RESUMO
Atrial fibrillation is the most common heart rhythm disorder after cardiac surgery. In previous studies it has been associated with prolonged hospitalization, increased costs and mortality. This study aimed to determine the prevalence of postoperative atrial fibrillation in cardiac surgery and its impact on the hospitalization period. Medical records of consecutive patients undergoing cardiac surgery (coronary artery bypass graft, valvular, or both) between January 2006 and November 2008 were included and retrospectively analyzed. Primary outcome was the presence of postoperative atrial fibrillation. The sample was divided into two groups, with and without atrial fibrillation in the postoperative. The clinical variables and length of hospital stay were compared between both groups. A total of 172 patients underwent surgery in this period. Seven patients were excluded from analysis due to lack of data. The mean age was 64.2 +/- 9.5 years, and they were predominantly male. Atrial fibrillation was the most common complication (23.6%). The average length hospital stay was 6.7 +/- 4.6 days. There were no significant differences between both groups, with atrial fibrillation (7.5 +/- 4.1 days), and without (6.5 +/- 4.7 days), p = 0.21. The presence of atrial fibrillation did not prolong hospitalization. Probably, such strategy of prevention would not be cost-effective.
Assuntos
Fibrilação Atrial/etiologia , Hospitalização/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Argentina/epidemiologia , Fibrilação Atrial/prevenção & controle , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND: We recommend the use of models to estimate mortality hospital risk in cardiac surgery (CC). The aim of this study was to validate a risk stratification system, widely used as the EuroSCORE (ES), in our institution. MATERIAL AND METHODS: We retrospectively analyzed the records of patients undergoing CC consecutively between January 2006 and November 2008. The ES was calculated retrospectively based on data from medical records. Mortality was considered until the time of discharge. In all patients, the ES was calculated by logistic and additive. To study the validity of the model, we analyzed their ability to calibration and discrimination through the goodness of fit test of Hosmer and Lemeshow and area under the ROC curve, respectively. RESULTS: 153 patients were included, mean age 64.1 ± 9.5 years, 77.8% men. The CRM was 60.8%, 24.8% and 14.4% valvular surgery combined (bypass + valve). Overall mortality was 3.9%. The area under the curve of the logistic model was 0.87 and the Hosmer Lemeshow test was 0.84. The area under the curve of the additive model was 0.86 and the Hosmer Lemeshow test was p = 0.89. A score greater than 7 points is additive had a sensitivity of 66% and 91,5% specificity for predicting hospital mortality. CONCLUSION: The ES is a useful model and can be used to estimate the risk of hospital mortality in CC in the city of Cordoba.
Assuntos
Procedimentos Cirúrgicos Cardíacos/mortalidade , Medição de Risco/métodos , Área Sob a Curva , Argentina , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Sensibilidade e EspecificidadeRESUMO
Introduction: High sensitivity cardiac Troponin T (hs-cTnT) dosage is recommended for myocardial infarction diagnosis, by applying the 99th percentile obtained from a healthy population by the manufacturer. The objective is to validate the 99th percentile in a population from our hospital (99L), compared with the manufacturer´s 99th percentile (99F) by using coronary angiography as gold standard. Materials and Methods: Retrospective analysis of every hs-cTnT (Roche) obtained from patients admitted with acute coronary syndromes (ACS) who underwent coronary angiography between 2015 and 2018. Results: 415 patients were included for analysis (118 females, 64.2 yo). 99F sensitivity (Sn) for significant coronary artery disease (stenosis >70%) was 83.6%, with a specificity (Sp) of 44.5%. Positive predictive value (PPV) and negative predictive value (NPV) were 77% and 55% respectively. 99L Sn was 69.7% and Sp 58.6%. PPV was 79% and NPV 46%. ROC curve was 0.641 for 99F and 0.641 for 99L. Conclusion: Given the importance of hs-cTnT in ACS diagnosis, the 99F should be the preferred upper reference limit since the sensitivity is better, although lower compared to prior studies.
