Amilcar O. Mocelin

Sildenafil effects on exercise, neurohormonal activation, and erectile dysfunction in congestive heart failure: a double-blind, placebo-controlled, randomized study followed by a prospective treatment for erectile dysfunction.

Background—Erectile dysfunction (ED) is common in patients with congestive heart failure (CHF). ED reduces quality of life, and it may affect compliance, thereby impairing the success of CHF treatment. Methods and Results—In the first phase (fixed-dose double-blind, randomized, placebo-controlled, two-way crossover study), we studied in 23 men with CHF the effects of 50 mg sildenafil on exercise and neurohormonal activation. Patients underwent a treadmill 6-minute cardiopulmonary walking (6′WT) test followed by a maximal cardiopulmonary exercise test (ET). In the second phase, patients received sildenafil, taken as required for ED. Sildenafil reduced the heart rate (HR) (bpm) before the 6′WT (from 75±15 to 71±14, P =0.02) and ET (from 75±15 to 71±15, P =0.02); the systolic blood pressure (mm Hg) before the 6′WT (from 116±18 to 108±18, P =0.004) and ET (from 116±15 to 108±17, P =0.001); the diastolic blood pressure before the 6′WT (from 69±9 to 63±11, P =0.01) and ET (from 70±8 to 65±10, P =0.004); and the Ve/Vco2 slope during the 6′WT (from 32±7 to 31±6, P =0.04) and ET (from 33±8 to 31±5, P =0.03). Sildenafil attenuated the HR increment during the 6′WT (P =0.003) and ET (P =0.000). Sildenafil increased the peak ˙ o2 from 16.6±3.4 to 17.7±3.4 mL/kg per min (P =0.025) and the exercise time from 12.3±3.4 to 13.7±3.2 minutes (P =0.003). Sildenafil improved most scores of International Index of Erectile Function. Conclusions—Sildenafil was tolerated and effective for ED treatment in CHF, and improved the exercise capacity. The reduction of HR during exercise with sildenafil could theoretically decrease the myocardial oxygen consumption during sexual activity.

Insuficiência cardíaca descompensada na unidade de emergência de hospital especializado em cardiologia

FUNDAMENTO: Estudos nacionais em insuficiencia cardiaca descompensada (ICD) sao fundamentais para o entendimento dessa afeccao em nosso meio. OBJETIVO: Determinar as caracteristicas dos pacientes com ICD em uma unidade de emergencia. METODOS: Examinamos prospectivamente 212 pacientes com o diagnostico de insuficiencia cardiaca descompensada, os quais foram admitidos em uma unidade de emergencia (UE) de hospital especializado em cardiologia. Estudaram-se variaveis clinicas, apresentacao e causas de descompensacao. Em 100 pacientes, foram analisados exames complementares, prescricao de drogas vasoativas, tempo de internacao e letalidade. RESULTADOS: Entre os pesquisados houve predominio de homens (56%) e a etiologia isquemica foi a mais frequente (29,7%), apesar da elevada frequencia de valvares (15%) e chagasicos (14,7%). A forma de apresentacao e a causa de descompensacao mais comuns foram, respectivamente, congestao (80,7%) e ma adesao/medicacao inadequada (43,4%). Na subanalise dos 100 pacientes, a disfuncao sistolica foi a mais frequente (55%), uso de drogas vasoativas ocorreu em 20% e a letalidade foi de 10%. Analise comparativa entre os pacientes que receberam alta e faleceram durante a internacao ratificou alguns criterios de mau prognostico: pressao arterial sistolica reduzida, baixo debito associado a congestao, necessidade de droga vasoativa, fracao de ejecao do ventriculo esquerdo reduzida, diâmetro diastolico do ventriculo esquerdo (DDVE) aumentado e hiponatremia. CONCLUSAO: Este trabalho apresenta dados sobre o perfil da populacao com insuficiencia cardiaca descompensada atendida na unidade de emergencia de um hospital especializado em cardiologia da regiao sudeste do Brasil. Na avaliacao inicial destes pacientes dados clinico-hemodinâmicos e de exames complementares fornecem subsidios para estratificacao de risco, auxiliando na decisao de internacao e estrategias terapeuticas mais avancadas.

Granulocyte-colony stimulating factor or granulocyte-colony stimulating factor associated to stem cell intracoronary infusion effects in non ischemic refractory heart failure.

We prospectively studied bone marrow stem cell (BMSC) therapy in 23 patients with non ischemic refractory heart failure(HF) in comparison with a HF control group with 17 patients. BMSC patients randomly underwent granulocyte-colony stimulating factor (G-CSF) administration (14 patients) or G-CSF associated to BMSC intracoronary infusion (eight patients). After the first month all BMSC patients received G-CSF with one-month interval between each one. CD34+ cell peaks (per mm(3)) in BMSC patients were 19+/-12 and in normal control 60+/-20 (p=0.003). In BMSC patients after the 1st G-CSF left ventricular(LV) ejection fraction (EF) increased from 21.4+/-4.7% to 23.6+/-7.7%(p=.048), peak VO(2) (ml/kg/min) from 9.9+/-2.4 to 11.6+/-3 (p=.04), functional class and quality of life improved whereas in the HF control group LVEF, RFEF and functional class were unchanged. Both BMSC subgroups presented improvement of LV function evaluated by DTI velocities. Evaluations after the first month in BMSC patients showed improvements in LVEF (p=.001), right VEF (p=0.01), DTI velocities (p=.009), peak VO(2) (p=0.04), functional class (p<0.001) and quality of life (p<0.001). In conclusion, CD34+ mobilization is impaired in HF. Stem cell therapy can improve HF. Randomized trials should be developed to confirm our results.

