Myocardial infarction in patients with systemic lupus erythematosus with normal findings from coronary arteriography and without coronary vasculitis--case reports.

The authors present the cases of two young patients, a man and a woman, who presented with myocardial infarction, in the absence of ischemic heart disease or stenosis of the coronary arteries. The woman was known to have systemic lupus erythematosus (SLE) for the past 3 years (the immunoglobulin M [IgM] anticardiolipins antibodies were positive), without a history of coronary risk factors. Suddenly she presented with acute chest pain on rest that lasted 4 hours and culminated in anterior wall myocardial infarction. She was admitted to the coronary care unit, where no thrombolysis was given. She did not have echocardiographic evidence of Libman-Sacks endocarditis, but myocardial infarction was evident at the electrocardiogram (ECG). The young man had SLE (the IgM anticardiolipins were absent, but he was positive for lupus anticoagulant antibodies), he was hyperlipidemic, was a moderate smoker and moderately obese, and had no history of ischemic heart disease. He suddenly presented with an acute myocardial infarction documented by ECG, enzymes, and gammagraphy. In both patients, coronary angiography findings were normal and myocardial biopsy did not show evidence of arteritis. The relevance of these cases is the rare association of ischemic heart disease in SLE, with normal coronary arteries and without evidence of arteritis or verrucous endocarditis.

A case of giant arteriovenous shunt in a renal carcinoma.

We present the case of a 51 year-old-white male with a giant right renal arteriovenous fistula secondary to a carcinoma. Neither the aorta nor the kidneys were visualized after the injection of 60 mL of contrast media into the abdominal aorta. Moreover, the right kidney could not be visualized after 30 mL of contrast media were injected selectively into the right renal artery. This was due to a great arteriovenous shunt through the right kidney. The right renal angiogram was obtained through digital imaging, after injecting contrast media into the right renal artery, previously occluded by a balloon-catheter. The image of an hypervascularized nephroma was obtained, depicting an important arteriovenous shunt of the contrast material toward the inferior vena cava from a fistula located in the right inferior renal pole. The occlusion of the right renal artery was partially achieved by injecting 40 mL of boiling contrast media, followed by small fragments of Gelfoam suspended in the contrast substance. The balloon-catheter remained inflated in the right renal artery until a nephrectomy was performed. As far as we know, a case in which the aorta and renal circulation are unable to be seen by means of conventional angiography, because of the presence of a renal arteriovenous shunt to the fistula, has not been described.

[Occlusion of interventricular septal rupture in 2 patients with an infarction]. / Oclusión de ruptura septal interventricular en dos pacientes con infarto.

We describe two women with interventricular septal rupture secondary to a myocardial infarction due to a total obstruction of the anterior descendent coronary artery. With the aim to stabilize the hemodynamic state of the patients before the surgical closure of the defect, we inserted a balloon-catheter introducing it to the left ventricle from the aorta and inflating it in the right ventricle after passing it through the septal orifice. After occlusion, we observed decreases in the pulmonary to systemic blood flow ratio (6% in one patient and 26% in the other) and in the arteriovenous blood flow shunt (8 and 31%); a 10% systemic blood flow increase was observed in one patient. Since the pulmonary arterial pressure did not change and the pulmonary blood flow increased, an increase of the pulmonary arterial resistance was observed but no modification of the pulmonary and systemic arterial pressure occurred. In the following days, the oxymetric differences between the pulmonary artery and the right atrium showed a tendency to remain below the figures before occlusion and the pulmonary blood flow and pressure showed a tendency to decrease. One patient died 14 days after the surgical closure of the rupture, and the other, seven days after the balloon occlusion of the rupture before any surgery. We present the physiological evolution of the patients.

Cholera and myocarditis--a case report.

