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2.
Intern Med ; 58(17): 2535-2538, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31118397

RESUMO

A 79-year-old man with dilated cardiomyopathy and severe functional mitral regurgitation presented with general fatigue and dyspnea. Auscultation revealed a systolic regurgitant murmur with a minimized second heart sound due to a low output. On the other hand, the third heart sound was ultimately enhanced, being visible and palpable as a pulsatile knock of the precordium. Phonocardiography and echocardiography successfully confirmed early-diastolic rapid distension of the left ventricle along with rapid ventricular filling and abrupt deceleration of the atrioventricular blood flow to be the precise etiology of the ultimate third heart sound, indicating critically deteriorated hemodynamics due to massive mitral regurgitation combined with a low output.


Assuntos
Cardiomiopatia Dilatada/fisiopatologia , Ruídos Cardíacos/fisiologia , Insuficiência da Valva Mitral/fisiopatologia , Idoso , Baixo Débito Cardíaco/fisiopatologia , Dispneia/etiologia , Ecocardiografia , Fadiga/etiologia , Auscultação Cardíaca , Hemodinâmica/fisiologia , Humanos , Masculino , Fonocardiografia , Disfunção Ventricular Esquerda/fisiopatologia
3.
Arch Dis Child Fetal Neonatal Ed ; 104(5): F541-F543, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30355780

RESUMO

Recipients of severe twin-to-twin transfusion syndrome (TTTS) may suffer from low cardiac output caused by myocardial hypertrophy and sudden postnatal drop in preload. Our hypothesis was that selective beta-1 adrenergic blockers improve cardiac function in TTTS recipients with left ventricular outflow tract obstruction. We analysed data from two TTTS recipients treated with esmolol/metoprolol. Despite intense circulatory support, both patients showed severe hypotension and tachycardia before therapy. Echocardiographic findings included hypertrophic ventricles with thickened intraventricular septum, reduced aortic valve velocity time integral (AV-VTI), left ventricular outflow tract obstruction and collapsing ventricles in systole. Beta blocker improved blood pressure as well as AV-VTI, which served as a surrogate parameter for left ventricular stroke volume, reduced heart rate and need for circulatory support. In conclusion, beta blockade may improve left ventricular function in TTTS recipients with low cardiac output due to myocardial hypertrophy.


Assuntos
Transfusão Feto-Fetal , Hipotensão , Metoprolol/administração & dosagem , Propanolaminas/administração & dosagem , Taquicardia , Obstrução do Fluxo Ventricular Externo , Antagonistas de Receptores Adrenérgicos beta 1/administração & dosagem , Baixo Débito Cardíaco/diagnóstico , Baixo Débito Cardíaco/etiologia , Baixo Débito Cardíaco/fisiopatologia , Ecocardiografia/métodos , Feminino , Transfusão Feto-Fetal/complicações , Transfusão Feto-Fetal/fisiopatologia , Humanos , Hipotensão/diagnóstico , Hipotensão/tratamento farmacológico , Hipotensão/etiologia , Recém-Nascido , Gravidez , Taquicardia/diagnóstico , Taquicardia/tratamento farmacológico , Taquicardia/etiologia , Resultado do Tratamento , Função Ventricular/efeitos dos fármacos , Obstrução do Fluxo Ventricular Externo/etiologia , Obstrução do Fluxo Ventricular Externo/fisiopatologia , Obstrução do Fluxo Ventricular Externo/terapia
4.
Heart Fail Clin ; 14(4): 601-616, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30266368

RESUMO

Inotropes are medications that improve the contractility of the heart and are used in patients with low cardiac output or evidence of end-organ dysfunction. Since their initial discovery, inotropes have held promise in alleviating symptoms and potentially increasing longevity in such patients. Decades of intensive study have further elucidated the benefits and risks of using inotropes. In this article, the authors discuss the history of inotropes, their indications, mechanism of action, and current guidelines pertaining to their use in heart failure. The authors provide insight into their appropriate use and related shortcomings and the practical aspects of inotrope use.


Assuntos
Baixo Débito Cardíaco , Cardiotônicos/uso terapêutico , Insuficiência Cardíaca/tratamento farmacológico , Função Ventricular/fisiologia , Baixo Débito Cardíaco/tratamento farmacológico , Baixo Débito Cardíaco/etiologia , Baixo Débito Cardíaco/fisiopatologia , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/fisiopatologia , Humanos , Resultado do Tratamento , Função Ventricular/efeitos dos fármacos
5.
J Interv Card Electrophysiol ; 53(1): 19-29, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30066291

