Dyspnea – ABC CARDIOL

ABCIC

Case Report

Echocardiographic Assessment During Treatment of Acquired Pulmonary Artery Stenosis Due to Mediastinal Mass Compression: A Case Report

Carolynne Ferreira Machado et al. Patrick Ventorim Costa Ana Carolina Main Lucas Fernando Luiz Torres Gomes … Fabricio Thebit Bortolon Laira Bernabe Mota Karllayno Camatta Milleri

Introduction

Acquired pulmonary artery stenosis is a rare entity that has scarcely been described in the literature, and it is mainly associated with compression of the pulmonary artery trunk and its branches by mediastinal tumors (teratomas and lymphomas). We report the case of a young patient with non-Hodgkin lymphoma in the anterior mediastinum that led to extrinsic compression and local luminal invasion of the pulmonary artery trunk, causing significant impact on the right heart chambers, with subsequent improvement after chemotherapy.

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ABC

Letter to the Editor

Does HFpEF Really Exist? From Mimics to Misclassification in Clinical Practice

Maria Giulia Bellicini

Dear Editor,

I read with interest the recent article by Villacorta et al. addressing the distinction between “true” heart failure with preserved ejection fraction (HFpEF) and conditions that merely mimic it. Their effort to clarify this conceptual ambiguity is commendable and timely. However, I believe the issue extends further, even when HFpEF mimics such as amyloidosis, constrictive pericarditis, or severe valvular disease are carefully excluded, the clinical entity known as HFpEF often dissolves under closer scrutiny.

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ABCHF

Review Article

Optimizing Post-Discharge Heart Failure Care: The Role of Natriuretic Peptides

Humberto Villacorta et al. Aline Sterque Villacorta

Abstract

Heart failure (HF) remains a leading cause of hospitalization, mortality, and health-care burden worldwide. The post-discharge period following acute decompensated heart failure (ADHF) is characterized by a heightened risk of rehospitalization and death, particularly during the first 90 days, known as the “vulnerable phase.” Effective strategies for risk stratification and therapy optimization during this phase are crucial to improve outcomes.

Natriuretic peptides (NPs), including B-type natriuretic peptide (BNP) and its N-terminal fragment (NT-proBNP), are well-established biomarkers of myocardial stress. Beyond their diagnostic role, NPs have emerged as powerful prognostic tools for post-discharge risk assessment and as potential guides for therapy titration. Elevated NP levels at discharge and persistently high concentrations one week post-discharge strongly predict adverse outcomes. Evidence from the STRONG-HF trial demonstrated that early, intensive follow-up incorporating NP monitoring and rapid guideline-directed medical therapy (GDMT) up-titration significantly reduced mortality and rehospitalization. Serial NP measurements further enhance risk stratification by capturing dynamic changes over time. Although trials such as GUIDE-IT showed mixed results for NP-guided therapy using fixed targets, patients achieving lower NP levels consistently demonstrated better outcomes.

In conclusion, NPs provide incremental prognostic value beyond clinical assessment in the vulnerable post-discharge phase and throughout long-term management. Early and serial NP monitoring can identify high-risk patients and support GDMT optimization. Future research should refine timing, thresholds, and integration of NP-guided strategies into multimodal risk models to enhance personalized HF care and improve global patient outcomes.

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ABCIC

Review Article

My Approach to Point-of-Care Ultrasound for Dyspnea Assessment

Adriana Brentegani et al. Fernando Arturo Effio Solis Milena de Paulis Marcelo Luiz Campos Vieira

Abstract

Dyspnea is a common and potentially serious symptom whose traditional diagnostic approach, based on physical examination and complementary tests, may present significant limitations. Point-of-care ultrasound (POCUS) has emerged as an effective tool for the rapid and accurate assessment of this symptom, both in outpatient settings and in emergency and critical care environments.

