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Introduction and Objectives: Left ventricular global longitudinal strain (LVGLS) is an indicator of myocardial function in patients with heart failure with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). Nevertheless, it is not clear whether LVGLS correlates with filling pressures and cardiac output (CO) in an ambulatory setting. We aimed to assess whether LVGLS is associated with invasive pulmonary artery pressures (PAP) and CO in outpatients using the invasive remote monitoring CardioMEMS™ system., Methods: This single-center, prospective observational study included patients with HFrEF undergoing remote monitoring using the CardioMEMS™ system, between January 2020 and December 2022. Repeated transthoracic echocardiography (TTE) studies were performed in each patient and invasive hemodynamic data were obtained during the TTE studies using the CardioMEMS™ system. Univariate and multivariate models were used to assess the potential association between LVGLS and invasive PAP and CO., Results: Twelve patients were included and 46 TTE studies were analyzed. LVGLS was correlated with diastolic (d) PAP (r=0.403, p=0.041) and CO (r=-0.426, p=0.039) in the univariate analysis. In multivariate models, LVGLS was an independent predictor of dPAP and CO, but not mean PAP or systolic PAP. The variation of LVGLS between TTE studies was correlated with the variation of dPAP during follow-up (r=0.60, p=0.017)., Conclusions: In a cohort of HFrEF patients under invasive hemodynamic remote monitoring, LVGLS was independently associated with invasive filling pressures and CO, in an outpatient setting. These findings reinforce the value of LVGLS for the management of outpatients with HFrEF., (Copyright © 2024 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction and Objectives: Patients with hypertrophic obstructive cardiomyopathy (HOCM) that remain symptomatic despite optimized medical therapy often undergo alcohol septal ablation (ASA). One of the most frequent complications is complete heart block (CHB), requiring a permanent pacemaker (PPM) in variable rates of up to 20% of patients. The long-term impact of PPM implantation in these patients remains unclear. This study aimed to evaluate the long-term clinical outcomes in patients who implant PPM after ASA., Methods: Patients who underwent ASA at a tertiary center were consecutively and prospectively enrolled. Patients with previous PPM or implantable cardio-defibrillator were excluded from this analysis. Patients with and without PPM implantation after ASA were compared based on their baseline characteristics, procedure data and three-year primary endpoint of composite of all-cause mortality and hospitalization and secondary endpoint of composite of all-cause mortality and cardiac cause hospitalization., Results: Between 2009 and 2019, 109 patients underwent ASA, 97 of whom were included in this analysis (68% female, mean age 65.2 years old). 16 patients (16.5%) required PPM implantation for CHB. In these patients, no vascular access, pacemaker pocket or pulmonary parenchyma complications were noted. The baseline characteristics of comorbidities, symptoms, echocardiographic and electrocardiographic findings were identical in the two groups, with higher mean age (70.6±10.0 years vs. 64.1±11.9 years) and lower beta-blocker therapy rate (56% vs. 84%) in the PPM group. Procedure-related data showed higher creatine kinase (CK) peaks in the PPM group (1692 U/L vs. 1243 U/L), with no significant difference in the alcohol dose. At three years after ASA procedure, there were no differences in the primary and secondary endpoints between the two groups., Conclusions: Permanent pacemaker after ASA induced CHB do not affect long term prognosis in hypertrophic obstructive cardiomyopathy patients., (Copyright © 2023. Publicado por Elsevier España, S.L.U.)

