Em uma análise secundária deste estudo, o criobalão apresentou menor taxa de reospitalização e re-intervenção.7Recentemente, dois estudos utilizando a crioenergia, demonstraram a superioridade da ablação como primeira linha de tratamento para controle de FA, quando comparada ao tratamento farmacológico.8Recentemente publicamos nos Arquivos Brasileiros de Cardiologia, a primeira experiência de um centro brasileiro, com o isolamento elétrico das veias pulmonares (IEVP) utilizando o balão de crioenergia como abordagem inicial para o tratamento não farmacológico da FA e demonstramos resultados similares aos obtidos em grandes centros internacionais.Apesar de todo avanço tecnológico, aproximadamente um terço dos pacientes, apresentam recidiva de arritmias atriais após um procedimento inicial bem-sucedido. A reconexão da condução nas VP e a ocorrência de focos fora das veias são os dois fatores principais que justificam a recorrência. Atualmente, os índices de isolamento agudo das VP são bastante elevados, e o grande desafio é manter esse isolamento a longo prazo.9Estudos prévios, avaliando pacientes submetidos a reablação após um procedimento inicial bem-sucedido com radiofrequência, demonstraram que a reconexão das VP é o fator dominante para recorrência, visto que entre os pacientes encaminhados a um segundo procedimento, 80% apresentam reconexão de alguma veia.10 relatam reconexão de VP em 77,8% dos pacientes encaminhados a um segundo procedimento de ablação após IEVP com criobalão, e observaram sítios de reconexão na região antero-superior da VP superior esquerda, e nas regiões septal e inferior da VP superior direita, e atribuíram os achados a uma maior espessura da parede dos átrios, dificultando o contato adequado do balão de crio. Estes achados diferem do estudo de Godin et al.,11 que observaram 64% de reconexão das VP em pacientes com FA paroxística encaminhados a segundo procedimento; e identificaram predomínio das lacunas de conexão na porção inferior das veias inferiores, sendo 80% na VP inferior esquerda e 67% na VP inferior direita, e também diferem dos resultados de Kettering et al.12 em que a distribuição dos sítios de reconexão foi semelhante entre as veias.No presente estudo, Nolasco et al.,O conhecimento de locais com maior predisposição para reconexão poderia servir de orientação para o desenvolvimento de tecnologias que auxiliem a vencer este grande desafio, no entanto, os resultados discrepantes com relação aos sítios de reconexão nos diferentes estudos não nos permitem definir uma região mais propensa à reconexão, e nos levam a crer que os locais de maior dificuldade para isolamento das veias se relacionam a variações anatômicas individuais. 1As life expectancy rises, it is estimated that AF prevalence will suffer a significant increase, and its adequate control will continue to be a major challenge.Atrial fibrillation (AF) is the most common sustained arrhythmia in the population and its incidence significantly increases with age.Until the end of the 90s, the therapeutic options available and most used in the reversion and prevention of AF recurrences were antiarrhythmic drugs (AA) and electrical cardioversion; however, clinical treatment with AA drugs has been shown ineffective in maintaining sinus rhythm, with a recurrence rate above 50%.The understanding of the mechanisms involved in the genesis of AF through atrial mapping technology, as well as the low effectiveness of AA drugs and the high prevalence of AF, have stimulated research in the search for new therapeutic options to control this arrhythmia.The discovery that ectopic foci located inside the pulmonary veins (PV) could trigger and perpetuate AF, ushered a new era in the treatment of this arrhythmia.Due to the various studies demonstrating the efficacy and safety of the ablation procedure in recent years, non-pharmacological treatment is being indicated earlier and more frequently.3Initially, this technique was indicated only in paroxysmal AF, until subsequent studies demonstrated its non-inferiority in relation to other more complex and comprehensive procedures, in patients with persistent AF.4Regardless of the type of energy or the technique used, complete isolation of the PV is recognized as a fundamental basis for the non-pharmacological treatment of AF and, therefore, has been recommended as an initial step in the ablation of AF in national and international guidelines.Currently, PV can be isolated using radiofrequency energy with focal point-to-point applications, or through freezing, using the cryoprobe.Although widely used in Europe and North America, it was only this year that cryoablation technology was regulated by the ANS - the national health agency - for use in Brazil.5Subsequently, other trials compared the technologies and demonstrated similar results.The “Fire and Ice” Study was the first large randomized multicenter study comparing the results of the use of cryoballoon and radiofrequency energy in the ablation of paroxysmal AF and it demonstrated that the technologies were similar, both in terms of effectiveness and safety. In a secondary analysis of this study, the cryo balloon showed a lower rate of rehospitalization and re-intervention.7Recently, two studies using cryoenergy have demonstrated the superiority of ablation as the first line of treatment for the control of AF when compared to pharmacological treatment.8We recently published in the Brazilian Archives of Cardiology the first experience of a Brazilian center using the cryoballoon for pulmonary vein isolation (PVI) as an initial approach for the non-pharmacological treatment of AF, and we demonstrated results similar to those obtained in large international centers.Despite all the technological advances, approximately one-third of the patients present recurrence of atrial arrhythmias after a successful initial procedure. The reconnection of the PV and the occurrence of foci outside the veins are the two main factors that justify the recurrence. Currently, the rates of acute PVI are quite high, and the major challenge is to maintain this isolation in the long term.9Previous studies evaluating patients undergoing redo ablation after a successful initial radiofrequency procedure have shown that the reconnection of the PV is the dominant factor for recurrence, since, among patients referred for a second procedure, 80% demonstrated reconnection of some vein.10reported reconnection of PV in 77.8% of patients referred for a second ablation procedure after PVI with cryoballoon, and observed sites of reconnection in the anterosuperior region of the upper left PV, and in the septal and inferior regions of the right upper PV, and attributed the findings to a greater thickness of the atrial wall, hindering the proper contact of the cryo balloon. These findings differ from the study by Godin et al.,11who observed 64% of reconnection of the PV in patients with paroxysmal AF referred for the second procedure; and identified a predominance of connection gaps in the lower portion of the lower veins, 80% in the lower-left PV and 67% in the lower right PV - also differing from the results of Kettering et al.12which saw that the distribution of the reconnection sites was similar between the veins.In the present study, Nolasco et al.The knowledge of sites with a greater predisposition for reconnection could serve as a guide for the development of technologies that would help overcome this great challenge, however, the discrepant results in relation to the sites of reconnection in the different studies do not allow us to define regions that are more prone to reconnection and lead us to believe that difficulty in achieving permanent PVI is due to individual anatomical variations.


Physical training is a well-established strategy for rehabilitation of the functional capacity of individuals with chronic peripheral arterial occlusive disease (PAOD). However, some individuals quit training after participating in a physical training program, undergoing detraining. There is scant literature on the effects of physical detraining in individuals with PAOD and it is therefore important to investigate the effects of this phenomenon.The objective of this article was to evaluate the effects of physical detraining on functional capacity in individuals with PAOD.Cross-sectional study with 22 individuals. Participants were divided into two groups: a detraining group (DG) and a control group (CG). The distance covered in the 6-minute walk test (6MWTD) and the pain-free walking distance (PFWD) were evaluated. The PFWD is the distance covered until claudication begins, i.e., the distance covered without pain.Mean age was 66 ± 8 in the DG and 67 ± 7 in the CG. There were no differences between the groups in either the 6MWTD or the PFWD .The present pilot study allows us to conclude that the functional capacity of individuals with PAOD who participated in a physical training program and subsequently underwent detraining was not superior in relation to individuals who did not participate in a physical training program. The results of the present study serve to encourage maintenance of physical exercise, since physical training is no longer effective if detraining occurs. Functional capacity is reduced in chronic peripheral arterial occlusive disease (PAOD) because of the atherosclerotic process involving the peripheral arteries,,-Physical training is one of the most important tools for increasing the functional capacity of people with PAOD.-Physical detraining raises questions about maintenance of the effects yielded by physical training, in terms of the 6MWTD and PFWD achieved by patients with PAOD. However, there is a gap in the literature, which lacks studies investigating the effects of physical detraining in PAOD.This is a cross-sectional, case-control study. The participants were divided into two groups: a detraining group (DG), comprising individuals who had participated in a 12-week physical training program and then undergone detraining for at least 3 months up to a maximum of 36 months; and a control group (CG), comprising patients with PAOD who had not participated in a physical training program in the preceding 36 months.The study was conducted at the Vascular Surgery Outpatient Clinic of a university hospital in southern Brazil, in 2018 and 2019. Patients over the age of 40 years with a diagnosis of intermittent claudication were recruited. All participants should also have an ankle-brachial index (ABI) below 0.9. The exclusion criteria were: cardiovascular events that occurred less than 3 months before enrollment; uncontrolled severe hypertension (systolic blood pressure ≥ 180 mmHg or diastolic blood pressure ≥ 110 mmHg) and/or uncontrolled diabetes (glycemic index ≥ 290); critical lower limb ischemia; limiting lung disease; or any type of contraindication to the exercise test.The study was approved by the local Research Ethics Committee (decision number 3.240.172) and conducted entirely in accordance with the ethical standards set out in the Helsinki Declaration. All patients provided written consent to participation before enrollment. One of the study groups (DG) comprised patients who had taken part in a randomized clinical trial that investigated the effects of 12 weeks of physical training on the functional capacity of individuals with PAOD.,Walking capacity was measured using the 6-minute walk test (6MWT) by a group of specialists, following American Thoracic Society guidelines.For the purposes of the present study, a simple questionnaire was administered covering physical activity levels. This instrument was based on the short form of the International Physical Activity Questionnaire (IPAQ).The sample was rigorously selected to minimize possible biases, with full patient history and clinical examination conducted by the team from the Lymphedema and Angiodysplasia Clinic. Additionally, all individuals who performed the 6MWT were assessed by the same researcher, to eliminate intra-examiner variability, even though a protocol recommended in the literature was followed.Sample size was calculated to detect differences between groups of 60 meters (m) for 6MWTD and 30 m for PFWD, with a standard deviation equal to the 6MWTD difference to be detected, 80% power, and a 5% significance level, which resulted in 14 participants per group.t test (unpaired) or the Mann-Whitney U test were used to analyze differences between groups for the main outcomes (6MWTD and PFWD) and other continuous variables, and the chi-square test was used for categorical variables. Normally distributed data were expressed as means and standard deviations and non-normal data were expressed as medians and interquartile ranges. Data were analyzed using SPSS, version 20.0 . Results with p < 0.05 were considered statistically significant.The Shapiro Wilk and Levene tests were used to analyze normality and homogeneity of data respectively. Student’s The study assessed 22 patients with PAOD, 11 in the DG and 11 in the CG. The DG had similar results to the CG for the number of days per week on which the patients engaged in mild walking . While there was a 68±149 min difference between the DG and CG in the time spent engaged in mild walking, the difference between the groups was not significant .There was no significant difference between the DG and the CG in the number of days per week on which the patients engaged in moderate walking . There was no significant difference between the groups in time engaged in moderate walking, .The groups had similar results for the number of days per week on which the patients engaged in vigorous walking  and in the time in minutes engaged in vigorous walking .