心血管疾患と診断

Background: Nowadays cardiovascular diseases are the main cause of morbid-mortality. Atherosclerosis is one of the most important in this class of diseases. Aim: Identifying subclinical atherosclerosis in a population of non-dialytic patients with chronic kidney disease. Methods: From November 2012 to December 2013, we selected 40 patients with stage 3 or 4 of CKD (Chronic kidney disease) who did not need hemodialysis. CACS (coronary artery calcium score) and MTCA (miointimal tichness carotid artery) were calculated and their mean and standard deviation, median and quartiles. To verify the association between the variables we used the Fisher exact test and the Spearman correlation (p<0.05). Results: The distribution of the CACS was not as expected and the median increased with age groups. The CACS was null in : 50% of the sample in all patients below 45 years of age, 50% of those between 45-49 years of age and 50-54 years of age, 53.8% in those 55-59 years of age and 25% of those 60-65 years of age, however p value=0.102. The median MTCA was 0.9 mm with interquartile range of 0.7-1.2 mm. In percentil75 for age and sex were : 80% of 45 year olds, 25% of 45-49 year olds, 66.7% of 50-54 year olds, 69.2% of 55-59 year olds and 50% of 60-65 year olds, though p value was 0.602. We found a moderate positive correlation between age and CACS (r=0.458 p=0.03) and between age and MTCA weak (r=0.346 p=0.029) when performed correlation of age with the values of CACS and MTCA. The correlation between MTCA and CACS was strong(r=0.807) p<0.001. Conclusion: Non-invasive tests in CKD non-dialytic patients can identify subclinical atherosclerosis through the CACS and MTCA. This may change the clinical management, evolution and prognosis.

Cardiothoracic ratio upper to 0.60 is a fact of poor prognostic in patients with Ebstein’s anomaly and the prognostic is worse if is associated with others congenital heart disease. We present 4-months black boy with Ebstein’s anomaly associated with atrial septal defect, pulmonary valve atresia and patent ductus arteriosus wherein the cardiothoracic ratio nearly 1.0. The patient died five hours after modified Blalock-Tausig shunt. Delay diagnosis of congenital heart disease is a big problem in developing countries and contributes for poor prognosis.

Background Changes of central and peripheral venous hemodynamics (PVH) are registered in patients with acute pulmonary embolism (PE) with right ventricular dysfunction (RVD). It can be assumed the change of PVH is detectable through spectral Doppler waveform analysis of the common femoral veins (CFV) and regular respiratory modulated (RM) flow is replaced as a function of the severity of the RVD by cardiac modulation (CM) of the velocity-time spectra. The aim of this study is to examine, through detection of CM at the CFV, whether indirect diagnostics of the RVD is possible in patients with acute PE. Methods Quantification of RVD was performed through an echocardiographic right heart score (RHS) in patients with acute PE. The RHS integrated four parameters: the size of the right ventricle, the RV kinetics, the motion of the interventricular septum and the right atrial size. The sonographic quantification of RM and CM at the CFV was performed through measurement of the flow duration directed towards the heart in the velocity-time spectrum. The results of the RHS and the respective spectral Doppler waveform at the CFV were comparatively analysed. Results In 47 acute PE-patients CM was found in 53.2%. A RHS of 1 was present in 17% and there was no CM. CM was found in 19% of patients with a RHS of 1.25, and in 92% of patients with a RHS of 1.5. All patients with a RHS of ≥ 1.75 had a CM. The sensitivity and specificity for the CM with a cut-off RHS of 1.5 amounted to 0.96 and 0.88 respectively. Conclusion The CM at the CFV is an indirect diagnostic criterion of RVD with acute PE. In the case of suspected PE, the absence of CM excludes a RVD. Disappearance of CM during the clinical course of PE indicates improvement in RV function.

