Trombose em artérias coronárias normais causando infarto agudo do miocárdio em paciente alcoólatra

Paciente jovem, etilista, que sofreu infarto agudo do miocárdio. Após terapêutica trombolítica sem sucesso, a cineangiocoronariografia na fase aguda evidenciava trombos em múltiplas artérias. Um 2º CATE, realizado no 7º dia de internação revelou coronárias normais. Não havia nenhum distúrbio do metabolismo lipídico, assim como outro fator de risco de doença arterial coronária, a não ser o fato de ser tabagista de oito a 10 cigarros ao dia, há dois anos, o que nos levou a acreditar que o abuso de álcool etílico possa ter contribuído para esse evento.

Fibroelastoma of the mitral valve as a cause of transient ischemic stroke

A 44-year-old woman had a transient ischemic stroke, fibroelastoma of the mitral valve being the source of the embolus. The patient evolved with neutropenia induced by ticlopidine after 10 days of treatment. We report the major clinical features, therapeutical options, and medicamentous toxicity resulting from the use of antiplatelet drugs.

New percutaneous techniques for perforating the pulmonary valve in pulmonary atresia with intact ventricular septum

We report new percutaneous techniques for perforating the pulmonary valve in pulmonary atresia with intact ventricular septum, in 3 newborns who had this birth defect. There was mild to moderate hypoplastic right ventricle, a patent infundibulum, and no coronary-cavitary communications. We succeeded in all cases, and no complications related to the procedure occurred. The new coaxial radiofrequency system was easy to handle, which simplified the procedure. Two patients required an additional source of pulmonary flow (Blalock-Taussig shunt) in the first week after catheterization. All patients had a satisfactory short-term clinical evolution and will undergo recatheterization within 1 year to define the next therapeutic strategy. We conclude that this technique may be safely and efficiently performed, especially when the new coaxial radiofrequency system is used, and it may become the initial treatment of choice in select neonates with pulmonary atresia and intact ventricular septum.

Primary coronary angioplasty in a nonagenarian

A woman aged 98 years entered the tertiary hospital service with a picture of acute myocardial infarction of the extensive anterior wall, which began 4 hours earlier. Due to the large myocardial risk area suggested by the electrocardiogram, the patient was taken to the hemodynamics laboratory for the performance of emergency coronary arteriography, which revealed occlusion in the proximal third of the anterior descending artery. Primary angioplasty followed by stent grafting was successfully performed. The patient had a satisfactory evolution (Killip I) and was discharged from the hospital on the seventh postinfarction day. We discuss here aspects of thrombolysis and coronary percutaneous interventions in the aged.

Obstruction of the left ventricular outflow tract after mitral valvuloplasty with implantation of Gregori's ring

Mitral valvuloplasty is efficient for repairing mitral valve disease with few complications. In some cases, obstruction of the left ventricular outflow tract may occur due to systolic anterior motion of the mitral valve. We report the case of a patient with this complication and a pressure gradient between the left ventricle and the aorta of 130 mm Hg after mitral valvuloplasty with implantation of a Gregori's ring. The management was clinical with suspension of the vasoactive drugs and introduction of a beta-blocker. Two years after the surgery, the patient is asymptomatic and has a normal life.

Influence of Quality of Sleep on the Nocturnal Decline in Blood Pressure During Ambulatory Blood Pressure Monitoring

OBJECTIVE: To assess the influence of the quality of sleep on the nocturnal physiological drop in blood pressure during ambulatory blood pressure monitoring. METHODS: We consecutively assessed ambulatory blood pressure monitoring, the degree of tolerance for the examination, and the quality of sleep in 168 patients with hypertension or with the suspected "white-coat" effect. Blood pressure fall during sleep associated with a specific questionnaire and an analogical visual scale of tolerance for ambulatory blood pressure monitoring were used to assess usual sleep and sleep on the day of examination. Two specialists in sleep disturbances classified the patients into 2 groups: those with normal sleep and those with abnormal sleep. RESULTS: Fifty-nine (35 %) patients comprised the abnormal sleep group. Findings regarding the quality of sleep on the day of ambulatory blood pressure monitoring as compared with those regarding the quality of sleep on a usual day were different and were as follows, respectively: total duration of sleep (-12.4±4.7 versus -42.2±14.9 minutes, P=0.02), latency of sleep (0.4±2.7 versus 17±5.1 minutes, P<0.001), number of awakenings (0.1±0.1 versus 1.35±0.3 times, P<0.001), and tolerance for ambulatory blood pressure monitoring (8±0.2 versus 6.7±0.35, P=0.035). An abnormal drop in blood pressure during sleep occurred in 20 (18%) patients in the normal sleep group and in 14 (24%) patients in the abnormal sleep group, P=0.53. CONCLUSION: Ambulatory blood pressure monitoring causes sleep disturbances in some patients, and a positive association between quality of sleep and tolerance for the examination was observed.

