Obstructive pulmonary artery sarcoma.

A 68 year-old woman presented with increasing dyspnoea (NYHA II) and systolic murmur at auscultation. Echocardiography showed thickened pulmonary valve leaflets, a systolic prolapsing mass provoking severe pulmonary stenosis (peak systolic pulmonary pressure: 42 mmHg), no regurgitation, minimal right ventricular dilatation but normal ventricular function. CT scan showed a dense structure extending from the right ventricular outflow tract (RVOT) up to the pulmonary bifurcation infiltrating the pulmonary valve (PV).

First Reported Successful Femoral Valve-in-Valve Transcatheter Aortic Valve Replacement Using the Edwards Sapien 3 Valve.

OBJECTIVES: Management of degenerated aortic valve bioprosthesis classically requires redo surgery, but transcatheter aortic valve-in-valve implantation is becoming a valid alternative in selected cases. In the case of a degenerated Mitroflow bioprosthesis, TAVR is associated with an additional challenge due to a specific risk of coronary occlusion. We aimed to assess the safety and feasibility of transfemoral valve-in-valve implantation of the new Edwards Sapien 3 (Edwards Lifesciences) in a degenerated Mitroflow bioprosthesis (Sorin Group, Inc). METHODS: We report here the safety and feasibility of transfemoral valve-in-valve implantation of a 23 mm Edwards Sapien 3 in a degenerated 25 mm Mitroflow valve and describe the specific assessment of the risk of coronary obstruction using a multi-imaging modality. RESULTS: The final result showed an absence of aortic regurgitation and a mean transvalvular gradient of 14 mm Hg. The patient had no major adverse cardiovascular events at 30-day follow-up. CONCLUSION: Transcatheter valve-in-valve implantation of an Edwards Sapien 3 in a degenerated Mitroflow is feasible and safe, considering a careful assessment of the risk of coronary obstruction with Mitroflow bioprosthesis due to leaflets mounted externally to the stent.

Estudo morfométrico do coração fetal: sua utilização como parâmetro para análise ecocardiográfica

OBJETIVO: Avaliar o diâmetro, o perímetro e a área das valvas atrioventriculares do coração fetal, bem como a espessura das paredes ventriculares e os diâmetros das cavidades ventriculares. MATERIAIS E MÉTODOS: Foram dissecados 20 corações de fetos com idade gestacional entre 28 e 36 semanas. Em seguida foram medidos os diâmetros ântero-posterior e transverso e aferidos as áreas e os perímetros das valvas mitral e tricúspide, bem como foram medidas as espessuras das paredes ventriculares e os diâmetros de suas cavidades, utilizando-se um paquímetro com acurácia de1/10 mm. RESULTADOS: Os diâmetros ântero-posterior e transverso da valva atrioventricular esquerda mediram, em média, 10,35 ± 1,62 mm e 9,90 ± 1,79 mm, respectivamente, e os diâmetros ântero-posterior e transverso da valva atrioventricular direita, 10,98 ± 1,90 mm e 9,51 ± 1,81 mm, respectivamente. A área e o perímetro da valva mitral foram de 84,06 ± 25,09 mm² e 29,87 ± 3,96 mm, respectivamente. A área e o perímetro da valva tricúspide mediram, respectivamente, 84,49 ± 26,79 mm² e 28,44 ± 3,85 mm. No ventrículo direito a espessura da parede anterior foi de 5,00 ± 1,70 mm e a da parede posterior foi de 3,83 ± 0,91 mm; no ventrículo esquerdo a espessura da parede anterior foi de 4,25 ± 0,87 mm e a da parede posterior foi de 4,14 ± 0,89 mm. O septo interventricular teve espessura de 4,10 ± 1,13 mm. O ventrículo direito teve como diâmetro ântero-posterior 9,25 ± 0,85 mm, e como diâmetro transverso 8,24 ± 0,42 mm. O ventrículo esquerdo mediu 9,95 ± 0,37 mm para o diâmetro ântero-posterior e 9,20 ± 0,40 mm para o diâmetro transverso. CONCLUSÃO: O conhecimento dos dados morfométricos do coração do feto é de grande importância para o diagnóstico ecocardiográfico de possíveis malformações cardíacas.

Aortic Annulus Stabilization Technique for Rapid Deployment Aortic Valve Replacement.

