Surgical revascularization after fibrinolysis in acute myocardial infarction. Long-term follow-up.

One hundred twenty-eight patients with myocardial infarction who underwent operation for myocardial revascularization and 147 patients who received medical therapy were followed up for up to 6 years: all patients had received treatment with intravenous streptokinase. In the surgical group, 91.5% of the patients had the region related to the infarction revascularized, and in 82.8% of them the mammary artery was used. Statistically significant differences were not detected between the groups according to infarct size, clinical features, and left ventricular ejection fraction. However, there was a higher risk in the surgical group, as compared with that in the medical group, in terms of anatomic characteristics: 99.2% versus 77.1% of the patients showed more than 70% residual obstruction at the "culprit" coronary artery (p < 0.001, 95% confidence interval 14.1% to 30.1%) and 76.8% versus 40.7% showed multivessel coronary disease (p < 0.001, 95% confidence interval 23.7% to 48.5%). In-hospital survival was 95.3% in the surgical group and 89.1% in the medical group (p = 0.096, 95% confidence interval -0.2% to 12.6%). Significantly higher survivals were obtained for the surgical group both during the first (93% +/- 2.3% versus 80.3% +/- 3.3%, p = 0.005) and the sixth (86.4% +/- 3.4% versus 68.4% +/- 4.3%, p = 0.003) year of follow-up. Statistically significant differences were also obtained when in-hospital deaths were excluded. A Cox regression model with 13 variables showed that only age (p = 0.0422) and medical treatment (p = 0.0194) correlated independently with mortality. It is concluded that in this nonrandomized study, operation led to a significantly higher survival both on a medium- and long-term basis, when compared with that obtained for patients receiving medical therapy.

Effects of phenytoin on the ventricular tachyarrhythmias of chronic Chagas' disease.

The effects of phenytoin on the ventricular tachyarrhythmias of 11 patients with chronic chagasic myocarditis were investigated, and correlated with the serum phenytoin levels. Physical examination, laboratory tests and 24- to 48-h ambulatory electrocardiographic recordings were performed before, during (7-14 days) and after treatment with phenytoin (4-6 mg/kg/day, orally, in three divided doses). Significant (greater than 90%) reduction of couplets, bigeminy and runs of ventricular tachycardia were observed in 50-67% of the patients, whereas the frequency of isolated premature ventricular contractions was significantly (greater than 70%) reduced in only 2 patients (18%). Proarrhythmic activity was not observed and adverse side effects were of mild intensity and usually transient, except in one patient, who developed pruritus and skin rash in the presence of toxic phenytoin serum levels (27 micrograms/ml). It is suggested that phenytoin may be useful for the control of repetitive forms of ventricular tachyarrhythmias in selected patients with chronic chagasic myocarditis.

Acute myocardial infarction treated with intravenous streptokinase: 6-year follow-up.

Our objective was to investigate variables which, although occurring during the acute period, could influence the medium (1st year) and long-term (6th year) survival of infarcted patients. Of a total of 332 patients treated consecutively and prospectively according to the same protocol which included intravenous streptokinase, 305 survived the hospital phase and represent the study population. Mean patient age was 55.6 +/- 10 years and mean follow-up time was 3.33 years, with 1008.59 patient-years. The clinical course of the group was analyzed according to the following variables: left ventricle ejection fraction, hypotension per/peri streptokinase infusion, CK-MB peak, previous myocardial infarction, number of obstructed coronaries, reinfarction, sex, 'definitive' treatment, residual obstruction, age, pain/streptokinase infusion interval, patency of the 'culprit' coronary and infarct location. Overall, patient survival was 93.8 +/- 1.4% during the 1st year and 83.7 +/- 2.6% at the 6th. The following groups showed significantly different (log-rank) survivals: (a) 1st year: 94.6% for absence and 82.6% for presence of reinfarction (P = 0.0451); 97.9% for inferior and 91.4% for anterior infarct location (P = 0.044); 96.4% for ejection fraction > 50% and 90.6% for ejection fraction < or = 50% (P = 0.0187); 96.5% for angioplasty/surgery and 90.1% for clinical treatment (P = 0.0028); 95.5% for absence and 80.6% for presence of previous infarct (P = 0.0001). (b) 6th year: 88.3% for ejection fraction > 50% and 73.9% for ejection fraction < or = 50% (P = 0.028); 87.4% for < or = 65 and 66.4% for > 65 years (P = 0.0114); 89.6% for aggressive and 76.8% for conservative treatment (P = 0.013); 86.6% for absence and 60.7% for presence of previous infarct (P = 0.0009).