This article provides a practical, illustrated guide to the integrated application of POCUS in the evaluation of dyspnea, with an emphasis on distinguishing cardiac from pulmonary causes. It describes techniques for acquiring cardiac, pulmonary, and venous ultrasound images, highlights key sonographic findings, and outlines a step-by-step approach to clinical application. Lung POCUS has demonstrated high sensitivity in detecting differential diagnoses of dyspnea. Its integration with echocardiography and lower limb ultrasound further refines diagnosis by identifying specific clinical patterns such as acute pulmonary edema (APE), pulmonary embolism (PE), and acute respiratory distress syndrome (ARDS).

The structured use of POCUS represents a significant advancement in the modern physical exam, enabling faster and more accurate bedside clinical decision-making. Its adoption should be encouraged among cardiologists, intensivists, and healthcare professionals working in critical care settings.

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ABCHF

Review Article

Relevant Aspects of Natriuretic Peptides in the Etiology of Dyspnea in the Emergency Room: Evidence, Indications, Confounding Factors, and Cost-Effectiveness

Humberto Villacorta

Abstract

Natriuretic peptides are hormones released by the heart after acute or chronic aggression. They are produced exclusively by the heart and are, therefore, specific cardiac biomarkers. Recent pivotal studies have confirmed that they are useful in the diagnostic assessment of patients with dyspnea in the emergency room, with a high predictive value in ruling out acute heart failure, and they are indicated when there are doubts in clinical examination. They are also useful as prognostic markers and in monitoring response to treatment. Multiple studies have demonstrated that they are cost-effective in the emergency room. However, it is important to underscore that they should always be used in conjunction with clinical examination, and they have the limitation of reduced accuracy in some subgroups, due to the influence of some clinical variables, such as age, renal function, atrial fibrillation, and obesity. The use of cutoff values stratified by age group and machine learning techniques minimize the influence of confounding factors.

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ABCIC

Case Report

Rare Cause of Chest Pain in Young Patient: Left Ventricular Myxoma

Gustavo Henrique Belarmino Góes et al. José Candido de Souza Ferraz Neto Ivaldo Pedrosa Calado Filho Ricardo de Carvalho Lima Dário Celestino Sobral Filho

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ABCIC

Editorial

How to Perform an Echocardiographic Assessment of a Non-Valvular Patient with Dyspnea of Cardiac Etiology

Maria Estefânia Bosco Otto et al. Simone Ferreira Leite

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ABC

Original Article

Coronary Artery Fistula: Association between Pathway Patterns, Clinical Features and Congenital Heart Disease

Daniel L. Cobo et al. Fernando Batigalia Ulisses A. Croti Adilia M.P. Sciarra … Marcos H.D. Foss Rafaela G.F. Cobo

Abstract

Background

Coronary artery fistula (CAF) is a direct connection of one or more coronary arteries to cardiac chambers or a large vessel; it may be associated with congenital heart disease.

Objective

To establish CAF pathway patterns from echocardiographic data and to correlate them with clinical aspects and congenital heart disease.

Methods

A total of 7.183 medical records of children under the age of five years with cardiac disease submitted to color Doppler echocardiography and Spearman’s Correlation test were used to associate signs and symptoms and cardiopathy to CAF with a significance level of 5%.

Results

Twenty six children (0.0036%) presented CAF: from the right coronary artery (RCA) to the right ventricle (RV) 26.92%, from the left coronary artery (LCA) to the RV 23.08%, from the anterior interventricular branch (AIVB) to RV 23.08%, RCA to right atrium (RA) 11.54%, LCA for pulmonary trunk (PT) 7.69% or AIVB for PT 7.69%. In 57.69% of the patients, there was a positively correlated symptomatology to CAF with p=0.445 related to dyspnea or cyanosis (53.84%); in 96.15%, congenital heart disease associated with CAF, mainly interventricular communication (IVC) or interatrial communication (IAC) in 34.62% positively correlated to CAF with p=0.295. CAF pathway was represented in three dimensions by software modeling, texturing and animation Cinema 4D R19.

