RESUMO
BACKGROUND: Patient-reported outcomes (PROs) quantify, from patients' perspectives, their symptoms, function, and quality of life. Our aim was to determine the feasibility of integrating PRO capture into routine clinical practice at a large heart failure (HF) clinic. METHODS: We examined the practicality of PRO completion at the time of clinic visit, the time required to complete the selected instruments, the completion rate, and the feasibility of immediate PRO scoring and integration of the results into the electronic health record (EHR). We deployed a computer program to capture PROs (Kansas City Cardiomyopathy Questionnaire, Patient-Reported Outcomes Measurement Information System) on a portable computer platform at the time of a clinic visit. An automated algorithm identified patients scheduled for appointments at the HF clinic at registration, provided a portable tablet computer with which to complete the appropriate PRO instruments and then scored and immediately integrated the results in the patient's EHR. RESULTS: In a 12-month period, 862 unique patients completed 1,320 PRO assessments. The mean age of this cohort was 60.1 ± 16.3 years and 66% were male. The average time for PRO assessment was 6.7 minutes and the completion rate among eligible patients was 58%, with 91% of started assessments completed in full. CONCLUSIONS: These preliminary data support the feasibility of serial PRO assessment with real-time integration into the EHR in a large outpatient population of patients with HF. We identified critical steps that should enhance adoption of this approach by clinicians and render PRO results meaningful and actionable in routine clinical care.
Assuntos
Sistemas Computacionais/normas , Insuficiência Cardíaca/diagnóstico , Medidas de Resultados Relatados pelo Paciente , Centros de Atenção Terciária/normas , Adulto , Idoso , Estudos de Coortes , Estudos de Viabilidade , Feminino , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/terapia , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
OBJECTIVE: To determine if health-related quality of life (HRQoL) improvement after cardiac resynchronization therapy (CRT) correlates with improved left-ventricular ejection fraction (EF). BACKGROUND: CRT was reported to improve EF and HRQoL in clinical trials of heart failure with reduced EF (HFrEF). It is unknown if improvements in HRQoL reflect EF response to CRT. METHODS: We included HFrEF patients who underwent CRT and had both pre- and post-CRT HRQoL assessment. EF response was categorized as absent (0% change or decrease), modest (0%-19% increase), or significant ( > 20% increase). We examined the associations between EF response and generic (PROMIS) and HF-specific (KCCQ-12) HRQoL. RESULTS: The group included 115 patients with mean age of 65 years and baseline EF of 31%; 39% were female (n = 45). Nineteen percent (n = 22) had significant, 57% (n = 66) modest, and 23% (n = 27) absent EF responses. AF burden across significant (8.9%), modest (4.8%), and absent EF responders (1.4%) was similar ( P = 0.20). Significant improvements in KCCQ-12 (43.4-57.5, P = 0.003), current health visual analog scale (49.1-55.9, P = 0.042), PROMIS fatigue (58.9-55.1, P = 0.026), and PROMIS satisfaction (42.7-46.4, P = 0.020) resulted following CRT across all groups. There was no association between significant EF improvement and HRQoL by KCCQ-12 (nonresponse, 44.4%; modest response, 33.3%; and significant response, 22.2%) at 1 year ( P = 0.52 across all groups). CONCLUSION: CRT was associated with a modest to significant EF response in a majority of patients. However, EF response did not significantly correlate with generic or HF-specific HRQoL measures. Further investigations are warranted into determinants of improved HRQoL following CRT.
Assuntos
Terapia de Ressincronização Cardíaca , Insuficiência Cardíaca , Humanos , Feminino , Idoso , Masculino , Terapia de Ressincronização Cardíaca/métodos , Volume Sistólico/fisiologia , Função Ventricular Esquerda , Qualidade de Vida , Insuficiência Cardíaca/terapiaRESUMO
BACKGROUND: Metastatic cardiac calcifications are often seen in patients with renal failure and dialysis associated with vascular calcification and calcifications in other organs. There is little to no evidence of metastatic cardiac calcification in patients with a history of rickets. CASE SUMMARY: A 40-year-old patient with a history of rickets treated in infancy and no personal history of cardiovascular or renal disease came for a periodical examination. Transthoracic echocardiogram showed an important calcification in the mitral annulus and the mitro-aortic junction. Computed tomography (CT) showed marked calcification affecting the heart fibrous skeleton. Coronary arteries were not affected. DISCUSSION: Distribution of heart calcification seen both with echocardiography and CT is important to report so they can be identified as dystrophic or metastatic. These two have different aetiologies so the description may help identify the possible cause.
