ABSTRACT
A cardiomiopatia periparto é uma causa rara de insuficiência cardíaca no período entre o último mês de gestação e os cinco meses após o parto. A síndrome do QT longo caracteriza-se pelo atraso da repolarização ventricular e pode se manifestar com síncope e morte súbita devido a um tipo de taquicardia ventricular polimórfica conhecida como torsades de pointes. Descrição do caso: J.S., 26 anos, sexo feminino, natural e procedente de São Paulo. Paciente puérpera - 40º dia (G3P3A0), procurou o pronto-socorro com queixa de síncope durante amamentação e dispneia em moderados esforços. Durante a avaliação no PS, evoluiu para desconforto torácico e agitação psicomotora, sendo notada taquicardia ventricular não sustentada no monitor cardíaco ( torsades de pointes), que foi controlada com cardioversão elétrica e sulfato de magnésio intravenoso. O eletrocardiograma mostrou ritmo sinusal, alteração difusa da repolarização ventricular e intervalo QTc de 580 ms. O ecocardiograma mostrou disfunção sistólica moderada, com fração de ejeção do ventrículo esquerdo de 43% à custa de hipocinesia difusa. Após avaliação da equipe de arritmologia chegou-se ao diagnóstico de cardiomiopatia periparto associado à síndrome do QT longo. Foi iniciado tratamento otimizado para insuficiência cardíaca e implantado cardiodesfibrilador por causa de episódios recorrentes de arritmia durante a internação. Discussão: A cardiomiopatia periparto é uma doença rara, porém, tem taxa de mortalidade elevada, entre 18% e 56%. A paciente descrita satisfez os quatro critérios para o diagnóstico: sintomas de insuficiência cardíaca nos primeiros 5 meses depois do parto, ausência de cardiomiopatia prévia, etiologia desconhecida e disfunção sistólica com FEVE < 45%. A síndrome do QT longo é uma doença genética de apresentações variáveis. Os fatores que desencadeiam as taquiarritmias são situações de instabilidade elétrica por hiperatividade do sistema simpático e também situações raras, como a cardiomiopatia periparto. Em casos de arritmias ventriculares graves, o tratamento é o implante de cardiodesfibrilador. Conclusão: A associação da cardiomiopatia periparto com a síndrome do QT longo é rara. A gravidade associada a essas condições torna importante o diagnóstico precoce e tratamento imediato pelo potencial risco de morte associado a ambas as condições clínicas
Peripartum cardiomyopathy is a rare cause of heart failure during the period between the last month of pregnancy and five months after delivery. Long QT syndrome is characterized by a delay in ventricular repolarization and may manifest with syncope and sudden death due to a type of polymorphic ventricular tachycardia known as torsades de pointes. Case description: J.S., 26-years-old, female, born and residing in São Paulo, Puerperal - 40th day (G3C3A0), went to the emergency room complaining of syncope during breastfeeding and dyspnea on moderate exertion. During evaluation in the ER, the patient developed thoracic discomfort and psychomotor agitation, with non-sustained ventricular tachycardia on the cardiac monitor (torsades de pointes), which was controlled with electrical cardioversion and intravenous magnesium sulfate. The electrocardiogram showed sinus rhythm, diffuse alteration of ventricular repolarization and QTc interval of 580 ms. The echocardiogram showed moderate systolic dysfunction, with a left ventricular ejection fraction of 43% influenced by diffuse hypokinesia. After evaluation by the arrhythmology team, the diagnosis of peripartum cardiomyopathy associated with long QT syndrome was made. Optimized treatment for heart failure was initiated and a cardioverter-defibrillator was implanted due to recurrent episodes of arrhythmia during hospitalization. Discussion: Peripartum cardiomyopathy is a rare disease, but it has a high mortality rate, between 18% and 56%. The patient described met the 4 diagnostic criteria: symptoms of heart failure in the first 5 months after delivery, absence of prior cardiomyopathy, unknown etiology, and systolic dysfunction with LVEF<45%. Long QT syndrome is a genetic disease of varying presentations. The factors that trigger the tachyarrhythmias are situations of electrical instability due to sympathetic system hyperactivity and rare situations, such as peripartum cardiomyopathy. In cases of severe ventricular arrhythmias, the treatment is a cardioverter-defibrillator implant. Conclusion: The association of peripartum cardiomyopathy with long QT syndrome is rare. The severity associated with these conditions points out early diagnosis and immediate treatment important because of the potential risk of death associated with both clinical conditions
Subject(s)
Humans , Female , Adult , Long QT Syndrome , Tachycardia, Ventricular , Peripartum Period , Cardiomyopathies/diagnosis , Syncope , Risk Factors , Torsades de Pointes , Electrocardiography/methods , Heart RateABSTRACT
Carcinoid tumors are rare malignancies able to spread and produce bioactive humoral products, mainly serotonin, which is responsible for the Carcinoid Syndrome (CS); its features are: flushing, diarrhea, bronchospasm and valvular heart disease. The Carcinoid Heart Disease (CHD) importantly worsens prognosis and it is found in up to 50% of patients with CS. After being produced by liver implants, serotonin finds its way straight into the right heart cavities, leading to valve tissue aggression and ventricular dysfunction. Early CHD diagnosis is still a challenge due to the asymptomatic initial stage, until right heart failure develops along with ascites, swelling and hepatomegaly. Echocardiography is still the main tool for diagnosis, especially due to its ability to appropriately evaluate ventricular and valve function, cardiac morphology and hemodynamics. Tricuspid regurgitation, pulmonic stenosis and dilated cardiomyopathy are the main impairments found in CHD. Magnetic resonance imaging has also developed well in this field, and it is now believed to be essential, due to accurate right cavities evaluation and fibrosis detection. For better prognosis, early diagnosis must be pursued, which has impact on clinical management and valve repair surgical decision.
