2026;123(8) – ABC CARDIOL

Original Article

Percutaneous Axillary Intra-Aortic Balloon Pump Implantation in Patients Hospitalized with Heart Failure: Initial Brazilian Experience

Bruno Alves da Mota Rocha et al. Pedro H. M. C. de Melo Luis Mapa Rafael Nunes Oliveira … Antônio Fernando Freire Hernán Patricio García Mejía Vanessa Corcioli Bellini Liliane Kopel Silvia Gelás Lage Fabiana Goulart Marcondes-Braga Sandrigo Mangini Monica S. Ávila Iascara Wozniak de Campos Fernando Bacal Fábio Sândoli de Brito Jr Alexandre A. Abizaid Pedro Felipe Gomes Nicz

Abstract

Background

The intra-aortic balloon pump (IABP) is the most widely used mechanical circulatory support device for patients with advanced heart failure (HF) in our setting. However, femoral implantation restricts patient mobility during support.

Objective

To report the initial experience of a Brazilian advanced HF referral center with percutaneous axillary IABP implantation.

Methods

Consecutive patients hospitalized for HF who underwent percutaneous axillary IABP implantation at a tertiary cardiology referral center were included. A p-value < 0.05 was considered statistically significant.

Results

Between December 2020 and December 2023, 22 patients underwent percutaneous axillary IABP implantation. The mean age was 53 ± 10.7 years. All patients were hospitalized with refractory HF and were listed for heart transplantation. The procedure was successfully performed in all patients selected for the axillary approach. The median duration of support was 15 days (interquartile range: 7–28 days). Observed complications included device migration (18.2%), limb ischemia (9.1%), and isolated infectious and neurological events. Half of the patients either underwent heart transplantation or were successfully weaned from mechanical support.

Conclusion

The initial experience with percutaneous axillary IABP implantation demonstrated that the technique is feasible, safe, and reproducible. Further studies are needed to establish the role of this strategy within the continuum of care for patients hospitalized with advanced HF while awaiting heart transplantation.

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Original Article

Incorporating Intracoronary Lithotripsy into Daily Practice: A Temporal Comparative Analysis of Safety, Efficacy, and Learning Curve

Guy F. A. Prado et al. Stefano Garzon José Mariani Junior Willterson Bandeira … Felipe Mateus Teixeira Bezerra Breno Oliveira Almeida Gustavo Neves de Araujo Ana Claudia Conrado João Silveira Emanuele Barbato Flavio Ribichini Pedro Alves Lemos

Abstract

Background

Intravascular lithotripsy (IVL) has emerged as a groundbreaking technology for treating calcified coronary lesions.

Objective

To assess whether case selection and interventional performance with IVL have evolved over time after its incorporation into daily practice.

Methods

We prospectively included 104 consecutive patients with 127 calcified coronary lesions treated with IVL. The cohort was divided into two temporal groups (52 patients each) based on the order of patient inclusion. Clinical data and procedural performance were compared between the groups. All statistical tests were two-sided, with a significance level of 0.05.

Results

The mean age was 73.2 ± 10.2 years, and 62.5% of patients presented with acute coronary syndromes. Severe calcification and type B2/C lesions were identified in 73.2% and 98.4%, respectively. Upfront IVL was performed in 92.9% of lesions, intravascular imaging was used in 78%, rotational atherectomy in 6.3%, and angiographic success was achieved in 96.0%. Compared with the first cohort, the latter cohort had more bifurcation lesions (60.0% vs. 41.9%; p = 0.04), more interventions in the circumflex artery (24.6% vs. 8.1%; p = 0.02), and a lower use of 4.0-mm diameter balloons (4.6% vs. 18.5%; p = 0.02). The latter cohort spanned a longer inclusion period (168 ± 90.8 vs. 120 ± 72.8 days; p = 0.004) and had fewer angiographic complications (1.5% vs. 14.5%; p = 0.01), whereas in-hospital major adverse cardiac events did not differ (3.8% vs. 5.8%; p = 1.0).

