Hipertensión materna y lesiones ateroscleróticas tempranas en aortas de fetos y neonatos fallecidos

Fundamento: la aterosclerosis es una enfermedad de origen multifactorial que se agrava a consecuencia de un medio ambiente adverso y de estilos de vida no saludables. Las evidencias confirman su inicio desde las etapas más tempranas de la vida. Objetivo: describir la presencia de lesiones ateroscleróticas tempranas en las aortas de fetos y neonatos fallecidos hijos de madres hipertensas. Método: se realizó un estudio descriptivo de tipo transversal que incluyó a los fetos mayores de 22 semanas y neonatos fallecidos hijos de madres hipertensas, a quienes se les realizó autopsia en el departamento de anatomía patológica, del Hospital Universitario Ginecobstétrico Eusebio Hernández Pérez, en el período comprendido entre enero del 2021 hasta diciembre 2022, con un total de 18. Se recogieron los siguientes datos en las historias clínicas: sexo del fallecido, edad gestacional en el momento del parto, peso postparto, edad materna y antecedentes de hipertensión arterial (crónica o gestacional). Se analizaron las 18 aortas (torácicas y abdominales) de los fallecidos seleccionados. Resultados: del total de fallecidos estudiados el 70,6 % presentó lesiones ateroscleróticas tempranas, caracterizadas por engrosamiento de la íntima a modo de cojinete, presencia de linfocitos en la íntima o en la pared arterial cercana a ella y/o macrófagos. En algunos casos se observó una de estas variantes histológicas y en otros la combinación de dos o tres. Conclusiones: las lesiones ateroscleróticas tempranas están presentes en las aortas de la mayoría de los fetos y neonatos estudiados, con predominio en las que presentaban hipertensión gestacional.

Foundation: atherosclerosis is a disease of multifactorial origin that is aggravated as a result of an adverse environment and unhealthy lifestyles. Evidence confirms its onset from the earliest stages of life. Objective: to describe the presence of early atherosclerotic lesions in the aortas of deceased fetuses and neonates born to hypertensive mothers. Method: a descriptive cross-sectional study was carried out that included fetuses older than 22 weeks and deceased neonates born to hypertensive mothers, who underwent autopsy in the pathological anatomy department of the Eusebio Hernández Pérez Gynecobstetric University Hospital, in the period between January 2021 and December 2022, with a total of 18. The following data were collected in the medical records: sex of the deceased, gestational age at the time of delivery, postpartum weight, maternal age, and history of arterial hypertension (chronic or gestational). The 18 aortas (thoracic and abdominal) of the selected deceased were analyzed. Results: of the total number of deceased studied, 70.6 % presented early atherosclerotic lesions, characterized by thickening of the intima as a cushion, presence of lymphocytes in the intima or in the arterial wall close to it and/or macrophages. In some cases, one of these histological variants was observed and in others a combination of two or three. Conclusions: early atherosclerotic lesions are present in the aortas of the majority of the fetuses and neonates studied, with a predominance in those with gestational hypertension.

Variaciones en el Origen de la Arteria Coronaria Derecha en Corazones de Avestruz (Struthio camelus) / Variations in the Origin of the Right Coronary Artery in Ostrich Hearts (Struthio camelus)

El avestruz (Struthio camelus) pertenece a un grupo de aves terrestres conocidas como ratites. La irrigación de su corazón presenta características muy similares a las de los mamíferos, con arterias distribuidas en la superficie cardíaca. La presencia de una sola arteria coronaria se considera una malformación congénita que podría provocar un déficit de perfusión coronaria y ser causa de sintomatología isquémica. Este estudio tiene como objetivo determinar las características morfológicas y anatómicas de las arterias coronarias en corazones de avestruz, con especial énfasis en la incidencia de malformaciones congénitas y su impacto clínico. Se analizaron 100 corazones de avestruz. Las aves tenían entre 12 a 15 meses de edad, con un peso promedio de 92 kg. Para una visualización precisa, se cateterizaron las arterias coronarias y se inyectó látex de neopreno 650 de Dupont, rojo para la arteria coronaria derecha y amarillo para la arteria coronaria izquierda. Los corazones se fijaron en formol al 10% durante 10 días. Se observaron dos casos en los que la arteria coronaria derecha se originaba como rama colateral de la arteria coronaria izquierda, uno discurría entre la aorta y la arteria pulmonar; el otro, anterior al tronco pulmonar, reemplazando a la arteria coronaria derecha. Las arterias coronarias tenían un diámetro de 3,2 mm y 2,5 mm, y se registró un trayecto de 90,4 mm y 123,4 mm, respectivamente, hasta llegar al margen derecho y la superficie diafragmática del corazón. Estas anomalías coronarias, aunque infrecuentes, pueden tener importantes implicaciones clínicas en avestruces debido a su alta velocidad al correr. La presencia de una arteria coronaria única puede aumentar el riesgo de compresión y, por ende, de isquemia. Estos hallazgos amplían el conocimiento sobre la anatomía coronaria del avestruz y subrayan la necesidad de más investigación para entender mejor sus implicaciones clínicas.

SUMMARY: The ostrich belongs to a group of terrestrial birds known as ratites. Their heart irrigation has characteristics very similar to those of mammals, with arteries distributed on the cardiac surface. The presence of a single coronary artery is considered a congenital malformation that could lead to a deficit in coronary perfusion and be a cause of ischemic symptomatology. We analyzed 100 ostrich hearts. Birds were aged between 12-15 months, with an average weight of 92 kg. For precise visualization, coronary arteries were catheterized and injected with Neoprene Latex 650 by Dupont, red for the right coronary artery, and yellow for the left coronary artery. They were fixed in 10 % formalin for 10 days. Two cases were observed where the right coronary artery originated as a collateral branch of the left coronary artery, one ran between the aorta and the pulmonary artery; the other anterior to the pulmonary trunk, replacing the coronary artery. Coronary arteries had a diameter of 3.2 mm and 2.5 mm; a 90.4 mm and 123.4 mm path was recorded reaching the right margin and diaphragmatic surface of the heart.

