Ultrasound-Guided Peripheral Venipuncture Decreases the Procedure's Pain and Positively Impacts Patient's Experience: The PRECISE Randomized Clinical Trial.

This study aimed to compare patients' experience of pain during ultrasound (US)-guided peripheral venipuncture versus conventional peripheral venipuncture. This randomized clinical trial was conducted at a public university hospital in 2021. Adult patients with indication for intravenous therapy compatible with peripheral intravenous catheters (PIVCs) were included: intervention group (IG), US peripheral venipuncture executed by specialist nurses; control group (CG), conventional peripheral venipuncture executed by clinical practice nurses. The primary outcome was patient experience of pain during the procedure and patient experience related to the PIVC placement method. Sixty-four patients were included, 32 for each group. The pain experienced was none-to-mild in the IG for 25 patients (78.1%) and moderate-to-severe in the CG for 21 patients (65.7%; P < .001). The overall pain rating was 2 (1-3) in the IG and 4 (3-6) in the CG (P < .001). The recommendation of the procedure in IG (net promoter score [NPS] + 90.6%) versus CG (NPS + 18.8%) was considered excellent and good, respectively (P < .001). Patients had less pain and significantly recommended the US-guided procedure. Patient experience with US-guided PIVC, performed by a specialist nurse, was superior to that of conventional peripheral venipuncture.

Pro- and Anti-inflammatory Biomarkers Responses after Aerobic Training in Heart Transplant Recipients: A Systematic Review and Meta-analysis.

BACKGROUND: Physical exercise (PE) may improve plasma concentration of interleukin- 6 (IL-6), tumor necrosis factor-alpha (TNF-alpha), and adiponectin (adpN) in heart transplant (HT) patients. However, no consistent data is available on this population. AIM: Thus, we aimed to conduct a systematic review and meta-analysis on the effects of PE over these pro- and anti-inflammatory biomarkers in HT patients. METHODS: Following the guidelines established by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement, we conducted a systematic literature search in the PubMed, Cochrane, and Scopus databases. Outcomes included IL-6, TNF-alpha, and adpN. Effect size (ES) was calculated using the standardized mean difference with a 95% confidence interval (CI). RESULTS: The PE group (aerobic modality) was associated with reduced IL-6 compared to the control group (ES: -0.53; 95% CI: -0.99 to -0.06 pg/mL; P = 0.026). However, the PE group did not show a significant effect on TNF-alpha and adpN levels (ES: -0.33; 95% CI: -0.79 to 0.13; P = 0.16 and ES: -0.20; 95% CI: -0.70 to 0.30 pg/mL; P = 0.444, respectively). CONCLUSION: PE is associated with IL-6 reductions, although TNF alpha and adpN did not change after this intervention in HT patients. Therefore, PE is an effective intervention to downregulate IL-6 in post-HT patients.

Catheter ablation of typical right atrial flutter in a 20-day-old neonate with tachycardiomyopathy.

Background: Fetal echocardiography can diagnose neonatal atrial flutter, which can cause heart failure in newborns. Little is known about catheter ablation in this population. Methods: Case report that aimed to review a successful ablation in a 20-day-old patient with refractory atrial flutter. Results: This is the first report of a successful neonatal atrial flutter ablation without any early recurrence after the procedure. Conclusions: Atrial flutter ablation performed on newborns is a reliable and long-lasting treatment option.

Prognosis of programmed ventricular stimulation in adult patients with syncope of unexplained origin: A historical cohort.

Background: Programmed ventricular stimulation (PVS) during electrophysiological study (EPS), is a globally accepted tool for risk stratification of sudden cardiac death (SCD) in some specific clinical situations. The aim of this study was to evaluate the prognosis of ventricular arrhythmia induction in a cohort of patients with syncope of undetermined origin (SUO). Methods: This is a historical cohort study in a population of patients with SUO referred for EPS between the years 2008-2021. In this interval, 575 patients underwent the procedure. Results: Patients with induced ventricular arrhythmias had a higher occurrence of structural heart disease (36.7% vs. 76.5%), ischemic heart disease (28.2 vs. 57.1%), heart failure (15.5% vs. 34.4%), and lower left ventricular ejection fraction (59.16% vs. 47.51%), when compared to the outcome with a negative study. PVS triggered ventricular arrhythmias in 98 patients, 62 monomorphic and 36 polymorphic. During a median follow-up of 37.6 months, 100 deaths occurred. Only the induction of sustained ventricular arrhythmias showed a significant association with the primary outcome (all-cause mortality) with a p value <.001. After the performance of EPS, 142 patients underwent cardioverter-defibrillator (ICD) implantation. At study follow-up, 30 patients had therapies by the device. Only the induction of sustained monomorphic ventricular arrhythmia showed statistically significant association with appropriate therapies by the device (p = .012). Conclusion: In patients with SUO, the induction of sustained monomorphic ventricular arrhythmia after programmed ventricular pacing is related to a worse prognosis, with a higher incidence of mortality and appropriate therapies by the ICD.