RESUMO
INTRODUCTION AND OBJECTIVES: Myxomas are the most common type of primary cardiac tumors. The aim of this study was to analyze the clinical forms of presentation of cardiac myxoma, the postoperative evolution, and the possibility of recurrence and tumoral embolism. PATIENTS AND METHOD: From July 1992 to March 1999, 31 patients with myxoma were studied. Cell cycles (ploidy pattern of the tumoral DNA) were studied in 12 patients to evaluate the risk of recurrence and tumoral embolism. RESULTS: The most frequent clinical manifestations were constitutional symptoms (74%), dyspnea (45%), and embolism (41%). Smaller-diameter myxomas correlated independently with tumoral embolism (45%). The in-hospital mortality was 3.2%, no deaths were observed during follow-up (mean: 4.8 years). No patients had clinical or echocardiographic signs of tumoral recurrence. Patients with tumoral embolism (n = 8) were compared with patients without embolism (n = 4). Patients who suffered embolism had higher S phase > 7 and/or DNA index > 1.2 (4/4 patients [100%], p= 0.061) than patients without embolism (2/8 patients [25%]). Cytometry of the only recurrent tumor (second operation) revealed a diploid tumor with a significantly more frequent S phase (10%) than in sporadic myxomas (4.27 2.32%, p = 0.039). CONCLUSIONS: Constitutional symptoms, dyspnea, and tumor embolism were the most frequent clinical manifestations. Clinical and anatomopathologic characteristics and the cell cycle were not significantly related to tumoral embolism, but there was a tendency toward a higher proportion of cells in S phase and a higher DNA index in tumors associated with embolism. The S phase was significantly more frequent in the only case of recurrent myxoma and could be a potential marker of recurrence.
Assuntos
Neoplasias Cardíacas/cirurgia , Mixoma/cirurgia , Adulto , Idoso , DNA de Neoplasias/química , Feminino , Neoplasias Cardíacas/diagnóstico , Neoplasias Cardíacas/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Miocárdio/patologia , Mixoma/diagnóstico , Mixoma/patologia , Células Neoplásicas Circulantes/patologia , Recidiva , Estudos RetrospectivosRESUMO
Use of a majority of structural variables (age, sex, height) to estimate oxygen consumption in the calculation of cardiac output (CO) by the Fick principle does not account for changes in physiological conditions. To improve this limitation, oxygen consumption was estimated based on the left ventricular pressure-volume area. A pilot study with 10 patients undergoing right cardiac catheterization showed that this approach was successful to estimate CO (r=0,73, vs. thermodilution measured CO). Further essays changing end-diastolic-volume in the pressure-volume area formula by body weight or body surface area showed that this last yielded the best correlation with the thermodilution measured CO (slope=1, ordinate =0.01 and r=0.93). These preliminary results indicate that use of a formula originated from the pressure-volume-area concept is a good alternative to estimate oxygen consumption for CO calculation.
Assuntos
Ventrículos do Coração/patologia , Consumo de Oxigênio , Superfície Corporal , Débito Cardíaco , Diástole , Ecocardiografia/métodos , Temperatura Alta , Humanos , Modelos Biológicos , Modelos Teóricos , Consumo de Oxigênio/fisiologia , Projetos Piloto , Pressão , Temperatura , Termodiluição/métodos , Pressão VentricularRESUMO
El aneurisma de la orejuela de la aurícula izquierda, ya sea congénito o adquirido, es una anomalía extremadamente rara. Es causado por la displasia congénita de los músculos auriculares o puede ser consecuencia de otras enfermedades cardíacas o sistémicas. Esta anomalía cardíaca generalmente es asintomática y su diagnóstico suele hacerse de manera incidental, pero en ocasiones puede manifestarse por taquiarritmias auriculares y/o por eventos tromboembólicos. En esta presentación se describe el caso de un paciente con un aneurisma congénito gigante de la orejuela de la aurícula izquierda.
Left atrial appendage aneurysm, either congenital or acquired, is a very rare anomaly. It is caused by congenital dysplasia of the atrial muscles, or it may be the result of other systemic or heart diseases. This anomaly is mostly asymptomatic and it is usually diagnosed incidentally; however, patients may present with atrial tachyarrhythmias and/or thromboembolic events. This report describes the case of a patient with giant congenital aneurysm of the left atrial appendage.
