Fernando Bacal

Inhaled nitric oxide leading to pulmonary edema in stable severe heart failure.

Abstract The mechanism of increased pulmonary wedge pressure and cardiac output after nitric oxide inhalation is not clear. Nitric oxide is rapidly inactivated by hemoglobin before it can produce systemic effects. 3 Thus, selective nitric oxide pulmonary vasodilator effects led to these preliminary results. The hypothesis is that acute reduction in right ventricular afterload caused an acute increment of right ventricular cardiac output. The acute increment of blood return to the impaired left ventricle not associated with reduction in afterload caused the increase in wedge pressure and consequently pulmonary edema. In addition, acute reduction in right ventricular afterload could lead to redistribution of blood volume to pulmonary circulation. The absence of pulmonary edema in these patients in the nitroprusside study reinforces the importance of selective nitric oxide effects in pulmonary circulation.

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.

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.

Partial left ventriculectomy with mitral valve preservation in the treatment of patients with dilated cardiomyopathy.

OBJECTIVE This study reports initial results of partial left ventriculectomy performed with preservation of the mitral valve in the treatment of 27 patients with idiopathic dilated cardiomyopathy. METHODS Patients were in New York Heart Association class III or IV. Partial ventriculectomy was performed as an isolated procedure in four patients and associated with mitral annuloplasty in 23 patients. There were four hospital deaths (14.8%) and the remaining patients were followed for 11.2 +/- 6 months. RESULTS Decrease of left ventricular diastolic diameter (81.8 +/- 8.7 to 68.5 +/- 7.6 mm, p < 0.001) and improvement of left ventricular wall shortening (12% +/- 3.1% to 18.1% +/- 3.9%, p < 0.001) were demonstrated by echocardiography after the operation. Left ventricular radioisotopic angiography showed reduction of diastolic volume (495 +/- 124 ml to 352 +/- 108 ml, p < 0.001) and increase of ejection fraction (17.7% +/- 4.6% to 23.7% +/- 8.8%, p < 0.001). Right-sided heart catheterization demonstrated improvement of stroke index (24.3 +/- 7.7 ml/m2 to 28.3 +/- 7.6 ml/m2, p < 0.01) and decrease of pulmonary wedge pressure (23.2 +/- 8.8 mm Hg to 17 +/- 7 mm Hg, p < 0.01). Similar results were documented at 6 and 12 months of follow-up. Functional class improved from 3.6 +/- 0.5 to 1.4 +/- 0.6 (p < 0.001). However, seven patients died at midterm follow-up because of heart failure progression or arrhythmia-related events, and survival rate was 59.2% +/- 9.4% from 6 to 24 months of follow-up. CONCLUSIONS Partial left ventriculectomy performed with preservation of the mitral valve improves left ventricular function and congestive heart failure in patients with dilated cardiomyopathy. Nevertheless, the high incidences of heart failure progression and arrhythmia-related deaths observed after this procedure preclude its wide clinical application.

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

Clinical and left ventricular function outcomes up to five years after dynamic cardiomyoplasty.

Improvement in congestive heart failure and left ventricular function after dynamic cardiomyoplasty has been reported in patients with severe cardiomyopathies, but the long-term effects of this procedure remain unclear. In this investigation 31 patients undergoing cardiomyoplasty for treatment of idiopathic dilated cardiomyopathy were annually investigated with radionuclide scintigraphy, Doppler echocardiography, and right-sided heart catheterization. They were in New York Heart Association functional class III or IV before the operation. No hospital deaths occurred, but one patient with progressive heart failure required urgent heart transplantation 42 days after cardiomyoplasty. The other patients were followed up from 6 to 70 months (mean 25.6 months) and 12 patients died at late follow-up. Actuarial survivals were 86% at 1 year, 61.4% at 2 years, and 42.5% at 3 to 5 years of follow-up. Multivariate analysis of factors influencing outcome showed that long-term survival was significantly affected by preoperative functional class and pulmonary vascular resistance. Functional class improved from 3.2 +/- 0.4 to 1.7 +/- 0.7 in the surviving patients (p < 0.01). Furthermore, left ventricular ejection fraction improved from 19.8% +/- 3% to 23.9% +/- 7.2% (p < 0.01), and significant changes in stroke index, arterial pressure, pulmonary wedge pressure, and left ventricular stroke work index were also found at 6 months of follow-up. In the late postoperative period, the left ventricular ejection fraction tended to decrease and returned to preoperative levels at 5 years, whereas hemodynamic variables did not change significantly. Thus, despite the tendency of the left ventricular ejection fraction to decrease at late follow-up, the long-term course of these patients seems to be characterized by the maintenance of hemodynamic improvement. However, long-term survival after cardiomyoplasty is limited by the severity of the patients condition before the operation.

