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1.
Int J Cardiol ; 330: 43-49, 2021 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-33571563

RESUMO

BACKGROUND: Pregnant women with repaired tetralogy of Fallot (rTOF) are at increased risk of adverse outcomes. Although pre-pregnancy pulmonary valve replacement (PVR) may be considered in some women to attenuate risk, published data to support this practice are lacking. Our objective was to explore the impact of pre-pregnancy PVR on pregnancy outcomes in rTOF. METHODS: Women with rTOF and cardiovascular magnetic resonance imaging (CMR) before and after pregnancy were included if CMR studies were completed within 3 years of pregnancy. Subjects were compared according to presence (+) or absence (-) of PVR at pre-pregnancy CMR. Pregnancy outcomes (cardiovascular, obstetric, and fetal/neonatal) were documented. RESULTS: Of the 29 study women identified, 7 were PVR+ and 22 were PVR-. Post-pregnancy, the PVR- group demonstrated interval increase in indexed right ventricular end-diastolic volumes (RVEDVi) (157 ± 28 versus 166 ± 33 ml/m2, p = 0.003) and end-systolic volumes (RVESVi) (82 ± 17 versus 89 ± 20 ml/m2, p = 0.003) as compared with pre-pregnancy, but no significant change in RV ejection fraction, RV mass, or left ventricular measurements. In the PVR+ group, there were no interval changes in RV measurements pre-versus post pregnancy. Interval rate of change in RVESVi of PVR- exceeded PVR+ women (+3.7 ± 5.0 versus -2.2 ± 5.0 ml/m2/year, p = 0.03). Pregnancy outcomes did not differ in PVR+ versus PVR- women. CONCLUSIONS: Pregnancy outcomes did not differ according to PVR status in our cohort. While RV volumes remained unchanged in PVR+ women, interval RV dilation was observed in PVR- women. Additional study of a larger population with longer follow-up may further inform clinical practice regarding pre-pregnancy PVR.

2.
Am J Perinatol ; 2020 Dec 22.
Artigo em Inglês | MEDLINE | ID: mdl-33352586

RESUMO

OBJECTIVE: Guidelines do not exist to determine timing of delivery for women with cardiovascular disease (CVD) in pregnancy. The neonatal benefit of a term delivery as compared with an early term delivery is well described. We sought to examine maternal outcomes in women with CVD who delivered in the early term period (37 + 0 weeks through 38 + 6 weeks) compared with those who delivered later. STUDY DESIGN: This is a prospective cohort study examining cardiac and obstetric outcomes in women with CVD delivering between September 2011 and December 2016. The associations between gestational age at delivery and maternal, fetal, and obstetric characteristics were evaluated. RESULTS: Two-hundred twenty-five women with CVD were included, 83 (37%) delivered in the early term period and 142 (63%) delivered at term. While the early term group had significantly higher rates of any hypertension during pregnancy (18.1 vs. 7%, p = 0.01) and intrauterine growth restriction (22.9% vs. 2.8%, p < 0.001), there was no difference in high-risk cardiac or obstetric characteristics. No difference in composite cardiac morbidity was found (4.8 vs. 3.5%, p = 0.24). Women in the early term group were more likely to undergo cesarean delivery than women in the term group (43.4 vs. 24.7%, p = 0.004). CONCLUSION: There is no maternal benefit of an early term delivery in otherwise healthy women with CVD. Given the known fetal consequences of early term delivery, this study offers support to existing literature suggesting term delivery in these women. KEY POINTS: · Question of delivery timing in women with cardiac disease.. · No difference in cardiac morbidity, term versus early term.. · Term delivery in women with asymptomatic cardiac disease..

3.
Pediatr Cardiol ; 41(8): 1795-1799, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32915291

RESUMO

Increasing numbers of women with repaired tetralogy of Fallot (rTOF) are reaching reproductive age and seek counseling regarding their cardiovascular risks related to pregnancy. Therefore, the aim of this study was to characterize changes in left ventricular (LV) strain in women with rTOF during pregnancy and in the postpartum period. Seventeen pregnancies in women with rTOF were included (mean age at repair = 3.2 years ± 5.5 years; mean age at delivery = 32.7 ± 4 years). Echocardiograms from three time periods were analyzed; baseline (prior to conception or in the first trimester), third trimester, and 4-6 weeks postpartum. Sixty-five percent of the patients had at least mild pulmonary regurgitation. Eight patients (47%) had undergone at least one pulmonary valve replacement. There were no changes in LV ejection fraction (EF) or circumferential strain across the three time periods. Significant differences were present in longitudinal strain within the three time points (p = 0.01). Postpartum strain decreased in magnitude compared to the third trimester value (- 17.7 ± 4.1 vs. - 21 ± 5, p-value = 0.003) but was not different when compared to baseline strain (- 17.7 ± 4.1 vs. - 19.4 ± 3.4; p-value = 0.15). In conclusion, in women with rTOF, changes in longitudinal strain were observed during pregnancy with a return to baseline after delivery; EF did not change. These findings provide evidence that pregnancy does not adversely impact LV mechanics in the short term in this potentially vulnerable patient population.

