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This review discusses atrial fibrillation according to the guidelines of Brazilian Society of Cardiac Arrhythmias and the Brazilian Cardiogeriatrics Guidelines. We stress the thromboembolic burden of atrial fibrillation and discuss how to prevent it as well as the best way to conduct cases of atrial fibrillatios in the elderly, reverting the arrhythmia to sinus rhythm, or the option of heart rate control. The new methods to treat atrial fibrillation, such as radiofrequency ablation, new oral direct thrombin inhibitors and Xa factor inhibitors, as well as new antiarrhythmic drugs, are depicted.

We report a case of a 59-year-old patient diagnosed with chagasic cardiomyopathy, who manifested sudden heart failure while hospitalized, evolving to death due to cardiogenic and septic shock. Anatomical-pathological studies revealed infarction of the papillary muscles together with histological changes compatible with 48 to 72 hours of evolution. Pulmonary edema was considered the cause of death, probably related to mitral regurgitation of ischemic nature. The cause of the papillary muscle infarction was not elucidated by study of the coronary tree, which presented no signs of recent thrombosis. Explanation for the papillary muscle infarction in this patient may be related to the presence of alterations in microcirculation represented by vasodilation and the consequent phenomenon of "stealing" of blood flow in this territory to the detriment of other areas, or due to the fact that the papillary muscles may represent convergence zones of two distinct coronary circulations.

Objective: To analyze the in-hospital outcome of elderly patients aged 70 years and older who underwent off-pump coronary artery bypass graft surgery with an intraluminal shunt in urgent, emergent, and elective coronary revascularizations., Methods: From July 1989 to July 2005, we analyzed 87 patients ranging in age from 70 to 92 years. Of the 87 patients enrolled, 50 (57.5%) patients had unstable angina, with three (3.4%) acute myocardial infarction; thirty-one (35.6%) patients underwent urgent and emergent surgery; thirteen (14.9%) patients had myocardial infarction in less than 30 days, and 34 (39.1%) in more than 30 days., Results: The main postoperative complications were: atrial fibrillation (32.2%), heart failure (12.6%), pneumonia (10.3%), septicemia (3.4%), acute myocardial infarction (2.3%), mediastinitis (1.1%) transient ischemic attack (1.1%), and pneumothorax (1.1%). The mean extubation time was 18.50+/-19.09 hours, the length of stay in the intensive care unit was 2.92+/-2.03 days, and hospital length of stay was 10.55+/-7.16 days. Packed red cells were given to nine (10.34%) patients and none of them was operated due to bleeding. The in-hospital mortality was 4.6%., Conclusions: In patients over 70 years-old, elective and non-elective off-pump coronary artery bypass grafting with intracoronary shunt showed to be safe and effective, associated with low rates of postoperative complications and mortality in relation to the studied population.

The authors discuss the epidemiology and pathogenesis of Chagas' disease in Brazil, including the use of treatment with a cardioverter-defibrillator in patients with low ejection fraction. Select patients may benefit from resynchronization therapy associated with cardioverter-defibrillator treatment. Electrophysiologic study is indicated in the assessment of the potential utility of an implantable cardioverter-defibrillator.

Context and Objective: There is uncertainty regarding the risk of major complications in patients with left ventricular (LV) infarction complicated by right ventricular (RV) involvement. The aim of this study was to evaluate the impact on hospital mortality and morbidity of right ventricular involvement among patients with acute left ventricular myocardial infarction., Design and Setting: Prospective cohort study, at Emergency Care Unit of Hospital Central da Irmandade da Santa Casa de Misericórdia de São Paulo., Methods: 183 patients with acute myocardial infarction participated in this study: 145 with LV infarction alone and 38 with both LV and RV infarction. The presence of complications and hospital death were compared between groups., Results: 21% of the patients studied had LV + RV infarction. In this group, involvement of the dorsal and/or inferior wall was predominant on electrocardiogram (p < 0.0001). The frequencies of Killip class IV upon admission and 24 hours later were greater in the LV + RV group, along with electrical and hemodynamic complications, among others, and death. The probability of complications among the LV + RV patients was 9.7 times greater (odds ratio, OR = 9.7468; 95% confidence interval, CI: 2.8673 to 33.1325; p < 0.0001) and probability of death was 5.1 times greater (OR = 5.13; 95% CI: 2.2795 to 11.5510; p = 0.0001), in relation to patients with LV infarction alone., Conclusions: Patients with LV infarction with RV involvement present increased risk of early morbidity and mortality.

