Sílvia Marta Oliveira

Thymulin inhibits monocrotaline-induced pulmonary hypertension modulating interleukin-6 expression and suppressing p38 pathway

The pathogenesis of pulmonary hypertension (PH) includes an inflammatory response. Thymulin, a zinc-dependent thymic hormone, has important immunobiological effects by inhibiting various proinflammatory cytokines and chemokines. We investigated morphological and hemodynamic effects of thymulin administration in a rat model of monocrotaline (MCT)-induced PH, as well as the pattern of proinflammatory cytokine gene expression and the intracellular pathways involved. Adult Wistar rats received an injection of MCT (60 mg/kg, sc) or an equal volume of saline. One day after, the animals randomly received during 3 wk an injection of saline, vehicle (zinc plus carboxymethyl cellulose), or thymulin (100 ng/kg, sc, daily). At d 23-25, the animals were anesthetized for hemodynamic recordings, whereas heart and lungs were collected for morphometric and molecular analysis. Thymulin prevented morphological, hemodynamic, and inflammatory cardiopulmonary profile characteristic of MCT-induced PH, whereas part of these effects were also observed in MCT-treated animals injected with the thymulins vehicle containing zinc. The pulmonary thymulin effect was likely mediated through suppression of p38 pathway.

Left atrial volume is more important than the type of atrial fibrillation in predicting the long-term success of catheter ablation

BACKGROUND The type of atrial fibrillation (AF) is the sole prognostic factor that affects the level of recommendation for catheter ablation in the current guidelines. Despite being recognized as a predictor of recurrence, relatively little emphasis is given to left atrium (LA) size. The aim of this study was to assess the relative importance of LA volume and type of AF as predictors of outcome after PVI. METHODS We assessed 809 consecutive patients with symptomatic drug-refractory AF (584 male, mean age 57 ± 11 years) undergoing 905 percutaneous PVI procedures in two centers. LA volume was assessed by cardiac CT and/or electroanatomical mapping prior to AF ablation. The study endpoint was symptomatic and/or documented AF recurrence. RESULTS The majority of patients (73.2%, n=592) had paroxysmal AF. The mean indexed LA volume was 55 ± 20 ml/m(2). During a follow-up of 2.4 ± 1.7 years, there were 280 recurrences. The relapse rate of patients with paroxysmal AF in the highest tertile of LA volume was higher than the relapse rate of patients with non-paroxysmal AF in the lowest tertile (20.0% vs. 10.9% per person-year, respectively, p=0.041). LA volume (HR 1.16 for each 10 ml/m(2), 95% CI 1.09-1.23, p<0.001), female gender (HR 1.55, 95% CI 1.19-2.03, p=0.001), and non-paroxysmal AF (HR 1.31, 95% CI 1.01-1.69, p=0.039) were the only independent predictors of AF recurrence. Split-sample cross-validation resampling confirmed LA volume as the strongest predictor of relapse after PVI. CONCLUSION Left atrial volume seems to be more important than the type of atrial fibrillation in predicting the long-term success of pulmonary vein isolation.

Surgical treatment of atrial fibrillation: an updated review

The first Cox-maze procedure was performed in 1987, demonstrating the feasibility of a non-pharmacological treatment for atrial fibrillation (AF). Since then, surgery for AF has changed over time, in parallel with technological advances. Replacement of surgical incisions with linear ablation lines made a previously cumbersome procedure accessible to most surgeons, without compromising success. On the other hand, new ablation technologies paved the way for the development of minimally invasive surgery, which may potentially extend the scope of surgery to patients who would otherwise be deemed unsuitable. Nonetheless, literature on minimally invasive surgery is still scarce and randomized clinical trials currently under way are expected to shed light on some controversial issues. Moreover, successful AF treatment will probably rely on close collaboration between surgery and electrophysiology. Indeed, the hybrid procedure, though still in its very beginning, seems to combine the best of catheter and surgical ablation. However, further studies are warranted to determine the effectiveness of this promising strategy, especially in patients with persistent and longstanding persistent AF. Better understanding of AF pathophysiology as well as more accurate preoperative localization of AF triggers will bring about the possibility of tailoring specific lesion sets and ablation modalities to individual patients. This, in turn, will increase recovery and maintenance of sinus rhythm, with significant benefits in long-term outcomes.

