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1.
Europace ; 20(11): 1813-1818, 2018 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-29509903

RESUMO

Aims: Cardiac resynchronization therapy (CRT) is an established procedure for patients with heart failure. However, trials evaluating its efficacy did not include patients with chronic Chagas cardiomyopathy (CCC). We aimed to assess the role of CRT in a cohort of patients with CCC. Methods and results: This retrospective study compared the outcomes of CCC patients who underwent CRT with those of dilated (DCM) and ischaemic cardiomyopathies (ICM). The primary endpoint was all-cause mortality and the secondary endpoints were the rate of non-advanced New York Heart Association (NYHA) class 12 months after CRT and echocardiographic changes evaluated at least 6 months after CRT. There were 115 patients in the CCC group, 177 with DCM, and 134 with ICM. The annual mortality rates were 25.4%, 10.4%, and 11.3%, respectively (P < 0.001). Multivariate analysis adjusted for potential confounders showed that the CCC group had a two-fold [hazard ratio 2.34 (1.47-3.71), P < 0.001] higher risk of death compared to the DCM group. The rate of non-advanced NYHA class 12 months after CRT was significantly higher in non-CCC groups than in the CCC group (DCM 74.0% vs. ICM 73.9% vs. 56.5%, P < 0.001). Chronic Chagas cardiomyopathy and ICM patients had no improvement in the echocardiographic evaluation, but patients in the DCM group had an increase in left ventricular ejection fraction and a decrease in left ventricular end-diastolic diameter. Conclusion: This study showed that CCC patients submitted to CRT have worse prognosis compared to patients with DCM and ICM who undergo CRT. Studies comparing CCC patients with and without CRT are warranted.


Assuntos
Terapia de Ressincronização Cardíaca , Cardiomiopatia Chagásica , Brasil/epidemiologia , Terapia de Ressincronização Cardíaca/efeitos adversos , Terapia de Ressincronização Cardíaca/métodos , Cardiomiopatia Dilatada/diagnóstico , Cardiomiopatia Dilatada/mortalidade , Cardiomiopatia Dilatada/fisiopatologia , Cardiomiopatia Dilatada/terapia , Cardiomiopatia Chagásica/diagnóstico , Cardiomiopatia Chagásica/mortalidade , Cardiomiopatia Chagásica/fisiopatologia , Cardiomiopatia Chagásica/terapia , Desfibriladores Implantáveis , Ecocardiografia/métodos , Feminino , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Volume Sistólico
2.
Int J Cardiol ; 250: 260-265, 2018 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-29079412

RESUMO

BACKGROUND: Chronic Chagas cardiomyopathy (CCC) is the most serious and frequent manifestation of Chagas disease. Conduction abnormalities and bradycardia requiring pacemaker are common. The aim of this study was to determine the rate and predictors of death in CCC patients with pacemaker. METHODS: In this single-center prospective cohort study we assessed the outcome of 396 CCC patients with pacemaker, followed-up for at least 24months. All patients underwent a clinical and device assessment, 12-lead electrocardiography and echocardiography. RESULTS: During the median follow-up of 1.9years (Interquartile range 1.6-2.4), there were 65 (16.4%) deaths, yielding an annual mortality rate of 8.6%. The major cause was sudden death (33.8%), followed by heart failure (HF), 32.3%. All the investigated variables were examined as potential predictors of death. The final multivariate logistic regression model included five independent variables: advanced HF functional class (OR [odds ratio] 6.71; 95% confidence interval [95% CI] 1.95-23.2; P=0.003), renal disease (OR 5.71; 95% CI 1.80-18.0; P=0.003), QRS ≥150ms (OR 2.80; 95% CI 1.08-7.27; P=0.034), left atrial enlargement (OR 2.75; 95% CI 1.09-6.95; P=0.032) and left ventricular ejection fraction ≤43% (OR 2.31; 95% CI 1.07-4.97; P=0.032). The model had good discrimination, confirmed by bootstrap validation (optimism-adjusted c-statistic of 0.78) and the calibration curve showed a proper calibration (slope=0.972). CONCLUSIONS: CCC patients with pacemaker have a high annual mortality rate despite that the pacemaker related variables were not predictors of death. The independent predictors of death can help us to identify the poor prognosis patients.


Assuntos
Cardiomiopatia Chagásica/diagnóstico , Cardiomiopatia Chagásica/mortalidade , Marca-Passo Artificial/tendências , Idoso , Doença Crônica , Estudos de Coortes , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Valor Preditivo dos Testes , Estudos Prospectivos
3.
In. Kalil Filho, Roberto; Fuster, Valetim; Albuquerque, Cícero Piva de. Medicina cardiovascular reduzindo o impacto das doenças / Cardiovascular medicine reducing the impact of diseases. São Paulo, Atheneu, 2016. p.955-986.
Monografia em Português | LILACS | ID: biblio-971577
4.
In. Pastore, Alberto Carlos; Samesima, Nelson; Tobias, Nancy Maria Martins de Oliveira; Pereira Filho, Horacio Gomes. Eletrocardiografia atual: curso do serviço de eletrocardiografia do InCor. São Paulo, Atheneu, 3º; 2016. p.341-349.
Monografia em Português | LILACS | ID: biblio-833697
5.
Europace ; 16(6): 887-92, 2014 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-24050965

