Ocorrência de distúrbios de condução e implante de marca-passo definitivo em pacientes submetidos a TAVI com abordagem minimalista / Occurrence of conduction disorders and permanent pacemaker implantation in patients undergoing TAVI with a minimalist approach

INTRODUÇÃO: O surgimento de distúrbios de condução e a necessidade de implante de marca-passo (MP) definitivo estão entre as complicações mais comuns relacionadas ao TAVI. Na aplicação do TAVI minimalista - em que se objetiva alta hospitalar oportuna < 48 horas - tais complicações são de central importância, e sua ocorrência deve ser monitorada sistematicamente. OBJETIVO: Avaliar a prevalência de alterações eletrocardiográficas sabidamente preditoras de distúrbios de condução após TAVI e a incidência de MP definitivo em até 30 dias após o procedimento, em pacientes (pctes) não-selecionados submetidos a TAVI minimalista em um hospital terciário do SUS. MÉTODOS: Estudo observacional e prospectivo, com inclusão de pctes consecutivos submetidos a TAVI minimalista no período de Set/2020 a Jan/2022, com análise do ECG antes e após a TAVI conforme protocolo institucional. Verificado a presença de alterações de ritmo e bloqueios atrioventriculares (BAV) e intraventriculares e a indicação de MP definitivo durante a internação e um mês após a alta hospitalar. RESULTADOS: Foram avaliados 50 pctes, com média de idade de 79,2 anos, com STS médio de 2,64% e 20 (40%) mulheres. Próteses balão-expansíveis foram utilizadas mais frequentemente (76%). O ritmo e distúrbios de condução antes da TAVI encontrados foram: • Ritmo sinusal: 41 (82%) • Fibrilação atrial: 12 (24%) • BAV 1 grau: 14 (28%) • Bloqueio de ramo direito: 3 (6%) • Bloqueio de ramo esquerdo: 7 (14%) • Ritmo de MP: 4 (8%) A ocorrência de bradiarritmias que justificassem monitorização estendida e vigilância intra-hospitalar por ao menos 24 horas ocorreu em 7 (14%) pcts, sendo: • Bloqueio atrioventricular total: 1 (2,5%) • Bloqueio atrioventricular avançado: 1 (2,5%) • Fibrilação atrial de baixa resposta ventricular: 2 (5%) • Ritmo juncional: 2 (5%) • Bradicardia sinusal e distúrbio de condução intraventricular: 1 (2,5%) Houve indicação de MP definitivo para 1 (2,5%) pcte. Não houve reinternação devido a distúrbios de condução ou implante de MP até 30 dias após a TAVI. CONCLUSÃO: Em nossa experiência, poucos pctes submetidos a TAVI com estratégia minimalista apresentaram distúrbios de condução necessitaram postergar a alta hospitalar. Apenas um paciente requereu implante de MP definitivo. A aplicação de protocolo institucional com alta hospitalar oportuna (<48h) não esteve relacionada à maior risco de distúrbios de condução em curto prazo (30 dias).

Percutaneous closure of atrial septal defects. The role of transesophageal echocardiography.

PURPOSE: Evaluation of the role of transesophageal echocardiography in percutaneous closure of atrial septal defects (ASD) with the Amplatzer septal occluder. METHODS: Patients were selected for percutaneous closure of ASD by transesophageal echocardiography (TEE), which was also used to monitor the procedure, helping to select the appropriate size of the Amplatzer device, to verify its position, and to access the immediate results of the procedure. During the follow-up, TEE was used to evaluate the presence and magnitude of residual shunt (RS), device position, and right cardiac chamber diameters. RESULTS: Twenty-two (40%) of a total of 55 studied patients were selected. Thirteen underwent Amplatzer device implantation, eight are still waiting for it, and one preferred the conventional surgical treatment. All procedures were successful, which was mainly due to proper patient selection. Six (23%) patients acutely developed RS, which spontaneously disappeared at the three-month follow-up examination in three patients. There was a significant reduction in the right ventricle diastolic diameter, from 27 mm (average) to 24 mm and 20 mm, one and three months after the procedure, respectively (p < 0.0076). CONCLUSION: With the aid of TEE, percutaneous closure of ASD can be successfully, safely, and effectively performed.