Avaliação Cardiodinâmica Não Invasiva por Cardiografia de Impedância durante o Teste de Caminhada de Seis Minutos em Pacientes com Insuficiência Cardíaca / Non-Invasive Assessment of Cardiodynamics by Impedance Cardiography during the Six-Minute Walk Test in Patients with Heart Failure

Resumo Fundamento O Teste de Caminhada de seis Minutos (TC6M) é comumente usado para avaliar pacientes com insuficiência cardíaca. No entanto, vários fatores clínicos podem influenciar a distância percorrida pelos pacientes no teste. A cardiografia de impedância (CI) na avaliação morfológica é uma ferramenta útil para avaliar a hemodinâmica cardíaca de maneira não invasiva. Objetivo Este estudo teve como objetivo comparar as respostas de aceleração e desaceleração do Débito Cardíaco (DC), da Frequência Cardíaca (FC), e do Volume Sistólico (VS) ao TC6M de indivíduos com insuficiência cardíaca e fração de ejeção reduzida (ICFEr) com as de controles sadios. Métodos Este é um estudo transversal observacional. O DC, a FC, o VS e o Índice Cardíaco (IC) foram avaliados antes, durante e após o TC6M por CI. O nível de significância adotado na análise estatística foi 5%. Resultados Foram incluídos 27 participantes (13 com ICFEr e 14 controles sadios). A aceleração do DC e da FC foi significativamente diferente entre os grupos (p<0,01 e p=0,039, respectivamente). Encontramos diferenças significativas no VS, no DC e no IC entre os grupos (p<0,01). A regressão linear mostrou uma contribuição deficiente do VS à mudança no DC no grupo com ICFEr (22,9% versus 57,4%). Conclusão O principal resultado deste estudo foi o fato de que indivíduos com ICFEr apresentaram valores mais baixos de aceleração do DC e da FC durante o teste de exercício submáximo em comparação a controles sadios. Isso pode indicar um desequilíbrio na resposta autonômica ao exercício nessa condição.

Abstract Background The six-minute walk test (6MWT) is commonly used to evaluate heart failure (HF) patients. However, several clinical factors can influence the distance walked in the test. Signal-morphology impedance cardiography (SM-ICG) is a useful tool to noninvasively assess hemodynamics. Objective This study aimed to compare cardiac output (CO), heart rate (HR), and stroke volume (SV) acceleration and deceleration responses to 6MWT in individuals with HF and reduced ejection fraction (HFrEF) and healthy controls. Methods This is a cross-sectional observational study. CO, HR, SV and cardiac index (CI) were evaluated before, during, and after the 6MWT assessed by SM-ICG. The level of significance adopted in the statistical analysis was 5%. Results Twenty-seven participants were included (13 HFrEF and 14 healthy controls). CO and HR acceleration significantly differed between groups (p<0.01; p=0.039, respectively). We found significant differences in SV, CO and CI between groups (p<0.01). Linear regression showed an impaired SV contribution to CO change in HFrEF group (22.9% versus 57.4%). Conclusion The main finding of the study was that individuals with HFrEF showed lower CO and HR acceleration values during the submaximal exercise test compared to healthy controls. This may indicate an imbalance in the autonomic response to exercise in this condition.

Biomarkers Associated with Thrombosis in Patients with Peripherally Inserted Central Catheter: A Systematic Review and Meta-Analysis.

BACKGROUND: The measurement and identification of plasma biomarkers can support the estimation of risk and diagnosis of deep vein thrombosis (DVT) associated with the use of a peripherally inserted central catheter (PICC). OBJECTIVES: This systematic review and meta-analysis aimed to identify the association between the levels of potential biomarkers that reflect the activation of the blood system, long-term vascular complications, inflammatory system, and the occurrence of PICC-related DVT. METHODS: Seven electronic databases (Embase, Web of Science, Medline, Scopus, Cinahl, Cochrane Central Register of Controlled Trials, and ERIC) were searched to identify literature published until December 2022. Studies were required to report: (I) adult and pediatric patients, outpatient or admitted to clinical, surgical, or ICU with PICC; (II) patients with PICC-related DVT and patients without PICC-related DVT as a comparator; and (III) at least one biomarker available. The Newcastle-Ottawa Scale was used to evaluate the quality of the studies. Study precision was evaluated by using a funnel plot for platelets level. We provided a narrative synthesis and meta-analysis of the findings on the biomarkers' outcomes of the studies. We pooled the results using random effects meta-analysis. The meta-analysis was conducted using Review Manager software v5.4. This systematic review is registered in PROSPERO (CRD42018108871). RESULTS: Of the 3564 studies identified (after duplication removal), 28 were included. PICC-related DVT was associated with higher D-dimers (0.37 µg/mL, 95% CI 0.02, 0.72; p = 0.04, I2 = 92%; p for heterogeneity < 0.00001) and with higher platelets (8.76 × 109/L, 95% CI 1.62, 15.91; p = 0.02, I2 = 41%; p for heterogeneity = 0.06). CONCLUSIONS: High levels of D-dimer and platelet were associated with DVT in patients with PICC. However, biomarkers such as APTT, fibrinogen, FDP, glucose, hemoglobin, glycated hemoglobin, INR, prothrombin time, prothrombin fragment 1.2, the thrombin-antithrombin complex, and WBC were not related to the development of DVT associated with PICC.

