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Background and Purpose: Mechanical thrombectomy (MT) in ischemic stroke patients with poor prestroke conditions remains controversial. We aimed to analyze the frequency of previously disabled patients treated with MT in clinical practice, the safety and clinical response to MT of patients with preexisting disability, and the disabled patient characteristics associated with a better response to MT. Methods: We studied all consecutive patients with anterior circulation occlusion treated with MT from January 2017 to December 2019 included in the Codi Ictus Catalunya registry—a government-mandated, prospective, hospital-based data set. Prestroke disability was defined as modified Rankin Scale score 2 or 3. Functional outcome at 90 days was centrally assessed by a blinded evaluator of the Catalan Stroke Program. Favorable outcome (to return at least to prestroke modified Rankin Scale at 90 days) and safety and secondary outcomes were compared with patients without previous disability. Logistic regression analysis was used to assess the association between prestroke disability and outcomes and to identify a disabled patient profile with favorable outcome after MT. Results: Of 2487 patients included in the study, 409 (17.1%) had prestroke disability (313 modified Rankin Scale score 2 and 96 modified Rankin Scale score 3). After adjustment for covariates, prestroke disability was not associated with a lower chance of achieving favorable outcome at 90 days (24% versus 30%; odds ratio, 0.79 [0.57–1.08]), whereas it was independently associated with a higher risk of symptomatic intracranial hemorrhage (5% versus 3%; odds ratio, 2.04 [1.11–3.72]) and long-term mortality (31% versus 18%; odds ratio, 1.74 [1.27–2.39]) compared with patients without disability. Prestroke disabled patients without diabetes, Alberta Stroke Program Early CT Score >8 and National Institutes of Health Stroke Scale score Conclusions: Despite a higher mortality and risk of symptomatic intracranial hemorrhage, prestroke-disabled patients return as often as independent patients to their prestroke level of function, especially those nondiabetic patients with favorable early ischemic signs profile. These data support a potential benefit of MT in patients with previous mild or moderate disability after large anterior vessel occlusion stroke.

Introduction and objectives: In December 2019, SARS-CoV-2, was discovered as the agent of COVID-19 disease. Cardiac arrhythmias have been reported as frequent but their incidence is unknown. The aim of this research was to assess the real incidence of cardiac arrhythmias among COVID-19 patients admitted to Portuguese hospitals and to understand the underlying prognostic implications. Methods: The Portuguese Association of Arrhythmology, Pacing and Electrophysiology (APAPE) conducted a survey in Portuguese hospitals to assess the occurrence of arrhythmias in COVID-19 patients, their clinical characteristics, the use of experimental therapies and the impact on QT interval. Results: Twenty hospitals participated, reporting 692 hospitalized patients. An arrhythmic episode occurred in 81 (11.7%) and 64 (79%) had detailed information on these episodes. New onset arrhythmias occurred in 41 (64%) patients, 45 (70.3%) male, median age 73.5 (61-80.3) years. There were 51 (79.7%) with associated comorbidities, mainly arterial hypertension (41, 64.1%). Of 53 patients (82.3%) on experimental therapy, 7 (10.9%) had an increased QTc interval. Regarding arrhythmias, two patients (3.1%) had ventricular tachycardia, 5 (7.8%) sinus bradycardia, 17 (26.6%) paroxysmal supraventricular tachycardia and 40 (62.5%) atrial fibrillation or flutter. At the time of reporting, there had been no deaths due to arrhythmic syndrome or related complications. Conclusions: In a population of COVID-19 patients. The incidence of cardiac arrhythmias is high but not associated with increased cardiac mortality although it does though occur frequently in extremely ill patients and with multiple organ failure. Regardless of the use of experimental drugs, the incidence of ventricular arrhythmias is low and atrial fibrillation and other supraventricular arrhythmias are the most prevalent arrythmias. Resumo: Introdução e objetivos: Em dezembro de 2019, o SARS-CoV-2 foi descoberto como agente da doença Covid-19. As arritmias cardíacas são reportadas como frequentes, mas a sua incidência é desconhecida. O objetivo deste trabalho foi entender a incidência de arritmias em doentes Covid-19 tratados em hospitais portugueses e entender as suas implicações prognósticas. Métodos: A Associação Portuguesa de Arritmologia, Pacing e Electrofisiologia (APAPE) conduziu um inquérito em hospitais portugueses, documentando a ocorrência de arritmias em doentes com Covid-19, as suas caraterísticas clínicas, o uso de terapêutica experimental e o seu impacto no intervalo QT. Resultados: Participaram 20 hospitais, reportando 692 doentes hospitalizados. Ocorreram episódios arrítmicos em 81 (11,7%), 64 (79%) com informação adicional. Documentaram-se arritmias de novo em 41 (64%) doentes, 45 (79%) do sexo masculino, idade mediana 73,5 (61-80,3) anos. Destes, 51 (79,7%) tinham comorbilidades associadas, maioritariamente hipertensão arterial (41, 64,1%). Dos 53 (82,3%) doentes sob terapêutica experimental, 7 (10,9%) tiveram aumento do intervalo QTc. Tiveram taquicardia ventricular 2 (3,1%) doentes, 5 (7,8%) bradicardia sinusal, 17 (26,6%) taquicardia paroxística supraventricular e 40 (7,8%) fibrilhação ou flutter auricular. Nenhum doente teve morte por causa arrítmica ou complicações associadas, à data do registo. Conclusões: Numa população de doentes com Covid-19, a incidência de arritmias é elevada, mas não associada a aumento de mortalidade cardíaca, apesar da ocorrência mais frequente em doentes graves e com falência multiorgânica. Independentemente do uso de terapêuticas experimentais, a incidência de arritmias ventriculares é baixa e a fibrilhação auricular e outras arritmias supraventriculares são as arritmias mais prevalentes.

Acesso ao texto integral: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6829762/ We report a case of a 43-year-old man with situs inversus and dextrocardia who was admitted with syncope in the setting of complete atrioventricular block. The complex anatomy poses a considerable challenge to transvenous permanent pacemaker implantation. We employed a novel technique using vascular ultrasound and agitated saline solution to assist with lead positioning. This technique could be useful in pediatric populations or younger patients, in whom the use of ionizing radiation is an important issue. info:eu-repo/semantics/publishedVersion

Pacemakers with sleep apnea monitor (SAM) provide an easy tool to assess obstructive sleep apnea over long periods of time. The link between respiratory disturbances at night and the incidence of acute decompensated heart failure (ADHF) is not well established. We aimed at (1) determining the ability of SAM pacemakers to evaluate the extent of left ventricular overload and (2) assess the impact of respiratory disturbances at night on the occurrence of ADHF over 1-year of follow-up. We conducted a single-center prospective study. Consecutive patients with SAM pacemakers were comprehensively assessed. SAM automatically computes a respiratory disturbance index (RDI, apneas/hypopneas per hour - AH/h) in the previous night and the percentage of nights with RDI >20 AH/h in the previous 6 months. Thirty-seven patients were included (79.3 ± 11.2 years, 46% males). A high RDI in the previous night and a higher %nights with increased RDI were associated with increased NT-proBNP values (p = 0.008 and p = 0.013, respectively) and were the sole predictors of increased noninvasive pulmonary capillary wedge pressures (PCWP) in the morning of assessment (p = 0.031 and p = 0.044, respectively). Receiver operating characteristic curve analysis revealed an area under the curve of 0.804 (95% confidence interval 0.656 to 0.953, p = 0.002) for %nights with RDI >20 AH/h in the prediction of high PCWP. Patients with >12.5% of nights with RDI >20AH/h tended to have more ADHF during follow-up (log-rank p = 0.067). In conclusion, a high burden of apneas/hypopneas at night is associated with elevated NT-proBNP and PCWP values and an increased risk of ADHF over 1 year. These patients might benefit from early tailored clinical management.

