Renal failure as a determinant of mortality after cardiac transplantation.

INTRODUCTION: Patients with heart failure frequently develop renal failure, which increases the mortality rate among patients undergoing cardiac transplantation. PURPOSE: To determine whether preoperative renal function influenced postoperative mortality in cardiac transplantation recipients. MATERIALS AND METHODS: The measurements of plasma urea, plasma creatinine, and 24-hour creatinine clearance in patients who underwent cardiac transplantation were correlated with mortality at 30, 90, and 365 days after the procedure, using Student t test for continuous variables and the chi-square test for categorical variables. RESULTS: All variables correlated with mortality, particularly plasma creatinine at 30, 90, and 365 days (P =.029,.003, and.0029, respectively). CONCLUSION: Preoperative renal failure is a mortality indicator in cardiac transplantation recipients.

Renal Failure as a Determinant of Mortality After Cardiac Transplantation

Introduction. Patients with heart failure frequently develop renal failure, which increasesthe mortality rate among patients undergoing cardiac transplantation.Purpose. To determine whether preoperative renal function influenced postoperativemortality in cardiac transplantation recipients.Materials and Methods. The measurements of plasma urea, plasma creatinine, and 24-hour creatinine clearance in patients who underwent cardiac transplantation werecorrelated with mortality at 30, 90, and 365 days after the procedure, using Student t test for continuous variables and the chi-square test for categorical variables.Results. All variables correlated with mortality, particularly plasma creatinine at 30, 90,and 365 days (P .029, .003, and .0029, respectively).Conclusion. Preoperative renal failure is a mortality indicator in cardiac transplantation recipients.

Programas supervisionados em reabilitaçào cardiovascular - abordagem de prescriçäo de exercício / Supervised programs in cardiovascular rehabilitation - approach to exercise prescription

Nas últimas décadas, a prática de exercícios físicos tem sido estimulada entre sadios e pacientes cardíacos. Os programas de reabilitaçäo cardíaca têm objetivos profiláticos e terapêuticos. Classicamente, esses programas säo divididos em 3 fases. A Fase I é dirigida para pacientes hospitalizados, convalescendo de infarto agudo do miocárdio ou pós-cirurgia cardiovascular visando evitar os efeitos negativos do repouso prolongado no leito, o retorno mais breve às atividades cotidianas, diminuir o impao psicológico e evitar complicaçöes pulmonares; os tipos de exercício para essa fase säo leves, graduais e individualizados. na Fase II é feita a estratificaçäo de risco (alto, médio e baixo): os de alto risco seräo orientados como os de Fase I e os demais fazem exercícios acima de 5 METs, 3 a 4 vezes por semana, em sessöes de 30 a 60 minutos. Os programas podem ser supervisionados ou näo. As contra-indicaçöes devem ser observadas. Na Fase III procede-se à avaliaçäo do consumo de oxigênio pelo teste caripulmonar para estabelecer o limiar anaeróbico e programa a instensidade de exercício, que deve ficar a 70 por cento da capacidade aeróbia máxima. como há linearidade entre o consumo de oxigênio e a frequência cardíaca, a contagem do pulso serve para determinar o limite de exercício. Cada sessäo deve durar de 30 a 60 minutos, 3 a 4 vezes por semana, observando-se o aquecimento, o estímulo e o desaquecimento. As reavaliaçöes devem ser feitas a cada 6 meses, quando poderäo ser reprogramados os exercícios.

Seleçäo de candidato a receptor: indicaçöes e contra-indicaçöes do transplante cardíaco / Heart transplantation recipients selection: indication and contraindication criteria