Functional training improves peak oxygen consumption and quality of life of individuals with heart failure: a randomized clinical trial.

BACKGROUND: Functional training may be an effective non-pharmacological therapy for heart failure (HF). This study aimed to compare the effects of functional training with strength training on peak VO2 and quality of life in individuals with HF. METHODS: A randomized, parallel-design and examiner-blinded controlled clinical trial with concealed allocation, intention-to-treat and per-protocol analyses. Twenty-seven participants with chronic HF were randomly allocated to functional or strength training group, to perform a 12-week physical training, three times per week, totalizing 36 sessions. Primary outcomes were the difference on peak VO2 and quality of life assessed by cardiopulmonary exercise testing and Minnesota Living with Heart Failure Questionnaire, respectively. Secondary outcomes included functionality assessed by the Duke Activity Status Index and gait speed test, peripheral and inspiratory muscular strength, assessed by hand grip and manovacuometry testing, respectively, endothelial function by brachial artery flow-mediated dilation, and lean body mass by arm muscle circumference. RESULTS: Participants were aged 60 ± 7 years, with left ventricular ejection fraction 29 ± 8.5%. The functional and strength training groups showed the following results, respectively: peak VO2 increased by 1.4 ± 3.2 (16.9 ± 2.9 to 18.6 ± 4.8 mL.kg-1.min-1; p time = 0.011) and 1.5 ± 2.5 mL.kg-1.min-1 (16.8 ± 4.0 to 18.6 ± 5.5 mL.kg-1.min-1; p time = 0.011), and quality of life score decreased by 14 ± 15 (25.8 ± 14.8 to 10.3 ± 7.8 points; p time = 0.001) and 12 ± 28 points (33.8 ± 23.8 to 19.0 ± 15.1 points; p time = 0.001), but no difference was observed between groups (peak VO2: p interaction = 0.921 and quality of life: p interaction = 0.921). The functional and strength training increased the activity status index by 6.5 ± 12 and 5.2 ± 13 points (p time = 0.001), respectively, and gait speed by 0.2 ± 0.3 m/s (p time = 0.002) in both groups. CONCLUSIONS: Functional and strength training are equally effective in improving peak VO2, quality of life, and functionality in individuals with HF. These findings suggest that functional training may be a promising and innovative exercise-based strategy to treat HF. TRIAL REGISTRATION: NCT03321682. Registered date: 26/10/2017.

Risk Factors Associated with Ischemic Stroke in the Immediate Postoperative Period of Cardiac Surgery.

INTRODUCTION: Stroke remains a major complication of cardiac surgery. Despite all efforts, the incidence of postoperative stroke remains as high as 6%. We aimed to investigate risk factors for ischemic stroke in a contemporary cohort of patients undergoing cardiac surgery. METHODS: This is a retrospective cohort study of 678 consecutive adult patients who underwent cardiac surgery requiring cardiopulmonary bypass in a tertiary hospital in Brazil between July 1, 2011, and December 31, 2018. The primary outcome was the rate of early (perioperative and seven-day postoperative) stroke, defined as the occurrence of the outcome during the index admission. We developed a predictive model of stroke using the Poisson regression analysis with robust variance. RESULTS: Postoperative stroke occurred in 24 patients (3.5%), 23 (3.3%) were ischemic, and 21 (3.0%) were diagnosed in the first 72 hours after surgical procedure. After multivariate analysis, the following factors were significantly associated with stroke: previous stroke/transient ischemic attack (relative risk [RR]=2.75; 95% confidence interval [CI], 1.11-6.82), carotid artery disease (RR=4.0; 95% CI, 1.43-11.0), previous atrial fibrillation (RR=3.26, 95% CI, 1.31-8.1), and postoperative platelets > 200,000/mm3 (RR=2.26; 95% CI, 1.01-5.1). CONCLUSION: We developed a contemporary model to determine risk predictors for stroke after cardiac surgery. This model may help clinicians to identify patients at risk and could be useful in clinical practice.