Introducción: El dosaje de troponina ultrasensible (TnT US) se recomienda para el diagnóstico de infarto de miocardio, para lo cual se utiliza como punto de corte el percentil 99 (p99) obtenido por el fabricante (99F) en población sana. El objetivo de este estudio es validar el p99 obtenido en la población de este hospital (99L) frente al 99F, utilizando la cinecoronariografía (CCG) como gold standard. Materiales y Métodos: análisis retrospectivo de TnT US Roche realizada a todos los pacientes que ingresaron por SCA (síndrome coronario agudo) a los que se les realizó CCG entre 2015 y 2018. Se utilizó para el procesamiento estadístico el programa IBM SPSS Statistics 24 y tablas de sensibilidad y especificidad para métodos diagnósticos (EviCardio). Resultados: se incluyeron 415 pacientes, 118 de sexo femenino, con edad de 64,2 ± 12,5 años. La sensibilidad del 99F para diagnóstico de enfermedad coronaria severa (obstrucción ≥ 70%) fue de 83,6% y la especificidad, 44,5%. El valor predictivo positivo (VPP) fue de 77% y el negativo (VPN) 55%. La sensibilidad del 99L se calculó en 69,7% y la especificidad, 58,6%. El VPP fue 79% y el VPN 46%. El ABC (área bajo la curva) resultó ser 0,641 para el 99Fy 0,641 para el 99L Conclusiones: Debido a la importancia de la sensibilidad en el uso de la TnT US como herramienta diagnóstica ante la sospecha de SCA, debemos seguir utilizando el 99F ya que mostró mayor sensibilidad que 99L (aunque menor a la reportada en estudios previos).
Assuntos
Troponina/sangue , Síndrome Coronariana Aguda/diagnóstico por imagem , Biomarcadores , Feminino , Hospitais Gerais , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
Background: Transesophageal echo (TEE) bubble study is the current gold standard for patent foramen ovale (PFO) diagnosis, but it has the disadvantage of being semi-invasive and not exempted from risks. The aim of this study was to determine the accuracy of TTE compared to TEE for PFO diagnosis. Methods and results: a systematic review was done on Medline with the terms "transthoracic echocardiography, transesophageal echocardiography, patent foramen ovale, diagnosis" yielding published literature of the last ten years. The search was completed in february 2018. Of 715 articles, 10 were analyzed. The total of patients were 1268 (mean age of 47 years +/-14) with a global prevalence of PFO of 48%. The sensibility of ETT was 90 % (IC 95: 88 % - 92 %) and the specificity 92% (IC 95: 89 % - 94 %). The positive predictive value was 93% (IC 95: 90 % - 94 %) and the negative predictive value 89 % (IC 95: 87 % - 91 %). The area under the curve and Q index value were 0,97 and 0,93 respectively. The positive and negative likelihood ratio were 18,989 and 0,072 respectively. Conclusion: The ETT shows a good specificity and sensibility for PFO diagnosis with last generation equipments, contrast use and valsalva maneuver; according to the analyzed studies.
Introducción: El ecocardiograma transesofágico (ETE) con burbujas es el estudio de referencia para el diagnóstico de foramen oval permeable (FOP), es semi-invasivo y no exento de riesgos. Nuestro objetivo fue determinar la eficacia del ecocardiograma transtorácico (ETT) para el diagnóstico de FOP, en comparación con el ETE. Métodos y resultados: Se realizó una búsqueda en MEDLINE de los últimos 10 años con las palabras claves: "ecocardiograma transtorácico, ecocardiograma transesofágico, foramen oval permeable, diagnóstico". La búsqueda se completó el 28 de Febrero de 2018. De 715 artículos, se seleccionaron 10 para analizar. El total de pacientes fue 1268, edad promedio de 47 años +/-14. La prevalencia global de FOP fue de 48%. La sensibilidad del ETT fue de 90% (IC 95: 88% - 92%) y la especificidad de 92% (IC 95: 89% - 94%). El valor predictivo positivo fue de 93% (IC 95: 90% - 94%) y el valor predictivo negativo de 89% (IC 95: 87% - 91%). El área bajo la curva y el índice Q fueron 0,97 y 0,93 respectivamente. El cociente de probabilidad positivo fue de 18,989 y el negativo de 0,072. Conclusión: El ETT muestra una buena especificidad y sensibilidad para el diagnóstico de FOP con equipos de última generación, uso de contraste y maniobra de Valsalva; según los estudios analizados.
