António Gaspar

New-onset atrial fibrillation during acute coronary syndromes: Predictors and prognosis

INTRODUCTION New-onset atrial fibrillation (AF) frequently complicates myocardial infarction, with an incidence of 6-21%. OBJECTIVE To assess the predictors and prognosis of new-onset AF during acute coronary syndromes (ACS). METHODS We performed a retrospective observational cohort study including 902 consecutive patients (mean age 64 years, 77.5% male) admitted to a single center over a two-year period, with a six-month follow-up. RESULTS AF rhythm was identified in 13.8% patients, of whom 73.3% presented new-onset AF and 26.8% pre-existing AF. New-onset AF was more frequent in older (p<0.001) and hypertensive patients (p=0.001) and in those with previous valvular heart disease (p<0.001) and coronary artery bypass grafting (p=0.049). During hospitalization, patients with new-onset AF more often had respiratory infection (p=0.002) and heart failure (p<0.001), and higher values of NT-proBNP (p=0.007) and peak creatinine (p=0.001). On echocardiography they had greater left atrial (LA) diameter (p<0.001) and more frequent significant mitral regurgitation (p<0.001) and left ventricular ejection fraction (LVEF) ≤40% (p<0.001) and were less likely to have significant coronary lesions (p=0.009) or to have undergone coronary revascularization (p<0.001). In multivariate analysis, age (OR 1.06, p=0.021), LVEF ≤40% (OR 4.91, p=0.002) and LA diameter (OR 1.14, p=0.008) remained independent predictors of new-onset AF. Together with age, diabetes and maximum Killip class, this arrhythmia was an independent predictor of overall mortality (OR 3.11, p=0.032). CONCLUSIONS Age, LVEF ≤40% and LA diameter are independent predictors of new-onset AF during ACS. This arrhythmia is associated with higher overall mortality (in-hospital and in follow-up).

Multimarker approach with cystatin C, N-terminal pro-brain natriuretic peptide, C-reactive protein and red blood cell distribution width in risk stratification of patients with acute coronary syndromes

INTRODUCTION AND AIM Biomarkers have emerged as interesting predictors of risk in patients with acute coronary syndromes (ACS). The aim of this study was to determine the utility of the combined measurement of cystatin C (CysC), C-reactive protein (CRP), N-terminal pro-brain natriuretic peptide (NT-proBNP) and red blood cell distribution width (RDW) in the risk stratification of patients with ACS. METHODS In this prospective study including 682 patients consecutively admitted to a coronary care unit for ACS, baseline measurements of CysC, CRP, NT-proBNP and RDW were performed. Patients were categorized on the basis of the number of elevated biomarkers at presentation. The primary outcome was 6-month mortality. RESULTS The number of biomarkers elevated on admission (study score) was an independent predictor of 6-month mortality; patients with four biomarkers elevated on admission had a significantly higher risk of 6-month mortality compared with patients with none or one. In addition, in patients with high risk defined by the GRACE score, our multimarker score was able to further categorize their risk of 6-month mortality. CONCLUSIONS A multimarker approach using CysC, NT-proBNP, CRP and RDW was an independent predictor of 6-month mortality and added prognostic information to the GRACE risk score in patients with ACS and high risk defined by GRACE, with increasing mortality in patients with a higher number of elevated biomarkers on admission.

Echocardiographic assessment of a cardiac lymphoma: beyond two-dimensional imaging

Lymphoma is usually recognized as the third most frequent metastatic malignancy involving the heart. In recent years, the incidence of cardiac lymphoma has increased, mainly because of HIV-infected patients. We present a case of secondary cardiac lymphoma in an HIV patient presenting with heart failure. Transthoracic echocardiography showed increased left ventricular (LV) wall thickness and an extensive mass in the right cavities with involvement of the tricuspid annulus (Figure 1). Doppler tissue imaging (DTI) showed reduced systolic and diastolic velocities at mitral and tricuspid annulus, compatible with systolic and diastolic myocardial dysfunction, likely owing to infiltration. After 2 weeks of chemotherapy, repeated exam showed significant reduction of the tumour mass and of the LV wall thickness, as well as normalized systolic and diastolic velocities at mitral and tricuspid annulus, as assessed by DTI. Use of transthoracic echocardiography, mostly two-dimensional imaging, has been described for several years for the diagnosis of cardiac involvement as well as for the assessment of tumour regression in response to chemotherapy. The present case report highlights the potential utility of other echocardiographic modalities, particularly DTI, for the assessment of cardiac lymphoma but also for monitoring the tumour response to adequate therapy.

Ischemic rupture of the anterolateral papillary muscle

We describe the case of a 59-year-old man who presented with chest pain and ST-segment elevation in the inferior leads, R>S in V1 and ST depression in the anterior leads due to proximal occlusion of the first obtuse marginal. Primary coronary angioplasty and stenting of this artery were performed. Twelve hours later the patient became hemodynamically unstable and severe mitral regurgitation due to rupture of one of the heads of the anterolateral papillary muscle was diagnosed. Emergency surgery was performed (papillary muscle head reimplantation, mitral annuloplasty with a rigid ring, tricuspid annuloplasty and coronary artery bypass grafting). On surgical inspection, it was observed that the detached muscle head had become trapped in the left ventricle by a secondary cord attached to the other head. This case is unusual in presenting two uncommon features of ischemic papillary muscle: rupture of the anterolateral muscle in myocardial infarction involving the inferoposterior walls, and the fact that the ruptured muscle head did not prolapse because it had become trapped in the left ventricle by secondary cord attachment.

