2017;109(6) – ABC CARDIOL

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Diagnosis and Treatment of Rare Complication after Endomyocardial Biopsy

Viviane Tiemi Hotta et al. Daniella Diniz do Nascimento Rangel Glaucia Maria Penha Tavares Sandrigo Mangini Pedro A. Lemos

Endomyocardial biopsy (EBM) is the gold standard method for the diagnosis of rejection after cardiac transplantation. Complications associated with the procedure are rare but can occur in about 8% of the cases. We describe a case of an uncommon complication probably associated with multiple EBMs in a transplanted patient. A 54-year-old male patient underwent orthotopic cardiac transplantation due to idiopathic dilated cardiomyopathy. Over the next ten months, the patient was submitted to eight EMBs and required pulse therapy on two occasions. In the routine outpatient evaluation, continuous systo diastolic murmur was observed in the left lower parasternal border and significant worsening of renal function. A transthoracic echocardiogram was performed, showing high velocity, right-sided apical flow on the color flow mapping and a significant dilation of the anterior descending coronary artery (ADA). The ADA presented significant dilatation with signs of communication with the right ventricle in the apical region, suggesting the diagnosis of coronary fistula ( and ). Coronary angiography revealed aneurysmal ADA and vascular remodeling due to hyperflow, confirming the diagnosis of coronary-cavitary fistula (). The patient was submitted to percutaneous closure of the coronary fistula with Coil Vortex-18 device and presented good clinical evolution and improvement of renal function. It is important to consider the risks associated with EBM. Echocardiography is a valuable method for the evaluation of patients with suspected complications after the procedure. This case describes a rare complication after EBM and the diagnosis of which was possible by echocardiographic evaluation.

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Viewpoint

Lung Ultrasound: The Cardiologists' New Friend

Marcelo Haertel Miglioranza et al. Antonio Carlos Sobral Sousa Caroline de Souza Costa Araujo Marcos Antonio Almeida-Santos Luna Gargani

The role of pulmonary congestion in heart failure and the limits of the traditional clinical examination

Pulmonary congestion, such as low cardiac output, is a preponderant element in patients with heart failure (HF), which is considered an important cause of hospital admissions and death.^, Thus, the identification of pulmonary extravascular fluid in patients with HF can be used as an aid in strategies to optimize clinical therapy.

Traditionally, assessment of pulmonary congestion has been based on the patient’s clinical status and physical examination. However, this evaluation presents limitations even for skilled professionals, showing high specificity, but low sensitivity for the detection of pulmonary congestion.^, Thus, cases of decompensation are often recognized at a very late stage of clinical congestion, so frequent hospitalizations are not avoided. In the cascade of congestion, the clinical manifestation represents a final stage, different from hemodynamic congestion (increase in left ventricular filling pressure), which is pulmonary and systemic. Pulmonary congestion corresponds specifically to the presence of extravascular pulmonary fluid, which can be evaluated by lung ultrasound.

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Case Report

Superior Vena Cava Syndrome after Radiofrequency Catheter Ablation for Atrial Fibrillation

Maria Luciana Zacarias Hannouche da Trindade et al. Ana Clara Tude Rodrigues Cristiano Faria Pisani Rafael Bonafim Piveta … Samira Saady Morhy Maurício Ibrahim Scanavacca

Introduction

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in clinical practice. Its prevalence increases with age, and it is commonly associated with structural heart diseases, leading to hemodynamic and thromboembolic complications with significant economical implications and increasing morbimortality.^, The AF ablation techniques, when carried out by experienced operators, have proved to be safe and to yield quite satisfactory results, but in some patients it is necessary to approach extra-venous focuses, such as the left atrial appendage, coronary sinus and superior vena cava. AF ablation is a complex procedure, not without risks. Important complications have been reported, including cerebrovascular accidents, pulmonary vein stenosis and atrioesophageal fistula.^, We report here a case of superior vena cava syndrome after radiofrequency ablation for AF.

