Orlando Campos Filho

Exeqüibilidade, segurança e acurácia do ecocardiograma sob estresse com dobutamina/ atropina para detecção de doença arterial coronariana em candidatos a transplante renal

OBJECTIVE To evaluate the feasibility, safety and accuracy of dobutamine/atropine stress echocardiography (DASE) for the detection of coronary artery disease (CAD) in renal transplant candidates. METHODS Patients candidates to renal transplant were submitted consecutively to DASE and coronary angiography. The adopted angiographic criteria for CAD were an obstructive lesion of > or = 50% and > or = 70%. RESULTS 148 patients underwent the DASE and the coronary angiography. Mean age was 52 +/- 9 years, 69% of the patients were males; 27% had diabetic nephropathy and 73% had LVH; 63% were asymptomatic; 36% and 22% presented coronary obstructions > or = 50% and 70%, respectively. The DASE performance was 91% and major complication rate was 2.7%. The sensibility, specificity and accuracy for the diagnosis of coronary obstruction > 50% were 53% (CI:45-61), 87% (CI:81-93), and 75% (CI:63-83) respectively. For coronary obstruction > or = 70% these values were, respectively, 71% (CI:64-92), 85% (CI:79-91) and 81% (CI:75-87). The sensibility to detect univessel and multivessel disease was 41% (CI:19-63) and 78% (CI:64-92), respectively. CONCLUSION The DASE was practical and safe; however, it presented a poor result for the detection of CAD regarding obstructions > or = 50%. It can be a useful screening for the detection of CAD in candidates with obstructions > or = 70% and multivessel disease.

Endocardial Border Delineation during Dobutamine Infusion Using Contrast Echocardiography

Background: A significant percentage of pharmacologic stress echocardiograms produce suboptimal images despite the use of second harmonic imaging. Intravenous continuous infusion of myocardial ultrasound contrast may enhance endocardial border delineation during dobutamine‐atropine stress echocardiography (DASE), improving wall‐motion analysis. Patients and Methods: We prospectively studied 68 patients (41 males and 27 females), mean age 58 years, with DASE during intravenous infusion of contrast using second harmonic imaging. Dobutamine was infused in scalar doses of 5 μg/kg/min to 40 μg/kg/min, and atropine was administered in doses of up to 1 mg. We diluted 0.1 mL of perfluorocarbon‐exposed sonicated dextrose albumin (PESDA) microbubbles into 80 mL of saline solution, which was used for continuous intravenous infusion. Blinded reviewers used a 16‐segment model at rest and peak DASE to analyze segmental wall delineation in two sets of images for each patient, with and without contrast. An endocardial delineation score of 0–3 (nondelineated to excellent delineation) was given to each segment. An endocardial delineation score index (EDSI), the number of endocardial delineation scores for each set of images divided by 16, was created. Results: The analysis of the mean EDSI for the 2176 segments was 1.46 (± 0.43) at rest and 1.30 (± 0.48) at peak for noncontrast images and 2.22 (± 0.52) and 2.29 (± 0.52) for contrast images. Complete left ventricle opacification was obtained in all patients, with a mean dose of 4 mL/min, although in 15 (22%) patients, signs of apical bubble destruction occurred. There were 1768 (81%) of 2176 segments delineated without contrast enhancement and 2057 (95%) of 2176 with enhancement (P < 0.05). Conclusion: Continuous infusion of myocardial ultrasound contrast improves endocardial border delineation using second harmonic imaging in patients undergoing DASE.

Correlação entre qualidade de vida e capacidade funcional na insuficiência cardíaca

BACKGROUND: Patients with cardiac failure (CF) present progressive incapacity and decreased quality of life, both related to dyspnea and fatigue. Thus, there is the increasing interest in measring the quality of life (QL), by generic instrument, such as the 36-item Short-Form Health Survey (SF-36), by specific instrument, such as Minnesota Living with Heart Failure (MLHFQ). OBJECTIVE: This study has the objective to correlate the QL surveys, SF-36 and MLHFQ, with the functional capacity of patients with CF, expressed by the cardiopulmonary test and the TC6M. METHODS: Using the SF-36 and MLHFQ surveys for QL evaluation, for the evaluation of the functional capacity, it was used the cardiopulmonary test, being executed using a tredmill with Weber protocol, as well sa the distance covered in the walk test of six minutes (TC6M). RESULTS: Forty-six patients were selected with CF diagnosis (22 men, average age of 52 years old), classes II and III of New York Heart Association. It was observed that the mild correlation between the physical and emotional domains of SF-36 and VE/VCO2.peak (r=-0.3; p<0.05) and the distance covered in TC6M (r=0.4; p<0.05), respectively. It was also observed the mild to moderate correlations of MLHFQ total score with VO2.peak (r=-0.5; p<0.05), the aerobic threshold (r=-0.4; p<0.05) and the distance covered in TC6M (r=-0.5; p<0.05). CONCLUSION: The data suggest that the application of both evaluation instruments of QL, generic (SF-36) and specific (MLHFQ) in patients with CF, showed mild and moderate correlation with the variable of the cardiopulmonary test with the variables of the cardiopulmonary test and the distance covered in TC6M.

