Catéter de arteria pulmonar en shock cardiogénico: novedades acerca de su valor pronóstico y marcadores derivados

El uso del catéter de arteria pulmonar es un método eficaz para la monitorización de los pacientes críticos. Aunque ampliamente utilizado en las Unidades de Cuidados Críticos Cardiológicos, no se ha demostrado en estudios previos el beneficio de su uso. Registros recientes y numerosos en pacientes graves cursando shock cardiogénico muestran un beneficio en términos de mortalidad asociada, sobre todo relacionado con una adecuada interpretación. Además, nuevos parámetros relacionados con insuficiencia ventricular como son el poder cardíaco y el índice de pulsatilidad de arteria pulmonar, así como el conocimiento de las presiones de llenado ventriculares, tanto izquierdas, como derechas, ayudan en la toma de decisiones, las opciones de tratamiento y estimación del pronóstico. Complementando lo anterior, la modernización en la tecnología del catéter de arteria pulmonar permite la medición del gasto cardíaco de forma continua a través de un sistema termodilución integrada. Este sistema también permite la monitorización más precisa del ventrículo derecho por medio de la valoración continua de su fracción de eyección y volumen de fin de diástole. La información obtenida por medio del catéter de arteria pulmonar en shock cardiogénico ha llevado a que su uso comience a ser cada vez más frecuente en unidades de cuidados críticos cardiológicos y que se empleen estos valores por equipos de shock cardiogénico para la toma de decisiones complejas. La evidencia descrita sobre el valor pronóstico relacionada al uso del catéter de arteria pulmonar se resume en esta revisión.

The pulmonary artery catheter is an effective tool for monitoring critically ill patients; however, the evidence showed limited value and a posible increased risk. Recently, numerous registries in critical ill patients in cardiogenic shock have shown a benefit in mortality, especially related to an adequate interpretation of findings. In addition, new parameters related to ventricular failure, such as cardiac power output and pulmonary artery pulsatility index have shown to be useful for a better treatment and estimation of prognosis. Besides, determination of filling pressures (right and/or left side) have an important role in terms of prognosis and management. Advances in pulmonary artery catheter technology allows us to continuously measure cardiac output through an integrated thermodilution system. This system also allows the continuous assessment of right ventricular ejection fraction and end-diastolic volume. The information obtained has led to an increased use of the pulmonary artery catheter monitoring in cardiac Intensive Care Units allowing improvements in treatment and complex decision-making.

Embolização percutânea de fístulas arteriovenosas pulmonares / Percutaneous embolization of pulmonary arteriovenous fistulas

Malformações arteriovenosas pulmonares são uma comunicação anormal entre uma artéria e uma veia, causando manifestações clínicas, como hipoxemia crônica e eventos embólicos. As malformações arteriovenosas eram tratadas cirurgicamente, com taxa expressiva de complicações. Na década de 1970, a primeira embolização percutânea por cateter foi realizada com molas. Descrevemos três casos nos quais técnicas de embolização percutânea foram efetivas em prevenir eventos embólicos, hemorrágicos e hipoxêmicos no seguimento dos pacientes.

Pulmonary arteriovenous malformation is an abnormal communication between an artery and a vein, causing clinical manifestations, such as chronic hypoxemia and embolic events. Arteriovenous malformations were treated surgically, with a significant rate of complications. In the 1970 ́s, the first percutaneous catheter embolization was performed with coils. We describe three cases in which percutaneous embolization techniques were effective to prevent embolic, hemorrhagic, and hypoxemic events in the follow-up of patients.

Asociación del complejo ring-sling con pig bronchus: a propósito de un caso pediátrico / Ring-sling complex association with pig bronchus: a pediatric case report

El complejo ring-sling es una asociación entre el sling de la arteria pulmonar y la estenosis traqueal congénita por anillos traqueales completos. El sling de la arteria pulmonar es una forma rara de anillo vascular dentro de las cardiopatías congénitas. Se presenta el caso clínico de un niño con estridor laríngeo asociado a dificultad respiratoria evaluado en otro centro, donde se realizó endoscopia respiratoria y se observó compresión traqueal extrínseca. Ante la sospecha clínica de anillo vascular, se solicitó angiotomografía computada (angioTC) y se confirmó diagnóstico de sling de arteria pulmonar. Fue derivado a nuestro hospital y durante la intervención quirúrgica se realizó nueva endoscopia respiratoria y traqueobroncografía. Se llegó al diagnóstico de estenosis traqueal congénita con bronquio derecho accesorio (pig bronchus) y anillos vasculares completos, ambos reparados en el mismo acto quirúrgico.

The ring-sling complex is an association between pulmonary artery sling and congenital tracheal stenosis. Pulmonary artery sling is a rare form of vascular ring in congenital heart disease. The clinical case of a child with inspiratory laryngeal stridor associated with respiratory distress is presented, evaluated in another center where respiratory endoscopy was performed, observing extrinsic tracheal compression. Given the clinical suspicion of a vascular ring, CT angiography was requested, confirming the diagnosis of pulmonary artery sling. He was referred to our hospital and during the surgical intervention a new respiratory endoscopy and tracheobronchography were performed, reaching the diagnosis of congenital tracheal stenosis, right accessory bronchus (pig bronchus) and complete vascular rings, both repaired in the same surgical act.