RESUMO

AIMS: To perform a comprehensive evaluation of heart rhythm disorders and the influence of disease/therapy factors in a large systemic lupus erythematosus (SLE) cohort. METHODS AND RESULTS: Three hundred and seventeen consecutive patients of an ongoing electronic database protocol were evaluated by resting electrocardiogram and 142 were randomly selected for 24 h Holter monitoring for arrhythmia and conduction disturbances. The mean age was 40.2 ± 12.1 years and disease duration was 11.4 ± 8.1 years. Chloroquine (CQ) therapy was identified in 69.7% with a mean use of 8.5 ± 6.7 years. Electrocardiogram abnormalities were detected in 66 patients (20.8%): prolonged QTc/QTd (14.2%); bundle-branch block (2.5%); and atrioventricular block (AVB) (1.6%). Age was associated with AVB (P = 0.029) and prolonged QTc/QTd (P = 0.039) whereas anti-Ro/SS-A and Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) scores were not (P > 0.05). Chloroquine was negatively associated with AVB (P = 0.01) as was its longer use (6.1 ± 6.9 vs. 1.0 ± 2.5 years, P = 0.018). Time of CQ use was related with the absence of AVB [odds ratio (OR) = 0.103; 95% confidence interval (CI) = 0.011-0.934, P = 0.043] in multiple logistic regression. Holter monitoring revealed abnormalities in 121 patients (85.2%): supraventricular ectopies (63.4%) and tachyarrhythmia (18.3%); ventricular ectopies (45.8%). Atrial tachycardia/fibrillation (AT/AF) were associated with shorter CQ duration (7.05 ± 7.99 vs. 3.63 ± 5.02 years, P = 0.043) with a trend to less CQ use (P = 0.054), and older age (P < 0.001). Predictors of AT/AF in multiple logistic regression were age (OR = 1.115; 95% CI = 1.059-1.174, P < 0.001) and anti-Ro/SS-A (OR = 0.172; 95% CI = 0.047-0.629, P = 0.008). CONCLUSIONS: Chloroquine seems to play a protective role in the unexpected high rate of cardiac arrhythmias and conduction disturbances observed in SLE. Further studies are necessary to determine if this antiarrhythmic effect is due to the disease control or a direct effect of the drug.


Assuntos
Antiarrítmicos/uso terapêutico , Arritmias Cardíacas/prevenção & controle , Cloroquina/uso terapêutico , Lúpus Eritematoso Sistêmico/tratamento farmacológico , Adulto , Antirreumáticos/uso terapêutico , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/epidemiologia , Brasil/epidemiologia , Cardiotônicos/uso terapêutico , Causalidade , Comorbidade , Eletrocardiografia/efeitos dos fármacos , Eletrocardiografia/estatística & dados numéricos , Estudos de Viabilidade , Feminino , Humanos , Lúpus Eritematoso Sistêmico/diagnóstico , Lúpus Eritematoso Sistêmico/epidemiologia , Masculino , Uso Off-Label , Prevalência , Estudos Retrospectivos , Medição de Risco , Resultado do Tratamento
6.
Clinics (Sao Paulo) ; 68(7): 986-91, 2013 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-23917664

RESUMO

OBJECTIVES: Few studies have evaluated cardiac electrical activation dynamics after cardiac resynchronization therapy. Although this procedure reduces morbidity and mortality in heart failure patients, many approaches attempting to identify the responders have shown that 30% of patients do not attain clinical or functional improvement. This study sought to quantify and characterize the effect of resynchronization therapy on the ventricular electrical activation of patients using body surface potential mapping, a noninvasive tool. METHODS: This retrospective study included 91 resynchronization patients with a mean age of 61 years, left ventricle ejection fraction of 28%, mean QRS duration of 182 ms, and functional class III/IV (78%/22%); the patients underwent 87-lead body surface mapping with the resynchronization device on and off. Thirty-six patients were excluded. Body surface isochronal maps produced 87 maximal/mean global ventricular activation times with three regions identified. The regional activation times for right and left ventricles and their inter-regional right-to-left ventricle gradients were calculated from these results and analyzed. The Mann-Whitney U-test and Kruskall-Wallis test were used for comparisons, with the level of significance set at p≤0.05. RESULTS: During intrinsic rhythms, regional ventricular activation times were significantly different (54.5 ms vs. 95.9 ms in the right and left ventricle regions, respectively). Regarding cardiac resynchronization, the maximal global value was significantly reduced (138 ms to 131 ms), and a downward variation of 19.4% in regional-left and an upward variation of 44.8% in regional-right ventricular activation times resulted in a significantly reduced inter-regional gradient (43.8 ms to 17 ms). CONCLUSIONS: Body surface potential mapping in resynchronization patients yielded electrical ventricular activation times for two cardiac regions with significantly decreased global and regional-left values but significantly increased regional-right values, thus showing an attenuated inter-regional gradient after the cardiac resynchronization therapy.


Assuntos
Mapeamento Potencial de Superfície Corporal/métodos , Terapia de Ressincronização Cardíaca/métodos , Insuficiência Cardíaca/terapia , Idoso , Bloqueio de Ramo/fisiopatologia , Terapia por Estimulação Elétrica , Feminino , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Valores de Referência , Estudos Retrospectivos , Estatísticas não Paramétricas , Fatores de Tempo , Resultado do Tratamento , Função Ventricular Esquerda/fisiologia , Função Ventricular Direita/fisiologia
7.
Clinics ; 68(7): 986-991, jul. 2013. tab, graf
Artigo em Inglês | LILACS | ID: lil-680714

RESUMO

OBJECTIVES: Few studies have evaluated cardiac electrical activation dynamics after cardiac resynchronization therapy. Although this procedure reduces morbidity and mortality in heart failure patients, many approaches attempting to identify the responders have shown that 30% of patients do not attain clinical or functional improvement. This study sought to quantify and characterize the effect of resynchronization therapy on the ventricular electrical activation of patients using body surface potential mapping, a noninvasive tool. METHODS: This retrospective study included 91 resynchronization patients with a mean age of 61 years, left ventricle ejection fraction of 28%, mean QRS duration of 182 ms, and functional class III/IV (78%/22%); the patients underwent 87-lead body surface mapping with the resynchronization device on and off. Thirty-six patients were excluded. Body surface isochronal maps produced 87 maximal/mean global ventricular activation times with three regions identified. The regional activation times for right and left ventricles and their inter-regional right-to-left ventricle gradients were calculated from these results and analyzed. The Mann-Whitney U-test and Kruskall-Wallis test were used for comparisons, with the level of significance set at p≤0.05. RESULTS: During intrinsic rhythms, regional ventricular activation times were significantly different (54.5 ms vs. 95.9 ms in the right and left ventricle regions, respectively). Regarding cardiac resynchronization, the maximal global value was significantly reduced (138 ms to 131 ms), and a downward variation of 19.4% in regional-left and an upward variation of 44.8% in regional-right ventricular activation times resulted in a significantly reduced inter-regional gradient (43.8 ms to 17 ms). CONCLUSIONS: Body surface potential mapping in resynchronization patients yielded electrical ventricular ...