4.
J Am Heart Assoc ; 9(9): e014820, 2020 05 05.
Artigo em Inglês | MEDLINE | ID: mdl-32342722

RESUMO

Background In adults with acquired heart disease, depression is common and associated with adverse outcomes. Depression may also be important in adults with congenital heart disease (CHD). Methods and Results We conducted a cohort study of outpatients with CHD, aged ≥18 years, enrolled in a prospective biobank between 2012 and 2017. Clinical data were extracted from medical records. Survival analysis assessed the relationship between depression, defined by a history of clinical diagnosis of major depression, with all-cause mortality and a composite outcome of death or nonelective cardiovascular hospitalization. A total of 1146 patients were enrolled (age, 38.5±13.8 years; 49.6% women). Depression had been diagnosed in 219 (prevalence=19.1%), and these patients were more likely to have severely complex CHD (41.3% versus 33.7%; P=0.028), cyanosis (12.1% versus 5.7%; P=0.003), and worse functional class (≥II; 33.3% versus 20.4%; P<0.0001), and to be taking antidepressant medication at time of enrollment (68.5% versus 5.7%; P<0.0001). Depression was associated with biomarkers indicative of inflammation (hsCRP [high-sensitivity C-reactive protein], 1.71 [25th-75th percentile, 0.82-4.47] versus 1.10 [0.45-2.40]; P<0.0001) and heart failure (NT-proBNP [N-terminal pro-B-type natriuretic peptide], 190 [92-501] versus 111 [45-264]; P<0.0001). During follow-up of 605±547 days, 137 participants (12.0%) experienced the composite outcome, including 33 deaths (2.9%). Depression was associated with increased risk for both all-cause mortality (multivariable hazard ratio, 3.0; 95% CI, 1.4-6.4; P=0.005) and the composite outcome (multivariable hazard ratio, 1.6; 95% CI, 1.1-2.5; P=0.025), adjusting for age, sex, history of atrial arrhythmia, systolic ventricular function, CHD complexity, and corrected QT interval. Conclusions In adults with CHD, major depression is associated with impaired functional status, heart failure, systemic inflammation, and increased risk for adverse outcomes.

5.
Am J Cardiol ; 125(6): 977-981, 2020 03 15.
Artigo em Inglês | MEDLINE | ID: mdl-31959431

RESUMO

The rationale for timing of pulmonary valve replacement (PVR) in patients with repaired Tetralogy of Fallot (rTOF) has focused on pre-PVR threshold values of indexed right ventricular end-diastolic volume (RVEDVi) that lead to normalization of right ventricular (RV) size after valve implantation. The goal of this study was to determine whether persistent RV dilation after PVR is associated with adverse clinical outcomes. Subjects with rTOF who underwent PVR and had a cardiac magnetic resonance (CMR) exam after valve implantation at a single center from 2001 to 2017 were included. The composite clinical outcome after PVR included: death, aborted sudden cardiac death, sustained ventricular tachycardia (VT), or NYHA class ≥3. In 189 rTOF subjects, the mean age at PVR was 23.5 ± 11.7 years, median follow-up was 6.0 years (IQR 3.4 to 8.7), and the primary outcome occurred in 14 subjects (7%). The 5- and 10-year event-free rates were 97% and 91%, respectively. Post-PVR RVEDVi was not associated with the composite outcome (p = 0.59). Independent predictors of the outcome were older age at PVR (hazard ratios [HR] 1.06; 95% confidence interval [CI] 1.02 to 1.11; p = 0.004), post-PVR lower RV ejection fraction (HR 0.91; 95% CI 0.86 to 0.97; p = 0.002), and post-PVR atrial tachyarrhythmia (HR 7.60, 95% CI 1.65 to 35.05, p = 0.009). Our study shows that post-PVR RV dilation as measured by CMR-derived RVEDVi was not associated with the composite adverse clinical outcome in this cohort. These findings challenge the validity of current guidelines for PVR, which are based on pre-procedural threshold values of RVEDVi aimed at achieving normal post-procedural RV volumes.


Assuntos
Implante de Prótese de Valva Cardíaca , Complicações Pós-Operatórias/diagnóstico , Valva Pulmonar/cirurgia , Tetralogia de Fallot/cirurgia , Disfunção Ventricular Direita/diagnóstico , Dilatação Patológica/diagnóstico , Dilatação Patológica/mortalidade , Seguimentos , Humanos , Complicações Pós-Operatórias/mortalidade , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/mortalidade , Tetralogia de Fallot/mortalidade , Resultado do Tratamento , Disfunção Ventricular Direita/mortalidade
6.
Am J Obstet Gynecol ; 222(1): 77.e1-77.e11, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31310750

