Humberto Felício Gonçalves de Freitas

Periodic breathing during incremental exercise predicts mortality in patients with chronic heart failure evaluated for cardiac transplantation

OBJECTIVES We hypothesized that exercise-related periodic breathing (EPB) would be associated with poor prognosis in advanced chronic heart failure (CHF). BACKGROUND Patients with CHF might present instability of the ventilatory control system characterized by cyclic waxing and waning of tidal volume (periodic breathing [PB]). This condition is associated with several deleterious circulatory and neuro-endocrine responses; in fact, PB in awake and asleep patients has been identified as an independent risk factor for cardiac death. During exercise, however, the prognostic value of PB is still unknown in CHF patients awaiting heart transplantation. METHODS Eighty-four patients with established CHF (65 male, 19 female) were submitted to clinical evaluation, echocardiogram, ventricular scintigraphy, determination of resting serum norepinephrine levels, and an incremental cardiopulmonary exercise test on cycle ergometer. Patients were followed for up to 49.7 months (median = 15.3), and 26 patients (30.9%) died during this period. RESULTS Twenty-five of 84 patients presented EPB (29.7%). The following variables were related to mortality according to Kaplan-Meier and univariate Cox regression analysis: EPB (p = 0.004), New York Heart Association class (p = 0.04), serum norepinephrine (p = 0.06), peak oxygen uptake (ml.min(-1).kg(-1) and % predicted; p = 0.085 and p = 0.10, respectively), slope of the ratio of change in minute ventilation to change in carbon dioxide output during exercise (p = 0.10), and scintigraphic left ventricular ejection fraction (p = 0.10). Cox multivariate analysis identified EPB as the only independent variable for cardiac death prediction (p = 0.007). Therefore, EPB alone was associated with a 2.97-fold increase in risk of death in this population (95% confidence interval = 1.34 to 6.54). CONCLUSIONS Exercise-related periodic breathing independently predicts cardiac mortality in CHF patients considered for heart transplantation.

Heart transplantation in a patient with endomyocardial fibrosis

A endomiocardiofibrose e uma doenca comum em paises tropicais, particularmente Uganda e Nigeria, e pode acometer tanto o ventriculo esquerdo como direito, gerando uma insuficiencia cardiaca restritiva que, alem dos sintomas classicos, manifesta-se por ascite desproporcional ao edema periferico. Apresentamos o caso de uma portadora de endomiocardiofibrose refrataria ao tratamento clinico, submetida ao tratamento cirurgico com melhora clinica por curto periodo, voltando a apresentar sintomas incapacitantes tres meses apos a cirurgia de resseccao de fibrose endomiocardica e plastia tricuspide. A paciente foi entao submetida a transplante cardiaco ortotopico bicaval, com boa evolucao clinica. E o primeiro caso de transplante cardiaco nesta doenca, mostrando-se uma alternativa de tratamento promissora.

Massa Ventricular Esquerda em Portadores de Insuficiência Cardíaca

OBJETIVO: Avaliar a massa ventricular esquerda em pacientes com insuficiencia cardiaca, as correlacoes com outras variaveis clinicas e com o prognostico. METODOS: Foram estudados 587 pacientes com idades entre 13,8 anos e 68,9 anos, 461 (78,5%) homens e 126 (21,5%) mulheres. A massa ventricular esquerda foi estimada com o uso do ecocardiograma no modo M e indexada pela altura. RESULTADOS: O indice da massa ventricular esquerda variou de 35,3 g/m a 333,5 g/m e aumentou conforme a idade. O indice da massa ventricular esquerda foi maior nos homens (media 175,7 g/m) do que nas mulheres (media 165,7 g/m). O indice da massa ventricular esquerda foi maior nos portadores de cardiomiopatia hipertensiva (media 188,1 g/m), de cardiomiopatia dilatada idiopatica (media 177,7 g/m) e de cardiomiopatias de outras etiologias (media 175,1 g/m) do que nos portadores de cardiomiopatia chagasica (media 164,3 g/m) e isquemica (media 162 g/m). O indice da massa ventricular esquerda de portadores de insuficiencia cardiaca demonstrou associacao com a idade, o sexo, a etiologia e o diâmetro do atrio esquerdo. A correlacao com a fracao de ejecao do ventriculo esquerdo foi negativa - o aumento do indice da massa ventricular esquerda associou-se a reducao da fracao de ejecao. O risco relativo de obito foi 1,22 para cada acrescimo de 50 g/m no indice da massa ventricular esquerda. CONCLUSOES: A estimacao da massa ventricular esquerda pode contribuir para a avaliacao prognostica de portadores de insuficiencia cardiaca.

Exercise-Induced Muscle Vasodilatation and Treadmill Exercise Test Responses in Individuals without Overt Heart Disease

Background: The beneficial effects of exercise on cardiovascular health may be related to the improvement in several physiologic pathways, including peripheral vascular function. The aim of this study was to evaluate the relationship between cardiovascular responses during the treadmill exercise test and exercise-induced muscle vasodilatation in individuals without overt heart disease. Methods: The study included 796 asymptomatic subjects (431 females and 365 males) without overt heart disease. We evaluated the heart rate (chronotropic reserve and heart rate recovery), blood pressure (maximum systolic and diastolic blood pressure as well as systolic blood pressure recovery) and exercise capacity during symptom-limited treadmill exercise testing. Exercise-induced muscle vasodilatation was studied with venous occlusion plethysmography and estimated by forearm blood flow and vascular conductance responses during a 3-min handgrip maneuver. Results: Forearm blood flow increase during the handgrip exercise was positively associated with heart rate recovery during treadmill exercise testing (p < 0.001). Forearm vascular conductance increase during the handgrip exercise was inversely associated with exercise diastolic blood pressure during exercise treadmill testing (p = 0.038). No significant association was found between exercise capacity and exercise-induced muscle vasodilation. Conclusion: In a sample of individuals without overt heart disease, exercise-induced muscle vasodilatation was associated with heart rate and blood pressure responses during treadmill exercise testing, but was not associated with exercise capacity. These findings suggest that favorable hemodynamic and chronotropic responses are associated with better vasodilator capacity, but exercise capacity does not predict muscle vasodilatation.

