Transient ascending ST-segment depression and widening of the S wave in 3-channel Holter monitoring-A sign of dromotropic disturbance in the right ventricular outflow tract in the Brugada syndrome: A report of five cases.

BACKGROUND: Brugada syndrome (BrS) is somewhat a challenging diagnosis, due to its dynamic pattern. One of the aspects of this disease is a significant conduction disorder located in the right ventricular outflow tract (RVOT), which can be explained as a consequence of low expression of Connexin-43. This decreased conduction speed is responsible for the typical electrocardiographic pattern. Opposite leads located preferably in inferior leads of the electrocardiogram may show a deep and widened S wave associated with ascending ST segment depression. Holter monitoring electrocardiographic (ECG) aspects is still a new frontier of knowledge in BrS, especially in intermittent clinical presentations. METHODS: We describe, as an exploratory analysis, five case series of intermittent type 1 BrS to demonstrate the appearance of ascending ST segment depression and widening of the S wave, during 3-channel 24h-Holter monitoring (C1, C2 and C3) with bipolar leads. RESULTS: In the five cases described, the ST segment depression was observed mainly in C2, but in some cases also in C1 and C3. Only case 1 presented concomitant intermittent elevation of the ST segment in C1. All cases were intermittent. CONCLUSION: The recognition of an ECG pattern with ascending ST-segment depression and widening of the S wave in 3-channel Holter described in this case series should raise a suspicion of the BrS and suggests the counterpart of a dromotropic disturbance registered in the RVOT and/or reciprocal changes.

The Vectorcardiogram and the Main Dromotropic Disturbances.

Until the mid-1980s, it was believed that the vectorcardiogram (VCG) presented a greater specificity, sensitivity and accuracy in comparison to the 12-lead electrocardiogram (ECG), in the cardiology diagnosis. Currently, the VCG still is superior to the ECG in specific situations, such as in the evaluation of myocardial infarctions when associated with intraventricular conduction disturbances, in the identification and location of accessory pathways in ventricular preexcitation, in the differential diagnosis of patterns varying from normal of electrical axis deviation, in the evaluation of particular aspects of Brugada syndrome, Brugada phenocopies, concealed form of arrhythmogenic right ventricular cardiomyopathy and zonal or fascicular blocks of the right bundle branch on right ventricular free wall.VCG allows us to analyze the presence of left septal fascicular block more accurately than ECG and in the diagnosis of the interatrial blocks and severity of some chambers enlargements. The three-dimensional spatial orientation of both the atrial and the ventricular activity provides a far more complete observation tool than the linear ECG. We believe that the ECG/VCG binomial simultaneously obtained by the technique called electro-vectorcardiography (ECG/VCG) brought a significant gain for the differential diagnosis of several pathologies. Finally, in the field of education and research, VCG provided a better and more rational tridimensional insight into the electrical phenomena that occurs spatially, and represented an important impact on the progress of electrocardiography.

Noninvasive assessment of autonomic modulation of heart rate variability in the Ts65Dn mouse model of Down syndrome: A proof of principle study.

INTRODUCTION: The Ts65Dn mouse is the most widely used animal model of Down syndrome (DS). Differences in autonomic regulation of heart rate variability (HRV) in individuals with DS have been hypothesized. Pharmacological studies in animal models may help us understand mechanisms underlying observed changes in HRV in people with DS. OBJECTIVE: To investigate the use a new, noninvasive technique to assess cardiac autonomic modulation in Ts65Dn mice under the effect of adrenergic and cholinergic agonists. METHOD: We recorded electrocardiograms (ECGs) from 12 Ts65Dn and 12 euploid control mice. A 30-min baseline recording was followed by the injection of an adrenergic (isoproterenol [Iso]) or cholinergic (carbachol [CCh]) agonist. Heart rate and HRV were analyzed using a series of methods customized for mice. RESULTS AND DISCUSSION: The ECG apparatus described here allowed us to detect noninvasively long series of heartbeats in freely-moving animals. During baseline conditions, the yield of detectable heartbeats was 3%-27% of the estimated total number of events, which increased to 35%-70% during the 15-min period after either Iso or CCh injections. Ts65Dn mice displayed a robust enhanced Iso-induced negative chronotropic rebound response compared with euploid control mice. We observed a significantly smaller CCh response in Ts65Dn versus control euploid mice in the 6- to 10-min-interval postcarbachol injection. CONCLUSION: This work showed that the techniques described here are sufficient for this type of study. However, future studies involving the use of more selective pharmacological agents and/or genetic manipulations will be key to advance a mechanistic understanding of cardiac autonomic regulation in DS.

