Heitor Ghissoni de Carvalho

Resultados iniciais do transplante de células de medula óssea para o miocárdio de pacientes com insuficiência cardíaca de etiologia chagásica

OBJECTIVE To evaluate early effects of bone marrow cell transplantation to the myocardium of patients with heart failure (CHF) due to Chagas disease. METHODS We studied 28 patients (mean age 52.2 +/- 9.9), of whom 24 were male. Despite optimized treatment, 25 patients were in NYHA class III and three patients, in NYHA class IV. The procedure consisted of aspiration of 50 mL of bone marrow, separation of the mononuclear fraction, and intracoronary injection. Effects on left ventricle ejection fraction (LVEF), distance walked in the six-minute walking test, quality-of-life, NYHA class, arrhythmogenic and biochemical parameters, were all evaluated. RESULTS There were no complications directly related to the procedure. Baseline left ventricular ejection fraction was 20.1 +/- 6.8%, and 60 days after transplantation it increased to 23.0 +/- 9.0%, p = 0.02. Significant improvements were observed in the NYHA class (3.1 +/- 0.3 to 1.8 +/- 0.5; p < 0.0001); quality-of-life (50.9 +/- 11.7 to 21.8 +/- 13.4; p < 0.0001); and distance walked in six minutes (355 +/- 136 m to 443 +/- 110 m; p = 0,003). The number of ventricular premature beats in 24 hours tended to increase (5,322 +/- 4,977 to 7,441 +/- 7,955; p = 0,062), but without increase in ventricular tachycardia episodes (61 +/- 127 to 54 +/- 127; p = 0.27). CONCLUSION Our data demonstrate for the first time that intracoronary injection of bone marrow mononuclear cells is feasible and suggest that it may be potentially safe and effective in patients with CHF due to Chagas disease.

Bone marrow cell transplantation in chagas' disease heart failure: report of the first human experience

FUNDAMENTO: Insuficiencia cardiaca (IC) causada por Doenca de Chagas (DC) e uma cardiomiopatia inflamatoria progressiva que afeta milhoes de pessoas na America Latina. Estudos com modelos de camundongo de IC devido a DC indicam que o transplante de celulas mononucleares derivadas da medula ossea (TCDMO) pode reduzir a inflamacao, fibrose e melhorar a funcao miocardica. OBJETIVO: O proposito desse estudo foi avaliar, pela primeira vez em seres humanos, a seguranca e a eficacia de TCDMO no miocardio de pacientes com IC devido a DC. METODOS: Um total de 28 pacientes com IC devido a DC (media de idade de 52,2 ± 9,9 anos) com classe funcional NYHA III e IV foram submetidos a TCDMO atraves de injecao coronariana. Os efeitos na fracao de ejecao do ventriculo esquerdo (FEVE), capacidade funcional, qualidade de vida, arritmias e parâmetros bioquimicos, imunologicos e neuro-humorais foram avaliados. RESULTADOS: Nao houve complicacoes diretamente relacionadas ao procedimento. A FEVE foi 20,1 ± 6,8% e 28,3 ± 7,9%, p < 0,03 a nivel basal e 180 dias apos o procedimento, respectivamente. No mesmo periodo, melhoras significantes foram observadas na classe funcional NYHA (3,1 ± 0,3 para 1,8 ± 0,5; p < 0,001), qualidade de vida (50,9 ± 11,7 para 25,1 ± 15,9; p < 0,001), e no teste de caminhada de seis minutos (355 ± 136 m para 437 ± 94 m; p < 0,01). Nao houve alteracoes nos marcadores de ativacao imune ou neurohormonais. Nenhuma complicacao foi registrada. CONCLUSAO: Nossos dados sugerem que a injecao intracoronariana de celulas derivadas da medula ossea e segura e potencialmente efetiva em pacientes com IC devido a DC. A extensao do beneficio, entretanto, parece ser discreta e precisa ser confirmada em estudos clinicos maiores, randomizados, duplo-cegos, controlados com placebo.