Introduction and Objectives: Transesophageal echocardiography (TEE) has been the standard method for guiding left atrial appendage occlusion (LAAO) procedures. Recently, intracardiac echocardiography (ICE) has emerged as an alternative to TEE due to several advantages, particularly the avoidance of general anesthesia. This analysis aims to assess the safety, feasibility and efficacy of ICE-guided LAAO procedures., Methods: We performed a retrospective analysis of ICE-guided LAAO procedures, including a comparison of embolic and bleeding events with the predicted standard scores and a comparison with TEE-guided procedures., Results: A total of 88 patients underwent echocardiography-guided percutaneous LAAO (43 patients with TEE and 45 with ICE), mean age 74.9 years, 68.2% male. In the ICE-guided population, the technical success rate was 93% and the major complication rate was 8.8%. During follow-up, yearly stroke and major bleeding rates were 1.4% and 8.4%, respectively, compared to the 4.0% and 8.7% predicted by the CHA 2 DS 2 -VASc and HAS-BLED scores. In the TEE versus ICE analysis (similar baseline characteristics), no statistically significant differences were seen regarding technical success (95.3% vs. 93.3%), procedure-related complications (14.0% vs. 8.9%), device thrombus (2.3% vs. 0%), residual minor peridevice leaks (14.0% vs. 24.4%), one-year all-cause mortality (9.3% vs. 4.4%), stroke (9.3% vs. 2.2%) or major bleeding events (9.3% vs. 11.1%)., Conclusion: ICE-guided LAAO was a safe and effective therapeutic strategy in a high embolic and bleeding risk population, compared to the event rates predicted by the CHA 2 DS 2 -VASc and HAS-BLED scores. The ICE-guided procedure compared well to TEE-guided procedures regarding procedure feasibility, safety, and efficacy., (Copyright © 2023 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: The coronary sinus Reducer (CSR) device has emerged as a complementary therapy in patients with severe angina refractory to optimal medical therapy and not amenable to revascularization. Our aim was to assess the safety and efficacy of the CSR in a real-world setting., Methods: Twenty-six patients with refractory angina (RA) and evidence of myocardial ischemia attributable to the left coronary artery considered unsuitable for revascularization were treated with the CSR at two centers between May 2017 and July 2019. Safety endpoints were procedural success and complications. Efficacy endpoints, assessed at six-month follow-up, were reduction in CCS class, improvement in quality of life (QoL) assessed using the short version of the Seattle Angina Questionnaire (SAQ-7), and reduction in antianginal therapy., Results: Twenty-three patients had end-stage coronary artery disease without revascularization targets and three had microvascular disease without epicardial stenosis. Procedural success was achieved in 23 patients, with two device/procedure-related complications and one anatomically-related failure to deliver the device. A total of 24 patients had the device implanted and entered the efficacy analysis. Eighteen patients (75.0%) had a reduction of at least one CCS class, 41.7% had a reduction of at least two classes, and 16.7% became asymptomatic, with a mean reduction in CCS class of 1.3±0.2 (p=0.001) at six-month follow-up. All SAQ-7 domains improved, notably physical limitation (p=0.001), angina frequency (p=0.005) and QoL (p=0.006). There was a mean reduction in anti-ischemic drugs from 3.4±1.1 to 2.9±1.2 (p=0.010)., Conclusion: In this real-world, multicenter experience, implantation of the CSR was associated with improvement in angina and QoL in patients with RA., (Copyright © 2023 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: Coronary vasomotion disorders (CVDs), including microvascular angina (MVA) and vasospastic angina (VSA), account for significant morbidity among patients with non-obstructive coronary artery disease (NOCAD). However, protocols for CVD assessment in clinical practice are seldom standardized and may be difficult to implement., Purpose: To assess the safety and feasibility of a comprehensive coronary function test (CFT) protocol for assessment of CVD and the prevalence of different phenotypes of CVD in patients with angina and NOCAD (ANOCA)., Methods: Patients with persistent angina referred for invasive coronary angiogram and found to have NOCAD were prospectively recruited and underwent a CFT. Functional parameters (fractional flow reserve, coronary flow reserve and index of myocardial resistance) and coronary vasoreactivity were assessed in all patients., Results: Of the 20 patients included, the mean age was 63±13 years and 50% were females. Most patients had persistent typical angina and evidence of ischemia in noninvasive tests (75%). The CFT was successfully performed in all subjects without serious complications. Isolated MVA was found in 25%, isolated VSA in 40%, both MVA and VSA in 10% and noncardiac chest pain in 25% of patients. Antianginal therapy was modified after the results of CFT in 70% of patients., Conclusion: A coronary function test was feasible and safe in a cohort of patients with ANOCA. CVD were prevalent in this selected group of patients, and some presented mixed CVD phenotypes. CFT may provide a definitive diagnosis in patients with persistent angina and prompt the stratification of pharmacological therapy., (Copyright © 2023 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: Some studies suggest that patients with low flow low gradient (LF-LG) aortic stenosis (AS) may achieve worse results after undergoing transcatheter aortic valve implantation (TAVI)., Purpose: To compare outcomes between LF-LG AS and high gradient (HG) AS patients submitted to TAVI., Methods: Inclusion of 480 consecutive patients who underwent TAVI between 2008 and 2020 at a single tertiary center. Patients were divided into high gradient AS and LF-LG AS; and baseline characteristics and outcomes after the procedure were collected and compared between groups., Results: Patients with LF-LG AS had worse baseline characteristics, with higher Society of Thoracic Surgeons score (p=0.008), New Euroscore II (p<0.0001), and NT pro-natriuretic peptide B (p=0.001), more frequent left ventricular ejection fraction (LVEF) <40% (p<0.0001), coronary artery disease (p<0.0001), including previous myocardial infarction (p=0.002) and coronary artery bypass graft (p<0.0001), poor vascular accesses (p=0.026) and periprocedural angioplasty (p=0.038). In a multivariate analysis, adjusted to differences in baseline characteristics, LF-LG AS was associated with worse functional class at one year (p=0.023) and in the long-term (p=0.004) and with heart failure hospitalizations at one year and in the long-term (p=0.001 and p<0.0001). In a sub-analysis including only patients with LF-LG AS, those with LVEF <40% had the worst outcomes, with more global (p=0.035) and cardiovascular (p=0.038) mortality., Conclusion: Patients with LF-LG AS have worse short and long-term outcomes, even when adjusted for baseline characteristic differences. The sub-group of patients with LVEF <40% have the most ominous global outcomes., (Copyright © 2022 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: Decompensated heart failure (HF) is associated with poor short- and long-term prognosis. Remote invasive monitoring of pulmonary artery pressures (PAP) enables early detection of HF decompensation before symptoms occur and may improve clinical outcomes. We aimed to describe our initial experience with the use of the CardioMEMS™ remote monitoring system in patients with HF, including its safety and effectiveness., Methods and Results: Five patients with HF in New York Heart Association class III and at least one hospitalization due to decompensated HF in last 12 months, who underwent invasive remote monitoring of PAP, were included in this prospective registry. The median age was 66.0 years (interquartile range [IQR] 50.5-77.5 years), 80.0% were men and all had HF with reduced ejection fraction. The pulmonary artery (PA) sensor was placed in a left PA branch in all patients and no major procedural complications occurred. In median follow-up of 40 days (IQR 40-61 days), a total of 271 pressure readings were transmitted, patient compliance was 100% and freedom from sensor failure 98.1%. In three patients, PAP remained within the goal during follow-up. Two patients presented an increase in PAP to values above the targets, despite the absence of symptom worsening. These required dietary and diuretic dose adjustment, without the need for outpatient clinic visits, which reduced PAP. No hospitalizations for HF or deaths occurred during follow-up., Conclusion: Hemodynamic-guided HF monitoring was safe and effective and may be a useful adjunctive tool to the standard-of-care management in selected HF patients, particularly in the context of the COVID-19 pandemic, where a reduction in the number of health care visits may be desirable., (© 2021 Sociedade Portuguesa de Cardiologia. Published by Elsevier España, S.L.U.)

