Progression of valve heart disease in a cohort of patients undergoing renal replacement therapy / Progressão da doença cardíaca valvar em coorte de doentes em terapia renal substitutiva

Abstract Introduction: Cardiovascular disease is an important cause of death among patients with chronic kidney disease (CKD). Valve calcification is a predictor of cardiovascular mortality and coronary artery disease. Objective: To assess heart valve disease frequency, associated factors, and progression in CKD patients. Methods: We conducted a retrospective study on 291 CKD patients at Hospital das Clínicas de Pernambuco. Inclusion criteria were age ≥ 18 with CKD and valve disease, while those on conservative management or with missing data were excluded. Clinical and laboratory variables were compared, and patients were categorized by dialysis duration (<5 years; 5-10 years; >10 years). Statistical tests, including chi-square, Fisher's exact, ANOVA, and Kruskal-Wallis, were employed as needed. Simple and multivariate binary regression models were used to analyze valve disease associations with dialysis duration. Significance was defined as p < 0.05. Results: Mitral valve disease was present in 82.5% (240) of patients, followed by aortic valve disease (65.6%; 86). Over time, 106 (36.4%) patients developed valve disease. No significant association was found between aortic, pulmonary, mitral, or tricuspid valve disease and dialysis duration. Secondary hyperparathyroidism was the sole statistically significant factor for mitral valve disease in the regression model (OR 2.59 [95% CI: 1.09-6.18]; p = 0.031). Conclusion: CKD patients on renal replacement therapy exhibit a high frequency of valve disease, particularly mitral and aortic valve disease. However, no link was established between dialysis duration and valve disease occurrence or progression.

Resumo Introdução: Doenças cardiovasculares são uma causa significativa de morte em pacientes com Doença Renal Crônica (DRC). A calcificação valvar é preditor de mortalidade cardiovascular e doença arterial coronariana. Objetivo: Avaliar a frequência, fatores associados e progressão de valvopatias em pacientes com DRC. Métodos: Coorte retrospectiva com 291 pacientes ambulatoriais no Hospital das Clínicas de Pernambuco. Inclusão: ≥18 anos com DRC e valvopatia; exclusão: tratamento conservador ou dados incompletos. Variáveis clínicas e laboratoriais foram comparadas e categorizadas por tempo de terapia dialítica (TTD): <5 anos, 5-10 anos, >10 anos. Foram aplicados os testes Qui-quadrado, exato de Fisher, ANOVA, Kruskal-Wallis. Associação entre valvopatia e TTD foi avaliada por regressão binária. Significância foi definida como p < 0,05. Resultados: A valvopatia mitral foi encontrada em 82,5% (240) dos casos, seguida da aórtica (65,6%; 86). Houve progressão da doença valvar em 106 (36,4%) pacientes. Não houve associação entre valvopatias aórtica, pulmonar, mitral ou tricúspide e TTD. Hiperparatireoidismo secundário foi a única variável explicativa significativa na regressão para valvopatia mitral (OR 2,59 [IC95%: 1,09-6,18]; p = 0,031). Conclusão: Encontramos alta frequência de valvopatias, especialmente mitral e aórtica, aem pacientes com DRC. Não houve associação entre TTD e valvopatia.

Morphological Assessment and Possible Clinical Implications of the Left Ventricle Papillary Muscles. Study in a Colombian Population Sample

SUMMARY: Papillary muscles in the left ventricle present multiple anatomic expressions that are relevant for medical fields focusing on the understanding of clinical events involving these structures. Here, the aim was to perform a morphological characterization of the left ventricle papillary muscles in a sample of Colombian population. In the study were included eighty-two hearts from male individuals who underwent autopsy at the Institute of Legal Medicine and Forensic Sciences in Bucaramanga, Colombia. In each heart was carefully performed a longitudinal incision on the obtuse margin to visualize the papillary muscles. Data set was registered, and analysis of the continuous and categorical variables was carried out. Single anterior papillary muscle was observed in 74 samples (90.2 %) whereas this represented only 48 specimens (58.5 %) for the posterior papillary muscle (p = 0.3). Mean length and breadth of the anterior muscle were 29.9 ± 4.94 and 11.74 ± 2.75 mm, and those for the posterior muscle were 27.42 ± 7.08 and 10.83 ± 4.08 mm. Truncated apical shape was the most frequent type observed on the papillary muscles, anterior 41 (50 %) and posterior 37 (45.1 %), followed by flat-topped in the anterior 25 (30.5 %) and bifurcated in posterior muscle 14 (17.1 %). A mean of 9.04 ± 2.75 chordae raised from the anterior and 7.50 ± 3.3 from posterior papillary muscle. In our study we observed a higher incidence of single papillary muscles and slightly larger dimensions than information reported in the literature. The anatomic diversity of the papillary muscles should be considered for the correct image interpretation, valve implantation and performance evaluation on myocardial ischemic events.

Los músculos papilares del ventrículo izquierdo presentan múltiples expresiones anatómicas que son relevantes para las áreas médicas que se centran en la comprensión de los eventos clínicos que involucran estas estructuras. El objetivo fue realizar una caracterización morfológica de los músculos papilares del ventrículo izquierdo en una muestra de población colombiana. En el estudio se incluyeron ochenta y dos corazones de individuos masculinos a los que se les realizó autopsia en el Instituto de Medicina Legal y Ciencias Forenses de Bucaramanga, Colombia. En cada corazón se realizó cuidadosamente una incisión longitudinal en el margen obtuso para visualizar los músculos papilares. Se registró el conjunto de datos y se realizó el análisis de las variables continuas y categóricas. Se observó un solo músculo papilar anterior en 74 muestras (90,2 %), mientras que este rasgo se presentó en 48 muestras (58,5 %) para el músculo papilar posterior (p = 0,3). La longitud y anchura media del músculo anterior fueron 29,9 ± 4,94 y 11,74 ± 2,75 mm, y las del músculo posterior fueron 27,42 ± 7,08 y 10,83 ± 4,08 mm. La forma apical truncada fue el tipo más frecuente observado en los músculos papilares, anterior 41 (50 %) y posterior 37 (45,1 %), seguido de la forma plana en los 25 anteriores (30,5 %) y bifurcada en el músculo posterior 14 (17,1 %). Una media de 9,04 ± 2,75 cuerdas elevadas desde el músculo papilar anterior y 7,50 ± 3,3 desde posterior. En nuestro estudio observamos una mayor incidencia de músculos papilares únicos y dimensiones ligeramente mayores que la información reportada en la literatura. La diversidad anatómica de los músculos papilares debe ser considerada para la correcta interpretación de imágenes, implantación valvular y evaluación del desempeño en eventos isquémicos miocárdicos.

