INTRODUCTION AND OBJECTIVES:Recommendations for implantable cardioverter-defibrillator (ICD) implantation to prevent sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HCM) have evolved over time, with late gadolinium enhancement (LGE) emerging as an important additional risk marker. Our study aimed to evaluate changes in the accuracy and discriminative performance of international guidelines for ICD recommendations and to determine whether LGE can improve this risk stratification. METHODS:We conducted a multicenter retrospective observational study of HCM patients who underwent cardiac magnetic resonance (CMR) imaging for diagnosis or risk assessment. ICD eligibility was determined based on the ESC guidelines (2014, 2022, 2023) and the American College of Cardiology (ACC) guidelines (2011, 2020, 2024). Our primary endpoint was a composite of sudden cardiac death (SCD), appropriate ICD discharge, or sustained ventricular tachycardia (VT). RESULTS:A total of 531 patients (median age 49 years; 57% male) were included. During a median follow-up of 49 months, twenty-eight events occurred (15 SCDs, six appropriate ICD discharges, seven sustained VTs). Over time, both European and American guidelines demonstrated improved sensitivity, positive predictive value, and discriminatory ability, while maintaining a high negative predictive value. The agreement between the recent ESC and ACC guidelines was moderate (κ≈0.6, p<0.001). Late gadolinium enhancement (LGE) was present in 80% of patients and LGE% independently predicted arrhythmic events (adjusted hazard ratio 1.09 per 1% increase; p<0.001). A burden ≥8% was the best predictor of events, while the absence of LGE identified patients without arrhythmic outcomes. CONCLUSIONS:The extent of LGE burden improves risk stratification for SCD, with the complete absence of LGE indicating a very low-risk subgroup. LGE thresholds should be individualized by integrating imaging results, clinical factors and the patient's context.

Immune checkpoint inhibitors (ICI) have revolutionized the treatment of various malignancies, but pose potential cardiotoxic risks, particularly in high-risk patients with pre-existing cardiovascular disease or prior cardiotoxic chemotherapy. A retrospective analysis was conducted on a Cardio-Oncology clinic (july 2018 - december 2024). Cardiotoxicity was defined as asymptomatic troponin/BNP elevation, new rhythm disturbances, new left ventricular dysfunction or myocarditis. Patients with pre-existing cardiovascular disease or prior cardiotoxic chemotherapy were classified as high risk. A total of 53 patients (median age: 66 years; 60% male) were included. Cardiovascular risk factors included hypertension (51%), dyslipidemia (51%), diabetes (19%), smoking history (40%) and overweight status (11%). Pre-existing cardiac conditions were present in 40% of patients, including coronary artery disease (11%), atrial fibrillation (9%) and heart failure (6%). Baseline medications included ACE inhibitors (21%), beta-blockers (36%) and statins (49%). Median left ventricular ejection fraction was 59%. Baseline high-sensitivity troponin levels were typically <1.9 ng/L and median BNP level was 158 pg/mL. The most frequently used ICI were pembrolizumab (59%) and nivolumab (25%). The most common malignancies were skin (25%), breast and kidney cancers (11% each), with other cancers including lung, stomach, urothelial, esophageal, thyroid, and endometrial malignancies. High cardiotoxicity risk was identified in 59% of patients, with 38% having prior exposure to cardiotoxic chemotherapy. Median treatment duration was 154 days. Over a median follow-up period of nine months, 13% of patients developed cardiotoxicity: troponin elevation (6%), BNP elevation requiring diuretics (2%), new-onset atrial fibrillation (2%) and myocarditis requiring hospitalization (4%). Cardio-protective therapy was initiated in 26% of patients, either preemptively (17%) or after cardiotoxicity (9%), Two patients developed myocarditis – one on pembrolizumab for breast cancer and another on nivolumab for kidney cancer. Both were hospitalized and managed with high-dose corticosteroids; one required additional immunosuppressive therapy. Both patients recovered but did not resume immunotherapy. Overall, 43% of patients died during the follow-up period, although no deaths were attributed to cardiac causes. The median survival time from cancer diagnosis was 27 months. While ICI are highly effective in treating malignancies, their cardiotoxicity potencial requires vigilant monitoring, particularly in high-risk patients. Though rare, ICI-associated myocarditis should be considered in patients with new-onset cardiac symptoms and elevated troponin, even in the absence of left ventricular dysfunction. Future research will bring new perspectives on risk stratification, optimal monitoring and safe immunotherapy resumption.

