Browsing by Author "Rodrigues, C"
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- An unusual trigger causing Takotsubo SyndromePublication . Abreu, G; Rocha, S; Bettencourt, N; Azevedo, P; Vieira, C; Rodrigues, C; Arantes, C; Braga, C; Martins, J; Marques, J
- Biventricular Takotsubo vs Myocarditis – a diagnostic challengePublication . Abreu, G; Azevedo, P; Vieira, C; Arantes, C; Martins, J; Galvão-Braga, C; Rodrigues, C; Salomé, N; Vieira, JBackground: Takotsubo cardiomyopathy (TCM) is an important differential diagnosis of acute coronary syndrome and myocarditis. It is characterized by normal or near-normal coronary arteries and regional wall motion abnormalities that extend beyond a single coronary vascular bed. Variants of the classical left ventricular (LV) apical ballooning are increasing in recognition as cardiac magnetic resonance (CMR) is more extensively used. Case report: We present a case of 69-year-old woman with a previous history of hypertension, diabetes and dyslipidaemia, transferred to our emergency department due to suspected acute coronary syndrome. She had a history of two episodes of an oppressive chest pain longer than 1 hour, orthopnoea and paroxysmal nocturnal dyspnoea 36 hours before. Two weeks before she had had a lower tract respiratory infection, that was not totally resolved. On admission, she only had dyspnoea. On examination, she had wheezing, arrhythmic pulse and hypertension. Breath sounds were absent in lower chest and rales were also noted. Electrocardiogram showed rapid atrial fibrillation, poor R wave progression in anteroseptal leads and inverted T waves in I, aVL and V2-V6 leads. Modest elevation in cardiac troponin (4.55 ng/mL) was observed. Chest x-ray showed bilateral pleural effusion. A transthoracic echocardiography (TTE) was immediately performed and revealed akinesis/dyskinesis of mid to apical segments (apical ballooning) of both ventricles, extended beyond a single epicardial coronary distribution, compatible with biventricular TCM. Cardiac catheterization showed absence of obstructive coronary disease. A CMR, performed two days later, showed moderate biventricular systolic dysfunction, hypokinesis in mid to apical segments of LV and hypokinesis in apical right ventricle. It also showed non-ischemic late gadolinium enhancement in antero-apical and lateral apical segments. After several days of medical management, the patient was discharged from the hospital in stable condition. TTE performed 6-month after evidenced complete biventricular function recovery and no segmental contractility changes. CMR supported the functional recovery and the resolution of contractility abnormalities, but noticed the intramyocardial late gadolinium enhancement in the segments previously reported. Conclusion: There are fewer reports of this unusual presentation of TCM, described by ETT. This case represents a good example of the diagnostic challenge between myocarditis and takotsubo cardiomyopathy. Taking in account the exuberance of the case, the mild elevation of troponin, the full recovery of biventricular function and resolution of contractility abnormalities, it seems more probably to be a TCM, in a patient who, probably had a previous scar of myocarditis. Although, the hypothesis of acute myocarditis as the primary diagnosis cannot be excluded.
