Percutaneous occlusion of patent foramen ovale in patients with paradoxical embolism.

INTRODUCTION: A patent foramen ovale can be found in about one quarter of adults and in a small percentage it is a wide opening and may be associated with aneurysmal formation. The association between a wide patent foramen ovale and paradoxical embolism is well established. In such cases percutaneous closure is indicated, as an alternative to life-long anticoagulant therapy or surgery. Percutaneous closure is an attractive technique and is more advantageous than other methods. METHODOLOGY: We describe the first cases of percutaneous occlusion of patent foramen ovale performed in Portugal, using the Amplatzer PFO occluder, in three female patients with documented cerebrovascular accidents due to paradoxical embolism. We also analyze the rationale for using this technique in such patients and its preliminary results. RESULTS: All three patients submitted to percutaneous occlusion of patent foramen ovale had a similar history of ischemic cerebrovascular accident. Transesophageal echocardiography showed a wide-open foramen ovale ranging from 9 to 12 mm, with spontaneous right-to-left shunt in all patients, and one of them also had an aneurysmal formation. Total procedure time ranged from 30 to 55 minutes and fluoroscopic time from 9 to 12 minutes. There were no complications and during the short follow up all patients are asymptomatic and free of recurrent events. CONCLUSIONS: Percutaneous closure of patent foramen ovale is a safe and promising technique in the prevention of recurrent systemic thromboembolism in appropriately selected patients. Prospective studies comparing antithrombotic therapy or surgery with percutaneous closure should clarify its efficacy and therapeutic value.

Early and medium term results of tailored therapy for heart failure.

UNLABELLED: Patients (pts) with advanced chronic heart failure, in NYHA functional class IV, refractory to conventional medical therapy, show a poor short-term survival prognosis. Heart transplant remains the therapy of choice but it can currently be performed in only a minority of pts. Therapy tailored to hemodynamic goals has been suggested as a potential alternative for patients with advanced congestive heart failure. Intravenous and, subsequently, oral vasodilators (v) and diuretics (d) are titrated, in order to achieve specific hemodynamic parameters: systolic arterial pressure (SAP) > 80 mmHg, pulmonary wedge pressure (PWP) < 15 mmHg, right atrial pressure (RAP) < 8 mmHg, and systemic vascular resistance (SVR) < 1200 dynes.sec.cm-5. AIM: To assess short and medium term (two years) results of a tailored therapy management program for treatment of patients with advanced heart failure. METHODS: 27 pts (19 males, 61 +/- 10 years), NYHA functional class IV, with dilated cardiomyopathy (13 idiopathic, 10 ischemic, 4 hypertensive), 17 with exclusion criteria for heart transplantation, were included. Echocardiographic left ventricular end-diastolic dimension and ejection fraction were 68 +/- 8 mm and 20 +/- 9%, respectively. Initial (i) serum sodium (Na+) was 136 +/- 5 mEq/l and i serum creatinine (Cr) was 1.4 +/- 0.8 mg/dl. Baseline, at referral, hemodynamics: SAP = 125 +/- 23, PWP = 23 +/- 6, RAP = 12 +/- 6, cardiac index (CI) = 1.9 +/- 0.5 l/min/m2, SVR = 2193 +/- 670. Using bedside right heart catheterization (Swan-Ganz catheter) we set out to achieve the above hemodynamic goals. RESULTS: 1) v and d used: sodium nitroprusside--cumulative dose = 196 +/- 121 mg, captopril--daily dose (dd) = 157 +/- 95 mg, isosorbide dinitrate--dd = 91 +/- 57 mg, hydralazine--dd = 95 +/- 67 mg, and furosemide--dd = 105 +/- 70 mg; 2) final (f) hemodynamic parameters on tailored therapy: SAP = 109 +/- 20*, PWP = 12 +/- 3*, RAP = 4 +/- 3*, CI = 2.5 +/- 0.6*, SVR = 1317 +/- 340* (*: p < 0.001 vs baseline); 3) duration of invasive monitoring was 3.0 +/- 1.9 days; 4) f Na+ = 134 +/- 5, and f Cr = 1.5 +/- 0.8 (NS vs i); 5) there was one (4%) in-hospital death; functional class of discharged pts: III--4 pts, II--18 pts, I--4 pts; 6) nine pts (35%) died after discharge--three due to refractory heart failure and six (including two potential heart transplant candidates) had sudden death; 7) actuarial survival (Kaplan-Meyer method): at 6 months (m)--80%, 12 m--71%, 18 m--64%, 24 m--55%; 8) after a mean follow-up of 18 +/- 8 m, functional class in survivors was: NYHA IV--2 pts, III--4 pts, II--8 pts, and I--3 pts. CONCLUSIONS: Therapy tailored to hemodynamic goals is a valid approach for pts with advanced heart failure, showing good hemodynamic and functional short-term results, and reasonable survival at two years. The significant incidence of sudden death demands strategies for risk stratification and a search for prophylactic measures in this population.

