Noninvasive cardiac assessment in children of women with systemic lupus erythematosus

OBJECTIVE: Noninvasive cardiac assessment of newborns and infants of women with systemic lupus erythematosus. The children had no congenital total atrioventricular block and were compared with the children of healthy women. METHODS: We prospectively assessed 13 newborns and infants aged 1 to 60 days, children of women with systemic lupus erythematosus and without congenital total atrioventricular block. These children were compared with 30 children of women who had no lupus or anti-Ro/SSA antibodies, and no risk factors for congenital heart disease either. Their age groups matched. The following examinations were performed: cardiological physical examination, electrocardiography, echocardiography, and signal-averaged electrocardiography. RESULTS: The statistical analysis showed no significant difference in ventricular function or in the cardiac conduction system between the groups. CONCLUSION: In regard to the conduction system and ventricular function in the absence of total atrioventricular block, no statistically significant difference was observed between the children of women with systemic lupus erythematosus and children of healthy women.

Follow-up study of morphology and cardiac function in rats undergoing induction of supravalvular aortic stenosis

OBJECTIVE: To characterize the follow-up of an experimental model of left ventricular hypertrophy (LVH) induced by supravalvular ascending aortic stenosis in young rats. METHODS: Wistar rats were submitted to thoracotomy and aortic stenosis was created by placing a clip on the ascending aorta (AoS group, n=12). Age-matched control animals underwent a sham operation (C group, n=12). Cardiac function was analysed by echocardiograms performed 6, 12, and 21 weeks after aortic banding. Myocardial morphological features and myocardial hydroxyproline concentration (HOP) were evaluated 2, 6, 12, and 21 weeks after surgery in additional animals. RESULTS: Aortic banding promoted early concentric LVH and a progressive increase in HOP. Under light microscopy, we observed myocyte hypertrophy and wall thickening of the intramural branches of the coronary arteries due to medial hypertrophy. Cardiac function was supranormal after 6 weeks (percentage of fractional shortening - EAo6: 70.3±10.8; C6: 61.3±5.4; p<0.05), and depressed in the last period. Diastolic dysfunction was detected after 12 weeks (ratio of early-to-late filling velocity - EAo12: 4.20±3.25; C12: 1.61±0.16; p<0.05). CONCLUSION: Ascending aortic stenosis promotes concentric LVH with myocardial fibrosis and minimal histological changes. According to the period of evaluation, cardiac function may be improved, normal, or depressed. The model is suitable and useful for studies on pathophysiology and treatment of the different phases of cardiac hypertrophy.

Spontaneous rupture of a right atrial angiosarcoma and cardiac tamponade

Primary cardiac angiosarcoma is a rare disease of difficult diagnosis and poor prognosis frequently associated with recurring hemopericardium. We report the case of a 30-year-old female with a right atrial angiosarcoma and spontaneous rupture to the pericardial cavity, who was diagnosed during an emergency exploratory thoracotomy, whose indication was cardiac tamponade. This is the 8th case reported in the literature. Clinical findings are discussed and a literature review is provided.

PARTICIPACIÓN DEL RECONOCIMIENTO INMUNE INNATO EN LA RESPUESTA DE CARDIOMIOCITOS DURANTE LA INFECCIÓN EXPERIMENTAL CON TRYPANOSOMA CRUZI. Characterization of the cardiac innate immune response during Trypanosoma cruzi experimental infection.