Rendimiento diagnóstico de un nuevo software de aprendizaje profundo para corrección de atenuación en la imagen de perfusión miocárdica utilizando una cámara CZT cardiodedicada. Experiencia en la práctica clínica / Diagnostic performance of a novel deep learning attenuation correction software for MPI using a cardio dedicated CZT camera: Experience in the clinical practice

Objetivo Evaluar el rendimiento diagnóstico de un nuevo software de aprendizaje profundo para corrección de atenuación (SAPCA) en imágenes de perfusión miocárdica (IPM) utilizando una cámara cardiodedicada de cadmio-cinc-telurio (CZT) con correlación con angiografía coronaria (AC) para el diagnóstico de enfermedad arterial coronaria (EAC) en una población de alto riesgo. Métodos Estudio retrospectivo de 300 pacientes (196 varones [65%], edad media de 68 años) desde septiembre de 2014 hasta octubre de 2019. Posteriormente realizaron una IPM, seguida de AC dentro de los 6 meses posteriores a la IPM. La probabilidad media pretest para EAC según los criterios de la Sociedad Europea de Cardiología fue del 37%. La IPM se realizó en una cámara CZT cardio dedicada (D-SPECT® Spectrum Dynamics) usando un protocolo de 2 días, de acuerdo con las guías de la Sociedad Europea de Medicina Nuclear (EANM). La IPM fue evaluada con y sin el SAPCA. Resultados La precisión diagnóstica global de la IPM sin el SAPCA para identificar pacientes con cualquier EAC obstructiva en la AC fue del 87%, sensibilidad del 94%, especificidad del 57%, valor predictivo positivo del 91% y valor predictivo negativo del 64%. Utilizando el SAPCA, la precisión diagnóstica global fue del 90%, la sensibilidad del 91%, la especificidad del 86%, el valor predictivo positivo del 97% y el valor predictivo negativo del 66%. Conclusión El uso del novel SAPCA mejora el rendimiento diagnóstico de la IPM usando la cámara CZT D-SPECT®, especialmente reduciendo el número de resultados falsos positivos al reducir los artefactos (AU)

urpose To evaluate the diagnostic performance of a novel deep learning attenuation correction software (SAPCA) for myocardial perfusion imaging (MPI) using a cadmium-zinc-telluride (CZT) cardio dedicated camera with invasive coronary angiography (ICA) correlation for the diagnosis of coronary artery disease (CAD) in a high-risk population. Methods Retrospective study of 300 patients (196 males [65%], mean age 68 years) from September 2014 to October 2019 undergoing MPI, followed by ICA and evaluated by means of quantitative angiography software, within six months after the MPI. The mean pre-test probability score for coronary disease according to the European Society of Cardiology criteria was 37% for the whole cohort. The MPI was performed in a dedicated CZT cardio camera (D-SPECT® Spectrum Dynamics) with a two-day protocol, according to the European Association of Nuclear Medicine guidelines. MPI was retrospectively evaluated with and without the SAPCA. Results The overall diagnostic accuracy of MPI without SAPCA to identify patients with any obstructive CAD at ICA was 87%, Sensitivity 94%, Specificity 57%, positive predictive value 91% and negative predictive value 64%. Using SAPCA the overall diagnostic accuracy was 90%, sensitivity 91%, specificity 86%, positive predictive value 97% and negative predictive value 66%. Conclusion Use of the novel SAPCA enhances performance of the MPI using the CZT D-SPECT® camera and achieves improved results, especially avoiding artefacts and reducing the number of false positive results (AU)

Clinical results of percutaneous coronary intervention in chronic total occlusions of the right coronary artery.

INTRODUCTION AND OBJECTIVES: Coronary chronic total occlusions (CTOs) of the right coronary artery (RCA) are a relatively common finding in the context of coronary angiography. However, the benefit of revascularization remains controversial. METHODS: A single-center retrospective cohort analysis prospectively collected outcomes of CTO patients undergoing percutaneous coronary intervention (PCI) in 2019 and 2020. Patients were divided into two groups according to the CTO vessel treated (left coronary artery [LCA]-CTO or RCA-CTO). The primary outcome was defined as the recurrence of angina and/or heart failure (HF) symptoms and secondary outcomes were myocardial infarction (MI) and all-cause mortality. RESULTS: A total of 177 patients (82.5% male) were included in the analysis, with a mean age of 65±11 years. The primary outcome occurred in 28 (16.6%) patients and was significantly more frequent in RCA-CTO patients (19, 24.7%, p=0.010) in a mean follow-up of 18 months. This was mainly driven by recurrence of HF symptoms (12, 15.6%, p=0.013). Treated RCA-CTO was an independent predictor of the primary outcome (p=0.019, HR 2.66, 95% CI 1.17-6.05). MI and mortality rates were no different between groups (RCA-CTO with 1.3%, p=0.361 and 2.6%, p=0.673, respectively, on survival analysis). Left ventricular ejection fraction was an independent predictor of mortality (p=0.041, HR 0.93, 95% CI 0.87-0.99). CONCLUSIONS: Revascularization of CTO lesions by PCI was associated with low rates of symptom recurrence, and clinical outcomes showed no differences regardless of which artery was treated. Recanalization of RCA-CTO was less beneficial in reducing the recurrence of HF symptoms.

Diagnostic performance of a novel deep learning attenuation correction software for MPI using a cardio dedicated CZT camera. Experience in the clinical practice.

PURPOSE: To evaluate the diagnostic performance of a novel deep learning attenuation correction software (DLACS) for myocardial perfusion imaging (MPI) using a cadmium-zinc-telluride (CZT) cardio dedicated camera with invasive coronary angiography (ICA) correlation for the diagnosis of coronary artery disease (CAD) in a high-risk population. METHODS: Retrospective study of 300 patients (196 males [65%], mean age 68 years) from September 2014 to October 2019 undergoing MPI, followed by ICA and evaluated by means of quantitative angiography software, within six months after the MPI. The mean pre-test probability score for coronary disease according to the European Society of Cardiology criteria was 37% for the whole cohort. The MPI was performed in a dedicated CZT cardio camera (D-SPECT Spectrum Dynamics) with a two-day protocol, according to the European Association of Nuclear Medicine guidelines. MPI was retrospectively evaluated with and without the DLACS. RESULTS: The overall diagnostic accuracy of MPI without DLACS to identify patients with any obstructive CAD at ICA was 87%, sensitivity 94%, specificity 57%, Positive Predictive Value 91% and Negative Predictive Value 64%. Using DLACS the overall diagnostic accuracy was 90%, sensitivity 91%, specificity 86%, Positive Predictive Value 97% and Negative Predictive Value 66%. CONCLUSION: Use of the novel DLACS enhances performance of the MPI using the CZT D-SPECT camera and achieves improved results, especially avoiding artefacts and reducing the number of false positive results.