Impact of atrial fibrillation type during acute coronary syndromes: Clinical features and prognosis

INTRODUCTION Atrial fibrillation (AF) is widely recognized as an adverse prognostic factor during acute myocardial infarction, although the impact of AF type - new-onset (nAF) or pre-existing (pAF) - is still controversial. OBJECTIVES To identify the clinical differences and prognosis of nAF and pAF during acute coronary syndromes (ACS). METHODS We performed a retrospective observational cohort study including 1373 consecutive patients (mean age 64 years, 77.3% male) admitted to a single center over a three-year period, with a six-month follow-up. RESULTS AF rhythm was identified in 14.5% patients, of whom 71.4% presented nAF and 28.6% pAF. When AF types were compared, patients with nAF more frequently presented with ST-elevation ACS (p=0.003). Patients with pAF, in turn, were older (p=0.032), had greater left atrial diameter (p=0.001) and were less likely to have significant coronary lesions (p=0.034). Regarding therapeutic strategy, nAF patients were more often treated by rhythm control during hospital stay (p<0.001) and were less often anticoagulated at discharge (p=0.001). Compared with the population without AF, nAF was a predictor of death during hospital stay in univariate (p<0.001) and multivariate analysis (OR 2.67, p=0.047), but pAF was not. During follow-up, pAF was associated with higher mortality (p=0.014), while nAF patients presented only a trend towards worse prognosis. CONCLUSIONS AF during the acute phase of ACS appears to have a negative prognostic impact only in patients with nAF and not in those with pAF.

Images in Cardiovascular Medicine Accessory Mitral Valve With Cordal Attachments to Mitral and Aortic Valves An Unusual Cause of Left Ventricular Outflow Tract Obstruction and Both Mitral and Aortic Insufficiencies

doi: 10.1161/CIRCULATIONAHA.111.021030Circulation€2011, 124:e434-e436http://circ.ahajournals.org/content/124/17/e434 located on the World Wide Web at: The online version of this article, along with updated information and services, ishttp://circ.ahajournals.org/content/suppl/2011/10/24/124.17.e434.DC1.htmle introduce the case of a 72-year-old woman referredwith exertional dyspnea and chest pain. On clinicalexamination, a grade III/VI harsh systolic murmur radiatingto the neck was audible. Transthoracic echocardiographyshowed a structure attached to the proximal left ventricularoutflow tract (LVOT) causing significant obstruction (maxi-mum and median gradients of 55 and 33 mm Hg, respec-tively), which led to the initial diagnosis of subaortic mem-brane (Figure 1A and 1B; Movie I in the online-only DataSupplement). Transesophageal echocardiography allowed thevisualization of a mobile structure in the proximal leftventricular outflow tract, with cordal attachments to thesubvalvular mitral apparatus and apparently to an aorticcuspid, conditioning severe mitral and moderate aortic insuf-ficiencies (Figure 1C and 1D; Movie II in the online-onlyData Supplement). These findings were consistent with thediagnosis of accessory mitral valve tissue (AMVT). Coronaryangiography revealed normal coronary arteries. Intraopera-tive three-dimensional echocardiography confirmed the pres-ence of AMVT in the proximal left ventricular outflow tractand better delineated the cordal attachment to the aortic valve(Figure 1E and 1F; Movies III and IV in the online-only DataSupplement).The patient underwent cardiopulmonary bypass. The as-cending aorta was opened and the aortic valve inspected. Theaortic insufficiency was due to cordal tissue coming from theAMVT and attached to the left coronary leaflet (Figure 2A).All the leaflets were thickened with a myxoid appearance.Left atriotomy was performed to directly inspect the mitralvalve.Theaccessorytissuewasattachedtotheanteriorleafletof the mitral valve, and through cords, to both the ventricleand aortic valve (Figure 2B). The tissue was difficult toindividualize from the original valve, and it was not possibleto enucleate all the tissue in security to realize aortic andmitral valve reconstruction. Both the valves and the excesstissue were resected, and 2 bioprosthetic valves wereimplanted.AMVT is a rare congenital cardiac anomaly, in particularin adults, that was first described by Mclean et al.

An Unusual Cause of Aborted Sudden Cardiac Death in a Middle-Aged Female Marathoner

Although most congenital coronary artery anomalies have no prognostic implications, associations with sudden cardiac death have been described, particularly in the young. We report an exercise-associated collapse in an otherwise asymptomatic middle-aged female marathoner. The aborted sudden cardiac death approach revealed an unexpected initial presentation of a malignant anomalous left main coronary artery origin, with ostial stenosis and interarterial course. The present case illustrates an unusually longstanding coexistence of a malignant anatomical variant with a persistent trigger.