Resultados Perinatais e Seguimento em Longo Prazo de Tumores Cardíacos Fetais: Estudo de Coorte Histórica de 30 Anos / Perinatal Results and Long-Term Follow-Up of Fetal Cardiac Tumors: A 30-Year Historical Cohort Study

Resumo Fundamento: Seguimento de coorte retrospectiva de 30 anos que se aproxima da história natural dos tumores cardíacos diagnosticados no feto uma vez que nenhum caso foi submetido à interrupção da gestação. Objetivo: Avaliar a morbidade e mortalidade perinatal e em longo prazo em fetos com diagnóstico de tumor cardíaco. Como objetivo secundário avaliar os fatores que influenciaram os resultados perinatais e pós-natais. Método: Estudo de coorte retrospectiva envolvendo 74 gestantes com diagnóstico ecocardiográfico fetal de tumor cardíaco acompanhadas em dois serviços de referência no período de maio de 1991 a novembro de 2021. Foi realizada análise descritiva dos dados por meio de frequências absolutas (n) e relativas (%), mediana e intervalos interquartis. Para avaliar a associação entre as características ecocardiográficas e as manifestações clínicas com os resultados perinatais e pós-natais, foi aplicado o teste exato de Fisher. O cálculo da sobrevida global foi realizado pelo método de Kaplan-Meier e a comparação de curvas pelo teste de log-rank. O tempo de seguimento, calculado em meses, foi definido a partir da data de alta do hospital à data do status atual (vivo/censura ou óbito). O nível de significância considerado foi de 5% (p<0,05). Resultados: o rabdomioma é o tipo mais frequente (85%) de tumor cardíaco; apresenta alta morbidade (79,3%) e mortalidade geral de 17,4%; a presença de hidropisia fetal preditiva de óbito. Conclusão: A presença de hidropisia fetal teve impacto na mortalidade, sendo fator importante para aconselhamento e estabelecimento de prognóstico. A maioria dos óbitos ocorrem antes da alta hospitalar.

Abstract Background: This was a 30-year retrospective cohort study that approximates closely to the natural history of cardiac tumors diagnosed in the fetus, since there was no case of pregnancy interruption Objective: To assess morbidity and mortality in the perinatal period and at long term in fetuses diagnosed with cardiac tumor. Our secondary objective was to assess the evaluating factors of perinatal and postnatal results. Methods: This was a retrospective cohort study with 74 pregnant women with an echocardiographic diagnosis of fetal cardiac tumor at two referral centers between May 1991 and November 2021. A descriptive analysis was performed, and data were expressed as absolute (n) and relative (%) frequencies, median and interquartile range. Fisher's exact test was used to evaluate the association of echocardiographic characteristics and clinical manifestations with perinatal and postnatal results. Global survival was calculated using the Kaplan-Meier method and the curves were compared by the log-rank test. The time of follow-up, calculated in months, corresponded to the time elapsed from hospital discharge to current status (survived/ censoring or death). The level of significance was set at 5% (p<0.05). Results: Rhabdomyoma is the most common type of cardiac tumor (85%), with a high morbidity (79.3%) and overall mortality of 17.4%. The presence of fetal hydrops was a predictor of death. Conclusion: The presence of fetal hydrops had an impact on mortality, and hence is an important factor in counselling and determining the prognosis. Most deaths occurred before hospital discharge.

Ablação por Cateter para Fibrilação Atrial em Pacientes com Fração de Ejeção do Ventrículo Esquerdo ≤ 45%: Uma Metanálise de Ensaios Clínicos Randomizados / Catheter Ablation for Atrial Fibrillation in Patients with Left Ventricular Ejection Fraction ≤ 45%: A Meta-Analysis of Randomized Controlled Trials

Resumo Fundamento A fibrilação atrial (FA) e a insuficiência cardíaca (IC) coexistem frequentemente, resultando em desfechos adversos. No entanto, permanecem controvérsias quanto à eficácia da ablação por cateter (AC) em pacientes com FA com disfunção ventricular esquerda grave. Objetivos O objetivo deste estudo foi realizar uma metanálise de ensaios prospectivos randomizados e controlados para avaliar a eficácia da AC versus terapia médica (TM) em pacientes com FA com fração de ejeção do ventrículo esquerdo (FEVE) ≤45%. Métodos Procuramos na literatura estudos que comparassem AC com TM em pacientes com FA com FEVE ≤45%. Foi realizada uma metanálise de 7 ensaios clínicos, incluindo 1.163 pacientes com FA e IC. A análise de subgrupo foi realizada com base na FEVE basal. Todos os testes foram bilaterais; apenas o valor p <0,05 foi considerado estatisticamente significativo. Resultados Descobrimos que a AC estava associada a menor mortalidade por todas as causas (taxa de risco: 0,52, IC 95%: 0,37 a 0,72; p<0,01) e maiores melhorias na FEVE (diferença média: 4,80%, IC 95%: 2,29% a 7,31%; p<0,01) em comparação com TM. Os pacientes do grupo AC apresentaram menor risco de hospitalização por IC e recorrência de FA e qualidade de vida significativamente melhor do que aqueles do grupo TM. Os resultados da análise de subgrupo indicaram que pacientes com disfunção ventricular esquerda mais leve melhoraram a FEVE após a ablação de FA (diferença média: 6,53%, IC 95%: 6,18% a 6,88%; p<0,01) em comparação com pacientes com doença mais grave (diferença média : 2,02%, IC 95%: 0,87% a 3,16%; p<0,01). Conclusões Nossa metanálise demonstrou que a AC foi associada a melhorias significativas nos resultados de pacientes com FA com FEVE ≤45%. Além disso, pacientes com FA com disfunção ventricular esquerda mais leve poderiam se beneficiar mais com a AC.