Self-terminating atrial arrhythmias are commonly detected on continuous rhythm monitoring, e.g. by pacemakers or defibrillators. It is unclear whether the presence of these arrhythmias has therapeutic consequences. We sought to summarize evidence on the prevalence of atrial high-rate episodes (AHREs) and their impact on risk of stroke. We performed a comprehensive, tabulated review of published literature on the prevalence of AHRE. In patients with AHRE, but without atrial fibrillation (AF), we reviewed the stroke risk and the potential risk/benefit of oral anticoagulation. Atrial high-rate episodes are found in 10–30% of AF-free patients. Presence of AHRE slightly increases stroke risk (0.8% to 1%/year) compared with patients without AHRE. Atrial high-rate episode of longer duration (e.g. those >24 h) could be associated with a higher stroke risk. Oral anticoagulation has the potential to reduce stroke risk in patients with AHRE but is associated with a rate of major bleeding of 2%/year. Oral anticoagulation is not effective in patients with heart failure or survivors of a stroke without AF. It remains unclear whether anticoagulation is effective and safe in patients with AHRE. Atrial high-rate episodes are common and confer a slight increase in stroke risk. There is true equipoise on the best way to reduce stroke risk in patients with AHRE. Two ongoing trials (NOAH-AFNET 6 and ARTESiA) will provide much-needed information on the effectiveness and safety of oral anticoagulation using non-vitamin K antagonist oral anticoagulants in patients with AHRE.

Objectives: The study aimed to evaluate the impact of a telestroke network on acute stroke care in Catalonia, by measuring thrombolysis rates, access to endovascular treatment, and clinical outcome of telestroke patients in a population-based study. Methods: Telestroke network was implemented on March 2013 and consists of 12 community hospitals and 1 expert stroke neurologist 24 h/7 day, covering a population of 1.3 million inhabitants. Rest of the population (6.2 million) of Catalonia is covered by 8 primary stroke centers (PSC) and 6 comprehensive stroke centers (CSC). After a 2-way videoconference and visualization of neuroimaging on a web platform, the stroke neurologist decides the therapeutic approach and/or to transfer the patient to another facility, entering these data in a mandatory registry. Simultaneously, all patients treated with reperfusion therapies in all centers of Catalonia are prospectively recorded in a mandatory and audited registry. Results: From March 2013 to December 2015, 1,206 patients were assessed by telestroke videoconference, of whom 322 received intravenous thrombolysis (IVT; 33.8% of ischemic strokes). Baseline and 24 h NIHSS, rate of symptomatic hemorrhage, mortality, and good outcome at 3 months were similar compared to those who received IVT in PSC or CSC (2,897 patients in the same period). The door-to-needle time was longer in patients treated through telestroke, but was progressively reduced from 2013 to 2015. Percentage of patients receiving thrombectomy after IVT was similar in patients treated through telestroke circuit, compared to those treated in PSC or CSC (conventional circuit). Population rates of IVT*100,000 inhabitants in Catalonia increased from 2011 to 2015, especially in areas affected by the implementation of telestroke network, achieving rates as high as 16 per 100,000 inhabitants. Transfers to another facility were avoided after telestroke consultation in 46.8% of ischemic, 76.5% of transient ischemic attacks, and 23.5% of hemorrhages. Conclusions: Telestroke favors safe and effective thrombolysis, helps to increase the population rate of IVT, and avoids a large number of interhospital transfers.

Aims: Left atrial (LA) fibrosis can be identified by late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) in patients with atrial fibrillation (AF). However, there is limited information about anatomical fibrosis distribution in the left atrium. The aim is to determine whether there is a preferential spatial distribution of fibrosis in the left atrium in patients with AF. Methods and results: A 3-Tesla LGE-CMR was performed in 113 consecutive patients referred for AF ablation. Images were post-processed and analysed using ADAS-AF software (Galgo Medical), which allows fibrosis identification in 3D colour-coded shells. A regional semiautomatic LA parcellation software was used to divide the atrial wall into 12 segments: 1–4, posterior wall; 5–6, floor; 7, septal wall; 8–11, anterior wall; 12, lateral wall. The presence and amount of fibrosis in each segment was obtained for analysis. After exclusions for artefacts and insufficient image quality, 76 LGE-MRI images (68%) were suitable for fibrosis analysis. Segments 3 and 5, closest to the left inferior pulmonary vein, had significantly higher fibrosis (40.42% ± 23.96 and 25.82% ± 21.24, respectively; P 60 years was significantly associated with increased LA fibrosis [95% confidence interval (CI) 0.19–8.39, P = 0.04] and persistent AF approached significance (95% CI −0.19% to 7.83%, P = 0.08). Conclusion: In patients with AF, the fibrotic area is preferentially located at the posterior wall and floor around the antrum of the left inferior pulmonary vein. Age >60 years was associated with increased fibrosis. This work was partially supported by Fondo de Investigaciones Sanitarias-Instituto de Salud Carlos III (PI13/01747 and PI16/00435); Agencia de gestió d´Ajuts Universitaris I de Recerca (AGAUR) Exp: 2014_SGR_471; CERCA programme/Generalitat de Catalunya; European Regional Development Fund (ERDF. European Union. A Way of Making Europe), the European Union's Horizon 2020 research and innovation programme under grant agreement No 633196 (CATCH ME), a grant by La MARATÓ-TV3 (20152730) and the Spanish Ministry of Economy and Competitiveness (DPI2015-71640-R).

Premature ventricular complex (PVC) ablation has been shown to improve left ventricular ejection fraction (LVEF) and New York Heart Association functional class in patients with left ventricular dysfunction. Both are considered key variables in predicting risk of sudden cardiac death.The objective of this study was to assess whether ablation might remove the primary prevention (PP) implantable cardioverter-defibrillator (ICD) indication in patients with frequent PVC.Sixty-six consecutive patients with PP-ICD indication and frequent PVC [33 (50%) men; mean age 53 ± 13 years; 11 (17%) with ischemic heart disease] underwent PVC ablation. The ICD was withheld and the indication was reevaluated at 6 and 12 months.LVEF progressively improved from 28% ± 4% at baseline to 42% ± 12% at 12 months (P.001). New York Heart Association functional class improved from 2 patients with NYHA functional class I (3%) at baseline to 35 (53%) at 12 months (P.001). The brain natriuretic peptide level decreased from 246 ± 187 to 176 ± 380 pg/mL (P = .004). The PP-ICD indication was removed in 42 patients (64%) during follow-up, from 38 (92%) of them at 6 months, showing an independent association with baseline PVC burden and successful sustained ablation. In patients with successful sustained ablation, a cutoff value of 13% PVC burden had a sensitivity of 100% and a specificity of 93% (area under the curve 99%) for removing ICD indication postablation. No sudden cardiac deaths or malignant ventricular arrhythmias were observed.In patients with frequent PVC and PP-ICD indication, ablation improves LVEF and, in most cases, allows removal of the indication. Withholding the ICD and reevaluating within 6 months of ablation seems to be a safe and appropriate strategy.