ABSTRACT
Aims: In patients with infective endocarditis, with risk of embolization, early identification of parenchymal changes may suggest the risk of splenic rupture. Presentation of Case: A 68-year-old male presented with a history of 2 months of fever and also left upper quadrant pain initiated 2 days before admission. Transesophageal echocardiogram demonstrated the presence of two mobile vegetations on the ventricular side of the aortic valve; the largest diameter being 2.1 cm. Enterococcus faecalis was isolated in blood culture after a diagnosis of subacute aortic valve infective endocarditis. He complained of abdominal pain. An abdominal computed tomography scan revealed infarction of the upper region of the spleen (septic embolism). Therapy with penicillin and gentamicin was initiated, but the patient developed symptoms of heart failure that led to a surgical treatment, and aortic bioprosthesis was implanted on day 14. On day 5 postoperatively, the patient developed sudden hemorrhagic shock signs due to splenic rupture and underwent emergency splenectomy. A pathological examination revealed areas of splenic laceration of the capsule, splenic infarction areas, and the absence of abscesses. Splenic rupture is a complication much rarely occurring due to infectious endocarditis caused by E. faecalis. Conclusion: This case highlights the importance of conducting serial imaging, particularly in symptomatic patients, for the early detection of parenchymal changes that may suggest the risk of rupture.
ABSTRACT
FUNDAMENTO: Há grande controvérsia quanto ao diagnóstico de Insuficiência Renal Aguda (IRA), existindo mais de 30 diferentes definições. OBJETIVO: Avaliar a incidência e os fatores de risco para desenvolvimento de IRA no pós-operatório de cirurgia cardíaca de acordo com os critérios RIFLE, AKIN e KDIGO, e comparar o poder prognóstico desses critérios. MÉTODOS: Estudo de corte transversal que incluiu 321 pacientes (62 [53 - 71] anos, 140 homens) consecutivamente submetidos a cirurgia cardíaca entre junho de 2011 e janeiro de 2012. Os pacientes foram acompanhados por 30 dias, com vistas ao desenvolvimento de um desfecho composto (mortalidade, necessidade de diálise e internação prolongada). RESULTADOS: A incidência de IRA variou de 15% - 51%, conforme o critério diagnóstico adotado. Enquanto a idade se associou ao risco de IRA nos três critérios, houve variação nos demais determinantes. Durante o acompanhamento, 89 pacientes apresentaram o desfecho e todos os critérios se associaram ao risco aumentado na análise Cox univariada e após o ajuste para idade, sexo, diabetes e tipo de cirurgia. Contudo, após novo ajuste para tempo de circulação extracorpórea e presença de baixo débito cardíaco, apenas o diagnóstico de IRA pelo critério KDIGO manteve esta associação significativa (HR= 1,89 [95% IC: 1,18 - 3,06]). CONCLUSÕES: A incidência e os fatores de risco para IRA pós-cirurgia cardíaca têm grande variação de acordo com os critérios diagnósticos utilizados. Em nossa análise, o critério KDIGO se mostrou superior ao AKIN e ao RIFLE quanto ao seu poder prognóstico.
BACKGROUND: There is considerable controversy regarding the diagnosis of Acute Kidney Injury (AKI), and there are over 30 different definitions. OBJECTIVE: To evaluate the incidence and risk factors for the development of AKI following cardiac surgery according to the RIFLE, AKIN and KDIGO criteria, and compare the prognostic power of these criteria. METHODS: Cross-sectional study that included 321 consecutively patients (median age 62 [53-71] years; 140 men) undergoing cardiac surgery between June 2011 and January 2012. The patients were followed for up to 30 days, for a composite outcome (mortality, need for dialysis and extended hospitalization). RESULTS: The incidence of AKI ranged from 15% - 51%, accordingly to the diagnostic criterion adopted. While age was associated with risk of AKI in the three criteria, there were variations in the remaining risk factors. During follow-up, 89 patients developed the outcome and all criteria were associated with increased risk in the univariate Cox analysis and after adjustment for age, gender, diabetes, and type of surgery. However, after further adjustment for extracorporeal circulation and the presence of low cardiac output, only AKI diagnosed by the KDIGO criterion maintained this significant association (HR= 1.89 [95% CI: 1.18 - 3.06]). CONCLUSION: The incidence and risk factors for AKI after cardiac surgery vary significantly according to the diagnostic criteria used. In our analysis, AKI the KDIGO criterion was superior to AKIN and RIFLE with regard its prognostic power.