Odilson Marcos Silvestre

Stress-induced cardiomyopathy (takotsubo cardiomyopathy) after liver transplantation-report of two cases.

Cardiac complications after liver transplantation are a common cause of death. Stress-induced cardiomyopathy, also called takotsubo cardiomyopathy, is a special form of cardiomyopathy that is precipitated by a stress situation. It can occur after a surgical procedure that results in acute heart failure. Herein we have presented 2 cases of reversible stress-induced cardiac dysfunction early in the period after liver transplantation. Before surgery, cardiac evaluation was normal, with both patients classified as low risk for cardiovascular events during the proposed procedure. Both patients experienced cardiac arrest after graft reperfusion with return of spontaneous circulation after resuscitation. Their early periods after transplantation were characterized by cardiogenic shock secondary to important ventricular dysfunction requiring vasoactive drugs. Subsequent investigations excluded coronary disease. The diagnosis of takotsubo cardiomyopathy was established based on the clinical features and ancillary tests, particularly echocardiography showing apical ballooning. In both cases, ventricular function recovered completely. In conclusion, stress-induced cardiomyopathy, an underestimated cause of heart complications, should be considered as a possible cause of cardiac failure in liver transplant patients.

Heart transplantation: review

ABSTRACT Heart transplantation is currently the definitive gold standard surgical approach in the treatment of refractory heart failure. However, the shortage of donors limits the achievement of a greater number of heart transplants, in which the use of mechanical circulatory support devices is increasing. With well-established indications and contraindications, as well as diagnosis and treatment of rejection through defined protocols of immunosuppression, the outcomes of heart transplantation are very favorable. Among early complications that can impact survival are primary graft failure, right ventricular dysfunction, rejection, and infections, whereas late complications include cardiac allograft vasculopathy and neoplasms. Despite the difficulties for heart transplantation, in particular, the shortage of donors and high mortality while on the waiting list, in Brazil, there is a great potential for both increasing effective donors and using circulatory assist devices, which can positively impact the number and outcomes of heart transplants.

Serum B-type natriuretic peptide in the initial workup of patients with new onset ascites: A diagnostic accuracy study

Heart failure (HF) is, after cirrhosis, the second‐most common cause of ascites. Serum B‐type natriuretic peptide (BNP) plays an important role in the diagnosis of HF. Therefore, we hypothesized that BNP would be useful in the differential diagnosis of ascites. Consecutive patients with new onset ascites were prospectively enrolled in this cross‐sectional study. All patients had measurements of serum‐ascites albumin gradient (SAAG), total protein concentration in ascitic fluid, serum, and ascites BNP. We enrolled 218 consecutive patients with ascites resulting from HF (n = 44), cirrhosis (n = 162), peritoneal disease (n = 10), and constrictive pericarditis (n = 2). Compared to SAAG and/or total protein concentration in ascites, the test that best discriminated HF‐related ascites from other causes of ascites was serum BNP. A cutoff of >364 pg/mL (sensitivity 98%, specificity 99%, and diagnostic accuracy 99%) had the highest positive likelihood ratio (168.1); that is, it was the best to rule in HF‐related ascites. Conversely, a cutoff ≤182 pg/mL had the lowest negative likelihood ratio (0.0) and was the best to rule out HF‐related ascites. These findings were confirmed in a 60‐patient validation cohort. Conclusions: Serum BNP is more accurate than ascites analyses in the diagnosis of HF‐related ascites. The workup of patients with new onset ascites could be streamlined by obtaining serum BNP as an initial test and could forego the need for diagnostic paracentesis, particularly in cases where the cause of ascites is uncertain and/or could be the result of HF. (Hepatology 2014;59:1043–1051)

Comparação entre BNP e NT-proBNP quanto à concordância e quanto à influência das variáveis clínicas e laboratoriais