RESUMO

PURPOSE: To evaluate whether catheter ablation is superior to conventional therapy for atrial fibrillation (AF) in patients with heart failure with reduced ejection fraction (HFrEF). METHODS: Electronic databases were searched for randomized, controlled trials of AF ablation compared with conventional therapy in adults with AF and HFrEF. Odds ratio (OR), standard mean difference (SMD), and 95% confidence intervals (CIs) were measured using the Mantel-Haenszel method. RESULTS: There were seven trials including 856 patients (mean age 62 years, male 86%). All-cause mortality in patients who underwent ablation was 10% vs. 19% in those who received conventional treatment (four trials, 668 patients, 47% relative reduction, 9% absolute reduction; OR 0.46, 95% CI 0.29-0.72). Improvement in the left ventricular ejection fraction was significantly higher for patients undergoing ablation (+ 9 ± 10%) compared to conventional treatment (+ 2 ± 7%) (seven trials, 856 patients, SMD 0.68, 95% CI 0.28-1.08). Freedom from AF was higher in patients undergoing ablation (seven trials, 856 patients, 70% vs. 18%, respectively; 64% relative reduction, 52% absolute reduction; OR 0.03 95% CI 0.01-0.11). There was no significant difference in major complications between both strategies (OR 1.13, 95% CI 0.58-2.20). CONCLUSIONS: Catheter ablation for AF in patients with HFrEF decreases mortality and AF recurrence and improves left ventricular function, functional capacity, and quality of life, when compared to conventional management, without increasing complications.


Assuntos
Fibrilação Atrial/cirurgia , Baixo Débito Cardíaco/fisiopatologia , Ablação por Cateter/métodos , Tratamento Conservador/métodos , Insuficiência Cardíaca/cirurgia , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/terapia , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/terapia , Humanos , Masculino , Prognóstico , Ensaios Clínicos Controlados Aleatórios como Assunto , Recidiva , Medição de Risco , Volume Sistólico , Taxa de Sobrevida , Resultado do Tratamento
6.
Heart ; 104(21): 1739-1748, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30030333

RESUMO

Heart failure with preserved ejection fraction (HFpEF) looms as a major public heart challenge with increasing prevalence due to an ageing population. Diagnosis can be challenging due to non-specific symptomatology, low natriuretic peptide levels and equivocal diastology on resting echocardiography. Diastolic stress echocardiography represents a non-invasive option to refining the diagnosis in this subset of patients. Diastolic responses to exercise are most commonly measured with a non-invasive measure of left ventricular filling pressures (LVFP) estimated by the ratio of the early mitral inflow wave to early diastolic tissue velocity (E/e' ratio). This is measured pre- and post-exercise , and is highly feasible. An elevation of exercise E/e' >15 is classified as an abnormal response as per current guidelines. An alternative measure of exercise-related diastolic performance, the Diastolic Functional Reserve Index has also been proposed, but has not been as well studied as exercise E/e'. A number of studies have validated exercise E/e' as a measure of LVFP against invasively measured LVFP using simultaneous echocardiography-catheterisation studies. The independent prognostic value of exercise E/e' has also been well delineated in a number of studies. While diastolic stress echocardiography can be considered for all patients with suspected HFpEF, it is of particular value in patients with normal or equivocal diastolic indices on resting echocardiography.


Assuntos
Diástole , Ecocardiografia sob Estresse/métodos , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/fisiopatologia , Disfunção Ventricular Esquerda/fisiopatologia , Baixo Débito Cardíaco/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Sensibilidade e Especificidade , Índice de Gravidade de Doença , Volume Sistólico/fisiologia , Disfunção Ventricular Esquerda/diagnóstico por imagem
8.
J Interv Card Electrophysiol ; 53(1): 41-46, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29627955

RESUMO

PURPOSE: Positive T wave polarity in lead aVR (TPaVR) is associated with a poor prognostic indicator in patients with heart failure reduce ejection fraction (HFrEF). Our aim was to investigate the relationship between positive TPaVR and mortality in patients with cardiac resynchronization therapy defibrillator (CRT-D). METHODS: We included retrospectively 224 HFrEF patients with CRT-D in sinus rhythm. Laboratory, electrocardiographic (ECG), and echocardiographic data were recorded. T wave polarity was measured in lead DI, DII, and aVR from surface ECG. RESULTS: The patients were divided as living and deceased. They followed for 2.5 ± 0.9 years. Thirty-three patients (14.7%) died. Six patients (18.2%) were TPaVR positive before CRT-D and this number increased to 22 (66.6%) after CRT-D in the deceased group. Pulse (p = 0.049), hyperlipidemia (p = 0.022), and NT-proBNP levels were higher in the deceased group (p = 0.001). TPaVR before CRT-D (p < 0.001) and TPaVR after CRT-D (p < 0.001) were significantly positive in the deceased group. Positive TPaVR after CRT-D was the only independent predictor for mortality in binominal logistic regression analysis (OR 1.211, 95% CI 1.105-1.328, p < 0.001). CONCLUSIONS: In CRT-D patients, a positive TPaVR in surface ECG may be a strong mortality indicator.


