2021;116(6) – ABC CARDIOL

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Editorial

One-Stop Shop for Non-Invasive Cardiovascular Imagers?

Rodrigo Julio Cerci et al. Afonso Akio Shiosaki

Over the past fifteen years, coronary computed tomography angiography (CCTA) has witnessed rapid technological and scientific advances in the detection of anatomical coronary artery disease (CAD), leading to an improvement in patient care. Visual assessment of stenosis severity using CCTA has a high sensitivity and negative predictive value when compared to invasive angiography, making it an ideal test to exclude obstructive CAD. With its high diagnostic performance associated with an important prognostic impact in the management of CAD, CCTA has finally established itself as a Class I recommendation in international guidelines (European Society of Cardiology – ESC).

However, CCTA is limited by modest diagnostic specificity and only provides anatomical assessment, which does not inform hemodynamic significance of specific lesions. CCTA combined with stress tomography evaluation of myocardial perfusion (CTP) is an accurate modality to determine regional myocardial flow repercussions of coronary stenosis, though it usually requires additional acquisition and is still underused. Derived flow fractional reserve – computed tomography (FFR-CT) is another “physiologic” CT approach in which computational fluid dynamics is applied to standard CCTA data and has emerged as a promising tool for the functional assessment of coronary stenosis. The diagnostic value of remotely performed FFR-CT has been prospectively validated in several large multicenter studies, but requires the use of offsite supercomputers, which can be time-consuming and cost-intensive, limiting its widespread clinical utility.^–

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Editorial

Still Trying to Understand the Role of Uric Acid in Cardiovascular Diseases

Gilson Soares Feitosa

In this issue of Arquivos Brasileiros de Cardiologia , Zhu et al. report an association between uric acid and the presence of pre-hypertension or hypertension in a cross-sectional study done in a population in North China, bringing about, once more, a possible role of uric acid in the determination of cardiovascular disease. In the study, the authors call our attention to the possibility of a relationship even though the measured uric acid serum level is relatively low as compared to what is referred to as normal in several Western populations, which presents a cutoff value of ≥7.0 mg/dL for men and ≥6.3 mg/dL for women in the United States and also so considered, a cutoff value of ≥7.0 mg/dL for men and ≥ 6.0 mg/dL for women in a Brazilian population of healthy individuals aged 20 to 55, in Rio de Janeiro, whereas in their the cut off values were ≥4.75 mg/dL and ≥4.04 mg/dL for men and women, respectively.

In workers from the Company of Generation and Distribution of Energy in Rio de Janeiro, Brazil, from both sexes, aged predominantly between 50 and 59, the mean uric acid level was 4.7±1.3 mg/dL.

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Editorial

Antioxidant and Anti-Inflammatory Effects of Orange Juice

Paula Felippe Martinez et al. Marianna Rabelo de Carvalho Maria Lua Marques Mendonça Marina Politi Okoshi Silvio Assis de Oliveira-Junior

Post myocardial infarction cardiac remodelling progression is a complex event involving several biological reactions; these include oxidative stress and inflammatory response.^– The release of reactive oxygen species (ROS) after myocardial ischemia stimulates pro-inflammatory mediators involved in fibroblast proliferation and tissue repair in the infarcted area. However, sustained ROS production in combination with hemodynamic overload and antioxidant system incapacity leads to oxidative stress in non-infarcted areas, which also undergo cardiac remodelling.^– These changes, associated with energy metabolism disorders, metalloproteinases activation, cardiomyocyte death and hypertrophy, interstitial fibrosis, and cardiac dysfunction characterize the cardiac remodelling process.

Studies on various bioactive compounds, often extracted from food, have been undertaken to assess their attenuating powers on disorders common to cardiac remodelling, such as oxidative stress and inflammation.^– However, the extraction and isolation of these substances can require a complex network of costly specialized technical procedures making it financially difficult for a large part of the population to access this resource. Additionally, taken in isolation one cannot evaluate the potential effects of interactions between food matrix components and the organism which may alter the metabolic effects. Alternatively, consuming the food in its entirety acts as a buffer in the digestive system allowing greater bioavailability of its active compounds. Therefore, nutritional approaches involving ingestion of natural foods, such as fruits and their products (peels, juices, pulps, puree, and jams, etc), which contain substances with antioxidant and anti-inflammatory properties, have increasingly gained interest.^, It is worth mentioning citrus fruits, which are rich in bioactive compounds that may change the metabolism and protect tissues from ROS accumulation injuries. Citrus fruit juices, in general, are abundant sources of vitamin C and other nutrients, such as potassium, folate, magnesium, vitamin A, and polyphenolic compounds. In this sense, orange juice is a complex food matrix with cardioprotective potential due to its antioxidant and anti-inflammatory capacity.^–

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Editorial

Mitral Regurgitation and Transcatheter Aortic Valve Replacement: Are There Any Other Prognostic Implications?