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Editorial

The Challenge of Eight Years as Arquivos Brasileiros de Cardiologia Editor-in-Chief

Luiz Felipe P. Moreira

When we took over as Editor-in-Chief of Arquivos Brasileiros de Cardiologia in January 2010, the journal was more than 60 years old and had already attained complete maturity from the huge work developed by the great masters of the Brazilian cardiology who had preceded us as Editors. Present in the most relevant international citation indexing services, the Arquivos Brasileiros de Cardiologia is the major outreach channel of the Brazilian scientific research in cardiovascular diseases, representing the major asset of the Brazilian Society of Cardiology. Several suggestions were implanted aimed at consolidating our editorial structure and reaching the position as the major scientific forum in cardiology in Latin America.

In the past eight years, the trajectory of the Arquivos Brasileiros de Cardiologia was characterized mainly by actions to improve its editorial process and to incorporate new edition technologies and new digital media. To face the great demand of the manuscripts submitted to publishing, which nowadays add up to 500 articles per year, the Arquivos Brasileiros de Cardiologia improved their electronic submission system and the review and editing processes, ensuring faster responses to the authors and better editorial quality publishing of the articles selected. Currently, the mean time of assessment and correction of the articles is around four months, while that time for Portuguese and English language publications is around four to five months. In addition, we provide the authors with the previous publishing of their articles in PubMed within less than eight months from their initial submission, guaranteeing the researchers the fast insertion of their work in the international literature. In parallel, we strived to incorporate the major editorial practices of the most prestigious international journals, such as the policies recommended by the International Committee of Medical Journal Editors (ICMJE) and the Association of the Editors of the European Society of Cardiology-affiliated journals, in addition to the inclusion of processes of language review, statistical review and antiplagiarism. Available in the electronic pdf format since 2011, the Arquivos Brasileiros de Cardiologia have counted since July 2012 with formats compatible with most tablets and smartphones, facilitating integral access to the journal in the major electronic media access systems.

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Editorial

Potential of Family Health Strategy Against Cardiovascular Disease

Gilberto Andrade Tavares et al. José Augusto Soares Barreto-Filho

Introduction

It is estimated that one out of three adults in the United States of America (USA) has one type of cardiovascular disease (CVD), acute myocardial infarction (AMI) being the major condition. In the USA, more than one million individuals per year are estimated to experience AMI. In Brazil, in 2011, 384,615 deaths were attributed to CVD. In 2010, the American Heart Association recommended the assessment of seven metrics related to cardiovascular health (CVH), which could have a great impact on the CVD control. According to the patient adherence to the seven metrics or their control, those metrics (smoking cessation, balanced healthy diet, physical activity practice, and control of body mass, blood pressure, cholesterol and glycemia) were classified as “ideal”, “intermediate” and “poor”, and the goal is to reduce by 20% the deaths from CVD in the USA by 2020.

Several countries have met that recommendation to assess the CVH of their populations. In China, individuals with “ideal” CVH had general mortality 30% lower than that of individuals with “poor” CVH. Regarding mortality from CVD specifically, there was a 39% reduction. In South Korea, the reduction was of 58% for all-cause mortality, and of 90% for mortality from CVD. In Brazil, based on data from the 2013 National Health Survey, only 1% of the Brazilian population reached an “ideal” level regarding the seven metrics. When the metrics were considered in isolation, only 3.2% of that population had an “ideal” diet, 23.6% of that population had an “ideal” physical activity practice, and 43.7% of that population had an “ideal” body mass index (BMI). Women had a higher prevalence of “ideal” levels regarding smoking (89.5%). Better levels of blood pressure (77.7%) and total cholesterol (87.3%) were found among men.