The role of antegrade and collateral flow in relation to left ventricular function post-thrombolysis.

UNLABELLED: The aim of the study was to analyze the relationship between antegrade and collateral flow degree to the "culprit" coronary artery, and between both variables and left ventricular systolic function. We analyzed five hundred patients with acute myocardial infarction, treated prospectively and consecutively within 6 h of evolution with intravenous streptokinase. The degree of antegrade (0-3) and collateral blood flow (0-3) were correlated with 18 other variables. RESULTS: (a) By simple regression analysis, antegrade flow degree correlated positively (p < 0.0001), and collateral flow degree negatively (p = 0.0073) with left ventricular ejection fraction; (b) By multiple regression analysis, antegrade flow degree (p = 0.0032), but not collateral flow degree (p > 0.1), correlated independently with left ventricular ejection fraction; (c) In the subgroup of patients with occluded "culprit" coronary artery, the mean ejection fraction was significantly higher for those with collateral flow 3 (60.2% +/- 13.3 in relation to those with collateral flow < 3 (53.9% +/- 13.1, p = 0.032, 95% CI. 11.96 to (0.53%). In conclusion, antegrade coronary flow degree, but not collateral flow degree, correlated significantly and independently with left ventricular ejection fraction. However, in the subgroup of patients with occluded "culprit" coronary artery, collateral flow 3 led to better left ventricular systolic function, in relation to collateral flow < 3.

Clinical and laboratory signs of reperfusion: are they reliable?

We studied 101 patients (88 men and 13 women, mean age 54.5 +/- 10 years) who arrived at the hospital during the first 6 hours of acute myocardial infarction evolution. Our objective was to assess the reliability of clinical and laboratory signs of recanalization using intravenous streptokinase as a thrombolytic agent. The mean time between the beginning of infusion and coronary arteriography was 53.83 +/- 43 hours. The positive predictive values for pain, arrhythmia, ST segment and enzymes were 97.9%, 94.2%, 91.8% and 90.8%, respectively; the negative predictive values were 46.8%, 40.8%, 37.2%, and 50% in the same order. Sensitivity was 65.7%, 62.8%, 58.4% and 77.6% and specificity 95.6%, 86.9%, 82.6% and 73.9%, respectively. The positive predictive value, calculated on the basis of the presence of each variable alone or in association showed a probability of recanalization of 76.9% for one sign, 84% for two, 96.3% for three and 100% for all four. When we compared the positive predictive values of each variable according to the interval between the beginning of pain and admission to the hospital (during the first 3 hours or between 3 and 6 hours) our results were 100%/94% for pain (P = NS), 97%/88% for arrhythmia (P = NS), 100%/75% for ST segment (P = 0.004), and 97%/80% for enzymes (P = 0.019). The same analysis applied to negative predictive values showing 22%/62% (P = 0.007), 17%/55% (P = 0.008), 21%/47% (P = NS), 27%/61% (P = NS) for pain, arrhythmia, ST segment and enzymes, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Pheochromocytoma with echocardiographic features of obstructive hypertrophic cardiomyopathy. A case report.

The authors report a case of pheochromocytoma in which the echocardiographic features suggested obstructive hypertrophic cardiomyopathy. The angiographic study and the computed tomography showed the tumor and its arterial supply. One month after resection of the tumor the echocardiographic features showed a tendency to normalization. The preoperative echocardiographic aspect was probably due to excessive production of catecholamines by the tumor.

Electrocardiography in Chagas' heart disease.