7 páginas, 2 tablas, 7 figuras., © 2015 Elsevier B.V. Hypoderma larvae are tissue invading parasites which spend several months migrating within the host tissues before completing their development in the sub-dermal tissues of the back. Subcutaneous stages of the parasite produce an inflammatory reaction in the skin called >warbles>, as well as holes through which larvae breathe. In order to elucidate the microscopical structure of the warbles, three hides from warbled cows were collected in a slaughterhouse in Lugo (NW, Spain) between March and May 2012. A total of 60 skin samples, including warbles at different phases of development, were chosen for histopathological and immunohistochemical examination. Microscopic lesions were classified into three groups, according to the predominance and distribution of different cell populations. In warbles containing living or recently dead larvae with apparently well preserved cuticle (type 1), plasma cells were observed in high number. However, macrophages and lymphocytes were the predominant cells in granulomas (type 2) formed in relation to remnants of the dead parasite, containing or not remains of the altered cuticle. Scars (type 3) were characterized by granulation tissue. Immunohistochemistry showed that B lymphocytes and IgG+ cells were predominant in the lesions, as long as the cuticle of the larvae is intact. On the other side, CD3+ lymphocytes increased once cuticle is destroyed and a granuloma is formed. Macrophages, revealed by CD68+, MAC387+ and lysozyme immunolabelling, were detected in all types of lesions, but they were more abundant in type 2 and scarce in scars. These cells appeared isolated around the intact larvae or forming aggregates around its remains in the granuloma. Moreover, a strong immunolabelling against MAC387 antibody was registered in the squamous epithelium covering the breathing pore. This finding may be associated with the expression of calprotectin, a molecule involved on the healing process of the skin after larvae outcome. Our results suggest the predominance of a humoral response inside the warble as long as larvae are intact. Once they are destroyed, cellular response occurred, isolating and destroying the remains of the larvae until healing process completes and scars with low numbers of inflammatory cells appear., This study was supported by the Research Project AGL-2009- 08939 and by a grantfor Consolidating and Structuring Competitive Research Groups (Xunta de Galicia CN2012/326). The authors also thank the Xunta de Galicia government for pre-doctoral grant to E. Cabanelas.

Fasting and sepsis induce profound changes in thyroid hormone (TH) central and peripheral metabolism. These changes affect TH action and are called the non-thyroidal illness syndrome (NTIS). To date, it is still debated whether NTIS represents an adaptive response or a real hypothyroid state at the tissue level. Moreover, even though it has been considered the same syndrome, we hypothesized that fasting and sepsis induce a distinct set of changes in thyroid hormone metabolism. Herein, we aimed to evaluate the central and peripheral expression of genes involved in the transport (MCT8/Slc16a2 and MCT10/Slc16a10), metabolism (Dio1, Dio2, and Dio3) and action (Thra and Thrb) of TH during NTIS induced by fasting or sepsis. Male mice were subjected to a 48 h period of fasting or cecal ligation and puncture (CLP)-induced sepsis. At the peripheral level, fasting led to: (1) reduced serum thyroxine (T4) and triiodothyronine (T3), expression of Dio1, Thra, Slc16a2, and MCT8 protein in liver; (2) increased hepatic Slc16a10 and Dio3 expression; and (3) decreased Slc16a2 and Slc16a10 expressions in the thyroid gland. Fasting resulted in reduction of Tshb expression in the pituitary and increased expression of Dio2 in total hypothalamus, arcuate (ARC) and paraventricular (PVN) nucleus. CLP induced sepsis resulted in reduced: (1) T4 serum levels; (2) Dio1, Slc16a2, Slc16a10, Thra, and Thrb expression in liver as well as Slc16a2 expression in the thyroid gland (3) Thrb and Tshb mRNA expression in the pituitary; (4) total leukocyte counts in the bone marrow while increased its number in peritoneal and pleural fluids. In summary, fasting- or sepsis-driven NTIS promotes changes in the set point of hypothalamus-pituitary-thyroid axis through different mechanisms. Reduced hepatic THRs expression in conjunction with reduced TH transporters expression in the thyroid gland may indicate, respectively, reduction in the peripheral action and in the secretion of TH, which may contribute to the low TH serum levels observed in both models.

Resumo: Introdução: A ressonância magnética cardíaca (RMC) tem vindo a adquirir grande relevância na avaliação diagnóstica de um espectro cada vez mais amplo de cardiomiopatias, incluindo as que apresentam potencial arritmogénico. Objetivo: Avaliação do valor acrescentado da RMC no diagnóstico etiológico de arritmias ventriculares, quando a investigação convencional inicial com outros métodos complementares de diagnóstico não é conclusiva. Métodos: Estudaram-se retrospetivamente os doentes que realizaram RMC para esclarecimento da etiologia de arritmias ventriculares, entre 2005-2011 (n = 113). Foram incluídos apenas doentes com arritmias ventriculares documentadas. Constituíram critérios de exclusão a obtenção de diagnóstico definitivo por exame complementar, de diagnóstico realizado previamente e a presença de história prévia sugestiva de doença coronária (antecedentes de síndrome coronária aguda ou história de angor típico, de elevação de biomarcadores de necrose miocárdica ou teste de isquemia positivo, quando realizado). Os resultados da RMC foram considerados relevantes quando sugeriram um diagnóstico provável. Resultados: Dos 113 doentes incluídos, 57,5% eram homens. A idade média foi 41,7 ± 16,2 anos. Quanto à arritmia documentada, 38,1% dos doentes foram referenciados por taquicardia ventricular/fibrilhação ventricular (FV/TV mantida) e 61,9% por extrassistolia ventricular com menor complexidade (ESV). A RMC mostrou alterações sugestivas de um diagnóstico específico em 42,5% dos doentes, foi totalmente normal em 36,3% e mostrou alterações inespecíficas nos restantes. Nos casos de referenciação por FV/TV mantida a RMC foi diagnóstica em 60,4% dos casos, enquanto nos casos de ESV foi-o em 31,4%.Os diagnósticos prováveis mais frequentes foram displasia arritmogénica do ventrículo direito, não compactação ventricular e miopericardite. Assinala-se que, apesar da ausência de evidências clínicas sugestivas pelos critérios atrás referidos, 6,2% dos doentes apresentaram áreas de realce tardio com distribuição e características atribuíveis a doença coronária obstrutiva. Conclusão: A RMC proporciona valor acrescentado no diagnóstico etiológico de arritmias ventriculares quando exames mais acessíveis ou realizados previamente não são conclusivos. A percentagem de doentes em que foi conclusiva foi de 42,5% (60,4% nos casos de referenciação por FV/TV mantida) e em que foi totalmente normal foi de 36,3%. Abstract: Introduction: Cardiac magnetic resonance (CMR) imaging is increasingly important in the diagnostic work-up of a wide range of heart diseases, including those with arrhythmogenic potential. Objective: To assess the added value of CMR in etiological diagnosis of ventricular arrhythmias after an inconclusive conventional investigation. Methods: Patients undergoing CMR between 2005 and 2011 for investigation of ventricular arrhythmias were included (n=113). All had documented arrhythmias. Those with a definite diagnosis from a previous investigation and those with evidence of coronary artery disease (acute coronary syndrome, typical angina symptoms, increase in biomarkers or positive stress test) were excluded. CMR results were considered relevant when they fulfilled diagnostic criteria. Results: Of the 113 patients, 57.5% were male and mean age was 41.7±16.2 years. Regarding the initial arrhythmia, 38.1% had ventricular fibrillation/sustained ventricular tachycardia (VF/VT) and 61.9% had less complex ventricular ectopy. CMR imaging showed criteria of a specific diagnosis in 42.5% of patients, was totally normal in 36.3%, and showed non-specific alterations in the remainder. In VF/VT patients, specific criteria were found in 60.4%, and in 31.4% of those with less complex ectopy.The most frequent diagnoses were arrhythmogenic right ventricular dysplasia, ventricular non-compaction and myopericarditis. It is worth noting that, although there was no evidence of previous coronary artery disease, 6.2% of patients had a late gadolinium enhancement distribution pattern compatible with myocardial infarction. Conclusion: CMR gives additional and important information in the diagnostic work-up of ventricular arrhythmias after an inconclusive initial investigation. The proportion of patients with diagnostic criteria was 42.5% (60.0% in those with VF/VT), and CMR was completely normal in 36.6%. Palavras-chave: Ressonância magnética cardíaca, Etiologia de arritmias ventriculares, Substrato arritmogénico, Keywords: Cardiac magnetic resonance, Diagnosis of ventricular arrhythmias, Arrhythmogenic substrate

