Left ventricular thrombus routine screening with contrast echocardiography in patients with anterior ST-elevation myocardial infarction: is it worth it?

BACKGROUND: Left ventricular (LV) thrombus has a higher incidence among patients with anterior ST-elevation myocardial infarction (STEMI) when compared to other types of acute myocardial infarction and is associated with worse prognosis. The management of LV thrombus diagnosis remains challenging. Contrast echocardiography (transthoracic echocardiography, TTE) has shown potential in improving the accuracy for its diagnosis, thereby influencing treatment strategies concerning antithrombotic/anticoagulation therapy. The aim of this study was to assess the effectiveness of contrast TTE as a routine screening method for detecting LV thrombus in the acute phase of anterior STEMI. METHODS: A prospective, single center, randomized controlled trial was conducted among patients with anterior STEMI. The study group underwent contrast TTE, while the control group received a conventional approach. Demographical, clinical, and diagnostic data were collected. Thrombus detection rates were compared between groups. RESULTS: A total of 68 patients were included (32 in the study group and 36 in the control group). No substantial baseline differences were observed between groups. Thrombus detection rate was 25.0% in the study group and 13.9% in the control group, however these results did not reach statistical significance (P = 0.24). The prevalence of anterior/apical aneurysm was higher in the study group (46.9% vs. 22.2%, P = 0.03). CONCLUSIONS: Conventional TTE may be adequate for diagnosing LV thrombus in the acute phase of anterior STEMI; however, further larger-scale and multicenter studies are necessary to obtain more robust and conclusive results. Ultrasound contrast may play a significant role in the detection of anterior/apical aneurysms, which are known risk factors for the subsequent development of thrombus. TRIAL REGISTRATION: NCT06480929 (ClinicalTrials.gov, Retrospectively registered).

Embolic stroke and misidentification candida species endocarditis: Case presentation and literature review.

Fungal endocarditis is a rare but serious form of infective endocarditis associated with high morbidity and mortality. Among fungal pathogens, Candida species are the most frequently isolated and commonly found in individuals with predisposing factors, such as prosthetic heart valves. The clinical presentation of endocarditis is highly variable and nonspecific, often including symptoms and signs of embolization. In this paper, we present a case of fungal prosthetic valve endocarditis in which the initial presentation was an acute ischemic stroke. The initial misidentification of Candida famata was attributed to limitations in the presumptive methodology used through selective chromogenic culture identification. However, the surgical specimen underwent mass spectrometry, leading to the correct identification of Candida guilliermondii instead of Candida famata. Furthermore, we conducted a non-systematic narrative review of the literature on Candida endocarditis. Our findings underscore the importance of considering fungal endocarditis in the differential diagnosis of patients with possible extracardiac complications, particularly those with a history of heart valve replacement. Early diagnosis and a comprehensive treatment strategy tailored by species identification and antifungal susceptibility testing are crucial in improving patient outcomes.

Impact of Emergency Medical System Transportation in ST-segment Elevation Myocardial Infarction: A Nationwide Retrospective Study.

INTRODUCTION: Emergency medical system transportation has been shown to reduce treatment times in ST-segment elevation myocardial infarction. The authors studied the Portuguese National Registry of Acute Coronary Syndromes to determine the nationwide impact of the emergency medical system transportation in the treatment of ST-segment elevation myocardial infarction. MATERIAL AND METHODS: A multicentric, nationwide, retrospective study of ST-segment elevation myocardial infarction patients inserted in the National Registry from 2010 to 2017 was performed. The patients were divided into: Group I, composed of patients transported by emergency medical system, and Group II, patients arriving to the Emergency department by other means. RESULTS: Of the 5702 patients studied, 25.9% were transported via emergency medical system. Rates of emergency medical system activation increased by 17% in the last 7 years. The emergency medical system provided a higher rate of transport to a percutaneous coronary intervention capable centre, of Emergency department bypass, of on-site fibrinolysis, and ensured a 59-minute reduction of the median reperfusion time (p < 0.001). There was no difference in in-hospital mortality. DISCUSSION: In this nationwide cohort, emergency medical system transportation is associated with a reduction in reperfusion times. It provides a higher amount of salvaged myocardium and reduces the incidence of acute heart failure. However, emergency medical system use did not result in lower in-hospital mortality, probably due to confounding factors of higher disease severity and comorbidity. CONCLUSION: The benefits associated with emergency medical system based transportation of patients with ST-segment elevation myocardial infarction do not translate into lower in-hospital mortality.