Conclusion

IVL is an effective modality for coronary calcium modification. Temporal changes in case selection and interventional performance may reflect a learning-adaptation curve.

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Letter to the Editor

Point-of-Care Ultrasound in Cardiology: When a Positioning Statement Does Not Reflect the State of the Art

Guilherme Pinheiro Machado et al. Guilherme Heiden Telo Gustavo Neves de Araujo Fernando Luis Scolari … Anderson Donelli da Silveira Rodrigo Wainstein Marco Wainstein

Dear Editor,

We read with interest the recently published Positioning Statement on the Use of Point-of-Care Ultrasound in Cardiovascular Medicine – 2026, in Arquivos Brasileiros de Cardiologia. This is a relevant initiative that acknowledges the growing role of point-of-care ultrasound (POCUS) as a fundamental tool in contemporary cardiovascular practice. Nevertheless, despite its merits, we believe that the document presents an important limitation: the lack of discussion and incorporation of a substantial body of evidence regarding the assessment of cardiac patients across different clinical scenarios, particularly ST-segment elevation myocardial infarction (STEMI).

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Letter to the Editor

Treatment of Heart Failure in Brazil: Where Cost-Effectiveness Studies and Public Access Data to Therapies Meet

Henrique Iahnke Garbin et al. Fernando Luis Scolari Andreia Biolo

Heart failure (HF) remains a leading cause of hospitalization and cardiovascular mortality in Brazil. In recent years, new prognostically modifying pharmacological therapies have been shown to reduce cardiovascular mortality, HF hospitalizations, and improve quality of life. In this context, the availability of these therapies in the public health system becomes a determining factor in improving clinical outcomes at the population level. A recent systematic review on the cost-effectiveness of HF therapies in Brazil demonstrated that several pharmacological interventions, including mineralocorticoid receptor antagonists, sodium-glucose cotransporter 2 (SGLT2) inhibitors, and angiotensin-neprilysin receptor inhibitors, have high economic attractiveness in the national scenario. Dapagliflozin, for example, showed an incremental cost-effectiveness ratio of Int$ 9,000/QALY, and is considered cost-effective.

Interestingly, Brazilian population-based evidence reinforces the clinical impact of these strategies, supporting the cost-effectiveness study. One analysis evaluated the temporal evolution of cardiovascular mortality and hospitalizations for heart failure after the implementation of the public access program for dapagliflozin in Brazil. The policy was initially approved for patients with type 2 diabetes mellitus or established cardiovascular disease aged ≥ 65 years. The medication was also made available to patients ≥ 18 years with heart failure with reduced ejection fraction, type 2 diabetes mellitus, or chronic kidney disease, upon presentation of a specialized medication report. The population-based study demonstrated a reduction in cardiovascular mortality trends (a 6.6% reduction in 2022, 4.7% in 2023, and 5.9% in 2024 compared to 2017) and hospitalizations for heart failure (a 23.8% reduction in 2024 compared to 2017) after the availability and access to medication in patients aged ≥ 65 years.

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Original Article

Systematic Review on the Safety of Physical Exercise in Hypertrophic Cardiomyopathy: Recommendations from the Brazilian Society of Cardiology

Ricardo Stein et al. Rodrigo Otávio Bougleux Alô Luiz Eduardo Fonteles Ritt Alexsandro Alves Fagundes … Anderson Donelli da Silveira Artur Haddad Herdy Clea Colombo Cristiano Faria Pisani Fabrício Braga Frank Nunes Luciana Sacilotto Marconi Gomes Silva Mauricio Milani Mauricio Pimentel Milena dos Santos Barros Campos Nágela Simão Vinhosa Nunes Pablo Marino Nascimento Susimeire Buglia José Ronyeryson dos Santos Evangelista Filipe Ferrari Leonardo Castro Luna

Abstract

Background

Although historically discouraged due to the risk of arrhythmias and sudden cardiac death (SCD), physical exercise (PE) may be safe and beneficial for individuals with hypertrophic cardiomyopathy (HCM).

