Multiple recurrences of cardiac myxomas with acute tumoral pulmonary embolism

We report the case of a 42-year-old female with a second recurrence of cardiac myxoma. Her first diagnosis was at the age of 24 years, when cardiac tumors were withdrawn from her right ventricle and left atrium. Her first recurrence was at the age of 36 years, when tumors were removed from the left and right atria, and the right ventricle. Six years later, the patient was admitted to the Hospital das Clínicas de Porto Alegre complaining of sudden dyspnea, dry cough, and pain in the right hypochondrium, which bore no relation to breathing. The transesophageal echocardiography showed a small tumor in the interatrial septum, close to the superior vena cava, and 2 larger tumors in the right ventricle, 1 close to the outflow tract and the other almost completely obstructing the right branch of the pulmonary artery. The patient was referred to surgery, in which myxomas were removed from the right atrium and ventricle with extension to the right pulmonary artery. The postoperative period was uneventful.

Ventricular resynchronization through biventricular cardiac pacing for the treatment of refractory heart failure in dilated cardiomyopathy

OBJECTIVE: The biventricular pacing (BVP) approach has good results in the treatment of congestive heart failure (CHF) in patients (pts) with disorders of intraventricular conduction. METHODS: We have applied BVP to 28 pts, with left ventricular pacing using minitoracotomy in 3 pts and the transvenous aproach via coronary sinus in 25 pts. The mean duration of the QRS complexes was 187 ms, in the presence of the left branch block in 22 pts, and right branch block + divisional hemiblock in 6 pts. All pts had been considerated candidates to cardiac transplantation, and were under optimized drug therapy. Sixteen pts were in Functional Class (NYHA) IV, and 12 in class III. The ejection fraction varied from 22 to 46% (average = 34%). The pacing mode employed was biventricular triple-chamber in 22 pts, and bi-ventricular dual-chamber in 6 pts (one with ICD). RESULTS: The pts were followed up for a period that ranged from 10 days to 14 months (mean 5 months). All pts presented clinical improvement after implant, chaging the NYHA Functional Class at the end of follow-up to Class I (9pts), Class II (10 pts) and Class III (6 pts). The initial mean ejection fraction have-raised to 37%. Two pts died suddenly. One patient died due to a pulmonary fungal infection. CONCLUSION: Ventricular resynchronization through BVP, improved significantly the Functional Class and, therefore, the quality of life. Assessments of myocardial function acutely performed do not reflect the clinical improvement observed.

Biventricular pacing improves clinical behavior and reduces prevalence of ventricular srrhythmia in patients with heart failure

PURPOSE: To analyze the influence of biventricular pacing (BP) on clinical behavior, ventricular arrhythmia (VA) prevalence, and left ventricular ejection fraction (LV EF) by gated ventriculography. METHODS: Twenty-four patients with left bundle branch block (LBBB) and NYHA class III and IV underwent pacemaker implantation and were randomized either to the conventional or BP group, all receiving BP after 6 months. RESULTS: Sixteen patients were in NYHA class IV (66.6%) and 8 were in class III (33.4%). After 1-year follow-up, 14 patients were in class II (70%) and 5 were in class III (25%). Two sudden cardiac deaths occurred. A significant reduction in QRS length was found with BP (p=0.006). A significant statistical increase, from a mean of 19.13 ± 5.19% (at baseline) to 25.33 ± 5.90% (with BP) was observed in LVEF Premature ventricular contraction prevalence decreased from a mean of 10,670.00 ± 12,595.39 SD or to a mean of 3,007.00 ± 3,216.63 SD PVC/24 h with BP (p<0.05). Regarding the hospital admission rate over 1 year, we observed a significant reduction from 60. To 16 admissions with BP (p<0.05). CONCLUSION: Patients with LBBB and severe heart failure experienced, with BP, a significant NYHA class and LVEF improvement. A reduction in the hospital admission rate and VA prevalence also occurred.