Abstract Background Atrial fibrillation (AF) and heart failure (HF) frequently coexist, resulting in adverse outcomes. However, controversies remain regarding the efficacy of catheter ablation (CA) in AF patients with severe left ventricular dysfunction. Objectives The purpose of this study was to perform a meta-analysis of prospective randomized controlled trials to evaluate the efficacy of CA versus medical therapy (MT) in AF patients with left ventricular ejection fraction (LVEF) ≤45%. Methods We searched the literature for studies that compared CA to MT in AF patients with LVEF ≤45%. A meta-analysis of 7 clinical trials was performed, including 1163 patients with AF and HF. Subgroup analysis was performed based on baseline LVEF. All tests were 2-sided; only the p-value <0.05 was considered statistically significant. Results We found that CA was associated with lower all-cause mortality (risk ratio: 0.52, 95% CI: 0.37 to 0.72; p<0.01) and greater improvements in LVEF (mean difference: 4.80%, 95% CI: 2.29% to 7.31%; p<0.01) compared to MT. Patients in the CA group had a lower risk of HF hospitalization and AF recurrence and a significantly better quality of life than those in the MT group. The results of subgroup analysis indicated that patients with milder left ventricular dysfunction improved LVEF after AF ablation (mean difference: 6.53%, 95% CI: 6.18% to 6.88%; p<0.01) compared to patients with more severe disease (mean difference: 2.02%, 95% CI: 0.87% to 3.16%; p<0.01). Conclusions Our meta-analysis demonstrated that CA was associated with significant improvements in outcomes of AF patients with LVEF ≤45%. Additionally, AF patients with milder left ventricular dysfunction could benefit more from CA.

Mapeamento do Potencial da Superfície Corporal durante a Despolarização Ventricular em Atletas com Intervalo PQ Prolongado após Exercício / Body Surface Potential Mapping during Ventricular Depolarization in Athletes with Prolonged PQ Interval after Exercise

Resumo Fundamento: O prolongamento do intervalo PQ, geralmente associado a um atraso na condução atrioventricular, pode estar relacionado a alterações na propagação do impulso intraventricular. Objetivo: Avaliar, por meio do mapeamento do potencial de superfície corporal (BSPM), o processo de despolarização ventricular em atletas com intervalos PQ prolongados em repouso e após o exercício. Métodos: O estudo incluiu 7 esquiadores cross-country com intervalo PQ superior a 200 ms (grupo PQ Prolongado) e 7 com intervalo PQ inferior a 200 ms (grupo PQ Normal). O BSPM de 64 derivações unipolares do tronco foi realizado antes (Pré-Ex) e após o teste ergométrico de bicicleta (Pós-Ex). Mapas equipotenciais da superfície corporal foram analisados durante a despolarização ventricular. O nível de significância foi de 5%. Resultados: Comparado com atletas com PQ Normal, o primeiro e o segundo períodos de posição estável dos potenciais cardíacos na superfície do tronco foram mais longos, e a formação da distribuição de potencial "sela" ocorreu mais tarde, no Pré-Ex, nos atletas com PQ Prolongado. No Pós-Ex, o grupo PQ Prolongado apresentou um encurtamento do primeiro e segundo períodos de distribuições de potencial estáveis e uma diminuição no tempo de aparecimento do fenômeno "sela" em relação ao Pré-Ex (para valores próximos aos do Normal -Grupo PQ). Além disso, no Pós-Ex, a primeira inversão das distribuições de potencial e a duração total da despolarização ventricular em atletas com PQ Prolongado diminuíram em comparação com o Pré-Ex e com valores semelhantes em atletas com PQ Normal. Em comparação com atletas com PQ Normal, a segunda inversão foi mais longa no Pré-Ex e Pós-Ex em atletas com PQ Prolongado. Conclusão: Atletas com PQ prolongado apresentaram diferenças significativas nas características temporais do BSPM durante a despolarização ventricular, tanto em repouso quanto após o exercício, em comparação com atletas com PQ normal.

Abstract Background: Prolongation of the PQ interval, generally associated with an atrioventricular conduction delay, may be related to changes in intraventricular impulse spreading. Objective: To assess, using body surface potential mapping (BSPM), the process of ventricular depolarization in athletes with prolonged PQ intervals at rest and after exercise. Methods: The study included 7 cross-country skiers with a PQ interval of more than 200 ms (Prolonged-PQ group) and 7 with a PQ interval of less than 200 ms (Normal-PQ group). The BSPM from 64 unipolar torso leads was performed before (Pre-Ex) and after the bicycle exercise test (Post-Ex). Body surface equipotential maps were analyzed during ventricular depolarization. The significance level was 5%. Results: Compared to Normal-PQ athletes, the first and second periods of the stable position of cardiac potentials on the torso surface were longer, and the formation of the "saddle" potential distribution occurred later, at Pre-Ex, in Prolonged-PQ athletes. At Post-Ex, the Prolonged-PQ group showed a shortening of the first and second periods of stable potential distributions and a decrease in appearance time of the "saddle" phenomenon relative to Pre-Ex (to the values near to those of the Normal-PQ group). Additionally, at Post-Ex, the first inversion of potential distributions and the total duration of ventricular depolarization in Prolonged-PQ athletes decreased compared to Pre-Ex and with similar values in Normal-PQ athletes. Compared to Normal-PQ athletes, the second inversion was longer at Pre-Ex and Post-Ex in Prolonged-PQ athletes. Conclusion: Prolonged-PQ athletes had significant differences in the temporal characteristics of BSPM during ventricular depolarization both at rest and after exercise as compared to Normal-PQ athletes.