Introduction: Cardiac magnetic resonance (CMR) imaging is increasingly important in the diagnostic work-up of a wide range of heart diseases, including those with arrhythmogenic potential. Objective: To assess the added value of CMR in etiological diagnosis of ventricular arrhythmias after an inconclusive conventional investigation. Methods: Patients undergoing CMR between 2005 and 2011 for investigation of ventricular arrhythmias were included (n=113). All had documented arrhythmias. Those with a definite diagnosis from a previous investigation and those with evidence of coronary artery disease (acute coronary syndrome, typical angina symptoms, increase in biomarkers or positive stress test) were excluded. CMR results were considered relevant when they fulfilled diagnostic criteria. Results: Of the 113 patients, 57.5% were male and mean age was 41.7±16.2 years. Regarding the initial arrhythmia, 38.1% had ventricular fibrillation/sustained ventricular tachycardia (VF/VT) and 61.9% had less complex ventricular ectopy. CMR imaging showed criteria of a specific diagnosis in 42.5% of patients, was totally normal in 36.3%, and showed non-specific alterations in the remainder. In VF/VT patients, specific criteria were found in 60.4%, and in 31.4% of those with less complex ectopy.The most frequent diagnoses were arrhythmogenic right ventricular dysplasia, ventricular non-compaction and myopericarditis. It is worth noting that, although there was no evidence of previous coronary artery disease, 6.2% of patients had a late gadolinium enhancement distribution pattern compatible with myocardial infarction. Conclusion: CMR gives additional and important information in the diagnostic work-up of ventricular arrhythmias after an inconclusive initial investigation. The proportion of patients with diagnostic criteria was 42.5% (60.0% in those with VF/VT), and CMR was completely normal in 36.6%. Resumo: Introdução: A ressonância magnética cardíaca (RMC) tem vindo a adquirir grande relevância na avaliação diagnóstica de um espectro cada vez mais amplo de cardiomiopatias, incluindo as que apresentam potencial arritmogénico. Objetivo: Avaliação do valor acrescentado da RMC no diagnóstico etiológico de arritmias ventriculares, quando a investigação convencional inicial com outros métodos complementares de diagnóstico não é conclusiva. Métodos: Estudaram-se retrospetivamente os doentes que realizaram RMC para esclarecimento da etiologia de arritmias ventriculares, entre 2005-2011 (n = 113). Foram incluídos apenas doentes com arritmias ventriculares documentadas. Constituíram critérios de exclusão a obtenção de diagnóstico definitivo por exame complementar, de diagnóstico realizado previamente e a presença de história prévia sugestiva de doença coronária (antecedentes de síndrome coronária aguda ou história de angor típico, de elevação de biomarcadores de necrose miocárdica ou teste de isquemia positivo, quando realizado). Os resultados da RMC foram considerados relevantes quando sugeriram um diagnóstico provável. Resultados: Dos 113 doentes incluídos, 57,5% eram homens. A idade média foi 41,7 ± 16,2 anos. Quanto à arritmia documentada, 38,1% dos doentes foram referenciados por taquicardia ventricular/fibrilhação ventricular (FV/TV mantida) e 61,9% por extrassistolia ventricular com menor complexidade (ESV). A RMC mostrou alterações sugestivas de um diagnóstico específico em 42,5% dos doentes, foi totalmente normal em 36,3% e mostrou alterações inespecíficas nos restantes. Nos casos de referenciação por FV/TV mantida a RMC foi diagnóstica em 60,4% dos casos, enquanto nos casos de ESV foi-o em 31,4%.Os diagnósticos prováveis mais frequentes foram displasia arritmogénica do ventrículo direito, não compactação ventricular e miopericardite. Assinala-se que, apesar da ausência de evidências clínicas sugestivas pelos critérios atrás referidos, 6,2% dos doentes apresentaram áreas de realce tardio com distribuição e características atribuíveis a doença coronária obstrutiva. Conclusão: A RMC proporciona valor acrescentado no diagnóstico etiológico de arritmias ventriculares quando exames mais acessíveis ou realizados previamente não são conclusivos. A percentagem de doentes em que foi conclusiva foi de 42,5% (60,4% nos casos de referenciação por FV/TV mantida) e em que foi totalmente normal foi de 36,3%. Keywords: Cardiac magnetic resonance, Diagnosis of ventricular arrhythmias, Arrhythmogenic substrate, Palavras-chave: Ressonância magnética cardíaca, Etiologia de arritmias ventriculares, Substrato arritmogénico

IntroductionStenosis, mediated by neointimal hyperplasia and thrombosis, is a major limiting factor in successful stent implantation. The introduction of a stent, coated in its endoluminal surface by antihuman CD34 antibodies with endothelial progenitor cell-capturing properties, opens the possibility of promoting a rapid and normal functioning coverage by endothelium and thus avoids both an excessive cell proliferation within stent and the need for long-term dual antiplatelet therapy. These stents, developed for adult coronary artery disease, have not yet been implanted in children or in those with congenital heart disease.Objective and methodsIn this paper, we describe the implantation of Genous®stents in three children with cyanotic congenital heart disease and obstructed systemic-to-pulmonary shunts. We describe the use of this stent and address its potential feasibility in paediatric congenital heart disease.ResultsTo maintain the patency of two modified Blalock–Taussig shunts and one ductus arteriosus, four Genous®stents were implanted in three infants with cyanotic heart disease. All procedures were immediately successful, with resolution of stenosis and improvement in transcutaneous oxygen saturation from 66% ± 3.6% to 92% ± 2.6%. In the follow-up, one stent had no occlusion; however, the remaining two had partial occlusion after 5 and 5.5 months, which were successfully managed with balloon dilatation preceding elective definitive surgical correction.ConclusionIn our preliminary experience, we demonstrated that Genous®stent implantation was feasible in infants with complex congenital heart disease. Additional studies with larger samples and longer follow-up are required to confirm the potential benefits of this technology in this clinical setting.

