Prevalence, risk factors and survival in dogs with myxomatous valve degeneration / [Prevalência, fatores de risco e sobrevivência em cães com degeneração mixomatosa valvar]

The objective of this study was to describe the prevalence, survival time, and risk factors of myxomatous mitral valve disease (MMVD) in dogs by a retrospective observational cohort study design of a Brazilian veterinary center, admitted from 2012 to 2018 (2.585 days). Considering the 105 dog files confirmed as MMVD, the prevalence of the disease was higher in small-breed dogs with ages from 10 to 19 years (30.3%). The survival time of the dogs at B1 stage (1.854 ± 145 days) was higher than the B2 (1.508+209) and C/D (930 ± 209). Higher risks of death (hazard ratio) were detected in the presence of syncope (2.5), pulmonary crackling (2.0), dyspnea (1.9), and higher values of vertebral heart scale (1.7), radiographic left atrium dimension (1.8), the ACVIM staging (1.7), and the duration of QRS complex (1.05). The results achieved demonstrated higher prevalence of MMVD in old small-breed dogs, associated with longer survival time in the B1 stage of the disease, and higher risk of death related to the presence of clinical signs, such as dyspnea, syncope, and pulmonary crackling, beyond some radiographic, echocardiographic, and electrocardiographic variables of heart or atrial enlargement.(AU)

O objetivo deste estudo foi descrever a prevalência, o tempo de sobrevivência e os fatores de risco da doença mixomatosa valvar mitral (DMVM) em cães, por meio de estudo de coorte observacional retrospectivo, os quais foram atendidos em um centro veterinário de 2012 a 2018 (2.585 dias). Considerando os 105 arquivos de cães com confirmação da DMVM, maior prevalência foi observada em raças pequenas com idades entre 10 e 19 anos (30,3%). O tempo de sobrevivência de cães em estágio B1 (1.854+145 dias) foi superior ao B2 (1.508+209) e ao C/D (930+209). Maior risco de morte (hazard ratio) foi observado na presença de síncope (2,5), crepitação pulmonar (2,0), dispneia (1,9), bem como de valores superiores de VHS (1,7), dimensão radiográfica do átrio esquerdo (1,8), estadiamento ACVIM (1,7) e duração do complexo QRS (1,05). Os resultados obtidos demonstraram maior prevalência de DMVM em cães idosos de raças pequenas, associada a maior tempo de sobrevida no estágio B1 da doença e a maior risco de morte relacionado à presença de sinais clínicos como dispneia, síncope e crepitação pulmonar, além de algumas variáveis radiográficas, ecocardiográficas e eletrocardiográficas de cardiomegalia ou aumento atrial esquerdo.(AU)

Sincronia e função ventricular esquerda em pacientes pediátricos portadores de marca-passo definitivo / Left ventricular synchrony and function in pediatric patients with definitive pacemakers

FUNDAMENTO: A estimulação crônica do ventrículo direito (EVD) induz um padrão de contração dessincronizado, produzindo assincronia interventricular e intraventricular. Muitos estudos têm mostrado a relação entre EVD e a forma e função ventricular esquerda (VE) comprometida. OBJETIVO: O objetivo deste estudo foi avaliar a sincronia e a função do VE em pacientes pediátricos que receberam EVD em comparação com aqueles que receberam estimulação do VE (EVE). MÉTODOS: As funções sistólica e diastólica e a sincronia do VE foram avaliadas em 80 pacientes pediátricos com bloqueio atrioventricular total não cirúrgico ou pós-cirúrgico, com estimulação a partir do endocárdio do ventrículo direito (VD) (n = 40) ou do epicárdio do VE (n = 40). Foram analisados dados ecocardiográficos obtidos antes da implantação do marca-passo, imediatamente após a implantação, e no final de um acompanhamento médio de 6,8 anos. RESULTADOS: A função diastólica do VE não se alterou em nenhum dos pacientes durante o acompanhamento. A função sistólica ventricular esquerda foi preservada nos pacientes que receberam EVE. No entanto, a fração de encurtamento e a fração de ejeção diminuíram de medianas de 41% ± 2,6% e 70% ± 6,9% antes da implantação para 32% ± 4,2% e 64% ± 2,5% (p < 0,0001 e p < 0,0001), respectivamente, no acompanhamento final. O atraso mecânico interventricular foi significativamente maior com a EVD (66 ± 13 ms) do que com a EVE (20 ± 8 ms). Da mesma forma, nos dois grupos houve uma diferença significativa entre os seguintes parâmetros: atraso mecânico do VE (EVD: 69 ± 6 ms, EVE: 30 ± 11 ms, p < 0,0001); atraso septo-lateral (RVP: 75 ± 19 ms, LVP: 42 ± 10 ms, p < 0,0001) e atraso septo-posterior (EVD: 127 ± 33 ms, EVE: 58 ± 17 ms, p < 0,0001). CONCLUSÃO: Quando comparado ao endocárdio do VD, o epicárdio do VE é um local ideal para a estimulação para preservar a sincronia e a função cardíaca.

