When residents die in Portuguese care facilities: The experiences and practices of care facility directors before and during the COVID-19 pandemic

This qualitative exploratory study aimed to describe the experiences and practices of care facility directors regarding residents dying in Portuguese residential care facilities (RCFs) before and during the COVID-19 pandemic. Data was obtained from 17 care director facilities who participated in focus groups. The data analysis followed the interpretative phenomenological approach. Participants stated that practices surrounding the death of the residents in Portuguese RCFs changed significantly from before to during the pandemic, regarding both those who died from COVID-19 infection and from other conditions. Four themes emerged that illustrated the situation during the peaks of the pandemic. During the pandemic, practices and experiences quite different from the usual ones have emerged. These results support the importance of a good death, and dying with dignity in RCFs, and the need for policies, practices, and training on the death of residents in RCFs in Portugal.

Impact of coronavirus disease 2019 on adult patients with congenital heart disease

Background

COVID-19 is responsible for a worldwide pandemic, causing more than 18,000 deaths to date in Portugal. Data already exists regarding the increased risk of adverse events in patients with cardiovascular diseases, however the impact of SARS-CoV-2 infection in patients (P) with congenital heart disease (CHD) is still under investigation.

Purpose

To study the impact of COVID-19 in a adult patients with CHD

Methods

Adult patients seen at the CHD outpatient's clinic at a tertiary centre, who became infected with SARS-CoV-2 infection up to December 2021 were included. Assessment of patients' symptoms, need for hospitalization and admission in an intensive care unit was assessed based on medical records.

Results

We identified seventy-nine patients (pts) with COVID-19 infection. Symptoms were present in 67 (84%). The median age was 44 (15) years, 52% were females. Eight P (10%) had complex cyanotic disease; seven Tetralogy of Fallot; five (6%) transposition of great arteries; eight (10%) right ventricle obstacle; two (3%) atrioventricular canal defect; sixteen (20%) atrial septal defect; nine (11%) ventricular septal defect; eight (10%) aortic coarctation; two (3%) had Eisenmenger syndrome. 49% of P had previous surgery or percutaneous procedure. 63% of P were at New York Heart Association (NYHA) class of I and 30% at NYHA II. Mild symptoms were reported by 56 P (71%). Ten adults (7,9%) experienced moderate symptoms (dyspnea and hypoxia) that led to hospitalization for oxygen therapy, none required mechanical ventilation. One death was reported in an 83-year-old patient with non-corrected interventricular communication and compromised biventricular function. There was a significant association between the gravity of CHD and hospitalizations (p=0.02).

Conclusion

Our pts had mainly mild to moderate symptoms and did not appear to have a disproportionately negative outcome; the need for hospitalization was more frequent in patients with higher CHD gravity. These findings are in line with the emerging data regarding COVID-19 in CHD P, and may be in part explained by the patient's young age and functional status.

Funding Acknowledgement

Type of funding sources: None.

Non-vitamin K antagonist oral anticoagulants in adult congenital heart disease: a single-center study

Introduction

Adults with congenital heart disease (ACHD) are at an increased risk for thromboembolic events and atrial arrhythmias are common in this population. Non-vitamin K anatagonist oral anticoagulants (NOACs) prescription is increasing, however data on efficacy and safety in ACHD is unclear, particularly in patients (P) with complex CHD. The aim of the study was to review the use of NOACs in various types of ACHD and assess its safety and efficacy.

Methods

Evaluation of consecutive ACHD P started on NOAC therapy from 2014 to 2020. P were followed-up for bleeding or thromboembolic events and mortality. CHA2DS2-VASc and HASBLED scores were calculated and risk factors for bleeding were identified.

Results

93 ACHD P were included, mean age 52±15 years, 58% female, 44% with complex CHD (3.2% with Fontan circulation), with diagnosis of: 22.2% atrial septal defect, 20% tetralogy of Fallot, 11.1% transposition of the great arteries, 10% Ebstein's anomaly, 8.9% ventricular septal defect, 7.8% pulmonary stenosis, 5.6% ductus arteriosus, 4.4% AV septal defect, 3.4% univentricular heart, 3.4% coarctation of aorta, 2.2% supra-aortic stenosis and 1% with Uhl disease.

Most P were anticoagulated with rivaroxaban (43%), followed by edoxaban (24%), apixaban (20%), and dabigatran (13%). The indications for anticoagulation were: atrial arrhythmias (81%), pulmonary embolism (PE) (6.3%), atrial thrombi (4.3%), thromboprophylaxis in Fontan circulation (3.2%), deep vein thrombosis (3.2%) and stroke (2%). 66% of P had a CHA2DS2-VASc score ≥2 and 82% HASBLED score ≤2.

In a mean follow-up of 41±21 months (400.4 patient-years), there were embolic events in 2P (1 splenic infarction and 1 PE) albeit both were in the context of oral anticoagulation interruption. The cardiovascular mortality was 2% and allcause mortality 5%, however with no relation to thrombosis or bleeding events.

6 P (6.5%) suffered a minor and 3 P (3.2%) suffered a major bleeding, a median time of 12 (IQR 15) months after starting NOAC therapy. The annual risk for bleeding was 2.2%/patient/year. P with bleeding events showed no significant difference regarding age (55±16 vs 52±15 years, p=0.587), gender (13% female vs 5.1% male, p=0.295) or CHD type (p=0.582). 8.6% of P required dose reduction, mostly for bleeding (3.2%) or renal impairment (2.2%).

Renal disease was a strong risk factor for major bleeding (HR 14.6 [95% CI 1.23–73.6], p=0.033 and multivariate analysis showed that an increased HASBLED score was an independent predictor of minor (adjusted HR 3.44 [95% CI 1.13–10.52], p=0.030) and major (adjusted HR 5.29 [95% CI 1.14–24.45], p=0.033) bleeding complications.

Conclusion

Anticoagulation with NOACs is a safe and effective option for selected ACHD P, although bleeding complications were not negligible, particularly in P with renal disease. Larger scale research studies are required, especially regarding complex CHD such as P with Fontan circulation.

Funding Acknowledgement

Type of funding sources: None.

Transesophageal echocardiography versus intracardiac echocardiography-guided left atrial appendage occlusion: a comparative analysis

Introduction

The left atrial appendage occlusion (LAAO) procedure is a therapeutic option for stroke prevention in patients with atrial fibrillation (AF) which have contraindication to oral anticoagulants or still develop embolic events despite therapeutic anticoagulation. Transesophageal echocardiography (TEE) has been the gold standard to guide this procedure, with the intracardiac echocardiography (ICE) emerging as an alternative because of the advantage of reducing the general anesthesia burden compared to TEE.