Antonio de Santis

There is a variable prevalence of moderate to severe mitral regurgitation (13 to 74%) in patients with severe degenerative aortic stenosis.^– In elderly and frail patients, this association can generate clinical dilemmas in cardiological practice: should I submit my patient to combined valve surgery, exposing him to higher morbidity and mortality, or contemplate only the severe aortic stenosis with a less aggressive treatment represented by the transcatheter aortic valve replacement (TAVR)? The variable degrees of severity associated with the commonly functional etiology (up to 80%) of the associated mitral regurgitation, places aortic valve stenosis in a high prominent position at this clinical hierarchy, with a resultant predilection for performing TAVR in these scenarios. In fact, some studies showed an improvement in the mitral regurgitation severity after TAVR, especially in patients with functional etiology and without pulmonary hypertension or atrial fibrillation.^–

The impact of baseline mitral regurgitation on patients undergoing TAVR is still controversial. Toggweiler et al. found that moderate to severe baseline mitral regurgitation in patients undergoing TAVR was associated with higher early mortality rates (first 30 days), with no difference in late mortality. Conversely, Barbanti et al., using data from the randomized Placement of Aortic Transcatheter Valve (PARTNER) trial cohort A, found that moderate to severe baseline mitral regurgitation was associated with higher late mortality only in the surgical aortic valve replacement group, with no prognostic implication in the TAVR group.

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Original Article

Evaluation of Coronary Circulation after Arterial Switch Operation

Mariana Nicoletti Ferreira Baldo et al. Henrique Simão Trad Tarcisio José da Silva Junior Paulo Henrique Manso

Abstract

Background

Coronary artery evaluation remains after arterial switch operation a clinical challenge.

Objective

This study aims to correlate anatomical changes diagnosed by cardiac computed tomography (CCT) with physiological alterations on clinical evaluation to diagnose coronary obstruction in late ASO patients.

Methods

This study included 61 consecutive patients with mean age of 9.4 years who underwent ASO. The patients were submitted to echocardiography, electrocardiography, cardiopulmonary exercise test, and cardiac computed tomography to evaluate functional capacity and coronary artery anatomy.

Results

Cardiac computed tomography revealed that only 3.3% of the patients had coronary stenosis. These patients were asymptomatic, and no signs of myocardial ischemia were detected by the tests.

Conclusion

The incidence of coronary abnormalities in late ASO patients was 3.3% in our cohort. There is no clear guideline as to why, when, and how these patients should be screened or what to propose when a coronary obstruction is diagnosed in asymptomatic patients.

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Original Article

Relationship between Mitral Regurgitation and Transcatheter Aortic Valve Implantation: a Multi-Institutional Follow-up Study

Luciana de Cerjat Bernardes P. da Cunha et al. Enio Eduardo Guerios Claudio Leinig Pereira da Cunha Luiz A. Carvalho … Pedro Lemos Neto Rogério Sarmento-Leite Alexandre A. Abizaid José Antonio Mangione Adriano Dourado Oliveira Alexandre Siciliano Vinicius Esteves Fábio Sândoli de Brito Jr

Abstract

Background

Mitral regurgitation (MR) is prevalent in patients undergoing transcatheter aortic valve implantation (TAVI). There are some controversies about the prognostic impact of MR in survival of TAVI patients.

Objective

To examine the relationship between TAVI and MR in a patient population from the Brazilian TAVI Registry.

Methods

Seven hundred and ninety-five patients from the Brazilian TAVI Registry were divided at baseline, discharge, and follow-up according to their MR grade as follows: absent/mild (AMMR) or moderate/severe (MSMR). They were subsequently regrouped according to their immediate and late changes in MR severity after TAVI as follows: no change, improved, or worsened MR. Predictors and prognostic impact on baseline as well as changes in MR severity were analyzed. Statistical significance was set at p < 0.05.

