RESUMO
BACKGROUND: Although widely used in cardiology, relation of heart failure biomarkers to cardiac haemodynamics in patients with CHD (and in particular with pulmonary insufficiency undergoing pulmonary valve replacement) remains unclear. We hypothesised that the cardiac function biomarkers N-terminal pro-brain natriuretic peptide (NT-proBNP), soluble suppressor of tumorigenicity 2, and galectin-3 would have significant associations to right ventricular haemodynamic derangements. METHODS: Consecutive patients ( n = 16) undergoing cardiac catheterisation for transcatheter pulmonary valve replacement were studied. NT-proBNP, soluble suppressor of tumorigenicity 2, and galectin-3 levels were measured using a multiplex enzyme-linked immunosorbent assay from a pre-intervention blood sample obtained after sheath placement. Spearman correlation was used to identify significant correlations (p ≤ 0.05) of biomarkers with baseline cardiac haemodynamics. Cardiac MRI data (indexed right ventricular and left ventricular end-diastolic volumes and ejection fraction) prior to device placement were also compared to biomarker levels. RESULTS: NT-proBNP and soluble suppressor of tumorigenicity 2 were significantly correlated (p < 0.01) with baseline mean right atrial pressure and right ventricular end-diastolic pressure. Only NT-proBNP was significantly correlated with age. Galectin-3 did not have significant associations in this cohort. Cardiac MRI measures of right ventricular function and volume were not correlated to biomarker levels or right heart haemodynamics. CONCLUSIONS: NT-proBNP and soluble suppressor of tumorigenicity 2, biomarkers of myocardial strain, significantly correlated to invasive pressure haemodynamics in transcatheter pulmonary valve replacement patients. Serial determination of soluble suppressor of tumorigenicity 2, as it was not associated with age, may be superior to serial measurement of NT-proBNP as an indicator for timing of pulmonary valve replacement.
Assuntos
Insuficiência Cardíaca/sangue , Hemodinâmica , Peptídeo Natriurético Encefálico/sangue , Fragmentos de Peptídeos/sangue , Insuficiência da Valva Pulmonar/sangue , Tetralogia de Fallot/cirurgia , Adolescente , Adulto , Biomarcadores/sangue , Cateterismo Cardíaco , Criança , Feminino , Insuficiência Cardíaca/diagnóstico por imagem , Implante de Prótese de Valva Cardíaca , Ventrículos do Coração/cirurgia , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Adulto JovemRESUMO
AIM: To investigated the prognostic value of the neutrophil-lymphocyte ratio (NLR) in patients with acute pancreatitis and determined an optimal cut-off value for the prediction of adverse outcomes in these patients. METHODS: We retrospectively analyzed 490 patients with acute pancreatitis diagnosed between March 2007 and December 2012. NLRs were calculated at admission and 24, 48, and 72 h after admission. Patients were grouped according to acute pancreatitis severity and organ failure occurrence, and a comparative analysis was performed to compare the NLR between groups. RESULTS: Among the 490 patients, 70 had severe acute pancreatitis with 31 experiencing organ failure. The severe acute pancreatitis group had a significantly higher NLR than the mild acute pancreatitis group on all 4 d (median, 6.14, 6.71, 5.70, and 4.00 vs 4.74, 4.47, 3.20, and 3.30, respectively, P < 0.05). The organ failure group had a significantly higher NLR than the group without organ failure on all 4 d (median, 7.09, 6.72, 6.27, and 6.24 vs 4.85, 4.49, 3.35, and 2.34, respectively, P < 0.05). The optimal cut-off value for baseline NLR was 4.76 in predicting severity and 4.88 in predicting organ failure in acute pancreatitis. CONCLUSION: Elevated baseline NLR correlates with severe acute pancreatitis and organ failure.