RESUMO

BACKGROUND: Although consensus guidelines on the management of cardiovascular disease in pregnancy reserve cesarean delivery for obstetric indications, there is a paucity of data to support this approach. OBJECTIVE: The objective of the study was to compare cardiovascular and obstetric morbidity in women with cardiovascular disease according to the plan for vaginal birth or cesarean delivery. STUDY DESIGN: We assembled a prospective cohort of women delivering at an academic tertiary care center with a protocolized multidisciplinary approach to management of cardiovascular disease between September 2011 and December 2016. Our practice is to encourage vaginal birth in women with cardiovascular disease unless there is an obstetric indication for cesarean delivery. We allow women attempting vaginal birth a trial of Valsalva in the second stage with the ability to provide operative vaginal delivery if pushing leads to changes in hemodynamics or symptoms. Women were classified according to planned mode of delivery: either vaginal birth or cesarean delivery. We then used univariate analysis to compare adverse outcomes according to planned mode of delivery. The primary composite cardiac outcome of interest included sustained arrhythmia, heart failure, cardiac arrest, cerebral vascular accident, need for cardiac surgery or intervention, or death. Secondary obstetric and neonatal outcomes were also considered. RESULTS: We included 276 consenting women with congenital heart disease (68.5%), arrhythmias (11.2%), connective tissue disease (9.1%), cardiomyopathy (8.0%), valvular disease (1.4%), or vascular heart disease (1.8%) at or beyond 24 weeks' gestation. Seventy-six percent (n = 210) planned vaginal birth and 24% (n = 66) planned cesarean delivery. Women planning vaginal birth had lower rates of left ventricular outflow tract obstruction, multiparity, and preterm delivery. All women attempting vaginal birth were allowed Valsalva. Among planned vaginal deliveries 86.2% (n = 181) were successful, with a 9.5% operative vaginal delivery rate. Five women underwent operative vaginal delivery for the indication of cardiovascular disease without another obstetric indication at the discretion of the delivering provider. Four of these patients tolerated trials of Valsalva ranging from 15 to 75 minutes prior to delivery. Adverse cardiac outcomes were similar between planned vaginal birth and cesarean delivery groups (4.3% vs 3.0%, P = 1.00). Rates of postpartum hemorrhage (1.9% vs 10.6%, P < .01) and transfusion (1.9% vs 9.1%, P = .01) were lower in the planned vaginal birth group. There were no differences in adverse cardiac, obstetric, or neonatal outcomes in the cohort overall or the subset of women with high-risk cardiovascular disease or a high burden of obstetric comorbidity. CONCLUSION: These findings suggest that cesarean delivery does not reduce adverse cardiovascular outcomes and lend support to a planned vaginal birth for the majority of women with cardiovascular disease including those with high-risk disease.


Assuntos
Cesárea/métodos , Parto Obstétrico/métodos , Cardiopatias , Complicações Cardiovasculares na Gravidez , Adulto , Arritmias Cardíacas , Cardiomiopatias , Doenças do Tecido Conjuntivo , Doença da Artéria Coronariana , Gerenciamento Clínico , Extração Obstétrica/métodos , Feminino , Cardiopatias Congênitas , Doenças das Valvas Cardíacas , Humanos , Hemorragia Pós-Parto/epidemiologia , Gravidez , Estudos Prospectivos , Manobra de Valsalva
7.
J. Health Biol. Sci. (Online) ; 7(1): 64-74, jan.-mar. 2019.
Artigo em Português | LILACS | ID: biblio-1005498

RESUMO

Introdução: a anomalia congênita é uma malformação na estrutura ou função que estão presentes no nascimento e durante o pré-natal. Estima-se que, todos os anos, 303.000 recém-nascidos morrem nas primeiras 4 semanas de nascimento devido a anomalias congênitas. Objetivo: discutir sobre a enfermagem no contexto familiar na prevenção de anomalias congênitas. Método: trata-se de uma revisão integrativa da literatura com busca de artigos nas bases de dados Medline, Lilacs, Scielo. Foram incluídos artigos disponíveis na íntegra, online, e gratuitos, publicados entre 2006 a 2017. Artigos de revisão foram desconsiderados, e artigos duplicados foram considerados apenas uma vez. Resultados: a busca inicial resultou em 405 estudos, dos quais 18 foram incluídos nesta revisão. Os artigos selecionados abordam o tema anomalias congênitas com foco no rastreamento e na prevenção. Os achados referiram intervenções de enfermagem a gestante e a família como: consulta de enfermagem, planejamento familiar, educação em saúde a família e a comunidade, acompanhamento por equipe multidisciplinar bem como orientações quanto à suplementação com ácido fólico, exposições a fatores internos e externos, a vacinação preventiva e ao rastreamento genético entre outros. Conclusão: o pré-natal e o planejamento familiar são de suma importância à prevenção e ao rastreamento de anomalias congênitas. A enfermagem pode contribuir com o aconselhamento genético, consultas de enfermagem e apoio emocional e visitas domiciliares no momento do diagnóstico de anomalia congênita e durante a adaptação da família nesse novo contexto. Para isso, a capacitação profissional é indispensável.


