2012;98(3) – ABC CARDIOL

Review Article

Gastrointestinal changes associated to heart failure

Fernando G. Romeiro et al. Katashi Okoshi Leonardo A. M. Zornoff Marina P. Okoshi

Over the last decade, several studies were conducted on the gastrointestinal changes associated to chronic heart failure. This article presents a literature review on the physiopathology and clinical consequences of pathological digestive changes of heart failure patients. Structural and functional abnormalities of the gastrointestinal tract, such as edema of absorptive mucosa and intestinal bacterial overgrowth, have been leading to serious clinical consequences. Some of these consequences are cardiac cachexia, systemic inflammatory activation and anemia. These conditions, alone or in combination, may lead to worsening of the pre-existing ventricular dysfunction. Although currently there is no therapy specifically earmarked for gastrointestinal changes associated to heart failure, the understanding of digestive abnormalities is germane for the prevention and management of systemic consequences.

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Case Report

Papillary fibroelastoma: report of seven cases

Lucas Cronemberger Maia Mendes et al. Jônatas Melo Neto Jonathan Batista Souza Edileide de Barros Correia … Mabel de Moura Barros Zamorano Lílian Mary da Silva

The papillary fibroelastoma (PFE) is a benign heart tumor, mainly found in the valves. Most tumors are asymptomatic, but when present, they are nonspecific or related to embolic phenomena. They are usually diagnosed at routine imaging studies or valve surgery and autopsies. Its treatment is controversial, due to its rarity. We describe seven PFE cases diagnosed and treated at our institution between 1989 and 2010, which constitutes the largest national case series study of this pathology to date.

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Letter to the Editor

The polyvalence of C-reactive protein in coronary artery bypass grafting

Marco Túlio Zanettini et al. Jacira Pisani Zanettini João Otávio Zanettini

LETTER TO THE EDITOR

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Point of view

Why publish in national journals?

Max Grinberg et al. Maria Cecília Solimene Maria do Carmo Cavarette Barreto

The reluctance of Brazilian authors to publish in Brazilian journals is historical and no longer justified. Currently, several Brazilian journals are indexed in international databases, of which English versions allow disclosure of our studies to foreign countries. The authors express their views on the importance of publishing in national journals and cite the example of the impact of publications from Instituto do Coração – InCor-HCFMUSP in the past two years.

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Artigo Original

Tendency of mortality in acute myocardial infarction in Curitiba (PR) in the period of 1998 to 2009

Cristina Pellegrino Baena et al. Márcia Olandoski Karin Regina Luhm Constantino Ortiz Costantini … Luiz César Guarita-Souza José Rocha Faria-Neto

BACKGROUND: Acute Myocardial Infarction (AMI) is the single leading cause of death among non-transmitted chronic diseases in Brazil. The knowledge of mortality trends is necessary for planning prevention strategies. OBJECTIVE: To evaluate trends in mortality from myocardial infarction in the period from 1998 to 2009 in Curitiba (PR), their distribution by gender, age and their impact in reducing the absolute number of deaths from this disease in this period. METHODS: Demographic data were obtained from the Brazilian Institute of Geography and Statistics (IBGE) and death data were obtained from the Mortality Information System of the Ministry of Health, considering gender, age and residence. From the fit of a Poisson regression model we estimated mortality rates and expected number of deaths that were not observed. RESULTS: We found significant downward trend (p < 0.001) in the period. The estimated average reduction in death rate from AMI each year was 3.8% (95% CI: 3.2% – 4.5%). There was no significant difference between genders (p = 0.238), although the evolution of age-specific standard mortality rates differed significantly between the groups (p = 0.018). It is estimated that the annual reduction of 3.8% in the mortality rate has resulted in 2,168 deaths below the number expected given the mortality rate observed in 1998 and projecting that number on the population growth occurred during the study period. CONCLUSION: Although it remains an important cause of death, mortality from AMI decreased significantly during the evaluation period

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Anatomopathological Session

Case 1: hypertensive 58-year-old woman with hepatic nodules presented dyspnea and pleural effusion one week after an episode of pulmonary embolism

