Intraoperative evaluation and surgical planning in the hypertrophic cardiomyopathy.

A male, 45 year old patient, with diagnosis of septum hypertrophic cardiomyopathy, having undergone a cardiofibrilator implant in the past. Despite the optimized clinical treatment, he evolved to a progressive clinical deterioration that led to invasive treatment. However, there was not an important gradient in the exit pathway of the left ventricle (EPLV) at the echocardiogram in rest and the challenging test with dobutamine was non conclusive because it did not reach the preconized cardiac frequency. The intraoperative evaluation with a transesophageal echocardiogram using isoproterenol was fundamental for the diagnosis of the EPLV obstruction. The septum myectomy was performed successfully and the patient presented good post-operative evolution.

Avaliação intraoperatória e planejamento cirúrgico na cardiomiopatia hipertrófica / Intraoperative evaluation and surgical planning in the hypertrophic cardiomyopathy / Evaluación intraoperatoria y planeamiento quirúrgico en la cardiomiopatía hipertrófica

Paciente de 45 anos do sexo masculino, com diagnóstico de cardiomiopatia hipertrófica septal assimétrica, tendo sido submetido a implante de cardiodesfibrilador no passado. Apesar do tratamento clínico otimizado, evoluiu com progressiva deterioração clínica suscitando tratamento invasivo. Entretanto, não havia gradiente importante na via de saída do ventrículo esquerdo (VSVE) ao ecocardiograma de repouso e o teste provocativo com dobutamina foi inconclusivo por não atingir a frequência cardíaca preconizada. A avaliação intraoperatória com ecocardiograma transesofágico em uso de isoproterenol foi fundamental no diagnóstico de obstrução da VSVE. A miectomia septal foi realizada com sucesso e o paciente apresentou boa evolução pós-operatória.

A male, 45 year old patient, with diagnosis of septum hypertrophic cardiomyopathy, having undergone a cardiofibrilator implant in the past. Despite the optimized clinical treatment, he evolved to a progressive clinical deterioration that led to invasive treatment. However, there was not an important gradient in the exit pathway of the left ventricle (EPLV) at the echocardiogram in rest and the challenging test with dobutamine was non conclusive because it did not reach the preconized cardiac frequency. The intraoperative evaluation with a transesophageal echocardiogram using isoproterenol was fundamental for the diagnosis of the EPLV obstruction. The septum myectomy was performed successfully and the patient presented good post-operative evolution.

Paciente de 45 años del sexo masculino, con diagnóstico de cardiomiopatía hipertrófica septal asimétrica, habiendo sido sometido a implante de cardiodesfibrilador en el pasado. A pesar del tratamiento clínico optimizado, evolucionó con progresivo deterioro clínico suscitando tratamiento invasivo. Entre tanto, no había gradiente importante en la vía de salida del ventrículo izquierdo (VSVI) al ecocardiograma de reposo y el test provocativo con dobutamina fue inconclusivo por no alcanzar la frecuencia cardíaca preconizada. La evaluación intraoperatoria con ecocardiograma transesofágico en uso de isoproterenol fue fundamental en el diagnóstico de obstrucción de la VSVI. La miectomía septal fue realizada con éxito y el paciente presentó buena evolución postoperatoria.

Síndrome metabólica secundária / Secondary metabolic syndrome

A síndrome metabólica é composta de vários achados clínicos e laboratoriais,incluindo: obesidade central, resistência à insulina, hipertensão arterial,aumento de triglicérides, redução de HDL-colesterol e um estado pró-inflamatório e pró-trombótico. Neste artigo foram revisados os efeitos metabólicos descritos secundários a doenças, medicamentos e estilos de vida. A resistência à insulina pode prover umaúnica hipótese para as diversas e complexas alterações metabólicas e bioquímicas presentes na obesidade e no diabetes. A doença renal é acompanhada de alterações características do metabolismo lipídico, as quais refletem primariamente alterações do perfil das lipoproteínas, mais que a elevação plasmática dos níveis lipídicoso A hipercolesterolemia no hipotireoidismo é composta pelo aumento de LDL-colesterol e da apolipoproteína B, decorrente da redução do "clearance" de LDL pelodecréscimo do número de receptores hepáticos para a LDL. Hormônios com propriedades progestogênicas e androgênicas, imunossupressores, esteróides hormonais,alguns anti-hipertensivos e alcoolismo são potencialmente aterogênicos. Inibidores da protease usados no tratamento de indivíduos HIV-positivos estão associados a obesidade central, dislipidemia e resistência à insulina. Adicionalmente são discutidas as diretrizes que sugerem várias abordagens terapêuticas que podem ser eficazes para a redução do risco cardiovascular nos pacientes com distúrbios metabólicos secundários, tais como mudanças do estilo de vida ou da terapêutica indutora das alterações metabólicas e uso de agentes farmacológicos, como ácido acetilsalicílico, anti-hipertensivos e redutores de colesterol.

Relation between the behaviors of P-wave and QT dispersions in elderly patients with heart failure.

OBJECTIVE: To assess the relation between P-wave and QT dispersions in elderly patients with heart failure. METHODS: Forty-seven elderly patients (75.6+/-6 years) with stable heart failure in NYHA functional classes II or III and with ejection fractions of 37+/-6% underwent body surface mapping to analyze P-wave and QT dispersions. The degree of correlation between P-wave and QT dispersions was assessed, and P-wave dispersion values in patients with QT dispersion greater than and smaller than 100 ms were compared. RESULTS: The mean values of P-wave and QT dispersions were 54+/-14 ms and 68+/-27 ms, respectively. The correlation between the 2 variables was R=0.41 (p=0.04). In patients with QT dispersion values > 100 ms, P-wave dispersion was significantly greater than in those with QT dispersion values < 100 ms (58+/-16 vs 53+/-12 ms, p=0.04 ). CONCLUSION: Our results suggest that, in elderly patients with heart failure, a correlation between the values of P-wave and QT dispersions exists. These findings may have etiopathogenic, pathophysiologic, prognostic, and therapeutic implications, which should be investigated in other studies.

Relaçäo entre os comportamentos das dispersões da onda P e o intervalo QT em idosos com insuficiência cardíaca / Relation between the behaviors of P-wave and QT dispersions in elderly patients with heart failure

OBJECTIVE - To assess the relation between P-wave and QT dispersions in elderly patients with heart failure. METHODS - Forty-seven elderly patients (75.6±6 years) with stable heart failure in NYHA functional classes II or III and with ejection fractions of 37±6 percent underwent body surface mapping to analyze P-wave and QT dispersions. The degree of correlation between P-wave and QT dispersions was assessed, and P-wave dispersion values in patients with QT dispersion greater than and smaller than 100 ms were compared. RESULTS - The mean values of P-wave and QT dispersions were 54±14 ms and 68±27 ms, respectively. The correlation between the 2 variables was R=0.41 (p=0.04). In patients with QT dispersion values > 100 ms, P-wave dispersion was significantly greater than in those with QT dispersion values < 100 ms (58±16 vs 53±12 ms, p=0.04 ). CONCLUSION - Our results suggest that, in elderly patients with heart failure, a correlation between the values of P-wave and QT dispersions exists. These findings may have etiopathogenic, pathophysiologic, prognostic, and therapeutic implications, which should be investigated in other studies