Reativação de Chagas no primeiro ano de transplante cardíaco / Chagas reactivation in the first year of heart transplantation

FUNDAMENTO: A doença de Chagas está entre as três principais indicações de transplante cardíaco no Brasil. Apesar de sua prevalência expressiva, principalmente nos casos avançados de insuficiência cardíaca, permanecem escassos os dados sobre seu comportamento clínico pós transplante. Durante o período de seguimento, é mandatória a monitorização dos valores séricos do Tripanozoma cruzi, seja por PCR ou biópsias, visando diagnóstico precoce de reativação. A depender do imunossupressor utilizado, a incidência da reativação varia entre 19,6% a 90%, sendo mostrado em um estudo maior associação com uso de micofenolato mofetil (MMF), com apresentação clínica igualmente variável. RELATO DE CASO: Paciente do sexo feminino, 62 anos, submetida a transplante cardíaco em julho de 2022, devido miocardiopatia chagásica. Estava em acompanhamento ambulatorial, em uso de terapia imunossupressora com tracrolimus 1mg/dia, micofenolato de sódio 720mg/dia e prednisona 20mg/dia. Em janeiro de 2023, paciente compareceu em consulta com queixa de pequena lesão cutânea ulcerada em glúteo e dosagem de PCR para citomegalovirus (CMV) negativa. Em fevereiro, persistia com lesão evolutivamente pior, quando iniciou quadro progressivo de hiporexia, dor abdominal e náuseas, associado injúria renal aguda, elevação de troponina e NT-proBNP. Foi então internada devido à hipótese de rejeição aguda do enxerto associada a infecção cutânea. O ecocardiograma não demonstrou piora da função ventricular, porém os PCR séricos para CMV e Chagas foram positivos. Além disso, foi realizada biópsia de lesão glútea demonstrou infiltrado eosinofílico e células ovaladas sugerindo forma livre do Trypanossoma cruzi. Chamava atenção linfopenia persistente, sendo suspenso micofenolato de sódio. A paciente recebeu tratamento com ganciclovir e benzonidazol, apresentando melhora clínica e laboratorial, incluindo da lesão cutânea. DISCUSSÃO E CONCLUSÃO: A reativação do T. Cruzi está associado à imunossupressão excessiva, onde a resposta linfocitária T helper 1 está comprometida. Existe uma maior associação com reativação quando o MMF está na prescrição. Os sintomas costumam ser similares a fase aguda da doença de Chagas, com artralgia, mialgia, febre, hiporexia, além de miocardite e meningoencefalite. O acometimento cutâneo se torna um desafio diagnostico devido seu alto grau de polimorfismo na apresentação. O diagnóstico pode ser feito através de PCR sérico, biópsias cutâneas de lesões ou miocárdicas. O tratamento com benzonidazol 2,5-5mg/kg/dia por 60 dias costuma ser eficaz. O uso profilático é controverso. Quando reconhecida e prontamente tratada, a mortalidade é menor que 1%. Palavras-chave: transplante cardíaco; Chagas; reativação; doença de Chagas.

Fungal endocarditis: what is the best time for surgery? The role of a heart team

Fungal endocarditis is an uncommon affliction with high mortality rate; it represents 2% of infectious endocarditis cases with a mortality rate of about 50% and many times diagnosed post-mortem.¹² It most frequently affects an adult's aortic or mitral valves. Standardized treatment requires antifungal therapy associated with surgical treatment.³ If there is an uncontrolled fungal infection, an early valvular replacement is recommended (<7 days). Patients that have received only medical treatment have a 100% mortality rate.² 78-year-old male, diabetic, with a previous bioprosthetic aortic valve replacement due to severe aortic stenosis, attended the emergency department with fever for the past two months, initially once a week and recently twice daily, associated with nonspecific unwellness and chills. He brought transthoracic echocardiogram that suggested prosthetic valve endocarditis. The patient was hospitalized. Blood cultures were taken and a transesophageal echocardiogram done, which showed typical vegetation annexed to the prosthetic's aortic ring (7x7mm) with mobile component projecting out of the left ventricle and restricting the opening of the prosthetic valve in this region, causing an increase of its gradients. A multi-sensitive Candida parapsilosis was shown in the blood cultures and then Anidulafungin 200mg/day was initiated for an estimated 42-day treatment.The case was discussed with Heart Team because of the high surgical risk and the early need of valve replacement. Initial course of action had us schedule surgery for the seventh day of the antifungal treatment. Patient maintained daily fever and blood cultures were collected every 72h showing increase in Candida parapsilosis in all samples and surgery was sped up.The patient was submitted to a bioprosthetic aortic valve replacement with amplification of the ring due to the presence of abscess evidenced in mid-surgery. The patient was admitted in critical condition to the ICU, hemodynamically unstable in use of ascending vasoactive drugs, in vasoplegic shock with refractory septic component. The patient remained refractory to instituted measures evolving to death 24h after surgery. Fungal endocarditis is a rare but extremely serious condition, and a multidisciplinary approach is extremely important. Discussing a case of reoperation with high surgical risk with all those responsible for the care is the role of Heart Team and was essential to decide the best time for the surgery.

