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BACKGROUND: Yellow fever (YF) is a viral hemorrhagic fever, endemic in parts of South America and Africa. There is scarce evidence about the pathogenesis of the myocardial injury. The objective of this study is to evaluate the cardiac pathology in fatal cases of YF. METHODS: This retrospective autopsy study included cases from the São Paulo (Brazil) epidemic of 2017-2019. We reviewed medical records and performed cardiac tissue histopathological evaluation, electron microscopy, immunohistochemical assays, RT-qPCR for YF virus (YFV)-RNA, and proteomics analysis on inflammatory and endothelial biomarkers. FINDINGS: Seventy-three confirmed YF cases with a median age of 48 (34-60) years were included. We observed myocardial fibrosis in 68 (93.2%) patients; cardiomyocyte hypertrophy in 68 (93.2%); endothelial alterations in 67 (91.8%); fiber necrosis in 50 (68.5%); viral myocarditis in 9 (12.3%); and secondary myocarditis in 5 (6.8%). Four out of five patients with 17DD vaccine-associated viscerotropic disease presented with myocarditis. The cardiac conduction system showed edema, hemorrhages and endothelial fibrinoid necrosis. Immunohistochemistry detected CD68-positive inflammatory interstitial cells and YFV antigens in endothelial and inflammatory cells. YFV-RNA was detected positive in 95.7% of the cardiac samples. The proteomics analysis demonstrated that YF patients had higher levels of multiple inflammatory and endothelial biomarkers in comparison to cardiovascular controls, and higher levels of interferon gamma-induced protein 10 (IP-10) in comparison to sepsis (p = 0.01) and cardiovascular controls (p < 0.001) in Dunn test. INTERPRETATION: Myocardial injury is frequent in severe YF, due to multifactorial mechanisms, including direct YFV-mediated damage, endothelial cell injury, and inflammatory response, with a possible prominent role for IP-10. FUNDING: This study was funded by Fundação de Amparo à Pesquisa do Estado de São Paulo, Bill and Melinda Gates Foundation, Conselho Nacional de Desenvolvimento Científico e Tecnológico, Coordenação de Aperfeiçoamento de Pessoal de Nível Superior.

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La Granulomatosis con Poliangeítis (GPA), o Granulomatosis de Wegener, es una vasculitis sistémica de pequeño y mediano vaso inmunológicamente mediada, que preferentemente compromete la vía aérea superior, pulmones y riñones, y es poco frecuente que se asocie a manifestaciones cardíacas. El compromiso del sistema éxcitoconductor (SEC) es muy raro y se han descrito casos aislados de distintos grados de bloqueo aurículoventricular (BAV). Describimos el caso de un paciente con GPA que durante una recidiva de su enfermedad consultó por disnea, documentándose signos de bajo débito, bradicardia de 30/ min, BAV de 2° grado avanzado y bloqueo completo de rama izquierda (BCRI) en el electrocardiograma (ECG). Se presenta una revisión de la literatura y discutimos sus causas, la evolución y manejo de estos pacientes.

Granulomatosis with Polyangiitis (GPA), or Wegener's Granulomatosis, is an immunologically mediated systemic vasculitis of small and medium vessels, which commonly compromises the upper airway, lungs, and kidneys and is rarely associated with cardiac manifestations. Compromise of the cardiac conduction system is rare, and isolated cases of different degrees of atrioventricular block (AVB) have been described. We report a case of a 49-year-old male patient previously diagnosed with GPA 3 years ago, who presented to the emergency department with dyspnea, clinical signs of low output, bradycardia of 30/min, advanced second-degree AVB and complete left bundle branch block (LBBB) on the ECG. A literature review is presented, and we discuss the causes, evolution, and management of this GPA complication.

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El eje cardíaco representa el promedio de la dirección del proceso de activación eléctrica de las células cardíacas, es uno de los parámetros que debe determinarse en la correcta lectura e interpretación del electrocardiograma y es útil no solo como criterio diagnóstico de cardiopatías, sino también como marcador de pronóstico y mortalidad de otras enfermedades. Con el paso de los años han surgido nuevas fórmulas que permiten calcular con mayor exactitud su valor. El método que utiliza D1 y aVF es uno de los más populares, sin embargo, presenta dos puntos no medibles. El primero es entre 0 y -30 grados, y el segundo entre los valores de 90 y 110 grados. Aunque existen propuestas con algoritmos que utilizan otras derivaciones, se exploró un método alternativo con D1 y D3 basados en la fórmula algebraica de la tangente inversa y método matemático para el cálculo exacto del eje cardíaco. Se destaca este como una propuesta de método rápido que mantiene la confiabilidad de la fórmula algebraica para determinar si el eje cardíaco se encuentra dentro de los rangos normales (-30 a 110 grados)

