José Ramos Filho

Miocárdio viável pela tomografia computadorizada com Tc-99m (MIBI) sensibilizada por nitroglicerina endovenosa

BACKGROUND The selection of patients with chronic coronary disease for recanalization is based on the detection of the affected myocardium that is potentially viable. OBJECTIVE To evaluate the potentially viable ischemic myocardium through single photon emission computed tomography (SPECT) with MIBI after a maximum tolerated dose of I.V. nitroglycerin. METHODS We prospectively investigated by SPECT with Tc-99m (MIBI), from April 2004 to November 2005, 40 patients (mean age: 62 +/- 8.9 yrs, 30 men) with coronary obstruction demonstrated angiographically; the myocardium scintigraphy was carried out at rest and after intravenous (I.V.) nitroglycerin, which was started at a dose of 1 microg/kg/min and increased every minute until the systolic blood pressure decreased by 20 mmHg. The decrease in the perfusion of the segments was classified as moderate or severe and compared after the nitroglycerin. The angiographic, hemodynamic and myocardial perfusion variables were analyzed. RESULTS We analyzed 680 myocardial segments at rest: 538 with a homogenous distribution and 142 with hypoperfusion (54 with moderate and 88 with severe decrease). After the nitroglycerin, there was an increase in the perfusion in 19 (47.5%) of 40 patients and 55 of 142 segments became viable: 33 (61.1%) with moderate and 22 (25%) with severe decrease; both presented a significant increase in the radiotracer distribution (p < 0.001, Chi-square). CONCLUSION One of the components with Tc-99m is Tc-99m 2-methoxy-isobutyl-isonitrile (MIBI), which, when used with an optimized dose of I.V. nitroglycerin, can increase the radiotracer uptake in areas with moderate and severe hypoperfusion. The results of the present study suggest the increase in the Tc-99m (MIBI) sensitivity by nitroglycerin for the detection of viable myocardium.

Marcapasso cardíaco artificial: considerações pré e per-operatórias

BACKGROUND AND OBJECTIVES Technological medical diagnosis advances in cardiology have markedly increased indications for temporary or permanent artificial cardiac pacemakers (PM). This means that, in addition to cardiologists, other specialists have become involved in the handling of these devices. When PM patients undergo surgery, anesthesiologists participation may be decisive for the success of the procedure. This review aimed at familiarizing anesthesiologists with major clinical indications and operation of these devices, as well as with PM-related pre and intraoperative cares. CONTENTS Classification, operation, and major clinical indications for PM implants are covered. In addition, primary PM-related pre and intraoperative cares required for success are explained. CONCLUSIONS Basic understanding of PM operation and indications should be part of anesthesiologists daily practice. Hence, handling and indication of temporary PM broadens these specialists scope, in addition to saving lives in emergency situations. Electric cautery should be avoided in artificial cardiac pacemaker patients.JUSTIFICATIVA Y OBJETIVOS: El progreso tecnologico de la propedeutica medica diagnostica en cardiologia difundio grandemente la indicacion de marcapaso (MP) cardiaco artificial, definitivo o temporario. Esto hizo con que otros especialistas, ademas de los cardiologistas, se envolvieran todavia mas en el manoseo de eses aparatos. Cuando pacientes portadores de MP se presentan para cirugia, la participacion del anestesista puede ser decisiva para el suceso del procedimiento. El objetivo de la actual revision es familiarizar al anestesista con las principales indicaciones clinicas y con el funcionamiento de eses dispositivos, ademas de los cuidados pre y per-operatorios que se debe tener. CONTENIDO: Fueron tratadas la clasificacion, funcionamiento y las principales indicaciones clinicas para la implantacion de MP. De la misma forma, se pretendio elucidar los principales cuidados pre y per-operatorios relativos al uso de MP para lograr exito en el procedimiento indicado. CONCLUSIONES: Los principales conocimientos sobre el funcionamiento del MP y sus indicaciones clinicas deben hacer parte de la practica diaria del anestesista. De esa forma, el manoseo y la indicacion del MP temporario amplia la actuacion de eses especialistas, ademas de que puede salvar vidas, inclusive en situaciones de emergencia dentro del centro quirurgico. El uso de eletrocauterio deberia ser evitado en portadores de MP.

Study of coronary sinus flow reserve through transesophageal Doppler echocardiography in normal subjects.