Relación de la presión sistólica de la arteria pulmonar medida por ecocardiograma con el tiempo y el tipo de terapia de reemplazo renal / The relationship between systolic pressure of the pulmonary artery measured by echocardiogram and the duration and type of renal replacement therapy

Resumen Introducción: Las alteraciones secundarias a la enfermedad renal crónica (ERC), como inflamación sistémica, anemia y sobrecarga hídrica, son un sustrato importante para el desarrollo de hipertensión arterial pulmonar. Objetivo: Valorar la relación de la presión sistólica de la arteria pulmonar (PSAP) por ecocardiograma con el tiempo y el tipo de terapia de reemplazo renal (TRR) en pacientes con ERC. Método: Estudio observacional, retrospectivo, llevado a cabo en el Hospital de Especialidades del Centro Médico Nacional La Raza, en el que se analizaron medidas de tendencia central y medidas de dispersión. Para comparar porcentajes se utilizó la prueba de χ2 con el programa estadístico SPSS 25. Resultados: Se incluyeron 141 pacientes con ERC en TRR con diálisis peritoneal o hemodiálisis. Se clasificaron de acuerdo con la PSAP en normal (30 pacientes, 21.28%), leve (43 pacientes, 30.5%), moderada (16 pacientes, 12%) y grave (52 pacientes, 36.88%). El tiempo de TRR está relacionado con una PSAP mayor, con 3.53 años en caso de PSAP normal, 5.51 años en caso de PSAP leve, 6.00 años para la PSAP moderada y 6.38 años para la PSAP grave. La PSAP grave se presentó en 13 de 56 pacientes en diálisis peritoneal y en 39 de 85 en hemodiálisis (p = 0.034). Conclusiones: Se encontró que existe relación entre la PSAP con el tiempo y el tipo de sustitución renal en pacientes con ERC.

Abstract Introduction: The disorders secondary to chronic kidney disease (CKD), such as systemic inflammation, anemia, and fluid overload are an important substrate for the development of pulmonary arterial hypertension. Objective: To assess the relationship between pulmonary artery systolic pressure (PASP) on echocardiogram and the duration and type of renal replacement therapy (RRT) in patients with CKD. Method: A retrospective observational study at Hospital de Especialidades del Centro Médico Nacional La Raza. The analysis was performed using measures of central tendency and dispersion. Chi square was used to compare percentages through the SPSS 25 statistical program. Results: A total of 141 patients with CKD on RRT with peritoneal dialysis or hemodialysis were included. They were classified according to PASP as normal (30 patients, 21.28%), mild (43 patients, 30.5%), moderate (16 patients, 12%) and severe (52 patients, 36.88%). The duration of RRT is related to a higher PASP, with 3.53 years for a normal PASP, 5.51 years for mild PASP, 6.00 years for moderate PASP, and 6.38 for those with severe PASP. Severe PASP occurred in 13 of 56 patients on peritoneal dialysis and 39 of 85 patients on hemodialysis (p = 0.034). Conclusions: This study found a relationship between PASP and the duration and type of renal replacement in patients with CKD.

Tempo de aceleração na via de saída do ventrículo direito: correlação com a função diastólica do ventrículo esquerdo, sexo e idade / Right ventricular outflow tract acceleration time: correlation with left ventricular diastolic function, sex, and age

Fundamento: O tempo de aceleração na artéria pulmonar (TAP) pode ser utilizado para avaliação da hipertensão pulmonar na análise da função diastólica do ventrículo esquerdo. Objetivo: Avaliar se existe correlação entre o valor do tempo de aceleração na artéria pulmonar e parâmetros da função diastólica do ventrículo esquerdo em indivíduos com função sistólica do ventrículo esquerdo preservada e de acordo com sexo, idade e fatores de risco cardiovasculares. Métodos: Estudo observacional, transversal. Foram selecionados 119 pacientes (59 mulheres; 49,6%). Os indivíduos foram submetidos ao ecocardiograma transtorácico incluindo os valores de tempo de aceleração na artéria pulmonar; ondas E e A e relação E/A ao Doppler espectral do influxo mitral; ondas e' septal, e' lateral e relação E/e' ao Doppler tecidual do anel mitral; pressão sistólica na artéria pulmonar e volume atrial esquerdo. Resultados: No sexo feminino, foi encontrada correlação positiva (coeficiente de correlação de Spearman) entre o valor do tempo de aceleração na artéria pulmonar e e' lateral (coeficiente de correlação de Spearman de 0,47; p=0,002), relação E/A (coeficiente de correlação de Spearman de 0,32; p=0,04) e e' septal (coeficiente de correlação de Spearman de 0,36; p=0,023) e uma correlação negativa entre o valor do tempo de aceleração na artéria pulmonar e pressão sistólica na artéria pulmonar (coeficiente de correlação de Spearman de -0,43; p=0,034). No sexo masculino, não foi encontrada correlação significativa. Foram encontrados menores valores de tempo de aceleração na artéria pulmonar em mulheres com hipertensão arterial sistêmica quando comparadas a mulheres sem hipertensão arterial sistêmica (0,13±0,03 segundos versus 0,16±0,03 segundos; p = 0,015). Conclusão: O presente estudo mostrou correlação significativa dos valores do TAP com alguns parâmetros da função diastólica do ventrículo esquerdo apenas no sexo feminino, sendo que mulheres hipertensas apresentaram menores valores de TAP. (AU)