Background We aimed to evaluate the cytokines monocyte chemotactic protein 1 (MCP-1), TNF soluble receptor (TNF-sR1) and interleukin 6 (IL-6) behavior in patients submitted to CABG (coronary artery bypass grafting) surgeries comparing roller to centrifugal extracorporeal circulation (ECC) pumping systems. Methods We randomized prospectively 43 adults who had elective on-pump CABG with the use of a roller (group I; n = 22) or a centrifugal system (group II; n = 21). Plasma levels of MCP-1, TNF-sR1 and IL-6 were determined by Elisa before the induction of anaesthesia (T1), 35 min after initiation of ECC (T2), 1 min after aortic declamping (T3), and 2, 6 and 24 h after the operation (T4, T5 and T6, respectively). The two groups were matched according to preoperative features. The groups I and II showed similar perioperative characteristics and clinical postoperative outcomes. The plasma levels of MCP-1 and TNF-sR1 reached a peak at T4 and T5 in both groups. MCP-1 in group I was significantly higher (P = 0.020) than in group II at T5, while plasma levels of TNF-sR1 in group I were significantly (P = 0.028) higher than in group II at T4. In both groups, the levels of IL-6 reached a peak at T5. Group I showed higher IL-6 plasma levels (P = 0.006). Conclusion We conclude that both roller and centrifugal pumps induce inflammatory responses to on-pump CABG procedures but higher levels of MCP-1, TNF-sR and IL6 were verified using roller systems.

Background and Purpose Monocular diplopia is often due to intraocular disease. It is rarely the result of cerebral causes, which include lesions in or near Brodmann’s area nineteen, the frontal eye fields or the cerebellum. Monocular diplopia has not been reported in a patient with a midbrain lesion. Methods and Results A patient with a history of hypertension presented with right monocular diplopia and headache. There was no ocular cause of the patient’s symptoms, and aside from bilateral ptosis, there were no relevant findings on neurological examination. MRI brain revealed an ischemic stroke affecting the right oculomotor nucleus. Her evaluation, including an ECG and 48-hour Holter monitor was unremarkable. A subsequent 30-day auto-trigger cardiac event monitor revealed paroxysmal atrial fibrillation. Conclusions This case shows that monocular diplopia can be associated with a midbrain lesion and underscores the importance of prolonged cardiac monitoring in patients with otherwise cryptogenic stroke.

Objectives: Adverse cardiac remodelling is a major cause of morbidity and mortality post myocardial infarction. The role of surgical ventricular restoration compared to medical and electrophysiological treatments has recently come under intense scrutiny. We aimed to evaluate 10-year clinical outcomes of surgical ventricular restoration in our institution. Methods: From January 2001 to 2011, surgical ventricular restoration was performed in 126 consecutive patients (M2.3: 1F), mean age 65.5 (44-86) years. All patients presented with angina, heart failure and/or ventricular tachycardia. Post-infarction left ventricular aneurysm was present in all patients and ischemic dilated cardiomyopathy with a large akinetic left ventricle in 11.6%. The preoperative left ventricular ejection fraction was 33.1 ± 8.9%. Multi-vessel disease was present in 117/126(93%) patients. Mitral regurgitation more than grade+2 was found in 39/126(31%). The mean Logistic EuroSCORE was 13.8 ± 5.9%. A minimum of two-year post-operative follow-up was obtained on all patients. Results: Most patients underwent endoventricular or elliptical patch repair; 94% had concomitant coronary revascularisation with a median of 2 grafts and 5% had mitral valve repair. Intra-aortic balloon pump was placed preoperatively in 24/126 (19%) patients while 21/126 (17%) needed inotropic support for more than 24 h. Postoperative stroke occurred in 2 patients. In-hospital mortality was 7/126 (5.5%). All cause cardiovascular mortality at ten years was 12/126 (9.5%). Mean follow-up in operative survivors was 8.2 ± 1.2 years. Actuarial survival was 95.3%, 90.6%, 86.3% and 79.1% at 1-month, 1, 5 and 10-years. Echocardiographic follow-up demonstrated a reduction in the mean left ventricular end-diastolic volume and left atrial diameter. Ejection fraction improved over first year from 33.1 ± 8.9 to 45 ± 8.6% (P<0.006). Conclusions: Left ventricular reconstruction surgery is a good surgical option for treatment of post-infarction left ventricular aneurysm.