Crisis hipercalcémica, presentación inusual de adenoma paratiroideo: reporte de 2 casos / Hypercalcemic crisis, unusual presentation of parathyroid adenoma

La crisis hipercalcémica (CH) es una emergencia endocrina inusual, definida por la presencia de calcemia > 14 mg/dl asociada a disfunción renal, alteraciones cardiovasculares, gastrointestinales y del sensorio; también podría considerarse en pacientes con síntomas graves y calcemia menor. El hiperparatiroidismo primario (HPTP) y las neoplasias malignas son las etiologías más comunes de la hipercalcemia (90% de los casos); sin embargo, rara vez el primero se presenta como CH. Debido a la alta mortalidad asociada a esta entidad, es de gran importancia establecer diagnóstico y tratamiento precoces. Presentamos dos pacientes con crisis hipercalcémica como primera manifestación del HPTP, el 1.° con bloqueo auriculoventricular (AV) completo y el 2.° con pancreatitis aguda. La anatomía patológica (AP) reveló adenoma oxifílico en ambos casos, que es una variante histológica poco frecuente y puede manifestarse clínicamente de forma grave. Conclusiones: los adenomas paratiroideos son causa poco frecuente de CH. Consideramos el tipo histológico observado (adenoma oxifílico) como probable factor condicionante. La pancreatitis y especialmente el bloqueo AV son manifestaciones poco frecuentes de la CH. Resaltamos la importancia de la determinación de los niveles de calcio dentro de la evaluación inicial de todo paciente con bloqueo AV. (AU)

Hypercalcemic crisis (HC) is an unusual endocrine emergency, defined as the presence of serum calcium > 14 mg/dl related to kidney dysfunction, cardiovascular, gastrointestinal and sensory disturbances. It could also be considered in patients with severe symptoms and lower serum calcium levels. Primary hyperparathyroidism (PHPT) and malignant neoplasms are the most common hypercalcemia etiologies (90% of cases), nevertheless, the former hardly ever occurs as HC. Due to the high mortality associated with HC, it is crucial to establish early diagnosis and treatment.We report two patients with HC as the first manifestation of PHPT; the former with atrioventricular (AV) block and the latter with acute pancreatitis. Pathology revealed oxyphilic adenoma in both cases, which is an infrequent histological variant that can have a severe clinical manifestation. Conclusions: parathyroid adenomas are a rare cause of HC. We consider the histological type observed (oxyphilic adenoma) as a probable conditioning factor. Pancreatitis and especially AV block are rare manifestations of HC. We emphasize the importance of determining calcium levels in the initial evaluation of all patients with AV block. (AU)

Infección por trypanosoma cruzi y bloqueo cardíaco del nodo auriculoventricular en el salvador / Trypanosoma cruzi infection and atrioventricular-nodal heart block in El Salvador

Resumen La enfermedad de Chagas es endémica en América Latina y sigue siendo un problema regional a pesar de que su frecuencia ha disminuido gracias a importantes avances en salud ambiental. Para determinar su frecuencia en pacientes con enfermedades miocárdicas de El Salvador, se llevó a cabo una in vestigación observacional retrospectiva en nuestro hospital que es un centro de referencia de nivel nacional. Se revisó el registro del Laboratorio de Chagas en el período 2013-2015 para conocer cuántos individuos internados en la Unidad Cardiológica eran positivos por serología para infección chagásica y cuáles fueron sus diagnósticos. Se realizó un total de 1472 pruebas a pacientes individuales durante los 36 meses del período de estudio. De los 557 pacientes con serología positiva para Chagas, 97 (17.4%) fueron eventualmente hospitalizados en la Unidad Cardiológica. A su vez, estos 97 pacientes representaron el 33.7% de los 288 pacientes con cardiopatías. Entre los 97 con cardiopatía chagásica, 40 (41.2%) cumplieron criterios para colocación de marcapaso permanente, mientras que solo 13 de 191 (6.8%) enfermos con cardiopatías no chagásicas cumplieron esos criterios. La frecuencia de bloqueos auriculoventriculares asociados a infección por Trypanosoma cruzi resultó mucho mayor que las publicadas en estudios previos realizados en Sudamérica.

