2007;88(1) – ABC CARDIOL

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Artigo Original

Echocardiography evaluation for asymptomatic patients with severe obesity

Isaura Elaine Gonçalves Moreira Rocha et al. Edgar Guimarães Victor Maria Cynthia Braga Odwaldo Barbosa e Silva Mônica de Moraes Chaves Becker

OBJECTIVE: To study the systolic and diastolic function of asymptomatic patients with severe obesity using a Doppler echocardiography. METHODS: Thirty candidates for bariatric surgery, with an average BMI of 49.2 ± 8.8 Kg/m² and no previous history of heart disease were evaluated through transthoracic echocardiography. RESULTS: Enlarged left chambers were observed in 42.9% of the sample, diastolic dysfunction in 54.6% and left ventricular hypertrophy in 82.1%, of which 50% of the cases presented the geometric pattern of eccentric hypertrophy. Indexation of left ventricular mass to height resulted in a significantly higher number of diagnoses for hypertrophy than indexation to body surface area (p = 0.0053), demonstrating that this index is more appropriate to determine ventricular hypertrophy in obese people. Correlations between left ventricular hypertrophy with obesity duration and pressure levels were positive as well as correlations between body mass index and diastolic dysfunction indicators. CONCLUSION: This study demonstrated that echocardiograms performed on asymptomatic severely obese patients can detect alterations in the cardiac structure that are common in cases of obesity cardiomyopathy and can be associated with the development of heart failure, arrhythmias and sudden death, enabling the identification of patients with greater cardiovascular risk.

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Case Report

Abdominal mycotic aneurysm and cerebral embolic event associated with infective endocarditis in a patient with chronic rheumatic valvar disease

Bernadete Lourdes Liphaus et al. Cláudia Goldenstein-Schainberg Letícia Monteiro Kitamura Clóvis Artur Almeida Silva

We report the case of a girl with chronic rheumatic valvar heart disease who developed infeccious endocarditis and two complications, ischemic stroke due to cerebral embolic event and mycotic aneurysm of the superior mesenteric artery.

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Case Report

Right to left shunt through a patent foramen ovale without pulmonary hypertension

Thiago Costa Lisboa et al. Clarice Daniele Oliveira Costa Thiago Quedi Furian Silvia Regina Rios Vieira

This article describes a patient presenting with dyspnea and platypnea and whose only clinical finding was presence of patent foramen ovale with a right to left shunt, without pulmonary hypertension, characteristic of the rare Platypnea-Orthodeoxya Syndrome, with very interesting pathophysiological findings and with therapeutic alternatives not yet defined.

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Case Report

Patient with von Willebrand disease undergoing mitral valve repair: a strategy for the control of the coagulopathy

Ally Nader Roquetti Saroute et al. Carlos Manuel de Almeida Brandão Marco Antônio Vieira Guedes Cyrillo Cavalheiro Filho Pablo Maria Alberto Pomerantzeff

We report a case of a 60 year-old woman with von Willebrand disease type I that was submitted to a mitral valve repair. The patient needed special care due coagulopathy and needed VIII factor (VIIIf) and von Willebrand factor (vWf), before, during and after surgery. There was no complication during or after surgery. Patient is asymptomatic nine months postoperatively. The correction of VIIIf and vWf allowed the realization of a safety surgery.

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Case Report

Left atrial myxoma associated with obstructive coronary artery disease

Ronaldo Altenburg Odebrecht Curi Gismondi et al. Renato Kaufman Gabriel Ângelo de Cata Preta Correa César Nascimento … Luiz Henrique Weitzel José Oscar Brito Reis Antônio Sérgio Cordeiro da Rocha Ademir Batista da Cunha

We describe a case of a 67 year-old patient with obstructive coronary artery disease that, in the preoperative survey for inguinal herniorraphy surgery, discovered, by a two-dimensional echocardiogram, a tumor in left atrium, mobile, non-obstructive. The patient underwent a cineangiocoronariography showing severe stenosis in the left anterior descending artery, moderate stenosis in the left circumflex artery, near the origin of the first marginal branch, and a non-obstructive plaque in the right coronary artery. There was also moderate left ventricular dysfunction. After that, the patient has gone coronary artery bypass surgery and resection of the left atrial tumor. The histological exam revealed that the tumor was, in fact, a myxoma.