-,-,The initial hypothesis that individuals in the DG would exhibit benefits in relation to the CG was based on evidence on the positive effects of detraining on different parameters in other populations.,Even though the present study did not detect any significant differences between the groups, it is important to emphasize that physical training is widely recommended for patients with PAOD, with the objective of promoting increases in functional capacity and, consequently, improving walking performance.The mean difference of 57 m in the DG during the training period compared with after detraining is extremely relevant, since, even after a mean detraining period of 19 months, these individuals did not exhibit significant loss (p = 0.145). Compared with the CG, the DG had a mean difference of 35 m, which was not a significant difference, thereby confirming that the groups were similar. Gardner et al.There was also no significant difference in PFWD between the DG and the CG p = 0.458). From a functional point of view, this is the more important variable for PAOD patients, since reduced PFWD is reflected in reduction in daily activities of living, causing depression and worsening quality of life. A reduction of 30 m is considered clinically relevant in the literature.. From a The present study has limitations. The first is the small sample size, which is because this is a pilot study. The second is the mean duration of detraining, which was relatively long (19±10 months) and had a large range. This could have the result that the expected effects were not manifest, because of the small sample with considerable heterogeneity. Moreover, the DG, which comprised individuals who had previously participated in a physical training program in a different study, only contained 11 people because four of the 15 people contacted dropped out before undergoing assessments. This is a significant limitation, since the sample size calculation defined the minimum number necessary as 14 individuals in each group; but there was no way of recruiting additional participants to the DG, because there were only 15 in total. One possible strategy for a future study could be to enroll more participants in the CG, with the objective of increasing the sample’s power for statistical inference.While the study has limitations, it also has strong points. To our knowledge, it is the first study to evaluate the effects of physical detraining on the functional capacity of individuals with PAOD. This is very important to guide clinical practice and find solutions to help patients remain physically active or participating in physical training programs.This study is very important for the clinical practice of specialists, since it demonstrates that physical detraining provokes significant losses of the adaptations achieved by physical training. It is therefore important that specialists create strategies for patients with PAOD to encourage engagement and continuity in physical training programs.This study assessed physical detraining in individuals with PAOD, comparing two groups. One group participated in a physical training program and then underwent detraining and the other did not take part in a physical training program and did not therefore undergo detraining. No significant differences were detected between these groups in 6MWTD or PFWD. However, it is important to point out that this study’s findings confirm the idea that individuals with PAOD require ongoing attention after participating in a physical training program, including planning for continuation of physical training and engagement in a daily physical activity routine. A doença arterial obstrutiva crônica periférica (DAOP) reduz a capacidade funcional, em função do processo aterosclerótico das artérias periféricas,-O treinamento físico é um dos principais instrumentos para aumentar a capacidade funcional de pessoas com DAOP-O destreinamento físico acaba gerando um questionamento sobre a manutenção dos efeitos gerados pelo treinamento físico em relação a DTC6M e DLDC nos pacientes com DAOP. No entanto, há uma lacuna na literatura em termos de estudos que investigam os efeitos do destreinamento físico em DAOPTrata-se de um estudo transversal caso-controle. Os participantes foram divididos em dois grupos: grupo destreinamento (GD), no qual foram incluídos indivíduos que participaram de 12 semanas de treinamento físico e tiveram destreinamento de pelo menos 3 meses e máximo de 36 meses; grupo controle (GC), composto por pacientes com DAOP que não participaram de programa de treinamento físico nos últimos 36 meses.O presente estudo foi realizado no Ambulatório de Cirurgia Vascular de um hospital universitário do sul do Brasil, entre 2018 e 2019. Foram recrutados pacientes acima dos 40 anos com diagnóstico de claudicação intermitente. Além disso, todos os participantes deveriam apresentar índice tornozelo-braço (ITB) abaixo de 0,9. Os critérios de exclusão foram: eventos cardiovasculares que ocorreram menos de 3 meses antes da inclusão; hipertensão grave não controlada  e/ou diabetes não controlada (índice glicêmico ≥ 290); isquemia crítica de membros inferiores; doença pulmonar limitante; e qualquer contraindicação para a realização do teste com exercício.O estudo foi aprovado pelo comitê de ética em pesquisa local (parecer nº 3.240.172) e conduzido inteiramente de acordo com os padrões éticos estabelecidos na Declaração de Helsinque. Todos os pacientes forneceram consentimento por escrito para participação antes da inscrição. Parte dos pacientes do estudo (GD) fizeram parte de um ensaio clínico randomizado que investigou o efeito de 12 semanas de treinamento físico sobre a capacidade funcional de indivíduos com DAOP.American Thoracic Society,A capacidade de caminhada foi medida pelo teste de caminhada de 6 minutos (TC6M) por um grupo de especialistas, de acordo com as diretrizes do International Physical Activity Questionnaire (IPAQ) versão curtaNo presente estudo, foi utilizado um questionário simples sobre nível de atividade física, baseado no Para minimizar possíveis vieses, a amostra foi rigorosamente selecionada, com uma anamnese completa, e com exame clínico realizado pela equipe do Ambulatório de Cirurgia Vascular. Complementarmente, todos indivíduos submetidos ao TC6M foram avaliados pelo mesmo pesquisador, para evitar variabilidade entre avaliadores, mesmo que fosse seguido o protocolo preconizado pela literaturaPara detectar uma diferença de 60 metros (m) para a DTC6 entre os grupos, e 30 m para a DLDC, com desvio padrão igual à diferença a ser detectada para a DTC6, com poder de 80% e nível de significância de 5%, o tamanho da amostra calculado foi de 14 para cada grupot de Student (não pareado) ou o teste de Mann-Whitney U para os desfechos principais (DTC6M e DLDC) e demais variáveis contínuas, e o teste de qui-quadrado para as variáveis categóricas. Os dados foram apresentados por meio de médias e desvio padrão caso apresentassem distribuição normal, ou mediana e intervalo interquartil, caso contrário. Os dados foram analisados por meio do software SPSS verão 20.0 . Os valores de p < 0,05 foram considerados estatisticamente significativos.Os testes de Shapiro Wilk e Levene foram utilizados para analisar a normalidade e a homogeneidade dos dados, respectivamente. Para analisar as diferenças entre os grupos, foram utilizados o teste O presente estudo avaliou 22 pacientes com DAOP, sendo que 11 faziam parte do GD e 11 do GC. Os dados de caracterização da amostra estão expostos na Os desfechos principais estão expressos na O GD apresentou resultados semelhantes, comparado ao GC, quanto ao número de dias da semana em que os pacientes praticavam caminhada leve . Apesar da diferença de 68±149 min entre o GD e o GC em relação ao tempo praticado de caminhada leve, os grupos não apresentaram diferença significativa .O GD não apresentou diferença significativa, comparado ao GC, quanto ao número de dias da semana em que os pacientes praticavam caminhada moderada . Em relação ao tempo praticado de caminhada moderada, os grupos não apresentaram diferença significativa .Ambos os grupos apresentaram resultados semelhantes quanto ao número de dias da semana em que os pacientes praticavam caminhada vigorosa , e também quanto ao tempo de caminhada vigorosa em minutos .-,-,A hipótese inicial de que os indivíduos do GD apresentariam benefícios em relação ao GC se dá em função de algumas evidências a respeito dos efeitos positivos do destreinamento sobre diferentes parâmetros em outras populações,Mesmo que o presente estudo não tenha apresentado diferenças significativas entre os grupos, é importante destacar que o treinamento físico é amplamente recomendado para pacientes com DAOP, com a finalidade de promover aumento da capacidade funcional e, consequentemente, melhorar a performance da marchaA diferença média de 57 m para o GD em relação ao período de treinamento comparado ao destreinamento é extremamente relevante, pois, mesmo após um período médio de destreinamento de 19 meses, os indivíduos não apresentaram perda significativa . Em comparação ao GC, o GD possui uma diferença média de 35 m, sem diferença significativa, comprovando assim que os grupos eram semelhantes. Gardner et al.A DLDC também não apresentou diferenças significativas entre o GD e o GC p = 0,458). Essa é a variável mais importante para a DAOP, do ponto de vista funcional, pois reduzir a DLDC gera redução nas atividades de vida diária, causando depressão e piorando a qualidade de vida. Uma redução clinicamente relevante de 30 m é considerada pela literatura. Essa é O presente estudo possui limitações: a primeira é o pequeno tamanho da amostra, por se tratar de um estudo piloto; a segunda é o tempo médio de destreinamento, o qual foi relativamente grande (19±10 meses), com uma variabilidade alta. Isso pode fazer com que os efeitos esperados não se expressem, por tratar-se de uma pequena amostra com grande heterogeneidade. Além disso, o GD, o qual participou previamente de um programa de treinamento físico em outro estudo, foi composto por 11 indivíduos, visto que, dos 15 contatados, quatro desistiram de fazer as avaliações. Isso é uma grande limitação, pois o cálculo amostral previu um número necessário de 14 indivíduos para cada grupo; no entanto, não tivemos como incluir mais participantes no GD, visto que tínhamos apenas 15 no total. Uma possível estratégia para um estudo futuro será incluir mais participantes no GC, com a finalidade de aumentar o poder da amostra de inferência estatística.Apesar de o estudo possuir limitações, também possui méritos. Segundo nosso conhecimento, este é o primeiro estudo que avaliou os efeitos do destreinamento físico sobre a capacidade funcional de indivíduos com DAOP. Isso é muito importante para guiar a prática clínica e encontrar alternativas para que os pacientes se mantenham fisicamente ativos ou inseridos em programas de treinamento físico.O presente estudo é fundamental para a prática clínica do especialista, ao demonstrar que o destreinamento físico promove perdas significativas nas adaptações geradas pelo treinamento físico. Portanto, é importante que o especialista crie estratégias de engajamento e continuidade em programas de treinamento físico para os pacientes com DAOP.O presente estudo avaliou o destreinamento físico em indivíduos com DAOP comparando dois grupos, um que participou de um programa de treinamento físico e realizou destreinamento e outro que não participou de um programa de treinamento físico e, consequentemente, não realizou destreinamento. Não foram encontradas diferenças significativas entre os grupos para a DTC6M e a DLDC. Apesar disso, é importante ressaltar que os achados do presente estudo reforçam a ideia de que, após a participação em um programa de treinamento físico, os indivíduos com DAOP merecem atenção, desde o planejamento para a continuação do treinamento físico até o engajamento em uma rotina de atividade física diária.


