Nos últimos anos, múltiplas técnicas imagiológicas foram desenvolvidas e aplicadas na ava-
liação morfológica e funcional do coração.
A ecocardiografia, sendo a mais antiga
[100], continua também a ser, por questões de acessibili-
dade, portabilidade, segurança e custo, a modalidade de imagem mais utilizada
[101-104]. A avaliação
das dimensões das câmaras, e da massa e função ventriculares são das indicações mais frequen-
tes para a requisição de um ecocardiograma
[105]. De acordo com as recomendações actuais, a
ecocardiografia é o método de imagem de primeira linha na avaliação de doentes com suspeita
de insuficiência cardíaca, fornecendo informação estrutural (anatomia, volumes e massa) e fun-
cional (incluindo a análise da função diastólica)
[106]. No entanto várias limitações dos diferentes
parâmetros ecocardiográficos devem ser tidas em conta aquando da sua utilização. Por exem-
plo, a fracção de ejecção, apesar de ser a medida mais generalizada de função sistólica global e
ter, comprovadamente, importância prognóstica, não é um índice de contractilidade e depende
fortemente da pré- e pós-carga, da frequência cardíaca e da função valvular
[106]. O mesmo se
aplica aos índices classicamente utilizados para avaliação da função diastólica
[78, 107, 108]. Novos
métodos ecocardiográficos entretanto desenvolvidos poderão permitir ultrapassar algumas
destas limitações, permitindo uma análise quantitativa da deformação miocárdica (uma medida
indirecta do encurtamento e distensão dos miócitos durante o ciclo cardíaco). Estas novas
técnicas baseiam-se na determinação das velocidades relativas de diferentes pontos do mio-
cárdio aplicando o princípio Doppler ao movimento do músculo cardíaco (Doppler tecidular)
ou no cálculo da distância inicial e final entre vários pontos na imagem bidimensional através
do seu seguimento ao longo do ciclo cardíaco (“speckle tracking”). A medida de deformação
miocárdica define-se como strain e é expressa em percentagem. A velocidade a que a defor-
mação miocárdica se dá, ou seja, a variação do strain num período de tempo é definida como
strain rate e é expressa em 1/segundo
[109, 110]. Não sendo medidas totalmente independentes
das condições de carga
[111-114],strain/strain rate são sobretudo determinados pela contractilida-
de intrínseca dos miócitos e correlacionam-se bem com índices invasivos de contractilidade
[115, 116]. A sua utilidade clínica tem sido demonstrada em diversos contextos – desde o diagnóstico
de doença subclínica (onde a sua maior sensibilidade permite detectar alterações da função
miocárdica em estadios precoces), à melhoria da acuidade diagnóstica na doença coronária e
à monitorização terapêutica
[117-122]. Foi igualmente documentado o seu potencial na avaliação
do prognóstico
[123-126].
Também na análise da função diastólica, os novos métodos ecocardiográficos, particular-
mente a análise das velocidades do miocárdio por Doppler tecidular, assumiram uma impor-
tância crescente. A velocidade de deslocamento do anel mitral no início da diástole (E’) é um
parâmetro mais sensível de relaxamento que as variáveis do fluxo mitral, correlacionando-se
bem com a constante Tau de relaxamento medida invasivamente
[127-130].Mais importante ainda
é a boa correlação da razão entre a velocidade da onda E mitral por Doppler pulsado (E) e
a velocidade da onda E’ com as pressões de enchimento do ventrículo esquerdo
[130, 131]. Esta
observação resulta do facto da velocidade E’ ser um indicador da quantidade do volume de
sangue que entra no ventrículo esquerdo durante a fase de enchimento rápido enquanto que a
velocidade da onda E representa o gradiente de pressão necessário para que essa quantidade
de sangue entre no ventrículo esquerdo. Assim, a razão E/E’ reflecte a quantidade de sangue
que entra no ventrículo esquerdo para um dado gradiente de pressão; uma razão E/E’ elevada
representa uma pequena mudança de volume para um gradiente aurícula esquerda/ventrículo
esquerdo elevado, e é um marcador de disfunção diastólica. Visto de outra forma, a velocidade
da onda E depende do relaxamento, do gradiente de pressão AE/VE e da idade enquanto que
a velocidade E’ depende sobretudo do relaxamento e da idade; deste modo, a razão entre as
duas permite eliminar o efeito do relaxamento e da idade traduzindo apenas o gradiente de
pressão entre as duas câmaras e a pressão de enchimento do ventrículo esquerdo
[132]. Atenden-
do a estes achados, a medição das velocidades diastólicas do anel mitral por Doppler tecidular
e a determinação da razão E/E’ são, de acordo com as recomendações actuais, mandatórias na
avaliação ecocardiográfica da função diastólica
[80].
A ressonância magnética cardíaca (RMC) tem, nos últimos anos, adquirido crescente impor-
tância na avaliação do sistema cardiovascular
[133]. A sua excelente resolução espacial permite-
lhe definir, com exactidão, os bordos endocárdico e epicárdico, sem dependência de qualquer
“janela acústica”. Deste modo, a RMC é considerada o método “gold-standard” na avaliação
dos volumes cardíacos e da fracção de ejecção
[133, 134]. Esta técnica permite igualmente avaliar
os vários componentes da deformação miocárdica utilizando diferentes técnicas
[135-138]. Final-
mente, a capacidade de caracterização tecidular da RMC, permite a quantificação de áreas de
edema ou fibrose, com identificação precisa de lesão miocárdica (mesmo subclínica) assim
como de miocárdio viável, sendo igualmente o actual “gold-standard” para a definição de via-
bilidade
[139-141].
Algumas destas novas modalidades de imagem foram já utilizadas na avaliação de doentes
com cirrose
[61, 64]. No entanto, dado o pequeno número de estudos e doentes envolvidos, a sua
utilidade na detecção de alterações morfológicas e funcionais neste contexto é ainda incerta e
o seu potencial papel no diagnóstico da cardiomiopatia cirrótica não está estabelecido.
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