Intervençoes percutâneas para revascularização do miocárdio no Brasil em 1996 e 1997 comparadas as do biênio 1992 e 1993. Relatório do registro CENIC (Central Nacional de Intervenoes Cardiovasculares)

PURPOSE To report the results of percutaneous coronary interventions, in Brazil, in the years 1996-97, comparing them to those of 1992-93. METHODS Data were collected in a standard form and the 1996-97 results were compared to those of 1992-93. RESULTS The current Registry received data from 79% effective members of the SBHCI in 127 hospitals, including 22,025 patients, 60.67% of whom underwent PTCA, 36.57% stent implantation, 2.3% PTRA, 0.06% DCA and 0.4% laser angioplasty. Balloon angioplasty was the most frequent procedure in 1996-97, but its overall rate fell from 6.75% to 55.8% (p = 0.0001) concomitantly, there was a 35% relative increase in the use of stents from 1992-93 to 1996-97. The success rate of the later period was higher (89.7% vs 92.8%, p = 0.000001), with lower residual stenosis (22% vs 19%, p = 0.001). Besides, there were lower major complications rates: acute myocardial infarction (2.5% vs 1.2%, p = 0.002) and death (1.8% vs 1.4%, p = 0.0003). CONCLUSION The procedures most often carried out in both periods were balloon angioplasty (60.67%) and implantation of stents (36.57%); the success rate high, abrupt closure rate was low (1.5%). These favorable results corroborate the high standards of the Brazilian Interventional Cardiology.PURPOSE: To report the results of percutaneous coronary interventions, in Brazil, in the years 1996-97, comparing them to those of 1992-93. METHODS: Data were collected in a standard form and the 1996-97 results were compared to those of 1992-93. RESULTS: The current Registry received data from 79% effective members of the SBHCI in 127 hospitals, including 22,025 patients, 60.67% of whom underwent PTCA, 36.57% stent implantation, 2.3% PTRA, 0.06% DCA and 0.4% laser angioplasty. Balloon angioplasty was the most frequent procedure in 1996-97, but its overall rate fell from 65.7% to 55.8% (p=0.0001) concomitantly, there was a 35% relative increase in the use of stents from 1992-93 to 1996-97. The success rate of the later period was higher (89.7% vs 92.8%, p=0.000001), with lower residual stenosis (22% vs 19%, p=0.001). Besides, there were lower major complications rates: acute myocardial infarction (2.5% vs 1.2%, p=0.002) and death (1.8% vs 1.4%, p=0,0003). CONCLUSION: The procedures most often carried out in both periods were balloon angioplasty (60.67%) and implantation of stents (36.57%); the success rate high, abrupt closure rate was low (1.5%). These favorable results corroborate the high standards of the Brazilian Interventional Cardiology.

Sedative and cardiovascular effects of midazolam and diazepam alone or combined with clonidine in patients undergoing hemodynamic studies for suspected coronary artery disease

