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Introduction: Conduction disturbances requiring permanent pacemaker (PM) implantation occur in 3–12% of patients after aortic valve replacement (AVR). Our aim was to assess long-term PM dependency and its predictors in these patients. Methods: We conducted a retrospective study of all consecutive patients undergoing permanent PM implantation after AVR between January 2004 and December 2010. Absence of sinus rhythm or atrial fibrillation with appropriate ventricular response at a pacing rate of 30 bpm for 10 s was defined as pacemaker dependency. Results: Ninety-one patients underwent permanent PM implantation and during follow-up (1026.6±732.0 days) 64% of them did not recover rhythm. Age, conduction disorders on the preoperative ECG, negative chronotropic medication before surgery, cardiopulmonary bypass and aortic cross-clamp times did not influence rhythm recovery. In multivariate analysis, valvular disease etiology related to endocarditis, prosthetic dysfunction and bicuspid valve were associated with long-term PM dependency (OR 5.05; CI: 1.43–17.75). Conclusions: The majority of patients undergoing permanent PM implantation after AVR did not recover from conduction disorders during follow-up. The etiology of valvular disease was an independent predictor of late PM dependence. Resumo: Introdução: Distúrbios da condução que requerem implantação de pacemaker (PM) permanente após a substituição da valva aórtica (SVA) ocorrem em 3-12% dos doentes. O objetivo do estudo foi avaliar a dependência do PM a longo prazo e os seus preditores neste grupo de doentes. Métodos: Foi realizado um estudo retrospetivo de todos os doentes submetidos a implantação de PM definitivo após SVA entre janeiro de 2004 e dezembro de 2010. A ausência de ritmo sinusal ou fibrilação auricular com frequência ventricular adequada sob PM a 30 batimentos/min durante um curto período de 10 segundos foi definido como dependência de PM. Resultados: Noventa e um pacientes foram submetidos a implantação de PM permanente e durante o período de follow-up (1026,6 ± 732,0 dias) 64% deles não recuperaram o ritmo. A idade, os distúrbios de condução no ECG pré-operatório, uso de medicação cronotrópica negativa antes da cirurgia, o tempo de circulação extracorporal e o tempo de clampagem da aorta não influenciaram a recuperação do ritmo. Na análise multivariada, a etiologia da doença valvular (endocardite, disfunção de prótese ou válvula bicúspide) esteve associada à dependência de PM a longo prazo (OR 5,05; IC: 1,43-17,75). Conclusões: A maioria dos doentes submetidos a implantação de PM permanente após SVA não recupera dos distúrbios de condução durante o follow-up. A etiologia da doença valvular foi um preditor independente da dependência de PM a longo prazo. Keywords: Aortic valve replacement, Permanent pacemaker, Conduction disorder, Palavras-chave: Substituição valvular aórtica, Pacemaker permanente, Distúrbios da condução

HIGHLIGHTS: Anti-diabetic drugs used at admission in myocardial infarction patients were studied. 195 admissions corresponding to different patients were under analysis. No difference in survival was seen in patients using or not using DPP-4 inhibitors. INTRODUCTION: Diabetes mellitus is frequently associated to cardiovascular disease. We aimed at studying the relations between anti-diabetic drugs in use at admission by diabetic patients with acute myocardial infarction and survival after a period of at least 36 and up to 52 months after admission. METHODS: Retrospective study based on electronic records. Data from a total number of 195 admissions corresponding to different patients were under analysis. RESULTS: Kaplan–Meier analysis, as well as Cox analysis, failed to show a difference in survival associated to the use of DPP-4 inhibitors (n = 35 patients). A non-significant trend toward increased survival was seen with metformin (n = 92 patients), and in the opposite direction with both insulin (n = 51 patients) and sulfonylureas (n = 51 patients). CONCLUSIONS: The use of DPP-4 inhibitors at admission, in patients with Diabetes mellitus admitted for acute myocardial infarction, was not associated to a different survival after no less than 36 months and up to 52 months after admission.