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Artigo Original

Cardiac and metabolic characteristics in long distance runners of sport and exercise cardiology outpatient facility of a tertiary hospital

Luciene Ferreira Azevedo et al. Patrícia Chakur Brum Dudley Rosemblatt Patrícia de Sá Perlingeiro … Antônio Carlos Pereira Barretto Carlos Eduardo Negrão Luciana Diniz Nagem Janot de Matos

OBJECTIVE: To characterize electrocardiographic and functional cardiac parameters and cardiopulmonary responses to exercise in long-distance Brazilian runners monitored at the Sport and Exercise Cardiology Outpatient Facility of a tertiary care hospital. METHODS: Of an initial population of 443 male and female athletes of different sport modalities, we assessed 162 (37%) long-distance male runners, aged from 14 to 67. Electrocardiographic (12 leads) and echocardiographic (M-mode and two-dimensional) parameters were recorded at rest. Cardiopulmonary responses were evaluated on a treadmill with a ramp protocol. RESULTS: Metabolic alterations and cardiovascular diseases were diagnosed in 17% and 9% of the runners, respectively. Sinus bradycardia and left ventricular hypertrophy were observed in 62% and 33% of the runners, respectively. Structural alterations such as ventricular cavity > 55mm, relative wall thickness > 0.44, and ventricular mass index > 134g/m2 were found in 15%, 11% and 7% of the runners, respectively. Ejection fraction < 55% was observed in 4% of the runners. Peak oxygen uptake (VO2peak) decreased as of the age of 41, although the anaerobic threshold relative to the VO2peak remained unchanged with age. CONCLUSION: Resting bradycardia and left ventricular hypertrophy are the most frequent cardiovascular adaptations in Brazilian long distance runners monitored by the Sport and Exercise Cardiology Outpatient Facility. Although VO2peak decreases after the age of 41, the relative oxygen uptake at the anaerobic threshold of these runners remained unchanged.

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Artigo Original

Clinical efficacy of percutaneous renal revascularization with stent placement in atherosclerotic renovascular disease

Janaína Andréa Altemar Gonçalves et al. Jorge Eduardo Amorim Milton Macedo Soares Neto Artur Beltrame Ribeiro Valter Correa Lima

OBJECTIVE: To evaluate the clinical efficacy of percutaneous renal revascularization with stenting to control hypertension and preserve/restore renal function in patients with atherosclerotic renovascular disease. METHODS: From May/1999 to October/2003, 46 patients with atherosclerotic renal artery stenosis (ARAS) underwent revascularization with stenting. The indication for the procedure was hypertension control and/or renal function preservation/restoration. Clinical characteristics: age range: 33-84 years (median = 58.5 ±10.7), males: 26 (56.5%), 4 (10%) patients with dia betes mellitus, 21 (46%) patients with coronary artery disease, creatinine <2.0mg/dl: 39 (64%), 6 patients (14%) with congestive heart failure, 20 (43%) patients with ostial stenosis and 15 (33%) patients with bilateral stenosis. Hypertension control was evaluated by the number of drugs used before the procedure and at follow-up (FU) and by blood pressure (BP) measurement. RESULTS: The minimum follow-up was 7 months (range of 7-52, median: 23, mean: 24.2 ± 15.2). There were no major complications. No patient experience any cardiovascular event. There was only one non-cadiac death (2%) and one technical failure in the treatment(2%). There was no serious complication in the procedure. None of the patients presented cardiovascular events. The renal function improved or stabilized in 32 patients (82%) and worsened in 4 (10%). The BP control improved in 19/44 (43,8%) patients and worsened / stabilized in 6 patients (14%). CONCLUSION: Angioplasty with renal artery stenting for ARAS showed to be an effective treatment strategy to restore and preserve renal function and to control blood pressure.

