Reinaldo B. Bestetti

Primary cardiac lymphoma

Primary cardiac lymphoma (PCL) is a very rare disorder. Histologically, the majority of cases of PCL are diffuse B-cell lymphoma. PCL occurs more frequently in immunocompromised patients. Symptoms may vary according to the heart site involved. The most frequent cardiac clinical manifestations associated with PCL are pericardial effusion, heart failure, and atrioventricular block (AV-block). Diagnosis of PCL can be suggested by transesophageal echocardiography, computed tomography, and magnetic resonance imaging. However, cytologic examination of cardiac tumor or pericardial effusion is paramount for a definite diagnosis of this condition. Prognosis of PCL is poor with a median survival of 7months after initial diagnosis. Newer modalities including immunotherapy with rituximab or auto stem cell transplantation are promising in the treatment of this lethal condition.

Prevalence of hypertension in the urban population of Catanduva, in the State of São Paulo, Brazil

OBJECTIVE To study the prevalence of systemic hypertension and its control in the population of Catanduva, in the state of São Paulo, Brazil. METHODS We carried out a randomized cross-sectional population-based study of the urban population of Catanduva with individuals above 18 years of age (688 individuals accounting for 0.9% of the referred population). We interviewed study participants to analyze the major qualitative and quantitative variables that could influence the hypertensive scenario and the risk for systemic hypertension. Blood pressure was measured through the indirect method according to the III Consenso Brasileiro de Hipertensão (III Brazilian Consensus on Hypertension), which established blood pressure levels >/= 140/90 mm Hg as hypertensive. RESULTS The prevalence of systemic hypertension was higher in individuals with: (1) history of hypertension (p<0.0001); (2) diabetes mellitus (p=0.05); (3) body mass index (B. M. I) >/= 25 kg/m(2) (p<0.001); (4) low educational level (p<0.0001); (5) familial income ranging from 1 to 5 minimum wages (p<0.05); (6) unmarried status (divorced/separated and widow(er)s) (p<0.0001). Of the interviewed individuals, 27.6% (p=0.05) had blood pressure levels under control. CONCLUSION Our study showed that the prevalence of systemic hypertension was 31.5%, and that 27.6% of the individuals interviewed had blood pressure levels under control at the time of the interview.

Switch from calcineurin inhibitors to sirolimus- induced renal recovery in heart transplant recipients in the midterm follow-up

Background. Calcineurin inhibitor (CI)-based immunosuppression has prolonged the survival of heart transplant recipients. However, CI-induced renal injury remains as a major problem in these patients. Sirolimus is an immunosuppressant with no significant impact on renal function. A limited number of recent papers have showed that the switch from CI to sirolimus improved renal function in late follow-up of heart transplant patients with CI-related nephrotoxicity. Methods. Ten heart transplant recipients with CI-induced nephrotoxicity (creatinine 3.9±1.8 mg/dl) at a median of 701 (465 to 1325) days posttransplant had CI switched to sirolimus (target though levels 10 to 14 ng/ml) while mycophenolate mofetil (MMF, 3g/day) was maintained and adjusted according to white blood cell count. Results. This maneuver caused a marked decrease in serum creatinine (P<0.00001) at 30 (1.2±0.4 mg/dl), 90 (1.3±0.4 mg/dl) and 180 (1.3±0.4 mg/dl) days postconversion and a significant decrease in serum potassium levels (5.1±0.5 at baseline vs. 3.9±0.3 at 180 days, P<0.00005). After the drugs switch no changes in hemoglobin levels, white blood cell count, platelets count, blood glucose and glutamic oxaloacetic transaminase plasma levels were observed. Total cholesterol increased from 242±28 to 290±117 mg/dl (P>0.05) after 90 days and decreased to 216±58 mg/dl at day 180 (P>0.05) after statins dose adjustment. Rejection and infection rates were not modified by sirolimus. Conclusions. Conversion to a sirolimus-based immunosuppression regimen associated with MMF allowed striking renal function recovery in heart transplant recipients with calcineurin inhibitor-induced renal impairment at midterm follow-up.

