Coronary artery complications after left bundle branch area pacing: An increasingly reported issue in the era of physiologic pacing.

Coronary artery lesions related to pacemaker implantation are rare complications. With the increasing adoption of the technique of permanent transseptal pacing of the left bundle branch area pacing (LBBAP), an increase in the incidence of these complications may be expected. We report two cases of coronary lesions after permanent transeptal pacing of the LBBAP: the first with a small coronary artery fistula, and the second with an extrinsic coronary compression. Both complications occurred with stylet-driven pacing leads with extendable helix. In the first case, since the shunt volume was small and no major complications were reported, the patient was treated conservatively with good outcome. The second case required lead repositioning due to acute decompensated heart failure.

Massive thrombosis and phlegmasia cerulea dolens while taking rivaroxaban: case report and review.

Our study describes a fatal case of phlegmasia cerulea dolens and massive venous thrombosis in a patient taking rivaroxaban regularly to treat cerebral venous sinus thrombosis. Blood tests samples were positive for lupus anticoagulant. The unique evolution of the case, as well as the positivity for lupus anticoagulant, raises the possibility of an acquired hypercoagulation syndrome. We highlight the fact that the test recommended as the first line for lupus anticoagulant diagnosis (dilute Russell viper venom time) is the most affected by rivaroxaban, leading to a high prevalence of false-positive results. We also discuss potential diagnoses for the current case and review the current state-of-the-art of use of the novel oral anticoagulation agents in this unusual situation. So far, there are no recommendations to use such agents as first options in cerebral venous sinus thrombosis or in hypercoagulation syndromes.

Nosso estudo descreve um caso fatal de flegmasia cerúlea dolens e trombose venosa maciça em um paciente usando regularmente rivaroxabana para o tratamento de trombose de seio venoso cerebral. A investigação laboratorial foi positiva para o anticoagulante lúpico. A evolução única do caso aumenta a possibilidade de uma síndrome de hipercoagulabilidade adquirida, bem como a positividade para o anticoagulante lúpico. Destacamos o fato de que o teste recomendado como primeira linha para o diagnóstico de anticoagulante lúpico (veneno de víbora de Russel diluído) é o mais afetado pela rivaroxabana, levando a uma alta prevalência de resultados falso-positivos. Também discutimos os potenciais diagnósticos para o presente caso e revisamos o estado da arte atual dos novos agentes de anticoagulação oral usados nessa situação incomum. Até o presente momento, não há recomendações para o uso de tais agentes como primeira opção na trombose de seios venosos cerebrais ou nas síndromes de hipercoagulação.

Polymorphism of the Beta-1 Gly389Arg receptor in patients with dual atrioventricular nodal physiology.

INTRODUCTION: Gly389Arg ß1 adrenergic receptor polymorphisms seem to exert an influence on the modulation of the adrenergic effect in several types of patients. This study aimed to determine the prevalence of Gly389Arg polymorphisms among patients with evidence of double nodal pathway and to correlate the electrophysiological properties with the different genotypes of the respective polymorphisms. METHODS: A cross-sectional, descriptive and analytical study was designed to assess 49 patients, with evidence of double nodal pathway, submitted to electrophysiological study. Genomic DNA was extracted from peripheral blood leukocytes and the genotypes of the Arg389Gly polymorphisms were identified in all individuals by PCR/RFLP (polymerase chain reaction/restriction fragment length polymorphism). RESULTS: The majority of patients were female and had supraventricular tachycardia (75.5%). The prevalence of Arg389Arg genotype was found in 32 patients (65.3%), Arg389Gly genotype in 16 patients (32.7%) and Gly389Gly genotype in 1 patient (2%). With respect to the induction of nodal reentrant tachycardia, it was possible to induce non-isoproterenol tachycardia in 32 patients (65.3%), of whom 24 had the Arg389Arg genotype and 8 the Arg389Gly and Gly389Gly genotype (p = 0.05). The resting heart rate of patients of the Arg389Arg genotype was 81 ± 18 bpm and the Arg389Gly and Gly389Gly genotype of 71 ± 9 bpm (p = 0.044). Body mass index (BMI) among patients with genotype Arg389Gly and Gly389Gly was 29.8 ± 7.1 and patients with the Arg389Arg genotype was 26.2 ± 4.6 (p = 0.034). CONCLUSION: The Arg389Arg genotype was more easily related to triggering arrhythmia, higher resting heart rate and lower BMI.