Assuntos
Linfócitos , Neutrófilos , Pancreatite/sangue , Insuficiência da Valva Pulmonar/sangue , Insuficiência Renal/sangue , Choque/sangue , Doença Aguda , Adulto , Idoso , Biomarcadores/sangue , Feminino , Humanos , Contagem de Linfócitos , Masculino , Pessoa de Meia-Idade , Pancreatite/complicações , Prognóstico , Insuficiência da Valva Pulmonar/epidemiologia , Insuficiência da Valva Pulmonar/etiologia , Curva ROC , Insuficiência Renal/epidemiologia , Insuficiência Renal/etiologia , Estudos Retrospectivos , Índice de Gravidade de Doença , Choque/epidemiologia , Choque/etiologiaRESUMO
The goal of this study is to evaluate whether NT-proBNP plasma levels may help as a screening biomarker for monitoring right ventricular dilatation, pulmonary regurgitation and the onset of heart failure in patients with repaired Tetralogy of Fallot. Our single-centre observational prospective study involved 43 patients (15.1 years, SD = 8) with corrected Tetralogy of Fallot. Data collection included: clinical parameters (electrocardiogram, chest X-ray, NYHA scale, time since last surgery), biochemistry (NT-proBNP levels) and MRI values (ventricular volumetry, pulmonary flow assessment). Mean time since last surgery was 13.5 years (SD = 7.8). There was a statistically significant correlation between the NT-proBNP levels (187.4 pg/ml, SD = 154.9) and right ventricular dilatation for both the right ventricular end-diastolic volume (124.9 ml/m2, SD = 31.2) (Pearson = 0.19, p < 0.01) and end-systolic volume (56.1 ml/m2, SD = 18.8) (Pearson = 0.21, p < 0.01) and also with the pulmonary regurgitation fraction (36.5%, SD = 16, Pearson = 0.12, p < 0.01). No significant correlation was found between NT-proBNP and right ventricular ejection fraction (54.6%, SD = 10.6, Pearson = -0.07), left ventricular ejection fraction (59.9%, SD = 7.1, Pearson = -0.18) or any clinical parameters. The receiver operating curve analysis evidenced that a NT-proBNP cut-off value above 133.2 pg/ml predicted the presence of dilated right ventricular end-diastolic and end-systolic volumes over centile 95 (sensitivity 82 and 83% and specificity 93 and 79%, respectively). In conclusion, in patients with surgically corrected Tetralogy of Fallot, NT-proBNP levels correlate with right ventricular dilatation and the degree of pulmonary regurgitation. Ambulatory determination of NT-proBNP might be an easy, readily available and cost-effective alternative for MRI follow-up evaluation of these patients.
Assuntos
Imageamento por Ressonância Magnética , Peptídeo Natriurético Encefálico/sangue , Fragmentos de Peptídeos/sangue , Insuficiência da Valva Pulmonar/sangue , Volume Sistólico , Tetralogia de Fallot/cirurgia , Disfunção Ventricular Direita/sangue , Adolescente , Biomarcadores/sangue , Criança , Eletrocardiografia , Feminino , Humanos , Masculino , Estudos Prospectivos , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Curva ROC , Disfunção Ventricular Direita/diagnóstico por imagem , Adulto JovemRESUMO
The echo Doppler end-diastolic pulmonary regurgitation (EDPR) gradient correlates well with catheter-derived pulmonary artery diastolic pressure. An elevated EDPR gradient is associated with worse clinical outcomes in patients with stable coronary artery disease. However, the prognostic significance of EDPR gradient in patients with heart failure (HF) is unclear. The aim of the present study was to investigate the prognostic impact of EDPR gradient in HF. We retrospectively examined 751 consecutive hospitalized patients with acute HF. Those with acute coronary syndrome or in-hospital death and those without accessible EDPR gradient data at discharge were excluded. Finally, 265 patients were examined and divided into 2 groups according to EDPR gradient (cutoff 9 mm Hg). Adverse events were defined as worsening HF and death. Patients with elevated EDPR gradient had higher B-type natriuretic peptide, lower age, and lower left ventricular ejection fraction at discharge than those with nonelevated EDPR gradient. During a median follow-up of 429 days, elevated EDPR gradient was independently associated with adverse events (hazard ratio 2.34, 95% CI 1.44 to 3.78, p <0.001) after adjustment for confounders. In conclusion, echo Doppler EDPR gradient might be a noninvasive predictor of clinical outcomes in hospitalized patients with HF.