La enfermedad de Chagas, causada por Trypanosoma cruzi, constituye la principal miocarditis infecciosa a nivel mundial. Crecientes evidencias revelan que la respuesta inmune innata tendría un rol determinante en la fisiopatología de las enfermedades cardiovasculares. La inmunidad innata es la primera línea de defensa, no específica, preprogramada para combatir agentes infecciosos. Este sistema censa la presencia de antígenos extraños a través de los receptores tipo toll (TLR) produciendo citoquinas y activando mecanismos microbicidas. Sin embargo, los TLRs también se hayan distribuidos en las células parenquimales no inmunes, jugando un importante rol tanto en la defensa como en la homeostasis de cada tejido. Durante la etapa aguda de la infección, el T. cruzi invade y se replica dentro de una amplia variedad de células y tejidos. Pero posteriormente, los parásitos son efectivamente eliminados de la mayoría de los tejidos persistiendo durante toda la vida en las células del músculo cardíaco y esquelético de los pacientes infectados. Debido a que el mantenimiento de la célula cardíaca infectada es crítica para la patogénesis de la enfermedad, los mecanismos que participan en la sobrevida de los cardiomiocitos están siendo foco de nuestro estudio. Hemos demostrado, que la infección ejerce efectos antiapoptóticos sobre células cardíacas aisladas. Nuestra hipótesis es que la inmunidad innata cardíaca estaría involucrada en el mantenimiento de la sobrevida de los miocitos así como en la defensa contra el parásito. Objetivo general: determinar la participación de la respuesta inmune innata cardíaca en el desarrollo de la enfermedad de Chagas experimental murina. Objetivos específicos: 1) Analizar el compromiso de TLRs en la respuesta anti-apoptótica y de autofagia de cardiomiocitos aislados de ratones salvajes y de ratones deficientes en TLR4, TLR2 y en MyD88, molécula adaptadora de la señalización por TLRs, sometidos a la infección con el parásito. 2) Determinar la importancia de la actividad cisteín proteasa parasitaria en el grado de infectividad y la sobrevida de cultivos primarios de ratones salvajes infectados con parásitos transgénicos que poseen disminuída o nula actividad cisteín proteasa. 3) Establecer la cinética de expresión de TLR2/TLR6, TLR4 y TLR9, factores antiapoptóticos (Bcl-2, Bcl-xL, etc.), daño cardíaco y la carga parasitaria en el tejido cardíaco de ratones infectados salvajes y/o deficientes antes mencionados. Materiales y Métodos: Los animales serán infectados i.p. con 5x103 parásitos y se determinará la cinética de expresión de los mediadores mencionados por western blot e inmunofluorescencia, la carga parasitaria será determinada por qRT-PCR. Como controles se procesarán animales inyectados con solución salina. En cultivos primarios de cardiomiocitos de ratones neonatos salvajes y deficientes infectados se estudiará la carga parasitaria, la activación de los mecanismos microbicidas (producción de óxido nítrico, metabolitos reactivos del oxígeno y del nitrógeno, ciclooxigenasa, etc.), producción de citoquinas y expresión de moléculas anti-apoptóticas (Bcl-2, Bcl-xL, Bax, etc.). Se explorará la tasa de apoptosis en cultivos deprivados de suero. La autofagia se analizará por microscopia electrónica. Cultivos controles serán mantenidos en medio o tratados con ligandos de los diferentes TLRs. Resultados preliminares sugieren que tanto TLR2 como Bcl-2 se incrementan en tejido cardíaco infectado. Esto nos lleva a profundizar en los mecanismos observados en cultivos y estudiarlos en un modelo in vivo, analizando la posible importancia que tiene la inmunidad innata cardíaca en el control del establecimiento de la infección. La comprensión de los mecanismos que mantienen la sobrevida de los cardiomiocitos y su respuesta a la infección es importante ya que el conocimiento de las bases moleculares es fundamental para el desarrollo de nuevos agentes quimioterapéuticos. Chagas disease is endemic in Central and South America and causes the most common myocarditis worldwide. We have previously reported that the cardiotrophic parasite Trypanosoma cruzi, its etiological agent, protects cardiomyocytes against apoptosis induced by growth factor deprivation activating the PI3K/Akt and MEK1/ERK signaling pathways. Recent studies have shown that local innate immunity plays a key role in initiating and coordinating homeostatic as well as defense responses in the heart. One of the mechanisms by which the innate immune system senses the presence of foreign antigens is through TLRs. The stimulation of these receptors leads to the activation and nuclear translocation of NF-kB transcription factor and the production of cytokines. Proinflammatory cytokines, in turn, appear to play a central role in the orchestration and timing of the intrinsic cardiac stress response providing, under different situations, instantaneous anti-apoptotic cytoprotective signals, which allow tissue repair and/or remodeling. The aim of the present project is to study the cardiomyocyte innate immune responses to T. cruzi infection and its role in target cell protection from apoptosis. Specific objectives: 1) Study the mechanism triggered by TLR in the anti-apoptotic response and parasite load of infected cardiomyocyte primary cultures from wild type and mice deficient in TLR2, TLR4 or MyD88. 2) Determine the effect of parasite cisteín protease activity on primary cultures from wild type mice. 3) Determine the TLR signaling-involvement in parasite load and survival indicators in deficient mice. Preliminary results showed us that cardiac-TLR2 may be involved in the anti-apoptotic effect elicited by the parasite and prompted us to establish the mechanisms triggered by the innate immunity that mediate parasite persistence within the host cell.

