2025;122(10) – ABC CARDIOL

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Letter to the Editor

Considerations on the Diagnosis and Prognosis of Primary Cardiac Lymphoma

Thalisson Gonçalves Almeida et al. Tales Gabriel Ferro de Oliveira Gustavo da Silva Soares Pedro Pereira Tenório

Dear Editor,

We would like to congratulate the authors on their relevant case report, “Cardiac Lymphoma: A Case Report,” published in the Arquivos Brasileiros de Cardiologia (ABC Cardiol). The article addresses a rare and challenging clinical condition, primary cardiac lymphoma (PCL), which, as highlighted in the article, is an aggressive tumor with a poor prognosis and nonspecific symptoms, making early diagnosis difficult. Among the article’s strengths, we highlight the rarity of the case, as it is a diffuse large B-cell lymphoma (DLBCL) with primary cardiac involvement, given the low incidence of these tumors (approximately 0.04% of primary malignant cardiac tumors, with lymphomas representing about 1.3% of these), with DLBCL being the most common subtype, frequently located in the right chambers of the heart.^,

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Review Article

Implementing Cardiac Prehabilitation in Brazil: Building an Evidence-based Framework for Surgical Outcomes

Flavia Mazzoli-Rocha et al. Ricardo Stein Carolin Steinmetz Monika Sadlonova … Audrey Borghi-Silva Thomas Schmidt

Abstract

Patients undergoing cardiac surgery often face multiple challenges, including comorbidities, frailty, and psychosocial factors, which complicate recovery. Multimodal prehabilitation programs have emerged as a promising strategy to address these issues, aiming to reduce the length of hospital stay, mitigate pulmonary complications, and enhance functional recovery.

This Review Article examines the components and benefits of a comprehensive cardiac prehabilitation program, with a focus on exercise-based prehabilitation. Additionally, it underscores the importance of integrating prehabilitation into Brazilian clinical guidelines as a valuable preoperative opportunity.

Emerging evidence, albeit of low to moderate quality, suggests that exercise-based prehabilitation, as a unimodal approach or integrating a multimodal program, can significantly improve functional capacity and postoperative outcomes in patients undergoing elective cardiac surgery. International guidelines have already supported cardiac prehabilitation as a valuable approach in this context. Globally, ongoing multicenter intervention trials seek to refine this evidence, pinpointing the ideal patient population and the most effective cardiac prehabilitation program. Given the growing burden of cardiovascular disease in Brazil, there is an unmet need for local research to assess the benefits of prehabilitation in patients undergoing cardiac surgery.

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Editorial

Middle-Aged Women — A High-Risk Group for Post-Myocardial Infarction Mortality

Maria Antonieta Albanez A. de Medeiros Lopes et al. Mayara Viana Júlia Nóbrega Heitor N. Albanez A. de Medeiros Gláucia Maria Moraes de Oliveira

Cardiovascular diseases (CVD) remain the leading cause of death worldwide, with acute myocardial infarction (MI) accounting for significant morbidity and mortality. Despite substantial reductions in overall cardiovascular mortality, gender disparities persist, particularly affecting women in different demographic contexts. In this mini-editorial, we highlight recent evidence from an original study conducted in the Brazilian Unified Health System (SUS) in Curitiba, Brazil, which followed 4,896 patients hospitalized for acute MI between 2008 and 2015. This pioneering study demonstrated that middle-aged women (45 to 54.9 years) have a significantly higher risk of post-infarction mortality compared to men of the same age group, regardless of adjusted clinical factors. These data provide a critical warning about the need for differentiated, specific clinical approaches for this group (). The analysis of the Brazilian public cohort strengthens international evidence on the gender paradox in CVD. It reinforces the critical role of hormonal changes and psychosocial determinants in worsening the prognosis for women after MI. This contradicts the common assumption that women in this age group maintain natural cardiovascular protection, raising critical questions about the attention given to cardiovascular health at this vital stage of life.

The so-called “gender paradox” in CVD is well established, especially among younger women. Studies show that women under 50 have almost three times higher mortality after MI than men of the same age group, regardless of previous medical history, disease severity, or type of treatment.^, This paradox is remarkable, given that middle-aged women often have fewer traditional cardiovascular risk factors and tend to have better outcomes after percutaneous coronary intervention. The study findings are aligned with global and national data that indicate that women develop MI approximately 5 years later than men (mean age 65.1 vs. 60.3 years). Still, the protective effect of the female sex diminishes and reverses in the 45-54.9 age range. This period coincides with perimenopause and the onset of menopause, highlighting the importance of hormonal changes in increasing cardiovascular susceptibility.