Acromegaly is a rare disease, mostly caused by a growth hormone (GH)-secreting benign pituitary tumor, with an increased production of GH and insulin-like growth factor 1 (IGF-1). Cardiovascular complications are common and are associated with cardiomyocyte apoptosis and concentric cardiac hypertrophy. Suppression of GH and IGF-1 appears to improve cardiac function only in the short term, with little or no decrease in left ventricular mass or improvement in cardiac function after prolonged treatment. Alcohol septal ablation (ASA) has emerged as a minimally invasive alternative to septal myectomy, with significant improvement in symptoms, gradients and left ventricular remodeling. In this report, we describe the case of a 73-year-old woman with acromegaly due to a pituitary adenoma diagnosed and treated surgically at the age of 38 but with recurrence and reoperation at the age of 50. She was referred to our cardiology department due to a three-month history of progressively worsening exercise-induced dyspnea and orthopnea under optimal medical therapy. Echocardiography and magnetic resonance imaging revealed severe basal hypertrophy of the interventricular septum (19 mm), dynamic left ventricular outflow tract obstruction with a gradient of 70 mmHg at rest and 120 mmHg with Valsalva maneuver, and systolic anterior movement (SAM). Genetic testing excluded the most frequent forms of familial hypertrophic cardiomyopathy. ASA was performed with injection of 2 cc of alcohol in the first septal branch of the left coronary artery, without complications. At one-year reassessment, significant clinical and echocardiographic improvement was noted, with disappearance of SAM. To our knowledge, there have been no previously reported cases of ASA in hypertrophic cardiomyopathy due to acromegaly. We report a case of successful ASA in acromegalic cardiomyopathy., (Copyright © 2016 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: Mitral regurgitation (MR) is the most common valvular disease and has recently become the target of a number of percutaneous approaches. The MitraClip is virtually the only device for which there is considerable experience, with more than 20,000 procedures performed worldwide., Objective: To describe our initial experience of the percutaneous treatment of MR with the MitraClip device., Methods: We describe the first six MitraClip cases performed in this institution (mean age 58.5 ± 13.1 years), with functional MR grade 4+ and New York Heart Association (NYHA) heart failure class III or IV (n=3), with a mean follow-up of 290 ± 145 days., Results: Procedural success (MR ≤ 2+) was 100%. Total procedure time was 115.8 ± 23.7 min, with no in-hospital adverse events and discharge between the fourth and eighth day, and consistent improvement in the six-minute walk test (329.8 ± 98.42 vs. 385.33 ± 106.95 m) and in NYHA class (three patients improved by two NYHA classes). During follow-up there were two deaths, in two of the four patients who had been initially considered for heart transplantation., Conclusion: In patients with functional MR the MitraClip procedure is safe, with both a high implantation and immediate in-hospital success rate. A longer follow-up suggests that the clinical benefit decreases or disappears completely in patients with more advanced heart disease, namely those denied transplantation or on the heart transplant waiting list., (Copyright © 2014 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.)

