Interrupted aortic arch: A misdiagnosed cause of hypertension.

We present the case of a 47-year-old man with hypertension for over 20 years, referred to our hospital due to mild aortic dilatation detected on a transthoracic echocardiogram. On physical examination weak lower limb pulses and a blood pressure differential of >50 mmHg between arms and legs were detected. Complete interruption of the aortic arch below the left subclavian artery was diagnosed by computed tomography angiography. With this case we aim to draw attention to aortic coarctation and interrupted aortic arch as potential causes of hypertension and to highlight the importance of the physical examination in the diagnosis of secondary causes of hypertension.

What has changed in surgical treatment of severe aortic stenosis with the advent of percutaneous intervention?

INTRODUCTION AND OBJECTIVE: Transcatheter aortic valve implantation (TAVI) is an alternative therapeutic approach to patients not considered suitable for surgical aortic valve replacement (SAVR) due to their high operative risk. We sought to assess the impact of TAVI on the profile and operative results of patients with severe aortic stenosis undergoing SAVR. METHODS: A total of 214 patients were included, of whom 103 consecutive patients underwent isolated SAVR in 2005 and 111 in 2009. Patients' demographic and operative data were collected retrospectively. Operative and one-year mortality and morbidity were analyzed. RESULTS: Patients' mean age was 70 years, and 56% were female. Following the introduction of a TAVI program, patients undergoing conventional surgery were older, with more comorbidities. Overall 30-day and one-year mortality were 2.8% and 7.0%, respectively. After the introduction of TAVI, the observed mortality rate for SAVR decreased, but not significantly (operative mortality: 3.9% before TAVI vs. 1.8% after TAVI, p = NS; one-year mortality: 10% vs. 4.5%, p = NS). Striking differences were observed in morbidity (operative morbidity: 23.3% before TAVI vs. 13.5% after TAVI, p = 0.047, and one-year morbidity: 20.4% vs. 9.9%, p = 0.032). CONCLUSIONS: Since the introduction of a TAVI program at our center, the number of patients undergoing SAVR has increased, with a slight rise in surgical risk, but without worsening the final operative results. The implementation of a TAVI program has thus had a positive impact on the volume of procedures, patient selection and outcomes in SAVR.

[Isolated left ventricular non-compaction: a single-center experience]. / Não compactação isolada do ventrículo esquerdo: experiência de um centro.

Isolated left ventricular noncompaction (LVNC) is a rare cardiomyopathy characterized by excessive and prominent trabeculations associated with deep recesses that communicate with the ventricular cavity. Determining the natural history of this condition has been hampered by differences in clinical features and prognosis in published series, which are partly the result of differing diagnostic criteria and the lack of management guidelines. This work aims to contribute to the characterization of isolated LVNC by analyzing an affected population in terms of clinical presentation, diagnosis, risk stratification, treatment and follow-up. We also discuss the most relevant data from the literature concerning this cardiomyopathy.

Complex ventricular septal rupture with dissection of the right ventricular wall in ischemic context.

A 72-year-old man was admitted to the local hospital with non-ST elevation myocardial infarction. In the first 24 hours, a new onset apical murmur was heard. Transthoracic and transesophageal echocardiography showed interventricular septal (IVS) rupture and dissection of the right ventricle (RV) wall forming an echolucent pseudocavity that partially occupied the RV and communicated with the true RV cavity. Multislice computed tomography characterized in detail the IVS and RV wall dissection, and further showed the right coronary artery in the outer border of the RV and pseudocavity, excluding pericardial fluid. Despite surgical correction, progression to cardiogenic shock and death occurred 33 days after admission.

Identification of isomeric spin adducts of Leu-Tyr and Tyr-Leu free radicals using liquid chromatography-tandem mass spectrometry.

Free radical species are generally short-lived due to their high reactivity and thus direct measurement and identification are often impossible. In this study we used a spin trap, 5,5-dimethyl-1-pyrroline-N-oxide (DMPO), to trap radical intermediates formed during the oxidation of isomeric dipeptides tyrosine-leucine (Tyr-Leu) and leucine-tyrosine (Leu-Tyr), induced by the hydroxyl radical. To investigate the influence of the amino acid position in the peptide chain on the oxidation and free radical generation, the spin adducts were characterized using LC-MS and MS(n) . We detected carbon and oxygen DMPO adducts and adducts bearing two DMPO, which were analyzed by MS(n) . Both alkoxyl and peroxyl radicals were identified. Radical intermediates were localized in Tyr during oxidation of Tyr-Leu, while radicals were identified in Leu and Tyr during oxidation of Leu-Tyr. DMPO adducts of acyl radical species formed from cleavage of the peptide backbone, promoted by the alkoxyl radical in α carbon of the N-terminal amino acid were observed. The results show that the amino acid position has an influence in the oxidation process, at least on small peptides, and that the α carbon of the N-terminal amino acid is more vulnerable to the attack of the electrophilic hydroxyl radical.