Vector electrocardiographic alterations after percutaneous septal ablation in obstructive hypertrophic cardiomyopathy: possible anatomic causes

OBJECTIVE: Analyze the dromotropic disturbances (vector-electrocardiographic), and the possible anatomic causes, provoked by selective alcohol injection in the septal branch, for percutaneous treatment, of obstructive hypertrophic cardiomyopathy. METHODS: Ten patients with a mean age of 52.7 years underwent percutaneous septal ablation (PTSA) from october 1998; all in functional class III/IV). Twelve-lead electrocardiogram was performed prior to and during PTSA, and later electrocardiogram and vectorcardiogram according to Frank's method. The patients were followed up for 32 months. RESULTS: On electrocardiogram (ECG) prior to PTSA all patients had sinus rhythm and left atrial enlargement, 8 left ventricular hypertrophy of systolic pattern. On ECG immediately after PTSA, 8 had complete right bundle-branch block; 1 transient total atrioventricular block; 1 alternating transient bundle-branch block either right or hemiblock. On late ECG 8 had complete right bundle-branch block confirmed by vectorcardiogram, type 1 or Grishman. CONCLUSION: Septal fibrosis following alcohol injection caused a predominance of complete right bundle-branch block, different from surgery of myotomy/myectomy.

Intra-His bundle block: clinical, electrocardiographic, and electrophysiologic characteristics

OBJECTIVE: To assess the clinical, electrocardiographic, and electrophysiologic characteristics of patients (pt) with intra-His bundle block undergoing an electrophysiologic study (EPS). METHODS: We analyzed the characteristics of 16 pt with second-degree atrioventricular block and symptoms of syncope or dyspnea, or both, undergoing conventional EPS. RESULTS: Intra-His bundle block was documented in 16 pt during an EPS. In 15 (94%) pt, the atrioventricular block was recorded in sinus rhythm; 4 (25%) pt had intra-His Wenckebach phenomenon, which correlated with Mobitz I (MI) atrioventricular block on the electrocardiogram. Seven (44%) pt had 2:1 atrioventricular block, 2 of whom were asymptomatic (12.5%). One (6%) pt had intra- and infra-His bundle block. Clinically, 11 (68%) pt had syncope or presyncope, 3 (18%) had dyspnea on exertion, and 2 (12.5%) were asymptomatic. Eight (50%) pt had bundle-branch block as follows: 4 (25%) pt had left bundle-branch block, and 4 (25%) had right bundle-branch block. Left anterosuperior divisional block was observed in 3 pt (19%), 2 of whom with associated right bundle-branch block. CONCLUSION: Intra-His bundle block was observed in 11% of the pt with second-degree atrioventricular block, syncope or presyncope, or both, it being the most frequent clinical presentation. Intra-His bundle block was more common in the elderly (> 60 years) and among females. The most frequent electrocardiographic presentations were second-degree Mobitz I or type 2:1 atrioventricular block.

Effect of arginine vasopressin on the canine epicardial coronary artery: experiments on V1-receptor-mediated production of nitric oxide

OBJECTIVE: To determine whether arginine vasopressin releases endothelium-derived nitric oxide (EDNO) from the epicardial coronary artery. METHODS: We studied segments of canine left circumflex coronary arteries suspended in organ chambers to measure isometric force. The coronary artery segments were contracted with prostaglandin F2alpha (2 x 10-6M) and exposed to a unique, strong arginine vasopressin concentration (10-6M) or titrated concentrations (10-9 a 10-5 M). RESULTS: The unique dose of arginine vasopressin concentration (10-6M) induced transient, but significant (p<0.05), relaxation in arterial segments with endothelium, and an increase, not significant, in tension in arteries without endothelium. Endothelium-dependent relaxation to arginine vasopressin was inhibited by Ng-monomethyl-L-arginine (L-NMMA, 10-5M) or N G-nitro-L-arginine (L-NOARG) (10-4M), 2 inhibitors of nitric oxide synthesis from L-arginine. Exogenous L-arginine (10-4M), but not D-arginine (10-4M), reversed the inhibitory effect of L-NMMA on vasopressin-mediated vasorelaxation. Endothelium dependent relaxation to vasopressin was also reversibly inhibited by the vasopressin V1-receptor blocker d(CH2)5Try(Me) arginine vasopressin (10-6M) (n=6, P<0.05). CONCLUSION: Vasopressin acts through V1 endothelial receptors to stimulate nitric oxide release from L-arginine.