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Original Article

Bone-Marrow-Derived Mesenchymal Stromal Cells (MSC) from Diabetic and Nondiabetic Rats Have Similar Therapeutic Potentials

Vitória Santório de São José et al. Gustavo Monnerat Barbara Guerra Bruno Dias Paredes … Tais Hanae Kasai-Brunswick Antonio Carlos Campos de Carvalho Emiliano Medei

Abstract

Background:

Diabetes mellitus is a severe chronic disease leading to systemic complications, including cardiovascular dysfunction. Previous cell therapy studies have obtained promising results with the use bone marrow mesenchymal stromal cells derived from healthy animals (MSCc) in diabetes animal models. However, the ability of MSC derived from diabetic rats to improve functional cardiac parameters is still unknown.

Objectives:

To investigate whether bone-marrow-derived MSC from diabetic rats (MSCd) would contribute to recover metabolic and cardiac electrical properties in other diabetic rats.

Methods:

Diabetes was induced in Wistar rats with streptozotocin. MSCs were characterized by flow cytometry, morphological analysis, and immunohistochemistry. Cardiac electrical function was analyzed using recordings of ventricular action potential. Differences between variables were considered significant when p < 0.05.

Results:

In vitro properties of MSCc and MSCd were evaluated. Both cell types presented similar morphology, growth kinetics, and mesenchymal profile, and could differentiate into adipogenic and osteogenic lineages. However, in an assay for fibroblast colony-forming units (CFU-F), MSCd formed more colonies than MSCc when cultured in expansion medium with or without hydrocortisone (1 µM). In order to compare the therapeutic potential of the cells, the animals were divided into four experimental groups: nondiabetic (CTRL), diabetic (DM), diabetic treated with MSCc (DM + MSCc), and diabetic treated with MSCd (DM + MSCd). The treated groups received a single injection of MSC 4 weeks after the development of diabetes. MSCc and MSCd controlled hyperglycemia and body weight loss and improved cardiac electrical remodeling in diabetic rats.

Conclusions:

MSCd and MSCc have similar in vitro properties and therapeutic potential in a rat model of diabetes induced with streptozotocin.

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Letter to the Editor

Cardiac Autonomic Functions May be Influenced by Body Weight

To the Editor,

I read the paper by Silva et al. entitled ‘‘Sensitivity, Specificity and Predictive Value of Heart Rate Variability Indices in Type 1 Diabetes Mellitus’’ published in Arquivos Brasileiros de Cardiologia in March 2017. They aimed to compare Heart Rate Variability (HRV) indices and evaluate their sensitivity, specificity, and predictive value in young type 1 diabetic patients and healthy volunteers. It was showed a decrease in sympathetic and parasympathetic activities, as well as overall variability of autonomic nervous system in the diabetic group. I would like to congratulate Silva et al. for their valuable effort in this study. I also have a few comments to do.

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Original Article

Characterization of Cardiopulmonary Exercise Testing Variables in Patients with Endomyocardial Fibrosis after Endocardial Resection

Ana Luiza C. Sayegh et al. Marcelo R. dos Santos Patricia de Oliveira Fábio Fernandes … Eduardo Rondon Francis R. de Souza Vera M. C. Salemi Maria Janieire de N. N. Alves Charles Mady

Abstract

Background:

Endomyocardial fibrosis (EMF) is a rare disease, characterized by diastolic dysfunction which leads to reduced peak oxygen consumption (VO₂). Cardiopulmonary exercise testing (CPET) has been proved to be a fundamental tool to identify central and peripheral alterations. However, most studies prioritize peak VO₂ as the main variable, leaving aside other important CPET variables that can specify the severity of the disease and guide the clinical treatment.

Objective:

The aim of this study was to evaluate central and peripheral limitations in symptomatic patients with EMF by different CPET variables.

Methods:

Twenty-six EMF patients (functional class III, NYHA) were compared with 15 healthy subjects (HS). Functional capacity was evaluated using CPET and diastolic and systolic functions were evaluated by echocardiography.