Results

Baseline MSMR was present in 19.3% of patients and was a predictor of increased late mortality. Immediately after TAVI, 47.4 % of cases improved to AMMR, predicted by a higher Society of Thoracic Surgeons score and a higher grade of baseline aortic regurgitation. Upon follow-up, 9.2% of cases of AMMR worsened to MSMR, whereas 36.8% of cases of MSMR improved to AMMR. Lower baseline left ventricular ejection fraction (LVEF) and improvement in LVEF at follow-up were predictors of MR improvement. Progressive worsening of MR upon follow-up was an independent predictor of higher late mortality after TAVI (p = 0.005).

Conclusions

Baseline MSMR predicts late mortality after TAVI. Lower LVEF and improved LVEF at follow-up predict MR improvement after TAVI. Progressive worsening of MR severity at follow-up is an independent predictor of late mortality, which is a rare finding in the literature.

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Editorial

Precordial Pain and Infarction in the Elderly. It´S no so Elementary, My Dear Watson!

Ricardo Wang et al. José Carlos da Costa Zanon Fernando Carvalho Neuschwander

In Medical School, we learn the traditional way to conduct the investigative process in order to reach a diagnosis. This process is traditionally based on the collection of anamnesis and clinical exams, clinical reasoning, the generation of a hypothesis, and tests with complementary exams. In general, we follow the the Occam’s razor principle: “the simplest answer is usually the correct answer,” or as William Osler’s aphorism: “Where you hear hoofs, you don´t think of zebras”. However, in this investigative process, the clinical reasoning is challenged in an elderly population over 80 years of age, and not always is the simplest answer the most correct. In this age group, the presence of comorbidities is quite common and can interfere, changing the perception of cardiovascular symptoms (depression, dementia, medications that interfere in the central nervous system, diabetes, analgesics, etc.), or even modify the symptomatology. The presence of atypical symptoms, such as dyspnea, sudoresis, vomiting, diarrhea, epigastric pain, and mental confusion can all mask the cardiovascular pathology.^,

Many studies have shown the difficulty in diagnosing acute myocardial infarction (AMI) in this population, which clearly entails delays in or the lack of treatment. Even when the diagnosis and early treatment of AMI is established, the mortality rate remains high in this population. The under-treatment or lack of treatment contribute to the increase in mortality in this age group.^– Understanding the factors that make the diagnosis difficult is of utmost importance in establishing protocols directed toward the older age elderly patient.

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Original Article

Influence of Consumption of Orange Juice (Citrus Sinensis) on Cardiac Remodeling of Rats Submitted to Myocardial Infarction

Bruna C. Oliveira et al. Priscila P. Santos Amanda M. Figueiredo Bruna P. M. Rafacho … Larissa Ishikawa Silméia G. Zanati Ana A. H. Fernandes Paula S. Azevedo Bertha F. Polegato Leonardo A. M. Zornoff Marcos F. Minicucci Sergio A. R. Paiva

Abstract

Background

Orange juice (OJ) is rich in polyphenols with anti-inflammatory and antioxidant properties. After myocardial infarction (MI), complex changes occur in cardiac structure and function, which is known as cardiac remodeling (CR). Oxidative stress and inflammation can modulate this process. We hypothesized that the consumption of OJ attenuates the CR after MI.

Objectives

To evaluate the influence of OJ on CR after MI by analysis of functional, morphological, oxidative stress, inflammation, and energy metabolism variables.

Methods

A total of 242 male rats weighing 200-250 g were submitted to a surgical procedure (coronary artery ligation or simulated surgery). Seven days after surgery, survivors were assigned to one of the four groups 1) SM, sham animals with water and maltodextrin (n= 20); 2) SOJ, sham animals with OJ (n= 20); 3) IM, infarcted animals with water and maltodextrin (n= 40); and 4) IOJ, infarcted animals with OJ (n = 40). Statistical analysis was performed by the two-way ANOVA supplemented by Holm-Sidak. Results are presented as mean ± standard deviation, the level of significance adopted was 5%.

Results

After 3 months, MI led to left ventricular (LV) hypertrophy, with systolic and diastolic dysfunction, and increased oxidative stress and inflammatory mediators. OJ intake reduced LV cavity and improved systolic and diastolic function. The OJ animals presented lower activity of glutathione peroxidase and higher expression of heme-oxygenase-1 (HO-1).

Conclusion

OJ attenuated CR in infarcted rats and HO-1 may be play an important role in this process.