Objectives

This study aims to compare the safety, procedure-related parameters and outcomes between TEE-guided LAAO and ICE-guided LAAO.

Methods

In a tertiary center, patients who underwent TEE-guided LAAO and ICE-guided LAAO were compared retrospectively regarding technical success, procedure-related events, procedure-related parameters (fluoroscopy time, dose of radiation and contrast volume), 45 days-transthoracic echocardiography (TTE) and 1-year outcomes (mortality, stroke and major bleeding).

Results

88 patients underwent LAAO between 2009 and 2020 (n=43 with TEE, n=45 with ICE). Baseline characteristics were similar. Success was achieved in 95.3% (n=41) and 95.6% (n=43) of the patients in the TEE and ICE groups, respectively (OR 0.95, p=0.96). Procedure-related complications (major vascular complications, perforation, device embolization) didn't show significant differences (14.0% vs 8.9%, OR 1.66, p=0.46) in the TEE and ICE groups, respectively. Fluoroscopy time was inferior in the TEE group (29.1±13.6 vs 44.1±17.4 minutes, p=0.001), while radiation dose (2761±1555 vs 3397±2118 mGy, p=0.113) and contrast volume (220.3±104.1 vs 204.0±100.9mL, p=0.469) showed no significant differences. 45 days-TTE showed no significant differences between the TEE and ICE groups regarding peri-device leaks (14.0% vs 24.4%, p=0.212), device thrombus (2.3% vs 0%, p=0.990) and iatrogenic atrial septal defects, all mild (4.7% vs 13.3%, p=0.174). 1-year outcomes showed no significant differences regarding stroke (9.3% vs 4.4%, p=0.186), major bleeding (9.3% vs 2.2%, p=0.78) and all-cause mortality (9.3% vs 11.1%, p=0.38) between the TEE and ICE groups, respectively.

Conclusions

ICE-guided LAAO is associated with similar results, procedure-related events, procedure related-parameters (fluoroscopy time being the only exception) and 1-year outcomes, compared with TEE-guided LAAO.

Funding Acknowledgement

Type of funding sources: None.

Pregnancy outcomes in women with severe congenital heart disease – a specialized centre experience

Introduction

Progress in pediatric cardiology and cardiac surgery has dramatically raised the number of women with severe complex congenital heart disease (SC-CHD) that reach reproductive age. Pregnancy (P) in this group of women has an increased risk of adverse cardiac and neonatal events and its predictive factors are not fully defined. Our purpose was to assess the experience of our center regarding P and neonatal outcomes in women with SC-CHD.

Methods

Retrospective analysis of obstetric data in women with CHD followed at our institution. P and neonatal outcomes were evaluated regarding patients presenting SC-CHD and mild and moderate complexity CHD (MMC-CHD), according to ESC guidelines CHD complexity classification.

Results

The study enrolled 680 women with CHD (median age, 27.2 years) who experienced 1262 pregnancies, resulting in 998 live births. A previous corrective procedure was found in 334 women (49.1%). CHD complexity was considered mild, moderate and severe in 263 (38.7%), 359 (52.8%) and 58 (8.5%), respectively. SC-CHD included 38 women with cyanotic CHD and 18 with pulmonary vascular disease. The most common heart defect in SC-CHD pts was cyanotic tetralogy of Fallot (19.0%), followed by dextro-transposition of the great arteries with atrial switch /palliative procedure (13.8%) – Figure 1.

Pts with SC-CHD had successful deliveries in 56.1% comparing with 82.1% in MMC-CHD. Women with SC-CHD had significantly higher incidence of preterm birth (24.6% vs 7.4%, p<0.001), spontaneous abortion (26.3% vs 12.3%, p=0.004) and neonatal mortality (10.3% vs 2.3%) comparing with MMC-CHD. Low birth weight was also extremely more frequent in the SC-CHD group (44.7% vs 8.5%, p<0.001). No difference was found relating to the presence of CHD in infants from SC-CHD mothers compared to off-spring from MMC-CHD (8.4 vs 5.3%, p=0.407). Cesarian deliveries had similar rates independently of increased CHD complexity (34.2% vs 32.1%). Overall, pregnancy was quite well tolerated, although cardiac complications were more common in SC-CHD P (0.4% vs 4.3%, p 0.013). Only one maternal death was registered, during 1st trimester, in a woman with a large unrepaired ventricular septal defect and cyanosis.

Conclusion

Severe complex CHD remains a challenging condition for pregnancy with increased maternal and neonatal morbimortality. This emphasizes the importance of extensive prepregnancy counselling and centralization of care to address specific risks and requirements of the condition.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Severe CHD

Impact of COVID-19 in adult patients with congenital heart disease

Background

COVID-19 is responsible for a worldwide pandemic, causing more than 13 000 deaths to date in Portugal. Data already exists regarding the increased risk of adverse events in patients with cardiovascular diseases, however the impact of SARS-CoV-2 infection in patients (P) with congenital heart disease (CHD) is still under investigation.

Aims

To evaluate the impact of COVID-19 in adult patients with congenital heart disease in our tertiary centre

Methods

Adult patients seen at the CHD outpatient's clinic at a tertiary centre, who became infected with SARS-CoV-2 infection up to February 2021 were included. Assessment of patients' symptoms, need for hospitalization and admission in an intensive care unit was assessed based on medical records.

Results

We identified 36 patients (pts) with COVID-19 infection. Symptoms were present in 31 (86%). The median age was 39 (32–49) years, 58% were females. Seven P (19%) had complex cyanotic disease; three (8%) Tetralogy of Fallot; three (8%) transposition of great arteries (one after Senning procedure and 2 after arterial switch); six (14%) right ventricle obstacle; two (8%) atrioventricular canal defect; four (11%) atrial septal defect; five (14%) ventricular septal defect; five (14%) aortic coarctation; two aortopathies (one submitted do David procedure); one subaortic stenosis; two (6%) had Eisenmenger syndrome. The majority (61%) of P had previous surgery and 58% were at New York Heart Association class of I. Mild symptoms were reported by 24 P (67%). Seven adults experienced moderate symptoms (dyspnea and hypoxia) that led to hospitalization for oxygen therapy, although none required mechanical ventilation. One death was reported. There was a significant association between the gravity of CHD and hospitalizations (p=0.012).

