Lesão da valva tricúspide por trauma torácico penetrante

As lesões da valva tricúspide decorrentes de trauma torácico penetrante são raras e frequentemente subdiagnosticadas. O objetivo deste relato é descrever um caso de insuficiência tricúspide grave secundária a acidente por arma branca com evolução insidiosa, diagnosticada 19 anos após o ocorrido. O caso enfatiza a importância do acompanhamento adequado dos pacientes vítimas de trauma torácico penetrante por longo período após a injúria, para detecção de possíveis complicações tardias do trauma

Exercise-induced ventricular arrhythmias and vagal dysfunction in Chagas disease patients with no apparent cardiac involvement

INTRODUCTION : Exercise-induced ventricular arrhythmia (EIVA) and autonomic imbalance are considered as early markers of heart disease in Chagas disease (ChD) patients. The objective of the present study was to verify the differences in the occurrence of EIVA and autonomic maneuver indexes between healthy individuals and ChD patients with no apparent cardiac involvement. METHODS : A total of 75 ChD patients with no apparent cardiac involvement, aged 44.7 (8.5) years, and 38 healthy individuals, aged 44.0 (9.2) years, were evaluated using echocardiography, symptom-limited treadmill exercise testing and autonomic function tests. RESULTS : The occurrence of EIVA was higher in the chagasic group (48%) than in the control group (23.7%) during both the effort and the recovery phases. Frequent ventricular contractions occurred only in the patient group. Additionally, the respiratory sinus arrhythmia index was significantly lower in the chagasic individuals compared with the control group. CONCLUSIONS : ChD patients with no apparent cardiac involvement had a higher frequency of EIVA as well as more vagal dysfunction by respiratory sinus arrhythmia. These results suggest that even when asymptomatic, ChD patients possess important arrhythmogenic substrates and subclinical disease

Heart rate recovery in asymptomatic patients with Chagas disease.

BACKGROUND: Chagas disease patients with right bundle-branch block (RBBB) have diverse clinical presentation and prognosis, depending on left ventricular (LV) function. Autonomic disorder can be an early marker of heart involvement. The heart rate recovery (HRR) after exercise may identify autonomic dysfunction, with impact on therapeutic strategies. This study was designed to assess the HRR after symptom-limited exercise testing in asymptomatic Chagas disease patients with RBBB without ventricular dysfunction compared to patients with indeterminate form of Chagas disease and healthy controls. METHODS: One hundred and forty-nine subjects divided into 3 groups were included. A control group was comprised of healthy individuals; group 1 included patients in the indeterminate form of Chagas disease; and group 2 included patients with complete RBBB with or without left anterior hemiblock, and normal ventricular systolic function. A symptom-limited exercise test was performed and heart rate (HR) response to exercise was assessed. HRR was defined as the difference between HR at peak exercise and 1 min following test termination. RESULTS: There were no differences in heart-rate profile during exercise between healthy individuals and patients in indeterminate form, whereas patients with RBBB had more prevalence of chronotropic incompetence, lower exercise capacity and lower HRR compared with patients in indeterminate form and controls. A delayed decrease in the HR after exercise was found in 17 patients (15%), 9% in indeterminate form and 24% with RBBB, associated with older age, worse functional capacity, impaired chronotropic response, and ventricular arrhythmias during both exercise and recovery. By multivariable analysis, the independent predictors of a delayed decrease in the HRR were age (odds ratio [OR] 1.11; 95% confidence interval [CI] 1.03 to 1.21; p = 0.010) and presence of RBBB (OR 3.97; 95% CI 1.05 to 15.01; p = 0.042). CONCLUSIONS: A small proportion (15%) of asymptomatic Chagas patients had attenuated HRR after exercise, being more prevalent in patients with RBBB compared with patients in indeterminate form and controls

Proportion of abnormal HRR according to the groups.

<p>Abnormal HRR was gradually more prevalent across groups from controls, patients with the indeterminate form to patients with RBBB.</p

Characteristics of the Patients at rest.

<p>Data are expressed as mean value ± SD or median [interquartile range] or), or absolute numbers (percentage).</p><p>*p<0.05 for comparison between controls and group 1 versus group 2.</p>†<p>Maximal systolic velocity at the tricuspid annulus by tissue Doppler velocity</p><p>A =  late transmitral flow velocity; BSA  =  body surface area; DBP  =  diastolic blood pressure; DT  =  deceleration time; E =  early diastolic transmitral flow velocity; E/e'  =  ratio of the early diastolic transmitral flow velocity to early diastolic mitral annular velocity; LA  =  left atrium; LVDd  =  left ventricular end-diastolic diameter; LVEF  =  left ventricular ejection fraction; LVSd  =  left ventricular end-systolic diameter; SBP  =  systolic blood pressure, SPAP  =  systolic arterial pulmonary pressure.</p

An ECG showing complete right bundle-branch block associated with left anterior hemiblock.

<p>An ECG showing complete right bundle-branch block associated with left anterior hemiblock.</p

Predictors of abnormal response of the HRR in the study population.

<p>Data are expressed as mean value ± SD or number (percentage) of patients.</p><p>LVEF  =  left ventricular ejection fraction; RBBB  =  right bundle branch block; E =  early diastolic transmitral flow velocity; A =  late transmitral flow velocity; DT  =  deceleration time; ms  =  milliseconds; E/e'  =  ratio of the early diastolic transmitral flow velocity to early diastolic mitral annular velocity; HR  =  heart rate; VO₂  =  oxygen uptake; VPB  =  ventricular premature beats.</p><p>*defined as more than 7 ventricular premature beats per minute <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0100753#pone.0100753-Meluzin1" target="_blank">[30]</a>.</p