Síncope por mixoma auricular: a propósito de un caso clínico / Syncope due to atrial myxoma: presentation of a clinical case / Síncope por mixoma atrial: a propósito de um caso clínico

Las neoplasias cardíacas se dividen en tumores primarios y secundarios; estos últimos son 30 veces más frecuentes. La mayoría de las neoplasias cardíacas son benignas y dentro de este grupo destaca el mixoma auricular. La presentación clínica es muy variable en relación con su ubicación, tamaño y movilidad, y los hallazgos a nivel de las pruebas complementarias son inespecíficos. Dado que su historia natural muchas veces pasa inadvertida, el mixoma puede culminar en la obstrucción auriculoventricular, obstrucción del tracto de salida ventricular o incluso embolias sistémicas; de esta forma, es el causante de sintomatología severa como síncope, insuficiencia cardíaca y muerte súbita cardíaca. Su manifestación clínica como un síncope es bastante frecuente. Se expone el caso de un paciente de sexo masculino de 81 años que consultó en el servicio de urgencias por un síncope. Durante su valoración, se identificó el mixoma auricular como etiología de este.

Cardiac neoplasms are divided into primary and secondary tumors, the latter are 30 times more frequent. Most are benign and within this group the atrial myxoma stands out. The clinical presentation is very variable in relation to its location, size and mobility, and the findings in the complementary tests are nonspecific. Since its natural history often goes unnoticed, the myxoma can culminate in atrial ventricular obstruction, ventricular outflow tract obstruction or even systemic embolism, causing severe symptoms such as syncope, heart failure and sudden cardiac death. Its clinical manifestation as syncope is quite common. The case of an 81-year-old male patient who consulted at the emergency department for syncope is presented, in which the atrial myxoma was subsequently identified as the etiology of the event during the further evaluation.

As neoplasias cardíacas dividem-se em tumores primários e secundários, estes últimos são 30 vezes mais frequentes. A maioria são benignas e dentro deste grupo destaca-se o mixoma auricular. A apresentação clínica é muito variável em relação com sua localização, tamanho e mobilidade, e os achados a nível dos testes complementares são inespecíficos. Dado que a sua história natural muitas vezes passa despercebida, o mixoma pode culminar na obstrução aurículo-ventricular, obstrução do tracto de saída ventricular ou mesmo embolias sistémicas, sendo assim o causador de sintomatologia severa como síncope, insuficiência cardíaca e morte súbita cardíaca. Sua manifestação clínica como síncope é bastante comum. Apresenta-se o caso de um paciente de sexo masculino de 81 anos que consultou no serviço de urgências para um síncope. Durante a sua avaliação, se identificou mixoma auricular como etiologia deste

Mixoma auricular gigante como diagnóstico diferencial de disnea: a propósito de un caso y revisión de la literatura / Giant atrial myxoma as differential diagnosis of dyspnea: a case report and literature review

Cardiac myxomas are the most common benign primary tumors and are most often located in the left atrium at the level of the interatrial septum, with the characteristic of being pedunculated and highly mobile, which is why they sometimes interfere with the functioning of the mitral valve, generating variable degrees of stenosis and mitral insufficiency. Diagnosis is by echocardiography and treatment is surgical resection. We present the case of a patient with a large atrial myxoma and severe double mitral lesion.

Níveis Reduzidos de CTRP3 em Pacientes com Doença Arterial Coronariana Estável Relacionados à Presença de Fibrilação Atrial Paroxística / Reduced CTRP3 Levels in Patients with Stable Coronary Artery Disease and Related with the Presence of Paroxysmal Atrial Fibrillation