Assuntos
Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Volume Sistólico , Disfunção Ventricular Esquerda/diagnóstico por imagem , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Diástole , Ecocardiografia Doppler , Feminino , Insuficiência Cardíaca/sangue , Insuficiência Cardíaca/complicações , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Peptídeo Natriurético Encefálico/sangue , Prognóstico , Modelos de Riscos Proporcionais , Insuficiência da Valva Pulmonar/sangue , Insuficiência da Valva Pulmonar/complicações , Estudos Retrospectivos , Disfunção Ventricular Esquerda/sangue , Disfunção Ventricular Esquerda/complicaçõesRESUMO
BACKGROUND AND AIMS: Patients with repaired tetralogy of Fallot may develop chronic right ventricular dysfunction and hepatic congestion over time. We hypothesized that bile acid metabolism is altered in repaired tetralogy of Fallot patients and therefore sought to correlate right ventricular indices with serum bile acid levels. METHODS: Indexed right ventricular end diastolic volume, as assessed by cardiac magnetic-resonance imaging, was classified as <100ml/m2 (Group 1, n = 5), 100-150ml/m2 (Group 2, n = 18), and >150ml/m2 (Group 3, n = 6) in 29 patients with repaired tetralogy of Fallot. Pulmonary regurgitation fraction and right ventricular ejection fraction were calculated. The serum bile acid profile, including 15 species, in these patients was determined by liquid chromatography coupled with mass spectrometry. RESULTS: Serum bile acid levels increased from Group 1 to Group 3 (2.5 ± 0.7; 4.1 ± 2.5; 6.0 ± 2.8 µmol/l, respectively) with significantly increased bile acid values in Group 3 compared to Group 1 (p≤0.05). In Group 3, but not in Group 1 and 2, a significant increase in glycine-conjugated bile acids was observed. Pulmonary regurgitation fraction increased (12 ± 1; 28 ± 16; 43 ± 3%, Groups 1-3, respectively) and right ventricular ejection fraction decreased (48.4 ± 6.4; 48.5 ± 6.5; 42.1 ± 5.3%, Groups 1-3, respectively) with rising indexed right ventricular end diastolic volume. CONCLUSIONS: These preliminary results suggest that serum bile acid levels are positively correlated with indexed right ventricular end-diastolic volume in patients with repaired tetralogy of Fallot; however, this needs to be confirmed in a larger patient cohort.
Assuntos
Ácidos e Sais Biliares/sangue , Fígado/metabolismo , Miocárdio/metabolismo , Complicações Pós-Operatórias/fisiopatologia , Insuficiência da Valva Pulmonar/diagnóstico , Tetralogia de Fallot/sangue , Adolescente , Adulto , Biomarcadores/sangue , Criança , Cromatografia Líquida , Feminino , Humanos , Masculino , Espectrometria de Massas , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/patologia , Estudos Prospectivos , Insuficiência da Valva Pulmonar/sangue , Insuficiência da Valva Pulmonar/etiologia , Insuficiência da Valva Pulmonar/fisiopatologia , Volume Sistólico , Tetralogia de Fallot/patologia , Tetralogia de Fallot/fisiopatologia , Tetralogia de Fallot/cirurgia , Função Ventricular DireitaRESUMO
Clinicians are currently encountering an increasing number of patients in the long-term period after tetralogy of Fallot (TOF) repair presenting with pulmonary valve regurgitation (PR) or right ventricular (RV) dysfunction. The purpose of this study was to evaluate the clinical utility of the plasma brain natriuretic peptide (BNP) level and consider surgical indications and timing of pulmonary valve replacement (PVR). We examined 33 patients (21 males, 12 females, mean age 14.5 ± 2.8 years) who underwent TOF repair at Kitasato University Hospital. All patients were evaluated using echocardiography and blood sampling. The mean age at the time of initial repair was 1.3 ± 0.7 years. The patients with moderate-severe PR exhibited significantly higher plasma BNP levels than the patients with trivial-mild PR (mean 37.5 ± 33.1 vs. 17.3 ± 6.6 pg/ml, p = 0.013). The mean plasma BNP level with cardiac symptoms was higher than that observed in the patients without any symptoms (71.4 ± 46.1 vs. 25.0 ± 14.0 pg/ml, p = 0.005). The mean BNP level was significantly decreased after PVR (71.3 ± 46.1-26.1 ± 13.2 pg/ml, p = 0.009), and the plasma BNP level was found to be positively correlated with the RV end-diastolic pressure (r = 0.851; p = 0.008). The optimal BNP cut-off value for considering PVR was 32.15 pg/ml (sensitivity, 85.7 %; specificity, 83.3 %). The plasma BNP level may become a useful diagnostic tool for considering the indications and optimal timing of PVR over the long term after TOF repair.
