Luiz Francisco Cardoso

Insuficiência cardíaca descompensada na unidade de emergência de hospital especializado em cardiologia

FUNDAMENTO: Estudos nacionais em insuficiencia cardiaca descompensada (ICD) sao fundamentais para o entendimento dessa afeccao em nosso meio. OBJETIVO: Determinar as caracteristicas dos pacientes com ICD em uma unidade de emergencia. METODOS: Examinamos prospectivamente 212 pacientes com o diagnostico de insuficiencia cardiaca descompensada, os quais foram admitidos em uma unidade de emergencia (UE) de hospital especializado em cardiologia. Estudaram-se variaveis clinicas, apresentacao e causas de descompensacao. Em 100 pacientes, foram analisados exames complementares, prescricao de drogas vasoativas, tempo de internacao e letalidade. RESULTADOS: Entre os pesquisados houve predominio de homens (56%) e a etiologia isquemica foi a mais frequente (29,7%), apesar da elevada frequencia de valvares (15%) e chagasicos (14,7%). A forma de apresentacao e a causa de descompensacao mais comuns foram, respectivamente, congestao (80,7%) e ma adesao/medicacao inadequada (43,4%). Na subanalise dos 100 pacientes, a disfuncao sistolica foi a mais frequente (55%), uso de drogas vasoativas ocorreu em 20% e a letalidade foi de 10%. Analise comparativa entre os pacientes que receberam alta e faleceram durante a internacao ratificou alguns criterios de mau prognostico: pressao arterial sistolica reduzida, baixo debito associado a congestao, necessidade de droga vasoativa, fracao de ejecao do ventriculo esquerdo reduzida, diâmetro diastolico do ventriculo esquerdo (DDVE) aumentado e hiponatremia. CONCLUSAO: Este trabalho apresenta dados sobre o perfil da populacao com insuficiencia cardiaca descompensada atendida na unidade de emergencia de um hospital especializado em cardiologia da regiao sudeste do Brasil. Na avaliacao inicial destes pacientes dados clinico-hemodinâmicos e de exames complementares fornecem subsidios para estratificacao de risco, auxiliando na decisao de internacao e estrategias terapeuticas mais avancadas.

Symptoms, left ventricular function, and timing of valve replacement surgery in patients with aortic regurgitation

BACKGROUND Because cardiac decompensation is subtle, the best time to perform aortic valve replacement surgery may be difficult to determine. We investigated the relation of symptoms to left ventricular (LV) function and the timing of valve replacement in patients with aortic regurgitation (AR) of largely rheumatic origin. METHODS Sixty-eight initially asymptomatic patients (mean age 29 years) with severe chronic AR were monitored for 36 months. Assessments included baseline and yearly echocardiograms and radioisotope ventriculography (resting and exercise) and clinical examinations every 6 months. RESULTS Forty-seven patients (69%) remained asymptomatic and 21 (31%) had symptoms develop after 24 to 36 months. Compared with symptomatic patients, asymptomatic patients had significantly (P <.05) lower baseline LV end-diastolic diameter, end-systolic diameter, end-systolic stress, and volume/mass ratio but greater shortening fraction and ejection fraction (EF) at rest. These variables remained stable without statistically significant change until surgical correction in symptomatic patients. Percent variation of EF from rest to exercise increased in patients who remained asymptomatic (EF 2.8% +/- 10.6%) but decreased in those who became symptomatic (EF -4.2% +/- 13%; P <.05). Twenty symptomatic patients (New York Heart Association class III/IV, angina and/or syncope) had valve replacement surgery, after which all were in New York Heart Association class I/II and had significant decreases of LV end-diastolic and end-systolic diameters and an increase on percent variation of EF from rest to exercise (P <.0001). CONCLUSIONS Development of symptoms did not correlate with change in any ventricular function indexes. Surgery on appearance of symptoms restored LV function to near normal.