Resumo Fundamento Os níveis de Proteína 3 relacionada ao fator de necrose tumoral/complemento sérico C1q (CTRP3) e a relação com a fibrilação atrial (FA) na doença arterial coronária estável (DAC) não estão claros atualmente. Objetivos O objetivo deste estudo foi investigar a mudança nos níveis séricos de CTRP3 e sua relação com a FA paroxística em DAC estável. Método O estudo incluiu 252 pacientes com DAC e 50 controles saudáveis com idade/sexo compatíveis. Os níveis séricos de CTRP3 foram medidos, além da anamnese de rotina, exame físico, exames laboratoriais e ecocardiograma. Os pacientes foram divididos em grupos com e sem DAC e indivíduos com DAC com e sem FA paroxística. Os valores eram estatisticamente significativos quando p<0,05. Resultados Os níveis séricos de CTRP3 foram significativamente menores em pacientes com DAC do que no grupo controle (p<0,001). A FA foi detectada em 28 pacientes (15,08%) no grupo DAC. A frequência de hipertensão e do sexo feminino, a proteína C reativa de alta sensibilidade (PCR-as), o nitrogênio ureico no sangue, os níveis de creatinina e o diâmetro diastólico do átrio esquerdo foram maiores (p<0,05 para cada um), e os níveis de CTRP3 foram mais baixos em pacientes com FA (p<0,001). Na análise de regressão logística, os níveis séricos de CTRP3 e os diâmetros diastólicos do átrio esquerdo foram independentemente determinados pelos pacientes com FA (p<0,01 para cada um). Nesta análise, observamos que cada 1 ng/mL de redução nos níveis de CTRP3 aumentou o risco de FA em 10,7%. Na análise ROC dos valores de CTRP3 para detectar pacientes com FA, a área da curva ROC para CTRP3 foi 0,971 (0,951-991) e considerada estatisticamente significativa (p<0,001). Quando o ponto de corte de CTRP3 foi considerado em 300 ng/mL, demonstrava a presença de FA com 87,9% de sensibilidade e 86,8% de especificidade. Conclusão Os níveis séricos de CTRP3 caíram significativamente em pacientes com DAC estável, e níveis reduzidos de CTRP3 estiveram relacionados à presença de FA paroxística nesses pacientes.

Abstract Background Serum Complement C1q/tumor necrosis factor-related protein-3 (CTRP3) levels and the relationship with atrial fibrillation (AF) in stable coronary artery disease (CAD) are not clearly known. Objective The aim of this study was to investigate the change in serum CTRP3 levels and its relationship with paroxysmal AF in stable CAD. Method The study included 252 patients with CAD and 50 age-sex matched healthy control subjects. Serum CTRP3 levels were measured in addition to routine anamnesis, physical examination, laboratory and echocardiography examinations. The patients were divided into groups with and without CAD and CAD patients with and without paroxysmal AF. Statistical significance was accepted as p<0.05. Results Serum CTRP3 levels were found to be significantly lower in patients with CAD than in the control group (p<0.001). AF was detected in 38 patients (15.08%) in the CAD group. The frequency of hypertension and female gender, hs-CRP, blood urea nitrogen, creatinine levels and left atrial end-diastolic (LAd) diameter were higher (p<0.05 for each one), and CTRP3 levels were lower in patients with AF (p <0.001). In the logistic regression analysis, serum CTRP3 levels and LAd diameters were independently determined the patients with AF (p<0.01 for each one). In this analysis, we found that every 1 ng/mL reduction in CTRP3 levels increased the risk of AF by 10.7%. In the ROC analysis of CTRP3 values for detecting patients with AF, the area under the ROC curve for CTRP3 was 0.971 (0.951-991) and was statistically significant (p<0.001). When the CTRP3 cut-off value was taken as 300 ng/mL, it was found to predict the presence of AF with 87.9% sensitivity and 86.8% specificity. Conclusion Serum CTRP3 levels were significantly reduced in patients with stable CAD and decreased CTRP3 levels were closely related to the presence of paroxysmal AF in these patients.

Correlação entre medidas ecocardiográficas e hemodinâmicas na avaliação do átrio direito e ventrículo direito em pacientes com hipertensão pulmonar / Correlation between echocardiographic and hemodynamic measurements in right atrium and right ventricle assessments of patients with pulmonary hypertension