Assuntos
Peptídeo Natriurético Encefálico/sangue , Insuficiência da Valva Pulmonar/sangue , Valva Pulmonar/cirurgia , Tetralogia de Fallot/sangue , Tetralogia de Fallot/cirurgia , Adolescente , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/métodos , Criança , Ecocardiografia , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Masculino , Valva Pulmonar/fisiopatologia , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/fisiopatologia , Tetralogia de Fallot/diagnóstico por imagem , Tetralogia de Fallot/fisiopatologia , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Chronic severe pulmonary regurgitation (PR) causes progressive right ventricular (RV) dysfunction and heart failure. Parameters defining the optimal time point for surgery of chronic PR are lacking. The present study prospectively evaluated the impact of preoperative clinical parameters, cardiorespiratory function, QRS duration and NT-proBNP levels on post operative RV function and volumes assessed by cardiac magnetic resonance imaging (CMR) in patients with chronic severe PR undergoing pulmonary valve replacement. METHODS AND RESULTS: CMR was performed pre- and 6 months postoperatively in 27 patients (23.6 ± 2.9 years, 15 women) with severe PR. Postoperatively, RV endsystolic (RVESVI) and enddiastolic volume indices (RVEDVI) decreased significantly (RVESVI pre 78.2 ± 20.4 ml/m² BSA vs. RVESVI post 52.2 ± 16.8 ml/m²BSA, p<0.001; RVEDVI pre 150.7 ± 27.7 ml/m²BSA vs. RVEDVI post 105.7 ± 26.7 ml/m²BSA; p<0,001). With increasing preoperative QRS-duration, postoperative RVEF decreased significantly (r=-0.57; p<0.005). Preoperative QRS-duration smaller than the median (156 ms) predicted an improved RVEF compared to QRS-duration≥ 156 ms (54.9% vs 46.8%, p<0.05). Multivariate analysis identified preoperative QRS duration as an independent predictor of postoperative RVEF (p<0.005). NT-proBNP levels correlated with changes in RVEDI (r=0.58 p<0,005) and RVESVI (r=0.63; p<0,0001). Multivariate analysis identified NT-proBNP levels prior to PVR as an independent predictor of volume changes (p<0.05). CONCLUSION: Valve replacement in severe pulmonary regurgitation causes significant reduction of RV volumes. Both, preoperative NT-proBNP level elevation and QRS prolongation indicate patients with poorer outcome regarding RV function and volumes.