Síndrome de Eisenmenger secundario a comunicación interatrial tipo ostium secundum en mujer adulta / Eisenmenger Syndrome Associated with an ostium secundum Atrial Septal Defect in an Adult Woman

El síndrome de Eisenmenger es la forma más severa de presentación de hipertensión arterial pulmonar secundaria a defectos cardíacos congénitos no reparados, aunque su prevalencia es baja, continúa siendo un reto para los sistemas de salud de los países en vías de desarrollo por su complejidad en el manejo. Presentación del caso. Paciente femenina sin antecedentes médicos conocidos quien consulta por disnea relacionada a los esfuerzos y policitemia. Intervención terapéutica. Se realiza ecocardiograma transesofágico que arroja la presencia de defecto interatrial tipo ostium secundum e hipertensión arterial pulmonar severa, con cortocircuito de derecha a izquierda, se inicia oxigenoterapia y terapia farmacológica. Evolución clínica. Paciente permaneció ingresada presentando notable mejora a la disnea, se le dio de alta con referencia a la clínica de cardiopatías congénitas del adulto en Hospital Nacional Rosales.

Eisenmenger syndrome is the most severe form of pulmonary arterial hypertension secondary to an unrepaired congenital heart disease. Despite the low prevalence, it remains a challenge for the public health service of developing countries due to the complexity of the treatment. Case presentation. A female patient without known medical history, who consults with dyspnea on exertion and polycythemia. Treatment. A transesophageal echocardiogram was performed, showing an ostium secundum atrial septal defect and severe pulmonary arterial hypertension with a right-left shunt. Supplemental oxygen was administrated and pharmacological treatment was started. Outcome. The patient presented remarkable clinical improvement to dyspnea, she was discharged with medical reference to the Adult Congenital Heart Disease clinic at Rosales National Hospital.

El verdadero origen histórico del trauma cardíaco penetrante / The true historical origin of penetrating cardiac trauma

Introducción. Los traumatismos cardíacos son lesiones graves y con elevado índice de letalidad, aspecto que influye en el interés mostrado por los lectores cada vez que aparecen reportados en publicaciones científicas. En ocasiones existe cierto grado de incongruencia a la hora de establecer el origen histórico de sucesos o eventos ocurridos y relacionados con la historia de la medicina. En el caso del trauma cardíaco penetrante han sido descritos diversos orígenes en algunos de los artículos científicos publicados, lo cual puede generar un grado de duda en los lectores. Métodos. Se realizó una revisión de la literatura, médica y no médica, para buscar información que ayudara a esclarecer el verdadero origen histórico de esta entidad. Resultados. El trauma cardíaco penetrante fue descrito por primera vez en la obra griega titulada La Ilíada, escrita por Homero en el siglo VIII A.C., y no en El papiro quirúrgico de Edwin Smith, como varios autores mencionan. Conclusiones. De todos los eventos de trauma cardíaco penetrante descritos, el más irrefutable es el narrado en el canto XIII, donde se cuenta la muerte de Alcátoo, producto de una herida cardíaca ocasionada por una lanza arrojada por Idomeneo durante una batalla

Introduction. Cardiac traumatic injuries are serious injuries with a high lethality rate, an aspect that influences the interest shown by readers each time they appear reported in scientific publications. Sometimes there is a certain degree of inconsistency when it comes to establishing the historical origin of occurrences or events related to the history of medicine. In the case of penetrating cardiac trauma, different origins have been described in some of the published scientific articles, which may generate a degree of doubt in the readers. Methods. A review of the medical and non-medical literature was carried out to seek information that would help to clarify the true historical origin of this entity. Results. Penetrating cardiac trauma was first described in a Greek work entitled The Iliad, written by Homer in the 8th century B.C., and not in The Surgical Papyrus of Edwin Smith as several authors mention. Conclusions. Of all the events of penetrating cardiac trauma described, the most irrefutable is the one narrated in canto XIII, where it recounts the death of Alcathous product of a cardiac wound caused by a spear thrown by Idomeneo during a battle.

Lesión cardíaca por arma blanca inadvertida durante la evaluación inicial en el servicio de emergencia / Missed cardiac stab injury during initial evaluation in the Emergency Department

Introducción. La incidencia reportada de traumatismo cardíaco es baja y su grado de resolución es variable, dependiendo de la causa, el mecanismo de la lesión, el lugar donde ocurra y las características del sistema sanitario. Su incidencia ha aumentado recientemente debido al incremento de los accidentes de tránsito y la violencia, predominando los traumatismos penetrantes asociados a heridas por armas cortopunzantes y de fuego. Los traumatismos cardíacos se acompañan de un alto grado de letalidad. Caso clínico. Mujer de 35 años que consultó a emergencia por trauma torácico penetrante ocasionado por arma blanca y fue intervenida de urgencia por derrame pleural izquierdo, sin mejoría hemodinámica. Fue reevaluada detectándose derrame pericárdico con taponamiento cardíaco, ocasionado por lesión cardíaca. Fue tratada quirúrgicamente con resultados satisfactorios. Resultados. Las manifestaciones clínicas en los traumatismos penetrantes generalmente son graves y fatales, pero en algunos casos puede no comprometer tanto la hemodinamia del paciente. Para consolidar el diagnóstico clínico pueden realizarse variados estudios, siendo la ecografía FAST extendida uno de los más recomendados por su elevada sensibilidad y especificidad. Dependiendo del adelanto tecnológico del centro hospitalario y la estabilidad hemodinámica del paciente, el tratamiento quirúrgico es el más indicado. Conclusión. El conocimiento del trauma cardíaco penetrante resulta de gran importancia, no solo para el médico del servicio de emergencia sino también para el médico general. Un diagnóstico rápido y acertado, unido a un manejo adecuado, pueden ser decisivos para salvar la vida del paciente.

Introduction. The reported incidence of cardiac trauma is low and its degree of resolution is variable depending on the cause, the mechanism of injury, the place where it occurs and the characteristics of the health care system. Their incidence has currently increased due to the increase in traffic accidents and violence, with a predominance of penetrating trauma associated with stab wounds and firearms. Cardiac trauma is accompanied by a high degree of lethality. Clinical case. A 35-year-old female patient, evaluated in the emergency room for penetrating thoracic trauma caused by stab wound. She underwent emergency intervention due to left pleural effusion, but without hemodynamic improvement. She was reevaluated and pericardial effusion with cardiac tamponade caused by cardiac injury was detected. She was treated surgically with satisfactory results. Results.The clinical manifestations generally described in penetrating cardiac trauma are severe and fatal, but in some cases and due to the characteristics of the injury caused, the patient's hemodynamics may not be so compromised. To consolidate the clinical diagnosis, several complementary studies can be performed, with FAST ultrasound being one of the most recommended due to its high sensitivity and specificity. Surgical treatment is still the most indicated, depending on the technological progress of the hospital and the hemodynamic stability of the patient. Conclusions.Knowledge of penetrating cardiac trauma is of great importance, not only for the emergency department physician but also for the general practitioner. A quick and accurate diagnosis, together with adequate management can be decisive in saving the patient's life.