RESUMO
La hipertrofia ventricular izquierda es un predictor de riesgo de eventos cardiovasculares. Los objetivos del presente trabajo fueron establecer los valores de referencia para la masa ventricular izquierda en una población aparentemente sana de la Ciudad Autónoma de Buenos Aires, analizar su correlación con la edad y variables antropométricas y definir la mejor manera de expresar esos datos. Para el cálculo de la masa ventricular izquierda se utilizó metodología ecocardiográfica avalada internacionalmente (American Society of Echocardiography/European Association of Echocardiography) y la fórmula de Devereux ajustada. Luego de aplicar criterios de exclusión estrictos, se incluyeron 1.898 individuos, 48,89% hombres y 51,1% mujeres (edad 38 ± 11 años). El valor de masa ventricular izquierda fue para hombres de 155 ± 30 g (percentil 95 206 g), con distribución normal, y para mujeres de 112 ± 24 g (percentil 95 153 g), con distribución no normal (p < 0,001 entre géneros). Los valores son comparables a los referidos en estudios con similar metodología. Los índices de masa ventricular izquierda calculados mostraron una correlación moderada para superficie corporal y peso, y diferencias significativas entre géneros. Las distintas variables calculadas exhibieron heterogeneidad en el tipo de distribución (normal o no normal) de sus datos, por lo que consideramos que el percentil 95 es la mejor manera de expresar los valores de referencia. En conclusión, se estimaron los valores de referencia para masa ventricular izquierda en una población sana y se observó una correlación moderada con superficie corporal y peso. Proponemos la utilización del percentil 95 para expresar el valor superior de referencia para los datos obtenidos.
Left ventricular hypertrophy is a risk predictor of cardiovascular events. The objectives of this study were to establish reference values for left ventricular mass in an apparently healthy population of the Autonomous City of Buenos Aires, to analyze its correlation with age and anthropometric variables and to define the best way to express the assessed data. Left ventricular mass was estimated using internationally supported echocardiographic methods (American Society of Echocardiography/European Association of Echocardiography) and the adjusted Devereux equation. After applying strict exclusion criteria, 1898 subjects with mean age of 38 ± 11 years, 48.89% of whom were male and 51.1% were female, were included in the study. Left ventricular mass was 155 ± 30 g for men (95th percentile 206 g) with normal distribution, and 112 ± 24 g for women (95th percentile 153 g) with non-normal distribution (p < 0.001 between genders). Values were comparable to those reported in studies using a similar methodology. Left ventricular mass index showed a moderate correlation with body surface area and weight, and significant differences between genders. As calculated variables exhibited heterogeneity in data distribution (normal or non-normal), the 95th percentile was assumed as the best way of expressing reference values. In conclusion, estimated reference values of left ventricular mass in a healthy population moderately correlated with body surface area and weight. We propose the use of the 95th percentile to express the upper reference value of the assessed data.
RESUMO
Objetivo Evaluar la gravedad de la ateromatosis de la aorta torácica y su relación con la mortalidad y los eventos vasculares cerebrales y coronarios. Material y métodos Entre 2005 y 2007 ingresaron prospectivamente 601 pacientes (p) enviados para ecocardiograma transesofágico (ETE). Edad: 64,53±13,61 años. Sexo masculino: 337 p. Se registró: Motivo del estudio: foco embolígeno (37,7%), endocarditis (22,1%), precardioversión (11,5%), valvulopatía mitral (9,8%), otros (18,95%). Factores de riesgo: diabetes, tabaquismo, hipertensión arterial, dislipemia. Presencia de fibrilación auricular. Los p fueron agrupados en: a. Con placas aórticas <4 mm y no complicadas: p = 465. b. Con placas ≥ 4 mm y/o ulceradas, con trombos o debris (ateromatosis aórtica compleja [AAC]): p = 136. Seguimiento: 1596 días (media: 759 días). Se contactaron 520 p (86,52%), considerándose los siguientes eventos: accidente cerebrovascular transitorio o permanente, IAM, angina, revascularización y/o causa de muerte en dicho período. Se utilizó el análisis multivariado para hallar predictores independientes. Se consideró significativa un p < de 0,01. Resultados Mortalidad cardiovascular: 3,2% (13/407 p) en el grupo a y 18,6% (21/113 p) en el grupo b (p < 0,01). Eventos vasculares combinados: 91/407 p (22,4%) en el grupo a y 45/113 p (39,8%) en el grupo b (p < 0,01). En el análisis multivariado, la AAC fue predictora independiente de mortalidad cardiovascular (OR 4,54, 95% IC 1,52-13,58 p < 0,01) y de eventos vasculares cerebrales y/o coronarios (OR 3,33, 95% IC 1,66-6,67 p < 0,01). Conclusión En esta población, la AAC fue predictora independiente de mortalidad cardiovascular y de eventos vasculares combinados.
