2007;88(4) – ABC CARDIOL

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Artigo Original

Effectiveness of the Amplatzer ™ device for transcatheter closure of an ostium secundum atrial septal defect

Cristiano Oliveira Cardoso et al. Raul Ivo Rossi Filho Paulo Renato Machado Lisia M. Galant François … Estela S. K. Horowitz Rogério Sarmento-Leite

OBJECTIVE: To evaluate the effectiveness of the Amplatzer™ septal occluder in the treatment of ostium secundum atrial septal defects (OS ASDs). METHODS: Retrospective cohort study conducted between November 1998 and September 2005 involving 101 OS ASD transcatheter occlusion procedures in our institution. All procedures were conducted in the hemodynamic laboratory under general anesthesia with transoesophageal echocardiographic monitoring (TEE). Clinical and echocardiography assessments of the patients were conducted at 30 days, six months and on an annual basis. The results are presented as averages, standard deviations and percentages. Event-free survival was estimated using the Kaplan-Meier curve. RESULTS: From the 101 patients, 60 (59.4%) were females. Mean age, weight, height, body mass index and body surface area were, respectively: 24.3 ± 18.31 years, 51.88 ± 23.76kg, 140.59 ± 39.3cm, 23.18 ± 18.9kg/m² and 1.24 ± 0.21m². The prevalence of interatrial septum aneurysms was 4.95%, and 98 cases had an isolated defect. ASD diameters were 21.47 ± 6.96mm using an angiography and 21.22 ± 7.93 mm using a TEE. The average size of the implanted devices was 23.92 ± 7.25mm, ranging from 9mm to 40mm. The procedure time was 90.47 ± 26.67 minutes and the average hospital stay was 2.51 ± 0.62 days. Clinical and echocardiography follow-up was conducted at 12.81 ± 8.41 months and all devices were securely anchored without any residual shunts. The procedure success rate was 93% (94/101). In five cases adequate deployment of the device was not possible and 2 patients presented residual ASD. No major complications occurred. CONCLUSION: The Amplatzer™ septal occluder is an effective OS ASD transcatheter treatment device.

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Artigo Original

Hospital costs of coronary artery bypass grafting on elective coronary patients

Nagib Haddad et al. Eliana Bittar Andréa Fabiana de Marchi Coralice dos Santos Veiga Kantorowitz … Andréa Cotait Ayoub Mayuli Lurbe Fonseca Leopoldo Soares Piegas

OBJECTIVE: To assess hospital costs associated with coronary artery bypass grafting performed on elective coronary patients, and the relation of costs with the number of grafts. METHODS: Descriptive prospective study carried out at Instituto Dante Pazzanese de Cardiologia in April, May and June of 2005. Coronary patients of different ages and both genders were included. Emergency patients, patients with other associated heart conditions and reoperation cases were excluded. Appropriate forms for the operating room, early postoperative period and for the final period in the ward were developed for the initial hospitalization phase preoperatively. RESULTS: The procedure was performed on 103 patients, at an average cost of R$6,990.00 (US$2,784.98), at a minimum of R$5,438.69 (US$2,166.81), and maximum of R$11,778.96 (US$4,692.81); standard deviation was R$1,035.47 (US$412.54) and the confidence interval was 95%, ranging from R$6,790.33 – R$7,190.27 (US$2,705.31 – US$2,864.67). The total average cost for three to five bypass grafts was higher (R$7,148.05) than for one and two bypass grafts (R$6,659.29) and the difference was significant (p < 0.05). CONCLUSION: The highest average costs were in the operating room (R$4,627.97), and in the early postoperative period (R$1,221.39), followed by costs incurred in the ward after the early postoperative period (R$840.04) and by the initial preoperative period in the ward (R$300.90).

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Case Report

Coronary giant cell arteritis and acute myocardial infarction

Pérsio Godoy et al. Stanley de Almeida Araújo Eduardo Paulino Júnior Marco Aurélio Lana-Peixoto

Giant cell arteritis (GCA) is a systemic immune-mediated granulomatous vasculitis of large- and medium-sized arteries mainly affecting elderly people. Death from GCA alone is rare and usually results of ruptured aorta. In this paper is reported a case of a 83-year-old woman who unexpectedly died during treatment of GCA. Necropsy revealed inflammatory involvement of the coronary arteries with left descendent anterior artery thrombosis, myocardial infarct and rupture of the anterior wall of the left ventricle, as well as hemopericardium and cardiac tamponade. Myocardial infarction leading to sudden death is an exceptional complication of GCA.

