ABC | Volume 112, Nº4, April 2019

Anatomopathological Correlation Pereira et al Arrhythmia and heart failure Arq Bras Cardiol. 2019; 112(4):466-472 Figure 1 – Left ventricular outflow tract: bivalve aortic valve, showing thickened semilunar leaflets (*), with moderate retraction at the free border, suggestive of valvular regurgitation. The anterior descending (ADA) and circumflex (Cx) coronary arteries originate from separate ostia, in the left Valsalva sinus; the ADA ostium lies posterior to the Cx ostium and is tangential. The right coronary artery (RCA) ostium is located in the right Valsalva sinus. dilatation and, in this situation, valvulopathy was secondary to the disease progression. The use of negative inotropic medications, corticosteroids, cardiotoxic chemotherapeutic drugs, non-steroidal anti‑inflammatory drugs, antiarrhythmics and glitazone or dipeptidyl phosphatase 4 inhibitors may be decompensation triggers, which can be used through self-medication or by not informing to other physicians about the presence of heart failure. (Dr. Marcella Abunahman Freitas Pereira, Dr. Wilma Noia Ribeiro) Diagnostic hypotheses: Infiltrative cardiomyopathy or idiopathic dilated cardiomyopathy. (Dr. Marcella Abunahman Freitas Pereira, Dr. Wilma Noia Ribeiro) Anatomopathological examination The explanted heart, devoid of the atria, weighed 598 g (normal = 300 to 350 g). Externally, there was discrete and focal epicardial thickening on the sternocostal and diaphragmatic surfaces of the right and left ventricles. The cross-sectional sections showed a bicuspid aortic valve, with fusion between the left semilunar and non‑coronary leaflets, without a median raphe (Figure 1), moderate and diffuse thickening of the semilunar leaflets, with marked retraction and slight calcification at the free border of the semilunar leaflets, macroscopically suggestive of valve regurgitation. The right coronary artery (RCA) ostium was typically located in the right Valsalva sinus. In the left Valsalva sinus, two ostia of coronary arteries originated: the most anterior ostium gave origin to the circumflex (Cx) artery and the posterior ostium, tangentially, originated the anterior descending artery (ADA) (Figure 1). The proximal segments of the ADA and Cx intersected, with the ADA being positioned higher than the Cx (Figure 2). An intramyocardial ("myocardial bridge") trajectory from the fifth to the seventh centimeter of the ADA was also observed (Figure 3). Right predominant coronary artery circulation was observed. There was no significant luminal obstruction in the coronary ostia or epicardial coronary arteries. There was moderate ventricular hypertrophy and dilatation and moderate atrial dilatation. Presence of moderate and diffuse retraction at the free border of the anterior cusp of the mitral valve was observed. The tricuspid and pulmonary valves showed discrete and diffuse retraction at the free border of their leaflets. Emerging from the superior vena cava, there was a cardiac pacemaker cable-lead that was implanted in the endocardium of the anterior wall of the right atrium. Another cardiac pacemaker cable-lead extended from the superior vena cava through the right atrium, tricuspid valve and right ventricle, and was implanted in the ventricular septum endocardium, in its apical portion. There were no thrombi in the heart cavities. The histological study showed moderate hypertrophy in cardiomyocytes and diffuse interstitial myocardial fibrosis, more pronounced in the left ventricle (Figure 4). (Dr. Léa Maria Macruz Ferreira Demarchi) Anatomopathological diagnoses: 1) bicuspid aortic valve; 2) Ventricular hypertrophy and dilatation; 3) Diffuse interstitial myocardial fibrosis, more pronounced in the left ventricle; 4) Congenital anomalies of the origin, course of the anterior and circumflex interventricular epicardial coronary arteries. (Dr. Léa Maria Macruz Ferreira Demarchi) Comment An association was observed between the bicuspid aortic valve and anatomical alterations in the coronary arteries in the patient’s explanted heart, which is a frequent 469