Descripción angiográfica de los aspectos anatómicos y clínicos de la arteria interventricular anterior en un grupo de personas colombianas / Angiographic description of the anatomy and clinical aspects of the anterior interventricular artery in a group of Colombians individuals

Introducción. La arteria interventricular anterior se origina en la coronaria izquierda, irriga la cara anterior de los ventrículos, el ápex y el tabique interventricular; es la segunda arteria más relevante del corazón. Objetivo. Describir las características anatómicas y clínicas de la arteria interventricular anterior mediante angiografía. Materiales y métodos. Se realizó un estudio descriptivo con 200 reportes angiográficos de personas colombianas; se valoraron el origen, el trayecto y la permeabilidad de la arteria interventricular anterior, así como la dominancia coronaria. Se incluyeron datos relacionados con dolor precordial, infarto agudo de miocardio, dislipidemia y alteración electrocardiográfica. No fue posible hacer pruebas estadísticas, debido a la escasa prevalencia de variaciones anatómicas de dicha arteria. Resultados. Se encontró una arteria interventricular anterior con su origen en el seno aórtico izquierdo, sin puente miocárdico, sin alteración de la permeabilidad y con dominancia izquierda. La frecuencia de los puentes fue del 2 % y la dominancia más frecuente fue la derecha en el 86 %. Se presentaron alteraciones de permeabilidad en el 43 % de los casos, las cuales afectaron principalmente al S13. El 25 % de los pacientes presentó dolor precordial; el 40 %, alteraciones ecocardiográficas; el 5 %, cardiopatía isquémica, y el 59 %, alguna alteración electrocardiográfica. Conclusiones. Las variaciones en el origen de la arteria interventricular anterior son poco prevalentes, según reportes de Chile, Colombia y España. Los puentes miocárdicos de esta arteria fueron escasos respecto a otros estudios, lo cual sugiere mejor especificidad de los hallazgos de la angiotomografía o de la disección directa. La permeabilidad coronaria se valora con la escala TIMI (Thrombolysis in Myocardial Infarction); puntajes de 0 y 1 indican una lesión oclusiva asociada con cardiopatía isquémica. La dominancia coronaria más frecuente, según diversas técnicas, es la derecha, seguida de la izquierda en hombres y de una circulación balanceada en mujeres.

Introduction. The anterior interventricular artery originates from the left coronary artery and irrigates the anterior surface of the ventricles, apex, and interventricular septum, making it the second most relevant artery of the heart. Objective. To describe the anatomical and clinical aspects of the anterior interventricular artery through angiography. Materials and methods. A descriptive study was conducted using 200 angiographic reports of Colombian individuals. The anterior interventricular artery's origin, course, patency, and coronary dominance were evaluated. Data related to chest pain, acute myocardial infarction, dyslipidemia, and electrocardiographic abnormalities were included. Statistical tests could not be performed due to this artery's low prevalence of anatomical variations. Results. One anterior interventricular artery was found to have originated from the left coronary sinus without a myocardial bridge, with no alteration in permeability, and with left dominance. The frequency of bridges was 2%, and the most frequent dominance was right in 86; permeability alterations occurred in 43% mainly affecting S13. Twenty-five per cent presented chest pain; 40%, echocardiographic alterations; 5%, ischemic heart disease, and 59%, electrocardiographic alterations. Conclusions. Variations of origin of the anterior interventricular artery have a low prevalence according to reports from Chile, Colombia, and Spain. anterior interventricular artery myocardial bridges were scarce compared to other studies, suggesting better specificity of computed tomography angiography or direct dissection for these findings. The assessment of coronary permeability is graded with the thrombolysis in myocardial infarction scale; values 0 and 1 indicate occlusive lesion associated with ischemic heart disease. According to various techniques, the most frequent coronary dominance the right, followed by the left in men and balanced circulation in women.

[Takotsubo cardiomyopathy associated with abnormal birth of the coronary arteries]. / Miocardiopatía de Takotsubo asociada al nacimiento anómalo de las arterias coronarias.

Background: Takotsubo cardiomyopathy (TM) is a form of non-ischemic cardiomyopathy. It is characterized by transient regional systolic dysfunction of the left ventricle that mimics acute myocardial infarction. The main objective of this article is to report the case of a patient with TM associated with abnormal birth of the left coronary trunk. Clinical case: A 76-year-old woman with typical angina at rest, with an electrocardiogram that showed dynamic changes in the T wave and elevation of biomarkers. Coronary angiography showed epicardial coronary arteries without significant lesions and abnormal birth of the left coronary trunk from the proximal segment of the right coronary artery. The patient progressed favorably, and the transthoracic echocardiogram showed no mobility disorders 3 months after the event. Conclusions: TM and abnormal birth of the coronary arteries are rare diseases whose simultaneous presentation is extraordinary. The diagnosis of both clinical entities is made by coronary angiography and echocardiogram, and their treatment is similar to that of patients with acute coronary syndrome. Abnormal birth of the left coronary trunk with retroaortic switch reaching the contralateral site has a good clinical prognosis and echocardiographic follow-up should be performed 4 weeks after the onset of the condition.

Introducción: la miocardiopatía de Takotsubo (MT) es una forma de miocardiopatía no isquémica. Se caracteriza por la disfunción sistólica regional transitoria del ventrículo izquierdo que imita al infarto agudo de miocardio. El objetivo principal de este artículo es reportar el caso de una paciente con MT asociada al nacimiento anómalo del tronco coronario izquierdo. Caso clínico: paciente mujer de 76 años que presentó angina típica en reposo, con un electrocardiograma que evidenció cambios dinámicos en la onda T y elevación de biomarcadores. La coronariografía evidenció a las arterias coronarias epicárdicas sin lesiones significativas y el nacimiento anómalo del tronco coronario izquierdo proveniente del segmento proximal de la arteria coronaria derecha. La paciente evolucionó de manera favorable y el ecocardiograma transtorácico no mostró trastornos en la movilidad a los tres meses del evento. Conclusiones: la MT y el nacimiento anómalo de las arterias coronarias son enfermedades raras cuya presentación simultánea es extraordinaria. El diagnóstico de ambas entidades clínicas se realiza mediante la coronariografía y el ecocardiograma, y su tratamiento es similar al de los pacientes con síndrome coronario agudo. El nacimiento anómalo del tronco coronario izquierdo con cruce retroaórtico que alcanza el sitio contralateral tiene un buen pronóstico y se debe realizar seguimiento clínico y ecocardiográfico a las cuatro semanas del inicio del padecimiento.

