Gustavo Glotz de Lima

New lead for in utero pacing for fetal congenital heart block

Complete heart block occurs in 4% to 15% of cases of fetal arrhythmia. Although it is usually well tolerated in the absence of complicating cardiac anomalies, as many as 25% of these fetuses have hydrops and die in utero. The pathophysiologic arguments for fetal ventricular pacing are compelling. We describe the case of a fetus presenting with complete heart block, hydrops, and associated structural heart defects, the mother of whom consented to attempts at in utero pacing. The purpose of this article is to describe a new lead for percutaneous implantation that minimizes surgical trauma to both the fetus and the mother.

Ventilatory profile of patients undergoing CABG surgery.

OBJECTIVEnTo assess the ventilatory, radiological and clinical profile of patients undergoing elective CABG in a cardiology reference hospital in South Brazil.nnnMETHODSnThis study included 108 patients undergoing elective CABG surgery, in the period between April 2006 and February 2007 at the Cardiology Institute of Rio Grande do Sul (IC-FUC). The surgical procedure involved median sternotomy, and the saphenous vein and/or internal mammary artery were used for grafting. Lung volume and capacity, as well as the possible existence of ventilatory changes, were assessed by spirometry, and the ventilatory muscle strength was assessed using a vaccum manometer. All evaluations were performed on the preoperative period and on the sixth postoperative day.nnnRESULTSnPreoperative levels of FEV1 and FVC were significantly reduced on the 6th postoperative day (P<0.001) when compared to the preoperative levels. A significant decrease of ventilatory muscle strength, expressed as maximum inspiratory and expiratory pressures (MIP and MEP), was also observed from the pre- to the sixth postoperative day (P<0.001). Pulmonary events were more frequent on the 6th postoperative day (78%) than on the 1st postoperative day (40%).nnnCONCLUSIONnPatients undergone CABG surgery present important reduction in pulmonary volume and capacity, as well as on the ventilatory muscle strength during the postoperative period.

Randomized study of surgical isolation of the pulmonary veins for correction of permanent atrial fibrillation associated with mitral valve disease

OBJECTIVEnChronic permanent atrial fibrillation is often due to mitral valve disease. The Cox maze procedure is the gold standard for treating this arrhythmia. Simpler techniques and ablation methods should have their efficacy tested in clinical practice. Our objective was to evaluate the effectiveness of surgical pulmonary vein isolation as compared with the Cox maze procedure.nnnMETHODSnSixty patients were randomly assigned to control group, modified maze group (Cox maze III), and surgical isolation of the pulmonary veins (SPVI) group from July 1999 to October 2004. All patients had mitral valve lesions treated concomitantly. Preoperative characteristics were similar between groups.nnnRESULTSnThere were 4 deaths: 3 in the Cox maze group and 1 in the SPVI group (P = .31). The Cox maze group presented longer times of extracorporeal circulation and myocardial ischemia (P < .001). The relative risk of late postoperative development of atrial fibrillation was 0.07 in the SPVI group (P < .001; 95% confidence intervals: 0.02-0.27) and 0.195 in the Cox maze group (P = .002; 95% confidence intervals: 0.07-0.56) as compared with the control group. No difference was found between the SPVI and Cox maze groups concerning prevention of atrial fibrillation recurrence (relative risk: 0.358; P = .215; 95% confidence intervals: 0.08-1.67).nnnCONCLUSIONSnThe modified Cox maze procedure and surgical pulmonary vein isolation were similarly effective in restoring sinus or regular rhythm in permanent atrial fibrillation associated with mitral valve disease. These results favor the adoption of surgical isolation as a preferable technique, simpler and equally effective in controlling atrial fibrillation. The results also can bring further information for understanding the mechanisms involved in origins and treatment of chronic permanent atrial fibrillation.