The authors describe the case of a fifty-nine-year-old white man, previously in good health, who initiated his present illness with acute episode of enterocolitis characterized by mild fever and, in the next eight hours, twenty-four episodes of watery diarrhea, nausea and vomiting, as well as generalized sweating and severe weakness secondary to hypovolemia and electrolyte disorder. These complications were corrected in seventy-two hours in the intensive care unit. Two days later, when the patient was stable hemodynamically, under cardiac monitoring and with normal laboratory studies including serum electrolytes, he developed electrocardiographic changes characterized by trifascicular block (prolonged P-R interval, complete right bundle branch block [CRBBB] and left posterior hemiblock [LPH]) with a cardiac rate of thirty beats per minute, for which a temporary pacemaker was inserted. Endomyocardial biopsy showed histopathologic signs of myocarditis and the immunologic study of the cardiac tissue revealed positive polymerize chain reaction (PCR+) with the presence of antitoxine choleric antibodies (AcTCA). After three weeks, the same conduction disturbances remained, for which a permanent pacemaker was inserted. On top of intravenous fluid replacement and electrolyte supplements, the patient was managed with tetracycline 2 g a day for one week and sulfamethoxazole-trimethoprim 800/160 mg a day for two weeks. The purpose of this study is to present a rare and very well-documented myocarditis by cholera in a patient with enteric disease, in whom several cardiac complications occurred.

A case of a coronary artery arising from the pulmonary artery.

We present a case of an anomalous origin of the left coronary artery arising from the pulmonary artery in a 60 year old woman with ventricular arrhythmias and ischemic electrocardiographic changes but who had tolerated eleven normal pregnancies and deliveries without complications. No cardiac surgical repair has been performed and she is asymptomatic and has been well controlled with diisopyramide during a ten year follow up.

[Asymptomatic ischemia in coronary arterial ectasia. Effects of anticoagulation]. / Isquemia asintomática en la ectasia arterial coronaria. Efecto de la anticoagulación.

We studied 23 patients (22 men and 1 woman), their ages ranged from 31 to 71 years (55.9 +/- 9.7 years), with isolated coronary arterial ectasia. Seventeen patients presented angina pectoris, 19 had myocardial infarction. An angiographic image of intracoronary thrombus was observed in 5 patients. Before the administration of anticoagulants (oral warfarin) 16 patients showed unstable angina, the exercise EKG was positive in 9 patients, and 16 patients presented silent ischemia (showed by EKG-Holter), whose duration was 35.21 +/- 29.27 min per day. After anticoagulants, only 5 patients showed unstable angina pectoris. Exercise EKG was positive in 7 patients and only 7 patients showed silent ischemia, whose duration decreased significantly (P < 0.001) to 12.47 +/- 22.5 min per day.

[Effectiveness of anticoagulant oral treatment in patients with thrombus in left ventricle after acute myocardial infarction]. / Eficacia del tratamiento anticoagulante oral en pacientes con trombo en ventrículo izquierdo después de un infarto agudo del miocardio.

Left ventricular mural thrombi (LVMT) is a complication of acute myocardial infarction (AMI), that may produce peripheral embolism which could be fatal. In order to establish an adequate time of oral anticoagulant (OA) therapy, we undertook a prospective study that included 45 patients with AMI and left ventricular thrombi detected by echocardiographic study, in the first 5 to 10 days postinfarction, the study was repeated, in 3 and 6 months. Treatment with oral anticoagulant was initiated at the point of the detection of thrombi maintaining an INR of 1.5 to 2. Thirty nine patients (79%) were males and 6 (11%) were females, with an age of 29 to 85 years and a range of 62 +/- 11 years. Forty four patients (98%) presented anterior wall infarction and 1 (2%) posteroinferior infarction. In patients with anterior infarction, in 38 (85%) the thrombi was located at the apical wall (p < 0.05), 5 (11%) in the septal wall and other (2%) in anterior and apical walls. The patient with the posteroinferior infarction presented extension to the right ventricle, where the thrombus was located (2%). The contractility alterations related with thrombi were diskinesia, followed by hipokinesia and finally akinesia. The ejection fraction had not relationship with thrombi formation. LVMT dissolved in 32 patients (71%) at 3 months (p < 0.05), in 8 (18%) in 6 months and in 5 (11%) it was maintained for more than 6 months. None of the patients presented complications of OA. We conclude that the LVMT are more frequent in anterior infarctions, essentially in those that present diskinesia. The majority of LVMT are resolved in 6 months with OA therapy.

[Identification and treatment of coronary atherosclerosis, before resection of abdominal aortic aneurysm]. / Reconocimiento y tratamiento de la enfermedad aterosclerosa coronaria, previos a la resección de aneurisma aortoabdominal.