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Point of view

Symptoms and dissatisfaction: context in the quality of life of patients with valve difference

POINT OF VIEW

Symptoms and dissatisfaction. Context in the quality of life of patients with valve difference

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Correlação Anatomoclínica

Case 1/2007: enterorrhagia and shock in a 69 year-old woman with rheumatic mitral stenosis and chronic atrial fibrillation

Rafael Amorim Belo Nunes et al. Luiz Alberto Benvenuti

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Artigo Original

Prevalence and risk factors for combined coronary artery disease and aortic aneurysm

Carlos Romério Costa Ferro et al. Dinaldo Cavalcanti de Oliveira Fábio de Freitas Guimarães Guerra Alexandre Jorge de Lucena … Fabiana Piech Nunes Sergio Tranchesi Ortiz Enilton Sergio Tabosa Egito Luis Carlos Bento de Sousa Adib Domingos Jatene Leopoldo Soares Piegas

OBJECTIVE: To evaluate CAD prevalence in patients with aortic aneurysm, as well as differences related to aneurysm topographies. To describe the primary risk factors for CAD related to this association and their occasional differences according to AA topographies. METHODS: This was an open, prospective, nonrandomized study that evaluated 95 patients (66 men and 33 women, mean age 63 ± 11.8). All patients, asymptomatic for CAD, had undergone aortic CT and coronary angiography. According to the AA topography, they were classified into three groups: 1) patients with thoracic aortic aneurysm (TAA); 2) thoracoabdominal aortic aneurysm (TAAA); and 3) abdominal aortic aneurysm (AAA). A database was created to store information from clinical data and complementary examinations. Statistical analysis was performed using the Student’s t test or analysis of variance (ANOVA) for continuous variables and chi-square test for categorical variables. P values 70% and 19 (31.6%), > 50%. Fifteen patients (25%) had single-vessel disease, 11 (18%) had two-vessel disease, and 34 (57%) had three-vessel disease. CONCLUSION: Asymptomatic CAD is highly prevalent in AA patients, particularly among those with AAA. Study results suggest the need for diagnostic stratification for CAD in patients with AA, especially those with AAA.

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Severe coronary milking in obstructive hypertrophic cardiomyopathy

Jorge Humberto Guardado et al. Hélder Pereira Carlos Catarino Hugo Vinhas … Jorge Marques Manuel Carrageta

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Severe coronary milking in obstructive hypertrophic cardiomyopathy

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Clinical Update

The concept of crosstalk and its implications for cardiovascular function and disease

Igor Calil et al. Rafael Angelo Tineli Walter Vilella de Andrade Vicente Alfredo José Rodrigues Paulo Roberto Barbosa Evora

CLINICAL UPDATE

The concept of crosstalk and its implications for cardiovascular function and disease

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Artigo Original

Assessment of a short food frequency questionnaire as predictor of hypercholesterolemia in adolescents

Márcia Henriques Teixeira et al. Gloria Valeria da Veiga Rosely Sichieri

OBJECTIVE: To evaluate a short questionnaire as predictor of serum cholesterol obtained from a probabilistic sample of adolescents. METHODS: A probabilistic sample of 5th to12th grade students from state public schools in Niteroi, state of Rio de Janeiro, Brazil was drawn based on 28 classes. Five hundred seventy-seven subjects had their blood collected, and 539 answered the simplified questionnaire (23.7% of non-respondents). The questionnaire internal consistence was evaluated through Cronbach’s alpha, and agreement between cholesterol levels and food intake was assessed through weighted Kappa (Kw). RESULTS: Weighted Kappa value was very low ( 0.66). CONCLUSION: The results show that the short questionnaire was not a predictor of cholesterol concentration.

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Artigo Original

Bone healing in drill hole defects in spontaneously hypertensive male and female rats' femurs: a histological and histometric study

Andresa Costa Pereira et al. Raquel Guedes Fernandes Yasmin Rodarte Carvalho Ivan Balducci Horácio Faig-Leite

OBJECTIVE: The aim of this study was to evaluate the bone healing in spontaneously hypertensive rats (SHR) and compare the results with normotensive rats, evaluating male and female animals. METHODS: A bone drill defect was created in the left femur of 24 SHR (12 males and 12 females) and 24 normotensive rats (12 males and 12 females). The animals were divided into two groups and sacrificed 7 and 21 days after the surgical procedure. After the routine laboratory processing, histological and histometric analysis were carried out and data were submitted to ANOVA and Tukey’s test (5%). RESULTS: Males and females from the same group had similar histological characteristics. After seven days, all animals presented irregular bone trabeculae. The periosteal osteoblasts were flattened in SHR, and presented a cuboid shape in normotensive animals. After 21 days, the bone defects of all specimens showed a linear closure in all the superficial extension. In addition, SHR presented flattened osteoblasts surrounding the bone trabeculae, while normotensive ones showed cuboidal cells. Statistical analysis of the histometric data indicated similar means between the male and female groups, except for normotensive rats on day 7. In addition, a larger amount of new bone formation was observed in hypertensive when compared to normotensive rats on day 21, in males as well as females. CONCLUSION: We conclude that bone healing in SHR was more significant than in normotensive ones, as shown by the histological and histometric evaluation 21 days after surgery.