Introduction: The index of microcirculatory resistance (IMR) enables/provides quantitative, invasive, and real-time assessment of coronary microcirculation status., Aims: The primary aim of this study was to validate the assessment of IMR in a large animal model, and the secondary aim was to compare two doses of intracoronary papaverine, 5 and 10 mg, for induction of maximal hyperemia and its evolution over time., Methods: Measurements of IMR were performed in eight pigs. Mean distal pressure (Pd) and mean transit time (Tmn) were measured at rest and at maximal hyperemia induced with intracoronary papaverine, 5 and 10 mg, and after 2, 5, 8 and 10 minutes. Disruption of the microcirculation was achieved by selective injection of 40-μm microspheres via a microcatheter in the left anterior descending artery., Results: In each animal 14 IMR measurements were made. There were no differences between the two doses of papaverine regarding Pd response and IMR values - 11 ± 4.5 U with 5 mg and 10.6 ± 3 U with 10 mg (p=0.612). The evolution of IMR over time was also similar with the two doses, with significant differences from resting values disappearing after five minutes of intracoronary papaverine administration. IMR increased with disrupted microcirculation in all animals (41 ± 16 U, p=0.001)., Conclusions: IMR provides invasive and real-time assessment of coronary microcirculation. Disruption of the microvascular bed is associated with a significant increase in IMR. A 5-mg dose of intracoronary papaverine is as effective as a 10-mg dose in inducing maximal hyperemia. After five minutes of papaverine administration there is no significant difference from resting hemodynamic status., (Copyright © 2013 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.)

Introduction: We describe our center's initial experience with alcohol septal ablation (ASA) for the treatment of obstructive hypertrophic cardiomyopathy. The procedure, its indications, results and clinical outcomes will be addressed, as will its current position compared to surgical myectomy., Objective: To assess the results of ASA in all patients treated in the first four years of activity at our center., Methods: We retrospectively studied all consecutive and unselected patients treated by ASA between January 2009 and February 2013., Results: In the first four years of experience 40 patients were treated in our center. In three patients (7.5%) the intervention was repeated. Procedural success was 84%. Minor complications occurred in 7.5%. Two patients received a permanent pacemaker for atrioventricular block (6% of those without previous pacemaker). The major complication rate was 5%. There were no in-hospital deaths; during clinical follow-up (22 ± 14 months) cardiovascular mortality was 2.5% and overall mortality was 5%., Discussion and Conclusion: The results presented reflect the initial experience of our center with ASA. The success rate was high and in line with published results, but with room to improve with better patient selection. ASA was shown to be safe, with a low complication rate and no procedure-related mortality. Our experience confirms ASA as a percutaneous alternative to myectomy for the treatment of symptomatic patients with obstructive hypertrophic cardiomyopathy refractory to medical treatment., (Copyright © 2013 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.)

Objective: To evaluate the clinical indications and guidelines for transcatheter aortic valve implantation (TAVI) and to propose adaptations for its use in Portugal., Methods and Results: The working group analyzed the epidemiology of aortic stenosis and current clinical recommendations in the light of current evidence, taking into consideration their own experience in Portugal. The evidence shows that TAVI significantly reduces mortality in patients with severe aortic stenosis considered unsuitable for surgery. This technique has a comparable safety profile, efficacy and quality of life improvement to conventional surgery in patients with high surgical risk, when carefully selected by multidisciplinary teams. TAVI procedures should be performed within multidisciplinary programs in centers with on-site cardiac surgery by experienced teams treating no fewer than 50 cases per year in order to maintain proficiency. The technique is little used in Portugal, with seven implantations/year per million population, a seventh of the European average and the lowest rate in Europe. From a societal standpoint, it is important to evaluate clinical outcomes and analyze the incremental cost involved in order to define the situations in which the technique is appropriate and should be used., Conclusion: TAVI is the only treatment for severe aortic stenosis in patients unsuitable for surgery, and can also be applied in selected cases with high surgical risk. Patients who are considered for this treatment should be evaluated in centers of excellence performing the technique and with a formal program of multidisciplinary team work. The first cases should be supervised until the team has established its routine. The program should perform the recommended minimum number of procedures per year in order to maintain proficiency and must keep a prospective clinical registry for monitoring purposes., (Copyright © 2013 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.)

Percutaneous transluminal coronary angioplasty (PTCA) with stent placement is widely used to achieve myocardial revascularization in patients with symptomatic ischemic heart disease and significant coronary artery stenosis. Drug-eluting stents are used in most patients undergoing percutaneous angioplasty. Stent thrombosis is an uncommon but serious complication, manifested mostly by sudden death or acute ST-elevation myocardial infarction. The authors report the case of a 68-year-old patient with acute anterior ST-elevation myocardial infarction. Five years previously, she had had a similar presentation and underwent primary angioplasty of the left anterior descending artery with implantation of a drug-eluting stent. The patient was discharged under antithrombotic therapy. She discontinued antiplatelet therapy and two days later suffered an acute anterior myocardial infarction. Primary angioplasty revealed stent thrombosis.