A rare cause of acute heart failure.

We describe a rare clinical case of ruptured sinus of Valsalva aneurysm (RSVA) into the right ventricle, complicated with severe aortic regurgitation (AR) and myocardial ischaemia. The AR was caused by a hemodynamic effect solely, in which the shunt of blood flow through the ruptured site pulled the right aortic cusp away from closure. The pathological mechanism of the AR was clearly visualized by transesophageal echocardiography. Early successful primary closure of the RSVA resulted in resolution of the associated AR without any additional procedure.

[Multislice computed tomography in the selection of candidates for transcatheter aortic valve implantation]. / Tomografia computorizada multicorte na avaliação de candidatos a implantação de prótese aórtica percutânea.

Transcatheter aortic valve implantation is an emerging treatment option for severe symptomatic aortic stenosis in patients considered unsuitable for surgical valve replacement. The authors review the use of multislice computed tomography in the selection of candidates for transcatheter aortic valve replacement, procedural support and post-interventional follow-up. A single-center experience of the role of this imaging technique is also described. Multislice computed tomography is an essential imaging tool in the selection and exclusion of candidates for transcatheter aortic valve implantation, providing evaluation of coronary anatomy and the relationship of the coronary ostia with the aortic valve structure, and accurate analysis of the valve annulus and aortic root, left ventricular outflow tract, aorta and peripheral vascular access routes. Multislice computed tomography is also central to the choice of appropriate prosthesis size. In addition, it guides arterial puncture by image fusion techniques and enables correct prosthesis apposition to be verified. This review aims to describe the role of computed tomography in this increasingly common interventional valve procedure, providing an overview of current knowledge and applications.

Influence of amino acid relative position on the oxidative modification of histidine and glycine peptides.

The radical oxidation of isomeric peptides containing one reactive amino acid [histidine (H)] and another less reactive amino acid [glycine (G)] in the form of dipeptides (HG and GH) and tripeptides (HGG, GHG, and GGH) was studied by mass spectrometry coupled to liquid chromatography (LC-MS) for detection and LC-MS(n) for structural characterization. The oxidation products identified were keto, hydroxy, keto-hydroxy, and hydroperoxide derivatives for both di- and tripeptides. Among these, it was found that insertion of oxygen atoms occurred at histidine for HG and HGG, and both histidine and glycine for GH, GHG, and GGH. In addition, oxidation products formed by alkoxyl rearrangement reactions with cleavage of the peptide chain were also identified for GH, GHG, and GGH, corroborating hydrogen abstraction step in G residues. These findings were supported through the identification of radical intermediate species formed and trapped with 5,5-dimethyl-1-pyrrolidine-N-oxide (DMPO) spin trap. The observation of DMPO adducts bearing two spin trap molecules reinforced the abstraction of two hydrogen atoms from the same molecule. Overall, modification sites identified showed that the outcome of oxidative behavior of peptides is influenced not only by the reactivity of the amino acid in the peptide sequence but also by its relative position within the sequence.

Cor triatriatum sinistrum--description and review of four cases.

Cor triatriatum sinistrum is a rare congenital cardiac anomaly in which the left atrium is divided into two compartments by a fibromuscular membrane. In most cases, the two cavities communicate through one or more openings. It is generally associated with other cardiac anomalies. The clinical manifestations depend mainly on the size of the fibromuscular membrane orifice(s) and the pressure gradient between the two cavities. The authors present four cases of cor triatriatum sinistrum diagnosed in different clinical contexts and age-groups. In all cases the diagnosis was based on echocardiographic findings (transthoracic and transesophageal) and was supplemented by other imaging modalities.

Real-time three-dimensional transesophageal echocardiography--an initial experience.