Background: Pulmonary artery acceleration time (PAAT) can be used as a parameter in the evaluation of pulmonary hypertension and aids left ventricular diastolic function (LVDF) analyses. Objective: To assess whether there is a correlation between PAAT and LVDF parameters in individuals with a preserved left ventricular systolic function and by sex, age, and cardiovascular risk factors. Method: Observational cross-sectional study. One hundred nineteen patients were selected (59 women [49.6%]). The subjects underwent transthoracic echocardiography including measurements of PAAT, E and A waves and E/A ratio, e' septal and e' lateral waves and E/e' ratio, pulmonary artery systolic pressure (PASP), and left atrial volume. Results: In female patients, a positive correlation (Spearman's correlation coefficient ­ Spearman correlation coefficient [SCC]) was found between the PAAT value and the lateral e' (SCC, 0.47; p = 0.002), with the E/A ratio (SCC, 0.32; p = 0.04), and with septal e' (SCC, 0.36; p = 0.023), and a negative correlation between PAAT and PASP (SCC, -0.43; p = 0.034). In men, no correlation was found between PAAT. and any parameters. Lower PAAT values were found in women with systemic arterial hypertension (hypertension) than in women without hypertension (0.13 ± 0.03 s versus 0.16 ± 0.03 s; p = 0.015). Conclusion: The present study showed a significant correlation between PAAT and some LVDF parameters in female patients only. Hypertension was correlated with lower PAAT values in women. (AU)

Origen anómalo de una de las ramas de la arteria pulmonar (OAAP): tratamiento quirúrgico y resultados / Anomalous origin of one of the branches of the pulmonary artery (AOPA): Surgical treatment and outcome

Resumen Introducción: El origen anómalo de una de las ramas de la arteria pulmonar procedente de la aorta ascendente es poco frecuente. Objetivo: Identificar las características clínicas y quirúrgicas de los pacientes sometidos a reimplante de la rama afectada. Método: Se realizó un estudio observacional, transversal, descriptivo, retrospectivo y retrolectivo, en el que se incluyeron los pacientes diagnosticados de origen anómalo de alguna de las ramas de la arteria pulmonar y que fueron tratados mediante cirugía correctiva en el Instituto Nacional de Cardiología Ignacio Chávez, en el periodo del 1 de enero de 2003 al 31 de enero de 2019. De los expedientes se extrajeron las características demográficas, los antecedentes quirúrgicos, los diagnósticos, los reportes ecocardiográficos y tomográficos, la técnica quirúrgica y el estado posquirúrgico. Resultados: Se encontraron nueve pacientes sometidos a cirugía de corrección, con un promedio de edad de 2 ± 2 años, un peso de 11.4 ± 1.5 kg y una talla de 82 ± 15 cm. El 67% fueron de sexo masculino. La rama afectada con más frecuencia fue la derecha; el 68% se originaban directamente de la aorta y el 42% de un conducto arterioso persistente. La corrección con circulación extracorpórea tuvo un tiempo promedio de pinzamiento aórtico de 35 minutos y de soporte circulatorio de 45 minutos. Se utilizó el implante directo o con material sintético. Las complicaciones fueron falla ventricular, sangrado, arritmias y neumonía nosocomial. La mortalidad fue del 11%. Conclusiones: El tratamiento quirúrgico para el reimplante de la rama anómala de la arteria pulmonar es el procedimiento de elección, y con cuidados quirúrgicos y posteriores tiene un buen pronóstico a mediano y largo plazo.

Abstract Introduction: The anomalous origin of one of the branches of the pulmonary artery from the ascending aorta is rare. Objective: To identify the clinical and surgical characteristics of the patients undergoing reimplantation of the affected branch. Method: An observational, cross-sectional, descriptive, retrospective and retrolective study was performed; patients diagnosed with anomalous origin of one of the branches of the pulmonary artery and treated by corrective surgery at the Instituto Nacional de Cardiología Ignacio Chavez, in the period from January 1, 2003 to January 31, 2019, were included. It was extracted from the files: demographic characteristics, surgical antecedents, diagnoses, echocardiographic and tomographic reports, surgical technique and post-surgical status. Results: Nine patients underwent correction surgery, with an average age of 2 ± 2 years, 11.4 ± 1.5 kg and height 82 ± 15 cm; 67% were male. The most frequent affected branch was the right, 68% originated directly from the aorta and 42% from a patent ductus arteriosus. The correction with extracorporeal circulation had an average aortic cross-clamp of 35 minutes and circulatory support of 45 minutes, the direct or synthetic implant was used. The complications were ventricular failure, bleeding, arrhythmias and nosocomial pneumonia. Mortality was 11%. Conclusions: Surgical treatment for reimplantation of the anomalous branch of the pulmonary artery is the procedure of choice, which with surgical and subsequent care has a good prognosis in the medium and long term.