OBJECTIVE To evaluate the Coronary Flow Reserve in the Coronary Sinus through transesophageal Doppler echocardiography in normal subjects. METHODS We obtained technically adequate flow samples for analysis in 10 healthy volunteers (37+/-8 years, 5 men) with no history of heart or systemic disease and with mean left ventricular mass index by transthoracic echocardiography of 87+/-18 g/m2. Coronary sinus flow velocity was recorded within the coronary sinus with the patient in a resting condition and during intravenous adenosine infusion at a dose of 140 micro g/kg/min for 4 minutes. Recording of coronary sinus blood flow was possible in all cases with measurement of peak systolic, diastolic, and retrograde velocities (PSV, PDV, and PRV, cm/sec), mean systolic and diastolic velocities (MSV and MDV, cm/sec), and systolic and diastolic velocity time integral (VTI S and VTI D, cm/sec). RESULTS The coronary flow reserve was calculated as the ratio between the blood flow in the basal state and the maximum measured hyperemic blood flow with adenosine infusion. Results are shown as mean and standard deviations. (CFR = PSV + PDV - PRV/basal PSV): 1st min = 2.2+/-0.21; 2nd min = 3+/-0.3; 3rd min = 3.4+/-0.37; 4th min = 3.6 +/- 0.33. CONCLUSION Although coronary sinus flow had significantly increased in the first minute, higher velocities were seen at third and fourth minutes, indicating that these should be the best times to study coronary sinus flow with intravenous adenosine in continuous infusion.

Pulmonary Hypertension Secondary to Coronary-to-Pulmonary Artery Fistula

The coronary fistula is an anomaly characterized by the communication between a coronary artery and a cardiac chamber, pulmonary artery, coronary sinus and pulmonary veins. It represents 0.2 to 0.4% of the congenital cardiopathies and 0.1% to 0.2% of the adult population submitted to coronary angiography. We report the clinical case of a 64-year-old female patient, whose anomaly was diagnosed during a clinical investigation due to chest discomfort, dyspnea and syncope; the surgical correction was indicated, with opening of the pulmonary artery through extracorporeal circulation.

Avaliação pré-operatória do pneumopata

BACKGROUND AND OBJECTIVES Lung complications are the most frequent causes of postoperative morbidity-mortality, especially in lung disease patients. So, those patients should be preoperatively carefully evaluated and prepared, both clinically and laboratorially. This review aimed at determining surgical risk and at establishing preoperative procedures to minimize peri and postoperative morbidity-mortality in lung disease patients. CONTENTS Major anesthetic-surgical repercussions in lung function have already been described. Similarly, we tried to select higher-risk patients, submitted or not to lung resection. To that end, clinical and laboratorial propedeutics were used. Finally, a proposal of a preoperative algorithm was presented for procedures with lung resection. CONCLUSIONS Lung disease patients, especially those with chronic evolution, need to be preoperatively thoroughly evaluated. ASA physical status and Goldmans cardiac index are important risk forecasting factors for lung disease patients not candidates for lung resection. Adding to these criteria, estimated postoperative max VO2, FEV1 and diffusion capacity are mandatory for some patients submitted to lung resection. beta2-agonists and steroids should be considered in the preoperative period of these patients.JUSTIFICATIVA E OBJETIVOS: As complicacoes pulmonares sao as causas mais frequentes de morbimortalidade pos-operatoria, especialmente nos pneumopatas. Por essa razao, esses pacientes devem ser criteriosamente avaliados e preparados no pre-operatorio, tanto do ponto de vista clinico como laboratorial. O objetivo da presente revisao e determinar o risco cirurgico e estabelecer condutas pre-operatorias para minimizar a morbimortalidade per e pos-operatorias, nos portadores de doencas respiratorias. CONTEUDO: As principais repercussoes do ato anestesico-cirurgico na funcao pulmonar foram relatadas. Da mesma forma, procurou-se selecionar os pacientes de maior risco, envolvidos ou nao em resseccao pulmonar. Para esse fim, utilizou-se da propedeutica clinica e laboratorial. Finalmente, foi apresentada uma proposta de algoritmo pre-operatorio para os procedimentos com resseccao pulmonar. CONCLUSOES: O portador de doenca respiratoria, especialmente as de evolucao cronica, necessita ser rigorosamente avaliado no pre-operatorio. A classificacao do estado fisico (ASA) e o indice de Goldman sao fatores de previsao de risco importantes nos pneumopatas nao-candidatos a resseccao pulmonar. Somando-se a esses criterios, nos candidatos a resseccao pulmonar, o VO2 max, o VEF1e capacidade de difusao estimados para o pos-operatorio, sao imprescindiveis, em algumas situacoes. Os b2-agonistas e corticoides devem ser considerados nos pre-operatorios desses pacientes.