We report the case of a man presenting with acute myocardial infarction and a history of percutaneous coronary intervention with implantation of a drug-eluting stent, which was now fractured. This case highlights the growing recognition of stent fracture as a potential mechanism for late stent thrombosis in the drug-eluting stent era. Following the case report, we review the literature on the incidence, contributing factors and clinical impact of stent fracture.

Introduction: Primary angioplasty is accepted as the preferred treatment for acute myocardial infarction in the first 12 hours. However, outcomes depend to a large extent on the volume of activity and experience of the center. Continuous monitoring of methods and results obtained is therefore crucial to quality control., Objective: To describe the demographic, clinical and angiographic characteristics as well as in-hospital outcomes of patients undergoing primary PCI in a high-volume Portuguese center. We also aimed to identify variables associated with in-hospital mortality in this population., Methods: This was a retrospective registry of consecutive primary PCIs performed at Santa Marta Hospital between January 2001 and August 2007. Demographic, clinical, and angiographic characteristics and in-hospital outcomes were analyzed. Independent predictors of in-hospital mortality were identified by multivariate logistic regression analysis., Results: A total of 1157 patients were identified, mean age 61+/-12 years, 76% male. Mean pain-to-balloon time was 7.6 hours and primary angiographic success was 88%. Overall in-hospital mortality was 6.9%, or 5.5% if patients presenting in cardiogenic shock were excluded from the analysis. Previous history of heart failure, cardiogenic shock on admission, invasive ventilatory support, major hemorrhage, and age over 75 years were found to be associated with increased risk of in-hospital death., Conclusions: In this center primary PCI is effective and safe. Angiographic success rates and in-hospital mortality and morbidity are similar to other international registries. Patients at increased risk for adverse outcome can be identified by simple clinical characteristics such as advanced age, cardiogenic shock on admission, mechanical ventilation and major hemorrhage during hospitalization.

Background: ST-elevation myocardial infarction (STEMI) with the culprit lesion in the left main artery is a rare cardiac emergency with a poor prognosis., Objective: Review and prognosis evaluation of primary percutaneous coronary intervention (PCI) performed in the setting of STEMI with left main occlusion in a single high-volume center., Methods: Of the 483 primary or rescue PCIs performed and followed in our hospital during a 24-month period (August 2004 to July 2006), we retrospectively evaluated those involving left main procedures and analyzed in-hospital mortality and major cardiac events (MACE) in a 12-month follow-up. We found nine patients, age 68 +/- 9 years, five male, seven with multivessel disease and two with isolated left main disease. Rescue PCI was performed in three patients and primary PCI in the others., Results: Seven patients presented in cardiogenic shock and two were classified in Killip class II on admission. Inotropic drugs, intra-aortic balloon pump and abciximab were used in eight patients. Drug-eluting stents were used in six patients, bare-metal stents in two, and isolated balloon angioplasty in one. Five patients (55%) died in the hospital and the four discharged home (two of them aged 81 and 82 years) were still alive and free from MACE at 12-month follow-up., Conclusions: Clinical presentation of STEMI with the culprit lesion in the left main artery was very severe. During PCI, drug-eluting stents, intra-aortic balloon pump and abciximab were used in almost all patients. This entity had a high mortality rate even though primary PCI was performed. Those who survived had a good mid-term prognosis.

Introduction: The use of drug-eluting stents in the context of mechanical reperfusion following ST-segment elevation myocardial infarction (MI) was initially viewed with concern. The main fear was that the drugs' action in unstable lesions could increase the risk of thrombotic stent occlusion. Furthermore, there was no evidence that the proven benefit of reduced instent restenosis could be extended to such patients, since they were excluded from the initial clinical trials., Objectives: To assess the safety and long-term clinical outcomes of the use of drug-eluting stents in primary angioplasty., Methods: The first 100 consecutive and non-selected patients admitted for MI and treated by primary angioplasty with drug-eluting stent implantation in the target lesion were analyzed retrospectively. The efficacy and safety of the procedure, in-hospital clinical evolution and the occurrence of major adverse cardiac events in the first year were assessed., Results: Patients' mean age was 58.2 +/- 11.5 years, and 78 were male. The success rate of primary angioplasty was 99%. Stents coated with sirolimus were used in 67 patients, paclitaxel in 19 and dexamethasone in 16. In-hospital mortality was 3%. The follow-up rate at 12 months was 98%. During this period, the rate of target vessel revascularization was 1% (with no patient requiring target lesion revascularization), MI 2%, and overall mortality 3.9%. Fourteen patients had clinical indication for repeat coronary angiography, which showed no significant in-stent restenosis. One event was considered to be due to acute stent thrombosis. The incidence of major adverse events was 5.9%., Conclusion: The use of drug-eluting stents in MI patients undergoing primary mechanical revascularization is safe and is associated with a reduced incidence of major adverse events, thrombosis and clinical restenosis at one year.