Validação para o português do Maugerl CaRdiac preventiOn-Questionnaire (MICRO-Q)

FUNDAMENTO: O Maugerl CaRdiac preventiOn-Questionnaire (MICRO-Q) é um instrumento específico, validado e utilizado para avaliar o conhecimento do paciente coronariano sobre aspectos relacionados à prevenção secundária da doença arterial coronariana (DAC). OBJETIVO: Traduzir, adaptar e validar o MICRO-Q para a língua portuguesa do Brasil. MÉTODOS: Duas traduções iniciais independentes foram realizadas para o português. Após sua comparação foi feita a tradução reversa, que foi revisada por um comitê e gerou a versão final, testada em um estudo-piloto. O instrumento foi aplicado em 212 pacientes coronarianos, com idade média de 60 a 72 anos (desvio padrão = 9,4; mín = 35; máx = 86), participantes de programas de reabilitação cardíaca. A consistência interna foi verificada por meio do coeficiente Alpha de Cronbach, a correlação através do Spearman Rho e a validade de construto foi verificada por análise fatorial exploratória. As médias foram analisadas comparando as escalas das questões corretas em função de variáveis, como idade, sexo, comorbidades associadas, grau de escolaridade, renda familiar, entre outros. RESULTADOS: A versão brasileira do MICRO-Q possui 25 questões. Essa versão, quanto à confiabilidade, apresentou Alpha de Cronbach de 0,64 e Spearman Rho das respostas corretas de 0,65. A análise fatorial revelou a existência de 6 fatores, relacionados aos domínios de conhecimento do questionário. A análise das características da população, em função das escalas das questões corretas, apresentou diferenças significativas apenas em função da renda familiar mensal e grau de escolaridade. CONCLUSÃO: A versão brasileira do MICRO-Q aprovada apresenta validade e confiabilidade adequadas para sua utilização em futuras pesquisas.

Oclusão percutânea do apêndice atrial esquerdo com o Amplatzer Cardiac PlugTM na fibrilação atrial

Fundamento: A fibrilação atrial está associada a acidentes vasculares embólicos que frequentemente resultam em morte ou invalidez. Eficaz na redução desses eventos, a anticoagulação possui várias limitações e vem sendo amplamente subutilizada. Mais de 90% dos trombos identificados nos portadores de fibrilação atrial sem doença valvar se originam no apêndice atrial esquerdo, cuja oclusão é investigada como uma alternativa à anticoagulação. Objetivo: Determinar a viabilidade da oclusão percutânea do apêndice atrial esquerdo em pacientes com alto risco de eventos embólicos e limitações ao uso de anticoagulação. Métodos: Relatamos a experiência inicial com o Amplatzer Cardiac PlugTM (St. Jude Medical Inc., Saint Paul, Estados Unidos) em pacientes com fibrilação atrial não valvar. Foram selecionados pacientes com alto risco de tromboembolia, sangramentos maiores e contraindicações ao uso ou grande labilidade na resposta ao anticoagulante. Os procedimentos foram realizados por via percutânea, sob anestesia geral e com ecocardiografia transesofágica. O desfecho primário foi a presença de complicações periprocedimento e o seguimento programado incluiu reavaliação clínica e ecocardiográfica em 30 dias e por contato telefônico após nove meses. Resultados: Nos cinco pacientes selecionados se conseguiu a oclusão do apêndice atrial esquerdo sem complicações periprocedimento. Não houve eventos clínicos no seguimento. Conclusão: Ensaios clínicos controlados são necessários antes que o fechamento percutâneo do apêndice atrial esquerdo constitua uma alternativa à anticoagulação na fibrilação atrial não associada a doença valvar. Mas o dispositivo se mostrou promissor em pacientes com alto risco de embolia e restrições ao uso de anticoagulantes.