Guía de presión encarcelada en el tratamiento percutáneo de las bifurcaciones coronarias: daño estructural y resultados clínicos / Jailed pressure wire technique for coronary bifurcation lesions: structural damage and clinical outcomes

Introducción y objetivos: El uso de una guía de presión encarcelada para evaluar los resultados de la rama lateral durante la técnica del stent provisional parece factible. Sin embargo, existen dudas sobre su seguridad por el daño mecánico de la guía y son escasos los datos referentes al pronóstico de los pacientes. El objetivo de este estudio fue evaluar el daño estructural de la guía de presión en la técnica de la guía encarcelada y examinar los resultados clínicos a medio plazo. Métodos: Se incluyó a 99 pacientes con lesiones bifurcadas tratadas mediante la técnica de guía de presión encarcelada y, como control histórico, a 114 pacientes tratados mediante la técnica de la guía encarcelada con guías no poliméricas. Se evaluó el daño de la guía mediante microscopía estereoscópica. El objetivo primario fue localizar la presencia de daño microscópico significativo. Se examinaron eventos cardiovasculares adversos mayores a los dos años de seguimiento. Resultados: El daño microscópico significativo fue más frecuente en las guías de presión que en las no poliméricas (53,5% vs 22,8%, p <0,001). No hubo fracturas en ningún grupo. Hubo menos intervenciones de la rama lateral en el grupo de la guía de presión (posdilatación 32,3% vs 56,1%, p=0,001; stent, 0,0% vs 2,6%, p=0,104). El riesgo de eventos cardiovasculares a los 2 años fue similar en ambos grupos (HRadj=0,42; IC95%, 0,10-1,73; p=0,229). Conclusiones: La guía de presión fue menos resistente al encarcelamiento que la guía no polimérica. Los pacientes tratados con guía de presión requirieron menos intervenciones de la rama lateral, pero tuvieron similar riesgo de eventos a los 2 años de seguimiento. (AU)

Introduction and objectives: The use of a pressure wire as a jailed wire to evaluate side branch results during provisional stenting seems feasible. However, safety concerns exist due to the mechanical damage of the wire and the lack of prospective data evaluating the prognosis of patients treated using this technique. This study sought to evaluate the structural damage of the pressure wire in patients treated using the jailed pressure wire technique and to assess mid-term clinical outcomes. Methods: We enrolled 99 patients with single bifurcation lesions and provisional stenting as the strategy of choice. A jailed pressure wire was used to guide side branch intervention according to the instantaneous wave-free ratio (iFR). A total of 114 patients and the respective nonpolymer-coated jailed wires were used as historical controls. Guidewire damage was evaluated by stereomicroscopy. The primary endpoint was significant microscopic damage. Major adverse cardiac events were evaluated at 2-year follow-up. Results: Significant microscopic damage was more frequent in pressure wires than in nonpolymer-coated wires (53.5% vs 22.8%, P<.001). There were no fractures in either group. There were fewer side branch interventions in the pressure wire group (postdilation/kissing balloon, 32.3% vs 56.1%, P=.001; stenting, 0.0% vs 2.6%, P=.104). The 2-year rate of major adverse cardiac events was similar between the 2 groups (HRadj, 0.42; 95%CI, 0.10-1.73; P=.229). Conclusions: Pressure wires were less resistant to jailing than conventional nonpolymer-coated wires. Patients treated with iFR-guided provisional stenting required fewer side branch interventions but had similar 2-year clinical outcomes than patients treated with the angiography-guided technique. (AU)

Cirugía coronaria: evolución de las características de la enfermedad coronaria y resultados inmediatos de la cirugía de revascularización miocárdica en una década

Introducción: En la evolución de las características de la cirugía coronaria (CC) intervienen factores como cambios demográficos, técnica quirúrgica y cuidados perioperatorios. Nuestro objetivo es analizar la evolución de las características de la enfermedad coronaria en pacientes tratados con CC y sus resultados inmediatos. Material y Método: Estudio analítico. Cohorte de pacientes operados con CC aisladas entre enero de 2006 y diciembre de 2008, y entre enero de 2016 y diciembre de 2018 en Hospital Clínico Regional de Concepción, Chile. Revisión bases datos y protocolos quirúrgicos, previa autorización comité de ética. Se utilizó SPSSv25® y pruebas estadísticas Chi-cuadrado y U Mann-Whitney, considerando significativo p < 0,05. Resultados: Total 1.400 CC aisladas, 658 primer período y 742 segundo período. Edad promedio: 62,0 ± 8,7 y 64,6 + 9,3 años según períodos (p < 0,001). Aumentaron significativamente en el segundo período: diabetes mellitus, enfermedad pulmonar obstructiva crónica, infarto agudo al miocardio (IAM), disfunción ventricular grave dentro de subgrupo con disfunción ventricular. Disminución significativa de la cirugía sin circulación extracorpórea, y aumento significativo del uso ≥ 2 puentes arteriales en el segundo período. EuroSCORE I aditivo aumentó de 3,6 ± 2,5 a 4,4 ± 2,7 (p = 0,001). Subgrupo de alto riesgo: 137 (20,8%) a 236 (31,8%), p < 0,001. Mortalidad de 13 (1,98%) y 16 (2,2%) según períodos, p = 0,813. Discusión: Se observó aumento significativo del riesgo operatorio estimado, sin embargo, la mortalidad se mantuvo sin variación. El aumento del riesgo operatorio se condice con el aumento de la edad promedio y de la prevalencia de comorbilidades, así como del aumento de disfunción ventricular grave dentro del grupo de pacientes con disfunción ventricular e IAM reciente en el segundo período.

Introduction: Several factors intervene in the evolution of the characteristics of Coronary artery bypass grafting (CABG), such as demographic changes, surgical technique, and perioperative care. Our objective was to analyze the evolution of the characteristics of coronary artery disease in patients treated with CABG and its immediate results. Methods: In an analytical study, we analyzed a cohort of patients with isolated CABG from January 2006 to December 2008 and from January 2016 to December 2018 in Hospital Clínico Regional Concepción, Chile. After the ethics committee's approval, we reviewed the database and surgical protocols. We used Chi-square and U Mann Whitney tests for statistical analysis (SPSSv25®), considering significant p < 0,05. Results: We analyzed 1,400 isolated CABG, 658 from the first period and 742 from the second, with a mean age of 62.0 ± 8.7 and 64.6 ± 9.3 respectively (p < 0.001). The subgroup with ventricular dysfunction in the second period showed a significant increase in diabetes mellitus, chronic obstructive pulmonary disease, acute myocardial infarction (AMI), and severe ventricular dysfunction. The second group decreased off-pump surgery and increased the use of ≥ 2 arterial grafts (p < 0.05). The Additive EuroSCORE I increased from 3.6 ± 2.5 to 4.4 ± 2.7 (p = 0.001). High-risk subgroup: 137 (20.8%) to 236 (31.8%), p < 0.001. Mortality of 13 (1.98%) and 16 (2.2%) in the first and second group respectively, p = 0.813. Conclusion: There was a significant increase in the estimated surgical risk; however, mortality remained unchanged. The increase in surgical risk is consistent with the increase in mean age and prevalence of comorbidities, as well as the increase in severe ventricular dysfunction in the group ofpatients with ventricular dysfunction and recent AMI in the second period.

