Henry Abensur

Home blood pressure monitoring in blood pressure control among haemodialysis patients: an open randomized clinical trial

BACKGROUND It is not known if the adjustment of antihypertensive therapy based on home blood pressure monitoring (HBPM) can improve blood pressure (BP) control among haemodialysis patients. METHODS This is an open randomized clinical trial. Hypertensive patients on haemodialysis were randomized to have the antihypertensive therapy adjusted based on predialysis BP measurements or HBPM. Before and after 6 months of follow-up, patients were submitted to ambulatory blood pressure monitoring (ABPM) for 24 h, HBPM during 1 week and echocardiogram. RESULTS A total of 34 and 31 patients completed the study in the HBPM and predialysis BP groups, respectively. At the end of study, the systolic (SBP) and diastolic (DBP) blood pressure during the interdialytic period measured by ABPM were significantly lower in the HBPM group in relation to the predialysis BP group (mean 24-h BP: 135 +/- 12 mmHg/76 +/- 7 mmHg versus 147 +/- 15 mmHg/79 +/- 8 mmHg; P < 0.05). In the HBPM analysis, the HBPM group showed a significant reduction only in SBP compared to the predialysis BP group (weekly mean: 144 +/- 21 mmHg versus 154 +/- 22 mmHg; P < 0.05). There were no differences between the HBPM and predialysis BP groups in relation to the left ventricular mass index at the end of the study (108 +/- 35 g/m(2) versus 110 +/- 33 g/m(2); P > 0.05). CONCLUSIONS Decision making based on HBPM among haemodialysis patients has led to a better BP control during the interdialytic period in comparison with predialysis BP measurements. HBPM may be a useful adjuvant instrument for blood pressure control among haemodialysis patients.

Blood Pressure Influences the Occurrence of Complex Ventricular Arrhythmia in Hemodialysis Patients

We investigated the relationship between blood pressure and the occurrence of complex ventricular arrhythmias (multiform, couplets, or runs) as assessed by 48-hour Holter monitoring in 74 stable long-term hemodialysis patients (44.5 +/- 12 years old; 54% men; 74% whites; dialysis duration, 51.3 +/- 36.1 months; systolic pressure, 146.6 +/- 19.3 mm Hg; diastolic pressure, 89.2 +/- 12.1 mm Hg; prevalence of arterial hypertension, 33.8%). Systolic and diastolic pressures represented the average of all predialysis determinations during the 3 months preceding the tests. Hemodialysis was performed midway through the Holter monitoring period. M-mode and bidimensional echocardiograms and myocardial perfusion tests were also obtained from all patients. Complex arrhythmias were observed in 37 individuals (50%). Univariate analysis showed that systolic pressure (P < .001), diastolic pressure (P < .05), age (P < .001), left ventricular posterior wall thickness (P < .01), left ventricular mass index (P < .05), and ischemic alterations on myocardial perfusion tests (P < .005) were significantly associated with complex arrhythmias. With the use of a multivariate model (stepwise logistic regression analysis) only systolic pressure (P < .01) and age (P < .05) were independently associated with complex arrhythmias. Sex; angina; dialysis duration; New York Heart Association functional class; use of digitalis; plasma levels of creatinine, sodium, potassium, calcium, and phosphate; hematocrit; left ventricular fractional shortening; left ventricular diastolic diameter; and ST segment deviation were not correlated with complex arrhythmias. The severity and frequency of complex arrhythmias were not influenced by hemodialysis. At follow-up (5 to 80 months) 5 patients had died of sudden death, 4 of whom were hypertensive and older than 45 years.(ABSTRACT TRUNCATED AT 250 WORDS)

Cutaneous Mycobacterium haemophilum infection in a kidney transplant recipient after acupuncture treatment

A.N. Castro‐Silva, A.O. Freire, R.S. Grinbaum, M.R. Elmor de Araújo, H. Abensur, M.R.T. Araújo, J.E. Romão Jr, J.L.M. Sampaio, I.L. Noronha. Cutaneous Mycobacterium haemophilum infection in a kidney transplant recipient after acupuncture treatment.
Transpl Infect Dis 2011: 13: 33–37. All rights reserved

Role of arterial hypertension in left ventricle hypertrophy in hemodialysis patients: an echocardiographic study.

