The role of left atrial enlargement and age in the prediction of recurrence in embolic strokes of undetermined source / El papel del crecimiento auricular izquierdo y la edad como predictores de recurrencia en infarto cerebral embólicos de origen indeterminado

Abstract Objectives: Left atrial disease is an independent risk factor for ischemic stroke and can be used to predict atrial fibrillation (AF). We examine whether left atrial enlargement (LAE) could predict stroke recurrence in patients with embolic stroke of undetermined source (ESUS). Materials and methods: Sixty-four patients with a confirmed diagnosis of ESUS were followed for a median of 22 months. Clinical data and echocardiogram findings were recorded. The echocardiogram interpretation was performed centrally and blindly. The Brown ESUS – AF score was used to categorize patients into high (human resource planning [HRP]: score > 2) and low-risk patients (non-HRP score 0-1). Stroke recurrence was the primary outcome. Results: The median age was 62 years (range: 22-85 years); and 33 (51.6%) were men. The median initial NIHSS score was three points (range: 0-27). Twelve (18.8%) patients were categorized as HRP. We found a significant tendency toward recurrence among HRP versus non-HRP patients. Three (25%) HRP versus 2 (3.8%) non-HRP experienced recurrence (OR: 8.3 95% CI 1.2-57; p=0.042); this association was related to severe atrial dilatation (OR: 14.5 95% CI 0.78-277, p = 0.02) and age > 75 years (OR: 12.7 95% CI 1.7-92.2, p = 0.03). We found no differences in recurrence in a univariate analysis. Conclusions: Patients with severe LAE who are 75 years old or older have a significant tendency to experience stroke recurrence.

Resumen Objetivos: La patología atrial izquierda es factor de riesgo independiente para infarto cerebral y puede utilizarse para predecir fibrilación auricular. Examinamos si el crecimiento aurícular izquierdo puede predecir recurrencia en pacientes con infarto embolico de origen indeterminado (ESUS). Materiales y métodos: Sesenta y cuatro pacientes con diagnóstico confirmado de ESUS fueron seguidos por una mediana de seguimiento de 22 meses. Registramos los datos clínicos y ecocardiográficos. La interpretación ecocardiográfica fue centralizada y cegada. La escala de Brown ESUS – AF fue utilizada para categorizar a los pacientes en riesgo alto (HRP puntaje > 2) y bajo riesgo (no-HRP: puntaje 0-1). El descenlace primario fue recurrencia de infarto cerebral. Resultados: Mediana de edad fue de 62 años (rango: 22-85 años); 33 (51.6%) fueron hombres. La mediana inicial de la escala de NIHSS fue de 3 putnos (rango de 0 a 27). 12 (18.8%) pacientes fueron de alto riesgo (HRP) y 52 (81.3%) de bajo riesgo (non- HRP). El grupo HRP mostró tendencia significatica hacia mayor recurrencia. Tres (25%) HRP versus 2 (3.8%) no-HRP experimentaron recurrencia (OR: 8.3 IC 95% 1.2-57; p = 0.042); esta asociación se relacionó con dilatación auricular severa (OR: 14.5 IC 95% 0.78-277, p = 0.02) y edad > 75 años (OR: 12.7 IC 95% 1.7-92.2, p = 0.03). En el análisis multivarioado, no encontramos significativas. Conclusiones: El crecimiento auricular izquierdo severo y la edad mayor de 75 años mostraron tendencia significativa a recurrencia de infarto cerebral.

Punção da artéria axilar para intervenções percutâneas em lactentes portadores de cardiopatias congênitas: "à procura de um caminho mais curto e mais seguro" / Axillary artery access for percutaneous interventions in infants with congenital heart disease: \"in search of a shorter and safer pathway"

INTRODUÇÃO: O acesso através da punção da artéria axilar (AAx) tem sido utilizado em adultos com bons resultados, porém seu uso em neonatos e lactentes jovens tem sido pouco relatado. Nosso objetivo foi relatar a experiência inicial com o uso desse acesso em diferentes intervenções nessa faixa etária de pacientes. Método: De janeiro de 2009 a setembro de 2010 foram incluídas 11 crianças submetidas a diferentes procedimentos intervencionistas realizados através de punção da AAx. O procedimento foi realizado com agulha 21 G, sendo utilizados introdutores 4 F ou 5 F pediátricos. Resultados: A média de idade foi de 26 + - 12 dias e o peso médio de 4,2 +- 1,7 kg. Os procedimentos intervencionistas realizados foram: implante de stent no canal arterial (6) valvoplastia aórtica (1) angioplastia aórtica (2), implante de stent em Blalock-Taussig (1), e redilatação do stent do canal arterial (!). A punção da AAx direita foi realizada com sucesso em todos os pacientes e sem dificuldade técnica. Os tempos médios do procedimento...

BACKGROUND: Axillary artery access (AxA) has been used in adults with good results, however, its use in neonates and infants has not been extensively reported. This study was aimed at reporting our initial experience using this access in different cardiac interventions in this age group. METHOD: From January 2009 to September 2010, 11 children were submitted to different cardiac interventions using AxA. The procedure was performed with a 21 G needle followed by the insertion of a 4 F or a 5 F pediatric sheats. RESULTS: Mean age was 26 ± 12 days and mean weight was 4.2 ± 1.7 Kg. The cardiac interventions performed were: stenting of the arterial duct (6), aortic valvoplasty (1), aortic angioplasty (2), stent implantation in a Blalock-Taussig shunt (1) and stent redilation in the arterial duct (1). Right AxA puncture was successfully obtained in all patients without technical difficulties. Mean procedure and fluoroscopy times were 52 ± 15 minutes and 13 ± 4 minutes, respectively. Pneumothorax without hemodynamic involvement was the single complication in one patient. The other patients did not have any abnormalities. There were no ischemic or neurologic complications in the ipsilateral limb. Mean time of Intensive Care Unit (ICU) stay was 48 ± 16 hours. There were no deaths during the interventional procedures and one patient died of sepsis at the ICU 5 days after the procedure. CONCLUSION: In our experience AxA proved to be a safe and effective alternative for different interventional procedures in neonates and infants with congenital heart diseases.

Estenose mitral congênita supravalvar / Supravalvular congenital mitral stenosis

Congenital supravalvular mitral stenosis is a rare malformation characterized by the presence of a shelf-like fibrous membrane, with 1 or 2 small orifices, covering and obstructing the mitral valve. The membrane is positioned closely to the mitral valve (and sometimes it is attached to it); therefore, a preoperative diagnosis is inevitably difficult, even with the use of biplane echocardiography. Two patients with supravalvular mitral stenosis aged 3 years and 3 months are described. In 1 patient, a preoperative diagnosis was made, and both successfully underwent correction