2009;93(3) – ABC CARDIOL

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Artigo Original

Acute kidney injury after on-pump coronary artery bypass graft surgery

Maurício de Nassau Machado et al. Rafael Carlos Miranda Isabela Thomaz Takakura Eduardo Palmegiani … Carlos Alberto dos Santos Marcos Aurélio Oliveira Osana M. Mouco Mauro E. Hernandes Maria Angélica Lemos Lília N. Maia

BACKGROUND: The acute kidney injury (AKI) is a complex disease for which there is no accepted standard definition nowadays. The Acute Kidney Injury Network (AKIN) represents an attempt to standardize the criteria for diagnosis and staging of acute renal dysfunction based on recently published RIFLE criteria, that means, (Risk, Injury, Failure, Loss, and End-stage kidney disease). OBJECTIVES: To evaluate the incidence and associated mortality of AKI in patients submitted to on-pump coronary artery bypass graft surgery (on-pump CABG). METHODS: A total of 817 patients were divided into two groups: negative AKI (-), with 421 patients (51.5%), and positive AKI (+), with 396 patients (48.5%). Increase of 0.3 mg/dL in creatinine or of 50% in creatinine’s basal value was considered as AKI. RESULTS: The rate of patient’s mortality with or without AKI within 30 days after cardiac surgery was 12.6% and 1.4%, respectively (p14 days) (14 versus 2%; p=0.0001). CONCLUSION: In the studied population, even a discrete alteration in renal function, based on AKIN criteria, was an independent predictor of death in 30 days after on-pump CABG. (ClinicalTrials.gov Registry: NCT00780845).

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Review Article

Occlusion of the left coronary trunk secondary to tertiary syphilis

Ricardo Wang et al. Gustavo Blume Newton Fernando Stadler Souza Filho Lidia Zytynski Moura

A 27-year-old patient with tertiary syphilis, manifested as myocardial ischemia, presenting unstable angina, secondary to left coronary trunk occlusion. The diagnosis was confirmed by the serological findings and the pathological assessment of the aorta fragment.

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Artigo Original

Percutaneous aortic valve replacement for the treatment of aortic stenosis: early experience in Brazil

Marco Antonio Perin et al. Fábio Sândoli de Brito Jr. Breno Oliveira Almeida Marco Aurélio M. Pereira … Alexandre Abizaid Flávio Tarasoutchi Eberhard Grube

BACKGROUND: Percutaneous aortic valve replacement for the treatment of aortic stenosis is an available and efficient alternative for patients at high surgical risk, especially those with advanced age and comorbidities. OBJECTIVE: The authors report the first experience made in our midst with the use of the CoreValve endoprosthesis. METHODS: In January 2008, two patients underwent percutaneous aortic valve replacement due to symptomatic aortic stenosis. They were selected for being elderly (77 and 87 years) and presenting comorbidities and a high surgical risk (EuroScore 7.7% and 12.1%). RESULTS: Percutaneous implantations of the CoreValve device were successfully performed. Enlargement of the valve area (from 0.7 to 1.5 cm² and from 0.5 to 1.3 cm²) and reduction of the aortic transvalvular gradient (from 82 to 50 mmHg and from 94 to 31 mmHg) were observed immediately after the intervention. During hospital stay, permanent pacemaker implantation was required in both patients due to atrioventricular block. At six months, an even greater drop in the aortic transvalvular gradient (gradient < 20 mmHg) and remission of symptoms of heart failure (NYHA III to NYHA I) were observed. CONCLUSION: The use of the CoreValve endoprosthesis for the treatment of aortic stenosis proved to be feasible and showed encouraging results in this early experience made in our midst.