Association between physical activity and coronary artery calcification estimated by computed tomography: A systematic review / Asociación entre la actividad física y el calcio arterial coronario estimado por tomografía computarizada: una revisión sistemática

Background: The relationship between physical activity and coronary artery calcification (CAC) was evaluated in different studies during the last years, although the results were conflicting. Objective: The main objective of the present systematic review was to assess the association between different levels of physical activity and CAC score estimated by computed tomography (CT). Methods: This systematic review was performed according to PRISMA guidelines. A literature search was performed to detect studies that evaluated the association between physical activity and CAC score. The levels of physical activity evaluated were those reported by the original publications. The CAC score was estimated by CT and was reported in Agatston units. Results: Twenty six studies including 89,405 subjects were considered eligible for this research. The studies developed in the general population showed different results regarding the association between physical activity and CAC score: no association (7 studies), a positive association (4 studies), an inverse relationship (6 studies), a U-shaped relationship (2 studies), or different results depending on the subgroup evaluated (2 studies). In the largest studies, a positive association was observed. When we analyzed the studies that evaluated athletes, four studies showed a positive association between exercise intensity and CAC. Conclusion: This systematic review showed disparate results regarding the association between physical activity and CAC score. The largest studies and most studies developed in athletes suggest that intense physical activity could be associated with high CAC score, although this hypothesis should be confirmed in future research.(AU)

Antecedentes: La relación entre la actividad física y el calcio arterial coronario (CAC) fue evaluada en diferentes estudios durante los últimos años, aunque los resultados fueron contradictorios. Objetivo: El principal objetivo fue evaluar la asociación entre diferentes niveles de actividad física y la puntuación de CAC estimada por tomografía computarizada (TC). Métodos: Esta revisión sistemática se realizó de acuerdo con las guías PRISMA. Se realizó una búsqueda bibliográfica para detectar estudios que evaluaran la asociación entre la actividad física y la puntuación de CAC. Los niveles de actividad física evaluados fueron los informados por las publicaciones originales. La puntuación de CAC se estimó por TC y se informó en unidades Agatston. Resultados: Veintiséis estudios que incluyeron 89.405 sujetos se consideraron elegibles para esta investigación. Los estudios desarrollados en población general mostraron diferentes resultados en cuanto a la asociación entre la actividad física y la puntuación de CAC: ninguna asociación (7 estudios), una asociación positiva (4 estudios), una relación inversa (6 estudios), una relación en forma de «U» (2 estudios), o resultados diferentes según el subgrupo evaluado (2 estudios). Los estudios más grandes y 4 de los estudios que evaluaron atletas reportaron una asociación positiva.(AU)

Práticas clínicas aplicadas a pacientes com infarto do miocárdio sem obstrução de artéria coronária (minoca) / Clinical Practices Applied To Patients With Myocardial Infarction Non-obstruction Coronary Arteries (Minoca) / Prácticas clínicas aplicadas a pacientes con infarto e miocardio sin obstruccion arteria coronaria (MINOCA)

Objetivo: Identificar práticas clínicas com resultados favoráveis aos pacientes com diagnóstico de infarto agudo do miocárdio sem obstrução de artéria coronária. Método: Revisão integrativa da literatura pela base de dados National Library of Medicine e Biblioteca Virtual de Saúde de estudos publicados entre 2018 e 2022. Resultados:87,5% dos estudos encontrados destacaram estratégias farmacológicas e destes, 62,5% citaram o uso da dupla antiagregaçãoplaquetária como mais utilizada, apesar de nenhum estudo evidenciar benefícios. Os inibidores do sistema renina-angiotensina-aldosterona comprovaram benefícios em três estudos. 75% dos artigos apontaram que esse grupo de pacientes recebem menos medicamentos preventivos comparados aos pacientes com infarto por obstrução coronariana. Outros seis estudos, revelaram condução clínica variável desses pacientes. Conclusão: O uso de inibidores do sistema renina-angiotensina-aldosterona deve ser considerado por ser a única medicação com redução da mortalidade evidenciada. São necessários estudos maiores para orientar com mais segurança à condução do infarto do miocárdio sem obstrução de coronária.(AU)

Objective: To identify clinical practices with favorable results for patients diagnosed with acute myocardial infarction without coronary artery obstruction. Method: Integrative literature review using the National Library of Medicine and Virtual Health Library databases of studies published between 2018 and 2022. Results: 87.5% of the studies found highlighted pharmacological strategies and of these, 62.5% cited the use of dual antiplatelet therapy as the most used, despite no study showing benefits. Inhibitors of the renin-angiotensin-aldosterone system have shown benefits in three studies. 75% of the articles pointed out that this group of patients receive less preventive medication compared to patients with infarction due to coronary obstruction. Another six studies revealed variable clinical management of these patients. Conclusion: The use of renin-angiotensin-aldosterone system inhibitors should be considered as it is the only medication with proven reduction in mortality. Larger studies are needed to guide with more safety the management of myocardial infarction without coronary obstruction.(AU)

Objetivo: Identificar prácticas clínicas con resultados favorables para pacientes con diagnóstico de infarto agudo de miocardio sin obstrucción arterial coronaria. Método: revisión integrativa de la literatura utilizando las bases de datos de la Biblioteca Nacional de Medicina y la Biblioteca Virtual en Salud de estudios publicados entre 2018 y 2022. Resultados: el 87,5% de los estudios encontrados destacaron estrategias farmacológicas y de estos, el 62,5% citó el uso de la terapia antiplaquetaria dual como el más utilizados, a pesar de que ningún estudio muestra beneficios. Los inhibidores del sistema renina-angiotensina-aldosterona han mostrado beneficios en tres estudios. El 75% de los artículos señalaron que este grupo de pacientes recibe menos medicación preventiva en comparación con los pacientes con infarto por obstrucción coronaria. Otros seis estudios revelaron un manejo clínico variable de estos pacientes. Conclusión: Se debe considerar el uso de inhibidores del sistema renina-angiotensina-aldosterona, ya que es el único medicamento con reducción comprobada de la mortalidad. Son necesarios estudios más amplios que orienten con mayor seguridad el manejo del infarto de miocardio sin obstrucción coronaria.(AU)

Variant origin of the right coronary artery from the left main coronary artery together with aortic valve stenosis: report of a rare case / Origen variante de la arteria coronaria derecha a partir de la arteria coronaria izquierda junto con estenosis de la valva aórtica: reporte de un caso raro

SUMMARY: Variations in the origin of the right coronary artery have an incidence between 0.09 % and 0.92 %. Herein, we report a rare case of a coronary artery anomaly in which the right coronary artery originates from the left main coronary artery. This variant was found during routine coronarography, combined with an artificial aortic valve. Despite their rare occurrence, some variations in the origins of the coronary arteries can be life threatening and are associated with a higher risk of sudden cardiac death. They can also pose serious technical challenges and predispose to complications during coronary angiographic procedures. Thus, knowledge of such anomalies is paramount for managing the patients correctly.