Abstract Chagas disease is endemic in Latin America and remains a regional problem despite improvements in en vironmental health conditions that have helped to control its transmission. To know more about its prevalence in heart disease patients, we carried out a survey in our national (El Salvador) reference hospital. We reviewed the Chagas Lab´s records 2013-2015 to find out how many of the patients admitted to the Hospital´s Heart Unit were serologically positives for Trypanosoma cruzi infection and which the associated diagnoses were. A total of 1472 patients were tested along the 36-month study period. Out of 557 (37.8%) patients with positive serology for Chagas infection, 97 (17.4%) were eventually admitted to the Heart Unit. Among these 97 Chagas infected patients with heart disease, 40 (41.2%) met the criteria for permanent pacemaker placement, while only 13 of 191 (6.8%) patients with non-chagasic heart disease met these criteria. The frequency of heart atrioventricular block associated with Trypanosoma cruzi infection was higher than frequencies reported in South American studies.

Distúrbios de condução cardíaca e taquicardia ventricular como complicação da granulomatose com poliangiíte em uma paciente. Relato de caso e revisão da literatura / Heart conduction system defects and sustained ventricular tachycardia complications in a patient with granulomatosis with polyangiitis. A case report and literature review

RESUMO A granulomatose com poliangiíte é um raro distúrbio inflamatório sistêmico que se caracteriza por vasculite de pequenas artérias, arteríolas e capilares, associada a lesões granulomatosas necrotizantes. Este artigo relata o caso de uma paciente com diagnóstico prévio de granulomatose com poliangiíte, admitida à unidade de terapia intensiva com quadro de crises convulsivas e instabilidade hemodinâmica em razão de bloqueio atrioventricular completo. Estas manifestações se associaram a múltiplos episódios de taquicardia ventricular sustentada; não havia alterações estruturais cardíacas, nem se detectaram distúrbios hidroeletrolíticos. Na unidade de terapia intensiva, a paciente foi submetida à implantação de marca-passo provisório, imunossupressão com uso de corticosteroides e terapia imunobiológica, resultando em melhora hemodinâmica completa. Distúrbios graves da condução cardíaca em pacientes com granulomatose com poliangiíte são raros, mas associam-se à grande morbidade. O reconhecimento precoce e o uso de intervenções específicas são capazes de prevenir a ocorrência de desfechos desfavoráveis, especialmente na unidade de terapia intensiva.

ABSTRACT Granulomatosis with polyangiitis is a rare systemic inflammatory disorder characterized by vasculitis of the small arteries, the arterioles and the capillaries together with necrotizing granulomatous lesions. This case reports on a young female patient, previously diagnosed with granulomatosis with polyangiitis, who was admitted to the intensive care unit with seizures and hemodynamic instability due to a complete atrioventricular heart block. The event was associated with multiple episodes of sustained ventricular tachycardia without any structural heart changes or electrolyte disturbances. In the intensive care unit, the patient was fitted with a provisory pacemaker, followed by immunosuppression with corticosteroids and immunobiological therapy, resulting in a total hemodynamic improvement. Severe conduction disorders in patients presenting granulomatosis with polyangiitis are rare but can contribute to increased morbidity. Early detection and specific intervention can prevent unfavorable outcomes, specifically in the intensive care unit.