The cardiac axis represents the average of the direction of the electrical activation process of the cardiac cells. It is one of the parameters determined in the correct reading and interpretation of the electrocardiogram. Also, not only is it useful as a diagnostic criterion for heart disease but also as a marker of prognosis and mortality in other diseases. Over the years, new formulas have emerged that allow its value to be calculated more accurately. The method using D1 and aVF is one of the most popular. However, it has two unmeasurable points. The first is between 0 and -30 degrees, and the second is between the values of 90 and 110 degrees. Although there are proposals with algorithms that use other leads, an alternative method was explored with D1 and D3 based on the algebraic formula of the inverse tangent and mathematical method for the exact calculation of the cardiac axis. A quick method is proposed that maintains the reliability of the algebraic formula to determine if the cardiac axis is within the normal ranges (-30 to 110 degrees)

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Longitudinal dissociation of the aggregated specialized cardiomyocytes within the non-branching portion of atrioventricular conduction axis has proved a controversial topic for both morphologists and electrophysiologists. We have now used morphological methods, including three-dimensional assessment, to revisit, in human, canine, and bovine hearts, the presence or absence of interconnections between the aggregated cardiomyocytes making up the non-branching bundle. We analyzed three datasets from human and canine hearts, and two from bovine hearts, using longitudinal and orthogonal serial histological sections. In addition, we assessed three hearts using translucent India ink injected specimens, permitting assessment of the three-dimensional arrangement of the cardiomyocytes. Using the longitudinal sections, we found numerous oblique interconnections between the groups of specialized cardiomyocytes. When assessing orthogonal sections, we noted marked variation in the grouping of the cardiomyocytes. We interpreted this finding as evidence of bifurcation and convergence of the groups seen in the longitudinal sections. The three-dimensional assessment of the bovine material confirmed the presence of the numerous interconnections. The presence of multiple connections between the cardiomyocytes in the non-branching bundle rules out the potential for longitudinal dissociation.

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Two groups of investigators investigated the heart pacemaker and its morphological basis in the early twentieth century. The first group was formed by Henrich Ewald Hering (physiologist), Sunao Tawara and Ludwig Aschoff (morphologists). The second group was composed of James Mackenzie (general practitioner and clinical investigator), Arthur Keith and Martin Flack (morphologists). These groups were formed almost at the same time in 1903. Their work resulted in the discovery of the atrioventricular node and Purkinje network (Sunao Tawara, in 1906), heart pacemaker (H E Hering, in 1907) and sinoatrial node (Keith and Flack, in 1907). Here, it is shown how the interconnections of the concurrent works of these groups resulted in the discovery not only of the function, but also of the structure of the sinoatrial node.

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PURPOSE OF REVIEW: The purpose of the current mini-review is to describe the importance of surface ECG for the diagnosis of conduction disorder. METHODS: The MEDLINE/PubMed database was used, with the keywords "ECG" and "conduction disorders"; over the past 10 years. Other documents were included because of their relevance. MAIN FINDINGS: Data on the anatomy and function of the cardiac electrical system have been described. Conduction disorders including sinus node dysfunction, atrioventricular blocks, intraventricular conduction disorders are exposed as to their epidemiology, etiology, presentation, anatomical site of impaired conduction of the electrical stimulus. The importance of ECG in patients with a cardiac implantable electronic device was also discussed, in addition to future perspectives. CONCLUSION: Surface ECG allows the diagnosis of atrioventricular and intraventricular conduction disorder and its anatomical block site most of the time, without the need for invasive tests such as electrophysiological study. Dysfunctions of cardiac implantable electronic devices can be diagnosed by ECG, as well as the prediction of response to cardiac resynchronization therapy.

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Sunao Tawara, who was born in 1873 and died in 1952, is considered the father of modern cardiac electrophysiology. He published his monumental monograph describing the atrioventricular conduction axis in 1906. He achieved this task in the face of multiple tribulations as a doctoral student working in a cultural environment that was not his own. Although his letters underscoring the publication of the monograph have been published, little emphasis has been placed on the potential problems he encountered in bringing his task to fruition. For example, it was not until the final 6 months of his studies that he resolved the issue of the connection between the atrioventricular bundle and the so called "Purkinje cardiomyocytes". His exchanges with his mentor, Ludwig Aschoff, emphasized that the difficulties he encountered in making the connection caused him quite some turmoil. We believe that this issue, and others that he identified in his correspondence, are worthy of further attention.

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RESUMEN Hombre de 80 años de edad, con antecedentes de miocardiopatía dilatada de origen isquémico, con disfunción sisto-diastólica del ventrículo izquierdo, que inicialmente presentó flutter auricular con inestabilidad hemodinámica y se realizó cardioversión eléctrica, luego de la cual se obtuvo un ritmo no precedido de onda P a 40 latidos por minuto, que fue interpretado como fibrilación auricular bloqueada; razón por la que se le colocó un marcapasos externo. Durante su evolución se realizó electrocardiograma de 12 derivaciones, donde se evidenció estimulación ventricular permanente con conducción retrógrada (ventrículo-auricular). Se disminuyó la frecuencia de estimulación para priorizar el ritmo espontáneo del paciente y se obtuvo marcada mejoría de la curva de presión arterial.

