P704 Mechanical complications of acute myocardial infarction in the era of early reperfusion therapy: a case report

Introduction

Left ventricular pseudoaneurysm is a rare mechanical complication of myocardial infarction, and its incidence has decreased with the widespread use of reperfusion therapies. Pseudoaneurysm is the result of a free wall rupture contained by pericardial adherences and mural thrombi, which contain the bleeding and prevent cardiac tamponade.

Clinical Presentation

A 68-year-old woman who had hypertension, diabetes mellitus and chronic kidney disease (caused by diabetic nephropathy) was first admitted with acute myocardial infarction of the inferior wall. Emergent coronary angiography revealed proximal occlusion of the right coronary artery. Primary angioplasty was performed with three stents implantation. However due to transitory no reflow, verapamil, nitrate and intracoronary abciximab were administered with recovery of coronary flow. Patient remained stable, without recurrence of symptoms. Echocardiography, at discharge, showed normal biventricular function and no mechanical complications.

Two months later, the patient was readmitted in the emergency room with constant chest pain, fatigue, prostration and loss of appetite beginning ten days earlier and an episode of syncope. Physical examination revealed fever, cardiac auscultation was rhythmic and without murmurs or pericardial friction rub, and pulmonary auscultation revealed crackles in inferior hemithorax. 12-lead electrocardiogram showed sinus rhythm, Q waves and negative T waves in inferior leads. Blood tests revealed leucocytosis, high sensibility troponin I was 28,8 ng/L and brain natriuretic peptide was 264,9 pg/mL. Chest-X-ray demonstrated enlargement of the cardiac silhouette and echocardiography showed moderate to large pericardial effusion with large amounts of fibrin close to right cardiac chambers and a basal inferior pseudoaneurysm with 23 mm x 24 mm; intracavitary contrast was administered without opacification of pericardial space; biventricular function remained normal.

Patient was promptly admitted on Cardiac Intensive Care Unit with diagnosis of pseudoaneurysm due to myocardial infarction. Therapeutic with ticagrelor was suspended and surgical correction was proposed, after discussion in Heart Team. False aneurysm correction was performed with a bovine pericardial patch without complications, and the patient was discharged asymptomatic eight days later.

Conclusion

Even with lower incidence, pseudoaneurysms remains as a potential life-threatening due to its high risk of rupture. Prompt diagnosis, usually with echocardiography and surgical referral are crucial.

Abstract P704 Figure. Inferior Pseudoaneurysm

P863 Large pericardial effusion two months after transcatheter aortic valve implantation: case report of a post-cardiac injury syndrome

We present a case of a 87-year-old female with a symptomatic severe aortic stenosis (aortic valve area 0.9 cm2, mean transvalvular pressure gradient 44 mmHg). She was refused to surgical aortic valve replacement due to marked aortic root calcification. A transcatheter aortic valve (ACCURATE neo™ 27) was electively implanted. In immediate post-procedure, the patient presented an episode of hypotension, rapidly reverted with supportive treatment. A transthoracic echocardiogram (TTE) showed a circumferential mild pericardial effusion (PE) without prosthetic valve disfunction and with preserved biventricular systolic function. Due to paroxysmal episodes of atrial fibrillation, it was decided to withdraw anti-aggregation and to start anticoagulation. Four days after transcatheter aortic valve implantation (TAVI) the patient presented newer intraventricular and atrioventricular conduction disturbance (left bundle branch block and type-I second-degree atrioventricular block). A definitive pacemaker was implanted without complications. PE maintained stable and seven days after TAVI the patient was discharged from hospital.

Two months after TAVI, the patient was admitted to Intensive care unit (ICU) with increasing asthenia, dyspnea and pleuritic thoracic pain over the preceding two weeks. Laboratory workup exhibited elevation of inflammatory markers (leukocytosis and C-reactive protein). A TTE was performed and showed a large circumferential PE (29 mm) with signs of hemodynamic impact (swinging heart, inferior vena cava dilation with <50% inspiratory collapse, right atrial collapse >1/3 of cardiac cycle, proto-diastolic right ventricular collapse and mitral respiratory flow variation >25%). The patient started treatment with anti-inflammatory drugs (aspirin 1000mg every 8h plus colchicine 0.5mg twice daily) and pericardiocentesis was initially postponed. In spite of clinical and echocardiographic improvement, she maintained elevated inflammatory markers and a moderate PE. Prednisolone 30mg daily was added to initial therapy and serial evaluations showed a pronounced reduction of PE as well as of inflammatory markers. Two weeks after admission to ICU the patient was discharged with a residual PE measuring less than 5mm. The previous recent cardiac intervention and the effective response to anti-inflammatory treatment suggest a post-cardiac injury syndrome.