Atrioventricular block in coronary artery bypass surgery: perioperative predictors and impact on mortality / Bloqueio atrioventricular pós-cirurgia de revascularização do miocárdio: fatores preditores perioperatórios e impacto na mortalidade

Abstract Introduction: Disturbances of the cardiac conduction system are frequent in the postoperative period of coronary artery bypass surgery. They are mostly reversible and associated with some injury of the conduction tissue, caused by the ischemic heart disease itself or by perioperative factors. Objective: Primary: investigate the association between perioperative factors and the emergence of atrioventricular block in the postoperative period of coronary artery bypass surgery. Secondary: determine the need for temporary pacing and of a permanent pacemaker in the postoperative period of coronary artery bypass surgery and the impact on hospital stay and hospital mortality. Methods: Analysis of a retrospective cohort of patients submitted to coronary artery bypass surgery from the database of the Postoperative Heart Surgery Unit of the Sao Lucas Hospital of the Pontifical Catholic University of Rio Grande do Sul, using the logistic regression method. Results: In the period from January 1996 to December 2012, 3532 coronary artery bypass surgery were carried out. Two hundred and eighty-eight (8.15% of the total sample) patients had atrioventricular block during the postoperative period of coronary artery bypass surgery, requiring temporary pacing. Eight of those who had atrioventricular block progressed to implantation of a permanent pacemaker (0.23% of the total sample). Multivariate analysis revealed a significant association of atrioventricular block with age above 60 years (OR=2.34; CI 95% 1.75-3.12; P<0.0001), female gender (OR=1.37; CI 95% 1.06-1.77; P=0.015), chronic kidney disease (OR=2.05; CI 95% 1.49-2.81; P<0.0001), atrial fibrillation (OR=2.06; CI 95% 1.16-3.66; P=0.014), functional class III and IV of the New York Heart Association (OR=1.43; CI 95% 1.03-1.98; P=0.031), perioperative acute myocardial infarction (OR=1.70; CI 95% 1.26-2.29; P<0.0001) and with the use of the intra-aortic balloon in the postoperative ...

Resumo Introdução: Os distúrbios do sistema de condução cardíaca são frequentes no pós-operatório de cirurgia de revascularização do miocárdio. Majoritariamente reversíveis, estão associados com alguma injúria do tecido de condução, causada pela própria cardiopatia isquêmica ou por fatores perioperatórios. Objetivo: Primário: investigar a associação entre fatores perioperatórios com o surgimento de bloqueio atrioventricular no pós-operatório de cirurgia de revascularização do miocárdio. Secundários: determinar a necessidade de estimulação cardíaca artificial temporária e de marca-passo definitivo no pós-operatório de cirurgia de revascularização do miocárdio e seu impacto na permanência e na mortalidade hospitalar. Métodos: Análise de Coorte retrospectiva de pacientes submetidos à cirurgia de revascularização do miocárdio, do banco de dados da unidade de Pós-Operatório de Cirurgia Cardíaca do Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul, pelo método de regressão logística. Resultados: No período de janeiro de 1996 a dezembro de 2012, foram realizadas 3532 cirurgias de revascularização do miocárdio. Duzentos e oitenta e oito (8,15%) pacientes apresentaram bloqueio atrioventricular durante o pós-operatório de cirurgia de revascularização do miocárdio, necessitando de estimulação cardíaca artificial temporária. Oito dos que apresentaram bloqueio atrioventricular evoluíram para implante de marcapasso definitivo (0,23% do total da amostra). A análise multivariada evidenciou associação significativa de bloqueio atrioventricular com idade acima de 60 anos (OR=2,34; IC 95% 1,75-3,12; P<0,0001), sexo feminino (OR=1,37; IC 95% 1,06-1,77; P=0,015), doença renal crônica (OR=2,05; IC 95% 1,49-2,81; P<0,0001), fibrilação atrial (OR=2,06; IC 95% 1,16-3,66; P=0,014), classe funcional III e IV da New York Heart Association (OR=1,43; IC 95% 1,03-1,98; P=0,031), infarto agudo do miocárdio perioperatório (OR=1,70; IC ...