Results:

Age and gender were similar between EMF patients and HS. Left ventricular ejection fraction was normal in EMF patients, but decreased compared to HS. Peak heart rate, peak workload, peak VO₂, peak oxygen (O₂) pulse and peak pulmonary ventilation (V_E) were decreased in EMF compared to HS. Also, EMF patients showed increased Δ heart rate /Δ oxygen uptake and Δ oxygen uptake /Δ work rate compared to HS.

Conclusion:

Determination of the aerobic capacity by noninvasive respiratory gas exchange during incremental exercise provides additional information about the exercise tolerance in patients with EMF. The analysis of different CPET variables is necessary to help us understand more about the central and peripheral alterations cause by both diastolic dysfunction and restrictive pattern.

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Anatomopathological Session

Case 6/2017 – A 28-Year-Old Man with Anasarca And Restrictive Heart Disease

Desiderio Favarato et al. Luis Alberto Benvenuti

Clinical aspects

The patient was a 28-year-old male with anasarca. There were moderate left systolic dysfunction and marked enlargement of the atria and right ventricle, with mild increase in pulmonary arterial pressure and moderate regurgitation of the atrioventricular valves.

Apparently diastolic dysfunction and dilatation of the ventricles and systolic dysfunction of the right ventricle predominated, indicating a restrictive heart disease.

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Original Article

Permanent Pacing After Transcatheter Aortic Valve Implantation: Incidence, Predictors and Evolution of Left Ventricular Function

Cláudio Monteiro et al. Andres Di Leoni Ferrari Paulo Ricardo Avancini Caramori Luiz Antonio Ferreira Carvalho … Dimytri Alexandre de Alvim Siqueira Luiz Eduardo Koenig São Thiago Marco Perin Valter C. de Lima Enio Guérios Fabio Sandoli De Brito Junior

Abstract

Background:

Transcatheter aortic valve implantation (TAVI) is a well-established procedure; however, atrioventricular block requiring permanent pacemaker implantation (PPI) is a common complication.

Objectives:

To determine the incidence, predictors and clinical outcomes of PPI after TAVI, focusing on how PPI affects left ventricular ejection fraction (LVEF) after TAVI.

Methods:

The Brazilian Multicenter TAVI Registry included 819 patients submitted to TAVI due to severe aortic stenosis from 22 centers from January/2008 to January/2015. After exclusions, the predictors of PPI were assessed in 670 patients by use of multivariate regression. Analysis of the ROC curve was used to measure the ability of the predictors; p < 0.05 was the significance level adopted.

Results:

Within 30 days from TAVI, 135 patients (20.1%) required PPI. Those patients were older (82.5 vs. 81.1 years; p = 0.047) and mainly of the male sex (59.3% vs 45%; p = 0.003). Hospital length of stay was longer in patients submitted to PPI (mean = 15.7 ± 25.7 vs. 11.8 ± 22.9 days; p < 0.001), but PPI affected neither all-cause death (26.7% vs. 25.6%; p = 0.80) nor cardiovascular death (14.1% vs. 14.8%; p = 0.84). By use of multivariate analysis, the previous presence of right bundle-branch block (RBBB) (OR, 6.19; 3.56-10.75; p ≤ 0.001), the use of CoreValve^® prosthesis (OR, 3.16; 1.74-5.72; p ≤ 0.001) and baseline transaortic gradient > 50 mm Hg (OR, 1.86; 1.08-3.2; p = 0.025) were predictors of PPI. The estimated risk of PPI ranged from 4%, when none of those predictors was present, to 63%, in the presence of all of them. The model showed good ability to predict the need for PPI: 0.69 (95%CI: 0.64 – 0.74) in the ROC curve. The substudy of 287 echocardiograms during the 1-year follow-up showed worse LVEF course in patients submitted to PPI (p = 0.01).

Conclusion:

BRD prévio, gradiente aórtico médio > 50 mmHg e CoreValve® são preditores independentes de implante de MPD pós-TAVI. Ocorreu implante de MPD em aproximadamente 20% dos casos de TAVI, o que prolongou a internação hospitalar, mas não afetou a mortalidade. O implante de MPD afetou negativamente a FEVE pós-TAVI.