New criteria for the diagnosis and treatment of atrioventricular node reentrant tachycardia.

The authors describe a new elecrocardiographic criterion to diagnose atrioventricular node reentrant tachycardia, review the electrocardiographic and electrophysiological diagnosis of this tachyarrhythmia and analyse the results of catheter ablation of fast versus slow pathway, selecting the fast pathway whenever the induction of atrioventricular node reentrant tachycardia is performed only after pharmacological maneuvers. The high specificity for atrioventricular node reentrant tachycardia of the criterion characterized by the absence of ST-segment depression found in left precordial leads from V4 to V6 suggests the need to include it in electrocardiographic algorithms for the differential diagnosis of tachycardias with a narrow QRS complex. The high primary and final success rates of catheter ablation obtained after a therapy stratification based on induction criteria, emphasize the use of the fast pathway ablation as a first option in selected cases and for the treatment of recurrences.

Nonpharmacological treatment of atrial tachycardia.

The authors analyse the efficacy and safety of catheter ablation and atrial pacing for the treatment of atrial tachycardia. Radiofrequency catheter ablation was selected whenever the arrhythmogenic focus was located on the free-wall or in the meso-septal area of the right atrium. In opposition, overdrive atrial pacing was chosen for tachycardias originating near the sinus complex or in the left atrium. Both therapies were safe, but had a low efficacy in converting the tachycardia into sinus rhythm. However, catheter ablation allows an irreversible destruction of small septally located foci. Thus, both the anatomical and the electrophysiological characteristics of the foci can be important factors in the selection of the most appropriate nonpharmacologic therapy.

[The use of Abciximab in patients with acute myocardial infarction undergoing direct percutaneous coronary revascularization]. / Utilização de Abciximab em doentes com enfarte agudo do miocárdio submetidos a angioplastia coronária directa.

OBJECTIVE: To evaluate the initial experience, in our Centre, with Abciximab in patients with acute myocardial infarction undergoing direct percutaneous transluminal coronary angioplasty (PTCA). METHODS: Between October 1996 and May 1998, 65 patients (51 males, mean age 56.9 +/- 11 years) underwent direct PTCA for acute myocardial infarction. In thirty-seven patients the myocardial infarction was anterior and 40 had multivessels disease. Mainly to compare the incidence of bleeding complications we considered 2 groups: Group A--17 patients submitted to PTCA without the use of Abciximab, and Group B--48 patients submitted to PTCA and to a bolus followed by a 12 hour infusion of Abciximab. All the patients were treated with aspirin and heparin (5,000 to 15,000 U according to ACT) and ticlopidine in case of stent implantation. RESULTS: Percutaneous coronary revascularization was successfully achieved in 92.3% of the patients. The total number of bleeding complications was ten cases (20.8%) in Group B and 1 case (5.8%) in Group A. Most of the bleeding complications in the Abciximab Group were minor and related to the femoral vascular access site (9 cases--18.7%) and were easily resolved with local measures (8 cases). There were also 3 cases of hematemesis and one of oral bleeding, all well tolerated. Major bleeding complications were identified in only one patient of the Abciximab Group related to the vascular access site, however there was an absolutely similar case in Group A (2% versus 5.8%). CONCLUSIONS: Although bleeding complications were more frequent in patients receiving Abciximab, mostly related to the vascular access site, they were transient and well tolerated.