OBJETIVO: Correlacionar os niveis sericos do peptideo natriuretico tipo B e da fracao N-terminal do pro-peptideo natriuretico tipo B, alem de analisar a influencia de idade, obesidade, insuficiencia renal, fracao da ejecao do ventriculo esquerdo, disfuncao diastolica e anemia nos niveis sericos de ambos os marcadores. METODOS: Estudo observacional, no qual se comparou a concordância entre esses marcadores em amostras consecutivas de 138 pacientes. Para a correlacao, utilizou-se o teste de Pearson e foi considerado estatisticamente significante p<0,05. RESULTADOS: Observou-se associacao linear entre peptideo natriuretico tipo B e fracao N-terminal do pro-peptideo natriuretico tipo B (r=0,907; p<0,001). Ao se avaliarem as medidas categorizadas como normais e alteradas, encontrou-se boa concordância, com 90,6% de classificacoes concordantes (p<0,001), sendo que valores alterados da fracao N-terminal do pro-peptideo natriuretico tipo B e normais de peptideo natriuretico tipo B representaram 8,7% do total, e o contrario representou 1% do total. A avaliacao da influencia dos fatores clinicos e laboratoriais nos niveis dos peptideos natriureticos mostrou que eles se elevam de acordo com a idade, mas que diminuem conforme aumenta a fracao de ejecao. Pacientes com anemia (p<0,001) ou com insuficiencia renal (p=0,007) apresentaram valores maiores de ambos os marcadores. Nao houve associacao entre obesidade e peptideo natriuretico tipo B. CONCLUSAO: Houve concordância satisfatoria entre peptideo natriuretico tipo B e a fracao N-terminal do pro-peptideo natriuretico tipo B. Idade, niveis de creatinina e hemoglobina, assim como funcao ventricular, influenciam os niveis sericos de ambos os peptideos natriureticos.ABSTRACT Objective: To correlate the serum levels of B type natriuretic peptide and the N-terminal fraction of the pro-B type natriuretic peptide, as well as to analyze the influence of age, obesity, renal failure, left ventricle ejection fraction, diastolic dysfunction, and anemia on serum levels of both markers. Methods: An observational study in which the agreement was compared between these markers in consecutive samples of 138 patients. For the correlation, Pearsons test was used, and p<0.05 was considered statistically significant. Results: A linear association was observed between the B type natriuretic peptide and N-terminal fraction of the pro-B type natriuretic peptide (r = 0.907; p<0.001). When evaluating the categorized measurements as normal and altered, there was good agreement, with 90.6% of agreement classifications (p<0.001) in which altered values of the N-terminal fraction of the pro-B type natriuretic peptide and normal values of the B type natriuretic peptide represented 8.7% of the total; the opposite situation represented 1% of the total. Assessment of the influence of the clinical and laboratorial factors on the levels of natriuretic peptides showed that they rise according to age, but that they fall as the ejection fraction increases. Patients with anemia (p<0.001) or with renal failure (p=0.007) had higher values of both markers. There was no association between obesity and the B type natriuretic peptide. Conclusion: There was satisfactory agreement between the B type natriuretic peptide and the N-terminal fraction of the pro-B type natriuretic peptide. Age, creatinine levels, and hemoglobin, as well as ventricular function, influence the serum levels of both natriuretic peptides.

Temporal trends in the contribution of Chagas cardiomyopathy to mortality among patients with heart failure

Background Chagas cardiomyopathy (ChC) prevalence is decreasing in Brazil and medical therapies for heart failure (HF) have improved in the last decade. Whether these changes modified the prognosis of ChC relative to non-Chagas cardiomyopathies (NChC) remains unknown. This study evaluated the temporal trends in population attributable risk (PAR) of ChC for 2-year mortality among patients with HF enrolled at years 2002–2004 (era 1) and 2012–2014 (era 2) in a Brazilian university hospital. Methods We prospectively studied 362 (15% with ChC) and 582 (18% with ChC) HF patients with ejection fraction ≤50% in eras 1 and 2, respectively and estimated the PAR of ChC for 2-year mortality. Results There were 145 deaths (29 in ChC) in era 1 and 85 deaths (26 in ChC) in era 2. In multivariable Cox-regression analysis adjusted for age, sex, ejection fraction, heart rate, body mass index, hypertension, diabetes mellitus, systolic blood pressure and ischaemic/valvar aetiology, ChC was associated with higher risk of death in era 1 (HR (95% CI)=1.92 (1.00 to 3.71), p=0.05) and era 2 (HR (95% CI)=3.51 (1.94 to 6.36), p<0.001). In fully adjusted analysis, the PAR of ChC for mortality increased twofold from era 1 (PAR (95% CI)=11.0 (2.8 to 18.5)%) to era 2 (PAR (95% CI)=21.9 (16.5 to 26.9)%; p=0.023 versus era 1). Conclusion Although the absolute death rates decreased over time in the ChC and NChC groups, the PAR of ChC for mortality increased among patients with HF, driven by increases in the HR associated with ChC. Our results highlight the need for additional efforts aiming to prevent and treat ChC.

Artéria coronária direita anômala com origem na artéria pulmonar e pericardite constritiva: uma associação inusitada

ABSTRACT The association of anomalous right coronary artery originating from the pulmonary artery and constrictive pericarditis has never been showed in the literature. We present the first case of this unusual association in a patient with right heart failure. After diagnosis, the patient was referred to surgery and underwent phrenic-to-phrenic pericardiectomy; graft implant of right internal thoracic artery to right coronary artery; and ligation of the anomalous origin of the right coronary artery from the pulmonary artery. Such procedures solved the potential risk of sudden death related to anomalous right coronary artery originating from the pulmonary artery and alleviated the symptoms of heart failure caused by constrictive pericarditis.