Conclusion

Our pts had mainly mild to moderate symptoms and did not appear to have a disproportionately negative outcome; the need for hospitalization was more frequent in patients with higher CHD gravity. These findings are in line with the emerging data regarding COVID-19 in CHD P, and may be in part explained by the patient's young age and functional status.

Funding Acknowledgement

Type of funding sources: None.

Improving risk stratifcation of pulmonary hypertension patients

Background

According to the 2016 ESC/ERS Guidelines on Pulmonary Hypertension (PH), the right atrial area (RAA) and the presence ofa pericardial effusion (PE) are the two main echocardiographic prognostic markers in PH patients (pts).

Aim

To assess the predictive ability of these two parameters.

Methods

Pts with PH were prospectively studied and several clinical/demographic/echocardiographic were retrieved as well as data from six-minute walk test (6MWT) and brain natriuretic peptide (BNP). All-cause mortality was analyzed by PE, RAA and other echocardiographic parameters for positive (PPV) and negative predictive value (NPV) to detect if the current guideline recommended cut-offs can precisely stratify risk in this setting. A survival analysis was performed to evaluate risk stratification (RS) provided by several different cut-offs.

Results

A total of 51 PH pts (mean age 54±46 years, 33.3% male, baseline BNP of 342.4±439.9pg/mL, mean 6MWT distance of 360.3±109.2 meters and baseline pulmonary artery systolic pressure of 78±26mmHg), of which 64.7% had Group I PH (GI) and 35.3% presented chronic thromboembolic pulmonary hypertension. There were no significant differences between these two groups, however pts in GI were significantly younger (p=0.001), achieved a lower 6MWT distance (p=0.038) and had worse values of right ventricular strain (p=0.040). 27 pts (52.9%) died during a mean follow-up of 52 months, with no differences between groups (p=0.756). The presence of a PE had a low NPV and PPV for the primary endpoint (45.0% and 45.5%, respectively), as well as the guideline recommended cut-offs for RAA (18cm2: NPV- 50.0% and PPV– 55.2%; 26cm2: NPV- 51.3% and PPV– 66.7%). A Pulsed Doppler Tei index (TIp) cut-off of 0.40 had a higher NPV (70.8%) and PPV (74.1%). By Kaplan-Meieran alysis, neither the presence of PE (log rank p=0.508) nor the recommended RAA cut-offs provided accurate risk discrimination (log rank p>0.05 for all). Pts below a TIp cut-off of 0.40 presented a significantly lower survival during follow-up (log rank p=0.002)

Conclusion

The currently recommended echocardiographic prognostic markers cannot precisely discriminate risk in PH pts. Markers of Right Ventricular Dysfunction may improve RS in this population.

Funding Acknowledgement

Type of funding sources: None.

PSXIII-15 Impact of forage allowance on performance and reproductive parameters in Nellore heifers

The objective was to evaluate the effects of forage allowance on the performance and pregnancy rate of Nellore heifers submitted to the fixed-time artificial insemination (FTAI) at 14±1 months. The experimental period was divided into the growing phase (GP; 173d) and breeding season (83d). Ninety weaned Nellore heifers [169±19 kg of body weight (BW); 210±28 days of age] were blocked by initial BW and randomly assigned to receive different forage allowance: (1) High (HFA; 7.17 kgDM/kgBW; and (2) Low (LFA; 3.27 kgDM/kgBW); and divided into 6 paddocks (2.15 to 2.4 ha each one). The grazing method used was continuous stocking with a variable stocking rate where treatment conditions were established varying the stocking rate on pasture (put-and-take). The supplement consisted of corn, soybean meal, urea, monensin, sodium chloride and minerals mix (80% TDN and 24% CP) and was provided daily (ad libitum; expected intake around 1% of BW). The final pregnancy rate was determined after two FTAI (d256). Heifers BW at the end of the GP was greater (P < 0.01) for HFA vs. LFA (268 vs. 255 kg). The overall average daily gain (ADG) was greater 68 g/d for animals maintained in HFA than LFA (P < 0.01; 0.713 vs. 0.645 kg/d). Supplement intake (kg/animal/d) had no treatment effect (P = 0.117). On d173, forage allowance affected (P < 0.01) the backfat thickness obtained by real-time carcass ultrasound (HFA = 3.08 vs. LFA = 2.85 mm). The pregnancy rate had no treatment effect (P = 0.223; on average 61%). However, the pregnant heifers per hectare had treatment effect (P = 0.036; HFA = 3.78 vs. LFA = 2.72 pregnant heifers/ha). In conclusion, the low forage allowance reduces the animal performance and affects the carcass composition but provides a greater number of pregnant heifers per hectare.

Cardiopulmonary exercise testing in repaired tetralogy of Fallot: a valuable tool for pulmonary regurgitation severity assessment

Funding Acknowledgements

Type of funding sources: None.

Introduction and purpose

The optimal timing for pulmonary valve replacement (PVR) in asymptomatic patients with repaired tetralogy of Fallot (TOF) and pulmonary regurgitation (PR) remains uncertain but is often guided by imaging characterization of the right ventricle. As cardiopulmonary exercise testing (CPET) performance is an accessible prognostic indicator, we assessed which CPET parameters best correlate with pulmonary regurgitation severity to potentially improve identification of high-risk patients.

Methods

A retrospective chart review was done from 2009 to 2018 on adult patients with repaired TOF who underwent maximal effort cardiopulmonary exercise testing with cycle ergometry and with concurrent pulmonary function testing. Demographics, standard measures of CPET interpretation, and major cardiovascular outcomes were collected.

Results

Cardiopulmonary exercise testing was performed in 54 adult repaired TOF patients (59% male), with a mean follow-up of 60 ± 33 months. The mean age was 34 ± 9 years. 30 patients (56%) had severe pulmonary regurgitation and 26 patients (48%) were submitted to PVR, with a 0% mortality rate. PVR was performed a mean 28 ± 7 years after TOF repair surgery. There was moderate to severe right ventricular dysfunction in 11 patients (20%). 12 patients (22%) had a hospitalization for heart failure. Arrhythmic events occurred in 9 patients (17%), mainly atrial fibrillation or atrial flutter (67%). 2 patients (4%) received an implantable cardioverter-defibrillator for secondary prevention of sudden cardiac death.