Objectives: To evaluate angiotensin converting enzyme gene (ACE) polymorphism with transthoracic bidimensional echocardiogram of normotensive young medical students, siblings of hypertensive parents comparing them with those with normotensive parents., Method: We had studied 80 normotensive youngs divided in two groups. Hypertensive parents' normotensive young medical students 40 x Normotensive parents' and normotensive medical students. Exclusion criteria were hypertension, obesity, smoke, use of oral contraceptives, as well as those who use chronically drugs or the presence of any disease. The group has been enrolled between 1994 to 1996. 50 students made transthoracic bidimensional echocardiogram. The statistical analysis was done by "T-student" test. The evaluation of polymorphism ACE gene was studied in 80 people in each step: 1) 5 mL of blood in EDTA tube, 2) extraction of DNA, 3) evaluation of DNA concentration by electrophoresis analyses; 4) Polymerase chain reaction with primer of ACE gene, 5) Analysis of polymorphism ACE gene by electrophoresis 6) Statistical analysis by Chi-square test., Results: The group of students with hypertensive parents presented thicker interventricular septum (7.82 mm +/- 0.69 against 7.38 mm +/- 0.8, p<0.05). On the other hand, we didn't find differences between the groups concerning ACE gene genotype: students with hypertensive parents DD: 42.5%, DI: 37.5%, II: 20% against Students with normotensive parents: DD: 37.5%, DI: 32.5%, II: 30%, (p=0.58), in addition we also did not find differences concerning the alleles Group of hypertensive parents: D: 61.25%, I: 38.75% versus normotensive parents: D: 53.75%, I: 46.25%, p=0.33. We divided these groups into two in relation to the mean thickness of interventricular septum and left ventricular mass and we did not find any difference: in students with hypertensive parents group septum > 7.82 mm: DD: 32%, DI: 24%, II: 20% x septum < 7.82 mm: DD: 8%, DI: 12%, II: 4%, p=0.7) in normotensive parents group septum septum > 7.38 mm: DD: 28%, DI: 12%, II: 12% x septum < 7.38 mm: DD: 16%, DI: 16%, II: 16%, p=0.59). The study of the left ventricular mass in hypertensive parents group mass > 131.52 g: DD: 20.69%, DI: 13.79%, II: 6.9% x mass < 131.52 g DD: 24.24%, DI: 17.24%, II: 17.24%, (p=0.72) in normotensive parents group mass > 117.11 g: DD: 30.43%, DI: 8.7%, II: 8.7% x mass < 117.11 g: DD: 13.04%, DI: 21.74%, II: 17.39%, (p=0.17)., Conclusion: We found differences between the thickness of the interventricular septum of normotensive students sibling of hypertensive parents and normotensive parents. On the other hand we didn't find any difference between the two groups concerning the ACE gene polymorphism as well as any relation of ACE gene and thickness of interventricular septum and interventricular left ventricular mass.

Objective: To assess the impact of smoking on in-hospital morbidity and mortality in patients who have experienced acute myocardial infarction and to assess the association between smoking and other cardiovascular risk factors and clinical data., Methods: A prospective cohort study analyzed 121 patients, including 54 smokers, 35 ex-smokers, and 32 nonsmokers., Results: Using the chi-square test (P<0.05), an association between smoking and the risk factors sex, age, and diabetes was documented. Among the morbidity and mortality variables, only acute pulmonary edema showed a statistically significant difference (OR=9.5; 95% CI), which was greater in the ex-smoker group than in the nonsmoker group., Conclusion: An association between smoking and some cardiovascular risk factors was observed, but no statistical difference in morbidity and mortality was observed in the groups studied, except for the variable acute pulmonary edema.

