Left Ventricular Mechanical Reverse Remodelling Not Followed by Electrical Reverse Remodelling: A Case Report.

Patients with severely depressed left ventricular ejection fractions (LVEFs) receive implantable cardioverter-defibrillators (ICDs) for the primary prevention of sudden death. However, in some patients, LVEFs may improve or even normalize over time, and these patients would no longer be qualified for ICD implantation based on the original criteria for which they have initially received an ICD. We report a patient with idiopathic dilated cardiomyopathy whose LVEF recovered to normal values after pharmacological therapy. Meanwhile, the patient had life-threatening ventricular fibrillation, aborted by the ICD. We reflect on the pathological features of left ventricular reverse remodelling and ventricular arrhythmogenesis, where the myocardial substrate appears to play an important role. Also, after LVEF improvement in a patient with a cardiac device, there is still a debate on whether we should perform a battery replacement.

Conservative management of a prosthetic valve thrombosis--report of a successful case.

Prosthetic valve thrombosis (PVT) refers to the presence of non infective material in valvular apparatus, interfering with its function. It is a potentially fatal complication of valvular replacement surgery. Treatment options include surgery, fibrinolysis and anticoagulation optimisation. The authors present the case of a young man, carrier of an aortic prosthetic mechanical valve, who didn't take his anticoagulant medicine, admitted for an acute obstructive PVT, with evidence of a large thrombotic mass on the aortic valve (> 1cm(2)). The patient refused surgical treatment and eventually presented a complete resolution of the acute PVT with anticoagulation optimisation.

Long-term follow-up of patients with postural tachycardia syndrome.

Postural tachycardia syndrome (POTS) refers to the presence of orthostatic intolerance symptoms with a heart rate increment ≥ 30 bpm, usually up to ≥ 120 bpm. Pathophysiology and POTS's clinical presentation are heterogeneous and its prognosis is uncertain. We reviewed the major clinical characteristics of POTS patients and assessed their long-term follow-up. Our series results, one with the longest follow-up, illustrate POTS as a clinical entity with variable, but usually benign outcome, in which most patients can reassume their daily activities without great limitations, after proper diagnosis and treatment are made.

[Hypocalcemia as a reversible cause of heart failure]. / Hipocalcemia como uma causa reversível de insuficiência cardíaca.

Calcium plays a key role in heart muscle contraction and relaxation. Hypocalcemic heart failure is a rare and potentially reversible disturbance, which reflects this intrinsic relationship. The authors present the case of a 35-year-old woman who developed acute heart failure during the early postoperative period following total thyroidectomy. The echocardiogram showed severe global left ventricular dysfunction. Laboratory tests showed severe hypocalcemia and new-onset hypoparathyroidism. Cardiac catheterization showed angiographically normal coronary arteries. After clinical, hemodynamic and metabolic stabilization, a repeat echocardiogram revealed recovery of left ventricular function. Subsequently, cardiac magnetic resonance imaging was performed, which also showed no alterations. The patient was discharged asymptomatic, medicated with calcium carbonate, calcitriol and levothyroxine. This case highlights the importance of considering hypocalcemia as a cause of reversible myocardial dysfunction.

Cardiac metastasis from epidermoid esophageal cancer mimicking anterior myocardial infarction.

Cardiac metastases are more common than primary tumors. Several types of malignant tumors have been reported to metastasize to the heart, mainly lung cancer, but in the setting of esophageal cancer, myocardial metastasis is comparatively rare. We report a case of a cardiac metastasis from esophageal squamous cell carcinoma detected 9 months after surgically curative esophagectomy, which presented mimicking acute myocardial infarction. The use of different imaging modalities was fundamental to a correct diagnosis considering the challenging presentation.

[Prevalence of late complications and survival of patients undergoing cardiac transplantation: a single-center experience]. / Complicações tardias e sobrevivência após transplantação cardíaca: análise de um centro hospitalar.