Abstract Introduction Aortic pressure increase per time unit (dP/dt) has been recently shown to predict the risk of progression of aortic stenosis (AS), with a proposed cut-off of 600 mmHg/s (Panel A). Whether it applies to other populations remains to be elucidated. Methods In this single-center retrospective study, we included patients with isolated moderate AS who had performed a complete transthoracic echocardiography (TTE) assessment in our center between 2014 and 2022. The primary endpoint was progression to severe AS, as documented by follow-up TTE. Uni- and multivariate analysis with Cox regression was used to assess the predictive value of dP/dt. Results A total of 103 patients were included, with a median age of 78 years (IQR 71 - 83), of which 58 (56%) were male. Median follow-up was 2.2 years (QR 1.1-3.7) and mean left ventricular ejection fraction (LVEF) was 54 ± 7%. We identified a total of 75 (73%) patients with a dP/dt ≥ 600mmHg/s; the mean value for dP/dt 737 ± 269 mmHg/s. Aortic dP/dt was independent of flow conditions, showing no correlation with stroke indexed volume (rho = 0.182; p = 0.08; r2 = 0.02) or LVEF (rho = 0.102; p = 0.31; r2 = 0.04). After adjustment for aortic maximum velocity (aHR 2.46 [1.08 - 5.5; p = 0.033]) and baseline creatinine (aHR 1.21 [1.06 - 1.37; p = 0.04]), dP/dt remained an independent predictor of progression to severe AS (aHR per 100 mmHg/s: 1.18 [1.03 - 1.34; p = 0.017]). The median time to AS progression was considerably shorter in patients with a dP/dt ≥ 600mmHg/s when compared with patients with a dP/dt < 600 mmHg/s (2.6 years [95%CI 2.0 – 3.3] vs. 5.3 years [95%CI 4.1-6.5]; Log-Rank p value < 0.001) (Panel B). The dP/dt cut-off of 600 mmHg/s had a sensitivity of 81% (95%CI: 69-90%), a specificity of 44% (95%CI: 30-60) a positive predictive value of 67% (95%CI 60-73%) and negative predictive value of 63% (95%IC: 48-75%). Conclusions Aortic dP/dt was validated in a single-center cohort of moderate aortic stenosis patients as an independent predictor of accelerated disease progression. This finding may help tailor individualized follow-up strategies.

Percutaneous mitral valve commissurotomy (PMC) is a viable alternative to mitral valve (MV) surgery in the treatment of patients with rheumatic mitral stenosis (RMS). In this single-center retrospective study of consecutive patients with RMS submitted to PMC from 1991 to 2008, we analyzed clinical, echocardiographic, and hemodynamic data and events during follow-up (FUP) until December 2021. Major adverse cardiovascular events (MACE) were a combined endpoint of all-cause death, cardiovascular hospitalization, and MV re-intervention. A total of 124 patients were enrolled: 108 (87.1%) were female, with a mean age at PMC of 46 [standard deviation (SD) 11] years. PMC was successful in 91.1%, with a mean reduction in invasive transmitral pressure gradient (TMPG) of 8 (SD 7) mmHg at PMC time. During the mean FUP of 20 (SD 6) years, 51 (41.1%) patients had MV re-intervention (86.3% surgery and 13.7% redo-PMC), 37 (29.8%) were hospitalized, and 30 (24.2%) died. Approximately 75% of patients remained MACE-free after 10 years, and this percentage decreased to around 40% after 20 years; at this time mark, about 8 in 10 patients were alive. A reduction of <5 mmHg in TMPG at PMC time was associated with a 2.7-fold greater rate of MACE compared to a reduction of ≥5 mmHg, independent of MV regurgitation after PMC and moderate disease of other valves (adjusted hazard ratio 2,7; 95% confidence interval 1.395-5.298, p=0.003). In this cohort with favorable long-term results after PMC, a reduction of <5 mmHg in TMPG at PMC time was associated with MACE during FUP. More studies are needed to validate this independent predictor.