Unusual ventricular activation produced by temporary transvenous cardiac pacing: electrovectorcardiographic findings.

Complete heart block (CHB) results from dysfunction of the cardiac conduction system, which results in complete electrical dissociation. The ventricular escape rhythm can have its origin anywhere from the atrioventricular node to the bundle branch-Purkinje system. CHB typically results in bradycardia, hypotension, fatigue, hemodynamic instability, syncope, or even Stokes-Adams syndrome. Escape rhythm originating above the bifurcation of the His bundle (HB) produces narrow QRSs with relatively rapid heart rate (HR) (except in cases of His system disease). We present a middle-aged man with an HR of 34 bpm, progressive fatigue, in whom a temporary pacemaker was implanted in the subtricuspid region. The post-intervention electrocardiogram had unusual features.

El bloqueo cardíaco completo (BCC) resulta de la disfunción del sistema de conducción cardíaco, lo que ocasiona una disociación eléctrica completa entre aurículas y ventrículos. El ritmo de escape resultante puede tener su origen en cualquier lugar desde el nodo auriculoventricular hasta el sistema His Purkinje. El BCC generalmente produce bradicardia, hipotensión, fatiga, inestabilidad hemodinámica, síncope o incluso el síndrome de Stokes-Adams. El ritmo de escape que se origina por encima de la bifurcación del haz de His produce intervalos QRS estrechos con frecuencia cardíaca no muy lenta (excepto en casos de enfermedad del sistema Hisiano). Presentamos a un hombre de mediana edad con una frecuencia cardíaca de 34 lpm, fatiga progresiva, en el que se implantó un marcapasos temporario en la región subtricuspídea. El electrocardiograma resultante a la intervención presentó características inusuales.

Zika Virus Alters the Viscosity and Cytokines Profile in Human Colostrum.

The resurgence of cases of Zika virus (ZIKV) infection, accompanied by epidemic of microcephaly in Brazil, has aroused worldwide interest in understanding the biological mechanisms of the virus that allow patient management and the viral dissemination control. Colostrum and human milk are possible sources of virus spread. Therefore, the objective of this study was to analyze the repercussions of ZIKV infection on rheological parameters and inflammatory cytokines of colostrum. The prospective cohort study included 40 puerperal donors of colostrum, divided into 2 groups: control (without ZIKV infection, n = 20) and a group infected with ZIKV during the gestational period (n = 20). Analyses were performed for the detection of ZIKV by polymerase chain reaction (PCR). In addition to obtaining the rheological parameters and quantification of IL-10 and IL-6 cytokines by flow cytometry, ZIKV and other flaviviruses were not detected in colostrum. However, maternal infection reflected increased viscosity, decreased levels of IL-10, and elevated levels of IL-6. The higher viscosity may represent a mechanical barrier that hinders the spread of the virus. The lower levels of anti-inflammatory mediators and higher inflammatory cytokines may possibly alter the viscosity, and it seems the higher viscosity represents a possible mechanism of adaptation of breastfeeding against a response to ZIKV.

Melatonin Action on the Activity of Phagocytes from the Colostrum of Obese Women.