Las variaciones en el origen de la arteria coronaria derecha tienen una incidencia entre el 0,09 % y el 0,92 %. En este documento, informamos un caso raro de una anomalía de la arteria coronaria en la que la arteria coronaria derecha se originaba en la arteria coronaria izquierda. Esta variante se encontró durante una coronariografía de rutina, combinada con una válvula aórtica artificial. A pesar de su rara aparición, algunas variaciones en los orígenes de las arterias coronarias pueden poner en peligro la vida y se asocian con un mayor riesgo de muerte súbita cardíaca. También pueden plantear serios desafíos técnicos y predisponer a complicaciones durante los procedimientos angiográficos coronarios. Por tanto, el conocimiento de dichas anomalías es fundamental para el manejo correcto de los pacientes.

Anomalous aortic origin of the left coronary artery / Origen aórtico anómalo de la arteria coronaria izquierda

Abstract We present an unusual case of an anomalous left coronary artery arising from the contralateral sinus of Valsalva: a 63-year-old male patient who consulted to our emergency department with 1-week history of progressive dyspnea on exertion with clinical signs of heart failure, associated with lung congestion on the chest X ray and elevated NT-proBNP levels (2000 pg/ml; normal value <150). Doppler echocardiography showed severe dilation of both left atrium and left ventricle, with severe deterioration of LV systolic function (Ejection fraction of 26%), global hypokinesia and a moderate mitral regurgitation with central jet. A cardiac cath eterization was performed, which evidenced an anomalous origin of the left main coronary artery from the right coronary sinus with a proximal lesion of nearly 50%. A coronary computed tomographic angiography confirmed the diagnosis of an anomalous origin with an intramyocardial path at the level of the interventricular septum, as sociated with moderate extrinsic compression. To determine the degree of functional ischemia presented by the left main coronary artery lesion we performed a fractional flow reserve evaluation, resulting in 0.75, which was ranked as significant. An angioplasty with implantation of a drug-eluting stent (with Everolimus) was performed successfully to the target lesion. The patient evolved favorably during hospitalization and was discharged from the medical center to continue outpatient follow-up. Patient remained asymptomatic at 1-month and 6 months, during clinical evaluation, without evidence of ischemia on noninvasive functional assessment.

Resumen Presentamos un raro caso de nacimiento anómalo de arteria coronaria izquierda en el seno de Valsalva contralateral. Se trata de un hombre de 63 años que consultó al servicio de emergencias de nuestro centro por disnea progresiva de una semana de evolución, con signos clínicos de insuficiencia cardíaca, aso ciado a signos de congestión en la radiografía de tórax, y valores de NT-proBNP elevados (2000 pg/ml; valor normal <150). El ecocardiograma Doppler evidenció dilatación grave de la aurícula y del ventrículo izquierdo, con deterioro grave de la función sistólica (fracción de eyección de 26%), hipoquinesia global e insuficiencia mitral moderada con jet central. Se realizó una cinecoronariografía que evidenció el nacimiento anómalo del tronco de arteria coronaria izquierda desde el seno coronario derecho, con una lesión cercana al 50%. Una angiotomografía coronaria confirmó el origen anómalo del vaso coronario, con trayecto intramiocárdico a nivel del septum interventricular asociado a compresión extrínseca moderada. Para determinar el grado de isquemia funcional que presentaba la lesión del tronco coronario izquierdo se evaluó la reserva de flujo fraccional, que arrojó un resultado de 0.75 el cual se consideró significativo, prosiguiendo a angioplastia con implante de stent liberador de droga (con Everolimus) a dicha lesión. El paciente evolucionó favorablemente durante la internación en el hospital, egresando de la institución para continuar seguimiento ambulatorio. Persistió asintomático en los controles realizados al mes y a los 6 meses, sin evidencia de isquemia en la evaluación funcional no invasiva.

Diagnostic performance of different cardiac stress protocols for myocardial perfusion imaging for the diagnosis of coronary artery disease using a cadmium-zinc-telluride camera with invasive coronary angiography correlation.

PURPOSE: To evaluate the diagnostic performance of three different cardiac stress protocols for myocardial perfusion imaging (MPI) using a cadmium-zinc-telluride (CZT) camera with invasive coronary angiography (ICA) correlation for the diagnosis of coronary artery disease in a high risk population. METHODS: Retrospective study of 263 patients (96 women and 167 males, mean age 68 years) from which 119 patients performed a bicycle stress test (BST), 113 pharmacological stress test (PST) and 31 a combination of the two (CST) between September 2014 and December 2018. The patients then underwent myocardial perfusion imaging (MPI), followed by ICA and evaluated by means of quantitative angiography software, within six months after the MPI. The mean pre-test probability score for coronary disease according to the European Society of Cardiology criteria was 36% for the whole population. The MPI was performed in a dedicated CZT cardio camera (D-SPECT Spectrum Dynamics) with a two-day protocol, according to the European Association of Nuclear Medicine guidelines. RESULTS: No significant difference was observed between the three stress protocols in terms of diagnostic accuracy (BST 85%, PST 88%, CST 84%). The overall diagnostic accuracy of MPI to identify patients with any obstructive CAD at ICA was 86%, Sensitivity 93%, Specificity 54%, PPV 90% and NPV 63%. CONCLUSION: The CZT D-SPECT camera achieves overall satisfactory results in the diagnosis of CAD, observing no significant differences in the diagnostic performance when the stress test was performed as a BST, PST or CST.

Jailed pressure wire technique for coronary bifurcation lesions: structural damage and clinical outcomes.

INTRODUCTION AND OBJECTIVES: The use of a pressure wire as a jailed wire to evaluate side branch results during provisional stenting seems feasible. However, safety concerns exist due to the mechanical damage of the wire and the lack of prospective data evaluating the prognosis of patients treated using this technique. This study sought to evaluate the structural damage of the pressure wire in patients treated using the jailed pressure wire technique and to assess mid-term clinical outcomes. METHODS: We enrolled 99 patients with single bifurcation lesions and provisional stenting as the strategy of choice. A jailed pressure wire was used to guide side branch intervention according to the instantaneous wave-free ratio (iFR). A total of 114 patients and the respective nonpolymer-coated jailed wires were used as historical controls. Guidewire damage was evaluated by stereomicroscopy. The primary endpoint was significant microscopic damage. Major adverse cardiac events were evaluated at 2-year follow-up. RESULTS: Significant microscopic damage was more frequent in pressure wires than in nonpolymer-coated wires (53.5% vs 22.8%, P<.001). There were no fractures in either group. There were fewer side branch interventions in the pressure wire group (postdilation/kissing balloon, 32.3% vs 56.1%, P=.001; stenting, 0.0% vs 2.6%, P=.104). The 2-year rate of major adverse cardiac events was similar between the 2 groups (HRadj, 0.42; 95%CI, 0.10-1.73; P=.229). CONCLUSIONS: Pressure wires were less resistant to jailing than conventional nonpolymer-coated wires. Patients treated with iFR-guided provisional stenting required fewer side branch interventions but had similar 2-year clinical outcomes than patients treated with the angiography-guided technique.