Conventional ECG still plays an important role in the overall knowledge of Chagas' cardiopathy, because of its importance in longitudinal and epidemiological studies, its diagnostic value, and its utility in prognostic evaluation. The authors discuss these aspects, as well as the use of eCG in the acute phase and the significance of a normal ECG in Chagas' disease. Correlations were made between ECG and Hemodynamic/angiographic variables among 1010 patients with positive laboratory tests for Chagas' disease: a) in the group with normal ECG there was no significant differences between symptomatic and non-symptomatic patients with regard to ejection fraction and angiographic abnormalities; b) slight abnormalities on the ECG corresponded to an intermediate level of severity of the disease, that is, between normal ECG and ECG with significant abnormalities C) fibrosis on the ECG was not predictive of akinesia in the related area on the angiography; d) combined ECG abnormalities generally correlated with greater myocardial compromises compared to isolated abnormalities; e) under multiple regression analysis the ECG abnormalities that independently correlated with depressed ejection fraction were: premature ventricular beats, ventricular tachycardia, left bundle branch block, atrial fibrillation, complete AV block, and anterior and inferior fibrosis. Male sex, cardiac insufficiency and cardiomegaly on the throat radiography were also significantly related.

[Cardiac rhabdomyomas]. / Rabdomiomas cardíacos.

Case report of cardiac rhabdomyoma in one two days old infant with important cyanosis and respiratory insufficiency with evolution to death in few hours. The radiologic feature was a great enlargement of the heart and the electrocardiographic study showed left branch block. The two-dimensional echocardiography study showed multiple intracavitary tumours in both ventricles and in the right atrium. These features were confirmed in the post-mortem study. The microscopic study of the tumors showed proliferation of the spider cells, and vacuolation with the presence glycogen. The diagnosis of cardiac rhabdomyoma was confirmed. The brain and the kidney were not studied for the diagnosis of tuberous sclerosis or kidney tumors. It is very important the early diagnosis by echocardiography, due to the possibility of surgical resection of the intracavitary tumors that cause severe obstruction to the blood flow.

[Double aortic arch associated with stenosis of left pulmonary artery]. / Duplo arco aórtico associado a estenosa da artéria pulmonar esquerda.

Case report on a 6-year-old patient with vascular ring, due to double aortic arch. The patient was asymptomatic. The barium-filled esophagus showed bilateral indentations and a large posterior indentation. Echocardiographic study in notch suprasternal view revealed features of this pathology. The diagnosis was made by the cineangiocardiographic study that showed double aortic arch with separate carotid and subclavian arteries arising from each arch. The right arch was larger than the left, and the descending aorta was on the left side. There was severe left pulmonary artery stenosis associated. The clinical management was chosen, because the patient was asymptomatic.

[Acute effects of propafenone in patients with ventricular pre-excitation]. / Efeitos agudos da propafenona em pacientes com pré-excitação ventricular.

PURPOSE: To evaluate the electrophysiological effects of intravenous propafenone in the anterograde and retrograde effective refractory period of the accessory pathways (AP), in patients with Wolff-Parkinson-White syndrome. METHODS: Forty symptomatic patients were studied. All patients were undergone to electrophysiologic study at baseline and after IV propafenone (2.0mg/kg). Drug effects were analysed according to the basal state of the anterograde and retrograde effective refractory periods of the AP > < 270ms. RESULTS: The mean anterograde and retrograde effective refractory periods of the AP were 275 +/- 76ms and 264 +/- 44ms at the control and 462 +/- 190ms and 438 +/- 184ms after drug respectively (p < 0.01 in both situations). The mean anterograde effective refractory period of the AV node was 236 +/- 40ms (control) and 276 +/- 57ms (post-drug)- p < 0.05. The mean atrial and right ventricular effective refractory period in the control were 210 +/- 23ms and 240 +/- 34ms passing to 215 +/- 24ms and 250 +/- 40 ms after drug respectively (p = ns). After drug, complete anterograde and retrograde block of the AP, occurred in 15 (42%) and 12 (35%) patients respectively. Out of 15 patients with complete anterograde block of the AP, 11 had anterograde effective refractory period of the AP > 270ms and 4, < 270ms (p < 0.02). Out of 12 patients with complete retrograde block of the AP after drug, 4 had retrograde effective refractory period > 270ms and 8, < 270ms (p: ns). CONCLUSION: Propafenone caused significant increase in the anterograde and retrograde effective refractory periods of the AP. There was a tendency of the drug to show better effectiveness in patients with anterograde effective refractory period of the AP > 270ms. This results were not seen in relation to the retrograde effective refractory period of the AP.

