Atrial Fibrillation Ablation: Impact of Intracardiac Echocardiography in Reducing Procedure Time and Hospitalization. / Ablação da Fibrilação Atrial: Impacto da Ecocardiografia Intracardíaca na Redução do Tempo de Procedimento e Internação.

BACKGROUND: Intracardiac echocardiography (ICE) allows visualization of cardiac structures and recognition of complications during atrial fibrillation ablation (AFA). Compared to transesophageal echocardiography (TEE), ICE is less sensitive to detecting thrombus in the atrial appendage but requires minimal sedation and fewer operators, making it attractive in a resource-constrained setting. OBJECTIVE: To compare 13 cases of AFA using ICE (AFA-ICE group) with 36 cases of AFA using TEE (AFA-TEE group). METHODS: This is a single-center prospective cohort study. The main outcome was procedure time. Secondary outcomes: fluoroscopy time, radiation dose (mGy/cm2), major complications, and length of hospital stay in hours. The clinical profile was compared using the CHA2DS2-VASc score. A p-value <0.05 was considered a statistically significant difference between groups. RESULTS: The median CHA2DS2-VASc score was 1 (0-3) in the AFA-ICE group and 1 (0-4) in the AFA-TEE group. The total procedure time was 129 ± 27 min in the AFA-ICE group and 189 ± 41 min in the AFA-TEE group (p<0.001); the AFA-ICE group received a lower dose of radiation (mGy/cm2, 51296 ± 24790 vs. 75874 ± 24293; p=0.002), despite the similar fluoroscopy time (27.48 ± 9. 79 vs. 26.4 ± 9.32; p=0.671). The median length of hospital stay did not differ; 48 (36-72) hours (AFA-ICE) and 48 (48-66) hours (AFA-TEE) (p=0.27). CONCLUSIONS: In this cohort, AFA-ICE was related to shorter procedure times and less exposure to radiation without increasing the risk of complications or the length of hospital stay.

FUNDAMENTO: O ecocardiograma intracardíaco (EIC) permite visualizar estruturas cardíacas e reconhecer complicações durante a ablação da fibrilação atrial (AFA). Comparado ao ecocardiograma transesofágico (ETE), o EIC é menos sensível para detecção de trombo no apêndice atrial, porém requer mínima sedação e menos operadores, tornando-o atrativo num cenário de recursos restritos. OBJETIVO: Comparar 13 casos de AFA utilizando EIC (grupo AFA-EIC) com 36 casos de AFA utilizando ETE (grupo AFA-ETE). MÉTODO: Trata-se de corte prospectiva realizada em um único centro. O desfecho principal foi o tempo de procedimento. Desfechos secundários tempo de fluoroscopia, dose de radiação (mGy/cm2), complicações maiores e tempo de internação hospitalar em horas. O perfil clínico foi comparado pelo escore CHA2DS2-VASc. Um valor de p <0,05 foi considerado uma diferença estatisticamente significativa entre os grupos. RESULTADOS: A mediana do escore de CHA2DS2-VASc score foi 1 (0-3) no grupo AFA-EIC e 1 (0-4) no grupo AFA-ETE. O tempo total de procedimento foi de 129 ± 27 min grupo AFA-EIC e 189 ± 41 no AFA-ETE (p<0,001); o grupo AFA-EIC recebeu uma dose menor de radiação (mGy/cm2, 51296 ± 24790 vs. 75874 ± 24293; p=0,002), no entanto, o tempo de fluoroscopia em minutos mostrou-se semelhante (27,48 ± 9,79 vs. 26,4 ± 9,32; p=0,671). As medianas do tempo de hospitalização não se mostraram diferentes, 48 (36-72) horas (AFA-EIC) e 48 (48-66) horas (AFA-ETE) (p=0,27). CONCLUSÃO: Nesta coorte, AFA-EIC foi relacionado a menores tempos de procedimento e menor exposição à radiação, sem aumentar o risco de complicações ou o tempo de internação hospitalar.

Ablação da Fibrilação Atrial: Impacto da Ecocardiografia Intracardíaca na Redução do Tempo de Procedimento e Internação / Atrial Fibrillation Ablation: Impact of Intracardiac Echocardiography in Reducing Procedure Time and Hospitalization

Resumo Fundamento O ecocardiograma intracardíaco (EIC) permite visualizar estruturas cardíacas e reconhecer complicações durante a ablação da fibrilação atrial (AFA). Comparado ao ecocardiograma transesofágico (ETE), o EIC é menos sensível para detecção de trombo no apêndice atrial, porém requer mínima sedação e menos operadores, tornando-o atrativo num cenário de recursos restritos. Objetivo Comparar 13 casos de AFA utilizando EIC (grupo AFA-EIC) com 36 casos de AFA utilizando ETE (grupo AFA-ETE). Método Trata-se de corte prospectiva realizada em um único centro. O desfecho principal foi o tempo de procedimento. Desfechos secundários tempo de fluoroscopia, dose de radiação (mGy/cm2), complicações maiores e tempo de internação hospitalar em horas. O perfil clínico foi comparado pelo escore CHA2DS2-VASc. Um valor de p <0,05 foi considerado uma diferença estatisticamente significativa entre os grupos. Resultados A mediana do escore de CHA2DS2-VASc score foi 1 (0-3) no grupo AFA-EIC e 1 (0-4) no grupo AFA-ETE. O tempo total de procedimento foi de 129 ± 27 min grupo AFA-EIC e 189 ± 41 no AFA-ETE (p<0,001); o grupo AFA-EIC recebeu uma dose menor de radiação (mGy/cm2, 51296 ± 24790 vs. 75874 ± 24293; p=0,002), no entanto, o tempo de fluoroscopia em minutos mostrou-se semelhante (27,48 ± 9,79 vs. 26,4 ± 9,32; p=0,671). As medianas do tempo de hospitalização não se mostraram diferentes, 48 (36-72) horas (AFA-EIC) e 48 (48-66) horas (AFA-ETE) (p=0,27). Conclusão Nesta coorte, AFA-EIC foi relacionado a menores tempos de procedimento e menor exposição à radiação, sem aumentar o risco de complicações ou o tempo de internação hospitalar.