INTRODUCTION: Heart transplantation is the treatment of choice in severe heart failure despite maximal medical therapy, which has no other surgical alternatives and exhibiting no contraindications. The aim of this study was to analyze the prevalence of late complications and survival of patients undergoing cardiac transplantation at our Hospital Center. METHODS: We evaluated 78 patients (mean age 43 ± 15 years) transplanted at our center between February 1987 and December 2011, with a mean follow-up of 6 years. RESULTS: Of late complications after heart transplantation, allograft vascular disease was detected in 10 patients ( 12.8%), was the one with impact on mortality, being responsible for four deaths. The most frequent complication was hypertension in 54.6% of cases, followed by dyslipidemia (47.4%), renal failure (47.4%), diabetes mellitus (21.8%) and neoplasms (11.5%). Atrial tachyarrhythmias was observed in eight patients (10.3%). The overall survival of our population at first and tenth year after heart transplantation was 81% and 69%, respectively. The mean survival of patients was 15.6 years (Cl 95%: [12,6-18,7]).. There were 23 deaths (29.5%), nine (11.5%) of which occurred within the first 30 days after transplantation. CONCLUSION: Cardiac transplantation remains a valid therapeutic option for patients with end-stage heart disease. Our center had a heart transplant survival rate and incidence of late complications similar to those seen in international registries.

[Prothrombotic events after percutaneous closure of an atrial septal defect]. / Complicações pró-trombóticas após o encerramento percutâneo de comunicação interauricular.

We describe the case of a 66 years-old patient, submitted to percutaneous closure of an ostium secundum atrial septal defect ( ASD ), with an " Amplatzer ASO 20 mm " ( Medical AGA Corp., MN (. There were no immediate complications and no residual leak. Eleven days after the procedure, atrial fibrillation ( AF ) ensued, followed by an acute myocardial infarction ( distal occlusion of the circumflex artery ). Three days later, this patient had also a transitory ischemic accident. Percutaneous closure of ASD is a procedure that can be associated with a few complications, namely AF and thromboembolic events. Although common, the use of dual antiplatelet therapy doesn't have an established efficacy to prevent these cases.

I-123-MIBG cardiac uptake imaging, in familial dilated cardiomyopathy.

UNLABELLED: The pathological significance of myocardial adrenergic activity in patients with heart failure is well documented. No previous study has assessed the usefulness of I123-metaiodobenzylguanidine (123I-MIBG) cardiac uptake imaging for the evaluation of familial dilated cardiomyopathy (DCM). OBJECTIVE: To evaluate cardiac adrenergic activity, using 123I-MIBG cardiac uptake imaging, in members of a genotyped family with DCM. METHODS: Clinical evaluation, 12-lead ECG, 2D echocardiogram, heart rate variability analysis by 24h Holter, plasma B-type natriuretic peptide (BNP) measurements and 123I-MIBG cardiac imaging were performed in all participants. Anterior projection planar images and single photon emission computed tomographies of the thorax were obtained 20 min and 4 hours after the intravenous administration of 370 MBq of 123I-MIBG (early and late images). Heart/mediastinal (H/M) ratio and myocardial washout (MW) rate were obtained based on the anterior planar images. In polar maps, segmental uptake of 123I-MIBG was evaluated using a 4-grade visual score: grade 1 - uptake > 75% of maximum myocardial uptake (MMU); grade 2 - uptake 51-75% of MMU; grade 3 - uptake 26-50% of MMU; grade 4 - uptake < or = 25% of MMU. RESULTS: Eleven adults were included: 4 with DCM, 4 with isolated left ventricular enlargement (LVE), and 3 with normal echocardiogram. Patients with DCM and LVE presented higher MW rates, lower H/M ratios and higher visual score grades than those with normal 2D echocardiograms. One patient with a normal echocardiogram but carrying the disease locus also presented an abnormal MIBG cardiac scintigram. CONCLUSION: Patients with the phenotypic expression of the disease (DCM and LVE) and even carriers of the DCM gene with normal echocardiograms may present an abnormal MIBG cardiac scintigram, probably reflecting cardiac adrenergic hyperactivity. If confirmed in larger numbers, this method may be useful for the evaluation of DCM families.

Myocardial dysfunction in Takotsubo syndrome: More than meets the eye?

