Vena Cava Filter Misplacement: A Killer Traveler

ABSTRACT Inferior vena cava filter embolization is not uncommon and can reach 11.8%. However, device migration to the heart is not frequent and occurs in cases after inferior vena cava filter fracture. We present the case of a young woman who was submitted to a routine inferior vena cava filter placement three days before and presented with hemodynamic instability. Since the device was not retrievable, the surgical team opted for an open cardiac surgery under cardiopulmonary bypass to remove the inferior vena cava filter and avoid other further complications.

Implications for clinical practice from a multicenter survey of heart failure management centers

OBJECTIVES: This observational, cross-sectional study based aimed to test whether heart failure (HF)-disease management program (DMP) components are influencing care and clinical decision-making in Brazil. METHODS: The survey respondents were cardiologists recommended by experts in the field and invited to participate in the survey via printed form or email. The survey consisted of 29 questions addressing site demographics, public versus private infrastructure, HF baseline data of patients, clinical management of HF, performance indicators, and perceptions about HF treatment. RESULTS: Data were obtained from 98 centers (58% public and 42% private practice) distributed across Brazil. Public HF-DMPs compared to private HF-DMP were associated with a higher percentage of HF-DMP-dedicated services (79% vs 24%; OR: 12, 95% CI: 94-34), multidisciplinary HF (MHF)-DMP [84% vs 65%; OR: 3; 95% CI: 1-8), HF educational programs (49% vs 18%; OR: 4; 95% CI: 1-2), written instructions before hospital discharge (83% vs 76%; OR: 1; 95% CI: 0-5), rehabilitation (69% vs 39%; OR: 3; 95% CI: 1-9), monitoring (44% vs 29%; OR: 2; 95% CI: 1-5), guideline-directed medical therapy-HF use (94% vs 85%; OR: 3; 95% CI: 0-15), and less B-type natriuretic peptide (BNP) dosage (73% vs 88%; OR: 3; 95% CI: 1-9), and key performance indicators (37% vs 60%; OR: 3; 95% CI: 1-7). In comparison to non- MHF-DMP, MHF-DMP was associated with more educational initiatives (42% vs 6%; OR: 12; 95% CI: 1-97), written instructions (83% vs 68%; OR: 2: 95% CI: 1-7), rehabilitation (69% vs 17%; OR: 11; 95% CI: 3-44), monitoring (47% vs 6%; OR: 14; 95% CI: 2-115), GDMT-HF (92% vs 83%; OR: 3; 95% CI: 0-15). In addition, there were less use of BNP as a biomarker (70% vs 84%; OR: 2; 95% CI: 1-8) and key performance indicators (35% vs 51%; OR: 2; 95% CI: 91,6) in the non-MHF group. Physicians considered changing or introducing new medications mostly when patients were hospitalized or when observing worsening disease and/or symptoms. Adherence to drug treatment and non-drug treatment factors were the greatest medical problems associated with HF treatment. CONCLUSION: HF-DMPs are highly heterogeneous. New strategies for HF care should consider the present study highlights and clinical decision-making processes to improve HF patient care.

Canine visceral leishmaniasis in the Northeast Region of Brazil

Visceral leishmaniasis (VL) is a zoonosis that affects dogs and other mammals, including humans. Contact with dogs is a major risk factor for humans. This disease is endemic in several regions of Brazil. The aim of this study was to determine the prevalence of Leishmania spp. infection in dogs and to correlate it with possible risk factors. Methods Blood samples were collected from 391 dogs of different ages, breeds, and both genders, coming from Campina Grande, Paraíba state, Brazil. An epidemiological questionnaire was employed in order to identify risk factors associated with the disease. Serological tests were performed using indirect immunofluorescence, enzyme-linked immunosorbent assay (ELISA S7®) and polymerase chain reaction. Results Leishmania spp. antibodies were detected in 33 (8.4 %) and 17 (4.3 %) dogs according to the indirect immunofluorescence test (IFAT) and enzyme-linked immunosorbent assay (ELISA S7®), respectively. PCR results indicated the presence of L. chagasi DNA in only eight (2 %) blood samples. There was a significant association between reactive animals and contact with animals from different houses (OR = 4.1; p= 0.02). Conclusions It is suggested that CVL may occur in urban areas. Moreover, it is demonstrated that the association among different diagnostic tests may lead to a more accurate identification of positive animals, which might help to improve the disease control and prevent euthanasia in false-positive results.

