Paulo Roberto Camargo

Favorable effects of immunosuppressive therapy in children with dilated cardiomyopathy and active myocarditis

Among 68 children with severe dilated cardiomyopathy, 43 (aged 10 months to 15 years) presented with active myocarditis, diagnosed by endomyocardial biopsy. They were divided into four treatment groups: I, controls: 9 patients submitted to conventional treatment (digitalis, diuretics, and vasodilators) for 8.1±0.7 (SD) months; II, prednisone: 12 patients received conventional therapy plus prednisone; III, azathioprine: 16 patients submitted to conventional therapy plus prednisone and azathioprine; IV, cyclosporine: 13 patients treated with conventional therapy plus prednisone and cyclosporine. Immunosuppressive therapy was maintained for a mean of 8.4±1.2 months. They were submitted to noninvasive (electrocardiogram, chest radiograph, Doppler echocardiogram, and radioisotopic scintigraphy) and invasive (hemodynamic) studies. In the control group only 2 of 9 patients showed clinical and hemodynamic improvement and 1 of 4, histologic regression of the myocarditis. Among patients submitted to conventional therapy plus prednisone, 3 of 12 presented clinical and hemodynamic improvement; 2 of 5 also showed histologic regression of inflammatory process. By contrast, patients treated with azathioprine or cyclosporine associated with prednisone had significantly better results: 13 of 16 and 10 of 13 patients, respectively, had clinical and hemodynamic improvement; all 6 patients in the azathioprine group and all 4 patients in the cyclosporine group had histologic regression of the myocarditis. Two patients in the prednisone group, one in the azathioprine group, and one in the cyclosporine group died during treatment, in cardiogenic shock. In our experience immunosuppressive therapy with azathioprine or cyclosporine associated with prednisone improves the prognosis of children with active myocarditis and severe ventricular dysfunction.

The Effects of Glibenclamide, a KATP Channel Blocker, on the Warm-Up Phenomenon

Background: The warm‐up phenomenon observed after the second of two sequential exercise tests is characterized by an increased time to ischemia and ischemic threshold, and the latter is related to ischemic preconditioning. Previous studies have demonstrated that a single dose of glibenclamide, a cardiac ATP‐sensitive K (KATP) channel blocker, prevents ischemic preconditioning. This study aimed to investigate the effects of chronic treatment with glibenclamide during two sequential exercise tests.

Myocarditis in children and detection of viruses in myocardial tissue: Implications for immunosuppressive therapy

BACKGROUND There is scarce information on the potential benefits of immunosuppression in children with myocarditis and viral genomes in myocardium. We investigated the occurrence of myocarditis in children with a preliminary diagnosis of dilated cardiomyopathy, the frequency of cardiotropic viruses in the myocardium, and the response to immunosuppression. METHODS Thirty patients (nine months to 12 years) with left ventricular ejection fraction of 22.8 ± 4.1% were subjected to right cardiac catheterization and endomyocardial biopsy. Specimens were analyzed for the presence of inflammatory elements (Dallas criteria) and viral genome (polymerase chain reaction). Patients with active myocarditis received immunosuppressants (azatioprine and prednisone) and were re-catheterized nine months later. A historical control group of nine patients with myocarditis who did not receive immunosuppressants was included. RESULTS Active myocarditis was diagnosed in ten patients (five with viral genomes detected). Immunosuppression resulted in a significant increase in left ventricular ejection fraction from 25.2 ± 2.8% to 45.7 ± 8.6% (versus 20.0 ± 4.0% to 22.0 ± 9.0% in historical controls, p<0.01) and cardiac index from 3.28 ± 0.51 L/min/m(2) to 4.40 ± 0.49 L/min/m(2) (versus 3.50 ± 0.40 L/min/m(2) to 3.70 ± 0.50 L/min/m(2) in controls, p<0.01), regardless of the presence of viral genomes (p=0.98 and p=0.22, respectively for the two variables). No relevant clinical events were observed. Non-inflammatory cardiomyopathy was diagnosed in 20 patients (seven with viral genomes). While on conventional therapy, there were four deaths and three assignments to transplantation, and no improvement of left ventricular ejection fraction in the remaining ones (22.5 ± 3.6% to 27.5 ± 10.6%). CONCLUSION Children with chronic myocarditis seem to benefit from immunosuppressive therapy, regardless of the presence of viral genome in the myocardium.