Assuntos
Cardiopatias Congênitas/fisiopatologia , Implante de Prótese de Valva Cardíaca , Peptídeo Natriurético Encefálico , Fragmentos de Peptídeos , Insuficiência da Valva Pulmonar/fisiopatologia , Função Ventricular Direita/fisiologia , Adulto , Doença Crônica , Eletrocardiografia , Feminino , Seguimentos , Cardiopatias Congênitas/sangue , Cardiopatias Congênitas/cirurgia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Masculino , Peptídeo Natriurético Encefálico/sangue , Fragmentos de Peptídeos/sangue , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/fisiopatologia , Cuidados Pré-Operatórios/métodos , Estudos Prospectivos , Valva Pulmonar/patologia , Valva Pulmonar/cirurgia , Insuficiência da Valva Pulmonar/sangue , Insuficiência da Valva Pulmonar/cirurgia , Fatores de Tempo , Adulto JovemRESUMO
OBJECTIVE: To evaluate the utility of plasma BNP measurement in the long term follow-up of patients with surgically repaired tetralogy of Fallot (TOF). METHODS: From 2002 to 2008, plasma BNP concentration was measured in 130 patients with TOF at the age of mean 16.1+/-7.1 years and mean 13.0+/-6.5 years after surgically repair. BNP levels were compared to age and gender-specific normal values, results of exercise testing, clinical, electrocardiographic, and echocardiographic data. RESULTS: BNP was <200 pg/ml in all and elevated in 60% of patients. Higher values were found in females (p=0.001), in patients waiting for pulmonary valve replacement (p<0.001), and in NYHA class II compared to NYHA I patients (p=0.012) with an inverse correlation between BNP and exercise time (r=-0.59, p<0.001). BNP was correlated with right ventricular dilatation (r=0.29, p=0.005) and severity of both tricuspid (r=0.22, p=0.015) and pulmonary regurgitation (r=0.20, p=0.029). Longitudinal data revealed increasing BNP levels before (p=0.04) and a BNP decrease after pulmonary valve replacement (p=0.03), but no change in patients without surgery. CONCLUSIONS: In patients with surgically repaired TOF, plasma BNP is significantly correlated with right ventricular volume load. In clinical practice a considerable overlap limits the estimation of right ventricular volume load by BNP, but longitudinal evaluation helps to appoint the appropriate timing of pulmonary valve replacement.
Assuntos
Biomarcadores/sangue , Peptídeo Natriurético Encefálico/sangue , Insuficiência da Valva Pulmonar/sangue , Tetralogia de Fallot/sangue , Tetralogia de Fallot/cirurgia , Adolescente , Adulto , Criança , Pré-Escolar , Ecocardiografia , Eletrocardiografia , Teste de Esforço , Feminino , Seguimentos , Humanos , Masculino , Insuficiência da Valva Pulmonar/diagnóstico , Insuficiência da Valva Pulmonar/cirurgia , Reprodutibilidade dos Testes , Estudos Retrospectivos , Tetralogia de Fallot/diagnóstico , Função Ventricular Direita , Adulto JovemRESUMO
Impairment of right ventricular functions, especially due to chronic pulmonary regurgitation (PR), is a well-known entity in patients with tetralogy of Fallot (ToF) after repair. The aim of this study was to examine the relation between B-type natriuretic peptide (BNP) levels and right ventricular dysfunction by cardiopulmonary exercise test (ET) in patients after repair of ToF. Twenty-five patients with a mean age of 14.1 +/- 4.4 years at follow-up who underwent repair of ToF at a mean age of 4.9 +/- 5.1 years and 29 age- and sex-matched healthy children at a mean age of 13.1 +/- 2.8 years were enrolled in this study. Plasma BNP levels were measured at baseline and at maximal exercise. The volume of right ventricle (RV) and the degree of PR were assessed by two-dimensional echocardiography and color Doppler. Plasma BNP levels were significantly higher in patients with ToF than in controls (28.3 +/- 24.1 vs 7.4 +/- 2.3 pg/mL, p = 0.0001). Exercise was associated with increased plasma BNP levels in both groups. A greater increase in BNP was noted in patients with ToF than in controls (37.6 +/- 27.5 vs 11.3 +/- 4.5 pg/mL, p = 0.0001). Forced vital capacity (FVC%) (84.9 +/- 16.9 vs 98.4 +/- 18.2, p = 0.01) and forced expiratory volume during the 1st second (FEV1%) (91.5 +/- 19.3 vs 103.8 +/- 16.1, p = 0.02) were decreased, exercise duration (ED) (10.1 +/- 1.9 vs 11.4 +/- 1.7 min, p = 0.02), maximum heart rate (HRmax) (171.2 +/- 18.9 vs 186.4 +/- 13.9 /min, p = 0.004), and maximum oxygen uptake (VO(2)max) (1.56 +/- 0.53 vs 2.1 +/- 0.6 L/min, p = 0.007) were lower in patients with ToF. There were significant correlations between the degree of PR and ED (r =-0.3, p = 0.009), HRmax (r =-0.4, p = 0.001), and VO(2)max (r =-0.4, p = 0.001). The correlations were significant both before and after exercise, being more pronounced after exercise between BNP level and the degree of PR (r = 0.6, p = 0.0001). As a result, the severity of PR has a negative influence on right ventricular functions and there is significant relation between right ventricular functions and exercise capacity after repair of tetralogy of Fallot.