Canine visceral leishmaniasis in the Northeast Region of Brazil

Background Visceral leishmaniasis (VL) is a zoonosis that affects dogs and other mammals, including humans. Contact with dogs is a major risk factor for humans. This disease is endemic in several regions of Brazil. The aim of this study was to determine the prevalence of Leishmania spp. infection in dogs and to correlate it with possible risk factors. Methods Blood samples were collected from 391 dogs of different ages, breeds, and both genders, coming from Campina Grande, Paraíba state, Brazil. An epidemiological questionnaire was employed in order to identify risk factors associated with the disease. Serological tests were performed using indirect immunofluorescence, enzyme-linked immunosorbent assay (ELISA S7®) and polymerase chain reaction. Results Leishmania spp. antibodies were detected in 33 (8.4 %) and 17 (4.3 %) dogs according to the indirect immunofluorescence test (IFAT) and enzyme-linked immunosorbent assay (ELISA S7®), respectively. PCR results indicated the presence of L. chagasi DNA in only eight (2 %) blood samples. There was a significant association between reactive animals and contact with animals from different houses (OR = 4.1; p= 0.02). Conclusions It is suggested that CVL may occur in urban areas. Moreover, it is demonstrated that the association among different diagnostic tests may lead to a more accurate identification of positive animals, which might help to improve the disease control and prevent euthanasia in false-positive results.(AU)

Left Atrial Volume Determinants in Patients with Non-Ischemic Dilated Cardiomyopathy / Determinantes do Volume do Átrio Esquerdo em Pacientes com Cardiomiopatia Dilatada Não Isquêmica

Left atrial volume (LAV) is a predictor of prognosis in patients with heart failure.

O Volume do Átrio Esquerdo (VAE) é preditor prognóstico em pacientes com insuficiência cardíaca.

Indicações e seleção do paciente para transplante cardíaco / Indications and patient selection for cardiac transplantation

O transplante cardíaco está indicado para pacientes cominsuficiência cardíaca grave com sintomas incapacitantes, a despeitode estarem recebendo tratamento farmacológico otimizado e deterem se esgotado as possibilidades cirúrgicas de tratamento. Entreoutros fatores, as limitações referentes à disponibilidade de doadoresde coração efetivos, principalmente no Brasil, tornam a escolhacriteriosa do receptor cardíaco, além de um desafio, uma granderesponsabilidade para a prática diária do cardiologista clínico.Hiponatremia, insuficiência renal, caquexia cardíaca, anemia, baixosníveis de colesterol, queda dos níveis de hemoglobina e dependênciade inotrópicos são fatores clínico-laboratoriais associados a mauprognóstico em pacientes com insuficiência cardíaca (IC) avançada.Os escores de risco [HFSS (Heart Failure Survival Score) eSHFM (Seattle Heart Failure Model)] devem ser utilizados comoferramentas acessórias para avaliar a gravidade dos pacientes comIC avançada. VO2 pico < 10 ml/kg/min e VE/VCO2 > 34 no teste doexercício cardiopulmonar estão relacionados com mortalidade empacientes ambulatorialmente avaliados para transplante cardíaco. Ahemodinâmica pulmonar, assim como o perfil imunológico, deveser rotineiramente acessada em pacientes candidatos a transplantecardíaco. Os pacientes com hipertensão pulmonar fixa estão sobrisco de desenvolverem insuficiência cardíaca direita fatal apóso transplante cardíaco. Por sua vez, a presença de anticorposcirculantes contra os antígenos HLA (Human Leukocyte Antigen)é um fator de risco para rejeição do enxerto após o transplantede coração. Finalmente, a indicação do transplante cardíaco emsituações clínicas extremas vem aumentando e se tornando umdesafio na prática clínica cardiológica.

The heart transplantation is indicated for patients with severeheart failure and disabling symptoms despite being receivingoptimal pharmacological treatment and having exhausted thepossibilities of surgical treatment. Among other factors, thelimitations related to the availability of effective heart donor,mainly in Brazil, make a judicious choice of the heart receptorin addition to a challenge, a huge responsibility for the dailypractice of clinical cardiologists. Hyponatremia, renal failure,cardiac cachexia, anemia, low cholesterol levels, decrease inhemoglobin levels and dependence on inotropes are clinical andlaboratory factors associated with poor prognosis in patientswith advanced heart failure. The risk scores [HFSS (HeartFailure Survival Score) and SHFM (Seattle Heart FailureModel)] should be used as ancillary tools to assess the severityof patients with advanced HF. Peak of VO2 < 10 ml/kg/minand VE/VCO2 > 34 during the cardio-pulmonary exercise testare related to mortality in ambulatory patients evaluated forcardiac transplantation. Pulmonary hemodynamics as wellas the immunological profile should be routinely accessed inpatients who are candidates for cardiac transplantation. Patientswith fixed pulmonary hypertension are at risk for fatal rightheart failure after heart transplantation. In turn, the presenceof circulating antibodies to Human Leukocyte Antigen HLA)is a risk factor for graft rejection after heart transplantation.Finally, the indication of cardiac transplantation in extremeclinical situations are increasing and becoming a challenge incardiology clinical practice.