The usefulness of SAGE score in predicting high pulse wave velocity in hypertensive patients: a retrospective cohort study.

Introduction: Aortic stiffness assessed by pulse wave velocity (PWV) is an important predictor to evaluate the risk of hypertensive patients. However, it is underutilized in clinical practice. We aimed to identify the optimal cutoff SAGE score that would indicate a risk PWV ≥ 10 m/s in Brazilian ambulatory hypertensive patients. Materials and methods: A retrospective cohort study. Patients underwent central blood pressure measurement using a validated oscillometric device from August 2020 to December 2021. A ROC curve was constructed using the Youden statistic to define the best score to identify those at high risk for PWV ≥ 10 m/s. Results: A total of 212 hypertensive individuals were selected. The mean age was 64.0 ± 12.4 years and 57.5% were female. The following comorbidities were present: overweight (47.6%), obesity (34.3%), and diabetes (25.0%). Most of the sample (68.9%) had PWV < 10 m/s. According to Youden's statistic, a cutoff point of 6 provided the optimal combination of sensitivity and specificity for identifying patients with a PWV ≥ 10 m/s. This cutoff achieved sensitivity of 97.0%, and specificity of 82.9%. In clinical practice, however, a cutoff point of 7 (where score values of at least 7 were considered to indicate high risk) had a positive likelihood ratio of 8.2 and a negative likelihood ration of 0.346, making this the ideal choice by accurately excluding patients who are less likely to have PWV ≥ 10 m/s. Conclusion: A SAGE score ≥7 identified Brazilian hypertensive patients with a high risk of PWV ≥ 10 m/s.

Critical appraisal of costly therapy modalities for heart failure in a developing country.

Contemporaneous challenges in heart failure management include strategies to rationally use health economic resources and relative donor shortage to adequately offer electric devices (cardiac resynchronization therapy [CRT] and implantable cardioverter defibrillators [ICD]), ventricular assist devices (VADs) and heart transplant, respectively. These issues are particularly important in countries with middle-income rates and limited structured heart transplant centers, such as Brazil. Use of CRT and ICDs need to follow strict guidelines, further customized to public financial health conditions. Experience with VADs in is the early days in Brazil and will require extreme caution to allocate health public resources to develop VAD programs in highly selected centers. Chagas' disease is epidemiologically important in Brazil; outcomes of patients with Chagas' on electric devices are unclear while these patients fare better post-transplant than non-Chagas' patients. Thus, heart transplant remains an attractive option regarding both favorable outcomes and resource allocation for advanced heart failure patients in Brazil.

Breaching septal veins while attempting left bundle branch area pacing. If necessary, septography contrast should be injected in a stepwise approach.

Permanent transseptal left bundle branch area pacing (LBBAP) is a promising technique developed to avoid the detrimental effects of pacing-induced dyssynchrony with right ventricular (RV) pacing, by offering more physiologic activation of the heart. Lesions to tributary veins of the coronary sinus have been increasingly reported, mostly associated with venous fistula or venous septal system infringement. Despite being mostly benign, venous complications may be related to the maneuver of contrast injection through the sheath and failure to follow simple but essential steps.

Risk Factors Associated with Ischemic Stroke in the Immediate Postoperative Period of Cardiac Surgery.