Marcapasso bi-atrial epicárdico subxifóide na obstrução da veia cava superior

A patient with a bi-atrial-ventricular permanent pacemaker due to paroxystic atrial fibrillation associated to sinus bradycardia, in chronic use of oral anticoagulant, presented clinical signs of superior vena cava syndrome. Digital subtraction venography showed total obstruction of the right brachiocephalic venous trunk and severe stenosis of the connection of the left trunk to the superior vena cava. The therapeutic approach consisted of complete removal of transvenous system followed by re-implant of the bi-atrial-ventricular system using an epicardial subxiphoid access with fluoroscopic assistance.

Prognostic value of cardiopulmonary exercise testing in children with heart failure secondary to idiopathic dilated cardiomyopathy in a non-β-blocker therapy setting

Peak oxygen consumption and resting left ventricular ejection fraction (LVEF) are independent predictors of survival in adult heart failure (HF) patients. Aim: To evaluate these factors in children.

Correlation between gallium-67 imaging and endomyocardial biopsy in children with severe dilated cardiomyopathy

Fourty-four patients (aged 10 months to 15 years) were assessed in a double-blind study to observe the correlation between myocardial uptake of 67-gallium and endomyocardial biopsy in the detection of moderate to severe myocardial inflammation. The sensitivity and specificity of gallium-67 imaging were 87 and 81%, respectively. Based on these findings, immunosuppressive therapy can be assigned to children with dilated cardiomyopathy and positive myocardial uptake, since moderate and severe myocardial inflammation may be detected by this non-invasive method.

A modified laparoscopic sleeve gastrectomy for the treatment of diabetes mellitus type 2 and metabolic syndrome in obesity

BACKGROUND Ghrelin is a gastrointestinal peptide hormone (a 28-amino acid peptide) produced primarily by X/A cells in the oxyntic glands of the stomach fundus and cells lining the duodenum cavern. It suppresses insulin secretion and action and commands a significant role in regulating food intake. The aim of the present study was to show that modified laparoscopic sleeve gastrectomy (MLSG), in which a significant part of the gastric fundus and body of the stomach is removed up to 1 inch from the pylorus vein, may contribute to decreasing circulating ghrelin levels. METHODS A study population consisting of 150 individuals was monitored after undergoing a MLSG, with individuals chosen based on a documented history of diabetes mellitus type 2 and metabolic syndrome, clinical results determining a body mass index (BMI) of 35 to 60 kg/m(2), peptide C level greater than 1, negative anti-glutamic acid decarboxylase, negative anti-insulin, and confirmed stability of drug/insulin treatment and glycosylated hemoglobin greater than 6.5% for at least 24 and 3 months, respectively, before enrollment. RESULTS Twenty-four months after surgery, 150 patients (86.6%) presented with normal glycemic levels between 77 and 99 mg/dL. All patients improved average serum insulin levels by 9 mU/L and average glycosylated hemoglobin levels by 5.1% (normal range, 4%-6%). All patients tested negative for Helicobacter pylori and stopped using insulin, with 3 patients prescribed twice-daily use of an oral hypoglycemiant. In 14% of cases, patients experienced partial hair loss with low serum zinc levels and were prescribed oral zinc reposition and topical hair stimulants. The average weight loss recorded was 44.6% for patients with a BMI less than 45 kg/m(2) and 58% for patients with a BMI greater than 50 kg/m(2). CONCLUSIONS The MLSG is a safe procedure with a low morbidity rate (2.7%) (4 cases of fistula and 2 of bleeding) and no surgical mortality in this study. This surgery can promote control of diabetes mellitus type 2 and aid the treatment of exogenous overweight and morbidly obese individuals. The results of this study show that only through resection of the ghrelin-producing gastric area can most obesity cases and diabetes type II conditions be reverted to nonobese and controlled diabetes.

Deficiência hídrica e aplicação de ABA nas trocas gasosas e no acúmulo de flavonoides em calêndula (Calendula officinalis L.)

The goal of this study was to evaluate the effects of water deficit and abscisic acid (ABA) application on physiological parameters and flavonoid production in marigold plant. The experiment was performed under nursery conditions with potted plants. It was tested water deficit by withholding water (control – diary irrigation, 3, 6 and 9 days without irrigation) followed by 3 ABA concentrations (0, 10 e 100 µM) applied in the beginning of blooming. It was evaluated the relative water content and the leaf gas exchange using a portable infrared gas analyzer (A: net photosynthesis, gs: stomatal conductance, E: transpiration, Ci: CO 2 intercellular concentration and EUA: water use efficiency). At the end of 9 days of water deficit there were significant decreases in all the characteristics evaluated, independent of ABA application. This suggests that the main effect of ABA was to cause a reduction on gs which was accompanied of a reduction in A, only when the plants were submitted to the water deficit. There was no significant difference among the levels of water deficit tested in relation to the total flavonoid content in inflorescences. However, ABA restricted the flavonoids biosynthesis both in control plant and stressed plants.