- Biventricular Takotsubo vs Myocarditis – a diagnostic challengePublication . Abreu, G; Azevedo, P; Vieira, C; Arantes, C; Martins, J; Galvão-Braga, C; Rodrigues, C; Salomé, N; Marques, JBackground: Takotsubo cardiomyopathy (TCM) is an important differential diagnosis of acute coronary syndrome and myocarditis. It is characterized by normal or near-normal coronary arteries and regional wall motion abnormalities that extend beyond a single coronary vascular bed. Variants of the classical left ventricular (LV) apical ballooning are increasing in recognition as cardiac magnetic resonance (CMR) is more extensively used. Case report: We present a case of 69-year-old woman with a previous history of hypertension, diabetes and dyslipidaemia, transferred to our emergency department due to suspected acute coronary syndrome. She had a history of two episodes of an oppressive chest pain longer than 1 hour, orthopnoea and paroxysmal nocturnal dyspnoea 36 hours before. Two weeks before she had had a lower tract respiratory infection, that was not totally resolved. On admission, she only had dyspnoea. On examination, she had wheezing, arrhythmic pulse and hypertension. Breath sounds were absent in lower chest and rales were also noted. Electrocardiogram showed rapid atrial fibrillation, poor R wave progression in anteroseptal leads and inverted T waves in I, aVL and V2-V6 leads. Modest elevation in cardiac troponin (4.55 ng/mL) was observed. Chest x-ray showed bilateral pleural effusion. A transthoracic echocardiography (TTE) was immediately performed and revealed akinesis/dyskinesis of mid to apical segments (apical ballooning) of both ventricles, extended beyond a single epicardial coronary distribution, compatible with biventricular TCM. Cardiac catheterization showed absence of obstructive coronary disease. A CMR, performed two days later, showed moderate biventricular systolic dysfunction, hypokinesis in mid to apical segments of LV and hypokinesis in apical right ventricle. It also showed non-ischemic late gadolinium enhancement in antero-apical and lateral apical segments. After several days of medical management, the patient was discharged from the hospital in stable condition. TTE performed 6-month after evidenced complete biventricular function recovery and no segmental contractility changes. CMR supported the functional recovery and the resolution of contractility abnormalities, but noticed the intramyocardial late gadolinium enhancement in the segments previously reported. Conclusion: There are fewer reports of this unusual presentation of TCM, described by ETT. This case represents a good example of the diagnostic challenge between myocarditis and takotsubo cardiomyopathy. Taking in account the exuberance of the case, the mild elevation of troponin, the full recovery of biventricular function and resolution of contractility abnormalities, it seems more probably to be a TCM, in a patient who, probably had a previous scar of myocarditis. Although, the hypothesis of acute myocarditis as the primary diagnosis cannot be excluded.
- Um caso raro de síncopePublication . Abreu, G; Arantes, C; Martins, J; Galvão-Braga, C; Rodrigues, C; Monteiro, M; Vilaça, A; Veira, C; Azevedo, P; Salomé, N; Pereira, C; Marques, J
- Incidence of in-stent restenosis over 13 years - a study based on a national registryPublication . Abreu, G; Braga, C; Arante, C; Martins, J; Rodrigues, C; Azevedo, P; Álvares-Pereira, M; Costa, J; Marques, JBackground: In-stent restenosis (ISR) is one drawback of coronary angioplasty with stent implantation. Purpose: We investigated the incidence of ISR, its clinical presentation and treatment from a national registry. Methods: From all patients (pts) undergoing percutaneous coronary intervention (PCI) from 2002 to 2014, we selected those who had previous history of PCI (n=15326). ISR was defined as diameter stenosis ≥ 50% in stent segment, being selected the interventions in which, at least, 1 IRS lesion was treated (n=3069). They were divided in 3 temporal groups:2002-2003 (group 1, n=179, 5.8%)– bare metal stent era; 2004-2008 (group 2,n=816, 26.6%)– 1st generation stent era; 2009-2014 (group 3, n=2074, 67.6%)– 2nd generation stent era. For each group we compared clinical features and treatment. Results: Over time, it has been observed a reduction in IRS incidence (24.8 vs 23.5 vs 18.6%;p for trend <0.001). Pts from group 3 were older (p=0.01), had higher prevalence of hypertension (63.7 vs 75.6 vs 78.4%;p<0.001), dyslipidemia (61.5 vs 68.5 vs 73.9%;p<0.001) and diabetes (31.3 vs 33.5 vs 38.5%;p=0.012). They also had more frequently history of previous myocardial infarction (p<0.001). Although admissions were more frequently due to stable angina (41% of total) or post non-ST segment myocardial infarction (16.3% of total); it was noticed, over time, an increase in admissions due to ST segment elevation myocardial infarction (1.1 vs 7.4 vs 11.4%;p<0.001) and unstable angina (1.1 vs 1.8 vs 3.7%;p<0.001). Most of pts presented with good systolic ventricular function, but an increase of pts with moderated (2.6 vs 9.0 vs 11.2%;p<0.001) and severe (1.3 vs 1.4 vs 4.7%;p<0.001) systolic dysfunction was observed. From 3069 PCI performed, a total of 3461 IRS lesions were treated. It was observed, at most, 3 IRS lesions for PCI. Over time, the most frequent presentation was 1 lesion for PCI (88.4% of total), being noticed a decreasing in number of multiple IRS lesions (15.1 vs 11.3 vs 9.6%;p=0.035). Incidence of ISR has increased in left descendant coronary artery (34.5 vs 39.8 vs 42.4%;p<0.001) and treatment was more frequently performed in more complex lesions (p<0.001). It was noticed a reduction in treatment with stent (72.7 vs 74.4 vs 52.8%;p<0.001) and an increasing use of only PCI balloon (39.3 vs 57.8 vs 45.8%;p=0.002) and trombectomy (0.0 vs 2.2 vs 8.2%;p<0.001). Conclusion: In spite of increasing in risk profile of pts over time, it was observed a reduction of incidence of ISR and multiple ISR lesions. It also was observed an increasing number of interventions avoiding second stent implantation.