Assuntos
Ecocardiografia Transesofagiana , Ecocardiografia , Forame Oval Patente/diagnóstico por imagem , Humanos , Valor Preditivo dos Testes , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: Heart transplantation is an effective treatment for patients with end-stage Chagas' heart disease. Re-activation of Chagas' disease in transplant recipients is frequent, triggered by immunosuppression level. Therefore, highly sensitive methods for early diagnosis of Chagas' disease relapse are necessary to initiate appropriate therapy. We analyzed the use of polymerase chain reaction (PCR) in the clinical follow-up of heart transplant recipients. METHODS: We prospectively evaluated 4 heart transplant recipients at the Hospital Privado, Cordoba, Argentina, who had terminal Chagas' disease. The parameters analyzed were presence of parasites in the blood (blood culture, Strout) and in endomyocardial biopsy (EMB) samples, and PCR was performed with oligonucleotides directed to a nuclear repetitive sequence of Trypanosoma cruzi. We evaluated these parameters weekly from the day of transplantation until results were negative and then during regular follow-up visits. RESULTS: In 2 patients, we detected T cruzi using PCR in peripheral blood 30 days before clinical evidence of re-activation. In the 3rd case, PCR results in peripheral blood were positive from the day before transplantation, followed by positive results in EMB and sub-cutaneous chagomas biopsy specimens. Only 1 patient had positive Strout results for parasites in skin lesions, and none showed amastigotes in the biopsy specimens. After clinical diagnosis, all patients received 5 mg/kg/day benzimidazole for 6 months, with acceptable tolerance and good clinical outcome. All patients had negative peripheral blood PRC results after 30 days of treatment. One patient had intermittent positive PCR results during follow-up, with no evidence of clinical re-activation. CONCLUSION: Polymerase chain reaction detection of T Cruzi in heart transplant recipients is a more sensitive and specific procedure in diagnosing Chagas' disease re-activation.
Assuntos
Cardiomiopatia Chagásica/diagnóstico , Transplante de Coração , Trypanosoma cruzi/isolamento & purificação , Animais , Cardiomiopatia Chagásica/cirurgia , Feminino , Humanos , Imunossupressores/uso terapêutico , Masculino , Pessoa de Meia-Idade , Reação em Cadeia da Polimerase , Recidiva , Sensibilidade e EspecificidadeRESUMO
In some patients with atrial fibrillation (AF), it has been suggested that left atrial mechanical dysfunction can develop after successful electrical cardioversion, justifying postcardioversion anticoagulant treatment. The purpose of this study was to investigate differences in left atrial appendage peak flow velocities and the incidence of left atrial spontaneous echo contrast in patients with AF before and after electrical cardioversion or intravenous amiodarone, studied using transesophageal echocardiography (TEE) and pulsed Doppler. We performed a control TEE in 7 patients in the electrical group and 6 in the amiodarone group, with no significant clinical differences between both groups. A second TEE was performed immediately in the 7 patients with successful electrical cardioversion. The peak flow velocities in the appendage before and after the procedure were: filling 43.3 +/- 22 vs 27.7 +/- 28 cm/sec (P = 0.01) and emptying 35.5 +/- 22 vs 23.6 +/- 17 cm/sec (P = 0.01), respectively. The spontaneous echo contrast increased in 4 of the 7 patients. In 4 patients of the amiodarone group, the peak flow velocities in the appendage during AF and within the first 24 hours after restoration of sinus rhythm were: filling 37.4 +/- 12 vs 37.8 +/- 18 cm/sec and emptying 36.4 +/- 18 vs 35.9 +/- 18 cm/sec, respectively (P = NS). There was no change in spontaneous echo contrast. In conclusion, patients with AF reverted to sinus rhythm using amiodarone did not show changes in left atrial mechanical function; however, patients with electrical cardioversion showed mechanical dysfunction. Further investigations on the effects of amiodarone and other drugs on the mechanical function of the atria are needed to determine if patients reverted pharmacologically require anticoagulation post reversion. (ECHOCARDIOGRAPHY, Volume 13, March 1996)
RESUMO
High serum levels of T troponin (TnT) have been described in patients with nonischemic myocardiopathies as markers of myocardial damage. We aimed to determine whether a highly sensitive TnT assay could identify patients with early stage chronic Chagas disease cardiopathy. We studied 39 outpatients with a serologic diagnosis of Chagas disease by clinical examination, electrocardiogram and echocardiogram. Among all patients, 15 had no cardiac lesions, 15 showed only typical electrocardiographic changes, and nine had echocardiographic alterations. All TnT determinations were negative except in one patient in the latter group (1 out of 9; 11.11%). This patient had the lowest ejection fraction (29%) and had a left ventricular diastolic diameter of 77 mm. Thus, in the present study troponin T levels were not associated with early signs of myocardial damage in Chagas disease.