A crescente demanda por transplantes do coraçäo e a escassez de órgäos, a par dos bons resultados que vêm sendo obtido, exigem cada vez maior critério na seleçäo dos candidatos. O procedimento está indicado em pacientes com insuficiência cardíaca grave, refratária à terapêutica otimizada, em portadores de cardiopatia näo-suscetível de cirurgia conservadora. Säo contra-indicaçöes absolutas: infecçäo ativa, sorologia positiva para HIV, neoplasia atual ou passada näo seguramente controlada, hipertensäpulmonar grave, úlcera péptica ativa, diabete melito dependente de insulina com lesäo em órgäos-alvo, embolia ou infarto pulmonar recente (menos de 3 meses), disfunçäo renal e/ou hepática irreversível, perfil psicológico/psiquiátrico desfavorável, condiçäo associada que limite a expectativa de vida, alcoolismo ou toxicomania e condiçäo socioeconômica inadequada. Säo contra-indicaçöes relativas: idade igual ou superior a 70 amos, diabete melito sem lesäo de órgäo-alvo, moradia distante do centro de translnte, disfunçäo renal e/ou hepática transitória, peso corporal elevado, doença crônica incurável, doença neurológica ou vascular central ou periférica, amiloidose, diverticulose. A priorizaçäo de pacientes na lista de espera deve obedecer aos críterios de justiça e potencial de benefícios.

Cuidados com o candidato a doador e critérios de seleçäo / Care with the donor candidate and selection criteria

O sucesso do transplante cardíaco depende, fundamentalmente, do receptor bem selecionado e do doador em bom estado orgânico. Além dos cuidados iniciais, a orientaçäo é para que, sempre que possível, seja realizada a operaçäo com receptor e doador em salas contíguas (lado a lado), seja evitado doador em peso inferior (até 10 por cento) ao do receptor, sejam evitadas pressöes elevadas e cirurgia cardíaca prévia no receptor. A busca de órgäos à distância fica para recptor com regime pressórico baixo artéria pulmonar. O diagnóstico de coma encefálico dever ser feito por meio de carotidoangiografia, demostrando ausência de fluxo sanguíneo encefálico; provas sorológicas negativas säo imprescindíveis para a realizaçäo do transplante, assim como a identidade ABO com o recptor. De rpreferência, näo usar drogas vasoativas (dopamina) no doador; se necessário, näo ultrapassar a dose de 10 ug/kg/min, mantendo adquados parâmetros de oxigenaçäo pela ventilaçäo mecânica. É necessária administraçäo generosa d íquidos por via endovenosa para evitar a ocorrência de hipovolemia/hipotensäo decorrentes de polúria desencadeada pelo diabete insípido. Quando o doador tem mais de 50 anos de idade ou nos casos em que o doador é do sexo feminino, é importante evitar-se o uso de agentes inotrópicos e que a cirurgia seja realizada no menor tempo isquêmico possível.

[Infective endocarditis in children and adolescents]. / Endocardite infecciosa na infância e adolescência.

PURPOSE: To assess infective endocarditis (IE) predisposing factors, etiologic agents and hospital course in infants and adolescents. METHODS: We Studied 222 patients admitted under compatible IE diagnosis, from 1985 to 1990. The population of this study is fifty patients (23%) under 16 years of age. RESULTS: Rheumatic valvular disease, as predisposing cardiopathy was proeminent within 9 to 16 years of age, markedly Statistical difference when compared to age range of 0 to 8 years (p < 0.05). Among congenital cardiopathies, the most frequent were: interventricular septal defect (26.0%) and tetralogy of Fallot (21.7%). Blood cultures, surgical material or emboli cultures were positive in 35 (70.0%) assessed patients. Streptococcus viridans (45.7%) and Staphylococcus aureus (42.8%) were the etiologic agents most often isolated. It was found that endocarditis by Staphylococcus aureus had mortality rate of 53.3% [(clinical (66.6%) and surgical (44.4%)], (p < 0.05) when compared to those by Streptococcus viridans; with total mortality of 6.2% (no clinical death and 16.6% in the surgical group). Total in-hospital mortality (clinical and surgical) was 26.0% (13 deaths). CONCLUSION: IE in infants and adolescents in this studied population presented Streptococcus viridans responsible for 46.7% of patients with endocarditis and the Staphylococcus aureus for 42.8% were the etiologic agents most often found. Total, clinical and surgical mortality was greater in patients with endocarditis by Staphylococcus aureus when compared with those by Streptococcus viridans. Among the congenital cardiopathies, whether operated on or not, ventricular septal defect and of Fallot's tetralogy were the most involved ones; rheumatic cardiopathy Still remains a significant predisposing factor to infective IE in our country.

[Infective endocarditis in patients with permanent pacemaker]. / Endocardite infecciosa em pacientes com marcapasso definitivo.