To assess the role of arterial hypertension in left ventricle (LV) hypertrophy among hemodialysis patients, echocardiographic evaluation was performed in 10 hypertensive and 13 normotensive hemodialysis subjects matched for age, sex, race, duration of dialysis treatment and degree of interdialytic volume expansion. We excluded from the latter group patients with previous hypertension since hypertensive heart disease may persist after adequate blood pressure control. We also studied 17 normal controls and 10 non-uremic patients with essential hypertension. Comparisons between the two uremic groups showed that the hypertensive patients had a higher mass index (222 +/- 74 x 108 +/- 26, p = 0.0001) and posterior wall thickness (12 +/- 2 x 9 +/- 2, p = 0.0001) and a reduced LV radius/wall thickness ratio (4.4 +/- 0.7 x 5.8 +/- 1, p = 0.0001). There were no significant echocardiographic differences between normal controls and normotensive uremics. In contrast, compared to controls, hypertensive uremic patients showed an increased LV mass index (222 +/- 74 x 83 +/- 21, p = 0.0001) and posterior wall thickness (12 +/- 2 x 7 +/- 1, p = 0.0001) and a reduced LV radius/wall thickness ratio (4.4 +/- 0.7 x 6.5 +/- 1.1, p = 0.001), characterizing concentric hypertrophy. They also had ventricular dilation with larger LV dimensions than in controls (53 +/- 5 x 47 +/- 4, p = 0.004). In patients with essential hypertension, the mass index (135 +/- 22), wall thickness (11 +/- 1) and LV radius/wall thickness ratio (4.3 +/- 0.7) significantly differed (p = 0.0001) from those in the controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Endocardite em válvula de Eustáquio

Eustachian valve endocarditis is a rare condition that affects mostly injectable drug users and patients using pacemakers or central venous catheter. We describe the case of a patient who underwent myocardial revascularization with extracorporeal circulation and who presented Eustachian valve endocarditis in the postoperative period, diagnosed by echocardiogram. The blood culture identified Klebsiella pneumoniae. He received appropriate antibiotic therapy and presented resolution of the condition within four weeks.

Echocardiography in cardiac resynchronization therapy

Cardiac resynchronization therapy has been an effective option in patients with advanced heart failure. However, 20 to 30% of the patients do not benefit from this therapy. Clinical, electrocardiographic and echocardiographic criteria have been studied in an attempt to select patients who will benefit from a cardiac resynchronization therapy, and the echocardiogram is important both in the selection and in the evaluation and optimization of the therapy. The objective of this review is to describe the main echocardiographic parameters used in the evaluation of the cardiac resynchronization therapy.La terapia de resincronizacion cardiaca (TRC) viene siendo una opcion efectiva en los pacientes con insuficiencia cardiaca avanzada. Sin embargo, del 20% al 30% de los pacientes no presentan beneficios en esa terapeutica. Criterios clinicos, electrocardiograficos y ecocardiograficos estan siendo estudiados en el intento de seleccionar a los pacientes que se beneficiaran con la resincronizacion cardiaca, pero lo ecocardiograma juega un rol importante tanto en la seleccion como en la evaluacion y la optimizacion de esa terapeutica. El objetivo de esta revision es describir los principales parametros ecocardiograficos utilizados en la evaluacion de la terapia de resincronizacion cardiaca.