Peak VO2 consumption (pVO2) showed no statistically significant correlation with severity of pulmonary regurgitation (HR 0.26, 95% CI 0.879-1.036, p= 0.262) or PVR (HR 0.92, 95% CI 0.829-1.028, p = 0.914), while percent of predicted pVO2 significantly correlated with severity of pulmonary regurgitation (HR 0.95, 95% CI 0.918-0.993, p = 0.020) and PVR (HR 0.94, 95% CI 0.886-0.992, p = 0.025).

VE/VCO2 slope was not a significant predictor of severity of pulmonary regurgitation (HR 1.03, 95% CI 0.929-1.130, p = 0.622) or PVR (HR 1.04, 95% CI 0.952-1.128, p = 0.414) or) and neither cardiorespiratory optimal point (HR 0.94, 95% CI 0.786-1.120, p = 0.480) nor maximum end-tidal carbon dioxide pressure (PETCO2) (HR 0.93, 95% CI 0.846-1.037, p = 0.213) correlated with severity of pulmonary regurgitation or PVR.

Conclusion

Percent of predicted peak VO2 had the highest predictive power of all CPET parameters analysed in adult repaired TOF patients. Preoperative CPET could be an accessible way to identify high-risk patients earlier for PVR and should therefore be included in the routine assessment of these patients.

Right atrial strain by speckle-tracking echocardiography as a prognostic predictor in a pulmonary hypertension cohort

Funding Acknowledgements

Type of funding sources: None.

Background

Right atrial (RA) strain is as a promising technique for assessment of RA function and several studies have suggested it is a powerful prognostic marker in pulmonary hypertension (PH) patients (pts). Our aim was to assess the prognostic power of RA strain in Pulmonary Arterial Hypertension (PAH) and Chronic Thromboembolic Pulmonary Hypertension (CTEPH) pts.

Methods

Pts with PH were prospectively studied and several clinical/demographic/echocardiographic were retrieved as well as data from six-minute walk test (6MWT) and brain natriuretic peptide (BNP). Correlation between RA strain and other variables was tested with Pearson"s correlation analysis. Regression and survival analysis were performed to assess the combined endpoint of all-cause mortality or hospitalization in the first follow-up year (MH1).

Results

A total of 51 PH pts (mean age 54 ± 46 years, 33.3% male, baseline BNP of 342.4 ± 439.9pg/mL and baseline pulmonary artery systolic pressure – PASP - of 78 ± 26mmHg), of which 64.7% had PAH and 35.3% presented CTEPH. 19 ots (37.3%) met the primary endpoint. The mean RA strain was -21.9 ± -4.9%, with no significant difference between groups (-23.4% vs -17.8%, p = 0.150), however male pts had a significantly lower RA strain (-15.9% vs -25.1%, p = 0.014). There was a statistically significant (p < 0.05) correlation between RA strain and age (r = -0.287), indexed RA area (r = -0.539), index RA volume (r = -0.522) and right ventricular strain (r = -0.453). There was no correlation between RA strain and BNP value (p = 0.150), 6MWT distance (p = 0.145) or PASP (p = 0.072). RA strain was a predictor of MH1 (OR = 0.94, 95% CI: 0.894-0.998, p = 0.048). Pts who met the primary endpoint had a significantly worse RA strain (-17.0 vs -24.6%, p = 0.032). Those with a RA strain worse than -19% presented a significantly lower survival free of events during the first follow-up year (log rank p = 0.022).

Conclusion

RA strain is a powerful predictor of adverse events in a PH population and should be systematically assessed in order to improve risk stratification.

Abstract Figure.

New onset atrial fibrillation after percutaneous Patent Foramen Ovale closure: how serious is this problem?

Background

Percutaneous Patent Foramen Ovale (pPFO) closure benefits for secondary prevention after cardio-embolic stroke have recently been proved. With the increasing number of cases and procedures, a concern with new onset atrial fibrillation (NOAF) has been raised.

Purpose

To evaluate long-term outcome regarding NOAF rate and to identify its predictors and clinical impact, in a real population submitted to pPFO closure.

Methods

From 2000 to 2017, consecutive patients (P) submitted to pPFO closure in a tertiary centre were prospectively enrolled. The primary endpoint was NOAF rate and secondary endpoints were all-cause, neurologic and cardiac mortality rates and recurrent ischemic events. Previous and follow-up electrocardiographic, echocardiographic and 24-hour heart rhythm monitoring data were analysed. Follow-up was performed through medical visits, medical charts consultation and a phone call based system, in order to assess clinical status, on-going treatment and events.

Results

496 patients were submitted to pPFO. Immediate success was achieved in 98.8% and 9.1% presented a residual shunt on the 1st year TEE. Mean age was 45.0±11.2 years-old with 50.2% of males. The prevalence of hypertension, hypercholesterolemia and atrial septum aneurysm (ASA) was 25.7%, 45.0% and 46.3%, respectively. Pre-procedural mean left atrial (LA) diameter was 36.0±5.3 mm. FU data was available for 490 (98.6%), for a mean FU time of 7.41±3.51 years. 34 P (6.9%) presented ischemic events recurrence (26 strokes and 8 TIA). The primary endpoint was observed in 21 P (4.3%) during the FU period.

Median time to 1st AF episode since PFO closure was 5.90±5.53 years. 11 P (52.3%) initiated oral anticoagulation. In univariate analysis, age (44.6±11.3 vs 51.8±6.0 years, p=0.005) and hypertension (24.7% vs 47.6%, p=0.019) were predictors of NOAF in this population. In multivariated analysis, only age remained a predictor of NOAF (OR 1.05 (1.007–1.101), p=0.025). LA pre pPFO closure dimensions, ASA, device type or size and the presence of residual shunt in TEE were not determinants of AF occurrence. The incidence of NOAF was associated with the need for hospitalization due to cardiac causes (19% vs 3.2%, p=0.001) and a trend towards higher rate of recurrent stroke (4.9% vs 14.3%, p=0.06).

Conclusion

Despite being a highly successful and safe procedure in most patients, pPFO closure was associated with a non-negligenciable rate of NOAF during long-term follow-up. NOAF predictors were related with classical cardiovascular risk factors, such as age and hypertension. None of the procedure or device features were associated with NOAF. Yet, a clinical impact was attributed to NOAF, with more hospitalizations and a trend towards ischemic events recurrence.

As young patients submitted to pPFO closure grow older, prevention strategies to diagnose and treat NOAF should be endeavoured.