Background: The last few years have seen significant progress in the treatment of advanced pulmonary arterial hypertension (PAH). The efficacy of new drugs has been proved mainly in idiopathic PAH or PAH associated with connective tissue diseases. As the pathophysiologic patterns are similar, it is reasonable to use these drugs also in Eisenmenger syndrome or in other congenital heart defects with PAH related to initial high pulmonary flow., Objectives: To evaluate our early experience with new drugs for PAH in patients with Eisenmenger syndrome., Methods: A retrospective study of five patients, aged 28 to 51 years (39.6 +/- 9.94), four female, with Eisenmenger syndrome due to atrial septal defect (n = 2), patent ductus arteriosus (n = 2) or ventricular septal defect (n = 1), who began therapy with iloprost (n = 4, later associated with sildenafil in one patient) and bosentan (n = 1), between April 2001 and May 2003. The existence of severe and fixed PAH, with predominant right-to-left shunt, was confirmed by hemodynamic study in all cases. The patients were evaluated by clinical examination, Doppler echocardiography and the six-minute walk test before treatment and throughout follow-up (9 to 34 months, 19.8 +/- 9.04). Before treatment two patients were in NYHA class III and three in class III with periods in class IV. By Doppler echocardiography the right ventricle-right atrium (RV-RA) gradient was 74 to 111 mmHg (90.6 +/- 15.73) and the Tei index was 0.53 to 2.05 (1.13 +/- 0.62). In the six-minute walk test the distance was 214 to 500 meters (296.8 +/- 115.27)., Results: All patients improved clinically, though three are still in class III. One patient is in class II and one patient died. At the latest evaluation the RV-RA gradient was 60 to 112 mmHg (84.8 +/- 19.11) and the Tei index was 0.5 to 1.33 (0.85 +/- 80.32). In the six-minute walk test a net increase in the distance covered was evident: 376 to 520 meters (420 +/- 57.89). The treatment was well tolerated in all cases, without serious adverse effects., Conclusions: Though the number of patients was small, our initial experience with the new specific drugs for PAH in Eisenmenger syndrome showed promising results, with clinical and functional improvement and without adverse effects.

Unlabelled: The therapeutic approach to severe pulmonary arterial hypertension (PAH), whether primary or secondary to connective tissue disorders, thromboembolic phenomena or congenital heart disease with Eisenmenger syndrome, has evolved in recent years following the introduction of selective pulmonary vasodilators, including prostacyclin analogs and endothelin receptor antagonists., Aim: To correlate three different endpoints (6-minute walk test, Tei index and peak tricuspid regurgitation velocity by Doppler echocardiographic study) during follow-up of PAH patients under selective vasodilator therapy., Methods: Eleven patients (9 female, age 42 +/- 18 years) with severe PAH (> or = 65 mmHg), 64% with Eisenmenger syndrome, in NYHA class > or = II, were assessed during a follow-up of 11 +/- 8 months. Eight patients were already under therapy with iloprost or bosentan., Results: There was no correlation between the three endpoints before and after therapy as assessed by Pearson's correlation coefficient. There was, however, an improvement in all of them after selective vasodilatory therapy., Conclusion: Therapeutic response can be accurately measured by the traditional endpoint (6-minute walk test) or by echocardiographic endpoints. However, the lack of correlation between them excludes their use as alternatives in patient follow-up.

Background: Primary coronary angioplasty is the best therapeutic approach in acute myocardial infarction (AMI), and more so in the population aged over 75 years, in whom the hemorrhagic risk of thrombolysis becomes almost unacceptable., Aim: To evaluate age-related influences on clinical evolution and in-hospital mortality in patients with AMI who undergo primary percutaneous coronary interventions (PCI)., Methods: We studied 245 consecutive patients (aged between 31 and 90, 63+/-13), who underwent primary PCI between January 2000 and December 2001. Forty-six patients (18.8%) aged over 75 years were compared with the rest. The following parameters were analyzed: risk factors for coronary artery disease including hypertension, diabetes, smoking, hypercholesterolemia and family history, previous AMI, PCI or angina, extent of coronary disease, angiographic results and in-hospital mortality., Results: Female gender was more frequent in older patients (56.5% vs. 23.1%; p<0.001) and smoking was more prevalent in the younger group (54.3% vs. 13.0%; p<0.001), as was previous AMI (p<0.05). PCI success was high in both groups (93.5% in the older population and 96.7% in the rest; p=NS), multivessel coronary disease was significantly more frequent in the elderly group (41.3% vs. 26.2%; p<0.05), and glycoprotein IIb/IIIa inhibitors were used less (80.4% vs. 91%; p<0.05). Killip class evolution was more favorable in the younger group (class I in 88.4% vs. 69.8% in older patients; p<0.001). The number of hemorrhagic complications and in-hospital mortality were higher in elderly patients (3.5% vs. 13.0%; p<0.05 and 4.5% vs. 19.6%; p<0.001, respectively)., Conclusions: Primary PCI has a similarly high success rate in elderly patients, although this age-group still has higher mortality. The increased rate of hemorrhagic complications in this population should lead to greater caution in the use of adjuvant antithrombotic drugs.