Conclusion

CAF is an uncommon anatomical entity that presents a clinical picture compatible with dyspnea and cyanosis, and this is associated with congenital heart disease, mainly with IVC or IAC. According to echocardiographic analyzes, fistulas in RCA, LCA, or AIVB represent about one-third of the patients, with a priority pathway for right heart chambers.

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ABCHF

Original Article

Acute Inspiratory Muscle Training Modifies Hemodynamic Indices in Patients with Heart Failure with Preserved Ejection Fraction

Márcio Garcia Menezes et al. Eduardo Lima Garcia Leandro Tolfo Franzoni Vanessa Grings Luiz Claudio Danzmann

Abstract

Background:

Heart failure with preserved ejection fraction (HFpEF), a syndrome associated to decrease functional capacity, is quite difficult to manage. Inspiratory muscle training (IMT) has been used to treat symptoms and to improve functional capacity of patients with HFpEF. Thus, we aimed to evaluate the immediate effects and after 1 h of IMT on arterial pulsatile hemodynamics and on hemodynamic indices of left ventricular filling derived from Doppler echocardiography in patients with HFpEF.

Methods:

Eighteen patients with HFpEF who underwent IMT at an intensity of 80% of maximum inspiratory pressure were evaluated by Doppler echocardiogram in the pre, post-immediate and post-late periods; furthermore, pulsatile hemodynamic variables were collected. Functional capacity was assessed using the 6-minute walk test.

Results:

The population was composed predominantly of women (66.7%), mean age of 61.3 (7.2) years. Modifications were observed in the non-invasive LV filling pressure index (E/e’) (pre: 10.33 (SD, 3.15) vs post: 8.73 (SD, 2.24); p < 0.001) and in the pulse wave velocity (pre: 8.33 (SD, 1.67) vs post: 7.63 (SD, 1.66) m/s; p < 0.001), as well as pulse pressure (pre: 54.81 (SD, 18.73) vs post: 48.52 (SD, 15.74) mm Hg; p = 0.023).

Conclusion:

Our results demonstrated that a unique session of high-intensity IMT improved hemodynamic indices of LV filling and arterial stiffness in patients with HFpEF.

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ABC

Original Article

Increased Pulmonary Arterial Stiffness and Impaired Right Ventricle-Pulmonary Artery Coupling In PCOS

Ozge Ozcan Abacioglu et al. Erdinc Gulumsek Hilmi Erdem Sumbul Mehmet Kaplan Fethi Yavuz

Abstract

Background:

Polycystic ovary syndrome (PCOS) is the most common endocrine-metabolic disease in women in reproductive age, and occurs in one of 10 women. The disease includes menstrual irregularity and excess of male hormones and is the most common cause of female infertility. Dyspnea is a frequent symptom and is often thought to be due to obesity, and whether it is due to cardiac dysfunction is unknown.

Objective:

To evaluate right ventricle-pulmonary artery (RV-PA) coupling and pulmonary arterial stiffness in patients with PCOS.

Methods:

44 PCOS patients and 60 controls were included; venous blood samples were taken for laboratory tests and 2-D, m-mode and tissue doppler transthoracic echocardiography were performed for all the participants. P<0,05 was considered as statistically significant.

Results:

When compared to the control group, PCOS patients had higher pulmonary artery stiffness values (p=0,001), which were positively correlated with HOMA-IR (r=0,545 and p<0,001). RV-PA coupling was also impaired in 34% of the study patients.