BACKGROUND Sedation during coronary angiography has been rarely studied, and it is important to know which drug is the best to sedate these patients. OBJECTIVE To evaluate the quality of sedation and the effects of midazolam and diazepam alone or combined with clonidine on the heart rate (HR) and blood pressure (BP) of patients with suspected coronary artery disease. METHODS This is a controlled, randomized, double-blind, prospective clinical study of 160 patients divided into five groups of 32 patients each, according to the drug used: group C (clonidine 0.5 microg/kg); group M (midazolam 40 microg/kg); group MC (combination of midazolam 40 microg/kg and clonidine 0.5 microg/kg); group D (diazepam 40 microg/kg); and group DC (combination of diazepam 40 microg/kg and clonidine 0.5 microg/kg). Sedation was evaluated based on the Ramsay scale and on the use of meperidine 0.04 mg.kg-1. Invasive BP monitoring, HR and the sedation score were analyzed every five minutes at four different time points. RESULTS Patients who received midazolam presented higher sedation scores as well as HR and BP variation (p < 0.05). Those who received diazepam or clonidine had lower sedation scores, which were more satisfactory for the performance of the procedure, and presented a lower BP and HR variation (p > 0.05). CONCLUSION Midazolam was associated with a greater sedative and cardiovascular effect, whereas for diazepam these effects were less intense. Clonidine and diazepam had similar effects on BP, HR and sedation.FUNDAMENTO: A sedacao durante a cineangiocoronariografia tem sido pouco estudada e saber qual e a melhor droga para sedar esses pacientes e um questionamento importante. OBJETIVO: Avaliar a qualidade da sedacao e os efeitos sobre a frequencia cardiaca (FC) e a pressao arterial (PA) do midazolam e do diazepam, associados ou nao a clonidina, em pacientes com suspeita de doenca coronariana. METODOS: Foi desenvolvido ensaio clinico prospectivo, duplo-cego, randomizado, controlado, com 160 pacientes divididos em cinco grupos de 32 pacientes cada, de acordo com o farmaco utilizado: grupo C (clonidina 0,5 µg/kg); grupo M (midazolam 40 µg/kg); grupo MC (associacao de midazolam 40 µg/kg e clonidina 0,5 µg/kg); grupo D (diazepam 40 µg.kg); e grupo DC (associacao de diazepam 40 µg/kg e clonidina 0,5 µg/kg). A sedacao foi avaliada com base na escala de Ramsay e no consumo de meperidina 0,04 mg.kg-1. A PA invasiva, a FC e o escore de sedacao foram analisados a cada cinco minutos em quatro diferentes momentos. RESULTADOS: Os pacientes que utilizaram midazolam apresentaram maiores escores de sedacao e variacao da FC e da PA (p 0,05). CONCLUSAO: O midazolam foi associado a maior efeito sedativo e cardiovascular enquanto o diazepam causou menor efeito sedativo e cardiovascular. A clonidina e o diazepam tiveram efeitos semelhantes na PA, na FC e na sedacao.

Transradial approach for coronary interventions

OBJECTIVE To assess the feasibility and safety of coronary interventions performed through the radial artery. METHODS We studied 103 patients with ages from 38 to 86 years (57+/-8.7), 90 (87%) males, and: radial pulse with a good amplitude, presence of ulnar pulse, a good collateral flow through the palmar arch assessed with the Allens test. RESULTS The vascular approach was obtained in 97 (94%) patients, 88 (91%) treated electively and 9 (9%) during acute myocardial infarction, for primary angioplasty; 56 (64%) unstable angina; 22 (25%) stable angina; 10 (11%) were asymptomatic, 6 referred for recanalization of chronic occlusion and 4 silent ischemia in the first week after acute myocardial infarction. We approached 107 arteries: anterior descending artery, 49 (46%); right coronary artery, 27 (25%); circumflex artery, 25 (23%); diagonal artery, 6 (6%); and 2 saphenous vein bypass grafts. We treated 129 lesions: 80 (62%) B2 type; 23 (18%) B1 type; 17 (13%) C type; and 9 (7%). A type. There were 70 stents, and 59 balloon angioplasties performed. Thirty-two (33%) patients used GP IIb/IIIa inhibitors. The mean duration of the elective procedure was 42.3+/-12.8 min. Success, correct stent deployment and residual lesion <20%, was reached in 100% of the lesions treated with stent implantation; arterial dilation with residual lesion <50% was obtained in 96% of the lesions treated with transluminal coronary angioplasty (TCA). Complications, were: 1 (1.0%) non-Q-wave acute myocardial infarction; 2 (2%) hematomas in the forearm; and 2 losses of radial pulse. CONCLUSION Radial artery approach is practical and safe for percutaneous coronary interventions there was a low incidence of complications.