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Original Article

The Cost of Medical Management in Advanced Heart Failure: A Latin American Perspective

Livia Adams Goldraich et al. Ana Paula Beck da Silva Etges Laura Caroline Tavares Hastenteufel Dayanna Machado Lemos … Andreas Zuckermann Mandeep R. Mehra Carisi Anne Polanczyk Nadine Clausell

Abstract

Background

The financial burden faced by patients with advanced heart failure (HF) who are ineligible for heart transplantation or lack have access to advanced therapy with left ventricular assist devices (LVADs) has not been described in Latin American.

Objective

To conduct a microcosting study in patients who were otherwise eligible for LVAD therapy who did not have access to it.

Methods

We evaluated the direct costs of care in a cohort of advanced HF patients treated at a Brazilian public hospital who were candidates for LVAD therapy (and ineligible for transplantation) but lacked access to the procedure. A patient-level cost analysis was performed from the time LVAD need was identified until death or end of follow-up. The total cost per patient was calculated using the time-driven activity-based costing methodology and expressed in international dollars (Int$). Patients were stratified by disease severity and all-cause mortality to assess cost variability.

Results

Conclusions

This study highlights the financial burden associated with ongoing medical management of advanced HF in patients who would otherwise be eligible for LVAD therapy. These findings provide a basis for evaluating the cost-effectiveness of device-based, life-saving interventions in selected advanced HF populations.

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Original Article

The Role of Indexed Left Atrial Volume in Detecting Adverse Outcomes in Patients with Chronic Obstructive Pulmonary Disease: A Cohort Study

Maria Clara C. Sposito et al. Leticia A. Branco Jaqueline Bianchi Fernanda O. Duarte … Krissia F. Godoy Joice M. A. Rodolpho Bruna Dias de Lima Fragelli Renan S. Marinho Stella Maris Firmino Audrey Borghi Silva Fernanda Freitas Anibal Meliza Goi Roscani

Abstract

Background

Chronic obstructive pulmonary disease (COPD) is a progressive disease with high mortality, and understanding the predictors of adverse outcomes can aid in developing individualized therapeutic approaches and in making decisions regarding hospital or intensive care unit admissions.

Objective

To assess the epidemiological and laboratory profiles of patients with COPD and to correlate clinical, echocardiographic, and biomarker variables with unfavorable outcomes due to exacerbation.

Method

This was a prospective study involving patients with COPD who underwent clinical evaluation, spirometry, transthoracic echocardiography, and laboratory tests. Patients were followed for 1 year to monitor for unfavorable outcomes. The significance level considered for all analyses was p < 0.05.

Results

A total of 228 patients were included, with the mean age of 71 ± 9 years. The majority of patients were male (58%), and smoking (72%), hypertension (66%), and GOLD B (55%) were predominant. Indexed left atrial volume (ILAV) demonstrated good accuracy in detecting hospitalization for exacerbation, with a cutoff point of 36.5 ml/m², yielding 100% sensitivity and 70% specificity. Patients with ILAV > 36.5 ml/m² exhibited worsening diastolic and systolic function, as indicated by mitral E wave peak velocity in the rapid filling phase/E′ velocity of displacement of the septal or lateral mitral annulus in the rapid filling phase (E/E′) (p = 0.02) and left ventricle ejection fraction (p = 0.01), along with elevated levels of tumor necrosis factor alpha (p = 0.05) and NT-proBNP (p = 0.03).

Conclusion

ILAV may be a reliable marker for predicting unfavorable outcomes in patients with COPD. Individualized strategies should be implemented to improve disease severity and cardiovascular function.

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Brief Communication

Constrictive Pericarditis with Caseous Necrosis: A Rare and Underrecognized Presentation

Plínio José Whitaker Wolf et al. Edileide Barros Correia Marcos de Oliveira Vasconcellos Larissa Ventura Ribeiro Bruscky … Ana Cristina de Souza Murta Yoná Afonso Francisco Eduardo Mikio Sassaki Sara Regina Alcalde Domingos Natan Alevato Donadon Gerson Miranda Raphael Rossi Victor Bemfica de Mello Mattos Fernanda de Brito Fortuna

Abstract

Caseous necrosis of the mitral valve is the term used to describe the liquefaction of calcium present in its fibrous ring and the consequent formation of a pseudotumor with a thick, pasty content within. Although rare, this degenerative process has been widely described in the context of the mitral valve; however, it is little known in the context of constrictive pericarditis. We describe a series of seven cases that presented with constrictive pericarditis associated with caseous necrosis. Of the seven patients, six were male, with a mean age of 42±14 years, all in functional class III/IV, with clinical signs related to restrictive syndrome. Chest tomography showed intense pericardial calcification with caseous necrosis, confirmed by pericardiectomy.