Objectives Prompt diagnosis of acute coronary syndrome (ACS) remains a challenge, with presenting symptoms affecting the diagnosis algorithm and, consequently, management and outcomes. This study aimed to identify sex differences in presenting symptoms of ACS. Design Data were collected within a prospective cohort study (EPIHeart). Setting Patients with confirmed diagnosis of type 1 (primary spontaneous) ACS who were consecutively admitted to the Cardiology Department of two tertiary hospitals in Portugal between August 2013 and December 2014. Participants Presenting symptoms of 873 patients (227 women) were obtained through a face-to-face interview. Outcome measures: Typical pain was defined according to the definition of cardiology societies. Clusters of symptoms other than pain were identified by latent class analysis. Logistic regression was used to quantify differences in presentation of ACS symptoms by sex. Results Chest pain was reported by 82% of patients, with no differences in frequency or location between sexes. Women were more likely to feel pain with an intensity higher than 8/10 and this association was stronger for patients aged under 65 years (interaction P=0.028). Referred pain was also more likely in women, particularly pain referred to typical and atypical locations simultaneously. The multiple symptoms cluster, which was characterised by a high probability of presenting with all symptoms, was almost fourfold more prevalent in women (3.92, 95% CI 2.21 to 6.98). Presentation with this cluster was associated with a higher 30-day mortality rate adjusted for the GRACE V.2.0 risk score (4.9% vs 0.9% for the two other clusters, P

The authors present a case report of successful treatment of pulmonary artery perforation by endovascular stent graft implantation. Resumo: Os autores descrevem um caso de sucesso do tratamento da rotura da artéria pulmonar com a implantação de um stent endovascular. Keywords: Swan-Ganz catheterization, Hemoptysis, Palavras-chave: Cateterização Swan-Ganz, Hemoptises

Heart transplantation is the treatment of choice in severe heart failure despite maximal medical therapy, which has no other surgical alternatives and exhibiting no contraindications. The aim of this study was to analyze the prevalence of late complications and survival of patients undergoing cardiac transplantation at our Hospital Center.We evaluated 78 patients (mean age 43 ± 15 years) transplanted at our center between February 1987 and December 2011, with a mean follow-up of 6 years.Of late complications after heart transplantation, allograft vascular disease was detected in 10 patients ( 12.8%), was the one with impact on mortality, being responsible for four deaths. The most frequent complication was hypertension in 54.6% of cases, followed by dyslipidemia (47.4%), renal failure (47.4%), diabetes mellitus (21.8%) and neoplasms (11.5%). Atrial tachyarrhythmias was observed in eight patients (10.3%). The overall survival of our population at first and tenth year after heart transplantation was 81% and 69%, respectively. The mean survival of patients was 15.6 years (Cl 95%: [12,6-18,7]).. There were 23 deaths (29.5%), nine (11.5%) of which occurred within the first 30 days after transplantation.Cardiac transplantation remains a valid therapeutic option for patients with end-stage heart disease. Our center had a heart transplant survival rate and incidence of late complications similar to those seen in international registries.

Hypoxia due to an Atrial Septal Defect (ASD), without Eisenmenger physiology, is reported rarely and may be underestimated due to difficulty in its diagnosis. We report the case of a 67-year-old woman with chronic cyanosis and hypoxia, in whom a large ASD was diagnosed by cardiac catheterization after an extensive workup to clarify the aetiology of the hypoxia. The right-to-left shunt at the ASD occurred probably due to a well-developed Eustachian valve, partly directing the right atrial flow into the left atrium, in the absence of pulmonary arterial hypertension.

Background: Alkaline phosphatase (ALP) removes phosphate groups from many types of molecules. The aim of the present research was to study the relation between plasma ALP and survival in diabetic patients with myocardial infarction. Methods: Retrospective study: from 954 admissions (15 months period) in a coronary care unit, we selected 200 admissions corresponding to 195 patients with myocardial infarction and diabetes mellitus. Survival after no less than 48 months, and up to 61 months, after the myocardial infarction episode, was under study, in association with ALP levels. Results: A relatively weak but significant correlation was seen between the peak plasma cardiac troponin I and ALP levels (r: 0.21, significance level: 0.003). Using the median value for ALP as cut-off (74 IU/L), plasma creatinine was significantly higher in patients with higher values for ALP. Patients with elevated ALP had decreased survival in Kaplan-Meier analysis (significance level in log-rank test: 0.032). This finding was noted for male patients (significance level in log-rank test: 0.035), but not for female patients (significance level in log-rank test: 0.497). Conclusions: Elevated ALP acts as a prognostic indicator of decreased survival in diabetic patients with acute myocardial infarction, possibly in association to decreased renal function. This finding is limited to male patients, pointing to a possible different role for phosphatase activity in cardiovascular disease in male and female diabetic patients.