Abstract Background Intracardiac echocardiography (ICE) allows visualization of cardiac structures and recognition of complications during atrial fibrillation ablation (AFA). Compared to transesophageal echocardiography (TEE), ICE is less sensitive to detecting thrombus in the atrial appendage but requires minimal sedation and fewer operators, making it attractive in a resource-constrained setting. Objective To compare 13 cases of AFA using ICE (AFA-ICE group) with 36 cases of AFA using TEE (AFA-TEE group). Methods This is a single-center prospective cohort study. The main outcome was procedure time. Secondary outcomes: fluoroscopy time, radiation dose (mGy/cm2), major complications, and length of hospital stay in hours. The clinical profile was compared using the CHA2DS2-VASc score. A p-value <0.05 was considered a statistically significant difference between groups. Results The median CHA2DS2-VASc score was 1 (0-3) in the AFA-ICE group and 1 (0-4) in the AFA-TEE group. The total procedure time was 129 ± 27 min in the AFA-ICE group and 189 ± 41 min in the AFA-TEE group (p<0.001); the AFA-ICE group received a lower dose of radiation (mGy/cm2, 51296 ± 24790 vs. 75874 ± 24293; p=0.002), despite the similar fluoroscopy time (27.48 ± 9. 79 vs. 26.4 ± 9.32; p=0.671). The median length of hospital stay did not differ; 48 (36-72) hours (AFA-ICE) and 48 (48-66) hours (AFA-TEE) (p=0.27). Conclusions In this cohort, AFA-ICE was related to shorter procedure times and less exposure to radiation without increasing the risk of complications or the length of hospital stay.

Gene therapy for refractory angina and cell therapy for heart failure: experience of a Brazilian research group.

Cell therapy has shown impressive effects in experimental cardiomyopathy models. To a lesser extent, gene therapy has also been studied. In both cases, translation to clinical therapy has been disappointing. This paper is intended to describe the experience and achievements of a multicenter working group located in Porto Alegre, southern Brazil, in experimental and translational research projects for cell-based and gene therapy methods in the treatment of dilated and ischemic cardiomyopathies. The results of preclinical and clinical studies showed that bone marrow mononuclear stem cells indeed have an effect in improving myocardial perfusion and contractile function, but the overall results are poorly translated to the clinical level. Gene therapy studies with direct myocardial injections of naked VEGF 165 plasmid showed improvement in myocardial perfusion and function in animal models. A randomized clinical trial found that this method is safe and improved myocardial perfusion, but the benefits disappeared after 1 year. An animal experiment associating VEGF 165 with angiopoietin was undertaken in mini pigs to extend the durability of that therapy. In conclusion, our efforts to better understand the mechanisms and functions of gene and cell-based therapies in cardiology resulted in significant findings and propose a future look at cell-free therapeutic approaches.

Unscheduled Emergency Visits after Cardiac Devices Implantation: Comparison between Cardioverter Defibrillators and Cardiac Resynchronization Therapy Devices in less than one year of Follow Up / Consultas Não Programadas em Emergência após Implante de Dispositivos Cardíacos: Comparativo entre Cardiodesfibriladores e Ressincronizadores em Seguimento Inferior a 1 Ano

Abstract Background: The use of Cardiovascular Implantable Electronic Devices (CIED), such as the Implantable Cardioverter Defibrillator (ICD) and Cardiac Resynchronization Therapy (CRT), is increasing. The number of leads may vary according to the device. Lead placement in the left ventricle increases surgical time and may be associated with greater morbidity after hospital discharge, an event that is often confused with the underlying disease severity. Objective: To evaluate the rate of unscheduled emergency hospitalizations and death after implantable device surgery stratified by the type of device. Methods: Prospective cohort study of 199 patients submitted to cardiac device implantation. The groups were stratified according to the type of device: ICD group (n = 124) and CRT group (n = 75). Probability estimates were analyzed by the Kaplan-Meier method according to the outcome. A value of p < 0.05 was considered significant in the statistical analyses. Results: Most of the sample comprised male patients (71.9%), with a mean age of 61.1 ± 14.2. Left ventricular ejection fraction was similar between the groups (CRT 37.4 ± 18.1 vs. ICD 39.1 ± 17.0, p = 0.532). The rate of unscheduled visits to the emergency unit related to the device was 4.8% in the ICD group and 10.6% in the CRT group (p = 0.20). The probability of device-related survival of the variable "death" was different between the groups (p = 0.008). Conclusions: Patients after CRT implantation show a higher probability of mortality after surgery at a follow-up of less than 1 year. The rate of unscheduled hospital visits, related or not to the implant, does not differ between the groups.

