Antônio Carlos Pereira-Barreto

Duration of symptoms in patients with infective endocarditis

Despite progress in the management of infective endocarditis, delays in diagnosis or prior antimicrobial treatment may adversely influence the symptom duration and outcome. The duration of symptoms in patients with infective endocarditis was studied in 683 cases among 653 patients with 703 episodes of the disease; patients were hospitalized within 10 days of symptom onset in 169 (24.7%) cases. Antimicrobial therapy before hospital admission was administered to 257 (36.5%) patients. Overall mortality was 25.6%. Symptom duration was longer when antimicrobials were administered before diagnosis (58.8+/-78.1 vs. 44.8+/-54.9 days), when vegetations were detected on echocardiogram (53.5+/-68.2 vs. 38.8+/-47.3) and among patients admitted before 1990 (42.3+/-67.1 vs. 54.2+/-62.4 days). Symptom duration was shorter in patients with prosthetic valve endocarditis (26.8+/-34.2 vs. 59.3+/-71.6 days). In 54 (26.5%) episodes of prosthetic valve endocarditis, patients had symptoms for more than 30 days. Staphylococcus aureus was the most frequent agent among patients with symptoms up to 10 days (41.2%) and Streptococcus among those with symptoms over 20 days (53.9%). Symptom duration did not significantly differ in regard to medical (51.3+/-69.2 days) or surgical (46.7+/-55.7 days) treatment. Mortality increased as symptom duration decreased and was highest for patients who experienced symptoms for less than 10 days (36.1%). In some patients medical care may be delivered relatively late in the course of infective endocarditis. Administration of antibiotics previous to hospital admission increased duration of symptoms, and cardiac valve prosthesis, staphylococcal infection and death were associated with more acute disease.

Esophageal manometry and vectorcardiography study of asymptomatic patients with Chagas' disease

A forma indeterminada da Doenca de Chagas e caracterizada por sorologia positiva com ausencia de manifestacoes clinicas, na presenca de resultados normais aos exames radiologico do tubo digestivo e eletrocardiografico. No presente trabalho, os autores estudam simultaneamente o esofago e o coracao, nos mesmos individuos. Treze adultos com diagnostico de forma indeterminada da Doenca de Chagas e nove adultos controles foram submetidos ao exame vetorcardiografico e a manometria esofagica em condicoes basais e sob estimulo com cloridrato de betanecol (0,08 mg/kg p.c). No grupo controle nenhum dos individuos apresentou concomitância de alteracoes esofagicas e cardiacas, enquanto no grupo chagasico 92,3% dos pacientes apresentaram exames concomitantemente alterados. Concluem que os pacientes estudados apresentam evidencias de desnervacao parassimpatica manifestada por alteracoes simultâneas esofagicas e cardiacas.

Effects of chlorthalidone and diltiazem on myocardial ischemia in elderly patients with hypertension and coronary artery disease

OBJECTIVE Antihypertensive therapy with thiazides decreases coronary events in elderly patients. However, the influence of diuretics on myocardial ischemia has not been fully investigated. The aim of this study was to compare the effect of chlorthalidone and diltiazem on myocardial ischemia. METHODS Following a randomized, double-blind, crossover protocol, we studied 15 elderly hypertensive patients aged 73.6+/-4.6 years with myocardial ischemia. All patients had angiographically documented coronary artery disease. We measured patients using 48- hour ambulatory electrocardiogram monitoring and exercise testing. After a 2-week period using placebo, patients received chlorthalidone or diltiazem for 4 weeks. RESULTS Both treatments lowered systolic and diastolic blood pressures. The number of ischemic episodes on ambulatory electrocardiogram recordings was reduced with the use of chlorthalidone (2.5+/-3.8) and diltiazem (3.2+/-4.2) when compared with placebo (7.9+/-8.8; p<0.05). The total duration of ischemic episodes was reduced in both treatments when compared with placebo (chlorthalidone: 19.2+/-31.9min; diltiazem: 19.3+/-29.6min; placebo: 46.1+/-55.3min; p<0.05). CONCLUSION In elderly hypertensive patients with coronary artery disease, chlorthalidone reduced myocardial ischemia similarly to diltiazem. This result is consistent with epidemiological studies and suggests that reduction of arterial blood pressure with thiazide therapy plays an important role in decreasing myocardial ischemia.

