Arrhythmic storm: Short-coupled variant torsade de pointes.

A 49-year-old woman, with no relevant family history, was admitted in 1996 for arrhythmic storm with polymorphic ventricular tachycardia (torsade de pointes) which degenerated into ventricular fibrillation. Iatrogenic causes were excluded, the electrocardiogram (ECG) was normal and there was no structural heart disease. She refused cardioverter-defibrillator implantation. Treatment was begun with amiodarone, which she took irregularly. She remained asymptomatic until 2014 when she was admitted for a new arrhythmic storm with torsade de pointes, refractory to antiarrhythmic therapy and aggravated by ventricular pacing (65 defibrillations). She had frequent ventricular extrasystoles (with short-coupled period <300 ms) preceding the tachycardia. After administration of isoprenaline infusion electric stability was maintained. In this setting and in the absence of structural heart disease or iatrogenic cause, a diagnosis of short-coupled variant torsade de pointes was established. A cardioverter-defibrillator was implanted and she was treated with verapamil, without recurrence of arrhythmias.

Permanent pacemaker implantation after aortic valve replacement: Long-term dependency or rhythm recovery?

INTRODUCTION: Conduction disturbances requiring permanent pacemaker (PM) implantation occur in 3-12% of patients after aortic valve replacement (AVR). Our aim was to assess long-term PM dependency and its predictors in these patients. METHODS: We conducted a retrospective study of all consecutive patients undergoing permanent PM implantation after AVR between January 2004 and December 2010. Absence of sinus rhythm or atrial fibrillation with appropriate ventricular response at a pacing rate of 30 bpm for 10 s was defined as pacemaker dependency. RESULTS: Ninety-one patients underwent permanent PM implantation and during follow-up (1026.6 ± 732.0 days) 64% of them did not recover rhythm. Age, conduction disorders on the preoperative ECG, negative chronotropic medication before surgery, cardiopulmonary bypass and aortic cross-clamp times did not influence rhythm recovery. In multivariate analysis, valvular disease etiology related to endocarditis, prosthetic dysfunction and bicuspid valve were associated with long-term PM dependency (OR 5.05; CI: 1.43-17.75). CONCLUSIONS: The majority of patients undergoing permanent PM implantation after AVR did not recover from conduction disorders during follow-up. The etiology of valvular disease was an independent predictor of late PM dependence.

Satisfação dos utentes do Centro de Saúde da Guarda / Satisfaction of users of the Guarda Health Center

Enquadramento: A satisfação dos utentes com as instituições de saúde apresenta-se na actualidade como um indicador fundamental na determinaçãodos aspetos a melhorar e a aperfeiçoar de forma prioritária ou seja na implementação de parâmetros contributivos para a qualidade dos serviços prestados. A fonte de preocupação dos profissionais em geral alicerça-se nas experiencias vividas na "primeira voz", do seu dia-a-diae por isso se torna imperioso o conhecimento dos níveis e determinantes da satisfação dos utilizadores com vista à excelência dos cuidados. Objetivos: Avaliar a Satisfação dos utentes do Centro de Saúde da Guarda e verificar associações existentes entre esta satisfação e algumas variáveis sociodemográficas, clínicas, e psicossociais. Métodos: Trata-se de um estudo não experimental, transversal, descritivocorrelacional e de caráter quantitativo, que envolveu 303 utentes do Centro de Saúde da Guarda. Para o efeito foi utilizado um questionário que contém variáveis sociodemográficas, clínicas e psicossociais e ainda a escala "EUROPEP" para avaliar o grau de satisfação. Resultados: Constatámos que a satisfação global da amostra é elevada uma vez que oscila entre um valor mínimo de 63 e um máximo de 275, correspondendo-lhe uma média de 218,92.Verificámos ainda que a dimensão com maiores níveis de satisfação(85.6%) dizem respeito á relação/comunicação, e inversamente os utentes estão mais insatisfeitos com aorganização do serviço. Os utentes com maiores rendimentos mensais e que percepcionam maiores benefícios nos programas de reabilitação são também aqueles que se apresentam mais satisfeitos. Conclusão: O nosso estudo reforça o paradigma de que a satisfação dos utentes com os cuidados prestados tem um carácter abrangente e multidimensional, depende de factores também variáveis no tempo, no espaço e nas populações, tratando-se portanto de um processo dinâmico e subjectivo em constante construção.

Background: Nowadays, the level of satisfaction of the different patients, while using health institutions, is crucial. It is seen as a priority in the evaluation of the quality of a health system. In this sense, the patient is now at the center of the health institutions agenda. By transitivity, health professionals do care to hear the patient in the first place, before any medical action. Within this context, more knowledge on the patients' level of satisfaction and associated determinants are needed. Objectives: Evaluation of the level of satisfaction of the patients of theGuarda Health Center. Additionally, verify the existence of this self-evaluation of satisfaction with other socio-demographic, clinical and psychosocial variables. Methodology: Non-experimental study, transverse, descriptive, correlational and quantitative. Having the Guarda Health Center as the universe, this study has an underlying sample of 303 patients. For this purpose, a questionnaire containing sociodemographic, clinical and psychological was used. To evaluate self-satisfaction, 'EUROPEP' scale was used. Main results: The level of global satisfaction of the sample is high; with an average value of 218.92, 63 as minimum and 275 as maximum. On the one hand, the dimension with the highest values of satisfaction (85.6%) corresponds to the relation/ communication. On the other hand, patients are less comfortable with the organization of the health institution. Globally, the uppermost values of satisfaction are associated to: a) patients with more monthly income and b) patients that are more able to perceive the benefits of the rehabilitation programs. Conclusion: The results of this studyare aligned with the existing literature; level of satisfaction of the patients is multidimensional. In this sense, it depends on variables that are dynamic in time, space and population that are circumscribed.

