Vânia Ribeiro

Permanent pacemaker implantation after aortic valve replacement: Long-term dependency or rhythm recovery?

INTRODUCTION Conduction disturbances requiring permanent pacemaker (PM) implantation occur in 3-12% of patients after aortic valve replacement (AVR). Our aim was to assess long-term PM dependency and its predictors in these patients. METHODS We conducted a retrospective study of all consecutive patients undergoing permanent PM implantation after AVR between January 2004 and December 2010. Absence of sinus rhythm or atrial fibrillation with appropriate ventricular response at a pacing rate of 30 bpm for 10 s was defined as pacemaker dependency. RESULTS Ninety-one patients underwent permanent PM implantation and during follow-up (1026.6 ± 732.0 days) 64% of them did not recover rhythm. Age, conduction disorders on the preoperative ECG, negative chronotropic medication before surgery, cardiopulmonary bypass and aortic cross-clamp times did not influence rhythm recovery. In multivariate analysis, valvular disease etiology related to endocarditis, prosthetic dysfunction and bicuspid valve were associated with long-term PM dependency (OR 5.05; CI: 1.43-17.75). CONCLUSIONS The majority of patients undergoing permanent PM implantation after AVR did not recover from conduction disorders during follow-up. The etiology of valvular disease was an independent predictor of late PM dependence.

Percutaneous Closure of a Fistulous Giant Coronary Aneurysm

Giant coronary artery aneurysms larger than 50 mm are rare and associated with important complications: namely, rupture. Its workup requires comprehensive imaging and standard treatment is surgical exclusion. We present a 60-year-old patient with previous ostium secundum atrial septal defect surgical closure diagnosed with a giant proximal right coronary artery aneurysm (70 x 62 mm) fistulizing into the right atrium. Percutaneous closure of its aortic origin with an atrial septal occluder was successfully performed, and thrombosis of the aneurysm confirmed on angiography and echocardiogram. This case depicts an innovative, minimally invasive approach to this worrisome entity.

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.