Assuntos
Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Mapeamento Potencial de Superfície Corporal/métodos , Terapia de Ressincronização Cardíaca/métodos , Insuficiência Cardíaca/terapia , Bloqueio de Ramo/fisiopatologia , Terapia por Estimulação Elétrica , Insuficiência Cardíaca/fisiopatologia , Valores de Referência , Estudos Retrospectivos , Estatísticas não Paramétricas , Fatores de Tempo , Resultado do Tratamento , Função Ventricular Esquerda/fisiologia , Função Ventricular Direita/fisiologia
8.
Ann Noninvasive Electrocardiol ; 17(2): 123-9, 2012 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-22537330

RESUMO

BACKGROUND: The controversial effects promoted by cardiac resynchronization therapy (CRT) on the ventricular repolarization (VR) have motivated VR evaluation by body surface potential mapping (BSPM) in CRT patients. METHODS: Fifty-two CRT patients, mean age 58.8 ± 12.3 years, 31 male, LVEF 27.5 ± 9.2, NYHA III-IV heart failure with QRS181.5 ± 14.2 ms, underwent 87-lead BSPM in sinus rhythm (BASELINE) and biventricular pacing (BIV). Measurements of mean and corrected QT intervals and dispersion, mean and corrected T peak end intervals and their dispersion, and JT intervals characterized global and regional (RV, Intermediate, and LV regions) ventricular repolarization response. RESULTS: Global QTm (P < 0.001) and QTc(m) (P < 0.05) were decreased in BIV; QTm was similar across regions in both modes (P = ns); QTc(m) values were lower in RV/LV than in Intermediate region in BASELINE and BIV (P < 0.001); only RV/Septum showed a significant difference (P < 0.01) in the BIV mode. QTD values both of BASELINE (P < 0.01) and BIV (P < 0.001) were greater in the Intermediate than in the LV region. CRT effect significantly reduced global/regional QTm and QTc(m) values. QTD was globally decreased in RV/LV (Intermediate: P = ns). BIV mode significantly reduced global T peak end mean and corrected intervals and their dispersion. JT values were not significant. CONCLUSIONS: Ventricular repolarization parameters QTm, QTc(m), and QTD global/regional values, as assessed by BSPM, were reduced in patients under CRT with severe HF and LBBB. Greater recovery impairment in the Intermediate region was detected by the smaller variation of its dispersion.


Assuntos
Mapeamento Potencial de Superfície Corporal , Bloqueio de Ramo/fisiopatologia , Bloqueio de Ramo/terapia , Terapia de Ressincronização Cardíaca/métodos , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/terapia , Análise de Variância , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento
9.
Circ Arrhythm Electrophysiol ; 2(1): 29-34, 2009 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-19808441

RESUMO

BACKGROUND: Although routinely administered, definitive evidence for the benefits of prophylactic antibiotics before the implantation of permanent pacemakers and implantable cardioverter-defibrillators from a large double-blinded placebo-controlled trial is lacking. The purpose of this study was to determine whether prophylactic antibiotic administration reduces the incidence of infection related to device implantation. METHODS AND RESULTS: This double blinded study included 1000 consecutive patients who presented for primary device (Pacemaker and implantable cardioverter-defibrillators) implantation or generator replacement randomized in a 1:1 fashion to prophylactic antibiotics or placebo. Intravenous administration of 1 g of cefazolin (group I) or placebo (group 2) was done immediately before the procedure. Follow-up was performed 10 days, 1, 3, and 6 months after discharge. The primary end point was any evidence of infection at the surgical incision (pulse generator pocket), or systemic infection related to be procedure. The safety committee interrupted the trial after 649 patients were enrolled due to a significant difference in favor of the antibiotic arm (group I: 2 of 314 infected patients-0.63%; group II: 11 of 335 to 3.28%; RR=0.19; P=0.016). The following risk factors were positively correlated with infection by univariate analysis: nonuse of preventive antibiotic (P=0.016); implant procedures (versus generator replacement: P=0.02); presence of postoperative hematoma (P=0.03) and procedure duration (P=0.009). Multivariable analysis identified nonuse of antibiotic (P=0.037) and postoperative hematoma (P=0.023) as independent predictors of infection. CONCLUSIONS: Antibiotic prophylaxis significantly reduces infectious complications in patients undergoing implantation of pacemakers or cardioverter-defibrillators.