Funding Acknowledgement

Type of funding source: None

Clinical characteristics and risk factors for mortality in obstetric patients with severe COVID-19 in Brazil: a surveillance database analysis

Objective

To describe clinical characteristics of pregnant and postpartum women with severe COVID‐19 in Brazil and to examine risk factors for mortality.

Design

Cross‐sectional study based on secondary surveillance database analysis.

Setting

Nationwide Brazil.

Population or sample

978 Brazilian pregnant and postpartum women notified as COVID‐19 Acute Respiratory Distress Syndrome (ARDS) cases with complete outcome (death or cure) up to 18 June 2020.

Methods

Data was abstracted from the Brazilian ARDS Surveillance System (ARDS‐SS) database. All eligible cases were included. Data on demographics, clinical characteristics, intensive care resources use and outcomes were collected. Risk factors for mortality were examined by multivariate logistic regression.

Main outcome measures

Case fatality rate.

Results

We identified 124 maternal deaths, corresponding to a case fatality rate among COVID‐19 ARDS cases in the obstetric population of 12.7%. At least one comorbidity was present in 48.4% of fatal cases compared with 24.9% in survival cases. Among women who died, 58.9% were admitted to ICU, 53.2% had invasive ventilation and 29.0% had no respiratory support. The multivariate logistic regression showed that the main risk factors for maternal death by COVID‐19 were being postpartum at onset of ARDS, obesity, diabetes and cardiovascular disease, whereas white ethnicity had a protective effect.

Conclusions

Negative outcomes of COVID‐19 in this population are affected by clinical characteristics but social determinants of health also seem to play a role. It is urgent to reinforce containment measures targeting the obstetric population and ensure high quality care throughout pregnancy and the postpartum period.

Tweetable abstract

A total of 124 COVID‐19 maternal deaths were identified in Brazil. Symptoms onset at postpartum and comorbidities are risk factors.

A total of 124 COVID‐19 maternal deaths were identified in Brazil. Symptoms onset at postpartum and comorbidities are risk factors.

Gravity stress tibiotalar laxity evaluation with a biomedical gyroscopes device - cadaver study with progressive sectioning of lateral ankle ligaments

Purpose

Despite the evidence on the role of gravity stress test to access the instability of other ankle injuries, there is limited literature regarding gravity stress on the lateral ankle ligament’s insufficiency. The objective of our study was to objectively measure the tibiotalar angular movement under gravity stress after progressive sectioning of the lateral ankle ligaments.

Methods

We performed sequential sectioning of the anterior talofibular (ATFL), calcaneofibular (CFL), and posterior talofibular ligaments (PTFL) in twelve ankle specimens. Under gravity stress, we measured the angular movement of the talus in relation to the tibia. The measuring device is based on a three-axis gyroscope and accelerometer.

Results

Comparing to the intact condition, the plantar flexion increased on average 1.78° (95% confidence interval [CI] 1.15;2.42), 5.13° (95%CI 3.10;7.16) and 8.63° (95%CI 6.05;11.22), the rotation increased by 1.00° (95 CI -0.51;2.51), 3.68° (95%CI 1.97;5.40) and 15.62° (95%CI 10.09;21.14), and the varus increased 2.89° (95% CI 1.39, 4.39), 8.12° (95% CI 5.16, 11.07) and 11.68° (95% CI 7.91, 15.46), after sectioning the ATFL, CFL, and PTFL, respectively. The overall changes were statistically significant.

Conclusions

There was a significant tibiotalar laxity after sectioning of lateral ankle ligaments when the foot position is influenced only by gravity. The tibiotalar angular displacement was significant when the CFL and PTFL were cut which suggests that the gravity test could be used to assess combined lateral ankle ligament injury. This evidence might be a step forward in the development of lateral ankle ligaments gravity stress tests.

Level of evidence

5 (cadaver study)

Gastrocutaneous fistulas after PEG removal in adult cancer patients: frequency and treatment options

INTRODUCTION AND AIMS

PEG removal in head and neck cancer patients (HNCPs) is performed after treatment, in case of disease remission and after adequate oral intake is resumed. The PEG tract usually closes spontaneously within 2-3 days. Persistent gastrocutaneous fistula (GCF) is a rare complication after PEG tube removal and is characterized by the persistence of gastric leakage through the fistulous tract for more than 1 month. Our main goal was to access the incidence and the success of a treatment algorithm for GCF in HNCPs.

METHODS

Retrospective unicentric study of HNCPs referred for PEG removal between 2014 and 2018. The patients with GCF were selected and their sequential treatment was reviewed.

RESULTS

In 331 patients with PEGs removed, 19 (5.7%) GCFs were documented. Medical therapy (4-8 weeks) was performed with clinical success (definitive closure of the GCF) in 12 (63.2%) patients. The remaining seven patients required endoscopic or surgical treatment. In four, endoscopic treatment had technical and clinical success (in three patients with fulguration of the gastric leak edges with argon plasma coagulation, silver nitrate in the path and external orifice, and closure of the internal orifice with hemoclips and in one with an over-the-scope-clip). Only three patients underwent surgery, one due to clinical failure of sequential endoscopic therapy and two had direct surgery.

CONCLUSION

GCF occurs rarely after PEG removal in HNCPs. Medical therapy is usually effective and should be maintained for at least 8 weeks. Endoscopic therapy is an effective second-line option with and surgery rarely required.

P229 Primary cardiac angiosarcoma of the right atrium: a rare entity presenting with an atrial arrhythmia

Introduction

Primary cardiac tumors are rare entities and 75% are benign. Angiosarcoma is the most common malignant primary cardiac tumor.

We report the case of cardiac angiosarcoma presenting with an atrial arrhythmia.

Clinical case

A 39-year-old female patient with no past medical history presented to the emergency department with heart palpitations and atypical chest pain.

Electrocardiogram on admission showed atrial flutter with a heart rate of 153 beats per minute.

Laboratory analysis were performed showing elevated D-dimer levels (2210 ug/L).

A thoracic CT scan was performed, which ruled out pulmonary embolism, but showed multiple pulmonary nodules and a right atrial (RA) mass measuring 48 mm that could correspond to a thrombus or neoplasia.

The patient was admitted in the Cardiology ICU of our hospital and was started on beta-blocker and amiodarone with conversion to sinus rhythm. Additional exams were performed:

- Transthoracic echocardiogram (TTE) revealed an heterogenous 32,6 x 17,7 mm mass in the lateral wall of the RA with an adherent mobile mass near the tricuspid valve with 28 mm diameter (possible adherent thrombus).