Introdução: Hipertensão Pulmonar (HP), uma condição clínica grave, pode levar à disfunção sistólica do ventrículo direto (DSVD), com implicações prognósticas. Pacientes com suspeita de HP devem ser submetidos ao ecocardiograma transtorácico (ECOTT) para diagnóstico e avaliação, colocando-o como o principal exame de triagem e acompanhamento. Objetivo: Verificar a associação e a concordância das medidas referentes à pressão média no átrio direito (AD) e à disfunção sistólica do ventrículo direto (DSVD) ao (ECOTT) e ao cateterismo de câmaras direitas (CCD) em pacientes com (HP). Métodos: Foram incluídos indivíduos com diagnóstico de (HP). Todos os pacientes foram submetidos ao ECOTT e CCD. Avaliou-se pelo ECOTT: área do átrio direito (AAD), pressão média do átrio direito (AD) através por meio do diâmetro e da colapsabilidade da veia cava inferior (PMADECOTT ), strain AD (SAD), TAPSE (excursão sistólica do plano anular tricúspide), MAF (mudança da área fracional), SPLVD (strain da parede livre do VD) e onda s´ tricuspídea. Pelo CCD avaliaram-se pressão média do (PMADCCD ) e índice cardíaco (IC). Resultados: Dos 16 pacientes, 13 eram do sexo feminino. A idade média foi de 44,4 anos (±14,9). Constataram-se associação entre pressão média do átrio direito PMADCCD com área do átrio direito, PMADECOTT pressão média do átrio direito e SAD strain do átrio direito (r=0,845, r=0,621 e r=-0,523, respectivamente; p< 0,05). Verificou-se associação entre as categorias de risco de mortalidade, mensuradas pelas medidas AAD da área do átrio direito e pressão média do átrio direito PMADCCD (X2=10,42; p=0,003), com concordância moderada (k=0,44; p=0,012). DSVD A disfunção sistólica do ventrículo direto estava presente em dez pacientes. Houve associação entre disfunção sistólica do ventrículo direto DSVD (presente ou ausente) e índice cardíaco IC (r=0,522; p=0,04), com concordância moderada (k=0,43; p=0,037). Conclusão: As medidas do ecocardiograma transtorácico (ECOTT) e cateterismo de câmara direita (CCD) demostraram associação na avaliação da pressão média do átrio direito com melhor associação entre área do átrio direito AAD e pressão média do átrio direito (PMADCCD) . Houve associação com concordância moderada quanto à disfunção sistólica do ventrículo direto (DSVD) entre métodos. (AU)

Introduction: Pulmonary hypertension (PH), a serious clinical condition, can lead to right ventricular systolic dysfunction (RVSD) with prognostic implications. Patients with suspected PH should undergo transthoracic echocardiography (TTE) for diagnosis and evaluation as the main screening and follow-up exam. Objective: To verify the associations of and agreement between measurements of mean pressure in the right atrium (RA) and RVSD with TTE Method: Individuals diagnosed with PH were included. All patients underwent TTE and RCC. The following were evaluated by TTE: right atrial area (RAA), mean right atrial pressure through the diameter and collapsibility of the inferior vena cava (RMAPTTE), RA strain (RAS), tricuspid annular plane systolic excursion, fractional area change, RV free wall strain, and tricuspid s' wave. Mean RA pressure (RMAPRCC) and cardiac index (CI) were evaluated through the RCC. Results: Of the 16 patients, 13 were female. The mean patient age was 44.4 (±14.9) years. An association was found between RMAPRCC and AAD, RMAPTTE, and RAS (r=0.845, r=0.621, and r=-0.523, respectively; p<0.05). There was an association between the mortality risk categories measured by the RAA and RMAPRCC measures (X2=10.42; p=0.003), with moderate agreement (k=0.44; p=0.012). RVSDJ was present in 10 patients. There was an association between RVSD (present or absent) and CI (r=0.522; p=0.04) with moderate agreement (k=0.43; p=0.037). Conclusion: The TTE and RCC measurements showed an association in the assessment of mean right atrial pressure, especially between RAA and RMAPRCC. An association with RVSD and moderate agreement between methods were also noted. (AU)

Disjunção do anel mitral: modalidades diagnósticas, implicações clínicas e evolução prognóstica / Mitral annulus disjunction: diagnostic modalities, clinical implications, and prognostic progression