Patologia do bloqueio atrioventricular na cardiomiopatia por depósito de desmina / Atrioventricular block pathology in cardiomyopathy by desmin deposition / Patología de bloqueo auriculoventricular en la miocardiopatía por depósito de desmina

Geralmente, a cardiomiopatia restritiva por deposição de desmina é caracterizada pela restrição ao enchimento diastólico ventricular e por diferentes graus de bloqueio atrioventricular (BAV). Neste relato, são descritas as alterações anatomopatológicas do sistema de condução cardíaco relacionadas ao BAV. O nó sinusal, o nó compacto e o feixe penetrante (feixe de His) não apresentavam anormalidades, entretanto, havia extensa fibrose das porções terminais do feixe ramificante e do início dos feixes esquerdo e direito, no topo do septo ventricular. A patogenia dessa substituição fibrosa é provavelmente a mesma que origina a extensa fibrose do miocárdio ventricular contrátil, e permanece por ser elucidada.

Generally, restrictive cardiomyopathy due to desmin deposition is characterized by restriction to ventricular diastolic filling and different degrees of atrioventricular block (AVB). In this report, we describe the pathological changes of the cardiac conduction system related to AVB. The sinus node, the compact node, and the penetrating bundle (bundle of His) had no abnormalities, however, there was extensive fibrosis of the terminal portions of the branching bundle and the beginning of the left and right bundles at the top of the ventricular septum. The pathogenesis of this fibrous replacement is probably the same that leads to extensive fibrosis of the working ventricular myocardium, and remains to be elucidated.

En general, la miocardiopatía restrictiva, debido a la deposición de desmina se caracteriza por la restricción de llenado diastólico ventricular y por los distintos grados de bloqueo auriculoventricular (BAV). En este informe, se describen los cambios anatómicos y patológicos del sistema de conducción cardiaco relacionado con BAV. El nodo sinusal, el nodo compacto y haz penetrante (haz de His) no tuvo alteraciones, sin embargo, había fibrosis extensa de las porciones terminales del haz en porción ramificante y del comienzo de los haces izquierda y derecha, en la parte superior del tabique ventricular. La patogenia de esta sustitución fibrosa es probablemente la misma que origina la fibrosis extensa del miocardio ventricular contráctil, y queda por dilucidar.

Bloqueio atrioventricular no pós-operatório de cirurgia cardíaca valvar: incidência, fatores de risco e evolução hospitalar / Atrioventricular block in the postoperative period of heart valve surgery: incidence, risk factors and hospital evolution

INTRODUÇÃO: Distúrbios do sistema de condução cardíaco são complicações potenciais e conhecidas dos procedimentos de cirurgia cardíaca valvar. OBJETIVOS: Investigar a associação entre fatores peri-operatórios com bloqueio atrioventricular (BAV) e a necessidade de estimulação cardíaca artificial temporária (ECAT) e, se necessário, implante de marcapasso definitivo no pós-operatório de cirurgia cardíaca (POCC) valvar. MÉTODOS: Coorte histórica de pacientes submetidos a cirurgia cardíaca valvar, sendo realizada análise de banco de dados por regressão logística. RESULTADOS: No período de janeiro de 1996 a dezembro de 2008, foram realizadas 1102 cirurgias cardíacas valvares: 718 (65,2%) na valva aórtica e 407 (36,9%) na valva mitral; destas, 190 (17,2%) cirurgias de revascularização miocárdica associadas à cirurgia valvar e 23 (2,1%) cirurgias valvares combinadas (aórtica+mitral). Cento e oitenta e sete (17%) pacientes apresentaram quadro clínico e eletrocardiográfico de BAV durante o POCC valvar, necessitando de ECAT. Quatorze (7,5%) pacientes evoluíram para implante de marcapasso definitivo (1,27% do total da amostra). A análise multivariada evidenciou associação significativa de BAV com cirurgia de valva mitral (OR=1,76; IC 95% 1,08-2,37; P=0,002), implante de prótese biológica (OR=1,59; IC 95% 1,02-3,91; P= 0,039), idade maior que 60 anos (OR = 1,99; IC 95% 1,35-2,85; P<0,001), uso prévio de medicações antiarrítmicas (propafenona e amiodarona) (OR = 1,86; IC 95% 1,04-3,14; P=0,026) e uso prévio de betabloqueador (OR = 1,76; IC 95% 1,25-2,54; P=0,002). Embora a presença do BAV e necessidade de ECAT não tenham se associado a aumento de mortalidade, prolongaram a permanência hospitalar significativamente (P<0,0001) e, portanto, o consumo de recursos hospitalares. CONCLUSÃO: Esse estudo evidencia um conjunto de fatores preditivos potenciais a um perfil de pacientes que determinam alto risco de bloqueio atrioventricular e necessidade de estimulação ...

