Dirceu Rodrigues Almeida

I Latin American Guidelines for the diagnosis and treatment of Chagas' heart disease: executive summary.

Jadelson Pinheiro de Andrade, Jose Antonio Marin Neto, Angelo Amato Vincenzo de Paola, Fábio Vilas-Boas, Glaucia Maria Moraes Oliveira, Fernando Bacal, Edimar Alcides Bocchi, Dirceu Rodrigues Almeida, Abilio Augusto Fragata Filho, Maria da Consolação Vieira Moreira, Sergio Salles Xavier, Wilson Alves de Oliveira Junior, João Carlos Pinto Dias et al Sociedade Brasileira de Cardiologia, Rio de Janeiro, RJ Brasil

Surgical Treatment of Acute Type B Aortic Dissection Using an Endoprosthesis (Elephant Trunk)

BACKGROUND The surgical treatment of acute complicated type B aortic dissection continues to be a challenge and is still associated with high morbidity and mortality rates. METHODS Seventy consecutive patients with an acute type B aortic dissection underwent an elephant trunk procedure through a median sternotomy during deep hypothermic circulatory arrest. An endoprosthesis that was 22 to 24 mm in diameter was inserted through an incision in the arch and held in place with only proximal sutures. RESULTS The mean arrest time was 31.4 +/- 8.7 minutes, and it was possible to adequately position the endoluminal graft in every patient. The procedure was done in association with other procedures in 13 patients. There were six in-hospital deaths not related to the endoprosthesis, and four late deaths. Late reoperation was necessary in 6 patients to manage leakage at the proximal suture line. CONCLUSIONS The insertion of an endoprosthesis through the arch for the management of a complicated acute type B dissection has several advantages over the conventional thoracotomy approach. The hospital mortality rate in this series of 70 patients was 20%, and the actuarial 5-year survival rate was 62.5%. We consider the elephant trunk procedure the treatment of choice in patients with type B acute dissections, regardless of whether the dissection is complicated or not.

Molecular Profiling Improves Diagnoses of Rejection and Infection in Transplanted Organs

The monitoring of transplanted hearts is currently based on histological evaluation of endomyocardial biopsies, a method that is fairly insensitive and that does not always accurately discriminate between rejection and infection in the heart. Accurate diagnosis of rejection and infection is absolutely crucial, however, as the respective treatments are completely different. Using microarrays, we analyzed gene expression in 76 cardiac biopsies from 40 heart recipients undergoing rejection, no rejection, or Trypanosoma cruzi infection. We found a set of genes whose expression patterns were typical of acute rejection, and another set of genes that discriminated between rejection and T cruzi infection. These sets revealed acute rejection episodes up to 2 weeks earlier, and trypanosome infection up to 2 months earlier than did histological evaluation. When applied to raw data from other institutions, the 2 sets of predictive genes were also able to accurately pinpoint acute rejection of lung and kidney transplants, as well as bacterial infections in kidneys. In addition to their usefulness as diagnostic tools, the data suggest that there are similarities in the biology of the processes involved in rejection of different grafts and also in the tissue responses to pathogens as diverse as bacteria and protozoa.

Pre- and post-transplant anti-myosin and anti–heat shock protein antibodies and cardiac transplant outcome

BACKGROUND The purpose this study was to investigate the relationship of anti-myosin and anti-heat shock protein immunoglobulin G (IgG) serum antibodies to the original heart disease of cardiac transplant recipients, and also to rejection and patient survival after cardiac transplantation. METHODS Anti-myosin and anti-heat shock protein (anti-hsp) IgG antibodies were evaluated in pre-transplant sera from 41 adult cardiac allograft recipients and in sequential post-transplant serum samples from 11 recipients, collected at the time of routine endomyocardial biopsies during the first 6 months after transplantation. In addition, the levels of these antibodies were determined from the sera of 28 healthy blood donors. RESULTS Higher anti-myosin antibody levels were observed in pre-transplant sera than in sera from normal controls. Moreover, patients with chronic Chagas heart disease showed higher anti-myosin levels than patients with ischemic heart disease, and also higher levels, although not statistically significant, than patients with dilated cardiomyopathy. Higher anti-hsp levels were also observed in patients compared with healthy controls, but no significant differences were detected among the different types of heart diseases. Higher pre-transplant anti-myosin, but not anti-hsp, levels were associated with lower 2-year post-transplant survival. In the post-transplant period, higher anti-myosin IgG levels were detected in sera collected during acute rejection than in sera collected during the rejection-free period, whereas anti-hsp IgG levels showed no difference between these periods. CONCLUSIONS The present findings are of interest for post-transplant management and, in addition, suggest a pathogenic role for anti-myosin antibodies in cardiac transplant rejection, as has been proposed in experimental models of cardiac transplantation.

