Dirceu Rodrigues de Almeida

I Latin American Guidelines for the assessment and management of decompensated heart failure

Edimar Alcides Bocchi, Fabio Vilas-Boas, Sergio Perrone, Angel G Caamano, Nadine Clausell, Maria da Consolacao VMoreira, Jorge Thierer, Hugo Omar Grancelli, Carlos Vicente Serrano Junior, Denilson Albuquerque, Dirceu Almeida,Fernando Bacal, Luis Felipe Moreira, Adonay Mendonza, Antonio Magana, Arturo Tejeda, Daniel Chafes, Efraim Gomez,Erick Bogantes, Estela Azeka, Evandro Tinoco Mesquita, Francisco Jose Farias B Reis, Hector Mora, Humberto Vilacorta,Jesus Sanches, Joao David de Souza Neto, Jose Luis Vuksovic, Juan Paes Moreno, Julio Aspe y Rosas, Lidia ZytynskiMoura, Luis Antonio de Almeida Campos, Luis Eduardo Rohde, Marcos Parioma Javier, Martin Garrido Garduno, MucioTavares, Pablo Castro Galvez, Raul Spinoza, Reynaldo Castro de Miranda, Ricardo Mourilhe Rocha, Roberto Paganini,Rodolfo Castano Guerra, Salvador Rassi, Sofia Lagudis, Solange Bordignon, Solon Navarette, Waldo Fernandes, AntonioCarlos Pereira Barretto, Victor Issa, Jorge Ilha Guimaraes.

Transplante cardíaco e infecção

Objective: To evaluate the incidence of infection, the etiological agents, to present the clinical aspects and the surgical morbi-mortality in patients who underwent cardiac transplant at Federal University of Sao Paulo. Material and Methods: From November 1966 to June 1998, a total of 97 patients were operated by the UNIFESP Cardiovascular Surgery team and survived longer than 1 week after the transplantation and were studied retrospectively as far as infections. The age of the patients ranged from 3 to 63 years (average 44.4 ± 13 years). Most of the patients had dilated myocardiopathy (46), or Chagas (24) or ischemis (23). The follow up ranged from 0.33 to 119 months (36 ± 30.7 months) Results: Of the 97 patients, 16 (16.4%) had infection as the main cause of death, followed by rejection in 10 (10.3%). The causes of infection were: bacterial sepsis in 6 patients, pneumonia in 6, intra-abdominal infection in 2, toxoplasmosis in 1 and cytomegalovirus infection in 1. There were 142 infection episodes, bacterial 76 (52.5%), viral 34 (28.8%), fungi 20 (17.5%) and protozoa 12 (12.4%). There were 8 episodes of the reactivation were treated successfully with alopurinol. Conclusions: Our data showed the predominance of bacterial infections as the cause of most mortality. In transplanted patients suffering from Chagas´disease, the reactivation of the disease may be adequately controlled by means of alopurinol. Such data serve as orientation in our community for our programs of transplants, since they show particular aspects of our enviroment.

Hospitalização e mortalidade por insuficiência cardíaca em hospitais públicos no município de São Paulo

BACKGROUND: Advances in the treatment of heart failure (HF) have resulted in reduced mortality and hospitalization rates. On the other hand, when hospitalized, patients are at high risk of death. OBJECTIVE: As there are few studies in this group of patients in Brazil, we analyzed the numbers of hospitalization and deaths due to HF in the Brazilian Public Health System (SUS) in the city of Sao Paulo. METHODS: Historical prospective study carried out between 1992 and 2010. The data were obtained from DATASUS. We used Chi-square and t tests for comparison between the periods 1992-1993 and 2008-2009 and logistic regression models when appropriate. The level of significance was set at 5%. RESULTS: There was a 32% decrease in the number of hospitalizations for HF between 1992-1993 and 2008-2009 (p = 0.002). The in-hospital mortality rate for HF was 15%, with a 15% increase in the period (p = 0.004). Between 1992 and 1993, the mean time of hospitalization for HF was 8.8 days. Between 2008 and 2009, it was 11.3 days (p = 0.001). August was the month with the highest incidence of hospitalizations for HF, 20% higher than in February, the month with the lowest incidence (p = 0.041). CONCLUSION: This study showed changes in trends of hospitalization for HF and mortality over the last two decades. We emphasize important implications: 1: 32% decrease in the number of hospitalizations for HF in SUS hospitals in Sao Paulo; 2: 25% increase in hospitalization time, and 3: seasonal pattern of hospitalization for HF, with a peak in the third quarter.