This case report wants to show that post-cardiac injury syndrome is a diagnosis that should be keep in mind after TAVI.

Abstract P863 Figure. TTE showing large pericardial effusion

1115 Ultra-slow low-dose thrombolytic therapy as an option of treatment in intracardiac thrombus: a case report

We present a case of a 57-year-old male with previously known primary severe mitral regurgitation, who was admitted to the ICU due to massive venous thromboembolism with associated right ventricle dysfunction and with two large mobile right atrial thrombi (2.4 x 1.5 cm and 3.6 x 3.7 cm). Despite of five days with a therapeutic aPTT achieved with unfractionated heparin (UFH), a TTE showed deterioration of the right ventricle systolic function, persistence of the right atrial masses with similar dimensions together with new mobile thrombi on the coronary sinus and on the right pulmonary artery. Due to deterioration of his clinical condition and given the refractoriness to the classical treatment with UFH, it was decided to administer an ultra-slow low-dose thrombolysis protocol, which consisted in a 24-hour infusion of 24 mg of alteplase at a rate of 1 mg per hour, without bolus. The treatment was continued by 48 consecutive hours, with clinical improvement and important reduction of the right atrial masses with resolution of the coronary sinus and right pulmonary artery thrombi. The patient started hypocoagulation with warfarin bridging with low molecular weight heparin (LMWH). Seven days after alteplase discontinuation there was complete resolution of the intracardiac thrombi. One month after ICU admission a successful mitral valve replacement surgery was conducted. Three months after discharge, the patient is in functional New York Heart Association (NYHA) class I with no cardiovascular events or hospitalizations. This case demonstrates that ultra-slow low-dose thrombolysis is a valid bailout treatment option in patients with large intracardiac thrombi refractory to anticoagulation.

Abstract 1115 Figure. TTE showing right atrial masses

The effect of elbow flexion and time of assessment on the measurement of grip strength in rheumatoid arthritis

Grip strength is one of the traditional outcome measures commonly used in rheumatoid arthritis trials. This study evaluated the degree of morning variation and the effect of elbow flexion in the assessment of grip strength in patients with rheumatoid arthritis. Grip strength was measured in 37 patients (1987 American Rheumatism Association criteria) at 8, 10, and 12 AM with a sphygmomanometer cuff folded on itself, taped permanently, and inflated to 20 mm Hg, with the elbow flexed at 90 degrees. At 10 AM grip strength was also measured with the elbow flexed at 30 and 130 degrees. Mean values for grip strength at 8, 10, and 12 AM were, respectively, 69, 79, and 83 mm Hg. Mean grip strength values with the elbow flexed at 30, 90, and 130 degrees were, respectively, 78, 79, and 75 mm Hg. There was a statistically significant correlation between grip strength and morning stiffness, grip strength and hand function, and grip strength and number of active joints. In rheumatoid arthritis trials, grip strength should be assessed at the same time of the day. Elbow flexion does not play a role in grip strength measurement.

Trypanosoma cruzi: early resistance induced by culture-derived trypomastigotes

Previous observations in this laboratory showed that injection of culture-derived trypomastigotes (CT), in CBA/J mice, induced an early increased resistance that was detected 24-72 hr after antigen injection and permitted mice to survive a challenge of 10(5) blood trypomastigotes (BT) corresponding to 2000 LD50%. Present experiments were conducted to determine the optimal conditions for inducing this early resistance and to investigate the early morphological changes which occurred in blood and lymphoid organs of mice infected with either BT or CT. Among nine antigens tested, only living CT showed a protective effect permitting most of mice to survive 30 days after BT challenge, while control mice injected with PBS or other antigens died at 10 +/- 1 days. A dose-response relationship was seen when different doses of CT were tested, higher doses of CT inducing higher survival and lower parasitemia. Injection of CT by either an im or ip route induced similar degrees of resistance but significantly different results were obtained when mice were challenged by using ip or im routes. Higher parasitemia and lower survival were always obtained when animals were challenged by the ip route. Within 72 hr, mice injected with BT presented a lymphopenia which reached a maximum at 48 hr, a depletion of thymic cortical zone, and splenomegaly with hyperplasia of the white pulp and congestion of the red pulp. No gross alterations were observed in animals infected with CT. Overall data suggest that the early resistance is a specifically induced phenomenon and that BT and CT induce different early reactions in the CBA/J lymphoid organs.(ABSTRACT TRUNCATED AT 250 WORDS)