Assuntos
Mapeamento Potencial de Superfície Corporal/métodos , Baixo Débito Cardíaco/fisiopatologia , Terapia de Ressincronização Cardíaca/métodos , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/terapia , Idoso , Estimulação Cardíaca Artificial/métodos , Estudos de Coortes , Ecocardiografia/métodos , Eletrocardiografia/métodos , Feminino , Insuficiência Cardíaca/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Taxa de Sobrevida , Resultado do Tratamento
9.
Eur Heart J Cardiovasc Imaging ; 19(6): 622-629, 2018 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-29534164

RESUMO

Aims: Secondary mitral regurgitation (MR) drives adverse remodelling towards late heart failure stages. Little is known about the evolution of MR under guideline-directed therapy (GDT) and its relation to cardiac remodelling and outcome. We therefore aimed to assess incidence, impact, and predictors of progressive secondary MR in patients under GDT. Methods and results: We prospectively enrolled 249 patients with chronic heart failure and reduced ejection fraction receiving GDT in this long-term observational study. Of patients with non-severe MR at baseline 81% remained stable whereas 19% had progressive MR. Those patients were more symptomatic (P < 0.001), had higher neurohumoral activation (encompassing various neurohumoral pathways in heart failure, all P < 0.05), larger left atrial size (P = 0.004) and more tricuspid regurgitation (TR, P = 0.02). During a median follow-up of 61 months (IQR 50-72), 61 patients died. Progression of MR conveyed an increased risk of mortality-univariately (HR 2.33; 95% CI 1.34-4.08; P = 0.003), that persisted after multivariate adjustment using a bootstrap-selected confounder model (adjusted HR 2.48; 95% CI 1.40-4.39; P = 0.002). In contrast, regression of MR was not associated with a beneficiary effect on outcome (crude HR 0.84; 95% CI 0.30-2.30; P = 0.73). Conclusions: Every fifth patient with chronic heart failure suffers from MR progression. This entity is associated with a more than two-fold increased risk of death even after careful multivariable adjustment. Symptomatic status, left atrial size, TR, and neurohumoral pathways help to identify patients at risk for progressive secondary MR in an early disease process and open the possibility for closer follow-up and timely intervention.


Assuntos
Progressão da Doença , Ecocardiografia Doppler/métodos , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/terapia , Insuficiência da Valva Mitral/diagnóstico por imagem , Adulto , Idoso , Baixo Débito Cardíaco/fisiopatologia , Estudos de Coortes , Feminino , Insuficiência Cardíaca/mortalidade , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Insuficiência da Valva Mitral/fisiopatologia , Insuficiência da Valva Mitral/terapia , Prognóstico , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Medição de Risco , Estatísticas não Paramétricas , Taxa de Sobrevida , Resultado do Tratamento
10.
Anesth Analg ; 126(4): 1133-1141, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29324494

RESUMO

BACKGROUND: Low cardiac output syndrome is a main cause of death after cardiac surgery. We sought to assess the impact of glucose-insulin-potassium (GIK) to enhance myocardial protection in moderate- to high-risk patients undergoing on-pump heart surgery. METHODS: A randomized controlled trial was performed in adult patients (Bernstein-Parsonnet score >7) scheduled for elective aortic valve replacement and/or coronary artery bypass surgery. Patients were randomized to GIK (20 IU of insulin, 10 mEq of potassium chloride in 50 mL of glucose 40%) or saline infusion given over 60 minutes on anesthetic induction. The primary end point was postcardiotomy ventricular dysfunction (PCVD), defined as new/worsening left ventricular dysfunction requiring inotropic support (≥120 minutes). Secondary end points were the intraoperative changes in left ventricular function as assessed by transoesophageal echocardiography, postoperative troponin levels, cardiovascular and respiratory complications, and intensive care unit and hospital length of stay. RESULTS: From 224 randomized patients, 222 were analyzed (112 and 110 in the placebo and GIK groups, respectively). GIK pretreatment was associated with a reduced occurrence of PCVD (risk ratio [RR], 0.41; 95% confidence interval [CI], 0.25-0.66). In GIK-treated patients, the left systolic ventricular function was better preserved after weaning from bypass, plasma troponin levels were lower on the first postoperative day (2.9 ng·mL(-) [interquartile range {IQR}, 1.5-6.6] vs 4.3 ng·mL(-) [IQR, 2.4-8.2]), and cardiovascular (RR, 0.69; 95% CI, 0.50-0.89) and respiratory complications (RR, 0.5; 95% CI, 0.38-0.74) were reduced, along with a shorter length of stay in intensive care unit (3 days [IQR, 2-4] vs 3.5 days [IQR, 2-7]) and in hospital (14 days [IQR, 11-18.5] vs 16 days [IQR, 12.5-23.5]), compared with placebo-treated patients. CONCLUSIONS: GIK pretreatment was shown to attenuate PCVD and to improve clinical outcome in moderate- to high-risk patients undergoing on-pump cardiac surgery.


