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El infarto agudo de miocardio en ausencia de enfermedad coronaria obstructiva (MINOCA) representa un reto diagnóstico en la práctica clínica. En su abordaje diagnóstico se incluye la documentación de un sustrato isquémico, con un tratamiento que debe ser específico según la etiología identificada. Un grupo de estos pacientes presenta isquemia secundaria a una alteración en la relación aporte/ demanda de oxígeno. Se presenta el caso de una paciente de sexo femenino y mediana edad, con hipertiroidismo severo y tirotoxicosis, que debuta con un síndrome coronario agudo, con troponina T marcadamente elevada y arterias coronarias sin lesiones significativas en la coronariografía. El tratamiento fue dirigido a manejar la causa desencadenante, de manera inicialmente farmacológica y posteriormente quirúrgica, con resolución total del cuadro, mejoría sintomática de la paciente y disminución de los biomarcadores cardíacos.

Purpose There is an unmet need for a noninvasive biomarker for cardiac allograft vasculopathy (CAV), that could obviate the need to perform surveillance coronary angiograms in HT recipients. Donor-derived cell free DNA (ddcf-DNA) has shown a good ability to rule out cellular rejection, but its performance as a biomarker for CAV has not been tested. We sought to evaluate the performance of ddcf-DNA as a biomarker of CAV in a cohort of patients undergoing routine coronariography. Methods We prospectively obtained ddcf-DNA levels in all patients who underwent routine coronary angiography >1 year after HT in our center between Jan and Sept 2019. Patients with concomitant acute rejection (n=5) or multi organ transplant (n=8) were excluded. Ddcf-DNA levels were correlated with CAV degree (ISHLT 2010 classification). Results We included 54 HT recipients (mean age 57 years, 70% men), with a mean of 10.2 years (IQR 4.3-16.9) after transplant. Coronary angiogram showed CAV0 in 59%, CAV1 in 22%, CAV2 in 6% and CAV3 in 13% (41% of patients with any degree of CAV). Median ddcf-DNA values for each CAV group are shown in figure 1A. Median levels did not differ significantly between patients with and without CAV: 0.64% in CAV0 (IQR 0.19-1.26) as compared to 0.525% (IQR 0.12-1.8) in CAV 1, 2 or 3, p=0.94. Area under the ROC curve for CAV diagnosis was 0.51 (Figure 1B). No significant differences were found between patients with "stable CAV" (no new significant coronary lesions since previous angiogram, n=39) and "progressive CAV" (presence of new coronary stenosis, n=15): median values were 0.5% (IQR 0.17-1.1) and 0.87% (IQR 0.12-4.2) respectively, p=0.51. No correlation was found between ddcf-DNA and Troponin I (r=0.03, p=0.86) or NTproBNP levels (r=-0.09, p=0.59). Conclusion In this preliminary experience, ddcf-DNA level did not seem to correlate with CAV, although sample size might be too small to reach definite conclusions. We hope that the ongoing recruiting (n=100) will shed light in this matter.

Kounis syndrome is defined as the coincidental occurrence of allergic reaction and acute coronary syndrome secondary to vasospasm. Anti-inflammatory drugs are included as one of the multiple causes. Current data available about this syndrome come from case reports. We present the case of a patient who suffered Kounis syndrome with cardiogenic shock and asystole after intravenous infusion of Metamizole, and in which no lesions were observed in coronariography. Resumo: A síndrome de Kounis é definida como a ocorrência concomitante de reação alérgica e síndrome coronariana aguda secundária ao vasoespasmo. Os medicamentos anti-inflamatórios estão incluídos como uma das múltiplas causas. Os dados atuais disponíveis sobre essa síndrome são provenientes de relatos de casos. Apresentamos o caso de um paciente que apresentou síndrome de Kounis com choque cardiogênico e assistolia após infusão intravenosa de metamizol, e no qual não foram observadas lesões na coronariografia. Keywords: Kounis syndrome, Metamizole, Cardiogenic shock, Asystole, Palavras-chave: Síndrome de Kounis, Metamizol, Choque cardiogênico, Assistolia

We present a case of a 52 year old female who suffered from a sudden syncope. A coronariography was performed and spontaneous coronary dissection was diagnosed in the posterior descending artery after an optical coherence tomography (OCT) was performed. A conservative management was decided. During hospitalization the patient presented with an episode of chest pain with an anterior ST elevation on ECG. Coronariography showed total occlusion of the left descending artery and again a dissection was diagnosed by OCT. This time, 2 stents were implanted in the affected artery. The hypothesis that the coronary adventitial volume of vasa vasorum is higher in patients with spontaneous coronary artery dissection has been demonstrated in a recent small study and it was observed in this patient. Conservative management is preferred in most cases, proceeding to revascularization for patients with ongoing chest pain, hemodynamic instability and ST elevation, mostly if it affects major arteries.