BACKGROUND: Chronic right ventricular pacing (RVP) induces a dyssynchronous contraction pattern,producing interventricular and intraventricular asynchrony. Many studies have shown the relationship of RVP with impaired left ventricular (LV) form and function. OBJECTIVE: The aim of this study was to evaluate LV synchrony and function in pediatric patients receiving RVP in comparison with those receiving LV pacing (LVP). METHODS:LV systolic and diastolic function and synchrony were evaluated in 80 pediatric patients with either nonsurgical or postsurgical complete atrioventricular block, with pacing from either the RV endocardium (n = 40) or the LV epicardium (n = 40). Echocardiographic data obtained before pacemaker implantation, immediately after it, and at the end of a mean follow-up of 6.8 years were analyzed. RESULTS: LV diastolic function did not change in any patient during follow-up. LV systolic function was preserved in patients with LVP. However, in children with RVP the shortening fraction and ejection fraction decreased from medians of 41% ± 2.6% and 70% ± 6.9% before implantation to 32% ± 4.2% and 64% ± 2.5% (p < 0.0001 and p < 0.0001), respectively, at final follow-up. Interventricular mechanical delay was significantly larger with RVP (66 ± 13 ms) than with LVP (20 ± 8 ms). Similarly, the following parameters were significantly different in the two groups: LV mechanical delay (RVP: 69 ± 6 ms, LVP: 30 ± 11 ms, p < 0.0001); septal to lateral wall motion delay (RVP: 75 ± 19 ms, LVP: 42 ± 10 ms, p < 0.0001); and, septal to posterior wall motion delay (RVP: 127 ± 33 ms, LVP: 58 ± 17 ms, p < 0.0001). CONCLUSION: Compared with RV endocardium, LV epicardium is an optimal site for pacing to preserve cardiac synchrony and function.

A novel noninvasive method to detect rejection after heart transplantation

Prompt and accurate detection of rejection prior to pathological changes after organ transplantation is vital for monitoring rejections. Although biopsy remains the current gold standard for rejection diagnosis, it is an invasive method and cannot be repeated daily. Thus, noninvasive monitoring methods are needed. In this study, by introducing an IL-2 neutralizing monoclonal antibody (IL-2 N-mAb) and immunosuppressants into the culture with the presence of specific stimulators and activated lymphocytes, an activated lymphocyte-specific assay (ALSA) system was established to detect the specific activated lymphocytes. This assay demonstrated that the suppression in the ALSA test was closely related to the existence of specific activated lymphocytes. The ALSA test was applied to 47 heart graft recipients and the proliferation of activated lymphocytes from all rejection recipients proven by endomyocardial biopsies was found to be inhibited by spleen cells from the corresponding donors, suggesting that this suppression could reflect the existence of activated lymphocytes against donor antigens, and thus the rejection of a heart graft. The sensitivity of the ALSA test in these 47 heart graft recipients was 100%; however, the specificity was only 37.5%. It was also demonstrated that IL-2 N-mAb was indispensible, and the proper culture time courses and concentrations of stimulators were essential for the ALSA test. This preliminary study with 47 grafts revealed that the ALSA test was a promising noninvasive tool, which could be used in vitro to assist with the diagnosis of rejection post-heart transplantation.

Ecocardiografia por Doppler tecidual no diagnóstico de rejeição após transplante cardíaco / Tissue doppler echocardiography in the diagnosis of heart transplantation rejection / Ecocardiografía con Doppler tisular en el diagnóstico de rechazo después de transplante cardíaco

FUNDAMENTO: A biópsia endomiocárdica (BEM) é o método padrão-ouro para o diagnóstico de rejeição celular (RC) após transplante cardíaco (TC). OBJETIVO: Testar a hipótese de que o exame de imagem por Doppler tecidual (IDT) pode detectar RC > 3A e agregar informação diagnóstica, comparado ao Doppler convencional. MÉTODOS: Cinquenta e quatro pacientes com TC foram submetidos à BEM e estudo ecocardiográfico através de IDT em até 24 horas. Comparamos os pacientes com TC e RC > 3A com pacientes com TC e RC < 3A, com um grupo controle normal (13 pacientes). Foram medidas através da IDT, as velocidades sistólica (S), diastólica precoce (e'), diastólica tardia (a') relação das velocidades e'/a' no anel ventricular esquerdo, nos segmentos basal e médio das paredes septal (SEP), lateral (LAT), inferior (INF) e no anel ventricular direito. RESULTADOS: Os pacientes com TC mostraram RC > 3A em 39/129 (30,2 por cento) das BEM. O melhor preditor isolado para o diagnóstico de RC foi a a'LAT, com sensibilidade de 76,3 por cento, especificidade de 73,8 por cento (p = 0,001). Na análise multivariada, a a'LAT (p = 0,001), a'SEP (p = 0,002), relação e'/a' LAT (p = 0,006), relação e'Mitral/ e'LAT (p = 0,014), SINF (p = 0,009) foram preditores de RC > 3A. Obtivemos um escore com sensibilidade de 88,2 por cento, acurácia de 79,6 por cento, e valor preditivo negativo de 92,9 por cento para diagnosticar RC > 3A. O Doppler convencional (fluxo mitral e pulmonar venoso) não foi relevante para predizer a RC > 3A. CONCLUSÃO: O estudo de IDT agregou informação diagnóstica para predizer RC > 3A quando comparado ao Doppler convencional. O modelo baseado em IDT pode ser tornar um método em potencial para detectar RC > 3A após TC.