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Case Report

Multi-arterial myocardial bridge: uncommon clinical and anatomical presentations

Luciano de Moura Santos et al. Edmur Carlos de Araújo Luciano Nogueira Liberato de Sousa

We report the case of a 42-year-old man with no risk factors for coronary artery disease admitted with atypical chest pain. The electrocardiogram performed after intravenous injection of nitrate revealed ST-segment elevation in leads V1 to V4. The coronary angiography showed myocardial bridges in the three coronary arteries, besides an unusual length of the left anterior descending artery (80 mm). The patient progressed well following the discontinuation of nitrate use and introduction of beta-blockers and calcium channel antagonists.

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Point of view

Health profiles: Brazil 2006 – changes and their causes

POINT OF VIEW

Health profiles Brazil 2006 changes and their causes

[…]

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Artigo Original

Effectiveness of sustained-release bupropion in the treatment of smoker patients with cardiovascular disease

Jaqueline Scholz Issa et al. Glória Heloise Perez Jayme Diament Angela Giuliana Zavattieri Kátia Ulrich de Oliveira

OBJECTIVES: To evaluate the effectiveness of and tolerability to sustained-release bupropion, in smokers with cardiovascular diseases treated in a smoking cessation service, as well as to investigate variables predictive of success or failure in smoking cessation. METHODS: Sustained-release bupropion was prescribed to 100 current smokers with cardiovascular disease for 12 weeks. Patients were followed for 52 week. The variables studied were gender, age, number of cigarettes, exhaled carbon monoxide, nicotine dependence (Fagerstrom Tolerance Questionnaire), depression (Beck Depression Inventory), anxiety (State-Trait Anxiety Inventory), alcohol consumption (Alcohol Use Disorders Identification Test), number of diagnoses other than smoking, adverse events, and use of medications concomitantly with sustained-release bupropion. RESULTS: Abstinence rate was 50% at week 12 and 25% at week 52. The logistic regression analysis showed that ageing was positively associated with success, whereas the worsening of the condition, as verified by the presence of a higher number of other health conditions associated with smoking, was negatively associated with success. CONCLUSION: We conclude that the prescription of bupropion for smokers with cardiovascular diseases proved to be safe and effective, especially during the treatment period (week 12).

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Artigo Original

Cost-effectiveness of sirolimus-eluting stents in percutaneous coronary interventions in Brazil

Carisi Anne Polanczyk et al. Marco V. Wainstein Jorge Pinto Ribeiro

OBJECTIVES: To compare the cost-effectiveness ratios of sirolimus-eluting stents (SES) with bare-metal stents (BMS) under two perspectives: the “supplementary medical system” (health plans and private patients) and the public health (SUS) system. METHODS: A decision-analytic model using three different therapeutic strategies for coronary lesions: percutaneous coronary intervention (PCI) with BMS; with SES; or with BMS followed by SES to treat symptomatic restenosis. Study endpoints were one-year event-free survival and life expectancy. Decision trees were constructed using the results of published registries and clinical trials. RESULTS: One-year restenosis-free survival was 92.7% with SES and 78.8% with BMS. Estimated life expectancy was very similar for all the strategies, ranging from 18.5 to 19 years. Under a nonpublic perspective, the cost difference in the first year between BMS and SES was R$3,816, with an incremental cost-effectiveness ratio of R$27,403 per event avoided in one year. Under the SUS perspective, the cost per event avoided in one year was R$47,529. In the sensitivity analysis, probability of restenosis, risk reduction expected with SES, the price of the stent and cost of treating restenosis were all important predictors. In the Monte Carlo simulation, data per years of life saved showed very high cost-effectiveness ratios. CONCLUSION: In the Brazilian model, the cost-effectiveness ratios for SES were elevated. The use of SES was more favorable for patients with high risk of restenosis, as it is associated with elevated costs in restenosis management of and under a nonpublic perspective.