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Original Article

Predictors of Total Mortality and Echocardiographic Response for Cardiac Resynchronization Therapy: A Cohort Study

Guilherme Ferreira Gazzoni et al. Matheus Bom Fraga Andres Di Leoni Ferrari Pablo da Costa Soliz … Anibal Pires Borges Eduardo Bartholomay Carlos Antonio Abunader Kalil Vanessa Giaretta Luis Eduardo Paim Rohde

Abstract

Background:

Clinical studies demonstrate that up to 40% of patients do not respond to cardiac resynchronization therapy (CRT), thus, appropriate patient selection is critical to the success of CRT in heart failure.

Objective:

Evaluation of mortality predictors and response to CRT in the Brazilian scenario.

Methods:

Retrospective cohort study including patients submitted to CRT in a tertiary hospital in southern Brazil from 2008 to 2014. Survival was assessed through a database of the State Department of Health (RS). Predictors of echocardiographic response were evaluated using Poisson regression. Survival analysis was performed by Cox regression and Kaplan Meyer curves. A two-tailed p value less than 0.05 was considered statistically significant.

Results:

A total of 170 patients with an average follow-up of 1011 ± 632 days were included. The total mortality was 30%. The independent predictors of mortality were age (hazard ratio [HR] of 1.05, p = 0.027), previous acute myocardial infarction (AMI) (HR of 2.17, p = 0.049) and chronic obstructive pulmonary disease (COPD) (HR of 3.13, p = 0.015). The percentage of biventricular stimulation at 6 months was identified as protective factor of mortality ([HR] 0.97, p = 0.048). The independent predictors associated with the echocardiographic response were absence of mitral insufficiency, presence of left bundle branch block and percentage of biventricular stimulation.

Conclusion:

Mortality in patients submitted to CRT in a tertiary hospital was independently associated with age, presence of COPD and previous AMI. The percentage of biventricular pacing evaluated 6 months after resynchronizer implantation was independently associated with improved survival and echocardiographic response.

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Review Article

Percutaneous Intervention in ST-Elevation Myocardial Infarction: Culprit-only or Complete Revascularization?

Ana Paula Susin Osório et al. Alexandre Schaan de Quadros José Luiz da Costa Vieira Vera Lucia Portal

Abstract

The best approach of multivessel coronary artery disease in the context of acute myocardial infarction with ST segment elevation and primary percutaneous coronary intervention is one of the main reasons for controversy in cardiology. Although the main global guidelines do not recommend routine complete revascularization in these patients, recent randomized clinical trials have demonstrated benefit of this approach in reducing cardiovascular outcomes. For this reason, an adequate review of this evidence is essential in order to establish scientifically based strategy and achieve better outcomes for these patients who present with acute myocardial infarction. This review aims to present objectively the most recent evidence available on this topic.

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Original Article

Waist Circumference is Associated with Blood Pressure in Children with Normal Body Mass Index: A Cross-Sectional Analysis of 3,417 School Children

Daiane Cristina Pazin et al. Caroline Filla Rosaneli Márcia Olandoski Edna Regina Netto de Oliveira … Cristina Pellegrino Baena Alyne S Figueredo Analin Ono Baraniuk Tatiana Lorena da Luz Kaestner Luiz Cesar Guarita-Souza José Rocha Faria-Neto

Abstract

Background:

The prevalence of childhood obesity and associated conditions, such as hypertension, has become a major problem of public health. Although waist circumference (WC) is a marker of cardiovascular risk in adults, it is unclear whether this index is associated with cardiovascular risk factors in children.

Objective:

Our aim was to evaluate the association between increased WC and elevated blood pressure (BP) in children with normal body mass index (BMI) ranges.

Methods:

Cross-sectional evaluation of students between 6 and 11 years with normal BMI. WC was categorized by quartile for each age group. Normal BP was defined as values < 90th percentile, and levels above this range were considered elevated. Values of p < 0.05 were considered statistically significant.