Long-term survival, autonomy, and quality of life of elderly patients undergoing aortic valve replacement.

Abstract  Aims: We reviewed the long‐term survival, autonomy, and quality of life (QoL) of elderly patients undergoing aortic valve replacement (AVR). Methods: Records of patients ≥75 years old that underwent AVR from 2002 to 2006 were retrospectively analyzed. Functional status was classified with Barthel Index (BI). QoL was presumed as the self‐perception of well‐being after AVR. Independent predictors of mortality were identified using the Cox proportional hazards model. Results: We included 114 patients, with a mean age of 78.5 ± 2.5 years. Seventy (59.8%) patients were females. Mean additive and logistic EuroSCORE were 7 ± 2 and 9 ± 7, respectively. Follow‐up on vital status was achieved for 113 (99.1%) patients after a mean period of 47.2 ± 23.4 months. Twenty‐seven (23.7%) patients died (including three operative deaths). Survival up to one, three, and five years of follow‐up was 94.4%, 86.7%, and 76.1%, respectively. Multivariate analysis showed that pulmonary hypertension and diabetes were independent predictors of all‐cause mortality. Information on BI score and QoL was obtained for 77 (89.5%) and patients. Among those, 69 (89.6%) were autonomous according to BI and 72 (93.5%) considered having had an improvement in QoL. Conclusion: Patients ≥75 years old undergoing AVR presented good medium‐term survival. Predictors of an adverse outcome were significant pulmonary hypertension and diabetes. At follow‐up, most achieved improvement of QoL and remained autonomous. These results stress that excellent long‐term outcomes with AVR can be achieved in appropriately selected elderly patients. (J Card Surg 2012;27:20–23)

Embolic complication of left ventricular non-compaction as an unusual cause of acute myocardial infarction

One of the greatest challenges in medicine consists of arriving at a correct diagnosis despite different presentations of the disease. We present a case in which, notwithstanding the initial diagnosis, the search for the etiology was essential for clinical guidance. Left ventricular non-compaction (LVNC) was first described by Chin et al. in 1990. This relatively new entity is characterized by excessive thickening of the myocardial wall, formed of a thin epicardial layer and a substantially thicker non-compacted endocardial layer. The clinical presentation is highly variable but it must always be borne in mind that heart failure, atrial and ventricular arrhythmias and embolic events are common complications of LVNC.

Cardiac metastasis from epidermoid esophageal cancer mimicking anterior myocardial infarction

Cardiac metastases are more common than primary tumors. Several types of malignant tumors have been reported to metastasize to the heart, mainly lung cancer, but in the setting of esophageal cancer, myocardial metastasis is comparatively rare. We report a case of a cardiac metastasis from esophageal squamous cell carcinoma detected 9 months after surgically curative esophagectomy, which presented mimicking acute myocardial infarction. The use of different imaging modalities was fundamental to a correct diagnosis considering the challenging presentation.

Cardiac 123I-MIBG scintigraphy and arrhythmic risk in left ventricular noncompaction

Left ventricular noncompaction is an unusual but increasingly recognized cardiomyopathy, the etiology of which is still not definitely established. Clinical presentation includes a wide spectrum of scenarios, including heart failure, thromboembolism and malignant arrhythmias, with half of deaths occurring suddenly. Early detection of LVNC is therefore essential to prevent sudden cardiac death. To our knowledge, this is the first report of the presence of cardiac sympathetic nervous dysfunction, assessed by 123iodine-metaiodobenzylguanidine myocardial scintigraphy, in a patient with LVNC, preserved left ventricular systolic function and exercise-induced nonsustained ventricular tachycardia. This finding may be related to the increased arrhythmic risk observed in this cardiomyopathy, giving a new insight into the pathophysiology of LVNC.