BACKGROUND AND OBJECTIVES: Breastfeeding promotion is an important public health strategy for counter-balancing the negative effects of maternal overweight and obesity. Colostrum contains melatonin, which can attenuate the impacts of excessive maternal weight and boost the infant's immune system. Therefore, the objective of this study was to analyze the effects of melatonin on mononuclear (MN) phagocytes from the colostrum of women with pre-gestational obesity. Materials and Methods: Colostrum samples were collected postpartum from 100 women at a public hospital in São Paulo, Brazil. The donors were divided into two groups: the control group and the high body mass index (BMI) group. Melatonin levels in the colostrum were determined by an ELISA Kit, and the functional activity of MN cells was assessed using the phagocytosis assay by flow cytometry, and reactive oxygen species (ROS), intracellular calcium, and apoptosis were assessed by fluorimetry using a microplate reader. RESULTS: The colostrum of mothers with pre-gestational high BMI exhibited higher melatonin levels (p < 0.05) and lower phagocytosis (p < 0.05) and ROS release (p < 0.05). Superoxide release was similar between the normal and high BMI groups (p > 0.05). Intracellular calcium release and apoptosis were also higher in the high BMI group (p < 0.05). Melatonin levels likely increased the phagocytosis rate and reduced intracellular calcium release and the apoptosis index (p < 0.05). CONCLUSIONS: The results suggest that melatonin is a possible mechanism for maternal-infant protection against obesity and restores the functional activity of colostrum phagocytes in obese mothers.

Obesity as an Inflammatory Agent Can Cause Cellular Changes in Human Milk due to the Actions of the Adipokines Leptin and Adiponectin.

Adiponectin and leptin play roles in the hunger response, and they can induce the inflammatory process as the initial mechanism of the innate immune response. It is possible for alterations in the levels of these adipokines to compromise the functional activity of human colostrum phagocytes. Therefore, the objective of this study is to analyze the effects of adiponectin and leptin on colostrum mononuclear (MN) cells. Colostrum was collected from 80 healthy donors, who were divided into two groups: the control group and the high body mass index (BMI) group. MN cells were used to analyze phagocytosis by flow cytometry, and reactive oxygen species (ROS), intracellular calcium, and apoptosis were assessed by fluorimetry using a microplate reader. Adipokines restored the levels of phagocytosis to the high BMI group (p < 0.05), with a mechanism that is action-dependent on the release of ROS and intracellular calcium. However, adiponectin and leptin simultaneously contributed to better microbicidal activity, thus reflecting an increase in the apoptosis level (p < 0.05) in the high BMI group. Probably, the maintenance of the balance between adiponectin and leptin levels enhances the protection and decreases the indices of neonatal infection in the breastfeeding infants of women with high BMI values. Therefore, policies that support pre-gestational weight control should be encouraged.

Left bundle branch block: Epidemiology, etiology, anatomic features, electrovectorcardiography, and classification proposal.

In left bundle branch block (LBBB), the ventricles are activated in a sequential manner with alterations in left ventricular mechanics, perfusion, and workload resulting in cardiac remodeling. Underlying molecular, cellular, and interstitial changes manifest clinically as changes in size, mass, geometry, and function of the heart. Cardiac remodeling is associated with progressive ventricular dysfunction, arrhythmias, and impaired prognosis. Clinical and diagnostic notions about LBBB have evolved from a simple electrocardiographic alteration to a critically important finding affecting diagnostic and clinical management of many patients. Advances in cardiac magnetic resonance imaging have significantly improved the assessment of patients with LBBB and provided additional insights into pathophysiological mechanisms of left ventricular remodeling. In this review, we will discuss the epidemiology, etiologies, and electrovectorcardiographic features of LBBB and propose a classification of the conduction disturbance.

