Fundamento: A COVID-19 causa grave acometimento pulmonar, porém o sistema cardiovascular também pode ser afetado por miocardite, insuficiência cardíaca e choque. A elevação de biomarcadores cardíacos tem sido associada a um pior prognóstico. Objetivos: Avaliar o valor prognóstico da Troponina T (TnT) e do peptídeo natriurético tipo B (BNP) em pacientes internados por Covid-19. Métodos: Amostra de conveniência de pacientes hospitalizados por COVID-19. Foram coletados dados dos prontuários com o objetivo de avaliar a relação da TnT e o BNP medidos nas primeiras 24h de admissão com o desfecho combinado (DC) óbito ou necessidade de ventilação mecânica. Análise univariada comparou os grupos com e sem DC. Modelo multivariado de Cox foi utilizada para determinar preditores independentes do DC. Resultados: Avaliamos 183 pacientes (idade=66,8±17 anos, sendo 65,6% do sexo masculino). Tempo de acompanhamento foi de 7 dias (1 a 39 dias). O DC ocorreu em 24% dos pacientes. As medianas de TnT e BNP foram 0,011 e 0,041 ng/ dl (p<0,001); 64 e 198 pg/dl (p<0,001) respectivamente para os grupos sem e com DC. Na análise univariada, além de TnT e BNP, idade, presença de doença coronariana, saturação de oxigênio, linfócitos, dímero-D, proteína C reativa titulada (PCR-t) e creatinina, foram diferentes entre os grupos com e sem desfechos. Na análise multivariada boostraped apenas TnT (1,12[IC95%1,03-1,47]) e PCR-t (1,04[IC95%1,00-1,10]) foram preditores independentes do DC. Conclusão: Nas primeiras 24h de admissão, TnT, mas não o BNP, foi marcador independente de mortalidade ou necessidade de ventilação mecânica invasiva. Este dado reforça ainda mais a importância clínica do acometimento cardíaco da COVID-19.

It was possible to reduce ventricular filling pressures to significantly lower values, obtaining a significant improvement of cardiac index, systemic vascular resistance index and pulmonary artery mean pressure, by using significantly higher doses of vasodilators.

Left internal thoracic artery fistula draining to left pulmonary artery is an extremely rare complication following myocardial revascularization. It may cause recurrent angina, dyspnea, heart failure, endocarditis, among other conditions. It should always be considered in the absence of a clear cause for the onset of these symptoms after myocardial revascularization. The diagnosis is made by coronary angiography, and most patients are treated by surgical or percutaneous closure of the fistula. CASE REPORTA 73-year-old white male patient with a history of systemic arterial hypertension and coronary artery bypass grafting six years ago using the following grafts: left internal thoracic (mammary) artery to anterior descending artery, sequential saphenous vein to the 1 st and 2 nd left marginal arteries and saphenous vein to the 1 st diagonal artery. The patient presented with asthenia and progressive exertional dyspnea, which has been getting worse over the last few months even on mild exertion. He had been taking captopril 150 mg/d, hydrochlorothiazide 25 mg/d, and acetylsalicylic acid 200 mg/d. The cardiovascular physical examination was normal, except for a fourth heart sound (S4). His lungs were found to be clean. First-degree atrioventricular block and left anterior hemiblock was seen on ECG. The echocardiogram revealed only left ventricular hypertrophy and diastolic disfunction. Myocardial ischemia investigation was performed through stress/rest myocardial perfusion scintigraphy. The scan ( fig.1) showed low uptake of the radiopharmaceutical (Tc-99 sestamibi) in the anteroseptal region on stress, which returned to normal at rest, a finding consistent with anteroseptal ischemia. Coronary angiography and left ventriculography were thus performed, showing patency of all grafts and a 70% obstruction of the right coronary artery. However, a large fistula arising at the initial portion of the left mammary artery draining to the left pulmonary artery was detected ( fig. 2 e 3). This fistula resulted in a significant steal of flow from the anterior descending artery, thought to be the cause of the anteroseptal ischemia. A surgical ligation of the fistula was performed, and the patient was discharged from the hospital. During the oneyear follow-up period, the patient was free of the symptoms which led to his hospitalization.We report a patient who developed dyspnea on mild exertion six years after coronary artery bypass graft surgery (CABG). Myocardial ischemia was documented by radionuclide imaging, and coronary angiography showed patency of all grafts and a large fistula between the left internal thoracic artery (LITA) and the left pulmonary artery (LPA). The patient was submitted to surgical closure of the fistula and made an excellent recovery.

Fat embolism syndrome (FES) is a known clinical situation, especially secondary to long bone trauma conditions. Bone marrow embolism for pulmonary circulation may cause changes in pulmonary function and right ventricular dysfunction, either through the release of chemical mediators from fracture locations, which change blood lipid solubility, causing coalition and subsequent pulmonary embolization, or through direct access of fat to venous circulation and, then, to lungs. A 72-year old female patient was submitted to an orthopedic surgery for femur fracture correction with placement of intramedullary rod. As the patient was aged, with coronary artery disease history and without possibility of a proper preoperative stratification, as it was an urgent surgery, she was submitted to preoperative monitoring with transesophageal echocardiogram for global and segmental ventricular function assessment. During intrabone preparation for rod receiving (milling), a great amount of hyperecogenic ( fig. 1), often forming small pieces ( fig. 2), was seen entering through the right heart and reaching out pulmonary circulation. As the interatrial septum was complete, an exuberant contrast difference could be seen between right and left atrial content. There was no change of pulmonary, cardiac or hemodynamic function after procedure completion, and the patient had good postoperative evolution, being discharged afterwards. Fig. 1 -During intramedullary milling procedure, a great amount of hyperecogenic material fills out the whole right atrium Fig. 2 -Marrow material coalescing in small pieces (arrow) were also seen passing through right heart