Comparison of Inhaled Nitric Oxide Versus Oxygen on Hemodynamics in Patients With Mitral Stenosis and Severe Pulmonary Hypertension After Mitral Valve Surgery

Pulmonary hypertension represents an important cause of morbidity and mortality in patients with mitral stenosis who undergo cardiac surgery, especially in the postoperative period. The aim of this study was to test the hypothesis that inhaled nitric oxide (iNO) would improve the hemodynamic effects and short-term clinical outcomes of patients with mitral stenosis and severe pulmonary hypertension who undergo cardiac surgery in a randomized, controlled study. Twenty-nine patients (4 men, 25 women; mean age 46 ± 2 years) were randomly allocated to receive iNO (n = 14) or oxygen (n = 15) for 48 hours immediately after surgery. Hemodynamic data, the use of vasoactive drugs, duration of stay, and short-term complications were assessed. No differences in baseline characteristics were observed between the groups. After 24 and 48 hours, patients receiving iNO had a significantly greater increase in cardiac index compared to patients receiving oxygen (p <0.0001). Pulmonary vascular resistance was also more significantly reduced in patients receiving iNO versus oxygen (-117 dyne/s/cm(5), 95% confidence interval -34 to -200, vs 40 dyne/s/cm(5), 95% confidence interval -34 to 100, p = 0.005) at 48 hours. Patients in the iNO group used fewer systemic vasoactive drugs (mean 2.1 ± 0.14 vs 2.6 ± 0.16, p = 0.046) and had a shorter intensive care unit stay (median 2 days, interquartile range 0.25, vs median 3 days, interquartile range 7, p = 0.02). In conclusion, iNO immediately after surgery in patients with mitral stenosis and severe pulmonary hypertension improves hemodynamics and may have short-term clinical benefits.

Comparison between Percutaneous Balloon Valvuloplasty and Open Commissurotomy for Mitral Stenosis

Eighty patients with tight and pliable mitral stenosis were randomized in a prospective trial comparing percutaneous balloon valvuloplasty and open commissurotomy. Mitral valve area increased significantly in both groups immediately after the procedures. However, a decrease in mitral valve area occurred in both groups at 6, 12 and 24 months during the follow-up. There was no death in either group. Two patients had significant mitral regurgitation after percutaneous balloon valvuloplasty. After 24 months, all patients in the commissurotomy group and 97.4% of the patients in the balloon valvuloplasty group were in New York Heart Association functional class I or II.

Resultados imediatos e tardios da valvoplastia mitral percutânea em pacientes com estenose mitral

BACKGROUND The analysis of immediate and long-term results of mitral valvoplasty by balloon catheter (MVRBC) are still lacking in literature, mainly in the national context. OBJECTIVE To assess the immediate and late results of patients submitted to mitral valve repair by balloon catheter. METHOD A total of 330 consecutive patients were followed-up by 47 +/- 36 months (up to 126 months). Univariate and multivariate analyses assessed the factors associated with the success of the procedure, restenosis and late events (death or necessity of new intervention on mitral valve). Kaplan-Meier method estimated survival without events. RESULTS The procedure was successful in 305 cases (92.4%). The mitral valve anatomy was the main predictor for immediate success for the procedure. During the procedure, restenosis occurred in 77 (23.3%) patients and was associated with smaller mitral valve area and with larger calcification before the process. In a mean period of 38 +/- 26-month follow-up, 67 events occurred. The probability of survival without events was of 95% in one year, 75% in five years and 61% in ten years. The predictors of survival without events were: age, echocardiography score and immediate result of the procedure. CONCLUSION Mitral valve repair by balloon catheter is an effective procedure, as 60% patients did not present events after the follow-up. The anatomical condition of the mitral valve and the patients age were the best predictors of survival without events, and should be taken into account when selecting patients for the mentioned procedure.

Effect of amiodarone on haemodynamics during cardiopulmonary resuscitation in a canine model of resistant ventricular fibrillation