NlmCategory="UNASSIGNED">Rapid deployment aortic valve replacement (RDAVR) with the use of rapid deployment valve systems represents a smart alternative to the use of standard aortic bioprosthesis for aortic valve replacement. Nevertheless, its use is still debatable in patients with pure aortic valve regurgitation or true bicuspid aortic valve because of the risk of postoperative paravalvular leak. To address this issue, an optimal annulus-valve size match seems to be the ideal surgical strategy. This article describes a new technique developed to stabilize the aortic annulus and prevent paravalvular leak after RDAVR. To confirm the feasibility, this technique was performed in six patients with severe symptomatic aortic stenosis who were scheduled to undergo aortic valve replacement at our center. All patients survived surgery and were discharged from the hospital. There were no new intracardiac conduction system disturbances observed, and a permanent pacemaker implantation was not required in any of the patients. The intraoperative and postoperative echocardiogram confirmed successful positioning of the valve, and no paravalvular leak was observed. In this preliminary experience, RDAVR through a full sternotomy or an upper hemisternotomy approach with the use of aortic annulus stabilization technique was safe, and no leak was observed. Future studies on large series of patients are necessary to confirm the safety and effectiveness of this technique in preventing paravalvular leak in patients with true bicuspid aortic valves or pure aortic regurgitation.

Procedural Results and Clinical Outcomes of Transcatheter Aortic Valve Implantation in Switzerland: An Observational Cohort Study of Sapien 3 Versus Sapien XT Transcatheter Heart Valves.

BACKGROUND: New generation transcatheter heart valves (THV) may improve clinical outcomes of transcatheter aortic valve implantation. METHODS AND RESULTS: In a nationwide, prospective, multicenter cohort study (Swiss Transcatheter Aortic Valve Implantation Registry, NCT01368250), outcomes of consecutive transfemoral transcatheter aortic valve implantation patients treated with the Sapien 3 THV (S3) versus the Sapien XT THV (XT) were investigated. An overall of 153 consecutive S3 patients were compared with 445 consecutive XT patients. Postprocedural mean transprosthetic gradient (6.5±3.0 versus 7.8±6.3 mm Hg, P=0.17) did not differ between S3 and XT patients, respectively. The rate of more than mild paravalvular regurgitation (1.3% versus 5.3%, P=0.04) and of vascular (5.3% versus 16.9%, P<0.01) complications were significantly lower in S3 patients. A higher rate of new permanent pacemaker implantations was observed in patients receiving the S3 valve (17.0% versus 11.0%, P=0.01). There were no significant differences for disabling stroke (S3 1.3% versus XT 3.1%, P=0.29) and all-cause mortality (S3 3.3% versus XT 4.5%, P=0.27). CONCLUSIONS: The use of the new generation S3 balloon-expandable THV reduced the risk of more than mild paravalvular regurgitation and vascular complications but was associated with an increased permanent pacemaker rate compared with the XT. Transcatheter aortic valve implantation using the newest generation balloon-expandable THV is associated with a low risk of stroke and favorable clinical outcomes. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01368250.

Apical access and closure devices for transapical transcatheter heart valve procedures.

The majority of transcatheter aortic valve implantations, structural heart procedures and the newly developed transcatheter mitral valve repair and replacement are traditionally performed either through a transfemoral or a transapical access site, depending on the presence of severe peripheral vascular disease or anatomic limitations. The transapical approach, which carries specific advantages related to its antegrade nature and the short distance between the introduction site and the cardiac target, is traditionally performed through a left anterolateral mini-thoracotomy and requires rib retractors, soft tissue retractors and reinforced apical sutures to secure, at first, the left ventricular apex for the introduction of the stent-valve delivery systems and then to seal the access site at the end of the procedure. However, despite the advent of low-profile apical sheaths and newly designed delivery systems, the apical approach represents a challenge for the surgeon, as it has the risk of apical tear, life-threatening apical bleeding, myocardial damage, coronary damage and infections. Last but not least, the use of large-calibre stent-valve delivery systems and devices through standard mini-thoracotomies compromises any attempt to perform transapical transcatheter structural heart procedures entirely percutaneously, as happens with the transfemoral access site, or via a thoracoscopic or a miniaturised video-assisted percutaneous technique. During the past few years, prototypes of apical access and closure devices for transapical heart valve procedures have been developed and tested to make this standardised successful procedure easier. Some of them represent an important step towards the development of truly percutaneous transcatheter transapical heart valve procedures in the clinical setting.