Assuntos
Procedimentos Cirúrgicos Cardiovasculares/efeitos adversos , Teste de Esforço , Peptídeo Natriurético Encefálico/sangue , Insuficiência da Valva Pulmonar/etiologia , Valva Pulmonar/patologia , Tetralogia de Fallot/cirurgia , Disfunção Ventricular Direita/tratamento farmacológico , Adolescente , Doença Crônica , Feminino , Volume Expiratório Forçado , Humanos , Masculino , Consumo de Oxigênio , Estudos Prospectivos , Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/sangue , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/patologia , Sensibilidade e Especificidade , Tetralogia de Fallot/sangue , Tetralogia de Fallot/fisiopatologia , Fatores de Tempo , Ultrassonografia , Disfunção Ventricular Direita/sangue , Disfunção Ventricular Direita/diagnóstico por imagem , Disfunção Ventricular Direita/patologia , Capacidade VitalRESUMO
BACKGROUND: Surgical repair of tetralogy of Fallot may leave the patient with pulmonary regurgitation, causing eventual right ventricle dilatation and dysfunction. Predicting clinical deterioration may help to determine the best timing for intervention. OBJECTIVES: To assess whether the clinical and humoral status of patients in the second decade after repair of ToF is worse than that of patients in the first decade after repair. METHODS: Twenty-one patients with repaired ToF underwent clinical assessment, electrocardiogram, echocardiogram and measurement of plasma B-type natriuretic peptide and N-terminal pro-BNP as well as the 6 minute walk distance test. Patients were divided into two groups: group A - less than 10 years after repair (n=10, age < 12 years old), and group B - more than 10 years after repair (n=11, age > 12 years old). The age at repair was similar in both groups. RESULTS: In all but one patient the distance in the 6 min walk test was less than the minimum for age. RV end-diastolic volume and the 6 min walk test correlated with age. NT-proBNP levels were significantly higher in the ToF group compared to 26 healthy controls (P < 0.0001) and were inversely correlated with RV ejection fraction. Comparison of the two groups showed no difference in RV end-diastolic volume indexed for body surface area, pulmonary regurgitation severity, right or left ventricular myocardial performance index, RV ejection fraction, QRS duration, or 6 min walk indexed to minimum for age. CONCLUSIONS: In this group of patients with similar age at operation and pulmonary regurgitation severity, most clinical, echocardiographic and humoral parameters were not worse in the second decade after repair of ToF. These data suggest that very early pulmonary valve replacement may not be of benefit.