A disjunção do anel mitral (DAM) é uma inserção anormal da linha de flexão do anel mitral na parede atrial. O anel mostra uma separação (disjunção) entre a junção folheto posterior-parede atrial e a crista miocárdica ventricular esquerda.1 A DAM foi descrita pela primeira vez há mais de 30 anos em estudo de autópsia, estando relacionada com prolapso da valva mitral (PVM) em 92% dos casos.2 Desde então, foram realizados diversos estudos, sendo a prevalência de DAM em pacientes com PVM reportada de forma variável, podendo ou não estar associada à insuficiência mitral. O ecocardiograma transtorácico (ETT) faz parte da avaliação inicial do prolapso valvar mitral, permitindo o diagnóstico e a avaliação de complicações relacionadas. Com a evolução de novos métodos diagnósticos, a ressonância magnética cardíaca (RMC) e o ecocardiograma transesofágico (ETE) passaram a aprimorar a avaliação dessa patologia, bem como de sua extensão e localização. Contudo, as características fenotípicas do PVM que estão mais associadas a DAM permanecem incertas, sobretudo devido ao número limitado de pacientes, nos estudos clássicos sobre o tema. Portadores de DAM podem desenvolver sintomas relacionados a arritmias ventriculares, configurando a síndrome arrítmica da DAM (SDAM), podendo evoluir para morte súbita. Na literatura, os dados prognósticos ainda são conflitantes entre os diversos estudos acerca do tema, indo desde critérios claros de diagnóstico, o melhor método de imagem a ser aplicado, o tratamento e o prognóstico. Esta revisão descreve as características da DAM associada ou não ao prolapso valvar, auxiliando no diagnóstico e na conduta dessa importante patologia. (AU)

Mitral annulus disjunction (MAD) is an abnormal insertion of the flexion line of the mitral annulus into the atrial wall. The annulus presents a separation (disjunction) between the posterior leaflet­atrial wall junction and the left ventricular myocardial crest.1 MAD was first described more than 30 years ago in an autopsy study and is reportedly related to mitral valve prolapse (MVP) in 92% of cases.2 Since then, several studies have been conducted, and reports on the prevalence of MAD in patients with MVP have varied. Ultimately, it may or may not be associated with mitral regurgitation. Transthoracic echocardiography is part of initial MVP assessment, allowing its diagnosis and the assessment of related complications. As new diagnostic methods emerged, cardiac magnetic resonance imaging and transesophageal echocardiography improved the assessment of this pathology in terms of its diagnosis, extension, and location. However, the phenotypic characteristics of MVP that are more closely associated with MAD remain uncertain mainly due to the limited number of patients in classic studies on the subject. Patients with MAD may develop symptoms related to ventricular arrhythmias, configuring the MAD arrhythmic syndrome, which may progress to sudden death. The literature presents conflicting prognostic data among several studies on the subject from clear diagnostic criteria and best imaging method to be used to treatment and prognosis. This review describes MAD characteristics associated (or not) with valve prolapse to improve the diagnosis and management of this important pathology. (AU)

Triatriatum sinistrum em adulto assintomático: relato de caso / Cor triatriatum sinistrum in an asymptomatic adult: a case report

Cor triatriatum é um anomalia cardíaca congênita rara frequentemente diagnosticada na primeira infância. Este estudo de caso apresenta um adulto com um achado acidental de cor triatriatum sinistrum. Com base na apresentação clínica, o paciente foi tratado de forma conservadora. São apresentados achados de imagens ecocardiográficas de cor triatriatum sinistrum deste paciente juntamente de revisão narrativa da literatura sobre essa doença.(AU)

Cor triatriatum is a rare congenital heart anomaly often diagnosed in early childhood. This case study features an adult with an incidental finding of cor triatriatum sinistrum. Based on the clinical presentation, the patient was treated conservatively. Cor triatriatum sinistrum echocardiographic image findings of this patient are presented along with a narrative review of the literature about this disease. (AU)

Fast growth rate of a right atrial myxoma

ABSTRACT Primary cardiac tumors are rare, with an incidence between 0.0017 and 0.19%, and are asymptomatic in up to 72% of cases. Approximately 75% of tumors are benign, and nearly 50% of these are myxomas. Concerning location, 75% of myxomas are in the left atrium, 15 to 20% in the right atrium, and more rarely in the ventricles. The finding of cardiac myxomas usually implies immediate surgical excision to prevent embolic events and sudden cardiac death. Reports with documented growth rate are rare, and the actual growth rate remains a controversial issue. We report the rapid growth rate of a right atrial myxoma in an oligosymptomatic 69-year-old patient, with negative previous echocardiographic history in the last two years, who refused surgery upon diagnosis, enabling monitoring of myxoma growth.