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Editorial

The Hidden Cost of Denied Access: Advanced Heart Failure in Latin America

Fernanda Almeida Andrade

Advanced heart failure (AHF) represents the terminal stage of the syndrome, characterized by refractoriness to currently available pharmacological and non-pharmacological strategies. It is a condition associated with high morbidity and mortality rates and a disproportionate consumption of healthcare resources, imposing a substantial burden on both healthcare systems and families. With population aging and the increased survival of individuals with chronic heart disease, the prevalence of AHF is projected to grow steadily, with escalating impact on direct costs (hospitalizations, advanced therapies, intensive support) and indirect costs (loss of productivity and social dependency).^,

In high-income countries, costly interventions such as heart transplantation and long-term mechanical circulatory support have become consolidated therapeutic pillars that can alter the natural history of the disease. Heart transplantation remains the gold standard of treatment, although its practical application is limited by donor shortages and a high proportion of clinically ineligible patients. Within this therapeutic gap, left ventricular assist devices (LVADs) have progressively emerged as increasingly effective alternatives, particularly as destination therapy. The introduction of continuous-flow technologies and, more recently, magnetically levitated pumps, such as the HeartMate 3, has redefined prognosis, providing survival beyond five years in specialized centers.

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Editorial

Cost Implications and Perspectives of TAVI versus SAVR in the Hospital Setting

Renato Paladino Nemoto et al. Roney Orismar Sampaio

The article “Transcatheter Aortic Valve Implantation vs. Aortic Valve Surgery in a Brazilian Public Health System (SUS) Hospital: Periprocedural Outcomes and Costs” addresses a relevant topic, especially after the inclusion of transcatheter aortic valve implantation (TAVI) in the list of procedures available in the SUS. Patients undergoing TAVI are typically older, with more comorbidities, and are more frail. Conversely, surgical aortic valve replacement (SAVR) in elderly patients can result in increased morbidity and length of hospital stay.

In the study, surgical risk was low in both groups (STS 3.62±2.28 in the TAVI group vs 1.64±0.94 in SAVR, p<0.001), which may demonstrate the limitation of surgical risk stratification with current tools. Mortality was lower in the TAVI group (2.8% vs. 5.0%), but without reaching statistical significance. The minimally invasive strategy (without general anesthesia, with transthoracic echocardiography monitoring) resulted in a shorter hospital length of stay (2.0 [1.0; 4.0] days in the TAVI group vs. 8.0 [7.0; 12.0] days in the SAVR group, p<0.001). However, the costs were higher than those of SAVR. The high prices of materials (R$ 55,750.90 [52,345.30; 92,286.8] TAVI vs. R$ 22,518.10 [19,130.60; 25,875.10] SAVR, p<0.001) is a significant factor. Late complications, such as a higher rate of hospital infection, including surgical wound infection, are unfavorable to surgery, due to increased hospitalization for use of antimicrobials, hospital human resources, among other costs.

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Original Article

Diagnostic Utility of P-Wave Duration in Identifying Left Atrial Enlargement: Insights from the ELSA-Brasil Cohort

Ana Cecília de Sena Oliveira et al. Vinicius Tostes Carvalho Marcelo Martins Pinto-Filho Luisa Caldeira Brant … Sandhi Maria Barreto Murilo Foppa Antonio Luiz Pinho Ribeiro

Abstract

Background

Atrial cardiomyopathy encompasses various atrial abnormalities, including left atrial enlargement (LAE), which is associated with adverse cardiovascular and neurocognitive outcomes. P-wave duration ≥120 ms on 12-lead electrocardiogram (ECG) is a widely available, cost-effective tool and one of the main diagnostic criteria adopted. However, its diagnostic performance in large-scale studies remains underexplored.

Objectives

To evaluate the correlation between P-wave duration and left atrial volume (LAV) measured by transthoracic echocardiogram (TTE) and determine the diagnostic accuracy of P-wave duration ≥120 ms for identifying LAE.

Methods

We conducted a cross-sectional analysis of baseline data from the ELSA-Brasil cohort participants in sinus rhythm. P-wave duration was automatically measured via standard 12-lead ECG, with ≥120 ms indicating enlargement. LAE was defined as LAV>34 mL/m² by TTE. Spearman’s rank test assessed correlation. Diagnostic performance metrics – sensitivity (Sn), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV), positive and negative likelihood ratio (LR+ and LR-) – were calculated. Also, a Receiver Operating Characteristic (ROC) was constructed. Statistical significance was set at p-value<0.05 with 95% confidence interval.

Results

The study included 2589 participants, 419 (16,1%) with LAV index>34 mL/m². P-wave duration correlated weakly with LAV (Spearman’s ρ = 0.120, p < 0.001). Diagnostic accuracy measurements were AUC = 0.557 ± 0.032; Sn = 0.296; Sp = 0.811; PPV = 0.232; NPV = 0.856; LR+ 1.566; LR- 0.868.

Conclusion

P-wave duration demonstrates limited diagnostic value for identifying LAE, suggesting against its recommendation as a standalone diagnostic criterion for this condition.