Introduction: congenital anomaly is a malformation in the structure or function that are present at birth and during the pre-natal care. It is estimated that every year, 303,000 newborns die within the first four weeks of birth due to congenital anomalies. Objective: Discuss about nursing in the family context in the prevention of congenital anomalies. Method: It is an integrative literature review to search for articles in the databases Medline, Lilacs, Scielo. Articles are available in full online, and toiletries published from 2006 to 2017 were included. Review articles were disregarded, and duplicated articles were considered only once. Results: The initial search resulted in 405 studies, of which 18 were included in this review. The selected articles addressing the topic congenital anomalies with focus on screening and prevention. The findings reported nursing interventions for maternal and family as: nursing consultation, family planning, health education in the family and the community, monitoring by the multidisciplinary team as well as guidelines regarding supplementation with folic acid, exposures to internal and external factors, the preventive vaccination and the genetic screening among others. Conclusion: The prenatal care and family planning are of paramount importance in the prevention and screening for congenital anomalies. Nurses can contribute to the genetic counseling, nursing consultations and emotional support and visits at


Assuntos
Anormalidades Congênitas , Cuidados de Enfermagem , Gravidez de Alto Risco , Serviços de Planejamento Familiar
8.
Circulation ; 134(11): 780-92, 2016 Sep 13.
Artigo em Inglês | MEDLINE | ID: mdl-27559041

RESUMO

BACKGROUND: Patients with diabetes mellitus (DM) are at increased risk of atherothrombotic events, underscoring the importance of effective platelet inhibiting therapies. Prasugrel and ticagrelor reduce thrombotic complications to a greater extent than clopidogrel. Subgroup analyses of pivotal clinical trials testing prasugrel and ticagrelor versus clopidogrel showed DM patients to have benefits that were consistent with the overall trial populations, although the magnitude of the ischemic risk reduction appeared to be enhanced with prasugrel. Whether these findings may be attributed to differences in the pharmacodynamic profiles of these drugs in DM patients remains poorly explored and represented the aim of this study. METHODS: In this prospective, randomized, double-blind, double-dummy, crossover pharmacodynamic study, aspirin-treated DM patients (n=50) with coronary artery disease were randomly assigned to receive prasugrel (60 mg loading dose [LD]/10 mg maintenance dose once daily) or ticagrelor (180 mg LD/90 mg maintenance dose twice daily) for 1 week. Pharmacodynamic assessments were conducted using 4 different assays, including VerifyNow P2Y12, vasodilator-stimulated phosphoprotein, light transmittance aggregometry, and Multiplate, which allowed us to explore ADP- and non-ADP-induced (arachidonic acid-, collagen-, thrombin receptor-activating, peptide-induced) platelet signaling pathways. The acute (baseline, 30 minutes, and 2 hours post-LD) and maintenance (1 week) effects of therapy were assessed. The primary end point of the study was the comparison of P2Y12 reaction units determined by VerifyNow P2Y12 at 1 week between prasugrel and ticagrelor. RESULTS: ADP- and non-ADP-induced measures of platelet reactivity reduced significantly with both prasugrel and ticagrelor LD and maintenance dose. P2Y12 reaction units defined by VerifyNow were similar between prasugrel and ticagrelor at 30 minutes and 2 hours post-LD. At 1 week, P2Y12 reaction units were significantly lower with ticagrelor than with prasugrel (52 [32-72] versus 83 [63-103]; least-square means difference: -31; 95% confidence interval, -57 to -4; P=0.022; primary end point). Pharmacodynamic assessments measured by vasodilator-stimulated phosphoprotein, light transmittance aggregometry, and Multiplate were similar between prasugrel and ticagrelor at each time point, including at 1 week. Rates of high on-treatment platelet reactivity were similar between groups with all assays at all time points. CONCLUSIONS: In DM patients with coronary artery disease, ticagrelor exerts similar or greater inhibition of ADP-induced platelet reactivity in comparison with prasugrel in the acute and chronic phases of treatment, whereas the inhibition of measures of non-ADP-induced platelet reactivity was not significantly different between the 2 agents. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01852214.


Assuntos
Adenosina/análogos & derivados , Doença da Artéria Coronariana/tratamento farmacológico , Complicações do Diabetes/tratamento farmacológico , Diabetes Mellitus Tipo 2/tratamento farmacológico , Inibidores da Agregação de Plaquetas , Cloridrato de Prasugrel , Adenosina/administração & dosagem , Adenosina/farmacocinética , Adolescente , Adulto , Idoso , Doença da Artéria Coronariana/sangue , Doença da Artéria Coronariana/etiologia , Estudos Cross-Over , Complicações do Diabetes/sangue , Diabetes Mellitus Tipo 2/sangue , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/administração & dosagem , Inibidores da Agregação de Plaquetas/farmacocinética , Cloridrato de Prasugrel/administração & dosagem , Cloridrato de Prasugrel/farmacocinética , Estudos Prospectivos , Ticagrelor
9.
Am J Cardiol ; 114(7): 1011-7, 2014 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-25118123