Assuntos
Antibacterianos/administração & dosagem , Antibioticoprofilaxia , Cefazolina/administração & dosagem , Desfibriladores Implantáveis/efeitos adversos , Marca-Passo Artificial/efeitos adversos , Infecções Relacionadas à Prótese/prevenção & controle , Infecção da Ferida Cirúrgica/prevenção & controle , Idoso , Método Duplo-Cego , Feminino , Humanos , Injeções Intravenosas , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Infecções Relacionadas à Prótese/microbiologia , Infecções Relacionadas à Prótese/mortalidade , Fatores de Risco , Infecção da Ferida Cirúrgica/microbiologia , Infecção da Ferida Cirúrgica/mortalidade , Fatores de Tempo , Resultado do Tratamento
10.
RELAMPA, Rev. Lat.-Am. Marcapasso Arritm ; 22(3): 143-151, jul.-set. 2009. ilus, tab, graf
Artigo em Português | LILACS | ID: lil-538323

RESUMO

Objetivo: Comparar o comportamento clínico-evolutivo de portadores de CDI por taquicardia ventricular (TV) sincopal ou parada cardíaca (PC) por TV/FV. Método: 585 pacientes foram submetidos a implante de CDI entre jan/2000 e jul/2005 para prevenção secundária de morte súbita cardíaca (MSC). Foram selecionados 415 pacientes de um banco de dados prospectivo, distribuídos em dois grupos: G1, com TV sincopal (n=318) e G2, com PC por TV/FV (n=97). As variáveis analisadas foram: idade, sexo, fração de ejeção do ventrículo esquerdo(FEVE), classe funcional de insuficiência cardíaca (CF IC), medicamentos, terapias de choque apropriadas (TCA) pelo CDI e óbitos. Para análise estatística...


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Desfibriladores Implantáveis , Morte Súbita Cardíaca/prevenção & controle , Síncope/complicações , Taquicardia Ventricular/induzido quimicamente
11.
Arq Bras Cardiol ; 90(2): 138-43, 2008 Feb.
Artigo em Inglês, Português | MEDLINE | ID: mdl-18392387

RESUMO

BACKGROUND: Cardiac resynchronization therapy (CRT) is an efficient treatment for patients with heart failure (HF), severe ventricular dysfunction and intraventricular block. Conventional pacemakers (CPM) implanted in the right ventricular apical area cause alterations in the normal sequence of cardiac activation similar to those induced by LBBB (left bundle-branch block). Therefore, patients with CPM and advanced HF could be candidates to undergo CRT, but as only small numbers of patients have been evaluated so far, definitive conclusions are lacking. OBJECTIVE: To assess the clinical and functional outcome of cardiac resynchronization therapy (CRT) in patients with conventional pacemakers. METHODS: Patients with CPM, who were in NYHA HF functional class III/IV class refractory to drug therapy, and left ventricular ejection fraction (LVEF) ) <35% underwent CRT. Patients clinical-functional behavior was assessed prospectively six months after the procedure. The improvement of one HF-functional class was set as an effective response to the procedure. The following was assessed: QRS duration (ECG), diastolic diameter (LVDd), left ventricular systolic diameter (LVSd) and LVEF seen on the echocardiogram. For the statistical analysis, Students paired t test and Spearmans correlation were used. RESULTS: Twenty-nine patients (mean age 61.5) were evaluated. Of these, six were females, and chagasic cardiomyopathy was predominant. During the clinical follow-up of 22.7+/-13 months, 86.2% of the patients benefited from CRT. Within this group, the mean LVEF increased by 18% (p=0.013), QRS duration dropped by 11.8% (p=0.002) and no significant reduction in left ventricular intracavitary diameters was observed. CONCLUSION: CRT is effective for patients with CPM and advanced HF as it yields a high rate of response (86.2%), significantly improves LVEF and reduces QRS duration.


Assuntos
Bloqueio de Ramo/terapia , Estimulação Cardíaca Artificial , Insuficiência Cardíaca/complicações , Cardiomiopatia Chagásica/fisiopatologia , Cardiomiopatia Chagásica/terapia , Diástole/fisiologia , Feminino , Seguimentos , Insuficiência Cardíaca/fisiopatologia , Frequência Cardíaca/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Índice de Gravidade de Doença , Volume Sistólico/fisiologia , Resultado do Tratamento , Disfunção Ventricular Esquerda/fisiopatologia
12.
Arq Bras Cardiol ; 90(3): 160-6, 2008 Mar.
Artigo em Inglês, Português | MEDLINE | ID: mdl-18392394

RESUMO

BACKGROUND: The ideal programming of the implantable cardioverter defibrillator (ICD) shock energy should be at least 10J above the defibrillation threshold (DFT), requiring alternative techniques when the DFT is elevated. OBJECTIVE: To assess the clinical behavior of ICD patients with DFT>25J and the efficacy of the chosen therapy. METHODS: Patients who had undergone ICD implantation between Jan/00 and Aug/04 (prospective database) and presented intraoperative DFT>25J were selected. The analyzed variables were: clinical characteristics, LVEF, rescue of arrhythmic events from ICD and causes of deaths. RESULTS: among 476 patients, 16 (3.36%) presented DFT>25J. The mean age was 56.5 years, and 13 patients (81%) were men. According to the baseline cardiomyopathy, 09 patients had Chagas' disease, 04 had ischemic cardiomyopathy and 03 had idiopathic cardiomyopathy. Mean LVEF was 0.37 and amiodarone was used by 94% of the patients. Mean follow-up (FU) period was 25.3 months. DFT was higher than maximum energy shock (MES) in 2 patients and it was necessary to implant an additional shock electrode (array). It was programmed MES in ventricular fibrillation zone of ICD therapy in the other patients. In the FU, 03 patients had 67 successful appropriate shock therapies (AST). There were 05 noncardiac and 02 heart failure deaths. The patients who died showed higher DFT levels (p=0.044) without correlation with death because there wasn't unsuccessful AST. CONCLUSION: In this cohort of ICD patients, the occurrence of elevated DFT (>25J) was low, leading to alternative therapies. There was an association with severe ventricular dysfunction, although without correlation to the causes of death.


