Isabel Monteiro

Obstructive sleep apnea syndrome: An important piece in the puzzle of cardiovascular risk factors

The obstructive sleep apnea syndrome (OSA) is a clinical entity characterized by recurring episodes of apnea and/or hypopnea during sleep, due to a total or partial collapse, respectively, of the upper airway. This collapse originates a set of pathophysiological changes that determine the appearance of several cardiovascular complications. OSA contributes for the development of hypertension, heart failure, arrhythmias and coronary heart disease. Nowadays it is recognized to be an important public health problem, taking into account not just its repercussions but also its prevalence, since the main risk factor for the disease is obesity, a growing problem worldwide, both in developed and developing countries. The present review summarizes the current knowledge about OSA, as regards its definition, pathophysiology, clinical manifestations, diagnosis, cardiovascular effects and treatment.

Endocardite pneumocócica em válvula aórtica nativa - apresentação fulminante

Pneumococcal endocarditis is a rare entity, corresponding to 1 to 3% of native valve endocarditis cases. It has a typically adverse prognosis, with high mortality. There is a reported predilection for the aortic valve; thus, a common presentation is acute left heart failure. We present a case of a 60-year-old woman with a history of sinusitis, who was admitted with the diagnosis of pneumonia. She rapidly deteriorated with signs of septic shock and was transferred to the critical care unit. The transesophageal echocardiogram revealed severe aortic regurgitation due to valve vegetations. Blood cultures were positive for Streptococcus pneumoniae. She underwent cardiac surgery and had multiple postoperative complications. Nonetheless, the patient made a slow and complete recovery. Infectious endocarditis should be ruled out if any suspicion arises, and echocardiography should be performed in an early stage in patients with poor response to vasopressors and inotropes. Patients with pneumococcal endocarditis benefit from an aggressive approach, with performance of early surgery.

A loud tear — acute aortic regurgitation with an unusual presentation

A 38-year-old man, with no relevant medical history, was admitted to the Emergency Room complaining of a murmur coming from his chest, which was first heard three days before, at night. He also felt more tired than usual, but denied dyspnoea, chest pain, or fever. A few days earlier he had fallen from an utility pole, although he managed to grasp a rope before hitting the ground. On admission, he was calm, haemodynamically stable, and his temperature was normal. The physical examination revealed a grade VI/VI diastolic murmur, discrete pulmonary rales and no peripheral oedema. In transthoracic echocardiogram the presence of a vibratile and filamentous image on the aortic valve and severe aortic regurgitation were noted. His left ventricle (LV) end-diastolic diameter was within normal limits, and he had preserved LV systolic function. A transoesophageal echocardiogram was performed, showing a flail right coronary cusp, with diastolic prolapse into the LV outflow tract and major regurgitation (Fig. 1). There was no elevation of inflammatory markers, serial blood cultures were negative, and a contrast-enhanced chest computed tomography scan revealed a normal aorta. The patient remained haemodynamically stable. He was transferred to a cardiac surgery centre and was submitted to surgery three days after hospital admission. There were multiple fenestrations on the aortic cusps and the right coronary cusp was ruptured and not amenable to repair (Fig. 2). The valve was replaced by a mechanical prosthesis. In the postoperative period he had minor complications only, and the patient was discharged home 12 days after his initial admission. This case represents an unusual presentation of a rare cause of acute valvular disease. Acute aortic regurgitation is usually a consequence of endocarditis, aortic dissection, rupture of a sinus of Valsalva aneurysm, or trauma. Aortic valve cusp fenestrations are commonly noted at pathology examination and during surgery, and according to small studies there is a higher prevalence in men. They may be congenital or an acquired degenerative change associated with age or with chronic hypertension, but their pathophysiology is not fully understood. Fenestrations are characteristically located between the line of closure and the free edge of the cusp, but they may extend from the region of the commissures to the nodule of Arantius. They are not usually associated with regurgitation because they are normally found distal to the line of closure. In this case, we assume the reported accident caused a rupture of one of the fenestrations, which extended beyond the line of closure or was unusually placed at the commissure, leading to a surprisingly well tolerated acute severe regurgitation. Acute aortic regurgitation is better tolerated in younger patients but, if untreated, is associated with significant morbidity and mortality. Surgery should not be delayed in this context. Intraoperative pathologic examination provides an insight into the mechanisms of this unusual disease.