Assuntos
Baixo Débito Cardíaco/prevenção & controle , Soluções Cardioplégicas/administração & dosagem , Ponte Cardiopulmonar , Ponte de Artéria Coronária , Parada Cardíaca Induzida/métodos , Implante de Prótese de Valva Cardíaca , Disfunção Ventricular Esquerda/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Débito Cardíaco , Baixo Débito Cardíaco/diagnóstico por imagem , Baixo Débito Cardíaco/etiologia , Baixo Débito Cardíaco/fisiopatologia , Soluções Cardioplégicas/efeitos adversos , Ponte Cardiopulmonar/efeitos adversos , Ponte de Artéria Coronária/efeitos adversos , Método Duplo-Cego , Procedimentos Cirúrgicos Eletivos , Feminino , Glucose/administração & dosagem , Glucose/efeitos adversos , Parada Cardíaca Induzida/efeitos adversos , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Infusões Intravenosas , Insulina/administração & dosagem , Insulina/efeitos adversos , Masculino , Pessoa de Meia-Idade , Potássio/administração & dosagem , Potássio/efeitos adversos , Fatores de Risco , Suíça , Fatores de Tempo , Resultado do Tratamento , Disfunção Ventricular Esquerda/diagnóstico por imagem , Disfunção Ventricular Esquerda/etiologia , Disfunção Ventricular Esquerda/fisiopatologia , Função Ventricular Esquerda
11.
J Cardiothorac Vasc Anesth ; 32(6): 2528-2536, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-29338996

RESUMO

OBJECTIVE: Patients with infective endocarditis undergoing cardiac surgery are a high-risk population. Few data on incidence and predictors of need for high-dose inotropic support in this setting are currently available. DESIGN: Retrospective study. SETTING: Tertiary-care hospital. PARTICIPANTS: Ninety consecutive patients undergoing cardiac surgery for infective endocarditis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Baseline, intraoperative and outcome data were collected. Stepwise multiple logistic regression analysis was performed to identify preoperative predictors of postoperative hemodynamic support. High-dose postoperative inotropic support was defined as inotropic score >10 (calculated as dobutamine dose (in µg/kg/min) + dopamine dose (in µg/kg/min) + (epinephrine dose [in µg/kg/min] × 100) + (norepinephrine dose [in µg/kg/min] × 100) + (milrinone dose [in µg/kg/min] × 10) + (vasopressin dose [in U/kg/min] × 10 000) + (levosimendan dose [in µg/kg/min] × 50) or need for mechanical circulatory support at intensive care unit admission. Postoperative high-dose inotropic or mechanical circulatory support was required in 57 cases (61%). Stepwise multiple logistic regression identified 5 variables independently associated with need for postoperative circulatory support: male sex (odds ratio [OR] = 10.9), surgery duration (OR for every minute increase = 1.01), impairment of kidney function (eGFR <60 mL/min/m2 - OR = 19), preoperative new-onset heart failure (defined by clinical, imaging and laboratory parameters - OR = 5.30), and low preoperative platelet count (for every 1×103/µl increase - OR = 0.99). CONCLUSIONS: Patients undergoing cardiac surgery for infective endocarditis are at high risk for postoperative hemodynamic instability. Preoperative organ failure is an important determinant for postoperative hemodynamic instability.


Assuntos
Baixo Débito Cardíaco/prevenção & controle , Cardiotônicos/administração & dosagem , Endocardite/cirurgia , Hemodinâmica/fisiologia , Cuidados Pós-Operatórios/métodos , Complicações Pós-Operatórias/prevenção & controle , Baixo Débito Cardíaco/epidemiologia , Baixo Débito Cardíaco/fisiopatologia , Relação Dose-Resposta a Droga , Feminino , Seguimentos , Alemanha/epidemiologia , Hemodinâmica/efeitos dos fármacos , Humanos , Incidência , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Fatores de Tempo
12.
Am J Obstet Gynecol ; 218(1): 124.e1-124.e11, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-29102503