Oclusão do apêndice atrial esquerdo com o Amplatzer Cardiac Plug em pacientes com fibrilação atrial

FUNDAMENTO: A oclusão percutânea do apêndice atrial esquerdo (OAAE) surgiu como alternativa à anticoagulação oral (AO) para prevenção do acidente vascular cerebral (AVC) em pacientes com fibrilação atrial não-valvular (FANV). OBJETIVO: Relatar os resultados imediatos e o seguimento clínico de pacientes submetidos a OAAE com o Amplatzer Cardiac Plug (ACP) em um único centro de referência. MÉTODOS: Oitenta e seis pacientes consecutivos com FANV, contra-indicação à AO e escore CHADS2= 2,6±1,2 foram submetidos a OAAE com implante de ACP. Realizou-se seguimento clínico e ecocardiográfico no mínimo 4 meses após o implante. RESULTADOS: Todos os implantes foram guiados apenas por angiografia. O sucesso do procedimento foi de 99% (1 insucesso por tamponamento cardíaco e consequente suspensão da OAAE). Houve 4 complicações maiores (o tamponamento já referido, 2 AVCs transitórios e uma embolização com retirada percutânea da prótese) e duas menores (um derrame pericárdico sem tamponamento e uma pequena comunicação interatrial evidenciada no seguimento). Houve 1 óbito hospitalar após 6 dias, não relacionado à intervenção. Todos os outros pacientes receberam alta sem AO. Após seguimento de 25,9 pacientes-ano (69 pacientes) não houve AVCs nem embolizações tardias de próteses. O AAE estava completamente ocluído em 97% dos casos. Seis pacientes apresentaram evidência de trombo sobre a prótese, que desapareceram após reinstituição de AO por 3 meses. CONCLUSÃO: OAAE se associa a um alto índice de sucesso, um índice aceitável de complicações e resultados promissores a médio prazo, podendo ser considerada uma alternativa válida à OA na prevenção do AVC em pacientes com FANV.

Applicability of Two International Risk Scores in Cardiac Surgery in a Reference Center in Brazil

Background:The applicability of international risk scores in heart surgery (HS) is not well defined in centers outside of North America and Europe.Objective:To evaluate the capacity of the Parsonnet Bernstein 2000 (BP) and EuroSCORE (ES) in predicting in-hospital mortality (IHM) in patients undergoing HS at a reference hospital in Brazil and to identify risk predictors (RP).Methods:Retrospective cohort study of 1,065 patients, with 60.3% patients underwent coronary artery bypass grafting (CABG), 32.7%, valve surgery and 7.0%, CABG combined with valve surgery. Additive and logistic scores models, the area under the ROC (Receiver Operating Characteristic) curve (AUC) and the standardized mortality ratio (SMR) were calculated. Multivariate logistic regression was performed to identify the RP.Results:Overall mortality was 7.8%. The baseline characteristics of the patients were significantly different in relation to BP and ES. AUCs of the logistic and additive BP were 0.72 (95% CI, from 0.66 to 0.78 p = 0.74), and of ES they were 0.73 (95% CI; 0.67 to 0.79 p = 0.80). The calculation of the SMR in BP was 1.59 (95% CI; 1.27 to 1.99) and in ES, 1.43 (95% CI; 1.14 to 1.79). Seven RP of IHM were identified: age, serum creatinine > 2.26 mg/dL, active endocarditis, systolic pulmonary arterial pressure > 60 mmHg, one or more previous HS, CABG combined with valve surgery and diabetes mellitus.Conclusion:Local scores, based on the real situation of local populations, must be developed for better assessment of risk in cardiac surgery.

Tai Chi Chuan for Cardiac Rehabilitation in Patients with Coronary Arterial Disease

Background:Several studies have shown that Tai Chi Chuan can improve cardiac function in patients with heart disease.Objective:To conduct a systematic review of the literature to assess the effects of Tai Chi Chuan on cardiac rehabilitation for patients with coronary artery disease.Methods:We performed a search for studies published in English, Portuguese and Spanish in the following databases: MEDLINE, EMBASE, LILACS and Cochrane Register of Controlled Trials. Data were extracted in a standardized manner by three independent investigators, who were responsible for assessing the methodological quality of the manuscripts.Results:The initial search found 201 studies that, after review of titles and abstracts, resulted in a selection of 12 manuscripts. They were fully analyzed and of these, nine were excluded. As a final result, three randomized controlled trials remained. The studies analyzed in this systematic review included patients with a confirmed diagnosis of coronary artery disease, all were clinically stable and able to exercise. The three experiments had a control group that practiced structured exercise training or received counseling for exercise. Follow-up ranged from 2 to 12 months.Conclusion:Preliminary evidence suggests that Tai Chi Chuan can be an unconventional form of cardiac rehabilitation, being an adjunctive therapy in the treatment of patients with stable coronary artery disease. However, the methodological quality of the included articles and the small sample sizes clearly indicate that new randomized controlled trials are needed in this regard.