Abdominal aortic aneurysms (AAA) are the most common type, even when compared to those involving other segments of the aorta. The prevalence and natural history of arterial aneurysms in abdominal organ transplant recipients remain uncertain. We report a case of abdominal aortic aneurysm in a kidney transplant patient with contrast allergy. Conventional abdominal aortic aneurysm repair was performed, constructing a bi-iliac aortic bypass. A temporary bypass was constructed from the right axillary artery to the right common iliac artery to maintain the renal graft. The patient was transferred to the intensive care unit, where he remained hemodynamically stable, and he was discharged on the 2nd postoperative day. Conventional open surgery with temporary extra-anatomic bypass is an alternative option for treatment of AAA in patients with transplanted kidneys. The underlying cause of his kidney disease was unknown and he was in follow-up at a Lymphedema and Angiodysplasia Clinic for an abdominal aortic aneurysm. He was asymptomatic. Physical examination found pulses present in all segments of the upper and lower limbs, a flaccid abdomen, and a pulsating mass and the renal graft in the right iliac fossa. He had a history of allergy to iodinated contrast. He was on mycophenolate sodium, tacrolimus, prednisone, losartan, and simvastatin. He is an ex-smoker. Abdominal computed tomography angiography was performed after antiallergic preparation, showing a fusiform aneurysm of the infrarenal segment of the aorta, with mural thrombi. The aneurysm began 13 mm from the emergence of the right renal artery, had a proximal neck measuring 24 x 24 mm, maximum diameters of 53 x 50 mm, and extended for 85 mm, up to the bifurcation of the aorta. The renal graft and its anastomosis to the right external iliac artery were identified .The decision was taken to perform open surgical repair of the AAA. A temporary bypass was constructed from the right axillary artery to the right common iliac artery with a 7 x 60 mm straight Dacron graft to maintain perfusion of the renal graft while the aorta was clamped. Conventional repair of the abdominal aortic aneurysm was accomplished with a bi-iliac aortic bypass using a 14 x 7 mm bifurcated Dacron graft anastomosed distally to the common iliac arteries . The aorThe patient was transferred to the intensive care unit, where he remained hemodynamically stable, and was discharged on the 2nd postoperative day. He had no motor dysfunction in any of his limbs. At 3 months’ follow-up the patient’s renal function is stable.,5Abdominal aortic aneurysms exhibit more aggressive behavior in transplant patients than in the general population, contradicting data that suggest immunosuppressant treatment reduces aneurysm growth.52), but unfortunately this is not yet available on the Brazilian National Health Service (Sistema Único de Saúde) at our institution.It is recommended that all AAA with diameters exceeding 5.0 cm should be repaired immediately and aneurysms with smaller diameters should be rigorously monitored (imaging every 6 months). Aortic aneurysms expand twice as fast in patients with abdominal organ or cardiac transplants than in patients who have not received transplants.,Surgical repair of aneurysms is complex in transplant patients because arterial support for the graft is generally supplied by the iliac artery, which is distal of the aneurysm.3There is no consensus on the ideal approach to protecting the renal graft during open AAA repair.3Open conventional surgery with a temporary extra-anatomic bypass is one option for treatment of AAA in patients with kidney transplants. -Os aneurismas de aorta abdominal (AAA) são os mais frequentes, mesmo quando comparados a outros segmentos da aorta2A prevalência e a história natural de aneurismas arteriais em receptores de transplante de órgão abdominal permanecem incertasPaciente do sexo masculino, 53 anos, transplantado renal há 12 anos, doador vivo, sem conhecimento da causa de base da doença renal, em seguimento no ambulatório de cirurgia vascular por aneurisma de aorta abdominal. Encontrava-se assintomático. Ao exame físico, pulsos presentes em todos os segmentos de membros inferiores e superiores, abdome flácido, com presença de massa pulsátil e enxerto renal em fossa ilíaca direita. Apresentou história de alergia ao contraste iodado. Em uso de micofenolato de sódio, tacrolimus, prednisona, losartana e sinvastatina. O paciente é ex-tabagista. A angiotomografia computadorizada de abdome, realizada após preparo antialérgico, visualizou aneurisma fusiforme do segmento infrarreal da aorta, com trombos murais, que se inicia 13 mm da emergência da artéria renal direita, com colo proximal de 24 x 24 mm, diâmetros máximos de 53 x 50 mm, e que se estende por 85 mm até a bifurcação da aorta. Foi identificada presença de enxerto renal com anastomose na artéria ilíaca externa direita .by-pass temporário da artéria axilar direita até a artéria ilíaca comum direita (prótese de Dacron reta 7 x 60 mm). Realizado o tratamento convencional do aneurisma de aorta abdominal com um by-pass aorto bi-ilíaco (prótese de Dacron bifurcada 14 x 7 mm) com as anastomoses distais nas artérias ilíacas comuns  para os aneurismas com menor diâmetro. Comparados aos pacientes sem transplante, os aneurismas da aorta em pacientes com transplantes de órgãos abdominais e cardíacos se expandem duas vezes mais rapidamente,by-pass na artéria ilíaca e não na artéria femoral, para evitar um novo acesso a região inguinal, já que a correção do aneurisma foi realizada com uma ponte aorto bi-ilíaca comum.O reparo cirúrgico dos aneurismas em transplantados é complexo, pois o suporte arterial do enxerto geralmente deriva da artéria ilíaca, localizada distalmente ao aneurisma3Não há consenso sobre o manejo adequado para a proteção do enxerto renal durante o reparo aberto do AAAA cirurgia convencional aberta com derivação extra anatômica temporária é uma alternativa para o tratamento do AAA em pacientes com transplante renal.


There is an error in affiliation 1 for author Oriana Figueroa. The correct affiliation 1 is: Doctorado en Ciencias de la Complejidad Social, Centro de Investigación en Complejidad Social, Facultad de Gobierno, Universidad del Desarrollo, Santiago, Chile.There is an error in affiliation 6 for author David Diaz. The correct affiliation 1 is: Centro de Investigación en Complejidad Social, Facultad de Gobierno, Universidad de Desarrollo, Santiago, Chile.


