Fístulas da Artéria Coronária

Coronary artery fistula is a rare anatomic abnormality of the coronary arteries that affects 0.002% of the general population and represents 14% of all anomalies of coronary arteries. Its clinical relevance focuses mainly on the mechanism of the coronary steal phenomenon, causing myocardial functional ischemia, even in the absence of stenosis; therefore, angina and effort dyspnea are common symptoms. The suggested diagnostic approach is driven by patients’ symptoms, and it consists of a number of instrumental examinations like ECG, treadmill test, echocardiography, computed tomography scan, cardiac magnetic resonance, and coronary angiography. If it is not an incidental finding, coronary angiography is required in view of optimal therapeutic planning. Small fistulae are usually asymptomatic, and prognosis is excellent if they are managed medically with clinical follow-up and echocardiography every 2 to 5 years. Large/giant, symptomatic fistulae, on the contrary, should undergo invasive closure, via either transcatheter approach or surgical ligation, whose results are equivalent at long-term follow-up. Antibiotic prophylaxis for prevention of bacterial endocarditis is recommended in all patients with coronary artery fistulae who undergo dental, gastrointestinal, or urological procedures. Life-long follow-up is always essential to ensure that the patient does not undergo progression of the disease or further cardiac complications.     

Low sensitivity of the echocardiograph compared with contrast transcranial Doppler in right-to-left shunt

Background

Contrast transcranial Doppler (c-TCD) has a high sensitivity for detecting right-to-left shunt (RLS), and is probably higher than transthoracic echocardiography (TTE) and comparable with transesophageal echocardiography (TEE).

Objective

To evaluate the accuracy of echocardiography (TTE and TEE) to detect RLS compared to c-TCD.

Material and methods

Observational study of patients <55 years old with cerebral ischaemia of undetermined origin (2007-2009). All underwent c-TCD monitoring to detect RLS, at rest and after Valsalva manoeuvre (VM). The TTE and TEE were performed when indicated by our cerebrovascular protocol. The accuracy of TTE and TEE for detecting RLS was calculated by comparing them with c-TCD.

Results

A total of 115 patients with c-TCD, mean age 43.3 (SD 10.3) years, 51.3% male. The TTE was performed in 102, and TEE in 81, patients. RLS detection was higher with c-TCD than with TTE (67.6% vs. 22.5%, P = .001) or TEE (77.8% vs. 53.1%, P = .001). The TTE, compared with c-TCD after MV showed: sensitivity 31.8%, specificity 96.9%, positive predictive value (PPV) 95.6%, negative predictive value (NPV) 40.5% and accuracy 52.9% to detect RLS. TEE, compared with c-TCD after MV showed: sensitivity 63.4%, specificity 83.3%, PPV 93%, NPV 39.4% and accuracy 67.9%. The accuracy of TTE and TEE improved when they were compared with c-TCD at rest.

Conclusions

TTE and TEE show a considerable number of false negatives for RLS detection. Clinical studies should consider the c-TCD as the best technique to diagnose RLS when a paradoxical embolism is suspected.     

Donor lungs cold preservation at 10 °C offers a potential logistic advantage in lung transplantation

Donor lung preservation at 10 °C appears to be an innovative and promising method that may improve transplant logistics by extending the cold ischemia time with excellent outcomes. We report the case of two lung transplants from two different donors involving the use of two different preservation methods, highlighting the benefits of using 10 °C lung storage.     

Infarto cerebelar após orquidopexia sob raquianestesia

The report describes a case of peri‐operative stroke that presented as diplopia and gait difficulty on 2nd post‐operative day after routine orchidopexy under spinal anesthesia in an otherwise healthy young boy. Magnetic resonance imaging of the brain revealed acute infarct in bilateral cerebellar hemispheres, left half of medulla and left thalamus. A diagnosis of acute stroke (infarct) was made and patient was started on oral aspirin 75 mg.day^?1, following which his vision started improving after 2 weeks. Possible mechanisms of development of stroke in the peri‐operative period are discussed, but, even after extensive investigations, the etiology of infarct may be difficult to determine. Acute infarct after elective non‐cardiac, non‐neurological surgery is rare; it may not be possible to identify the etiology in all cases. Clinicians must have a high index of suspicion to diagnose such unexpected complications even after routine surgical procedures in order to decrease the morbidity and long term sequelae.     

Performance Diagnóstica da FFR por Angiotomografia de Coronárias através de Software Baseado em Inteligência Artificial

BackgroundThe non-invasive quantification of the fractional flow reserve (FFRCT) using a more recent version of an artificial intelligence-based software and latest generation CT scanner (384 slices) may show high performance to detect coronary ischemia.ObjectivesTo evaluate the diagnostic performance of FFRCT for the detection of significant coronary artery disease (CAD) in contrast to invasive FFR (iFFR) using previous generation CT scanners (128 and 256- detector rows).MethodsRetrospective study with patients referred to coronary artery CT angiography (CTA) and catheterization (iFFR) procedures. Siemens Somatom Definition Flash (256-detector rows) and AS+ (128-detector rows) CT scanners were used to acquire the images. The FFRCT and the minimal lumen area (MLA) were evaluated using a dedicated software (cFFR version 3.0.0, Siemens Healthineers, Forchheim, Germany). Obstructive CAD was defined as CTA lumen reduction ≥ 50%, and flow-limiting stenosis as iFFR ≤0.8. All reported P values are two-tailed, and when <0.05, they were considered statistically significant.ResultsNinety-three consecutive patients (152 vessels) were included. There was good agreement between FFRCT and iFFR, with minimal FFRCT overestimation (bias: -0.02; limits of agreement:0.14-0.09). Different CT scanners did not modify the association between FFRCT and FFRi (p for interaction=0.73). The performance of FFRCT was significantly superior compared to the visual classification of coronary stenosis (AUC 0.93vs.0.61, p<0.001) and to MLA (AUC 0.93vs.0.75, p<0.001), reducing the number of false-positive cases. The optimal cut-off point for FFRCT using a Youden index was 0.85 (87% Sensitivity, 86% Specificity, 73% PPV, 94% NPV), with a reduction of false-positives.ConclusionMachine learning-based FFRCT using previous generation CT scanners (128 and 256-detector rows) shows good diagnostic performance for the detection of CAD, and can be used to reduce the number of invasive procedures.