- Massa intracardíaca – um desafio diagnóstico!Publication . Abreu, G; Arantes, C; Martins, J; Vilaça, A; Monteiro, M; Galvão-Braga, C; Rodrigues, C; Vieira, C; Azevedo, P; Salomé, N; Pereira, C; Marques, JA prevalência do linfoma de burkitt em indivíduos com VIH é cerca de 20-30%, contudo o atingimento cardíaco desta entidade é raro, reportando-se a casos pontuais. Os autores descrevem o caso de um homem de 64 anos com antecedentes de hipertensão, tabagismo e serologias positivas para VIH 1 e HCV desde 2004, sem seguimento em consulta de infecciologia. Recorreu ao serviço de urgência por episódio de síncope precedida de palpitações, seguida de náusea, vómito alimentar e tonturas. Reportava episódio semelhante 2 meses antes, mas de menor intensidade. Referia ainda astenia de longa data, negando outros sintomas do foro cardiovascular. Ao exame objetivo apresentava-se taquicárdico (FC 120/min), sem outras alterações. O eletrocardiograma evidenciou ritmo sinusal com ectopia ventricular em padrão de trigeminismo e onda T invertida em I, aVL, V3-V6. Analiticamente, salientava-se apenas subida ligeira isolada de TropI (0,32 ng/dl) e CD4 total 47/uL. O ecocardiograma transtorácico evidenciou função sistólica biventricular conservada; massa ecodensa heterogénea (30x25mm), ao nível da aurícula direita, envolvendo o anel da tricúspide/junção auriculoventricular e segmento basal da parede livre do ventrículo direito, parecendo estender-se até ao pericárdio. Realizou TC toraco-abdomino-pélvica que confirmou imagens descritas no ecocardiograma e acrescentou adenomegalias pericardíacas, múltiplas imagens nodulares pulmonares bilaterais de natureza indeterminada; assimetria dimensional renal (rim direito maior) e focos hiperdensos bilateralmente. A RMN cardíaca identificou massa sólida, heterogénea, com áreas de captação de contraste, centrada na parede lateral da aurícula direita, estendendo-se inferiormente para o sulco AV e para a parede do ventrículo direito, invadindo o folheto posterior da válvula tricúspide, com 7,3x4,4x4,8 cm, bem como lesão nodular intramiocárdica no segmento apical septal e espessamento focal significativo do segmento basal anterior do ventrículo esquerdo. Adenomegalias mediastínicas, nódulos hepáticos foram também objetivados. O doente foi submetido a biopsia renal ecoguiada de uma das lesões renais à direita que demonstrou linfoma B de alto grau com características morfológicas e fenotípicas de linfoma de burkitt; estudo de translocação do gene c-MYC: t(8;14)(q24;q32). O aspirado medular não evidenciou atingimento medular. Foi transferido para o serviço de Oncologia e iniciou quimioterapia dirigida, tendo-se observado remissão das massa intracardíacas no ecocardiograma posterior. Este caso ilustra a importância da multimodalidade de imagem no diagnóstico de um tumor altamente agressivo de apresentação clínica atípica.