Mortality and Embolic Potential of Cardiac Tumors

Background: Cardiac tumors are rare, mostly benign with high embolic potential. Objectives: To correlate the histological type of cardiac masses with their embolic potential, implantation site and long term follow up in patients undergoing surgery. Methods: Between January 1986 and December 2011, we retrospectively analyzed 185 consecutive patients who underwent excision of intracardiac mass (119 females, mean age 48±20 years). In 145 patients, the left atrium was the origin site. 72% were asymptomatic and prior embolization was often observed (19.8%). The diagnosis was established by echocardiography, magnetic resonance and histological examination. Results: Most tumors were located in the left side of the heart. Myxoma was the most common (72.6%), followed by fibromas (6.9%), thrombi (6.4%) and sarcomas (6.4%). Ranging from 0.6cm to 15cm (mean 4.6 ± 2.5cm) 37 (19.8%) patients had prior embolization, stroke 10.2%, coronary 4.8%, peripheral 4.3% 5.4% of hospital death, with a predominance of malignant tumors (40% p < 0.0001). The histological type was a predictor of mortality (rhabdomyomas and sarcomas p = 0.002) and embolic event (sarcoma, lipoma and fibroelastoma p = 0.006), but not recurrence. Tumor size, atrial fibrillation, cavity and valve impairment were not associated with the embolic event. During follow-up (mean 80±63 months), there were 2 deaths (1.1%) and two recurrences 1 and 11 years after the operation, to the same cavity. Conclusion: Most tumors were located in the left side of the heart. The histological type was predictor of death and preoperative embolic event, while the implantation site carries no relation with mortality or to embolic event.

Resistance Training After Myocardial Infarction in Rats: Its Role on Cardiac and Autonomic Function

Background: Although resistance exercise training is part of cardiovascular rehabilitation programs, little is known about its role on the cardiac and autonomic function after myocardial infarction. Objective: To evaluate the effects of resistance exercise training, started early after myocardial infarction, on cardiac function, hemodynamic profile, and autonomic modulation in rats. Methods: Male Wistar rats were divided into four groups: sedentary control, trained control, sedentary infarcted and trained infarcted rats. Each group with n = 9 rats. The animals underwent maximum load test and echocardiography at the beginning and at the end of the resistance exercise training (in an adapted ladder, 40% to 60% of the maximum load test, 3 months, 5 days/week). At the end, hemodynamic, baroreflex sensitivity and autonomic modulation assessments were made. Results: The maximum load test increased in groups trained control (+32%) and trained infarcted (+46%) in relation to groups sedentary control and sedentary infarcted. Although no change occurred regarding the myocardial infarction size and systolic function, the E/A ratio (-23%), myocardial performance index (-39%) and systolic blood pressure (+6%) improved with resistance exercise training in group trained infarcted. Concomitantly, the training provided additional benefits in the high frequency bands of the pulse interval (+45%), as well as in the low frequency band of systolic blood pressure (-46%) in rats from group trained infarcted in relation to group sedentary infarcted. Conclusion: Resistance exercise training alone may be an important and safe tool in the management of patients after myocardial infarction, considering that it does not lead to significant changes in the ventricular function, reduces the global cardiac stress, and significantly improves the vascular and cardiac autonomic modulation in infarcted rats.