Association between physical activity and coronary artery calcification estimated by computed tomography: A systematic review.

BACKGROUND: The relationship between physical activity and coronary artery calcification (CAC) was evaluated in different studies during the last years, although the results were conflicting. OBJECTIVE: The main objective of the present systematic review was to assess the association between different levels of physical activity and CAC score estimated by computed tomography (CT). METHODS: This systematic review was performed according to PRISMA guidelines. A literature search was performed to detect studies that evaluated the association between physical activity and CAC score. The levels of physical activity evaluated were those reported by the original publications. The CAC score was estimated by CT and was reported in Agatston units. RESULTS: Twenty six studies including 89,405 subjects were considered eligible for this research. The studies developed in the general population showed different results regarding the association between physical activity and CAC score: no association (7 studies), a positive association (4 studies), an inverse relationship (6 studies), a U-shaped relationship (2 studies), or different results depending on the subgroup evaluated (2 studies). In the largest studies, a positive association was observed. When we analyzed the studies that evaluated athletes, four studies showed a positive association between exercise intensity and CAC. CONCLUSION: This systematic review showed disparate results regarding the association between physical activity and CAC score. The largest studies and most studies developed in athletes suggest that intense physical activity could be associated with high CAC score, although this hypothesis should be confirmed in future research.

Prevenção Farmacológica Secundária da Doença Arterial Coronariana em Pacientes Submetidos ao Manejo Clínico, Intervenção Coronária Percutânea ou Cirurgia de Revascularização Miocárdica / Secondary Pharmacological Prevention of Coronary Artery Disease among Patients Submitted to Clinical Management, Percutaneous Coronary Intervention, or Coronary Artery Bypass Graft Surgery

Resumo Fundamento A prevenção secundária é recomendada a pacientes com evidência de doença arterial coronariana (DAC) independentemente da indicação de tratamento por cirurgia de bypass da artéria coronária (CABG) ou intervenção coronária percutânea (ICP). Objetivos Este estudo avaliou se o tratamento clínico, a ICP ou o CABG teve influência na adesão à prevenção secundária farmacológica em pacientes com DAC estável. Métodos Esta coorte incluiu pacientes com idade ≥40 anos com DAC estável confirmada por angiografia coronária estável. A decisão por tratamento clínico isolado, ou combinado com ICP ou CABG foi feita por médicos assistentes. A adesão às drogas prescritas recomendadas pelas diretrizes de prevenção secundária (tratamento farmacológico ótimo), incluindo agentes antiplaquetários, drogas hipolipemianetes, betabloqueadores, e bloqueadores do sistema angiotensina aldosterona, foi avaliada no acompanhamento. Diferenças com valores de p < 0,05 foram consideradas estatisticamente significativas. Resultados Dos 928 pacientes incluídos inicialmente, 415 apresentaram DAC leve e 66 apresentaram DAC leve a moderada. O período médio de seguimento foi 5,2 ± 1,5 anos. Os pacientes submetidos ao CABG apresentaram maior probabilidade de receberem tratamento farmacológico ótimo que aqueles submetidos à ICP ou tratamento clínico (63,5% versus 39,1% versus 45,7% respectivamente, p=0,003). Fatores basais independentemente associados com maior probabilidade de prescrição de tratamento ótimo foram CABG [39% maior (6% - 83%, p=0,017)] em comparação a outros tratamentos e diabetes [25% maior (1% - 56%), p=0,042] em comparação à ausência de diabetes. Conclusões Pacientes com DAC submetidos ao CABG são mais frequentemente tratados com prevenção secundária farmacológica ótima que pacientes tratados com ICP ou exclusivamente com tratamento clínico.

Abstract Background Secondary prevention is recommended for patients with evidence of coronary artery disease (CAD) regardless of the indication for treatment by coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI). Objectives This study evaluated whether clinical treatment, PCI or CABG had an influence on adherence to the pharmacological secondary prevention in patients with stable CAD. Methods This cohort included patients aged ≥40 years with stable CAD confirmed by coronary angiography. The decision for medical treatment alone, or additionally with PCI or CABG, was made by the attending physicians. Adherence to the prescribed drugs recommended by the guidelines for secondary prevention (optimal pharmacological treatment), including antiplatelet agents, lipid-lowering drugs, beta-blockers, and renin-angiotensin-aldosterone system blockers, was assessed at follow-up. Differences were considered significant for p values <0.05. Results From 928 patients enrolled at baseline, 415 had mild CAD and 66 moderate to severe CAD. The average follow-up was 5.2 ± 1.5 years. Patients submitted to CABG were more likely to receive the optimal pharmacological treatment than those submitted to PCI or treated clinically (63.5% versus 39.1% versus 45.7% respectively, p=0.003). Baseline factors independently associated with greater probability of having a prescription of optimal treatment at follow-up were CABG [39% higher (6% - 83%, p=0.017) and diabetes [25% higher (1% - 56%), p=0.042] than their counterparts treated by other methods and participants without diabetes, respectively. Conclusions Patients with CAD submitted to CABG are more commonly treated with optimal pharmacological secondary prevention than patients treated by PCI or exclusively with medical therapy.

Development and content validity of a website for patients with coronary artery disease / Desarrollo y validación de contenido de un sitio web para pacientes con enfermedad arterial coronaria / Desenvolvimento e validação de conteúdo de um website para pacientes com doença arterial coronariana

ABSTRACT Objectives: to develop and analyze content validity evidence of a website for patients with coronary artery disease. Methods: a methodological study, carried out in the phases: Definition - determined contents for inclusion in the website, architecture and design; Implementation - subjects included in the website; Assessment - website submitted to analysis by 13 experts and eight laypersons regarding organization, content and design, on a scale of 1 (no agreement) to 4 (complete agreement). Items that reached Content Validity Ratio (CVR) higher than the established critical values and Content Validity Index greater than 0.80 were considered valid. Results: eight domains related to secondary prevention in coronary heart disease were included on the website. Critical CVR and adequate CVI were obtained according to professional and lay experts. Conclusions: the website was developed, achieving adequate content validity evidence, and can be used as an educational tool for this population.