Lung and myocardial thallium-201 kinetics in resting patients with congestive heart failure: Correlation with pulmonary capillary wedge pressure

Increased lung thallium-201 activity occurs with exercise in patients with severe coronary artery disease as a result of increased pulmonary capillary wedge pressure. No study has shown resting lung kinetics in chronic congestive heart failure. To better understand the relationship between lung and myocardial thallium uptake and pulmonary capillary wedge pressure, this study was performed. Resting lung and myocardial thallium uptake, expressed as a ratio, were compared with simultaneous pulmonary capillary wedge pressure in 16 patients with congestive heart failure and cardiomyopathy, all New York Heart Association class IV. There were no variations in pulmonary capillary wedge pressure throughout the study protocol. There was a significant reduction in the lung/myocardium thallium ratio from 10 to 60 minutes (0.83 +/- 0.30 to 0.59 +/- 0.17; p less than 0.001). At 60 minutes after thallium injection there was a linear correlation between the lung/myocardium ratio and capillary wedge pressure with an r value of 0.62 (p less than 0.01). Thus thallium-201 washout is rapid despite persistence of pulmonary capillary wedge pressure elevation, indicating that clearance does not imply resolution of congestive heart failure. In addition, a significant but imprecise correlation was found between capillary pressure and the lung/myocardium ratio. Rapid changes in lung activity during the early postinjection period may limit the clinical use of the lung/myocardium ratio.

Endoscopic placement of stents in aneurysms of the descending thoracic aorta

This is a case of a patient with two saccular aneurysms in the descending aorta. Two self-expanding stents were inserted through an opening in the aortic arch, guided by the use of an Olympus endoscope, under profound hypothermia and total circulatory arrest. The bloodless field made possible the identification of the main thoracic branches, facilitating the positioning and deployment of both stents. Immediate postoperative recovery was excellent.

I Diretriz Latino-Americana para o diagnóstico e tratamento da cardiopatia chagásica: resumo executivo

Jadelson Pinheiro de Andrade, Jose Antonio Marin Neto, Angelo Amato Vincenzo de Paola, Fábio Vilas-Boas, Glaucia Maria Moraes Oliveira, Fernando Bacal, Edimar Alcides Bocchi, Dirceu Rodrigues Almeida, Abilio Augusto Fragata Filho, Maria da Consolação Vieira Moreira, Sergio Salles Xavier, Wilson Alves de Oliveira Junior, João Carlos Pinto Dias et al Sociedade Brasileira de Cardiologia, Rio de Janeiro, RJ Brasil

Sleep-Disordered Breathing Exacerbates Muscle Vasoconstriction and Sympathetic Neural Activation in Patients with Systolic Heart Failure

Background—Sleep-disordered breathing (SDB) is common in patients with heart failure (HF), and hypoxia and hypercapnia episodes activate chemoreceptors stimulating autonomic reflex responses. We tested the hypothesis that muscle vasoconstriction and muscle sympathetic nerve activity (MSNA) in response to hypoxia and hypercapnia would be more pronounced in patients with HF and SDB than in patients with HF without SDB (NoSBD). Methods and Results—Ninety consecutive patients with HF, New York Heart Association functional class II–III, and left ventricular ejection fraction ⩽40% were screened for the study. Forty-one patients were enrolled: NoSDB (n=13, 46 [39–53] years) and SDB (n=28, 57 [54–61] years). SDB was characterized by apnea–hypopnea index ≥15 events per hour (polysomnography). Peripheral (10% O2 and 90% N2, with CO2 titrated) and central (7% CO2 and 93% O2) chemoreceptors were stimulated for 3 minutes. Forearm and calf blood flow were evaluated by venous occlusion plethysmography, MSNA by microneurography, and blood pressure by beat-to-beat noninvasive technique. Baseline forearm blood flow, forearm vascular conductance, calf blood flow, and calf vascular conductance were similar between groups. MSNA was higher in the SDB group. During hypoxia, the vascular responses (forearm blood flow, forearm vascular conductance, calf blood flow, and calf vascular conductance) were significantly lower in the SDB group compared with the NoSDB group (P<0.01 to all comparisons). Similarly, during hypercapnia, the vascular responses (forearm blood flow, forearm vascular conductance, calf blood flow, and calf vascular conductance) were significantly lower in the SDB group compared with the NoSDB group (P<0.001 to all comparisons). MSNA were higher in response to hypoxia (P=0.024) and tended to be higher to hypercapnia (P=0.066) in the SDB group. Conclusions—Patients with HF and SDB have more severe muscle vasoconstriction during hypoxia and hypercapnia than HF patients without SDB, which seems to be associated with endothelial dysfunction and, in part, increased MSNA response.

Experience with utilization of auto-expandable stents introduced through the femoral artery for treatment of thoracic aortic diseases

INTRODUCTION: The authors describe their experience with the implantation of endovascular self-expanding stent-grafts for the treatment of descending aortic thoracic diseases. METHOD: From June 1996 to April 2002, 14 endovascular self-expanding stent-grafts were implanted, 10 in acute type B dissections, 3 in atherosclerotic aneurysms and 1 in a penetrating aortic ulcer. The patients ages varied between 43 and 77 years (mean = 63.3 years). In the majority of cases the procedure was performed under general anesthesia. The delivery of the stent-graft endoprostheses was performed using the trans-femoral system. RESULTS: There was one death on the sixth postoperative day by pulmonary thromboembolism. One patient was operated on for the implantation of an endovascular self-expanding stent-graft through the aortic arch under deep hypothermia and circulatory arrest, and died eight months after operation. All the survivors were well and imaging studies showed adequate correction of the aortic disease. CONCLUSION: Preliminary results suggest that this technique will contribute to improve surgical results in the treatment of descending thoracic aortic diseases.

Diretriz Brasileira de Insuficiência Cardíaca Crônica e Aguda

Parte 1: Diretriz Brasileira de Insuficiencia Cardiaca Cronica […] Diretriz Brasileira de Insuficiencia Cardiaca Cronica e Aguda