[Initial experience in percutaneous closure of interatrial communication with the amplatzer device]. / Experiência inicial no fechamento percutâneo da comunicação interatrial com a prótese de Amplatzer.

PURPOSE: To evaluate our initial experience with percutaneous closure of secundum type atrial septal defects (ASD) with the Amplatzer septal occluder. METHODS: Seven patients underwent occlusion by anterograde approach, under general anesthesia and transesophageal echocardiography (TEE) guidance. One child had 2 ASD and a patent ductus arteriosus (PDA). The ASD size ranged from 8.7 to 20 mm as measured by TEE. A transthoracic echocardiogram was performed in the morning after the procedure. RESULTS: Eight devices were successfully implanted in 7 patients and the PDA was occluded with a Gianturco coil at the same session. In this patient, there was an episode of supraventricular tachycardia during the occlusion of one ASD which was reverted with adenosin. All patients were discharged the day after, with complete occlusion of all defects. CONCLUSION: The procedure is safe, effective and versatile. It can be applied as an initial alternative to the treatment of selected patients with ASD.

[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.

[Infectious endocarditis in a drug addict]. / Endocardite infecciosa em toxicômanos.

PURPOSE: To compare two groups of patients with infective endocarditis, the drug addicts and non-drug addicts. We attempted to set particularities among the various aspects that involve the patient with endocarditis, due to the concurrent chronic use of cocaine intravenously. METHODS: Twenty nine patients, group B, whose clinical diagnose was compatible with infective endocarditis, with risk factor of parenteral toxicomania by cocaine were treated at Institute "Dante Pazzanese de Cardiologia" and Hospital "Emilio Ribas" in São Paulo, from 1984 to 1990. The data obtained for etiological agents, previous cardiac pathology, affected heart structures, affected heart side and clinical-surgical evolutions of group B were compared to group A (193 patients), which was also composed of patients with endocarditis, without chronic endovenous use of cocaine antecedent. The data obtained were analysed comparatively according to the chi square with Yates correction. RESULTS: Male gender (89.7%) was predominate in group B towards group A (57.0%); (p < 0.01). Previous cardiopathy, either congenital or acquired, as antecedent proning to endocarditis, was found in 89.1% of patients in group A, significantly higher than 17.2% of patients group B (p < 0.001). Staphylococcus aureus was the most frequent agent, which accounted for endocarditis of group B in 86.4% of the cases, significantly higher when compared to 23.9% of cases of group A (p < 0.01). Streptococcus viridans was the most frequent etiological agent for endocarditis of group A (44.8%), significantly higher than group B (4.5%), (p < 0.01). In concern to the affected structures, the tricuspid valve was most affected in group B (65.5%), significantly higher than group A (4.7%) p < 0.001. The mitral valve was significantly more affected in group A (45.1%) in comparison to group B (6.9%), (p < 0.05). In group A 82 patients (42.5%) required surgical treatment and this occurred in 3 patients of group b (10.3%), (p < 0.05). No significant statistical difference was found as for the general mortality (clinical and surgical) in both groups. CONCLUSION: a) presence of previous cardiac disease was lower suggesting permanent contamination blood flow by pathologic agents, mainly of those found in the skin as S. aureus; b) right side of the heart is most frequently affected, specially the tricuspid valve even without previous damage.

[Meningitis and other neurological complications in infectious endocarditis]. / Meningite e outras complicações neurológicas na endocardite infecciosa.