Stiff Left Atrium Syndrome After Atrial Fibrillation Ablation ­ A Diagnosis Not To Forget

Atrial fibrillation is the most prevalent arrhythmia in clinical practice and has different strategies for its control. Of these strategies, the percutaneous ablation of the pulmonary veins stands out, with robust results in relation to drug treatment. It is an invasive procedure and, therefore, not free from complications, which must be properly diagnosed and treated. Among the possible complications, there is stiff atrium syndrome, characterized by reduced atrial compliance caused by post-ablation fibrosis, which, in turn, leads to atrial filling dysfunction and the consequent increase in atrial and venous capillary pulmonary pressures. The case report demonstrates this infrequent but important complication, which presents good results for clinical treatment, in addition to the contribution of cardiac magnetic resonance in its diagnosis and in the assessment of arrhythmia recurrence rates.

Successful Left Atrial Appendage Closure with Watchman Device Implantation in Two Patients with Inferior Vena Cava Filters

Percutaneous procedures through femoral access in patients with inferior vena cava (IVC) filter may be at risk of complications. We evaluated the feasibility and safety of left atrial appendage closure (LAAC) through femoral access in patients previously implanted with IVC filter. We described the WatchmanTM device implantation in two patients with formal contraindication for oral anticoagulation. First patient had a GreenfieldTM filter and the second one an OpteaseTM filter, and in this patient an attempt to withdrawal the filter immediately before the LAAC procedure failed. A femoral approach was performed in both patients using a 14 Fr sheath. Before crossing IVC filters, venographies did not detect any thrombus. All steps of IVC filter crossing were performed under fluoroscopic guidance. No immediate or intrahospital complications related to the procedure occurred. Herein, we presented two cases of successful LAAC closure with Watchman device in patients with two different kinds of IVC filters.

Tumor renal con extensión al atrio derecho a través de la vena cava inferior: reporte de caso / Renal tumor with extension to the right atrium through the inferior vena cava: case report

Resumen El presente articulo describe un caso clínico de una paciente con un ''trombo tumoral''. Estos son tumores que se extienden desde el órgano afectado hasta el atrio derecho, por la vena cava inferior. Hasta el 10 % de los tumores descritos pueden alcanzar la vena cava inferior y el 1 % de estos llegan a atrio derecho. El carcinoma de células renales es el más frecuente en producir este cuadro. El objetivo del articulo es mostrar que es fundamental realizar un adecuado diagnóstico diferencial, ya que existen diferentes procesos tumorales que pueden causar un ''trombo tumoral'' y diferentes causas de masas en el atrio derecho. La clínica de los pacientes con este cuadro será por obstrucción de la vena cava. El diagnóstico se realiza con estudios de imágenes, ultrasonido (US), ecocardiograma, tomografía axial computarizada (TAC) y resonancia magnética. El manejo debe de ser quirúrgico, sin embargo, presenta pronóstico desfavorable, en algunos casos se puede resecar el tumor primario y extraer la masa que ha invadido la vena cava inferior.

Abstract: This article describes a clinical case of a patient with a 'tumoral thrombus''. These are tumors that extend from the affected organ to the right atrium, through the inferior vena cava. Up to 10% of the tumors described can reach the inferior vena cava and 1% of these reach the right atrium. Renal cell carcinoma is the most common to produce this condition. The objective of the article is to show that it is essential to carry out an adequate differential diagnosis since there are different tumor processes that can cause a ''tumoral thrombus'' and different causes of masses in the right atrium. The symptoms of patients with this condition will be caused by the obstruction of the vena cava. The diagnosis is made with imaging studies, ultrasound (US), echocardiography, computerized axial tomography (CT) and magnetic resonance imaging. The management must be surgical, however it has an unfavorable prognosis, in some cases the primary tumor can be resected and the mass that has invaded the inferior vena cava removed.

A Remodelação do Sistema Nervoso Autônomo Cardíaco pode Desempenhar um Papel na Fibrilação Atrial: Um Estudo do Sistema Nervoso Autônomo e Receptores Miocárdicos / Cardiac Autonomic Nervous System Remodeling May Play a Role in Atrial Fibrillation: A Study of the Autonomic Nervous System and Myocardial Receptors

