2008;90(6) – ABC CARDIOL

Correlação Clínico-Radiográfica

Case 3/2008: fourteen month old female infant with pulmonary arteriovenous fistula

Edmar Atik

CLÍNICORADIOLOGICAL SESSION

Case 3/2008 Fourteen month old female infant with pulmonary arteriovenous fistula

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Case Report

Adult patient with anomalous origin of anterior interventricular artery at main pulmonary artery

Haroldo Adans Ferraz et al. Leonardo Alves Batista Fernando Mendes Sant'Anna Leonardo da Costa Buczynski … Marcelo Bastos Brito Carlos Alberto Mussel Barrozo

From all congenital cardiopathies, anomalous origin of anterior interventricular artery occurs once per 300,0000 live births, reporting high mortality in the first year after birth. However, if good collateral circulation is available for the artery related to the abnormality, the patient may be kept asymptomatic until mature age. This is the report on a rare case of a 43-year-old patient who was oligosymptomatic, with normal ventricular function in this pathology presentation. The patient was submitted to surgical treatment with no extracorporeal circulation.

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Artigo Original

Novel no-touch technique of harvesting the saphenous vein for coronary artery bypass grafting

Fabio de Rueda et al. Domingos Souza Ricardo de Carvalho Lima Alexandre Menezes … Benny Johansson Michael Dashwood Emmanuel Thé Mário Gesteira Mozart Escobar Frederico Vasconcelos

BACKGROUND: Optimization of the saphenous vein for myocardial revascularization. OBJECTIVE: To present the no-touch technique of the saphenous vein preparation. This technique consists of harvesting the vein with a pedicle of surrounding tissue, which protects the vein from spasms, obviating the need for distension. METHODS: A prospective, randomized study with 156 patients who underwent artery bypass grafting was performed comparing three saphenous vein harvesting techniques: conventional, intermediate, and no-touch. A morphological study of the endothelium was carried out using scanning microscopy. An angiographic assessment of the vein graft patency was performed at a mean follow-up time of 18 months. Also, an immunohistochemical assessment was carried out to identify the endothelial enzyme nitric oxide synthase (eNOS) in the vein wall RESULTS: The preservation of the endothelial cell integrity was greater in the no-touch technique than in the other procedures. At angiographic follow-up, the patency for the no-touch group was 95.4%, 88.9% for the grafts of the conventional technique group, and 86.2% for the grafts performed in the intermediate technique group. The immunohistochemical assessment revealed eNOS in all three layers of the vein wall in the no-touch group and reduction of this enzyme in the conventional group. CONCLUSION: The endothelial integrity and eNOS activity were better preserved when using the no-touch technique for vein graft harvesting. The mechanical protection provided by the cushion of surrounding tissue in the no-touch group, the vasorelaxation and thromboresistant activities of nitric oxide may be responsible for the reduction of vasospasms and improved patency rate.

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Artigo Original

Unsupported valvuloplasty for degenerative mitral regurgitation: long-term results

Alexsandra L. Balbinot et al. Renato A. K. Kalil Paulo R. Prates João Ricardo M. Sant'Anna … Orlando C. Wender Guaracy Fernandes Teixeira Filho Rogério S. Abrahão Ivo A. Nesralla

BACKGROUND: The advantages of valve repair for treatment of degenerative mitral regurgitation are well established. The procedure is associated with low mortality and morbidity rates, and low indices of reoperation, thromboembolic events and endocarditis have been reported. In most series, annuloplasty rings are implanted, but some institutions give preference to unsupported valvuloplasty. OBJECTIVE: To assess the clinical outcome of patients submitted to unsupported valvuloplasty for degenerative mitral regurgitation. METHODS: Between January 1980 and January 2003, 116 patients were submitted to the procedure. A total of 62 (53.4%) were men, and mean age was 47.2 ± 16.5 years. The procedures included: Wooler annuloplasty (65.5%), unilateral annuloplasty (15.5%), quadrangular resection of the posterior leaflet (35.3%), anterior chordal shortening (20.7%), posterior chordal shortening (6.9%), and calcium debridement (0.9%). Mean follow-up was 6.5 ± 5.1 years, and the longest follow-up was 24 years. RESULTS: Mortality was 0.86% (1 pt) early and 6.03% (7 pt) late. Actuarial survival was 85.3% in 20 years. Most patients (55.2%) presented preoperative NYHA functional class III, whereas class I was more frequent in the postoperative period (66.4%). Thromboembolic complications were observed in 4 patients (3.4%), and no correlation was seen with atrial fibrillation. Freedom from thromboembolic events was 94.8%, and similar results were observed for bacterial endocarditis. Survival free from reoperation was 79%, and 53% at 5 and 10 years, respectively. CONCLUSION: Unsupported valvuloplasty is effective and safe for treatment of degenerative mitral regurgitation, representing an adequate therapeutic alternative for selected cases.