Introduction: Breast cancer patients undergoing trastuzumab therapy have greater risk of cardiovascular disease. Risk factors for this effect have been proposed. However, the role of dyslipidemia is not completely understood. This systematic review aimed to explore the role of dyslipidemia in trastuzumab-induced cardiotoxicity. Methods: The investigators searched MEDLINE, Scopus, and Web of Science up to October 25, 2020. A random-effects model was used to determine pooled estimates of the results. The primary endpoint was trastuzumab-induced cardiotoxicity in patients with and without dyslipidemia. Results: A total of 39 studies were selected for inclusion in our systematic review assessing 21 079 patients. One study demonstrated a statistically significant association between dyslipidemia and cardiotoxicity (OR=2.28, 95% CI 1.22-4.26, p=0.01). In all other studies, no such association was observed. Twenty-one studies including 6135 patients were eligible for meta-analysis. In this meta-analysis of unadjusted data, dyslipidemia was significantly associated with cardiotoxicity (OR=1.25, 95% CI 1.01-1.53, p=0.04, I2=0%), however, a subgroup analysis of studies reporting adjusted measures did not demonstrate a significant association (OR=0.89, 95% CI 0.73-1.10, p=0.28, I2=0%).

Caso Apresenta-se o caso de um homem de 52 anos, com antecedentes de hepatite-C e abuso de drogas endovenosas, que estava internado no serviço de infectologia de outro hospital por espondilodiscite e abcesso no músculo psoas. Durante o internamento isolou-se Staphylococcus aureus em culturas de sangue, urina e líquido cefalorraquidiano, pelo que se iniciou antibioterapia dirigida. Realizou-se ecocardiograma transtorácico, que não mostrou sinais de vegetações, abcessos ou fístulas. Por manutenção de febre e suspeita de endocardite infeciosa (EI), foi submetido [...]

Breast cancer (BC) patients treated with anthracyclines and/or anti-HER2-targeted therapies (AHT) are highly associated with cardiovascular toxicity (CVT). Our objective was to evaluate the risk of CVT secondary to cancer treatment and the role of cardioprotective-drugs (CPD) in BC patients. We collected a retrospective cohort of females with BC treated with chemotherapy and/or AHT from 2017 to 2019. CVT was defined as LVEF<50% or decline ≥10% during follow-up. As CPD, we considered renin-angiotensin-aldosterone-system inhibitors and beta-blockers. A subgroup analysis of the AHT patients was also performed. A total of 203 women were enrolled. The majority had high or very-high CVT risk score and normal cardiac function at presentation. As for CPD, 35.5% were medicated pre-chemotherapy. All patients were submitted to chemotherapy; AHT were applied to 41.7%. During a 16 months follow-up, 8.5% developed CVT. There was a significant decrease of GLS and LVEF at 12-months (decrease of 1.1% and 2.2%, p<0.001). AHT and combined therapy were significantly associated with CVT. In the AHT sub-group analysis (n=85), 15.7% developed CVT. Patients previously medicated with CPD had a significative lower incidence of CVT (2.9% vs 25.0%, p=0.006). Patients already on CPD presented a higher LVEF at 6-months follow-up (62.5% vs 59.2%, p=0.017). Patients submitted to AHT and anthracycline therapy had higher risk of developing CVT. In the AHT sub-group, pre-treatment with CPD was significantly associated with a lower prevalence of CVT. These results highlight the importance of cardio-oncology evaluation and strengthen the value of primary prevention.