Cisto esplênico não-parasitário e não-neoplásico

The authors present a rare case of pathology from spleen, a nonparasitic, non-neoplastic splenic cyst, in an adult male patient without a previous history of abdominal trauma. Principal clinical findings were pain in left upper quadrant, nausea, regurgitation and precocious satiation. On investigation, ultrasonography and CT scan showed an expansive lesion in the spleen, compressing the stomach. Surgical procedure was splenectomy and a microscopical examination revealed a non- parasitic, non-neoplastic splenic cyst. Splenic cysts are usually benigns, but surgical remotion is necessary when they are symptomatic or exist risk of rupture. In this report is presented the classification of splenic cysts, clinical manifestations, diagnostics methods and discussed their surgical treatment.

Complicações maternas associadas à via de parto em gestantes cardiopatas em um hospital terciário de Fortaleza, CE

OBJETIVO: Verificar a associação entre complicações maternas e tipo de parto em gestantes cardiopatas, assim como identificar os possíveis fatores clínicos e obstétricos, implicados na determinação da via de parto. MÉTODOS: Estudo retrospectivo e descritivo analisando prontuários médicos das gestantes cardiopatas internadas em Hospital de Referência terciário no município de Fortaleza, Ceará, no período de 2006 a 2007. A população do estudo incluiu todas as gestantes com diagnóstico anteparto de cardiopatias admitidas para realização do parto e excluiu as gestantes que tiveram o diagnóstico de cardiopatia após o parto, independente da idade e semana gestacional. Utilizou-se um questionário semiestruturado com variáveis demográficas, clínicas e obstétricas. Realizou-se, inicialmente, uma análise descritiva por meio de frequências simples e proporções das variáveis sociodemográficas, clínicas e obstétricas. Em seguida foram analisadas possíveis associações entre os aspectos clínicos, obstétricos e tipo de parto, verificando associação entre complicações maternas e tipo de parto. Para isso, foi aplicado o teste Exato de Fischer, considerando p<0,05 para o estabelecimento da significância estatística. Os dados coletados foram processados e analisados utilizando o software Epi-InfoTM, versão 6.04, Atlanta, USA. RESULTADOS: Foram incluídas 73 gestantes cardiopatas. Dentre as congênitas, a comunicação interatrial foi a mais observada (11,0%) e entre as adquiridas, a estone mitral a mais freqüente (24,6%). A proporção de partos cesáreos foi maior do que entre os vaginais, exceto para mulheres com cardiopatia adquirida. Foi encontrada associação entre tipo de cardiopatia e tipo de parto (p=0,01). Houve 13 complicações maternas (17,8%). Dentre as complicações, dez (76,9%) ocorreram por parto cesáreo e três por via vaginal. Não foi encontrada associação entre complicações maternas e tipo de parto em gestantes cardiopatas (p=0,74). CONCLUSÕES: Não houve associação entre a ocorrência de complicações maternas e a via de parto em gestantes cardiopatas.

Study of the cardiac left atrioventricular valvar complex in water buffaloes (Bubalus bubalis) of the Jafarabadi breed

Atrioventricular valve complex of 30 Jafarabadi water buffaloes, adult males were studied in this research with no heart diseases. The animals were obtained from a slaughterhouse in Brazilian State of Parana. The hearts were opened at the third portion affording access to the valve complex. The complexes had its area, number and type of tendinous cords submitted to analysis. The results showed that the complex is composed by two cusps and four accessory cusps, two or three papillary muscles in which 10-25 tendinous cords fix on the cusps that face the ventricle wall. The total area of the complex was on average 38.56cm², with a minimum of 24.96cm² and a maximum of 55.54cm². Statistically, no relation between the number of cords and the cusps' area where they are inserted or with the number of papillary muscle where they originated from was observed.