Resumo Fundamento Alterações do substrato elétrico e anatômico do coração são fatores que originam e perpetuam a fibrilação atrial (FA), porém, os mecanismos envolvidos não foram totalmente elucidados ainda. Objetivo: Avaliar o papel do remodelamento do sistema nervoso cardíaco intrínseco (SNCI), incluindo fibras nervosas e receptores muscarínicos e β-adrenérgicos, na FA permanente humana. Métodos Foram avaliadas 4 amostras em átrios de 13 corações obtidos em necrópsias de pacientes com doença cardíaca e FA permanente, e em 13 controles com as mesmas doenças, porém, sem FA. Utilizando imunoperoxidase e histomorfometria, quantificamos a densidade das fibras do SNCI, bem como a porcentagem positiva de miocárdio para receptores β-adrenérgicos 1, 2 e 3, receptor quinase 5 acoplado à proteína G (GRK-5), e receptores muscarínicos 1 a 5. Os resultados foram comparados usando ANOVA e ANOVA hierarquizada e ajustados pelo volume do átrio esquerdo e, para avaliação da expressão de receptores β e GRK-5, pelo uso de β-bloqueadores. Adotamos como significativo α = 0,05. Resultados Houve aumento na densidade das fibras ( p <0,01), especialmente nas fibras simpáticas ( p =0,02). Quanto aos receptores muscarínicos, só houve diferença nos M1, que estavam aumentados (5,87±4,52 vs 2,85±2,40; p =0,03). Quanto aos componentes do sistema adrenérgicos analisados, houve expressão aumentada de β-3 (37,41 vs 34,18, p =0,04) e GRK-5 (51,16 vs 47,66; p<0,01). O uso de β-bloqueadores não teve impacto na expressão de receptores beta. Conclusão O aumento na inervação do SNCI e a alteração na expressão de receptores em regiões suscetíveis de desencadear FA podem ter um papel na fibrilação atrial permanente.

Abstract Background The primary factors that originate and perpetuate atrial fibrillation (AF) are electrical and anatomical substrate alterations. However, the central mechanisms governing AF perpetuation have not been elucidated yet, which is reflected on the modest results of the treatment in patients with long persistent AF. Objective To evaluate if human intrinsic cardiac autonomic nervous system (ICANS) remodeling, including nervous system fibers and muscarinic and β-adrenergic receptors, play a role in permanent AF. Methods Heart necropsy samples from thirteen patients with heart disease and permanent AF and thirteen controls without AF were used. By using immunoperoxidase and histomorphometry quantification, we identified the following: the density of all fibers of the ICANS, sympathetic and parasympathetic fibers; and the percentage of myocardium positive for β-adrenergic receptors 1, 2 and 3; G protein-coupled receptor kinase-5 (GRK-5); and muscarinic receptors M1 to M5. The results were compared using ANOVA and nested ANOVA and were adjusted according to the left atrium volume for all variables, and β-blocker use to evaluate the expression of β-receptors and GRK-5. Results There was an overall increase in the density of fibers of the ICANS (p=0.006), especially in atrial sympathetic nerve fibers (p=0.017). Only M1 muscarinic receptors were increased (5.87 vs 2.35, p=0.032). For adrenergic receptors, the results were positive for increased expression of β-3 (37.41 vs 34.18, p=0.039) and GRK-5 (51.16 vs 47.66; p<0.001). β-blocker use had no impact on β-receptor expression. Conclusion Increased ICANS innervation and remodeling receptor expression in regions prone to triggering AF may play a role in permanent AF.

Cardiac Masses: Pathological and Surgical Features - A Multicenter Study

Abstract Introduction: This study aimed to review the surgical excision results and pathological diagnostic features of rarely observed intracardiac masses in the light of the literature. Diagnosis and treatment approaches and complications were evaluated. Methods: Forty patients (26 females, mean age 52.1±18.1 years, and 14 males, mean age 48.1±20.5 years), who had undergone surgery for intracardiac mass between January 2008 and December 2018, were included in this study. The patients' data were analyzed retrospectively from the medical records of both centers. Results: When the pathological diagnoses were examined, 85.8% of the masses (n=35) were observed to be benign (benign tumor + hydatid cyst) and 14.2% (n=5) were malignant tumors. The masses were most commonly located in the left atrium (75%, n=30), and this was followed by the right ventricle (12.5%, n=5), right atrium (7.5%, n=3), and left ventricle (5%, n=2). Of the patients, 7.5% (n=3) died during the early postoperative period, while the remaining 92.5% (n=37) were discharged with healing. In the histopathological diagnosis of the patients, in whom in-hospital major adverse cardiovascular events were observed, there was malignancy in two cases. Conclusion: Intracardiac masses, which have pathological features, are severe life-threatening problems. In-hospital mortality is frequent, especially in malignant tumors.