INTRODUCTION: Takotsubo syndrome (TTS) is characterized by transient left ventricular (LV) dysfunction, typically mimicking an anterior wall myocardial infarction (MI), without obstructive coronary artery disease. In the few published reports assessing myocardial deformation in TTS and MI, no consistent differences have been described between the two entities. We sought to characterize global and regional function in TTS and to compare it with a population with MI. METHODS: Clinical data, including echocardiography, were gathered from 17 TTS patients and 20 anterior wall ST-segment elevation myocardial infarction (STEMI) controls. Peak systolic longitudinal strain was determined for each LV segment using speckle tracking imaging, and global and mean apical, midventricular and basal longitudinal strain were calculated from these. RESULTS: Both TTS and STEMI patients presented significant LV systolic dysfunction, and there were no significant differences in ejection fraction or global longitudinal strain. Regional longitudinal strain was more severely impaired in basal inferolateral and mid anterolateral segments in the TTS group and in apical anteroseptal segments in the STEMI group. Mean longitudinal strain was worse in the basal segments of TTS patients (-9.8±2.9 vs. -12.4±4.1%, p=0.010), with no significant differences in mid and apical segments. The basal/apical ratio was significantly lower in this group as well (1.51±0.86 vs. 2.94±1.88, p=0.006). CONCLUSIONS: While both TTS and STEMI feature significantly impaired global systolic function, we found a regional pattern of worse basal longitudinal strain and a lower basal/apical ratio in the former. These suggest generalized myocardial impairment in TTS, providing new clues about its pathophysiology and possible specific echocardiographic changes.

A case of acute heart failure due to giant aortic pseudoaneurysm with fistulization to the right ventricle after a modified Bentall operation.

Simultaneous en bloc replacement of the ascending aorta and aortic valve by a composite valve graft, as first described by Bentall and De Bono in 1968 and with later modifications, has become the standard surgical technique in the treatment of aneurysms of the aortic root associated with severe aortic valve dysfunction. Despite the good surgical results overall, it is still associated with considerable perioperative mortality and with dire complications in the long run. We report a case of a giant aortic pseudoaneurysm compressing the right heart chambers and communicating with the right ventricle presenting as rapidly progressing heart failure a few months after a Bentall operation.

Percutaneous Closure of a Fistulous Giant Coronary Aneurysm.

Giant coronary artery aneurysms larger than 50 mm are rare and associated with important complications: namely, rupture. Its workup requires comprehensive imaging and standard treatment is surgical exclusion. We present a 60-year-old patient with previous ostium secundum atrial septal defect surgical closure diagnosed with a giant proximal right coronary artery aneurysm (70 x 62 mm) fistulizing into the right atrium. Percutaneous closure of its aortic origin with an atrial septal occluder was successfully performed, and thrombosis of the aneurysm confirmed on angiography and echocardiogram. This case depicts an innovative, minimally invasive approach to this worrisome entity.

Left ventricular reverse remodeling in dilated cardiomyopathy- maintained subclinical myocardial systolic and diastolic dysfunction.

In idiopathic dilated cardiomyopathy (DCM), myocardial deformational parameters and their relationships remain incompletely characterized. We measured those parameters in patients with DCM, during left ventricular reverse remodeling (LVRR). Prospective study of 50 DCM patients (in sinus rhythm), with left ventricular ejection fraction (EF) <40%. LVRR was defined as an increase of ten units of EF and decrease of diastolic left ventricular diameter (LVDD) in the absence of resynchronization therapy. Performed morphological analysis, myocardial performance quantification (LV and RV Tei indexes) and LV averaged peak systolic longitudinal strain (SSR long) and circumferential strain (SSR circ). At baseline, mean EF was 25.4 ± 9.8%, LVDD was 62.4 ± 7.4 mm, LVDD/BSA of 34.2 ± 4.5 mm/m2 and 34% had MR grade >II/IV. LVRR occurred in 34% of patients within 17.6 ± 15.6 months and was associated with a reduced rate of death or heart failure hospitalization (5.9% vs. 33.3; p = 0.03). Patients with LVRR had a final EF of 48.9 ± 7.9% (Δ LV EF of 22.4%) and there was a significant decrease (p < 0.05) in: LVDD/BSA, LV systolic diameter/BSA, LV diastolic volume, LV systolic volume, LV mass; an increase (p < 0.05) in sphericity index. However, measures of diastolic function (LA volume/BSA, e'velocity and' E/e'ratio), final LV and RV Tei indexes were not significantly different from baseline. Additionally, final SSR circ and SSR long values were not different from basal. Patients who recovered EF >50% (n = 10), SSR circ and SSR long were inferior to normal. Improvement in EF occurred in one-third of DCM pts and was associated with a decrease of major cardiac events. There was an improvement of diastolic and systolic volumes and in sphericity index, confirming truly LV reverse reshaping. However, myocardial performance indexes, SSR long and SSR circ in reverse-remodeled DCM were still abnormal, suggesting a maintained myocardial systolic and diastolic dysfunction.