Background: In acute myocardial infarction (AMI), primary percutaneous transluminal coronary angioplasty (PTCA) has proved to be the best therapeutic approach. Several factors have been associated with worse outcome in AMI in females. Are there differences in outcome in women undergoing PTCA for AMI?, Aim: To evaluate gender influence on clinical outcome and in-hospital mortality in patients with AMI who undergo primary percutaneous interventions., Methods: We studied 245 consecutive patients (72 women, 29.4 %), who underwent primary PTCA between January 2000 and December 2001. The following parameters were analyzed: risk factors for coronary artery disease including hypertension, diabetes, smoking, hypercholesterolemia and family history, previous AMI, PTCA or angina, pain-to-balloon time, extent of coronary disease and outcome., Results: Female patients were older (67.9+/-11.6 vs. 59.6+/-13; p < 0.001) with a higher prevalence of hypertension (65.3 % vs. 47.4 %; p < 0.05) and angina (29.0 % vs. 16.0 %; p < 0.05) and lower prevalence of smoking (27.8 % vs. 54.3 %; p < 0.001). Pain-to-balloon time was longer in women (6.8+/-4.1 vs. 5.4+/-3.7 hours; p < 0.05). Extent of coronary disease was similar in both groups. Glycoprotein IIb/IIIa inhibitors were used in 84.7 % of women and 90.8 % of men. The frequency of hemorrhagic complications (5.6 % vs. 5.2 %) and arrhythmias (15.3 % vs. 10.4%) and in-hospital mortality (9.7 6.4 %) were higher in females, although without statistical significance (p = NS). Hospitalization time was similar in both groups., Conclusions: Despite the growing awareness of a gender bias in therapeutic approaches to AMI, there are still some differences in outcome, with a trend towards higher mortality rates in women. Older age and longer pain-to-balloon time could account for this.

The authors describe a new elecrocardiographic criterion to diagnose atrioventricular node reentrant tachycardia, review the electrocardiographic and electrophysiological diagnosis of this tachyarrhythmia and analyse the results of catheter ablation of fast versus slow pathway, selecting the fast pathway whenever the induction of atrioventricular node reentrant tachycardia is performed only after pharmacological maneuvers. The high specificity for atrioventricular node reentrant tachycardia of the criterion characterized by the absence of ST-segment depression found in left precordial leads from V4 to V6 suggests the need to include it in electrocardiographic algorithms for the differential diagnosis of tachycardias with a narrow QRS complex. The high primary and final success rates of catheter ablation obtained after a therapy stratification based on induction criteria, emphasize the use of the fast pathway ablation as a first option in selected cases and for the treatment of recurrences.

Aim: The aim of this study was to make a noninvasive comparison, by means of Doppler echocardiography, of the hemodynamic performance of biological stentless xenografts and mechanical bileaflet (MB) prostheses (P) in aortic position., Methods: We studied 20 patients (pts) with normofunctional (nf) aortic Toronto (T) Stentless Porcine valves (SPV)--Group I--8 males, aged 69 +/- 12 years, 32 +/- 9 months after surgery, and 30 pts with nf MB aortic P (Carbomedics or St. Jude Medical)--Group II--17 males (p = NS vs G I), aged 61 +/- 12 years (p < 0.01 vs G I), 30 +/- 12 months after implantation (p = NS vs G I). Both groups were comparable with regard to body surface area and surgical indication. P diameters ranged from 21 to 25 mm (G I: 22.9 +/- 1.7; G II: 22.8 +/- 1.7 - p = NS), the number of pts with the same P diameter in each group being similar. We analysed, at rest: aortic orifice diameter (AoOd - cm), maximal (GMax) and mean (GMean) transprosthesic pressure gradients, P functional area (PFA) and P resistance (PRes). Gradients (mm Hg) were calculated by means of the Bernoulli equation, PFA (cm2) by means of the continuity equation and PRes (dynes.s.cm-5) as 1333 x Gmean x SEP/SV (SEP = systolic ejection period; SV = stroke volume)., Results: AoOd (G I vs G II): P 21--1.78 +/- 0.04 vs 2.00 +/- 0.10 (p < 0.001); P 23--1.91 +/- 0.10 vs 2.19 +/- 0.10 (p = 0.01); P 25--2.22 +/- 0.24 vs 2.29 +/- 0.19 (NS). Doppler parameters: [table: see text], Conclusions: P T SPV show better hemodynamic performance when compared to P MB with the same diameter, in aortic position. In addition, our results suggest that P T SPV allow the use of larger valve sizes for the same aortic orifice diameter.

The authors describe the main etiopathogenic factors and clinical importance of atrial fibrillation and analyse the results of catheter ablation of atrioventricular accessory pathways in Wolff-Parkinson-White syndrome. Atrial vulnerability is the principal mechanism and radiofrequency catheter ablation of atrioventricular accessory pathways seems to be useless to prevent atrial fibrillation.