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Artigo Original

Heart rate recovery after treadmill electrocardiographic exercise stress test and 24-hour heart rate variability in healthy individuals

Ivana Antelmi et al. Eliseu Yung Chuang Cesar José Grupi Maria do Rosário Dias de Oliveira Latorre Alfredo José Mansur

BACKGROUND: Heart rate recovery after treadmill electrocardiographic exercise stress test is modulated by the autonomic nervous system. Analysis of heart rate variability can provide useful information about autonomic control of the cardiovascular system. OBJECTIVE: The aim of the study was to test the hypothesis of association between heart recovery after treadmill electrocardiographic exercise test and heart rate variability. METHODS: We studied 485 healthy individuals aged 42± 12.1 (range 15-82) years, 281(57.9%) women, submitted to treadmill electrocardiographic exercise stress tests and heart rate variability evaluations over time (SDNN, SDANN, SDNNi, rMSSD, pNN50) and frequency (LF, HF, VLF, LF/HF ratio) domains in 24-hour ambulatory electrocardiographic monitoring. RESULTS: Heart rate recovery was 30± 12 beats in the 1st minute and 52± 13 beats in the 2nd minute after exercise. Younger individuals recovered faster from the 2nd to the 5th minute after exercise (r= 0.19-0.35, P< 0.05). Recovery was faster in women than in men (4± 1.1 beats lower in the 1st minute, p<0.001; 5.7± 1.2 beats lower in the 2nd minute, p<0.01; 4.1± 1.1 beats lower in the 3rd minute, p<0.001). There was no significant correlation between heart rate recovery and heart rate variability in 1st and 2nd minutes after exercise. SDNN, SDANN, SDNNi, rMSSD, and pNN50 indices demonstrated a significant correlation with heart rate recovery only at the 3rd and 4th minutes. CONCLUSION: The hypothesis of association between heart rate recovery and 24-hour heart rate variability in the first two minutes after exercise was not substantiated in this study. Heart rate recovery after exercise was associated with age and gender.

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Artigo Original

Blood pressure: effect of body mass index and of waist circumference on adolescents

Isabel Cristina Britto Guimarães et al. Alessandro Moura de Almeida Adiméia Souza Santos Daniel Batista Valente Barbosa Armênio Costa Guimarães

BACKGROUND: Increased body mass index (BMI) and waist circumference (WC) have been associated with blood pressure elevation. OBJECTIVE: To evaluate the effect of BMI and WC on blood pressure (BP) of adolescents. METHODS: Cross-sectional analytical study including 536 adolescents from public and private schools. BMI was calculated and classified as high-normal (> 50th p and 85th p and 95th p). WC was measured and considered increased if > 75th p. BP was considered elevated if > 90th p. RESULTS: 319 (59.5%) adolescents were girls, the mean age was 14.0± 1.99 years, high-normal weight was found in 39.6%, overweight in 37.1% and obesity in 23.3%. The percentage of high SBP and DBP followed the increase in BMI (p=0.000), reaching 46.4% among boys and 39.3% among obese girls for SBP and 42.0% and 44.6% for DBP, respectively. High SBP and DBP were 3.9 and 3.4 times more frequent among boys and 2.2 to 2.0 times more frequent among girls with WC > 75th p, respectively. Using simple linear regression analysis, each increment in BMI would increase SBP by 1.198 mmHg, and in WC by 0.622 mmHg. The PR for elevated SBP and DBP in relation to BMI > 85th p was 3.9 (95% CI 2.0-7.4[p=0.000]) and 4.3(95% CI 2.2-8.5[p=0.000]), respectively; in relation to WC > 75th p was 1.8(95% CI 1.0 to 3.0 [p=0.036]) and 1.4 (95% CI 0.8 to 2.4). BP > 90th p with WC < 75th p was found in 16/181 (8.8%) of the adolescents with high-normal weight. CONCLUSION: BMI and WC values have a strong influence on BP values in adolescents.

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Case Report

Right heart emboli-in-transit: case report and literature review

Ivan Romero Rivera et al. Maria Alayde Mendonça da Silva Ricardo César Cavalcanti Edmilton Wanderley Cavalcante Roberto Lúcio de Gusmão Verçosa

Emboli in transit in right atrium are rare. When they occur, they are associated to high rate of pulmonary embolism and mortality. This is a case report on an embolus in transit in right chambers, with clinical suspicion of pulmonary thromboembolism. Diagnosis was obtained through transesophageal echocardiography. The patient had a positive response post-anticoagulation. The team discussed presentation forms, treatment and condition development.