Introduction: Gated SPECT myocardial perfusion imaging (MPI) has been used to quantify mechanical dyssynchrony. Mechanical dyssynchrony appears to be related to response to cardiac resynchronization therapy. Objective: To evaluate the presence and predictors of mechanical dyssynchrony in patients with impaired left ventricular function (LVEF) ≤50%. Methods: The study included 143 consecutive patients referred for gated SPECT MPI with LVEF ≤50%. Gated SPECT MPI was performed according to a stress/rest protocol acquiring images with Tc 99m-tetrofosmin. Emory Cardiac Toolbox software was used for phase analysis and a standard deviation (SD) ≥43° was considered to indicate mechanical dyssynchrony. Results: Mechanical dyssynchrony was present in 53.1% of the patients. Its predictors were diabetes (OR 2.0, p≤0.05), summed stress score (OR 1.1, p≤0.0005), summed rest score (OR 1.1, p≤0.0001), end-diastolic volume (OR 1.0, p≤0.0001), LVEF (OR 0.9, p≤0.0001), LVEF ≤35% (OR 3.1, p≤0.005) and LVEF ≤35% and QRS ≥120 ms (OR 3.5, p≤0.05). In this study QRS width and QRS ≥120 ms were not predictors of mechanical dyssynchrony. Conclusions: Myocardial perfusion imaging can be used to assess mechanical dyssynchrony. In patients with impaired ventricular function mechanical dyssynchrony was highly prevalent and was related to parameters of left ventricular function and perfusion. Resumo: Introdução: A avaliação de dessincronia ventricular mecânica através da análise do histograma de fase na cintigrafia de perfusão miocárdica tem sido descrita na literatura. Segundo a evidência atual, a presença de dessincronia mecânica encontra-se relacionada com a resposta à terapêutica de ressincronização. Objectivos: Avaliar a presença e os preditores de dessincronia ventricular mecânica em pacientes com fração de ejeção ventricular esquerda (FEVE) ≤ 50%. Métodos: Foram incluídos pacientes que realizaram cintigrafia de perfusão miocárdica e cuja FEVE foi inferior ou igual a 50%. A amostra estudada incluiu 143 pacientes. As imagens de perfusão foram adquiridas de acordo com o protocolo esforço seguido de repouso com Tc-99m Tetrafosmina. A avaliação de dessincronia baseou-se na determinação do desvio padrão obtido através da análise do histograma de fase (Emory Toolbox Software). A presença de dessincronia foi considerada quando o desvio-padrão no histograma de fase foi superior ou igual a 43°. Resultados: A presença de dessincronia foi observada 53,1% dos doentes. Foram preditores de dessincronia, a diabetes (OR 2,0, p ≤ 0,05), o score de esforço (OR 1,1, p ≤ 0,0005), o score de repouso (OR 1,1, p ≤ 0,0001), o volume telediastólico (OR 1,0, p ≤ 0,0001), a FEVE (OR 0,9, p ≤ 0,0001), FEVE ≤ 35% (OR 3,1, p ≤ 0,005) e a presença em simultâneo de FEVE ≤ 35% e QRS ≥120 ms (OR 3,5, p ≤ 0,05). Nesta avaliação a duração do QRS ou a presença de QRS ≥ 120 ms não se relacionaram com a presença de dessincronia. Conclusões: A cintigrafia de perfusão miocárdica pode ser usada na avaliação de dessincronia e esta tem uma elevada prevalência em pacientes com FEVE diminuída relacionando-se com parâmetros de função ventricular e perfusão miocárdica. Keywords: Myocardial perfusion imaging, Gated SPECT, Dyssynchrony, Coronary artery disease, Heart failure, Palavras-chave: Cintigrafia de perfusão miocárdica, Gated SPECT, Dessincronia, Doença coronária, Insuficiência cardíaca

This research aims to determine the cardiac morphological and functional changes that occur during the competitive season in elite athletes with previously-induced adaptive changes.Two echocardiographic examinations were performed in each player of a senior professional football team, the first at the beginning of the training phase and the other at the peak of the competitive season.It was demonstrated that after the brief period of deconditioning during the holiday period, further changes took place, even in these athletes with several years of prior professional activity.There was a significant increase between the two assessments in left ventricular wall thickness and mass, and in left atrial diameter, but left ventricular diastolic diameter and the diastolic function parameters considered remained the same. Greater left ventricular wall hypertrophy was related to more competitive playing time in these players.The main limitation of the study is the small number of athletes studied. Resumo: A presente investigação tem por objetivo estabelecer quais as alterações cardiológicas morfo-funcionais, que ocorrem ao longo de uma época desportiva, em atletas de alta competição com modificações adaptativas previamente induzidas.Para tal, realizaram-se dois exames ecocardiográficos a cada um dos atletas do plantel sénior de uma equipa de futebol profissional, um no início da fase de treinos e outro no período de maior intensidade competitiva, considerado como o pico de esforço.Demonstrou-se que, após o breve período de descondicionamento que correspondeu às férias desportivas, existe lugar a adaptações adicionais, mesmo em atletas com vários anos de prática profissional prévia.Entre as duas avaliações, verificou-se o aumento significativo da espessura das paredes do ventrículo esquerdo e respetiva massa, e do diâmetro da aurícula esquerda, com manutenção do diâmetro telediastólico do ventrículo esquerdo, e dos parâmetros de função diastólica considerados. Uma maior extensão da hipertrofia da musculatura ventricular relacionou-se com maior utilização em competição por parte dos atletas em que ela ocorreu.A principal limitação do estudo prende-se com o pequeno número de atletas estudados. Keywords: Athlete's heart, Cardiac adaptations to effort, Echocardiography in athletes, Palavras-chave: Coração de atleta, Adaptações cardíacas ao esforço, Ecocardiografia em atletas

Early weaning is associated with changes in the developmental plasticity. Here, we studied the adipocytes morphology, adipokines expression or content in adipose tissue as well as adrenal and thyroid function of neonate and adult offspring primed by early weaning. After birth, lactating rats were divided into 2 groups: EW (early weaning) – dams were wrapped with a bandage to block access to milk during the last 3 days of lactation, and Control – dams whose pups had free access to milk throughout lactation (21 days). At postnatal day (PN) 21, EW pups had lower visceral and subcutaneous adipocyte area ( − 67.7% and − 62%, respectively), body fat mass ( − 26%), and leptin expression in visceral adipocyte ( − 64%) but higher leptin expression in subcutaneous adipocyte (2.9-fold increase). Adrenal evaluations were normal, but neonate EW pups presented lower serum T3 ( − 55%) and TSH ( − 44%). At PN 180, EW offspring showed higher food intake, higher body fat mass (+21.6%), visceral and subcutaneous adipocyte area (both 3-fold increase), higher leptin (+95%) and ADRβ3 (2-fold increase) content in visceral adipose tissue, and higher adiponectin expression in subcutaneous adipose tissue (+47%) but lower in visceral adipose tissue ( − 40%). Adult EW offspring presented higher adrenal catecholamine content (+31%), but no changes in serum corticosterone or thyroid status. Thus, early weaning primed for hypothyroidism at weaning, which can be associated with the adipocyte hypertrophy at adulthood. The marked changes in catecholamine adrenal content and visceral adipocyte ADRB3 are generally found in obesity, contributing to the development of other cardiovascular and metabolic disturbances.

Leptin has been shown to regulate the hypothalamus–pituitary–thyroid axis, acting primarily through the STAT3 pathway triggered through the binding of leptin to the long-chain isoform of the leptin receptor, ObRb. We previously demonstrated that although hyperthyroid rats presented leptin effects on TSH secretion, those effects were abolished in hypothyroid rats. We addressed the hypothesis that changes in the STAT3 pathway might explain the lack of TSH response to leptin in hypothyroidism by evaluating the protein content of components of leptin signalling via the STAT3 pathway in the hypothalamus and pituitary of hypothyroid (0.03% methimazole in the drinking water/21 days) and hyperthyroid (thyroxine 5 μg/100 g body weight /5 days) rats. Hypothyroid rats exhibited decreased ObRb and phosphorylated STAT3 (pSTAT3) protein in the hypothalamus, and in the pituitary gland they exhibited decreased ObRb, total STAT3, pSTAT3 and SOCS3 (P