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Artigo Original

Evaluating cardiac vagal activity on a conventional electrocardiogram

Flávia P. Teixeira et al. Djalma R. Ricardo Claudia Lucia Barros de Castro Claudio Gil S. de Araújo

OBJECTIVE: To determine the viability of using a conventional electrocardiogram (ECG) tracing for assessment of CVA. METHODS: We retrospectively analyzed 1395 individuals (995 males), aged 46 ± 17.2 years (mean ± standard deviation) with conventional ECG tracings to measure the delta RR (which represents the difference in milliseconds (ms) between the greatest and smallest RR interval) and results of a second autonomic parasympathetic evaluation, the 4-second exercise test (T4s), that quantifies CVA by the cardiac vagal index (CVI). ROC curves were obtained to determine the values of Delta RR for a closer correlation with sensitivity and specificity for 1.20 and 1.95 ms, the low and high CVA cutoff points, respectively. RESULTS: The delta RR levels correlated significantly with those of the CVI (r=0.40; p<0.001). We identified 120 ms as the best cutoff points for low and high CVA. Sensitivity was 75% and 57%, specificity was 62% and 79%, and the areas of the ROC curves were 0.76 and 0.74, respectively. CONCLUSION: The visual measurement of delta RR on an ECG tracing seems to be a valid quick preliminary clinical evaluation of CVA and can be useful in medical offices, emergency units, or situations in which the use of more sophisticated methods may not be feasible, appropriate, or convenient.

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Artigo Original

Serum ferritin and obstructive coronary artery disease: angiographic correlation

Moacir Fernandes de Godoy et al. Isabela Thomaz Takakura Rafael Dinardi Machado Luciano Vaccari Grassi Paulo Roberto Nogueira

OBJECTIVE: To verify the possible association between the levels of serum ferritin and the degree of obstructive coronary artery disease. METHODS: 115 patients with coronary arteriography and concomitant evaluation of serum ferritin were studied. The adopted cut-off values were 80 ng/ml for women and 120 ng/ml for men. RESULTS: The mean ferritin levels for males and females were 133.9±133.8 ng/ml and 214.6±217.2 ng/ml, respectively (p=0.047). It was observed that 44.1% of the women had normal serum ferritin levels in comparison to 30.9% of the men (p=0.254). In the patients without obstructive coronary artery disease or with less severe obstructions (group A) the serum ferritin level was 222.3±325 ng/ml. On the other hand, for those with moderate (group B) and severe obstructions (group C) the levels were 145.6+-83.7 ng/ml and 188.9±150.6 ng/ml, respectively. There was no correlation between the degree of coronary artery disease and the mean level of serum ferritin. Regarding the cut-off value, the number of women with serum ferritin level > 80 ng/ml in groups B+C or only C was significantly higher than the number of women in group A (ODDS RATIO 9.71 with 95%CI from 1.63 to 57.72). For males there was no significant difference between the number of cases above or below the cut-off values (ODDS RATIO 0.92 with 95%CI from 0.28 to 2.95). CONCLUSION: It was verified that women with serum ferritin levels > 80 ng/mL presented more severe obstructive coronary artery disease than women with lower levels. In men, the serum ferritin level was not a predictor element of the degree of obstruction.

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Artigo Original

Correction of simple congenital heart defects in children and adolescents through minithoracotomies

Wilson Luiz da Silveira et al. Fabiana A. Penachi Bosco Adélio Ferreira Leite Fernanda A. Oliveira Peixoto … Mirna de Sousa Carlos César Elias de Souza

OBJECTIVE: To evaluate the repair of congenital heart defects through minithoracotomies. METHODS: Between January 1998 and March 2005, 98 patients underwent minithoracotomies for simple congenital heart defect repairs at our institution. All patients were female between the ages of 14 months and 16 years (mean 4.6) with weights ranging from 8 to 58 Kg (mean 20). Diagnoses included 78 cases of atrial septal defects (ASD) (six with associated partial anomalous pulmonary venous drainage and four with pulmonary valve stenosis) and 20 cases of perimembranous ventricular septal defects (PVSD). All diagnoses were confirmed with an echocardiogram; therefore, cardiac catheterization was not required. A right submammary minithoracotomy was performed on 10 patients and a minithoracotomy with a partial median sternotomy was performed on 88 patients. RESULTS: All defects were corrected successfully with satisfactory exposure. Cardiopulmonary bypass times ranged from 8 to 30 min (mean 10) and aortic clamping times ranged from 5 to 22 min (mean 12). All patients were extubated in the operating room and hospital stays ranged from 3 to 7 days (mean 5). There were no deaths during the operation or severe postoperative complications. No residual shunts were observed. CONCLUSION: Our study demonstrated that the minithoracotomy is a safe effective and technically viable alternative to a median sternotomy to correct selected simple congenital heart defects. The advantages of this approach include less trauma, partial or complete preservation of sternum continuity and integrity, and elimination of postoperative deformities such as pectus carinatum. The cosmetic outcome was superior to a median sternotomy.

