Simone N. Santos

Luminal Esophageal Temperature Monitoring With a Deflectable Esophageal Temperature Probe and Intracardiac Echocardiography May Reduce Esophageal Injury During Atrial Fibrillation Ablation Procedures Results of a Pilot Study

Background— Luminal esophageal temperature (LET) monitoring is one strategy to minimize esophageal injury during atrial fibrillation ablation procedures. However, esophageal ulceration and fistulas have been reported despite adequate LET monitoring. The objective of this study was to assess a novel approach to LET monitoring with a deflectable LET probe on the rate of esophageal injury in patients undergoing atrial fibrillation ablation. Methods and Results— Forty-five consecutive patients undergoing an atrial fibrillation ablation procedure followed by esophageal endoscopy were included in this prospective observational pilot study. LET monitoring was performed with a 7F deflectable ablation catheter that was positioned as close as possible to the site of left atrial ablation using the deflectable component of the catheter guided by visualization of its position on intracardiac echocardiography. Ablation in the posterior left atrial was limited to 25 W and terminated when the LET increased 2°C from baseline. Endoscopy was performed 1 to 2 days after the procedure. All patients had at least 1 LET elevation >2°C necessitating cessation of ablation. Deflection of the LET probe was needed to accurately measure LET in 5% of patients when ablating near the left pulmonary veins, whereas deflection of the LET probe was necessary in 88% of patients when ablating near the right pulmonary veins. The average maximum increase in LET was 2.5±1.5°C. No patients had esophageal thermal injury on follow-up endoscopy. Conclusions— A strategy of optimal LET probe placement using a deflectable LET probe and intracardiac echocardiography guidance, combined with cessation of radiofrequency ablation with a 2°C rise in LET, may reduce esophageal thermal injury during left atrial ablation procedures.

One-Month Therapy with Simvastatin Restores Endothelial Function in Hypercholesterolemic Children and Adolescents

Simvastatin has been shown to restore endothelial function in children with familial hypercolesterolemia after 28 weeks of treatment. The aim of this study was to evaluate 1-month simvastatin treatment effect on endothelial function in hypercholesterolemic children and adolescents. Eighteen hypercholesterolemic patients (HC group) and 18 healthy controls, aged 6–18 years, were studied with medical history, physical examination, full lipid profile, serum apolipoprotein B (apo B), fibrinogen, hepatic transaminases, and creatine kinase concentrations. Flow-mediated dilatation (FMD) was performed by high-resolution ultrasound of the brachial artery. The HC group received simvastatin 10 mg/day for 1 month. Arterial diameter was measured by two experienced sonographers who were unaware of subjects’ conditions. At baseline, FMD was impaired in the HC group (mean, 5.27 ± 4.67%) compared to controls (mean, 15.05 ± 5.97%) (p < 0.001). After treatment, we observed a significant reduction in total cholesterol (TC) (29%), low-density lipoprotein cholesterol (LDL-C); (37%), apo B concentrations (36%) and FMD restoration (mean, 12.94 ± 7.66%), with an absolute increase of 7.66 ± 8.58 (p = 0.001). These results show that children and adolescents with hypercholesterolemia present endothelial dysfunction, and simvastatin, in addition to significantly reducing TC, LDL-C, and apo B concentrations, restores endothelial function with 1-month treatment.

Timing and Dose of Statin Therapy Define Its Impact on Inflammatory and Endothelial Responses During Myocardial Infarction

Objective—Clinical trials of statins during myocardial infarction (MI) have differed in their therapeutic regimes and generated conflicting results. This study evaluated the role of the timing and potency of statin therapy on its potential mechanisms of benefit during MI. Methods and Results—ST-elevation MI patients (n=125) were allocated into 5 groups: no statin; 20, 40, or 80 mg/day simvastatin starting at admission; or 80 mg/day simvastatin 48 hours after admission. After 7 days, all patients switched their treatment to 20 mg/day simvastatin for an additional 3 weeks and then underwent flow-mediated dilation in the brachial artery. As of the second day, C-reactive protein (CRP) differed between non–statin users (12.0±4.1 mg/L) and patients treated with 20 (8.5±4.0 mg/L), 40 (3.8±2.5 mg/L), and 80 mg/day (1.4±1.5 mg/L), and the daily differences remained significant until the seventh day (P<0.0001). The higher the statin dose, the lower the elevation of interleukin-2 and tumor necrosis factor-&agr;, the greater the reduction of 8-isoprostane and low-density lipoprotein(−), and the greater the increase in nitrate/nitrite levels during the first 5 days (P<0.001). Later initiation of statin was less effective than its early introduction in relation to attenuation of CRP, interleukin-2, tumor necrosis factor-&agr;, 8-isoprostane, and low-density lipoprotein(−), as well as in increase in nitrate/nitrite levels (P<0.0001). At the 30th day, there was no longer a difference in lipid profile or CRP between groups; the flow-mediated dilation, however, was proportional to the initial statin dose and was higher for those who started the treatment early (P=0.001). Conclusion—This study demonstrates that the timing and potency of statin treatment during MI are key elements for their main mechanisms of benefit. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT00906451.