RESUMO

BACKGROUND: The classification of hypertensive disorders of pregnancy is based on the time at the onset of hypertension, proteinuria, and other associated complications. Maternal hemodynamic interrogation in hypertensive disorders of pregnancy considers not only the peripheral blood pressure but also the entire cardiovascular system, and it might help to classify the different clinical phenotypes of this syndrome. OBJECTIVE: This study aimed to examine cardiovascular parameters in a cohort of patients affected by hypertensive disorders of pregnancy according to the clinical phenotypes that prioritize fetoplacental characteristics and not the time at onset of hypertensive disorders of pregnancy. STUDY DESIGN: At the fetal-maternal medicine unit of Ziekenhuis Oost-Limburg (Genk, Belgium), maternal cardiovascular parameters were obtained through impedance cardiography using a noninvasive continuous cardiac output monitor with the patients placed in a standing position. The patients were classified as pregnant women with hypertensive disorders of pregnancy who delivered appropriate- and small-for-gestational-age fetuses. Normotensive pregnant women with an appropriate-for-gestational-age fetus at delivery were enrolled as the control group. The possible impact of obesity (body mass index ≥30 kg/m2) on maternal hemodynamics was reassessed in the same groups. RESULTS: Maternal age, parity, body mass index, and blood pressure were not significantly different between the hypertensive disorders of pregnancy/appropriate-for-gestational-age and hypertensive disorders of pregnancy/small-for-gestational-age groups. The mean uterine artery pulsatility index was significantly higher in the hypertensive disorders of pregnancy/small-for-gestational-age group. The cardiac output and cardiac index were significantly lower in the hypertensive disorders of pregnancy/small-for-gestational-age group (cardiac output 6.5 L/min, cardiac index 3.6) than in the hypertensive disorders of pregnancy/appropriate-for-gestational-age group (cardiac output 7.6 L/min, cardiac index 3.9) but not between the hypertensive disorders of pregnancy/appropriate-for-gestational-age and control groups (cardiac output 7.6 L/min, cardiac index 4.0). Total vascular resistance was significantly higher in the hypertensive disorders of pregnancy/small-for-gestational-age group than in the hypertensive disorders of pregnancy/appropriate-for-gestational-age group and the control group. All women with hypertensive disorders of pregnancy showed signs of central arterial dysfunction. The cardiovascular parameters were not influenced by gestational age at the onset of hypertensive disorders of pregnancy, and no difference was observed between the women with appropriate-for-gestational-age fetuses affected by preeclampsia or by gestational hypertension with appropriate-for-gestational-age fetuses. Women in the obese/hypertensive disorders of pregnancy/appropriate-for-gestational-age and obese/hypertensive disorders of pregnancy/small-for-gestational-age groups showed a significant increase in cardiac output, as well as significant changes in other parameters, compared with the nonobese/hypertensive disorders of pregnancy/appropriate-for-gestational-age and nonobese/hypertensive disorders of pregnancy/small-for-gestational-age groups. CONCLUSION: Significantly low cardiac output and high total vascular resistance characterized the women with hypertensive disorders of pregnancy associated with small for gestational age due to placental insufficiency, independent of the gestational age at the onset of hypertension. The cardiovascular parameters were not significantly different in the women with appropriate-for-gestational-age or small-for-gestational-age fetuses affected by preeclampsia or gestational hypertension. These findings support the view that maternal hemodynamics may be a candidate diagnostic tool to identify hypertensive disorders in pregnancies associated with small-for-gestational-age fetuses. This additional tool matches other reported evidence provided by uterine Doppler velocimetry, low vascular growth factors in the first trimester, and placental pathology. Obesity is associated with a significantly higher cardiac output and outweighs other determinants of hemodynamics in pregnancy; therefore, in future studies on hypertensive disorders, obesity should be studied as an additional disease and not simply as a demographic characteristic.


Assuntos
Hipertensão Induzida pela Gravidez/fisiopatologia , Adulto , Velocidade do Fluxo Sanguíneo/fisiologia , Baixo Débito Cardíaco/fisiopatologia , Estudos de Casos e Controles , Estudos de Coortes , Feminino , Humanos , Recém-Nascido , Recém-Nascido Pequeno para a Idade Gestacional , Insuficiência Placentária/fisiopatologia , Gravidez , Resistência Vascular/fisiologia
13.
Anesth Analg ; 126(5): 1476-1483, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29116972

RESUMO

BACKGROUND: Peak systolic global longitudinal strain (GLS) is increasingly used to quantify left ventricular systolic function. The primary objective of this study was to assess whether GLS obtained during intraoperative transesophageal echocardiogram, performed before cardiopulmonary bypass, improves the prediction of postoperative low cardiac output syndrome (LCOS) after adult cardiac surgery. METHODS: GLS from 275 patients undergoing on-pump cardiac surgery was calculated retrospectively using two-dimensional- speckle tracking echocardiography (aCMQ module from Qlab software version 10.5, Philips Medical, Brussels, Belgium). LCOS was defined as the need for inotropic or mechanical circulatory support for >24 hours postoperatively. Patient and procedure characteristics associated with LCOS at the univariable level (P ≤ .05) were entered into a forward stepwise logistic regression to create a first predictive model. A second model was created by adding GLS. The 2 models were compared using the likelihood-ratio test, the area under the receiver operating characteristic (ROC) curve, and the integrated discrimination index. The optimal cutoff value of GLS associated with LCOS was determined by maximizing the Youden index of the ROC curve. Secondary outcomes included time until complete weaning from inotropes, discharge from the intensive care unit and from the hospital, and 30-day mortality. RESULTS: GLS was significantly associated with LCOS (P < .001) at the univariable level. Predictors of LCOS retained in the first model were cardiopulmonary bypass duration, decreased left ventricular ejection fraction, mitral valve surgery, and New York Heart Association functional class III or IV. Adding the GLS value improved the prediction of LCOS (P = .02). However, the area under the ROC curve did not differ between the 2 models (0.83; 95% confidence interval [CI], 0.77-0.99 vs 0.84; 95% CI, 0.79-0.90; P = .15). The integrated discrimination index associated with addition of GLS was 0.02 (P = .046), meaning that the difference in predicted risk between patients with and without LCOS increased by 2% after adding GLS. A GLS cutoff value of -17% (95% CI, -18.8% to -15.3%) was found to best identify LCOS. After adjusting for covariates included in model 1, a lower GLS value was significantly associated with a lower cumulative probability of weaning from inotropes postoperatively (hazard ratio, 0.90; 95% CI, 0.82-0.97; P = .01). No association was found between GLS and other secondary outcome measures. CONCLUSIONS: GLS is an independent predictor of LCOS after on-pump cardiac surgery. Its incremental value over other established risk factors for postoperative LCOS is, however, limited.