Monocyte-to-lymphocyte ratio as predictor of cancer therapy-related cardiotoxicity in patients with breast cancer: a pilot cohort study.

BACKGROUND: Elevated pre-treatment baseline inflammation has been associated with cancer therapy-related cardiac dysfunction (CTRCD) in patients with breast cancer. Monocyte-to-lymphocyte ratio (MLR), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio and systemic immune-inflammation index (NLR × platelets) have emerged in clinical context as markers of disease-related inflammation. OBJECTIVES: To evaluate development of CTRCD according to pre-treatment blood inflammatory biomarkers in patients with breast cancer. METHODS: Pilot cohort study including consecutive female patients ≥ 18 years with HER2-positive early breast cancer who consulted at the institution's breast oncology outpatient clinic between march/2019 and march/2022. CTRCD: absolute reduction in LVEF > 10% to below 53% (2D-echocardiogram). Survival analysis was performed using Kaplan-Meier curves, compared by the log-rank test, and discrimination ability was evaluated through AUC-ROC. RESULTS: Forty-nine patients (53.3 ± 13.3 y) were included and followed-up for a median of 13.2 months. CTRCD was observed in 6 (12.2%) patients. Patients with high blood inflammatory biomarkers had lower CTRCD-free survival (P < 0.050 for all). MLR showed statistically significant AUC (0.802; P = 0.017). CTRCD was observed in 27.8% of patients with high MLR versus 3.2% with low MLR (P = 0.020); negative predictive value was 96.8% (95%CI 83.3-99.4%). CONCLUSION: In patients with breast cancer, elevated pre-treatment inflammatory markers were associated with increased risk of cardiotoxicity. Among these markers, MLR had good discriminatory performance and high negative predictive value. The incorporation of MLR might improve risk evaluation and selection of patients for follow-up during cancer therapy.

Anthropometric measurements and their association with endothelial function and arterial stiffness of eutrophic individuals and with overweight.

Objective: The objective of the study was to assess the association of anthropometric measurements with endothelial function and arterial stiffness of eutrophic individuals and with overweight. Subjects and methods: A cross-sectional study was carried out with individuals with body mass index (BMI) between 18.5 kg/m2 and < 30 kg/m2, low to intermediate global cardiovascular risk scores, and aged ≥ 18 and < 60 years. We assessed the sociodemographic data, anthropometric variables (body weight, height, circumferences of the waist [WC], neck [NC], hip [HC], sagittal abdominal diameter [SAD], [BMI], waist-to-hip ratio [WHR], and waist-to-height ratio [WHtR]), biochemical parameters (lipid profile and nitric oxide), endothelial function (flow-mediated dilation [FMD], by ultrasound), and arterial stiffness (pulse wave velocity [PWV] and the amplification index [AIx@75] by oscillometry). Thirty-six individuals were included, 18 eutrophic and 18 with overweight, with a mean age of 37.5 ± 10.2 years, mostly at low cardiovascular risk (86.1%), female (80.6%), single (52.8%), employed with formal contracts (44.4%), and with over twelve years of education (88.9%). Results: The PWV presented positive and moderate correlation with the WC (r = 0.584; P = 0.001), WHR (r = 0.513; P = 0.001), and WHtR (r = 0.590; P = 0.001), and positive and low correlation with the NC (r = 0.372; P = 0.013) and SAD (r = 0.356; P = 0.033). Moreover, no anthropometric parameter presented a correlation with the AIx@75 or the FMD percentage in the total sample. Conclusion: Our findings show that in eutrophic individuals and with overweight the WC, WHR, WHtR, SAD, and NC were positively correlated with the PWV but not to the endothelial function in the overall sample. These are hypothesis-generating findings and they should be replicated in other studies.

Atrial Fibrillation Ablation: Impact of Intracardiac Echocardiography in Reducing Procedure Time and Hospitalization. / Ablação da Fibrilação Atrial: Impacto da Ecocardiografia Intracardíaca na Redução do Tempo de Procedimento e Internação.

