David Pamplona

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

A case of a young patient, heavy drinker, who suffered an acute myocardial infarction (AMI), and whose cinecoronariography, early post unsuccessful intravenous thrombolysis, showed the presence of thrombi in multiple arteries is reported. A second cinecoronariography performed on the 7th day post AMI revealed normal coronary arteries. There were no plasmatic lipid or coagulation abnormalities, nor other risk factors for coronary artery disease. We speculate about the role of the heavy alcohol ingestion in this particular case.

Antagonism of the acute hemodynamic effects of captopril in decompensated congestive heart failure by aspirin administration

The concomitant use of angiotensin-converting enzyme inhibitors and aspirin may cause pharmacological antagonism. Hence we examined the effect of aspirin on the neurohormonal function and hemodynamic response to captopril in heart failure patients. Between April 1999 and August 2000, 40 patients were randomized into four equal groups: 1) captopril, 2) aspirin, 3) captopril-aspirin: captopril was given alone on the first day, followed by aspirin on the remaining days, and 4) aspirin-captopril: aspirin was given alone on the first day, followed by captopril on the remaining days. Hemodynamic, norepinephrine and prostaglandin measurements were performed pre- and post-medication for 4 days. Captopril (50 mg) was given orally every 8 h and 300 mg aspirin was given on the first day, and 100 mg/day thereafter. In the captopril group and only on the first day of captopril-aspirin, captopril produced increases in cardiac index (2.1 +/- 0.6 to 2.5 +/- 0.5 l min-1 m-2, P<0.0001), and reduced peripheral vascular resistance (1980 +/- 580 to 1545 +/- 506 dyn s-1 cm-5/m , P<0.0001) and pulmonary wedge pressure (20 +/- 4 to 15 +/- 4 mmHg, P<0.0001). In contrast, aspirin alone or associated with captopril showed no significant hemodynamic changes. Norepinephrine decreased (P<0.02) only in the captopril group. Prostaglandin levels did not differ significantly among groups. Thus, aspirin compromises the short-term hemodynamic and neurohormonal effects of captopril in patients with acute decompensated heart failure.

Infecção de prótese vascular em cirurgia da aorta torácica: revisão da experiência e relato de caso tratado por técnica não convencional

We report the case of a 37-year-old-female patient who had undergone a Bentall procedure at our service and returned with intense chest pain and acute aortic dissection type III, which was diagnosed and clinically treated. One year after this episode, this dissection expanded, and the patient underwent surgery with interposition of a Dacron graft in the descending aorta. In the immediate postoperative period, the patient experienced left bronchopneumonia and was discharged afebrile and in good condition. One month after discharge, she returned with fever and toxemia. Pleural empyema was diagnosed, and she underwent an exploratory thoracotomy that did not confirm this diagnosis, but revealed intense effusion thickening. Four months after the exploratory thoracotomy, Klebsiella pneumoniae and Enterobacter sp were isolated in a blood culture. Magnetic resonance imaging revealed shapes compatible with perigraft infection. With this clinical and laboratory picture, graft removal was indicated as was axillo-bifemoral grafting. Surgery was successfully performed, the patient was discharged in good condition, and remains well after a 57-month follow-up without complications. The methods used for diagnosis and treatment of prosthesis infection in thoracic aorta surgery are discussed.

Coronary Steal due to Collateral Circulation from Circumflex Coronary to Right Pulmonary Artery Leading to Unstable Angina in Takayasu's Arteritis

Mulher de 63 anos com arterite de Takayasu, envolvendo arco aortico, arterias subclavias e arteria pulmonar direita, com dor precordial progressiva. O eletrocardiograma de esforco revelou depressao do segmento ST. A cineangiocoronariografia nao mostrou lesoes estenoticas ostiais e nem epicardicas e, sim, comunicacao entre a arteria coronaria circunflexa e o ramo do lobo superior da arteria pulmonar direita. O fluxo sanguineo atraves da comunicacao arterial foi considerado de grau importante, provocando, provavelmente, sindrome do roubo de fluxo coronario e, consequentemente, o quadro de angina de peito com carater progressivo.A sixty three year old woman suffering fromTakayasu’s arteritis with involvement of the aortic arch,subclavia arteries and occlusion of the right pulmonaryartery, developed progressive precordial pain. Exerciseelectrocardiogram disclosed ST segment depression.Coronary arteriograms demonstrated no coronarystenosis, but collateral circulation arising from circumflexcoronary artery to right pulmonary artery. The collateralblood flow was considered to be of great importance, andcausing the coronary steal syndrome, leading to anginapectoris.Mulher de 63 anos com arterite de Takayasu, envol-vendo arco aortico, arterias subclavias e arteria pulmo-nar direita, com dor precordial progressiva. Oeletrocardiograma de esforco revelou depressao do seg-mento ST. A cineangiocoronariografia nao mostrou le-soes estenoticas ostiais e nem epicardicas e, sim, comuni-cacao entre a arteria coronaria circunflexa e o ramo dolobo superior da arteria pulmonar direita. O fluxosanguineo atraves da comunicacao arterial foi conside-rado de grau importante, provocando, provavelmente,sindrome do roubo de fluxo coronario e, consequentemen-te, o quadro de angina de peito com carater progressivo.A sixty three year old woman suffering from Takayasus arteritis with involvement of the aortic arch, subclavia arteries and occlusion of the right pulmonary artery, developed progressive precordial pain. Exercise electrocardiogram disclosed ST segment depression. Coronary arteriograms demonstrated no coronary stenosis, but collateral circulation arising from circumflex coronary artery to right pulmonary artery. The collateral blood flow was considered to be of great importance, and causing the coronary steal syndrome, leading to angina pectoris.

Does a circadian variation occur in myocardial ischemia over 48 hours in patients with unstable angina

OBJECTIVE To study the incidence of and variation in myocardial ischemia over 48 hours in patients with unstable angina. METHODS Thirty-nine patients with unstable angina underwent long-term electrocardiography for 48 hours. The number of events and the period of time of ischemia (in minutes) were analyzed for the 48 hours, in two periods of 24 hours, and in periods of 4 hours. RESULTS We analyzed 1755.8 hours of monitoring tapes, and ischemic episodes were detected in 18 (46.2%) patients, corresponding to 173 ischemic episodes, allowing the evaluation of 1304 minutes of ischemia.only 4 of which were (2.2%) symptomatic, Considering the entire period of time of recording and the predetermined time intervals, we observed a higher number of ischemic episodes (38) and a longer duration of ischemia (315.4 minutes) between 11:00 am and 3:00 pm. However, no significant differences occurred among the values in the different intervals. CONCLUSION Long-term electrocardiography over 48 hours showed a high incidence (97.8%) of silent ischemic episodes in patients with unstable angina. No evidence of a circadian variation of myocardial ischemia in unstable angina was observed.