Treatment of chronic systolic heart failure secondary to Chagas heart disease in the current era of heart failure therapy

The treatment of chronic heart failure secondary to Chagas disease has been based on extrapolation of data achieved in the treatment of non-Chagas disease heart failure. Because beta-blockers decrease the incidence of sudden cardiac death in non-Chagas disease heart failure and sudden cardiac death occurs preferentially in patients with mild Chagas disease heart failure, beta-blockers may be administered first to class I/II patients with Chagas disease heart failure. In advanced Chagas disease heart failure, angiotensin-converting enzyme inhibitor and diuretics may be given at first to compensate for congestive symptoms. After clinical status improvement, beta-blockers should be given at targeted doses, if necessary reducing angiotensin-converting enzyme inhibitor doses. Primary and secondary prevention of sudden cardiac death may be accomplished with implantable cardioverter defibrillators because of the high recurrence of life-threatening arrhythmias despite amiodarone administration. In refractory heart failure, heart transplantation is the treatment of choice.

Outcome of Chagas cardiomyopathy in comparison to ischemic cardiomyopathy

BACKGROUND Chagas cardiomyopathy and ischemic heart disease (IHD) are frequent causes of chronic systolic heart failure (CHF) in areas where the former is endemic. Nonetheless, a specific comparison of outcome and role of etiology of CHF failure has not been performed in patients with both conditions. METHODS Two-hundred twenty two patients with Chagas cardiomyopathy and 79 with IHD with CHF were included in the study. A Cox proportional hazards model was used to establish independent predictors of mortality for the studied population. Survival analysis was performed with the Kaplan-Meir product limit method. RESULTS In the multivariable model, Beta-Blocker therapy [(hazard ratio (HR)=0.36; 95% confidence interval (CI) 0.24 to 0.52; p<0.005)], Chagas etiology of CHF (HR=3.6; 95% CI 2.0 to 6.5; p<0.005), serum sodium levels (HR=0.95; 95% CI 0.91 to 0.98; p<0.005), digoxin use (HR=2.1; 95% CI 1.19 to 3.80, p=0.01), and spironolactone use (HR=1.7; 95% CI 1.10 to 2.80; p=0.02) were determined independent predictors of all-cause mortality for this cohort. Probability of survival at 12, 24, 36, 48, and 60 months was 92%, 92%, 88%, 81%, and 78%, respectively, in IHD patients, and 79%, 61%, 49%, 41%, and 35%, respectively, in Chagas cardiomyopathy patients (p<0.005). CONCLUSION Outcome in patients with chronic systolic heart failure secondary to Chagas cardiomyopathy is poorer than that seen in those with IHD.

Partial left ventriculectomy:: Preoperative risk factors for perioperative mortality

This study aimed at determining risk factors for perioperative mortality for patients undergoing partial left ventriculectomy. Fourteen patients with end-stage congestive heart failure underwent partial ventriculectomy at our institution from February, 1995 to October, 1997. Mean age was 48+/-11 years, symptoms duration 44+/-34 months, New York Heart Association symptoms score 4+/-0, systolic blood pressure 97.69+/-20.06 mmHg, diastolic blood pressure 65.38+/-13.91 mmHg, heart rate 91+/-15 beats/min, furosemide daily dose 121.66+/-96.65 mg and captopril daily dose 68.75+/-76.76 mg. Seven (50%) patients needed inotropic support for hemodynamic stabilization. On echocardiography, left ventricular diastolic dimension was 81.71+/-11.92 mm. Left ventricular ejection fraction determined by radionuclide ventriculography or echocardiography was 16.71+/-5.13. At heart catheterization, mean right atrial pressure was 12.50+/-7.72 mmHg, mean pulmonary capillary wedge pressure 23.60+/-7.79 mmHg, and mean pulmonary artery pressure 34.10+/-12.81 mmHg. Twelve patients had idiopathic dilated cardiomyopathy and two patients had a globally dilated heart with single vessel coronary artery disease. Aneurysmectomy, mitral valve surgery or coronary artery bypass surgery were not performed in any patient. Four (28%) patients died: three in the operating theatre and one from low output syndrome 2 days after surgery. The proportion of patients operated on with cardiogenic shock was four (100%) in nonsurvivors and 0% in survivors (P=0.001). Inotropic support was necessary in three (30%) survivors and in four (100%) nonsurvivors (P=0.06). Thus, preoperative hemodynamic instability may be associated with perioperative mortality after partial left ventriculectomy.