Clinical overt cardiac cachexia is a late ominous sign in patients with heart failure (HF) and reduced left ventricular ejection fraction (LVEF). The main goal of this study was to assess the feasibility and prognostic significance of muscle mass quantification by cardiac magnetic resonance (CMR) in HF with reduced LVEF. HF patients with LVEF < 40% (HFrEF) referred for CMR were retrospectively identified in a single center. Key exclusion criteria were primary muscle disease, known infiltrative myocardial disease and intracardiac devices. Pectoralis major muscles were measured on standard axial images at the level of the 3rd rib anteriorly. Time to all-cause death or HF hospitalization was the primary endpoint. A total of 298 HF patients were included (mean age 64 ± 12 years; 76% male; mean LVEF 30 ± 8%). During a median follow-up of 22 months (IQR: 12–33), 67 (22.5%) patients met the primary endpoint (33 died and 45 had at least 1 HF hospitalization). In multivariate analysis, LVEF [Hazard Ratio (HR): 0.950; 95% Confidence Interval (CI): 0.917–0.983; p = 0.003), NYHA class I–II vs III–IV (HR: 0.480; CI: 0.272–0.842; p = 0.010), creatinine (HR: 2.653; CI: 1.548–4.545; p < 0.001) and pectoralis major area (HR: 0.873; 95% CI: 0.821–0.929; p < 0.001) were independent predictors of the primary endpoint, when adjusted for gender and NT-pro-BNP levels. Pectoralis major size measured by CMR in HFrEF was independently associated with a higher risk of death or HF hospitalization. Further studies to establish appropriate age and gender-adjusted cut-offs of muscle areas are needed to identify high-risk subgroups.

INTRODUCTION:The prevalence of hypoalbuminemia, early changes of plasma albumin (P-Alb) levels, and their effects on mortality in cardiogenic shock are unknown.MATERIALS AND METHODS:P-Alb was measured from serial blood samples in 178 patients from a prospective multinational study on cardiogenic shock. The association of hypoalbuminemia with clinical characteristics and course of hospital stay including treatment and procedures was assessed. The primary outcome was all-cause 90-day mortality.RESULTS:Hypoalbuminemia (P-Alb < 34g/L) was very frequent (75%) at baseline in patients with cardiogenic shock. Patients with hypoalbuminemia had higher mortality than patients with normal albumin levels (48% vs. 23%, p = 0.004). Odds ratio for death at 90 days was 2.4 [95% CI 1.5-4.1] per 10 g/L decrease in baseline P-Alb. The association with increased mortality remained independent in regression models adjusted for clinical risk scores developed for cardiogenic shock (CardShock score adjusted odds ratio 2.0 [95% CI 1.1-3.8], IABP-SHOCK II score adjusted odds ratio 2.5 [95%CI 1.2-5.0]) and variables associated with hypoalbuminemia at baseline (adjusted odds ratio 2.9 [95%CI 1.2-7.1]). In serial measurements, albumin levels decreased at a similar rate between 0h and 72h in both survivors and nonsurvivors (ΔP-Alb -4.6 g/L vs. 5.4 g/L, p = 0.5). While the decrease was higher for patients with normal P-Alb at baseline (p<0.001 compared to patients with hypoalbuminemia at baseline), the rate of albumin decrease was not associated with outcome.CONCLUSIONS:Hypoalbuminemia was a frequent finding early in cardiogenic shock, and P-Alb levels decreased during hospital stay. Low P-Alb at baseline was associated with mortality independently of other previously described risk factors. Thus, plasma albumin measurement should be part of the initial evaluation in patients with cardiogenic shock.TRIAL REGISTRATION:NCT01374867 at ClinicalTrials.gov.