Cardiac involvement in total generalized lipodystrophy (Berardinelli- Seip syndrome)

Total generalized lipodystrophy (Berardinelli - Seip Syndrome) is a rare hereditary disease characterized by insulin-resistant diabetes mellitus and a small quantity of adipose tissue and is of unknown origin. Common cardiovascular alterations related to this syndrome are cardiac hypertrophy and arterial hypertension. This article reports a case of Berardinelli - Seip syndrome and reviews the literature with special emphasis on the cardiovascular manifestations of this syndrome.

EXtreme ecosystem studies in the deep OCEan : Technological Developments

EXOCET/D was a three-year project that started in 2004 and that was funded by the European Commission (STREP, FP6-GOCE-CT-2003-505342). The general objective of this project was to develop, implement and test specific technologies aimed at exploring, describing and quantifying biodiversity in deep-sea fragmented habitats as well as at identifying links between community structure and environmental dynamics. The MoMARETO cruise, held during the summer 2006, was the main demonstration action of EXOCET/D. After nearly 3 years of development, the project was a real success with the at sea trial and validation of 13 instrument prototypes developed for the study of deep-sea extreme habitats. These instruments were dedicated to quantitative imaging, in situ measurements, faunal sampling and in vivo experiments.

Respostas cardiopulmonares ao exercício em pacientes com insuficiência cardíaca congestiva de diferentes faixas etárias

OBJETIVOS: Comparar a capacidade funcional cardiorrespiratoria no exercicio, representada pelos indices de limitacao funcional, consumo maximo de oxigenio (VO2max) e limiar anaerobico, em pacientes com insuficiencia cardiaca congestiva (ICC) de diferentes faixas etarias, e comparar as respostas cardiopulmonares ao exercicio maximo. METODOS: Foram avaliados 54 pacientes com ICC, agrupados por faixa etaria, como segue: grupo I - idade entre trinta e 39 anos (n = 12); grupo II - idade entre quarenta e 49 anos (n = 18); grupo III - idade entre cinquenta e 59 anos (n = 17); grupo IV - idade igual ou maior que sessenta anos (n = 7). Os pacientes foram submetidos a um teste cardiopulmonar maximo, em esteira rolante. Para a comparacao entre os diferentes grupos etarios foi realizada uma analise de variância com um fator. RESULTADOS: Nao houve diferenca significante dos valores obtidos de consumo maximo de oxigenio e de limiar anaerobico entre os grupos etarios, bem como dos valores maximos das variaveis producao de dioxido de carbono, pulso de oxigenio, razao de trocas gasosas, ventilacao pulmonar, equivalentes ventilatorios para o oxigenio e para o dioxido de carbono. CONCLUSOES: Os resultados obtidos sugerem que a capacidade funcional cardiorrespiratoria no exercicio de pacientes com ICC, assim como as variaveis cardiopulmonares obtidas no exercicio maximo podem ser afetadas de forma semelhante pela doenca cardiaca em todas as faixas etarias estudadas.

Tratamento dos aneurismas da aorta descendente por endoprótese (tromba de elefante)

Os aneurismas da aorta descendente ainda causam grande mortalidade e morbidade, apesar dos avancos da cirurgia cardiovascular moderna. Neste trabalho utilizamos, originalmente em nosso meio, uma tecnica recente que consiste na insercao de uma protese de Dacron intraluminar, suturada apenas em sua porcao proximal, logo apos a subclavia esquerda e que transpoe a zona do aneurisma, ficando solta no interior da aorta em sua porcao distai (tromba de elefante). A operacao e realizada com circulacao extracorporea, hipotermia profunda de 19oC, com parada circulatoria no tempo suficiente para a insercao da protese e sutura da sua borda proximal. Desde maio de 1988, oito pacientes fizeram parte deste estudo, sendo que seis eram disseccoes da aorta tipo B e dois casos, aneurismas verdadeiros. A simplicidade e rapidez do procedimento, assim como os resultados pos-operatorios obtidos nos animam a prosseguir e recomendar este tipo de alternativa tatica, especialmente nas disseccoes de aorta tipo B.