- Cardiac magnetic resonance imaging confirmed a RA tumor with invasion of the atrial free wall and compression of the superior vena cava.

Due to the unclear etiology of the RA mass, ultrasound-guided intracardiac biopsy was performed. Pathological examination revealed spindle cell proliferation, consistent with the diagnosis of angiosarcoma. Immunohistochemical staining was positive for Vimentin, CD34 and CD31, with 70% Ki67 expression.

Later on, the patient developed melena with significant drop of hemoglobin levels, requiring daily red blood cell transfusions and anticoagulation had to be stopped.

The patient was transferred to the Internal Medicine ward and thoracic-abdomen-pelvis staging computed tomography (CT) scan showed a significant increase in the number of pulmonary nodules, bilateral ovarian masses, 4 hepatic nodules and ileum metastization.

During hospitalization, the patient developed right leg deep venous thrombosis and thoracic CT scan revealed bilateral pulmonary embolism.

After improvement of the clinical status, palliative chemotherapy was started and the patient was discharged, maintaining regular outpatient follow-up in the Oncology Department for 1 month.

Cardiac angiosarcoma generally presents in a late stage of the disease with metastatic involvement. When surgical treatment is not possible, despite agressive chemotherapy, the prognosis remains poor.

Abstract P229 Figure. Echocardiogram: right atrium mass

P1774 Myocardial work indices in adult patients with repaired aortic coartation

Background

Myocardial strain analysis is a tool that allows a more precise assessment of cardiac performance. However, strain is relatively load dependent. New tools have been developed, with afterload adjustment. It was our objective to assess myocardial work (MW) in patients with repaired aortic coartation (ACo).

Methods

Study of consecutive adult patients with corrected ACo submitted to a routine transthoracic echocardiogram in 2018 at our centre. Patients with an aortic valve prosthesis, more than mild aortic stenosis / regurgitation, with pacemakers, with other non-corrected congenital heart diseases (with the exception of bicuspid aortic valve) were excluded from the analysis. A semi-automated strain analysis was performed with speckle tracking technology and both global longitudinal strain (GLS) and MW were estimated using GE software™. Blood pressure was simultaneously measured in the patient’s right arm. We specifically assessed: Global Work Index (GWI), Global Constructive Work (GCW), Global Work Waste (GWW) and Global Work Efficiency (GWE)

Results

Twenty patients were included in the study, mean age of 36 ± 9 years, 30% males. Mean body surface area was 1.7. In this group of patients, 40% were hypertensives and in 55% there was a concomitant bicuspid aortic valve. Mean maximum aortic valve gradient was 11 mmHg and mean descending aortic gradient was 19 mmHg. Compared to recently published reference values for a normal population, repaired ACo patients had lower values of MW (Table). In multivariate linear regression analysis, independent predictors of GWI are systolic blood pressure (β=0.441) and let atrial volume indexed (LAVI) (β=0.507). For GCW, male gender (β=-0.605), LAVI (β=0.530) and diastolic blood pressure (β=-0.742). For GWE, the only predictor was LAVI (β=0.498) and no predictor was identified for GWW. The presence of bicuspid aortic valve, aortic valve gradient and descending aortic gradient did not have any influence in MW parameters, although higher aortic valve gradients were excluded from this study.

Conclusion

Adult patients with repaired ACo, present lower MW indices and the main determinant for that difference are LAVI and blood pressure. GWW is the most independent parameter.

Results Variable Reference population n = 226 Patients with repaired ACo n = 20 p-value GWI (mmHg%) 1896 ± 308 1782 ± 389 <0.001 GCW (mmHg%) 2232 ± 331 2154 ± 390 <0.001 GWW (mmHg%) 78 (53-122) 76 (56-197) <0.001 GWE (mmHg%) 96 (94-97) 95 (91-97) <0.001

P1313 A curious case of endocarditis

INTRODUCTION

Nonbacterial thrombotic endocarditis (NBTE) is a rare form ofnoninfectious endocarditis in which a small sterile vegetations deposited on the heart valves (mostly aortic and mitral).It has been reported in every age group, most commonly affecting patients between the fourth and eighth decades of life with no sex predilection. Patients with advanced malignancy and those with systemic lupus erythematosus are the most common populations affected by NBTE, and they are typically asymptomatic until embolization occurs. Here, we report a case of a female patient with rheumatoid arthritis whose diagnosis was made prior to any thromboembolic event.

CASE REPORT DESCRIPTION

An 83-year-old female patient with a 10-year history of rheumatoid arthritis, was admitted for urinary tract infection with exacerbation of chronic renal disease and decompensated heart failure of unknown etiology. On physical examination, she was febrile (38,3ºC) with a blood pressure of 130/70 and pulse rate of 90 beats/min. Cardiac auscultation revealed a sistolic murmur of grade 1/4 in the fifth left intercostal space. A joint deformities in the hands were noted, such as interosseous atrophy and ulnar deviation. To evaluate this new sistolic murmur,the transthoracic echocardiogramwas performed and showed a vegetation in the mitral valve. Then, a transesophageal echocardiogram(TEE) was requested to better characterize this vegetation, showing a vegetation of 19x4mm involving the posterior cusp of the mitral valve leaflet, with moderate mitral regurgitation,being the hypothesis of infective endocarditis (IE) proposed. There were no other significant abnormalities in the remaining echocardiogram. Empirical antibiotic therapy to IE was initiated. The TEE was repeated after 4 weeks of antibiotic therapy with maintenance of the referred vegetation and mention of a smaller one (10x2mm). Clinical investigation didn’t show any infectious process. Hence, the hypothesis of NBTE was established. Anti-coagulation therapy was started immediately. The NBTE lesion disappeared in the follow-up echocardiography three months post anti-coagulation treatment.

CONCLUSION

Although NBTE is an uncommon and difficult diagnosis that requires a high degree of suspicion, its timely diagnosis is essential since it allows the prevention of thromboembolic events, resulting in a positive impact on patients" quality of life. In addition, the existence of this clinical condition may allow the diagnosis of another underlying disease, such as a hidden neoplasia. Thus, the authors believe that the sharing of this clinical case will allow a reflection on this entity emphasizing the importance in the hypotheses of vegetation diagnosis. From the authors" knowledge, from the available medical literature, the clinical case presented is one of the few NBTEs described in patients with rheumatoid arthritis, with mitral valve involvement and whose diagnosis was made before any thromboembolic event.