Introduction: Despite successful repair of aortic coarctation (AC), systemic hypertension (HTN) can persist in a significant percentage of patients. Exercise-induced HTN is also common in these patients, although its clinical significance is still unclear. In this study we aimed to assess the prevalence of exercise-induced HTN in adult patients with repaired AC. Methods: We retrospectively reviewed the clinical records of patients aged >18 years with repaired AC followed at an adult congenital heart disease outpatient clinic in a tertiary care center. Demographic and clinical data including age at intervention, blood pressure (BP) at rest and on exercise, transthoracic echocardiogram (TTE) and treadmill exercise test results were evaluated. Exercise-induced HTN was defined as peak systolic BP ≥210 mmHg for men and ≥190 mmHg for women. Results: We analyzed 65 patients (40 [61.5%] male; mean age at follow-up 30±8 years). Median age at AC repair was 7 years (P25-P75: 4-20) and mean follow-up was 20±7 years. Only one patient had diabetes and 10 (15.4%) had dyslipidemia. The majority of patients had controlled BP at rest and only nine (18%) were under antihypertensive medication. Forty-nine patients performed a treadmill exercise test. The mean duration of exercise was 10.7±3.1 minutes and mean peak heart rate was 166±18 beats per minute. Eleven (22%) patients had a hypertensive response, among whom only three (33%) had uncontrolled BP at rest. In our study treatment with angiotensin-converting enzyme inhibitors (ACEI) (OR 4.0 [95% CI 1.9–18.1]) and the peak instantaneous gradient in the descending aorta by TTE (OR 8.2 [95% CI 1.8–37.0]) were predictors of a hypertensive response with exercise. Age at surgery and type of AC repair were not associated with a hypertensive response on exercise. Conclusions: In this study we found a significant prevalence of exercise-induced HTN in adult patients after successful AC repair despite adequate BP control at rest. Exercise-induced HTN was significantly related to higher peak gradient in the descending aorta and treatment with ACEI. These results highlight the complexity of the adult AC population and show that, even after a good surgical result, several patients remain at high cardiovascular risk and require long-term follow-up. Resumo: Introdução: Apesar de a correção bem-sucedida da coartação da aorta, a hipertensão arterial pode persistir numa percentagem significativa de doentes. A resposta hipertensiva ao esforço é também um achado comum nestes doentes, embora com significado clínico ainda pouco esclarecido. No presente estudo pretendemos avaliar a prevalência de hipertensão induzida pelo exercício numa população adulta com coartação da aorta corrigida. Métodos: Análise retrospetiva de dados demográficos e clínicos de adultos operados a coartação da aorta, seguidos numa consulta de cardiopatias congénitas do adulto num centro terciário. Foram avaliados os dados correspondentes às características clínicas à data da cirurgia, perfil tensional atual, gradiente máximo residual na aorta descendente por ecocardiograma transtorácico (ETT) e parâmetros da prova de esforço. A resposta hipertensiva foi definida para uma pressão sistólica máxima no exercício ≥ 210 mmHg nos homens e ≥ 190 mmHg nas mulheres. Resultados: Avaliamos 65 doentes [40 (61,5%) do sexo masculino; idade média 30±8 anos]. A idade mediana à data da cirurgia foi 7 anos [percentil 25 - percentil 75 (P25-75)] (P25-75: 4-20 anos). O tempo médio de seguimento foi 20±7 anos. Apenas um doente tinha diabetes mellitus e 10 (15,4%) tinham dislipidemia. A maioria dos doentes tinha a pressão arterial controlada em repouso e apenas 9 (18%) doentes ainda estavam sob titulação da terapêutica anti-hipertensiva. Quarenta e nove doentes foram submetidos a prova de esforço, sendo a duração média da prova de 10,7±3,1 minutos e a frequência cardíaca máxima de 166±18 batimentos por minuto. Onze (22%) doentes tiveram uma resposta hipertensiva com o exercício e apenas 3 (72,7%) destes mantinham