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Original Article

Diastolic Blood Pressure Dipping During Sleep Shows Superior Unadjusted Predictive Power Compared to Systolic Dipping: A Retrospective Cohort Study

Mateus de Carvalho Gonçalves et al. Daniely Santos da Silva Vitória Nogueira Ribeiro Vanessa Burgugi Banin … Vanessa dos Santos Silva Rodrigo Bazan Silméia Garcia Zanati Bazan Pasqual Barretti Luis Cuadrado Martin

ABSTRACT

Background:

Sleep blood pressure (BP) fall is a prognostic marker. Few studies have evaluated whether systolic BP (SBP) or diastolic BP (DBP) dipping more accurately predicts clinical outcomes.

Objective:

To determine which type of BP dipping has greater predictive value for clinical outcomes.

Methods:

This retrospective cohort evaluated patients who underwent ambulatory blood pressure monitoring (ABPM) between January 27, 2004, and February 16,2012. Patients were followed until the occurrence of the primary outcome (death from any cause), or until the end of follow-up period (February 01, 2022). Cox survival curves were constructed to assess which dipping classification – SBP or DBP – better distinguished the occurrence of outcomes. Dipping was defined as a nocturnal BP reduction of 10-20%. Absent and attenuated dipping were defined as reductions of ≤ 0% and 0-10%, respectively. Statistical significance was set at p < 0.05.

Results:

A total of 756 patients were included, with a mean age of 54±16.4 years; 42% were male. In predicting the primary outcome (all-cause mortality), the absence of DBP dipping, adjusted for 24-hour SBP, was associated with a hazard-ratio (HR) of 2.051 (95% confidence interval [95%CI]: 1.147 – 3.670 (p=0.015). For the secondary outcome (cardiovascular mortality), the absence of DBP dipping, also adjusted for 24-hour SBP, showed a HR of 3.329 (95%CI: 1.317-8.412; p=0.011). In contrast, the absence of SBP dipping, when adjusted for 24-hour SBP, was not significantly associated with either outcome. In the fully adjusted model, which included age, diabetes, smoking, atherosclerotic vascular disease and chronic kidney disease, both SBP and DBP dipping lost statistically significant associations.

Conclusion:

DBP dipping demonstrates superior predictive power for outcomes compared to SBP dipping, and adds to the prognostic value of mean 24-hour SBP. ().

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Case Report

Reversal of Left Bundle Branch Block Following Treatment in Alcoholic Cardiomyopathy

Manuela Cristina Ribeiro Dias Barroso et al. Heleutério da Conceição Nicolau Madogolele Deborah de Sá Pereira Belfort Bruno Biselli … Silvia Moreira Ayub-Ferreira Edimar Alcides Bocchi

Introduction

Left bundle branch block occurs in the context of several cardiomyopathies; however, its reversal is rarely described. We describe a case of alcoholic cardiomyopathy with left bundle branch block that presented reversal after institution of targeted treatment and alcohol cessation.

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Editorial

Alcohol Consumption and Its Association with Lifestyle in Individuals with and without Cardiovascular Disease

Paulo Henrique Godoy

The association between alcohol consumption and lifestyle is multifaceted. The amount and pattern of alcohol intake both influence and are influenced by other lifestyle factors, such as dietary habits, physical activity, smoking, sleep, body composition, and socioeconomic status, among others.^–

Higher levels of alcohol consumption are generally associated with less healthy lifestyle behaviors (LSB). Excessive alcohol intake is frequently accompanied by increased caloric consumption, poorer dietary quality, and a higher prevalence of smoking and physical inactivity.^,

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Editorial

Testosterone, SHBG Levels, and Heart Failure Risk: Does the Correlation Imply Causation?

Érique José Farias Peixoto de Miranda

The authors describe a meta-analysis of six observational studies with low risk of bias, which suggests a modest association between low testosterone levels, but not Sex Hormone-Binding Globulin (SHBG), and incidence of heart failure (HF) in men, but not in women. In short, for each reduction of one standard deviation of serum testosterone levels, the hazard ratio of HF increased 10% (HR 1.10, 95% CI: 1.03-1.17).

The polled data show that a total of 233,474 middle-aged participants were followed up for at least 7.7 years; the vast majority of them (90.2%) registered in one single cohort, 3,991 (1.71%) of them had events. In other words, we could observe a small absolute risk increase in comparison to the overall population. Among individuals aged ≥45 years, the incidence of HF is 6.0 per 1,000 person-years, increasing to 21.1 per 1,000 person-years among those aged 65 years or more.

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Original Article

Transcatheter Aortic Valve Implantation vs. Aortic Valve Surgery in a Brazilian Public Health System (SUS) Hospital: Periprocedural Outcomes and Costs

Gabriel Prado Saad et al. Alberto Collella Cervone José Henrique Delamain Vitor Belloti … Ana Paula Beck da Silva Etges Giullia Sarabando Perez Bruna Bronhara Damiani Mario Issa Farid Samaan Auristela Isabel de Oliveira Ramos Fausto Feres Dimytri Alexandre Alvim de Siqueira

Abstract

Background

Transcatheter aortic valve implantation (TAVI) has emerged as a preferred treatment for severe, symptomatic aortic stenosis (AS). However, comparative data with surgical aortic valve replacement (SAVR) within the Brazilian public health system (SUS) remain limited.

