ABC | Volume 113, Nº5, November 2019

Original Article Value of Contrast Transesophageal Echocardiography in the Detection of Intrapulmonary Vascular Dilatations in Hepatosplenic Schistosomiasis Aparecida de Gouvea, 1 Claudio Henrique Fischer, 1 Jaquelina Sonoe Ota Arakaki, 1 Frederico José Mancuso, 1 Paulo Brant, 1 Valdir Ambrósio Moisés, 1 Orlando Campos Filho 1 Universidade Federal de São Paulo - Escola Paulista de Medicina, 1 São Paulo, SP – Brazil Mailing Address: Aparecida de Gouvea • Universidade Federal de São - Paulo Escola Paulista de Medicina -Rua Botucatu, 740. Postal Code 04023-062, São Paulo, SP – Brazil E-mail: cidagouveamrh@gmail.com Manuscript received August 03, 2018, revised manuscript December 18, 2018, accepted February 13, 2019 DOI: 10.5935/abc.20190200 Abstract Background: Hepatopulmonary syndrome (HPS), found in cirrhotic patients, has been little studied in hepatosplenic schistosomiasis(HSS) and includes theoccurrenceof intrapulmonaryvasculardilatations(IPVD).Contrasttransesophageal echocardiography (cTEE) with microbubbles is more sensitive than contrast transthoracic echocardiography (cTTE) with microbubbles in the detection of IPVD in cirrhosis. Objective: To assess the performance of the cTEE, compared with that of cTTE, in detecting IPVD for the diagnosis of HPS in patients with HSS. Methods: cTEE and cTTE for investigation of IPVD and laboratory tests were performed in 22 patients with HSS. Agitated saline solution was injected in peripheral vein during the cTEE and cTTE procedures. Late appearance of the microbubbles in the left chambers indicated the presence of IPVD. Results of the two methods were compared by the Student’s t-test and the chi-square test (p < 0.05). Results: cTEE was performed in all patients without complications. Three patients were excluded due to the presence of patent foramen ovale (PFO). The presence of IPVD was confirmed in 13 (68%) of 19 patients according to the cTEE and in only six (32%, p < 0.01) according to the cTTE. No significant differences in clinical or laboratory data were found between the groups with and without IPVD, including the alveolar-arterial gradient. The diagnosis of HPS (presence of IPVD with changes in the arterial blood gas analysis) was made in five patients by the cTEE and in only one by the cTTE (p = 0.09). Conclusion: In HSS patients, cTEE was safe and superior to cTTE in detecting IPVD and allowed the exclusion of PFO. (Arq Bras Cardiol. 2019; 113(5):915-922) Keywords: Echocardiography, Transesophageal/methods; Dilatation, Pathologic; Schistosomiasis; Hypoxia; Cardiac Output; Liver Injury, Chronic/physiopathology. Introduction Intrapulmonary vascular dilatations (IPVD) are the anatomical substrate for clinical changes, particularly hypoxemia, observed in patients with chronic liver disease, portal hypertension or congenital or acquired portosystemic shunt, and constitute the hepatopulmonary syndrome (HPS) triad. 1-3 However, IPVD and HPS have been little described in patients with hepatosplenic schistosomiasis (HSS) and portal hypertension, even in those with normal liver function. 4,5 Diversion of venous blood through the liver, observed in portal hypertension in cirrhotic or HSS patients, or even in cavopulmonary anastomosis (Glenn procedure), is the pathophysiological determinant for IPVD. The imbalance between vasoconstrictor and vasodilator substances, dependent on hepatic synthesis or metabolization, favor the accumulation of vasodilator agents in the lungs, including the nitric oxide which plays an important role in this mechanism. 6,7 Dilated capillaries, combined with increased cardiac output, found in hepatic dysfunction without cardiac or lung disease, lead to a ventilation perfusion mismatch, resulting in hypoxemia or alveolar–arterial gradient (A-aO 2 ). IPVD can be identified by microbubble contrast transthoracic echocardiography (cTTE). Although it has been considered the standard diagnostic method, 8 the method has limitations including inadequate window or false positive results for the diagnosis of IPVD, due to the presence of left‑to‑right shunt through the patent foramen ovale (PFO). 9 Contrast transesophageal echocardiography (cTEE) with microbubbles provides better image definition and higher diagnostic accuracy than cTTE for identification and classification of IPVD in cirrhotics. 10-12 In addition, cTEE enables a precise, direct detection of PFO since it enables the early detection of microbubbles in the left atrium. Although some studies have reported the use of cTTE in patients with HSS, 4 there is no study on the use of cTEE in these patients. Considering the high diagnostic performance of cTEE for the detection of IPVD in cirrhotics, the present study aimed to establish the role of cTEE in identifying and quantifying IPVD in HSS and compare with the results obtained by cTTE. 915