Ana Rita Ferreira

Acute coronary syndrome of paradoxical origin

We describe a rare case of acute myocardial infarction secondary to paradoxical embolism complicating acute pulmonary embolism. A 44-year-old woman presented to the emergency department with chest pain. The physical examination was unremarkable except for oxygen saturation of 75%, and the electrocardiogram showed ST-segment elevation in the inferior leads. Urgent coronary angiography showed a distal occlusion of the right coronary artery and multiple thrombi were aspirated. Despite relief of chest pain and electrocardiogram normalization, her oxygen saturation remained low (90%) with high-flow oxygen by mask. The transthoracic echocardiogram showed a mass in the left atrium and dilatation of the right chambers, while the transesophageal echocardiogram showed a thrombus attached to the interatrial septum in the region of the foramen ovale. Color flow imaging was consistent with a patent foramen ovale. Thoracic computed tomography angiography documented thrombi in both branches of the pulmonary trunk. After five days on anticoagulation, the patient underwent surgical foramen ovale closure.

Pulse pressure can predict mortality in advanced heart failure

INTRODUCTION Pulse pressure (PP) is the difference between systolic and diastolic blood pressure (BP). PP rises markedly after the fifth decade of life. High PP is a risk factor for the development of coronary heart disease and heart failure. The aim of this study was to assess whether PP can be used as a prognostic marker in advanced heart failure. METHODS We retrospectively studied patients in NYHA class III-IV who were hospitalized in a single heart failure unit between January 2003 and August 2012. Demographic characteristics, laboratory tests, and cardiovascular risk factors were recorded. PP was calculated as the difference between systolic and diastolic BP at admission, and the patients were divided into two groups (group 1: PP >40 mmHg and group 2: PP ≤40 mmHg). Median follow-up was 666 ± 50 days for the occurrence of cardiovascular death and heart transplantation. RESULTS During follow-up 914 patients in NYHA class III-IV were hospitalized, 520 in group 1 and 394 in group 2. The most important difference between the groups was in left ventricular dysfunction, which was greater in patients with lower PP. On Kaplan-Meier analysis, group 2 had higher mortality (38 vs. 24 patients, log-rank p=0.002). CONCLUSIONS PP is easily calculated, and enables prediction of cardiovascular death in patients with advanced heart failure.

Multiple coronary artery aneurysms

A 71-year-old woman was admitted electively to our hospital in October 2013 for vascular surgery of an abdominal aortic aneurysm, diagnosed two months before through abdominal ultrasound performed on an outpatient basis due to recurrent abdominal pain. Her medical history included hypertension and dyslipidemia. No other cardiovascular disease was known. During the surgical procedure, the patient developed acute pulmonary edema and was transferred to the intensive care unit. The physical exam was notable for a harsh, grade IV/VI mitral systolic murmur and diffuse lung crackles. Transthoracic echocardiography performed at the patient’s bedside showed moderate depression of left ventricular systolic function (40% ejection fraction) and severe mitral regurgitation. Since abdominal aortic aneurysms are frequently associated with clinically significant coexisting coronary artery disease, after hemodynamic stabilization coronary angiography was performed. This showed multiple aneurysms involving all the main coronary arteries without significant stenosis (Figure 1). To better assess the coronary arteries cardiac computed tomography was performed, which showed a large aneurysm involving the anterior descending and circumflex arteries. The right coronary artery also had an aneurysm, smaller than in the left coronary (Figures 2 and 3). It is still not known how best to handle such aneurysms, and the type of surgical intervention should be

A rare aortic wall vegetation

A 69-year-old man was admitted to the emergency room due to acute pulmonary edema. He had no known history of cardiovascular disease. The physical exam was notable for a harsh, grade IV/VI aortic systolic murmur and diffuse lung crackles. A transthoracic echocardiogram showed severe aortic stenosis, with normal biventricular systolic function. Coronary angiography was performed, as aortic valve surgery was envisioned. The next day the patient presented with fever and no other symptoms. Empirical antibiotic therapy was started. Blood cultures were drawn and methicillin-sensitive Staphylococcus aureus was identified, prompting a change in antibiotic therapy to vancomycin and gentamicin. Endocarditis was suspected and a transesophageal echocardiogram was performed. The exam showed a 14 mm pedunculated and highly mobile mass attached to the intima, protruding from the posterior wall of the ascending aorta, at the level of the sinotubular junction (Figures 1 and 2). Given the high embolic risk and to avoid the development of a mycotic aneurysm, the case was discussed with the cardiac surgeon and the patient was operated the next day. An inflamed ascending aorta was detected in the operating theater; the mass was excised and the ascending aorta and aortic valve were replaced. The histopathology was notable for aortic endarteritis, with granulocyte infiltration (Figure 3). After the operation, antibiotics were continued to complete an eight-week course. The patient was discharged thereafter. Our case illustrates a very rare location of a vegetation

Electrocardiogram in acute myocardial infarction: what to expect?

Mailing Address: Ana Rita Pereira Alves Ferreira Rua Primeiro de Maio, 11 – Requião. Postal Code: 4770-454 – Vila Nova de Famalicão – Portugal E-mail: ritafmup@gmail.com Electrocardiogram in Acute Myocardial Infarction: What to Expect? Ana Rita Pereira Alves Ferreira1, Manuel Vaz da Silva2, Julia Maciel2 Centro Hospitalar e Universitário de Coimbra1 – Hospitais da Universidade de Coimbra – Serviço de Cardiologia A Coimbra, Centro Hospitalar de São João2, Porto – Portugal

Unusual form of tricuspid stenosis

We report the case of a 72-year-old man who, in 1982, in Switzerland, underwent surgical ablation for WolfParkinson-White syndrome. The procedure was complicated by complete atrioventricular block. Permanent pacemaker was implanted. In 1992, in Portugal, the patient was hospitalized due to an infection and necrosis of the pacemaker pocket and its leads. While in hospital, the generator was removed and there was an unsuccessful attempt to extract the leads of the permanent pacemaker, which remained inside the right ventricle. Patient follow-up was lost after hospital discharge.

Intensive glycemic control in patients with acute myocardial infarction: diabetes time duration counts!

Background: Cardiovascular disease (CVD) is the leading cause of death in patients with diabetes. The presence of type 2 diabetes mellitus (T2DM) puts the patients with and without history of myocardial infarction at risk for significant cardiovascular risk. Objective: To evaluate the prognostic impact of the time of duration and metabolic control of T2DM in a population hospitalized for acute coronary syndrome. Methods: Retrospective study of 731 consecutive patients admitted for acute coronary syndrome from May 2007 to August 2013. Patients were stratified into: Group 1 (n=297) with known diabetes mellitus (DM) (prior to hospitalization) and hemoglobin A1c (HbA1c) <6.5%; Group 2 (n=383) with known DM and HbA1c ≥6.5%; Group 3 (n=39), with recently diagnosed DM (during hospitalization) and HbA1c <6.5% and Group 4 (n=12) recently diagnosed with DM and HbA1c ≥6.5%. The primary endpoint was death from all causes (cardiovascular and non-cardiovascular) at one year, and the secondary endpoint at two years of follow-up. Results: The distribution by sex and age was similar in both groups. In-hospital mortality was also higher in Group 2 (4.4%). Mortality from all causes over one year was higher in Groups 1 (8.3%) and 4 (8.3%), and at two years was higher in Group 1 (9.8%). Group 3 had better prognosis. Conclusion: Of the data presented, the authors consider that the diabetes time of duration is important to decide the therapy and adjust the target of metabolic control of patients with ACS.