Assuntos
Cardiomiopatia Chagásica/sangue , Troponina T/sangue , Doença Crônica , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
Resumen: La miocardiopatía hipertrófica (MCH) es una enfermedad frecuente del miocardio, asociada a muerte súbita cardíaca (MSC). Las principales causas de muerte en MCH son la MSC, la insuficiencia cardíaca y el tromboembolismo. La fibrilación ventricular (FV) es la causa más común de MSC, seguida de asistolia, actividad eléctrica sin pulso y bloqueo auriculoventricular completo. El sustrato de estas arritmias complejas es la hipertrofia asociada a desorganización miofibrilar y fibrosis, que facilitan el desarrollo de arritmias reentrantes y secundarias a actividad desencadenada. Dado que la FV puede ser tratada con el implante de un desfibrilador automático implantable (DAI), la identificación de los pacientes que presentan mayor riesgo se transforma en la principal preocupación del cardiólogo tratante. La indicación de implante de DAI es clara en la prevención secundaria de MSC, pero es compleja en el resto de los pacientes que no han presentado FV o taquicardia ventricular sostenida, lo que configura la prevención primaria de MSC. Debemos estratificar la MCH con el uso de los factores de riesgo derivados de datos clínicos y estudios complementarios. Los principales factores de riesgo relacionados a MSC son: edad temprana al diagnóstico, antecedentes heredofamiliares de MSC, síncope inexplicado, taquicardia ventricular no sostenida, hipotensión arterial inducida durante la prueba de esfuerzo, obstrucción del tracto de salida del ventrículo izquierdo, hipertrofia ventricular izquierda severa, agrandamiento auricular izquierdo y captación de realce tardío en la resonancia magnética. El uso adecuado de los dos principales modelos de estratificación de riesgo actualmente disponibles nos ayuda a estimar el riesgo individual en cada paciente y proceder en consecuencia.
Summary: Hypertrophic cardiomyopathy is one of the most frequent cardiac muscle disorders associated with sudden cardiac death, heart failure and thromboembolism. Ventricular fibrillation is the most common cause of sudden cardiac death in hypertrophic cardiomyopathy, followed by asystole, pulseless electrical activity, and complete atrioventricular block. The substrate behind these complex arrhythmias is the hypertrophy due to myocardial disarray and fibrosis, facilitating the development of reentrant arrhythmias and triggered activity. An implanted cardioverter defibrillator is the treatment of choice, so the identification of high risk patients for ventricular fibrillation is crucial. Implanted cardioverter defibrillator indication is well established in sudden cardiac death secondary prevention, but not in patients without evidence of ventricular fibrillation or sustained ventricular tachycardia, which configures the sudden cardiac death primary prevention group. Identification of sudden cardiac death risk factors is derived from clinical data, complementary studies and validated in risk stratification models. These are: early age at diagnosis, family history of sudden death, unexplained syncope, non-sustained ventricular tachycardia, abnormal blood pressure response with exercise, left ventricular outflow tract obstruction, severe left ventricular hypertrophy, left atrial enlargement and late gadolinium enhancement on cardiac magnetic resonance imaging. The proper use of two available main risk stratification models helps us to estimate the individual patient´s risk and to proceed consequently.