[Pulmonary thromboembolism angiographically confirmed: clinical and prognostic aspects]. / Tromboembolismo pulmonar com confirmação angiográfica: aspectos clínicos e prognósticos.

OBJECTIVE: The aim of this study was to evaluate the clinical profile and prognosis of patients with an angiographically proven thromboembolism. METHODS: Data from 22 consecutive patients (13 males, 9 females; mean age 57.3 +/- 16.8 years) with pulmonary embolism confirmed by pulmonary angiography were reviewed. All our patients were previously submitted to non-invasive diagnostic procedures (blood examinations, EKG, chest x-ray, echocardiography). A V/Q scan was also performed in 5 patients. Fourteen patients were traditionally treated with heparin alone and the rest received thrombolytic therapy and heparin. Two patients had a thromboembolectomy. At discharge, all our patients were submitted to an oral anticoagulant therapy. The mean duration of the follow-up period was 26 +/- 12 months. RESULTS: The majority of the patients were in the 6th decade of life and it was possible to identify a hypercoagulable state in 82%. The most common symptom at the time of presentation was sudden chest pain (64%). The most specific sign in non-invasive procedures were right side cardiac dilatation seen echocardiographically (73%) and the mismatch in the V/Q scan (80%). The most common haemodynamic parameter (91%) observed in the right heart catheterization of these patients was the finding of a gradient between diastolic pulmonary artery and pulmonary capillary wedge pressures. Uneventful angiography was performed in all patients who showed massive pulmonary embolism (86%). Three patients (13.6%) died during the acute phase. At the end of the follow-up period, 10 patients were asymptomatic and 5 had heart failure. Four died, which corresponds to an overall mortality of 31.8% in 2.2 years of follow-up. None of the clinical or haemodynamic parameters analyzed (age, gender, arterial blood gases at presentation, hypercoagulable states, thrombolysis, pulmonary hypertension and extension of the embolism) were related to mortality. CONCLUSION: Angiographically confirmed pulmonary thromboembolism is still a poor outcome situation, even when a lot of diagnostic and therapeutic procedures are available.

[Should all patients with ventricular pre-excitation of the Wolff-Parkinson-White syndrome type undergo catheter ablation?]. / Devem todos os doentes com pré-excitação ventricular do tipo Wolff-Parkinson-White realizar ablação por cateter?

The authors make a concise review concerning clinical, electrocardiographic and electrophysiologic risk stratification in Wolff-Parkinson-White syndrome and present the results of radiofrequency catheter ablation of atrioventricular accessory pathways. The low sensitivity of electrophysiologic criteria for the identification of a high risk profile limits their use in asymptomatic patients with a low incidence of sudden death. The greater risk of ventricular fibrillation in symptomatic patients makes radiofrequency catheter ablation the treatment of choice for these patients. Therefore, the authors do not recommend an electrophysiologic risk stratification in Wolff-Parkinson-White syndrome, but emphasize that catheter ablation should be performed in all symptomatic patients.

[The nonpharmacological treatment of atrial fibrillation]. / Tratamento não-farmacológico da fibrilhação auricular.

The authors describe the main forms of nonpharmacological treatment of atrial fibrillation considering catheter ablation and surgical therapy. A new methodology to modify atrioventricular conduction is discussed as well its long-term results. All studies are non-randomised with selected patients, which makes the development of a therapeutical algorithm difficult. However, the results have shown that it is possible to recover sinus rhythm through surgery or catheter ablation and to control the ventricular rate either by His ablation or modification of atrioventricular conduction.

[A structural analysis of the entrance exams for specialist interns from 1994 to 1996]. / Análise estrutural dos exames de ingresso nos internatos complementares de 1994 a 1996.

In order to obtain specialist training in Portugal, doctors must pass a multiple-choice examination. The aim of this article is to present a structural and mathematical analysis of the examinations in the last three years. We based our work on the calculation of reliability coefficient of the examinations, and the difficulty and discrimination index of the questions and the examinations as a whole. A detailed analysis of the examinations, including that of each of the three hundred questions, will be published by the Department of Health Manpower in January, 1997.

[A review of infectious endocarditis due to Candida]. / Revisão de endocardite infecciosa a cândidas.