HDL levels and oxidizability during myocardial infarction are associated with reduced endothelial-mediated vasodilation and nitric oxide bioavailability

OBJECTIVE Acute phase response modifies high-density lipoprotein (HDL) into a dysfunctional particle that may favor oxidative/inflammatory stress and eNOS dysfunction. The present study investigated the impact of this phenomenon on patients presenting ST-elevation myocardial infarction (STEMI). METHODS Plasma was obtained from 180 consecutive patients within the first 24-h of onset of STEMI symptoms (D1) and after 5 days (D5). Nitrate/nitrite (NOx) and lipoproteins were isolated by gradient ultracentrifugation. The oxidizability of low-density lipoprotein incubated with HDL (HDLaoxLDL) and the HDL self-oxidizability (HDLautox) were measured after CuSO4 co-incubation. Anti-inflammatory activity of HDL was estimated by VCAM-1 secretion by human umbilical vein endothelial cells after incubation with TNF-α. Flow-mediated dilation (FMD) was assessed at the 30(th) day (D30) after STEMI. RESULTS Among patients in the first tertile of admission HDL-Cholesterol (<33 mg/dL), the increment of NOx from D1 to D5 [6.7(2; 13) vs. 3.2(-3; 10) vs. 3.5(-3; 12); p = 0.001] and the FMD adjusted for multiple covariates [8.4(5; 11) vs 6.1(3; 10) vs. 5.2(3; 10); p = 0.001] were higher than in those in the second (33-42 mg/dL) or third (>42 mg/dL) tertiles, respectively. From D1 to D5, there was a decrease in HDL size (-6.3 ± 0.3%; p < 0.001) and particle number (-22.0 ± 0.6%; p < 0.001) as well as an increase in both HDLaoxLDL (33%(23); p < 0.001) and HDLautox (65%(25); p < 0.001). VCAM-1 secretion after TNF-a stimulation was reduced after co-incubation with HDL from healthy volunteers (-24%(33); p = 0.009), from MI patients at D1 (-23%(37); p = 0.015) and at D30 (-22%(24); p = 0.042) but not at D5 (p = 0.28). CONCLUSION During STEMI, high HDL-cholesterol is associated with a greater decline in endothelial function. In parallel, structural and functional changes in HDL occur reducing its anti-inflammatory and anti-oxidant properties.

Life-Threatening Cardiac Manifestations of Pheochromocytoma

Pheochromocytoma is a catecholamine-secreting tumor of the adrenal glands, usually with benign manifestations, whose typical clinical presentation includes the triad of headache, palpitations and diaphoresis. However, a wide range of signs and symptoms may be present. In the cardiovascular system, the most common signs are labile hypertension and sinus tachycardia. Systolic heart failure and ST-segment deviations mimicking myocardial infarction have also been reported, as well as QT interval prolongation and, rarely, ventricular tachycardia. We describe a challenging diagnosis of pheochromocytoma with many cardiovascular manifestations, which could have been missed due to the absence of typical symptoms.

Elevated CETP activity during acute phase of myocardial infarction is independently associated with endothelial dysfunction and adverse clinical outcome