RESUMO
La fibrilación auricular es el trastorno del ritmo más frecuente luego de la cirugía cardíaca. En estudios previos se ha asociado a prolongación de la internación, aumento en los costos e incremento en la mortalidad. El objetivo de este estudio fue conocer la prevalencia de fibrilación auricular en el postoperatorio de cirugía cardíaca y determinar el efecto en el tiempo de estadía hospitalaria. Se analizaron retrospectivamente las historias clínicas de pacientes sometidos a cirugía cardíaca consecutivamente (de revascularización miocárdica, valvulares o ambas) entre enero 2006 y noviembre 2008. El punto final evaluado en el postoperatorio fue la presencia de fibrilación auricular. Se dividió a la muestra en dos grupos según tuvieran o no fibrilación auricular, y se compararon las variables clínicas y el tiempo de estadía hospitalaria. Ciento setenta y dos pacientes fueron operados en este período. Se excluyeron del análisis siete pacientes por falta de datos. La edad media fue 64.2 ± 9.5 años, con predominio del sexo masculino. La fibrilación auricular fue la complicación más frecuente (23.6%). El tiempo promedio de internación fue 6.7 ± 4.6 días. No hubo diferencias relevantes al comparar la estadía hospitalaria entre los grupos con o sin fibrilación auricular, 7.5 ± 4.1 días vs. 6.5 ± 4.7 días respectivamente, p = 0.21. La presencia de fibrilación auricular no prolongó la hospitalización. Probablemente una estrategia de prevención indiscriminada no sería costo-efectiva.
Atrial fibrillation is the most common heart rhythm disorder after cardiac surgery. In previous studies it has been associated with prolonged hospitalization, increased costs and mortality. This study aimed to determine the prevalence of postoperative atrial fibrillation in cardiac surgery and its impact on the hospitalization period. Medical records of consecutive patients undergoing cardiac surgery (coronary artery bypass graft, valvular, or both) between January 2006 and November 2008 were included and retrospectively analyzed. Primary outcome was the presence of postoperative atrial fibrillation. The sample was divided into two groups, with and without atrial fibrillation in the postoperative. The clinical variables and length of hospital stay were compared between both groups. A total of 172 patients underwent surgery in this period. Seven patients were excluded from analysis due to lack of data. The mean age was 64.2 ± 9.5 years, and they were predominantly male. Atrial fibrillation was the most common complication (23.6%). The average length hospital stay was 6.7 ± 4.6 days. There were no significant differences between both groups, with atrial fibrillation (7.5 ± 4.1 days), and without (6.5 ± 4.7 days), p = 0.21. The presence of atrial fibrillation did not prolong hospitalization. Probably, such strategy of prevention would not be cost-effective.
Assuntos
Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fibrilação Atrial/etiologia , Hospitalização/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Argentina/epidemiologia , Fibrilação Atrial/prevenção & controle , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Tempo de Internação/estatística & dados numéricos , Prevalência , Estudos Retrospectivos , Fatores de RiscoRESUMO
Current diagnosis of chronic Chagas disease relies on serologic detection of specific immunoglobulin G against Trypanosoma cruzi. However, the presence of parasites detected by polymerase chain reaction (PCR) in patients without positive conventional serologic testing has been observed. We determined the prevalence and clinical characteristics of persons with seronegative results and T. cruzi DNA detected by PCR in a population at high risk for chronic American trypanosomiasis. We studied a total of 194 persons from two different populations: 110 patients were recruited from an urban cardiology clinic, and 84 persons were citizens from a highly disease-endemic area. Eighty (41%) of persons had negative serologic findings; 12 (15%) had a positive PCR. Three patients with negative serologic findings and positive PCR results had clinical signs and symptoms that suggested Chagas cardiomyopathy. This finding challenges the current recommendations for Chagas disease diagnosis, therapy, and blood transfusion policies.