Tânia Marie Ogawa et al. Ricardo Mauro Ghetti Cabral Vera Demarchi Aiello

ANATOMOPATHOLOGICAL SESSION

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Case Report

Dynamic myocardial perfusion imaging by dual-source computed tomography

José Rodrigues Parga Filho et al. Cintia Souza Lima Moraes Lima Felipe Gallego Lima Tiago da Silveira Jaques … Luiz Francisco Rodrigues de Ávila Roberto Kalil Filho

We report a dual-source computed tomography study of dynamic and quantitative myocardial perfusion in a 44-year-old patient with previous documented coronary artery disease. Quantitatively, the tomography showed myocardial perfusion deficit in the territories with significant coronary stenosis, confirmed by computed tomography angiography and conventional angiography. Dual-source computed tomography allowed dynamic perfusion and anatomic evaluation in a single study during the follow-up of this patient.

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Artigo Original

Prognostic value of fasting glucose levels in elderly patients with acute coronary syndrome

Adriane Monserrat Ramos et al. Lucia Campos Pellanda Pedro Lima Vieira Daniel Pinto Ribeiro … Eduardo Menti Vera Lúcia Portal

BACKGROUND: The fasting plasma glucose (FPG) test is a predictor of complications after Acute Coronary Syndrome (ACS). However, its prognostic value is not yet fully established in different age groups. OBJECTIVE: To evaluate the role of admission fasting plasma glucose (FPG) as a predictor of 30 days after ACS, and the association of hyperglycemia with major cardiovascular events (MACE): death, reinfarction and coronary artery bypass grafting, in two different age groups (65 year-old patients). METHODS: Contemporary cohort of patients hospitalized for ACS in the Institute of Cardiology of Rio Grande do Sul (Southern Brazil). In the first 24 hours of admission, patients answered a questionnaire with clinical information and had peripheral blood collected for measurement of FPG. Patients were followed up during hospitalization and for 30 days for the presence of MACE. Statistical analyses were performed using the SPSS 15.0 with the chi-square or Fisher Exact test (categorical variables) and the Student t test (numerical variables). Multivariate analysis was performed. RESULTS: 580 patients were included in the study. Mean age was 61.2 (Â±12.3) years, with 38.6% of the patients (224) >65 years old, and 67.7% (393) were male. Multivariable analysis showed that, after 30 days of follow-up, only FPG (OR= 1.01, 95% CI:1.00-1.01, P= 0.001) was associated with MACE in both age groups. CONCLUSION: Admission FPG was an independent predictor for MACE in the early phase of ACS.

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Artigo Original

Vitamin d deficiency is associated with increased il-17 and tnfα levels in patients with chronic heart failure

Milena Milovanovic et al. Gordana Pesic Valentina Nikolic Tatjana Jevtovic-Stoimenov … Karin Vasic Zorica Jovic Marina Deljanin-Ilic Srdjan Pesic

BACKGROUND: Recent studies revealed a strong association between vitamin D (VD) status and chronic heart failure (CHF). It is now commonly considered that proinflammatory immune response underlies CHF development. OBJECTIVE: Since VD expresses anti-inflammatory properties, we investigated its impact on cytokines implicated in CHF, such as TNFα and IL-17, in patients suffering from CHF. METHODS: Blood was obtained from forty patients with CHF secondary to hypertension and/or coronary heart disease. VD status, IL-17 and TNFαlevels were assessed using 25-hydroxy VD3 EIA and cytokine ELISAs. Clinical assessment and echocardiography was also performed. RESULTS: Elderly patients with CHF in Nis (Southeast Europe, latitude 43ºN) exhibited 25-hydroxy VD3 levels below normal. Our data identified that patients with CHF secondary to hypertension have significantly lower 25-hydroxy VD3, increased TNFα and IL-17A levels in comparison to donors with CHF secondary to coronary disease. CONCLUSION: This study reveals that even in regions with a lot of sunny days VD deficiency represents a concerning issue. Data suggest that impaired VD status contributes to high IL-17 and TNFα levels and thereby may support CHF development.