Access to emergency surgical treatment for congenital heart diseases in the state of São Paulo

Abstract Objective To analyze access to surgical care for congenital heart diseases in public specialized centers in the state of São Paulo before and during the COVID-19 pandemic and availability of surgical care in specialized hospitals, to identify bottlenecks in the care path for neonatal cardiac surgery. Methods This study included 1,437 children, under one year old, with congenital heart disease and formal referral to heart surgery between February 1, 2019, and February 28, 2021. Quantitative data analysis was performed using t-tests or the Mann-Whitney test. Results Approximately 30 % of children with urgent congenital heart disease could not access recommended care, mainly those needing complex surgeries (categories RACHS 4 to 6). The main diagnoses of neonates accessing care were patency of the ductus arteriosus (10.5 %) and coarctation of the aorta (10.1 %). Referral time for children in RACHS 1 to 3 was 4 days (median), while for those in categories 4 to 6, it was 7 days (p< 0.001). Longer referral time (20 days) was associated with court orders. During the pandemic, referral time decreased to 3 days, compared to 5 days (median) in the pre-pandemic period (p< 0.001). Conclusion The emergency surgical treatment supply for congenital heart diseases is insufficient compared to the current demand. Future research should evaluate if access to care in publicly funded hospitals could be improved by better access to prenatal care for pregnant women, increased diagnostic and therapeutic capacity in pediatric cardiology, and financial incentives for complex cardiac surgeries.

Evaluation of cardiac autonomic function and low-grade inflammation in children with obesity living in the Northeast Brazilian region

Abstract Objective Evaluate autonomic function and low-grade inflammation and characterize the correlation between these variables in schoolchildren with obesity living in the Brazilian northeast region. Methods 84 children with obesity and 41 with normal weight were included in this cross-sectional study. Anthropometry, body composition, blood pressure (BP), inflammatory biomarkers, and heart rate variability (HRV) indexes were analyzed in children aged 7 to 11 years. Results children with obesity had increased systolic (p= 0.0017) and diastolic (p= 0.0131) BP and heart rate (p= 0.0022). The children with obesity displayed significantly lower SDNN, RMSSD, NN50, HF (ms), HF (nu), SD1, SD2, and higher LF (ms), LF (nu), LF/HF, SD1/SD2, DFA-α1, and DFA-α2, compared to normal weight. A lower and higher capacity for producing IL-10 (p= 0.039) and IL-2 (p= 0.009), respectively, were found in children with obesity compared to children with normal weight. Although IL-2, IL-4 and IL17A did not correlate with HRV parameters, IL-6 was positively correlated with SDNN, LF (ms) and SD2, TNF-α was positively correlated with LF/HF and SD1/SD2 ratio, and IFN-γ was positively correlated with SDNN, RMMSSD, NN50, LF (ms), HF (ms), SD1, and SD2. Conclusions The findings suggest that children with obesity have impaired autonomic function and systemic low-grade inflammation compared to children within the normal weight range, the inflammatory biomarkers were correlated with HRV parameters in schoolchildren living in the northeastern region of Brazil.

Patau and Edwards Syndromes in a University Hospital: beyond palliative care / Síndrome de Edwards e Patau em um hospital universitário: além do paliativo

ABSTRACT Objective: To describe the newborn population with Patau (T13) and Edwards Syndrome (T18) with congenital heart diseases that stayed in the Intensive Care Unit (ICU) of a quaternary care hospital complex, regarding surgical and non-surgical medical procedures, palliative care, and outcomes. Methods: Descriptive case series conducted from January/2014 to December/2018 through analysis of records of patients with positive karyotype for T13 or T18 who stayed in the ICU of a quaternary hospital. Descriptive statistics analysis was applied. Results: 33 records of eligible patients were identified: 27 with T18 (82%), and 6 T13 (18%); 64% female and 36% male. Eight were preterm infants with gestational age between 30-36 weeks (24%), and only 4 among the 33 infants had a birth weight >2500 g (12%). Four patients underwent heart surgery and one of them died. Intrahospital mortality was 83% for T13, and 59% for T18. The majority had other malformations and underwent other surgical procedures. Palliative care was offered to 54% of the patients. The median hospitalization time for T18 and T13 was 29 days (range: 2-304) and 25 days (13-58), respectively. Conclusions: Patients with T13 and T18 have high morbidity and mortality, and long hospital and ICU stays. Multicentric studies are needed to allow the analysis of important aspects for creating protocols that, seeking therapeutic proportionality, may bring better quality of life for patients and their families.

RESUMO Objetivo: Descrever a população de recém-nascidos com síndrome de Patau (T13) e Edwards (T18) portadores de cardiopatias congênitas, que permaneceram em Unidades de Terapia Intensiva (UTI) de um complexo hospitalar quaternário, com relação a conduta cirúrgica ou não, cuidados paliativos e seus desfechos. Métodos: Série de casos de pacientes internados entre janeiro de 2014 a dezembro de 2018, com análise dos prontuários de portadores de T13 ou T18 que permaneceram internados em UTI que recebem neonatos nesse hospital quaternário. Utilizou-se análise estatística descritiva. Resultados: Foram identificados 33 prontuários para análise — 27 T18 (81,8%) e seis T13 (18,2%); 64% do sexo feminino e 36% do sexo masculino. Oito foram prematuros, nascidos com 30 a 36 semanas (24,2%), e apenas quatro nasceram com mais de 2500 g (12,1%). Quatro pacientes foram submetidos a cirurgia cardíaca e um deles foi a óbito. A mortalidade intra-hospitalar foi de 83% para T13 e 59% para T18. A maioria apresentava outras malformações e foi submetida a outras cirurgias. Cuidados paliativos foram oferecidos a 54% dos pacientes. A mediana do tempo de hospitalização para T18 e T13 foi respectivamente de 29 dias (variação: 2-304) e 25 dias (13-58). Conclusões: Pacientes com T13 e T18 cursam com alta morbimortalidade e longa permanência hospitalar em UTI. São necessários estudos multicêntricos para melhor análise de aspectos importantes para a criação de protocolos que, buscando proporcionalidade terapêutica, tragam melhor qualidade de vida para os pacientes e suas famílias.