Ischemic Mitral Regurgitation (MR) has early prognostic impact in Myocardial Infarction (MI). Its medium-term importance, especially of mild MR, has not been established.to determine new clinical/analytical predictors of MR in MI-patients and establish its prognostic value during two-year follow-up [endpoints: mortality, decompensated heart failure (dHF)].796 patients admitted for MI (age 68.8±13.4, 63.2% males, 44.6% STEMI).Admission analytical study, risk scores, coronariography, pre-discharge echocardiogram. Patients followed for two years. Clinical/analytical predictors of pre-discharge MR assessed. Predictive model for presence of pre-discharge MR included GRACE for intra-hospital mortality [IHM](OR=1.008, p0.001), glomerular filtration rate (GFR)[OR=0.993, p=0.048], admission haemoglobin (OR=0.84, p=0.003). In univariate analysis, moderate-severe MR predicted 2-year mortality (OR=3.32, p0.001), but not dHF. Two year mortality rate was proportional to severity of pre-discharge MR. Mild MR (vs. no MR) associated with higher risk for 2-year mortality (OR=2.04, p=0.014) and re-admission for dHF (OR=2.55, p=0.001). Predictive model for 2-year mortality included MR severity (OR=1.42, p=0.033) and GRACE for IHM (OR=1.023, p0.001).GRACE score for IHM, GFR and admission haemoglobin independently predicted risk for pre-discharge MR. MR, including its milder form, was an independent predictor of 2-year mortality, adding prognostic power to GRACE score.

Aneurysm of the left main coronary artery is a rare angiographic finding, with few cases described in the international literature. We report the case of a 42-year-old male with a previous history of acute myocardial infarction, whose coronariography indicated triple vessel coronary disease and an aneurysm of the left main coronary artery. A review of the etiology, clinical aspects, and surgical management of coronary arterial aneurysm is presented.

OJBETIVOS: Demonstrar nossa experiência com o implante da artéria torácica interna, para revascularização do miocárdio, procedimento proposto por Vineberg, em 1946. CASUÍSTICA E MÉTODO: De agosto de 1994 a setembro de 1998, foram operados 10 pacientes nos quais foi implantada a artéria torácica interna esquerda na parede ântero-lateral do ventrículo esquerdo. Em todos esses pacientes também foi feito enxerto de safena aorto-coronária. A idade dos pacientes variou de 42 a 73 anos, tendo sexo masculino prevalecido (60%). Todos os pacientes apresentavam doença coronária arterosclerótica difusa, mas com miocárdio viável. A indicação para o implante de artéria torácica interna foi feita durante a operação, devido a impossibilidade de fazer enxerto ou endarterectomia. RESULTADOS: Todos os pacientes estavam muito bem no pós-operatório imediato. O reestudo angiográfico foi feito em 9 pacientes entre 45 dias e 23 meses de pós-operatório, mostrando patência da artéria implantada e uma vasta rede que se comunicava com a coronária nativa. CONCLUSÃO: O implante de artéria torácica interna em miocárdio viável pode ter lugar no arsenal terapêutico da revascularização miocárdica, em casos especiais. Agora, baseados nos erros do passado, podemos selecionar os pacientes e obter melhores resultados. É uma técnica pouco estudada, que deveria ser mais usada, assim possibilitando uma avaliação mais precisa de sua eficácia. OBJECTIVE: To demonstrate our experience with the myocardial revascularization using the implantation of left internal mammary artery. This procedure was proposed by Vineberg, in 1946. MATERIAL AND METHODS: From August 1994 to September 1998, 10 patients were operated on, all of them had the left internal mammary artery implanted in the anterolateral part of the wall of the left ventricle and all of them had a saphenous vein bypass graft. The age of the patients ranged from 42 years to 73 years with the prevalence of males. All patients had a diffuse and severe coronary artery disease mainly of the interventricular (descending) anterior artery, but with myocardial viability. The indication for internal mammary implantation was made during the procedure, because the techniques as saphenous vein bypass or endarterectomy were not considered applicable to these cases. RESULTS: All the patients were very well in the post operative period; from 45 days to 23 months, coronariography study were performed on nine patients, showing the implanted internal mammary artery arborizing and communicating with the native coronary arteries. CONCLUSION: The internal mammary artery implanted in a viable myocardium should have its place on myocardial revascularization treatment, in selected cases. Nowadays, observing the misinterpretation on the past papers, we can select the patients with appropriate indication for this technique, obtained good results. The Vineberg technique needs more experience to define the evaluation of its real effectiveness.