difícil controlo da pressão arterial em repouso. A terapêutica concomitante com inibidores da enzima de conversão da angiotensina (i-ECA) [OR 4.0 (95% IC 1,9 – 18,1)] e um gradiente máximo na aorta descendente obtido por ETT [OR 8,2 (95% IC 1,8 – 37,0)] associaram-se a resposta hipertensiva ao esforço. A idade à data da cirurgia ou o tipo de cirurgia não se correlacionaram com a resposta hipertensiva ao exercício. Conclusões: Neste estudo encontramos uma prevalência significativa de resposta hipertensiva ao exercício, após a correcção bem-sucedida da CoAo, e apesar de um adequado controlo da pressão arterial em repouso. A resposta hipertensiva ao exercício esteve significativamente associada a um maior gradiente máximo na aorta descendente obtido por ETT, bem como ao uso de i-ECA como antihipertensores. Estes resultados realçam a complexidade da população adulta com CoAo e o facto de que muitos doentes permanecem sob importante risco cardiovascular, apesar de uma prévia correcção da CoAo bem-sucedida. Keywords: Aortic coarctation, Exercise-induced hypertension, Follow-up, Palavras-chave: Coartação da aorta, Hipertensão arterial, Exercício, Follow-up

Aim: The aim of this study was to determine the early and long-term results of percutaneous balloon mitral valvotomy (PBMV) in patients with Wilkins score (WS) between 9 and 11. Methods: We performed a retrospective review of clinical records of patients with rheumatic mitral stenosis who underwent PBMV between November 1991 and March 2008. Follow-up was obtained by telephone interview and/or clinical records. The procedure was considered unsuccessful when post-procedure mitral valve area was <1.5 cm2. Results: We analyzed 124 patients, 108 (87.1%) of them women. Mean age at the time of repair was 46±11 years and mean follow-up time was 10±4 years. Before the procedure, 100 patients (80.6%) had WS ≤8 and 24 (19.4%) were in the “gray zone” (>8 and <11). Patients with WS ≤8 and patients in the gray zone had similar ages at first intervention (45±11 vs. 49±11 years; p=0.095) and follow-up time (10±4 vs. 11±5 years; p=0.55). There were no differences between groups in gender (women: 86% vs. 92%; p=0.735), or in baseline echocardiographic measurements (mitral valve area by planimetry 1.0 cm2 [P25-P75: 0.9-1.1] vs. 0.9 [P25-P75: 0.8-1.2], p=0.514; pulmonary artery systolic pressure 53 mmHg [P25-P75: 45-63] vs. 50 [P25-P75: 44-54], p=0.823]; left atrial diameter >55 mm [16.5% vs. 13.6%, p=1.00]; mitral regurgitation [46.5% vs. 37.5%, p=0.428]) or baseline transmitral gradient (13 mmHg [P25-P75: 10-19] vs. 13 mmHg [P25-P75: 7-20]). Improvements in mitral valve area by planimetry and in hemodynamic gradient were similar in the two groups (0.91±0.39 cm2 vs. 0.84±0.44 cm2, p=0.55; 8.8±5.3 mmHg vs. 7.3±5.9 mmHg, p=0.275, respectively). There were no significant differences in major complications or success rates (4.0 vs. 12.5 p=0.131; 89.9% vs. 95.8%, p=0.69) or in need for urgent surgery or future reintervention (2.0 vs. 8.3%, p=0.168; 22% vs. 27.3%, p=0.594). In-hospital mortality occurred only in patients in the WS gray zone (2 [8.3%] vs. 0%, p=0.04), one death (4.2% vs. 0%, p=0.194) possibly being related to a higher WS (secondary to stroke) and the other as a consequence of peripheral vascular complication. Improvements in NYHA functional class soon after the procedure and during follow-up were similar in the two groups. Total mortality was similar in the two groups (3.1 vs. 8.7%, p=0.244). Conclusions: PBMV was a safe and effective procedure in patients in the WS gray zone. Optimal results can be achieved in these patients if they are carefully selected and operated at experienced centers. Resumo: Objetivo: O objetivo deste estudo foi o de determinar os resultados a curto e longo prazo da valvulotomia percutânea mitral por balão em pacientes com score de Wilkins de 9 a 11. Métodos: Foi realizado um estudo retrospetivo através da recolha de dados de clínicos de doentes com estenose mitral reumática submetidos a valvulotomia