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The prognostic value of atrial thrombi (AT) among elective patients with atrial fibrillation (AF) referred for a rhythm control strategy is unclear. In this study, clinical variables were correlated with the presence of AT and long term survival among 205 patients submitted to transesophageal echocardiography before elective AF cardioversion or ablation. Atrial thrombi were present in 7.8% of cases and were significantly associated with reduced survival. Obesity was the only independent clinical predictor of AT [OR 4.27 (1.15–15.79), p = 0.03]. In patients with AF, AT appear to be associated with adverse outcomes, possibly indicating more advanced atrial cardiomyopathy.

SUMMARY OBJECTIVE: Hydroxychloroquine and Ivermectin are advocated as potential treatments for coronavirus disease 2019 (COVID-19) despite the lack of supportive clinical evidence. In this study, outcomes associated with Hydroxychloroquine and/or Ivermectin were determined in a series of patients with confirmed COVID-19 from a single institution in Brazil. METHODS: Consecutive patients admitted between March and July 2020 were retrospectively analyzed and divided into four treatment categories: no treatment (Group 0), Ivermectin only (Group I), Hydroxychloroquine only (Group II), and Hydroxychloroquine and Ivermectin (Group III). Intensive care unit admission, mechanical ventilation, and death were compared between the Groups. RESULTS: A total of 230 patients were included, with the following treatment distribution: 35.2% (0), 9.1% (I), 48.3% (II), and 7.4% (III). Groups I, II, and III had the higher rates of Intensive care unit admission, mechanical ventilation, or death (0: 23.5% versus I: 38.1% versus II: 37.8% versus III: 70.6%, p=0.002), and the greatest mortality was found in Group III (0 versus III: 13.6% versus 35.3%, p=0.03). In the multivariate analysis, Hydroxychloroquine remained significantly associated with death (OR 3.3, 95%CI 1.1–9.6, p=0.03). CONCLUSION: In a series of consecutive hospitalized patients with COVID-19, Ivermectin was not associated with improved outcomes and Hydroxychloroquine may have resulted in a harmful effect.

No momento da elaboracao deste editorial, uma nova realidade esta em construcao na medicina mundial. A pandemia associada ao coronavirus da sindrome respiratoria aguda grave 2 (SARS-CoV-2) continua a avancar, impondo um onus sem precedentes em diversos sistemas de saude pelo mundo. No Brasil, a escassez de recursos e o risco de contaminacao sao preocupacoes diarias de gestores e profissionais de saude, colocando o uso racional de exames diagnosticos e intervencoes terapeuticas como medidas prioritarias em todas as especialidades medicas [...]

Coronavirus Disease-2019 (COVID-19) has been associated with potentially life threatening cardiovascular complications, including fulminant myocarditis and cardiac tamponade. Optimal management strategies are still unclear, including the role of immunomodulatory therapies and extracorporeal membrane oxygenation (ECMO) in the context of cardiogenic shock. We report a case of a middle-aged female with COVID-19 who developed respiratory distress and hemodynamic deterioration with elevated troponin levels on the seventh day of symptoms. Echocardiography demonstrated pericardial effusion with diastolic restriction of the right ventricle. Cardiac arrest developed during pericardiocentesis, resulting in emergency thoracotomy and pericardial drainage. Venoarterial ECMO was subsequently initiated due to refractory cardiogenic shock. Tocilizumab, immunoglobulin, methylprednisolone and convalescent plasma were added to supportive care, with progressive recovery of cardiac function and successful weaning from mechanical ventilation. This case highlights the potential role of ECMO, convalescent plasma and immunomodulatory therapies in the management of cardiogenic shock associated with COVID-19 myopericarditis., Highlights • Fulminant myopericarditis in patients with COVID-19 is a rare complication associated with poor outcomes. • Optimal management strategies are unclear, particularly regarding immunomodulatory therapies and hemodynamic support. • In selected cases, venoarterial extracorporeal membrane oxygenation may provide the foundation for both spontaneous recovery and the administration of potentially effective directed therapies, such as convalescent plasma.