Neuropeptide Y (NPY) inhibits TRH neurons in fed state, and hypothalamic NPY higher expression during fasting has been proposed to be involved in fasting-induced suppression of the hypothalamus-pituitary–thyroid (HPT) axis. We investigated the role of central Y5 receptors in the control of thyrotropin (TSH) and thyroid hormone (TH) secretion. Fed and fasting rats received twice daily central injections (3rd ventricle) of Y5 receptor antagonist (CGP71683; 15nmol/rat) for 72h. Fasted rats also received a single central injection of CGP71683 (15nmol/rat) at the end of 72h of fasting. In fed rats, Y5 receptor blockade reduced total food intake by 32% and body mass by almost 10% (p

Adult Still's Disease has systemic consequences, an inflammatory origin and unknown etiology. Knowledge about this disease is still limited, but some evolution has occurred in the last few years.Using a clinical case as example, the purpose of this paper is to review actual knowledge about Adult Still's Disease, giving special relevance to the most recent findings.Search in Pubmed and Cochrane database (1970-2009) for the terms Adultonset Still's Disease for all available papers. Those considered clinically and historically relevant were selected. An additional search was done in scientific journals and textbooks and other web sites. The information was analysed, using a clinical case in an atypical age as illustration.Adult Still's Disease as multiple manifestations, being fever, evanescent skin rash and arthralgia the most typical. Laboratorial parameters are inespecific, but high glycosilated ferritin is highly suggestive. Non-steroid anti-inflammatory, corticoids, immunosuppressors, and recent biological agents are used in treatment.Being uncommon, actual knowledge about this disease is based in isolated descriptions or very short series. There are no specific guidelines, but diagnostic criteria have been improved in recent years, as have the insights in pathophysiology and therapeutic resources.

Previous studies have proposed a role for neuromedin B (NB), a bombesin-like peptide, in the control of body weight homeostasis. However, the nature of this role is unclear. The actions of NB are mediated preferentially by NB-preferring receptors (NBRs). Here we examined the consequences of targeted deletion of NBRs in female mice on body weight homeostasis in mice fed a normolipid diet (ND) or a high-fat diet (HFD) for 13 weeks. Body weight and food ingestion of neuromedin B receptor knockout (NBR-KO) mice fed a normolipid diet showed no difference in relation to wild-type (WT). However, the high-fat diet induced an 8.9- and 4.8-fold increase in body weight of WT and NBR-KO, respectively, compared to their controls maintained with a normolipid diet, even though the mice ingested the same amount of calories, regardless of genotype. Comparing mice fed the high-fat diet, NBR-KO mice accumulated approximately 45% less fat depot mass than WT, exhibited a lower percentage of fat in their carcasses (19.2 vs. 31.3%), and their adipocytes were less hypertrophied. Serum leptin and leptin mRNA in inguinal and perigonadal fat were lower in HFD NBR-KO than HFD WT, and serum adiponectin was similar among HFD groups and unaltered in comparison to ND-fed mice. HFD-fed WT mice developed glucose intolerance but not the HFD-fed NBR-KO mice, although they had similar glycaemia and insulinaemia. NBR-KO and WT mice on the normolipid diet showed no differences in any parameters, except for a trend to lower insulin levels. Therefore, disruption of the neuromedin B receptor pathway did not change body weight homeostasis in female mice fed a normolipid diet; however, it did result in partial resistance to diet-induced obesity.

Objectives: To evaluate and understand which aspects of verbal and non-verbal communication patients refer as more satisfying. Type of Study: Cross-sectional Study Location: Centro Hospitalar Cova da Beira (CHCB) - Emergency Room Study Population: Patients attending the Emergency Room Methods: A questionnaire was applied by direct interview to 200 patients with 18 years-old or older, at the Emergency Room, during 10 random days, between November and December 2008. Results: Most participants referred that speed of speech (83.5%), visual contact (90%), physical closeness (68,5%) and doctor’s movements, such as nodding while listening patient’s complains (70%), are important for their satisfaction. On the other hand, they believe that doctor’s hair (78%), way of dressing (69,5%) and accent (68%) are irrelevant. When asked about more specific aspects of communication, they say they are more satisfied when the doctor speaks slowly (95,7%), as loud as them (87%) with common expressions (94,3%), dresses up in an informal manner (82,3%), touches them (67,5%), sits in front of them behind the desk (57,2%), and when female doctors have long (66,7%) and well combed hair (93,8%). When asked about the sex and age of the physician who contributes most to their satisfaction, patients show a preference for female physicians (75,7%); and by those who are under 50 years-old (70,1%). Conclusion: There are variables of verbal and non-verbal communication part of the doctor-patient relationship that influence the patients satisfaction.

Previous studies have shown that alterations in thyroid status may lead to changes in serum leptin and adiponectin, both in humans and rodents. The mechanisms, especially for adiponectin, are unclear. In the present study, we investigated the effect of triiodothyronine (T3) on the expression of adiponectin mRNA and the release of leptin and adiponectin by white adipose tissue (WAT) explants obtained from epididymal (visceral) or inguinal (subcutaneous) depots from normal rats. We also analyzed the effects of other known regulators of adiponectin and leptin release, such as rosiglitazone and dexamethasone. T3 acted directly at rat WAT explants in a depot-specific manner and in a unique fashion to each hormone. T3 was able to inhibit leptin release only by epididymal explants, and to reduce adiponectin mRNA expression only in inguinal explants. However, T3 was incapable of modifying adiponectin release by both explants. Additionally, rosiglitazone exhibited an inhibitory effect on adiponectin release by both WAT explants, even though adiponectin mRNA was importantly upregulated only in inguinal explants. Rosiglitazone acted as an inhibitor of leptin release by both studied fat depots, while only epididymal explants responded to the stimulatory effect of dexamethasone on leptin release. Therefore, the present model of isolated rat white adipose tissue explants highlights the fact that the regulation of hormonal production by white adipose tissue depends on the type of depot and its anatomical location. In this context, our results show for the first time a potential inhibitory effect of T3 on adiponectin mRNA expression specifically on WAT from a subcutaneous depot.

Diabetes Mellitus e Hipertensao Arterial sao entidades clinicas que se associam frequentemente num mesmo doente; juntas exercem um efeito sinergico provocando, entre outras, deterioracao acelerada da funcao renal e um aumento do risco cardiovascular. A tensao arterial no doente diabetico deve ser rigorosamente controlada de modo a atingir valores inferiores a 130/80 mmHg. Objectivos: Analise das classes farmacologicas de anti-hipertensores mais indicadas no tratamento do diabetico hipertenso. Metodos: Revisao bibliografica incluindo tratados de referencia e artigos recentemente publicados nas areas da Diabetologia e Hipertensao Arterial. Conclusoes: Os anti-hipertensores de primeira linha deverao ser os inibidores da enzima de conversao da angiotensina I, devido aos seus efeitos protectores renais e cardiovasculares, ou os antagonistas dos receptores de angiotensina II, caso haja intolerância ou contra-indicacao aos primeiros. A estes podem-se associar diureticos tiazidicos em baixa dose. Numa segunda linha do arsenal terapeutico temos os b-bloqueantes e os bloqueadores dos canais de calcio. Os diureticos de ansa, agentes centrais e a-bloqueantes sao farmacos de terceira linha a ser empregues face a casos de hipertensao arterial resistente as classes anteriores e/ou em casos especificos.