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Editoriais

Ibero-American cardiovascular magazines: proposals for a necessary collaboration

Fernando Alfonso et al. Katihurca Almonte Kaduo Arai Fernando Bacal … José M. Drago Silva Javier Galeano Figueredo Eduardo Guarda Oswaldo Gutiérrez Sotelo Luis Guzmán Jorge León Galindo Bey Mario Lombana Manlio F. Márquez Francisco Luis Moreno Martínez José Navarro Robles Fausto Pinto Carlos Romero Carlos D. Tajer Hugo Villarroel Fernando S. Wyss Quintana

EDITORIAL

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Artigo Original

Prevalence of anemia and renal insufficiency in non-hospitalized patients with heart failure

Francisco José Farias Borges dos Reis et al. André Maurício Souza Fernandes Almir Galvão Vieira Bitencourt Flávia Branco Cerqueira Serra Neves … André Yoichi Kuwano Victor Hugo Pinheiro França Cristiano Ricardo Bastos de Macedo Cristiano Gonçalves da Cruz Viviane Sahade Roque Aras Júnior

BACKGROUND: Heart Failure (HF) is a common disease with a high rate of mortality. Anemia and renal failure (RF) are often found in patients with HF associated with higher severity of the heart disease and a worse prognosis. OBJECTIVE: To evaluate the prevalence of anemia and RF, as well as the association between these two conditions, in non-hospitalized patients with HF. METHODS: Patients treated at the HF Outpatient Clinic of a university hospital were followed from July 2003 to November 2006. Anemia was defined as hemoglobin levels < 13 mg/dl for men and 12 mg/dl for women. Renal function was assessed by the glomerular filtration rate (GFR), calculated by the simplified formula of the MDRD (Modification of Diet in Renal Disease) study. RESULTS: Of the 345 patients included in this study, 26.4% (n = 91) had anemia and 29.6% had moderate to severe renal failure (GFR < 60 ml/min). The association between anemia and a higher prevalence of renal failure was statistically significant (41.8% vs. 25.2%; p = 0.005). The patients at functional class III and IV presented a higher incidence of anemia (39.0% vs. 19.4%; p <0.001) and renal failure (38.2% vs. 24.8%; p = 0.007). No association was observed between anemia or renal failure and history of hypertension, diabetes, systolic function or etiology of HF. CONCLUSION: The prevalence of anemia and renal failure was high in this population and was associated with the severity of the HF (functional classes III and IV).

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Point of view

Gender, age, social level and cardiovascular risk factors: considerations on the Brazilian reality

Carlos Scherr et al. Jorge Pinto Ribeiro

POINT OF VIEW

Gender, age, social level and cardiovascular risk factors: considerations on the Brazilian reality

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Case Report

Coronary artery bypass using only computed tomography as pre-operative angiogram

Diego Felipe Gaia et al. José Honório Palma João Nelson Rodrigues Branco Carlos Alberto Teles … Roberto Catani Enio Buffolo

Coronary artery bypass graft (CABG) is a well established procedure with current precise indications. The advent and spread of this technique was possible after the introduction of the coronary angiogram. Although many evaluation methods have been developed in the past years, to date, none have been able to replace the invasive coronary angiogram as a pre-operative exam. Computed tomography angiography (CTA) has emerged as an alternative to invasive coronary angiogram. In this report we describe two CABG cases that were performed using only this technique as a pre-operative anatomic coronary arteries evaluation.

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Case Report

Large bilateral coronary artery fistula: the choice of clinical treatment

Luciana Oliveira Cascaes Dourado et al. Aécio Flávio Teixeira de Góis Whady Hueb Luiz Antônio Machado César

CASE REPORT

Large bilateral coronary artery fistula: the choice of clinical treatment

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Artigo Original

Postoperative outcome of patients with prosthetic valve leak

Roney Orismar Sampaio et al. Francisco Costa da Silva Jr. Iraí Santana de Oliveira Celso Madeira Padovesi … Joyce Aparecida Soares William Manoel da Silva Luciana de Paula Samorano Flávio Tarasoutchi Guilherme Sobreira Spina Max Grinberg