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Review Article

2020 Top 10 Original Articles in the Arquivos Brasileiros de Cardiologia and the Revista Portuguesa de Cardiologia

Ricardo Fontes-Carvalho et al. Gláucia Maria Moraes de Oliveira Nuno Cardim Carlos Eduardo Rochitte

Introduction

In recent years, the Revista Portuguesa de Cardiologia (RPC) and the Arquivos Brasileiros de Cardiologia (ABC Cardiol) have gotten together annually to elaborate a list of the most relevant papers published in both journals,^, highlighting some of the best scientific articles in Portuguese.

Based on the success of that initiative, the editors of both journals have decided to cooperate once again to elaborate the ‘Top 10’ list of 2020 of each journal. The year 2020 was marked by the huge impact of the COVID-19 pandemic in both countries, with an enormous pressure on the healthcare institutions and professionals. Despite those challenges, the scientific quality of the publications in both journals remained extremely high, with excellent original articles.

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Editorial

Infections of Cardiac Implantable Electronic Devices – A Growing, Worrying Reality

Eduardo Arrais Rocha et al. João Lins de Araújo Neto Ricardo Pereira Silva

Infection rates of Cardiac Implantable Electronic Devices (CIEDs) have been increasing, determining the need for a wide debate on the subject. Several reasons can justify the issue, such as: a greater number of devices implanted over the latest years, overaging of the population, new techniques and equipment, with more complex and prolonged procedures.

Maciel and Silva address this topic in a clear, objective manner, bringing an important contribution from the national literature, in a significant case selection, confirming those worrying findings and discussing their impacts, considering the high rates of morbidity and mortality and high costs involved, particularly in the cases of endocarditis and sepsis.

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Research Letter

Spiked Helmet Sign: An Atypical Case of Transient ST-Segment Elevation on ECG

Acácio F. Cardoso et al. Marco Alexander V. Akamine Rafael M. Pessoa Elizabeth T. Takitani … José V. Kairiyama Manfredo K. Naritoni

Case report

Male, 35 years old, smoker, user of illicit drugs (marijuana, cocaine and inhalant solvents), on antipsychotics and antidepressants (haloperidol and escitalopram), several episodes of vomiting and diarrhea for the past two days, mental confusion at home, and admitted to the emergency room with reduced level of consciousness and irregular breathing. Soon afterwards, he presented cardiopulmonary arrest (CRP) with ventricular fibrillation (VF) on the cardiac monitor. After six minutes of cardiopulmonary resuscitation maneuvers, adrenaline infusion and two cardiac defibrillations, pulse and heart rate were recovered. An electrocardiogram (ECG) was performed, which demonstrated atypical and diffuse ST-segment elevation ( ). Initial laboratory tests showed severe metabolic acidosis with high serum lactate (serum lactate = 26 mg/dl), in addition to hypernatremia (serum sodium = 153 mg/dl), hypokalemia (serum potassium = 3.2 mg/dl), severe leukocytosis and a slight increase in serum troponin. The patient was intubated and placed on mechanical ventilation. Volume resuscitation was performed, metabolic acidosis was corrected, and broad-spectrum antibiotics were initiated. One hour after initial consultation, a new ECG was performed, which demonstrated a reduction of approximately 50% in ST elevation ( ). Given the atypical character of the ST segment abnormalities on ECG, we chose not to perform an emergency coronary angiography. Six hours after the event, the initial ECG abnormalities receded completely ( ). An echocardiogram was performed, which showed severe left ventricular dysfunction at the expense of diffuse hypokinesia (ejection fraction = 0.36). A new echocardiogram was performed two days later, which revealed complete recovery of ventricular function (ejection fraction = 0.69). Coronary angiotomography was performed during hospitalization, which demonstrated the absence of obstructive lesions and ruled out coronary anomalies. The patient progressed well and was discharged after eight days of hospitalization.

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Editorial

Left Main Coronary Artery Percutaneous Intervention. Why are Real-World Data so Important?

Vinicius Daher Vaz

The estimated prevalence of left main artery disease found during diagnostic angiography is 6% in published series. The enthusiasm for a less invasive therapy than coronary artery bypass grafting (CABG) for patients with unprotected left main coronary artery (ULMCA) disease dates back to the 90s. Although the contribution of CABG in the survival of patients with ULMCA disease is undeniable, in the last few years, several authors have demonstrated the safety and efficacy of percutaneous coronary intervention (PCI).

