Inês Cruz

Controlled pericardiocentesis in patients with cardiac tamponade complicating aortic dissection: Experience of a centre without cardiothoracic surgery

Background: Cardiac tamponade has been reported in 18.7% of patients with acute type A aortic dissection and its presence is associated with worse outcomes. Emergency aortic repair together with intra-operative pericardial drainage is the recommended treatment approach. However, controversy surrounds how to manage patients with haemopericardium and cardiac tamponade who cannot survive until surgery. Purpose: To describe a case series of patients with critical cardiac tamponade complicating aortic dissection admitted to a hospital without cardiothoracic surgery, and in whom preoperative controlled pericardial drainage was performed. Methods and results: Single centre retrospective study: during a nine-year period, 21 patients with Stanford type A aortic dissection were admitted at our centre; six of them (28.6%) presented clinical and echocardiographic signs of cardiac tamponade (four males; mean age 58±17 years). In this subgroup, controlled pericardiocentesis was safely performed with no major immediate complications and it was effective in five patients, improving haemodynamic instability and allowing transfer to the operating room. Conclusions: Preoperative controlled pericardiocentesis can be lifesaving when managing patients with critical cardiac tamponade (pulseless electrical activity or refractory hypotension) complicating acute type A aortic dissection, namely when cardiac surgery is not immediately available.

Is the time in therapeutic range using the ratio of tests equivalent to the Rosendaal method

The percentage of time in therapeutic range (TTR) is a measure of anticoagulation quality with vitamin K antagonists (VKAs). The method most commonly used in clinical trials is the Rosendaal TTR. However, the application of this method in daily practice for clinical decision lacks appropriate instruments. We aimed to evaluate the percentage of tests within the target international normalized ratio (INR) (tests ratio) as a surrogate of Rosendaal TTR. We performed an observational and retrospective study to evaluate the TTR according to the Rosendaal method and tests ratio. We included all outpatients who attended the cardiology anticoagulation clinic of a Portuguese hospital (2011–2013), whose target INR was 2.0–3.0. Three hundred and seventy-seven VKA-treated patients followed for a mean 1.3 years were evaluated. Rosendaal methold and tests ratio significantly correlated (Rho Spearman 0.88, P < 0.001), but the Bland–Altman plot evaluation showed a clinically relevant data dispersion [95% confidence interval (95% CI) –12.9 to 23.1] around a mean difference in TTR -5.1% using the tests ratio method. The linear regression Passing-Bablok confirmed the existence of significant data dispersion and systematic differences. The tests ratio less than 60% had a sensitivity of 91.6%, specificity of 72.3%, positive predictive value (PPV) of 72.2% and negative predictive value (NPV) of 91.6%, for the diagnosis of patients inadequately anticoagulated (Rosendaal TTR <60%). Tests ratio had a c-statistics of 0.94 (95% CI 0.91–0.96). Number of tests in 6 months had a c-statistics of 0.70 (95% CI 0.65–0.75). Tests ratio underestimated TTR in 5% and was not considered equivalent to Rosendaal TTR due to the high variability between methods. Nevertheless, the use of tests ratio less than 60% may be a reasonable option to detect inadequate anticoagulation, as it is a sensitive method and excluded most of the patients with adequate control.

Clinical applications of exercise stress echocardiography in the treadmill with upright evaluation during and after exercise.

Exercise stress echocardiography is the most frequently used stress test in our laboratory. Exercise echocardiography is used mainly in the study of patients with coronary artery disease. However, the technique is increasingly being used to study other diseases.In our centre, we use an original methodology, published by us in 2000, in which we evaluate heart function during exercise in the treadmill. After the exercise, patients are maintained in orthostatic position when appropriate or lying down in left lateral decubitus for further evaluation. Since this method seems to increase the quality and the quantity of information obtained in so many clinical arenas, we now present a detailed review of this methodology and its applications.

