Echocardiography equipment's evolution toward better downsizing and lower price made the technique even more assessible in the past decade. The use of echocardiography offers the intensive care phisician a tool for a quick and comprehensive diagnosis of the critically ill; also, the examination is fast, does not require the involvement of other health personnel or disposable materials. The information is assessed in real time and obtained based on direct visualization of the heart. Specific issues for the intensive care are also studied using echocardiography. Among them is the sepsis related cardiomyopathy. In anesthesiology the use of echocardiography is quite established, especially in cardiac surgery monitoring. However echocardiography is also a valuable tool in noncardiac surgery. The evaluation of volume status, left ventricular performance or right heart chambers monitorng are all significant information, not provided by other monitoring tools. The expanded use of echocardiography in non-cardiac surgery should be the next step in this evolution, and many anesthesiologists are using it. Specific monitoring protocols for specific situations must be implemented. The assessment of the patients on the emergency room using echocardiography is an area of growing interest. Contrast echocardiography is a good example. Although patients with suspected heart disease are more often evaluated, the possibilities of echocardiography go far beyond this type of patients. Many features of the approach used in the intensive care can be applied, as well as other potential uses beyond strict heart imaging. Echocardiography is now an image technique used by several non cardiologists specialists. A specific knowledge in this different settings is expected, emerging from its use in distinct disciplines.

Echocardiography is a non-invasive tool, aimed towards the anatomical and functional characterization of the heart. In Intensive Care it is considered nowadays as a necessary tool for patient evaluation. However, the information obtained using echocardiography is not the same as provided by other means, namely the invasive ones. In recent years there has been a significant evolution in the general concepts of haemodynamic support for the critically ill patient. In this new environment, echocardiography has gained particular relevance. In this text the new positioning of echocardiography in the light of the new concepts for hemodynamic support is described, as well as, the need for a specific formative program directed towards Intensive Care physicians. A new generation of biomarkers can also add relevant information and start a new era in haemodynamic support. They may help to further characterize the disease process, identifying patients at risk, as well as, characterize specific organ failure as well as monitoring therapy.

Echocardiography has shown to be an essential diagnostic tool in the critically ill patient's assessment. In this scenario the initial fluid therapy, such as it is recommended in the actual clinical guidelines, not always provides the desired results and maintains a considerable incidence of cardiorrespiratory insufficiency. Echocardiography can council us on these patients' clinical handling, not only the initial fluid therapy but also on the best-suited election of the vasoactive/ inotropic treatment and the early detection of complications. It contributes as well to improving the etiological diagnosis, allowing one to know the heart performance with more precision. The objective of this manuscript is to review the more important parameters that can assist the intensivist in theragnosis of hemodynamically unstable patients.

Bedside echocardiography in emergency room (ER) or in intensive care unit (ICU) is an important tool for managing critically ill patients, to obtain a timely accurate diagnosis and to immediately stratify the risk to the patient's life. It may also render invasive monitoring unnecessary. In these patients, contrast echocardiography may improve quality of imaging and also may provide additional information, especially regarding myocardial perfusion in those with suspected coronary artery disease. This article focuses on the principle of contrast echocardiography and the clinical information that can be obtained according to the most frequent presentations in ER and ICU.

Myocardial dysfunction is one of the main predictors of poor outcome in septic patients, with mortality rates next to 70%. During the sepsis-induced myocardial dysfunction, both ventricles can dilate and diminish its ejection fraction, having less response to fluid resuscitation and catecholamines, but typically is assumed to be reversible within 7-10 days. In the last 30 years, It's being subject of substantial research; however no explanation of its etiopathogenesis or effective treatment have been proved yet. The aim of this manuscript is to review on the most relevant aspects of the sepsisinduced myocardial dysfunction, discuss its clinical presentation, pathophysiology, etiopathogenesis, diagnostic tools and therapeutic strategies proposed in recent years.

The goal of hemodynamic monitoring and management during major surgery is to guarantee adequate organ perfusion, a major prerequisite for adequate tissue oxygenation and thus, end-organ function. Further, hemodynamic monitoring should serve to prevent, detect, and to effectively guide treatment of potentially life-threatening hemodynamic events, such as severe hypovolemia due to hemorrhage, or cardiac failure. The ideal monitoring device does not exist, but some conditions must be met: it should be easy and operator-independently to use; it should provide adequate, reproducible information in real time. In this review we discuss in particular the role of intraoperative use of transesophageal echocardiography (TOE). Although TOE has gained special relevance in cardiac surgery, its role in major non cardiac surgery is still to be determined. We particularly focus on its ability to provide measurements of cardiac output (CO), and its role to guide fluid therapy. Within the last decade, concepts oriented on optimizing stroke volume and cardiac output mainly by fluid administration and guided by continuous monitoring of cardiac output or so called functional parameters of cardiac preload gained particular attention. Although they are potentially linked to an increased amount of fluid infusion, recent data give evidence that such pre-emptive concepts of hemodynamic optimization result in a decrease in morbidity and mortality. As TOE allows a real time direct visualization of cardiac structures, other potentially important advantages of its use also outside the cardiac surgery operation room can be postulated, namely the ability to evaluate the anatomical and functional integrity of the left and the right heart chambers. Finally, a practical approach to TOE monitoring is presented, based on a local experience.

Echocardiography (echo) is a powerful technique that permits direct visualization and assessment of all the cardiac structures and assessment of the patients' haemodynamic status at the bedside. Echo allows detection of valvular disease, evaluation of ventricular function and the pericardium, detection of intracardiac/intrapulmonary shunts, and can be used to calculate flows and relative pressures between the cardiac chambers. This rapid point-of-care haemodynamic evaluation provides information to guide therapeutic interventions, including volume resuscitation, instigation of vasoactive therapy and/or referral for specialist cardiac/surgical intervention. Although there is abundant evidence in the cardiology literature regarding the use of echo, data in the critical care arena is less well defined, but emerging. The use of echo by intensive care doctors is likely to become routine, and therefore training for intensivists in this technique needs to be developed and supported. The Portuguese Working Group on Echocardiography has developed a skill-based program, FADE (Focused Assessment Diagnostic Echocardiography) in order to train clinicians in the use of bedside ultrasound as a diagnostic and monitoring tool for the critically ill.

Degeneration of cardiac tissues is considered a major cause of mortality in the western world and is expected to be a greater problem in the forthcoming decades. Cardiac damage is associated with dysfunction and irreversible loss of cardiomyocytes. Stem cell therapy for ischemic heart failure is very promising approach in cardiovascular medicine. Initial trials have indicated the ability of cardiomyocytes to regenerate after myocardial injury. These preliminary trials aim to translate cardiac regeneration strategies into clinical practice. In spite of advances, current therapeutic strategies to ischemic heart failure remain very limited. Moreover, major obstacles still need to be solved before stem cell therapy can be fully applied. This review addresses the current state of research and experimental data regarding embryonic stem cells (ESCs), myoblast transplantation, histological and functional analysis of transplantation of co-cultured myoblasts and mesenchymal stem cells, as well as comparison between mononuclear and mesenchymal stem cells in a model of myocardium infarction. We also discuss how research with stem cell transplantation could translate to improvement of cardiac function.