The effect of dobutamine without and with L-arginine on arterial compliance in heart failure patients.

The effect of dobutamine on carotid and brachial arteries compliance and the association of L-arginine as a potential nitric oxide pathway restorer were evaluated in patients with heart failure. Twenty-seven outpatients participated. Drugs used for the treatment of heart failure were withheld at least 24 hours before the study. The carotid and brachial artery diameters and hemodynamic variables were evaluated by ultrasonography and Doppler in baseline conditions, with dobutamine, with flow-mediated dilatation (FMD), and with placebo or L-arginine alone and associated with dobutamine. There was a significant increase in carotid peak blood flow with dobutamine when compared with that at baseline (P = 0.0001) or with L-arginine or placebo (P = 0.0001 and P = 0.0001, respectively), with increase of the cardiac index (P = 0.0001). Dobutamine did not increase carotid arterial compliance. FMD significantly increased the brachial peak blood flow (P = 0.0022) and the artery diameter (P = 0.0001). Dobutamine did not change the brachial artery diameter. Brachial peak blood flow was increased with dobutamine alone or associated with placebo or L-arginine comparing with L-arginine or placebo alone (P = 0.0168 and P = 0.0140, respectively), but was not increased compared with that at baseline. L-arginine infusion was not associated with changes in carotid, brachial, or in the cardiac index. We concluded that dobutamine increased carotid peak blood flow in patients with heart failure, although without changing the arterial compliance. The FMD of brachial artery was maintained, while brachial artery response to dobutamine infusion was less reliable. The carotid artery may be under the direct influence of the heart, while the brachial artery may be under predominant local control.

Síndrome de icterícia pós-operatória após substituiçäo valvar mitral: relato de caso / Postoperative jaundice following mitral valve replacement. a case report

Mulher de 52 anos foi submetida a substituiçäo valvar mitral. O ato operatório transcorreu sem anormalidades. Desde o primeiro dia pós-operatório (po), apresentou icterícia de intensidade progressiva as custas de bilirrubina direta. A semiologia abdominal foi normal, e näo havia sinais de infecçäo ou instabilidade hemodinámica. A taxa de bilirrubina direta foi 6 mg/dl no segundo dia po, 20,4 mg/dl no sexto e 32 mg/dl no décimo. A taxa de gamaglutamil transferase foi 600 U/L (normal até 18 U/L) e a de desidrogenase lática 396 U/L (normal até 240 U/L) no sétimo dia po. A taxa de fosfatase alcalina foi 1880 U/L (normal até 170 U/L), enquanto que a de transminase glutâmico-oxalacética foi 60 U/L (normal até 15 U/L) e transaminase glutâmico-pirúvica 66 U/L (normal até 17 U/L) no décimo dia po. A ultrassonografia do abdome näo revelou dilataçäo das vias biliares intra ou extra-hepáticas. A paciente morreu depois depois de uma biopsia hepática percutânea. A icterícia foi atribuída a sínddrome colestática, freqüente no período po de cirurgia cardíaca, na qual há distúrbio transitório da funçäo excretora do hepatócito de etiologia multifatorial

A 52-year old woman was submitted to mitral valve replacement. The operation proceeded without complications. Jaundice had been noted since the first postoperative (po) day and increased progressively due to conjugated bilirubin. Abdominal examination was normal and no signs of infection or circulatory failure were noted. Conjugated bilirubin levels increased from 6 mg/dl on the second po day to 20,4 mg/ dl on the sixth po day and to 32 mg/dl on the tenth po day. Gamaglutamyl transferase levels were 600 U/L (normal up to 18 U/L) and lactate dehydrogenase levels were 396 U/L (normal) up to 240 U/L) on the seventh po day. Alkaline phosphatase levels were 1880 U/L (normal up to 170 U/L) whereas glutamic oxalacetic transaminase levels were 60 U/ L (normal up to 15 U/L) and glutamic pyruvic transaminase levels were 66 U/L (normal up to 17 U/L) on the tenth po day. Abdominal ultrasonography did not disclose dilatation of intra and extra-hepatic biliary system. The patient died after a percutaneous hepatic biopsy procedure. The jaundice was atributted to a cholestatic syndrome after cardiac surgery and cardiopulmonary bypass, due to an impairment of the excretory function of the hepatocyte.