Dextrocardia con doble salida del ventrículo derecho con comunicación interventricular no relacionada asociada a malposición de grandes vasos / Right ventricular double outlet dextrocardia with unrelated ventricular septal defect associated with great vessel malposition

Resumen En el siguiente reporte se expone un caso complejo en el que coexisten malformaciones cardiacas congénitas de presentación atípica con un doble tracto de salida del ventrículo derecho, en un paciente con múltiples anomalías menores en la exploración física y un cariotipo normal. La atipia de cada una de estas y su coexistencia hacen pensar en posibles alteraciones genéticas que aún son desconocidas. Lo anterior supone un reto terapéutico con el fin de restaurar una fisiología cardiaca compatible con la vida, lo cual se logra en este caso mediante un cerclaje exitoso de la arteria pulmonar.

Abstract The following report presents a complex case in which congenital cardiac malformations of atypical presentation coexist with a double outlet right ventricle, in a patient with multiple minor abnormalities on the physical examination and a normal karyotype. The atypia of these and their coexistence suggest possible genetic alterations that are still unknown. Therefore, a therapeutic challenge in order to restore a cardiac physiology compatible with life is proposed, which is achieved in this case through a successful banding of the pulmonary artery.

Damage control surgery for thoracic outlet vascular injuries: the new resuscitative median sternotomy plus REBOA / Cirugía de control de daños para lesiones del opérculo torácico: nuevo abordaje mediante esternotomía mediana y REBOA

Abstract Thoracic vascular trauma is associated with high mortality and is the second most common cause of death in patients with trauma following head injuries. Less than 25% of patients with a thoracic vascular injury arrive alive to the hospital and more than 50% die within the first 24 hours. Thoracic trauma with the involvement of the great vessels is a surgical challenge due to the complex and restricted anatomy of these structures and its association with adjacent organ damage. This article aims to delineate the experience obtained in the surgical management of thoracic vascular injuries via the creation of a practical algorithm that includes basic principles of damage control surgery. We have been able to show that the early application of a resuscitative median sternotomy together with a zone 1 resuscitative endovascular balloon occlusion of the aorta (REBOA) in hemodynamically unstable patients with thoracic outlet vascular injuries improves survival by providing rapid stabilization of central aortic pressure and serving as a bridge to hemorrhage control. Damage control surgery principles should also be implemented when indicated, followed by definitive repair once the correction of the lethal diamond has been achieved. To this end, we have developed a six-step management algorithm that illustrates the surgical care of patients with thoracic outlet vascular injuries according to the American Association of the Surgery of Trauma (AAST) classification.

Resumen El trauma vascular torácico está asociado con una alta mortalidad y es la segunda causa más común de muerte en pacientes con trauma después del trauma craneoencefálico. Se estima que menos del 25% de los pacientes con una lesión vascular torácica alcanzan a llegar con vida para recibir atención hospitalaria y más del 50% fallecen en las primeras 24 horas. El trauma torácico penetrante con compromiso de los grandes vasos es un problema quirúrgico dado a su severidad y la asociación con lesiones a órganos adyacentes. El objetivo de este artículo es presentar la experiencia en el manejo quirúrgico de las lesiones del opérculo torácico con la creación de un algoritmo de manejo quirúrgico en seis pasos prácticos de seguir basados en la clasificación de la AAST. que incluye los principios básicos del control de daños. La esternotomía mediana de resucitación junto con la colocación de un balón de resucitación de oclusión aortica (Resuscitative Endovascular Balloon Occlusion of the Aorta - REBOA) en zona 1 permiten un control primario de la hemorragia y mejoran la sobrevida de los pacientes con trauma del opérculo torácico e inestabilidad hemodinámica.

Agenesia unilateral de la arteria pulmonar: presentación de dos casos y revisión de la literatura / Unilateral agenesis pulmonary artery: presentation of two cases and review of the literature

Unilateral agenesis of the pulmonary artery is a rare malformation, sometimes asymptomatic and underdiagnosed. Right agenesis is usually isolated, while the left agenesis is more frequently associated with cardiovascular malformations. Some patients have recurrent respiratory infections, exercise limitation, hemoptysis, and/or pulmonary hypertension. The diagnosis is suspected by chest radiograph showing a hypoplastic lung ipsilateral to the agenesis. It is confirmed with contrast-enhanced chest computed tomography. In asymptomatic patients, management should be conservative, however, the search for collateral vessels should be started from adolescence, because they can bleed. In symptomatic patients or those with serious complications, the treatment must be interventional. The objective of this article is to present two patients with right and left pulmonary artery agenesis respectively and review the literature.

La agenesia unilateral de la arteria pulmonar es una malformación poco frecuente, en ocasiones asintomática y subdiagnosticada. La agenesia derecha suele ser aislada, en cambio la izquierda se asocia más frecuentemente a malformaciones cardiovasculares. Algunos pacientes presentan infecciones respiratorias recurrentes, limitación al ejercicio, hemoptisis y/o hipertensión pulmonar. El diagnóstico se sospecha al solicitar una radiografía de tórax que muestra un pulmón hipoplásico ipsilateral a la agenesia. Se confirma con tomografía computada de tórax con contraste. En pacientes asintomáticos el manejo debe ser conservador, sin embargo, se debe iniciar la búsqueda de vasos colaterales especialmente durante la adolescencia, los que pueden sangrar. En cambio, en los pacientes sintomáticos o que presentan complicaciones graves, el tratamiento debe ser intervencional. El objetivo de este trabajo es presentar a dos pacientes con agenesia de la arteria pulmonar derecha e izquierda respectivamente y hacer una revisión de la literatura.