Conclusion:

Pulmonary artery stiffness is increased and RV-PA coupling is impaired in patients with PCOS. (Arq Bras Cardiol. 2021; 116(4):806-811)

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ABC

Original Article

Takotsubo Multicenter Registry (REMUTA) – Clinical Aspects, In-Hospital Outcomes, and Long-Term Mortality

Gustavo Luiz Gouvêa de Almeida Junior et al. João Mansur Filho Denilson Campos de Albuquerque Sergio Salles Xavier … Álvaro Pontes Elias Pimentel Gouvêa Alexandre Bahia Barreiras Martins Nágela S. V. Nunes Lilian Vieira Carestiato João Luiz Fernandes Petriz Armando Márcio Gonçalves Santos Bruno Santana Bandeira Bárbara Elaine de Jesus Abufaiad Luciana da Camara Pacheco Maurício Sales de Oliveira Paulo Eduardo Campana Ribeiro Filho Pedro Paulo Nogueres Sampaio Gustavo Salgado Duque Luiz Felipe Camillis André Casarsa Marques Francisco Carlos Lourenço Jr José Ricardo Palazzo Cláudio Ramos da Costa Bibiana Almeida da Silva Cleverson Neves Zukowski Romulo Ribeiro Garcia Fernanda de Carvalho Zonis Suzana Andressa Morais de Paula Carolina Gravano Ferraz Ferrari Bruno Soares da Silva Rangel Roberto Muniz Ferreira Bárbara Ferreira da Silva Mendes Isabela Ribeiro Carvalho de Castro Leonardo Giglio Gonçalves de Souza Luiz Henrique dos Santos Araújo Alexandre Giani

Abstract

Background

Takotsubo syndrome (TTS) is an acquired form of cardiomyopathy. National Brazilian data on this condition are scarce. The Takotsubo Multicenter Registry (REMUTA) is the first to include multicenter data on this condition in Brazil.

Objective

To describe the clinical characteristics, prognosis, in-hospital treatment, in-hospital mortality, and mortality during 1 year of follow-up.

Methods

This is an observational, retrospective registry study including patients admitted to the hospital with diagnosis of TTS and patients admitted for other reasons who developed this condition. Evaluated outcomes included triggering factor, analysis of exams, use of medications, complications, in-hospital mortality, and mortality during 1 year of follow-up. A significance level of 5% was adopted.

Results

The registry included 169 patients from 12 centers in the state of Rio de Janeiro, Brazil. Mean age was 70.9 ± 14.1 years, and 90.5% of patients were female; 63% of cases were primary TTS, and 37% were secondary. Troponin I was positive in 92.5% of patients, and median BNP was 395 (176.5; 1725). ST-segment elevation was present in 28% of patients. Median left ventricular ejection fraction was 40 (35; 48)%. We observed invasive mechanical ventilation in 25.7% of cases and shock in 17.4%. Mechanical circulatory support was used in 7.7%. In-hospital mortality was 10.6%, and mortality at 1 year of follow-up was 16.5%. Secondary TTS and cardiogenic shock were independent predictors of mortality.

Conclusion

The results of the REMUTA show that TTS is not a benign pathology, as was once thought, especially regarding the secondary TTS group, which has a high rate of complications and mortality. (Arq Bras Cardiol. 2020; 115(2):207-216)

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ABC

Letter to the Editor

Circulatory System Diseases in Patients with COVID-19: Description of Clinical and Epidemiological Profile of 197 Deaths

Carlos Dornels Freire de Souza et al. Thiago Cavalcanti Leal Lucas Gomes Santos

Dear Editor,

On December 31, 2019, China notified the World Health Organization (WHO) of an outbreak of pneumonia in the city of Wuhan, capital of the Hubei province. A few days later, the causative agent, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified.

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IJCS

Viewpoint

Challenges in Pharmacological Management of Cardiovascular Diseases in Covid-19: do Benefits Outweigh Risks?