Objective: To analyze the immune response in peripheral blood of patients with infective endocarditis., Methods: We studied 10 patients with infective endocarditis, age range from 20 to 50 years-old, males and females, and 20 healthy subjects in the same age range. The diagnosis of the disease was based on the clinical picture, echocardiogram, and hemoculture based upon samples drawn and tested before the treatment started. The were no history of atopy or malnutrition, no autoimmune disease, and they were not using any immunosuppressant or antibiotic medication., Results: The patients with endocarditis had significantly higher T and B lymphocyte, CD4+ and CD8+ cell counts, IgM and IgG serum levels, and C4 component of the complement than the control group; no significant difference concerning serum IgA and neutrophil oxidative metabolism; a significant decrease in C3, chemotaxis, and monocyte phagocytosis;cryoglobulins were detected in 66.6% of patients and they were formed by IgG, IgM, IgA, C3, and C4., Conclusion: The patients with infective endocarditis were immunocompetent in most sectors of immune response and, at a certain moment, an autoimmune component may be present.

The patient arrived at the emergency unit with a history of acute myocardial infarction, for which she was treated. Without improvement in the pain, the patient developed heart failure and underwent a hemodynamic study, which showed normal coronary arteries and extensive ventricular impairment. During evolution, the clinical findings improved and herpes zoster appeared on the right shoulder. In a few months the clinical findings subsided, and the findings of the electrocardiogram, chest X-ray, and ventricular function were normal. The patient is currently asymptomatic.

The word iatrogeny derives from the Greek and concerns any disorder caused to the patient by inaproppriate medical practice. Unfortunately, the rise of an iatrogenic disease is related to the daily handline of cardiac disease. There are two types of iatrogeny: that caused by a medical action and omission iatrogeny, caused by the lack of a medical action. Iatrogeny occurs in all steps of medical practice starting with the patient-doctor relationship including diagnosis treatment and finally prevention of diseases. This article makes a brief commentary about iatrogenic heart disease and mentions some examples of it.

Purpose: To determine, by means of transesophageal echocardiography (TEE), the risk factors for intracavitary thrombosis or prethrombotic state and for embolic accidents in patients with atrial fibrillation., Methods: We studied 49 patients with chronic atrial fibrillation, submitted to clinical examination, EKG, chest X-ray, and TEE., Results: Thirty percent of patients had valvopathies, 29% myocardiopathies, intracavitary thrombus or prethrombotic state were found in 37%, 40% of them had embolic accidents. We did not find statistical significance between myocardiopathies and valvulopathies. The left atrial diameter did not preview embolic accidents. We have observed 6 patients without structural cardiopathies, three of them presented embolic events, and one prethrombotic state., Conclusion: Embolic phenomena are inherent to atrial fibrillation and independent of structural cardiopathies, with indication to prophylactic use of oral anticoagulants.

Purpose: To relate our experience with thrombolytic therapy in 8 patients with cardiac metal prosthesis complicated with thrombosis., Methods: Eight patients with clinical and echocardiographic diagnosis of cardiac valvar prosthesis thrombosis were treated., Results: The treatment efficacy was evaluated by clinical and echocardiographic improvement. The authors recognized improvement in all 8 patients. One case of hemorrhage was observed (coxo-femoral articulation). Late death were observed twice: 24 months after, sudden death and 30 months later by hemorrhagic stroke., Conclusion: The results indicated that thrombolytic therapy is best way to treat patients with cardiac valve thrombosis, instead of surgical treatment.

Purpose: To analyze the clinical, laboratory and pathological aspects of 20 cases of infectious endocarditis (IE) who died. The authors compared patients with diagnosis before death of IE and those with diagnosis was made after autopsy., Methods: Twenty patients who died with IE between April 1982 and November 1991 were studied. We looked for the clinical aspects (fever, cardiac murmurs, anemia, splenomegaly, embolic events and skin manifestation), laboratory aspects (hemocultures), echocardiographic and anatomopathologic features (valvar vegetations events and embolic accidents founded at autopsy). The sample was divided in two sub-groups: A--with clinical diagnosis of IE before and B--without diagnosis before death., Results: Group A--9 patients aged 8-58 years, 3 men, all them with cardiac murmurs, fever and anemia, 5 with splenomegaly. Hemocultures were done in 7 patients and positive in 1. Echocardiogram with valvar vegetation were found in 4 out of 5 patients (80% positive). At autopsy mitral valve vegetation were present in 7, aortic 3, tricuspid 3. One patient showed the exposure of three valves and two of 2 valves. Embolic events were found in 4. Group B--11 patients most of them older then 50 years (54.5%) (p < 0.05) 5 men, all them presented fever and anemia. Cardiac murmurs in 6 (54%) and none with splenomegaly. In one case hemoculture and echocardiogram, were done and were negative. Anatopathologic study showed compromise of mitral valve in 5, aortic 4, tricuspid 2, pulmonary 1. Two patients had 2 valves compromised. In one case a mural vegetation (right atrium) was found. Embolic events were present in 2 cases., Conclusion: In group B a significant number of patients (p < 0.05) were older than 50 years and presented his symptoms as an acute illness. We concluded that older patients with compromised general state and fever with or without embolic events IE must be remember.