Efeito do treinamento aeróbio em parâmetros cardiorrespiratórios, hemodinâmicos e autonômicos de pacientes com doença renal crônica em hemodiálise / Effect of aerobic training on cardiorespiratory, hemodynamic, and autonomic parameters of chronic kidney disease patients on hemodialysis

A doença renal crônica (DRC) é uma condição clínica de alto risco cardiovascular e os pacientes nos estágios mais avançados da doença que dependem de terapia renal substitutiva frequentemente tem prejuízo cardiorespiratório, níveis elevados de pressão arterial (uso de múltiplas medicações para controle), modulação autonômica prejudicada e graus variados de inflamação. Deste modo este estudo tem como objetivo verificar se o exercício físico aeróbio intradialítico tem impacto em modificar estas alterações. Os pacientes foram selecionados em duas unidades de hemodiálise em São Luís do Maranhão, Brasil, entre junho de 2016 e outubro de 2019, e foram alocados conforme aceitação em grupo controle (GC) e grupo exercício (GE). O GE foi submetido a treinamento aeróbio com bicicleta por um período de 12 semanas. Avaliação física antropométrica, teste de caminhada de 6 minutos (TC6m), ecocardiograma, eletrocardiograma com análise da variabilidade da frequência cardíaca e medidas laboratoriais foram realizadas incluindo interleucina 6 (IL6) antes e após 12 semanas em ambos os grupos. Trinta e um pacientes foram avaliados 15 pacientes no grupo controle (GC) e 16 pacientes no grupo exercício (GE). Após 12 semanas de treinamento houve diminuição da pressão arterial sistólica do grupo exercício em relação ao basal (129,8 ± 9,41mmHg vs 112,00 ± 12,0 mmHg p = 0,03). Não houve alterações na composição corporal e na maioria dos exames laboratoriais, exceto pelo aumento do KTV (índice de adequação de diálise) e diminuição do LDL colesterol no grupo exercício em relação ao grupo controle. No entanto, os níveis de HDL colesterol aumentaram (39,92 ± 6,1 mg/dL vs 48,00 ± 7,85 mg/dL p = 0,02) e IL6 diminuíram (4,56 ± 1,2 pg / mL vs 2,14 ± 1,0 pg / mL p = 0,02). Houve aumento da distância percorrida no teste de caminhada no grupo exercício (473,80 ± 98,6 metros vs 573,50 ± 74,22 metros p = 0,01). Na avaliação ecocardiográfica, verificou-se que no GE houve diminuição da pressão da artéria pulmonar estimada (31,38 ± 2,9 mmhg vs 24,2 ± 1,7 mmhg p = 0,001). Houve melhora na modulação autonômica no GE (RMSSD 11,7 ± 4,2 vs 18,4 ± 5,7 p=0,02), LFnu (52,9 ± 17,2 vs 32,0 ± 18,2 p=0,02) e HFnu (48,1 ± 17,2 vs 68,0 ± 18,2 p=0,01). Não foram evidenciados efeitos adversos e não houve abandono do treinamento. Baseados nestes resultados, é possível concluir que o exercício aeróbio intradialítico por 12 semanas pode melhorar parâmetros cardiorrespiratórios, hemodinâmicos e autonômicos, com boa aderência e sem eventos adversos, podendo ser usado como medida coadjuvante para melhora clínica destes pacientes.

Chronic kidney disease (CKD) is a clinical condition of high cardiovascular risk and patients in the more advanced stages of the disease who depend on renal replacement therapy often experience cardiorespiratory impairment, high blood pressure levels (use of multiple medications for control), modulation impaired autonomy and varying degrees of inflammation. Thus, this study aims to verify whether intradialytic aerobic exercise has an impact on modifying these variables. The patients were selected in two hemodialysis units in São Luís do Maranhão, Brazil, between May 2016 and October 2019, and were allocated according to acceptance in the control group (CG) and exercise group (EG). The group exercise was submitted to aerobic exercise with bicycle for a period of 12 weeks. Anthropometric physical evaluation, 6-minute walk test (6MWT), echocardiogram, electrocardiogram with analysis of heart rate variability (VFC) and laboratory measurements were performed including interleukin 6 (IL6) before and after 12 weeks in both groups. Thirty-one patients were evaluated 15 patients in the control group (CG) and 16 patients in the exercise group (EG). After 12 weeks of training, there was a decrease in systolic blood pressure in the exercise group compared to baseline (129.8 ± 9.41 mmHg vs 112.00 ± 12.0 mmhg p = 0.03). There were no changes in body composition and in most laboratory tests, except for an increase in KTV (dialysis adequacy index) and a decrease in LDL cholesterol in the exercise group compared to the control group. However, HDL cholesterol levels increased (39.92 ± 6.1 mg / dL vs 48.00 ± 7.85 mg / dL p = 0.02) and IL6 decreased (4.56 ± 1.2 pg / mL vs 2.14 ± 1.0 pg / mL p = 0.02). There was an increase in the distance covered in the walking test in the exercise group (473.80 ± 98.6 m vs 573.50 ± 74.22 m p = 0,01). In the echocardiographic evaluation, it was found that in the EG there was a decrease in the estimated pulmonary artery pressure (31.38 ± 2.9 mmhg vs 24.2 ± 1.7 mmhg p = 0.001). There was an improvement in autonomic modulation in the EG (RMSSD 11.7 ± 4.2 vs 18.4 ± 5.7 p = 0.02), LFnu (52.9 ± 17.2 vs 32.0 ± 18.2 p = 0.02) and HFnu (48.1 ± 17.2 vs 68.0 ± 18.2 p = 0.01). There were no adverse effects and training was not abandoned. Based on these results, it is possible to conclude that intradialytic aerobic exercise for 12 weeks can improve cardiorespiratory, hemodynamic, and autonomic parameters, with good adherence and without adverse events, and can be used as a supporting measure for the clinical improvement of these patients.