ABSTRACT An 80-year-old male patient is presented, with previous dilated cardiomyopathy of ischemic etiology, with systo-diastolic left ventricular dysfunction, who initially presented atrial flutter and hemodynamic instability, thus, an electrical cardioversion was performed. After this procedure, a blocked atrial fibrillation was observed. Thus, an external pacemaker was placed. During the evolution, a 12 lead electrocardiogram was performed, showing permanent ventricular stimulation with retrograde conduction (ventriculo-atrial). The pacing rate was diminished for prioritizing the patient's spontaneous rhythm resulting in an improvement of the blood pressure curve.

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A rule of human anatomy is that all structures within the body should be described relative to the so-called "anatomical position." Along with those describing structures such as the skull and liver, those accounting for the components of the heart consistently break this rule, describing the organ as if removed from the body and positioned on its apex, the so-called "Valentine position." Although potentially appropriate to some animal species, this approach produces problems when used in human anatomy, even if the right and left ventricles are only viewed in truly right-sided and left-sided positions when assessed in the Valentine fashion. The names of the ventricles, of course, are never going to change. This is not necessarily the case with other cardiac components. Consider the artery that extends between the ventricles on their diaphragmatic surface. Blockage produces inferior myocardial infarction, which is to be expected, since the vessel is located in inferior and interventricular position. It is incorrect to describe the artery as being posterior and descending. Such infelicities are now the more obvious with the advent of techniques that, in clinical cardiology, show the components of the heart as it lies within the chest. In this review, we have assessed the frequency of use of the Valentine approach in popular textbooks used by students of human anatomy. We show that, using the conduction tissues as a model, this system also being incorrectly described in the majority of the textbooks, the situation can be improved by use of attitudinally appropriate description. Clin. Anat. 32:585-596, 2019. © 2019 Wiley Periodicals, Inc.

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Abstract Background: Recent studies suggest that baseline prolonged PR interval is associated with worse outcome in cardiac resynchronization therapy (CRT). However, a systematic review and meta-analysis of the literature have not been made. Objective: To assess the association between baseline prolonged PR interval and adverse outcomes of CRT by a systematic review of the literature and a meta-analysis. Methods: We comprehensively searched the databases of MEDLINE and EMBASE from inception to March 2017. The included studies were published prospective or retrospective cohort studies that compared all-cause mortality, HF hospitalization, and composite outcome of CRT with baseline prolonged PR (> 200 msec) versus normal PR interval. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate the risk ratios and 95% confidence intervals. Results: Six studies from January 1991 to May 2017 were included in this meta-analysis. All-cause mortality rate is available in four studies involving 17,432 normal PR and 4,278 prolonged PR. Heart failure hospitalization is available in two studies involving 16,152 normal PR and 3,031 prolonged PR. Composite outcome is available in four studies involving 17,001 normal PR and 3,866 prolonged PR. Prolonged PR interval was associated with increased risk of all-cause mortality (pooled risk ratio = 1.34, 95 % confidence interval: 1.08-1.67, p < 0.01, I2= 57.0%), heart failure hospitalization (pooled risk ratio = 1.30, 95 % confidence interval: 1.16-1.45, p < 0.01, I2= 6.6%) and composite outcome (pooled risk ratio = 1.21, 95% confidence interval: 1.13-1.30, p < 0.01, I2= 0%). Conclusions: Our systematic review and meta-analysis support the hypothesis that baseline prolonged PR interval is a predictor of all-cause mortality, heart failure hospitalization, and composite outcome in CRT patients.

Resumo Fundamento: Estudos recentes sugerem que intervalo PR basal prolongado está associado a prognóstico ruim para a terapia de ressincronização cardíaca (TRC). No entanto, nunca foram feitas uma revisão sistemática e meta-análise da literatura. Objetivo: Avaliar a associação entre intervalo PR basal prolongado e resultados adversos da TRC por meio de uma revisão sistemática e meta-análise da literatura. Métodos: Pesquisamos de forma abrangente os bancos de dados MEDLINE e EMBASE, desde o início até março de 2017. Os estudos incluídos eram de coorte prospectivos ou retrospectivos que comparavam mortalidade por todas as causas, hospitalização por insuficiência cardíaca e desfecho composto por TRC com PR basal prolongado (> 200 ms) versus intervalo PR normal. Os dados de cada estudo foram combinados pelo modelo de efeitos aleatórios, variância genérica inversa de DerSimonian e Laird para calcular as razões de risco e os intervalos de confiança de 95% (IC95%). Resultados: Foram incluídos seis estudos de janeiro de 1991 a maio de 2017 nesta metanálise. A taxa de mortalidade por todas as causas foi mencionada em quatro estudos envolvendo 17.432 intervalos PR normais e 4.278 prolongados. Hospitalização por insuficiência cardíaca foi abordada em dois estudos envolvendo 16.152 PR normais e 3.031 prolongados. Desfecho composto esteve presente em quatro estudos com 17.001 PR normais e 3.866 prolongadas. Intervalo PR prolongado foi associado a risco aumentado de mortalidade por todas as causas (razão de risco agrupado = 1,34, IC95%: 1,08-1,67, p < 0,01, I2= 57,0%), hospitalização por insuficiência cardíaca (razão de risco agrupado = 1,30, 95 % de IC95%: 1,16-1,45, p < 0,01, I2= 6,6%) e desfecho composto (razão de risco agrupado = 1,21, IC95%: 1,13-1,30, p < 0,01, I2= 0%). Conclusões: Nossa revisão sistemática e metanálise suportam a hipótese de que o intervalo PR basal prolongado é um preditor de mortalidade por todas as causas, hospitalização por insuficiência cardíaca e desfecho composto em pacientes submetidos à TRC.