PURPOSE: To study the localization, etiological agents and the respective prognosis in patients with infective endocarditis with or without neurological complications, with emphasis on the association of endocarditis and meningitis. METHODS: 222 patients with clinical, echocardiographic and laboratory diagnosis of infective endocarditis were treated at Instituto Dante Pazzanese de Cardiologia from 1985 to 1990. They were classified in two groups: group A-116 patients without neurological complications, ages 4 months-76 (mean 30) years old and 66.3% males. group B-56 patients with neurological complication, ages 1-71 (mean 31) years old and 46.4% males. A third group, group C, comprised 17 patients, ages 8-51 (mean 23.7) years old and 9 patients (52.9%) male, assisted at Hospital Emilio Ribas, which is specialized at infectious diseases, which presented meningitis as the unique manifestation of neurological complication associated to the diagnosis of infective endocarditis (IE). In all patients the diagnosis of IE was based on the presence of at least two of three essential findings: echocardiogram with vegetations or valvar dysfunctions, positive hemocultures and the compatible clinical picture. For the comparative analysis among the groups was employed through the chi-square test corrected according to Yates. RESULTS: No differences of sex and age of the patients were found among the three groups. Predominated the Staphylococcus aureus as etiological agent. The localization of cardiac lesions was similar in the three groups, except for the tricuspid valve affected in 16.3% of patients of group A and 2.3% of group B. There was a greater association of the structures on the left side of the heart with IE of group B (p < 0.05). Group B and C showed a general mortality rate greater than group A (p < 0.001). CONCLUSION: Meningitis and other neurological complications showed interrelationship between the presence of "Staphylococcus aureus" as etiological agent of endocarditis and the association with infection of the left heart side.

[The importance of the early diagnosis of infectious endocarditis in an aortic prosthesis by transesophageal two-dimensional Doppler echocardiography]. / Importância do diagnóstico precoce de endocardite infecciosa em prótese aórtica pela ecodopplercardiografia bidimensional transesofágica.

A female patient, 21 years old, was submitted to surgical treatment of severe aortic insufficiency. She was doing well until the 9th postoperative day, when she presented sepsis and an embolic cerebrovascular attack. The transesophageal echo-Doppler-cardiogram showed paraprosthetic abscess and vegetations, that were not seen on the transthoracic echo-Doppler-cardiogram performed one day before. We are convinced that the findings on the echocardiogram were very important for the good results obtained by the prompt surgical procedure.

[Infective endocarditis. Prospective Doppler-echocardiographic study]. / Endocardite infecciosa. Estudo Doppler-echocardiográfico prospectivo.

PURPOSE: To study of the Doppler-echocardiographic aspects in patients with IE and its correlation with the prognosis and evolution. PATIENTS AND METHODS: One hundred and eight patients with clinical of IE were prospectively studied by Doppler-echocardiography (D-E) in order to determine whether the simple presence of vegetation, its size, mobility and place of attachment could identify high risk groups. Vegetations were classified according to its size (longest axis) into small (veg less than 5 mm), medium (5 mm less than veg less than 10 mm) and large (veg less than 10 mm); according to its kind into "sessible" or "mobile" and according to its appearence into "cotton like" or "calcified". RESULTS: Patients with (84.2%) and without (15.8%) vegetations didn't show any significant difference in the complications incidence (emboli, heart failure or death) and the same happened with its size. However, patients with aortic positioned vegetations showed ligher incidence of HF (Aortic 53.8 x Mitral 31.0% x Tricuspid 3.7%) need for surgery (Aortic 69.2% x Mitral 34.5% x Tricuspid 3.7%) and death (Aortic 30.7% x Mitral 13.7% x Tricuspid 7.4%). Emboli were observed in 81.4% of the patients with tricuspid valve vegetations. Eight patients showed IE on aortic prothesis. Five of them needed surgical treatment and 2 of them died. Among 12 patients with IE on mitral prothesis, 7 needed surgery and 3 died. Pericardial effusion were verified in 51 patients (47.2%), chordal rupture in 14 (12.8%) and valve abcess in 6 (5.5%). All patients with valve abcess were submitted to surgery. CONCLUSION: Doppler-echocardiography is an excellent method in the diagnosis of IE and its aspects may have, sometimes, a positive correlation with the prognosis and patient's evolution.