Avaliação clínico-cardiológica e ecocardiográfica, seqüencial, em crianças portadoras da síndrome de Marfan

OBJETIVO: Descrever a apresentacao clinica cardiologica e a evolucao temporal, estimar a incidencia de ectasia ânulo-aortica e de prolapso da valva mitral, e avaliar a tolerância e a efetividade dos betabloqueadores em criancas com sindrome de Marfan. METODOS: Foram submetidas a exame clinico e ecocardiografico seriado, durante um ano, 21 criancas com sindrome de Marfan. No ecocardiograma foram analisados: presenca de prolapso mitral, diâmetro da raiz aortica, refluxos das valvas mitral e aortica, e o crescimento dos diâmetros aorticos na vigencia de betabloqueadores. Em 11 pacientes foi possivel obter duas medidas da raiz aortica no intervalo de um ano. RESULTADOS: Durante o estudo as criancas nao apresentaram sintomas. Prolapso mitral foi encontrado em 11 (52%) criancas. Ectasia ânulo-aortica ocorreu em 16 (76%) pacientes, sendo de grau discreto em 42,8%, moderado em 9,5%, e importante em 23,8%. Um desses pacientes foi submetido com sucesso a cirurgia de Bentall DeBono. Com o uso de betabloqueador a frequencia cardiaca diminuiu 13,6% (de 85 para 73 bpm; p < 0,009), mas houve um crescimento da raiz aortica de 1,4 mm/ano (p < 0,02). Uma crianca nao pode receber betabloqueador em razao de asma bronquica, e nao foram observados efeitos colaterais significativos nas outras criancas, incluindo uma com asma bronquica. CONCLUSAO: Os resultados obtidos sugerem que, no periodo observado, as criancas permaneceram assintomaticas, o uso de betabloqueadores diminuiu significativamente a frequencia cardiaca e nao se acompanhou de efeitos adversos significativos. Ao contrario da literatura, a incidencia de ectasia ânulo-aortica foi elevada e maior do que a de prolapso valvar mitral, tendo crescimento mesmo na vigencia de uso eficaz de betabloqueador.

Função sistólica do ventrículo esquerdo pela ecocardiografia em crianças e adolescentes com osteossarcoma tratados com doxorrubicina com e sem dexrazoxane

OBJECTIVE: To evaluate left ventricular (LV) systolic function by means of echocardiography in patients with osteosarcoma treated with doxorubicin alone or in combination with dexrazoxane. METHODS: The study analyzed 55 patients with osteosarcoma, with or without metastasis, undergoing a six-cycle chemotherapy regimen of doxorubicin, who were divided into two groups according to dexrazoxane use. Group I: Thirty-seven patients who did not receive dexrazoxane (28 males, average age 15.4 years). Group II: Eighteen patients who did receive dexrazoxane (15 males, average age 15.1 years). Four echocardiographic evaluations were performed: 1) before the beginning of the chemotherapy (initial evaluation); 2) up to two weeks after the third cycle; 3) up to two weeks after the fifth cycle; and 4) up to four weeks after the sixth cycle of chemotherapy (final evaluation). The left ventricular systolic function was assessed by the fractional percentage of systolic shortening (FS%) on echocardiography. Alterations in the contractile function or cardiac toxicity were defined as FS% values equal to or lower than 29%, and/or by a drop in FS% by an absolute value equal to or greater than 10 units of the baseline value of each patient. RESULTS: No significant difference as to age, gender, and race was observed between the groups. The cumulative dose of doxorubicin was significantly higher in group II throughout all phases of the treatment: 174 x 203 mg/m2; 292 x 338 mg/m2 and 345 x 405 mg/2 (p < 0.0001). According to previously established criteria, the incidence of LV systolic dysfunction was not significantly different (p=0.248) between patients in group I (18.92%) and patients in group II (11.1%). The variance analysis with repeated measurements did not show significant differences in the means of fractional percentage of systolic percentage (FS%) throughout the study (p=0.967). However, a significant difference (p=0.029) was observed between the FS% means in groups I and II at evaluations 2 (35.67 x 37.21%), 3 (34.95 x 38.47%) and 4 (35.26 x 38.22%). CONCLUSION: Data in this study show that in patients with osteosarcoma treated with doxorubicin alone or combined with dexrazoxane, the LV systolic function, as assessed by the fractional percentage of systolic shortening mean, showed a better performance in the group that received dexrazoxane. On the other hand, the occurrence of systolic dysfunction was similar in both groups.