Ablação com RF de arritmia na infância: registro observacional em 125 crianças

BACKGROUND Radiofrequency ablation (RFA) in children is an increasingly common practice. OBJECTIVE To evaluate, in our institution, the results of RFA in children younger than 15 years. METHODS A total of 125 children submitted to RFA between May 1991 and May 2010 were analyzed. RESULTS Sixty-seven (53.6%) children were males, aged between 44 days and 15 years (mean 8.6 ± 3.3 years) with median weight of 31 kg. Heart disease was present in 21 (16.8%) patients. The RFA of accessory pathways (AP) was the most common procedure (62 children - 49.6%). The RFA of nodal reentrant tachycardia (NRT) was the second most common arrhythmia in 27 (21.6%), followed by atrial tachycardia (AT) in 16 (12.8%) and ventricular tachycardias (VT) in 8 (6.4%) children. The success criteria were achieved in 86.9%, 96.1%, 80% and 62.5% of patients undergoing RFA of AP, NRT, AT and VT, respectively. Transient AVB occurred during RFA in 4 (3.2%) and LBBB in 7 (5.6%) children. Twenty-five children underwent a new RFA due to initial failure or recurrence. During the mean follow up of 5.5 ± 3.4 years, 107 (88.4%) remained without recurrence. There was no statistical difference regarding the results and the age at which the patient underwent the procedure. No child had persistent AVB or required a permanent pacemaker. CONCLUSION Catheter ablation is a safe and effective alternative therapy in children with recurrent tachycardias refractory to medical treatment.

Avaliação Hemodinâmica e Evolução Clínica de Crianças Portadoras de Cardiomiopatia Dilatada Grave Candidatas a Transplante Cardíaco

PURPOSE To evaluate hemodynamic parameters and clinical outcome of children with severe cardiomyopathy who are candidates for heart transplantation. METHODS Twenty four children aged from 4 months to 10 years and 8 months (mean 3.7 +/- 2.5 years) from February 1992 to May 1996, were submitted to hemodynamic study and the following parameters were measured: cardiac output, mean pulmonary artery pressure (MPAP) and capillary wedge pressure. The pulmonary vascular resistance index (PVRI) and transpulmonary pressure gradient (TGP) were calculated. RESULTS Ten (41.6%) children were transplanted (group A), 5 (20.8%) are still waiting heart transplantation (group B) and 9 (37.6%) died (group C). The mean age of the B and C group were significantly different. The PVRI, MPAP and TPG were significant lower in group A than group C (p = 0.01; p = 0.044 and p = 0.023 respectively). CONCLUSION The profile of the hemodynamic parameters of children with severe dilated cardiomyopathy was compatible with the clinical findings. The age was the only difference comparing groups B and C. PVRI, MPAP and TPG were significant factors between group A and C. The older the patient, the worse was the prognosis.OBJETIVO: Estudar o perfil dos parâmetros hemodinâmicos e a evolucao clinica de criancas candidatas a transplante cardiaco, portadoras de cardiomiopatia grave. METODOS: Foram 24 criancas, com idade entre 4 meses e 10 anos e 8 meses (media de 3,7±2,5 anos), no periodo de fevereiro/92 a maio/96, submetidas a estudo hemodinâmico e medidos os seguintes parâmetros: debito cardiaco, pressao media de arteria pulmonar (PMAP) e pressao capilar pulmonar. Foram calculados o indice de resistencia vascular pulmonar (IRVP) e gradiente de pressao transpulmonar (GPT). RESULTADOS: Do ponto de vista evolutivo, 10 (41,6%) criancas foram transplantadas (grupo A), 5 (20,8%) aguardam o transplante (grupo B) e 9 (37,6%) faleceram (grupo C). Observou-se que a media das idades dos pacientes do grupo B foi significativamente menor que do grupo C. Dos dados hemodinâmicos, a PMAP, GTP e IRVP apresentaram medias significativamente menores no grupo A em relacao ao grupo C. CONCLUSAO: O perfil hemodinâmico de criancas candidatas ao transplante cardiaco mostrou-se compativel ao quadro clinico de insuficiencia cardiaca grave. A idade foi o unico fator que diferenciou o grupo B e C (p= 0,036). O IRVP, PMAP e o GTP foram fatores que diferenciaram de modo significativo o grupo A e o grupo C (p=0,010; p=0,044 e p=0,023, respectivamente). Quanto maior a idade no momento da indicacao do transplante na crianca, pior foi seu prognostico.