Abstract P1313 Figure. A vegetation of mitral valve

P1728 Pulmonary hypertension in a pregnant Women - a rare anatomical aetiology

A 32 year old female patient, with a medical history of an ill-characterized Pulmonary Arterial Hypertension associated with congenital heart disease, lost in the follow up with no medical therapy, attended an emergency department for a gynecological hemorrhage at 16 weeks of pregnancy. Due to high maternity mortality risk, informed consent was obtained, and termination of pregnancy was performed. She was then referred to our pulmonary hypertension center.

At our center she had complains of fatigue with moderate intensity exertion, classified in a class II of the World Health Organization (WHO) classification, but was otherwise asymptomatic, with no history of dyspnea, angina or syncope. There was allusion to a self-limited episode of hemoptysis in the past. On physical examination she had an increased pulmonary component of the second heart sound, continuous heart murmur in left sternal border and no cyanosis (O2 peripheral saturation in the upper and lower limbs of 99% at room air).

The performed echocardiograms (both transthoracic and transesophageal) showed an estimated systolic pulmonary artery pressure of 120 mmHg with severe right ventricular hypertrophy and systolic dysfunction. There was dilatation of the trunk and right pulmonary artery. The left pulmonary artery was not seen.

Biochemical evaluation and viral serologies were unremarkable. The pulmonary function tests and the arterial blood gases were normal.

Cardiac MRI demonstrated the presence of a right aortic arch and a right patent arterial duct. An anomalous origin of the left pulmonary artery from the ascending thoracic aorta could be noted. Associated congenital cardiac defects were excluded.

A right heart catheterization confirmed the presence of severe pulmonary hypertension with mean pulmonary artery pressure of 86 mmHg and Pulmonary vascular resistance of 11 Wood Units. A large persistent arterial duct to the right pulmonary artery was confirmed with persistent left to right shunt. The left pulmonary artery was visualized when injection was performed in the aortic root. Coronary arteries were normally implanted.

The patient was started on Sildenafil and Bosentan (later replaced by Macitentan due to hepatic toxicity). After 3 years of follow up, there was an improvement in symptoms and in the 6 minutes walking test, remaining in a low risk category and on a WHO class I.

This case reports a very rare congenital abnormality identified in an adult patient. Despite the complex anatomy and severe pulmonary hypertension, the patient is reasonably well under medical therapy and close follow up.

Abstract P1728 Figure. Cardiac MRI Cine Sequences

Nonbacterial thrombotic endocarditis

An 83-year-old woman with a 10-year history of rheumatoid arthritis was admitted for urinary tract infection with exacerbation of chronic kidney disease and decompensated heart failure of unknown etiology. Transesophageal echocardiography (TEE) showed a vegetation involving the posterior mitral valve leaflet, and a hypothesis of infective endocarditis was proposed. Empirical antibiotic therapy was initiated. TEE was repeated after antibiotic therapy, and showed persistence of the original vegetation and revealed the presence of another, smaller vegetation. Clinical investigation revealed no infectious process, and so a diagnosis of nonbacterial thrombotic endocarditis (NBTE) was established. Anticoagulant therapy was started immediately. The NBTE lesion had disappeared on the follow-up echocardiogram two months after anticoagulant therapy.

[Tunica albuginea adenomatoid tumor. A challenging case managed conservatively]

The adenomatoid tumors are rare benign mesothelial lesions that in males affect mainly the epididymis. They account for over one third of paratesticular tumors, and the treatment of choice has been surgical excision. The origin in testicular parenchyma or the tunica albuginea is extremely rare. Clinical signs and imaging studies are often inconclusive in differentiate from a more common malignant intratesticular solid tumour, which can result in unnecessary orchiectomies. We present a case of adenomatoid tumor of tunica albuginea where clinical suspicion and intraoperative frozen section analysis led to a partial orchiectomy.

Anti-JCV antibody serostatus and longitudinal evaluation in a Portuguese Multiple Sclerosis population

Multiple Sclerosis (MS) treatment with natalizumab is associated with Progressive Multifocal Leukoencephalopathy (PML). The risk of PML being related to the anti-JCV antibody index is well established, but there is less known about seroconversion rates in natalizumab-treated patients and longitudinal variation in the anti-JCV antibody index. Our objective was to assess anti-JCV antibody prevalence in an MS population and to evaluate the evolution of the anti-JCV antibody index in natalizumab-treated patients. To assess anti-JCV antibody prevalence, we included all patients who had the anti-JCV antibody test in our consultation, regardless of the treatment. To evaluate the evolution of the anti-JCV antibody index and seroconversion, only natalizumab-treated patients with at least two samples were selected. Demographic characteristics were evaluated. From a total of 371 patients included, 68.19% (n=253) were seropositive for anti-JCV antibodies (JCV+). There was a significant difference in anti-JCV antibody seropositivity concerning gender (male 76.27% vs. female 64.43%, p=0.023), but not age. To evaluate seroconversion, 85 patients who were initially seronegative (JCV-) were selected. The annual rate of seroconversion in the first two years was stable, but after that there was a significant increase with treatment duration (ρ=0.90, p=0.037): in the first year it was 5.88% (n=5/85); in the second, 5.71% (n=4/70); in the third, 6.82% (n=3/44); in the fourth, 10.34% (n=3/29); and in the fifth, 15.0% (n=3/20). The mean index variability was higher in patients who experienced seroconversion (1.16±0.97), followed by JCV+ patients (0.44±0.48), compared to JCV- patients (0.08±0.05). In conclusion, anti-JCV antibody prevalence in our population is comparable to other reported cohorts. The seroconversion rate increased with treatment duration. We found a high fluctuation in the antibody index in JCV+ patients.

Titration with automatic continuous positive airway pressure in obstructive sleep apnea

BACKGROUND AND OBJECTIVE

Autotitrating positive airway pressure (APAP) is an accepted titration method to determine the optimal positive airway pressure (PAP), for the treatment of obstructive sleep apnea (OSA). The required duration of APAP monitoring to determine a fixed continuous positive airway pressure level still remains to be established. We aimed to evaluate the variation in PAP level, delivered by APAP devices, at different periods of treatment, to determine the APAP treatment duration required to reach an effective and stable PAP level.

METHODS

A cross-sectional study of 62 patients newly diagnosed with OSA were evaluated after 3 months of APAP therapy. APAP data corresponding to the first day (D1), first week (W1), seventh week (W7) and twelfth week (W12) under APAP therapy was collected. For the analysis of the pressure behaviour, the difference of P95th pressure level between W12 and W7 (P W12-W7), W12 and W1 (P W12-W1) and W12 and D1 (P W12-D1) was calculated.

