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Objectives: The underutilization of manual thrombus aspiration (MTA) may have reduced the benefits of ischemic postconditioning (PostCon), as it reduces thrombus embolization. We aimed to assess the benefits of PostCon in patients with ST-segment elevation myocardial infarction (STEMI) after the systematic utilization of MTA. Methods: A total of 87 patients were enrolled in a prospective, randomized trial (43 PostCon and 44 controls). After MTA, PostCon was performed on the treatment group by applying 4 cycles of alternate reperfusion and reocclusion (60 seconds each) using the angioplasty balloon. The primary end point was infarct size assessed by the area under the curve (AUC) of troponin T (TnT) activity. The secondary end points were left ventricle ejection fraction (LVEF) and major cardiac events (new myocardial infarction or cardiac death) both at discharge and at follow-up. Results: The AUC for TnT was no different with respect to study arms (median [interquartile range]): PostCon = 8.9 (10.6) versus control = 8.2 (10.6), P = .68. Left ventricle ejection fraction improved from in-hospital to follow-up (9 ± 3 months) for the entire cohort (46.3% ± 7.3% vs 52.2% ± 10.7%, P < .001), with no differences between PostCon and controls (51.6% ± 9.5% vs 52.7% ± 11.9%, P = .89); major cardiac events at 14 ± 4 months of follow-up were also no different (PostCon = 1.0 (2.3%) vs control = 0, P = .49). Conclusion: In patients with STEMI treated with MTA, PostCon offered no benefits to infarct size, LVEF, or major cardiac events.

Takotsubo cardiomyopathy is an acute cardiac entity with clinical manifestations similar to myocardial infarction, accounting for 1-2% of acute coronary syndrome admissions. Its underlying pathophysiology is not yet well established. It is usually associated with acute physical or emotional stress, but the list of potential triggers has grown as the condition attracts the attention of the medical community. In order to diagnose the condition correctly and to gain new insights into it, we need to know its potential triggers as well as its clinical presentation and diagnostic criteria. We report a case of takotsubo cardiomyopathy triggered by hyponatremia. Resumo: A cardiomiopatia de Takotsubo é uma entidade nosológica que se caracteriza por manifestações clínicas similares às do enfarte agudo do miocárdio, representando cerca de 1-2% de todos os doentes admitidos por síndrome coronária aguda. A sua etiopatogenia ainda não está totalmente esclarecida. Geralmente, está associada a vigorosos estímulos físicos ou emocionais. Com o crescente reconhecimento desta entidade, a lista de potenciais estímulos despoletadores tem crescido nos últimos anos. O conhecimento destes novos estímulos permitirá não só um diagnóstico correcto mas também o aprofundamento dos seus mecanismos fisiopatológicos. Os autores descrevem um caso de cardiomiopatia de Takotsubo induzida por hiponatremia. Keywords: Stress cardiomyopathy, Takotsubo cardiomyopathy, Hyponatremia, Palavras-chave: Cardiomiopatia de stress, Cardiomiopatia de Takotsubo, Hyponatremia

Neuromediated stunned myocardium is a well-known complication of subarachnoid hemorrhage but has rarely been reported in association with other central nervous system disorders. The pathophysiology of this entity remains unclear, but a catecholamine-induced neurocardiogenic injury has been proposed as a causal factor. Typically, patients have rapid full cardiovascular recovery within a few days. We report a case of ischemic stroke, coexisting with ischemic electrocardiographic changes, increased cardiac-specific necrosis biomarkers, regional wall motion abnormalities and a cardiac SPECT consistent with inferior myocardial infarction despite normal coronary arteries. Interestingly, left-ventricular dysfunction in this case persisted longer than usually described despite full neurologic recovery. This case also illustrates the diagnostic challenges posed by this entity which frequently mimics acute myocardial infarction and emphasizes the investigation needed in this area.

Intramyocardial dissecting haematoma (IDH) is a rare complication of myocardial infarction, with very scarce reports in medical literature. Before the advent of non-invasive imaging techniques, the diagnosis of IDH was only made by necropsy. It can develop in the left ventricular free wall, the right ventricle, or the interventricular septum. We present a case of a patient with an IDH after acute anterolateral myocardial infarction, focusing on the utility of echocardiography in the diagnosis and follow-up of this unusual complication. By this imaging modality, it was possible to see the various acoustic densities of the progressive clotting of the intramyocardial haematoma, its extension through the haemorrhagic dissection, as well as its independency in relation to ventricular cavities and extracardiac space by confirming intact epicardial and endocardial layers. Based on this report, we believe that serial two-dimensional echocardiography, added, when necessary, by the use of contrast agents is the non-invasive method ideally suited to confirm the diagnosis and monitor its evolution at the patient's bedside.

Dyspnea and hypoxemia are among the most common symptoms and signs that need to be assessed in clinical practice.This case illustrates how simple steps in history taking and physical examination can be crucial for diagnosis.We present a patient with intermittent hypoxemia, initially attributed to a pulmonary infection. However, the hypoxemia persisted even after successful treatment of the infection. Computed tomography angiography of the chest and ventilation/perfusion lung scan excluded pulmonary embolism.We then observed that the hypoxemia and dyspnea were triggered by orthostatism. An echocardiogram with a bubble test showed a patent foramen ovale, with a right-to-left shunt, without pulmonary hypertension. After percutaneous closure of the foramen ovale, the symptoms completely resolved.This is a case of platypnea-orthodeoxia syndrome, which is usually associated with patent foramen ovale or atrial septal defect and is typically observed in the elderly. The features and causes of this curious syndrome are discussed. Resumo: A dispneia e hipoxemia são dos sintomas e sinais mais comuns que avaliamos diariamente na prática clínica.Este caso ilustra como uma avaliação simples da anamnese e exame físico podem ser cruciais para o diagnóstico.Apresentamos um doente com hipoxemia intermitente, inicialmente atribuída a uma infeção respiratória. Contudo, a hipoxemia manteve-se apesar de tratamento eficaz da infeção. A angiotomografia computorizada do tórax e cintigrafia de ventilação-perfusão excluíram tromboembolismo pulmonar. Verificámos posteriormente que a hipoxemia e dispneia eram despoletadas pelo ortostatismo. Um ecocardiograma com administração de soro agitado revelou a presença de foramen ovale patente, com fluxo espontâneo direito-esquerdo, sem hipertensão pulmonar. Após encerramento do forâmen ovale patente, os sintomas desapareceram.Este é um caso de síndrome de platipneia-ortodeoxia, que geralmente se associa a foramen ovale patente ou comunicação interauricular, e é especialmente frequente em idosos. Discutimos as características e causas desta interessante síndrome. Keywords: Platypnea, Orthodeoxia, Patent foramen ovale, Atrial septal defect, Palavras-chave: Platipneia, Ortodeoxia, Foramen ovale patente, Comunicação interauricular