Despite the controversies regarding the 5-year publication of the Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial, when it comes to hard outcomes, as death and stroke, in the last years several randomized and non-randomized trials have demonstrated non-inferiority or even superiority of PCI against CABG.^– Recently, these data were compiled in two meta-analysis where long term follow-up has shown no significant difference in mortality and stroke rate between PCI and CABG.^, In addition, two of these randomized trials with extended long-term follow-up, up to 10 years, have demonstrated sustained good results after PCI, with death rates similar to CABG, respectively, 14.5% x 13.8% and 27% x 28%.^,

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Letter to the Editor

Teachers who were Academic Examples

We currently live in an extremely competitive and individualistic society, which makes mistakes and defects more apparent. The health pandemic, in addition to the endemics of corruption in politics and the social fabric, has led us to a perfect storm. Its damage is difficult to solve, as several factors are chronic, ingrained, almost atavistic, and are present in all segments of society. The solution is called education. As Paulo Freire says, educated and respected, but criticized by the uneducated, education changes individuals, making them evolve. These change society. It is, therefore, a long-term project.^–

As I have commented in several articles in the press, we have human resources of high moral and intellectual level. However, with the current political system, malignant, consisting of corporatism and solid physiologisms, which dispute, command, and disengage, evolution is blocked. This criminal system removes most of the well-meaning people from the scene. Some manage to win by overcoming obstacles. Moreover, they make history. In addition, they leave positive marks, making us more educated and prepared to carry out their teachings. Quality is recognized by the heirs, carrying out the good school. InCor is an example to be followed; it has been recently qualified as one of the best public hospitals in the world. It is a source of pride for our country.

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Image

Pulmonary Arterial Intramural Hematoma Due to Acute Aortic Dissection

Lucas de Pádua Gomes de Farias et al. Ana Cristina Favaretto Luciana de Pádua Silva Baptista Gustavo Borges da Silva Teles

A 54-year-old male patient, who was a smoker, was admitted to the emergency room with acute chest pain and dyspnea. Investigation was initiated by means of computed tomography angiography of the chest, which showed extensive dissection of the thoracic aorta, beginning in the ascending segment (Stanford type A), associated with intramural hematoma of the pulmonary artery trunk and its main branches. It was more evident on the right, which determines local pulmonary luminal reduction, in addition to a small para-aortic and subaortic mediastinal hematoma. There were no signs of pulmonary thromboembolism, and the evaluation of the parenchyma showed no signs of pulmonary hemorrhage ( and ).

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Original Article

Macroscopic Evaluation of Atherosclerosis in the Arteries: An Autopsy Assessment Tool

Mariana Silva Oliveira et al. Bianca Gonçalves Silva Torquato Maria Helena Soares Maria Luiza Gonçalves dos Reis Monteiro … Guilherme Ribeiro Juliano Laura Sanches Aguiar Vicente de Paula Antunes Teixeira Mara Lúcia da Fonseca Ferraz

Abstract

Background

Atherosclerosis, in some cases, is an asymptomatic condition, and it is important to know the degree of arterial impairment caused by plaques and its association with risk factors. Autopsy examination provides understanding of basic disease processes and assessment to data about macroscopic characteristic of atherosclerotic involvement.

Objective

To macroscopically assess and standardize atherosclerotic involvement of aorta, carotid and iliac arteries and compare with age, gender and causes of death.

Methods

We collected 53 aortic arteries, 53 right carotid arteries, 53 left carotid arteries, 53 right iliac arteries and 53 left iliac arteries. For this assessment, the extension of fatty streaks, atheromatous plaques, fibrosis and calcification were considered, being the reference to score the degree of atherosclerotic involvement. Many degrees of atherosclerosis and accurate values were observed for mild, moderate and severe classification. For statistical analysis, data were analyzed using the software GraphPad Prism® 7.0. Differences were considered statistically significant if p-value was less than 5% (p <0.05).

Results

Carotid arteries had greater atherosclerotic involvement compared to the other arteries (K = 15.73, p = 0.0004). Atherosclerosis was progressive and significant with increasing age (carotid arteries: t = 6.321; p <0.0001; aorta: U = 83.5; p <0.0001; iliac: U = 306; p <0.0001) and as cause of cardiovascular death (carotids: t = 5.047; p <0.0001; aorta: U = 98.5; p = 0.0068; iliac: U = 467.5; p = 0.0012).

Conclusion

Macroscopic assessment of atherosclerosis is an innovative and low-cost way of direct visualization of atherosclerotic plaques, enabling an association with risk factors such as increasing age and cardiovascular diseases, providing important data for clinical practice.