Assuntos
Baixo Débito Cardíaco/diagnóstico por imagem , Baixo Débito Cardíaco/etiologia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Sístole/fisiologia , Idoso , Baixo Débito Cardíaco/fisiopatologia , Procedimentos Cirúrgicos Cardíacos/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos
14.
Eur Heart J Cardiovasc Imaging ; 19(3): 339-346, 2018 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-28387860

RESUMO

Aims: Prolonged central circulation transit time (TT) has long been associated with heart failure (HF) and left ventricular (LV) dysfunction. In this study, we assessed the central circulation TT using cardiovascular magnetic resonance imaging (CMR) in patients with HF of preserved ejection fraction (HFpEF) and of reduced EF (HFrEF) and investigated its relation to haemodynamics. Methods and results: Fifty eight prospectively recruited volunteers underwent CMR. TT was taken as the time between the peaks of time-intensity curves from first pass perfusion images and normalized to cardiac cycle length intervals. Left ventricular ejection fraction was 55 ± 3%, 57 ± 7%, and 28 ± 10% in control (N = 10), HFpEF (N = 20), and HFrEF (N = 28), respectively (P < 0.001). Global central TT from right atrium to ascending aorta was significantly prolonged in patients with HFrEF [17 ± 5 cardiac cycles (cc)] and HFpEF (12 ± 3 cc) when compared to the normal controls (8 ± 1 cc) (P < 0.001). Regional TT was also prolonged in HF patients between right atrium and pulmonary artery (PA), PA and left atrium (LA), and LA and ascending aorta (all P-value < 0.001) with the longest delay seen between PA and LA. Among 48 HF patients, 28 underwent same day cardiac catheterization. Multivariate regression analysis suggested while reduced left and right ventricular EF were the strongest correlates for HFrEF increased pulmonary capillary wedge (PCWP) and reduced PA oxygen saturation were the strongest correlates for HFpEF. Conclusions: Global and regional central TT can be assessed in the first pass perfusion imaging. Prolonged normalized global TT correlates with reduced EF in HFrEF and increased PCWP in HFpEF.


Assuntos
Baixo Débito Cardíaco/diagnóstico por imagem , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/fisiopatologia , Imagem Cinética por Ressonância Magnética/métodos , Disfunção Ventricular Esquerda/diagnóstico por imagem , Adulto , Idoso , Velocidade do Fluxo Sanguíneo/fisiologia , Baixo Débito Cardíaco/fisiopatologia , Estudos de Coortes , Intervalos de Confiança , Feminino , Hemodinâmica/fisiologia , Humanos , Processamento de Imagem Assistida por Computador , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Prognóstico , Estudos Prospectivos , Análise de Onda de Pulso , Medição de Risco , Volume Sistólico/fisiologia
15.
Semin Dial ; 31(1): 15-20, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-28990213

RESUMO

There are currently near 400 000 patients on hemodialysis in the United States. More than 50% of those treated by chronic hemodialysis die because of a cardiovascular (CV) event. The majority of these patients have functional arteriovenous fistulas (AVFs). AVFs have an adverse effect on cardiac function, but their exact contribution to CV morbidity is not clear. It has long been known that a vascular access with an inappropriately high-flow rate may cause high-output heart failure. Paradoxically, there may be hemodynamic and cardiopulmonary benefits conferred by AVF particularly in severe chronic obstructive pulmonary disease. While Brescia-Cimino`s basic idea of the AVF has saved millions of lives, we would like to stress that there are dangers from their often high blood flow rates, which unfortunately have proved difficult to evaluate.


Assuntos
Derivação Arteriovenosa Cirúrgica/efeitos adversos , Baixo Débito Cardíaco/etiologia , Insuficiência Cardíaca/etiologia , Falência Renal Crônica/terapia , Diálise Renal/efeitos adversos , Idoso , Baixo Débito Cardíaco/mortalidade , Baixo Débito Cardíaco/fisiopatologia , Feminino , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Humanos , Falência Renal Crônica/diagnóstico , Falência Renal Crônica/mortalidade , Masculino , Pessoa de Meia-Idade , Prognóstico , Fluxo Sanguíneo Regional , Diálise Renal/métodos , Medição de Risco , Análise de Sobrevida
16.
Eur Heart J Cardiovasc Imaging ; 19(1): 74-83, 2018 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-28158459