BACKGROUND: Intracardiac echocardiography (ICE) allows visualization of cardiac structures and recognition of complications during atrial fibrillation ablation (AFA). Compared to transesophageal echocardiography (TEE), ICE is less sensitive to detecting thrombus in the atrial appendage but requires minimal sedation and fewer operators, making it attractive in a resource-constrained setting. OBJECTIVE: To compare 13 cases of AFA using ICE (AFA-ICE group) with 36 cases of AFA using TEE (AFA-TEE group). METHODS: This is a single-center prospective cohort study. The main outcome was procedure time. Secondary outcomes: fluoroscopy time, radiation dose (mGy/cm2), major complications, and length of hospital stay in hours. The clinical profile was compared using the CHA2DS2-VASc score. A p-value <0.05 was considered a statistically significant difference between groups. RESULTS: The median CHA2DS2-VASc score was 1 (0-3) in the AFA-ICE group and 1 (0-4) in the AFA-TEE group. The total procedure time was 129 ± 27 min in the AFA-ICE group and 189 ± 41 min in the AFA-TEE group (p<0.001); the AFA-ICE group received a lower dose of radiation (mGy/cm2, 51296 ± 24790 vs. 75874 ± 24293; p=0.002), despite the similar fluoroscopy time (27.48 ± 9. 79 vs. 26.4 ± 9.32; p=0.671). The median length of hospital stay did not differ; 48 (36-72) hours (AFA-ICE) and 48 (48-66) hours (AFA-TEE) (p=0.27). CONCLUSIONS: In this cohort, AFA-ICE was related to shorter procedure times and less exposure to radiation without increasing the risk of complications or the length of hospital stay.

FUNDAMENTO: O ecocardiograma intracardíaco (EIC) permite visualizar estruturas cardíacas e reconhecer complicações durante a ablação da fibrilação atrial (AFA). Comparado ao ecocardiograma transesofágico (ETE), o EIC é menos sensível para detecção de trombo no apêndice atrial, porém requer mínima sedação e menos operadores, tornando-o atrativo num cenário de recursos restritos. OBJETIVO: Comparar 13 casos de AFA utilizando EIC (grupo AFA-EIC) com 36 casos de AFA utilizando ETE (grupo AFA-ETE). MÉTODO: Trata-se de corte prospectiva realizada em um único centro. O desfecho principal foi o tempo de procedimento. Desfechos secundários tempo de fluoroscopia, dose de radiação (mGy/cm2), complicações maiores e tempo de internação hospitalar em horas. O perfil clínico foi comparado pelo escore CHA2DS2-VASc. Um valor de p <0,05 foi considerado uma diferença estatisticamente significativa entre os grupos. RESULTADOS: A mediana do escore de CHA2DS2-VASc score foi 1 (0-3) no grupo AFA-EIC e 1 (0-4) no grupo AFA-ETE. O tempo total de procedimento foi de 129 ± 27 min grupo AFA-EIC e 189 ± 41 no AFA-ETE (p<0,001); o grupo AFA-EIC recebeu uma dose menor de radiação (mGy/cm2, 51296 ± 24790 vs. 75874 ± 24293; p=0,002), no entanto, o tempo de fluoroscopia em minutos mostrou-se semelhante (27,48 ± 9,79 vs. 26,4 ± 9,32; p=0,671). As medianas do tempo de hospitalização não se mostraram diferentes, 48 (36-72) horas (AFA-EIC) e 48 (48-66) horas (AFA-ETE) (p=0,27). CONCLUSÃO: Nesta coorte, AFA-EIC foi relacionado a menores tempos de procedimento e menor exposição à radiação, sem aumentar o risco de complicações ou o tempo de internação hospitalar.

Electrophysiological study as a predictor of mortality in unexplained syncope.

Background: Electrophysiological study can help in the diagnosis of arrhythmic syncope. According to the electrophysiological study finding, the prognosis of patients with syncope is still a matter of study. Objective: The aim of this study was to assess the survival of patients undergoing electrophysiological study according to their findings and to identify clinical and electrophysiological independent predictors of all-cause mortality. Methods: A retrospective cohort study included patients with syncope who underwent electrophysiological study from 2009 to 2018. A Cox logistic regression analysis was performed to identify independent prognostic factors for all-cause mortality. Results: We included 383 patients in our study. During a mean follow-up of 59 months, 84 (21.9%) patients died. The split His group had the worst survival compared with the control group, followed by sustained ventricular tachycardia and HV interval ≥ 70 ms, respectively (p = .001; p < .001; p = .03). The supraventricular tachycardia group showed no differences compared with the control group (p = .87). In the multivariate analysis, independent predictors of all-cause mortality were Age (OR 1.06; 1.03-1.07; p < .001); congestive heart failure (OR 1.82; 1.05-3.15; p = .033); split His (OR 3.7; 1.27-10.80; p = .016); and sustained ventricular tachycardia (OR 1.84; 1.02-3.32; p = .04). Conclusion: Split His, sustained ventricular tachycardia, and HV interval ≥ 70 ms groups had worse survivals when compared to the control group. Age, congestive heart failure, split His, and sustained ventricular tachycardia were independent predictors for all-cause mortality.

UltraSound guided PEripheral Catheterization increases first-atTempt success RAte in hospitalized patients when compared with conventional technique: SPECTRA - Randomized Clinical Trial.