OBJECTIVE Amiodarone has been shown to be superior to both placebo and lidocaine in improving survival to hospital admission for victims of out-of-hospital refractory ventricular fibrillation. Concern had been expressed about the known vasodilatatory effects of amiodarone if given without precedent vasoconstrictive medications. The haemodynamic effects of intravenous amiodarone administered during ongoing CPR have not been systemically investigated. Our intention was to verify if amiodarone alone produced significantly lower resuscitation haemodynamics than did either adrenaline (epinephrine) alone or the combination of amiodarone and adrenaline. DESIGN Prospective, randomized, comparative study. SETTING Research laboratory of a medical school. SUBJECTS Thirty mongrel dogs. INTERVENTIONS After 8 min of untreated VF, defibrillation was attempted once at 3 J/kg and external chest compressions and ventilation started. Those animals resistant to the defibrillation attempt were randomized, ten to an adrenaline (0.02 mg/kg) group, ten to an amiodarone (5 mg/kg) group, and ten to a group receiving a combination of both drugs. MEASUREMENTS AND MAIN RESULTS Aortic systolic and diastolic, and coronary perfusion pressures were all significantly lower in the group receiving amiodarone alone than in the other two groups. Amiodarone combined with adrenaline produced pressures during CPR similar to adrenaline alone. CONCLUSION Amiodarone can be safely administered simultaneously in combination with adrenaline and such a combination results in similar haemodynamic support as adrenaline alone. Amiodarone administered alone produces significantly lower coronary perfusion pressure than when combined with adrenaline.

Resistance to thyroid hormone due to mutations in the THRB gene impairs bone mass and affects calcium and phosphorus homeostasis.

CONTEXT Resistance to thyroid hormone (RTH) is an inherited syndrome of reduced tissue responsiveness to thyroid hormone, which is usually due to mutations in the thyroid hormone receptor β gene (THRB). Few studies have been conducted to investigate bone and mineral metabolism in RTH. OBJECTIVE The objective of the study was to evaluate the clinical and biochemical parameters related to bone and mineral metabolism in RTH due to mutations in the THRB gene (RTHβ). DESIGN AND PARTICIPANTS We conducted a cross-sectional study on 14 patients with RTHβ (RTHG), eight adults and six children, and 24 control subjects (CG). OUTCOMES Serum measures included total calcium (TCa), inorganic phosphate (iP), alkaline phosphatase (AP), parathyroid hormone (PTH), 25-hydroxyvitamin D (25OHD), osteocalcin (OC), carboxyterminal telopeptide (CTX), and fibroblast growth factor 23 (FGF-23). We estimated the renal threshold phosphate concentration (TmPO4/GFR) and assessed bone mass using dual X-ray absorptiometry. RESULTS Adults and children with RTH showed higher serum levels of TCa than controls (P=.029 and, P=.018 respectively). However, only children with RTH exhibited lower serum levels of iP than controls (P=.048). FGF-23 was higher in RTHβ children (P=.04). RTHβ adults had lower whole-body (P=.01) and lumbar spine (P=.01) bone mineral density than control subjects. The same pattern was observed when the results were expressed as Z-scores between groups, with a lower value in RTHG than in CG for the lumbar spine of adults (P=.03). No difference was observed between groups in PTH, 25OHD, AP, OC, and CTX. CONCLUSION Biochemical abnormalities are seen in children with RTH (Low iP, high FGF23), while high calcium (with normal UCa) is seen in RTH subjects of all ages, and later on, in adult life, low BMD is seen. Considering that the TRα1 isoform is the predominant TR in the skeleton, we hypothesize that probably these patients may exhibit enhanced calcium flux from bone to circulation. Our data represent a challenge for new studies to unveil the control of calcium and phosphorus homeostasis and fracture risk in these patients.

Disseminating Cardiopulmonary Resuscitation Training by Distributing 9,200 Personal Manikins

OBJECTIVES Community members should be trained so that witnesses of cardiac arrests are able to trigger the emergency system and perform adequate resuscitation. In this study, the authors evaluated the results of cardiopulmonary resuscitation (CPR) training of communities in four Brazilian cities, using personal resuscitation manikins. METHODS In total, 9,200 manikins were distributed in Apucarana, Itanhaém, Maringá, and São Carlos, which are cities where the populations range from 80,000 to 325,000 inhabitants. Elementary and secondary school teachers were trained on how to identify a cardiac arrest, trigger the emergency system, and perform chest compressions. The teachers were to transfer the training to their students, who would then train their families and friends. RESULTS In total, 49,131 individuals were trained (6.7% of the population), but the original strategy of using teachers and students as multipliers was responsible for only 27.9% of the training. A total of 508 teachers were trained, and only 88 (17.3%) transferred the training to the students. Furthermore, the students have trained only 45 individuals of the population. In Maringá and São Carlos, the strategy was changed and professionals in the primary health care system were prepared and used as multipliers. This strategy proved extremely effective, especially in Maringá, where 39,041 individuals were trained (79.5% of the total number of trainings). Community health care providers were more effective in passing the training to students than the teachers (odds ratio [OR] = 7.12; 95% confidence interval [CI] = 4.74 to 10.69; p < 0.0001). CONCLUSIONS Instruction of CPR using personal manikins by professionals in the primary health care system seems to be a more efficient strategy for training the community than creating a training network in the schools.