Assuntos
Doença de Chagas/parasitologia , Trypanosoma cruzi/isolamento & purificação , Adolescente , Adulto , Idoso , Animais , Anticorpos Antiprotozoários/sangue , Argentina/epidemiologia , Doença de Chagas/epidemiologia , Estudos Transversais , DNA de Protozoário/química , DNA de Protozoário/genética , Ensaio de Imunoadsorção Enzimática , Feminino , Técnica Indireta de Fluorescência para Anticorpo , Testes de Inibição da Hemaglutinação , Humanos , Masculino , Pessoa de Meia-Idade , Reação em Cadeia da Polimerase , População Rural , Estudos Soroepidemiológicos , Trypanosoma cruzi/genética , População UrbanaRESUMO
Introducción: La miocardiopatía chagásica durante el período crónico es una causa frecuente de insuficiencia cardíaca avanzada, pero la indicación de trasplante cardíaco aún es controversial en algunos centros. Objetivos: Evaluar en estos pacientes la mortalidad, las complicaciones postrasplante, la frecuencia de reactivación de T. Cruzi (TC) y la utilidad de su detección a través de la reacción en cadena de la polimerasa (PCR). Material y métodos: Se evaluaron 27 pacientes trasplantados desde el año 1997: 4 pacientes chagásicos (grupo A) y 23 en el grupo control (grupo B). El análisis de PCR se realizó con empleo de la secuencia de oligonucleótico TCZ1 y TCZ2. El diagnóstico de reactivación de T. Cruzi se realizó en base a la visualización histopatológica de amastigotas en muestra de tejidos. Resultados: El seguimiento promedio fue de 28,75 ± 23,38 meses en el grupo A y de 28,04 ± 16,84 meses en el grupo B. La sobrevida a los 3 años fue del 75 por ciento y el 65 por ciento respectivamente (p = 0,59). La reactivación de TC ocurrió en los 4 pacientes chagásicos. La infección por CVM (p = 0,05) fue más frecuente en el grupo A. La PCR positiva precedió en 30-60 días a la aparición de los síntomas en 3 pacientes y se negativizó en todos los pacientes luego del tratamiento. Conclusiones: Los pacientes trasplantados chagásicos tienen una mortalidad similar a los no chagásicos a pesar de la reactivación de TC. La parasitemia detectada por PCR es de utilidad para el diagnóstico precoz y el monitoreo terapéutico de la reactivación de la tripanosomiasis.
Assuntos
Humanos , Transplante de Coração , Cardiomiopatia Chagásica/mortalidade , Argentina , Doença de Chagas , Hospitais , Reação em Cadeia da Polimerase , Trypanosoma cruziRESUMO
En el presente estudio, se analiza cuantitativamente la contractilidad ventricular segmentaria y los flujos diastólicos mitrales de pacientes con enfermedad de Chagas en distintos estadios clínicos. Se estudiaron 20 pacientes con test de inmunofluorescencia positivo para Chagas. Ocho pacientes fueron asintomáticos (clase I); 9 pacientes tuvieron anormalidades electrocardiográficas (clase II) y 3 pacientes tuvieran insuficiencia cardíaca (clase III). Diez sujetos sanos conformaron el grupo control. Se obtuvieron imágenes ecodardiográficas bidimensionales desde las posiciones paraesternal y de cuatro cavidades y se analizaron cuantitativamente los cambios regionales en los ejes cardíacos y el espesor de la pared ventricular durante el ciclo cardíaco de acuerdo a métodos previamente validados. Con Doppler pulsado se registraron las velocidades y tiempos de los flujos diastólicos a nivel de la válvula mitral. Los pacientes chagásicos presentaron alteraciones significativas en la motilidad del segmento posterobasal del ventrículo isquierdo con respecto al grupo control. Estas anormalidades fueron evidentes incluso en pacientes de la clase I. El número de segmentos con motilidad anormal fue mayor en las clases II y III. Los pacientes chag sicos preentaron la velocidad máxima de la onda A significativamente más alta que el grupo control (0,67 + 0,17 y 0,49 + 0,08 m/s, p = 0,01) pero sin un patrón de flujos diastólicos característico. Se concluye que las anormalidades regionales en la motilidad ventricular aparecen inicialmente en la Enfermedad de Chagas, lo cual sugiere actividad de la enfermedad en el miocardio aun durante el período asintomático.