Objective

To evaluate the association between PE and the incidence of mortality and arrhythmic events in adults with HCM, stratifying the analysis according to different types and intensities of exercise.

Methods

Systematic review of randomized clinical trials (RCTs) and observational studies identified in PubMed, Embase, and the Cochrane Library through December 2024. Studies including individuals exposed to different intensities of PE were eligible. Risk of bias was assessed using the RoB 2 and ROBINS-I tools, and certainty of evidence using GRADE. Recommendations were developed by an expert panel of the Brazilian Society of Cardiology.

Results

Eight studies (four RCTs and four observational studies; 9,744 participants) were included. None reported an increased risk of mortality or severe arrhythmic events associated with PE, even at moderate or vigorous intensities. Syncope was rare. Additionally, a Korean observational study involving more than 7,000 participants (mean age: 59 years) demonstrated reduced all-cause mortality with higher physical activity intensity (dose–response curve). In low-risk athletes, competitive sports were not associated with severe adverse events. The quality of evidence ranged from moderate to very low.

Conclusion

PE in HCM should be encouraged based on individualized assessment. In patients without high-risk criteria for SCD, benefits appear to outweigh risks. For higher-risk subgroups, recommendations are more cautious and based on expert consensus.

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Research Letter

Hypertension in Pregnancy: From Guidelines to the Cardiologist's Clinical Practice

Walkiria Samuel Ávila

Introduction

The Brazilian Guidelines of Hypertension– 2025 of the Brazilian Society of Cardiology objectively address hypertension during pregnancy, dedicating a specific chapter to the topic. The document covers diagnostic definitions, strategies for the prediction and prevention of preeclampsia, therapeutic management during pregnancy and the postpartum period as well as the assessment of future cardiovascular risk associated with hypertensive disorders of pregnancy (HDPs).

In the international setting, the 2025 European Society of Cardiology (ESC) Guidelines for the Management of Cardiovascular Disease During Pregnancy provide detailed algorithms for proteinuria assessment, emergency management, and the treatment of hypertension and preeclampsia. Their recommendations are based predominantly on expert consensus, reflecting the scarcity of randomized clinical trials in this field.

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Original Article

A Predictive Model for Pulmonary Embolism in Patients with Atrial Fibrillation Based on Thromboelastography and Coagulation Parameters

Xingqi Huang et al. Jianmei Liu

Abstract

Background

Patients with atrial fibrillation (AF) face an elevated risk of pulmonary embolism (PE), yet existing prediction tools demonstrate limited accuracy.

Objectives

This study aimed to develop and validate a novel predictive model integrating thromboelastography (TEG) parameters with conventional coagulation markers for PE risk assessment in AF patients.

Methods

We conducted a retrospective study of 271 hospitalized AF patients who underwent CTPA for suspected PE (41 with PE, 230 without). The mean age was 76.5 years, 56.5% were male, and hypertension was the most common comorbidity (67.5%). PE diagnosis was confirmed by computed tomography pulmonary angiography. Baseline characteristics, TEG parameters (including reaction time, maximum amplitude [MA], and α-angle), and standard coagulation markers (D-dimer, fibrinogen) were analyzed. Statistical significance was defined as a two-sided P-value < 0.05. Multivariate logistic regression identified independent predictors, which were incorporated into a nomogram. Model performance was evaluated using receiver operating characteristic (ROC) analysis, calibration curves, and decision curve analysis (DCA).

Results

The prevalence of PE was 15.1%. Patients with PE exhibited significantly higher TEG-MA, D-dimer, and fibrinogen levels compared to the non-PE group (all P<0.05). Multivariate analysis identified these three markers as independent predictors. The nomogram demonstrated excellent discrimination (AUC=0.878, 95% CI:0.806-0.949), with 87.8% sensitivity and 78.0% specificity at the optimal cutoff. The model showed good calibration (Hosmer-Lemeshow p=0.965) and significant clinical utility.