Purpose: To characterize the occurrence of bacteremia during delivery and to verify the necessity of prophylaxis against infective endocarditis., Methods: The authors collected hemoculture of 100 women, 15,30 and 45 minutes after delivery. The data were collected from May 1992 until May 1993. The positive hemocultures were followed by antibiogram., Results: Seven hemocultures were positive: six for Staphylococcus, one for Candida sp, Penicilium sp, Clandosporum sp and Aspergillus sp that were found in association. Four patients had prematures amniorrhexis, longer than 6 hours before delivery (p < 0.05). Six patients had labor longer than 6 hours after admission (p < 0.05). The authors did not observe differences related to vaginal delivery with or without forceps or cesarean section. The samples were all sensible to cefalotin at the antibiogram., Conclusion: Labor and delivery is a high risk procedure for bacteremia and so for ineffective endocarditis in susceptible patients. The statistical analysis recognize as risk factors labor longer than 6 hours inside the hospital and premature amniorrhexis. We propose the use of intravenous cefalotin 1g 60 minutes before expulsion and repeated 6 and 12 hours later.

Six patients with Q-wave myocardial infarction in the ECG, two with coronary disease, two with metabolic alterations, one with acute myocarditis and another with ischemic stroke had an improvement of ECG tracings with disappearance of the Q wave. All had normal plasmatic levels of CPK and CKMB. It is believed that metabolic transitory disturbance of the myocardium increases the rest transmembrane potential turning the cell nonresponsive to electrical stimulus and without mechanical activity (inactive electrical zone, not a necrosis zone, which is an anatomo-pathological diagnosis).

Purpose: To evaluate if fever is an objective criterion in the assessment of response to antibiotic therapy and in the prognosis of patients undergoing treatment for infective endocarditis (IE)., Methods: Fifty-eight cases of IE, occurring from January 1980 to December 1989 have been analysed retrospectively in this study. Emphasis was given to the clinical history and body temperature changes during the first five weeks of treatment. Patients were divided in three groups according to the number of febrile peaks per week. Temperature was assessed weekly from each patient's highest peak weighed average., Results: At the first exam, 52 patients (86.2%) presented fever. All patients had at least one episode of fever during their hospitalization. There seemed to be a relation between the number of febrile peaks during a one week period and the mean body temperature, so that these patients who presented four or more peaks in a week had a higher mean body temperature than those with two or less febrile peaks during the week. After the second week of treatment, patients with two or less febrile peaks had a 93.1% survival and average of 35.5 days of hospitalization, whereas those with three or more febrile peaks had 63.6% survival and an average of 47.5 days of hospitalization., Conclusion: The results of this study show that the intensity of fever is linked to the number of febrile peaks per week, regardless to treatment duration. Should there be three or more febrile peaks weekly after the second week of treatment, therapeutic strategy should be reviewed, considering even surgical treatment. In many cases, the persistence of fever represented the clinical expression of complications which determined a higher mortality rate and a longer hospitalization.

Purpose: To analyze the clinical result of the mitral valve substitution for the porcine bioprostheses, the incidence of dysfunction caused by calcification and its importance related to the durability of bioprostheses and also the patients' survival., Methods: Twenty-nine children of about seven to sixteen years old were operated on from November 1977 to August 1982 and all of them received porcine bioprostheses of low profile., Results: There were three (10.34%) hospital deaths and nine other late mortalities. The follow-up period varied from 4 to 128 months with average of 58.17 months and with the loss of nine patients. An actuarial survival rate of 46.08% has been observed at 11 years after surgery. Calcification of 21 bioprostheses occurred in 14 out of 17 follow-up patients; 47.6% of them happened until the third year of pos-operative and 85.7% until the fifth year. Eleven patients were reoperated on with 9.09% of hospital mortality. There were no cases of thromboembolism., Conclusion: Porcine bioprostheses works well with an evident clinical improvement of patients, with no thromboembolic accidents. However, its durability has been affected by the high incidence of calcification, which is responsible for an increase in late morbidity and mortality. Mitral valve disease treatment in children must be conservative, in an attempt to solve the problem with the different available plastic technics and leave the valve substitution to be a last option. In that case, the preference is given to the homologous bioprostheses.

