Smoking-dependent and haplotype-specific effects of endothelial nitric oxide synthase gene polymorphisms on angiographically assessed coronary artery disease in Caucasian- and African-Brazilians.

The nitric oxide produced by endothelial nitric oxide synthase (eNOS) plays a pivotal role in protecting the arterial wall from damages and atherosclerosis. The T-786C, the 27-bp repeat in intron 4, and the E298D eNOS gene polymorphisms were studied in 715 Brazilian patients (447 Caucasian- and 268 African-Brazilians) who underwent coronary angiography. The -786C frequency was increased in coronary artery disease (CAD) cases with significant lesions (> or =50% luminal obstruction) when compared with lesion-free controls; this difference was detected in smokers but not in nonsmokers, both in Caucasian- (p=0.011) and African-Brazilians (p=0.005). The interaction between -786C carriers and smoking was an independent CAD predictor (OR: 2.9, 95% CI: 1.4-5.9; p=0.003) in multiple logistic regression. The 298D mutation frequency was also higher among CAD cases (p=0.036) in African-Brazilian smokers, but this effect was not independent from other variables in the regression model. Though not associated with CAD, the 4-repeat allele combined with different T-786C alleles showed protective and susceptible effects in Caucasian-Brazilian smokers. The -786C/4-repeat/298E haplotype frequency was higher (p=0.020), whereas -786T/4-repeat/298E was lower (p=0.023) in these cases. These results showed a smoking-dependent effect of the T-786C eNOS polymorphism on CAD in both Caucasian- and African-Brazilians. Additionally, the haplotype analysis revealed different eNOS haplotypes associated with protection and susceptibility to the disease.

[Early results of bone marrow cell transplantation to the myocardium of patients with heart failure due to Chagas disease]. / Resultados iniciais do transplante de células de medula óssea para o miocárdio de pacientes com insuficiência cardíaca de etiologia Chagásica.

OBJECTIVE: To evaluate early effects of bone marrow cell transplantation to the myocardium of patients with heart failure (CHF) due to Chagas disease. METHODS: We studied 28 patients (mean age 52.2 +/- 9.9), of whom 24 were male. Despite optimized treatment, 25 patients were in NYHA class III and three patients, in NYHA class IV. The procedure consisted of aspiration of 50 mL of bone marrow, separation of the mononuclear fraction, and intracoronary injection. Effects on left ventricle ejection fraction (LVEF), distance walked in the six-minute walking test, quality-of-life, NYHA class, arrhythmogenic and biochemical parameters, were all evaluated. RESULTS: There were no complications directly related to the procedure. Baseline left ventricular ejection fraction was 20.1 +/- 6.8%, and 60 days after transplantation it increased to 23.0 +/- 9.0%, p = 0.02. Significant improvements were observed in the NYHA class (3.1 +/- 0.3 to 1.8 +/- 0.5; p < 0.0001); quality-of-life (50.9 +/- 11.7 to 21.8 +/- 13.4; p < 0.0001); and distance walked in six minutes (355 +/- 136 m to 443 +/- 110 m; p = 0,003). The number of ventricular premature beats in 24 hours tended to increase (5,322 +/- 4,977 to 7,441 +/- 7,955; p = 0,062), but without increase in ventricular tachycardia episodes (61 +/- 127 to 54 +/- 127; p = 0.27). CONCLUSION: Our data demonstrate for the first time that intracoronary injection of bone marrow mononuclear cells is feasible and suggest that it may be potentially safe and effective in patients with CHF due to Chagas disease.

Sex-specific effect of the thermolabile C677T mutation in the methylenetetrahydrofolate reductase gene on angiographically assessed coronary artery disease in Brazilians.