BACKGROUND: Endomyocardial biopsy (EMB) is the gold standard method for the diagnosis of cellular rejection (CR) after heart transplantation (HT). OBJECTIVE: To test the hypothesis that tissue Doppler imaging (TDI) could detect CR > 3A and add diagnostic information compared to conventional Doppler. METHODS: Fifty-four HT patients underwent 129 EMB and a TDI echocardiographic study within 24 hours. We compared HT patients with CR > 3A versus HT patients with CR < 3A, with a normal matched control group (13 patients). We measured TDI systolic (S), early diastolic (e'), late diastolic (a') velocities and e'/a' ratio in the left ventricular annulus, basal and medium (mid) segments of the septal (SEP), lateral (LAT), inferior (INF), anterior (ANT) walls; and in the right ventricular annulus. RESULTS: HT patients showed CR > 3A in 39/129 (30.2 percent) EMB. The best isolated predictor for CR diagnosis was a'LAT, with a sensitivity of 76.3 percent, specificity of 73.8 percent (p = 0.001). In the multivariate analysis, a'LAT (p = 0.001), a'SEP (p = 0.002), e'/a' LAT ratio (p = 0.006), e'Mitral/ e'LAT ratio (p = 0.014), SINF (p = 0.009) predicted CR > 3A. We obtained a score with a sensitivity of 88.2 percent, accuracy of 79.6 percent and negative predictive value of 92.9 percent to diagnose CR > 3A. Conventional Doppler (mitral and pulmonary venous flow) was not relevant to predict CR > 3A. CONCLUSION: TDI added diagnostic information to predict CR > 3A compared to conventional Doppler. A TDI-based model could become a potential method to detect CR > 3A after Heart Transplantation.

FUNDAMENTO: La biopsia endomiocárdica (BEM) es el método gold standard para el diagnóstico de rechazo celular (RC) después de transplante cardíaco (TC). OBJETIVO: Testear la hipótesis de que el examen de imagen con Doppler tisular (IDT) puede detectar RC > 3A y agregar información diagnóstica, comparado al Doppler convencional. MÉTODOS: Cincuenta y cuatro pacientes con TC fueron sometidos a BEM y estudio ecocardiográfico a través de IDT en hasta 24 horas. Comparamos los pacientes con TC y RC > 3A con pacientes con TC y RC < 3A, con un grupo control normal (13 pacientes). Fueron medidas a través de la IDT, las velocidades sistólica (S), diastólica precoz (e`), diastólica tardía (a') relación de las velocidades e'/a' en el anillo ventricular izquierdo, en los segmentos basal y medio de las paredes septal (SEP), lateral (LAT), inferior (INF) y en el anillo ventricular derecho. RESULTADOS: Los pacientes con TC mostraron RC > 3A en 39/129 (30,2 por ciento) de las BEM. El mejor predictor aislado para el diagnóstico de RC fue la a'LAT, con sensibilidad de 76,3 por ciento, especificidad de 73,8 por ciento (p = 0,001). En el análisis multivariado, la a'LAT (p = 0,001), a'SEP (p = 0,002), relación e'/a' LAT (p = 0,006), relación e'Mitral/e'LAT (p = 0,014), SINF (p = 0,009) fueron predictores de RC > 3A. Obtuvimos un escore con sensibilidad de 88,2 por ciento, precisión de 79,6 por ciento, y valor predictivo negativo de 92.9 por ciento para diagnosticar RC > 3A . El Doppler convencional (flujo mitral y pulmonar venoso) no fue relevante para predecir la RC > 3A. CONCLUSIÓN: El estudio de IDT agregó información diagnóstica para predecir RC > 3A cuando fue comparado al Doppler convencional. El modelo basado en IDT puede volverse un método en potencial para detectar RC > 3A después de TC.