Proposta de escore de risco para predição de fibrilação atrial após cirurgia cardíaca

Objective: Atrial fibrillation (AF) is a common complication following cardiac surgery and is associated with an increased patient morbidity and mortality. The objective of this study was to develop a risk index proposal to predict AF after cardiac surgery. Methods: A prospective observational study in that 452 patients were selected to assess the incidence and risk factors associated with postoperative AF. Only patients following cardiac surgery were selected. Continuous cardiac monitor and daily electrocardiogram were assessed. The most associated in a multivariable logistic model were selected for the risk index. Results: The average incidence of AF was 22.1%. The most associated factors with AF were: patients older than 75 years of age, mitral valve disease, no use of a beta blocker, withdrawal of a beta-blocker and a positive fluid balance. The absence risk factor determined 4.6% chance to postoperative AF, and for one, two and three or more risk factors, the chance was 16.6%, 25.9% and 46.3%, respectively. Conclusion: In a multivariable logistic model was possible to develop a risk index proposal to predict postoperative AF with a major risk of 46.3% in the presence of three or more risk factors. Descriptors: Atrial fibrillation. Thoracic surgery. Risk

Controle do tempo de protrombina em sangue capilar e venoso em pacientes com anticoagulação oral: correlação e concordância

BACKGROUNDnOral anticoagulants (OAC) are widely used in cardiology and are mainly indicated in cases of atrial fibrillation and prosthetic heart valves. Regular prothrombin time (PT) control is required for patients using OAC. New portable monitoring systems for measuring prothrombin time, eliminate the need to collect blood by venous puncture and facilitate daily life for these patients.nnnOBJECTIVEnTo compare PT measurements using the Coaguchek S system with capillary blood and the standard method in venous blood.nnnMETHODSnOne hundred and twenty-seven patients from the Cardiology Institutes anticoagulation clinic underwent conventional blood collection and capillary blood collection via a finger prick for measurements using the Coaguchek S system.nnnRESULTSnThe mean age was 58 +/- 14 years and 90% of the patients were white. OAC indications were atrial fibrillation (49.6%) and prosthetic heart valves (37.0%). The correlation coefficient, r s , was 0.90 (p<0.0001; CI:95% 0.87-0.93) between the Coaguchek S system and the control method. The Kappa measure of agreement among the patients with INR <2, INR between 2 and 3.5 and INR > 3.5 was 73.5%. The Coaguchek S system overestimated INR by 0.15 +/- 0.85 units. A great deal of discrepancy was found between the two techniques for INR values higher than 3.5 units.nnnCONCLUSIONnThe Coaguchek S system when compared to the control method revealed good correlation and a high degree of agreement for results lower than 4 units. However, confirmation is required for INR values above 3.5 using the standard method.

Fatores de risco e morbimortalidade associados à fibrilação atrial no pós-operatório de cirurgia cardíaca

OBJETIVO: Determinar a incidencia de fibrilacao atrial no pos-operatorio de cirurgia cardiaca, seu impacto sobre a morbimortalidade e o tempo de internacao hospitalar e analisar os fatores de risco presentes no pre, trans e pos-operatorio. METODO: Estudo de coorte contemporâneo com 158 pacientes adultos submetidos a cirurgia cardiaca, sendo excluidos aqueles com fibrilacao atrial no pre-operatorio. Os pacientes foram avaliados por monitorizacao cardiaca continua e eletrocardiogramas diarios e a fibrilacao atrial considerada como qualquer episodio de ritmo irregular, com presenca de ondas f de morfologia e amplitude variaveis. RESULTADOS: A incidencia de fibrilacao atrial foi de 28,5%, sendo 21,6% para os pacientes revascularizados e 44,3% para os submetidos a correcao valvar. Fatores independentemente associados a fibrilacao atrial foram insuficiencia cardiaca esquerda no pre-operatorio (p=0,05; RC=2,2), balanco hidrico total (p=0,01; RC=1,0), tempo de cirurgia (p=0,03; RC=1,01) e outros fatores associados: idade > 70 anos, doenca valvar aortica, agitacao psicomotora, tempo de permanencia de drenos, congestao pulmonar e insuficiencia respiratoria no pos-operatorio. O uso de betabloqueadores (p=0,01; RC=0,3) foi um fator de protecao. Fibrilacao atrial pos-operatoria associou-se a aumento do tempo de internacao hospitalar (16,9 ± 12,3 dias vs 9,2 ± 4,0 dias, p<0,001) e a maior incidencia de acidente vascular cerebral ou obito pos-operatorio, (p=0,02). CONCLUSAO: A incidencia de fibrilacao atrial no pos-operatorio de cirurgia cardiaca foi elevada e ocasionou significativo aumento de morbimortalidade e tempo de internacao hospitalar. Entre os fatores de risco independentes destaca-se o balanco hidrico excessivo e, como fator protetor, uso de betabloqueadores.