Hyperhomocysteinemia is associated with increased coronary artery disease (CAD) risk. Methylenetetrahydrofolate reductase (MTHFR) is a key enzyme in the metabolism of homocysteine and presents a common mutation (C677T) that leads to a thermolabile enzyme, mild hyperhomocysteinemia, and increased CAD risk. The C677T MTHFR mutation was studied in 772 subjects (480 Caucasian Brazilians and 292 African Brazilians) who underwent coronary angiography at the hemodynamic center of the Santa Izabel Hospital in Salvador, Bahia State, Brazil. The 677T allele frequency was increased in Caucasian Brazilians (28.1%) compared to the frequency observed in African Brazilians (18.3%; p < 0.001). In Caucasian Brazilians the frequency of the 677T homozygous genotype was increased in CAD cases (10.4%) compared to control subjects (1.4%; p = 0.014) in males but not in females. In African Brazilians the mutation was not associated with CAD in either sex. The multivariate logistic regression analysis of all the samples shows that the 677T homozygous interaction with sex was a significant CAD predictor, independent of other classical risk factors and ethnic group. The odds ratio associated with male 677T homozygotes was increased 9.2-fold (p = 0.021) compared to the 677C carriers. The present study suggests that the C677T MTHFR mutation is associated with increased CAD risk in a sex-dependent manner in Brazilians.

Paraoxonase 1 gene polymorphisms in angiographically assessed coronary artery disease: evidence for gender interaction among Brazilians.

BACKGROUND: Paraoxonases (PON) are members of an enzyme family involved in preventing low-density lipoprotein oxidation and therefore protecting against atherosclerotic plaque formation. METHODS: We studied the Met55Leu and Gln192Arg PON1 polymorphisms in 712 patients (437 Caucasian- and 275 African-Brazilians) who underwent coronary angiography. RESULTS: Among Caucasian-Brazilians, the homozygous 55LeuLeu frequency was higher among patients with significant coronary artery disease (CAD, obstructive lesions >/=50%) than among lesion-free controls (51% vs. 30.3%; p=0.022) in females, but not in males. The Gln192Arg PON1 polymorphism was not associated with CAD, although 192GlnGln homozygotes presented lower high-density lipoprotein (HDL)-cholesterol (p=0.035) and higher triglyceride (p=0.012) levels than 192Arg allele carriers among Caucasian-Brazilian males, but not females. No other lipid-genotype association was detected. Multivariate logistic regression corrected for classic CAD risk factors shows that 55LeuLeu PON1 homozygotes were at increased CAD risk (odds ratio OR=2.852; p=0.003) and that this genotype interacted with gender in its association with CAD risk (OR=0.290; p=0.006) among Caucasian-Brazilians. CONCLUSIONS: This report shows that the 55LeuLeu PON1 genotype increases CAD risk among female Caucasian-Brazilians, irrespective of other CAD risk factors. In addition, 192GlnGln PON1 homozygotes show higher triglyceride and lower HDL-cholesterol levels in male Caucasian-Brazilians. No associations were detected among African-Brazilians.

Resultados iniciais do transplante de células de medula óssea para o miocárdio de pacientes com insuficiência cardíaca de etiologia chagásica / Early results of bone marrow cell transplantation to the myocardium of patients with heart failure due to chagas disease

OBJETIVO: Avaliar efeitos precoces do transplante de células de medula óssea para o miocárdio de pacientes com insuficiência cardíaca (IC) de etiologia chagásica. MÉTODOS: A amostra consistiu de 28 pacientes, idade média 52,2±9,9 anos, 24 masculinos, 25 em classe NYHA III e 3 em NYHA IV, apesar de tratamento otimizado. O procedimento consistiu na aspiração de 50ml de medula óssea, separação da fração mononuclear e injeção intracoronariana. Foram avaliados os efeitos sobre a fração de ejeção ventricular esquerda (FEVE), distância no teste de 6 minutos, qualidade de vida, classe NYHA, efeitos arritmogênicos e bioquímicos. RESULTADOS: Não houve complicações relacionadas diretamente ao procedimento. A fração de ejeção ventricular esquerda em repouso antes do transplante era 20,1±6,8 por cento e, após 60 dias, aumentou para 23,0±9,0 por cento, p = 0,02. Houve melhora da classe NYHA (3,1±0,3 para 1,8±0,5; p<0.0001); qualidade de vida (50,9±11,7 para 21,8±13,4; p<0.0001); distância caminhada (355±136 m para 443±110 m; p = 0,003). O número de extrassístoles ventriculares em 24h apresentou tendência à elevação (5.322±4.977 para 7.441±7.955; p = 0,062), porém sem incremento dos episódios de taquicardia ventricular (61±127 para 54±127; p = 0,27). CONCLUSÃO: Nossos dados demonstram que a injeção intracoro¡nariana de células mononucleares da medula óssea é exeqüível e sugere ser potencialmente segura e eficaz em pacientes com IC de etiologia chagásica.