Samuel de Sousa Pedro et al. Fernanda Carla Ferreira de Brito Christianne Bretas Vieira Scaramello

Introduction

Cardiovascular diseases (CVD) are the main cause not only of global mortality but also of reduced quality of life. They cover ischemic heart disease, stroke, heart failure, peripheral artery disease, and various other heart and vascular conditions. In 2017, CVDs caused about 17.8 million deaths worldwide, corresponding to 330 million years of life lost and another 35.6 million years of life with disabilities. Almost 80% of deaths occur in low- and middle-income countries, such as Brazil, where the occurrence of CVDs and their risk factors are on the rise as a result of an ongoing epidemiological transition. In low-income countries CVDs greatly affect working-age populations, and the total economic loss resulting from this group of diseases is high, representing 2% of Gross Domestic Product. In addition, the disability caused by CVDs has economic consequences at multiple levels: individual, family, economic agents, public institutions, government, and society as a whole.

Recent studies also show that chronic conditions, such as CVD, increase the risk of aggravation and death associated with the new coronavirus 2019 disease (COVID-19), whose outbreak was characterized as a pandemic by the World Health Organization (WHO) in March 2020. The new coronavirus is a betacoronavirus called SARS-CoV-2 (Severe Acute Respiratory Syndrome coronavirus 2), phylogenetically identical to other coronaviruses capable of determining acute respiratory distress syndrome (ARDS), which is responsible for numerous deaths. The most common symptoms of COVID-19 include fever, cough, dyspnea, myalgia, fatigue, diarrhea, sore throat, chest pain, confusion, and lethargy. Acute and chronic cardiovascular complications have also been observed in the course of COVID-19, being attributed to several mechanisms, such as relative ischemia, systemic inflammation mediated by pathogens, with increased levels of several biomarkers. In this context, studies point to the relevance not only of chronic conditions, such as hypertension, but also of the age and immunological status of the host, characterizing a complex, multifactorial, and bidirectional model that can comprehend the drugs used to treat these pathologies.

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IJCS

Viewpoint

Covid-19 and Safety in the Cath Lab: Where We Are and Where We Are Headed

Giordana Zeferino Mariano et al. Viviana Guzzo Lemke Maria Sanali Moura Paiva Gláucia Maria Moraes de Oliveira

Safety measures in the procedure preparation stage

A study conducted in China with 72,314 patients with COVID-19 (44,672 laboratory-confirmed cases, 16,186 suspected cases, and 10,567 clinically diagnosed cases) has reported fever, cough, dyspnea, myalgia, fatigue and diarrhea as the most common symptoms. Other signs and symptoms have been reported, such as sore throat, chest pain, mental confusion, and lethargy. The authors have highlighted that COVID-19 had a benign course in 80% of the cases, and that many patients, although asymptomatic, could carry the virus. It is worth noting the importance of the differential diagnosis of dyspnea and fatigue, especially when associated with the other symptoms.

During a respiratory pandemic, patients and their families should be informed about the risks of contamination, despite all additional measures taken to minimize them. Because the number of elective procedures will be drastically reduced during that period, the length of hospital stay is predicted to be the minimum necessary for each protocol consensually elaborated. Moreover, defining a procedure as elective requires clinical judgement, because postponing it might have effects that will increase the likelihood of decompensation and adverse events during the pandemic, such as in high-risk patients with unstable angina. Therefore, the decision about performing a procedure should be individualized and based on the patient’s risk and benefit analysis.

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IJCS

Editorial

COVID-19: A Matter Close to the Heart

Gláucia Maria Moraes de Oliveira et al. Fausto J. Pinto

The world is facing a new challenge, the novel coronavirus disease 2019 (COVID-19), caused by a betacoronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), phylogenetically identical to the SARS-CoV (severe acute respiratory syndrome coronavirus) and the MERS-CoV (Middle East respiratory syndrome coronavirus) responsible for innumerable deaths in China in 2003 and in the Middle East in 2012, respectively.

On March 11, 2020, the COVID-19 outbreak was characterized as a pandemic by the World Health Organization (WHO). Twenty-three days after that announcement, the cases reported reached 1,056,777 in 182 countries, with 55,781 deaths, most of which occurring in Italy, Spain, France, China and Iran. So far, Brazil has registered 8,195 cases and 335 deaths, while Portugal, 9,886 cases and 246 deaths, figures that have increased steeply since the beginning of the pandemic.