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Artigo Original

Discontinuous sets of knee extensions induce higher cardiovascular responses in comparison to continuous ones

Marcos Doederlein Polito et al. Roberto Simão Vitor Agnew Lira Antônio Cláudio Lucas da Nóbrega Paulo de Tarso Veras Farinatti

BACKGROUND: The strength training can promote significant cardiovascular responses during its performance and it is interesting to devise strategies to reduce them, without compromising the strength production. OBJECTIVE: To compare the acute cardiovascular responses of systolic arterial pressure (SAP), diastolic arterial pressure (DAP), heart rate (HR) and double product (DP) during the unilateral knee extension (four series of 8 maximum repetitions) performed continuously or discontinuously. Both protocols involved a 2-minute interval between the series and the discontinuous protocol had an extra interval of 2 seconds between the 4th and the 5th repetitions. METHODS: Eight healthy men trained in muscular strength (aged 26± 6 years) participated in the data collection and were randomly divided in two non-consecutive days. The cardiovascular responses were measured by photoplethysmography (Finapres, Ohmeda, Louisville, CO, USA) at rest, at the end of each series and 2 minutes after the performance of each protocol. RESULTS: The discontinuous series showed significantly higher values when compared to the protocol of the continuous series for: SAP (mmHg) at the 2nd (173.1± 5.4 vs 152.0± 4.0; p=0.001), 3rd (188.9± 8.6 vs 162.4± 6.0; p=0.000) and 4th series (193.1± 8.1 vs 161.6± 5.9; p=0.000); DAP (mmHg) at the 3rd (103.8± 4.1 vs 86.1± 3.3; p=0.000) and 4th series (104.1± 2.7 vs 83.4± 3.3; p=0.000); DP (mmHg.bpm) at the 2nd (17,907.5± 1,350.7 vs 14,541.9± 1,848.0; p=0.03), 3rd (19,687.3± 1,444.3 vs 15,612.1± 1,180.3; p=0.008) and 4th series (21,271.0± 1,794.2 vs 15,992.0± 1,093.4; p=0.001). CONCLUSION: The discontinuous protocol promoted higher increase in pressure responses when compared to the continuous one. However, due to the characteristics of the study design, further studies are necessary to support these findings.

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Artigo Original

Decompensated heart failure in the emergency department of a cardiology hospital

Sandrigo Mangini et al. Fábio Serra Silveira Christiano Pereira Silva Petherson Suzano Grativvol … Luís Fernando Bernal da Costa Seguro Sílvia Moreira Ayub Ferreira Amílcar Oshiro Mocelin Luiz Francisco Cardoso Fernando Bacal Edimar Alcides Bocchi

BACKGROUND: National studies on decompensated heart failure (DHF) are key to the understanding of this condition in our midst. OBJECTIVE: To determine the characteristics of DHF patients in an emergency department. METHODS: A total of 212 patients diagnosed with decompensated heart failure who had been admitted to an emergency department (EU) of a cardiology hospital were prospectively evaluated. Clinical variables, form of presentation and causes of decompensation were studied. In 100 patients, ancillary tests, prescription of vasoactive drugs, length of hospital stay and mortality were also analyzed. RESULTS: There was a predominance of the male gender (56%) and the most frequent etiology was ischemia (29,7%) despite high frequency of valvular (15%) and chagasic (14,7%) etiologies. The most common form of presentation and cause of decompensation were congestion (80.7%) and poor compliance/inadequate medication (43.4%), respectively. In the subanalysis of the 100 patients, systolic dysfunction was the most common cause of decompensation (55%); use of vasoactive drugs occurred in 20%, and mortality was 10%. The comparative analysis between the patients who were discharged and those who died during hospitalization confirmed some criteria of poor prognosis: reduced systolic blood pressure, low cardiac output associated with congestion, need for vasoactive drugs, reduced left ventricular ejection fraction, increased left ventricular diastolic diameter (LVDD) and hyponatremia. CONCLUSION: This study presents information about the profile of decompensated heart failure patients attended on the emergency unit of a brazilian southeast cardiology hospital. Clinical, hemodynamical and ancillary data may provide information for risk assessment in the initial evaluation helping the decision on hospitalization and advanced strategic therapies.