Atherosclerotic aortic aneurysm, is frequently associated to coronary atherosclerosis. When myocardial ischemia is asymptomatic, aortic surgery commonly is deferred because unexpected ischemic cardiopathy. To diminish the risk of aortic surgery, aortocoronary bypass must be installed before the aortic graft. Percutaneous transluminal coronary angioplasty is an alternative treatment of coronary atherosclerosis, principally in elderly patients. We present the case of a male patient with an abdominal aortic aneurysm and myocardial silent ischemia secondary to right coronary artery stenosis treated by mean the percutaneous transluminal coronary angioplasty (PTCA) before aortic surgery, with the objective of decreasing surgical risk and its possible complications (myocardial infarction, cardiogenic shock, death, etc.). Nine months after the PTCA, the patient is asymptomatic and stress test on treadmill is negative.

[Cardiac rupture in acute myocardial infarct. Presentation of 20 postmortem cases]. / Ruptura cardiaca en el infarto agudo del miocardio. Presentación de 20 casos postmortem.

With the advancement of the Coronary Care Units in the past three decades, there had been an important reduction in mortality secondary to arrhythmias in acute myocardial infarction (AMI): been now days, cardiogenic shock and cardiac rupture the first and second causes of in-hospital death in these patients. The purpose of this report is to know the anatomoclinical characteristics in our hospital of cardiac rupture and to look for risk factors that may be considered to diagnose at the precise time this complication that might cause sudden death secondary to hemodynamic and electromechanical changes. From 300 postmortem cases with AMI proved clinical, and by anatomopathological studies, 20 cases with cardiac rupture were obtained, among which: 11 (55%) were males with an average age of 61.7 years and 9 (45%) females, with an average age of 60 years. The following coronary risk factors were detected: systemic hypertension in 15 (75%) cases; cigarette smoking in 13 (65%) cases and diabetes mellitus in 11 (55%) cases. Long lasting or recurrent history of chest pain previous to death was present in 14 (70%) cases. Conduction disturbances were detected in 13 (65%) cases; among them, 7 (35%) had third degree heart block in whom permanent pacemaker was inserted; 4 (20%) had CRBBB and 2 (10%) ASB. The average heart weight was 478 gr. in males and 434 gr. in females. Evidence of an old MI was present in 7 (35%) cases. All patients had transmural MI. Free cardiac wall rupture was seen in 14 (70%) cases and from the ventricular septum, 6 (30%) cases. Hemopericardium was present in all cases (100%) with an average amount of 425 ml of blood. Pericarditis in 3 (15%). The average time of evolution since the beginning of the AMI until death were 4 days and the main causes of death were cardiogenic shock in 17 (85%) and congestive heart failure in 3 (15%).

[Acute myocardial infarction with normal coronary arteries as initial manifestation of polyarteritis nodosa. A case report]. / Infarto agudo del miocardio con coronarias normales como primera manifestación de poliarteritis nudosa. Reporte de un caso.

A thirty four-year-old-white man in good health developed an acute anterior wall myocardial infarction (AMI), Killip II with normal coronary arteries. No thrombolytic therapy was given. Selective angiography revealed multiple aneurysms in mesenteric and renal arteries. The diagnosis of polyarteritis nodosa (PAN) was performed. AMI in PAN is secondary to arteritis with thrombosis, or to atherosclerosis due to steroid therapy. This case, having multiorgan vascular aneurysms involvement without previous cardiac symptomatology nor steroid therapy, presented as his first cardiac complication an AMI with normal coronary arteries probably due to selective arteritis.

[Limitation of myocardial expansion in late thrombolysis evaluated by two-dimensional echocardiography]. / Limitación de la expansión miocárdica con trombolisis tardía evaluada por ecocardiografía bidimensional.