INTRODUCTION: Stroke remains a major complication of cardiac surgery. Despite all efforts, the incidence of postoperative stroke remains as high as 6%. We aimed to investigate risk factors for ischemic stroke in a contemporary cohort of patients undergoing cardiac surgery. METHODS: This is a retrospective cohort study of 678 consecutive adult patients who underwent cardiac surgery requiring cardiopulmonary bypass in a tertiary hospital in Brazil between July 1, 2011, and December 31, 2018. The primary outcome was the rate of early (perioperative and seven-day postoperative) stroke, defined as the occurrence of the outcome during the index admission. We developed a predictive model of stroke using the Poisson regression analysis with robust variance. RESULTS: Postoperative stroke occurred in 24 patients (3.5%), 23 (3.3%) were ischemic, and 21 (3.0%) were diagnosed in the first 72 hours after surgical procedure. After multivariate analysis, the following factors were significantly associated with stroke: previous stroke/transient ischemic attack (relative risk [RR]=2.75; 95% confidence interval [CI], 1.11-6.82), carotid artery disease (RR=4.0; 95% CI, 1.43-11.0), previous atrial fibrillation (RR=3.26, 95% CI, 1.31-8.1), and postoperative platelets > 200,000/mm3 (RR=2.26; 95% CI, 1.01-5.1). CONCLUSION: We developed a contemporary model to determine risk predictors for stroke after cardiac surgery. This model may help clinicians to identify patients at risk and could be useful in clinical practice.

Anthropometric measurements and their association with endothelial function and arterial stiffness of eutrophic individuals and with overweight.

Objective: The objective of the study was to assess the association of anthropometric measurements with endothelial function and arterial stiffness of eutrophic individuals and with overweight. Subjects and methods: A cross-sectional study was carried out with individuals with body mass index (BMI) between 18.5 kg/m2 and < 30 kg/m2, low to intermediate global cardiovascular risk scores, and aged ≥ 18 and < 60 years. We assessed the sociodemographic data, anthropometric variables (body weight, height, circumferences of the waist [WC], neck [NC], hip [HC], sagittal abdominal diameter [SAD], [BMI], waist-to-hip ratio [WHR], and waist-to-height ratio [WHtR]), biochemical parameters (lipid profile and nitric oxide), endothelial function (flow-mediated dilation [FMD], by ultrasound), and arterial stiffness (pulse wave velocity [PWV] and the amplification index [AIx@75] by oscillometry). Thirty-six individuals were included, 18 eutrophic and 18 with overweight, with a mean age of 37.5 ± 10.2 years, mostly at low cardiovascular risk (86.1%), female (80.6%), single (52.8%), employed with formal contracts (44.4%), and with over twelve years of education (88.9%). Results: The PWV presented positive and moderate correlation with the WC (r = 0.584; P = 0.001), WHR (r = 0.513; P = 0.001), and WHtR (r = 0.590; P = 0.001), and positive and low correlation with the NC (r = 0.372; P = 0.013) and SAD (r = 0.356; P = 0.033). Moreover, no anthropometric parameter presented a correlation with the AIx@75 or the FMD percentage in the total sample. Conclusion: Our findings show that in eutrophic individuals and with overweight the WC, WHR, WHtR, SAD, and NC were positively correlated with the PWV but not to the endothelial function in the overall sample. These are hypothesis-generating findings and they should be replicated in other studies.

Ventricular Tachycardia Precipitated by Short-long-short Sequence in a Patient with Implantable-cardioverter Defibrillator.

Abrupt changes in heart rate, particularly short-long-short sequences in the ventricular cycle length (CL), might precede initiation of ventricular tachycardia/fibrillation (VT/VF). These changes may be facilitated or caused by pacing activity in patients with pacemakers or implantable-cardioverter defibrillators (ICDs). We describe a patient with two episodes of acquired VT precipitated by short-long-short sequences and diagnosed from the ICD recordings. In such cases, the knowledge of the device parameters is extremely important for a correct diagnosis and management.

Acute effect of coffee on arterial stiffness and endothelial function in overweight and obese individuals: A randomized clinical trial.

