Eduardo Arrais Rocha

Ressincronização ventricular: comparando os marcapassos biventriculares com os marcapassos bifocais de ventrículo direito

OBJECTIVE To analyze the conventional biventricular pacing (BV) and the bifocal (BF) right ventricular (RV) pacing, and to perform a comparative analysis of these two techniques in relation to clinical, functional and echocardiographic parameters in a population without the exclusion criteria of the major studies. METHODS A prospective non-randomized analysis of 36 patients undergoing surgery for multisite pacemaker implantation due to QRS > or =130 ms, severe left ventricular dysfunction, and NYHA functional class III or ambulatory class IV congestive heart failure was performed. RESULTS Favorable results of resynchronization were obtained with both techniques, with no significant differences in the comparison of the two groups, except for a higher QRS narrowing in the BV group, and a trend of a lower number or hospital admissions in the BV group. When the groups were analyzed separately and compared before and after the procedures, we observed that improvement was much more significant in the biventricular group, as were the more statistically relevant rates. CONCLUSION Cardiac resynchronization therapy proved to be an efficient therapy in both groups analyzed, although with more significant outcomes in the biventricular group.

Clinical Course After Cardioverter-Defibrillator Implantation: Chagasic Versus Ischemic Patients

Background: The outcome of Chagas disease patients after receiving implantable cardioverter defibrillator (ICD) is still controversial. Objective: To compare clinical outcomes after ICD implantation in patients with chronic Chagas cardiomyopathy (CCC) and ischemic heart disease (IHD). Methods: Prospective study of a population of 153 patients receiving ICD (65 with CCC and 88 with IHD). The devices were implanted between 2003 and 2011. Survival rates and event-free survival were compared. Results: The groups were similar regarding sex, functional class and ejection fraction. Ischemic patients were, on average, 10 years older than CCC patients (p < 0.05). Patients with CCC had lower schooling and monthly income than IHD patients (p < 0.05). The number of appropriate therapies was 2.07 higher in CCC patients, who had a greater incidence of appropriate shock (p < 0.05). Annual mortality rate and electrical storm incidence were similar in both groups. There was no sudden death in CCC patients, and only one in IHD patients. Neither survival time (p = 0.720) nor event-free survival (p = 0.143) significantly differed between the groups. Conclusion: CCC doubles the risk of receiving appropriate therapies as compared to IHD, showing the greater complexity of arrhythmias in Chagas patients.

Pharmacotherapeutic follow-up of patients with Chagas disease using benznidazole: drug-related problems and pharmaceutical interventions

INTRODUCTION Benznidazole (BNZ) is a drug available for the etiological treatment of Chagas disease. However, this drug is toxic and has a limited effectiveness on the chronic phase of this disease, often leading to poor treatment adherence. METHODS: This is a descriptive and exploratory study conducted at the Pharmaceutical Care Service for Chagas disease patients of the Federal University of Ceará. Drug-related problems (DRPs) and pharmaceutical interventions (PIs) were classified according to the Second Consensus of Granada. RESULTS: The average age of patients with Chagas disease was 62 years, with the majority residing in the Ceará countryside (86.7%), and having low education levels (63.3% with elementary school education). Regarding family income, most patients belonged to a household that earned ≤1-2 times the minimum wage per month. Approximately 73% of these patients complied with the BNZ treatment, and nearly 7% underwent therapy interruption after medical evaluation. A total of 189 DRPs were identified, of which 51.9% (n=98) were classified as potential, and 48.1% (n=91) as actual. The most frequent DRPs were related to safety (qualitative safety; n=70; 37%), necessity (non-adherence; n=52; 27.5%), and effectiveness (qualitative effectiveness/non-optimal drug selection; n=45; 23.8%). Among the 216 PIs conducted, the majority were related to patient education (n=168; 77.8%) and pharmacological strategy (n=42; 19.4%). CONCLUSIONS: This study indicates the need for pharmacotherapeutic monitoring in patients with Chagas because of the high number of therapeutic interventions, DRPs (approximately 3 DRPs/patient), BNZ adherence, and polypharmacy.

Who Are the Super-Responders to Cardiac Resynchronization Therapy?

Fundamento: Pacientes submetidos a ressincronizacao cardiaca podem evoluir com padroes de resposta acima do esperado, com normalizacao dos parâmetros clinicos e ecocardiograficos. Objetivo: Analisar as caracteristicas clinicas e ecocardiograficas desta populacao de super-respondedores, comparando-as com os demais pacientes submetidos a terapia de ressincronizacao cardiaca. Metodos: Estudo de coorte observacional, prospectivo, envolvendo 146 pacientes, consecutivamente submetidos a implantes de ressincronizador cardiaco. Para comparacao das variaveis, foram realizados o teste exato de Fisher e o teste de Mann-Whitney. Foram considerados super-respondedores os pacientes com fracao de ejecao > 50 % e classe funcional I/II (New York Heart Association) apos 6 meses da terapia de ressincronizacao cardiaca. Resultados: A idade media foi de 64,8 ± 11,1 anos, sendo 69,8% do sexo masculino, com mediana da fracao de ejecao de 29%, sendo 71,5% com bloqueio de ramo esquerdo, 12% com bloqueio de ramo direito associado a bloqueios divisionais; 16,3% com marca-passo cardiaco definitivo, 29,3% com miocardiopatia isquemica, 59,4% com miocardiopatia dilatada e 11,2% com miocardiopatia chagasica. Foram observados 24 (16,4%) super-respondedores, sendo que 13 (8,9%) apresentaram normalizacao da fracao de ejecao, dos diâmetros diastolicos do ventriculo esquerdo e da classe funcional. Quando comparados com os pacientes nao super-respondedores, em relacao as caracteristicas pre-implante, os super-respondedores apresentaram-se mais no sexo feminino (58,3% vs. 22,8%; p = 0,002), maior indice de massa corporal (26,8 vs. 25,5; p = 0,013), maior fracao de ejecao basal (31,0 vs. 26,9; p = 0,0003) e menores diâmetros diastolicos do ventriculo esquerdo (65,9 mm vs. 72,6 mm; p = 0,0032). Dez pacientes (41,6% dos super-respondedores) com bloqueio de ramo direito e bloqueio divisional evoluiram como super-respondedores, entretanto apenas um paciente com doenca de Chagas e apenas na primeira avaliacao. Conclusoes: Os super-respondedores apresentaram cardiopatia de base menos avancada e sem diferencas em relacao ao tipo de disturbio de conducao basal. Pacientes com bloqueio de ramo direito e bloqueio divisional, mas sem cardiopatia chagasica podem tambem evoluir como super-respondedores.