Case report: an unexpected case of minoca in a 56-year-old male with myocardial bridge

INTRODUCTION: A myocardial bridge (MB) is typically asymptomatic, but sometimes can lead to a myocardial infarction with several mechanisms such as: coronary spasm, thrombosis, coronary dissection, or the development of focal atherosclerosis immediately proximal to the MB. Sometimes more than one mechanism can be present. The use of intracoronary images modalities, as Optical Coherence Tomography (OCT) in patient with MB can accurately define the mechanism of the myocardial infarction and provide further guidance to management strategy. CASE REPORT: 56-yearold male with past medical history of systemic arterial hypertension and active tobacco use, attended the emergency department with severe oppressive chest pain after a long car trip in the heat. The initial electrocardiogram showed ST-elevation in anterior leads. Coronary angiography revealed a myocardial bridge with a systolic constriction of more than 90% in the proximal third of the left anterior descending artery (LAD), OCT demonstrate a lesion < 20% with no signs of rupture. The patient was diagnosed with MINOCA with multiple mechanisms such as supply and demand imbalance, cigarette-induced vasospasm and hypovolemia. The patient was treated with beta blockers and antiplatelet therapy and discharged 3 days later. There was no recurrence of chest pain at follow-up appointments. CONCLUSION: Myocardial bridge (MB) is a congenital anatomic anomaly whereby a length of the artery tunnels beneath a section of myocardium. It can potentially be associated with phasic arterial spasm and ischemia. About 67-98% of cases have their anatomical location in the LAD. The gold standard for diagnosis is autopsy, but angiography and OCT provides more information about MBs, such as assessment of vulnerable plaque and coronary morphology. Unlike classic atherosclerotic plaque that produces a fixed stenosis, MB produces a dynamic effect that varies with cardiac cycle, heart rate, and sympathetic tone. According to the classification by Schwarz 2009, this case is classified as type C, with altered intracoronary hemodynamics. The clinical management was maintained with pharmacological therapy, which is the mainstay treatment. Angioplasty would be suggested only for cases with refractory symptoms. The patient was conducted with medications for management of heart failure and general orientation, with no recurrence of chest pain.

Aneurysmal dilation of the coronaries: a case series

Aneurysmal dilation of the coronaries arteries has a prevalence rate between 1-3% (1). It can be classified in aneurism or ectasia. The first, defined as a focal dilation of about 1.5x the normal diameter and the second as a diffuse dilation The right coronary is the most targeted with 40% of cases, followed by 32% of the left anterior descending (2). Fifty percent are associated with atherosclerosis, the rest is caused by congenital anomalies and inflammatory diseases, such as Kawasaki`s (1). Most are clinically silent and are only detected incidentally during coronary angiography or computed tomography. Due to the lack of evidence, management is challenging. Usually, these patients are more susceptible to presenting complications like local thrombosis, distal embolization and myocardial infarction (5). The use of anticoagulants in the context of the acute coronary syndrome (ACS) is implicated in the reduction of major adverse cardiovascular events (MACE) in observational studies. Similar evidence sustains the use of dual antiplatelets (2,4). We present here a serie of 9 cases with aneurysm/coronary ectasia with median follow up of 3,5 years. All 9 patients had Myocardial infarction with non-obstructive coronary artery, 7 with ST-Elevation, due to aneurysm/coronary ectasia, of which 6 were men and 3 women, median age 54,5 years. Two patients had a family history of early coronary artery disease and previous infarction. Three patients had diabetes, history of smoking and obesity. Four patients were dyslipidemic and six had history of hypertension. One patient had atrial fibrillation/Flutter. The ejection fraction ranged from 40 to 60%, with an average of 52.7%. In the treatment, all patients were using statins and beta-blockers. Regarding antiplatelet and anticoagulation of these patients, 2 were using warfarin associated with P2Y12 inhibitors (iP2Y12), 1 was using warfarin alone, 1 was using direct-acting oral anticoagulant alone, 1 was using aspirin alone, 1 was using warfarin associated with aspirin and iP2Y12, and 2 used aspirin associated with iP2Y12. One of the patients evolved with dyspneia and 3 with angina. Three patients had another ACS. No deaths were recorded. Aneurysmal dilation of coronary vessels is a challenging and misdiagnosed entity, with lack of evidence, supporting an individualized management.