Mapeamento epicárdico da taquicardia ventricular sustentada em cardiopatias não isquêmicas / Epicardial mapping of sustained ventricular tachycardia in nonischemic heart disease / Mapeo epicárdico de la taquicardia ventricular sostenida en cardiopatías no isquémicas

FUNDAMENTO: A complexidade dos circuitos reentrantes relacionados às taquicardias ventriculares diminui os índices de sucesso dos procedimentos de ablação por radiofrequência. OBJETIVO: Avaliar se o mapeamento epicárdico com múltiplos eletrodos realizado simultaneamente com o mapeamento endocárdico auxilia na ablação da taquicardia ventricular (TV) sustentada em pacientes com cardiopatia não isquêmica. MÉTODOS: Vinte e seis pacientes com TV sustentada recorrente, sendo 22 (84,6 por cento) com cardiopatia chagásica crônica, dois (7,7 por cento) com cardiomiopatia dilatada idiopática e dois (7,7 por cento) portadores de displasia arritmogênica do ventrículo direito, foram submetidos a mapeamento epicárdico com dois ou três microcateteres, com 8 eletrodos cada, simultaneamente ao mapeamento endocárdico convencional. Utilizou-se cateter com ponta de 4 mm para ablação com radiofrequência (RF) realizada durante a TV induzida. RESULTADOS: Das 33 TVs induzidas, 25 foram mapeadas e 20 tiveram sua origem definida. Onze com origem epicárdica e 9 endocárdica. A estimulação ventricular programada não induziu TV sustentada em 11 (42,0 por cento) dos 26 pacientes após a ablação. Eventos como recorrência da TV e morte ocorreram em 10,0 por cento dos pacientes submetidos à ablação com sucesso, e em 59,0 por cento dos insucessos, em seguimento ambulatorial médio de 357 ± 208 dias. CONCLUSÃO: Circuitos subepicárdicos são frequentes em pacientes com cardiopatia não isquêmica. O mapeamento epicárdico com múltiplos cateteres realizado simultaneamente com o mapeamento endocárdico contribui para a identificação destes circuitos em um mesmo procedimento.

BACKGROUND: The complexity of reentrant circuits related to ventricular tachycardias decreases the success rate of radiofrequency ablation procedures. OBJECTIVE: To evaluate whether the epicardial mapping with multiple electrodes carried out simultaneously with the endocardial mapping helps in ablation procedures of sustained ventricular tachycardia (VT) in patients with nonischemic heart disease. METHODS: Twenty-six patients with recurrent sustained VT, of which 22 (84.6 percent) presenting chronic chagasic cardiomyopathy, 2 (7.7 percent) with idiopathic dilated cardiomyopathy and 2 with right ventricular arrhythmogenic dysplasia (RVAD), were submitted to epicardial mapping with two or three microcatheters, with 8 electrodes each, simultaneously to the conventional endocardial mapping. A catheter with a 4-mm tip was used for the ablation by radiofrequency (RF) carried out during the induced VT. RESULTS: Of the 33 induced VT, 25 were mapped and 20 had their origin defined. Eleven had epicardial and 9 had endocardial origin. The programmed ventricular stimulation did not induce sustained VT in 11 (42.0 percent) of the 26 patients after the ablation. Events such as VT recurrence and death occurred in 10.0 percent of the patients submitted to successful ablation and in 59.0 percent of the unsuccessful cases, during a mean ambulatory follow-up of 357 ± 208 days. CONCLUSION: Subepicardial circuits are frequent in patients with nonischemic heart disease. The epicardial mapping with multiple catheters carried out simultaneously with the endocardial mapping contributes to the identification of these circuits in a same procedure.

FUNDAMENTO: La complejidad de los circuitos reentrantes relacionados a las taquicardias ventriculares disminuye los índices de éxito de los procedimientos de ablación por radiofrecuencia. OBJETIVO: Evaluar si el mapeo epicárdico con múltiples electrodos realizado simultáneamente con el mapeo endocárdico ayuda en la ablación de la taquicardia ventricular (TV) sostenida en pacientes con cardiopatía no isquémica. MÉTODOS: Veinte y seis pacientes con TV sostenida recurrente, siendo 22 (84,6 por ciento) con cardiopatía chagásica crónica, dos (7,7 por ciento) con cardiomiopatía dilatada idiopática y dos (7,7 por ciento) portadores de displasia arritmogénica del ventrículo derecho, fueron sometidos a mapeo epicárdico con dos o tres microcatéteres, con 8 electrodos cada uno, simultáneamente al mapeo endocárdico convencional. Se utilizó catéter con punta de 4 mm para ablación con radiofrecuencia (RF) realizada durante la TV inducida. RESULTADOS: De las 33 TVs inducidas, 25 fueron mapeadas y 20 tuvieron su origen definido. Once con origen epicárdica y 9 endocárdica. La estimulación ventricular programada no indujo TV sostenida en 11 (42,0 por ciento) de los 26 pacientes después de la ablación. Eventos como recurrencia de la TV y muerte ocurrieron en 10,0 por ciento de los pacientes sometidos a la ablación con éxito, y en 59,0 por ciento de los fracasos, en control ambulatorio medio de 357 ± 208 días. CONCLUSIÓN: Circuitos subepicárdicos son frecuentes en pacientes con cardiopatía no isquémica. El mapeo epicárdico con múltiples catéteres realizado simultáneamente con el mapeo endocárdico contribuye a la identificación de estos circuitos en un mismo procedimiento.