Transplante de células da medula óssea na insuficiência cardíaca chagásica: relato da primeira experiência humana

FUNDAMENTO: Insuficiencia cardiaca (IC) causada por Doenca de Chagas (DC) e uma cardiomiopatia inflamatoria progressiva que afeta milhoes de pessoas na America Latina. Estudos com modelos de camundongo de IC devido a DC indicam que o transplante de celulas mononucleares derivadas da medula ossea (TCDMO) pode reduzir a inflamacao, fibrose e melhorar a funcao miocardica. OBJETIVO: O proposito desse estudo foi avaliar, pela primeira vez em seres humanos, a seguranca e a eficacia de TCDMO no miocardio de pacientes com IC devido a DC. METODOS: Um total de 28 pacientes com IC devido a DC (media de idade de 52,2 ± 9,9 anos) com classe funcional NYHA III e IV foram submetidos a TCDMO atraves de injecao coronariana. Os efeitos na fracao de ejecao do ventriculo esquerdo (FEVE), capacidade funcional, qualidade de vida, arritmias e parâmetros bioquimicos, imunologicos e neuro-humorais foram avaliados. RESULTADOS: Nao houve complicacoes diretamente relacionadas ao procedimento. A FEVE foi 20,1 ± 6,8% e 28,3 ± 7,9%, p < 0,03 a nivel basal e 180 dias apos o procedimento, respectivamente. No mesmo periodo, melhoras significantes foram observadas na classe funcional NYHA (3,1 ± 0,3 para 1,8 ± 0,5; p < 0,001), qualidade de vida (50,9 ± 11,7 para 25,1 ± 15,9; p < 0,001), e no teste de caminhada de seis minutos (355 ± 136 m para 437 ± 94 m; p < 0,01). Nao houve alteracoes nos marcadores de ativacao imune ou neurohormonais. Nenhuma complicacao foi registrada. CONCLUSAO: Nossos dados sugerem que a injecao intracoronariana de celulas derivadas da medula ossea e segura e potencialmente efetiva em pacientes com IC devido a DC. A extensao do beneficio, entretanto, parece ser discreta e precisa ser confirmada em estudos clinicos maiores, randomizados, duplo-cegos, controlados com placebo.

Clonidine in Cineangiocardiography: Sedative Effects on Blood Pressure and Heart Rate

OBJECTIVE To evaluate the effects of clonidine on heart rate (HR), and blood pressure (BP) as well as its sedative effect on patients submitted to a cineangiocardiography. METHODS A randomized, controlled, double blind, prospective clinical trial was conducted on 62 patients submitted to an elective cineangiocardiography. The patients were divided in two groups: the clonidine group, that were administered a 0.8 microg/kg dose of this drug and the control group, that were administered a 0.9% saline solution. Sedation was evaluated based on the Ramsay Scale and the administration of a 0.04 mg/kg dose of meperidine that was given to the patients who were agitated or anxious during the procedure. The invasive BP, HR and sedation score based on the Ramsay Scale were analyzed every 5 minutes and four different intervals were considered for the assessment: I1- start of the test; I2- 5 minutes after the start of the test; I3- median time of the test and I4- end of the test. RESULTS The clonidine group presented better BP and HR stability and sedation efficacy while the control group presented a higher intake of meperidine (p<0.05). In the statistical analysis, the inference of the continuous variables was calculated using the Students t-test or Mann-Whitney test and the chi2 or Fisher Exact Probability test was used for the categorical variables. CONCLUSION This study demonstrated that clonidine was an efficient means to control BP and HR and provided a conscious sedation for patients submitted to a cineangiocardiography.

