João Abecasis

Left atrial volume calculated by multi-detector computed tomography may predict successful pulmonary vein isolation in catheter ablation of atrial fibrillation

AIMS Catheter ablation (CA) of atrial fibrillation (AF) might be a definitive curative therapy for selected groups of patients (pts). However, current ablation protocols are not standardized and predictors of CA success and sinus rhythm maintenance are not clearly defined. To evaluate whether left atrium (LA) volume quantification provided by multi-detector computed tomography (MDCT) might predict the success of pulmonary vein (PV) isolation procedure. METHODS AND RESULTS We evaluated 99 pts, 66 male, mean age 54.4 +/- 10.1 years, referred for CA because of drug resistant AF. All pts were submitted to 64-slice MDCT scan for electroanatomic mapping integration, pulmonary veins anatomy delineation, LA thrombi exclusion, and LA volume estimation. Complete isolation of all the PVs was always performed with eventual cavo-tricuspid isthmus ablation. For a mean follow-up period (Fup) of 16.7 +/- 6.6 months, clinical success was assessed after a 3-month blanking period. Anti-arrhythmic drug therapy was discontinued or modified at the clinicians criteria. At the end of the Fup, 29 pts suspended anti-arrhythmic drug therapy and 26% were of oral anticoagulation. Univariate analysis showed that the probability of AF relapse after CA was higher in pts with non-paroxysmal forms of AF. The probability of relapse was significantly higher in pts with LA volumes greater than 100 mL when assessed by MDCT. We found that the LA volume of 145 mL was a good cut-off value for AF recurrence prediction. Patients with LA volumes greater than 145 mL had significantly higher recurrence rates of arrhythmia, even when adjusted for the effect of age, gender, body mass index, hypertension, and type of AF. CONCLUSION Left atrium volume estimated by MDCT may be useful to identify pts in whom successful AF ablation can be achieved with simpler ablation procedures, restricted to PV isolation.

Symptomatic charcoal heart

A 47-year-old woman with a past history of left choroidal malignant melanoma submitted to eye enucleation 13 years before presented to the emergency department because of pleuritic chest pain, shortness of breath, and tiredness. Transthoracic echocardiography revealed pericardial thickening and multiple confluent hypoechoic nodular images, extending into …

Uncommon acquired Gerbode defect following extensive bicuspid aortic valve endocarditis

Gerbode defect is a rare type of left ventricle to right atrium shunt. It is usually congenital in origin, but acquired cases are also described, mainly following infective endocarditis, valve replacement, trauma or acute myocardial infarction. We report a case of a 50-year-old man who suffered an extensive and complex infective endocarditis involving a bicuspid aortic valve, the mitral-aortic intervalvular fibrosa and the anterior leaflet of the mitral valve. After dual valve replacement and annular reconstruction, a shunt between the left ventricle and the right atrium - Gerbode defect, and a severe leak of the mitral prosthesis were detected. Reintervention was performed with successful shunt closure with an autologous pericardial patch and paravalvular leak correction. No major complications occurred denying the immediate post-surgery period and the follow-up at the first year was uneventful.

NT-proBNP na estratificação de risco no tromboembolismo pulmonar

INTRODUCTION Pulmonary embolism (PE) is an entity with high mortality and morbidity, in which risk stratification for adverse events is essential. N-terminal brain natriuretic peptide (NT-proBNP), a right ventricular dysfunction marker, may be useful in assessing the short-term prognosis of patients with PE. AIMS To characterize a sample of patients hospitalized with PE according to NT-proBNP level at hospital admission and to assess the impact of this biomarker on short-term evolution. METHODS We performed a retrospective analysis of consecutive patients admitted with PE over a period of 3.5 years. Based on the median NT-proBNP at hospital admission, patients were divided into two groups (Group 1: NT-proBNP<median and Group 2: NT-proBNP ≥ median). The two groups were compared in terms of demographic characteristics, personal history, clinical presentation, laboratory, electrocardiographic and echocardiographic data, drug therapy, in-hospital course (catecholamine support, invasive ventilation and in-hospital death and the combined endpoint of these events) and 30-day all-cause mortality. A receiver operating characteristic (ROC) curve was constructed to determine the discriminatory power and cut-off value of NT-proBNP for 30-day all-cause mortality. RESULTS Ninety-one patients, mean age 69±16.4 years (51.6% aged ≥75 years), 53.8% male, were analyzed. Of the total sample, 41.8% had no etiological or predisposing factors for PE and most (84.6%) were stratified as intermediate-risk PE. Median NT-proBNP was 2440 pg/ml. Patients in Group 2 were significantly older (74.8±13.2 vs. 62.8±17.2 years, p=0.003) and more had a history of heart failure (35.5% vs. 3.3%, p=0.002) and chronic kidney disease (32.3% vs. 6.7%, p=0.012). They had more tachypnea on initial clinical evaluation (74.2% vs. 44.8, p=0.02), less chest pain (16.1% vs. 46.7%, p=0.01) and higher creatininemia (1.7±0.9 vs. 1.1±0.5mg/dl, p=0.004). Group 2 also more frequently had right chamber dilatation (85.7% vs. 56.7%, p=0.015) and lower left ventricular ejection fraction (56.4±17.6% vs. 66.2±13.5%, p=0.036) on echocardiography. There were no significant differences in drug therapy between the two groups. Regarding the studied endpoints, Group 2 patients needed more catecholamine support (25.8% vs. 6.7%, p=0.044), had higher in-hospital mortality (16.1% vs. 0.0%, p=0.022) and more frequently had the combined endpoint (32.3% vs. 10.0%, p=0.034). All-cause mortality at 30 days was seen only in Group 2 patients (24.1% vs. 0.0%, p=0.034). By ROC curve analysis, NT-proBNP had excellent discriminatory power for this event, with an area under the curve of 0.848. The best NT-proBNP cut-off value was 4740 pg/ml. CONCLUSION Elevated NT-proBNP levels identified PE patients with worse short-term prognosis, and showed excellent power to predict 30-day all-cause mortality. The results of this study may have important clinical implications. The inclusion of NT-proBNP measurement in the initial evaluation of patients with PE can add valuable prognostic information.