Neuromedin B (NB), a neuropeptide highly concentrated in pituitary, has been proposed to be an inhibitor of thyrotropin (TSH) secretion. Previous study showed that mice with disruption of neuromedin B receptor (NBR-KO) have higher TSH release in response to thyrotropin-releasing hormone (TRH), although TSH seems to have decreased bioactivity. Here we examined in NBR-KO mice the response of TSH to thyroid hormone (TH) deprivation, obtained by methimazole treatment, or excess, obtained by acute and chronic TH administration. In response to hypothyroidism NBR-KO mice exhibited a lower magnitude increase in serum TSH compared to wild-type (WT) mice (1.7 vs. 3.3-times increase compared to euthyroid values, respectively, P 0.001). One hour after a single T4 injection (0.4μg/100 g BW), WT and NBR-KO hypothyroid mice presented similar degree of serum TSH reduction (54%, P 0.05). However, 3 h after T4 administration, WT mice presented serum TSH similar to hypothyroid baseline, while NBR-KO mice still had decreased serum TSH (30% reduced in comparison to hypothyroid baseline P 0.05). T3 treatment of euthyroid mice for 21 days, with progressively increasing doses, significantly reduced serum TSH similarly in WT and NBR-KO mice. Also, serum T4 exhibited the same degree of suppression in WT and NBR-KO. In conclusion, disruption of neuromedin B receptor did not interfere with the sensitivity of thyroid hormone-mediated suppression of TSH release, but impaired the ability of thyrotroph to increase serum TSH in hypothyroidism, which highlights the importance of NB in modulating the set point of the hypothalamus–pituitary–thyroid axis at hypothyroidism.

Leptin has been shown to modulate deiodinase type 1 (D1) and type 2 (D2) enzymes responsible for thyroxine (T4) to triiodothyronine (T3) conversion. Previously, it was demonstrated that a single injection of leptin in euthyroid fed rats rapidly increased liver, pituitary, and thyroid D1 activity, and simultaneously decreased brown adipose tissue (BAT) and hypothalamic D2 activity. We have now examined D1 and D2 activities, two hours after a single subcutaneous injection of leptin (8 microg/100 g BW) into hypo- and hyperthyroid rats. In hypothyroid rats, leptin did not modify pituitary, liver and thyroid D1, and thyroid D2 activity, while pituitary D2 was decreased by 41% (p

A secreção de tireotrofina (TSH) é determinada pelo efeito estimulatório do hormônio hipotalâmico estimulador de tireotrofina (TRH) e pela retroalimentação negativa exercida pelos hormônios tireóideos (HT). Superpostos, atuam outros reguladores e aferências do sistema nervoso central. Somatostatina e dopamina inibem a secreção de TSH, já as vias alfa-adrenérgicas centrais são predominantemente estimuladoras e participariam no estímulo da secreção de TSH pelo frio. O estado nutricional modula o eixo através da leptina, por vias diretas e indiretas. O estresse induz redução da secreção de TSH, e discute-se a participação dos glicocorticóides, citocinas e opiáceos. Recentemente, evidenciou-se que fatores locais produzidos na adenohipófise podem atuar de forma autócrina/parácrina, modulando a secreção de TSH. Dentre estes, destacam-se a neuromedina B e o peptídeo liberador de gastrina, que atuam como inibidores locais da secreção de TSH. Discute-se ainda, as alterações do TSH decorrentes da programação neonatal, por hormônios ou desnutrição.

We investigated the effect of acute cold exposure, leptin, and the somatostatin analog octreotide (OCT) on thyroid type I (D1) and II (D2) deiodinase activities. Microsomal D1 and D2 activities were measured by the release of 125I from 125I-reverse triiodothyronine (rT3) under different assay conditions. Rats exposed to 4°C (15, 30, 60, and 120 min) showed progressive reduction in thyroidal D1 and D2, reaching ∼40% at 2 h ( P < 0.05) despite increased circulating TSH ( P < 0,05) associated with the higher thyroid D1 and D2 in hypothyroid rats. A single injection of leptin (8 μg/100 g body wt sc) induced increased thyroid and liver D1 ( P < 0.05), but not thyroid D2, activities at 30 and 120 min, independently of the serum TSH rise shown only at 2 h. OCT (1 μg/kg body wt sc) increased D1 and D2 activity significantly 24 h after a single injection, with no changes in serum TSH. Therefore, leptin and somatostatin are potential physiological upregulators of thyroid deiodinases, and their low secretion during acute cold exposure may be a potential mechanism contributing to cold-induced reduction in thyroid deiodinase activity.

We have shown that protein restriction during lactation is associated with higher levels of serum and milk tri-iodothyronine (T(3)) with lower serum thyroxine (T(4)), suggesting an increased T(4) to T(3) conversion. To investigate this hypothesis, the activity of type 1 (D1) and/or type 2 (D2) iodothyronine deiodinases was evaluated on days 4, 12 and 21 of lactation in several tIssues of dams fed an 8% protein-restricted (PR) diet and controls fed a 23% protein diet. Serum TSH, T(3) and T(4) were measured by radioimmunoassay. Deiodinase activity was determined by the release of (125)I from (125)I-reverse T(3), under specific conditions for D1 or D2. PR dams had a transitory reduction in liver D1 activity (P

The obstructive sleep apnea syndrome (OSA) is a clinical entity characterized by recurring episodes of apnea and/or hypopnea during sleep, due to a total or partial collapse, respectively, of the upper airway. This collapse originates a set of pathophysiological changes that determine the appearance of several cardiovascular complications. OSA contributes for the development of hypertension, heart failure, arrhythmias and coronary heart disease. Nowadays it is recognized to be an important public health problem, taking into account not just its repercussions but also its prevalence, since the main risk factor for the disease is obesity, a growing problem worldwide, both in developed and developing countries. The present review summarizes the current knowledge about OSA, as regards its definition, pathophysiology, clinical manifestations, diagnosis, cardiovascular effects and treatment.

Resumo: Os benefícios demonstrados com a terapêutica de ressincronização cardíaca (TRC) na redução da mortalidade e hospitalização por ICC, melhoria da classe funcional e obtenção de remodelagem inversa em doentes selecionados com insuficiência cardíaca (ICC), têm contribuído para a crescente utilização destes dispositivos na prática clínica.No entanto, permanece controverso o impacto da TRC como fator causador de arritmias ventriculares complexas. Apresentamos o caso duma doente com cardiopatia valvular operada, disfunção sistólica grave e ICC classe III da NYHA, com terapêutica médica otimizada, sem documentação prévia de arritmias ventriculares significativas. Após implantação do sistema de TRC com cardioversor‐desfibrilhador, desenvolveu quadro de tempestade arrítmica com múltiplos episódios de taquicardia ventricular monomórfica (TV) e necessidade de 12 choques, mantendo padrão de bigeminismo ventricular reprodutível e indução de salvas de TV pelo pacing biventricular. Dada a inacessibilidade a outra veia tributária do seio coronário foi decidido implantar elétrodo epicárdico em localização diferente (de veia póstero‐lateral para posição lateral‐mediana), sem registo de recorrência de arritmias num follow‐up de seis meses. Este caso sugere que a TRC pode contribuir para um efeito pró‐arrítmico com consequências clínicas potencialmente graves. Abstract: The demonstrated benefits of cardiac resynchronization therapy (CRT) in reducing mortality and hospitalizations for heart failure, improving NYHA functional class and inducing reverse remodeling have led to its increasing use in clinical practice. However, its potential contribution to complex ventricular arrhythmias is controversial.We present the case of a female patient with valvular heart failure and severe systolic dysfunction, in NYHA class III and under optimal medical therapy, without previous documented ventricular arrhythmias. After implantation of a CRT defibrillator, she suffered an arrhythmic storm with multiple episodes of monomorphic ventricular tachycardia (VT), requiring 12 shocks. Subsequently, a pattern of ventricular bigeminy was observed, as well as reproducible VT runs induced by biventricular pacing.Since no other vein of the coronary sinus system was accessible, it was decided to implant an epicardial lead to stimulate the left ventricle, positioned in the left ventricular mid‐lateral wall. No arrhythmias were detected in the following six months.This case highlights the possible proarrhythmic effect of biventricular pacing with a left ventricular lead positioned in the coronary sinus venous system. Palavras‐chave: Ressincronização cardíaca, Pacing epicárdico, Heterogeneidade da repolarização, Keywords: Cardiac resynchronization, Epicardial pacing, Repolarization heterogeneity