Longterm effects of cardiac mediastinal nerve cryoablation on neural inducibility of atrial fibrillation in canines

In canines, excessive activation of select mediastinal nerve inputs to the intrinsic cardiac nervous system induces atrial fibrillation (AF). Since ablation of neural elements is proposed as an adjunct to circumferential pulmonary vein ablation for AF, we investigated the short and long-term effects of mediastinal nerve ablation on AF inducibility. Under general anesthesia, in 11 dogs several mediastinal nerve sites were identified on the superior vena cava that, when stimulated electrically during the atrial refractory period, reproducibly initiated AF. Cryoablation of one nerve site was then performed and inducibility retested early (1-2 months post Cryo; n=7) or late (4 months post Cryo; n=4). Four additional dogs that underwent a sham procedure were retested 1 to 2 months post-surgery. Stimulation induced AF at 91% of nerve sites tested in control versus 21% nerve sites early and 54% late post-ablation (both P<0.05). Fewer stimuli were required to induce AF in controls versus the Early Cryo group; this capacity returned to normal values in the Late Cryo group. AF episodes were longer in control versus the Early or Late Cryo groups. Heart rate responses to vagal or stellate ganglion stimulation, as well as to local nicotine infusion into the right coronary artery, were similar in all groups. In conclusion, focal damage to intrinsic cardiac neuronal inputs causes short-term stunning of neuronal inducibility of AF without major loss of overall adrenergic or cholinergic efferent neuronal control. That recovery of AF inducibility occurs rapidly post-surgery indicates the plasticity of intrathoracic neuronal elements to focal injury.

Warfarin and phenprocoumon: experience of an outpatient anticoagulation clinic

FUNDAMENTO: Os anticoagulantes orais sao amplamente utilizados na cardiologia. Contudo, uma avaliacao sobre o seu uso na pratica clinica ainda e necessaria. OBJETIVOS: Descrever as diferencas na manutencao do controle da anticoagulacao, bem como a incidencia de eventos hemorragicos e tromboembolicos entre os usuarios de varfarina e femprocumona. METODOS: Estudo de coorte nao concorrente de 127 pacientes em uso de anticoagulacao oral. RESULTADOS: A femprocumona foi o anticoagulante mais utilizado em 60% dos pacientes. A prevalencia de INR<2 na ultima consulta era maior entre os usuarios de varfarina (46% vs. 19,5%; p<0,001). Durante o seguimento, os usuarios da femprocumona estiveram dentro dos niveis terapeuticos em 60,7% do periodo em comparacao com 45,6% dos usuarios da Varfarina (OR:1,84;CI95%:1,59-2,13;p<0,001). A incidencia de sangramentos foi de 5,3/100 pacientes/ano no grupo da femprocumona contra 18,8/100 pacientes/anos no grupo varfarina (RR:3,5;CI95%:1,87-6,48;p<0,001). CONCLUSAO: Pacientes que faziam uso da varfarina permaneceram em niveis subterapeuticos por um maior periodo, contudo tambem apresentaram mais eventos hemorragicos. Usuarios da femprocumona eram mais jovens e estavam utilizando a anticoagulacao oral por um periodo maior, tendo apresentado menos efeitos adversos dessas medicacoes.BACKGROUNDnOral anticoagulants are broadly used in cardiology. However, it is still necessary to evaluate their use in clinical practice.nnnOBJECTIVESnTo describe the differences in the maintenance of anticoagulation control, as well as the incidence of hemorrhagic and thromboembolic events among users of warfarin and phenprocoumon.nnnMETHODSnNon-concurrent cohort study of 127 patients using oral anticoagulation.nnnRESULTSnPhenprocoumon was the most frequently used anticoagulant in 60% of the patients. The prevalence of RNI<2 at the last medical appointment was higher among warfarin users (46% vs. 19.5%; p<0.001). During the follow-up, Phenprocoumon users were within the therapeutic range during 60.7% of the period, in comparison with 45.6% of warfarin users (OR:1.84; 95%CI:1.59-2.13; P<0.001). The incidence of bleeding was 5.3/100 patients/year in the phenprocoumon group versus 18.8/100 patients/year in the warfarin group (RR: 3.5; 95%CI: 1.87-6.48; P<0.001).nnnCONCLUSIONnPatients that used Warfarin remained at subtherapeutic levels for a longer period; however, they also presented more hemorrhagic events. Phenprocoumon users were younger and had been using oral anticoagulation for longer periods, presenting fewer drug-related adverse events.