A Rare Associated Anomaly in Tetralogy of Fallot: Scimitar Syndrome in an Infant

Abstract Pulmonary venous connections may be infrequently abnormal in patients with tetralogy of Fallot (TOF). A special subgroup of partial anomalous pulmonary venous return,"scimitar cyndrome", and its coexistence with TOF is less frequently reported. It may proceed unnoticed, as cyanosis already predominates in the clinical picture. This uncommon association must be kept in mind for patients with TOF who have an accessory flow in the inferior vena cava, especially when all pulmonary venous return to the left atrium is not clearly seen.

Evolución del traumatismo penetrante cardíaco operado / Penetrating cardiac injury: evolution of characteristics, severity and mortality in surgery treated patients

Resumen Introducción: El traumatismo penetrante cardíaco (TPC) es una lesión poco frecuente y con alta morbilidad y mortalidad. Objetivo: Analizar la evolución de características clínicas, anatómicas, gravedad, morbilidad y mortalidad de pacientes operados por TPC. Materiales y Métodos: Estudio analítico de pacientes tratados quirúrgicamente por TPC en Hospital Clínico Regional "Dr. Guillermo Grant Benavente", Concepción, Chile. Se analizaron los periodos: enero-1990 a diciembre-2004 y enero-2005 a diciembre-2019. Se comparó: sexo, edad, lesiones asociadas, agente y mecanismo del traumatismo, comportamiento fisiopatológico, ubicación anatómica de la lesión, clasificaciones del traumatismo cardíaco Attar, Saadia y OIS-AAST, IGT (índices de gravedad del traumatismo): ISS, RTS-T y TRISS, morbilidad y mortalidad según periodos. Se realizó análisis estadístico con SPSS25®, se utilizaron las pruebas chi-cuadrado, exacta de Fisher y Mann-Whitney. Se consideró significativo un valor p < 0,05. Resultados: Total 235 TPC, 112 en el primer periodo y 123 en el segundo. Mecanismo arma blanca en 96 (85,7%) y 104 (84,6%) según periodos. En el segundo periodo se observó un aumento de lesiones extratorácicas asociadas, paro cardiorrespiratorio y lesión de ubicación izquierda. Las clasificaciones del traumatismo cardíaco y los IGT ISS, RTS-T y TRISS mostraron mayor gravedad y probabilidad de muerte en los pacientes del segundo periodo. La mortalidad no mostró diferencias: 14 (12,5%) y 14 (11,4%) según periodos (p = 0,792). Discusión: En nuestra serie los pacientes tratados por TPC han evolucionado hacia un perfil de mayor gravedad tanto en parámetros fisiológicos como anatómicos. La mortalidad se ha mantenido estable a través del tiempo.

Background: Penetrating cardiac injury (PCI) is a rare injury with high morbidity and mortality. Aim: To analyze the evolution of clinical and anatomical characteristics, severity, morbidity and mortality of patients operated on by PCI. Materials and Methods: Analytical study of patients surgically treated for PCI at the "Guillermo Grant Benavente" Regional Clinical Hospital, Concepción, Chile. Two periods were analyzed: January-1990 to December-2004 and January-2005 to December-2019. Sex, age, associated injuries, trauma agent and mechanism, pathophysiological behavior, anatomic location of the injury, classifications of cardiac trauma: Attar, Saadia and OIS-AAST, TSI (trauma severity indices): ISS, RTS-T and TRISS, morbidity and mortality were compared according to periods. Statistical analysis was performed with SPSS25®, the chi-square, Fisher exact and Mann-Whitney tests were used. A p value < 0.05 was considered significant. Results: Total 235 PCI, 112 in the first period and 123 in the second. Stab as mechanism in 96 (85.7%) and 104 (84.6%) according to periods. An increase in associated extra thoracic injuries, cardiorespiratory arrest, and injury to the left location were observed in the second period. The cardiac trauma classifications and the TSI ISS, RTS-T and TRISS showed greater severity and probability of death in the second period patients. Mortality did not show differences: 14 (12.5%) and 14 (11.4%) according to periods, p = 0.792. Discussion: In our series, patients treated with PCI have evolved towards a more severity profile in both, physiological and anatomical parameters. Mortality has been stable over time.