Remodelamento cardíaco: análise seriada e índices de detecção precoce de disfunção ventricular / Cardiac remodeling: serial analysis and indexes for early detection of ventricular dysfunction / Remodelación cardiaca: análisis seriado e índices de detección precoz de disfunción ventricular

Fundamento: A estenose aórtica supravalvar (EAo) é utilizada para o estudo da remodelação cardíaca (RC) por sobrecarga pressórica. Nesse modelo, não estão claramente estabelecidos o comportamento da RC desde a fase inicial, nem os melhores parâmetros para a identificação da disfunção ventricular. OBJETIVOS: 1) Caracterizar, precoce e evolutivamente, as modificações morfofuncionais durante a RC em ratos com EAo e 2) identificar o índice mais sensível para detecção do momento do aparecimento da disfunção diastólica e sistólica do ventrículo esquerdo (VE). Métodos: Ratos Wistar foram divididos em dois grupos - controle (GC, n=13) e EAo (GEAo, n=24) - e estudados nas 3ª, 6ª, 12ª e 18ª semanas pós-cirurgia. Os corações foram analisados por meio de ecocardiograma (ECO). Resultados: Ao final do experimento, as relações do VE, do ventrículo direito e dos átrios com o peso corporal final foram aumentadas no GEAo. O ECO mostrou que o átrio esquerdo sofreu uma remodelação significativa a partir da 6ª semana. No GEAo, a porcentagem de encurtamento endocárdico apresentou queda significativa a partir da 12ª semana e a porcentagem de encurtamento mesocárdico, na 18ª semana. A relação onda E e onda A (E/A) foi superior no GC em comparação ao GEAo em todos os momentos analisados. Conclusões: O ventrículo esquerdo dos ratos com EAo, durante o processo de remodelação, apresentou hipertrofia concêntrica, disfunção diastólica precoce e melhoria da função sistólica, com posterior deterioração do desempenho. Além disso, constatou-se que os índices ecocardiográficos mais sensíveis para a detecção da disfunção diastólica e sistólica são, respectivamente, a relação E/A e a porcentagem de encurtamento endocárdico.

Background: Supravalvar aortic stenosis (SVAS) is used to study overload-induced cardiac remodeling (CR). In this model, neither CR behavior since beginning stage nor the best parameters to identify ventricular dysfunction are clearly stated. Objective: 1) Characterizing, early and evolutively, morphological and functional modifications during CR in rats with SVAS and 2) identifying the most sensitive index for detecting the moment when the diastolic and systolic dysfunction first appeared in the left ventricle (LV). Methods: Wistar Rats were divided into two groups - control (CG, n=13) and SVAS (SVASG, n=24) - and studied in post-surgical 3rd, 6th, 12th and 18th weeks. Hearts were analyzed by means of an echocardiogram (ECHO). Results: By the end of the experiment, ratios between the LV, right ventricle and atria and the final body weight were increased in the SVASG. The ECHO showed that the left atrium underwent significant remodeling from the 6th on. The percent of endocardial shortening underwent significant drop as of the 12nd week and the percent of, as of the 18th week, in the SVASG. The ratio between E- wave and A-wave (E/A) was higher in CG compared to the SVASG in all events analyzed. Conclusions: During the remodeling process, the left ventricle of rats with SVAS presented concentric hypertrophy, early diastolic dysfunction and improvement of systolic function, with posterior performance deterioration. Besides this, the study found out the most sensitive echocardiographic indexes for detecting systolic and diastolic dysfunction are, respectively, the ratio E/A and the percent of endocardial shortening.