Introdução: O transporte através de sistemas de emergência médica reduz os tempos de tratamento no enfarte agudo do miocárdio com elevação do segmento ST. Os autores estudaram o Registo Nacional de Síndromes Coronários Agudos para avaliar o impacto nacional do transporte através de sistema de emergência médica no tratamento do enfarte agudo do miocárdio com elevação do segmento ST. Material e Métodos: Foi realizado um estudo retrospetivo, multicêntrico de doentes com enfarte agudo do miocárdio com elevação do segmento ST inseridos no Registo Nacional desde 2010 até 2017. Os doentes foram divididos em Grupo I, representando doentes transportados por viaturas de emergência médica e Grupo II, doentes que chegaram ao Serviço de Urgência por outros meios. Resultados: Do total de 5702 doentes, 25,6% foram transportados por viaturas de emergência médica. Registou-se um aumento no uso de viaturas de emergência médica de 17% nos últimos sete anos. Os sistemas de emergência médica garantiram uma maior taxa de transporte para centros capazes de realizar intervenção coronária percutânea, de bypass do Serviço de Urgência e de fibrinólise no local. O transporte através de viaturas de emergência médica conseguiu uma redução da mediana do atraso para a reperfusão de 59 minutos (p < 0,001). Não houve diferença na mortalidade intra-hospitalar. Discussão: Nesta amostra nacional, é evidente que os sistemas de emergência médica reduziram significativamente os tempos de reperfusão, associando-se a uma menor incidência de insuficiência cardíaca aguda pós-enfarte. No entanto, esse benefício não resultou numa menor mortalidade intra-hospitalar, provavelmente devido ao facto dessa população representar um subgrupo de doentes com doença mais grave e mais comorbilidades. Conclusão: Os benefícios associados ao uso de sistemas de emergência médica no transporte de doentes com enfarte agudo do miocárdio com elevação do segmento ST não se traduziram numa menor mortalidade intra-hospitalar.

Acute Heart Failure Registry: Risk Assessment Model in Decompensated Heart Failure / Registro de Insuficiência Cardíaca Aguda: Modelo de Avaliação de Risco na Insuficiência Cardíaca Descompensada

Abstract Background: Heart failure (HF) is a highly prevalent syndrome. Although the long-term prognostic factors have been identified in chronic HF, this information is scarcer with respect to patients with acute HF. despite available data in the literature on long-term prognostic factors in chronic HF, data on acute HF patients are more scarce. Objectives: To develop a predictor of unfavorable prognostic events in patients hospitalized for acute HF syndromes, and to characterize a group at higher risk regarding their clinical characteristics, treatment and outcomes. Methods: cohort study of 600 patients admitted for acute HF, defined according to the European Society of Cardiology criteria. Primary endpoint for score derivation was defined as all-cause mortality and / or rehospitalization for HF at 12 months. For score validation, the following endpoints were used: all-cause mortality and / or readmission for HF at 6, 12 and 24 months. The exclusion criteria were: high output HF; patients with acute myocardial infraction, acute myocarditis, infectious endocarditis, pulmonary infection, pulmonary artery hypertension and severe mitral stenosis. Results: 505 patients were included, and prognostic predicting factors at 12 months were identified. One or two points were assigned according to the odds ratio (OR) obtained (p < 0.05). After the total score value was determined, a 4-point cut-off was determined for each ROC curve at 12 months. Two groups were formed according to the number of points, group A < 4 points, and group B = 4 points. Group B was composed of older patients, with higher number of comorbidities and predictors of the combined endpoint at 6, 12 and 24 months, as linearly represented in the survival curves (Log rank). Conclusions: This risk score enabled the identification of a group with worse prognosis at 12 months.