Neurally Mediated Syndromes

A syncope is a transient loss of consciousness because of reduced brain blood flow with loss of postural tonus followed by fast and spontaneous recovery. It is a common medical condition that accounts for up to 6% of hospitalizations, 3% of emergency consultancy episodes and high recurrence rate (34%) 1 . The medical term “syncope” comes from the Greek “syncopa”, meaning “to cut short” or “faint” in English and just “faint” in Portuguese. Hippocrates, one thousand years before Christ, reported that patients who suffered frequent faints usually died, whereas Engel reports that the single difference between syncope and sudden death is the fact that the patient wakes up in the first case 2 . At the inicial syncope evaluation, the physician should try to distinguish potentially fatal causes, such as hypertrophic cardiomyopathy; aortic stenosis; severe coronary insufficiency; total or advanced atrioventricular blockage; and sustained ventricular tachycardia from autonomic dysfunctions/disorders. It is known that syncopes in cardiac patients are related to a high mortality rate, whereas vasovagal syncopes point to increased morbidity 1,3,4

Trypanosoma cruzi seroprevalence among solid organ donors in Ceará State, Brazil

INTRODUCTION The transmission of Chagas disease (CD) through blood transfusion, organ transplantation, and oral transmission has gained greater visibility as a result of intensified vector control activities in endemic regions and to control CD in non-endemic regions. In Brazil, Ceará is one of the states that perform the most organ transplants. Therefore, the objective of this study was to assess the prevalence of Trypanosoma cruzi infection in organ donor candidates. METHODS A retrospective analysis was performed on data from potential organ donors at the Center of Transplantation of the State of Ceará from 2010 - 2015. RESULTS Data from a total of 2,822 potential donors were obtained, of which 1,038 were effective donors and 1,784 were excluded, likely due to lack of family authorization or medical contraindication. The prevalence of T. cruzi infection among these potential donors was 1.3% (n = 29). The majority of infected donors were males aged 41 - 60 years, residing in the interior of the state. Interestingly, 72.4% (n = 21) had positive or inconclusive serology for additional infections, such as cytomegalovirus, hepatitis B and C, and toxoplasmosis. Probability analysis revealed that stroke was the most common cause of death among potential donors with CD. CONCLUSIONS There was a high prevalence of CD and other coinfections among potential solid organ donors in Ceará, and statistical tests have shown that these individuals are at increased risk of stroke when compared to potential non-reactive donors. This work highlights the importance of screening DC infection in potential donors.

Analysis of Cardiac Dyssynchrony - An Unsolved Issue! How to improve selection and response to Cardiac Resynchronization Therapy?

DOI: 10.5935/abc.20180200 The authors Nascimento et al.,1 published an important work demonstrating the value of myocardial perfusion scintigraphy (SPECT-Gated) to identify cardiac dyssynchrony (CD) and with posterior implantation of left ventricle (LV) electrode in the area with higher dyssynchrony, with favorable correlation with clinical results and cardiac function. The study rises important issues in the attempt to reduce non-respondent rate (30-40%). These high rates are due to implants in very advanced or irreversible phases of the disease or to positioning of the LV electrode in areas with fibrosis or due to absence of dyssynchrony.

Prognostic Value of Coronary Flow Reserve Obtained on Dobutamine Stress Echocardiography and its Correlation with Target Heart Rate

Background Normal coronary flow velocity reserve (CFVR) (≥ 2) obtained in the left anterior descending coronary artery (LAD) from transthoracic echocardiography is associated with a good prognosis, but there is no study correlating CFVR with submaximal target heart rate (HR). Objective To evaluate the prognostic value of CFVR obtained in the LAD of patients with preserved (>50%) left ventricular ejection fraction (LVEF) who completed a dobutamine stress echocardiography (DSE), considering target HR. Methods Prospective study of patients with preserved LVEF and CFVR obtained in the LAD who completed DSE. In Group I (GI = 31), normal CFVR was obtained before achieving target HR, and, in Group II (GII = 28), after that. Group III (G III=24) reached target HR, but CFVR was abnormal. Death, acute coronary insufficiency, coronary intervention, coronary angiography without further intervention, and hospitalization were considered events. Results In 28 ± 4 months, there were 18 (21.6%) events: 6% (2/31) in GI, 18% (5/28) in GII, and 46% (11/24) in GIII. There were 4 (4.8%) deaths, 6 (7.2%) coronary interventions and 8 (9.6%) coronary angiographies without further intervention. In event-free survival by regression analysis, GIII had more events than GI (p < 0.001) and GII (p < 0.045), with no difference between GI and GII (p = 0.160). After adjustment, the only difference was between GIII and GI (p = 0.012). Conclusion In patients with preserved LVEF and who completed their DSE, normal CFVR obtained before achieving target HR was associated with better prognosis.