Objective

To compare clinical outcomes and perform a cost-analysis of TAVI versus SAVR in SUS patients.

Methods

This retrospective, single-center study evaluated clinical outcomes and direct medical costs, using a statistical significance threshold of 5%.

Results

Between 01/2018 and 12/2022, 320 patients (139 TAVI, 181 SAVR) were included. TAVI patients were older (77.9 vs. 64.9 years, p<0.001) and had higher surgical risk (STS 3.62% vs. 1.64%, p<0.001). Mortality (2.9% vs. 5.0%) and stroke rates (1.4% vs. 3.3%) were numerically lower for TAVI, but not statistically significant. In a risk-adjusted composite outcome (death, stroke, re-hospitalization), TAVI showed potential superiority (5.8% vs. 12%, OR 2.68, 95% CI 1.04-7.65, p=0.05), though not statistically significant. TAVI was associated with a shorter hospital stay (2.0 vs. 8.0 days, p<0.001). TAVI’s total cost was significantly higher than SAVR’s (R$ 55,750.90 [52,345.30; 92,286.80] vs R$ 22,518.10 [19,130.60; 25,875.10, – p<0.001]).

Conclusions

In this study, TAVI displayed similar clinical outcomes compared to SAVR, while being performed on older patients with higher surgical risk. From an economic perspective, costs of TAVI treatment were significantly higher than SAVR, driven mainly by device costs, while in-hospital length of stay was significantly lower. With extended follow-up and reduced procedural costs, TAVI may become a cost-effective option in the SUS.

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Original Article

Middle-Aged Women and Post-Myocardial Infarction Mortality: A Vulnerable Group? Real-World Evidence from a Brazilian Public Health System Cohort

Edson Marcos Campos Lessa Júnior et al. Carolina Perin Maia da Silva Tatiana Lorena da Luz Kaestner Cecília Rubini Rocha … Gabriela Redivo Stroher Gabriele da Silva Giovanni Augusto de Oliveira Baccin Marcia Olandoski Andre Bernardi José Rocha Faria Neto

Abstract

Background

Cardiovascular diseases are the leading cause of death in Brazil, with acute myocardial infarction (MI) accounting for a significant share of these fatalities. Women tend to experience MI at older ages and in the presence of more comorbidities — factors that may negatively impact prognosis. Locally generated evidence is essential to guide targeted strategies within the public health care system.

Objective

To assess the influence of age and sex on post-MI mortality among patients treated within the Brazilian Unified Health System.

Methods

This retrospective cohort study included patients residing in Curitiba who were hospitalized for MI (International Classification of Diseases, 10th Revision code I21) between 2008 and 2015. Mortality data were obtained from the Brazilian Mortality Information System. In-hospital mortality, as well as mortality at 6 and 12 months and at the end of follow-up, were analyzed. Age (both as a continuous and categorical variable) and sex, as well as their interaction, were included in the analysis. Statistical significance was set at 5% (p < 0.05).

Results

The sample included 4,896 patients (mean age 62 ± 12.4 years; 34.1% women), with an average follow-up of 50.9 months. Overall mortality was 29.5%. On average, women experienced MI 5 years later than men (65.1 vs. 60.3 years; p < 0.001) and had higher follow-up mortality (p < 0.001). However, in the multivariate analysis, only age remained significantly associated with mortality. Age-stratified analysis revealed a higher risk of death among women aged 45-54.9 years (p = 0.004).

Conclusion

Older age contributes to the worse post-MI prognosis observed among women compared to men. However, women in early middle age showed an increased risk of death, representing a potentially vulnerable group requiring specific attention.

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Original Article

Paclitaxel-Coated Balloons versus Drug-Eluting Stents in Small Vessel Coronary Artery Disease: A Systematic Review and Meta-Analysis

Marília Oberto da Silva Gobbo et al. Renan Yuji Ura Sudo Ancy Jenil Franco Mable Pereira … Tanize Louize Milbradt Zeynep Eylul Bakir Iago Zang Pires Stephen Akinfenwa Gustavo Luís Agostini Denise Pellegrini Paulo R. A. Caramori

Abstract

Background

Drug-eluting stents (DES) remain the standard of care for percutaneous coronary intervention in small vessel coronary artery disease (SVD). Paclitaxel-coated balloons (PCB) have emerged as an alternative, with recent trials suggesting favorable short- and mid-term outcomes, although most were limited by small sample sizes.

Objectives

To compare angiographic and clinical outcomes between DES and PCB in patients with SVD.