Comparação do desfecho entre a cardiopatia chagásica e a miocardiopatia dilatada idiopática

FUNDAMENTO: Pouco se sabe sobre o desfecho dos pacientes com cardiopatia chagasica, em comparacao aos pacientes com miocardiopatia dilatada idiopatica na era contemporânea. OBJETIVO: Comparar o desfecho dos pacientes chagasicos com insuficiencia cardiaca sistolica cronica decorrente da cardiopatia chagasica ao observado em pacientes com MDI na era contemporânea. METODOS: Foi incluido um total de 352 pacientes (246 com cardiomiopatia chagasica e 106 com miocardiopatia dilatada idiopatica), seguidos prospectivamente em nossa Instituicao, de janeiro de 2000 a janeiro de 2008. Todos os pacientes receberam tratamento clinico contemporâneo padrao. RESULTADOS: Na analise multivariada com o modelo de risco proporcional de Cox, o uso da digoxina (relacao de risco = 3,17; intervalo de confianca de 95%, de 1,62 a 6,18; p = 0,001) necessitou de suporte inotropico (relacao de risco = 2,08; intervalo de confianca de 95%, de 1,43 a 3,02; p < 0,005). A fracao de ejecao do ventriculo esquerdo (relacao de risco = 0,97; intervalo de confianca de 95%, de 0,95 a 0,99; p < 0,005) e a etiologia da cardiopatia chagasica (relacao de risco = 3,29; intervalo de confianca de 95%, de 1,89 a 5,73; p < 0,005) foram associadas positivamente a mortalidade, enquanto a terapia com betabloqueadores (relacao de risco = 0,39; intervalo de confianca de 95%, de 0,26 a 0,56; p < 0,005) foi associada negativamente a mortalidade. A probabilidade de sobrevida para pacientes com cardiomiopatia chagasica em oito, 24 e 49 meses foi de 83%, 61% e 41%, respectivamente. Ja para pacientes com cardiomiopatia dilatada idiopatica, foi de 97%, 92% e 82%, respectivamente (p < 0,005). CONCLUSAO: Na era atual do tratamento da insuficiencia cardiaca, os pacientes com cardiomiopatia chagasica tem um desfecho pior em comparacao aos pacientes com cardiomiopatia dilatada idiopatica.

Salmonella tricuspid endocarditis in an intravenous drug abuser with human immunodeficiency virus infection

We describe a case of Salmonella tricuspid endocarditis in an intravenous drug abuser with human immunodeficiency virus infection. He was successfully treated with antibiotics with no clinical relapse. To our knowledge, this is the first case of this kind reported in the literature. Physicians should be on the alert for this potentially curable cardiac complication of human immunodeficiency virus infection.

Prognosis of patients with chronic systolic heart failure: Chagas disease versus systemic arterial hypertension