[In-hospital survival predictors in infarction patients undergoing fibrinolytic therapy]. / Preditores da sobrevida intra-hospitalar em pacientes infartados submetidos à terapêutica fibrinolítica.

PURPOSE: To analyze the in-hospital predictors of survival in a population of infarcted patients submitted to the same therapeutic protocol that included IV streptokinase (SK) in the dose of 750,000 units. METHODS: Three hundred and thirty two patients (mean age 55.6 +/- 10 years, 82.3% men) with acute myocardial infarction (AMI) were studied within six hours of onset of symptoms in a prospective and consecutive protocol. Using simple and multiple regression analysis, the following variables were selected for correlation with survival: LV ejection fraction by contrast ventriculography > 50%; CK-MB peak < or = 100 UI/1; male sex; invasive treatment (surgery or angioplasty); patent "culprit" coronary on cineangiography; age < or = 65 years; time interval between the onset of pain and the beginning of SK infusion < 3 hours; residual obstruction < 70% at the "culprit" coronary; inferior AMI location on ECG; absence of hypotension per-peri SK infusion, previous AMI, multivessel coronary artery disease and reinfarction. RESULTS: By simple regression analysis, ejection fraction > 50% (p < 0.001), CK-MB peak < or = 100 UI/1 (p = 0.003), and the absence of hypotension (p < 0.001), previous AMI (p = 0.009), multivessel coronary artery disease (p = 0.02) and reinfarction (p = 0.049), correlated significantly with survival. By multiple regression analysis ejection fraction > 50% (p = 0.017) and the absence of hypotension (p < 0.01), multivessel coronary artery disease (p = 0.032) and reinfarction (p = 0.037) correlated independently with survival. CONCLUSION: The data presented strongly support the concept of preventing atherosclerosis and maintaining myocardial viability using either direct measures such as recanalization, or indirect measures such prevention of hypotension and reinfarction.

[Survival and predictive factors of late mortality in the surgical treatment of aortic stenosis]. / Sobrevida e fatores preditivos da mortalidade tardia no tratamento cirúrgico da estenose aórtica.

PURPOSE: Study of 161 patients submitted to aortic valve replacement due to aortic stenosis to evaluate survival and predictive factors of late mortality. METHODS: The mean age was 45.8 years +/- 13.2 and 122 patients were men. Surgical mortality was 6.8%. The survival actuarial curve showed 59.28% of the patients alive after 16 years. Among the survival 62.3% +/- 10% were event free, including prosthesis thrombosis, thromboembolism, infective endocarditis and reoperation. Symptoms, age, gradient LV/Ao, ejection fraction (EF) and the compliance (CO) were related to prognosis. Sudden death after surgery was studied, with incidence of the 0.8 events/100 patients year. RESULTS: The asymptomatic patients had better evolution than symptomatic (p less than 0.05). The age above 60 years was not predictive of the prognosis in 10 years of follow-up, but no patients survived after 10 years. The gradient LV/Ao was not an important factor in the survival. The group with EF greater than 50% had 66.4% of survival, while the group with EF less than 50% survival was 39%. Normal or decreased compliance was not important in the survival. All patients with EF less than 50% always has decreased CO. Fifteen patients were dead due to heart failure and the most important predictive factor was the left ventricular dysfunction (p = 0.02). CONCLUSION: In aortic stenosis: a) severe ventricular dysfunction does not preclude the surgical treatment; b) the actuarial analysis suggests that EF less than 50% determines worse prognosis and always occurs with decreased CO; c) the excellent evolution of the asymptomatic patients does not generalize the surgical treatment in this phase; d) the incidence of the sudden death was not high after the surgical treatment; e) patients with pre-operative left ventricular dysfunction had greater mortality due to heart failure, than patients with normal left ventricular function; f) despite of the morbid events our results confirm the real benefit of the surgical treatment in the aortic stenosis.