RESUMEN Objetivos: desarrollar y analizar evidencias de validez de contenido de un sitio web para pacientes con enfermedad arterial coronaria. Métodos: estudio metodológico, realizado en las siguientes fases: Definición - determinado los contenidos para su inclusión en el sitio web, la arquitectura y el diseño; Implementación - temas incluidos en el sitio web; Evaluación - sitio web sometido a análisis por 13 expertos y ocho legos en cuanto a organización, contenido y diseño, en una escala de 1 (sin acuerdo) a 4 (totalmente de acuerdo). Se consideran válidos los artículos que alcanzaron un Índice de Validez de Contenido (CVR) superior a los valores críticos establecidos y un Índice de Validez de Contenido superior a 0,80. Resultados: se incluyeron en el sitio web ocho dominios relacionados con la prevención secundaria en enfermedades coronarias. Se obtuvo un CVR crítico y un CVI adecuado en opinión de expertos profesionales y legos. Conclusiones: se elaboró el sitio web, lográndose evidencias adecuadas de validez de contenido, pudiendo ser utilizado como herramienta educativa para esta población.

RESUMO Objetivos: desenvolver e analisar as evidências de validade de conteúdo de um website para pacientes com doença arterial coronariana. Métodos: estudo metodológico, realizado nas fases: Definição - determinado os conteúdos para inclusão no website, arquitetura e design; Implementação - assuntos incluídos no website; Avaliação - website submetido à análise por 13 especialistas e oito leigos quanto à organização, conteúdo e design, em uma escala de 1 (não concordância) a 4 (total concordância). Considerados válidos os itens que atingiram uma Razão de Validade de Conteúdo (CVR) superior aos valores críticos estabelecidos e um Índice de Validade de Conteúdo superior a 0,80. Resultados: incluídos no website oito domínios relacionados à prevenção secundária em coronariopatias. Um CVR crítico e um IVC adequado foram obtidos na opinião de especialistas profissionais e leigos. Conclusões: o website foi desenvolvido, alcançando adequadas evidências de validade de conteúdo, e pode ser utilizado como ferramenta educacional para esta população.

Comparação de Soluções Cardioplégicas em Cirurgia de Revascularização Miocárdica sobre Mecanismos de Autofagia e Apoptose / Comparison of Cardioplegic Solutions in Coronary Bypass Surgery Over Autophagy and Apoptosis Mechanisms

Resumo Fundamento A doença arterial coronariana (DAC) devido à isquemia miocárdica causa perda permanente de tecido cardíaco. Objetivos Nosso objetivo foi demonstrar o possível dano ao miocárdio em nível molecular através dos mecanismos de autofagia e apoptose em pacientes submetidos à cirurgia de revascularização miocárdica. Métodos Um grupo recebeu uma solução de cardioplegia Custodiol e o outro grupo uma solução de cardioplegia sanguínea. Duas amostras miocárdicas foram coletadas de cada paciente durante a operação, imediatamente antes da parada cardíaca e após a liberação do pinçamento aórtico. Foram avaliadas as expressões de marcadores de autofagia e apoptose. O nível de significância estatística adotado foi de 5%. Resultados A expressão do gene BECLIN foi significativa nos tecidos miocárdicos do grupo CS (p=0,0078). Os níveis de expressão dos genes CASPASE 3, 8 e 9 foram significativamente menores no grupo CC. Os níveis pós-operatórios de TnT foram significativamente diferentes entre os grupos (p=0,0072). As expressões dos genes CASPASE 8 e CASPASE 9 foram semelhantes antes e depois do pinçamento aórtico (p=0,8552, p=0,8891). No grupo CC, os níveis de expressão gênica de CASPASE 3, CASPASE 8 e CASPASE 9 não foram significativamente diferentes em amostras de tecido coletadas após pinçamento aórtico (p=0,7354, p=0,0758, p=0,4128, respectivamente). Conclusões Com nossos achados, acreditamos que as soluções CC e CS não apresentam diferença significativa em termos de proteção miocárdica durante as operações de by-pass.

Abstract Background Coronary artery disease (CAD) due to myocardial ischemia causes permanent loss of heart tissue. Objectives We aimed to demonstrate the possible damage to the myocardium at the molecular level through the mechanisms of autophagy and apoptosis in coronary bypass surgery patients. Methods One group was administered a Custodiol cardioplegia solution, and the other group was administered a Blood cardioplegia solution. Two myocardial samples were collected from each patient during the operation, just before cardiac arrest and after the aortic cross-clamp was released. The expressions of autophagy and apoptosis markers were evaluated. The level of statistical significance adopted was 5%. Results The expression of the BECLIN gene was significant in the myocardial tissues in the BC group (p=0.0078). CASPASE 3, 8, and 9 gene expression levels were significantly lower in the CC group. Postoperative TnT levels were significantly different between the groups (p=0.0072). CASPASE 8 and CASPASE 9 gene expressions were similar before and after aortic cross-clamping (p=0.8552, p=0.8891). In the CC group, CASPASE 3, CASPASE 8, and CASPASE 9 gene expression levels were not found to be significantly different in tissue samples taken after aortic cross-clamping (p=0.7354, p=0.0758, p=0.4128, respectively). Conclusions With our findings, we believe that CC and BC solutions do not have a significant difference in terms of myocardial protection during bypass operations.

Fenótipos MINOCA - Um Desafio para o Manejo Específico do Paciente / MINOCA Phenotypes - A Challenge for Patient-Specific Management

Resumo O infarto do miocárdio com artérias coronárias não obstrutivas (MINOCA) é um fenômeno clínico intrigante e de prognóstico incerto, caracterizado pela evidência de infarto do miocárdio (IM) com artérias coronárias normais ou quase normais na angiografia1. Atualmente, não há diretrizes para o manejo e muitos pacientes recebem alta sem uma etiologia determinada, significando muitas vezes que o tratamento ideal é adiado.Relatamos três estudos de caso MINOCA com as principais causas fisiopatológicas cardíacas, particularmente epicárdicas, microvasculares e não isquêmicas, levando ao tratamento diferencial. Os pacientes apresentavam dor torácica aguda, aumento da troponina e nenhuma doença coronariana angiograficamente significativa.Neste estudo, analisamos a etiologia, diagnóstico clínico e tratamento da MINOCA em relação à literatura relevante.MINOCA é considerado um diagnóstico de trabalho dinâmico, incluindo distúrbios coronários, miocárdicos e não coronários. Estudos prospectivos e registros são necessários para melhorar o atendimento e o resultado do paciente.

Abstract Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a puzzling clinical phenomenon with an unclear prognosis, characterized by evidence of myocardial infarction (MI) with normal or near-normal coronary arteries on angiography1. Currently, there are no guidelines for management, and many patients are discharged without a determined etiology, often meaning that optimal treatment gets postponed.We report three MINOCA case studies with main pathophysiological cardiac causes, particularly epicardial, microvascular, and non-ischemic, prompting differential management. The patients presented with acute chest pain, troponin raise, and no angiographically significant coronary disease.In this study, we analyzed the etiology, clinical diagnosis, and treatment of MINOCA concerning the relevant literature.MINOCA is considered to be a dynamic working diagnosis, including coronary, myocardial, and non-coronary disorders. Prospective studies and registries are needed to improve patient care and outcome.