Clinical characterization of chronic chagasic cardiomyopathy in dogs

On the American continent, almost 15 million people are affected by Chagas disease, resulting in important economic and social damages. Dogs are considered to be an excellent experimental model to study Chagas' disease; as a result, in this research, the characterization of cardiovascular abnormalities was performed in dogs experimentally infected with Trypanosoma cruzi (the Colombian strain) that were at chronic stage. Thirteen adult female dogs were evaluated by electrocardiographic, echocardiographic, hematological and biochemical analyses in the chronic phase. For the electrocardiographic studies, respiratory sinus arrhythmia was the predominant rhythm during the entire research period (49.55% to 67%), with a low prevalence of right bundle branch block (0-13%) and first-degree atrioventricular block (0-14%). The spectral Doppler echocardio-graphy showed E and A mitral wave reversal (0.71±0.17), confirming the diastolic dysfunction present in all dogs. An increase in the enzymes activities was detected in the serum analysis, indicating myocardial injury by the infection. Six dogs died during the follow-up. In this way, the clinical characterization of experimentally infected dogs, as described here, increases the knowledge and allows for recognition of the behavioural modifications present in Chagas' disease in affected dogs.

Auscultatory and electrocardiographic characteristics of Crioulo horses

In order to determine auscultatory and electrocardiographic characteristics of Crioulo horses, one hundred animals ranging between one and twenty-six years of age (21 stallions, nine geldings, 27 pregnant mares e 43 not pregnant mares) were evaluated. The cardiac auscultation was performed during the clinical examination of the cardiovascular system, evaluating frequency, rate, normal and abnormal heart sounds (heart murmurs). The electrocardiographic examination followed the bipolar base-apex derivative system with animals at rest, by using an ECG-PC TEB equipment. The cardiac frequency, heart rate, morphology, duration, wave and complex amplitudes and interval durations were determined. The results were submitted to ANOVA and Tukey tests with an error probability of 5%. The cardiac auscultation revealed presence of functional systolic and diastolic murmur (10.00%) and systolic murmur compatible with tricuspid regurgitation besides normal heart sounds S1 (100.0%), S2 (100.0%), S3 (19.0%) and S4 (34.0%). The cardiac frequency obtained the average of 43.64 bpm, observing significative differences in relation to sexual and age factors and training level. The sinus rhythm was the most frequent (57.00%), followed by sinus tachycardia (38.00%) and sinus arrhythmia (5.00%), being observed rhythm disturbances in 16% of tracings. The P and T waves were observed more frequently in their forms P bifida positive (95.00%) and biphasic T (91.00%), being variable at tracing. There were also observed Q waves in 12.00% of the tracings. Thus, it was concluded that the auscultatory characteristics of Crioulo horses are according to the described in the literature for the species and the sexual factor, category, age factor and training level can influence some electrocardiographic parameters.

Celiotomy by plastrotomy in a yellow-footed tortoise (Geochelone denticulata)

One herein reports a successful case of celiotomy by plastrotomy for removal of foreign bodies in yellow-footed tortoise (Geochelone denticulata). The animal was treated at the Veterinary Hospital of the Federal University of Piaui, with appetite loss, regurgitation, constipation, lethargy, reluctance to walk and slightly reddish ocular mucous membranes. Radiographic examination was performed, confirming the presence of foreign bodies in the stomach. The tortoise underwent celiotomy by plastrotomy for the removal of the foreign bodies. The opening of the plastron was performed through the abdominal shields, with the aid of a circular mini grinding saw. One performed an incision in the midline between the two abdominal veins to access the abdominal cavity. A gastrotomy for removal of the foreign bodies (nails, toothpicks, stones, pieces of plastic, glass and crockery pieces) was performed after the location of the stomach. The surgery was successful and confirmed with radiographic evaluation in the immediate postoperative period. The celiotomy by plastrotomy for removal of foreign bodies in that animal proved to be a viable, very important and safe technique to the survival of chelonians.

Performance of two-dimensional Doppler echocardiography for the assessment of infarct size and left ventricular function in rats