Assuntos
Complicações Pós-Operatórias/diagnóstico , Tetralogia de Fallot/cirurgia , Adolescente , Adulto , Análise de Variância , Criança , Pré-Escolar , Ecocardiografia , Eletrocardiografia , Teste de Esforço , Feminino , Humanos , Masculino , Peptídeo Natriurético Encefálico/sangue , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/fisiopatologia , Insuficiência da Valva Pulmonar/sangue , Insuficiência da Valva Pulmonar/diagnóstico , Insuficiência da Valva Pulmonar/fisiopatologia , Estatísticas não Paramétricas , Tetralogia de Fallot/sangue , Tetralogia de Fallot/fisiopatologia , Resultado do TratamentoRESUMO
BACKGROUND: Cardiac volumetry by magnetic resonance imaging can guide the timing for reoperation in minimally symptomatic or asymptomatic patients with pulmonary insufficiency after corrected tetralogy of Fallot. Pro-brain natriuretic peptide (BNP) is a marker of ventricular dysfunction and wall stress, and levels may complement magnetic resonance imaging in cardiac assessment before and after pulmonary valve replacement. METHODS: Between May 2004 and October 2005, 23 consecutive patients with corrected tetralogy, severe pulmonary insufficiency, and right ventricular end-diastolic volume index greater than 150 mL/m2 underwent elective pulmonary valve replacement. Plasma proBNP levels and magnetic resonance imaging were obtained before and 6 months after pulmonary valve replacement. RESULTS: There was no surgical mortality or morbidity. Preoperative right ventricular end-diastolic volume index correlated with pulmonary insufficiency, and inversely so with left ventricular ejection fraction, reflecting interventricular interaction. Preoperatively (r = -0.47) and 6 months postoperatively (r = -0.54), log BNP was inversely correlated with right ventricular ejection fraction. Mean preoperative proBNP levels, right ventricular end-diastolic volume index, and pulmonary insufficiency significantly (p < 0.0001) diminished 6 months after pulmonary valve replacement (231 versus 114 ng/L, 184 versus 109 mL/m2, and 44% versus 2%, respectively). CONCLUSIONS: Plasma proBNP is elevated in patients with corrected tetralogy, severe pulmonary insufficiency, and right ventricular dilatation, and it significantly diminishes 6 months after pulmonary valve replacement, mirroring magnetic resonance imaging-documented better right ventricular ejection fraction and smaller right ventricular end-diastolic volume index. Pro-brain natriuretic peptide complements magnetic resonance imaging for cardiac assessment in patients requiring pulmonary valve insertion. Future validation of cutoff levels are required to establish proBNP as a useful diagnostic and follow-up tool in patients with chronic pulmonary insufficiency and failing right ventricles.
Assuntos
Implante de Prótese de Valva Cardíaca , Hipertrofia Ventricular Direita/cirurgia , Imageamento por Ressonância Magnética , Peptídeo Natriurético Encefálico/sangue , Fragmentos de Peptídeos/sangue , Complicações Pós-Operatórias/cirurgia , Insuficiência da Valva Pulmonar/cirurgia , Tetralogia de Fallot/cirurgia , Biomarcadores , Pré-Escolar , Progressão da Doença , Humanos , Hipertrofia Ventricular Direita/sangue , Hipertrofia Ventricular Direita/etiologia , Hipertrofia Ventricular Direita/patologia , Lactente , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/patologia , Estudos Prospectivos , Insuficiência da Valva Pulmonar/sangue , Insuficiência da Valva Pulmonar/etiologia , Insuficiência da Valva Pulmonar/patologia , Reoperação , Volume Sistólico , Tetralogia de Fallot/sangue , Tetralogia de Fallot/patologia , Fatores de TempoRESUMO
OBJECTIVE: This study examines the incidence and factors associated with the failure of homograft valves and identifies those factors that are modifiable. METHODS: From 1990 to 2001, 96 homograft valves were implanted in the right ventricular outflow tract of 83 children (mean age 5.1 +/- 5.6 years). Clinical and blinded serial echocardiographic follow-up was performed on all 90 valves in the 77 survivors. RESULTS: Eighteen homograft valves were replaced as the result of pulmonary insufficiency (3), stenosis (9), or both (6). Freedom from reoperation was 71% at 9 years (95% confidence interval, 58%-84%). Forty-eight valves developed progressive pulmonary insufficiency of at least 2 grades, 26 valves developed transvalvular gradients of 50 mm Hg or greater, and 14 of these valves were also insufficient. The freedom from echocardiographic failure (progressive pulmonary insufficiency >or=2 grades or >or=50 mm Hg gradient) was only 27% at 5 years (95% confidence interval, 17%-37%). In a multivariate analysis (Cox regression), use of an aortic homograft (P =.001) and short antibiotic preservation time (P =.04) were associated with reoperation. Younger age (P =.01), ABO mismatch (P =.04), and diagnosis (P =.005) were associated with echocardiographic failure. In the subanalysis of patients with human leukocyte antigen typing, age (P =.002), aortic homograft (P =.04), and human leukocyte antigen-DR mismatch (P =.03) were associated with echocardiographic valve failure. CONCLUSION: Many homografts rapidly become insufficient and require replacement. In our analysis of both reoperation and echocardiographic failure, several immunologic factors are consistently associated with homograft failure. Matching for human leukocyte antigen-DR, blood group, and avoiding short preservation times (thus minimizing antigenicity) offers the potential to extend the life of these valves.