INTRODUCTION: Coffee is one of the most consumed foodstuffs worldwide. Studies of coffee intake in healthy subjects have shown controversial effects on vascular function. However, little is known of coffee intake effects on the endothelium of overweight and obese individuals. OBJECTIVE: To investigate the acute effects of caffeinated and decaffeinated coffee intake on the endothelial function and arterial stiffness in overweight and obese individuals. METHODS: A randomized, double-blind, crossover clinical trial was designed to investigate the effects of regular caffeinated coffee and decaffeinated coffee on the endothelium. Each subject had both caffeinated coffee and decaffeinated coffee, separated by a washout period of seven days. The endothelial function was measured by flow-mediated dilation (FMD) assessed by ultrasound. Arterial stiffness was measured by an automatic oscillometric device. Blood samples were collected to assess the lipid and nitric oxide profiles. RESULTS: There were 18 subjects included in the study, aged 37.4 ± 10.0 years, with an average BMI of 28.96 ± 2.42, with the majority being female (61.1%). The caffeinated coffee increased central systolic blood pressure (P < 0.001), central diastolic blood pressure (P < 0.001) and pulse wave velocity (P < 0.001), but the decaffeinated coffee did not affect these variables. However, there was a better effect on FMD in the caffeinated coffee intake group (P = 0.014). CONCLUSION: In overweight and obese individuals, caffeinated coffee increased central blood pressure and pulse wave velocity but not the decaffeinated coffee. While caffeinated coffee showed an improvement on hyperemia-induced endothelial function. REGISTRATION NUMBER OF CLINICAL TRIAL: Platform of the Brazilian Registry of Clinical Trials under number RBR-65cxtr.

Tuberculosis with multiarticular involvement diagnosed by positive acid-fast staining in synovial fluid: An unusual case report.

Osteoarticular tuberculosis (TB) is an uncommon form of extrapulmonary TB, comprising approximately 5% of all TB and 10%-15% of extrapulmonary TB cases. Multifocal skeletal TB is rare and accounts for 10% of all osteoarticular TB cases. Sometimes, the diagnosis is difficult. The potential delay in the clinical diagnosis may be critical for patients since it can cause the spread of the infection from the bone to the adjacent joints and surrounding tissues. We present a rare case of military TB with multiarticular involvement in a patient with chronic tophaceous gout. The initial diagnosis was confirmed throughout the positive analysis for Ziehl-Nielsen acid-fast staining in synovial fluid of two different joints, which is unusual. The patient was treated with antituberculosis drugs and presented good recovery signs.

Genetic polymorphisms of the adrenergic system and implantable cardioverter-defibrillator therapies in patients with heart failure.

AIMS: We investigated whether the combination of beta(1)-Gly389Arg and GNB3 C825T, two genetic polymorphisms strictly related to adrenergic system modulation, could act as predictors of appropriate therapies in patients with heart failure (HF) using implantable cardioverter-defibrillators (ICDs). METHODS AND RESULTS: Patients with HF and ICD implantation for primary and secondary prevention were studied. All ICD therapies were registered and classified as appropriate (secondary to ventricular tachycardia) or inappropriate (others). Genetic analysis was performed by polymerase chain reaction and restriction fragment length polymorphism methods. Seventy-three patients with mean left ventricular ejection fraction of 35 +/- 11% were evaluated. Overall, 35 ICD therapies occurred during follow-up in 31 (42.5%) patients. Twenty-four therapies (33%) were appropriate, and 11 (15%) were inappropriate. Individual analysis of each polymorphism only identified T825 carriers of GNB3 C825T as predictor of appropriate shocks. The combined presence of risk genotypes (Arg389 of the beta(1)-Gly389Arg and T825 of the GNB3 C825T) identified patients with higher risk of appropriate shocks. Patients with two at-risk genotypes had a survival rate free of appropriate shocks lower than those with none or only one of these markers (87 vs. 54%, respectively; log-rank statistic = 0.006). Using a Cox regression model, each at-risk genotype was associated with an increment of risk of appropriate ICD shocks (odds ratio = 3.9, 95% confidence interval of 1.3-12.0; P = 0.02). CONCLUSION: Genetic polymorphisms of the adrenergic system may help to identify HF patients who are more likely to receive appropriate ICD therapies. Further studies are necessary to determine the clinical applicability of these polymorphisms as predictors of arrhythmias.