Resumo Fundamento: O uso de dispositivos cardíacos eletrônicos implantáveis (DCEI) como o cardiodesfibrilador (CDI) e terapia de ressincronização cardíaca (TRC) - é cada vez maior. O número de eletrodos de estimulação e desfibrilação varia de acordo com o dispositivo. A colocação do eletrodo no ventrículo esquerdo aumenta o tempo cirúrgico podendo associar-se a maior morbidade no acompanhamento após alta hospitalar, evento muitas vezes confundível com a gravidade da patologia base. Objetivo: Avaliar a taxa de internação não programada na emergência e óbito após cirurgia de dispositivos implantáveis estratificados pelo tipo de aparelho. Métodos: Estudo de coorte prospectivo analisando 199 pacientes submetidos à implante de dispositivos cardíacos. Os grupos foram divididos de acordo com o tipo de dispositivo: CDI (n = 124) e TRC (n = 75). Estimativas de probabilidades foram analisadas pelo método de Kaplan-Meier de acordo com o desfecho. Valor de p < 0,05 foi considerado significativo nas análises estatísticas. Resultados: A maioria da amostra era do sexo masculino (71,9%) - idade média de 61,1 ± 14,2. A fração de ejeção do ventrículo esquerdo foi similar entre os grupos (TRC 37,4 ± 18,1 vs. CDI 39,1 ± 17,0; p = 0,532). A taxa de visita não programada na emergência relacionada ao dispositivo foi de 4,8% no grupo CDI e de 10,6% no grupo TRC (p = 0,20). A probabilidade de sobrevida relacionada ao dispositivo da variável "óbito" mostrou-se diferente entre os grupos (p = 0,008). Conclusões: Paciente após o implante de TRC apresenta maior probabilidade de mortalidade após o procedimento cirúrgico no seguimento menor que 1 ano. A taxa de visita hospitalar não programada, relacionadas ou não ao implante, não difere entre os grupos.

Coronary sinus cannulation predicts atrioventricular nodal reentry as mechanism of supraventricular tachycardia.

INTRODUCTION: Common clinical teaching, for invasive electrophysiology, is that if the first year fellow cannulates the coronary sinus (CS) in his first attempt, the arrhythmia is more likely to be atrioventricular nodal reentry tachycardia (AVNRT). This general perception has not yet been clinically tested. We evaluated this theory in prospective patients undergoing an electrophysiological study (EPS) for paroxysmal supraventricular tachycardia (PSVT). METHODS: Cohort study. CS ease of cannulation (CSCS) was graded as: 1) 1st year fellow cannulates in first attempt; 2) 1st year fellow needs more than one attempt or maneuver to cannulate the CS; 3) staff physician cannulates in first attempt after the fellow was unsuccessful; 4) staff physician requires more than one maneuver to cannulate the CS; 5) staff physician judges that the cannulation process was extremely difficult. RESULTS: Of the 1361 patients undergoing EPS in our institution, 165 were selected. Age was 49 ±â€¯15 years. AVNRT occurred in 77.6%, atrioventricular reentry tachycardia (AVRT) in 15.1% and atrial tachycardia (AT) in 7.3% of cases. The CSCS = 1 was more prevalent in AVNRT, 89% versus 68% AVRT and 58.3% of AT (P = 0.0005). Patients with CSCS = 1 have a higher chance of the PSVT being AVNRT (odds ratio: 4.41; 95CI: 1.84-10.56; P = 0.0009). CONCLUSION: The CSCS predicts the likelihood of the induced PSVT being AVNRT as compared to AVRT and AT. More studies are required to try to associate this finding to clinical patient characteristics to create a score for PSVT mechanism prediction.

Unscheduled Emergency Visits after Cardiac Devices Implantation: Comparison between Cardioverter Defibrillators and Cardiac Resynchronization Therapy Devices in less than one year of Follow Up.

BACKGROUND: The use of Cardiovascular Implantable Electronic Devices (CIED), such as the Implantable Cardioverter Defibrillator (ICD) and Cardiac Resynchronization Therapy (CRT), is increasing. The number of leads may vary according to the device. Lead placement in the left ventricle increases surgical time and may be associated with greater morbidity after hospital discharge, an event that is often confused with the underlying disease severity. OBJECTIVE: To evaluate the rate of unscheduled emergency hospitalizations and death after implantable device surgery stratified by the type of device. METHODS: Prospective cohort study of 199 patients submitted to cardiac device implantation. The groups were stratified according to the type of device: ICD group (n = 124) and CRT group (n = 75). Probability estimates were analyzed by the Kaplan-Meier method according to the outcome. A value of p < 0.05 was considered significant in the statistical analyses. RESULTS: Most of the sample comprised male patients (71.9%), with a mean age of 61.1 ± 14.2. Left ventricular ejection fraction was similar between the groups (CRT 37.4 ± 18.1 vs. ICD 39.1 ± 17.0, p = 0.532). The rate of unscheduled visits to the emergency unit related to the device was 4.8% in the ICD group and 10.6% in the CRT group (p = 0.20). The probability of device-related survival of the variable "death" was different between the groups (p = 0.008). CONCLUSIONS: Patients after CRT implantation show a higher probability of mortality after surgery at a follow-up of less than 1 year. The rate of unscheduled hospital visits, related or not to the implant, does not differ between the groups.

Early Emotional Symptoms Predicting Carotid Atherosclerosis in Youth: Results From a Birth Cohort in Latin America.

Background Emotional disorders are risk factors for atherosclerosis and consequent cardiovascular disease. However, it is not clear whether emotional symptoms (ESs) have direct effects on cardiovascular disease. The aim of the present study is to investigate the effects of early ESs on carotid atherosclerosis in young adults. Methods and Results We tested the association between expression of ESs at 11 and 15 years of age and carotid intima-media thickness at 18 years of age in the 1993 Pelotas Birth Cohort (N=5249, n=4336 with complete mental health data). ES s were assessed using the Strengths and Difficulties Questionnaire. Propensity score weighting procedure was run using generalized boosted regression model to adjust for potential confounding between exposure and outcome. We also tested whether traditional cardiovascular risk factors could mediate this relationship. Adjusted high expression of ESs , both at 11 and 15 years of age, led to mean increases in carotid intima-media thickness of 1.84 and 2.58 µm, respectively, at 18 years of age (both P<0.001). Longitudinal effects of ESs on atherosclerosis were direct and not significantly mediated by traditional cardiovascular risk factors. Male sex at age 15 years significantly enhanced the effects of ESs on carotid intima-media thickness at age 18 years ( P<0.001 for interaction): although high expression of ESs led to mean increases of 1.14 µm in females ( P<0.05), it led to mean increases of 5.83 µm in males ( P<0.001). Conclusions In this large birth cohort, expression of ESs in adolescence was longitudinally associated with a higher carotid intima-media thickness in young adults. The association is direct and not mediated by traditional cardiovascular risk factors. Interactions by sex might have important implications for designing future interventions.