RESUMO

Ischemic mitral regurgitation (IMR) is associated with poor outcomes in patients with coronary artery disease. The impact of percutaneous coronary intervention (PCI) on patients with IMR is not well elucidated. We sought to determine the outcomes of patients with severe IMR who underwent PCI. Patients with severe (≥3+) IMR who underwent PCI from 1998 to 2010 were identified. Improvement in IMR was defined as reduction in severity from ≥3+ to ≤2+ without any other invasive intervention beyond PCI. Outcomes were compared between patients with and without improvement in IMR after PCI. One hundred thirty-seven patients with severe IMR were included in our study. After PCI, 50 patients (36.5%) had improvement in IMR with PCI alone and 24 patients (18.5%) required another intervention. Left atrial size was a significant predictor of improvement in IMR (odds ratio 0.39, 95% confidence interval 0.2 to 0.8). Left ventricular size decreased (systolic diameter 3.9±0.3 vs 4.6±0.2 cm, p=0.0008 and diastolic diameter 5.2±0.2 vs 5.7±0.2 cm, p=0.002) and ejection fraction increased (39.1±4.0% vs 33.1±1.9%, p=0.002) significantly after PCI in the patients with improvement in IMR compared with patients without improvement. Patients with improvement in IMR had numerically better survival; however, it was not statistically significant (p log-rank=0.2). In conclusion, 1/3 of the patients with IMR had improvement in severity of IMR with PCI alone. Improvement in IMR was associated with left ventricular reverse remodeling. Left atrial size was an important predictor of improvement in IMR after PCI.


Assuntos
Doença da Artéria Coronariana/cirurgia , Insuficiência da Valva Mitral/complicações , Intervenção Coronária Percutânea , Idoso , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/diagnóstico , Progressão da Doença , Ecocardiografia Doppler , Feminino , Seguimentos , Humanos , Masculino , Insuficiência da Valva Mitral/diagnóstico , Insuficiência da Valva Mitral/mortalidade , Ohio/epidemiologia , Tomografia por Emissão de Pósitrons , Período Pós-Operatório , Prognóstico , Estudos Prospectivos , Índice de Gravidade de Doença , Taxa de Sobrevida/tendências , Fatores de Tempo
10.
Diabetes Res Clin Pract ; 103(3): 452-7, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-24529565

RESUMO

AIMS: To investigate early alterations on bone mineral density (BMD) and RANK, RANKL and OPG mRNA expression in peripheral blood leukocytes (PBL) in children and adolescents with type 1 diabetes (T1D) and the relationship with glycemic control and bone biomarkers. METHODS: This cross-sectional study included 75 children and adolescents with T1D and 100 individuals without diabetes (normoglycemic-NG) aged 6-20 years old. T1D individuals were considered to have good (T1DG) or poor (T1DP) glycemic control according to the values of HbA1c. Phosphorus, magnesium, total and ionized calcium, osteocalcin, alkaline phosphatase and tartaric-resistant acid phosphatase (TRAP) values were determined in blood samples. BMD was measured by DEXA. RANK, RANKL and OPG mRNA expression was measured in PBL by real-time PCR. RESULTS: Osteocalcin values were decreased in diabetic groups in comparison to NG group (p<0.05), and a negative correlation with both serum glucose (r=-0.265, p<0.01) and Hb1Ac (r=-0.252, p<0.01) in T1D group was found. BMD was lower in diabetic groups in comparison with NG group (p<0.05) and a negative correlation was observed between BMD and both serum glucose (r=-0.357, p<0.01) and HbA1c (r=-0.351, p<0.01) in T1D group. OPG mRNA expression was significantly increased in T1D and T1DP groups in comparison with NG group (p<0.05). In conclusion, children and adolescents with early onset T1D presented low bone mineral density associated to unsatisfactory glycemic control, increased OPG mRNA expression and low osteocalcin concentration.


Assuntos
Biomarcadores/sangue , Densidade Óssea , Diabetes Mellitus Tipo 1/fisiopatologia , Hiperglicemia/etiologia , Hipoglicemia/etiologia , Osteoprotegerina/genética , Adolescente , Adulto , Fosfatase Alcalina/sangue , Cálcio/sangue , Estudos de Casos e Controles , Criança , Estudos Transversais , Feminino , Humanos , Hiperglicemia/diagnóstico , Hipoglicemia/diagnóstico , Leucócitos Mononucleares , Masculino , Osteocalcina/sangue , Osteoprotegerina/sangue , Fósforo/sangue , Ligante RANK/sangue , Ligante RANK/genética , RNA Mensageiro/genética , Reação em Cadeia da Polimerase em Tempo Real , Receptor Ativador de Fator Nuclear kappa-B/sangue , Receptor Ativador de Fator Nuclear kappa-B/genética , Reação em Cadeia da Polimerase Via Transcriptase Reversa , Adulto Jovem
11.
Heart Rhythm ; 11(5): 799-805, 2014 May.
Artigo em Inglês | MEDLINE | ID: mdl-24444444