Avaliação funcional do apêndice atrial esquerdo ao ecocardiograma transesofágico antes e após valvotomia percutânea na estenose mitral

OBJECTIVE To assess the effects of the relief of the mitral stenosis by percutaneous ballon valvotomy in the function of the left atrial appendage. METHODS Twelve patients with symptomatic mitral stenosis, in sinus rhythm, were studied. They were submitted to the transesophageal echocardiogram before and after effective percutaneous ballon valvotomy. Concerning the left atrial appendage, the peak flow velocities and the respective integral of the anterograde and retrograde flow, in addition to the ejection fraction calculated through the planimetry of the area of that structure, were analyzed at the pulsatile Doppler. RESULTS There was a significant increase of the anterograde flow velocity of the left atrial appendage after percutaneous ballon valvotomy (pre: mean of 0.30 m/s; post: mean of 0.47 m/s; p<0.05) and their respective integrals. The same happened with the retrograde flow velocity (pre: mean of 0.35 m/s, post: mean of 0.53 m/s; p<0.05). There was a tendency of increase of the ejection fraction of the left atrial appendage after the procedure (pre: mean of 20%, post: mean of 31%; p=0.08). CONCLUSION The effective opening of the stenosed mitral orifice resulting from the percutaneous ballon valvotomy determined an improvement of the flow pattern of the left atrial appendage, which can potentially contribute for the reduction of the embolic risk.

Role of Dobutamine-Atropine Stress Echocardiography in Prognostic Evaluation of 300 Women

Background: Dobutamine‐atropine stress echocardiography (DASE) is a safe and accurate method to diagnose coronary artery disease (CAD), and can identify individuals at high risk for cardiac events such as myocardial infarction and cardiac‐related death. The literature is limited regarding the prognostic value of DASE in women. Objective: The objective was to determine the prognostic value of DASE in 300 women with known or suspected CAD. Results: The 300 women underwent DASE and were followed up for 65 months (mean: 27 months). Ninety‐five women had positive tests and 205 had negative tests. We demonstrated that women with negative tests had a 94% hard‐event‐free survival rate at follow‐up (myocardial infarction and death), and in those with positive tests the event‐free survival rate was 27% (P = 0.0003). The difference between women with positive and negative tests was also significant when minor events and total events were considered. Women with positive tests had 16.7 times more chance of having events than women with negative tests. Furthermore, women with positive tests but without cardiac events at follow‐up (mean of peak WMSI – rest WMSI = 0.24 ± 0.16) had less ischemic myocardium than women with positive tests and cardiac events at follow‐up (mean of peak WMSI – rest WMSI = 0.34 ± 0.26)(P < 0.04). Conclusion: Dobutamine‐atropine stress echocardiography has good prognostic value for cardiac events in women. Women with negative tests have low probability for follow‐up infarction or death. Women with positive tests and higher severity of induced ischemia have the highest incidence of cardiac events. (ECHOCARDIOGRAPHY, Volume 21, February 2004)

Coronary Spasm during the Dobutamine Stress Echocardiography

The drug most widely used in pharmacological stress is dobutamine. Its sympathomimetic, inotropic and positive chronotropic action increases myocardial oxygen consumption and may trigger ischemia in patients with significant obstruction of coronary arteries. This agent is well tolerated and has a short half-life (2 to 3 minutes). Therefore, its effect can be stopped relatively quickly and safely. Betablockers such as metoprolol are often used at the end of the test to reverse the effects of dobutamine.

Chronic left ventricular pseudoaneurism of undetermined etiology

Pseudoaneurysms occur as a rare complication of the myocardial infarction, of which hemorrhagic process is contained by adherences of the visceral or parietal pericardium - or of both - preventing the development of cardiac tamponade. We report the case of a 55-year-old patient, with a chronic left ventricular pseudoaneurysm of undetermined etiology, who was submitted to a conservative treatment.Os pseudoaneurismas ocorrem como rara complicacao do infarto do miocardio, apos rotura miocardica, cujo processo hemorragico e contido por aderencias do pericardio visceral, parietal - ou de ambos -, impedindo o desenvolvimento de tamponamento cardiaco. Relatamos o caso de um paciente de 55 anos, com pseudoaneurisma cronico do ventriculo esquerdo de etiologia indefinida, de longa evolucao, que foi submetido a tratamento conservador.

Preliminary sketch of medical residency in cardiology. Committee of Medical Residency and Training in Cardiology SBC/FUNCOR.

In mid-1997, the new board of directors of SBC/ FUNCOR established the Committee of Medical Residency and Training to assist with the evaluation of training in cardiology. Besides providing subsidies and criteria for accreditation of the courses, this committee was encouraged to address the problem of cardiologists’ training in our country. During six months of work, the committee concluded that, despite the apparent dichotomy between the official programs of Medical Residency (MR) approved by the Brazilian Department of Education and Culture and those endorsed by SBC/FUNCOR, the establishment of a link between the two institutions was a priority. The following proposal resulted from this recognition of the need for greater cooperation and was developed from contributions of participants from the main cardiology MR program in São Paulo state, during the seminar “Medical Residency and Brazilian Society of Cardiology”, held on February 7, 1998 at the SBC/FUNCOR headquarters. Subsequently with the approval of the board of directors of SBC, this project was presented to the National Committee of Medical Residency (NCMR) in April 1998, and was well received by its members. Both groups recognized that a proposal was needed. In conjunction with NCMR, a national seminar would be held to carefully examine and define the main consensual proposals. We present here the proposal in its preliminary form in the hopes of inspiring discussion of this significant topic affecting the evolution of cardiological education in our country.