Transient left anterior and septal fascicular blocks after self-expandable percutaneous transcatheter aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) is indicated in severe symptomatic aortic stenosis, when there is intermediate-high surgical risk, or a condition considered inoperable, as in the case of "porcelain aorta" that could turn clamping or cannulation of the ascending aorta hazardous in open-heart surgery. Among the complications of this less invasive procedure, intraventricular conduction disorders subsequent to the procedure stand out. TAVI causes worsening of intraventricular dromotropic disorders in more than 75% of the cases, with the presence of preexisting right bundle branch block and first-degree atrioventricular block, deep prosthesis implant, male gender, size of the aortic annulus smaller than the prosthesis, and porcelain aorta being predictive of requirement for permanent pacemaker implant.

The tetrafascicular nature of the intraventricular conduction system.

The existence of a tetrafascicular intraventricular conduction system remains debatable. A consensus statement ended up with some discrepancies and, despite agreeing on the possible existence of an anatomical left septal fascicle, the electrocardiographic and vectorcardiographic characteristics of left septal fascicular block (LSFB) were not universally accepted. The most important criteria requested to confirm the existence of LSFB is its intermittent nature. So far, our group has published cases of transient ischemia-induced LSFB and phase 4 or bradycardia-dependent LSFB. Finally, anatomical, anatomopathological, histological, histopathological, electrocardiographic, vectorcardiographic, body surface potential mapping, and electrophysiology studies support the fact that the left bundle branch divides into three fascicles or a "fan-like interconnected network."

Relationship between Proinflammatory Cytokines/Chemokines and Adipokines in Serum of Young Adults with Obesity.

BACKGROUND AND OBJECTIVE: The adipose tissue has been recognized as an important endocrine organ, which is metabolically active and expresses and secretes various inflammatory cytokines. Inflammation is involved in obesity-related complications. As such, the present study investigated the correlation between biochemical parameters, serum proinflammatory cytokines and adipokines in individuals with obesity. METHODS: Based on the body mass index (BMI), 30 subjects were divided into 3 groups: eutrophic (GC, n = 10), overweight (GOW, n = 10) and obese (GOB, n = 10). Serum glucose, cholesterol (total-C, HDLC and LDL-C), triglycerides, total proteins, uric acid and insulin were determined, as well as cytokines IL-8, TNF-α, IL-1ß, and IL-6, leptin and adiponectin. RESULTS: GOB showed the highest glucose, total and LDL-C, triglycerides, uric acid, insulin, leptin, IL- 8, IL-1ß, IL-6, TNF-α and lowest adiponectin levels. In general, adiponectin exhibited an inverse correlation with BMI, abdominal circumference, LDL-C, IL-6, TNF-α, leptin and leptin-adiponectin ratio (LAR) and a positive correlation with HDL-C. Leptin was positively correlated with BMI, abdominal circumference, insulin, IL-6, TNF-α and LAR and negatively correlated with HDL-C and adiponectin. The LAR was positively correlated with BMI, waist circumference, insulin, TNF-α and negatively associated with HDL-C. CONCLUSION: The results confirm that obesity changes the lipid and glycemic profiles of individuals, increases the proinflammatory adipokine levels and reduces those of anti-inflammatory adipokines, promoting a state of chronic inflammation.

Acute coronary syndrome of very unusual etiology.

Aortitis is one of many possible manifestations of tertiary syphilis. Aortic disease is the most common of all cardiovascular syphilitic lesions. Aortic diseases caused by tertiary syphilis include aortitis, aortic root dilation, aneurysm formation, aortic regurgitation and coronary ostial stenosis. A less common manifestation of syphilitic aortitis is coronary artery ostial narrowing related to aortic wall thickening. We report a case of a 40-year-old male patient admitted with a clinical picture of acute coronary syndrome (unstable angina). He had no risk factors for coronary artery disease. The physical examination revealed nothing remarkable. The admission electrocardiogram (ECG) showed ST segment depression in the anterolateral and inferior leads (Figure 1). The coronary angiogram showed critical ostial stenosis of the right (RCA) and left main coronary artery (Figure 2a, b). Cardiac-computed tomography showed aortic wall thickening with involvement of bilateral coronary ostia (Figure 2b, c). The patient was referred for coronary bypass surgery after treatment with two doses of penicillin G. The laboratory test was strongly positive for syphilitic infection. Postoperative treatment with benzathine penicillin, in doses recommended for tertiary syphilis, was implemented.