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RESUMO A granulomatose com poliangiíte é um raro distúrbio inflamatório sistêmico que se caracteriza por vasculite de pequenas artérias, arteríolas e capilares, associada a lesões granulomatosas necrotizantes. Este artigo relata o caso de uma paciente com diagnóstico prévio de granulomatose com poliangiíte, admitida à unidade de terapia intensiva com quadro de crises convulsivas e instabilidade hemodinâmica em razão de bloqueio atrioventricular completo. Estas manifestações se associaram a múltiplos episódios de taquicardia ventricular sustentada; não havia alterações estruturais cardíacas, nem se detectaram distúrbios hidroeletrolíticos. Na unidade de terapia intensiva, a paciente foi submetida à implantação de marca-passo provisório, imunossupressão com uso de corticosteroides e terapia imunobiológica, resultando em melhora hemodinâmica completa. Distúrbios graves da condução cardíaca em pacientes com granulomatose com poliangiíte são raros, mas associam-se à grande morbidade. O reconhecimento precoce e o uso de intervenções específicas são capazes de prevenir a ocorrência de desfechos desfavoráveis, especialmente na unidade de terapia intensiva.

ABSTRACT Granulomatosis with polyangiitis is a rare systemic inflammatory disorder characterized by vasculitis of the small arteries, the arterioles and the capillaries together with necrotizing granulomatous lesions. This case reports on a young female patient, previously diagnosed with granulomatosis with polyangiitis, who was admitted to the intensive care unit with seizures and hemodynamic instability due to a complete atrioventricular heart block. The event was associated with multiple episodes of sustained ventricular tachycardia without any structural heart changes or electrolyte disturbances. In the intensive care unit, the patient was fitted with a provisory pacemaker, followed by immunosuppression with corticosteroids and immunobiological therapy, resulting in a total hemodynamic improvement. Severe conduction disorders in patients presenting granulomatosis with polyangiitis are rare but can contribute to increased morbidity. Early detection and specific intervention can prevent unfavorable outcomes, specifically in the intensive care unit.

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Background: Pazopanib (PZP) may induce prolonged cardiac repolarization and proarrhythmic effects, similarly to other tyrosine kinase inhibitors. Objectives: To demonstrate PZP-induced prolonged cardiac repolarization and proarrhythmic electrophysiological effects and to investigate possible preventive effects of metoprolol and diltiazem on ECG changes (prolonged QT) in an experimental rat model. Methods: Twenty-four Sprague-Dawley adult male rats were randomly assigned to 4 groups (n = 6). The first group (normal group) received 4 mL of tap water and the other groups received 100 mg/kg of PZP (Votrient® tablet) perorally, via orogastric tubes. After 3 hours, the following solutions were intraperitoneally administered to the animals: physiological saline solution (SP), to the normal group and to the second group (control-PZP+SP group); 1 mg/kg metoprolol (Beloc, Ampule, AstraZeneca), to the third group (PZP+metoprolol group); and 1mg/kg diltiazem (Diltiazem, Mustafa Nevzat), to the fourth group (PZP+diltiazem group). One hour after, and under anesthesia, QTc was calculated by recording ECG on lead I. Results: The mean QTc interval values were as follows: normal group, 99.93 ± 3.62 ms; control-PZP+SP group, 131.23 ± 12.21 ms; PZP+metoprolol group, 89.36 ± 3.61 ms; and PZP+diltiazem group, 88.86 ± 4.04 ms. Both PZP+metoprolol and PZP+diltiazem groups had significantly shorter QTc intervals compared to the control-PZP+SP group (p < 0.001). Conclusion: Both metoprolol and diltiazem prevented PZP-induced QT interval prolongation. These drugs may provide a promising prophylactic strategy for the prolonged QTc interval associated with tyrosine kinase inhibitor use. .