Resultados da cardiomioplastia no tratamento da cardiomiopatia dilatada

A cardiomioplastia tem sido proposta como uma alternativa ao transplante cardiaco no tratamento das cardiomiopatias isquemicas ou dilatadas. No periodo de maio de 1988 a outubro de 1990, 16 pacientes portadores de cardiomiopatia dilatada foram submetidos a cardiomioplastia no Instituto do Coracao. Dez pacientes estavam em classe funcional III e seis em classe IV. Nao houve obitos no periodo de pos-operatorio imediato. O tempo medio de seguimento foi de 16,9 ± 2,5 meses e a sobrevida atuarial foi 74% no 1o ano e 64,8% no 2o ano apos a cardiomioplastia, sendo influenciada pela ma evolucao dos pacientes operados com diâmetro de ventriculo esquerdo maior do que 80 mm. Esses valores foram superiores, contudo, a sobrevida de um e dois anos de 39,5 e 29,6%, respectivamente, apresentada pelo grupo controle de 20 pacientes mantidos clinicamente (p = 0,06). Cinco dos 11 pacientes em seguimento apos a cardiomioplastia, retornaram a classe funcional I e seis estao em classe II. Aos seis meses de pos-operatorio, foi documentada a elevacao da fracao de ejecao do ventriculo esquerdo de 20,1 ± 3,8 para 26 ± 7,8% pelo estudo radioisotopico (p < 0,01), sendo que esse parâmetro se alterou principalmente em pacientes com menor dilatacao da câmara ventricular esquerda. A Doppler-ecocardiografia mostrou que o encurtamento segmentar do ventriculo esquerdo se elevou de 12 ± 3,1 para 17,8 ± 2,3% (p < 0,01), enquanto que o volume sistolico aumentou de 23,6 ± 5,2 para 32,3 ± 7,9 ml (p < 0,01). Elevacoes semelhantes do indice sistolico, associados a queda da pressao em territorio pulmonar, foram tambem observadas pelo cateterismo cardiaco. O estudo ergoespirometrico documentou o aumento do consumo maximo de oxigenio de 14,9 ± 3,9 para 18,2 ± 3,4 ml/kg/min (p < 0,05). Um ano e aos 18 meses apos a operacao, as alteracoes decorrentes da cardiomioplastia permaneceram essencialmente as mesmas. Em conclusao, a cardiomioplastia melhora a funcao ventricular esquerda, reverte o quadro congestivo e melhora a sobrevida de pacientes portadores de cardiomiopatia dilatada. Fatores como a existencia de grande cardiomegalia podem, contudo, influenciar a evolucao tardia dos pacientes submetidos a este procedimento.

Tratamento cirúrgico da endomiocardiofibrose: substituição valvar versus técnicas conservadoras

Sixty-six (66 patients) with endomyocardial fibrosis underwent surgical treatment at the Heart Institute between January 1978 and June 1990. A study involving two subgroups was designed with the aim to compare the operative techniques; 1) patients submitted to endocardiectomy and valvar substitution; and 2) patients submitted to endocardiectomy and valvoplasty. Clinical, radiologic, hemodynamic, surgical and postoperative parameters were included in the protocol. It is a retrospective study, an statistical analysis was performed using Pearsons X2 test and Loog-Rank test. At this time, the comparative analysis does not reveal significant statistical differences between the two subgroups, both regarding nosocomial mortality and late survival, however comparison of the actuarial survival curves allows to identify a tendency towards improvement, with decrease in the nosocomial mortality and a great late survival, when the conservative technique for surgical treatment of endomocardial fibrosis is used. Therefore, endocardiectomy associated to atrioventricular valvoplasty for surgical treatment of the patients with endomyocardial fibrosis is recommended.

Limitações da cardiomioplastia no tratamento das cardiomiopatias

A cardiomioplastia melhora a funcao ventricular esquerda e a sobrevida de pacientes portadores de cardiomiopatias severas. O objetivo deste estudo e identificar os fatores que influenciaram os resultados da cardiomioplastia em 22 pacientes operados entre maio de 1988 e dezembro de 1991. Todos os pacientes estavam em classe funcional III ou IV, apesar do uso de terapeutica clinica otimizada. Dezoito pacientes tinham diagnostico de cardiomiopatia idiopatica, a cardiomiopatia era chagasica em 2 e isquemica em 2. Nao houve obitos no periodo pos-operatorio imediato e os pacientes foram seguidos por um periodo medio de 20,5 meses. Nove pacientes faleceram tardiamente e a sobrevida atuarial foi 76,1 % no primeiro ano e 63,8% no segundo ano de seguimento. Seis pacientes estao, atualmente, em classe funcional I, e 7 em classe II. A mortalidade e a manutencao dos sintomas, no primeiro ano pos cardiomioplastia, foi relacionada a ocorrencia de tromboembolismo pulmonar e a progressao da insuficiencia cardiaca em pacientes com alteracoes isquemicas do enxerto muscular, no pos-operatorio imediato (pico de liberacao plasmatica da creatinoquinase > 1500 U.I.) (p=0,03). Paralelamente, aelevacao da fracao de ejecao do ventriculo esquerdo, documentada aos seis meses de seguimento, foi mais importante em pacientes que apresentaram valores menores de liberacao da creatinoquinase apos a operacao (p=0,02). Ja o tamanho da cavidade ventricular esquerda pareceu influenciar a variacao da fracao de ejecao apenas quando foram retirados da analise os pacientes com comprometimento importante do enxerto muscular (p=0,06). Apesar de nao ter havido influencia da classe funcional pre-operatoria sobre esse parâmetro e sobre a evolucao clinica, no primeiro ano de seguimento, os pacientes operados em classe funcional IV apresentaram uma sobrevida, no segundo ano de pos-operatorio, significativamente inferior a dos pacientes operados em classe III (33,3% versus 78,1%, p=0,04). Em conclusao, a melhora da funcao ventricular esquerda e a melhor evolucao clinica apos a cardiomioplastia podem ser limitadas pela ocorrencia de lesao isquemica do enxerto muscular. A condicao clinica pre-operatoria, bem como o grau de dilatacao das câmaras ventriculares, sao, tambem, fatores importantes para o sucesso deste procedimento no tratamento das cardiomiopatias.