[Univentricular heart: angiographic features in 31 patients]. / Coração univentricular: aspectos angiográficos em 31 pacientes.

PURPOSE: Evaluation of angiographic features of univentricular heart. METHODS: Thirty-one patients were divided into 3 groups according to morphological type of univentricular heart: left ventricle type, right ventricle type and undetermined. They were studied for atrio-ventricular junction, position of rudimentary chamber in relation to principal chamber, ventricle-arterial junction, the position of the two great arteries in relation to each other and whenever possible, the origin of the coronary arteries. RESULTS: There were 16 cases of left ventricle type with A-V junction through 2 valves in 8 and through single valve in 6. The rudimentary chamber position was superior and to the right in 4 cases of dextrocardia and superior and to the left in 8 of levocardia. The ventricle-arterial junction was discordant in 9 patients and concordant in 4, double outlet of rudimentary chamber in 2 and single outlet in 1. The aorta was anterior to the pulmonary artery in 13 patients. Anomalous origin of the coronary arteries occurred in 5 of 9 cases studied. Right ventricle type occurred in 9 patients with absence of one of the A-V junctions in 5. Trabecular pouch was seen in 6 patients, posterior and inferior positioned in all of them. Double outlet from principal chamber occurred in 8 patients. The aorta was anterior in 66.6%. Undetermined type occurred in 6 patients with A-V junction through single valve in 5. In 3 there was double outlet from principal chamber showing pulmonary stenosis and in the remaining 3 there was pulmonary atresia. CONCLUSION: Discordant ventricle-arterial junction is common for left ventricle type; trabecular pouch is frequent in right ventricle type; single A-V valve is common for undetermined type; obstruction of pulmonary flow happens in all 3 types but it is more frequent in undetermined type; the aorta is anterior to the pulmonary artery in most cases; it is common the anomalous origin of the coronary arteries from the aortic sinus.

[Left ventricular function in the acute phase of patients with myocardial infarction randomly treated with 750,000 or 1.5 million units of streptokinase]. / Função ventricular esquerda na fase aguda de infartados submetidos aleatoriamente a 750,000 ou 1.5 milhão de unidades de estreptoquinase.

PURPOSE: To compare the doses of 750,000 and 1.5 million units (U) of streptokinase (SK), relatively to the left ventricular (LV) systolic function analyzed through contrasted ventriculography. METHODS: We included 110 patients with acute myocardial infarction (AMI) within 6h of the onset (mean-age 60 years, 83.6% men), that were randomized to receive 750,000U of SK in 15 min (55 patients), or 1.5 million U in 30 min (55 patients). The study main goal was the comparison between the groups relatively to LV ejection fraction, global and regional shortening, obtained at the fifth day of the AMI. RESULTS: The 750,000 and 1.5 million groups were homogeneous relatively to 15 analyzed variables. Relatively to the main goal of the study, it was found respectively: a) ejection fraction analysis (median): 64% and 60.5% for the total population (p = 0.25, 95% CI -2.7 to 10), 64% and 57.5% for anterior AMI (p = 0.2, 95% CI -3.6 to 16.3), 65% and 65% for inferior AMI (p = 0.99, 95% CI -8.4 to 8.4); b) global shortening analysis: -2.53 and -2.66 for the total population (p = 0.3, 95% CI -0.47 to 0.87), -2.27 and -2.53 for anterior AMI (p = 0.18, 95% CI -0.3 to 1.4), -1.82 and 1.72 for inferior AMI (p = 0.9, 95% CI -0.82 to 0.75); c) regional shortening analysis: anterior AMI -2.6 and -2.67 (p = 0.47, 95% CI -0.7 to 1.5), inferior AMI -2.3 and -2.32 (p = 0.9, 95% CI -0.82 to 0.75). CONCLUSION: The dose of 750,000U was as efficacious as the 1.5 million relatively to LV systolic function, one of the best survival predictors of short-medium and long-term survival post AMI.