Tetralogia de Fallot com anomalia do ramo esquerdo da artéria pulmonar tratamento cirúrgico / Tetralogy of Fallot with anomalous left branch of the pulmonary artery-surgical treatment

Os autores relatam os resultados cirurgicos de 5 pacientes com tetralogia de Fallot e anomalia do ramo esquerdo da arteria pulmonar (REAP) que consistia em: ausencia do REAP em 3 casos, agenesia na origem do REAP que se enchia atraves persistencia de canal arterial em 1 caso e, no ultimo caso, o REAP tinha origem na aorta ascendente. Nos pacientes com ausencia do REAP foi feita ventriculosseptoplastia e alargamento da via de saida do ventriculo direito, anel pulmonar e tronco da arteria pulmonar, ocorrendo 1 obito no pos-operatorio imediato. No paciente com agenesia na origem do REAP, o canal arterial foi retirado da aorta e anastomosado ao tronco da arteria pulmonar. No paciente em que o REAP tinha origem na aorta ascendente, cerclamos o REAP e realizamos cirurgia de Brock.Ambos os pacientes apresentam boa evolucao

Reestudo dos pacientes submetidos a revascularização do miocárdio / Re-study of patients subjected to myocardial revascularization

Foram analisados os reestudos cineangiograficos em 66 pacientes submetidos a revascularizacao cirurgica do miocardio. O indice de oclusao foi de 17% das 126 pontes de veia safena. A indicacao para o reestudo foi a presenca de angina de peito, arritmias, insuficiencia cardiaca ou a positividade do teste ergometrico. Em 42 pacientes (64%) foi medida a fraccao de ejecao (FE). Observou-se que, em 69%, a FE ou melhorou ou nao sofreu alteracao.Em 31% dos casos, houve piora de FE. A oclusao de todas as pontes ocorreu em 6 pacientes (9%). Destes, 4 foram reoperados ocorrendo 1 obito no pos-operatorio imediato e 3 encontram-se assintomaticos. Os outros 2 casos sofreram infarto do miocardio e encontram-se assintomaticos. A hipertensao arterial sistemica, a oclusao de pontes e o infarto do miocardio foram os determinantes da piora da FE no periodo tardio da revascularizacao miocardica

Síndrome da cimitarra. Apresentação de sete casos / Scimitar syndrome.Report of 7 cases

Sao apresentados sete pacientes portadores da sindrome da cimitarra, sublinhando suas caracteristicas anatomicas, os padroes radiologicos e angiograficos que permitem a correta identificacao da maioria de suas malformacoes

Intervençoes percutâneas para revascularização do miocárdio no Brasil em 1996 e 1997 comparadas as do biênio 1992 e 1993. Relatório do registro CENIC (Central Nacional de Intervenoes Cardiovasculares) / Percutaneous myocardial revascularization procedures in Brazil in 1996-1997 compared to the 1992-1993 period. A report of the National Registry--National Center for Cardiovascular Interventions (CENIC)

PURPOSE: To report the results of percutaneous coronary interventions, in Brazil, in the years 1996-97, comparing them to those of 1992-93. METHODS: Data were collected in a standard form and the 1996-97 results were compared to those of 1992-93. RESULTS: The current Registry received data from 79effective members of the SBHCI in 127 hospitals, including 22,025 patients, 60.67of whom underwent PTCA, 36.57stent implantation, 2.3PTRA, 0.06DCA and 0.4laser angioplasty. Balloon angioplasty was the most frequent procedure in 1996-97, but its overall rate fell from 6.75to 55.8(p = 0.0001) concomitantly, there was a 35relative increase in the use of stents from 1992-93 to 1996-97. The success rate of the later period was higher (89.7vs 92.8, p = 0.000001), with lower residual stenosis (22vs 19, p = 0.001). Besides, there were lower major complications rates: acute myocardial infarction (2.5vs 1.2, p = 0.002) and death (1.8vs 1.4, p = 0.0003). CONCLUSION: The procedures most often carried out in both periods were balloon angioplasty (60.67) and implantation of stents (36.57); the success rate high, abrupt closure rate was low (1.5). These favorable results corroborate the high standards of the Brazilian Interventional Cardiology.