Poincaré plot analysis of ultra-short-term heart rate variability during recovery from exercise in physically active men.

BACKGROUND: Recently there has been increasing interest in the study of ultra-short-term heart rate variability (HRV) in sports performance and exercise physiology. In order to improve standardization of this specific analysis, we evaluated the ultra-short-term HRV analysis through SD1Poincaré Index to identify exercise induced responses. METHODS: We investigated 35 physically active men aged between 18 and 35 years old. Volunteers performed physical exercise on treadmill with intensity of 6.0 km/hour + 1% slope in the first five minutes for physical "warming up." This was followed by 25 minutes with intensity equivalent to 60% of maximal oxygen consumption, with the same slope according to the Conconi threshold. HRV was analyzed in the following periods: the five-minute period before the exercise and the five-minute period immediately after the exercise, the five minutes were divided into five segments of 60 RR intervals. Ultra-short-term RMSSD and SD1 analysis were performed. RESULTS: Ultra-short-term RMSSD and SD1 were significantly (P<0.0001) reduced during the initial five minutes divided into five segments of 60 RR intervals compared to (at rest) control. Heart rate was significantly (P<0.0001) increased 1 min and 3 min immediately after exercise compared to (at rest) control. At rest ultra-short-term SD1 presented significant correlation with short-term (256 RR intervals) RMSSD (r=0.78; P<0.0001), HF (r=0.574; P=0.0007) and SD1 (r=0.78; P<0.0001). Additionally, visual analysis with the Poincaré plot detected changes in HRV after exercise. CONCLUSIONS: Ultra-short-term HRV analysis through Poincaré plot identified heart rate autonomic responses induced by aerobic exercise.

Catecholaminergic polymorphic ventricular tachycardia, an update.

Catecholaminergic polymorphic ventricular tachycardia is a rare devastating lethal inherited disorder or sporadic cardiac ion channelopathy characterized by unexplained syncopal episodes, and/or sudden cardiac death (SCD), aborted SCD (ASCD), or sudden cardiac arrest (SCA) observed in children, adolescents, and young adults without structural heart disease, consequence of adrenergically mediated arrhythmias: exercise-induced, by acute emotional stress, atrial pacing, or ß-stimulant infusion, even when the electrocardiogram is normal. The entity is difficult to diagnose in the emergency department, given the range of presentations; thus, a familiarity with and high index of suspicion for this pathology are crucial. Furthermore, recognition of the characteristic findings and knowledge of the management of symptomatic patients are necessary, given the risk of arrhythmia recurrence and SCA. In this review, we will discuss the concept, epidemiology, genetic background, genetic subtypes, clinical presentation, electrocardiographic features, diagnosis criteria, differential diagnosis, and management.

Brugada phenocopy caused by a compressive mediastinal tumor.

Recently, it has been shown that even experts in electrocardiography cannot differentiate the electrocardiographic pattern of genuine Brugada syndrome (BrS) from Brugada phenocopy (BrP). For this reason, this differentiation depends on the presence of established criteria both for BrS and BrP. In this manuscript, we present a patient with type 1 Brugada electrocardiographic pattern caused by expansive anterior mediastinal non-Hodgkin's lymphoma (NHL) with mechanical compression on the right ventricular outflow tract. The electrocardiographic pattern disappeared rapidly after antineoplastic measures.

Changes in the biochemical and immunological components of serum and colostrum of overweight and obese mothers.