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Artigo Original

Feasibility, safety and accuracy of dobutamine/atropine stress echocardiography for the detection of coronary artery disease in renal transplant candidates

Pedro Antonio Muniz Ferreira et al. Valter Correia de Lima Orlando Campos Filho Manuel Adan Gil … Adriana Cordovil Cristiano Vieira Machado José Osmar Medina Pestana Antonio Carlos de Camargo Carvalho

OBJECTIVE: To evaluate the feasibility, safety and accuracy of dobutamine/atropine stress echocardiography (DASE) for the detection of coronary artery desease (CAD) in renal transplant candidates. METHODS: Patients candidates to renal transplant were submitted consecutively to DASE and coronary angiography. The adopted angiographic criteria for CAD were an obstructive lesion of > 50% and > 70%. RESULTS: 148 patients underwent the DASE and the coronary angiography. Mean age was 52 ± 9 years, 69% of the patients were males; 27% had diabetic nephropathy and 73% had LVH; 63% were asymptomatic; 36% and 22% presented coronary obstructions > 50% and 70%, respectively. The DASE performance was 91% and major complication rate was 2.7%. The sensibility, specificity and accuracy for the diagnosis of coronary obstruction > 50% were 53% (CI:45-61), 87% (CI:81-93), and 75% (CI:63-83) respectively. For coronary obstruction > 70% these values were, respectively, 71% (CI:64-92), 85% (CI:79-91) and 81% (CI:75-87). The sensibility to detect univessel and multivessel disease was 41% (CI:19-63) and 78% (CI:64-92), respectively. CONCLUSION: The DASE was practical and safe; however, it presented a poor result for the detection of CAD regarding obstructions > 50%. It can be a useful screening for the detection of CAD in candidates with obstructions > 70% and multivessel disease.

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Artigo Original

Non-invasive estimate of cardiac output during exercise based on impedance cardiography and oxygen uptake in the elderly

Maurício Nunes Rodrigues et al. Jacques Henri-Paul Vanfraechem Paulo de Tarso Veras Farinatti

OBJECTIVE: This study assessed the agreement between cardiac output (Q) measurements generated by two indirect methods and their applicability in 54 men e 77 women (aged 60-90). METHODS: The subjects performed a cardiopulmonary test with incremental to maximal exercise on a cycle-ergometer. “Q” was estimated based on oxygen uptake and on impedance cardiography at 50% and 100% of the maximal workload (Wmax) reached during the test. The limits of agreement and mean differences (biases) were estimated using the methodology proposed by Bland-Altman, whereas the relationship between the methods was analyzed by linear regression and intra-class correlation (ICC). RESULTS: For the load equivalent do 50% of Wmax, the bias between the means of the two methods was -0.58 L•min-1 (6.3% smaller for the impedance measurement) and the limit of agreement was ± 2.54 L•min-1 (24.7%). At 100% of Wmax, the bias was 1.03 L•min-1 (8.5% greater for the impedance measurement) with a limit of agreement of ± 3.35 L•min-1 (27.6%). ICC values and the regression curves obtained between the methods were: Qimp=1.82+0.75Q VO2 (r²=0.765, p<0.001; ICC=0.727, p<0.01) at 50% Wmax; and Qimp=0.93+1.00Q VO2 (r²=0.755, p<0.001; ICC=0.796, p<0.01) at 100% Wmax. CONCLUSION: These results suggest that there is a good agreement between the two methods for the measurement of Q during exercise in the elderly, which is compatible with the findings of similar studies with young subjects.

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Artigo Original

Unstable angina patients treated with percutaneous coronary intervention in the new millennium: what characterizes them?