INTRODUCTION: Echocardiography (echo) has gained increasing importance in cardiology as technological developments have enabled progression from one-dimensional to two-dimensional imaging and the inclusion of physiological information with the Doppler principle. Although three-dimensional (3D) echo is not a new concept, its use has been limited by image artifacts and the need for time-consuming offline processing. Despite several improvements since its introduction in the 1990s, real-time 3D echo was until 2007 limited to transthoracic studies, but a real-time 3D transesophageal (TE) echo probe has recently become commercially available. The objective of this article is to describe our initial experience with this probe, to assess its ability to visualize different cardiac structures and to discuss its advantages and shortcomings. METHODS: We performed 103 transesophageal studies between 08/05/2008 and 10/31/2009 using an iE33 ultrasound system with an X7-2t probe (Philips Medical Systems, Andover, Massachusetts, USA). Successful intubation was achieved in all patients. The 3D images obtained were exported to a workstation equipped with QLAB version 6.0 software for review and post-processing. RESULTS: Three-dimensional images were obtained in 73 studies, mostly for pre- or post-closure evaluation of atrial septal defects (ASD; 31.5%) and assessment of mitral valve disease or mitral prostheses (30%). Most of the images were acquired using 3D zoom mode. The additional information provided by 3D study was very useful for evaluation of mitral valve disease and mitral valve prostheses, enabling quick and reliable recognition of the cardiac anatomy and the pathological processes involved in each case. The interatrial septum was clearly visualized and the anatomical relations of defects were identified in most exams, in spite of the presence of dropouts in some cases. Imaging of more anterior cardiac structures, particularly the aortic, pulmonary and tricuspid valves, is generally suboptimal with this technique and good-quality images were obtained in only a few studies. CONCLUSION: After a relatively short training period and without prolonging the study time significantly, we were able to visualize the various components of the mitral valve clearly and identify its anatomical relations; in our initial experience, this was the major advantage of the technique, which will probably become the gold standard for preoperative evaluation of mitral valve disease. Programming and guiding ASD closure is another promising area for 3D TE echo. On the other hand, imaging of anterior cardiac structures is poor and needs refinement.

Reactivity of Tyr-Leu and Leu-Tyr dipeptides: identification of oxidation products by liquid chromatography-tandem mass spectrometry.

The exposure of peptides and proteins to reactive hydroxyl radicals results in covalent modifications of amino acid side-chains and protein backbone. In this study we have investigated the oxidation the isomeric peptides tyrosine-leucine (YL) and leucine-tyrosine (LY), by the hydroxyl radical formed under Fenton reaction (Fe(2+)/H(2)O(2)). Through mass spectrometry (MS), high-performance liquid chromatography (HPLC-MS) and electrospray tandem mass spectrometry (HPLC-MS(n)) measurements, we have identified and characterized the oxidation products of these two dipeptides. This approach allowed observing and identifying a wide variety of oxidation products, including isomeric forms of the oxidized dipeptides. We detected oxidation products with 1, 2, 3 and 4 oxygen atoms for both peptides; however, oxidation products with 5 oxygen atoms were only present in LY. LY dipeptide oxidation leads to more isomers with 1 and 2 oxygen atoms than YL (3 vs 5 and 4 vs 5, respectively). Formation of the peroxy group occurred preferentially in the C-terminal residue. We have also detected oxidation products with double bonds or keto groups, dimers (YL-YL and LY-LY) and other products as a result of cross-linking. Both amino acids in the dipeptides were oxidized although the peptides showed different oxidation products. Also, amino acid residues have shown different oxidation products depending on the relative position on the dipeptide. Results suggest that amino acids in the C-terminal position are more prone to oxidation.

Identification of leucine-enkephalin radical oxidation products by liquid chromatography tandem mass spectrometry.

The oxidation of the peptide leucine-enkephalin (YGGFL) induced by the hydroxyl radical (HO*), formed under Fenton-like conditions [Cu (II)/H(2)O(2)], was studied and monitored by LC-MS. The oxidation products identified included products resultant from (a) the insertion of oxygen atoms (1-5), (b) peptide backbone cleavage (short-chain products formed by diamide pathway) and (c) radical-radical crosslinking reactions. In order to identify the modified residues, LC-MS/MS spectra were obtained. The insertion of oxygen atoms into the peptide originated hydroxide, di-hydroxide and/or hydroperoxide derivatives. In addition it was found that the aromatic amino acids are most susceptible to being hydroxylated, while the aliphatic amino acids are more prone to forming hydroperoxides. Oxidation products with double bonds were also identified. The short chain products resulted from the alpha-carbon radical of terminal amino acids (Tyr and Leu). Products resulting from cross-linking reactions between intact carbon-centered peptide radical (with and without one HO group) and a side chain radical (*C(7)H(7)O) were identified. It was found that, although all amino acids residues of the peptide undergo modifications, the N-terminal seems to be prone to oxidative modifications under these conditions.