Myocardial expansion in acute myocardial infarction (AMI) is present in about 45% of the patients within the first 72 hours. This is associated with ventricular aneurysm formation, myocardial rupture, heart failure and early death. Experimental studies in animals with AMI have used late reperfusion to decrease the incidence of expansion with success. The present is a prospective, longitudinal, open and randomized study in 21 patients with anterior AMI, to evaluate if the late reperfusion (6 to 12 hours) can decrease the incidence of myocardial expansion graded quantitatively with bidimensional echocardiography. Two groups were made: group A (n = 12) who received thrombolysis with streptokinase 1.5 mill. IU plus oral aspirin 150 mg OD (n = 9). Both groups had the same characteristics of AMI and functional class of Killip and Kimball (I-II class). Intrahospital treatment was given freely in both groups. The expansion was evaluated with bidimensional echocardiography used Jugdutt's method. In group A, expansion was present in 25% of the cases, while in group B was 66.6% (p < 0.0005). The distortion area, distortion peak, septal thickness and large asynergic segment were more sensitive parameters to identify myocardial expansion. Our results are similar to some experimental studies. We conclude that late thrombolysis can be useful in decreasing the incidence of myocardial expansion. Bidimensional echocardiography is a useful, fast and safe method to identify myocardial expansion.

[Transrectal recatheterization under echocardiography control]. / Recateterismo transeptal bajo control ecocardiográfico.

We present the case of a 36 years-old woman, in whom antegrade mitral intraluminal valvulotomy was performed under transesophageal echocardiography control. Inadvertently, we retired the Inoue's catheter to the right atrium from the left atrium, before the dilation of the mitral valve was accomplished. Under echocardiographic control we reintroduced the transseptal catheter across the former septal orifice, avoiding a new septal puncture, and its possible complications. Now a days, the antegrade intraluminal mitral valvulotomy is easy performed, because the transesophageal echocardiography monitoring. The transesophageal echocardiography has modified the transseptal catheterization contraindications.

Acute myocardial infarction during pregnancy and puerperium: a review.

The purpose of this review is to analyze the possible parameters that lead to the development of what is a rare event--acute myocardial infarction (AMI) during pregnancy and puerperium. Through the Index Médicus, 109 publications on the subject were obtained. Since the first well-documented case by Katz in 1922, 136 patients have been reported, and from these reports the following data have been gathered: the average age was 32.1 years. This event is more frequent during the third trimester and puerperium of the first and second pregnancies. In 42.6% of the patients no coronary risk factors were observed, but when present, hypertension and cigarette smoking were the most common. The anterior wall along or in combination with any other anatomic area was affected in 73% of cases. Coronary angiograms, when taken, appeared normal in 47%. The maternal mortality rate was 26/136 (19.1%) and was higher during the third trimester, labor, and puerperium. Eight patients (8/26) (30.7%) had sudden death. In 5 of these, (62.5%) coronary thrombosis was found. In 18/26 deaths, an autopsy was performed; 9/18 (50%) had coronary thrombus formation and in 7/18 (39%) variable degrees of atherosclerosis were detected. On the other hand, the fetal mortality rate was 16.9%; however, in only 52% was death coincidental with that of the mother. Coronary artery spasm associated with a probable hypercoagulability state was the most likely mechanism in the majority of these patients, followed by atherosclerotic heart disease and coronary dissection-the last being secondary most likely to hormonal changes. During the AMI these patients should be studied by a medical team composed of a cardiologist, gynecologist, and anesthesiologist. A complete cardiologic work-up should be made to decide individually about further pregnancies.

Acute myocardial infarction with normal coronary arteries in a patient with dermatomyositis. Case report.

The authors present a forty-year-old man, with a history of dermatomyositis for the past twelve years, managed intermittently with prednisone. During an exacerbation of his illness he developed an acute anterior wall myocardial infarction with normal coronary arteries. A literature review indicates this represents a rare association.

[Percutaneous mitral commissurotomy using Inoue's balloon during pregnancy]. / Comisurotomía mitral percutánea con balón de Inoue durante el embarazo.