0298: Prosthetic valve endocarditis. A 15-years cohort study

Introduction Prosthetic valve endocarditis (PVE) is an uncommon complication after valve replacement surgery, but potentially fatal. The scarcity of clinical trials makes harder the diagnostic and therapeutic approach of this entity. Aim To define the clinical characteristics and in-hospital evolution of a population with PVE. Methods Retrospective study based on a sample of 173 patients (P) with the diagnosis of infective endocarditis (IE), according to the modified Duke criteria, admitted from 1998 to 2013. We analyzed demographic and clinical features, complications and in-hospital mortality of P with PVE. Results We found 34 P (20%) with PVE, mean age 60.2±17.6 years with a female predominance (53%). The most common form was the community-acquired IE, registering 11 P (32%) with health care-associated IE. There was a preferential engagement of the mitral valve (56%) and 26% had early PVE. The cardinal complaints at presentation were constitutional symptoms (97%) and fever (74%); 50% of P showed signs of acute heart failure (HF). The most common analytical abnormalities were elevated inflammatory biomarkers (CRP 94% and leukocytosis 41%), anemia (88%) and increased creatinine (60%). The microbial agent was isolated in 24 P (71%), being Staphylococcus spp (26%) and Streptococcus spp (21%) the most common. The prosthesis dehiscence (60%), severe regurgitation (29%) and perivalvular abscess (21%) were the most frequent complications seen at initial echo-cardiographic evaluation. The most common adverse events were acute kidney injury (74%), persistence of HF (56%), septic shock (15%) and stroke (12%). There was need for urgent referral to surgery in 38% of P. The in-hospital mortality was higher than other P with IE (21% vs 13%). Conclusion The PVE is associated with a poor prognosis at short term. Its adverse developments should lead to the early identification of riskier P and timely consideration of the possible benefit of surgery.

0299: De novo atrial fibrillation in the acute coronary syndrome

Introduction De novo atrial fibrillation (AF) is common in the acute coronary syndrome (ACS), but most patients (P) are discharged in sinus rhythm (SR). The recurrence of arrhythmia in follow-up (FU) remains unknown and its undervaluation may have prognostic impact. Aim To characterize a population with ACS and de novo AF and determine its prognostic impact. To evaluate the recurrence of AF and the incidence of ischemic stroke/systemic embolism in FU. Methods We analyzed 2383 P consecutivelly admitted with ACS and with a minimum of 180 days FU. De novo AF has been defined as AF first detected on admission or during hospitalization. Results It has been observed de novo AF in 199 P (8.4%), the majority being male (70.4%). These patients were significantly older (p The echocardiographic evaluation showed a higher prevalence of mitral insufficiency (p The in-hospital mortality (9.5% vs 3.3%, p 95 patients with de novo AF were followed for a median period of 690 days and it was observed the occurrence of ischemic stroke/systemic embolism in 9 P (9.5%), but only one was under oral anticoagulation. AF occurred in 37.5% of P that were in SR on discharge. Conclusion The presence of de novo AF was associated with increased risk of adverse events, although it may constitute only a marker of severity. We observed recurrence of AF in a considerable sample, which denotes the need for appropriate evaluation of thromboembolic risk of these P.

0125: Observational study on Takotsubo cardiomyopathy

Introduction Takotsubo cardiomyopathy (TC) is a still rarely diagnosed clinical syndrome, which is characterized by transient cardiac dysfunction with reversible wall motion abnormalities. Aim Determine the demographic characteristics, clinical presentation and prognosis of patients with TC. Methods Retrospective study of 39 patients admitted for TC in a cardiology center during a period of 3 years. Results In the population studied, the mean age was 67.15±12.01 years and women were predominant.The most frequent comorbidities were hypertension (76.9%), dyslipidemia (51.3%), psychiatric illness (23.1%) and diabetes mellitus (12.8%). The emotional stress was the most common triggering event (n=10), however, in 17 patients we were not able to identify any precipitating factor. Cardinal symptoms which led to admission, were acute chest pain (n=28) and dyspnoea (n=15). The most common ECG findings were ST segment elevation (n=21), inversion of the T wave (n=21) and QTc prolongation (n=22). All patients had typical wall motion abnormalities in the echocardiography and/or ventriculography. The mean ejection fraction was 35.59±5.54%. The most common in-hospital complication was acute heart failure (n=16, 41%), whereas 3 patients developed cardiogenic shock. The presence of moderate to severe LVS dysfunction ( p =0.048) and higher levels of C reactive protein ( p =0.02) and pBNP ( p =0.042) were associated with the development of acute heart failure. Rhythm disturbances occurred in 3 patients and there was only one non-cardiovascular death. At follow-up at 6 months all patients showed recovery of LVS function; there was one recurrence and 3 deaths from non-cardiovascular causes. Conclusion According to the literature, our review shows higher prevalence of TC in women and a clinical and electrocardiographic presentation similar to the picture of an acute coronary syndrome. In the acute phase, the TC is not necessarily a benign entity, because we observed a high prevalence of acute heart failure.