Methods

Searches were conducted in PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov for studies comparing PCB and DES in SVD, defined as a reference vessel diameter < 3.0 mm. A random-effects meta-analysis was performed, and results were reported as mean differences (MD) or risk ratios (RR). Statistical significance was set at p < 0.05. Heterogeneity was assessed using the chi-square, Tau, and Tau² tests. The review protocol was registered in PROSPERO (CRD42024506502).

Results

A total of 12 studies comprising 17,441 patients (mean age of 58-73 years) were included, with clinical follow-up of 8 to 36 months. All studies evaluated PCB. No significant differences were found between PCB and DES in target lesion revascularization (RR, 1.24; 95% CI, 0.82-1.85; p = 0.30), late lumen loss (MD, –0.09 mm; 95% CI, –0.41 to 0.23; p = 0.57), major adverse cardiovascular events (RR, 1.01; 95% CI, 0.76-1.33; p = 0.95), all-cause mortality (RR, 0.81; 95% CI, 0.50-1.31; p = 0.39), cardiovascular mortality (RR, 1.74; 95% CI, 0.78-3.89; p = 0.17), and myocardial infarction (RR, 0.76; 95% CI, 0.46-1.27; p = 0.30).

Conclusions

PCB angioplasty demonstrated clinical and angiographic outcomes comparable to DES in SVD, supporting its role as a safe, effective alternative in selected patients.

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Case Report

Brazil's First High-Risk Percutaneous Coronary Intervention with Hemodynamic Support from a Percutaneous Pulsatile Device: A Case Report

André M. Nicolau et al. Pedro H. M. C. de Melo Lucas Aguiar Alencar de Oliveira Rafael Bergo … Thiago A. Kleinsorge Roger Renault Godinho Fábio Sândoli de Brito Jr Alexandre A. Abizaid Carlos de Magalhães Campos

Abstract

Percutaneous coronary intervention (PCI) is the most widely used coronary revascularization method worldwide, even in cases of high anatomical complexity. However, this increasing complexity has increased the risks associated with the procedure. Mechanical circulatory assist devices (MCADs), such as the iVAC 2L, have been used for hemodynamic support in high-risk PCIs.

We describe the first case in Brazil of PCI performed with the support of the iVAC 2L, a pulsatile MCAD. The patient, an 81-year-old man, had functional class III angina and severe lesions in the left main coronary artery (LMCA), left anterior descending artery (LAD), and circumflex artery (CX), associated with extensive calcification. The procedure was performed with the support of the iVAC 2L, and PCI was performed with stenting of the LMCA, LAD, and CX. The entire procedure was performed without the need for vasoactive drugs, and the device was removed without vascular complications.

High-risk PCI has become increasingly common, often requiring ventricular mechanical support. The iVAC 2L offers advantages such as pulsatile flow and ease of implantation, making it an alternative to the intra-aortic balloon pump and Impella. This report highlights the potential use of the iVAC 2L in Brazil, expanding therapeutic options for high-risk patients.

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Case Report

Cardiac Sarcoidosis Reactivation in a Transplanted Heart: An Unusual Case of New Graft Dysfunction

Manuela Cristina Ribeiro Dias Barroso et al. Heleutério da Conceição Nicolau Madogolele Danielle Louvet Guazzelli Luis Fernando Bernal da Costa Seguro … Fabiana Goulart Marcondes-Braga Sandrigo Mangini Monica Samuel Ávila Gabriel Barros Aulicino Iascara Wozniak Campos Samuel Padovani Steffen Fabio Antonio Gaiotto Fernando Bacal

Introduction

Cardiac sarcoidosis (CS) is an uncommon yet potentially life-threatening manifestation of systemic sarcoidosis. Recurrence of CS following heart transplantation (HTx) is an exceedingly rare event and presents a significant diagnostic challenge.

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Editorial

Small-Vessel Coronary Disease and Drug-Coated Balloons: Time to Reconsider Our Strategy?

Guy F. A. Prado et al. Henrique Barbosa Ribeiro

Percutaneous coronary intervention (PCI) with drug-eluting stents (DES) has dramatically transformed coronary revascularization, reducing restenosis and the need for repeat interventions. Nevertheless, despite major advances in stent bioengineering and procedural techniques, the permanent implantation of metallic platforms and polymer coatings remains associated with long-term stent failure, particularly in small coronary arteries, with an annual incidence of stent thrombosis of approximately 1–2%. The underlying mechanisms include neointimal hyperplasia, neoatherosclerosis, stent fracture, and the inability to achieve positive remodeling, all resulting from the “caging” of vessels with metallic struts. Against this background, the use of drug-coated balloons (DCBs) for the treatment of de novo lesions—embodying the “leave nothing behind” strategy—has emerged as an attractive alternative to overcome limitations inherent to stent implantation.