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Original Article

Percutaneous Coronary Intervention in Unprotected Left Main Coronary Artery Lesions

Douglas dos Santos Grion et al. Debora Carvalho Grion Igor Veiga Silverio Leonardo Shingu de Oliveira … Isabela Faria Larini Anna Victória Martins Juliana Moreira Marianne Machado Lissa Shizue Tateiwa Niekawa Adriana dos Santos Grion Cintia Magalhães Carvalho Grion

Abstract

Background

The advent of drug-eluting stents allowed the percutaneous coronary intervention to present safe results in lesions in the left main coronary artery.

Objectives

To analyze the results of the percutaneous treatment of unprotected left main coronary artery lesion with the use of intravascular ultrasound.

Methods

Study of consecutive case series carried out from January 2010 to December 2018. Clinical data were collected from patients as well as prognostic scores and data on coronary lesion. Low-grade residual lesion (less than 50%) on angiography and minimum luminal area greater than 6 mm²on intravascular ultrasound were considered successful. The adopted significance level was 5%.

Results

107 cases were analyzed. The multivessel lesion was predominant, with most (39.25%) of the lesions being found in three vessels in addition to the left main coronary artery. The SYNTAX score had a mean of 46.80 (SD: 22.95), and 70 (65.42%) patients had a SYNTAX score above 32 points. Angiographic success of percutaneous intervention was considered in 106 (99.06%) patients. The overall rate of major cardiac and cerebrovascular events in the hospital outcome was 6.54%, being similar in patients with SYNTAX score ≤ 32 (8.10%) and ≥ 33 (5.71%; p = 0.68).

Conclusions

Percutaneous intervention in cases of unprotected left main coronary artery lesion was safely performed and presented excellent results. Considerable angiographic success of treatment guided by intravascular ultrasound was achieved. The rate of major cardiac and cerebrovascular events was similar between patients at low and high risks.

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Research Letter

17-Year-Old Man with Pulmonary Atresia and Intact Ventricular Septum Submitted to Fontan Operation, and with Persistent Coronary-Cavitary Fistula

Introduction

Pulmonary atresia with intact ventricular septum is a congenital anomaly with total interruption of blood flow between the right ventricle and the pulmonary trunk, and in general it is not accompanied by associated defects, except for interatrial septal defect, present in 20%, with predominance of patent foramen ovale. Valve atresia results from the lack of embryological development of this fibrous structure, which can be located at the valve level (fibrous membrane) but also at the infundibular level (blind fundus). As a consequence, myocardial hypertrophy and hypoplasia of the right ventricle, hypoplasia of the ring and tricuspid valve, mild tricuspid insufficiency and pulmonary flow dependent on the ductus arteriosus appear. In view of greater hypertension in right ventricle, direct connections with the coronary circulation are formed through sinusoids, with flow towards the aorta. In this situation, it is said that the coronary circulation is dependent on the right ventricle, and when these connections are present in great magnitude, they predispose to myocardial infarction, arrhythmias and right ventricular volume overload, due to retrograde flow from the aorta.

In cases where valve atresia develops later in the fetus, the right ventricular cavity may be well formed with its three portions, the entrance route, the trabecular and the exit route and, as a consequence, there is marked tricuspid insufficiency, even with Ebstein-type alteration of the redundant and myxomatous valve, ventricular wall thinning, ventricular dysfunction and right heart failure, the latter superimposed on hypoxia. In general, it is not accompanied by other associated defects and the pulmonary arteries are of adequate size. In these cases, there is no connection between the right ventricle and the coronary arteries by sinusoids.

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Editorial

Importance of the Anesthetic Technique and Analgesia in the Implantation of Subcutaneous and Endovascular Defibrillator: An Aspect Often Ignored

Jorge Elias Neto

Originally introduced by Mirowski 50 years ago, the implantable cardioverter-defibrillator (ICD) has become a cornerstone to preventing SCD related to ventricular tachyarrhythmias.

However, besides their lifesaving capacities, the transvenous leads carry their own risk.

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Original Article

Prognostic Value of Plasma NT-proBNP levels in Hospitalized Patients Older than 80 Years of Age in a Hospital in Beijing, China

Qiwei Zhu et al. Peng Gao Shihui Fu Hao Wang … Yongyi Bai Leiming Luo Ping Ye

Abstract

Background

Despite growing evidence that N-terminal pro-brain natriuretic peptide (NT-proBNP) has an important prognostic value in older adults, there is limited data on its prognostic predictive value.

Objectives

The aim of this study is to evaluate the clinical significance of NT-proBNP in hospitalized patients older than 80 years of age in Beijing, China.