II DIRETRIZ BRASILEIRA DE CARDIOPATIA GRAVE

NTRODUCAOInumeras pesquisas tem demonstrado que, se, por um lado, a expectativa de vida do brasileiro cresceu nos ultimos dez anos, ha, por outro, um indice muito maior de doencas cardiovasculares. Verifi cou-se, entre essas, o incremento de situacoes graves, que impedem o retorno de muitos pacientes ao trabalho. Tornou-se, entao, fundamental conceituar Cardiopatia Grave, para a orientacao tanto do cardiologista como de colegas de outras especialidades. Com essa intencao, a Sociedade Brasileira de Cardiologia propos esta Diretriz.O termo Cardiopatia Grave aparece pela primeira vez na legislacao brasileira com a Lei n.o 1711 (item III, do Artigo 178) do Estatuto dos Funcionarios Civis da Uniao, sancionada em 28 de outubro de 1952, que visava benefi ciar os pacientes acometidos de molestia profi ssional, acidente em servico, tuberculose ativa, alienacao mental, neoplasia maligna, cegueira, lepra, paralisia irreversivel e incapacitante, cardiopatia grave e estados avancados da doenca de Paget (osteite deformante). Esta lei foi reeditada em outras ocasioes, sem modifi cacoes signifi cativas. A partir de 1.o de janeiro de 1989, passou a vigorar como a Lei 7713/88, incluindo, entao, a sindrome de imunodefi ciencia adquirida (SIDA/AIDS) e benefi ciando os pacientes acometidos pelas mesmas doencas listadas na lei anterior, mesmo que tenham sido contraidas depois da aposentadoria ou reforma (Artigos 6.o, XVI e 57.o). Em 30 de dezembro de 2004, foi publicada, no Diario Ofi cial da Uniao, a inclusao das hepatopatias graves, nefropatias graves, doencas causadas por radiacao ionizante e a doenca de Parkinson, como merecedoras do mesmo beneficio. Em 1952, uma comissao multidisciplinar de medicos enunciou o conceito de Cardiopatia Grave como doenca que leva, em carater temporario ou permanente, a reducao da capacidade funcional do coracao, a ponto de acarretar risco a vida ou impedir o servidor de exercer as suas atividades. A incapacitacao laboral deve ser avaliada por pericia medica. Nesse procedimento, o segurado ou paciente, vitima de uma doenca ou acidente de trabalho, e examinado por um profi ssional especializado (medico-perito), que avalia as condicoes de saude e a capacidade laborativa, decidindo sobre a conveniencia do afastamento ou o retorno as atividades laborativas habituais, de acordo com as normatizacoes contidas nos Estatutos do Funcionalismo Publico Civil ou Militar dos municipios, estados e federacao (Manual do Medico Perito, 1980; Pericia Medica, 1990).O medico-perito, diferentemente do medico-cardiologista-clinico, nao exerce a medicina clinica, pois nao cuida de enfermos. Utiliza os conhecimentos medicos apenas para estabelecer o diagnostico e o prognostico clinico, para julgar a capacidade laborativa e sua imputabilidade. Assim, a atividade e o conhecimento pericial sugerem uma especialidade de cunho medico-judicial, na qual, alem dos conhecimentos profundos de clinica, existe a necessidade de uma postura, raciocinio e julgamento, como fi m. A adaptacao do conhecimento medico as exigencias das normas legais realiza-se com criterios e principios diferentes dos que regem a apreciacao dos problemas clinicos. As exigencias da medicina clinica sao diferentes da pericial, que se ve envolvida com a legislacao, que devem sustentar o parecer pericial.A medicina pericial exercida atualmente em muito difere da praticada ha 30 ou 40 anos. Mais do que nunca, passou-se a exigir a comprovacao diagnostica por meio de uma rigorosa avaliacao clinica e comprovacao laboratorial (metodos complementares nao-invasivos e invasivos), evitando-se as conclusoes baseadas em impressoes subjetivas ou alegacoes emanadas dos pacientes, sem o corroborativo laboratorial, tao sujeitas a erros ou interpretacoes enganosas.

Comparison of Surgical Cut and Sew versus Radiofrequency Pulmonary Veins Isolation for Chronic Permanent Atrial Fibrillation: A Randomized Study

Background: Surgical pulmonary veins isolation (PVI) is done to restore sinus rhythm (SR) in patients with chronic permanent atrial fibrillation (CPAF) and mitral valve disease. Here we compare the efficacy of electrical block lines performed with radiofrequency (RF) compared with conventional surgery.