Myocardial cleft in a patient with Takotsubo cardiomyopathy: An unusual association identified by cardiac magnetic resonance

We present the case of an 84-year-old woman admitted for Takotsubo cardiomyopathy complicated by congestive heart failure. Cardiovascular magnetic resonance (CMR) imaging was performed on day five and confirmed severely depressed left ventricular systolic function with typical apical ballooning. In steady-state free precession long-axis cine imaging, a basal inferior myocardial cleft was also observed, with no signs of myocardial noncompaction or regional wall motion abnormalities involving this segment. The pre-discharge CMR study confirmed the presence of a basal inferior myocardial cleft and significant improvement in left ventricular systolic function. Myocardial clefts are congenital abnormalities that have been described in healthy individuals as well as in the setting of hypertrophic cardiomyopathy, but it is not clear whether it is a benign structural variant or a distinct cardiomyopathy phenotype. To our knowledge this is the first reported case of this abnormality in a patient with Takotsubo cardiomyopathy.

Reply to Tannous et al.

We thank Tannous et al. [1] for their valuable comments on our review [2]. We agree that pacemaker implantation is an important complication of surgical ablation of atrial fibrillation (AF). As we cited, a recent systematic review on minimally invasive radiofrequency ablation of AF found a rate of pacemaker implantation of 1.4%, which was considerably lower than the 6.9% presented by Tannous et al. and other authors [3]. This difference is likely related to the setting of AF ablation (lone intervention versus concomitant surgery, respectively). Indeed, a recent retrospective analysis of the predictors and risk of pacemaker implantation after the Cox-Maze procedure found concomitant procedures to be associated with a non-significantly higher risk than lone interventions (15 vs 6%, P = 0.060, at 1 year). Age was the single independent predictor of pacemaker implantation [4]. In concomitant AF ablation, associated cardiac diseases and procedures might influence the pacemaker implantation rate by inducing conduction or sinus-node disturbances. In our experience of concomitant AF ablation, pacemaker implantation was the most common complication. Nearly 15% of the patients (n = 170) required definitive pacemaker implantation following radiofrequency ablation (unpublished data). Patients undergoing bi-atrial ablation procedures had a significantly higher risk of postoperative pacemaker implantation (P < 0.001), which was in line with prior reports [3, 5]. Worku et al. compared several energy modalities and lesion sets, and suggested that microwave energy and right atrial ablation lines increased risk of postprocedural pacemaker implantation. Their findings were recently corroborated by Pecha et al., who identified bi-atrial ablation as the single independent predictor of pacemaker implantation. This is though not consensual as Kim et al. [6] suggested that bi-atrial cryoablation reduced AF recurrence without increasing postoperative complications, namely pacemaker implantation, when compared with procedures restricted to the left atrium. Pacemaker implantation was required only for a minor fraction of patients undergoing bi-atrial procedures (1.8%). Of note, Pecha et al. [3] found cryoablation to be associated with a marginally lower rate of pacemaker implantation in comparison with radiofrequency energy. In conclusion, pacemaker implantation is recognized as one of the main complications of AF ablation. Concomitant procedures and bi-atrial lesion sets seem to increase this risk, but further evidence on the independent predictors is eagerly warranted.

Triple-orifice congenital stenotic mitral valve: a unique finding characterized by multimodality echocardiography

A 23-year-old woman, with mitral stenosis since childhood, presented with worsening exertional dyspnoea. She had no previous acute rheumatic fever. Two-dimensional transthoracic echocardiogram demonstrated thickened mitral leaflets, with diastolic dome-shape due to restricted posterior leaflet and a formerly non-recognized triple-orifice mitral valve ( Panels A and B ). Doppler revealed a mean gradient of 17 mmHg and larger orifice area was 0.6 cm2. These findings were consistent with severe congenital mitral stenosis. In addition, a muscular ventricular septal defect (VSD) and severe pulmonary …