A 16-year-old patient was evaluated for congestive heart failure and pulmonary hypertension, suggesting mitral valve stenosis. A left atrial membrane with a 4 mm orifice was seen in echocardiography and angiography, and a diagnosis of cor triatriatum was made. The membrane was successfully removed by surgery.

Purpose: To analyse clinical aspects, diagnosis and treatment of infective endocarditis (IE), in order to guide medical procedures and indicate the surgical treatment., Patients and Methods: 83 patients were submitted to clinical treatment of IE between January 1980 and December 1987; clinical aspects, laboratory and pathologic-anatomy findings, the site of infection and the entrance of micro-organism were studied., Results: 37 (44.6%) patients were males. Fever was present in 75 (90.4%) cases, cardiac murmur in 76 (91.5%), splenomegaly in 28 (33.7%) and heart failure (III and IV) in 32 (39.8%) patients. Blood culture was positive in 55.5%; staphylococcus 50% of blood cultures; anemia was present in 66 cases (79.5%) and high serum mucoprotein in 58 (92%); echocardiography was 85.7% positive. The mortality was 39.76%; congestive heart failure was the main cause of death; 78.1% of these ones occurred in the first 15 days of antibiotic-therapy. The mitral valve was the one most impaired and the most frequent entrance of micro-organisms in oropharynx., Conclusion: Congestive heart failure, sepsis and systemic embolisms were the main complications that led the patient to death in course of IE, usually before 15 days of antibiotic-therapy. In these cases, we may hypothesize that prompt surgical treatment could have diminished the mortality of IE.

Purpose: To describe the clinic evolution during admission of a group of patients over age 70, who experienced acute myocardial infarction (AMI)., Patients and Methods: Fifty-one patients, over age 70, with confirmed diagnosis of AMI, were studied. Thirty-six (70.6%) males and 15 (29.4%) females., Results: Near half (49.1%) were admitted before four hours of beginning of pain. The complications were divided into mechanical, electrical, persistent ischemia and others, not related with coronary heart disease. In the coronary care unit (CCU), 84.3% of patients complicated, and 50.0% at the ward. AMI of the anterior wall complicated more frequently with tachiarrhythmia, and inferior wall with atrioventricular block. There were not statistical difference in the incidence of mechanical complications, according to the affected wall. There was statistical significance (p less than 0.05) comparing mortality and the time elapsed between beginning of pain and hospital admission, but not comparing mortality and the wall involved. The patients with congestive heart failure and cardiogenic shock died in 93.3%. Mortality at the CCU was mostly related to complications of AMI, but mortality at ward to other complications not directly related with coronary heart disease., Conclusion: Myocardial infarction over age 70 implies high mortality and morbidity, with significantly, better prognosis with earlier arrival of the patient to the hospital.

Anticoagulation is the chief problem during pregnancy of women with mechanical prosthetic valves. Many studies have investigated a nonthrombogenic valve. Since 1978 we have used a biological porcine prosthetic valves in 16 pregnancies, 11 patients with regular clinical electrocardiographic, echocardiographic and chest roentgenographic follow-up. The patients' ages were 19 to 32 years during pregnancy. Nine had mitral, one aortic and one mitro-aortic prosthesis. Two patients dropped out during the study so we completed it with 14 pregnancies. Six patients coursed with grade I heart failure (HYHA), five grade II and three grade IV. All of them were treated clinically. Four valves had dysfunction and calcification during pregnancy and two before pregnancy. The pregnancies resulted in three abortions, seven normal deliveries and four caesarean section with obstetric indication. Fetal distress was not observed during or after delivery. The physiopathology of valve dysfunction during pregnancy was discussed and it was concluded that the biologic porcine prosthetic valve allows hemodynamic stabilization. If dysfunction appears it may be clinically controlled without need of anticoagulation, risk of calcification nor dysfunction during pregnancy. The biologic valves are best indicated for women who wish to become pregnant after valve substitution.