Resumo Fundamento: A insuficiência cardíaca (IC) é uma síndrome de elevada prevalência. Apesar de existir na literatura informação relativa aos fatores prognósticos a longo prazo na IC crônica, esta é mais escassa no que diz respeito aos pacientes com IC aguda. Objetivos: Desenvolver um score preditor de eventos prognósticos desfavoráveis em doentes admitidos com síndromes de IC aguda e caracterizar um grupo de maior risco quanto às suas características clínicas, terapêutica e resultados. Métodos: Estudo de coorte de 600 doentes internados com IC aguda, definida de acordo com os critérios da Sociedade Europeia de Cardiologia. O endpoint primário para a derivação do score foi definido como mortalidade de qualquer causa e/ou reinternação por IC aos 12 meses. Para a validação do score, foram utilizados como endpoints: mortalidade de qualquer causa e/ou reinternação por IC aos 6, 12 e 24 meses. Os critérios de exclusão foram: IC de alto débito, pacientes com infarto agudo do miocárdio, miocardite aguda, endocardite infeciosa, infeção pulmonar, hipertensão arterial pulmonar e estenose mitral grave. Resultados: Foram incluídos 505 doentes e identificados preditores prognósticos aos 12 meses. Atribuíram-se 1 ou 2 pontos (p.) de acordo com os odds ratio (OR) obtidos (p < 0,05). Após a determinação do valor de score total, foi estabelecido um cut-off de 4 pontos por curva ROC. Constituíram-se 2 grupos de acordo com a pontuação, grupo A < 4 p. versus grupo B = 4 p. O grupo B era constituído por idosos, com maior número de comorbidades e preditor de endpoint combinado aos 6, 12 e 24 meses traduzido linearmente nas curvas de sobrevida (Log rank). Conclusões: Este score de risco permitiu identificar um grupo com pior prognóstico aos 12 meses.

Acute Heart Failure Registry: Risk Assessment Model in Decompensated Heart Failure.

BACKGROUND: Heart failure (HF) is a highly prevalent syndrome. Although the long-term prognostic factors have been identified in chronic HF, this information is scarcer with respect to patients with acute HF. despite available data in the literature on long-term prognostic factors in chronic HF, data on acute HF patients are more scarce. OBJECTIVES: To develop a predictor of unfavorable prognostic events in patients hospitalized for acute HF syndromes, and to characterize a group at higher risk regarding their clinical characteristics, treatment and outcomes. METHODS: cohort study of 600 patients admitted for acute HF, defined according to the European Society of Cardiology criteria. Primary endpoint for score derivation was defined as all-cause mortality and / or rehospitalization for HF at 12 months. For score validation, the following endpoints were used: all-cause mortality and / or readmission for HF at 6, 12 and 24 months. The exclusion criteria were: high output HF; patients with acute myocardial infraction, acute myocarditis, infectious endocarditis, pulmonary infection, pulmonary artery hypertension and severe mitral stenosis. RESULTS: 505 patients were included, and prognostic predicting factors at 12 months were identified. One or two points were assigned according to the odds ratio (OR) obtained (p < 0.05). After the total score value was determined, a 4-point cut-off was determined for each ROC curve at 12 months. Two groups were formed according to the number of points, group A < 4 points, and group B = 4 points. Group B was composed of older patients, with higher number of comorbidities and predictors of the combined endpoint at 6, 12 and 24 months, as linearly represented in the survival curves (Log rank). CONCLUSIONS: This risk score enabled the identification of a group with worse prognosis at 12 months.

A conservative strategy in non-ST-segment elevation myocardial infarction - constraints and prognosis: The situation in Portugal.