OBJECTIVE: As fungal endocarditis is a serious disease, frequently requiring cardiac surgery, a review was made of the experience of our Departments in this pathology. DESIGN: A retrospective analysis of clinical, echocardiographic and surgical data. SETTING: Patients studied in a tertiary care Hospital with cardiac surgery available. PATIENTS: Between 1984 and 1994 there were ten cases of candida endocarditis in nine patients, four male and five female, mean age--45 +/- 12 years (31-65). INTERVENTIONS: The following parameters were analysed: clinical (predisposing factors, clinical evolution, complications, therapy and mortality), echocardiographic (presence of vegetations, abscesses, valvular regurgitations). Patients studied in other Centres and referred to our Department only for examination (echocardiograms) were excluded from this analysis. RESULTS: Eight cases in seven patients were prosthetic valve endocarditis and two native valve endocarditis. No patient was drug addicted. Seven cases of prosthetic valve endocarditis developed less than one year after surgery and another had a gynecological fungal infection as the cause of the endocarditis. Four patients had had previous endocarditis. There were four embolic events and three developed heart failure. There were three perivalvular infections, six valvular regurgitations and only one case with huge vegetations on echocardiography. Nine patients were treated with amphotericin B, in five fluocytosin was added and in four ketoconazol, which was replaced by flukonazol in one patient. Therapy was continued for at least eight weeks. Six patients were operated during the acute stage and one died. One patient was operated on late after the infection. Three patients died during the active stage. In a follow up of 5.2 +/- 4.8 years (8 months to 8 years) there was one fatal candida endocarditis relapse, one fatal candida sepsis, one non cardiac death, one patient developed a periprosthetic leak and one had recurrent systemic embolization. Abscesses/pseudoaneurysms were found in five out of seven patients submitted to surgery. CONCLUSION: Candida infective endocarditis has a bad prognosis, specially in those patients not operated early; it develops in patients with predisposing factors, which in our series were a previous infective endocarditis (four patients) and/or a prosthetic valve implantation less than one year before; it has important morbidity with multiple embolic events, perivalvular involvement, valvular regurgitation and heart failure.

[Significance of the exercise test in the assessment of graft patency after myocardial revascularization with arteries only]. / Importância da prova de esforço na avaliação da permeabilidade dos enxertos após revascularização miocárdica com utilização exclusiva de artérias.

UNLABELLED: Although treadmill exercise testing (TET) has been used to identify ischaemia and determine clinical prognosis after myocardial revascularization, considerable controversy remains on its role in the detection of obstructive lesions of the arterial grafts. AIM: To assess the value of TET in determining the patency of arterial conduits after coronary bypass surgery with complete revascularization. METHODS: Twenty five patients - 21 men and 4 women; age 53.7 +/- 8.7 years - submitted to complete myocardial revascularization exclusively with arterial conduits (CABG-A), undergoing coronary angiography and a symptomlimited TET (Bruce protocol) within 9 months after CABG-A. Angiograms were visually classified in 2 groups (Group I - conduits without lesions, n = 14; Group II > 50% stenosis or occlusion of > or = 1 conduit, n = 11). Clinical characteristics and the following parameters of the TET were compared: total exercise time (ETime); metabolic equivalents (METS); % of predicted maximal heart rate (% MHR); exercise-induced ST depression (decreases ST); and occurrence of angina. The arterial conduits used were: left internal mammary artery -24-; right internal mammary artery -11-; gastroepiploic artery -14-. RESULTS: There were no differences in age, gender, left ventricular systolic function, severity of coronary artery disease, and number of conduits per patient. Group I attained superior values for the following parameters: ETime (p < 0.01) and METS (p < 0.01). Among Group II there were more patients with angina (p = 0.03). Fourteen patients exceeded 8 METS (11 from Group I and 3 from Group II - p = 0.002-). There was no statistical difference among the number of patients with ST depression during exercise. CONCLUSIONS: After CABG-A the exercise tolerance seems to be related with the patency of the conduits and may play an important role in the detection of graft abnormalies. On the contrary, exercise-induced ST depression had low specificity in detecting obstructive lesions of the conduits.