Assuntos
Sistema ABO de Grupos Sanguíneos/sangue , Antígenos HLA/sangue , Valva Pulmonar/transplante , Adolescente , Adulto , Fatores Etários , Canadá/epidemiologia , Criança , Proteção da Criança , Pré-Escolar , Progressão da Doença , Ecocardiografia , Feminino , Seguimentos , Antígenos HLA-DR/sangue , Cardiopatias Congênitas/sangue , Cardiopatias Congênitas/mortalidade , Cardiopatias Congênitas/cirurgia , Implante de Prótese de Valva Cardíaca , Teste de Histocompatibilidade , Humanos , Incidência , Lactente , Bem-Estar do Lactente , Recém-Nascido , Masculino , Análise Multivariada , Falha de Prótese , Valva Pulmonar/anormalidades , Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/sangue , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/cirurgia , Estenose da Valva Pulmonar/sangue , Estenose da Valva Pulmonar/diagnóstico por imagem , Estenose da Valva Pulmonar/cirurgia , Reoperação , Índice de Gravidade de Doença , Estatística como Assunto , Análise de Sobrevida , Transplante Homólogo , Obstrução do Fluxo Ventricular Externo/sangue , Obstrução do Fluxo Ventricular Externo/congênito , Obstrução do Fluxo Ventricular Externo/cirurgiaRESUMO
Microscopic polyangiitis (mPA) is a systemic necrotizing nongranulomatous vasculitis that affects small blood vessels. Clinical features include constitutional symptoms such as fever, anorexia, fatigue, and weight loss. Skin lesions include purpura and splinter hemorrhages, which occur in 50% of patients. Another characteristic feature is rapidly progressive glomerulonephritis, which often affects the kidneys in the early stages of the condition. Diagnosis is based on typical clinical features, biopsy, and presence of antineutrophil cytoplasmic antibodies (ANCA). This disorder tends to involve middle-aged and older persons, with a predilection for males; it is very rare in children. A 21-year-old female patient with mPA who did not respond well to treatment, required hemodialysis, developed vasculitis allergica cutis (VAC) later, and had a relatively short-term survival is reported herein.
Assuntos
Anticorpos Anticitoplasma de Neutrófilos/sangue , Glomerulonefrite/terapia , Peroxidase/imunologia , Diálise Renal/métodos , Vasculite Leucocitoclástica Cutânea/imunologia , Adulto , Evolução Fatal , Feminino , Glomerulonefrite/sangue , Glomerulonefrite/diagnóstico , Humanos , Insuficiência da Valva Pulmonar/sangue , Insuficiência da Valva Pulmonar/patologia , Diálise Renal/efeitos adversosRESUMO
Blood lactate and pyruvate levels and lactate-pyruvate ratios were determined in 20 patients with severe hypoxemia due to pulmonary insufficiency, 18 patients having arterial oxygen tensions (pO2) lower than 50 mm. of mercury, and 8 having tensions lower than 40 mm. of mercury. Most of the patients had normal lactate levels and lactate-pyruvate ratios in spite of severe hypoxemia, and there was no correlation between pO2 or oxygen content and raised levels. All but 1 patient with an elevated lactate level and lactate-pyruvate ratio had a disorder of systemic circulation with hypotension. On the other hand, failure of the right side of the heart with cor pulmonale did not lead to hyperlactatemia. In the resting state generalized tissue hypoxia and increased anaerobic metabolism are seldom due to clinical hypoxemia per se. When present, increased anaerobic metabolism is related to a systemic circulatory disorder, with resultant inadequate tissue perfusion.