Angiogenesis between coronary grafts through the aortic wall.

Following a total coronary occlusion, residual perfusion to the myocardium persists through native coronary collateral channels. Provided that they are of adequate size, collateral circulation may protect against myocardial infarction and death [1]. However, there is tremendous individual variability in the function of those neovascularizations among patients with chronic stenosis. Thus, the detailed mechanism of collateral artery growth is still unknown in the human adult. This report describes a case of a 61-year-old man that was admitted with progressive angina (CCS III on admission) for the last 3 months. He had a previous history of hypertension, dyslipidemia and insulindependent diabetes and two surgical myocardial revascularizations performed 14 and 8 years prior to admission. Medications taken on a daily basis included atenolol, amlodipine, trimetazidine, propatylnitrate, atorvastatin, metformin and insulin. Tc-Sestamibi Scintigraphy demonstrated irreversible defect of basal-inferior wall and moderate reversible defect of anterior-apical wall, along with reduced ventricular function during exercise. Coronary angiography showed occlusion of native vessels, pervious left internal mammary graft to a marginal branch and collateral circulation (CC) grade III to right coronary artery. Moreover, there was an ostial occlusion of a free right internal thoracic artery graft (RITA) to left anterior descending artery, which had a delayed filling through CC from a saphenous vein graft (SVG) to a

Diretriz Brasileira de Insuficiência Cardíaca Crônica e Aguda

Parte 1: Diretriz Brasileira de Insuficiencia Cardiaca Cronica […] Diretriz Brasileira de Insuficiencia Cardiaca Cronica e Aguda

Cardiac dysfunction related to cirrhosis

Dear Editor, A systematic review of Mota and Markman Filho1 demonstrates that Doppler echocardiography is indicated in cases of cirrhosis, for investigation of pulmonary and vascular complications of cirrhotic cardiomyopathy. We agree that this test may show cardiac abnormalities related to cirrhosis. In our experience, 184 patients prospectively evaluated showed structural cardiac abnormalities at rest, which correlated with the severity of cirrhosis2. However, the presence of these abnormalities is not sufficient to characterize cirrhotic cardiomyopathy. The criteria for diagnosis are not yet established or validated internationally. Clinical manifestations occur in conditions of stress. At rest, the heart is functionally normal. Hence, Doppler echocardiography at rest is often insufficient to characterize cirrhotic cardiomyopathy.

Case 5: 50-year-old woman with restrictive cardiomyopathy, renal failure and proteinuria

Section Edition: Alfredo José Mansur (ajmansur@incor.usp.br) Associated Editors: Desidério Favarato (dclfavarato@incor.usp.br) Vera Demarchi Aiello (anpvera@incor.usp.br) Woman with 50 years of age, born in Pernambuco, coming from São Paulo, sought medical assistance due to dyspnea caused by minor stress. Four months ago, the patient presented signs of dyspnea caused by moderate effort, which 2 month ago progressed to minimum effortand orthopnea. The patient also presented edema on lower limbs. She sought medical assistance, was diagnosed with heart failure and was admitted for treatment. The patient knew she had hypothyroidism for years. During admission, the patient underwent thoracocentesis to drain pleural effusion. The biochemal analysis of the pleural liquid (6 Dec 2007) revealed lactate dehydrogenase (LDH) (pleural effusion/serum) 104/216 = 0.48; protein (pleural effusion/serum) 2.8/6.2 = 0.45; albumin gradient = 1.5. The patient was discharged with prescription of 80 mg of Furosemide, 50 mg of Spironolactone, 75 mg of Captopril, 100 μg of levotiroxin on a daily basis, and 0.25 mg of Digoxin every other day. Her dyspnea showed some improvement, however, some days later the dyspnea worsened again upon effort levels below the usual ones. The patient sought medical assistance in this Hospital. Physical examination (9 Jan 2008) revealed eupneic patient, with increased jugular venous pressure, heart rate at 100 bpm and blood pressure 90 / 80 mm Hg. Lung examination revealed a decreased vesicular murmur on the right hemithorax middle third and abolition on the lower third of both hemithoraxes. Cardiac semiology revealed 4th heart sound, with no murmurs or pericardial friction rub. Her abdomen was painful to percussion in right hyponchondrium region. Her liver was palpated at 10 cm from the right coastal edge; there was edema +++/4+ on lower limbs. Chest radiography (9 Jan 2008) revealed a huge bilateral pleural effusion.