RESUMO

BACKGROUND: It is difficult to predict adverse patient outcomes associated with transvenous lead extraction (TLE) procedures. OBJECTIVE: The purpose of this study was to examine the safety and efficacy of chronic endovascular pacemaker and implantable cardioverter-defibrillator (ICD) lead extraction and risk factors associated with adverse patient outcomes. METHODS: Consecutive patients undergoing TLE at the Cleveland Clinic between August 1996 and August 2011 were included in the analysis. Univariate and multivariable logistic regression analyses were performed to evaluate for associations with outcomes. Continuous data are given as median (25th, 75th percentile). Categorical data are given as number (percentage). RESULTS: In total, 5521 leads (4137 [74.9%] pacemaker, 1384 [25.1%] ICD) were extracted during 2999 TLE procedures (patient age 67.2 [55.2, 76.2] years, 30.2% female). Lead implant duration was 4.7 (2.4, 8.3) years, and 2.0 (1.0, 2.0) leads were extracted per procedure. Powered sheaths were used in 74.9% of procedures. Overall, there was 95.1% complete procedural success, 98.9% clinical success, and 1.1% failure, with 3.6% minor complications and 1.8% major complications. All-cause mortality within 30 days of TLE was 2.2%. Multivariable predictors of major complications included cerebrovascular disease, ejection fraction ≤15%, lower platelet count, international normalized ratio ≥1.2, mechanical sheaths, and powered sheaths. Multivariable predictors of all-cause mortality within 30 days of TLE included body mass index <25 kg/m(2), end-stage renal disease, higher New York Heart Association functional class, lower hemoglobin, higher international normalized ratio, lead extraction for infection, and extraction of a dual-coil ICD lead. CONCLUSION: TLE in this single-center experience was highly successful. Risk factors associated with adverse patient outcomes were identified.


Assuntos
Desfibriladores Implantáveis , Remoção de Dispositivo/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Marca-Passo Artificial , Complicações Pós-Operatórias/epidemiologia , Idoso , Remoção de Dispositivo/métodos , Falha de Equipamento , Feminino , Seguimentos , Cardiopatias/terapia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Ohio/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Resultado do Tratamento
12.
Heart Rhythm ; 10(10): 1444-50, 2013 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-23816440

RESUMO

BACKGROUND: Comparative safety and efficacy associated with transvenous lead extraction (TLE) of recalled and non-recalled implantable cardioverter-defibrillator (ICD) leads has not been well characterized. OBJECTIVES: To compare the indications, techniques, and procedural outcomes of recalled vs non-recalled ICD lead extraction procedures. METHODS: TLE procedures performed at our institution from June 2002 to June 2012 in which Riata, Sprint Fidelis, or non-recalled ICD leads were extracted were included in the analysis. RESULTS: ICD lead extraction procedures were performed in 1079 patients, including 430 patients with recalled leads (121 Riata, 308 Sprint Fidelis, and 1 Riata and Sprint Fidelis) and 649 patients with non-recalled ICD leads. A total of 2056 chronic endovascular leads were extracted, of which 1215 (59.1%) were ICD leads. Overall, there was 96.8% complete procedural success, 99.1% clinical success, and 0.9% failure, with 3.9% minor complications and 1.5% major complications. Procedural outcomes for Riata and Sprint Fidelis TLE procedures were no different. Lead implant duration was significantly less in recalled than in non-recalled ICD lead TLE procedures. Complete procedural success was higher in recalled (424 of 430 [98.6%]) than in non-recalled (621 of 649 [95.7%]; P = .007) ICD lead TLE procedures. Minor complications were lower in recalled (10 of 430 [2.3%]) than in non-recalled (32 of 649 [5.0%]; P = .030) ICD lead TLE procedures. Rates of clinical success, failure, and major complications were no different in the recalled and non-recalled ICD lead TLE procedures. CONCLUSION: In our experience, recalled ICD leads were extracted with safety and efficacy comparable to that of non-recalled ICD leads.


Assuntos
Cateterismo Cardíaco , Desfibriladores Implantáveis , Remoção de Dispositivo , Taquicardia/terapia , Idoso , Desenho de Equipamento , Falha de Equipamento , Feminino , Humanos , Masculino , Recall de Dispositivo Médico , Pessoa de Meia-Idade , Seleção de Pacientes , Estudos Retrospectivos , Resultado do Tratamento
13.
J Interv Card Electrophysiol ; 37(1): 41-6, 2013 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-23263895

RESUMO

OBJECTIVES: We sought to identify the characteristics, treatment, and outcomes of periprocedural cerebrovascular accident (PCVA) during electrophysiologic (EP) procedures. BACKGROUND: Periprocedural cerebrovascular accident is one of the most feared complications during EP procedures with very few data regarding its characteristics, management, and outcomes. METHODS: Between January 1998 and December 2008, we reviewed 30,032 invasive EP procedures for PCVA occurrence and characteristics. Management and outcomes were also determined. RESULTS: Thirty-eight CVAs were identified. Twenty (53 %) were intraprocedural and 18 (47 %) postprocedural. Thirty-two (84 %) were classified as strokes and six (16 %) as transient ischemic attacks. All CVAs except one (37, 97 %) were ischemic and the vast majority occurred during ablation procedures (36, 95 %). Among the 31 patients with ischemic stroke, 11 (35 %) were treated with reperfusion (eight catheter-based therapy and three intravenous t-PA) of whom five (46 %) had complete recovery, three (27 %) had partial recovery, and three (27 %) had no recovery. No hemorrhagic transformations occurred. CONCLUSION: Periprocedural cerebrovascular accident during EP procedures is rare and is almost always ischemic. It occurs more frequently during ablation procedures. Reperfusion therapy is feasible and safe.