[Effects of enalapril on left ventricular hypertrophy in patients with mild or moderate essential hypertension]. / Efeitos do enalapril na hipertrofia ventricular esquerda em pacientes com hipertensão essencial leve ou moderada.

PURPOSE: To evaluate the effects of enalapril maleate on the regression of left ventricular hypertrophy (LVH) associated to hypertension. PATIENTS AND METHODS: Fifteen male, age between 45 and 65 years (mean age = 56 y) with diagnosis of mild-to-moderate essential hypertension (greater than diastolic blood pressure [DBP] less than between 90 and 114 mmHg) and LHV at the echocardiogram. The administration of enalapril maleate was initiated with a 20 mg daily dosage and titrated up to a maximum of 40 mg daily, whenever DBP was maintained above 90 mmHg and no adverse experience occurred. RESULTS: Fourteen patients completed the clinical trial and all of them achieved satisfactory blood pressure (BP) control. The dosage of enalapril was 20 mg/day for 11 patients and 40 mg/day for the other three. The mean systolic blood pressure in supine position decreased from an initial value of 151.4 +/- 9.5 to 126.4 +/- 9.4 mmHg at the end of treatment and the mean diastolic blood pressure from 100.0 +/- 5.0 to 80.4 +/- 1.5 mmHg (p less than 0.001). There was a reduction of mean diastolic septal wall thickness from 11.5 +/- 0.05 to 10.1 +/- 0.05 mm and left ventricular posterior wall thickness from 11.2 +/- 0.7 to 9.8 +/- 0.6 mm (p less than 0.05). The diastolic dimension and left ventricular volume did not show significant changes. The mean of calculated left ventricular mass showed a decrease from 263.6 +/- 32.9 to 231.3 +/- 34.7 g at the end of treatment (p less than 0.05). Mean ejection fraction and fractional fiber shortening showed light, but non significant increase. The tolerability to the drug was satisfactory. Two patients complained of transient palpitations and two other, irritative cough, that determined the treatment discontinuation in one case. CONCLUSION: Enalapril maleate 20 to 40 mg daily, besides the satisfactory control of BP in patients with mild-to-moderate essential hypertension, promoted regression of left ventricular hypertrophy, without impairment of left ventricular function.

[Visualization of coronary artery obstructions by echocardiography]. / Visibilização de obstruções em artérias coronárias pela ecocardiografia.

PURPOSE: The purpose of this study was to determine the sensitivity and specificity of 2D ECO in identifying proximal and medial obstruction of the coronary artery. PATIENTS AND METHOD: Sixty five patients with coronary artery disease were studied. In thirty three patients with previous coronary angiography the echocardiographer had knowledge of the topography and the degree of the coronary obstruction (group I) but in thirty two patients he didn't (group II). The mean age of group I was 54.4 years (44 to 76) and the mean age of the group II was 58 years (42 to 74). Two-dimensional echocardiography was performed at short-axis cross-sectional of aortic valve and images were frozen at end-diastole and reject settings were used to best visualize the coronary artery. RESULTS: It was possible to observe by 2D ECO the left main coronary artery in all patients. It was also possible to identify the proximal segment of the three main arteries. The detection of obstruction was overestimated by 2D ECO when it was in the left main coronary artery. In the proximal segment, in group I, the detection of obstruction in LAD, RCA and CXA was 87.5%, 66.6% and 50% and in group II, 77.7%, 100% and 50% respectively. In the medial segment, in group I, the detection of obstruction in LAD and CXA was respectively 100% and 33.3% and in group II, 60% and 75%. These results show that the sensitivity and specificity to detect obstruction was highest in the LAD. The method overestimated the presence of obstruction in the medial segment of RCA in both groups. CONCLUSION: These findings indicate that 2D ECO is a feasible noninvasive method in assessing obstruction of the main coronary arteries with good sensitivity and specificity.