Can the Cardiopulmonary 6-Minute Walk Test Reproduce the Usual Activities of Patients with Heart Failure?

OBJECTIVE The 6-minute walk test is an way of assessing exercise capacity and predicting survival in heart failure. The 6-minute walk test was suggested to be similar to that of daily activities. We investigated the effect of motivation during the 6-minute walk test in heart failure. METHODS We studied 12 males, age 45 +/- 12 years, ejection fraction 23 +/- 7%, and functional class III. Patients underwent the following tests: maximal cardiopulmonary exercise test on the treadmill (max), cardiopulmonary 6-minute walk test with the walking rhythm maintained between relatively easy and slightly tiring (levels 11 and 13 on the Borg scale) (6EB), and cardiopulmonary 6-minute walk test using the usual recommendations (6RU). The 6EB and 6RU tests were performed on a treadmill with zero inclination and control of the velocity by the patient. RESULTS The values obtained in the max, 6EB, and 6RU tests were, respectively, as follows: O2 consumption (ml.kg-1.min-1) 15.4 +/- 1.8, 9.8 +/- 1.9 (60 +/- 10%), and 13.3 +/- 2.2 (90 +/- 10%); heart rate (bpm) 142 +/- 12, 110 +/- 13 (77 +/- 9%), and 126 +/- 11 (89 +/- 7%); distance walked (m) 733 +/- 147, 332 +/- 66, and 470 +/- 48; and respiratory exchange ratio (R) 1.13 +/- 0.06, 0.9 +/- 0.06, and 1.06 +/- 0.12. Significant differences were observed in the values of the variables cited between the max and 6EB tests, the max and 6RU tests, and the 6EB and 6RU tests (p < 0.05). CONCLUSION Patients, who undergo the cardiopulmonary 6-minute walk test and are motivated to walk as much as they possibly can, usually walk almost to their maximum capacity, which may not correspond to that of their daily activities. The use of the Borg scale during the cardiopulmonary 6-minute walk test seems to better correspond to the metabolic demand of the usual activities in this group of patients.

Correção de comunicação interatrial com cirurgia minimamente invasiva em pacientes pediátricos

Visando um melhor resultado estetico pode-se optar por tecnicas minimamente invasivas na correcao cirurgica das cardiopatias congenitas. Entre os acessos utilizados realizamos a esternotomia parcial em 20 pacientes pediatricos para correcao de comunicacao interatrial (CIA). Apos analise deste grupo de pacientes concluimos tratar-se de tecnica cirurgica segura, de facil execucao e com otimo resultado estetico. Nao ocorreram complicacoes especificas relacionadas ao acesso cirurgico.

Operação de Senning com a utilização de tecidos do próprio paciente

O grande atrativo da Operacao de Senning como descrita originalmente e a utilizacao das paredes do proprio atrio do paciente para a realizacao dos tuneis venosos. A atrioseptostomia por balao, utilizada atualmente na grande maioria dos casos de transposicao das grandes arterias (TGA), cria grandes comunicacoes interatriais. Com isso, e necessario a utilizacao de enxertos biologicos ou sinteticos (Dacron, Teflon e pericardio bovino) na septacao do atrio esquerdo. Doze criancas consecutivas, com idades de 5 meses a 4 anos (media = 20 meses), foram submetidas a Operacao de Senning com a utilizacao de tecidos do proprio paciente. O diagnostico era de TGA em 9, TGA com comunicacao interventricular (CIV) em 1, TGA com estenose pulmonar valvar discreta em 1, TGA com justaposicao das auriculas em 1 caso e todas as criancas foram submetidas a atrioseptostomia com balao no periodo neonatal. Em 5 casos foi utilizada a auricula esquerda aberta e invertida para a septacao interatrial, 1 com inversao e, em 5, inversao com abertura da auricula esquerda e uso do proprio pericardio in situ para a realizacao do tunel das veias pulmonares, devido as reduzidas dimensoes do atrio direito (1 caso de justaposicao das auriculas). O tempo de internacao variou de 10 a 24 dias (media 15 dias), sendo que o periodo de pos-operatorio variou de 7 a 22 dias (media 12 dias). Nao houve obitos no periodo de internacao hospitalar. O seguimento no pos-operatorio foi de 8 a 34 meses (media 23 meses) e todos os pacientes apresentaram boa evolucao clinica. O ecocardiograma realizado no periodo de internacao e no seguimento pos-operatorio nao evidenciou sinais de obstrucao ao fluxo nos tuneis intracardiacos. O uso de tecidos do proprio paciente in situ, com potencial possibilidade de crescimento, resgata a vantagem principal da tecnica originalmente descrita por Senning.