RESUMO

Aims: Impairment of cardiac sympathetic innervation is a potent prognostic marker in heart failure, while left ventricular mechanical dyssynchrony (LVMD) has recently been noted as a novel prognosis determinant in heart failure patients with reduced LV ejection fraction (HFrEF). This study was designed to determine the correlation between cardiac sympathetic innervation quantified by metaiodobenzylguanidine (MIBG) activity and LVMD measured by electrocardiogram-gated myocardial perfusion imaging and to evaluate their incremental prognostic values in HFrEF patients. Methods and results: A total of 570 consecutive HFrEF patients were followed up for 19.6 months with a primary endpoint of lethal cardiac events (CE) such as sudden cardiac death, death due to pump failure and appropriate ICD shock against life-threatening ventricular tachyarrhythmias. Cardiac sympathetic function and innervation were quantified as heart-to-mediastinum ratio (HMR) and washout kinetics of cardiac MIBG activity. LVMD was assessed by a standard deviation (SD) of systolic phase angle in gated myocardial perfusion imaging. Patients with CE (n = 166, 29%) had a significantly lower HMR and a significantly greater phase SD than did non-CE patients: 1.46 ± 0.28 vs. 1.63 ± 0.29, P < 0.0001 and 39.1 ± 11.6 vs. 33.1 ± 10.1, P < 0.0001, respectively. Compared to the single use of optimal cut-offs of late HMR (1.54) and phase SD (38), their combination more precisely discriminated high-risk or low-risk patients from others with log rank values from 7.78 to 65.2 (P = 0.0053 to P ≤ 0.0001). Among significant univariate variables, multivariate Cox proportional hazards model identified NYHA functional class, estimated glomerular filtration rate (eGFR), HMR 1.54 and phase SD 60 as significant determinants of CE with hazard ratios of 3.108 (95% CI, 2.472-3.910; P < 0.0001), 0.988 (95% CI, 0.981-0.996; P = 0.0021), 0.257 (95% CI, 0.128-0.498; P < 0.0001) and 1.019 (95% CI, 1.019-1.037; P = 0.0228), respectively. By combining the four independent determinants, the prognostic powers synergistically (P < 0.0001) increased maximally to 263.8. Conclusions: Left ventricular mechanical dyssynchrony and impairment of cardiac sympathetic innervation are synergistically related to lethal cardiac events, contributing to better stratification of lethal cardiac event-risks and probably to optimization of therapeutic strategy in patients with HFrEF.


Assuntos
3-Iodobenzilguanidina , Morte Súbita Cardíaca , Insuficiência Cardíaca/diagnóstico por imagem , Imagem de Perfusão do Miocárdio/métodos , Disfunção Ventricular Esquerda/diagnóstico por imagem , Idoso , Baixo Débito Cardíaco/diagnóstico por imagem , Baixo Débito Cardíaco/fisiopatologia , Eletrocardiografia/métodos , Feminino , Sistema de Condução Cardíaco/fisiopatologia , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Volume Sistólico , Sistema Nervoso Simpático/fisiopatologia , Disfunção Ventricular Esquerda/mortalidade
17.
Eur Heart J ; 38(38): 2900-2909, 2017 Oct 07.
Artigo em Inglês | MEDLINE | ID: mdl-29019615

RESUMO

Aims: To evaluate associations between haemodynamic profiles and symptoms, end-organ function and outcome in children listed for heart transplantation. Methods and results: Children <18 years listed for heart transplant between 1993 and 2013 with cardiac catheterization data [pulmonary capillary wedge pressure (PCWP), right atrial pressure (RAP), and cardiac index (CI)] in the Pediatric Heart Transplant Study database were included. Outcomes were New York Heart Association (NYHA)/Ross classification, renal and hepatic dysfunction, and death or clinical deterioration while on waitlist. Among 1059 children analysed, median age was 6.9 years and 46% had dilated cardiomyopathy. Overall, 58% had congestion (PCWP >15 mmHg), 28% had severe congestion (PCWP >22 mmHg), and 22% low cardiac output (CI < 2.2 L/min/m2). Twenty-one per cent met the primary outcome of death (9%) or clinical deterioration (12%). In multivariable analysis, worse NYHA/Ross classification was associated with increased PCWP [odds ratio (OR) 1.03, 95% confidence interval (95% CI) 1.01-1.07, P = 0.01], renal dysfunction with increased RAP (OR 1.04, 95% CI 1.01-1.08, P = 0.007), and hepatic dysfunction with both increased PCWP (OR 1.03, 95% CI 1.01-1.06, P < 0.001) and increased RAP (OR 1.09, 95% CI 1.06-1.12, P < 0.001). There were no associations with low output. Death or clinical deterioration was associated with severe congestion (OR 1.6, 95% CI 1.2-2.2, P = 0.002), but not with CI alone. However, children with both low output and severe congestion were at highest risk (OR 1.9, 95% CI 1.1-3.5, P = 0.03). Conclusion: Congestion is more common than low cardiac output in children with end-stage heart failure and correlates with NYHA/Ross classification and end-organ dysfunction. Children with both congestion and low output have the highest risk of death or clinical deterioration.