Sumário de atualização da II Diretriz Brasileira de Insuficiência Cardíaca Aguda 2009/2011

In the past two years we observed several changes in the diagnostic and therapeutic approach of patients with acute heart failure (acute HF), which led us to the need of performing a summary update of the II Brazilian Guidelines on Acute Heart Failure 2009. In the diagnostic evaluation, the diagnostic flowchart was simplified and the role of clinical assessment and echocardiography was enhanced. In the clinical-hemodynamic evaluation on admission, the hemodynamic echocardiography gained prominence as an aid to define this condition in patients with acute HF in the emergency room. In the prognostic evaluation, the role of biomarkers was better established and the criteria and prognostic value of the cardiorenal syndrome was better defined. The therapeutic approach flowcharts were revised, and are now simpler and more objective. Among the advances in drug therapy, the safety and importance of the maintenance or introduction of beta-blockers in the admission treatment are highlighted. Anticoagulation, according to new evidence, gained a wider range of indications. The presentation hemodynamic models of acute pulmonary edema were well established, with their different therapeutic approaches, as well as new levels of indication and evidence. In the surgical treatment of acute HF, CABG, the approach to mechanical lesions and heart transplantation were reviewed and updated. This update strengthens the II Brazilian Guidelines on Acute Heart Failure to keep it updated and refreshed. All clinical cardiologists who deal with patients with acute HF will find, in the guidelines and its summary, important tools to help them with the clinical practice for better diagnosis and treatment of their patients.

Heart failure impairs cerebral oxygenation during exercise in patients with COPD

To the Editor: Impaired systemic oxygen delivery, particularly during exertion, is the key pathophysiological feature shared by chronic obstructive pulmonary disease (COPD) and heart failure with reduced left ventricular ejection fraction (HFrEF). Unfortunately, COPD and HFrEF frequently coexist not only because of their high individual prevalence but also due to common risk factors, including cigarette smoking, advanced age, oxidative stress and systemic inflammation [1]. It is expected that any reduction in the rate of oxygen transfer due to COPD and/or HFrEF would be particularly deleterious to tissues heavily dependent upon constant oxygen flow, such as the central nervous system (as reviewed in [2]). Exercise cerebral oxygenation (Cox) (as noninvasively determined by near-infrared spectroscopy) depends upon the dynamic balance between the instantaneous rate of oxygen delivery and oxygen utilisation [3]. Koike et al . [4], for instance, reported that congestive heart failure (CHF) HFrEF was associated with appreciable decreases in COx during exertion. Our laboratory found that exercise COx might be impaired in some patients with more advanced COPD, even if not overtly hypoxaemic [5]. Moreover, improvement in cardiac output with noninvasive ventilation (under the same arterial oxygen content) had positive effects on COx in COPD [6]. These data suggest that reduced cerebral blood flow might be mechanistically linked to impaired exercise COx in some patients with moderate-to-severe COPD. It is conceivable that the presence of HFrEF would further deteriorate this scenario by adding components of dysfunctional cerebral autoregulation, lower cardiac output and hypocapnia-induced vasoconstriction [4]. The compound effects of HFrEF plus COPD on …

Does Exercise Ventilatory Inefficiency Predict Poor Outcome in Heart Failure Patients With COPD

PURPOSE: To investigate whether the opposite effects of heart failure (HF) and chronic obstructive pulmonary disease (COPD) on exercise ventilatory inefficiency (minute ventilation [ E]-carbon dioxide output [ CO2] relationship) would negatively impact its prognostic relevance. METHODS: After treatment optimization and an incremental cardiopulmonary exercise test, 30 male patients with HF-COPD (forced expiratory volume in 1 second [FEV1] = 57% ± 17% predicted, ejection fraction = 35% ± 6%) were prospectively followed up during 412 ± 261 days for major cardiac events. RESULTS: Fourteen patients (46%) had a negative outcome. Patients who had an event had lower echocardiographically determined right ventricular fractional area change (RVFAC), greater ventilatory inefficiency (higher E/ CO2 nadir), and lower end-tidal CO2 (PETCO2) (all P < .05). Multivariate Cox models revealed that E/ CO2 nadir >36, &Dgr;PETCO2(PEAK-REST)≥2 mm Hg, and PETCO2PEAK⩽33 mm Hg added prognostic value to RVFAC⩽45%. Kaplan-Meyer analyses showed that although 18% of patients with RVFAC>45% had a major cardiac event after 1 year, no patient with RVFAC>45% and E/ CO2 nadir ⩽36 (or PETCO2PEAK>33 mm Hg) had a negative event. Conversely, although 69% of patients with RVFAC⩽45% had a major cardiac event after 1 year, all patients with RVFAC⩽45% and &Dgr;PETCO2(PEAK-REST)≥2 mm Hg had a negative event. CONCLUSION: Ventilatory inefficiency remains a powerful prognostic marker in HF despite the presence of mechanical ventilatory constraints induced by COPD. If these preliminary findings are confirmed in larger studies, optimal thresholds for outcome prediction are likely greater than those traditionally recommended for HF patients without COPD.