Change in cycle length during narrow complex tachycardia: what is the mechanism?

Major spontaneous variation in cycle length during supraventricular tachycardia is quite an uncommon phenomenon, which sometimes can mislead a correct diagnosis. We describe a patient who developed spontaneous variation in cycle length during electrophysiologic study in whom the coronary sinus cannulation was extremely difficult. In this situation, careful inspection of the mechanisms associated with this variation and classic pacing maneuvers are important to make a correct diagnosis of the supraventricular tachycardia.

Case series of sporotrichosis at a teaching hospital in Brazil.

INTRODUCTION: Sporotrichosis is a subcutaneous fungal infection with a worldwide distribution and higher incidence in tropical and subtropical areas, such as the Brazilian territory, where it has been standing out due to its frequent epidemics. Thus, the present study aimed to evaluate the prevalence of sporotrichosis and profile the affected patients at a university teaching hospital in the central region of Rio Grande do Sul, Brazil. METHODS: This study was a case series of patients diagnosed with Sporothrix spp. from January 2006 to December 2015 by microscopic examination or fungal isolates. Medical records were reviewed for epidemiological data. RESULTS: Forty-three cases of sporotrichosis were diagnosed through the period. The sample comprised predominantly young male adults and rural workers. The most common disease type was lymphocutaneous (51%), followed by fixed cutaneous form (32.5%). The predominant location was the upper limbs (70%), followed by the lower limbs (16%). A significant association was observed between the lymphocutaneous form and upper limb location and between the fixed cutaneous form and lower limb location (p = 0.019). Potassium iodine and itraconazole were the most common treatments. CONCLUSIONS: This study will help update the epidemiological situation of sporotrichosis in the central region of the state of Rio Grande do Sul, Brazil, over the last decade.

Health Care Utilization After Ventricular Tachycardia Ablation: A Propensity Score-Matched Cohort Study.

BACKGROUND: Catheter ablation of ventricular tachycardia (VT) can reduce the burden of ventricular arrhythmia (VA) but its effect on health care utilization and costs after such therapy is poorly known. We sought to compare the rates of cardiovascular (CV)-related hospitalizations, survival, and health care costs in patients with recurrent VT treated either with VT ablation or with medical therapy. METHODS: One-hundred implantable cardioverter-defibrillator patients with structural heart disease who underwent VT ablation were included. Propensity score-matched patients with recurrent VT treated with medical therapy were identified from a prospective registry of approximately 7000 de novo implantable cardioverter-defibrillator patients. Outcomes and costs were ascertained using health administrative databases. RESULTS: Among patients who underwent VT ablation, the cumulative rates of VA-related hospitalizations were lower in the 2 years after their ablation procedure compared with the year before (rate ratio, 0.3; 95% confidence interval [CI], 0.22-0.43). Rates of CV-related hospitalization and hospitalization because of VA post index date were similar between the VT ablation and medical therapy groups (hazard ratio [HR], 0.94; 95% CI, 0.57-1.54 and HR, 1.04; 95% CI, 0.57-1.91, respectively). Health care costs in the VT ablation patients were not increased post-ablation compared with the medical management group. The risk of all-cause mortality was lower among patients in the VT ablation group relative to the medical therapy group (HR, 0.64; 95% CI, 0.4-0.99). CONCLUSIONS: Patients who underwent VT ablation experienced a significant reduction in their rate of VA-related hospitalizations. Patients treated with VT ablation had similar rates of CV-related hospitalization compared with those treated with medical therapy without increased health care-related costs.