Acute coronary syndrome and predictors of quality of life.

INTRODUCTION: Coronary disease in its various forms of presentation is associated with a reduction in the patients' own perception of their quality of life (QoL). QoL is an important measure of effectiveness of treatment; however, the predictors of QoL after admission for acute coronary syndrome (ACS) are not completely clear. AIM: To identify the clinical, demographic and psychosocial characteristics of patients admitted for ACS that were predictive of QoL in clinical follow-up. METHODS: Physical and mental QoL were prospectively evaluated in 278 patients admitted for ACS, using Short Form-36 v2 physical (PCS) and mental (MCS) component summary scales. Based on the median PCS (55) and MCS (56) scores, the population was divided into two groups. Depressive symptoms were assessed using the Beck Depression Inventory. RESULTS: The patients with a better QoL perception were male, young, smokers and had more than 12 years' education. A greater proportion of patients with PCS and MCS below the median score presented prior cardiovascular events and depressive symptoms. A worse physical QoL perception was more common in unmarried, hypertensive and diabetic patients. There was no association between clinical evolution or in-hospital complications and baseline QoL scores. Baseline PCS and MCS were 55 +/- 24 and 55 +/- 27 and at 16 months, 63 +/- 25 and 66 +/- 29. Clinical follow-up was achieved in 181 patients. A worse mental QoL perception at follow-up was related to female gender, baseline MCS < 56 and depressive symptoms. A PCS below median score at follow-up was more frequent in women and in patients with prior cardiovascular events, hypertension, diabetes, dyslipidemia and a lower level of education. Patients with better physical QoL at follow-up were smokers, presented higher baseline PCS and MCS, and had fewer depressive symptoms. Percutaneous myocardial revascularization was associated with a better physical QoL. In a logistic regression model the independent predictors of PCS were: gender, baseline PCS, level of education and prior cardiovascular events. Gender and depressive symptoms were independent predictors of MCS. CONCLUSIONS: In the study population, baseline clinical and psychosocial characteristics were the most important predictors of QoL after ACS. Depression was associated with worse mental QoL. In-hospital evolution and treatment did not appear to strongly affect patients' follow-up perceptions of QoL.

Acute coronary syndrome and depression.

INTRODUCTION: Clinical depression is associated with poor compliance in risk reduction recommendations and has been suggested as an independent risk factor for increased postmyocardial infarction morbidity and mortality. AIM: To determine the prevalence of depressive symptoms, their main determinants and their influence on clinical evolution in acute coronary syndromes (ACS) patients. METHODS: We studied depressive symptoms, sociodemographic variables, cardiovascular status and therapeutic procedures in 240 consecutive patients admitted for ACS. Depressive symptoms were assessed using the Beck Depression Inventory (BDI) after clinical stabilization, in patients with more than 4 years' education. RESULTS: The majority of the patients were male (203); their average age was 59.4 +/- 13 yrs; 31.8% were admitted for unstable angina, 33.1% for acute myocardial infarction with ST elevation and 31.8% without ST elevation. Depressive symptoms (BDI > or =10) were present in 100 patients (41.6%). Depressed patients were older (61.1 vs. 58.2 years, p = 0.06) and had a history of previous cardiovascular events /47.5 vs. (34.8% p = 0.05). The proportion of female was higher in the group of patients with BDI > or =10 (24% vs. 9.3%, p = 0.02). Traditional cardiovascular risk factors were not associated with depressive symptoms. There were no statistically significant differences between the depressed and non-depressed patients in admission diagnosis, in-hospital clinical evolution and treatment. There were 35 patients (14.6%) with moderate/severe depression (BDI > or =19), 12 of whom were women (OR = 3.8, p = 0.001); no relation was established between age and previous cardiac events. These scores were less frequent in patients with a higher level of education (OR = 0.28, p = 0.09) and married (OR = 0.31 vs. not married, p = 0.03). Clinical follow-up of 158 patients was achieved (16 +/- 4 months), in patients with BDI > or =19, the presence of cardiovascular symptoms (angina, congestive heart failure) was higher (46% vs. 23%, OR = 2.8, p = 0.03), even after adjustment for age (OR = 2.5; p = 0.06). However, there was no association between the presence of depressive symptoms and readmission and/or fatal events. CONCLUSION: Depression is a common finding after hospital admission for ACS, particularly in women, and is mainly associated with prehospital factors. In our group of patients, the presence of depressive symptoms was closely related to clinical status during follow-up.