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Brief Communication

Zinc in children undergoing cardiac surgery with cardiopulmonary bypass

Lourdes Zélia Zanoni et al. Petr Melnikov Luiz Carlos Consolo Nilva Ré Poppi … Aparecida Afif Ossais Marcus Vinicius Caldas Ivoney Assad Maior

BRIEF COMMENTS

Zinc in children undergoing cardiac surgery with cardiopulmonary bypass

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Review Article

Factors and mechanisms involved in left ventricular hypertrophy and the anti-hypertrophic role of nitric oxide

José Antonio Dias Garcia et al. Erika Kristina Incerpi

The left ventricular hypertrophy (LVH) occurs in response to the hemodynamic overload in some physiological and pathological conditions. However, it has not been completely elucidated whether the primary stimulation for the hypertrophy is the mechanical stretching of the heart, neurohumoral factors, or even the interaction of both. These factors are translated inside the cell as biochemical alterations that lead to the activation of second (cytosolic) and third (nuclear) messengers that will act in the cell nucleus, regulating transcription, and will finally determine the genic expression that induces LVH. The LVH is characterized by structural alterations due to the increase in the cardiomyocyte dimensions, the proliferation of the interstitial connective tissue and the rarefaction of the coronary microcirculation. Recently, nitric oxide (•NO) has appeared as an important regulator of cardiac remodeling, specifically recognized as an anti-hypertrophic mediator. Some studies have demonstrated the cellular targets, the anti-hypertrophic signaling pathways and the functional role of •NO. Thus, the LVH seems to develop as a result of the loss of the balance between the pro and the anti-hypertrophic signaling pathways. This new knowledge about the pro and anti-hypertrophic signaling pathways will allow the development of new strategies in the treatment of pathological LVH.

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Artigo Original

Premature mortality due to cardiovascular disease and social inequalities in Porto Alegre: from evidence to action

Sérgio Luiz Bassanesi et al. Maria Inês Azambuja Aloyzio Achutti

BACKGROUND: Two perspectives, the economic (disease causing impoverishment) and social (poverty causing illness), have internationally disputed the justification for public health policies. OBJECTIVE: To investigate the relationship between early mortality by cardiovascular disease (CVD) and socioeconomic (SE) conditions in the city of Porto Alegre (PA), and discuss bases and strategies for the prevention of CVD. METHODS: An ecological analysis of the association between mortality by CVD at 45-64 years of age and SE conditions of 73 districts/neighborhoods in PA. The relative risk (RR) and the fraction of risk (FRA) attributable to inequality among the districts grouped into 4 SE strata were estimated. RESULTS: Early mortality by CVD was 2.6 times higher in the districts classified in the worst compared to the best of the 4 SE strata. Among the extreme districts, the RR reached 3.3 for CVD and 3.9 for cerebrovascular disease. Compared to the mortality in the best stratum, 62% of the early deaths in the worst stratum and 45% of those in the city as a whole could be attributed to socioeconomic inequality. CONCLUSION: Almost half of the mortality by CVD before 65 years of age can be attributed to poverty. Disease, on the other hand, contributes towards poverty and reduces competitiveness of the country. It is necessary to reduce illness and recover the health of the poorest inhabitants with investments that result in national economic development and improvement of the social conditions of the population.

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Artigo Original

Association between central obesity, triglycerides and hypertension in a rural area in Brazil

Adriano Marçal Pimenta et al. Gilberto Kac Andrea Gazzinelli Rodrigo Corrêa-Oliveira Gustavo Velásquez-Meléndez

BACKGROUND: Hypertension represents a serious public health problem and is one of the most frequent causes of morbidity around the world. OBJECTIVE: To estimate the prevalence of hypertension and its risk factors in a rural community located in the north-eastern state of Minas Gerais, Brazil. METHODS: A cross-sectional study was carried out in 2004 in the Virgem das Graças Village, a rural community located the Jequitinhonha Valley. The sample consisted of 287 males and females aged between 18 to 88 years. Hypertension was defined according to Joint National Committee criteria (systolic blood pressure > 140 mmHg and/or diastolic blood pressure > 90 mmHg): subjects already receiving anti-hypertensive treatment were considered to be hypertensive. Bivariate analysis was performed to test the relationship between the independent variables and hypertension. Logistic regression was used to adjust for confounding and to identify interactions. The strength of association was measured using Odds Ratio (OR) and its 95% confidence intervals [CI (95%)]. RESULTS: The crude prevalence of hypertension was 47.0% [CI (95%): 41.1 – 53.0], the age-standardized prevalence was 43.2% [CI (95%): 35.7 – 50.7], while the schooling-standardized prevalence was 44.1% [CI (95%): 43.9 – 44.3]. Age, triglycerides, waist circumference and sex were found to be independent risk factors for hypertension according to multivariate analysis. CONCLUSION: The findings provide important evidence concerning the hypertension as a public health problem and its association with dyslipidemia and abdominal obesity in the rural area of Minas Gerais.

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