Fundamento: Pazopanibe (PZP) pode induzir prolongamento da repolarização cardíaca e efeitos pró-arrítmicos, à semelhança de outros inibidores da tirosina quinase. Objetivos: Demonstrar prolongamento da repolarização cardíaca e efeitos eletrofisiológicos pró-arrítmicos induzidos pelo PZP, assim como investigar possíveis efeitos de metoprolol e diltiazem na prevenção de alterações no ECG (prolongamento do intervalo QT) em um modelo experimental em ratos. Métodos: Ratos Sprague-Dawley adultos machos (24) foram designados de modo aleatório para quatro grupos (n = 6). O primeiro grupo (normal) recebeu 4 ml de água da torneira, enquanto os demais receberam 100 mg/kg de PZP (comprimido de Votrient®) através de sonda orogástrica. Após 3 horas, os animais receberam por via intraperitoneal: solução salina, para o grupo normal e para o segundo grupo (controle-PZP+SP); 1 mg/kg de metoprolol (Beloc, Ampola, AstraZeneca), para o terceiro grupo (PZP+metoprolol); e 1mg/kg de diltiazem (Diltiazem, Mustafa Nevzat), para o quarto grupo (PZP+diltiazem). Uma hora após a administração desses medicamentos, e sob anestesia, calculou-se o intervalo QTc registrando-se o ECG em DI. Resultados: Os valores médios do intervalo QTc foram: grupo normal, 99,93 ± 3,62 ms; grupo controle-PZP+SP, 131,23 ± 12,21 ms; grupo PZP+metoprolol, 89,36 ± 3,61 ms; e grupo PZP+diltiazem, 88,86 ± 4,04 ms. Os grupos PZP+metoprolol e PZP+diltiazem apresentaram intervalos QTc significativamente mais curtos comparados aos do grupo controle-PZP+SP (p < 0,001). Conclusão: Ambos metoprolol e diltiazem evitaram o prolongamento do intervalo QT induzido por PZP. Tais medicamentos podem ser uma promissora estratégia para evitar o prolongamento do intervalo QTc associado ao uso de inibidores da tirosina quinase. .

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Introducción El implante valvular aórtico percutáneo es una opción terapéutica cada vez más utilizada en pacientes en los que se descarta la cirugía. A pesar de que las alteraciones agudas de la conducción son una de las complicaciones más frecuentes, su significado clínico y electrocardiográfico no es del todo claro. Objetivos Determinar las implicaciones pronósticas del desarrollo de alteraciones agudas de la conducción luego del implante valvular aórtico percutáneo. Resultados Entre marzo de 2009 y febrero de 2012 se incluyeron para el análisis 47 pacientes; de ellos, 30 (63%) presentaron alteraciones agudas de la conducción: 19 pacientes solo bloqueo completo de rama izquierda (BCRI), 9 pacientes solo bloqueo auriculoventricular completo (BAVC) y 2 pacientes presentaron ambos trastornos, los que totalizaron 21 BCRI y 11 BAVC. A 12 (25%) se les implantó un marcapasos definitivo previo al alta: en 11 por BAVC y en 1 por BCRI agudo más fibrilación auricular. En solo un paciente el BAVC revirtió en hemodinamia. Los pacientes que persistieron con BAVC posintervención presentaron una media de estimulación ventricular en la intervalometría al mes del 90%, mientras que en el paciente con BAVC que revirtió en hemodinamia fue de solo el 3% y en el paciente con BCRI más fibrilación auricular fue < 10%. La incidencia de insuficiencia cardíaca en el posoperatorio fue mayor en los pacientes con alteraciones agudas de la conducción (p = 0,007), al igual que la estadía hospitalaria (p = 0,045). En el seguimiento no hubo diferencias en la tasa de reinternación ni en la mortalidad. Conclusiones En el presente estudio el desarrollo de alteraciones agudas de la conducción mostró un aumento en la incidencia de insuficiencia cardíaca y en los días de internación, sin incremento en la tasa de otros eventos mayores. La colocación de un marcapasos definitivo luego del BAVC podría realizarse en forma inmediata, ya que el trastorno generalmente es irreversible.(AU)

Introduction The indication of transcatheter aortic valve implantation in patients considered not suitable candidates for surgery is increasing. Despite acute disorders of the conduction system are common complications, their clinical and electrocardiographic significance is not completely clear. Objectives To determine whether acute disorders of the conduction system after transcatheter aortic valve implantation has prognostic implications. Results Between March 2009 and February 2012, 47 patients were included in the analysis. Thirty patients (63%) had acute disorders of the conduction system: 19 patients presented isolated complete left bundle branch block (LBBB), 9 patients isolated complete atrioventricular block (CAVB), and 2 patients both conduction disorders, with a total of 21 LBBBs and 11 CAVBs. A definite pacemaker was implanted in 12 patients (25%) before discharge: in 11 due to CAVB and in 1 due to acute LBBB plus atrial fibrillation. Complete AVB reverted in the catheterization laboratory in only one patient. At one month, average ventricular pacing was 90% in patients with persistent CAVB after the intervention, only 3% in the only patient in whom CAVB reverted at the catheterization laboratory and < 10% in the patient with LBB plus atrial fibrillation. The incidence of postoperative heart failure and hospital stay was greater in patients with acute disorders of the conduction system (p = 0.007 and p = 0.045, respectively). There were no differences in new hospitalizations and mortality during follow-up. Conclusions In this study, the development of acute disorders of the conduction system was associated with increased incidence of heart failure and hospital stay but not with the incidence of major events. A definite pacemaker could be implanted immediately after CAVB develops as the conduction disorder is generally irreversible.(AU)