In recent years, an increasing number of trials have underscored the clinical relevance of DCB angioplasty for de novo lesions. The avoidance of permanent device implantation into the vessel wall is particularly appealing. On the other hand, a key objective of PCI is to achieve acute luminal gain while minimizing dissections and impaired flow—an aspect where stents retain a clear advantage. Still, PCI with DES in small arteries has consistently been associated with higher rates of target lesion failure. In this context, a DCB-based angioplasty is compelling. Recent evidence has suggested comparable outcomes between DCBs and DES in small-vessel disease; however, non-inferiority designs and small sample sizes have limited these findings.

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Review Article

Transcatheter Aortic Valve Implantation (TAVI) Versus Surgical Valve Replacement on Clinical Outcomes in Patients with Aortic Stenosis

André Luiz Lisboa Cordeiro et al. Emmanuel de Souza Gonçalves Rute Macêdo de Santana Tayane Siqueira Martins dos Santos

Abstract

Aortic stenosis (AS) is one of the most prevalent valve lesions, and transcatheter aortic valve replacement (TAVI) has emerged as an alternative to surgical aortic valve replacement (SAVR). TAVI is a minimally invasive procedure that has proven to be a safer option in several aspects. The objective is to review the impact of TAVI compared to surgical aortic valve replacement on mortality, postoperative complications, hospitalization, and quality of life in patients with AS. A systematic review was conducted using the PICO strategy, with searches in the PubMed, Central, and LILACS databases, employing the following descriptors: aortic stenosis, hospitalization, mortality, clinical trial, transcatheter aortic valve implantation, quality of life, postoperative complications, combined with the Boolean operators “AND” and “OR.” A total of 29 articles were found after reading the titles and abstracts. Of these, nine showed lower mortality in patients undergoing TAVI, while three reported lower mortality in the SAVR group. Eight articles had similar findings regarding complications, with six showing a lower incidence of postoperative complications in TAVI and three in SAVR. Additionally, three articles showed better quality of life in TAVI patients, while one study indicated a shorter hospital stay for TAVI patients. In all studies, the patients analyzed were over 70 years old. TAVI reduced mortality compared to SAVR in patients with AS. Furthermore, TAVI was associated with a reduction in hospital stay and improvement in quality of life. Regarding postoperative complications, the results indicated that TAVI tends to have a lower complication rate, although variations exist between studies.

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Original Article

Impact of Low Testosterone and SHBG Levels on Heart Failure Risk: A Systematic Review and Meta-Analysis

Thiago Artioli et al. Layane Bonfante Batista Kleber Franchini José Nunes de Alencar

Abstract

Background

Studies suggest a possible link between low levels of testosterone and sex hormone binding globulin (SHBG) and adverse cardiovascular outcomes; however, this relationship remains poorly defined.

Objectives

This systematic review aimed to evaluate the predictive value of baseline levels of testosterone, dihydrotestosterone (DHT), and SHBG for the incidence of heart failure (HF), providing deeper insight into the hormonal influence on HF risk.

Methods

We conducted a comprehensive search of the MEDLINE, Scopus, and Web of Science databases to identify cohort and nested case-control studies that measured hormone levels in adults without prior HF. Risk of bias was assessed using the ROBINS-E tool. Pooled hazard ratios (HRs) and odds ratios (ORs) were estimated using bivariate random-effects models. A statistical significance level of 0.05 was applied to all analyses.

Results

Out of 1,209 articles screened, 738 remained after deduplication. Six studies, including 233,474 participants (11,663 women), met the inclusion criteria. A one standard deviation decrease in testosterone levels was modestly associated with an increased risk of HF in men (HR 1.10, 95% CI: 1.03-1.17), but not in women (HR 1.05, 95% CI: 0.98-1.16). Comparisons across quartiles or quintiles did not reveal significant associations, and SHBG levels were not significant predictors of HF risk. Bayesian analysis provided weak evidence for the association (Bayes factor = 0.99).

Conclusions

This meta-analysis suggests that low testosterone levels are modestly associated with an increased risk of HF in men, highlighting a potentially important yet underexplored aspect of cardiovascular health. The heterogeneity in study designs and population characteristics, combined with the weak associations observed, underscores the need for further rigorous investigation. Well-designed randomized controlled trials are essential to confirm these findings and to elucidate the underlying biological mechanisms.

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Original Article

Harmful Alcohol Consumption in Patients with Heart Disease: A Risk Analysis by Lifestyle Behavior – The Brazilian PROSA Project (Projeto Saúde e Álcool)

Martino Martinelli-Filho et al. Caio Vitale Spaggiari Roberta Vanalli Baroni Cinthya Ibrahim Guirao Gomes … Thiago Ovanessian Hueb Sergio Augusto Mezzalira Martins Anísio Alexandre Andrade Pedrosa Silvana Angelina Dório Nishioka Sergio Freitas de Siqueira

Abstract

Background

Moderate alcohol intake appears to have a protective cardiovascular effect, whereas harmful alcohol consumption (HAC) is associated with a high rate of chronic diseases and mortality. The amount of alcohol intake has been associated with lifestyle behaviors; however, this relationship has not been assessed in patients with heart disease (HD).