Thrombus entrapment: the clue for coronary embolism

A 78-year-old obese and hypertensive female presented to the emergency department with acute chest pain. On physical examination blood pressure was 90/50 mmHg and her heart rate was 110 b.p.s. The electrocardiogram ( Panel A ) was notable for right-axis deviation and ST-segment elevation in DI, aVL and …

Attempting and aborting percutaneous closure of a peculiar atrial septal defect: important contribution of multiple real-time imaging modalities

The case of a 19-year-old female with a neonatal diagnosis of Tetralogy of Fallot and complete atrioventricular (AV) septal defect is described. She had had a corrective surgery at the age of 6. She did well afterwards despite recent complain of fatigability with mild arterial hypoxaemia. Transoesophageal echocardiography depicted a 12 mm atrial septal defect (ASD) with a bidirectional shunt, with features of a defect of the Ostium Primum type. The reason for the bidirectional shunt was unclear, and cardiac catheterization was performed. The presence of an ASD of the Ostium Primum type was confirmed with normal pulmonary arterial pressures and resistances. The distance to the AV valves seemed compatible with the implantation of a small device and percutaneous closure of the ASD was attempted. However, it was noted that the device deployment would cause deviation of the tricuspid regurgitation jet to the left atrium. Direct coronary sinus catheterization demonstrated its direct roof opening to the left atrium. The device impaired the drainage of the coronary sinus, actually increasing the right-to-left shunt (Figure 4). The implantation was aborted and surgical correction was proposed. Coronary sinus septal defect is a rare form of ASD. Its diagnosis is often difficult because of non-specific features. In this case, oxygen desaturation at presentation seemed to be explained by the regurgitating jet of the right component of AV valve through the Ostium primum defect into the left atrium. Percutaneous closure of the defect was attempted. However, it became clear that the device-increased the right-to-left shunt is also allowing the diagnosis of an unroofed coronary sinus. Under these circumstances, surgery seemed to be the best option.

Evaluation of scimitar syndrome by multislice computed tomography.

A 12 YEAR-OLD BOY WAS REFERRED FOR INVESTIgation of a cardiac murmur. The electrocardiogram depicted right axis deviation, showing an increased R to S ratio in V4R, with deep S waves in leads V3R through V3. A chest radiography showed the heart to be predominantly located in the right side of the chest, with the cardiac apex directed to the right, and presence of a crescent-like shadow at the lower right lung, the socalled scimitar sign (Fig. 1). Echocardiography revealed usual atrial arrangement, enlargement of the chambers of the right heart, and anomalous connection of the right pulmonary veins to the inferior caval vein. Computed tomography confirmed the diagnosis. A venous collector, the scimitar vein, was indentified receiving the right pulmonary veins, and shown to drain into the inferior caval vein just below the diaphragm (Figs. 2, 3). At cardiac catheterization, a significant left-to-right shunt was documented,

Understanding cardiac myxoma recurrence: A case report

Recurrence of cardiac myxoma is a rare condition, observed in about 3% of patients in sporadic cases, although it is more frequent in familial ones. Several mechanisms have been proposed to explain such recurrence, and the importance of increased vascularization as a facilitating feature is the subject of debate. The authors report the case of a non-familial right atrial myxoma, unusual for both its histopathology and recurrence.

Rare presentation of sarcoidosis: Multimodal imaging diagnosis of cardiac involvement

We report a case of sarcoidosis with an unusual presentation, initially manifesting as bilateral pulmonary embolism and then as a cardiac form of the disease with an ominous clinical event consisting of sustained ventricular tachycardia. The diagnosis was established by clinical and magnetic resonance criteria despite normal conventional echocardiographic study. Detailed functional assessment provided by tracking techniques (speckle tracking echocardiography and cardiac magnetic resonance tissue tracking) enabled the detection of regional deformation abnormalities, indicating prominent circumferential strain and epicardial layer alterations, partly matching the structural changes depicted by distribution of delayed enhancement. We find this case notable for various issues it raises concerning diagnosis and management of cardiac sarcoidosis. These are mainly related to recent developments in imaging modalities that enable non-invasive identification of structural and functional abnormalities in this condition early, before overt deterioration in left ventricular ejection fraction. Information from different imaging modalities and tools provide information that could potentially assist preclinical diagnosis, with possible prognostic implications.

Um caso de endocardite infecciosa de válvula nativa em doente imunocomprometido

Infective endocarditis continues to be associated with high mortality, despite the medical and surgical therapeutic options available. Surgical intervention is indicated in cases of heart failure or uncontrolled infection and sometimes for the prevention of embolic phenomena. The authors present the case of a 56-year-old male patient, with fibro-calcific mitral-aortic valve disease, splenectomized and with recently relapsed Hodgkins lymphoma, who was admitted with infective endocarditis due to Streptococcus dysgalactiae. On the thirtieth day of directed antibiotic therapy, the mitral vegetation showed a significant increase in size and mobility. Surgery was considered at this point. However, given the patients clinical stability and laboratory results, it was decided to adopt a conservative approach and to extend antibiotic therapy. The vegetation had regressed considerably seven days later. Given this atypical vegetation behavior, with slower than usual regression for the causative agent, the authors suggest that antibiotic therapy should be extended in patients with some degree of immunosuppression.