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Artigo Original

Total plasmatic homocysteine and von Willebrand factor in experimental diabetes mellitus

Renato Delascio Lopes et al. Lindalva Batista Neves Vânia D'Almeida Gleice Margarete de Souza Conceição Alexandre Gabriel Junior

OBJECTIVES: To determine the plasma homocysteine and von Willebrand factor levels as markers of endothelial dysfunction in rats with diabetes mellitus induced by streptozotocin. METHODS: Thirty-five adult male rats (Rattus norvegicus albinus) (weight between 180-200g) were randomized into three groups: control group (n=10), which received no drugs or vehicles; sham group (n=10), which received streptozotocin solution; and diabetic group (n=15), which received streptozotocin. Eight weeks after diabetes mellitus induction, the animals were weighed and anesthesized; blood samples were collected from abdominal aorta for plasma total homocysteine, von Willebrand factor and glucose levels. RESULTS: The experimental model was reproducible in 100% of animals. The mean plasma homocysteine levels were: 7.9 µmol/l (control), 8.6µmol/l (sham) and 6.1µmol/l (diabetic), with difference among the groups (p<0.01). Multiple comparison analysis among the groups showed that values in the diabetic group were lower than in the sham group (p<0.01). The mean von Willebrand factor values were 0.15 U/l (control), 0.16U/l (sham) and 0.18 U/l (diabetic), with difference among the groups (p=0.03). The mean value was higher in the diabetic group than in the control group (p<0.05). Correlation between homocysteine and von Willebrand factor was not observed in the diabetic group. CONCLUSION: Reduced homocysteine levels and increased von Willebrand factor levels were observed in diabetes mellitus induced by streptozotocin; nevertheless, there were no correlations between them and with final glucose levels.

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Case Report

Coronary artery bypass surgery in patients with anomalous circumflex artery

Walter J. Gomes et al. Rodrigo P. Paez Francisco A. Alves

The anomalous origin of the circumflex artery (Cx) is uncommon and presents course variations that might make the coronary artery bypass surgery (CABG) difficult. Two patients presenting unstable angina were submitted to coronary angiography that disclosed tri-vessel disease and presence of Cx with an anomalous origin and retroaortic course with severe stenosis. Both patients underwent CABG with use of bilateral internal thoracic artery (ITA) grafts. Therefore, CABG with bilateral ITA use is feasible in cases of an anomalous origin of the Cx artery. However, this finding may constitute an additional technical setback.

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Artigo Original

Aortopulmonary window: impact of associated lesions on surgical results

Cinthia Siqueira Gangana et al. Ana Flávia de Araújo Malheiros Elizabete Vilar Alves Maurício Amir de Azevedo … Renata Moll Bernardes Luiz Carlos Simões

OBJECTIVES: The aortopulmonary window (APW) is a communication between the pulmonary artery (PA) and the ascending aorta in the presence of two separate semilunar valves. This review describes the natural history of the APW and the impact of associated defects on surgical results in patients treated at our institution. METHODS: Retrospective longitudinal study, based on the review of medical files of patients diagnosed between 1995 and 2005. RESULTS: Of nine patients diagnosed as having APW, six had associated lesions. Seven patients were submitted to surgical treatment with two deaths. One patient was not submitted to surgery due to pulmonary hypertension and another one died before the surgery due to a respiratory infection complication. CONCLUSION: The surgical results are satisfactory when the APW presents as an isolated defect and when surgery is performed early, preventing the development of irreversible arterial pulmonary hypertension (APH). The presence of associated complex congenital heart disease is a bad prognostic factor in our series.