Segurança e eficácia da angioplastia com implante de stent intracoronariano em pacientes com síndromes coronarianas instáveis: comparaçäo com síndromes coronarianas estáveis / Safety and efficacy of angioplasty with intracoronary stenting in patients with unstable coronary syndromes: comparison with stable coronary syndromes

OBJECTIVE: To assess safety and efficacy of coronary angioplasty with stent implantation in unstable coronary syndromes. METHODS: Retrospective analysis of in-hospital and late evolution of 74 patients with unstable coronary syndromes (unstable angina or infarction without elevation of the ST segment) undergoing coronary angioplasty with stent placement. These 74 patients were compared with 31 patients with stable coronary syndromes (stable angina or stable silent ischemia) undergoing the same procedure. RESULTS: No death and no need for revascularization of the culprit artery occurred in the in-hospital phase. The incidences of acute non-Q-wave myocardial infarction were 1.4 percent and 3.2 percent (p=0.6) in the unstable and stable coronary syndrome groups, respectively. In the late follow-up (11.2+/-7.5 months), the incidences of these events combined were 5.7 percent in the unstable coronary syndrome group and 6.9 percent (p=0.8) in the stable coronary syndrome group. In the multivariate analysis, the only variable with a tendency to significance as an event predictor was diabetes mellitus (p=0.07; OR=5.2; 95 percent CI=0.9-29.9). CONCLUSION: The in-hospital and late evolutions of patients with unstable coronary syndrome undergoing angioplasty with intracoronary stent implantation are similar to those of the stable coronary syndrome group, suggesting that this procedure is safe and efficacious when performed in unstable coronary syndrome patients.

Aneurisma anular subvalvar mitral do ventrículo esquerdo: apresentação de quatro casos / Mitral annular subvalvular aneurysm of the left ventricle: report of 4 cases

Säo apresentados quatro pacientes portadores de aneurisma (Aneu) anular subvalvar mitral do ventrículo esquerdo (VE). No primeiro caso, o Aneu expandía-se anteriormente, em direçäo ao septo interventricular e via de saída do ventrículo direito, causando estenose infundibular. No segundo caso expandía-se posteriormente para a face inferior do coraçäo causando insuficiência mitral. No terceiro caso, a expansäo era superior, causando compressäo da aurícula esquerda e do ramo esquerdo da artéria pulmonar. No quarto caso, havia dois aneurismas, um expandindo-se superiormente e outro lateralmente, porém, sem repercursäo hemodinâmica. Os três primeiros casos foram operados, com um óbito

Cirurgia orovalvar na criança: experiência de 135 casos / Valvular surgery in children: experience with 135 cases

Foram analisados 135 pacientes levados a cirurgia do aparelho valvar, com idade inferior a quinze anos, no período de 11 anos (fevereiro de 1975 a fevereiro de 1986). Os pacientes foram divididos em dois grupos, de acordo com o tipo de cirurgia realizada. No grupo I, formado por 60 crianças, foi preservado o aparelho valvar por técnicas cirúrgicas reparadoras da anatomia e funçäo valvar. Tivemos uma mortalidade cirúrgica de 7%, 34% estäo sem seguimento. Dos pacientes acompanhados, 72% encontram-se assintomáticos, ou pouco sintomáticos; 2 pacientes (5%) foram a óbito tardio e 22% foram reoperados para implante de prótese. No grupo II, 75 pacientes foram levados a cirurgia, para implante de prótese. A mortalidade hospitalar foi de 12% e 13 pacientes (20%) estäo sem seguimento. Dos pacientes acompanhados, 71% estäo assintomáticos, ou pouco sintomáticos; 4% voltaram a apresentar sintomas; 13% (7 pacientes) foram a óbito tardio e 23% (12 pacientes) foram reoperados. A análise mais detalhada dos dois grupos, as mortalidades hospitalar e tardia nos induzem a concluir que se deve fazer todo o empenho na preservaçäo do aparelho valvar lesado. O baixo nível sócio-econômico, responsável pela baixa faixa etária em que säo atingidos os pacientes em suas lesöes valvares, é também responsável pela extrema dificuldade em se manter o acompanhamento clínico pós-operatório