Methods

This prospective, observational study was conducted in 724 very elderly patients in a geriatric ward (age ≥80 years, range, 80100 years, mean, 86.6 3.0 years). Multivariate linear regression analysis was used to screen for factors independently associated with NT-proBNP, and the Cox proportional hazard regression model was used to screen for relationships between NT-proBNP levels and major endpoints. The major endpoints assessed were all-cause death and MACEs. P values < 0.05 were considered statistically significant.

Results

The prevalence rates of coronary heart disease, hypertension, and diabetes mellitus were 81.4%, 75.1%, and 41.2%, respectively. The mean NT-proBNP level was 770 ± 818 pg/mL. Using multivariate linear regression analyses, correlations were found between plasma NT-proBNP and body mass index, atrial fibrillation, estimated glomerular filtration rate, left atrial diameter, left ventricular ejection fraction, use of betablocker, levels of hemoglobin, plasma albumin, triglycerides, serum creatinine, and blood urea nitrogen. The risk of all-cause death (HR, 1.63; 95% CI, 1.0052.642; P = 0.04) and major adverse cardiovascular events (MACE; HR, 1.77; 95% CI, 1.2893.531; P = 0.04) in the group with the highest NT-proBNP level was significantly higher than that in the group with the lowest level, according to Cox regression models after adjusting for multiple factors. As expected, echocardiography parameters adjusted the prognostic value of NT-proBNP in the model.

Conclusions

NT-proBNP was identified as an independent predictor of all-cause death and MACE in hospitalized patients older than 80 years of age.

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Original Article

Comparative Study between Subcutaneous and Endovascular Defibrillator Recipients Regarding Tolerance to the Implant Procedure and Perception of Quality of Life

Pablo Esteban Auquilla-Clavijo et al. Naiara Calvo-Galiano Marina Povar-Echeverría Teresa Oloriz-Sanjuan … Francisco Diaz-Cortejana Antonio Asso-Abadia

Abstract

Background

The totally subcutaneous implantable cardioverter-defibrillator (S-ICD) is a safe alternative to the conventional transvenous ICD (TV-ICD) system to prevent sudden death.

Objective

To compare the impact of the type of ICD system and surgical technique on patients’ quality of life, as well as the severity of discomfort and pain, between S-ICD and TV-ICD recipients.

Methods

Consecutively implanted patients with an S-ICD system were matched with patients with a TV-ICD system. In addition, patients undergoing S-ICD implantation after removal of a TV-ICD due to complications were included. Quality of life (measured with the 12-item short-form health survey) and severity of pain and discomfort were evaluated. Statistical significance was defined as p < 0.05.

Results

A total of 64 patients implanted with S-ICD or TV-ICD under local anesthesia and conscious sedation were analyzed. Patients with S-ICD and TV-ICD systems did not differ significantly in quality of life scores. S-ICD patients had a higher level of perioperative pain; no differences were found regarding severity of intraoperative pain. The magnitude of aesthetic discomfort and sleep disturbances did not differ between groups. An S-ICD was implanted in 7 additional patients after removal of a TV-ICD. All but one of these patients recommended the S-ICD system.

Conclusions

The type of ICD system and the surgical technique have negligible impact on patients’ quality of life. These results suggest that conscious sedation, provided by an experienced electrophysiology team, could be considered as an alternative to general anesthesia to manage patients undergoing S-ICD implantation.

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Editorial

What to Expect from Cardiovascular Life at 85?

While there is plenty of literature for risk prediction of cardiovascular disease and preventive therapies, risk estimates are less well known for patients aged > 80 years. There is a need to address this gap in knowledge, as the health status of very elderly people will increasingly impact on health care.

A detailed study carried out in Beijing by Zhu et al., published in this journal, describes the 5-year risk of cardiovascular disease in 724 very elderly Chinese patients – all > 80 years old, most of them men. They were admitted to the geriatric cardiology department, something that is an evolving field at the international level. The reasons for hospital admission were mostly related to coronary artery disease and hypertension control; only a few were admitted for respiratory or digestive tract disease. After a median follow-up of 5.3 years and a follow-up rate of 98%, about 50% of the patients died, most of them from infections and only 1 in 16 patients from a cardiac cause. The study shows that cardiovascular morbidity and all-cause mortality risk in this population can be successfully predicted by the N-terminal pro-B-type natriuretic peptide levels (NT-proBNP).