Segundo a OMS, o Brasil é o terceiro país com mais casos confirmados da SARS-CoV-2, ficando atrás somente dos Estados Unidos da América e Índia,3 a qual é também considerada um país emergente e com problemas socioeconômicos semelhantes aos enfrentados pela população brasileira.A doença causada pelo coronavírus SARS-CoV-2, identificada na China no final de 2019 e denominada COVID-19 , as mais frequentes.7Os sintomas da infecção pelo SARS-CoV-2 podem variar desde uma Síndrome Gripal (SG), com sinais e sintomas leves como febre, tosse, congestão nasal e fadiga, até uma Síndrome Respiratória Aguda Grave (SRAG), com sintomas como dispneia, saturação de O2 ≤ 93%, frequência respiratória ≥ 30 respirações por minuto, pressão arterial de oxigênio (PaO2) /fração inspirada de oxigênio (FIO2) < 300, linfopenia e edema alveolar.8 tiveram como objetivo descrever a prevalência de SRAG por COVID-19 e analisar os fatores associados a essa condição em adultos e idosos com DCV crônica no Brasil até a 30a semana epidemiológica de 2020. Os autores utilizaram dados fornecidos pelo Sistema de Informação de Vigilância Epidemiológica da Gripe (SIVEP-Gripe) e incluíram pessoas acima de 18 anos com DCVs hospitalizados com SRAG. Neste estudo, foram incluídos 116 343 pacientes, sendo que 61,9% foram diagnosticados com SRAG por COVID-19. Os autores encontraram características clínicas, sinais e sintomas semelhantes aos descritos na literatura.9 Os fatores associados a SRAG por COVID-19 foram febre, tosse, internação em unidade de terapia intensiva, uso de suporte ventilatório invasivo e não invasivo, e infecção nosocomial. Os resultados do estudo apontam maior prevalência de SRAG na faixa etária acima de 60 anos e na região Sudeste do Brasil.Diante da alta prevalência das doenças cardiovasculares (DCVs), principalmente entre os idosos e sua associação com o desenvolvimento de quadros graves da doença, Paiva et al.,8 refletem o que já foi apontado em estudos anteriores.10 Destaca-se como principal contribuição, os dados de prevalência de SRAG por COVID-19 analisada por cada variável. Observou-se que a maior parte dos casos de SRAG no Nordeste e no Norte foram ocasionados pela COVID-19, um padrão diferente do Sul do país, onde somente 39,9% dos casos foram ocasionados pela COVID-19. Esses resultados demonstram que a prevalência de SRAG por COVID-19 tem um fator regional, refletindo a diferença de acesso ao sistema de saúde e a desigualdade social entre as regiões do Brasil. Um estudo publicado por Baggio et al.,11 em Alagoas, mostrou alta taxa de incidência de COVID-19 nos municípios com os melhores índices de desenvolvimento humano, assim como, nos municípios com alta vulnerabilidade social. Entretanto, as maiores taxas de mortalidade foram observadas nos municípios mais pobres. No norte do país, foram observadas as maiores prevalências de comorbidades em pessoas internadas pela COVID-19, o que explica parcialmente o maior risco de morte nessa região.13 Somado a isso, precisamos levar em consideração o perfil de morbidade, a infraestrutura de saúde , o acesso aos testes de diagnóstico e o tratamento em UTI com processos qualificados e seguros ao paciente.Os resultados de Paiva et al.A fim de aprimorar a análise realizada pelos autores seria interessante a inclusão dos dados sobre a presença de outras comorbidades, além das DCVs, como nível de atividade física prévia e acompanhamento médico para as DCVs. Além disso, a inclusão de outras comorbidades e o nível de atividade física na análise multivariada, permitiria estabelecer a curva de sobrevivência e mortalidade associado às outras comorbidades, como DM, obesidade, sedentarismo entre outros, as quais são comuns nessa população e possuem um papel importante no desenvolvimento de quadros graves da COVID-19. 3 According to the WHO, Brazil is the third country in number of cases, with the USA on the top of the list, followed by India,3 which is also considered an emerging country with problems similar to those faced by the Brazilian population.The COVID-19 (Coronavirus disease-19), a disease caused by the SARS-CoV-2, was identified in China at the end of 2019 and announced as a pandemic by the World Health Organization (WHO) in March 2020, with more than 20 million cases confirmed in Brazil, and more than 583 thousand deaths from complications of the disease, by the end of epidemiological week 35, on September 4, 2021.2 saturation ≤ 93%, respiratory rate ≥ 30 breaths per minute, partial pressure of oxygen (PaO2)/fraction of inspired oxygen (FiO2)< 300, lymphopenia, and alveolar edema.5 Nearly 1,775,816 cases of ARDS secondary to COVID-19 were recorded in Brazil and 32.2% of the cases progressed to death.6 Of the 342,636 deaths for ARDS due to COVID-19 recorded up to the epidemiological week 36 in 2021, 59.5% had at least one comorbidity, with heart diseases, cerebrovascular diseases, systemic arterial hypertension and diabetes mellitus (DM) as the most common ones.7Symptoms of the SARS-CoV-2 infection may vary from a flu-like syndrome, with mild symptoms and signs like fever, cough, nasal congestion and fatigue, to acute respiratory distress syndrome (ARDS), with symptoms including dyspnea, O8 aimed at describing the prevalence of ARDS due to COVID-19 and evaluating the factors associated with this condition in adults and elderly with chronic CVD in Brazil up to the 30th epidemiological week in 2020. The authors used data from the epidemiological surveillance system on influenza  and included individuals with CVDs, aged over 18 years old, hospitalized for ARDS. In their study, 116,343 patients were included, 61.9% of them received a diagnosis of ARDS due to COVID-19. The authors found clinical features, signs and symptoms that were similar to those described in the literature.9 Factors associated with ARDS due to COVID-19 were fever, cough, intensive care unit admission, use of invasive and non-invasive ventilation, and nosocomial infection. The results indicated a higher prevalence of ARDS in individuals aged over 60 years from the southeast of Brazil.Considering the high prevalence of cardiovascular diseases (CVDs), especially in the elderly, and its association with more severe cases of the disease, Paiva et al.8 reflect what has already been pointed out in previous studies.10 The main contribution of the study is the data on the prevalence of ARDS by COVID-19 analyzed by each variable. The authors found that most cases of ARDS in the north and northeast regions of Brazil were caused by COVID-19, which differed from the cases in the south of the country, where 39.9% of the cases were caused by COVID-19. These data indicate that the prevalence of COVID-19-related ARDS has a regional factor, and reflect the difference in the access to healthcare and social inequalities among the regions. A study published by Baggio et al.,11 in Alagoas, showed a high incidence of COVID-19 in the cities with the highest human development indexes, as well as in those with high social vulnerability. However, the highest mortality rates were found in the poorest cities. The highest prevalence of comorbidities was observed in patients hospitalized for COVID-19, which explain in part the highest risk of death in this region.13 Besides, one should consider the morbidity profile, healthcare infrastructure , and access to diagnostic tests and intensive therapy with qualified and safe processes by the patients.The results of Paiva et al.The inclusion of data about the presence of other comorbidities, in addition to CVDs, like physical activity level and clinical follow-up for CVDs, would aid to improve the analysis conducted by the authors. Also, the inclusion of other comorbidities and physical activity level to the multivariate analysis would allow the establishment of survival and mortality curves associated to other comorbidities, including DM, obesity, sedentary lifestyle, among other common conditions that play an important role in the development of severe cases of COVID-19.


Determine the value of the combination of fasting glucose less than the 10th percentile (FG < p10) during 75 gram oral glucose tolerance test (75g OGTT) with maternal characteristics to predict low birth weight (LBW) established by Intergrowth-21st tables.Prospective cohort study of pregnant women who was underwent 75g OGTT between 24 and 28.6 weeks. The 10th percentile fasting glucose of the population was determined at 65 mg/dL and women with risk factors that could modify fetal weight, including those related to intrauterine growth restriction, were excluded. Two groups were formed: group FG < p10 and group with normal fasting glucose. The main finding was the diagnosis of LBW. The association between FG < p10, maternal characteristics and LBW was established by multivariate logistic regression. The predictive performance of the models constructed was evaluated by receiver operating characteristic (ROC) curve and area under the curve (AUC) analysis.349 women were eligible for study, of whom 66 (18.91%) had FG < p10; neonates in this group had lower birth weights , higher frequencies of LBW  and of weights < 2500 g in term births . The basal prediction model consisted of nulliparity by achieving an AUC of 60%, while the addition of FG < p10 resulted in the significant improvement of the previous model .In pregnant women without factors that could modify fetal weight, the predictive model created by combining FG < p10 during 75g OGTT with nulliparity was significantly associated with increased risk of LBW.NCT04144595.ClinicalTrials.gov:  In 2015 according to estimates by the World Health Organization (WHO), 1 in 7 live newborns (20.5 million) in the world had LBW –Low fasting serum glucose (FSG) levels during pregnancy have been associated with LBW since the 1970s. Multiple FG values (< 61 mg/dL to < 87 mg/dL) have been used as a cut-off point to establish this association,Hypoglycemia in pregnancy is the result of a relative hyperinsulinemic state that may be due to increased levels of insulin or its receptors but also to a decrease in one or more of the diabetogenic hormones such as placental lactogenAbnormal maternal glucose metabolism could lead to an adverse intrauterine environment and increase obstetric complications. Thus, the American Diabetes Association (ADA) recommends the 75 gram oral glucose tolerance test (75g OGTT) for the diagnosis of gestational diabetes (GD) between 24 and 28 weeks of pregnancy. Although in this test a FG value ≥ 92 mg/dL is considered abnormalAlthough previous research suggested that hypoglycemia during pregnancy is associated with LBW and poor neurodevelopmentOn the other hand, because of the important influence that birth weight has on the short and long term prognosis of individuals, the international project Intergrowth-21st (IG21) proposed a global standard both to define and classify birth weights and to facilitate clinical decision making based on these weightsUntil now, there is no information in Mexico about the association between low FG with LBW, but any cut-off point in FG was proposed to establish it. The aim of this study was to determine the value of combining low FG during 75g OGTT with maternal characteristics to predict LBW defined by IG21 tables.NCT04144595.Prospective cohort study conducted at the Department of Obstetrics of the Hospital Universitario Dr. José Eleuterio González of the Universidad Autónoma de Nuevo León in Monterrey, Mexico. Received approval from the university ethics committee (GI19-00006) and registration in ClinicalTrials.gov:In January 2019, in a pilot trial conducted under ethical standards and including 200 pregnant women, the 10th percentile of FG during 75g OGTT of the population to be studied (65 mg/dL) was determined; for the purposes of the research, for values lower than this, GA was considered low. Patients were recruited between March and November 2019.The sample size was calculated based on the difference in proportions of newborns with LBW reported in women with low glucose during the oral glucose tolerance test,All pregnant women who underwent 75g OGTT between 24 and 28.6 weeks of gestation were invited to participate. Before being recruited, the objective of the research was explained, the confidential nature of the information and informed consent was requested. Inclusion criteria were: pregnancy with a single fetus and reliable amenorrhea or first trimester ultrasound to establish gestational age. Serum glycemia values were recorded at 0.60 and 120 minutes. With those results, participants with GD diagnosed as established by the ADA with at least one of the following values were excluded: FG ≥ 92 mg/dL, 1 hour ≥ 180 mg/dL, 2 hours ≥ 153 mg/dLPatients who developed intra-amniotic infections , IUGR or preeclampsia during gestationThe main finding was the diagnosis of LBW, defined for the purposes of the study as birth weight less than the 10th percentile for gestational age (BW< p10), the secondary findings were the diagnoses of birth weight less than the 3rd percentile (BW < p3) and < 2500 gram. The birth weight percentiles were established using the tables for gestational age and gender defined in IG212) and obesity (BMI ≥ 30 kg/m2)Maternal characteristics collected were: age, body mass index (BMI) during 75g OGTT dichotomized as established by the American College of Obstetricians and Gynecologists into underweight (BMI < 18. 5 kg/mTwo groups were formed according to FG during 75g OGTT: study group (FG < 10th percentile) and control group (FG ≥ 10th percentile and < 92 mg/dL). No clinical decision was made based on the finding of FG < 10th percentile, as this result was blinded for both participants and obstetrics and pediatrics personnel. During prenatal care, the diagnosis and follow-up of fetuses weighing less than the 10th percentile for gestational age (FP < p10) in either group was according to intrahospital guidelines based on international protocols and not on the result of the FGThe neonatal data analyzed were: gestational age, gender, Apgar score and birth weight. The latter was classified according to the percentile defined in IG21.2 test or Fisher’s exact test.The distribution of quantitative variables was established using the Kolmogorov-Smirnov test. Those with parametric distribution were expressed as mean  and compared with Student’s t test. Nonparametric variables were described as median (interquartile range) and contrasted with the Mann-Whitney U test. Categorical variables were compared with Pearson’s X,The association between FG < 10th percentile with BW < p3, BW < p10, weight < 2500 gram and maternal characteristics ,2 statistic as a measure of goodness-of-fit using X2 Wald, their predictive capacity was determined with receiver operating characteristic (ROC) and area under the curve (AUC) analysis. SPSS version 22.0  and MedCalc Statistical Software version 19.1.5  were used for statistical analysis. All statistical tests were considered significant at p values < 0.05.The basal model included risk factors for LBWDuring the recruitment period, the 75g OGTT results of 3984 women were reviewed, of whom 355 (8.91%) were excluded for a diagnosis of GD and 3280 for having any risk factor that could decrease fetal weight. A total of 349 were eligible for study and, of these, 10 (2.87%) were eliminated . Of the The characteristics of women in the FG < 10th percentile and control groups were similar except for FG which was significantly lower in the study group .Neonates in the FG < 10th percentile group were characterized by lower birth weights and IG21 percentiles, as well as having higher frequencies of BW < p3, BW < p10 and weights < 2500 gram at term births . There were no differences between groups with respect to gestational age at birth, neonatal gender, Apgar score at 5 minutes or weight < 2500 gram when including preterm births .The correlation between FG and birth weight was significant in the FG group < p10 .Multivariate logistic regression analysis was used to establish the association between FG < 10th percentile with BW < p3, BW < p10, weight < 2500 gram and maternal characteristics while controlling for potentially confounding variables such as: maternal age, BMI during 75g OGTT, gestational weight gain, parity, anemia and neonatal gender.2 of 2.9% and AUC of 0.60, 95%CI 0.55–0.65. FG < 10th percentile was independently associated with increased risks of BW < p3 , BW < p10  and weights < 2500 gram , but the latter only in term pregnancies. The prediction basal model in FG < 10th percentile had a Nagelkerke’s R2 of 8.8%. Adding FG < 10th percentile to the basal model showed a Nagelkerke’s R2 of 12.2%, AUC 0.72, 95%CI 0.67–0.77 significantly improving the previous model (DeLong: p = 0.005). Of the maternal characteristics, the only one significantly associated with BW < p10 was nulliparity with an OR 2.28, 95%CI 1.07–4.83, p = 0.032. This variable was used to construct the basal model to predict LBW with Nagelkerke RThese results present that, when excluding risk factors and controlling for confounding variables with potential negative effect on fetal weight, FG < 10th percentile during 75g OGTT independently predicts LBW. The only maternal characteristic, besides FG < 10th percentile, with influence on birth weight was nulliparity, and the result of combining both variables was to increase their ability to predict LBW.,Although multiple risk factors have been cited as possible causes of IUGR, many of these fetuses remain undetected by ultrasonography until birth and a large number of metabolic causes was not established,,Some fetuses weighing less than the 10th percentile for gestational age of unexplained cause have hypoglycemia and in these pregnancies the mothers have 22% higher insulin sensitivity with lower plasma glucose, insulin and placental lactogen levels after glucose tolerance testing compared to those with normal weight fetusesIdentification of the cause of LBW is essential to establish prevention and treatment strategies. It is not always possible to attribute it to well-known risk factors such as aneuploidies, structural defects, placental insufficiency or infections–The data presented are similar to previous research that found a relationship between low serum glucose levels during GD screening with LBW,,Similar to other reports, we also found no association with preterm birth, low Apgar, or maternal morbidity In this analysis, maternal age was not a factor associated with LBW, contrary to the study by Pugh et al. who described that women with hypoglycemia were younger and with lower pregestational BMI,,,,Our research has several assets, so far we know that it is the first national study that reported the 10th percentile of FG during 75g OGTT in pregnant women, as well as the association between FG below that cutoff point with neonatal weight classified by IG21. Furthermore, it was the prospective design in which unlike previous studies (mostly retrospective)Some limitations should be considered: first, a potential selection bias because the study was performed in only one third level referral center with a high prevalence of GD and risk factors that could affect fetal growth. Second, although we tried to exclude and control characteristics considered risk factors for IUGR and LBW, it would be possible to find unknown maternal, placental or fetal factors with the potential to modify birth weight. Third, this study included only Mexican women; therefore, external validity could be limited by the homogeneity of the cohort.Finally, potential confounding variables that could modify birth weight such as socioeconomic status, pregestational BMI, caloric intake during gestation and serum lipid levels were not obtained.In pregnant women without risk factors that could modify fetal weight, the predictive model created by combining FG < p10 during 75g OGTT with nulliparity was significantly associated with increased risk of LBW. Although the discriminatory capacity of the proposed model was moderate, it could represent a useful clinical tool to identify women at high risk of having a low birth weight neonate, in addition to providing an opportunity for possible prophylactic actions, as well as to design predictive models involving fetal ultrasonographic parameters in order to decrease the rate of infant morbidity and mortality related to LBW. ,El bajo peso al nacer (BPN) de neonatos es un problema mundial de salud pública. En 2015 según estimaciones de la Organización Mundial de la Salud (OMS), 1 de cada 7 recién nacidos vivos (20.5 millones) en el mundo tuvo BPN–Los niveles bajos de glucosa sérica en ayunas (GA) durante el embarazo han sido relacionados con BPN desde la década de 1970. Múltiples valores de GA (< 61 mg/dL a < 87 mg/dL) han sido utilizados como punto de corte para establecer esta asociación,La hipoglucemia en el embarazo es el resultado de un estado hiperinsulinémico relativo que puede deberse al incremento en los niveles de insulina o sus receptores, pero también a la disminución de una o más de las hormonas diabetogénicas como el lactógeno placentarioPuesto que el metabolismo materno anormal de la glucosa podría originar un ambiente intrauterino adverso e incrementar las complicaciones obstétricas, la American Diabetes Association (ADA) recomienda la prueba de tolerancia oral a la glucosa con 75 gramos (PTG-75g) para el diagnóstico de diabetes gestacional (DG) entre las 24 y 28 semanas de embarazo. Aunque en esta prueba el valor de la GA ≥ 92 mg/dL es considerado anormalHyperglycemia and Adverse Pregnancy Outcome (HAPO)Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS)A pesar de que investigaciones previas han sugerido que la hipoglucemia durante el embarazo se asocia con BPN y un pobre neurodesarrolloPor otra parte, debido a la importante influencia que tiene el peso al nacer sobre el pronóstico a corto y largo plazo de los individuos, el proyecto internacional Intergrowth-21st (IG21) propuso un estándar mundial tanto para definir y clasificar los pesos al nacimiento como para facilitar la toma de decisiones clínicas basadas en ellosHasta el momento, no existe información en México acerca de la asociación entre GA baja con BPN y mucho menos se ha propuesto algún punto de corte en la GA para establecerla. El objetivo de este estudio fue determinar el valor de la combinación de la GA baja durante la PTG-75g con características maternas para predecir BPN definido mediante tablas de IG21.NCT04144595.Estudio de cohorte prospectivo realizado en el Departamento de Obstetricia del Hospital Universitario Dr. José Eleuterio González de la Universidad Autónoma de Nuevo León en Monterrey, México. Recibió aprobación del comité de ética universitario (GI19-00006) y registro en ClinicalTrials.gov:En enero de 2019, en una prueba piloto que se condujo bajo los estándares éticos y que incluyó a 200 mujeres embarazadas, se determinó el percentil 10 de la GA durante la PTG-75g de la población que estudiar (65 mg/dL); según los propósitos de la investigación para los valores inferiores a ese se consideraron GA baja. Se reclutaron a las pacientes entre marzo y noviembre de 2019.El tamaño de la muestra fue calculado con base en la diferencia de proporciones de recién nacidos con BPN reportada en mujeres con glucosa baja durante la prueba de tolerancia oral a la glucosa,Se invitó a participar a todas las mujeres embarazadas que se realizaron PTG-75g entre las 24 y 28.6 semanas de gestación. Antes de ser reclutadas, se explicó el objetivo de la investigación, el carácter confidencial de la información y se solicitó el consentimiento informado. Se consideraron criterios de inclusión: cursar embarazo con feto único y tener amenorrea confiable o ultrasonido de primer trimestre para establecer edad gestacional. Se registraron los valores de glucemia sérica a los 0, 60 y 120 minutos. Con esos resultados se excluyeron las participantes con DG diagnosticada según lo establecido por la ADA con al menos uno de los siguientes valores: GA ≥ 92 mg/dL, 1 hora ≥ 180 mg/dL, 2 horas ≥ 153 mg/dLSe eliminaron del estudio a las pacientes que desarrollaron infecciones intraamnióticas , RCIU o preeclampsia durante la gestaciónEl hallazgo principal fue el diagnóstico de BPN, definido para propósitos del estudio como peso al nacimiento menor que el percentil 10 para la edad gestacional (PN < p10), los secundarios fueron los diagnósticos de peso al nacer menor que el percentil 3 (PN < p3) y < 2500 gramos. Los percentiles del peso al nacimiento fueron establecidos mediante las tablas para edad gestacional y género asignadas en IG212) y obesidad (IMC ≥ 30 kg/m2)Las características maternas recolectadas fueron: edad, índice de masa corporal (IMC) durante la PTG-75g dicotomizada según lo establecido por el American College of Obstetricians and Gynecologists en bajo peso (IMC < 18.5 kg/mSe formaron dos grupos según la GA durante la PTG-75g: grupo de estudio (GA < percentil 10) y grupo control (GA ≥ percentil 10 y < 92 mg/dL). No se tomó ninguna decisión clínica con base en el hallazgo de GA <percentil 10, pues este resultado fue cegado tanto para las participantes como para el personal de obstetricia y pediatría. Durante el control prenatal, el diagnóstico y seguimiento de los fetos con peso menor que el percentil 10 para la edad gestacional (PF < p10) de cualquier de los dos grupos fue acorde a lineamientos intrahospitalarios basados en protocolos internacionales y no al resultado de la GALos datos neonatales analizados fueron: edad gestacional, género, puntuación en escala Apgar y peso al nacer. Este último lo clasificaron según el percentil asignado en IG21X2 de Pearson o exacta de Fisher.La distribución de las variables cuantitativas fue establecida mediante la prueba de Kolmogorov-Smirnov. Las que tuvieron distribución paramétrica fueron expresadas como media  y comparadas con prueba t de Student. Las no paramétricas fueron descritas como mediana  y contrastadas con prueba U de Mann-Whitney. Las variables categóricas fueron comparadas con pruebas ,La asociación entre GA <percentil 10 con PN < p3, PN < p10, peso < 2500 gramos y características maternas ,2 de Nagelkerke como medida de bondad de ajuste usando X2 Wald, su capacidad predictiva fue determinada con análisis de la curva característica operativa del receptor (ROC) y área bajo la curva (ABC). Para el análisis estadístico se utilizaron los programas SPSS versión 22.0  y MedCalc Statistical Software versión 19.1.5 . Todas las pruebas estadísticas se consideraron significativas con valores de p < 0,05.El modelo basal incluyó factores de riesgo para BPNDurante el periodo de reclutamiento, se revisaron los resultados de la PTG-75g de 3984 mujeres, de las cuales fueron excluidas 355  por diagnóstico de DG y 3280 por tener algún factor de riesgo que pudiera disminuir el peso fetal. Un total de 349 fueron elegibles para estudio y, de estas, 10  fueron eliminadas . De las Las características de las mujeres de los grupos GA < percentil 10 y control fueron similares excepto por la GA que fue significativamente más baja en el grupo de estudio .Los neonatos del grupo GA < percentil 10 se caracterizaron por pesos al nacer y percentiles IG21 más bajos, así como por tener mayores frecuencias de PN < p3, PN < p10 y pesos < 2500 gramos en nacimientos de término . No hubo diferencias entre los grupos con respecto a la edad gestacional al nacer, género neonatal, escala Apgar a los 5 minutos ni en peso < 2500 gramos al incluir nacimientos pretérmino .La correlación entre GA y peso al nacer fue significativa en el grupo GA < p10 .El análisis de regresión logística multivariante se utilizó para establecer la asociación entre GA < percentil 10 con PN < p3, PN < p10, peso < 2500 gramos y características maternas mientras se controlaron variables potencialmente confusoras como: edad materna, IMC durante la PTG-75g, ganancia de peso gestacional, paridad, anemia y género neonatal.2 de Nagelkerke de 2,9% y ABC de 0,60, IC 95% 0.55–0.65. La GA < percentil 10 estuvo independientemente asociada con riesgos incrementados de PN < p3 , PN < p10  y pesos < 2500 gramos , pero esta última únicamente en embarazos de término. El modelo de predicción basado en la GA < percentil 10 tuvo R2 de Nagelkerke de un 8,8%. Al añadir al modelo basal la GA < percentil 10 se mostró un R2 de Nagelkerke de un 12,2%, ABC 0,72, IC 95% 0.67–0.77 mejorando significativamente el modelo previo . En la De las características maternas, la única significativamente asociada con PN < p10 fue la nuliparidad con un OR 2,28, IC 95% 1.07–4.83, p = 0,032. Esta variable fue utilizada para construir el modelo basal para predecir BPN con REstos resultados presentan que, al excluir los factores de riesgo y controlar variables confusoras con potencial efecto negativo sobre el peso fetal, la GA < percentil 10 durante la PTG-75g predice independientemente el BPN. La única característica materna, además de la GA < percentil 10, con influencia sobre el peso al nacer fue la nuliparidad, y el resultado de combinar ambas variables fue el incremento de su capacidad para predecir BPN.,Aunque múltiples factores de riesgo han sido citados como posibles causas de RCIU, muchos de estos fetos permanecen sin detectarse por ultrasonografía hasta el nacimiento y una gran cantidad de las causas metabólicas no han sido establecidas,,Algunos fetos con peso menor que el percentil 10 para la edad gestacional de causa no explicable tienen hipoglucemia y en estos embarazos las madres tienen una sensibilidad a la insulina 22% mayor con niveles plasmáticos de glucosa, insulina y lactógeno placentario más bajos después de la prueba de tolerancia a la glucosa comparadas con aquellas con fetos con peso normalLa identificación de la causa del BPN es crítica para establecer estrategias de prevención y tratamiento. No siempre es posible atribuirlo a factores de riesgo bien conocidos como aneuploidías, defectos estructurales, insuficiencia placentaria o infecciones–Los datos presentados son similares a investigaciones previas que encontraron relación entre niveles bajos de glucosa sérica durante el tamizaje de DG con BPN,,De manera similar a otros reportes, tampoco encontramos relación con nacimientos pretérmino, Apgar bajo ni morbilidad maternaEn este análisis, la edad materna no fue un factor asociado con BPN, contrario al estudio de Pugh et al. que se describió que las mujeres con hipoglucemia eran más jóvenes y con IMC pregestacional más bajo,,,,Nuestra investigación tiene varias fortalezas, hasta el momento sabemos que es el primer estudio nacional que reportó el percentil 10 de GA durante la PTG-75g en mujeres embarazadas, así como la asociación entre la GA menor a ese punto de corte con el peso neonatal clasificado con IG21. Además, fue el diseño prospectivo en el que a diferencia de los estudios previos (en su mayoría retrospectivos)Algunas limitaciones deben considerarse: primera, un potencial sesgo de selección porque se realizó el estudio en un único centro de referencia de tercer nivel con alta prevalencia de DG y factores de riesgo que podrían afectar el crecimiento fetal. Segunda, aunque se trató de excluir y controlar características consideradas factores de riesgo para RCIU y BPN, podría haber factores maternos, placentarios o fetales aún desconocidos con el potencial de modificar el peso al nacer. Tercera, este estudio incluyó únicamente a mujeres mexicanas, por lo tanto, la validez externa podría estar limitada por la homogeneidad de la cohorte.Finalmente, potenciales variables de confusión que podrían modificar el peso al nacer como nivel socioeconómico, IMC pregestacional, ingesta calórica durante la gestación y nivel de lípidos séricos no fueron obtenidas.En mujeres embarazadas sin factores de riesgo que pudieran modificar el peso fetal, el modelo predictivo creado combinando GA < p10 durante la PTG-75g con nuliparidad estuvo asociado significativamente con el incremento en el riesgo de BPN. Aunque la capacidad discriminatoria del modelo propuesto fue moderada, podría representar una herramienta clínica útil para identificar mujeres con riesgo alto de tener un neonato con bajo peso al nacer, además de proporcionar una oportunidad para posibles acciones profilácticas, así como para diseñar modelos predictivos que involucren parámetros ultrasonográficos fetales con la finalidad de disminuir la tasa de morbimortalidad infantil relacionada con BPN.