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Artigo Original

Blood pressure measurement in children and adolescents: guidelines of high blood pressure recommendations and current clinical practice

Maria Alayde Mendonça da Silva et al. Ivan Romero Rivera Maria Goretti Barbosa de Souza Antonio Carlos de Camargo Carvalho

OBJECTIVE: To determine, in a school-based sample of children and adolescents, aged from 7 to 17 years, of both gender, in public and private schools, the frequency of students already submitted to blood pressure measure. METHODS: A cross-sectional study was carried out, sampling from a population pool of elementary and middle schools, randomly selected. The sample was calculated based on the expected prevalence of hypertension for the age group. Data were collected through a questionnaire. Blood pressure was measured twice and hypertension was defined as mean systolic and/or diastolic blood pressure over the 95th percentile. Independent variables studied: sex; age groups; economic status; public/private school. RESULTS: The final sample included 1253 students. The response rate was 97%: 1215 students; 531 males; mean age 12,4±3 years (236 from 7 to 9 years; 638 from 10 to 14 years; 341 from 15 to 17 years). Prevalence of hypertension was 7.7%; 348 students (29%) were already submitted to blood pressure measures (54% once; 35% 2 to 4 times; 11% 5 or more times). High economic status, private school and adolescent group were significantly associated to previous blood pressure measure. CONCLUSION: Despite of pediatric consensus statements and guidelines recommendations about importance of blood pressure measure at every examination after age 3 years, there is a very low frequency of this practice (29%) in children and adolescents.

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Artigo Original

Macroscopic aspects of chronic Chagas heart disease in aging

Flávia Aparecida de Oliveira et al. Vicente de Paula Antunes Teixeira Ruy de Souza Lino Junior Marina Clare Vinaud Marlene Antônia dos Reis

OBJECTIVE: To describe the macroscopic characteristics of chronic Chagas heart disease in autopsied elderly. METHODS: The elderly studied were 60 or older. Twenty of them had chronic Chagas heart disease (CHD) and positive serology for the disease, and 14 had no heart disease (WHD) nor morphological changes suggestive of it and were serologically negative for Chagas disease. RESULTS: The CHD elderly had cardiac weight greater than the WHD (385 ± 141.1 vs 306.8 ± 62.1g, respectively; p > 0.05), in addition to significantly higher heart weight-to-body weight ratio (0.71% [0.5-1.42%] vs 0.59% [0.47-0.91%] p < 0.05). When compared, the CHD elderly presented lower fibrous thickening and/or atherosclerosis in the ascending aorta, mitral and tricuspid valves, and left and right coronaries than the WHD elderly. In the aortic and mitral valves, the lesions were significantly less severe (p < 0.05). Left ventricular apical lesion was observed in 45% of the CHD elderly, and intracardiac thrombosis in the left ventricle was found in 10% of them. CONCLUSION: Fibrous thickening and/or atherosclerosis were found to be less severe in the valves and arteries of the CHD elderly. Moreover, heart weight and intracardiac thrombosis frequency were lower than those detailed in the literature for non-elderly individuals.

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Image

Left atrial appendage: real-time three-dimensional transthoracic echocardiographic image

Marcelo Luiz Campos Vieira et al. Gláucia M. P. Tavares Alexandre Cury Edgar B. Lira Filho … Adriana Cordovil Ana C. T. Rodrigues Cláudia G. Mônaco Gustavo Naccarato Cláudio H. Fischer Samira S. Morhy

IMAGE

Left atrial appendage: real-time three-dimensional transthoracic echocardiographic image

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Artigo Original

Metabolic syndrome in patients undergoing coronary artery bypass graft: prevalence and a marker of morbidity/mortality during hospitalization and 30 days after hospital discharge

Eduardo Pimenta et al. Oswaldo Passarelli Junior Flávio Borelli Márcio G. Sousa … Carlos Gun Vivian Amato Celso Amodeo Leopoldo Soares Piegas

