Paulo Ceratti de Azambuja

Glicose insulina e potássio (GIK) na revascularização do miocárdio de pacientes diabéticos: ensaio clínico randomizado

OBJECTIVE: This study was undertaken to determine whether GIK infusion improves hemodynamic performance by reducing the use of inotropic agents, as well as the morbidity of diabetic patients submitted to CABG. METHODS: Patients with type 2 DM referred for CABG were randomized to receive GIK or subcutaneous insulin from anesthetic induction up to 12 hours postoperatively. The primary clinical outcome was the cardiac index (CI) and the secondary clinical outcomes were the remaining hemodynamic parameters; the use of inotropics and vasodilators, the glycemic control (maintenance of plasma glucose levels), and the postoperative morbidity. Hemodynamic and laboratory measurements were performed in the first 24 hours postoperatively, and the patients were followed up for 30 days to detect any surgery-related complications. RESULTS: Twenty-four patients were randomly included in the study. IC did not show significant difference (mean cardiac index at 24 hours in both GIK group 3.49±0.94 and Control group 3.38±0.75; p=0.74). The GIK group revealed lower blood glucose levels in the infusion period (glucose at 12 hours GIK group 195.6±68.25 versus Control group 269.6±78.48; p=0.02), with a lower incidence of hyperglycemia in the GIK group, two (16%) against eight (64%) in the control group (RR 0.25; 95%CI 0.07-0.94; p=0.03). Postoperative infectious complications were less frequent in the GIK group than in Control group, three (25%) against 10 (80%), respectively (RR 0.30; 95%CI 0.11 - 0.83; p=0.01). CONCLUSIONS: Studies have proven that GIK improves hemodynamic performance of both patients with or without DM submitted to CABG, what was not confirmed in this study. The use of GIK neither improved the CI improvement nor reduced the use of inotropic drugs, but it provided better glucose control. Secondary clinical outcome, including postoperative infections, was more frequent in the control group.

Ventricular evoked response in patients with hypertrophic obstructive cardiomyopathy treated with DDD pacing

OBJECTIVE To assess the changes in ventricular evoked responses (VER) produced by the decrease in left ventricular outflow tract gradient (LVOTG) in patients with hypertrophic obstructive cardiomyopathy (HOCM) treated with dual-chamber (DDD) pacing. METHODS A pulse generator Physios CTM (Biotronik, Germany) was implanted in 9 patients with severe drug-refractory HOCM. After implantation, the following conditions were assessed: 1) Baseline evaluation: different AV delay (ranging from 150 ms to 50 ms) were sequentially programmed during 5 to 10 minutes, and the LVOTG (as determined by Doppler echocardiography) and VER recorded; 2) standard evaluation, when the best AV delay (resulting in the lowest LVOTG) programmed at the initial evaluation was maintained so that its effect on VER and LVOTG could be assessed during each chronic pacing evaluation. RESULTS LVOTG decreased after DDD pacing, with a mean value of 59 +/- 24 mmHg after dual chamber pacemaker, which was significantly less than the gradient before pacing (98 + 22 mmHg). An AV delay > 100 ms produced a significantly lower decrease in VER depolarization duration (VERDD) when compared to an AV delay < or = 100 ms. Linear regression analyses showed a significant correlation between the LVOTG values and the magnitude of VER (r = 0.69; p < 0.05) in the 9 studied patients. CONCLUSION The telemetry obtained intramyocardial electrogram is a sensitive means to assess left ventricular dynamics in patients with HOCM treated with DDD pacing.

Aortic aneurysm rupture into the esophagus

We present the case of a patient with a descending aorta aneurysm rupture into the esophagus, which, after aortoplasty with Dacron tube interposition and suture of esophageal laceration, developed a pleural-esophagus fistula on the 3rd postoperative day. She needed re-intervention and intensive care, followed by adequate recovery. Considering this unusual case and the knowledge acquired through its management, we reviewed the literature in order to discuss the best alternative for the correction of this rare and often fatal form of presentation of aortic diseases.

Estimulação cardíaca com variação de freqüência em sistema de alça fechada e sensor de contractilidade miocárdica: avaliação tardia em estudo multicêntrico

INTRODUCTION: The treatment of bradycardias with bicameral pacemakers (PM) with frequency response (DDD,R) has motivated the search of an ideal sensor. We did a late re-evaluation (3 years) the frequency response of those PM with myocardial contractility sensor in closed loop system. MATERIAL AND METHODS: Thirty patients (pts) of the initial study done in 1997, who presented binodal disease and 3-year implantation were evaluated, being 60% male, ages between 17-87 (average = 61). Their heart frequency (HF) was observed through a 24 Holter monitoring and MP frequency histogram on the daily activities, plus 6-minute walk and going up and downstairs tests. Chronic pacing thresholds were determined as well as atrial (A) and ventricular (V) sensitivity, checking them against those obtained in the implantation and immediate post-operative periods. RESULTS: The average threshold in the intra-operative, 30 days and 3 years were as follows: A pacing (0.8, 1.4 and 1.1V) and V (0.5, 1.1 e 1.0V), A sensitivity (2.3, 2.8 e 2.6mV) and V (10.6, 6.3 and 6.3mV). The HF at the 3rd year increased for daily activities (physical and mental) from 33 to 91%, and for physical exercises tests from 21 to 130%, similarly to the results obtained in 30 days (test t student and variation analysis). This contractility sensor kept at the 3rd year the same good results obtained at the 30th day, presenting the following adverse effects: high-energy consumption in 2 pts and difficulty of sensor adjustment in other 2.