BACKGROUND: Prosthetic valve leak is a possible complication of surgical valve replacement. Although uncommon, its consequences may be serious. Few studies correlate the degree of prosthetic valve leak with clinical events. OBJECTIVE: To compare the postoperative outcome of patients with mild/moderate (Mi/Mo) or severe (Sev) prosthetic valve leak METHODS: A total of 185 patients with prosthetic valve leak were selected among 1350 patients undergoing heart valve surgery between 1999 and 2001. Of these, a sample of 58 patients (37 men) with prosthetic valve leak (36 with Mi/Mo versus 22 with Sev leak) in the pre and/or postoperative period of heart valve replacement had complete medical record data, so their clinical, laboratory and echocardiographic data could be retrospectively assessed. RESULTS: The incidence of reoperation was 11.1% in the Mi/Mo group, versus 22.7% in the Sev group (odds ratio = 2.35 [95% CI 0.56-9.94]). Endocarditis was the cause of reoperation in 75% of the patients of the Mi/Mo group and in 60% of the Sev group. Aortic bioprostheses were those most frequently related to leak (55.8% in the Mi/Mo group and 57.7% in the Sev group). Forty percent of the patients with previous Mi/Mo leak did not present prosthetic valve leak on postoperative day 2 versus 21.4% of the patients with Sev prosthetic valve leak. No significant differences were found regarding laboratory variables. CONCLUSIONS: (1) Patients with severe leak are more likely to undergo reoperation. (2) Endocarditis was the most frequent cause of reoperation for any leak degree. (3) Severe prosthetic valve leak is more difficult to fully resolve after surgical treatment.

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Image

Mechanical prosthetic valve thrombosis

Márcio Silva Miguel Lima et al. Marcelo Luiz Campos Vieira

CARDIOVASCULAR IMAGE

Mechanical prosthetic valve thrombosis

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Artigo Original

Isolated mitral and aortic valve replacement with the St. Jude Medical valve: a midterm follow-up

Alfredo José Rodrigues et al. Paulo Roberto Barbosa Évora Solange Bassetto Lafaiete Alves Jr. … Adilson Scorzoni Filho Walter Villela A. Vicente

BACKGROUND: In our country, the biological valvular prostheses predominate, considering the difficulties related to anticoagulation, even in young patients, in spite of the need for repeated operations due to the degeneration of the bioprostheses. OBJECTIVES: To report our consecutive series of recipients of isolated St Jude Medical mechanical valve prosthesis in the mitral (MVR) or aortic (AVR) position. METHODS: Data from patients operated between January 1995 and December 2003 were revised in order to determine patient survival and prosthesis-related events up to December 2006. RESULTS: One hundred sixty eight patients had MVR and 117 had AVR. In the MVR cohort, the mean age was 45 years, 75% were 55 years old or younger, and 65% were females. In the ARV cohort, the mean age was 45 years, 66% were 55 years old or younger and 69% were males. Operative mortality for AVR and MVR was 7% and 7.5%, respectively. Freedom from late mortality was 81.8% at 10 years for MVR and 83% for AVR (p=0.752). Freedom from valve-related death at 10 years for the MVR cohort and AVR was 85.6% and 88.7%, respectively (p=0.698). In the MVR cohort, the freedom from reoperation was 97% and 99% in the AVR cohort (p=0.335). Freedom from thromboembolic events was 82% in the MVR cohort and 98% in the AVR cohort (p=0.049). Freedom from bleeding was 71% in the MVR cohort and 86% n the AVR cohort (0.579). Freedom from endocarditis was 98% in the MVR cohort and 99% in the AVR cohort (p=0.534). CONCLUSIONS: This series of predominantly young adult patients undergoing isolated MVR and AVR with the St Jude Medical mechanical prosthesis confirms the good performance of this valve prosthesis in agreement with previous reports.

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Brief Communication

Myocardial homing after intrapericardial infusion of Bone Marrow Mononuclear Cells

Érika Branco et al. Emerson Ticona Fioretto Rosa Cabral Carlos Alberto Sarmento Palmera … Guilherme Buzon Gregores Angelo João Stopiglia Paulo César Maiorka Pedro Alves Lemos Carlos Campos Celso Takimura José Antônio Franchini Ramires Maria Angelica Miglino

BRIEF COMMUNICATION

Myocardial homing after intrapericardial infusion of Bone Marrow Mononuclear Cells

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Artigo Original

ABPM in COPD patients with sleep desaturation

Neila Anders Aidar et al. Márcio Alberto Carvalho da Silva César Augusto Melo e Silva Pedro Nery Ferreira Júnior Paulo Tavares