Assuntos
Insuficiência Cardíaca/fisiopatologia , Hemodinâmica/fisiologia , Adolescente , Baixo Débito Cardíaco/mortalidade , Baixo Débito Cardíaco/fisiopatologia , Cardiomiopatias/complicações , Cardiomiopatias/mortalidade , Cardiomiopatias/fisiopatologia , Criança , Pré-Escolar , Doença Crônica , Deterioração Clínica , Feminino , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/mortalidade , Ventrículos do Coração/anormalidades , Humanos , Lactente , Recém-Nascido , Masculino
18.
Herzschrittmacherther Elektrophysiol ; 28(3): 260-267, 2017 Sep.
Artigo em Alemão | MEDLINE | ID: mdl-28812138

RESUMO

Remote follow-up of patients with implantable electronic cardiac devices (IECD) is a scientifically well-evaluated and technically mature method. Advantages over conventional follow-up include rapid detection of clinically relevant events (i. e. arrhythmias) and of technical problems. Additionally, telemetric follow-up of IECDs has a high degree of acceptance among both patients as well as health care professionals and carries the potential to reduce health care costs. The implementation of a remote follow-up programme is associated with organisational, infrastructural and legal aspects, which are reviewed.


Assuntos
Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/terapia , Desfibriladores Implantáveis , Marca-Passo Artificial , Tecnologia de Sensoriamento Remoto , Telemetria , Assistência ao Convalescente/estatística & dados numéricos , Idoso , Arritmias Cardíacas/fisiopatologia , Bloqueio de Ramo/diagnóstico , Bloqueio de Ramo/fisiopatologia , Bloqueio de Ramo/terapia , Baixo Débito Cardíaco/diagnóstico , Baixo Débito Cardíaco/fisiopatologia , Baixo Débito Cardíaco/terapia , Cardiomiopatia Dilatada/diagnóstico , Cardiomiopatia Dilatada/fisiopatologia , Cardiomiopatia Dilatada/terapia , Doença das Coronárias/diagnóstico , Doença das Coronárias/fisiopatologia , Doença das Coronárias/terapia , Estudos Transversais , Desfibriladores Implantáveis/estatística & dados numéricos , Desfibriladores Implantáveis/tendências , Eletrocardiografia , Falha de Equipamento , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Marca-Passo Artificial/estatística & dados numéricos , Marca-Passo Artificial/tendências , Tecnologia de Sensoriamento Remoto/estatística & dados numéricos , Tecnologia de Sensoriamento Remoto/tendências , Processamento de Sinais Assistido por Computador , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/fisiopatologia , Taquicardia Ventricular/terapia
19.
Herz ; 42(6): 536-541, 2017 Sep.
Artigo em Alemão | MEDLINE | ID: mdl-28597027

RESUMO

Many patients with severe aortic stenosis have a "low-flow, low-gradient" aortic stenosis. The management of these patients can be quite difficult, as these patients often show impairment of the left ventricle, which can lead to false measurements of the severity of stenosis and also leads to a higher risk during aortic valve replacement. More diagnostic tools than only standard echocardiography are needed to correctly differentiate true severe aortic stenosis from pseudo severe aortic stenosis.


Assuntos
Estenose da Valva Aórtica/terapia , Velocidade do Fluxo Sanguíneo/fisiologia , Algoritmos , Estenose da Valva Aórtica/classificação , Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/fisiopatologia , Baixo Débito Cardíaco/classificação , Baixo Débito Cardíaco/mortalidade , Baixo Débito Cardíaco/fisiopatologia , Baixo Débito Cardíaco/terapia , Comorbidade , Diagnóstico Diferencial , Ecocardiografia , Humanos , Prognóstico , Fatores de Risco , Taxa de Sobrevida , Disfunção Ventricular Esquerda/classificação , Disfunção Ventricular Esquerda/mortalidade , Disfunção Ventricular Esquerda/fisiopatologia , Disfunção Ventricular Esquerda/terapia
20.
Int J Cardiovasc Imaging ; 33(10): 1483-1489, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28488096

RESUMO

Low cardiac output syndrome (LCOS) after surgical aortic valve replacement (SAVR) is related to increased mortality and treatment related costs. We aimed to evaluate whether echocardiography-derived left ventricular global longitudinal strain (LV-GLS) relates to the occurrence of postoperative LCOS in patients undergoing SAVR. We prospectively enrolled 75 patients with symptomatic severe aortic stenosis, left ventricular ejection fraction (LVEF) >40%, NYHA Class

Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Baixo Débito Cardíaco/diagnóstico por imagem , Ecocardiografia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Função Ventricular Esquerda , Função Ventricular Direita , Idoso , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/fisiopatologia , Área Sob a Curva , Fenômenos Biomecânicos , Baixo Débito Cardíaco/etiologia , Baixo Débito Cardíaco/mortalidade , Baixo Débito Cardíaco/fisiopatologia , Distribuição de Qui-Quadrado , Feminino , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Variações Dependentes do Observador , Razão de Chances , Valor Preditivo dos Testes , Estudos Prospectivos , Curva ROC , Reprodutibilidade dos Testes , Medição de Risco , Fatores de Risco , Estresse Mecânico , Fatores de Tempo , Resultado do Tratamento
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