Kawasaki disease: involution of giant coronary aneurysms after prolonged anti-inflammatory treatment

The patient is a 5-year-old male with Kawasaki disease, whose involution of giant aneurysms of the left coronary arteries was surprising after a prolonged period of treatment, which lasted 80 uninterrupted days and comprised anti-inflammatory drugs associated with anticoagulation agents. The distal diameters of the anterior interventricular, the diagonal, and the circumflex arteries normalized by the end of the treatment. A residual giant aneurysm localized at the beginning of the anterior interventricular artery did not cause ischemia. Continuation of the medication for a prolonged period was recommended.

Frequency of hypertension in chronic Chagas' disease: retrospective clinical study

OBJECTIVE: To assess the frequency of hypertension in chagasic patients, as well as its clinical behavior and cardiologic findings. METHODS: We carried out a retrospective study with 225 patients with chronic Chagas' disease and hypertension (104 males), mean age of 55.1 ± 11.8. These patients were being followed up in the outpatient care clinics from 1984 to 2000. The study assessed the clinical, electrocardiographic, and radiological viewpoints. RESULTS: Of the 225 hypertensive patients (prevalence = 33.3%), 78 (34.7%) had mild hypertension, 108 (48%) had moderate hypertension, and 39 (17.3%) had severe hypertension. The association of left anterosuperior divisional block and right bundle-branch block occurred in 39 cases (17.3%), and enlargement of the cardiac area on radiological examination occurred in 93 (44.9%) of the 207 cases studied. The undetermined form of Chagas' disease was the most prevalent, 30.2% of the cases, followed by the form associated with conduction disorders in 27.1%, and the isolated form of conduction disorders in 21.3%. CONCLUSION: Chagasic patients had a frequency of hypertension similar to that of the general population, and the clinical profile of the hypertensive chagasic patients seemed not to differ a lot from that of the chagasic patients.

Spectral Analysis Related to Bare-Metal and Drug-Eluting Coronary Stent Implantation

Background: The autonomic nervous system plays a central role in cardiovascular regulation; sympathetic activation occurs during myocardial ischemia. Objective: To assess the spectral analysis of heart rate variability during stent implantation, comparing the types of stent. Methods: This study assessed 61 patients (mean age, 64.0 years; 35 men) with ischemic heart disease and indication for stenting. Stent implantation was performed under Holter monitoring to record the spectral analysis of heart rate variability (Fourier transform), measuring the low-frequency (LF) and high-frequency (HF) components, and the LF/HF ratio before and during the procedure. Results: Bare-metal stent was implanted in 34 patients, while the others received drug-eluting stents. The right coronary artery was approached in 21 patients, the left anterior descending, in 28, and the circumflex, in 9. As compared with the pre-stenting period, all patients showed an increase in LF and HF during stent implantation (658 versus 185 ms2, p = 0.00; 322 versus 121, p = 0.00, respectively), with no change in LF/HF. During stent implantation, LF was 864 ms2 in patients with bare-metal stents, and 398 ms2 in those with drug-eluting stents (p = 0.00). The spectral analysis of heart rate variability showed no association with diabetes mellitus, family history, clinical presentation, beta-blockers, age, and vessel or its segment. Conclusions: Stent implantation resulted in concomitant sympathetic and vagal activations. Diabetes mellitus, use of beta-blockers, and the vessel approached showed no influence on the spectral analysis of heart rate variability. Sympathetic activation was lower during the implantation of drug-eluting stents.