Daniele da Silva Peixoto et al. Luiz Fernando Leite Tanajura Amanda G. M. R. Sousa Marinella Patrizia Centemero … Áurea Jacob Chaves Júlio de Paiva Maia Alberto Gomes Taques Fonseca Luiz Alberto Piva e Mattos Fausto Feres José Eduardo M. R. Sousa

OBJECTIVE: To identify clinical and angiographic profiles of patients with unstable angina seen at a tertiary hospital and treated with percutaneous coronary intervention (PCI). METHODS: Study of a consecutive series of 1413 patients, selected from a computerized database, who underwent percutaneous revascularization in the three-year period of 2002-2004. There were no inclusion/exclusion criteria. RESULTS: Systemic arterial hypertension (74%) and hypercholesterolemia (65%) were the classical risk factors for coronary disease most frequently observed. Coronary artery bypass grafting and history of myocardial infarction were found in 24% and 28% of the cases, respectively. The subgroups most commonly treated were the IIB (48%) and IIIB (28%). Clopidogrel was prescribed for 51% of the patients and glycoprotein IIb/IIIa inhibitors, for 7%. Multivessel disease evidenced by coronary angiography was detected in 42% of the cases. Type B2 or C lesions were treated in 64%, 94% of which in native vessels. Restenotic lesions were dilated in 5% of the patients. All interventions were performed using coronary stents, the majority of which (67%) were standard bare-metal stents. CONCLUSIONS: 1) Subgroups IIB and IIIB were the most frequently treated (76%); 2) Clopidogrel was the most prescribed antithrombotic agent (51%); 3) Multivessel coronary artery disease was found in 42% of the cases, most of which were complex target lesions located in native vessels; 4) Coronary stent implantation was the chief dilation technique used.

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Artigo Original

Cardiovascular rehabilitation of patients with ischemic heart disease undergoing medical treatment, percutaneous transluminal coronary angioplasty, and coronary artery bypass grafting

Tales de Carvalho et al. Ana Luiza Hallal Curi Dalton Francisco Andrade Julio da Motta Singer … Magnus Benetti Alfredo José Mansur

OBJECTIVE: To evaluate the occurrence of death and myocardial infarction in subgroups of coronary artery disease patients with hemodynamically significant coronary stenoses undergoing treatment in a cardiovascular rehabilitation program and considered severely ill for: a) not having undergone intervention treatment; b) presenting signs of myocardial ischemia; c) presenting multivessel occlusive disease. METHODS: Retrospective cohort study of 381 patients presented previous coronary angiography showing hemodynamically significant coronary stenoses, for which, because of the anatomic bias, intervention treatment was indicated. The patients were categorized according to the presence or absence of intervention treatment; presence or absence of ischemia in the exercise test; and number of critical coronary stenoses. Statistical analysis was performed using the Kaplan-Meier and logistic regression methods. RESULTS: Survival probability was not different when patients undergoing medical treatment were compared to those undergoing previous intervention treatment (OR 0.813; 95% CI; 0.366-1.809); with and without evidence of ischemia in the exercise test (OR 0.785; 95% CI; 0.366-1.684); and with one-vessel coronary artery disease and with more-than-one-vessel coronary artery disease (OR 0.824, 95% CI; 0.377-1.798). CONCLUSION: In this cohort study, no unfavorable outcome was observed in the subgroups comprised of medically treated patients, with evidence of myocardial ischemia and with multivessel coronary artery disease.

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Review Article

Cardiorenal intersection: crossroads to the future

Peter A. McCullough

REVIEW ARTICLE

Cardiorenal intersection: crossroads to the future

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Artigo Original

Vegetarian diet and cholesterol and triglycerides levels

Simone Grigoletto De Biase et al. Sabrina Francine Carrocha Fernandes Reinaldo José Gianini João Luiz Garcia Duarte