[Brazilian multicenter study of sotalol effectiveness in ventricular arrhythmias]. / Estudo multicêntrico Brasileiro da eficácia do sotalol em arritmias ventriculares.

PURPOSE: To evaluate the effects of sotalol in patients with nonsustained ventricular tachyarrhythmia (NSVT). METHODS: Ninety patients were enrolled. Patients were submitted to a double-blind crossover randomized study (placebo x 320 ms/po/d/sotalol; 4 weeks, after a wash-out control period. Holter recordings were performed in control (Ct), placebo (Pb) and drug (Dg) periods. Eligible patients had > 50/h isolated ventricular premature beats (VPB), in control, with or without pairs (P) or nonsustained VT (NSVT; > 3 beats, > 100bpm). Drug efficacy criteria were; > or = 75% reduction in isolated VPB, reduction > or = 90% of P and NSVT. The effects of the Dg were evaluated in the global population, in patients with Chagas' disease, idiopathic arrhythmias and ischemic/hypertensive patients. RESULTS: Differences between control and placebo were NS. Isolated VPB; Dg was effective in 42% (38/90 patients) with a mean of Pb and Dg respectively of 11,770 +/- 13,818 and 1,043 +/- 1,554 (p < 0.001). Pairs: drug was effective in 48% (32/67 patients) with a mean of Pb and Dg respectively of 439 +/- 586 and 27 +/- 52 (p < 0.001). NSVT: drug effectiveness was 53% (19/36 patients) with a mean of Pb and Dg respectively of 445 +/- 1,148 and 2.5 +/- 5.8 (p < 0.102). In patients with Chagas' disease, the reduction in VPB was 33% (13/39 patients), in pairs was 42+ (14/34) and in NSVT was 64% (12/22). In idiopathic patients the reduction of VPB was 53% (17/32 patients), in pairs was 50% (10/20) and in NSVT was 36% (4/11). In ischemic and hypertensive patients the reduction of VPB was 47% (7/15 patients) and 73% in pairs (8/11). CONCLUSION: In the present study, sotalol was effective in the control of nonsustained ventricular tachyarrhythmia, with minimal side-effects.

[The cholesterol profile in the city of São José do Rio Preto]. / Perfil do colesterol na cidade de São José do Rio Preto.

PURPOSE: To analyze: a) the cholesterol profile in adults older than 29 years, from São José do Rio Preto (300,000 inhabitants), city located in one of the country's richest regions; b) the variables that correlated with cholesterolemia. METHODS: An specialized firm was hired, and data was obtained through quantitative research, where a survey was done, using a sample stratified by sex and age; the error limits admitted was +/- 4%, for a 95% confidence interval, and Reflotron was utilized for cholesterol measurements. It was studied 672 persons (47% men), with mean age of 47.15 +/- 12.28 years; 35% were between 30 and 39 years, 25% between 40 and 49.22% between 50 and 59, and 18% were 60 or more years old. Thirteen variables were compared with cholesterolemia through simple regression; following, six of them, selected as predictors by stepwise regression, were compared with cholesterol through multiple regression analysis. RESULTS: a) Cholesterol levels: 192.5 +/- 48.9 mg/dl on global average, with 187.6 +/- 53.3 for men and 196.8 +/- 44.2 for women (p = 0.01, 95% CI 2.3 to 17.1); 176.5 +/- 44.7 mg/dl for people > or = 30 < 40 years old, 191.3 +/- 51.7 for those > or = 40 < 50 years (p = 0.002, 95% CI 4.6 to 24.2), 206.8 +/- 44.4 for those > or = 50 < 60 years (p = 0.005, 95% CI 4.6 to 26.4), and 208.5 +/- 47.8 for those > or = 60 years (p = 0.765,95% CI 9.5 to -12.5); 62% of the population showed < or = 200 mg/dl, and 16% > or = 240; b) through simple regression analysis, significant correlations were found between cholesterolemia and: age (p < 0.001), systolic (p < 0.001) and diastolic (p < 0.001) arterial pressures, diet (any, the great majority hypocaloric, p = 0.001), height (inverse correlation, p = 0.003), and female gender (p = 0.011); under multiple regression analysis, significant correlations were found for age (p < 0.001), educational level (p < 0.001), systolic arterial pressure (p < 0.001), weight (p = 0.004) and height (inverse correlation, p = 0.012). CONCLUSION: In the population older than 29 years, from São José do Rio Preto: a) the mean cholesterolemia is 192.5 +/- 48.9 mg/dl, being significantly higher for women, in relation to men, and showing significant increases between 3rd, 4th and 5th decades of life; b) correlated significantly with cholesterolemia, through simple regression analysis: age, systolic and diastolic arterial pressures, diet, height (inverse), and female gender; under multiple regression analysis: age, educational level, systolic arterial pressure, weight and height (inverse).

