RESUMO
We report on the successful treatment with sildenafil of a unique case of severe chronic thromboembolic pulmonary hypertension which developed as a late complication in a 71-year-old heart transplant recipient, with focus on the potential therapeutic challenges encountered in the management of such a peculiar association of clinical conditions.
Assuntos
Anti-Hipertensivos/uso terapêutico , Transplante de Coração , Hipertensão Pulmonar/tratamento farmacológico , Inibidores da Fosfodiesterase 5/uso terapêutico , Piperazinas/uso terapêutico , Embolia Pulmonar/tratamento farmacológico , Sulfonas/uso terapêutico , Idoso , Anti-Hipertensivos/efeitos adversos , Humanos , Hipertensão Pulmonar/etiologia , Masculino , Inibidores da Fosfodiesterase 5/efeitos adversos , Piperazinas/efeitos adversos , Embolia Pulmonar/fisiopatologia , Purinas/efeitos adversos , Purinas/uso terapêutico , Citrato de Sildenafila , Sulfonas/efeitos adversos , Resultado do TratamentoRESUMO
OBJECTIVES: Cardiac resynchronization therapy (CRT) elicits more beneficial effects on left-ventricular (LV) structure and function, and long-term clinical outcomes in nonischemic heart failure patients. Rates of ß-blocker use in recent heart failure trials are higher than in CRT trials and this may influence the response to CRT. This study examined the long-term effects of CRT on LV structure and function in New York Heart Association class III-IV ß-blocker-treated patients. METHODS: One hundred and four (41 ischemic and 63 nonischemic) CRT patients, who were receiving ß-blockers before and throughout 12 months following device implantation, were retrospectively selected. Variations in echocardiographic parameters recorded before, and 6 and 12 months after CRT were analyzed. RESULTS: Selected patients were all stable on ß-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (97%) and diuretics (97%) before implantation. CRT was associated with significant improvements in LV morphological and systo-diastolic functional parameters at 6 months, with further improvements between 6 and 12 months seen in nonischemic patients only. Accordingly, rates of echocardiographic response to CRT were similar at 6 months but significantly higher in nonischemic patients after 1 year. The degree of reduction in LV diameters and volumes, and of increase in ejection fraction, was significantly larger in nonischemic patients at both 6 and 12 months. In addition, a significant reduction in LV mass and severity of mitral regurgitation was more evident in nonischemic patients both 6 and 12 months following CRT. CONCLUSIONS: Ischemic aetiology of heart failure is associated with less favorable long-term effects of CRT on LV structure and function despite the systematic use of ß-blockers.
Assuntos
Antagonistas Adrenérgicos beta/uso terapêutico , Terapia de Ressincronização Cardíaca , Insuficiência Cardíaca/terapia , Isquemia Miocárdica/complicações , Função Ventricular Esquerda/efeitos dos fármacos , Remodelação Ventricular/efeitos dos fármacos , Idoso , Análise de Variância , Distribuição de Qui-Quadrado , Ecocardiografia Doppler , Feminino , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/tratamento farmacológico , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/fisiopatologia , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/fisiopatologia , Estudos Retrospectivos , Volume Sistólico , Fatores de Tempo , Resultado do TratamentoRESUMO
The impact of left ventricular (LV) diastolic dysfunction on risk of atrial fibrillation (AF) recurrence is still unknown. The aim of this study was to assess the role of LV diastolic dysfunction in predicting AF recurrence after successful electrical cardioversion in patients with nonvalvular AF. In 51 patients with a first episode of nonvalvular AF undergoing successful electrical cardioversion, tissue Doppler echocardiography was performed to measure peak early diastolic mitral annulus velocity (E(m)) and the ratio of mitral inflow to mitral annulus velocity at end-diastole (E/E(m)). Clinical end points were recurrent persistent AF at 2-week follow-up (early AF recurrence [ERAF]) and at 1-year follow-up (including ERAF and late AF recurrence). Seventeen patients showed evidence of ERAF, whereas late AF recurrence occurred in another 5 patients. In time-independent analysis E/E(m) (odds ratio [OR] 1.746, p = 0.0084) and indexed LV end-systolic volume (OR 1.083, p = 0.040) were independent predictors of ERAF. Based on a logistic model risk of ERAF was 25% for an E/E(m) of 5.6 but increased to 50% for an E/E(m) of 8.1 and to 75% for an E/E(m) of 10.5. In time-dependent analysis E/E(m) emerged as the only predictor of ERAF (OR 1.757, p = 0.0078). E/E(m) also independently predicted risk of recurrence at 1 year in time-independent (OR 1.757, p = 0.0078) and time-dependent (OR 1.319, p = 0.0003) analyses. In conclusion LV diastolic dysfunction independently predicts AF recurrence in patients with nonvalvular AF undergoing successful electrical cardioversion.