An unusual case of stabbing chest pain literally: a case report.

Background: Cardiac surgery is associated with a significant risk of potential postoperative complications. We describe a case of a patient with an unusual late cardiac perforation caused by a needle used to fix temporary epicardial pacing wires to the skin, which slowly migrated across subcutaneous tissues for 2 years following postoperative period. Case summary: We report a case of middle-aged woman admitted to the cardiac intensive care unit due to suspected acute myocardial infarction. Multimodality imaging revealed the presence of an unusual intracardiac foreign body, located inside the interventricular septum and perforating towards the left atria, complicated by a small intracardiac fistula between septal coronary branches and the right ventricle. Analysis of previous examinations revealed that a needle used to fix temporary epicardial pacing wires to the skin had been left inside the patient, beneath the level of the diaphragm, after cardiac surgery in 2018. This foreign body slowly migrated across the diaphragm, towards the mediastinum, finally lodging inside the heart, after a period of 3 years. The patient was referred to cardiac surgery for foreign body retrieval. Discussion: We describe an unusual case of cardiac perforation caused by a needle used to fix these wires to the skin, which migrated across subcutaneous tissues and finally lodged inside the basal interventricular septum and left atria. Full compliance with standardized surgical care bundles, as well as the implementation of a structured incident reporting system, is of upmost importance to prevent postoperative complications and improve surgical care.

Iatrogenic Complications During the Diagnostic Work-Up of an Inflammatory Cardiomyopathy

Abstract A 72-year-old woman was admitted for acute heart failure. The echocardiography revealed moderate depression of the left ventricular ejection fraction. Coronary disease was excluded by coronarography. Cardiac magnetic resonance showed predominantly left ventricular septal hypertrophy and severe depression of the left ventricular systolic function. There was also a bright, multifocal and patchy late gadolinium enhancement with subendocardial, mesocardial and subepicardial involvement, suggestive of sarcoidosis. Biochemical study, thoracic computed tomography and positron emission tomography were inconclusive for extra-cardiac sarcoidosis. Therefore, an endomyocardial biopsy was performed. The procedure was complicated by the development of complete atrioventricular block, requiring implantation of a cardiac resynchronization pacing device. A few days after device implantation, the patient developed fever. The echocardiography revealed extensive vegetations, and thus the diagnosis of a device-associated infective endocarditis was made. Even though antibiotic therapy was promptly started, the patient ended up dying. Biopsy results revealed lymphocytic myocarditis. This case is paradigmatic because it shows how the etiologic diagnosis of dilated cardiomyopathy can be challenging. Non-invasive diagnostic exams may not provide a definite diagnosis, requiring an endomyocardial biopsy. However, the benefits versus risks of such procedure must always be carefully weighted.

Double coronary thrombosis in a patient with Behçet's disease.

Behçet's disease is a chronic relapsing multisystem autoinflammatory condition, in which cardiac involvement is rare, but among the most life-threatening complications. Treatment is largely empirical, and is aimed at suppressing vasculitis. In this role glucocorticoids and colchicine are frequently used. We present the case of a 42-year-old male with previously diagnosed Behçet's disease presenting to our emergency department with an anterior-inferior STEMI. He presented combined thrombosis of the distal anterior descending coronary artery and proximal right coronary artery, and was treated with sequential primary percutaneous coronary interventions and implantation of drug-eluting stents, but required two interventions due to high thrombotic load. His clinical course during hospitalization was good, with no systolic dysfunction at discharge. During follow-up, he has so far had no new cardiovascular events.

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.

Short- and medium-term prognosis of Takotsubo syndrome in a Portuguese population.

INTRODUCTION: Takotsubo syndrome (TTS) is characterized by transient left ventricular (LV) systolic dysfunction. AIM: To characterize a Portuguese population with TTS and to determine their short- and medium-term prognosis. METHODS: We conducted a multicenter study in Portuguese hospitals that included all patients diagnosed with TTS, initially retrospectively and subsequently prospectively. Short- and medium-term clinical complications and mortality were assessed. Independent predictors of in-hospital complications and prognostic factors were determined. RESULTS: A total of 234 patients (210 female, age 68±12 years) were included. During hospitalization, 32.9% of patients had complications: acute heart failure (24.4%), atrial fibrillation (9.0%), ventricular arrhythmias (2.6%), complete atrioventricular block (2.1%), stroke/transient ischemic attack (1.7%), and LV thrombus (1.3%). Chronic kidney disease (CKD) (p=0.02), coronary artery disease (CAD) (p=0.027), lower LV ejection fraction (LVEF) on admission (p=0.003), and dyspnea at presentation (p=0.019) were predictors of in-hospital complications. In-hospital mortality was 2.2%. At the mean follow-up of 33±33 months, all-cause mortality was 4.4%, cardiovascular mortality was 0.9% and TTS recurrence was 4.4%. Prolonged QTc interval on admission was associated with complications in follow-up (p=0.001). CONCLUSION: TTS has a good short- and medium-term prognosis. However, the rate of in-hospital complications is high and should not be overlooked. Dyspnea at presentation, CKD, CAD and lower LVEF on admission were independent predictors of in-hospital complications. Prolonged QTc on admission was associated with complications in follow-up.

Septic Shock of Unknown Origin: A Case Report of a Pseudoaneurysm of the Mitral-Aortic Intervalvular Fibrosa.

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa (P-MAIVF) is a rare complication of infective endocarditis and trauma, particularly of aortic valve surgery. Clinical symptoms are usually unspecific and generally due to complications. Transesophageal echocardiography (TEE) is the most commonly used exam to diagnose P-MAIVF. The main echocardiographic feature is the presence of a cavity communicating with the left ventricular outflow tract that expands during systole and collapses during diastole. Most frequent complications are formation of a fistulous tract and compression of adjacent structures. Surgical correction is usually the treatment of choice. The authors describe a case of a female patient with a septic shock of unclear origin. After antibiotic therapy and organ-supporting measures without apparent improvements, a TEE revealed infective endocarditis, complicated with P-MAIVF. Despite adequate treatment, the patient did not survive for long enough to be submitted to surgical repair.

Silent cardiac tumor with neurological manifestations.

Atrial myxoma is rare and can be completely asymptomatic. However, an untreated myxoma may result in catastrophic events. Diagnosis is usually suggested by echocardiography, and other imaging modalities can add important information. Myxoma can be cured surgically, and histological analysis usually gives the definite diagnosis. This article describes the case of a 61-year-old woman whose clinical presentation of an atrial myxoma was a stroke. Echocardiographic findings were highly suggestive of a cardiac myxoma. However, cardiac magnetic resonance showed unusual features for myxoma, since the mass was hyperintense in T1-weighted images and hypointense in T2-weighted sequences. Histology confirmed myxoma and the patient was surgically treated. This case enhances the importance of multimodality imaging in the differential diagnosis of cardiac masses. .

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.

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.