Assuntos
Cateterismo Cardíaco/mortalidade , Técnicas Eletrofisiológicas Cardíacas/mortalidade , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/terapia , Idoso , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Ohio/epidemiologia , Estudos Retrospectivos , Medição de Risco , Análise de Sobrevida , Taxa de Sobrevida , Resultado do Tratamento
14.
Braz. j. pharm. sci ; 46(3): 539-549, July-Sept. 2010. ilus, tab
Artigo em Inglês | LILACS | ID: lil-564921

RESUMO

The relationship between lipid peroxidation, antioxidant defense and diabetic osteopenia remains unclear. This study evaluated the relationship among lipid peroxidation index, antioxidant defense parameters and bone metabolism in a premenopausal diabetic model using measures including thiobarbituric acid-reactive substances concentration (TBARS) and reduced glutathione (GSH) content in brain homogenates, histomorphometric analysis, biomechanical testing and bone mineral density (BMD). Female Wistar rats with regular estrous cycle were divided into two groups: Group 1: control rats (n = 15) and Group 2: diabetic rats (n = 15). Diabetes was induced by alloxan and confirmed by glycemia >250 mg/dL. The lipid peroxidation index, measured by TBARS concentration, showed a significant increase (p<0.05) in diabetic animals in comparison to control animals. However, the antioxidant parameter measured by GSH content, was significantly lower (p<0.05) in diabetic animals. Histomorphometric analysis showed a significant increase (p<0.05) in femoral trabecular separation together with a significant decrease (p<0.05) in trabecular thickness, and reduced trabecular bone volume in diabetic rats. Moreover, biomechanical testing and BMD values were significantly lower (p<0.05) in the diabetic group. Thus, our results demonstrated that increased lipid peroxidation and altered antioxidant defense could be related to the development of oxidative stress and diabetic osteopenia in premenopausal rats.


A relação entre peroxidação lipídica, defesa antioxidante e osteopenia diabética permanece obscura. Este estudo avaliou a associação entre índice de peroxidação lipídica, parâmetro de defesa antioxidante e metabolismo ósseo em um modelo diabético pré-menopausa através de medidas como a concentração de substâncias reativas ao ácido tiobarbitúrico (SRAT) e conteúdo de glutationa reduzida (GSH) no homogenato cerebral, análises histomorfométricas, teste biomecânico e densidade mineral óssea (DMO). Ratos Wistar fêmeas com ciclo estral regular foram distribuídos em dois grupos: Grupo 1 - ratas controle (n = 15) e Grupo 2 - ratas diabéticas (n = 15). O diabetes foi induzido pela aloxana e confirmado pela glicemia >250 mg/dL. O índice de peroxidação lipídica, medido pela concentração de SRAT, demonstrou um aumento significativo (p<0.05) nos animais diabéticos, em relação aos animais controle. Entretanto, o parâmetro de defesa antioxidante, mensurado pelo conteúdo de GSH, foi reduzido significativamente (p<0.05) nos animais diabéticos. As análises histomorfométricas mostraram um aumento significativo (p<0.05) da separação trabecular do fêmur, associado à diminuição significativa da espessura trabecular (p<0.05) e volume ósseo trabecular reduzido nas ratas diabéticas. Além disso, o teste biomecânico, medido pela força máxima, e valores de DMO foram reduzidos significativamente (p<0.05) no grupo diabético. Dessa maneira, nossos resultados demonstraram que a peroxidação lipídica aumentada e defesa antioxidante modificada podem estar relacionadas ao desenvolvimento do estresse oxidativo e osteopenia diabética em ratas pré-menopausadas.


Assuntos
Animais , Feminino , Adulto , Ratos , Diabetes Mellitus/induzido quimicamente , Doenças Ósseas Metabólicas/patologia , Estresse Oxidativo , Pré-Menopausa , Epidemiologia Experimental , Ciclo Estral , Peroxidação de Lipídeos
15.
J Bone Miner Metab ; 23(1): 58-68, 2005.
Artigo em Inglês | MEDLINE | ID: mdl-15616896