Implante transcateter de valva aórtica sem a necessidade de marca-passo definitivo em uma série de casos consecutivos: é possível predizer o risco de bloqueio atrioventricular?

INTRODUCAO: O implante transcateter de protese valvar aortica (ITVA) tem sido relatado, de forma crescente, como uma opcao terapeutica para pacientes com estenose aortica de elevado risco cirurgico. Embora eficaz e relativamente segura, o ITVA e atualmente associado a taxa de necessidade de marca-passo definitivo de 20% a 30%, com alguns preditores do risco dessa complicacao ja descritos na literatura METODO: Relatamos uma serie de 8 casos consecutivos de pacientes com estenose aortica tratados com ITVA (Corevalve Revalving, Medtronic Inc., Estados Unidos) RESULTADOS: Foram incluidos pacientes de alto risco cirurgico (na media, Escore STS = 22,9% e EuroSCORE = 27,2%). Todos os pacientes apresentavam pelo menos uma caracteristica preditora de bloqueio atrioventricular de alto grau apos o procedimento. A intervencao foi bem-sucedida em todos os pacientes, exceto em um caso que apresentou tamponamento e obito intra-hospitalar. O gradiente transaortico maximo reduziu-se de 91,3 ± 26,9 mmHg para 19,4 ± 6,3 mmHg. Apos a alta, o tempo de seguimento clinico variou de quatro semanas a doze meses. Durante o seguimento, nao houve obitos e nenhum paciente apresentou bloqueio atrioventricular de 2o ou 3o graus novo, com taxa zero de marca-passo definitivo CONCLUSAO: Embora o acaso possa explicar a ausencia de marca-passo definitivo na populacao do estudo, nossa experiencia inicial sugere que a necessidade de marca-passo apos ITVA nao e prontamente previsivel por meio dos preditores de risco atualmente descritos.

Avaliação comparativa entre valvoplastia percutânea e comissurotomia a céu aberto na estenose mitral

PURPOSE: To compare immediate and late (12 months) follow up of clinical and Doppler echocardiographic results between percutaneous mitral balloon valvuloplasty and open commissurotomy in a prospective and randomized trial. METHODS: Eighty eight symptomatic patients with severe mitral stenosis and favorable anatomy were randomized in a prospective trial comparing the two procedures. All patients were submitted to clinical and Doppler echocardiographic evaluation before the procedures and immediate and twelve months thereafter. RESULTS: Mean mitral gradient (mmHg) decreased from 12.2±5.8 to 5.80±2.7 (p<0.001) in commissurotomy group (CG) and from 11.7±6.1 to 5.0±2.4 (p<0.001) in the balloon valvuloplasty group (VG). Mitral valve area (cm2) increased from 0.98±0.21 to 2.52±0.46 in CG and from 1.05±0.25 to 2.18±0.40 in VG (p<0.001). In both groups there was a slight decrease in mitral valve area at 12 month follow-up. There was no death in either group. One patient in the VG had moderate mitral regurgitation and underwent surgery. At the 12 month follow-up, all patients in CG and 97.7% of patients in VG were in New York Heart Association functional class I or II. CONCLUSION: Both procedures were safe and showed similar immediate improvement in mitral gradient and functional class. Mitral valve area had a greater increase immediately after commissurotomy, however there was a significantly greater reduction in the CG after 12 months of follow-up, when compared to balloon valvuloplasty. In both groups, mitral gradient remained reduced and most patients did not change functional class during the follow-up.