Aneurisma de arteria pulmonar: un hallazgo incidental / Pulmonary artery aneurysm: an incidental finding

Resumen Los aneurismas de la arteria pulmonar son entidades infrecuentes y su tratamiento es tema de discusión. Desde el punto de vista etiológico pueden ser congénitos o adquiridos. Los primeros, generalmente se asocian a malformaciones cardiacas que producen hipertensión pulmonar, siendo el ductus arterioso la más frecuente. Otras anomalías incluyen defectos auriculares o ventriculares. Las causas adquiridas pueden ser idiopáticas o estar asociadas a infecciones (tuberculosis, sífilis), traumatismos o colagenopatías. Presentamos el caso de una mujer de 62 años, quien consultó por un cuadro clínico en el que se destacaba su sintomatología neurológica e infecciosa, con posterior progresión a un choque séptico y en quien los hallazgos de las imágenes mostraron un aneurisma gigante de la arteria pulmonar siendo este un hallazgo incidental y sin relación a la sintomatología de la paciente.

Abstract Aneurysms of the pulmonary artery are rare entities and their treatment is a matter of discussion. From the etiological point of view, they can be congenital or acquired. Those in the first group are generally associated with cardiac malformations that generate pulmonary hypertension, with the ductus arteriosus being the most frequent. Other abnormalities include atrial or ventricular defects. The acquired causes may be idiopathic or associated with infections (tuberculosis, syphilis), trauma, or collagen disease. We present the case of a 62-year-old woman, which consulted for a clinical condition where neurological and infectious symptoms stood out, with subsequent progression to a state of septic shock, and in whom the imaging finding showed a giant pulmonary artery aneurysm. this being an incidental finding and unrelated to the patient's symptoms.

Origen anómalo de la arteria coronaria izquierda a partir de la arteria pulmonar / Anomalous origin of left coronary artery from the pulmonary artery

Introducción: El origen anómalo de la arteria coronaria izquierda que nace en la arteria pulmonar, conocido como síndrome de Bland, White y Garland, es una enfermedad cardiaca congénita, de baja incidencia, espectro clínico variable y no es exclusiva de la edad pediátrica. Tiene una alta mortalidad en el primer año de vida si no se diagnostica y trata oportunamente. Objetivo: Describir las características del diagnóstico del síndrome de Bland, White y Garland. Métodos: Se realizó la caracterización de la entidad en Cuba en un decenio (2005 a 2015). Se incluyeron todos los pacientes con manifestaciones clínicas sugerentes de síndrome de Bland, White y Garland y confirmación ecocardiográfica. Se realizó el cálculo de la prevalencia de la entidad y se empleó el porcentaje en las variables cualitativas y la prueba exacta de Fisher. La validación estadística de los resultados de la investigación adoptó nivel de significación menor a 5 por ciento. Resultados: La prevalencia estimada en esa década en Cuba estaba alrededor de 2,9 por 300 000 nacidos vivos. Se demuestra la variabilidad en sus manifestaciones clínicas y amplio rango de edad de presentación. El tratamiento es quirúrgico con excelente supervivencia y pronóstico. Conclusiones: El diagnóstico del síndrome de Bland, White y Garland es difícil mediante el método clínico debido a la diversidad en su presentación. La prevalencia estimada en Cuba es mayor que lo registrado en el mundo actual. El diagnóstico temprano y tratamiento oportuno mejora de forma significativa la supervivencia y el pronóstico de los pacientes aquejados por esta dolencia(AU)