BACKGROUND: Sleep hypoxemia may change blood pressure by sympathetic activation. Few studies have analyzed blood pressure parameters in COPD patients who do not present sleep apnea, but do present sleep desaturation. OBJECTIVES: To analyze blood pressure parameters in COPD patients with sleep desaturation not caused by apnea. METHODS: Thirteen patients with COPD underwent spirometry, blood gas, polysomnography and ABPM for blood pressure evaluation. Fourteen patients without COPD underwent spirometry, oximetry and ABPM. Blood pressure analyses were carried out both during wakefulness and sleep. Both groups were comprised of patients with no history of hypertension. RESULTS: The two groups were similar as regards age, height, weight, and body mass index. A significant difference (p<0.05) was found between blood pressure levels during the wakefulness, sleep, 24-hour and sleep dip periods. Higher blood pressure levels were observed in patients with COPD, except for diastolic levels during wakefulness and maximum values during sleep and in the 24 hours. Sleep dip in the COPD group was attenuated, whereas physiological dip was observed in the control group, with lower blood pressure levels. CONCLUSIONS: Systolic and diastolic blood pressure levels in the COPD group were higher than those of the control group, with a significant difference found for all periods studied, except for diastolic levels during wakefulness and in the 24 hours. We can conclude that the group of COPD patients with sleep desaturation has significantly higher blood pressure levels than the control group.

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Artigo Original

Heart rate variability, blood lipids and physical capacity of obese and non-obese children

Mário Augusto Paschoal et al. Patrícia Fernandes Trevizan Natália Folco Scodeler

BACKGROUND: Obesity can affect the cardiac autonomic modulation, blood lipid levels and the physical capacity. OBJECTIVE: To study the effect of obesity on the heart rate variability (HRV), blood lipid levels and physical capacity of obese children. METHODS: Thirty children aged 9 to 11 years were studied, divided in two groups: a) 15 obese children (O) aged 10.2 ± 0.7 years and body mass index (BMI) between the 95th and the 97th percentiles; b) 15 non-obese children (NO) aged 9.8 ± 0.7 years and BMI between the 5th and 85th percentiles. All children were submitted to an anthropometric and clinical assessment, analysis of the HRV at rest and a physical exercise protocol (PEP). Non-parametric tests were used to compare the variables between the groups. The level of significance was set at p < 0.05. RESULTS: The waist circumference and levels of triglycerides were higher in O. The cardiac sympathetic activity in the standing position in normalized units (LF n.u.) was higher in O, 71.4%, when compared to NO, 56.3%. The low frequency/high frequency ratio (LF/HF) was 3.8 in O and 1.7 in NO. The PEP showed differences between the groups, with higher values observed in NO children regarding the total distance, time of exposure to PEP, peak oxygen consumption (VO2 peak) and metabolic equivalent (MET). CONCLUSION: Obesity in children resulted in alterations in cardiac autonomic control in the standing position and decreased the physical capacity.

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Editoriais

Children with adult hearts

Isabela de Carlos Back Giuliano et al. Bruno Caramelli Bruce Bartholow Duncan Lucia Campos Pellanda

EDITORIAL

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Página do Presidente

The 64th edition of the Brazilian Congress of Cardiology confirms the internationalization of the event

Antonio Carlos Palandri Chagas

THE PRESIDENT’S PAGE

The 64^th edition of the Brazilian Congress of Cardiology confirms the internationalization of the event

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Artigo Original

Severity of angiographic coronary obstruction and the apolipoprotein E polymorphism in acute coronary syndromes

Arlisa Monteiro de Castro Dias et al. Amália Faria dos Reis Claudia Guerra Murad Saud Maria das Graças Leitão Chilinque … Rafaela Ferreira Leite Rosemery Nunes Cardoso Abdalah Mariana Ferreira Fiqueiredo Georgina Severo Ribeiro Carlos Augusto Cardozo de Faria