Os critérios para classificação da insuficiência mitral não foram adequados na cardiomiopatia dilatada / Criteria for mitral regurgitation classification were inadequate for dilated cardiomyopathy

FUNDAMENTO: A insuficiência mitral (IM) é frequente nos pacientes com cardiomiopatia dilatada. Não se sabe se os critérios para classificação da IM são adequados para pacientes com cardiomiopatia dilatada OBJETIVO: Avaliar a concordância entre os quatro métodos ecocardiográficos mais utilizados para classificação da IM. MÉTODOS: Noventa pacientes com cardiomiopatia dilatada foram incluídos. A IM foi classificada por quatro métodos ecocardiográficos: área do jato regurgitante (AJ), vena contracta (VC), área do orifício regurgitante (AOR) e volume regurgitante (VR). A IM foi classificada em leve, moderada ou importante segundo os critérios da American Society of Echocardiography e também foi dividida em tercis conforme os valores absolutos. O teste de Kappa foi utilizado para avaliar a concordância entre os métodos. O coeficiente de Pearson foi utilizado para avaliar a correlação entre os valores absolutos por cada método. RESULTADOS: A classificação da IM, de acordo com cada método, foi a seguinte: AJ: 26 leve, 44 moderada, 20 importante; VC: 12 leve, 72 moderada, 6 importante; AOR: 70 leve, 15 moderada, 5 importante; VR: 70 leve, 16 moderada, 4 importante. A concordância entre os métodos foi ruim (kappa = 0,11; p < 0,001), porém foi observada uma forte correlação entre os valores absolutos de cada método (0,70 a 0,95; p < 0,01). A concordância foi melhor com a divisão dos valores em tercis (kappa = 0,44; p < 0,01). CONCLUSÃO: Os critérios para classificação da IM não são adequados para os pacientes com cardiomiopatia dilatada. É necessário estabelecer novos valores de corte para classificar a IM nestes pacientes.

BACKGROUND: Mitral regurgitation (MR) is common in patients with dilated cardiomyopathy (DCM). It is unknown whether the criteria for MR classification are inadequate for patients with DCM. OBJECTIVE: We aimed to evaluate the agreement among the four most common echocardiographic methods for MR classification. METHODS: Ninety patients with DCM were included. Functional MR was classified using four echocardiographic methods: color flow jet area (JA), vena contracta (VC), effective regurgitant orifice area (ERO) and regurgitant volume (RV). MR was classified as mild, moderate or important according to the American Society of Echocardiography criteria and by dividing the values into terciles. The Kappa test was used to evaluate whether the methods agreed, and the Pearson correlation coefficient was used to evaluate the correlation between the absolute values of each method. RESULTS: MR classification according to each method was as follows: JA: 26 mild, 44 moderate, 20 important; VC: 12 mild, 72 moderate, 6 important; ERO: 70 mild, 15 moderate, 5 important; RV: 70 mild, 16 moderate, 4 important. The agreement was poor among methods (kappa=0.11; p<0.001). It was observed a strong correlation between the absolute values of each method, ranging from 0.70 to 0.95 (p<0.01) and the agreement was higher when values were divided into terciles (kappa = 0.44; p < 0.01) CONCLUSION: The use of conventional echocardiographic criteria for MR classification seems inadequate in patients with DCM. It is necessary to establish new cutoff values for MR classification in these patients.

Miocardiopatias restritivas / Restrictive cardiomyopathies

As miocardiopatias restritivas constituem um grupo heterogêneo de doenças que acometem o músculo cardíaco que tem em comum os sinais e sintomas de insuficiência cardíaca congestiva. Disfunção diastólica com função sistólica preservada é, com frequência única anormalidade ecocardiográfia que pode ser observada, embora a disfunção sistólica e espessamento das paredes possam também ser uma parte integral de algumas patologias específicas, particularmente em casos mais avançados, tais como a infiltração amiloide do coração e hemocromatose. De longe, a maioria das cardiopatias restritivas é secundária as desordens sistêmicas tais como amioloidose, hemocromatose, sarcoidose, esclerodermia, doenças de depósios, síndrome hipereosinofilica e endomiocardiofibrose. Bem mais rara é a miocardiopatia restritiva idiopática, diagnóstico realizado na ausência de doença sistêmica, através de biópsia ou necropsia. O diagnóstico da miocardiopatia restritiva é baseado em história clínica, examo físico, eletrocardiograma, radiografia de tórax, ecocardiografia, ressonância nuclear magnética e biópsia emdomiocárdica. Devido à sua grande disponibilidade, o ecocardiograma é provavelmente o exame mais importante para investigar e detectar a disfunção ventricular esquerda, deve ser realizado precocemente e por operador familiarizado com a grande variedade de etiologias. Finalmente o diagnóstico diferencial com pericardite constritiva é necessário.