The value of NT-proBNP in early risk stratification of acute coronary syndromes.

INTRODUCTION: The N-terminal portion of brain natriuretic peptide (NT-proBNP) has been identified as an indicator of prognosis in different cardiovascular diseases. Its role in risk stratification in patients with acute coronary syndromes (ACS) is still under evaluation. OBJECTIVE: We aimed to evaluate the prognostic value of NT-proBNP measured in the first 48 hours after admission due to an acute coronary syndrome. METHODS: Our study included 142 patients (aged 62.7 +/- 12.0 years, 70.4% males) admitted to a cardiology unit with an ACS. All laboratory evaluations were performed in the first 48 hours after admission. The mean follow-up was 200 days. Death from any cause or hospitalization because of a major acute cardiovascular event (whichever occurred first) was defined as the end-point. RESULTS: Cardiovascular risk factors were found in a significant proportion of our sample (hypertension in 56.3%, diabetes mellitus in 38.0%, current or previous smoking in 51.4%, dyslipidemia in 67.6%). Fifty-eight patients had left ventricular systolic dysfunction (LVSD). Serum levels of NT-proBNP were 2174 +/- 4801 pg/ml. Variables associated with event-free survival in univariate analysis were: NT-proBNP (HR 1.007, 95% CI 1.003-1.011, for each 100 pg/ml increment), serum glucose (hazard ratio [HR] 1.007, 95% CI 1.001-1.012, for each 1 mg/dl increment) and maximum cardiac troponin I (cTnI) level (HR 1.005, 95% CI 1.001-1.009, for each 1 ng/ml increment). The white blood count (WBC) was marginally associated with a poor prognosis (HR 1.152, 95% CI 0.994-1.335, for each 1000/mm3 increment). After adjustment for the above variables, age, sex, left ventricular systolic dysfunction, diabetes, coronary anatomy and coronary revascularization using a forward likelihood ratio Cox regression model, NT-proBNP remained the only variable with significant prognostic value (HR 1.007, 95% CI 1.003-1.011, for each 100 pg/ml increment). CONCLUSIONS: These data suggest that NT-proBNP is a strong clinical predictor of prognosis in acute coronary syndromes. Its early measurement should be included in the risk stratification strategy in this setting.

Electrocardiographic evaluation in athletes: 'Normal' changes in the athlete's heart and benefits and disadvantages of screening.

Young athletes are considered the healthiest group in society. Although rare, there are still reports of sudden death or cardiac arrest on the playing fields. Clinical evaluation is of paramount importance for the identification of possible pathological states that confer increased risk of these events. Interpretation of the electrocardiogram of young athletes can help identify changes associated with heart disease that might preclude the participation in sports. In this context, it is essential to recognize the electrocardiographic patterns that represent the structural and electrical remodeling resulting from continued adaptation to exercise, and which thus do not increase the risk of adverse events during exercise. The European Society of Cardiology (ESC) and the American Heart Association (AHA) have issued consensus documents summarizing which electrocardiographic abnormalities should be considered 'physiological', resulting from adaptation to exercise ('athlete's heart'), and which should be considered pathological and thus require further study. However, the two societies have different approaches with respect to the electrocardiographic screening of athletes. This paper provides a brief review of current evidence regarding the electrocardiographic findings considered normal and abnormal in athletes, and presents the arguments of the ESC and AHA for electrocardiographic screening in this population.

Pseudoaneurysm of the mitral-aortic fibrosa: myocardial ischemia secondary to left coronary compression.

In the current study we describe the cases of 2 patients operated on for left-sided endocarditis, who later had myocardial ischemia develop secondary to left coronary artery compression from a pseudoaneurysm of the mitral-aortic fibrosa. Because the symptoms of angina persisted despite medical treatment, both patients had second surgeries. Myocardial revascularization was performed in 1 patient; the other patient, who had a severely depressed ventricular function, was given an orthotopic cardiac transplant.