Cirurgia orovalvar na criança: experiência de 135 casos

Valvular surgery was performed in 135 patients under the age of 15 years during the period between February 1975 and February 1986. They are devided in two groups: group I) plastic repair, 60 patients; group II) prosthetic surgery, 75 patients. In group I hospital mortality was 7%. Were lost to follow-up 34% of the survivors. Among the patients under control, 72% have no symptoms. 5% died and 22% have had another surgery for prosthesis placement. In group II hospital mortality was 12% and 20% of survivors were lost to follow-up. Of the remaining patients, 71 % have no, or few symptoms, 4% are symptomatic and not doing well; 13% have died and 23% have had a second operation. In conclusion, we think that every effort should be made to preserve native valves in this young group of patients.

The anatomicopathological findings in jatene's procedure

At present, the most promising technique for correcting transposition of the great arteries is the arterial switch with coronary reimplantation, which is also being used to correct the Taussig-Bing double outlet right ventricle. A study was undertaken in 5 postmortem hearts from 11 patients aged from 2 to 17 months (average 10.6) who underwent surgery in Salvador, Brazil, between November 1976 and October 1980. Four of these patients died during surgery and 1 soon after. The anatomical diagnoses were transposition of the great arteries in 4 and double outlet right ventricle in 1. The anatomy of each heart was carefully studied, revealing some outstanding aspects: the interatrial septum was intact in 1 case, there was a patent foramem ovale in 2, an atrial septal defect created by atrioseptostomy in 1, and a single atrium in 1; the interventricular septum was intact in 2 cases, a ventricular septal defect of the membranous and muscular type was found in 1 and an atrioventricular canal type in 2; a ventriculotomy (40 mm) for closing a ventricular septal defect was seen in 2 cases; a shortened aortic stump was found in 3 cases and in 1 of these it had been necessary to interpose a dacron conduit between this stump and the pulmonary artery segment; a shortened pulmonary artery stump was seen in 3 cases; the caliber of the pulmonary artery stump had been reduced by 10 mm in 1 of the cases to facilitate anastomosis with the pulmonary artery stump; in 2 cases there was a retraction at the level of the anastomosis between the pulmonary artery stump and the aortic segment due to disproportionate calibers; in 3 cases there was a partial occlusion of the left coronary ostium, and in still another case the right coronary ostium was also partially occluded; displacement of coronary artery ostia from their original sites to new ones ranged from 5 to 13 mm (average 8.5 mm) for the right coronary artery and from 5 to 7 mm (average 6.5 mm) for the left coronary artery; in 1 case the left coronary artery was completely occluded very close to its point of origin, due to torsion and folding.

Prevalência de estenose da artéria subclávia em pacientes candidatos a cirurgia de revascularização do miocárdio: registro multicêntrico

BACKGROUND: Approximately 90% of the patients submitted to coronary artery bypass graft surgery (CABG) receive a left internal thoracic artery (LITA) graft. Stenosis of the left subclavian artery can result in graft failure due to restricted coronary flow. The prevalence of stenosis of the left subclavian artery in patients with severe coronary atherosclerosis, deemed candidates to CABG, is not known. OBJECTIVE: To assess the prevalence of stenosis of left subclavian artery in CABG candidates, as well as the diagnostic effectiveness of clinical evaluation. METHODS: In a multicenter registry, selective angiography of the left subclavian artery was carried out in patients considered candidates to CABG during coronary cineangiography. Stenoses > 50% proximal to the origin of the LITA were considered significant. RESULTS: A total of 205 patients were included. Significant stenosis of the left subclavian artery was observed in 16 (7.8%) patients. Noninvasive differential arterial blood pressure measurement > 10 mmHg between both arms showed low sensitivity (37.5%) and low positive predictive value (13.3%) for stenosis identification. No clinical predictors of significant stenosis were identified by univariate analysis. CONCLUSION: Stenosis of the left subclavian artery is not uncommon in CABG candidates. Noninvasive blood pressure gradient between both arms has low diagnostic accuracy. Therefore, in patients candidates to CABG, selective angiography of the left subclavian artery should be considered, because of the risk of reduced flow and coronary-subclavian steal syndrome in patients with non-diagnosed stenosis of the subclavian artery who receive a LITA graft.