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Introducción El implante valvular aórtico percutáneo es una opción terapéutica cada vez más utilizada en pacientes en los que se descarta la cirugía. A pesar de que las alteraciones agudas de la conducción son una de las complicaciones más frecuentes, su significado clínico y electrocardiográfico no es del todo claro. Objetivos Determinar las implicaciones pronósticas del desarrollo de alteraciones agudas de la conducción luego del implante valvular aórtico percutáneo. Resultados Entre marzo de 2009 y febrero de 2012 se incluyeron para el análisis 47 pacientes; de ellos, 30 (63%) presentaron alteraciones agudas de la conducción: 19 pacientes solo bloqueo completo de rama izquierda (BCRI), 9 pacientes solo bloqueo auriculoventricular completo (BAVC) y 2 pacientes presentaron ambos trastornos, los que totalizaron 21 BCRI y 11 BAVC. A 12 (25%) se les implantó un marcapasos definitivo previo al alta: en 11 por BAVC y en 1 por BCRI agudo más fibrilación auricular. En solo un paciente el BAVC revirtió en hemodinamia. Los pacientes que persistieron con BAVC posintervención presentaron una media de estimulación ventricular en la intervalometría al mes del 90%, mientras que en el paciente con BAVC que revirtió en hemodinamia fue de solo el 3% y en el paciente con BCRI más fibrilación auricular fue < 10%. La incidencia de insuficiencia cardíaca en el posoperatorio fue mayor en los pacientes con alteraciones agudas de la conducción (p = 0,007), al igual que la estadía hospitalaria (p = 0,045). En el seguimiento no hubo diferencias en la tasa de reinternación ni en la mortalidad. Conclusiones En el presente estudio el desarrollo de alteraciones agudas de la conducción mostró un aumento en la incidencia de insuficiencia cardíaca y en los días de internación, sin incremento en la tasa de otros eventos mayores. La colocación de un marcapasos definitivo luego del BAVC podría realizarse en forma inmediata, ya que el trastorno generalmente es irreversible.

Introduction The indication of transcatheter aortic valve implantation in patients considered not suitable candidates for surgery is increasing. Despite acute disorders of the conduction system are common complications, their clinical and electrocardiographic significance is not completely clear. Objectives To determine whether acute disorders of the conduction system after transcatheter aortic valve implantation has prognostic implications. Results Between March 2009 and February 2012, 47 patients were included in the analysis. Thirty patients (63%) had acute disorders of the conduction system: 19 patients presented isolated complete left bundle branch block (LBBB), 9 patients isolated complete atrioventricular block (CAVB), and 2 patients both conduction disorders, with a total of 21 LBBBs and 11 CAVBs. A definite pacemaker was implanted in 12 patients (25%) before discharge: in 11 due to CAVB and in 1 due to acute LBBB plus atrial fibrillation. Complete AVB reverted in the catheterization laboratory in only one patient. At one month, average ventricular pacing was 90% in patients with persistent CAVB after the intervention, only 3% in the only patient in whom CAVB reverted at the catheterization laboratory and < 10% in the patient with LBB plus atrial fibrillation. The incidence of postoperative heart failure and hospital stay was greater in patients with acute disorders of the conduction system (p = 0.007 and p = 0.045, respectively). There were no differences in new hospitalizations and mortality during follow-up. Conclusions In this study, the development of acute disorders of the conduction system was associated with increased incidence of heart failure and hospital stay but not with the incidence of major events. A definite pacemaker could be implanted immediately after CAVB develops as the conduction disorder is generally irreversible.