Value of the Qrs-T Angle in Predicting the Induction of Ventricular Tachyarrhythmias in Patients with Chagas Disease

Background:The QRS-T angle correlates with prognosis in patients with heart failure and coronary artery disease, reflected by an increase in mortality proportional to an increase in the difference between the axes of the QRS complex and T wave in the frontal plane. The value of this correlation in patients with Chagas heart disease is currently unknown.Objective:Determine the correlation of the QRS-T angle and the risk of induction of ventricular tachycardia / ventricular fibrillation (VT / VF) during electrophysiological study (EPS) in patients with Chagas disease.Methods:Case-control study at a tertiary center. Patients without induction of VT / VF on EPS were used as controls. The QRS-T angle was categorized as normal (0-105º), borderline (105-135º) or abnormal (135-180º). Differences between groups for continuous variables were analyzed with the t test or Mann-Whitney test, and for categorical variables with Fisher's exact test. P values < 0.05 were considered significant.Results:Of 116 patients undergoing EPS, 37.9% were excluded due to incomplete information / inactive records or due to the impossibility to correctly calculate the QRS-T angle (presence of left bundle branch block and atrial fibrillation). Of 72 patients included in the study, 31 induced VT / VF on EPS. Of these, the QRS-T angle was normal in 41.9%, borderline in 12.9% and abnormal in 45.2%. Among patients without induction of VT / VF on EPS, the QRS-T angle was normal in 63.4%, borderline in 14.6% and abnormal in 17.1% (p = 0.04). When compared with patients with normal QRS-T angle, those with abnormal angle had a fourfold higher risk of inducing ventricular tachycardia / ventricular fibrillation on EPS [odds ratio (OR) 4; confidence interval (CI) 1.298-12.325; p = 0.028]. After adjustment for other variables such as age, ejection fraction (EF) and QRS size, there was a trend for the abnormal QRS-T angle to identify patients with increased risk of inducing VT / VF during EPS (OR 3.95; CI 0.99-15.82; p = 0.052). The EF also emerged as a predictor of induction of VT / VF: for each point increase in EF, there was a 4% reduction in the rate of sustained ventricular arrhythmia on EPS.Conclusions:Changes in the QRS-T angle and decreases in EF were associated with an increased risk of induction of VT / VF on EPS.

Echocardiographic Predictors of Worse Outcome After Cardiac Resynchronization Therapy

Abstract Background: Cardiac resynchronization therapy (CRT) is the recommended treatment by leading global guidelines. However, 30%-40% of selected patients are non-responders. Objective: To develop an echocardiographic model to predict cardiac death or transplantation (Tx) 1 year after CRT. Method: Observational, prospective study, with the inclusion of 116 patients, aged 64.89 ± 11.18 years, 69.8% male, 68,1% in NYHA FC III and 31,9% in FC IV, 71.55% with left bundle-branch block, and median ejection fraction (EF) of 29%. Evaluations were made in the pre‑implantation period and 6-12 months after that, and correlated with cardiac mortality/Tx at the end of follow-up. Cox and logistic regression analyses were performed with ROC and Kaplan-Meier curves. The model was internally validated by bootstrapping. Results: There were 29 (25%) deaths/Tx during follow-up of 34.09 ± 17.9 months. Cardiac mortality/Tx was 16.3%. In the multivariate Cox model, EF < 30%, grade III/IV diastolic dysfunction and grade III mitral regurgitation at 6‑12 months were independently related to increased cardiac mortality or Tx, with hazard ratios of 3.1, 4.63 and 7.11, respectively. The area under the ROC curve was 0.78. Conclusion: EF lower than 30%, severe diastolic dysfunction and severe mitral regurgitation indicate poor prognosis 1 year after CRT. The combination of two of those variables indicate the need for other treatment options.

Uma raça cromossômica natural de Tityus bahiensis (Scorpiones-Buthidae)