The authors present three cases of pregnant women with symptomatic severe mitral stenosis with a mean age of 28.6 +/- 2.3 years, and during 27.6 +/- 1.52 weeks of pregnancy. Two patients were in class III and one in class IV of the New York Heart Association (NYHA). All patients had a mitral valvular area equal or less than 1 cm2, with a Wilkins score of 7 to 9 and mitral insufficiency grade I in two cases; two, had severe pulmonary arterial hypertension (mean > 50 mm Hg). After Percutaneous Mitral Valvuloplasty (PMV) the mitral valve measured by 2D echocardiography increased form 0.83 +/- 0.2 cm2 to 1.8 +/- 0.15 cm2; the mean transmitral gradient diminished from 13 +/- 3.4 mm Hg to 3.6 +/- 1.15 mm Hg; the degree of mitral insufficiency was no modified in neither case. Hemodynamic results revealed increasing of the mitral valve from 0.83 +/- 0.18 cm2 to 2.23 +/- 0.3 cm2; the mean mitral gradient decreased from 21.6 +/- 9 to 4.3 +/- 0.5 mm Hg; the mean left atrial pressure from 30 +/- 12 to 12.3 +/- 4 mm Hg; the mean pressure of the pulmonary artery diminished suddenly from 44.3 +/- 16 to 25.6 +/- 11 mm Hg. The average fluoroscopic time was 15.3 +/- 3 minutes. There were no complications. The patients were discharged 48 hours after the procedure and continued their pregnancies in class I NYHA, which resolved in a non complicated vaginal delivery with normal products. We conclude that PMV is a safe and useful therapy in pregnant patient with severe mitral stenosis refractory to medical treatment.

Paroxysmal atrial tachycardia recorded by Holter monitoring during an episode of fear. A case report.

A twenty-four-year-old, white, athletic woman, free of heart disease, experienced an episode of fear when she was assaulted in the street without physical injury while under-going twenty-four-hour Holter monitoring. She developed an important sympathetic response in which, besides the symptoms characterized by palpitations, chest pain, dyspnea, asthenia, dizziness, nausea, and profuse cold sweating, she had an episode of paroxysmal atrial tachycardia. The causes and mechanism of this not well-documented event in humans are discussed.

Pulmonary valvular stenosis associated with Takayasu's Disease. Favorable response to corticosteroids. A case report.

The authors describe the first reported case of type IV Takayasu's arteritis with pulmonary valve stenosis. After thirty months under corticosteroid therapy the disappearance of the pulmonary valve stenosis signs was observed in the patient. In the same patient coarctation of the aorta, aortic insufficiency, stenosis of both pulmonary arteries, and left coronary artery stenosis were observed. This case illustrates the extensive cardiovascular involvement that can occur in Takayasu's arteritis and suggests that pulmonary valvular stenosis could be secondary to the same inflammatory process.

Coronary fistula associated with double mitral valve disease. A case report.

The authors report a case of a 54-year-old white male with a coronary fistula associated with double mitral valve disease. The patient was studied by invasive and non-invasive cardiac methods including coronary angiogram in order to reach the correct diagnosis and to define the successful surgical treatment that included the closure of the fistula, partial resection of the left atrium and insertion of a mechanical mitral valve prosthesis. It is concluded that this case represents a very rare association between coronary fistula and double mitral valve disease.

[Indications for coronarography in heart valve diseases]. / Indicación de la coronariografía en las valvulopatías cardíacas.

Among 407 patients with rheumatic heart disease studied in our department, we found 8.3% with coronary atherosclerosis: 2.7% with mitral stenosis and 2.4% with aortic stenosis, lower figures than those reported in the literature. In our patients with coronary atherosclerosis, the male to female ratio was 1.6:1. The mean age of men and women with coronary atherosclerosis were 58.9 +/- 8.48 years and 60.33 +/- 5.75 years respectively. The cumulated relative frequency curve of the age was shifted to the right in the patients with coronary atherosclerosis, compared with the age frequency curve of the patients with normal coronary arteries: 50% of the cases with coronary atherosclerosis were < or = 60 years old; on the other hand, 50% of the patients with normal coronary arteries were < 53 years old. We only discovered 3 patients younger than 50 years old with coronary atherosclerosis. In order of frequency, the coronary arteries more affected were the anterior descending, right and circumflex. The mean coronary stenosis was 75.2 +/- 21.2%. Disease of one vessel was observed more frequently. We believe that age is not a good parameter to indicate coronarography in patients with valvular heart disease. If coronarography would be performed in all patients with valvular disease > or = 30 or 40 years old, would result in a great number of normal studies, with the consequent misspend of supplies and the increased risk of complications. On the other hand, restricting the coronarography indication, would miss the diagnosis in patients that might need myocardial revascularization. To restrict or to increase the indication of coronarography in patients with valvular disease will depend of the frequency between rheumatic heart disease and associated coronary atherosclerosis, and also on the atherosclerosis risk factors present in each patient. We recommend not to use the age of the patients as an index to indicate coronarography.