Risk Factors Associated with Ischemic Stroke in the Immediate Postoperative Period of Cardiac Surgery

ABSTRACT Introduction: Stroke remains a major complication of cardiac surgery. Despite all efforts, the incidence of postoperative stroke remains as high as 6%. We aimed to investigate risk factors for ischemic stroke in a contemporary cohort of patients undergoing cardiac surgery. Methods: This is a retrospective cohort study of 678 consecutive adult patients who underwent cardiac surgery requiring cardiopulmonary bypass in a tertiary hospital in Brazil between July 1, 2011, and December 31, 2018. The primary outcome was the rate of early (perioperative and seven-day postoperative) stroke, defined as the occurrence of the outcome during the index admission. We developed a predictive model of stroke using the Poisson regression analysis with robust variance. Results: Postoperative stroke occurred in 24 patients (3.5%), 23 (3.3%) were ischemic, and 21 (3.0%) were diagnosed in the first 72 hours after surgical procedure. After multivariate analysis, the following factors were significantly associated with stroke: previous stroke/transient ischemic attack (relative risk [RR]=2.75; 95% confidence interval [CI], 1.11-6.82), carotid artery disease (RR=4.0; 95% CI, 1.43-11.0), previous atrial fibrillation (RR=3.26, 95% CI, 1.31-8.1), and postoperative platelets > 200,000/mm3 (RR=2.26; 95% CI, 1.01-5.1). Conclusion: We developed a contemporary model to determine risk predictors for stroke after cardiac surgery. This model may help clinicians to identify patients at risk and could be useful in clinical practice.

Anthropometric measurements and their association with endothelial function and arterial stiffness of eutrophic individuals and with overweight

ABSTRACT Objective: The objective of the study was to assess the association of anthropometric measurements with endothelial function and arterial stiffness of eutrophic individuals and with overweight. Subjects and methods: A cross-sectional study was carried out with individuals with body mass index (BMI) between 18.5 kg/m² and < 30 kg/m², low to intermediate global cardiovascular risk scores, and aged ≥ 18 and < 60 years. We assessed the sociodemographic data, anthropometric variables (body weight, height, circumferences of the waist [WC], neck [NC], hip [HC], sagittal abdominal diameter [SAD], [BMI], waist-to-hip ratio [WHR], and waist-to-height ratio [WHtR]), biochemical parameters (lipid profile and nitric oxide), endothelial function (flow-mediated dilation [FMD], by ultrasound), and arterial stiffness (pulse wave velocity [PWV] and the amplification index [AIx@75] by oscillometry). Thirty-six individuals were included, 18 eutrophic and 18 with overweight, with a mean age of 37.5 ± 10.2 years, mostly at low cardiovascular risk (86.1%), female (80.6%), single (52.8%), employed with formal contracts (44.4%), and with over twelve years of education (88.9%). Results: The PWV presented positive and moderate correlation with the WC (r = 0.584; P = 0.001), WHR (r = 0.513; P = 0.001), and WHtR (r = 0.590; P = 0.001), and positive and low correlation with the NC (r = 0.372; P = 0.013) and SAD (r = 0.356; P = 0.033). Moreover, no anthropometric parameter presented a correlation with the AIx@75 or the FMD percentage in the total sample. Conclusion: Our findings show that in eutrophic individuals and with overweight the WC, WHR, WHtR, SAD, and NC were positively correlated with the PWV but not to the endothelial function in the overall sample. These are hypothesis-generating findings and they should be replicated in other studies.

Development of ventricular fibrillation after implantation of a biventricular implantable cardioverter defibrillator: what is the mechanism?

Syncopal spells in heart failure patient with cardiovascular implantable electronic devices (CIED) require multiple assessments. T-wave oversensing is a well-described phenomenon that remains significant in modern implantable cardioverter defibrillators (ICD) systems. It can lead to inappropriate therapies and loss of biventricular pacing in those with cardiac resynchronization devices. Strategies to overcome this problem are important.