Analysis of Dyssynchrony and Ventricular Function in Right Univentricular Stimulation at Different Positions.

INTRODUCTION: Chronic stimulation of the right ventricle with pacemaker is associated with ventricular dyssynchrony and loss of contractility, even in subjects without previous dysfunction. In these patients, there is a debate of which pacing site is less associated with loss of ventricular function. OBJECTIVE: To compare pacemaker-induced dyssynchrony among different pacing sites in right ventricular stimulation. METHODS: Cross-sectional study of outpatients with right ventricle stimulation higher than 80% and preserved left ventricular ejection fraction. Pacing lead position (apical, medial septum or free wall) was assessed through chest X-rays. Every patient underwent echocardiogram to evaluate for dyssynchrony according to CARE-HF criteria: aortic pre-ejection time, interventricular delay and septum/posterior wall delay on M mode. RESULTS: Forty patients were included. Fifty-two percent had apical electrode position, 42% mid septum and 6% free wall. Mean QRS time 148.97±15.52 milliseconds. A weak correlation between the mean QRS width and pre-aortic ejection time (r=0.32; P=0.04) was found. No difference in QRS width among the positions could be noted. Intraventricular delay was lower in apical patients against mid septal (34.4±17.2 vs. 54.3±19.1 P<0.05) - no difference with those electrode on the free wall. No difference was noted in the pre-aortic ejection time (P=0.9). CONCLUSION: Apical pacing showed a lower interventricular conduction delay when compared to medial septum site. Our findings suggest that apical pacing dyssynchrony is not ubiquitous, as previously thought, and that it should remain an option for lead placement.

Analysis of dyssynchrony and ventricular function in right univentricular stimulation at different positions

Abstract Introduction: Chronic stimulation of the right ventricle with pacemaker is associated with ventricular dyssynchrony and loss of contractility, even in subjects without previous dysfunction. In these patients, there is a debate of which pacing site is less associated with loss of ventricular function. Objective: To compare pacemaker-induced dyssynchrony among different pacing sites in right ventricular stimulation. Methods: Cross-sectional study of outpatients with right ventricle stimulation higher than 80% and preserved left ventricular ejection fraction. Pacing lead position (apical, medial septum or free wall) was assessed through chest X-rays. Every patient underwent echocardiogram to evaluate for dyssynchrony according to CARE-HF criteria: aortic pre-ejection time, interventricular delay and septum/posterior wall delay on M mode. Results: Forty patients were included. Fifty-two percent had apical electrode position, 42% mid septum and 6% free wall. Mean QRS time 148.97±15.52 milliseconds. A weak correlation between the mean QRS width and pre-aortic ejection time (r=0.32; P=0.04) was found. No difference in QRS width among the positions could be noted. Intraventricular delay was lower in apical patients against mid septal (34.4±17.2 vs. 54.3±19.1 P<0.05) - no difference with those electrode on the free wall. No difference was noted in the pre-aortic ejection time (P=0.9). Conclusion: Apical pacing showed a lower interventricular conduction delay when compared to medial septum site. Our findings suggest that apical pacing dyssynchrony is not ubiquitous, as previously thought, and that it should remain an option for lead placement.

Combined Analysis of Endothelial, Hematopoietic, and Mesenchymal Stem Cell Compartments Shows Simultaneous but Independent Effects of Age and Heart Disease.

Clinical trials using stem cell therapy for heart diseases have not reproduced the initial positive results obtained with animal models. This might be explained by a decreased regenerative capacity of stem cells collected from the patients. This work aimed at the simultaneous investigation of endothelial stem/progenitor cells (EPCs), mesenchymal stem/progenitor cells (MSCs), and hematopoietic stem/progenitor cells (HSCs) in sternal bone marrow samples of patients with ischemic or valvular heart disease, using flow cytometry and colony assays. The study included 36 patients referred for coronary artery bypass grafting or valve replacement surgery. A decreased frequency of stem cells was observed in both groups of patients. Left ventricular dysfunction, diabetes, and intermediate risk in EuroSCORE and SYNTAX score were associated with lower EPCs frequency, and the use of aspirin and ß-blockers correlated with a higher frequency of HSCs and EPCs, respectively. Most importantly, the distribution of frequencies in the three stem cell compartments showed independent patterns. The combined investigation of the three stem cell compartments in patients with cardiovascular diseases showed that they are independently affected by the disease, suggesting the investigation of prognostic factors that may be used to determine when autologous stem cells may be used in cell therapy.

Simple risk stratification score for prognosis of syncope.

PURPOSE: The aim of this study is to describe a new simple score to predict the occurrence of severe adverse events in patients admitted for syncope to a tertiary cardiology referral center. METHODS: Three hundred ninety-three subjects with emergency department visits for syncope were identified and followed prospectively. The primary endpoint was death or unplanned hospital admission after the syncopal episode. The score consisted of sum of the following: previous syncope (2 points), an abnormal electrocardiogram (3 points), and history of heart disease (4 points). The accuracy of our score was compared to other scores available in the literature. RESULTS: Of the 393 subjects, 87 were diagnosed with syncope secondary to structural or electrical heart disease and 306 with noncardiac syncope. The primary endpoint occurred in 202 cases, including death occurring in 25 patients during the 12-month follow-up. The 30-day event rate for the primary endpoint was 26.5 %. The c-statistic for the new score was 0.76 (95 % CI 0.71-0.80) similar to other scores when applied to our sample. Patients with a score of 3 out of 9 had a hazard ratio of 3.46 (95 % CI 1.22-6.11) for death during the follow-up. CONCLUSIONS: In the study population, the new syncope score detected patients with an increased risk of death after discharge from a syncopal event. Our score predicted adverse events comparably to other scores reported in the literature. It has the advantage of being simple and easily obtained from the history and an inexpensive noninvasive test-the ECG.