EPM-ROM Scale: an evaluative instrument to be used in rheumatoid arthritis trials

Different tools are available for the measurement of functional status; however, only a few of them are based on the evaluation of the joint range of motion (ROM). This study is aimed at the design and evaluation of the measurement properties of a ROM scale to be used as an evaluative instrument in rheumatoid arthritis (RA) trials. The EPM-ROM Scale evaluates 10 distinct movements of the small and large joints. The score of each joint varies from 0 (full movement) to 3 (severe limitation) and the cut-off degrees of motion are, in general, based on the lack of ability to perform some determined activities of daily living. The test-retest characteristic of the scale was assessed by administering the scale twice, 5 days apart, to 35 RA patients. The product moment correlation was 0.775 (P less than 0.001). The cross-sectional construct validity of the scale was assessed by the concomitant scoring of the EPM-ROM Scale and the functional ability dimension of the Health Assessment Questionnaire (a reliable, valid and responsive instrument) in these patients. The product moment correlation was 0.518 (P less than 0.001). The evaluation of its longitudinal construct validity and responsiveness are now in progress.

Crosscultural reliability of the physical ability dimension of the health assessment questionnaire

Functional ability evaluation constitutes an important outcome measurement in any proposed trial involving patients with rheumatoid arthritis (RA). We performed a crosscultural study directed at the translation into Portuguese of the Physical Ability Dimension of the Health Assessment Questionnaire (HAQ) and the evaluation of its reliability. Five questions were modified in the Portuguese version of the HAQ to suit Brazilian conditions. The test-retest correlation coefficient was 0.905 (p less than 0.001) and the interobserver correlation coefficient was 0.830 (p less than 0.001) Our results provide evidence of instrument reliability. The instrument kept its face and content validity and the evaluation of the longitudinal construct validity is now in progress.

A functional idiotypic network of T helper cells and antibodies, limited to the compartment of "naturally" activated lymphocytes in normal mice

As shown previously, idiotype (Id) sharing between anti-2,4,6-trinitrophenyl T helper (Th) cells and antibodies in BALB/c mice results from immunoglobulin (Ig)-dependent selection of the T cell repertoire. In contrast, a clonotype defined by the same F6(51) anti-Id antibody is expressed by C57BL/6 anti-(4-hydroxy-3-nitrophenyl)acetyl Th cells independently of Ig influences. We have now used these systems to test the hypothesis that Ig-dependent Th cell repertoire selection occurs in the compartment of "naturally" activated lymphocytes. "Naturally" activated or resting splenic L3T4+ cells were separated from normal BALB/c and C57BL/6 mice and tested, either directly or after in vitro priming, in hapten-specific helper assays for expression of the clonotope defined by the F6(51) anti-Id antibody. The results show the selective expression of the antibody-dependent T cell Id in the "naturally" activated helper cell compartment. In contrast, when the T cell Id is expressed in the absence of Ig-dependent selection, it is only detected in the resting helper cell repertoire. Furthermore, BALB/c "natural" IgM antibodies with anti-Id specificities similar to F6(51) show functionally relevant interactions with syngeneic "naturally" activated Th cells. These are also characterized by high paratopic/Id degeneracy, as compared to helper cells obtained by conventional immunization. These results demonstrate repertoire differences between the set of (resting) lymphocytes participating in immune responses, vs. those "internally" activated in normal individuals. They also suggest the importance of Id network interactions in the compartment of "naturally" activated T and B cells.

Idiotypic multireactivity of 'natural' antibodies. 'Natural' anti-idiotypes also inhibit helper cells with cross-reactive clonotypes

One hundred and twenty IgM-secreting hybridomas derived from unmanipulated 6-day-old BALB/c mice were screened for reactivity with the prototype idiotypic and anti-idiotypic monoclonal antibodies, defining three well established systems, namely TEPC 15:10/13-15, J558:CD3.2, and MOPC 460:F 6(51). Up to 25% of all IgM antibodies reacted with at least one of the six specific ligands, half of the latter being 'monospecific', the others reacting with two or more antibodies. A detailed analysis of the four most multi-reactive clones showed individually specific patterns of reactivity and revealed reactions of the same IgM molecule in idiotypic systems previously studied independently. Furthermore, when tested for functional interactions with syngeneic helper T cells expressing MOPC 460-like clonotypes, one of these antibodies was found to inhibit effector helper activity. The results show the existence of 'natural antibodies' with idiotypic reactivities related to recurrent clonotypes in the strain. They may be either 'specific' or 'multireactive', and might connect idiotypes on T and B cells and on antigenic systems so far studied independently.