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ABC

Editorial

COVID-19 and the Heart

Tânia Mara Varejão Strabelli et al. David Everson Uip

We have been living with the new coronavirus pandemic since March 11, 2020. Initially, on January 1, 2020, the World Health Organization (WHO) declared the new coronavirus infection a global emergency and proceeded to name the disease COVID-19. The Coronavirus Study Group of the International Committee on Taxonomy of Viruses proposed the adoption of the name SARS-Cov-2. Genomic sequencing and phylogenetic analysis have indicated that it is a betacoronavirus from the same subgenus as the severe acute respiratory syndrome (SARS) that caused an epidemic in China in 2003 and the Middle East respiratory syndrome (MERS) that caused the same condition in the Middle East in 2012. It has 96.2% genetic identity with betaCoV/bat/Yunnan, a virus isolated in bats. The structure of the virus’s cell-binding receptor gene is very similar to that of the SARS coronavirus, and the virus appears to use the same angiotensive-converting enzyme 2 (ACE2) receptor to enter the cell.

The clinical picture of COVID-19 is similar to that of other respiratory viruses, namely, fever, generally dry cough, fatigue, and, in severer cases (5%), dyspnea, pulmonary bleeding, severe lymphopenia, and renal failure. Symptoms are mild in 80% of cases. Diagnosis of symptomatic cases should be confirmed by testing for the virus via polymerase chain reaction (PCR) of a nasal swab.

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IJCS

Case Report

Epipericardial Fat Necrosis. An Important Differential Diagnosis of Chest Pain

Núbia Bernardes Carvalho et al. Natália de Paula Lopes e Silva Pedro Paulo Nunes Pereira André Volani Morganti … Sinval Lins Silva André Silva Rodrigues

Introduction

Epipericardial fat necrosis (EPFN) is a rare, benign, and self-limiting condition, first described in 1957 by Jackson et al. Currently, there are only 33 cases described in the literature.^–

The pathophysiology of the disease remains uncertain. Likely predisposing factors include torsion of the vascular pedicle of adipose tissue, structural alterations that make the tissue more vulnerable and obesity, which, like the Valsalva maneuver, can lead to increased capillary pressure, causing hemorrhage into the adipose tissue. There are also reports of association with chest trauma or infections.

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ABC

Case Report

Pseudo-pulmonary Embolism – A Case of Hypoxemia Associated with Right-to-left Shunt

Mariana Faustino et al. Ana Oliveira Soares Fernando Rodrigues Rui Anjos … António Freitas Victor M. Gil

Introduction

Platypnea orthodeoxia is a rare syndrome characterized by dyspnea and decreased arterial oxygen saturation when passing from the dorsal decubitus position to the sitting or upright position. It usually results from an intracardiac right-to-left shunt; however, the pathophysiological mechanism responsible for the positional nature of the shunt has not been clarified^,. We report a case of dyspnea and orthostatic hypoxemia, which was attributed to a right-to-left shunt due to atrial septal defect (ASD).

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ABC

Anatomopathological Session

Case 1 /2011- seventy-four-year-old female patient with sudden apnea and acute cholecystitis, five days after acute myocardial infarction without critical coronary lesions

Ricardo Casalino Sanches de Moraes et al. Leonardo Celeste Mangili Luiz Alberto Benvenuti

ANATOMOPATHOLOGICAL SESSION

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ABC

Artigo Original

Correlation between quality of life and functional capacity in cardiac failure

Ivan Daniel Bezerra Nogueira et al. Denise Maria Servantes Patrícia Angélica de Miranda Silva Nogueira Amália Pelcerman … Xiomara Miranda Salvetti Fernando Salles Dirceu Rodrigues Almeida Marco Túlio de Mello Orlando Campos Filho Japy Angelini Oliveira Filho