Objective

To evaluate the association between lifestyle behavior and HAC in HD patients.

Methods

This is an observational study that included one group of patients with HD and one group of volunteers designed to assess the association of HAC with lifestyle behavior using a score of lifestyle behavior (the LBS score). We assessed alcohol consumption using the AUDIT-C test. LBS was developed by assigning 1 point to each variable – smoking; overweight or obese (body mass index ≥24.9); anxiety; depression and lack of physical activity, and classified into healthy (0/1 point), regular (2/3 points), or unhealthy (4/5 points). Statistical analysis adopted as a significance level p-value <0.05.

Results

The study included 1,999 patients with HD and 2,081 volunteers. Regression analysis controlled for age and sex, revealed that regular and unhealthy LBS are independent predictors of HAC (OR= 1.35, p=0.04 and OR= 1.76, p=0.001, respectively) in HD patients, similar as volunteers. Good discrimination capability of the regression model was reported in the temporal validation (ROC 0.80). Furthermore, LBS improvements were associated with HAC reductions (p=0.02).

Conclusions

This study showed that risk assessment for HAC using a new lifestyle score is a reliable predictor in HD patients. Also, it was observed that improving lifestyle behavior may help to reduce HAC.

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Editorial

LBBB and the Paradigm Shift from STEMI to Occlusion MI

Jesse T.T McLaren et al. Hans C. Helseth Stephen W. Smith

The current paradigm for acute coronary syndrome (ACS) is based on ST elevation myocardial infarction (STEMI) electrocardiogram (ECG) criteria. This is defined as ST elevation in the absence of left bundle branch block (LBBB). Nevertheless, this creates an obvious dilemma: what about patients with LBBB? In their systematic review and meta-analysis of 51 studies, Alencar et al. help resolve longstanding debates by comparing guidelines with evidence. This not only clarifies how to address this specific diagnostic dilemma, but also how a paradigm shift from STEMI to Occlusion MI (OMI) could transform patient care.

As Alencar found, LBBB appeared in only 3.3% of ACS, but had higher mortality than acute MI without BBB. The current paradigm creates the twin dangers of unnecessary cath lab activation or even thrombolytics for LBBB without OMI, or delayed reperfusion for LBBB with OMI.

[…]

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Original Article

Accuracy of Left Bundle Branch Block Chronology and Electrocardiography Criteria for Acute Myocardial Infarction Diagnosis: A Systematic Review and Meta-analysis

José Nunes de Alencar et al. Gleydson Wesley Freire Lima Haissa Assad dos Santos Geraldo Rinaldo Carvalho Fernandes … Matheus Kiszka Scheffer Sandro Pinelli Felicioni Mariana Fuziy Nogueira De Marchi

Abstract

Background

The diagnostic utility of new or presumed new left bundle branch block (LBBB) for acute myocardial infarction (AMI) in the setting of acute coronary syndrome (ACS) remains controversial.

Objective

To evaluate whether the timing of LBBB predicts AMI and to compare its diagnostic accuracy with ischemic electrocardiography (ECG) criteria, particularly the Modified Sgarbossa Criteria (MSC).

Methods

We searched PubMed and Scopus for studies involving patients with ACS with LBBB through December 2023. Sensitivity, specificity, positive (LR+) and negative (LR–) likelihood ratios, and diagnostic odds ratios (DOR) were calculated to assess diagnostic accuracy. Incidence and mortality data were also analyzed. Risk of bias was evaluated using the Newcastle-Ottawa Scale (NOS) and the revised Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool.

Results

A total of 51 studies were included. LBBB occurred in 3.3% of ACS presentations and was associated with higher in-hospital mortality. Differentiating new from old LBBB was diagnostically neutral: LR+ 1.30 (95% CI: 0.75 to 1.85), LR– 0.90 (95% CI: 0.79 to 1.02), and DOR 1.44 (95% CI: 0.93 to 2.24); all confidence intervals crossed the null value of 1.0. In contrast, MSC demonstrated 83.6% sensitivity (95% CI: 55.4 to 95.5%) and 92.6% specificity (95% CI: 78.9 to 97.7%) for angiographically confirmed occlusive AMI, with LR+ 11.34 (95% CI: 3.67 to 34.99) and LR– 0.18 (95% CI: 0.054 to 0.575).

Conclusion

LBBB chronology alone does not significantly impact the likelihood of AMI. Ischemic ECG criteria — especially the MSC — provide substantially greater diagnostic accuracy and should guide clinical decision-making in ACS patients with LBBB.

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