Assuntos
Arritmias Cardíacas/terapia , Desfibriladores Implantáveis , Cardioversão Elétrica , Amiodarona/uso terapêutico , Antiarrítmicos/uso terapêutico , Arritmias Cardíacas/tratamento farmacológico , Arritmias Cardíacas/mortalidade , Morte Súbita Cardíaca/etiologia , Morte Súbita Cardíaca/prevenção & controle , Desfibriladores Implantáveis/normas , Limiar Diferencial , Cardioversão Elétrica/normas , Técnicas Eletrofisiológicas Cardíacas , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Taquicardia Ventricular/terapia , Fibrilação Ventricular/terapia
13.
Arq. bras. cardiol ; 90(3): 177-184, mar. 2008. ilus, graf, tab
Artigo em Inglês, Português | LILACS | ID: lil-479618

RESUMO

FUNDAMENTO: A programação ideal da energia de choque do CDI deve ser pelo menos 10 J acima do limiar de desfibrilação (LDF), necessitando de técnicas alternativas quando o LDF é elevado. OBJETIVO: Avaliar o comportamento clínico dos portadores de CDI com LDF>25 J e a eficácia da terapêutica escolhida. MÉTODOS: Foram selecionados portadores de CDI, entre janeiro de 2000 e agosto de 2004 (banco de dados prospectivo), com LDF>25 J intra-operatório, e analisaram-se: características clínicas, FEVE, resgate de eventos arrítmicos pelo CDI e óbitos. RESULTADOS: dentre 476 pacientes, 16 (3,36 por cento) apresentaram LDF>25J. Idade média de 56,5 anos, sendo 13 pacientes (81 por cento) do sexo masculino. Quanto à cardiopatia de base 09 eram chagásicos, 04 isquêmicos e 03 com etiologia idiopática. A FEVE média dos pacientes foi 37 por cento e 94 por cento utilizavam amiodarona. O seguimento médio foi de 25,3 meses. Em 02 pacientes com LDF > Choque Máximo (CM), foi necessário implante de eletrodo de choque adicional (array), sendo mantido programação com CM em zona de FV (>182bpm) nos demais. Durante o seguimento 03 pacientes apresentaram 67 terapias de choque apropriadas (TCA) com sucesso. Ocorreram 07 óbitos sendo 5 por causas não cardíacas e 2 por insuficiência cardíaca avançada. Os pacientes que foram a óbito apresentaram níveis de LDF maiores (p=0,0446), entretanto sem relação com a causa dos mesmos tendo em vista que não ocorreram TCA sem sucesso. CONCLUSÃO: Nessa coorte de pacientes com CDI, a ocorrência de LDF elevado foi baixa, implicando terapêuticas alternativas. Houve associação com disfunção ventricular grave, entretanto sem correlação com as causas de óbito.


BACKGROUND: The ideal programming of the implantable cardioverter defibrillator (ICD) shock energy should be at least 10J above the defibrillation threshold (DFT), requiring alternative techniques when the DFT is elevated. OBJECTIVE: To assess the clinical behavior of ICD patients with DFT>25J and the efficacy of the chosen therapy. METHODS: Patients who had undergone ICD implantation between Jan/00 and Aug/04 (prospective database) and presented intraoperative DFT>25J were selected. The analyzed variables were: clinical characteristics, LVEF, rescue of arrhythmic events from ICD and causes of deaths. RESULTS: among 476 patients, 16 (3.36 percent) presented DFT>25J. The mean age was 56.5 years, and 13 patients (81 percent) were men. According to the baseline cardiomyopathy, 09 patients had Chagas' disease, 04 had ischemic cardiomyopathy and 03 had idiopathic cardiomyopathy. Mean LVEF was 0.37 and amiodarone was used by 94 percent of the patients. Mean follow-up (FU) period was 25.3 months. DFT was higher than maximum energy shock (MES) in 2 patients and it was necessary to implant an additional shock electrode (array). It was programmed MES in ventricular fibrillation zone of ICD therapy in the other patients. In the FU, 03 patients had 67 successful appropriate shock therapies (AST). There were 05 noncardiac and 02 heart failure deaths. The patients who died showed higher DFT levels (p=0.044) without correlation with death because there wasn't unsuccessful AST. CONCLUSION: In this cohort of ICD patients, the occurrence of elevated DFT (>25J) was low, leading to alternative therapies. There was an association with severe ventricular dysfunction, although without correlation to the causes of death.


Assuntos
Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Arritmias Cardíacas/terapia , Desfibriladores Implantáveis , Cardioversão Elétrica , Amiodarona/uso terapêutico , Antiarrítmicos/uso terapêutico , Arritmias Cardíacas/tratamento farmacológico , Arritmias Cardíacas/mortalidade , Limiar Diferencial , Morte Súbita Cardíaca/etiologia , Morte Súbita Cardíaca/prevenção & controle , Desfibriladores Implantáveis/normas , Técnicas Eletrofisiológicas Cardíacas , Cardioversão Elétrica/normas , Seguimentos , Estudos Prospectivos , Taquicardia Ventricular/terapia , Fibrilação Ventricular/terapia
14.
Arq. bras. cardiol ; 90(2): 151-156, fev. 2008. ilus, tab
Artigo em Inglês, Português | LILACS | ID: lil-479610

RESUMO

FUNDAMENTO: A terapia de ressincronização cardíaca (TRC) é eficiente no tratamento de pacientes com insuficiência cardíaca (IC), disfunção ventricular grave e bloqueio intraventricular. O marcapasso convencional (MPC) em região apical de ventrículo direito provoca alterações da seqüência de ativação normal do coração semelhante às do BRE. Nesse sentido, pacientes com MPC e IC avançada poderiam ser candidatos a TRC, mas reduzidas casuísticas foram avaliadas e não há conclusões definitivas. OBJETIVO: Analisar o comportamento clínico-funcional da terapia de ressincronização cardíaca (TRC) nos portadores de marcapasso convencional. MÉTODOS: Pacientes com MPC, IC-CF(NYHA) III/IV refratária a terapêutica medicamentosa, fração de ejeção do ventrículo esquerdo (FEVE) <35 por cento, foram submetidos a TRC. O comportamento clínico-funcional foi avaliado prospectivamente após seis meses. A redução de uma CF-IC foi estabelecida como resposta efetiva ao procedimento. Foram analisados: duração do QRS (ECG), diâmetro diastólico (DDVE), diâmetro sistólico do ventrículo esquerdo (DSVE) e FEVE ao ECO. A análise estatística utilizou os testes t de Student pareado e a correlação de Spearman. RESULTADOS: Vinte e nove pacientes com idade média de 61,5 anos foram estudados. Seis eram do sexo feminino e houve predomínio da cardiomiopatia chagásica. Em seguimento clínico de 22,7±13 meses, 86,2 por cento dos pacientes melhoraram com a TRC. Nesse grupo, a FEVE média aumentou em 18 por cento (p=0,013); houve redução da duração do QRS em 11,8 por cento (p=0,002) e não houve redução significativa dos diâmetros intracavitários do ventrículo esquerdo. CONCLUSÃO: A TRC é efetiva para pacientes com MPC e IC avançada porque proporciona taxa elevada de responsivos (86,2 por cento), melhora significativa da FEVE e redução da duração do QRS.