Chagas disease is a major health problem in South American because it affects 11 million people; 90 million are at risk of acquiring the disease, and about 12,500 persons die of the disease yearly [1]. Furthermore, Chagas disease has become global because of international immigration. It is caused by the protozoan Trypanosoma cruzi, which is transmitted to humans through the contact of feces of blood-sucking bugs with human mucosa. Many years after infection, about 30% of patients develop chronic cardiomyopathy, whichmanifests by life-threatening ventricular arrhythmias [2], chronic systolic heart failure (CHF) [3], sudden cardiac death [4], and thromboembolism [5]. Chagas disease is the principal cause of CHF in referral centers where the disease is endemic. Prognosis for patients with CHF secondary to Chagas cardiomyopathy is very poor, with an annual mortality around 20% [6]. Overall, outcome for CHF secondary to Chagas cardiomyopathy is poor to that found in non-Chagas disease heart failure [7]. Systemic arterial hypertension (SAH)may affect about 33% of patients with chronic Chagas disease, and 8% of them develop CHF [8]. The purpose of this investigationwas to compare outcome of patients with CHF secondary to Chagas cardiomyopathywith thosewith CHF secondary to SAH in view of lack of such data in the medical literature. All patients with the diagnosis of CHF secondary to either Chagas cardiomyopathy or SAH routinely followed at our Cardiomyopathy Outpatient Service from January, 2000 to January, 2008 were initially considered for the study. Patients were entered in the study if they had 1) positive serology for Chagas disease and left ventricular systolic dysfunction or 2) SAH (systolic blood pressure N 140 × 90 mmHg) at physical examination on admission or normal systemic arterial pressure but with a history of SAH treated with antihypertensive medication at study entry associated with left ventricular systolic dysfunction, as previously reported. Details of this patients cohort have been described elsewhere [9]. All Chagas disease heart failure patients were treated as previously described [10], whereas hypertensive patients received standard treatment for CHF. The daily dose of each medication at the last follow-up visit before study close was noted. The T test for unpaired sample was used to compare continuous variables between patients with CHF secondary to Chagas cardiomyopathy and those with CHF secondary to SAH at baseline. A Cox proportional hazard models, adjusted for confounders, were used to determine independent predictors of mortality for this specific patient population. Kaplan–Meier survival curves were constructed to estimate survival probability for both groups, and the log-rank sum test was used to compare survival probability between both patient groups. Differences at the level of p b 0.05 were considered of statistical significance. Table 1 lists the comparison of relevant clinical characteristics at baseline of patients with CHF secondary to Chagas cardiomyopathy and those with CHF secondary to SAH. Of interest, mean daily dose of carvedilol (21.7 ± 17.4 mg × 34.4 ± 19.7 mg; p b 0.005) and metoprolol succinate (106.2 ± 67.6 mg × 144.3 ± 65.4 mg; p b 0.06) was lower in Chagas disease patients than in those with SAH with CHF. Onmultivariable analysis, Beta-Blocker therapy [Hazard Ratio (HR)= 0.31; 95% Confidence Interval (95%) 0.2 to 0.44; p b 0.005], Chagas etiology of heart failure (HR= 2.2; 95% CI 1.47 to 3.40; p b 0.005), need of inotropic support (HR= 1.72; 95% CI 1.19 to 2.47; p= 0.004), left ventricular diastolic diameter (HR= 1.02; 95% CI 1.19 to 2.47; p= 0.002) and serum sodium levels (HR= 0.95; 95% CI 0.91 to 0.98; p= 0.006) were independent predictors of all-cause mortality. Overall, patients were followed for 33 ± 21 months. Probability of survival for patients with CHF secondary to Chagas cardiomyopathy at 12, 24, 36, 48, and 60 months was 76%, 56%, 45%, 37%, and 29%, respectively; nonetheless, probability of survival for those with CHF secondary to SAH at 12, 24, 36, 48, and 60 months was 96%, 92%, 82%, 77%, and 73%, respectively (p b 0.05). Fig. 1 illustrates these data.

Ruptured chordae tendineae of the posterior leaflet of the tricuspid valve as a cause of tricuspid regurgitation following blunt chest trauma

A 12-year-old boy suffered a blunt chest trauma. Some hours later, a pulsatile bilateral jugular venous distension, a holosystolic murmur heard at the low parasternal border and hepatomegaly were observed. On echocardiography, ruptured chordae tendineae of the posterior leaflet of the tricuspid valve, as well as tricuspid regurgitation were detected. He remained asymptomatic during hospital stay and was discharged home in good condition. Thus, isolated ruptured chordae tendineae of the posterior leaflet of the tricuspid valve is another cause of tricuspid regurgitation following blunt chest trauma.