Selection of patients for percutaneous balloon mitral valvotomy: is there a definitive limit for the Wilkins score?

AIM: The aim of this study was to determine the early and long-term results of percutaneous balloon mitral valvotomy (PBMV) in patients with Wilkins score (WS) between 9 and 11. METHODS: We performed a retrospective review of clinical records of patients with rheumatic mitral stenosis who underwent PBMV between November 1991 and March 2008. Follow-up was obtained by telephone interview and/or clinical records. The procedure was considered unsuccessful when post-procedure mitral valve area was <1.5 cm(2). RESULTS: We analyzed 124 patients, 108 (87.1%) of them women. Mean age at the time of repair was 46 ± 11 years and mean follow-up time was 10 ± 4 years. Before the procedure, 100 patients (80.6%) had WS ≤ 8 and 24 (19.4%) were in the "gray zone" (>8 and <11). Patients with WS ≤ 8 and patients in the gray zone had similar ages at first intervention (45 ± 11 vs. 49 ± 11 years; p=0.095) and follow-up time (10 ± 4 vs. 11 ± 5 years; p=0.55). There were no differences between groups in gender (women: 86% vs. 92%; p=0.735), or in baseline echocardiographic measurements (mitral valve area by planimetry 1.0 cm(2) [P25-P75: 0.9-1.1] vs. 0.9 [P25-P75: 0.8-1.2], p=0.514; pulmonary artery systolic pressure 53 mmHg [P25-P75: 45-63] vs. 50 [P25-P75: 44-54], p=0.823]; left atrial diameter >55 mm [16.5% vs. 13.6%, p=1.00]; mitral regurgitation [46.5% vs. 37.5%, p=0.428]) or baseline transmitral gradient (13 mmHg [P25-P75: 10-19] vs. 13 mmHg [P25-P75: 7-20]). Improvements in mitral valve area by planimetry and in hemodynamic gradient were similar in the two groups (0.91 ± 0.39 cm(2) vs. 0.84 ± 0.44 cm(2), p=0.55; 8.8 ± 5.3 mmHg vs. 7.3 ± 5.9 mmHg, p=0.275, respectively). There were no significant differences in major complications or success rates (4.0 vs. 12.5 p=0.131; 89.9% vs. 95.8%, p=0.69) or in need for urgent surgery or future reintervention (2.0 vs. 8.3%, p=0.168; 22% vs. 27.3%, p=0.594). In-hospital mortality occurred only in patients in the WS gray zone (2 [8.3%] vs. 0%, p=0.04), one death (4.2% vs. 0%, p=0.194) possibly being related to a higher WS (secondary to stroke) and the other as a consequence of peripheral vascular complication. Improvements in NYHA functional class soon after the procedure and during follow-up were similar in the two groups. Total mortality was similar in the two groups (3.1 vs. 8.7%, p=0.244). CONCLUSIONS: PBMV was a safe and effective procedure in patients in the WS gray zone. Optimal results can be achieved in these patients if they are carefully selected and operated at experienced centers.

The role of pacemaker in hypersensitive carotid sinus syndrome.

AIMS: About 15% of patients with the hypersensitive carotid sinus syndrome (CSS) have no clinical improvement after permanent pacemaker implantation. We aimed to assess the outcome of patients with CSS treated with pacemaker and to determine predictors of symptoms' recurrence. METHODS AND RESULTS: A retrospective analysis of 138 patients in whom pacemaker was implanted for CSS was carried out from February 1990 to October 2008. Data were collected from clinical records. Mean age was 69 ± 10.7 years and 104 patients (75.4%) were men. Mean follow-up period was 4.9 ± 4.4 years. Twenty-one (15.2%) patients presented mixed CSS and 117 (84.8%) cardioinhibitory CSS. The head-up tilt test (HUTT) was performed in 93 patients (67.4%). After pacemaker implantation, 115 (83.3%) patients had no further symptoms, 8 (5.8%) presented minor symptoms and in 15 (10.9%), the symptoms remained unchanged. Among patients with symptoms' recurrence, 8 (38.1%) had mixed CSS and 15 (12.8%) cardioinhibitory CSS. Mixed CSS was the only independent predictor of symptoms' recurrence in total population {hazard ratio (HR) 2.84 [95% confidence intervals (CI) 1.20-6.71]; P = 0.017} and in patients who performed HUTT [HR 1.84 (95% CI 1.01-3.35); P = 0.045]. Although the HUTT result was not related to symptoms' recurrence, patients with mixed CSS were more likely to present a vasodepressor response (61.9 vs. 19.4%; P < 0.001) and a reproduction of spontaneous symptoms (28.6 vs. 2.8%; P = 0,001) on HUTT. CONCLUSIONS: Permanent pacemaker is an effective treatment for CSS. However, the recurrence of symptoms was two- to three-fold more frequent in patients with mixed CSS, probably due to the persistence of vasodepressor component.