Five patients who had permanent pacemaker and infective endocarditis were analyzed. Diagnose was confirmed by a positive blood cultures in all patients and 2 of them had identifiable vegetation in the echocardiogram too. The etiologic agent was Staphylococcus aureus in 3, Staphylococcus epidermidis in 1 and Staphylococcus viridans in 1. Three patients were treated with antibiotics alone: one had no clinical conditions to be operated, one died before surgery and one had good response to antimicrobial therapy alone. Two patients were submitted to antibiotic therapy and surgical removal of the pacemaker system, without complications. It was concluded that the surgical removal of the pacemaker system, as soon as possible, is the choice's therapy.

[Radiologic signal of dehiscence of Starr-Edwards aortic prosthesis]. / Sinal radiológico de deiscência de prótese aórtica de Starr-Edwards.

A male 54 years-old patient with infective endocarditis through Staphylococcus aureus with prosthesis of Starr-Edwards aortic with clinical and echocardiographic signs compatible with dysfunction classified as severe. The x-ray images presented double silhouette of the prosthesis, thus suggesting its partial dehiscence. This case report points out that the detailed analysis of the X-ray may supply relevant data for the diagnosis of one of this complication thus influencing on management and prognosis.

[Myocardial infarction in infective endocarditis]. / Infarto do miocárdio na endocardite infecciosa.

Two patients with chronic valvular heart disease and myocardial infarction were assisted at our hospital. Both of them were febrile and only one had petechiae associated with signs of valvular involvement led to suspicion of infective endocarditis. Although blood cultures were negative, echocardiographic, surgical and anatomopathologic findings were compatible with infective endocarditis. They required cardiac surgery during the acute phase of the infection because they presented progressive hemodynamic deterioration and no satisfactory response to antimicrobial regimen too. One patient died at late follow-up (two weeks after the hospital discharge) and the other survived, but with signs of cardiac failure (class II of NYHA) one year after the procedure.

[Embolomycotic pseudoaneurysm of the common femoral artery in infective endocarditis]. / Pseudoaneurisma embolomicótico da artéria femoral comum na endocardite infecciosa.

A male patient, six years old, with mitral valve endocarditis presented with pseudoaneurysm of the right femoral artery. He was submitted to surgical treatment with reconstruction of the artery with good outcome.

[Information-related changes in attitude to mucocutaneous leishmaniasis of a population from an endemic region of the south of Bahia]. / Mudança do componente cognitivo da atitude de uma população de região endêmica do Sul da Bahia diante da leishmaniose tegumentar.

The mutilant nature of the mucosal form of leishmaniasis can cause alterations in personal relations. To identify the level of understanding of leishmaniasis and the psychological reaction to it patients and houseowners in an endemic area of Bahia were interviewed. Several false beliefs were identified and there was a strong tendency to reject mutilated patients among the population for a false fear of contagion. Possibly future clarification of the real nature of leishmaniasis could change such a negative attitude among the resident population.

[Use of isosorbide-5-mononitrate in acute myocardial infarction]. / Emprego do 5-mononitrato de isossorbida no infarto agudo do miocárdio.

Isosorbide mononitrate in a dose of 20 mg t.i.d. was used in 25 patients admitted few hours after acute myocardial infarction. The following parameters were analysed: systolic and diastolic blood pressure, heart rate, clinical features, and laboratory data. Heart rate and diastolic blood pressure remained unchanged, however systolic blood pressure was slightly reduced (p less than 0.01). There was a reduction in the angina episodes post-AMI. None of the patients included in the study had clinical deterioration or showed infarction extension. There were no changes in laboratory data. After the interruption of the drug, one patient died on the 6th day with acute mitral insufficiency. In conclusion, isosorbide mononitrate can be safely used during an uncomplicated acute myocardial infarction, without the risk of haemodynamic deterioration, and helps to prevent post-infarction angina.

Insuficiência tricúspide provocada por traumatismo fechado do tórax. Relato de um caso / Tricuspid insufficiency caused by closed trauma of the thorax. Report of a case

E apresentado um caso de insuficiencia tricuspide isolada decorrente de traumatismo fechado do torax, em paciente que se mantem assintomatico e nao operado apos 13 anos do evento