BACKGROUND: Cardiac resynchronization therapy (CRT) is an efficient treatment for patients with heart failure (HF), severe ventricular dysfunction and intraventricular block. Conventional pacemakers (CPM) implanted in the right ventricular apical area cause alterations in the normal sequence of cardiac activation similar to those induced by LBBB (left bundle-branch block). Therefore, patients with CPM and advanced HF could be candidates to undergo CRT, but as only small numbers of patients have been evaluated so far, definitive conclusions are lacking. OBJECTIVE: To assess the clinical and functional outcome of cardiac resynchronization therapy (CRT) in patients with conventional pacemakers. METHODS: Patients with CPM, who were in NYHA HF functional class III/IV class refractory to drug therapy, and left ventricular ejection fraction (LVEF) ) <35 percent underwent CRT. Patients’ clinical-functional behavior was assessed prospectively six months after the procedure. The improvement of one HF-functional class was set as an effective response to the procedure. The following was assessed: QRS duration (ECG), diastolic diameter (LVDd), left ventricular systolic diameter (LVSd) and LVEF seen on the echocardiogram. For the statistical analysis, Student’s paired t test and Spearman’s correlation were used. RESULTS: Twenty-nine patients (mean age 61.5) were evaluated. Of these, six were females, and chagasic cardiomyopathy was predominant. During the clinical follow-up of 22.7±13 months, 86.2 percent of the patients benefited from CRT. Within this group, the mean LVEF increased by 18 percent (p=0.013), QRS duration dropped by 11.8 percent (p=0.002) and no significant reduction in left ventricular intracavitary diameters was observed. CONCLUSION: CRT is effective for patients with CPM and advanced HF as it yields a high rate of response (86.2 percent), significantly improves LVEF and reduces QRS duration.


Assuntos
Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Bloqueio de Ramo/terapia , Estimulação Cardíaca Artificial , Insuficiência Cardíaca/complicações , Cardiomiopatia Chagásica/fisiopatologia , Cardiomiopatia Chagásica/terapia , Diástole/fisiologia , Seguimentos , Insuficiência Cardíaca/fisiopatologia , Frequência Cardíaca/fisiologia , Estudos Prospectivos , Índice de Gravidade de Doença , Volume Sistólico/fisiologia , Resultado do Tratamento , Disfunção Ventricular Esquerda/fisiopatologia
15.
Anadolu Kardiyol Derg ; 7 Suppl 1: 213-5, 2007 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-17584728

RESUMO

OBJECTIVE: There is little research on the ventricular electrical aspects following cardiac resynchronization therapy (CRT). This study sought to establish electrocardiographic criteria associated to the ventricular electrical activation process that could identify patients with functional class (FC) improvement after CRT, by using the noninvasive method of body surface potential mapping (BSPM). METHODS: Fifty-six patients with chronic heart failure and left bundle-branch block (LBBB), who had undergone CRT, with mean age 59.9+/-10.8 years, left ventricular ejection fraction 30.9+/-8.3%, QRS 184+/-35 ms, FC (NYHA) II - 16%, III - 68% and IV - 16%, were selected. Through the 87-lead BSPM isochronous maps, ventricular activation times (VAT) of both right (RV) and left ventricles (LV) were analysed, in two situations: (1) native LBBB and (2) during biventricular pacing. After CRT, patients were divided in two groups: with and without FC improvement. The VATs were compared by the Mann-Whitney's test. The ratio of patients with and without FC improvement who showed RV-to-LV VAT difference =or<20 ms, and >20 ms, was compared using the Fisher's test. Significance level was accepted as p=or<0.05. RESULTS: Clinical characteristics of patients before CRT were similar in the groups. Patients with FC improvement (47) had RV-to-LV VAT difference during biventricular pacing shorter than those without FC improvement (14.40+/-13.0 ms vs 23.8+/-9.4 ms, p=0.0151). Moreover, the majority of patients with FC improvement had an RV-to-LV VAT difference =or<20 ms during biventricular pacing (70% vs 22%, RR 5.8, CI 95% 1.334-25.517, p=0.01). CONCLUSION: The RV-to-LV ventricular activation time difference of less than or equal to 20 milliseconds, as characterised by BSPM, could identify patients who presented with improved functional class after undergoing CRT.