Introdução: As infecções de dispositivos cardíacos podem acometer a loja da unidade geradora, o sistema endovascular ou ambos. Embora a retirada de todo o sistema é fundamental para um sucesso terapêutico, o procedimento pode cursar com um alto risco de complicações, quando então a antibioticoterapia supressora deve ser considerada. Caso: Homem, 90 anos, portador de demência, diabetes, fibrilação atrial e insuficiência cardíaca isquêmica, submetido a implante de cardiodesfibrilador há 9 anos, sem história de choques. Procurou atendimento após extrusão da unidade geradora, com sinais inflamatórios locais. Indicada a retirada de todo o sistema, mas por dificuldades técnicas e fragilidade clínica subjacente, foi removida apenas a unidade geradora, com lavagem extensa do local, coleta de material para cultura e proposta de antibioticoterapia supressora contínua. Três dias depois houve crescimento de Proteus mirabilis, além de queda do estado geral, sem febre. Iniciado ceftriaxone e coletadas hemoculturas que revelaram a mesma bactéria. Após 6 semanas de antibiótico venoso houve resposta adequada e negativação das culturas, sendo mantido cefuroxime oral para uso domiciliar. Após 1 mês, houve recidiva dos sintomas com reinternação e nova identificação de P. mirabilis em múltiplas hemoculturas. Submetido a FDG-PET/TC que confirmou atividade inflamatória no cabo sepultado (Figura – setas). Além do novo curso de ceftriaxone, foi indicada a retirada do cabo sepultado, apesar dos riscos inerentes ao procedimento. O mesmo foi realizado sem intercorrências, e o paciente apresentou evolução satisfatória após completar o período de antibiótico. Conclusão: Nas infecções de dispositivos cardíacos, a antibioticoterapia isolada sem a retirada do sistema deve ser reservada para situações restritas, por estar associada a maiores taxas de falha terapêutica e morte. Mesmo em pacientes frágeis e com múltiplas comorbidades, a remoção do dispositivo deve ser almejada para a resolução do quadro infeccioso, independente da bactéria envolvida.

Promising therapeutic interventions were initially focused on three main components: plasma tissue factor (TF), thrombin and protein C The immune system and coagulation pathways interact through a complex array of cross-signaling, which could potentially result in immunothrombosis Despite similar findings from observational studies, these results require confirmation from randomized trials, since reduced mortality rates have been less clear in the absence of disseminated intravascular coagulation (DIC) (4) [ ]response is not only driven by pro-inflammatory cytokines, but also by other detrimental mediators including activated thrombin, heat shock proteins, high-mobility group proteins and the complement system (10) According to observational data, markedly elevated D-dimer levels and the sepsis-induced coagulopathy score are encouraging criteria to guide heparin therapy (15)

As arboviroses constituem um importante problema de saude publica especialmente em paises de regioes tropical e subtropical, como o Brasil. Nesses locais, predominam os virus das familias Flaviviridae, responsaveis pela Dengue, Zika e Febre Amarela (FA), e Togaviridae, causador da Chikungunya. Nos anos mais recentes, o numero de casos aumentou devido a diversos fatores, dentre os quais destacam-se as modificacoes ocorridas no meio ambiente, tais como desmatamento e mudancas climaticas, ocupacao desordenada das cidades com baixas condicoes higienico-sanitarias, alem do [...]

Objective Complications after percutaneous coronary interventions (PCI) are associated with significant morbidity and mortality, although institutional discrepancies can occur when public and private hospitals coexist within the healthcare system. The aim of this study was to compare the in-hospital complication rates and mortality in addition to long-term survival following elective PCI in two reference public and private cardiology hospitals in Rio de Janeiro, Brazil. Methods From January 1st 2013 to December 31st 2014, a total of 440 procedures were identified in both hospitals (public: 328 vs. private: 112) and retrospectively analyzed by chart review. Results There were no significant differences between the two hospitals regarding the total number of procedures with at least one complication (public: 23.8 vs. private: 17.9%, p = 0.2) or in-hospital mortality rates (public: 0.6% vs. private: 0%, p = 0.5). Post-procedural renal insufficiency was more frequent in the private hospital, whereas coronary-related complications were more prevalent in the public hospital. After a mean follow up of 30.3 months (SD ± 9.2), the survival rate was also similar. Conclusions Clinical complications after elective PCI are common both in public and private hospitals. Meticulous pre-procedural clinical assessment and patient selection as well as adherence to guideline-based practices could minimize the risk of PCI-related adverse events.