BACKGROUND: Peripheral intravenous catheter (PIVC) insertion is the most common invasive procedure in the hospital setting. Ultrasound guided PIVC insertion in specific populations and settings has shown patient care benefits. OBJECTIVE: To compare the success rate of first attempts of ultrasound guided PIVC insertion performed by nurse specialists with conventional PIVC insertion performed by nurse assistants. METHOD: Randomized, controlled, single-center clinical trial registered on the ClinicalTrials.gov platform under registration NTC04853264, conducted at a public university hospital from June to September 2021. Adult patients hospitalized in clinical inpatient units with an indication for intravenous therapy compatible with a peripheral venous network were included. Participants in the intervention group (IG) received ultrasound guided PIVC performed by nurse specialists from the vascular access team, while those in the control group (CG) received conventional PIVC by nurse assistants. RESULTS: The study included a total of 166 patients: IG (n = 82) and CG (n = 84), mean age 59.5 ± 16.5 years, mostly women (n = 104, 62.7%) and white (n = 136, 81.9%). Success rate on the first attempt of PIVC insertion in IG was 90.2% and in CG was 35.7% (p < 0.001), with a relative risk of 2.5 (95% CI 1.88-3.40) for success in IG versus CG. Overall assertiveness rate was 100% in IG and 71.4% in CG. Regarding procedure performance time, the medians in IG and CG were 5 (4-7) and 10 (6-27.5) min respectively (p < 0.001). As for the incidence of negative composite outcomes, IG had lower rates compared to CG, 39% versus 66.7% (p < 0.001), generating a 42% lower probability of negative outcomes in IG, 0.58 (95% CI: 0.43-0.80). CONCLUSION(S): Successful first-try insertion was higher in the group receiving ultrasound-guided PIVC. Moreover, there were no insertion failures and IG presented lower insertion time rates and incidence of unfavorable outcomes.

Non-Invasive Assessment of Cardiodynamics by Impedance Cardiography during the Six-Minute Walk Test in Patients with Heart Failure. / Avaliação Cardiodinâmica Não Invasiva por Cardiografia de Impedância durante o Teste de Caminhada de Seis Minutos em Pacientes com Insuficiência Cardíaca.

BACKGROUND: Central Illustration: Non-Invasive Assessment of Cardiodynamics by Impedance Cardiography during the Six-Minute Walk Test in Patients with Heart Failure. The six-minute walk test (6MWT) is commonly used to evaluate heart failure (HF) patients. However, several clinical factors can influence the distance walked in the test. Signal-morphology impedance cardiography (SM-ICG) is a useful tool to noninvasively assess hemodynamics. OBJECTIVE: This study aimed to compare cardiac output (CO), heart rate (HR), and stroke volume (SV) acceleration and deceleration responses to 6MWT in individuals with HF and reduced ejection fraction (HFrEF) and healthy controls. METHODS: This is a cross-sectional observational study. CO, HR, SV and cardiac index (CI) were evaluated before, during, and after the 6MWT assessed by SM-ICG. The level of significance adopted in the statistical analysis was 5%. RESULTS: Twenty-seven participants were included (13 HFrEF and 14 healthy controls). CO and HR acceleration significantly differed between groups (p<0.01; p=0.039, respectively). We found significant differences in SV, CO and CI between groups (p<0.01). Linear regression showed an impaired SV contribution to CO change in HFrEF group (22.9% versus 57.4%). CONCLUSION: The main finding of the study was that individuals with HFrEF showed lower CO and HR acceleration values during the submaximal exercise test compared to healthy controls. This may indicate an imbalance in the autonomic response to exercise in this condition.

FUNDAMENTO: Figura Central: Avaliação Cardiodinâmica Não Invasiva por Cardiografia de Impedância durante o Teste de Caminhada de Seis Minutos em Pacientes com Insuficiência Cardíaca. O Teste de Caminhada de seis Minutos (TC6M) é comumente usado para avaliar pacientes com insuficiência cardíaca. No entanto, vários fatores clínicos podem influenciar a distância percorrida pelos pacientes no teste. A cardiografia de impedância (CI) na avaliação morfológica é uma ferramenta útil para avaliar a hemodinâmica cardíaca de maneira não invasiva. OBJETIVO: Este estudo teve como objetivo comparar as respostas de aceleração e desaceleração do Débito Cardíaco (DC), da Frequência Cardíaca (FC), e do Volume Sistólico (VS) ao TC6M de indivíduos com insuficiência cardíaca e fração de ejeção reduzida (ICFEr) com as de controles sadios. MÉTODOS: Este é um estudo transversal observacional. O DC, a FC, o VS e o Índice Cardíaco (IC) foram avaliados antes, durante e após o TC6M por CI. O nível de significância adotado na análise estatística foi 5%. RESULTADOS: Foram incluídos 27 participantes (13 com ICFEr e 14 controles sadios). A aceleração do DC e da FC foi significativamente diferente entre os grupos (p<0,01 e p=0,039, respectivamente). Encontramos diferenças significativas no VS, no DC e no IC entre os grupos (p<0,01). A regressão linear mostrou uma contribuição deficiente do VS à mudança no DC no grupo com ICFEr (22,9% versus 57,4%). CONCLUSÃO: O principal resultado deste estudo foi o fato de que indivíduos com ICFEr apresentaram valores mais baixos de aceleração do DC e da FC durante o teste de exercício submáximo em comparação a controles sadios. Isso pode indicar um desequilíbrio na resposta autonômica ao exercício nessa condição.