Assuntos
Mapeamento Potencial de Superfície Corporal , Bloqueio de Ramo/fisiopatologia , Sistema de Condução Cardíaco/fisiopatologia , Insuficiência Cardíaca/fisiopatologia , Bloqueio de Ramo/complicações , Bloqueio de Ramo/terapia , Estimulação Cardíaca Artificial , Desfibriladores Implantáveis , Feminino , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/terapia , Humanos , Masculino , Pessoa de Meia-Idade
16.
Arq Bras Cardiol ; 88(3): 251-7, 2007 Mar.
Artigo em Inglês, Português | MEDLINE | ID: mdl-17533464

RESUMO

OBJECTIVES: To assess cardiac electrical activation by using body surface potential mapping (BSPM), in patients with congestive heart failure (CHF) and left bundle branch block (LBBB) undergoing cardiac resynchronization therapy (CRT) with biventricular pacemaker (BIV-PM) implantation. METHODS: Mean cardiac electrical activation times were analyzed in the right ventricle (RV) (mean RV activation time = mRV), anteroseptal area (mAS), and left ventricle (mLV) of 28 patients (mean age 61.2 +/- 9.5 years; NYHA class III-IV CHF; ejection fraction <40%; LBBB of mean QRS 181.2+/-19.4 ms, SAQRS -8.5 masculine+/-68.6 masculine), as shown in their BSPM isochronous maps, before and after implantation of atriobiventricular pacemaker, comparing those with values obtained from a control group of normal individuals [CG], in three situations: (1) native LBBB; (2) RV pacing; and (3) atriobiventricular pacing. RESULTS: Situation (1): mRV and mAS values were similar (41.0+/-11.8 ms x 43.6+/-13.4 ms), with delayed mLV (81.0+/-12.5 ms, p<0.01) and asynchronous with RV and AS areas; situation (2): mRV was greater than in CG (86.8+/-22.9 ms, p<0.001), with greater difference between mAS and mLV (63.4+/-20.7 ms vs. 102.7+/-20.3 ms; p<0,001); situation (3): mLV and mRV were similar (72.0+/-32.0 ms vs. 71.6+/-32.3 ms), mRV was greater than in CG and native LBBB (71.6+/-32.3 ms vs. 35.1+/-10.9 ms and 41.0+/-11.8 ms; p<0.001), and mAS was close to CG and native LBBB values (51.3+/-32.8 ms vs. 50.1+/-11.4 ms and 43.6+/-13.4 ms). CONCLUSION: The body surface potential mapping showed that RV and LV activation times which are similar, and are close to those of the AS area, suggest patterns of synchronized ventricular activation in patients with CHF and LBBB during atriobiventricular pacing.


Assuntos
Mapeamento Potencial de Superfície Corporal , Bloqueio de Ramo/fisiopatologia , Estimulação Cardíaca Artificial , Insuficiência Cardíaca/fisiopatologia , Bloqueio de Ramo/terapia , Estudos de Casos e Controles , Feminino , Insuficiência Cardíaca/terapia , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Marca-Passo Artificial , Fatores de Tempo , Função Ventricular/fisiologia
17.
REBLAMPA Rev. bras. latinoam. marcapasso arritmia ; 20(1): 7-12, jan.-mar. 2007. ilus, tab, graf
Artigo em Português | LILACS | ID: lil-465753

RESUMO

Em pacientes com disfunção ventricular e distúrbio de condução pelo ramo esquerdo, a ressincronização cardíaca é utilizada no tratamento da insuficiência cardíaca (IC) refratária ao tratamento clínico, com resultados comprovadamente eficazes em curto e médio prazos. No final da década de 90, foram introduzidos métodos para cateterização e estimulação com eletrodos específicos para o seio coronário. Atualmente, a técnica endovenosa é considerada o principal método para ressincronização cardíaca; entretanto, a toracotomia ainda é um método efetivo e eficaz nos casos de posições instáveis, altos limiares, estimulação frênica, trombose venosa, entre outros. O presente estudo teve como objetivo descrever a prevalência de toracotomias na casuística do InCor-HCFMUSP desde os primeiros casos (fevereiro de 1997 a dezembro de 1999, quando era a única opção disponível) até dezembro de 2005, listando os principais motivos de sua realização.


Assuntos
Humanos , Insuficiência Cardíaca/terapia
18.
Arq. bras. cardiol ; 88(3): 251-257, mar. 2007. ilus, graf
Artigo em Português | LILACS | ID: lil-451724

RESUMO

OBJETIVOS: Avaliar a ativação elétrica cardíaca usando Mapeamento Eletrocardiográfico de Superfície (MES), em pacientes com ICC e bloqueio de ramo esquerdo [BRE] submetidos a terapia de ressincronização cardíaca (CRT) com implante de marca-passo átrio-biventricular (MP-BIV). MÉTODOS: Foram analisados os tempos médios de ativação elétrica cardíaca no ventrículo direito (tempo médio de ativação do VD [mVD]), área ântero-septal (mAS), e ventrículo esquerdo (mVE), de 28 pacientes (idade média 61,2±9,5 anos, ICC classe III-IV NYHA, fração de ejeção <40 por cento, BRE com QRS médio 181,2±19,4ms, SAQRS= -8,5°±68,6°), mostrados nos mapas de linhas isócronas do MES, antes e após implante de marca-passo átrio-biventricular, e comparados a valores obtidos em um grupo controle composto de indivíduos normais [GNL], em três situações: (1) BRE nativo, (2) estimulação do VD; e (3) estimulação átrio-biventricular. RESULTADOS: situação (1): mVD e mAS foram semelhantes (41,0±11,8ms x 43,6±13,4ms), com mVE tardio (81,0±12,5ms, p<0,01) perdendo o sincronismo com o VD e a área ântero-septal; situação (2): mVD foi maior que no GNL (86,8±22,9ms, p<0,001), com maior diferença entre mAS e mVE (63,4±20,7ms x 102,7±20,3ms; p<0,001); situação (3): mVE e mVD foram semelhantes (72,0±32,0ms x 71,6±32,3ms), mVD foi maior que no GNL e BRE nativo (71,6±32,3ms x 35,1±10,9ms e 41,0±11,8ms; p<0,001), mAS se aproximou do GNL e BRE nativo (51,3±32,8ms x 50,1±11,4ms e 43,6±13,4ms). CONCLUSÃO: Pelo mapeamento eletrocardiográfico de superfície, tempos de ativação semelhantes no VD e VE e próximos daqueles da região ântero-septal indicam padrões de ativação ventricular sincronizada em portadores de ICC e BRE durante estimulação átrio-biventricular.