Evoluçãode crianças com idade inferior a 2 anos submetidas a implante de marcapasso cardíaco permanente / late results with permanent cardiac pacing in children less than two years of age

A estimulação epicárdica predomina no implante de marcapasso em crianças pequenas. Objetivo: revisar a evolução de pacientes menores de dois anos submetidos a estimulação epimiocárdica após a alta hospitalar e até uma década. Método: Estudo de coorte histórica entre 1997 e 2010 que incluiu 34 pacientes, 22 (64,7%) do sexo feminino e 12 (35,3%) do masculino, com idades variando de 1 dia a 22 meses, submetidos a implante de marcapasso utilizando cabo-eletrodo epimiocárdico sem sutura e gerador unicameral (VVI). A arritmia pre dominante foi o bloqueio atrioventricular (n=30; 88,2%); 29 (85,3%) tinham cardiopatia estrutural e 22 (67,4%) haviam sido previamente submetidos a cirurgia cardíaca. Acompanhados durante um tempo médio de 60,5 meses, tiveram registrados os eventos adversos e calculada a probabilidade de sobrevida conforme Kaplan-Meyer. Resultados: Ocorreram três óbitos (8,8%) por infecção, cirurgia cardíaca ou mal súbito. A mortalidade foi superior naqueles sem cirurgia cardíaca prévia (16,7% versus 4,5%). Ao longo do acompanhamento, cinco pacientes (14,7%) necessitaram de nova intervenção, dois por infecção e três para reimplante de cabo-eletrodo. Um dos pacientes submetidos a nova intervenção por infecção evoluiu para óbito. A probabilidade de sobrevida foi de 93,8% no primeiro ano e 90,3% até 10º ano. A sobrevida livre de eventos adversos foi de 90,8% no primeiro ano, 79,8% do 5º ao 9º e 66,5% no 10º ano. Conclusão: Os resultados evidenciam sobrevida satisfatória das crianças após o implante epicárdico, especialmente aquelas com cirurgia cardíaca prévia. O implante de cabo-eletrodo epimiocárdico merece cuidados adicionais em pacientes com estatura reduzida, malformações cardíacas específicas, acesso dificultado à veia cava superior ou com procedimento cirúrgico associado...

Objective: Epicardial stimulation remains the technique of choice for pacing in small children. Our objective is to review the results of epicardial pacemaker implantation in patients with less than 2 years of age and after hospital discharge. Methods: Historical cohort study including 34 patients with age ranging from one day to 22 months with hospital discharge after permanent pacemaker implantation with a sutureless epimyocardial electrode and single chamber generator (VVI mode) between 1997 and 2010. Twenty-two patients were female and 12 male. Predominant arrhythmia was atrioventricular block (30 patients; 88.2%). Twenty-nine patients (85.3%) had structural heart disease and 22 (67.4%) had been submitted to a previous heart surgery. Patients were followed-up for a mean time of 60.5 months. Recorded events were analyzed and probability of survival was estimated according to Kaplan-Meyer analysis. Results: There were 3 (8.8%) deaths, due to infection, heart surgery or sudden death. Increased mortality was observed for patients without previous heart surgery (16.7% versus 4.5%). Five patients (14.7%) required pacemaker reintervention during the follow-up, 2 due to infection and 3 to re-implant the electrode. One of the patients who had a reintervention due to infection died. Probability of survival was 93.8% in the first year and 90.3% subsequently up to the 10 years of follow-up. Event-free survival was 90.8% in the first year, 79.8% from year 5 to 9, 66.5% after 10 years. Conclusion: This study demonstrates the probability of satisfactory survival after epicardial pacemaker implantation, especially in patients with previous heart surgery. Epimyocardial electrode implantation deserves consideration in patients with small physical structure, those with specific cardiac malformations, and difficult access to superior vena cava or those who need to have an associated surgical procedure...

Lung ultrasound for the evaluation of pulmonary congestion in outpatients: a comparison with clinical assessment, natriuretic peptides, and echocardiography.

OBJECTIVES: The aim of this study was to define the performance of lung ultrasound (LUS) compared with clinical assessment, natriuretic peptides, and echocardiography, to evaluate decompensation in patients with systolic heart failure (HF) in an outpatient clinic. BACKGROUND: Evaluation of pulmonary congestion in chronic HF is challenging. LUS has been recently proposed as a reliable tool for the semiquantification of extravascular lung water through assessment of B-lines. METHODS: This was a cohort study of patients with moderate to severe systolic HF. Receiver-operating characteristic (ROC) analyses were performed to compare LUS with a previously validated clinical congestion score (CCS), amino-terminal portion of B-type natriuretic peptide (NT-proBNP), E/e' ratio, chest x-ray, and 6-min walk test. RESULTS: Ninety-seven patients were enrolled. Decompensation was present in 57.7% of patients when estimated by CCS, 68% by LUS, 53.6% by NT-proBNP, and 65.3% by E/e' ≥15. The number of B-lines was correlated to NT-proBNP (r = 0.72; p < 0.0001), E/e' (r = 0.68; p < 0.0001), and CCS (r = 0.43; p < 0.0001). In ROC analyses, considering as reference for decompensation a combined method (E/e' ≥ 15 and/or NT-proBNP >1,000 pg/ml), LUS yielded a C-statistic of 0.89 (95% confidence interval: 0.82 to 0.96), providing the best accuracy with a cutoff ≥ 15 B-lines (sensitivity 85%, specificity 83%). A systematic approach using CCS, E/e', NT-proBNP, chest x-ray, and 6-min walk test in different combinations as reference for decompensation also corroborated this cutoff and found a similar accuracy for LUS. CONCLUSIONS: In an HF outpatient clinic, B-lines were significantly correlated with more established parameters of decompensation. A B-line ≥15 cutoff could be considered for a quick and reliable assessment of decompensation in outpatients with HF.