Fístula da Artéria Coronária: Associação entre Padrões de Trajetos, Características Clínicas e Cardiopatias Congênitas / Coronary Artery Fistula: Association between Pathway Patterns, Clinical Features and Congenital Heart Disease

Resumo Fundamento A fístula da artéria coronária (FAC) é uma conexão direta entre uma ou mais artérias coronárias e câmaras cardíacas ou um grande vaso; pode estar associada à cardiopatia congênita. Objetivo Estabelecer os padrões de trajetos de FAC a partir de dados ecocardiográficos e correlacioná-los com aspectos clínicos e cardiopatias congênitas. Métodos Um total de 7.183 prontuários médicos de crianças menores de 5 anos de idade com cardiopatia submetidas a ecodopplercardiograma colorido foram analisados utilizando o teste de correlação de Spearman para associar sinais, sintomas e cardiopatia à FAC, com nível de significância de 5%. Resultados Vinte e seis crianças (0,0036%) apresentaram FAC, nos seguintes trajetos: da artéria coronária direita para o ventrículo direito (26,92%), da artéria coronária esquerda para o ventrículo direito (23,08%), do ramo interventricular anterior para o ventrículo direito (23,08%), da artéria coronária direita para o átrio direito (11,54%), da artéria coronária esquerda para o tronco pulmonar (7,69%) e do ramo interventricular anterior para o tronco pulmonar (7,69%). Em 57,69% dos pacientes, houve uma correlação positiva entre sintomas e a FAC (p = 0,445), relacionada à dispneia ou cianose (53,84%). Em 96,15%, a cardiopatia congênita estava associada à FAC; principalmente, a comunicação interventricular e a comunicação interatrial, em 34,62% dos casos, correlacionaram-se positivamente com a FAC (p = 0,295). O trajeto da FAC foi representado em três dimensões pelo software de modelagem, texturização e animação Cinema 4D R19. Conclusão A FAC é uma entidade anatômica incomum que apresenta quadro clínico compatível com dispneia e cianose e está associada a cardiopatias congênitas, principalmente com a CIV ou a CIA. De acordo com as análises ecocardiográficas, as fístulas na ACD, na ACE ou no RIVA representam aproximadamente um terço dos pacientes, com trajeto prioritário para as câmaras cardíacas direitas.

Abstract Background Coronary artery fistula (CAF) is a direct connection of one or more coronary arteries to cardiac chambers or a large vessel; it may be associated with congenital heart disease. Objective To establish CAF pathway patterns from echocardiographic data and to correlate them with clinical aspects and congenital heart disease. Methods A total of 7.183 medical records of children under the age of five years with cardiac disease submitted to color Doppler echocardiography and Spearman's Correlation test were used to associate signs and symptoms and cardiopathy to CAF with a significance level of 5%. Results Twenty six children (0.0036%) presented CAF: from the right coronary artery (RCA) to the right ventricle (RV) 26.92%, from the left coronary artery (LCA) to the RV 23.08%, from the anterior interventricular branch (AIVB) to RV 23.08%, RCA to right atrium (RA) 11.54%, LCA for pulmonary trunk (PT) 7.69% or AIVB for PT 7.69%. In 57.69% of the patients, there was a positively correlated symptomatology to CAF with p=0.445 related to dyspnea or cyanosis (53.84%); in 96.15%, congenital heart disease associated with CAF, mainly interventricular communication (IVC) or interatrial communication (IAC) in 34.62% positively correlated to CAF with p=0.295. CAF pathway was represented in three dimensions by software modeling, texturing and animation Cinema 4D R19. Conclusion CAF is an uncommon anatomical entity that presents a clinical picture compatible with dyspnea and cyanosis, and this is associated with congenital heart disease, mainly with IVC or IAC. According to echocardiographic analyzes, fistulas in RCA, LCA, or AIVB represent about one-third of the patients, with a priority pathway for right heart chambers.

Coexistent mitral stenosis and left circumflex coronary artery to left atrial fistula in a patient with severe pulmonary hypertension

Abstract Coronary artery to left atrial fistula is rare in patients with mitral stenosis. We report an interesting case of a patient with concomitant mitral valve stenosis and coronary fistulae, originating from the left circumflex artery and drained into the left atrium with two terminal orifices.