Não errem na precificação do Strain

As vantagens do Strain no acompanhamento da quimioterapia jã são documentadas e concretas.

Falta o pagamento.

Veja o argumento da ASE

Value Proposition for Payers

Potential benefits to payers associated with limited coverage of this code as detailed above include the following:

−Potential to reduce hospitalizations and overall healthcare costs in patients receiving potentially cardio toxic chemotherapy

            −Opportunity to help women with advanced breast cancer (the majority of   patients receiving anthracyclines, trastuzumab)

            −Congruent with most payers core principle of innovation

            −Low risk proposition (for example V67.2 comprised just 3% of indications for  echocardiography at Saint Luke’s Mid America Heart Institute in 2014)

Americanos sempre falam em dinheiro.

E em reduções de gastos associados aos benefícios de novas tecnologias.

Além do livro. 3D economiza RM e TC.

O livro é muito bom.

Mas compara o 3D com o 2D.

Discordamos cordialmente.

O concorrente do 3D Echo é a RM e TC.

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Um aparelho 3D moderno e verdadeiro, sem atalhos ilusórios, elimina a necessidade de RM Cardíaca em 99% dos casos.

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É fato, um software completo de cardiologia para RM custa mais de 200 mil dólares e é PERFEITAMENTE dispensável se existir um aparelho 3D verdadeiro no local, comprado por menos da metade do preço.

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O valor do AE em volume

http://www.revportcardiol.org/en-left-atrial-volume-index-can-articulo-S2174204918303556

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LA volume was estimated by the area-length method. LA area and length were measured at end-systole in apical 4- and 2-chamber views, excluding the atrial appendage and pulmonary veins. LA volume was calculated using the formula (A1×A2/L)×8/3π, where A1 and A2 are the LA areas from 4- and 2-chamber views, respectively, and L is the shorter of the two long-axis lengths

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normal LA size was defined as LAVI ≤34 ml/m2, mild dilatation as 35-41 ml/m2, moderate dilatation as 42-48 ml/m2 and severe dilatation as >48 ml/m2.

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However, in this study only moderate and severe LA enlargement and age >75 years were predictors of all-cause mortality and only severe LA enlargement, moderate-to-severe LV systolic dysfunction, LV hypertrophy and moderate mitral regurgitation were independent predictors of both composite endpoints.

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Átrios acima de 28 ml/m2 e abaixo de 34 ml/m2 são normais?

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Provavelmente não.

Mas para capturar o impacto na sobrevida seria necessário um número maior de pacientes e de tempo de acompanhamento.

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Ecoanestesista Americano

Anesthesiologists using TEE provide information equivalent to that provided by any consulting physician (e.g., cardiologist) using echocardiography for a given indication. This is not part of, but rather in addition to, the anesthesia service being provided.

Anestesiologistas que usam ETE fornecem informações equivalentes às fornecidas por qualquer médico consultor (por exemplo, cardiologista) usando ecocardiografia para uma determinada indicação. Isso não faz parte, mas sim adiciona, além do serviço de anestesia fornecido.

https://anesthesiology.pubs.asahq.org/article.aspx?articleid=1932826&_ga=2.245030861.951318709.1569841030-1119417261.1569841030

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https://www.asahq.org/standards-and-guidelines/statement-on-transesophageal-echocardiography

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Parece que nos EUA o grupo de anestesistas é independente também e decidem o que quiser na área.

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Uma pena a falta de diálogo e de um treinamento com especialistas de verdade.

Diástole e Trombos

Impact of Diastolic Function Parameters on the Risk for Left Atrial Appendage Thrombus in Patients with Nonvalvular Atrial Fibrillation: A Prospective Study

https://doi.org/10.1016/j.echo.2016.01.014

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Conclusions

This prospective and concomitant evaluation of diastolic function and LAA thrombus in patients with NVAF demonstrates that E/e′ ratio and e′ velocity are associated with LAA thrombus, independent of CHA2DS2-VASc score, and may play a role in identifying patients at low risk for LAA thrombus. These data suggest that diastolic function assessment may improve stroke prediction in patients with NVAF.

Interessante uso da relação E/e´na fibrilação atrial.

Valores acima de 12 realmente estão relacionados a estase e trombos.

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A FAC já é uma disfunção importante quando perde a organização do ritmo sinusal.

Mas pode ser pior.

Anestesistas do US

Anestesistas continuam firmes no seu plano de serem ecocardiografistas titulados.

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Data limite de inscrição 30/setembro/2019.

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Já que é assim, podemos fazer a anestesia/sedação dos pacientes para Cardioversão elétrica e Transesofágico com certificação?

Como posso obter o título de anestesista para procedimentos cardíacos???

É só pegar um papel assinado do chefe da cardiologia?

Posso planilhar para receber dos convênios os procedimentos anestésicos?

Perigo: Machine Learning chegando

Results

Disease prevalence of our cohort was 29.4%. The area under the curve for the classification result on validation set was 0.87, and the average analysis time was 10 ± 3 ms per subject. Sensitivity, specificity and accuracy were 88.9%, 73.3% and 77.8%, respectively.

http://www.onlinejacc.org/content/73/9_Supplement_1/1610

Função ventricular em 2019

https://www.mayoclinicproceedings.org/article/S0025-6196(18)30654-2/fulltext

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Table 

Normal Values for the Assessment of Left Ventricular Function a

ParameterValue
Left ventricular ejection fraction (%)≥52 (males)≥54 (females)
Stroke volume (mL), range70-100
Rate of ventricular pressure rise (mm Hg/s)>1200
Global longitudinal strain (2-D) (%), mean (range)−20 (−15.9 to −22.1)
Global circumferential strain (2-D) (%), mean (range)−23 (−20.9 to −27.8)
Global radial strain (2-D) (%), mean (range)+47 (+35.1 to +59.0)

a2-D = two-dimensional.

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Pena que a técnica abaixo não vingou na rotina

Doppler Assessment of Stroke Volume

Cardiac stroke volume can be estimated by multiplying the velocity-time integral obtained from Doppler examination of the LV outflow tract by the LV outflow tract area . Doppler examination requires parallel alignment of the pulse-wave beam with the LV outflow tract. Nonparallel beam alignment can result in a reduced LV stroke volume by underestimating the velocity-time integral. Furthermore, this method requires accurate estimation of the LV outflow tract diameter; minor inaccuracies in diameter estimation result in marked errors in the area calculation because of the squaring of the radius.

Mas padece dos mesmos vícios que a estimativa de área valvar na estenose aórtica.

Assessment of LV function remains the most common reason for cardiac imaging because of its powerful ability to predict morbidity and mortality. Current routine methods of quantifying LV function (with LVEF) is not without limitations. Strain imaging that uses speckle tracking in 2-D and 3-D offers promise for quantifying LV function, particularly for patients with borderline LV function, because of the potential to identify subclinical disease. Strain imaging offers the treating physician a unique opportunity to alter management before the onset of overt LV dysfunction, which may, in turn, improve prognosis.

A onda A estava quieta demais!

https://onlinelibrary.wiley.com/doi/full/10.1111/echo.14472

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Conclusion

Transmitral A‐wave‐AccT can be used as an early marker in detecting PAF without dilated left atrium.

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É incrível.

Na era do 3D, Strain e Doppler Tecidual, alguém prova o valor da simples medida do tempo de aceleração da onda A no fluxo mitral.

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Não é um marcador de impacto mas é tão fácil de fazer que merece a atenção