Tratamento cirúrgico para fibrilação atrial: [revisão] / Surgical treatment for atrial fibrillation: [review] / Tratamiento quirúrgico para la fibrilación auricular: [revisión]

A fibrilação atrial é a arritmia sustentada mais comum e está associada ao aumento do risco de acidente vascular encefálico (AVE), à insuficiência crdíaca e à mortalidade geral. Os resultados obtidos com o tratamento desta arritmia ainda são insatisfatórios, Em geral, o diagnóstico de FA recorrente implica me prescrição de drogas antiarritmicas e antitrombóticas potencialmente tóxicas para o resto da vida do paciente. A limitação do tratamento atual, junto ao melhor entendimento eletrofisiológico da arritmia, motivaram o tratamento baseado em intervenção, seja por meio de estudo eletrofisiológico ou cirurgia, visando ablação do substrato anatômico e, potencialmente, a cura na base fisiopatológica para seu uso, nos resultados obtidos e nas indicações. São apresentados, resumidamente, os resultados do nosso grupo com técnica cirúrgica simplicada, proposta para o tratamento da FA em pacientes com valvulopatia mitral que necessitam correção valvar.

The atrial fibrillation is the most common sustained arrhythmia and it is associated with the increased risk of vascular encephalic strokes (VES), with heart failure and with overall mortality. The results from the treatment of this arrhythmia are not yet satisfactory. Generally, the diagnostics of recurrent AF indicates prescribing life-long, potentially toxic, antiarrhythmic and antithrombotic drugs to the patients. The limitation of the current treatment, with the better electrophysiological understanding of arrhythmia, motivated the treatment based on intervention, whether through surgery or electrophysiologic study, aimed at ablation of the anatomical substrate and potentially cure the arrhythmia. In this paper, our goal is to review the surgical treatment for AF, with a focus on the physiological basis for its use, and the results obtained in the indications. The results of our group with simplified surgical technique are shown briefly, proposed for the treatment of AF in patients with mitral valve disease requiring valve repair.

La fibrilación auricular es la arritmia sostenida más común y está asociada con el aumento del riesgo de accidente vascular encefálico (AVE), la insuficiencia cardiaca y la mortalidad general. Los resultados obtenidos con el tratamiento de esta arritmia todavía son insatisfactorios. En general, el diagnóstico de FA recurrente involucra la prescripción de drogas antiarrítmicas y antitrombóticas potencialmente tóxicas para el resto de la vida del paciente. La limitación del tratamiento actual, junto con la mejor comprensión electrofisiológica de la arritmia, han motivado el tratamiento basado en la intervención, sea por medio de estudio electrofisiológico o cirugía, con vistas a la ablación del sustrato anatómico y, potencialmente, la cura de la arritmia. En el presente artículo, nuestro objetivo es revisar el tratamiento quirúrgico para la FA, con énfasis en la base fisiopatológica para su uso, los resultados obtenidos y las indicaciones. Se presentan, resumidamente, los resultados de nuestro grupo con técnica quirúrgica simplificada, propuesta para el tratamiento de la FA en pacientes con valvulopatía mitral que necesitan corrección valvar.

VEGF gene therapy for angiogenesis in refractory angina: phase I/II clinical trial.

OBJECTIVE: Safety, feasibility and early myocardial angiogenic effects evaluation of transthoracic intramyocardial phVEGF165 administration for refractory angina in no option patients. METHODS: Cohort study, in which 13 patients with refractory angina under optimized clinical treatment where included, after cineangiograms had been evaluated and found unfeasible by surgeon and interventional cardiologist. Intramyocardial injections of 5 mL solution containing plasmidial VEGF165 where done over the ischemic area of myocardium identified by previous SPECT/Sestamibi scan. Evaluations included a SPECT scan, stress test, Minnesota QOL questionnaire and NYHA functional class and CCS angina class determinations. RESULTS: There were no deaths or new interventions during the study period. There were no significant variations in SPECT scans, QOL scores and stress tests results during medical treatment in the included patients. After the 3rd post operative month, there was improvement in SPECT segmental scores, SSS (18.38 ± 7.51 vs. 15.31 ± 7.29, P = 0.003) and SRS (11.92 ± 7.49 vs. 8.53 ± 6.68, P = 0.002). The ischemic area extension, however, had non-significant variation (23.38 ± 13.12% vs. 20.08 ± 13.88%, P = 0.1). Stress tests METs varied from 7.66 ± 4.47 pre to 10.29 ± 4.36 METs post-op (P = 0.08). QOL score improved from 48.23 ± 18.35 pre to 30.15 ± 20.13 post-op points (P = 0.02). NYHA class was 3.15 ± 0.38 pre vs. 1.77 ± 0.83 post-op (P = 0.001) and angina CCS class, 3.08 ± 0.64 vs. 1.77 ± 0.83 (P = 0.001). CONCLUSIONS: Intramyocardial VEGF165 therapy for refractory angina, in this small trial of no option patients, resulted feasible and safe. Early clinical and scintilographic data showed improvements in symptoms and myocardial perfusion, with regression of ischemia severity in treated areas.