mitral por balão, de novembro de 1991 a março de 2008. O follow-up foi obtido por meio de entrevista telefónica e/ou através dos registros clínicos. O procedimento foi considerado com sucesso quando a área valvular mitral <1,5 cm2 no final da intervenção. Resultados: Foram analisados 124 doentes, 108 (87,1%) mulheres. A média de idades no momento da valvuloplastia percutânea foi de 46 ± 11 anos e a média de tempo de follow-up foi de 10 ± 4 anos. Antes do procedimento, 100 (80,6%) doentes apresentavam score de Wilkins ≤ 8 e 24 (19,4%) apresentavam um total de score na zona cinzenta (> 8 e <11). A média de idades à data da primeira intervenção dos doentes com score de Wilkins ≤ 8 foi semelhante à dos doentes com score de Wilkins na zona cinzenta (45 ± 11 versus 49 ± 11 anos, p = 0,095), bem como o tempo de follow-up (10 ± 4 versus 11 ± 5 anos, p = 0,55). Não houve diferenças entre sexo entre os grupos (mulheres: 86% versus 92%, p = 0,735), ou valores ecocardiográficos basais [área da válvula mitral por planimetria 1,0 cm2 (P25-75: 0,9-1,1) versus 0,9 (P25-75: 0,8-1,2), p = 0,514; pressão sistólica da artéria pulmonar 53 mmHg (P25-75: 45-63) vs 50 (P25-75: 44-54), p = 0,823), diâmetro da aurícula esquerda> 55 mm (16,5% versus 13,6%, p = 1,00), insuficiência mitral (46,5% versus 37,5%, p = 0,428)] ou no gradiente hemodinâmico transmitral (13 mmHg (P25-75: 10-19) vs 13 mmHg (P25-75: 7-20). A área valvular mitral (planimetria) e a melhoria do gradiente hemodinâmico foram semelhantes nos dois grupos (0,91 ± 0,39 cm2 versus 0,84 ± 0,44 cm2, p = 0,55; 8,8 ± 5,3 mmHg versus 7,3 ± 5,9 mmHg, p = 0,275, respetivamente). Não houve diferenças significativas na incidência de complicações major ou na taxa de sucesso (4,0 versus 12,5 p = 0,131; 89,9% versus 95,8%, p = 0,69), assim como na necessidade de cirurgia urgente ou futura reintervenção (2,0 versus 8,3%, p = 0,168; versus 22% 27,3%, p = 0,594). A mortalidade hospitalar ocorreu apenas em doentes com score de Wilkins na zona cinzenta [2 (8,3%) versus 0%, p = 0,04], sendo uma morte (4,2% versus 0%, p = 0,194) eventualmente correlacionados com uma maior pontuação Wilkins (secundária a acidente vascular cerebral), e a restante ocorreu em consequência de complicação vascular periférica. No que diz respeito à melhoria da classe funcional após o procedimento e durante o follow-up os resultados não foram estatisticamente significativos, tendo sido semelhantes entre os grupos. A mortalidade total foi semelhante em ambos os grupos (3,1 versus 8,7%, p = 0,244). Conclusões: A valvulotomia percutânea mitral por balão foi um procedimento seguro e eficaz em doentes na zona cinzenta do score de Wilkins. A seleção destes doentes para obtenção de melhores resultados deve ser criteriosa e cuidadosamente avaliada. A referenciação destes doentes é fundamental e deve ser realizada em centros com grande experiência nesta técnica. Keywords: Mitral stenosis, Percutaneous balloon valvotomy, Wilkins score, Palavras-chave: Estenose mitral, Valvuloplastia percutânea mitral por balão, Score de Wilkins

Right ventricular infarction is uncommon in isolation but can be observed in 50% of cases of inferior wall myocardial infarction. Diagnosis is difficult and suspicion of this condition should always be borne in mind. Progression to cardiogenic shock is not uncommon, when the outcome is similar to left ventricular infarction; mortality can reach 60%. We present the case of a 64-year-old woman with known coronary disease who was admitted to our coronary care unit after an anterior myocardial infarction. Cardiac catheterization showed diffuse stenosis of the left descending and 70% stenosis of the posterior descending arteries. She was surgically revascularized with a favorable evolution, but was later readmitted for acute decompensated heart failure with cardiogenic shock. She was refractory to medical therapy, with biventricular dysfunction on echocardiographic examination. Cardiac magnetic resonance imaging confirmed the diagnosis of right ventricular infarction.