Cardiomyopathy, adult valve disease and heart failure in South America

Continued assessment of temporal trends in mortality and epidemiology of specific cardiovascular diseases in South America is needed to provide a scientific basis for rational allocation of the limited healthcare resources and introduction of strategies to reduce risk and predict the future burden of cardiovascular disease. The epidemiology of cardiomyopathies, adult valve disease and heart failure (HF) in South America is reviewed here. Diseases of the circulatory system are the main cause of death based on data from about 50% of the South American population. Among the cardiovascular causes of death, cerebrovascular disease is predominant followed by ischaemic heart disease, other heart diseases and hypertensive disease. Of note, cerebrovascular disease is the main cause of death in women, and race also influenced cardiovascular mortality rates. HF is the most important cardiovascular reason for admission to hospital due to cardiovascular disease of ischaemic, idiopathic dilated cardiomyopathic, valvular, hypertensive and chagasic aetiologies. Also, mortality due to HF is high, especially owing to Chagas’ disease. HF and aetiologies associated with HF are responsible for 6.3% of deaths. Rheumatic fever is the leading cause of valvular heart disease. The findings have important public health implications because the allocation of healthcare resources, and strategies to reduce the risk of HF should also consider controlling Chagas’ disease and rheumatic fever in South American countries.

Determinants of midterm outcome of partial left ventriculectomy in dilated cardiomyopathy

BACKGROUND Partial left ventriculectomy has been proposed for treatment of severe cardiomyopathies. This study reports midterm results of this procedure in 37 patients with dilated cardiomyopathy. METHODS All patients were in New York Heart Association class III (16) or IV (21). Partial ventriculectomy was associated with mitral annuloplasty in 27 patients and with mitral replacement in 2. RESULTS There were seven operative deaths (18.9%). During a mean follow-up of 18.2+/-9.3 months, 9 more patients died. Actuarial survival was 56.7%+/-8.1% at 6 and 24 months. Analysis of factors influencing outcome showed that midterm survival was significantly affected only by myocardial cell diameter. Otherwise, functional class improved from 3.5+/-0.5 to 1.8+/-0.9 in the survivors (p < 0.001). Furthermore, left ventricular diastolic volume decreased from 523+/-207 to 380+/-148 mL (p < 0.001), and left ventricular ejection fraction increased from 17.1%+/-4.6% to 23%+/-8% (p < 0.001), whereas significant changes in cardiac index, stroke index, and pulmonary pressures were found at 1 month of follow-up. Although left ventricular diastolic volume tended to increase in the late postoperative period, left ventricular ejection fraction and hemodynamic variables did not change significantly. CONCLUSIONS Partial ventriculectomy improves left ventricular function and congestive heart failure in patients with dilated cardiomyopathy for up to 24 months of follow-up. Nevertheless, this procedures clinical application is limited by the high mortality observed in the first postoperative months. Otherwise, new perspectives may be advised by the identification that partial ventriculectomy results seem to be influenced by compromised myocardial cells.

Validation of the Portuguese version of the Minnesota Living with Heart Failure Questionnaire

BACKGROUND The Minnesota Living with Heart Failure Questionnaire (MLHFQ) is an important measurement instrument for assessing the quality of life of heart failure patients. Despite being largely used within our context, the questionnaire had not yet been translated and validated into the Portuguese language. OBJECTIVE Of this study was to translate and validate the Portuguese version of the MLHFQ for use in heart failure patients. METHODS Forty patients with heart failure (30 men, LVEF 30+/-6%, 55% ischemic etiology, classified as NYHA I to III), clinically stable and on optimized drug therapy underwent maximal cardiopulmonary stress testing to assess their physical capacity. Right after the test, the MLHFQ duly translated into Portuguese was administered by the same investigator. The NYHA functional classification was provided by the medical team. RESULTS The Portuguese version of the MLHFQ had the same structure and metrics of the original version. There was no difficulty in the administration of the questionnaire or in the patients understanding of the questions. The Portuguese version of the MLHFQ was consistent with peak VO2, duration of the cardiopulmonary test, and NYHA functional classification. There was no difference in the score mean for the questionnaire between the group of patients with ischemic etiology and the group with non-ischemic etiology. CONCLUSION The Portuguese version of the MLHFQ proposed in this study proved to be valid for heart failure patients, and constitutes a new and important instrument for assessing quality of life.

Validação da versão em português do Minnesota Living with Heart Failure Questionnaire

BACKGROUND The Minnesota Living with Heart Failure Questionnaire (MLHFQ) is an important measurement instrument for assessing the quality of life of heart failure patients. Despite being largely used within our context, the questionnaire had not yet been translated and validated into the Portuguese language. OBJECTIVE Of this study was to translate and validate the Portuguese version of the MLHFQ for use in heart failure patients. METHODS Forty patients with heart failure (30 men, LVEF 30+/-6%, 55% ischemic etiology, classified as NYHA I to III), clinically stable and on optimized drug therapy underwent maximal cardiopulmonary stress testing to assess their physical capacity. Right after the test, the MLHFQ duly translated into Portuguese was administered by the same investigator. The NYHA functional classification was provided by the medical team. RESULTS The Portuguese version of the MLHFQ had the same structure and metrics of the original version. There was no difficulty in the administration of the questionnaire or in the patients understanding of the questions. The Portuguese version of the MLHFQ was consistent with peak VO2, duration of the cardiopulmonary test, and NYHA functional classification. There was no difference in the score mean for the questionnaire between the group of patients with ischemic etiology and the group with non-ischemic etiology. CONCLUSION The Portuguese version of the MLHFQ proposed in this study proved to be valid for heart failure patients, and constitutes a new and important instrument for assessing quality of life.