Gender-Based Differences in Cardiac Remodeling and ILK Expression after Myocardial Infarction

Background: Gender can influence post-infarction cardiac remodeling. Objective: To evaluate whether gender influences left ventricular (LV) remodeling and integrin-linked kinase (ILK) after myocardial infarction (MI). Methods: Female and male Wistar rats were assigned to one of three groups: sham, moderate MI (size: 20-39% of LV area), and large MI (size: ≥40% of LV area). MI was induced by coronary occlusion, and echocardiographic analysis was performed after six weeks to evaluate MI size as well as LV morphology and function. Real-time RT-PCR and Western blot were used to quantify ILK in the myocardium. Results: MI size was similar between genders. MI resulted in systolic dysfunction and enlargement of end-diastolic as well as end-systolic dimension of LV as a function of necrotic area size in both genders. Female rats with large MI showed a lower diastolic and systolic dilatation than the respective male rats; however, LV dysfunction was similar between genders. Gene and protein levels of ILK were increased in female rats with moderate and large infarctions, but only male rats with large infarctions showed an altered ILK mRNA level. A negative linear correlation was evident between LV dimensions and ILK expression in female rats with large MI. Conclusions: Post-MI ILK expression is altered in a gender-specific manner, and higher ILK levels found in females may be sufficient to improve LV geometry but not LV function.

Physical Stress Echocardiography: Prediction of Mortality and Cardiac Events in Patients with Exercise Test showing Ischemia

Background: Studies have demonstrated the diagnostic accuracy and prognostic value of physical stress echocardiography in coronary artery disease. However, the prediction of mortality and major cardiac events in patients with exercise test positive for myocardial ischemia is limited. Objective: To evaluate the effectiveness of physical stress echocardiography in the prediction of mortality and major cardiac events in patients with exercise test positive for myocardial ischemia. Methods: This is a retrospective cohort in which 866 consecutive patients with exercise test positive for myocardial ischemia, and who underwent physical stress echocardiography were studied. Patients were divided into two groups: with physical stress echocardiography negative (G1) or positive (G2) for myocardial ischemia. The endpoints analyzed were all-cause mortality and major cardiac events, defined as cardiac death and non-fatal acute myocardial infarction. Results: G2 comprised 205 patients (23.7%). During the mean 85.6 ± 15.0-month follow-up, there were 26 deaths, of which six were cardiac deaths, and 25 non-fatal myocardial infarction cases. The independent predictors of mortality were: age, diabetes mellitus, and positive physical stress echocardiography (hazard ratio: 2.69; 95% confidence interval: 1.20 - 6.01; p = 0.016). The independent predictors of major cardiac events were: age, previous coronary artery disease, positive physical stress echocardiography (hazard ratio: 2.75; 95% confidence interval: 1.15 - 6.53; p = 0.022) and absence of a 10% increase in ejection fraction. All-cause mortality and the incidence of major cardiac events were significantly higher in G2 (p < 0. 001 and p = 0.001, respectively). Conclusion: Physical stress echocardiography provides additional prognostic information in patients with exercise test positive for myocardial ischemia.

Focused Cardiac Ultrasound Using a Pocket-Size Device in the Emergency Room

Background:Cardiovascular urgencies are frequent reasons for seeking medical care. Prompt and accurate medical diagnosis is critical to reduce the morbidity and mortality of these conditions.Objective:To evaluate the use of a pocket-size echocardiography in addition to clinical history and physical exam in a tertiary medical emergency care.Methods:One hundred adult patients without known cardiac or lung diseases who sought emergency care with cardiac complaints were included. Patients with ischemic changes in the electrocardiography or fever were excluded. A focused echocardiography with GE Vscan equipment was performed after the initial evaluation in the emergency room. Cardiac chambers dimensions, left and right ventricular systolic function, intracardiac flows with color, pericardium, and aorta were evaluated.Results:The mean age was 61 ± 17 years old. The patient complaint was chest pain in 51 patients, dyspnea in 32 patients, arrhythmia to evaluate the left ventricular function in ten patients, hypotension/dizziness in five patients and edema in one patient. In 28 patients, the focused echocardiography allowed to confirm the initial diagnosis: 19 patients with heart failure, five with acute coronary syndrome, two with pulmonary embolism and two patients with cardiac tamponade. In 17 patients, the echocardiography changed the diagnosis: ten with suspicious of heart failure, two with pulmonary embolism suspicious, two with hypotension without cause, one suspicious of acute coronary syndrome, one of cardiac tamponade and one of aortic dissection.Conclusion:The focused echocardiography with pocket-size equipment in the emergency care may allow a prompt diagnosis and, consequently, an earlier initiation of the therapy.