Results:

Of the 5,037 children initially assessed, 404 (8%) were excluded for being underweight and 1,216 (24.1%) were excluded for being overweight or obese. A final sample of 3,417 children was evaluated. The prevalence of elevated BP was 10.7%. In children with WC in the lowest quartile, the prevalence of elevated BP was 8.1%. This prevalence increased in upper quartiles: 10.6% in the second, 12.4% in third and 12.1% in the upper quartile. So, in this group, being in the highest WC quartile was associated with a 57% higher likelihood to present elevated BP when compared to those in the lowest quartile (Q4 vs Q1; OR 1.57 – 95%CI 1.14 – 2.17).

Conclusion:

In children aged 6 to 11 years, increased waist circumference is associated with elevated BP even when BMI is normal.

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Original Article

Incremental Prognostic Value of Conventional Echocardiography in Patients with Acutely Decompensated Heart Failure

Fabio Luis de Jesus Soares et al. Janine Magalhães Garcia de Oliveira Gabriel Neimann da Cunha Freire Lucas Carvalho Andrade … Marcia Maria Noya-Rabelo Luis Claudio Lemos Correia

Abstract

Background:

Acutely decompensated heart failure (ADHF) presents high morbidity and mortality in spite of therapeutic advance. Identifying factors of worst prognosis is important to improve assistance during the hospital phase and follow-up after discharge. The use of echocardiography for diagnosis and therapeutic guidance has been of great utility in clinical practice. However, it is not clear if it could also be useful for risk determination and classification in patients with ADHF and if it is capable of adding prognostic value to a clinical score (OPTIMIZE-HF).

Objective:

To identify the echocardiographic variables with independent prognostic value and to test their incremental value to a clinical score.

Methods:

Prospective cohort of patients consecutively admitted between January 2013 and January 2015, with diagnosis of acutely decompensated heart failure, followed up to 60 days after discharge. Inclusion criteria were raised plasma level of NT-proBNP (> 450 pg/ml for patients under 50 years of age or NT-proBNP > 900 pg/ml for patients over 50 years of age) and at least one of the signs and symptoms: dyspnea at rest, low cardiac output or signs of right-sided HF. The primary outcome was the composite of death and readmission for decompensated heart failure within 60 days.

Results:

Study participants included 110 individuals with average age of 68 ± 16 years, 55% male. The most frequent causes of decompensation (51%) were transgression of the diet and irregular use of medication. Reduced ejection fraction (<40%) was present in 47% of cases, and the NT-proBNP median was 3947 (IIQ = 2370 to 7000). In multivariate analysis, out of the 16 echocardiographic variables studied, only pulmonary artery systolic pressure remained as an independent predictor, but it did not significantly increment the C-statistic of the OPTMIZE-HF score.

Conclusion:

The addition of echocardiographic variables to the OPTIMIZE-HF score, with the exception of left ventricular ejection fraction, did not improve its prognostic accuracy concerning cardiovascular events (death or readmission) within 60 days

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Original Article

Left Atrial Appendage Closure with Amplatzer Cardiac Plug in Nonvalvular Atrial Fibrillation: Safety and Long-Term Outcome

Marcio José Montenegro da Costa et al. Esmeralci Ferreira Edgard Freitas Quintella Bernardo Amorim … Alexandre Fuchs Ricardo Zajdenverg Hugo Sabino Denilson Campos de Albuquerque

Abstract

Background:

Atrial fibrillation (AF) is a cardiac arrhythmia with high risk for thromboembolic events, specially stroke.

Objective:

To assess the safety of left atrial appendage closure (LAAC) with the Amplatzer Cardiac Plug for the prevention of thromboembolic events in patients with nonvalvular AF.

Methods:

This study included 15 patients with nonvalvular AF referred for LAAC, 6 older than 75 years (mean age, 69.4 ± 9.3 years; 60% of the male sex).