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Antecedentes. El conocimiento exacto de la integración anatomofisiológica del sistema de conducción del corazón, es fundamental para la comprender la fisiopatología, el diagnóstico y el manejo de muchas de las complicaciones de la enfermedad coronaria y de las cardiopatías en general. Uno de los aspectos fundamentales, más variable y con mayores repercusiones clínicas corresponde al origen y recorrido de las arterias encargadas de irrigar el nódulo sinoatrial. Objetivo. Determinar el origen, recorrido y distribución de las arterias que irrigan el nódulo sinoatrial en una muestra de población colombiana. Material y métodos. La muestra de análisis fueron 60 bloques cardiopulmonares y digestivos seleccionados a través de muestreo por conveniencia. A estos se les realizó una disección convencional de los genitales para la determinación del sexo y posteriormente se procedió con la disección de las arterias coronarias específicamente de la arteria del nódulo sinoatrial, con el fin de establecer su origen y recorrido. Resultados. Como hallazgo principal se encontró que el origen de la arteria del nódulo sinoatrial en 75% provenía de la coronaria derecha, un 15% procedía de la arteria circunfleja y el 10% restante fue codominante. En cuanto al trayecto 86,6% fueron lineales, mientras 13,4% tuvieron formas alternas como Y, doble Y o en tridente. Conclusiones. Se evidenció predominio del origen de la arteria del nódulo sinoatrial en la coronaria derecha, hallazgo coincidente con investigaciones similares e independiente de la procedencia geográfica y el origen racial. Sin embargo, en este estudio se evidenciaron recorridos no reportados en la literatura como la distribución en Y, en doble Y, en K invertida y en tridente.

Background. Accurate knowledge regarding the cardiac conduction system's anatomical-physiological integration is essential for understanding the pathophysiology, diagnosis and management of many complications regarding coronary disease and heart disease in general. One of the more variable fundamental aspects, having the greatest clinical impact, concerns the origin and course of arteries irrigating the sino-atrial node (SAN). Objective. Determining the origin, course and distribution of arteries supplying the SAN in a sample of the Colombian population. Materials and methods. 60 cardiopulmonary and digestive blocks were taken by convenience sampling. Conventional dissection of the genitalia determined gender; the coronary artery was then dissected, specifically the SAN, to establish origin and route. Results. It was found that 75% of the SAN artery's blood supply came from the right coronary artery (RCA), 15% from the circumflex artery and 10% was co-dominant. 86.6% of courses were linear; 13.4% were Y-shaped or Y-and double trident shaped. Conclusions. The prevalence of SAN artery origin in the RCA in this study was consistent with similar research findings, regardless of geographical and racial origin. However, this study report some courses not previously described in the literature, such as Y-, double Y-, inverted K- and trident-shaped forms.

RESUMO

Geralmente, a cardiomiopatia restritiva por deposição de desmina é caracterizada pela restrição ao enchimento diastólico ventricular e por diferentes graus de bloqueio atrioventricular (BAV). Neste relato, são descritas as alterações anatomopatológicas do sistema de condução cardíaco relacionadas ao BAV. O nó sinusal, o nó compacto e o feixe penetrante (feixe de His) não apresentavam anormalidades, entretanto, havia extensa fibrose das porções terminais do feixe ramificante e do início dos feixes esquerdo e direito, no topo do septo ventricular. A patogenia dessa substituição fibrosa é provavelmente a mesma que origina a extensa fibrose do miocárdio ventricular contrátil, e permanece por ser elucidada.

Generally, restrictive cardiomyopathy due to desmin deposition is characterized by restriction to ventricular diastolic filling and different degrees of atrioventricular block (AVB). In this report, we describe the pathological changes of the cardiac conduction system related to AVB. The sinus node, the compact node, and the penetrating bundle (bundle of His) had no abnormalities, however, there was extensive fibrosis of the terminal portions of the branching bundle and the beginning of the left and right bundles at the top of the ventricular septum. The pathogenesis of this fibrous replacement is probably the same that leads to extensive fibrosis of the working ventricular myocardium, and remains to be elucidated.

En general, la miocardiopatía restrictiva, debido a la deposición de desmina se caracteriza por la restricción de llenado diastólico ventricular y por los distintos grados de bloqueo auriculoventricular (BAV). En este informe, se describen los cambios anatómicos y patológicos del sistema de conducción cardiaco relacionado con BAV. El nodo sinusal, el nodo compacto y haz penetrante (haz de His) no tuvo alteraciones, sin embargo, había fibrosis extensa de las porciones terminales del haz en porción ramificante y del comienzo de los haces izquierda y derecha, en la parte superior del tabique ventricular. La patogenia de esta sustitución fibrosa es probablemente la misma que origina la fibrosis extensa del miocardio ventricular contráctil, y queda por dilucidar.