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Artigo Original

Assessment of aortic valve area combining echocardiography and magnetic resonance imaging

Werner Nickl et al. Reiner Füth Jan Smettan Till Köhler … Mark Lankisch Frank Kramer Thomas Krahn Michael Coll Barroso Rolf Michael Klein Wilfried Dinh

BACKGROUND: Transthoracic echocardiography (TTE) is routinely used to calculate aortic valve area (AVA) by continuity equation (CE). However, accurate measurement of the left ventricular outflow tract (LVOT) can be difficult and flow acceleration in the LVOT may lead to miscalculation of the AVA. OBJECTIVE: The aim of our study was to compare AVA measurements by standard TTE, cardiac magnetic resonance imaging (MRI) and a hybrid approach combining both techniques. METHODS: AVA was calculated in 38 patients (age 73±9 years) with standard TTE, cine-MRI planimetry and a hybrid approach: Hybrid Method 1: TTE-derived LVOT measurement in the CE numerator was replaced by the MRI assessment of the LVOT and AVA was calculated: (LVOT MRI/*LVOT-VTI TTE)/transaortic-VTI TTE. Method 2: We replaced the SV in the numerator by the MRI-derived SV and calculated AVA = SV MRI/ transaortic-VTI TTE. RESULTS: Mean AVA derived by TTE was 0.86 cm²±0.23 cm² and 0.83 cm²±0.3 cm² by MRI- planimetry, respectively. The mean absolute difference in AVA was 0.03cm² for TTE vs. MRI planimetry. AVA calculated with method 1 and method 2 was 1.23 cm²±0.4cm² and 0.92cm²±0.32cm², respectively. The mean absolute difference between TTE and method 1 and method 2 was 0.37cm² and 0.06cm², respectively (p<0.001). CONCLUSION: MRI-planimetry of AVA and hybrid method 2 are accurate and showed a good agreement with standard TTE measurements. Therefore, hybrid method 1 is a reasonable alternative if poor acoustic windows or LVOT flow accelerations limit the accuracy of TTE, particularly in patients at high risk for an invasive hemodynamic study.

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Artigo Original

Myocardial remodeling after large infarcts in rat converts post rest-potentiation in force decay

Danilo Sales Bocalini et al. Leonardo dos Santos Ednei Luiz Antonio Alexandra Alberta dos Santos … Ana Paula Davel Luciana V. Rossoni Dalto Valentim Vassalo Paulo José Ferreira Tucci

BACKGROUND: Post-rest contraction (PRC) of cardiac muscle provides indirect information about the intracellular calcium handling. OBJECTIVE: Our aim was to study the behavior of PRC, and its underlying mechanisms, in rats with myocardial infarction. METHODS: Six weeks after coronary occlusion, the contractility of papillary muscles (PM) obtained from sham-operated (C, n=17), moderate infarcted (MMI, n=10) and large infarcted (LMI, n=14) rats was evaluated, following rest intervals of 10 to 60 seconds before and after incubation with lithium chloride (Li+) substituting sodium chloride or ryanodine (Ry). Protein expression of SR Ca(2+)-ATPase (SERCA2), Na+/Ca2+ exchanger (NCX), phospholamban (PLB) and phospho-Ser(16)-PLB were analyzed by Western blotting. RESULTS: MMI exhibited reduced PRC potentiation when compared to C. Opposing the normal potentiation for C, post-rest decays of force were observed in LMI muscles. In addition, Ry blocked PRC decay or potentiation observed in LMI and C; Li+ inhibited NCX and converted PRC decay to potentiation in LMI. Although MMI and LMI presented decreased SERCA2 (72±7% and 47±9% of Control, respectively) and phospho-Ser16-PLB (75±5% and 46±11%, respectively) protein expression, overexpression of NCX (175±20%) was only observed in LMI muscles. CONCLUSION: Our results showed, for the first time ever, that myocardial remodeling after MI in rats may change the regular potentiation to post-rest decay by affecting myocyte Ca(2+) handling proteins.

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Artigo Original

Carvedilol attenuates oxidative stress in chronic chagasic cardiomyopathy

Patrícia Budni et al. Roberto Coury Pedrosa Thais Regina Garlet Eduardo Monguilhott Dalmarco … Juliana Bastos Dalmarco Manuel Rosa de Oliveira Lino Edésio Luiz Simionato Jorge Antônio Amara Tânia Sílvia Frode Danilo Wilhelm Filho