Terapia gênica com VEGF para angiogênese na angina refratária: ensaio clínico fase I/II / VEGF gene therapy for angiogenesis in refractory angina: phase I/II clinical trial

OBJETIVO: Avaliar a segurança, viabilidade e efeitos iniciais, clínicos e sobre a perfusão miocárdica, da administração intramiocárdica, transtorácica, de VEGF 165 plasmidial em pacientes com doença arterial coronariana avançada e angina refratária, não passíveis de revascularização percutânea e cirúrgica. MÉTODOS: Ensaio clínico fase I/II. Treze pacientes cardiopatas isquêmicos com angina refratária apesar de tratamento medicamentoso máximo por no mínimo seis meses, não passíveis de revascularização cirúrgica ou por cateter foram submetidos a injeções intramiocárdicas de 2000µg VEGF 165 plasmidial. Os pacientes foram avaliados por cintilografia miocárdica, teste ergométrico, questionário de qualidade de vida (Minnesota) e determinação das classes de insuficiência cardíaca (NYHA) e angina (CCS). RESULTADOS: Não houve óbitos ou reintervenções. Durante o período de tratamento medicamentoso máximo, não se observou diferenças em cintilografias miocárdicas, testes ergométricos e questionários de qualidade de vida, ainda, houve tendência a piora das classes NYHA (P=0,05) e CCS (P=0,05). Três meses após intervenção, observou-se melhora dos escores cintilográficos SSS (18,38±7,51 vs. 15,31±7,29, P=0,003) e SRS (11,92±7,49 vs. 8,53±6,68, P=0,002), porém não na proporção da extensão da área de miocárdio isquêmico (23,38±13,12 por cento vs. 20,08±13,88 por cento, P=0,1). Houve tendência a melhora dos METs nas ergometrias (7,66±4,47 vs. 10,29±4,36, P=0,08), melhora do escore de qualidade de vida (48,23±18,35 vs. 30,15±20,13; P=0,02) e das classes NYHA (3,15±0,38 vs. 1,77±0,83, P=0,001) e CCS (3,08±0,64 vs. 1,77±0,83, P=0,001), no mesmo período. CONCLUSÕES: A terapia demonstrou-se segura e viável nesta série de pacientes. Os resultados iniciais tendem a demonstrar melhora na gravidade da angina e redução da intensidade da isquemia miocárdica.

OBJECTIVE: Safety, feasibility and early myocardial angiogenic effects evaluation of transthoracic intramyocardial phVEGF165 administration for refractory angina in no option patients. METHODS: Cohort study, in which 13 patients with refractory angina under optimized clinical treatment where included, after cineangiograms had been evaluated and found unfeasible by surgeon and interventional cardiologist. Intramyocardial injections of 5mL solution containing plasmidial VEGF165 where done over the ischemic area of myocardium identified by previous SPECT/Sestamibi scan. Evaluations included a SPECT scan, stress test, Minnesotta QOL questionnaire and NYHA functional class and CCS angina class determinations. RESULTS: There were no deaths or new interventions during the study period. There were no significant variations in SPECT scans, QOL scores and stress tests results during medical treatment in the included patients. After the 3rd post operative month, there was improvement in SPECT segmental scores, SSS (18.38±7.51 vs. 15.31±7.29, P=0.003) and SRS (11.92±7.49 vs. 8.53±6.68, P=0.002). The ischemic area extension, however, had non-significant variation (23.38±13.12 percent vs. 20.08±13.88 percent, P=0.1). Stress tests METs varied from 7.66±4.47 pre to 10.29±4.36 METs post-op (P=0.08). QOL score improved from 48.23±18.35 pre to 30.15±20.13 post-op points (P=0.02). NYHA class was 3.15±0.38 pre vs. 1.77±0.83 post-op (P=0.001) and angina CCS class, 3.08±0.64 vs. 1.77±0.83 (P=0.001). CONCLUSIONS: Intramyocardial VEGF165 therapy for refractory angina, in this small trial of no option patients, resulted feasible and safe. Early clinical and scintilographic data showed improvements in symptoms and myocardial perfusion, with regression of ischemia severity in treated areas.

[Warfarin and phenprocoumon: experience of an outpatient anticoagulation clinic]. / Varfarina e femprocumona: experiência de um ambulatório de anticoagulação.

BACKGROUND: Oral anticoagulants are broadly used in cardiology. However, it is still necessary to evaluate their use in clinical practice. OBJECTIVES: To describe the differences in the maintenance of anticoagulation control, as well as the incidence of hemorrhagic and thromboembolic events among users of warfarin and phenprocoumon. METHODS: Non-concurrent cohort study of 127 patients using oral anticoagulation. RESULTS: Phenprocoumon was the most frequently used anticoagulant in 60% of the patients. The prevalence of RNI<2 at the last medical appointment was higher among warfarin users (46% vs. 19.5%; p<0.001). During the follow-up, Phenprocoumon users were within the therapeutic range during 60.7% of the period, in comparison with 45.6% of warfarin users (OR:1.84; 95%CI:1.59-2.13; P<0.001). The incidence of bleeding was 5.3/100 patients/year in the phenprocoumon group versus 18.8/100 patients/year in the warfarin group (RR: 3.5; 95%CI: 1.87-6.48; P<0.001). CONCLUSION: Patients that used Warfarin remained at subtherapeutic levels for a longer period; however, they also presented more hemorrhagic events. Phenprocoumon users were younger and had been using oral anticoagulation for longer periods, presenting fewer drug-related adverse events.