Results:

The mean CHADS₂ score was 3.4 ± 0.1, and mean CHA₂DS₂VASc , 4.8 ± 1.8, evidencing a high risk for thromboembolic events. All patients had a HAS-BLED score > 3 (mean, 4.5 ± 1.2) with a high risk for major bleeding within 1 year. The device was successfully implanted in all patients, with correct positioning in the first attempt in most of them (n = 11; 73.3%).

Conclusion:

There was no periprocedural complication, such as device migration, pericardial tamponade, vascular complications and major bleeding. All patients had an uneventful in-hospital course, being discharged in 2 days. The echocardiographic assessments at 6 and 12 months showed neither device migration, nor thrombus formation, nor peridevice leak. On clinical assessment at 12 months, no patient had thromboembolic events or bleeding related to the device or risk factors. In this small series, LAAC with Amplatzer Cardiac Plug proved to be safe, with high procedural success rate and favorable outcome at the 12-month follow-up. (Arq Bras Cardiol. 2017; [online].ahead print, PP.0-0)

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Original Article

Progression and Prognosis of Paravalvular Regurgitation After Transcatheter Aortic Valve Implantation

Rafael Alexandre Meneguz-Moreno et al. Antônio de Castro-Filho Auristela Isabel de Oliveira Ramos Mayra Zumarraga … David Le Bihan Rodrigo Barretto Dimytri Alexandre de Alvim Siqueira Alexandre Antonio Cunha Abizaid Amanda Guerra de Moraes Rego Sousa J. Eduardo Sousa

Abstract

Background:

The impact of paravalvular regurgitation (PVR) following transcatheter aortic valve implantation (TAVI) remains uncertain.

Objective:

To evaluate the impact of PVR on mortality and hospital readmission one year after TAVI.

Methods:

Between January 2009 and June 2015, a total of 251 patients underwent TAVI with three different prostheses at two cardiology centers. Patients were assessed according to PVR severity after the procedure.

Results:

PVR was classified as absent/trace or mild in 92.0% (n = 242) and moderate/severe in 7.1% (n = 18). The moderate/severe PVR group showed higher levels of aortic calcification (22% vs. 6%, p = 0.03), higher serum creatinine (1.5 ± 0.7 vs. 1.2 ± 0.4 mg/dL, p = 0.014), lower aortic valve area (0.6 ± 0.1 vs. 0.7 ± 0.2 cm², p = 0.05), and lower left ventricular ejection fraction (49.2 ± 14.8% vs. 58.8 ± 12.1%, p = 0.009). Patients with moderate/severe PVR had more need for post-dilatation (p = 0.025) and use of larger-diameter balloons (p = 0.043). At one year, all-cause mortality was similar in both groups (16.7% vs. 12%, p = 0.08), as well as rehospitalization (11.1% vs. 7.3%, p = 0.915). PVR grade significantly reduced throughout the first year after the procedure (p < 0.01). The presence of moderate/severe PVR was not associated with higher one-year mortality rates (HR: 0.76, 95% CI: 0.27-2.13, p = 0.864), rehospitalization (HR: 1.08, 95% CI: 0.25-4.69, p=0.915), or composite outcome (HR: 0.77, 95% CI: 0.28-2.13, p = 0.613).

Conclusion:

In this sample, moderate/severe PVR was not a predictor of long-term mortality or rehospitalization. (Arq Bras Cardiol. 2017; [online].ahead print, PP.0-0)

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Acute Coronary Syndrome

Protective Effect of Ischemic Preconditioning on Myocardium Against Remote Tissue Injury Following Transient Focal Cerebral Ischemia in Diabetic Rats

Meltem Kumas et al. Ozge Altintas Ersin Karatas Abdurrahim Kocyigit

Abstract

Background:

Remote ischemic preconditioning (IPreC) could provide tissue-protective effect at a remote site by anti-inflammatory, neuronal, and humoral signaling pathways.

Objectives:

The aim of the study was to investigate the possible protective effects of remote IPreC on myocardium after transient middle cerebral artery occlusion (MCAo) in streptozotocin- induced diabetic (STZ) and non-diabetic rats.