Anthropometric measurements and their association with endothelial function and arterial stiffness of eutrophic individuals and with overweight

ABSTRACT Objective: The objective of the study was to assess the association of anthropometric measurements with endothelial function and arterial stiffness of eutrophic individuals and with overweight. Subjects and methods: A cross-sectional study was carried out with individuals with body mass index (BMI) between 18.5 kg/m² and < 30 kg/m², low to intermediate global cardiovascular risk scores, and aged ≥ 18 and < 60 years. We assessed the sociodemographic data, anthropometric variables (body weight, height, circumferences of the waist [WC], neck [NC], hip [HC], sagittal abdominal diameter [SAD], [BMI], waist-to-hip ratio [WHR], and waist-to-height ratio [WHtR]), biochemical parameters (lipid profile and nitric oxide), endothelial function (flow-mediated dilation [FMD], by ultrasound), and arterial stiffness (pulse wave velocity [PWV] and the amplification index [AIx@75] by oscillometry). Thirty-six individuals were included, 18 eutrophic and 18 with overweight, with a mean age of 37.5 ± 10.2 years, mostly at low cardiovascular risk (86.1%), female (80.6%), single (52.8%), employed with formal contracts (44.4%), and with over twelve years of education (88.9%). Results: The PWV presented positive and moderate correlation with the WC (r = 0.584; P = 0.001), WHR (r = 0.513; P = 0.001), and WHtR (r = 0.590; P = 0.001), and positive and low correlation with the NC (r = 0.372; P = 0.013) and SAD (r = 0.356; P = 0.033). Moreover, no anthropometric parameter presented a correlation with the AIx@75 or the FMD percentage in the total sample. Conclusion: Our findings show that in eutrophic individuals and with overweight the WC, WHR, WHtR, SAD, and NC were positively correlated with the PWV but not to the endothelial function in the overall sample. These are hypothesis-generating findings and they should be replicated in other studies.

Ablação da Fibrilação Atrial: Impacto da Ecocardiografia Intracardíaca na Redução do Tempo de Procedimento e Internação / Atrial Fibrillation Ablation: Impact of Intracardiac Echocardiography in Reducing Procedure Time and Hospitalization

Resumo Fundamento O ecocardiograma intracardíaco (EIC) permite visualizar estruturas cardíacas e reconhecer complicações durante a ablação da fibrilação atrial (AFA). Comparado ao ecocardiograma transesofágico (ETE), o EIC é menos sensível para detecção de trombo no apêndice atrial, porém requer mínima sedação e menos operadores, tornando-o atrativo num cenário de recursos restritos. Objetivo Comparar 13 casos de AFA utilizando EIC (grupo AFA-EIC) com 36 casos de AFA utilizando ETE (grupo AFA-ETE). Método Trata-se de corte prospectiva realizada em um único centro. O desfecho principal foi o tempo de procedimento. Desfechos secundários tempo de fluoroscopia, dose de radiação (mGy/cm2), complicações maiores e tempo de internação hospitalar em horas. O perfil clínico foi comparado pelo escore CHA2DS2-VASc. Um valor de p <0,05 foi considerado uma diferença estatisticamente significativa entre os grupos. Resultados A mediana do escore de CHA2DS2-VASc score foi 1 (0-3) no grupo AFA-EIC e 1 (0-4) no grupo AFA-ETE. O tempo total de procedimento foi de 129 ± 27 min grupo AFA-EIC e 189 ± 41 no AFA-ETE (p<0,001); o grupo AFA-EIC recebeu uma dose menor de radiação (mGy/cm2, 51296 ± 24790 vs. 75874 ± 24293; p=0,002), no entanto, o tempo de fluoroscopia em minutos mostrou-se semelhante (27,48 ± 9,79 vs. 26,4 ± 9,32; p=0,671). As medianas do tempo de hospitalização não se mostraram diferentes, 48 (36-72) horas (AFA-EIC) e 48 (48-66) horas (AFA-ETE) (p=0,27). Conclusão Nesta coorte, AFA-EIC foi relacionado a menores tempos de procedimento e menor exposição à radiação, sem aumentar o risco de complicações ou o tempo de internação hospitalar.