OBJECTIVE: Compare levels of triglyceride (TG), total cholesterol (TC), low density lipoprotein (LDL) and high density lipoprotein (HDL) among vegetarians and omnivores. METHODS: Blood samples were collected from 76 individuals – both males and females – separated in four different diet groups: omnivores, lacto-ovo vegetarians, lacto vegetarians, and restricted vegetarians (or vegans). Dosing was done for: TC, LDL, HDL and TG. RESULTS: Significant difference was reported for TC, LDL and TG levels among the samples. Higher levels were reported by omnivores, with decreased levels for vegetarians as animal products were restricted, with lowest levels having been reported by vegans. Mean and standard deviation for TC were 208.09 ± 49.09 mg/dl in the group of omnivores, and 141.06 ± 30.56 mg/dl in the group of vegans (p < 0.001). LDL values for omnivores and vegans were respectively: 123.43 ± 42.67 mg/dl and 69.28 ± 29.53 mg/dl (p < 0.001). As for TG, those values were 155.68 ± 119.84 mg/dl and 81.67 ± 81.90 mg/dl (p < 0.01). As for HDL level no difference was reported between the samples, but HDL/TC ratio was significantly higher in vegans (p = 0.01). CONCLUSION: Vegetarian diet was associated to lower levels of TG, TC and LDL as compared to the diet of omnivores.

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Artigo Original

Comparison between international normalized ratio using a portable device and conventional methodology

Luciana Pereira Almeida De Piano et al. Célia Maria Cássaro Strunz Antonio de Pádua Mansur Roberto Abi Rached

OBJECTIVE: to compare the international normalized ratio (INR) measured by a point-of-care (POC) testing device with that measured by the conventional method in patients undergoing anticoagulation therapy with warfarin sodium. METHODS: The INR of 383 warfarin-treated patients (mean age: 56.5 years; 207 female) was measured in capillary blood using the Hemochron Jr. device and compared with that of venous plasma samples determined by the conventional method performed in a Coag-A-Mate analyzer. Results were evaluated globally and for the following subgroups: INR 3.5. RESULTS: Using both methods, the comparison between INR values yielded a correlation coefficient (r) of 0.86. However, mean differences in INR in both tests, considering the three subgroups, proved to be statistically significant (p <0.001): 0.14 ± 0.21 (INR< 2.0); 0.54 ± 0.31 (2.0 < INR 3.5). Paired Student’s t-test analysis revealed a p value < 0.001 for the three subgroups studied. CONCLUSION: The use of point-of-care testing for monitoring oral anticoagulation has some limitations. Anticoagulation intensity was underestimated by this method in the three subgroups studied.

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Artigo Original

Analysis of ventilation and hemodynamic changes resulting from noninvasive bilevel pressure mechanical ventilation applied to patients with congestive heart failure

Ariadne Fernandes de Barros et al. Luciana Costa de Barros Márcia Cristina Sangean Joaquim Minuzo Vega

OBJECTIVE: To observe in practice how noninvasive bilevel positive pressure, applied at different levels, may interfere with systolic arterial pressure (SAP), diastolic arterial pressure (DAP), mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR), and peripheral oxygen saturation (SpO2), in patients with congestive heart failure (CHF). METHODS: Fourteen CHF patients (mean age 62.85 years) were treated with noninvasive bilevel mechanical ventilation. Patients were consecutively treated with an expiratory positive airway pressure (EPAP) of 5 cmH2O, 10 cmH2O, 15 cmH2O, 10 cmH2O, and 5 cmH2O, maintaining a variation in pressure (deltaP) of 5 cmH2O between the inspiratory pressure (IPAP) and the expiratory pressure (EPAP). Ventilation and hemodynamic data were collected at these time points, as well as 5 minutes before the beginning of the protocol and 5 minutes after its completion. RESULTS: A statistically significant difference was observed in the respiratory rate between the moment just before the beginning of the protocol and 5 minutes after positive pressure mask placement (p=0.022), and in oxygen saturation, between the final minute of EPAP at 5 cmH2O and after the removal of the mask (p=0.05). CONCLUSION: Noninvasive bilevel mechanical ventilation improves oxygenation and reduces respiratory work, thus being beneficial for patients with congestive heart failure. It was not possible to observe statistically significant changes in the hemodynamic data due to the small number of patients and to other associated heart diseases.

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Kawasaki disease: giant coronary arteries aneurysms regression and later stenosis

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Kawasaki disease: giant coronary arteries aneurysms regression and later stenosis

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Three-dimensional transesophageal echocardiographic imaging of mitral valve bioprosthesis leaflets perforation due to infective endocarditis

Marcelo Luiz Campos Vieira et al. Pablo M. A. Pomerantzeff Carlos M. Brandão Max Grinberg … Wilson Mathias Junior José A. F. Ramires

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Three-dimensional transesophageal echocardiographic imaging of mitral valve bioprosthesis leaflets perforation due to infective endocarditis

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