Troponin elevation after coronary angioplasty is a prognostic marker associated with significant morbidity and mortality, although its prevalence varies according to clinical and procedural characteristics. We analyzed the frequency of post-procedural enzyme elevation among 112 elective interventions between 2013 and 2014 in a private hospital in Brazil. Troponin increase was observed in 62.5% of the procedures, and was related to age, female sex, low pre-procedural hemoglobin, prior angiotensin converting enzyme inhibitor or angiotensin receptor blocker use and multivessel angioplasty. PCI is not a risk free procedure and these results underscore the importance of a careful clinical assessment before its utilization.

Kounis syndrome (KS) consists of an association between hypersensitivity reactions triggered by various environmental and pharmacological factors and acute coronary syndromes. Blood supply may be compromised by either vasospasm (type I), native plaque destabilization (type II) or stent thrombosis (type III). Although the prognosis is generally favorable, treatment should include aggressive anti-thrombotic and anti-allergic therapies. A case compatible with type III KS, manifested as a macular rash followed by two episodes of stent thrombosis after primary angioplasty (PCI) of the right coronary artery is presented, and complemented by a review on the topic.

In the last 30 years, the number of cardiovascular diagnostic and therapeutic invasive procedures has progressively increased in many countries around the world. According to the American Heart Association, almost 1,03 million coronary angiographies, 955 thousand percutaneous coronary interventions (PCI) and 397 thousand heart surgeries were performed in the United States (US) alone in the year 2010 [1]. Although since the year 2006 the number of angioplasties seems to be stable in the US, in other countries such as Brazil the procedure count continues to rise [2]. This trend underscores the importance of concurrently analyzing the behavior of intervention related complications, particularly because PCI associated in hospital mortality remains at around 1.31%, notwithstanding the total complication rate which is even more significant. [1] In this context, post-procedural enzyme elevation is a frequently overlooked complication that has an important independent prognostic value.

Background/purpose Although troponin I (TnI) elevation and myocardial injury after percutaneous coronary interventions (PCI) are frequent findings, their prognoses remain controversial. We aimed to determine the association between any or ≥5 times TnI elevation after elective PCI and subsequent one year mortality rates and long term survival. Methods Consecutive patients admitted for elective PCI between January 2013 and December 2014 were retrospectively analyzed by chart review in two hospitals in Rio de Janeiro. Only patients with post-PCI TnI measurements were included. Clinical, angiographic and procedural characteristics were correlated with any or ≥5 times TnI elevation, as well as 1 year mortality and long term survival. Results A total of 407 interventions were included in the analysis. Post-PCI TnI elevation was observed in 74.7% of cases and ≥5 times elevations occurred in 41.3%. Age ≥ 70 years, female gender and multistenting were predictors of enzyme elevation. Prior aspirin or hypoglycemic therapy were protective factors. One year mortality was significantly associated with any TnI elevation (6.6% vs 1.05%, p = 0.035) and values ≥5 times above the normal limit predicted the highest mortality rates (8.13% vs 3.14%, p = 0.031). Survival of patients with single vessel disease was also adversely affected by ≥5 times enzyme elevation (log-rank: p = 0.039). Conclusion Troponin I elevation after elective PCI is frequent and associated with progressively higher mortality rates at 1 year. A cutoff value ≥5 times the 99th percentile, currently defined as myocardial injury, appears to be an even more significant predictor of this outcome, even in lower risk subgroups.

Ndrepepa et al. [(1)][1] proposed to study whether the prognostic value of post-procedural high-sensitivity troponin T (hs-TnT) elevation after elective percutaneous coronary interventions (PCI) was related to baseline hs-TnT levels. Their results suggested that only the pre-procedural hs-TnT was