Tratamiento con dosis fija de tiroxina en gestantes con hipotiroidismo subclínico

BACKGROUND Hypothyroidism is usually treated with thyroxine doses on patient weight. In some cases, however, fixed doses have proved to useful to normalize TSH levels, which is especially important during pregnancy. PATIENTS AND METHODS Sixty-eight women diagnosed with subclinical hypothyroidism, autoimmune or not, during pregnancy were given a fixed dose of thyroxine 50 mcg/day. TSH measurements were performed to assess the need to change the dose, which was increased or decreased by 25 mcg/day when necessary. RESULTS With a dose of 50 mcg/day of thyroxine, 42% of patients reached a TSH level less than 3 μU/mL, 79.4% reached a TSH level less than 4.5 μU/mL, and 20.6% had TSH levels higher than 4.5 μU/mL. DISCUSSION Our data suggest that a fixed dose of thyroxine 50 mcg/day is inadequate in a significant proportion of pregnancy-diagnosed hypothyroidism regardless of whether the reference of TSH level used is 4.5 or 3 μU/mL. S starting dose of 75 mcg/day is probably more adequate, but studies are needed to evaluate the possibility of overtreatment with such dose.

Value of cardiovascular magnetic resonance in patients with suspected inflammatory pericarditis

Background Although the diagnosis of inflammatory pericarditis is usually presumed on a combination of clinical signs and noninvasive testing, especially echocardiography, the presence and extent of pericardial inflammation as such cannot be visualized. Alternatively cardiovascular magnetic resonance imaging (CMR) has shown appealing to study the pathologic pericardium. In this study we sought to explore the findings and the diagnostic value of cardiovascular magnetic resonance imaging (CMR) in patients with clinically suspected inflammatory pericarditis.

Um caso de tromboembolismo pulmonar e dissecção aórtica: importância do ecocardiograma

Please cite this article as: Cruz I, et al. Um caso de tromboembolismo pulmonar e dissecção aórtica: importância do ecocardiograma. Rev Port Cardiol. 2013. http://dx.doi.org/10.1016/j.repc.2012.12.010. ∗ Corresponding author. E-mail address: inesmariarosariocruz@gmail.com (I. Cruz). exertion, pain and edema in the right leg and muscle weakness in both legs rendering her unable to walk, over the previous two weeks. On physical examination she was cooperative, with blood pressure 100/40 mmHg, heart rate 70 bpm, good peripheral pulses, crackling rales in the lung bases, and flaccid

Left ventricular thrombus in repaired Tetralogy of Fallot

We present a 48 year-old female patient with a previous history of Tetralogy of Fallot submitted to surgical repair at 18 years old. Recent echocardiograms were remarkable for the absence of residual interventricular communication, a good left ventricular systolic function withoutregionalwallmotionabnormalities,andamoderatepulmonary regurgitation. Thepatientwasadmittedtotheemergencyroomwithsuddenonset dyspnea without any triggering, worsening or relief factor, accompanied by palpitations. There were no other symptoms such angina, syncope or lower limb edema. The patient had adequate blood pressure, and the physical examination was only remarkable for a tachycardia.

PW043 Predictors of outcome in takotsubo cardiomyopathy – a multicenter study

quences and detection of late gadolinium enhancement (LGE) which was used as a marker of early myocardial involvement. Results: Six (14%) patients had LGE, mainly involving apical, mid-basal inferoseptal and basal inferolateral segments. The presence of LGE was significantly higher in the group who had electrocardiographic abnormalities (29% vs. 4%, p <0.05). Of these 6 patients, 3 had regional wall motion abnormalities (2 with isolated apical dyskinesis and 1 with lateral hypokinesis). Only one patient showed oedema on STIR sequences suggestive of active inflammatory activity. With CMR as the method of reference, the ECG had a sensitivity of 83% and a negative predictive value of 96% to detect CCM. Conclusion: ECG proves to be a useful, inexpensive and globally available tool for the screening of CCM in asymptomatic patients but with proven myocardial involvement in the CRM.

El lavado de la aguja aumenta la rentabilidad diagnóstica de la punción-aspiración con aguja fina de tiroides