Fundamento: La estenosis aórtica supravalvular (EAo) se utiliza para el estudio de la remodelación cardiaca (RC) por sobrecarga de presión. En este modelo, no están claramente establecidos el comportamiento del RC desde la fase inicial, ni los mejores parámetros para la identificación de la disfunción ventricular. OBJETIVO: 1) Caracterizar, precoz y evolutivamente, las modificaciones morfofuncionales durante el RC en ratones con EAo, y 2) identificar el índice más sensible para detección del momento de la aparición de la disfunción diastólica y sistólica del ventrículo izquierdo (VI). Métodos: Ratones Wistar se dividieron en dos grupos - control (GC, n=13) y EAo (GEAo, n=24) - y estudiados en las 3ª, 6ª, 12ª y 18ª semanas post cirugía. Los corazones se analizaron por medio de ecocardiograma (ECO). Resultados: Al final del experimento, las relaciones del VI, del ventrículo derecho y de los atrios con el peso corporal final fueron aumentadas en el GEAo. El ECO mostró que el atrio izquierdo sufrió una remodelación significativa a partir de la 6ª semana. En el GEAo, el porcentaje de acortamiento endocárdico presentó disminución significativa a partir de la 12ª semana y el porcentaje de acortamiento mesocárdico, en la 18ª semana. La relación onda E y onda A (E/A) fue superior en el GC en comparación al GEAo en todos los momentos analizados. Conclusión: El ventrículo izquierdo de los ratones con EAo, durante el proceso de remodelación, presentó hipertrofia concéntrica, disfunción diastólica precoz y mejora de la función sistólica, con posterior deterioro del desempeño. Además de ello, se constató que los índices ecocardiográficos más sensibles para la detección de la disfunción diastólica y sistólica son, respectivamente, la relación E/A y el porcentaje de acortamiento endocárdico.

Aspectos anátomo-patológicos e histológicos en el corazón de pacientes con endocarditis infecciosa / Anatomopathological and hystological aspects of the heart of patients with infectious endocarditis

Se discute aquellos aspectos anatomopatológicos e histológicos del corazón considerando la patogénesis, bacteremia, patología valvular previa y la morfología de las vegetaciones.

A fibrose subendocárdica que acompanha o remodelamento ventricular do infarto do miocárdio está associada a redução da pressão de perfusão coronariana durante a fase aguda / Subendocardial fibrosis in remote myocardium results from reduction of coronary driving pressure during acute infarction in rats

OBJECTIVE: To investigate the role of hemodynamic changes occurring during acute MI in subsequent fibrosis deposition within non-MI. METHODS: By using the rat model of MI, 3 groups of 7 rats each [sham, SMI (MI <30 percent), and LMI (MI >30 percent)] were compared. Systemic and left ventricular (LV) hemodynamics were recorded 10 minutes before and after coronary artery ligature. Collagen volume fraction (CVF) was calculated in picrosirius red-stained heart tissue sections 4 weeks later. RESULTS: Before surgery, all hemodynamic variables were comparable among groups. After surgery, LV end-diastolic pressure increased and coronary driving pressure decreased significantly in the LMI compared with the sham group. LV dP/dt max and dP/dt min of both the SMI and LMI groups were statistically different from those of the sham group. CVF within non-MI interventricular septum and right ventricle did not differ between each MI group and the sham group. Otherwise, subendocardial (SE) CVF was statistically greater in the LMI group. SE CVF correlated negatively with post-MI systemic blood pressure and coronary driving pressure, and positively with post-MI LV dP/dt min. Stepwise regression analysis identified post-MI coronary driving pressure as an independent predictor of SE CVF. CONCLUSION: LV remodeling in rats with MI is characterized by predominant SE collagen deposition in non-MI and results from a reduction in myocardial perfusion pressure occurring early on in the setting of MI

Expression of CD40 ligand, interferon-gamma and Fas ligand genes in endomyocardial biopsies of human cardiac allografts: correlation with acute rejection

The purpose of the present study was to investigate the expression (mRNA) of CD40 ligand (CD40L), interferon-gamma (IFN-gamma) and Fas ligand (FasL) genes in human cardiac allografts in relation to the occurrence of acute cardiac allograft rejection as well as its possible value in predicting acute rejection. The mRNA levels were determined by a semiquantitative reverse transcriptase-polymerase chain reaction method in 39 samples of endomyocardial biopsies obtained from 10 adult cardiac transplant recipients within the first six months after transplantation. Biopsies with ongoing acute rejection showed significantly higher CD40L, IFN-gamma and FasL mRNA expression than biopsies without rejection. The median values of mRNA expression in biopsies with and without rejection were 0.116 and zero for CD40L (P<0.003), 0.080 and zero for IFN-gamma (P<0.0009), and 0.156 and zero for FasL (P<0.002), respectively. In addition, the levels of IFN-gamma mRNA were significantly increased 7 to 15 days before the appearance of histological evidence of rejection (median of 0.086 in pre-rejection biopsies), i.e., they presented a predictive value. This study provides further evidence of heightened expression of immune activation genes during rejection and shows that some of these markers may present predictive value for the occurrence of acute rejection.

Cardiac pathology of permanent pacemaker implementation.