OBJECTIVE Recent data suggests that cholesteryl ester transfer protein (CETP) activity may interact with acute stress conditions via inflammatory-oxidative response and thrombogenesis. We investigated this assumption in patients with ST-elevation myocardial infarction (STEMI). METHODS Consecutive patients with STEMI (n = 116) were enrolled <24-h of symptoms onset and were followed for 180 days. Plasma levels of C-reactive protein (CRP), interleukin-2 (IL-2), tumor necrosis factor (TNFα), 8-isoprostane, nitric oxide (NOx) and CETP activity were measured at enrollment (D1) and at fifth day (D5). Flow-mediated dilation (FMD) was assessed by ultrasound and coronary thrombus burden (CTB) was evaluated by angiography. RESULTS Neither baseline nor the change of CETP activity from D1 to D5 was associated with CRP, IL-2, TNFα, 8-isoprostane levels or CTB. The rise in NOx from D1 to D5 was inferior [3.5(-1; 10) vs. 5.5(-1; 12); p < 0.001] and FMD was lower [5.9(5.5) vs. 9.6(6.6); p = 0.047] in patients with baseline CETP activity above the median value than in their counterparts. Oxidized HDL was measured by thiobarbituric acid reactive substances (TBARS) in isolated HDL particles and increased from D1 to D5, and remaining elevated at D30. The change in TBARS content in HDL was associated with CETP activity (r = 0.72; p = 0.014) and FMD (r = -0.61; p = 0.046). High CETP activity at admission was associated with the incidence of sudden death and recurrent MI at 30 days (OR 12.8; 95% CI 1.25-132; p = 0.032) and 180 days (OR 3.3; 95% CI 1.03-10.7; p = 0.044). CONCLUSIONS An enhanced CETP activity during acute phase of STEMI is independently associated with endothelial dysfunction and adverse clinical outcome.

Sudden Cardiac Arrest in General Anesthesia as the First Manifestation of Anomalous Origin of the Left Coronary Artery

BACKGROUND AND OBJECTIVES This case report describes a rare and potentially fatal condition associated with anesthesia administration. Our aim was to discuss the causes of sudden cardiac arrest during the perioperative period in apparently healthy patients and the pathophysiology of anomalous origin of the coronary arteries as a cause of sudden cardiac arrest. CASE REPORT Female patient, 44 years old, with no previous symptoms of heart disease or arrhythmias, had a sudden cardiac arrest during general anesthesia in two different situations. In the first episode, the patient presented signs of acute abdomen, but remained hemodynamically stable. Following induction of anesthesia, the patient exhibited bradycardia and hypotension refractory to volume replacement and vasopressors. The condition progressed to asystole. The patient was successfully resuscitated and discharged from the hospital in good condition. In the second episode, one year after the first, the patient was in good clinical condition to undergo an elective surgery. After induction of anesthesia, the patient developed ventricular tachycardia followed by asystole, which was promptly reversed. After extensive investigation, an anomalous origin of the left coronary artery was identified. CONCLUSIONS Our report is illustrative as it emphasizes that a thorough diagnostic investigation should be done in cases of sudden cardiac arrest during the perioperative period, even in patients that appear to be healthy.

Renal resistance index predicting outcome of renal revascularization for renovascular hypertension

BACKGROUND Renal artery stenosis (RAS) is a potentially correctable cause of hypertension and ischemic nephropathy. Despite successful renal revascularization, not all patients (pt) overcome it and some get worse. OBJECTIVE This study was designed to assess the value of renal resistance index (RI) in predicting the outcome of renal revascularization. METHODS Between Jan 1998 and Feb 2001, 2,933 pts were referred to renal duplex ultrasound. 106 out of these had significant RAS and underwent angiography and renal revascularization. Arterial blood pressure (BP) was measured before and after the intervention, at intervals of up to 2 years and medications recorded. Prior to revascularization, RI was measured at 3 sites of each kidney and averaged. RESULTS Out of the 106 patients, 81 had RI<80 and 25 RI>80. RAS was corrected with angioplasty (PTA) alone in 25 pts, PTA + stent in 56 pts and corrected by surgery in 25 pts. Of patients who benefited from renal revascularization; 57 of the 81 patients with RI <80 improved as compared to 5 of 25 with RI>80. Using a multiple logistic regression model, RI was significantly associated with BP outcome (p=0.001), adjusted for the effects of age, sex, SBP, DBP, duration of hypertension, type of revascularization, number of medication in use, creatinine level, presence of diabetes mellitus, hypercholesterolemia, stroke, peripheral and coronary artery disease and kidney size (OR 99.6 - 95%CI for OR 6.1 to 1,621.2). CONCLUSION Intrarenal arterial resistance measured by duplex ultrasound plays an important role in predicting BP outcome after renal revascularization for RAS.FUNDAMENTO: A estenose arterial renal (EAR) e uma causa potencialmente reversivel de hipertensao arterial sistemica (HAS) e nefropatia isquemica. Apesar da revascularizacao bem sucedida, nem todos os pacientes (pt) apresentam melhora clinica e alguns podem piorar. OBJETIVO: O presente estudo se destina a avaliar o valor do indice de resistividade renal (IR) como preditor dos efeitos da revascularizacao renal. METODOS: Entre janeiro de 1998 e fevereiro de 2001, 2.933 pacientes foram submetidos ao duplex ultrassom renal. 106 desses pacientes apresentaram EAR significativa e foram submetidos a angiografia e revascularizacao renal. A pressao arterial (PA) foi medida antes e depois da intervencao, em intervalos de ate 2 anos e as medicacoes prescritas foram registradas. Antes da revascularizacao, o IR foi medido em 3 locais do rim, sendo obtida uma media dessas medicoes. RESULTADOS: Dos 106 pacientes, 81 tiveram IR 80. A EAR foi corrigida somente por angioplastia (PTA) em 25 pts, PTA + stent em 56 pts e cirurgicamente em 25 pts. Dos pacientes que se beneficiaram da revascularizacao renal; 57 dos 81 pacientes com IR 80. Usando um modelo de regressao logistica multipla, o IR esteve significativamente associado a evolucao da PA (p = 0,001), ajustado de acordo com os efeitos da idade, sexo, PAS, PAD, duracao da hipertensao, o tipo de revascularizacao, numero de farmacos em uso, nivel de creatinina, presenca de diabete melito, hipercolesterolemia, volume sistolico, doenca arterial periferica e coronariana e tamanho renal (OR 99,6-95%CI para OR 6,1-1.621,2). CONCLUSAO: A resistividade intrarrenal arterial, medida por duplex ultrassom, desempenha um papel importante na predicao dos efeitos pos revascularizacao renal para EAR.