Objective: The aim of this study was to evaluate the clinical profile and prognosis of patients with an angiographically proven thromboembolism., Methods: Data from 22 consecutive patients (13 males, 9 females; mean age 57.3 +/- 16.8 years) with pulmonary embolism confirmed by pulmonary angiography were reviewed. All our patients were previously submitted to non-invasive diagnostic procedures (blood examinations, EKG, chest x-ray, echocardiography). A V/Q scan was also performed in 5 patients. Fourteen patients were traditionally treated with heparin alone and the rest received thrombolytic therapy and heparin. Two patients had a thromboembolectomy. At discharge, all our patients were submitted to an oral anticoagulant therapy. The mean duration of the follow-up period was 26 +/- 12 months., Results: The majority of the patients were in the 6th decade of life and it was possible to identify a hypercoagulable state in 82%. The most common symptom at the time of presentation was sudden chest pain (64%). The most specific sign in non-invasive procedures were right side cardiac dilatation seen echocardiographically (73%) and the mismatch in the V/Q scan (80%). The most common haemodynamic parameter (91%) observed in the right heart catheterization of these patients was the finding of a gradient between diastolic pulmonary artery and pulmonary capillary wedge pressures. Uneventful angiography was performed in all patients who showed massive pulmonary embolism (86%). Three patients (13.6%) died during the acute phase. At the end of the follow-up period, 10 patients were asymptomatic and 5 had heart failure. Four died, which corresponds to an overall mortality of 31.8% in 2.2 years of follow-up. None of the clinical or haemodynamic parameters analyzed (age, gender, arterial blood gases at presentation, hypercoagulable states, thrombolysis, pulmonary hypertension and extension of the embolism) were related to mortality., Conclusion: Angiographically confirmed pulmonary thromboembolism is still a poor outcome situation, even when a lot of diagnostic and therapeutic procedures are available.

Right ventricle dysplasia (RVD) is a rare clinical entity, described in young people, and a known cause of ventricular arrhythmias and sudden death. A genetic transmission has been suggested from the study of familial cases. The disease is characterized by a dilated right ventricle, cardiac infiltration with fatty tissue and focal fibrosis. Lymphoplasmocyte infiltrates are documented. The diagnosis is based on electrocardiography, echocardiography, magnetic resonance imaging and right ventricular endomyocardial biopsy. The authors report a case of a young woman with symptomatic ventricular tachycardia (VT) in whom the diagnosis of RVD was established. Programmed ventricular stimulation was used to reproduce the clinical VT and to test the efficacy of the anti-arrhythmic drug therapy. The diagnosis criteria and therapeutic options are discussed.

Prosthetic valve obstruction is one of the most serious complications of mechanical cardiac valves. Clinicians must be aware of this diagnosis in patients with a worsening of functional NYHA class. Over the past years, echocardiography has imposed itself as the method of choice to diagnose and evaluate patients with suspected prosthetic valve obstruction. We present three clinical reports of prosthetic valve malfunction that have unusual echocardiographic features.

Unlabelled: Although treadmill exercise testing (TET) has been used to identify ischaemia and determine clinical prognosis after myocardial revascularization, considerable controversy remains on its role in the detection of obstructive lesions of the arterial grafts., Aim: To assess the value of TET in determining the patency of arterial conduits after coronary bypass surgery with complete revascularization., Methods: Twenty five patients - 21 men and 4 women; age 53.7 +/- 8.7 years - submitted to complete myocardial revascularization exclusively with arterial conduits (CABG-A), undergoing coronary angiography and a symptomlimited TET (Bruce protocol) within 9 months after CABG-A. Angiograms were visually classified in 2 groups (Group I - conduits without lesions, n = 14; Group II > 50% stenosis or occlusion of > or = 1 conduit, n = 11). Clinical characteristics and the following parameters of the TET were compared: total exercise time (ETime); metabolic equivalents (METS); % of predicted maximal heart rate (% MHR); exercise-induced ST depression (decreases ST); and occurrence of angina. The arterial conduits used were: left internal mammary artery -24-; right internal mammary artery -11-; gastroepiploic artery -14-., Results: There were no differences in age, gender, left ventricular systolic function, severity of coronary artery disease, and number of conduits per patient. Group I attained superior values for the following parameters: ETime (p < 0.01) and METS (p < 0.01). Among Group II there were more patients with angina (p = 0.03). Fourteen patients exceeded 8 METS (11 from Group I and 3 from Group II - p = 0.002-). There was no statistical difference among the number of patients with ST depression during exercise., Conclusions: After CABG-A the exercise tolerance seems to be related with the patency of the conduits and may play an important role in the detection of graft abnormalies. On the contrary, exercise-induced ST depression had low specificity in detecting obstructive lesions of the conduits.