[Transluminal coronary angioplasty combined with cardiomyoplasty in the treatment of coronary disease associated with dilated cardiomyopathy]. / Angioplastia transluminal coronária combinada à cardiomioplastia no tratamento de doença coronária associada à cardiomiopatia dilatada.

A 53-year-old white female candidate to cardiomyoplasty to control heart failure class III (NYHA). Submitted to coronary angioplasty, presented at the coronarography 75% obstruction of the left anterior descending (LAD) artery and at the left ventriculography diffuse and severe hypocontractility ejection fraction (EF) = 17%. After primary success of the coronary dilatation, she was operated on with a good surgical outcome. Six months after the surgery, she did well clinically (class II) and at the coronarography the LAD artery presented free from restenosis or progression of the disease and the left ventriculography showed improvement of the ventricular function (EF = 28%).

[Myocarditis simulating acute myocardial infarction. A case report]. / Miocardite simulando infarto agudo do miocárdio. Relato de caso.

A six month-old infant presenting congestive heart failure and electrocardiographic features of acute myocardial infarction, including increased CK-MB levels. The echocardiographic study showed normal origin of the coronary arteries and features compatible with myocardiopathy. After good early response to conventional therapy, the patient developed severe congestive heart failure and shock, and died. In the post-mortem study, the coronary arteries were previous. Microscopic study was compatible with acute myocarditis.

[Pulmonary artery aneurysm. Report of 2 cases]. / Aneurisma de artéria pulmonar. Relato de dois casos.

The clinical suspicion of pulmonary artery aneurysm was made in two patients from the clinical signs and radiographic features. The echocardiographic studies showed features concerned with this pathology, and hemodynamic studies confirmed the diagnosis by pulmonary angiography. Both patients presented pulmonary valve insufficiency due to the huge pulmonary artery and dilatation of the valvular annulus. Other congenital malformations of the heart and pulmonary hypertension were not present in these patients. Surgical treatment was indicated in both patients. Surgery in patient no. 2 consisted of resection of the main pulmonary artery aneurysm and replacement with a valved conduit bovine pericardium and anastomosed with a patch of bovine pericardium connecting the left and right pulmonary arteries. The postoperative period was uneventful.

[Traumatic ventricular septal defect. A case report]. / Communicção interventricular traumática. Relato de caso.

A 34 years old woman, without previous cardiac symptoms, suffered a closed thoracic trauma in a car accident. Three days after presented dyspnea and orthopnea. Physical examination revealed a systolic murmur consistent with ventricular septal defect (VSD). Doppler echocardiography and angiography confirmed the presence of a muscular VSD with severe left-to-right shunt. Surgical intervention was indicated and VSD closure was performed with a patch, through a right atrium approach. Third degree atrioventricular block developed after surgery and a definitive pacemaker was implanted. The patient is asymptomatic and without murmurs in postoperative follow-up.