TCF7L2 polymorphism is associated with low nitric oxide release, endothelial dysfunction and enhanced inflammatory response after myocardial infarction

Backgound The favorable effects of insulin during myocardial infarction (MI) remain unclear due to the divergence between mechanistic studies and clinical trials of exogenous insulin administration. The rs7903146 polymorphism of the transcription factor 7-like 2 (TCF7L2) gene is associated with attenuated insulin secretion. Methods In non-diabetic patients with ST-elevation MI (STEMI), using such a model of genetically determined down-regulation of endogenous insulin secretion we investigated the change in plasma insulin, C-peptide, interleukin-2 (IL-2), C-reactive protein (CRP), and nitric oxide (NOx) levels between admission (D1) and the fifth day after MI (D5). Coronary angiography and flow-mediated dilation (FMD) were performed at admission and 30 days after MI, respectively. Homeostasis Model Assessment estimated insulin secretion (HOMA2%β) and insulin sensitivity (HOMA2%S). Results Although glycemia did not differ between genotypes, carriers of the T-allele had lower HOMA2%β and higher HOMA2%S at both D1 and D5. As compared with non-carriers, T-allele carriers had higher plasma IL-2 and CRP at D5, higher intracoronary thrombus grade, lower FMD and NOx change between D1 and D5 and higher 30-day mortality. Conclusion In non-diabetic STEMI patients, the rs7903146 TCF7L2 gene polymorphism is associated with lower insulin secretion, worse endothelial function, higher coronary thrombotic burden, and higher short-term mortality. General significance During the acute phase of MI, a lower capacity of insulin secretion may influence clinical outcome.

Traumatic Laceration of Left Common Iliac Vein during Catheter Ablation — An Unusual Presentation of Cockett-May-Thurner Syndrome

A paciente não apresentava doença cardíaca estrutural ou histórico de embolia cerebral ou pulmonar, ou trombose venosa profunda. Ela já havia sido anticoagulada com varfarina por 4 meses e a Razão Normalizada Internacional (RNI) no dia da ablação era de 2,5. Inicialmente, a veia jugular direita foi acessada para o cateterismo do seio coronariano. O acesso à veia femoral direita foi obtido através de punção transseptal dupla e a via femoral esquerda foi acessada por meio do cateter ECI. O cateter ECI foi inserido sob visões fluoroscópicas e houve dificuldade em inserir o cateter imediatamente antes da bifurcação da veia cava inferior (VCI), mas, posteriormente, o cateter ECI foi posicionado no átrio direito. A punção transseptal foi realizada sob orientação do ECI e pela luz fluoroscópica sem dificuldades, mas, alguns minutos depois, a pressão arterial caiu para 50 mmHg. O ECI foi então colocado no ventrículo direito e não apresentou derrame pericárdico. Devido à dificuldade em inserir o cateter através da veia ilíaca/VCI, o cateter ECI foi retirado, e realizou-se flebografia.