Multiple Thrombi in the Inferior Vena Cava and Right Atrium – Recurrent Thromboembolism Due to Polycythemia Vera

Mailing Address: Kevin Domingues • Avenida Bernardo Santareno. CEP 2005-177, Santarém – Portugal E-mail: kev.domingues@gmail.com Manuscript received January 16, 2016; revised manuscript March 01, 2016; accepted March 01, 2016 Thromboembolic events are a major cause of morbidity in patients with polycythemia vera (PV), accounting for a third of the deaths in this population. PV is a clonal disorder in which disturbed hematopoiesis leads to increased erythropoiesis, myelopoiesis, and/or megakaryopoiesis, characterizing this disorder as a prothrombotic state.

Linfoma primário do coração em doente com neoplasia renal síncrona

Primary cardiac lymphoma is defined as non-Hodgkin lymphoma involving the heart and/or pericardium. It is a rare cancer that primarily affects the right heart and in particular the right atrium. By contrast, renal cell carcinoma is a relatively common cancer, which in rare circumstances can metastasize to the heart. It is now known that there is an association between non-Hodgkin lymphoma and renal cell carcinoma, although the underlying mechanisms are not fully understood. The authors present a case of primary cardiac non-Hodgkin lymphoma in a patient with concomitant renal cell carcinoma and explore the possible reasons for this association.

Excesso de fator VIII em doente com síndroma coronária aguda

Factor VIII is a clotting factor that plays a crucial role in the coagulation cascade. Above-normal levels are found in 11% of the general adult population. Various studies have established a causal association between elevated factor VIII and venous thrombosis; some studies also suggest a relation with arterial thrombosis, particularly myocardial infarction and stroke. We report the case of a 36-year-old man with obesity, smoking and dyslipidemia as cardiovascular risk factors and a history of acute myocardial infarction at age 26. He was admitted to the coronary care unit with a diagnosis of ST-elevation myocardial infarction. Coronary angiography showed a thrombus in the distal segment of the first obtuse marginal artery, which was causing the obstruction. The thrombus was aspirated but there was no reflow. A coagulation study revealed elevated factor VIII; other parameters were normal. Even though this patient presented several cardiovascular risk factors, we highlight the need for more studies on the effect of elevated factor VIII on thrombus formation leading to acute coronary syndrome. Another important question is the use of oral anticoagulation in these patients as an integral part of the management of acute coronary syndrome.

Um caso assintomático de uma aurícula esquerda gigante

A 59-year-old woman, an agricultural worker, came to the emergency department (ED) due to fever and odynophagia. She had an irregular pulse, a predominantly apical systolicdiastolic murmur on cardiac auscultation, reduced bilateral breath sounds on pulmonary auscultation, dullness on dorsal percussion of the thorax and mild peripheral edema. The ECG revealed atrial fibrillation at 93 bpm. The chest X-ray showed marked cardiomegaly (cardiothoracic ratio 0.92) and splaying of the carina and of the main bronchi (Figure 1). Echocardiography revealed a giant left atrium (GLA), with an anteroposterior diameter of 10.5 cm and a volume indexed to body surface area of 1054 ml/m (Figure 2 and Video 1); dome-shaped mitral valve, suggesting a rheumatic etiology (Video 2), with severe regurgitation and stenosis; and severe tricuspid regurgitation, with pulmonary artery systolic pressure of 74 mmHg. The patient refused further intervention and follow-up. A year later, after coming to the ED for a hand injury, she returned to work and continued to refuse treatment. GLA is defined as a left atrium with an anteroposterior diameter of ≥8 cm on echocardiography or reaching the right lateral side of the chest wall on X-ray. It is associated with rheumatic mitral valve disease, in particular with severe mitral regurgitation, and it thus rarely asymptomatic. Symptoms occur due to the underlying valve disease, but