RESUMO

Although osteopenia has been associated with human diabetes mellitus, the pathogenesis of diabetic osteopenia is unclear. In the present study, we evaluated the effect of diabetes on histomorphometry, bone mineral density (BMD)-measured by dual-energy X-ray absorptiometry (DXA)-and biomarkers of bone metabolism in rats up to 120 days after the onset of experimental diabetes. Female Wistar rats with a regular estrous cycle were randomly divided into two groups: control rats (n = 15) and diabetic rats without insulin treatment (n = 25). Diabetes was induced by injection of alloxan and was confirmed by the determination of blood glucose concentration (>250 mg/dl). The results revealed an approximate threefold increase of femoral trabecular distance in diabetic rats compared to controls. Conversely, trabecular thickness and bone trabecular volume were reduced twofold and 77%, respectively. BMD in both the metadiaphyseal region and total area of the femur was found to be clearly reduced in diabetic animals, with no significant differences between the groups. Serum alkaline phosphatase (ALP) and tartarate-resistant acid phosphatase (TRAP) activities showed significant six- and twofold increases, respectively, in diabetic rats. There were significant decreases in serum calcium and albumin concentrations in diabetic rats, but no difference was observed in serum magnesium, phosphorus, or creatinine concentrations between the groups. Overall, our findings support the conclusion that the diabetic state is associated with alterations in bone turnover, resulting in the development of osteopenia, which is related to the time of evolution of the disorder.


Assuntos
Doenças Ósseas Metabólicas/etiologia , Doenças Ósseas Metabólicas/patologia , Diabetes Mellitus Experimental/complicações , Diabetes Mellitus Experimental/patologia , Fosfatase Ácida/sangue , Fosfatase Alcalina/sangue , Animais , Biomarcadores/análise , Biomarcadores/sangue , Glicemia/metabolismo , Densidade Óssea/fisiologia , Doenças Ósseas Metabólicas/metabolismo , Osso e Ossos/metabolismo , Osso e Ossos/patologia , Cálcio/sangue , Creatina/sangue , Diabetes Mellitus Experimental/sangue , Diabetes Mellitus Experimental/induzido quimicamente , Ciclo Estral , Feminino , Isoenzimas/sangue , Ratos , Ratos Wistar , Albumina Sérica/análise , Fosfatase Ácida Resistente a Tartarato
16.
Pediatria (Säo Paulo) ; 26(1): 43-48, 2003.
Artigo em Português | LILACS | ID: lil-384084

RESUMO

O Grupo de Humanizacao Hospitalar do Instituto da Crianca do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo(ICr HC/FMUSP), Sao Paulo, SP, apresenta, para conhecimento, o documento preliminar do...


Assuntos
Humanos , Política de Saúde , Hospitais Pediátricos/organização & administração , Programas Nacionais de Saúde , Planos e Programas de Saúde , Humanismo , Política Organizacional , Assistência ao Paciente , Desenvolvimento de Programas , Sistemas de Saúde
17.
Mundo saúde (Impr.) ; 20(10): 329-36, nov.-dez. 1996.
Artigo em Português | LILACS | ID: lil-191076

RESUMO

A fonoaudiologia tem por objetivo de estudo os disturbios da comunicacao humana, abrangendo pesquisa, prevencao, aprimoramento, diagnostico e reabilitacao. Temos observado que o paciente com queixas fonoaudiologicas, procura os profissionais da area medica em primeira instancia, buscando a atuacao fonoudiologica somente apos o ecaminhamento destes. O objetivo do presente trabalho e evidenicar a importancia da atuaco fonoaudiologica em nivel diagnostico e reabilitacao na equipe multidisciplinar.


Assuntos
Humanos , Diagnóstico , Reabilitação , Distúrbios da Fala , Fonoterapia
18.
Recurso educacional aberto em Português | CVSP - Brasil | ID: una-5063

RESUMO

Na atenção primária à saúde, além de desenvolverem as funções relacionadas à dinâmica vivenciada no cotidiano das unidades básicas, os profissionais enfermeiros também precisam lidar com o cumprimento das metas, coberturas dos programas solicitados pelos gestores e as questões relacionadas às exigências do trabalho em equipe. O objetivo deste estudo foi analisar a produção científica sobre a sobrecarga de trabalho dos profissionais da enfermagem na atenção primária em saúde. Foi realizada pesquisa bibliográfica no período de dezembro de 2012 a março de 2013. Utilizou-se a Biblioteca Virtual de Saúde (BVS), onde foram selecionados textos da base de dados Lilacs e Scielo, além de livros e dissertações de mestrado. Como palavras-chave foram utilizadas sobrecarga de trabalho, atenção primária e trabalho da enfermagem. O trabalho em equipe é uma característica forte da Estratégia de Saúde da Família, assim como a necessidade dos profissionais que trabalham neste setor possuírem aptidões para trabalhos comunitários. O estresse dos profissionais, os vínculos frágeis com as instituições e a necessidade de humanizar a assistência prestada são parte do cotidiano da atenção primária à saúde. Constatou-se que o trabalho na estratégia de saúde da família trouxe como exigência o trabalho em equipe e o cumprimento de metas. Assim, se configura como um trabalho que exige saberes complexos e multidisciplinares para garantir uma atenção integral aos usuários. Além disso, ficou evidente a necessidade dos enfermeiros investirem no trabalho em equipe como forma de evitar a sobrecarga no trabalho.


Assuntos
Atenção Primária à Saúde
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