RESULTS

There was a high correlation in P95th pressure level between D1 and W12 (r=0.771; p>0.0001), W1 and W12 (r=0.817; p>0.0001), and W7 and W12 (r=0.926; p>0.0001). This correlation progressively increased with APAP use. A significance difference was found in concordance between P W12-W7 and P W12-D1 (p=0.046) within the pressure range ±2cmH₂O. However there was no significant difference in concordance between P W12-W7 and P W12-W1.

CONCLUSIONS

One week of APAP therapy seems sufficient to determine an effective and stable PAP level, within the pressure range ±2cmH₂O.

Pancreas Burkitt primary lymphoma in pediatric age

We present an the case of an eight-year-old Portuguese boy with no history of traveling, admitted with non-specific abdominal pain. An analytic study revealed high levels of lipase and amylase. Ultrasound, abdominal computerized tomography (CT), and an abdominal magnetic resonance imaging (MRI), were performed. The imaging findings are suggestive of a pancreatic tumor which is an extremely rare entity in children. A biopsy was performed by opened surgery and identified a Burkitt lymphoma.

Interferon-induced psychosis: Myth or reality?

Introduction

Interferon combined with ribavirin is widely used to decrease the burden of Hepatitis C virus (HCV), but some serious side effects might limit its usefulness. There has been recently a growing awareness about neuropsychiatric complications of many drug treatments. Anecdotal case reports of HCV treatment induced psychosis were published but there seems to be no consensus about the causative relation and no systematic reviews were done to the date.

Objective

To describe a paradigmatic case that was managed as an iatrogenic psychotic episode following interferon associated with ribavirin.

Aim

Call attention to problems that interfere with the recognition, diagnosis and management of drugs induced psychosis.

Methods

Bibliographic research was conducted through the PubMed in the Medline library and clinical information was obtained through medical records and clinical interviews with the patient.

Results

A 50-year-old Brazilian woman, with a previous episode of postpartum depression, presented with paranoid psychosis six months after initiating HCV antiviral therapy. Psychotic symptoms consisted of persecutory delusions and auditory hallucinations and developed together with agitation and aggressive behavior. Psychiatric hospitalization was required and psychosis resolved with discontinuation of therapy and initiation of risperidone. Laboratory tests and brain images were of no help in the etiologic investigation.

Conclusions

There are many drugs known to possibly cause neuropsychiatric symptoms. It is the job of every physician to be aware of this hypothesis especially in cases with acute onset and atypical presentations.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Seven Years Of Occupational Psychiatry In A Portuguese Universitary Hospital

Introduction

Occupational psychiatry is the field of psychiatry that focuses on work, its importance in the lives of individuals and work organizations. It gained visibility in the 2000 decade, after the creation of the Academy of Occupational and Organizational Psychiatry. Following that trend, occupational psychiatry outpatient started in 2008 at Hospital de Santa Maria.

Objective

To describe the structure and functioning of that project; to characterize the population that has been referred to this subspecialty, as well as the main motives for referral; and to highlight some paradigmatic cases that deserve special attention.

Aims

Call attention to the importance of occupational psychiatry at the individual and institutional level.

Methods

All the patients ever referred to the occupational psychiatry consultation were considered for the analysis. Clinical information was obtained through medical records and interviews with the patients. Bibliographic research was conducted through the PubMed in the Medline library.

Results

In our hospital, the prototype patient referred to occupational psychiatry is a middle-aged woman working as a medical assistant. The most frequent motives for referral were related to difficulties in accomplishing job duties and definite psychiatric diagnosis corresponded more often to the common mental disorders (anxiety, depression and adjustment disorders). At the institutional level, the initiative was received with great enthusiasm.

Conclusions

As Freud stated “To Love and work are the cornerstone of our humanness”, in line with that we consider that occupational psychiatry should be taken as a priority in what concerns to mental health policies.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Dissociative disorder – unraveling the mystery

Introduction

Dissociative disorders are among the most enigmatic and controversial psychiatric pathologies. In the last decades, great interest has emerged in understanding its pathophysiology, nonetheless, problems in recognition and management of these disorders are still challenging the psychiatric community.

Objectives

We describe a paradigmatic case of a dissociative disorder illustrating the “choice” of dissociation as a strategy for coping with a traumatic reality.

Aim

Call attention to problems that interfere with the recognition, diagnosis and management of dissociative disorders.

Methods

Bibliographic research was conducted through the PubMed in the Medline library and clinical information was obtained through medical records and clinical interviews with the patient.

Results

A 51-year-old Brazilian woman with no psychiatric history presented to the psychiatric outpatient care with apparent dissociative symptoms, these consisted of amnesia for episodes of agitation and aggressive behavior that occurred mainly at bed time. She had been previously on general practice and neurology consultations but none organic diagnose was made. Already in psychiatry, it was recognized that those symptoms developed together after a car accident and the beginning of a romantic relationship. It was also recognized that she has sexual dysfunction and a history of sexual abuse by a family member during her childhood, a known risk factor to dissociative disorders.

Conclusions

Skepticism and lack of understanding might be the reason for late psychiatric referral after the realization of various expensive and time-consuming medical exams. Improving the recognition of dissociative disorders will conduce not only to better clinical outcomes but also improve cost effectivity of medical interventions.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Effect of waterfalls and the flood pulse on the structure of fish assemblages of the middle Xingu River in the eastern Amazon basin

The structure of fish assemblages in Neotropical rivers is influenced by a series of environmental, spatial and/or temporal factors, given that different species will occupy the habitats that present the most favourable conditions to their survival. The present study aims to identify the principal factors responsible for the structuring of the fish assemblages found in the middle Xingu River, examining the influence of environmental, spatial, and temporal factors, in addition to the presence of natural barriers (waterfalls). For this, data were collected every three months between July 2012 and April 2013, using gillnets of different sizes and meshes. In addition to biotic data, 17 environmental variables were measured. A total of 8,485 fish specimens were collected during the study, representing 188 species. Total dissolved solids, conductivity, total suspended matter, and dissolved oxygen concentrations were the variables that had the greatest influence on the characteristics of the fish fauna of the middle Xingu. Only the barriers and hydrological periods played a significant deterministic role, resulting in both longitudinal and lateral gradients. This emphasizes the role of the connectivity of the different habitats found within the study area in the structuring of its fish assemblages.