INTRODUCTION: Disturbances of the cardiac conduction system are potential complications after cardiac valve surgery. OBJECTIVES: This study was designed to investigate the association between perioperative factors and atrio-ventricular block, the need for temporary cardiac artificial pacing and, if necessary, permanent pacemaker implantation after cardiac valve surgery. METHODS: Retrospective analysis of the Cardiac Surgery Database - Hospital São Lucas/PUCRS. The data are collected prospectively and analyzed retrospectively. RESULTS: Between January 1996 and December 2008 were included 1102 valve surgical procedures: 718 aortic valves (65.2%), 407 (36.9%) mitral valve and 190 (17.2%) coronar artery bypass grafting combined with valve repair and 23 (2.1%) aortic and mitral combined surgery. 187 patients (17%) showed clinical and electrocardiographic pattern of atrio-ventricular block requiring artificial temporary pacing. Of these, 14 patients (7.5%) required permanent pacemaker implantation (1.27% of the total valve surgery patients). Multivariate analysis showed association of the incidence of atrio-ventricular block and temporary pacing with mitral valve surgery (OR 1,76; CI 95% 1.08-2.37; P=0.002), implantation of bioprosthetic devices (OR 1.59; CI 95% 1.02-3.91; P=0,039), age over 60 years (OR 1.99; CI 95% 1.352.85; P<0.001), prior use of anti-arrhythmic drugs (OR 1.86; CI 95% 1.04-3.14; P=0.026) and previous use of b-blocker (OR 1.76; CI 95% 1.25-2.54; P=0.002). Remarkably the presence of atrio-ventricular block did not significantly show association with increased mortality, but significantly prolonged (P<0.0001) hospital length-of-stay and, therefore, hospital costs. CONCLUSIONS: Our study presents a group of predictive factors referring to a specific patient profile by which high risk of atrio-ventricular block and the need of temporary cardiac pacing after cardiac valve surgery it is determined.

Esclerosis sistémica complicada con síncope y bloqueo AV completo / Systemic sclerosis complicated with syncope and complete AV block

La esclerosis sistémica es una compleja enfermedad que afecta el tejido conectivo, el sistema vascular y el sistema inmunológico, y se caracteriza por fibrosis cutánea y de órganos viscerales. Los bloqueos de rama y los hemibloqueos se presentan en el 25 a 75% de los casos y constituyen predictores independientes de mortalidad. Los bloqueos auriculoventriculares de segundo o tercer grado son muy raros. Presentamos el caso de una mujer de 47 años de edad, con diagnóstico de esclerosis sistémica, quien presenta episodio sincopal secundario a bloqueo auriculoventricular completo con necesidad de implante de marcapasos definitivo.

Systemic sclerosis is a complex disease that affects the connective tissue, the vascular system and the immune system. It typically produces skin and organ fibrosis. Cardiac bundle branch blocks and fascicular blocks occur in 25-75% of the cases and were found to be independent predictors of mortality. Second and third degree atrioventricular block are very rare. We present the case of a 47 year-old female with diagnosis of systemic sclerosis, presented with syncope secondary to complete atrioventricular block requiring permanent pacemaker implantation.