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RESUMO

FUNDAMENTO: Sarcoidose é uma doença granulomatosa multissistêmica de origem desconhecida que pode causar morte súbita. OBJETIVO: Avaliação eletrofisiológica de pacientes com sarcoidose com suspeita de comprometimento cardíaco. MÉTODOS: Foram estudados 22 pacientes com média de idade de 55,32 ±13,13 anos, com diagnóstico de sarcoidose e suspeita de comprometimento cardíaco. Foram submetidos à avaliação clínica, exames laboratoriais, eletrocardiograma, ecocardiograma, Holter de 24h, cintilografia com gálio ou tecnécio e estudo eletrofisiológico. Em casos selecionados foi realizada tomografia por emissão de pósitrons ou ressonância magnética. Os pacientes foram seguidos ambulatoriamente com consultas trimestrais. RESULTADOS: Comprometimento cardíaco foi comprovado em quatro (18,2 por cento) pacientes. Extrassístoles ventriculares com densidade > 100/24h foram documentadas no Holter de 24h em 12 (54,5 por cento) pacientes. O estudo eletrofisiológico revelou aumento do intervalo HV em sete (31,8 por cento) e ponto de Wenckebach aumentado em quatro (18,2 por cento) pacientes. Houve indução de fibrilação atrial em sete (31,8 por cento) e de taquicardia ventricular sustentada em um (4,5 por cento). Nos quatro pacientes com sarcoidose cardíaca confirmada, extrassístoles ventriculares, com densidade > 100/24h foram documentadas em todos, dois apresentavam intervalo HV prolongado e fibrilação atrial foi induzida em dois. Taquicardia ventricular sustentada não foi induzida em nenhum desses pacientes. Após período médio de acompanhamento de 20,9 ± 15,7 meses, um paciente com sarcoidose cardíaca apresentou morte súbita. CONCLUSÃO: Pacientes com sarcoidose e suspeita de envolvimento cardíaco apresentam alta prevalência de EVs e distúrbios do sistema de condução.

BACKGROUND: Sarcoidosis is a multisystem granulomatous disease of unknown origin that can cause sudden death. OBJECTIVE: Electrophysiological evaluation of patients with suspected sarcoidosis with cardiac involvement. METHODS: We studied 22 patients with mean age of 55.32 ± 13.13 years, diagnosed with sarcoidosis and suspected cardiac involvement. These patients underwent clinical evaluation, laboratory tests, electrocardiogram, echocardiogram, 24-hour Holter, technetium or gallium scintigraphy and electrophysiological study. In selected cases, we performed positron emission tomography or magnetic resonance imaging. Patients were followed up in the outpatient care service with quarterly visits. RESULTS: Cardiac involvement was confirmed in four (18.2 percent) patients. Ventricular extrasystoles with density > 100/24h were documented in 24-Holter monitoring in 12 (54.5 percent) patients. Electrophysiological studies revealed an increased HV interval in seven patients (31.8 percent) and increased Wenckebach point in four (18.2 percent) patients. There was induction of atrial fibrillation in seven patients (31.8 percent) and sustained ventricular tachycardia in one patient (4.5 percent). Four patients with confirmed cardiac sarcoidosis had documented ventricular extrasystoles with density > 100/24h. Out of these, two had prolonged HV interval and atrial fibrillation was induced in two of them. Sustained ventricular tachycardia was not induced in any of these patients. After mean follow-up period of 20.9 ± 15.7 months, one patient with cardiac sarcoidosis had sudden death. CONCLUSION: Patients with sarcoidosis and suspected cardiac involvement have a high prevalence of ventricular extrasystoles (VEs) and conduction system disorders.

FUNDAMENTOS: Sarcoidosis es una enfermedad granulomatosa multisistémica de origen desconocido que puede causar la muerte súbita. OBJETIVOS:Evaluación electrofisiológica de los pacientes con sarcoidosis con sospecha de afectación cardíaca. MÉTODOS:Se estudiaron a 22 pacientes con una media de edad de 55,32 ± 13,13 años, con diagnóstico de sarcoidosis y sospecha de afectación cardíaca.Se sometieron a evaluación clínica, exámenes de laboratorio, electrocardiograma, ecocardiograma, Holter de 24 h, centellografía con galio o tecnecio y estudio electrofisiológico. En los casos seleccionados se realizó tomografía por emisión de positrones o la resonancia magnética.Los pacientes fueron seguidos en ambulatorio, en consultas trimestrales. RESULTADOS:La afectación cardíaca se comprobó en cuatro (18,2 por ciento) pacientes.Extrasístoles ventriculares con densidad > 100/24 h se documentaron en el Holter de 24 h en 12 (54,5 por ciento) pacientes.Los estudios electrofisiológicos revelaron un aumento del intervalo HV en siete (31,8 por ciento) y punto de Wenckebach aumentado en cuatro (18,2 por ciento) pacientes. No hubo inducción de fibrilación auricular en siete (31,8 por ciento) y de taquicardia ventricular sostenida en uno (4,5 por ciento). En los cuatro pacientes con sarcoidosis cardiaca confirmada, extrasístoles ventriculares (EVs), con densidad > 100/24 h se documentaron en todos, dos presentaban prolongación del intervalo HV y fibrilación auricular se indujo en dos. La taquicardia ventricular sostenida no fue inducida en cualquiera de estos pacientes. Después de un periodo medio de seguimiento de 20,9 ± 15,7 meses, un paciente con sarcoidosis cardíaca tuvo muerte súbita. CONCLUSIÓN: Los pacientes con sarcoidosis y sospecha de afectación cardíaca tienen una alta prevalencia de EVs y trastornos del sistema de conducción.

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