The cardiac findings in five cases of permanent pacemaker implantation seen at autopsy in a three-year period is reported. Implantation was done for complete heart block in four patients and sick sinus syndrome in one. The periods of implantation ranged from seven days to four years. The common findings were right sided valvar and mural bland thrombus formation. Additional findings included superior vena caval thrombosis, endocardial 'tunnel' formation for the pacing wires, perforation of the tricuspid leaflet and a gross morphology similar to that seen in right sided endomyocardial fibrosis.

Diagnosis of rheumatic fever: current status of Jones Criteria and role of echocardiography.

The original Jones Criteria as proposed by Dr. T. Duckett Jones have been modified four times and the updated revised criteria were published in 1992. According to this latest publication major manifestations are carditis, polyarthritis, chorea, erythema marginatum and subcutaneous nodules. Minor manifestations include fever, arthralgia and laboratory findings of elevated erythrocyte sedimentation rate, C-reactive protein and prolonged PR interval on ECG. For making a diagnosis of acute rheumatic fever, two major, or one major and two minor manifestations must be accompanied by supporting evidence of antecedent group A streptococcal infection in the form of positive throat culture or elevated or rising anti-streptolysin titre. The updated guidelines also highlighted a subgroup of "exceptions to Jones Criteria" for patients with chorea, indolent carditis and previous history of rheumatic fever or "rheumatic heart disease". Role of echocardiography has not been defined in these modifications but may be important, as clinical detection of soft murmurs may be difficult due to tachycardia. Doppler and color flow mapping is more sensitive in picking up minor digress of valvular regurgitation. Several studies have confirmed that the yield of carditis with valvular regurgitation increased with use of echocardiography in patients with acute rheumatic fever. Also echocardiography is of great help in mixed valve lesions to determine the severity of each lesion. Other abnormalities detected on echocardiography in acute carditis include prolapse of the valve, focal nodular thickening of leaflets and pericardial effusion. Jones Criteria are guidelines to assist the physician and should not be substituted for clinical judgement as strictly following them may result in underdiagnosis of this disease in our country.

Fenotipo y reactividad de linfocitos T aislados de la placa ateromatosa. Enseñanzas de un trasplante / Phenotype and reactivity of T lymphocytes isolated from atheromatous plaque. Knowledge derived from a heart transplant case

La hipótesis de la reacción inmmunológica primaria reconoce que el daño inicial en la formación de la placa ateromatosa está mediado por linfocitos T reactivos dirigidos contra proteínas de choque térmico, lipoproteínas, bacterias, virus o antígenos del sistema principal de histocompatibilidad del donador. Una causa frecuente de falla de trasplante cardiaco es la formación de lesiones ateromatosas en los vasos arteriales del órgano trasplantado a pesar de la ausencia de dichas lesiones en el donador, lo cual sugiere que las lesiones obstructivas de novo son consecuencia de una respuesta inmune celular por parte del receptor. En este estudio determinamos el fenotipo y la reactividad de linfocitos T aislados de sangre periférica y de biopsias de endomiocardio y aterectomía de un paciente vivo e inmunosuprimido, sometido a trasplante cardiaco en 1989. Los linfocitos del paciente fueron enfrentados a un grupo de linfocitos B transformados por EBV con diferences alelos HLA. Los resultados demostraron un incremento notable en el porcentaje de linfoncitos CD4+ en la placa ateromatosa y en el endocardio, una importante cantidad de linfocitos T TCRd+ en la placa, y una considerable pérdida de alorreactividad a diferentes antígenos HLA. Estos re sultados sugieren que a pesar de que existen poblaciones linfocíticas adecuadas para generar una respuesta celular, existe un estado de energia a los antígenos HLA, que pudiera ser secundario al prolongado tratamiento inmunosupresor. Creemos que las lesiones obstructivas en este paciente no responden a alorreactividad a los antígenos HLA, sino más bien a un cambio en el tipo de respuesta inmune celular como consecuencia a una exposición crónica a algún antígeno del donador, explicando así la elevada proporción de linfocitos T TCRd+

Endocarditis infecciosa en el Hospital ABC / Infectious endocarditis at the ABC Hospital

En los últimos años, el diagnóstico de la endocarditis infecciosa ha cambiado significativamente, tomando encuenta aspectos clínicos, ecocardiográficos y microbiológicos. Presentamos el primer estudio epidemiológico de endocarditis infecciosa realizado en Latinoamérica en un hospital de asistencia privada. El estudio incluyó 15 pacientes con diagnóstico de endocarditis infecciosa establecido según los criterios de Duke; estos enfermos fueron admitidos en el Hospital ABC en un periodo de 18 meses. Se analizó prevalencia, frecuencia, características epidemiológicas, etiología, evolución y tratamiento recibido. La mayoría de los resultados obtenidos en el estudio correlacionan con lo publicado en la literatura mundial

Endomyocardial biopsy causing coronary artery-right ventricular fistula after cardiac transplantation.