Infarto agudo do miocárdio como complicação de mixoma atrial / Acute myocardial infarction as a complication of atrial myxoma

INTRODUÇÃO: Os mixomas são as neoplasias cardíacas primárias mais comuns. Geralmente se apresentam com sintomas de doença valvar mitral ou de eventos tromboembólicos. Apesar de mais frequentes em mulheres, os homens apresentam maior probabilidade de apresentar evidências de embolização. A incidência de embolização está associada a tamanhos menores (≤4,5 cm). Embora a embolização sistêmica seja frequente, o envolvimento da artéria coronária, levando a sua oclusão e consequentemente infarto agudo do miocárdio (IAM), é extremamente raro. OBJETIVO: Descrição de uma série de casos de associação de mixomas com IAM por embolização coronariana. MÉTODOS: Análise retrospectiva de prontuários de hospital terciário de Cardiologia, dos últimos 38 anos. Foram avaliados 138 pacientes portadores de mixomas. RESULTADOS A associação de mixoma atrial com evento coronariano foi evidenciado em 3 pacientes, do sexo feminino, de 28, 47 e 48 anos. A apresentação clínica inicial foram sintomas de insuficiência cardíaca em 1 paciente; as outras duas eram assintomáticas. A ressonância magnética cardíaca (RMC) definiu realce tardio de padrão coronariano com acometimento transmural e redução significativa da fração de ejeção nas três pacientes. Os mixomas tinham grandes dimensões, o menor com 4,5 cm de diâmetro. As principais características dos eventos estão descritas na tabela1. CONCLUSÃO: A ocorrência de embolização coronária na evolução dos mixomas deve ser lembrada e pesquisada, principalmente nos pacientes que têm redução de fração de ejeção. A ausência de sinais e sintomas específicos dificulta o diagnóstico e retarda o tratamento. Estes achados sugerem a recomendação do tratamento cirúrgico precoce e anticoagulação assim que o diagnóstico de mixoma for feito para prevenção das complicações embólicas.

Morbidity in extreme low birth weight newborns hospitalized in a high risk public maternity / Morbidade em recém- nascidos prematuros de extremo baixo peso em unidade de terapia intensiva neonatal

Abstract Objectives: to determine the prevalence of the most common morbidities in extremely low birth weight (ELBW) infants hospitalized in a newborn intensive care unit (NICU) and to evaluate the influence of these morbidities through the length of in-hospital stay. Methods: observational, longitudinal, prospective and analytical study in a high risk reference maternity NICU from Sergipe, realized with 158 ELBW infants admitted between March 2014 and April 2015. The analysis of the hospitalization time was realized through the Kaplan-Meier method. Results: the average weight of premature was 785,2g ± 138,2g. The gestational age vary from 22 to 35 weeks and the average was 26,8 weeks. Of those admitted at NICU, sixty three (39,9%) were discharged and 95 (60,1%) died. The time of hospitalization was influenced for morbidities as: patent ductus arteriosus (PDA), intraventricular hemorrhage and sepsis. Acute respiratory distress syndrome was the most common complication (157 - 99,4%). The incidence of persistent arterial duct, intraventricular hemorrhage, sepsis, hypothermia, hypoglycemia and retinopathy of prematurity was 39,2%, 17,1%, 32,3%,50,3%, 52,3% e 16,6% respectively. Conclusions: the morbidities from respiratory tract, cardiac, neurological and infectious were the most prevalent, whilst PDA, intraventricular hemorrhage and sepsis were the morbidities that significantly influenced the time of hospitalization.

Resumo Objetivos: determinar a prevalência das morbidades mais comuns em recém-nascidos de extremo baixo peso (RNEBP) internados em uma unidade de terapia intensiva neonatal (UTIN) e avaliar a influência dessas morbidades no tempo de internamento. Métodos: estudo observacional, longitudinal, prospectivo e analítico, na UTIN de uma maternidade publica referência em alto risco do estado de Sergipe, realizado com 158 RNEBP admitidos no período de março de 2014 a abril de 2015. A análise do tempo de internamento foi realizada através do método Kaplan- Meier. Resultados: os RNEBP apresentaram médio de 785,2g ± 138,2g. A idade gestacional variou entre 22 e 35 semanas e média de 26,8 semanas. Dos admitidos na UTIN, 63 (39,9%) receberam alta e 95 (60,1%) tiveram óbito como desfecho. O tempo de internamento foi influenciado por morbidades como: persistência do canal arterial (PCA), hemorragia intracraniana e sepse. Síndrome do desconforto respiratório foi a morbidade mais comum 157 (99,4%). A incidência de persistência do canal arterial, hemorragia intraventricular, sepse, hipotermia , hipoglicemia e retinopatia da prematuridade foi de 39,2%, 17,1%, 32,3%,50,3%, 52,3% e 16,6%respectivamente. Conclusões: as morbidades do aparelho respiratório, cardíacas, neurológicas e infecciosas foram as mais prevalentes, enquanto a PCA, hemorragia intracraniana e sepse foram as morbidades que influenciaram significativamente o tempo de internação.