INTRODUCTION AND OBJECTIVES: The aim of this study was to assess the impact of a conservative strategy in non-ST-segment elevation myocardial infarction in patients in the Portuguese Registry of Acute Coronary Syndromes. METHODS: The 3780 patients included in the study over a three-year period were divided into three groups: group 1, patients treated by a conservative strategy during hospitalization; group 2, patients who underwent coronary angiography without percutaneous coronary intervention (PCI); and group 3, patients who underwent PCI. Clinical and procedural data and in-hospital complications were compared. The primary endpoint was defined as in-hospital or one-year mortality and the secondary endpoint as the presence of at least one of the following in-hospital complications: major bleeding according to the GUSTO criteria, need for blood transfusion, invasive ventilation, heart failure or reinfarction. RESULTS: Of the patients analyzed, 16.5% were treated by a conservative strategy. Patients in this group were older, more often women, and had more high-risk factors. A conservative strategy was associated with a higher rate of the primary endpoint - in-hospital mortality (10.6% vs. 1.1% vs. 0.6% in groups 1, 2 and 3, respectively, p<0.001, odds ratio (OR) 6.974, 95% confidence interval [CI]: 2.775-17.527) and one-year mortality (26.1% vs. 6.8% vs. 4.1%, p<0.001, hazard ratio (HR) 2.925, 95% CI: 1.433 -5.974) - and of the secondary endpoint - 37.2% vs. 18.9% vs. 14.6%, p<0.001; OR 1.471 95% CI: 1.043 -2.076. CONCLUSIONS: In this patient population, a conservative strategy is an independent predictor of in-hospital mortality, in-hospital complications and one-year mortality.

[Twiddler syndrome: rare cause of definitive pacemaker dysfunction]. / Síndrome de Twiddler: Causa Rara de Disfunção de Pacemaker Definitivo.

The authors present a case of Twiddler's syndrome, a rare complication after pacemaker implantation, first described in 1968. The article is complemented by an approach to the etiology and manifestations of this entity.

Os autores apresentam um caso de síndrome de Twiddler, uma complicação rara após implantação de pacemaker definitivo, primeiramente descrito em 1968, complementado com uma abordagem à etiologia e manifestações desta entidade.

Arrhythmogenic right ventricular cardiomyopathy: contribution of different electrocardiographic techniques.

Arrhythmogenic right ventricular cardiomyopathy, also known as arrhythmogenic right ventricular dysplasia, is a condition in which myocardium is replaced by fibrous or fibrofatty tissue, predominantly in the right ventricle. It is clinically characterized by potentially lethal ventricular arrhythmias, and is a leading cause of sudden cardiac death. Its prevalence is not known exactly but is estimated at approximately 1:5000 in the adult population. Diagnosis can be on the basis of structural and functional alterations of the right ventricle, electrocardiographic abnormalities (including depolarization and repolarization alterations and ventricular arrhythmias) and family history. Diagnostic criteria facilitate the recognition and interpretation of non-specific clinical features of this disease. The authors present a case in which the diagnosis of arrhythmogenic right ventricular cardiomyopathy was prompted by the suspicion of right ventricular disease on transthoracic echocardiography. This was confirmed by detection of epsilon waves on analysis of the ECG, which generally go unnoticed but in this case were the key to the diagnosis. Their presence was also shown by non-conventional ECG techniques such as modified Fontaine ECG. The course of the disease culminated in the occurrence of ventricular tachycardia, which prompted placement of an implantable cardioverter-defibrillator.

Left Partial Anomalous Pulmonary Venous Return and Mitral Stenosis in an Adult.

Partial anomalous pulmonary venous return (PAPVR) is a relatively common congenital cardiac malformation in which one to three pulmonary veins drain to a systemic vein, the right atrium or the coronary sinus, resulting in a left-to-right shunt and the risk of developing pulmonary hypertension (PHT). It is frequently associated to other congenital cardiac defects (mainly atrial septal defect) but seldom associated with acquired cardiac disease, and normally involves the right lung. When it involves the left lung, the surgical correction in children is normally performed without prosthetic material. The authors report a case of associated mitral stenosis and left PAPVR corrected with comissurotomy and extra-anatomic derivation with a synthetic vascular graft.

Hypertrophic cardiomyopathy associated with left ventricular noncompaction cardiomyopathy and coronary fistulae: a case report. One genotype, three phenotypes?

The authors present a rare case of hypertrophic cardiomyopathy associated with left ventricular noncompaction cardiomyopathy and coronary artery-left ventricular fistulae in a 42-year-old woman presenting with non-ST-elevation myocardial infarction. Coronary angiography, transthoracic echocardiography and cardiac magnetic resonance revealed the structural abnormalities of the left ventricle and the coronary tree.