Effect of Ticagrelor on Left Ventricular Function in Patients with Mildly Reduced Ejection Fraction after Acute Myocardial Infarction

Abstract Background There are limited data about the effect of new P2Y12 inhibitors on left ventricular ejection fraction (LVEF) after acute myocardial infarction (AMI). Objectives We aimed to investigate the effect of ticagrelor on left ventricular function, compared to clopidogrel in patients with heart failure with mildly reduced ejection fraction (HFmrEF) after AMI. Methods In this cross-sectional, single-center study, we included 251 patients with LVEF between 40% and 50% after AMI before discharge. The patients were divided into 2 groups according to the use of ticagrelor (166 patients) and clopidogrel (85 patients). At the end of the 12-month period, LVEF changes were assessed by echocardiography. P < 0.05 was considered statistically significant. Results The mean LVEF before discharge was 46.5% ± 3.6%, and no difference was observed between the ticagrelor and clopidogrel groups (p = 0.20). At the end of the first year, the mean LVEF of the patients increased to 49.8% ± 7.6% in both groups. The use of ticagrelor (β ± SE = 2.05 ± 0.93; p = 0.029), low creatinine level (β ± SE = −10.44 ± 2.35; p < 0.001), low troponin level (β ± SE = −0.38 ± 0.14; p = 0.006), and low heart rate (β ± SE = −0.98 ± 0.33; p = 0.003) were found to be independent predictors of the increase in LVEF (β ± SE 2.05 ± 0.93; 95% confidence interval: 0.21 to 3.90; p = 0.029). Conclusion In our study, ticagrelor improved left ventricular function in 12 months follow-up compared to clopidogrel in patients with HFmrEF after AMI.

Perfil clínico, farmacoterapêutico e laboratorial de pacientes internados com insuficiência cardíaca aguda / Clinical, pharmacotherapeutic and laboratory profile of hospitalized patients with acute heart failure / Perfil clínico, farmacoterapéutico y de laboratorio de los pacientes hospitalizados com insuficiência cardíaca aguda

A insuficiência cardíaca aguda (ICA) é uma das causas mais comuns de internação hospitalar, associada a um alto risco de mortalidade. O tratamento atual é principalmente sintomático, sendo os exames laboratoriais realizados, a fim de complementar a avaliação clínica no diagnóstico e auxiliar no estabelecimento do perfil de risco admissional e prognóstico. Este estudo teve como objetivo caracterizar o perfil clínico, farmacoterapêutico e laboratorial de pacientes internados com insuficiência cardíaca aguda em hospital referência regional. Trata-se de um estudo transversal retrospectivo, descritivo, de abordagem quantitativa. Os participantes do estudo foram aqueles com alta médica por ICA pela classificação Internacional de Doenças (CID-10), admitidos na sala de emergência. Excluindo-se a participação de pacientes com tempo de internação inferior a 24 horas, menores de 18 anos. Para análise estatística foi usado o programa SPSS versão 21.0. Quanto ao perfil farmacoterapêutico, os medicamentos mais frequentes foram os que atuam no aparelho cardiovascular e aparelho digestivo e metabolismo, sendo a furosemida o fármaco mais frequente. A análise entre as alterações laboratoriais e a escala de ADHERE, revelou diferença estatística significativa entre os pacientes com risco baixo e risco intermediário/alto nos valores de hemoglobina (p=0,005), TGO (p=0,001), creatinina (p=0,000), ureia (p=0,000), potássio (p=0,004), TTPA (p=0,004) e RNI (p=0,021). Concluiu-se que os medicamentos frequentemente corresponderam ao tratamento recomendado no manejo inicial de pacientes com ICA. O risco de mortalidade intra-hospitalar intermediário/alto de acordo com a escala de ADHERE estavam associados com alterações laboratoriais dos pacientes com ICA.

Acute heart failure (AHF) is one of the most common causes of hospitalization, associated with a high risk of mortality. The current treatment is mainly symptomatic, and laboratory tests are carried out in order to complement the clinical evaluation in the diagnosis and help in establishing the admission and prognostic risk profile. This study aimed to characterize the clinical, pharmacotherapeutic and laboratory profile of patients hospitalized with acute heart failure in a regional reference hospital. This is a retrospective, descriptive, cross-sectional study with a quantitative approach. Study participants were those discharged due to AHF according to the International Classification of Diseases (ICD-10), admitted to the emergency room. Excluding the participation of patients with hospitalization time of less than 24 hours, under 18 years old. For statistical analysis, SPSS version 21.0 was used. As for the pharmacotherapeutic profile, the most frequent drugs were those that act on the cardiovascular and digestive systems and metabolism, with furosemide being the most frequent drug. The analysis between laboratory changes and the ADHERE scale revealed a statistically significant difference between patients at low risk and intermediate/high risk in hemoglobin (p=0.005), TGO (p=0.001), creatinine (p=0.000) values, urea (p=0.000), potassium (p=0.004), APTT (p=0.004) and INR (p=0.021). It was concluded that the medications often corresponded to the recommended treatment in the initial management of patients with AHF. Intermediate/high risk of in-hospital mortality according to the ADHERE scale were associated with laboratory alterations in patients with AHF.