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Editorial

Coronary Arteries after Jatene Operation for Transposition of Great Arteries: The Role of CT Coronary Angiography on Follow-up

Antonio Joaquim Marinho-da-Silva

The correction of transposition of the great arteries (TGA) by the Jatene technique was one of the greatest achievements of cardiac surgery in congenital heart disease. By replacing the transposed arteries in their proper anatomical arrangement, this technique — atrial switch operation (ASO) – achieves a normal spatial arterial relationship. However, this new arrangement requires excision of the coronary artery buttons and their implantation in the new aorta. The difficulty of this step relates to the type of coronary origin and distance to the new insertion site.

Once this anatomical normalization step has been achieved, cardiac functional normalization is sought. The most common post-surgical complications are related to the complexity of associated anomalies (ventricular septal defect (VSD), coarctation of the aorta, valve stenosis, and others), suture sites of the neovessels, pulmonary ramification and dilation of the neoaorta, Not neglectable and object of concern, late complications of either congenital or acquired coronary circulation are well known. The actual incidence of such complications ranges from 0,8% to 27,5% according to reporting series and time of follow-up.^,

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Original Article

Diagnostic Performance of a Machine Learning-Based CT-Derived FFR in Detecting Flow-Limiting Stenosis

Thamara Carvalho Morais et al. Antonildes Nascimento Assunção-Jr Roberto Nery Dantas Júnior Carla Franco Grego da Silva … Caroline Bastida de Paula Roberto Almeida Torres Tiago Augusto Magalhães César Higa Nomura Luiz Francisco Rodrigues de Ávila José Rodrigues Parga Filho

Abstract

Background

The non-invasive quantification of the fractional flow reserve (FFRCT) using a more recent version of an artificial intelligence-based software and latest generation CT scanner (384 slices) may show high performance to detect coronary ischemia.

Objectives

To evaluate the diagnostic performance of FFRCT for the detection of significant coronary artery disease (CAD) in contrast to invasive FFR (iFFR) using previous generation CT scanners (128 and 256- detector rows).

Methods

Retrospective study with patients referred to coronary artery CT angiography (CTA) and catheterization (iFFR) procedures. Siemens Somatom Definition Flash (256-detector rows) and AS+ (128-detector rows) CT scanners were used to acquire the images. The FFRCT and the minimal lumen area (MLA) were evaluated using a dedicated software (cFFR version 3.0.0, Siemens Healthineers, Forchheim, Germany). Obstructive CAD was defined as CTA lumen reduction ≥ 50%, and flow-limiting stenosis as iFFR ≤0.8. All reported P values are two-tailed, and when <0.05, they were considered statistically significant.

Results

Ninety-three consecutive patients (152 vessels) were included. There was good agreement between FFRCT and iFFR, with minimal FFRCT overestimation (bias: -0.02; limits of agreement:0.14-0.09). Different CT scanners did not modify the association between FFRCT and FFRi (p for interaction=0.73). The performance of FFRCT was significantly superior compared to the visual classification of coronary stenosis (AUC 0.93vs.0.61, p<0.001) and to MLA (AUC 0.93vs.0.75, p<0.001), reducing the number of false-positive cases. The optimal cut-off point for FFRCT using a Youden index was 0.85 (87% Sensitivity, 86% Specificity, 73% PPV, 94% NPV), with a reduction of false-positives.

Conclusion

Machine learning-based FFRCT using previous generation CT scanners (128 and 256-detector rows) shows good diagnostic performance for the detection of CAD, and can be used to reduce the number of invasive procedures.

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Editorial

What Is the Role of Kidney Injury Biomarkers in Contrast-Induced Nephropaty?

Pedro Pimenta de Mello Spineti

Contrast-induced acute kidney injury (CI-AKI) is a potential severe complication in the use of iodinated radiological contrast media and is associated with higher rates of morbidity and mortality and increased length of hospital stay in patients undergoing cardiac catheterization. Its incidence is variable in the literature according to the criteria used for its diagnosis. The CI-AKI definition most often used in clinical trials is an increase in serum creatinine (Cr) levels of 0.5 mg/dl or 25% over baseline within 72 h after exposure to contrast medium.

However, Cr has a number of limitations as a marker of renal function. Its serum level is influenced by external factors such as sex, age, skin color, weight and muscle mass. It underestimates renal function in women, in the elderly or in underweight individuals. Its variation overestimates renal damage in individuals with previous kidney failure. Another important limitation is the fact that Cr rises only after 24 h of an acute kidney injury, being considered a “slow marker” of acute kidney injury.^,

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