Resultados da cardiomioplastia no tratamento da cardiomiopatia dilatada

A cardiomioplastia tem sido proposta como uma alternativa ao transplante cardiaco no tratamento das cardiomiopatias isquemicas ou dilatadas. No periodo de maio de 1988 a outubro de 1990, 16 pacientes portadores de cardiomiopatia dilatada foram submetidos a cardiomioplastia no Instituto do Coracao. Dez pacientes estavam em classe funcional III e seis em classe IV. Nao houve obitos no periodo de pos-operatorio imediato. O tempo medio de seguimento foi de 16,9 ± 2,5 meses e a sobrevida atuarial foi 74% no 1o ano e 64,8% no 2o ano apos a cardiomioplastia, sendo influenciada pela ma evolucao dos pacientes operados com diâmetro de ventriculo esquerdo maior do que 80 mm. Esses valores foram superiores, contudo, a sobrevida de um e dois anos de 39,5 e 29,6%, respectivamente, apresentada pelo grupo controle de 20 pacientes mantidos clinicamente (p = 0,06). Cinco dos 11 pacientes em seguimento apos a cardiomioplastia, retornaram a classe funcional I e seis estao em classe II. Aos seis meses de pos-operatorio, foi documentada a elevacao da fracao de ejecao do ventriculo esquerdo de 20,1 ± 3,8 para 26 ± 7,8% pelo estudo radioisotopico (p < 0,01), sendo que esse parâmetro se alterou principalmente em pacientes com menor dilatacao da câmara ventricular esquerda. A Doppler-ecocardiografia mostrou que o encurtamento segmentar do ventriculo esquerdo se elevou de 12 ± 3,1 para 17,8 ± 2,3% (p < 0,01), enquanto que o volume sistolico aumentou de 23,6 ± 5,2 para 32,3 ± 7,9 ml (p < 0,01). Elevacoes semelhantes do indice sistolico, associados a queda da pressao em territorio pulmonar, foram tambem observadas pelo cateterismo cardiaco. O estudo ergoespirometrico documentou o aumento do consumo maximo de oxigenio de 14,9 ± 3,9 para 18,2 ± 3,4 ml/kg/min (p < 0,05). Um ano e aos 18 meses apos a operacao, as alteracoes decorrentes da cardiomioplastia permaneceram essencialmente as mesmas. Em conclusao, a cardiomioplastia melhora a funcao ventricular esquerda, reverte o quadro congestivo e melhora a sobrevida de pacientes portadores de cardiomiopatia dilatada. Fatores como a existencia de grande cardiomegalia podem, contudo, influenciar a evolucao tardia dos pacientes submetidos a este procedimento.

Papel do ecocardiograma na avaliação ventricular do coração transplantado versus rejeição cardíaca

BACKGROUND Heart transplantation is an alternative for individuals with end-stage heart disease. However, episodes of heart rejection (HR) are frequent and increase morbidity and mortality, requiring the use of an accurate non-invasive exam for their diagnosis, since endomyocardial biopsy (EMB) is not a complication-free procedure. OBJECTIVE To compare the parameters obtained by use of Doppler echocardiography in a group of transplanted patients with HR (TX1) and another group of transplanted patients without rejection (TX0), having as reference a control group (CG) and observing the behavior of the left ventricular systo-diastolic function expressed as the myocardial performance index (MPI) METHODS: Transthoracic echocardiographies were performed from January 2006 to January 2008 to prospectively assess 47 patients divided into three groups: CG (36.2%); TX0 (38.3%); and TX1 (25.5%). The MPI was compared between the groups, and data were analyzed by use of Fisher exact test and nonparametric Kruskal-Wallis test, both with significance level of 5%. RESULTS The groups did not differ regarding age, weight, height, and body surface. When compared to GC, TX0 and TX1 showed a change in the left ventricular systo-diastolic function, expressed as an increase in MPI, which was greater in TX1 [0.38 (0.29 - 0.44); 0.47 (0.43 - 0.56); 0.58 (0.52 - 0.74), respectively; p < 0.001]. CONCLUSION Echocardiography was a very accurate test to detect changes in the systo-diastolic function of the transplanted heart; however, it did not prove to be reliable to replace BEM in the safe diagnosis of HR.

Aneurisma de apêndice atrial esquerdo: diagnóstico ecocardiográfico

O aneurisma de apendice atrial esquerdo e condicao rara que se manifesta frequentemente por arritmias cardiacas ou tromboembolismo. Relatamos um caso de paciente portador de aneurisma de apendice atrial esquerdo, diagnosticado pela ecocardiografia e submetido a resseccao cirurgica.

Defeito do anel fibroso mitral posterior com aneurisma de átrio esquerdo e insuficiência mitral: tratamento cirúrgico com sucesso

Atrial aneurysm is a rare condition and can be found on the atrial appendage or on the atrial wall. Most patients are asymptomatic, but arrhythmias, thromboembolism, and heart failure are common complications. We present a 39 years old female patient with posterior mitral ring defect causing a great aneurysm of the left posterior atrial wall with mitral insufficiency. The diagnosis was achieved by chest roentgenogram (marked prominence of the upper left heart border) and echocardiography (great left atrial aneurysm behind the left posterior ventricular wall with mitral insufficiency). Left ventricular cineangiogram suggested the presence of a false aneurysm of the left ventricle. The patient subsequently underwent surgical treatment with cardiopulmonary bypass. Posterior mitral valve annuloplasty was performed with aneurysm exclusion and posterior left atrial wall reconstruction using a bovine pericardial patch. The postoperative course was uneventful, and the patient was discharged sympton-free on the eighth postoperative day.