La insuficiencia cardiaca aguda (ICA) es una de las causas más frecuentes de hospitalización, asociada a un alto riesgo de mortalidad. El tratamiento actual es principalmente sintomático y se realizan pruebas de laboratorio para complementar la evaluación clínica en el diagnóstico y ayudar a establecer el perfil de riesgo de ingreso y pronóstico. Este estudio tuvo como objetivo caracterizar el perfil clínico, farmacoterapéutico y de laboratorio de pacientes hospitalizados con insuficiencia cardíaca aguda en un hospital regional de referencia. Se trata de un estudio retrospectivo, descriptivo, transversal con enfoque cuantitativo. Los participantes del estudio fueron los dados de alta por ICA según la Clasificación Internacional de Enfermedades (CIE-10), ingresados en urgencias. Se excluye la participación de pacientes con tiempo de hospitalización menor a 24 horas, menores de 18 años. Para el análisis estadístico se utilizó SPSS versión 21.0. En cuanto al perfil farmacoterapéutico, los fármacos más frecuentes fueron los que actúan sobre los sistemas cardiovascular, digestivo y el metabolismo, siendo la furosemida el fármaco más frecuente. El análisis entre los cambios de laboratorio y la escala ADHERE reveló una diferencia estadísticamente significativa entre los pacientes de riesgo bajo e intermedio/alto en los valores de hemoglobina (p=0,005), TGO (p=0,001), creatinina (p=0,000), urea (p =0,000), potasio (p=0,004), APTT (p=0,004) e INR (p=0,021). Se concluyó que los medicamentos correspondían muchas veces al tratamiento recomendado en el manejo inicial de pacientes con ICA. El riesgo intermedio/alto de mortalidad hospitalaria según la escala ADHERE se asoció con alteraciones de laboratorio en pacientes con ICA.

Adaptación cultural y análisis psicométrico de una escala de comportamientos de autocuidado en personas con insuficiencia cardíaca / Cultural adaptation and psychometric analysis of a scale of self-care behaviors in persons with heart failure

INTRODUCCIÓN: La Insuficiencia Cardiaca se ha descrito como un síndrome de proporciones epidémicas, con una prevalencia de un 1-3% de la población adulta mundial menor de 60 años. Las conductas de autocuidado constituyen una estrategia clave en la elaboración de intervenciones exitosas que disminuyan la re-hospitalización, mortalidad y mejoren la calidad de vida. OBJETIVO: Adaptar y validar la Escala Revisada de Comportamientos de Autocuidado en Falla Cardiaca (Revised Heart Failure Self Care Behavior Scale) en personas con insuficiencia cardíaca, que se encuentran en seguimiento ambulatorio, en dos Hospitales Públicos chilenos. METODOLOGÍA: Estudio transversal de adaptación y análisis psicométrico del instrumento de medición Escala de Valoración de Comportamientos de Autocuidado en personas con Insuficiencia Cardíaca diseñada por Nancy Artinian. Emplazamiento: Unidades ambulatorias de seguimiento en Hospitales Públicos chilenos. Participantes: Usuarios con Insuficiencia Cardíaca que asistieron a dos Policlínicos de seguimiento de Insuficiencia Cardiaca de dos Centros de Salud de nivel secundario de dos comunas de Santiago en Chile. Método: Se realizó juicio de expertos para la adaptación cultural del instrumento, se aplicó el análisis factorial exploratorio con rotación oblicua. RESULTADOS: Escala Chilena de Valoración Comportamientos de Automanejo en Insuficiencia Cardiaca presentó una adecuada adaptación cultural, pruebas sicométricas que garantizan su validez de constructo y fiabilidad adecuada, con Alfa de Cronbach del Instrumento de 0,84 IC [0,80-0,88]. CONCLUSIONES: Se proporciona un instrumento que permite conocer conductas de autocuidado de los pacientes con IC, esto le permite ser utilizado por los profesionales que atienden a personas que padecen de IC en Chile.

INTRODUCTION: Heart failure (HF) has been described as a syndrome of epidemic proportions, with a prevalence of 1-3% amongst the global adult population under 60 years of age. Self-care behaviors are a key strategy in the development of successful interventions that reduce re-hospitalization, mortality and improve quality of life. OBJECTIVE: To adapt and validate the Revised Heart Failure Self-Care Behavior Scale in people with heart failure, who are in outpatient follow-up, in two Chilean public hospitals. DESIGN: Cross-sectional study of adaptation and psychometric analysis of the measuring instrument Scale of Assessment of Self-Care Behavior in Persons with Heart Failure, designed by Nancy Artinian. Location: Outpatient follow-up units in Chilean public hospitals. Participants: Patients with Heart Failure who attended two heart failure outpatient follow-up clinics within two secondary healthcare centers located in two districts of Santiago, Chile. Method: Expert judgments were made for the cultural adaptation of the instrument, followed by exploratory factor analysis with oblique rotation. RESULTS: The Chilean Scale of Assessment of Self-Management Behaviors in Heart Failure presented adequate cultural adaptation, psychometric tests that guarantee its validity in terms of its construction and adequate reliability. Cronbach's Alpha of the Instrument was 0,84 IC [0,80-0,88] CONCLUSIONS: The study provides a tool that allows us to ascertain the self-care behaviors of patients with HF, allowing it to be used by professionals who care for people with HF in Chile.

El puntaje de Framingham ayudaría en la estratificación del riesgo de pacientes con ergometría positiva y SPECT normal / The Framingham score could help in risk stratification of patients with positive ergometry and normal SPECT

Antecedentes. El valor pronóstico de una ergometría positiva en el contexto de imágenes tomográficas de perfusión miocárdica de estrés y reposo (SPECT) normales no está bien establecido. Objetivos. Documentar la incidencia de infarto, muerte y revascularización coronaria en pacientes con una ergometría positiva de riesgo intermedio e imágenes de perfusión SPECT normales, y explorar el potencial valor del puntaje de riesgo de Framingham en la estratificación pronóstica de estos pacientes. Métodos. Cohorte retrospectiva integrada por pacientes que habían presentado síntomas o hallazgos electrocardiográficos compatibles con enfermedad arterial coronaria durante la prueba de esfuerzo, con criterios de riesgo intermedio en la puntuación de Duke y perfusión miocárdica SPECT normal. Fueron identificados a partir de la base de datos del laboratorio de cardiología nuclear del Instituto de Cardiología y Cirugía Cardiovascular de la ciudad de Posadas, Argentina. Resultados. Fueron elegibles 217 pacientes. El seguimiento fue de 3 1,5 años. La sobrevida libre de eventos (muerte,infarto de miocardio no fatal, angioplastia coronaria o cirugía de bypass de arteria coronaria) a uno, tres y cinco años fue significativamente menor (Log-rank test, p= 0,001) en el grupo con puntaje de Framingham alto o muy alto (77, 71y 59 %, respectivamente) que en el grupo de puntaje bajo o intermedio (89, 87 y 83 %). Tomando como referencia a los pacientes con riesgo bajo en el puntaje de Framingham, luego de ajustar por edad, sexo y puntaje de Duke, los pacientes categorizados en los estratos alto y muy alto riesgo del puntaje de Framingham presentaron una incidencia del evento combinado cercana al triple (hazard ratio [HR] 2,81; intervalo de confianza [IC] del 95 % 0,91 a 8,72; p= 0,07 y HR 3,61;IC 95 % 1,23 a 10,56; p= 0,019 respectivamente). Conclusiones. La estimación de riesgo con el puntaje de Framingham sería de ayuda en la estratificación pronóstica de los pacientes con ergometría positiva y SPECT normal. (AU)