Objective To evaluate the severity of atheromatosis of the thoracic aorta and its relation with mortality and cerebrovascular and coronary events. Material and Methods Between 2005 and 2007, 601 patients (ps) were referred for evaluation with transesophageal echocardiography (TEE). Age: 64.53±13.61 years Male gender: 337ps. The following variables were included: Reason for ordering the study: embolic source (37.7%), endocarditis (22.1%), previous to cardioversion (11.5%), mitral valve disease (9.8%), other reasons (18.95%). Risk factors: diabetes, smoking habits, hypertension, dyslipidemia. Presence of atrial fibrillation. The patients were divided into two groups: With uncomplicated aortic plaques < 4 mm: ps = 465. With complex aortic atheromatosis (CAA): aortic plaques ≥ 4 mm, with ulcers, thrombi or aortic debris: ps = 136. Follow-up: 1596 days (mean: 759 days). A total of 520 ps (86.52%) were contacted; the following events were considered: transient ischemic attack or stroke, AMI, angina, revascularization and/or cause of mortality during that period. Multivariate analysis was used to identify independent predictors. A p value < 0.01 was considered statistically significant. Results Cardiovascular mortality: 3.2% (13/407 ps) in group a and 18.6% (21/113 ps) in group b (p<0.01). Combined vascular events: 91/407 ps (22.4%) in group a and 45/113 ps (39.8%) in group b (p<0.01). Multivariate analysis showed that CAA was an independent predictor of cardiovascular mortality (OR 4.54, 95% CI 1.52-13.58, p<0.01) and of cerebrovascular and/or coronary events (OR 3.33, 95% CI 1.66-6.67, p<0.01). Conclusions In this population, CAA was an independent predictor of cardiovascular mortality and combined vascular events.
RESUMO
Introducción El procedimiento de Ross para el tratamiento de la valvulopatía aórtica se ha utilizado durante décadas. A pesar de sus resultados alentadores, ciertos interrogantes han limitado su uso masivo; su durabilidad es uno de los principales motivos de preocupación. Objetivo Analizar los resultados de la cirugía de Ross en nuestro centro. Material y métodos El presente es un estudio de cohorte retrospectivo. De julio de 1995 a mayo de 2008, 198 pacientes fueron sometidos a cirugía de Ross; en todos ellos se empleó la técnica de reemplazo de la raíz aórtica. Los eventos asociados con la válvula se analizaron con el método de Kaplan-Meier. Para el análisis de las variables se emplearon el log-rank test y el modelo de Cox. Resultados La edad media fue de 39 ± 13 años; el 77% eran hombres. La cirugía fue indicada por estenosis aórtica (58%) e insuficiencia aórtica (42%). La mortalidad hospitalaria fue del 2,5% (5 pacientes). El seguimiento a 10 años fue completo en el 93% para los primeros 165 pacientes. La sobrevida a los 10 años fue del 94,8% (IC 95% 89-98). La libertad de endocarditis a los 10 años fue del 95% (IC 95% 84-98) y la libertad de eventos relacionados con la válvula a los 10 años fue del 91% (IC 95% 86-96). Cinco pacientes requirieron reoperación, 4 de ellos por disfunción del autoinjerto y enfermedad de otras válvulas. Conclusiones La cirugía de Ross es una técnica quirúrgica con una tasa baja de eventos a los 13 años y debe ser considerada para el tratamiento de la enfermedad valvular aórtica en pacientes seleccionados.
Background The Ross procedure has been used for decades for the treatment of aortic valve disease. Despite the promising outcomes of this technique, its limited durability is one of the major drawbacks against its massive indication. Objective To analyze the outcomes of the Ross procedure in our oenter. Material and Methods We conducted a retrospective study in a cohort of patients. From July 1995 to May 2008, 198 patients underwent Ross procedure with aortic root replacement technique. Kaplan-Meier method was used to analyze the events associated with the valve, and the variables were analyzed using the log-rank test and Cox model. Results Mean age was 39± 13 years and 77% were raen. The procedure was indicated due to aortic stenosis (58%) and aortic regurgitation (42%). In-hospital mortality was 2.5% (5 patients). Complete follow-up at 10 years was achieved in 93% of the first 165 patients. Survival at 10 years was 94.8% (95% CI, 89-98) After 10 years, 95% (95% CI, 84-98) of patients did not present endocarditis and 91% (95% CI, 86-96) had no valve-related events. Five patients required reoperation, 4 due to autograft dysfunction and disease of other valves. Conclusions Ross procedure has a low event rate after 13 years and should be considered for the treatment of aortic valve disease in selected patients.
RESUMO
Cardiac rehabilitation programs (CRP), include exercise training, medical advice and education related to cardiovascular pathologies, psychosocial support and behavioral characteristics. This approach shows a sustained positive impact over the cardiovascular risk factors, the physical training and the health-related quality of life of the patients and on adherence to dietary recommendations. During the 2004 the authors started the implementation of the Integral Teaching Program (ITP), focused to convalescent patients after a cardiovascular event and with the purpose to enter in a plan of cardiac rehabilitation and secondary preventions with exercise training programs and with a multidisciplinary approach. The aim of this report was to describe the results of the ITP in a cohort of patients submitted to cardiovascular surgery. In a second term, the impact of the ITP will be measured including the total and partial adherence to the different planes of cardiac rehabilitation programs and the management of vascular risk factors. Also it was studied the improvement in physiological outcomes and health-related quality of life in patients with acute myocardial infarction.