We had previously shown that GRP acts directly at the pituitary gland inhibiting basal and TRH-stimulated TSH secretion in adult male rats. In this study we showed a gender dimorphism in this response of old animals pituitaries to GRP. In both female and male young adult animals, GRP-incubated pituitaries showed approximately 50% less basal and TRH-stimulated TSH secretion to the medium, without affecting the pituitary content of TSH. However, GRP did not have any significant effect upon TSH secretion in old male rats, but the old female showed the same degree of response to GRP as the young adult female rat, regarding basal and TRH-stimulated TSH secretion, while the TSH pituitary content after GRP incubation was higher than that of the young female group. Our data suggest a loss of thyrotrope responsiveness to GRP in aged male rats that could contribute to the decrease in TSH pituitary stores leading to lower basal and TRH-stimulated TSH secretion. Meanwhile, the preservation of GRP responsiveness could help in the relative maintenance of these parameters in the old female rat.

Aims This study assessed the benefit of peri-implantable cardioverter–defibrillator implant ventricular tachycardia (VT)-substrate ablation in patients with structural heart disease (SHD). Methods and results Patients with SHD and indication for secondary prevention ICD implant were prospectively included. Patients presenting with incessant and/or slow VT or frequent (≥2) VT episodes who underwent peri-ICD VT-substrate ablation (the scar dechannelling technique) were compared with those who received ICD alone and did not meet ablation criteria. The primary endpoint was any sustained VT/ICD therapy during follow-up. Of 206 patients included (43.2% non-ischaemic), 70 were assigned to ablation and 136 received ICD implant alone. During a mean follow-up of 45.6 ± 24.7 months, the primary endpoint was more frequent in the non-ablation group (47.1 vs. 22.9%; P < 0.0001). Higher VT recurrence-free survival rate [log-rank P = 0.001; HR = 0.42 (0.24–0.73), P = 0.002] and ICD shock-free survival rate [log-rank P = 0.007; HR = 0.36 (0.17–0.78); P = 0.01] were observed in the ablation group. Higher relative risk reduction was observed in ischaemic [HR = 0.38 (0.18–0.83); P = 0.015] vs. non-ischaemic patients [HR = 0.49 (0.23–1.01); P = 0.08]. Patients with left ventricular ejection fraction (LVEF)

Obesity is a worldwide epidemic. Calcium influences energy metabolism regulation, causing body weight loss. Because maternal nicotine exposure during lactation programs for obesity, hyperleptinemia, insulin resistance (IR), and hypothyroidism, we decided to evaluate the possible effect of dietary calcium supplementation on these endocrine dysfunctions in this experimental model. Osmotic minipumps containing nicotine solution (N: 6 mg/kg per day for 14 days) or saline (C) were s.c. implanted in lactating rats 2 days after giving birth (P2). At P120, N and C offspring were subdivided into four groups: 1) C – standard diet; 2) C with calcium supplementation (CCa, 10 g calcium carbonate/kg rat chow); 3) N – standard diet; and 4) N with calcium supplementation (NCa). Rats were killed at P180. As expected, N offspring showed higher visceral and total body fat, hyperleptinemia, lower hypothalamus leptin receptor (OB-R) content, hyperinsulinemia, and higher IR index. Also, higher tyrosine hydroxylase (TH) expression (+51%), catecholamine content (+37%), and serum 25-hydroxyvitamin D3(+76%) were observed in N offspring. Dietary calcium supplementation reversed adiposity, hyperleptinemia, OB-R underexpression, IR, TH overexpression, and vitamin D. However, this supplementation did not reverse hypothyroidism. In NCa offspring,Sirt1mRNA was lower in visceral fat (−37%) and higher in liver (+42%). In conclusion, dietary calcium supplementation seems to revert most of the metabolic syndrome parameters observed in adult offspring programed by maternal nicotine exposure during lactation. It is conceivable that the reduction in fat massper se, induced by calcium therapy, is the main mechanism that leads to the increment of insulin action.

Introduction: Stanford type A aortic dissection is a rare phenomenon with high short-term mortality and clinical manifestations that can make differential diagnosis a lengthy process requiring several diagnostic examinations. Objectives: Based on a case report, the aim is to highlight the importance of physical examination in the initial management of these patients and of rapid access to a surgical center. A brief review follows on the diagnosis and treatment of ascending aortic dissection, and its specific nature in Marfan syndrome. Case report: A 33-year-old man was admitted to the emergency department of a district hospital with chest and back pain associated with vomiting, 20 hours after symptom onset. Initial physical examination revealed an aortic systolic murmur and musculoskeletal morphological abnormalities compatible with Marfan syndrome. Given suspected aortic dissection, a transthoracic echocardiogram was immediately performed, which showed an extensive intimal flap originating at the sinotubular junction. He was transferred to the cardiothoracic surgery department of a referral hospital where he was treated by a Bentall procedure. Conclusion: In this case, careful physical examination during initial assessment raised the suspicion that this patient was in a high-risk group for aortic dissection, thus avoiding unnecessary and lengthy exams. This diagnosis requires emergent surgical treatment, and so direct contact in real time between those making in the diagnosis and the surgeon is essential, as well as protocols governing immediate access to a surgical center. Resumo: Introdução: A Dissecção da Aorta tipo A de Stanford é um fenómeno raro, com alta mortalidade a curto prazo e com manifestações clínicas que por vezes tornam o diagnóstico diferencial um processo moroso pela necessidade de realização de várias modalidades de exames complementares no Serviço de Urgência. Objectivos: Através da alusão a um caso clínico, pretende-se realçar a importância do exame objectivo na abordagem inicial destes doentes e da rapidez do acesso a um centro cirúrgico. É feita uma breve revisão acerca do diagnóstico e tratamento da Dissecção da Aorta Ascendente, e das particularidades desta na Síndrome de Marfan. Caso clínico: Homem de 33 anos, admitido no Serviço de Urgência de um Hospital Distrital com quadro de dor dorsal e pré-cordial associada a vómitos, com 20 horas de evolução. O exame objectivo inicial mostrou a presença de sopro sistólico no foco aórtico e anomalias morfológicas músculo-esqueléticas compatíveis com Síndrome de Marfan. Com a suspeita de Dissecção da Aorta, realiza-se imediatamente ecocardiograma transtorácico que mostrou exuberante flap intimal com origem na junção sino-tubular. É transferido para o Serviço de Cirurgia Cárdio-Torácica do hospital de referência onde foi tratado com cirurgia tipo Bentall. Conclusão: No caso apresentado, uma primeira abordagem na qual se realizou um exame objectivo atento levantou a hipótese de o doente pertencer a um grupo de alto risco para Dissecção da Aorta, evitando exames complementares desnecessários e morosos. Este diagnóstico exige tratamento cirúrgico emergente, de modo que se torna imperiosa a existência de um contacto directo, em tempo real, entre quem faz o diagnóstico e o cirurgião, bem como protocolos de acesso imediato a um centro cirúrgico. Keywords: Ascending aortic dissection, Marfan syndrome, Bentall procedure, Palavras-chave: Disseção da aorta ascendente, Síndrome de Marfan, Cirurgia de Bentall