Restrictive cardiomyopathies constitute a heterogeneous group of heart muscle conditions that all have, in common, the symptoms of heart failure. Diastolic dysfunction with preserved systolic function is often the only echocardiography abnormality that may be noted, although systolic dysfunction may also be a complete part of some specific pathologies, particularly in the most advanced cases such as amyloid infiltration of the heart and hemochromatosis. By far, the majority of restrictive cardiomyopathy are secondary to a systemic disorder such as amyloidosis, sarcoidosis, scleroderma, hemochromatosis, eosinophilic heart disease or endomyocardial fibrosis. The most uncommon diagnosis of idiopathic restrictive cardiomyopathy is supported only by the absence of specific pathology on either endomyocardial biopsies or at post-mortem. Restrictive cardiomyopathy is diagnosed based on clinical data, physical examination, electrocardiogram, chest X-ray, echocardiography, and magnetic resonance imaging and endomyocardil biopsy. With its broad availability, echocardiography is probably the most Important investigation to Identify the left ventricular dysfunction and should be performed early and by groups that are familiar with the broad variety of etiologies. Finally, the deferential diagnosis from constrictive pericarditis may be necessary.

Estabilidade do modelo animal de lesão pulmonar aguda induzida por ácido oleico / Stability of the animal model of oleic acid-induced acute lung injury

OBJETIVO: Avaliar a estabilidade das variáveis hemodinâmicas, da mecânica respiratória e de troca gasosa do modelo animal de lesão pulmonar aguda induzida por ácido oleico. MÉTODOS: Trata-se de um estudo experimental no qual foram utilizados 10 cães de raça indeterminada. As variáveis foram aferidas inicialmente e em 30, 60, 90 e 120 min após a administração do ácido oleico. Para analisar as medidas repetidas, foram testados efeitos lineares e quadráticos e foram utilizados ajustes de modelos lineares mistos com estruturas de variâncias e covariâncias diversificadas, dependendo da variável analisada. RESULTADOS: Observamos estabilidade da pressão arterial média aos 30 min, assim como da frequência cardíaca, da pressão arterial pulmonar e da pressão de capilar pulmonar aos 60 min. Frequência respiratória, volume corrente, volume minuto e trabalho respiratório estabilizaram aos 30 min. Quanto às variáveis de troca gasosa, PaO2, relação PaO2/FiO2 e fração de shunt pulmonar estabilizaram-se aos 30 min. As demais variáveis mantiveram-se em ascensão ou queda contínuas. CONCLUSÕES: O modelo de lesão pulmonar aguda induzida por ácido oleico é estável para algumas das variáveis testadas; porém, a estabilização se dá em momentos diferentes. As variáveis da mecânica respiratória e de troca gasosa estabilizaram em 30 min, e as hemodinâmicas, em 60 min.

OBJECTIVE: To evaluate the stability of hemodynamic, respiratory and gas exchange variables in an animal model of oleic acid-induced acute lung injury. METHODS: This was an experimental study involving 10 mongrel dogs. The variables were measured at baseline, as well as at 30, 60, 90 and 120 min after the administration of oleic acid. In order to analyze repeated measurements, linear and quadratic effects were tested. Mixed linear models with diversified variance and covariance structures were used, depending on the variable studied. RESULTS: We found that mean arterial blood pressure stabilized at 30 min, as did heart rate, pulmonary arterial pressure and pulmonary capillary pressure at 60 min. Respiratory rate, tidal volume, minute volume and respiratory work stabilized at 30 min. Regarding gas exchange variables, PaO2, PaO2/FiO2 ratio and pulmonary shunt fraction stabilized at 30 min. The remaining variables maintained a continuous rise or fall. CONCLUSIONS: This oleic acid-induced acute lung injury model is stable for some of the variables tested, although stabilization occurs at different times. The respiratory and gas exchange variables stabilized at 30 min, whereas the hemodynamic variables stabilized at 60 min.