Background. The prognostic value of positive exercise testing with normal SPECT myocardial perfusion imaging is not well established. Objectives. To document the incidence of infarction, death, and coronary revascularization in patients with a positive intermediate-risk exercise test and normal SPECT perfusion images and to explore the potential value of the Framingham Risk Score in the prognostic stratification of these patients. Methods. A retrospective cohort comprised patients who presented symptoms or electrocardiographic findings compatible with coronary artery disease during the stress test, with intermediate risk criteria in the Duke score and normal SPECT myocardial perfusion. They were identified from the database of the nuclear cardiology laboratory of the Instituto de Cardiología y Cirugía Cardiovascular of Posadas, Argentina. Results. 217 patients were eligible. Follow-up was 3 1.5 years. Event-free survival (death, non-fatal myocardial infarction, coronary angioplasty, or coronary artery bypass surgery) at one, three, and five years was significantly lower (Log-ranktest, p: 0.001) in the group with a score of Framingham high or very high (77, 71 and 59 %, respectively) than in the lowor intermediate score group (89, 87 and 83 %). Taking as reference the low-risk patients in the Framingham score, after adjusting for age, sex, and Duke score, the patients categorized in the high-risk and very high-risk strata showed about three times higher incidence of the combined event (hazard ratio [HR] 2.81; 95 % confidence interval [CI] 0.91 to 8.72;p=0.07 and HR 3.61; 95 % CI 1.23 to 10.56; p=0.019 respectively). Conclusions. Risk estimation with the Framingham score would be helpful in the prognostic stratification of patients with positive exercise testing and normal SPECT. (AU)

Research Progress in the Effect of His-Purkinje Conduction System Pacing on Cardiac Function / 中山大学学报(医学科学版)

Cardiac pacing is an effective treatment for cardiac pacing and conduction dysfunction and severe heart failure. However， the conventional right ventricular pacing may increase the incidences of heart failure and atrial fibrillation， and biventricular pacing has a relatively high non-response rate. As a new technique of physiological pacing， a number of studies in recent years have been conducted to show the stability of pacing parameters and good cardiac synchronization of his-purkinje system pacing. This article reviews the current status of research and progress in the effects of his-purkinje conduction system pacing on cardiac function， so as to provide a theoretical basis for promoting the development of this technology.

Cardiovascular health status in Chinese school aged children / 中国学校卫生

Objective@#The American Heart Association released the Life s Essential 8 (LE 8) for the overall evaluation of cardiovascular health (CVH) on individual level. The present study aimed to describe the overall CVH in Chinese school aged children using LE 8 metrics.@*Methods@#Data of the present analysis came from a national representative multicentered cross sectional study conducted in 7 provinces of China in 2013. The original study used a multistage cluster sampling method. A total of 10 326 children aged 5 to 19 years with complete data of health behaviors and health outcomes were included in the study. Children s health behavior indicators included diet, physical activity, nicotine exposure and sleep health. Health outcome factors included body mass index, fast blood glucose, lipid profile and blood pressure.@*Results@#The median CVH score was 73.3 ( IQR =14.4) in boys and 73.4 ( IQR = 13.5) in girls. Compared to children aged ≤9 years, the health behavior scores were lowest in the 13-15 age group, with boys scoring 7.73 lower (95% CI =-8.35--7.12, P <0.01) and girls scoring 9.15 (95% CI =-9.83--8.48, P <0.01) lower. The ≥16 age group had the lowest health outcome scores, with boys scoring 7.85 (95% CI =-9.07--6.63, P <0.01) lower and girls scoring 6.11 (95% CI =-7.12--5.09, P <0.01) lower.@*Conclusions@#Chinese school aged children are generally at a moderate level of cardiovascular health. Specific LE 8 components vary substantially between groups and therefore require targeted intervention strategies.

Heart rate variability analysis to investigate autonomic nervous system activity among the three premature ventricular complex circadian types: An observational study

Background and Objective@#Premature ventricular complex (PVC) burden exhibits one of three circadian types, classified as fast-type, slow-type, and independent-type PVC. It is unknown whether PVC circadian types have different heart rate variability (HRV) parameter values. Therefore, this study aimed to evaluate differences in HRV circadian rhythm among fast-, slow-, and independent-type PVC. @*Methods@#This cross-sectional observational study consecutively recruited 65 idiopathic PVC subjects (23 fast-, 20 slow-, and 22 independent-type) as well as five control subjects. Each subject underwent a 24-hour Holter to examine PVC burden and HRV. HRV analysis included components that primarily reflect global, parasympathetic, and sympathetic activities. Repeated measures analysis of variance was used to compare differences in HRV circadian rhythm by PVC type. Results. The average PVC burden was 15.7%, 8.4%, and 13.6% in fast-, slow-, and independent-type idiopathic PVC subjects, respectively. Global, parasympathetic nervous system, and sympathetic nervous system HRV parameters were significantly lower in independenttype PVC versus fast- and slow-type PVC throughout the day and night. Furthermore, we unexpectedly found that tendency towards sympathetic activity dominance during nighttime was only in independent-type PVC.@*Conclusion@#The HRV parameters are reduced in patients with independent-type PVC compared to fast- and slowtype PVC. Future research is warranted to determine possible differences in the prognosis between the three PVC types.