Ventricular tachycardia in Chagas' disease: a comparison of clinical, angiographic, electrophysiologic and myocardial perfusion disturbances between patients presenting with either sustained or nonsustained forms.

UNLABELLED: Ventricular tachycardia (VT) is common among patients with Chagas' heart disease but the ultimate mechanisms responsible for its sustained and nonsustained forms are not understood. This study aimed at determining which factors differentiate between patients with sustained (S-VT) and nonsustained VT (NS-VT). Fifty-six consecutive chagasic patients with VT were prospectively selected: 28 patients with spontaneous S-VT and 28 patients with NS-VT. The patients underwent clinical, angiographic, electrophysiologic and myocardial perfusion examination. Syncope episodes (S-VT: 43% versus NS-VT: 11%, p = 0.007) and induction of S-VT by programmed ventricular stimulation (S-VT: 89% versus NS-VT: 7%, p = 0.001) were significantly more frequent in S-VT patients. Evidence of a scar-related reentry was observed in all 24 S-VT patients who underwent endocardial mapping for attempted radiofrequency ablation of 33 VTs. Overall, 29 VTs arose from the LV (88%) and 4 VTs arose from the RV (12%). Among these, 27 VTs (82%) were related to LV inferolateral scar, 2 VTs (6%) were related to LV apical scar, and 4 VTs (12%) were related to RV scars. A significantly higher prevalence of wall motion abnormalities (S-VT: 82% versus NS-VT: 46%, p = 0.005) and myocardial perfusion defects (basal segments, S-VT: 95.5% versus NS-VT: 44%, p = 0.001) was documented within the LV inferior and/or posterolateral regions in S-VT patients compared to NS-VT. IN CONCLUSION: (a) VT may arise from various regions in both ventricles, but LV inferolateral scar is the main source of S-VT reentrant circuits; (b) there is good topographic correlation between myocardial perfusion, wall motion abnormalities and areas that originate S-VT; (c) although to a lesser extent, wall motion and perfusion defects also occur in a relevant proportion of chagasics with NS-VT.

Valvoplastia mitral pela técnica de inoue: registro do hospital das clínicas da faculdade de medicina de Ribeirão Preto da universidade de São Paulo / Mitral valvuloplasty with the Inoue ballon technique: registry of patients treated at hospital das clínicas, Ribeirão Preto medical school

Introdução: Apesar da alta prevalência de estenose mitral no Brasil, nota-se impressionante subnotificação dos procedimentos de tratamento percutâneo dessa afecção na literatura nacional. Este artigo tem como objetivo relatar os resultados e a evolução dos pacientes com estenose mitral reumática, tratados pela técnica de Inoue. Métodos: Foram analisados parâmetros clínicos, ecocardiográficos e relacionados ao procedimento de pacientes tratados no período de 1997 a 2009 e acompanhados por pelo menos um mês. Resultados: Foram avaliados 102 pacientes, a maioria do sexo feminino (89,2%), com média de idade de 38,1 + 11,1 anos, dos quais 80,4% estavam em classe funcional II-III. A área valvar média pela ecocardiografia (ECO) era de 1,01 + 0,19 cm2 e pelo cateterismo (CAT), de 0,87 + 0,2 cm2. O escore de Wilkins & Block estava entre 5 e 8 em cerca de 90% dos pacientes e 88,2% estavam em ritmo sinusal. O procedimento alcançou sucesso em 76,5% dos casos, com aumento da área valvar mitral média de 1,9 + 0,5 cm2 pelo ECO (P < 0,001) e de 2 + 0,5 cm2 pelo CAT (P < 0,001). O gradiente médio átrio esquerdo-ventrículo esquerdo reduziu- se de 16,6 mmHg para 4,2 mmHg (P < 0,001). O débito cardíaco aumentou de 3,75 l/min para 4,67 l/min (P < 0,001), sendo um preditor de sucesso para o procedimento. Em 79,4% dos pacientes obteve-se a evolução de um ano, em que 87,6% dos pacientes estavam em classe funcional I e apenas 2 pacientes necessitaram tratamento cirúrgico. Durante o seguimento de cinco anos não foi observado nenhum caso de acidente vascular cerebral ou óbito de causa cardíaca. Conclusões: A valvoplastia mitral por técnica de Inoue para o tratamento da estenose mitral reumática é técnica eficaz a médio prazo, e com baixa taxa de complicações.