We present 3 cases of coronary artery-right ventricular fistulae diagnosed on yearly check-ups on 160 cardiac transplant patients between September 1982 and January 1995. The fistula was communicating with the ventricular branch of the right coronary artery, the septal branch of the left anterior descending artery and the distal right coronary artery in the three cases being reported. Histological examination of the endomyocardial biopsy specimen showed the presence of small calibre arteries which were not seen in other cases. Although endomyocardial biopsy carries a risk of less than 0.5 percent, the possibility of causing coronary artery-ventricular fistula should be added to the list of the complications of this procedure. The shunt caused by these fistulae is small and has no hemodynamic significance and usually does not warrant any treatment.

Endomyocardial biopsy in Chagas' heart disease: pathogenetic contributions

Endomyocardial biopsy procedure has been performed in many centers around the world, allowing a better treatment and follow-up of the patients with myocardial disease. In Chagas' disease, it has been performed in Sao Paulo Heart Institute since 1978 and has brought important contributions to the understanding of the disease and consequently of the patient's clinical stage. In the present work we summarize the principal findings regarding the pathogenesis of Chagas' disease obtained mainly from the studies using Endomyocardial biopsy specimens. Nowadays we do not have doubts that the inflammatory infiltrate aggressing myocardial fibers has fundamental role in the progression of the myocardial damage in Chagas' disease what culminates in chronic heart failure. The parasite seems to have active participation in the maintenance of such myocardial inflammation.

Estudo hemodinâmico com cateter de Swan-Ganz, concomitante a biópsia endomiocárdica, em transplantados cardíacos: importância no diagnóstico precoce da rejeiçäo / Acute Electrophysiologic and Echocardiogrophic Effects of Xamoterol in Long-term Chagasic Patients With tinus Nodal Dysfunction

PURPOSE--To evaluate the role of hemodynamic parameters in the diagnosis of acute rejection who underwent orthotopic cardiac transplantation. METHODS--A protocol was carried out in 19 patients who underwent heart transplantation and in whom Swan-Ganz hemodynamics was performed immediately prior to routine endomyocardial biopsy in the first few months postoperatively. The results of 28 biopsies were divided in group I--severe rejection who needed pulse-therapy (n = 10) and group II--No or mild/moderate rejection who did not need any pulse (n = 18). Hemodynamic parameters were compared between both groups. RESULTS--There were significant differences among hemodynamic parameters in groups I and II. Group I had higher mean right atrial pressures (13.0 x 7.3 mmHg), mean pulmonary pressure (26.3 x 20.4 mmHg), mean wedge pressure (14.4 x 10.9 mmHg) and lower cardiac index (2.57 x 3.10 l/min/m2). CONCLUSION--In a routine situation, hemodynamic measurements, as obtained with Swan-Ganz catheter, simultaneously with endomyocardial biopsies, show significant alterations in transplanted patients who develop acute rejection. This information, obtained earlier than the biopsy results, could shorten the time to initiate pulse-therapy in patients with severe rejection

Objetivo - Analisar o papel de parâmetros hemodinâmicos no diagnóstico de rejeição aguda em pacientes submetidos a transplante cardíaco ortotópico. Métodos - Dezenove pacientes submetidos a transplante cardíaco foram avaliados hemodinamicamente com cateter de Swan- Ganz imediatamente antes das biópsias endomiocárdicas de rotina nos primeiros meses pós-transplante. Os resultados de 28 biópsias foram divididos em 2 grupos: rejeição grave, necessitando de tratamento (N=10) - grupo I e rejeição leve/moderada ou ausente, não necessitando de tratamento (N=18) -grupo II. Foram comparadas as medidas hemodinâmicas entre os dois grupos. Resultados - Aos quadros de rejeição grave, necessitando tratamento (grupo I) estiveram associadas significantes alterações hemodinâmicas como aumento da pressão atrial direita média (13,0x7,3mmHg - Grupo IxGrupo II), pressão média pulmonar (26,3x 20,4mmHg), pressão média de capilar pulmonar (14,4xl0,9mmHg) e índice cardíaco (2,57x3,10 1/min/ m2). Conclusão - Em situação rotineira, as alterações hemodinâmicas obtidas através de cateterismo direito, concomitante à realização da biópsia endomiocárdica, mostraram-se confiáveis no diagnóstico de rejeição grave e poderiam abreviar o início da terapêutica imunossupressora com pulsoterapia em pacientes transplantad

Fibrolamellar carcinoma of the liver--an unusual presentation.

Non-bacterial thrombotic endocarditis was found at autopsy in a 17 year old male patient of fibrolamellar type of hepatocellular carcinoma with pericardial metastases. This had resulted in multiple embolic cerebral infarcts with long standing hemiplegia and later death due to acute left ventricular failure.