Chest pain due to right atrial compression caused by a thymolipoma

On physical examination, the patient was hydrated, acyanotic,anicteric, eupneic, afebrile, with healthy coloring, in regular gene-ral condition, and had neither jugular venous distension nor peri-pheral edema. His blood pressure was 140/100 mmHg and hisheart rate was 120 bpm. His pulses were palpable, symmetric,rhythmic, with no changes in peripheral perfusion. The ictus cordiswas located on the fifth left intercostal space, at the level of theleft midclavicular line, and had approximately 2 digital pulps. Thecardiac sounds had normal intensity and no cardiac murmur washeard. On pulmonary auscultation, the respiratory sounds werepresent bilaterally, and no rales were heard. The abdomen wasflat, flaccid with hydro-aerial noises, not tender on palpation, andno visceromegaly was observed.The biochemical tests and electrocardiogram showed nochanges. On chest radiography, a mild enlargement of the cardiacarea was observed with an expanding lesion in the anteroinferiormediastinum, in continuity with the cardiac image (fig.1). Theesophagogram showed no signs of extrinsic compression of theesophagus. Upper digestive endoscopy showed only a mild enan-thematous antral gastritis.Transthoracic echodopplercardiography showed a mild extrinsiccompression of the anterolateral region of the right atrium. Thetransesophageal echocardiogram confirmed this compression withno significant hemodynamic repercussions, and the presence of amild systolic reflux (escape) in the tricuspid valve (fig. 2).To complement the investigation, the patient underwent chestcomputed tomography performed with 5- and 10-mm-thick axialsections after intravenous infusion of contrast medium. The tomo-graphy revealed the presence of an expanding lesion with a fatattenuation coefficient, regular and precise contours, located in theanterior mediastinum to the right, slightly deviating from the rightatrium posteriorly. The lesion measured 12.0 x 7.4 x 9.6 cm andwas suggestive of thymolipoma or pericardial lipoma (fig. 3).With these hypotheses, the patient was referred for surgicaltreatment. Thoracotomy provided complete excision of the tumoralmass, which weighed approximately 580 g. No regional macros-copic metastases were evident, and later anatomicopathologicalexamination confirmed the diagnosis of thymolipoma (fig. 4).

Aneurisma do tronco da artéria coronária esquerda

Aneurysm in the coronary trunk is an uncommon angiographic finding, with few cases reported. The mortality is high and the therapeutics are still uncertain. The aneurysm of the left main coronary artery is a rare and the worse cause of coronary artery disease. We report a case of a 61-year-old-female patient admitted in the Hospital Emergency Unit with a history of acute coronary syndrome. Coronary angiography showed a giant aneurysm in the left main coronary artery. The patient was submitted to coronary artery bypass grafting and remains asymptomatic after a one-year follow-up.

Endomiocardiofibrose biventricular associada à amiloidose renal

Endomyocardiofibrosis is a restrictive cardiomyopathy characterized by fibrotic involvement of the endocardium and adjacent myocardium, and by diastolic dysfunction caused by changes in distensibility making ventricular filling inadequate while preserving the systolic function. Clinically, it appears as heart failure, but etiological symptomatic discernment, suspicion and a clinical examination would be necessary in order to make a correct etiological diagnosis. The case of a patient with biventricular endomyocardial fibrosis associated with renal amyloidosis is presented.