De acordo com as estimativas do Estudo GBD 2019, entre as DCV, a doença isquêmica do coração (DIC) foi a primeira causa de morte no Brasil, seguida pelo acidente vascular cerebral (AVC). A DIC foi responsável por 12,03%  e 12,2%  dos óbitos e 4,78%  e 6,48%  de anos de vida ajustados por incapacidade (DALYs), em mulheres e homens, respectivamente. Óbitos e DALYs por AVC foram maiores em mulheres do que em homens, 10,39%  e 8,41%  dos óbitos e 4,62%  e 4,19% de DALYs , respectivamente.2 A Pesquisa Nacional de Saúde (PNS) de 2013, inquérito epidemiológico de base domiciliar, com entrevistas com representatividade nacional, utilizando o “Questionário de Angina da OMS/Rose”, relatou que a prevalência de angina leve (grau I) foi de 9,1%  e 5,9% , em mulheres e homens, respectivamente.3 Em relação à angina moderada/grave (grau II), na PNS de 2019, também foi 5,5% mais frequente em mulheres do que em homens. 3,3%.4Em 2019, no Brasil, a taxa de incidência de DIC  padronizada por idade foi de 78  por 100.000 em mulheres e 148  por 100.000 em homens. Em relação à DIC crônica , a prevalência padronizada por idade foi de 1.046  por 100.000 mulheres e 2.534  por 100.000 homens.1 O FR que mais aumentou no Brasil, de 1990 a 2019, foi o índice de massa corporal (IMC) elevado, causando alterações metabólicas que levarão à hipertensão arterial, diabetes e dislipidemia, aumentando o risco individual, principalmente para as mulheres.5 Fatores de risco específicos para AVC nas mulheres incluem gravidez, pré-eclâmpsia, diabetes gestacional, uso de contracepção oral, uso de hormônios na menopausa e alterações no estado hormonal.6Entre os fatores de risco (FR) para DCV em mulheres brasileiras, destacam-se a hipertensão arterial sistêmica, os riscos dietéticos, a obesidade, o aumento do colesterol sérico e a glicemia de jejum elevada   .1 O FR versus 21,1%, respectivamente).4 A mortalidade cardiovascular atribuída à hipertensão arterial foi maior nas mulheres de 65 a 79 anos de idade, e em homens de 50 a 79 anos.2 Nos EUA, embora menos mulheres tenham hipertensão antes dos 55 anos, a porcentagem de mulheres com hipertensão é maior entre 55-74 anos, e mais mulheres do que homens têm hipertensão após os 75 anos.6 É importante notar que em vários ensaios clínicos randomizados com anti-hipertensivo, o risco de resultados adversos foi significativamente reduzido pelo tratamento farmacológico e foi comparável para mulheres e homens.7A prevalência de hipertensão autorreferida no Brasil foi de 23,9%, sendo maior no sexo feminino do que no masculino  com excesso de peso e obesidade em 2019 foram, respectivamente, 62,6%  e 29,5%  para mulheres e 57,5%  e 21,8%  para homens. Observou-se aumento progressivo da obesidade com o aumento da idade, variando de 10,7%   na faixa etária de 18-24 anos a 34,4%   na faixa etária de 40-59 anos. Destaca-se que a maior prevalência de excesso de peso e obesidade foi no sexo feminino para todas as faixas etárias.2 Dados da PNS (2014 a 2015), no Brasil, mostraram que a prevalência foi maior em mulheres, indivíduos com idade superior a 30 anos e entre aqueles com sobrepeso ou obesidade.4 O diabetes é um fator de risco coronariano mais poderoso para as mulheres do que para os homens, anulando seu efeito protetor de sexo mesmo entre mulheres na pré-menopausa.10Obesidade, padrão alimentar e sedentarismo são fatores de risco bem conhecidos para o desenvolvimento de diabetes tipo 2. A prevalência de diabetes aumenta claramente à medida que a prevalência de obesidade aumenta.Women’s Health Initiative , os sintomas depressivos aumentaram significativamente o risco de morte cardiovascular e mortalidade por todas as causas.11 Utilizando dados da PNS de 2013, com 31.847 mulheres, os episódios depressivos maiores e a ideação suicida foram avaliados com o Patient Health Questionnaire . A vitimização por violência e outras variáveis sociodemográficas foram autorreferidas. As mulheres apresentaram maiores prevalências de episódio depressivo , ideação suicida  e vitimização por violência , e melhora dos determinantes sociais. No entanto, as taxas de mortalidade por AVC e DALYs ainda são altas em mulheres. Além disso, há evidências recentes de que a taxa de declínio pode ter diminuído e que está ocorrendo sinais precoces de reversão em alguns grupos populacionais, como adultos jovens, principalmente mulheres. Essa tendência foi observada nos EUA cerca de 5 anos antes do Brasil. Provavelmente está associado às lacunas no tratamento das DCV em mulheres, e ao aumento do sobrepeso e obesidade, diabetes, estresse e síndrome depressiva/ansiedade em mulheres jovens.14É fundamental destacar que, no início da década de 1970 nos países desenvolvidos e na década de 1980 no Brasil, houve uma diminuição significativa da mortalidade por DCV. Esse fenômeno provavelmente foi associado ao controle dos FR , tratamento de pacientes com alto risco cardiovascular  are the major cause of death and disability in Brazil, in women and men. According to the GBD 2019 Study estimates, among CVDs, IHD was the number 1 cause of death in Brazil, followed by Stroke. IHD was responsible for 12.03% (II95 10.66%-12.88%) and 12.2% (II95 11 .5%-12.77%) , of deaths and 4.78 %(II95 4.08%-5.47%) and 6.48% (II95 5.92%-7.05%) of Disability Adjusted Life Years (DALYs) , in women and men, respectively. Deaths and DALYs from Stroke were higher in women than in men, 10.39% (II95 9.25-11.11%) and 8.41% (II95 7.84%-8.83%) of the deaths and 4.62% (II 4.01%-5.18%) and 4.19% of DALYs (3.82%-4.53%), respectively.2 The PNS 2013, a household-based epidemiological survey with nationally representative interviews, using the “WHO/Rose Angina Questionnaire,” reported that the prevalence of mild angina (grade I) was 9.1% (95%CI 8.5 - 9.7) and 5.9% (5.3 - 6.4), in women and men respectively.3 Regarding moderate/severe angina (grade II), in the 2019 PNS, it was also 5.5% more frequent in women than in men. 3.3%.4In 2019, in Brazil, the incidence rate of IHD  standardized by age was 78  per 100,000 in women and 148  per 100,000 in men. Regarding chronic IHD , the age-standardized prevalence rate was 1,046  per 100,000 women and 2,534  per 100,000 men.1 The RF that increased the most in Brazil, from 1990 to 2019, was the high BMI, causing metabolic changes that will lead to arterial hypertension, diabetes, and dyslipidemia, increasing the individual’s risk, especially for women.5 Sex-specific stroke risk factors in women include pregnancy, pre-eclampsia, gestational diabetes, oral contraception use, menopausal hormone use, and changes in hormonal status.6Among the risk factors (RF) for CVD in Brazilian women, systemic arterial hypertension, dietary risks, obesity, increased serum cholesterol, and high fasting glucose stand out   .1 The R4 and CV mortality attributed to arterial hypertension is higher in women aged 65 to 79 years old and in younger age groups in men, 50 to 79 years old.2 In the USA, although fewer women have hypertension before age 55, the percentage of women with hypertension is higher between ages 55-74, and far more women than men have hypertension after age 75.6 It is important to note that in multiple randomized controlled trials of antihypertensive treatment, the risk for adverse outcomes was significantly reduced by pharmacologic treatment and was comparable for women and men.7The prevalence of self-reported hypertension in Brazil was 23.9%, and was higher in females than in males ,5 Efficacy of counseling for encouraging physical activity indicated significant gender differences with women requiring more substantive follow-up than men to induce behavioral changes and sedentary lifestyle reversal.8Dietary risks were the second most crucial RF for CVD in 2019, accounting for 5.0 and 5.7% of deaths from IHD and 2.6 and 2.4% of deaths from stroke in women and men, respectively. Physical inactivity, another behavioral RF, increased from 1990 to 2019 in Brazil, with a predominance of women, 4.7%, compared to men, 3.1%.2 In the US, obesity has increased substantially. from the 1960s to the present, with obesity more common in women than men.6According to data from IBGE, in Brazil, the percentages of adults (age ≥18 years) with excess weight and obesity in 2019 were, respectively, 62.6%  and 29.5%  for women, and 57.5%  and 21.8 %  for men. Progressive increase of obesity was observed with age increase, ranging from 10.7%   in the age group of 18-24 years to 34.4%   in the age group of 40-59 years The higher prevalence of excess weight and obesity in females is worth noting for all age groups.2 Data from the PNS (2014 to 2015), in Brazil, have shown the prevalence was higher in women, individuals aged over 30 years, and among those with overweight or obesity.4 Diabetes is a more powerful coronary risk factor for women than men, negating their gender protective effect even among premenopausal women.10Obesity, diet pattern, physical inactivity and sedentary lifestyle are well-known risk factors for the development of type 2 diabetes. The prevalence of diabetes clearly increases as the prevalence of obesity increases.11 Using data from the 2013 Brazilian National Health Survey, with 31,847 women, the major depressive episodes and suicidal ideation were evaluated with the Patient Health Questionnaire. Violence victimization and other sociodemographic variables were self-reported. Women had higher prevalences of major depressive episode , suicidal ideation  and violence victimization , treatment of high-risk CV patients , and improvement of social determinants. However, stroke mortality rates and DALYs are still high in women. In addition, recent evidence that the rate of decline may have diminished and early signs of reversal in some population groups, as young adults, especially women. This trend was observed in the USA about five years before Brazil. It is probably associated with the gaps in CVD treatment in women and the increase in overweight and obesity, diabetes, stress, and the depressive/anxcety syndrome in young women.17Although CVD is increasing in young women, systematic CVD risk assessment in women <50 years of age and men <40 years of age with no known CVD factors is not recommended in guidelines. Given the increase in CVD in young adults, we suggest that younger age thresholds may be warranted. Evidence suggests that lifetime BP evolution differs in women compared to men, potentially resulting in an increased CVD risk at lower BP thresholds. Also, prolonged smoking is more hazardous for women than men, and women with type 2 DM, and atrial fibrillation appear to have a particularly higher risk for stroke.14Sex-related risk factors require special considerations that are summarized in 18 It is fundamental to promote initiatives to increase knowledge about the importance of cardiovascular health across a woman’s lifespan. Furthermore, it is crucial to understand better local disparities in women’s cardiovascular health to define public policy and health care, reduce gaps, and promote gender equity in Brazilian health care.Future guidelines should avoid integration of historical, unsubstantiated perspectives that impede improvements in women’s health during pregnancy and throughout women’s reproductive lives.