OBJECTIVES: To compare the morbidity and mortality of patients with and without metabolic syndrome (MS) (according to the First Brazilian Guidelines for Diagnosis and Treatment of MS) undergoing coronary artery bypass graft (CABG) during hospitalization and after 30 days. METHODS: A total of 107 patients who underwent CABG with no associated procedures were assessed between August and October 2005; 74 (69.2%) of them had MS. Criteria of in-hospital outcome were: acute atrial fibrillation (AF), prolonged mechanical ventilation (MV), need for transfusion of blood products, number of hours spent in the ICU, length of hospital stay (days), respiratory and surgical wound infection, and death. For 30 days, the combination of events such as the need for readmission to hospital, surgical wound infection and death was assessed. RESULTS: The mean age was 60.6±9.7 years, and the group with MS presented a higher body mass index and body surface, and a higher prevalence of diabetes. No statistically significant difference was observed in the occurrence of in-hospital events such as AF (15.2% vs. 16.2%), MV (3.0% vs. 2.7%), number of units of blood products used (3.2±2.7 vs. 2.6±2.9), length of ICU stay (53.7±27.3 vs. 58.9±56.5), length of hospital stay (9.2±8.7 x 8.5±8.5), respiratory infection (6.1% vs. 2.7%), surgical wound infection (3.0% vs. 5.4%), and mortality rate (3.0% vs. 0.0%). The occurrence of combined events in 30 days was similar in both groups (12.2% vs. 20.3%, p = NS). CONCLUSION: Patients with MS did not have increased morbidity and mortality when undergoing CABG, however they had a higher trend of occurrence of surgical wound infection.

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Artigo Original

Impact analysis of drug-eluting stent in the unified health system budget

Denizar Vianna Araújo et al. Valter Correia Lima Marcos Bosi Ferraz

BACKGROUND: Drug-eluting stents represent an additional option to treat coronary artery disease. This technology represents a major breakthrough that may require additional funding in the short-term to enable its inclusion in procedures of the Unified Health System. OBJECTIVE: To estimate the impact on the Unified Health System budget in the first year of use of drug-eluting stents. METHODS: A Budget Impact Model was designed to predict the economic impact of the inclusion of drug-eluting stents in the Unified Health System budget. Data about costs and local procedures were collected in multiple sources, specifically procedure volume data, hospital costs, cost of stents, drug costs and number of stents used in single and multi-vessel procedures. RESULTS: The results in the first year indicate that the impact on the Unified Health System is of 12.8% in the best scenario and 24.4% in the worst scenario, representing an increase by R$ 24 to 44 million in the total projected budget. CONCLUSION: Drug-eluting stents have an additional cost compared with standard stents in the first year of use in the Unified Health System.

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Point of view

Surgical treatment of patients with heart failure through myocardial revascularization, ventricular reconstruction, and mitral valve surgery

POINT OF VIEW

Surgical treatment of patients with heart failure through myocardial revascularization, ventricular reconstruction, and mitral valve surgery

[…]

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Artigo Original

A study on systemic arterial hypertension in Campo Grande, MS, Brazil

Ana Rita Araújo de Souza et al. Anselmo Costa Diogo Nakamura Leandro Nascimento Mocheti … Paulo Roberto Stevanato Filho Luiz Alberto Ovando

OBJECTIVES: To detect the actual prevalence of systemic hypertension in the city of Campo Grande, MS, Brazil, and frequent factors. METHODS: Cross-sectional study with a randomized sample of the adult population of the city of Campo Grande, MS, in a total of 892 individuals. A questionnaire on age, gender, level of education, smoking, alcohol consumption, and aspects of the treatment was applied. Anthropometric data (weight and height) were collected. According to the WHO, a BMIBMI 30 obesity. Criteria for hypertension were based on the JNC VII report, with blood pressure cut-off values of 140 x 90 mmHg. RESULTS: The prevalence of hypertension was 41.4%, varying with age (up to 29 years: 11.8%; 30-39: 24.8%; 40-49: 43.3%; 50-59: 42.4%; 60-69: 48.6% and > 70: 62.3%). A higher prevalence was observed among men (51.8%), whereas among women the prevalence was 33.1%.Individuals with basic level of education tended to present higher rates. Among overweight and obese individuals, a higher prevalence of hypertension was observed: normal BMI (27.9%), overweight (45.6%) and obesity (58.6%). Above 60 years of age, a higher percentage of isolated systolic hypertension was observed, with 16.4% (60-69 years) and 24.6% (>70 years). Daily or weekly alcohol consumption was also related to a higher incidence, of 63.2% and 47.2%, respectively. Only 59.7% were known to be hypertensive. Of the hypertensive individuals, 57.3% were undergoing some type of treatment. Of those undergoing regular treatment, 60.5% presented hypertension. CONCLUSION: The prevalence of hypertension was 41.4%, therefore higher than the average verified in some studies. This calls the attention for worsened epidemiologic conditions and cardiovascular repercussions, thus showing the need for higher public investment on education and orientation of these population groups as regards prevention.