Methods:

48 male Spraque Dawley rats were divided into eight groups: Sham, STZ, IPreC, MCAo, IPreC+MCAo, STZ+IPreC, STZ+MCAo and STZ+IPreC+MCAo groups. We induced transient MCAo seven days after STZ-induced diabetes, and performed IPreC 72 hours before transient MCAo. Remote myocardial injury was investigated histopathologically. Bax, Bcl2 and caspase-3 protein levels were measured by Western blot analysis. Total antioxidant status (TAS), total oxidant status (TOS) of myocardial tissue were measured by colorimetric assay. Oxidative stress index(OSI) was calculated as TOS-to-TAS ratio. For all statistical analysis, p values < 0.05 were considered significant.

Results:

We observed serious damage including necrosis, congestion and mononuclear cell infiltration in myocardial tissue of the diabetic and ischemic groups. In these groups TOS and OSI levels were significantly higher; TAS levels were lower than those of IPreC related groups (p < 0.05). IPreC had markedly improved histopathological alterations and increased TAS levels in IPreC+MCAo and STZ+IPreC+MCAo compared to MCAo and STZ+MCAo groups (p < 0.05). In non-diabetic rats, MCAo activated apoptotic cell death via increasing Bax/Bcl2 ratio and caspase-3 levels. IPreC reduced apoptotic cell death by suppressing pro-apoptotic proteins. Diabetes markedly increased apoptotic protein levels and the effect did not reversed by IPreC.

Conclusions:

We could suggest that IPreC attenuates myocardial injury via ameliorating histological findings, activating antioxidant mechanisms, and inducing antiapoptotic activity in diabetic rats.

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Original Article

Incremental Prognostic Value of the Incorporation of Clinical Data Into Coronary Anatomy Data in Acute Coronary Syndromes: SYNTAX-GRACE Score

Mateus dos Santos Viana et al. Fernanda Lopes Antonio Mauricio dos Santos Cerqueira Junior Jessica Gonzalez Suerdieck … André Barcelos da Silva Ana Clara Barcelos da Silva Thiago Menezes Barbosa de Souza Manuela Campelo Carvalhal Marcia Maria Noya Rabelo Luis Claudio Lemos Correia

Abstract

Background:

When performing coronary angiography in patients with acute coronary syndrome (ACS), the anatomical extent of coronary disease usually prevails in the prognostic reasoning. It has not yet been proven if clinical data should be accounted for in risk stratification together with anatomical data.

Objective:

To test the hypothesis that clinical data increment the prognostic value of anatomical data in patients with ACS.

Methods:

Patients admitted with objective criteria for ACS and who underwent angiography during hospitalization were included. Primary outcome was defined as in-hospital cardiovascular death, and the prognostic value of the SYNTAX Score (anatomical data) was compared to that of the SYNTAX-GRACE Score, which resulted from the incorporation of the GRACE Score into the SYNTAX score. The Integrated Discrimination Improvement (IDI) was calculated to evaluate the SYNTAX-GRACE Score ability to correctly reclassify information from the traditional SYNTAX model.

Results:

This study assessed 365 patients (mean age, 64 ± 14 years; 58% male). In-hospital cardiovascular mortality was 4.4%, and the SYNTAX Score was a predictor of that outcome with a C-statistic of 0.81 (95% CI: 0.70 – 0.92; p < 0.001). The GRACE Score was a predictor of in-hospital cardiac death independently of the SYNTAX Score (p < 0.001, logistic regression). After incorporation into the predictive model, the GRACE Score increased the discrimination capacity of the SYNTAX Score from 0.81 to 0.92 (95% CI: 0.87 – 0.96; p = 0.04).

Conclusion:

In patients with ACS, clinical data complement the prognostic value of coronary anatomy. Risk stratification should be based on the clinical-anatomical paradigm, rather than on angiographic data only.

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