A New Use for the Amplatzer Duct Occluder Device

We report a case in which the Amplatzer device for percutaneous occlusion of ductus arteriosus was successfully used for occluding a large systemic-pulmonary collateral vessel in a patient who had previously undergone surgery for correction of pulmonary atresia and ventricular septal defect (Rastelli technique), and was awaiting the change of a cardiac tube. In the first attempt, the device embolized to the distal pulmonary bed and, after being rescued with a Bitome, it was appropriately repositioned with no complications and with total occlusion of the vessel.

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.

Electrocardiographic abnormalities in neurological diseases

OBJECTIVE: To evaluate electrocardiographic abnormalities in patients with neurologic diseases. METHODS: We studied 161 patients with neurologic disorders by analyzing the 12-lead electrocardiogram during the pathological process. An expert who did not know anything about the patients evaluated the traces. RESULTS: Neurological process included brain tumor (41%), stroke (27.3%), cerebral aneurysm (15.5%), subarachnoid hemorrhage (6.8%), subdural hemorrhage (5%), and head injury (4.4%). Electrocardiograms were normal in 61% of cases, and the most frequent abnormality was ventricular repolarization (23.7%). The presence of T waves (4.6%) and prolonged QT intervals (8.8%) was the most characteristic of brain injuries. CONCLUSION: We observed a lower incidence of electrocardiographic abnormalities than that described in the literature.

O teste ergométrico é útil, seguro e eficaz, mesmo em indivíduos muito idosos, com 75 anos ou mais

OBJETIVO: Descrever as variáveis clínicas e hemodinâmicas obtidas pelo teste ergométrico em idosos >75 anos. MÉTODOS: Estudados 100 indivíduos de 75-94 anos (80±4 anos), submetidos a teste ergométrico sintoma limitante, sendo 65% assintomáticos, 25% com dor torácica não anginosa e 10% com precordialgia típica, 32% eram homens, 50% hipertensos, 36% dislipidêmicos, 14% diabéticos e 9% com doença arterial coronariana prévia. O protocolo utilizado foi uma adaptação para rampa, do protocolo de Bruce, acrescido de 1min de aquecimento com velocidade de 1,0mph sem inclinação. RESULTADOS: Não houve complicações e 92% dos testes foram eficazes. Os pacientes atingiram em média 95% da freqüência cardíaca máxima prevista. A duração do exame e os equivalentes metabólicos alcançados foram, em média, respectivamente: 6,8 ±2min e 6,6 ±2,3 METs. Apresentaram resposta inotrópica hiperreativa 11 dos pacientes e observadas arritmias ventriculares e supraventriculares não complexas em 37% da amostra. Foram positivos para isquemia miocárdica 18% dos testes. Os pacientes com precordialgia típica apresentaram mais respostas isquêmicas do que os com dor torácica não anginosa e assintomáticos: 70% vs 16% (p<0,001) e 70% vs 10% (p<0,01), respectivamente. CONCLUSÃO: O teste ergométrico sintoma limitante é útil, seguro e eficaz para analisar as respostas isquêmicas e hemodinâmicas, mesmo no indivíduo muito idoso.

Associação entre evolução da função cognitiva e mortalidade após a alta hospitalar em pacientes idosos com insuficiência cardíaca avançada

OBJETIVO: Avaliar a associação entre a evolução do desempenho cognitivo e o prognóstico de idosos após compensação de insuficiência cardíaca avançada. MÉTODOS: Selecionados, consecutivamente, 31 pacientes internados com insuficiência cardíaca classe IV da New York Heart Association, com idade > 64 anos (68 ±7) e fração de ejeção < 0,45 (0,38 ± 0,06). Submetidos a testes cognitivos (digit span, digit symbol, letter cancellation, trail making A e B) e teste de caminhada de 6min, 4 dias antes da alta (T1) e 6 semanas após (T2), cujos desempenhos foram comparados pelo teste T. O valor prognóstico dos escores dos testes cognitivos foram analisados pela regressão logística e o valor de maior acurácia dos testes associado com o prognóstico determinado pela ROC curve. RESULTADOS: Após 24,7 meses, 17 (55%) pacientes faleceram. Os desempenhos ao teste de caminhada e maioria dos testes cognitivos melhoraram entre T1 e T2. O escore do digit span entre os sobreviventes variou de 3,9 para 5,2 (p=0,003), permanecendo inalterado entre os que faleceram (4,1para 3,9; p=0,496). Melhora < 0,75 pontos no escore foi associada à mortalidade (risco relativo de 8,1; p=0,011). CONCLUSÃO: Em idosos, após a compensação de insuficiência cardíaca avançada, a ausência de melhora evolutiva do desempenho cognitivo foi associada a pior prognóstico.