A natural chromosomal race of Tityus babiensis (Scorpiones Buthidae) is described in the present paper. Five males and seven females received from St. Joaquim, State of S. Paulo, gave the following interesting results: All the spermatogonia of the five males were provided with 9 chromosomes of different sizes. All primary spermatocytes showed at metaphase one independent bivalent of normal shape and a complex group formed by 7 chromosomes which have exchanged parts. Some of the chromosomes associated in the complex group, to Judge by their behavior, were composed of fragments of three different chromosomes, being thus paired with three other members of the compound group. The manner in which all the 7 components of the group have paired with each other showed to be very constant. They gave always origin to a double-cross configuration, the longst branch of which being formed by a long chromosome paired with two components of the group and with a third chromosome that did not belong to the group. The chromosomes of the independent bivalent separate regularly, going to different poles. From the 7 elements of the compound group, 4 go to one pole and 3 to the opposite one. Consequently, secondary spermatocytes with 4 and 5 chromosomes are produced. The females, so far as it can be inferred from the study of the follicular cells of the ovariuterus, have 10 chromosomes. These females are, therefore, considered as being monogametic, that is, as producing eggs with 5 chromosomes. A sex-determining mechanism arose in this manner, the spermatozoa with 5 chromosomes giving origin to females and those with 4 to males. The fact that the sex chromosome is one of the elements taking part in the formation of the group, seems highly interesting to the author. Tetraploid cysts have been occasionally found in the testis. In one individual the chromosomes of the tetraploid primary spermatocytes behaved as expected, forming a group of 14 elements, and two independent pairs or a tetravalent group In another individual, the chromosomes of the tetraploid cells have formed two independent groups of 7, and two independent pairs, as if both chromosomal sets were by their turn entirely independent frcm one another. This fact is certainly not devoid of special interest. The males as well as the females studied in this paper differed in nothing from the typical members of the species. The unique differential character of the new race is found in the umber and behavior of its chromosomes. It is highly remarkable that the occurrences which have transformed the 6 chromosomes normally present in the species into a new set of 9 elements, 7 of which have been profoun- dly altered in their structure, do not show any influence on the morphology of the organism. This fact, together with those found in the salivary-chromosomes races of Drosophila and Sciara. compromises strongly the genetical concept of position effects.

Biologia da Arsenura xanthopus (Walker, 1855) ( Lepidoptera - Adelocephalidae ), praga do «Açoita-Cavalo» (Luehea spp.) e notas sôbre seus inimigos naturais