Manoseo peri-operatorio del paciente en uso de amiodarona

BACKGROUND AND OBJECTIVES Amiodarone is quite an effective anti-arrhythmic drug indicated for controlling ventricular and supra-ventricular arrhythmias, and it is being widely administered in clinical practice. However, its chronic use may be associated to severe side effects which may be worsened by anesthetic-surgical acts, thus increasing the risk of such procedures. This study aimed at reviewing major amiodarone effects and relating them to anesthetic procedures. CONTENTS The study covers major amiodarone properties, its clinical use, as well as major adverse effects, which may increase patients surgical risk. CONCLUSIONS Amiodarone, although normally safe and effective, may present adverse effects, especially on cardiovascular system, during anesthetic-surgical procedures. This is possibly due to interactions between this drug and anesthetic agents mainly related to general anesthesia. There are reports on severe, treatment - resistant bradycardias as well as on different degrees of atrioventricular block (AVB). Patients should be carefully monitored, especially during major procedures, and vasoactive drugs (isoproterenol) and temporary artificial pacemaker, should be available because they may be critical during the adverse effects treatment.JUSTIFICATIVA Y OBJETIVOS: La amiodarona es un antidisritmico bastante eficaz y indicado en el tratamiento de disritmias ventriculares y supraventriculares, motivo por el cual viene siendo extensamente administrada en la practica clinica. Entretanto, su uso cronico puede estar asociado con serios efectos colaterales, que pueden ser agravados por actos anestesico-cirugicos, aumentando el riesgo de los procedimientos. El presente estudio objetiva revisar los principales efectos de la amiodarona y asociarlos a la practica clinica del anestesista. CONTENIDO: Se trato de las principales propiedades de la amiodarona, su uso clinico, bien como los mas importantes efectos adversos que pueden aumentar el riesgo quirurgico de los pacientes en uso de este antidisritmico. CONCLUSIONES: La amiodarona, a pesar de habitualmente segura y eficiente, puede presentar efectos adversos exacerbados, especialmente para el aparato cardiovascular, durante procedimientos anestesico-cirugicos. Esto se debe posiblemente a las interacciones entre ese farmaco y agentes anestesicos, asociados principalmente a la anestesia general. Hay relatos de bradicardias graves y resistentes a la terapeutica, bien como bloqueo atrioventricular (BAV) en grados variados. El paciente debe ser rigurosamente monitorizado, especialmente en los procedimientos de grande porte, y el anestesista debe estar amparado en el peri-operatorio con drogas vasoactivas (isoproterenol) y marcapaso cardiaco artificial temporario, que pueden ser fundamentales durante el procedimiento.

Peri-operative management of amiodarone patients

BACKGROUND AND OBJECTIVES Amiodarone is quite an effective anti-arrhythmic drug indicated for controlling ventricular and supra-ventricular arrhythmias, and it is being widely administered in clinical practice. However, its chronic use may be associated to severe side effects which may be worsened by anesthetic-surgical acts, thus increasing the risk of such procedures. This study aimed at reviewing major amiodarone effects and relating them to anesthetic procedures. CONTENTS The study covers major amiodarone properties, its clinical use, as well as major adverse effects, which may increase patients surgical risk. CONCLUSIONS Amiodarone, although normally safe and effective, may present adverse effects, especially on cardiovascular system, during anesthetic-surgical procedures. This is possibly due to interactions between this drug and anesthetic agents mainly related to general anesthesia. There are reports on severe, treatment - resistant bradycardias as well as on different degrees of atrioventricular block (AVB). Patients should be carefully monitored, especially during major procedures, and vasoactive drugs (isoproterenol) and temporary artificial pacemaker, should be available because they may be critical during the adverse effects treatment.JUSTIFICATIVA Y OBJETIVOS: La amiodarona es un antidisritmico bastante eficaz y indicado en el tratamiento de disritmias ventriculares y supraventriculares, motivo por el cual viene siendo extensamente administrada en la practica clinica. Entretanto, su uso cronico puede estar asociado con serios efectos colaterales, que pueden ser agravados por actos anestesico-cirugicos, aumentando el riesgo de los procedimientos. El presente estudio objetiva revisar los principales efectos de la amiodarona y asociarlos a la practica clinica del anestesista. CONTENIDO: Se trato de las principales propiedades de la amiodarona, su uso clinico, bien como los mas importantes efectos adversos que pueden aumentar el riesgo quirurgico de los pacientes en uso de este antidisritmico. CONCLUSIONES: La amiodarona, a pesar de habitualmente segura y eficiente, puede presentar efectos adversos exacerbados, especialmente para el aparato cardiovascular, durante procedimientos anestesico-cirugicos. Esto se debe posiblemente a las interacciones entre ese farmaco y agentes anestesicos, asociados principalmente a la anestesia general. Hay relatos de bradicardias graves y resistentes a la terapeutica, bien como bloqueo atrioventricular (BAV) en grados variados. El paciente debe ser rigurosamente monitorizado, especialmente en los procedimientos de grande porte, y el anestesista debe estar amparado en el peri-operatorio con drogas vasoactivas (isoproterenol) y marcapaso cardiaco artificial temporario, que pueden ser fundamentales durante el procedimiento.