BACKGROUND: Obesity in pregnancy is associated with systemic inflammation, immunological changes and adverse maternal-fetal outcomes. Information on the association between maternal obesity and breast milk composition is scarce. This study describes changes and relationships between biochemical and immunological parameters of colostrum and serum of overweight and obese women. METHODS: Colostrum and blood samples were collected from 25 normal weight, 24 overweight and 19 obese women for determination of glucose, total protein, triglycerides, cholesterol, immunoglobulins, complement proteins (C3 and C4), fat and calorie content and C-reactive protein (CRP). RESULTS: Glucose was higher in colostrum of obese women (p = .002). In normal weight and obese women, total protein content was higher in colostrum than in serum (p = .001). Serum triglycerides (p = .008) and cholesterol (p = .010) concentrations were significantly higher in overweight and obese women than in their normal weight counterparts, but in colostrum their concentrations were similar across the three groups. Secretory IgA (sIgA) in colostrum and IgA in serum concentrations were significantly higher (p = .001) in overweight and obese mothers, whereas IgG and IgM concentrations did not vary among the groups (p = .825). Serum C3 (p = .001) and C4 (p = .040) concentrations were higher in obese women. No differences in colostrum complement proteins were detected among the groups. Calorie content (p = .003) and fat (p = .005) concentrations in colostrum and serum CRP (p = .002) were higher in obese women. CONCLUSIONS: The results corroborate the hypothesis that colostrum of overweight and obese women undergoes biochemical and immunological changes that affect its composition, namely increasing glucose concentrations, calorie content, fat and sIgA concentrations.

Carnitine supplementation effects on nonenzymatic antioxidants in young rats submitted to exhaustive exercise stress.

Previous studies have demonstrated that exercise stress increases oxidative stress in rats. However, antioxidant supplement therapy effects on reactive oxygen substances are conflicting. We evaluated the effects of carnitine on renal nonenzymatic antioxidants in young rats submitted to exhaustive exercise stress. Wistar rats were divided into 3 groups: (a) control group (not submitted to exercise stress), (b) exercise stress group, and (c) exercise stress and carnitine group. The rats from group 3 were treated with gavage administration of 1 ml of carnitine (5 mg·kg⁻¹) for 7 consecutive days. The animals from groups 2 and 3 were submitted to a bout of swimming exhaustive exercise stress. Kidney samples were analyzed for reactive substances to thiobarbituric acid by malondialdehyde (MDA), reduced glutathione (GSH), and vitamin-E levels. Carnitine treatment attenuated MDA increase caused by exercise stress (1: 0.16 ± 0.02 vs. 2: 0.34 ± 0.07 vs. 3: 0.1 ± 0.01 mmmol per milligram of protein; p < 0.0001). It also increased the renal levels of GSH (1: 23 ± 4 vs. 2: 23 ± 2 vs. 3: 58 ± 9 µmol per gram of protein; p < 0.0001); however, it did not change renal vitamin E (1: 24 ± 5 vs. 2: 27 ± 1 vs. 3: 28 ± 5 µM per gram of tissue; p < 0.001). In conclusion, carnitine improved oxidative stress and partially improved the nonenzymatic antioxidant activity in young rats submitted to exhaustive exercise stress.

Peak expiratory flow values are higher in older and taller healthy male children: an observational study.

PURPOSE: Peak expiratory flow (PEF) was measured in healthy children aged five to ten years in order to provide baseline values and to determine correlations between PEF and factors such as gender, age and type of school. METHODS: After the Ethical Committee of Research in Human of the School of Medicine of ABC - FMABC approval, PEF and height were measured in 1942 children between five and ten years old from nine public schools and nine private schools throughout São Bernardo do Campo City. PEF was measured using the Mini-Wright Peak Flow Meter (Clement Clarke International Ltd.) and. height was measured using a Sanny professional stadiometer . RESULTS: Significant differences were found in values for PEF: higher values were seen in older students in comparison with younger students, in males in comparison with females and in students from private schools in comparison with public schools, with average values ranging from 206 L/min to 248 L/min,. Linear correlations were seen for PEF values with both height and age (Spearman Coefficient). CONCLUSIONS: Differences were seen for PEF between genders and between types of school, and a linear correlation was seen for PEF with both age and height in healthy children from five to ten years old.