Background: Despite the high prevalence of mitral stenosis in Brazil, there is a significant underreporting of percutaneous procedures in the treatment of this disease in the national literature. This study is aimed at reporting the results and course of patients with rheumatic mitral stenosistreated with the Inoue balloon. Methods: Clinical, echocardiographicand procedure-related parameters of patients treated from 1997 to 2009 who were followed-up for at least a month were evaluated. Results: One hundred and two patients were evaluated, most of them females (89.2%), with mean age of 38.1 + 11.1 years, 80.4% were in functional class II-III. Mean mitral valve area obtained by echocardiography (ECHO) was 1.01 + 0.19 cm² and 0.87 + 0.2 cm² byhemodynamic measurements (HEMO). Wilkins & Block score ranged from 5 to 8 in about 90% of the patients and 88.2% of them were in sinus rhythm. The procedure was successful in 76.5% patients with mean mitral valve area increasing to 1.9 + 0.5 cm² as measured by ECHO (P < 0.001) and to2 + 0.5 cm² as calculated by HEMO (P < 0.001). Mean left atrial-left ventricular gradient was reduced from 16.6 mmHgto 4.2 mmHg (P < 0.001). Cardiac output increased from 3.75 L/min to 4.67 L/min (P < 0.001) and this change was a predictor of success. Of 79.4% patients who were followedup for 1 year, 87.6% were in functional class I and only 2 cases required surgical treatment. During the 5-year follow-up there were no cases of stroke or death due to cardiac causes. Conclusions: Mitral valvuloplasty with the Inoue balloon is effective for the treatment of rheumatic mitral stenosis in the medium term and has a low complication rate.

Estratificação prognóstica em sobreviventes ao infarto agudo do miocárdio. Teste ergométrico versus cinecoronariografia / Risk Stratification after Acute Myocardial Infarction. Exercise Stress Test versus Coronary Angiography

PURPOSE: To compare the predictive accuracy for future ischemic events of heart rate limited treadmill exercise test (HET) and coronary angiography (CA) applied to survivors of an uncomplicated myocardial infarction. METHODS: 142 consecutive patients (55 +/- 11 years, 80males), presenting a non complicated acute myocardial infarction (AMI) were included. HET was performed 10 +/- 3 days after AMI, and CA during hospital stay or within 4-6 weeks. HET positivity criteria were: 1) horizontal or down-sloping ST segment displacement > or = 1 mm; 2) angina; 3) arterial pressure drop during exercise; 4) low workload (< 6 METS); 5) complex ventricular arrhythmia. At CA lesions causing > or = 50of luminal reduction were considered significant. HET and CA results were correlated to ischemic events occurring during the follow-up (unstable angina in 20, cardiac death 6, and reinfarction 6). RESULTS: HET was positive in 69 (49) patients, exhibiting a positive predictive value for ischemic events (PV+) of 26and a negative predictive value (PV-) of 77. The mean event-free time was 43 +/- 3 months for positive HET and 46 +/- 3 months for a negative one (p = 0.48). CA showed 0-1 vessel involvement in 93 (66) patients and > or = 2 vessels in 49 (34) patients. The presence of multivascular disease at CA presented a PV+ of 37and PV- of 82; the mean event-free time was 37 +/- 4 months for patients with multivascular involvement and 48 +/- 2 months for patients without this pattern (p = 0.007). CONCLUSION: The predictive accuracy of HET for future ischemic events in the thrombolytic era is markedly reduced. This population of AMI survivors presents an overall good prognosis that seems to justify the poor predictive accuracy of this test.