BACKGROUND: Patients with cardiac failure (CF) present progressive incapacity and decreased quality of life, both related to dyspnea and fatigue. Thus, there is the increasing interest in measring the quality of life (QL), by generic instrument, such as the 36-item Short-Form Health Survey (SF-36), by specific instrument, such as Minnesota Living with Heart Failure (MLHFQ). OBJECTIVE: This study has the objective to correlate the QL surveys, SF-36 and MLHFQ, with the functional capacity of patients with CF, expressed by the cardiopulmonary test and the TC6M. METHODS: Using the SF-36 and MLHFQ surveys for QL evaluation, for the evaluation of the functional capacity, it was used the cardiopulmonary test, being executed using a tredmill with Weber protocol, as well sa the distance covered in the walk test of six minutes (TC6M). RESULTS: Forty-six patients were selected with CF diagnosis (22 men, average age of 52 years old), classes II and III of New York Heart Association. It was observed that the mild correlation between the physical and emotional domains of SF-36 and VE/VCO2.peak (r=-0.3; p<0.05) and the distance covered in TC6M (r=0.4; p<0.05), respectively. It was also observed the mild to moderate correlations of MLHFQ total score with VO2.peak (r=-0.5; p<0.05), the aerobic threshold (r=-0.4; p<0.05) and the distance covered in TC6M (r=-0.5; p<0.05). CONCLUSION: The data suggest that the application of both evaluation instruments of QL, generic (SF-36) and specific (MLHFQ) in patients with CF, showed mild and moderate correlation with the variable of the cardiopulmonary test with the variables of the cardiopulmonary test and the distance covered in TC6M.

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Artigo Original

Levosimendan in decompensated heart failure patients: efficacy in a Brazilian cohort. Results of the BELIEF study

Edimar Alcides Bocchi et al. Fábio Vilas-Boas Maria da Consolação Moreira Antonio Carlos Pereira Barretto … Silvia Lage Denilson Albuquerque Jader Baima Salvador Rassi Jorge Pinto Ribeiro

BACKGROUND: Levosimendan is a new inodilatory agent that enhances cardiac contractility via Ca(2+) sensitization and induces vasodilation through the activation of KATP/BKCa. OBJECTIVE: To study the efficacy and safety of levosimendan in a decompensated heart failure (DHF) Brazilian cohort, and in b-adrenergic agonist resistant patients. METHODS: The Brazilian Evaluation of Levosimendan Infusion Efficacy (BELIEF) study was prospective, multicenter, observational and included 182 high-risk DHF patients, all of which received open-label levosimendan. Primary end point was hospital discharge without additional inotropic therapy (responder). Secondary end points were changes in hemodynamics, clinical parameters, and brain natriuretic peptide (BNP). RESULTS: Mortality rate was 14.8%, and 139 of 182 patients were responders. In non responders it was 62.8%. Systolic blood pressure was a predictor of response. In b-adrenergic agonist resistant group, 55.8% were responders. Overall, 54 patients experienced at least one adverse event; most of them resolved either spontaneously or after levosimendan dose reduction. A significant improvement in quality of life was verified at 2-6 months of follow-up (p<0.0001). CONCLUSION: Our results suggest levosimendan infusion as an alternative therapy in the short term management of DHF patients. HF severity can influence the response to levosimendan treatment. Prospective studies are warranted in a Brazilian cohort including Chagas heart disease.

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ABC

Case Report

Right to left shunt through a patent foramen ovale without pulmonary hypertension

Thiago Costa Lisboa et al. Clarice Daniele Oliveira Costa Thiago Quedi Furian Silvia Regina Rios Vieira

This article describes a patient presenting with dyspnea and platypnea and whose only clinical finding was presence of patent foramen ovale with a right to left shunt, without pulmonary hypertension, characteristic of the rare Platypnea-Orthodeoxya Syndrome, with very interesting pathophysiological findings and with therapeutic alternatives not yet defined.

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