Abstract Background Intracardiac echocardiography (ICE) allows visualization of cardiac structures and recognition of complications during atrial fibrillation ablation (AFA). Compared to transesophageal echocardiography (TEE), ICE is less sensitive to detecting thrombus in the atrial appendage but requires minimal sedation and fewer operators, making it attractive in a resource-constrained setting. Objective To compare 13 cases of AFA using ICE (AFA-ICE group) with 36 cases of AFA using TEE (AFA-TEE group). Methods This is a single-center prospective cohort study. The main outcome was procedure time. Secondary outcomes: fluoroscopy time, radiation dose (mGy/cm2), major complications, and length of hospital stay in hours. The clinical profile was compared using the CHA2DS2-VASc score. A p-value <0.05 was considered a statistically significant difference between groups. Results The median CHA2DS2-VASc score was 1 (0-3) in the AFA-ICE group and 1 (0-4) in the AFA-TEE group. The total procedure time was 129 ± 27 min in the AFA-ICE group and 189 ± 41 min in the AFA-TEE group (p<0.001); the AFA-ICE group received a lower dose of radiation (mGy/cm2, 51296 ± 24790 vs. 75874 ± 24293; p=0.002), despite the similar fluoroscopy time (27.48 ± 9. 79 vs. 26.4 ± 9.32; p=0.671). The median length of hospital stay did not differ; 48 (36-72) hours (AFA-ICE) and 48 (48-66) hours (AFA-TEE) (p=0.27). Conclusions In this cohort, AFA-ICE was related to shorter procedure times and less exposure to radiation without increasing the risk of complications or the length of hospital stay.

Risk Factors Associated with Ischemic Stroke in the Immediate Postoperative Period of Cardiac Surgery

ABSTRACT Introduction: Stroke remains a major complication of cardiac surgery. Despite all efforts, the incidence of postoperative stroke remains as high as 6%. We aimed to investigate risk factors for ischemic stroke in a contemporary cohort of patients undergoing cardiac surgery. Methods: This is a retrospective cohort study of 678 consecutive adult patients who underwent cardiac surgery requiring cardiopulmonary bypass in a tertiary hospital in Brazil between July 1, 2011, and December 31, 2018. The primary outcome was the rate of early (perioperative and seven-day postoperative) stroke, defined as the occurrence of the outcome during the index admission. We developed a predictive model of stroke using the Poisson regression analysis with robust variance. Results: Postoperative stroke occurred in 24 patients (3.5%), 23 (3.3%) were ischemic, and 21 (3.0%) were diagnosed in the first 72 hours after surgical procedure. After multivariate analysis, the following factors were significantly associated with stroke: previous stroke/transient ischemic attack (relative risk [RR]=2.75; 95% confidence interval [CI], 1.11-6.82), carotid artery disease (RR=4.0; 95% CI, 1.43-11.0), previous atrial fibrillation (RR=3.26, 95% CI, 1.31-8.1), and postoperative platelets > 200,000/mm3 (RR=2.26; 95% CI, 1.01-5.1). Conclusion: We developed a contemporary model to determine risk predictors for stroke after cardiac surgery. This model may help clinicians to identify patients at risk and could be useful in clinical practice.

Impact of the left common ostium following pulmonary vein isolation in AF: Systematic review and meta-analysis.

Purpose: Pulmonary vein isolation (PVI) through catheter ablation is the basis for the treatment of atrial fibrillation (AF). The left common ostium (LCO) is a high prevalence anatomical variation and has conflicting results in the effects on the prognosis following ablation. We undertook a systematic review and meta-analysis of studies that compared the arrhythmia recurrence rate after radiofrequency ablation or cryoablation balloon between patients with normal pattern pulmonary vein and patients with LCO. Methods and Results: Results were pooled using a fixed or random effect, at the discretion of heterogeneity (>25%), in addition, we associated subgroup analysis in these cases and when clinically indicated. Fourteen non-randomized studies totaling 3278 patients were included. In analyses using the two energies all patients: OR 1.01 (95% CI 0.84-1.23; P = .90, I 2 = 67%) and excluding patients with any type of persistent AF (PeAF) and those submitted to linear atrial lesion (LAL) OR 0.80 (95% CI 0.52-1.22; P = .30, I 2 = 71%). Using CRYO: all patients OR 1.34 (95% CI 1.03-1.74; P = .03, I 2 = 0%). Using RF: all patients-OR 0.55 (95% CI 0.32-0.95; P = .03, I 2 = 49%); excluding studies with long duration PeAF and the performance of LAL concomitant-OR 0.45 (95% CI 0.23-0.91; P = .03, I 2 = 44%). Conclusion: The results suggest a better prognosis in patients with LCO, submitted to PVI without additional LAL under RF energy in paroxysmal AF and short-duration PeAF. In patients undergoing CRYO, the presence of LCO suggests a worse prognosis.