O prognóstico do paciente com doença de TCE pode ser melhorado com a revascularização miocárdica (RM). Com aprimoramento técnico e medicação antitrombótica eficaz, a intervenção coronária percutânea (ICP) evoluiu como uma modalidade terapêutica alternativa. Em pacientes com doença de TCE grave com complexidade anatômica baixa a intermediária, tanto a RM quanto a ICP são métodos eficazes de revascularização com taxas comparáveis de morte, infarto do miocárdio e acidente vascular cerebral em longo prazo.2 Os pacientes mais adequados para implante de stent no TCE são aqueles com doença ostial isolada/doença de TCE média, doença de TCE protegido e aqueles submetidos a implante de stent eletivo. Em um estudo recente, foram relatados 8% de mortalidade e 8% de taxa de revascularização da lesão-alvo durante o seguimento de um ano.3O tronco de coronária esquerda (TCE) origina-se do seio esquerdo de Valsalva, passa entre a artéria pulmonar principal e o apêndice atrial esquerdo antes de entrar no sulco coronário e bifurca-se na artéria descendente anterior esquerda (DAE) e na artéria circunflexa esquerda (CXE). Na maioria dos indivíduos, o TCE supre ≈75% do ventrículo esquerdo (VE).Um homem caucasiano de 72 anos de idade veio ao pronto-socorro com queixa de dor torácica opressiva prolongada em repouso há uma hora associada a diaforese fria e dificuldade respiratória. Ele tinha histórico de diabetes mellitus tipo 2 e dislipidemia, detectada quatro anos antes. Dois meses antes, ele tinha apresentado dor precordial opressiva a esforços moderados, que desaparecia rapidamente com repouso. A transient left septal fascicular block ).5 Esses “achados mínimos” no cenário de angina estável devem alertar o médico sobre a possibilidade de isquemia miocárdica grave em pacientes sem uma explicação lógica para os achados do ECG, como hipertrofia ventricular esquerda com strain na cardiopatia estrutural. Ambas as características do ECG são evidentes, com achados isquêmicos mais pronunciados no ECG realizados na admissão quando o paciente apresentava síndrome coronariana aguda.Um eletrocardiograma realizado devido a sintomas de angina estável 30 dias antes da internação hospitalar mostrou um padrão sugestivo de doença de TCE e possivelmente algum grau de suboclusão transitória do tronco da coronária esquerda ;A base do músculo papilar anterolateral (MPA) da válvula mitral dependente do fascículo anterior esquerdo (FAE) na parede parasseptal anterior, logo abaixo da inserção do MPA (vetor 1PI). Esses dois vetores iniciais têm direções opostas e se cancelam com predominância mínima do vetor 1PI direcionado para trás ( loop QRS (despolarização ventricular) no plano horizontal, dependente do vetor septal 1AM .10 Em seguida, o estímulo é direcionado para a região médio-septal ou parasseptal esquerda, bloqueada por inúmeras áreas do sistema de Purkinje, deslocando as forças para a frente e para a esquerda, resultando em forças anteriores proeminentes ( FAP). A 11A base do músculo papilar posteromedial (MPP) da válvula mitral dependente do fascículo posterior esquerdo (FPE). Está localizado na parede parasseptal posterior, a cerca de um terço da distância do ápice até a base . O aparecimento de BFAE durante o infarto agudo do miocárdio não é sinal de coexistência de estenose significativa da DAE ou de doença arterial coronariana mais grave ou extensa. Nesses pacientes, outros mecanismos, como o grau da circulação colateral coronariana, podem ter um papel importante na ocorrência desse distúrbio de condução e corroboram os relatos experimentais e clínicos de que o BFAE pode estar relacionado a lesões afetando o feixe de His por meio de uma dissociação longitudinal dessa estrutura.13FAE: o suprimento sanguíneo para o FAE do ramo esquerdo (RE) teve origem em 50% dos casos não apenas no ramo septal anterior da DAE, mas também da artéria nodal atrioventricular (AV), um ramo da artéria coronária direita (ACD) em 90% dos casos, e na CXE em 10%.14 tornam o bloqueio fascicular posterior esquerdo (BFPE) isolado muito raro.15 O MPP onde o FPE termina é suprido por ramos arteriais que terminam na superfície diafragmática do VE e, mais comumente, por uma junção de ramos terminais da LCX e da ACD. Quando a LCX supre quase toda a superfície diafragmática do VE (10% dos corações humanos), seus ramos fornecem todo o suprimento sanguíneo para o MPP. O FPE é irrigado em 10% dos casos apenas pela DAE, em 40% dos casos pela DAE e ACD e em 50% dos casos apenas pela ACD.FPE: a ampla natureza do FPE, sua localização protegida na via de entrada do ventrículo esquerdo e seu suprimento duplo de sangueFascículo septal esquerdo (FSE): é irrigado exclusivamente pela artéria perfurante septal da DAE, que supre 2/3 da porção superior do septo interventricular (SIV) neste local. A maior parte do suprimento de sangue para o SIV é fornecida pela DAE. Os ramos no septo da artéria descendente posterior raramente penetram mais de 10 mm do epicárdio , de modo que, para fins práticos, é possível considerar todo o suprimento sanguíneo do SIV derivado de quatro a seis ramos perfurantes septais de tamanho quase igual a da DAE   .No recente artigo de consenso brasileiro, foram estabelecidos os seguintes critérios para LSFB. Eles são os seguintes, com modificações e comentários esclarecedores do nosso grupo:Presença de forças anteriores proeminentes (FAP) do QRS, sendo transitórias em traçados sequenciais. A natureza transitória das FAPs e as derivações envolvidas indicam uma alta probabilidade de obstrução proximal crítica da artéria coronária descendente anterior esquerda (DAE). Quando esse padrão é observado no cenário da síndrome coronariana aguda ou durante um teste de esforço, deve ser considerada uma angiografia coronariana urgente;Duração normal do QRS ou aumento discreto (até 110 ms) quando não associado a outros bloqueios;Linhas do plano frontal inalteradas;16  com a onda R crescente de V1 a V3 e diminuindo de V5 para V6;AM);18 confirmado experimentalmente em corações humanos explantados por Durrer et al.,19Ausência de onda q em V5, V6 e I . With technical improvement and effective anti-thrombotic medication, percutaneous coronary intervention (PCI) has evolved as an alternative therapeutic modality. In patients with severe LMCA disease having low to intermediate anatomic complexity, both CABG and PCI are effective methods of revascularization with comparable long-term rates of death, myocardial infarction, and stroke.2 Patients most suitable for LMCA stenting are those with isolated ostial/mid LMCA disease, protected LMCA disease and those who undergo an elective stenting procedure. In a recent study, 8% mortality and 8% target lesion revascularization rate during one-year follow-up was reported.3The left main coronary artery (LMCA) originates from the left sinus of Valsalva, passes between the main pulmonary artery and the left atrial appendage before entering the coronary sulcus and bifurcates into the left anterior descending (LAD) and the left circumflex (LCX) coronary arteries. In most individuals, the LMCA supplies ≈75% of the left ventricle (LV).A 72-year-old Caucasian male presented at the emergency department complaining of prolonged oppressive chest pain at rest since ≈1 hour associated with cold diaphoresis and respiratory distress. He had a history of type 2 diabetes mellitus and dyslipidemia had been detected four years before. Two months earlier, he had oppressive precordial pain on moderate exertion, which disappeared rapidly after rest. 5 These “minimal findings” in the scenario of stable angina should alert the clinician about the possibility of severe myocardial ischemia in patients without a logical explanation for the ECG findings, such as left ventricular hypertrophy with strain in structural heart disease. Both ECG features are evident, with more pronounced ischemic findings in the ECG performed at admission when the patient had acute coronary syndrome.An ECG performed due to stable angina symptoms 30 days before the hospital admission, showed a pattern suggestive of LMCA disease and possibly some degree of LSFB.9 As the LAD is a continuation of the LMCA, significant LMCA obstruction, may lead to ischemia in the mid-portion and apical territory of the left ventricle, where the left septal fascicle runs, thereby causing LSFB.Several successive manuscripts from our group and others have shown that a large proportion of cases with transient left septal fascicular block (LSFB), manifested by prominent anterior QRS forces, is caused by critical proximal obstruction of the LAD before its first septal perforator branch.In the presence of LSFB, the sequence of ventricular activation begins only at two points:AMvector);The base of the anterolateral papillary muscle (ALPM) of the mitral valve dependent on the left anterior fascicle (LAF) in the anterior paraseptal wall, just below the ALPM attachment (1PI). These two initial vectors have opposite directions, and they cancel each other with minimal predominance of the 1PIvector directed backward .10 Next, the stimulus is directed to the mid-septal or left paraseptal region, blocked by numerous Purkinje passage areas, thus shifting the forces to the front and the left, resulting in prominent anterior forces (PAF). 11The base of the posteromedial papillary muscle of the mitral valve (PMPM) dependent on the left posterior fascicle (LPF). It is located in the posterior paraseptal wall, at about one-third of the distance from the apex to the base  nodal artery, a branch of the right coronary artery (RCA) in 90 % of the cases and of the LCX in 10%.12 Thus, anatomic data support the observation that occlusion of the proximal segment of the LAD is not a prerequisite for the occurrence of LAFB. The appearance of LAFB during acute myocardial infarction is not a sign of a coexistent significant stenosis of the LAD or of more severe or extensive coronary artery disease. In these patients, other mechanisms such as the degree of the coronary collateral circulation may play a role in the occurrence of this conduction disturbance and supports the experimental and clinical reports that LAFB may be due to lesions involving the His bundle by means of a longitudinal dissociation of this structure.13LPF: the broad nature of the LPF, its protected location in the left ventricular inflow tract, as well as its dual blood supply14 makes isolated LPFB very rare.15 The PMPM where LPF ends is supplied by arterial branches that terminate on the diaphragmatic surface of the LV, and most commonly by a junction of terminal branches of the LCX and of the RCA. When the LCX supplies nearly all the diaphragmatic surface of the LV (10 % of human hearts), its branches provide the entire blood supply for the PMPM. The LPF is irrigated in 10% of cases by LAD only, in 40% of cases by LAD and RCA and in 50% of cases by RCA only.Left septal fascicle (LSF): it is irrigated exclusively by the septal perforating artery from the LAD, which supplies the upper2 /3portion of the interventricular septum (IVS) at this site. Most of the blood supply to the IVS is provided by the LAD. Branches into the septum from the posterior descending artery rarely penetrate more than 10 mm from the epicardium , so that for practical purposes one may consider the entire blood supply of the IVS to be derived from four to six nearly equal size septal perforating branches of the LAD  of the QRS, being transient in sequential tracings. The transitory nature of PAF and the leads involved in it indicate a high likelihood of critical proximal obstruction of the left anterior descending coronary artery (LAD). When this pattern is observed in the scenario of acute coronary syndrome or during a stress test, urgent coronary angiography should be considered;Normal QRS duration or discrete increase (up to 110 ms) when not associated to other blocks;Unaltered frontal plane leads;16  with R wave “in crescendo” from V1 through V3 and decreasing from V5 to V6;AMseptal vector)18 ; confirmed experimentally in explanted human hearts by Durrer et al.19Absence of q wave in V5, V6 and I (by absence of 1To our knowledge, this is the first case in the literature describing ECG features compatible with LSFB associated with LMCA subocclusion. This evolution should alert clinicians about the possibility of severe coronary artery disease in patients with an ECG pattern of LSFB associated with wide-spread ST-segment depression both in patients with stable angina and those with acute coronary syndrome. Coronary angiography without delay should be considered.