BACKGROUND: There is increasing evidence suggesting that Chagas disease involves oxidative damage and contributes to heart disease progression. OBJECTIVE: To evaluate the effect of carvedilol on oxidative stress markers in chronic Chagas disease. METHODS: The study population included 42 patients with Chagas cardiomyopathy and oxidative stress biomarkers were measured before and after a period of six months of treatment with carvedilol (37.5 mg/day). Patients were considered according to the Los Andes classification and the activity of superoxide dismutase, catalase, glutathione peroxidase, S-transferase and reductase, myeloperoxidase and adenosine deaminase; levels of reduced glutathione, thiobarbituric acid reactive species, carbonyl protein, vitamin E and nitric oxide were measured in blood. RESULTS: After treatment with carvedilol, all groups showed significant reductions in levels of carbonyl protein and reduced glutathione, whereas the levels of nitric oxide and adenosine activity increased significantly only in group IA. Moreover, most of the antioxidant enzymes showed decrease in activity in groups IA and IB. CONCLUSION: The data suggest that treatment with carvedilol was effective in attenuating oxidative damage, an effect that may be particularly important in patients with chronic Chagas’ disease cardiomyopathy.

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Artigo Original

Use of fluorescence in a modified disector method to estimate the number of myocytes in cardiac tissue

Rômulo Dias Novaes et al. Arlete Rita Penitente André Talvani Antônio José Natali … Clóvis Andrade Neves Izabel Regina Santos Costa Maldonado

BACKGROUND: Conventional disector methods currently require considerable financial, technical and operational costs to estimate the number of cells, including cardyomyocytes, in a 3D area. OBJECTIVE: To use fluorescence microscopy in a modified disector method to determine the number of myocytes in cardiac tissue in normal and pathological conditions. METHODS: The study employed four-month-old male Wistar rats with weight of 366.25 ± 88.21g randomized in control (CG, n=8) and infected (IG, n=8) groups. IG animals were inoculated with T. cruzi Y strain (300,000 trypomastigotes/50g wt). After eight weeks, the animals were weighted and euthanized. The left ventricles (LV) were removed for stereological analysis of numerical density of cardiomyocytes (Nv[c]) and total number of these cells in the LV (N[c]). These parameters were estimated using a fluorescent disector (FD) and compared with the conventional optical (OD) and physical (PD) disector methods. RESULTS: In both disector methods, IG animals presented significant decrease of Nv[c] and N[c] compared to CG animals (P 0.05). A strong correlation, equal or above 96%, was obtained between FD, OD and PD. CONCLUSION: The FD method seems to be equally reliable to determine Nv[c] and N[c] in normal and pathological conditions and presents some advantages compared to conventional disector methods: reduction of histological slices and images in the stereological analysis, reduction of time to analyze the images, construction of FD in simple microscopes using the epifluorescence mode, distinction of disector planes in lower magnifications.

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Artigo Original

Multislice coronary angiotomography in the assessment of coronary artery anomalous origin

Daniel Rocha Rabelo et al. Márcio Vinicius Lins Barros Maria do Carmo Pereira Nunes Cristiane Carneiro C. Oliveira Maria Helena Albernaz Siqueira

Background: Anomalous origin of coronary arteries is a relatively rare entity, which may show different clinical forms and develop an adverse outcome. Multislice coronary angiotomography has gained importance in daily clinical practice, representing an important patient assessment method with great potential in the anatomical evaluation of these arteries. Objective: This study aimed to describe angiotomographic findings and evolution of patients with anomalous origin of coronary arteries. Methods: From January 2008 to March 2011 404 patients were evaluated consecutively, who had been referred for coronary angiotomography for several reasons, with a mean follow-up of 21 months. Results: Nine patients (2.2%) had anomalous origin of coronary arteries, of which four had an anomalous origin of the Circumflex (Cx) artery in the Right Coronary Artery (RCA), two had anomalous origin of the RCA (one originating from the Cx and one in the left coronary sinus), a patient with single coronary trunk (anterior descending and Cx out of the left coronary sinus), one had anomalous left main coronary artery trajectory between the aorta and pulmonary artery and one patient with left coronary trunk originating from the right coronary sinus. Of the evaluated patients, one received an implantable cardiodefibrillator; one died due to sudden death during hospitalization; and the others showed no complications. Conclusion: The multislice coronary angiotomography represents minimally invasive assessment method that allows detecting the origin, course and termination of anomalous coronary arteries with excellent accuracy, allowing the correct diagnosis and aiding therapeutic planning.

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