Biology of Arsenura xanthopus (Walker, 1855) (Lep., Adelocephalidae), a pest of Luehea spp. (Tiliaceae), and notes on its natural enemies. In the beginning of 1950, one of the Authors made some observations about the biology of Arsenura xanthopus (Walker), in Piracicaba, State of S. Paulo, Brazil. From 1951 to 1953, both Authors continued the observations on such an important Adelocephalidae, the caterpillars of which represent a serious pest of Luehea spp. leaves. Actually, in some occasions, the caterpillars can destroy completely the leaves of the trees. The species is efficientely controlled by two natural enemies: an egg parasite (Tetrastichus sp., Hym., Eulophidae) and a fly attacking the last instar caterpillar (Winthemia tricolor (van der Wulp), Dip., Tachinidae). Tetrastichus sp. can destroy 100% of the eggs and the fly, 70 to 100% of the caterpillars. Indeed, facts as such are very interesting because we rarely know of a case of so complete a control of a pest by an insect. A. xanthopus had not yet been mentioned in our literature. Actually neither the systematic bibliography nor the economic one has treated of this species. However, a few other species of Arsenura are already known as living on Luehea spp. According to the Authors' observations, W. tricolor was also unknown by the Brazilian entomological literature. Arsenura xanthopus (Walker, 1855) After giving the sinonimy and a few historical data concerning the species, and its geographical distribution, the Authors discuss its placing in the genus Arsenura Duncan or Rhescyntis Huebner, finishing by considering Arsenura xanthopus as a valid name. The Authors put the species in the family Adelocephalidae, as it has been made by several entomologists. The host plant The species of Tiliaceae plants belonging to the genus Luehea are called "açoita-cavalo" and are well known for the usefulness of their largely utilized wood. The genus comprises exclusively American plants, including about 25 species distributed throughout the Latin America. Luehea divaricata Mart, is the best known species and the most commonly cultivated. Biology of Arsenura xanthopus Our observations show that the species passes by 6 larval stages. Eggs and egg-postures, all the 6 instars of the caterpillars as well as the chrysalid are described. The pupal period is the longest of the cycle, taking from 146 to 256 days. Data on the eclosion and habits of the caterpillars are also presented. A redescription of the adult is also given. Our specimens agreed with BOUVIER's description, except in the dimension between the extremities of the extended wings, which is a little shorter (107 mm according to BOUVlErVs paper against from 80 to 100mm in our individuals). Winthemia tricolor (van der Wulp, 1890) Historical data, geographical distribution and host are first related. W. tricolor had as yet a single known host-; Ar^-senura armida (Cramer). This chapter also contains some observations on the biolcn gy of the fly and on its behaviour when trying to lay eggs on the caterpillars' skin. The female of W. tricolor lays from 1 to 33 eggs on the skin of the last instar caterpillar. The mam region of the body where the eggs are laid are the membranous legs. Eggs are also very numerous oh the ventral surface of the thorax and abdomen. The. preference for such regions is easily cleared up considering the position assumed by the caterpillar when fixed motionless in a branch. In such an occasion, the fly approaches, the victim, puts the ovipositor out and lays the eggs on different parts of the body, mainly on the mentioned regions, which are much more easily reached. The eggs of the fly are firmly attached to the host's skin, being almost impossible to detach them, without having them broken. The minute larvae of the fly enter the body of, the host when it transforms into chrysalid. Chrysalids recentely formed and collected in nature f requentely show a few small larvae walking on its skin and looking for an adequate place to get into the body. A few larvae die by remaining in the skin of the caterpillar which is pushed away to some distance by the active movements of the chrysalid recentely formed. From 1 to 10 larvae completely grown may emerge from the attacked chrysalid about 8 days after their penetrating into the caterpillars' body and soon begin to look for an adequate substratum where they can transform themselves into pupae. In natural conditions, the metamorphosis occurs in the soil. The flies appear within 15 days. Tetrastichus sp. This microhymenoptera is economically the most interesting parasite, being commonly able to destroy the whole pos^ ture of the moth. Indeed, some days after the beginning of the infestation of the trees, it is almost impossible to obtain postures completely free of parasites. The active wasp introduces the ovipositor into the egg of the moth, laying its egg inside, from 80 to 120 seconds after having introduced it. A single adult wasp emerges from each egg. Sarcophaga lambens Wiedemann, 1830 During the observations carried out, the Authors obtained 10 flies from a chysalid that were recognized as belonging to the species above. S. lambens is a widely distributed Sarcophagidae, having a long list of hosts. It is commonly obtained from weak or died invertebrates, having no importance as one of their natural enemies. Sinonimy, list of hosts and distribution are presented in this paper. Control of Arsenura xanthopus A test has been carefully made in the laboratory just to find out the best insecticide for controlling A. xanthopus caterpillars. Four different products were experimented (DDT, Pa-rathion, BHC and Fenatox), the best results having been obtained with DDT at 0,25%. However, the Authors believe in spite of the initial damages of the trees, that the application of an insecticide may be harmful by destroying the natural agents of control. A biological desiquilibrium may in this way take place. The introduction of the parasites studied (Tetrastichus sp. and Winthemia tricolor) seems to be the most desirable measure to fight A. xanthopus.

Adubação e irrigação de café: adubação combinada com irrigação no primeiro ano da instalação das covas

This paper deals with different types of fertilizer applications in coffee hill in the moment of transfering the plants to the field. During the first year, irrigation was applied in the dry season. After one year, the following characters were analised: plant height; plant diameter; number of productive branches; lenght and number of nodes in the first branch of the plant. The results obtained can be summarized as follows: the irrigation employed did not affect the treatments and mineral fertilizers combined with organic fertilizer were better than the others treatments used for comparisons.

Estudos sobre a alimentação mineral do cafeeiro: XII. efeito da adubação na composição mineral das fôlhas

Leaf samples from coffee plants under three different fertilizations, namely NPK, NP and PK, were collected for chemical analysis. It was found that the contents of N, K, Ca, Mg and S in the first, second, third and fourth pair of leaves were the same from the statistical point of view. On the onder hand, there was a significant effect of the position of the leaf in the branch on the P content, which was higher in the first pair. With the exception of the P level ,the four pairs of leaves are chemically uniform. Nevertheless it is not considered as convenient to mix all kinds of leaves into one sample, since the composition may vary a great deal when sampling is done some other time, such as the period of fruit growing. It is recommended therefore that either the third or the fourth pair leaves should be collected for routine work in foliar diagnosis.