Conclusion

The TEG-based nomogram combining MA, D-dimer, and fibrinogen provides accurate, bedside-accessible PE risk stratification for AF patients. This tool may facilitate early identification of high-risk individuals and guide clinical decision-making regarding anticoagulation therapy. Further prospective studies are warranted to validate these findings.

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Original Article

Association between the Neutrophil-to-HDL-Cholesterol Ratio and Myocardial Infarction: A Cross-Sectional Study

Youpeng Wang et al. Qian Yin Ying Lei Juncang Duan

Abstract

Background

Myocardial infarction (MI) remains a major global health burden. Inflammation and lipid metabolism’s roles in MI pathogenesis have drawn more attention. The neutrophil-to-high-density lipoprotein cholesterol ratio (NHR) is a new composite biomarker integrating inflammation and lipid metabolism markers, but its association with MI is unclear.

Objectives

We investigated the association between NHR and MI.

Methods

We analyzed data from 25,248 eligible participants from NHANES between 2005 and 2016. A history of MI was determined using questionnaire data, and NHR values were derived from laboratory measurements. Logistic regression models were used to assess the associations of NHR, neutrophil count, and high-density lipoprotein cholesterol (HDL-C) with the odds of MI. Restricted cubic spline (RCS) analysis was used to evaluate potential nonlinear associations. Subgroup analyses and interaction tests were performed to explore potential heterogeneity across demographic and clinical subgroups. Sensitivity analyses were performed to evaluate the robustness of the primary findings. A two-sided P value of <0.05 was considered statistically significant.

Results

Higher NHR was independently associated with higher odds of MI. In the fully adjusted model, participants in the highest NHR quartile had 49% higher odds of MI than those in the lowest quartile. Neutrophil count alone was not significantly associated with MI, whereas HDL-C levels were inversely associated with MI. RCS suggested a modest nonlinear association between NHR and MI. Although a data-driven inflection point was identified at 6.93, this result should be interpreted as exploratory and descriptive rather than a clinically meaningful threshold. Subgroup analyses suggested a stronger association in women, and the interaction by sex was statistically significant. Sensitivity analyses confirmed the robustness of these findings.

Conclusion

In this large, representative sample, elevated NHR was independently associated with higher odds of MI, suggesting that NHR may serve as a potentially informative epidemiological marker for MI. Prospective studies are needed to determine causality and elucidate the underlying mechanisms.

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Case Report

Use of Manually Covered Stent with Tegaderm in Vascular Perforations: Case Series Report

Alexandre Damiani Azmus et al. Antônio Carlo Klug Cogo Luis Manuel Rodriguez Oyuela João Vitor Slaviero … Andre Luiz Langer Manica Eduardo Mascarenhas Azevedo

Introduction

Coronary perforation during percutaneous coronary intervention (PCI) is a rare but potentially lethal complication, with an estimated incidence of 0.2% to 0.6% of angioplasties.

Risk factors include advanced age, previous coronary artery bypass graft (CABG) surgery, complex coronary artery disease, tortuosity, calcification, or the presence of chronic total occlusions. The Ellis classification remains widely used to define severity and guide management.

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Editorial

Scientific Publishing in the era of Artificial Intelligence: Integrity and Responsibility

Mário Martins Oliveira et al. Gláucia Maria Moraes de Oliveira

Artificial Intelligence (AI) is transforming the scientific process across all stages, making it an innovative tool, used globally, influencing research generation, experimental design, data analysis, writing, and all complex dynamics of peer review and dissemination of results.

While the entire scientific community is incorporating AI as part of the research process to enhance efficiency, the development of regulations and adequate algorithms to monitor the quality, truthfulness, and integrity of data science is becoming a critical matter of discussion, regarding the fundamental role of scientific communication.

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