Introduction: The anomalous origin of left coronary artery that originates in the pulmonary artery, known as Bland, White and Garland is a congenital heart disease, with low incidence, variable clinical spectrum and is not exclusive of the pediatric age group. It has a high mortality in the first year of life if not diagnosed and treated early. Objective: To describe the characteristics of the diagnosis of Bland, White and Garland syndrome. Methods: It was made the characterization of the entity in Cuba in a decade (2005 to 2015). There were included all the patients with clinical manifestations suggestive to Bland, White and Garland syndrome and echocardiographic confirmation. It was made the calculation of this entity´s prevalence and it was used the percentage in the qualitative variables and Fisher's exact test. The statistical validation of research results had a significance level lower than 5 percent. Results: The estimated prevalence in that decade in Cuba was around 2.9 per 300 000 live births. It was demonstrated the variability in its clinical manifestations and wide range of onset´s age. The treatment is surgical with excellent survival and prognosis. Conclusions: The diagnosis of Bland, White and Garland syndrome is difficult through the clinical method due to the diversity in its presentation. The estimated prevalence in Cuba is greater than what was registered in the world today. Early diagnosis and prompt treatment significantly improves the survival and prognosis of patients suffering from this condition(AU)

Agenesia da artéria pulmonar direita: descrição de caso / Agenesis of the right pulmonary artery: a case report

RESUMO: Agenesia isolada da artéria pulmonar direita ou esquerda é uma rara anomalia congênita dada pela falta do desenvolvimento embriológico de um dos arcos aórticos. A apresentação clínica é variável, sendo a mais comum na infância, na forma de hipertensão pulmonar contralateral. No adulto, a hemoptise pode ser uma das manifestações clínicas, e nos indivíduos assintomáticos esta anomalia pode ser reconhecida em exames de diagnóstico por imagem. Relatamos o caso de paciente do sexo feminino, 63 anos, encaminhada para investigação de imagem nodular no hilo pulmonar esquerdo observada em radiografia torácica. Tomografia computadorizada evidenciou agenesia da artéria pulmonar direita com suprimento arterial pulmonar homolateral ocorrendo por vasos colaterais, pulmão esquerdo com proeminência das artérias e veias hilares e peri-hilares, provavelmente simulando uma nodulação na radiografia realizada previamente, volume discretamente reduzido do pulmão direito com espessamento liso dos septos interlobulares secundário, provavelmente devido ao aumento da microcirculação colateral intraparenquimatosa. (AU)

ABSTRACT: Isolated agenesis of the right or left pulmonary artery is a rare congenital anomaly due to the lack of embryological development of one of the aortic arches. The clinical presentation is variable, being the most common in childhood, in the form of contralateral pulmonary hypertension. In adults, hemoptysis may be one of the clinical manifestations, and in asymptomatic individuals, this anomaly can be recognized in diagnostic imaging tests. We report the case of a female patient, 63 years old, referred for investigation of the nodular image in the left pulmonary hilum observed on chest radiography. Computed tomography showed right pulmonary artery agenesis with homolateral pulmonary arterial supply occurring by collateral vessels, left lung with a prominence of the hilar and peri-hilar arteries and veins probably simulating nodulation on the radiograph previously performed, a discreetly reduced volume of the right lung with smooth thickening of the septa secondary to probably increased intraparenchymal collateral microcirculation. (AU)

Agenesia de artéria pulmonar direita: relato de caso / Agenesis of right pulmonary artery: case report

RESUMO: A agenesia de artéria pulmonar é uma malformação congênita rara, que ocorre devido ao não desenvolvimento do sexto arco aórtico. Entretanto, não é relacionada com malformações cardíacas. Além das artérias intrapulmonares, a vascularização pulmonar e a árvore brônquica geralmente não sofrem alterações. No presente relato, a paciente apresenta quadro de febre, tosse produtiva e taquipneia. Devido à clínica, optou-se por realizar radiografia simples de tórax, na qual se evidenciou a presença de opacidade interstício-alveolar peri-hilar à direita com desvio do mediastino à direita e assimetria da transparência pulmonar. Então, foi solicitada tomografia computadorizada de tórax que evidenciou pulmão direito de volume reduzido. Para melhor compreensão, realizou-se angiotomografia computadorizada do tórax, a qual detectou agenesia da artéria pulmonar direita. Importância do problema: relatar um caso de agenesia de artéria pulmonar direita. (AU)

ABSTRACT: Pulmonary artery agenesis is a rare congenital malformation, which occurs due to the non-development of the sixth aortic arch. However, it is not related to cardiac malformation, and also the intrapulmonary arteries, as well as the pulmonary vascularization and the bronchial tree usually do not change. In the present case study, the patient presents fever, productive cough, and tachypnea. A simple chest X-ray was performed because of the clinic, demonstrating right perihilar interstitial-alveolar opacity with right mediastinal deviation and asymmetry of pulmonary transparency. Due to the radiological finding, a computed tomography of the chest was requested, which showed the right lung of reduced volume. To provide a better understanding of the condition, the radiology team suggested computed angiotomography of the chest, which detected agenesis of the right pulmonary artery. The importance of the problem is to report a case of agenesis of the right pulmonary artery. (AU)

Left main coronary artery compression by the right pulmonary artery in a patient with congenital pulmonic stenosis / Compresión del tronco coronario izquierdo por la arteria pulmonar derecha en un paciente con estenosis pulmonar congénita

Abstract Congenital pulmonary stenosis (PS) can be associated with pulmonary artery (PA) dilatation. In some cases, this can cause compression of nearby structures including the left main coronary artery (LMCA). This compression causes angina and is considered an indication for surgical treatment. We present the case of a patient with PS and angina secondary to LMCA compression by the right PA and review the main indications and options for surgical treatment.