Dez anos de cirurgia dos aneurismas e dissecções crônicas da aorta ascendente no Instituto do Coração - FMUSP

From January 1980 to Dezember 1990, 109 patients, 86 males and 16 females, ranging in age from 12 to 70 years, were operatated on for aneurysms or chronic dissections of the ascending aorta, associated or not to aortic valve insufficiency. Thirty-four patients were in New York Heart Association class IV, 51 in class III, 18 in class II and six in class I. Fifty-two patients had chronic aortic dissection, 29 annulo-aortic ectasia, 10 saaular aneurysm, remaining 8 ethiologics. The early mortality was 12.8% (14 deaths). Twenthy-seven patients were lost for follow-up during a period ranging from three months to 10 years (average 82 months). The late mortality was 13.4% (11/82). Among the 72 patients survivors, clinicai improvement was observed in the majority of patients (90.5% are in class I or II). Among the several operative techniques, the Bentatt and De Bono showed better early survival and is preferable option when indicated. The actuarial curve showed a 70% survival for the whole group, after 120 months. The results observed in terms of survival and clinical improvement suggest that surgery is the treatment of choice for aneurysms and chronic dissections of ascending aorta.

Endomiocardiofibrose: resultados do tratamento cirúrgico com conservação das valvas atrioventriculares

Between April 1988 and January 1991 we operated on 25 consecutive patients with endomyocardial fibrosis (EMF) with an approach to preserve the atrioventricular valves. Nineteen patients were females and six males. Their ages ranged from 11 to 5 years, with an average of 40.6 years. Seventeen patients had biventricular involvement, six had involvement of the left ventricle and only two patients had an isolated lesion of the right ventricle. All of them were in advanced stage of heart failure, 19 of which were in class IV of the NYHA, and six were in class III. Prior to the operation, tricuspid insufficiency was present in 24 patients and mitrai insufficiency was present in 22 patients. All the patients were operated on with the support of extracorporeal circulation and systemic hipothermia of 28oC. Intermitent aortic cross-clamping was used so as to permit better exposition of the ventricular cavities. The fibrosis of the right ventricle was always removed through the tricuspid valve, while the fibrosis of the left ventricle was removed through a small apical left ventriculotomy in all the patients. An DeVegas annuloplasty of the tricuspid valve was necessary in all the patients with tricuspid insuffiency. On the other hand, seven patients had spontaneous correction of the ventricle insufficiency after the removal of the fibrosis of the left ventricle, while fifteen needed an annuloplasty. There was one (4.0%) in-hospital death and no late deaths. All patients experienced clinical improvement and are in NYHA functional class I or II.

Evolução tardia do transplante cardíaco na doença de Chagas: long-term evolution in cardiac transplantation

Nas formas cardiacas da doenca de Chagas que evoluem com insuficiencia cardiaca refrataria ao tratamento clinico, o transplante e a unica alternativa, ao lado da cardiomioplastia. Os autores apresentam a evolucao tardia de seis pacientes com miocardiopatia chagasica terminal submetidos a transplante cardiaco ortotopico. O periodo medio de observacao foi de 25,2 meses. O diagnostico de reativacao da doenca de Chagas apoiou-se na observacao clinica, na investigacao laboratorial do parasita, nas biopsias endomiocardicas e dos nodulos de subcutâneo. A analise dos resultados demonstra que: 1) os testes laboratoriais mostraram-se ineficazes no diagnostico da reativacao da doenca, sendo que as biopsias mostraram maior indice de positividade; 2) a pulsoterapia com corticoide predispoe a reativacao; 3) a doenca linfoproliferativa apresenta alta incidencia na doenca de Chagas, sendo a principal complicacao tardia. Possivelmente, o benzonidazol apresente seu efeito oncogenico potencializado. Tendo em vista o carater endemico da doenca e a falta de alternativa terapeutica, tornou-se obrigatoria a analise do esquema imunossupressor, do tratamento da reativacao e a maior experiencia clinica, para posicoes mais definidas.