Varfarina e femprocumona: experiência de um ambulatório de anticoagulação / Warfarin and phenprocoumon: experience of an outpatient anticoagulation clinic / Warfarina y femprocumona: experiencia de una unidad de anticoagulación

Fundamento: Os anticoagulantes orais são amplamente utilizados na cardiologia. Contudo, uma avaliação sobre o seu uso na prática clínica ainda é necessária. Objetivos: Descrever as diferenças na manutenção do controle da anticoagulação, bem como a incidência de eventos hemorrágicos e tromboembólicos entre os usuários de varfarina e femprocumona. Métodos: Estudo de coorte não concorrente de 127 pacientes em uso de anticoagulação oral. Resultados: A femprocumona foi o anticoagulante mais utilizado em 60 por cento dos pacientes. A prevalência de INR<2 na última consulta era maior entre os usuários de varfarina (46 por cento vs. 19,5 por cento; p<0,001). Durante o seguimento, os usuários da femprocumona estiveram dentro dos níveis terapêuticos em 60,7 por cento do período em comparação com 45,6 por cento dos usuários da Varfarina (OR:1,84;CI95 por cento:1,59-2,13;p<0,001). A incidência de sangramentos foi de 5,3/100 pacientes/ano no grupo da femprocumona contra 18,8/100 pacientes/anos no grupo varfarina (RR:3,5;CI95 por cento:1,87-6,48;p<0,001). Conclusão: Pacientes que faziam uso da varfarina permaneceram em níveis subterapêuticos por um maior período, contudo também apresentaram mais eventos hemorrágicos. Usuários da femprocumona eram mais jovens e estavam utilizando a anticoagulação oral por um período maior, tendo apresentado menos efeitos adversos dessas medicações.

Background: Oral anticoagulants are broadly used in cardiology. However, it is still necessary to evaluate their use in clinical practice. Objectives: To describe the differences in the maintenance of anticoagulation control, as well as the incidence of hemorrhagic and thromboembolic events among users of warfarin and phenprocoumon. Methods: Non-concurrent cohort study of 127 patients using oral anticoagulation. Results: Phenprocoumon was the most frequently used anticoagulant in 60 percent of the patients. The prevalence of RNI<2 at the last medical appointment was higher among warfarin users (46 percent vs. 19.5 percent; p<0.001). During the follow-up, Phenprocoumon users were within the therapeutic range during 60.7 percent of the period, in comparison with 45.6 percent of warfarin users (OR:1.84; 95 percentCI:1.59-2.13; P<0.001). The incidence of bleeding was 5.3/100 patients/year in the phenprocoumon group versus 18.8/100 patients/year in the warfarin group (RR: 3.5; 95 percentCI: 1.87-6.48; P<0.001). Conclusion: Patients that used Warfarin remained at subtherapeutic levels for a longer period; however, they also presented more hemorrhagic events. Phenprocoumon users were younger and had been using oral anticoagulation for longer periods, presenting fewer drug-related adverse events.

Fundamento: Los anticoagulantes orales son ampliamente utilizados en la cardiología. Con todo, una evaluación acerca de su utilización en la práctica clínica es necesaria todavía. Objetivo: Describir las diferencias en el mantenimiento del control de la anticoagulación, así como la incidencia de eventos hemorrágicos y tromboembólicos entre sus usuarios de warfarina y femprocumona. Métodos: Estudio de cohorte no concurrente de 127 pacientes en tratamiento con anticoagulación oral. Resultados: La femprocumona fue el anticoagulante más utilizado en el 60 por ciento de los pacientes. La prevalencia de INR<2 en la última consulta era mayor entre los usuarios de warfarina (46 por ciento vs 19,5 por ciento; P<0,001). Durante el seguimiento, los usuarios de la femprocumona estuvieron dentro de los niveles terapéuticos en el 60,7 por ciento del período en comparación con el 45,6 por ciento de los usuarios de la warfarina (OR:1,84;CI95 por ciento:1,59-2,13;P<0,001). La incidencia de sangrados fue de 5,3/100 pacientes/año en el grupo de la femprocumona contra 18,8/100 pacientes/años en el grupo warfarina (RR:3,5;CI95 por ciento:1,87-6,48;P<0,001). Conclusión: Pacientes que hacían uso de la warfarina permanecieron en niveles subterapéuticos por un mayor período, sin embargo presentaron también más eventos hemorrágicos. Los usuarios de la femprocumona eran más jóvenes y estaban utilizando la anticoagulación oral por un período mayor, habiendo presentado menos efectos adversos de estas medicaciones.

Modificacões no perfil do paciente submetido à operacão de revascularizacão do miocárdio / Changes in profile of patients submitted to coronary bypass graft surgery

INTRODUÇAO: Indicacões da operacão de revascularizacão miocárdica (RM) foram modificadas pela introducão de novas drogas e da angioplastia coronária transluminal percutânea (ACTP), sendo o procedimento cada vez considerado em pacientes com doenca multiarterial coronária e de condicão clínica mais grave. OBJETIVO: Comparar perfil clínico e cirúrgico entre dois grupos de pacientes submetidos a RM com intervalo de 10 anos, bem como observar sua influência na mortalidade hospitalar. MÉTODO: Estudo de coorte retrospectivo, envolvendo 307 pacientes submetidos a RM em 1991/92 (grupo INICIAL, n=153) ou 2001/02 (grupo ATUAL, n=154). Para cada grupo foram identificadas características demográficas, doencas cardíacas, co-morbidades e eventos operatórios, visando comparacão e determinacão dos fatores relacionados à mortalidade hospitalar aumentada. RESULTADOS: Grupo recente tinha idade mais avancada, condicão cardíaca mais grave(classe funcional, prevalência de insuficiência cardíaca e número de vasos com lesão grave) e maior prevalência de co-morbidades. Pacientes iniciais mostraram maior prevalência na indicacão cirúrgica de urgência. Não ocorreu diferenca na mortalidade hospitalar (respectivamente 3,3 por cento e 1,9 por cento para grupos INICIAL e ATUAL). CONCLUSÕES: Pacientes atualmente submetidos a RM são mais idosos e de condicão clínica mais grave (cardíaca e sistêmica) que os operados há 10 anos, embora isto não tenha influenciado de modo significativo a mortalidade hospitalar, que é menor recentemente.