Resumen La estenosis pulmonar congénita se asocia a dilatación de la arteria pulmonar. En algunos casos esto puede causar compresión de las estructuras adyacentes incluyendo el tronco de la coronaria izquierda. Esta compresión causa angina y es considerada una indicación para tratamiento quirúrgico. Presentamos el caso de un paciente con estenosis pulmonar y angina secundaria a compresión del tronco de la coronaria izquierda por la arteria pulmonar derecha y revisamos las indicaciones y opciones de tratamiento quirúrgico.

A Rare Cause of Angina After Coronary Bypass Grafting; Left İnternal Mammary Artery to Pulmonary Artery Fistula and Successful Treatment with Transcatheter Coil Embolization / Uma Causa Rara de Angina Após Revascularização do Miocárdio: Fístula da Artéria Mamária Interna Esquerda para Artéria Pulmonar e Tratamento Bem-Sucedido com Embolização Transcateter com Molas

Abstract Fistula from left internal mammary artery (LIMA) to pulmonary artery (PA) is rarely encountered in daily practice. In recent years, endovascular therapy options have emerged for the treatment of fistula formations and replaced with surgery. A 53-year-old man admitted to our outpatient clinic with symptoms of typical angina and shortness of breath despite optimal medical therapy. In his relevant history, he had a coronary artery bypass graft (CABG) operation in 2009 in which his LIMA was anastomosed to left anterior descending (LAD) and ramus artery sequentially. Coronary angiography including selective imaging of LIMA demonstrated a fistula formation originating from the proximal portion of the LIMA and draining to PA. After successful closure of fistula with transcatheter coil embolization, the patient was discharged without any complication and symptom. In conclusion, although LIMA to PA fistula is an infrequent clinical condition, it should be considered as a potential cause of persistent angina after CABG operation. Treatment options include conservative medical therapy, surgical ligation and endovascular interventions. The best therapy should be individualised for each patient in respect to patient's symptoms, surgical compatibility and anatomy of fistula.

Resumo A fístula da artéria mamária interna esquerda (AMIE) para a artéria pulmonar (AP) é raramente encontrada na prática diária. Nos últimos anos, opções de terapia endovascular surgiram para o tratamento de formações de fístula e foram substituídas por cirurgia. Um homem de 53 anos de idade, internado em nosso ambulatório com sintomas de angina típica e falta de ar, apesar da terapia clínica ideal. Em seu histórico relevante, ele teve uma cirurgia de revascularização miocárdica (CRM) em 2009, na qual sua AMIE foi anastomosada à descendente anterior esquerda (DAE) e à artéria ramus sequencialmente. A angiografia coronária, incluindo imagens seletivas da AMIE, demonstrou uma formação de fístula proveniente da porção proximal da AMIE e drenando para AP. Após o fechamento bem-sucedido da fístula com embolização transcateter com mola, o paciente recebeu alta sem qualquer complicação e sintoma. Em conclusão, embora fístula entre AMIE e AP seja uma condição clínica pouco frequente, deve ser considerada como uma causa potencial de angina persistente após a operação de revascularização do miocárdio. As opções de tratamento incluem terapia médica conservadora, ligadura cirúrgica e intervenções endovasculares. A melhor terapia deve ser individualizada para cada paciente em relação aos sintomas do paciente, compatibilidade cirúrgica e anatomia da fístula.

Sling de la arteria pulmonar en paciente preescolar con compromiso de la vía aérea / Pulmonary artery sling in preschool patient with airway compromise

Resumen Introducción: El sling de la arteria pulmonar izquierda es una rara malformación congénita del arco aórtico en la que la rama pulmonar izquierda se origina a partir de la arteria pulmonar derecha. Generalmente se sitúa entre la tráquea y el esófago, que frecuentemente la comprimen. Dependiendo del grado de compromiso de la vía aérea, el esófago y las anomalías cardíacas asociadas, las manifestaciones clínicas varían. El tratamiento de esta malformación es quirúrgico; con el paso de los años, este abordaje ha mejorado, y se ha logrado una disminución de la morbilidad y mortalidad en esta condición. Caso clínico: Se presenta el caso de una paciente preescolar con hallazgo de sling de la arteria pulmonar izquierda con compromiso de la vía aérea. Conclusiones: Después de la corrección quirúrgica, se logró una respuesta clínica favorable y una mejoría significativa en la vía aérea, evidenciada en los hallazgos en la fibrobroncoscopia, sin necesidad de intervenciones adicionales.

Abstract Background: Left pulmonary artery sling is a rare congenital malformation of the aortic arch in which this artery originates from the right pulmonary artery and courses over the trachea and the esophagus. Clinical manifestations vary depending on the degree of airway compromise, the esophagus and associated cardiac anomalies. The treatment for this malformation is surgical; over the years, this approach has improved, achieving a decrease in morbidity and mortality in this condition. Case report: A preschool patient with incidental finding of sling of the left pulmonary artery with compromise of the airway is presented. Conclusions: After the surgical procedure, a favorable clinical outcome was observed and a significant improvement in the airway was shown by a fibrobronchoscopy, without any additional intervention.