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Case Report

Infracardiac total anomalous pulmonary venous drainage: a diagnostic challenge

Célia M. C. Silva et al. Victor M. Oporto Patrícia Silveira Ayrton Bertini Junior … Carlos Eduardo Bernini Kapins Antonio Carlos Camargo Carvalho

Infracardiac total anomalous pulmonary venous drainage can be erroneously diagnosed as respiratory distress of several different etiologies during the neonatal period. A cross-sectional echocardiography study with Doppler color flow mapping can preoperatively determine the precise drainage site and pulmonary venous return pattern, thereby allowing cardiac surgery to be performed promptly, prior to any clinical deterioration.

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Editorial

Economic analysis of drug-eluting coronary stents in Brazil: a choice for all or just for a few patients?

EDITORIAL

Economic analysis of drug-eluting coronary stents in Brazil: a choice for all or just for a few patients?

[…]

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Artigo Original

Combined analysis of genetic and environmental factors on essential hypertension in a brazilian rural population in the Amazon region

Silvia Regina Sampaio Freitas et al. Pedro Hernan Cabello Rodrigo Soares Moura-Neto Luciana Cresta Dolinsky Marcio Neves Bóia

OBJECTIVE: In the present study, we evaluated the contribution of six genetic polymorphisms of the Renin-Angiotensis-Aldosterone system (RAAS) and clinical risk factors in the development of essential hypertension in a Brazilian rural population in the Amazon region. METHODS: Eighty-two hypertensive patients and seventy-eight normotensive individuals were evaluated. Genotyping for renin (REN G1051A), angiotensinogen (AGT) M235T, insertion/deletion of angiotensin-converting enzyme (ACE I/D), angiotensin II type 1 receptor (AGTR1) A1166C and aldosterone synthase (CYP11B2) C344T polymorphisms were performed using polymerase chain reaction, with further restriction analysis when required. The influence of genetic polymorphisms and clinical risk factors on blood pressure variation was assessed by stepwise linear regression. RESULTS: We report the co-occurrence of clinical risk factors and angiotensin-converting enzyme (ACE) gene polymorphism in a Brazilian rural population in the Amazon region. Our results indicate that increase of systolic blood pressure (SBP) is favored by ACE I/D- D allele and advanced age, while alcohol consumption and aging are associated with high diastolic blood pressure (DBP). CONCLUSION: These findings suggest that in the Santa Isabel do Rio Negro population, the residents that carry ACE-D allele or have an alcohol consumption habit present higher values of SBP and DBP, respectively, with the passing of years.

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Artigo Original

Echocardiograph pulmonary venous flow patterns in congenital heart defects with increased pulmonary flow

Ivan Romero Rivera et al. Maria Alayde Mendonça da Silva Valdir Ambrósio Moises José Lázaro de Andrade … Orlando Campos Filho Ângelo Amato de Paola Antonio Carlos Carvalho

OBJECTIVES: To describe pulmonary venous flow patterns using transthoracic echocardiograms on children suffering from different congenital heart defects with increased pulmonary flow. METHODS: Prospective study and consecutive selection of children suffering from congenital heart defects with increased pulmonary flow. The transthoracic, apical view, Doppler echocardiogram was used, positioning the sample-volume at the lower pulmonary vein, 4mm from its junction with the left atrium. The data analyzed included: dominant systolic or diastolic pulmonary venous flow and atrial contraction waveform characteristics, designated as “A” for absent and “R” for reversed. RESULTS: The study included twenty-nine patients with a mean age of 29.9 ± 58.9 months, suffering from the following congenital heart conditions: interatrial and interventricular communication defects, patent ductus arteriosus, atrioventricular septal defects, total transposition of the great arteries and truncus arteriosus. All the patients presented a continuous pattern of high velocity pulmonary venous flow. Nine patients presented a dominant systolic waveform (31%), eighteen presented a dominant diastolic wave form (62%) and 2 patients had systolic and diastolic wave forms of equal amplitude (7%). Six patients (21%) presented a R atrial contraction waveform and 23 (79%) presented an A atrial contraction waveform. CONCLUSION: Congenital heart diseases with increased pulmonary flow present a continuous pattern of high velocity pulmonary venous flow with alterations mainly in the atrial contraction reversal pattern.

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