Background and objective Nodular thyroid disease is a common condition in our clinical practice, and fine needle aspiration biopsy (FNAB) is the diagnostic procedure of choice. Its main limitation is the number of non-diagnostic samples. Since the Bethesda criteria were implemented in 2007 (a consensus document on the morphologic criteria and diagnostic terminology for interpretation of thyroid cytological samples), a higher prevalence of non-diagnostic FNAB was shown. In addition to the standard technique, we decided to collect and centrifuge the material remaining in puncture needles by washing them in a ThinPrep® solution, and to assess the increase in the diagnostic yield of FNAB after this change.BACKGROUND AND OBJECTIVE Nodular thyroid disease is a common condition in our clinical practice, and fine needle aspiration biopsy (FNAB) is the diagnostic procedure of choice. Its main limitation is the number of non-diagnostic samples. Since the Bethesda criteria were implemented in 2007 (a consensus document on the morphologic criteria and diagnostic terminology for interpretation of thyroid cytological samples), a higher prevalence of non-diagnostic FNAB was shown. In addition to the standard technique, we decided to collect and centrifuge the material remaining in puncture needles by washing them in a ThinPrep(®) solution, and to assess the increase in the diagnostic yield of FNAB after this change. PATIENTS AND METHODS Systematic sampling of 168 patients who underwent FNAB at the Nutrition and Endocrinology Department of the Xeral-Cies Hospital (Vigo, Spain) from January 2010 to November 2011. Patients were classified into 2 groups: 75 patients in whom the residual material in the needle was not collected (non-washing group) and 93 patients in whom the material was collected (washing-group). All FNABs were performed by the same endocrinologist. Data are shown as percentage (± standard error) for ordinal variables or as mean (± standard deviation) for quantitative variables. A Chi-square test was used for statistical analysis of comparisons between percentages, and a Students t test for comparisons between quantitative variables. A value of p<0.05 was considered statistically significant. RESULTS No significant differences were found between the groups in age, sex, plasma TSH levels or nodule size. The rate of non-diagnostic FNABs was 44% (± 0.06) in the non-washing group and 17.2% (± 0.04%) in the washing group, with a significant difference (p < 0.01). DISCUSSION Collection and subsequent processing of the residual material in the needle after FNAB significantly decreased the prevalence of non-diagnostic punctures in our patients. Collection of the residual material in the needle in this way is strongly recommended.

OriginalEl lavado de la aguja aumenta la rentabilidad diagnóstica de la punción-aspiración con aguja fina de tiroidesNeedle washing increases the diagnostic yield of fine needle aspiration biopsy of the thyroid gland

Background and objective Nodular thyroid disease is a common condition in our clinical practice, and fine needle aspiration biopsy (FNAB) is the diagnostic procedure of choice. Its main limitation is the number of non-diagnostic samples. Since the Bethesda criteria were implemented in 2007 (a consensus document on the morphologic criteria and diagnostic terminology for interpretation of thyroid cytological samples), a higher prevalence of non-diagnostic FNAB was shown. In addition to the standard technique, we decided to collect and centrifuge the material remaining in puncture needles by washing them in a ThinPrep® solution, and to assess the increase in the diagnostic yield of FNAB after this change.BACKGROUND AND OBJECTIVE Nodular thyroid disease is a common condition in our clinical practice, and fine needle aspiration biopsy (FNAB) is the diagnostic procedure of choice. Its main limitation is the number of non-diagnostic samples. Since the Bethesda criteria were implemented in 2007 (a consensus document on the morphologic criteria and diagnostic terminology for interpretation of thyroid cytological samples), a higher prevalence of non-diagnostic FNAB was shown. In addition to the standard technique, we decided to collect and centrifuge the material remaining in puncture needles by washing them in a ThinPrep(®) solution, and to assess the increase in the diagnostic yield of FNAB after this change. PATIENTS AND METHODS Systematic sampling of 168 patients who underwent FNAB at the Nutrition and Endocrinology Department of the Xeral-Cies Hospital (Vigo, Spain) from January 2010 to November 2011. Patients were classified into 2 groups: 75 patients in whom the residual material in the needle was not collected (non-washing group) and 93 patients in whom the material was collected (washing-group). All FNABs were performed by the same endocrinologist. Data are shown as percentage (± standard error) for ordinal variables or as mean (± standard deviation) for quantitative variables. A Chi-square test was used for statistical analysis of comparisons between percentages, and a Students t test for comparisons between quantitative variables. A value of p<0.05 was considered statistically significant. RESULTS No significant differences were found between the groups in age, sex, plasma TSH levels or nodule size. The rate of non-diagnostic FNABs was 44% (± 0.06) in the non-washing group and 17.2% (± 0.04%) in the washing group, with a significant difference (p < 0.01). DISCUSSION Collection and subsequent processing of the residual material in the needle after FNAB significantly decreased the prevalence of non-diagnostic punctures in our patients. Collection of the residual material in the needle in this way is strongly recommended.