OBJECTIVES: To assess cardiac electrical activation by using body surface potential mapping (BSPM), in patients with congestive heart failure (CHF) and left bundle branch block (LBBB) undergoing cardiac resynchronization therapy (CRT) with biventricular pacemaker (BIV-PM) implantation. METHODS: Mean cardiac electrical activation times were analyzed in the right ventricle (RV) (mean RV activation time = mRV), anteroseptal area (mAS), and left ventricle (mLV) of 28 patients (mean age 61.2 ± 9.5 years; NYHA class III-IV CHF; ejection fraction <40 percent; LBBB of mean QRS 181.2±19.4ms, SAQRS -8.5°±68.6°), as shown in their BSPM isochronous maps, before and after implantation of atriobiventricular pacemaker, comparing those with values obtained from a control group of normal individuals [CG], in three situations: (1) native LBBB; (2) RV pacing; and (3) atriobiventricular pacing. RESULTS: Situation (1): mRV and mAS values were similar (41.0±11.8ms x 43.6±13.4ms), with delayed mLV (81.0±12.5ms, p<0.01) and asynchronous with RV and AS areas; situation (2): mRV was greater than in CG (86.8±22.9ms, p<0.001), with greater difference between mAS and mLV (63.4±20.7ms vs. 102.7±20.3ms; p<0,001); situation (3): mLV and mRV were similar (72.0±32.0ms vs. 71.6±32.3ms), mRV was greater than in CG and native LBBB (71.6±32.3ms vs. 35.1±10.9ms and 41.0±11.8ms; p<0.001), and mAS was close to CG and native LBBB values (51.3±32.8ms vs. 50.1±11.4ms and 43.6±13.4ms). CONCLUSION: The body surface potential mapping showed that RV and LV activation times which are similar, and are close to those of the AS area, suggest patterns of synchronized ventricular activation in patients with CHF and LBBB during atriobiventricular pacing.


Assuntos
Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Mapeamento Potencial de Superfície Corporal , Bloqueio de Ramo/fisiopatologia , Estimulação Cardíaca Artificial , Insuficiência Cardíaca/fisiopatologia , Bloqueio de Ramo/terapia , Estudos de Casos e Controles , Insuficiência Cardíaca/terapia , Ventrículos do Coração/fisiopatologia , Marca-Passo Artificial , Fatores de Tempo , Função Ventricular/fisiologia
19.
REBLAMPA Rev. bras. latinoam. marcapasso arritmia ; 19(2): 112-117, abr.-jun. 2006. ilus, tab
Artigo em Português | LILACS | ID: lil-438640

RESUMO

Objetivo: Avaliar a importância clínica da presença de marcapasso definitivo (MPD) previamente ao implante de CDI de nossa instituição, foram selecionados 275 submetidos a implante de CDI para prevenção secundária de morte súbita cardíaca (MSC), agrupados de acordo com a cardiomiopatia de base e a presença de MPD prévio ao implante de CDI. As variáveis analisadas foram: sexo, idade, CF-NYHAA, medicações, ritmo cardíaco, FEVE e TVNS. Para análise estatística, utilizou-se o método de Kaplan Meier e o teste de log-rank. Resultados: A amostra reduzida de pacientes com consistentes...


Assuntos
Humanos , Masculino , Feminino , Adolescente , Adulto , Pessoa de Meia-Idade , Doença de Chagas/complicações , Doença de Chagas/diagnóstico , Morte Súbita/prevenção & controle , Marca-Passo Artificial/efeitos adversos , Marca-Passo Artificial
20.
REBLAMPA Rev. bras. latinoam. marcapasso arritmia ; 19(1): 45-52, jan.-mar. 2006. ilus, tab, graf
Artigo em Português | LILACS | ID: lil-438633

RESUMO

Identificar marcadores de melhora clínica no subgrupo de pacientes com bloqueio completo de ramo esquerdo (BRE) da coorte submetida a ressincronização cardíaca (RC) no InCor-SP do HCFMUSP. Material e método: Foram analisadas características clínicas e epidemiológicas prospectivas de 121 pacientes com IC e BRE submetidos a RC. O critério de melhora clínica foi a redução de pelo menos duas classes funcionais (CF-NYHA) durante acompanhamento mínimo de seis meses. As variáveis analisadas pré e pós RC para comparação do comportamento dos grupos foram: CF-NYHA, sexo, idade, drogas, cardiopatia de base, ritmo cardíaco de base, BRE espontâneo X BRE induzido por marcapasso (troca de sistema ou primeiro implante), diâmetro diastólico final do ventrículo esquerdo (DdVE) e fração de ejeção do ventrículo esquerdo (FEVE - ecocardiograma). A análise estatística foi realizada por meio dos testes de Qui-Quadrado, exato de Fisher e regressão logística de Cox. Resultados: Houve redução de duas CF em 36 por cento dos pacientes e de uma CF em 54 por cento (inalterada em 10 por cento). Associaram-se à redução significativa da CF (análise univariada) o ritmo sinusal (p igual a 0,023), BRE espontâneo (p igual a 0,035), cardiomiopatia dilatada (CMD) (p igual a 0,03), não uso de amiodarona (p igual a 0,003) DdVE (p igual a 0,044). DdVE e CMD foram preditores independentes de melhora clínica (análise múltipla). conclusões: 1. A melhora clínica foi maior em pacientes com BRE espontâneo em relação ao BRE induzido. 2. As medidas dio DdVE e CMD discriminaram subgrupos de resposta clínica satisfatória (seguimento tardio) e foram preditores independentes deste comportamento.


Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Cardiomiopatia Dilatada/complicações , Cardiomiopatia Dilatada/diagnóstico , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/diagnóstico , Isquemia/complicações , Isquemia/diagnóstico
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