Although echocardiography has been used in rats, few studies have determined its efficacy for estimating myocardial infarct size. Our objective was to estimate the myocardial infarct size, and to evaluate anatomic and functional variables of the left ventricle. Myocardial infarction was produced in 43 female Wistar rats by ligature of the left coronary artery. Echocardiography was performed 5 weeks later to measure left ventricular diameter and transverse area (mean of 3 transverse planes), infarct size (percentage of the arc with infarct on 3 transverse planes), systolic function by the change in fractional area, and diastolic function by mitral inflow parameters. The histologic measurement of myocardial infarction size was similar to the echocardiographic method. Myocardial infarct size ranged from 4.8 to 66.6% when determined by histology and from 5 to 69.8% when determined by echocardiography, with good correlation (r = 0.88; P < 0.05; Pearson correlation coefficient). Left ventricular diameter and mean diastolic transverse area correlated with myocardial infarct size by histology (r = 0.57 and r = 0.78; P < 0.0005). The fractional area change ranged from 28.5 ± 5.6 (large-size myocardial infarction) to 53.1 ± 1.5% (control) and correlated with myocardial infarct size by echocardiography (r = -0.87; P < 0.00001) and histology (r = -0.78; P < 00001). The E/A wave ratio of mitral inflow velocity for animals with large-size myocardial infarction (5.6 ± 2.7) was significantly higher than for all others (control: 1.9 ± 0.1; small-size myocardial infarction: 1.9 ± 0.4; moderate-size myocardial infarction: 2.8 ± 2.3). There was good agreement between echocardiographic and histologic estimates of myocardial infarct size in rats.

Primary and secondary esophageal contractions in patients with gastroesophageal reflux disease

We studied the primary and secondary esophageal peristalsis in 36 patients with heartburn and acid regurgitation and in 14 asymptomatic volunteers. Primary peristalsis was elicited by ten swallows of a 5-mL bolus of water and secondary peristalsis was elicited by intra-esophageal infusion of 5, 10, and 15 mL water, 0.1 N hydrochloric acid and air. Esophageal contractions were measured by an 8-lumen manometric catheter assembly incorporating a 6-cm sleeve device. Contractions were registered at 3, 9, and 15 cm from the upper margin of the sleeve and the infusion was done through a side hole located at 12 cm. Twenty patients had normal endoscopic esophageal examination, 10 with normal (group I) and 10 with abnormal pH-metric examination (group II), and 16 had esophagitis (group III). The amplitude of contractions after swallows was lower (97.8 ± 10.0 mmHg) in the distal esophagus of group III patients than in controls (142.3 ± 14.0 mmHg). Patients of group III had fewer secondary contractions (water: 25% of infusion) than patients of the other groups and controls (67% of infusion). Patients of group III also had a lower amplitude of secondary peristalsis in the distal esophagus (water: 70.1 ± 9.6 mmHg) than controls (129.2 ± 18.2 mmHg). We conclude that patients with esophagitis have an impairment of primary and secondary peristalsis in the distal esophagus.

N-terminal prohormone brain natriuretic peptide (NT-proBNP) as a noninvasive marker for restrictive syndromes

Constrictive pericarditis (CP) and restrictive cardiomyopathy share many similarities in both their clinical and hemodynamic characteristics and N-terminal prohormone brain natriuretic peptide (NT-proBNP) is a sensitive marker of cardiac diastolic dysfunction. The objectives of the present study were to determine whether serum NT-proBNP was high in patients with endomyocardial fibrosis (EMF) and CP, and to investigate how this relates to diastolic dysfunction. Thirty-three patients were divided into two groups: CP (16 patients) and EMF (17 patients). The control group consisted of 30 healthy individuals. Patients were evaluated by bidimensional echocardiography, with restriction syndrome evaluated by pulsed Doppler of the mitral flow and serum NT-proBNP measured by immunoassay and detected by electrochemiluminescence. Spearman correlation coefficient was used to analyze the association between log NT-proBNP and echocardiographic parameters. Log NT-proBNP was significantly higher (P < 0.05) in CP patients (log mean: 2.67 pg/mL; 95%CI: 2.43-2.92 log pg/mL) and in EMF patients (log mean: 2.91 pg/mL; 95%CI: 2.70-3.12 log pg/mL) compared with the control group (log mean: 1.45; 95%CI: 1.32-1.60 log pg/mL). There were no statistical differences between EMF and CP patients (P = 0.689) in terms of NT-proBNP. The NT-proBNP log tended to correlate with peak velocity of the E wave (r = 0.439; P = 0.060, but not with A wave (r = -0.399; P = 0.112). Serum NT-proBNP concentration can be used as a marker to detect the presence of diastolic dysfunction in patients with restrictive syndrome; however, serum NT-proBNP levels cannot be used to differentiate restrictive cardiomyopathy from CP.