Assistência circulatória em choque cardiogênico pós-infarto agudo do miocárdio

Em pacientes com insuficiencia coronariana aguda e choque cardiogenico, a mortalidade e alta. O dispositivo mais utilizado para suporte hemodinâmico e o balao intra-aortico que, no entanto, pode ser insuficiente em pacientes com choque cardiogenico refratario. Relato de caso com dois dias de dor precordial opressiva e intensa, irradiada para membro superior esquerdo. ECG com supradesnivelamento anterior. Realizado angioplastia e implante de stent na arteria descendente anterior. Evolucao com choque cardiogenico refratario ao uso de drogas vasoativas e balao intra-aortico. Foram realizadas medidas hemodinâmicas e decidiu-se pela colocacao do Impella® 2,5 por via percutânea para assistencia circulatoria.

Endocardite infecciosa com apresentação inicial de abdome agudo

A 35-year-old patient was seen in an Emergency Department. with six hours of pain in the right iliac fossa and fever. The hypothesis diagnosis was acute appendicitis and an exploring laparotomy for appendectomy was carried out. The patient returned to the hospital three days after having been discharged. debilitated. feverish. having alterations in speech. reduction in the level of consciousness and complete hemiparesis to the left. The computed tomography scan of the skull and the liquor puncture were normal. Cerebral magnetic resonance image showed aspects compatible with vertebrobasilar ischemic stroke. Transesphofagic echocardiogram showed vegetation of the aortic valve and moderate aortic insufficiency. Blood cultures were positive for Enterococcus bovis.Paciente de 35 anos de idade foi atendido em Servico de Emergencia com seis horas de dor em fossa iliaca direita e febre. Feita hipotese diagnostica de apendicite aguda e realizada laparotomia exploradora. com apendicectomia. O paciente retornou ao hospital tres dias apos alta hospitalar. prostrado. febril. com alteracao de fala. diminuicao de nivel de consciencia e com hemiparesia completa a esquerda. CT scan de crânio e puncao de liquor normal. RMN de encefalo revelou aspectos compativeis com AVC isquemico vertebro-basilar. Ecocardiograma transesofagico demonstrou vegetacao em valva aortica e insuficiencia aortica moderada e hemoculturas foram positivas para Enterococcus bovis.

Endocarditis infecciosa con presentación inicial de abdomen agudo

A 35-year-old patient was seen in an Emergency Department. with six hours of pain in the right iliac fossa and fever. The hypothesis diagnosis was acute appendicitis and an exploring laparotomy for appendectomy was carried out. The patient returned to the hospital three days after having been discharged. debilitated. feverish. having alterations in speech. reduction in the level of consciousness and complete hemiparesis to the left. The computed tomography scan of the skull and the liquor puncture were normal. Cerebral magnetic resonance image showed aspects compatible with vertebrobasilar ischemic stroke. Transesphofagic echocardiogram showed vegetation of the aortic valve and moderate aortic insufficiency. Blood cultures were positive for Enterococcus bovis.Paciente de 35 anos de idade foi atendido em Servico de Emergencia com seis horas de dor em fossa iliaca direita e febre. Feita hipotese diagnostica de apendicite aguda e realizada laparotomia exploradora. com apendicectomia. O paciente retornou ao hospital tres dias apos alta hospitalar. prostrado. febril. com alteracao de fala. diminuicao de nivel de consciencia e com hemiparesia completa a esquerda. CT scan de crânio e puncao de liquor normal. RMN de encefalo revelou aspectos compativeis com AVC isquemico vertebro-basilar. Ecocardiograma transesofagico demonstrou vegetacao em valva aortica e insuficiencia aortica moderada e hemoculturas foram positivas para Enterococcus bovis.

Infective endocarditis with initial presentation of acute abdomen

A 35-year-old patient was seen in an Emergency Department. with six hours of pain in the right iliac fossa and fever. The hypothesis diagnosis was acute appendicitis and an exploring laparotomy for appendectomy was carried out. The patient returned to the hospital three days after having been discharged. debilitated. feverish. having alterations in speech. reduction in the level of consciousness and complete hemiparesis to the left. The computed tomography scan of the skull and the liquor puncture were normal. Cerebral magnetic resonance image showed aspects compatible with vertebrobasilar ischemic stroke. Transesphofagic echocardiogram showed vegetation of the aortic valve and moderate aortic insufficiency. Blood cultures were positive for Enterococcus bovis.Paciente de 35 anos de idade foi atendido em Servico de Emergencia com seis horas de dor em fossa iliaca direita e febre. Feita hipotese diagnostica de apendicite aguda e realizada laparotomia exploradora. com apendicectomia. O paciente retornou ao hospital tres dias apos alta hospitalar. prostrado. febril. com alteracao de fala. diminuicao de nivel de consciencia e com hemiparesia completa a esquerda. CT scan de crânio e puncao de liquor normal. RMN de encefalo revelou aspectos compativeis com AVC isquemico vertebro-basilar. Ecocardiograma transesofagico demonstrou vegetacao em valva aortica e insuficiencia aortica moderada e hemoculturas foram positivas para Enterococcus bovis.