BACKGROUND: There is evidence of the association between the apolipoprotein E (APOE) and coronary disease; however, there are controversies. OBJECTIVE: To evaluate the association between the number of coronary vessels with significant obstruction defined by angiography, the APOE polymorphism and clinical variables. METHODS: This was a cross-sectional, multicenter study with 207 patients (138 men), with acute coronary syndrome (ACS), in the city of Niteroi, state of Rio de Janeiro, Brazil, who underwent coronary angiography and genotype determination for the APOE *2*3*4 polymorphism by the Restriction Fragment Length Polymorphism (RFLP) method. RESULTS: The frequency of the alleles was APOE *2 – 6.8%, *3 – 82.5%, *4 – 10.7%. Regarding the number of affected vessels, 27% of patients presented monoarterial obstruction, 33.8% biarterial and 39.1% triarterial and/or left coronary trunk. The degree of multivascular lesion did not correlate with the presence of the *4 allele (p= 0.78), but with age > 55 years (p=0.025), being an ex-smoker (p=0.004) and dyslipidemia (p=0.05) at the multivariate analysis and also with previous coronary artery disease (CAD) (p=0.05), diabetes (p=0.038) and metabolic syndrome (p=0.021) at the univariate analysis. The prevalence of dyslipidemia, diabetes and systemic arterial hypertension (SAH) was elevated regarding similar studies, with progressive increases in the prevalence of SAH (p=0.59) and diabetes (p=0.06), according to the number of affected vessels. CONCLUSION: The APOE polymorphism was not associated with the number of coronary vessels with significant obstruction at any age range. On the other hand, age > 55 years, being an ex-smoker and dyslipidemia associated with the multivascular lesion.

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Artigo Original

Body mass index has a good correlation with proatherosclerotic profile in children and adolescents

Geodete Batista Costa et al. Naira Horta Zulmira Freire Resende Graziela Souza … Larissa Machado de Farias Barreto Luis Henrique Correia Thiago Augusto Nascimento Clay Barreto Rios José Augusto Barreto-Filho Heno Ferreira Lopes

BACKGROUND: More recently, the association of different risk factors has been described as the metabolic syndrome. Different definitions are being used for the same syndrome. Regardless of the name or classification, it has been well established that a cardiovascular cluster including overweight/obesity, increased blood pressure, and lipid and glucose abnormalities are associated with an increased risk of atherosclerosis in adults. OBJECTIVE: The aim of this study was to correlate body mass index percentiles with blood pressure, insulin resistance index, and lipid profiles in children and adolescents, which characterize a proatherosclerotic profile. METHODS: Cardiovascular risk factor clusters were evaluated in 118 children and adolescents divided according to body mass index percentile (BMIP) quartiles: Q1 (n=23) with BMIP 93%. Statistically significant differences were not observed for age (F=2.1; p=0.10); sex (chi-square test=3.0; p=0.38), and ethnicity (chi-square test=4.7; p=0.20) between different quartiles. RESULTS: A statistically significant difference was observed for systolic BP (F=15.4; p<0.0001), diastolic BP (F=9.5; p<0.0001), glycemia (F=9.6; p<0.0001), insulin (F=12.9; p<0.0001), HOMAir (F=30.8; p<0.0001), and triglyceride levels (F=2.7; p=0.05) between the different quartiles. CONCLUSION: Excess weight evaluated by BMIP was associated with increased blood pressure, triglycerides, HOMAir index, and low HDL-cholesterol, a proatherosclerotic profile in children and adolescents.

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Artigo Original

Obesity and its association with other cardiovascular risk factors in school children in Itapetininga, Brazil

Abel Pereira et al. Alexis D. Guedes Ieda T.N. Verreschi Raul D. Santos Tânia L.R. Martinez