Bloqueo AV completo, reversible, en relación a hiperkalemia grave por enalapril y espironolactona: caso clínico / Complete atrioventricular block, reversible, related to serious hyperkalemia due to enalapril and spironolactone: case report

La hiperkalemia es una de las principales complicaciones potenciales del uso de drogas del tipo IECA, bloqueadores ARAII y antagonistas del receptor de aldosterona, en relación a su dosis, su eventual uso combinado y la función renal del paciente. A continuación se reporta el caso de un paciente de 71 años de edad, hipertenso y diabético que se encontraba en tratamiento con Enalapril 10 mg c/12 h y Furosemida 40 mg a/ 12 h, que sufre una bloqueo aurículo ventricular de 3º grado, secundario a una hiperkalemia de 8.53 mEq/l.

Arrhythmia in early post cardiac surgery in pediatrics: Siriraj experience.

OBJECTIVES: To determine the incidence, risk factors and outcome of early postoperative arrhythmias in pediatric patients with congenital heart disease. MATERIAL AND METHOD: A prospective study was conducted in every pediatric patient who consecutively underwent open-heart surgery at Siriraj Hospital from January 1st to December 31st, 2006. The collected data were demographic data, diagnosis, pre-operative arrhythmia, cardiac surgical data and continuous electrocardiographic monitoring data throughout the post operative intensive care period. RESULTS: A total of 191 pediatric patients underwent cardiac surgery. Forty-five cases (23.5%) developed early post operative cardiac arrhythmias i.e. junctional ectopic tachycardia 18 cases (40%), heart block 7 cases (15.6%), supraventricular tachycardia 2 cases (4.4%). Cardiac arrhythmia occurred mostly within 24 hours after the operation. Patients with single ventricle physiology repaired developed the highest incidence of acute post operative arrhythmia (36.4%). Longer, cardiopulmonary bypass time- and redo-operation were the risk factors. Thirty-nine cases were treated with medications, 7 cases with temporary pacing, and 1 case with electrical cardioversion. Four patients needed long-term anti-arrhythmic agents. Cardiac arrhythmia played role in the causes of death in 2 cases (1.1% of total cases). CONCLUSIONS: Post operative arrhythmias remained common and important complications of pediatric open-heart surgery. Long cardiopulmonary bypass time and redo-operation were risk factors for early post operative arrhythmia.

In hospital complications and mortality of patients of inferior wall myocardial infarction with right ventricular infarction.

This is a cross-sectional study of patients with inferior wall Myocardial Infarction (MI), who attended emergency and got admitted in ICU/CCU of TU Teaching Hospital, Maharajgunj and Bir Hospital, Kathmandu, Nepal during November 1999 to October 2000. This study was undertaken to compare the in-hospital complications and mortality of patients of inferior wall myocardial infarction with or without associated right ventricular infarction. Total 53 consecutive patients with acute inferior wall myocardial infarction were enrolled in the study. Right ventricular infarction was determined by the presence of ST elevation of more than 0.1 mv in V4R. All the patients of inferior wall myocardial infarction were divided into two groups. Group A consisted of patients of inferior wall MI with right ventricular infarction and group B consisted of patients of inferior wall MI without right ventricular infarction. In-hospital complications and mortality of group A were compared with group B. Among 20 patients of group A and 33 patients of group B, incidence of cardiogenic shock was significantly higher in patients of group A compared to group B (p=0.05). Ten patients of group A developed third degree AV Block compared to only one in group B; the incidence of which was significantly higher (p<0.001). Sinus nodal dysfunction, manifested by junctional rhythm was found in six patients of group A compared to only two patients of group B (p<0.05). Mortality was found higher in patients of group A, but it was not statistically significant. Two patients of group A expired on first day whereas only one patient of group B expired on the eighth day of admission. In hospital complications especially cardiogenic shock, complete A-V block and junctional rhythm are significantly higher in inferior wall MI when associated with RV infarction.