BACKGROUND: Paucity of data on childhood obesity and cardiovascular risk in Brazil. OBJECTIVE: To determine the prevalence of hypertension, dyslipidemia, obesity and their correlations in a sample of school children in Itapetininga, State of Sao Paulo, Brazil. METHODS: Cross-sectional study with systematic collection of anthropometric data (weight, height, waist circumference, BMI and blood pressure levels) and determination of glucose, total cholesterol, LDL, HDL, uric acid, and apolipoproteins A and B in a random sample representative of school children from the public education system in Itapetininga, State of Sao Paulo. For data analysis, we used population parameters from the NCHS curves (2000), blood pressure categories from NHBPEP (2004), and the serum cholesterol levels proposed by the AHA for children and adolescents (2003). RESULTS: A total of 494 children and adolescents participated in the study. Of these, 11.7% had HBP, 51% increased total cholesterol, 40.5% increased LDL-cholesterol, 8.5% increased triglycerides, and 6.1% low HDL-cholesterol levels. Mean (± standard deviation) TC, HDL-cholesterol, LDL-cholesterol and triglycerides were 172.1(27.9), 48.1(10.0), 105.7(23.1) and 90.9(43.8), respectively. Obesity and overweight were detected in 12.8% and 9.7% of the sample, respectively. Individuals of the obese group had a greater chance of presenting with dyslipidemia and hypertension in comparison with those of the other groups. CONCLUSION: This study supports the hypothesis of different prevalences of excess weight among school children from the public education system of the northeastern and southeastern regions of Brazil, with higher rates in the latter. Additionally, it demonstrates an association of obesity with dyslipidemia and hypertension in that group. In light of the paucity of Brazilian data on this issue, our study provides important data for further comparisons.

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Review Article

Joint hypermobility in patients with mitral valve prolapse

Simone Cavenaghi et al. Lais Helena Carvalho Marino Patrícia Pantaleão Oliveira Neuseli Marino Lamari

Studies on hypermobility have aroused great interest in the last decades, as they are associated to musculoskeletal disorders, as well as abnormalities in several organic systems, such as the mitral valve prolapse. Therefore, in this study, data on the association between joint hypermobility and the mitral valve prolapse were investigated and reviewed. Studies in the literature have shown that genetic alterations in the collagen composition seem to be the main cause of this association.

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Correlação Anatomoclínica

Case 4/2009: a 55-year-old male patient with Chagas cardiomyopathy who developed progressive worsening of dyspnea, chest pain and pulmonary interstitial infiltrate

Angela Cristina Matera Bolonhez et al. Murilo Capreti da Silva Rodrigo Caruso Chate Paulo Sampaio Gutierrez

ORIGINAL ARTICLE

Case 4/2009 a 55-year-old male patient with Chagas cardiomyopathy who developed progressive worsening of dyspnea, chest pain and pulmonary interstitial infiltrate

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Artigo Original

Reversal atrial electrical remodeling following cardioversion of long-standing lone atrial fibrillation

Eduardo Correa Barbosa et al. Paulo Roberto Benchimol-Barbosa Alfredo de Souza Bomfim Plínio José da Rocha … Silvia Helena Cardoso Boghossian Denilson Campos de Albuquerque

BACKGROUND: Atrial fibrillation (AF) itself promotes electrophysiological changes, termed “electrical remodeling”, facilitating its recurrence and maintenance. There is evidence that the remodeling process is reversible after restoration of the sinus rhythm (SR). However, the timing for the recovery of electrophysiological properties is still undefined. OBJECTIVE: The aim of this study was to assess the atrial electrical activation using P-wave signal-averaged electrocardiogram (P-SAECG) post-cardioversion of long-standing AF, focusing on the reversal remodeling process to identify the timing of the process stabilization. METHODS: Subjects with lone persistent AF, eligible for cardioversion and successfully converted to SR, were enrolled at the study. SAECG was performed immediately after reversion to SR and repeated on days seven and thirty. RESULTS: Of 31 subjects, nine presented early recurrence of atrial fibrillation, all of them in the first seven days post-cardioversion; 22 remained in SR for at last one month and SAECG was obtained on days seven and thirty after cardioversion. In the latter, P-wave duration progressively abated from the first to the third SAECG (P-wave duration: 185.5±41.9 ms vs 171.7±40.5 ms vs 156.7±34.9 ms, respectively, first, second and third SAECG; p<0.001 for all matches). In the frequency domain analysis, spectral turbulence was not apparent in SAECG immediately post-cardioversion, but sharply increased on day seven and remained unchanged on day thirty. CONCLUSION: This study suggests that the first seven days post-cardioversion of long standing AF are critical for reversal remodeling process and arrhythmia recurrence.

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